Yet again a familar case
17 yo unemployed male living with his family. Several
months of social withdrawal, unkemptness and poor hygiene. Heavy tobacco smoker
and regular cannabis user. Previous experimentation with amphetamines and LSD.
Experiences paranoid beliefs that he is under surveillance by bikie gangs, phone
is tapped and that listening devices are in his house. Also experiences auditory
hallucination of persecutory nature and more recently, command hallucinations to
commit suicide.
Examination revealed casually dressed male with evidence of poor self-care. He
was orientated to time, place and person but appeared anxious, fearful and
agitated. Conversation was often tangential and preoccupied by themes of being
killed by bikie gangs. He demonstrated impairment in short term memory that may
have been influenced by his thought disorder. He showed poor insight and
judgment and was resistive to admission and treatment.
The patient was detained to the locked ward of a mental health unit whereupon he
became increasing agitated and paranoid and attempted to abscond. This required
temporary physical restraint. Eventually spontaneously settles without chemical
sedation. Commenced on risperidone and agitation settles overnight but paranoia
persists. Later in the week, behaviour settles and patient is transferred to
open ward. Patient begins complaining of muscle stiffness and pain, stiff gait
and hand tremor which is temporarily relieved with benztropine but followed by
blurred vision and dry mouth. Persistent stiffness results in medication changed
to olanzapine responding with gait improvement a few days later. The patient
continued with individual supportive counseling and family meetings were
organised for education.
SOAPE after the first week........
S
Day 7 admissionActive Problems1) First presentation of
acute psychotic disorder - ongoing paranoia - recent move from closed to open
ward) 2) THC abuse +/- others? 3) Agitation - settling now with risperidone (no
longer absconding risk)
Now complaining of muscle stiffness and pain, stiff gait, hand tremor
O
evidence of tremor and hypertonia with Parkisonian-like
gait, currently no fever
A
1) muscle stiffness - ?EPS reaction to antipsychotic
??early neuroleptic malignant syndrome (but unlikely due to short duration of
new medication)
2) Paranoid psychosis - ongoing but settling
P
commence benztropine and observe for response, if ongoing
issues consider switching to olanzapine, observe for new changes in mental
state, fever and do serums CK (to rule out NMS). Organise Social
work/Psychologist input later this week re family meeting.
E
Patient encouraged to be involved with ward activities and report any change in condition.