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History of Present Illness

History of Present Illness

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Published by Haruka Hitori

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Categories:Types, School Work
Published by: Haruka Hitori on Mar 08, 2011
Copyright:Attribution Non-commercial


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History of Present Illness: The patient is a 36-year old single male with a historyof profuse salivation and labile moods since his childhood. He was observed tobe sleeping excessively, disoriented and confusing family and householdmember’s name. When interviewed at the time of psychiatric assessment, thepatient said he had difficulty in speech, poor concentration, impaired thinking andmelancholia brought about by the stresses of his work and the break-up with hisflight attendant girlfriend. He also claimed he felt clumsy and uncoordinated. Healso describes what appeared to be a deep sense of foreboding and feeling thatthe “world was coming to an end.”Current Symptoms:1.Psychomotor retardation2. Slowed gait and activity3. Lack of Initiative.4. Melancholia5. Fatigue6. Lack of self-confidence.7. Lack of sexual interestSubstance Abuse History:* Smoker = Yes, up to two (2) packs a day* Drugs = Yes, teen-age experimentation with Marijuana and various pills* ETOH = Yes, solitary drinker MMSEThe Psychologist conducting the interviews noticed that the patient wouldoccasionally walk slowly and aimlessly around the room when being interviewed.He appeared inattentive, vague, non-spontaneous and detached in interactions,but passively followed simple commands. He appeared disoriented. There wassome difficulty in communicating due to his deep depression and melancholia.On mental state examination, he was a lanky man of medium height who wasmildly psychomotor retarded with a latency of verbal replies, and a slowness of movement. He was preoccupied with his inner thoughts, brooded and feltmelancholy. He appeared quite elevated and irritable when he spoke of the losshe was feeling when he recounted his relationship with his girlfriend. Heexpressed a poorly-formed grandiose delusion that the world was ending anddescribed feelings of foreboding but no disturbance in any other sensorymodality. The patient was oriented in person and place, with only very mildimpairment of time. Attention and concentration deficits were evident, thoughmuch in the slightest and confirmed on formal testing that he had minor difficultyin counting down by seven from 100 and could not readily spell some wordsbackwards. Registration and short term memory were intact on testing but hewas often distracted and distant. There was evidence of dysphasia, mild difficultywith three-step commands, concretism and trial-constructional dysphasia (hecould not copy complex diagrams). No confabulation or remote memory deficitswere identified. His Mini-Mental State Examination (MMSE) score totaled 28/30.No cognitive impairments. He denied being in need of medical assistance andexplained his presence in the school as being due to his sister’s concerns, butdid not appear suspicious of possible motives or irritated by his presence in thedepartment. He denied that he had any cognitive deficits. He said he required
medication and dietary modification, but did not accept medication offered in factrequiring detailed explanation on why the medication had to be taken.In as much as the patient exhibits the following symptoms (1) Depressed mood(i.e. feeling sad and empty) most of the day for 10 days, (2) Markedly diminishedinterest on pleasure in almost all activities (including lack of sexual interest) mostof the day for 10 days, (3) A noticeable fluctuation of appetite most of the day for 10 days, (4) Psychomotor agitation or retardation (i.e. increased restlessness)most of the day for 10 days, (5) A diminished ability to concentrate ordering onindecisiveness most of the day for 10 days, (6) Insomnia nearly everyday, (7)Fatigue nearly everyday , And (8) a feeling of foreboding everyday. He isdiagnosed as suffering from Major Depressive Disorder.
mini-mental state examination
) or
Folstein test
is abrief 30-point questionnaire test that is used to screen for cognitiveimpairment. It is commonly used inmedicineto screen fordementia. It is also used to estimate the severity of cognitive impairment at a givenpoint in time and to follow the course of cognitive changes in anindividual over time, thus making it an effective way to document anindividual's response to treatment. In the time span of about 10minutes it samples various functions includingarithmetic,memoryand orientation. It was introduced by Folstein
et al.
in 1975,
. This test isnot the same thing as amental status examination. The standardMMSE form which is currently published by Psychological AssessmentResources is based on its original 1975 conceptualization, with minorsubsequent modifications by the authors.Various other tests are also used, such as the Hodkinson
 abbreviatedmental test score(1972,geriatrics) or theGeneral Practitioner Assessment Of Cognitionas well as longer formal tests for deeperanalysis of specific deficits.
An Official Statement from the Department of Psychology of the School of Social Sciences of Ateneo de Manila University
On 9 April 2010, the Ateneo Psychology Department issued astatement regarding the psychiatric evaluation which was allegedly signed by 
Fr. Carmelo (Tito) Caluag
who was claimed to be a faculty of our Department in 1996.</EM< p>In our response, we said that the document is false; that Fr. Caluag isnot a psychologist or a psychiatrist and has never been affiliated withthe Ateneo Psychology Department.Today, 27 April 2010, another fabricated psychiatric evaluation hascirculated in the news, allegedly written and signed in 1979 by our founder and current professor, Fr. Jaime C. Bulatao, SJ. Fr. Bulatao hasearlier released his response, categorically denying that he has written

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