CDD WORKSHEET

PART II

1. Name: Masigan, Joey Guerero Rank: CPT AFPSN: O-134135 BOS: PA

2. Date of Enlistment: Total Year in Service:
3. Date of Previous Hospitalization: 2014 ETE:
4. Date of Present Hospitalization: 05 Oct. 2018

5. History of Present Illness:

Chief complaint: hearing of voices, loss of sleep

Since 2004, patient has been working in the armed force. From 2004 to 2015, patient has been assigned
in Mindanao where he had war encounters.
4 years prior to consult patient experienced stress, loss of interest in his work and felt depressed.
Patient sought consult and was admitted at an army hospital. Patient could not recall his diagnosis at
that time. Patient was subsequently discharged.
Before 2017, per the patient, he has been admitted twice already and was assessed to have bipolar
disorder type 1, patient had unrecalled medication.
1year prior to consult patient started to experience hearing voices like someone giving order and also
had visual perceptions of battlefield. Patient still have depressed mood accompanied with social
withdrawal and loss of interest in daily activities. Patient was eventually assigned in a mission which
aggravated the symptoms. In addition to that, he was not able to complete the said mission. Patient also
had difficulty of sleeping with only 2-3hrs per day. Patient used to have distressing memories and
dreams as well. Patient was noted to be avoidant and does not want to return to battlefield anymore.
Patient also had difficulty concentrating and had flashbacks. Persistence of all the symptoms prompted
for consultation hence admission.
6. Physical Examination on Admission
General Survey: Conscious, Coherent, Oriented to person and place
Vital Signs: BP: 110/80, PR: 86bpm, RR: 24cpm, T:36.8
HEENT: pink palpebral conjunctivae, anicteric sclera,(-) neck mass, (-) hoarseness of voice
Chest/Lungs: symmetrical chest expansion, clear breath sounds
Heart: Adynamic Precordium, normal rate, regular rhythm,
Abdomen: Flabby, soft and non-tender
Extremities: no gross deformities, full and equal pulses, CRT >2seconds

7. Mental Status Examination

Patient seen and examined an adult male, looks appropriate for his age, well kempt and clad in
hospital uniform. Patient is cooperative and answers to cues able to maintain eye contact. No tics, or
mannerisms noted. Speech is normoproductive at a normal rate and soft tone. Has euthymic mood with
congruent affect but feels sad when recalling the events in war. Patient has logical, relevant and
organized flow of thinking. Patient had no auditory and visual hallucinations. Patient has flashbacks of
incidents in war. He is oriented to person, place and time. Patient has good concentration and good fund
of knowledge. The patient’s immediate, recent and remote memory were all intact. Patient has fair
insight and judgement.

8. Course in the Ward

On the day of admission (05-10-2018), patient was brought to ACU/ ward A/officer ward, and
consent was acquired, patient was placed on a caffeine-free diet, as well as low salt and low fat diet.
Routine diagnostics and ancillaries were requested and done including CBC q PC, blood typing, UDA,
FBS, BUN, Creatinine, SGOT, SGPT, Na, K, HbsAg, TC, TG, HDL, LDL, RPR/VDRL, 12LECG,
CXR(PA View). Medications were started including (Vitamin C 500mg/tab 1 tab OD, Multivitamin + B
Complex 1 tab OD, Irbesartan 150mg/tab, 1 tab OD, Allopurinol 300mg, 1 tab OD, Aripiprazole
15mg/tab). Sleep pattern was monitored, and the patient was for battery of psychological exam
On the 20th hospital day (25-10-18), patient was given paracetamol 500mg/tab, 1 tab q4 then
PRN for >37.7C, and was still for observation.
On the 23rd hospital day (28-10-2018), Coamoxiclav 625mg/tab, 1tab BID was started, and was
advised to increase oral fluid intake, dysuria was noted with WBC of 25-30 and RBC 5-8.
On the 37th hospital day (06-11-2018), repeat urinalysis was ordered at early AM on Nov. 18, no
subjective complaints, has good sleep and good appetite, patient had euthymic mood with congruent
affect, Coamoxiclav was discontinued.
On the 38th hospital day (07-11-2018), patient was advised to increase OFI and ciprofloxacin
500mg tab for 7 days was started, patient was also for repeat Urinalysis after 7days of antibiotics use.
On the 15thhospital week (15-01-2019), patient was for CDD processing.
On the 22nd hospital week (6-3-2019), elevated lab results were seen, and were referred to IM
Gen Med.
On the 22nd week hospital week (07-03-2019), general medicine suggested to revise the diet to
low salt, low cholesterol, caffeine free, and rosuvastatin 20mg/tab 1 tab OD was started, with
continuation of Irbesartan 150mg/tab, 1 tab OD, patient was under BP monitoring TID.
On the 25th hospital week (18-03-2019), the fasting blood glucose was improved, and diet was
revised to low carbohydrate, high protein, low salt, caffeine free diet, patient was also referred to
dietary service for dietary counseling, and was advised to exercise for 30mins 3x a week.
On the 26th hospital week (26-03-2019), patient had good sleep and appetite, no hallucination
and delusion, and still for CDD. Present medications and management still continued.
On 32nd hospital week (07-05-2019), patient had no subjective complaints, patient had good
sleep and appetite, no perceptual disturbances, has euthymic mood with congruent affect, still for CDD
processing, and still for observation.
On 32nd hospital week (09-05-2019), medical certificate was issued, but still for CDD
processing.
On 32nd hospital week (11-06-2019), patient had good sleep and appetite, and was for repeat
CBC, PC, cholesterol, creatinine, SGOT, SGPT, glucose, HbA1c, HDL, LDL triglycerides, BUN,
present medications and management still continued.
On the 33rd hospital week (12-06-2019), patient was referred to IM for close monitoring.
On the 34th hospital week (18-06-2019), urinalysis and KUB utz were done.
On the 37th hospital week (09-07-2019), patient had good sleep and appetite, has euthymic
mood with congruent affect, still for CDD processing, present management and medications still
continued.
On the 40th hospital week (17-07-2019), urinalysis, and KUB utz were done and was referred
back to GU. Levofloxacin 500mg/tab, 1 tab OD for 2weeks was started, was requested for urine GS/CS
and urinalysis after 2weeks.
On the 40th hospital week (20-07-2019), patient was for repeat urinalysis on 31 July 2019, and is
for referral to GU service with results, still for CDD processing. Present management and medications
were continued.
 CDD WORKSHEET

PART III

Name: Masigan, Joey Guerero Rank: CPT AFPSN: O-134135 BOS: PA

Date of Enlistment: Total Year in Service:

9. Laboratory Examination
CBC 06/oct/18 26/oct/18 6/Mar/ 12/Jun/ Blood 09/oct/18 06/MAR/ 08/m 12/Jun/19
19 19 Chemistry 19 ar/19
Hemoglobin 164 167 164 169 HBA1C 5.76%
Hematocrit 0.50 0.51 0.48 0.49 SGOT 56.6 34.9
RBC 6.07 6.23 5.97 6.27 SGPT 151.7 60.80
WBC 6.50 15 6.40 8.00 cholesterol 5.37
Segmenters 0.44 0.71 0.42 0.45 Crea 109.13 113.31
Lymphocytes 0.37 0.21 0.43 0.42 BUN 5.91 5.45
Eosinophils 0.11 0.03 0.09 0.08 glucose 6.33 5.57
Monocytes 0.07 0.05 0.06 0.05 Na 141.4 140.8
Basophils 0.02 0.00 0.00 0.00 K 4.40 4.41
MCV 82 81 81 79 Cl 106 101
MCH 27 27 27 29 Ca 1.19 1.15
MCHC 33 34 34 34 Mg 0.54 0.52
RDW 10.85 11.22 10.80 11.22 FBS 6.46 6.46
Platelet 189 222 244 222 OGTT 10.26 10.26
1sthr
Blood Type OGTT 7.03 7.03
2sthr
URINALY 10-6-2018 10-7- 10-27-2018 11-7-2018 15/nov/2018 3-6- 19/june/20
SIS 2018 2019 19
Color LIGHT YELLO DARKYELL YELLOW LIGHT YELL LIGHT
YELLOW W OW YELLOW OW YELLOW
Clarity Slightly Slightly Slightly Slightly Slightly Turbid Slightly
Turbid Turbid Turbid Turbid Turbid Turbid
Specific 1.030 1.025 1.025 1.030 1.025 1.030 1.010
Gravity
PH 6.0 6 6.0 6 6.0 6 6
CHON Negative Negative Negative Negative Negative Negati Negative
ve
GLUCOSE Negative Negative Negative negative Negative negati
ve
RBC 0-1/HPF 0-1/HPF 5-8/HPF 0-2/HPF 0-2/HPF 6- 0-2/HPF
8/HPF
Pus cells 6-8/HPF 0-1/HPF 25-30/HPF 18-20/HPF 5-7/HPF 18- 5-7/HPF
20/HP
F
Epithelial Moderate RARE RARE RARE RARE RARE RARE
cells
Mucus Moderate RARE many FEW FEW FEW
Threads
Amorphous Many RARE moderate moderate FEW FEW FEW
Urates

10. Chest X-ray (09 oct 2018)

Lungs are clear.
Heart is not enlarged
Aorta is not dilated.
Diaphragm and sulci are intact.
The rest of the visualized chest structures are unremarkable.
11. KUB ultrasound
- prostatic concretions
-negative ultrasound study of both kidneys and urinary bladder
12 L ECG
- sinus rhythm
- poor R wave progession v1-v3
13. Urine GS/CS
- NO GROWTH AFTER 48 HRS OF INCUBATION

14. Treatment
Vitamin C 500mg/tab 1 tab OD
Multivitamin + B Complex 1 tab OD
Irbesartan 150mg/tab, 1 tab OD
Allopurinol 30Omg, 1 tab OD
Aripiprazole 15mg/tab

15. Psychological Examination Result:

16. Diagnosis:
- Schizophrenia, hyperuricemia, HTN ST II CONTROLLED
16. Remarks: for CDD

Head, Department of MHBS