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. ANAMNESIS. A. Informants B. NPI C. Genogram D. Developmental Task.. PHYSICAL ASSESSMENT MENTAL STATUS EXAMINATION A. Initial. B. Final. DEFINITION OF TERMS ANATOMY AND PHYSIOLOGY PSYCHODYNAMICS. A. Etiology 1. Predisposing 2. Precipitating. B. Symptomatology C. Schematic Tracing D. Narrative MEDICAL MANAGEMENT A. Actual Laboratory/Diagnostic Test B. Drug Study NURSING MANAGEMENT A. Nursing Care Plan B. Discharge Plan PROGNOSIS REFERENCES

II.

III. IV.

V. VI. VII.

VIII.

IX.

X. XI.

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. Bills 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 patients 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.Zs 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 Patients 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 patients 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 doesnt mean you have to hurt your child thats why when his children commit mistake he just talked to them and instead of hitting . Patient Zs Father belong to a middle class society. He taked Bachelor of Science in Education during College at St. Marys 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 dont allow her to go to disco even with the company of their cousins. Baby Girl doesnt 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 schoolworks 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 doesnt 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 dont 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 girls 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 dont 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 mothers 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 dont 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 Patients 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 dont 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 dont 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 dont 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 tab Am tab Hs BPN 2mg 1tab BID, Rivotril 2 mg 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 butan 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 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. Task Achieved Not achieved Justification

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

Pts 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:_______________________________ I. Pre-Examination

Date:______________________

A. General Apperance:________________________________________________ B. General Mobility:___________________________________________________ 1.Posture & Gait:___________________________________________________ 2. Activity: ( ) normoactive ( )hyperactive ( )Psychomotor retardation ( )agitated

3. Facial Expression:_______________________________________________ C. Behavior ( ) friendly ( ) negativistic ( )withdrawn D. Doctor- Patient Interaction ( ) cooperative ( ) uncooperative ( )impulsive ( ) evasive ( )embarrassed ( )angry ( )seductive ( )indifferent

( ) 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 ( ) neologism ( ) others

( ) Irrelevant ( ) flight of ideas ( ) incorrect C. Accessibility ( ) good ( ) fair III. ( ) self absorbed ( ) mute ( ) circumstantiality

( ) defensive ( ) inaccessible

EMOTIONAL STATE AND REACTIONS A. Mood ( ) euthymic B. Affect ( ) appropriate ( ) Inappropriate Quality: ( ) flat ( ) Blunted ( ) hostile ( ) elated ( ) labile ( ) anxious ( ) Histrionic ( ) angry ( ) others_______________________ ( ) depression ( ) euphoria

C. DEPERSONALIZATION and DEREALIZATION ( ) present ( )absent

D. SUICIDAL IDEATION ( ) present ( ) absent

IV.

THOUGHT CONTROL A. PERCEPTION ( ) present B. DELUSIONS ( ) Present ( ) absent ( ) absent

Type:___________________________________________________________ C. IDEAS OF REFERENCE ( ) present ( ) absent ( ) absent ( ) absent

D. PREOCCUPATIONAL AND RUMINATIONS ( ) present E. DJ VU and JAMAIS VU ( ) present

V.

NEUROVEGETATIVE DYSFUNCTION A. SLEEP ( ) normal ( ) Hypersomnia ( ) MNA ( ) EMA ( ) DFA ( ) 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:_______ ( ) Fair Recent:________Immediate:_____ ( ) Poor

C. ATTENTION SPAN: ( ) Good

D. GENERAL INFORMATION___________________________________________ E. ABSTRACT THINKING ABILITY______________________________________ F. JUDGEMENT AND REASONING ( ) unimpaired ( ) impaired

VII.

INSIGHT: ( ) unimpaired ( ) impaired ( ) intellectual ( ) true

VIII.

SUMMARY OF MENTAL STATUS EXAMINATION A. DISTURBANCE IN ( ) Presentation ( ) Stream of Talk ( ) thought Control ( ) insight B. DIAGNOSTIC CATEGORY ( ) Functional ( ) Organic ( ) psychotic ( ) non-psychotic ( ) Neurovegetative dysfunction ( ) General Sensorium and Intellectual status ( 0 Emotional state and Reaction

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:_______________________________ IX. Pre-Examination

Date:______________________

E. General Apperance:________________________________________________ F. General Mobility:___________________________________________________ 1.Posture & Gait:___________________________________________________ 2. Activity: ( ) normoactive ( )hyperactive ( )Psychomotor retardation ( )agitated

4. Facial Expression:_______________________________________________ G. Behavior ( ) friendly ( ) negativistic ( )withdrawn H. Doctor- Patient Interaction ( ) cooperative ( ) uncooperative ( )impulsive ( ) evasive ( )embarrassed ( )angry ( )seductive ( )indifferent

( ) initially ( ) all throughout Quality: ( ) warm ( ) hostile ( ) distant ( ) dependent

( ) suspicious ( ) talkative

Others:__________________________________ X. Stream Of Talk D. Character ( ) spontaneous ( ) deliberate ( ) Pressured ( ) blocking

E. Organization ( ) relevant ( ) loose association ( ) Tangentiality ( ) neologism ( ) others

( ) Irrelevant ( ) flight of ideas ( ) incorrect F. Accessibility ( ) good ( ) fair XI. ( ) self absorbed ( ) mute ( ) circumstantiality

( ) defensive ( ) inaccessible

EMOTIONAL STATE AND REACTIONS E. Mood ( ) euthymic F. Affect ( ) appropriate ( ) Inappropriate Quality: ( ) flat ( ) Blunted ( ) hostile ( ) elated ( ) labile ( ) anxious ( ) Histrionic ( ) angry ( ) others_______________________ ( ) depression ( ) euphoria

G. DEPERSONALIZATION and DEREALIZATION ( ) present ( )absent

H. SUICIDAL IDEATION ( ) present XII. ( ) absent

THOUGHT CONTROL F. PERCEPTION ( ) present G. DELUSIONS ( ) Present ( ) absent ( ) absent

Type:___________________________________________________________ H. IDEAS OF REFERENCE I. ( ) present ( ) absent ( ) absent ( ) absent

PREOCCUPATIONAL AND RUMINATIONS ( ) present ( ) present

J. DJ VU and JAMAIS VU

XIII.

NEUROVEGETATIVE DYSFUNCTION F. SLEEP ( ) normal ( ) Hypersomnia ( ) MNA ( ) EMA ( ) DFA ( ) 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 I. Remote:_______ ( ) Fair Recent:________Immediate:_____ ( ) Poor

ATTENTION SPAN: ( ) Good

J. GENERAL INFORMATION___________________________________________ K. ABSTRACT THINKING ABILITY______________________________________ L. JUDGEMENT AND REASONING XV. INSIGHT: ( ) unimpaired ( ) impaired ( ) intellectual ( ) true ( ) unimpaired ( ) impaired

XVI.

SUMMARY OF MENTAL STATUS EXAMINATION

D. DISTURBANCE IN ( ) Presentation ( ) Stream of Talk ( ) thought Control ( ) insight E. DIAGNOSTIC CATEGORY ( ) Functional ( ) Organic ( ) psychotic ( ) non-psychotic ( ) Neurovegetative dysfunction ( ) General Sensorium and Intellectual status ( 0 Emotional state and Reaction

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 dopamines role in the reward system. Three hypotheses hedonia, learning, and incentive salience have been proposed as explanations for dopamines 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 Genetics

Presen t

Absent

Justification

Rationale

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

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

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] Abo ut half of those with schizophrenia use drugs and/or alcohol excessively (Pocket Guide for Nurses Lippincott and Williams 4th edition)

Environmental Stress

Patients environment was calm and quiet. There house is made of light materials but all things are fixed.

It is widely agreed that environmental play an important role in triggering illness (Merikangas et al. 2002; Sulivan, Neale, and Kendler, 2000)

Infections

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. Refers to traumatic experiences of a person that involves loss of significant person.(Psychiatric Nursing, 8th edition)

Trauma

Patients uncle was shot in front of him causing trauma. And pt. has delusion of persecution.

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 Positive Symptoms Hallucination Delusion Negative Symptoms Blunted affect Alogia Anhedonia Asociality avolition Present Absent Justification Rationale

Schematic Tracing

Narrative:

Medical management Actual laboratory test/ Diagnostic Test Complete Blood Count Patient Name: Z Physician Name: Dela Cerna Hospital Routine Hemoglobin Hematocrit White Blood Cells Neutrophils Lymphocytes Monocytes Eosinophils Ref # 11903 Sex: M Result Interpretation Date: 01/23/2012 Age:33

Normal Value

Donna P. Gallosa RMT/Ariel P. Guillermo RM Medtech

Oscar P. Orageda, M.D FPSP Pathologist

Urinalysis Physical Normal value Result Interpretation

Color Transparency pH Specific Gravity

Straw Clear 5.0 1.005 Chemical

Protein Glucose

Negative Negative Microscopic

Pus Cells RBC

0.2/HPF 0-1/HPF

ECG Result

Buhangin Medical Clinic and Diagnostic Center

January 30, 2012

Atrial Ventricular Rate: 78/min Rhythm: Axis Pwave: Sinus +45 Degree Upright

PR interval: With in Normal Range QRS interval: With in Normal Range QTinterval: With in Normal Range

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 Medications Exercise Treatment Hygiene Out patient Diet Spirituality Sexuality Rationale

Prognosis Criteria Duration Of Illness Onset of Illness Predisposing/Precipitating factor Compliance to treatment regimen Age Environment Family Support Total Poor fair Good Justification

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