Step 1: View clinicals

A 19 year old man presents with confusion for 2 days, in a background of multiple episodes of agitation during the last 6 months. During the latter time period, he was employed at a video store, where his behavior became progressively bizarre. He would tell customers that his employer had planted numerous small video cameras to detect his mistakes, and that the CIA was 'out to get him'. He resigned from his job a few days ago after accusing his employer of monitoring him via all of the television screens in the shop, and of also surreptitiously observing him at home. He also says that he has been hearing voices, which claimed that he is "a bad person". His medical history is unremarkable, and there is no family history of psychiatric disorders. His growth and development had been normal. He consumes alcohol in moderation, does not smoke, and denies recreational drug abuse.

Step 2: Order all relevant investigations

Serum Electrolytes + Renal Profile

Na+: 137 mEq/L(135-145) K+: 4.2 mEq/L (3.5-5.5) Cl-: 101 mEq/L (97-105) Ca++: 9.1 mg/dL (8.5-10.2) Blood Urea, Serum Creatinine: within normal parameters

CT Brain

The CT scan of the brain appears completely normal.

Urine Drug Screen

The urine drug screen is negative for alcohol, cocaine, opioids, and cannabis.

Liver Profile

AST: 20 U/L (<35) ALT: 18 U/L (<35) ALP: 45 U/L (40-125) GGT: 30 U/L (5-55) S. Bilirubin: 0.1 mg/dL (<1) INR: 1 (0.9-1.1) Albumin: 3.8 g/dL (3.4-5.4)

Step 3: Select appropriate management

Cognitive Behavioural Therapy
Transcranial Magnetic Stimulation

Score: ★★☆