Case Report: JR

Melissa Leviste and Nami Muzo

IDENTIFYING DATA
Name: John Ryan Almagro
Sex: Male
Age: 25 years old
Birthdate: March 12, 1988
Civil status: Single
Ethnicity: Filipino
Location: Sucat, Paranaque
Religion: Roman Catholic
Educational attainment: 2
nd
year college

CHIEF COMPLAINT

According to brother: di na ma-control sa bahay
Gusto lagi lumabas ng bahay tapos pag ayaw
payagan nagagalit.

According to patient: di ko alam, di ko nga alam
kung bakit ako andito eh
HISTORY OF PRESENT ILLNESS
15 years PTA (1999): Patient was allegedly
diagnosed with Manic Depression at the age of 10.
His fathers first family didnt treat him well and he
had feelings of resentment towards his siblings from
his fathers first family because they werent treating
him like a brother. Medications were given with
allegedly poor compliance to medication due to
financial constraints, where the patient would seldom
take his medications.

6 years PTA (2008): Patients mother died due to
sepsis. He then had a recurring episode of
depression because he was really close with his
mother (he confides everything with her and he
spends most of his time with her). According to
patients brother: grabe yung depress niya depress
na depress siya to the point where he wouldnt eat,
he would lock himself in his room and he wouldn't
speak much. Symptoms exhibited were insomnia,
anorexia and weight loss. It was around this time he
started to smoke excessively.

4 years PTA (2010): Patient was diagnosed with
Bipolar I Disorder. Symptoms exhibited were
violence, talking to himself, auditory hallucinations
(which were identified as bulong), restlessness, no
appetite, suicidal ideations, hurting himself and
insomnia. He was also smoking excessively during
this time. He was brought to a psychologist and
received therapy for a year.

3 years PTA (2011): Patients family had decided to
bring him to a psychiatric facility (rehab) in Cebu
where he was admitted twice. He was allegedly
hyper and he often talks to himself before but then
after rehab he allegedly became very sluggish
(naging sluggish yung galaw physically and
mentally).

About a few weeks PTA (end of January 2014): Patient
returned to Manila then had a check up on February
2014 at Perpetual Help, Las Pias (sister: kung pwede
matignan)
About a few days PTA (February 2014): Patient was
insisting on leaving the house (umaakyat ng bakod,
binabalak baklasin yung gate) his family let him leave
the house since he was observed for about a week and
he was coming back home. But then he started to panic
(naging nerbyoso) and he started to become scared of
the people living with him (nilalayuan) so his family
didnt let him go out. He then started to accuse the
people his living with, gusto niyo ko i-isolate, gusto niyo
ako ikulong. Pinagtutulungan niyo ako and whenever
they wouldnt let him out he would throw a fit.

4 days PTA (February 2014): Patient went out of the house
and wandered alone. He said he just wanted to get out of their
house so he was allowed to. He was found 3 days after in
front of their village gate and was brought home with wounds
(dry) and bruises all over his body. When asked about what
happened patient would state that he couldnt remember. His
family then decided to bring him to the emergency room.
Patient insisted that he had no problem and that he was okay.
His brother was sharing some stories when he decided to ask
the patient about what happened and the patient suddenly
remember everything and said that he was beaten near the
Domestic Airport while he was wandering around. (wala
naman ako ginagawa sa kanila)
Patient is currently admitted to PGH Ward 7 and is currently
exhibits delusions, disorganized behaviour and negative
symptoms. His condition has stopped her from being able to
work.

PAST PSYCHIATRIC HISTORY
1999 2010 2011 2014
Patient was allegedly
diagnosed with Manic
Depression.
Symptoms were not
stated although
medications were said
to be given with
allegedly poor
compliance to
medication.
Patient was diagnosed
with Bipolar I
disorder. Symptoms
exhibited were
violence, talking to
himself, auditory
hallucinations (which
were identified as
bulong), restlessness,
no appetite, suicidal
ideations, hurting
himself and insomnia.
Maintained on
valproic acid and
olanzapine with
allegedly poor
compliance to
medication.
Patient was brought to
a psychiatric facility
in Cebu because they
werent able to control
him anymore.
(nagwawala)
Patient was brought to
PGH Ward 7 after
leaving for a about 3
days and came back
with wound and
bruises on him. Used
to take on valproic
acid and olanzapine
but now maintained on
Aripriprazole
15mg/tab 1 tab
ODHS and
Haloperidol 5mg/mL
1mL +
Diphenhydramine
50mg/mL IM for
severe agitation or
refusal to take
medications.
PAST MEDICAL HISTORY
History of asthma
Suffers from slipped disc
Has skin allergy
loratadine and co-amoxiclav (ointment)
Neverundergone any surgeries
Not afflicted by any neurological conditions.
No history of diabetes, hypertension, and the like.

PERSONAL HISTORY
Born the 12
th
of March 1988
normal spontaneous vaginal delivery
no complications or developmental delays reported.
Eldest of 4 on his fathers 2
nd
family.
Reported to have close family relationships and even
with the first family.
but his brother stated that parang asot pusa sila ng father
namin
hes really close with his mom and ate.
Hes only close with his brother (3
rd
out of 4) whenever they
play computer games.
his youngest brother was his favourite but the youngest brother
doesnt like him.
Childhood: described as friendly
said to have episodes of being depressed
He was also said to be envied by his siblings from his fathers first family.
He was a below average student but was able to reach 1
st
year college
couldnt finish a course
he kept on shifting
Unemployed
No criminal record
During Free time: plays video games, read books (mostly about mythology)
and watch anime.
Smoker= over 1 pack/day
Drink occasionally (2-3 bottles)
But reported to have had a lot of alcoholic beverages in his house in Cebu.
His family and close friends are very supportive and encourage treatment.
Currently lives with his brother, two cousins and a friend but when he gets
discharged he would be living with 3 people (kakilala) from Cebu, a friend
and his brother (3
rd
).
FAMILY HISTORY
Father: Salvador P. Almagro
retired pilot
Mother: Rosalinda S. Almagro
Died = sepsis
There is no family history of psychiatric illness other
than his mom being allegedly depressed.
Father: hypertension

MENTAL STATUS EXAMINATION
General appearance and behavior
He is seen half-lying on the bed during the interview.
Observed to have very slow gait.
He has fair grooming and wears clothing appropriate
for age and gender.
His expression was flat.
He does not maintain good eye contact.
Able to follow commands.

Speech and language
He was apathetic but cooperative and had a flat
expression during the interview.
Responses were kept short.
No evidence of stuttering or vocal tics

Mood and Affect.
He displayed flat affect during the interview
He was also apathetic.
showed no interest, enthusiasm, or concern

Perception, Thought and Cognition
Thoughts circulated on wanting to go home
Denied presence of hallucinations and delusions
He answered after about 30secs to a minute
He is able to understand English
Language skills are at par with educational attainment
Denied suicide attempt
Although his brother once mentioned he tried to commit suicide
before and smoking was also his way of killing himself.

Orientation
Oriented in place.
Oriented in year, month and day of the week except
exact date and time.
Oriented in person.

Memory
Recent Memory
Good
He remembered the meds he was supposed to take.
Remote Memory
Good
He was able to answer where Jose Rizal was shot and where hes
from.
Immediate Memory
Good
He was able to repeat the 3 items I asked him to repeat during
MMSE. (paru-paro, lamesa at mansanas)

Impulse control
Fair
Judgment
Fair Judgment
Asked what he would do if he found a stamped envelope on the
street with the address and he said ihuhulog ko sa P.O. Box
Asked what he would do if he was in a movie thetre and he
smelled smoke and he answered didiretso ako sa fire exit
Insight to Illness
Poor
di ko alam kung bakit ako andito
sabi ng doctor may bipolar daw ako
wala ako bipolar, manic depression lang
Reliability
Poor
There were instances where he would answer after long periods
of time (ranging from 30secs to a minute)

MINI-MENTAL STATUS EXAMINATION
Oriented in place year, month and day of the week
except exact date and time
Registers information well
Has good attention and calculation
Immediate recall was Good
Was able to understand and follow commands.
Overall score is 27/30, which is within the range of
normal (23-30).
DIAGNOSIS
Although he was diagnosed Bipolar I with Psychotic
features we think that he might actually have
Schizophrenia (unspecified).

Criterion A: met because Hallucinations (auditory) and
Delusions (Grandiose, persecutory), disorganized
behaviour, and Negative symptoms are present.
Criterion B: met because he stopped working even after
he got out of rehab.
Criterion C is met because the duration of disturbance
has been at least 6 months.
Criterion E is met because the disturbance not due to
substance.

DIFFERENTIAL DIAGNOSIS
Ruled-in Ruled-out
Bipolar I Disorder with
psychotic features
Mood disturbances present
with psychotic features.
He still has psychotic
features even without mood
disturbances.
Schizoaffective Disorder Mood disturbances present
together with psychotic
features.
Mood Symptoms are not
present majority of the time.
Brief Psychotic Disorder Symptoms present for over
6 months.
PROGNOSIS: POOR
+ -
Supportive family and friends. Poor insight to illness.
Cannot be totally controlled by family.
History of poor compliance to
medications due to financial constraints
BIOPSYCHOSOCIAL FORMULATION
Predisposing Precipitating Perpetuating
Bio Non-compliance to
medication
Psycho Distress from
problems summing
up.
Trauma: gone for
three days and got
beaten up
Denying delusions
observed.
Distress from not
getting what he
wants.
Social Relationship with
father and siblings
(1
st
family).
Mothers Death.
Social stigma.
COMPREHENSIVE TREATMENT PLAN
Short Term Long Term
Educate patient regarding Illness.
Encourage patient to participate in
occupational therapy to improve motor
skills.
Clarify other precipitating factors to help
in decreasing the chance of relapse in the
future.
The patient, family and friends must be
educated about the factors to be able to
manage the condition better.
Continuation of good compliance with
medication to ensure that the condition is
alleviated and possible relapse is
decreased
Encourage the patient to continue
consulting his doctors.
Re-educate patient and relatives about the
condition and contributing factors.
Support Groups.