CASE REPORT

Objectives

 To be able to discuss and understand the history of the patient
 To be able to do physical examination and Mental status examination to the patient
 To be able to correctly diagnose the case of the patient
 To be able to discuss the psychodynamics
 To be able to correctly state the prognosis of the patient

History

Identifying Data

This is a case of Janice Cabaya., a 31 year old female, single, Latter Day Saints member,
Civilian Patient, college undergraduate, unemployed, and was born on the 27
th
of September 1982
at Eastern Samar and is presently residing at #222 Taal St Armor Village Group 11 Southside Makati,
who was admitted at our institution for the first time on August 11, 2014.

Chief Complaint
Patient : “Gusto ko lang pong makaalis at alagaan yung nanay ko.”
Sister: “Baka po lalong makadagdag sa problema ng nanay ko.”

Informant and Reliability
• Patient: 0%
• Sister: 75%

Premorbid Personality
“Siya po yung nag-aalaga sa aming magkakapatid noong bata pa kame. Honor student din po sya.
Mahilig magbasa at magsulat pero tahimik po siya noon.” As stated by the informant

History of Present Illness

The present illness started 15 years prior to admission when the patient together with her
family decided to live in Manila. She was observed to be always in her room talking to no one. There
are times that when she gets out of their house, she would go home late at night and when asked
her whereabouts, she would say “Galing lang ako sa school.” Patient was observed to be quiet and
does not interact with her family.

Twelve years prior to admission, patient was observed to have decreased sleep and was
very talkative and flight of ideas was noted. At that time, she was on her 2
nd
year college, taking up
Computer Secretarial at STI Makati. She was brought to a quack doctor due to the symptoms
mentioned but no relief was noted. At this time, patient stopped her going to school because of
frequently not attending her class and would only stay at home, but patient is still able to do self-
care independently.

Eight years prior to admission, patient had her 1
st
boyfriend, Tranquillino Gallo, who was the
driver of their jeepney. According to her sister, there was a time when they went to a motel and they
had their first sexual intercourse. When their jeepney was not functional anymore, they lost their
communication which ended their relationship. She was still noticed to be very talkative at that
time.

Six years prior to admission, patient was brought to NCMH for consultation because she
was observed to be talking to herself, more talkative, prefers to be alone and always found in the
corner of her room. There are times while watching, she was seen talking to the characters in the
television. At that time, she needs to be prodded to eat, and was very irritable to anyone she sees.
She was heard saying to her mother “Lahat nalang ako ang gumagawa. Ikaw nakikipagtsismisan
lang sa kapitbahay.” She was admitted for 3 days and was given Haloperidol, Biperiden and
unrecalled sedative as home medications. After being discharged, patient worked as a housemaid
and caregiver for 6 months but at that time she was not taking her medications and her employer
noticed that she was always “tulala” and slow-moving. At home, she always talks at a loud tone and
summons fight against her family members. Patient’s sister claimed that the patient was having her
regular check-up but was not adherent to her medications and when asked why, she would say
“Hindi ko na kailangan ng gamot, magaling na ako.”

Interval history revealed that patient was still having difficulty in sleeping, talkative, talks to
herself, irritable especially when the television is turned off. She goes to church every Sunday and
can be asked to do household chores only if she wanted to do it. She was still non adherent to her
medications.

Three years prior to admission, patient’s sister said that “wala po siyang ginagawa kung di
sumigaw at di nag pampatulog sa gabi” which prompted them to seek consult to NCMH and was
admitted for four days. Before she was admitted, she still has good appetite, still active in her church
but with decreased sleep described as “idlip lang”. There was an incident that she was arguing with
the Bishop insisting that she was always right. Assaultive behavior was also observed when in the
house such as pinching her nephew’s ear and slapping him on the gluteal area. There was a time
when she slapped her mother on the head because she was stopped in doing her laundry. She was
adherent to her medication for three to four months after being discharged from NCMH and was
noted to have good sleep, good appetite and not irritable. But then she stopped taking her
medications and was noted to be talkative and with assaultive behavior. When asked why she
stopped taking she would say “masisira lang ang kidney ko”. Patient did not go home for a week,
and when she returned she was very filthy, dark skinned and thin. When asked about her
whereabouts she said “naghanap lang ako ng trabaho, may nagpatira sa akin na police na tricycle
driver”. Her sister saw signs of strangulation on her neck but patient did not disclosed if it is self-
inflicted or not.

Two years prior to admission, patient’s father died due to cardiac arrest. She was still
observed to be talkative and not sleeping adequately. She was also still non adherent to her
medications saying “lalo lang akong masisiraan”. Patient’s sister claimed that she would always
remember her dad but there was one incident wherein her brother did not like what the patient said
about their dad that led to the brother punching the patient. According to the sister, the patient
tried to apply for work three times but was rejected. She was also observed to be having
conversations with unseen individuals talking about business plans.

One year prior to admission, patient was not having adequate sleep, easily distracted on her
household chores, summons fight without provoking factors and when asked to go to the market,
she would buy things not on the list but can go to the movies alone. The family member decided to
bring her to NCMH again and was admitted for four days. After discharge she was adherent to her
medications such as Biperiden, Clonazepam, Risperidone and Divalproex Na for one and a half
months. When asked why she stopped taking her medications “magaling na ako imbes ibili ng
gamot, ibili na lang ng pagkain”.

Two months prior to admission, patient was observed to be talking to herself, disruptive,
assaultive and noted to have said “kinidnap ako, muntik nako ma-rape, naglaban lang ako.”
However, the patient’s family did not further asked about the incident. At this time, patient is still
with good appetite, can do her own laundry, goes to church regularly. There are times when she was
seen crying and then laughing after a few seconds. Still, the patient is non-adherent to her
medications.

One month prior to admission, patient was always out of their house and goes home wet.
She would say that she went out to watch movies. Due to the persistence of her symptoms, patient
was brought in our institution and hence admission.


Past Medical History
Patient has no known allergies to any food or drugs. Patient has no history of seizures or
convulsions. She has no previous hospitalizations and no previous surgeries.


Family Medical and Psychiatric History
Patient has family history of Diabetes Mellitus (mother) and hypertension (father, mother
and brother). There is no family history of psychiatric illness.


Personal and Social History
Patient is the eldest in a brood of 8, of Romeo and Floria. She is a computer secretarial
undergraduate. She lived with her maternal uncle and grandmother from 13-16 years of age.
She is presently living with her family in #222 Taal St Armor Village Group 11 Southside
Makati.
Patient is known to be non-smoker and an occasional alcoholic beverage drinker. Her sister
denied that the patient is using marijuana or shabu.



ANAMNESIS

Prenatal and Perinatal
Patient was born to a then 18-year-old G1 P0 via normal spontaneous delivery in a hospital
in Samar assisted by an Obstetrician. Patient’s sister claimed that the pregnancy was planned and
wanted but the patient claims that she was an unwanted pregnancy because her parents preferred
their first child to be a boy. There were no noted problems or complications at the time of delivery.

Early Childhood
Patient was bottle fed right after delivery. Her mother and a nanny took care of her. The
informant does not know if the patient was toilet-trained during this time.

Middle Childhood
Patient started her primary school at Boronggan Pilot Elementary School at Eastern Samar.
She got good grades, and was a consistent honor student. Patient was known to be quiet at school.
After school, patient would go home straight. Patient was fond of reading and writing. There was an
instance when she was called by her mom as “buwaya” because when she was born, her 2 younger
siblings died.

Late Childhood
Patient studied at Eastern Samar for her secondary education. She also got good grades, and
was still a consistent honor student. Patient had good relationships with his teachers. She lived with
her maternal uncle and grandmother from age 13-16 years and transferred to Manila with her family
thereafter. She is a college undergraduate taking up Computer Secretarial. Patient was not able to
finish her course because her condition started during this time.

Adulthood
Patient had her first boyfriend at age 23; it was their jeepney driver. Their relationship lasted
for only few months. Patient’s sister could not specify how long. She also had her first sexual contact
with the same partner.

Occupational History
Patient worked as a sales agent at a bank but was not able to finish her contract due to
unknown reasons. She tried to apply for a job but she was rejected for three times.

Educational History
Patient started her primary school at Boronggan Pilot Elementary School at Eastern Samar.
She got good grades, and was a consistent honor student. Patient was known to be quiet at school.
After school, patient would go home straight. Patient was fond of reading and writing.
Patient studied at Eastern Samar for her secondary education. She also got good grades, and
was still a consistent honor student. Patient had good relationships with her teachers.
She is a college undergraduate taking up Computer Secretarial. Patient was not able to finish
her course because her condition started during this time.

Marital and Relationship History
Patient had her first boyfriend at age 23; it was their jeepney driver. Their relationship lasted
for only few months. Patient’s sister could not specify how long. She also had her first sexual contact
with the same partner.
She has a long time crush for 1 year named Manuel Saranillas who is the brother of their
Bishop in their church. She was courted by a lot of men but she cannot bring them to their house
because she was afraid of her father.

Psychosexual History
Patient had her menarche at age 12. She had his first contact at age 23 with her boyfriend.
According to the informant, the patient only had one sexual intercourse with her boyfriend.


Religion
Patient is a baptized Catholic but converted to Jesus Christ of Latter Day Saints when she
was in high school.

Legal History
Patient has never been accused of any crime.

Social Activity
Patient’s sister claimed that the patient only have few friends. She would usually go out to
watch movies and attend church every Sunday.

Current Living Situation
Patient lives in a bungalow house, with 2 rooms. Patient’s mother, 2 sisters and her nephew
would stay on the first room and she would stay on the 2
nd
room with her other siblings.
Their garbage was collected every morning. Patient’s sister, Jessa and Juvenile, who both
work as a saleslady, were the breadwinner of their family.

Family Profile and Genogram


PARENTS
Father
Romeo died at the age of 51 due to Cardiac Arrest. The informant claimed that the father
would hit them every time he comes home from his work.

Mother
Floria, 50 years old, is diagnosed with Diabetes Mellitus Type II; S/P BKA. According to the
informant, she would always neglect the patient and hit the patient every time her husband hits her.

SIBLINGS
Janice
Index Patient
Romeo Jr
Died at 2 years old due to high fever.

Janet
Died at 2 years old due to high fever
Jerome
He is 26 years old. The informant said that the patient would sometimes follow what he says
but had one incident of argument last 2012.

Jessa
She is 25 years old. She frequently accompanies the patient but they would sometimes
argue because of the patient’s attitude.

Juvenile
She is 22 years old. She is not in a good relationship with the patient. They would often fight
due to petty things like the usage of bathroom and doing the laundry.

Jully Ann
She is 19 years old and is currently pregnant. She would always get irritable to the patient
because of her loud voice.

Jojo
He is 15 years old. He usually accompanies the patient especially when he is at home.
According to the informant, the patient is afraid of him because he would tend to fight back with the
patient.

NEPHEW
Scott
He is 3 ½ years old. He does not want to go near the patient because he is afraid of her.

Physical Examination (Done during Admission)

General: Patient is conscious, coherent and ambulatory
Vital Signs: BP: 120/80 mmHg PR: 80 bpm RR: 19 cpm Temp: 37.0C
Skin: skin is warm to touch, moist, with good skin turgor
HEENT: head has no gross deformities, anicteric sclera, pink palpebral conjunctiva, no nasoaural
congestion, no enlarged tonsils, and no cervical lymphadenopathy
Chest/Lungs: symmetric chest expansion, no retractions, no adventitious sounds, clear breath
sounds
Heart: adynamic precordium, normal rate, regular rhythm, no murmur
Abdomen: flabby abdomen, no lesions, normoactive bowel sounds, non tender on all 4 quadrants,
tympanitic
Extremities: full and equal pulse

NEUROLOGICAL EXAMINATION
Cerebrum: Patient is conscious and coherent, GCS 15
Cranial Nerves:
I. Not assessed
II. Pupils are 2 – 3 mm and both reactive to light
III, IV, VI Intact extra-ocular movements
V. Able to open and close mouth
VII Able to smile, frown and has no facial asymmetries
VIII Able to hear
IX,X Uvula is midline, gag reflex is intact
XI. Can shrug shoulders against gravity
XII. Able to protrude tongue with no deviations


Deep tendon reflex: 2+ on all
Cerebellum: Patient has no abnormal gait.
Pathologic Reflex: No pathologic reflexes noted

MSE
 Patient is an adult female, dark-skinned, medium built, looks appropriate for her age. She is
fairly kempt and groomed clad in blue shirt, maong shorts and flat black shoes and holds
bottled water and noted to have psychomotor agitation.
 She is able to maintain good eye contact with the examiner.
 She leans back on the chair with her hands crossed.
 No tremors, tics, mannerisms or stereotypical behavior noted
 Patient was conversant but gives irrelevant and tangential responses to questions
 Speech was hyperproductive, cannot be interrupted while talking, with normal tone
 Mood is labile with appropriate affect
 Patient cried during the interview and when asked why, she said “Gusto ko lang umuwi na.
Ayoko ng ibabalik ako sa mental. Mabait ang papa ko. Na mental ang papa ko at ang ate
ko”.
 Thought process is noted to have flight of ideas
 Oriented to time, place and person
 With intact memory
 Poor impulse control and judgement
 Insight level I


Admitting Diagnosis

Bipolar I Disorder, Current Episode Manic with Psychotic Features

Course in the Wards

August 11, 2014 (Hospital Day 1)

The patient was admitted under the service of Drs. Soriano and Dr. Pajarillo.
Diet: Diet as Tolerated
Diagnostics:
CBC with Platelet count
Urinalysis
Lipid profile
FBS
Na, K
BUN, Creatinine
SGPT, SGOT
Pregnancy Test
Chest X-ray PA View
12-L-ECG

Theurapeutics:
Bipolar I Disorder, Current Episode Manic with Psychotic Features

Start Risperidone 2mg/tab, 1 tab OD HS
Divalproex Na 250 mg/tab, 1 tab BID
Clonazepam 2mg/tab, 1 tab x 5 nights
Clonazepam 2mg/tab, 1 tab for insomnia PRN

Refer to social worker for issuance of permanent dependency
Admit to TR on 2 point restraints per protocol

Examinations Results Normal Values
Urea (BUN) 3.5 mmol/L 1.9-9.2 mmol/L
Creatinine 60 umol/L 53-133 umol/L
FBS 5.6 mmol.l 3.5-6.3 mmol/L
Cholesterol 4.3 mmol/L 0-5.9 mmol/L
Triglycerides 0.8 mmol/L 0-2.2 mmol/L
Sodium 141 mmol/L 135-156 mmol/L
Potassium 3.0 mmol/L 3.6-5.5 mmol/L
HDL 1.1 mmol/L 0.8-2.0 mmol/L
LDL 2.9 mmol/L 1.7-4.8 mmol/L
SGPT 18 U/l 0-20 U/l
SGOT 23 U/l 0-31 U/L

August 13, 2014 (Hospital Day 3)
The patient MSE
For full release to the general ward
Shift Risperidone to Quetiapine 200 mg, ½ tablet BID

August 18, 2014 (Hospital Day 8)
For repeat serum K tomorrow am
Start FeSO4 + FA, 1 tablet OD

Examination Results Normal Value
Potassium 4.2 mmol/L 3.5-5.5 mmol/L


August 21, 2014 (Hospital Day 11)
Repeat Urinalysis
Quetiapine 200 mg/tab, 1 tab BID
Divalproex Na 250 mg/ml, 1 tablet TID

September 3, 2014
Shift Divalproex Na to Lithium carbonate 450 mg/tab, 1 tablet OD
For lithium assay after 5 days of taking lithium

September 10,2014
For Thyroid exam (TSH, T3, T4)

Final Diagnosis

Bipolar I Disorder, Current Episode Manic with Psychotic Features