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Board doctors: question about psychiatric diagnosis
Posted by td01241 on 6/5/20 at 5:36 pm27
So I saw a new patient yesterday coming to me from a retiring psych, his notes had a diagnosis of Bi-Polar (seems everyone is these days) co-morbid with PTSD and ADHD (gross). They weren’t what what I’d consider thorough and these are all diagnosis with overlapping systems. Med regiment included Klonopin 2mg BID; 1mg daily mid day, Vyvanse 70mg daily; has Dexedrine booster for PRN didn’t need to refill yet but I don’t really have an issue with it, Mirtazapine 30mg nightly, Seroquel 50mg morning 300mg night, Lithium 300mg BID. Clonidine .2mg nightly (why?). During intake symptoms struck me as more BPD than Bi-Polar with PTSD particularly as it relates to lack of sleep (could be the vyvanse but with so many sedatives I find it unlikely). How would you proceed in this case? I’ve only been in practice for about 1 year. I started tapering Klonopin and nixed Mirtazapine and Clonidine continue the rest and asked to see again in 2 weeks with labs done immediately needed to continue lithium and seroquel. Referral to CBT-D which if they want to continue benzo at a lower dose (1mg BID is my target) I insisted on to try and solve anxiety issues. Drug screen showed Benzo and Amphetamine as expected also Marijuana which I explained can’t be in future UDS or I discontinue controlled substances. Contract with pill count call ins signed. I get crazy Med regimens a lot but both controlled substances being above FDA daily recommendation is concerning imo, don’t really mind the stimulant being slightly over especially considering Vyvanse conversion to dexamphet being what it is but that’s way too much Klonopin imo especially when they’re taking that much amphetamine.
This post was edited on 6/5 at 8:24 pm
re: Board doctors: question about psychiatric diagnosisPosted by Mingo Was His NameO on 6/5/20 at 7:23 pm to td01241
This seems like something I wouldn't post on the internet
re: Board doctors: question about psychiatric diagnosisPosted by td01241 on 6/5/20 at 8:25 pm to Mingo Was His NameO
No identifying info, could just as well be a hypothetical and I’m worried about moving too fast removing and tinkering with medication. Looking for recs from more experienced people.
This post was edited on 6/5 at 8:26 pm
quote:
So I saw a new patient yesterday
dates are considered PHI. you posted today and stated yesterday, hence the date of 6/4/20.
Your location is listed as Savannah, so a geographical location... also PHI
Why the frick would you post something so specific and high-level on a sports message board? Do you not have colleagues? mentors? frick, I hope you have someone more senior than you at this clinic. Go ask that person.
re: Board doctors: question about psychiatric diagnosisPosted by djangochained on 6/5/20 at 11:52 pm to td01241
Damn
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re: Board doctors: question about psychiatric diagnosisPosted by OleWarSkuleAlum on 6/6/20 at 6:39 am to td01241
Yeah...this definitely is something that is better asked from a practicing physician you know and not a message board.
re: Board doctors: question about psychiatric diagnosisPosted by bootlegger on 6/6/20 at 8:35 am to td01241
I understood about 4 words of that entire post
re: Board doctors: question about psychiatric diagnosisPosted by LSU Patrick on 6/8/20 at 11:36 am to td01241
As others posted, this is not the pace I would ask for help with this. However, since you already posted it, I'll offer a brief response. Hopefully, this will help you out until you can find another professional in person to bounce this off of. Build up that network, especially if you are in private practice!
I'm a psychologist with 10+ years experience as a treatment team member (me, psychiatrist, social worker, RN) at a psychiatric hospital. The things that jump out at me at first glance are the presence of both Bipolar Disorder and ADHD. In my experience, this is typically a red flag for an amphetamine addict. If the diagnosis of Bipolar Disorder is accurate, then that diagnosis should trump the ADHD diagnosis. You mentioned the overlap so I'm sure you had similar concerns. Stimulant medications for ADHD are going to at least exacerbate mania. They might even account for onset of mania if this patient had not presented with a manic episode prior to the initiation of of that medication.
I have seen this a lot with younger patients (ages 18-25), typically male, who presented with sleep disturbance, trouble concentrating, and hyperactivity earlier in adolescence and were diagnosed and treated for ADHD. However, it later became clear that those symptoms were actually early signs of a mood disorder that were misdiagnosed.
I am also curious about the PTSD diagnosis. Depending on whether this stems from childhood sexual abuse or combat experiences, that might lead me in different directions in terms of diagnoses. You mention that you are thinking more Borderline Personality Disorder than Bipolar Disorder but do not provide any background or examples of current symptoms. Is there a presence of self-harm, history of volatile and shallow relationships, splitting behavior, identity confusion, therapy interfering behavior?
These are all things I would want answered to be able to differentially diagnose this case.I would refer this patient for a psychological assessment. Psychological testing and a thorough clinical interview would probably help a lot. This is generally how I proceed when I have patients like this one.
I'm a psychologist with 10+ years experience as a treatment team member (me, psychiatrist, social worker, RN) at a psychiatric hospital. The things that jump out at me at first glance are the presence of both Bipolar Disorder and ADHD. In my experience, this is typically a red flag for an amphetamine addict. If the diagnosis of Bipolar Disorder is accurate, then that diagnosis should trump the ADHD diagnosis. You mentioned the overlap so I'm sure you had similar concerns. Stimulant medications for ADHD are going to at least exacerbate mania. They might even account for onset of mania if this patient had not presented with a manic episode prior to the initiation of of that medication.
I have seen this a lot with younger patients (ages 18-25), typically male, who presented with sleep disturbance, trouble concentrating, and hyperactivity earlier in adolescence and were diagnosed and treated for ADHD. However, it later became clear that those symptoms were actually early signs of a mood disorder that were misdiagnosed.
I am also curious about the PTSD diagnosis. Depending on whether this stems from childhood sexual abuse or combat experiences, that might lead me in different directions in terms of diagnoses. You mention that you are thinking more Borderline Personality Disorder than Bipolar Disorder but do not provide any background or examples of current symptoms. Is there a presence of self-harm, history of volatile and shallow relationships, splitting behavior, identity confusion, therapy interfering behavior?
These are all things I would want answered to be able to differentially diagnose this case.I would refer this patient for a psychological assessment. Psychological testing and a thorough clinical interview would probably help a lot. This is generally how I proceed when I have patients like this one.
This post was edited on 6/8 at 11:40 am
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