Psychosis

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍hallucinationsdelusions

Specific symptoms: ‍auditory hallucinationsvisual hallucinations



Associated symptoms: *Try using right-click for negatives*

‍auditory hallucinations

‍visual hallucinations

‍delusion of persecution

‍delusion of grandeur

‍disorganized speech

‍disorganized behavior

‍catatonic behavior

‍affective flattening

‍avolition

‍depression

‍suicidal ideation

‍homicidal ideation

‍anxiety

‍social withdrawal

‍agitation

‍irritability

‍sleep disturbances



Recent stressors: ‍

Impact on daily activities is ‍minimal



Contributing factors:

‍medication noncompliance

no history of: ‍schizophrenia, ‍schizoaffective disorder, ‍bipolar disorder, ‍major depression with psychotic features

no use of: ‍oral steroids ‍new medication

no family history of: ‍schizophrenia, ‍bipolar disorder, ‍depression



Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍nonecannabis, ‍IVDU



Occupation: ‍ ‍lowhigh risk of injury for self or others

Living situation: ‍alonewith familywith friendshomelessinstitutionalized

Support system: ‍strongmoderateweaknone





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Neurologic:

- Mental status: ‍alert, oriented to ‍3 spheres, speech ‍intact

- Cranial nerves: ‍all intact

- Strength: ‍intact 5/5 throughout except for ‍4/5 on ‍rightleft ‍, ‍pronator drift

- Sensation: ‍intact throughoutdecreasedabsent to ‍light touch on ‍

- Reflexes: ‍intact 2+ throughout except for ‍1+ on ‍rightleft ‍, ‍plantar downward

- Cerebellar function: ‍intact, ‍normalimpaired finger-nose, ‍normalimpaired rapid alternating movements, ‍normalimpaired heel-shin, Romberg ‍negative, Dix-Hallpike ‍negative

- Gait: ‍steadyunsteady, ‍intactimpaired tandem gait, ‍intactimpaired heel walk and toe walk

Mental Status:

Appearance: ‍well-dressed, ‍well-groomed, ‍goodpoor eye contact, appears ‍age-appropriate

Behavior: ‍cooperativenon-cooperative

Psychomotor activity: ‍normalretardedagitated

Speech: ‍clear, ‍slowrapid, ‍monotonoustalkative

Mood: ‍euthymicdysthymic, ‍anxious, ‍

Affect: ‍euthymic, ‍reactivenon-reactive, ‍full range, ‍appropriate to situation, ‍congruent with mood

Thought process: ‍organizeddisorganized, ‍coherentincoherent, ‍logicalillogical, ‍

Thought content: ‍normalpreoccupationshopelessness, ‍delusions, ‍suicidal ideations, ‍homicidal ideations

Perception: ‍normal, ‍hallucinations, ‍illusions

Cognition: ‍alert, oriented to ‍3 spheres, disoriented to ‍, attention ‍intactdistractible, memory ‍intactimpaired

Judgment: ‍goodmoderatepoor

Insight: ‍goodmoderatepoor into condition

Reliability: ‍goodmoderatepoor





ASSESSMENT:

‍Psychotic Disorder ‍likelysuspectedpossible

DDx: schizophrenia, schizoaffective disorder, delusional disorder, brief psychotic disorder, bipolar disorder with psychotic features, major depressive disorder with psychotic features, substance-induced psychotic disorder, psychotic disorder due to another medical condition, paranoid personality disorder, schizophreniform disorder, shared psychotic disorder, psychotic disorder not otherwise specified, neurocognitive disorders, temporal lobe epilepsy, infectious diseases (e.g., HIV, syphilis), autoimmune disorders (e.g., lupus), endocrine disorders (e.g., thyroid disease), nutritional deficiencies (e.g., vitamin B12 deficiency), traumatic brain injury, seizure disorders, malignancy, delirium





PLAN:

Investigations:

- Blood work: ‍CBC, ‍TSH, ‍electrolytes, ‍glucose, ‍B12, ‍folate, ‍LFTs, ‍creatinine, ‍calcium, ‍HIV test, ‍syphilis test

- Urine drug screen

- Urinalysis

- CT scan of the head

Treatments:

- Psychoeducation about psychosis

- ‍Antipsychotics

- ‍Mood stabilizers

- ‍Antidepressants if depressive symptoms are present

- ‍Benzodiazepines for acute agitation or severe anxiety

- Supportive therapy

- Cognitive behavioral therapy

Further care:

- Psychiatric hold

- Admit to psychiatry unit

- Referral to psychiatrist

- Referral to psychologist

- Referral to social worker

- Follow-up in ‍ ‍weeksmonths

- Return if symptoms worsen or if new symptoms develop such as confusion, memory loss, or changes in behavior or mood