Richard Bonneville is a 45 year old man who is single and lives alone. He has a close relationship with his parents, ages 70 and 75, and his younger sister, age 40. All of his family lives in the same city. Richard is employed as a teller at a local bank; however while at work today he became disruptive, was unable to fulfill his responsibilities and was unable to control his angry outbursts. Bank officials summoned the police who took him to the emergency department. The emergency room nurse has just notified Richard’s sister.
Richard was incoherent upon arrival at the hospital. His sister provided his medical history, which included diabetes mellitus controlled by daily insulin, no known allergies, and weight loss within the last few weeks. Richard’s sister described him as social, except for occasional periods during which he appeared to be “high, on the move, rambling and unable to concentrate.” She described times when Richard was “down, lost weight and had problems with his diabetes.”
Richard shocked his family last week when he purchased a new car that he did not need. Two days ago, he announced that he was quitting his job for a better one. Richard has never been treated for a mental illness and his family is concerned about his recent behavior. The nurses have employed physical restraints because Richard repeatedly attempts to run out of the examining room to physically assault staff and other clients.
Richard is uncooperative with the physical examination, but he is able to answer some questions coherently. His speech is rapid, rambling and anxious. He frequently states that he needs to go home and sleep. He appears tired, with circles under his eyes and is sweating. His clothing fits loosely, but he is clean and dressed appropriately. He is unable to maintain eye contact for more than 3 seconds and alternates between yelling and speaking in a normal tone of voice, laughing inappropriately and being belligerent. At times Richard’s responses are incongruent with his appearance and history. He denies that he is having problems, stating that his diabetes has been cured and his life is perfect. He also denies hallucinations but believes that he needed to quit his job because he had become president of the bank.
Richard is orientated to person, place and time but demonstrates flight of ideas and is, at times, unable to answer questions. His remote, recent and immediate memories are intact; however, he is unable to concentrate or calculate. He verbalizes no insight into his illness, repeating that his health, life and new position are perfect.
He is 5ft, 9in tall and weighs 145 lbs. His usual weight, according to his sister, is 160 lbs. His blood pressure is 140/90, his heart rate is 95 beats per minute (bpm), his respirations are 25 breaths per minute, and his oral temperature is 37.1 C.
The client’s diagnostic findings are as follows:
Blood glucose: 1.4 mmol/L
Urinalysis: Positive for glucose and ketones
Urine drug screen: Negative for illicit drugs