Date: April 27, 2022

Name of Student: Marjorie N. Soberano

Name of Patient: Cherrylynn Tatpeic
Address: La Trinidad, Benguet
Age: 46 years old Sex: Female Marital Status: Single Occupation: none
Diagnosis: Schizoaffective Disorder
Medication and time due: Nirva 100mg once daily at 8pm
Special treatment/Procedure/Activities: OT activities (ADL, behavioral modification technique)
Chief Complaint: patient experiencing having hallucinations and delusions with sleeplessness and
aggressive behavior.
History of Present Status: CT is a 46 years old female for whom psychiatric evaluation is requested due to
aggressive behavior. She has been admitted before with the same diagnosis and is noted to have a relapse.
She admits that she had difficulty sleeping which made her irritable and restless at times. She admits
getting angry at her nephews by throwing things and being rude to them whenever they are drinking beers
as she stated that God doesn’t want those acts. CT denies having depression and ideations.

MENTAL STATUS EXAMINATION:

Appearance: patient is neat in appearance with appropriate clothes, clean and short nails, hair is tidy and
neat.
Speech: her speech is normal having fluency in Tagalog. Rate, tone and pitch is congruent.
Mood/Affect: She is observed with euthymic mood and in normal range in affect.
Thought Content: patient exhibits religious ideations and visual hallucinations
Orientation: patient is oriented to person, date, time and place
Judgement: She has fair judgement
Memory: has good memory
Abstraction: has good abstraction
Attention/concentration: able to attend and focus on a certain task
Disorder of Perception: patient has visual hallucinations
Understanding of illness/ Insight: Fair understanding of illness
Self-concept: patient is aware of herself, her ability to do things and her goals in life
Role and relationship: patient identifies her role in the family
Psychological and self-care concern: patient has fair self-awareness especially when triggered in some
situation