Miss Saroja, an 18-year-old unmarried female, has been diagnosed with schizophrenia. This is her fourth episode of the illness, characterized by reduced sleep, increased talking, hallucinations and reduced food intake. She has a history of schizophrenia for the past 3 years and is currently in remission. A mental status examination revealed thought retardation, delusions of grandeur and reference, and auditory hallucinations.
Miss Saroja, an 18-year-old unmarried female, has been diagnosed with schizophrenia. This is her fourth episode of the illness, characterized by reduced sleep, increased talking, hallucinations and reduced food intake. She has a history of schizophrenia for the past 3 years and is currently in remission. A mental status examination revealed thought retardation, delusions of grandeur and reference, and auditory hallucinations.
Miss Saroja, an 18-year-old unmarried female, has been diagnosed with schizophrenia. This is her fourth episode of the illness, characterized by reduced sleep, increased talking, hallucinations and reduced food intake. She has a history of schizophrenia for the past 3 years and is currently in remission. A mental status examination revealed thought retardation, delusions of grandeur and reference, and auditory hallucinations.
Miss Saroja, an 18-year-old unmarried female, has been diagnosed with schizophrenia. This is her fourth episode of the illness, characterized by reduced sleep, increased talking, hallucinations and reduced food intake. She has a history of schizophrenia for the past 3 years and is currently in remission. A mental status examination revealed thought retardation, delusions of grandeur and reference, and auditory hallucinations.
Download as DOCX, PDF, TXT or read online from Scribd
Download as docx, pdf, or txt
You are on page 1/ 10
INTRODUCTION:
As a part of Psychiatric Nursing Clinical Posting we are posted at NIMHANS hospital
from 01-04-2015 to 30-04-2014.As a part of Clinical rotation I was posted in Female general ward and selected the patient name Miss Saroja for my case history. She was been diagnosed as Schizophrenic – undifferentiated in remission and to provide basic nursing care according to priority needs
IDENTIFICATION DATA
Name of patient : Miss. Saroja
Age : 18 years
Sex : Female
IP No : 613568
Ward : Female general ward
Address : C/O Rethnamma, Chennathakkunnu,
Pangode, Lekshamveedu.
Religion : Hindu
Marital Status : Unmarried.
Education : SSLC Fail
Occupation : Nil.
Monthly Income : Rs.4000/-
Date of admission : 10/03/13
Diagnosis : Schizophrenic – undifferentiated in
remission INFORMANT
Mrs. Rethnamma is the informant. She is the mother of patient and she is living together with her daughter. She had good intellectual and observation ability. She had higher degree of concern regarding the patient.
PRESENTING CHIEF COMPLIANT
According to patient she had no problem. She is absolutely alright.
According to informant this is the fourth episode of Ms. Saroja’s illness. She had complaints of fearfulness, reduced sleep, increased activity, talk with herself and increased talk, hallucination and reduced food intake also present.
HISTORY OF PRESENT ILLNESS
This is the fourth episode of illness. Miss. Saroja was admitted to this hospital with complaints of reduced sleep, increased talk, tremors, and assaultive behavior for 1 week. On examination she has brad kinesis, increased talk, delusion of grandiosity and delusion of persecution and reference, apathetic and tremor present. During admission Inj.Haloperidol 1amp 1M & Inj.phenergan 25mg 1M stat administered. Now her condition has improved. Now she is oriented euphoric, increased activity, delusion of grandervisity thought block etc present. She was maintained good rapport and she had good memory and insight.
PAST PSYCHIATRIC AND MEDICAL HISTORY
Miss. Saroja is a known case of schizophrenia since 3 years. This is the fourth episode of disease. Initially she was treated in medical college hospital, Manipal and was on T.Clozapin, T.Pentril and T.Sodium valproate. Then she was referred to mental health center, perroorkada. She was on same drugs since 9/9/06. Possible precipitating factor was beating from her mother. During first episode she was depressed, crying behavior and reduced sleep was present. 1 st episode was 3 years back and each year he was developing disease. Now the disease I in severe form
Miss. Saroja had no history of any medical or surgical history. No history of head injury prior to illness. TREATMENT HISTORY
This is the fourth episode of illness. During the previous episode and follow up she was on : T.Petril, Tab. Valproate & T.Clozapin. No further history is available.
FAMILY HISTORY
Miss. Saroja is living with her mother. Her father left their family. She is living with her mother and younger sister. No history of mental illness in the family. No family history of diseases like DM, HTN, Cancer etc. on e of her uncle died due to myocardial infection during at his 35 years of age.
FAMILY TREE
--------------------------------
---------------------------------------
PERSONAL HISTORY
1. Personal history No history of any febrile illness, drug, alcoholism etc during pregnancy. She is born by normal vaginal delivery. No complications present during perinatal period. 2. Childhood history Miss. Saroja is brought up by her mother. She is a wanted child. She had no history of any illness and behavioral disorder during childhood. 3. Education history Ms. Saroja started her formal education at her 5 year of age. She was very interested in study. She used to get 1st rank in class. No absentism in school. She had good relationship with peers and teachers. 4. Play history She was engaged in play and she was very happy to participate in play. She had good relationship with peers of same and opposite sex. 5. Puberty She attained menarche during her 14 years of age. No behavior changes present during menarche. 6. Menstrual history Miss. Saroja’s menstrual cycle is regular and it is 28 days cycle. She had abdominal pain and back pain during menstruation. 7. Marital & sexual history Miss. Saroja is unmarried. She had no sexual relationship with others. 8. Occupational history Nil. 9. Interpersonal relationship Miss. Saroja had good interpersonal relationship with family members, friends and superiors. Use of leisure time – no specific hobbies as use of leisure time. She had good attitude towards self and she had poor self confidence. She is only concerned with herself Family life – she is very happy in her home Habit – she had no specific habits and food fads. 10. Environmental history Ms. Saroja house is hatched. The source of water supply is from well. Disposal of excreta is through sanitary latrine. 11. Nutritional history Miss. Saroja had no specific likes and dislikes. She in non – vegetarian. She used to eat 3 times a day. Now she had reduced intake of food because of illness. 12. Socioeconomic status Ms. Saroja family belongs to low class family. Her mother have the monthly income of around Rs.2000/-. Her father is not with them. He has left their family.
PHYSICAL EXAMINATION
a. Vital signs Temperature – Normal Pulse – 80/mt Respiration – 24/mt BP – 110/80 mmHg
b. Head to foot examination.
Body parts Observations
Skin condition Skin color is paler, scaling present, rough texture. Good skin turger. No lesions and edema. Nails Pale in color, normal shaped, capillary refill is good Hair and scalp Equal distribution of hair. No complaints of alopecia. Infestation with the present Skull Normal size. No exophthalmoses Eyes and vision Good vision, normal ocular movement, no infection, redness etc. star looking present. Ears No infection. Good hearing capacity. No pain and use of hearing aids. Nose No frequent colds. No changes in sense of smell. No DNS and discharges. Mouth & throat Pink muuosa, dry mouth, no halitosis, no gum hyperplasia and dental ache. Neck Good range of motion, no thyroid enlargement and distension of lymphnodes present.
Chest expansion on breathing is symmetric and bilaterally
Thorax and chest equal. No adventitious breath sounds present. No palpable masses present. Normal color, soft, not tender and no distension present Abdomen Good range of motion. No tenderness, frequent hand movement present. Upper extremities Good range of motion. No tenderness. She used to walk too frequently. So walking had some instability. Lower extremities Miss. Saroja had no specific physical impairments. She had only symptoms associated with schizophrenia.
Remark : apathetic, relaxed posture, mannerism of walking and poor hygiene and grooming present.
MOTOR DISTURBANCE:
Present i.e., hyperactivity
DISORDER OF THOUGHT
a. Form of thought disorder – thought retardation present
b. Disorder of content of thought Delusion – Present i.e., delusion of grandiosity and delusion of reference (Patient says that she know all things and all of the people are talking about her) Phobic – absent Fantasy – absent
Remark : she had delusion of grandiosity and reference.
DISORDER OF SPEECH:
1. Pressure of speech – decelerated
2. Flight of ideas – present (Patient says many things at same time) 3. Thought block – present
Hallucination – present. Auditory hallucination all times she is talking with herself
DISORDER AFFECT
1. Affect – inappropriate Subjective – patient says “I am happy” Objective – anxious, depressed and sometimes laughing 2. Pleasurable effect – present , euphoric 3. Un pleasurable effect – absent 4. Mood swing – present
DISORDER OF MEMORY
1. Immediate memory Q: what you had for your breakfast? A: wheat conjee 2. Recent memory Q: when did you slept yesterday? A: 9 O’ clock 3. Remote memory Q: who was your best friend? A: Reshma 4. Any disorder in memory – absent
Remark: immediate, recent and remote memory are unaffected.
DISORDER OF ORIENTATION
1. Orientation to time Q: what is the time now? (10:00AMP A: 7am 2. Orientation to place Q: which place is this ? A: Bangalore 3. Orientation to person? Q: who am I? A: Sister
