A Female Presenting Multiple Psychotic Symptoms

Case Study 3 Assignment-Student
ID: Sarah is a 20-year-old single Caucasian female of Jewish heritage who is one of three children. She has never been married, has no children, and lives independently in a one bedroom apartment for the past year until approximately 2 weeks ago when her mother moved in. She is being evaluated on the inpatient psychiatric unit to which she has recently been admitted on a voluntary status.
CHIEF COMPLAINT: “I am hearing voices to kill myself and my mom and boyfriend”
HISTORY OF CHIEF COMPLAINT: This is the sixth inpatient admission for Sarah. She presented to the crisis center last night on a voluntary basis after a recommendation by her private psychiatrist. She reports being plagued with command auditory hallucinations to cut her wrist with a razor or a knife and to kill her mother and boyfriend with a knife or a gun. She reports experiencing these command auditory hallucinations of a man's voice at least 10 to 20 times daily for the past two weeks along with paranoid delusions of others laughing and talking about her. She denies any past or present suicide or homicidal attempts. She denies access to weapons. She alleges that she has not been able to work for the past two weeks because of her symptoms. However her mom indicated that the patient has not been able to work consistently for the past three months due to multiple hospitalizations. The patient reports irritability, racing thoughts, feeling that sadness, lack of interest in usual activities, poor appetite, fatigue, lack of motivation, interrupted sleep of four hours per night, increased anxiety, and fears about the future for the past two weeks. She reports sporadic compliance with topiramate and risperidone for the past two weeks. She attributes the auditory hallucination to medication changes from lithium and valproic acid to topiramate and risperidone due to her declining renal status. Recent stressors include her mother moving in with her two weeks ago after her mother broke up with her own boyfriend. Mother has been voicing her disapproval of the patient's boyfriend since moving in, which the patient identifies as being stressful. The patient is requesting to be placed back on lithium and valproic acid. Her psychotropic medications prior to admission include topiramate 100 milligrams PO HS, risperidone 1 milligram PO BID, Trazodone 100 milligrams PO HS, and hydroxyzine 50 milligrams PO Q4H PRN.
PAST PSYCHIATRIC HISTORY
The patient was initially diagnosed with bipolar disorder five years ago at age 15 during her sophomore year when she was first hospitalized at a psychiatric hospital due to aggressive behavior toward her mother and sister. She was treated with lithium 600 milligrams PO BID and valproic acid 1000 milligrams PO HS. Following her hospitalization, she was treated by a private therapist and psychiatrist.
For a second psychiatric hospitalization, which was at the age of 16 for depression related to her father's death and regret that she did not confront him about past sexual abuse. Prior to the hospitalization, she confronted her mother about the abuse, and her mother denied ever knowing about the abuse and expressed remorse.
A third inpatient psychiatric hospitalization occurred when she was 18 for depression. During the hospitalization, there were no medication changes and she was discharged to outpatient treatment after a few days.
The fourth hospitalization occurred a year ago when she was 19, for manic symptoms and her first episode of command auditory hallucinations to hurt random people. During that admission, her medication was changed because of declining renal status from the valproic acid 1000 milligrams PO HS and lithium 600 milligrams PO BID to topiramate 100 milligrams PO HS and paliperidone 6 milligrams PO BID.
The paliperidone helped eliminate her homicidal thoughts and voices for about two months; however, symptoms returned and precipitated her fifth psychiatric admission. She reports that the paliperidone was discontinued. She was then started on haloperidol 5 milligrams PO BID which was stopped due to EPS after two days and then started on risperidone 1 milligram PO BID. Trazodone 100 milligrams PO HS, and hydroxyzine 50 milligrams PO Q4H PRN were also ordered during the hospitalization. The patient reports that she was discharged after a week to her outpatient therapist and private psychiatrist. Two weeks ago, her symptoms returned.
MEDICAL HISTORY
Review of previous hospital admission records indicates EKG findings with slight QTc prolongation of 460 ms.
NKDA
No hospitalizations, no surgeries
Hypertension currently treated with carvedilol 3.125 milligrams PO BID and Losartan 50 milligrams PO
BID
Type 2 diabetes currently treated with glipizide 5 milligrams PO in the AM
Hyperlipidemia
Obesity (BMI 31)
Gout treated with allopurinol 300 milligrams PO in the AM
She was diagnosed with sleep apnea six months ago and uses a CPAP machine at night
She denies past or present use of substances including tobacco and alcohol.
FAMILY HISTORY
The patient is one of three children. She has had no contact with her maternal grandparents as her grandparents’ severed ties with her mom when she married her dad who was not very religious and did not have the Jewish background. She states her family only went to the temple occasionally during holidays while growing up. Her father died suddenly when the patient was 18 years old. Her mother is currently living with her. No known psychiatric illnesses in the family.
PERSONAL HISTORY
She was born full term with no complications at birth. She attended public school and was an A/B student until high school. She was a sophomore in high school when she was initially admitted to the psychiatric hospital for aggressions towards her mother and sister. The patient was able to graduate high school with a B average. She reports having had just a few friends in high school.
She got a job in the Jewish Community Center as a youth worker shortly after high school.
She has never been married, has no children, and has lived independently in a one-bedroom apartment for the past year until two weeks ago when her mother moved in.
She has a boyfriend who she has been seeing for about 9 months. She denies any legal history and has never served in the military.
TRAUMA HISTORY
As a child, the patient experienced sexual abuse by her father. She never spoke about the sexual abuse to anyone until she saw a therapist for the first time when she was 15 and was admitted to a psychiatric unit.
MENTAL STATUS EXAMINATION
She is disheveled with poor ADLs, apathetic and reluctant to answer questions. normal motor activity with poor eye contact. Fully alert and oriented. Oriented to person place and date. Memory intact immediate, recent, and remote recall. Speech is with a slow rate and normal volume. Command auditory hallucinations of a male voice telling her to hurt herself and others. Thought process is logical and coherent, reports racing thoughts. There are paranoid delusions of others talking and laughing at her. Reports thoughts to cut wrists for the past two weeks due to the voices that resolved after arrival at the hospital. Reports thoughts to kill mother and boyfriend for the past two weeks due to the voices best friend. Mood is dysphoric and anxious. Affect is flat. Impulse control is good during the interview. Judgment is poor; needed others to coax her to seek help. Insight is fair but understands present mental state.
Which diagnosis should be considered? Give your rationale.
What other diagnosis should be considered? Give rationale.
What tests or tools should be considered to help identify the correct diagnosis?
What treatment would you prescribe and what is the rationale? Please keep in mind the patient’s renal impairment, metabolic syndrome please tell me you found and QTC prolongation. Include medications for her medical conditions. Remember this is an inpatient. Include diagnostic lab testing. Include types of psychotherapy.