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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Given a description of a patient case, identify and assess the symptoms of an acute episode of bipolar disorder.

  • Recommend appropriate pharmacotherapy for patients with acute mania.

  • Generate parameters for monitoring anticonvulsant therapy for bipolar disorder.

  • Identify the pharmacotherapeutic options for treating the subtypes of bipolar disorder.

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PATIENT PRESENTATION

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Chief Complaint

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“I am trying to keep the evil spirits away!”

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HPI

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Tyler Clemens is a 28-year-old man brought by the police to the Crisis Center for an emergency evaluation. According to neighbors who called the police, the patient has been acting increasingly strange. The lights in the house are left on all night, and loud music is played at all hours. Last evening, he dug a trench around his front yard with an electric lawn edger and filled it with various herbal plants. This evening, he hung wreaths and horseshoes on his front door and threw many of his belongings into his yard and the street. When approached by neighbors, he apparently began screaming and preaching at them. When the police arrived, they found the patient standing naked on the dining room table in his front yard preaching. When the police approached, he began throwing garlic cloves at them and screaming, “I refuse to let you all curse me in my own home.” He became increasingly hostile during the arrest shouting, “You can’t do this – I have rights!” He then tried to bite one of the officers.

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PMH

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Manic episodes first occurred while he was in college, leading to psychiatric admissions at ages 21 and 23 for acute mania. Patient was treated with haloperidol and lithium, with adequate response and discharged on both occasions after about a month. Adherence to outpatient treatment has been inconsistent, with several documented missed appointments and prescription refills.

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He also receives outpatient treatment for migraine headaches and shift work disorder.

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Patient Interview

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Patient is disheveled with pungent body odor. He is pacing the room, waving his hands in the air and preaching in an elated, loud, sing-songy voice. He is wearing a dirty t-shirt and jeans. When asked how he felt, he stated, “Playful, with intense clarity, sharp, spiffy, and clean.” He then became hostile and angry, insisting that he be discharged before sunrise or he would “be tormented by the demons forever.” He claims to have witnessed spirits that attached themselves to various people and that now control their thoughts and actions. He spoke in long run-on sentences with many political, religious, and sexual references. He was very difficult to interrupt. For example, at one point he stated, “Can’t you see, or are you an idiot?! I am being persecuted by the evil spirits I ...

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