Biographic Data Name: C.C.

Age: 55 y/o Gender: Female Status: Single Date of Birth: June 5, 1852 Place of Birth: Caloocan City Permanent Address: Caloocan City Medical Diagnosis: Undifferentiated Schizophrenia

Past Health History: The client was first admitted at National Center of Mental Health for years and later on transferred at Reality Based Therapeutic Care (RBTC). The client was diagnosed to have an undifferentiated schizophrenia according to her medical records. She lived with her family including her father, mother, two sisters and four brothers. Since her father died, she couldnt accept the situation. She stated to feel alone and lonely that leads to a state of depression. Due to her depression, her condition did not go well. She started to show signs of grandeur, anger, guilt, hallucination and delusion that made her in this present state.

III.2. Assessment- Laboratory January 17, 2012 Hematology Report Actual Findings Hemoglobin 113 Hematocrit RBC WBC .34 3.77 14.50 Normal Findings 120-150 gml .38-.48 4-6 x 10/l 5-10 x 10/l .20-.35 120-150 gml .38-.48 4-6 x 10/l 5-10 x 10/l .45-.65 .20-.35 Result Decreased. Possible cause is anemia. Normal Normal Increased. Possible cause is leukocytosis infection. Normal Decreased. Possible cause is anemia. Normal Normal Normal Normal Increased. Possible causes are viral infection and chronic bacterial infection. Decreased. Possible cause is anemia. Normal Normal Normal Normal Decreased. Possible cause is anemia. Decreased. Possible causes are dietary deficiency and anemia. Normal Normal Normal Normal

Lymphocytes .26 December 6, 2010 Hematology Report Hemoglobin 103 Hematocrit RBC WBC Segmenters Lymphocytes .32 4.10 9.70 .52 .48

October 1, 2010 Hematology Report Hemoglobin 102 Hematocrit .34 RBC 3.96 WBC 8.70 Lymphocytes .28 June 3, 2010 Hematology Report Hemoglobin 77 Hematocrit RBC WBC Lymphocytes Eosinophil .25 2.96 8.1 26 .1

120-150 gml .38-.48 4-6 x 10/l 5-10 x 10/l .20-.35 120-150 gml .38-.48 4-6 x 10/l 5-10 x 10/l .20-.35 .1-.4

Reference of Results: Kozier and Erbs Fundamentals in Nursing Volume II 8th Ed. Pg. 799-800

October 7, 2010 FBS Creatinine Sodium Potassium SGPT Actual Findings 5.22 mmol/l 46.30 umol/l 137.10 mmol/l 2.43 mmol/l 92 u/l Normal Findings 3.33-6.10 mmol/l 53-97 umol/l 135-148 mmol/l 3.50-5.30 mmol/l 0-36 u/l Result Normal Normal Normal Decreased. Possible cause is poor intake of potassium. Increased. Possible causes are hepatitis, infectious mononucleosis and acute pacreatitis. Increased. Possible causes are liver diseases and anemia. Normal

SGOT Alkaline Phosphatase May 24, 2010 Urinalysis Color Transparency Specific gravity pH

75 u/l 176.6 u/l

0-32 u/l 100-290 u/l

Reference of Results: Kozier and Erbs Fundamentals in Nursing Volume II 8th Ed. Pg. 803-804

Actual Findings Straw Clear 1.000 Acidic

Normal Findings Straw, amber transparent Clear 1.010-1.025 4.5-8

Result Normal Normal Decreased. The urine is diluted. Acidic. Acidic urine is found in starvation, with diarrhea, or with a diet high in protein foods. Normal Normal

Glucose Protein

Negative Negative

Not present Not present

Reference: Kozier and Erbs Fundamentals in Nursing Volume II 8th Ed. Pg. 1293

October 7, 2010 Whole Abdomen/ Pelvic Ultrasound Impression: Consider mild liver parenchymal disease Consider bilateral renal parenchymal disease Subserous myoma Normal gallbladder, spleen; urinary bladder by ultrasound Non-dilated biliary tree

May 24, 2010 Chest Xray Roentgenological Findings: Both lungs are clear The heart is not enlarged Diaphragm and bony thorax are uinremarkable Impression: Essentially normal chest

January 6, 2009 Skull Xray Findings: No fractures seen in the visualized osseous structures Inner and outer tables are intact The rest of the study is unremarkable Impression: Negative xray of the skull