psychiatric history 1

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University of Northern PhilippinesTamag, Vigan City, Ilocos Sur

College of Medicine

Psychiatry

The Case of A !

Prepared "y#Stephen A U$ano

II % &

Prepared for#'r (ohann )ee

March *+, *+-


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I PS)C.IAT/IC .IST0/)

Date/Time: March 15, 2016 3:20pmDate of Admission: March 15, 2012

Identifying 'ata

Patient A.G. is a 26 year-old female, Pastoral Ministry student admitted for the first timeat Tan-Yee Therapeutic Home Care, Psychiatric and eha!ilitation Center. "he #as !orn in$enito "oli%en, &sa!ela on Au'ust 22, ()*). "he is a +ilipino, sin'le, and an affiliate of $orn

A'ain eli'ion. "he currently resides in intar, &locos orte.

/eferral 1 Informants# Patient

Chief Complaint#A'riya#riya#, haan na/ ma/aturo', haan na/ ma/a/a/aan, /en /anayon na/ madandana'an0as %er!ali1ed !y the patient

.istory of Present Illness

( days prior to admission 3+e!ruary 2*, 24(25 patient #as admitted at Ga!riella "ilan'General Hospital due to en'ue and Pneumonia.

(( days prior to admission, #hile restin' in her !ed at the Medical 7ard of the samehospital, a ne#s came that there is a !om! inside the institution and that all should e%acuateimmediately. The patient claimed e%ery!ody inside the #ard #as in dis!elief, panic/in' andscreamin' so is she. "he #as so scared and panic/ed as #ell #hile screamin' and runnin'to#ards the outside of the hospital. "he claimed she thou'ht she #as a!out to die that e%en asthey already #ent out, she is still sha/in' and %ery afraid.

"ince the incident happened, her parents noticed that her !eha%iour has chan'ed. "he!ecame so %i'ilant, 8uieter !ut often screams #ithout any reason, prefers to stay in her !ed,doesn9t li/e to eat or ta/e a !ath, !ecame a''ressi%e, has difficulty in sleepin' and 'oes out ofthe house to 'o to their church to pray in the middle of the afternoon. "he also doesn9t #ant total/ to anyone !ut mum!les and tal/s alone sometimes. Her relationship #ith her family #as%ery affected !ecause of her !eha%iours. "he #as 'i%en #ith a medication 3name unrecalled5 topromote sleep !ut afforded only minimal relief. "he sho#s the same !eha%iour as soon as she#a/es up. "he then #asn9t a!le to do her common acti%ities of daily li%in' and #asn9t a!le toattend her classes anymore.

Her condition and !eha%iour remained the same e%ery day that on March (, 24(2, herparents decided to see/ for psychiatric e%aluation, and #as she su!se8uently admitted.

"he didn9t ha%e any prior e:perience of a traumatic e%ent.

"he claims that she doesn9t #ant to 'o !ac/ to Ga!riela "ilan' General Hospital a'ain.

Past .istory

a.Pschiatric:o history of pre%ious contact #ith psychiatric and other ser%ices for mental hhealth

pro!lems.

!. Medica":

Admitted at Ga!riela "ilan' General Hospital last +e!ruary 2*, 24(2 due to to den'ueand pneumonia. Treatment 'i%en #as unrecalled.

o history of pre'nancy, epilepsy, head in;ury, or central ner%ous system infection.

c. A"coho" and #$!stance:The patient denies alcohol drin/in' or any illicit dru's use.


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2amily .istory#

o family history of psychiatric illnesses, neurolo'ical disorders, suicides, criminal!eha%iours, a!use, alcoholism and depression.

Personal and Social .istory 3Anamnesis4#

1. Prenatal and Perinatal:Patient #as !orn premature 3< mos5 %ia normal spontaneous deli%ery at their home

attended !y a mid#ife. "he claims that her mother did not ta/e any terato'enic a'ents. o !irthcomplication or con'enital defects.

2. Early childhood (Birth through age 3):Patient #as purely !reastfed up to 6 months of a'e and had no feedin' or sleep

distur!ances. Patient is a %ery ener'etic and playful yet 8uiet 'irl and had no !eha%ioural orde%elopmental pro!lems. "he is solely ta/en cared !y her mother.

3. Middle childhood (ages 3 to 11):

"he is a timid 'irl !ut friendly type of person in preschool. "he prefers to stay at home#hen she has no classes to study. Plays #ith peers #ell and has no history of !eha%iouralpro!lems.

"he has no learnin' difficulties and #as a top performin' student in the class durin' herprimary school. Thou'h she claims she #as an inconsistent honor student !ecause she lost herfocus in her studies durin' her intermediate school !ecause she has to #or/ and help at home.

"he admits that her parents are strict #hen it comes to discipline. They #ere disciplinedthrou'h %er!al punishments and reprimands or throu'h physical punishments li/e !ein' slapped#hen they do somethin' #ron'.

"he claims she is afraid of sna/es and God.

4. Late childhood (puberty through adolescence):

"he had her menarche at the a'e of (2, re'ular and consumes a!out *-(4 pads #ith 4*.> Acute "tress isorder >4).*( Posttraumatic "tress isorder

A7IS II#


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5M'/ 35ye Movement 'esensiti:ation and /eprocessing4

- &ncorporates elements of co'niti%e-!eha%ioral therapy #ith eye mo%ements orother forms of rhythmic, left-ri'ht stimulation, such as hand taps or sounds.These #or/ !y Dunfree1in'D the !rain9s information processin' system, #hich is

interrupted in times of e:treme stress.

psychiatric history 1

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