Republic of the PhilippinesDepartment Of Health

BAGUIO GENERAL HOSPITAL AND MEDICAL CENTERPSYCHIATRY DEPARTMENT

Baguio City

CLINICAL HISTORY

GENERAL DATA:This is the case of Dela Cruz, Elsa, 47 year-old female, single, Filipino, Roman Catholic, born on February 26, 1968 in Pangasinan,

currently residing on Poblacion Aguilar, Pangasinan. This is her first admission in our institution due to her multiple digital wounds bilaterally. The informant is his sister with a percentage reliability of 85%.

CHIEF COMPLAINT:According to the patient: “Nalulungkot ako.”According to the informant: “Dahil po sa sugat nya”

HISTORY OF THE PRESENT ILLNESS:

20 years PTA, the patient was noted to have difficulty of sleeping for 3 days, they sought consult and she was prescribed with sleeping pills. She was noted pften opted to be alone with blank stares, withdrawn and with occasional physical assualtibeness, no consult was done at that time.

10 year PTA, the patient was observed to walk aimlessly even going to other barangays with associated physical assaultiveness, talking to cats along the road as if they were humans. No auditory hallucinations noted and still no consult was done.

1 year PTA, the patient began to put rings from both hands until it tightens, resulting wounds around her fingers and thus confined in Region I hospital wherein she was scheduled for an operation for its removal.

6 months PTA, the patient again started to place rings around her fingers, both hands except her thumbs. And she aggressively reacting once someone is trying to check on it. There is a foul smelling discharges noted and still persisted, hence seek consult and thus admitted. PAST MEDICAL HISTORY:

SURGICAL: Removal of previous rings around her fingers (Region I hospital-2014). No history of fall, trauma or accidents that require surgical management.MEDICAL: admitted due to sleep disturbances (1990’s)PSYCHIATRIC: No previous consults nor admission to any Psychiatric institutions. First consult/first admission

She has no known allergies to food or drugs, or illnesses like hypertension, DM, CAD or asthma. The patient is a non smoker and non alcohol drinker.

FAMILY HISTORY:Father: Julian, 72, deceased due to prostate cancerMother: Leonila, 77, deceased due to breast cancer

Siblings: 1. Elvira, 49, highschool graduate, housewife2. Patient3. Elma, 45, highschool graduate, housewife4. Ella, 42, highschool graduate, housewife5. Eddie, 38, highschool graduate, pedicab driver

The family has no known any of the psychiatric disorders, no heredofamilial disease like HPN, DM, and cancer noted on both sides of the family.

PERSONAL, DEVELOPMENTAL, SOCIAL, AND ENVIRONMENTAL HISTORY:The patient was born via NSVD with cephalic presentation by a traditional birth attendant. The patient has a complete immunization. Her developmental milestones are in par with his age and were unremarkable. She was an average student when she was an elementary and highschool and has a good relationship with classmates and friends. She wasn’t able to continue her studies due to financial constraints. The patient works as a housekeeper for 5 years and stopped until she was observed sitting alone by the window with blank stares and difficulty of sleeping. The patient was resistant to state stories about her work experience and since then she just stayed at home.

REVIEW OF SYSTEMS:

General: (-) fatigue, (+) weight change, (-) fever, (-) chills, (-) diaphoresis, (-) dizziness, (-)body weaknessIntegumentary: (-) rash, (-) sores- upper and lower extremities, and at the back, (-) hives, Head and Neck: (-) headache,: (-) trauma, (-) pain, (-) stiffness

Eyes: (-) pain, (-) diplopia, (-) visual dysfunction, (-) dryness, (-) redness, (-) tearingEars: (-) difficulty hearing, (-) tinnitus, (-) pain, (-) dischargeNose: (-) epistaxis, (-) discharge, (-) smell dysfunction, (-) sneezing

Mouth: (-) soreness, (-) hoarseness, (-) cyanosis, (+) change in tone of voice, (-) decreased gustatory sensationRespiratory: (-) cough, (-) dyspnea, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) occupational exposure, (-) TBCardiac: (-) chest pains/ discomfort, (-) orthopnea, (-) dyspnea, (-) paroxysmal nocturnal dyspnea, (-) palpitation, (-) undue fatigue, (-) edema, (-) cyanosis, (-) syncope, (-) hypertensionVascular: (-) intermittent claudicating, (-) leg crampsGastrointestinal: (-) vomiting, (-) nausea, (-) dysphagia, (-) hematemesis, (-) indigestion, (-) melena, (-)hematochezia, (-) heartburn, (-) abdominal pain, (-) abdominal distention, (-) jaundice, (-) diarrhea, (-) constipation, (-) change in bowel habitsRenal and Urinary: (-) dysuria, (-) hematuria, (-) incontinence, (-) urinary frequencyMusculoskeletal: (-) muscle pains, (-) joint pains, (-) cramps, (-) weakness, (-) stiffness, (-) Hx of trauma, (+) limitation of motion, (-) backacheHematological: (-) anemia, (-) excessive bleeding, (-) easy bruisingEndocrine and Metabolic: (-) heat/cold intolerance, (+) weight change, (-) excessive sweating, (-) polydipsia,(-)polyphagia, (-) polyuriaNervous System: (-) headache, (-) syncope, (-) seizures, (-) left or right sided weakness, (-) head trauma, (-) sleep disorder, (-) coordination problemPsychiatric/Emotional: (+) anxiety, (+) depression, (+) loss of control/violence, (+) nervousness, (-) memory change,(-) substance abuse

PHYSICAL EXAMINATION:General Survey: Conscious, awake, ambulatory and not in cardiopulmonary distressVital Signs: BP:130/90 mmHg, CR: 83bpm, RR: 20 cpm, Temp: 36.6OC Skin: No cyanosis, no pallor, no jaundice, good skin turgor, warm to touchHEENT:

Head: Face is symmetrical, no involuntary movement. No tenderness, no masses. No bony depression of the skull.Eyes: Symmetrical with well distributed eyebrows, no lid lag. Pink palpebral conjunctiva with anicteric sclera.Ears: Ears are symmetrical, no deformities, discharges and lesions noted. Nose: Septum at midline. No gross deformities. No nasal discharge and congestion. Frontal and maxillary sinuses non-tender.Mouth and Throat: Moist pinkish lips and mucosa, no lesions, lumps or cracking. Able to protrude tongue, no deviations, no

tonsillopharyngeal enlargement, uvula at midline.Neck: No gross deformities. No cervical lymphadenopathies.

Chest and Lungs: Symmetrical chest wall expansion. No retractions or lagging. No scars or lesions. No tenderness. Clear breath sounds.Heart: adynamic precordium. PMI at 5th ICS left midclavicular line. No heaves or thrills. Regular rate and rhythm. No murmurs. Abdomen: soft, flabby, no scars or lesions, normoactive bowel sounds, No tenderness.Extremities: (+) necrotic foul smelling wound around her hand digits except thumbs, no clubbing, no gross deformities. 2+ equal and

bilateral pulse on all extremities. 2-3 sec capillary refill.

Neurologic Examination:Cerebral function: AwakeGCS: 14Cerebellar function: No nystagmus, no tremors, no dysmetria, no dysdiadochokinesiaCranial Nerve Function Test:

I: not asssessedII: intact sense of sightIII, IV, VI: pupils 2-3mm in size both equally round and reactive to light and accomodation, intact EOMs, no preferential gazeV: facial sensory functioning intact, can chewVII: facial symmetryVIII: intact sense of hearingIX, X: uvula in midline, no deviation XI: able to turn head from left to right, able to raise and shrug shouldersXII: midline protrusion of the tongue, no fasciculation, no deviation

MOTOR: SENSORY: REFLEXES:

MENTAL STATUS EXAMINATION:Seen and examined a 47 y/o female patient, wearing a blue shirt and floral pants with poor hygiene and grooming. The patient is calm answering the questions with “hindi ko alam”. The patient is afraid with flat affect, low tone, low volume, and monotonous voice. Impaired concentration and abstract thought. Poor judgement and poor insight. No mannerisms or gait problem noted. The patient is disoriented to time, place and person, constricted affect and euthymic mood.

5/5 5/5

5/5 5/5

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100 100

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ICD-10: Hebephrenic SchizophreniaDSM-V: Schizophrenia, multiple episodes, currently in acute episode

Bases:A. The following are present for a significant portion of time during a 1-month period.

1. Delusions: patient had delusion of control. The patientkeep putting things on her fingers as ordered by the said employer. Delusion of persecution “ayaw ko ipagalaw yung sugat ko, baka saktan ako ng employer ko.”2. Hallucinations: patient had auditory hallucinations that “itago ko daw tong dalawang singsing sa katawan ko, sabi ng employer ko.” Visual hallucinations: nakikita nya ung employer nya na inuutusan sya.3. Disorganized speech4. Grossly disorganized or catatonic behavior-hoarding behavior: “tinatago nya ang mga basura sa loob ng bahay.”5. Negative symptom: the patient has poor hygiene, poor self care, had flat affect, decreased appetite,.

B. For significant portion of the time since the onset of disturbance, level of functioning in work: the patient stopped working as a house helper and stayed at home.Interpersonal relationship: the patient preferred to be alone, withdrawnSelf care: the patient havn’t took a bath for a week

C. Continuous signs of the disturbance persist for as markedly below the level achieved prior to the onset of 20 years. In our patient symptoms persisted for more than a year when patient started to have change in behavior 20 years ago.

D. Schizoaffective disorder and depressive bipolar disorder with psychotic features have been ruled out because no major depressive or manic episode have occurred concurrently with the active phase symptoms.

E. The disturbance is not attributable to the physiological effects of a substance or another medical condition: No history of substance use and of any other medical condition.

F. There no history of autism spectrum disorder or communication disorder of childhood onset.

BASIS: Multiple episode, currently the patient is in his acute episode: the patient had episodes 20 years ago and 10 years ago.

ASSESSMENT: ICD-10: Hebephrenic SchizophreniaDSM-V: Schizophrenia, multiple episodes, currently in acute episode

PLAN Diagnostics: CBC, Urinalysis, FBS, BUN, Creatinine, SGOT, SGPT, Lipid profile, Chest X-rayDisposition: Please admit to female psychiatry ward under the green service of Dr. Cayad/Dr. Bautista

Please secure consent for admission and managementMeals and Meds with supervisionRestrain patient as neededProvide 24-hour responsible watcherStrict assault/escape/suicide precautionDATMonitor vital signs and record q 24 hour

Therapeutics: Risperidone 2mg/tab; ½ tab in AM and 1 tab at nightDiphenhydramine 50mg/cap; take 1 cap once a day at nightHaloperidol 5mg/deep IM for refusal to take oral Haloperidol with BP precaution Haloperidol 10 mg + Diphenhydramine 50 mg deep IM, as needed for psychotic agitation with BP precaution to a maximum of 3 doses q 1 hour interval

# Wounds on both hands (digitals) with foul smelling odor and dischargesDaily wound care pleaseRefer to Ortho ward for joint managementRefer accordingly

Prepared by:

BANIQUED, ARZEEH JOYCE G.Ward Junior Intern Resident In-Charge