Psychiatry Case Presentation

Candice Reyes, MS III

Pacific Hospital of Long Beach
 History of Present Illness
J.K. is a 34 y/o Caucasian male with a h/o Schizophrenia, Paranoid Type
x 16yrs who was admitted on a 5150 for DTS. He has been living in Scandia
Board & Care x 8yrs. The manager was concerned about recent changes in
the patient's behavior. The police found him hitting and kicking a locked
door that was closed on him to prevent him from attacking another person.
In addition, he was yelling, God told me to kill myself! He had also been
refusing psychiatric medications, stating, Im fine without them.

During the past several weeks, the patient has been unpredictable,
responding to internal stimuli and cursing. He paces the hallways and
screams, put it in the butt and fuck you. He also tickles himself and
laughs inappropriately.

The patient has been treated with Haldol 10mg PO bid, Depakote
250mg/d, and Valium 5mg/d since he started living at Scandia. He
experienced moderate extrapyramidal syndrome (EPS), which has been
responsive to Cogentin (2 mg at bedtime).

There is a h/o stimulant use methamphetamines at the age of 21. He

denied substance abuse treatment. According to staff at the board and care,
there has been no observed change in sleep pattern and no identifiable
perturbation in the patient's psychosocial milieu.
 Past Psychiatric History
The patient's symptoms at the onset of his
illness included auditory hallucinations of Gods
voice, suspiciousness, ideas of reference and
hostility, and moderately severe conceptual
disorganization.

Except for his conceptual disorganization, the

patient's symptoms were attenuated through the
use of neuroleptics and supportive therapy.

He has a longstanding recurrent history of

medication noncompliance that has led to
multiple psychiatric admissions since he was 18.
 Family Psychiatric History
Unremarkable.
 Past Medical History
Chronic bronchitis, Schizophrenia,
Paranoid type. Pt denies history of head
trauma, seizures, or HIV.
 Social and Developmental History
The patient is the oldest of 3 boys and has
completed a high-school education.
After graduating, he obtained work in a lot
of jobs that he refuses to talk about. Since
his diagnosis, he has not worked and now
receives disability support. Family is
described as disengaged, having contact
with him periodically.
 Review of Symptoms
General: The patients medical health has been fairly
stable
Skin: No skin d/o requiring medical attention
HEENT: Other than respiratory infections, no other
problems referable to this system
Neck: No swelling, dysphagia, or thyroid disease
Pulm: No asthma, TB, or pneumonia
CV: No known heart disease or hypertension
GI: No dyspepsia, PUD, biliary tract disease,
pancreatitis, or colitis
GU: No UTIs, venereal disease, or kidney stones
Neuromuscular: No muscle weakness or wasting. No
syncope, vertigo, or diplopia
 Physical Exam
Vital Signs: Ht 511 Wt 196lb BP 117/91 when admitted P 92 R 20
Skin: Warm and dry with good turgor
HEENT: NCAT. Ears clear. Eyes show no evidence of icterus or
conjunctivitis. PERRLA. Nose is clear. Throat is negative.
Neck: Supple with no neck vein distention, thyroid enlargement, or
bruits.
Lungs: CTA and percussion. No rales, rhonchi, or wheezes
CV: RRR with no murmurs, thrills, heaves, or rubs. First and second
heart sounds normal. No S3 or S4.
Abdomen: Flat and soft. No guarding or rigidity. Bowel sounds
WNL.
Pulses: present and symmetrical
Lymph: Patient is free of lymphadenopathy
Extremities: No evidence of wasting or edema.
Neuro: Intact and symmetrical. Unremarkable for evidence of gross
movement disorders.
 Mental Status Exam
The patient is an overweight Caucasian male who looks
older than his stated age. He is A&O x 3. Motor is
slowed. Speech is slowed. Mood is depressed.
Suicidal ideation risk, i.e., OD on medications.
Homicidal ideations are denied. Thought processes are
loose. Thought content is guarded. The voices telling
him to kill himself on recurrent basis. Immediate, recent,
and remote memory are intact as evidenced by recall.
Impulse control and judgment are diminished.
Insight and reliability are diminished demonstrated by
medication noncompliance and poor insight regarding
his illness.
 Lab Data
The patient's toxicology screen was
negative.
CXR 2 views was normal
 Summary
The patient is a 34 y/o Caucasian male with Schizophrenia,
paranoid type, who was decompensating due to medication
noncompliance. He presented with symptoms of paranoia, suicidal
ideations, internal stimuli and conceptual disorganization, which
were hallmarks of his other breakdowns with no identifiable change
in her psychosocial milieu. After administration of medications, he is
now in a stable phase of illness following one of multiple recurrent
psychotic episodes.

Articles:

Schizophrenia and Violence: Systematic Review and Meta-Analysis

Greater Impairment in Negative Emotion Evaluation Ability in Patients

with Paranoid Schizophrenia

Indicated Prevention of Schizophrenia

Reality of Auditory Verbal Hallucinations