Bipolar CIS Flashcards
pt is BIB PD from DIA for starting altercation with passenger on plane re: Glenn Beck being truly awesome. He reports 3 weeks ago he had a large incident at work, took a LOA. Oddly he began to feel better than ever, colors began to assume “meanings”, and he realized he was “beyond sleep”.
His wife failed to understand his new abilities of “expanded consciousness” and “having the true understanding of God.” He suspected she might be poisoning him and he realized he needed “freedom”. So he bought a plane ticket and set out for San Francisco with only his Bible.
In ED, Utox is Negative
Diagnoses you would most consider:
Bipolar I, MRE hypomanic with psychosis Bipolar II, MRE hypomanic with psychosis Bipolar I, MRE manic with psychosis Bipolar II, MRE manic without psychosis Bipolar I, MRE manic without psychosis
Man from DIA-
In the ED, he denies SI/HI/AH/VH but whispers to you that he is sure the security guard is an agent of Satan and wanting to kill him. He refuses to allow you to call any collateral info, and demands to be released. Based on this information, what is your next step:
Place patient on 72 hr Mental Health Hold
Discharge patient on his own recognizance
Inject atypical antipsychotic intra-muscularly
Offer atypical antipsychotic orally
Call his wife anyway.
call wife
offer antipsychotic
Man from DIA
Wife informs you that he has bipolar d/o, with 2 hosps in last 19 yrs with similar precipitants, and has been managed on Valproate for 15 yrs. She thinks he’s been off meds for 4 weeks.
He admits to having a wife, but says he’s leaving her. He admits to a past dx of Bipolar, but that he “outgrew” it. However, he claims to have continued adherence with Valproate for “my depression.”
Which labs would you check:
A. Obtain VPA level and LFTs B. Obtain CBC C. Obtain lipid panel D. Obtain BMP and TSH E. A and C F. B and D G. A,B,C, and D
all of them; valproate is hepatically metabolized, check LFTs. Can cause thrombocytopenia; check CBC
BMP and TSH- anticipatory re: the ability to give lithium in the future
lipid panel- anticipatory re: giving an atypical antipsychotic
Man from DIA–
Labs return: VPA undetectable, CBC = WNL, BMP = WNL, LFTs = AST 220/ ALT 480, Lipids = TGs elevated, TSH = 4.1 . After much discussion, your patient admits to having foregone meds for 6 weeks, and agrees to cooperate with stabilization. What is the next step:
A. Start Lithium. B. Start Valproate as it worked before. C. Start atypical antipsychotic for psychotic sxms. D. Check Hepatitis serologies E. A, C, and D F. B and C
LFTs are bad- don’t restart Valproate, o/w we would
start lithium and probably an atypical antipsychotic
check hepatitis serologies is a good plan.
The Man from DIA
Your patient improves quickly over the next 8 days on Li and Olanzapine, with resolution of all psychotic sxms, normalization of sleep, and appropriate speech. You find that he is very pleasant, calm and quite well mannered. Li level = 0.8, Hep serologies negative. As he prepares to go home, what might your last interventions be:
A. Provide psychoeducation re: Li usage and warnings
B. Discuss need to monitor for post-mania depression
C. Refer to PCP for f/u of LFTs
D. Discuss tapering meds in the near future
E. A and B
F. B and C
G. A - D
A-D
need to give a lot of education re: lithium usage; avoid NSAIDs, tremor and acne can be a problem
monitor for post-mania depression
amount of meds to get out of a manic episode is much higher than maintenance doses
Really down
A 34 yo MLF is BIB Husband for current depressive sxms. She has a successful career in political campaigning, currently on staff with the governor. Over last 3 weeks, she has become withdrawn, stopped tweet-ing at all, sleeps 12hrs/day, poor appetite, and had such difficulty “keeping up” at work that she was forced to take LOA a week ago. On interview, she is blunted, latent in speech, and admits that she hears a voice urging her to kill self b/c “I caused 9/11”.
She has had 2 prior significant depressive episodes, last 2 yrs ago. No prior psychotic episodes, no hosps. Husband notes a couple of times a year she will have periods of ~2 wks with really high energy, will work excessively for 16 hrs/day, desire sex 2+ times a day, talk “incessantly”, and sleep 3-4 hrs a night.
Admits to THC 2-3 x/mo, last use 2 weeks ago
Utox: negative, TSH: 0.4
Family Hx: Mother and cousin- BAD I
Which diagnosis is most likely:
A. New onset schizophrenia
B. MDD, severe, with psychosis
C. Bipolar I, MRE depressed, w/o psychosis
D. Bipolar I, MRE depressed, w/ psychosis
E. Bipolar II, MRE depressed, w/o psychosis
F. Bipolar II, MRE depressed, w/ psychosis
** I think the answer to this was MDD, severe, with psychosis. Not 100% sure he came right out and said it.
someone may have not had a manic episode but depression is not responding to drugs. thoughts?
Maybe try a mood stailizer; may be bipolar but not have had the manic part yet
super depressed lady now treated
having manic episode (it’s interfering with her work, she’s buying lots of expensive stuff)
What is your current working diagnosis:
A. Bipolar D/o, II, MRE manic w/ psychosis
B. Bipolar D/o, I, MRE manic w/psychosis
C. Bipolar D/o, II, MRE manic w/out psychosis
D. Bipolar D/o, I, MRE manic w/out psychosis
B
(current episode)
Not Quite So Down -8
You hospitalize your patient and restart her on Lithium and Risperidone. Over 2 weeks she stabilizes and returns to baseline. Lithium levels = 0.8.
What labs will you most likely follow in addition:
CBC, Lipids, TFTs
CBC, Lipids, BMP, BMI
CBC, BMI, LFTs
BMI, Lipids, TFTs, BMP
BMI, TFTs, CBC
lipid panel due to being on Risperidone (plus baseline hemoglobin A1C)
lithium- watch BMI
creatinine, BMP
difference between bipolar I and schizoaffective disorder - bipolar type
bipolar- the mood episode resolves and the psychosis is also gone
En Fuego!
prominent plastic surgeon takes a bat to the Mercedes of a pt, etc.
wife says recent aggressiveness and grandiosity are new
he’s picking at his skin
6 gin and tonics/ wk
what of the following tests should we order?
BMP and CBC
Urine Drug screen
CT Head
LFTs and TFTs
CT can show if it’s frontotemporal dementia but may delay depending on other results
LFTs and TFTs in case planning to use lithium and valproate
also BMP and CBC, urine drug screen
En Fuego!
The patient loudly demands that you release him so he can get back to “being awesome.” He continually talks to/at anyone in sight. At one point he launches into a better-than-expected rendition of Roar by Katy Perry.
CBC/BMP = WNL
LFTs and TFTs = WNL
Utox = Cocaine metabolites
CT Head not yet performed 2/2 busy Fri Night
A. Cancel CT, explore HI, admit inpatient
B. Cancel CT, admit inpatient, notify state PHP
C. Explore HI, let him rest it off
D. Explore HI, confront him on lying, await CT
we have a legal duty to notify authorities if a provider in our community is endangering pts
we have what we need to admit.
so the answer is B.
What else is in differential for manic-like state:
PCP, Meth Prescription stimulants Thyroid storm/exogenous thyroid hormone Energy drink intox ICM (intracranial mass)- FTD is perhaps more useful to consider Anti-depressant induction
lady w/ 2-3 yrs alternating highs and lows, less than 2 mos between. Feeling blah, drags through day, - lasts a week or so. Highs last about 2 days.
No hosps or attempts.
Given all labs WNL, what is best diagnosis:
Cyclothymic d/o Bipolar d/o, I, MRE hypomanic Bipolar d/o, II, MRE hypomanic ADHD PMDD Precocious Peri-Menopause
no major depressive episode or manic episode;
Cyclothymic d/o
Which statements about cyclothymic d/o are correct:
A. Family hx shows Bipolar I relative in 30%
B. Completed suicide rate of 8-12%
C. 1/3 will go on to have BAD or MDD dx
D. 2/3 respond well to Valproate
A and C
Family hx shows Bipolar I relative in 30%
1/3 will go on to have BAD or MDD dx
