Hi Johan88
this is an interesting case and you have quite a few things to work through.
Just before discussing it : is your case hypothetical or is it a real case? Have you used a pseudonym? You must protect your patient's confidentiality and you must meet the requirements of your country re: confidentiality. So there are ethical and legal requirements that control you posting such a case on the internet. Have you met these requirements?
More than happy to help but this needs to be established.