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 Crispin, Casmer, 25 year-old male, single, Filipino, Roman Catholic, born on October 09, 1990 in Bagulin, La Union and
currently residing in the same locality. This is his 1st admission in this institution. The informant is his mother with a percentage reliability of 90%.
CHIEF COMPLAINT:
According to the Patien: Wala kong sakit, ewan ko sa kanila sumusunod lang ako
According to the informant: Tinatanggi niya kami na Pamilya niya.
HISTORY OF THE PRESENT ILLNESS:
2 years prior to consultation, when the patient came home to La Union since he is studying here in Baguio. He suddenly said to his mother
Hindi ikaw ang mama ko, iba mama ko with no associated decrease in sleep and no loss of appetite. No consultations done and no medications taken.
1 years prior to consultation, he went home again from Baguio, since he could not function well in school. There was visual hallucination where
the patient said May babaeng umiiyak galling Baguio and a persecutory delusion, saying: May papatay sa akin. The patient even looks out through
the windows and doors. Interval History shows that the patient always stays at their house and locks himself inside. He sleeps most of the time, unable
to do usual daily activities but maintain good hygiene and grooming. Irritable most of the time, specially when he is confronted by his parents.
1 week prior to consultation, the condition worsened. The patient didnt want his siblings to enter their house and the patient said sumasanib
si satanas sa kanila. The patient also said that he has another family and not his current family that he is staying with.
1 day prior to consultation, when the father confronted the patient and had a conversation which eventually led to a fight, but no assaultive
behavior, so they decided to bring the patient in this institution for consultation and admission.
PAST MEDICAL HISTORY:
SURGICAL: No history of any operation.
MEDICAL: 1 y/o the patient had convulsion due to high fever.
PSYCHIATRIC: - No history of any psychiatric illness..
He has no known history of allergies to food or drugs, or illnesses like hypertension, DM, or CAD. He is a non-alcoholic beverage drinker. Non-smoker and no use of illegal
drugs.
FAMILY HISTORY:
Father: Capolo Crispin, 56 y/o, high school graduate, Good interpersonal relationship
Mother: Ciloria Crispin, 57 y/o, College graduate, good interpersonal relationship
Siblings:
1.
Camelio 31 years old, college graduate, housewife, not in good terms with the patient
2.
Kennedy 28 years old, Army, good interpersonal relationship
3.
Crispolo 18 y/o, 3rd year college student, good interpersonal relationship
4.
Crisologo 15 y/o, 4th year high school, good interpersonal relationship
5.
Crismay 13 y/o 2nd year high school, good interpersonal relationship
No other family members suffer with the same condition with the patient. there was no family Hypertension, DM, and seizure disorder.
PERSONAL, DEVELOPMENTAL, SOCIAL, AND ENVIRONMENTAL HISTORY:
He was born via NSVD in a Hospital, term, with no neonatal complications. Developmental milestones were at par with other children in his
age. Patient started his primary education when he was 4 years old excelling in his academics during elementary and secondary education. During his
tertiary education, he took BS Criminology however stopped on his 3 rd year due to failing grades, he got depressed. The patient interacts with other
people however spends most of his time alone. Patient lives with his parents and siblings.
REVIEW OF SYSTEMS:
General: (-) fatigue, (-) weight change, (-) fever, (-) chills, (-) diaphoresis, (-) dizziness, (-)body weakness
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
Respiratory: (-) cough, (-) dyspnea, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) occupational exposure, (-) TB
Cardiac: (-) chest pains/ discomfort, (-) orthopnea, (-) dyspnea, (-) paroxysmal nocturnal dyspnea, (-) 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
Renal and Urinary: (-) dysuria, (-) hematuria, (-) incontinence
Musculoskeletal: (-) muscle pains, (-) joint pains, (-) cramps, (-) weakness, (-) stiffness, (-) Hx of trauma, (-) 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, (-) head trauma, (+) sleep disorder, (-) coordination problem
Psychiatric/Emotional: (-) anxiety, (-) nervousness, (-) substance abuse
PHYSICAL EXAMINATION:

General Survey:
Conscious, ambulatory, not in cardiopulmonary distress
Vital Signs:
BP:130/90 mmHg, CR: 91 bpm, RR: 18 cpm, Temp: 36.9OC
Skin:
No cyanosis, no pallor, good skin turgor, warm to touch
HEENT:
Head:
Face is symmetrical, no involuntary movement, no lesions. No tenderness, no masses. No bony depression of the skull.
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.
Nose:
Septum at midline. No gross deformities. No nasal discharge and congestion. Frontal and maxillary sinuses non-tender.
Mouth and Throat: Moist pinkish lips and mucosa, no lesions, lumps or cracking. No deviations, no tonsillopharyngeal enlargement, uvula at
midline.
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. Regular rate and rhythm. No murmurs.
Abdomen: Flabby, no scars or lesions, normoactive bowel sounds, No tenderness.
Extremities: No clubbing, no gross deformities. 2+ equal and bilateral pulse on all extremities. 2-3 sec capillary refill.
Neurologic Examination:
Cerebral function: Awake
Cerebellar function: No nystagmus, no tremors
Cranial Nerve Function Test:
I: not asssessed
II: able to see
III, IV, VI: intact EOMs
V: facial sensory functioning intact, can chew
VII: facial symmetry
VIII: intact sense of hearing
IX, X: (+) gag reflex
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
MENTAL STATUS EXAMINATION:
Seen and examine 25 year-old male appropriately dressed to age and gender, wearing a gray jacket and jogging pants, with fair hygiene and
grooming, oriented to time, place, and person, with good eye contact, speaks in moderate tone, appropriately answers questions, full appropriate affect,
elated mood, good judgment and insight about condition. No hallucinations, delusions, illusions or suicidal ideations at the time of interview. With
persistent persecutory delusions.
ICD-10: Bipolar affective disorder, current episode manic with psychotic symptoms
DSM-V: Bipolar 1 disorder current, manic, severe with mood congruent psychotic features
Basis for Bipolar 1 Disorder
A.

Context have been met for at least 1 manic episode

a.
A distinct period of abnormally and persistently elated mood and abnormally and persistently inverse energy lasting at least 1 week and present most of the day, nearly
every day.
b.
During the period f mood disturbance and inversed energy. The following symptoms are present
i. Inflated self esteem or grandiosity Magician ako
ii. Decreased need for sleep Patient feel rested even with 3 hours of sleep
iii. More talkative than usual relatives noted increase in talking
c.
The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning Patient cant continue his work as a farmer
d.
The episode is not attributable to the physiological effects of a substance or another medical condition - no history of substance use , PE is essentially normal
B. The occurrence of the manic and major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusion disorder or other
specified or unspecified schizophrenia spectrum and other psychotic disorder

Basis for the mood congruent psychosis:

During manic episode the content of delusion which is He is a magician is consistent with the typical manic themes of grandiosity.
Basis for severe

The number of symptoms is substantially in excess for those required to make the diagnosis. The intensity of the symptpoms is seriously
distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.
PLAN
Diagnostics: CBC, UA
Disposition:
Admit to male psychiatry ward under the 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:Olanzapine 10mg/ tab 1 tab once a day at bedtime
Sodium Divalproex 500mg/tab 3x a day
Haloperidol 5 mg deep IM for refusal to take oral Risperidone with BP precuation
Haloperidol 10 mg + Diphenhydramine 50 mg deep IM for psychotic agitation with BP precaution to a max of 3 doses with 1 hour
interval.
Prepared by:
Verceles, Timothy Joy E
Ward Medical Clerk
SLU School of Medicine