ILOCOS TRAINING AND REGIONAL MEDICAL CENTER

Department of Community and Family Medicine

“…in the frontline of primary health care renewal”
City of San Fernando, La Union
Landline Numbers: (072)607-6418/(072)607-6422 (Office: loc. 151)
Email address: [email protected] or visit our website: www.itrmc.doh.ph

LEARNING PORTFOLIO
PSYCHIATRY ROTATION

Julienne Anjeli J. Cabradilla

Clinical Clerk
January 16 - February 15, 2018
 CURRICULUM VITAE

PERSONAL PROFILE
Name : JULIENNE ANJELI J. CABRADILLA
Address : Pilar, Sta. Cruz, Ilocos Sur
Date of Birth : November 24, 1993
Place of Birth : Tagudin, Ilocos Sur
Civil Status : Single
Father’s Name : Rolando A. Cabradilla
Mother’s Name : Julieta J. Cabradilla
Siblings : Rolinz Angelo J. Cabradilla
Kriztel-Ann J. Cabradilla PICTURE

EDUCATIONAL BACKGROUND
Primary : Sta. Cruz Institute
1998-2000
Intermediate : Sta. Cruz Institute
2000-2006
Secondary : Sta. Cruz Institute
2006-2010
Tertiary : Saint Louis University, Baguio City
Bachelor of Science in Psychology
2010-2014
Graduate : University of Northern Philippines, Vigan City
Doctor of Medicine (2014-Present)
 EXPECTATION PAPER

In my experience as a psychology major, we enjoy learning about mental illness

and talking to mentally ill people, who often have a refreshing knack for saying
things exactly how they are. In a fit of inspiration, some medical students tell me
that psychiatry is the only specialty that enables them to think about themselves,
about other people, and about life in general. They also like the lifestyle an hour
for each patient, ‘special interest’ days, protected time for teaching, light on calls
from home, and guaranteed career progression. In medicine they might treat yet
another anonymous case of asthma, chest pain, or pulmonary oedema. In
surgery they might do one knee replacement after another, up until the day they
retire or collapse. But in psychiatry there can be no factory line, no standard
procedure, and no mindless protocol: each patient is unique, and each patient
has something unique to return to the psychiatrist. I often come across those
same students again, months or sometimes years later. After the smiles and the
niceties, it transpires that they are no longer so interested in psychiatry. So what
happened?

Here I am no longer a Psychology College student but a Medical Clerk about to

delve in BGH and deal with the so called world of Psychiatry, my forever first love.

JI Name: Julienne Anjeli J. Cabradilla

Date of Rotation: January 16, 2018 to February 15, 2018
 DCFM JUNIOR INTERNS BATCH 2017-2018
PERFORMANCE EVALUATION

BASIS PERCENTAGE
Ward activities/ Specialty conference (40%)
Shifting Exam/ Quizzes (20%)
Reporting (10%)
Exit Exam (10%)
Family Health Care Program (15%)
Oral Revalida (7.5%)
Written paper (7.5%)
Community-based Health Program (15%)
Oral Revalida (7.5%)
Written paper (7.5%)
Allied Course (10%)
Pathology (5%)
Radiology (5%)
Learning Portfolio (10%)
EBM (5%)
Attitude (5%)
TOTAL (100%)
DCFM Performance

TOTAL HOURS OF DEMERIT (Make up Duties): ________________________________________

Verified by:

Marvin F. Munar, MD Dr. Joanna Marie Bucaycay

Junior Interns’ Monitor Chief Resident

ILOCOS TRAINING AND REGIONAL MEDICAL CENTER

Department of Community and Family Medicine
“…in the frontline of primary health care renewal”
City of San Fernando, La Union
Landline Numbers: (072) 607-6418/(072) 607-6422 (Office: loc. 151)
Email address: [email protected] or visit our website: www.itrmc.doh.ph

Republic of the Philippines

Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
PSYCHIATRY DEPARTMENT
Baguio City
CLINICAL HISTORY

GENERAL DATA:
This is the case of Modelo, Mary Joy Gonzales, 24-year old male, single, Filipino, Roman Catholic, born on
August 19, 1993, currently residing in Evangelista, Tayug, Pangasinan, admitted in this institution on December 5,
2017. The informant is the patient’s mother with reliability of 90%.

CHIEF COMPLAINT:
Violent behavior

HISTORY OF THE PRESENT ILLNESS:

The condition started 3 weeks prior to admission when the patient experienced sexual assault. From that time
on, the patient was observed to have loss of sleep. She had difficulty initiating or maintaining sleep. Often times, she would
wake up scared and shaking. She began to lose her appetite until she doesn’t want to eat or drinking anything. She was
unable to do her daily activities at home. The patient doesn’t want to talk to anyone and just stare at the floor. Sometimes,
she would speak of what is happening to her then suddenly pause or stop. The patient would say that people are talking
about her and that she felt like she was being watched.
The symptoms persisted until few hours prior to admission, the patient intentionally stabbed her right hand with
scissors, and attempted to stab her sister in the back of the head. She was immediately brought in this institution, hence
admission.

PAST MEDICAL HISTORY:

The patient had no known history of surgeries, no allergies to food or medications and no history of trauma.
She is a non-smoker and non-alcoholic.

FAMILY HISTORY:
Father: MM, civil engineer, civil engineering graduate, with hypertension, with good interpersonal
relationship.
Mother: LM, housewife, commerce graduate, no noted comorbid conditions, with good interpersonal
relationship.
Sister: NM, Masscom graduate, no noted comorbid conditions, with good interpersonal relationship.
Sister: LM, BSHRM graduate, no noted comorbid condition, with good interpersonal relationship.

Personal, Developmental, Social and Environmental History:

Childhood:
Patient was raised in her hometown of Evangelista, Tayug, Pangasinan. Primary caregiver was her
mother. She had no feeding sleep and behavioral problems while growing up. Developmental milestone were at par
with age.

Adolescence:
Patient was an average student, and is a BS Nursing graduate of Saint Louis University School of
Nursing. She had good interpersonal relationship with her family and friends. There was no behavioral problem noted.

Adulthood:
The patient worked as a nurse.

REVIEW OF SYSTEMS:

General: (+) recent weight loss, (+) poor appetite, (-) fever, (-) chills, (-) weakness, (+) insomnia
HEENT: (-) visual changes, (-) hearing loss, (-) ear pain, (-) nasal congestion, (-) epistaxis, (-) dental pains, (-)
odynophagia
Respiratory: (-) cough, (-) hemoptysis, (-) dyspnea, (-) wheezing
Cardiovascular: (-) chest pain/heaviness, (-) palpitations, (-) shortness of breath, (-) peripheral edema, (-) blood clots,
(-) varicose veins, (-) cramping thighs, (-) syncope
Gastrointestinal: (-) abdominal pain, (-) heartburn, (-) nausea, (-) vomiting, (-) diarrhea, (-) bloody stool, (-)
bloatedness, (-) changes in bowel movement
Genitourinary: (-) frequent urination, (-) urgency, (-) dysuria, (-) hematuria, (-) flank pains
Musculoskeletal: (-) joint pains, (-) restricted motion, (-) musculoskeletal pain, (-) back pains
Integumentary: (-)rashes, (+) sores, (-) blisters, (-) growths, (-) itching
consciousness, (-) seizures, (+) changes in behavior, (+) anxiety, (-) confusion, (+) depression, (+) insomnia
Endocrine: (-) Heat or cold intolerance, (-) polydipsia, (-) polyuria
Hematologic/ Lymphatic: (-) abnormal bleeding, (-) bruising, (-) Rashes, (-) enlarged nodes
Immunologic: (-) allergic reaction, (-) recurrent infections, (-) asthma, (-) rhinitis

PHYSICAL EXAMINATION:

General Survey: Awake, conscious, coherent, ambulatory not in cardiopulmonary distress

Vital Signs: BP:120/80 mmHg, CR: 103bpm, RR: 21cpm, Temp: 36.7 OC, SpO2: 97%
Skin: No jaundice/cyanosis, no pallor, warm to touch, with good skin turgor
HEENT: Anicteric sclera, pinkish palpebral conjunctiva
Chest and Lungs: Symmetrical chest wall expansion. No lagging. No retractions. Clear breath sounds on both lung
fields.
Heart: PMI at 5th ICS left midclavicular line. No heaves or thrills. Normal rate and regular rhythm. No
murmurs.
Abdomen: Flat, non-distended, normoactive bowel sounds, tympanitic, soft, non-tender on all quadrants
upon light and deep palpation.
Extremities: No gross deformities, 2+ equal and bilateral pulse on all extremities. 2-3 sec capillary refill, with
long and dirty nails
Neurologic examination:
Cerebrum: awake, conscious, coherent, oriented to time, person and place; not in cardiopulmonary distress
Cerebellum: no tremors, no nystagmus, no gait abnormalities
Cranial Nerves
 CN I: not assessed
 CN II: able to see
 CN III, IV, VI: intact EOMs, no preferential gaze, pupils 2-3mm in size, both equally round and reactive to light and
accomodation
 CN V: intact corneal reflex, can clenched jaw and puff cheek
 CN VII: no facial asymmetry
 CN VIII: able to hear
 CN IX: uvula at midline, no deviations
 CN X: intact gag reflex
 CN XI: able to shrug shoulders and can move head from side-to-side
 CN XII: tongue in midline, no tremors and/or fasciculations
Sensory: able to feel pain, light touch and with intact proprioception
Motor: Sensory: Reflexes:
5/5 5/5 100% 100% ++ ++

5/5 5/5 100% 100% ++ ++

MENTAL STATUS EXAMINATION

The patient is dressed accordingly for weather, age and sex, good hygiene and grooming, she is calm, non-responsive to
questions, paucity of speech, flat affect, poor concentration, poor insight and judgment.

INITIAL IMPRESSION
BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE, SEVERE DEPRESSION WITH PSYCHOTIC SYMPTOMS
BASIS
Diagnostic Criteria:
A. An uninterrupted period of illness during which there is a major depressive episode concurrent with Criterion A of
Schizophrenia.
B. Symptoms must meet criteria for a major mood episode (depression or mania) during the lifetime duration of the
illness.
C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the
active and residual duration of the illness.
D. The disturbance is not attributable to the effects of a substance (e.g. a drug abuse, a medication) or another medical
condition.

PLAN:
Diagnostics:
CBC, UA, Pregnancy Test, FBS, BUN, Creatinine, SGOT, SGPT, FT4, TSH, Serum Electrolytes

Therapeutics:
 Olanzapine 10mg, ½ tab in AM, 1 tab HS
 Fluoxetine 20mg/cap OD in AM
 Diphenhydramine 50 mg/cap, 1 cap OD HS
  Lithium Carbonate 450mg/tab OD in AM
 Alprazolam 500mcg/tab, 1 tab SD then ½ tab QID

Increase oral fluid intake

Monitor VS TID
Restrain patient PRN
Full diet
Meals and meds supervision
Provide 24-hour responsible watcher at all times
Suicidal/Assault/Escape Precaution

Prepared by:

Cabradila, Julienne Anjeli J.

Clinical Clerk in Charge

Republic of the Philippines

Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
PSYCHIATRY DEPARTMENT
 Baguio City

CLINICAL HISTORY

GENERAL DATA:
This is the case of CALIBUSO, NELJUN, 19 years old, Male, Filipino, Iglesia ni Cristo, Single born
on March 31, 1999 in Cuyapo, Nueva Ecija and currently living in Cuyapo, Nueva Ecija. This is the first
hospital admission in this institution on December 11, 2017. The informant is the patient’s mother with a
percent reliability of 80%.

CHIEF COMPLAINT: Violent to behavior

HISTORY OF PRESENT ILLNESS

One week prior to admission, patient felt headache, chest, nape and abdominal pain. There was
also associated difficulty of breathing. He was then brought to a local hospital. The patient claims that he was
brought to the hospital because his coworker did witch craft on him, ECG, urinalysis and CBC were done but
the results were not obtained by the watcher because the patient felt uneasy, restless and wants to go home.
They were prescribed with IV furosemide but the mother did not know why.
Six days prior to admission, the patient was returned home in Nueva Ecija. The patient was noticed
to be rumbling about a mother with 2 children named Soling, and children, Ezekiel and Pidong. Patient
claimed that Soling placed something in his water and in his clothes. He claims that “Nakulam nila ako”. The
patient had good appetite but was not sleeping. He was restless and taunted people around him. He was
also very rowdy, noisy and imitates the animals he sees. The family gave Biogesic, Flanax and herbal
medications from a witch doctor “albularyo” but no relief was given.
Interval history showed persistence of symptoms.
One day prior to admission, while the patient was shooting and running the father and his brother
tried to reprimand him to stop but the patient became violent and started hitting his father and brother. Due to
the persistence of the symptoms, consult was done.

PAST MEDICAL HISTORY:

Patient was previously hospitalized on December 2016 due to dehydration. There was history of
head trauma in 2011 where he fell from a guava tree and caused loss of consciousness. There are no other
history of accidents, sexually transmitted infections and allergies to food or drugs.

FAMILY HISTORY:
There are no family history of psychiatric conditions, substance abuse, suicide, cardiac diseases,
stroke and cancer. There is a family history of diabetes and hypertension.

PERSONAL, DEVELOPMENT:
The patient is the 1st among the 3 siblings and the informant stated that they had good interpersonal
relationship but had occasional fights which were resolved immediately. His mother is a housewife and his
father is a farmer. The informant states that they have good interpersonal relationships.
There were no complications during infancy and developmental milestones were at par with age though
the patient is easy to anger. The mother is the primary health care provider.
The patient only finished 3rd year high school and the informant states that he had difficulty learning
new topics. It would take him long duration of time to understand a specific topic. There were no history of
bullying during his childhood and adolescent years.
He currently works as a farmer and a conductor of a school bus.

REVIEW OF SYTEMS:
General: (-) fatigue, (+) recent weight loss, (-) dizziness, (-) insomnia (-) fever
Head and Neck: (-) headache, (-) trauma, (-) pain, (-) stiffness
Eyes: (-) pain, (-) diplopia, (-) visual dysfunction, (-) dryness, (-) redness, (-) tearing
Ears: (-) dryness, (-) vertigo/dizziness, (-) difficulty hearing, (-) tinnitus, (-) pain, (-) discharge
Nose: (-) epistaxis, (-) dryness (-) pain, (-) discharge (-) dysfunction
Mouth and neck: (-) cyanosis (-) dryness, (-) soreness, (-) pain, (-) ulcers, (-) hoarseness, (-) gum
and dental problems
Breasts: (-) tenderness (-) increased sensitivity of nipples, (-) lumps/mass, (-) discharge
Respiratory: (-) dyspnea, (-) sputum, (-) hemoptysis (+) cough
Cardiac: (-) chest pains / discomforts, (-) dyspnea, (-) palpitations, (-) easy fatigability
Vascular: (-) intermittent claudication, (-) leg cramps, (-) ulcers, (-) varicose veins, (-)edema
Gastrointestinal: (-) abdominal pain, (+) change in bowel habits: constipation, (-) nausea, (-) vomiting (-)
anorexia, (-) heartburn (-) constipation
Renal and Urinary: (-) urinary frequency (-) dysuria, (-) hematuria, (-) nocturia, (-) incontinence, (-) dribbling
Neuropsychiatric: (-) loss of consciousness (-) seizures (+) changes in behavior (+) anxiety, (+) confusion, (+)
headache, (+) insomnia
Musculoskeletal: (-) muscle pains, (-) joint pains, (-) cramps, (-) weakness, (-) stiffness, (-) limitation of
motion, (-) swelling, (-) backache
PHYSICAL EXAMINATION:
General survey: awake, conscious, coherent, ambulatory and not in cardiopulmonary distress.
Vital signs: BP=110/70 CR= 94 bpm RR= 20 cpm Temp= 36.7°C SPO2= 95% at room air
secondary to restraint application, no wounds
HEENT: anicteric sclera, pink palpebral conjunctiva, moist lips, moist buccal mucosa, (-) no ear and nasal
discharges, no Cervical Lymph adenopathies
Chest and Lungs: symmetrical chest wall expansion, (-) retractions, (-) lagging, clear breath sounds
Heart: PMI at 5th ICS LMCL, no murmurs, normal rate and regular rhythm, no heaves or thrills
Abdomen: Flat, nondistended, tympanitic, soft
Extremities: no gross deformities, no bipedal edema, full peripheral pulses, 1-2 sec capillary refill

NEUROLOGIC EXAMINATION:
Cerebral Function: Conscious
Cerebellum: no ataxia, no nystagmus
CN I: not assessed
CN II able to see
CN III, IV, VI: intact EOMS
CN VII no facial asymmetry
CN VII: able to hears
CN IX, X: not assessed
CN XI: able to shrug shoulders
CN XII: not assessed
Motor: 5/5 on all extremities

MENTAL STATUS EXAMINATION:

The patient is dressed appropriately according to age, sex and weather. Patient does not respond
to questions, patient claims that someone is talking to him to escape. Patient talks in fragments.
He claims that he feels nothing. Affect ranges from flat to happy to disturbed. The patient could not
formulate, rganize and express his thoughts. There were flight of ideas and patient does not answer
questions directly and there was thought blocking. He is not oriented to time, place and person. He can not
maintain his concentration. He has poor recall of past and recent memories. He had poor insight and patient
is not aware of his symptoms. He has poor judgement.

INITIAL IMPRESSION:
ICD 10: Acute and Transient Psychotic Disorder
DSM 5: Brief Psychotic Disorder

A. Presence of two of the following four symptoms:

1. Delusions. Delusion of Persecution:“Kinukulam ng katrabaho” claiming that something was placed on his
drink and clothes
2. Hallucinations. Visual and auditory hallucination: Patient claims to see and converse to 3 unseen beings
named “Soling, Ezekiel and Pidong”

Specify if:
Without marked stressor(s)

PLAN:
Diagnostics:
CBC, UA, FBS, BUN, Creatinine, BUA, Lipid Profile, AST, ALT, Drug Testing, Chest X-ray, 12 Lead ECG

Therapeutics:
Olanzapine 10 mg, ½ tablet in A.M., 1 tablet in P.M.
Diphenhydramine 50 mg + Haloperidol 5 mg PRN for agitations with BP precautions.

Prepared by:

Cabradilla, Julienne Anjeli

Clinical Clerk in Charge

CLINICAL HISTORY

GENERAL DATA
 This is the case of De Vera, Efren Jr., 34 year- old male, married, Filipino, Roman Catholic, farmer, born on
January 26, 1981 in Rosario, La Union, currently residing in the same locality, admitted for the third time in this
institution on June 1, 2015. The informant is the patient and his wife, Beverlyn De Vera.

CHIEF COMPLAINT
According to the patient: “Nahihilo ako”
According to the informant: “Kung sana mapa-admit siya maski 1 week”

HISTORY OF THE PRESENT ILLNESS:

According to the patient
1 week prior to admission he experienced headache, diffuse, non-radiating and was accompanied by weakness
and body malaise. No medications taken. Headache is not aggravated by anything and is relieved by rest but
immediately returns a few minutes after waking.
1 day PTA, there was persistence of headache, body malaise with accompanying blurring of vision, thus
prompting the patient and his wife to seek consult. There was no accompanying fever, dizziness, loss of consciousness
and colds.
According to the informant
3 years PTA, patient was diagnosed with schizophrenia in this institution. He was said to be conversing and
mumbling with himself, removing clothing and walking as if modeling and sometimes aimlessly. He would be
physically and verbally assaultive with family members, thus sought consultation in this institution. He was admitted for
1 week and was given Clozipine, dosage unrecalled.
2 years PTA, patient was taken into this institution for the second time for consultation of the same signs and
symptoms above. Patient was then admitted and was prescribed with Clozipine 100mg/tab 1 tab once a day at night and
Biperiden 2mg/tab once a day in the morning which relieved symptoms. After admission, patient was lost to follow-up.
2 weeks PTA, patient’s medication ran out, so he was prescribed to be getting worse with his assaultive
outbursts and sometimes observed to have auditory hallucinations as if he was talking to someone. The patient’s
condition persisted until one day prior to admission, thus sought consult in this institution.

PAST MEDICAL HISTORY

Patient was born via NSVD with the aid of a midwife with no complications. Immunizations and childhood
illnesses were unrecalled. Patient has no known allergies to foods or drugs. With history of trauma with hospital
admission when he was on his 3 rd elementary grade. There was no other history of hospital consultation. There was
history of asthma exacerbation.

FAMILY HISTORY
Father- Efren, 59 years old, deceased, with hypertension and unknown cardiac disease (when still living he
usually give financial support to the patient and noted to be his favorite child)
Mother- Lydia, 58 years old, housewife, elementary grade (sometimes has conflict with patient)
Siblings:
1. Shirley, 38, housewife, healthy
2. Evangeline, 35, housekeeper, single, healthy
3. Patient
4. Rowena, 31, housekeeper, married, healthy (closest sibling, sometimes give financial support)
5. Edward, 29, farmer, single healthy
6. Mary Ann, 27, married healthy
*All have good interpersonal relationship with the patient; relatives have no symptoms like the patient

Wife: Beverly, 26, housewife, high school graduate, healthy (recently with several episodes of arguments with
regards to money matters)
Children:
1. John Hayden- 5 years old
2. April Joy- 3 years old

There were no other heredofamilial diseases known by the informant such as psychiatric disorders, diabetes,
arthritis and cancer.

PERSONAL, DEVELOPMENTAL, SOCIAL AND ENVIRONMENTAL HISTORY

Patient is a Diesel Mechanic graduate but primarily working as a farmer. Developmental milestones were at
par with other children of the same age. He was described to be active in class. He started elementary grade at the age of
7. He was friendly and was an average student. He started smoking and drinking at the age of 17, with number of sticks
unknown to the informant. Patient is an occasional alcoholic beverage drinker. No history of illicit drug use.

REVIEW OF SYSTEMS
General: (+) body weakness, (-) fatigue, (-) weight change, (-) fever, (-) chills, (-) diaphoresis, (-) dizziness
Integumentary: (-) rash, (-) sores, (-) hives,
Head and Neck: (+) headache, (-) trauma, (-) pain, (-) stiffness
Eyes: (-) pain, (-) diplopia, (-) visual dysfunction, (-) dryness, (-) redness, (-) tearing
Ears: (-) difficulty hearing, (-) tinnitus, (-) pain, (-) discharge
 Nose: (-) epistaxis, (-) discharge, (-) smell dysfunction, (-) sneezing
Mouth: (-) soreness, (-) hoarseness, (-) cyanosis, (-) change in tone of voice, (+) poor oral care
Respiratory: (-) cough, (-) dyspnea, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) occupational exposure, (-) TB
Cardiac: (-) chest pains/ discomfort, (-) orthopnea, (-) dyspnea, (-) paroxysmal nocturnal dyspnea, (-) palpitation, (-)
undue fatigue, (-) edema, (-) cyanosis, (-) syncope
Vascular: (-) intermittent claudicating, (-) leg cramps
Gastrointestinal: (-) vomiting, (-) nausea, (-) dysphagia, (-) hematemesis, (-) indigestion, (-) melena, (-) hematochezia,
(-) heartburn, (-) abdominal pain, (-) abdominal distention, (-) jaundice, (-) diarrhea, (-) constipation, (-) change in
bowel habits
Renal and Urinary: (-) dysuria, (-) hematuria, (-) incontinence, (-) urinary frequency
Musculoskeletal: (-) muscle pains, (-) joint pains, (-) cramps, (-) weakness, (-) stiffness, (-) limitation of motion, (-)
backache
Hematological: (-) anemia, (-) excessive bleeding, (-) easy bruising
Endocrine and Metabolic: (-) heat/cold intolerance, (-) weight change, (-) excessive sweating, (-) polydipsia, (-)
polyphagia, (-) polyuria
Nervous System: (-) headache, (-) syncope, (-) seizures, (-) left or right sided weakness, (-) head trauma, (-) sleep
disorder, (-) coordination problem
Psychiatric/Emotional: (+) substance abuse (alcohol and cigarette), (-) anxiety, depression, (-) nervousness, (-)
memory change,

PHYSICAL EXAMINATION
General Survey: Awake, ambulatory not in cardiopulmonary distress
Vital Signs: BP: 100/70 mmHg (left arm, supine) CR: 60 bpm, RR: 15 cpm, Temp: 35.8OC
Skin: no cyanosis, no jaundice, good skin turgor
HEENT:
Head: Face is symmetrical, no involuntary movement, no lesions. No tenderness, no masses.
Eyes: Symmetrical with well distributed eyebrows, no lid lag. Conjunctiva is pinkish with anicteric sclera.
Ears: Ears are symmetrical, no deformities, discharges and lesions noted. With cerumen AO
Nose: Septum at midline. No gross deformities. No nasal discharge and congestion.
Mouth and Throat: Dry lips and moist buccal mucosa, no lesions, lumps or cracking. Slightly swollen tonsils
Neck: No gross deformities. No cervical lymphadenopathies.
Chest and Lungs: Symmetrical chest wall expansion. No retractions or lagging. No scars or lesions. No tenderness.
Clear breath sounds.
Heart: Adynamic precordium. PMI at 5th ICS left midclavicular line. No heaves or thrills. Normal rate and
regular rhythm. No murmurs.
Abdomen: flat, no scars or lesions, normoactive bowel sounds, No tenderness.
Extremities: no clubbing, no gross deformities. 2+ equal and bilateral pulse on all extremities. 1-2sec capillary
refill, with long and dirty nails and with wounds on his fingers
Neurologic Examination:
Cerebral function: Awake
GCS: 15 (M6, V5, E4)
Cranial Nerve Function Test:
I: able to smell
II: intact sense of sight
III, IV, VI: pupils 2-3mm in size both equally round and reactive to light and accomodation, intact
EOMs, no preferential gaze
V: facial sensory functioning intact, intact muscles of mastication
VII: symmetrical facial movements
VIII: intact sense of hearing
IX, X: uvula in midline, no deviation
XI: able to turn head from left to right, able to raise and shrug shoulders
XII: midline protrusion of the tongue, no fasciculation, no deviation
Cerebellar function: No nystagmus, no tremors, with poor finger pursuit test
Motor: No spasticity, no rigidity, no atrophy, 5/5 strength in upper and lower extremities
Sensory System: Able to feel pain; light touch and with intact proprioception
Pathologic Reflexes: (-) Babinski

MENTAL STATUS EXAMINATION

Seen and examined a 34 year old male, looks and dressed appropriately for age and sex, wearing a blue jacket,
gray pants and slippers, with fair grooming and hygiene. Patient had flight of ideas and incoherent thoughts. He was
alert, oriented to time and person but not to place, oriented to 3 spheres, answers to questions inappropriately with poor
insight and judgement. Patient was restless and had some delusions and hallucinations during interview.

ICD-10: Paranoid schizophrenia

DSM- V: Schizophrenia, Multiple Episode currently in Acute Episode

I. Bases for Schizophrenia

A. Characteristic Symptoms:
1. Auditory Hallucinations: hearing voices telling him something and sometimes respond to them
 2. Disorganized Speech: incoherent thoughts and speech
3. Negative Symptoms: verbally assaultive behavior
B. Social and Occupational Dysfunction: he was not able to work properly because of his assaultive
behavior. He was verbally assaultive to others.
C. Duration: 1 10/12 years
D. Schizoaffective and Mood Disorder exclusion: No major depressive, manic, mixed episodes that
have occurred concurrently with the active symptoms
E. Substance/GMC were ruled out: based on the history and physical examination, the patient was not
under the influence of direct physiologic effects of substance
F. Patient has no history of autistic disorder or another pervasive developmental disorder

II. Bases of Paranoid Type

A. Preoccupation with auditory hallucinations: patient was observed to be talking to unseen beings
B. None of the following is prominent: disorganized or catatonic behavior or flat or inaapropriate
affect

III. Bases for Multiple Episode currently in Acute Episode

o There was more than a year duration and there were two episodes of the disorder with remission and
relapse

ASSESSMENT: Paranoid Schizophrenia

PLAN
Diagnostics: CBC, Urinalysis
Disposition: Admit at male psychiatry ward under green service
Secure consent for admission and management
Meals and Meds with supervision
Restrain patient as needed
Provide 24-hour responsible watcher
Strict assault/escape/suicide precaution
DAT
Monitor vital signs and record
Therapeutics: Clozapine 100mg/tab, 1 tab BID
Biperiden 2mg/tab, 1 tab in AM
Haloperidol 5mg/deep IM for refusal to take oral Clozapine with BP precaution
Haloperidol 10 mg + Diphenhydramine 50 mg deep IM, as needed for psychotic agitation
with BP precaution to a maximum of 3 doses q 1 hour interval

Prepared by:

Cabradilla, Julienne Anjeli J.

Ward Junior Intern
 CLINICAL HISTORY

GENERAL DATA
This is the case of Ngamoy, Adam., 20 year- old male, single, Filipino, Roman Catholic, farmer, born on
August 19, 1997 in Bagulin, La Union, currently residing in the same locality, admitted for the first time in this
institution on December 1, 2016. The informant is his sister, evelyn Ngamoy-Bumacas.

CHIEF COMPLAINT
According to the patient: -
According to the informant: “Gusto niyang patayin ang aswa ko.”

HISTORY OF THE PRESENT ILLNESS:

According to the patient
Patient does not respond to questions
According to the informant
The condition started 2years prior to admission, the patient’s relatives noticed that the patient had changed in
behavior. He often confined himself in his room, lying in bed but not sleeping. He became distant to his relatives. Self-
care such as grooming was not done by the patient.
He began mumbling to himself as claimed and claimed that people, even his relatives, were trying to hurt or
poison him with food given to him.at this point, patient refuses to eat. Patient was brought in this institution wherein he
was given medications however patient was lost to follow up.
Until few months prior to admission, patient began to be more aggressive. He had delusions of himself being
“superman” or being a strong person and he claimed that he can kill anyone he wants to kill. He was reported destroying
their house’s windows and motorcycles of his relatives. He perceives his neighbors as dogs or chicken. He often get
easily triggered by simple jokes.
One day prior to admission, patient as said to have urges to kill his sister’s husband. He was agitated and
started to become aggressive. According to the sister, sometimes he doesn’t recognize his relatives. This prompted the
relatives to bring the patient in this institution hence admission.
PAST MEDICAL HISTORY
Patient has no history of hypertension, DM, bronchial asthma, or cardiac problem. Immunizations and
childhood illnesses were unrecalled. Patient has no known allergies to foods or drugs. There was no history of trauma
and no other history of hospital consultation.

FAMILY HISTORY
Patient has a good interpersonal relationship with his parents and siblings. There were no heredofamilial
diseases known by the informant such as psychiatric disorders, diabetes, arthritis and cancer.

PERSONAL, DEVELOPMENTAL, SOCIAL AND ENVIRONMENTAL HISTORY

Patient is a high school graduate and is currently working as a farmer. Developmental milestones were at par
with other children of the same age. He was described to be active in class. He started elementary grade at the age of 7.
He was friendly and was an average student. Patient is a smoker and is an occasional alcoholic beverage drinker
according to the informant. No history of illicit drug use.

REVIEW OF SYSTEMS
General: (-) body weakness, (-) fatigue, (-) weight change, (-) fever, (-) chills, (-) diaphoresis, (-) dizziness
Integumentary: (-) rash, (-) sores, (-) hives,
Head and Neck: (-) headache, (-) trauma, (-) pain, (-) stiffness
Eyes: (-) pain, (-) diplopia, (-) visual dysfunction, (-) dryness, (-) redness, (-) tearing
Ears: (-) difficulty hearing, (-) tinnitus, (-) pain, (-) discharge
Nose: (-) epistaxis, (-) discharge, (-) smell dysfunction, (-) sneezing
Mouth: (-) soreness, (-) hoarseness, (-) cyanosis, (-) change in tone of voice, (+) poor oral care
Respiratory: (-) cough, (-) dyspnea, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) occupational exposure, (-) TB
Cardiac: (-) chest pains/ discomfort, (-) orthopnea, (-) dyspnea, (-) paroxysmal nocturnal dyspnea, (-) palpitation, (-)
undue fatigue, (-) edema, (-) cyanosis, (-) syncope
Vascular: (-) intermittent claudicating, (-) leg cramps
Gastrointestinal: (-) vomiting, (-) nausea, (-) dysphagia, (-) hematemesis, (-) indigestion, (-) melena, (-) hematochezia,
(-) heartburn, (-) abdominal pain, (-) abdominal distention, (-) jaundice, (-) diarrhea, (-) constipation, (-) change in
bowel habits
Renal and Urinary: (-) dysuria, (-) hematuria, (-) incontinence, (-) urinary frequency
Musculoskeletal: (-) muscle pains, (-) joint pains, (-) cramps, (-) weakness, (-) stiffness, (-) limitation of motion, (-)
backache
Hematological: (-) anemia, (-) excessive bleeding, (-) easy bruising
Endocrine and Metabolic: (-) heat/cold intolerance, (-) weight change, (-) excessive sweating, (-) polydipsia, (-)
polyphagia, (-) polyuria
Nervous System: (-) headache, (-) syncope, (-) seizures, (-) left or right sided weakness, (-) head trauma, (-) sleep
disorder, (-) coordination problem
Psychiatric/Emotional: (-) anxiety, depression, (-) nervousness, (-) memory change,

PHYSICAL EXAMINATION
General Survey: Awake, ambulatory not in cardiopulmonary distress
Vital Signs: BP: 110/70 mmHg, CR: 97 bpm, RR: 18 cpm, Temp: 37OC
Skin: no cyanosis, no jaundice, good skin turgor
HEENT:
Head: Face is symmetrical, no involuntary movement, no lesions. No tenderness, no masses.
Eyes: Symmetrical with well distributed eyebrows, no lid lag. Conjunctiva is pinkish with anicteric sclera.
Ears: Ears are symmetrical, no deformities, discharges and lesions noted. With cerumen AO
Nose: Septum at midline. No gross deformities. No nasal discharge and congestion.
Mouth and Throat: Dry lips and moist buccal mucosa, no lesions, lumps or cracking. Slightly swollen tonsils
Neck: No gross deformities. No cervical lymphadenopathies.
Chest and Lungs: Symmetrical chest wall expansion. No retractions or lagging. No scars or lesions. No tenderness.
Clear breath sounds.
Heart: Adynamic precordium. PMI at 5th ICS left midclavicular line. No heaves or thrills. Normal rate and
regular rhythm. No murmurs.
Abdomen: flat, no scars or lesions, normoactive bowel sounds, No tenderness.
Extremities: no clubbing, no gross deformities. 2+ equal and bilateral pulse on all extremities. 1-2sec capillary
refill, with long and dirty nails and with wounds on his fingers
Neurologic Examination:
Cerebral function: Awake
GCS: 15 (M6, V5, E4)
Cranial Nerve Function Test:
I: able to smell
II: intact sense of sight
III, IV, VI: pupils 2-3mm in size both equally round and reactive to light and accomodation, intact
EOMs, no preferential gaze
V: facial sensory functioning intact, intact muscles of mastication
VII: symmetrical facial movements
VIII: intact sense of hearing
IX, X: uvula in midline, no deviation
XI: able to turn head from left to right, able to raise and shrug shoulders
XII: midline protrusion of the tongue, no fasciculation, no deviation
Cerebellar function: No nystagmus, no tremors, with poor finger pursuit test
Motor: No spasticity, no rigidity, no atrophy, 5/5 strength in upper and lower extremities
Sensory System: Able to feel pain; light touch and with intact proprioception
Pathologic Reflexes: (-) Babinski

MENTAL STATUS EXAMINATION

Seen and examined a 20 year old male, looks and dressed appropriately for age and sex, with poor grooming
and hygiene. Patient is noted to be agitated with violent behavior, poor eye contact, uncooperative, refused to answer
questions.

ICD-10: Paranoid schizophrenia

DSM- V: Schizophrenia, Multiple Episode currently in Acute Episode

Bases:

A. The following are present for a significant portion of time during a 1 year period:
1. Delusion
a. persecution (Always vigilant to his surrounding, believing that someone will hurt him; He
believes that the food being given to him has poison)
b. reference (Believes that the people around him are talking about him)
2. Hallucinations. (Mumbling alone, Talking incomprehensible words)
3. Grossly disorganized behavior. (Collecting garbage without a purpose)
4. Negative symptoms (Diminished emotional expression, flat affect)

B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major
areas, such as work (unable to do household chores), interpersonal relations (family members are afraid of her), and
self-care (poor grooming), are markedly below the level achieved prior to the onset

C. Continuous signs of the disturbance persist for three years.

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because no
major depressive or manic episodes have
occurred concurrently with the active-phase symptoms
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition. (No
history of substance abuse and the patient does not have another medical condition)

F. There was no history of autism spectrum disorder or a communication disorder of childhood onset.

Specifier: Multiple episodes currently in acute episode

2015: First episode
2016: Several episodes but no consult
2017: Currently in acute episode

ASSESSMENT: Paranoid Schizophrenia

PLAN
Diagnostics: CBC, Urinalysis
Na, K, Cl
BUN, Creatinine
AST, ALT
FBS, HBA1C
Lipid Profile
ECG
CXR-PA
Disposition: Admit at male psychiatry ward under yellow service
Secure consent for admission and management
Meals and Meds with supervision
Restrain patient as needed
Provide 24-hour responsible watcher
Strict assault/escape/suicide precaution
DAT then NPO post-midnight
Monitor vital signs q8 and record
Therapeutics: Olanzapine 10mg ½ tab in AM, 1 tab HS
Refer to RIC/ROD once with severe agitation

Prepared by:
CABRADILLA, JULIENNE ANJELI J.
Ward Junior Intern
 CLINICAL HISTORY

GENERAL DATA
This is the case of Ngamoy, Adam., 20 year- old male, single, Filipino, Roman Catholic, farmer, born on
August 19, 1997 in Bagulin, La Union, currently residing in the same locality, admitted for the first time in this
institution on December 1, 2016. The informant is his sister, evelyn Ngamoy-Bumacas.

CHIEF COMPLAINT
According to the patient: -
According to the informant: “Gusto niyang patayin ang aswa ko.”

HISTORY OF THE PRESENT ILLNESS:

According to the patient
Patient does not respond to questions
According to the informant
The condition started 2years prior to admission, the patient’s relatives noticed that the patient had changed in
behavior. He often confined himself in his room, lying in bed but not sleeping. He became distant to his relatives. Self-
care such as grooming was not done by the patient.
He began mumbling to himself as claimed and claimed that people, even his relatives, were trying to hurt or
poison him with food given to him.at this point, patient refuses to eat. Patient was brought in this institution wherein he
was given medications however patient was lost to follow up.
Until few months prior to admission, patient began to be more aggressive. He had delusions of himself being
“superman” or being a strong person and he claimed that he can kill anyone he wants to kill. He was reported destroying
their house’s windows and motorcycles of his relatives. He perceives his neighbors as dogs or chicken. He often get
easily triggered by simple jokes.
One day prior to admission, patient as said to have urges to kill his sister’s husband. He was agitated and
started to become aggressive. According to the sister, sometimes he doesn’t recognize his relatives. This prompted the
relatives to bring the patient in this institution hence admission.

PAST MEDICAL HISTORY

Patient has no history of hypertension, DM, bronchial asthma, or cardiac problem. Immunizations and
childhood illnesses were unrecalled. Patient has no known allergies to foods or drugs. There was no history of trauma
and no other history of hospital consultation.

FAMILY HISTORY
Patient has a good interpersonal relationship with his parents and siblings. There were no heredofamilial
diseases known by the informant such as psychiatric disorders, diabetes, arthritis and cancer.

PERSONAL, DEVELOPMENTAL, SOCIAL AND ENVIRONMENTAL HISTORY

Patient is a high school graduate and is currently working as a farmer. Developmental milestones were at par
with other children of the same age. He was described to be active in class. He started elementary grade at the age of 7.
He was friendly and was an average student. Patient is a smoker and is an occasional alcoholic beverage drinker
according to the informant. No history of illicit drug use.

REVIEW OF SYSTEMS
General: (-) body weakness, (-) fatigue, (-) weight change, (-) fever, (-) chills, (-) diaphoresis, (-) dizziness
Integumentary: (-) rash, (-) sores, (-) hives,
Head and Neck: (-) headache, (-) trauma, (-) pain, (-) stiffness
Eyes: (-) pain, (-) diplopia, (-) visual dysfunction, (-) dryness, (-) redness, (-) tearing
Ears: (-) difficulty hearing, (-) tinnitus, (-) pain, (-) discharge
Nose: (-) epistaxis, (-) discharge, (-) smell dysfunction, (-) sneezing
Mouth: (-) soreness, (-) hoarseness, (-) cyanosis, (-) change in tone of voice, (+) poor oral care
Respiratory: (-) cough, (-) dyspnea, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) occupational exposure, (-) TB
Cardiac: (-) chest pains/ discomfort, (-) orthopnea, (-) dyspnea, (-) paroxysmal nocturnal dyspnea, (-) palpitation, (-)
undue fatigue, (-) edema, (-) cyanosis, (-) syncope
Vascular: (-) intermittent claudicating, (-) leg cramps
Gastrointestinal: (-) vomiting, (-) nausea, (-) dysphagia, (-) hematemesis, (-) indigestion, (-) melena, (-) hematochezia,
(-) heartburn, (-) abdominal pain, (-) abdominal distention, (-) jaundice, (-) diarrhea, (-) constipation, (-) change in
bowel habits
Renal and Urinary: (-) dysuria, (-) hematuria, (-) incontinence, (-) urinary frequency
Musculoskeletal: (-) muscle pains, (-) joint pains, (-) cramps, (-) weakness, (-) stiffness, (-) limitation of motion, (-)
backache
Hematological: (-) anemia, (-) excessive bleeding, (-) easy bruising
Endocrine and Metabolic: (-) heat/cold intolerance, (-) weight change, (-) excessive sweating, (-) polydipsia, (-)
polyphagia, (-) polyuria
Nervous System: (-) headache, (-) syncope, (-) seizures, (-) left or right sided weakness, (-) head trauma, (-) sleep
disorder, (-) coordination problem
Psychiatric/Emotional: (-) anxiety, depression, (-) nervousness, (-) memory change,

PHYSICAL EXAMINATION
General Survey: Awake, ambulatory not in cardiopulmonary distress
Vital Signs: BP: 110/70 mmHg, CR: 97 bpm, RR: 18 cpm, Temp: 37OC
Skin: no cyanosis, no jaundice, good skin turgor
HEENT:
Head: Face is symmetrical, no involuntary movement, no lesions. No tenderness, no masses.
Eyes: Symmetrical with well distributed eyebrows, no lid lag. Conjunctiva is pinkish with anicteric sclera.
Ears: Ears are symmetrical, no deformities, discharges and lesions noted. With cerumen AO
Nose: Septum at midline. No gross deformities. No nasal discharge and congestion.
Mouth and Throat: Dry lips and moist buccal mucosa, no lesions, lumps or cracking. Slightly swollen tonsils
Neck: No gross deformities. No cervical lymphadenopathies.
Chest and Lungs: Symmetrical chest wall expansion. No retractions or lagging. No scars or lesions. No tenderness.
Clear breath sounds.
Heart: Adynamic precordium. PMI at 5th ICS left midclavicular line. No heaves or thrills. Normal rate and
regular rhythm. No murmurs.
Abdomen: flat, no scars or lesions, normoactive bowel sounds, No tenderness.
Extremities: no clubbing, no gross deformities. 2+ equal and bilateral pulse on all extremities. 1-2sec capillary
refill, with long and dirty nails and with wounds on his fingers
Neurologic Examination:
Cerebral function: Awake
GCS: 15 (M6, V5, E4)
Cranial Nerve Function Test:
I: able to smell
II: intact sense of sight
III, IV, VI: pupils 2-3mm in size both equally round and reactive to light and accomodation, intact
EOMs, no preferential gaze
V: facial sensory functioning intact, intact muscles of mastication
VII: symmetrical facial movements
VIII: intact sense of hearing
IX, X: uvula in midline, no deviation
XI: able to turn head from left to right, able to raise and shrug shoulders
XII: midline protrusion of the tongue, no fasciculation, no deviation
Cerebellar function: No nystagmus, no tremors, with poor finger pursuit test
Motor: No spasticity, no rigidity, no atrophy, 5/5 strength in upper and lower extremities
Sensory System: Able to feel pain; light touch and with intact proprioception
Pathologic Reflexes: (-) Babinski

MENTAL STATUS EXAMINATION

Seen and examined a 20 year old male, looks and dressed appropriately for age and sex, with poor grooming
and hygiene. Patient is noted to be agitated with violent behavior, poor eye contact, uncooperative, refused to answer
questions.

ICD-10: Paranoid schizophrenia

DSM- V: Schizophrenia, Multiple Episode currently in Acute Episode

Bases:

A. The following are present for a significant portion of time during a 1 year period:
1. Delusion
a. persecution (Always vigilant to his surrounding, believing that someone will hurt him; He
believes that the food being given to him has poison)
b. reference (Believes that the people around him are talking about him)
2. Hallucinations. (Mumbling alone, Talking incomprehensible words)
3. Grossly disorganized behavior. (Collecting garbage without a purpose)
4. Negative symptoms (Diminished emotional expression, flat affect)

B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major
areas, such as work (unable to do household chores), interpersonal relations (family members are afraid of her), and
self-care (poor grooming), are markedly below the level achieved prior to the onset

C. Continuous signs of the disturbance persist for three years.

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because no
major depressive or manic episodes have
occurred concurrently with the active-phase symptoms
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition. (No
history of substance abuse and the patient does not have another medical condition)

F. There was no history of autism spectrum disorder or a communication disorder of childhood onset.

Specifier: Multiple episodes currently in acute episode

2015: First episode
2016: Several episodes but no consult
2017: Currently in acute episode

ASSESSMENT: Paranoid Schizophrenia

PLAN
Diagnostics: CBC, Urinalysis
Na, K, Cl
BUN, Creatinine
AST, ALT
FBS, HBA1C
Lipid Profile
ECG
CXR-PA
Disposition: Admit at male psychiatry ward under yellow service
Secure consent for admission and management
Meals and Meds with supervision
Restrain patient as needed
Provide 24-hour responsible watcher
Strict assault/escape/suicide precaution
DAT then NPO post-midnight
Monitor vital signs q8 and record
Therapeutics: Olanzapine 10mg ½ tab in AM, 1 tab HS
Refer to RIC/ROD once with severe agitation

Prepared by:

Cabradilla, Julienne Anjeli J.

Ward Junior Intern
 CLINICAL ABSTRACT

Patient Name (Surname, First Name, M.I.) Hospital Number:

Kay-an, Maylynn B. 577035
Present Address:
Camp 7, Baguio, Benguet
Date of Birth: (Month/Date/Year) Age: Sex: Civil Status:
May 5, 1982 35 Female Single
Date of Admission: Date of Discharge: Still Admitted? (Please Check)
December 17, 2017 01/18/2018
YES NO

I. Clinical History
Patient is a known case of Delusional Disoredr since May 2016. Patient was admitted in this
institution for more than a month. Her condition improved, hence discharged.
According to the sister, 2 weeks PTA, patient was apparently well however, upon failing an exam in
her German class for her application an Germany as a nurse, the patient began to have changes in her
behaviors. The landlord in her apartment noticed hat she is always walking back and forth and was seen
talking to an unseen being and was also noticed to be seen smiling while holding her phone and claimed that
she is texting her boyfriend “Mohammed”. The family claimed that upon checking her phone when the patient
was not looking, there was no conversation nor reply from the number that she was texting. She is also
easily irritated and most of the time angry at her siblings.
According to the patient, 3 days PTA while at her German class, one of her classmates accused her
that she was pregnant. This made the patient anxious. She also claimed that “maraming monitor at CCTV
and nagbabantay sa akin nandoon sa room.”
The patient was not able to sleep for 2 days since then, she claims, “wala akong sakit. Okay ako.”
She was brought to the hospital by her family and was subsequently admitted.

II. Diagnosis
ICD 10: Delusional Disorder
DSM 5: Delusional Disoder, Erotomanic and persecutory type, multiple episodes

III. Management
Diagnostics CBC with APC

Urinalysis

SGOT, SGPT, Lipid Profile, BUN, Crea

Medication in the ward:

1. Na Divalproex 500 mg BID
2. Risoeridone 2mg BID
3. Olanzapine 10 mg ODHS
4. Risperidone 25 mg/vial; 1 vial IM

IV. Plan
Home medication/s:
1. Risperidone 2 mg/ta; 1 tab BID
2. Olanzapine 10 mg/tab; 1 tab at bedtime
3. Divalproex Na 500 mg/tab; 1 tab BID

Follow-up at the BGHMC Psychiatry OPD on January 25, 2018.

Prepared by:
Cabradilla, Julienne Anjeli J. Dr. Abat
Clinical Clerk in Charge PRC License No.: __________________
Signature over Printed Name of Attending
Physician

.
 CLINICAL ABSTRACT

Patient Name (Surname, First Name, M.I.) Hospital Number:

Hipol, Peter Tamondong 353090
Present Address:
Aringay, La Union
Date of Birth: (Month/Date/Year) Age: Male Civil Status:
January 15, 2018 38 Single
Date of Admission: Date of Discharge: Still Admitted? (Please Check)
January 15, 2017 January 29, 2018
YES NO

I. Clinical History
Patient was noted to have changes in behavior in 2004 (25 year old) but patient’s parents was
said to be in denial with the patient’s condition. No consult was done.
Patient had his first consult in our institution in 2008 when he was diagnosed with Bipolar I
Disorder. He was sent home with medications but he was not compliant with taking medications and was
lost to follow-up. In 2015, patient was brought to Roseville Rehabilitation center where he stayed there for
45 days. His condition improved and was sent home with maintenance mdications however, the patient is
still not compliant hence and was then again lost to follow-up. 4 months PTA, patient totally stopped
taking medications and was noted to have violent behavior, “Naghuhubad at naghahabol ng may hawak na
bato.” He was also noted to have delusions of persecution.
1 week prior to admission, he was seen walking around for 2 hours going to nearby barangays
and was said to be repeatedly murmuring words and was also physically assaultive to his family. He was
then brough here at our institution for further evaluation and management, hence, admission.
II. Diagnosis
ICD 10: Paranoid Schizophrenia
DSM 5: Paranoid Schizophrenia

III. Management
Diagnostics: CBC with APC

Medication in the ward:

5. Biperidine 2mg/tab PRN for EPS
6. Olanzapine 10 mg ODHS

IV. Plan
Home medication/s:
4. Olanzapine 10 mg/tab; ½ tab in AM and ½ tab HS

Follow-up at the BGHMC Psychiatry OPD after 2 weeks.

Prepared by:
Cabradilla, Julienne Anjeli J. Dr. Rebucal/ Dr. Bautista
Clinical Clerk in Charge PRC License No.: __________________
Signature over Printed Name of Attending
Physician
 REFLECTION PAPER:

PSYCHIATRY
It’s nice to be away from ITRMC for a while. A month long stay in Baguio is indeed
a fun experience. At first, it was a bit hard to adjust to the cold weather and new people.
It’s a bit hard to learn new things when you have been doing the old for quiet sometime.
And here is a new place, new people, new work, new patients, and new cases to deal
with.

One of the best things I learned in my Psychiatry Rotation is how important a

sound mind is. It breaks my heart to talk to people who have a lot of things to say but
kept their mouth closed due to fear of emotions, or sadness. It breaks my heart to talk to
family member and listen to their stories of how they managed to go through their
everyday lives knowing that part of their family are in battles with themselves and that
their lives are also affected in some ways.

Psychiatry rotation also made me bring back what I learned in college as a

Psychology Major. It made ma apply my already left profession for quite sometime just
to follow the dream of becoming a doctor.

It was a worthy experience. Surely, everyone who went to psychiatry rotation would
wish a little more extension before going back to ITRMC. I for one is not an exception