82. Case#1 A 24-year-old male graduate student without prior medical or psychiatric history is reported by his mother to have been very anxious over the past 6 months, with increasing concern that people are watching him. He now claims to hearing voices, telling him what must be done to fix the country. Important workup ? thyroid-stimulating hormone TSH, rapid plasma reagain (RPR), and brain imaging. Questions: 1. What is the diagnosis of this patient? 2. What is the age onset of this disorder? 3. What socioeconomic group suffers from this disorder? 4. What is the subtype of this disorder in this patient ? 5. List five positive and negative symptoms that we can find in schizophrenia disorder> 6. What is the treatment? 7. What are five characteristics associated with better prognosis? Case#2 Ms. Torrez is a 17-year-old Caucasian woman without prior psychiatric history who is brought to the Emergency room by ambulance after her parents called 911 when they found her having a seizure in their living room. She was admitted to the medical intensive care units in status epilepticus and was quickly stabilized with intramuscular lorazepam and fosphenytoin loading. Her heigh is 5 feet 6 inches, she is of medium build, and her weight is 101 lbs. (BMI16.3kg/m2). She does not suffer any medical conditions, and this is her first seizure. Laboratory workup shows an electrolyte imbalance as the most likely cause of the seizures. Although initially reluctant, she admits to purging with the use of ipecac several times this week. She reports that although she normally restricts her daily caloric intake to 500 calories, she regularly induces vomiting if her weight is above 100 lbs. Her last menstrual cycle was 1 year ago. Psychiatric consultation is requested in order to confirm the diagnosis The on-call psychiatry notes in Terrys chart Patient appears underweight and younger than her stated age. She is mild distress, has a nasogastric tube in place, and exhibits poor eye contact. She reports feeling sad and admitted to experiencing constant preoccupation about her physical appearance and says, I am fat; I hate my body. She also reports insomnia, low energy levels, and history of self-harm behavior by cutting her forearms. She reports that she is careful hiding her symptoms from her parents, whom she describes as strict disciplinarians. She also expresses concerns that she will disappoint them. Ms. Torrez parents describe her as a perfectionist. They say that she is involve in multiple school activities, takes advanced placement classes, and has been recently concerned about being accepted at her college of choice. They report that she maintains a 4.0 grade point average in high school, and they are expecting her to become a lawyer. Her parents have noticed that she is underweight and rarely see her eat but attributed this to stress from her many academic pursuits. Ms. Torrez mom was diagnosed with obsessive-compulsive disorder. Questions 1. What is the diagnosis of Ms. Torrez? 2. Is her condition more common in men or female? 3. What subdivision of her condition, does Ms. Torrez belongs too? 4. List three criteria of Ms. Torrez disorder? 5. What are some physical findings related to Ms. Torrez disorder? 6. What are some medical complications associated with her condition? Case#3 Ms. Ross is a 31-year-old woman who was refereed to the psychiatrist by her gynecologist after undergoing multiple exploratory surgeries for abdominal pain and gynecologic concerns with no findings. The patient reports that she has extensive medical problems dating back to adolescence. She reports periods of extreme abdominal pain, vomiting, diarrhea, and possible food intolerances. The obstetrician is her fourth provider because my other doctors where not able to help me. Ms. Ross reports fear that that her current physician will also fail to relieve her distress. She was reluctant ton see a psychiatrist and did so only after her obstetrician agreed to follow her after her psychiatric appointment. Ms. Ross states that her problems worsened in college, which was the first time she underwent surgery. She reports that due to her health problems and several lack of energy, it took her 5 ½ years to graduate from college. She did better for a year or two after college but then had to return of symptoms. She reports recently feeling very lonely and isolated because she has not been able to find a boyfriend who can tolerate her frequent illness. She also reports that physiological intimacy is difficult to her because she finds sex painful. Additionally, she is concerned that she might lose her job due to the large number of days she has missed. On review of systems, she endorses period where she is short of breath , has double vision , regular heart palpitations, irregular menses, bloating , frequent urinary tract infections and burning on urination, diffusion muscle and joint pain, frequent headaches and periods of ringing in her ears. Questions 1. What is Ms. Ross diagnosis? 2. What are the four criteria of Ms. Ross Disorder? 3. What is one pharmacological treatment for Ms. Ross disorder? Case#4 A 25-year-old female was brought to the ER by her family after experiencing sudden neurologic symptoms. She had been delivering food while working in a local retiree resident facility when she reported suddenly passing out for a couple of seconds while on the elevator. She stated that she woke up with blurred vision that developed into loss of vision in both eyes. She also reported an inability to stand due to weakness in her left leg. While in the emergency department, the patient described seeing only shadows. She stated that she was generally in good health without significant medical issues or any history of chronic medical conditions or surgeries, which was confirmed by her mother. The patient had no reported mental health history and no history of aversive childhood experiences (i.e., abuse or neglect). She had never been seen by a psychiatrist or been on any psychiatric medications. There was also no reported use of tobacco, alcohol, herbal supplements, or over-the-counter or illicit drugs. The patients family history was not significant for medical or psychiatric diseases, including anxiety, depression, or psychosis; however, the patients mother reported that her daughter was experiencing significant situational stressors from working 2 jobs, attending school, being a single parent to a 4-year-old child, experiencing significant financial difficulties, and having a difficult relationship with her childs father. On physical examination, the patient was alert, awake, and oriented to person, time, and place. Her vital signs were stable with a blood pressure of 120/80 mm Hg and no orthostatic changes, a heart rate of 80 beats per minute, and a temperature of 97.6ºF. A thorough systemic examination was normal, including of her cardiovascular system, with no abnormalities detected on her electrocardiogram. On neurologic examination, her speech was normal, her pupils were slightly sluggish but reactive, she was able to see light that was shined into her eyes, and she demonstrated a full range of eye movement, but there was no visual acuity to hand motion or finger counts. The patient had no facial asymmetry and had normal strength in her upper extremities. She had some trouble lifting her left leg off the bed but was able to walk with assistance. No sensory deficits were noticed. A Mini-Mental State Examination yielded a score of 30, indicating normal cognition. All laboratory work was normal, including a complete blood count, comprehensive metabolic panel, blood glucose test, and drug screening. Imaging studiesincluding CT scan, contrast-enhanced CT angiogram of the brain, MRI, and magnetic resonance angiography of the head and neckwere normal. The patient was admitted to the hospital and observed for 24 hours, during which time neurology and ophthalmology consultants examined her. Their evaluation revealed no clear anatomical cause for her vision loss or left leg weakness, prompting consultation with the psychiatry department. The psychiatrist who examined her made a diagnosis of CD based on the findings of unexplained vision loss (i.e., it was not associated with an identifiable lesion in her visual pathway); normal physical examination and patient history; and observations of the patient and her family. Following the diagnosis, the psychiatrist engaged the patient in a brief session of cognitive behavioral therapy and supportive therapy, to which she responded well. The following day, she reported feeling less stressed, was able to walk normally, and her eyesight gradually improved but was still blurry. The patient was referred for outpatient psychotherapy. After a few days, she was in complete remission per a follow-up visit with her primary care physician. Questions 1. What is the diagnosis of this patient? 2. What is the (la belle indifference)? Case#5 A 6-year-old boy was seen in a physician’s office for possible pneumonia. According to his mother, the child had been coughing and wheezing for the past 6 days. In addition, the mother stated that the child had a temperature of 103.9°F (39.9°C), decreased oral intake for the last 3 days, and decreased urine output for 2 days. The child had been treated with home albuterol nebulizers and antibiotics for 3 days. Over the last 24 hours, the child developed nausea, vomiting, and diarrhea. A sibling in the house had been diagnosed with bronchitis. The child’s past medical history included neurofibromatosis, asthma, seizure disorder, attention-deficit/hyperactivity disorder, and pneumonia. The child had a prior workup that showed negative results for hyperglycemia. Current medications included methylphenidate, 20 mg twice per day; the albuterol nebulizer treatments; and amoxicillin, 250 mg 3 times per day. He had no known drug allergies. Family history was positive for a mother with neurofibromatosis and insulin-dependent diabetes mellitus. There was also a family history of asthma. The child lived with his parents and 1 sister. There were no smokers in the household, but there was an inside dog. They had central heat, and the boy’s immunizations were current. Physical examination revealed a well-nourished, well-developed, lethargic, and ill-appearing boy who was uncooperative and somnolent during the initial examination. His temperature was 96.5°F (35.8°C), pulse rate was 129 beats per minute, blood pressure was 116/56 mm Hg, and respiratory rate was 28. His eyes had a disconjugate gaze, but the remainder of the HEENT examination was normal. Results of cardiovascular examination were normal, and his lungs were clear to auscultation with no wheezing noted. Although the neurologic examination was difficult to assess secondary to the child’s lethargy, he did move all extremities. His skin showed multiple café-au-lait areas and was extremely diaphoretic. Initial laboratory evaluation revealed a white blood cell count of 16,200/mL (normal range, 350010,000/mL), plasma sodium level of 140 mmol/L (normal range, 135145 mmol/L), plasma chloride level of 106 mmol/L (normal range, 98107 mmol/L), plasma potassium level of 2.3 mmol/L (normal range, 3.55.0 mmol/L), plasma carbon dioxide level of 20 mmol/L (normal range, 2228 mmol/L), normal serum urea nitrogen and creatinine levels, and a plasma glucose level of 31 mg/dL (normal range, 60110 mg/dL). Owing to mental status concerns, a computed tomography scan of the head was performed with normal results. The child was admitted for further evaluation. Following multiple injections of intravenous (i.v.) glucose during the first 3 hours after admission, the child’s blood sugar rose appropriately, only to fall again shortly after the physician left the room. The patient’s blood sugar level then normalized for the next 48 hours. On day 3, the child’s mother was informed that administration of i.v. glucose was being discontinued. That night, the child’s blood sugar level dropped into the high 40s despite repeated attempts to treat with i.v. solutions. Curiously, once the day shift started, the child’s blood sugar level again normalized. Very early the next morning, the child’s blood sugar level once again dropped, this time into the 30s, with poor response to appropriate measures. Growth hormone, cortisol, insulin, C peptide, and lactate levels were measured. The child’s blood sugar level continued to fluctuate despite aggressive management. Of interest is that at one time during this episode, the i.v. tubing was noted to be leaking. Upon inspection, the tubing had a hole that looked like it was created by a needle. Once the blood sugar level normalized again, dextrose was removed from the i.v. solution. Without the mother’s knowledge, however, the i.v. bag was intentionally mislabeled to suggest ongoing dextrose administration. The child’s subsequent blood sugar levels remained normal. Suspicions that the mother was injecting some of her insulin into the child’s i.v. access were triggered by the fact that her son’s abnormally low blood sugar levels occurred only when she was in the room. The mother also voiced concern that her child was becoming a diabetic just like her, and the child knew how to perform his own finger prick for glucose monitoring. Behavioral aberrations on the part of the mother were also noted, as evidenced by her remaining curled up in a fetal position on the parent’s bed during her child’s most severe hypoglycemic episode. On the fifth day of admission, the mother was removed from the room and the child’s blood sugar level subsequently remained normal. Laboratory results received that day from analysis of blood drawn on day 3 showed an insulin level of 9776 µU/mL (normal range, 525 µU/mL) and a C peptide level of 0.5 ng/mL (normal range, 0.84.0 ng/mL). The mother subsequently expressed concern about her child’s blood sugar level and confessed to covert administration of insulin. The child was removed from the mother’s custody and made a full recovery. Questions 1. What is the name of this disorder? 2. To which cluster of personality disorder this disorder comes from? Case #6 A patient claim that he frequent episodes of seizures. Starts on medications, and joins an epilepsy support group. It becomes known that he is doing this in order to collect disability money. Questions 1. What is the diagnosis of this patient ? 2. What personality disorder is most common in this disorder? Case#7 A 22-year-old female is found by a couple, walking alone at night. She states that she is ok, but she is unable to state a name or any contact information. She was found holding a bus ticket that suggested that she traveled from a nearby state. When questioned she could not remember how she got there? Questions 1. What is the diagnosis?