Republic of the Philippines
Department of Health
Vicente Sotto Memorial Medical Center
Center for Behavioral Sciences
B. Rodriguez St., Cebu City
PSYCHIATRIC REPORT
RESIDENT: DR. DIMATINGKAL
INTERN: MHAM – DUMAO, CAMILLE MAE A.
GENERAL DATA
A case of patient MU.SY, 33 years old, male, born on November 11, 1990, barangay
encoder, single, Filipino, Roman Catholic from Basak, San Nicholas, Cebu City, sought
consultation for the fifth time at VSMMC-CBS this August 8, 2024.
SOURCE AND RELIABILITY
Patient’s Mother: 70%
CHIEF COMPLAINT
“Di mo tingog, di mo kaon, di mo inom og tambal unya mag storya sa kaugalingon”,
as verbalized by the SO.
HISTORY OF PRESENT ILLNESS
1 week PTC, the patient stopped taking his prescribed maintenance medication as
claimed by his SO. When his mother gives him the medicine, the patient would say “ako ra
kay kabalo ko”. The mother noticed that for the past 5 months her son complains about
work, stating that,“gi kapoy kuno siya”. She also claimed that the patient suddenly stopped
going to work and decided to stay at home then further added, “dili na siya motumar sa
tambal, dili na mokaon, dili na maligo og magyawyaw siya sa iyang kaugalingon”.
In the interim, the mother noticed worsening of symptoms wherein the patient had
difficulty in sleeping, exhibiting blank stares and didn't socialize with anyone in the house.
There are no changes in his appetite, hygiene practices, still non-compliant to his
medications and still talking to himself.
On the day of consult, it is supposedly his scheduled follow-up check up but his
mother decided to admit him since he no longer takes his medications.
PAST PSYCHIATRIC HISTORY
The patient’s mother could not recall the number of previous consultations at our
institution. However, she mentioned that the patient was diagnosed with schizophrenia
around 6 years ago. Since then he had been managed with clozapine 100mg/tab 1 tab BID.
He had been compliant with his medications until 1 week prior to his consultation.
SUBSTANCE USE HISTORY
Patient claims to be a non-smoker, non-alcoholic, and has no history of illicit drug
use. She is a non-coffee drinker. Denies gambling or other risk-taking behaviors.
PAST MEDICAL HISTORY
Patient has no known childhood illnesses. SO claimed he had complete childhood
vaccinations at the barangay health center and had 2 doses of COVID vaccines. No history
of cancer, hypertension, diabetes, asthma, hyperthyroidism, metabolic syndrome, or renal
disorders. He had a single episode of febrile seizure when he was younger. No head injury,
and pain disorders. No allergies to food nor any medications.
FAMILY HISTORY
The patient’s mother is 60 y.o,”labandera”, living and well without any comorbidities.
The patient’s father is 57 y.o, unemployed , living and well without any comorbidities.
Heredofamilial diseases on the maternal side include hypertension and unknown on the
paternal side . He is the eldest among her 7 siblings. SO claimed he was close to both her
parents and siblings. Patient’s mother denies any psychiatric history in their family.
● Sibling #2- 29/M, living and well without any comorbidities
● Sibling #3 - 28/F, living and well without any comorbidities
● Sibling #4 - 26/M, living and well without any comorbidities
● Sibling #5 - 25/F, living and well without any comorbidities
● Sibling #6 - 20/M, living and well without any comorbidities
● Sibling #7 - 18/M, living and well without any comorbidities
DEVELOPMENTAL AND SOCIAL HISTORY
The patient grew up in Cebu City in their own house. She was born from a
G11P9(8128) mother via normal spontaneous vaginal delivery (NSVD) at home. No birth
complications were noted. She was breastfeed for the first 6 months but was introduced to
complementary feeding thereafter. Her mother claimed that the patient had a tooth eruption
at 3 months old. Little is known about the prenatal, natal, and postnatal history, as well as
the developmental milestones.
The mother described her son as a shy and quiet child who prefers to stay home and
play with his toy car. His mother mentioned he rarely goes outside to play with other children.
He graduated elementary as an average student, “Di ra kaayo taas, di sad kaayo mubo
iyang mga grado.” stated by his mother.
During his teenage years the patient remained shy and quiet with poor social
interaction. His mother mentioned he has no group of friends and prefers to be alone,
“ganahan ra siya mag inusara” and when the patient is asked why he did not give any reply.
He graduated highschool as an average student. He had no vices and romantic relationships
as claimed by his mother. He pursued college and graduated with a bachelor in science in
information technology.
After his college in 2009, he had his first job at the city hall as an encoder for 3 years.
His mother mentioned the reason for quitting his job was,“ Naka feel siya na di na kaya kay
kapoy.”In 2012, he worked as a call center agent for 6 months but also quit his job with the
same reason as claimed by the mother. During the time he had no work, the patient's mother
claimed he stayed at home and did nothing,”Magpuyo ra siya sud sa kwarto. Magtanga og di
mostorya bisan kinsa.” Recently, he was working as an encoder in their barangay but
suddenly stopped about a week ago.
MENTAL STATUS EXAMINATION
Patient was seen and examined awake, calm, verbally unresponsive and
uncooperative. Seated on the chair. He was poorly groomed, with a bad odor, he was
wearing black polo and denim jeans with soiled untrimmed nails. Patient cannot maintain
good eye contact. He cannot speak spontaneously. The rest of the MSE could not be
assessed.
PHYSICAL EXAMINATION
• Blood pressure: 120/90 mmHg
• Pulse rate: 120 bpm
• Respiratory rate: 18 cpm
• Temperature: 36.5 C
• O2 saturation: 95%
PRIMARY IMPRESSION
Schizophrenia, Multiple Episodes, Currently in Acute episode
PLAN
● Laboratory tests - CBC, BUA, BUN, CREA, SGPT, SGOT, SERUM ELECTROLYTES,
FBS,HBA1C, LIPID PROFILE
● Pharmacotherapy:
Clozapine 100mg/tab,1 tab now then 1 tab ODHS
● Psychotherapy
-Secure consent to care
-For strict suicide, homicide, and escape precautions at all times
