Republic of the Philippines

Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
PSYCHIATRY DEPARTMENT
Baguio City
GENERAL DATA:
This is the case of patient ARELLANO, JEMMYLYN, 27 y/o female, single, Filipino, Bor Again
Christian, born on March 8, 1987 in Oriental Mindoro and currently residing in Rosario, La Union,
admitted for the 1st time in this institution due to destructive behavior, the informant is the
patients uncle with 90% reliability.
CHIEF COMPLAINT:
ACCORDING TO THE PATIENT: Hindi ko po alam kung bakit ako nandito
ACCORDING TO THE INFORMANT: Nawawala siya sa sarili at nagiging baolente kapag
nagagalit
HISTORY OF PRESENT ILLNESS:
Six months prior to admission, the patient got separated from her live in partner due to
frequent physical harassment for almost a year. The said llive in partner was a user of marijuana
which could have possibly caused discord when under the influence of marijuana as claimed by the
informant.
Four months prior to admission, the patient was sent to Rosario, La Union by her sister due
to strange changes in behavior such as being verbally assaultive, unable to take care of her 1 year
old son and hurts him whenever he cries.
Three months prior to admission, the above symptoms persisted, hence her uncle decided
to seek consult at their local psychiatric institution in Baltazar, Agoo, La union. Nakakaabala na
kasi siya at kawawa na anak niya, as stated by her uncle. Patient was admitted for less than a
month and was sent home with unrecalled medications.
Two months prior to admission, the patient became uncompliant with her medications. The
patient stated, herbal lang gusto ko inumin. Patient again became verbally assaultive and keeps
on hurting her son hence another consult was done at the same institution and was readmitted for
less than 3 weeks with unrecalled medications.
One week prior to admission, the above symptoms persisted hence her uncle decided to
seek help from Rosario RHU and was hen referred to our institution and was subsequently
admitted.
PAST MEDICAL HISTORY:
PSYCHIATRIC:
The patient was admitted in Baltazar, Agoo, La Union, on August 2015 for less than a
month due to strange changes in behavior and was sent home clinically improved with unrecalled
medications. She was readmitted on October 2015 for 3 weeks due to poor compliance with
medications in the same institution but was abel to escape.
MEDICAL:
The patient had no history of hospitalization other than giving birth. No history of
operations, trauma, or accidents noted.
SUBSTANCE USE:
No history of intake and use of illicit drugs.
FAMILY HISTORY:
Parents
1. Father: Jaime, no communication
2. Mother: Nimfa, OFW

Children:
1. Paolo, 12 (from first partner)
2. Charlene Rose, 11 (from first partner)
3. Xian Jacob, 1

Siblings:
1. Jaime- 32, high school graduate,
apparently healthy
2. Patient, 27, high school graduate
3. JP- 25, elementary graduate, apparently
healthy
4. Jennylyn- 20, high school graduate,
apparently healthy
5. Jaime, 17, Computer Science student
There is no noted family history of Hypertension, Diabetes Mellitus, Cancer, Bronchial
asthma, and other heredofamilial diseases. No family history of psychiatric illness noted.
PERSONAL, DEVELOPMENTAL, SOCIAL, AND ENVIRONMENTAL HISTORY:

The patient was born term via NSVD at home by a midwife with no complications. The
primary caregiver was his mother and the patient was breastfed. The patients development were
at par with her age. The patient entered school at age 7 and able to finish high school as an
average student. The patient went to college and was an undergraduate of BS Tourism. The
informant claimed that patient had good interpersonal relationship with family and friends.
REVIEW OF SYSTEMS:
General: (-) Febrile episodes, (-) weakness (-) numbness (-) weight loss
Integument: (-) pallor, (-) cyanosis (-) jaundice (-) pruritus
Head and Neck: (-) colds, (-) headache, (-) epistaxis (-) dizziness
Respiratory: (-) cough, (-) colds, (-) nasal congestion, (-) dyspnea
Cardiovascular: (-) orthopnea (-) chest pain, (-) palpitations
Gastrointestinal: (-) diarrhea, (-) abdominal pain, (-) vomiting, (-) hematochezia (-) acid reflux (-)
loss of appetite, (-) constipation
GUT: (-) hematuria, (-) dysuria, (-) perineal pain, (-) frequency
Musculoskeletal: (-) weakness, (-) numbness, (-) shooting pain, (-) stiffness, (-) limitation of
activity/playing, (-) joint pains
Hematological: (-) bleeding, (-) easy bruising, (-) past transfusions
Endocrine and Metabolic: (-) excessive sweating, (-) palpitation
Nervous System: (-) loss of consciousness, (-) seizures, (-) head trauma
PHYSICAL EXAMINATION:
General Survey: conscious, , ambulatory, not in cardiopulmonary distress
Vital Signs: BP: 120/80 mmHg PR: 85 bpm
RR: 18 cpm
T: 36.60C
Skin: (-) pallor, (-) cyanosis, (-) jaundice, (-) hyperpigmentation, good skin turgor, warm to touch
HEENT: No alopecia, anicteric sclera, pinkish palpebral conjunctivae, pupils equally round reactive
to light, no nasoaural discharges, no fronto-maxillary sinus tenderness, moist lips and buccal
mucosa, no tongue deviation, no cervical LAD
C/L: symmetric chest wall expansion, no retractions, no lagging, clear breath sounds
Heart: adynamic precordium, PMI @ 5th LICS MCL, normal rate with regular rhythm, no murmurs
noted
Abdomen: flabby, normoactive bowel sounds, soft, tympanitic, no tenderness
Extremities: no gross deformity noted, no clubbing, no edema, full and equal pulses, pink nail beds
with good capillary refill
Neurologic Examination:
Cerebrum: conscious and coherent
Cerebellum: no nystagmus, no tremors
Cranial Nerves:
CNI: not assessed
CNII: able to see moving pen
CNIII, IV, VI: intact EOMs
CNV: patient was able to open jaw and perform chewing motion
CNVII: no facial asymmetry
CNVIII: able to hear
CNIX, X: (+) gag reflex
CNXI: (+) shrug shoulders, (+) move head from side to side
CNXII: (+) protrude tongue, (-) deviations
Motor:
5/5
5/5
5/5
5/5
Sensory:
Reflexes:

100%

100%
100%

++
++

++
++

100%

Mental Status Exam:

Seen and examined a 27 year old, female, single, dressed appropriately for age, gender,
and weather, with fair hygiene and grooming, wearing white tshirt and pants. The patient has a
euthymic mood and blunted to constricted affect. The patient is calm, cooperative and responds to
questions with fair good eye contact and talks in a mnormal rate, tone and volume of voice. No
hallucinations and delusions at the time of interview. She is oriented to 3 spheres, abstract thought
is impaired, fair concentration, and poor insight.
ICD 10: Bipolar Affective Disorder, Current Episode, Manic with Psychotic Symtoms

DSM 5: Bipolar I Disorder, Most Recent Episode, Manic Severe with Mood Congruent
Psychotic Features
Basis for Bipolar I Disorder
Criteria have been met for at least 1 manic episodes:
A. A distinct period of abnormality and persistently expansive mood and abnormally and
persistently increased goal directed activity lasting 1 week and present most of the day.
Patient was noted to be more talkative than usual
B. During the period of mood disturbance and increased activity, 5 of the following symptoms
are present to a significant degree and represent a noticeable change from usual behavior.
1. Inflicted self-esteem- Patient states nagbiyabiyahe ako sa ibat ibang lugar sa ibat
ibang bansa and bayani ako kasi nililigtas ko mga tao s ksalanan nila
2. Decreased need for sleep. Patient is still energetic the next day despite lack of sleep.
3. More talkative than usual
4. Flight of ideas- Patient talks about looking for a job then shift to another topic
5. Distractibility as observed and reported by others
6. Increase in goal-directed activity like patient always cleaning the house even at night
C. The mood disturbance is sufficiently severe to cause marked impairment in social or
occupational functioning (patient is hurting her 1 year old son) And to necessitate
hospitalization to prevent harm to others. There are also psychotic features like auditory and
visual hallucinations that someone was talking to her
D. The episode is not attributable to the physiological features or effects of a substance: No
history of intake of other substances. Or to another medical condition: Physical examination
is essentially normal.
E. The occurrence of the manic episode is not better explained by schizoaffective disorder,
schizophrenic, schizophreniform disorder, delusion disorder or other specified or unspecified
schizophrenic spectrum and other psychotic disorder.
Basis for Mood Congruent Psychotic Feature
During manic episodes the content of all delusions and hallucinations is consistent with the
typical manic themes of grandiosity but may include themes of paranoia
Basis for Severe
The number of symptoms is substantially in excess of those required to make the diagnosis,
the intensity of the symptoms is seriously distressing and unmanageable and the symptoms
markedly interfere with social and occupational functioning.
Plan
-

Admit to female psychiatry ward under the green service (Dr. Cayad/Dr.Bautista)
Secure consent for admission
Provide 24-hour watcher
Monitor V/S every 24 hours and record
DAT
With meals and med supervision
Strict assault/escape/suicide precaution
Restrain as necessary
Diagnostic: CBC, Urinalysis
Therapeutics:
o Olanzapine 10mg/tab, 1 tablet at bedtime
o Na Divalproex 500mg/tablet, 1 tablet 3x a day
o Haloperidol 5mg deep IM as needed for refusal to take oral Olanzapine with BP
precatution
o Haloperidol 10mg + Diphenhydramine 50mg deep Im as needed for psychotic
agitation with BP precaution to a maximum of 3 doses at 1 hour interval.
GA
RCIA, Janice D.
Clinical clerk in charge