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Chief Complaint: “I want to see my lawyer.”
SUBJECTIVE:
HPI: AG is a 32 year old female brought to the state hospital by the police for
her first admission. She had created a disturbance at a local fast-food
restaurant, the police were called, and she was brought to the hospital on an
order of protective custody. The patient exhibits numerous delusions,
including believing that people sneak into her room at night and place a
thousand worms inside her body, she is being raped by passing men on the
street, her ideas have been given to a Cuban communist who is pretending to
be her, her feet were cut off and were reattached after they were sent back
from Central America, eggs were taken from her body, she used to have
transmitters in her backbone, and snakes were in her stomach. She also
demonstrates some grandiose ideations, including believing she used to be a
surgeon, she owns gold, she owns the fast-food restaurant, and she has great
wealth. She also has rambling speech.
Past Psych History: Denies any prior hospitalizations
Family Psych History: claims her family is not really her family and she is not
sure who is her family
PMH: Gallbladder surgery 2 months ago, no documentation of broken hip, no
documentation of rape
SH: + tobacco (2 ppd), denies drug or alcohol use; divorced, lives in an
apartment alone
Meds: Unknown
All: Penicillin - rash
ROS: Reports occasional GI upset, complains that worms are inside her
stomach
OBJECTIVE:
MSE: Appearance: wf of Hispanic ethnicity, morbidly obese, modestly
dressed w/some disarray. Hair unwashed
Speech: clear, constant, pressured, rambling, flight of ideas, hyperverbal
Mood: euphoric, marked grandiosity
Affect: mood-congruent
Thought process: illogical, delusional, grandiose
Thought content: no auditory/visual hallucinations, no suicidal/homicidal
ideation, marked delusions with paranoid ideation prominent
Memory: immediate, recent, and remote are fair
Concentration: adequate
Intellectual function: average
Judgment: markedly impaired
Insight: markedly impaired
,PE: VS: BP 140/85, P 80, RR 17, T 37.1, Wt 97 kg, Ht 5’3”, BMI: 37.9 (Obesity
class II), CrCl 91 mL/min; Skin: scratches on both hands; Remainder wnl
Labs: Neutrophils 66%, Lymphocytes 24%, Monocytes 8%, GGT 38, Total
cholesterol 208, Phosphate 5.1, remainder wnl. Urine pregnancy negative
Complete Problem List: Schizophrenia, paranoid type, Obesity
Problem 1: Schizophrenia, paranoid type
Assessment:
The patient endorses at least 3 of the 5 characteristic symptoms of
schizophrenia (criterion A from DSM-IV-TR), including delusions,
disorganized speech, and grossly disorganized behavior. Based on the
information provided in the HPI and the MSE, it is difficult to discern if the
patient has any negative symptoms (affective flattening, avolition, anhedonia,
etc). The patient was disarrayed with unwashed hair, indicating she may have
some impairment in self-care. It is difficult to discern if she has demonstrated
impairments in other areas of function, such as work or interpersonal
relationships. There is no information provided regarding duration of
symptoms in this patient. In order to warrant a diagnosis of schizophrenia,
the patient must have continuous signs of disturbance for at least 6 months
with at least 1 month of symptoms (less if patient is treated). Although we
have no information regarding duration of symptoms, the patient does have
characteristic symptoms of schizophrenia and would warrant a diagnosis of
schizophrenia. Since the patient has prominent delusions, particularly
persecutory and grandiose delusions, she would further be classified as
having paranoid type schizophrenia.
While any antipsychotic could be used to treat the patient, it is preferred to
use a second generation antipsychotic for initial treatment
(TMAP Schizophrenia algorithm, accessible at
http://www.dshs.state.tx.us/mhprograms/disclaimer.shtm), excluding
clozapine which is reserved for treatment resistant cases. Options within the
atypical antipsychotic class include risperidone, quetiapine, olanzapine,
aripiprazole, ziprasidone, paliperidone, and the recently approved, but not yet
available, iloperidone. There is no clinical evidence demonstrating that any
atypical agent is more efficacious than another atypical agent. As such, the
adverse effect profile should be taken into account, particularly for this obese
female. The propensity for weight gain in the recommended and available
atypical antipsychotics is as follows: olanzapine > quetiapine > risperidone =
paliperidone > ziprasidone ~= aripiprazole. The patient’s unknown
employment status and unknown insurance status should also be considered.
, It is important to note that this patient’s primary symptoms are delusions,
and delusions are the last symptom of schizophrenia to resolve, if they do
resolve. The possibility of these delusions being fixed delusions and
unresponsive to medications should always be considered. If the delusions do
resolve with the use of medication, it may take from 4 to 12 weeks to resolve.
Plan:
Goals of therapy: Resolution of target symptoms – ultimate goal is remission
of symptoms; Minimize adverse effects from medications; Improved quality
of life
Non-pharmacological plan:
Educate patient about schizophrenia and medications. Stress
importance of adherence with medication regimen. Review the onset of effect
of medication since efficacy is not seen for many weeks and patient should be
aware to not discontinue medication believing it is ineffective
Pharmacological plan: Any of the following
Risperidone 1 mg BID, titrate up daily by 1-2 mg/day. MDD per PI: 16
mg/day, usual dose range 2-8 mg/day.
Aripiprazole 10 mg qAM, titrate up q2weeks to response. MDD per PI:
30 mg/day, clinical trials have used up to 45 mg/day
Quetiapine 25 mg BID x 1 day, 50-75 mg BID x 2 days, 150-200 mg BID,
continue to titrate to response. MDD per PI: 800 mg/day, clinical trials
have used up to 1600 mg/day
Olanzapine 10 mg qday (preferentially HS), titrate up by 5 mg/d weekly
to response. MDD per PI: 20 mg/day, clinical trials have used up to 60
mg/day. No evidence showing increased efficacy >20 mg/day in treatment
naïve pts. May be greater efficacy with high dose in treatment refractory
patients.
Ziprasidone 20 mg BID with food (full meal), titrate up no more
frequently than 2 day intervals. MDD per PI: 100 mg BID
Paliperidone 6 mg qday, titrate up no more frequently than 5 day
intervals. MDD per PI: 12 mg
*Notes for facilitators
Any atypical antipsychotic agent, except for clozapine, would be
appropriate for initial treatment for this patient. Alternatively, a typical agent
could be used, provided that the students provide rationale for choosing a
typical agent over an atypical agent. The only absolutely wrong answer is
clozapine.
Chief Complaint: “I want to see my lawyer.”
SUBJECTIVE:
HPI: AG is a 32 year old female brought to the state hospital by the police for
her first admission. She had created a disturbance at a local fast-food
restaurant, the police were called, and she was brought to the hospital on an
order of protective custody. The patient exhibits numerous delusions,
including believing that people sneak into her room at night and place a
thousand worms inside her body, she is being raped by passing men on the
street, her ideas have been given to a Cuban communist who is pretending to
be her, her feet were cut off and were reattached after they were sent back
from Central America, eggs were taken from her body, she used to have
transmitters in her backbone, and snakes were in her stomach. She also
demonstrates some grandiose ideations, including believing she used to be a
surgeon, she owns gold, she owns the fast-food restaurant, and she has great
wealth. She also has rambling speech.
Past Psych History: Denies any prior hospitalizations
Family Psych History: claims her family is not really her family and she is not
sure who is her family
PMH: Gallbladder surgery 2 months ago, no documentation of broken hip, no
documentation of rape
SH: + tobacco (2 ppd), denies drug or alcohol use; divorced, lives in an
apartment alone
Meds: Unknown
All: Penicillin - rash
ROS: Reports occasional GI upset, complains that worms are inside her
stomach
OBJECTIVE:
MSE: Appearance: wf of Hispanic ethnicity, morbidly obese, modestly
dressed w/some disarray. Hair unwashed
Speech: clear, constant, pressured, rambling, flight of ideas, hyperverbal
Mood: euphoric, marked grandiosity
Affect: mood-congruent
Thought process: illogical, delusional, grandiose
Thought content: no auditory/visual hallucinations, no suicidal/homicidal
ideation, marked delusions with paranoid ideation prominent
Memory: immediate, recent, and remote are fair
Concentration: adequate
Intellectual function: average
Judgment: markedly impaired
Insight: markedly impaired
,PE: VS: BP 140/85, P 80, RR 17, T 37.1, Wt 97 kg, Ht 5’3”, BMI: 37.9 (Obesity
class II), CrCl 91 mL/min; Skin: scratches on both hands; Remainder wnl
Labs: Neutrophils 66%, Lymphocytes 24%, Monocytes 8%, GGT 38, Total
cholesterol 208, Phosphate 5.1, remainder wnl. Urine pregnancy negative
Complete Problem List: Schizophrenia, paranoid type, Obesity
Problem 1: Schizophrenia, paranoid type
Assessment:
The patient endorses at least 3 of the 5 characteristic symptoms of
schizophrenia (criterion A from DSM-IV-TR), including delusions,
disorganized speech, and grossly disorganized behavior. Based on the
information provided in the HPI and the MSE, it is difficult to discern if the
patient has any negative symptoms (affective flattening, avolition, anhedonia,
etc). The patient was disarrayed with unwashed hair, indicating she may have
some impairment in self-care. It is difficult to discern if she has demonstrated
impairments in other areas of function, such as work or interpersonal
relationships. There is no information provided regarding duration of
symptoms in this patient. In order to warrant a diagnosis of schizophrenia,
the patient must have continuous signs of disturbance for at least 6 months
with at least 1 month of symptoms (less if patient is treated). Although we
have no information regarding duration of symptoms, the patient does have
characteristic symptoms of schizophrenia and would warrant a diagnosis of
schizophrenia. Since the patient has prominent delusions, particularly
persecutory and grandiose delusions, she would further be classified as
having paranoid type schizophrenia.
While any antipsychotic could be used to treat the patient, it is preferred to
use a second generation antipsychotic for initial treatment
(TMAP Schizophrenia algorithm, accessible at
http://www.dshs.state.tx.us/mhprograms/disclaimer.shtm), excluding
clozapine which is reserved for treatment resistant cases. Options within the
atypical antipsychotic class include risperidone, quetiapine, olanzapine,
aripiprazole, ziprasidone, paliperidone, and the recently approved, but not yet
available, iloperidone. There is no clinical evidence demonstrating that any
atypical agent is more efficacious than another atypical agent. As such, the
adverse effect profile should be taken into account, particularly for this obese
female. The propensity for weight gain in the recommended and available
atypical antipsychotics is as follows: olanzapine > quetiapine > risperidone =
paliperidone > ziprasidone ~= aripiprazole. The patient’s unknown
employment status and unknown insurance status should also be considered.
, It is important to note that this patient’s primary symptoms are delusions,
and delusions are the last symptom of schizophrenia to resolve, if they do
resolve. The possibility of these delusions being fixed delusions and
unresponsive to medications should always be considered. If the delusions do
resolve with the use of medication, it may take from 4 to 12 weeks to resolve.
Plan:
Goals of therapy: Resolution of target symptoms – ultimate goal is remission
of symptoms; Minimize adverse effects from medications; Improved quality
of life
Non-pharmacological plan:
Educate patient about schizophrenia and medications. Stress
importance of adherence with medication regimen. Review the onset of effect
of medication since efficacy is not seen for many weeks and patient should be
aware to not discontinue medication believing it is ineffective
Pharmacological plan: Any of the following
Risperidone 1 mg BID, titrate up daily by 1-2 mg/day. MDD per PI: 16
mg/day, usual dose range 2-8 mg/day.
Aripiprazole 10 mg qAM, titrate up q2weeks to response. MDD per PI:
30 mg/day, clinical trials have used up to 45 mg/day
Quetiapine 25 mg BID x 1 day, 50-75 mg BID x 2 days, 150-200 mg BID,
continue to titrate to response. MDD per PI: 800 mg/day, clinical trials
have used up to 1600 mg/day
Olanzapine 10 mg qday (preferentially HS), titrate up by 5 mg/d weekly
to response. MDD per PI: 20 mg/day, clinical trials have used up to 60
mg/day. No evidence showing increased efficacy >20 mg/day in treatment
naïve pts. May be greater efficacy with high dose in treatment refractory
patients.
Ziprasidone 20 mg BID with food (full meal), titrate up no more
frequently than 2 day intervals. MDD per PI: 100 mg BID
Paliperidone 6 mg qday, titrate up no more frequently than 5 day
intervals. MDD per PI: 12 mg
*Notes for facilitators
Any atypical antipsychotic agent, except for clozapine, would be
appropriate for initial treatment for this patient. Alternatively, a typical agent
could be used, provided that the students provide rationale for choosing a
typical agent over an atypical agent. The only absolutely wrong answer is
clozapine.
