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NCMH Psychiatric History #1!

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Informant: Patient and Brother-in-Law!

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General Data:
F.R is a 21 year old male filipino, catholic, single, born on sept. 19, 1992 in Quezon City. This is his!
first admission to NCMH!

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Chief Complaint: According to Brother-in-Law - Substance abuse!

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HPI:
The patient is a known drug abuser indulging in shabu and marijuana 2x a day on most days since!
age 19. the patient was apparently well with no abnormal behaviour until 4 months prior to consult!
when the patient was noted to have decreased sleep and began experiencing auditory!
hallucinations, the content of which was unintelligible. No consult was done. 2 weeks later the!
patient, still with above symptoms was noted to have shouting sprees, and was noted to be!
irritable. no consult was done, no medications were taken. !

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During the interim the patient continued to indulge in shabu and continued to experience auditory!
hallucinations and shouting sprees, with associated irritability until 3 weeks prior to admission!
when the patients relatives brought him to our institutions emergency room for consult. at the ER!
the patient was advised for admission but the relatives opted out. unrecalled medications were!
prescribed which relieved the auditory hallucinations and shouting spells of the patient. 2 weeks!
prior to consult the patient was noted to continue indulging in shabu and was caught trying to sell!
his watch. his family again brought him to our institutions ER where he was advised admission for!
detox therapy. the patients relatives agreed, prompting admission. !

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Past psychiatric and medical history:!

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The patient has no known prior psychiatric disorders and no comorbid medical or neurological!
illnesses. !

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Family History:!

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The patients father is 70 years old and has no known comorbid illnesses such as diabetes,!
hypertension, asthma, PTB or any psychiatric conditions.!

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The patients mother is 40 years old and has no known comorbid illnesses such as diabetes,!
hypertension, asthma, PTB or any psychiatric conditions.!

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! ! Late Childhood: ! ! The patient got along with his classmates and did well in school but dropped out at 2nd year high! school. ! ! Adulthood: ! ! The patient has had no job experience since he dropped out of high school.! ! . ! ! Sexual History: ! ! The patient had his first girlfriend at 16 and lost his virginity at 18.! ! Fantasies and dreams: ! ! No fantasies were elicited in the patient. or! military history. He did well in school and got along with other children. The patient states his dream is to become a member of! the PBA. he developed a passion for basketball and had his first girlfriend at 16. He currently lives with his family in a 2 storey! well ventilated house with 4 inhabitants. The patient is a practicing catholic. He has a satisfactory social life however his! drug abuse has caused him problems with his family.shabu and marijuana. He began to abuse! drugs at age 19 . water is provided by maynilad and the house is not in a! flood prone area. he began to drink 1 case of beer per week at age 14. He denies any involvement with the police or the barangay hall. ! ! Early Childhood: ! ! The patient and the informant have no knowledge of this aspect of the patients history! ! Middle Childhood: ! ! The patient notes that the was often scolded by his father and punished by being beaten with a! ruler. he has no marital history. which he took almost daily. he is not currently sexually! active.Anamnesis:! ! Prenatal and Perinatal history: the patient and the informant has no knowledge of this aspect of the! patients life. losing his virginity at! 18.

no retractions.! ! Extremities:! ! Grossly normal extremities. The patient! denies auditory hallucinations currently however admitted to experiencing them 3 months ago. No blocking. no edema no cyanosis full equal pulses.! when asked what he would do with a wallet he found he said that he would return it! ! ! ! Physical Examination:! ! General Data: patient is conscious. Not able to calculate. circumstantiality. non tender. no thrills. During the course of the interview the patient displayed good! eye contact and was noted to be irritable. no murmurs! ! Abdomen:! ! Flat. soft in volume. symmetric chest expansion. normal rate. no lifts. no heaves. The patient displayed good stream of! thought with good coherence. or tangentiality was noted. His speech was normoproductive. Soft. The! patient is alert. and desires to help his family once he stops abusing drugs. no masses.3! ! HEENT:! ! Normocephalic. Tattoo on left pectoralis area. He is! dressed appropriately in black shirt and red shorts. He has good judgement. place and person. He appears clean. not in cardiorespiratory distress.! ! ! . oriented to time. His mood was euthymic with appropriate affect. full range of motion.! recent and remote memory. oriented to person only. RR 18. He is well groomed with medium length hair! and trimmed nails. Pink palpebral conjunctiva.! ! Neuro Exam! Cerbrum:! ! Conscious.Virtues: ! ! The patient heavily values family. He has no delusions or suicidal ideations. Normoactive bowel sounds. no adventitious breath sounds. He is of athletic build and tall height. ! ! Mental Status Exam:! ! F. PMI: 5th ICS Left MCL. The patient has good fund of knowledge. tympanitic all over. poor immediate and recent memory. with! clear fluency. no cervical lymph adenopathy. coherent. no anterior neck mass. clear breath sounds. lagging. regular rhythm.R is a 21 year old male that appears old for his age. and intact abstract thinking -! he can note the similarities and differences between a car and airplane. no neck vein engorgement! ! Chest and Lungs:! ! Grossly normal chest. with poor concentration. He! was unable to articulate what these voices said.! no ! CVS:! ! Adynamic precordium. no bruises non tender cranium. T 36. ! ! Vital Signs: BP 110/ 80 CR 80. and intact immediate. no tonsillo-pharyngeal congestion. incoherent.

no agraphia. VI : intact EOM! CN V: good masseter tone! CN VII: no facial asymmetry! CN VIII: can hear bilaterally! CN IX X: good gag reflex! CN XI: can shrug shoulder against resistance! CN XII: tongue in midline! ! ! ! Motor:! ! ! ! ! ! Sensory! .Cerebellum:! ! No Dysmetria. no dysdiachokinesia. IV. negative romberg’s test! Cranial Nerves! ! CN I : not assessed! CN II: pupils equally reactive to light! CN III.