OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF PSYCHIATRY
Quirino Ave. corner Roxas Blvd., Malate Manila, Philippines
Patients Name

JL

Hospital No.

Age/Sex
Address

:
:

43/M
Del Pilar, San Pascual, Batangas

Date of Consult

Clerks-in-Charge

April 14, 2015

This is a case of 43 year old male who came in for consult with complaints of auditory hallucinations
IDENTIFYING DATA
This is a case of a 43 year old male, married for 13 years with 3 children (13/M, 11/F, 10/F). He is the eldest of 4 children. He graduated college with a degree
of BSMT and currently works as a seaman. He is a practicing Born-Again Christian who came in for consult for the first time at the Department of Psychiatry at
OMMC.
CHIEF COMPLAINT
may naririnig akong mga boses na nangungutya, nananakot. Nakita ako ng mga katrabaho ko na tawa ng tawa at may kinakausap na wala naman doon.
HISTORY OF PRESENT ILLNESS
18 years PTC (1997), the patient had his first auditory hallucination with a language he could not understand. Around that time he had another auditory hallucination that urged him to kill somebody but he reports that he counters the things the hallucinations urges him to do. No consult was done.
10 years PTC (2005), the patient had another episode of auditory hallucination where the recalls the voices to have challenged him to go outside their house.
Next thing he knew, he went out their house and started to run naked around their neighborhood. He reports that he was aware of what was happening, however he felt out of control, after the episode he recalls to have felt embarrassed and ashamed of what he did. To this, the patient sought consult to a psychiatrist in their hometown, he was then prescribed with Olanzepine (Zyprexa) 10 mg, 14 pcs but was only able to buy and take 5 pieces. Since then, the patient
reports to having regular follow-ups to his psychiatrist.
7 years PTC (2008), the patient recalls having been confined at a psychiatric ward in a hospital in Lipa City for 1 month. He took unrecalled medications during the stay, which resolved his hallucinations. After the confinement, he was prescribed Chlorpromazine (Laractyl) 200 mg and reports to be compliant to
medication.
6 years PTC (2009), he set out to work on a ship. Around this time the patient was taking Chlorpromazine 200 mg, however because he felt sleepy during the
day, he opted to take half the dose (100 mg). Because of this, the patient reports to having another episode of losing control over his actions which was associated with auditory hallucinations and because this happened at work, his bosses had his co-workers keep an eye on him for fear that he might jump off ship.
Around this time, the patient also recalls to having an episode where he felt like a robot where he couldnt move from where he was standing.
In the interim, the patient reports to having no episodes of hallucinations or episodes of losing control.
1 year PTC (2014), the patient was prescribed (1) Risperdone (2 mg) and (2) Clozapine (Ziproc, Leponex), unrecalled dose, however, he was only able to take
the Clozapine due to the expense.
1 month PTC (March, 2015), another incident happened at work while he is on a ship where he had another auditory hallucination and his work-mates caught
him laughing loudly and talking on his own. This prompted his co-workers and bosses to be worried so they had to let him out of his contract early to have him
consult a psychiatrist. He also had suicidal ideations around this time due to the urges of his hallucinations.
14 days PTC (Apr 1, 2015), the patient sought consult to a psychiatrist in Turkey where the doctor advised him to have a Cranial CT Scan done (Apr 14, 2015
result: small physiologic calcifications at the anterior and posterior falx cerebri otherwise essentially normal plain Cranial CT Scan) he was then prescribed
with Olanzapine, OD at bedtime, 10 mg. He reports to be compliant to medication since then and reports to having no episodes of hallucination since this day
to current.
7 days PTC (Apr 7, 2015), the patient is back in the country, he then sought consult to his original psychiatrist in his hometown where he was prescribed with
(1) Olanzapine, 10 mg to be taken at bedtime and (2) Risperidone, 3 mg to take half tablet in the morning.
1 day PTC (Apr 13, 2015), he again sought consult at a clinic near his office where he was referred to our institution.
The patient was not able identify specific stressors that causes his episodes. His attitude or perceptions towards the hallucinations is that they are trying to
humiliate and sabotage him.
PAST MEDICAL HISTORY
Prev. Hospitalizations: 2008- confined for 1 month for psychiatric symptoms
Medications: (1) Olanzapine, 10 mg at bedtime, (2) Risperidone, 3 mg to take a half tablet in the morning, (3) Glucosamine tablets, BID at bedtime and in the
morning (self-medicated)
Suicide History: March 2015, due to the urges of his hallucinations.
Allergies: Shrimp
DM/BA/HPN: none
SOCIAL HISTORY
Cigarette use: 30 pack-years, quit 1006
Alcohol Intake: occasional alcoholic beverage drinker
Shabu/Marijuana/Rugby: denies illicit drug use
ANAMNESIS
I.
Prenatal/Perinatal
The patient reports no abnormalities or health problems during his mothers gestation. He reports that his mother did not use any illicit drugs nor cigarettes
during her pregnancy. The patient was born term via NSD at was attended by a local hilot.
II.
Early Childhood
The patient was an active child and often play with his siblings at home.
III.
Middle Childhood

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF PSYCHIATRY
Quirino Ave. corner Roxas Blvd., Malate Manila, Philippines
Patient reports to having an active social life during gradeschool, and that he had bestfriends and a group he felt he belonged to. He is also academically excellent, in that he received awards for his achievements.
IV.
Late Childhood
The patient reports to be focused in his schoolwork and arning money during this stage in his life.
V.
Adulthood
The patient had his first job when he was 20 years old being a trainee to be a sea-man, destined in Japan. He continued this career path until present and just
recently got his degree in BS MT. He had his first girlfriend when he was 23 years old and had invited her to elope but she refused so they broke up. He met his
current wife in 1999 and was married in 2001 at 30 years old.
The patient is a baptized catholic but converted to a Born-Again Christian just last 2007.
He currently lives with his wife and 3 children in a house they own in Batangas. He is the only financial provider for the family/. Patient was never arrested.
VI.
Sexual History
The patients first sexual experience is with a prostitute when he was 22 years old, since then the patient reports to having at least 10 sexual partners and is
still having sex with prostitutes even now that he married.
VITAL SIGNS
BP: 100/70

HR: 52 bpm

RR: 18

Temp: 36.0 degrees

O2Sat: 96%

PHYSICAL EXAMINATION
HEENT:
PERTL, EOMs intact and full, (-) TPC, (-) CLAD
Chest:
Symmetrical Chest Expansion, Vesicular BS
Heart:
Adynamic Precordium,
Abdomen: Globular, Normoactive BS
Extremities: Grossly Normal
MENTAL STATUS EXAMINATION
I.
General Description:
Patient is well groomed, awake, coherent and euthymic
II.
Mood:
Euthymic
III.
Affect:
Broad and Appropriate
IV.
Speech:
Spontaneous, slow, of normal quality and without impairment
V.
Perceptual Disturbances:
Auditory Hallucinations
VI.
Thought Process:
Continous
VII.
Thought Content:
(+) Suicidal Ideations, (+) Preoccupations: voices in his head is out to sabotage him
VIII.
Sensorium & Cognition:
a.
Alertness/ Level of Consciousness: Alert, Conscious, Coherent
b.
Orientation:
Oriented to 3 spheres
c.
Memory:
Intact
d.
Attention & Concentration:
intact
e.
Capacity to read & write:
intact
f.
Visuospatial ability:
intact
g.
Abstract Thinking:
intact
h.
Fund of Information/ Intelligence: adequate
ASSESSMENT:
PLAN