Chief Complaint: “I am overwhelmed and can’t sleep so I took a handful of Tylenol”
HPI: 23 year old Bangladeshi female, single, domiciled with her parents and siblings, junior in college with no past psychiatric or medical history was BIBEMS after ingesting a handful of Tylenol. Patient states that she is under a lot of stress with school, her job and her relationship since two months ago. The most significant stressor is from her relationship of three and a half years and a recent breakup with her boyfriend. Patient states “it all started two months ago when my boyfriend told me he was not happy in our relationship and he wanted some space. I gave him some space, he went to the Poconos with his friends and all was good when he came back. Then about a week ago he took me out for ice cream and told me that the relationship is over because it is not working.” Patient states that she was overwhelmed with emotions for the last few days and was having difficulty sleeping so she took a handful of approximately 20 500mg Tylenol so she could sleep. Patient says “all I wanted was to sleep so the emotional pain can go away. I did not want to go to sleep and never wake up.” Patient endorses a decreased appetite and difficulty falling asleep. Patient denies suicidal and homicidal thoughts and visual or auditory hallucinations in the past and at the present time. Patient has poor insight and judgement, and minimizes the seriousness of her actions. Patient does not think she needs counseling or medications at this time.
Pertinent positives: endorses feelings of sadness, depression and being overwhelmed, appetite changes and difficulty falling asleep.
Pertinent negatives: denies suicidal thoughts or a plan to harm self. Denies alcohol, tobacco, marijuana and opioid abuse.
PMHx: No past medical history
PSHx: No past surgeries
Allergies: NKDA
Medications: No medications
Social: No smoking, alcohol or illicit drug use. Lives with parents and three sisters, junior in college and works at Tmobile.
FMHx: mother is 45 y/o alive and well, father is 53 y/o alive and well.
Physical Exam
Vitals: BP 118/74 mmHg; HR 99 bpm; RR 18 bpm; T 98.0 oF ; Ht 5’4”; Wt 120lbs; BMI 20.6
General: Thin, casually groomed female in no acute distress. Alert but tired.
Skin: Warm and moist, good turgor, nonicteric, no lesions, scars or tattoos noted.
Head: Normocephalic, atraumatic.
Eyes: EOM intact. PERRLA.
Neck: Supple, no JVD, no lymphadenopathy. Thyroid non-tender.
Heart: Normal S1, S2, regular rate and rhythm. No murmurs, rubs, gallops.
Lungs: Clear to auscultation bilaterally in all lung fields. No wheezing, rhonchi, crackles.
Strength: 5/5 bilateral upper and lower extremities.
Neuro: Reflexes 2+ throughout
Cranial Nerves: CN II-XI intact
Mental Status
Appearance/Behavior: Alert, casually dressed. Speech and Language: Normal rate, volume, frequency.
Mood: Depressed, congruent, denies suicidal ideation or a plan.
Thought Process/Content: Logical, no perceptual disturbances
Insight and Judgement: Poor insight, denies the seriousness of her suicidal attempt. Judgement is poor.
Memory/Attention: A/Ox3, remote and recent memory intact, attention intact.
Average cognitive functions judged by patient’s response to questions.
Diagnosis:
-Adjustment disorder with depressed mood
Labs
-depression is a clinical diagnosis but this patient ingested approximately 20 500mg tablets of Tylenol so it is important to check her serum levels of acetaminophen in addition to other labs.
Labs: CBC (H/H:13.1/38.6, WBC 10.2, PLT 241)
BMP (NA+ 138, K+ 3.7, Cl– 102, CO2 23, BUN 7, Cr 0.77, Glu 129)
Acetaminophen 75 µg/mL
Alk phos 48, ALT 10, AST 13, Tbili 1.6
Imaging: none
Assessment: 23 y/o Bangladeshi female, domiciled with family, currently a student, with no past psychiatric history BIBEMS secondary to suicidal attempt by overdosing on approximately 20 500mg tablets of Tylenol. Patient presents with a depressed mood, minimizing symptoms and the events leading to her overdosing. Patient will be admitted to the Comprehensive Psychiatric Evaluation Program (CPEP) for further evaluation and stabilization.
Plan:
-Admit to Comprehensive Psychiatric Evaluation Program for stabilization
-Follow up Labs
-Referral to outpatient counseling
-Activated Mobile Crisis Unit to follow up with patient after discharge
-Advise patient to return to Emergency Department is she experiences overwhelming emotions and feels like she wants to hurt herself.
Treatment:
This patent does not believe that she is depressed or her actions was a suicidal attempt. First line therapy for this patient would be cognitive behavioral therapy (CBT). If that is insufficient or patient is non-compliant the next level would be a prescription for a SSRI.
Cultural Factors/Beliefs:
In the Indian community mental health illness carries a certain stigmatism with it. People from these cultures are not open to discussing their mental illnesses unless it is required. People who are diagnosed with depression are reluctant to seek counseling from a therapist as they are valued less in the community because of their illness. Patients with mental illnesses are valued less in their cultural community and as a result are non-compliant or have poor compliance with routine follow ups and mental health therapy.
It is important to recognize that patients from certain cultures especially the Asian cultures are reluctant to seek medical care for mental illnesses. So in addition to referral to an outpatient clinic it as also important to activate the mobile crisis unit that checks in with the patient after discharge from the emergency psychiatric unit. The parents of my patient does not believe that there is anything wrong with their daughter and she does not need any help at this time. The parents of my patient does not think that their daughter attempted suicide and minimizes the severity of their daughter’s action. This patient was stabilized in the Comprehensive Psychiatric Evaluation Program (CPEP) and was discharged with a referral to an outpatient clinic for counseling. There is a low probability that this patient will follow through with counseling, so in addition to the outpatient follow up the mobile crisis unit has also been activated for this patient. The mobile crisis unit will check in with this patient within a couple days of discharge from the CPEP.
Conflicts with Cultural Beliefs
This scenario at present can lead to conflicts as the clinician believes that it is in the best interest of the patient to seek counseling for her adjustment disorder and depressed mood. However, the patient and her parents does not think that there is a problem at that needs medical intervention or counseling. As clinicians we give the best information and guidance to the best of our knowledge. We recommend, we refer and we follow up but we cannot force patients to go to counseling if they chose not to. We have to respect their beliefs and customs and respect their choices.
Cultural Competencies
As a clinician it is important to recognize the beliefs of a patient’s culture and practice so as to not offend or practice in a way that creates conflict with the patient’s culture. In a systematic review that was published in Psychological Medicine in 2015 found that stigma has a small to moderate size negative effects of patients seeking medical care. Patients also delay seeking medical care and therapy for their mental illness because of the effects that the stigma of mental illnesses. A culturally competent clinician will respect patients’ wishes and beliefs and recommend alternative methods of coping with depression with relaxation techniques such as meditation, yoga and tai chi.
Patient Education:
Ms. T.C. you are under a lot of stress right now with school, your job and your personal relationship with your boyfriend. I know it is a lot to handle especially you being so young. After you are discharged from the CPEP we will arrange for you to speak with a therapist, where you can express your feelings and thoughts to him/her and they would discuss your feelings with you. You should be able to speak freely and openly about your feelings and thoughts with your therapist as what you discussed with your therapist is confidential and will not be shared or discussed with your parents. You are young and have your whole life ahead of you and you have so much going on for you right now, you are about to graduate with your Bachelors in accounting. It seems that you have a wonderful and supportive family who cares a lot about you, so think about how they would feel if something happens to you. If you hurt yourself your parents and your sisters are the ones who would lose the most and they will be sad. If you feel overwhelmed and feel like you want to hurt yourself you can call the hotline 24/7 at 1800 273 TALK or if you have a strong urge to hurt yourself you should come back to the emergency room.
Resource:
https://www.ncbi.nlm.nih.gov/pubmed/24569086
