Informant: Mother of the patient Reliability: 80%

Chief complaint: Nagwild na kaayo siya, as verbalized by the mother.

General Data: A case of A.P., 20 years old, single, Roman Catholic, born on September
27, 1996, residing in Balamban, Cebu, sought consult in VSMMC-CBS for the first
time.

History of Present Illness:

6 months prior to consult, the patients mother observed that Naa na siyay
kausaban sa iyaha. Nanluya siya kay naglaum na ang iyahang mata. Naguol siya
tungod sa nagbuwag sila sa iyahang ikaduha na uyab. The mother also claims that
during this time dili siya ganahan mukaon, ginagmay ra ang iyahang kaonon
Months after this, the mother claims that her son is still depressed, with decreased
appetite and doesnt socialize with neighbors but still able to do his ADLs like taking
a bath.

1 month prior to consult, the patients mother observed wala siyay gana mukaon,
ginagmay ra ang kaonon. Pag-uli nako sa balay naa ra gihapon ang snacks na akong
gi-prepara sa iyaha. The mother verbalized that the patient claims gikapoy na
kaayo ko. The mother further observed sa una magduwa siya basketball ug mag-
jogging siya sa gawas pero karon wala na siya nagduwa. Hilumon man ni siya doc
pero nakabantay ko na dili na siya ganahan mu-iskwila During this time frame the
mother, claims that the patient went to the forest far from their house and claims
that he went there to look for a snake. The mother followed and claims that her son
was just blank staring in that place.

A week PTC, mother claims that the patient went to a disco party and conversed
with some people there claiming Ako hatagan powers ang inyong anak

5 days PTC, the mother observed that naghinuktok ra siya doc, dili siya katug, dili
gihapon siya mukaon, kung mukaon siya ginagmay ra gihapon

4 days PTC, the mother claims that wala na siyay gikaon, dili sad siya katog,
nagreklamo siya na Gikapoy na kaayo siya.

3 days PTC, mother claims that the patient was tig sud gawas siya sa balay, nag-wild
siya, dili gihapon siya katug ug ginagmay ang kaon niya. When the mother asked
why he frequently goes in and out of the house mga inip kuno ang tao sa balay.
Mother further added Dili man na siya ganahan if saba, kay balikason ug maldita
kaayo sa iyaha ang katong asawa sa iyahang kamaguwangan

1 day PTC, the mother verbalized padung to siya sa Mercado, nilakso siya sa motor
human nasamad siya. At home, the mother gave citerizine and the patient fell
asleep but when he woke up mother claims gisumbag niya ang iyahang amahan
maw gidala namo siya diri
Past Medical/Psychiatric History: No history of any psychiatric consults in the past.
The patient is non-hypertensive, non-asthmatic, and non-diabetic. Mother claims
that when the patient was 7 years old, he had a head trauma when he fell down in
the ground. No previous hospitalizations or any surgeries. No known allergies to
food and medications.

Substance History: Patient denies illicit drug use. Mother verbalized that the patient
drinks alcoholic beverages but uncertain of the quantity. Mother claims that the
patient smokes cigarette but uncertain of the amount consumed.

Family History: The patient is the youngest among 4 children. His mother, 50 years
old, is alive and hypertensive, diabetic and has high cholesterol level. She claims that
she maintains Amlodipine with unrecalled dosage. His father, 51 years old, is alive
and well. His 2 siblings are alive and well. No other heredofamilial diseases in both
maternal and paternal side. No family history of any psychiatric illnesses. Mother
claims that the patient has good relationship with his parents and siblings.

Personal History: Patient was born via NSVD at home in Balamban by a hilot. His
mother and father were 33 and 34 years old, respectively, when he was conceived.
His developmental milestones were at par with his age. He entered grade school
when he was 7 years old. Mother claims that the patient was an average student
doesnt belong to the top 10; however, he has no failing grades from gradeschool to
high school. Mother added Hilumun ra kaayo siya. Seryoso kay siya sa pagkabata.
Dili na siya tig-laag ug tig-barkada. During high school, mother claims that the
patient loves to play basketball and jog. Patient is currently enrolled in BS Education
course in UV Toledo. He is now in his third year. It was his sisters decision for him
to take up that course although he really wanted to study a computer-related
course. Mother claims dili man siya ganahan mag-education Mother also claims
that ever since the patients brother got married, the patient and his sister-in-law
are always having a feud. Mother claims kay pirmi man mumalikas ug malditahon
siya, referring to the sister-in-law of the patient. The patient had two previous
intimate relationships but the mother was uncertain of the cause of break-up
although she mentioned that the patient was really depressed after the separation
with the second girl friend.

Mental Status Examination: Patient was received awake, conscious, sitting in the
chair. He appears fairly groomed wearing white sleeveless shirt, short pants and
shoes. He is not oriented to time, place and person. He was not cooperative though
he maintains good eye contact. He gives irrelevant answers when asked. He speaks
in a soft voice with normal rate and rhythm. He was in a depressed mood with
congruent affect. When asked how he felt at that time he responded, feel nako
mulagsik ko. He was crying and agitated in between the interview. He is
preoccupied with kapoy na ang akong lawas, while crying. He denies any form of
hallucinations. No delusions. Poor recent, remote, and past memory. Poor insight.
When asked about the similarities between pen and pencil, he replied: para unsa
na? Nanong kinahanglan na nimo pangutan-on. Judgement was not assessed
because the patient did not respond. In between the interview, patient was
observed to be imitating the actions of another patient in the ward.

A: Major Depressive Disorder with Psychotic Features

P: Haloperidol 5 mg/mL + Diphenhydramine 50 mg/mL IM injection now

Risperidone 2 mg/tab 1 tab BID
Biperiden 2 mg/tab 1 tab OD in AM
Chlorpromazine 100 mg/tab 1 tab q HS
Strict suicide, homicide and escape precaution at all time
Escitalopram 10 mg/tab 1 tab q HS