IDENTIFICATION: The patient is a 20-year-old single, third-generation,

American-born 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 10 months until 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 this 20-year-old female. 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 hallucination 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 2 weeks along with
paranoid delusions of others laughing and talking about her. She denies any
past or present suicide or homicide attempts. She denies access to weapons.
She alleges that she has not been able to work for the past 2 weeks because of
her symptoms. However, as
per collateral from her mother, the patient has not been able to work
consistently for the past 3 months due to multiple hospitalizations. The
patient reports irritability, racing thoughts, feelings of sadness, lack of
interest in usual activities, poor appetite, fatigue, lack of motivation,
interrupted sleep of 4 hours per night, increased anxiety, and fears about the
future for the past 2 weeks. She reports sporadic compliance with topiramate
and risperidone for the past 2 weeks. She attributes the auditory
hallucinations 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 2 weeks ago after 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
mg PO HS, risperidone 1 mg PO BID, trazodone 100 mg PO HS, and
hydroxyzine 50 mg PO Q4h PRN.
PAST PSYCHIATRIC HISTORY
The patient was initially diagnosed with bipolar disorder 5 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 mg PO BID and valproic acid 1000 mg PO HS.
Following her hospitalization, she was treated by a private therapist and
psychiatrist. Her second psychiatric hospitalization 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 the mother denied ever knowing about the abuse
and expressed remorse.
A third inpatient psychiatric hospitalization occurred when she was 18 for
depression. During this 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 valproic acid 1000 mg PO HS and lithium 600 mg
PO BID to topiramate 100 mg PO HS and paliperidone 6 mg PO BID.
The paliperidone helped eliminate her homicidal thoughts and voices for
about 2 months; however, symptoms returned and precipitated her fifth
psychiatric admission. She reports that the paliperidone was discontinued.
She was then started on haloperidol 5 mg PO BID which was stopped due to
EPS after 2 days and then started on risperidone 1 mg PO BID. Trazodone
100 mg PO HS, and hydroxyzine 50 mg 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 electrocardiogram
(ECG) findings with slight QTc prolongation of 460 ms. No known allergies,
medical hospitalizations, or surgeries.
The patient has a history of:
Hypertension currently treated with carvedilol 3.125 mg PO BID and losartan
50 mg PO BID.
Type II diabetes currently treated with glipizide 5 mg PO am.
Hyperlipidemia
Obesity
Gout treated with allopurinol 300 mg PO am.
She was diagnosed with sleep apnea 6 months ago and uses a continuous
positive airway pressure machine at HS.
HISTORY OF DRUG OR ALCOHOL ABUSE: She denies past or present
use of substances including tobacco and alcohol.
FAMILY HISTORY: The patient is one of three children. Her non-Hassidic
Orthodox Jewish maternal grandparents severed ties with her mom when she
married her dad who was not very religious even though of a non-Hassidic
Orthodox Jewish background. She states her family only went to the temple
occasionally during holidays while growing up. Her father died when the
patient was 18 years old. Her mother is currently living with her. No known
psychiatric illnesses in the family.
PERSONAL HISTORY
Perinatal: No known perinatal complications.
Childhood: No history of head banging, rocking, attachment issues,
intellectual or motor skill deficits, separation anxiety, gender identity
development, friendship difficulties, learning disabilities, nightmares,
phobias, bedwetting, fire setting, or cruelty to animals.

Adolescence: Attended public school as opposed to a Jewish school, which

she later regretted and was jealous about her sister attending a Jewish school.
She was a sophomore in high school when she was initially admitted to a
psychiatric hospital for aggressiveness toward her mother and sister. The
patient was able to graduate high school with a B average. She reports having
had a few friends in high school.

Adulthood
She got a job in the Jewish community center as a youth worker shortly after
high school.
The patient subscribes to the Jewish religion. She currently observes Rosh
Hashanah and Yom Kippur.
The patient has never been married, has no children, and has lived
independently in a one-bedroom apartment for the past 10 months until 2
weeks ago when her mother who recently broke up with her boyfriend moved
in. The patient has a boyfriend who is American born of Italian heritage. She
has been seeing him for 9 months and he spent weekends at her apartment
until her mother moved in. The patient met her boyfriend at work. The patient
denies any criminal or delinquent history and has never served in the military.

TRAUMA/ABUSE 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. She did not want to provide any details about the sexual
abuse, such as the frequency or length of time, to this provider at the time of
this evaluation.

MENTAL STATUS EXAMINATION

Appearance: Disheveled with poor ADLs.
Behavior and psychomotor activity: Apathetic and reluctant to answer
questions. Normal motor activity with poor eye contact.
Consciousness:Fully alert.
Orientation: Oriented to person, place, and date.
Memory: Intact immediate, recent, and remote recall.
Concentration and attention: Unimpaired; serial 7s intact.
Visuospatial ability: Not assessed.
Abstract thought: Adequate proverb interpretation.
Intellectual functioning: Average.
Speech and language: Slow rate with normal volume.
Perceptions: Command auditory hallucinations of a male voice telling her to hurt herself and
others.
Thought processes: Logical and coherent, reports racing thoughts.
Thought content: Paranoid delusions of others talking and laughing at her.
Suicidality or homicidality:
Reports thoughts to cut wrist for the past 2 weeks due to the voices that
resolved after arrival at the hospital. Reports thoughts to kill mother and
boyfriend for the past 2 weeks due to the voices.
Mood: Dysphoric and anxious.
Affect: Flat.
Impulse control: Good during the interview. No history of impulsiveness.
Judgment: Poor. Needed others to coax her to seek help.
Insight: Fair, understands present mental state.
Reliability: Generally seems to be a reliable historian.