Submitted by: Joyce B.

Ramirez
History taken by: Dr. Stephanie Miaco
Informant: Patient and sister
Reliability: 85%
Date taken: August 3, 2018

IDENTIFYING DATA:

Patient is M.C., a 17-year-old, single, Filipino woman born on July 18, 2001, from
Mabinay, Negros Oriental. She is a former Grade 10 student of Mabinay National High
School, who used to work as a housekeeper and was admitted at Talay Rehabilitation
and Psychiatric Center on April 25, 2018 due to agitation and behavioral changes.

CHIEF COMPLAINT: “sige kog wild”

HISTORY OF PRESENT ILLNESS:

MC is a 17-year-old woman who reports that she has been repeatedly sexually
harassed and threatened with a gun by her employer 3 months PTA. 1 month PTA,
patient decided that she can’t take it anymore and decided to quit and go back to
Mabinay. Patient’s sister noted a change in her behavior from being energetic to being
apathetic. No vomiting, dizziness, or any sign of pregnancy was noted.

3 weeks PTA, patient decided to live with her 26-year-old boyfriend in Bayawan
whom she has just met. Patient mentioned that she did household chores and went with
her boyfriend to do groceries during this time, aside from that she doesn’t really
remember much. However 5 days PTA, patient was brought back home by her
boyfriend’s family due to aggression.

During her stay at home, patient noted sudden onset of undocumented fever.
She took paracetamol twice a day and felt slight relief. She claimed that her fever was
due to “barang” by her former boyfriend from Manila, since he found out that she was
unfaithful and had another boyfriend. Associated symptoms include chest pain,
insomnia, loss of appetite and visual hallucinations of her boyfriend from Manila in the
evenings further solidifying her theories about her condition. Patient suddenly had violent
episodes as manifested by smashing of glasses because she claims that she is a child
of God. She had hallucinations of God coming down to earth telling her to be good.
Patient eventually could not recognize the people around her and continuously roamed
around. Patient’s aggression and agitation continued on for 4 days which urged the
family to tie her down. After which, patient’s family decided to bring her to Talay
Rehabilitation and Psychiatric Center on April 25, 2018 for admission.

Patient was admitted in the isolation room due to her aggression. She was given
Olanzapine twice a day, one taken at 8am and one taken at 6pm. It took 3 weeks before
a significant change in behavior was noted, according to her sister.

PAST MEDICAL HISTORY:

 No persistent childhood illness. No known adult comorbidities. No previous
surgeries or blood transfusions. No food or drug allergies. No vices or illicit drug use. No
addictions. No criminal record. Patient claims to have history of undocumented fever
prior to admission at Talay. However, this was not treated and patient just self-
medicated with Paracetamol taken twice a day.

ANAMNESIS:

Patient’s mother was assisted by a hilot during delivery of the patient in their
house at Bais, Negros Oriental. The patient is the youngest of 4 siblings; the eldest
being 24 years old at present. Patient’s mother works as a farmer.

Patient grew up in Bais before transferring to Mabinay. Although her parents

were occasionally strict, she still grew up with a happy childhood. Her sister mentioned
that their father has dissociative episodes and becomes violent towards them. The
siblings will huddle together and protect the patient from harm. The siblings are very
close. The patient claims that she was just silent as a child but would still talk to people
she knows.

Despite having to work as a farmer at an early age, patient was still encouraged
by mother to continue studying. She graduated elementary from a public school in Bais
City. The patient had her high school education ate Bayawan National High School,
patient claimed to have many friends and described her life then as enjoyable. Patient
is just an average student having grades of approximately 80%. Her favorite subjects
are Math and Filipino.

Patient is an occasional alcoholic drinker, consuming approximately 4 bottles of

Red Horse beer before getting drunk. The patient claims that she just sleeps when
drunk. Patient denies being a smoker; also denies use of illicit drugs such as shabu and
marijuana.

FAMILY HISTORY:

Patient claims that her mother has TB and that no other family member has
experienced the same psychiatric symptoms that she has. However, her sister claims
that their father also has the same illness. The symptoms were recurrent and consist of
episodes of mania and depression. On certain instances, the father would not recognize
his children and go naked even if sober. Patient’s father was also treated at Talay
Rehabilitation and Psychiatric Center. Patient’s father died when she was 6 years old.
However, she is not aware of the cause of death of her father. The sister claims that the
cause of death was suicide due to overdose of the medications from the Rehabilitation
Center.

MENTAL STATUS EXAM:

The patient appears to be a 17-year-old petite female with medium built. She is
afebrile, conscious and alert, oriented (to time/ place/ person) and attentive to questions.
Her age is appropriate to looks which features a medium body structure with natural
light-brown skin; her black mid-length wavy hair was slightly disheveled. She appeared
well-groomed and was wearing a striped T-shirt and maroon pants and is free from any
 sort of jewelry. The patient was comfortable and cooperative throughout the interview.
She appears to have extrapyramidal symptoms which can probably be attributed to use
of Olanzapine. She speaks facing the speaker. She speaks in fluent Visayan vernacular,
with good comprehension, slower speed, and decreased amounts of speech; but speech
appears to be telegraphic. She also claims that she is happy but with slightly constricted
affect. The patient does not have suicidal thoughts. No obsessional thoughts,
compulsions, and delusions noted. No visual and auditory hallucinations noted. No
illusions noted. No depersonalization nor derealization.
She appears alert and oriented to time/place/person. She is not able to count
backwards when asked to. She is able to recall dates of birthdays. She failed to identify
the some of the presidents. She has poor abstraction ability and has poor judgement.
She is unaware of the reason for her admission and rationale of treatments, claiming her
sister noted that she was very aggressive and had behavioral changes.
REFLECTION:
During the interview session, it was very apparent that psychiatry has a different
approach than the other fields, like for example internal medicine. Since in psychiatry, you
have to be very sensitive about the patient’s appearance, words and actions. We also have
to be more critical in filtering the patient’s words and be goal-oriented during the interview
since you don’t want to get lost in the conversation. It’s also important to be time conscious
when dealing with these types of patients since you can never predict when their mood will
change, so you have to be critical and precise while interviewing. Rapport was also very
important; since it’ll help you extract a much more detailed information when the patient is
comfortable with you and that it could also help in the diagnosis. All in all, this type of
teaching is better than the traditional one since we’re able to see an actual example of what
and what not to do. It was a very educational class.

PRIMARY WORKING IMPRESSION

POST-TRAUMATIC STRESS DISORDER

The patient met the criteria for PTSD according to DSM V:
 Criterion A: The person was exposed to: threatened death and actual or threatened sexual
violence by direct exposure
 Criterion B: The traumatic event is persistently re-experienced, in the following way(s):
Unwanted upsetting memories
Nightmares
Flashbacks
Emotional distress after exposure to traumatic reminders
Physical reactivity after exposure to traumatic reminders
 Criterion C (one required): Avoidance of trauma-related stimuli after the trauma, in the following
way(s):
Trauma-related thoughts or feelings
Trauma-related reminders
 Criterion D (two required): Negative thoughts or feelings that began or worsened after the
trauma, in the following way(s):
Negative affect
Decreased interest in activities
Feeling isolated
 Difficulty experiencing positive affect
 Criterion E (two required): Trauma-related arousal and reactivity that began or worsened after
the trauma, in the following way(s)
Irritability or aggression
Risky or destructive behavior
Hypervigilance
Difficulty sleeping
 Criterion F (required): Symptoms last for more than 1 month.
 Criterion G (required): Symptoms create distress or functional impairment (e.g., social,
occupational).
 Criterion H (required): Symptoms are not due to medication, substance use, or other illness.