Suicidal Ideation and Muscle Twitches | Case Study

A new case study in which the patient, a 40 yr-old mixed-race woman presents to her primary care physician with concerns about suicidal ideation. She has some other troubling symptoms as well including muscle twitches, fatigue, difficulty concentrating and memory lapses.

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Suicidal Ideation and Muscle Twitches | Case Study

Chief Complaint

Suicidal ideation, fatigue, difficulty concentrating, memory lapses and muscle twitches.

History of Present Illness

"My children begged me to come in. They are so worried about me. The other day, my son started yelling at me – he said I had been standing in front of the open....um...oh what is it called...where you keep your food cold...for 20 minutes, just staring.” Patient states she has been experiencing symptoms for more than a year. "They came on so gradually. I used to be such an upbeat, happy person. My best friend called me a few months ago and I couldn't remember her name, so I stopped returning her calls. I've been thinking lately about ending it all. I just can't take it anymore, but my kids need me.” She can't think of any precipitating reason for onset of symptoms. She states low mood and other mental symptoms began over a year ago, muscle twitches have been happening for at least 6 months.

General Appearance

She appears her stated race, age and gender. She is slender with short hair and a downcast expression. She doesn't make eye contact and her clothing is wrinkled and stained. "I'm sorry for how I look. I just can't seem to find the energy to do anything.” During her assessment you notice her head jerk to the side (toward the right shoulder) and she flexes her fingers continuously.

Past Medical History

Unremarkable. No complications with either pregnancy.

Family History

Patient was adopted when an infant. Her family history is unknown because she was found in a basket at the local fire station when she was only three weeks old. She has been divorced for five years and has a 21 yr-old daughter who is away at college and a 17 yr-old son who lives at home. Her adoptive parents are alive and well and living 1000 miles away.

Social History

Drinks 5- 6 alcoholic beverages weekly, smokes 3 cigarettes per day. "I'm trying to quit. I'm down from half a pack a day 6 months ago.” She works from home as a medical coder. "I've had to take a lot of time off. I can't seem to concentrate. I'm worried I'm going to get fired.”

Medications

Multi vitamin, occasional acetaminophen for headaches, melatonin for insomnia

Allergies

NKA

Vital Signs

  • BP 138/80 sitting, LA
  • HR 70 and regular
  • RR 18 unlabored
  • T 98.8oF
  • HT 5'4"
  • WT 110 lbs

What information will help with diagnosis? What labs do you want? What other diagnostic tests should we run?

DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

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SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse, is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, "Safety Rules!", on allnurses.com.

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Any psych hx? Particularly psych meds? 

What is her diet? Any substance use?

Results of CBC and metabolic panel would be interesting to see. 

I love these case studies! New grad LPN and I have a lot to learn ?.

Oh yeah- maybe going overboard but MRI or CT of brain? 

 

 

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Specializes in Education, Informatics, Patient Safety.

No psych history or psych meds, her diet is unremarkable, no history of substance abuse. You'll get the labs in about a week. Thanks for participating and for the positive feedback!

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Specializes in School Nursing.

Are any genetics tests ordered to rule out inherited diseases in absence of a medical history?

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Would want to see electrolytes regarding neuromuscular functioning and some information about nutrition status, vitamin D levels and thyroid regarding depression S/S… would want to know what she has been eating, adequate nutrition/hydration, Foods that have risks regarding toxins/heavy metals? How has her digestion been, S/S leaky gut?

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I would ask the MD for a vitamin B and at thyroid panel, as well as an MRI, EEG, EMG if bloodwork is normal.  

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Specializes in Public Health, TB.

Vaccination history, travel, any unusual skin lesions? Is she having any pain? Check cranial nerves, optic fundal exam. What are her reflexes? What is her activity level, as she appears sl. underweight? How is her sleep? 

And yes, CT/MRI head, complete metabolic panel, CBC, thyroid panel. 

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Def. would think CMP, CBC, Thyroid panel, check Vit. B and D.  With not knowing her family history, would think you would want to start there before ordering more extensive testing.

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Specializes in Education, Informatics, Patient Safety.

She is fully vaccinated, is not in any pain and her diet is unremarkable for toxins. She reports no issues with digestion.  More to come next week, including labs and other useful information - stay tuned!

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Specializes in BMT/blood cancers.

Head CT—r/o stroke; hormonal (estradiol) blood work—peri-menopausal depression/cognitive alteration? 

Any recent (in the last ~year) stressful/traumatic incidences?

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Specializes in Education, Informatics, Patient Safety.

No stressful or traumatic incidences in past year - other results will come next week. Great questions everyone!

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Thyroid panel.

Infectious disease panel-lyme disease and possible coexisting infections such as babesia and bartonella.

Vitamin D levels.

B vitamin and folate levels

Iron levels.

Electrolye levels.

Ask her about her diet.

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