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CASE 47: BIPOLAR DISORDER
By Ryan Raroque
Bipolar Disorder Spectrum
Chief Complaints
Older sister says: “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.”
History of Present Illness 31-year-old female
named B.J. brought to the hospital by ambulance
Found slumped over in a car in front of funeral home
Two empty bottles of sleeping pills and a Bible opened to the 23rd Psalm found on the seat beside her
Left a suicide note Funeral home
director discovered her with her hair oily and unkempt
Seemed like she hadn’t bathed in a long time
Past Medical History
Episodes of depression first occurred as a junior in high school
Admitted to psychiatric ward at age 15 and 19
Met her first husband in psych ward at age 19 following a suicide attempt
Patient was treated with antidepressants and psychotherapy and discharged on both occassions after approximately 5 weeks
Interview with Patient’s Older Sister Parents were both
alcoholics State took kids
away and sent them to foster homes
Some kids were beaten or sexually abused
Interview with Patient’s Older Sister
B.J. has been in several detoxification centers for alcohol abuse
Is in her second marriage
Has three daughters
Interview with Patient’s Older Sister B.J. was diagnosed with BD about six years
ago Fell into a terrible depression after giving
birth to her third child Responded negatively to antidepressants
“She told me that movie stars were talking to her whenever she went to the movies”
“Her speech became impossible to understand” “She would stay up all night and just pace about
the house”
Interview with Patient’s Older Sister Doctors initially thought she had a thyroid
condition, but it turned out to be BD B.J. would sometimes call her at 3 AM to
talk Cycled between being hostile/sarcastic and
apologetic Rambled and “preached” about random topics
Family tried to convince her she needed help, but she believed she was absolutely fine
Interview with Patient’s Older Sister According to B.J.: “You’re all just jealous
because I’m finally happy and feeling good about myself” Went on shopping sprees 2-3 days at a
time and max out her credit cards Family tried to tell her that this was
dangerous behavior but she wouldn’t listen When she finally “crashed,” she was
taken to the hospital and diagnosed with BD
Interview with Patient’s Older Sister Had been taking lithium ever since and
was fine until recently Death of parents marked the beginning
of a downward spiral Had been losing a lot of weight Was drinking and smoking more than
usual
Family History
Strong history of mental illness – paternal grandmother suffered from depression; two maternal aunts diagnosed with bipolar disorder
Both parents have died – her father from pancreatic cancer that had metastasized to bone and her mother from heart failure
Both parents had a long history of alcohol abuse Father was previously diagnosed with pancreatitis and then
diabetes mellitus for which he had been taking insulin Mother had been relatively well (except for a “smoker’s cough”)
with few serious medical problems until her husband’s death; some said that she “died from a broken heart”
Patient has 3 living brothers, 3 living sisters, and 3 daughters One brother died from AMI at age 34; another brother died at 6
moths from “water on the brain”
Social History
Divorced and remarried Has worked primarily as a nurse’s aide
and more, recently, as a health insurance claims adjuster
Is religious and goes to church regularly Has smoked 1 ppd for nearly 15 years Has history of alcohol abuse with several
Driving While Intoxicated violations History of IVDA but has not used for
more than 10 years
Medications
Lithium 600 mg po Q AM and 600 mg po Q HS
Sumatriptan 50-200 mg po PRN
ASA -> Swelling of face
Migraine headaches, 2-3/month
(-) for aura but (+) for nausea, vomiting, and photophobia
Allergies Review of Systems
Performed three hours after gaining consciousness
Patient is tired-looking, white female in NAD
Very pale “Dark rings”
under her eyes
PE and Lab Tests Gen
Vital Signs
BP 110/72 (supine)
RR 16 and unlabored
HT/WT 5’6’’/135 lbs
P 81 and regular
T 98.6 °F
SaO2 97% on room air
Patient Case Questions
Are any of the patient’s vital signs significantly abnormal?
Why has the patient been taking sumatriptan as needed?
Identify this patient’s two most significant risk factors for bipolar disorder.
Identify two additional potential contributing factors to bipolar disorder in this patient.
Patient Case Questions
Are any of the patient’s vital signs significantly abnormal?
Why has the patient been taking sumatriptan as needed?
Identify this patient’s two most significant risk factors for bipolar disorder.
Identify two additional potential contributing factors to bipolar disorder in this patient.
Vital Signs
BP 110/72 (supine)
RR 16 and unlabored
HT/WT 5’6’’/135 lbs
P 81 and regular
T 98.6 °F
SaO2 97% on room air
Vital Signs
BP 110/72 (supine)
RR 16 and unlabored
HT/WT 5’6’’/135 lbs
P 81 and regular
T 98.6 °F
SaO2 97% on room air
Patient Case Questions
Are any of the patient’s vital signs significantly abnormal?
Why has the patient been taking sumatriptan as needed?
Identify this patient’s two most significant risk factors for bipolar disorder.
Identify two additional potential contributing factors to bipolar disorder in this patient.
ASA -> Swelling of face
Migraine headaches, 2-3/month
(-) for aura but (+) for nausea, vomiting, and photophobia
Allergies Review of Systems
ASA -> Swelling of face
Migraine headaches, 2-3/month
(-) for aura but (+) for nausea, vomiting, and photophobia
Allergies Review of Systems
Patient Case Questions
Are any of the patient’s vital signs significantly abnormal?
Why has the patient been taking sumatriptan as needed?
Identify this patient’s two most significant risk factors for bipolar disorder.
Identify two additional potential contributing factors to bipolar disorder in this patient.
Significant Risk Factors
Significant Risk Factors
Significant Risk Factors
Genetics Environment
Patient Case Questions
Are any of the patient’s vital signs significantly abnormal?
Why has the patient been taking sumatriptan as needed?
Identify this patient’s two most significant risk factors for bipolar disorder.
Identify two additional potential contributing factors to bipolar disorder in this patient.
Skin
Comedones on forehead, nose, and chin with several cystic lesions on chin
Normal turgor Soft, intact, warm,
dry, and very pale No evidence of rash,
ecchymoses, petechiae, or cyanosis
Head Normocephalic and
atraumatic Eyes
PERRLA EOMI Funduscopy revealed
normal, clear disc margins without lesions
(-) nystagmus
Ears TMs intact
Nose (-) discharge or
congestion Throat
(-) exudates or erythema
Dry mucous membranes
Neck Supple No enlarged nodes,
thyromegaly, bruits, or jugular venous distention
Heart RRR S1 and S2 normal
without additional cardiac sounds
Lungs CTA & P bilaterally
Abd (+) BS (-) pain or tenderness Soft and non-
distended (-) hepatomegaly,
splenomegaly, masses, bruits
Breasts Exam deferred
Genit/Rect Exam deferred
MS/Ext Full ROM Distal pulses normal
at 2+ bilaterally (-) edema, cyanosis,
clubbing No joint swelling or
tenderness
Neuro Slightly lethargic but
oriented to person, place, and time
Deep tendon reflexes full and symmetric
Babinski negative bilaterially
Normal strength throughout
Sensation intact CNs II-XII intact Speech: No
dysarthria, rate normal
Neuro (contd) Gross and fine motor
coordination are normal Cerebellar: finger-to-
nose and heel-to-shin WNL
Able to toe and tandem walk without difficulty
Gait normal in speed and step length
Able to perform serial 7s and can abstract
Short and long-term memories intact
Case Questions
Does this patient have any signs of abnormal renal function?
Does this patient have any signs of abnormal hepatic function?
Case Questions
Does this patient have any signs of abnormal renal function?
Does this patient have any signs of abnormal hepatic function?
Patient Case Table 47.2 Laboratory Blood Test Results
Na 139 meq/L
MCV 90.2 fl
Bilirubin, total 0.7 mg/dL
K 3.7 meq/L
MCH 31 pg
Alb 2.9 g/dL
Cl 108 meq/L
MCHC 34.4 g/dL
Protein, total 4.8g/dL
HCO3 23 meq/L
Plt 150,000/mm3
Ca 8.7 mg/dL
BUN 10 mg/dL
WBC 9,400/mm3
Mg 2.0 mg/dL
Cr 0.7 mg/dL
Diff • Neutros 65% • Lymphs 25% • Monos 7% • Eos 2% • Basos 1%
Lithium 0.08 meq/L
Steady-state serum lithium concentrations should always be maintained at a concentration of 0.6-1.2 meq/L
Glu, fasting 102 mg/dL
AST 33 IU/L
Phos 3.2 mg/dL
Hb 12.2 g/dL
ALT 20 IU/L
TSH 4.1 µU/mL
Hct 36.8%
Alk Phos 59 IU/L
Cortisol @ 8AM 9.3µg/dL
RBC 4.73 x 106/mm3
GGT 82 IU/L
Vitamin B12 203 pg/mL
Patient Case Table 47.2 Laboratory Blood Test Results
Na 139 meq/L
MCV 90.2 fl
Bilirubin, total 0.7 mg/dL
K 3.7 meq/L
MCH 31 pg
Alb 2.9 g/dL
Cl 108 meq/L
MCHC 34.4 g/dL
Protein, total 4.8g/dL
HCO3 23 meq/L
Plt 150,000/mm3
Ca 8.7 mg/dL
BUN 10 mg/dL
WBC 9,400/mm3
Mg 2.0 mg/dL
Cr 0.7 mg/dL
Diff • Neutros 65% • Lymphs 25% • Monos 7% • Eos 2% • Basos 1%
Lithium 0.08 meq/L
Steady-state serum lithium concentrations should always be maintained at a concentration of 0.6-1.2 meq/L
Glu, fasting 102 mg/dL
AST 33 IU/L
Phos 3.2 mg/dL
Hb 12.2 g/dL
ALT 20 IU/L
TSH 4.1 µU/mL
Hct 36.8%
Alk Phos 59 IU/L
Cortisol @ 8AM 9.3µg/dL
RBC 4.73 x 106/mm3
GGT 82 IU/L
Vitamin B12 203 pg/mL
According to the National Institute of Health, a normal BUN value is between 6-20mg/dL.
A normal Cr is between 0.6 and 1.1 mg/dL for women.
Case Questions
Does this patient have any signs of abnormal renal function?
Does this patient have any signs of abnormal hepatic function?
Patient Case Table 47.2 Laboratory Blood Test Results
Na 139 meq/L
MCV 90.2 fl
Bilirubin, total 0.7 mg/dL
K 3.7 meq/L
MCH 31 pg
Alb 2.9 g/dL
Cl 108 meq/L
MCHC 34.4 g/dL
Protein, total 4.8g/dL
HCO3 23 meq/L
Plt 150,000/mm3
Ca 8.7 mg/dL
BUN 10 mg/dL
WBC 9,400/mm3
Mg 2.0 mg/dL
Cr 0.7 mg/dL
Diff • Neutros 65% • Lymphs 25% • Monos 7% • Eos 2% • Basos 1%
Lithium 0.08 meq/L
Steady-state serum lithium concentrations should always be maintained at a concentration of 0.6-1.2 meq/L
Glu, fasting 102 mg/dL
AST 33 IU/L
Phos 3.2 mg/dL
Hb 12.2 g/dL
ALT 20 IU/L
TSH 4.1 µU/mL
Hct 36.8%
Alk Phos 59 IU/L
Cortisol @ 8AM 9.3µg/dL
RBC 4.73 x 106/mm3
GGT 82 IU/L
Vitamin B12 203 pg/mL
Normal ranges according to NIH:
Bilirubin: 0.3 to 1.9 mg/dLAlbumin: 3.4 - 5.4 g/dL
AST: 10 to 34 IU/L.ALT: 10 to 40 IU/LAlk Phos: 44 to 147 IU/LGGT: 0 to 51 IU/L
Patient Case Table 47.2 Laboratory Blood Test Results
Na 139 meq/L
MCV 90.2 fl
Bilirubin, total 0.7 mg/dL
K 3.7 meq/L
MCH 31 pg
Alb 2.9 g/dL
Cl 108 meq/L
MCHC 34.4 g/dL
Protein, total 4.8g/dL
HCO3 23 meq/L
Plt 150,000/mm3
Ca 8.7 mg/dL
BUN 10 mg/dL
WBC 9,400/mm3
Mg 2.0 mg/dL
Cr 0.7 mg/dL
Diff • Neutros 65% • Lymphs 25% • Monos 7% • Eos 2% • Basos 1%
Lithium 0.08 meq/L
Steady-state serum lithium concentrations should always be maintained at a concentration of 0.6-1.2 meq/L
Glu, fasting 102 mg/dL
AST 33 IU/L
Phos 3.2 mg/dL
Hb 12.2 g/dL
ALT 20 IU/L
TSH 4.1 µU/mL
Hct 36.8%
Alk Phos 59 IU/L
Cortisol @ 8AM 9.3µg/dL
RBC 4.73 x 106/mm3
GGT 82 IU/L
Vitamin B12 203 pg/mL
Normal ranges according to NIH:
Bilirubin: 0.3 to 1.9 mg/dLAlbumin: 3.4 - 5.4 g/dL
AST: 10 to 34 IU/L.ALT: 10 to 40 IU/LAlk Phos: 44 to 147 IU/LGGT: 0 to 51 IU/L
Case Questions
Identify this patient’s three most significant abnormal blood laboratory test results and propose a reasonable explanation for these results.
What is suggested by the patient’s serum TSH, cortisol, and vitamin B12 concentrations?
Case Questions
Identify this patient’s three most significant abnormal blood laboratory test results and propose a reasonable explanation for these results.
What is suggested by the patient’s serum TSH, cortisol, and vitamin B12 concentrations?
Abnormal Blood Test Results Less-than-normal albumin levels
Elevated GGT
Lithium concentration in serum below steady-state levels
Lithium 0.08 meq/L
Steady-state serum lithium concentrations should always be maintained at a concentration of 0.6-1.2 meq/L
Case Questions
Identify this patient’s three most significant abnormal blood laboratory test results and propose a reasonable explanation for these results.
What is suggested by the patient’s serum TSH, cortisol, and vitamin B12 concentrations?
Patient Case Table 47.2 Laboratory Blood Test Results
Na 139 meq/L
MCV 90.2 fl
Bilirubin, total 0.7 mg/dL
K 3.7 meq/L
MCH 31 pg
Alb 2.9 g/dL
Cl 108 meq/L
MCHC 34.4 g/dL
Protein, total 4.8g/dL
HCO3 23 meq/L
Plt 150,000/mm3
Ca 8.7 mg/dL
BUN 10 mg/dL
WBC 9,400/mm3
Mg 2.0 mg/dL
Cr 0.7 mg/dL
Diff • Neutros 65% • Lymphs 25% • Monos 7% • Eos 2% • Basos 1%
Lithium 0.08 meq/L
Steady-state serum lithium concentrations should always be maintained at a concentration of 0.6-1.2 meq/L
Glu, fasting 102 mg/dL
AST 33 IU/L
Phos 3.2 mg/dL
Hb 12.2 g/dL
ALT 20 IU/L
TSH 4.1 µU/mL
Hct 36.8%
Alk Phos 59 IU/L
Cortisol @ 8AM 9.3µg/dL
RBC 4.73 x 106/mm3
GGT 82 IU/L
Vitamin B12 203 pg/mL
Patient Case Table 47.3 Urinalysis
Color Yellow
SG 1.021
Appearance Cloudy
Blood Negative
Glucose Negative
pH 6.3
Bilirubin Negative
Protein Negative
Ketones Negative
Nitrites Negative
Case Questions
List a minimum of eight clinical manifestations observed in this patient that were helpful toward an initial diagnosis of bipolar disorder.
Identify all signs of brain damage that may have occurred from the patient’s most recent suicide attempt.
Case Questions
List a minimum of eight clinical manifestations observed in this patient that were helpful toward an initial diagnosis of bipolar disorder.
Identify all signs of brain damage that may have occurred from the patient’s most recent suicide attempt.
Clinical Manifestations
Clinical Manifestations
Feature Assessed Major Depressive Episode
Major Manic Episode
Appearance Talks fast
Movement Hyperactive and restless
Affect/Mood SadnessHelplessnessHopelessnessIsolationEmptiness
Inappropriately joyous, elated, jubilant
Thought Rapid shifting of ideas
Perceptions Hallucinations
Suicide Attempted it once before
Aggression No patience or tolerance for others
Judgment Poor financial investments, doesn’t listen to advice, poor insight on behavior
Case Questions
List a minimum of eight clinical manifestations observed in this patient that were helpful toward an initial diagnosis of bipolar disorder.
Identify all signs of brain damage that may have occurred from the patient’s most recent suicide attempt.
Signs of Brain Damage
Neurological exam turned out fine Migraine
headaches, 2-3/month
(-) for aura but (+) for nausea, vomiting, and photophobia
Review of Systems
Case Questions
Does the patient in this case study require inpatient treatment or is outpatient therapy totally appropriate?
Do you think that the prognosis for this patient is favorable or less than favorable?
Case Questions
Does the patient in this case study require inpatient treatment or is outpatient therapy totally appropriate?
Do you think that the prognosis for this patient is favorable or less than favorable?
Case Questions
Does the patient in this case study require inpatient treatment or is outpatient therapy totally appropriate?
Do you think that the prognosis for this patient is favorable or less than favorable?
Prognosis
Late age of onset Few thoughts of
suicide Few psychotic
symptoms Few medical
problems
Poor job history Alcohol abuse Psychotic features Early age of onset Complications: poor
judgment and decision making, substance abuse, risky behaviors
Favorable Less Than Favorable