SCHIZOPHRENIA

A Clinical Case Study

SCENARIO

Patient and Setting: JD, a 43-year-old male; inpatient psychiatric unit

Chief Complaint: Auditory hallucinations and paranoid delusions of the PNP/AFP/NBI tracking
him around the city, believe they want to arrest him in a plot to assassinate the President
Rodrigo Duterte III, agitated and aggressive toward staff and other patients (believes they are
part of NBI/AFP/PNP plot to frame him); has been drinking excessive amounts of colas and
coffee over previous week or so.

HISTORY OF PRESENT ILLNESS

Stopped taking his olanzapine as an outpatient approximately

3 weeks ago due to weight gain (approx. 10 kg in 3 weeks), was admitted to unit 3 weeks ago
with current chief complaint, has history of akathisia
to antipsychotics (including olanzapine) in the past

MEDICAL HISTORY

Hepatitis C positive, HTN

SURGICAL HISTORY

None

PSYCHIATRIC HISTORY

Schizophrenia with multiple hospitalizations over past 22 years, history of noncompliance with
medications as outpatient, previous antipsychotic trials of olanzapine, risperidone,
perphenazine, aripiprazole, quetiapine, loxapine, haloperidol, chlorpromazine, and thioridazine

FAMILY HISTORY

Father was diagnosed with bipolar disorder, paternal grandmother had unknown mental illness

SOCIAL HISTORY

Patient has mother and two sisters that visit him regularly; prior history of IV heroin use—none
in more than 5 years, current cigarette
smoker 2 packs/day for 20 to 25 years; no reported alcohol intake

MEDICATIONS

Clozapine, 50 mg QAM and 100 mg QHS (started 5 days ago and being titrated upward)
Haloperidol, 10 mg BID
Clonazepam, 1 mg BID
Benztropine, 0.5 mg BID
Propranolol, 10 mg BID
Lisinopril, 40 mg PO QD
HCTZ, 50 mg QD
Docusate sodium, 100 mg BID
Multiple vitamin (MVI), QD
Lorazepam, 0.5–1 mg PO q8h PRN agitation
Haloperidol, 5 mg IV q8h PRN extreme agitation/ psychosis
Benztropine, 2 mg IV q8h PRN extreme agitation/ psychosis
Lorazepam, 1 mg IV q8h PRN extreme agitation/ psychosis
APAP, 325–650 q4–6h PRN pain
MOM, 30 mL QD PRN

ALLERGIES

No known medication allergies

REVIEW OF SYSTEMS

GEN: Obese, poorly kept, acutely psychotic male

VS: BP 148/92, HR 96, RR 23, T 37.8C, Wt 88 kg (Wt 1 month earlier, 76 kg), Ht 178 cm
HEENT: WNL
COR: WNL
CHEST: WNL
ABD: Mildly enlarged liver noted, no tenderness
GU: Deferred
RECT: Deferred
EXT: WNL
NEURO: Alert but inattentive, oriented to person and time only, believes he is in jail

RESULTS OF PERTINENT LABORATORY TESTS, SERUM DRUG CONCENTRATIONS,

AND DIAGNOSTIC TESTS
Drawn this morning (7:45 AM)

Na 132 Hgb 135 Glu 5.94

K 3.7 Lkcs 6.8 X10^9 AST 1.42 (85) Ca 2.2 (4.4)
CI 99 (99) ALT 1.53 (92) PO4 0.97 (3.0)
HCO3 25 (25) Plts 223 x 10^9 LDH 4.50 (270) Mg 1.0 (2.0)
BUN 6.4 (18) Alk Phos 2.25 Uric Acid 309
CR 97.2 (1.1) MCV 103 (103) HgbA1C 0.065 Alb 35 (3.5)
T Bili 34.2 (2.0) Hct 0.37 (37)

Hepatitis Panel (drawn upon admission): anti-HAV-negative, anti-HBc-negative, anti-HCV-

positive
Hepatitis C labs (drawn 2 weeks ago): HCV RNA-positive, genotype-3A
Urine toxicology screen (drawn at admission): negative for cocaine, opiates, barbiturates, and
amphetamines; positive for benzodiazepines

TASKS

1. IDENTIFY THE PROBLEMS IN THE CASE SCENARIO. GIVE YOUR PHARMACIST’S

INTERVENTION.

2. MAKE A DETAILED PHARMACIST'S CARE PLAN FOR THE PATIENT.