Introduction
The patient was brought in for evaluation by two of her roommates, who noted that Jess was having ideas and, at the same time, hearing things that others could not. According to them, this kind of behavior began 12 days after Jess’ younger brother committed suicide in front of her via GSW. This was right after his girlfriend broke up with him. She is not on good terms with her parents, and her brother is the only close person she has – he is her only sibling. Besides sleeping for only about two hours a day, Jess also eats canned foods. She smokes cannabis on a daily basis – this started back when she was 16 years old. She also goes out occasionally with her roommates, specifically during weekdays. She currently has an active job as she works in a bakery. She was initially prescribed alprazolam 1mg twice daily as needed by her PCP for 15 days.
Past Medical History
- General Statement: The patient noted that she did not have any medical history or psychiatric hospitalization. In addition to this, Jess denied having a personal psychiatrist. This information is necessary for the healthcare provider to understand any history and pattern of her illness and treatments.
- Caregivers (if applicable): There are no caregivers mentioned since the patient is estranged from her parents. She currently lives with her two roommates, Rachel and Liz.
- Hospitalizations: The patient denies having been previously hospitalized.
- Medication trials: Although the patient takes certain medications, she failed to disclose them.
- Psychotherapy or Previous Psychiatric Diagnosis: The patient denies having a history of mental hospitalization and psychotherapy.
Substance Current Use and History: Jess started smoking cannabis at the age of 16 years and occasionally ( 1 or 2 times a week) goes out with her roommates to drink a couple of beers.
Family Psychiatric/Substance Use History: The patient did not report any family history. Family history is important as it allows healthcare providers to understand the root cause of the problem. More importantly, it helps the care provider rule out heredity or substance use in her family.
Psychosocial History: The patient lives with her two roommates and occasionally hangs out with them (2-3 times a week), smoking cannabis and drinking a couple of beers.
Medical History:
- Current Medications: Alprazolam 1 mg BID as needed for 15 days
- Allergies: Medical Tape
- Reproductive Hx: The patient is not sexually active, does not have any children, and has no known miscarriage
ROS:
- GENERAL: The patient appears to be in a healthy condition with vitals showing T- 98.6 P- 86 R 20 GENERAL: 120/70 Ht 5’2 Wt 126lb
- HEENT: No vision
- SKIN: There are no rashes, bruises, or swelling observed
- CARDIOVASCULAR: No edema, chest pain, or palpitation, as well as signs of swelling in bilateral lower extremities
- RESPIRATORY: No respiratory disease or condition observed, no dyspnea, and no chest pain
- GASTROINTESTINAL: No known cases of vomiting and nausea, and no abdominal pain observed
- GENITOURINARY: The patient denies experiencing any pain during urination or any sign of polyuria
- NEUROLOGICAL: The patient denies experiencing seizures or headaches
- MUSCULOSKELETAL: Ambulates without any assistance
- HEMATOLOGIC: No blood disorder
- LYMPHATICS: No inflammation observed
- ENDOCRINOLOGIC: No endocrine condition
Objective Data
Physical exam
Vital Signs: T- 98.6 P- 86 R 20 GENERAL: 120/70 Ht 5’2 Wt 126lb
Diagnostic results: Although no diagnostic labs were observed, additional tests were required to arrive at an accurate diagnosis. According to Forbes et al (2019) study, CT scans undertaken on patients with schizophrenia tend to show lateral and third ventricle expansion and a considerable decrease in cortical volume. The care provider may also order an MRI or a blood test to rule out a possible medical-related condition.
Assessment
Mental Status Examination
The 30-year-old female patient appears alert and well-oriented. She maintains eye contact, is well-groomed, dresses appropriately, and is well-mannered but a little anxious. In addition to this, the patient appears to be paranoid as she states that “The Russians men and whores are listening to her, and they communicate by drilling all night long.” She talks in a low tone most of the time, with her speech appearing more disorganized. Her posture and attitude show clearly that she is under immense stress. Although she denies suicidal or homicidal ideations, her affect is congruent, and her association is loose.
Differential Diagnoses
Schizophrenia [295.20] F20.9
Schizophrenia is a chronic brain condition commonly associated with delusions, hallucinations, and disorganized speech. Diagnostic and Statistical Manual of Mental Disorders (DSM-V) describes schizophrenia as a condition that presents with two or more of the following symptoms: hallucinations, delusions, and disorganized speech. These symptoms must appear within a period of one month (Strauss et al., 2018). As for the patient in question, it is clear that she has been experiencing a range of symptoms, such as delusions, hallucinations, and disorganized speech. This condition is the main diagnosis because the patient meets all the DSM-5 criteria, and the screening results also confirm the same.
Schizoaffective disorder [295.70] F 25.0
Schizoaffective disorder is described in DSM-V as a type of disorder with specific psychotic features. For instance, the patient may experience both manic and depressive episodes at times. Similarly, manic or depressive episodes may occur only for a short period of time (Hartman et al., 2019). The condition is also described as having a combination of the symptoms of mood disorder and schizophrenia. In some cases, people presenting with mood disorders might experience difficulties performing or completing certain tasks. In the case of Jess, she only sleeps for about 1-2 hours and has not been eating well. Therefore, this condition is the second choice because the patient does not experience mania.
Anxiety Disorder
Anxiety disorder is a type of mental illness commonly associated with persistent thoughts and the urge to repeat certain actions. According to Cervin and Perrin (2021), the urge to perform specific actions often leads to “worry, annoyance, and deterioration of mental health” (p. 23). The most common symptoms associated with this condition include feelings of isolation, panic attacks, anxiety, and sadness (Axmon et al., 2019). The major risks associated with anxiety disorder relate to genetics and hereditary composition.
Reflections
If I were to conduct the session again, I would screen the patient for obsessive-compulsive disorder. The patient might develop this disorder due to the delusions and hallucinations she currently experiences. From an ethical point of view, the principle of truth-telling might conflict with those of nonmaleficence and beneficence, especially when dealing with patients diagnosed with schizophrenia. For instance, the patient might harm herself if she is informed that she is delusional and hallucinating. Another critical issue for consideration relates to patient autonomy – the patient might not think properly, which might make it difficult for the psychiatrist to trust their decisions. More specifically, the psychiatrist may find it hard to allow patient autonomy if the patient decides she does not want to be treated. Overall, I will educate her roommates to consider spending more time with her and watch her condition. I will also recommend that she start treatment immediately to help improve her mental health.
References
Axmon, A., El Mrayyan, N., Eberhard, J., & Ahlström, G. (2019). Pharmacotherapy for mood and anxiety disorders in older people with intellectual disability in comparison with the general population. BMC Psychiatry, 19(1), 1-8. Web.
Cervin, M., Perrin, S., Olsson, E., Claesdotter-Knutsson, E., & Lindvall, M. (2021). Involvement of fear, incompleteness, and disgust during symptoms of pediatric obsessive–Compulsive disorder. European Child & Adolescent Psychiatry, 30(2), 271-281. Web.
Forbes, M., Stefler, D., Velakoulis, D., Stuckey, S., Trudel, J. F., Eyre, H., & Kisely, S. (2019). The clinical utility of structural neuroimaging in first-episode psychosis: A systematic review. Australian & New Zealand Journal of Psychiatry, 53(11), 1093-1104. Web.
Hartman, L. I., Heinrichs, R. W., & Mashhadi, F. (2019). The continuing story of schizophrenia and schizoaffective disorder: one condition or two?. Schizophrenia Research: Cognition, 16, 36-42. Web.
Strauss, G. P., Nuñez, A., Ahmed, A. O., Barchard, K. A., Granholm, E., Kirkpatrick, B., & Allen, D. N. (2018). The latent structure of negative symptoms in schizophrenia. Journal of American Medical Association Psychiatry, 75(12), 1271-1279. Web.
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