Clinical Detective The Case of the Hallucinating Haberdasher
The Case of the Hallucinating Haberdasher
A 58-year-old hat-factory worker, Mr. Smith, had fallen on the job and was hospitalized for observation due to a 30 minute loss of consciousness. He was in the hospital over night when he grew increasingly nervous and agitated. He began hearing voices that were unstructured, and ill-developed. The attending physician has not ordered any medications for this patient, other than standing Motrin 800 prn up to TID, and Temazepam 15 mg po prn insomnia.Imaging studies did not detect any encephalopathy including cerebrovascular problems, space occupying lesions. The doctor calls the C&L service saying that the patient has been examined for head injury and believes that this is just a “psych case.”You present to the room as the on-call consultant
The Case of the Hallucinating Haberdasher
1. What type of history would you want to obtain on this patient?
2. What other modes of data collection are available to you?
The Case of the Hallucinating Haberdasher
Consider Historical InformationChronology of symptom formation
Onset, Duration, Character, Aggravating factors, Reliving factors, Timing and Severity
Past Mental Health HistoryPast Medical HistoryCurrent MedicationsFamily illnessesSubstance UseDevelopmental
Personality Disorder under stress likely to experience psychotic symptoms
Sexual History
The Case of the Hallucinating Haberdasher
Other data available:Observe the physical findingsReview the medical record for:
VitalsAdmission notesNursing notesPhysical examMedicationsPast medical historyLabs and procedures ordered/results
Collateral Information from available friends/relatives
The Case of the Hallucinating Haberdasher
You learn that he has worked in the same factory for over 20 years without difficulty. He has been married for 30 years.His physician has noted on admission that he has treated Mr. Smith as an outpatient for several years, and this is the first onset of auditory hallucinations.Nursing notes indicate that Mr. Smith keeps scratching at his arms and neck and they have had to place a dressing on his left forearm secondary to bleeding from his scratching.During your interview he appears to be sweating profusely. He also appears tremulous and is becoming increasingly agitated. He denies suffering from hallucinations. He says he sometimes see’s shadows.
The Case of the Hallucinating Haberdasher
The patient is showing impaired concentration and poor reality testing. He denies any history of significant medical or psych problems. You consider him an unreliable historian.
The Case of the Hallucinating Haberdasher
Is this presentation typical for schizophrenia so far?Why?
The Case of the Hallucinating Haberdasher
AnswerNot typical
Age range (peak onset 18-24)Hallucinations are acute (occurring in hospital setting)Hallucinations are ill-definedPhysical symptoms acute
NoteGood premorbid adjustment is seen more often in patients with psychosis due to neurologic/systemic disorders, whereas poorer adjustment is more common in patients with mental illness. Baseline behavior useful discriminant.
Persons with schizophrenia, for example, often demonstrate evidence of disturbed thinking between psychotic episodes.Interpersonal relationship and work histories tend to be more disrupted in patients with primary psychiatric disease
The Case of the Hallucinating Haberdasher
Your review of available data show:
VitalsSBP >200 mmHg, DBP >110 mmHg; HR >140T >101F
Labs:Decreased AlbuminElevated SodiumAbnormal LFTs
Elevated Gamma-glutamyl transpeptidase, GGTElevation of Aspartate Transaminase (AST) and Alanine Transaminase (ALT)
AST:ALT ratio of 2:1Elevated Mean Corpuscular Volume (macrocytosis)Elevated Carbohydrate-deficient transferrin (CDT)
CAGE Score = 3 C1A1G1E0
The Case of the Hallucinating Haberdasher
Your collateral interview with wife provides the following:Her husband comes home every night and just sits in front of the television drinking beer. He has a 30 year drinking history, but intake has increased over the past few years.Most of the time he just falls asleep in front of the television and she has gotten to the point she just leaves him there. He eventually stumbles into bed some time in the night, but usually he has trouble sleeping and will leave the house before she awakens. He doesn’t eat much anymore even though he used to have a voracious appetite. With more questioning you learn that the patient’s father was alcoholic and so was his paternal grandfather.
The Case of the Hallucinating Haberdasher
Alcohol HallucinosisTypical Presentation
30-60 years oldAcuteIf due to withdrawal, begins 8-12 hours after cessation of drinkingHallucinations are usually auditoryAnxious, DepressedImpairment of cognitive functioning Spontaneous improvement (last <week)