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Research the 3 highest priority Differential Diagnoses, the proposed interventions with rationale and respond to the case.  

The man who thought he was miniature

Case Study by Rebekah Feeney BSN, RN

Chief Compliant

Pt is a 47yo Caucasian male, presenting to an outpatient clinic for new psychiatric provider establishment for ongoing hallucination and delusions. Pt was referred by PCP after being seen for evaluation at a local psychiatric hospital but was deemed not necessary for inpatient treatment.

CC: “I’m struggling with more hallucinations and can’t seem to get a handle on things.”

History of present illness

Pt presents alone for evaluation. He is a good historian, alert and oriented x3. MS was seen last week at PCP for increased delusions and hallucinations. He has a historical diagnosis of schizoaffective disorder, bipolar type. He reports taking Invega hafyera and his next injection is due in 8 weeks. He is also taking oral Risperdal since last week and feels it has helped some. He has seen psychiatry for several years and has been consistently taking medication, but feels he is more unstable over the past few months. Endorses relationship strains with wife and other family members as a possible contributor.

Pt reports having ongoing anxiety for years. Currently taking Xanax. He was abruptly taken off Xanax a few months ago and began feeling extremely ill and nervous. He saw his PCP and was immediately restarted on Xanax and felt “much better”. He endorses “a lot” of panic and anxiety that exacerbates his mood and behavior. He does have some times of obsessive thoughts and ritualistic behaviors. Reports purchasing or doing things in even numbers because he feels something bad will happen to him is something occurs in an odd number. He has periods of ruminating thoughts and these obsessional feelings affect his daily life.

History of present illness continued

He reports AH/HV, and increased paranoia. The hallucinations are something he has lived with for many years and is accustom to, however, reports they are “louder and clearer” at this time. He has had numerous delusions in the past few weeks that have affected his daily life, including thinking he was miniature and went outside urinating in the road because he thought he was small and no one could see him. He recently thought he could run at “warp speed” and thought he could fly. He did not act on the thoughts of flying because “something told me it was dangerous”. He reports he has periods were he cannot tell what is “real or make believe”. There are times when these thoughts interfere with his family life. He has become increasingly paranoid and thought his mother was in a cult until recently, when the oral Risperdal was started.

His mood is “good”, but reports frustration over the increased hallucinations and paranoia. Report energy and motivation levels as good. Appetite good. No sleep disturbances. Endorses getting upset easily and feels overwhelmed frequently. Denies SI/HI. Reports occasional episodes of depression and his personal hygiene suffers. He has a history of trauma that includes years of physical and emotional abuse by step father.

Social history

Former smoker. Denies alcohol, or other illicit drug use.

Currently living with wife and 2 children in stable home. He is disabled, but endorses a long time career as a magician prior to debilitating psychiatric symptoms. Reminisces on past career fame, meeting with various celebrities, international travels, and accomplishments throughout appointment. Hoping to return to work at some point in his life.

No legal or financial concerns. No military service.

Family history

Mother: Ovarian Cancer

Father: Heart Disease

Brother: Cancer

Psychiatric Medications

Prior psychiatric medications:


Invega Sustenna

Invega Trinza








Current Psychiatric Medications:

Invega hafyera

Inderal 20mg TID

Effexor 150mg BID

Xanax 1mg BID

Lamictal 100mg BID

*Risperdal 0.5mg BID (just started for hallucination/delusion coverage last week)

Complete Medication List

Albuterol inhaler 90mcg/puff q4hr PRN

Alprazolam (Xanax) 1mg tab PO BID

Amlodipine beslate/benazepril 10-40mg 1 cap PO daily

Clonidine 0.1mg tab PO BID PRN (for BPs greater than 160/90)

Lamotrigine (Lamictal) 100mg tab PO BID

Pantoprazole (Protonix) 40mg tab PO daily

Paliperidone palmitate (Invega hayfera) 156mg/ml

Propanolol (Inderal) 20mg tab PO TID

Risperidone (Risperdal) 0.5mg tab PO BID

Testosterone cypionate 200mg IM q14days

Tirzepatide (Mounjaro) 15mg subq q7days

Tizanidine (Zanaflex) 4mg tab PO BID PRN

Venlafaxine (Effexor) 150mg cap PO BID

Medical and psychiatric history

Historical Diagnoses include:

Anxiety, Bipolar I disorder, depression, OCD, PTSD, Sleep apnea, obesity, hyperlipidemia

Focal seizures, seeing neurology

Surgeries: None

Allergies: None

Past hospitalizations: 1 (for medication adjustment for increased hallucinations/delusions)

Currently in CBT therapy


Sodium 132

Possatium 4.5

Chloride 95

CO2 26


Cr 1.02

Glucose 83

Calcium 9.4

Bili total 0.6

ALT 18

AST 15

Total protein 7.3

Albumin 4.6

Anion Gap 11

GFR 78

BUN/Cr ration 9

WBC 6.39

RBC 4.39

Hemoglobin 13.3

Hematocrit 39.2

MCV 89.3

MCH 30.3

MCHC 33.9

Platelet 291

RDW CV 12.1

MPV 9.2

Vitamin B12 557

TSH 1.350

Folate 4.6

Testosterone 24.4

MSE and vital signs

Appearance: Appropriate

Speech: Normal

Eye contact: Normal

Motor Activity: Normal

Affect: Flat, anxious

Mood: Anxious

Orientation: A&O x3

Memory impairment: None

Attention: Normal

Hallucinations: Visual and auditory

Derealization/depersonalization: none

Behavior: cooperative

Insight: poor

Judgement: poor

What are your thoughts?


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