60 yo F Patient works in the IT department of Ford, recently retired
CC: ALTERED MENTAL STATUS
MRI: Ventricles and sulci are normal in size. No extra-axial fluid collections mass effect hemorrhage or midline shift.
Few very small areas of bright signal intensity in the white matter bilaterally on FLAIR and T2-weighted imaging sequences. These do not enhance and likely due to demyelination. This is nonspecific in their MR appearance most frequently seen with microvascular ischemic changes. Mild mucosal thickening in the ethmoid air cells bilaterally.
IMPRESSION: A few small areas of demyelination in periventricular white matter.
Extended Workup:
Lumbar Puncture/ CSF Studies: RBC: 2, WBC: 2 Glc 57 Protein: 38 LDH: 21 HSV: Negative Culture: negative
Sed Rate: 22 Crp 0.9 HIV Neg, Ammonia WNL AST/ALT Normal
30 minute and 48 hour EEG: Normal
SECONDARY STUDIES: Crypto neg, VDRL neg, JC Virus Neg, 14-3-3 and Tau Protein Neg,
NMDA Neg Vit B1: 66 (nl)
PSYCH EVAL: Episodes of Altered Mental Status/Confusion/Agitation
Severity: moderate to severe (requiring multiple hospitalizations)
Associated signs/symptoms: psychomotor agitation, confusion
Context/Contributing factors/stressors: retirement
Timing: daily
Pt was perseverative “you have a nice smile” The pt also expressed interest in going into the bathroom so that she can feel safe. She is concerned about ‘technology, that we all use, we all have it, and we are all love and love each other”. On exam she denies any medical complaints but continues to state “the thing with technology is that it is changing” and ” I worry about security” and “I just want everyone safe” and “I just need to trust people.”
Sexual/Physical Abuse: (No response)
Rapport: minimally cooperative, +moderately interactive, usually pleasant but intermittently agitated and irritable
Thought Process: non-linear, + nonsequitors, non-coherent, intermittently goal directed
Thought Content: denies suicidal/homicidal ideation, difficult to exclude hallucination/delusion, though none apparent
Speech: regular rate, rhythm, volume, tone, articulation, prosody
Motor: + psychomotor agition; no rigidity appreciated
Mood: “tired”
Affect: Congruent, animated, anxious
Insight/Judgment: poor/poor
Cognition: pt is oriented to person and place; not oriented to time; not oriented to situation
- Given the extensive negative medical workup, what diagnoses are left in your differential?
- What about her initial history gave clues for a possible psych diagnosis?
Diagnosis is not the end, but the Beginning of Practice
Martin Fischer
