Ms. D
Ms. D, age 69, has a 20-year history of bipolar II disorder, for which she is taking citalopram, 30 mg/d. She has a chief complaint of depressed mood and the therapist refers her for psychiatric hospitalization and electroconvulsive therapy consultation. Upon admission, Ms. D reports that her depressed mood has worsened over the past 5 weeks after a trip to the Dominican Republic. Ms. D had a negative encounter with airport security that she attributed to her 2 artificial knees and caused her to miss her flight. She endorses poor appetite, loss of energy, anhedonia, difficulty concentrating, poor memory, and feelings of hopelessness.
She reports increasingly frequent panic attacks as well as right-sided discomfort, unusual noxious smells, and increased falls. She says the falls likely are a result of weakness coupled with imbalance. Ms. D says she has experienced brief occasions of foul-smelling odors while showering without evidence of an offending substance. She also reports a mild headache stemming from the back of her head (occipital area).
Four years ago, Ms. D was hospitalized for a depressive episode without psychotic features and diagnosed with generalized anxiety disorder, for which she is taking clonazepam, 1.5 mg/d. Her last hypomanic episode was several years ago, and was characterized by increased energy with decreased need for sleep, flight of ideas, increased productivity, and impulsivity. Her medical history includes noninsulin dependent diabetes mellitus, chronic low back pain, hyperlipidemia, arthritis, and gastroesophageal reflux disease; her medications include pioglitazone, 30 mg/d, oxybutynin, 15 mg/d, rosuvastatin, 20 mg/d, losartan, 50 mg/d, and omeprazole, 20 mg/d. She also had bilateral knee replacements 9 years ago and an L4-S1 spinal fusion 11 years ago. She has no history of head injuries or seizures. Ms. D's father had major depressive disorder, her mother died of a cerebrovascular accident at an unknown age, and her brother died of a myocardial infarction at age 52.
At the time of admission, Ms. D has a blood pressure of 127/68 mm Hg, heart rate of 74 beats per minute, respiratory rate of 16 breaths per minute, and temperature of 36.5[degrees]C. Neurologic examination reveals a left facial droop of unknown duration. Motor strength is weak throughout with left-sided focal weakness. Ms. D's daughter notes that her mother's smile appears "funny" in her admission photograph but is unsure when the asymmetry in her facial appearance began. Ms. D had been ambulatory before admission. Nursing staff observes Ms. D leans toward her left side and exhibits possible left-sided neglect during the first 12 hours of hospitalization. When asked about her facial droop, Ms. D replies that she had not noticed any change in her appearance lately. She does not appear to be concerned about her worsening ambulation. On hospital day 2, Ms. D seems to have difficulty using utensils to eat breakfast. Ms. D is dismissive of her worsening motor function and asks to be left alone to finish her meal.
She reports increasingly frequent panic attacks as well as right-sided discomfort, unusual noxious smells, and increased falls. She says the falls likely are a result of weakness coupled with imbalance. Ms. D says she has experienced brief occasions of foul-smelling odors while showering without evidence of an offending substance. She also reports a mild headache stemming from the back of her head (occipital area).
Four years ago, Ms. D was hospitalized for a depressive episode without psychotic features and diagnosed with generalized anxiety disorder, for which she is taking clonazepam, 1.5 mg/d. Her last hypomanic episode was several years ago, and was characterized by increased energy with decreased need for sleep, flight of ideas, increased productivity, and impulsivity. Her medical history includes noninsulin dependent diabetes mellitus, chronic low back pain, hyperlipidemia, arthritis, and gastroesophageal reflux disease; her medications include pioglitazone, 30 mg/d, oxybutynin, 15 mg/d, rosuvastatin, 20 mg/d, losartan, 50 mg/d, and omeprazole, 20 mg/d. She also had bilateral knee replacements 9 years ago and an L4-S1 spinal fusion 11 years ago. She has no history of head injuries or seizures. Ms. D's father had major depressive disorder, her mother died of a cerebrovascular accident at an unknown age, and her brother died of a myocardial infarction at age 52.
At the time of admission, Ms. D has a blood pressure of 127/68 mm Hg, heart rate of 74 beats per minute, respiratory rate of 16 breaths per minute, and temperature of 36.5[degrees]C. Neurologic examination reveals a left facial droop of unknown duration. Motor strength is weak throughout with left-sided focal weakness. Ms. D's daughter notes that her mother's smile appears "funny" in her admission photograph but is unsure when the asymmetry in her facial appearance began. Ms. D had been ambulatory before admission. Nursing staff observes Ms. D leans toward her left side and exhibits possible left-sided neglect during the first 12 hours of hospitalization. When asked about her facial droop, Ms. D replies that she had not noticed any change in her appearance lately. She does not appear to be concerned about her worsening ambulation. On hospital day 2, Ms. D seems to have difficulty using utensils to eat breakfast. Ms. D is dismissive of her worsening motor function and asks to be left alone to finish her meal.
Ms. D's head CT reveals a large right-sided temporoparietal low-density lesion with 8-mm left lower midline shift (Figure). She undergoes a right temporal craniotomy with resection of the mass, which is confirmed by surgical pathology to be a glioblastoma multiforme World Health Organization grade 4 tumor. Postoperative MRI shows evidence of infarction in the right posterior cerebral artery distribution and residual tumor is identified on follow-up imaging. Ms. D is referred to radiation oncology, where she receives a prognostic median life expectancy of 14 months with radiation and temozolomide treatment.