Schizophrenia and the Tools and Tests to Consider in the Diagnosis

ID: John is a 22-year-old single white male who was brought into the emergency department for a psychiatric evaluation
Chief Complaint: “I was just trying to find the truth so I could save the world from the aliens.”
History of Chief Complaint: Prior to being brought into the emergency room by police, the police were called when the patient was observed wandering for hours in a parking lot. Approximately one month ago the patient had been fired from his job he had only been at for three weeks for inappropriate behavior. According to his mother, the police had to be called to escort him from the premises because he refused to leave. Since that time, the patient has barely been able to sleep and the family heard him laughing and talking to himself in the night. The patient said that his appetite has been nonexistent for the past two to three weeks. His mother said that although the patient is usually frugal he has recently spent excessive amounts of money buying expensive business suits, electric bikes, and comic books. His mother says that John has never showed interest and in riding bikes or collecting comic books and is unsure where this is coming from. He is spending excessive amounts of money and charging to a credit card and is currently unemployed. John states that he does have a job and that “I am working on creative projects that will save the world from the aliens” but that “I am not at liberty to talk about the creative projects”. He is religiously preoccupied and speaks of his special relationship with God. The special relationship “helps me with my project to save the world”. He is sexually preoccupied and has been making sexually inappropriate comments to female nurses in the emergency room.
Past Psychiatric History: The patient has had no previous hospitalizations and was prescribed fluoxetine about four weeks ago by his primary care provider for depressive symptoms. His mother states that he had had some depressive symptoms such as crying, difficulty getting up out of bed, unable to concentrate on his school work and feeling hopeless. He went to his primary care provider and was placed on fluoxetine. He did receive some counseling about a year ago at the university center for depression. His mother said that because John has been living away from home they had not been aware of his problems until about four weeks ago when he was placed on fluoxetine.
Medical History: The patient has no known drug allergies. He is currently in good physical health, normal height and weight and stable vital signs. Labs drawn in the ER include complete blood count, comprehensive metabolic panel, thyroid stimulating hormone, and thyroxine which were all in normal limits.
History of Drug or Alcohol Abuse: the patient says he began drinking alcohol and smoking marijuana at age 17. He considers himself a binge user of both substances. He says months will go by without him smoking marijuana and then he will have a period of increased use. He said the same is true of drinking and he has experience blackouts during increased alcohol use. The most recent episode was a binge drinking about a month prior.
Family History: The patient's paternal aunt has bipolar disorder. a younger brother has been diagnosed with depression but his illness is not well managed. The patient lives independently and is currently in college. He is currently unemployed as of recent. He has a maternal cousin with schizophrenia.
the patient was raised in a family where their parents had an intact marriage and both or financially secure. The patient is the second oldest of four children he has a younger sister a younger brother and an older brother. He states he gets along with his siblings
PERSONAL HISTORY
Childhood: He did well academically in elementary middle and high school.
Adulthood: He is currently in his senior year of college and has done well academically until last semester. He contributes his low grades to the binging on alcohol and marijuana. He was arrested last semester for trespassing and resisting arrest. He said he was intoxicated with alcohol at the time and the charges were dropped. He was recently fired from his job a month ago.
Trauma/abuse history: The patient denies any history of trauma or abuse stating he had a “wonderful” childhood.
MENTAL STATUS EXAM
The patient appears his stated age. He is well groomed and casually dressed. He is cooperative and makes appropriate eye contact. He is energetic during the examination and animated. Alert and oriented to person, place, time. He is easily distracted by things in the environment. For example, in the middle of a sentence he was distracted by a small detail in a painting in a room and spoke about it in great length. He needs frequent redirection back to the topic. His responses indicate that he is able to understand concepts. Above average intelligence. Speech is spontaneous, over productive, and somewhat pressured. Thought process is tangential with flight of ideas. The patient displays grandiosity, religious and sexual preoccupation, and some mild paranoia. The patient complains of having intrusive thoughts about other people and fearing that they could read his mind through “the aliens” and know what he was thinking. The patient denies any suicidal plan or intent but says sometimes he “thinks it would be better off if he wasn't here”. His family says that he has threatened suicide when intoxicated. He has never attempted suicide. He denies homicidal ideation. Family says he becomes quite angry when intoxicated but has never become physically aggressive. Mood is elevated and expansive. Affect is over animated and congruent with his elevated mood. Impulse control is impaired as evidence by his excessive spending and inappropriate sexual comments. Judgment and insight: The patient has impaired judgment however he has considerable insight into the fact that he has an illness and needs medication and treatment to manage it.
What diagnosis should be considered?
What is the rationale for the diagnosis?
What tools are tests should be considered to help identify the correct diagnosis?
What diagnosis should be considered?
What treatment would you prescribe and what is the rationale?