Wednesday, May 7, 2008

A case study about Schizophrenia

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Case Summary
This is a case of A.O., 30 years old, female, from Amamaros, Pototan, Iloilo, who was admitted at Pototan Mental Health Unit last February 10, 2008, with a chief complaint of behavioral changes and a working diagnosis of Schizophrenia. She’s under the supervision of Dr. Ali Robles.

Analysis of the Case

History of Past Illness

Two weeks PTA (prior to admission), A.O. together with her sister arrived at Iloilo. They came from Antipolo and they will stay at their Aunt’s house at Amamaros, Pototan.
Two days PTA, patient A.O. complained that she cannot sleep well and that she had sleep disturbances. The Aunt had also noticed that A.O. was exhibiting strange and peculiar behaviors in the past few days. She barely talks and was found to be staring blankly at the ceiling. Sometimes, she talked to herself, with words her Aunt can’t understand. One moment, she walked aimlessly inside their house.

There were also moments when she prefers to stay at one corner of her room.
1 day PTA, as the Aunt was about to go to sleep, she was startled when she heard A.O. yelling. She went to her room and found A.O. going wild. She was throwing her things and was yelling incoherent words. She was uncontrolled. Then Aunt forced her to take medication and after a few hours, she was calm.
Few hours PTA, the Aunt brought A.O. at Pototan Mental Health Unit for consultation. She was alarmed with the patient’s behaviors last night. Thus, she was admitted with a chief complaint of behavioral changes.

Review of Systems-Mental Status Examination
I. General Appearance and Behavior
o Physical Appearance
Patient A.O. is about 4’9’’ tall, wears appropriate dress; always attend to her hygiene; hair is short, black, wavy, on neck length, kempt; appearance is appropriate to situation and weather
o Facial Expressions
Most of the time has flat affect; sometimes stares blankly into space or at the student nurses; has poor eye contact. Odd mannerisms are crossing her hands, placing hands on face (as if wiping it), stretching hands, or legs and make some cracking sounds of bones. A.O. answers questions in a soft, sometimes barely audible voice.
o Manner of Client During Nurse-Patient Interaction
A.O. is passive; only talk if you student nurses talk first or when being asked. She never initiates to open a topic; changes the subject of discussion whenever the topic is about her family or the reason why she was admitted. A.O. is sometimes very unpredictable. One moment she is normal, the suddenly she would talk about weird things and would speak incoherent words. Sometimes she would answer in a monosyllabic speech even when asked with open-ended questions.

II. Characteristics of Speech Quantitative Speech
A.O. barely take the initiative to talk; answers open-ended questions with monosyllabic speech; sometimes would answer questions in a barley audible voice; the longest answer in about 4-5 words only.
 Qualitative Speech
A.O. would sometimes answer questions inappropriately or completely irrelevant to the questions asked; neologisms was also noted; and talks about bizarre things like “barang” or “ninakaw ang kaluluwa”.

III. Mood and Affect
Most of the times A.O. does not exhibit any significant mood and has flat affect. Sometimes there are also sudden changes of mood. However, there are also times when A.O’s mood and affect is appropriate to the thought content.

IV. Thought Content

No significant themes were noted. Patient most of the times answer in a monosyllabic speech. Delusions were noted:
SN: “Sino po si Cesar manang?”
Pt.: “Cesar Montano…asawa ko…”
Patient has delusion of grandeur. She’s claiming that Cesar Montano is her husband.

V. Perception
Hallucination was also noted when she kept on insisting and pointing that there was something itchy under the table, though there was none.

VI. Sensorium Functions Patient is oriented to person, place and time.

1. Rote Memory- Patient rote memory is impaired
2. Recent Memory- Patient recent memory is intact. When she was asked what she did this morning, her answer coincides with the answer of the folk.
3. Remote Memory- Patient remote memory is intact as evidenced when asked when her birthday is and she answered Sept. 27, 1977. Her birthday is indeed September 27, 1977.
4. Immediate Memory- Patients’ immediate memory is impaired.

Attention and Concentration Patient’s attention and concentration is questionable. Student nurses cannot tell whether the attention is really impaired or the patient is just having difficulty to think.

Insight and Judgment

 Patient is aware of her condition. Though, she does not know that her condition is a serious matter and not merely “nerbiyos”.
 Patient exhibits good judgment. Her decisions were appropriate to the situation given.

Past Health History-Contributory Factors to Condition:
A. History of Psychological Problems
A.O’s uncle in the father side has been thought to have a psychological disturbance because his wife left him. A.O’s aunt in the paternal side and her cousin’s father in the maternal side were diagnosed to have nervous breakdown. Her cousin on the maternal side also has a psychological problem, which is believe a cause of high level of intelligence.

B. Childhood Upbringing
A.O’s primary caregiver is not her mother but her yaya (an Aunt from the mother side). Though, her mother is the one who gives her milk. She’s cuddled and breastfed by her mother per demad. The mother cannot attend to all her necessities since she’s also busy doing household chores and taking care of her other children.
When A.O. entered high school, she was left in the care of her Aunts in the maternal side at Negros Occidental, whom supported her secondary education.
When she entered college, she stayed in a boarding house under the supervision of a family friend named Father A.

C. Frequent Relocations of the Family

Their original residence is at Amamaros, Pototan, Iloilo, where she stayed until she was 12 years old. She left Iloilo and went to Negros Occidental to study high school to the care of her Aunts in the maternal side. She moved back to Iloilo again when she was about to enter college and stayed in a boarding house.
Then, the family migrated to Antipolo, Manila last 2005. That is when she consulted a specialist to treat her psychological problems.
Two weeks PTC, she went back again to Pototan, to the care of her Aunt to continue her consultation at PMHU.
The family members would notice that every time they move into a new place, A.O. would have a hard time adjusting to the new environment.
D. Loses
She lost her father when she was just 7 years old. It was hard for her since she was closer to her father than her mother was. Until now, she would still mention her father.

E. Unachieved Desires or Frustrations
She really wanted to study since she excels in academics since she was in elementary. However, she was told to stop schooling due to the recurrence of the signs and symptoms and the relapse of her condition.

F. Altered Self-esteem
Among the five of them (patient has 4 siblings), she is the “not-so-pretty”. Her classmates in high school would tease her “law-ay”. She is very sensitive when it comes to that matter. Sometimes, the family members would find her crying in one corner.

G. Traumatic Experience
18 years PTC, A.O. had experienced a traumatic event. She was with her mother and an aunt. They came to Iloilo (from Negros) for a vacation. They were riding a public jeepney when a track loaded with bamboo poles crashed them. She witnessed the scene when a bamboo pole struck her Aunt right to her chest and declared dead upon arrival in the hospital. She was in state of shock for several weeks.

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