Republic of the Philippines

Department Of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
PSYCHIATRY DEPARTMENT
Baguio City
CLINICAL HISTORY
GENERAL DATA:
This is the case of Dela Cruz, Elsa, 47 year-old female, single, Filipino, Roman Catholic, born on February
26, 1968 in Pangasinan, currently residing on Poblacion Aguilar, Pangasinan. This is her first admission in our
institution due to her multiple digital wounds bilaterally. The informant is his sister with a percentage reliability of
85%.
CHIEF COMPLAINT:
According to the patient: Nalulungkot ako.
According to the informant: Dahil po sa sugat nya
HISTORY OF THE PRESENT ILLNESS:
20 years PTA, the patient was noted to have difficulty of sleeping for 3 days, they sought consult and she was
prescribed with sleeping pills. She was noted pften opted to be alone with blank stares, withdrawn and with
occasional physical assualtibeness, no consult was done at that time.
10 year PTA, the patient was observed to walk aimlessly even going to other barangays with associated physical
assaultiveness, talking to cats along the road as if they were humans. No auditory hallucinations noted and still no
consult was done.
1 year PTA, the patient began to put rings from both hands until it tightens, resulting wounds around her fingers and
thus confined in Region I hospital wherein she was scheduled for an operation for its removal.
6 months PTA, the patient again started to place rings around her fingers, both hands except her thumbs. And she
aggressively reacting once someone is trying to check on it. There is a foul smelling discharges noted and still
persisted, hence seek consult and thus admitted.
PAST MEDICAL HISTORY:
SURGICAL: Removal of previous rings around her fingers (Region I hospital-2014). No history of fall, trauma or
accidents that require surgical management.
MEDICAL: admitted due to sleep disturbances (1990s)
PSYCHIATRIC: No previous consults nor admission to any Psychiatric institutions. First consult/first admission
She has no known allergies to food or drugs, or illnesses like hypertension, DM, CAD or asthma. The patient is a
non smoker and non alcohol drinker.
FAMILY HISTORY:
Father: Julian, 72, deceased due to prostate cancer
Mother: Leonila, 77, deceased due to breast cancer
Siblings:
1.
2.
3.
4.
5.

Elvira, 49, highschool graduate, housewife

Patient
Elma, 45, highschool graduate, housewife
Ella, 42, highschool graduate, housewife
Eddie, 38, highschool graduate, pedicab driver

The family has no known any of the psychiatric disorders, no heredofamilial disease like HPN, DM, and cancer noted
on both sides of the family.
PERSONAL, DEVELOPMENTAL, SOCIAL, AND ENVIRONMENTAL HISTORY:
The patient was born via NSVD with cephalic presentation by a traditional birth attendant. The patient has a
complete immunization. Her developmental milestones are in par with his age and were unremarkable. She was an
average student when she was an elementary and highschool and has a good relationship with classmates and

friends. She wasnt able to continue her studies due to financial constraints. The patient works as a housekeeper for
5 years and stopped until she was observed sitting alone by the window with blank stares and difficulty of sleeping.
The patient was resistant to state stories about her work experience and since then she just stayed at home.
REVIEW OF SYSTEMS:
General: (-) fatigue, (+) weight change, (-) fever, (-) chills, (-) diaphoresis, (-) dizziness, (-)body weakness
Integumentary: (-) rash, (-) sores- upper and lower extremities, and at the back, (-) hives,
Head and Neck: (-) headache,: (-) trauma, (-) pain, (-) stiffness
Eyes: (-) pain, (-) diplopia, (-) visual dysfunction, (-) dryness, (-) redness, (-) tearing
Ears: (-) difficulty hearing, (-) tinnitus, (-) pain, (-) discharge
Nose: (-) epistaxis, (-) discharge, (-) smell dysfunction, (-) sneezing
Mouth: (-) soreness, (-) hoarseness, (-) cyanosis, (+) change in tone of voice, (-) decreased gustatory sensation
Respiratory: (-) cough, (-) dyspnea, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) occupational exposure, (-) TB
Cardiac: (-) chest pains/ discomfort, (-) orthopnea, (-) dyspnea, (-) paroxysmal nocturnal dyspnea, (-) palpitation, (-)
undue fatigue, (-) edema, (-) cyanosis, (-) syncope, (-) hypertension
Vascular: (-) intermittent claudicating, (-) leg cramps
Gastrointestinal:
(-) vomiting, (-) nausea, (-) dysphagia, (-) hematemesis, (-) indigestion, (-) melena,
(-)hematochezia, (-) heartburn, (-) abdominal pain, (-) abdominal distention, (-) jaundice, (-) diarrhea, (-)
constipation, (-) change in bowel habits
Renal and Urinary: (-) dysuria, (-) hematuria, (-) incontinence, (-) urinary frequency
Musculoskeletal: (-) muscle pains, (-) joint pains, (-) cramps, (-) weakness, (-) stiffness, (-) Hx of trauma, (+)
limitation of motion, (-) backache
Hematological: (-) anemia, (-) excessive bleeding, (-) easy bruising
Endocrine and Metabolic: (-) heat/cold intolerance, (+) weight change, (-) excessive sweating, (-) polydipsia,
(-)polyphagia, (-) polyuria
Nervous System: (-) headache, (-) syncope, (-) seizures, (-) left or right sided weakness, (-) head trauma, (-) sleep
disorder, (-) coordination problem
Psychiatric/Emotional: (+) anxiety, (+) depression, (+) loss of control/violence, (+) nervousness, (-) memory
change,(-) substance abuse
PHYSICAL EXAMINATION:
General Survey: Conscious, awake, ambulatory and not in cardiopulmonary distress
Vital Signs:
BP:130/90 mmHg, CR: 83bpm, RR: 20 cpm, Temp: 36.6 OC
Skin:
No cyanosis, no pallor, no jaundice, good skin turgor, warm to touch
HEENT:
Head:
Face is symmetrical, no involuntary movement. No tenderness, no masses. No bony depression of
the skull.
Eyes:
Symmetrical with well distributed eyebrows, no lid lag. Pink palpebral conjunctiva with anicteric
sclera.
Ears:
Ears are symmetrical, no deformities, discharges and lesions noted.
Nose:
Septum at midline. No gross deformities. No nasal discharge and congestion. Frontal and
maxillary sinuses non-tender.
Mouth and Throat: Moist pinkish lips and mucosa, no lesions, lumps or cracking. Able to protrude tongue,
no deviations, no tonsillopharyngeal enlargement, uvula at midline.
Neck:
No gross deformities. No cervical lymphadenopathies.
Chest and Lungs: Symmetrical chest wall expansion. No retractions or lagging. No scars or lesions. No tenderness.
Clear breath sounds.
Heart:
adynamic precordium. PMI at 5th ICS left midclavicular line. No heaves or thrills. Regular rate and
rhythm. No murmurs.
Abdomen:
soft, flabby, no scars or lesions, normoactive bowel sounds, No tenderness.
Extremities:
(+) necrotic foul smelling wound around her hand digits except thumbs, no clubbing, no gross
deformities. 2+ equal and
bilateral pulse on all extremities. 2-3 sec capillary refill.
Neurologic Examination:
Cerebral function: Awake
GCS: 14
Cerebellar function: No nystagmus, no tremors, no dysmetria, no dysdiadochokinesia
Cranial Nerve Function Test:
I: not asssessed
II: intact sense of sight
III, IV, VI: pupils 2-3mm in size both equally round and reactive to light and accomodation, intact
EOMs, no preferential gaze
V: facial sensory functioning intact, can chew
VII: facial symmetry
VIII: intact sense of hearing
IX, X: uvula in midline, no deviation
XI: able to turn head from left to right, able to raise and shrug shoulders
XII: midline protrusion of the tongue, no fasciculation, no deviation

MOTOR:
5/5

5/5

100

5/5

5/5

100

100

SENSORY:
++
++

100

++

REFLEXES:

++

MENTAL STATUS EXAMINATION:

Seen and examined a 47 y/o female patient, wearing a blue shirt and floral pants with poor hygiene and grooming.
The patient is calm answering the questions with hindi ko alam. The patient is afraid with flat affect, low tone, low
volume, and monotonous voice. Impaired concentration and abstract thought. Poor judgement and poor insight. No
mannerisms or gait problem noted. The patient is disoriented to time, place and person, constricted affect and
euthymic mood.
ICD-10: Hebephrenic Schizophrenia
DSM-V: Schizophrenia, multiple episodes, currently in acute episode
Bases:

A. The following are present for a significant portion of time during a 1-month period.
1. Delusions: patient had delusion of control. The patientkeep putting things on her fingers as
ordered by the said employer. Delusion of persecution ayaw ko ipagalaw yung sugat ko, baka
saktan ako ng employer ko.
2. Hallucinations: patient had auditory hallucinations that itago ko daw tong dalawang singsing
sa katawan ko, sabi ng employer ko. Visual hallucinations: nakikita nya ung employer nya na
inuutusan sya.
3. Disorganized speech
4. Grossly disorganized or catatonic behavior-hoarding behavior: tinatago nya ang mga basura
sa loob ng bahay.
5. Negative symptom: the patient has poor hygiene, poor self care, had flat affect, decreased
appetite,.
B. For significant portion of the time since the onset of disturbance, level of functioning in work: the
patient stopped working as a house helper and stayed at home.
Interpersonal relationship: the patient preferred to be alone, withdrawn
Self care: the patient havnt took a bath for a week
C. Continuous signs of the disturbance persist for as markedly below the level achieved prior to the
onset of 20 years. In our patient symptoms persisted for more than a year when patient started
to have change in behavior 20 years ago.
D. Schizoaffective disorder and depressive bipolar disorder with psychotic features have been ruled
out because no major depressive or manic episode have occurred concurrently with the active
phase symptoms.
E. The disturbance is not attributable to the physiological effects of a substance or another medical
condition: No history of substance use and of any other medical condition.
F. There no history of autism spectrum disorder or communication disorder of childhood onset.

BASIS: Multiple episode, currently the patient is in his acute episode: the patient had episodes 20 years ago and 10
years ago.
ASSESSMENT:
ICD-10: Hebephrenic Schizophrenia
DSM-V: Schizophrenia, multiple episodes, currently in acute episode
PLAN
Diagnostics:
Disposition:

Therapeutics:

CBC, Urinalysis, FBS, BUN, Creatinine, SGOT, SGPT, Lipid profile, Chest X-ray
Please admit to female psychiatry ward under the green service of Dr. Cayad/Dr. Bautista
Please secure consent for admission and management
Meals and Meds with supervision
Restrain patient as needed
Provide 24-hour responsible watcher
Strict assault/escape/suicide precaution
DAT
Monitor vital signs and record q 24 hour
Risperidone 2mg/tab; tab in AM and 1 tab at night
Diphenhydramine 50mg/cap; take 1 cap once a day at night
Haloperidol 5mg/deep IM for refusal to take oral Haloperidol with BP precaution

Haloperidol 10 mg + Diphenhydramine 50 mg deep IM, as needed for psychotic agitation

with BP precaution to a maximum of 3 doses q 1 hour interval
# Wounds on both hands (digitals) with foul smelling odor and discharges
Daily wound care please
Refer to Ortho ward for joint management
Refer accordingly

Prepared by:
BANIQUED, ARZEEH JOYCE G.
Ward Junior Intern

Resident In-Charge