Case Study: Asher Cohan is a 42-year-old, single male with a diagnosis of schizophrenia. His current symptoms include auditory hallucinations, disorganized speech, and diminished emotional
expression. His father, Daniel, brings Asher to the inpatient psychiatric unit for treatment. This is his third psychiatric admission in two years. Daniel tries to tell you what's happening while
Asher is present.
While Daniel is talking, you can hear Asher talking in the background, sometimes you can hear his words but the speech is not very understandable. The transcript of his speech is at the bottom of this page.
Daniel: I’m so thankful a bed is available for Asher. I love my son so much, but my wife and I can’t have him in the house anymore. He needs more help. [sigh] Asher stopped taking his Seroquel and melatonin a week ago when he told us was feeling “so good he didn’t need the medication anymore.” Which has happened before, and why he’s been here before. And what can we do? We try to keep life normal, trying to get him to help around the house, such as with the groceries and cooking.
But as expected, things went downhill as soon as he stopped his medication. Yesterday, we made soup and then he said, “They told me to put eggs in. I have to egg.” And he grabbed a raw egg and cracked over my soup bowl.
He’s been responding to internal stimuli and talks to himself a lot. He said he’s a secret spy and the government has bugged our home through our security system. He recently broke his phone because it was being used by a conspiracy to control him. Asher thinks it’s his responsibility to debug our house and therefore stays awake for most nights to design a plan to 2 undo it. He’s afraid they will come in the house during the night and put a mind control chip in him.
To be honest, when he does talk, I don’t understand half the things he tells me. It a word salad I heard it called…and doesn’t make much sense. When he does it, he talks on and on and on, like he’s doing right now.
Asher? Asher? The nurse would like to talk with you now.
Asher, can you pay attention please?
Asher: Huh? Whuh? Can I go … home now? I need to get it back. They say I must go do it right now. With rainbow blowing in trees, system can be fixed and that’s happening. They destroying lies to make robots for …
Asher's background speech: I…I know they see, I mean unicorns murder rainbows but not no-no, no unicorns can see me that’s dumb. They, you know THEY see brie me please. Can’t
sleep, rainbow murder don’t they, may get us. Maybe dad was taken. Is dad robot to kill me?
Must, must stay up pay up so they can’t track us frack us. Eyeballs painted in the basement. Must
stay up, death bots, maybe dad will get me. Tracking! That’s how they find you. Eyeballs changed. Then someone then say it but no one, nothing admits and that is when you know…
[yawns, immediately claps hands over mouth] Damn I’m tired wired mired. Do rainbows tire wire mire? What color are their eyeballs? No, no room for bots to learn return burn kill me. In
me Dad looks normal today, is he back? If you feel it behind you it’s THEM. He could come back? I should ask him if they about the rainbows in him. What if it not him? I’ll check his eye.
No rainbows inside I hope pope cope.
Vital signs: BP 148/72, HR 88, R 18, pulse ox 98%
Ht: 6’ 1”
Wt: 200 pounds
Appearance: Unkempt, poor hygiene, not dressed for the weather
Blood work: A1C 6.2, total cholesterol 188 mg/dl, HDL 22 mg/dl, LDL 176 mg/dl
Triglycerides: 148 mg
All other lab results are within normal limits.
Medications: Seroquel 400 mg BID for psychosis and melatonin 6 mg for sleep
You know you will change Asher’s antipsychotic medication. Address the following
1. Identify any laboratory testing you would order prior to initiating antipsychotic
therapy and explain your rationale. Identify what you would continue to
monitor on an ongoing basis (such as laboratory tests, vital signs,
height/weight/BMI/waist circumference, and so on) and explain your rationale.
Identify and include at least one clinical practice guideline for the assessment
and/or treatment of schizophrenia. (2 pages2 references)
2. Considering the information provided (such as vital sign, height/weight,
appearance, lab results, and so on), what will you do to address Asher’s
psychiatric symptoms? Name the type of typical or atypical antipsychotic you
would prescribe. Include the name (generic and brand), starting dose and
how you would titrate, route, and frequency. What education would you
provide to Asher for these medications? (1 page 2 references)
3. Would you add any other medication or recommend the addition of another
medication to address other symptoms Asher is having or any physical
problems you are concerned about? Why? Would you refer Asher to any
other providers (such as primary care, psychotherapy, social worker,
dietician, or others)? Who would you refer Asher to and how or in what way
would you expect this
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