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MFAC 3503 PSYCHIATRYWRITTEN CASE HISTORY

Student no. z3167924Word count: 1800(excludes headings, in-text citation, tables and references)

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Demographics

Mrs P.J is a 52 year old Caucasian divorcee that have recently moved from Queensland

to Sydney to spend time with her mum who is dying due to lung cancer that was

diagnosed 4 years ago. According to her brother, although she is unemployed at the

moment, she is living well on her savings from her previously successful business.

Interviews and observations were carried out during her admission to kiloh general

ward. A collateral history was also obtained through a phone call to her brother.

History

History of presenting complaint

Mrs P.J was brought into acute kiloh ward by the ambulance after her brother who was

concerned of her wellbeing called the acute care team. Collateral history from her

brother revealed that Mrs P.J has been experiencing worsening mood ever since she

moved from Queensland to Sydney to spend time with her mother who was dying from

lung cancer. For the past 6 months, she has experienced multiple episodes of suicidal

thoughts followed by an occasion when she had an attempted suicide by swimming out

into the ocean.

During her stay at Kiloh observation ward, her insomnia did not improve mood was

resistant to treatment with Diothiepin. She continued to complain of decreased appetite

resulting in low energy levels and unmotivated to do anything. She also reported of an

overwhelming sense of hopelessness and worthlessness since the start of her divorce 4

years ago. She also became agitated and tried to abscond from the wards when she was

not discharged according to her will.

Past psychiatric illness

- Declines any past psychiatric illness

- Her past medical records from Queensland Hospital reports of several suicidal

ideations since the age of 16 years old.

Legal issues

- No forensic history

Drug and alcohol history

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- Declines any use of any illegal drugs.

- Smoked for 20 pack years

- Denies any alcohol abuse or dependence

Family medical/mental history- Mother is dying of lung cancer.

- No other known medical or mental history

Medical history

- Declines any known or significant medical conditions.

Drugs and Allergies

- No known drug allergies

Past medications

- Antidepressants: Diothiepin

Current medications

Mrs P.J declines being on any medications, despite evidence from medical notes

describing that she was administered with the following medications:

- Anxiolytic: Midazolam

- Antidepressants: Diothiepin

- Antipsychotics: Quetiapine

Developmental and personal history

Mrs P.J was born in Canberra. She had a good childhood and enjoyable teenage years.

However during young adulthood, she describes to have increasing difficulties in

relationships. Although she was married to her boyfriend of 5 years, she reports of

having difficulties from the start of the relationship which led to the separation 4 years

ago.

Current functioning and supports

She has stopped worked for 10 years. She used to run a successful fitness business

many years ago and is able to support herself and owns a property.

Have very little emotional support apart from her brother. She is distressed about her

recent divorce and her mums state of lung cancer.

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Mental state examination

Appearance & Behaviour

My first impression of Mr PJ is that she is relatively well groomed and casuallydressed. During the interview, she only established eye contact intermittently. Overall,

she was very withdrawn providing very short answers which proved to be very

uncooperative.

Speech

She had a slurred speech.

Mood

Her mood was depressed throughout the interview.

Affect

Her affect was inappropriate (E.g. She was laughing when she said she smelt like

faeces)

Thought form

There was poverty of thought throughout her interview as reflected by her lack of

responses.

Thought content

She has no auditory or visual hallucinations. She reports of olfactory delusions as she

describes herselfas smelling foul and that other people thinks that she is foul despite

providing evidence that she doesnt. In addition, she also complained of nihilistic

thoughts of herself being made up of rubbish that is taking up oxygen. She also

reports ongoing suicidal ideation if she was released from the hospital. She also has

delusions of poverty as she thinks that she is not achieving anything in life even thought

she had a successful fitness business.

Insight

She has poor insight to her psychiatric illness.

Judgement

Mrs PJ also has mild impaired judgement as well. She denies that she is receiving any

form of treatment at the moment. She became very aggressive and resistant to attend a

tribunal to extend her stay in the hospital for further treatment.

Cognitive examination

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She was alert. She was orientated to the time, date and place (she was aware that she is

admitted in the mental institution Kiloh Centre) at the time of the interview. The

cognitive assessment was cut short as the patient said she felt intimidated and

embarrassed by the questions asked. There was no evidence of language deficits (she

was able to converse well) or memory deficits (she could remember past events like her

divorce and recent significant events like her mum who is dying from lung cancer), thatis suggests of a cognitive disorder.

Risk Assessment

A mental risk assessment was performed on Mrs PJ enquiring about general risk

factors, risk for suicide, violence/aggression, other vulnerabilities.

Background Current

General risk factors Major depressive disorder Major depressive disorderPsychotic nihilistic delusions

Risk for suicide Multiple suicide attempts

since the age of 16

Divorced

Isolated and unemployed

Mother is dying from lung cancer.

Hopelessness

Expresses high levels of distress

Has plans to commit suicide after being

discharged

Violence/aggression Agitated during current admission

Paranoid ideation about others

She no thoughts of harming others.

Other vulnerabilities. History of absconding

from wards

Current nihilistic delusional beliefs

Desired to leave hospital displayed by

her multiple attempts to abscond from

the ward.

Investigations

Investigation Indications Results

Full Blood Count

Blood Electrolytes

Regular monitoring Normal

Regular blood pressure

monitoring

Regular monitoring 135/90 mmHg

Weight monitoring Regular monitoring to

monitor possible weight

lost as a result of lost of

appetite

No weight fluctuation from

initial weight on admission

65kg.

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Impression/Formulation

Mrs PJ is not functional during this current admission. She does not have any symptoms

or signs that are suggestive of a cognitive disorder. My impression of Mrs P.J is that she

has psychotic depressive disorder.

Differential diagnosis

Psychotic depressive disorder

Mrs PJ was observed to have severely depressed mood. Her provisional diagnosis of

psychotic depressive disorder is supported by the presence of various clinical findings.

Throughout her stay at Kilo, she consistently reported pathological guilt (She feels

guilty for being a living waste that takes up oxygen.). Although she does not report of

any auditory hallucinations, she has delusions of poverty (describing herself as such a

failure in life not being able to achieve anything despite having a successful business in

the past). Mrs PJ also expressed thoughts of olfactory delusions (She insists that she

smells like rubbish despite being told that she doesnt) and nihilistic delusions of

herself smelling like faeces, thereby supporting the diagnosis of psychotic depressivedisorder where delusions are more common than hallucinations as in schizophrenia

related disorders.

Melancholic depressive disorder

During the initial phase of her current admission, she reported increasing symptoms of

anhedonia and diurnal variation in terms of mood and energy. During the ward round

interviews, she was unresponsive towards the interviewers. Furthermore, she was often

observed to remain motionless in bed. Taking into account of the predominant

psychomotor disturbance picture during her initial phase of her admission, a possible

differential diagnosis would be melancholic depressive disorder.

Post traumatic stress disorder (PTSD)

Mrs P.Js depressive symptoms lasted more than a month, ever since her divorce four

years ago. Since then, it has caused her clinically significant distress and impairment in

her social and occupational aspect of her life. As such, post traumatic stress disorder is

another differential diagnosis to consider.

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However, Mrs P.Js diagnosis does not fit the picture of PTSD for the following

reasons:

1. She reported depressive symptoms of insomnia, anhedonia, worthlessness and

helpless leading multiple suicidal ideation and attempts ever since the age of 16,

years before her divorce.

2. She did not persistently re-experience the events that led to and came after herdivorce.

Provisional diagnosis

Psychotic depression with persisting suicidal ideations.

Axis Summary

Axis Comments

Axis I Major Depressive Disorder

Axis II Possible underlying Borderline Personality Disorder

Axis III Nil

Axis IV Inadequate social support

Dying mother (from lung cancer)

Axis V GAF = 45 (on admission)

Management plan

Despite being a patient with high suicidal risk and having psychotic features of

depression, Mrs P.J was reluctant to be hospitalized. As a result, she was scheduled

under the Mental Health Act to receive involuntary treatment. Overall management of

Mrs P.J can be divided into largely short term and long term.

Short Term

The short term management plan of Mrs P.J involves providing her with anxiolytic

(midazolam) to calm her down. Antipsychotic quietiapine was administered to curb her

auditory delusion, while Diothiepin was administered for her depressed mood.

On the 10th day of admission, she tried to abscond from the wards. As a result she was

kept in an isolation room where facilities were kept to a minimal to remove

potentially dangerous objects. Daily ward rounds from the treating psychiatrist

were made to monitor Mrs P.Js mood.

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As her mental health enquiry was held on her 14 th day of admission to extend her length

of stay in treatment at Kiloh to enforce involuntary treatment, as her psychotic

delusions and suicidal ideations have not subsided.

Although Mrs P.J was initially kept in an isolated room that is locked have tried to

abscond from the wards, special considerations were made on the basis that her mumwho was dying would be visiting her. As a result, the treating psychiatrist accepted her

requested to stay at the general ward with heightened supervision instead of being

locked up in the isolation room.

Meanwhile, meetings with a clinical psychologist were arranged to help her cope with

the bad news of her mothers health condition.

Long term management

The option of electroconvulsive therapy was explained to Mrs P.J for her consideration

on her 14th day of admission, as her symptoms of low mood, suicidal ideation wereescalating and she have even tried to escape from the wards to avoid treatment.

Prior to her discharge, the acute care team was notified of her situation. The acute care

team would be responsible for providing brief crisis intervention to Mrs P.Js well

being, through daily phone calls after she is being discharged.

A referral to a private psychiatric hospital (St. John of God, Burwood) for long term

psychotherapy was planned for Mrs P.J to help her cope with her intermittent suicidal

ideations.