PERSONAL DATA

Name: Name of Client: Agripa, Randy Maravilla

Age: 38 y/o

Birth date: September 8, 2017

Birthplace: Lucena City

Address: C/O 222 Elegance Subd. P-3 Sariaya City

Gender : male

Civil Status: Single

Nationality: Filipino

Religion: Catholic

Educatonal Attaiment: Grade 2

Date of Admission: October 9, 2010

Time of Admission: 2:58 PM

Admitting Physician: Raymond Joseph S. Valdez, M.D

Chief Complaints:

Patient was brought in by barangay volunteer from Quezon province. Accordingly,

patient was seen touching the private parts of young women in their place. He would also go to
other people’s houses. He was also seen running naked around his neighborhood.
As per record, patient has been chronically ill with several previous admissions in our center. He
was last admitted last August 13, 1991 and was discharged compound last September 23, 2010.
His home meds was Chlorpromazine 100-200mg TID which was poorly compliant.

Admitting Diagnosis: Undifferentiated Schizophrenia

Final Diagnosis:

Agency: National Center for Mental Health, Mandaluyong City

CHIEF COMPLAINT

Patient was brought in by barangay volunteer from Quezon province. Accordingly,

patient was seen touching the private parts of young women in their place. He would also go to
other people’s houses. He was also seen running naked around his neighborhood.
As per record, patient has been chronically ill with several previous admissions in our center. He
was last admitted last August 13, 1991 and was discharged compound last September 23, 2010.
His home meds was Chlorpromazine 100-200mg TID which was poorly compliant.

HISTORY OF PRESENT ILLNESS

Client is fair-skinned man with medium physique and semi bald hairstyle. He was seen
wearing NCMH patient’s uniform and was fairly kempt in appearance. The present condition of
the client started when he was 19 years old. Due to some circumstances, the client has
disorganized thinking and showed untoward behaviors. He was readmitted on October 9, 2010
with a diagnosis of Schizophrenia undifferentiated type. He has a regular check up and taking the
medications religiously. The client’s condition now was already stable and manageable, but
sometimes he still manifests some symptoms like hallucinations and tends to mumble to himself.

Meanwhile, he was disoriented to time but was compliant to assigned tasks.

PAST MEDICAL HISTORY

The client has a regular medical check up when she was still at normal state. The client
was first admitted at the National Center for Mental Health at August 13, 1991 because of the
same chief complaint, untoward behaviors. He was then diagnosed to have Schizophrenia,
undifferentiated type. According to the client he never heard of voices and even saw things
which were vague for her.

After less than a month after, at 2:58pm in the afternoon of September 23 2010, he was
readmitted brought by a barangay volunteer from Quezon Province. According to him he wasn’t
sure what was he doing at that time. He doesn’t even remember what was the cause why was he
admitted in this Mental Hospital. The client then denied the presence of auditory and visual
hallucinations and claimed to have a good sleep. He also added that he was been admitted at the
center before but didn’t take any medications after. He claimed to have been taking up
medications after he was readmitted. The client was been at the National Center for Mental
Health for about 16 years.
FAMILY HISTORY

The client barely remembers his family. They were five siblings in their family and have
already their own families respectively and the client claims that he was the only one who has
the condition. His father was police and and his mother is a housewife. He said that both of his
parents are already dead and he was the only one left in the family. The client claimed to have a
child the same age as his student nurse.

GENERAL APPEARANCE AND MOTOR BEHAVIOR

The client stated his age of 17 years old, wearing a Blue suit for patients in NCMH, well
groomed and with good personal hygiene. He is taking a bath everyday with a good daily
routine. The client has a good posture, gait and coordination. During interaction, he has a good
eye to eye contact. He tend to laugh at everything while he is sharing a story and uses a lot of
hand gestures. He is very thin and has a fair skin and has no sleeping difficulties by the absence
of dark circles under her eyes. He was well oriented with time, place, date and reality. The client
considered the interview as a normal thing and he was guided accordingly with no harsh or
offending questions thrown to him during the interview. He was very cooperative and shares a
lot but has disorganized speech and behavior.

SENSORIUM AND INTELLECTUAL PROCESSES

The client is well oriented with time, place, date and reality. He is very confused in terms
of certain events in his life. The client cannot recall the exact date or time when did it happen.
There are certain topic that the client mention when he is sharing parts of his life that are far
from reality. He said that “aswang ako eh marami ako napatay kinakain ko sila.” The client talks
from one topic to another and sometimes doesn’t answer the question the student nurse asks and
keeps on talking. The client displayed a broad affect and smiles or laughs while using hand
gestures a lot while sharing his story. The client do cross legs and kicks his foot fast while
sitting.

During the interview, he stated that he knows he has a problem and he is ill. He was
worried about his legs and kept repeating that he needs “smoke”. He said that it was a herbal to
your body. He is used to touch his head part and sometimes, his face. Objectively, he appears to
be concern on his situation while looking at his feet. He smiles and laughs alot especially if the
topic is worth smiling for.

THOUGHT PROCESS AND CONTENT

The patient speaks in a soft and spontaneous manner. He speaks Filipino all the time. His
speech is sometimes unclear and there are words that are poorly articulated making it difficult to
understand. His thoughts are disorganized, and sometimes he answer the questions being asked
to him with different answers not related to the question being asked by the student nurse. He
also manifests looseness
of association but he still manages to answer some questions. Sometimes, he also
manifest blocking but returns to function immediately. He is quite circumstantial, answers
questions but includes unnecessary details and skips one topic from another having flight of
ideas, looseness of association, perseveration and tangential thinking.

The client believes that he is an aswang and said that they cut his wings in order to avoid harm
on others. Moreover, he is also preoccupied with the thought that he will be killed here soon in
the pantry with the other patients. In addition, he feels unworthy of himself and believes that he
is useless in this world that is why he liked being here because all he does is eat. He likewise said
that he had a wife and daughter, when in fact he is still single. Furthermore, he is inconsistent in
remembering the real situations that happened to him. (About his occupation: he graduated on a
vocational course, family). Other than that, there were no noted signs of hallucination or any
illusion.

JUDGMENT AND INSIGHTS

The patient has fair and sound decisions regarding his everyday activities in the hospital.
He cooperates well with the therapies he is engaging too. He is ready to answer questions asked
by the student nurse. He said that if ever he will be able to go back in his home, he will make lots
of money and have fun but still prefer in this hospital.

Patient knows that he has problem that is why he was admitted at the hospital. He also
thinks that the reason why he is not allowed to leave the hospital and go home is because he is
mentally ill. According to him, he secretly takes a smoke every evening when everybody is
asleep together with his co-patients. He said that someone is giving the smoke and when they’re
caught smoking, they will be restrained in bed for few hours to days. He knows that it is bad for
the health especially for the lungs but claims that it felt good to him and his body when doing it.
He also made mentioned that he is more like of a prisoner because he was in the hospital for 16
years already unlike the prisoner who suffers only on the jail for 10 years. He is already tired of
complying with his medicines but he said that he needs to take his drugs everyday so that he can
be treated with his illness. He is unable to identify the reason why he was admitted in the
institution by saying “Wala kasi kami makain kaya dinala ako ng nanay ko dito hahaha”. He was
able to cope up in his stay in the hospital.

SELF CONCEPT

The client said that he is not bad rather a good person. He is a jolly and a happy person
and likes to interact with someone. He always asks if we will come back tomorrow because he is
very happy to be with us and he is very excited to see us always. He said that he is somewhat sad
without student nurses entertaining them. The client said that even if he ate too many his body
built doesn’t change and said to be born very thin as always. He said that he is good in doing so
many things like planting, making certain things like smoke, bullet etc. He said that he had
always dreamt of being a security guard to guard every people doing bad and said that he works
as a security guard in the past.

ROLES AND RELATIONSHIPS

The client views himself as a helper, friend, and a colleague. He views his primary roles
at this stage of his life as being a helper and a friend to his other co-patient. He enjoys close
relationships with other people and interacts with them. He said that he is the second eldest in his
family. Since the client claimed that he doesn’t have any visitors visiting him because his family
are all dead, he felt sad. He believes that he was the only one left in his family.

The client has a select group of friends in the hospital but feels to be alone at times. She
prefers to socialize with friends especially the student nurses because he felt good and healthy
around them. When asked if he often got a fight between other people inside the hospital, he said
sometimes he fights with them without a certain reason. He stated that he enjoys recreational
activities that we student nurses created for them because it helps lessen their sadness and
loneliness.

PSYCHOLOGIC AND SELF –CARE CONSIDERATIONS

The client eats meal three times a day with in between snacks. He stated that he eats a lot
and tends to eat the leftovers of his co-patents. According to my observation, the client likes to
eat santol and kamyas on the trees beside the cubicles and eat them whenever he likes he even
eat the whole santol.

The client said he thoroughly enjoys sleeping and generally achieve 8-10 hours of sleep
per night which he thinks provides her with ample rest and recuperation from her daily activities.
Most of the time he sleeps at around 8:00 pm and wakes up at around 6:00 am. The client stated
that he has neither noticed nor experienced any significant change to her sleep pattern in many
years.
The client said that sometimes he has difficulty breathing and his legs hurt due to the
wounds that he got. He admits that he used to smoke half of the pack per day but now he often
smokes. He also likes to drink alcohol. If he had seen one he will automatically pick it and drink
same with a smoke. He claimed to have been taking up his medications in the hospital. He said
that he is able to perform activities of his daily living whatever what tasks assigned to him. He is
very obedient in everything that he told him to do.
Ref

https://hubpages.com/health/A-Case-Study-of-Undifferentiated-Schizophrenia

https://www.slideshare.net/candicelainereyes/schizophrenia-psychiatry-case-presentation

https://www.scribd.com/doc/65649044/Case-Study-of-Undifferentiated-Schizophrenia

http://www.shipmethis.com/2014/01/case-study-of-patients-affected-with.html

http://nursingcrib.com/case-study/schizophrenia-case-study/

https://www.scribd.com/doc/56796742/Schizophrenia-NCMH-Case-Study

http://psychologicalstudies.blogspot.com/2013/05/schizophrenia-case-study.html