March 03, 2023

04:00pm

DFCM CLINIC

Chief Complaint: For Psychiatric Wellness

JM stands 164cm and weighs 73kg, medium brown skin color. He was born on the 4 th of July 1989 in V.
Luna hospital in Quezon City. He is happily married for 6 years to Jen and was given with two adorable
daughters Janiah and Jannah who is 5 and 4 years old. They are living together in a mortgaged house in
San Jose del Monte Bulacan. He is currently working in Justice Jose Abad Santos Hospital in Binondo,
Manila as a Regular Physician and Resident Physician of Family and Community Medicine and having a
part time in Ospital ng Malabon as emergency physician. He is the breadwinner of my family while my
wife who is a nurse in profession took care of our home.

He is third to the four children of Luis and Teresita. His siblings live together with their parents and niece
and nephew from her eldest who dies last 2019 due to Cancer. They just live few houses from his home.

In his childhood – he is good in school and have honors and recognitions. He belongs to the top of the
classes. He plays with my playmates like, hiding, water gun, “sumpit”, top, text, pogs, “tansan” and even
running but not physical games because of his asthma. He has a good child-hood memories with his
playmates and classmates. He sees his family as a perfect family and model in their community as he
always hears my neighbor that they like their family and always looks on them when they need. Most of
the time he spends also his time with his siblings.

Life starts to have some drama when his father had a bad encounter in his job where they need to hide in
Bulacan and live temporarily. He saw his parents worried for the first time. JM and his brother continue
school temporarily in Bulacan while his sisters who were in college lives in their friends’ houses. He
finds difficult to get along with his classmates since they already have group of friends but later had
become close to them. After few months they need to go back in their home in Malabon where they first
live and left his friends in Bulacan. When he get back to his old school, the lectures were ahead from
what he have learned from Bulacan which gives me stress to cope up with his subjects. But its ok for him
since he was already in his last year of elementary days and will move out to other school for secondary
school.

JM studied at Torres Highschool in Manila as average student. It became hard for him and had failing
subject in Chemistry and Social Studies. He doesn’t know why he felt that time that his classmates were
far from him like he was worst student of their class. But because of he is behave in class his teacher
gave him a chance to be part to help of their teaching evaluation and passed his grades.

This is the first time he had what he called his best friends. He doesn’t know how it started but he just
knew that he goes with them most of the time. His two best friends are important to him as they are
always with him specially in times that he had family problem. His friends were very studious and excel
in class. He remembers the time that he appreciated his friends when he saw them very happy for him
when he knew where his good and got high grades. They knew that he excels in their Art Class.

They graduated and had different colleges. JM took up nursing as preparatory to medicine. His mother
enrolled him very early to Our Lady of Fatima University and choose nursing for him. He doesn’t have
problem with that because he still doesn’t have any preferred course that time. He just met his friends
occasionally because they became busy in their school.

JM excel academically when he was in college, he doesn’t know but he thinks that his school in his
secondary level is a good one which made his college subjects not that difficult. And because of that he
thinks that he caught the attention of his classmates specially the person his interested with and had his
love relationship. They didn’t had label because of their love hate relationship and decided to be just
friends. He met other person but didn’t work because of his friend that he still loves, they still see each
other most of the time but still as friends. Until he just focused on his studies. His parents that time still
had quarrels and fights, and this is the reason why he learned how go outside of his comfort zone of house
and school tour only. Now he goes with his friends’ houses and dorms learned how to drink and even
tried smoking good thing is he never enjoy. But doing these things he still managed to do good in school.

On the days he was reviewing for the Nursing Licensure examination. His grandmother got sick and he
need to go to Bulacan and took care of his grandmother, He also help his niece and nephews to go to
school, His mother also got sick and has breast cancer. He is not the eldest in the family but He is the only
available that time. He pitied his self for not having enough time for his self and for his incoming board
examination. But still he passed the board exam.

After passing the exam he looked for a job but unfortunately nursing that time is over populated.
Hospitals are not hiring and just giving training with fee and no assurance of being absorbed. He never
dreamed to go abroad like his colleague. He passed his resume and become a volunteer nurse for a few
months in a nearby hospital. After 6 months, his father offered him to study medicine since he just
volunteering and had no salary. That time the money they had is just his father pension from his
retirement. He doesn’t want to use it because its’ his fathers’ money and he believe that his father should
enjoy it. He wants to study medicine with his saving from working as a nurse as he planned. But he
grabbed the opportunity and study medicine. He can’t afford to fail and repeat another semester or year.
Luckily, he only had remedials and got passed every semester.

As a rest day from everyday studying and schooling, he decided to go out with his friend who he is still
interested. They see each other more often and become his girlfriend. Though its very hard to manage the
time for studying and having time to her partner, understanding, patience and love help them to keep each
other. His family is very supportive to his med school but he also feels the pressure on it. Her sister gave
money for everyday expenses, but sometimes he feels that her sister should not be doing this for him. He
should be looking for job to help the family and not studying in times like this that they are having debts
due to studying medicine. Sometimes he goes to school even without money because he felt that he is a
burden to the family. That is why he always push to do his best not to fail.

After passing the exam he wanted to go to residency training right away, but since he is still not decided
of what specialty he wanted to take and due to family financial problem, He decided to go moonlight as
general practitioner. He worked a lot and help his parents to pay their debt from relatives and somehow
able to support his self and his younger brother. He had his own family, and got married to the one he
loves and got 2 daughters now. They live separately to his parents and siblings.

In August 2019, His eldest sister who is a teacher by profession and currently taking Law that time,
suddenly become sick and diagnosed with Liver Cancer. He was on his from duty status when his father
woke him up very sad and told him that they need to go to the hospital because of her sister. JM was so
worried since his brother in-law is crying that time and asking me to go to the hospital because the
surgeon want to talk to JM. He just prayed that time that wanted to see his sister alive whatever the news
is.

The surgeon talked to him and said that his sister is in late stage of Liver Cancer. He cannot even
comprehend what the surgeon is saying. He become speechless like in movies he watched. He just cried
and ask the doctor to let him see his sister. Her sister looks fine like she had just an ordinary operation.
He was asked by his brother in-law not to say any information to his sister about its condition. He cannot
help his self but just cry. Everybody in the family depends on him since he is a doctor, but he wanted to
be just a brother to his sister that time. They had followed up check-ups and spends his sisters’ time to a
family vacation. Still thankful that they just had time spent for his sister, they moved from Malabon to
Bulacan. Until the time that his sister passed away September 2019. He had anxiety after what happen,
its like a reset button of his life. It’s a very life changing situation for him. Its like a new JM. He even
diagnosed his self with depression. He cried most of the time, He slept late nights, and sometimes he
doesn’t. He woke up very late, He go late at work, He don’t care anymore of his career, but He don’t
want to talked about it and convinced his self to show like nothing happened. It’s like he need to wear
mask everyday just to hide the sadness, He managed his self to be composed even he is very down. He
doesn’t even dream anymore to be a great doctor and have a long title on his name, He doesn’t even want
to be the best that he can be, He doesn’t care how he look, he gives up on his dream to be rich. His so
worried of his family since they had a high familial risk of cancer. He doesn’t want to talked about it
because it made him anxious.

2020 COVID 19 Pandemic, He is not even anxious of what happening to the world. For him, anytime
everyone will all die soon. But when he saw his family having mild symptoms of covid. He becomes
anxious again, but this time instead of getting down again he chooses to think positively because he
doesn’t want another member of the family to be sick again. He tried to convince his self that life needs
to goes on whatever happens. He needs to become more appreciative of everything, He chooses not to
care so much, He chooses to spend the best of my life with my love ones and those who need him. For
him he still in moving on process of what happened to his sister and nightmares of having malignancy.
His still learning to care about his self so he can his family.

Vital Signs:

110/70mmhg
 89bpm

20cpm

98% o2 saturation

Afebrile

164cm by height

Weight: 73kg

BMI: overweight

Past Medical History:

Dyslipidemia, Multiple Vertebral Spondylosis, Asthma

No known Allergy but had episodes of Anaphylaxis probably secondary to Rabies Vaccine

No Surgical History

Family Medical History:

Hypertension – mother and Maternal Side

Cardiac disease - mother

Diabetes – Father

Cancer – Mother and Sisters

No psychiatric history

Personal And Social History:

Non-smoker, Non-alcoholic, No Illicit Drug Use

Mental Status Examination:

General appearance: the patient is medium built, wearing blue polo shirt, pants and rubber shoes, he has
light brown complexion, short black hair and seems well kept.

Behaviour: the patient was observed to respond appropriately and sits properly.
Attitudes: Most of the time patient was cooperative and coherent. He listens carefully and responds
clearly

Speech: Patient speak in soft calm voice.

Mood: when asked how he feels, He feels good.

Affect: The patient seems to have appropriate affect from his words.

Thinking: The patient denied any visual nor auditory hallucinations.

Sensorium: patient was conscious, alert, oriented to time, place, person. Able to recall some events from
his life.

Memory:

A) immediate: the patient able to repeat the three words given to him ”Lapis Mansanas Tubig"

B) recent: when asked what was he did before he went here he answer he checked his cellphone

Attention and concentration: Able to recite the months of the year in order backwards

Calculation: patient able to recite when asked to deduct 7 from 100,

Insight: patient knew clearly about his condition.

Judgement: when asked what he'll do if he found a wallet full of money with i.d of the owner. He respond
that he will get the wallet and call the owner.