Medical Report

Patient Name: HUSSEIN ABDUL Age: 48 Gender:male

RAHMAN AL HUSSEIN
Nationality:Saudi ID No.:1011475025 File No.:792
Date of Admission: Contact No. Date of Report:18/05/2021
03/06/2006
Code Status: Physician:
Nurse:
Family:

Diagnosis: Chronic schizophrenia

Present Condition and Hospital Course:

48 years old Saudi , long standing history of mental illness ,

the patient is bed ridden , mute, incontinent for urine and stool .

Progress of patient status

-He had suffered an attack of tonic-clonic convulsion and he had been referred to king Khalid University
Hospital and letter he go discharged on ( Epanutin 100 mg tds).

After that he suffered severe vomiting and aspiration pneumonia and he had been referred to king Khalid
University Hospital where had been admitted and treated ,then discharged on nasogastric feeding tube to
Eradah complex of mental health before sending him back to our center .

Past Medical History: chronic schizophrenia

Clinical Examination:
The patient conscious and he is bed ridden , mute, incontinent for urine and stool

General Condition:
Stable Non-Stable

Cooperative Non-Cooperative

Vital Signs:
Temperature: _____36.7C___ Pulse: ____88____ RR: _18________ BP: 120/70
_________

Restraint:
Yes No
Physical Chemical

Contraptions:
NGT Colostomy

PEG Tube Suprapubic

Foley Catheter External Urinary Condom

Current Medications:
Bran For Regula
Generic Dose Route Frequency PRN Indication
d m r

RISPERIDONE 6mg tab oral 2mg am yes psychosis

4mg pm
ESCITALOPRA 10 mg tab oral OD yes depression
M
HALOPERIDOL 5 mg tab oral BID yes psychosis

Updated Lab Test: (Attached to medical report)

Nutritional Status: Regular Oral Diet Formula

Type: ______________ _semi solid diet _____________
Weight:90________
Height: __170
BMI: ___31.14_______

Functional Status:

Totally dependent on nurses, bed ridden

Current Mental State Examination:

He is hypoactive, bed ridden, mute, oriented to surroundings, no behavioral disturbance

Detailed mental state examination

Couldn’t be conducted

Family History:

Negative FH Power of Attorney Name

 Contact No.:

Social History:

Single, jobless, lack of social support

Discharge Psychiatric Care Plan:

Patient currently bed ridden , incontinent for urine and stool , patient completely
dependent on others and need continuous nursing care, medical follow up.

Attending Psychiatrist Consultant Psychiatrist:

Dr Bisher Fuad Dr Mahmood AL Ameer

Consultant physician

Dr Mohammad Mustafa

Medical Director

Dr Hassan Alshehri