Holy Child School of Davao

E. Jacinto Street, Davao City

College of Nursing

A Case Study on

Schizophrenia – Paranoid type

In Fulfillment of the Requirements in

Nursing Care Management 105

Related Learning Exposure

Psychiatric Nursing Exposure

Submitted to :

Ms. Clara Grace Lising

Mr. Kenneth Sabido

Submitted By :

March 12, 2012

TABLE OF CONTENTS

I. INTRODUCTION……………………………………………………………….A. Goals and Objectives……………………………………………………….B. Spot Map…………………………………………………………………….

II. ANAMNESIS…………………………………………………………………….A. Informants……………………………………………………………………B. NPI……………………………………………………………………………C. Genogram……………………………………………………………………D. Developmental Task………………………………………………………..

III. PHYSICAL ASSESSMENT……………………………………………………

IV. MENTAL STATUS EXAMINATION…………………………………………………………………A. Initial………………………………………………………………………….B. Final………………………………………………………………………….

V. DEFINITION OF TERMS………………………………………………………

VI. ANATOMY AND PHYSIOLOGY………………………………………………

VII. PSYCHODYNAMICS………………………………………………………….A. Etiology

1. Predisposing……………………………………………………………2. Precipitating…………………………………………………………….

B. Symptomatology……………………………………………………………C. Schematic Tracing…………………………………………………………D. Narrative……………………………………………………………………

VIII. MEDICAL MANAGEMENTA. Actual Laboratory/Diagnostic Test………………………………………B. Drug Study…………………………………………………………………

IX. NURSING MANAGEMENTA. Nursing Care Plan…………………………………………………………B. Discharge Plan……………………………………………………………

X. PROGNOSIS…………………………………………………………………XI. REFERENCES………………………………………………………………

Introduction

 “Once were thought to be possessed by demons and were feared, tormented, exiled or locked up forever”.

Schizophrenia, also sometimes colloquially called split personality disorder, is a chronic,

severe, debilitating mental illness. With the sudden onset of severe psychotic

symptoms, the individual is said to be experiencing acute schizophrenia. Psychotic

means out of touch with reality or unable to separate real from unreal experiences.

There is no known single cause of schizophrenia. As discussed later, it appears that

genetic factors produce a vulnerability to schizophrenia, with environmental factors

contributing to different degrees in different individuals. Symptoms of schizophrenia may

include delusions, hallucinations, catatonia, negative symptoms, and disorganized

speech or behavior. People with schizophrenia are at increased risk of having a number

of other mental-health conditions, committing suicide, and otherwise dying earlier than

people without this disorder.

There are five types of schizophrenia based on the kind of symptoms the person has at

the time of assessment: paranoid, disorganized, catatonic, undifferentiated, and

residual.

Our patient given name “Mr. Bill” was chosen to be the subject of this case study. He

was diagnosed with Schizophrenia-Paranoid type and manifest symptoms such as

hallucinations and delusions.

Schizophrenia occurs in all societies regardless of class, color, religion or culture. It is found in over one percent of the population over the age of 18 or as many as 51 million people worldwide.It appears between the ages of 15 and 25 with men getting the disease earlier than women according to Schizophrenia.Com, a non-profit online community that provides information, support, and education to people with schizophrenia.Schizophrenia is costly for both families and society. In the US alone, schizophrenia consumes a total of $63 billion a year for direct treatment, societal, and family costs. It is one of the Top 10 causes of disabilities in developed countries, according to the World Health Organization.

In the Philippines, a disability survey made by the National Statistics Office revealed that mental illness (which includes schizophrenia) is the third most common form of disability with a prevalence rate of 88 cases per 100,000 population.

Here in Davao, Dr. Padilla said that the Davao Mental Hospital receives an average of eight to 10 patients a day suffering from schizophrenia.

This case study is an in depth look at patients environment, we study his unique experiences and behaviors to improve some aspects of his behaviors.

This case study would help us manage future pt. with similar disease. And be a reference for future researchers this will also implicates understanding human mind and behavior in general.

This Case study was conducted at Dela Cerna Psychiatric Clinic and Rehabilitation Center at Cabantian Davao City to a 32 years old Psychiatric Pt. in cooperation with his significant others.

A.OBJECTIVES

General Objectives

At the end of the clinical exposure at Dela Cerna Psychiatric Clinic and Rehabilitaion

center for mentally challenge individual at Cabantian Davao City. We the 3rd year nursing

students of Holy Child College of Davao will be able to understand insanity and conduct a

thorough and comprehensive study about “Mr. Bill’s” disease according to data gathered from

series of interview, patients chart and data gathered from extensive research.

Specific Objectives:

1.Organized Patients data for reference of background information.

2. Show families health history, as well as the past and present illness to correlate factors that

can contribute to patients illness.

3. Make Genogram and of patients family and trace factors that can predispose to patients

disease.

4. Trace psychological development of our patient through the use of the different

developmental theories .

5. Give the best definition of the disorder and understand unfamiliar terms

6. To have a good overview of patients over all health status by presenting data gathered from a

thorough physical assessment.

7. To discuss Anatomy and Physiology of system involved

8. Make a diagram showing the pathophysiology of Schizophrenia and its relation to its

symptoms to have idea on how this affects a person.

9. To perform and evaluate the patient’s Mental Status Exam

10. To study appropriate and actual drugs of Patient.

11. To formulate individualized care plan to address needs and problems.

12. Prognose probable outcome of nursing management rendered to patient.

II. ANAMNESIS

A. Personal Data

Patient name is “Z”,33 years old Male and was born on March 17, 1978, He is a Filipino

citizen and was baptized under Catholic Religion. He is single and the eldest to their

family he resides at Prk 1 Alejal Carmen Davao del Norte.His mother is Mrs Y 48 years

old She is a plain housewife while Pt.Z’s Father Mr X, 64 yrs old a retired Principal at

Alejal Elementary School Carmen Davao del Norte.And currently manage their 24 hectar

land at Dujali, Carmen Davao del Norte.Where they grow Rice, Banana and Coconut

trees which is the source of their income.

B. Family History

1. Maternal and Paternal Grand Lineages

Mental Disease was not present on both parties. On the Paternal side, they are just a

small family, with three siblings and 2 of them are professionals, while on the Maternal

side they have a bigger family with 9 siblings The Patient’s Mother was married at the

age of 15 and next to her marry a soldier and has abundant life compare to their other

brothers and sisters.On the Maternal side Chronic unemployment is present, eccentricity

and dependency and also Drug addiction is present.

The Mother claimed that the patient was living in one of his brother in Tanay Rizal in

Manila for 3 years after graduating in college and that they heard that her brother was a

user and a pusher. They believed that the patient was influenced and used drugs when

he stayed there and also her brother was killed in front of the patient by unknown

suspects.

2. Father

The patient’s father Mr. X 64 years old is a kind and loving father he is not strict and a

good provider. He always ensure that his family meet their needs and inculcate the

importance of education to his children. His father also claimed that Patient Z was one

of his favorites. He is also a responsible husband to his wife and believes that in

disciplining it doesn’t mean you have to hurt your child that’s why when his children

commit mistake he just talked to them and instead of hitting .

Patient Z’s Father belong to a middle class society. He taked Bachelor of Science in

Education during College at St. Mary’s College at Tagum City and was able to finished

his education. He worked as a Teacher right after graduation, Although he is already

living in with the patients mother they got married just after graduation.

3. Mother

Mrs Y same with Mr X she is also a loving and caring mother. She is not so strict same

with his husband she is just a high school student when she got married to Mr. X.She did

finished her highschool and did not pursue college education because she wanted to

take care of her children. She had her first baby Pt Z. When she is 14 years old so she

needs to go to school and entrusted Pt. Z to his grandmother. She got married at the

age of 15. According to Mr Y, Mrs X is an affectionate wife she is understanding and

helps his husband at all times.

4. Sibling

Pt. Z has two younger brother and sister. Baby Boy 32 years old is next to him and Baby

Girl 31 the youngest and only girl in the family. Although sibling rivalry is present with Pt

Z and Baby Boy they still care for each other,He helps Baby Boy at all times especially

school works. Baby Girl said that Pt. Z is a strict Brother he often scold her if she come

home late and don’t allow her to go to disco even with the company of their cousins.

Baby Girl doesn’t smoke but drinks occasionally same with Baby Boy

.

C. Personal History

a.Prenatal

Mrs Y is just 14 years old when she conceived Pt. Z. They are not expecting but they are

happy when they heard that she is pregnant.Obstetrical supervision is adequate,she had

her regular check up at her Ob-gyne Dr. Abad at Christ the king Hospital Tagum City.

She had completed her pre natal check up and doses of tetanus vaccine and was able

to take her vitamins.

b.Birth

March 16, 1978 Mrs Y felt pain and starts to labor. She was rushed to Christ the King

Hospital in Tagum City. She was examined and assisted by her Doctor, Dr. Abad,After

39 weeks of conception Mrs Y gave birth to a live Baby Boy on March 17, 1978 3:30 am.

She labored for 2days and 1 night. She gave birth via normal spontaneous vaginal

delivery

c.Infancy

,The patient did not completed his vaccination because during their time the implication

of vaccination is not that strict unlike today. He was only given BCG.vaccine. Patient

was breastfeed for 3months Mrs Y would always cuddle him and feed him everytime he

cries. Because Mrs Y is still studying . she needs to entrust Mr Bill to her mother, They

then decided to bottle feed him with Bona. Every morning before going to school she

would prepare her babies milk. And her mother would take care of him until she comes

home. Her mother said that she feeds the baby when it cries and cuddle him almost all

the time He is the first grandson so he is really well loved. Mrs Y first noticed that he

sprouted his first tooth when he is 3months they had observed that he become irritable

and starts biting behavior and drooling . When both parents are at home they would start

to teach him how to walk, and talk. Pt. Z started to walked when he is 1 year and 3

months and started to talked at 1 .Mrs Y reported his first illness during his first year, he

was admitted for 1 weak at Cainglet Hospital at Panabo under the service of Dr. Boiser

because of typhoid fever.

d. Psychosexual History

At 3 years old they saw that Pt. Z starts to fondle his penis and both parents just ignored

this behavior. Masturbatory practices was not observed by parents. He was circumcised

at age 6 and lowered speech of voice was first observed during his High School year at

age 14.

e. Play Life

Pt. Z preferred to play marble when he was young according to his parents. He often

play with his Brother and sister and also to his peers outside with both sexes. He usually

leads the game but noted also by his peers to be a good follower. He usually played

mostly outside of their house than in their neighborhood. The parents did not noticed any

habit formed by particular games nor playmates. He always make sure that all his

household chores and schoolwork’s are finished and had his snacks before going out to

play.

f. School History

Patient started to enter school at age 7 at Alejal elementary School where his father is

working as a teacher , He graduated with Honors. He had his HighSchool at Carmen

National High school at age 13 he become an active member of the ROTC he attented

numerous seminars about leadership during high School According to patients

classmates he is a good to everyone.His teachers stated that he is not a problem to

them, and he is a responsible and a good leader.According to his parents he doesn’t

want to miss school even without a “Baon” it is ok with as long as he will not miss his

classl. He usually study for 30 minutes to 1 hour everyday.His Favorite subject is Art.

Even in his free time Patient Z would paint on their wall and curved wood. He graduated

with Honors again in High School.He then started his first year in College at University of

Mindanao in Tagum and taked up Bachelor of Science in Criminology, at this time the

patient started to engaged self in alcohol and cigarettes. Then patient decided to transfer

to a new school according to him people in his previous school are bad influence to him.

He finished his course at University of Mindanao in Bolton Davao City at age 22 last

March 5 1999.

g. Religious and Social Adaptability

Patient Z is noted to be friendly he selects his friends and he usually hang out with

intelligent people of their class. He is choosy, shy but if he knows you already he is

friendly. Even thou he is choosy he is still kind to other people its just that he is much

closer to his choosen friends. Patient Z was born and and baptized in the catholic

religion. He is an active member of his church and he would always goes to church

every Sunday. When patient feels down and failured he would usually sit on the corner

and keep it himself.

h. Occupational history

The patient has no current job and reported to worked only as a security guard at age

23 in Manila after graduation for 1 year.Parents don’t know the reason why patient

decided to quit his job. And that he has not saved any money during his work.

i.Marital Status

According to patients significant others he had his first girlfriend in highschool but the

girl’s parent did not liked him and that caused their breakup. Then after graduation he

went to Manila and meet his second girl they become lived in partner in manila for 2

years until the girl decided to live for no known reason.The patient is said to be a

secretive person especially in his lovelife,.And so some of love life and problems about it

are not known to them.

j.Substance used and abused

Patient is reported to abused drugs during his stay at his uncles house who is pusher in

manila. He smoked and drink alcohol regularly during his stay in Manila usually with

people around their place.When he came back in Carmen he would be invited by friends

to drink and when already drunk he usually shout and hunt his younger brother.

k. Coping Strategy

Patient is reported to be secretive in terms of problem, he usually don’t tell anyone when

he is upset. He will be found walking and sitting in there baranggay hall when he is upset

or angry but after an hour he would come back and act normally. When he cames back

from manila he would easily get mad and use his fist when he is angry to someone.

l.Family physical or mental problems

There is no mental problems within the family .But one of the Patients uncle is said to be

a drug user and pusher. And patient is said to be influenced by his uncle. And his uncle

eventually died after being shoot by an unidentified person this happens 6 years ago.

m. Onset of Present illness

The family of Patient believed that his mental illness started after he come back from

Manila. When the patient is 22 years old right after his graduation in college, He decided

to go to Manila because of his dream to enter the Armed Forces of the Philippines, Even

thought all his family tried to stop him and instead work as a policeman in their province

Patient Z still decided to go. April 21, 2000. He lived in Tanay Rizal in one of his

mother’s Older brother. They did not monitor his life with his uncle, all they know is that

he is working as a security guard and that he did enter the AFP but they don’t know what

really happens at AFP. And one of his aunt who lived in quiapo said that on June 16 of

2000 Patient Z visited them and they saw that the patient seems so emaciated, If they

ask how is he he would just answer he is fine Z also told them that he is now living in

with his girlfriend whom she meet a month ago. Then that was the last visit that the

patient did until a one morning of December 2002 a news was reported that somebody

has been killed and that man was the patients uncle and they said that it was a planned

killing because his uncle was a user and a pusher and the patient had disappear, Until

the Patient’s decided to find him with the help of his aunt. Her aunt was a overseas

worker who happened to come back at same year she was married to a soldier and

decided to find him it was almost 5 years since the family has not received any news

from the patient. Untill the patients aunts imbestigator send a good news. He has found

the Pt. in one of the provinces in quezon. According to his description he was wearing a

sack and covered his head with a plastic cellophane and he had a long hair and a beard,

dirty and he is staying on the trees.The aunt decided to bring him to a clinic so he can be

check, they give them food, cut his hair,clean him, and he was given a maintenance .

Then they decided to send him back to alejal where his parents are waiting for him. So

his aunts husband, the soldier, take him to Carmen riding a plane but The patient don’t

want to see the other soldier he seems afraid even with their uniforms. He starts to have

delusion that he is going to be persecuted by those person. So the soldiers wear civilian

clothes just for him to ride the plane and after coming back home at Carmen Davao del

Norte on May 2006 his family take care of him they continue to give him his

maintenance. They claimed improvement and they did not send him to doctor for a

check up for his past condition. According to the patients sister he seems to be anxious

of someone and afraid of people who pass at there house, that wears a black dress a

helmet and rode a motorcycle. He even told his sister not to talked to anyone he don’t

know. His sister told this to her mother but the mother seemed to be in denial when told

that his son is having mental illness and so the mother just ignore this symptoms.

Everyday the patients just stay at their house and don’t go out his brother was in davao

that time working as a security guard.Then one day, there is a disco. And the patients

friend come to there house and invited him. The patient go and took a glass of liquor

then reported to involved in a riot. Behavioral changes are seen everyday, hysterical

behaviors, poor sleep was noted but his parents managed it by giving him herbal

medicines then they brought him in an acupuncture clinic at PORRAS in tagum and they

claimed improvement. But after a months patient starts to talked to self and they

discovered that pt. is taking all his meds at once when scolded by his father he would

answer “kanus.a pman diay ko mahuman ug inum ana” so they brought him back to

PORRAS. They claimed improvement but after 5 months had relapse, Patient smoke 2

packs of cigarette per day, and drinks liquor. On Jan.8 2012 he was reported that he

slapped his cousins face and tend to become violent he verbalized “patyon ko ninyo” He

isolates himself and cries alone; Hence bought to the Davao Mental Hospital on January

20 2012. He was an out patient in Southern Philippines Medical Center prior to DMH on

January 8 2012.under the service of Dr. Lacro and was advised to be back after 2 week

for a follow up check up he was given medications such as Risperidone 2 mg 1 tab Am

and 1 tab HS, Haloperidol 5mg 1 amp IM and akidin 2mg 1 tab BID PRN for

EPS.Admitting Impression, Schizophrenia Paranoid Type and Final Diagnosis was

Schizoprenia Paranoid type.Because of overwhelming number of patients at DMH The

Parents decided to transfer the patient to Dela Cerna Psychiatric Hospital and

Rehabilitation on January 22 2012, 2pm Under the service of his physician Dr. Janet

Perez and Phsychia incharge Dr. ma. Lythia Dela Cerna Cervera. Pt. wearing a blue

shirt and maong shorts also wearing a rosary and accompanied by his parents, he is

crying, Conscious and responsive and a fair affect was noted. Medication are

Risperidone 4 mg ¼ tab Am ¼ tab Hs BPN 2mg 1tab BID, Rivotril 2 mg ¼ tab. Patient

was in Homicidal, Suicidal and escape precaution.

The patient was reported that he did not completed his immunization during childhood

her mother told that the patient at an early age suffer from many childhood diseases

such as Typhoid fever after 1 weak from discharge he was again admittedfor 1 week

under the service of Dr. Boiser because of loose bowel discharge at Cainglet Hospital at

Panabo and with diagnosis of Amoebiasis. And during his 3 years of age he was again

admitted for 1 week at the same Hospital and same attending physician because his

mother noted a yellowish discoloration in his skin he was diagnosed to have hepatitis A.

A. Informants

1. Name: Mr. X

2. Address:Prk 1 Alejal Carmen Davao del Norte

3. Relationship to Patient:Father

4. Length of time knowing the Patient: Since Birth

5. Apparent understanding to present illness of patient: “Nag adik man gud na siya

atong pag adto niya ug manila human cguro frustration pud nga wla xa kasulod sa

AFP mao na ing ana siya”

6. Characteristic and attitude of informant: The father warmly and happily welcomes

us. He is very kind and friendly. He was cooperative and answers all our question.

1. Name: Mrs Y

2. Address:Prk 1 Alejal Carmen Davao del Norte

3. Relationship to Patient: Mother

4. Length of time knowing the Patient: Since Birth

5. Apparent understanding to present illness of patient:” Wala man me kabalo naunsa

na siya nagkalit lang man, naa lang mga istorya nga sa Manila daw kay naga

drugs siya.”

6. Characteristic and attitude of informant: The mother is simple and smiled when she

see us. She is also cooperative when ask about information about his son.

1. Name: Mrs Nena

2. Address:Prk 1 Alejal Carmen Davao del Norte

3. Relationship to Patient:Aunt

4. Length of time knowing the Patient: Since Birth

5. Apparent understanding to present illness of patient: “na troma man gud na siya

kay gepatay akng igsuon sa iya jud atubangan”

6. Characteristic and attitude of informant: The informant was talkative and happily

shares information about the patient.

1. Name: Lea

2. Address:Prk 1 Alejal Carmen Davao del Norte

3. Relationship to Patient: Sister

4. Length of time knowing the Patient:Since Birth

5. Apparent understanding to present illness of patient: “Nasugdan man gud na og

adik-adik mao na ing.ana na kay kana man gud igsuon sa akong mama getudluan

na nila akong kuya.”

6. Characteristic and attitude of informant: The informant was a strong person she

was hesitant at first but eventually open up and shared information about her

brother.

1. Name: Rasec

2. Address:Prk 8 Ising Carmen Davao del Norte

3. Relationship to Patient: Friend

4. Length of time knowing the Patient:Since High School

5. Apparent understanding to present illness of patient: “natingala lang man

nganu na ing. Ana mn siya nga but’an man kaau na siya nga tao wla pud bisyo

atong nag iskwela pa me, ingon nila sa manila daw naadik dawn na siya

human wla niya ma control mao na ing.ana”

6. Characteristic and attitude of informant: Informant was nice and openly shares

information about the patient

Narrative History:

On the paternal side both pts grandparents died of old age. They only have 3 sibling.Ram the

eldest was aborted accidentally when Ning slipped on the floor, then Luz 65 years old a retired

teacher and has hypertension. Then the youngest is the pts father X 63 years old male he dont

have any ailments because he is a sporty person.On the maternal side his Grandparents linda

and Jose are both deceased jose died because of old age while his wife linda died with no

known reason. They have 9 siblings Boy the eldest died at age 18 because of vehicular

accident then next Yna married with no work then Lando died because of a gunshot and is

rereported to be a drug addict.Then next is The pts mother Y 43 years old with no noted

ailments at present. Next to her is Linda with hypertension, Then Nato who died also at age 24

because of a vehicular accident Then Kardo with arthritis and Mario with arthritis also then pila

with hypertension and the eldest is Ben.X and Y has 3 siblings Patient Z eldest and diagnosed

recently with Paranoid schizophrenia Next to her is Ben 32 years old and the Eldest the only

female Lisa 31years old.

D. Developmental Task

Developmental

stage

Task Achieved Not

achieved

Justification

Trust Vs,

Mistrust

(Birth to 18

months)

Autonomy Vs.

Shame and

doubt

(18 months to 3

years)

Initiative Vs.

Guilt

(3 to 5 years old)

Industry Vs.

Inferiority

(6 to 12 years)

Identity Vs. Role

Confusion

( 12 to 18 years)

Intimacy Vs.

Isolation

( 18-35 years)

III. Physical Assessment

Name: Z

Date of Assessment: March 2, 2012

Time of Assessment:2:30 pm

Location of Assessment:Dela Cerna Psychiatric and Rehabilitation Center

Cabantian Davao City.

Vital Signs: BP 100/60milimeter mercury

Wt: 76 kilogram

CR: 79beats per minute

RR: 24 cycles per minute

Temp: 36.5 Degrees Celsius

General Survey:

Our Pt. Z was assessed on March 2, 2012@ 2:30pm. He was siiting on the chair behind

the wall of the convention room. He was conscious, oriented and coherent when asked. He is

cooperative and appears happy. He is wearing a clean white shorts and a blue shirt.

Skin

Patient has fair skin, has good skin turgor,Nails were properly trimmed with no traces of dirt

noted upon inspection, warm to touch skin, No rashes nor inflammation noted.Pt. Temperature

is in normal range.

Head

Pt’s head is normocephalic. Involuntary, Lesions, bleeding and bruises were not seen upon

inspection.Hair is Black and well cut. With no dandruff noted.

Eyes

Eyelids are symmetrical, pink conjunctiva noted. Sclerae is clear and icteric. Iris appears black

on both eyes. She has isocoric pupil of 2mm; Round and reactive to light accommodation. Both

eyes moved in unison with no signs of scratches and discharges on both eyes.

Ears

Externa pinnae are aligned to the outer canthus of each eye and are symmetrical.The shaped of

the pinnae are oval with no discharges noted. Ears are firm and non tender. Signs of lasions,

lacerations, swelling and bruises were not seen upon inspection. She was able to repeat

sentences when softly said behind his ears, which reveals that he has no hearing problems.

Nose

External surface of the nose is smooth and oily. Nasolabial folds are symmetrical. Nostrils are

also symmetrical with no flaring and discharges. Nasal hairs are present upon inspection. Nasal

septum is not deviated. Both nostrils are patent. No signs of tenderness noted. Patient was able

to distinguish the smell of the rubbing alcohol and female Perfume while eyes are closed.

Mouth

Gums and buccal mucosa are pinkish in color. Uvula is positioned in the midline of the soft

palate Tongue is in the midline of the mouth. No signs of inflammation and laceration of the

uvula. Tonsils are not inflamed. Bleeding, ulceration and swellingwere not seen upon

inspection.Patyient was on Diet as tolerated and does not have difficulty in eating and

swallowing.

Neck

The neck of pt. can moved easily without any difficulty, which includes right and left rotation and

hyperextension. Neck properly supports head with no signs of thyroid enlargement and lymph

nodes. No deformities noted.

Chest and lungs

Chest muscle expand during inspiration and relaxation, during expiration are symmetrical and

painless. No presence of scars and lesions. He was not in respiratory distress. Respiratory rate

is 24cycles per minute, rhythm was regular. Breath sounds were clear on both lungs.

Heart

Heart rate is normal and regular in rhythm. Apical pulse is auscultated at fifth intercostals space

left midclavicular line. Heart sound is clear. Murmurs are not noted.

Abdomen

Patient abdomen is globular and not distended upon inspection. Normoactive bowel sound of 16

in one full minute is noted. Tenderness is not noted. No abrasion or scars noted.

Genitourinary

Patient refused to assess genital area. However patient verbalized no pain or difficulty upon

urination and defecation. His total urine output for 8 hours was about 640cc. It is a straw colored

urine. And defecate once a day with clay colored urine.

Upper Extremities

Patients upper limbs and shoulders and arms were symmetrical. No tenderness noted on both

bones of the wrist and fingers. No deformioties and swelling noted. He could freely move her

shoulders. The patient has strong grip when asked to squeeze one of my hands. No structural

deviation noted. And edema was not noted.

Lower Extremities

Both legs of patients are symmetrical and can stretch, flexed, rotate, extend and bend without

any difficulty. No signs of deformities, lesions, and lacerations noted bruises were not seen

upon inspection.

Holy Child College of Davao

College of Nursing

MENTAL STATUS EXAMINATION

Name of Patient:_______________________________ Date:______________________

I. Pre-Examination

A. General Apperance:________________________________________________

B. General Mobility:___________________________________________________

1.Posture & Gait:___________________________________________________

2. Activity: ( ) normoactive ( )Psychomotor retardation

( )hyperactive ( )agitated

3. Facial Expression:_______________________________________________

C. Behavior ( ) friendly ( )impulsive ( )angry

( ) negativistic ( ) evasive ( )seductive

( )withdrawn ( )embarrassed ( )indifferent

D. Doctor- Patient Interaction

( ) cooperative ( ) uncooperative

( ) initially

( ) all throughout

Quality: ( ) warm ( ) distant ( ) dependent

( ) hostile ( ) suspicious ( ) talkative

Others:__________________________________

II. Stream Of Talk

A. Character

( ) spontaneous ( ) deliberate ( ) Pressured ( ) blocking

B. Organization

( ) relevant ( ) loose association ( ) Tangentiality

( ) Irrelevant ( ) flight of ideas ( ) neologism

( ) incorrect ( ) circumstantiality ( ) others

C. Accessibility

( ) good ( ) self absorbed ( ) defensive

( ) fair ( ) mute ( ) inaccessible

III. EMOTIONAL STATE AND REACTIONS

A. Mood

( ) euthymic ( ) depression ( ) euphoria

B. Affect

( ) appropriate ( ) Inappropriate

Quality:

( ) flat ( ) elated ( ) Histrionic

( ) Blunted ( ) labile ( ) angry

( ) hostile ( ) anxious ( ) others_______________________

C. DEPERSONALIZATION and DEREALIZATION

( ) present ( )absent

D. SUICIDAL IDEATION

( ) present ( ) absent

IV. THOUGHT CONTROL

A. PERCEPTION

( ) present ( ) absent

B. DELUSIONS

( ) Present ( ) absent

Type:___________________________________________________________

C. IDEAS OF REFERENCE ( ) present ( ) absent

D. PREOCCUPATIONAL AND RUMINATIONS( ) present ( ) absent

E. DÉJÀ VU and JAMAIS VU ( ) present ( ) absent

V. NEUROVEGETATIVE DYSFUNCTION

A. SLEEP

( ) normal ( ) MNA ( ) DFA

( ) Hypersomnia ( ) EMA ( ) interrupted sleep

B. APPETITE_____________________________________________________

C. DIURAL VARIATION_____________________________________________

D. WEIGHT_____________________________

E. LIBIDO______________________________

VI. GENERAL SENSORIUM AND INTELLECTUAL STATUS

A. ORIENTATION Time:_________ Place:________ Person:_______

Situation:______________________________________

B. MEMORY Remote:_______ Recent:________Immediate:_____

C. ATTENTION SPAN: ( ) Good ( ) Fair ( ) Poor

D. GENERAL INFORMATION___________________________________________

E. ABSTRACT THINKING ABILITY______________________________________

F. JUDGEMENT AND REASONING ( ) unimpaired( ) impaired

VII. INSIGHT:

( ) unimpaired ( ) intellectual

( ) impaired ( ) true

VIII. SUMMARY OF MENTAL STATUS EXAMINATION

A. DISTURBANCE IN

( ) Presentation ( ) Neurovegetative dysfunction

( ) Stream of Talk ( ) General Sensorium and Intellectual status

( ) thought Control ( 0 Emotional state and Reaction

( ) insight

B. DIAGNOSTIC CATEGORY

( ) Functional ( ) psychotic

( ) Organic ( ) non-psychotic

C. DSM III-R DIAGNOSIS

AXIS I_______________________________________________________

AXIS II_______________________________________________________

AXIS III_______________________________________________________

AXIS IV

Psychosocial Stressors_____________________________________

Severity_________________________________________________

AXIS V

Current GAF______________________________________________

Past Year GAF_____________________________________________

________________________ ______________________ _________________

Student Resident Consultant

Holy Child College of Davao

College of Nursing

MENTAL STATUS EXAMINATION

Name of Patient:_______________________________ Date:______________________

IX. Pre-Examination

E. General Apperance:________________________________________________

F. General Mobility:___________________________________________________

1.Posture & Gait:___________________________________________________

2. Activity: ( ) normoactive ( )Psychomotor retardation

( )hyperactive ( )agitated

4. Facial Expression:_______________________________________________

G. Behavior ( ) friendly ( )impulsive ( )angry

( ) negativistic ( ) evasive ( )seductive

( )withdrawn ( )embarrassed ( )indifferent

H. Doctor- Patient Interaction

( ) cooperative ( ) uncooperative

( ) initially

( ) all throughout

Quality: ( ) warm ( ) distant ( ) dependent

( ) hostile ( ) suspicious ( ) talkative

Others:__________________________________

X. Stream Of Talk

D. Character

( ) spontaneous ( ) deliberate ( ) Pressured ( ) blocking

E. Organization

( ) relevant ( ) loose association ( ) Tangentiality

( ) Irrelevant ( ) flight of ideas ( ) neologism

( ) incorrect ( ) circumstantiality ( ) others

F. Accessibility

( ) good ( ) self absorbed ( ) defensive

( ) fair ( ) mute ( ) inaccessible

XI. EMOTIONAL STATE AND REACTIONS

E. Mood

( ) euthymic ( ) depression ( ) euphoria

F. Affect

( ) appropriate ( ) Inappropriate

Quality:

( ) flat ( ) elated ( ) Histrionic

( ) Blunted ( ) labile ( ) angry

( ) hostile ( ) anxious ( ) others_______________________

G. DEPERSONALIZATION and DEREALIZATION

( ) present ( )absent

H. SUICIDAL IDEATION

( ) present ( ) absent

XII. THOUGHT CONTROL

F. PERCEPTION

( ) present ( ) absent

G. DELUSIONS

( ) Present ( ) absent

Type:___________________________________________________________

H. IDEAS OF REFERENCE ( ) present ( ) absent

I. PREOCCUPATIONAL AND RUMINATIONS( ) present ( ) absent

J. DÉJÀ VU and JAMAIS VU ( ) present ( ) absent

XIII. NEUROVEGETATIVE DYSFUNCTION

F. SLEEP

( ) normal ( ) MNA ( ) DFA

( ) Hypersomnia ( ) EMA ( ) interrupted sleep

G. APPETITE_____________________________________________________

H. DIURAL VARIATION_____________________________________________

I. WEIGHT_____________________________

J. LIBIDO______________________________

XIV. GENERAL SENSORIUM AND INTELLECTUAL STATUS

G. ORIENTATION Time:_________ Place:________ Person:_______

Situation:______________________________________

H. MEMORY Remote:_______ Recent:________Immediate:_____

I. ATTENTION SPAN: ( ) Good ( ) Fair ( ) Poor

J. GENERAL INFORMATION___________________________________________

K. ABSTRACT THINKING ABILITY______________________________________

L. JUDGEMENT AND REASONING ( ) unimpaired( ) impaired

XV. INSIGHT:

( ) unimpaired ( ) intellectual

( ) impaired ( ) true

XVI. SUMMARY OF MENTAL STATUS EXAMINATION

D. DISTURBANCE IN

( ) Presentation ( ) Neurovegetative dysfunction

( ) Stream of Talk ( ) General Sensorium and Intellectual status

( ) thought Control ( 0 Emotional state and Reaction

( ) insight

E. DIAGNOSTIC CATEGORY

( ) Functional ( ) psychotic

( ) Organic ( ) non-psychotic

F. DSM III-R DIAGNOSIS

AXIS I_______________________________________________________

AXIS II_______________________________________________________

AXIS III_______________________________________________________

AXIS IV

Psychosocial Stressors_____________________________________

Severity_________________________________________________

AXIS V

Current GAF______________________________________________

Past Year GAF_____________________________________________

________________________ ______________________ _________________

Student Resident Consultant

Definition of Diagnosis

Paranoid Schizophrenia-

Reference:

Paranoid Schizophrenia

Reference:

Paranoid Schizophrenia

Reference:

VI. ANATOMY AND PHYSIOLOGY

Mesolimbic pathway

Mesolimbic dopaminergic and serotonergic pathways.

The mesolimbic pathway is one of the dopaminergic pathways in the brain. The pathway

begins in the ventral tegmental area of the midbrain and connects to the limbic system via

the nucleus accumbens, the amygdala, and the hippocampus as well as to the medial prefrontal

cortex. The mesolimbic dopamine system is widely believed to be a "reward" pathway, but that

theory is not universally accepted.

Following structures are considered to be a part of the mesolimbic pathway:

Ventral Tegmental Area

The ventral tegmental area (VTA) is a part of the midbrain. It consists of

dopaminergic, GABAergic, and glutamatergic neurons.The VTA communicates with the nucleus

accumbens via the medial forebrain bundle.

Nucleus Accumbens

The nucleus accumbens is found in the ventral striatum and is composed of medium spiny

neurons It is subdivided into limbic and motor subregions known as the shell and core. [2] The

medium spiny neurons receive input from both the dopaminergic neurons of the VTA and the

glutamatergic neurons of the hippocampus, amygdala, and medial prefrontal cortex. When they

are activated by these inputs, the medium spiny neurons' projections release GABA onto

the ventral pallidum. The release of dopamine in this structure drives the mesolimbic system.

Amygdala

The amygdala is a large nuclear mass in the temporal lobe anterior to the hippocampus. It has

been associated with the assignment of emotions, especially fear and anxiety. There are two,

one in each temporal lobe, and their functions may be lateralized.

Hippocampus

The hippocampus is located in the medial portion of the temporal lobe. It is known for its

association with double memory (i.e., bothprocedural and declarative memory).

Bed Nucleus of the Stria Terminalis

Controversy over mesolimbic dopamine function

There is some controversy regarding dopamine’s role in the reward system. Three hypotheses

— hedonia, learning, and incentive salience — have been proposed as explanations

for dopamine’s function in the reward system. The hedonia hypothesis suggests

that dopamine in thenucleus accumbens acts as a 'pleasure neurotransmitter'. Historically, in

the late 1970s, it was found that some drugs of abuse involved dopamine activity, particularly in

the nucleus accumbens, to cause the "high" or euphoric state. However, not all rewards or

pleasurable things involve activation of the reward system, which may suggest that the

mesolimbic pathway may not be just a system that works merely off enjoyable things

(hedonia). Learning, on the other hand, deals with predictions of future rewards and association

formation. Studies have shown that rats that had their ventral tegmental area and nucleus

accumbens destroyed do not lose their learning capabilities, but rather lack the motivation to

work for a reward.Incentive salience (wanting) stands out as a possible role for dopamine as it

regards this molecule as being released when there is a stimulus worth working hard for, thus

making an individual work to get it. This is one of the reasons whydopamine transport has been

extensively studied in the case of ADD and ADHD. It is now widely understood that most people

suffering from some form of attention deficit disorder most likely lack dopamine stimulation. This

also explains why dopamine reuptake inhibitors and stimulants often dramatically improve

symptoms of attention disorders. In self-administration studies, animals have been trained to

give anoperant response (lever press, nose poke, wheel turn, etc.) in order to obtain either a

drug or mate. It has been shown that the animals will continue to perform the required task until

the reward is received, or fatigue sets in.

Clinical significance

Since the mesolimbic pathway is shown to be associated with feelings of reward and desire, this

pathway is heavily implicated inneurobiological theories of addiction, schizophrenia,

and depression. Drug addiction, the loss of control over drug use or the compulsive seeking and

taking of drugs despite adverse consequences, with the four major classes of abused drugs

(psychostimulants, opiates, ethanol, and nicotine) are due to increased dopamine transmission

in the limbic system-each by different mechanisms.Like drug addiction, schizophrenia and

depression have similar structural changes with dopamine transmission.

Psychodynamics

Etiology

Predisposing

Factors

Presen

t

Absent Justification Rationale

Genetics X According to our

interview no one

suffer from mental

illness in the family.

It is widely agreed that

both hereditary and

environmental play an

important factor . Because

genes can be passed

through the next

generation. (Merikangas et

al, 2002: Sulivan, Neale,

and kindler, 2000)

Maternal Factors X The mother has

adequate pre natal

care. She was not

stree and well

nourished during her

conception.

Factors such as hypoxia

and infection, or stress

and malnutrition in the

mother during fetal

development, may result

in a slight increase in the

risk of schizophrenia later

in life.

Age-27 years old He was 27 when

symptoms occur.

Schizophrenia may

developed usually in

middle adulthood.

Gender- Male Client manifested

symptoms such as

delusion,

hallucinations and a

flat affect.

Schizophrenia are

commonly affecting male

than female.

Race- asian X He is born in the

Philippines which is a

tropical country.

People diagnosed with

schizophrenia are more

likely to have been born in

winter or spring (at least in

thenorthern hemisphere),

Precipitating Factor Presen

t

Absent Justification Rationale

Substance Abuse Patient was reported

to use drugs during

his stay in Manila.

A number of drugs have

been associated with the

development of

schizophrenia,

including cannabis, cocain

e, and amphetamines.

[3] About half of those with

schizophrenia use drugs

and/or alcohol excessively

(Pocket Guide for Nurses

Lippincott and Williams 4th

edition)

Environmental Stress X Patients environment

was calm and quiet.

It is widely agreed that

environmental play an

There house is made

of light materials but

all things are fixed.

important role in triggering

illness (Merikangas et al.

2002; Sulivan, Neale, and

Kendler, 2000)

Infections X Patient was

hospitalized but

those illness that

cant trigger his

mental conditions.

A recent study shows that

exposure to influenza and

trend tend to stimulate

faulty firings of

neurotransmitters.

Trauma Patient’s uncle was

shot in front of him

causing trauma. And

pt. has delusion of

persecution.

Refers to traumatic

experiences of a person

that involves loss of

significant person.

(Psychiatric Nursing, 8th

edition)

Biological Factors

a. Endocrine

system

b. Cortisol

c. Neurotransmitt

ers

Patient has mood

problems which a

result of imbalances

in his

neurotransmitters.

The biological model

explores chemical

changes in the body

during depressed states.

Significant abnormalities

can be seen in many body

systems during depressive

illness. (Psychiatric

Nursing 8th edition)

Symptomatology

Signs and

Symptoms

Present Absen

t

Justification Rationale

Positive

Symptoms

Hallucination

Delusion

Negative

Symptoms

Blunted affect

Alogia

Anhedonia

Asociality

avolition

Schematic Tracing

Narrative:

Medical management

Actual laboratory test/ Diagnostic Test

Complete Blood Count

Patient Name: Z Ref # 11903 Date: 01/23/2012 Age:33

Physician Name: Dela Cerna Hospital Sex: M

Routine Normal Value Result Interpretation

Hemoglobin

Hematocrit

White Blood Cells

Neutrophils

Lymphocytes

Monocytes

Eosinophils

Donna P. Gallosa RMT/Ariel P. Guillermo RM Oscar P. Orageda, M.D FPSP

Medtech Pathologist

Urinalysis

Physical Normal value Result Interpretation

Color Straw

Transparency Clear

pH 5.0

Specific Gravity 1.005

ChemicalProtein Negative

Glucose Negative

Microscopic

Pus Cells 0.2/HPF

RBC 0-1/HPF

ECG Result

Buhangin Medical Clinic and Diagnostic Center January 30, 2012

Atrial Ventricular Rate: 78/min PR interval: With in Normal Range

Rhythm: Sinus QRS interval: With in Normal Range

Axis +45 Degree QTinterval: With in Normal Range

Pwave: Upright QRS Complex:With in Normal Range

ST Segment: With in Normal Range

Others:_________________________________________________________________

________________________________________________________________________

Interpretation: Normal Sinus Rhythm

Victorio C. Aguirre MD

Internal Medicine

Discharge Planning

Action/Order Rationale

Medications

Exercise

Treatment

Hygiene

Out patient

Diet

Spirituality

Sexuality

Prognosis

Criteria Poor fair Good Justification

Duration Of Illness

Onset of Illness

Predisposing/

Precipitating factor

Compliance to treatment

regimen

Age

Environment

Family Support

Total

Reference: