Comprehensive Psychiatric Evaluation – Schizophrenia Spectrum

Comprehensive Psychiatric Evaluation – Schizophrenia Spectrum

Case

Name: J.D.

Age: 20 years old

Gender: Male

Diagnosis: Schizophrenia Spectrum

The patient is a 20-year-old male patient with a past psych history of bipolar, psychiatrically hospitalized due to erratic and high-risk behavior. The patient had a domestic violence charge in February and had gone to court for a hearing on the day of presentation to the ED. The patient started acting bizarre and ran into traffic; police were able to get him and brought him to the hospital for evaluation. The patient is bizarre, hyperverbal, and grandiose. The patient seems to be responding to internal stimuli. The patient denies a history of suicide attempts and has told the therapist he tried inhaling roach spray to potentially harm himself. The patient acknowledges a history of mania and psychosis. Reports on several medications in the past, but unable to recall their names. The patient admits noncompliance with the medication regimen but is willing to try again because he wants to feel better.

Mental state evaluation was performed, and questions were asked. The patient is disoriented to place, location, and time. The patient observed with an awkward behavior and a tangential thought process. The patient observed sadness and displays poor short-term and long-term memory. The patient observed with poor judgment. The patient confirms suicidal thoughts and potential harm to self and others. He also confirms signs of hallucination, delusions, paranoia, and grandiosity.

Based on the DSM-V diagnostic criteria, the client is diagnosed with Schizophrenia Spectrum.

The patient will start on Ziprasidone (Geodon) 40mg orally twice daily and anxiety and Seroquel 50 at bedtime. The patient will receive cognitive behavior therapy three times a week at the outpatient hospital and follow-up in two weeks.

Subjective:

CC (chief complaint): “I’m here because I have been feeling really strange, and I did some weird things, like inhaling roach spray. I want to get better.”

HPI: J.D., a 20-year-old male with a history of bipolar disorder, seeks a comprehensive psychiatric evaluation following recent erratic behavior and a domestic violence incident. He has a vague recollection of past medications and admits to noncompliance. Notably, he tried inhaling roach spray as a form of self-harm. J.D. exhibits bizarre, hyperverbal, and grandiose behavior, seemingly influenced by internal stimuli. He is disoriented in time, place, and location, with impaired memory, poor judgment, and tangential thought patterns. Additionally, he reports suicidal thoughts, potential harm to self and others, hallucinations, delusions, paranoia, and grandiosity. These severe symptoms significantly impact his daily life. Based on DSM-5 criteria, J.D. is diagnosed with Schizophrenia Spectrum Disorder, necessitating prompt intervention and treatment planning to improve his well-being and safety.

Past Psychiatric History:

• General Statement: J.D. has a history of psychiatric issues, including bipolar disorder, which he mentioned during the evaluation.
• Caregivers (if applicable): None
• Hospitalizations: J.D. has been recently psychiatrically hospitalized due to erratic and high-risk behavior. No history of previous hospitalizations.
• Medication trials: J.D. reports having been on several medications in the past to manage his mental health. Unfortunately, he is unable to recall the names of these medications. He also acknowledges noncompliance with his previous medication regimen.
• Psychotherapy or Previous Psychiatric Diagnosis: The patient acknowledges a history of mania and psychosis.

Substance Current Use and History: J.D. reports a history of alcohol use, consuming 4-5 drinks daily, last used two days ago. He occasionally smokes marijuana (one joint/week, last use three days ago) and cigarettes (half a pack/day, lasting an hour). He consumes caffeine (1-2 cups/day) but hasn’t experienced severe withdrawal symptoms.

Family Psychiatric/Substance Use History: J.D.’s paternal grandmother was diagnosed with schizophrenia in her early twenties. His maternal uncle has a history of bipolar disorder and has experienced multiple hospitalizations. J.D.’s father struggled with alcohol use disorder in his late thirties but completed a rehabilitation program and has maintained sobriety for over a decade. However, his older sister, currently 24 years old, has been actively using marijuana and occasionally experimenting with other illicit substances.

Psychosocial History: J.D. grew up in a stable, supportive family environment. He completed high school and briefly attended college before his mental health struggles began, affecting his social life and academic pursuits.

Medical History:

• Current Medications:D. has been prescribed Ziprasidone (Geodon) 40mg twice daily for managing his Schizophrenia Spectrum Disorder and Seroquel 50mg at bedtime to address anxiety and sleep disturbances.
• Allergies: There are no reported drug, food, and environmental allergies

• Reproductive Hx: Not sexually active. No history of STIs.

ROS:

• GENERAL: No significant weight loss, fever, or fatigue was reported.
• HEENT (Head, Eyes, Ears, Nose, Throat): No visual or hearing changes, no headaches.
• SKIN: No rashes, lesions, or itching.
• CARDIOVASCULAR: No chest pain or palpitations.
• RESPIRATORY: No shortness of breath or cough.
• GASTROINTESTINAL: No nausea, vomiting, diarrhea, or abdominal pain.
• GENITOURINARY: No urinary frequency, urgency, or changes in urinary habits.
• NEUROLOGICAL: Reports of disorientation, poor memory, and bizarre behavior
• MUSCULOSKELETAL: No joint pain, muscle weakness, or limited mobility.
• HEMATOLOGIC: No bleeding disorders.
• LYMPHATICS: No swollen lymph nodes.
• ENDOCRINOLOGIC: No excessive thirst or urination, no heat or cold intolerance.

Objective:

Diagnostic Results:

• Complete Blood Count (CBC): To rule out significant hematologic disorders as a contributor to symptoms (Sadock et al., 2015).
• Comprehensive Metabolic Panel (CMP): To determine the electrolyte levels and kidney and liver function to rule out metabolic abnormalities (Sadock et al., 2015).
• Urinalysis: To rule out urinary tract infections or abnormalities (Sadock et al., 2015).
• Thyroid Function Tests (TSH, T3, T4): To rule out thyroid dysfunction as a potential cause (Sadock et al., 2015).
• Brain Imaging (MRI or CT Scan): Recommended to assess for structural abnormalities in the brain, contributing to disorientation and neurological symptoms (Sadock et al., 2015).
• Toxicology Screen: To identify any recent substance use, including drugs or alcohol, which may influence the clinical presentation (Sadock et al., 2015).

Assessment:

Mental Status Examination:

J.D. is a 20-year-old male with a disheveled appearance, consistent with his recent erratic behavior and hospitalization. He appears agitated and occasionally makes abrupt, purposeless movements during the evaluation, indicating psychomotor agitation. His grooming is suboptimal, reflecting a decline in self-care. His speech is hyperverbal and marked by tangential thought processes, making it challenging to maintain a coherent conversation. He frequently exhibits inappropriate laughter and displays a grandiose mood and affect, often describing himself as extraordinary. During the assessment, J.D. reported auditory hallucinations, describing voices criticizing and commanding him. He expressed paranoid beliefs, feeling as though he was being monitored and followed. Additionally, he endorsed delusions of grandeur, believing he possesses exceptional abilities and influence. J.D. admitted to experiencing suicidal thoughts and demonstrated poor judgment by attempting self-harm by inhaling roach spray. His cognitive functioning is compromised, as he is disoriented to time, place, and location and displays profound memory deficits, both short-term and long-term. His insight into his condition is limited, and his judgment is severely impaired. Top of Form

Differential Diagnoses:

Schizophrenia Spectrum Disorder (ICD-10: F20.0)

Primary Diagnosis: Schizophrenia Spectrum Disorder aligns with J.D.’s clinical presentation, characterized by disorganized thought processes, auditory hallucinations, paranoid beliefs, grandiosity, impaired judgment, and significant psychosocial dysfunction. His symptoms meet the DSM-5 criteria for this diagnosis.

Rationale: J.D. displays classic positive and negative symptoms of schizophrenia, including hallucinations, delusions, disorganized thinking, and marked impairment in social and occupational functioning (Whiting et al., 2022).

Schizoaffective Disorder (ICD-10: F25.0)

Schizoaffective disorder is considered due to J.D.’s history of bipolar disorder and the presence of both mood and psychotic symptoms. However, it is less likely than schizophrenia spectrum disorder because mood symptoms are less prominent than psychotic symptoms, and the disorganized thought processes and cognitive deficits are more in line with schizophrenia (Miller & Black, 2019).

Delusional Disorder (ICD-10: F22.1)

Delusional disorder is considered due to prominent delusions without the extensive disorganized thought processes seen in schizophrenia. However, the hallucinations, bizarre behavior, and cognitive impairment observed in J.D.’s case are inconsistent with the typical presentation of delusional disorder (American Psychiatric Association, 2013).

Substance-Induced Psychotic Disorder (ICD-10: F16.94)

J.D.’s substance use history, including marijuana and cigarette smoking, raises the possibility of a substance-induced psychotic disorder. However, his symptoms persist even when substance use is absent, and his history of erratic behavior predates recent substance use (American Psychiatric Association, 2013).

Reflections:

In a similar patient evaluation, I strive to improve the cultural competency of the assessment. Understanding cultural factors can play a crucial role in preventing and treating mental health disorders. I would focus more on cultural nuances, beliefs, and values to ensure a comprehensive and sensitive evaluation.

One social determinant of health from Healthy People 2030 relevant to this case is “Social and Community Context.” The social environment can influence J.D.’s history of erratic behavior, exposure to violence, and potential substance use (Zakhari, 2020). Addressing these contextual factors is essential in psychiatry to formulate a holistic treatment plan.

As a future advanced provider, a health promotion activity could involve creating culturally tailored psychoeducation programs addressing mental health stigma within specific communities. Patient education should emphasize the importance of medication adherence and regular follow-ups, as disparities often arise from a lack of access to mental health care. Providing resources and support for families and caregivers can also improve outcomes for patients with severe mental illnesses, reducing mental health care access and outcomes inequities (Zakhari, 2020).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Miller, J. N., & Black, D. W. (2019). Schizoaffective disorder: A review. Annals of clinical psychiatry: official journal of the American Academy of Clinical Psychiatrists, 31(1), 47-53. https://doi.org/10.3109/10401239109147967

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Whiting, D., Gulati, G., Geddes, J. R., & Fazel, S. (2022). Association of schizophrenia spectrum disorders and violence perpetration in adults and adolescents from 15 countries: A systematic review and meta-analysis. JAMA psychiatry, 79(2), 120-132.

Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.

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Age: 20 years old

Gender: Male

Diagnosis: Schizophrenia Spectrum

The patient is a 20-year-old male patient with a past psych history of bipolar, psychiatrically hospitalized due to erratic and high-risk behavior. The patient had a domestic violence charge in February and had gone to court for a hearing day of the presentation to the ED. The patient started acting bizarre and ran into traffic, police were able to get him and brought him to the hospital for evaluation. The patient is bizarre, hyperverbal, and grandiose. The patient seems to be responding to internal stimuli. The patient denies a history of suicide attempts and has told the therapist he tried inhaling roach spray to potentially harm himself. The patient acknowledges a history of mania and psychosis. Reports on several medications in the past, but unable to recall their names. The patient admits noncompliance with medication regimen but is willing to try again because he wants to feel better.

Mental state evaluation was performed, and questions were asked. Patient is disoriented to place, location, and time. Patient observed with an awkward behavior and a tangential thought process. Patient observed sadness and displays poor short-term and long-term memory. Patient observed with poor judgment. The patient confirms suicidal thoughts and potential harm to self and others. He also confirms signs of hallucination, delusions, paranoia, and grandiosity.

Based on the DSM-V diagnostic criteria, the client is diagnosed with Schizophrenia Spectrum.

The patient will start on Ziprasidone (Geodon) 40mg orally twice daily and anxiety and Seroquel 50 at bedtime. Patients will receive cognitive behavior therapy three times a week at the outpatient hospital and follow-up in two weeks.

CC (chief complaint):

HPI:

Past Psychiatric History:

• General Statement:
• Caregivers (if applicable):
• Hospitalizations:
• Medication trials:
• Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

• Current Medications:
• Allergies:

• Reproductive Hx:

ROS:

• GENERAL:
• HEENT:
• SKIN:
• CARDIOVASCULAR:
• RESPIRATORY:
• GASTROINTESTINAL:
• GENITOURINARY:
• NEUROLOGICAL:
• MUSCULOSKELETAL:
• HEMATOLOGIC:
• LYMPHATICS:
• ENDOCRINOLOGIC:

Physical exam: if applicable

Diagnostic results:

Assessment

Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?

Mental Status Examination:

Differential Diagnoses:

Reflections:

Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health.  As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

 References

Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.