CAGAYAN VALLEY MEDICAL CENTER

Department of Behavioral Medicine

PSYCHIATRIC CASE PRESENTATION

PRAVEENRAJKUMAR
CSU JUNIOR INTERN
 GENERAL DATA
• Patient’s Name: J.A
• Age: 46 y/o
• Sex: Male
• Birth Year: 1975
• Birthplace: Isabela
• Marital Status: Separated
• Address: Isabela
• Nationality: Filipino
• Occupation: RadiatorTechnician
• Previous Admission: Multiple
• Informant: Patient
• Reliabliity: 70%
 Chief complaint:

‘Nakipag away sa loob ng kulungan’

‘involved in fights inside the prison’
 History of present illness:
15 Yrs PTA
• Patient claimed that he killed someone in the fight .during
that murder he was fully drunk and he could not able to
control his emotions. The person he killed was annoying and
irritating for him . He got surrendered himself to the
police.he was suffered 9 years in the prison for that murder.
Intervel History
• During that 9 years in prison his mother , daughters and
siblings visited him occasionally.
• Multiple times he was brought to cvmc behavioral medicine
by prison guard for fighting with inmates in the prison.
6 yrs prior to admisssion
• After 9 years of imprisonment the patient was released and resumed his
job as a radiator technician.
Intervel History
• Again he got arrested by police due to destroying the motorcycle of his
tenant cousin. he was very irritated with his tenant cousin .so he did that
incident. he got arrested by 8 months for this incident. After 8 moths he
got released from prison.
• Then he went on a vacation in Batangas in which he was arrested by police
again. he was depressed in batangas. Because he did not have enough
money to sustain his needs then he wanted to return to isabela.On that
time he saw a motorcycle with a key on it. then he decided to stole that
motorcycle .but he was caught by police on his way to isabela. Then police
arrested him. he spent 3 months in jail for that incident. Then he
returned to Roxas,Isabela.
1 yr prior to admission
• He was falsely accused of possesing illegal drugs. He claimed
that was only ‘tawas powder’ and it was not drugs. He was
arrested and detained at BJMP in Roxas Isabella.
• Inside the prison cell he got into argument with another
inmate and they end up with fighting. But there were another
two inmates who helped his opponent. So he was overcamed
by the three inmates.
• Hence, reffered back to CVMC for therapy.
Past PSYCHIATRIC AND medical history:
• Childhood illness: (+)chicken pox,(+) measles
• Adult Illness: (-) Diabetes (-) Hypertension (-) Asthma (-)
epilepsy (-) STI
• Allergies: Shrimp
• Surgical:
Fractured forearm (1995)
 FAMILY HISTORY
• Father:
Deceased (55 yrs old) due to HTN and Diabetes
Occupation :Teacher and Radiator Technician
• Mother:
71 yrs old
Housewife
• Siblings:
6 siblings-1 brother and 5 sisters
 PERSONAL AND SOCIAL HISTORY

•Prenatal/perinatal history
He is the second child in a brood of 7.
•Early Childhood
He was taken care of by his mother
There were no noted history of thumb sucking, nail biting,
temper tantrums and head banging.
•Middle Childhood
He was noted to be very happy and playful child. He was very
close to his siblings.
• Late childhood
He does not intrested in studies
Occasion minor fights in school
• Adolescence
He got into vices eg: Drinking and smoking
Worked as a radiator technician
 Educational History
• Elementary - Roxas Central School
• High School - Roxas National High School
• Vocational Course - Ilagan Isabela
 Occupational History
• Radiator technician
 Religious History
• Patient is an INC. He claims to be very active in his religion
before going to prison.
 Substance History
• Smokes 1 pack a day when he was young
• Drinks 6 bottle of red horse with 1 bottle of gin a day since 14
years until the time of imprisonment
• Usage of illegal drugs 2 times when he was 26 years old
 Legal history
• 2004 - homicide
• 2013 - 2017
 Destroying of property
 Stealing
• 2018 - Possession of illegal drugs
 Marital History
• Married in 1999
• Separated - 2004
• Present - in a relationship with his childhood friend
 Psychosexual history

Patient claims to have sexual intercourse with his childhood

friend when he was 9 years old and impregnated her.
 Current Living Condition
He lives with his mother and 2 daughters in Roxas, Isabela.
Currently admitted in the Department of Behavioral Medicine
in CVMC.
 Premorbid and Personality
• Patient described himself to be friendly and sociable.
According to him he always drinks alcohol with his friends.
 REVIEW OF SYSTEMS:
• Constitutional: (-) fever, (-) weight loss, (-) fatigue.
• Integumentary: (-) itchiness, (-) rashes, (-) dryness
• HEENT:
Head: (-) Headache, (-) dizziness and light-headedness
Eyes: (-) pain. (-) blurring of vision, (-) double vision, (-) redness,
(-) lacrimation
Ears: (-) loss of hearing, (-) discharge
Nose: (-) epistaxis, (-) nasal stuffiness, (-) discharges.
Throat: (-) sore throat, (-) dysphagia, (-) hoarseness. o Neck: (-)
pain, and (-) stiffness o Respiratory: (-) cough, (-) sputum
production, (-) hemoptysis, and (-) dyspnea.
• Cardiovascular: (-) chest pain, (-) orthopnea, (-) dyspnea, (-)
palpitations.
• Gastrointestinal: (-) nausea, (-) vomiting,(-) loss of appetite
(-) diarrhea and (-) constipation.
• Peripheral Vascular: No leg cramps and no varicose veins.
• Urinary: (-) nocturia, (-) dysuria, (-) polyuria. (-) urinary
urgency (-) incontinence.
• Musculoskeletal: (-) muscle weakness, (-) muscle pain (-)
stiffness, (-) joint pain,
• Psychiatric: (-) hallucination, (-) delusions, (-) depression,
(-) insomnia (-) nervousness, (-) anxiety
• Neurologic: (-) seizures, (-) tremors, (-) memory loss,
• Hematologic: (-) easy bruising, (-) bleeding,
• Endocrine: (-) polydipsia, (-) polyphagia, (-) cold/heat
intolerance, (-) excessive sweating.
 PHYSICAL EXAMINATION:
• General Survey: Patient is conscious, coherent and
cooperative. He is oriented to time, place and person.
• Neurologic Examination:
Cranial nerves all are intact.
Motor: Good muscle bulk and tone. Strength 5/5 all
throughout
Sensory: Normal sensation on all extremities. Point
localization is
normal.
Reflex: reflexes are 2+ and symmetric throughout
 MENTAL STATUS EXAMINATION

General appearance: Patient has normal posture, properly

groomed, wearing sunglasses and clean
clothes with red polo and shorts sleeves.

Behavior: Patient was well mannered, good eye

contact, has ability follow
commands/requests.

Attitude: Patient was cooperative and answered all

the questions asked.

Level of consciousness: Patient was alert.

Orientation: Patient knows his full name, oriented to

time, place and person.
 MENTAL STATUS EXAMINATION
Mood Patient is happy, energetic and has not
irritable.
Affect Patient was behaving with congruency
during interview
Thought Process Organized and coherent thought in
response to general questioning during
the interview. Looseness of associations,
irrelevance and incoherence to some
questions
Thought content Patient describes desire to go home, he
misses home. He is not scared or worried
to something.
Suicidality and homicidality Patient has no thoughts of committing
suicide and does not want to harm
anyone.
 MENTAL STATUS EXAMINATION
Judgment and Insight He is completely aware of being sick and
needing help. Patient exhibits fine
judgment and is conscious about what is
inappropriate and appropriate in terms of
actions
Attention Patient could repeated a sequence of
given number forward and backward. He
could spell word forward and backward.
He could calculate a given mathematical
problem.
Memory Recent, remote memory and immediate
memory are intact.
Intellectual Patient’s intellectual ability is probably in
average
 SALIENT FEATURES:
• 46 yrs/old
• Male
• Separated
• Alcoholic drinker
• Smoker
• Involve in fights
• Thefts
• Use of illegal Drug use
• History of imprisonment
Differential Diagnosis
Antisocial Personality Disorder

Rule in Rule out

46 yrs old Cannot rule out
Fights
Theft
Substance use
Illegal activity
Substances Use Disorder

Rule in Rule out

(+) Smoking Cannot totally
(+) Alcoholic rule out
drinker
(+) Use of
illegal drugs
 Initial Impression

t/c Antisocial Personality Disorder,Substance

abuse
 PLAN
• Admit the patient to Psychiatric Ward
Diagnostics: CBC,Drug test,Liver Function test,CT scan
• Psychosocial Therapy
– Family-Oriented Therapies
– Group Therapy
– Cognitive Behavior Therapy
– Art Therapy
– Personal Therapy
• Pharmacotherapy
– Methylphenidate
– Carbamazepine
– Atenolol
Thank You