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Case Study

Introduction (to be followed)


Goal and Objectives:
a. Gather clients data thoroughly;
b. identify clients need as perform complete assessment;
c. discuss clients present condition;
d. construct a plan for client that are specific, measurable, attainable, realistic, and time
bounded goal of care and interventions;
e. formulate priority interventions or plan of care;
f. implement the plan of care;
g. conduct an evaluation if the plan of care have been met, partially or not met;
h. emphasize the value of life, respect and privacy during the care of the patient
A. Personal Data
Name:
Address:
Age :
Gender :
Birth date:
Birth Place
Ordinal Rank:
Nationality:
Civil Status:
Religion:
Educational Attainment:
Occupation:
Fathers Name:
Occupation:
Mothers Name:
Occupation:
B. CLINICAL DATA
Agency:
Date of Admission:
Came in due to:
Attending Physician
Diagnosis:
Genogram (Family) The family genogram is a pictorial display of a person's family
relationships and medical history

ANAMNESIS
Informants

COURSE IN THE HOSPITAL


Mental Status Examination
A. MENTAL STATUS EXAMINATION
June 11, 2014 (Orientation Phase)
I. PREEXAMINATION
A. GENERAL APPEARANCE
B. GENERAL MOBILITY
-Posture & Gait:
- Activity: ( ) Normoactive ( ) Psychomotor retardation ( ) Hyperactive ( ) Agitated
- Facial Expression:
C. BEHAVIOR: ( ) friendly ( ) impulsive ( ) angry ( ) embarrassed ( ) negativistic ( ) evasive
( ) seductive ( ) indifferent ( ) withdrawn
D. NURSE-PATIENT INTERACTION
( ) cooperative ( ) initially ( ) uncooperative () all throughout
Quality:
( ) warm ( ) distant ( ) dependent
( ) hostile ( ) suspicious ( ) talkative
II STREAM OF TALK:
A. CHARACTER
() spontaneous ( ) deliberate ( ) pressure ( ) blocking
B. ORGANIZATION OF TALK
( ) relevant ( ) loose of association ( ) tangentiality
( ) irrelevant ( ) flight of ideas ( ) neologism
( ) incorrect ( ) circumstantiality ( ) others ____
C. ACCESSIBILITY
() good ( ) self-absorbed ( ) defensive
( ) fair ( ) mute ( ) inaccessibility
III. EMOTIONAL STATE & REACTIONS:
A. MOOD
( ) euthymic ( ) depression ( ) euphoria
B. AFFECT
( ) appropriate ( ) inappropriate
Quality:
( ) flat ( ) elated ( ) histrionic
( ) blunted ( ) labile ( ) angry
( ) hostile ( ) anxious others _______
Progress Notes
C. DEPERSONALIZATION & DEREALIZATION
( ) present () absent

D. SUICIDAL HOMICIDIAL ESCAPE POTENTIAL


() present ( ) absent
IV THOUGHT CONTROL:
A. PERCEPTION
( ) present ( ) absent
B. DELUSIONS
( ) present () absent
C. IDEAS OF REFERENCE
( ) present () absent
D. PREOCCUPATIONS & RUMINATIONS
E. DEJAVU & JAMAIS VU
( ) present () absent
V NEUROVEGETATIVE DYSFUNCTION:
A. SLEEP
B. APPETITE:
C. DIURNAL VARIATION:
D. WEIGHT
E. LIBIDO
VI GENERAL SENSORIUM & INTELLECTUAL STATUS:
A. ORIENTATION:
B. MEMORY:
C. ATTENTION SPAN:
( ) good ( ) fair ( ) poor
D. GENERAL INFORMATION
E. ABSTRACT THINKING ABILITY
E. JUDGEMENT & REASONING
() unimpaired ( ) impaired
VII - INSIGHT
() unimpaired ( ) impaired
VIII SUMMARY OF MENTAL STATUS EXAMINTATION:
A. Disturbance in:
() Presentation ( ) Insight
( ) Stream of talk () Neurovegetative Dysfuntion
() Thought Control ( ) General Sensorium & Intellectual Status
() Emotional state and reaction
B. Diagnosis Category
() Psychotic ( ) Non psychotic

C. DSM IV-TR Diagnosis


Axis 1- ___(Clinical Syndromes)
Axis ii- ____ (Personality and development disorder)
Axis iii- ___(Physical disorders and conditions)
Axis 1V- ____(Psychosocial and Environmental problems)
B. MENTAL STATUS EXAMINATION
(Working Phase)
DATE: June 12, 2014
I PREEXAMINATION
A. GENERAL APPEARANCE
Psychodynamics
Definition of Diagnosis
MEDICAL MANAGEMENT
Drug Studies
Diagnostics
Nursing Care Plans
Prognosis
Health Teachings