Interpretation of schizophrenia case

generally

Liu Mou, 16 years old, student, unmarried
.

Main complaint: emotional instability, nervousness with physical discomfort, poor sleep, and a total course of 2.
5 years
.

History of present illness

November 2018: In the second year of the junior high school, I transferred from Nanjing to Shanghai to study.
I felt nervous and heavier
.
Depressed, unhappy, crying in bed, insomnia, difficulty falling asleep, nightmares, and a person who looks exactly like him in the dream claims to kill her and replace her life

June 2019: My condition is stable, my final exam is not good (second year), I didn't suspend school, during treatment, I would fall asleep after taking medicine
.
I have been biting my fingernails since I was a child, and started biting my hands this year

August 2020: The condition is still the same, there are still auditory hallucinations and delusions.
When I hear someone scolding myself at home, whenever I feel that someone is going to kill myself, I feel that I am going to replace myself in my mind
.
He was given olanzapine 10 mg qn, fluoxetine 40 mg qd, and aripiprazole 5 mg qd

November 2020: The condition is still the same, after a period of time, it has improved, and when I encounter bad memories in the past, I feel depressed.
When I return to school, I feel nervous.
I feel like I have entered a space and cannot hear other people's voices.
As soon as 8 o'clock, Hallucinations appear, feeling manipulated
.
Everything was normal during the day, except for school, no discomfort, maintained the original treatment plan

July 2021: The condition recurs.
The patient feels that he is gaining weight and is unwilling to continue taking the medication, so he stopped taking the medication by himself in May
.
One month after stopping the medication, I started to have the phenomenon of not knowing people, and I had severe hallucinations.

Past history

Allergic rhinitis
.

Personal history

There is no abnormality during pregnancy, full-term delivery, breastfeeding, normal growth and development in childhood
.

Family history

Deny the family history of mental abnormalities in two lines and three generations
.
Deny the family history of neurological diseases in two lines and three generations

Mental examination

Clear consciousness, contact and cooperation, low mood, obvious auditory hallucinations, negative behavior
.

diagnosis

Schizophrenia is accompanied by severe depressive symptoms
.

After treatment

Week 1: Lurasidone 40 mg qn, olanzapine 5 mg bid, fluoxetine 40 mg qd, amisulpride 200 mg bid
.

Week 2: Lurasidone 80 mg qn, Olanzapine 2.
5~5 mg, Fluoxetine 40 mg qd, Amisulpride 200 mg bid
.

Week 3: Lurasidone 80 mg qn, Olanzapine 5 mg qn, Fluoxetine 20 mg qd, Amisulpride 200 mg bid
.

Efficacy evaluation: After 3 weeks of treatment, the patient's hallucinations have been significantly improved, and he no longer sees his boyfriend
.
The mood has improved significantly, and there is no self-injury or self-harm.

Treatment thinking and experience

The patient is diagnosed with schizophrenia, has obvious hallucinations and delusions, and has more stubborn emotional problems
.
The patient's previous medication can be adhered to under the supervision of the parents