Clinical abstracts - Assignment Example

Republic of the Philippines Health Department MANILA PAEDIATRIC CENTRE Palitos Avenue, Mindanao CLINICAL of patient: Claudio, Bravo GladiolaAge: 3 Sex: MALE Citizenship: FILIPINODate Admitted : April 10, 2015 Time Admitted: 7.30 AMDate Discharged: April 21, 2015 Time Discharged: 3.20 PMAttending Physician: Alvarez P. Suarez, M.D. Admission Diagnostics: MENTAL DISORDERChief Complaint: SCHEDULED MENTAL STAUS EXAMINATIONHISTORY OF PRESENT ILLNESS After being born to a 29 y/o mother and subjected to regular prenatal check-up with an OB Gyne, stable results were obtained.

Additionally, a full term NSD was delivered at a lying-in with no observable complications. 3 months prior to admission, noted to have unwanted obsessions, hallucinations without external stimuli and circumstantiality. After consultations, advised to seek therapy and slight change of environment (Morrison, 2014). 1 month prior to admission, patient was noted to have developed mild mutism, echolalia, neulogisms, and tangential speech. Day of admission, the patient was scheduled for a mental status examination hence admitted.

PAST MEDICAL HISTORY (-) DM (+) Skin asthma (-) HPNFAMILY HISTORY (+) Hypertension (+) Cerebral malariaPHYSICAL EXAMINATIONTemp: 36.7 C HR: 96/MIN RR: 44/MINWeight: 5.8KGSGENERAL APPEARANCE, MENTAL STATUS & BEHAVIOR: awake; dull, not in cardio respiratory distressSHEENT: (+) Icteric sclera, no CLAD, good skin turgor, nasal discharge, pink palpebral conjunctivaHEART/CARDIOVASCULAR: normal rate regular rhythm, no murmur, adynamic precordiumABDOMEN: (+) hepatomegaly, NABS, globularEXTREMITIES: full pulses, no cyanosisASSESSMENT Mild mental retardationPLAN: For admission The patient was admitted at Monela Ward Room 231 under the service of Dr.

Juan/ Jordi/Pedro. Consent for admission was signed by the patient’s guardians. Vital signs were monitored at 3 hour intervals and the BP at 2 hours intervals. PLRS 1 L runs at 51 ugtts/m. Medications administered were antibiotics 200mg/10ml after every 6 hours for tem > 36.5 (Stickley, & Basset, 2008). Patient was watched out for seizures and soliloquys. Works CitedMorrison, J. R. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians. New York: The Guilford Press.

Stickley, T., & Basset, T. (2008). Learning about mental health practice. Chichester, England: Wiley.