Chapter 30

Wojewódzki Szpital dla Nerwowo i Psychicznie Chorych w Lubi??u

(Voivodeship Hospital for Nervous and Mentally Ill in Lubi??)

Psychiatric Inpatient Record - Closed Ward

(Translated from original Polish documentation)

Patient Name: Magdalena [Surname redacted]

Age: 24 years

Sex: Female

Gestational Age: Approx. 32–34 weeks

Mode of Admission: Emergency admission following suicide attempt

Legal Status: Involuntary admission under psychiatric hold

Reason for Admission

Patient admitted following a suicide attempt and ongoing risk of harm to self and unborn child.

Prior to admission, patient reportedly engaged in repeated attempts to terminate pregnancy through self-inflicted means, resulting in multiple internal injuries requiring gynecological evaluation.

Initial Presentation

Upon arrival, patient was highly agitated, disorganized, and resistant to examination.

Observed:

Loud, pressured speech

Episodes of screaming and crying

Rapid shifts between agitation and withdrawal

Refusal of physical contact, followed by sudden aggressive outbursts

Patient required physical and pharmacological restraint upon admission due to risk posed to herself and staff.

Mental Status Examination

Appearance: Disheveled, poor self-care

Behavior: Severely agitated, unpredictable, occasionally aggressive

Speech: Pressured, incoherent at times

Mood: Labile (rapidly shifting), predominantly fearful and distressed

Affect: Intense, unstable

Thought Process: Disorganized, tangential

Thought Content:

Fixed delusional belief that the fetus is “the devil”

Expressed conviction that the child intends to kill her

Recurrent statements indicating need to “destroy it before it is born”

Perception: Possible auditory hallucinations (patient observed responding to internal stimuli)

Insight: Absent

Judgment: Severely impaired

Risk Assessment

High risk of self-harm: Confirmed by recent suicide attempt

High risk to fetus: Ongoing intent to harm pregnancy

Risk to others: Patient demonstrates unpredictable aggression and paranoid ideation

Patient assessed as severely mentally unstable and dangerous without supervision.

Physical / Obstetric Findings

Patient in late-stage pregnancy

Evidence of prior self-inflicted trauma requiring ongoing monitoring

Obstetric consultation requested immediately upon admission

Clinical Impression

Presentation consistent with:

Acute psychotic episode with severe paranoid and delusional features

Possible peripartum (antenatal) psychosis

Differential diagnosis includes bipolar disorder (manic episode with psychotic features)

Condition considered psychiatric emergency.

Treatment Plan

Immediate Measures:

Admission to closed psychiatric ward with constant observation (1:1 supervision)

Removal of all potentially harmful objects

Use of restraints only as necessary for safety

Pharmacological Treatment:

Initiation of antipsychotic medication (e.g., Haloperidol – dose adjusted)

Sedative support (e.g., Diazepam) for acute agitation

Close monitoring for effects on pregnancy

Psychiatric Management:

Daily psychiatric evaluation

Stabilization of psychotic symptoms as primary goal

Gradual reduction of agitation and paranoid ideation

Obstetric Care:

Ongoing fetal monitoring

Coordination with obstetrics team regarding risks and delivery planning

Safety Measures:

Continuous supervision due to persistent risk

Staff instructed on high-risk behavioral profile

Prognosis

Guarded.

Stabilization possible with intensive psychiatric treatment; however, current condition represents severe and acute mental disturbance requiring prolonged inpatient care.

Attending Staff

Attending Psychiatrist: Dr. El?bieta Kamińska

Ward Nurse: Maria Zielińska, RN

Wojewódzki Szpital dla Nerwowo i Psychicznie Chorych w Lubi??u

(Voivodeship Hospital for Nervous and Mentally Ill in Lubi??)

Psychiatric Discharge Summary (Epikrisis)

(Translated from original Polish documentation)

Patient Name: Magdalena [Surname redacted]

Age: 25 years

Sex: Female

Reason for Admission

Patient was admitted to the closed psychiatric ward in late-stage pregnancy following a suicide attempt and presentation of acute psychotic symptoms, including severe paranoid and delusional beliefs concerning the fetus, accompanied by a high risk of self-harm.

Course of Hospitalization

At the time of admission, the patient presented in a severely disturbed mental state, characterized by agitation, emotional instability, and fixed delusional thinking. She required close supervision and pharmacological intervention.

Throughout the course of hospitalization, the patient received intensive psychiatric treatment, including antipsychotic medication and supportive care.

A gradual and sustained improvement in mental state was observed:

Resolution of acute psychotic symptoms

Stabilization of mood and behavior

Increased cooperation with medical staff

Partial restoration of insight

Obstetric Course

During hospitalization, the patient gave birth to a live infant. Due to her psychiatric condition at the time, caregiving responsibility was transferred to the child’s father.

The child has remained in the father’s care in a stable environment since birth.

Mental Status at Discharge

At the time of discharge, the patient is:

Calm and cooperative

Oriented and coherent in thought and speech

Free of active delusions or hallucinations

Demonstrating improved, though still partial, insight

No current suicidal ideation reported.

Diagnosis

Acute psychotic disorder associated with pregnancy (peripartum psychosis), currently in remission under treatment

Treatment and Recommendations

Medication:

Continuation of prescribed antipsychotic treatment is essential. Compliance is critical to maintaining stability.

Follow Up Care:

Regular outpatient psychiatric follow-up is required, with close monitoring of mental state and treatment adherence.

Living Situation:

Patient is discharged to reside with the child’s father and infant. The home environment has been assessed as stable and supportive.

Supervision:

Family members have been instructed to observe for any signs of relapse, including:

Return of paranoid or delusional thinking

Behavioral instability

Withdrawal or agitation

Immediate psychiatric consultation is advised if symptoms recur.

Risk Assessment

At the time of discharge:

Risk of self-harm: Low (conditional on treatment adherence)

Risk of relapse: Moderate

Risk to others: Low

Conclusion

The patient is considered psychiatrically stabilized and suitable for discharge under structured outpatient care and family supervision.

Continued treatment compliance is essential for maintaining remission.

Attending Staff

Attending Psychiatrist: Dr. El?bieta Kamińska

Ward Nurse: Katarzyna Wójcik, RN

Komenda Miejska Policji we Wroc?awiu

(Municipal Police Headquarters in Wroc?aw)

Missing Persons Report / Incident Report

(Translated from original Polish documentation)

Case Number: KMP-WR/MP/0412/97

Date of Report: [Filed same day as incident]

Reporting Officer: Sgt. Piotr Zieliński

Reporting Party

Name: Tomasz [Surname redacted]

Age: 28 years

Address: [Redacted – Wroc?aw]

Relation to Missing Persons: Father of minor child / cohabitant of adult female

Missing Persons

1. Magdalena [Surname redacted]

Age: 26 years

Sex: Female

Description: Thin build, pale complexion, dark hair (shoulder length)

Medical Background: Documented history of psychiatric hospitalization, including psychotic episodes

2. Child (Name Redacted)

Age: Approximately 18 months

Sex: Male

Description: Infant/toddler, dark hair

Statement of Reporting Party

Reporting party states that during nighttime hours, Magdalena left the shared residence without notice, taking the child with her.

He reports that both individuals were present in the residence earlier in the evening. At approximately 06:30, he awoke to find them missing. No note or indication of destination was left behind.

The reporting party emphasizes extreme concern for the safety of the child, citing the mother’s psychiatric history.

According to his statement:

The mother has previously been hospitalized for severe psychotic episodes

During pregnancy, she expressed fixed delusional beliefs that the child was “the devil”

She made documented attempts to harm the unborn child

Although stabilized following treatment, he reports ongoing concern regarding her mental state

The reporting party further states:

He and Magdalena are not in a romantic relationship

He allowed her to reside in his apartment in order to:

Provide stability for her

Ensure safety of their child

Fulfill his parental responsibilities

He describes her recent behavior as withdrawn and increasingly tense, though no direct threats were made prior to the incident.

Assessment

Due to:

Prior history of severe psychiatric disturbance with delusional content involving the child

Documented risk of harm during pregnancy

Sudden, unannounced departure during nighttime hours

This case is classified as high-risk missing persons (child endangerment concern)

Actions Taken

Immediate missing persons report filed

Case entered into national police system

Patrol units notified and instructed to conduct area search

Alert issued to nearby jurisdictions

Hospitals and emergency services notified

A formal search operation has been initiated.

Additional Notes

No evidence of forced entry or third-party involvement at residence.

Investigation ongoing.

Reporting Officer

Sgt. Piotr Zieliński

Komenda Miejska Policji we Wroc?awiu

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