Psychiatric History General Data

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Psychiatric History

General Data:
This is a case of patient Bejemino, Armenio, 33 yrs old, Male, Single, Filipino, Roman
Catholic from Calinog, Iloilo. No previous admissions in this institution, the
informants were the patient and his brother with 90% reliability.
Chief complaint:
Folk: sleeplessness, ang appetite problemado, kag restless
Patient: interview
HPI:
3 year PTA, patient presented with pain from the abdomen to his lower
extremities while lifting heavy equipment at work. Patient described the pain as
shooting and cramping rated as 7/10. This incident also resulted to gross deformity
in the ankle. Patient was brought in for consult in the next port and was treated
medically. Upon disembarkaton, patient was again referred for medical treatment
and subsequent rehabilitation. Patient was evaluated as fit to work and was given
another contract. During the said period, patient constatntly complained of the pain
from level of the xiphoid to his lower extremities. Upon disembarkation, patient was
terminated. Patient continually sought consult for his pain using his own funds.
Patient was examined, laboratories were requested which showed normal results.
Patient applied to other companies but to no avail.
2 months PTA, patient started to present with loss of appetite with associated
behavioral changes preferring isolation and confinement.
3 week PTA, patient, still with loss of appetite, experienced burning sensation
on the epigastric area. Patient tried to seek consult to a private physician but was
unavailable. Patient started to hear voices but chose to ignore it.
2 days PTA, patient claimed to have heard voices shouting which urged him
to run towards the field to escape. He sustained multiple abrasions on his face,
back/spine, and all extremities, thus, this admission
Past Medical History and Psychiatric History:
Patient is non-hypertensive, non-diabetic, and non-asthmatic with no known
food or drug allergies. Previous history of injury in 2013. Has not been treated for
any psychiatric condition or illness.
Family history:
Strong family history of cardiovascular disease and tuberculosis on the
paternal side. Strong family history of diabetes on the maternal side. No significant
family psychiatric history.
Genogram:

Personal History:
Patient is a college graduate, a nonsmoker, and an occasional alcoholic
beverage drinker. Patient stays at home with parents and his little sister who has 2
kids. Patient was said to have become distant towards his nephew and nieces these
past few weeks.

Physical Examination:
Ambulatory, Consicous, oriented to place and person
Aniciteric sclerae, pale conjunctivae, dry lips and tongue, PERLA, (-) CLAD, (-)
NVE
Symmetrical chest expansion, clear and equal breath sounds
Adynamic precordium, regular in cardiac rate and rhythm, (-) murmurs
Flat, soft abdomen with normoactive bowel sounds
Grossly normal back and spine.
Multiple abrasions and lacerations on his chest and back, upper and lower
extremities.
MSE:
Appropriately dressed, well-groomed, well-kempt hygiene. Clean fingernails
Calm, cooperative with poor eye contact, conversant with normal tone
Hypomanic episodes, euthymic usually
(-) LOA, FOI
(-) visual hallucinations & suicidal ideas
(+) auditory hallucination
Oriented to person BUT disoriented to time and date
Good concentration, fair memory, poor impulse control
Good abstract reasoning and judgement

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