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A Simple Case PresentationSchizophrenia(Undifferentiated Type)
Castillon, Shermaine M.
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HISTORY OF PRESENT ILLNESS
I.K. a.k.a Mr. X is a 33 y/o male with a h/o
Schizophrenia, Undifferentiated type. Hehas been living in SPMC for 8 years.
The patient has been treated withHaloperidol 20 mg 1 tab. @ HS, Biperiden
2mg/tab PRN for EPS since he started livingin SPMC.
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BRIEF HISTORY AND
PERTINENT FINDINGS:
April 29,2005- Pt. brought in by 911 sevenyears ago diagnosed with schizophrenia,undifferentiated type. Pt. escaped from themale ward 4 days ago with positivemultiple healed scar wounds on both feet.
June 25,2012- Pt. self-extracted his tooth 5days ago.
July 05,2012- Pt. self-extracted his tooth 10days ago.
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PAST PSYCHIATRIC HISTORY
The patients symptoms at the onset of his
illness included ideas of reference andhostility.
The patients symptoms were attenuatedthrough the use of antipsychotics and
supportive therapy.
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FAMILY PSYCHIATRIC
HISTORY
Unremarkable
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PAST MEDICAL HISTORY
Chronic bronchitis, Schizophrenia,
Undifferentiated type. Pt. denies history ofhead trauma.
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REVIEW OF SYMPTOMS
General: The patients medical health hasbeen fairly stable.
Skin: No skin disease requiring medicalattention.
HEENT: Other than respiratoryinfection, no
other problems referable to this system. Neck: No swelling, disphagia, or thyroid
disease.
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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 kidneystones.
Neuromuscular: No muscle weakness orwasting. No syncope, vertigo, or diplopia.
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PHYSICAL EXAM
Vital Signs: BP-120/90, PR- 92, RR-22 whenadmitted
Skin: Warm and Dry with good turgor
HEENT: Ears clear. Eyes show no evidenceof icterus or conjunctivitis. Nose is clear.
Throat is negative. Neck: Supple with no neck vein distention,
thyroid enlargement or bruits.
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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 orrigidity.
Pulses: Present and symmetrical.
Lymph: Pt. is free of lymphadenopathy.
Extremities: No evidence of wasting oredema.
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MENTAL STATUS EXAMINATION:
I. PRESENTATION:
A. GENERAL APPEARANCE
The patient appears to be older than his realage which is 33. During theinterview at SPMC,he wore a psychiatry uniform. The patientappears to be untidy. He has dirty clothing, longfingernails and toenails with traces of dirtevidently seen on both. At the time of theinterview, the patient was alert and responsive.
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B. General Mobility
a. Posture The patient slouches when
seated but holdshimself erect when standing and walking. His
mannerisms include spitting and scratchinghis head.
b. ActivityAt some point the patientsmovement is organized and purposefulduring the interview. He moves in a normalpace and does not show any signs of overand under activity.
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Attitude towards the Examiner
He entertained my questions and
answered almost all of them. However, his
eye contact was poor. He often looksdown.
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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 andinstead, he just spends his time watching his companionsuntil he falls asleep.
B.Appetite
The patient has increased appetite. He was eating hisbreakfast well and was able to consume a moderate amount of
rice and viand. He eats a lot however, he is choosy in hisfood. Ganahan q muinom kanang juice.Lami, reported bythe patient.
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LABORATORY DATA
The patients toxicology screen was
negative.
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DRUG STUDY
DRUG INDICATION MECHANISM OFACTION
Brand Name: Haldol
Generic Name: Haloperidol
Classification: Antipsychotic drug
Route: Oral
Dosage: 20 mg/tab
Frequency: tab @ HS
Management of manifestationsof psychotic disorders.
Mechanism not fully understood;antipsychotics block postsynapticdopamine receptors in the brain,depress the RAS, including thoseparts of the brain involved withwakefulness and emesis;chemically resembles thephenothiazines.
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CONTRAINDICA-TIONS
ADVERSEEFFECTS
NURSINGRESPONSIBILITIES
Contraindicated withhypersensitivity to typical
antipsychotics, coma or severeCNS depression, bone marrow
depression, blood dyscrasia,circulatory collapse, subcortical
brain damage, Parkinsonsdisease, liver damage, cerebral
arteriosclerosos.
Not all effects have beenreported with haloperidol;
however,because haloperidol hascertain pharmacologic similarities
to the phenothiazine class ofantipsychotic drugs, all adverse
effects associated withphenothiazine therapy should bekept in mind when haloperidol is
used.
10 rights when givingmedication.
Monitor vital signs.
Provide safety.
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Thank You and GodBless Us All!