A 19-Year-Old Student With Declining Grades and Odd Behavior

Anne McBride, MD; Glen Xiong, MD

Disclosures

December 26, 2018

Physical Examination and Workup

Upon examination, the patient is a tall, thin young man. He is dressed in oversized clothing that appears to have stains on the front. His hair appears greasy and unkempt. He is somewhat malodorous. He rarely makes eye contact and looks down while talking. He sits down and maintains an odd rigid posture.

The patient speaks minimally, with little spontaneity. He provides answers that are typically one or two words and contain sparse detail. He reports that his mood is "fine," but it appears neutral. His outward emotions are extremely restricted. His affect appears to be flat.

When asked why he left college approximately 6 months prior, the patient mumbles something about being poisoned and that "they" know his "true identity." He does not make eye contact with the physician. He denies excessive use of drugs or alcohol and reports he stopped smoking marijuana at the request of his roommate. He has no history of head trauma. He also reports an aunt on his mother's side who was in a psychiatric hospital for decades.

He states that he does not hear or see things that others don't hear or see. He also does not acknowledge smelling things that others do not. However, he is observed in the waiting room occasionally talking out loud to unseen others. When asked about thoughts or plans of suicide, he stated that he "would not do such things." He denies any homicidal thoughts. His thought process is slow, and his ideas are occasionally disconnected. His affect is flat, and he uses a monotone voice, even when describing efforts to poison him.

The patient is oriented to time, place, and person. His memory, although vague, is intact for immediate, recent, and long-term events. When he is asked abstract meaning for such quotes as "a person who lives in a glass house should not throw stones," his replies are personalized, expansive, and overly abstract.

The patient's basic metabolic panel, complete blood count, thyroid-stimulating hormone level, liver function tests, lipid panel, urinalysis, urine drug screen, and blood alcohol level findings are all normal. An MRI of the head is obtained, which is unremarkable (Figure 1).

Figure 1.

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