How to Write a Case Presentation

Biodata 

Name: Matthew Anderson 

Age: 15 

Sex: Male 

Residence: Star-Court Ridge, CA. 

Occupation: Student 

Religion: Christian 

Marital Status: Single 

Level of Education: High School Level 

Date of Interview: 12/10/2019 

Informant: Patient 

Developmental Stage: Adolescence 

Chief Complaint/Clinical Presentation 

Headaches that have been unresponsive to normal treatment 2/52 

History of Presenting Illness 

The patient was well until a week ago when he had headaches that were not responding to normal treatment. The headaches were radiating to the back. The patient says that he has had these headaches from 2016, and they were to some extent responding to normal medication but that recently he still felt them while taking the medication. That is when the patient’s parents decided to bring him to the local referral hospital. He says that the headaches occur mostly in the morning and at night and that at times they come with nosebleeds. The patient also states that some precipitating factors to the headaches are noisy environments, such as when he is around televisions or radios. The only alleviating factors to the headaches were the medications that he was being given at the referral hospital and sleep. The patient claims that the headaches are also associated with auditory hallucinations such as hearing songs that he generally detested. At the same time, he would also have loss of interest in performing certain activities, such as getting up in the morning to prepare for school or joining other students during games sessions. The patient says that the headaches began while in third grade and that the doctors told him that he should avoid reading too much as that may be the reason as to why he was experiencing them. During this time the patient also reports that he has had significant weight loss, loss of sleep mainly due to the headache, and even a feeling of worthlessness. 

Demography Information and Social/Family History 

Family History 

The patient has two parents, who are both alive and well. They are elementary school teachers. He has two siblings who are younger and are both in elementary school (one sister and one brother). He reports no history of mental illness within the family or of close relatives. There have also been no hospitalizations of any of his family members. 

Personal History 

Social History 

No history of alcohol abuses or any form of drug abuse. The patient is an avid rugby fan. 

The patient says that he has several friends and that he does not have issues bonding or socializing. 

Sexual History 

The patient reports that he has had one girlfriend and that he is yet to make his sexual debut. 

Education 

The patient completed his middle and junior high school and got admitted to high school. He had to repeat grade 10 due to the complications that he was getting from the headaches, for example, the illusions and the hallucinations. He had no learning disabilities and reports no truancy. 

Developmental and Childhood History 

The patient has no records of his prenatal and antenatal care. However, he reports that he was told that he did not delay or skip any developments milestones. He reports a normal childhood and that he had several close friends. 

Employment History 

The patient has no history of employment (only 15 years) 

Forensic History 

Never been arrested or jailed 

Past Medical History 

The patient has not had prior admissions but has visited the local referral hospital and other hospitals from time to time due to the headaches. The patient has no allergies and has no history of surgery. He also does not have hypertension or diabetes mellitus. The patient also reports no major past childhood traumas, whether physical or emotional, except for being hit by a branch when he was still young. He required stitches and even has a scar from the incident. The patient is HIV negative. 

Premorbid Personality 

Patient reports that he has always been a hard worker in school and has been known as a dedicated and calm person both at home and at school. 

History of ETOH and Substance Abuse 

This is the patient’s first visit to a psychiatric clinic. He says that he has had suicidal ideation only once in the past and that he attempted to kill himself using a knife, but it was quickly snatched away from him. The episode occurred in high school. The patient also says that apart from the auditory hallucinations mentioned earlier, he says that he had had visual illusions where he thought he was seeing a man when all along it was only a tree. He says that the man made him fearful. This happened when he was in seventh grade. 

Mental State Examination 

Appearance 

The patient is well kempt and has a normal gait. He maintained eye contact throughout the interview. He was well mannered and had a normal gait. 

Speech 

The patient speaks at a normal rate, low volume, and low pitch. 

Mood 

The patient appeared tired and sad 

Affect 

Constricted 

Thought Process 

No neologisms during the interview. The patient had no looseness of association, circumstantiality, flight of ideas, or tangentiality. 

Thought Content 

Auditory hallucinations of music he did not want to listen to. Visual illusions of a man instead of a tree. 

Judgement 

Not impaired as he said he would save a baby from a smoking house 

Insight 

The patient recognized the fact that he was sick and was willing to take medication if prescribed. 

Orientation 

Well oriented in terms of date and time 

Abstract Thinking 

The patient was able to class mangoes and oranges as fruits. 

Concentration 

The patient was okay as he was able to complete his serial sevens 

Memory 

Short term intermediate, and long term memory all intact. 

Formulation 

The patient is a 15-year-old male that presents with headaches that are associated with nosebleeds and auditory hallucinations that have been ongoing for two weeks and are unresponsive to medication. The headaches are alleviated with sleep and medication from KNH. They are aggravated by noisy environments. During these episodes, the patient also reports that he has had significant weight loss, loss of sleep mainly due to the headache, and also a feeling of worthlessness. The headaches have been recurring since third grade, and the patient also reports visual illusions of a tree that looked like a man. There is no history of mental illness in the family. The patient has insight and is willing to take medication and seek other forms of therapy. 

Review of Systems 

Constitutional: Weight at 113lbs, height 5’8”. Composed and at an appropriate energy level. 

HEENT: Clear vision and hearing. No nasal obstruction or epistaxis. No history of tonsillectomy. Healthy dentition with no dentures. 

Respiratory: No chest sounds, wheezing, pneumonia, or pulmonary emboli. 

CVS: Normal hearth sounds. No clotting complications. 

G.I: Sporadic cramping and abdominal conditions. No history of gastric or abdominal surgery. 

G.U: No history of hesitancy, frequency, or dysuria. 

Neuromuscular: No history of syncope or seizures. Full range of motion and ambulatory. 

Endocrine: No history of hyperthyroidism. 

Psychiatric: Cognitive and emotional instability, salient symptoms of anxiety and depression. 

Appropriate Testing 

1.Laboratory Work-up 

Thyroid Function – Evaluation of serum T4 and TSH is important to rule out hyperthyroidism as one of the causes of the patient’s anxiety and even depression 

Complete blood cell count to rule out blood dyscrasias, infection, and anemia. 

Stat urine or serum drug screen to determine if illicit drugs are contributing to psychosis and change in mental status 

Computed Tomography or Magnetic Resonance Imaging to rule out brain lesions. 

Kidney and Liver Function 

NA: 133 mEq/L 

K+: 3.9 mEq/L 

BUN: 11 mg/dl 

CREA: 1.07 mg/dL 

GLU: 96 mg/dL 

ALBUMLX: 4.6 G/dL 

ALT: 39 IntUnit/L 

AST: 27 IntUnit/L 

Lipid Profile 

CHOL: 158 

HDL: 38 

LDL (CAL): 111 

TRIG: 66 

Complete Blood Count (CBC) 

WBC: 15.1 

RBC: 7.3 

HGB: 15.5 

HCT: 59 

MCV: 62 

Platelet: 410 

Diagnosis DSM 5 

Major Depressive Disorder 

Depressed Mood- The patient was somber and felt empty 

Suicidal ideation – the patient attempted to stab himself once while at school 

Loss of interest (does not want to engage in other activities in a similar manner to his schoolmates). 

Significant Weight Loss 

B. Symptoms causing clinically significant impair emend 

C. Symptoms not attributable to substance abuse as the patient confesses as never to have been involved in drug use. 

D. The symptoms of the patient cannot be attributed to schizoaffective, delusional, or schizophrenic disorders. 

E. Absence of a manic episode. 

The DSM-5 criterion is an authoritative guide for diagnosing mental disorders globally. The descriptions and symptoms of the conditions provide a common language for psychiatrists to communicate and establish a reliable diagnosis. The criteria for diagnosing anxiety disorders is contingent on the manifestations of fear and highly comorbid related behavioral disturbances. The DSM-5 criteria for generalized anxiety disorders are based on the manifested level and frequency of occurrence of worry (American Psychiatric Association, 2019). According to the criteria, worry about certain events or activities, and persists for at least six months meets the diagnosis of GAD. 

Suicidal Risk Assessment 

This method involves evaluating the patient’s suicidal tendencies. This is through observing the possible indicators such as warning signs, protective factors, risk factors, and the responses and changes to situations and psychiatric therapy. During the evaluation, the patient is assessed for the potential to inflict harm on themselves or others (American Psychiatric Association, 2019). An important indication for suicidal ideation in the case was the patient’s assertion that he would wish to end it all forever. 

SBQ-R Test 

The Suicide Behaviors Questionnaire-Revised (SBQ-R) is an assessment test that is used to evaluate the risk of suicide for psychiatric patients between the ages of thirteen and eighteen. There are four questions in the test. These questions are required to be filled by the child psychiatric patient. Filling the questionnaire usually takes between 3 and 5 minutes to be fully completed. This specific tool is quite effective and reliable with regard to children in the adolescent ages. It has also been established that the test can also be successfully used in individuals attending college or university, that is young adults. An advantage of the tool is that it asks questions on the individual’s future anticipation on suicidal ideations or tendencies together with similar past behaviors. This is not particularly a strength of other suicide assessment tools. 

Patient Test Scores 

Q1 score of 3a- had a plan once to kill himself but did not want to die (Ever Thought) 

Q2 score 2- Rarely one time (How Often) 

Q3 score1- No. (Never told someone) 

Q4 score 2- Rather Unlikely (Future Attempts) 

Total Score 8 

Differential Diagnosis 

Bipolar Disorder 

The patient displays symptoms of a mood disorder as he often shifts between feelings of elation and depressive or hypomanic behavior. There is, however, absence of manic episodes. According to the DSM-5 criteria for Bipolar Mood disorder, the patient meets the criteria of a depressive episode presenting with a depressed mood for most of the day, feelings of worthlessness, and suicidal tendencies (American Psychiatric Association, 2013). However, the patient does not have a significant hypomanic episode. 

Borderline Personality Disorder 

The patient has in recent months and weeks showed reduced self-esteem as he continually feels that he does not belong at his high school. He feels not at peace with his fellow schoolmates and has a restrained and constrained relationship with them. He has an abnormally intense fear of failure, which explains the reason as to why he reads feverously. The patient says that although he wants to be helped and to improve the relationship with those around him, he also harbors feelings of hostility to those around him and usually is withdrawn and feels unwanted. The relationship with those around him is extensively constrained. The patient meets two criteria of DSM-5, which are unstable interpersonal relationships and suicidal ideation and tendencies (American Psychiatric Association, 2013). 

Generalized Anxiety Disorder 

The patient says that he has been recently feeling the pressure of joining high school and that he thinks that he may have issues integrating both socially and academically. Additionally, he has also shown increased signs of fear and anxiety that are not remotely proportional to the external emotional stimulus (American Psychology Association, 2019). The fear, worry, and restlessness are severe enough to impair his normal social and also his role as a student (Portico, 2019). There is also interrupted sleep patterns and profuse sweating without symptoms of fever and abdominal disturbances. These features are a part of the DSM-5 criteria for Generalized Anxiety Disorder. 

Drug-Induced Mood Disorder 

The patient also displays symptoms of a mood disorder as he often shifts between feelings of elation and depressive or hypomanic behavior. The patient may be hiding a history of drug abuse considering his tender age. The patient meets DSM-5 criteria for a depressed mood, that cannot be explained by delirium, the disturbance is not explained by a mood disorder, and the symptoms cause significant social distress (American Psychiatric Association, 2013). 

Adjustment Disorder with Depressed Mood 

The patient may still be finding it difficult to adapt to his new high school environs and this coupled with the depressed mood can be classified as Adjustment Disorder with Depressed Mood according to DSM-5 (American Psychiatric Association, 2013). 

Treatment Plan 

Pharmacotherapy 

Selective Serotonin Reuptake Inhibitors (SSRIs) such as fluoxetine 

Tricyclic Antidepressants if unresponsive 

Mood Stabilizers such as Valproic Acid (Acute Mania), Carbamazepine (Tegretol), or Lamotrogine. 

Atypical antipsychotics: Olanzapine for agitation and restlessness. 

Antidepressants such as imipramine or fluoxetine as the cause of the mood disorder appear to be depression 

Psychotherapy 

Drug counseling and supportive therapy may be beneficial. 

Cognitive-behavioural therapy, 

Individual Psychotherapy 

Insight-oriented psychotherapy - elimination of symptoms and the durable reshaping of abnormal interpersonal patterns. It is assumed that important past experiences shaping the patient's difficulties have been forgotten. 

Family Counselling - Helps to lower Family expressed emotion and to reduce patient relapse and teach patients and their family members to cope with the illness. 

Life Skill Training 

Social Skill Training: - Work and Social Skills, Grooming and Self-care. 

-Vocational Rehabilitation and Supported Employment 

Electroconvulsive Therapy (ECT) 

Electroconvulsive Therapy is a medical intervention that is usually applied to psychiatric patients who have symptoms of a bipolar mood disorder or in other instances, patients with extensive or severe major depression. Normally these patients show an inadequate response to other forms of interventions, especially pharmacotherapy. The process involves passing electrical current briefly through the brain when the patient is under general body anesthesia. 

Prognosis 

The patient has insight and is, therefore, likely to recover from the disorder as he is also willing to comply with medication. Absence of comorbid conditions such as diabetes and cardiovascular complications may improve prognosis. However, these factors should be handled in a cautionary manner considering the patient’s age. Absence of personality disorders and no history of drug abuse also improves prognosis. 

Web Information and Patient Referrals 

Several online sites and platforms can help the patient deal with his condition in a much better way. A good example would be the website of the Anxiety and Depression Association which offers several resources that can help the patient learn his condition better and how to handle different symptoms for his betterment and ultimate cure. Addition American Psychiatric Association offers similar information for free. Currently, there are no available support services for the patient at his current location. 

References 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders.  BMC Med ,  17 , 133-137. 

American Psychiatric Association. (2019). DSM-5: Frequently Asked Questions. Retrieved on 27 th September 2019 from https://www.psychiatry.org/psychiatrists/practice/dsm/feedback-and-questions/frequently-asked-questions 

American Psychology Association (APA). (2019). What Are Anxiety Disorders? Retrieved on 27 th September 2019 from https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders 

Portico. (2019). Anxiety Disorders. Assessment and Diagnosis. Retrieved on 28 th September from https://www.porticonetwork.ca/treatments/disorders-qr/anxiety-disorders/anxiety-disorders-assessment-diagnosis