Psychiatry · Year 3 · from Psychiatry
Case 3: The Uncooperative Patient - Biopsychosocial Formulation
Patient Demographics
- Age: 45 years old
- Sex: Male
- Occupation: Unemployed (former construction worker)
Chief Complaint
"I don't need to be here. The cops brought me for no reason."
History of Present Illness
The patient was brought to the emergency department by police after being found walking in traffic on a busy highway. Bystanders called 911 when he appeared confused and was yelling at passing cars. The patient is a poor historian and is uncooperative with the interview. Limited collateral information is available. Police report states he smelled of alcohol and had an empty vodka bottle in his backpack. He is irritable and intermittently threatening, stating "I'll leave when I want to leave." When asked about walking in traffic, he states "I was just trying to get somewhere." He refuses to answer questions about suicidal ideation, stating "That's none of your business."
Mental Status Examination
Appearance: Middle-aged man appearing older than stated age, malodorous (alcohol, body odor), disheveled clothing with stains, unshaven with poor dentition, visible tremor of hands
Behavior: Hostile, uncooperative, frequently interrupts interviewer, attempts to leave the room multiple times, pacing when seated
Speech: Loud volume, rapid rate, slurred articulation, profane
Mood: "Pissed off"
Affect: Irritable, labile, dysphoric at times when discussing his situation
Thought Process: Difficult to assess due to poor cooperation; appears disorganized with frequent tangents and difficulty staying on topic
Thought Content: Limited assessment possible; denies suicidal intent when directly asked but refused to elaborate; no overt paranoid ideation expressed; preoccupied with leaving the hospital
Perceptions: Unable to assess thoroughly; no obvious response to internal stimuli observed
Cognition:
- Alert but disoriented to date (states "I don't know, maybe Tuesday?" when it is Saturday)
- Attention impaired - unable to complete serial 7s or spell WORLD backward
- Memory: Unable to recall events leading to hospitalization; remote memory grossly intact
Insight: Poor - does not acknowledge any problems with substance use or behavior
Judgment: Poor - walking in traffic, refusing evaluation, threatening to leave
Psychiatric Workup
Screening Tools:
- Unable to complete standardized assessments due to poor cooperation
- CIWA-Ar score: 12 (moderate withdrawal risk)
- AUDIT-C: Unable to complete
Laboratory Studies:
- Blood alcohol level: 285 mg/dL
- Urine drug screen: Positive for alcohol, negative otherwise
- Glucose: 68 mg/dL (low)
- CMP: K+ 3.2 mEq/L (low), Mg 1.4 mg/dL (low), otherwise normal
- CBC: MCV 104 fL (elevated, suggesting chronic alcohol use)
- Liver function: AST 78, ALT 45, GGT 124 (elevated)
- Ammonia: 35 mcg/dL (normal)
- CT Head: No acute intracranial abnormality
Biopsychosocial Formulation
Biological Factors:
- Acute alcohol intoxication (BAL 285)
- At risk for alcohol withdrawal
- Evidence of chronic alcohol use (elevated MCV, LFTs)
- Electrolyte abnormalities (hypokalemia, hypomagnesemia)
- Hypoglycemia contributing to altered mental status
Psychological Factors:
- Poor frustration tolerance
- Limited insight into substance use
- Possible underlying depression or trauma (requires further assessment when sober)
- Hostility may represent defense mechanism
Social Factors:
- Unemployment
- Apparent homelessness (belongings in backpack)
- Unclear social support
- Brought by police, suggesting limited resources for self-care
Diagnosis
Provisional Diagnoses:
- Alcohol Use Disorder, Severe (F10.20) - pending confirmation of DSM-5 criteria when patient is sober
- Alcohol Intoxication (F10.129)
- Suicidal ideation, unspecified - cannot rule out given behavior and refusal to discuss
Treatment Plan
Acute Management:
- Medical admission for detoxification and medical stabilization
- CIWA-Ar protocol with lorazepam
- IV fluids with dextrose, thiamine, folate
- Electrolyte repletion (potassium, magnesium)
- 1:1 observation until suicidality can be properly assessed
Re-assessment:
- Complete psychiatric evaluation when BAL <100 and patient is not in active withdrawal
- Collateral information (attempt to contact family, review prior records)
- Assess for comorbid psychiatric conditions
Disposition Planning:
- Social work consultation for housing, benefits
- If alcohol use disorder confirmed, discuss treatment options (inpatient rehabilitation vs. intensive outpatient)
- Assess motivation using motivational interviewing techniques