Psychiatry Case Challenge: A 9-Year-Old With Suicidal Behavior

James Robert Brasic, MD, MPH


January 25, 2022

Physical Examination and Workup

Upon physical examination, the patient was a slender, poorly developed, poorly nourished boy who appeared his stated age of 9 years, in no acute respiratory distress. He was awake and alert. He was anxious. He moved constantly during the examination. He looked around the examination room as if responding to stimuli not present in the environment. The boy demonstrated a moderately severe articulation deficit.

His vital signs were normal. His head was normocephalic. Eyes were normal. His right myringotomy tube was surrounded by wax, so it was removed. His left myringotomy tube was intact; it was functioning well. His nose appeared healthy. Examination of the mouth revealed a midline scar over the repaired cleft palate.

Neck examination findings were normal. The thyroid was not enlarged. His thorax was resonant to percussion. Breath sounds were normal in all lung fields.

Upon cardiac examination, S1 and S2 findings were normal. No murmurs, gallops, or friction rubs were noted.

His abdomen was scaphoid. Bowel sounds were normal in all quadrants. No tenderness was observed. The abdomen was tympanitic throughout. No organomegaly or masses were noted.

A well-healed scar was noted on the right scrotum. The testes were normal. The genital examination findings were normal.

Cranial nerve examination findings were normal. Motor strength was normal. Reflexes were normal. Light touch, pain, position, and vibration senses were normal on all extremities. His pulse was within the reference range. No lymphadenopathy was observed. His skin was intact without lesions.

His emotions seemed flat despite seriously destructive behavior. At times, his thoughts seemed disconnected. He did express thoughts and plans to hurt himself and others. His judgement was poor based on his recent history. His intellect was average for his age and grade. He was oriented to time, place, and person. His memory on recall immediate, recent, and distant was good. He could do "serial 3s" (subtract 3 from 100, then 3 from 97, and so on). His ability to handle abstract ideas was poor. For example, he could not answer nor find the meaning of the statement "a stitch in time saves nine."

During the examination, he reported that, only in his right ear, he heard "devils" outside his head both during the day and at night; they ordered him to kill himself by leaping off the roof of a building. He reported that he saw Jason Voorhees, a frightening character from a horror film, as well as cockroaches that turned into red devils. He saw a vision of hell: an inferno surrounded by cockroaches. These hallucinations and delusions only began for the first time within the few days prior to presentation.

Audiograms revealed normal hearing in his left ear. A mild right conductive hearing loss at 1 kHz and 4-8 kHz was demonstrated. At 1.5-3 kHz, hearing was normal on the right. Electroencephalography findings were normal.


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