Case 1:: Rule in Rule Out
Case 1:: Rule in Rule Out
Case 1:: Rule in Rule Out
Case 2
52 year old businessman, admitted at the ICU of Lung Center.
He had severe pneumonia and had to be intubated. He was sedated with Diazepam 10 mg at
bedtime. He was mostly asleep, however upon waking up he became agitated and started to
pull everything out from his body.
He claimed that his business associates were out to kill him. He pulled out his IV, and his
ET tube. He was also maintained on levofloxacin 750mg / IV every 24 hours. He is referred to a
psychiatrist for the management of his agitation. His wife denies any psychiatric illness but has
noted that her husband has shown depressed mood, initial insomnia and loss of appetite for
3 weeks.
1. What are the possible causes of his agitation?
● Pneumonia
○ Severe pneumonia can lead to serious complications such as agitation.
● Diazepam 10 mg
○ Taking too much of this drug can cause depression of your central nervous
system (CNS). Symptoms include: drowsiness. confusion.
● Mental Disorder (MDD)
○ The patient show depressed mood, initial insomnia and loss of appetite
2. Does he have a mental disorder? If yes, how does his pneumonia or the management of
his pneumonia affect his mental disorder?
● Yes.
● The hospitalization for pneumonia increased the risk of subsequent depression,
functional disability and cognitive impairment.
● Pneumonia patients with DD were associated with poor treatment outcomes
compared to patients without DD.
3. How does or how can his mental disorder affect his medical illness?
● One reason for the increase in severity of respiratory diseases in people with mental
health conditions: they are less likely to seek care for their physical health.
● People with mental disorders can also develop unhealthy habits that can play a role in
increasing disease severity.
● Mental disorders can make dealing with medical illnesses more difficult.
Case 3
A 48 year old female diabetic, hypertensive with end stage renal disease has been on
hemodialysis 3 times a week for 2 years. She had often lamented how tired she was of
going for hemodialysis 3 times a week. A kidney donor that was a perfect match was found
and she was scheduled for a kidney transplant. During the preparation for her transplant, she
developed initial insomnia, became agitated and kept asking her doctor and her family if they
can reassure her of the success of her transplant. She was worried she might die on the
operating table or might have postoperative complications that will make her condition worse.
2 days before her operation she wanted to back out prompting the consult.
1. 1. Why did the patient change her mind? Does she have a mental illness? If no, what is
the explanation for her behavior?
● No???? The patient might have pre-operative anxiety or surgical fear in which
she has an uncomfortable, tense and unpleasant mood prior to surgery. This is
an emotional state resulting from anticipation of a threatening event by patients
waiting for surgery.
● Her anxiety might be coming from the fear of the surgery itself, not waking up
after anesthesia, loss of control, and/or the possible complications after surgery.
2. If she does have a mental illness what is it and how will you manage it?
● Adjustment Disorder with anxiety OR with mixed anxiety and depressed mood
(not sure!)
○ Adjustment disorders are characterized by an emotional response to a
stressful event. Stressor involves financial issues, a medical illness, or
relationship problems.(Kaplan)
○ Adjustment disorders are one of the most common psychiatric diagnoses
for disorders of patients hospitalized for medical and surgical problems.
(Kaplan)
○ The development of emotional or behavioral symptoms in response to an
identifiable stressor(s) occurring within 3 months of the onset of the
stressor(s). (DSM-5)
○ Adjustment disorders can be diagnosed immediately and persist up to 6
months after exposure to the traumatic event. (DSM-5)
○ Management:(Kaplan)
■ Psychotherapy - treatment of choice
■ Crisis Intervention - short-term treaments aimed at helping
persons with adjustment disorders resolve their situations quickly
by supportive techniques, suggestion, reassurance, environmental
modification, and even hospitalization, if necessary
■ Pharmacotherapy - no studies have assessed the efficacy of
pharmacological interventions, but it may be reasonable to use
medication to treat specific symptoms for a brief time.
■ Severe anxiety bordering on panic: anxiolytics
■ Withdrawn or inhibited states: psychostimulant medication
■ Antidepressants
ADJUSTMENT DISORDER
● Insomnia
● Being anxious or agitated (anxiety)
● Feeling depressed???- She had often
lamented how tired she was of
going for hemodialysis 3 times a
week.
● Reassurance seeking - anxiety
● Women are diagnosed with the
disorder twice as often as men
Case 4
Patient is a 34 year old male, married, admitted because of recurrent abdominal pain,
weight loss, easy fatigability, and jaundice. Diagnostics were done which included abdominal
ultrasound, blood chemistry, and fine needle biopsy. The diagnosis of pancreatic cancer was
not disclosed to the patient and his family. Patient was informed by the 1st year resident that
he needs to have chemotherapy. Patient became agitated and refused chemotherapy.
Patient was then referred to psychiatry for evaluation and management of agitation.
1. What are the possible differential diagnoses for the patient's agitation?
○ Depressive Disorder due to another Medical Condition
■ Researchers have long noted that depression and anxiety are common in
pancreatic cancer patients. When patients with newly diagnosed
advanced gastric or pancreatic cancer were assessed for depression, the
patients with pancreatic cancer were found to have a greater incidence of
depression and related symptoms, which can contribute to a lower quality
of life.
■ Depression is a common symptom of pancreatic cancer, with some early
data suggesting that the mood disturbance is mediated by alteration of
brain serotonergic function through proinflammatory cytokines
○ Anxiety Disorder
■ It is also common in pancreatic cancer patients with a high prevalence
rate of 68% alongside depression. Practitioners often think that this is a
normal condition since it is common but any excessive feeling is not
normal which can lead to impaired functioning and increase intensity of
symptoms and distortion of perception
■ DSM - 5 Panic Disorder
1. Recurrent unexpected panic attacks
2. A panic attack is an abrupt surge of intense fear or intense
discomfort that reaches a peak within minutes, and during which
time four (or more) of the following symptoms occur;
3. Note: The abrupt surge can occur from a calm state or an anxious
state.
○ Acute Stress Disorder
■
3. What should the psychiatrist do in this situation? What steps should be done to help both
the patient and the consultee?
○ Psychiatric Care
■ Offer expert diagnosis and management of comorbid psychiatric
conditions
■ Collaborated with oncologist on psychiatric conditions that get in the way
of oncologic care
■ Recognize and manage cancer-related or cancer-treatment-related
neuropsychiatric syndromes
■ Help patient and their families cope with the different phases of cancer
diagnosis and treatment
■ Facilitate the patient’s strengths and adaptive capacity
■ Bolster the patient’s outside resources
○ Psychiatric liaison
■ Speak directly with the referring clinician
1. Resident to resident / consultant to consultant
■ Review the current records and pertinent past records.
■ Review the patient’s medications.
■ Gather collateral data.
■ Ask if the patient knows that he/she is referred to a psychiatrist.
■ Interview and examine the patient.
■ Formulate diagnostic and therapeutic strategies.
■ Write a note.
■ Speak directly with the referring