CC:
" I was recently diagnosed with schizophrenia"
HPI
The patient is a 20 years old AAM who presented for a psych evaluation, he stated that he was recently diagnosed
with schizophrenia a month ago, he has had schizophrenia since March,2022 and he was not aware he had
schizophrenia, he had always believed he is being watched through his phone, he broke into his mother's house and
broke the window when he was psychotic, he was sad that he did that, he has been thinking about life and death
more since he developed schizophrenia, he has been more alone, isolated, He is scared of the voices, he doesn’t want to hear the voices at all, he stated that the first time he had the voices was march, 2022 and the last time he
heard the voices was two days ago, he started taking Invega and the voices went away, then they came back but not as strong as it used to be, he explained that the voices kind of pushes him to be better, they kind of also were bad,
he will do certain things that are normal like breaking into his mother’s house or bursting the window, He reported that they said the schizophrenia is caused by marijuana, he started using Marijuana at age 18. He reported that when he was actively using marijuana he was responding to the voices but without marijuana he was not responding to the
voices. He reported that the last time he used marijuana was about 1 or 2 months ago, he endorsed some depression, and passive death wish, he doesn’t have plans, he just thinks about how death could be due to no "life
living" He reported that his appetite is good, sleep is good, he is picking up on his energy, he is picking up on interest as well. He used to be hopeless but not anymore, he used to have VH seeing small blurs but not anymore. he denies HI
PsychHx
HX of psych inpatient hospitalization at MedStar and Sheppard Pratt recently, hospitalized last year once and two
time this year. Discharged from Sheppard Pratt on Oct 10th, received second dose of Invega on Oct 9th before discharge, next dose due on 11/10/2023 according to discharge summary
Denies suicidal attempts.
*Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.
Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest 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.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), 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.).
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