Khristofher P.

Santos
Date & Time: July 16, 2015; 5:30 PM
Source: Patient
Reliability: 90%
General Data:
Sarah B. is a 25 yrs. old single Filipino female, a Roman Catholic born on June
10, 1990. She is residing at Geronimo St., Tandang Sora, Quezon City and currently
has no job. She self-referred for the first time at MCU-FDTMF Hospital on July 15,
2015
Chief Complaint:
Pakiramdam ko po wala akong kwenta at nadedepress po ako.
History of Present Illness:
The patient stated that her current difficulties began 10 months ago following
the end of a 3 year relationship with her first boyfriend. She stated that she has
never felt that kind of sadness before. The patient stated that she used to lock
herself in her room day and night for almost 2 weeks after their break-up which
affected her job and daily activities in that time. It took her almost 4 months to start
to move on, but stated that it didnt go so well and instead began to have a feeling
of low mood most of the day, decrease in energy, decrease interest in most of her
activities and even developed insomnia. Due to these stated difficulties, the patient
lost her job 3 months ago because of continuous poor performance. This incident
about her job made the patient feel depressed, worthless and stated that she finds
it hard to concentrate on a single activity. She has no actual suicidal attempts but
admitted that sometimes she thinks that dying is a good solution to relieve her sad
feelings. Despite her suicidal ideation, she does not think of hurting others. Because
of her condition, the patients family become so concerned and urged the patient to
seek medical care since they all noticed that she is becoming thinner and looking
unhealthy. Due to believing that her condition is not normal and the continuous
persuasion of her family, the patient decided to seek medical care and experts
advice in MCU-FDTMF Hospital.
Past Psychiatric History:
The patient stated that this is the first time she ever felt bad about herself.
She has no past psychiatric complaints and no other past emotional traumas.
Substance Use:
The patient is not taking any recreational drugs. She does not smoke nor take
any alcoholic beverages.
Past Medical History:

The patient did not have any childhood diseases and claims that this is her
first time seeking medical assistance and no record of surgery and hospitalization
from other hospitals. She stated that she has complete vaccination, but no vaccine
records were presented. She has no known food and drug allergies.
Family History:
Her mother is 55 and her father is 60, both parents have controlled
hypertension and currently manage their own store business. She has one 18 yr. old
brother, who has no known disease and currently studying in college. She stated
that she has no knowledge of any mental and psychiatric illness in any of her 1 st
degree relatives. She added that there are no known suicidal incidents that
happened in her family. Other heredo-familial diseases such as asthma, cancer,
diabetes and cardiovascular disease are not present in her family.
Developmental and Social History:
The patient was born in Quezon City, the eldest with one younger brother.
During her childhood days, her mother stayed at home while she was growing up.
She describes her relationship with her family as warm, and reports that she is
particularly close with her mother. Her family members are relatively shy people
and only have a small circle of close friends. She cannot recall most of her early
childhood, but stated that there was no major occasion that occurred. She is
uncomfortable around people she doesnt know well and would rather stay alone.
She met her first boyfriend during college. He is also the first and only man with
whom she had been sexual active. She stated that the relationship ended because
he wanted to see other people. Since then, her difficulties started and began to
affect her life.
Review of System:
A. General: (-) Fever, (-) Fatigue, (+) Weakness, (+) Decrease weight, (-) Night
sweating, (+) loss of appetite
B. Skin: (-) Back acne, (-) Rashes, (-) Pruritus, (-) Changes in color, (-) Changes in
hair, nails, (-) Changes in
sizes and color of moles
C. HEENT
Head: (-) headache, (-) head injury, (-) Dizziness
Eyes: (-) vision problems, (-) corrective lenses, (-) eye pain, (-) diplopia, (-)
excessive lacrimation & redness
Ears: (-) hearing loss, tinnitus, & otorrhea
Nose: (-) rhinorrhea, epistaxis, obstruction, (-) Cold
Throat: (-) dysphonia (hoarseness), dysphagia, & odynophagia
D. Breast: (-) Lumps, (-) Pain

E. Respirator: (-) Cough, (-) Sputum production, (-) Chest pain, (-) Hemoptysis, (-)
Dyspnea
F. Cardiovascular: (-) Chest pain, (-) Palpitation, (-) Dyspnea, orthopnea, (-) Easy
fatigability, (-) Edema
G. Gastrointestinal: (-) Abdominal pain, (-) Nausea, vomiting, (-) Heartburn, (-)
Flatulence,
(-) Hematemesis, (-) Hematochezia, (-) Melena, (-) Diarrhea,
(-) Constipation
H. Genitourinary: (-) Dysuria, (-) Frequency, (-) Urgency, (-) Hesitancy, (-) Urinary
dribbling, (-) Polyuria, (-) Nocturia, (-) Hematuria, (-) Genital pruritus,
(-) Discharge,
I. Musculoskeletal: (-) Myalgia, (-) Arthralgia, (-) Arthritis, (-) Cramps, (-) Backache
J. Hematologic: (-) Anemia, (-) Easy bruising, (-) Bleeding,
K. Endocrine: (-) Heat and cold intolerance, (-) Hyperhidrosis, (-) Polydipsia,
polyphagia, polyuria
L. Nervous: (-) Syncope, (-) Seizure, (-) Paresis (weakness), (-) Hypoesthesia
(numbness), (-) Paresthesia (abnormal sensation), (-) Memory problem
M. Psychiatric: (-) nervousness, (+) tension, (+) mood swings, (+) depression, (+)
suicidal ideation, (+) decrease in social interest
Physical Examination:
General Survey:
The patient is ambulatory and looks thin. The patient is alert, coherent and
with moderate distress. She is properly dressed and not well groomed but with no
foul odor.
Vital Signs:
Pulse Rate: 78 bpm
Respiratory rate: 16 cycle per minute
Temperature: 36.8 C
Blood pressure: 120/80
Pain: 0 / 10
Height: 1.6 m
Weight: 49 kg
BMI: 19.14 kg/m2
Skin: Skin is soft, dry, warm and fair. No lesions. Nails are not trimmed. Nailbeds
pink with no cyanosis or clubbing. Hair is fine and scalp has no lesions

Eyes: Visual acuity 20/20 without corrective lenses. Pupils equal, round and
reactive to light, extra ocular movements intact. Conjunctiva is pale with no redness
or exudates. Eyelids without lesions. Sclera without icterus.
ENT: Hearing grossly intact. External auditory canals patent, free of cerumen,
auricles without lesions, tympanic membranes intact with visible landmarks. Nares
patent andmucus membranes moist without erythema or exudates. No sinus pain
to palpation. No throat redness nor lesions.
Mouth: Dentition without lesions. Lips dry and chapped. Gums, tongue and mucosa
without lesions. Tonsils not enlarged and not erythematous and without exudates.
Pharynx clear.
Neck:
Full range of motion. Thyroid not palpable.
lymphadenopathy.

Trachea at midline. No

Breasts: Exam deferred.

Pulmonary: Chest symmetrical expansion. No deformities on posterior chest wall.
Lungs clear to auscultation and percussion, without adventitious sounds.
Cardiovascular: No neck distention. No deformities on anterior chest wall. PMI at
5th intercostals space, midclavicular line. Heart sounds Normal S1 and single S2.
No S3, S4, rubs, or murmurs. Carotids bilaterally without bruits.
Abdomen: No scars, inspection unremarkable. Bowel sounds normoactive. No pain
to superficial or deep palpation. Liver span 7 cm at the midclavicular line. Spleen
not palpated.
Genitorinary: exam not performed
Musculoskeletal: Full range of motion. No pain, edema, or deformity. Pulses full and
equal. No cyanosis, clubbing, or edema.
Neuro: Cranial nerves IIVII intact, Muscle bulk is appropriate in upper and lower
extremities. Motor strength is 5/5 in upper and lower extremities bilaterally.
Sensation intact to light touch, temperature, and pinprick. DTRs 2+ in biceps,
triceps, quadriceps and ankles. Gait full without impairment. Coordinationable to
do rapid alternating movements well and finger to nose test well with eyes open
and closed. Babinski responses negative.
Mental Status Examination:

Appearance and Behavior: The patient is not well groomed but still with proper
hygiene and appropriate facial expression.
She is in moderate distress but
cooperative. She acknowledges that she has a problem.
Motor activity: She has normal movements but has a habit of nibbling her thumb.
No abnormal or involuntary movements noted.
Speech: She is fluent, monotonous, pauses when needed and speaks in low voice.
No unnecessary statements and no foul words stated.
Mood: The patient is very sad.
She is crying while telling her story. She talks
positively, but her emotion states otherwise.
Affect: The patients expressions are appropriate with her sad emotion. No signs of
irritability noted.
Thought content: She fears that she will never find another man that will love her
like her first boyfriend. She is convinced that it was her fault that her boyfriend
ended their relationship to look for another people. She feels that it was her
punishment for being fired in her job and thinks that it will be hard for her to find a
new job. She also thinks about committing suicide but no actual attempt is made
yet.
Thought process: The patient knows that something is wrong with her and wants to
do something to change and improve herself. She is goal oriented and expresses
herself fully with sense.
Perceptual Disturbances: She has no hallucinations, no abnormal perceptual
misinterpretation of her external stimulus, and has intact grasp and sensation of
reality.
Cognition: The patient has trouble concentrating; she also has difficulty memorizing
long terms but easily remembers short terms. She can perform basic arithmetic but
has difficulty solving complex problems. The patient has no interest in new
knowledge and tends to rely on her previous experiences.
Abstract reasoning: The patient only sees what she wants to see and doesnt search
for other meanings in her life. She only focuses on what is in front of her and
disregard other things that might help her. She is afraid of her present and what her
future might bring.
Insight: She is well aware that something is wrong with her.
Judgement: She has good sense of judgement, because she wants to change and do
something about her problem.

Prepared by:

KHRISTOFHER P. SANTOS