A CASE STUDY In Partial Fulfillment of the Requirements in NCM 102 (Related Learning Experience) “Undifferentiated Schizophrenia”

Lorma Colleges, San Fernando, La Union January 18 to February 10, 2010 Submitted By: BSNIII-8 Group I Alihuddin, Alnah D. Avila, John Derrick Aquino, Donna Leah Balangue, Jesusa Boado, Jasmin Buen, Ailen Camacho, Florence Joy Cabusora, Athena Dumpit, Jennifer Esguerra, Christopher Feraldo, Bennie Vic Submitted to: Mr. Jerry Abriam & Mr. Charles Rivera Clinical Instructors Group IV Alcantara, Carlita Padilla, Aprille Rimas, Edelia Rivera, Claire Sanchez, Virgie Sevilla, Jezelle Sobrevilla, Kimberly Tan, Mary Ann Tejano, Rose Jane Vera, Kervy June Verceles, Cresencio

I. INTRODUCTION Schizophrenia is characterized by a lack of grounding in reality, known as psychosis. People in a state of psychosis can experience hallucinations, delusions, and other events in which they break from reality. Individuals with schizophrenia experience psychosis and can also develop symptoms such as disorganized speech, lack of interest in social interactions, a flat affect, inappropriate emotional responses to situations, confusion, and disorganized thinking. Patients with undifferentiated schizophrenia do not experience the paranoia associated with paranoid schizophrenia, the catatonic state seen in patients with catatonic schizophrenia, or the disorganized thought and expression observed in patients with disorganized schizophrenia. However, they do experience psychosis and a variety of other symptoms associated with schizophrenia, including behavioral changes which may be noticeable to family and friends. This mental disorder is challenging to diagnose, and it can take weeks or months to confirm a diagnosis of schizophrenia. During this process, other causes for the symptoms are ruled out, and the patient is observed to collect information about changes in the patient's personality, modes of expression, and mood. Family members and friends may also be interviewed and asked for information with a goal of painting a more complete picture of what is going on inside the patient's mind. There are a number of treatment options available for undifferentiated schizophrenia. Patients can discuss treatment options with their physicians, although it is important to be aware that it can take time for treatment to be effective. Once patients start experiencing a change, they may require periodic adjustments to their medications and treatment regimen to respond to changes they experience over time. Undifferentiated schizophrenia cannot be cured, but it can be managed with a cooperative effort. Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process with many different varieties and symptoms. It is usually diagnosed in late adolescence

or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. The symptoms of schizophrenia are categorized into two major categories, the positive symptoms which include delusion, hallucinations, and grossly disorganized thinking, speech, and behavior, and negative symptoms as flat affect, lack of volition, and social withdrawal or discomfort. Medication treatment can control the positive symptoms but frequently the negative symptoms persist after positive symptoms have abated. The persistence of these negative symptoms over time presents a major barrier to recovery and improved the functioning of client’s daily life. The prevalence rate for schizophrenia is approximately 1.1% of the population over the age of 18 or, in other words, at any one time as many as 51 million people worldwide suffer from schizophrenia, including;
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6 to 12 million people in China (a rough estimate based on the population) 4.3 to 8.7 million people in India (a rough estimate based on the population) 2.2 million people in USA 285,000 people in Australia Over 280,000 people in Canada Over 250,000 diagnosed cases in Britain The number of people who will be diagnosed as having schizophrenia in a year is about 1

in 4,000, so about 1.5 million people will be diagnosed with schizophrenia this year, worldwide. About 100,000 people in the United States will be diagnosed with schizophrenia this year. Dr. Noel Reyes, a psychiatrist at the National Center for Mental Health in Mandaluyong City, said that one of the most common brain diseases among Filipinos is schizophrenia, which afflicts one percent of the total population. He said that it (cases of mental illness) increases as the population increases. For example for schizophrenia, if the population now is 88 million, expect that 880,000 of it are schizophrenic.

The student nurses will be able to gain awareness of several myths and facts about Schizophrenia.In San Fernando City. 3. The patient will be able to socialize with her relatives and neighbors. . 3. The patient will be able to identify behaviors that alienate significant others and family members. 2. The patient will be able to verbalize her experience of delusions without engaging in power struggle over the content or the entire reality of the delusions. 4. SPECIFIC OBJECTIVES After 7 days of community visit: PATIENT CENTERED OBJECTIVES: 1. there are 17 cases of schizophrenia. 4. The student nurses will be able to demonstrate ability to identify signs and symptoms of Schizophrenia. supportive relationship 2. NURSE CENTERED OBJECTIVES: 1. The patient will be able to talk about her feelings in the context of a trusting. La Union. The student nurses will be able to gain deeper understanding of Schizophrenia. Seven of which are diagnosed as paranoid schizophrenia and the rest have no specific diagnoses. The student nurses will be able to implement proper nursing interventions to the patient.

She became sleepless at nights. her family decided to bring her to Baguio General Hospital and Medical Center. She is a housekeeper and a store owner. On that night she dreamed about the news but the ones performing the sexual act was her and her husband. According to Mrs. LF’s signs and symptoms manifested on the month of December 2009. On that day. She was born on September 19. January 5. Bacnotan La Union. Her husband said that she taught that the camera of the phone will be used against her that videos of her are being taken already. Biographic Data Mrs. Mrs. living at Upper Carcaramay. Her behaviors turned aggressive and she stared angrily. 1968 via NSD. She was uncooperative and resistant. The morning after. LF a 41 year old female. On the night of January 4. She became mistrustful of the people around her especially those holding mobile phones. She refused to go out and just stayed in her store. B. 2010 after she watched news on television about a sex video scandal the night before. she was worried about her sari-sari store. she did not respond nor looked at them. it took 3 of her brothers and nephew have . She was agitated even when asked softly and calmly. LF became withdrawn. She is married to CF and they have 2 children. She lost her appetite which contributed to her big weight loss. She exhibited ideas of reference. PATIENT’S HEALTH PROFILE A. Whenever somebody came to buy. Her sleep patterns changed. Her mental illness became prominent on January 05. They are affiliated to the Roman Catholic Church. She delivered her children via NSD through her mother’s help. an amount left in her store was stolen but when her husband was asked there were no incident as such. She is the 5th among the 8 siblings but two of them died when they were still younger. According to her husband. History of Present Illness Mrs.II. 2010. LF. According to her husband. She would yell at anyone whom she caught looking at her. She accused her nephew to have manipulated the sex video that was connected on their television. she woke up doing bizarre things already according to her husband. Her profits are depleting and her capital has accumulated into debts incurred by their neighbor.V. 2010 she was restless in front of the television and kept walking around the house while glancing on the T.

colds and fever. 2010 Mrs. “ nawala na…nawala na kasi pinakain ako ni CF…nawala na…nawala na.” which is a manifestation of verbigeration Mrs. laughing at her and mocking her. LF was depressed and she repeatedly asked “babalik pa kaya ang isip ko?”. The husband of Mrs. C.in-law she suffered from hair loss during her adolescence. According to her husband.to restraint and hold her in order to bring her to Lower Carcarmay to take the ride going to town for a bus to Baguio City. . She was prescribed with the following medications: haloperidol 5 mg OD before bedtime. LF’s was brought back to BGHMC for a follow-up check up last January 26. During the initial interview. Mrs. LF knew hat her wife was into medications before but has no idea if hat it was. According to her sister. she admitted the fear of experiencing it but she denied having experienced it as what the husband has reported. Her family believed that it was caused the by bad spirits.inunahan na. When asked about the experience of being mocked and being laughed at. 2010. January 20. LF’s mother the common diseases that she had during her childhood were cough. She repeatedly say. She kept hearing voices at night. LF verbalized to have taken medications for her heart disease.. She turned irritable when her husband shared her experience without asking. Past Health History According to Mrs. She was scheduled to go back on February 17. the windows of their house facing her neighbors were closed and she refused to have them opened. She has not been vaccinated. olanzapine and biperiden 2mg OD. She did not go out of their house fearing that she might hear them mock her about her being “ nasisiraan ng ulo” Due to her nervousness. she has experienced auditory hallucination. 2010 and she was prescribed with medications for one month. She verbalized suspicion against her neighbors. She can no longer remember the name and type of drugs she has taken and when was it taken. but she could not present any prescriptions.

LF’s mother denied of having a history of psychiatric illness. b. Her children are attending school. The family frequently has vegetable soup with their rice.Mrs. She reported to have high T3 and T4 when she undergone a test. LF was alone in their house because her husband is working in a cement factory. Her two siblings died when they were younger. She can cook rice but most of the household chores are done by her husband. . E. but she could not present the laboratory result which was already misplaced. Her children’s needs are provided by her husband and mother. Lifestyle and Health Practices a. fish and vegetables. the family eats fish with their vegetables. Nutrition and Waste Management The client’s typical food intake is composed of rice. LF was diagnosed with goiter in 1989. her toxic goiter made her eyes bulge (proptosis). LF’s father died four years ago after an abdominal surgery. But when interviewed if how they are related to a certain family in Lower Carcarmay. Mrs. she acknowledged them to be her husband’s brothers and relatives. The one died of tetanus and the other from leukemia. Occasionally. These families have a family member with a psychiatric illness. LF has a poor appetite and drinks less than 8 glasses a day. According to her husband. Description of Typical Activity Most often Mrs. Her youngest sister has toxic goiter too. Mrs. D. Her sister-in-law reported that he had a cancer. She consulted various medical institutions such as Bacnotan District Hospital and ITRMC to seek for treatment and for the management of her disease. Family Health History Mrs. Sometimes her youngest sister accompanies her and helps her with the house chores.

She is able of self care. Sleep and Rest Mrs. She has been injected with olanzapine when she was brought to Baguio General Hospital and Medical Center. f. biperiden (Akineton) 2mg 1 tab OD. Before her mental illness. LF’s current medications include haloperidol 5mg. She has no history of substance abuse. 1 tab OD. d.She used to defecate everyday but after she has taken her antipsychotic medications she defecates once in every three days already. diphenhydramine 50mg OD as needed. Medications Mrs. . She was up until early morning. LF’s being suspicious and mistrustful inhibits her to socialize. sleeps for a few hours and then wakes up again. e. Before her mental illness she has a good sleeping pattern. Self Concept and Self-Care Responsibilities She expresses concern and worry over not performing her responsibilities to both her husband and children. She has limited time talking with her relatives and neighbors. LF has decreased physical mobility. She verbalizes of wanting to get well soon in order that she can resume her former role as a mother and a wife. She appears weak and is slow-paced when changing positions like sitting. standing and walking. g. Activity Level and Exercise Mrs. she could do household chores which served as her regular exercise. c. Social Activities Mrs. She manages to take a bath and maintain good hygiene except prior to and during her psychotic break out. LF before her psychotic break out has difficulty sleeping already.

she accepted the student nurses in her home. The family believes in quack doctors. LF finished her elementary education at Lower Carcarmay Elementary School and her secondary education at Quirino National High School. Despite having suspicions and nervousness. They believed that bad spirits caused her illness. Each stage has a unique developmental task or dilemma that must be resolved wherein an individual is presented with a crisis he must resolve. She worked in Bataan for several years ironing sewn clothes. she managed a small sari sari store as their source of income. She took a vocational course in dressmaking at Don Pacifico Leonzo School Foundatiuon in Hermosa. III. Values and Belief System Mrs. she was brought to an “albularyo” to determine if what was wrong with her. Patient LF was born via normal spontaneous delivery. she was breastfed for 12 months and was well taken cared of. It was in Bataan that she met her husband. LF to BGHMC. i. Bataan. Despite of her inability to resume with her ADLs. the management of the store was transferred it to her brother. identity crises. The family is affiliated to Roman Catholic. TRUST vs. But they seldom go to church because their home is situated in the mountainous part of the barangay. MISTRUST (birth to 18 mos) The goal is to develop trust and trust is being developed from the inner feeling of selfworth that is transmitted through maternal care. Prior to bringing Mrs.h. . she verbalizes of wanting to take care of her children. She has an optimistic attitude as manifested by her hope to be able to recover. Education and Work Mrs. and identity confusion in the dynamics of personality development. According to her mother. DEVELOPMENTAL LEVEL Erik Erikson’s Psychosocial Theory of Personality Development emphasizes the concept of identity or an inner sense of sameness that perseveres through external changes. LF is a family-oriented person. Before the onset of her disorder. Now.

She was cuddled. she was able to acquire sense of independence and competence. she constantly encouraged her to go to the toilet whenever she feels so. patient LF loves to play with her siblings and with other children in the neighborhood. GUILT (3 – 5 y/o) The goal is to develop a sense of purpose and the ability to initiate and direct one’s own activities. In this stage. Mental and motor abilities were developed thus her sense of initiative was reinforced mastering this developmental stage. She is close to her younger sister. the task in this developmental stage was achieved wherein trust has been developed and she having a sense of the world as a safe and dependable place to live with. AUTONOMY vs. As stated by her mother. She has lots of female friends whom she mingles and interacts with. Patient LF only attained high school level. INDUSTRY vs. INFERIORITY (6-12 y/o) The goal is to develop a sense of duty or to achieve a sense of self-confidence. According to the mother. Though she wanted to enter . Her mother started to toilet train her at the age of 2 and she was able to master the task at 3 years old. with patience. IDENTITY vs. Patient LF feels unworthy whenever her efforts were not recognized. hence. She was given the freedom to play with others. With this. fondled and played with by her mother. SHAME and DOUBT (18 mos to 3 y/o) The goal is to gain self-control and independence within the environment. emotional stability and be able to view self as a unique individual. However. she develops some gratification and the pleasure in the interaction and involvement with others. ROLE CONFUSION (12 – 18 y/o) The goal is to develop sense of confidence. INIATIVE vs. Her needs were attended and were adequately met. she is not afraid of failure as she always tries to explore new things/activities.

she met Charlie. productivity.college. Patient LF is classified under this developmental stage as to her age. She gave up managing their sari-sari store. because of her illness. They are married for fourteen years now and were blessed with two children. However. It was manifested in this developmental task the patient LF was able to integrate the task mastered in the previous stages into a secure sense of self. if not all of her daily chores and responsibilities for her family. Patient LF was able to achieve this developmental task as she was able to reach out and make contact with other people. Patient LF is friendly and likes to socialize as she attends parties and other events. She just remains silent whenever conflict arises between her and her husband. lasting relationship or the ability to pledge a total commitment to another. she cannot cope up with the demands of the daily activities in life. they are happy and are living peacefully. She is not the type of person who easily gets jealous. They owned a sarisari store then. She started to feel confuse and anxious. She became unproductive and just stayed at home. She consults her husband’s opinions whenever decisions are to be made in life. STAGNATION (41 – 64 y/o) The goal is to achieve a sense of gratification from personal and professional achievements and from meaningful contributions to others. she was not able to due to financial constraints. INTIMACY vs. She worked as a sewer and stayed with her relatives thereat. creative and active are the developmental tasks that patient LF failed to do. family and societal responsibilities. During the stay of patient LF in Bataan. However. and became her husband. In this stage. . as a source of family income. GENERATIVITY vs. She cannot perform parental. She was able to share with and care for another person without fear of losing oneself in the process. Nevertheless. Though they live a simple life. patient LF is hopeful to get better and would soon resume most. she went to vocational school and taken up a short course in dressmaking in Bataan. being constructive. thus making her stagnant. ISOLATION (19 – 40 y/o) The goal is to perform an intense.

GENOGRAM .IV.

changes in alertness noted BP. 2010 I. place.V.6° HR-83 PR-82 RR-22 Weight-48 kg Height-5 feet 2 inches • • • • • • • • • • • II. Vital Signs III. Eyes • • • . General survey • • Thin body built With erect and rigid posture Clean and without body odor Fairly good appetite Can eat without assistance Oriented to date. PHYSICAL ASSESSMENT Date: January 20. person. time. Head a. Head-to-Toe Assessment A.150/70 T-36. Face • • • Blunted affect Able to puff cheeks(CNVII) Able to frown(CNVII) Able to close eyes(CNVII) Able to smile but not fully (CNVII) Able to differentiate sensation such as touch and temperature Able to read word/s from a distance of 6-7 feet (+) PERRLA (+) Corneal reflex (CNV) • • • b.

Ears • • • • • • • • • • • • e. Neck • Symmetrical carotid pulse No palpable lymph nodes Slightly enlarged thyroid Able to move head slowly from one side to another Able to hyperextend the head by 60° • • • • . Lower teeth-12 With cavities Salivating (+) gag reflex Able to swallow and masticate Buccal mucosa is pink Able to protrude tongue (CNXII) Able to purse lips (CNVII) • • • • • c. downward and sideward) (CNIII.VI) With pale pink conjunctiva With yellowish sclera Slight bulging eyes No secretions noted Able to differentiate the smell of coffee from soap (CNI) No abnormal secretions Able to hear normal voice tones Able to repeat words spoken by the examiner Able to hear whispered words with dentures (two front upper teeth) Upper teeth-13.IV.• (Both eyes coordinate and move in unison and with parallel alignment(upward. Mouth • B. Nose d.

adduct. Upper Extremities (+)radial and brachial pulse Cold and clammy hands Capillary refill less than 2 seconds Able to feel light touch and pressure With full movement against gravity and against full resistance Bilateral fine tremors noted audible bowel sounds smooth and no tenderness noted not assessed able to abduct. Genitals • • • • G. no deformities noted Back is straight Shallow respiration Skin intact and dry Heart murmurs noted • • • b.• • • Able to bend head forward Able to turn head slightly against a resistance Able to shrug shoulders slightly against a resistance C. Chest and Back a. move forward and back With full movement against gravity and against full resistance Bilateral mild tremors noted • • • E. Anterior thorax • • • • D. Posterior thorax • • • Skin intact With dry Skin Spinal column is straight. Abdomen • • F. Lower Extremities .

Vital Signs III. Eyes • . Face • • • Symmetric temporal pulse Unable to puff cheeks(CNVII) Able to frown(CNVII) Able to close eyes(CNVII) Able to smile but not fully (CNVII) Able to differentiate sensation like touch and pressure Teary • • • b.80/60 T-36.6° HR-142 PR-120 RR-28 Weight-48 kgs Height-5 feet 2 inches • • • • • • • • • • • II. changes in alertness noted BP. Head a.Date: February 3. person. place. 2010 I. Head-to-Toe Assessment A. General survey • • Thin body built With erect and rigid posture Clean and without body odor Fairly good appetite Can eat without assistance Oriented to date.

Neck • Symmetrical carotid pulse No palpable lymph nodes Slightly enlarged thyroid • • . Nose d. Ears • • • • • • • e.IV. Lower teeth-12 With cavities (+) Gag reflex Has difficulty swallowing Buccal mucosa is pink Unable to protrude tongue(CNXII) Able to purse lips but with difficulty (CNVII) • • • • • c. downward and sideward) (CNIII. Mouth • • • • • • • B.VI) With pale pink conjunctiva With yellowish sclera No abnormal secretions noted Able to differentiate the smell of coffee and soap (CNI) No abnormal secretions found Able to hear normal voice tones Able to repeat words spoken by the examiner Able to hear whispered words With dry lips With sticky saliva With dentures (two front upper teeth) Upper teeth-13.• • • Able to read word/s from a distance of 6-7 feet (+) PERRLA (+) Corneal reflex but reacted slowly(CNV) Both eyes coordinate and move in unison and with parallel alignment(upward.

Lower Extremities . move forward and back Normal full movement against gravity and against full resistance Bilateral tremors noted • • • • • E. Chest and Back a. no deformities shallow respiration skin intact and dry Heart murmurs noted • • • b.• • Able to hyperextend the head but with difficulty Able to bend head forward but with difficulty Able to turn head laterally but with difficulty Unable to turn head laterally against a resistance Able to shrug shoulders but with difficulty Unable to shrug shoulders against a resistance • • • • C. Upper Extremities (+)radial and brachial pulse Cold and Clammy hands Capillary refill less than 2 seconds Able to feel light touch and pressure normal full movement against gravity and against full resistance bilateral fine tremors noted audible bowel sounds smooth and no tenderness noted not assessed able to abduct. Anterior thorax • • D. Genitals G. Posterior thorax • skin intact and dry spinal column is straight. Abdomen • • • • • • F. adduct.

In addition to twin studies. A person whose parent has schizophrenia has a ten percent chance of inheriting the condition. at least plays an important role in the development of the illness. The best schizophrenia type’s definition for this type of schizophrenia is ‘mixed clinical condition’. Genetics. environmental triggers. the patient’s symptoms may fluctuate. Studies of identical twins have established that genetics. In this schizophrenia type. PSYCHODYNAMICS The causes of schizophrenia are unknown: while several possible causes exist. and is diagnosed when a schizophrenic patient does not exhibit symptoms resembling any of the other types of schizophrenia. schizophrenia genetics research has also studied parent/sibling genetics. or might stay excessively stable. Undifferentiated Schizophrenia is the one that does not fall into the category of either. the other twin has a forty to fifty percent chance of developing the mental illness. birth defects. Of all the schizophrenia sub types. . Genetical cause of Schizophrenia Schizophrenia genetics have been well studied. If one identical twin develops schizophrenia. no single cause explains all cases of schizophrenia. if not the cause of schizophrenia.VI. and imbalances of the neurotransmitter dopamine are all considered possible causes of schizophrenia. causing a doubt in placing it under any other sub type.

but genetics alone cannot be considered the root cause of schizophrenia. genetics are thought to make certain people more susceptible to schizophrenia.psychiatric-disorders. Environmental causes of Schizophrenia Life stressors may trigger schizophrenia in people whose genetics leave them susceptible to the illness. finding a cause for schizophrenia may be extremely complicated: many of the possible theories given above may be true for different varieties of schizophrenia. Ending relationships. Instead. Instead. as have pre-existing problems with cognitive and perception distortion. It is also worth noting that many schizophrenia experts believe schizophrenia is actually more than one disorder.php) . and other life stressors have been linked to schizophrenia onset in some cases. may combine with schizophrenia genetics to trigger the disorder. Low levels of social competence and a diminished ability to experience pleasure have been linked to schizophrenia. Too many schizophrenia patients have no family history of the illness.com/articles/schizophrenia/schizophrenia-causes. schizophrenia genetics leave some people susceptible to the illness. (http://www. Other considerations. which is triggered by environmental factors. such as environmental factors. may predispose individuals to the disease.Such studies indicate schizophrenia is influenced by genetics. while not causes of schizophrenia themselves. Certain personality traits. leaving home. and that schizophrenia symptoms are actually caused by several subtly different mental disorders. Genetics and Environment: Multiple Schizophrenia Causes Current schizophrenia theories suggest no single cause of schizophrenia exists. If true.

The dopamine hypothesis suggests that an excess of dopamine in the brain contributes to schizophrenia. Secondly. drugs that increase levels of dopamine. since dopamine receptors inhibit the release of glutamate. There is evidence that supports and counters the dopamine hypothesis. and their effects have helped many people cope with symptoms. Studies show an underactivity of glutamate in schizophrenic patients.  Glutamate — Glutamate is another important neurotransmitter implicated in schizophrenia. proteins. block dopamine receptors. often cause psychotic symptoms and a schizophrenic-like paranoid state. and amino acids play a role in causing schizophrenia. which are used to treat schizophrenia.  Dopamine — Dopamine is the primary brain chemical implicated in schizophrenia. The main support for the theory that too much dopamine causes schizophrenia is the fact that antipsychotic medications. . The medications are designed to bind to dopamine receptors in the brain. It is thought that the brains of people with schizophrenia and other psychotic disorders produce too much dopamine.Brain Chemical Imbalances There is evidence that chemical imbalances in certain neurotransmitters. like amphetamines. This supports the dopamine hypothesis. The Dopamine Hypothesis Dopamine is a neurotransmitter that transports signals between nerve endings in the brain.

it is noteworthy that two key pharmacological clues to the pathophysiology of schizophrenia—clinical efficacy of D2 receptor antagonist and increased probability of developing schizophrenia after cannabis use during adolescence—are consistent with deficient NMDA receptor function in schizophrenia. For example. Cannabis. working memory. These include GABA interneurons whose morphology has been altered in schizophrenia (Lewis et al. 1992). These slow EPSPs are considered critical for the proper expression of complex behaviors. such as associative learning. Along the same lines. Cannabinoid CB1 receptor and D2 receptors are localized presynaptically on glutamate terminals and work to inhibit the release of glutamate.. NMDA receptors are a major subtype of glutamate receptors and mediate slow excitatory postsynaptic potentials (EPSPs).Glutamatergic Activity in Schizophrenia The glutamate hypothesis of schizophrenia posits that the function of the N-methyl-Daspartate (NMDA) receptor is compromised in this disease. is dependent on activation of NMDA receptors on these neurons (Johnson et al. reduces glutamate release. behavioral flexibility.. in particular in corticostriatal regions (Gerdeman . NMDA receptors also play an essential role in the development of neural pathways. which is thought to be an integral component of their proper response to environmental stimuli. and attention. including pruning of cortical connections during adolescence. many of which are impaired in schizophrenia. 2005). making them a critical component of developmental processes whose malfunction may lead to schizophrenia. and dopamine neurons. Glutamate neurons regulate the function of other neurons that have been strongly implicated in the pathophysiology of schizophrenia. which are the target of antipsychotic drugs. bursting of dopamine neurons. therefore.

Yamamoto and Davy. Some studies also suggest that abnormalities in the temporal lobes. reasoning. it is highly unlikely that schizophrenia is the result of any one problem in any one region of the brain. patients with autoimmune thyroid disease may develop psychoses that are nonspecific. are well known.. This is expected because autoimmune thyroid disorders typically cause a disorganization of the nervous system. 2001). indicating a deficit in the volume of brain tissue. Thyroid Disease: Behavioral and Psychiatric Changes Psychiatric symptoms in thyroid diseases such as Hashimoto's thyroiditis and Graves' disease.and Lovinger. and decision-making. . the area of the brain responsible for planning. In particular. 2001. abnormalities in brain structure may also play a role in schizophrenia. This neurobiologic disorganization is also a common feature of nonspecific psychoses. leading to deficient activation of NMDA receptors. Cognitive dysfunction is also a common feature of hypothyroidism and this symptom may confuse diagnoses of psychoses and other psychiatric illnesses. 1992). But despite the evidence of brain abnormalities. including bipolar disorders. hippocampus. There is also evidence of abnormally low activity in the frontal lobe. and amygdala are connected to schizophrenia’s positive symptoms. whereas reduced D2 receptor function produces modest increases in glutamate release (Cepeda et al. Enlarged brain ventricles are seen in some schizophrenics. Abnormal Brain Structure In addition to abnormal brain chemistry.

Psychiatric Aspects of Hyperthyroidism and Hypothyroidism The symptoms of hypothyroid psychoses are most pronounced in patients who suddenly move from hyperthyroidism to hypothyroidism. including patients undergoing treatment for hyperthyroidism with radioiodine ablation. and patients may speak rapidly. and occasionally episodes of intellectual dysfunction.cfm/thyroid_disease) . dysphoria. expressing disjointed thoughts. emotional lability. Concentration may be impaired.suite101. Hyperthyroidism itself causes multiple and varied neurobehavioral and psychological changes including anxiety. and surgery.com/article. (http://thyroid-disorders. insomnia. excessively high doses of anti-thyroid drugs.

She was easily distracted by the noise and passersby. LF is a 41. Gait and Motor Coordination Mild tremors were observed from Mrs. LF was cooperative and slightly distant during the interview. Behavior Mrs. LF’s hands were trembling when she was asked to do draw. LF was appropriately dressed. Her hair was uncombed and her fingernails were not trimmed. A. She looked older for her age. A.VII. She was able to stand erect and slightly swayed when asked to stand with eyes open and she moved her feet when asked to stand with eyes closed. Manner and Approach B. has a shoulder length hair which was slightly disheveled and with an erect posture.1 Presenting Appearance Mrs. She was able to slightly turn her neck from one side to another and to shrug her shoulders.3.year old Filipino woman of average weight and height. Basic Grooming and Hygiene During the interview (January 20. 2010). LF during visitation. She was found to have ataxic gait when Romberg’s test was done. She is brownskinned. Her skin was dry and her feet were dirty. B. General Appearance A. MENTAL STATUS EXAMINATION Date: January 20. She was able to repeatedly and rhythmically touch her nose when asked to do the FingerTo-Nose test. 2010 I. She was irritable when her husband butted in to the .2. Mrs.1. It was observed that Mrs. She walked with upright posture and steady gait in slow pace. She also was able to alternately supinate and pronate her hands in a little fast rate.

Receptive Language Mrs. a. Repetitions to what she was saying were also noted. Her sentences trailed off and do not finish them unless there was some motivation.3. LF was able to comprehend questions asked of her. B.conversation and shared information regarding her condition. LF articulated herself in a slow manner during the course of interview. She repeatedly blamed her husband for forgetting what she was supposed to say. She was able to recall objects that were asked for her to remember after 15 minutes of conversation. She stared blankly when asked about her sari-sari store which was closed and transferred to her brother’s house. LF made a minimal eye contact during the interview. b. Expressive Language Mrs. especially when recalling experiences that made her anxious. Speech Mrs. She often paused and answered only when motivated. particularly when mentioning about the unpaid debts her neighbors have from her sari-sari store. Recall and Memory Mrs. B. using crayons instead of a pencil and determining shapes and sizes. She did not deviate from the topic but paused several times before finishing her answers to the questions. She drove away children who came in their house and kept saying “bangad”. B. She spoke softly throughout the conversation. She answered the questions correctly and was related to the topic. LF was able to recall recent and past events. Eye Contact Mrs. LF expressed herself with difficulty. She was able to follow instructions like folding a paper into half. She has difficulty finding words during the conversations.4.2. She was able to recall the content of her breakfast and the . She was able to answer correctly questions related to a storytelling test.

LF . LF. She was able to follow instructions to draw a clock. what place she was in. what year. She counted her fingers every time she was asked to subtract.2. Orientation Mrs. 86. She was able to subtract 7 from 100. Alertness Mrs. Her answers to the questions were associated and relevant. who were interviewing her and what country she was in. D. 79 but made more than 4 errors as the test progressed. D. This test was given to measure the frustration tolerance which affects the concentration and attention of a person. LF successfully indicated the correct time but placed the numbers in slightly unequal gaps. Concentration and Attention Mrs. D. oriented and was able to answer questions. Mrs. This was a manifestation of an alteration in the focus of attention of Mrs. This manifested her capability in the recollection of her remote memories. LF responded with coherence and was easy to understand. LF was able to answer the serial 7s test.3. an average person can repeat 4-6 series of numbers in reverse order.1. LF was able to answer accurately when asked if what day was it. These showed her capability for immediate recollection She was also able to recall experiences related to the pictures of her and her family when she was younger. She placed the numbers on the edge/line of the clock and outside the face of it. Coherence Mrs. While doing the test. 93. She was able to identify relatives that were present during the interview. Orientation.color of her children’s clothes leaving for school. LF was alert. Mrs. She was able to recite the reverse of 87 and 649 without difficulty and had a difficulty giving the reverse of the 4-digit number Normally. D. She answered in simple and concrete manner without unnecessary and overly details.4. Alertness and Thought Process D.

Hallucinations and Delusions Mrs.5. as . LF was able to recall information that was asked relevant to the storytelling. LF’s thought stream was slow. She was obsessed with her condition and was constantly asking about the rate and the possibility of her improvement and recovery from her mental illness. She became suspicious. D. Ideas of reference were also noted. She did not use any new or created new words. LF experienced hallucination. She also manifested nihilistic delusion.kept complaining that she did a wrong clock but her frustration was not enough to make her stop what she has been instructed to do. making her withdrawn and not going out of their home to socialize. She said that she was not like herself and that her real self is separated from her body. Mrs. She shared story of a dream which she did not really knew if it was a dream. Thought Processes Mrs. Thoughts that her psychotic symptoms will not be cured despite treatment were causing her anxiety.6. Content Mrs. She denied having hallucinations but her husband reported that his wife experienced hearing voices without him hearing one. LF was depressed and anxious about her health. D. LF was feeling guilty for not being able to care for her children and husband since the onset of her psychotic manifestations. Her husband also reported that Mrs. LF complained of hearing voices. She kept saying that her brain is missing and is not connected to her head anymore. She answered questions in a slow manner and paused most of the time. She was having suspicions that her neighbors and relatives were gossiping about her being psychotic. Form Mrs. Repetitions to what she was saying were evident. She verbalized experience of depersonalization. She often paused during conversations but continue to speak in relation to the topic. LF was able to answer questions spontaneously and directly. Stream Mrs. She believed that the people in their neighborhood were gossiping and making fun of her.

Judgment and Insight When asked about her condition. laughing or calling. . She believed that her brain is missing and is not connected to her body. ikinamatay nya. LF also experienced nihilistic delusion. She cooperated with the therapy and religiously took her medications. LF has an average intellectual ability. She kept spitting during the conversation and complained of sand in her tongue and something was stuck in her mouth but there was none when checked. 8. Mrs. She insisted that the windows must be closed all the time for the fear of seeing “those” people who were laughing at her. She was able to answer most of the questions like: “What is the capital of the Philippines?”. “Who is the Governor of La Union?”. She said that she pity her children because she has become useless for them. Mrs. D. a wife and a store owner. Mrs. Intellectual Ability Mrs. She reacted with amazement when asked if what she can say about the absurdity: “ May isang lalaki na naaksidente ng dalawang beses. LF accepted the fact that she was ill and required treatment. and “Who is the president of the Philippines?”. Ngunit ang pangalawang aksidente. She was cooperative in going to the hospital for check up and was compliant with management.” She argued that the man could not be alive again because he was already dead. LF manifested gustatory hallucination. She has also verbalized suspicion about her neighborhood making fun of her and gossiping about her illness which was a manifestation of ideas of reference. Noong unang nadisgrasya sya dahil nasagasaan nga sasakyan.if mocking and laughing at her. “Name four countries in Asia”.7. She was hoping that she can be “stronger” again to pursue her role as a mother. she denied having experienced it. nahospital lamang siya. but when she was asked directly if she has heard voices without seeing who was talking. Her abstract skill was remarkable. D.

LF was given an examination or a test.2. Mrs.E. LF has not shown manifestations and has no ideation regarding suicide and harming others. Suicidal and Homicidal Ideation Mrs. Risk for Violence Mr.4 Response to Failure on Test Items Every time Mrs. E. E. LF only looked away and became tensed. LF during the interview usually has bland affect. E. and then blank. LF was difficult to manage during the onset of her illness.1.3. relaxed. she irritably stared at him and got annoyed. She smiled minimally and often stared blankly when asked if what made her happy. She would only speak when motivated. CF has reported that Mrs. she was worried that all of her answers were wrong. She also got frustrated and anxious when she thought that her response to what was asked of her to do was wrong or a mistake. When questions were asked related to sensitive information as per reported by the husband. She was withdrawn and never wanted to be held or touched. MOOD AND AFFECT E. She needed to be held by several persons in order to be brought to the hospital. She was acting violent and resisted in going to the hospital for a check up. . Her expressions vary from being tensed. When her husband disclosed information ahead of her. Mood and Affect Mrs.

Score the total number of correct answers (0-5). 0=0-4 5/5 1=5-9 2=10-14 3=15 & above Age: 41 years old Is Patient alert? Yes Maximum Score: 27=Mild Neurocognitive Disorder Ask the patient if he or she can recall the five words you previously asked him or her remember. then you went to a store to buy Coke for 15 pesos and a bread for 10 pesos. 2010 Name: Mrs. House. then asks the patient to name all three of them. Dog. 0=87 1=649 2=8537 Give the patient a paper with a drawing of a circle. The patient’s response is used for scoring. Instruct her to put hour markers in it and the time is 11:10. 1/1 2/2 1/3 How much did you spend? How much money do you have left? Please name as many animals as you can in one minute. . The examiner repeats them until patient learns all of them. Let her assume that it is a clock face.Mental State Examination Date: January 20 & 25. LF Level of Education: Secondary Patient’s Score Questions: 1/1 1/1 1/1 What day is it? What year is it? What country are you in? The examiner names five unrelated objects clearly and slowly. 1/2 4/4 Ask the patient to recite the numbers you will give in backwards manner. (Mango. Pencil) You have 50 pesos in your pocket. Cat.

“Juana is a 21-year old woman who lives in Bacnotan. Ask the patient to listen to the story and inform him or her that questions will be ask later after the story. She works in the town’s municipal building. She works as a clerk and she does good in it.2/2 Ask the patient to place an x in the triangle and a check to biggest shape among the three. Juana loves to dress herself. Juana walks her way to work every day. Juana has no husband and no children yet” 2/2 2/2 2/2 2/2 What was the woman’s name in the story? When does she go to work? Where does she work? What is her work? Interpretation: Result Normal Mild Neurocognitive D/O Severe cognitive Impairment High School 27-30 21-26 1-20 Less than High School Education 25-30 20-24 1-19 .

VIII. NURSE-PATIENT INTERACTION .

DRUG STUDY .IX.

LF. She complained that her brain was not attached to her head and that she was not herself. It was learned that she has experienced delusions. LF’s behavior. On the last day of the visitation. specifically ideas of reference and nihilistic delusion. the student nurses were able to identify the patient’s signs and symptoms. EVALUATION On the duration of the visitations and conversations with Mrs. She verbalized her suspicions against her neighbor making fun of her and gossiping about her. 2010. . She was thankful for what the group has shared and for having helped her. Proper nursing interventions were also formulated and implemented.. She said that there were voices laughing at her and mocking her being psychotic. sufficient information has been obtained regarding her psychiatric condition. She thought of being worthless because she could not look after her children’s and husband’s needs. February 3. With all these changes in Mrs. The student centered objectives were met. She shared a story about a dream which she was not sure if it was a dream or a reality already. By sharing these thoughts and experiences. it is concluded that the group’s patient centered objectives are met.X. After three weeks of therapy. She started socializing and going to her siblings’ houses again. the patient followed the student nurses in the host family’s house and bid goodbye. the patient started mingling. Her old self has wandered and has not returned to her body. it manifested Mrs. LF’s trust and being able accept company especially those who are not her immediate relatives. She has expressed her feelings of unworthiness. By understanding schizophrenia.

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