MEDICAL HISTORY Name of patient: Personal, Antonio Age/sex: 27/Male Date of admission: May 21, 2015 Ward: A!" 1 General Data: #$is is a %ase %ase of AP, 27&year 27&year old male, single, single, 'ilipino, 'ilipino, (oman (oman at$oli%, )ig$s%$ool *ndergrad*ate, +orn on April 17, 1-- in Mindoro, %*rrently residing in #amarra. #amarra. "t, "t, rgy a *ra, *ra, "an 3ose, 4%%idental 4%%idental Mindoro, Mindoro, admitted admitted for t$e rst rst time at National enter for Mental )ealt$ on May 21, 2015 Presenting Complaints: A%%ording to informant: 6aad ng aad89 6Parang .ala sa sarili8 A%%ording A%%ording to patient: No er+al o*tp*t Source o Inormation: li;a+et$ Personal, <- years old, female, $ig$s%$ool grad*ate, mot$er and lies in t$e same $o*se as t$e patient, sells lo%al prod*%e in t$e maret Histor! o Present Illness: = years prior to admission, patient $ad on&and&o> feer do%*mented +y to*%$ for almost a .ee not asso%iated .it$ +o.el %$anges, %$anges, a+dominal pain nor omiting )e so*g$t %ons*lt at a regional $ospital and .as managed as ?* Persisten%e of feer no. a%%ompanied .it$ altered +e$aio*r, restless pa%ing and $air loss prompted %ons*lt at @P&P) .$ere $e .as diagnosed .it$ typ$oid feer .it$ psy%$osis )e .as pres%ri+ed .it$ *nre%alled anti+ioti%s and antipsy%$oti%s .$i%$ t$e patient too religio*sly A mont$ prior to admission, t$ere .ere noted %$anges in patientBs +e$aio*r s*%$ as m*m+ling .ords to $imself, la*g$ing on $is o.n, diC%*lty sleeping, sipping meals, disappear .it$o*t asing for permission, ref*sing to tae $is medi%ations and tried to sta+ $imself .it$ a it%$en nife A day prior to admission, patient stepped on a s$arp .ood .$ile tending $is farm .$i%$ infe%ted $is left foot )is mot$er *sed t$is ex%*se to %onin%e patient to see %ons*lt .$i%$ lead to $is admission at NM) Past Me"ical Histor!: a%%ine $istory is %omplete Patient $ad %$i%enpox d*ring $is %$ild$ood #$ere .as no $istory of depression depression or dr*g a+*se )e is non&$ypertensi non&$ypertensie, e, non& dia+eti%, non&ast$mati% and e*t$yroid #$ere .ere no prior s*rgeries, a%%idents nor +lood transf*sion No no.n food or dr*g allergies #amil! Histor!: randmot$er on maternal side is $ypertensie and dia+eti% )is parents and ot$er si+lings are all apparently .ell Patient lies .it$ $is parents in $is %$ild$ood $ome .it$ $is si+lings residing .it$in .aling distan%e Personal$Social Personal$Social Histor!:
P(NA#A/P(!NA#A: Patient .as +orn f*ll term ia normal spontaneo*s aginal deliery at $ome, attended +y mid.ife #$ere .ere no +irt$ %ompli%ations, defe%ts or intae of medi%ations d*ring pregnan%y !N'ANE AND A(E )!D)44D: #$e primary %aregier .as t$e mot$er )e .as +reastfed *ntil 2 years old, started .aling at t$e age of 1 and toilet training at 2 4t$er milestones .ere *nre%alled M!DD )!D)44D: Patient .as an aerage st*dent )e is ery s$y .it$ fe. friends at s%$ool )e .as o%%asionally spaned +y $is parents as form of dis%ipline No maFor illness or a%%ident AD4"N: )e .as not a+le to nis$ $ig$s%$ool +e%a*se patient opted to $elp .it$ t$e familyBs nan%es to s*pport $is t.o yo*nger si+lingsB ed*%ation )e enFoys dra.ing and set%$ing s%eneries, animals and plants Patient did not experiment .it$ illegal dr*gs, %igarettes or al%o$oli% +eerages E4@N AD@#)44D: Patient is single .it$ no $istory of $aing relations$ip .it$ t$e opposite sex )e deoted $is attention on tending t$eir farm )e *s*ally s$ares $is pro+lems .it$ $is +rot$er
Se%ual Histor!: Patient $ad no $istory of sex*al %onta%t E"ucational Histor!: )e attended elementary and $ig$s%$ool in a goernment s%$ool .it$in .aling distan%e from t$eir $ome )e .as an aerage st*dent ex%ept d*ring $is sop$omore year .$en $is grades started dropping )e adamantly ref*ses to parti%ipate in dra.ing %ompetitions .$en %oer%ed +y $is tea%$ers Religion Histor!: Patient is a +apti;ed at$oli% and o%%asionally goes to %$*r%$ )is mot$er tried to %onin%e $im to Foin !glesia Ni risto +*t patient ref*sed )e is seldom seen praying PHYSICAL E&AMI'ATIO' General appearance: %ons%io*s, am+*latory, not in %ardiorespiratory distress, .it$ initial ital signs of: 120/0 mm)g P, 20%pm ((, +pm P(, =G= temperat*re S(in: +ro.n, .arm to to*%$, good sin t*rgor, no fres$ .o*nds HEE'T: normo%ep$ali%, +la% $air .it$ een distri+*tion, ani%teri% s%lera, pin palpe+ral %onF*n%tia, patent nasal sept*m, no nasoa*ral dis%$arge, s*pple ne%, no ne% ein engorgement, no %eri%al lymp$adenopat$y, no tenderness C)est an" Lungs: symmetri%al %$est expansion, no retra%tions, %lear +reat$ so*nds Heart: adynami% pre%ordi*m, apex +eat at 5 t$ left inter%ostal spa%e mid%lai%*lar line, no m*rm*rs A*"omen: glo+*lar a+domen, normoa%tie +o.el so*nds, ?at, non tender E%tremities: no gross deformities, no edema, no %yanosis, f*ll and eH*al p*lses 'E+ROLOGICAL E&AMI'ATIO' Cere*rum: not assessed Cere*ellum: no gait dist*r+an%e, no nystagm*s Cranial ner,es:
!: not assessed !!: 2&= mm p*pils eH*ally rea%tie to lig$t !!!, !, !: inta%t extrao%*lar m*s%les : a+le to %len%$ teet$ !!: no fa%ial asymmetry !!!: inta%t gross $earing !I, I: a+le to s.allo. I!: a+le to t*rn $ead side to side I!!: not assessed
ME'TAL STAT+S E&AMI'ATIO' N(A APPA(AN: Patient $as large +ody frame, appears $ealt$y, appropriately dressed in gray s$irt and +la% s$orts .it$ %lean s$ort $air )A!4@(: )e is seated on +ed, .it$ <&point restraints, noted to +e disinterested t$ro*g$o*t t$e interie. A##!#@D: )e is *n%ooperatie and .o*ld not ans.er any of t$e H*estions Patient does not maintain eye %onta%t .it$ interie.er "P): not assessed M44D AND A''#: Patient appears to +e deta%$ed #)!NJ!N: not assessed P(P#!4N: not assessed "N"4(!@M: )e is a.ae +*t .o*ld dire%t $is attention a.ay from interie.er .$en ased a H*estion !N"!)#: not assessed 3@DMN#: not assessed !MP@": $e .o*ld loo a.ay .$en ased a H*estion
