Chief Complaint (CC):
- A 36-year-old male presenting with restlessness, agitation, disorganized speech, impaired cognition, and periodic delusions.
History of Present Illness (HPI):
- Symptoms have fluctuated over three weeks with episodes of restlessness alternating with lack of motivation and withdrawal. Delusions and hallucinations have persisted for four weeks.
Past Psychiatric History:
- Diagnosed with bipolar disorder 10 years ago and schizophrenia at age 30. Non-adherence to medication is a noted issue.
- History of one hospitalization following a suicide attempt.
- Previous and current medications are detailed, including issues experienced with fluphenazine.
Substance Use History:
- History of binge drinking, cigarette, and cannabis use since his undergraduate years. Still smokes cigarettes and drinks alcohol occasionally.
Family Psychiatric/Substance Use History:
- Schizophrenia in the paternal grandfather and a family history of substance use (cigarette smoking, alcohol).
Psychosocial History:
- Married with one child, working as a software engineer. History of violent behavior leading to arrest and imprisonment.
Medical History:
- History of head injuries from violent behavior and a minor car accident, as well as past hospitalization for malaria.
Current Medications:
- Sodium valproate, sertraline, alprazolam, and aripiprazole.
Allergies:
Reproductive History:
- Heterosexual, married with one child, sexually active with occasional withdrawal during symptom flares.
Review of Systems (ROS):
- General: Weight gain.
- HEENT: Normal.
- Skin: Warm, normal turgor.
- Cardiovascular: Normal BP and heart rate.
- Respiratory: Normal.
- Gastrointestinal: Normal.
- Neurological: Tingling in limbs and difficulty moving feet.
- Musculoskeletal: Stiffness in lower extremities.
- Other systems are unremarkable.
Diagnostic Results:
- Head CT scan showed no physical injury.
- Blood tests revealed positive for alcohol, cigarette, and cannabis use.
Mental Status Examination:
- Appropriately dressed, aware of time and occasion.
- Admitted to suicidal ideation.
Differential Diagnoses:
- Schizophrenia, Bipolar Disorder, Major Depressive Disorder.
- Schizophrenia is diagnosed based on DSM-5 criteria.
Reflections:
- The diagnosis of schizophrenia requires careful assessment, supported by symptom clusters and appropriate diagnostics. The case reinforced the need for a compassionate approach to psychiatric care, emphasizing public education on modifiable risk factors like substance abuse.
