Problem:
What is the diagnosis of this patient? 18 year old Hispanic male admitted for auditory hallucinations. This is his first hospitalization, no prior psychiatric hx. Pt was not sleeping for days and experienced auditory hallucinations. Pt has no previous psychiatric history. Pt had a break up with girlfriend in the beginning of the year which was a stressor to him, resulting in first time episode of feeling depressed, isolated, hopeless and low energy and him using cannabis for the first time in March 2024 and increasingly using it. As per nursing, no overnight events, pt received PRN Trazodone 50 mg at 2102 and slept about 8 hours. Upon approach, pt has poor eye contact. Pt is calm and superficially cooperative. Mood is depressed and anxious, affect is appropriate. Insight and judgement are fair. Pt denies SI/HI/AVH. No behavioral or perceptual disturbances noted since admission. Pt refused Sertraline 50 mg last night, however was compliant with Risperidone 0.5 BID. Psychoeducation reinforced regarding Sertraline and its antidepressant effects as well as its effect on anxiety. Pt verbalized understanding and in agreement to comply. Plan is to continue Sertraline 50 mg daily and Risperidone 0.5 mg BID. Daily cannabis use since March 2024