Case Study: Analyzing a Patient's Acute Inpatient Stay

This case study examines the case of a 60-year-old Cambodian woman, Carolyn, admitted to an acute inpatient facility due to erratic and threatening behavior indicative of a manic schizophrenic episode. The study details her medical history, including diabetes, hypothyroidism, and a history of schizoaffective and bipolar disorders, along with potential links to childhood trauma and domestic abuse. The analysis suggests a relapse caused by non-compliance with medication, and the patient's symptoms, including auditory and visual hallucinations, are explored. Treatment includes de-escalation, observation for hallucinations, and medication with cariprazine, considering her renal impairment and past medical history. The case study concludes with a discussion of the patient's stabilization and discharge plan.

Running head:CASE STUDY IN ACUTE INPATIENT FACILITY
Case Study in Acute Inpatient Facility
Name of the Student
Name of the University
Author Note

1CASE STUDY IN ACUTE INPATIENT FACILITY
Introduction
Acute inpatient facilities may be referred to as units where a patient is admitted in
case of an acute symptom (something that requires immediate attention and is very sudden) in
order to treat them for a short period of time, like for a couple of days and then releasing
them. This entails giving the patient active but short-term care as opposed to long-term care.
The treatment in such a facility is often recovery-oriented and focused on reducing the
symptoms and stabilizing the patient. This is opposed to that of chronic illness care. Chronic
symptoms include long term symptoms which manifest over a period of time like a month or
year. They need the patient to be rehabilitated over a longer period. The acute inpatient
facility admits the patient for a shorter period of time in order to stabilize them. This paper
focuses on a case study about a 60-year-old patient named Carolyn who was admitted by her
family to a nearby acute inpatient facility, including a description of her condition, her mental
and physical medical history and the analysis of her conditions.
Case Study
A 60-year-old Cambodian woman named Carolyn was brought to the Emergency
Room of an Acute Inpatient Facility by her family members due to unstable and threatening
behaviour that included shouting obscenities to the apparently no one or any member of her
family, threatening to stab someone, reaching out in front of her and throwing anything that
she can lay her hands on in her general vicinity. This was followed by a state of withdrawal
where she refused to answer any questions or respond to anyone, but talking to herself. It also
included having delusions regarding a person being present in her room and talking to her.
During the initial consultation with the psychiatrist, the patient seemed to be staring at the
wall and occasionally shouting obscenities or laughing uncontrollably. The patient seemed to
hear the psychiatrist but did not seem inclined to try and answer them. It was unclear whether

2CASE STUDY IN ACUTE INPATIENT FACILITY
the patient could comprehend the questions or not. The nurse observed her behaviour and
facial expressions and the patient seemed to be conversing with someone, most likely an
argument. This was revealed by apparent agitation on her part and the occasional obscenities.
This was alternated by a calmer phase where she seemed almost normal but did not give any
inclination that she was comprehending anyone speaking to her.
Background
The patient is Cambodian, and she grew up during the Cambodian Civil War in a
lower-middle-class household. Her father was killed violently when she was 16 years of age.
She was married at the age of 22 to a man who was a decade older than her. Her husband was
reported to be mentally and physically abusive and he was a raging alcoholic. He was
reported of violent behaviour in his younger years and the patient reported domestic violence
multiple times in the course of their forty years of staying together. The patient was
previously employed as a retail worker, but is currently unemployed and separated from the
husband. The patient lives with her son and daughter-in-law.
Physical History
The patient has a medical history of diabetes and hypothyroidism. Her
hypothyroidism has been believed to be brought by the use of lithium drugs. She has been
treated with thyroxine tablets for her hypothyroidism. She also has a history of
hyperprolactinemia which has not been treated as per the knowledge of the medical staff.
Apart from this, the patient has a history of renal impairment which is believed to have been
caused as a side effect by the longterm use of insulin and her diabetic medications. However,
she has a clean history with regards to using hard drugs and no reported case of alcohol
abuse. It is unclear whether she was prescribed the lithium drug by a physician or she chose
to take it by a nonmedical opinion.

3CASE STUDY IN ACUTE INPATIENT FACILITY
Psychiatric History
The patient has been diagnosed with schizoaffective disorder in the past but no
episodes of the same have occurred in the last two years. For this, the antipsychotic agent
Aripriprazole has been prescribed. The patient also has a diagnosis of bipolar disorder. For
this, she has been prescribed Sodium Valproate. However, the patient is non-complaint with
her medications; hence she has been most likely treated with Zuclopenthixol injections. It is
unclear whether anyone in the patient’s family has had similar episodes or disorders.
Assessment and Treatment
From the description and the history of the patient, it can be believed that the patient
is suffering from a manic schizophrenic episode. Her symptoms very much suggested a
manic episode that included irritability, unreasonable anger, hyperactivity and euphoria
(Daglas et al., 2014). It is possible that the psychotic episode may be caused by her
hypothyroidism (Ueno et al., 2015). The cause of her hypothyroidism is believed to be
lithium-induced. This suggests that a lithium-drug such as lithium carbonate may have been
used in conjunction with sodium valproate as a treatment to her bipolar disorder (Cheung,
2018). This is no doubt enhanced by her non-compliance towards taking medications such as
thyroxine tablets. It has been seen that patients with poor health and comorbidities are more
prone to experiencing recurrent bipolar disorder (Conus, Macneil & McGorry, 2014). The
patient’s less than favourable childhood may have played a role in her experiencing mental
disorders such as bipolar disorder. Childhood neglect may have been playing a part in it as
well (Watson et al., 2014). The patients traumatic past seems to play a role in her
experiencing such a manic episode. It has been proven by studies that trauma tends to affect a
person’s imagination thus leading to worse schizophrenic episodes (Van der Kolk, 2014). The
patient experiencing delusions and a shift between hyperactive and calmer state seems to
signify a manic bipolar episode as well. There has been evidence of genetic overlaps between

4CASE STUDY IN ACUTE INPATIENT FACILITY
schizoaffective disorders and bipolar disorders (Cardno & Owen, 2014). So it is possible that
this may be caused by either of the patient’s illnesses. The episode most likely occurred
because the patient refused to take her antipsychotic medications including aripiprazole. It
has been seen that the patients who refuse their antipsychotic medication are at increased risk
of experiencing a relapse episode (Patel, Cherian, Gohil & Atkinson, 2014). Since according
to her past medical history, she had not experienced a psychotic episode in the last couple of
years, it is very likely that this episode is in fact, a relapse.
The patient is primarily calmed by the nurse and restrained lightly to make sure she
does not harm herself or anyone around her in case she has another hyperexcitable burst of
energy. The patient is de-escalated, which is important for her own safety and safety of the
staff (Lavelle et al., 2016). The nurse observed the patient for noticing any changes in her
facial expression and her way of talking to understand whether the patient is experiencing
auditory or visual hallucinations (Jensen & Clough, 2016). The same is documented clearly.
It was clear that she was experiencing both auditory and visual hallucinations as she was
clearly talking to someone and actively communicating.
The patient was sedated and put on a treatment plan with cariprazine, as it was
generally believed to be an effective antipsychotic drug against bipolar manic episodes
(Sachs et al., 2015). It was generally free of high side effects and there are many advantages.
However, since it is a novel drug, there are very little information on it in relation to renal
impairment. Since the patient already suffers from renal impairment, she must be kept under
close observation while she is on this treatment (Campbell, Diduch, Gardner & Thomas,
2017). Zuclopenthixol is also an option if the patient refuses the treatment. It is an
intramuscular injection and thus can be administered safely without the patient trying to
throw it up. Lithium medications, though effective, could not be prescribed to the patient due
to her hypothyroidism. She must be kept under constant surveillance and ensured that she

5CASE STUDY IN ACUTE INPATIENT FACILITY
does not harm herself or anyone around her. While mood stabilizers may be helpful for
bipolar disorder, it is often important to avoid them unless absolutely necessary. Especially
because there has been a clear manic episode. Such drugs may have an increased risk of
inducing a manic episode. But it also must be remembered that the benefits of using
antidepressants outweigh the risks and the patient has no history of worsening mood with
antidepressants and no family history of mania. So it might be considered in an emergency
(McInerney & Kennedy, 2014). The patient is stabilized and followed by psychiatric therapy.
The patient is kept in the inpatient facility for a couple of days and then released with
instructions to the family and prescriptions for necessary medications.
Conclusion
From this paper, it can be concluded that the patient is experiencing a manic
schizophrenic episode where she is experiencing auditory and visual hallucinations. It is clear
that her past clearly plays a role in her problem. She has been prescribed cariprazine and
antidepressants for emergency situations. She will be kept in close observation in the facility
for a couple of days until her condition is stabilized.

6CASE STUDY IN ACUTE INPATIENT FACILITY
Reference
Campbell, R. H., Diduch, M., Gardner, K. N., & Thomas, C. (2017). Review of cariprazine in
management of psychiatric illness. Mental Health Clinician, 7(5), 221-229.
Cardno, A. G., & Owen, M. J. (2014). Genetic relationships between schizophrenia, bipolar
disorder, and schizoaffective disorder. Schizophrenia bulletin, 40(3), 504-515.
Cheung, D. S. (2018). Bipolar Patient Presenting with Lithium-Induced Hyperparathyroidism
Following Years of Lithium-Induced Hypothyroidism. Proceedings of UCLA
Health, 22.
Conus, P., Macneil, C., & McGorry, P. D. (2014). Public health significance of bipolar
disorder: implications for early intervention and prevention. Bipolar disorders, 16(5),
548-556.
Daglas, R., Conus, P., Cotton, S. M., Macneil, C. A., Hasty, M. K., Kader, L., ... & Hallam,
K. T. (2014). The impact of past direct-personal traumatic events on 12-month
outcome in first episode psychotic mania: trauma and early psychotic
mania. Australian & New Zealand Journal of Psychiatry, 48(11), 1017-1024.
Jensen, L., & Clough, R. (2016). Assessing and treating the patient with acute psychotic
disorders. Nursing Clinics, 51(2), 185-197.
Lavelle, M., Stewart, D., James, K., Richardson, M., Renwick, L., Brennan, G., & Bowers, L.
(2016). Predictors of effective de‐escalation in acute inpatient psychiatric
settings. Journal of clinical nursing, 25(15-16), 2180-2188.
McInerney, S. J., & Kennedy, S. H. (2014). Review of evidence for use of antidepressants in
bipolar depression. The primary care companion for CNS disorders, 16(5).

7CASE STUDY IN ACUTE INPATIENT FACILITY
Patel, K. R., Cherian, J., Gohil, K., & Atkinson, D. (2014). Schizophrenia: overview and
treatment options. Pharmacy and Therapeutics, 39(9), 638.
Sachs, G. S., Greenberg, W. M., Starace, A., Lu, K., Ruth, A., Laszlovszky, I., ... & Durgam,
S. (2015). Cariprazine in the treatment of acute mania in bipolar I disorder: a double-
blind, placebo-controlled, phase III trial. Journal of affective disorders, 174, 296-302.
Ueno, S., Tsuboi, S., Fujimaki, M., Eguchi, H., Machida, Y., Hattori, N., & Miwa, H. (2015).
Acute psychosis as an initial manifestation of hypothyroidism: a case report. Journal
of medical case reports, 9(1), 264.
Van der Kolk, B. (2014). The body keeps the score: Mind, brain and body in the
transformation of trauma. Penguin UK.
Watson, S., Gallagher, P., Dougall, D., Porter, R., Moncrieff, J., Ferrier, I. N., & Young, A.
H. (2014). Childhood trauma in bipolar disorder. Australian & New Zealand Journal
of Psychiatry, 48(6), 564-570.