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TIONGSON, NESTLEY JUNE B EAC MEDICINE III

STUDENT NO.: 16-1-11614

Name of Patient: MF Preceptor: Dr. Liecel Fulgencio


Informant: Niece Hospital: PGH WARD 7
Reliability: Good Date of Admission: Nov. 30, 2017
Historian: Nestley June Tiongson Date of Wardwork: Dec. 09, 2017
Group No.: 3 Date Submitted: DEC 11, 2017

CLINICAL HISTORY

GENERAL DATA

MF, 36 years old, female, Filipino, Roman Catholic, currently residing in


Malvar, Batangas. A stay-at-home mom of 3 kids. Admitted for the second time in
WARD 7 of Philippine General Hospital, Manila.

CHIEF COMPLAINT

Drug overdose from Quetiapine

HISTORY OF PRESENT ILLNESS:

23 Days prior to current admission; Patient was in a depressive mood,


hypersomnia, no appetite, blank stares and having suicidal thoughts. Patient was
admitted and later on released last November 13, 2017 because of excellent
behavior.

Hours prior to admission; Patient attempted suicide by taking seven (7) tablets
of her prescription pills, Quetiapine as witnessed by her brother-in-law. She was
transferred to ward 7 of PGH last November 30,2017.

PAST MEDICAL / PSYCHIATRIC HISTORY

2008 – diagnosed with bipolar disorder , unrecalled prescribed drugs


(may be due post-partum depression)
TIONGSON, NESTLEY JUNE B EAC MEDICINE III
STUDENT NO.: 16-1-11614

2011 – 2nd attack of bipolar disorder ,


prescriptions drugs : lamotrigine and some unrecalled drugs

2015 – 3rd attack , Worst episode with suicidal attempt


Prescription drugs : lithium maintenance , sertraline and meperidine
( most likely post partum again)
2017 – 4th attack
Prescribed drugs: quetiapine and lithium (nov.7-13)

2017– overdosed 7 tabs of quetiapine


o Prescription Drugs: (nov 27 – present) quetiapine, lithium ,
simvastatin, metformin

FAMILY MEDICAL HISTORY

- Maternal – DM
o Aunt (suffered from depression)

- Father – DM

PERSONAL AND SOCIAL HISTORY

Patient MF had a good childhood life, as well as social life growing up.
Patient is a graduate of Bachelor Degree in Computer Science and reportedly never
have had a problem with studies. Past jobs includes being a data analyst in Pure
Gold. Is in a relationship with her Common Law Husband for 10 years which they
have 3 kids and are all girls.

Patient MF denies drinking alcohol or smoking and she’s also not into
illegal drugs; Loves gardening and taking care of her kids.

REVIEW OF SYSTEMS

UNREMARKABLE
TIONGSON, NESTLEY JUNE B EAC MEDICINE III
STUDENT NO.: 16-1-11614

PHYSICAL EXAM
Vital Signs:
Temp. = 36.8 OC, axilla
RR = 18 breaths/min, regular breathing, not in distress
PR = 82/bpm
BP = 80/50 mmHg (arterial)

Mental Status Examination

Appearance and Behavior:


Patient is alert, well groomed, clothes appropriate for age, good posture.
well oriented to place, time and person. She is cooperative and seems interested
during the interview.

Speech:

Her speech was coherent, spontaneous, appropriate but with slow rate
and rhythm and low volume.

Mood:
She described her mood as flat and objectively, we saw the the same
objectively., consistency with mood, congruency with thought content..

Affect
She said she does not feel any emotions during the interview. Her behavior
is appropriate to the situation

Thought Content:
For the thought content, she said that she feels detached from people
around her. She confirms suicidal thoughts before and knows the effect that
would bring to her family when she dies
TIONGSON, NESTLEY JUNE B EAC MEDICINE III
STUDENT NO.: 16-1-11614

Cognition

Her memory is intact for recent and remote events. Her concentration
and attention were both adequate. She was able to do serial 3s and was able
to add and subtract figures without any difficulty.

Abstract reasoning : intact,


Insight
She denied any ideation of worthlessness or hopelessness. She denied
any auditory or visual hallucinations. She denied any preoccupations, illusions or
phobias.

Judgment:

Patient’s decision making is good and exceptional by answering a situational


question that she would go out of the fire exit when asked of what she will do if
there would be fire in the hospital during her stay.

WORKING DIAGNOSIS:

POSTPARTUM DEPRESSION

DIFFERENTIAL DIAGNOSIS:

Major Depressive Disorder.


Bipolar II disorder
Obsessive-compulsive disorder
Panic disorder
Phobic disorders
Posttraumatic stress disorder

PLAN OF MANAGEMENT:
TIONGSON, NESTLEY JUNE B EAC MEDICINE III
STUDENT NO.: 16-1-11614

Medical Management

 Antidepressant therapy. This would be prescribed by the physician once


the diagnosis of postpartum depression is determined.
 Counseling. Psychological counseling is recommended for a woman
undergoing postpartum depression to let her express her feelings and
restore her psychological health.

Nursing Assessment

 Assess the woman’s psychological health even before the delivery.


 Assess her history of illnesses to determine if she needs any counseling
prior to her delivery to avoid postpartum depression.

PHARMACOLOGICAL TREATMENT:

 ANTIDEPRESSANTS
 Such as fluoxetine (Prozac), sertraline (Zoloft) and amitriptyline,
are generally thought to be safe for use while breastfeeding
 Selective serotonin reuptake inhibitors (SSRIs) are usually the first-choice
medicines. Most SSRIs are thought to be safe for use while a woman is
breastfeeding. That's because SSRIs generally pass into the breast milk at low
levels.
 Tricyclics are generally thought to be safe for use while a woman is
breastfeeding.
TIONGSON, NESTLEY JUNE B EAC MEDICINE III
STUDENT NO.: 16-1-11614