A Simple Case Presentation Schizophrenia (Undifferentiated Type)

Castillon, Shermaine M.

HISTORY OF PRESENT ILLNESS

I.K. a.k.a Mr. X is a 33 y/o male with a h/o Schizophrenia, Undifferentiated type. He has been living in SPMC for 8 years. The patient has been treated with Haloperidol 20 mg 1 tab. @ HS, Biperiden 2mg/tab PRN for EPS since he started living in SPMC.

BRIEF HISTORY AND PERTINENT FINDINGS:

April 29,2005- Pt. brought in by 911 seven years ago diagnosed with schizophrenia, undifferentiated type. Pt. escaped from the male ward 4 days ago with positive multiple healed scar wounds on both feet. June 25,2012- Pt. self-extracted his tooth 5 days ago. July 05,2012- Pt. self-extracted his tooth 10 days ago.

PAST PSYCHIATRIC HISTORY

The patients symptoms at the onset of his illness included ideas of reference and hostility. The patients symptoms were attenuated through the use of antipsychotics and supportive therapy.

FAMILY PSYCHIATRIC HISTORY

Unremarkable

PAST MEDICAL HISTORY

Chronic bronchitis, Schizophrenia, Undifferentiated type. Pt. denies history of head trauma.

REVIEW OF SYMPTOMS

General: The patients medical health has been fairly stable. Skin: No skin disease requiring medical attention. HEENT: Other than respiratoryinfection, no other problems referable to this system. Neck: No swelling, disphagia, or thyroid disease.

Pulm: No asthma,TB, or pneumonia. CV: No known heart disease or hypertension. GI: No dyspepsia, PUD, biliary tract disease, pancreatitis, or colitis. GU: No UTIs, venereal disease, or kidney stones. Neuromuscular: No muscle weakness or wasting. No syncope, vertigo, or diplopia.

PHYSICAL EXAM

Vital Signs: BP-120/90, PR- 92, RR-22 when admitted Skin: Warm and Dry with good turgor HEENT: Ears clear. Eyes show no evidence of icterus or conjunctivitis. Nose is clear. Throat is negative. Neck: Supple with no neck vein distention, thyroid enlargement or bruits.

Lungs: No rales, rhonchi or wheezes. CV: No murmurs, thrills, heaves, or rubs.

First and second heart sounds are normal. Abdomen: Flat and soft. No guarding or rigidity. Pulses: Present and symmetrical. Lymph: Pt. is free of lymphadenopathy. Extremities: No evidence of wasting or edema.

MENTAL STATUS EXAMINATION:

I.

PRESENTATION: A. GENERAL APPEARANCE The patient appears to be older than his real age which is 33. During theinterview at SPMC, he wore a psychiatry uniform. The patient appears to be untidy. He has dirty clothing, long fingernails and toenails with traces of dirt evidently seen on both. At the time of the interview, the patient was alert and responsive.

B. General Mobility a. Posture The patient slouches when seated but holds himself erect when standing and walking. His mannerisms include spitting and scratching his head. b. Activity At some point the patients movement is organized and purposeful during the interview. He moves in a normal pace and does not show any signs of over and under activity.

Attitude towards the Examiner He entertained my questions and answered almost all of them. However, his eye contact was poor. He often looksdown.

NEUROVEGETATIVE STATE
A.Sleep

The patient usually sleeps at 12 midnight and usually wakes up at 5am getting at least 5 hours of sleep. He says that he finds it hard to sleep at night and instead, he just spends his time watching his companions until he falls asleep. B.Appetite The patient has increased appetite. He was eating his breakfast well and was able to consume a moderate amount of rice and viand. He eats a lot however, he is choosy in his food. Ganahan q muinom kanang juice.Lami, reported by the patient.

LABORATORY DATA

The patients toxicology screen was negative.

DRUG STUDY
DRUG
Brand Name: Haldol Generic Name: Haloperidol Classification: Antipsychotic drug Route: Oral Dosage: 20 mg/tab Frequency: tab @ HS

INDICATION
Management of manifestations of psychotic disorders.

MECHANISM OF ACTION
Mechanism not fully understood; antipsychotics block postsynaptic dopamine receptors in the brain, depress the RAS, including those parts of the brain involved with wakefulness and emesis; chemically resembles the phenothiazines.

CONTRAINDICATIONS

ADVERSE EFFECTS

NURSING RESPONSIBILITIES

Contraindicated with hypersensitivity to typical antipsychotics, coma or severe CNS depression, bone marrow depression, blood dyscrasia, circulatory collapse, subcortical brain damage, Parkinsons disease, liver damage, cerebral arteriosclerosos.

Not all effects have been reported with haloperidol; however,because haloperidol has certain pharmacologic similarities to the phenothiazine class of antipsychotic drugs, all adverse effects associated with phenothiazine therapy should be kept in mind when haloperidol is used.

10

rights when giving medication. Monitor vital signs. Provide safety.

Thank You and God Bless Us All!