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
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.
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.
Mother: Ovarian Cancer
Father: Heart Disease
Prior psychiatric medications:
Current Psychiatric Medications:
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
Past hospitalizations: 1 (for medication adjustment for increased hallucinations/delusions)
Currently in CBT therapy
Bili total 0.6
Total protein 7.3
Anion Gap 11
BUN/Cr ration 9
RDW CV 12.1
Vitamin B12 557
MSE and vital signs
Eye contact: Normal
Motor Activity: Normal
Affect: Flat, anxious
Orientation: A&O x3
Memory impairment: None
Hallucinations: Visual and auditory
What are your thoughts?