Chief complaint: Variola is accompanied by her mother who speaks limited English, she expresses concern that her daughter has been losing weight over the past three months and has developed strange eating habits such as only eating tonmtonm (a type of steamed bread fruit) and drinking pre-boiled water. She claims Variola had stopped visiting her over the past two months and was “sounding strange over the phone”, so she went to see her last week and found her “not to be herself” and “too thin”. Her husband suggested it might be a good idea if his wife (Variola) visited with her mother for a few days. Variola (patient) remains silent during the initial conversation and when asked: “How are you feeling today?” she responds: “How are you feeling today?” with a blank stare.
The client cooperates with the RN as she collects initial data, she responds to the nurse’s questions with brief one- or two-word answers, denies pain or discomfort.
Vital signs: B/P 106/58, Pulse- 66, Respirations- 16, Temp- 99.9, O2 sat- 97%
Height: 5’4” Weight: 102 lbs
Urine: amber, cloudy, concentrated
CBC finger stick reveals:
RBC- 3.8, Hgb- 10.1, Hct- 49%, WBC- 11,000, Glucose- 68
When asked about her current appetite and sleep patterns the client states: “I eat only what has not been poisoned.” When the RN responds: “I am not sure I understand.” The client responds in an agitated manner: “Don’t be so smug, you know about all the chemicals out there?”
She reports sleeping “When I need to.”
Present Medical History:
No currently prescribed medications
Reports using unidentified herbal teas with pre-boiled water
Last physical WNL (within normal limits), 18 months ago prior to her 1st marriage, she has no identified PCP (primary care provider)
Lives with her husband in a rented apartment, no children. Previously employed as a waitress for 9 months but left her job after getting married. Completed high school in Haiti, immigrated to NYC in 2007 with her mother and two brothers (25 y/o & 23 y/o) following her father’s murder in Port Au Prince. Attended community college for one year but dropped out to help support her mother and younger siblings. States her husband treats her well but “I think he wants me to leave.” Client’s mother reports “Variola never had a lot of friends, she was very quiet, but a good girl, always helping me at home.”
Past Medical History:
Client was a full-term delivery with unremarkable vaginal birth by midwife at home. Her mother states: “She was a gift from God because I was very sick from our cats when I was pregnant, and I thought Variola would never be born alive.”
Client achieved all developmental milestones as a child. No previous surgeries or hospitalizations.
Family medical history:
Father deceased allegedly murdered during a robbery attempt, he was diagnosed with hypertension and liver disease. Client’s paternal uncle committed suicide. Mother age 48 y/o treated for toxoplasmosis and post-partum depression. No known history regarding mother’s bio-parents as a cousin adopted her. Patient’s two male siblings reported to have no significant illnesses. Both are married and moved to Los Angeles with limited family contact.
MSE (mental status exam):
Cooperative but guarded, dressed appropriately but disheveled appearance. A&O x 3, denies suicidal, homicidal ideation, expresses anxiety and fear claiming, “They are out to kill my whole family, not just my father.” Client endorses the presence of voices, unidentifiable adult males, who whisper to her that she must; “be careful and avoid the poisons.” The client when asked: “When did you first hear these men talking to you?” the client responded several months ago. She feels the voices are “my angels” and has not told her husband or mother as she fears they will not understand. “That’s why my mother brought us to NYC, but I knew they would always try to get us.” “They want to kill us because we are God’s chosen ones and they are disciples of Satan, that’s why they killed my father. The Police lied to us when they said it was about drugs.”
Denies any history of physical or sexual abuse. Identifies her mother as main support. Unable to identify a supportive friend. Claims she was introduced to her husband by her family and married within two months.
Denies using alcohol, “It’s sinful”, but admits to recently smoking marijuana with her husband over the past few months: “He said it makes me more beautiful and will stop me from losing weight.”
The client’s speech becomes increasingly pressured, as she appears agitated by the continuing interview.
The client’s mother begins to sob, stating: “this is not my daughter.”
1. What additional questions would you ask?
2. Would you order any additional lab or diagnostic tests?
3. Preliminary diagnosis?
4. Recommended treatment?