Leanne is a 55-year old, Caucasian woman currently admitted in hospital under General Surgery for obstipation (large bowel obstruction). Evaluation has been requested regarding hypomanic symptoms (October 2003).
Leanne lives alone in a London apartment on a disability pension and now describes having had a 2-3 week history of abdominal pain, distention, nausea, vomiting, and obstipation. In hospital she is being managed conservatively with IV fluids, n.p.o. and enemas.
She admits she has been non-compliant with her oral medications including Lithium, Cogentin (benztropine), and L-thyroxine. She has not taken them for 2 weeks. She claims she had been feeling well. did not wish to be medication dependent, and thought that she could cope well without them. She did have her intramuscular injection of fluphenazine decanoate in June, 1995 while being evaluated in the ER for abdominal pain.
Since stopping her medications, she has not done well. She complains of hearing a female voice calling her a "she devil". She explains that she is constantly seeing series of numbers dancing in a party. She has difficulty thinking clearly. She describes not being able to do her activities of daily living, including washing, cooking, shopping. She says "I just cannot cope".
She describes her mood as being both up and down. Currently, she says she is manic. She notices she has had only 2-3 hours of sleep for the last nine days and feels well rested in the morning. She notices that she is more talkative than usual and that her thoughts are racing. She denies suicidal or homicidal ideation. She recognizes that her physical illness, having stopped her medications, and some recent alcohol use have all impacted on her psychiatric condition. She describes having a 40-year history of paranoid schizophrenia and a 20-year history of bipolar affective disorder. Her last admission to a psychiatric ward in London was 1980.
Her medications include Fluphenazine decanoate (18 mg q2 weeks). Her last dose was given intramuscularly in June 1995; Lithium (900 mg p.o. o.d. (currently on hold); Cogentin (0.5 mg p.o. o.d. (currently on hold); L-thyroxine 0.1 mg p.o. o.d. (currently on hold). In hospital she has received the following medications: Demerol (50-75 mg i.m. q4h p.r.n.); Gravol (50 mg i.m.q4h p.r.n.); Lorazepam (1 mg sublingual q.h.s. p.r.n.).
Leanne has allergies to penicillin, amoxicillin and Septra. She had a cholecystectomy in 1990 (laparoscopic tubal ligation). She smokes one pack per day and drinks alcohol, 3-4 drinks per week. She denies using street drugs.
She was born in London and had one adopted brother. She describes having had a happy childhood. She remembers getting mentally ill at "around 15 years of age". She did manage to finish her high school education. She took one retail course after graduating and did some work in retail. She describes having been promiscuous throughout her youth. Her mother is demented and being cared for in a nursing home. Leanne has declining social support. She has little contact with her brother and her father is deceased. She has had several convictions for petty theft for which she has paid fines in lieu of a prison sentence. What few friends she has remaining, have been recently ignoring her. She has poor financial status.
On mental status examination, the psychiatrist wrote: "This is a middle age woman that looks slightly older than her stated age. She has short hair that is dyed peroxide blonde with the roots showing. She has cigarette stains on her fingers. She is wearing a hospital gown and generally looks unkempt. She is cooperative and maintains good eye contact. Speech is pressured. At times she is very loud and boisterous, and at other times speaks in a barely audible whisper as if she is concerned that others might hear what she has to say. There were no other people in the room. Her mood is described as "manic". Her affect is very labile. She cried 3-4 times during the interview and within seconds became composed and quite jubilant. Her thought form is at limes tangential and she displays flight of ideas and some loosening. She denies suicidal and homicidal thoughts but ruminates about being "mentally unwell". She is awake, alert, and well-oriented. There is some decrease in her concentration ability and short term memory. Her insight is impaired. She has trouble recognizing that she has been admitted for bowel obstruction."
"This woman has an apparent history of schizophrenia and bipolar affective disease who is admitted currently with large bowel obstruction. She is currently psychotic having visual and auditory hallucinations. She also manifests manic symptoms. This worsening in her psychiatric condition is likely secondary to her voluntary and involuntary non-compliance with medication, alcohol and her recent medical illness. There is also a possibility that her neuroleptic might have played a role in her bowel obstruction."
The Psychiatry Consultation Team's recommendations are:
1. to continue conservative management for her bowel obstruction; 2. re-start her Lithium, Cogentin, and L-thyroxine when she is able to take medications orally; 3. use Ativan 1 mg q12h sublingual or imramuscularly p.r.n. for agitation and insomnia; 4. the Psychiatry Team will follow her during her hospitalization in order to assess whether or not her current mania will delay her discharge.
Some PCL Learning Issues for January 19
* How is a patient's competence determined in regard to: a) understanding and complying with treatment; b) personal care; and c) financial status? * Is there a relationship between creativity and mental illness? * Discuss placement of mentally-ill patients unable to care for themselves. * Discuss physician (or healthcare) paternalism and conflicts with patient autonomy. Consider scenarios and resolutions in psychiatry, palliative care, patient lifestyle.