1. CASE 47: BIPOLAR DISORDER By Ryan Raroque

2. Bipolar Disorder Spectrum

3. 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.”

4. 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 23 rd 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

5. 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

6. 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

7. 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

8. 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”

9. 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

10. 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

11. 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

12. 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”

13. 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

14. Medications  Lithium 600 mg po Q AM and 600 mg po Q HS  Sumatriptan 50-200 mg po PRN

15.  ASA -> Swelling of face  Migraine headaches, 2-3/month  (-) for aura but (+) for nausea, vomiting, and photophobia AllergiesReview of Systems

16.  Performed three hours after gaining consciousness  Patient is tired-looking, white female in NAD  Very pale  “Dark rings” under her eyes PE and Lab TestsGen

17. Vital Signs BP 110/72 (supine)RR 16 and unlaboredHT/WT 5’6’’/135 lbs P 81 and regularT 98.6 °FSaO 2 97% on room air

18. 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.

19. 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.

20. Vital Signs BP 110/72 (supine)RR 16 and unlaboredHT/WT 5’6’’/135 lbs P 81 and regularT 98.6 °FSaO 2 97% on room air

21. Vital Signs BP 110/72 (supine)RR 16 and unlaboredHT/WT 5’6’’/135 lbs P 81 and regularT 98.6 °FSaO 2 97% on room air

22. 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.

23.  ASA -> Swelling of face  Migraine headaches, 2-3/month  (-) for aura but (+) for nausea, vomiting, and photophobia AllergiesReview of Systems

24.  ASA -> Swelling of face  Migraine headaches, 2-3/month  (-) for aura but (+) for nausea, vomiting, and photophobia AllergiesReview of Systems

25. 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.

26. Significant Risk Factors

28.  Genetics  Environment

29. 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.

30. 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

31.  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

32.  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

33.  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

34.  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

35. Case Questions  Does this patient have any signs of abnormal renal function?  Does this patient have any signs of abnormal hepatic function?

36. Case Questions  Does this patient have any signs of abnormal renal function?  Does this patient have any signs of abnormal hepatic function?

37. Patient Case Table 47.2 Laboratory Blood Test Results Na 139 meq/LMCV 90.2 flBilirubin, total 0.7 mg/dL K 3.7 meq/LMCH 31 pgAlb 2.9 g/dL Cl 108 meq/LMCHC 34.4 g/dLProtein, total 4.8g/dL HCO3 23 meq/LPlt 150,000/mm 3 Ca 8.7 mg/dL BUN 10 mg/dLWBC 9,400/mm 3 Mg 2.0 mg/dL Cr 0.7 mg/dLDiff 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/dLAST 33 IU/LPhos 3.2 mg/dL Hb 12.2 g/dLALT 20 IU/LTSH 4.1 µU/mL Hct 36.8%Alk Phos 59 IU/LCortisol @ 8AM 9.3µg/dL RBC 4.73 x 10 6 /mm 3 GGT 82 IU/LVitamin B12 203 pg/mL

38. Patient Case Table 47.2 Laboratory Blood Test Results Na 139 meq/LMCV 90.2 flBilirubin, total 0.7 mg/dL K 3.7 meq/LMCH 31 pgAlb 2.9 g/dL Cl 108 meq/LMCHC 34.4 g/dLProtein, total 4.8g/dL HCO3 23 meq/LPlt 150,000/mm 3 Ca 8.7 mg/dL BUN 10 mg/dLWBC 9,400/mm 3 Mg 2.0 mg/dL Cr 0.7 mg/dLDiff 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/dLAST 33 IU/LPhos 3.2 mg/dL Hb 12.2 g/dLALT 20 IU/LTSH 4.1 µU/mL Hct 36.8%Alk Phos 59 IU/LCortisol @ 8AM 9.3µg/dL RBC 4.73 x 10 6 /mm 3 GGT 82 IU/LVitamin 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.

39. Case Questions  Does this patient have any signs of abnormal renal function?  Does this patient have any signs of abnormal hepatic function?

40. Patient Case Table 47.2 Laboratory Blood Test Results Na 139 meq/LMCV 90.2 flBilirubin, total 0.7 mg/dL K 3.7 meq/LMCH 31 pgAlb 2.9 g/dL Cl 108 meq/LMCHC 34.4 g/dLProtein, total 4.8g/dL HCO3 23 meq/LPlt 150,000/mm 3 Ca 8.7 mg/dL BUN 10 mg/dLWBC 9,400/mm 3 Mg 2.0 mg/dL Cr 0.7 mg/dLDiff 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/dLAST 33 IU/LPhos 3.2 mg/dL Hb 12.2 g/dLALT 20 IU/LTSH 4.1 µU/mL Hct 36.8%Alk Phos 59 IU/LCortisol @ 8AM 9.3µg/dL RBC 4.73 x 10 6 /mm 3 GGT 82 IU/LVitamin B12 203 pg/mL Normal ranges according to NIH: Bilirubin: 0.3 to 1.9 mg/dL Albumin: 3.4 - 5.4 g/dL AST: 10 to 34 IU/L. ALT: 10 to 40 IU/L Alk Phos: 44 to 147 IU/L GGT: 0 to 51 IU/L

41. Patient Case Table 47.2 Laboratory Blood Test Results Na 139 meq/LMCV 90.2 flBilirubin, total 0.7 mg/dL K 3.7 meq/LMCH 31 pgAlb 2.9 g/dL Cl 108 meq/LMCHC 34.4 g/dLProtein, total 4.8g/dL HCO3 23 meq/LPlt 150,000/mm 3 Ca 8.7 mg/dL BUN 10 mg/dLWBC 9,400/mm 3 Mg 2.0 mg/dL Cr 0.7 mg/dLDiff 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/dLAST 33 IU/LPhos 3.2 mg/dL Hb 12.2 g/dLALT 20 IU/LTSH 4.1 µU/mL Hct 36.8%Alk Phos 59 IU/LCortisol @ 8AM 9.3µg/dL RBC 4.73 x 10 6 /mm 3 GGT 82 IU/LVitamin B12 203 pg/mL Normal ranges according to NIH: Bilirubin: 0.3 to 1.9 mg/dL Albumin: 3.4 - 5.4 g/dL AST: 10 to 34 IU/L. ALT: 10 to 40 IU/L Alk Phos: 44 to 147 IU/L GGT: 0 to 51 IU/L

42. 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?

43. 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?

44. 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

45. 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?

46. Patient Case Table 47.2 Laboratory Blood Test Results Na 139 meq/LMCV 90.2 flBilirubin, total 0.7 mg/dL K 3.7 meq/LMCH 31 pgAlb 2.9 g/dL Cl 108 meq/LMCHC 34.4 g/dLProtein, total 4.8g/dL HCO3 23 meq/LPlt 150,000/mm 3 Ca 8.7 mg/dL BUN 10 mg/dLWBC 9,400/mm 3 Mg 2.0 mg/dL Cr 0.7 mg/dLDiff 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/dLAST 33 IU/LPhos 3.2 mg/dL Hb 12.2 g/dLALT 20 IU/LTSH 4.1 µU/mL Hct 36.8%Alk Phos 59 IU/LCortisol @ 8AM 9.3µg/dL RBC 4.73 x 10 6 /mm 3 GGT 82 IU/LVitamin B12 203 pg/mL

47. 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

48. 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.

49. 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.

50. Clinical Manifestations

51. Feature AssessedMajor Depressive EpisodeMajor Manic Episode AppearanceTalks fast MovementHyperactive and restless Affect/MoodSadness Helplessness Hopelessness Isolation Emptiness Inappropriately joyous, elated, jubilant ThoughtRapid shifting of ideas PerceptionsHallucinations SuicideAttempted it once before AggressionNo patience or tolerance for others JudgmentPoor financial investments, doesn’t listen to advice, poor insight on behavior

52. 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.

53. 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

54. 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?

55. 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?

56. 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?

57. 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 FavorableLess Than Favorable