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Patient Deng XX, female, 18 years old, student; chief complaint: the suspect was killed for 8 months
.
History of present illness
History of present illnessAfter the patient had an argument with his classmates 8 months ago, he felt that his classmates were talking about themselves, saying bad things behind their backs, and monitoring themselves.
Every word and deeds of the patient were monitored by strangers.
He felt that someone would want to harm himself and his family
.
The patient believed in this, and was very scared and nervous
Mental examination
Mental examinationClarity, complete orientation, correct answers to questions, nervous expression, lack of coordination with the surrounding environment, coordination with inner experience, being commented, persecuted delusions, average reaction, still focused, decreased memory, normal bowel movements, difficulty falling asleep , Many nightmares, early wake up, good appetite, incomplete insight
.
Physical examination
Physical examinationClear consciousness, stable vital signs, no obvious abnormalities in cardiopulmonary auscultation; no positive signs in the nervous system
.
Laboratory examination
Laboratory examinationBlood routine, liver and kidney function, blood lipids: no abnormalities
.
CT chest radiograph: the heart and lungs are normal
Auxiliary examination
Auxiliary examinationSCL-90: Moderate somatization, depression, anxiety
.
Self-evaluation of depression and anxiety: moderate
initial diagnosis
initial diagnosisICD-10: Schizophrenia
.
Treatment programs
Treatment programs1.
Lurasidone 40 mg orally once a day; 2.
Mirtazapine 7.
5 mg orally once a night
.
In the second week, the patient was monitored and the delusion of being persecuted was relieved, but he was still nervous, worried, and still had poor sleep
.
Lurasidone was increased to 80 mg/d, and mirtazapine was increased to 15 mg
Current condition
Current conditionAfter increasing the dosage of lurasidone, the patient's current spirit and appetite are okay, and there is no complaint that anyone is targeting and persecuting himself, and he clearly knows that the previous symptoms are untrue, his insight is restored, and he can sleep at night
.
Continue to take medication to consolidate treatment
Treatment discussion
Treatment discussionLurasidone not only performs well in controlling positive symptoms in the acute phase of schizophrenia, but also performs well in negative symptoms, emotional symptoms and cognitive improvement; more importantly, in the long-term maintenance treatment of schizophrenia, Lurasidone also has little effect on weight gain, blood lipids and blood glucose metabolism, especially for female patients
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