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In the Subjective section, provide:

• Chief complaint

• History of present illness (HPI)

• Past psychiatric history

• Medication trials and current medications

• Psychotherapy or previous psychiatric diagnosis

• Pertinent substance use, family psychiatric/substance use, social, and medical history

• Allergies

• ROS

In the Objective section, provide:

• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history

• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

In the Assessment section, provide:

• Results of the mental status examination, presented in paragraph form

• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rule out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

In the Plan section, provide:

• Your plan for psychotherapy

• Your plan for treatment and management, including alternative therapies. Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

• Incorporate one health promotion activity and one patient education strategy.

Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

Written Expression and Formatting – English Writing Standards:

Correct grammar, mechanics, and punctuation

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Subjective:

CC (chief complaint): “My sister made me come here.”

HPI: S.T is a 53-year-old African American male who presents for a psychiatric exam. He reports that he sees people outside the window watching him. He hears them talking and sees shadows of them, and he doesn’t believe they see him. He stated that he had these hallucinations for “weeks, weeks, and weeks.” He hears heavy metal music that others do not listen to and also sees birds flying. He stated that the voices are so loud that he has trouble staying asleep and has been awake for many days. He believes the unseen others poison his food, and he has locked all the food in the refrigerator. He does not go to the grocery store because he thinks the unseen others would follow him there. He has not been taking any medications because he thinks they poison him. He believes that his sister relates to the government and plotting against him and that they tapped his phone. He made calls to 911 to report the unseen others that were following him.

Past Psychiatric History: Hospitalized in the past for schizophrenia. Three times at age ’20s.

Medication trials: Risperidone, but I didn’t like the side effects of gynecomastia. Did not like the

results of Haldol and Thorazine. Seroquel was helpful to him.

Psychotherapy or Previous Psychiatric Diagnosis: Psychiatric inpatient and outpatient

treatments.

Substance Use History: He smokes three packs of tobacco daily and drinks 12 packs of beer for 

the week. He quit smoking marijuana three years ago before his mother passed away.

Family Psychiatric/Substance Use History: His father was diagnosed with paranoid

schizophrenia. His mother suffered from anxiety.

Social History: The patient is unemployed. His highest level of education is the 10th grade. He

was raised by is a mother and his sister raised him. He lived with his mother three years ago, but 

she died, and now he lives with his sister. He had emotionally and verbally been abused by his 

father as a child.

Medical History: Diabetes. Fatty liver disease.

 

Current Medications: Metformin
Allergies: No allergies or drug allergies
Reproductive Hx: Never been married and no children.

ROS:

GENERAL: No weight loss, no fever or chills, no weakness, no fatigue.
HEENT: Vision is clear. No nasal drainage, no congestion, no hearing loss.
SKIN: Skin is intact.
CARDIOVASCULAR: No edema. Regular heart rhythm. No cyanosis.
RESPIRATORY: No respiratory distress, no cough, no sputum.
GASTROINTESTINAL: Regular bowel movements. Normal stools.
GENITOURINARY: Urine is clear and yellow. No pain or burning at urination.
NEUROLOGICAL: No dizziness, no numbness or tinging, no loss of balance.
MUSCULOSKELETAL: No muscle or joint pain.
HEMATOLOGIC: No bleeding disorders, no anemia.
LYMPHATICS: No swollen lymph nodes.
ENDOCRINOLOGIC: No night sweats, no hot flashes, no polydipsia, or polyuria.

Objective:

Diagnostic tests: CBC, CMP, Vitamin B levels, A1C. Urine drug screen, Kidney function test. 

Lipid Panel Test.

Diagnostic results: Pending 

Assessment

Physical exam: will be done at the next visit

Mental Status Examination: The patient is a 53-year-old African American male who appears staged for his age and has no signs of discomfort. The patient is well-groomed, clean, and well-dressed. He did not fidget but could not stay still for extended periods. The patient is anxious. He maintains fair eye contact and maintains an upright stance. His speech rate, rhythm, and volume are normal. Congruent affect and euthymic mood. He has visual and auditory hallucinations and persecutory delusions that the government is after him. Flight of ideas and clang associations was observed during the interview stating, “my taxes are high so high in the sky” and “never cleaver’s ever.” He has unclear, nonlogical psychotic thoughts. Judgment and insight are impaired. Alert and oriented to person, place, time, and situation. The recent and remote memory are impaired. Attention span and concentration during an interview are impaired due to auditory hallucinations of hearing music and visual hallucinations of a flying bird. Gait is normal with good muscle strength and restless motor activity. Denies any suicidal, homicidal thought.

Diagnostic Impression

Paranoid Schizophrenia 295.30 (F20.0): According to DSM-5 diagnostic criteria, a preoccupation with one or two or more of the following one consists of auditory hallucinations (APA, 2013). For a significant portion of the time since the onset of the disturbance, the level of functioning in one or more critical areas, work, interpersonal relations, or self-care, is markedly below the level achieved before the onset. Continuous signs of the disturbance persist for at least 6 months. The most frequent types of schizophrenia were paranoid and undifferentiated schizophrenia (Osorio, et al., 2021). In this case, the patient false beliefs are mainly concerned with being persecuted or punished by others. The patient feels that his sister and the government are after him; he states he is constantly hearing voices. Someone’s voice may be heard, which the individual believes is punishing them. The patient assumed that someone had been conducting a top-secret assignment. The most frequent psychiatric diagnosis associated with substance use disorder was schizophrenia (50%) (Teixeira et al., 2022). This is the primary diagnosis why I chose him.

Delusional disorder297.1 (F22): The central theme of the delusion involves the individual’s belief that they are being conspired against, cheated, spied on, followed, poisoned, drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. Delusions are certain beliefs that are not amenable to change considering conflicting evidence (APA, 2013). The patient suffering from a delusion will cling to their belief despite evidence to the contrary. Delusion of persecution is when a person believes that they are being mistreated, that someone is spying on them, or that someone is planning to harm them. 

Schizoaffective Disorder 295.70 (F25.0 or F25.1): Although the schizoaffective disorder is a diagnosis in the DSM-5, its rationality remains debatable. A diagnosis of the schizoaffective disorder requires that a major depressive or manic episode occur concurrently with the active-phase symptoms and that the mood symptoms be present for most of the total duration of the active period. The continual period of illness during which there is a significant mood episode or manic concurrent. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode; depressive or manic during the lifetime duration of the illness. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. The diagnosis is likely to be schizophrenia, but schizophrenia requires 6 months of prodromal or residual symptoms but schizoaffective disorder 2 or more weeks. However, schizoaffective disorder is a psychotic disease like schizophrenia (APA, 2013). Patients with psychotic depression are particularly vulnerable to conversion to other major psychiatric disorders. Conversion to psychotic disorders occurs earlier than bipolar disorder. Males are at higher risk for progression to psychotic disorders (Baryshnikov et al., 2020).

Reflections

 I selected the primary diagnosis of paranoid schizophrenia because of his auditory and visual hallucinations, where he thinks people are after him and where he also feels that people are plotting against him. The patient also spends a lot of time in his delusions, which causes him not to go out of the house or have a social life. He smokes all day. The examiner did ask appropriate questions, and I would not change anything about the initial psychiatric examination. She informed him that she would be able to help him and treated him well. It tended to assign a care worker on consecutive days to each patient, which is one of the critical factors in promoting trust between patients and care workers. This leads to the efficacy of monitoring a patient’s disease progression and treatment (Krityakierne et al., 2022).

Case Formulation and Treatment Plan

I would start Abilify 5 mg PO daily to help the psychotic symptoms and a low dose of Seroquel 25 mg to help him sleep since he said Seroquel was helping him. The patient is none compliant with PO medications. Abilify maintena 400 mg Long Acting once a month treatment option. Eventually, I would recommend patient receive medication once a month (Mustafa et al., 2019). Abilify has side effects increased chance of weight gain, high cholesterol, and diabetes, which we would monitor patient labs due to the patient’s existing diabetes diagnosis (Mahakal & Chandrani, 2017). The goal is to treat symptoms so the patient can have everyday life. I would also advise a therapy for the patient, such as Cognitive behavioral therapy, which helps people set goals, normalize their experiences, and question beliefs about hallucinations and delusions. I would recommend the patient quit smoking and educate him on the importance of medication compliance (Wehring et al., 2019). Most psychiatric patients are well known for noncompliant medication because they do not think they do not have schizophrenia. It is essential that he needs support from family or community. 

 

References 

American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, fifth edition DSM-5 American Psychiatric Association, 2013

Baryshnikov, I., Sund, R., Marttunen, M., Svirskis, T., Partonen, T., Pirkola, S., & Isometsä, E. T. (2020). Diagnostic conversion from unipolar depression to bipolar disorder, schizophrenia, or schizoaffective disorder: A nationwide prospective 15‐year register study on 43 495 inpatients. Bipolar Disorders, 22(6), 582-592. https://doi.org/10.1111/bdi.12929

Henry Osorio, J., Valencia, G., & Manuel Pérez, J. (2021). Evolution in schizophrenia diagnosis in the department of Caldas, Colombia. 2010-2015. Revista Facultad de Medicina de La Universidad Nacional de Colombia, 69(3), 1-6. https://doi.org/10.15446/revfacmed.v69n3.73159

Krityakierne, T., Limphattharachai, O., & Laesanklang, W. (2022). Nurse-patient relationship for multi-period home health care routing and scheduling problem. PLoS ONE, 17(5), 1-26. https://doi.org/10.1371/journal.pone.0268517

Mahakal, P. M., & Chandrani, K. (2017). Aripiprazole Induced Weight Gain: A Case Report. INDIAN JOURNAL OF PSYCHIATRY, 59(6), S233.

Mustafa, S., Bougie, J., Miguelez, M., Clerzius, G., Rampakakis, E., Proulx, J., & Malla, A. (2019). Real-life assessment of aripiprazole monthly (Abilify Maintena) in schizophrenia: a Canadian naturalistic non-interventional prospective cohort study. BMC Psychiatry, 19(1), 114. https://doi.org/10.1186/s12888-019-2103-x

Teixeira, J., Alexandre, S., Cunha, C., Raposo, F., & Costa, J. P. (2022). Impact of clozapine as the mainstay therapeutical approach to schizophrenia and substance use disorder: A retrospective inpatient analysis. Psychiatry Research Communications, 2(3). https://doi.org/10.1016/j.psycom.2022.100056

Wehring, H., Powell, M., Sayer, M., Hackman, A., Buchanan, R., Nichols, R., Adams, H., Richardson, C., Vyas, G., McMahon, R., Earl, A., Sullivan, K., Luttrell, S., Dickerson, F., Narang, S., Koola, M., RachBeise, J., McEvoy, J., Liu, F., & Feldman, S. (2019). T85. THE EFFECT OF ADJUNCT ARIPIPRAZOLE ON MEASURES OF TOBACCO USE AND CRAVING IN WOMEN WITH PSYCHOTIC DISORDERS…The 2019 Congress of the Schizophrenia International Research Society, April 10-14, 2019, Orlando, Florida. Schizophrenia Bulletin, 45, S236. https://doi.org/10.1093/schbul/sbz019.365

 

 

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SCIENCE
HEALTH SCIENCE
NURSING
NRNP 6675

 

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