35 y/o year old female with no past medical history presenting to the emergency department with abdominal pain. She states the pain started off intermittently 10 months ago but has been constant over the last month. She is “always in pain” and feels it diffusely throughout the abdomen. No medications have worked and no position makes it better or worse. Patient was seen by PCP and a gastroenterologist, where many tests and exams were done but all came out negative. She has tried cutting out dairy, wheat, and meat with no relief. She is worried and anxious that something is wrong and has missed many days of work and events because of fear of getting another stomach “attack”. Husband states his wife is constantly looking up her symptoms, and that she is unhappy and depressed for 10 months. No history of trauma, gastrointestinal disorders, or psychiatric history. 

 

Past Medical History:

None  

 

Past Surgical History:

None 

Denies any other past injuries or transfusions.

 

Medications:

None

 

Allergies:

NKA

 

Family History:

Father – type 2 diabetes 

Mother – history of anxiety 

 

Social History:

Patient works as an administrative assistant. Denies drinking alcohol, smoking or using illicit drugs. Denies a history of sexually transmitted diseases. 

 

Review of Systems:

General – Admits to feeling fatigued. Denies recent weight loss or gain, loss of appetite, generalized weakness, fever or chills, or night sweats.

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

 Head – Denies headache, vertigo or head trauma.

 Eyes – Denies pruritus, lacrimation, corrective lenses, photophobia or other visual disturbances.

 Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

 Nose/sinuses – Denies discharge, obstruction or epistaxis.

 Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. 

 Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast – Denies any changes in breast, discharge, lumps.

 Pulmonary system –Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular system – Denies chest pain, irregular heartbeat, palpitations, edema/swelling of ankles or feet, syncope or known heart murmur

Gastrointestinal system – Admits to diffuse abdominal pain. Denies nausea, vomiting, diarrhea or constipation. 

Genitourinary system – Denies urinary frequency, urgency, or nocturia.

Menstrual/ Obstetrical – Nulligravida. Menarche age 12. Denies breakthrough bleeding/ spotting or vaginal discharge.

 Nervous – Denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system – Denies muscle/joint pain, deformity or swelling, redness or arthritis.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – Denies anemia, easy bruising, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

Psychiatric – Admits to being depressed and anxious. Denies OCD or other psychiatric disorders. 

 

Physical Exam

Vitals 

Pulse: 99, regular 

BP: 126/86

RR: 16, unlabored 

Temperature: 98.8 F oral

Pulse ox: 99% on room air 

 

General – AOX3, in no acute distress, good hygiene, appears stated age

HEENT – no masses, lesions, deformities. PERRLA, EOM. No papilledema, nasal discharge, exudates, lymphadenopathy, erythema. Trachea midline

Skin – warm and dry, good turgor. No rashes, bruises, or masses.  

Cardiac – regular rate and rhythm. No murmurs/rubs/gallops. No JVD or carotid bruits. 

Lungs – clear to auscultation bilaterally. No use of accessory muscles. No wheezes/ rales/ rhonchi

Abdominal – Bowel sounds present in all quadrants. Abdomen soft. Non tender and non distended. No CVA tenderness. No aortic/ renal bruits. No organomegaly.

Musculoskeletal – Pain on palpation of ribs. No soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. FROM in upper and lower extremities b/l. No spinal deformities. 

Peripheral Vascular – Color and temperature wnl. Pulses 2+ bilaterally in upper and lower extremities b/l. No cyanosis, clubbing or edema. No palpable varicose veins.

Neurological – AOx3. Memory and attention intact. Receptive and expressive abilities intact. No dysarthria, dystonia or aphasia. 

CN I – XI: all intact 

Psychiatric:

• Appearance – Normal
• Attitude and behavior – Attitude is appropriate and behavior demonstrates a preoccupation with physical symptoms and complaints
• Mood – Mildly anxious and depressed
• Affect – Full range and appropriate
• Thought disorder – None, although thoughts are limited to issues around physical symptoms
• Hallucinations – None
• Delusions – None
• Obsessions – None
• Compulsions – None
• Attention – Within normal range
• Memory – Within normal range
• Concentration – Within normal range
• Orientation – Oriented to time, place, and person
• Insight and judgment – Insight appears limited in that nonmedical causes of symptoms are not considered; judgment appears unimpaired
• Suicidal and homicidal ideation – No evidence 

 

Labs/Diagnostics

CMP

138| 102 | 9   < 86

4.1 | 24| 0.8

 

CBC

7.14> 12.1< 359

           36.6

 

Albumin 4.2

Bilirubin 0.4

AST 17

ALT 14

Alk phosphatase 82

 

UA- wnl 

CXR – wnl

Abdominal CT normal 

ECG – normal sinus rhythm 

 

Assessment and Plan

35 y/o female with no past medical history presenting with abdominal pain for 10 months.

DDX:

1. Somatic symptom disorder   
2. Conversion disorder
3. Illness anxiety disorder
4. Munchausen disorder 
5. Malingering 

Plan:

1. Pain control with Tylenol 
2. Support/ reassurance
3. Referral to psychiatry 
4. SSRI

Day 2:

Tardive dyskinesia and EPS

TD are involuntary movements of the tongue, face, lips, trunk and extremities that can occur in those who have been treated with long-term dopaminergic antagonists. EPS and TD are frequent problems associated with the older generation of antipsychotic medications. It is most common in patients with schizophrenia, schizoaffective disorder or bipolar disorder who are treated with antipsychotic medications for a long period of time. TD is associated with polymorphisms of both the dopamine receptor D2 gene, Taql A/B/ and similar haplotypes, the dopamine receptor D3 gene, the dopamine transporter gene, and the MnSOD gene. 

A variety of movement phenotypes in EPS (extrapyramidal side effects) include dystonia, akathisia, and parkinsonism, which occur more acutely in tardive akathisia and tardive dyskinesia. These symptoms interfere with social functioning, communication, motor tasks, and activities of daily living. 

 

Steven Johnson Syndrome

SJS is a severe skin reaction that can be caused by a variety of medications including anticonvulsants and antipsychotics. It often begins with a fever and flu-like symptoms, followed by skin blisters that can peel and form painful erosions. The skin erosions begin on the face and chest and then spread to other parts of the body. Mucous membranes, including the lining of the mouth and airways, can also be affected and cause swallowing and breathing difficulty. The eyes can become irritated and red and cause damage to the cornea. 

Severe damage to the skin and membranes can make SJS/TEN life threatening. Loss of fluids and infections can develop, including serious complications like pneumonia, sepsis, shock, multiple organ failure, and death.  

 

Kendra Law

Kendra’s Law is a New York State law that has been effective since 1999. It allows judges to issue orders that require people who meet certain criteria to regularly undergo psychiatric treatment. Originally, this was proposed by the National Alliance on Mental Illness, the Alliance on Mental Illness of New York State, and other local NAMI chapters. These organizations were concerned that laws were preventing people with serious mental illness from receiving treatment until they became “dangerous to self or others”. This law was viewed as a less restrictive and more humane alternative to inpatient commitment. 

This has helped reduce homelessness, suicide attempts, substance abuse, physical harm to others, property destruction, hospitalization, arrests, and incarceration. 

 

Serotonin Syndrome 

Serotonin Syndrome is a potentially life-threatening drug reaction that can occur when two medications that affect the body’s level of serotonin are taken at the same time. It can also occur if the dosage of a medication is increased. These medications include antidepressants such as SSRIs and SSNRIs, and also migraine medications (triptans). 

If there is too much serotonin in the body, it can cause a variety of symptoms that affect the brain, muscles, and other parts of the body. Symptoms include confusion, irritability, anxiety, muscle muscles, diarrhea, tachycardia, hypertension, nausea, hallucinations, hyperreflexia, seizures, or unresponsiveness. 

 

https://emedicine.medscape.com/article/1151826-overview

https://www.ncbi.nlm.nih.gov/books/NBK534115/

https://ghr.nlm.nih.gov/condition/stevens-johnson-syndrome-toxic-epidermal-necrolysis#genes

https://mentalillnesspolicy.org/kendras-law/kendras-law-overview.html

https://www.healthline.com/health/serotonin-syndrome#symptoms