C.

PATIENT CARE DURING HOSPITALIZATION

A. PATIENTS DATA
Name: Psychiatric Ward- 2
Sex : female Race : Indian Age : 46 yo
Height : Weight : BMI:
Admission Date: 13/3/17 Discharged Date:

B. CHIEF COMPLAINTS
Altered behaviour for 4/7

C. HISTORY OF PRESENT ILLNESS

History from pts boyfriend: claimed by friends that pt been having
altered behaviour since last 4 days ago, otherwise previously well.
She been talking to herself, talking non-stop, shouting, dancing in the
living room with loud music.
She also occasional been reporting that she does not want to live anymore.
However, no noted aggressive behaviour, no suicidal/ homicidal ideation/
attempts.
History from pt:
Claimed has poor sleep.
AH-voices of late mother, commending
Claims only able to see her mother during at temple after prayers.
When stress, she feels theres a snake inside her body, controlling her limbs.

D. PAST MEDICAL HISTORY

Schizophrenia since 10 years ago
-first admission at hospital Sultanah Amirah for 2 weeks (never f/u then)

-second admission at hospital Melaka brought by police.

-third admission at hospital Pulau Peneng.

Called to H.PP, pt had multiple admission at HPP from 2006 to 2016.
(Total 7 admission excluding clinic visits). All admission due to non-
compliance to medication resulting in Relapsed Schizophrenia.
Last admission July 2016. At hospital Peneng, she was on T.
Risperidone and then subsequently changed to I.M. Clopixol 200mg
monthly.
Last taken I.M Clopixol on 15 July 2016.
1
 Unable f/u since august 2016. Pt defaulted medication for 8 months not
been to continue depot due to feld sedated after depot.

-forth admission at hospital Ipoh and used to follow up at clinic.

E. PAST MEDICATION HISTORY

Ro
Name of drugs Dose Freq Indication
ute
IM Clopixol 200mg weekly IM Schizophrenia who have a poor
(Zuclopenthixol) compliance with medication and
suffer frequent relapses of illness.

F. FAMILY HISTORY
No psychiatry illness in family members
Separated with husband 15 years ago but no official divorce.
Has 2 sons 18yo worked as IT staff, 8yo stayed at rumah kebajikan.
Now got a Pakistani boyfriend.

G. SOCIAL HISTORY
Non-smoker, non-alcoholic, deny high risk behaviour.

H. ALLERGY
NIL

I. PHYSICAL AND LABORATORY EXAMINATION

Alert, conscious, GCS full, Pupil equal and reactive, no tachypnea, CRT <
2secs, good pulse volume, hydration
CVS: S1S2 no murmur.
LUNG: clear
ABD: SNT
CNS: UL & LL are normal, negative for cerebellum sign.

J. WORKING DIAGNOSIS
Altered behavior TRO U/L schizophrenia

K. DIFFERENTIAL DIAGNOSIS
-

L. MANAGEMENT PLAN
1. For Vital sign monitoring
2. To trace all pending blood test
3. Keep in view for CT brain

2
 4. To refer to psychiatric function inpul.

INVESTIGATIONS
1. FBC, Ca2+, Mg2+, PO43-
2. Urine toxicology test
3. Urine pregnancy test

M. THE RESULTS OF LABORATORY INVESTIGATIONS

Nor
Para
Uni mal 13
meter
ts ran /3
s
ge
Full Blood Count
WBC x10 4.0- 10
9
/L 11. .1
0
Hb g/d 11. 13
L 5- .1
15.
3
 5
RBC x10 4.2-
9
/L 5.4
Hct % 36. 41
0-
52.
0
Plt x10 150 37
9
/L - 9
400
Electrolytes
Sodiu mm 135 13
m ol/ - 4
L 145
Potass mm 3.5- 3.
ium ol/ 5.0 6
L
Calciu mm 2.1 2.
m ol/ 4- 25
L 2.5
8
Correc mm 2.1
ted Ca ol/ 4-
L 2.5
8
Phosp mm 0.8- 0.
hate ol/ 1.4 61
L 5
Magn mm 0.7- 0.
esium ol/ 1.3 79
L
Chlori mm 96- 99
de ol/ 106
L
Coagulation profile
PT sec 10-
ond 13.
s 5
APTT sec 26-
ond 42
s
INR <1.
5
Renal Profile
Urea mm 1.7- 4.
ol/ 8.3 9
L
SCr um 64- 62
ol/ 122
4
 L
CrCl ml/ 80-
min 120
Liver Profile
Total g/L 66- 74
Protei 87
n
Albu g/L 35- 35
min 50
T. um <20 7
Biliru ol/
bin L
ALT IU/ <32 15
L
AST IU/
L
ALP IU/ 53- 86
L 141
Cardiac Profile
CK IU/ 24-
L 195
Trop- <0.
T 1
LDH IU/ 0-
L 248
Lipid Profile
C- mm <5.
Total ol/ 7
L
C- TG mm <1.
ol/ 7
L
C- mm >1.
HDL ol/ 7
L
C- mm <3.
LDL ol/ 9
L

Blood Glucose
Dat
Time Mmol/L Remarks
e

5
6
N. Vital Signs Chart
Date Time Temperature Blood Heart RR/ Pain
Pressure Rate SPO2 score
13/3 0605 37 152/84 80 20/100% 0
1000 37 148/72 82 20/100% 0
1150 37 123/73 64 20/100% Unable
to assess
1830 37 135/78 70 20/100% Unable
to assess
14/3 0600 37 127/69 81 21/99% Unable
to assess
0800 37 137/93 69 20/100% Unable
to assess
1200 37 138/80 67 20/100% Unable
to assess
1900 37 147/75 76 20/100% Unable
to assess
15/3 0600 37 130/80 80 20/100% Unable
to assess

O. CULTURE & SENSITIVITY TEST

Date Sample & Test Result
NIL NIL NIL

P. PROGRESS NOTES
Date Subjective Objective Assessme Plan
nt
13/3 Alert BP: 152/84 Schizophr Medical plan:
0850 conscious RR: 80 enia in
Afebrile acute Medication plan:
DXT: 5.6mmol/dl episode 1. IM Midazolam
Lung: clear 5mg stat
ABD: SNT, no mass 2. To get more
palpable history from
CNS: PRMM, no Hospital PP.
neck stiffness, gross 3. T. Risperidone
normal. 1mg BD
4. T. Clonazepam
1mg PRN
5. KIV to give
MSE:
depot later
Middle age 6. To trace old
lady, good notes at HKL
eye contact. 7. Abscond

7
 Speech caution.
adherent/
relevant in
normal
tone/volume/
rate
Rapport
superficial
Euthymic
Afferent
reduced
No AH/ no
VH/ no
suicidal
ideation
Orientated to
TPP
Fair insight
poor at times.
1210 Conscious, BP: 123/73 Schizophr Plan:
good pulse HR: 64 enia in 1. To get more
volume, SPO2: 100% acute history from
CRT<2 RR: 19 episode H.PP
secs, warm T:37C 2. T.Risperidone
peripheries, 1mg BD
not LUNG: Clear 3. T.Clonazepam
tachypnea. CNS: DRNM 1mg PRN
4. KIV for notes at
PA: SNT, no mass
HKL
palpable.
5. Cont. abscond
caution
1450 Plan:
1. Trace old notes
2. To call H.PP for
social work
history
3. Monitor vital
sign
4. Cont. abscond
caution
14/3/17 O/E: Alert, Relapse Plan:
0745 conscious schizophre 1. Cont. T.
BP: 127/69 nia Risperidone 1mg
PR: 81 BD
T: 37 2. Trace old notes
8
 SPO2: 100% from HKL
3. Off cautionTo
MSE: refer community
Middle aged indian upon discharge
female in hospital 4. KIV to discharge
attire. tomorrow.
Good hygiene
Coherent, relevant
Mood euythmic
Afferent: appropriate
No AH, no VH
No suicidal
idealation
0930 MSE: Relapse Plan:
Middle aged indian schizophre 1. Increase T.
female in hospital nia Risperidone 2mg
attire BD
Good hygiene 2. KIV for IM
Rapport established Depot on
Good eye contact Thursday
No AH, no VH 3. Cont
No suicidal ideation. psychoeducation
4. KIV to refer to
community upon
discharge
5. For social
welfare report
6. Cont
observation.
15/3 Alert BP: 130/80 Relapse Plan:
0600 conscious PR: 80 schizophre 1. V/S monitoring
T:37 nia 2. Cont T.
SPO2: 100% Risperidone 1mg
RR: 20 BD
3. To refer
community upon
discharge
4. To call back
social workers
regarding report
5. KIV to allow
discharge
6. Off branula

9
Q. CURRENT MEDICATIONS
Date

Drug Regimen Drug Class/ Indication Started Stoppe

d
Antipsychotic
T.Risperidone 1mg BD Benzisoxazole atypical 13/3 14/3
antipsychotics with mixed
serotonin-dopamine antagonist
activity that binds to 5-HT2-
receptors in the CNS and in the
periphery with a very high
affinity. The binding affinity to
dopamine 2 receptors with less
affinity and 20 times lower than
the 5-HT2 affinity. Th addition of
serotonin antagonism to
dopamine antagonism is thought
to improve negative symptoms
of psychoses and reduce the
incidence of EPS.
T.Risperidone 1mg OM 14/3 ongoing

T.Risperidone 2mg ON

IM Haloperidol 5mg stat Butyrophenone antipsychotic 13/3 stop

which blocks postsynaptic
mesolimbic dopaminergic D1 and
D2 receptors in the brain,
depresses the release of
hypothalamic and hypophyseal
hormones; believes to depress
the reticular activating system
thus affecting basal metabolism,

10
 body temperature, wakefulness,
vasomotor tone, and emesis.
sedative
IM.Midazolam 5mg stat Moderate sedation 13/3 stop
T.Clonazepam 1mg PRN Adjunct therapy for 13/3 stop
schizophrenia
T.Clonazepam 1mg BD 14/3 stop
T. Lorazepam 1mg ON Adjunct therapy for 14/3 stop
schizophrenia
Also counter the side effect of
insomnia in patient taking
Risperidone.

R. DISCHARGED MEDICATIONS
Date
Drug Regimen Drug Class/ Indication Started Stoppe
d
Antibiotics

Diuretics

Anti-hypertensive

Electrolytes

Anti-epileptics

Topical Application

Others

S. FINAL DIAGNOSIS
11
 Relapse Schizophrenia

T. PHARMACEUTICAL CARE ISSUES

Date: 15/3/17
Pharmaceutical Care Issue (1):
Unsolved Auditory hallucination and Grandiose delusion

Pharmacist Recommendation:
Family intervention (try to contact the family and discuss to provide
support)
Psychoeducation - to develop a collaborative relationship between the
patients, family members, and physician so that patients can learn to
understand and manage their illness, take drugs as prescribed, and handle
stress more effectively.
Social skills training- conversation skills to avoid patient focus on the voice
hallucination
Cognitive remediation therapy (CRT)
Counseling and supportive psychotherapy

Outcome:
To minimize the occurrence of AH & GD.

Monitoring:
Monitor the mental status progression in patients. Assess for AH and delusions on
every appointment.

Evidence:

Date:15/3/17
Pharmaceutical Care Issue (2):
Relapsed Schizophrenia due to non-compliance with anti-psychotic medication.

Pharmacist Recommendation:
Components of adherence intervention include
o family intervention
o psychoeducation
o motivational interview
o cognitive psychotherapy
o compliance counselling
o service level interventions
o behavioural strategies:
1) appointment given before discharge from hospital
2) prompt in the forms of letters and telephone calls before
12
appointment date
3) cue to remember taking daily medications

Patient education on effectiveness and risks of treatment, psychosocial

programming and involvement of family members to monitor responses to
medication.

Depot Antipsychotic is administered once patient is discharge. Before depot is

given, patient must be stabilised on oral therapy. Follow protocol, Risperidone for
example, risperidone 10-15 times oral daily dose with once-monthly dose of
Risperidone overlap for 1st month.

Dose of oral risperidone mg/day Dose of intramuscular risperidone

mg/fortnight
< 2mg 25mg
Between 2 and 4 mg 25 to 37.5mg
>4mg 37.5 to 50mg
25 mg every 2 weeks; increase if necessary to maximum of 37.550 mg every
2 weeks. Give supplemental oral antipsychotic for the first 3 weeks. Do not adjust
dose more frequently than every 4 weeks. Effects of a dose increase will not be
seen for 3 weeks.

Outcome:
Improve drug adherence
Monitoring:
Vital sign; fasting lipid profile and fasting blood glucose/Hgb A1C (prior to
treatment, at 3 months, then annually); CBC; BMI, personal/family history of
obesity, waist circumference; blood pressure; mental status, abnormal involuntary
movement scale (AIMS), EPS; orthostatic blood pressure changes for 3-5 days after
starting or increasing dose. Weight should be assessed prior to treatment, at 4
weeks, 8 weeks, 12 weeks, and then at quarterly intervals. Consider titrating to a
different antipsychotic agent for a weight gain 5% of the initial weight.
Evidence:
Guidelines for the use of risperidone long acting injection, NHS, 2009

Date: 15/3/17
Pharmaceutical Care Issue (3):
Body weight of patient is not recorded.

Pharmacist Recommendation:
Body weight of patient should be recorded every day so that to trace the difference
between initial weight and current weight. Weight gain is one of the side effects of
risperidone. Consider titrating to a different antipsychotic agent for a weight gain
5% of the initial weight.

Outcome:
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To minimize side effect of weight gain.

Monitoring:
Monitor body weight everyday

Evidence:
Lexicomp, Drug Information Handbook, 22nd edition

Date: 15/3/17
Pharmaceutical Care Issue (4):
Counselling on Risperidone

Pharmacist Recommendation:
The common adverse effect of Risperidone are insomnia, akathisia and headache,
followed infrequent such as rhinitis, incontinence, sexual adverse effect, EPSE
other than akathisia and angioedema.

Inform doctor when the symptom of akathisia (rocking or swaying from foot to
foot, repeated lifting and lowering if the foot, repeated bobbing of the head,
bending of the neck or other motions of that area, repeated shifting or twisting of
the waist or trunk of the body) is persistent, the management are dosage reduction
or modest dose of propranolol (30-80mg a day) (Maju Mathews, etc, 2005).

Counselling on Antipsychotics:

Taking your antipsychotic medicine regularly is important:

because stopping or taking it irregularly is associated with high risk of

relapse and suicide

In order to prevent an episode, rather than taking it after symptoms occur.

Outcome:
Improve compliancy of drug

Monitoring:
-

Evidence:

Mathews, M., Gratz, S., Adetunji, B., George, V. (2005), Antipsychotic-induced

movement disorders: evaluation and treatment.

Signs of hypophosphatemia include a lower than normal blood phosphate

level. Other electrolyte values are likely to be affected, depending on your
14
disease. There are no symptoms of hypophosphatemia, unless the values
are critically low. Then you may notice trouble breathing or respiratory
problems, confusion, irritability, or coma. These all may occur with
phosphorous levels of 0.1-0.2 mg/ dL.

Cognitive remediation therapy (CRT), also called cognitive

enhancement therapy (CET), is designed to improve neurocognitive
abilities such as attention, working memory, cognitive flexibility and
planning, and executive functioning which leads to improved social
functioning.

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