PYCHIATRY CASE STUDY

BY:

CHRISANTOS OTWORI OTOCHI

COLLEGE NUMBER: D/NURS/21001/2211

CLASS: SEPTEMBER 2020

A CASE STUDY PRESENTED IN THE PARTIAL FULFILLMENT OF

THE AWARD OF DIPLOMA IN NURSING AT THE KENYA

MEDICAL TRAINING COLLEGE – NAIROBI CAMPUS

SUPERVISOR: MR. MUCHINA

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ACKNOWLEDGEMENT.

Carrying out this psychiatric case study required adequate time, guidance, supervision and
understanding. Thus, this called for collective responsibilities of many people within and outside
Kenya Medical Training College

First of all, I would like to express sincere gratitude to my supervisor Mr. Muchina for his
attention to detail and generosity in sharing both his knowledge on the case study and most
importantly, for helping me grow immeasurably as a student. With higher guidance and support,
writing this case study was a powerful learning experience.

I would like to extend my appreciation to Mathari National Teaching and Referral Hospital Ward
6 Female, the in-Charge Mrs. Florence and her entire staff for allowing me to carry out my case
study in the respective ward and for the entire support they rendered to me during the time of the
study.

I would also wish to thank my client who also consented to take part in the study.

Above all thanks be to the all-mighty GOD for granting me strength, knowledge and wisdom
during the course of this work.

Thank you very much and may God bless you.

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IDENTIFICATION DATA

Name: Mrs. R.N

Age:56 years

Gender: Female

Marital status: Divorced

Residence: Ruiru

Occupation: Farmer

Religion: Christian (catholic)

Next of kin: G.M(son)

Ward: 6F

Ip No: 58870

Date of admission: 30/11/2022

MODE OF ADMISSION

The mode of admission was involuntary whereby the patient was brought to the Hospital by her
son. The son requested for admission by filling the form MOH 614 in duplicate and the medical
officer signed the form MOH 615 recommending for the admission.

REASONS FOR ENCOUNTER

 Violent and aggressive

 Talking a lot and makes a lot of noise

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  Poor relationship with others at home
 Being angry to the son and others at home
 Refuses shopping done for her and throws them away
 Abusive and talks words which are not understood
 Refusal to eat and take her medication
 Locks herself in the house and does nothing while in the house

DURATION

One week

ONSET

Gradual

PATIENT’S REACTION TO ALLEGATIONS

The patient refuses the above allegations and insists that she is not sick and that’s why she
refused taking her medication.

HISTORY OF PRESENTING ILLNESS

The son reports that the patient was in her usual state of good health until one week ago prior to
admission when he started noticing her bizarre behaviors. The patient started making a lot of
noise at home with aggressive behavior, throwing away shopping bought for her from the house,
being abusive and talking words that are not understood, locks herself in the house and does
nothing while in the house, poor relationship at home with others, being angry to the son and

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other family members and refusing to eat and take her medication. The son then decided to bring
her to Mathari Hospital on 30/11/2022.

PERSONAL HISTORY

PREGNANCY AND CHILD BIRTH HISTORY

The son reports that from the information he had from his grandmother, the patient was born in
1966 through spontaneous vertex delivery at home. She was born at term. The mother did not
have any complications during child birth, diseases or any physical injury during the time she
was pregnant.

EARLY CHILDHOOD EXPERIENCE

The son reports that the patient did not have any traumatic experience or separation with the
mother. She never had any physical trauma affecting the central nervous system, she never had
any delayed milestones during her childhood development and was not fully immunized as per
what the grandmother told him. She had no history of anxiety traits during her childhood as well
as any signs of emotional disorders such as temper tantrums, nail biting or sleep walking.

EDUCATION HISTORY

The son reports that the patient was not able to go to school because at that time her father was
not in a position to take her to school to study and was not well exposed to the benefits of the
same.

OCCUPATIONAL HISTORY

The patient is a farmer at home keeping cattle and goats. She also plants crop such as maize,
beans as well as vegetables which she sells to the locals that earns her approximately three

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hundred shillings a week. She also sells milk to the locals which can earn her close to three
thousand shillings a month.

SOCIAL HISTORY

The patient is a Christian(catholic) but does not go to church. She lives in Ruiru. She has friends
both male and female and relates well with them. She is also social and likes talking with other
people. She does not abuse any substance or drug and does not smoke cigarettes or tobacco. She
spends most of her leisure time reciting the rosary. She also relates well with her family
members.

PREMORBID HSTORY

The patient was an extrovert who used to relate well with her friends and liked spending her time
in the farm and in her house. She also had good attitude towards self, others, life and illness.

PAST MEDICAL AND PSYCHIATRIC HISTORY

Patient has no history of any chronic illness such as hypertension or diabetes, no history of any
surgery, blood transfusion or allergies to drugs or food. She has no history of any other medical
admission besides mental illness admission which she was admitted to Mathari Hospital twice
and this is the third admission. She was admitted twice before due to bipolar mood disorder and
was treated and given medication then discharged home on home treatment.

MARITAL STATUS

Patient was married but divorced fifteen years ago in 2007. She was blessed with five children
whom she is not living with currently. Even though they separated with her husband, they used
to have a good a good relationship with each other according to the son’s report.

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Children in chronological order

BIRTH GENDE AGE EDUCATIO OCCUPATIO MARITA HEALT

ORDE R IN N N L H
R YEAR STATUS STATUS
S
1 M 39 Primary Farmer Married Alive
2 M 37 Secondary Farmer Married Alive
3 F 36 Secondary House wife Married Alive
4 F 32 College Self employed Married Alive
5 F 30 College Business lady married Alive

PSYCHOSEXUAL HISTORY

Patient was divorced fifteen years ago. The patient had a good relationship wit the husband
before but divorced due to her mental condition. Currently she is not in any sexual relationship.

FAMILY HISTORY

The patient is the second born in a family of five siblings. Her father is alive and well but the
mother died due to a dog bite. The son did not specify the year she passed on. The patient relates
well with her father and with other family members. There is no history of any mental illness in
the family except the patient. There is no history of any chronic illness in the family like
hypertension, diabetes or epilepsy. There is no history of substance abuse or alcoholism in the
family as well as any sibling rivalry. The son was not able to give the mothers’ siblings
chronological order.

MENTAL STATUS EXAMINATION.

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GENERAL APPEARANCE

Grooming and dressing- the patient appears neat and well kempt with appropriate dressing

Hygiene- patient has no bad breath or odor and the skin is well hydrated with no cracks

Hair color and texture- looks clean and healthy

Posture- upright posture when standing and while seated

Level of eye contact- intermittent

Facial expression- sad facial expression

Steady gait with absent tics, no tremors and no involuntary movements present

Nutritional status- Patient looks well nourished

Restless behavior, agitated and uncooperative

Mannerisms; patient keeps clicking as a sign of annoyance.

SPEECH

Pressure of speech with high pitch and volume.

GENERAL ATTITUDE

patient is uncooperative and uninterested. she does not answer questions willingly

MOOD

Unhappy, angry, hostile and irritable (patient says that she does not want to be disturbed)

AFFECT

Incongruent and shallow.

THOUGHT CONTENT

Patient has delusions of grandiose. Claims she can disqualify whatever anyone says

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THOUGHT PROCESS

Patient presented with flight of ideas, with illogical connection between her thoughts and
loosening of association.

PERCEPTION

Patient does not have hallucinations or illusions.

COGNITION

Attention; poor, she was unable to say the days of the week

Concentration; poor, using serial three she was unable to subtract 3 from 20.

Abstract reasoning; good, patient was able to interpret the riddle “nanywa supu natupa nyama”
by answering that it is sugarcane. It took her almost one and half minutes.

Judgement; poor, patient when asked what she can do if she sees a young boy wanting to cross
on a busy highway like Muthaiga she said she will do nothing and said that “kwani dereva hana
macho asimamishe gari”

ORIENTATION

Patient is well oriented to time and person but not well oriented to place

MEMORY

Immediate memory; good, patient was able to remember when she ate lunch

Recent memory; poor, patient does not remember when she was brought to the hospital

Remote memory; poor, patient cannot remember the first president of Kenya

RAPPORT

Able to establish but unable to maintain

INSIGHT

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Poor;

patient is unable to interpret where she is

she denies some of the allegations

she does not acknowledge the fact that the therapy will help her

PHYSICAL EXAMINATION

HEAD; on inspection, presence of well distributed hair which is well maintained and normal
head size

EYES; on inspection, both eyes are present with no discharge

EARS; on inspection, both ears are present, equal in size, no discharge noted from the ears and
patient has no problem with hearing

NOSE; nose is present on inspection with a well-formed septum at the middle, no discharge
noted

MOUTH; on inspection all the teeth are present, mucous membranes pink in color and no pallor

NECK; on inspection no scars, lumps or swelling present, jugular veins not distended

CHEST; on inspection symmetrical with no lesions, both breasts present

UPPER LIMBS; both limbs present and symmetrical, no extra digits

ABDOMEN; on palpation no masses or lumps present, not distended on inspection

BACK; on inspection no deformity noted, the spine is continuous on palpation

LOWER LIMBS; on inspection both present and symmetrical, not swollen, no varicose veins
noted

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DIAGNOSIS

Bipolar mood disorder

SUPPORTIVE DATA

 Irritable mood
 Delusions of grandiosity
 Flight of ideas
 Pressured speech
 Easy distractibility
 More talkative than usual
 Poor concentration

NURSING INTERVENTIONS

 Admit the patient to the ward

 Administer prescribed medication
 Orient the patient to the ward
 Ensure milieu
 Psychotherapeutic group therapy
 Occupational therapy
 Supervise bathing
 Enhance sleep

VITAL SIGNS

Blood pressure; 126/90mmHg

Pulse; 86bpm

Temperature; 36.2 degrees Celsius

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NURSING CARE PLAN

CLUSTE NURSIN GOALS NURSING RATION IMPLEMENT EVALUA

R OF G AND INTERVE ALE ATION TION
CUES DIAGN EXPEC NTION
OSIS TED
OUTCO
MES
On Disturbed Within Ensure This will Student nurse Goal met
assessme thought 24 hours milieu and make the Otwori isolated
nt the process of orient the environme the patient in
patient is related to nursing patient to nt seclusion room
irritable, panic interventi the ward conducive
violent, level of on the and let her for her and
aggressiv anxiety as patient be in her reduce
e, talks a evidence will be room with anxiety
lot ant is by the able to no
abusive patient demonstr stimulants Nurse Kamau Goal met
with no being ate To calm administered
apparent irritable reduced Administer down the carbamazepine
reason, and irritabilit carbamazepi patient by 100mg STAT
she is restless in y and ne to the inhibiting
restless the stop patient the actin of
hospital abusing dopamine
environm others in and
ent the ward serotonin
neurotrans
mitters
Patient Impaired Within Use simple To Simple words Goal
has verbal 24 hours and clear minimize were used in partially

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 unusual communi of words and misunderst communicating met
communi cation nursing make anding with the patient
cation related to interventi directions as
pattern, altered on the clear as
inappropr perceptio patient possible
iate n as will
verbalizat evidenced express
ion, by thoughts
thought unusual and her
blocking, communi feelings
excessive cation in a
complaini pattern logical
ng manner
Patient Impaired Within 2 Keep the To reduce Client kept in a Goal
appears social days of patient in an unnecessar conducive ongoing
upset, interactio nursing environment y agitation, environment in
agitated, n related interventi free from anxiety and the ward
anxious, to on the stimuli such inability to
spend exaggerat patient as noises concentrate
most of ed will be and due to
the time response able to crowding external
alone, to alerting respond stimuli
verbalizes stimuli as well to
discomfor evidenced alerting
t in by patient stimuli
hospital being
environm upset and Patient to Engage the To make Client was able Goal met
ent anxious maintain patient in the client to attend
interactio group feel safe psychotherapeu

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 n with therapy and tic group
other competent therapy
patients in
in the graduated
ward in interaction
course of
hospitali
zation

PHARMACOTHERAPY

Drugs used

Carbamazepine 100mg STAT

Haloperidol 6mg OD

Artane 5mg PRN

Modecate 25mg IM

CARBAMAZEPINE

Classification

A mood stabilizer. It is a versatile antiepileptic agent with psychotropic properties.

Mode of action

As an anticonvulsant, it acts by reducing postsynaptic responses and blocking the post-tetanic

potentiation which results from the drugs ability to limit repetitive firing of potential by a
sustained depolarization of neurons

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Indications

 Complex partial seizures

 generalized tonic clonic seizures
 pain in trigeminal
 post hepatic neuroglia.
 It is also used in pain in diabetic neuropathy mania.
 Schizoaffective disorder
 alcohol withdrawal syndrome and migraine prophylaxis

Contraindication

 Hypersensitivity to carbamazepine
 known sensitivity to tricyclic antidepressants like amitriptyline
 history of bone marrow depression
 concurrent use with mono amine oxidase inhibitors.

Adverse effects

 Drowsiness
 Dizziness
 Vertigo
 Ataxia
 Diplopia
 blurred vision
 nausea
 vomiting
 hypersensitivity reactions.

Drug interaction

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  Phenobarbitone, phenytoin and valproic acid may increase the metabolism of
carbamazepine.
 Carbamazepine reduces the plasma concentration and therapeutic effects of haloperidol
and propoxyphene
 erythromycin may block the metabolism of carbamazepine.

Nursing interventions

 Monitor for the following reactions which commonly occur during early therapy;
drowsiness, dizziness, light-headedness, ataxia and gastric upset

HALOPERIDOL

Classification

It is a typical first-generation antipsychotic

Mode of action

Competitive blockage of postsynaptic dopamine receptors in the mesolimbic dopaminergic

system hence blocking the activity of dopamine in the brain reducing psychotic symptoms

Indications

 Treatment of psychosis
 Tourette’s disorder
 severe behavioral problems in children.
 It is also used for emergency sedation of severely agitated or delirious patients and
amphetamine related psychosis.

Contraindications

 Hypersensitivity to haloperidol
 narrow-angle glaucoma and Parkinsonism

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Drug interaction

 Decreased effect with carbamazepine, phenobarbitone.

 There is increased toxicity with central nervous system and depressed lithium and
anticholinergic

Precautions

Use with caution in patients with cardiovascular diseases or seizures

Over dosage/toxicology

Symptoms include deep sleep, dystonia, agitation, dysrhythmias, and extrapyramidal symptoms

Side effects

 Parkinsonian extra pyramidal effects

 swelling of breasts
 weight gain
 blurred vision
 nausea
 vomiting
 photosensitivity
 agranulocytosis
 heart stroke
 obstructive jaundice
 gastrointestinal upsets
 dry mouth

Nursing interventions

 Observe for seizures, use with caution in patients with pre-existing seizures disorders as
haloperidol decreases seizures threshold.

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  Adverse reactions like hypotension should be monitored, cardiovascular changes like
tachycardia should be monitored.
 Haloperidol should be used with caution in elderly patients as they develop tardive
dyskinesia hence a lower dose is given.
 Monitor for anticholinergic side effects such as dry mouth, constipation and urinary
retention.

ARTANE(TRIHEXYPHENIDYL)

Classification

It is an anticholinergic drug that is antiparkinsonian

Mode of action

It reduces the muscarinic action of acetylcholine in the striatum

Indication

 second line drug for Parkinsonia’s disease

 Involuntary movements due to side effects of other psychiatric drugs such as haloperidol

Contraindication

Hypersensitivity to Artane

Side effects

 Drowsiness
 Dizziness
 Nausea
 constipation
 Blurred vision
 Dry mouth

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Drug interaction

Should never be used together with pramlintide

MODECATE (fluphenazine)

Classification

First generation antipsychotic drug

Mode of action

Competitive antagonism of dopamine D2 receptors in the mesolimbic pathway

Indication

 Manic phase of bipolar disorder

 Schizophrenia extrapyramidal symptoms
 Tourette’s syndrome

Side effects

 Marked sedation
 Extrapyramidal symptoms
 Gynecomastia
 Constipation
 Galactorrhea

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BRIEF DESCRIPTION OF BIPOLAR MOOD DISORDER

DEFINITION

It is a chronic recurrent illness marked by shifts in mood, oscillations, energy and ability to
function

Signs and symptoms range from severe mania (exaggerated euphoria or irritability) to severe
depression.

Bipolar disorder is very different from the mood swings that moody people have which last a few
minutes or hours.
Some people with bipolar disorder can have periods where they have mixed symptoms where
they quickly alternate between depressive symptoms and manic symptoms (usually within a few
hours). This is known as a mixed bipolar episode

AETIOLOGY

 Genetics- with strong hereditary there is 80-90% chance of getting bipolar while its 5-10
times higher in people with relatives who have the condition. Risk for children with one
sick parent is 28%, if both 2-3 times higher rate.
 Biochemical influences- there is increased norepinephrine, dopamine and serotonin in
mania while the same are decreased in depression.
 Physiological influences- neurotomical factors, structural changes in prefrontal cortex,
enlarged lateral ventricle and subcortical white matter
 Medication side effects- steroids, antidepressants, anticonvulsants, narcotics,
amphetamines are associated with manic episodes.
 Electrolyte imbalance- increase in sodium and calcium are associated with mania.
 Neuroendocrine- abnormalities in hypothalamic-pituitary-thyroid-adrenal axis.
Hypothyroidism is known to cause depression.

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  Psychosocial factors- stressful events like loss of relationship, financial difficulties,
failing examination could trigger bipolar disorder.
 Environmental factors- more in upper socioeconomic class. patients with bipolar tend to
do well in school and at work compared to patients with unipolar depression.
 Transactional model- suggests there is an interaction between genetics, biological and
psychosocial determinants.

MANIA

Elevated, expansive, irritable mood and abnormally and persistently increase goal-oriented
activity or energy lasting at least one week and present most of the day and nearly every day

Condition characterized by excessive happiness with inflated self-esteem (grandiosity)

It is quite common for a patient in manic state to believe that he or she is a special person and
may believe that he or she is on a special mission from God.

PRESENTING FEATURES OF MANIA

• Expansive or irritable mood. The person feels extremely high. He or she may describe the
experience as feeling on top of the world. Patient may shift from highly elated mood to
being angry and irritable if they perceive to have been obstructed.

• Hyperactivity or psychomotor agitation

• Delusions of grandiosity.

• Pressured speech.

• Flight of ideas.

• Easy distractibility and respond to multiple unimportant stimuli

• Dress on bright colors often that do not match

• Excessive make-up and jewelry

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 • Marked impairment in occupational functioning, social activities or relationships

• Hallucinations most commonly auditory

• Excessive involvement in activities that have a high potential for painful consequences.

ETIOLOGY

 Genetic factors: Mania run through families.

 Biochemical factors: Mania is considered to be due to excessive biogenic amines (excess
norepinephrine and serotonin)
 Psychological factors: stress commonly precedes the 1st episode of both major depression
and mania.

MEDICAL MANAGEMENT

• Admit all forms of mania

• Mood stabilizers: drugs with mood stabilizers properties e.g., sodium valproate,
carbamazepine, lamotrigine and lithium should be instituted early in treatment

• Antipsychotic drugs such as olanzapine, haloperidol or chlorpromazine may be co-

administered during the initial period to control behavior and psychosis.

• Benzodiazepines particularly lorazepam may be used to treat mania. They complement

antipsychotic dose given in 24hrs reducing Extrapyramidal side effects

NURSING MANAGEMENT OF MANIC PATIENT

• Avoid any unnecessary verbal confrontation as the patient can be easily irritated.

• Maintain therapeutic calm environment. Remove any external stimulation such as noise
and lights where possible.

• Observe the patient for fluctuation of mood. Mood fluctuates from excessive happiness to
being irritable.

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 • Administer prescribed mood stabilizers and antipsychotics to reduce restlessness and
sleepless caused by over activity.

• Provide the patient with consistent limits on dressing and activities

• Observe the patient for any destructive activities that may result in injury.

• Engage the patient in active games, ward occupation and creative work to channel his
energy

• Ensure the patient take food for physiological needs. The patient is usually too busy to eat
hence may lose weight and dehydration may occur. Meals and fluids should be given
under supervision.

DEPRESSIVE PHASE

Five or more of the following symptoms are present during a two-week period and must bring
about change in function. At least one of the symptoms must be depressed mood or loss of
interest or pleasure

MAJOR DEPRESSIVE EPISODE

• feeling of worthlessness or guilt

• impaired concentration

• loss of energy of fatigue

• suicidal thoughts

• loss or increased appetite and weight

• insomnia or excessive sleep.

• psychomotor retardation or agitation

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Major depression may be present with or without psychotic features like delusions, hallucination
or bizarre behavior

Sleep impairment may involve initial insomnia, middle insomnia or terminal insomnia.

Suicidal ideation may range from passive ideas e.g., wishing one was death to active plans on
how to kill oneself.

EPIDEMIOLOGY

• The life time risk of developing major depressive disorder is 15% overall.

• It is more common in women than men in ratio of 2:1

• The range of onset ranges from childhood to old age. The mean age is 40yrs

• Recurrence is common. 50% of people who have one episode of Major depressive
disorder will have one or more additional episode.

PSYCHOPATHOLOGY

• Depression result from the low level of mono-amines specifically serotonin and
norepinephrine.

ETIOLOGY

The exact cause is unknown however some of the implicated factors include: -

• Genetic factors: the incidence of Major depressive disorder is higher among relatives of
individuals with the disorder than among the general population. 50% of the people with
Major depressive disorder have a first degree relative with mood disorder.

• Biochemical factors: The level of mono-amines Serotonin and Norepinephrine are

reduced in individual with major depressive illness

• Cognitive factors: narrow negative view of self, the environment and future

• Psychosocial factors like unemployment, loss of loved one, stress

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PREDISPOSING FACTORS TO MAJOR DEPRESSIVE EPISODE

• Family history of depression

• Gender: women are twice likely to get depression than men

• Health condition like cancer, heart disease and thyroid disorder

• Violence, physical or emotional abuse such as rape

• Unemployment

• Divorce

• Changes and stressful events such as relationship breakups, starting of a new job.

SOMATIC SYMPTOMS OF DEPRESSION

• Significant decrease in appetite and weight

• Early morning awakening at least 2 or more hours before usual time of waking up.

• Lack of interest and lack of reactivity to pleasurable stimuli.

• Psychomotor agitation or retardation

FORMS OF DEPRESSION

• Reactive depression (exogenous depression): state of depression that people experience in

response to external stressor. Caused in reaction to external event or circumstance such as
death of a family member, divorce or break up.

• Endogenous depression: depression that has no obvious cause. Believed to be originating

from within individual. Linked with genetic nature of individual

MANAGEMENT

• Antidepressants: selective serotonin reactive inhibitors, tricyclic antidepressant,

Monoamine oxidase inhibitors

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 • Physical therapies: Electroconvulsive therapy indicated for severe depression with
suicidal risk

• Psychotherapy: Emphasizes helping patients gain insight into the cause of their
depression

• cognitive therapy: aims at correcting the depressive negative cognitions like hopelessness
and pessimistic ideas

• supportive psychotherapy: various techniques are employed to support the patient. They
are reassurance, occupational psychotherapy, relaxation

• Group Therapy: sharing experiences to improve expression of their feelings

• Behavior therapy: includes social skill training.

• Family therapy: used to reduce or modify stressors.

ACUTE MANAGEMENT

• First line treatment in severe depression is a tricyclic antidepressant unless it is contra-

indicated. The main contra-indications are coexisting cardiac disease and intolerance to
anticholinergic side effects like urine retention such as amitriptyline, imipramine,
clomipramine (25-50mg OD)

• Main alternatives to tricyclic antidepressant are the selective serotonin reactive inhibitors
which do not have side effects, are not sedating, and are safe in overdose. The main side
effects are nausea, diarrhea and agitation. Such as chlorpromazine (50-100mg per oral)

• If the patient does not respond to 6 weeks of treatment on a therapeutic dose of tricyclic
antidepressant or a selective serotonin reactive inhibitor, consider increasing the dose of
current medication or changing to anti-depressant

• Anti-psychotics should be used if the depression is accompanied by psychotic episode

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 • Electroconvulsive therapy is indicated in the management of resistant depression and
where anti-depressants are contra-indicated or when patient’s life may be at risk from
suicide or dehydration arising from refusal to eat or drink.

• Relapse prevention- Anti-depressants should be continued for a minimum of 6 months

after the resolution of acute episode

NURSING MANAGEMENT OF PATIENT WITH DEPRESSION

• Encourage the patient to express emotions. Provide the patient opportunity to cry out and
ventilate their anger.

• Assess if there is any suicidal tendency. Take safety measures and keep vigil if patient
has suicidal ideas.

• Administer prescribed antidepressants in time and monitor food intake.

• Provide non-intellectual activities e.g., cleaning physical exercises provide safe and
effective methods of discharging vent up tension.

• Promote sleep and food intake. Most patient have insomnia and lack appetite

• Keep strict record of sleeping pattern. Discourage sleep during the day to promote more
restful sleep at night.

• Promote or interact with the patient and focus and not far in future.

• Provide health education to patient and relatives regarding disease and drugs.

HEALTH EDUCATION

• Take medications regularly and the right dosage.

• Teach the patient when therapeutic effects will be seen. At least 2 to 3 weeks must elapse
before he/she feels better

• Inform the patient of the side effects of antidepressants

• Teach the patient to avoid alcohol as it causes drug interaction and may cause harm.
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 • Not to stop medication without medical advice

• Advice the family to watch for any suicidal ideas or gestures and inform the clinician
immediately.

• To give adequate support and encouragement to the patient

• To accept patient as he/she is and give him/her hope and care

• To provide correct history to clinician.

MENTAL STATUS EXAMINATION(SECOND)

DATE 06/12/2022

GENERAL APPEARANCE

Grooming and dressing- the patient appears neat and well kempt with appropriate
dressing(uniform)

Hygiene- patient has no bad breath or odor and the skin is well hydrated with no cracks

Hair color and texture- looks clean and healthy

Posture- upright posture when standing and while seated

Level of eye contact- sustained and intense

Facial expression- happy facial expression

Steady gait with absent tics, no tremors and no involuntary movements present

Behavior- calm

Nutritional status- Patient looks well nourished

Mannerisms; no mannerisms noted

SPEECH

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Normal coherent speech with normal volume and pitch without any difficulty in forming words.

GENERAL ATTITUDE

Patient is friendly, attentive, cooperative and interested. she answers questions willingly and
actively participates in the interview process.

MOOD

Euthymic

AFFECT

Appropriate, the outward emotional expression is what would be in a certain situation

THOUGHT CONTENT

Patient has no delusions

THOUGHT PROCESS

No thought block, thought withdrawal and no flight of ideas

PERCEPTION

Patient does not have any hallucinations or illusions.

COGNITION

Attention; good, she was able to say the days of the week in reverse.

Concentration; good, using serial three she was able to subtract 3 from 20 to 17, 14, 11, 8, 5

Abstract reasoning; good, she was asked the meaning of “pole pole ndiyo mwendo,” and she said
“ukichukuwa muda kufanya kitu matokeo ni mazuri”

Judgement; good, patient when asked what she can do if she sees a young boy wanting to cross a
busy highway like Muthaiga she said she will take the boy to a foot bridge to cross.

ORIENTATION

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Patient is well oriented to time, place and person (patient could tell the estimate of time well,
knows where she is, and knows the people she is talking to)

MEMORY

Immediate memory; good, patient was able to remember that we are nurses when asked

Recent memory; good, patient was able to remember what she took for breakfast by answering it
is tea with four slices of bread

Remote memory; good, patient was able to remember the first president of Kenya

RAPPORT

Able to establish and maintain well

INSIGHT

Good;

Patient is able to interpret where she is that she is in Mathari Teaching and Referral Hospital

Presently the patient is aware that she is mentally sick and wants to take her medication well as
these benefits her to get well then go home.

MENTAL STATUS EXAMINATION(THIRD)

DATE 13/12/2022

GENERAL APPEARANCE

Grooming and dressing- the patient appears neat and well kempt with appropriate
dressing(uniform)

Hygiene- patient has no bad breath or odor and the skin is well hydrated with no cracks

Hair color and texture- looks clean and healthy

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Posture- upright posture when standing and while seated

Level of eye contact- sustained and intense

Facial expression- happy facial expression

Steady gait with absent tics, no tremors and no involuntary movements present

Behavior- calm

Nutritional status- Patient looks well nourished

Mannerisms; no mannerisms noted

SPEECH

Normal coherent speech with normal volume and pitch without any difficulty in forming words.

GENERAL ATTITUDE

Patient is friendly, attentive, cooperative and interested. she answers questions willingly and
actively participates in the interview process.

MOOD

Euthymic

AFFECT

Appropriate, the outward emotional expression is what would be in a certain situation

THOUGHT CONTENT

Patient has no delusions

THOUGHT PROCESS

No thought block, thought withdrawal and no flight of ideas

PERCEPTION

Patient does not have any hallucinations or illusions.

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COGNITION

Attention; good, she was able to say the months of the year in reverse.

Concentration; good, using serial seven she was able to subtract 7 from 70 to 63, 56, 49, 42, 35

Abstract reasoning; good, she was asked the meaning of “Mwenda pole hajikwai,” and she said
(ukichukuwa muda kufanya kitu sio rahisi kufanya makosa)

Judgement; good, patient when asked what she can do if she sees a house on fire while inside
with other people asleep what she will do, she said she will shout fire for the others to hear and
move out quickly but carefully.

ORIENTATION

Patient is well oriented to time, place and person (patient could tell the estimate of time well,
knows where she is, and knows the people she is talking to)

MEMORY

Immediate memory; good, patient was able to remember that we are nurses when asked

Recent memory; good, patient was able to remember what she was taught in group therapy and
said it was about the benefits of adhering to medication

Remote memory; good, patient was able to remember the year she got married

RAPPORT

Able to establish and maintain well

INSIGHT

Good;

Patient is able to interpret where she is that she is in Mathari Teaching and Referral Hospital

Presently the patient is aware that she is mentally sick and wants to continue taking her
medication as these benefits her to get well, be discharged then go home.

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CONCLUSION

Mrs. R.N was admitted on 30/11/2022 through the outpatient department escorted by her son
with complains of making a lot of noise at home with aggressive behavior, throwing away
shopping bought for her from the house, being abusive and talking words that are not
understood, locks herself in the house and does nothing while in the house, poor relationship at
home with others, being angry to the son and other family members and refusing to eat and take
her medication. A mental status examination was done and physical examination and a diagnosis
of bipolar mood disorder was made. Legal forms MOH 614 and MOH 615 were signed in
duplicate and the patient was admitted in the mental facility in ward 6 female under involuntary
admission.

She was given carbamazepine intramuscular injection and remained admitted in Mental Health
Unit where daily nursing care including daily supervision of bathing, individual and group
therapy as well as occupational therapy was carried out in the ward. Oral medications listed
above were also given in the ward. While in the ward the patient was reviewed every Tuesday
and Friday by a psychiatrist. Last review was on 13/12/2022 and she was discharged home on
above medications and a return date of one month was given for follow up at the psychiatric
outpatient clinic.

RECOMMENDATION

I would like to recommend that the ministry of health should make it clear to the people through
social media platforms and mass media that mental illness can be managed hence families which
may encounter the same should not isolate their members as well as the society as a whole but
take them to mental health facilities for review and treatment

I would like to recommend to all the mental health units to make sure they engage the patients in
individual and group therapy as well as occupational therapy while in the wards as this makes
them actively involved and a feeling of self-worth.

BIBLIOGRAPHY

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  The African textbook of Clinical Psychiatry and Mental Health by Professor David
Musyimi Ndetei.
 A short textbook for psychiatry, seventh edition by Dr. M.S. Bhatia
 Concise textbook of clinical psychiatry 2nd edition by Kaplan
 Google www.health.com
 Google en.wikipedia.org/wiki/bipolar; disorder

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