Woody is a 30-year-old male who presents in your office with a history of psychosis starting at age 21

Case study for Week 4 (Woody)

Woody is a 30-year-old male who presents in your office with a history of psychosis starting at age 21. He started becoming psychotic and paranoid while living with roommates in college. He was noted to withdrawal and worry about the government spying on him. He decided that he could only eat white foods like cottage cheese, frozen yogurt, and vanilla ice cream. His roommates noticed that he began talking to himself, started hiding from others, and quit going to class so they called his mom who took him to the hospital and began getting his treatment and moved home with mom. 

He was started on olanzapine and did well for two years, but it was discontinued.

He was then changed to an SGA that made it painful hard to keep his legs still.  

He trialed another Second Generation Antipsychotic next that was dosed high very quickly and he began to experience gynecomastia. 

Which two of the SGAs tend to be more weight neutral than the others? 

Some mood stabilizers were trialed, but one caused tremors and he became toxic when dehydrated. 

He was then hospitalized for malnutrition after he stopped eating. He claimed that he was chosen, and it was time to fast for the month. While inpatient, he was treated for dehydration and given Haldol which was effective for his psychosis and he was discharged in stable condition. He remained on Haldol for a year and was able to work at the local grocery until he became to display some severe EPS making it difficult for him to continue bagging groceries at the store. After losing his job he began to start withdrawing and refusing his medication. He began to start hiding from the mailman everyday thinking that the government was spying on him. He said that the military was whispering in is ear telling him to kill himself to protect the world. He attempted to hang himself with his bedsheet but his mom walked in and saved him. He was immediately admitted to the hospital. 

He continued to have suicidal ideations and whispered so that the government could not hear him.  

Answer each of the following questions:

1.  What is most likely his diagnosis? What would be your differentials? Which labs would you want to order and why? What are some organic conditions that may present with psychosis?   

  1. What      reasons can you think of for discontinuing the olanzapine      medication? 
  2. What side      effects of the Second Generation Antipsychotics medication could be so      troublesome to get in the way of normal everyday activities?
  3. Which      medication was this likely to cause the gynecomastia and why? How would      you monitor for worsening of this? 
  4. What are      the special considerations for each of the Second Generation      Antipsychotics?
  5. If a      patient is noncompliant with medications what is a less frequent option      that may be more sustainable? What needs to be trialed before this      option? 
  6. What      medication was that likely to cause the tremors and dehydration? What      special monitoring does this medication require? 
  7. After      many trials of medications for psychosis and mood stabilization which SGA may      now be indicated due to the patient failing many others that can be very      effective for managing psychosis but would require a provider to be on a      registry before it can be prescribed? Why should this medication be      reserved for those with many previous trials of antipsychotics that have      failed? What is the most worrisome side effect of this medication? How      often does it need to be monitored and how? 
  8. What      additional resources could be helpful for this patient and his      family? 
  9. What are      the 5 components of a suicide risk assessment, that need to be asked each      shift until he no longer is suicidal? (See PowerPoint/Kaltura from      Module1). 
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