Name: Ernesto V. Ignacio Jr.

Status: Post Graduate Medical Intern

Date of Rotation: July 08 – 15, 2018

ARMED FORCES OF THE PHILIPPINES MEDICAL CENTER

VICTORIANO LUNA GENERAL HOSPITAL
Department of Mental Health and Behavioral Science

Name: Llagas, Rafael Duke G. Age: 25

Address: Cagayan De Oro Sex: Male
Admitting Diagnosis: Hypoglycemia Rank: PFC
Ward: Psych A Date of Admission: 05/31/2018

July 10, 2018 S Initially diagnosed as a case of hypoglycemia, with fainting

spells. Patient is has good appetite, socializes actively w/
other patients and medical staff, is able to sleep w/o
interruptions at night. No verbalized complaints or
symptoms.
O Observed and examined a young male, normosthenic, w/
good hygiene and appropriately clothing (red shirt and black
shorts), cooperative with good eye contact. Ambulates
normally, with no noted abnormal mannerisms or behavior,
w/ good posture and coordination of movements. Affect is
appropriate, lively with euthymic mood. Speaks in an
unhurried manner, with appropriate pitch and tone,
elaborates as necessary. Though content and flow are
normal. With fair insight and judgment. Oriented to person,
place and time. Short and long term memory are both intact.
A Hypoglycemia, Mild Depression
P Vitamin B Complex, 1 tab TID
Vitamin C 500mg/tab, 1 tab OD
Paracetamol 500mg/tab, 1 tab Q6h for headache
Escitalopram 10mg/tab, ½ tab ODHS

July 13, 2018 S Initially diagnosed as a case of hypoglycemia, with fainting

spells. Patient is has decreased appetite since last week,
socializes actively w/ other patients and medical staff, is able
to sleep w/o interruptions at night. No verbalized complaints
or symptoms.
O Observed and examined a young male, normosthenic, w/
good hygiene and appropriately clothing (white shirt and
black shorts), cooperative with good eye contact. Ambulates
normally, with no noted abnormal mannerisms or behavior,
w/ good posture and coordination of movements. Affect is
appropriate, lively with euthymic mood. Speaks in an
 unhurried manner, with appropriate pitch and tone,
elaborates as necessary. Though content and flow are
normal. With fair insight and judgment. Oriented to person,
place and time. Short and long term memory are both intact.
A Hypoglycemia, Mild Depression
P Continue present meds
Diet shifted to low salt, low cholesterol, low purine diet

Name: Llamsares, Jezreel Age: 30

Address: South Cotabato Sex: Male
Admitting Diagnosis: PTSD Rank: PFC
Ward: Psych A Date of Admission: 01/09/2018

July 10, 2018 S Diagnosed as a case of PTSD, patient has good appetite,
complete uninterrupted sleep. He socializes and joins in on
group activities with other patients and the medical staff. No
new verbalized symptoms or complaints.
O Observed and examined a male young adult, wearing a black
shirt and blue shorts, well kempt, with good hygiene. Has
good eye contact and converses actively with a well-
modulated voice, in an unhurried manner. Thought content
is appropriate. With good short term and long term memory,
insight and judgment is fair. Oriented appropriately to
person, place and time. W/ well-coordinated movements, no
abnormal mannerisms or behavior observed.
A PTSD, Epistaxis resolved, t/c Varicocoele, Left
P Continue present medications
Refer accordingly

July 13, 2018 S Diagnosed as a case of PTSD, patient has good appetite,
complete uninterrupted sleep. He socializes and joins in on
group activities with other patients and the medical staff. No
new verbalized symptoms or complaints.
O Observed and examined a male young adult, w/ appropriate
clothing, well kempt, with good hygiene. Has good eye
contact and converses actively with a well-modulated voice,
in an unhurried manner. Thought content is appropriate.
With good short term and long term memory, insight and
judgment is fair. Oriented appropriately to person, place and
time. W/ well-coordinated movements, no abnormal
mannerisms or behavior observed.
A PTSD, Epistaxis resolved, t/c Varicocoele, Left
P Continue present medications
For inguinal-scrotal UTZ on July 16
For close observation
Name: Hamid, Reynan S. Age: 27
Address: - Sex: Male
Admitting Diagnosis: PTSD Rank: PVT
Ward: Psych A Date of Admission: 06/13/2018

July 10, 2018 S Patient is a known case of PTSD. He has difficulty initiating
sleep, with good appetite and actively socializes with other
patients and the medical staff. No recurrence of
hallucinations or flashbacks noted. No verbalized symptoms
or complaints.
O Observed and examined a young male, with good hygiene,
wears appropriate clothing, no noted abnormal gait,
mannerisms or behavior. Interacts and answers questions
appropriately, with good eye contact, Though content and
flow are normal. Appropriate affect, mood is stable. Speech
tone, pitch and volume are normal. Oriented to person, place
and time. Insight and judgment are fair.
A PTSD
P Vitamin B complex, 1 tab OD
Vitamin C 1 tab OD
Escitalopram 10mg/tab 1 tab OD
Hydroxyzine 25mg/tab OD prn for difficulty initiating sleep
For battery of psychological exams

July 13, 2018 S Patient is a known case of PTSD. He has difficulty initiating
sleep, with good appetite and actively socializes with other
patients and the medical staff. No recurrence of
hallucinations or flashbacks noted. No verbalized symptoms
or complaints.
O Observed and examined a young male, with good hygiene,
wears appropriate clothing, no noted abnormal gait,
mannerisms or behavior. Interacts and answers questions
appropriately, with good eye contact, Though content and
flow are normal. Appropriate affect, mood is stable. Speech
tone, pitch and volume are normal. Oriented to person, place
and time. Insight and judgment are fair.
A PTSD
P Continue present medications
Refer accordingly
Name: Trespecios, Val Alden Age: 31
Address: - Sex: Male
Admitting Diagnosis: Rank: CPL
t/c Substance Intoxication
HPN Stage 1
Ward: Psych A Date of Admission: 04/04/2018

July 10, 2018 S Patient is a suspected case of Substance intoxication. Noted

to have good appetite, good sleep with active participation in
socialization between medical staff and other patients. No
reported hallucinations or any disturbances noted. No new
verbalized complaints or symptoms.
O Observed and examined a mid adult male, with good hygiene,
appropriately dressed in a black sando and black shorts. He
actively participates in a conversation with other patients. In
conversations, he has good eye contact, communicates with a
well-modulated voice, unhurried speech. Content is
appropriate. With well coordinated movements. No
abnormal mannerisms noted. He has fair insight and
judgment. Oriented to person, place and time.
A t/c Substance Intoxication
HPN Stage 1
P Vitamin B complex, 1 tab OD
Vitamin C 1 tab OD
Aripiprazole 10mg/tab, 1 tab OD
Mefenamic Acid 500mg/tab prn for pain
Irbesartan 150mg/tab, 1 tab OD

July 13, 2018 S Patient is a suspected case of Substance intoxication. Noted

to have good appetite, good sleep with active participation in
socialization between medical staff and other patients. No
reported hallucinations or any disturbances noted. No new
verbalized complaints or symptoms.
O Observed and examined a mid adult male, with good hygiene,
appropriately dressed. He is seen lying on the bed while
using his cellphone. In conversations, he has good eye
contact, communicates with a well-modulated voice,
unhurried speech. Answers cooperatively with appropriate
content. He has well coordinated movements. No abnormal
mannerisms noted. He has fair insight and judgment.
Oriented to person, place and time.
A t/c Substance Intoxication
HPN Stage 1
P Continue present management
Refer accordingly
Name: Eubank, Henry L. Age: 39
Address: Naga Sex: Male
Admitting Diagnosis: Bipolar I Rank: CPL
Ward: Psych B Date of Admission: 12/04/2018

.July 10, 2018 S Patient is a known case of Bipolar I disorder. He is noted to

have good appetite, good uninterrupted sleep, and active
socialization with the medical staff and other patients. No
noted new complaints or symptoms.
O Observed and examined an adult male, hyposthenic, wearing
a green army shirt and shorts. He appears well kempt and
with good hygiene. Ambulates independently with normal
gait. He has well coordinated moves and has good posture.
There were no noted abnormal behavior or mannerisms.
Affect is appropriate, mood is lively. He converses using a
well-modulated voice with good eye contact. Thought
content is normal. Oriented to person, place and time. With
fair insight and judgment.
A Bipolar I, Type 2 DM
P Continue present medications
For CDD processing
For close observation

July 13, 2018 S Patient is a known case of Bipolar I disorder. He is noted to

have good appetite, good uninterrupted sleep, and active
socialization with the medical staff and other patients. No
noted new complaints or symptoms.
O Observed and examined an adult male, hyposthenic, wearing
appropriate clothing. He appears well kempt and with good
hygiene. Ambulates independently with normal gait. He has
well coordinated moves and has good posture. There were
no noted abnormal behavior or mannerisms. Affect is
appropriate, mood is lively. Cooperates actively and
converses using a well-modulated voice with good eye
contact. Thought content is normal. Oriented to person, place
and time. With fair insight and judgment.
A Bipolar I, Type 2 DM
P To start Rosuvastatin 20mg/tab 1 tab ODHS
Referred to IM Endo for DM type II and Dyslipidemia
Refer accordingly
Name: Tabuniag, Henry V. Age: 44
Address: - Sex: Male
Admitting Diagnosis: Rank: PFC
t/c Brief Psychotic Disorder r/o
Schitzophrenia
Ward: Psych Date of Admission: 03/16/2018

July 10, 2018 S Patient is a suspected case of Brief Psychotic disorder. He is

noted to have good sleep and appetite. No hallucinations or
other disturbances. Active socialization to staff and other
patients.
O Observed and examined an adult male, with good hygiene.
He appears well kempt, wearing a white shirt and blue
shorts. With proper posture and gait. Movements are well-
coordinated with no abnormal behavior or manners noted.
He speaks in a well modulated voice with good eye contact.
With appropriate mood and affect. Memory is intact.
Oriented appropriately to person, place and time. Insight and
judgment are fair. Thought content is normal.
A t/c Brief Psychotic Disorder r/o Schitzophrenia
P Vitamin B complex, 1 tab OD
Vitamin C 1 tab OD
Risperidone 2mg/tab, 1 tab ODHS
Mefenamic Acid 500mg/tab prn for pain
Ceterizine discontinued

July 13, 2018 S Patient is a suspected case of Brief Psychotic disorder. He is

noted to have good sleep and appetite. No hallucinations or
other disturbances. Active socialization to staff and other
patients.
O Observed and examined an adult male, with good hygiene.
He appears well kempt and neat. He has proper posture and
gait. Movements are well-coordinated with no abnormal
behavior or manners noted. He speaks in a well modulated
voice with good eye contact. With appropriate mood and
affect. Memory is intact. Oriented appropriately to person,
place and time. Insight and judgment are fair. Thought
content is normal.
A t/c Brief Psychotic Disorder r/o Schitzophrenia
P Continue present medications
For CDD processing
Refer accordingly
Name: Encia, Randy C. Age: 29
Address: Zamboanga Sex: Male
Admitting Diagnosis: Bipolar I Rank: CPL
Ward: Psych Date of Admission: 04/17/2018

July 10, 2018 S Patient is a known case of Bipolar I. He is noted to have good
sleep, good appetite. He actively communicates with both
medical personnel and other patients. No noted
hallucinations or disturbances. He has no verbalized ne
complaints or symptoms.
O Observed and examined a young male, medium built with
appropriate clothing. Appears well kempt with good hygiene.
Gait and posture are normal. With well-coordinated
movements and no noted abnormal mannerisms or
behaviors. With good eye contact during communication.
Thought content is appropriate. Speech is well modulated.
Insight and judgment are both fair. Oriented to person, place
and time.
A Bipolar I disorder, Sensorineural Hearing Loss moderate AU
P Continue present management and medications
For semen analysis
Refer to uro once semen analysis results are received
Still for CDD processing

July 13, 2018 S Patient is a known case of Bipolar I. He is noted to have good
sleep, good appetite. He actively communicates with both
medical personnel and other patients. No noted
hallucinations or disturbances. He has no verbalized ne
complaints or symptoms.
O Observed and examined a young male, medium built with
appropriate clothing. Appears well kempt with good hygiene.
Gait and posture are normal. With well-coordinated
movements and no noted abnormal mannerisms or
behaviors. With good eye contact during communication.
Thought content is appropriate. Speech is well modulated.
Insight and judgment are both fair. Oriented to person, place
and time.
A Bipolar I disorder, Sensorineural Hearing Loss moderate AU
P Still for CDD processing
Continue present meds and management
Refer to Uro once with semen analysis results.