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Situation: David Carter, a 28-year-old male, was admitted today after he became violent with his mother and threw a table at her when she asked him to take his medications. She then called the police, who brought him to the emergency room. Background: David has a 10-year history of schizophrenia and has previously been stable on his medications. However, recently he has become more isolated, not going out and always sitting at his computer, and his mother reports that he has been posting some pretty weird updates online. Lately he has also been talking about his food being poisoned, so his mother suspects that he has stopped taking his medications, probably because he believes they are responsible for his weight gain. The current medications, which he has been taking for the last year, include olanzapine 10 mg and venlafaxine XR 75 mg daily. During his admission, he was alternately agitated and withdrawn, but he did answer questions, although at times inappropriately. He has paranoid delusions, believing that people are listening to his thoughts, and he has auditory hallucinations telling him that he should not eat the hospital food because it is poisoned. His speech is tangential with some evidence of neologisms, and it is difficult to carry on a conversation with him. He has refused a shower and has a disheveled, dirty appearance. Assessment: I have finished most of the admission; I have taken his vital signs, recorded his history, and obtained the history of his present illness from his mother. All that is left is the mental status examination. He is in his room, and his mother just left. David refused to eat his dinner but did drink a few sips of water from a sealed water bottle. His vital signs, as follow, are stable: temperature, 37.2°C (99°F); heart rate, 90 beats/min; respiratory rate, 16 breaths/min; blood pressure, 134/84; and blood oxygen saturation, 96%. He appears tired. With a lot of coaxing, I did get him to take his medications. Recommendation: Please complete a mental status examination, orient him to reality, offer food, and find ways to encourage him to eat it. Please also call the charge nurse with the report when you have completed your assessment.

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