CASE STUDY
CC: I see stuffs, I hear things
HPI
The client is a 15 years old who presented for a psych evaluation, he stated he sees things and he hears stuff everyday that started October , 2022, he sees like shadow figures, and things like object moving, he hears whispers,
and random voices telling him to pick up stuffs but he doesn’t act on it. He denies using any illicit drugs, he reported that the hallucinations bother him , it affects his daily life, he mentioned that in September 2022 a friend gave him
edible one time without telling him so he thought it was food he ate it. he reported that his Uncle has HX of schizophrenia, he hears voices, he was in the Navy and his uncle drinks to make the voices go away. he stated that he doesn’t just want the schizophrenia diagnosis as that bothers him, he doesn’t want to have schizophrenia, he also mentioned that he doesn’t want his mother to know about the edible he tried one time. He stated his appetite is good, he reported that he has difficulty sleeping, he has insomnia, he sleeps sometimes, but he stated he takes melatonin and Benadryl sometimes. He stated his mood fluctuates a lot, he gets angry, agitated, anxiety and depression. He reported feeling hopeful, he reported that his energy level is moderate, he endorsed anhedonia, he endorsed lack of concentration/focusing, he stated he can’t focus because of the hallucinations. the client reported that he is currently taking Abilify 15 mg, he denies any side/adverse effects of the med, he stated the med is helping with the hallucination but not resolved completely, he also mentioned he was on sertraline but he topped it because of side effect of nausea.
The client’s mother was interviewed, she reported that her son was hearing voices, and experiencing mood spins
PsychHx
HX of psych inpatient hospitalization at Sheppard Pratt for 1 day -three months ago
HX of medication sertraline and Abilify-he stopped taking the sertraline due to nausea
he stated that the Abilify is helping with the voices
HX of therapy
PMHx
Asthma
PSHx
Comments: None
PsychFHx
Uncle has HX of Schizophrenia
parents has HX of depression
sister has HX of Bipolar
No Family HX of SUD
PsychSHx
he was Born in Baltimore
He has one brother and one sister
Upbringing- Parents raised him, it was interested, he added that he witnessed domestic violence between his
parents , he stated his parents fought a lot
He has good relationship with his parents but he reported that he was involved in a fight with his father X 1
He is attending online school
Currently in 10th grade
Unemployed
Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
Objective: What observations did you make during the interview and review of systems?
Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
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