Nelly Fan

CONFIDENTIAL – PATIENT REVIEW BOARD FORM

Institution: Blackwood Psychiatric Facility
Date: October 26, 2023
Review Board Case #: 23-BWF-1184
Patient Name: Nelly Furtado
Attending Physician: Dr. C.P. Silberman

Type of Review: Involuntary Commitment Certification & Behavioral Review

1. Reason for Review:
Patient Nelly Furtado’s 72-hour involuntary hold is under review for extension. Her presentation has become increasingly complex, volatile, and threatening. This review must address her refusal of treatment, her fixation on fellow patients, and a specific, credible threat made against a staff member.

2. Synopsis of Patient’s Current Presentation:
The patient’s ideation remains grandiose and persecutory but has incorporated a strong political-revenge fantasy. She engages in lengthy, pressured monologues, pivoting rapidly between topics due to apparent underlying Acute ADHD, which complicates her psychosis.

• Fixation on Ronald Reagan: She demonstrates clear obsessive-compulsive (OCD) behaviors regarding the 40th U.S. President, incessantly quoting from his biography. She has conflated his “Evil Empire” speech with her own perceived struggle.
• Conflict with Patient Linda Hamilton: She openly denounced Hamilton’s “Judgement Day” nuclear fears, shouting that her own vision is a “Swords into Plowshares” initiative for global peace. This is not rational pacifism, but a grandiose delusion of her own messianic role in unilateral disarmament.
• Political Grandiosity: She insists she is destined to become the “Prime Minister of Canada” to “purge the nation’s sociopathic elite.” She explicitly stated that upon gaining power, she would subject this “elite” to “just as many drug injections as I receive in this hellhole,” indicating a clear homicidal ideation framed as retaliatory justice.

3. Documented Threat:
On October 25, at 14:30, when Nurse Evans attempted to administer scheduled medication, the patient became physically agitated and stated: “Whoever leads into captivity shall go into captivity. It is written in Revelation 13:10. Remember that when you come for me with your needle.” This was perceived by the staff member as a direct and credible threat of retaliation.

4. Clinical Assessment:

• Primary Diagnosis: F20.0 – Paranoid Schizophrenia (with pronounced grandiose and persecutory delusions).
• Complicating Factors:
  • ADHD: Manifests as severe distractibility, racing thoughts, and an inability to engage in sustained therapeutic dialogue.
  • OCD: Obsessive focus on Ronald Reagan as a central figure in her delusional narrative. This is not a hobby but a compulsive, ritualistic reiteration.
• Risk Analysis: The combination of a systematized persecutory delusion, specific homicidal ideation (against a nebulous “elite”), a direct verbal threat to staff, and profound lack of insight creates a perfect storm of high-risk variables.

5. Updated Risk Assessment:

• Risk to Self: High. Based on neglect of needs and potential for self-sacrificial behavior within her messianic delusion.
• Risk to Others: Severe. The threat against Nurse Evans, though scriptural, was specific and contextual. The stated intent to forcibly medicate others upon gaining (delusional) power confirms a willingness to enact violence. Her agitation makes her unpredictable.
• Grave Disability: Absolute. She cannot manage her own affairs or personal safety.

6. Revised Treatment Plan & Rationale:

• Recommended Action: APPROVE CONTINUED INVOLUNTARY COMMITMENT and AUTHORIZE INVOLUNTARY MEDICATION. The situation is untenable without chemical intervention.
• Immediate Treatment Goals:
  1. Chemical Stabilization: Immediate initiation of a long-acting injectable (LAI) antipsychotic (e.g., Haloperidol Decanoate) to bypass oral refusal and ensure consistent serum levels. A mood stabilizer (e.g., Valproate) is also indicated for impulse control.
  2. Behavioral Management: Maintain enhanced one-to-one observation. Seclusion may be necessary during periods of extreme agitation.
  3. Pharmacological Management of Comorbidities: Once stabilized, introduce a non-stimulant medication for ADHD (e.g., Guanfacine) and an SSRI for OCD features, to be carefully monitored for worsening psychosis.

CERTIFIED

7. Physician’s Recommendation:
This is no longer a case of simple psychosis. We are managing a dangerous and intellectually elaborate individual whose delusions are now driving specific threats. Her quote from Revelation was not a random bible verse; it was a calculated warning. We must respond with unequivocal authority. I recommend the panel APPROVE THE CERTIFICATION FOR CONTINUED COMMITMENT AND AUTHORIZE THE INVOLUNTARY TREATMENT PROTOCOL without delay.

Signature:

Dr. C.P. Silberman, MD
Attending Psychiatrist
Blackwood Psychiatric Facility

Review Board Decision:

[ ] Certification Approved – Commitment continued for a period not to exceed 30 days.
[ ] Certification Denied – Patient to be discharged.
[ ] Involuntary Medication Authorization: [ ] Approved [ ] Denied