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Difficulty: Very hardPersonality Disorders

A 26-year-old woman is admitted to the medical ward for treatment of a localized methicillin-sensitive Staphylococcus aureus (MSSA) cutaneous abscess on her left forearm, which developed after a superficial self-inflicted laceration. She is currently receiving intravenous vancomycin. Her home medications include fluoxetine. Over the past 48 hours, she has been highly demanding, frequently yelling at nurses for 'ignoring' her, while praising the attending physician as her 'savior.' She has a long-standing history of intense, unstable relationships, chronic feelings of emptiness, and frequent, rapid mood shifts from extreme euphoria to deep dysphoria that last for a few hours, typically triggered by interpersonal conflicts. She reports that after a recent breakup, she heard voices telling her she was worthless for 2 days; this resolved without psychiatric intervention. Today, when told the attending physician is off duty, she becomes enraged, states she is being abandoned, and demands to be discharged immediately. She denies active suicidal ideation. Which of the following is the most appropriate next step in the management of this patient?

  1. Switch vancomycin to intravenous cefazolin, establish strict behavioral limits with a unified medical team approach, and consult psychiatry for dialectical behavior therapy.Answer
  2. B
    Continue intravenous vancomycin, increase her fluoxetine dose to address mood lability, and schedule a family meeting to discuss her behavior.
  3. C
    Switch vancomycin to intravenous cefazolin, diagnose schizophreniform disorder based on her history of auditory hallucinations, and initiate risperidone.
  4. D
    Switch vancomycin to intravenous cefazolin, discontinue fluoxetine, and immediately initiate tranylcypromine for her severe mood reactivity.
  5. E
    Switch vancomycin to intravenous cefazolin, attribute her presentation to bipolar depression, and optimize her fluoxetine monotherapy by increasing the dose.

Answer

The most appropriate management is to switch the antibiotic to intravenous cefazolin, establish strict behavioral limits with a unified medical team approach, and consult psychiatry for dialectical behavior therapy.
The correct answer accurately addresses both the infectious and psychiatric needs of the patient. From an infectious disease standpoint, the patient has a methicillin-sensitive Staphylococcus aureus (MSSA) infection, which should be treated with narrow-spectrum beta-lactams like cefazolin or nafcillin rather than broad-spectrum vancomycin to promote antibiotic stewardship. Psychiatrically, she exhibits classic features of Borderline Personality Disorder (BPD), including splitting (idealizing the attending, devaluing nurses), chronic emptiness, intense abandonment fears, self-harm, affective instability (mood shifts lasting hours), and transient stress-related micropsychotic episodes. The most appropriate immediate management on a medical ward is to prevent staff splitting through unified, consistent team communication and firm boundary setting. Long-term, dialectical behavior therapy (DBT) is the evidence-based treatment of choice.

Step-by-Step Solution

1
Analyze the microbiological data and current pharmacological treatment.
The patient has an MSSA infection but is receiving broad-spectrum vancomycin.
To determine if the antibiotic regimen is appropriate; vancomycin should be switched to a targeted narrow-spectrum beta-lactam like cefazolin to promote antibiotic stewardship.
2
Evaluate the psychiatric symptom timeline and triggers.
The patient exhibits hour-to-hour mood shifts, chronic emptiness, splitting, and transient 2-day stress-related hallucinations.
To differentiate Borderline Personality Disorder (BPD) from Bipolar Disorder (requires days-to-weeks of mood shifts) and Schizophreniform Disorder (requires 1-6 months of psychosis).
3
Identify the safest pharmacological transition if psychiatric medications were to be changed.
The patient is on fluoxetine; switching to an MAOI requires a mandatory 5-week washout.
To rule out unsafe medication changes that could precipitate Serotonin Syndrome.
4
Determine the best immediate ward management for splitting behavior.
Establish strict behavioral limits with a unified medical team approach.
To prevent the patient from successfully turning staff members against each other, which severely disrupts medical care on the ward.

Key Concept

Management of Borderline Personality Disorder and MSSA infections on the medical ward
Estimated Time:3m 0s
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Topics

Personality Disorders

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