WK# 3 Schizophrenia

9.24 MWS

NR 546 Week 3 Case Study

Subjective Objective

Patient’s Chief Complaints:

“They are out to get me”

History of Present Illness

T.M. is a 20-year-old African American male

brought into the clinic by his parents due to

increasingly erratic behavior, social withdrawal,

and impaired occupational functioning. He

believes he is being followed and that "the CIA

is out to get me" T.M. hears two voices that tell

him he is being watched and that people want to

lock him up. These auditory hallucinations have

been occurring for the past 8 months and have

become more frequent. T.M. displays

disorganized thoughts, paranoid ideation, and

auditory hallucinations. His family is concerned

about his well-being and has sought

professional help due to his decline in

functioning.

Past psychiatric history: None

Past Medical History: Occasional

headaches, treated with OTC pain

relievers.

Family History

• Father is alive, has diabetes

• Mother is alive, has history of

hypertension

Physical Examination: General

Alert, appropriately dressed African American male in no

apparent distress. He appears older than his stated age.

Vital Signs: BP-128/84, T-98.8F, P-84, RR-20, SpO2: 98%

Wt 220 lbs, Ht 5’10”

9.24 MWS

• Two older sister- both healthy

• Mother reports her brother has

schizophrenia

Social History

• Lives with parents

• Does not have many friends

• unemployed, has not been able to keep

a job due to worsening paranoia

• High school graduate

• Smokes 1 pack a day

• Drinks socially, 1-2 times a week,

mostly beer

• Several gasses of coke or sweet tea

during the day

• Smoke marijuana daily, 3-4 times a day

• no formal exercise

• no hobbies

Review of Systems

• Occasional headaches relieved with

acetaminophen

• Appetite good, weight stable

• Sleeps 4-5 hours at night

Allergies: NKDA

Mental status exam:

•Cranial nerves II-VIII intact

•Gait steady

•Denies headache and dizziness

Appearance: Disheveled appropriate dress for age and

situation, well nourished, eye contact poor, No apparent

distress

Alertness and Orientation: Fully oriented to person‚ place‚

time‚ and situation, Alert

Behavior: Cooperative

Speech: Soft, flat

Mood: Euthymic

Affect: Constricted, congruent

Thought Process: Tangential, loose associations

Thought content: Paranoid with delusions that he is being

followed by the CIA. No thoughts of suicide‚ self-harm‚ or

passive death wish, denies thoughts of wanting to harm

others.

Perceptions: No response to internal stimuli noted during

interview, however, seen talking to himself while being

observed from a distance, reports auditory hallucinations.

Memory: Recent and remote WNL

Judgement/Insight: Insight is poor, Judgement is poor

Attention and observed intellectual functioning: Attention

intact for purpose of assessment.

Fund of knowledge: Good general fund of knowledge and

vocabulary

Musculoskeletal: Normal gait and station

Diagnosis: F20.9 Schizophrenia, unspecified

Psychopharmacology Questions: see the discussion guidelines rubric