I.

GENERAL INFORMATION

Client name: P.P.L.

Ward: Male Ward
Doctor: Dr. D.L.T, MD, FPPA
Age: 23 years old
Sex: Male
Allergies: None
Diet: Regular except chocolates or with caffein
Height: 5’8ft
Weight: 55kg
Vital Signs: 120/90mmhg, 36.9°c, 74bpm, 14breaths/min, 98%o2sat
Name and Phone No. of significant other: Margie Lozada, 09074285284
Race: Caucasian
Dominant Language: Hiligaynon
Marital Status: Single
City of Residence: Iloilo City
Chief complaint: “gabayolente tana” as verbalized by the mother.
Diagnosis (admitting and current): Bipolar Mood Disorder

HISTORY OF PRESENT ILLNESS

Patient P.P.L. has known history of Bipolar Mood Disorder since 2017 with prior to medical follow-
up was brought by mother due to non-adherence to follow – up and rebellion. Had several admission at Psych
hospital due to scene , on and off violent, restlessness, upset, (+) delusion. On February 1 at home and outside
the area patient attempts to hold knife and shouting, threatening family members. Thus, mother decided to ask
help with Brgy. Captain to police thus they brought to PMHU.