Name of Patient: Tubaing, Rolly E.

Hospital: CCMH – OPD

Informant: Patient and Mother Consultant: Dr. Resontoc
Reliability: Good Date Taken: May 7. 2019
Historian: Alfonso Martin E. Plantilla Date Submitted: May 8. 2019

PSYCHIATRIC HISTORY

GENERAL DATA

R.T., 39-year-old male, Filipino, single, unemployed, right-handed, Roman Catholic,

college graduate, second of three siblings, born on December 1, 1979 in Zamboanga City and
currently residing in Dasmariñas City, Cavite sought consult for the first time at the CCMH- OPD
on May 7, 2019 at around 9:00 am. He is accompanied by his mother and 2 barangay officials.

PRE – MORBID PERSONALITY AND LEVEL OF FUNCTIONING

The patient was described to be introverted, shy, but hardworking. According to his
mother he has already been showing signs of mental instability since early childhood but
dismissed it.

CHIEF COMPLAINT

According to the patient, “napagkamalang may deperensya at tino-torture nila ako”

According to the patient’s mother, “mamartilyuhin ako at binabasag ang gamit sa bahay”

DURATION

Since childhood

HISTORY OF PRESENT ILLNESS

The patient was apparently well twenty-nine years prior to consultation, when the patient
had an accident in which he burned his neighbors house with no apparent reason. He also runs
with a knife to catch his father’s mistress. The mother also noted that the patient laughs and
talks to himself. Also noted that it takes him an hour to brush his teeth and to defecate. On the
interim there was persistence of laughing and talking by himself and he picks a fight with
neighbors who are older than him.
Three years prior to consultation, patient worked overseas in Dubai and one of his co-
workers pushed him down the stairs in which the co-worker got away with it. This incident led
him to attempt suicide by jumping of the building. He sustained minor injuries according to the
mother. He then went back to the Philippines. The mother noted that he thinks that here is
always someone who wants to harm or kill him. He only stays at home and does not want to talk
to others. The mother said: “tinatakpan niya ang mga bintana at sumisilip sa mga butas.” He is
unable to sleep at night but sleeps during the day.
Three days prior to consultation, the mother noticed that the patient wanted to hurt
others. He parades down the street with his axe and wants to harm people. His violent behavior
prompted the mother to seek consult at CCMH.
PAST MEDICAL / PSYCHIATRIC ILLNESS

The patient has no previous history of any medical illnesses such as hypertension,
Diabetes mellitus, bronchial asthma, tuberculosis, cancer nor kidney disease. He has no
previous hospitalizations, surgical operations, injuries. There is no known history of allergies.

FAMILY HISTORY

There is history of diabetes mellitus in the maternal side. No other history of

hypertension, bronchial asthma, tuberculosis, cancer nor kidney disease. There is no history of
psychiatric illnesses in the family

PERSONAL AND SOCIAL HISTORY

Patient is a college graduate who majored in Commerce and is currently unemployed.

He previously worked as an OFW in Dubai. He is a non-alcoholic beverage drinker nor a
smoker. He lives with his mother alone.

ANAMNESIS

Pre-natal: The patient’s mother’s pregnancy with him was planned. He was born full
term via VSD in a hospital attended by a doctor. No maternal health problems or complications
during pregnancy, delivery, or after delivery.

Early Childhood: The patient was breastfed but unsure of duration. He was at par with
age and started to speak at the age of 1. The mother was the primary caregiver. He is the
middle child. There were no noted problems such as separation anxiety or temper tantrums.

Middle Childhood: The patient was well-adjusted at school however, he had poor
academic performance which led him to fail a subject and repeat a grade level. He was noted to
be a slow learner. He had no problems with his teachers and friends but he would always pick a
fight with his elderly neighbors.

Late Childhood: He had a few close friends but his mother does not know about any
romantic relationships he had.

Adulthood: The patient graduated college as a Commerce student and had an office job
in Dubai. Patient’s mother does not recall the patient having any romantic nor sexual
relationships.

REVIEW OF SYSTEMS

General (-) Weakness (-) Loss of appetite (-) Weight gain (-) Easy
Fatigability
(-) Wound (-) Rashes (-) Erythema (-) Pallor (-) Clubbing of nails
Integument
(-) Hyperpigmentation (-) Hypopigmentation
(-) Stiffness (-) Headache (-) Distention of veins (-) Masses
Head and Neck
(-) Swelling
Eyes (-) Corrective lenses (-) Pain (-) Redness (-) Discharge
 Nose (-) Water discharge (-) Epistaxis (-) Colds
Ears (-) Otalgia (-) Vertigo (-) Dizziness (-) Tinnitus
Mouth and Throat (-) Tongue fasciculations
Respiratory (-) Cough (-) Dyspnea (-) Hemoptysis (-) Tachypnea (-) chest pains
Cardiovascular (-) Angina (-) Dyspnea (-) Palpitations (-) Orthopnea
(-) Anorexia (-) Abdominal pain (-) Constipation (-) Vomiting
GIT (-) Retching (-) Diarrhea (-) Abdominal distention (-) Nausea
(-) Melena (-) Hematemesis
(-) Increased in frequency (-) Polyuria (-) Oliguria (-) Nocturia
GUT
(-) Dysuria (-) Palpable mass (-) Flank pains
Hematologic (-) Easy Bruising (-) Easy bleeding
(-) Polyuria (-) Polyphagia (-) Polydipsia (-) Diaphoresis (-)
Endocrine
Heat/cold intolerance
MSS/Extremities (-) Fractures (-) Joint pains (-) Edema
Nervous System (-) Seizures (-) Tremors (-) Slurring of speech (-) Headache

MENTAL STATUS EXAMINATION

Patient identifies himself as Rolly and appears his chronological age of 39 years old. He
is appropriately dressed wearing a yellow shirt and gray-colored shorts. He does not have any
ticks nor mannerisms. He has good eye contact with the examiner. He is guarded towards the
examiner. When asked how does he feel, he answered: “tinorture nila ako.” He has good range
of affect, spontaneous speech with high volume. When asked about hallucinations, he said:
“useless yan, babaligtarin nila ako.” Patient has looseness of association when he answers
questions. No suicidal indications but when asked if he tends to hurt others, he remained quiet.
He is not oriented to time since when asked, he answered: “wala akong cellphone” and “obvious
ba, hapon!”. He is oriented to place and person. Memory, fund of knowledge, concentration,
reading and writing, visuospatial ability, ability to follow three-step commands, abstract thinking,
judgment and insight were not assessed since patient was uncooperative.

PHYSICAL AND NEUROLOGIC EXAMINATION

GENERAL SURVEY
The patient is conscious, coherent, oriented to place, and person, but not time. He
appears well developed and well nourished, ambulatory, not in cardio-respiratory distress, and
appears his chronological age of 39.

VITAL SIGNS
Blood Pressure = 120/80 mmHg, sitting
Cardiac Rate = 96 bpm, regular
Respiratory Rate = 18 cpm
Temperature = 35.9 °C, axillary

SKIN
Inspection: (-) pallor, (-) jaundice (-) erythema (-) hypo/hyperpigmentation (-) edema
Palpation: (-) warm/cool to touch (+) good skin turgor (+) normal moisture (-) dryness
HEENT
Head: (+) symmetrical (+) normocephalic skull (+) normal hair pattern
Eyes: (+) pink palpebral conjunctiva (-) redness (-) discharge
Ears: (+) symmetrical (-) lesions (-) swelling (-) discharge
Nose: (+) nasal septum, midline (+) symmetrical (-) deformities (-) discharge (-) epistaxis
Throat: (+) midline trachea
Palpation: (-) cervical lymphadenopathies (-) tenderness

CHEST AND LUNGS

Inspection: symmetrical chest, no lesions, masses, ulcerations, no subcostal retractions
Auscultation: bronchovesicular breath sounds, no wheezing, no stridor

HEART
Inspection: no precordial bulge, (-) heaves, thrills
Auscultation: normal rate, regular rhythm, (-) murmurs

ABDOMEN
Inspection: (-) masses (-) lesions
Palpation: soft, non-tender abdomen

EXTREMITIES
Inspection: (-) gross deformities, (-) edema
Palpation: (+) full and equal peripheral pulses, (-) tenderness

NEUROLOGIC EXAMINATION

CN I Not assessed
CN II (+) direct and consensual light reflex; 2 – 3 mm EBRTL
CN III, IV, VI Good and intact EOM’s (-) nystagmus
CN V Good masseter and temporalis tone, equal facial sensation
CN VII Symmetrical facial movement
CN VIII Good gross hearing and balance
CN IX, X Can swallow and cough
CN XI Good SCM tone, good trapezius tone
CN XII Tongue midline with no fasciculations and weakness

Sensory Motor

DIAGNOSIS: F 20. Schizophrenia, Paranoid Type

DIFFERENTIAL DIAGNOSIS

Schizophreniform disorder is siimilar to schizophrenia but the duration of symptoms is less. The
patient has experienced symptoms for longer than one week but less than six months. This
diagnosis is often considered the first step towards an eventual schizophrenia diagnosis, which
requires continuous signs of disturbance for at least six months.

Schizoaffective disorder can manifest with manic and major depressive episodes, and patients
with this disorder can exhibit increased agitation and irritability. It differs from bipolar disorder
with respect to timing; patients with schizoaffective disorder exhibit psychosis even during
periods of euthymia, whereas patients with bipolar disorder only exhibit psychosis in periods of
mania or major depression.

Schizotypal personality disorder develops by early adulthood and is characterized by pervasive

deficits in social and interpersonal skills, eccentric behavior, discomfort forming close personal
relationships, as well as cognitive and perceptual distortions.

Borderline personality disorder can manifest itself with uncontrollable anger and affective
instability. Patients with this disorder exhibit problematic impulsive behavior and poor
psychosocial functioning.

CASE DISCUSSION

Schizophrenia is a mental illness that causes a change in a person’s thinking, emotion,

perception and behavior. Schizophrenia is an illness, it is not a weakness or character fault. It is
not a split personality, multiple personality, or developmental disability. When treated effectively
schizophrenia is not an illness that makes people more violent or aggressive. Schizophrenia
affects on average 1% of the population, It does not affect any specific group of people. It can
affect anyone regardless of gender, ethnicity, culture, sexuality, class, intelligence or level of
education. Most people have their first episode of schizophrenia as adolescents or young
adults. 20 –30% of people have only one or two psychotic episodes in their life, for others
schizophrenia is more chronic.
The paranoid subtype of schizophrenia is the most common of subtypes. Those with the
paranoid subtype will have delusions and suspicions that increase during the course of the
illness. Their delusions are mostly persecutory, grandiose, or feelings of inadequacy, and will
tend to have interpersonal problems. The delusions may be multiple, but usually have a theme.
Other features include anxiety, anger, aloofness, and argumentativeness. These features
become increasingly suspicious of relatives and close friends. The individual may display a
superior or patronizing manner, and may be extremely formal or intense in their interactions.
They function at a higher level than most other schizophrenics because of the lack of negative
symptoms. Their diagnosis is more stable than for the other types, and they respond better to
treatment as well. Individuals suffering from the paranoid subtype also suffer from social
withdrawal and persistently hold grudges and perceive attacks.

PLAN OF MANAGEMENT

In this case, the patient was given anti-psychotic medications which includes:
Risperidone 2 mg ½ tablet once a day at night, Levomepromazine 100 mg ½ tablet once a day
and Haloperidol 2 mg ½ tablet once a day. Patient was advised to come back for consultation a
week after taking the medications to see whether or not an improvement is seen or if there is a
need for the patiet to increase medication dosages or to be admitted.
 It should be noted that while antipsychotic medication is effective in treating the positive
symptoms of schizophrenia, it does not address negative symptoms. Furthermore, these drugs
can have unwanted side effects including weight gain, drowsiness, restlessness, nausea,
vomiting, low blood pressure, dry mouth, and lowered white blood cell count. Moreover, they
can also lead to the development of movement disorders, like tremors and tics. This should be
taken into consideration in giving anti-psychotic medications.
In addition to anti-psychotics, psychotherapy also plays an important role in the
treatment of schizophrenia. Cognitive behavioral therapy has been shown to help patients
develop and retain social skills, alleviate comorbid anxiety and depression symptoms, cope with
trauma in their past, improve relationships with family and friends, and support occupational
recovery.