Psychiatric Case History – Mental Health Nursing Clinical Presentation

I. Identification Data

II. Chief Complaints (as reported by daughter/informant)

• Reduced sleep
• Anger outbursts
• Excessive/unnecessary talking
• Muttering to self, laughing to self
• Suspiciousness of neighbours
• Pacing around the house/wandering on the streets
• Poor self-care (not bathing, not changing clothes)
• Not performing household activities

III. History of Present Illness

• 9 years back: Patient was apparently well, doing all household chores, adequate sleep (6–8 hrs), regularly going for daily wage work.
• At age 31: Gradual decrease in sleep (late sleep onset after 11 pm). One day she reportedly displayed "god-possession"-type behaviour, after which she began talking excessively to family members. Sleep reduced further to 2–3 hrs/day; remained awake at night, talked and laughed to self, became irritable when questioned, and scolded others.
• Subsequently developed complete insomnia, paced around the house at night, muttered to self, and spoke inappropriately with neighbours to the extent that neighbours got frightened. Family took her to a local ("mediyal") hospital where she was admitted and treated (details not available); medication compliance was irregular thereafter, though she was able to resume work.
• 2 years ago: Stopped going to daily wage work; remained at home, neglected self-care - irregular bathing (once in 3-4 days), needed prompting.
• 1 year ago: Stopped all household activities; started wandering aimlessly on the streets.
• 1 month ago: After learning of her daughter's love marriage (without parental consent), she began excessively worrying/talking about the issue, was observed talking to herself continuously, and refused medications.
• 2 weeks ago: Reported to her daughter that the kitchen stove burner was "missing" and suspected the neighbours had stolen it. On searching, the burner was found abandoned/damaged at the street corner - indicating a delusional/misinterpretive belief.
• Reported that neighbours were monitoring her through her phone and passing information about her to others, inciting people to pick fights with her - consistent with delusions of persecution/reference.
• Intermittent inappropriate laughter to self; when scolded, would cry inconsolably for up to 2 days.
• Daughter is the sole caregiver and requested inpatient admission due to inability to manage her at home.

IV. Past History

• No past psychiatric illness prior to this episode's evolution, no seizure disorder, no suicidal attempts.
• No known Diabetes, Hypertension, Thyroid disorder, or Coronary Artery Disease.

V. Family History

• No family history of psychiatric illness, missing family members, or suicide.
• Two children (son 20 yrs, daughter 18 yrs) - both apparently well.

VI. Personal History

• Started schooling at 5 years; studied up to 4th–6th standard, then failed/discontinued.
• Started working (daily wages) from age 16.

VII. Marital History

• Married at age 20; has 2 children.
• Husband is an alcoholic (reported psychosocial stressor in the home environment).

VIII. Menstrual History

• Attained menarche at appropriate age; cycles reported as regular (NVD/LMP details not clearly legible in the record).

IX. Premorbid Personality

• Cooperative, welcomed responsibilities.
• Good interpersonal relationships.
• Extroverted, attached to family members.

X. General/Physical Examination

• Patient conscious, oriented, afebrile, gait and posture normal.
• Vitals (on admission): BP ~90/60–110/80 mmHg, PR 76–96/min, SpO2 97–99% on room air.
• CVS: S1S2 heard, normal; RS: bilateral air entry equal; P/A: soft; CNS: no focal neurological deficit.
• Later noted c/o toothache (right side) - dental opinion sought.

XI. Mental Status Examination (MSE)

XII. Diagnosis

XIII. Investigations

• CBC, RBS, Blood Urea, Serum Creatinine, LFT ordered.
• Results (05/08/2026): Glucose 80 mg/dL; Urea 17 mg/dL; Creatinine 0.6 mg/dL; SGOT 19, SGPT 30, ALP 217 U/L; Total protein 6.3 g/dL, Albumin 4.1 g/dL; Total bilirubin 0.8 mg/dL, Direct bilirubin 0.3 mg/dL - all within normal limits, ruling out an organic/metabolic cause.

XIV. Treatment Given (Inpatient)

• Inj. Haloperidol 5 mg + Inj. Promethazine 50 mg IM (SOS, for agitation)
• Tab. Olanzapine 5 mg - 0-0-1 (later increased to 0-0-2)
• Tab. Diazepam 5 mg - 0-0-2
• Supportive care, dental referral for toothache

XV. Progress on Follow-up (Days 2–3 post-admission)

• Sleep and appetite adequate; bowel/bladder normal.
• Self-care improved, irritability reduced initially, then fluctuated (episodes of irritability requiring repeat Haloperidol/Promethazine IM).
• Disorganised symptoms and tangentiality persisted; talk fluctuated between relevant and irrelevant.
• No fresh delusions or perceptual abnormalities elicited on the later review.

Nursing Care Priorities Suggested by this History

1. Safety/risk assessment - monitor for agitation, aggression, and self-neglect; ensure a safe, low-stimulation environment.
2. Medication adherence support - past history of irregular compliance was a major relapse driver; psychoeducation for patient and daughter (sole caregiver) is essential.
3. Self-care and ADL rehabilitation - structured routine for hygiene, nutrition, and sleep.
4. Family psychoeducation - address caregiver burden (daughter is sole support; husband is alcoholic and likely unavailable as a support), and educate on early relapse signs (reduced sleep, suspiciousness, muttering to self).
5. Monitoring for extrapyramidal side effects from Haloperidol/Olanzapine (tremor was already noted).
6. Psychosocial stressor management - the daughter's marriage was an identifiable trigger for symptom exacerbation; supportive counselling around this family conflict is indicated.