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 Bernabe, Benigno Petras, 23 year-old male, single, Filipino, Roman Catholic, born on January 17,
1992 at Lingayen, Pangasinan. He is a jeepney driver and currently residing at Salay, Mangaldan, Pangasinan. This is his first
admission with previous one consultation here in this institution due to aggressive behavior. The informant is his mother, Delia
Abrogar with a percentage reliability of 85%.
CHIEF COMPLAINT:
According to the patient: Papatayin nila ako, lalasunin ako dito.
According to the informant: Aggressive/Homicidal behavior
HISTORY OF THE PRESENT ILLNESS:
7 years PTA, patient came into our institution for consulatation because of changes in behavior after he was hit by a
group of men, and one of them was killed by unknown person. Those group of men accused him that he was the
one who killed the person who died. Starting from the stated incident, his behavior changed, there was an observed
difficulty of talking to him and depression, hence decided to seek consult in our institution. He was examined and
evaluated by a Psychiatrist and was given medications such as Fluoxetine, Chlorpromazine, Birepeden and was sent
home. The informant stated that they comply with his medications for only 2 months after observing that the
patient improved, went back to his normal activities and function thus failure to follow up afterwards.
4 months PTC, there are observed changes in behavior such as being talkative, aggressive, restlessness, stares at
one place, flight of ideas, and the patient cannot sleep at night. No consult was done.
1 month PTC, there are persistence of the behavior mentioned 4 months ago accompanied now with hallucinations,
delusions, self inflictive, being too aggressive and assaultive to siblings, to his wife and children by hurting them.
Repeatedly uttering, Linalason nila ako, lason ang tinusok sa akin, hence seek consult.
PAST MEDICAL HISTORY:
SURGICAL: Appendectomy-2013 at Region I District Hospital (Dagupan, Pangasinan)
MEDICAL: Unable to eat, walk, and weakness- (year unrecalled by the mother)- 2 days of hospitalization-San Carlos,
Pangasinan
PSYCHIATRIC: The patient has a history of mental illness: Major Depressive Disorder, Single episode, severe with mood
congruent psychotic features (July 2008)-BGHMC
He has no known allergies to food or drugs, or illnesses like hypertension, DM, CAD or asthma. Non-smoker. He has no history
of alcohol use or abuse.
FAMILY HISTORY:
Father: Benito, 44, deceased due to Lung Cancer
Mother: Delia, 45, housewife, with Breast Cancer (Mastectomy-2012 at ITRMC)
Siblings:
1. Patient
2. Bernadeth, 20: youngest (same father), 2nd year college, currently healthy
3. Geraldine, 13: first step sister, Grade 7, healthy
4. Gerico, 11: step brother, Grade 5, healthy
5. Gennylyn, 8: second step sister, Grade 2, healthy
Wife: Danica, healthy
Children:
1. Precious: 8 y/o, eldest, healthy
2. Prince: 5 y/o, 2nd, healthy, construction worker
They have history of lung cancer from the father and breast cancer from the mother, no hypertension, bronchial asthma,
psychiatric disorder family history.

PERSONAL, DEVELOPMENTAL, SOCIAL, AND ENVIRONMENTAL HISTORY:

The patient was born via NSVD with cephalic presentation by a midwife no complications, with prenatal check ups and complete
intake of vitamins. The patient has a complete immunization. His developmental milestones are in par with his age and were
unremarkable. He was an average student back then and has a good relationship with classmates and friends. He wasn t able to
finish his study and only finished primary school. He claims to have a good relationship with his wife and his children and so as
well to the rest of his family members and friends and neighbors. Their fund was from his job as a jeepney driver. They have
sometimes petty quarrels but they resolved it at once. Patient is a non-smoker and drinks occasionally. There was no history of
substance abuse or use.
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, combative, ambulatory not in cardiopulmonary distress
Vital Signs:
BP:110/70 mmHg, CR: 92bpm, RR: 18 cpm, Temp: 36.6 OC
Skin:
No cyanosis, no pallor, good skin turgor
HEENT:
Head:
Face is symmetrical, no involuntary movement, with some abrasive lesions. No tenderness, no masses. No
bony depression of the skull.
Eyes:
Symmetrical with well distributed eyebrows, no lid lag. Conjunctiva is pinkish 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:
flat, no scars or lesions, normoactive bowel sounds, No tenderness.
Extremities:
no clubbing, no gross deformities. 2+ equal and bilateral pulse on all extremities. 2-3 sec capillary refill.
Neurologic Examination:
Cerebral function: Awake
GCS: 15 (M6, V5, E4)
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

10
0
10
0

10
0
10
0

SENSORY:
+
+
+
+
+
+
+
+

REFLEXES:

5/
5
5/
5
MENTAL STATUS EXAMINATION:
Seen and examined a 23 y/o male patient, dressed appropriately according to age, gender and weather, with fair grooming and
hygiene. No mannerisms or gait problem noted. The patient speaks with loud voice, high tone and fluent. Patient is aggressive,
with self infliction. Patient has flight of ideas, hallucination and delusion at the time of interview. Patient has depressed mood
and blunt affect. Patient is awake, conscious, oriented to time, place, but not to person. Has poor insight on illness and has poor
social judgment.
ICD-10: Bipolar Affective Diorder, current episode, mixed with psychotic symptoms
DSM-V: Bipolar I Disorder, most recent episode, manic severe with mixed features, with mood congruent psychotic features
I.

II.

III.

IV.
V.

Bases for Bipolar I Disorder

A. Criteria have been met for at least one manic episode
B. The occurrence of the manic and major depressive episode is not better explained by schizoaffective
disorder, schizophreniform disorder, delusional disorder or other specified or unspecified schizophrenia
spectrum and other psychotic disorder.
Bases for Manic episode
A. A distinct period of abnormally and persistently elevated and expansive, irritable mood and
abnormally and persistently increased energy lasting for four months and present most of the day.
B. During the period of mood disturbance and increased energy, three of the following symptoms are
present:
1. Inflated self esteem and grandiosity: May power na manggamot. At
Pinakamakapangyarihan sa lahat as said by the patient.
2. Decreased need for sleep but still energetic the next day.
3. More talkative than usual
4. Flight of ideas: according to the mother dami dami nyang naiisip na gagawin
5. Psychomotor agitation: aimlessly walking at night
C. The mood disturbance is sufficiently severe to cause marked impairment in social: :Nilalayuan na
siya ng mga tao sa mga ginagawa nya and occupational functioning: Hindi na siya nagtatrabho
at halos wala na syang ginagawa, and to necessitate hospitalization to prevent harm to self,
others and there are psychotic features such as auditory hallucination and delusion of
persecution.
D. The episode is not attributable to the physiological effects of substance (No history of drug abuse,
medication and other treatment involved) and not attributable to another medical condition
Bases for Mixed Features
A. Full criteria are met for a manic episode and 3 of the following symptoms are present:
1. Prominent depressed mood as observed by the mother, Umiiyak sya kapag
naalala yung pagkamatay ng tatay niya.
2. Diminished interest in almost all activities as indicated by his mother Halos
nakatulala lang sya sa isang lugar
3. Recurrent thoughts of death of his father.
B. Mixed symptoms are observable by others and represent a change from the persons normal
behavior
C. For individuals whose symptoms meet full episode criteria for both mania and depression
simultaneously, the diagnosis should be manic episode with mixed featured due to marked
impairment and clinical severity of full mania.
D. The mixed symptoms are not attributable to the physiological effects of a substance.
Bases for severe
The intensity of symptoms is seriously distressing and unmanageable and the symptoms markedly
interfere with social functioning and occupational functioning.
Bases for Mood congruent psychotic features
During manic episodes, the content of all delusions and hallucinations is consistent with the typical
manic themes of grandiosity.

ASSESSMENT:
ICD 10: Bipolar Affective Disorder, Current episode, Mixed with Psychotic symptoms
DSM V: Bipolar I Disorder, most recent episode, Manic Severe with Mixed features with Mood
Congruent Psychotic feature
PLAN
Diagnostics:
Disposition:
Cayad/Dr. Bautista

CBC, Urinalysis, FBS, BUN, Createnine, SGOT, SGPT

Admit to male psychiatry ward under the service of Green service if Dr.

Therapeutics:

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
Olanzapine 10 mg, once a day HS
Na divalproex 500mg/tab, three times a day
Diphenhydramine 50 mg/cap, PRN
Biperiden 2mg/tab, 1 tab in AM PRN for EPS
Haloperidol 5mg/deep IM for refusal to take oral Clozapine 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

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

Resident In-Charge