Admission Notes (ER)

Presenting Complaints
According to informants: Nanghihipo
Nangaaway
Nagpadala ng ice pick
According to patient ok Lang po

MSE

Seen examined male agitated disturbed lying in bed in 4 point loose restraint. Speech spontaneous
talkative mood is labile in appropriate affect. He has bizarre delusions for his wife is pregnant and
wants people in NCMH to be godparents. He was auditory hallucinations of women voice details of
which elaborated. He is clear and assaultive poor judgement and insight poor

Admission

MSE
Patient was seen and examined an adult male with average height and weight. Patient was fairly
groomed, clad in blue uniform. Patient as uncooperative seen restless. Patient

Clinical Abstract/Discharge Summary

General Data

This the case of D.S. , 42 yrs old male single Filipino Roman Catholic elementary graduate graduate
unemployed born on April 18 1974 currently residing in Sampaloc, Manila., brought by barangay
officials and admitted on January 19 2017.

Brief Background

Patient has been mentally ill since September 2009 and with previous admission last 2014. He was
discharged and maintained with unrecalled medication to which he is poor poorly compliant. He was
lost to follow up. He was intermittent tolerable relapses until.

One month prior to admission, he was noted to be restless irritable and sexually preoccupied
Few hours prior to admission , patient was disruptive in the barangay and assaultive using ice picks,
and wood planks. patient was brought to NCMH hence, admitted.

Mental Status Examination

He was seen and examined an adult male average height and weight dark complexion fairly groomed
uncooperative, poor eye contact restless with shouting spells.audible, and pressured, fairly vibrant.
Mood was irritable and affect as appropriate. He had arguement with another patient inside the ward
but apprehended immediately. He verbalized "mayos ako, wala ako ng sakit.". He neglected having
auditory hallucination nor ideation / homicide. He had decreased need for speed and racing thought.
He was conscious and oriented to time place and person. He had poor impulse control, poor insight and
poor judgement.

Social Worker Notes

Patient Salvador, Dennis y Hati , Male 42 years old single, born on April 18 1974 Filipino catholic
elementary graduate unemployed residing at 639 M.V. Delos Reyes St. Brgy 403 Sampaloc Manila was
ab roughy by Mr Delmacio Manalastas (Barangay Staff) to our hospital and admitted January 19 2017

Undersigned tried to conduct with the patient to gather the whereabouts of his family. Accordingly, his
name real name is Dennis Hati Salvador male 42 years old born April 18 1974 Filipino Catholic
reached Grade 5 Level pedicab driver and a resident of 639 M.V. Delos Santos St. Brgy 403 Zone 41
Sampaloc, Manila. He allegedly the fifth among nine siblings namely Josie, Julia, Gina, Chona,
Evelyn, Myla, Angelica, and Danilo. To Parents Danilo (deceased) and Leonila Hate. Patient verbalized
that his father died ten years ago while his mother is 64 years old who is now living with his siblings in
riverbank marikina. He further claimed that he does that not know the exact address of his mother of
his mother and siblings and has no idea either about their contact neighbor. He mention that he left
their house when he was still nine years old because his father used inflict physical pain since he was a
child. His mother allegedly went Bicol that time so he had no choice but to leave their house and roam
around the street of Manila. Patients said that he has been working as a pedicab driver and sleeps in his
pedicab at night the barangay safes of Sampaloc Manila have Been very supportive to him as per his
narration and even extended food assistance to him. Patients wanted to be brought back to the barangay
staff of Sampaloc Manila.
Until no further data gathered undersigned decided to terminated the interview as per write up of ms.
San Juan (ER social worker. Patients escort Delmacio Manalastas is willing lot fetch the patient once
discharged form the hospital.
Hence undersigned recommends that the patients be directly discharged to his escort Delmacio
Manalastas once ordered for discharged upon the approve door proper authorities.