Assessment of Paranoid Schizophrenia in a 53-Year-Old Patient

Week 5 Stephanie Frankel College of Nursing-PMHNP, Walden University NRNP 6675: PMHNP Care Across the Lifespan II Dr. Takia Starkes-Perry January 1, 2023

2 Week 5 Subjective: CC (chief complaint): seeing things and hearing voices, not sleeping – up for days due to the voices being loud HPI : The 53-year-old male presents to the mental health clinic with complaints of being watched outside. He states that he can see and hear the people watching him even though they are unaware of his presence. He claims that he has seen and heard the people for several weeks. He also commented that the people were government agents sent to monitor him because of the high taxes accumulated over time. During the interview, Tremaine claims to see a bird and hear metallic music. He also claims that the voices he hears during the night are so loud, preventing him from getting a good night’s sleep because he stays awake for days. Substance Current Use: Smokes Cigarettes – 3 packs per day, drinks beer - daily Medical History:  Current Medications : Metformin - diabetes  Allergies : NKDA  Reproductive Hx : Single, no children ROS :

3  GENERAL: Alert, cooperative, no fatigue, no chills, no weight loss, no weakness, no fever.  HEENT: No blurred, double and loss of vision  ENT: no hearing loss, drainage, pain, congestion, runny nose, or sore throat. Neck supple, without meningismus.  SKIN: No rash or diaphoresis. No itching.  CARDIOVASCULAR: No chest pain, chest pressure, or discomfort. No palpitations or edema. Normal rate and rhythm.  RESPIRATORY: No shortness of breath, cough, or sputum. No accessory muscle use or stridor.  GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood in the stool.  GENITOURINARY: No burning during urination, urgency, hesitancy, or odor.  NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling of extremities. No obvious focal deficits.  MUSCULOSKELETAL: Full range of motion. No joint stiffness or pain.  HEMATOLOGIC: No bruising, no anemia, no bleeding,

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4  LYMPHATICS: No lymph node swelling, no discharge.  ENDOCRINOLOGIC: No sweating, no heat or cold intolerance. Objective: Diagnostic results : Covid-19: Negative; CMP, CBC: WNL; Urine Drug Tox: Normal; Urinalysis: Normal; Head CT: No evidence of acute intracranial abnormality. Assessment: Mental Status Examination: He is a fifty-three-year-old African American male who appears as the stated age. He is alert and composed and cooperates during the interview. He is clean, and dressed well. The motor activity is normal. He has a clear speech but is pressured at times. The thought process is non-goal directed and not logical sometimes. There is a flight of ideas. His mood is euphoric. He has an appropriate affect. He has both auditory and visual hallucinations. He has no homicidal or suicidal tendencies. Cognitively, he is oriented and alert. He has no gross deficits, and remote memory is intact. He has impaired concentration and poor insight. Diagnostic Impression: 1) Paranoid Schizophrenia – Paranoid schizophrenia presents with primary symptoms of hallucinations, jumbled speech, or delusions. Other common symptoms of paranoid schizophrenia include; reduced emotional expression, catatonic behavior, inappropriate affect or flat

5 affect, disorganized speech, and gross disorganization. An individual can also present with a lack of motivation and behavior disturbance. The symptoms should be present for six months or more. Paranoid schizophrenia is known to cause impairment in individuals' interpersonal relationships and work levels (García-Cabeza et al., 2018). The patient presents with auditory and visual hallucinations in the case study. He states that he can see and hear the people watching him every time. He also has poor insight and impaired concentration. The patient also has a family history of paranoid schizophrenia, which increases the risk of developing the condition. 2) Schizophrenia Schizophrenia is a condition that mainly presents with two or more of the symptoms; hallucinations, delusions, negative symptoms, disorganized speech, and grossly disorganized. The negative symptoms can include; anhedonia, lack of motivation, and poverty of speech. An individual must present with signs of disturbance for at least six months, and there must be dysfunction in an individual's occupation or social activities (Hany et al., 2022). The patient meets the diagnostic criteria of schizophrenia. He sees the shadows of people he believes the government sent to watch him and hears them. He states that when he tries to watch TV, people come and poison his food, and therefore he has locked everything in the fridge. 3) Substance/Medication-Induced Psychotic Disorder – (smokes cigarettes – smoker, three packs a day, and drinks alcohol daily) Substance/medication-induced psychotic disorder refers to psychotic, depressive, anxiety, and manic symptoms which occur as a physiological consequence of medication or substance

6 use. The symptoms can present during active use, withdrawal or intoxication. The most common manifestations of the condition include; irritability, anergy, hopelessness, retardation, suicidal ideation, sad mood, decreased libido, anorexia, helplessness, impulsivity, racing thoughts, increased energy, and distractibility. The symptoms usually resolve following acute withdrawal or severe intoxication (Revadigar & Gupta, 2020). Concerning the case study, the patient states that he takes three packets of cigarettes per day and also consumes alcohol. Reflections: It is vital to come up with a plan of care by using the information that is obtained during the interview. I have learned about the need to pay attention to how the patient is communicating in addition to the behaviors to obtain detailed information. The subjective and objective information is essential because it plays a role in formulating the various differential diagnoses. It is vital to obtain all the patient information, including; medical history, current substance use, review of systems, and objective data. It is also essential to obtain the mental status examination because it enables the healthcare provider to assess the patient's emotional, cognitive, and behavioral functioning and therefore come up with various differential dragonesses. I have also learned to ensure that while assessing patients with mental health conditions, it is vital to listen to them actively and ask them questions they can answer at that time. Obtaining the correct diagnosis can play a role in ensuring effective treatment, leading to better patient outcomes and recovery. I have also learned that paranoid schizophrenia can be inherited. There is a need for carrying out various diagnostic tests such as MRI, CT scan, and blood tests. The most effective ethical principle for the case is non-maleficence. It means doing no harm ( Bipeta, 2019) . There is a need to always treat patients with respect and compassion.

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7 Case Formulation and Treatment Plan: The treatment plan for the patient includes; psychotherapy and medications. The treatment of choice for the patient is antipsychotics. The antipsychotic to be administered is olanzapine. It works by blocking various receptors for several neurotransmitters, including dopamine and serotonin. It is mainly used to treat adults and children older than 13 years. The most common side effects of olanzapine include; weight gain, postural hypertension, flatulence, and sleepiness. The medications can play a role in relieving the patient's symptoms and therefore treating all three conditions. The type of psychotherapy that is essential for the patient is cognitive behavioral therapy. The therapy plays a role in enabling the patient to deal with the various symptoms and improve thoughts and emotions. It is vital to ensure that the patient attends the sessions for at least one month. It involves coping skills training, behavioral experiments, cognitive restricting, and self-monitoring. Educating the patient on the importance of medication adherence, quitting smoking, and staying physically active is essential. The patient will attend a follow-up visit after one month.

8 References Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian Journal of Psychological Medicine , 41 (2), 108. https://doi.org/10.4103/ijpsym.ijpsym_59_19 García-Cabeza, I., Díaz-Caneja, C. M., Ovejero, M., & de Portugal, E. (2018). Adherence, insight and disability in paranoid schizophrenia. Psychiatry Research , 270 , 274–280. https://doi.org/10.1016/j.psychres.2018.09.021 Hany, M., Rehman, B., Azhar, Y., & Chapman, J. (2022). Schizophrenia . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539864/#:~:text=Schizophrenia %20-%20StatPearls%20-%20NCBI%20Bookshelf.%20Derived%20from%C2%A0the Revadigar, N., & Gupta, V. (2020). Substance Induced Mood Disorders . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK555887/

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