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Chief Complaint
“I want to see my lawyer.”

This is the first inpatient admission for Anita Gonzalez, a 32-year-old woman who was brought
to the psychiatric 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 evaluated 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 identification to
take possession of all of her property. She states that she is having difficulty getting her property

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

Denies any prior hospitalization for mental health problems. Denies any illicit drug or alcohol
use. Smokes two packs of cigarettes per day.
Medical 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 her
family is.

None noted

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, 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 markedly 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.

Review of Systems
Reports occasional GI upset; complains that worms are inside her stomach; otherwise negative
VS BP 140/85 mm Hg, P 80 bpm, RR 17, T 37.1°C; Wt 97 kg; Ht 5′3″
Skin Scratches on both hands
HEENT PERRLA; EOMI; fundi benign; throat and ears clear; TMs intact
Neck Supple, no nodes; normal thyroid
Lungs CTA
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

Na 140 mEq/L Hgb 14.6 g/dL WBC 11.0 × 103/mm3 AST 34 IU/L
K 3.9 mEq/L Hct 45.7% Neutros 66% ALT 22 IU/L
Cl 104 mEq/L RBC 4.7 × 106/mm3 Lymphs 24% Alk phos 89 IU/L
CO2 22 mEq/L MCV 90.2 μm3 Monos 8% GGT 38 IU/L
BUN 19 mg/dL MCH 31 pg Eos 1% T. bili 0.9 mg/dL
SCr 1.1 mg/dL MCHC 34.5 g/dL Basos 1% Alb 3.6 g/dL
Glu 100 mg/dL Urine pregnancy (–) Plt 232 × 103/mm3 T. chol 208 mg/dL
RPR negative TSH 4.5 μIU/mL Phos 5.1 mg/dL Ca 9.6 mg/dL

Urine drug screen Urinalysis

Amphetamines (–)
Barbiturates (–) Color yellow appearance slightly cloudy
Benzodiazepines (–) glucose (–)
Cannabinoids (–) bilirubin (–)
Cocaine (–) ketones, trace
Opiates (–) SG 1.025
PCP (–) blood (–)
Oxycodone (–) pH 6.0
protein (–)
nitrites (–)
leukocyte esterase (-)

 Psychiatric diagnosis: schizophrenia, first episode, currently in acute episode
 Medical diagnoses: S/P cholecystectomy; obesity; tobacco use disorder
Problem Identification
1.a. Create a list of the patient’s drug therapy problems.

1.b. What information (signs, symptoms, laboratory values) indicates the presence or severity of
an acute exacerbation of schizophrenia?

Desired Outcome
2. What are the goals of pharmacotherapy in this case?

Therapeutic Alternatives
3.a. What nondrug therapies might be useful for this patient?

3.b. What pharmacotherapeutic options are available for the treatment of this patient?

Optimal Plan
4.a. What drug, dosage form, dose, schedule, and duration of therapy are best for this patient?

4.b. What alternatives would be appropriate if the initial therapy fails or cannot be used?

Outcome Evaluation
5. What clinical and laboratory parameters are necessary to evaluate the therapy for achievement
of the desired therapeutic outcome and to detect or prevent adverse effects?

Patient Education
6. What information should be provided to the patient to enhance adherence, ensure successful
therapy, and minimize adverse effects?

1. Perform a literature search regarding weight gain with each of the second-generation
antipsychotics currently marketed. Which ones are more likely to cause weight gain?
Which ones are less likely to cause weight gain?
2. Perform a literature search regarding QTc changes with both first- and second-generation
antipsychotics. Which antipsychotics are more likely to alter the QTc interval?
Opiod Analgesic

Chief Complaint
“Everything hurts. My pain is 10/10, it is always at a 10/10! I have tried the medications that
everyone has prescribed me, but they never seem to work and I’m still in pain. I’ve tried PT and
it makes my pain worse! I’m told to wear my CPAP mask, that it will help my sleep and help my
pain. But every time I wear it, I get claustrophobic and my anxiety increases, so I don’t wear it
anymore. I have been in pain for 30 years, and every time I ask for a medication that works,
like oxycodone, which I know works, I am told to try another medication I have never tried, and
to see PT and the psychologist. Well, I’m sick of trying medications that don’t work, and I’m
sick of being told the pain is in my head! The pain isn’t in my head, it’s all over my body! I just
want a shot or a pill that will take all my pain away!”

Danica Mole is a 56-year-old female with pain from temporomandibular-joint disorder,
fibromyalgia, and ruptured L4-L5. She states that her pain began when she was assaulted by one
of her high school students 25 years ago. There was never a report filed of an assault, and she has
been on disability since the time of the assault. She has been a patient in this pain clinic for five
years during which she has failed multiple medications; every time a new nonopioid medication
began to work, she developed adverse reactions to it. Thus, she has been prescribed and using
opioid medications to control her pain. While she has never overtly misused her opioid
medications, she has been calling and asking for early refills of her opioid medications due to
overuse, and lost or stolen prescriptions. She bristles at any suggestion that she may be
“chemically coping.” She states proudly that she used to have an alcohol problem, but “took care
of herself” and did not need any “12 Step program or rehab hospital.” She has never embraced
PT, and states that her pain is made worse by PT. She is antagonistic to behavioral therapy and
has been fired as a patient by two of the clinic’s psychiatrists in five years. The clinic’s
interventionists have declined to offer her epidural or facet injections because they fear further
complaints from her regarding complications from the procedure. She has tried trigger-point
injections (TPI) only once, stating that they made her pain worse.

 Fibromyalgia × 25 years
 Degenerative disk disease × 25 years
 TMJ disorder × 30 years
 Obesity × 20 years
 OSA × 20 years
 PTSD × 25 years
 HTN × 10 years
 Hyperlipidemia × 10 years
 Remote history of substance use disorder, alcohol, “clean” for 6 years


Patient is a retired high school teacher. She retired after she was assaulted by one of her students
and placed on medical disability over 30 years ago. She has been married for 30 years. She
spends her days caring for their 22-year-old daughter who cannot work due to severe migraine
headaches and fibromyalgia. She and her husband are pursuing medical disability for their
daughter. She often sleeps until one in the afternoon and then stays up most of the night talking
to her daughter. She has one younger sister and one younger brother. She makes multiple plans
to volunteer and to take care of her elderly in-laws, but never is able to complete these plans.

 Oxycodone IR 15 mg PO Q 6 H PRN for pain
 Morphine ER 30 mg PO TID for pain
 Atorvastatin 10 mg PO HS
 Hydrochlorothiazide 25 mg PO Q AM
 Diazepam 5 mg PO TID PRN

 APAP: increased pain, stomach upset
 Amitriptyline: rash
 Duloxetine: stomach upset, “mania”
 NSAIDs (all): ulcer
 Gabapentin: “could not think”
 Pregabalin: weight gain
 Venlafaxine: stomach upset, increased depression

Positive for total body pain. She states all her muscles hurt, that she has electrical, shooting
stinging pain from her back, legs, and feet bilaterally. Her mood is agitated.
Physical Examination
Gen Patient is a 56-year-old obese woman with wide spread allodynia
VS BP 150/96 mm Hg, P 96 bpm, RR 15, T 37.5°C; Wt 137.6 kg, Ht 158 cm, BMI 55
Neck Supple, no JVD, no bruits
Resp CTA and P; no crackles or wheezes
CV NSR without MRG
Breasts Negative
Abd Soft, NT, liver and spleen not palpable, (+) BS
Genit/Rect Heme (–) stool, pelvic exam deferred
MS/Ext Widespread, extreme allodynia with any touch; axial spine had good alignment of
the spine. Spine demonstrated excellent range of motion; however, there was
widespread allodynia on her spinous muscles. Thoracic spine was normal except
for allodynia. Cervical spine demonstrated good range of motion; positive
allodynia. She had spasm and tenderness in the trapezius muscles bilaterally (left
greater than right), in the rhomboid muscles (right side principally), and in the
scalene muscles (the right side of her neck greater than the left side although both
sides were affected).
Neuro  CN II–XII intact, A & O × 3
 Normal motor strength in the upper extremities with reflexes 1+ and
symmetric and normal sensation extremities, no CCE
Labs  Chem 7: WNL
 CBC: WNL except for elevated Hgb and Hct
 MRI: Slight degenerative disk disease, that is appropriate for age

 Fibromyalgia
 Depression
 Anxiety
 Obesity
 Possible medication related aberrant behavior
 Hyperlipidemia
Problem Identification
1.a. Create a list of the patient’s drug therapy problems.

1.b. What information indicates the presence or severity of chronic nonmalignant pain?

1.c. Could any of the patient’s problems have been caused by drug therapy?

1.d. What additional information is needed to satisfactorily assess this patient’s pain?

1.e. Address the patient’s concerns and expectation regarding her pain and medication therapy.

1.f. Determine if the patient is at risk for medication-related aberrant behavior.

1.g. Assess the patient’s risk for additional morbidity from her medications.

Desired Outcome
2.a. What are the patient’s goals of pharmacotherapy in this case?

2.b. What are the clinician’s goals of pharmacotherapy in this case?

Therapeutic Alternatives
3.a. What nonpharmacologic therapies might be useful for this patient?

3.b. What behavioral therapies might be useful for this patient?

3.c. Compare the opioid medication pharmacotherapeutic alternatives available for treatment of
this patient’s pain.

Optimal Plan
4.a. What is the best approach to safe prescribing of opioid medications for DM?

4.b. What drug, dosage, form, schedule, and duration of therapy are best for treating this
patient’s pain, based on DM’s total daily opioid dose in morphine-equivalent dose (MED)?

4.c. What are the advantages and disadvantages of using an extended release (ER) opioid
medication compared with an immediate release (IR) opioid medication?

Outcome Evaluation
5.a. What outcome parameters can be utilized to gauge DM’s progress?

5.b. What tools can be employed to monitor for medication-related aberrant behavior?

5.c. What steps can be taken if DM begins to exhibit medication-related aberrant behavior, yet
has a valid reason to continue opioid medications?
5.d. If DM continues to exhibit medication-related aberrant behavior, what strategies can be used
to wean her opioid medications?

5.e. Compare and contrast the terms: physical dependence, tolerance, pseudo-addiction,
addiction, and withdrawal.

Patient Education
6. What information should be provided to the patient to enhance compliance, ensure successful
therapy, and minimize adverse effects?