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QUESTION

Case Study : Carter Louis  

Carter Louis, a 25-year-old male, the eldest of three siblings in a middle class family, was diagnosed with paranoid schizophrenia. He is currently in an inpatient unit.

His parents and a close relative reported he has been reserved and shy since childhood, rarely initiating a conversation or any activity and hesitant to talk to others. Behavioral changes were noticed by members of the family as he entered adolescence but were taken in a lighter vein and ignored. His irritable nature and antisocial behavior worsened over the years, and recently, he had a violent bust out on a minor financial issue with a neighbor.

There was no history of any complicated trauma, no alcohol or drug dependence, nor physical or psychiatric illness of the mother during pregnancy. His was in school from age four through 19. There are no reports of school phobias or any kind of learning difficulty. He quit his studies in accordance with his parents’ advice. He prefers indoor and solo games, such as video games, rarely indulges in group activities, and does not have very healthy relationships with his younger siblings. His activities are mostly sedentary. He at times regrets not being sent to a more established and well reputed high school.

The mental status examination revealed that his eye contact was not continuous and he moved his eyes suspiciously and furtively. He tried a little hard to change the body postures and lethargic movements of the limbs (particularly) were also noticed. Quantity of speech was reduced, and he became hesitant on expression of some of his views and beliefs. During conversation, there were blank intervals and tangentiality in his train of thoughts, with changes in pitch. Generalizations based on inappropriate or limited information were also present. He was not able to understand and use the concepts easily. His attention and concentration were intact to an extent. Reaction time was normal, and no compulsive acts or habits were present. Orientation to time, place, and person were intact. His insight into the illness was minimal, as he completely attributed it to others around him.

Carter’s dad reported suspicious behavior, and delusions of reference, persecution (such as a relative inflicting him with some mantras), auditory (sounds of people talking about him), and olfactory (poisoning of the air). Hallucinations were also present but were rare. On investigation, it was learned that, in the prodromal state Carter presents nonspecific symptoms like loss of interest, irritability, oversensitivity, lack of appetite, and insomnia. The parents reflected on his non-compliant behavior makes administration of medication difficult for them (who then resort to tricks, such as saying, “These drugs are for your psycho-sexual disorder,” as he once had a hallucination that his penis nerve was being cut).

In addition to the presence of the atypical clinical features, a history of head injury was reported when Carter was 10 years old, when a metal rod pierced his fore brain. Deterioration of psycho-social functioning was observed and reported by the parents.

Questions
You are seeing Carter and his family during a family meeting on the inpatient unit. From your perspective as Carter’s psychiatric nurse practitioner, answer the following questions in a two- to three-page double-spaced paper (not including the reference page) and in APA format. Include at least three peer-reviewed, evidence-based references.

What diagnosis would you give Carter? Please match Carter’s symptoms with the DSM-5 criteria.
What recommendations relative to medications would you make? Name the type of typical or atypical antipsychotic you would prescribe and identify the dosing and administration. Please include the dose and time of administration Give evidence to support your decision.
Decide whether you would add any other non-pharmacological treatment. Provide current literature (EBP, research article, or textbook reference) to support your decision.
Based on the medications you prescribe, what education would you provide to Carter and his family?
Identify any laboratory testing you would order and explain your rationale.
Would you refer Carter to any other providers, and if so, to whom? Provide your rationale for any referrals.

 

 

 

Subject Case Study Pages 3 Style APA

Answer

 

Case Study: Carter Louis

Diagnosis

Carter Louis was diagnosed with schizophrenia, paranoid type in accordance with the Diagnostic and statistical manual of mental disorders –fourth edition (DSM-IV) but has been since dropped in the DSM-5 manual by the American Psychiatric Association (APA) (Substance Abuse and Mental Health Services Administration, 2016). In accordance to DSM-5, Carter’s current diagnosis is termed categorically as schizophrenia (DSM-5 295.90 (F20.9)). Schizophrenia criteria, as outlined in the DSM-5 must include at least one of the following symptoms that have presented for one month duration. These include delusions, hallucinations, disorganized speech, negative symptoms (diminished emotional expression) and catatonic behavior or being completely disorganized (APA, 2013). Carter experiences delusion of reference, suspicious behavior, perception of persecution, and olfactory and auditory hallucinations. In addition, he demonstrates signs of diminished emotional expression since he is hesitant in starting a conversation and is conserved in his speech. Most of these symptoms have been observed since childhood.

The other DSM-5 criterion for schizophrenia is that the level of function in one or more of the major areas including interpersonal relations, work, or self-care should be clearly below the level that had been achieved before the onset of the disease (APA, 2013). Similarly, Carter demonstrates symptoms such as poor relations with his siblings, is self-isolating, and has since dropped from school. Carter also meets another criterion for schizophrenia since his disturbance has lasted for more than 6 months (APA, 2013). Besides, his diagnosis meets another criterion that state that disturbance should not be better explained by depressive disorder, bipolar disorder, or a schizoaffective disorder. Besides, his disturbance cannot be associated with any physiologic effects of substance, medication, drug, or any existing medical condition. Lastly, but not the least, Carter has not history of a communication disorder or autism spectrum disorder of childhood onset (APA, 2013). Therefore, his signs and symptoms meet the DSM-5 criteria for schizophrenia.   

Management Recommendations

Pharmacologic Intervention

            First-line recommended antipsychotic medications for Carter include risperidone and olanzapine to manage psychotic symptoms and a benzodiazepine; particularly, diazepam to control behavioral disturbances (Hany et al., 2020).  Risperidone is a parenteral and oral atypical antipsychotic of the benzisoxazole class. Carter should be prescribed risperidone at a starting dose of 2 mg/day PO as a single dose or 1 mg PO twice per day to minimize risk of a syncope and orthostatic hypotension. The dose can be adjusted gradually, if well tolerated to an effective dose range of 4 mg/day to 16 mg/day PO (Prescribers’ Digital Reference (PDR), 2021a). Similarly, olanzapine is an atypical antipsychotic administered at a dose of 5 to 10 mg PO once daily (PDR, 2021b). Lastly, diazepam, an anticonvulsant, a benzodiazepine, is administered at a dose of 2 to 10 mg PO 2 to 4 times per day subject to the severity of symptoms (PDR, 2021c).

Non-Pharmacologic Intervention

            Art and drama therapies as well as cognitive behavioral therapy can be used to help counteract the negative symptoms of schizophrenia. These interventions can also help to improve the Carter’s insight and assist in relapse prevention (Hany et al., 2020).

Education for Carter and his Family

            Patient and family education should focus on reinforcing the need of medication adherence and in helping Carter to understand and accept his condition. Besides, side effects of medications should be included in patient and family education. Risperidone can cause a syncope ad orthostatic hypotension. Carter should be instructed not to operate any machinery or ingest alcohol upon starting risperidone therapy since the drug can impair motor and cognitive skills (PDR, 2021a). Similarly, the patient should not operate machine after using olanzapine or ingest alcohol for the same reasons. Besides, Carter need to be monitored for signs and symptoms of suicidal ideation caused by olanzapine (PDR, 2021b).

Laboratory Tests

            Carter should be investigated for potential organic causes of schizophrenia such as human immunodeficiency virus infection, syphilis, multiple sclerosis, Parkinson’s disease, heavy metal toxicity, brain lesions, dementia, delirium, and metabolic/endocrine disorders. Relevant investigations for the above potential causes of schizophrenia need to be performed (Hany et al., 2020). Besides, urea and electrolytes investigation is indicated since electrolyte imbalance can lead to delirium. Serum calcium levels should also be determined since hyperthyroidism or hypothyroidism can have psychiatric manifestations. Blood glucose test is also indicated since hypoglycemia is associated with confusion that can be mistaken for psychosis. In addition, a thyroid function test should be performed since hypothyroidism can cause depression. A 24-hour cortisol collection and quantification is required since both adrenocortical insufficiency (Addison disease) and hypocortisolism (Cushing syndrome) can present with psychiatric symptoms. Urinary toxicological screen may be required for detection of recreational drug use such as cannabis. Magnetic Resonance Imaging or a Computed Tomography scan can be performed for detection of suspected neurological abnormality or injury (Hany et al., 2020). The patients vital signs, particularly blood pressure need to be established (PDR, 2021b).

Referrals

            Carter should be referred to other healthcare providers. These include a psychiatrist for further assessment and a licensed mental health counselor for management of behavioral disturbances. The patient and the family need to be involved in making of a referral plan (HealthCare ToolBox, 2016).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. https://doi.org/10.1176/appi.books.9780890425596

Prescribers’ Digital Reference. (2021a). Risperidone – drug summary. https://www.pdr.net/drug-summary/Risperidone-risperidone-3120

Prescribers’ Digital Reference. (2021b). Olanzapine – drug summary. https://www.pdr.net/drug-summary/Zyprexa-olanzapine-2269

Prescribers’ Digital Reference. (2021c). Diazepam – drug summary. https://www.pdr.net/drug-summary/Diazepam-Injection-diazepam-719

HealthCare ToolBox. (Jan 15, 2016). Basic of trauma-informed care. https://www.healthcaretoolbox.org/what-providers-can-do/when-and-how-to-refer-for-mental-health-care.html

Hany, M., Rehman, B., Azhar, Y., & Chapman, J. (Dec 08, 2020). Schizophrenia. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539864/

Substance Abuse and Mental Health Services Administration. (Jun 2016). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Author: Rockville (MD). https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t22/

 

 

 

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