Psychosis and Schizophrenia Case Study Example | Topics and Well Written Essays - 1500 words

Psychosis and Schizophrenia - Case Study Example For the past two days he has not slept at all, only eats food out of cans that he himself has opened, and refuses to leave the house. PPH: He was hospitalized for five days in July of 2007 for a â€Å"nervous breakdown† after being fired from a summer job. His parents indicate that at that time, he was talking to himself all the time and not thinking clearly. He was treated with Haloperidol but they cannot remember the dose. They said he was much better after leaving the hospital but only took the medicine for a few weeks because it made him feel stiff and slowed down. PMH: Not significant, only the usual childhood illnesses SH: Graduated high school in upper third of his class and participated in extra-curricular and social activities. Began having academic difficulties this year and is now down to part-time status after failing two classes last semester. He has returned to live at home with his parents because he could not get along with his roommate. Non-smoker; social drin ker Meds: Was on Haloperidol on July 2007, but stopped abruptly due to side effects Current Meds: None PE: WNL Vitals - BP 120/70, P 88, RR 17, T 98.6, Ht 5’7† Wt 100 kg Heart- NRRR HEENT - PERRLA, EOMI, fundi benign Neck - no bruits, no JVD, no thyromegaly Lungs – CTA Abd- +BS, No masses or bruits MS/Ext - nl ROM, muscle strength 5/5 in UE and LE, no peripheral edema Neuro - all cranial nerves intact Labs: Chem 7 - WNL HEME 18 - WNL UA - WNL Urine Drug Screen (+) for cannabinoids MSE: Appearance = poorly groomed white male who appears his stated age Behavior = hypervigilant and suspicious but cooperative Speech = slightly pressured and rambling Thought Process = tangential with occasional interruptions suggesting thought blocking Thought Content = positive for auditory hallucinations and ideas of reference Affect = anxious Cognition = A&O x 3, recent and remote memory intact I. AP Note A. Present Problem Gerald is brought to the hospital by his parents due to hi s odd behavior which includes false beliefs, sleeplessness and irrational suspicions which increase in frequency over the past two weeks. B. Risk Factors Puberty History of psychiatric problem Previous intake of antipsychotic drug Substance abuse C. Assessment 1. Evaluation Gerald is brought by his parents to the hospital due to his peculiar behavior. Two weeks ago, he started exhibiting persecutory delusions and insisted on keeping their house lights on all the time. He was reportedly seen awake on most nights. Gerald also had delusions of reference wherein he accuses his ex-girlfriend of bugging his room and his former roommate to be sending threat messages over the radio. Gerald is awake for more than 48 hours now and manifests paranoia by eating only self-opened canned foods. His persecutory delusion has led me to refuse leaving their house. The presence of delusions, hallucinations and disorganized speech, according to DSM-IV-TR, places Gerald in the classification of Paranoid type of Schizophrenia. However, by considering that his urine drug screen tested positive for cannabinoids, thorough diagnosis of his symptoms is needed to rule out the physiologic etiology of substance abuse. He needs pharmacological intervention appropriate for Schizophrenia with co-morbidity of substance abu