Case Study For Patient Complaining Of Hallucinations And Delirium

Case Study For Patient Complaining Of Hallucinations And Delirium

Subjective Data

chief complaint: hallucinations and delirium

History Of Presenting Illness: The patient is a 65-year-old female presenting with hallucinations and delirium. The onset of symptoms was sudden and acute, occurring over the past 72 hours. The patient’s family reports that she began experiencing vivid and distressing hallucinations, primarily visual in nature. She describes seeing people and objects that are not present, often expressing fear and confusion in response to these perceptual disturbances. Additionally, the patient has been exhibiting signs of delirium, marked by fluctuating levels of consciousness, disorientation to time and place, and incoherent speech. The family notes that the patient’s attention span is severely compromised, and she has difficulty maintaining focus on a conversation or a task. They also report periods of heightened agitation, during which the patient becomes restless and attempts to interact with the hallucinated figures. There is no history of substance use or recent medication changes that could account for the sudden onset of these symptoms. The patient denies any previous history of hallucinations or delirium episodes. There is no reported history of psychiatric illness, and the family emphasizes that the patient has been relatively independent in her activities of daily living before the sudden onset of these symptoms. Case Study For Patient Complaining Of Hallucinations And Delirium

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Substance Current Use: The patient denies any current substance use, including alcohol, illicit drugs, or misuse of prescription medications.

past Medical History: the patient has a documented medical history of hypertension. She has been prescribed amlodipine 5 mg daily as part of her treatment plan for hypertension. Regular monitoring of blood pressure and adjustments to her antihypertensive medication have been carried out to maintain optimal blood pressure control. Routine healthcare maintenance, including screenings and vaccinations, has been pursued as recommended by her healthcare providers.

Current Medications: Amlodipine 5 mg daily for hypertension.

Allergies: the patient has no known, food, drugs, and environmental allergies.

Social History: The patient is currently divorced and lives independently. In assessing her living situation, it was found that she resides in her own apartment, managing activities of daily living without immediate familial support. The patient is retired from her previous occupation as an administrative assistant. The patient’s social network is limited, consisting mainly of a few close friends and sporadic community connections. The patient is engaged in a few recreational activities, including reading and attending local community events. These activities serve as her outlets for relaxation, enjoyment, and socialization. She leads a sedentary lifestyle and denies the use of alcohol and cigarette smoking.

Family History: The patient’s family history reveals a notable occurrence of psychiatric disorders, including schizophrenia. One maternal uncle was diagnosed with schizophrenia in his early adulthood. Aside from psychiatric disorders, the patient reports a family history free from significant medical conditions or chronic illnesses. This absence of major medical issues in the family helps focus attention on the mental health aspects and potential genetic factors related to schizophrenia.

Reproductive History: The patient reports a regular menstrual cycle with an average cycle length of 28 days. Menarche occurred at the age of 12. The patient has a history of two pregnancies and deliveries. She gave birth to her first child, a daughter, at the age of 25, and her second child, a son, at the age of 29. Both deliveries were uncomplicated, taking place vaginally at term with no reported complications for the mother or infants. After the birth of her second child, the patient opted for tubal ligation as a permanent form of contraception. She underwent the procedure at the age of 30. Since then, she has not used any hormonal contraceptives or other family planning methods. The patient is currently in the postmenopausal stage. Menopause occurred at the age of 51, marked by the absence of menstrual periods for the past five years. She reports typical symptoms of menopause, including hot flashes and mild mood changes, which she manages without hormone replacement therapy. The patient reports regular gynecological check-ups, including Pap smears and breast examinations, with no reported abnormalities or concerns. She has not undergone any gynecological surgeries or procedures apart from tubal ligation. Case Study For Patient Complaining Of Hallucinations And Delirium

Review of Systems

General: reports fatigue and increased restlessness.

HEENT: she denies headaches, visual disturbances, or hearing abnormalities.

Skin: she denies rashes or significant changes in skin condition.

Cardiovascular: she complains of occasional palpitations but denies chest pain or shortness of breath.

Respiratory: she denies respiratory symptoms such as cough or wheezing.

Gastrointestinal: she denies significant changes in appetite or weight, abdominal pain, nausea, vomiting, and reflux.

Genitourinary: she denies urinary frequency, urgency, or changes in bowel habits.

Neurological: she has symptoms of increased confusion and disorientation. however, she denies numbness and tingling sensations.

Musculoskeletal: she denies joint pain or stiffness reported.

Hematologic: she denies a history of bleeding disorders or anemia.

Lymphatics: she has no swollen glands or lymphadenopathy reported.

Endocrinologic: she denies polyuria, polydipsia, or temperature intolerance.

Objective Data

General appearance: The patient appears disheveled and agitated. She is observed pacing around the room and intermittently attempting to interact with hallucinated figures. There are signs of restlessness and heightened motor activity. The patient’s grooming is suboptimal, and her clothes appear unkempt. Case Study For Patient Complaining Of Hallucinations And Delirium

Vitals Signs

Blood Pressure: 140/90 mmHg

Heart Rate: 110 beats per minute

Respiratory Rate: 20 breaths per minute

Temperature: 98.9°F (oral)

Respiratory System: The patient’s respiratory rate is within the normal range, and no abnormal breath sounds or respiratory distress are noted upon auscultation. Oxygen saturation is 98% on room air.

Cardiovascular System: Heart Sounds are Regular rhythm without murmurs, gallops, or rubs. the peripheral Pulses are palpable and equal bilaterally. The jugular Venous Pressure is not elevated.

Neurological Evaluation: The patient’s level of consciousness fluctuates, demonstrating periods of alertness and increased agitation, followed by moments of drowsiness. Pupils are equal and reactive to light. there is no facial asymmetry or weakness is observed. There are no focal motor deficits noted and the Strength is intact bilaterally. There are no sensory abnormalities reported.

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Diagnostic Tests:  Complete Blood Count (CBC) for an assessment of white blood cell count, hemoglobin, and platelet count. Comprehensive Metabolic Panel (CMP) for electrolyte levels, liver function, and renal function. Urine Toxicology Screen to rule out the presence of substances that may contribute to the observed symptoms. CT Scan or MRI to assess for structural abnormalities, signs of acute neurological conditions, or any lesions that may be contributing to the sudden onset of hallucinations and delirium.

Assessment

Mental Status Examination

The patient appears disheveled and restless, exhibiting signs of heightened agitation. She engages in sporadic attempts to interact with hallucinated figures, suggesting a notable behavioral disturbance. Her restlessness is consistent with the reported delirium symptoms. The patient’s mood is characterized by fear and confusion, as reported by both the patient and her family. Her affect appears labile, displaying emotional fluctuations corresponding to the distressing nature of the hallucinations. The thought process is marked by incoherence, with the patient expressing disorganized and tangential speech. Her ability to convey thoughts logically and sequentially is compromised, consistent with the reported signs of delirium. The patient describes vivid and distressing hallucinations, primarily visual in nature. She reports seeing people and objects that are not present, indicating a departure from reality. These hallucinated figures evoke fear and confusion, contributing to the patient’s distress. The presence of vivid and distressing hallucinations, primarily visual, suggests a significant disturbance in perception. The patient’s cognitive functioning is severely impaired, marked by fluctuating levels of consciousness and disorientation to time and place. The compromised attention span is evident, as reported by the family, with difficulty maintaining focus on a conversation or a task. Insight into the severity of symptoms appears limited, as the patient engages with the hallucinations and expresses fear and confusion without recognizing their hallucinatory nature. Judgment appears impaired, as evidenced by the restlessness and attempts to interact with the perceived figures. Case Study For Patient Complaining Of Hallucinations And Delirium

Differential Diagnoses

Schizophrenia is a severe mental health disorder characterized by a range of symptoms affecting thinking, emotions, and behaviors. The patient experiences hallucinations, primarily visual in nature, perceiving people and objects that are not present. This aligns with the criterion of “delusions, hallucinations, or disorganized speech” as one of the characteristic symptoms of schizophrenia (Kahn, 2020). The patient’s family reports a decline in occupational functioning and increased social withdrawal. This aligns with the criterion of “social/occupational dysfunction” as a consequence of the symptoms.

Brief Psychotic Disorder is characterized by the sudden onset of psychotic symptoms (such as hallucinations, delusions, or disorganized speech) lasting between one day and one month. While the patient’s symptoms share similarities with schizophrenia, the time frame for Brief Psychotic Disorder is more circumscribed, and there is an expectation of a full return to premorbid functioning after the episode (Fusar-Poli et al., 2022). the diagnostic criteria include the Presence of one or more of the following symptoms: delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior. Duration of an episode is at least one day but less than one month, with eventual full return to premorbid functioning. The disturbance is not better explained by another mental disorder, a medical condition, or the effects of a substance.

Delirium is a state of acute confusion and altered consciousness. Medical conditions, such as infections, metabolic imbalances, or neurological disorders, can lead to delirium. In this case, urgent laboratory tests have been ordered to rule out potential medical causes for the acute onset of symptoms. The fluctuating level of consciousness, disorientation, and incoherent speech observed in the patient may align with the criteria for delirium. the diagnostic criteria include a disturbance in attention characterized by a reduced ability to direct, focus, sustain, and shift attention and awareness (Wilson et al., 2020)Case Study For Patient Complaining Of Hallucinations And Delirium . The disturbance develops over a short period (usually hours to a few days) and tends to fluctuate during the course of the day. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin.

Treatment Plan

1. Prescribe an antipsychotic medication to address positive symptoms (hallucinations, delusions) and stabilize mood. Atypical antipsychotics such as risperidone, olanzapine, or aripiprazole (Kahn, 2020). Monitor for side effects and adjust medications as needed.
2. Provide psychoeducation about schizophrenia, including the nature of the illness, expected course, and the role of medications. Offer information on potential side effects and coping strategies.
3. Engage the patient in individual psychotherapy, such as cognitive-behavioral therapy for psychosis (CBTp) or supportive therapy to enhance coping skills, and promote insight into the illness.
4. Schedule regular follow-up appointments to assess treatment response, medication adherence, and potential side effects. Adjust the treatment plan based on ongoing clinical assessments and the patient’s evolving needs.

Reflection Note

As the treating healthcare provider, it is crucial to reflect on the complexity of this case and the challenges it presents. The acute onset of hallucinations and delirium in a 65-year-old patient necessitates a multidisciplinary approach, combining psychiatric and medical interventions. The urgency of the situation requires careful consideration of both pharmacological and non-pharmacological interventions. The immediate goal is stabilization through the initiation of antipsychotic medication and addressing acute symptoms with benzodiazepines. Simultaneously, an urgent medical evaluation is underway to rule out potential medical causes contributing to the symptoms.

 References

Fusar-Poli, P., De Pablo, G. S., Rajkumar, R. P., López-Díaz, Á., Malhotra, S., Heckers, S., … & Pillmann, F. (2022). Diagnosis, prognosis, and treatment of brief psychotic episodes: a review and research agenda. The Lancet Psychiatry, 9(1), 72-83. https://doi.org/10.1016/S2215-0366(21)00121-8

Kahn, R. S. (2020). On the origins of schizophrenia. American Journal of Psychiatry, 177(4), 291-297. https://doi.org/10.1176/appi.ajp.2020.20020147

Wilson, J. E., Mart, M. F., Cunningham, C., Shehabi, Y., Girard, T. D., MacLullich, A. M., … & Ely, E. W. (2020). Delirium. Nature Reviews Disease Primers, 6(1), 90. https://doi.org/10.1038/s41572-020-00223-4

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template AND the Rubric as your guide.  It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required.  After reviewing full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS

Read rating descriptions to see the grading standards! 

In the Objective section, provide:

• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.

Read rating descriptions to see the grading standards!

In the Assessment section, provide:

• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

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Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis.  Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

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

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

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

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

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

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

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

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

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression.  You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression.  You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Case Formulation and Treatment Plan

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.  *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

 

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

 

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

 

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

 

Client has emergency numbers:  Emergency Services 911, the  Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

 

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

 

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

 

Follow up with PCP as needed and/or for:

 

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

 

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

 

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

 

 

Case Study For Patient Complaining Of Hallucinations And Delirium