A 75-year-old woman, Gladys, was brought to the psychiatric clinic in a manic state by her concerned sister. The patient was disheveled, dehydrated, and having difficulty expressing her thoughts. Vital signs included a blood pressure of 200/94 mm Hg; pulse, 88 beats/min; temperature, 98.4°F; and respiratory rate, 20 breaths/min. Psychiatric history included a diagnosis of schizoaffective disorder with inconsistent adherence to treatment regimens, particularly mood stabilizers; and attention-deficit/hyperactivity disorder, for which she took methylphenidate regularly. Medical history was significant for asthma, osteoporosis, hypertension, type 2 diabetes, and hypothyroidism.
Gladys tended to become involved in personal relationships that adversely affected her mental health. This, in fact, had just happened: A “friend” had taken advantage of her kindness and then abruptly moved away, triggering the patient’s current decompensation. She was referred for admission for psychiatric evaluation and treatment.
During the three-week hospitalization, Gladys was diagnosed with bipolar I disorder. She agreed to take mood-stabilizing medication primarily to alleviate her insomnia during manic episodes. She was discharged on a multidrug regimen for her coexisting conditions (see Table 1). Of note, her blood pressure at discharge was 148/66 mm Hg.
At outpatient follow-up five days later, the patient reported feeling better and stronger. However, five weeks after discharge, Gladys returned with complaints of tiredness during the day (though sleeping well at night), severe dry mouth, aching joints, and poor appetite. Her blood pressure was 100/50 mm Hg. She denied abdominal pain or change in the color of her urine or stool. She also denied use of alcohol, illicit drugs, or OTC medications. Laboratory results revealed elevated levels of several liver enzymes (see Table 2), all of which had been normal when she was admitted to the hospital two months earlier.
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