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Case Presentation 2 Id: EMS is a 56 year old male who lives in Mayaguez with his wife. He is divorced and he remarried to his current wife of 15 years. He has 2 sons with his first wife a 35 yr old and 29 yr old. He has 2 children from his 2nd wife a 23 yr old and 21 yr old. Patient worked for 15 yrs as an industrial mechanic. Is currently on disability leave. Patient is reliable. Chief Complaint: Me siento triste, sin animo, sin energia, no puedo dormir, desde mas de 2 meses. Present Illness This is a 56 year old male patient with past history of Major Depressive Disorder who is currently taking Paroxetine 40 mg, Divolproex 500mg TID, Xanax 2mg PO HS, Haldol 2mg PO HS. He presents with decreased energy, absence of pleasure, decreased sleep, decreased eating, anxiousness, stress, slowness and hallucinations which call out his name and various faces for 2 months. He also refers irritability and having lots of ³coraje´ or anger. He refers having an accident at work 5 years ago where a machine fell on him and herniated several cervical discs. He refers that a month later his mother day and he attributes these causes to the beginning of his symptoms. He states that his wife noticed several changes in his behavior and thought he might be depressed. He decided to seek help at her insistence. The patient denies use of any additional psychiatric medications. He denies current alcohol use, denies current cocaine use. States that he smokes ½ a box of cigarrettes a day and that he smokes marijuana once a day to calm him down. Denies obsessions or compulsions, psychosis, pressured speech, grandiose thoughts, and flight of
Family Psychiatric History: Father has a history alcoholism and committed homicide as well as attempted suicide. hypertension and alcoholism. Vaccinations are up to date. Patient has 2 brothers. Family Medical History: There is a history of hypertension. Past medical history: The patient has a history of a work accident that herniated C2-C3 which occurred in 2007. He denies command hallucinations. arthritis. Ramipril 2. Past psychiatric history: He refers having similar symptoms to those he is presenting now previously on two different occasions. The patient also denies any suicidal/homicidal ideas. Aspirin. . sinusitis and tendinitis. The patient has not suffered from seizures. Father is alive and suffers from diabetes.5 mg PO daily. His 52 yr old brother is healthy. dyslipidemia and kidney failure. He refers a catheterization in 2002 and a gallbladder removal 1990.ideas. repetitive behaviors. Patient states that he is currently taking Metoprolol of 50mg PO BID. Mother is alive and suffers from diabetes.160mg PO daily. hyperlipidemia. hyperthyroidism. intrusive thoughts. palpitations. or anemia. hypothyroidism. The patient has no known allergies or drug sensitivities. Refers hypertension. diabetes mellitus type 2. Insulin 75/25 injectable. diabetes and alcoholism in the family. The patient refers no other psychiatric conditions in the family. The 60 yr old brother is an alcoholic and suffers from hypertension. He refers no psychiatric hospitalizations. He refers head trauma as a 6 year old child for which he was in a coma for several months but he does not remember the cause. experiencing or being witness of a life threatening event. agoraphobia.
NY as an uncomplicated vaginal birth at 40 weeks from a planned pregnancy. He states that his dad left the house when he was 7 years old and they moved in with his aunt because of their poor economic status. toys and food. He refers no personal physical abuse because he would leave the house when his dad was too drunk. He refers that his dad did abuse him verbally and emotionally. He was born in Bronx. NY. He reports liking school because it was an escape from the troubles at home. emotionally and physically abused his mother. Middle Childhood: He reports living in the Bronx New York in an apartment in public housing. He negates any sexual abuse. He refers being very poor and having very little clothing. He reports meeting his developmental milestones and no illness or traumas during infancy. Early Childhood: The patient is the second child and has 2 siblings from the same father and mother.Social/Developmental History: Prenatal History and Perinatal History: EMS¶s father was a grocery store manager and his mom was a cashier at a clothing store. He refers getting into many fights with the children there. He reports having a small group of friends. Late childhood: At the age of 8 his brothers and him where removed from their home and placed in a halfway home in Hicksville. He states that his father was an alcoholic who verbally. The patient states that at the age of 8 he was removed from his mom¶s care because his older brother accused his mom of abuse. He refers that this was a lie and his mom never hurt them. He states that he had a good relationship with his brothers though they would sometimes get into physical fights. He attended school but would cut a lot of class and started smoking cigarettes at .
At 25 he started becoming involved in gangs. He refers very little contact with his family members and refers to his first symptoms of depression. They separate after 4 years of living in Puerto Rico and she moves back to NY with both children. Their first son is born and they move to Mayaguez. He began using cocaine at 26 as well as crack on a regular basis. His first son was born in NY. He states they have a good relationship and she offers him support. cigarette and marijuana use. He refers a tumultuous relationship with his wife with lots of fighting. He refers good relationship with his wife. PR. Patient met his second wife at the age of 31. He graduated high school when he turned 18 and left the halfway house and moved back to the Bronx. The boys are currently 23 and 21. He states that owned a gun and was involved in many shootings as well as murders. They move to Ponce. smoke cigarettes and marijauna. He was born with Down syndrome. The patient currently states that he lives alone with his wife and a dog in a house in Mayaguez. They do not live in Mayaguez but he refers good relationships with them. He stopped using cocaine and crack. alcohol. At the age of 27 their second son is born. He states that it was necessary to be protected otherwise you were vulnerable to be attacked. He drinking began drinking and smoking marijuana at the age of 14. Their second son is born 2 years later. They decide to move to Puerto Rico where his parents are originally from. Patient continues occasional cocaine.the age of 11. At the age of 21 he meets his first wife and they get married. He continued to drink. He begins to work as a mechanic at a friends shop. She was from Mayaguez. PR. He refers no legal troubles because the police were too afraid to go into those neighborhoods. Adulthood: When back in the Bronx he had a series of jobs working in grocery stores and clothing stores. He also . PR where his mom has some aunts. He states that he has symptoms of depression during this time. He read in the newspaper that his dad was suspected of throwing a man off a roof and then tried to kill himself. He is currently on disability leave due to the accident he had in a factory 5 years ago.
Patient looks his age. He states that the younger child with Down syndrome who is 29 lives with his mom and that he talks to him twice a week. had kids and lives in Alabama. He says that the older one who is currently 35 is married. He refers that he still smokes ½ box of cigarettes a day. drinks the occasional bottle of beer during the weekend and smokes marijuana daily. He also drinks 4 cups of coffee daily. He refers getting really stressed and upset because he feels that his ex-wife does not treat him well. although at slow rate and speed. He states that he does not see his two sons from his first wife because they are back in the states. He states he does not take cocaine or crack anymore. answers questions spontaneously. He states that they have closed off the areas where he can walk the dog and that he barely takes the dog out because of it. there were no signs of tremor or abnormal movements. behavior and attitude EMS is a 48 year-old Hispanic male of 5 ft 10 in and 185 lbs.refers that his mom died a few months later. Patient was cooperative throughout the interview. He refers no actual plans to kill his neighbors. He refers having many confrontational situations with his neighbors. He maintained eye contact at all times. At the time of examination. He states that they do not like his dog walking around the neighborhood. Mental Status Exam: General appearance. On appearance. he was well groomed and well dressed. He has not seen them. He identifies these as triggers for his current symptoms. This situation gives him a lot of ³coraje´. He states that she locks him in his bedroom and screams at him at all times. He refers that the situations with the neighbors make him very angry and at times he wants to kill them because of it. Speech Articulates clearly. Affect Appropriate Mood Depressed .
Suicidal or homicidal ideation was not detected. Content No general worries or concerns. depersonalization. no new or created words. Form Coherent. misinterpretations. were not elicited. Perception Patient exhibits normal perception. Symptoms. relevant and logical. c. Questions answered spontaneously and directly. He denies any delusions. Insight Poor Judgement Poor MMSEScored: 30/30 . No formal thought disorder. passivity phenomena. Stream Decreased b. phobias or compulsions.Thought a. such as illusions. Cognition He was alert and orientated to time and place. He was able to answer questions and recall his past.
5. no softening and inflammation of the gums. Neck: no lumps or swollen lymph nodes y y y y y y y Skin: No rash or other abnormalities Respiratory: No cough. Mouth: no abnormality. Musculoskeletal: Neck pain Physical Exam EMS is an alert. Thyroid isthmus palpable . y HEENT o Head ± the skull is normocephalic/atraumatic (NC/AT). no difficulty breathing and no use of accessory muscles. septum midline. no sinus tenderness. Ears ± acuity good to whispered voice. Nose ± nasal mucosa pink. Weber midline. BP 125/75. Eyes ± Visual acuity not impaired. Nails without clubbing or cyanosis. some mucus production. some sputum production Cardiovascular: No palpitations Neurological: No decreased sensation on extremities GI: No pain or other complaints GenitoUrinary: No changes in stool frequency or stool composition. y Skin o Normal skin color. active 56 year old male y Vital Signs: o Height is 5¶10´. petechiae. skin warm but appears dry. Eyes: normal vision according to age. Throat (or Mouth) ± oral mucosa pink. RR 17. pharynx without exudates o Neck ± Trachea midline. or ecchymoses.Review of Symptoms y HEENT: Head: No headaches. weight 185. Tympanic membranes (TMs) with good cone of light. Ears: normal hearing according to age. Hair with average texture. No rash. BMI: 26.
Cranial Nerves normal. Breath sounds vesicular. arthritis. It is soft and nontender. No CVA tenderness y Musculoskeletal: o The range of motion is severely decreased in neck. no murmurs or bruits y Abdomen: o Abdomen is protuberant. no rales. The range of motion and reflexes of other extremities are intact. y Neurologic: o Normal gait. tendinitis. Major depressive disorder recurrent. no palpable masses or hepatosplenomegaly. y Cardiovascular o Regular rate and rhythm. sinusitis Axis IV: interpersonal problems GAF-55 Differential (5) Differential Substance induced Mood disorder with depressive features Positive Pertinent y y y y Irritable Feelings of sadness Anhedonia Trouble sleeping y y y Negative Pertinent Anxiety No suicidal or homicidal thoughts No feelings of guilt and worthlessness .o Lymph Nodes ± No cervical. wheezes or ronchi. Lungs resonant. full neurologic exam not performed Diagnosis Axis I: Moderate. disc herniation C2-C3. Diabetes Mellitus 2. axillary adenopathy y Thorax and Lungs o Thorax is symmetric with good expansion. r/o Substance induced mood disorder with depressive features Axis II: deferred Axis III: hypertension. dyslipidemia. Diaphragm descends 4 cm bilaterally.
y y y y Eating less Psychomotor retardation Lack of energy Symptoms developed during or within a month of substance use or withdrawal y Symptoms precede onset of substance abuse y Major Depressive Disorder . Recurrent y Symptoms cause impairment y 2 or more major depressive episodes Interval >2 consecutive months in which criteria no met for MDD y No suicidal or homicidal thoughts y No feelings of guilt and worthlessness y y y y y y y Dysthmia y y Feelings of sadness Anhedonia Trouble sleeping Eating less Psychomotor retardation Lack of energy Duration > 2 weeks Sadness 2 or more symptoms of depression y Depressed mood for most of the day for more days than not for at least 2 years y Loss of interest and pleasure y Never more than 2 months without the symptoms in 2 years y y y Changes in appetite Changes in sleep patterns Significant impairment in daily functioning y y Low self-esteem Feelings of hopelessness .
. recurrent MDD.y y Bipolar Disorder Poor concentration Not directly due to a substance or medication y y y y Feelings of sadness Loss of interest Lack of energy Duration > 2 weeks y No symptoms of mania like grandiose. Biological There is a lot of research that shows that early head injury and concurrent observation or personal history of physical abuse predisposes individuals to violent behavior. increased goal directed activity. Patient is currently compliant with medications. flights of ideas or racing thoughts y y No elevated mood No excessive involvement in pleasurable activities with high risk negative consequences GAD y y y y Nervousness Difficulty sleeping Fatigue Irritability y y y No trouble concentrating No muscle tension No worries about multiple nonspecific things for a period of > 6 months Biopyschosocial profile EMS is a 56 year old male who presents with a Moderate. .
Any major brain illness or trauma that affects any of these areas could potentially result in a mood disorder. the hippocampus and the amygdala. the patient has had positive results previously taking Paroxetine which is a serotonin selective reuptake inhibitor. Researchers found that those who had been exposed to violence showed increased brain activity in the anterior insula and amygdala. the father of the patient attempted suicide which increases his likelihood of attempting suicide. Depressive symptoms are common among persons diagnosed with substance abuse or substance dependence. This is a neurobiological risk factor which increases the children's susceptibility to later mental illness like depression. There is strong evidence from studies of twins. This builds an enhanced reactivity to a threat cue such as anger. and siblings brought up separately indicates that the cause of alcohol abuse has a genetic component. Finally. the anterior cingulated. and less likely to respond well or quickly to treatment for their mental illness. cocaine and marijuana. When he was younger the patient began abusing alcohol. adoptees. Finally. Patient suffered from a coma as a child from an unknown cause since he has had several instance of recurrent depression it is possible that the anatomy and function of his brain was altered during the coma. . Also. Basic science research has demonstrated evidence that links the downregulation or decreased sensitivity of beta adrenergic receptors and clinical antidepressant responses. The patient¶s father abused alcohol. the patient is taking antihypertensives such as Metoprolol which have been linked with depression.Studies show that people who suffered maltreatment as children were twice as likely as those who had normal childhoods to develop persistent and recurrent depression. Evidence has also linked presynaptic Beta-2 receptors because their activation leads to a decrease in the amount of norepinephrine released as well as regulate the amount of serotonin released. The anatomy of the four brain regions in the regulation of normal emotions: the prefrontal cortex (PFC).
His occupations have not provided him with true generativity and he settled for engagement in random occupations that he described as not challenging. The patient referred feelings of . This feeling of personal stagnation may have begun when he fist left the halfway house and felt the need to fend for himself back to the Bronx. t hrough eit her perso nal exper ience or by o bser vat ion o f ot hers.Psychological: Several theories can explain the patient¶s aggressiveness and irritability. stagnation (40-60 yrs). S ince t he pat ient wit nessed emo t ional. He also began a long lifetime use of drugs. The patient is a 56 year old male who quit schooling after high school. All o f t hese t heor ies t oget her can expla in t he pat ient ¶s t endencies t owards vio lence and aggr essiveness. Anot her t heor y by Albert Bandur a st at es t hat people acquire aggressio n. The patient is currently in the stage of generative vs. phys ical abuse and personally exper ienced it his exper iences left him predisposed to develop aggressive t endencies t owards ot hers. He then felt the need to join gangs and commit lots of violent acts in order to survive. The psychoanalyst Erikson created the theory of epigenetic principles. Older pat ient s wit h perso nalit y disor ders were found to be four t imes more like ly t o exper ience maint enance or reemergence o f depressive sympt oms. According to Ainsworth expanded theory of attachment. Also according t o Freud aggressio n co mes pr imar ily fro m t he red ir ect ion o f t he self-dest ruct ive deat h inst inct away fro m t he se lf and to ward ot hers. In this theory he states that each stage must be resolved properly for development to proceed successfully. While t he pat ient wit nessed much har m in his yout h he int er nalized it and t hen dir ect ed it unt o other. These children may react in bizarre ways when threatened and this may be a precursor to severe personality disorder in adolescence and early adulthood. he states that children who have parents who are emotionally distant or abusive develop insecure disorganized attachment. The patient observed and experienced personal abuse and responded by eventually joining gangs and leading a life of crime.
He is not in contact with his eldest son that lives in Alabama or his grandchildren from that son. He reports lots of anger. Therein he worries about the maltreatment and safety of his child there. The patient has injuries that occurred during a work accident and he has to learn how to live with his new role as a person on disability leave. These earlier feelings could contribute to the development Moderate Recurrent. The patient is an avid marijuana and cigarette smoker with possible dependence. Patient had his mom die five years ago. The patient also has stress being contributed because of the situation with his exwife and his Down syndrome child who live in NY. Treatment Plan The treatment plan includes switching the patient from his previous medications to Sertraline 50mg PO AM. Social: EMS currently lives with his wife who was the initial person to notice his symptoms and report changes in his behavior. Sertraline is a serotonic selective reuptake inhibitor that treats depressive symptoms. diabetes and hypertension amongst other medical diseases and to rule out other causes of his symptoms labs should . which he identifies as a trigger towards his symptoms as he saw her as a support figure. He reports a tense environment in his neighborhood because of conflicts about the walking of his dog. Since the patient has a past history of hyperlipidemia. The patient reports not belonging to any specific community or church or group activity. Patient does not have much family support since he is estranged from his dad¶s side of the family and most of his mother¶s family. The patient has several risk factors such as substance dependence. Major Depressive Illness. death of a close family member that together are risk factors that contribute to a large propensity for major depressive illness. These are known depressants and could be contributing to his illness. tension and stress towards his neighbors because of their limitations of his boundaries. work accident.failed expectations in reviewing his past.
TSH. T herefore social skills t raining might be helpful in add it io n t o t hose t herapies alread y ment io ned. The patient could also benefit from individual therapy. People t hat do not know how to communicat e effect ively adopt an abrasive st yle o f self-expr essio n.be ordered which include: valproic acid levels. lipid profile. Continue encouraging him to continue seeking support from his wife and to allow her to face any stressors together. Since the patient has been smoking for the majority of his life is extremely important to approach the subject of quitting smoking while keeping in mind that it is imperative to provide him with as much support and help that he needs. . hyperlipidemia. Vitamin-B12. VDRL. CBC. and diabetes. CMP. The patient should be encouraged to continue his other medications for blood pressure. A t echnique for reducing t he frequency o f su ch behavior invo lves providing t hese persons wit h t he social skills t hat t hey sorely lack. cognitive behavioral therapy and smoking cessation counseling. folate and a toxicology screen. A major cause for aggressive encount ers is lack o f basic social sk ills. U/A.
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