Republic of the Philippines

BICOL UNIVERSITY TABACO CAMPUS

NURSING DEPARTMENT
Tabaco City

Psyche Case # 3

Identity:

Name Sasuke Uchiha

Date of Admission March 12, 2021 @ 12:00pm
Age 19 y/o
Gender Male
Civil Status Single
Date of Birth February 21, 2002
Address Tinago, Ligao City, Albay
Religion Catholic
Informant Grandmother

Chief Complaint: Suicidal ideation and agitation

History of Present Illness:

– This 19-year old-man was suffering from difficulty of sleeping and persistent nightmares.

- According to the informant, 1 month prior to admission the patient’s parents were killed by his
brother, who is a drug addict. His brother is currently imprisoned at Ligao City Jail.

- The grandmother has sought the help of an “albularyo” who has been performing rituals for the
patient once a week to hopefully treat the patient but to no avail.

- 1 week prior to admission the patient would suddenly shout at night and becomes very
agitated. This happens approximately 3 to 5 times whenever the patient attempts to sleep.

- 1 day prior to admission the patient became extremely agitated and was verbalizing that he
wants to die.

– The family has not traveled to other provinces since the start of the community quarantine.

Physical Examination:

General Appearance:

The patient looked agitated and with prominent eye bags. There were no signs of respiratory
distress. There is no jaundice in the sclera

Vital Signs:
Temperature – 36.5 C
RR - 22 cpm
PR – 122 bpm
Wt – 55 kg

Respiratory System:
 Inspection – normal bilateral chest movement, antero – poster diameter is normal, trachea is in
Midline, chest expansion is normal
Auscultation – normal bilateral air entry, vesicular breathing
Percussion – no dullness or hyper resonance areas

Abdomen:
Inspection – no abnormality detected
Palpation – soft, tips of spleen
Auscultation – hyperactive bowel sounds, presence of barborygmi

CNS Exam:
No neck rigidity
(-) Kernigs Sign
(-)Brudzinki’s sign

Mental Status Exam:

(-) eye contact
Easily startled and frightened
Has difficulty remembering details surrounding the death of his parents
(+) suicidal ideation

Integumentary:
(+) pallor
(+) dryness

Family History:
The child is the 2nd out of two siblings
The other sibling is a drug dependent.

Initial Diagnosis : Post traumatic stress disorder

Lab Exams:

1. Complete Blood Count

Test Result Units Ref Range
WBC 9, 000 X 1,000/mm3 3.9 – 11.1
RBC 3.0 X 10/mm3 4.2 – 5.70
HGB 7 g/dl 13.2 – 16.9
Platelet 195 X 1,000/mm3 140 - 390

2. Chest X- Ray – normal chest x-ray

Medications:

– IV Fluids (BBraun) – Plain NSS 1l @ 40gtts/ min

– Ferrous sulphate (Ferron) 130mg 1 tab per orem BID
– Fluoxetine (Prozac) 20mg 1 tab per orem BID
– Diazepam (Valium) 10mg TIVT PRN for aggressive behavior

Diet –soft diet

On SHEA (Suicide, Homicide, Escape and Assault) Precaution

Requirements:

1. Nursing Health History

2. Drug Study
3. NCP
4. RAPP Sheet and Concept Map
 5. Lab exams
6. FDAR notes
7. Reflective journal

Prepared by:

NEOLAN C. AÑONUEVO, RN, MAED

Clinical Instructor