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Clinical abstracts - Assignment Example

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Additionally, a full term NSD was delivered at a lying-in with no observable complications.
3 months prior to admission, noted to have unwanted…
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Clinical abstracts
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Republic of the Philippines Health Department MANILA PAEDIATRIC CENTRE Palitos Avenue, Mindanao CLINICAL of patient: Claudio, Bravo Gladiola
Age: 3 Sex: MALE Citizenship: FILIPINO
Date Admitted : April 10, 2015 Time Admitted: 7.30 AM
Date Discharged: April 21, 2015 Time Discharged: 3.20 PM
Attending Physician: Alvarez P. Suarez, M.D.
Admission Diagnostics: MENTAL DISORDER
Chief Complaint: SCHEDULED MENTAL STAUS EXAMINATION
HISTORY 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
(-) HPN
FAMILY HISTORY
(+) Hypertension
(+) Cerebral malaria
PHYSICAL EXAMINATION
Temp: 36.7 C HR: 96/MIN RR: 44/MIN
Weight: 5.8KGS
GENERAL APPEARANCE, MENTAL STATUS & BEHAVIOR: awake; dull, not in cardio respiratory distress
SHEENT: (+) Icteric sclera, no CLAD, good skin turgor, nasal discharge, pink palpebral conjunctiva
HEART/CARDIOVASCULAR: normal rate regular rhythm, no murmur, adynamic precordium
ABDOMEN: (+) hepatomegaly, NABS, globular
EXTREMITIES: full pulses, no cyanosis
ASSESSMENT
Mild mental retardation
PLAN: 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 Cited
Morrison, 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. Read More
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