雙相情感障礙躁狂發作伴精神病性症狀病例報告

精神科標準病歷範本-POMR

一、【POMR 範本】Bipolar affective disorder, manic episode, severe with psychotic behaviors

2023/01/11 10:30 AM

^{S: 我的體質容易被附身，我常常被濟公上身，有神力…全台灣都是黑頭汽車，台灣錢淹腳目，你認為這是誰的功勞，這都是我弄的。我是台灣的總統，是台灣的神。我爸爸是濟公，…(患者開始嚎啕大哭)，我想到爸爸，他很疼我，都跟我一起抽菸…}

^{O: Vital sign: BP:138/88mmHg, HR:92/min, RR:18/min, BT:37℃, TST:4/5’hr}

^{Consciousness: clear}

^{Appearance: clean}

^{Attitude: fair}

^{Attention: distractibility}

^{Affect: labile}

^{Mood: elevated, labile, euphoria}

^{Speech: hypertalkative, coherent, relevant but pressure of speech}

Behaviors and movement: hyperactivity, psychomotor agitation, mild hands tremor

Thought: delusion of grandeur, delusion of religion, flight of ideation, mood congruent delusion

Perception: denied any type of hallucination

Insight: impaired

Problem:

Problem#1: Bipolar affective disorder, manic episode, severe with psychotic behaviors

^{A: Obvious labile mood and psychotic symptoms under treatment with Lithonate (300mg) 1# BID, Depakin (500mg) 1# BID and Clozaril (100mg) 1# HS.}

^{P: We titrated Clozaril (100mg) to 1.25# HS.}

^{Regular monitor WBC and watch for Clozaril induced agranulocytosis}

^{Establishing reality and insight.}

^{Educating patient about mood disorder and drugs}

^{簽名: 住院醫師/主治醫師}

支持性心理治療

會談目的: 澄清情緒及精神症狀，進一步建立現實感。

會談內容: 引導患者陳述症狀，針對患者誇大而與現實不符之妄想，並以溫和態度請患者舉例，透過症狀的討論建立患者的現實感及病識感。

^{簽名: 住院醫師/主治醫師}

二、【POMR 範本】Dementia

2023/01/11 10:30 AM

^{S: 不再主動提及被照顧者下藥毒害，且可配合吃下照顧者給予之餐點。}

^{可簡單表達肚子餓，要如廁。}

^{O: Vital sign: BP:130/70mmHg, HR:72/min, RR:20/min, BT:36℃, TST:8/10hr}

^{Appearance: unkempt}

^{Facial expression: apathy}

^{Attention: poor}

^{Affect: flat}

^{Speech: hypotalkative, poverty of speech}

Behaviors: psychomotor retardation, mild self talking, social withdrawal, 頻走錯房間, 躺他人床位, 上廁所坐在馬桶上卻未脫褲子,偶有吃掉他人放在活動室食物之情形

Thought: poverty of thought, no obvious delusional content was noted

Perception: denied hallucination

Compliance: fair under monitor

Problem:

Problem #1: Dementia

^{A: Decfreased persecutory delusion under treatment with Abilify (15mg) 0.5# QD and Aricept (5mg) 1# QD}

^{P:Preventing that patient falling down or chocking}

^{Monitor patient’s self care function}

^{Training patient about daily activity}

^{Giving mental support}

^{簽名: 住院醫師/主治醫師}

支持性心理治療

會談目的: 給予心理支持，減少患者因錯誤而帶來的沮喪心情。

會談內容: 溫和且反覆提醒患者生活事項，協助患者透過門上紙條辨識自己的房間，安撫因吃錯他人食物或將褲子弄髒所帶來的沮喪感受。

^{簽名: 住院醫師/主治醫師}

三、【POMR 範本】Major depressive disorder

2023/01/11 10:30 AM

^{S: 常覺得家裡要是沒有我拖累，孩子、先生一定過得很好，我是個沒用的人，連家事都做不好，生這個病十幾年了，也不會好，不如死一死，常常這裡痛那裡痛，還要家裡的人帶我來看病。連燒炭都被鄰居發現，我不會感激他…}

^{O: Vital sign: BP:156/92mmHg, HR:88/min, RR:20/min, BT:35.8℃, TST:7/10hr}

^{Consciousness: clear}

^{Appearance: clean}

^{Attention: impaired}

^{Facial expression: shallow}

^{Mood: depressive}

^{Speech: hypotalktive, coherent, relevant speech}

Behaviors: social withdrawal, hypoactivity, psychomotor retardation, suicidal attempt

Thought: guilty feeling, hopeless, worthless, suicide idea, thought retardation

Intellectual function (JOMAC): defect in calculation

Insight: impaired

Problem:

Problem #1: Major depressive disorder, recurrent, severe without mention of psychotic behaviors

^{A: Remained strong suicide idea and psychomotor retardation under treatment with Efexor (37.5mg) 1# BID}

^{P:Note that patient suicide or self harm}

^{Titrating Efexor (37.5mg) to 2# BID}

^{Mental support, reassurance and empathy & inviting family to visit patient}

^{Problem #2: Hypertension}

^{A: Elevated blood pressure was noted after admission}

^{P: Adding Norvasc (5mg) 1# QD}

^{Suggesting patient diet and body weight control}

^{Closely monitor vital sign}

^{簽名: 住院醫師/主治醫師}

支持性心理治療

會談目的: 處理負面認知：患者有強烈低自尊感，因此想自我了斷。

會談內容: 同理患者無望、無價值感的感受，強調這種感覺是症狀之一。在患者周遭還是有許多關心他的人，只是憂鬱症讓其看不到事情好的一面。教導患者練習以正向的角度審度當下生活，減少憂鬱的負向認知。

^{簽名: 住院醫師/主治醫師}

四、【POMR 範本】Organic brain syndrome

2023/01/11 10:30 AM

^{S: 我聽到活動室很吵，頭就很痛，我很不爽，控制不住才會出來罵人，叫他們小聲一點。可是他們講不聽，我就抓狂，才會那椅子砸他們。}

^{O: Vital sign: BP:126/76mmHg, HR:86/min, RR:16/min, BT:36.6℃, TST:8/8’hr}

^{Consciousness: clear}

^{Appearance: unkempt}

^{Attitude: defensive}

^{Attention: fair}

^{Affect: appropriate}

^{Speech: coherent, rerelevant, pressure of speech}

Behaviors: aggression, violence, conflicted with other patients, isolation, no psychotic behaviors was noted

Thought: rigidity, referent ideas, denied persecutory delusion

Perception: denied any type of hallucination

Insight: poor

Problem:

Problem #1: Organic brain syndrome, chronic

^{A: Easy loss of control under treatment with Depakin chrono (500mg) 1# QAM&HS}

^{P:Titrating Depakin chrono (500mg) to 1# QD and 2# HS}

^{Regular monitor Valproic acid level (TDM)}

^{Psychotherapy ( educating patient how to control mood)}

^{Note that patient violence}

^{簽名: 住院醫師/主治醫師}

支持性心理治療

會談目的: 教導情緒控制。

會談內容: 患者會不由自主的憤怒，甚至想打人。教導情緒控制金字塔模式，協助減少acting out.

^{簽名: 住院醫師/主治醫師}

五、【POMR 範本】Schizophrenic disorder, paranoid type, chronic with acute exacerbation

2023/01/11 10:30 AM

^{S: 頻問何時出院. 表示今天冬至,要吃湯圓,..你們醫院有農民曆喔…藥吃這樣就夠了, 不然口水會流一整地, 現在耳朵“ㄅ一ㄚˇ, ㄅ一ㄚˇ”的聲音都沒有了.}

^{O: Vital sign: BP:119/75mmHg, HR:78/min, RR:18/min, BT:36.6℃, TST:9/11hr}

^{Appearance: clean}

^{Facial expression: blunted}

^{Affect: inappropriate}

^{Attitude: uncooperative}

^{Attention: impaired}

^{Speech: irrelevant speech}

Behaviors: bed rest all day long, isolation, social withdrawal, mild self talking, intermittent silly laughter.

Thought: loosening of association, poverty of thought, rigidity, persecutory and referent delusion

Perception: decreased auditory hallucination frequency

Insight: poor

Problem:

Problem #1: Schizphrenic disorder, paranoid type, chronic with acute exacerbation

^{A: Mild improved auditory hallucination under treatment with Clozaril (100mg) 1.5# HS}

^{P:Note that patient falling down}

^{Watch for drooling and daytime somnolence}

^{Encourage patient taking part in ward exercise and social interact with other patients}

^{Establish reality and insight}

^{簽名: 住院醫師/主治醫師}

支持性心理治療

會談目的: 鼓勵患者減少躺床,多參與病房活動

會談內容: 對於患者較合作之態度予以鼓勵,並建議在病況改善之下能多起身活動,與其他病友互動,這樣工作人員也能藉由觀察患者的行為,言詞,行為之改善與否,判斷是否穩定,是否可安排出院.

^{簽名: 住院醫師/主治醫師}