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Old 08-23-2014
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Default Can anyone explain this question!!! thanks

47-year-old woman is admitted to the hospital for evaluation of a 2-week history of increased irritability and racing thoughts. Her family reports that she argues with anyone who does not agree with her. She has been talking incessantly at a rapid rate and pacing around the house. She says that, for years, she has been hearing the voice of God telling her that she has been chosen for a special mission. She has barely slept for the past week, waiting to hear further messages from God. She is disheveled and dehydrated. Serum studies show:


Na+ 137 mEq/L
Cl– 96 mEq/L
K+ 3.8 mEq/L
HCO3– 22 mEq/L
Urea nitrogen (BUN) 30 mg/dL
Glucose 68 mg/dL
Creatinine 1.2 mg/dL

Mental status examination shows disorganized thoughts and flight of ideas. She is agitated and has difficulty staying seated. She is too distractible to perform cognitive tests. Toxicology screening is negative. Which of the following is the most likely diagnosis?

A
) Acute renal failure

B
) Borderline personality disorder

C
) Diabetes insipidus

D
) Narcissistic personality disorder

E
) Schizoaffective disorder

F
) Schizoid personality disorder
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  #2  
Old 08-24-2014
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Quote:
Originally Posted by s.med View Post
47-year-old woman is admitted to the hospital for evaluation of a 2-week history of increased irritability and racing thoughts. Her family reports that she argues with anyone who does not agree with her. She has been talking incessantly at a rapid rate and pacing around the house. She says that, for years, she has been hearing the voice of God telling her that she has been chosen for a special mission. She has barely slept for the past week, waiting to hear further messages from God. She is disheveled and dehydrated. Serum studies show:


Na+ 137 mEq/L
Cl– 96 mEq/L
K+ 3.8 mEq/L
HCO3– 22 mEq/L
Urea nitrogen (BUN) 30 mg/dL
Glucose 68 mg/dL
Creatinine 1.2 mg/dL

Mental status examination shows disorganized thoughts and flight of ideas. She is agitated and has difficulty staying seated. She is too distractible to perform cognitive tests. Toxicology screening is negative. Which of the following is the most likely diagnosis?

A
) Acute renal failure

B
) Borderline personality disorder

C
) Diabetes insipidus

D
) Narcissistic personality disorder

E
) Schizoaffective disorder

F
) Schizoid personality disorder

A. Acute renal failure ==> excluded
because case is not consistent with that one. BUN is increased just becoz she is dehydrated, renal perfusion decreased.



B. Borderline ==> excluded
because in borderline personality disroder, there's splitting (someone is completely good and the other is absolutely bad). no psychosis either.

C. Diabetes insipidus ==> excluded
not consistent

D. Narcissistic personality disorder ==> no
Narcissistic are someone who think themselves very important persons. eg, a patient come to your office, and your receptionist ask him to wait. He become very angry and shout to the receptionist that "do you know how important I am"?

F. Schizoid personality disorder ==> no
schizoid tends to live alone , not like dependent personality disorder (in dependent personality disorder, they also tend to avoid people, just because they are afraid of rejection, not because of their natural wish)

Ans is Schizoaffective disorder

this is the best one although I don't like it 100% since to diagnosis schizoaffective, you need 2 facts,

1.mood disorder to be present in majority of illness (majority of psychosis illness).
2. there have to be at least one mood free psychosis episode (at least 2 weeks)

her mood symptoms just only started. So, I don't know may be the diagnosis could be change from pure schizophrenia to schizoaffective (assuming her mood symptoms would last long together with psychosis symptoms).

just my 2 cents.
may be I wrong.
Thanks
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  #3  
Old 08-24-2014
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Quote:
Originally Posted by doingmybest View Post
A. Acute renal failure ==> excluded
because case is not consistent with that one. BUN is increased just becoz she is dehydrated, renal perfusion decreased.



B. Borderline ==> excluded
because in borderline personality disroder, there's splitting (someone is completely good and the other is absolutely bad). no psychosis either.

C. Diabetes insipidus ==> excluded
not consistent

D. Narcissistic personality disorder ==> no
Narcissistic are someone who think themselves very important persons. eg, a patient come to your office, and your receptionist ask him to wait. He become very angry and shout to the receptionist that "do you know how important I am"?

F. Schizoid personality disorder ==> no
schizoid tends to live alone , not like dependent personality disorder (in dependent personality disorder, they also tend to avoid people, just because they are afraid of rejection, not because of their natural wish)

Ans is Schizoaffective disorder

this is the best one although I don't like it 100% since to diagnosis schizoaffective, you need 2 facts,

1.mood disorder to be present in majority of illness (majority of psychosis illness).
2. there have to be at least one mood free psychosis episode (at least 2 weeks)

her mood symptoms just only started. So, I don't know may be the diagnosis could be change from pure schizophrenia to schizoaffective (assuming her mood symptoms would last long together with psychosis symptoms).

just my 2 cents.
may be I wrong.
Thanks
That's what I thought...that you need at least a 2 weeks period without mood sx's. but I guess according to this question you don't...>?.. I was thinking Narsacistic cuz' pt said she's the chosen one from God...has some grandiosity features. although doesn't fit the exact picture either. but it doesn't fit the exact picture for Schizoaffective either. thanks
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Old 08-24-2014
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Quote:
Originally Posted by s.med View Post
That's what I thought...that you need at least a 2 weeks period without mood sx's. but I guess according to this question you don't...>?.. I was thinking Narsacistic cuz' pt said she's the chosen one from God...has some grandiosity features. although doesn't fit the exact picture either. but it doesn't fit the exact picture for Schizoaffective either. thanks
Narsicisstic is way more unlikely. she thought she's chosen from god is delusion. Narcissistic persons have grandiosity but not delusion. Moreover, we can assume that delusion as Bizzare delusion. personality disorder don't come with bizzare delusion. Eg, delusional personality disorder might have delusion but the delusion is not bizzare (like someone is trying to poison his/her food).

yes, I assume she did have psychotic features (delusion for years).

Oh wait I rechecked the question, she also had auditory hallucination for years ===> She says that, for years, she has been hearing the voice of God telling her that she has been chosen for a special mission

clearly psychotic symptoms. not Narsicisstic.
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Old 08-24-2014
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Quote:
Originally Posted by doingmybest View Post
Narsicisstic is way more unlikely. she thought she's chosen from god is delusion. Narcissistic persons have grandiosity but not delusion. Moreover, we can assume that delusion as Bizzare delusion. personality disorder don't come with bizzare delusion. Eg, delusional personality disorder might have delusion but the delusion is not bizzare (like someone is trying to poison his/her food).

yes, I assume she did have psychotic features (delusion for years).

Oh wait I rechecked the question, she also had auditory hallucination for years ===> She says that, for years, she has been hearing the voice of God telling her that she has been chosen for a special mission

clearly psychotic symptoms. not Narsicisstic.
"for years"...I completely ignored that!! lol....now it makes this question so easy. for years and they gave 2-weeks.
thanks.
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