Caroline Lamar Pihl
July 19, 2015
Write Up #2
Psychiatry Clerkship – MS3
ID/CC:
JC is a 52-year-old male with hx of major depression, who was transferred from Crisis Diversion Facility staff on 7/12/15 with altered cognitive function, severe latency of speech and severe psychomotor retardation.
HISTORY OF PRESENT ILLNESS
Per PES note July 13, Dr. Cashman
“Mr. C was brought to the Crisis Diversion Facility by SPD after he was wandering, apparently aimlessly, in the International District. At CDF arrival, he was "red in the face, sweaty, and presented with latency in speech. . .Client had been walking around in the sun and reported latency has been an issue for the past 2 - 3 years." He was sunburned, which he said occurred when he walked around all day while Union Gospel Mission was closed. He mentioned having a history of bipolar disorder and non-insulin-dependent diabetes. His blood glucose was 106. He responded nonsensically to a query about suicidality: "he endorsed SI and was asked what his plan for this was; he stated, 'Oh, by keeping not being accountable.' " Nursing staff opted to give him 5 mg. of olanzapine, which he accepted. However, his behavior became more altered than before the medication dose by one hour afterward. He became completely nonverbal.
He was transferred to HMC ED, where upon arrival, he opened eyes, follow complex commands, was able to say his name but did not respond to questioning. He was evaluated medically, then he was transferred to PES, where he slept until late evening. When he awoke, he came from his room holding his blanket in his arms in a fashion which the nurses took to be menacing. He did not cooperate with verbal redirection. He was placed in seclusion in his room. I spoke with him through the closed door. He made one verbal response and on two occasions he nodded to indicate his "yes/no" answer but otherwise he stood holding the blanket bunched up in his arms. I told him that I was concerned because his behavior with the blanket had scared the nurses and we want to keep everyone safe.
Mr. C has urinated on his blanket. He is malodorous, suggesting very poor self-care lately. He now is only able to comply at a very slow rate with one-step commands such as "Sit on your bed" and "Put the pill in your mouth." When a nurse tried to assist him by gently guiding his pill hand toward his mouth so we could give him an oral lorazepam dose, Mr. C demonstrated "gegenhalten" resistance to the guided motion.”
PAST PSYCHIATRIC HISTORY:
Per PES note July 13, Dr. Cashman
IP: Voluntary at Overlake 1/11/2012 - 1/17/2012 (1 week after went to Overlake ED following being found in a ditch confused and amnestic -- he'd been at the wheel.)
- ITA at Navos 1/21/2012 - 2/01/2012
OP: Has seen a Dr. Timmons in Bellevue in the past. Had an intake session 5/13/2015 at SeaMar but didn't go back.
Dx: Per patient, bipolar disorder. Per outside records, bipolar disorder with severe manic episode with psychotic features; cognitive disorder NOS.
SA: Unknown
Meds: risperidone, mirtazapine, quetiapine
Past scanned outside records indicate that on 12/05/2012 he mentioned to his primary physician concerns about memory loss and rage attacks.
SUBSTANCES:
Alcohol use: denies
Drug use: Denies.
Tobacco use: (+) Tobacco use.
PAST MEDICAL HISTORY:
1. NIDDM
2. s/p LLE DVT with pulmonary embolism 11/2008* -- has IVC filter, has been on anticoagulation
3. Hx of MVA 1/04/2012 -- found in a ditch confused and amnestic -- he'd been at the wheel.
4. obstructive sleep apnea, untreated
5. obesity
6. hypertension
ADMISSION MEDICATIONS:
Per past records, warfarin (likely d/c'd), glyburide, metformin.
ALLERGIES: penicillins
SOCIAL HISTORY: Per PES note July 13, Dr. Cashman
The patient used to work as a janitor, as a driver for a courier service, and as a newspaper delivery person. He and his wife separated in 2008. His daughter lives in Florida with his wife. He has a son. Per outside records, he was having more difficulty with depression 12/2012 after learning in 11/2012 that his son had been sexuallly abused by a family member.
Per inpatient psychiatry team
Pt reported that after his MVA, things for him were "like night and day." Denies being given a TBI diagnosis at the time. He endorses a hx of depression and anger prior to the accident but noted that he became less able to cope after the accident, lost his strength and became less talkative. Pt has struggled to maintain employment since then, as he is "just not able to perform like I used to."
FAMILY MEDICAL HISTORY:
Mother – depression, MI, dementia, Parkinson’s
Father – 2 strokes
Brother – PE, bipolar d/o
Son – age 10, healthy
ADMISSION EXAM: Per PES note July 13, Dr. Cashman
Mental Status Exam:
Appearance: disheveled, sunburned.
Behavior: responding to internal stimuli, uncooperative, bizarre, psychomotor retardation is present which occasionally "breaks" into sudden burst of motoric activity or a short utterance.
Speech: mute.
Thought Process: illogical, concrete, disorganized.
Thought Content: unable to assess.
Mood: bizarre, irregular.
Affect: flat.
Orientation: unable to assess.
Memory: unable to assess.
Insight/Judgment: grossly impaired.
Attention/Conc: unable to assess.
Symptom Review
Affective depressed mood, guilt/worthlessness, decreased interest, anhedonia, fatigue, anger, irritability, impulsivity, decreased need for sleep recently, per CDF report.
Anxiety somatic concerns.
Psychosis intrusive thoughts.
Cognitive confusion, memory problems, concentration problems.
ADMISSION PHYSICAL EXAM
Per ED Note 7/12, Alaro Lawson
Constitutional:
Well developed/well nourished.
Vital Signs : Vital Signs - ED
7/12/2015 15:46 SBP - Noninvasive 140 mmHg
DBP - Noninvasive 96 mmHg High
Heart Rate 103 bpm High
Respiratory Rate 16 br/min
SpO2 95 %
Temperature - C 37.9 degC High
Temperature Source Temporal Artery .
HENT: Moist mucous membranes.
Eyes: Pupils equal round reactive to light, extraocular movements intact.
Cardiovascular: Regular rate and rhythm, no murmur, rub or gallop.
Respiratory/Chest: Clear to auscultation bilaterally.
Gastrointestinal: Soft. Normal bowel sounds. Abdomen non-tender. Abdomen non-distended.
Musculoskeletal: Normal strength, tone and range of motion.
Neurologic: No focal deficits. Follows command.
Skin: face erythematous.
Psychiatric: not cooperative with interview.
RESULTS REVIEW:
7/12/2015 16:01 Na 131 mEq/L Low
K 3.5 mEq/L Low
Cl 97 mEq/L Low
CO2 23 mEq/L
Anion Gap 11
Glucose Level 139 mg/dL High
BUN 17 mg/dL
Creatinine 0.69 mg/dL
Ca 9.2 mg/dL
AST (GOT) 68 units/L High
ALT (GPT) 77 units/L High
Alk Phos (Total) 60 units/L
Bilirubin (Total) 0.7 mg/dL
Protein (Total) 7.3 g/dL
Albumin 3.9 g/dL
WBC 9.53 thousand/microL
RBC 4.64 million/microL
Hb 12.6 g/dL Low
HCT 37 % Low
MCV 80 fL Low
MCH 27.2 pg Low
MCHC 34.1 g/dL
PLT 138 thousand/microL Low
RDW-CV 14.2 %
% Neutrophils 77 %
% Lymphocytes 14 %
% Monocytes 9 %
% Eosinophils 0 %
% Basophils 0 %
% Immature Granulocytes 0 %
Neutrophils 7.29 thousand/microL High
Lymphocytes 1.35 thousand/microL
Monocytes 0.81 thousand/microL High
Eosinophils 0.03 thousand/microL
Basophils 0.02 thousand/microL
Immature Granulocytes 0.03 thousand/microL
Ethyl Alcohol LeveNegative mg/dL
7/12/2015 L-Lactate, Venous Whole Blood 1.2 mmol/L
MENTAL STATUS EXAM AT TIME OF ASSESSMENT: (per inpatient progress note, Caroline Pihl, 7/17)
Appearance: Older gentleman (looks older than age) with white hair and glasses, obese, in hospital clothing. Lethargic.
Attitude: Frustrated, flippant, sarcastic.
Activity: Bradykinetic, psychomotor retardation. No tremor. Wide shuffling gait.
Speech: Slow rate, increased latency, soft tone. Rarely spontaneous.
Mood: "special. could be better."
Affect: Dysthymic, angry, blunted. Constricted mobility. Reactive and responsive.
Thought process: linear
Thought content: Somewhat nihilistic. Fluctuating SI. No HI. Possible delusions of being on a terrorist list (or he used this as an expression of negativity about his situation, as he has with "send me to Timbuktu" and the "USSR").
Cognition: Grossly oriented.
Insight: Somewhat intact - recognizes that his life recently has been a "vicious circle" and that everytime he tries to do something good, something bad happens. Poor insight into his need for housing and the steps he will need to work on to progress toward leaving the hospital.
ASSESSMENT:
JC is a 52-year-old male with history of major depression, homelessness, and numerous medical comorbidities (DVT, PE, T2DM) who was transferred to the PES from DESC after presenting with altered cognitive function, severe latency of speech and severe psychomotor retardation on July 12. He has an unclear psychiatric history: self-reports a hx of bipolar disorder, but denies any historical symptoms of mania. Current records cannot confirm bipolar history. He describes a significant hx throughout his adult life of depressive and “angry” episodes. Following his divorce in 2008, he describes spending the majority of his time experiencing depressive symptoms including sad mood, anhedonia, feelings of guilt regarding his son, psychomotor retardation and suicidal ideation. This qualifies him for a diagnosis of major depression. His exacerbation of symptoms in the last few weeks is suggestive of a major depressive exacerbation on top of chronic depression. In terms of the possibility of mania, pt denies any time when he experienced decreased need for sleep, increased energy, grandiosity, or when he took on numerous, new pleasurable activities. Based on our current understanding and the information we have been able to gather, we cannot substantiate a diagnosis of bipolar disorder – either I or II. JC’s psychiatric history of the last 3 years has been likely complicated by cognitive dysfunction secondary to TBI from a MVA in Jan 2012. Since that time, his sister reports numerous episodes of bizarre and sometimes aggressive behavior (wandering outside in the snow with his pants at his ankles, barbecuing in the middle of winter, dismantling furniture and “wrecking” her basement, altercations with his brother). However, even in these episodes, there is no clear history of decreased need for sleep, being pressured and talkative, or engaging in high risk, pleasurable activities. As such, these “bizarre” behaviors seem more in line with cognitive dysfunction or the psychosis of a MDE. These activities have led to numerous inpatient psychiatric hospitalizations, during which he has consistently been diagnosed with cognitive dysfunction. Initiated treatments from these stays include risperidone, quetiapine and mirtazapine. His most recent psychiatric stay was from June 16 to July 9, 2015, for acute delirium and continued cognitive deficits. He has also experienced seizures since the time of his MVA. Only 3 days after being discharged, JC presented to the crisis center at DESC dehydrated, disoriented, and with significant psychomotor retardation, leading to his presentation at the PES.
Pt presented to the inpatient team with a high suspicion for catatonia, given his psychomotor retardation and significantly increased latency of speech. Using the Bush-Francis Catatonia scale, our exam revealed a score of 15 out of 23: immobility/stupor (2), mutism (2), staring (1), posturing (2), automatic obedience (1), gegenhalten (3), ambitendency (3), and autonomic abnormality (1). The Bush-Francis Catatonia Screen revealed a positive screen based on: abnormal movements and speech, ambitendence and automatic obedience. Pt reported that these symptoms of being “stuck” developed in the last two weeks, which helps us rule out a baseline of psychomotor retardation and latency of speech secondary to cognitive dysfunction. In terms of the associated diagnosis that relates to this patient’s catatonia, his worsening symptoms of depression suggest that mood disorder may be contributory. However, he also has a complicated medical history, so we cannot entirely rule out catatonia due to an organic medical condition. He did present with abnormal electrolytes, including hyponatremia (131), hypokalemia (3.4) and hypochloremia (97) – but these could be associated with poor nutrition and hydration status at presentation. Even if not the main etiology associated with his catatonia, electrolyte imbalances could certainly be contributory. His utox was negative on admission, most likely ruling out a drug-induced catatonia. Cursory evaluation in the ED did not reveal a significant acute medical condition that we should be concerned with at this time. Given his history of DVT and PE, as well as poorly controlled T2DM, pt should be monitored carefully for any continued changes in vital signs or labs.
JC’s diagnosis of major depression with catatonia is complicated by his uncertain history of cognitive disorder. He reports a significant decline in his level of function after the MVA, including poor self-control, seizures, and social and employment disturbance. This time course was supported by collateral from pt’s sister. Despite benign CT imaging at the time, his symptoms since the accident are highly suggestive of a TBI. Furthermore, mild TBI has not been associated with abnormal imaging, despite often causing significant and persistent cognitive dysfunction.[1] It is plausible that this TBI has contributed to JC’s exacerbations of mood disturbance. Prospective observational studies have found a significant association between depression and TBI patients.[2] Rather than splitting all of JC’s possible etiologies of catatonia and cognitive disturbance, it may be more productive in terms of initial treatment plan to consider JC as a patient with cumulative neurophysiological insults. First, a family history of depression, Parkinson’s and dementia that is concerning for underlying genetic susceptibility. Hagemeyer et al in 2012 discovered a linkage between a myelin gene, CNP, and susceptibility to a catatonia-depression syndrome.[3] In this study, aging acted as a “pro-inflammatory hit” that exacerbated reduced expression of CNP. The combination of genetic predisposition and this second aging-related hit were shown to amplify psychiatric disease. JC has a history suggesting chronic depression prior to his accident, making him even more susceptible to further neurophysiologic insult upon TBI.
Catatonia can be a presenting symptom for frontotemporal dementia.[4] This pt fits the age criteria at-risk for FTD. He is at increased risk for FTD because of his family history of dementia and his own personal psychiatric history with depression.[5] While he does seem to show signs of apathy, he does not express the hyperorality or disinhibition classically associated with FTD. This may be interesting to look into further with JC and back up with any collateral history, as a number of case studies have shown some association between catatonia and the frontotemporal atrophy found in FTD.[6] Beyond simply FTD, his TBI history puts him at increased risk for any early-onset dementia. Washington et al have proposed a simplified system for considering all of the cognitive changes that may occur after a TBI: rather than searching for distinct neurodegenerative etiologies, traumatic encephalopathy can be thought of as all of the cumulative pathologies in the brain following a TBI.[7] This might be the most plausible way of approaching JC’s diagnosis. Rather than parsing out cognitive dysfunction from major depression with catatonia from TBI, at this time, we may need to approach JC as experiencing a traumatic encephalopathy with risk factors for continued major depression and dementia that should be closely monitored after resolving his catatonia.