Case 1:

38 year old female married sari-sari store owner

8 days PTA, had undocumented fever for 2 days relieved without intake of medicine.
6 days PTA, patient was noted by husband to have blank stares, no headache, no insomnia, no
hallucinations reported, no irritability, decreased appetite, no fever. Patient was brought to a
hospital, CT scan was negative. 4 days PTA, patient was incoherent, aggressive, disoriented
and with no verbal output. Husband noted "seizure like movement of arms". No fever was
noted. Persistence of symptoms prompted consult and admission. Patient had a history of "
depression" in high school but no consult was done no meds taken. Patient was referred
to psychiatry for evaluation and management.
1. What are your differential diagnoses for this case?
● Absence seizures - brief sudden lapses of consciousness; staring blankly into
space for few seconds -> quick return to normal level of alertness
● Depression relapse - hx of untreated or unconsulted depression, decreased
appetite, blank stares, no verbal output, aggression
2. What information would you need to find out if given a chance to interview the husband?
● HPI
○ Any other associated symptoms
○ Does the patient have disruptions in her previous routines?
○ What makes the symptoms worse?
○ Why is there no consultation about her previous depression?
○ Has it happened before? First time?
● Personal and social history
○ Ask for her lifestyle, vices and diet?
○ Does the patient have a good support system from her family when she is
young and also now to his husband and family?
○ Sleep patterns
● PMH
○ If diagnose with other diseases
○ Other previous hospitalizations
3. What is the most probable diagnosis for this case?
a. Depression

Rule in Rule out

● History of untreated depression

● Decreased appetite
● Blank stares
● No verbal output
● Aggression
○ Sometimes anger can be a
 symptom of depression

4. How will you manage this case?

● PHARMACOTHERAPY
○ Antidepressants
● CBT
● Patient education
● Psychotherapy

Case 2
52 year old businessman, admitted at the ICU of Lung Center.
He had severe pneumonia and had to be intubated. He was sedated with Diazepam 10 mg at
bedtime. He was mostly asleep, however upon waking up he became agitated and started to
pull everything out from his body.
He claimed that his business associates were out to kill him. He pulled out his IV, and his
ET tube. He was also maintained on levofloxacin 750mg / IV every 24 hours. He is referred to a
psychiatrist for the management of his agitation. His wife denies any psychiatric illness but has
noted that her husband has shown depressed mood, initial insomnia and loss of appetite for
3 weeks.
1. What are the possible causes of his agitation?
● Pneumonia
○ Severe pneumonia can lead to serious complications such as agitation.
● Diazepam 10 mg
○ Taking too much of this drug can cause depression of your central nervous
system (CNS). Symptoms include: drowsiness. confusion.
● Mental Disorder (MDD)
○ The patient show depressed mood, initial insomnia and loss of appetite

2. Does he have a mental disorder? If yes, how does his pneumonia or the management of
his pneumonia affect his mental disorder?
● Yes.
● The hospitalization for pneumonia increased the risk of subsequent depression,
functional disability and cognitive impairment.
● Pneumonia patients with DD were associated with poor treatment outcomes
compared to patients without DD.
 3. How does or how can his mental disorder affect his medical illness?
● One reason for the increase in severity of respiratory diseases in people with mental
health conditions: they are less likely to seek care for their physical health.
● People with mental disorders can also develop unhealthy habits that can play a role in
increasing disease severity.
● Mental disorders can make dealing with medical illnesses more difficult.

Case 3
A 48 year old female diabetic, hypertensive with end stage renal disease has been on
hemodialysis 3 times a week for 2 years. She had often lamented how tired she was of
going for hemodialysis 3 times a week. A kidney donor that was a perfect match was found
and she was scheduled for a kidney transplant. During the preparation for her transplant, she
developed initial insomnia, became agitated and kept asking her doctor and her family if they
can reassure her of the success of her transplant. She was worried she might die on the
operating table or might have postoperative complications that will make her condition worse.
2 days before her operation she wanted to back out prompting the consult.
1. 1. Why did the patient change her mind? Does she have a mental illness? If no, what is
the explanation for her behavior?
● No???? The patient might have pre-operative anxiety or surgical fear in which
she has an uncomfortable, tense and unpleasant mood prior to surgery. This is
an emotional state resulting from anticipation of a threatening event by patients
waiting for surgery.
● Her anxiety might be coming from the fear of the surgery itself, not waking up
after anesthesia, loss of control, and/or the possible complications after surgery.
2. If she does have a mental illness what is it and how will you manage it?
● Adjustment Disorder with anxiety OR with mixed anxiety and depressed mood
(not sure!)
○ Adjustment disorders are characterized by an emotional response to a
stressful event. Stressor involves financial issues, a medical illness, or
relationship problems.(Kaplan)
○ Adjustment disorders are one of the most common psychiatric diagnoses
for disorders of patients hospitalized for medical and surgical problems.
(Kaplan)
○ The development of emotional or behavioral symptoms in response to an
identifiable stressor(s) occurring within 3 months of the onset of the
stressor(s). (DSM-5)
○ Adjustment disorders can be diagnosed immediately and persist up to 6
months after exposure to the traumatic event. (DSM-5)
○ Management:(Kaplan)
■ Psychotherapy - treatment of choice
■ Crisis Intervention - short-term treaments aimed at helping
persons with adjustment disorders resolve their situations quickly
by supportive techniques, suggestion, reassurance, environmental
modification, and even hospitalization, if necessary
 ■ Pharmacotherapy - no studies have assessed the efficacy of
pharmacological interventions, but it may be reasonable to use
medication to treat specific symptoms for a brief time.
■ Severe anxiety bordering on panic: anxiolytics
■ Withdrawn or inhibited states: psychostimulant medication
■ Antidepressants

ADJUSTMENT DISORDER

RULE IN RULE OUT

● Insomnia
● Being anxious or agitated (anxiety)
● Feeling depressed???- She had often
lamented how tired she was of
going for hemodialysis 3 times a
week.
● Reassurance seeking - anxiety
● Women are diagnosed with the
disorder twice as often as men

3. What is your recommended management for this patient?

● Crisis Intervention - short-term treatments aimed at helping persons with
adjustment disorders resolve their situations quickly by supportive techniques,
suggestion, reassurance, environmental modification, and even hospitalization, if
necessary
● Educate the patient as well as the family about the surgical procedure and help
them prepare for the transplant process.
● Self-help groups provide patients with preoperative and postoperative support.
● Listen to the patient’s concerns and help her understand that her safety is of
utmost priority.
● Encourage the family to show support to the patient by being positive about the
transplantation process.
● Coordination of care
● Involvement of anesthesia personnel
● Autonomy-enhancing behavioral techniques - coping

Case 4
Patient is a 34 year old male, married, admitted because of recurrent abdominal pain,
weight loss, easy fatigability, and jaundice. Diagnostics were done which included abdominal
ultrasound, blood chemistry, and fine needle biopsy. The diagnosis of pancreatic cancer was
not disclosed to the patient and his family. Patient was informed by the 1st year resident that
he needs to have chemotherapy. Patient became agitated and refused chemotherapy.
Patient was then referred to psychiatry for evaluation and management of agitation.
1. What are the possible differential diagnoses for the patient's agitation?
○ Depressive Disorder due to another Medical Condition
■ Researchers have long noted that depression and anxiety are common in
pancreatic cancer patients. When patients with newly diagnosed
advanced gastric or pancreatic cancer were assessed for depression, the
patients with pancreatic cancer were found to have a greater incidence of
depression and related symptoms, which can contribute to a lower quality
of life.
■ Depression is a common symptom of pancreatic cancer, with some early
data suggesting that the mood disturbance is mediated by alteration of
brain serotonergic function through proinflammatory cytokines
○ Anxiety Disorder
■ It is also common in pancreatic cancer patients with a high prevalence
rate of 68% alongside depression. Practitioners often think that this is a
normal condition since it is common but any excessive feeling is not
normal which can lead to impaired functioning and increase intensity of
symptoms and distortion of perception
■ DSM - 5 Panic Disorder
1. Recurrent unexpected panic attacks
2. A panic attack is an abrupt surge of intense fear or intense
discomfort that reaches a peak within minutes, and during which
time four (or more) of the following symptoms occur;
3. Note: The abrupt surge can occur from a calm state or an anxious
state.
○ Acute Stress Disorder
■

○ Adjustment Disorder with anxiety

■ The development of emotional or behavioral symptoms in response to an
identifiable stressor/s occurring within 3 months of onset of the stressor
■ Evidence by one or both:
1. Marked distress that is out of proportion to the severity or intensity
of the stressor, taking into account the external context and the
cultural factors that might influence the severity and presentation
2. Significant impairment in social, occupational, or other important
areas of functioning
■ The stress - related disturbance does not meet the criteria for another
mental disorder and is not merely an exacerbation of preexisting mental
disorder
■ The symptoms do not represent normal bereavement
 ■ Once the stressor or consequences have terminated, the symptoms do
not persist for more than an additional 6 months

2. Should this patient be referred to Psychiatry? What type of Consultation Model is

described by this referral?
○ Yes, Crisis - Oriented Consultation because the patient is agitated already due to
immediate assessment and rapid disclosure of treatment without informing the
patient the diagnosis or the reason why he is referred to chemotherapy.

3. What should the psychiatrist do in this situation? What steps should be done to help both
the patient and the consultee?
○ Psychiatric Care
■ Offer expert diagnosis and management of comorbid psychiatric
conditions
■ Collaborated with oncologist on psychiatric conditions that get in the way
of oncologic care
■ Recognize and manage cancer-related or cancer-treatment-related
neuropsychiatric syndromes
■ Help patient and their families cope with the different phases of cancer
diagnosis and treatment
■ Facilitate the patient’s strengths and adaptive capacity
■ Bolster the patient’s outside resources
○ Psychiatric liaison
■ Speak directly with the referring clinician
1. Resident to resident / consultant to consultant
■ Review the current records and pertinent past records.
■ Review the patient’s medications.
■ Gather collateral data.
■ Ask if the patient knows that he/she is referred to a psychiatrist.
■ Interview and examine the patient.
■ Formulate diagnostic and therapeutic strategies.
■ Write a note.
■ Speak directly with the referring