Mental Status Examination Discussion Paper

Schizophrenia is a persistent mental condition characterized by psychosis, which includes delusions and auditory hallucinations, as well as other signs and symptoms. Anomalies in neurotransmitters, the anatomy of the brain, as well as the immune response, are all involved in schizophrenia’s pathophysiology. Although the exact etiology of schizophrenia is unclear, numerous risk factors are recognized, including substance usage, genes, and certain perinatal circumstances. It is reported that schizophrenia affects one percent of the world’s population. It often manifests itself between the ages of late adolescence and mid-thirties, and it affects both females and males alike Mental Status Examination Discussion Paper

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Patient Information

Initials: S.T.

Age: 49 years

Sex: Male

Race: Caucasian

 

SUBJECTIVE DATA

Cc: “I’ve been thinking of killing myself and I keep hearing voices.”

HPI: ST is a 49-year-old Caucasian male who was presented to the medical hospital by the police. His brother had stated to the police that the patient had informed him that he was planning to fall out of the balcony and injure himself. He claims that he has been hearing voices that instruct him that he is a waste of space and that he should take his own life. The patient has been suffering from schizophrenia for the last 21 years and is now on FD-12 due to suicidal thoughts. He categorically denies experiencing feelings of hopelessness, fatigue, reduced appetite, decreased energy, a depressed mood, or any other indication. In the present, he reports no delusions, auditory or visual hallucinations, or homicidal thoughts. He admits that he has not been adhering to his prescribed drug regimen; however, he claims that he took his medicines last night.

Past Psychiatric History: He was diagnosed with schizophrenia at the age of 28 and started treatment the following year, which was 21 years ago. He has a record of many past psychiatric admissions, the most recent of which was five months ago.

Substance Use History: Reports occasional drinking. Denies smoking, usage of illegal substances, or caffeine consumption.

Family Psychiatric/Substance Use History: He claims that there is no history of mental issues in his family, no history of suicides or attempted suicides and no history of drug abuse.

Psychosocial History: ST was born in Florida and raised by his mother as a single parent in a household. He is the second child in a family of three children, including an elder sister and a younger brother. He is presently living on his own in New York. He is a divorced man with no children. He said that he has a bachelor’s degree in Philosophy as his greatest level of educational attainment. His hobbies include playing guitar and dancing. He quit his job as an editor at the company where he had been working for 6 years two months ago. He has no present or previous legal issues and has never been the victim of assault or trauma Mental Status Examination Discussion Paper

Medical History: Reports that he has high blood pressure and is on treatment. Denies any other health issues.

Current Medications:

Zyprexa 10 mg twice a day orally

Lisinopril 20 mg once daily

Haloperidol 5 mg twice daily

Allergies: Denies any food or drugs allergies

Reproductive Hx: Heterosexual. Denies currently being sexually active. The last sexual encounter was one year ago.

ROS

  • GENERAL: He denies recent weight change, fever, loss of appetite, fatigue, or heat/cold intolerance.
  • HEENT: Head: denies head injury, dizziness, or headache. Eye: denies blurry vision or vision loss. Ear: denies ear pain, loss of hearing, or ringing in the ears. Nose: denies rhinitis, epistaxis, nasal blockage, or loss of the sense of smell. Throat: denies sore throat or hoarse voice.
  • SKIN: denies changes in skin color, rashes, or itchiness.
  • CARDIOVASCULAR: denies shortness of breath, chest pain or discomfort, palpitations, or edema.
  • RESPIRATORY: denies labored breathing, wheezing, cough, or production of phlegm or sputum.
  • GASTROINTESTINAL: denies nausea, vomiting, anorexia, abdominal pain, or diarrhea.
  • GENITOURINARY: denies urinary frequency, incontinence, hematuria, or burning sensation on urination.
  • NEUROLOGICAL: denies dizziness, paralysis, seizures, ataxia, tingling, or numbness.
  • MUSCULOSKELETAL: denies muscle pain, back pain, joint pain or stiffness.
  • HEMATOLOGIC: denies anemia, easy bruising, or bleeding.
  • LYMPHATICS: denies history of splenectomy or swelling of lymph nodes
  • ENDOCRINOLOGIC: denies frequent urination, excessive sweating, or heat or cold intolerance.

OBJECTIVE DATA

 

Vital Signs: B.P.- 112/83 HR- 79, R.R.- 19, Temp- 98.1, SpO2- 98%, Ht.- 5’7” inches, Wt.- 165 lbs.

Physical Examination

General Appearance: Mildly distressed male but appears stable. Well-groomed, and dressed appropriately.

HEENT: Head: normocephalic, atraumatic, no swelling or scars, normal hair distribution, no tenderness on palpation. Eye: PERRLA, normal visual acuity. White sclera, pink and moist conjunctiva, no discharge, regular extraocular movements. Ear: grey tympanic membranes, no bulging or discharge. Nose: patent nasal turbinates, septum in the midline, no nasal discharge. Throat: intact and moist oral mucosa membranes, tonsils not palpable, uvula in the midline.

Neck: Supple, no edema or scars. Full range of movement noted. No tenderness noted, trachea in the midline, and no masses.

Skin: the skin color is in line with his ethnicity. Intact skin without rash or scars. Warm and dry skin, normal skin turgor.

Cardiovascular: Regular heart rate and rhythm. S1, S2 clear to auscultation, no murmurs, rubs, or gallops. No chest deformity noted, no jugular vein distension, no lesions, or edema. Peripheral pulses palpable, normal rhythm, rate. Capillary refill less than 2 seconds.

Gastrointestinal: Flat abdomen, no lesions or scars. Bowel sounds are normal and audible in all 4 quadrants. Tympany noted in the abdomen, no tenderness or organomegaly.

Respiratory: Normal breath sounds. The chest moves with breathing, no chest deformity, or lesions. No tenderness noted on palpation. Tactile fremitus present and equal bilaterally. Resonant chest.

Neurological: alert and oriented x3. He is cooperative. He has normal muscular strength and tone in all of his muscle groups. Intact cranial nerves and sensations. His short-term and long-term memory is both fully intact. Normal speech.

Genitourinary: Normal distribution of pubic hair. No tenderness in the groin and suprapubic region, no lesions or masses.

Musculoskeletal: no deformities noted, no joint swelling. Steady gait, erect posture. No muscle or joint tenderness. Full range of motion in upper and lower extremities.

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Diagnostics:

CBC

Comprehensive Metabolic Panel

Vitamin D

Vitamin B12

HbA1c

Fasting lipids

Rapid pulse radiography

ASSESSMENT

Mental Status Examination

ST is a 49-year-old Caucasian male who seems to be the same age as his reported age. He is well-dressed and groomed, and his nutritional state is good. He is cooperative. Has a calm posture, and maintains eye contact. His speech is clear and coherent, and its tempo, volume, and rhythm are all within normal ranges. He has a depressed mood. His affect is mood-congruent. He has a history of suicidal thoughts, including a suicide scheme, as well as auditory hallucinations. Denies having delusions or being paranoid about anything. His thought process is unambiguous, rational, and intact. His intellectual functioning is average. He denies homicidal ideation. He has intact insight, and he is alert and follows orders. He is oriented to place, person and time. Immediate, recent, and remote memory is intact. Judgment is grossly intact.

Primary Diagnosis: Mental Status Examination Discussion Paper

F20.9 Schizophrenia: Schizophrenia is a severe mental condition in which one perceives reality in an incorrect manner, causing significant interference with the everyday functional ability of the ailing person (Alanen et al., 2018). Individuals suffering from schizophrenia believe that their experiences are real. Auditory and visual hallucinations, gloomy mood, paranoia, delusions, lethargy, disordered communication, and a bland affect are some of the symptoms of this condition. ST was presented to the clinic by the authorities after informing his brother of his suicide plot, and he has been suffering from schizophrenia for the past 21 years. He has also failed to take his prescription drugs on a consistent basis as instructed.

Differential Diagnoses:

F25.9 Schizoaffective disorder: Schizoaffective disorder is a psychiatric illness characterized by a mix of symptoms of schizophrenia and a mood disorder, like depression or bipolar disorder (Miller & Black, 2019). There may be several symptoms that appear at the same time or on separate occasions. Periods of recovery are frequently followed by cycles of serious symptoms. Some of the symptoms may comprise hallucinations, delusions, depressive bouts, and manic times of excessive energy. According to American Psychiatric Association (2013), in order to be diagnosed with schizoaffective disorder, a person must exhibit the following symptoms: uninterrupted episodes of sickness; a manic episode, a significant depressive episode, or a combination of both; schizophrenia signs and symptoms; and at least two bouts of psychotic symptoms, typically lasting two weeks. One of the bouts must occur without any signs of depression or manic behavior.

F23 Brief psychotic disorder: Brief psychotic disorder is a serious psychiatric condition characterized by a sudden commencement of psychotic characteristics that lasts less than a month, accompanied by a full recovery with the possibility of future exacerbations (Lieberman, 2018). Disorientation, eating habits alterations, hallucinations, delusions, decreased concentration, catatonic mannerisms, mood disturbances, and disordered speech are the symptoms of this condition.

F31.9 Bipolar disorder: Bipolar disorder, formerly referred to as manic depression, is a psychiatric condition that causes severe mood fluctuations ranging from increased vigor and functional abilities to mania and depression (Carvalho et al., 2020). Manic episodes are characterized by symptoms such as excessive energy, a decreased need for sleep, and a lack of contact with one’s surroundings. Reduced energy, decreased morale, and a general lack of interest in everyday tasks are all common signs of depressive episodes. Depression episodes may last anywhere from a few days to many months at a time, and they can be connected with suicidal thoughts. Mental Status Examination Discussion Paper

PLAN

Management

In order to effectively treat schizophrenia, it is necessary to combine psychological, psychosocial, and medicinal interventions (Keepers et al., 2020). To begin, ST must first be admitted to the 5S voluntary unit, from which he will undergo basic admission tests, which will include thyroid-stimulating hormone (TSH), complete blood count (CBC), comprehensive metabolic panel (CMP), rapid pulse radiography (RPR), fasting lipids, HbA1c, vitamin B12, and Vitamin D. An EKG will also be required to assess the patient’s cardiovascular health on a baseline basis (Polcwiartek et al., 2019). In managing the patient’s condition, the following steps will be taken:

  • Prescribe Clozapine 25 mg per qhs orally, with the intention of gradually increasing to the prior dose.
  • Prescribe a combination of Benztropine 1 mg PO Q6H PRN+ Lorazepam 2 mg PO Q6H PRN+ Haldol 5 mg PO Q6H PRN
  • Recommend milieu treatment, group therapy, individual therapy, and physical therapy.  Mental Status Examination Discussion Paper

Patient Education

  • Educate about the dangers, benefits, and alternatives to Clozapine prior to taking the medication.
  • Explain how Clozapine may induce a hazardous blood disorder known as agranulocytosis, and why regular lab testing is required prior to and throughout therapy with Clozapine.
  • Provide guidance on notifying a healthcare professional if he has flu-like symptoms such as a high fever and sore throat, shivers, a racing or irregular pulse, or any other symptoms of infection.
  • Educate on the necessity of adhering to drug regimens and participating in support group activities.

Health Promotion and Disease Prevention

  • Instruct on medication therapy monitoring
  • Inform on the need to quit substance abuse
  • Inform on avoiding situations that trigger symptoms

Referral

  • ST will be referred for psychotherapy

Follow-up

After four weeks, the patient will be seen again for a reassessment and treatment review.

Conclusion

In a nutshell, ST is a patient who has been diagnosed with schizophrenia for the last 21 years, but who has failed to comply with drug treatment. He presented to the facility with complaints of suicidal ideation and auditory hallucinations. The patient had a long history of hospitalizations, and during a mental evaluation, a depressed mood was observed, leading to a diagnosis of schizophrenia being made for the patient. As a result, it was determined that ST should begin psychotherapy as well as the medications Clozapine, Benztropine, Lorazepam, and Haldo. He was also instructed to return to the hospital four weeks later for a follow-up assessment Mental Status Examination Discussion Paper.

References

Alanen, Y. O., Fleck, S., Jackson, M., & Leinonen, S. L. (2018). Schizophrenia: Its origins and need-adapted treatment. Routledge. https://www.taylorfrancis.com/books/mono/10.4324/9780429479731/schizophrenia-yrj%C3%B6-alanen-stephen-fleck-murray-jackson-sirkka-liisa-leinonen

American Psychiatric Association, D. S., & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (Vol. 5). Washington, DC: American psychiatric association. https://www.amberton.edu/media/Syllabi/Spring%202022/Graduate/CSL6798_E1.pdf

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66. https://doi.org/10.1056/nejmra1906193

Keepers, G. A., Fochtmann, L. J., Anzia, J. M., Benjamin, S., Lyness, J. M., Mojtabai, R., Servis, M., Walaszek, A., Buckley, P., Lenzenweger, M. F., Young, A. S., Degenhardt, A., & Hong, S. (2020). The American psychiatric association practice guideline for the treatment of patients with schizophrenia. American Journal of Psychiatry, 177(9), 868-872. https://doi.org/10.1176/appi.ajp.2020.177901

Lieberman, J. A., & First, M. B. (2018). Psychotic disorders. New England Journal of Medicine, 379(3), 270-280. https://doi.org/10.1056/nejmra1801490

Miller, J. N., & Black, D. W. (2019). Schizoaffective disorder: A review. Annals of clinical psychiatry: official journal of the American Academy of Clinical Psychiatrists, 31(1), 47-53. https://europepmc.org/article/med/30699217

Polcwiartek, C., Kragholm, K., Hansen, S. M., Atwater, B. D., Friedman, D. J., Barcella, C. A., Graff, C., Nielsen, J. B., Pietersen, A., Nielsen, J., Søgaard, P., Torp-Pedersen, C., & Jensen, S. E. (2019). Electrocardiogram characteristics and their association with psychotropic drugs among patients with schizophrenia. Schizophrenia Bulletin. https://doi.org/10.1093/schbul/sbz064 Mental Status Examination Discussion Paper