Schizophrenia
Schizophrenia
For the discussion boards this term please include:
Any differential diagnoses
Your diagnosis and reasoning
Any additional questions you would have asked
Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.
Any labs and why they may be indicated
Screener scales or diagnostic tools that may be beneficial
Additional resources to give (Therapy modalities, support groups, activities, etc.)
CASE 1
Dusty
Dusty a 21 year old, somewhat frail looking, Caucasian male who appeared quitedisheveled and agitated upon presentation at the admissions department at Specialty Hospital. He is 5’ 10” and weighs approximately 140 lbs (BMI=20.1). His attitude was friendly. His mother accompanied him to hospital.
Chief complaint: “I can’t get it together.” “I can hear through metal.” Dusty was hyper-alert, orientation was to self and mother. He did not know what city he was in and was confused as to the date and day of week. His thought processes were chaotic and circumstantial with bizarre and paranoid ideation. Speech was disorganized. Long and short- term memory was moderately affected. He was cooperative and at times quite bizarre, in the evaluation process. Concentration was poor – he was very distractible. Emotional state was one of moderate agitation. Speech was somewhat pressured and he had poor eye contact. Visual and auditory hallucinations are present and were in the past two weeks. He was intermittently responding to these internal stimuli during the evaluation.
Dusty denies suicidal ideation, although he reported homicidal ideation toward his girlfriends X-husband. He was unable to sit still during the evaluation process. He would pace, lie down on the couch, look out door suspiciously and pace again.
Patient states: “all this began on Father’s day” (although mother states three to
four weeks ago) when he “lost” his pickup truck. The previous evening, he states, that he drank some Jack (Jack Daniels whiskey) and smoked some marijuana. States he was “raped” by a man who he hitched hiked with while looking for his vehicle. Police officers found Dusty, wandering barefoot and disheveled, looking for his vehicle. His feet were bleeding and quite raw from aimlessly wandering barefooted. He was taken to the home of his mother, where had been living, since the University was out for the summer.
Dusty had a four- year scholarship at a moderately large University. This last semester he states, he had done poorly because he “couldn’t get it together, I was taking some drugs and drinking….but that didn’t seem to help.”
Mother reports that while at her home, he exhibited bizarre behaviors: such as, going outside and laying in the flower- bed, laying in a dry tub and sticking his
chest with old lancets, that mother had used for testing blood sugars. When asked
what he was doing he stated that he was “testing himself for heart trouble.” His mother reported that his appetite of late has been poor.
Dusty states that he is heterosexual but qualifies his statement with, “I guess I’m open to anything.” Dusty cannot be viewed as a reliable historian now.
History
Dusty was the youngest of seven children. He has six siblings, four sisters and two brothers. His father has been described as a physically violent man with an alcohol problem. He died two years ago from cirrhosis of the liver. Dusty has no contact with his biological father. Mother was physically abused, although denies that father ever abused children. Mother divorced her husband, when Dusty was nearing age two, and at this time placed all seven children in the Masonic home. The children would visit their mother on some weekends and a month during the summer. Approximately three years after the divorce their mother married again. Dusty expressed that he liked his step father…”the only father that I knew”. The children continued to live at the Masonic home despite mother’s re-marriage. Dusty and one sister report being both physical and sexual abused by a house parent at the home. Mother states that the children never told her that this occurred.
Rusty reports that he has a long history of drug and alcohol abuse. At age 11, he began smoking marijuana at age eleven, at fifteen he started to drink alcohol. By age twenty- one, he was using Ice, Ecstasy, GHB and anything else that was available.
In April, Dusty was terminated from his job at a metal factory and shortly began looking for another job, with no success. Rusty had a four- year scholarship to College. During this past year, his grades have suffered and the scholarship is no longer available. His estimated intelligence is above – average. He met his girlfriend in the last four months. She was married and pregnant.
Dusty’s delusions revolve around being able to hear thru stee1 and “being called” into the military to save Iraq. He quotes the Bible and states that the Book of Numbers gives him permission to kill, if he were in the military. His goals in life are very unrealistic – at one moment wanting to be a philosopher, a military soldier, a priest.
Dusty relates that the “voices” started (hallucinations) after reading the Remembrance magazine. “The women that were in there shot me – we were having a fireside chat.” States that each time he looks in the mirror he hears voices stating, “That’s what ice cream is for”. He has denied any command hallucinations or voices, which negate him.
Dusty reports no physiological illnesses or any prescribed medications. He states that he has been in good physical health. He reports intermittent sleep problems. A physical done (by an FNP), at admission, substantiates his report. Only injuries noted were abrasions to feet.
A drug screen, CBC, CMP, UA, RPR, TSH, B12/Folic Acid, and HIV screen were all within normal limits.
Include:
• Any differential diagnoses
• Your diagnosis and reasoning
• Any additional questions you would have asked
• Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.
• Any labs and why they may be indicated
• Screener scales or diagnostic tools that may be beneficial
• Additional resources to give (Therapy modalities, support groups, activities, etc.)
CASE 2
25 year old woman found unresponsive
History of present illness:
A 25 year old woman is brought to the ER, apparently unresponsive. She was found, lying on a park bench, by the police, and when they could not arouse her, they called an ambulance. Her vital signs are normal: B/P=115/80, HR=76, temp. 98.6F and respiratory rate =16. Physical examination reveals no signs of trauma or obvious injury. The patient is gaunt and looks malnourished. Her eyes are closed, and she does not respond to voice or sternal rub. Strangely, when the ER physician tries to move her arms, he meets strong resistance and moves her arm to a new position only with great effort. Even more to his surprise, he finds that her arm stays in the new position, even after he releases it.
Luckily, the patient had identification in her purse, which, with some prying, was taken from her on admission. Her mother is contacted. Mother states that she is frightened after hearing her daughter’s condition because nothing like this has happened to her before. The mother is relieved that her daughter was found. Until about 3 months ago, the pt. was living with her mother but not had been seen since then. Mother describes her as a cooperative child who never made unreasonable demands and was quiet and introspective while growing up.According to mother, the pt. had finished high school and had started classes at a community college. However, she had stopped school after one semester because of poor grades. The patient spent most of her time doing clerical work in the family real estate business. She had become more withdrawn over the past year, but mother interpreted this behavior as being “a little down” because her only friend had graduated from college and was now engaged to be married. Approximately 7 months ago, the patient’s mother became more concerned because her daughter had become more reclusive, missing work and often spending many days at a time in her room. She would come out only to eat a few morsels of food and then quickly retreat to the confines of her room. At that point in time, she states that her daughter appeared preoccupied with whether the food she was eating had been “killed in a morally acceptable way”. She expected her daughter to “snap out of it” but eventually told her she was going to take her to see a doctor. The next morning the patient disappeared (3 mo. Before current presentation).
Past Psychiatric Hx:
According to mother, the patient has no history of psychiatric illness and, as far as she knew, never used drugs. The mother recalls a cousin with mental illness who is now in an “institution”.
Past Medical Hx:
The patient has no medical problems, takes no medication, and has no known allergies.
Laboratory:
WBC—6,000
Hemoglobin…13.3
Sodium…141
Potassium…4.1
Calcium…10.3
Mg…2.0
Phosphorus…2.1
Arterial blood gasses…WNL
Pulse oximetry…97% on room air
Diagnostic Testing:
Stat CT scan…reveals no evidence of bleeding, mass or infarct
CSF (lumbar puncture) was clear
no signs of infection, cultures and PCR pending.
Mental Status Exam:
The pt. is a slightly cachectic looking woman, lying on a stretcher, with eyes shut. She does not respond to questions or touch. She does not move spontaneously, and when placed, her extremities hold their position.
Limba have cogwheel rigidity on flexion and extension. There is no spontaneous speech, or thought content. Orientation cannot be assessed, nor can judgment or insight.
Questions:
• Any differential diagnoses
• Your diagnosis and reasoning
• Any additional questions you would have asked
• Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.
• Any labs and why they may be indicated
• Screener scales or diagnostic tools that may be beneficial
• Additional resources to give (Therapy modalities, support groups, activities, etc.)
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