Psychiatry Case Challenge: A 60-Year-Old Woman With Sleep Problems and Odd Behavior

Donald M. Hilty, MD, MBA; Jose Feliberti, MD


May 15, 2023

Physical Examination and Workup

Upon physical examination, the patient was 5'2" and weighed 110 lb (49.9 kg). She had mild agitation on psychomotor examination but appeared decently groomed. Her eye contact was minimal, as she frequently looked down. She denied audial, tactile, and visual hallucinations, as well as false beliefs and suicidal or homicidal ideation.

The cognitive examination revealed she was oriented to place and time, with memory 3/3 immediate and 2/3 at 5 minutes; this was repeated after her daughter joined and was 3/3 at 5 minutes. She remembered what she ate for breakfast and dinner the day before. She recalled where and when she went to high school. When asked to do serial 7s, she said 7 from 100 was 93, 7 from 93 was 86, 7 from 86 was 79. When asked to explain the abstract saying "People who live in glasses houses should not throw stones," she replied, "If you have problems, you should not criticize others."

Results from a recent physical examination from her primary care provider were made available. Her temperature was 98.2°F (36.78°C). Her pulse was regular, at 76 beats/min. Her respiration was 16 breaths/min. Her blood pressure was 116/76 mm Hg. Her jugular venous pressure was 8 cm. Her thyroid was not palpable. No masses or adenopathy was noted.

Her chest was clear, without rales, rhonchi, wheezes, or rubs. Her heart had regular rhythm without murmur. Her abdomen was soft and flat, with no bruits, tenderness, or masses. Her liver span was > 12 cm as assessed by percussion. Her extremities demonstrated chronic venous stasis changes, with no edema or clubbing. On neurologic examination, cranial nerves III-XII, motor strength, and sensory were all intact. She could move all extremities. Her genitourinary and rectal examination findings were within normal limits.

A complete blood cell count revealed a white blood cell count of 9000 cells/mm3, a hemoglobin level of 12 g/dL, a hematocrit of 38%, a mean corpuscular volume of 96 fL/red cells, and a platelet count of 218,000 cells/µL. Her alanine aminotransferase level was 46 U/L, aspartate aminotransferase level 120 U/L, and lactic acid dehydrogenase level 274 U/L.

An ECG revealed normal sinus rhythms with no ST elevations. A chest x-ray revealed probable mild cardiomegaly. MRI results are shown in Figure 1.

Figure 1.


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