VALDEZ, Gail-Marie R. EAEC- 3rd yr. PSYCHIATRIC ASSESSMENT AND MENTAL STATUS EXAM GENERAL DATA Name: A. B. J.

Address: Bicutan, Manila Sex: Male Religion: Roman Catholic Birthday: December 18, 1979 Age: 31 Marital Status: single Place of Current Interview: Ward 7, PGH Source of Information: Patient and watcher Reliability: seems reliable Referral: brought in

CHIEF COMPLAIN: As I ask the patient what brought him to the hospital, he answered “ Wala Po”. I proceeded with my interview, and along the way I asked him again what brought him to the hospital and he answered “Pinilit ko si Nanay na pumunta dito”. Then, I asked him what is the reason you forced your mother to bring you here he answered back to me, “ Kailangan ko ng gamot para gumaling.” I told him, “Kuya ano ba ang dahilan at kailangan mo ng gumaling ano ba ang sakit mo?” He answered “Wala naman”. After I have asked him that, I also asked his father who is also his watcher the reason of his son’s hospitalization, and he told me that he remembered the onset when he first noticed something was different about his son, “Dalawang araw ako sa Taytay noon, pagbalik ko nalaman ko na kumuha sha ng pera ng hindi namin alam, pagkatapos noon ay iba na ang kilos niya,

pabalik-balik at hindi natatapos sa trabaho. at hindi na din siya nakakatulog. Reason for consult: Q: “Where you upset about anything?” He answered “Wala. Precipitating Events: The patient responded “wala”. PAST MEDICAL HISTORY Psychiatric (Treatments.” He told me that when he saw these absurd things about his son they decided to bring him to a hospital and the doctor have told him that the patient was diagnosed with schizophrenia.” What ways did the Illness affects the patient?: The patient was affected gradually. HISTORY OF PRESENT ILLNESS Onset: Q: “When did you first notice something happening to you?” A: “ Wala naman”. but when I asked his father he told me that there were many times the patient was institutionalized. salita siya ng salita at ligo ng ligo paulit ulit. (Alcohol. Then the next episode was in 1997 since then the patient will be on and off mental institutions. sa bahay lang ako”. . (Any incidence of losing consciousness or seizure) The patient said that his mother told him that he had many seizure episodes during his childhood but when I asked his father about this he said that he cannot recall any. History of Previous Hospitalization and Treatment: The patient answered me. Hospitalizations) The patient related to me that this was the first time he was hospitalized. Substance Abuse) The patient said that he forgot if he ever drank any alcohol beverages but his father told me that the patient drinks alcohol whenever he is at home. I asked his father about his and he told me the first hospitalization was in the year 1995 where he first noticed the symptoms. “Wala.

Patient’s Attitude towards Parents and Siblings: The father told me that the patient is a caring and loving son to them. The father also told me that when the patient was an adult he would get angry and be angry and be violent to them if they do not allow him to go out or smoke cigarette. He also told me that he would beat his wife before.Mr. (Relationship of each Family Member in the Patient’s Upbringing) Mr. The patient told me that his brother also drank alcohol and would always beat him up. said that he had experienced marijuana and shabu. J. birthdays.B. Christmas and New Year. Antisocial Behavior) The father told me that before he drank alcohol almost every day but now he stopped.J. told me that they his mother and father is good to him except his brother because they always fight. PERSONAL HISTORY (Anamnesis) . B. Family Attitude towards Illness: The father said he and his wife were both very concerned with what happened to the patient but the brother doesn’t care and would even shout at the patient every time. (Family Traditions) The father told me that their family would get together in special occasions like. his father related to me that he only saw his son to possess marijuana FAMILY HISTORY (Family Members with Psychiatric Illness and their Hospitalization and Treatment) None (Family History of Alcohol and Substance Abuse. A. A.

as a child. Adulthood: . Toilet Training: The patient was toilet trained early and did not have any bedwetting episodes as he grew up. Age of Puberty: The patient told me that he remembered his pubic hair growing when he was 15 years old.Birth and Infancy: The father told me that the patient was a normal delivery and that his mother was around 35 years old that time. Drug Use: The patient has had experience of substance abuse and smoking. Adolescence: School: The patient loves to go to school Grades: His grades were low but he passed and never flunked any subject. Play with peers: The patient do not play with other children even his brother said his father. Childhood: Feeding Habits: The patient would have milk and congee every day until he was able to eat solid foods. They do not have problems in feeding him according to the father. 1st childhood memory: The patient remembered that he would watch T. he remembers that he was 7 years old that time and he would go to school.V. Emotional Problems: He told me he does not have any.

Have you been more or less active than usual? No Motoric Behavior: He moves normally. he does not have ataxia. Family History: Their family owned a house in Bicutan and they all live there. The father was an alcoholic before but he stopped when the patient is hospitalized. The brother seems to doesn’t care at all. He does not have any concern or interest about his sex life. Clothes: Patient was wearing a t-shirt and short during the interview. He does not have a girlfriend and was never married. Posture: He was stooping when I was talking with him.The patient never experienced to work because he was first hospitalized at the age of 14. Older or Young for Age: He looks appropriate for his age. They never had any problems until the patient was diagnosed to have schizophrenia. flexibility. He remembered that his mother told him he was christened when he was 7 months old but he cannot recall if he ever attended mass. Gestures: He did not show any gestures while he was talking. . They all sleep in the same room. He is well groomed. they were clean. MENTAL STATUS EXAM General Appearance: Gait: The patient does not have gait problems he walks steadily. and ne was seating on a chair. dyslexia. Facial Expressions: He smiles appropriately once in a while during our conversation. hyperactivity. Sexual History: He learned about sex in watching T.V. The mother was very concerned with this and she was the one very much affected with the situation.

Attitude Toward the Interview: He seems shy and will not look at me straight in the eye. no one is trying to influence him. Affect: The patient has appropriate content. the T. When is you birthday? He tol me December 18. person and place. He does not have dysartria upon saying Methodist Episcopalian.V. He does not have thought of harming himself.” Sensorium: Level of Consciousness: The patient is alert. Perceptual Disorder: The patient told me he does not hear any voices. He is oriented to time. and clouded. When I asked him about the meaning of the proverb “Nasa Diyos ang Awa nasa tao ang Gawa” he responded “ Hindi ko alam. He is defensive but cooperative. Mood: The patient has a gloomy and depressed mood. does not have special powers. does not have thoughts that he cannot get out of his mind. does not think about the end of the world. . confused. Thought Content: He does not feel that people wants to harm him. Memory: Where were you Born? He told me that his mother told him he is born in their house in Bicutan. is talking to him. He does not have any fantasies or dream.Emotional Appearance: The patient seems depressed. But. Speech: The patient has spontaneous speech. but he cannot recall what year. does not have strange body sensations. and people cannot read his mind. does not have strange experiences in sleep and does not have strange smells. Voice: The patient has whispered speech.

” What are your plans for the future? He said “Ganon pa rin. Philippine Presidents: He answered. gusto ko na nga umuwe. Jose Rizal. and Manuel Quezon.Where did you study? He said Daang Hari Elementary School Rcent Recall: Where were you yesterday? “ Andito pa din” What did you eat last night? “Isdang Bangus” Immediate memory: He was able to count six digits forward and backward. miss ko na pumasok sa school eh”. maglalaba at papasok sa school. Insight Level: Do you think you have a Problem? He answered “wala” Do you think you need help? He said “Hindi. gabi. Marcos. beans. Judgement: What will you do if you find an envelope in a taxi stamped addressed and sealed? He said he will not meddle with it because it belongs to someone else. Emilio Jacinto. lanka. . Manuel Roxas. 3 non related items and tested for five minutes: He forgot. amapalaya. Andress Bonifacio. Concentrations and Calculations: Count 1-10: able Simple Calculation: was not able to answer correctly Information & Intelligence: Name some vegetable: He answered. togue.

MULTI AXIAL DIAGNOSTIC SYSTEM AXIS 1: Schizophrenia AXIS 2: Obsessive Compulsive Disorder. Antisocial Personality Disorder AXIS 3: Obesity AXIS 4: Lack of an adequate support system AXIS 5: .