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Batmc Psych

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Dorish Faith Carillo
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28 views5 pages

Batmc Psych

Uploaded by

Dorish Faith Carillo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Informant: C.

V
Relationship to Patient: Caregiver

PATIENT IDENTIFYING DATA:


Patient W.R, 16 years old, male, Filipino, SPED student, single, Catholic, currently residing at Lipa,
Batangas.

CHIEF COMPLAINT:
Recurrent aggressive outbursts.

HISTORY OF THE PRESENT ILLNESS:


Throughout his childhood. W.R. has been very friendly to the people around him. He usually
accompanies his mother who works as a vendor at a public market. Since his parents were separated, he
grew up occasionally visiting his father’s family to have a vacation. Unfortunately, his father who was a
known schizophrenic would beat him up from time to time.
Whenever his mother is very busy at work, W.R. would be entrusted to the care of either his
aunt or grandmother. It was 2 years ago, when he started to physically hurt his grandmother, like
throwing slippers at her. But she just tolerated this behavior considering the mental condition of her
grandchild.
Over the past years, this behavior of W.R persisted and 2 weeks ago hurt again his grandmother.
Because of this he was sent back to his mother’s care. 1 week ago, W.R.’s aggressive behavior worsened;
he physically hurt his mother in which she can no longer control and tolerate. W.R. also shows deviation
from his daily routine and eats small meals. This prompted his mother to bring his a BATMC psychiatric
facility.

PAST PSYCHIATIRC HISTORY:


No previous consults prior to first admission.

PAST MEDICAL HISTORY:


 (+) diagnosed with Intellectual delay since childhood.
 No known allergies
 No childhood illnesses
 No previous surgery
 No previous Hospitalization
 No history of accident or trauma
 Complete childhood immunization: unrecalled

FAMILY HISTORY:
 Maternal side: No psychiatric disorder. No hypertension, no diabetes, no cancer or
malignancies, no heart disease, no stroke.
 Paternal side: (+) father was diagnosed with schizophrenia. No hypertension, no diabetes, no
cancer or malignancies, no heart disease, no stroke.

SUBSTANCE USE HISTORY:


 Non-smoker, non-alcoholic beverage drinker
 Denies use of illicit drugs

PERSONAL & SOCIAL HISTORY:


W.R. was born with Moderate Intellectual Development Disorder. He is the only child of his parents.
During pregnancy, his mother was an alcoholic drinker and only stopped during the half of the 2 nd
trimester. Though he grew up with a broken family, he was friendly and loves to make dance videos on
his Tiktok account. Occasionally, he spent vacation in his biological father’s place. He has also lived with
his aunt and grandmother for some time. Due to his condition, he was been enrolled to a SPED class,
and is now in grade 1.

REVIEW OF SYSTEMS:
General:
(+) fatiguability. No chills, no fever, no weight changes.

Skin:
No rashes, no pruritus, no dryness, no change in color.

HEENT:
Head: No head trauma, no lesions, no scars, no headache, no seizzures.
Eyes: No blurring of vision, eye pain, or eye redness.
Ears: No changes in hearing.
Nose: No colds, no epistaxis.
Mouth: (+) mouth sores. No hoarseness, no gum bleeding.
Throat: No sore throat, no dysphagia.
Neck: No pain, no lumps, no stiffness.

Respiratory:
no cough, hemoptysis, dyspnea

Cardiovascular:
no palpitations, chest pain, orthopnea, paroxysmal nocturnal dyspnea

Gastrointestinal:
No diarrhea, abdominal pain, nausea, vomiting, constipation
Genitourinary:
No nocturia, polyuria, dysuria, urgency, incontinency
Musculoskeletal:
No joint swelling, joint pain, edema

Endocrine:
No cold/heat intolerance, excessive sweating

Neurologic & Psychiatric:


Please see HPI.

PHYSICAL EXAMINATION:

General:
Conscious, coherent, ambulatory, not in cardiorespiratory distress.

Vitals:
BP 110/80 mmHg
HR 102 bpm
RR 20 cpm
Temp 36.9 0 C
O2 Sat: 97%

Skin:
(+) excoriation on left lower arm.
No pallor, cyanosis

HEENT:
Head: Normocephalic, w/o lesions. No palpable mass.
Eyes: Anicteric sclera, pink conjunctiva, pupils are 4mm non-constricting, equally round, and reactive to
light and accommodation. No nystagmus.
Ears: No deformity, no discharge, no obstruction, no inflammation.
Nose: Symmetric, no deformity, no lesions, no discharge.
Throat/mouth: (+) Sialorrhea. No lesions, no oral mucosa bleeding.

Neck:
No tenderness, no visible mass, no palpable superficial and deep lymph nodes, no stiffness.

Chest & Lungs:


Symmetric chest expansion. No retractions. Tactile fremitus bilaterally equal. Lungs are resonant upon
percussion. Clear Breath Sounds.

Heart:
No scars, no lesions, adynamic precordium. No lifts, no heaves, no thrills. PMI is located on Left
Midclavicular line 5th ICS. Regular heart rate and rhythm. No bruit, no splitting of heart sounds heard,
no murmur.

Abdomen:
No scars, no lesions, no visible masse. Flat with normoactive bowel sounds. No rebound tenderness.

Genital and Rectal:


Not performed.

Musculoskeletal & Extremities:


No lesions, scars, masses, numbness. Full passive range of motion.

Neurologic:
Mental Status: The patient was seen and examined as a young Filipino male, with thin build and average
stature, tanned skinned, looking slightly appropriate for chronological age. He was wearing t-shirt and
shorts, and his hair was disheveled. He was slightly restless, with avoidant eye contact but able to look
straight when being called by name. His speech was normal, but with decrease fluency, slow speed, and
childlike tone. He had euthymic mood with flat affect. He had looseness of associations and some
tangentiality. He had no suicidal or homicidal ideations, hallucinations, delusions, obsessions, and
compulsions. He was unable to repeat and recall the 3 words and spell the word backwards. Unable to
write a sentence, but able to copy pentagon.

Cranial Nerves:
CN1: Both nostrils are intact, but identified coffee smell as “anting-anting”
CN2: Pupils 2mm equally brisk reaction to light.
CN3,4,&6: Intact extraocular muscles
CN5: v1-v3 sensation is intact, temporalis and masseter tone not done, corneal reflex not done
CN7: Symmetrical and equal contraction of muscles of facial expression. Taste not tested.
CN8: hearing intact bilaterally to whispered voice, Rinne's test: AC>BC, Weber's test: symmetrical to
both sides
CN9&10: uvula and pharynx midline; has good swallow; gag reflex not done.
CN11: Good shoulder shrug. Sternocleidomastoid and trapezius muscle strength not done
CN12: Tongue is midline

Motor:
No tremors, no muscle rigidity in all extremities.
L R
Upper extremities: 4/5 4/5
Lower extremities 4/5 4/5

Gait, coordination, stance:


 normal gait
 Able to walk on toes without difficulty
 Able to hop in place
 Unable to do tandem walk and walk on heels

Sensory:
Left upper and lower extremities- 100%
Right upper and lower extremities- 100%

Reflexes:
++ on all extremities

SALIENT FEATURES:
 Recurrent aggressive behavior
 Family history
 Intellectual development delay

DIFFERENTIALS:
 Autism Spectrum Disorder
 Post Traumatic Stress Disorder
 Intermittent Explosive Disorder
 Schizophrenia
 Intellectual Disability

PRIMARY WORKING DIAGNOSIS:


Intellectual Disability with Behavioral Disorder

DIAGNOSTICS:
CBC
Urinalysis
HGT/FBS
ECG
Non-contrast head CT scan

MANAGEMENT:
Anti-psychotics
CBT

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