Name of Patient: Monroy, Christian T.

Hospital: CCMH – OPD

Informant: Patient and Sister Consultant: Dr. Resontoc
Reliability: Good Date Taken: May 7. 2019
Historian: Alfonso Martin E. Plantilla Date Submitted: May 8. 2019

PSYCHIATRIC HISTORY

GENERAL DATA

C.M., 39-year-old male, Filipino, single, unemployed, right-handed, Roman Catholic,

elementary graduate, born on March 31, 1980 in Parañaque City and currently residing in
Bacoor City, Cavite sought consult for the first time at the CCMH- OPD on May 7, 2019 at
around 1:00 pm. He is accompanied by his sister.

PRE – MORBID PERSONALITY AND LEVEL OF FUNCTIONING

The patient was described to be introverted, and shy. According to his sister he has
already been admitted in a mental hospital before due to the same mental illness.

CHIEF COMPLAINT

According to the patient, may naririnig ako”

According to the patient’s mother, “hindi makatulog”

DURATION

One week

HISTORY OF PRESENT ILLNESS

The patient was apparently well seven months prior to consultation where in patient’s
father died due to trauma and this was all witnessed by the patient. After the incident, the patent
was seen to have changes in behavior one month after. He became more irritable and begins to
sell household belongings and runs away from home only to come back to beg for money. He
also has notions that he wants to be killed or someone wants to harm him. On the interim, the
was persistence of symptoms.
One week prior to consultation, patient’s relatives noticed difficulty of sleeping and tends
to hide sharp objects. This alarmed the patient’s relatives to seek consult at CCMH.

PAST MEDICAL / PSYCHIATRIC ILLNESS

The patient has no previous history of any medical illnesses such as hypertension,
Diabetes mellitus, bronchial asthma, tuberculosis, cancer nor kidney disease. He has no
previous hospitalizations, surgical operations, injuries. He has a previous history of
hospitalization in a mental institution. There is no known history of allergies.
FAMILY HISTORY

There is history of hypertension and goiter in the maternal side. No other history of
diabetes mellitus, bronchial asthma, tuberculosis, cancer nor kidney disease. There is no history
of psychiatric illnesses in the family.

PERSONAL AND SOCIAL HISTORY

Patient is a elementary graduate and is currently unemployed. He previously worked as

a tricycle driver. He is a non-alcoholic beverage drinker but smokes. He has a four-year history
of illicit drug use (Methamphetamine).

ANAMNESIS

Pre-natal: The patient’s mother’s pregnancy with him was planned. He was born
premature via VSD in a hospital attended by a doctor. No maternal health problems or
complications during pregnancy, delivery, or after delivery.

Early Childhood: The patient was breastfed but unsure of duration. He was at par with
age. The mother was the primary caregiver. He is the third of eight children. There were no
noted problems such as separation anxiety or temper tantrums.

Middle Childhood: The patient stopped school. He had poor academic performance.

Late Childhood: He had been close with his friends but his mother does not know about
any romantic relationships he had.

Adulthood: The patient became a tricycle driver. He became distant and does not
interact with friends nor family members.

REVIEW OF SYSTEMS

General (-) Weakness (-) Loss of appetite (-) Weight gain (-) Easy
Fatigability
(-) Wound (-) Rashes (-) Erythema (-) Pallor (-) Clubbing of nails
Integument
(-) Hyperpigmentation (-) Hypopigmentation
(-) Stiffness (-) Headache (-) Distention of veins (-) Masses
Head and Neck
(-) Swelling
Eyes (-) Corrective lenses (-) Pain (-) Redness (-) Discharge
Nose (-) Water discharge (-) Epistaxis (-) Colds
Ears (-) Otalgia (-) Vertigo (-) Dizziness (-) Tinnitus
Mouth and Throat (-) Tongue fasciculations
Respiratory (-) Cough (-) Dyspnea (-) Hemoptysis (-) Tachypnea (-) chest pains
Cardiovascular (-) Angina (-) Dyspnea (-) Palpitations (-) Orthopnea
(-) Anorexia (-) Abdominal pain (-) Constipation (-) Vomiting
GIT (-) Retching (-) Diarrhea (-) Abdominal distention (-) Nausea
(-) Melena (-) Hematemesis
(-) Increased in frequency (-) Polyuria (-) Oliguria (-) Nocturia
GUT
(-) Dysuria (-) Palpable mass (-) Flank pains
Hematologic (-) Easy Bruising (-) Easy bleeding
 (-) Polyuria (-) Polyphagia (-) Polydipsia (-) Diaphoresis (-)
Endocrine
Heat/cold intolerance
MSS/Extremities (-) Fractures (-) Joint pains (-) Edema
Nervous System (-) Seizures (-) Tremors (-) Slurring of speech (-) Headache

MENTAL STATUS EXAMINATION

Patient identifies himself as Christian and appears his chronological age of 39 years old.
He is appropriately dressed wearing a blue and white stripped polo shirt and blue pants. He
does not have any ticks nor mannerisms. He has poor eye contact with the examiner. He is
guarded towards the examiner. He has constricted affect together with a hypo-productive low
volume speech. He experiences auditory hallucinations but refuses to tell the examiner what he
hears. He is oriented to place and person but not to time. He has no suicidal nor homicidal
ideations. Patient repeatedly mumbles “papatayin ako”. Memory, fund of knowledge,
concentration, reading and writing, visuospatial ability, ability to follow three-step commands,
abstract thinking, judgment and insight were not assessed since patient was uncooperative and
refuses to answer questions. He has Level 1 of insight.

PHYSICAL AND NEUROLOGIC EXAMINATION

GENERAL SURVEY
The patient is conscious, coherent, oriented to place, and person, but not time. He
appears well developed and well nourished, ambulatory, not in cardio-respiratory distress, and
appears his chronological age of 39.

VITAL SIGNS
Blood Pressure = 110/60 mmHg, sitting
Cardiac Rate = 89 bpm, regular
Respiratory Rate = 19 cpm
Temperature = 36.4 °C, axillary

SKIN
Inspection: (-) pallor, (-) jaundice (-) erythema (-) hypo/hyperpigmentation (-) edema
Palpation: (-) warm/cool to touch (+) good skin turgor (+) normal moisture (-) dryness

HEENT
Head: (+) symmetrical (+) normocephalic skull (+) normal hair pattern
Eyes: (+) pink palpebral conjunctiva (-) redness (-) discharge
Ears: (+) symmetrical (-) lesions (-) swelling (-) discharge
Nose: (+) nasal septum, midline (+) symmetrical (-) deformities (-) discharge (-) epistaxis
Throat: (+) midline trachea
Palpation: (-) cervical lymphadenopathies (-) tenderness

CHEST AND LUNGS

Inspection: symmetrical chest, no lesions, masses, ulcerations, no subcostal retractions
 Auscultation: bronchovesicular breath sounds, no wheezing, no stridor

HEART
Inspection: no precordial bulge, (-) heaves, thrills
Auscultation: normal rate, regular rhythm, (-) murmurs

ABDOMEN
Inspection: (-) masses (-) lesions
Palpation: soft, non-tender abdomen

EXTREMITIES
Inspection: (-) gross deformities, (-) edema
Palpation: (+) full and equal peripheral pulses, (-) tenderness

NEUROLOGIC EXAMINATION

CN I Not assessed
CN II (+) direct and consensual light reflex; 2 – 3 mm EBRTL
CN III, IV, VI Good and intact EOM’s (-) nystagmus
CN V Good masseter and temporalis tone, equal facial sensation
CN VII Symmetrical facial movement
CN VIII Good gross hearing and balance
CN IX, X Can swallow and cough
CN XI Good SCM tone, good trapezius tone
CN XII Not assessed

Sensory Motor

DIAGNOSIS: F20.3 Schizophrenia, Undifferentiated Type

DIFFERENTIAL DIAGNOSIS

Schizoaffective disorder can manifest with manic and major depressive episodes, and patients
with this disorder can exhibit increased agitation and irritability. It differs from bipolar disorder
with respect to timing; patients with schizoaffective disorder exhibit psychosis even during
periods of euthymia, whereas patients with bipolar disorder only exhibit psychosis in periods of
mania or major depression.

Borderline personality disorder can manifest itself with uncontrollable anger and affective
instability. Patients with this disorder exhibit problematic impulsive behavior and poor
psychosocial functioning. It is differentiated from bipolar disorder by its much shorter duration of
altered mood (usually lasting hours at most), compared with bipolar disorder (which can last
weeks to months).

CASE DISCUSSION

Schizophrenia is a mental disorder characterized by disintegration of thought processes

and of emotional responsiveness. It most commonly manifests as auditory hallucinations,
paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by
significant social or occupational dysfunction. The onset of symptoms typically occurs in young
adulthood. Diagnosis is based on observed behavior and the patient's reported experiences.
In this case, the patient has undifferentiated type of schizophrenia. The undifferentiated
type of schizophrenia is a categorization for people who do not fit into four other categories of
schizophrenia. While such individuals do experience significant delusions, hallucinations,
disorganized speech, or disorganized or catatonic behavior, their symptoms are not
predominantly positive, disorganized, or movement disordered.

PLAN OF MANAGEMENT

Taking antipsychotic medication is the main treatment for most types of schizophrenia,
including undifferentiated schizophrenia. Some newer medications have fewer side effects than
medications that have been around for a longer time. There are many different antipsychotic
medications available, including ones like Aripiprazole and Risperidone. It is important for
people with undifferentiated schizophrenia to continue taking their medication even when their
symptoms lessen or disappear, since discontinuing medication may lead to symptoms coming
back.
If in cases the person with undifferentiated schizophrenia is also experiencing
depression or anxiety, antidepressants or anti-anxiety drugs, along with antipsychotic
medications, may help.
In this case, the patient was admitted in a mental institution and placed in the acute
crisis intervention unit (ACIU) for observation and treatment for three days. Medications given to
the patient includes: Risperidone 2 mg ½ tablet once a day at night, Levomepromazine 100 mg
½ tablet once a day and Diphenhydramine capsule 50 mg once a day.