MEDICAL HISTORY

Name of patient: Personal, Antonio

Age/sex: 27/Male
Date of admission: May 21, 2015
Ward: ACIS 1
General Data:
This is a case of AP, 27-year old male, single, Filipino, Roman Catholic,
Highschool undergraduate, born on April 17, 1988 in Mindoro, currently residing in
Tamarraw St., Brgy La Curva, San Jose, Occidental Mindoro, admitted for the first
time at National Center for Mental Health on May 21, 2015.
Presenting Complaints:
According to informant: Lakad ng Lakad; Parang wala sa sarili
According to patient: No verbal output
Source of Information:
Elizabeth Personal, 48 years old, female, highschool graduate, mother and
lives in the same house as the patient, sells local produce in the market.
History of Present Illness:
3 years prior to admission, patient had on-and-off fever documented by touch
for almost a week not associated with bowel changes, abdominal pain nor vomiting.
He sought consult at a regional hospital and was managed as flu. Persistence of
fever now accompanied with altered behaviour, restless pacing and hair loss
prompted consult at UP-PGH where he was diagnosed with typhoid fever with
psychosis. He was prescribed with unrecalled antibiotics and antipsychotics which
the patient took religiously.
A month prior to admission, there were noted changes in patients behaviour
such as mumbling words to himself, laughing on his own, difficulty sleeping,
skipping meals, disappear without asking for permission, refusing to take his
medications and tried to stab himself with a kitchen knife.
A day prior to admission, patient stepped on a sharp wood while tending his
farm which infected his left foot. His mother used this excuse to convince patient to
seek consult which lead to his admission at NCMH.
Past Medical History:
Vaccine history is complete. Patient had chickenpox during his childhood.
There was no history of depression or drug abuse. He is non-hypertensive, nondiabetic, non-asthmatic and euthyroid. There were no prior surgeries, accidents nor
blood transfusion. No known food or drug allergies.
Family History:
Grandmother on maternal side is hypertensive and diabetic. His parents and
other siblings are all apparently well. Patient lives with his parents in his childhood
home with his siblings residing within walking distance.
Personal/Social History:

PRENATAL/PERINATAL: Patient was born full term via normal spontaneous

vaginal delivery at home, attended by midwife. There were no birth complications,
defects or intake of medications during pregnancy.
INFANCY AND EARLY CHILDHOOD: The primary caregiver was the mother. He
was breastfed until 2 years old, started walking at the age of 1 and toilet training at
2. Other milestones were unrecalled.
MIDDLE CHILDHOOD: Patient was an average student. He is very shy with few
friends at school. He was occasionally spanked by his parents as form of discipline.
No major illness or accident.
ADOLESCENCE: He was not able to finish highschool because patient opted to
help with the familys finances to support his two younger siblings education. He
enjoys drawing and sketching sceneries, animals and plants. Patient did not
experiment with illegal drugs, cigarettes or alcoholic beverages.
YOUNG ADULTHOOD: Patient is single with no history of having relationship
with the opposite sex. He devoted his attention on tending their farm. He usually
shares his problems with his brother.
Sexual History:
Patient had no history of sexual contact.
Educational History:
He attended elementary and highschool in a government school within
walking distance from their home. He was an average student except during his
sophomore year when his grades started dropping. He adamantly refuses to
participate in drawing competitions when coerced by his teachers.
Religion History:
Patient is a baptized Catholic and occasionally goes to church. His mother
tried to convince him to join Iglesia Ni Cristo but patient refused. He is seldom seen
praying.
PHYSICAL EXAMINATION
General appearance: conscious, ambulatory, not in cardiorespiratory distress,
with initial vital signs of: 120/90 mmHg BP, 20cpm RR, 99bpm PR, 36.3C
temperature.
Skin: brown, warm to touch, good skin turgor, no fresh wounds.
HEENT: normocephalic, black hair with even distribution, anicteric sclera, pink
palpebral conjunctiva, patent nasal septum, no nasoaural discharge, supple neck,
no neck vein engorgement, no cervical lymphadenopathy, no tenderness.
Chest and Lungs: symmetrical chest expansion, no retractions, clear breath
sounds.
Heart: adynamic precordium, apex beat at 5th left intercostal space midclavicular
line, no murmurs.
Abdomen: globular abdomen, normoactive bowel sounds, flat, non tender.
Extremities: no gross deformities, no edema, no cyanosis, full and equal pulses.
NEUROLOGICAL EXAMINATION
Cerebrum: not assessed
Cerebellum: no gait disturbance, no nystagmus
Cranial nerves:

I: not assessed
II: 2-3 mm pupils equally reactive to light
III, IV, VI: intact extraocular muscles
V: able to clench teeth
VII: no facial asymmetry
VIII: intact gross hearing
IX, X: able to swallow
XI: able to turn head side to side
XII: not assessed
MENTAL STATUS EXAMINATION
GENERAL APPEARANCE: Patient has large body frame, appears healthy,
appropriately dressed in gray shirt and black shorts with clean short hair.
BEHAVIOUR: He is seated on bed, with 4-point restraints, noted to be disinterested
throughout the interview.
ATTITUDE: He is uncooperative and would not answer any of the questions. Patient
does not maintain eye contact with interviewer.
SPEECH: not assessed
MOOD AND AFFECT: Patient appears to be detached
THINKING: not assessed
PERCEPTION: not assessed
SENSORIUM: He is awake but would direct his attention away from interviewer when
asked a question.
INSIGHT: not assessed
JUDGMENT: not assessed
IMPULSE: he would look away when asked a question.