74-year-old African American woman, Ms. Richardson, was brought to the hospital emergency room by the police. She is unkempt, dirty, and foul-smelling. She does not look at the interviewer and is apparently confused and unresponsive to most of his questions. She knows her name and address, but not the day of the month. She is unable to describe the events that led to her admission.
The police reported that they were called by neighbors because Ms. Richardson had been wandering around the neighborhood and not taking care of herself. The medical center mobile crisis unit went to her house twice but could not get in and presumed she was not home. Finally, the police came and broke into the apartment, where they were met by a snarling German shepherd. They shot the dog with a tranquilizing gun and then found Ms. Richardson hiding in the corner, wearing nothing but a bra. The apartment was filthy, the floor littered with dog feces. The police found a gun, which they took into custody. The following day, while Ms. Richardson was awaiting transfer to a medical unit for treatment of her out-of-control diabetes, the psychiatric provider attempted to interview her. Her facial expression was still mostly unresponsive, and she still didn’t know the month and couldn’t say what hospital she was in. She reported that the neighbors had called the police because she was “sick,” and indeed she had felt sick and weak, with pains in her shoulder; in addition, she had not eaten for 3 days. She remembered that the police had shot her dog with a tranquilizer and said the dog was now in “the shop” and would be returned to her when she got home. She refused to give the name of a neighbor who was a friend, saying, “he’s got enough troubles of his own.” She denied ever being in a psychiatric hospital or hearing voices but acknowledged that she had at one point seen a psychiatrist “near downtown” because she couldn’t sleep. He had prescribed medication that was too strong, so she didn’t take it. She didn’t remember the name, so the interviewer asked if it was Thorazine. She said no, it was “allal.” ‘Haldol?”, ask the interviewer. She nodded.
The interviewer was convinced that was the drug, but other observers thought she might have said yes to anything that sounded remotely like it, such as “Elavil.” When asked about the gun, she denied, with some annoyance, that it was real and said it was a toy gun that had been brought to the house by her brother, who had died 8 years ago. She was still feeling weak and sick, complained of pain in her shoulder, and apparently had trouble swallowing. She did manage to smile as the team left her bedside
Based on the information provided, Ms. Richardson appears to be experiencing significant cognitive and physical impairment, potentially due to uncontrolled diabetes and neglect of self-care. She is also exhibiting symptoms of confusion, disorientation, and possibly delirium. It is important to note that Ms. Richardson’s behavior may also be influenced by cultural and socioeconomic factors, as well as potential past experiences with psychiatric care.

Given her poor health and potential risk to herself and others, it is appropriate for Ms. Richardson to receive medical attention and treatment. The medical team should prioritize stabilizing her diabetes and addressing any acute physical concerns, such as shoulder pain and difficulty swallowing.

The psychiatric provider should conduct a comprehensive evaluation to determine the extent and cause of Ms. Richardson’s mental status changes, including a review of her medication history and possible adverse effects. It is also important to assess for any underlying psychiatric conditions, such as depression or anxiety, which may be contributing to her symptoms.

The medical team should also consider the possibility of neglect or abuse, given the poor living conditions and potential lack of support from family or community. Social work and case management services should be involved to ensure that Ms. Richardson receives appropriate care and support, including assistance with housing and other basic needs.

Finally, given Ms. Richardson’s history of owning a gun and potential confusion around its status, the medical team should ensure that appropriate safety measures are in place and that any potential risks are addressed.

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