case presentation bipolar 1 manic type

7/28/2019 Case Presentation Bipolar 1 Manic Type

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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!

case presentation bipolar 1 manic type

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