What other differential diagnosis would be appropriate for this patient?

Subjective:

CC (chief complaint): “I was smoking meth. I started getting paranoid that the police were conspiring to kill me or put me in jail.”

HPI: JS is a 32-year-old Hispanic male with a history of PTSD and polysubstance use (Meth, alcohol, cannabis). The patient presents for follow-up care post-discharge. The patient initially presented to the ED with paranoid delusions and thoughts of harming himself and others in the setting of stimulant intoxication (Utox positive for Amphetamines and THC in the ED). The patient has had multiple prior ED visits for ALOC and /or psychosis in the setting of polysubstance intoxication (alcohol, cannabis, and methamphetamine). The patient has a significant history of trauma (Stabbed on different occasions, witnessing two friends dying in his arms, and being incarcerated). The patient denies suicidal or homicidal thoughts.

Medical History/Surgical History: Denies

Current Medications: Invega Sustenna, Cogentin, Trazodone, Zoloft

Medication Trials: The Patient has been on multiple medication trials.

Allergies: Denies

Reproductive Hx: The Patient is not sexually active and has no children. He denies STI concerns.

Psychiatric History: The patient has had multiple hospitalizations for psychosis in the setting of acute intoxication. The patient is in well-established psychiatric care. He is not open to psychotherapy.

Substance Current Use: The Patient reports drinking alcohol regularly. His last drink was a week ago. He smokes 3 packs of cigarette a day, uses marijuana daily, and uses methamphetamine 2-3 days a week. He denies tobacco or other substance use.

Family Psychiatric/Mental/Substance Use History: The Patient denies any family history of psychiatric or substance use problems.

Psychosocial History: JS is single, never married, and has no children. The patient was raised by both parents. JS is currently conserved and unemployed and lives in a board and care facility. The patient reports he spends most of his watching TV and “getting high.” His highest education level was the 8th grade. The patient has a history of multiple arrests and incarcerations. He denies any current legal issues.

ROS:

· GENERAL: He appears stated age, disheveled looking with a rosary around his neck. He sits upright in the setting, fidgeting and gesticulating as he speaks. Not in acute distress.

· HEENT: Atraumatic, normcephalic

· SKIN: Skin intact. No rash or lesions. No jaundice.

· CARDIOVASCULAR: No reported abnormalities

· RESPIRATORY: Normal respiratory effort. No SOB.

· GASTROINTESTINAL: No nausea or abdominal pains

· GENITOURINARY: Voiding, regular BM.

· NEUROLOGICAL: CN II XII grossly intact.

· MUSCULOSKELETAL: Moves all extremities. Normal muscle tone

· HEMATOLOGIC: No bleeding disorders

· LYMPHATICS: No lymphadenopathy.

· ENDOCRINOLOGIC: No polyuria, polyphagia, polydipsia

Objective:

Diagnostic results: CBC, CMP, TSH, and HbA1C are unremarkable, and Utox is positive for THC, Amphetamines.

Assessment:

Mental Status Examination: JS is a 32-year-old Hispanic male with a history of PTSD and polysubstance use (Meth, alcohol, cannabis). He is well-nourished and appears stated age. The patient is alert and oriented to his surroundings. He is sitting upright but is fidgety during the session. He speaks fluently in English with a normal rate and tone, gesticulating as he speaks. Mild PMA, no PMR was noted. His thought process is linear, with no overt delusional content. His mood is euthymic, affect is superficially bright, and mood-congruent. The patient denies AVH and suicidal or homicidal ideation. Insight and judgment are improving; he understands the consequences of his substance use and is amenable to pharmacotherapy. Long-term and short-term memories appear grossly intact as the patient can recall events.

Diagnostic Impression:

· Schizophrenia: This is an appropriate diagnosis given that the patient’s burden of symptoms manifests with persistent persecutory delusions, hallucinations, and pervasive sleep abnormalities, in the absence of a significant mood component (Wang et al.,2022)

· Psychotic Disorder to R/O Substance-induced psychotic disorder: This diagnosis is being considered because the patient presents with primary symptoms of psychosis that include hallucinations and delusions. His symptoms could be a direct consequence of smoking three packs of cigarettes a day, methamphetamine, THC and drinking alcohol regularly, all which are strongly associated with incidences of non-affective psychoses including schizophrenia (King et al.,2021)

· Insomnia disorder: This differential diagnosis is being considered because the patient reports going for days without sleep due to auditory hallucinations. Insomnia is a prevalent comorbid condition with a strong association with psychosis (Andorko et al., 2017). Insomnia can also manifest psychosis-like experiences (Andorko et al., 2017). It is, however, difficult to confirm a causal relationship between persistent sleep disturbance and an underlying psychotic disorder (Wang et al.,2022)

Reflections:

I would have wanted to evaluate for Major depression as it is unclear from the patient’s history how he is coping with the recent demise of his mom. It is also unclear whether he is re-experiencing any of his traumatic events. His PTDS was not adequately evaluated to determine whether flashbacks and nightmares contributing to his insomnia, or if his substance use is a direct consequence of difficulty adjusting or coping with PTSD.

Case Formulation and Treatment Plan:

The patient is currently open to restarting pharmacotherapy. Therefore we will continue his routine medications. The patient is not exhibiting any dangerousness towards himself or others and has a viable plan for food, clothing, and shelter. I will consider a referral for psychotherapy. The patient is also likely to benefit from occupational therapy as he spends most of his day watching tv and “getting high”. The patient was educated on how to reduce his substance use as well a smoking cessation. The patient was provided a crisis hotline and encouraged to call 911 or go to the nearest emergency if his symptom worsened or he became suicidal or homicidal. I will follow up with the patient in 30 days.

Questions:

1. What other differential diagnosis would be appropriate for this patient? Why.?

2. What pharmacologic treatment would you consider for this patient?

3. This patient is a high utilizer of ED services, and for similar complaints of acute intoxication. What treatment approaches would you consider helping minimize ED