When I was first reading up on JM (identifying information changed), I thought the case would go smoothly, well, as smoothly as any inpatient psychiatry case can go. All I had known about her is that she was an elderly woman who was recently released from jail. When the staff came to escort JM to her freedom, instead of being overjoyed as most likely would be, she was agitated and said she would not speak with them and would not leave until she was ready. She was also speaking to someone else in the cell that the staff could not see or hear. The staff came to find out that she was speaking to Jesus Christ regarding an ongoing skirmish between angels and demons that she took part in. The mental health staff at the jail decided to 302 her. The most recent info in the chart said “schizophrenia spectrum disorder,”so I thought we would change some medications, inquire about compliance, get some collateral from family, maybe start a long-acting injectable, and she would be on her way in a few days. I quickly learned how wrong that assumption was.
JM arrived to us for management of delirium in the setting of unknown cause after being cleared at Presby — all they had found was mild hyperthyroidism on labs with no clinical stigmata. When our team met with her in her room, we were immediately shown the door, saying she was too tired for this. We complied with her wishes, and I went to investigate further in the chart. I learned that JM had been given the provisional diagnosis of schizophrenia spectrum disorder a few months back during a hospital stay for osteomyelitis. At the time she had disorganized thinking and delusions about her son being tortured, which resolved within one day of hospitalization. We reached out to her emergency contact, she is a pastor at the church JM attends. She told us that JM has been homeless for over a decade for reasons that were never clear to the pastor, and that she had been progressively “deteriorating” over the years. She went from grooming, bathing and socializing at the church to looking more and more disheveled and isolating herself. The pastor said that, at times, it appeared JM forgot that she was homeless or that her son had passed away years ago. We had let JM sleep and planned to try again with an interview the next morning with our newfound information.
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