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Student no. z3167924 Word count: 1800

(excludes headings, in-text citation, tables and references)

Mrs P.J is a 52 year old Caucasian divorcee that have recently moved from Queensland to Sydney to spend time with her mum who is dying due to lung cancer that was diagnosed 4 years ago. According to her brother, although she is unemployed at the moment, she is living well on her savings from her previously successful business. Interviews and observations were carried out during her admission to kiloh general ward. A collateral history was also obtained through a phone call to her brother.

History of presenting complaint Mrs P.J was brought into acute kiloh ward by the ambulance after her brother who was concerned of her wellbeing called the acute care team. Collateral history from her brother revealed that Mrs P.J has been experiencing worsening mood ever since she moved from Queensland to Sydney to spend time with her mother who was dying from lung cancer. For the past 6 months, she has experienced multiple episodes of suicidal thoughts followed by an occasion when she had an attempted suicide by swimming out into the ocean. During her stay at Kiloh observation ward, her insomnia did not improve mood was resistant to treatment with Diothiepin. She continued to complain of decreased appetite resulting in low energy levels and unmotivated to do anything. She also reported of an overwhelming sense of hopelessness and worthlessness since the start of her divorce 4 years ago. She also became agitated and tried to abscond from the wards when she was not discharged according to her will.

Past psychiatric illness - Declines any past psychiatric illness - Her past medical records from Queensland Hospital reports of several suicidal ideations since the age of 16 years old. Legal issues - No forensic history Drug and alcohol history

Declines any use of any illegal drugs. Smoked for 20 pack years Denies any alcohol abuse or dependence

Family medical/mental history - Mother is dying of lung cancer. - No other known medical or mental history Medical history - Declines any known or significant medical conditions. Drugs and Allergies - No known drug allergies Past medications - Antidepressants: Diothiepin Current medications Mrs P.J declines being on any medications, despite evidence from medical notes describing that she was administered with the following medications: - Anxiolytic: Midazolam - Antidepressants: Diothiepin - Antipsychotics: Quetiapine

Developmental and personal history Mrs P.J was born in Canberra. She had a good childhood and enjoyable teenage years. However during young adulthood, she describes to have increasing difficulties in relationships. Although she was married to her boyfriend of 5 years, she reports of having difficulties from the start of the relationship which led to the separation 4 years ago. Current functioning and supports She has stopped worked for 10 years. She used to run a successful fitness business many years ago and is able to support herself and owns a property. Have very little emotional support apart from her brother. She is distressed about her recent divorce and her mums state of lung cancer.

Mental state examination

Appearance & Behaviour My first impression of Mr PJ is that she is relatively well groomed and casually dressed. During the interview, she only established eye contact intermittently. Overall, she was very withdrawn providing very short answers which proved to be very uncooperative. Speech She had a slurred speech. Mood Her mood was depressed throughout the interview. Affect Her affect was inappropriate (E.g. She was laughing when she said she smelt like faeces) Thought form There was poverty of thought throughout her interview as reflected by her lack of responses. Thought content She has no auditory or visual hallucinations. She reports of olfactory delusions as she describes herself as smelling foul and that other people thinks that she is foul despite providing evidence that she doesnt. In addition, she also complained of nihilistic thoughts of herself being made up of rubbish that is taking up oxygen. She also reports ongoing suicidal ideation if she was released from the hospital. She also has delusions of poverty as she thinks that she is not achieving anything in life even thought she had a successful fitness business. Insight She has poor insight to her psychiatric illness. Judgement Mrs PJ also has mild impaired judgement as well. She denies that she is receiving any form of treatment at the moment. She became very aggressive and resistant to attend a tribunal to extend her stay in the hospital for further treatment. Cognitive examination

She was alert. She was orientated to the time, date and place (she was aware that she is admitted in the mental institution Kiloh Centre) at the time of the interview. The cognitive assessment was cut short as the patient said she felt intimidated and embarrassed by the questions asked. There was no evidence of language deficits (she was able to converse well) or memory deficits (she could remember past events like her divorce and recent significant events like her mum who is dying from lung cancer), that is suggests of a cognitive disorder.

Risk Assessment
A mental risk assessment was performed on Mrs PJ enquiring about general risk factors, risk for suicide, violence/aggression, other vulnerabilities. General risk factors Risk for suicide Background Current Major depressive disorder Major depressive disorder Psychotic nihilistic delusions Multiple suicide attempts Mother is dying from lung cancer. since the age of 16 Hopelessness Expresses high levels of distress Divorced Has plans to commit suicide after being discharged Isolated and unemployed Agitated during current admission Paranoid ideation about others Other vulnerabilities. History of absconding from wards She no thoughts of harming others. Current nihilistic delusional beliefs Desired to leave hospital displayed by her multiple attempts to abscond from the ward.


Investigation Full Blood Count Blood Electrolytes Regular blood pressure monitoring Weight monitoring Indications Regular monitoring Regular monitoring Regular monitoring to monitor possible weight lost as a result of lost of appetite Results Normal 135/90 mmHg No weight fluctuation from initial weight on admission 65kg.

Mrs PJ is not functional during this current admission. She does not have any symptoms or signs that are suggestive of a cognitive disorder. My impression of Mrs P.J is that she has psychotic depressive disorder.

Differential diagnosis
Psychotic depressive disorder Mrs PJ was observed to have severely depressed mood. Her provisional diagnosis of psychotic depressive disorder is supported by the presence of various clinical findings. Throughout her stay at Kilo, she consistently reported pathological guilt (She feels guilty for being a living waste that takes up oxygen.). Although she does not report of any auditory hallucinations, she has delusions of poverty (describing herself as such a failure in life not being able to achieve anything despite having a successful business in the past). Mrs PJ also expressed thoughts of olfactory delusions (She insists that she smells like rubbish despite being told that she doesnt) and nihilistic delusions of herself smelling like faeces, thereby supporting the diagnosis of psychotic depressive disorder where delusions are more common than hallucinations as in schizophrenia related disorders. Melancholic depressive disorder During the initial phase of her current admission, she reported increasing symptoms of anhedonia and diurnal variation in terms of mood and energy. During the ward round interviews, she was unresponsive towards the interviewers. Furthermore, she was often observed to remain motionless in bed. Taking into account of the predominant psychomotor disturbance picture during her initial phase of her admission, a possible differential diagnosis would be melancholic depressive disorder. Post traumatic stress disorder (PTSD) Mrs P.Js depressive symptoms lasted more than a month, ever since her divorce four years ago. Since then, it has caused her clinically significant distress and impairment in her social and occupational aspect of her life. As such, post traumatic stress disorder is another differential diagnosis to consider.

However, Mrs P.Js diagnosis does not fit the picture of PTSD for the following reasons: 1. She reported depressive symptoms of insomnia, anhedonia, worthlessness and helpless leading multiple suicidal ideation and attempts ever since the age of 16, years before her divorce. 2. She did not persistently re-experience the events that led to and came after her divorce.

Provisional diagnosis Psychotic depression with persisting suicidal ideations. Axis Summary Axis Axis I Axis II Axis III Axis IV Axis V Comments Major Depressive Disorder Possible underlying Borderline Personality Disorder Nil Inadequate social support Dying mother (from lung cancer) GAF = 45 (on admission)

Management plan
Despite being a patient with high suicidal risk and having psychotic features of depression, Mrs P.J was reluctant to be hospitalized. As a result, she was scheduled under the Mental Health Act to receive involuntary treatment. Overall management of Mrs P.J can be divided into largely short term and long term. Short Term The short term management plan of Mrs P.J involves providing her with anxiolytic (midazolam) to calm her down. Antipsychotic quietiapine was administered to curb her auditory delusion, while Diothiepin was administered for her depressed mood. On the 10th day of admission, she tried to abscond from the wards. As a result she was kept in an isolation room where facilities were kept to a minimal to remove potentially dangerous objects. Daily ward rounds from the treating psychiatrist were made to monitor Mrs P.Js mood.

As her mental health enquiry was held on her 14th day of admission to extend her length of stay in treatment at Kiloh to enforce involuntary treatment, as her psychotic delusions and suicidal ideations have not subsided. Although Mrs P.J was initially kept in an isolated room that is locked have tried to abscond from the wards, special considerations were made on the basis that her mum who was dying would be visiting her. As a result, the treating psychiatrist accepted her requested to stay at the general ward with heightened supervision instead of being locked up in the isolation room. Meanwhile, meetings with a clinical psychologist were arranged to help her cope with the bad news of her mothers health condition. Long term management The option of electroconvulsive therapy was explained to Mrs P.J for her consideration on her 14th day of admission, as her symptoms of low mood, suicidal ideation were escalating and she have even tried to escape from the wards to avoid treatment. Prior to her discharge, the acute care team was notified of her situation. The acute care team would be responsible for providing brief crisis intervention to Mrs P.Js well being, through daily phone calls after she is being discharged. A referral to a private psychiatric hospital (St. John of God, Burwood) for long term psychotherapy was planned for Mrs P.J to help her cope with her intermittent suicidal ideations.