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Subjective Data
Chief Complaint:
“I think people are watching me through the TV and I can hear them talking about me.”
History of Present Illness (HPI):
A 24-year-old male presents with worsening paranoia, auditory hallucinations, and
social withdrawal over the past 6 months. The patient reports hearing voices that
comment on his actions and believes that people are spying on him. He has diRiculty
sleeping and has quit his job due to “not being able to trust coworkers.” His family
reports bizarre behavior, neglect of hygiene, and increasing isolation.
Demographic Data:
Age: 24
Gender: Male
Race: Caucasian
Marital Status: Single
Occupation: Unemployed (formerly a retail worker)
Living Situation: Lives with parents
Insurance: Medicaid
Risk Factors:
Family history of schizophrenia (maternal uncle)
Early childhood trauma (reported physical abuse)
Cannabis use beginning at age 15, ongoing
History of academic and social diRiculties in adolescence
Past Medical History:
No significant chronic illnesses
Up-to-date on vaccinations
Surgical History:
None
Psychiatric History:
No previous formal diagnosis
Emergency department visit 6 months ago for bizarre behavior but left before being
evaluated
No current medications
Denies suicidal or homicidal ideation but expresses paranoid delusions
Objective Data
Vital Signs:
BP: 118/76 mmHg
HR: 82 bpm
RR: 16
Temp: 98.7°F
BMI: 22.5
Physical Exam Findings:
General: Appears disheveled, poor hygiene
HEENT: No abnormalities
Cardiac: Normal rate and rhythm, no murmurs
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender
Neurological: No focal deficits
Mental Status Exam:
Appearance: Disheveled, unshaven, unkempt clothing
Behavior: Guarded, suspicious, limited eye contact
Speech: Normal rate but sometimes tangential
Mood: “Nervous”
ARect: Restricted
Thought Process: Disorganized, tangential
Thought Content: Paranoid delusions, auditory hallucinations (“voices talking about
me”)
Insight: Poor
Judgment: Impaired
Cognition: Alert and oriented to person and place, unsure of date
Recommended Diagnostic Tests
Laboratory Tests:
CBC, CMP – rule out medical causes and establish baseline
Thyroid Function Tests (TSH, T4) – to rule out thyroid-related psychosis
Vitamin B12 and folate levels – rule out deficiency-related cognitive impairment
Urine Drug Screen (UDS) – assess for substance-induced psychosis
HIV and RPR (syphilis) – to rule out infectious causes
HbA1c, Lipid Panel – baseline due to possible future use of antipsychotics
Imaging:
MRI or CT Brain – if new onset psychosis with atypical features or neurologic signs
(optional in straightforward primary psychosis)
Psychiatric Evaluation:
Referral for comprehensive psychiatric assessment to confirm diagnosis and initiate
treatment plan
INSTRUCTIONS-
Based on the information provided above, list your top three mental health di6erentials
diagnoses.
ii. Choose the most likely diagnosis.
iii. Support your decision with APA scholarly sources that represent a logical link between
the above case study and article information. Communicate with minimal errors in English
grammar, spelling, syntax, and punctuation.
iv. Present information in a logical, meaningful, and understandable sequence that is
relevant to the discussion topic.
v. Good writing calls for the limited use of direct quotes. Direct quotes in discussions are
to be limited to one short quotation (not to exceed 10 words). The quote must add
substantively to the discussion.
vi. Reference Citation: Use current APA format to format citations and references and is
free of errors.
