FINDINGS:

SUBJECTIVE:

PATIENT DETAILS: AG,a 32 year old woman.

CC: She wanted to see her lawyer.

HPI:

- was brought to the psychiatric hospital by the police .

- has been delusional and believes people sneak into her room at night when she is asleep and
place a thousand worms inside her body.
- According to the patient, she bought a hamburger and sat down to eat it, and for some reason,
somebody called the police and charged her with illegal trespassing.
- Speech is quiet rambling.
- Claims that she has worms in her that are the type that kill dogs and horses and says that they
have been put there by the government.

PAST PSYCHIATRIC HISTORY:

- Denies any prior hospitalization for mental health problems.

- Denies any illicit drug or alcohol use.
- Smokes two packs of cigarettes per day.

PAST MEDICAL HISTORY:

- have no medical history known.

FAMILY PSYCHIATRIC HISTORY:

- Patient AG claims that her alleged family is not really her family and that she is not sure who
her family is.

ALLERGIES:

- Rash.

LEGAL/SOCIAL STATUS: Divorced; heterosexual; lives in an apartment alone;

OBJECTIVE:

MENTAL STATUS EXAMINATION (MSE):

- White female of Hispanic ethnicity, modestly dressed, with some disarray.

- Morbidly obese
- hair is black and unwashed. She is alert, oriented, and in no acute distress.
- Speech is clear, constant, and pressured, with many grandiose delusions and illogical thoughts
- She is quiet rambling, going from one subject to the other without interruption.
 - Mood is congruent, euphoric, and there is a marked degree of grandiosity.
- Thought processes are quite illogical, with markedly delusional thinking.
- No current evidence of auditory hallucinations, and she denies visual hallucinations.
- Denies any suicidal or homicidal ideation, but she is quite verbal and pressured in her thought
content, verbalizing a great deal about the things that have been taken away from her illegally
by people impersonating her.
- Has delusional symptoms with paranoid ideation prominent.
- Memory (immediate, recent, and remote) is fair.
- Cognition and concentration are adequate.
- Intellectual functioning is within the average range.
- Insight and judgment are markedly impaired.

REVIEW OF SYSTEMS: Reports occasional GI upset; complains that worms are inside her stomach.

VITALS SIGNS: negative BP 140/85 mm Hg, P 80 bpm, RR 17, T 37.1°C; Wt 97 kg; Ht 5′3″

SKIN: Scratches on both hands

NEURO: A & O × 3; reflexes symmetric; toes down-going; normal gait; normal strength; sensation intact;
CNs II–XII intact.

LABORATORY VALUES= all lab test are within normal

URINE DRUG SERUM = all tested negative

URINALYSIS:= all tests done were negative

ASSESSMENT:

 Schizophrenia (first episode, currently in acute episode) . There is no medication given.

 Tobacco use disorder. No medication was given.

RESOLUTION:

 APA recommends that patients with schizophrenia be treated with an antipsychotic

medication either of typical antipsychotics (FGA-first-generation antipsychotic) or from
the atypical group (SGA- second-generation antipsychotic) since there is very little
difference in terms of efficacy and adherence. (1) The exception to this is the second-
generation drug clozapine which is found to be more effective than other antipsychotics
for the treatment of schizophrenia. (2)
 CLONZAPINE: From a starting dose of 12.5 mg once or twice daily, the daily clozapine
dose can be increased by, at most, 25 mg to 50 mg per day to a target dose of 300 mg to
450 mg per day.
 EXAMPLES OF FIRST GENERATION:
1. Chlorpheniramine - Initial dose: 25-100mg/day, Typical dose range:
200-800 mg/day , Maximum dose: 1000-2000 mg/day
2. fluphenazine - Initial dose: 2.5 - 10 mg/day, Typical dose range : 6-20
mg/day, Maximum daily dose: Oral: 40 , IM: 10 mg/day
 3. haloperidol (Haldol)- Initial dose: 1 – 15 mg/day, Typical dose
range: 5-20 mg/day , Maximum dose: Oral:100 , IM: 20 mg/day
4. Trifluoperazine (Stelazine)
5. thiothixene (Navane)
 SECOND-GENERATION:
1. Asenapine (Saphris, Secuado)
2. Clozapine (Clozaril)
3. loperidone (Fanapt, Zomaril)
4. Lumateperone (Caplyta)
5. Lurasidone (Latuda)

Reference:

THE AMERICAN PSYCHIATRIC ASSOCIATION PRACTICE GUIDELINE FOR THE TREATMENT OF PATIENTS
WITH SCHIZOPHRENIA. (2019). Retrieved from:
https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/
APA-Draft-Schizophrenia-Treatment-Guideline-Dec2019.pdf

Washington, N.( 2021, April 21). MNT investigates: Second-generation antipsychotic drugs for
schizophrenia. Retrieved from:https://www.medicalnewstoday.com/articles/schizophrenia-second-
generation-antipsychotics

MONITORING:

 For First Generation Antipsychotics: Monitor side effects such as Parkinsons-like

symptoms. These may include:tremors, rigidity, shuffling gait, reduced facial
expressions.(1)
 For Second-generation antipsychotics : Monitor metabolic side effects, such as:
Weight gain, High cholesterol, High blood pressure, High blood sugar.(1)
 Monitor side effects with clozapine : some common early side effects such as sedation,
postural hypotension, or nausea may improve or resolve after the first several days or
weeks of treatment, and patients can be encouraged to tolerate or temporarily manage
these short-term effects. Other side effects, notably parkinsonism and akathisia, are
likely to persist with long-term treatment and additional approaches to management
may be needed. (2)

Reference:

Washington, N.( 2021, April 21). MNT investigates: Second-generation antipsychotic drugs for
schizophrenia. Retrieved from:https://www.medicalnewstoday.com/articles/schizophrenia-second-
generation-antipsychotics

THE AMERICAN PSYCHIATRIC ASSOCIATION PRACTICE GUIDELINE FOR THE TREATMENT OF PATIENTS
WITH SCHIZOPHRENIA. (2019). Retrieved from:
https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/
APA-Draft-Schizophrenia-Treatment-Guideline-Dec2019.pdf