National Center for Mental Health Mandaluyong City

Pavillion 4 and 35 Requirements For Medical Clerks (2 Clinical Histories and 6 MSE)

Submitted by: Mendoza, Vincent-Lou Reyes FEU-NRMF 14 February 2013

NATIONAL CENTER FOR MENTAL HEALTH Mandaluyong City PSYCHIATRIC HISTORY GENERAL DATA: Abrigo, Maria Magdalena, 22 years old, Female, Single, Filipno, Roman Catholic, Unemployed, born on April 14, 1990 in Bulacan, currently residing at Balagtas BMA, San Rafael, Bulacan admitted for the first time at NCMH on February 2, 2013. CHIEF COMPLAINT: Nagwawala Nangangagat onset: December 2012 informant: mother HISTORY OF PRESENT ILLNESS: The history of present illness started about two years prior to admission when the patient was playing outside their house, when she was bitten by a street dog at the right leg. They cleaned the wound with soap and fresh water, however, no consult done, no medications taken. The patient was well until, one month prior to admission when the patient became irritable and hot tempered. No loss of appetite, no visual disturbances, no difficulty of sleeping noted. No consult done. No medications taken. Three days prior to admission, still hot tempered and irritable, the patient now most of the time shouting and destroying the furnitures inside their house, they restrained her, but no consult done, no medications taken. Until one day prior to admission, the patient became violent nambabato and nangangagat, she also was running around and trying to hurt everyone she sees infront of her. This prompted consult and was subsequently admitted PAST MEDICAL HISTORY: No history of head trauma, seizure, allergy, hypertension, diabetes mellitus, hypertension, mental illness ANAMNESIS: PRENATAL: Patient is 5th child among eleven siblings. She was born to a 28 year old G4P5, full term via normal spontaneous delivery at home, attended by a traditional birth attendant. It was a wanted pregnancy. Mother did not have prenatal check-up but no fetomaternal complications was noted. EARLY CHILDHOOD: Patient was breastfed with no feeding problem. She was diagnosed as deaf and mute. Her parents were farmers and was taken

care of by older siblings. Sometimes, when her mother would sell vegetables at the market, she would accompany her. MIDDLE CHILDHOOD: The patient did not had any formal schooling. She did not have any friends or socialization to other children. She is a follower and able to cooperate and comply with rules. LATE CHILDHOOD: She liked to play with her siblings inside their house. She did not get involve in any trouble with authoroties. No alcohol or drug abuse. She did not had any sexual activity. ADULTHOOD: EDUCATIONAL HISTORY: The patient did not had any formal education. OOCUPATIONAL HISTORY: The patient has never worked and is unemployed. PSYCHOSEXUAL HISTORY: Patient is fifth among eleven siblings. She was a planned pregnancy without any fetomaternal complications. She had a good infant-mother relationship as well as to her siblings and caregiver. Patient was playful as a child. She was not exposed to violence growing-up. MENTAL STATUS EXAMINATION: Seen and examined a 22 years old female clad in white shirt and pink pajama pants. Fairly kempt, with signs of hyperactivity and aggression. Patient is uncooperative and hostile. She is anxious with constricted affect that is inappropriate for mood. Patient is not spontaneous and responsive to cues whan being interviewed. Speech is rapid with impairments of speech. She appears to have hesitant thinking. Thought is vague, she is conscious, not oriented to time, date, and person. Recent past is impaired, impaired concentration and attention. She cannot read and write. Poor impulse control and judgement. FAMILY HISTORY: Parents: Timoteo, 58 years old, apparently healthy Elizabeth, 50 years old, apparently healthy Siblings: 1st Ramir, 31, deceased due to unknown heart disease, farmer,

closest sibling to the patient 2nd Annaliza, 28, laundry woman 3rd Dexter, 25, farmer 4th Claire, 23, laundry woman 5th Maria Magdalena, 22, Patient 6th Rogelio, 20, farmer 7th Mary Jane, 19, unemployed 8th Babylyn, 16, farmer 9th Dolores, 14, student 10th Mercilino, 9, student 11th Mannilyn, 8, student

PHYSICAL EXAMINATION: GENERAL SURVEY: conscious, disoriented, not in cardiorespiratory distress with the following vital signs of: BP= 130/70 CR= 99 RR= 23 T=37.0 HEENT: head is normocephalic, pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion NECK: supple, no neck vein engorgement, no cervical lymphadenopathy CHEST: symmetrical chest expansion, no retractions, no wheezes, no crackles, vesicular breath sounds HEART: adynamic precordium, normal rate, rgular rhytmn, no murmur ABDOMEN: soft, flabby, non-tender, with normoactive bowel sounds EXTREMITIES: no gross defomities, full and equal pulses, (+) multiple abrasions at dorsal part of both hands SKIN: no active dermatoses, no edema NEUROLOGICAL EXAMINATION: Cerebrum: disoriented Cerebellum: no nystagmus Cranial Nerves: 1- not assessed 2- 2-3 mm pupils equally reactive to light 3, 4, 6- cannot follow object with eyes in 6 cardinal gaze 5- with bicorneal reflex 7- no facial asymmetry 8- cannot hear both ears 9, 10- with gag reflex 11- can shrug both shoulders 12- not assessed

Motor

Sensory

DTR

5/5 5/5

5/5 5/5

100% 100%

100% 100%

++ ++

++ ++

Pathologic Reflexes: no ankle clonus, no babinski Signs of menigeal irritation: no nuchal rigidity, no brodzinski, no kernig ASSESSMENT: Undiffirentiated Mental Retardation BASIS: violent and irritable disoriented

JI MENDOZA, VINCENT-LOU REYES FEU-NRMF

NATIONAL CENTER FOR MENTAL HEALTH Mandaluyong City PSYCHIATRIC HISTORY GENERAL DATA: Castillo, Lucy, 49 years old, Female, Married, Filipno, Roman Catholic, Housemaid, born on December 10, 1963 in Capiz, currently residing at Block 17 Lot 35, Pinagsama Village, Taguig City admitted for the first time at NCMH on February 6, 2013. CHIEF COMPLAINT: Nagwawala Nakakapanakit at nambabato onset: January 31 2013 informant: husband HISTORY OF PRESENT ILLNESS: The history of present illness started about ten months prior to admission when the patients pet dog died, it was said that she had a deep love and connection for the dog. She became sleeplees, however no loss of appetite, no consult done, no medications taken. The patient was well until two weeks prior to admission, when the patient became hot tempered and irritable, still with difficulty of sleeping, no loss of appetite. She was also suspicious of their neighbors, she complained may naghahanap sa akin at gusto akong patayin, no consult done, no medications taken. Three days prior to admission, relatives noted the patient to restless, still with difficulty of sleeping, now associated with decrease in appetite, the patient was irritable, hot tempered and was throwing objects out side their house towards other people and their neighbors houses, she also tried to jump off the roof of their house, she said may humahabol sa akin at imamasacre ako , she was immediately apphrended by family members. No consult done, no medications taken. Until few hours prior to admission, the patient became violent, she held hostage her mother-in-law with a knife and was threatening to kill her, she was apprehended by barangay officials and family members. She was saying may humahabol at gusto akong patayin. This prompted consult and was subsequently admitted.

PAST MEDICAL HISTORY: No history of seizure, head trauma, allergy, hypertension, diabetes mellitus, hypertension, mental illness. Had the usual childhood diseases such as measles, mumps, and chickenpox. ANAMNESIS: PRENATAL: Patient is the youngest child among five siblings. She was born to a 24 year old G4P5, full term via normal spontaneous delivery at home, attended by a traditional birth attendant. It was a wanted pregnancy. Mother did not have prenatal check-up but no fetomaternal complications was noted. EARLY CHILDHOOD: Patient was breastfed with no feeding problem. Her father was farmers and mother was housewife, she was taken care of by older siblings and relatives. She liked to play with her siblings and was friendly towards other children. No delay in developmental milestones and they were at par with age. MIDDLE CHILDHOOD: The patient started schoolin at the age of six years old and went to a public school in Capiz. She claimed she was an average student. She was an extrovert and had a lot of friends. She liked to play street games like patintero ant tumbang preso. She is a follower and able to cooperate and comply with rules. During weekends and summer vacations, the patient and the siblings would help out with the farm by plowing and tilling the land. LATE CHILDHOOD: After finishing elementary, she went to Capiz National High School for her secondary education. She liked to play with her siblings and friends. She did not get involve in any trouble with authorities. No alcohol or drug abuse. She had good relationship with her parents. ADULTHOOD: EDUCATIONAL HISTORY: She finished high school. She wanted to go to college. However, she knew her parents could not afford to send her. OOCUPATIONAL HISTORY: The patient is currently a househelper. PSYCHOSEXUAL HISTORY: Patient is the youngest among five siblings. She was a planned

pregnancy without any fetomaternal complications. She had a good infant-mother relationship as well as to her siblings and caregiver. Patient was playful as a child. She was not exposed to violence growing-up. MENTAL STATUS EXAMINATION: Seen and examined a 49 years old female clad in red and white stripe shirt and brown pants. Fairly kempt, with no signs of hyperactivity and aggression. Patient is cooperative. She is anxious with blunted affect that is inappropriate for mood. Patient is spontaneous and responsive to cues whan being interviewed. Speech is slow with no impairments of speech. Patient claims to have auditory hallucinations, described as may humahabol sa akin, at gusto nila akong imassacre at patayin tumakbo ka na at unahan mo sila. She appears to have hesitant thinking. Thought is vague, she is conscious, oriented to time, date, and person. Recent past is intact, intact concentration and attention. She can read and write. Answers to questions concretely abstract, and can count change from Php 100 after a purchase of less than Php 5. Patient appears to have poor impulse control and judgement. FAMILY HISTORY: Parents: Unknown name and age, deceased, unknown disease Unknown name and age, deceased, unknown heart disease Siblings: 1st Erlinda, 60, housewife, closest to the sibling to the patient 2nd Violy, 57 3rd Cony, 54 4th Ernesto, 51 5th Lucy, 49, patient PHYSICAL EXAMINATION: GENERAL SURVEY: conscious, disoriented, not in cardiorespiratory distress with the following vital signs of: BP= 120/90 CR= 87 RR= 21 T=36.8 HEENT: head is normocephalic, pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, with contusion hematoma measuring 2 x 2 cm at the frontal area NECK: supple, no neck vein engorgement, no cervical lymphadenopathy CHEST: symmetrical chest expansion, no retractions, no wheezes, no crackles, vesicular breath sounds HEART: adynamic precordium, normal rate, rgular rhytmn, no murmur

ABDOMEN: soft, flabby, non-tender, with normoactive bowel sounds EXTREMITIES: no gross defomities, full and equal pulses, (+) multiple hematoma at both the upper extremities, with abrasion at the right proximal forearm SKIN: no active dermatoses, no edema NEUROLOGICAL EXAMINATION: Cerebrum: oriented to time, date, and person Cerebellum: no nystagmus Cranial Nerves: 1- not assessed 2- 2-3 mm pupils equally reactive to light 3, 4, 6- can follow object with eyes in 6 cardinal gaze 5- with bicorneal reflex 7- no facial asymmetry 8- can hear both ears 9, 10- with gag reflex 11- can shrug both shoulders 12- tounge at midline

Motor

Sensory

DTR

5/5 5/5

5/5 5/5

100% 100%

100% 100%

++ ++

++ ++

Pathologic Reflexes: no ankle clonus, no babinski Signs of menigeal irritation: no nuchal rigidity, no brodzinski, no kernig ASSESSMENT: Undiffirentiated Schizophrenia BASIS: violent and irritable auditory hallucinations

JI MENDOZA, VINCENT-LOU REYES FEU-NRMF MENTAL STATUS EXAMINATION (Date of Exam: February 4-7, 2013) 1. Ronquillo, Ernilo, 34 years old, Male 80 Mariano Ponce St., Bagong Barrio, Kalookan City DOA: February 10, 2012 Seen and examined an adult male clad in blue detainee shirt and blue short pants, well kempt, without mannerisms, no signs of aggression and hyperactivity. Patient is cooperative. He said gabi na and gusto ko ng umuwi. With normal affect appropriate for mood. Patient is spontaneous and responsive to cues when being interviewed. Speech is slow, normoproductive without impairments. Patients claims not to have hallucinations nor illusions. Thought is not clear. He does not have delusions, preoccupations, suicidal ideations. He is conscious, not oriented to time, oriented to place and person. Memory is intact as well as concentration and attention. He can read and write. He answers questions concretely and can count change from 100 after purchase of 5. He appears to have good impulse control and judgement. He is aware and has understanding of court proceedings. He is aware of the nature of his illness and expresses compliance to treatment.

2. Roncales, Jovito Jr., 38 years old, Male 122 Tramo Riverside, Pasay City DOA: December 29, 2009 Seen and examined an adult male clad in blue detainee shirt and blue short pants, well kempt, without mannerisms, no signs of aggression and hyperactivity. Patient is cooperative. With wide range of affect not appropriate for mood, he complains of malungkot ako dito and gusto ko ng umuwi and also said wala ang utak sa tiyan nasa talamapakan. Patient is spontaneous and responsive to cues when being interviewed. Speech is slow, normoproductive without impairments. Patients claims not to have hallucinations nor illusions. Thought is not clear. He does not have delusions, preoccupations, suicidal ideations. He is conscious, oriented to time, oriented to place and person. Memory is intact as well as concentration and attention. He can read and write. He answers questions concretely and can count change from 100 after purchase of 5. He appears to have good impulse control and judgement. He is aware and has understanding of court proceedings. He is aware of the nature of his illness and expresses compliance to treatment.

3. Bundang, Edwin Palili, 48 years old, Male 2245 Marigman St., San Roque, Brgy. Poblacion, Rizal Province DOA: August 19, 2011 Seen and examined an adult male clad in blue detainee shirt and blue short pants, fairly kempt, without mannerisms, no signs of aggression and hyperactivity. Patient is calm and cooperative. With normal affect appropriate for mood, he complains of malungkot dito and gusto ko makita ang pamilya ko. Patient is spontaneous and responsive to cues when being interviewed. Speech is slow, normoproductive without impairments. Patients claims not to have hallucinations nor illusions. Thought is clear. He does not have delusions, preoccupations, suicidal ideations. He is conscious, oriented to time, oriented to place and person. Memory is intact as well as concentration and attention. He can read and write. He answers questions concretely and can count change from 100 after purchase of 5. He appears to have good impulse control and judgement. He is aware and has understanding of court proceedings. He is aware of the nature of

his illness and expresses compliance to treatment.

4. Delfin, Romeriano Jr. Bomalondon, 29 years old, Male Sitio Cabutungan, Panitan, Capiz DOA: July 7, 2008 Seen and examined an adult male clad in blue detainee shirt and blue short pants, fairly kempt, with mannerisms, no signs of aggression and hyperactivity. Patient is calm and cooperative. With normal affect appropriate for mood, he complains of malungkot dito and gusto ko makita ang pamilya ko. Patient is spontaneous and responsive to cues when being interviewed. Speech is slow, normoproductive without impairments. Patients claims not to have hallucinations nor illusions. Thought is clear. He does not have delusions, preoccupations, suicidal ideations. He is conscious, oriented to time, oriented to place and person. Memory is intact as well as concentration and attention. He can read and write. He answers questions concretely and can count change from 100 after purchase of 5. He appears to have good impulse control and judgement. He is aware and has understanding of court proceedings. He is not aware of the nature of his illness but expresses compliance to treatment.

5. Vista, Rico Bernabe, 34 years old, Male Block 27 Lot 40, Filinvest, San Pedro, Laguna Province DOA: March 6, 2008 Seen and examined an adult male clad in blue detainee shirt and blue short pants, fairly kempt, without mannerisms, no signs of aggression and hyperactivity. Patient is calm and cooperative. With normal affect appropriate for mood. Patient is spontaneous and responsive to cues when being interviewed. Speech is slow, normoproductive without impairments. Patients claims not to have hallucinations nor illusions. Thought is clear. He does not have delusions, preoccupations, suicidal ideations. He is conscious, oriented to time, oriented to place and person. Memory is intact as well as concentration and attention. He can

read and write. He answers questions concretely and can count change from 100 after purchase of 5. He appears to have good impulse control and judgement. He is aware and has understanding of court proceedings. He is aware of the nature of his illness but expresses compliance to treatment. 6. Florenosos, Jose Palmitos, 42 years old, Male Poblacion, Tagoloan, Calapan City DOA: October 15, 2008 Seen and examined an adult male clad in blue detainee shirt and blue short pants, fairly kempt, with no mannerisms, no signs of aggression and hyperactivity. Patient is calm and cooperative. With normal affect appropriate for mood. Patient is spontaneous and responsive to cues when being interviewed. Speech is rapid, normoproductive without impairments. Patients claims not to have hallucinations nor illusions. Thought is clear. He does not have delusions, preoccupations, suicidal ideations. He is conscious, oriented to time, oriented to place and person. Memory is intact as well as concentration and attention. He can read and write. He answers questions concretely and can count change from 100 after purchase of 5. He appears to have good impulse control and judgement. He is aware and has understanding of court proceedings. He is aware of the nature of his illness but expresses compliance to treatment.

JI MENDOZA, VINCENT-LOU REYES FEU-NRMF