Subjective:
CC (chief complaint): “My sister made me come in”
HPI: S.T. is a Caucasian female patient who is 53 years old and was admitted to the psychiatric unit at the request of her sister. The patient said that the majority of the time she has the sensation that people are observing her via the window on the outside of the room. She asserts that she can hear them. According to what she claimed, these occurrences had been going on for weeks. While the patient was watching television, she insisted that the persons she saw on the screen were plotting to poison her food to murder her. Denies having used medicines and or having a history of seizures. There were no reports of having suicidal thoughts or intentionally hurting herself in any way.
Past Psychiatric History:
General Statement: The patient has a past that is marked by episodes of psychosis.
Caregivers (if applicable): Due to their mother’s death, she now shares a home with her sister.
Hospitalizations: substantiates prior mental hospitalizations on three separate occasions by the time she was 29 years old.
Medication trials: Thorazine and Haldol were previously used to treat the patient’s mental problems, but she stopped taking them since she felt they were not helping. However, she developed larger breasts while on risperidone, which she finds unattractive. Verifies Seroquel’s excellent efficacy. However, she seldom adheres to the prescribed dosages.
Psychotherapy or Previous Psychiatric Diagnosis: None.
Substance Current Use: The patient admits to smoking three packs of cigarettes a day regularly. She also often consumes 12 bottles of wine. But once her mother died, she gave up smoking pot.
Family Psychiatric/Substance Use History: Both the patient’s mother and the patient’s father have been diagnosed with mental illnesses. The patient’s mother has a history of anxiety disorder, while the patient’s father was diagnosed with paranoid schizophrenia disorder. She says that none of her family has ever committed suicide.
Psychosocial History: After their mother’s death three years ago, the patient and her sister moved in together. She has only completed high school. She says she has never been married and has no kids. No one is hiring her. There are no documented arrests for her, yet. She confirms having good sleep and eating well.
Medical History: Fatty liver and diabetes.
Current Medications: Managing blood sugar using metformin.
Allergies:No documented sensitivities to drugs, foods, or the environment.
Reproductive Hx: Identifies as heterosexual yet is single and childless.
ROS:
GENERAL: Denies having any symptoms such as lethargy, fever, leanness, nausea, or weight loss.
HEENT: Head: denies any evidence of a headache or injury. No soreness, itching, discharge, or ringing in the ears. No redness, tears, itching, or vision impairments in the eyes. Nose: denies stuffiness, sinusitis, irritation, or congestion. Throat & Mouth: Denies dental issues, bleeding gums, swallowing issues, or sore throats.
SKIN: No hives, rashes, or itching; just warm, moist, and comfortable.
CARDIOVASCULAR: denies experiencing chest pressure, orthopnea, dyspnea, edema in the lower limbs, palpitations, or syncope.
RESPIRATORY: denies experiencing chest discomfort, shortness of breath, hemoptysis, cough, or snoring.
GASTROINTESTINAL: denies experiencing nausea, vomiting, hematemesis, abdominal swelling, diarrhea, constipation, or bloody stools.
GENITOURINARY: denies having frequent or urgent urination, incontinence, nighttime urination, burning while urinating, or pee that contains blood.
NEUROLOGICAL: denies experiencing headaches, balance issues, dizziness, weakness, numbness, or abrupt loss of neurological function.
MUSCULOSKELETAL: denies any joint soreness or stiffness. demonstrates the complete range of motion in all joints.
HEMATOLOGIC: denies a history of easy bruising, irregular bleeding, or hypercoagulability.
LYMPHATICS: denies having swollen lymph nodes in the past.
ENDOCRINOLOGIC: denies tiredness, a weight increase or loss, polyuria, polyphagia, or polydipsia.
Objective:
Diagnostic results: Standard blood tests like CBC and WBC were taken. The fundamental metabolic panel was also kept track of. To evaluate the impact of the previously used psychiatric medications, liver and renal function tests were also requested. To rule out physical reasons for the patient’s symptoms, imaging investigations like MRIs and CT scans are requested (Jauhar et al., 2018). The Calgary Depression Scale for Schizophrenia, Brief Psychiatric Rating Scale (BPRS), SANS and SAPS Tests, and Positive and Negative Syndrome Scale are further diagnostic instruments used (PANSS).
Assessment:
Mental Status Examination: The patient, who was 53 years old, arrived well-groomed and dressed appropriately for his age. She has a good sense of time, location, and the people around her. However, she gives off the impression of being uncomfortable. During the course of the interview, she is cooperative; yet, she is quickly distracted and has a limited focus span. Her ability to think has been impaired. She seems to be depressed. Exhibits the proper amount of both short-term and long-term memory. In addition to that, she exhibits symptoms of delirium and hallucinations. Denies having suicidal thoughts or engaging in self-harming actions.
Diagnostic Impression:
Schizophrenia Spectrum and Other Psychotic Disorders: Schizophrenia symptoms include acting in bizarre ways because of a disconnection from reality (Palomar-Ciria et al., 2019). In addition to hallucinations, other symptoms might include delirium, confusion, and bizarre behavior. Two of the aforementioned symptoms, in addition to negative symptoms or catatonic conduct, are required by the DSM-V for a diagnosis. Most of these symptoms were present in the patient in the presented case study, and the patient had a history of psychosis, therefore this is the most likely diagnosis.
Bipolar I Disorder with psychotic features: The DSM-V makes it very apparent that people who have this condition often exhibit manic episodes together with psychotic symptoms such as hallucination and delusion (Kesebir et al., 2020). The patient in the presented case study solely exhibited psychotic symptoms and did not have any manic episodes; as a result, this diagnosis cannot be made for them.
Delusional Disorder: Delusion is a symptom that is present in the majority of different mental diseases. However, the DSM-V defined this as a separate disorder when a patient comes with delusion clinical manifestations a month with no other related symptoms indicating another mental disease. This is the case when a patient meets the criteria for this condition (Perrotta, 2020). In addition to having delusions, the patient in the supplied case study reported having several other psychotic symptoms.
Reflections: The mental assessment that was performed by the PMHNP was carried out acceptably and had sufficient information to enable a medical diagnosis to be made. The clinician made a concerted effort to engage the patient in the conversation using a kind and non-condemnatory tone, which enabled the patient to feel at ease while discussing her problems. However, since the patient’s ability to think was impaired, the patient’s sister needed to be contacted so that further information on her mental status could be obtained (Jauhar et al., 2018). As a consequence of this, the PMHNP is required to respect the patient’s right to privacy and confidentiality while at the same time revealing the patient’s diagnosis and treatment to the patient’s sister so that the sister may assist the patient in taking her prescription at home.
Case Formulation and Treatment Plan:
Primary diagnosis: Schizophrenia Spectrum and Other Psychotic Disorders
Psychotherapy: Cognitive behavioral therapy and interpersonal therapy (El-Mallakh et al., 2019).
Alternative psychotherapy: Family counseling in addition to Coordinated Specialty Care (CSC).
Pharmacotherapy: Extended-release tablets of Quetiapine (Rx) 300 milligrams should be taken orally once a day. To get the optimum amount necessary for a beneficial result, increase the dose by increments of 300 mg every week (Maroney, 2020).
Patient Education: Inform the patient of the significance of taking her medicine exactly as it was given to her to improve the results of the therapy (Maroney, 2020).
Health Promotion: In addition to eating healthily, the patient has to be encouraged to get regular exercise and should be counseled to give up smoking (Maroney, 2020).
Follow-up: The patient is required to return to the clinic once each week for the dosage to be modified.
References
El-Mallakh, R. S., Rhodes, T. P., & Dobbins, K. (2019). The case for case management in schizophrenia. Professional Case Management, 24(5), 273-276. DOI: 10.1097/NCM.0000000000000385
Jauhar, S., Krishnadas, R., Nour, M. M., Cunningham-Owens, D., Johnstone, E. C., & Lawrie, S. M. (2018). Is there an asymptomatic distinction between affective psychoses and schizophrenia? A machine learning approach. Schizophrenia Research, 202, 241-247. https://doi.org/10.1016/j.schres.2018.06.070
Kesebir, S., Koc, M. I., & Yosmaoglu, A. (2020). Bipolar Spectrum Disorder May Be Associated With a Family History of Diseases. Journal of Clinical Medicine Research, 12(4), 251. DOI: 10.14740/jocmr4143
Maroney, M. (2020). An update on current treatment strategies and emerging agents for the management of schizophrenia. Am J Manag Care, 26(3 Suppl), S55-S61. DOI: 10.37765/ajmc.2020.43012
Palomar-Ciria, N., Cegla-Schvartzman, F., Lopez-Morinigo, J. D., Bello, H. J., Ovejero, S., & Baca-Garcia, E. (2019). Diagnostic stability of schizophrenia: a systematic review. Psychiatry Research, 279, 306-314. https://doi.org/10.1016/j.psychres.2019.04.020
Perrotta, G. (2020). Psychotic spectrum disorders: definitions, classifications, neural correlates, and clinical profiles. Annals of Psychiatry and Treatment, 4(1), 070-084. https://doi.org/10.17352/apt.000023