J.K. is a 34-year-old man with a 16-year history of schizophrenia who was admitted to the hospital after becoming unpredictable and threatening violence. He had been refusing medications and experiencing auditory hallucinations telling him to harm himself. Upon examination, he displayed symptoms of loose thought processes, depression, and diminished judgment. His condition is thought to have decompensated due to medication noncompliance, which has led to multiple hospital admissions in the past.

1. Psychiatry Case Presentation Candice Reyes, MS III Pacific Hospital of Long Beach

2. History of Present Illness J.K. is a 34 y/o Caucasian male with a h/o Schizophrenia, Paranoid Type x 16yrs who was admitted on a 5150 for DTS . He has been living in Scandia Board & Care x 8yrs. The manager was concerned about recent changes in the patient's behavior. The police found him hitting and kicking a locked door that was closed on him to prevent him from attacking another person. In addition, he was yelling, “God told me to kill myself!” He had also been refusing psychiatric medications , stating, “I’m fine without them.” During the past several weeks, the patient has been unpredictable, responding to internal stimuli and cursing . He paces the hallways and screams, “put it in the butt” and “fuck you.” He also tickles himself and laughs inappropriately . The patient has been treated with Haldol 10mg PO bid, Depakote 250mg/d, and Valium 5mg/d since he started living at Scandia. He experienced moderate extrapyramidal syndrome (EPS), which has been responsive to Cogentin (2 mg at bedtime). There is a h/o stimulant use – methamphetamines at the age of 21. He denied substance abuse treatment. According to staff at the board and care, there has been no observed change in sleep pattern and no identifiable perturbation in the patient's psychosocial milieu.

3. Past Psychiatric History The patient's symptoms at the onset of his illness included auditory hallucinations of God’s voice, suspiciousness , ideas of reference and hostility, and moderately severe conceptual disorganization . Except for his conceptual disorganization, the patient's symptoms were attenuated through the use of neuroleptics and supportive therapy . He has a longstanding recurrent history of medication noncompliance that has led to multiple psychiatric admissions since he was 18.

4. Family Psychiatric History Unremarkable.

5. Past Medical History Chronic bronchitis, Schizophrenia, Paranoid type . Pt denies history of head trauma, seizures, or HIV.

6. Social and Developmental History The patient is the oldest of 3 boys and has completed a high-school education . After graduating, he obtained work in a lot of jobs that he refuses to talk about. Since his diagnosis, he has not worked and now receives disability support. Family is described as disengaged , having contact with him periodically.

7. Review of Symptoms General: The patient’s medical health has been fairly stable Skin: No skin d/o requiring medical attention HEENT: Other than respiratory infections, no other problems referable to this system Neck: No swelling, dysphagia, or thyroid disease Pulm : No asthma, TB, or pneumonia CV: No known heart disease or hypertension GI: No dyspepsia, PUD, biliary tract disease, pancreatitis, or colitis GU: No UTIs, venereal disease, or kidney stones Neuromuscular : No muscle weakness or wasting. No syncope, vertigo, or diplopia

8. Physical Exam Vital Signs: Ht 5’11’’ Wt 196lb BP 117/91 when admitted P 92 R 20 Skin: Warm and dry with good turgor HEENT: NCAT. Ears clear. Eyes show no evidence of icterus or conjunctivitis. PERRLA. Nose is clear. Throat is negative. Neck: Supple with no neck vein distention, thyroid enlargement, or bruits. Lungs: CTA and percussion. No rales, rhonchi, or wheezes CV: RRR with no murmurs, thrills, heaves, or rubs. First and second heart sounds normal. No S3 or S4. Abdomen: Flat and soft. No guarding or rigidity. Bowel sounds WNL. Pulses: present and symmetrical Lymph: Patient is free of lymphadenopathy Extremities: No evidence of wasting or edema. Neuro: Intact and symmetrical. Unremarkable for evidence of gross movement disorders.

9. Mental Status Exam The patient is an overweight Caucasian male who looks older than his stated age. He is A&O x 3 . Motor is slowed . Speech is slowed . Mood is depressed . Suicidal ideation risk, i.e., OD on medications. Homicidal ideations are denied. Thought processes are loose . Thought content is guarded . The voices telling him to kill himself on recurrent basis. Immediate, recent, and remote memory are intact as evidenced by recall. Impulse control and judgment are diminished . Insight and reliability are diminished demonstrated by medication noncompliance and poor insight regarding his illness.

10. Lab Data The patient's toxicology screen was negative. CXR – 2 views – was normal

11. Summary The patient is a 34 y/o Caucasian male with Schizophrenia, paranoid type, who was decompensating due to medication noncompliance. He presented with symptoms of paranoia, suicidal ideations, internal stimuli and conceptual disorganization, which were hallmarks of his other breakdowns with no identifiable change in her psychosocial milieu. After administration of medications, he is now in a stable phase of illness following one of multiple recurrent psychotic episodes. Articles: Schizophrenia and Violence: Systematic Review and Meta-Analysis Greater Impairment in Negative Emotion Evaluation Ability in Patients with Paranoid Schizophrenia Indicated Prevention of Schizophrenia Reality of Auditory Verbal Hallucinations