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Identifying Data
J.S. is a 30 years old, male, single, high school undergraduate, Roman Catholic, currently
residing at Sta. Ana Manila, who had been admitted in institution for second time.
II. Source of Information: First wife of patient with reliability of 80% and current wife with reliability
of 85%
III. Chief Complaint: According to the current wife patient had blank stare and talks to himself.
IV. History of Present Illness
Patient is a known alcoholic, approximately 4 bottles of 350 mL of gin every week for 19
years. Patient also takes Methamphetamine and cannabis for approximately for 9 years.
1 year and 1 month PTC, patient was noted to
V. Past Psychiatric History
February 16 2015 Admitted at UPPGH Psychiatric ward for 2 weeks, Methamphetamine-
induced Psychotic Disorder, Risperidone ODHS, Olanzapine
X. REVIEW OF SYSTEM
(-) weight change (-) urinary/bowel changes
(-) fever (-) blood-stained stools
(-) cough/colds (-) polydipsia/polyuria
C. SKIN
The patients skin is pink, moist, with good skin turgor and warm to touch. There is
no edema, erythema, cyanosis, and masses noted. The nail beds were pink and neither clubbing
nor koilonychias were observed.
D. HEENT
The patient has long length black hair with evenly distributed volume, pattern and
texture. Her head is symmetrical and normocephalic without lesions, masses, scars and tenderness.
The scalp has no lesions, non-edematous, no parasites nor scales. Neck has no limitation of
motion, nuchal spasm or rigidity. Upon inspection, there was no enlargement of her parotid,
submandibular glands and cervical lymph nodes. Thyroid gland moves with swallowing and
trachea is in midline position. On inspection of her eyes, eyes are symmetrical and not protruding.
There were no ptosis or strabismus noted. The eyebrows are also symmetrical and with equal hair
distribution, eyelids were non-edematous. Lacrimal glands were not swollen or tender. She has
pink palpebral conjunctiva with no inflammation, masses nor ulcerations noted. She has anicteric
sclera with no corneal ulcers or opacities. Her pupils are equally reactive to light, accommodation,
consensual reflex. There were no visible lesions, masses, ulcerations or serous drainage in her
ears. Her auricles were symmetrical. Her nose is symmetrical and nasal septum is in midline.
External nares are equal in size and shape. Vestibule and nasal cavity has no masses,
serous/purulent/blood-tinged drainage. Both nostrils are patent without watery/ mucous discharge.
No nasal flaring was noted. The lips are symmetrical and no masses. Gums and buccal areas are
pinkish, free of lesions, masses or ulcerations. The tongue is pinkish and mobile, free of masses or
ulcerations. The palate is smooth and free of lesions. The floor of mouth is free of masses or
ulcers.
E. THORAX AND LUNGS
Thoracic cavity is symmetrical with a prominent rib cage. There were no chest
retractions, use of accessory muscles, stridor, masses, lesions and discolorations noted. Upon
palpation, there was an equal chest expansion, normal tactile fremitus, no tenderness and palpable
mass noted. On percussion, all lung fields were resonant. On auscultation, there was symmetrical
and clear breath sounds, no wheezes or adventitious sounds. Upon inspection of breast, there was
a surgical scar on the left breast in the upper outer quadrant. No tenderness, ulcerations and
discharge noted.
F. CARDIOVASCULAR
There were full and symmetrical peripheral pulses with grade of +2 and normal
capillary refill. Carotid pulse is rapid upstroke and gradual downstroke, no presence of thrills and
bruits. Upon inspection of the chest, there were no masses, lesions and precordial bulging. On
palpation, there were no thrills and heaves noted. On auscultation, normal rate and rhythm of heart
sounds was noted. No murmurs, distinct S1 and S2 with PMI at 5th ICS LMCL. There was no
cyanosis, clubbing, venous engorgement or edema.
G. ABDOMEN
On inspection, abdomen was flabby with inverted umbilicus. No presence of spider
angiomas, palmar erythema, dilated superficial veins around the umbilicus. Upon auscultation,
there was normoactive bowel sounds on all quadrants. No presence of bruits and borborygmi. On
percussion, all quadrants are tympanitic. Spleen was not palpated in the Traubes space. Upon light