Training Title 29
Name: Mr. Harold Feldman
Gender: male
Age:20 years old
T- 98.4 P- 76 R 18 116/74 Ht 5’6 Wt 120lbs
Background: European-American male. He has two younger sisters, one with history of ADHD,
the other with history of separation anxiety. His mother has depression; his father has paranoia
schizophrenia. He is home for spring break. He has no previous medical problems.
Developmental milestones met as child. Appetite is inconsistent and it seems he has lost 18lbs
since first going back to school in the fall. He had a short trial of risperidone in the last six
months of high school for mild paranoia. He stopped the medication after graduation as he could
not tolerate due to side effects of over-sedation. Harold has HS several friends but has not kept in
touch with them since being back home. He has not been showering. Sleeping 14 hrs./ he admits
to episodic cannabis use weekly. Allergies shellfish
Symptom Media. (Producer). (2016). Training title 29 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-29

NRNP 6635 Case History Report – Week 7: Schizophrenia and Other Psychotic Disorders; Medication‑Induced Movement Disorders
Training Title 29: Mr. Harold Feldman
1. Introduction
Patient: Mr. Harold Feldman, 20‑year‑old European‑American male.

Context: Case study from Symptom Media video (2016).

Clinical Focus: Schizophrenia spectrum disorders, psychotic features, and medication‑induced movement disorders.

Importance: Illustrates genetic vulnerability, early onset of psychotic symptoms, and challenges with medication adherence due to side effects.

2. Demographics and Background
Age: 20 years old.

Gender: Male.

Vitals: T 98.4, P 76, R 18, BP 116/74 (normal).

Height/Weight: 5’6”, 120 lbs (BMI ~19.4 → underweight).

Family: Two younger sisters (one with ADHD, one with separation anxiety). Mother with depression; father with paranoid schizophrenia.

Education/Occupation: College student, home for spring break.

Medical History: No previous medical problems.

Psychiatric History: Short trial of risperidone in high school for mild paranoia; discontinued due to sedation.

Allergies: Shellfish.

Lifestyle: Inconsistent appetite, 18‑lb weight loss since fall semester. Sleeps 14 hours/day. Poor hygiene (not showering). Episodic cannabis use weekly.

3. Psychosocial Stressors
Family Psychiatric History: Strong genetic predisposition (father with schizophrenia, mother with depression).

Social Isolation: Lost contact with high school friends.

Academic Stress: Transition to college, possible stressors.

Medical Concerns: Significant weight loss, poor appetite.

Substance Use: Cannabis use may exacerbate psychotic symptoms.

Functional Decline: Poor hygiene, excessive sleep, social withdrawal.

4. Clinical Presentation (Psychotic Features)
Reported Symptoms:

Mild paranoia in high school.

Social withdrawal.

Poor hygiene.

Excessive sleep.

Weight loss.

Behavioral Indicators:

Guardedness, possible suspiciousness.

Decline in functioning.

Cannabis use complicates presentation.

Risk Factors:

Strong family history.

Early onset age (late adolescence/early adulthood typical for schizophrenia).

Medication intolerance.

Substance use.

5. Mental Status Examination (MSE)
Appearance: Thin, underweight, poor hygiene.

Behavior: Withdrawn, possibly guarded.

Speech: Normal rate/volume, may be reduced.

Mood: Neutral or depressed.

Affect: Flat or blunted.

Thought Process: Possible disorganized or tangential.

Thought Content: Paranoia, suspiciousness.

Cognition: Alert, oriented ×3.

Insight/Judgment: Limited, poor adherence to treatment.

6. Differential Diagnosis
Schizophrenia: Chronic psychotic disorder with delusions, hallucinations, disorganized thought, negative symptoms.

Schizophreniform Disorder: Similar to schizophrenia but duration <6 months.

Schizoaffective Disorder: Psychosis with mood episodes.

Substance‑Induced Psychotic Disorder: Cannabis use may precipitate psychosis.

Major Depressive Disorder with Psychotic Features: Depression plus psychosis.

Medical Causes: Thyroid dysfunction, neurological illness.

7. Diagnostic Considerations (DSM‑5)
Schizophrenia Criteria:

≥2 symptoms (delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms).

Duration ≥6 months.

Impaired functioning.

Schizoaffective Disorder: Psychosis plus mood episodes.

Schizophreniform Disorder: Symptoms lasting 1–6 months.

Harold’s Case:

Family history, paranoia, social withdrawal, poor hygiene, functional decline.

Likely schizophrenia spectrum disorder.

8. Medication‑Induced Movement Disorders
Antipsychotic Medications:

Typical (first‑generation): haloperidol, chlorpromazine.

Atypical (second‑generation): risperidone, olanzapine, quetiapine.

Movement Disorders:

Extrapyramidal Symptoms (EPS): Dystonia, akathisia, parkinsonism.

Tardive Dyskinesia (TD): Involuntary movements, often irreversible.

Neuroleptic Malignant Syndrome (NMS): Rare, life‑threatening.

Risk Factors:

Long‑term antipsychotic use.

High doses of typical antipsychotics.

Family history of psychiatric illness.

9. Assessment Tools
PANSS (Positive and Negative Syndrome Scale): Measures schizophrenia symptoms.

AIMS (Abnormal Involuntary Movement Scale): Screens for tardive dyskinesia.

Barnes Akathisia Rating Scale: Measures akathisia.

Simpson‑Angus Scale: Assesses parkinsonism.

10. Treatment Plan
Pharmacological:

Antipsychotics:

Atypical preferred (lower EPS risk).

Clozapine for treatment‑resistant schizophrenia.

Adjunctive Medications:

Anticholinergics (benztropine) for EPS.

VMAT2 inhibitors (valbenazine) for tardive dyskinesia.

Psychotherapy:

CBT for psychosis.

Psychoeducation.

Social skills training.

Lifestyle Interventions:

Structured routine.

Stress management.

Nutrition and exercise.

Supportive Measures:

Family involvement.

Case management.

Community support services.

11. Monitoring and Follow‑Up
Regular psychiatric visits.

Medication monitoring (side effects, adherence).

Movement disorder screening (AIMS).

Suicide risk reassessment.

Collaboration with primary care.

12. Challenges
Medication Intolerance: Sedation from risperidone.

Substance Use: Cannabis complicates psychosis.

Family History: Strong genetic predisposition.

Functional Decline: Poor hygiene, social withdrawal, weight loss.

Stigma: Mental health stigma in psychotic disorders.

13. Ethical and Cultural Considerations
Confidentiality: Respect patient privacy.

Consent: Informed consent for treatment.

Safety: Suicide risk management.

Cultural Sensitivity: Address stigma, respect autonomy.

14. Case Summary
Mr. Harold Feldman: 20‑year‑old male with family history of schizophrenia and depression, presenting with paranoia, social withdrawal, poor hygiene, weight loss, and cannabis use.

Likely Diagnosis: Schizophrenia spectrum disorder.

Treatment: Antipsychotics, psychotherapy, lifestyle interventions, supportive care.

Outcome Goal: Symptom reduction, improved functioning, prevention of relapse, monitoring for movement disorders.

📝 Quiz (15 Questions)
Multiple Choice – Select the best answer.

What is Harold’s age? a) 18 b) 20 c) 22 d) 24

What psychiatric history does Harold’s father have? a) Depression b) Paranoid schizophrenia c) ADHD d) Bipolar disorder

What psychiatric history does Harold’s mother have? a) Anxiety b) Depression c) Schizophrenia d) OCD

What psychiatric history do Harold’s sisters have? a) ADHD and separation anxiety b) Depression and bipolar disorder c) OCD and PTSD d) None

How much weight has Harold lost since fall semester? a) 10 lbs b) 18 lbs c) 25 lbs d) 30 lbs

What medication did Harold trial in high school? a) Olanzapine b) Risperidone c) Haloperidol d) Clozapine