Trinity University of Asia

St. Luke’s College of Nursing

E. Rodriguez Sr. Avenue, Cathedral Heights,
Quezon City, Philippines

Case: For Observation of Psychosis

A Case Study
Presented to Joycelyn Ramos, RN MAN

Submitted by:
3NU01 RLE 1
Binwag, Isabelle Clarisse Gaddi

May 3, 2019
I. Definition of the case
Psychotic disorders form a diverse group of illnesses that are serious and often
treatable. Psychotic disorders affect the way a person may act, think, see, hear or feel, and
makes it difficult for them to distinguish what is real and not real.
There are different types of psychotic disorders. Some of these include:
 Schizophrenia
 Schizoaffective disorder
 Brief psychotic disorder

II. General signs and symptoms

 Hallucinations
 Delusions
 Difficulties with concentration and completing work tasks
 Lacking energy and motivation in undertaking what were usual work tasks and activities
 Loss of interest in person hygiene
 Loss of interest in activities and becoming withdrawn and socially isolated
 Displaying inappropriate emotions responses e.g. laughing out of context
 Anxiety and mood swings, or mood symptoms such as depression
 Slowed or unusual movements
 Displayed strange or odd behavior
 Disorganized or erratic speech often jumping from one topic to the next

III. Risk factors

 Biological factors: There may be an imbalance of certain chemicals in the brain. The
person may be particularly sensitive to or produce excessive amounts of a chemical
called dopamine
 Genetic factors: A history of psychotic illnesses in the family may increase the risk
 Environmental factors: Stress, drug abuse, and major life changes and events may
trigger an episode in people who are vulnerable to the disorder

IV. Patient’s Profile

Demographic Data
Name of client: N.T.C Age: 33 years old
Gender: Male Civil status: Single
Birthdate: February 10, 198 Birth place: Quezon City
Religion: Catholic Nationality: Filipino
Educational attainment: None Occupation: None
Father’s Name: Febro Culasi Mother’s Name: Susan Tejero
Address: 46 Int. 6 Project 4, Barangay Escopa III., Quezon City
V. Admission History
a. History of patient
N.T.C, 33 year old, male, single, Filipino, Catholic, elementary graduate, currently
unemployed, born and raised in Quezon City, was brought to National Center for Mental
Health (NCMH) by the Barangay Officials on March 20, 2019 at 3:40AM.
As per social barangay report, the patient was allegedly destructive to property,
assaultive and poured paint to self. Police district as allegedly requested and patient was
said to have continued running around and allegedly kicked EX-O by Barangay which was
said to have prompted to hit the patient by the town’s people.
He was allegedly brought to QMMC but was brought to the hospital due to alleged
disturbed behaviour and was admitted to NCMH, according to informant, the patient was
under influence of solvent inhalation.
b. Chief complaint
“Nanghihipo”, “nagbabasag”, “nagbuhos ng pintura”, “nagwala”
Informant: Eloy M. Galapon (Social worker)
Reliability of informant: 80%

c. Past medical illness

(-) HTN
(-) DM

c. Family history
Mother of patient N.T.C had a mental illness.
 Mental Status Examination (MSE) of Patient N.T.C

General appearance:
The patient was an adult male, average height and built, short cropped hair, present tattoos
on his upper extremities and had multiple physical injury.
Behavior during the interview:
The patient was fairly cooperative with good eye contact.
Social skills:
The patient claimed to have been using solvent inhalant when was destructive to property.
He also claimed that he previously used Methamphetamine which was taken a month ago.
He was able to give a fair account of himself. However, he had inconsistent answers when
he was asked about the circumstance of his confinement. He denied experiences of
hallucination and delusions. He denied use of Methamphetamine but admitted to drinking
alcohol at time to help him have good sleep.
Amount and type of motor activity:

Speech patterns:
Speech was spontaneous and nonproductive. The volume and intonation of his speech were
normal.
Degree of concentration and attention span:
Patient has fair concentration.
Orientation:
Patient was well oriented of the time, date and location.
Memory:
Patient has poor memory.
Intellectual functioning:
Patient mentioned that he only finished 3rd grade. He claimed that he is not able to draw
well but knows how to read a little.
Affect:
Patient is feeling sad during the interview.
Mood:
He claims to be “malungkot” about the incident that has happened to him.
Thought clarity:
He admitted to feel sad about his mental problem but denied feeling of hopelessness, and
worthlessness.
He admitted to use of substance which is why he failed to elaborate why his answers were
inconsistent when asked about the effect of the substance to him. Moreover, when asked
about the reason for destructive to property, he claimed to have disorganized thoughts and
he started to be teary-eyed.
Thought content:
He claimed to have suicidal, homicidal and escape thoughts. He denied any medical illness.
Thought processes reflected in speech:
Insight:
Good insight.
Judgment:
Patient had poor judgment.
Motivation:
He was logical and goal-oriented. He mentioned that when he gets discharged from the
institution, he plans to change himself for the betterment of his life. He verbalized, “Aayusin
ko na sarili ko pag labas ko dito.”