Grand Rounds Discussion: Complex Case Study Presentation

Grand Rounds Discussion: Complex Case Study Presentation

Caroline E Sam

College of Nursing-PMHNP, Walden University

PRAC 6675: Grand Rounds Discussion Complex Case Study Presentation 07/27/2022

Subjective:

CHIEF COMPLAINT: ''Attempted suicide because the voices told me to do so."

HPI: C.P is a 55-year-old African-American male with a reported history of schizophrenia depression type that presents to the hospital for psychiatric assessment due to increased suicidal ideation and auditory hallucinations. The patient reports that one time he attempted suicide by cutting his wrist because he was hearing voices telling him to do so. C.P further reports that he has always struggled with medication compliance and in other cases, he has also had difficulty refilling his prescription due to lack of funding. He mentions being off his medications for 2 weeks. The patient further reports feeling lonely after his only sister left home for college and he was unable to take his medication refilled. He started experiencing visions and sounds that he could not understand (visual and auditory hallucinations). The patient reported experiencing poor sleep patterns. C.P further notes high levels of anxiety, depressed mood, anhedonia, low energy, and increased suicidal ideation. The patient also reports attempting to burn the family house after his sister abandoned him for college because he could not stand living there alone.

Past Psychiatric History:

· General Statement: The patient experienced his first symptoms of mental illness at the age of 26 years, was hospitalized on three occasions, and received treatment. Factors that contributed to his hospitalization include feelings of paranoia and impulsiveness regarding thoughts of harm to others and self.

· Caregivers (if applicable): None

· Hospitalizations: Hospitalized on three occasions.

· Medication trials: Depakote, Zyprexa, trazodone, Haldol, and Lithium.

· Psychotherapy or Previous Psychiatric Diagnosis: Schizophrenia

Substance Current Use and History: None

Family Psychiatric/Substance Use History: C. P's mother had psychiatric problems and his father had alcohol and substance use issues.

Psychosocial History: The patient has never been married and has no children. He was in special education all through his primary and secondary school. She lived with his sisters before she left for college.

Medical History: Hypertension

· Current Medications: Lisinopril

· Allergies: None

· Reproductive Hx: Not sexually active

ROS:

· GENERAL: The patient reports fatigue and weight loss, and denies weakness, chills, or fever.

· HEENT: Eyes: Denies yellow sclera, double vision, blurred vision, and visual loss. Ears, Nose, Throat: Denies sore throat, runny nose, congestion, sneezing, or hearing loss.

· SKIN: No itching or rash.

· CARDIOVASCULAR: No edema or palpitations. No chest discomfort, chest pressure, or chest pain.

· RESPIRATORY: No sputum, cough, or shortness of breath.

· GASTROINTESTINAL: No abdominal pain or blood. No diarrhea, vomiting, nausea, or anorexia.

· GENITOURINARY: No odd color, odor, hesitancy, urgency, or burning sensation on urination

· NEUROLOGICAL: No change of bladder or bowel control. No syncope, dizziness, headache, numbness, ataxia, paralysis, or tingling in the extremities.

· MUSCULOSKELETAL: No joint pain, back pain, or muscle pain/stiffness.

· HEMATOLOGIC: No bruising, bleeding, or anemia.

· LYMPHATICS: No splenectomy history. No enlarged nodes

· ENDOCRINOLOGIC: no report of polydipsia or polyuria. No reports of heat intolerance, cold, or sweating.

Objective:

Physical exam:

Vital Signs: Temperature 98.7, respiration 18, blood pressure 120/80lying down, Pulse 96 regular.

Generally, a well-developed, normal-weight African-American man

HEENT; Normal.

Neck: Normal, no masses, thyroid not palpable.

Nodes: no adenopathy.

Chest: Breast-no masses or discharges, non-tender. Lungs: No dullness. Diaphragm moves well with respiration. No wheezes, rubs, or rhonchi.

Heart; regular rhythm.

Spine: non tender, no costovertebral tenderness.

Abdomen: soft, flat, bowel sounds present, no bruits. Non tender to palpation.

Extremities: skin warm and smooth, no edema, no clubbing nor cyanosis

Neurological; Awake, alert, and fully oriented.

Diagnostic results: Routine lab exams were performed. Liver and kidney function, routine blood tests, computed tomography (CT) of the head, and electrocardiograph (ECG) were normal.

Assessment:

Mental Status Examination: C.P is a 55-year-old African-American male with a reported history of schizophrenia depression type that presents to the hospital for psychiatric assessment due to increased suicidal ideation and auditory hallucinations. The patient's appearance is unkempt. The attitude is cooperative. His gait is steady and appropriate for his age. His mood is depressed and his affect is constricted. The speech is normal in rate, volume, and tone. The patient's language is intact. His thought processes are disorganized. His thought content is paranoia. The patient reports suicidal and homicidal ideation with a plan. The patient reports auditory and visual hallucinations. He is alert and oriented to place, person, situation, and time. The patient's insight is fair and judgment is poor. The patient attention and concentration are poor. His fund of

knowledge is grossly intact. He is calm, cooperative, and has good eye contact. His short-term and long-term memory is intact.

Differential Diagnosis

DSM-5 295.70 (F25.1) Schizoaffective disorder, depressive type

According to Parker (2019), Schizoaffective disorder is characterized by the co­ occurrence of psychotic and mood disorders (mania or depression) as well as the persistence of psychotic features for at least a week after experiencing mood symptoms At least three of the following psychotic symptoms should be present: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (Wy & Saadabadi, 2019). The bipolar type includes episodes of mania and sometimes major depression while the depressive type only includes depressive episodes. According to Beckmann et al. (2020), the patient also has to present with delusions or hallucinations for a minimum of two weeks, major mood symptoms, and the impairment in daily functioning is not due to the effects of substance use or another underlying medical condition. Schizoaffective disorder with depression is the most probable diagnosis in this case because the patient presents with psychotic features such as hallucinations, delusions, and disorganization as well as mood symptoms such as depressed mood, anhedonia, and poor sleep. Psychotic symptoms are co-occurring with a depressed mood; hence, Schizoaffective disorder, depressed type is the most likely diagnosis.

DSM-V 295.90 (F20.9) Schizophrenia

According to Stepnicki et al. (2018), schizophrenia is characterized by a range of cognitive, behavioral, and emotional impairments. The key symptoms of schizophrenia include hallucinations, delusions, disorganized speech, catatonic behaviors, and negative emotions such as decreased motivation and diminished expressiveness. According to Mccutcheon et al., 2020),

patient also presents with cognitive deficits affecting their memory, speed of mental processing, and executive functions. Schizophrenia also impairs the patient's level of functioning in fundamental areas such as work, interpersonal relations, and self-care. While schizophrenia is a consideration in this case due to the patient's psychotic features, it will be disregarded because the patient also presents with key depressive symptoms such as anhedonia and poor sleep.

DSM 296.20 (F32.9) Major depressive disorder, single episode, unspecified.

According to Hasin et al. (2018), major depressive disorder (MDD) is diagnosed when a patient present with at least two weeks of persistent anhedonia, depressed mood, and hopelessness as well as feelings of guilt, increased disturbances in sleep and appetite, and suicide ideation or attempt. Mullen (2018) also notes that MDD is characterized by weight loss/gain, lack of energy, restlessness or slowness, and difficulty concentrating on indecisiveness. MDD is a consideration in this case because the patient presents with depressive symptoms such as low mood, anhedonia, and poor sleep patterns. However, it will be disregarded because these symptoms also co-occur with psychotic features that cannot be ignored.

Case Formulation and Treatment Plan:

The patient is not safe to leave the hospital. The patient is not on multiple antipsychotics. Non­ adherence is suspected to lead to exacerbation in symptoms. According to Schnitzer et al. (2020), antipsychotic treatment is the mainstay of pharmacotherapy for conditions included in the schizophrenia spectrum including both bipolar and depressive subtypes of schizoaffective disorder. Therefore, I will start the previously effective Zyprexa/Depakote and make dose adjustments as indicated. The plan is;

· Start Zyprexa 10 mg Qhs for psychosis

· Start Depakote 500 mg BID for mood

· Obtain Dep lvl on 3/29

If required, further adjustments will be made to the medications pending new lab results. The therapist will coordinate with the social worker to assess outpatient support follow-up along with gathering collateral information. The therapist will follow internal med recs regarding medical concerns. The risks and benefits of all the above medications/treatments are discussed with the patient and the patient voices understanding and agree to continue with the plan unless otherwise specified.

Reflection: This is a case of schizoaffective disorder with is a condition whereby the patient presents with symptoms of both schizophrenia and mood disorders. However, the symptoms are insufficient to meet the diagnostic criteria of either a mood disorder or schizophrenia. In the future, I would explore the mood and schizophrenia symptoms further to establish whether the patient meets the criteria of any of these conditions. Patient education should also emphasize medication adherence which is a major concern in psychosis. The issue of poor insight and the patient not being of sound mind also introduces ethical and legal issues that should be considered such as informed consent.

Questions

1. What are the key symptoms of schizoaffective disorder?

2. What is the mainstay of pharmacotherapy for schizoaffective disorder, depressive type?

3. What are some of the reasons that people with schizoaffective disorder are more at risk of medication non adherence?

References

Beckmann, D., Schnitzer, K., & Freudenreich, 0. (2020). Approach to the diagnosis of schizoaffective disorder. Psychiatric Annals, 50(5), 195-199. https://doi.org/10.3928/00485713-20200408-01

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA psychiatry, 75(4), 336-346. doi:10.1001/jamapsychiatry.2017.4602

McCutcheon, R. A., Marques, T. R., & Howes, 0. D. (2020). Schizophrenia-an

overview. JAMA Psychiatry, 77(2), 201-210. doi:10.1001/jamapsychiatry.2019.3360

Mullen, S. (2018). Major depressive disorder in children and adolescents. Mental Health Clinician, 8(6), 275-283. DOI: 10.9740/mhc.2018.11.275

Parker, G. (2019). How well does the DSM-5 capture schizoaffective disorder? The Canadian

Journal of Psychiatry, 64(9), 607-610. https:ljdoi.org/10.ll 77/0706743719856845

Schnitzer, K., Beckmann, D., & Freudenreich, 0. (2020). Schizoaffective disorder: treatment considerations. Psychiatric Annals, 50(5), 200-204. https://doi.org/10.3928/00485713-

20200409-01

St pnicki, P., Kondej, M., & Kaczor, A. A. (2018). Current concepts and treatments of schizophrenia. Molecules, 23(8), 2087. doi:10.3390/molecules23082087

Wy, T. J.P., & Saadabadi, A. (2019). Schizoaffective Disorder. StatPearls [Internet]