Wild Mood Swings and Outbursts of Anger: What's Wrong with this Man? | Case Study

Published
by SafetyNurse1968 SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

A new case study in which the patient, a 50-yr-old male of mixed race visits his primary care physician with concerns about wild mood swings and outbursts of anger. “I’ve been screaming at my husband. The other day I even pushed him. Not hard, but it frightened me. My dad used to knock my mother around and I don’t want to be like him. I don’t understand what’s going on – I’m a happy person.”

What’s causing mood swings and outbursts of anger?

Wild Mood Swings and Outbursts of Anger:  What's Wrong with this Man? | Case Study
If you think you know the correct diagnosis for this Case Study (CSI)...

DO NOT POST ANSWER HERE.

Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below.

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.


Chief Complaint

A 50-yr-old male of mixed-race states that over the past six months he has been experiencing mood swings and outbursts of anger. “I’m out of control. One minute I’m happy and the next I’m furious. I’ve been screaming at my poor husband. The other day I even pushed him, and all he did was break my favorite coffee mug. I didn’t push him hard, but it frightened me. My dad used to knock my mother around and I don’t want to be like him. If I sit still for too long, I start thinking about all the bad things in my life and my heart starts racing. It feels sometimes like the world is coming to an end. I don’t understand what’s going on – I’m a happy person. I hope I don’t have a brain tumor or something.”

History of Present Illness

Patient states that after pushing his partner last week, they sat down and talked about the incident. “My husband helped me realize that I’ve been getting worse. I hadn’t realized it, but when I think back I can recall these feelings being around for at least 6 months. I think I’ve been in denial.” Patient has gained 20 lbs since his last visit 9 months ago.

General Appearance 

Patient appears tired and is tearful. His skin is light brown in color, and he appears to be slightly overweight, though he is also muscular. He has male pattern baldness and wears glasses. His hair is cut short and he is clean-shaven and appropriately dressed. Speech is rushed at times, but content is normal. Patient has difficulty making eye contact during assessment.

Past Medical History

Unremarkable

Family History

Father died from colon cancer 5 years ago at the age of 67. Patient states his friends from back home report his mother is alive and well. His only sibling, a brother died of an opioid overdose at age 41. No other known family history of mental illness.

Social History

The patient has been married to his partner for over ten years He and his partner are physically active and enjoy hiking and gardening together. Eighteen months ago, his brother died of an overdose. He became estranged from his parents fifteen years ago after coming out. “My brother kept me posted about my father’s illness, but they didn’t want me to visit. I wasn’t invited to the funeral. Now there’s no chance for reconciliation. I don’t even know if my mother knows where I live. I really wish she could accept me for who I am. I was close to my brother – I really miss him. The last few years have been hard.”

Patient drinks 1-2 beers several times a week, has never smoked. “I used to party pretty hard in college, but I don’t use drugs anymore, not with my brother’s situation. It just seemed wrong.”

The patient is an attorney for a low-cost legal service in his county. His partner is an elementary school teacher. They are very active in their Unitarian Church.

Medications

He takes loratadine for allergies and atorvastatin for high cholesterol. 

Allergies

NKA

Questions

  1. Is there a mental health diagnosis that fits these symptoms? If not, what’s causing his mood swings and outbursts of anger?
  2. What about the weight gain, racing heart and feelings of worry?
  3. What information could you ask for that would give you the most information for a diagnosis?
  4. What labs do you want?
  5. What other diagnostic tests should we run? Ask me some questions!

REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com.

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20 Comment(s)

Davey Do

Specializes in Psych (25 years), Medical (15 years). Has 43 years experience. 1 Article; 9,855 Posts

I need to request more information, like sleeping habits, spending habits, areas of interest, and anything where his behavior has affected other areas of his life besides his relationship- his work as a lawyer, for example.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 520 Posts

18 minutes ago, Davey Do said:

I need to request more information, like sleeping habits, spending habits, areas of interest, and anything where his behavior has affected other areas of his life besides his relationship- his work as a lawyer, for example.

Thank you for asking, Davey Do! When asked about sleeping habits the patient says, "I just want to sleep all the time. I'm so tired." He has struggled with wanting to go to church and has felt too tired to garden. "The only thing that hasn't been affected is work. I'm good at compartmentalizing, I guess." His spending habits have not changed.

Davey Do

Specializes in Psych (25 years), Medical (15 years). Has 43 years experience. 1 Article; 9,855 Posts

Thank you for that additional information, SafetyNurse.

I am not giving a diagnosis, just wanted to share something I learned from a couple of situations.

In the early '90's, I worked at a state mental hospital and noted that a patient was prescribed Tegretol. I checked the patient's chart and found no history of seizures, or an axis III of a seizure d/o.

I asked the psychiatrist his reason for prescribing Tegretol, a med that I had a history of administering only for a seizure d/o. The psychiatrist told me, "We've found that seizure medication helps patients who experience explosive episodes".

Years later, after I had experienced administering meds like Tegretol, Depakote, and Lamictal to patients for symptoms of explosive episodes or mood swings, I questioned a neurologist. I asked him if an explosive episode was not unlike a seizure, with an inordinate amount of neurotransmitters being released in the brain helter skelter.

The neurologist affirmed my belief, that indeed this was what occurred in the brain during an explosive episode.

Just interesting tidbits, I thought.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 520 Posts

1 hour ago, Davey Do said:

Thank you for that additional information, SafetyNurse.

I am not giving a diagnosis, just wanted to share something I learned from a couple of situations.

In the early '90's, I worked at a state mental hospital and noted that a patient was prescribed Tegretol. I checked the patient's chart and found no history of seizures, or an axis III of a seizure d/o.

I asked the psychiatrist his reason for prescribing Tegretol, a med that I had a history of administering only for a seizure d/o. The psychiatrist told me, "We've found that seizure medication helps patients who experience explosive episodes".

Years later, after I had experienced administering meds like Tegretol, Depakote, and Lamictal to patients for symptoms of explosive episodes or mood swings, I questioned a neurologist. I asked him if an explosive episode was not unlike a seizure, with an inordinate amount of neurotransmitters being released in the brain helter skelter.

The neurologist affirmed my belief, that indeed this was what occurred in the brain during an explosive episode.

Just interesting tidbits, I thought.

Yes! I love learning - thanks for that - I will squirrel that knowledge away and break it out for a future case study.

nursej22, MSN, RN

Specializes in Public Health, TB. Has 37 years experience. 2,244 Posts

I would want to check thyroid, and a CMP to rule out any metabolic issues. Also, perhaps check for hepatitis B and C, and HIV status. At his age, I would get an EKG. Perhaps not related to this crisis, but I hope he has had colon cancer screening, due to family hx and age. 

Interesting that the patient mentioned brain tumor. Is there a good reason for this? 

NRSKarenRN, BSN, RN

Specializes in Vents, Telemetry, Home Care, Home infusion. Has 45 years experience. 11 Articles; 17,185 Posts

Any thyroid labs available ... need to rule out endocrine issues which are often overlooked in men.

Davey Do

Specializes in Psych (25 years), Medical (15 years). Has 43 years experience. 1 Article; 9,855 Posts

Good calls, nursej and Karen!

It was a standard practice to draw labs and see if anything was off with the Chemistry and might be the underlying cause!

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 520 Posts

The patient mentioned concern over having a brain tumor because he is incredibly anxious and worried about his health and behavior. There are many folks who automatically think they have cancer when they start having mysterious or unexpected symptoms. 

evastone

evastone, BSN, RN

Specializes in CEN. Has 4 years experience. 131 Posts

Any skin changes that he has noticed? Pigmentation or thinning of the skin? Hair loss on his legs?

EKG for heart abnormalities?

Is he getting sick more often?

What are his sugar levels and A1C?

What about testing for TSH, T3, T4, thyroid antibodies, estrogen, or cortisol?

allnurses Admin Team

allnurses Admin Team

Has 50 years experience. 276 Posts

REMEMBER ....

If you think you know the correct diagnosis for this Case Study (CSI)...

DO NOT POST ANSWER HERE.

Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below.

NP_hopeful19

NP_hopeful19

66 Posts

12 minutes ago, allnurses Admin Team said:

REMEMBER ....

If you think you know the correct diagnosis for this Case Study (CSI)...

DO NOT POST ANSWER HERE.

Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below.

Oh, I'm sorry! Was reading on my phone and completely missed that.