The Evaluation Of Psychosis With Paranoid Delusions Discussion

The Evaluation Of Psychosis With Paranoid Delusions Discussion

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Name: KW

Gender: Female

Chronological Age: 30

PEC for the evaluation of psychosis with paranoid delusions.

Chief complaint: “My baby daddy lied on me trying to make me look crazy because he does not want to pay child support.” The Evaluation Of Psychosis With Paranoid Delusions Discussion

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HPI: KW is a 30-year-old single mother of six children, brought to the emergency room after repeated calls to the police complaining of her ex-boyfriend stalking her. The patient alleges her ex-boyfriend controls her car by remote and talks to her through her car keys. KW states that she hears her “ex” saying that “I am going to make you kill yourself .” KW also alleges that her ex-boyfriend has hacked her mother’s phone, reads her messages, and is aware of their conversations. She states that she has reported this to the police, but they don’t believe her. The patient’s UDS is positive for amphetamines, but she denies use, alleging that her “ex” must have given her something. The patient did endorse marijuana use since age 13 and stated her last use was one month ago when her sister died. KW denies that she is paranoid or delusional; however, according to staff reports, she called the police since arriving in the inpatient unit. The patient currently denies SI or HI with plan or intent, positive for auditory hallucinations and delusions. According to collateral information, the patient has a history of schizophrenia with medication noncompliance. The Evaluation Of Psychosis With Paranoid Delusions Discussion

Psychiatric history: Schizophrenia with noncompliance

Medical history: patient denies significant medical history

ROS: Normal

Diagnosis (APA, 2013)

Schizophrenia F20.9

Differential Diagnosis

Generalized Anxiety Disorder F41.1

Substance Use Disorder (Amphetamine induced- psychotic disorder) F15.159

Treatment plan

Admit to the acute inpatient unit for symptom stabilization/resolution

Suicide precautions (command hallucinations)

Labs: CBC, CMP, LFTs, TSH, HIV, RPR, U/A, Urine HCG, and EKG prior to initiation of medications The Evaluation Of Psychosis With Paranoid Delusions Discussion

Vital signs twice a day

Medications (Stahl, 2018)

Risperdal 1 mg p.o. twice a day, increase 1mg/day until desired effect(psychosis)

Cogentin 0.5mg p.o. twice a day (eps)

Buspar 10mg p.o. twice a day (anxiety and mood)

Vistaril 25mg p.o. at bedtime (anxiety and sleep)

Referrals

Refer for psychotherapy CBT

Refer to social services for discharge planning The Evaluation Of Psychosis With Paranoid Delusions Discussion

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References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). American Psychiatric Association Publishing.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry (Eleventh ed.). LWW.

Stahl, S. M. (2018). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (6th ed.). Cambridge University Press. The Evaluation Of Psychosis With Paranoid Delusions Discussion