IDENTIFYING/DEMOGRAPHIC DATA: Sampaguita is a 29-year-old female from the Philippines.
A 60-year-old African American woman is brought to the emergency room (ER) for evaluation by her family, who is concerned about her recent behavior, including nearly striking her daughter with a soup ladle after the latter spilled a few drops on the table while helping to serve dinner that evening The patient is a self-employed trial attorney who has been working long hours to prepare for an upcoming trial Over the past 10 days, the patient has become increasingly irritable and argumentative with her family, is sleeping less and less, talking faster than usual, and has started to express paranoid concerns about the opposing attorney ‘stealing my briefs.’ Her family was present when the patient first saw an emergency medicine specialist. She was loud, voluble, interrupted frequently, and was verbally belligerent, often threatening to leave, but agreeing to stay only because of the pleas from her family and the implied threat that she met criteria for an involuntary psychiatric hold She has no history of psychiatric contact or substance use disorders; however, she has a family history of major depression She has hypertension that is being treated with lisinopril and has a family history of diabetes mellitus type 2 To obtain some basic medical work-up the patient agreed to take a low dose of oral risperidone 1 mg together with lorazepam 1 mg The complete blood count (CBC), comprehensive laboratory chemistry panel, and thyroid stimulating hormone (TSH) were normal, and the urine toxicology screen was negative (except for the presence of lorazepam); of note, aspartate transaminase (AST) and alanine transaminase (ALT) were normal, and the estimated glomerular filtration rate (eGFR) was 88 ml/min (average eGFR for adults 60-69 years old is 85 ml/min) A non-contrast head computer tomography (CT) scan was also normal Telepsychiatry support was provided to the ER, and after interviewing the patient (who was somewhat somnolent) and reviewing the work-up, the consulting psychiatrist indicated to the family that their mother appears to look manic but that she is too old to have new onset bipolar disorder, so her symptoms might just be due to sleep deprivation A prescription for risperidone 1 mg q hs was provided and a referral given for outpatient psychiatric follow-up in 1 week The patient presents to your clinic 1 week later with her husband and daughter The patient is mildly irritable, hyperverbal, expansive (calling you her best friend), and grandiose, alluding to her ‘unparalleled talent’ as a trial lawyer; the patient’s clothes are wrinkled, and her hair is uncombed The family notes that the patient appeared somewhat better this past week and has been sleeping more, but is clearly not at her baseline; moreover, they just found out that she spent a large sum of money online The patient scores 29/30 on the Saint Louis University Mental Status (SLUMS) and denies hallucinations, suicidal ideation, or homicidal ideation In addition to the findings above, there is paranoid content about the opposing attorney, but some admission by the patient that she is not sure if the other attorney is doing anything nefarious The patient endorses prior alcohol abuse, but none in the last 18 months She claims that her family has been watching her take her medication (risperidone 1 mg PO qhs), every night. 4. Is there enough evidence to assign a bipolar disorder diagnosis despite the new onset of symptoms at age 60, or should further medical work-up be pursued since new-onset bipolar I disorder is uncommon at this age? A. As the etiology is unclear, the patient will continue on risperidone 1 mg qhs and further work-up will be pursued to rule out other causes B. As the etiology is unclear, the patient will continue on risperidone, but the dose will be increased to 2 mg qhs, since she remains symptomatic on 1 mg qhs, and further work-up will be pursued to rule out other causes C. Due to her age, health, and laboratory results, the optimal decision is to start a first-line mood stabilizer, with lithium being the preferred option; risperidone 1 mg qhs will be continued until lithium is therapeutic D. Due to her age, health, and laboratory results, the optimal decision is to start a first-line mood stabilizer, with divalproex being the preferred option; risperidone 1 mg qhs will be continued until divalproex is therapeutic
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