Assignment: “Captain of the Ship” Project – Schizophrenia Spectrum and Other Psychotic Disorders

In 2 pages, write a treatment plan for your client in which you do the following:

 

FYI: HPI (Health and Physical Information of the pt:

W.K is a 32-year-old Caucasian male that presents with a flat, expressionless gaze. His chief complaint “Most days I feel extremely disorganized, uninterested in my normal activities, and I keep seeing and hearing things that my wife say that is not real”. He reports” approximately a year ago, my primary physician suspected that my symptoms aligned with Schizophrenia and referred me to a therapist”. He mentioned that he ignored the referral and was never properly diagnosed or treated. W.K has a medical past history of HTN. He takes Norvasc 10mg PO daily, and Lasix 20 mg P.O daily. He denies adverse reactions. He has no known drug allergies. He has no surgical history. He reported that his grandfather had schizophrenia. W.K.’s new diagnosis according to the DSM is schizophrenia. His weight is stable and remains unchanged. He denies difficulty with sleeping. He is a heterosexual male that has been married for 3 years. He has no children. He is alert and oriented to name, place, time, and situation. His speech is rapid. His facial expressions and demeanor reveal an anxious mood. He denies homicidal or suicidal ideations. Affect is appropriate and congruent with mood. There are reports of hallucinations, bizarre behaviors, or other indicators of psychotic processes. He denies illicit drug use or alcohol usage. His vital signs are stable. He is well-groomed and dressed appropriately for the occasion and the season. His behavior in the session was attentive and productive with no gross and behavioral abnormalities. He reports I” I just need to get help so that I can maintain my marriage”. The plan is to initiate psychoeducation about schizophrenia, individual CBT, add intermittent family therapy sessions to his regime, Abilify 15 mg PO daily was prescribed. A follow-up appointment was scheduled for four weeks.

 

 

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