Patient Presentation
Chief Complaint
“I want to see my lawyer.”
HPI
This is the first admission for Anita Gonzalez, a 32-year-old woman
who was brought to the state hospital by the police. Earlier today
she was brought to the Crisis Center by a friend in her apartment
building after the landlord threatened to call the police since Anita
was creating a disturbance. At the Crisis Center Anita became
increasingly agitated and suspicious; the police were called;
however, she left before being seen by staff. The patient
apparently has been delusional and believes people sneak into her
room at night when she is asleep and place a thousand worms
inside her body. She also believes that she is being raped by
passing men on the street. She is quite preoccupied about having
massive wealth. She claims to have bought some gold and left it at
the grocery store. She believes that her ideas have been given to a
Cuban communist who has had plastic surgery to look like her and
is using her ID to take possession of all of her property. She states
that she is having difficulty getting her property back.
Apparently, the precipitating event today that eventually resulted
in her hospitalization was that she created a disturbance at a local
fast food restaurant, claiming that she owned it. Because of the
disturbance, police were called, and she subsequently was sent
here on an order of protective custody. According to the patient,
she bought a hamburger and sat down to eat it, and for some
reason somebody called the police and charged her with illegal
trespassing. She claims that 6 years ago she was raped by a
relative of a sister and broke her hip in the process. She states that
her feet were cut off because she would not do what her
impostors wanted her to do, and her feet were subsequently sent
back to her from Central America and were reattached.
Her speech is quite rambling. She speaks of having been part of
an experiment in Monterey, Mexico, in which 38 eggs were taken
from her body, and children were produced from them and then
killed by the government. She claims that she has worms in her
that are the type that kill dogs and horses and says that they have
been put there by the government. She also claims that at one
time she had transmitters in her backbone and that it took 3 years
to have them taken out by the government. She claims to have
had surgery in the past, and the surgeon did not know what he
was doing and took out her gallbladder and put it in the
intestines, where it exploded. The patient also states that on one
occasion a physician was removing the snakes from her abdominal
cavity, and the snakes killed the doctor and a nurse. She also
claims that she worked as a surgeon herself before 1963.
Past Psychiatric History
The patient denies any prior hospitalization for mental problems
and denies any street drugs or significant substance use. There is
some history of her having frequent visits to the local hospital. She
denies any drug or alcohol use. She smokes two packs of
cigarettes per day.
PMH
The patient’s past records indicate that she did have gallbladder
surgery (cholecystectomy) 2 months ago.
There is no record of her ever being raped or having a broken hip.
No further medical history is known.
Family Psychiatric History
The patient claims that her alleged family is not really her family
and that she is not sure who is her family.
Meds
None noted
All
Penicillin → rash
Legal/Social Status
Divorced; heterosexual; lives in an apartment alone; employment
history unknown
Mental Status Examination
The patient is a white female of Hispanic ethnicity, modestly
dressed, with some disarray. She is morbidly obese. Her hair is
black and unwashed. She is alert, is oriented, and in no acute
distress. Her speech is clear, constant, and pressured, with many
grandiose delusions and illogical thoughts. She is quite rambling,
going from one subject to the other without interruption. Her
affect is mood-congruent, her mood is euphoric, and there is a
marked degree of grandiosity. Her thought processes are quite
illogical, with marked delusional thinking. There is no current
evidence of auditory hallucinations, and she denies visual
hallucinations. She denies any suicidal or homicidal ideation, but
she is quite verbal and pressured in her thought content,
verbalizing a great deal about the things that have been taken
away from her illegally by people impersonating her. She has
marked delusional symptoms, with paranoid ideation prominent.
Her memory (immediate, recent, and remote) is fair. Her cognition
and concentration are adequate. Her intellectual functioning is
within the average range. Insight and judgment are markedly
impaired.
ROS
Reports occasional GI upset; complains that worms are inside her
stomach; otherwise negative
Physical Examination
VS
BP 140/85 mm Hg, P 80 bpm, RR 17, T 37.1°C; Wt 97 kg; Ht 5′3″
HEENT
PERRLA; EOMI; fundi benign; throat and ears clear; TMs intact
Skin
Scratches on both hands
Neck
Supple, no nodes; normal thyroid
Lungs
CTA & P
CV
RRR, normal S1 and S2
Abd
(+) BS, nontender
Ext
Full ROM, pulses 2+ bilaterally
Neuro
A & O × 3; reflexes symmetric; toes downgoing; normal gait;
normal strength; sensation intact; CNs II–XII intact
Labs
Lab Values
Na 140
Hgb 14.6
WBC 11.0 ×
AST 34
Ca 9.6
mEq/L
g/dL
103/mm3
IU/L
mg/dL
K 3.9
Hct 45.7%
Neutros 66%
ALT 22
Phos 5.1
IU/L
mg/dL
Alk phos
TSH 4.5
89 IU/L
μIU/mL
mEq/L
Cl 104
RBC 4.7 ×
mEq/L
106/mm3
Lymphs 24%
CO2 22
MCV 90.2
mEq/L
μm3
BUN 19
MCH 31 pg
Monos 8%
Eos 1%
mg/dL
GGT 38
RPR
IU/L
negative
T. bili 0.9
Urine
mg/dL
pregnancy
(–)
SCr 1.1
MCHC 34.5
mg/dL
g/dL
Basos 1%
Alb 3.6
g/dL
Glu 100
Plt 232 ×
T. chol 208
mg/dL
103/mm3
mg/dL
UA
Color yellow; appearance slightly cloudy; glucose (–); bili (–);
ketones, trace; SG 1.025; blood (–); pH 6.0; protein (–); nitrites (–);
leukocyte esterase (–)
Assessment
Axis I: schizophrenia, paranoid type, acute exacerbation
Axis II: none
Axis III: patient allergic to penicillin by history; S/P gallbladder
surgery 2 months ago; obesity
Axis IV: unemployment
Axis V: GAF Scale = 32