Bipolar Disorder (15 points total) cc. “Our mother died three weeks ago and we l

Question

Bipolar Disorder (15 points total)

cc. “Our mother died three weeks ago and we lost our father several months ago. I think that my sister was depressed and just wanted to be with them.”

HPI. B.J. is a 31 y/o F who was brought to the hospital by ambulance. She was found slumped over in her car in front of the funeral home where memorial services for both her father and mother had been recently held. There were two empty bottles of sleeping pills on the seat beside her and a note that read, “I am going to be with my mom and dad. It is just too sad being here without them. I love you all and you will be in my prayers.” When she was found by the director of the funeral home, her hair was oily and unkempt and she smelled as if she had not bathed in a long time. She was dressed in a dirty, orange tee shirt, jeans, and tennis shoes.

Recently, per patient’s sister, B.J. would call her at odd times of the day, such as 3am just to talk. She would ramble on the phone, become sarcastic and hostile and hang up. She preached about religion and her bad parents and sex. She would also go on 2-3 day shopping sprees and max out credit cards. She was recently started on Lithium which was starting to work. B.J. has not been coping well with the death of her parents.

PMH. Episodes of depression first occurred when the patient was a junior in high school and led to psychiatric admissions at 15 and 19 years of age. She met her first husband in the psychiatric ward of the hospital at age 19 following a suicide attempt. The patient was treated with antidepressants and psychotherapy and discharged on both occasions after approximately 5 weeks. She was a foster child with abusive caregivers, biological parents were alcoholics. Patient was diagnosed with bipolar disorder 6 years ago. After her 3rd baby, she went into depression. Per sister, patient “got weird” after being started on Paxil.

SH. 3 daughters, currently in second marriage, has worked as a nurses aid and health insurance adjuster. Smoked 1 ppd for nearly 15 years, history of alcohol abuse with DUIs, history of IVDA but has not used for more than 10 years.

FH.      Strong history of mental illness-paternal grandmother suffered from depression, two maternal aunts diagnosed with bipolar disorder

Both parents had a long history of alcohol abuse

Father was previously diagnosed with pancreatitis and then diabetes mellitus

Mother has been relatively well and died from a “broken heart”

Patient has 3 living brothers, 3 sisters and 3 daughters

One brother died from AMI at age 34, another brother died at age 6 months

Meds.             Lithium 600mg PO QAM and 600mg PO QHS

Sumatriptan 50-200mg PO PRN

Allergies: Aspirin (swelling of the face)

ROS. Migraine headaches, 2-3x/month. (-) aura but (+) for nausea, vomiting and photophobia

PE and Lab Tests.

General. Tired looking patient, white female in NAD. Pt is very pale and there are “dark rings” under her eyes.

Skin. Comedones on forehead, nose and chin with several cystic lesions on chin (c/w acne), normal turgor, no evidence of rash, ecchymosis, petechiae or cyanosis

Eyes. PERRLA. EOMI.

Throat. Dry mucous membranes

Heart. RRR, S1 & S2 normal without additional cardiac sounds

Lungs. CTA bilaterally

Abd. (+) bowel sounds, no pain or tenderness, soft, non-distended; (1) hepatomegaly, splenomegaly, masses or bruits

MS/Ext. Full ROM. Distal pulses normal at 2+ bil. (-) edema, cyanosis or clubbing.

Neuro. Slightly lethargic but oriented to person, place and time. DTRs full and symmetric. Babinski negative bil. Normal strength throughout. Tone and sensation normal. CNs II-XII intact. Speech without dysarthria. Gross and fine motor coordination are normal. Cerebellar: finger-to-nose and heel-to-shin WNL. Able to toe and tandem walk without difficulty.

Question 1. Why has this patient been taking sumatriptan as needed? (2 pts)

Question 2. Does this patient have lithium toxicity? (2 pts)

Question 3. Identify two significant risk factors for bipolar disorder (2 pts)

Question 4. Describe the two primary types of bipolar disorder. (2 pts)

Question 5. Does this patient have any signs of abnormal hepatic function? (2 pts)

Question 6. Identify two abnormal blood laboratory test results and propose a reasonable explanation for these results. (2 pts)

Question 7. Brain damage may have occurred from this patient’s most recent suicide attempt. List 2 symptoms of brain damage. (2 pts)

Question 8. Does this patient require inpatient treatment or is outpatient therapy totally appropriate? (1 pt)

Adapted from: Bruyere, H.J. (2009). 100 Case Studies in Pathophysiology. Baltimore, MD: Lippincott Williams & Wilkins.

Explanation / Answer

Question 1. Why has this patient been taking sumatriptan as needed?

Sumatriptan is a drug which is used for the remedy of migraines and cluster headaches. It belongs to the family of Triptans and and is an analog of neuro-active alkaloids dimethyltryptamine(DMT) . It helps to effectively end or relieve the intensity of migraine and cluster headaches. It is to be taken at the start of the headache.

Question 2. Does this patient have lithium toxicity?

The patient is being given lithium 600 mg , for the treatment of bipolar disorder. The therapeutic dose is 300-2700 mg/d with desired serum levels of 0.6-1.2 mEq/L. For poisoning or toxicity, the amount of lithium consumed has to be more than the prescribed level, consumed at regular intervals , for chronic poisoning, or at once, for acute poisoning. As for chronic poisoning, the patient is not showing any long term symptoms.

Question 3. Identify two significant risk factors for bipolar disorder

The risk factors of bipolar disorder may include

-environmental factors such as a history of childhood abuse, and long-term stress.

- genes - certain genes exhibit bipolar disorders, which show mild to severe effects of the gene. There has been heterogeneity found between genes with single nucleotide polymorphisms observed at genes CACNA1C, ODZ4, and NCAN. Different families show variation in different genes.

Question 4. Describe the two primary types of bipolar disorder.

Bipolar disorder, also known as manic depression, is a mental disorder that shows two periods - periods of depression and periods of elevated mood.

The elevated mood period is significant and is known as mania or hypomania. The nomenclature of the condition depends on its severity. During mania, an individual behaves or feels abnormally energetic, happy, or irritable. They make poorly thought decisions regardless of the consequences. Their sleep hours are reduced during manic phases.

The periods of depression include crying and a negative outlook on life.The risk of suicide is higher at greater than 6 percent over 20 years, while percentage of self-harm occurs in 30–40 percent. Other mental health issues such as anxiety disorders and substance use disorder are commonly associated.

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