Today I had 2 patients that I was planning on discharging. A 34 year old many with schizophrenia paranoid type and chronic marijuana use who recently missed his 2 week injection of antipsychotic medication. Within a week of missing his medication he started hearing voices and became more and more psychotic until he brought himself into the ER because the voices were telling him to hurt himself and his mother. We got him back on his medications and over the course of 6 days saw him go from crying and psychotic to smiling and nearly normal. He tends to get healthy and then let his medications slide and use more marijuana until he has a psychotic break and needs hospitalization. Today he was doing great and ready for discharge. I wrote him his prescriptions and got his outpatient appointments set up through the social worker and sent him home.
The second patient was another schizophrenic patient who had been improving but decompensated yesterday when she grabbed her nurses breast and twisted it clockwise and then kicked her in the crotch. I hate it when that happens. Why did she decompensate? It was curious to me that she had improved so much over the course of the week and then suddenly became aggressive and psychotic again. I asked the nurses and read some of their notes to try to see if anything stuck out as a reason for her getting worse. I soon realized that my patient had the same last name of another patient on the unit and one of our nurses gave an injection of a medication for the other patient to my patient. This was a medication that last a month and was not meant to be given to my patient.
Once I found this error it all made sense to me. My patient had become worse because she was on a medication that she was not used to and the feeling worsened her psychosis. I had to talk with the nurse and show her the error and also my attending physician who of course was upset. Then I had the joy of calling the patient's husband who fortunately is a physician and completely understood. Actually the medication given by accident could be a beneficial medicine for my patient in the long run but not at the dose she received. The husband was totally cool about it and when I told him what the medication was he said "well she could benefit from the medication anyways."
The husband was very thankful for the progress we had made with his wife because he was at the end of his rope and did not know what to do and was considering putting his wife in a nursing home. She has a long history of schizoaffective disorder with mania and had been fairly well controlled for the last 15 years on lithium but recently her psychiatrist stopped the lithium because her kidneys started to fail. Kidney failure is a potential risk of long term lithium use. She was switched to resperidol in December and basically spun completely out of control to the point where the husband could no longer care for her. He wanted to put her back on lithium despite the kidney failure because she was at least manageable on the lithium. He begged us to reconsider lithium but we told him we would try a couple of different medications until we found something that worked. We put her on valproic acid and amazingly she responded very well. The husband visited and remarked that she was even better than when she had been on lithium. The husband and the some were both very happy. It was great to see.
We had her ready to go today but because of the increased aggression caused by administration of the wrong medication we decided to keep her a couple of more days until her aggressive behavior is better controlled.
I am going to miss psychiatry!
2 comments:
You made an excellent job looking for the cause why your patient had decompensate. You must be proud of your behaviour, it's allways great when we can make de diference. I'm very interested in having my psychiatry rotation too, expecially after reading yours posts. My brother have schizophrenia and I know how important is the quality of the service prested to the patient and also to his family.
Thanks for the input. I am sorry to hear about your brother. I have a whole new appreciation for schizophrenia and how devastating it can be for the patient and family. Good luck on your rotations.
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