An 18 year-old man, Rhys, is brought to the ED by his mother. It is the weekend and they are on holiday in the area. His mother is concerned that there is something wrong with him. She states that they came on holiday to have a break as he has just finished his exams. Over the last few months he has become more reclusive, saying that people are moving and interfering with his belongings in his room when no one has been into his room.
In the ED, Rhys is very suspicious of the doctor, believing him to be a government spy. After a little time, the doctor gains Rhys trust and Rhys explains that he knows people have been watching him over the last few weeks. He says that he was looking forward to going on holiday, as he thought “they” wouldn’t be able to follow him. However, since arriving, it has got a lot worse and the only safe place for him now is in his hotel room. When asked by the ED doctor how he knows that people are following him, Rhys says that he can see them and that occasionally the television has been talking to him, warning him. Also, he mentions that hes noticed more people looking at and following him. Occasionally he has heard those men taking about him, saying they are watching him. There is no evidence of abnormal mood, incoherence of speech or disturbed motor function. He has no past relevant medical history or psychiatric history and is generally fit and well. Collateral history from his mother confirms this. He denies alcohol or other substance abuse. He is beginning to become agitated again.
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What is the next step in the management of this patient?
Observations and blood test and urine test results are all in normal range. What is the most likely diagnosis based on current findings?
Which of these suggest a psychiatric presentation as opposed to an organic cause?
As Rhys continues to wait in the department, you notice him getting more and more agitated. He feels that everyone is watching him, and they are conspiring against him. He starts pacing around the cubicle, hitting and kicking furniture and walls in the cubicle space.
What is the next step in his management?
Briefly, Rhys becomes calmer but then his agitation escalates rapidly. He is now convinced that he is surrounded by government spies who are threatening his life. He starts throwing small items in the cubicle at any member of staff who tries to approach him. You and your senior agree that sedation has become appropriate as he is at risk of harming himself and others. Your first choice of sedation is: