Sessions 1 and 2 Assignment: Present a case for pre-approved psychiatric disorder and submit a full H&P for this patient, including a mental status exam.

Disorder: Factitious Disorder Imposed on Self

Patient Name: Elaine Smith

Age: 44 years

Location: Emergency Department

Transportation: EMS

Chief Complaint:

“I can’t breathe” x 4 hours

History of Present Illness:

ES is a 44 year old questionably reliable Caucasian female with a significant past medical history of asthma and HTN presents to the ED via EMS complaining of shortness of breath x 4 hours. She reports that her symptoms started abruptly while she was watching television and notes that it “feels like something is sitting on my chest.” She denies any aggravating or alleviating factors. She admits to having a rescue inhaler but did not use it. She admits to chest tightness, lightheadedness, and dizziness. She denies any fever, chills, body aches, coughing, nausea, vomiting, diarrhea, or any other symptoms. She reports that she was very hesitant to seek medical care today due to the pandemic but ultimately presented because she felt “really nervous that I am dying.”

Past Medical History:

Present Illnesses:

• Asthma
  • Since childhood
  • Reports more attacks in the last few years; pulmonologist prescribed albuterol rescue inhaler and Symbicort, but she does not take them
• Hypertension
  • Diagnosed 2 years ago
  • Follows up with cardiologist

Past Illnesses:

• Unspecified abdominal pain 4 years ago
  • Hospitalized several times at hospital in California
  • Multiple CT scans and diagnostic tests and an exploratory laparotomy with inconclusive results
  • Refuses to give access to past medical records
• Multiple hospitalizations for asthma attacks over the last few years
  • Hospitalized in California
  • Refuses to give access to past medical records
• Presumed lower GI bleed x 1 month ago
  • Hospitalized at NSUH
  • Colonoscopy performed – normal without signs of bleeding
  • Refuses to give access to past medical records
• Displaced fracture of right radial head 30 years ago
  • Hospitalized in California
  • Refuses to give access to past medical records

Immunizations:

• Up to date

Screening:

• Pap smear 2019 – normal
• Mammogram 2019 – normal
• Diagnostic colonoscopy April 2020 – normal

Past Surgical History:

• Exploratory laparotomy 2016 due to persistent abdominal pain
  • Hospital in California
  • No obvious pathology
  • No complications
• Tonsillectomy during childhood
  • Hospital in California
  • No complications
• Correction of displaced right radial head fracture 1990
  • Hospital in California
  • No complications

Denies any other surgeries, illnesses, or blood transfusions.

Medications:

1. Lisinopril
2. Albuterol inhaler
3. Symbicort
4. Allegra allergy relief

Notes that she has not taken her medications in a while because she recently moved to New York from California and her old providers have not transferred her prescriptions over and with the pandemic she has been hesitant to find new providers.

Allergies:

• Reports severe allergy to pollen
• Denies any known allergies to medications or foods.

Family History:

• Mother – died in MVA when she was very young; history unknown
• Father – “had everything” – HTN, T2DM, HLD; died from MI at 55
• Brother – denies knowledge of history as they haven’t spoken in >10 years
• No knowledge of grandparents’ medical history.

Social History:

• Denies use of tobacco, alcohol, or any elicit drugs
• Denies any recent travel
• Single, never married
• Not currently sexually active; no history of STIs
• Not currently working due to her recent health issues; used to work in retail
• Recently moved to New York from California about 2 months ago because she “needed a change of scenery.” Lives alone in an apartment without pets
• Sleeps well

Review of Systems:

General:

Denies fever, chills, night sweats, fatigue, weakness, loss of appetite, recent weight gain or loss

Skin, hair, nails:

Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution

Head:

Denies headache, vertigo, head trauma, unconsciousness, coma, fracture

Eyes:

Denies use of contacts or glasses, visual disturbances, fatigue, lacrimation, photophobia, or pruritus

Ears:

Denies deafness, pain, discharge, tinnitus, or use of hearing aids

Nose/Sinuses:

Denies discharge, epistaxis, obstruction

Mouth and throat:

Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, or use of dentures

Neck:

Denies localized swelling/lumps, stiffness/decreased range of motion

Breast:

Denies lumps, nipple discharge, pain

Pulmonary:

Admits to SOB and chest tightness. Positive history of asthma. Denies cough, wheezing, hemoptysis, cyanosis, orthopnea, PND

Cardiovascular:

Reports chest tightness and a squeezing sensation. Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur

Gastrointestinal:

Denies changes in appetite, intolerance to foods, nausea and vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, pain in flank

Genitourinary:

Denies frequency, changes in olor of urine, incontinence, dysuria, nocturia, urgency, oliguria, polyuria

Musculoskeletal:

Denies muscle/joint pain, deformity or swelling, redness, arthritis

Peripheral Vascular:

Denies Iintermittent claudication, coldness, trophic changes, varicose veins, peripheral edema, color changes

Hematologic:

Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE

Endocrine:

Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Nervous System:

Denies seizures, loss consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, weakness

Psychiatric:

Reports that she “used to feel sad many years ago” but is better now. Denies any thoughts or plans of hurting herself or others. Denies anxiety, obsessive/compulsive disorder, history of seeing mental health professionals

Physical Exam:

 Vital Signs:

Blood Pressure: 152/87, right arm, sitting

Heart Rate: 82 bpm, regular

Respiration Rate: 26 bpm, quiet

Temperature: 99.1 F, oral

O₂ Sat: 97%, room air

Height: 65 inches

Weight: 178 lbs

General Appearance:

44 y.o. male/ female. AAO x 4. Well dressed with good hygiene. At times appears to breathe very fast and hard, but in no acute distress.

Skin:

Warm and moist with good turgor. Large scar on her abdomen in the RLQ and scar on her right elbow

Nails:

No clubbing, no infection, capillary refill <2 sec throughout.

Hair:

Average quantity and distribution, no signs of alopecia, seborrhea, or lice.

Head:

normocephalic, atraumatic, nontender to palpation throughout, no signs of alopecia, seborrhea, or lice.

Eyes:

Symmetrical OU, no evidence of strabismus or ptosis noted, sclera (white/ red), conjunctiva and cornea clear. Visual fields full OU, PERRLA, EOMI full with no nystagmus.

Neck:

Trachea midline. No masses, lesions, scars, pulsation noted. Supple, nontender to palpation. FROM no stridor noted. Thyroid non-tender, no palpable masses, no thyromegaly. No thyroid bruits noted.

Chest:

Symmetrical, no deformities, no signs of trauma. Appears to intermittently take very rapid, shallow breaths. Lat AP diameter 2:1. Non-tender to palpation.

Lungs:

Clear to auscultation bilaterally, no rales/rhonchi/wheezes

Cardiovascular:

RRR. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.

Abdomen:

BS present in all 4 quadrants. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness.   No CVAT noted bilaterally.

Peripheral Vascular: Extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E  B/L) No stasis changes or ulcerations noted.

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.  No evidence of spinal deformities.

Neurological:

Grossly intact.

MSE:

Observations:

1. Appearance: Appearance is one of the first things we observe about a patient as they enter the room or when we approach them at bedside or in triage. What do you see? What are your first impressions of this patient?

Stature – Average height, slightly overweight

Alertness- Alert

Dress – Dressed appropriately for the weather and situation

Hygiene – Well-groomed with good hygiene

Accessories – Large abdominal scar and scar on right arm from surgery to correct fracture. She is carrying a notebook with hand-written lab results from her last annual physical exam.

Gait – Walks appropriately

2. Attitude: The patient’s attitude can tell the provider a lot about their psychological state at the time of assessment.

Patient is superficially compliant, but uncooperative when asked about collateral contacts or past medical records.

Patient is friendly throughout the exam, but becomes evasive and mildly irate when asked about collateral or access to past medical records.

3. Behavior: Similarly to a patient’s attitude, their behavior during the assessment can give the evaluator a lot of information about their psychological state and any underlying pathology.

Psychomotor activity – Within normal limits.

Eye contact – Maintains good eye contact.

Abnormal movements – No signs of any tics, tremors, or other stereotypies or mannerisms.

4. Speech

Rate – Normal.

Rhythm – regular.

Volume – Normal.

Latency – Answers questions without delay.

Content- Fluent.

Emotions:

1. Mood

“I feel fine, but I am nervous that I am dying.”

2. Affect

Normal affect; appears happy and comfortable

      3. Range

Displays full range of affect.

Congruent

Affect congruent to mood.

Appropriate

Appropriate to the content of the discussion.

Thoughts & Perceptions Thought Process

1. Thought process assesses the way the patient is thinking during evaluation. Describes the rate of thoughts and how they flow and how each thought is connected

Logical and coherent. Expresses goal-directed thoughts; expresses interest in getting better and finding a job and making friends.

            Normal thought patterns.

Thought patterns positive for abstraction; explained that “the grass is always greener on the other side” means that “someone else’s situation always looks better than your own.”

Thought Content looks at the actual content of what the patient is saying

Seems to be very preoccupied with the hospital course – asks if she will be receiving oxygen, if surgery will be necessary, informs the staff to perform any tests that they think are appropriate despite potential risks or pain.

Perceptions

Denies hallucinations, illusions, delusions, derealization, or depersonalization.

Cognition

1. AAO x 4
2. Normal attention – able to spell “WORLD” backwards.
3. Memory – immediate recall, delayed recall, short-term recall, and long-term recall intact.

Insight and Judgment

Insight – Good.

Judgment – Appropriate.

“If you were walking in the street and saw an envelope on the ground with an address and a stamp, what would you do?”  – “Mail it.”

Differential Diagnosis:

1. Factitious disorder imposed on self (Munchausen Syndrome)
2. Illness anxiety disorder
3. Malingering
4. Somatic symptom disorder
5. Panic attack
6. Asthma exacerbation

Assessment:

ES is a 44 year old questionably reliable Caucasian female with a significant past medical history of asthma and HTN presents to the ED via EMS complaining of shortness of breath x 4 hours. Patient history and physical exam findings are consistent with factitious disorder imposed on self.

Plan:

1. Factitious disorder imposed on self
   1. Discharge home with referral for cognitive behavioral therapy +/- group therapy with people with the same diagnosis
   2. Set up follow up with outpatient psychiatrist within 1 week
2. Asthma (mild-moderate persistent)
   1. Albuterol inhaler
      1. 2 puffs Q4-6 hours as needed
   2. Singulair 10 mg PO QD at bedtime
   3. Follow up with outpatient PCP or pulmonologist within 1 week
3. Hypertension
   1. Lisinopril 10 mg
   2. Follow up with outpatient PCP or cardiologist within 1 week

Session 3 Assignment: Define the 10 psychiatric defense mechanisms and provide an example of each

Denial

Denial is the defense mechanism by which one refuses to accept reality as it is and instead distorts it to suit their wishes. For example, many addicts exhibit denial when they do not acknowledge that they have an addiction and can stop whenever they want.

Repression

Repression is the unintentional burying of upsetting or unwanted thoughts or feelings from consciousness into unconsciousness. For example, the victim of an attack may be unable to recall any details about the attack.

Projection

Projection is the mechanism by which one attributes their own unacceptable behaviors, thoughts, or feelings to someone else. For example, someone who feels inadequate might project this onto others and think that no one wants to work with them instead.

Displacement

Displacement is the transfer of a negative emotion to someone or something that is unrelated. For example, a child who gets in trouble with a teacher at school might take their anger out on a more vulnerable student or younger sibling since they cannot express their anger to their teacher.

Regression

Regression is the defense mechanism by which, when confronted with stress, one begins to behave in a way they did during an earlier developmental stage. For example, an adolescent with a big test coming up may start wetting the bed again when they haven’t since they were a young child.

Rationalization

Rationalization is when one comes up with excuses to justify a situation rather than admit the actual unwanted reason. For example, one might justify the fact that another employee got the promotion they wanted at work because that employee is good friends with the boss instead of admitting that employee might have been better suited for the job.

Sublimation

Sublimation is when one channels an unacceptable behavior or impulse into a socially acceptable one. For example, rather than lashing out at a someone else after being treated poorly, one might write a song to channel their feelings into.

Reaction Formation

Reaction formation is when one thinks and behaves in the opposite way of their true feelings. For example, someone who is gay but hasn’t come out yet acts very homophobic to other gay people.

Compartmentalization

Compartmentalization is a defense mechanism used to avoid cognitive dissonance by completely separating conflicting thoughts or ideas from each other so that they cannot mix. For example, a soldier can kill during war but would never hurt someone outside of that setting.

Intellectualization

Intellectualization is when one addresses a situation in a factual and analytical manner instead of addressing their emotions in the subject. For example, someone who has been diagnosed with cancer might spend their time researching the diagnosis, prognosis, and treatment options rather than deal with their feelings about their diagnosis.