CASE: Unable to communicate
Mrs. A, age 44, is airlifted to the emergency room after a motor vehicle accident in which she was the restrained front seat passenger. She was on the way to a mental health follow-up appointment with her husband, who died on the scene, and 24-year-old son, who sustained multiple injuries. At the accident scene, Mrs. A was awake and responded to all questions by saying, “I don’t know.” No other history could be obtained. She was carrying documents from a local psychiatric facility that stated she had been discharged 1 month ago with a diagnosis of psychotic disorder, not otherwise specified (NOS). Her discharge medications were olanzapine, 15 mg at bedtime; escitalopram, 20 mg/d; lamotrigine, 100 mg/d; zolpidem, 10 mg as needed at bedtime; and diazepam, 5 mg tid.
Initial assessment reveals mild concussion, nondisplaced fractures of the left C7 and T1 transverse processes, and fracture of the posterior left first rib. Mrs. A is admitted to the trauma surgery service. Soon after, nurses report that Mrs. A is not able to report symptoms. Psychiatry service is consulted to evaluate her continued confusion and inability to communicate.
The authors’ observations
Mrs. A seems anxious because of my repeated attempts to communicate. Her affect is restricted, and her speech is limited to “I don’t know” but fluent. She does not appear to be responding to internal stimuli. Neurologic examination, including cranial nerves and reflexes, is normal. A chart review reveals that her psychiatric medications have been continued upon admission.
HISTORY: Always nervous
We contact Mrs. A’s son, who also was admitted to the hospital, for more information. He reports that his mother has a long history of “nerve problems,” which he describes as “crying and feeling sad and nervous.” He says Mrs. A’s mother also had these problems, and Mrs. A’s childhood was difficult (Table 1). Because of this condition, Mrs. A lives alone in a trailer next to the house where her husband and children live.
Mrs. A’s son said that she had a “nervous breakdown” a few months ago, was admitted to the local psychiatric facility, and since then had been saying only, “I don’t know.” She can communicate her wishes by pointing at “Yes” or “No” written on paper. At home, she can perform all activities of daily living (ADLs), including paying bills. He denies that his mother engages in drug abuse.
We obtain Mrs. A’s treatment records from the psychiatric facility and learn she was admitted with a history of confusion, auditory and visual hallucinations, and crying episodes. She had a history of noncompliance with outpatient medications, which included diazepam, duloxetine, and ziprasidone. Upon admission to that facility, Mrs. A was alert but disoriented to place and time. She answered questions slowly but was brief, sometimes incoherent, and having auditory and visual hallucinations.
During that hospitalization, clinicians established a working diagnosis of psychotic disorder, NOS. Mrs. A was noted to have a urinary tract infection, which they treated with amoxicillin/clavulanate. Ziprasidone was discontinued and olanzapine was started. Escitalopram and lamotrigine were added. Mrs. A’s hallucinations gradually resolved, and she was able to perform ADLs. However, she did not communicate much and started answering most questions with “I don’t know.” At discharge, she was sent home to the care of her sister and husband.
Since then, Mrs. A had been taking her medications regularly but did not show improvement in her speech or methods of communication.
The authors’ observations