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