RLE1 Case Presentation

Prepared by: RLE Group 1 Acompa ado, Liana Adan, Kate Alarcon, Jocelyn Albia, James Bechayda, John John Besmonte, Michelle Bisenio, Princess Bordon, Dan Joseph Borja, Clarissa Bosch, Jan Mathew

UNDIFFERENTIATED SCHIZOPHRENIA

Psychosocial Assessment
HISTORY Age: 32 yrs. old Developmental Stage: Genital stage onwards Cultural consideration: Filipino culture Spiritual belief: Roman Catholic, with background of being an altar boy during grade school Previous History: No history of mental illness as based form the patients chart and verbalization; no history of any condition such as alcoholism, smoking but with suicidal ideation before being admitted.

GENERAL ASSESSMENT AND MOTOR BEHAVIOR Hygiene and grooming: has clean cut hair, trimmed nails, no body odor, has his own time of taking a bath as verbalized by the NOD, brushes his teeth and washes his hands as the verbalized by the patient APPROPRIATE DRESS: wears clean and neat green uniform. POSTURE: can stand, no limping gait, with little stooping when standing EYE CONTACT: has eye contact during communication process UNUSUAL MOVEMENT OR MANNERISM: no unusual movements or mannerism SPEECH: speaks in an organized, coherent, soft way. No tattering and slurred speech with complete thought.

MOOD AND AFFECT EXPRESSED EMOTIONS: usually , he was able to express his emotions through gestures like hand movements and eye contact. FACIAL EXPRESSION: his facial expression is congruent with his feeling or emotions, but with time s of being flat affect.

THOUGHT PROCESS AND CONTENT CONTENT: the content of the clients verbalization depends on the question or the topic of the conversation. There are periods when the client is asked about his frustrations and the content of his verbalization were altered and contains lots of delusions and loose of associations but he answers appropriately if asked with a different topic. PROCESS: the client responds immediately with subsequent eye contact which indicate quick thinking process.

CLARITY OF IDEAS: his idea depends on the question or topic. There are times that his idea is clear and appropriate to the question being asked but during question related to frustrations, the clarity of idea is quite poor. It is filled with lots of delusions an d sometimes, it is inappropriate to the question. SELF-HARM- SUICIDE URGES: Though he never verbalized that he had committed any suicide attempts, unconsciously, in his verbalizations like he grabbed a gun and pointed it to his head in his mind, is a sign of suicide ideation, a clear risk for suicide attempts.

SENSORIUM AND INTELLECTUAL PROCESSES ORIENTATION: he is oriented of his location, time and his situation except for his condition as he denies that he has a mental illness. CONFUSION: he never showed any signs of confusion. MEMORY: he has good memory about the things about him , his family and his studies.

ABNORMAL SENSORY EXPERIENCES OR MISPERCEPTION CONCENTRATION: he has a good level of concentration and span of attention with some instances of attention shifts. BSTRACT THINKING ABILITIES: he had a good formal education. He has normal abstract thinking abilities and can even use terms such as analysis and can analyze idioms and metaphors and interpret it well.

JUDGEMENT AND INSIGHTS: He has a good judgment abilities and can still differentiate the or bad options. He was also able to analyze and compare two situations and identify the good or bad. He also has some problems with his insights about his situation as manifested by his denial of his condition but fully aware of his behavior.

SELF-CONCEPT PERSONAL VIEW OF SELF: He perceives himself to be lacking of something like his family and his own dignity. PERCEPTION OF PHYSICAL SELF: He had described himself as ok naman as an individual of unsure level of self esteem. PERSONAL QUALITIES OR ATTRIBUTES: He stated that he is quiet and hindi naman siya palaaway

ROLES AND RELATIONSHIP CURRENT ROLES: He views himself as a person, a brother and a son. But not as a mental patient. SATISFACTION OF ROLES: He is not quite satisfied anf his current role since he verbalized regret of taking care of their parents. SUCCESS OF ROLES: he verbalized nothing about the success and contents in his current

SIGIFICANT RELATIONSHIP: He verbalized that he had previously a girlfriend but he later broke up with her. SUPPORT SYSTEM: He had his father as his primary support system who visited just two weeks ago.

PHYSIOLOGIC AND SEF CARE CONSIDERATIONS EATING HABITS: He has no problems with eating habits as he verbalized that ok naman yung pagkain and has a good appetite . SLEEPING PATTERNS: Has a good sleeping pattern as verbalized as mabuti naman yung tulog ko HEALTH PROBLEM: He has no HPN, DM, and Trauma. However, hypopigmentation in his arms as a result of fungal infection in present.

COMPLIANCE WITH PRESCRIBED MEDICATIONS: No history or record of hoarding medications or any refusal to take medications. He said that iniinom ko naman mga gamot ko ABILITY TO PERFORM ACTIVITES OF DAILY LIVING: He stated that he practice good hygiene (bathing, brushing teeth,) but the NOD sad that he is not obedient when it comes to the proper schedule of taking a bath and just take it whenever he wants or when he saw someone taking or doing it.

Physical Assessement

Cephalocaudal
y Head: slightly rounded oblong in shape y Hair: short black hair evenly distributed y Eyes: PERRLA, +2 pupil size light accommodation, no y y y y

nystagmus and strabismus noted Ears: bilaterally equal, no tinnitus, no pain, Jaw: no pain in mastication Sinuses: no pain in sinuses and +illumination maxillary sinus Thyroid: no pain and tenderness, no mass noted during palpation

y Lungs: Tracheobronchovesicular sounds

heard on

auscultation: normal lung sounds

y Circulation: capillary refill >1 sec y Skin: with moles distributed in the body, and has skin

hypopigmentations all over the body; mostly at the extremities y Skin Color: fleshy pinkish cream in color

Anatomy and Physiology

The areas of the brain implicated in schizophrenia are the forebrain , hindbrain and limbic system .

Forebrain
-The anterior and largest portion of the brain -Includes the cerebral hemisphere, limbic system, thalamus and hypothalamus and corpus callosum. -the forebrain functions to control cognitive, sensory and motor function, and regulate temperature, reproductive functions, eating, sleeping and the display of emotions.

Frontal Lobe
y -The frontal lobe is important in controlling

movement and in planning behavior. y -emotional control center and home to our .personality

Temporal lobe
y y

- Concerned with the control of hearing. - It also functions to enable us to recognize objects and faces.

Hindbrain
y -The area of the brain comprising the pons,

medulla and cerebellum. -Functions collectively to co-ordinate motor activity, posture, equilibrium and sleep patterns and regulate unconscious but essential functions, such as breathing and blood circulation.

PATHOPHYSIOLOGY (Undifferentiated Schizophrenia)

(MRI)Less brain tissue and cerebrospinal fluid (CT ) Enlarged ventricles and cortical atrophy in the brain is present. (PET) Glucose metabolism and oxygen are diminished in the frontal cortical structures of the brain Alteration in the level of neurotransmitter Dopamine and Serotonin

Decreased brain volume and abnormal brain function in the frontal and temporal areas Traumatic Experience Manifestations of positive and negative symptoms of schizophrenia

Diagnostic Tests

Medications

NCP s

Discharge Planning

Thank you po Ma am=)