Rxp slideshare psychotic case

Clinical Detective

The Case of the Hallucinating Haberdasher


A 58-year-old hat-factory worker, Mr. Smith, had fallen on the job and was hospitalized for observation due to a 30 minute loss of consciousness. He was in the hospital over night when he grew increasingly nervous and agitated. He began hearing voices that were unstructured, and ill-developed. The attending physician has not ordered any medications for this patient, other than standing Motrin 800 prn up to TID, and Temazepam 15 mg po prn insomnia.Imaging studies did not detect any encephalopathy including cerebrovascular problems, space occupying lesions. The doctor calls the C&L service saying that the patient has been examined for head injury and believes that this is just a “psych case.”You present to the room as the on-call consultant


1. What type of history would you want to obtain on this patient?

2. What other modes of data collection are available to you?


Consider Historical InformationChronology of symptom formation

Onset, Duration, Character, Aggravating factors, Reliving factors, Timing and Severity

Past Mental Health HistoryPast Medical HistoryCurrent MedicationsFamily illnessesSubstance UseDevelopmental

Personality Disorder under stress likely to experience psychotic symptoms

Sexual History


Other data available:Observe the physical findingsReview the medical record for:

VitalsAdmission notesNursing notesPhysical examMedicationsPast medical historyLabs and procedures ordered/results

Collateral Information from available friends/relatives


You learn that he has worked in the same factory for over 20 years without difficulty. He has been married for 30 years.His physician has noted on admission that he has treated Mr. Smith as an outpatient for several years, and this is the first onset of auditory hallucinations.Nursing notes indicate that Mr. Smith keeps scratching at his arms and neck and they have had to place a dressing on his left forearm secondary to bleeding from his scratching.During your interview he appears to be sweating profusely. He also appears tremulous and is becoming increasingly agitated. He denies suffering from hallucinations. He says he sometimes see’s shadows.


The patient is showing impaired concentration and poor reality testing. He denies any history of significant medical or psych problems. You consider him an unreliable historian.


Is this presentation typical for schizophrenia so far?Why?


AnswerNot typical

Age range (peak onset 18-24)Hallucinations are acute (occurring in hospital setting)Hallucinations are ill-definedPhysical symptoms acute

NoteGood premorbid adjustment is seen more often in patients with psychosis due to neurologic/systemic disorders, whereas poorer adjustment is more common in patients with mental illness. Baseline behavior useful discriminant.

Persons with schizophrenia, for example, often demonstrate evidence of disturbed thinking between psychotic episodes.Interpersonal relationship and work histories tend to be more disrupted in patients with primary psychiatric disease


Your review of available data show:

VitalsSBP >200 mmHg, DBP >110 mmHg; HR >140T >101F

Labs:Decreased AlbuminElevated SodiumAbnormal LFTs

Elevated Gamma-glutamyl transpeptidase, GGTElevation of Aspartate Transaminase (AST) and Alanine Transaminase (ALT)

AST:ALT ratio of 2:1Elevated Mean Corpuscular Volume (macrocytosis)Elevated Carbohydrate-deficient transferrin (CDT)

CAGE Score = 3 C1A1G1E0


Your collateral interview with wife provides the following:Her husband comes home every night and just sits in front of the television drinking beer. He has a 30 year drinking history, but intake has increased over the past few years.Most of the time he just falls asleep in front of the television and she has gotten to the point she just leaves him there. He eventually stumbles into bed some time in the night, but usually he has trouble sleeping and will leave the house before she awakens. He doesn’t eat much anymore even though he used to have a voracious appetite. With more questioning you learn that the patient’s father was alcoholic and so was his paternal grandfather.


What is your most likely diagnosis?


Alcohol HallucinosisTypical Presentation

30-60 years oldAcuteIf due to withdrawal, begins 8-12 hours after cessation of drinkingHallucinations are usually auditoryAnxious, DepressedImpairment of cognitive functioning Spontaneous improvement (last <week)

Education

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