REPUBLIC OF THE PHILIPPINES

CITY OF MANILA
ABC MENTAL HOSPITAL

Department of Psychiatry
Quirino Ave. corner Roxas Blvd., Malate, Manila

PSYCHIATRIC DISCHARGE SUMMARY

Name of Patient: Lucky M. Lobo Attending: Dr. Frank S. Stein

Date Admitted: 9/13/2015 Date of Discharge: 2/23/2017

Identifying Information:

- Patient is identified as Lucky M. Lobo, 29 years of age, male, and was first admitted in
this hospital in 2009 due to schizoprenia and was released in 2013 and again readmitted
in 2015 after suffering from relapse

Brief Hospital Course:

- Patient still appears to be very quiet and well mannered

- He told me that the cases of “black-outs” he suffered came back after he started working
under a very strict boss who always shouts and berates at him
- He also told me that he occasionally pictures their “mother” shouting at him and
threatening to hurt him during those moments
- Patient before admission was suffering from insomnia and was found to be increasingly
reclusive to socialize

Diagnosis:

Relapse of Schizophrenia, paranoid subtype

Treatment Plan:

Due to Mr. Lobo’s serious diagnosis, a tendency of violence towards himself and others, and
lack of effective medication, he is deemed admitted as an in-patient at the hospital. He will be
placed on a combination of medicine cocktails and electroconvulsive therapy, placed on the
long term treatment unit indefinitely.

Medication/s Administered:

- Metformin 500 mg p.o. b.i.d.

- Risperdal 5 mg p.o. b.i.d.
- Trazodone 200 mg p.o. at bedtime.
- Naprosyn 250 mg p.o. b.i.d. p.r.n. for pain or headache.
Hospital Course:

Schizophrenia: On admission, the patient's medication was gradually icnreased. He tolerated

the medication well with no side effects and reported that his hallucinations improved. He
denied psych symptoms prior to discharge. The patient presented as very organized in his
thoughts, linear, logical and appropriate. He did not have any behavioral or management
problems while in the unit and participated in groups very well with good interactions with staff
and peers, as there has been some question whether the patient also has a mood component of
his psychiatric disease. His mood improved throughout hospitalization.

Outgoing Mental Examination:

Appearance and Behavior: He had good eye contact, well groomed, fair hygiene

Speech and Language: Normal volume, tone and rate, nonpressured

Mood and Affect: Mood was hopeful and jovial and affect was congruent and loose. Thought
processes linear and goal directed.

Thought Content: Hopeful with fear of a possible relapse upon any indication of stress upon
him

Perceptual Abnormalities: No reports of previous visual, auditory, gustatory and tactile

hallucinations

Orientation: He is alert and oriented. Memory and abstractions are fair. Fund of knowledge
and IQ are average and insight and judgment are limited and good, neurologic exam was
normal.

Discharge Condition: Good and fit to rejoin society and interact with other people but with
possibility to fall to relapse

Psychiatric Note: Complete remission of schizophrenia symptoms is uncommon.

Schizophrenia relapses occur without warning and they are usually a return of symptoms that
have occurred in the past. Due to patient’s history, a possibility of relapse of schizophrenia
cannot be fully discounted especially when exposed to personal triggers such as abusive
authority figures of the opposite sex. However it is my belief that patient would greatly benefit
and is fit enough to rejoin society and interacting with other normal people

Discharge Instructions:
- Take medications as prescribed and not making any changes without first consulting with his
outpatient doctor.
- Advised to avoid any substance that could affect his mental state
- Should follow up with bi-weekly check-ups
- Avoid stressful environments

Dr. Frank S. Stein, MD, PhD

Director of Psychiatry
ABC Mental Hospital