HISTORY TAKING
PERSONAL DATA/ DEMOGRAPHIC DATA
Name: Patient X
Age: 26 years old
Sex: female
Address: Quezon City
Religion: Roman Catholic
Occupation: helping in their small restaurant
Marital Status: Single
CHIEF COMPLAINTS:
- Being lost of interest and quiet.
- Lack of insight
- Complaining about different voices
- Talking alone (verbalized by the S.O)
-
HISTORY OF PRESENT ILLNESS
1. According to the Patient:
She was in grade school, she was bullied by her classmates and some
friends which reduce her self-esteem and started a poor performance in
school. She experience the feeling of always being alone.
She think later on that every people that she saw talking were talking about
her.
then when she tried to apply for a job, she was accepted but eventually she
left because she could not hold on to her job and because of that she
decided to help in their small restaurant.
She also said that she consulted to a psychiatric because she feels some
sexual abuse from her father.
She also complains that she cannot tolerate noises.
2. According to the Parents:
She was still healthy not until she was her fifth grade. She became less
interested in all her activities and started to perform poor in her classes.
her farther also saw her hitting all the people walking in to their restaurants
saying that they intend to harm her
Because of that, they decided to take her to a psychiatric for treatment.
After months of treatment, she slowly improved in her school.
But at the age of 19, she showed less interest again and became anxious all
the time. And started to say that someone was going to harm her and that
, she can hear different voices in her room.. So they admitted her again for
treatment for her condition.
HISTORY OF PAST ILLNESS
- No history of past illness
FAMILY HISTORY
- Her grandfather and aunt had some sort of psychiatric disorder but the details are
unknown
PERSONAL HISTORY:
Appetite is poor
Bowel is regular (1-2/day)
Sleep is reduce
No allergies
MENTAL STATUS EXAMINATION:
1. General Appearance and behavior
The patient looks anxious and scared.
She has a messy hair and unhygienic
2. Speech
She replies soon before the questions is finished but he answer were not about the
questions
Volume: audible
3. Mood and Affect
Reduce interest in all activities
4. Thought
Stream and thought: social in appearance
Content: losing her charm day by day
5. Perception
Bullied by her classmates, feeling anxious, and feeling of sexual abuse
6. Cognition
Consciousness: present
Attention: less
concentration: unfocused
intelligence: impaired
7. Insight
grade 6 (awareness of ill)
8. Judgment
Impaired
INTRODUCTION
Schizophrenia is a chronic brain disorder. When schizophrenia is active, symptoms
can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of
motivation. However, with treatment, most of schizophrenia will greatly improve and the like
of a recurrence can be diminished. While there is no cure for schizophrenia, research is
leading to innovative and safer treatment. The complexity of schizophrenia may help explain
why there are misconceptions about the disease. Schizophrenia does not mean split
, personality or multiple-personality. Most people with schizophrenia are not any more
dangerous or violent than people in the general population. While limited mental health
resources in the community may lead to homelessness and frequent hospitalizations, it is a
misconception that people with schizophrenia end up homeless or living in hospitals. Most
people with schizophrenia live with their family, in group homes or on their own.
Schizophrenia tends to run in families, but no single gene is thought to be responsible.
Studies of people with schizophrenia have shown there are subtle differences in the structure
of their brains. These changes are not seen in everyone with schizophrenia and can occur in
people who do not have a mental illness.
Neurotransmitters are chemicals that carry messages between brain cells. There is a
connection between neurotransmitters and schizophrenia because drugs that alter the levels of
neurotransmitters in the brain are known to relieve some of the symptoms of schizophrenia.
Research suggests schizophrenia may be a change in the level of 2 neurotransmitters:
dopamine and serotonin. Some studies indicated an imbalance between the 2 may be a basis
of the problem. Others have found a change in the body’s sensitivity to the neurotransmitter
is part of the cause of schizophrenia.
SIGNS AND SYMPTOMS
Positive Symptoms (those abnormally present)
Hallucinations, such as hearing voices or seeing things that do not exist
Paranoia and exaggerated or distorted perceptions, beliefs and behaviors
Negative Symptoms (those abnormally absent)
A loss or decrease in the ability to initiate plans, speak, express emotion or
find pleasure
Disorganized symptoms
Confused and disordered thinking and speech, trouble with logical
thinking and sometimes bizarre behaviour or abnormal movements
Conversation Communication Type of Remarks
Technique communication
Nurse Patient
Good day “who are you? Where Giving Verbal The patient is showing an expression
Ms. Cruz I am?” looking around recognition. communication of confusions
with confused look on Acknowledging
her face. the patient by
her last name
can enhance
self-esteem and
communicates
PERSONAL DATA/ DEMOGRAPHIC DATA
Name: Patient X
Age: 26 years old
Sex: female
Address: Quezon City
Religion: Roman Catholic
Occupation: helping in their small restaurant
Marital Status: Single
CHIEF COMPLAINTS:
- Being lost of interest and quiet.
- Lack of insight
- Complaining about different voices
- Talking alone (verbalized by the S.O)
-
HISTORY OF PRESENT ILLNESS
1. According to the Patient:
She was in grade school, she was bullied by her classmates and some
friends which reduce her self-esteem and started a poor performance in
school. She experience the feeling of always being alone.
She think later on that every people that she saw talking were talking about
her.
then when she tried to apply for a job, she was accepted but eventually she
left because she could not hold on to her job and because of that she
decided to help in their small restaurant.
She also said that she consulted to a psychiatric because she feels some
sexual abuse from her father.
She also complains that she cannot tolerate noises.
2. According to the Parents:
She was still healthy not until she was her fifth grade. She became less
interested in all her activities and started to perform poor in her classes.
her farther also saw her hitting all the people walking in to their restaurants
saying that they intend to harm her
Because of that, they decided to take her to a psychiatric for treatment.
After months of treatment, she slowly improved in her school.
But at the age of 19, she showed less interest again and became anxious all
the time. And started to say that someone was going to harm her and that
, she can hear different voices in her room.. So they admitted her again for
treatment for her condition.
HISTORY OF PAST ILLNESS
- No history of past illness
FAMILY HISTORY
- Her grandfather and aunt had some sort of psychiatric disorder but the details are
unknown
PERSONAL HISTORY:
Appetite is poor
Bowel is regular (1-2/day)
Sleep is reduce
No allergies
MENTAL STATUS EXAMINATION:
1. General Appearance and behavior
The patient looks anxious and scared.
She has a messy hair and unhygienic
2. Speech
She replies soon before the questions is finished but he answer were not about the
questions
Volume: audible
3. Mood and Affect
Reduce interest in all activities
4. Thought
Stream and thought: social in appearance
Content: losing her charm day by day
5. Perception
Bullied by her classmates, feeling anxious, and feeling of sexual abuse
6. Cognition
Consciousness: present
Attention: less
concentration: unfocused
intelligence: impaired
7. Insight
grade 6 (awareness of ill)
8. Judgment
Impaired
INTRODUCTION
Schizophrenia is a chronic brain disorder. When schizophrenia is active, symptoms
can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of
motivation. However, with treatment, most of schizophrenia will greatly improve and the like
of a recurrence can be diminished. While there is no cure for schizophrenia, research is
leading to innovative and safer treatment. The complexity of schizophrenia may help explain
why there are misconceptions about the disease. Schizophrenia does not mean split
, personality or multiple-personality. Most people with schizophrenia are not any more
dangerous or violent than people in the general population. While limited mental health
resources in the community may lead to homelessness and frequent hospitalizations, it is a
misconception that people with schizophrenia end up homeless or living in hospitals. Most
people with schizophrenia live with their family, in group homes or on their own.
Schizophrenia tends to run in families, but no single gene is thought to be responsible.
Studies of people with schizophrenia have shown there are subtle differences in the structure
of their brains. These changes are not seen in everyone with schizophrenia and can occur in
people who do not have a mental illness.
Neurotransmitters are chemicals that carry messages between brain cells. There is a
connection between neurotransmitters and schizophrenia because drugs that alter the levels of
neurotransmitters in the brain are known to relieve some of the symptoms of schizophrenia.
Research suggests schizophrenia may be a change in the level of 2 neurotransmitters:
dopamine and serotonin. Some studies indicated an imbalance between the 2 may be a basis
of the problem. Others have found a change in the body’s sensitivity to the neurotransmitter
is part of the cause of schizophrenia.
SIGNS AND SYMPTOMS
Positive Symptoms (those abnormally present)
Hallucinations, such as hearing voices or seeing things that do not exist
Paranoia and exaggerated or distorted perceptions, beliefs and behaviors
Negative Symptoms (those abnormally absent)
A loss or decrease in the ability to initiate plans, speak, express emotion or
find pleasure
Disorganized symptoms
Confused and disordered thinking and speech, trouble with logical
thinking and sometimes bizarre behaviour or abnormal movements
Conversation Communication Type of Remarks
Technique communication
Nurse Patient
Good day “who are you? Where Giving Verbal The patient is showing an expression
Ms. Cruz I am?” looking around recognition. communication of confusions
with confused look on Acknowledging
her face. the patient by
her last name
can enhance
self-esteem and
communicates
