Gibeah Mental Health Centre
Psych Consult – Schizophrenia
Evaluation and Management (E/M) Patient
SHAUL MATRITE-BENJAMIN
IDENTIFYING DATA:
The patient, a 68-year-old white Jewish male, is a retired politician and soldier. He lives with his wife of 45 years who was present on his admission but did not attend my consultation.
CHIEF COMPLAINT:
"I’m here in prison because I was wrongly arrested on false allegations of attempted murder”.
HISTORY OF PRESENT ILLNESS:
The patient has minimal insight into the circumstances that resulted in his admission. He reports being diagnosed with late-onset schizophrenia but states that he has maintained his stable baseline for many months of treatment.
The patient was escorted to this clinic from the Western Galilee. He was admitted to the emergency room after attempting to plunge more than three hundred meters from the promontory, Katef Shaul (‘Saul’s Shoulder’) on Mount Gilboa and into the Harod Valley below.
A group of tourists reported his crawling to the edge of the look-out and threatening to jump clear, in order to escape someone who was trying to murder him.
As he was restrained by two doctors in the crowd, he clutched at his head moaning that his potential assassin had sent the flocks of vicious raptors that he imagined were circling overhead, waiting to claw him to death.
Before and on arrival at this clinic after transfer from the Emek Medical Centre, Afula, the patient was disorganized with everyone in authority. He has since been detained on a 72-hour involuntary psychiatric hospitalisation order for grave disability. 
At interview, the patient is still disorganised and confused. He believes that he has been arrested and is in prison. He reports a recent history of mental health treatment, but denies benefiting from this and considers it unnecessary.
I have spoken to his wife and eldest son by telephone. His wife reports that the patient is paranoid and has bizarre behaviour at baseline, particularly and increasingly during the past five years, with occasional episodes of symptomatic worsening, from which he spontaneously recovers.
His son estimates the patient spends about twenty per cent of the year in episodes of worse symptoms and that during the past two months, the patient has become worse than he has ever seen him with increased paranoia above the baseline.
The son reports that the patient has barricaded himself in the family home three times and has threatened himself (i.e. the son) and his long-term partner with the sports javelins he keeps with him at all times.
The patient’s wife confirms that he sleeps barely three-four hours a night. However, she has been unaware of any obvious medical changes in recent weeks coinciding with the onset of the symptomatic worsening. She also reports the patient’s longstanding poor compliance with treatment of his mental health and age-related conditions and attributes this to his dislike of taking medicine. She also reports that the patient believes that he does not suffer from the condition.
PAST PSYCHIATRIC HISTORY:
The patient’s wife reports that he was first diagnosed with schizophrenia ten years ago and he has been admitted to other psychiatric and rehabilitation facilities in Israel and abroad. The patient last had outpatient mental health treatment three years ago but dropped out of care, initially without her knowledge.
He was most recently prescribed Seroquel, from which he claimed to suffer unpleasant side-effects.
MEDICAL HISTORY:
CURRENT MEDICATIONS:
None.
ALLERGIES:
No known drug allergies.
SUBSTANCE AND ALCOHOL HISTORY:
The patient had not smoked until the onset of his condition but his habit has increased steadily during the interim and he now smokes two-three packs per day. He consumes alcohol occasionally, but not excessively and has never used illicit substances.
MENTAL STATUS EXAM:
Attitude:
The patient demonstrates only variable co-operation with interview, requires frequent redirection to respond to questions. His appearance is cachectic with poor grooming.
Affect:
His affect is fairly detached.
Mood:
He describes his mood as "O.K.”.
Speech:
His speech is normal rate and volume.
Tone:
His volume was decreased initially, but this improved during the interview.
Thought Process:
His thought processes are markedly tangential.
Thought content:
The patient is fairly scattered. He will provide history with frequent redirection, but he does not appear to stay on one topic for any length of time. He denies current auditory or visual hallucinations, though his wife and son say that this is present at baseline. Paranoid delusions are elicited as described by the incidents at Gilboa.
Homicidal/Suicidal Ideation:
The patient denies suicidal or homicidal ideation. He also denies his recent suicide attempt (see above).
Cognitively, he is alert and oriented to person and year only. His memory is intact to the names of his close family and former work colleagues.
Insight / Judgment:
His insight is absent as evidenced by his repeated questioning of the validity of his mental health diagnoses. His judgment is poor as evidenced by his longstanding pattern of minimal engagement in the treatment of his mental health and physical health conditions.
Assets:
The patient’s material assets include property and financial resources enhanced by a strong and supportive relationship with his wife and some family members.
Limitations:
His limitations include his history of poor compliance with treatment.
FORMULATION:
The patient is a 68-year-old white Jewish male with a history of schizophrenia. He was admitted for disorganized and assaultive behaviour, having withdrawn from all medication for several weeks.
DIAGNOSES:
I: Schizophrenia by history.
II: Anaemia.
III: Relationship strain and the possibility that he may be unable to return to his home upon discharge; minimal engagement in mental health providers.
PLAN:
I will attempt to increase the database and will specifically request records from all previous mental health providers. The Internal Medicine Service will evaluate and treat any acute medical issues that could be helpful.
With the patient’s permission, I will start Quetiapine at a dose of 100 mg at bedtime, given a report of a partial response to this agent in the past.
Dr Reuven Pearl
Director
Emergency Room Admissions
_________
The above will be a chapter in a fantasy based loosely on the end days of the the reign of King Saul, the first monarch of Ancient Israel.
_________
Natalie Wood
(Copyright, Natalie Irene Wood – 25 November 2013)
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