Faculty of Health Sciences

Department of nursing
Tripoli Campus

Psychiatric and mental health

NURS 419

Case Report #1

Prepared By: Razan Nasereddine

ID:201803107
Dr’s Name : Maha Dankar

Date: 2/12/2019
Outline:

1. Patient initial and habits.

2. Cause of admission/history of present illness.
3. Past medical and surgical history and blood tests
4. Symptoms reported by the patient.
5. Medical and nursing management provided to the patient.

1.A) Patient initial :

 Patient’s name : Janin Fajlun

 Age : thirty eight years old
 Date of birth: 5/9/1981
 Marital status : single
 Living : Lives with his mother
 Address : herkabta
 Occupation :Army
 Accident: patient has a gunshot scar in his face
 Patient got retired and have a monthly income
 Niece: edwar,George,hanan,hwayda
 Patient’s family visits him every 2 weeks (his mother and his big brother)

B) Patient habits:

 Sleeps well (eight hours/day)

 Eats well ( three meals/day)
 Drink alcohol and smoke cigarettes (1.5 packet/day)
 Takes shower every 2/3 days
 Listen to music (musicians Ali Deek, Naim Shekh)
 Doesn’t watch TV or read news
 Patient used to help his mother in house cleaning after his retirement

2. Cause of admission:

 Patient admitted to Rached Soukari Hospital in 22/7/2019 through the admission door
under the psychologist doctors name: Dr Jamal Hafez , Dr Rached Soukari and
medical doctor : Dr Georger Safourin
 Admitting diagnosis: korsakoff syndrome and trouble in character
 Differential diagnosis : chronic alcoholic
 Medical observation on entry : hallucination and aggressiveness

3. past medical history:

 Patient has previous hospitalization in Dar AL Salib Hospital for 4 months

 patient has heart muscle weakness and liver disease and his doctor was : Dr Bou
Karam
 patient when entered the hospital his blood pressure was 100/60mmhg and he took 1
capsule of respiradole 4mg before entrance
 patient evaluation on scale DSM-IV-TR showed:
i. axis 1: hallucination with substance(alcohol) abuse
ii. axis 2: agitation
iii. axis 3 : nothing
iv. axis 4: nothing
v. axis 5: 30-21 :

Behavior is considerably influences by delusions or hallucinations OR serious

impairment in communication or judgment (eg. Sometimes incoherent, acts grossly
inappropriately, suicidal preoccupation) OR inability to function in almost all areas ( eg.
Stays in bed all day, no job, home, or friends).

 Patient GAF was 70 at admission.

Patient blood tests : (10/9/2019) with Dr Jamal Ayoubi

Blood test value Normal range

WBC 103 / μL 3.7 4.4-11.3
Monocytes % 11.6 2-10
GGT IU/L 120 5-67

 After seeing the results Dr Jamal stated that Mr Janin is calm and stable
with normal heart ryhms and a normal blood pressure of 110/90 mmhg

Patient surgical history:

Patient had a gunshot in his face under his mouth when he was an army and he was
transferred to the hospital immediately and a small circumcision was done

4. Symptoms reported by the patient: (24/9/2019)

 Patient has extreme depression

 Patient is not cooperative and hopeless
 Patient is confused and doesn’t answer the questions properly
 Patient is agitated
 Patient’s level of understanding is average

Result of documentation shows that the patient has: social,professional,familial

disfunction.

 Semiology psychiatric: (19/8/2019)

 Appearance : proportional weight-looks older-presence of scar

Dress neatness: proper hygiene

Expression: null

Visual contact : fixed,receding

Attitude: closed

 Motor activity: slowdown

Movement: rigid

Walk: insured

 Language : little loquacious

Vocab: poor

Flow: slow

Volume: low

 Emotional: indifferent
 Operation of thoughts : bradypsychia
 Perception: hallucinations
 Cognitive function : oriented
Memory: intact ( long and short)
 judgment and self-criticism:
 Judgment: impaired

Self-criticism: absent

Social: isolated

Insight: absent

 symptoms specific for addiction:

 substance abuse: alcohol and tobacco

 dependence : presence of tolerance

Often taken in larger quantile than before

Activities necessary to obtain the substance

Unsuccessful efforts to control the use

Reduction of social, professional and important activities

 somatic symptoms :
 gastrointestinal problems
 vomiting
 muscle weakness
 Thoracic pain
 Drowsiness
 Fatigue
 5. Medical and nursing management provided to the patient:

Medical management:

Take medications as ordered from the physician.

Patient medications(24/9/2019):

 largactel 100mg x3 /day

 resperdal 4mg (0.5 in the morning and 1 at night)
 benzyxol 5mg(0.5 in the morning and 1 at night)
 Haldol 5mg (1 at the morning and 1 at night)
 Prometal 25mg x3

Nursing management:

 Extended brief intervention for alcohol abuse(20-30 minutes; follow-up optional)

 Discuss the overall treatment plan with the patient and the person who will support
him or her
 Uses basic skills from motivational interviewing

 Indicates how to deal with underlying problems
 Ideally delivered by an alcohol health worker
 Discuss the aims (safety and comfort) of the medically assisted withdrawal plan and
complications that would require urgent medical assessment (such as delirium,
confusion, seizures, falls, severe nausea or vomiting, and high levels of distress)
 Supply vitamin supplements if ordered
Interventions for coping and treating depression and isolation:

 Discuss the overall treatment plan with the patient and the person who will support
him.
 Assume active role in initiating communication. This can be done by sharing
observation of patient’s behavior, speaking slowly and allowing ample time for him
to respond, encouraging him to talk and write down feelings, and by providing a
structured routine which may include non-competitive activities.
 Educate patient about depression. Explain that depression can be eased by expressing
feelings and engaging in pleasurable activities. Emphasize that there are effective
methods available for relief of symptoms.
 Help patient recognize distorted perceptions and link them to his depression.
 Ask patient whether he thinks about death or suicide. Signal an immediate need for
consultation and assessment. Risk of suicide is higher with lifting of depressed mood.
 Stress the need for medication compliance. Review adverse effects with the patient.