NIGHTINGALE INSTITUTE OF

NURSING
CASE PRESENTATION

SUBJECT :
TOPIC : SCHIZOPHRENIA 

SUBMITTED TO:- SUBMITTED BY:-

SUBMITTED ON:-
 IDENTIFICATION DATA
DEMOGRAPHIC DATA
NAME OF THE PATIENT :- ravi shanker

AGE :- 52 years
GENDER :- male
MARITAL STATUS :- married
RELIGION :- muslim
EDUCATION :- C.A
OCCUPATION :- pvt. job
ADDRESS :- 402 , vasantkunj, n-delhi
WARD :- ward 2
NAME OF THE HOSPITAL :- bhagwati hospital
DATE OF ADMISSION :- 10th june, 2021
PROVISIONAL DIAGNOSIS :- a b n o r m a l
talking
FINAL DIAGNOSIS :- SCHIZOPHRENIA 
CHIEF COMPLAINTS:-

The client was admitted to the hospital due to abnormal talking since 1 day.
SOCIO ECONOMIC STATUS:-

Middle class
Nuclear family

Monthly income of the family- Rs-20000-/-

FACILITIES:-

Proper ventilation
Water - tap water

Drainage- closed drainage

Toilet- attached to house
Social relationship with neighbours-good
FAMILY HISTORY

s.no Name of the family Age/ Relationshi Marital Education occupation Health
member sex p with status status
patient

1 Ravi shanker Self Married CA Job Unhealthy

52/m

2 Rani shanker 50/f Wife Married BA Housewife Healthy

3 Pooja 25/f Daughter Single Graduation Job Healthy

4 Rajeev 20/m Son Single Collage Study Healthy

 FAMILY TREE:-

female

Ravi shanker Rani shanker

52/m 50/f male

patient

Rajeev pooja
20/m 25/f
FAMILY MEDICAL HISTORY:-

The client shiv shankar of 52 years old belongs to a nuclear family.he doesn’t
have any history of hereditary diseases.
PERSONAL HISTORY:-
Diet - vegetarion
Bath - daily

Sleeping pattern - regular at night for 7 to 8 hrs Urinary

elimination pattern - 2 to 3 times a day Bowal
elimination pattern - 1 time in a day

Hobbies - reading,net surfing,eating

 Bad habbits - no bad habbits

PAST MEDICAL HISTORY:-

The client have past medical history of chest pain since 1 day.
PAST SURGICAL HISTORY:-

The client doesn’t have any past surgical history.

PRESENT MEDICAL HISTORY:-

The client was admitted in the hospital with complaints of abnormal
talking since 1 day after the investigations.he was diagnosed with Schizophrenia .

PRESENT SURGICAL HISTORY:-

The client doesn’t have any present surgical history.

 PHYSICAL EXAMINATION

IDENTIFICATION DATA
NAME OF THE PATIENT :- ravi shanker

AGE :- 52 years

GENDER :- male

DIAGNOSIS :- Schizophrenia

VITAL SIGN

TEMP. :- 99’f

PULSE :-88b/min

RESPIRATION :-24 b/min

BLOOD PRESSURE :-130/80 mmhg

ANTHROPOMETRIC MEASUREMENTS

HEIGHT :- 170CM

WEIGHT :- 60 KG
GENERAL APPEARANCE AND MENTAL STATUS

CONSCIOUS :- Conscious

ATTITUDE :-Calm

BODY BUILT :-average

POSTURE :-erect

GAIT :-co-ordinated
HEAD AND FACE

HEAD :-no lesions,scar,wound

FACE :-patient was anxious
HAIR AND SCALP

COLOUR :-Black

DISTRIBUTION :- disturbed

DANDRUFF :-not present

INFECTION :-no infection present

SKIN

COLOUR :-Black

TEXTURE :- smooth

TEMPRATURE :-warmth
EYE
EYE BROW :-present

EYE LIDS :-present

EYE LASHES :-present

PUPIL :-reactive to light

VISUAL ACTIVITY :-normal 6/6

CONJUNCTIVA :-no infection

EAR

LOCATION :-on either side of the cranium ot approximately eye level

DISCHARGE :-no discharge

HEARING ACTIVITY :-normal

NOSE
NOSTRILS :-clear

NASAL SEPTUM :-normal, no deviation

NASAL POLYPS :-not present

DISCHARGE :-not discharge

MOUTH AND PHARYNX

LIPS :-pink colour

TEETH :-yellowish

TONGUE :-red in colour

PHARYNX :-exudate
NECK

THYROID GLAND :- not enlarged

LYMPH NODES :-Non-palpable, non tender
CHEST

INSPECTION :-normal symmetry

PALPATION :-no abnormal masses found

AUSCULTATION :-deep shallow breathing S1 and S2, heart sound heard

PERCUSSION :-abnormal sounds present

ABDOMEN

INSPECTION :-no scars,leasions

PALPATION :-bowal sound heard

AUSCULTATION :- no presence of fluid distension

PERCUSSION :- not tenderness

NAILS

SHAPE :-elongated

NAIL BED ANGLE :-160’ angle

CAPILLARY REFILLS :- immediate

BACK

CURVATURE :-patient was having normal body curvature.

EXTERMITIES

UPPER EXTERMITIES :-normal range

of motion LOWER EXTERMITIES :-normal range
of motion
EXTERNAL GENITALIA

HEMORRHOIDS :-not present

FISSURE :-not present

FISTULA :-not present

IMPRESSION:- The patient Mr ravi Shanker,52 years male was

admitted in BHAGWATI HOSPITAL with complaints of irrelevant talking
since 1 day.

INVESTIGATION
  ECG

 EEG

 NCV

 Mri

 CT

MEDICATION
S.NO NAME OF DRUGS DOSE ROUTE FREQUENCY
1 Tab.clozapine 50-700mg p/o TDS

2 Tab.paliperidone 3-6mg p/o BD

3 Tab.aripiparazole 10-30 mg P/O HS

4 Tab.flupintexol 1mg P/O OD