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I.

Identifying Data
J.S. is a 30 years old, male, single, high school undergraduate, Roman Catholic, currently
residing at Sta. Ana Manila, who had been admitted in institution for second time.
II. Source of Information: First wife of patient with reliability of 80% and current wife with reliability
of 85%
III. Chief Complaint: According to the current wife patient had blank stare and talks to himself.
IV. History of Present Illness
Patient is a known alcoholic, approximately 4 bottles of 350 mL of gin every week for 19
years. Patient also takes Methamphetamine and cannabis for approximately for 9 years.
1 year and 1 month PTC, patient was noted to
V. Past Psychiatric History
February 16 2015 Admitted at UPPGH Psychiatric ward for 2 weeks, Methamphetamine-
induced Psychotic Disorder, Risperidone ODHS, Olanzapine

VI. Substance use, Abuse and Addiction


Patient is a smoker , non-alcohol beverage drinker and denies illicit drug use. She used to
drink 3 cups of coffee every day.

VII. Past Medical History


2000 Benign breast cyst excision, UERM Hospital
December 2014 Muscle strain
January 2015 Scoliosis

VIII. Family History


Patient is the third of 4 siblings, 2 sons and 2 daughters, in their family. Her younger
sibling looks up on her because she was a diligent, obedient and respectful daughter which her parents
usually praise.
Lucio is Sonias father, 65 years old, retired cooked in a cruise ship and currently
working as a cook in a restaurant. He is a very responsible father to his family. Though he was always
out working, he makes it to a point to spend time with his family during his vacation days. At the age
of 60 years old, he retired from cooking in the cruise ship and rested from work for a couple of years.
He is a supportive father to all of his children especially in terms of their decisions in what field his
children will take. When Sonia got sick, he went back to work as a cook in a restaurant so he can
provide money for her treatment. He feels sad about what happened to Sonia because she was the one
that he was hoping that could help out in schooling of his youngest son. Lucio and Sonia have a good
father and daughter relationship. They never had any argument or fight because Sonia always obeys
and respects Lucios words. Sonia respects him so much that she wants to give him back all the money
he spent on Sonias schooling.
Sandra is Sonias mother, 63 years old, high school undergraduate and a full time mother.
She is a loving mother to her children and caring wife to her husband. She is very understanding to
Sonias condition. She praises and set Sonia as a good example among her children since Sonia is an
obedient and respectful daughter.
Father Pulmonary Tuberculosis (resolved); Hypertension
Mother and Sister Benign breast cyst
First degree cousin Bipolar Mood Disorder

IX. Personal History (Anamnesis)

X. REVIEW OF SYSTEM
(-) weight change (-) urinary/bowel changes
(-) fever (-) blood-stained stools
(-) cough/colds (-) polydipsia/polyuria

XI. PHYSICAL EXAMINATION

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A. GENERAL SURVEY
The patient is alert, cooperative, oriented to time, person, and place and ambulatory. She
looks healthy, not in acute respiratory distress and in pain. She is a medium built woman, dress
and groomed appropriate for her age.
B. VITAL SIGNS
BP 110/60 mmHg Normotensive
HR 70 bpm Normal
Pulse Rate 73 bpm Normal
RR 16 breaths/min Normal
Temperature 37. 5 C Afebrile

C. SKIN
The patients skin is pink, moist, with good skin turgor and warm to touch. There is
no edema, erythema, cyanosis, and masses noted. The nail beds were pink and neither clubbing
nor koilonychias were observed.
D. HEENT
The patient has long length black hair with evenly distributed volume, pattern and
texture. Her head is symmetrical and normocephalic without lesions, masses, scars and tenderness.
The scalp has no lesions, non-edematous, no parasites nor scales. Neck has no limitation of
motion, nuchal spasm or rigidity. Upon inspection, there was no enlargement of her parotid,
submandibular glands and cervical lymph nodes. Thyroid gland moves with swallowing and
trachea is in midline position. On inspection of her eyes, eyes are symmetrical and not protruding.
There were no ptosis or strabismus noted. The eyebrows are also symmetrical and with equal hair
distribution, eyelids were non-edematous. Lacrimal glands were not swollen or tender. She has
pink palpebral conjunctiva with no inflammation, masses nor ulcerations noted. She has anicteric
sclera with no corneal ulcers or opacities. Her pupils are equally reactive to light, accommodation,
consensual reflex. There were no visible lesions, masses, ulcerations or serous drainage in her
ears. Her auricles were symmetrical. Her nose is symmetrical and nasal septum is in midline.
External nares are equal in size and shape. Vestibule and nasal cavity has no masses,
serous/purulent/blood-tinged drainage. Both nostrils are patent without watery/ mucous discharge.
No nasal flaring was noted. The lips are symmetrical and no masses. Gums and buccal areas are
pinkish, free of lesions, masses or ulcerations. The tongue is pinkish and mobile, free of masses or
ulcerations. The palate is smooth and free of lesions. The floor of mouth is free of masses or
ulcers.
E. THORAX AND LUNGS
Thoracic cavity is symmetrical with a prominent rib cage. There were no chest
retractions, use of accessory muscles, stridor, masses, lesions and discolorations noted. Upon
palpation, there was an equal chest expansion, normal tactile fremitus, no tenderness and palpable
mass noted. On percussion, all lung fields were resonant. On auscultation, there was symmetrical
and clear breath sounds, no wheezes or adventitious sounds. Upon inspection of breast, there was
a surgical scar on the left breast in the upper outer quadrant. No tenderness, ulcerations and
discharge noted.
F. CARDIOVASCULAR
There were full and symmetrical peripheral pulses with grade of +2 and normal
capillary refill. Carotid pulse is rapid upstroke and gradual downstroke, no presence of thrills and
bruits. Upon inspection of the chest, there were no masses, lesions and precordial bulging. On
palpation, there were no thrills and heaves noted. On auscultation, normal rate and rhythm of heart
sounds was noted. No murmurs, distinct S1 and S2 with PMI at 5th ICS LMCL. There was no
cyanosis, clubbing, venous engorgement or edema.
G. ABDOMEN
On inspection, abdomen was flabby with inverted umbilicus. No presence of spider
angiomas, palmar erythema, dilated superficial veins around the umbilicus. Upon auscultation,
there was normoactive bowel sounds on all quadrants. No presence of bruits and borborygmi. On
percussion, all quadrants are tympanitic. Spleen was not palpated in the Traubes space. Upon light

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and deep palpation, there were no pain and tenderness. There was no costovertebral angle
tenderness was noted.
H. MUSCULOSKELETAL:
Upon inspection, there were no inflammation, lesions and ulcerations noted. Muscle
tone on the both upper and lower extremities is symmetrical. Muscle strength grade of 5 in all
upper extremities and lower extremities. No presence of flaccidity, rigidity and joint pains noted.
I. NEUROLOGIC
Patient was oriented to person, time and place. She was conscious, coherent and
cooperative during the interview. All cranial nerves were intact, pupils equally reactive to light
with normal consensual reflex and accommodation. All DTRs were elicited with a grade of +2.
Patient was negative Babinski test. Sensory pathway was intact and symmetrical (pain and
temperature, light touch, proprioception).

XII. MENTAL STATUS EXAMINATION


A. Appearance: Patient appears to be well groomed, dressed appropriate for her age and medium
built. She is cooperative during the interview.
B. Motor: Patient was lying down on her bed with knees bent hugging a pillow. She has a brief eye
contact. No unusual tics,
C. Speech: Speech is understandable, clear, coherent, soft spoken, slow and limited.
D. Affect & Mood: Affect is constricted with diminished emotional expression. Mood is depressed
and anxious.
E. Thought Content: Patient presents with somatic and persecutory delusions. No preoccupied
suicidal ideation.
F. Thought Process: Patients thought process is linear, organized and goal directed.
G. Cognition: Patient is alert, oriented to time, place and person. She was able to count backwards by
7 starting at 100 therefore, normal concentration. Immediate, recent and long term memory is
intact since patient was able to tell me what she ate for breakfast this morning, repeat the three
numbers and was able tell me her childhood experiences. Patient was able to calculate correctly
322 multiplied by 2 and was also able to identify the similarities between a chair and a table.
H. Insight: Patient denies that she is delusional and with psychiatric problem but patient is aware that
she is sick.
I. Judgement: When patient was asked if she was inside a building on fire with a child what will she
do next? She said that she will save the child and herself so both of them can escape the building
together.
XIII. DSM V DIAGNOSIS: Substance-induced Psychotic Disorder (Alcohol vs Methamphetamine)
XIV. TREATMENT PLAN

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