Case Study for Virtual Psychiatry Nursing Clinical Rotation

Case:

Patient H, 25-years-old Female, Single, Filipino, born on Feb 1, 1996 in Baguio City and living at Cruz,
La Trinidad, Benguet. Working as a bank teller at Metro La Trinidad, Catholic, was admitted on February
1, 2021 @ 1 PM due to psychomotor agitation, auditory hallucination, sleeplessness, poor hygiene and
poor food intake. Admitted under the service of Dr. Tuldague. Initial diagnosis: Bipolar Affective Disorder
with Manic Episode and psychotic symptoms.
Situation: You are on duty at 3-11 shift and you receive the following data during endorsement;
 Diet as tolerated

Meds:
 Olanzapine (Zyprexa)

 Quetiapine (Seroquel)

 Risperidone (Risperdal)

 Ziprasidone (Geodon)

 Clozapine

History:

 Born full-term via NSD in BGHMC, well love and cared by parents during childhood. 3 rd out of 4
children of a vegetable dealer (father) and a sari-sari store owner (mother) . All siblings have no
psycho-social problems. Sociable and easy to get along with. Complaints of the usual diseases during
childhood such as headache, fever and flu. Patients parents are sociable, family oriented and church
goers. Father occasionally drinks rice wine specially when he is very tired. 2 months ago, she
verbalizes to her mother that her workmate borrowed money from her. 1 month ago, she asks her
work mate to pay her but unfortunately, she did not and a verbal tussle ensued. 20 days PTA, patient
complaints to her mother that her workmate resigned without paying her credit to her. 10 days PTA,
Patient complained that her workmates started telling stories behind her back saying that she is the
reason why their work mate resigned. 5 days PTA, patient started isolating herself, not eating properly
and irritated. 3 days PTA, patient started talking to herself, unable to sleep, unable to eat. 1-day PTA,
patient went out of their house at the dead of the night and walks aimlessly along the highway where
she was spotted by a patrolling policeman which is actually her neighbor and called her parents in
violation of curfew hours. 1 hr. PTA, patient is becoming violent hence mother brought daughter to
BGHMC for check-up hence admission. Initial blood test taken. normal CBC.

Nursing assessment includes: RR 30 cpm, T 37.2 C, PR 95 cpm, SPO2 98% and an elevated blood
pressure. Able to do ADL with assistance, with dark flowy disheveled hair and with visible streak of
yellow colored hair, eyes are symmetrical and pupils are reactive to light, nose and mouth are
symmetrical, upper and lower extremities are symmetrical with some scratches particularly in the
upper arm. Slight foul smell from breathing and body odor and cloths are obviously dirty.
 You are to put at least 2 descriptions on the areas that has no assessment based on the case of
the patient.
 You can add data on this case as long as it is based on the case presented.

Cover Page
Table of contents
1. Profile
2. History of present illness
3. History of past illness
4. Family History
5. Socio-environmental History
6. PE
7. Diagnostics
8. Patho
9. Nursing Theory (TFN Based)
10. FDAR
11. Journal
12 Drug study
13. NPI

You may separate DS and NCP.

Questions? Pm is the key.

Goodluck.