West Visayas State University Medical Center

Department of Psychiatry

PSYCHIATRIC REPORT

GENERAL DATA
Patients Name : N.D.R.
Age : 13
Sex : Female
Civil Status : Single
Language : Hiligaynon
Race : Ilonggo
Previous Hospitalizations : 1
Birthdate : 10/17/2003
Birthplace : Calinog, Iloilo
Religion : Roman Catholic
Nationality : Filipino
Educational Status : Grade 8
Address : Malibong Sentro, Calinog, Iloilo
Date/Time of Interview : July 1, 2017

Informant : Patient s mother

Reliability : 80%

CHIEF COMPLAINT
This is a case of a 13 year-old female, single, from Brgy. Malibong Sentro, Calinog, Iloilo who was
admitted at the Psych Ward with a chief complaint of Natulala sya, according to the patients mother.

HISTORY OF PRESENT ILLNESS

1 year PTA, the patient came home crying. She told her mother that she was bullied by her
classmates. Her classmates allegedly tried to raise her skirt. The mother also noted generalized pruritic
rashes, erythematous and difficulty of breathing with no fever or other symptoms. Patient asked her
mom to let her be absent from school. No consult was done and no medications were taken. Above
symptoms persisted until so the patient was brought to a private physician who prescribed Co-amoxiclav
1 tab BID and Ebastine/Betamethasone 10 mg/500 mcg/tab 1 tab OD. Patient went home and rested.
When the folks were about to wake the patient, she was noted to be unresponsive with locked jaw.
Patient was immediately brought to a traditional faith healer but without relief of symptoms. The
patient was then brought to Calinog District Hospital for further evaluation and was promptly referred
to this institution. Laboratory results were found to be normal except for the findings of UTI. The patient
was then referred to the Department of Psychiatry by the Department of Pediatrics for co-management
and she was diagnosed with Major Depressive Disorder with Psychotic Features: Catatonia. The patient
eventually recovered after 2 weeks of treatment. Patient was discharged with maintenance
medications.
2 weeks after discharge, the mother decided to stop giving the patient's maintenance
medications after she noticed that the patients attitude changed in that she would take things from
other people and hoard clothes and things from other houses. The patient was also noted to be more
active and noisy. She was also noted to suddenly use makeup which she previously didn't have interest
on. This went on for about a month. After a few days, the patient started to be unresponsive again. The
patient was brought to a faith healer and rituals were done. Eventually the patient spontaneously
recovered. The patient from then on was apparently well.
4 days PTA, the patient talked with her father who works overseas over the phone. According to
the mother, the father told the patient that he was to be hospitalized and to have surgery and that he
might go home earlier than his contract stipulated because of his illness, but he assured the patient that
she doesn't need to worry about having enough money for their education because their parents will
figure it out. The patient was worried nonetheless and started to cry. Over the next 3 days, the patient
was not able to sleep well and would wake her mother at night.
1 day PTA, the patient woke her mother up at night saying that she cannot sleep. The mother
did some rituals on her child taught to her by the faith healer. She also gave 1 tablespoon of a herbal
medicine to the patient. After a few hours, patient was noted to be unresponsive with blank stares and a
mumbling voice. In the morning, the mother asked help from the neighbours to bring the child to the
hospital, thus this admission.

PAST PSYCHIATRIC HISTORY

Medical: Patient had previous hospitalization for Dengue Fever in 2011 where she was admitted
for 4 days and discharged apparently well. On April 2017, she was admitted due to dysmenorrhea. On
May 2017, she was again admitted for UTI and was discharged without complications. There is no
history of congenital cardiac anomalies, bronchial asthma. Patient is noted to be allergic to shrimp.
Psychiatric: Patient has had no other prior psychiatric consult.

SUBSTANCE USE HISTORY

There was no history of substance use or abuse as claimed by the mother.

FAMILY HISTORY
Patient lives with her mother and younger brother. The patient is the eldest among 2 siblings.
Her mother had 2 abortions after the birth of her younger brother. Mother, a housewife is apparently
well with history of comorbidity. Her father is an OFW (driver) for 7 years who comes home every three
years and stays for 3 months. Her father is a known hypertensive but is currently not on any
maintenance medications. The paternal grandfather and maternal grandmother had history of
malignancy. Paternal grandfather died of cerebrovascular disease. There is a strong belief in faith
healers in both sides of the family. The mother believes that they come from a long line of faith healers
and that the patient is next in line to receive the skills. She attributes the patients illness to the spirits
trying to sway the patient from receiving the skill of a faith healer.

Genogram:

I
II
PERSONAL HISTORY (ANAMNESIS)
PRENATAL AND PERINATAL
Cannot be recalled.

EARLY CHILDHOOD
Patients birth was planned. The mother had regular prenatal check-up at Silay. No maternal illnesses
during the course of the pregnancy. The patient was born NSVD with no complications. Patient was
noted to be easily consolable as an infant. Patient was breastfed up to 2 years of age. Patient was noted
to be close to her mother ever since. There were no history of temper tantrums, head bobbing, pica and
other destructive behavior.

MIDDLE CHILDHOOD
The patient was noted as an honor student in school, always belongs to the top 10 of her class since
kindergarten. Patient is shy type, and has few close friends. Patient was noted by her parents as easily
irritated by nagging and sermons and would usually answer her parents with oo na gani, tama na gani.
During this time, the family transferred residences from Negros to Iloilo City. They stayed in a house
owned by the patient's grandmother, but they're staying there with the family of the patient's uncle
with which they have been regularly quarrelling with.

Sexual History: Cannot be assessed.

Fantasies and Dreams: Cannot be assessed.

MENTAL STATUS EXAMINATION

Appearance : The patient was lying in bed, unresponsive to verbal stimuli and does not
follow any instructions. Patient would occasionally open her eyes with blank
stares and preferential upward gaze
Behavior : She was not cooperative and has poor eye contact.
Motor activity : The patient had no gross movements and no response to stimuli.
Speech and Language : Patient has no verbal output. Patient does not responds when asked.
Mood and Affect : Cannot be assessed.
Perception : Cannot be assessed.
Form of thinking : Cannot be assessed.
Thought content : Cannot be assessed.
Orientation : Cannot be assessed.
Attention and concentration: Cannot be assessed.
Memory : Cannot be assessed.
Abstract Thinking : Cannot be assessed.
Judgement : Cannot be assessed.
Insight : Cannot be assessed.
PHYSICAL EXAMINATION
General Survey: The patient was lying in bed, unresponsive to verbal stimuli and does not follow any
instructions. Patient would occasionally open her eyes with blank stares and preferential upward gaze.

Vital Signs:
Temperature 37.1C
Pulse rate 100 bpm
Respiratory rate 20 cpm
Blood pressure 120/80
O2 saturation 98%

Skin: Uniformly smooth and warm to touch. Brown complexion with good skin turgor, with no lesions of
masses.
HEENT: Normocephalic, anicteric sclera, pale conjunctiva, brisk pupillary reaction to light and
accommodation (approx. 2-3mm),non-hyperemic non-enlarged tonsils; No cervical lymphadenopathies;
no neck vein engorgement.
Chest/Lungs: Symmetrical chest expansion, clear breath sounds, slightly tachypneic
Cardiovascular: Adynamic precordium; normal rate, regular rhythm, PMI at 5th ICS MCL left.
Abdomen: No masses or lesions noted; normoactive bowel sounds; soft, flat abdomen with no
tenderness at epigastric area.
Extremities: Shoulders, elbows, and wrists along with the hand joints were non-tender and were able to
move in full range of motion; full peripheral pulses; capillary refill time <2 seconds.

CRANIAL NERVE ASSESSMENT

I Cannot be assessed. VIII Cannot be assessed.
Pupils equally round, approx. 3-4
II, III mm, reactive to light and IX
No gag reflex.
accommodation
III, IV, VI Cannot be assessed. X
V Cannot be assessed. XI Cannot be assessed.
VII No facial asymmetry XII Cannot be assessed.

Sensory: Cannot be assessed.

Cerebellar function: Cannot be assessed.

INITIAL IMPRESSION
Major Depressive Disorder with Psychotic Features: Catatonia

INITIAL TREATMENT PLAN

CASE DISCUSSION

PARADIGMS OF PSYCHIATRY

DSM V CRITERIA FOR

.

DSM V CRITERIA FOR

DSM V CRITERIA FOR MAJOR DEPRESSIVE EPISODE

WORKING DIAGNOSIS
Bipolar I Disorder with Catatonia; R/O Schizophrenia

COURSE IN THE WARDS

Hospital Day Subjective/Objective Assessment Plan

LABORATORY RESULTS

CLINICAL HEMATOLOGY
Complete blood count
Hemoglobin 120-160
Hematocrit 0.37-0.47
Red blood cells 4.2-5.4
White blood cells 4.5-11
Differential count
Neutrophil number fraction
Segmenters 0.50-0.70
Lymphocytes 0.20-0.40
Eosinophils 0.01-0.04
Monocyte 0.04-0.08
Basophil 0.00-0.01
Blood Indices
MCH 27.27-33.27
MCV 83.89-100.7
MCHC 31.85-33.87

Urinalysis (//17)
URINALYSIS
Complete blood count
Color
Transparency
Reaction (ph)
Specific Gravity
Chemical Test
Sugar
Albuin
Microscopic Findings
Pus Cells
Red Blood Cells
Crystal
Amorphous Urates
Squamous E. Cells
Mucus Threads

Clinical Chemistry (//17)

CLINICAL CHEMISTRY

Creatinine 53-115 Umol/L

BUN 2.5-6.4 mmol/L

Sodium 135-148 mmol/L

Potassium 3.5-5.3 mmol/L

ALT/SGPT 12-78 U/L

AST/SGOT 15-37 U/L

CLINICAL CHEMISTRY

FBS 4.1-5.9 mmol/L

Cholesterol 1.3-5.2 mmol/L

Triglycerides 0.17-1.70 mmol/L

HDL 0.90-1.55 mmol/L

LDL 0-3.9 mmol/L

Uric Acid 155-428 U/L

DIAGNOSTIC FORMULATION

DIFFERENTIAL DIAGNOSES

Rule In Rule Out

MANAGEMENT

DRUG STUDY

Drug Rationale

PSYCHOSOCIAL THERAPY
Support from family and relatives
Integration into the community, participation in activities
PSYCHOTHERAPEUTICS
Cognitive Therapy - Develop alternative, flexible, and positive ways of thinking; rehearse new
cognitive and behavioural responses.
Behavioral Therapy Addressing maladaptive behaviors in therapy, patients learn to function in
the world in such a way that they receive positive reinforcement. Patient may be given positive
reinforcement every time he decides not to drink alcohol.
Interpersonal Therapy Active therapeutic approach, focuses on one or two of a patients
current interpersonal problems such that the current interpersonal problems are likely to have
their roots in early dysfunctional relationships. Patients relationship with his wife, his brothers
and sisters or his neighbours may be considered.
Psychoanalytically Oriented Therapy Effect a change in a patients personality structure or
character, not simply to alleviate symptoms. Improvements in interpersonal trust, capacity for
intimacy, coping mechanisms, the capacity to grieve, and the ability to experience a wide range
of emotions.
Family Therapy Examines the role of the mood-disordered member in the overall
psychological well-being of the whole family; it also examines the role of the entire family in the
maintenance of the patients symptoms.
Psychoeducation to inform the patient with his family of his illness, diagnosis and treatment,
and to allow them to express their feelings and concerns