VALDEZ, Gail-Marie R.

EAEC- 3rd yr.

PSYCHIATRIC ASSESSMENT AND MENTAL STATUS EXAM

GENERAL DATA

Name: A. B. J.

Address: Bicutan, Manila

Sex: Male

Religion: Roman Catholic

Birthday: December 18, 1979

Age: 31

Marital Status: single

Place of Current Interview: Ward 7, PGH

Source of Information: Patient and watcher

Reliability: seems reliable

Referral: brought in

CHIEF COMPLAIN:

As I ask the patient what brought him to the hospital, he answered “ Wala
Po”. I proceeded with my interview, and along the way I asked him again
what brought him to the hospital and he answered “Pinilit ko si Nanay na
pumunta dito”. Then, I asked him what is the reason you forced your mother
to bring you here he answered back to me, “ Kailangan ko ng gamot para
gumaling.” I told him, “Kuya ano ba ang dahilan at kailangan mo ng
gumaling ano ba ang sakit mo?” He answered “Wala naman”.

After I have asked him that, I also asked his father who is also his watcher
the reason of his son’s hospitalization, and he told me that he remembered
the onset when he first noticed something was different about his son,
“Dalawang araw ako sa Taytay noon, pagbalik ko nalaman ko na kumuha
sha ng pera ng hindi namin alam, pagkatapos noon ay iba na ang kilos niya,
pabalik-balik at hindi natatapos sa trabaho, salita siya ng salita at ligo ng ligo
paulit ulit, at hindi na din siya nakakatulog.” He told me that when he saw
these absurd things about his son they decided to bring him to a hospital and
the doctor have told him that the patient was diagnosed with schizophrenia.

HISTORY OF PRESENT ILLNESS

Onset: Q: “When did you first notice something happening to you?”

A: “ Wala naman”.

Precipitating Events: The patient responded “wala”.

Reason for consult: Q: “Where you upset about anything?” He answered

“Wala.”

What ways did the Illness affects the patient?: The patient was affected
gradually.

History of Previous Hospitalization and Treatment: The patient answered me,

“Wala, sa bahay lang ako”. I asked his father about his and he told me the
first hospitalization was in the year 1995 where he first noticed the
symptoms. Then the next episode was in 1997 since then the patient will be
on and off mental institutions.

PAST MEDICAL HISTORY

Psychiatric

(Treatments, Hospitalizations)

The patient related to me that this was the first time he was
hospitalized, but when I asked his father he told me that there were
many times the patient was institutionalized.

(Any incidence of losing consciousness or seizure)

The patient said that his mother told him that he had many seizure
episodes during his childhood but when I asked his father about this he
said that he cannot recall any.

(Alcohol, Substance Abuse)

The patient said that he forgot if he ever drank any alcohol beverages
but his father told me that the patient drinks alcohol whenever he is at
home.
 Mr. A. B. J. said that he had experienced marijuana and shabu, his
father related to me that he only saw his son to possess marijuana

FAMILY HISTORY

(Family Members with Psychiatric Illness and their Hospitalization and

Treatment)

None

(Family History of Alcohol and Substance Abuse, Antisocial Behavior)

The father told me that before he drank alcohol almost every day but now he
stopped. He also told me that he would beat his wife before. The patient told
me that his brother also drank alcohol and would always beat him up. The
father also told me that when the patient was an adult he would get angry
and be angry and be violent to them if they do not allow him to go out or
smoke cigarette.

(Relationship of each Family Member in the Patient’s Upbringing)

Mr. A.B.J. told me that they his mother and father is good to him except his
brother because they always fight.

(Family Traditions)

The father told me that their family would get together in special occasions
like, birthdays, Christmas and New Year.

Family Attitude towards Illness:

The father said he and his wife were both very concerned with what
happened to the patient but the brother doesn’t care and would even shout
at the patient every time.

Patient’s Attitude towards Parents and Siblings:

The father told me that the patient is a caring and loving son to them.

PERSONAL HISTORY (Anamnesis)

Birth and Infancy:

The father told me that the patient was a normal delivery and that his
mother was around 35 years old that time.

Childhood:

Feeding Habits:

The patient would have milk and congee every day until he was able to eat
solid foods. They do not have problems in feeding him according to the
father.

Toilet Training:

The patient was toilet trained early and did not have any bedwetting
episodes as he grew up.

Play with peers:

The patient do not play with other children even his brother said his father.

1st childhood memory:

The patient remembered that he would watch T.V. as a child, he remembers

that he was 7 years old that time and he would go to school.

Adolescence:

School: The patient loves to go to school

Grades: His grades were low but he passed and never flunked any subject.

Emotional Problems:

He told me he does not have any.

Drug Use:

The patient has had experience of substance abuse and smoking.

Age of Puberty:

The patient told me that he remembered his pubic hair growing when he was
15 years old.

Adulthood:
The patient never experienced to work because he was first hospitalized at
the age of 14. He does not have a girlfriend and was never married. He
remembered that his mother told him he was christened when he was 7
months old but he cannot recall if he ever attended mass.

Sexual History:

He learned about sex in watching T.V. He does not have any concern or
interest about his sex life.

Family History:

Their family owned a house in Bicutan and they all live there. They all sleep
in the same room. They never had any problems until the patient was
diagnosed to have schizophrenia. The father was an alcoholic before but he
stopped when the patient is hospitalized. The mother was very concerned
with this and she was the one very much affected with the situation. The
brother seems to doesn’t care at all.

MENTAL STATUS EXAM

General Appearance:

Gait: The patient does not have gait problems he walks steadily.

Clothes: Patient was wearing a t-shirt and short during the interview, they
were clean. He is well groomed.

Posture: He was stooping when I was talking with him, and ne was seating
on a chair.

Gestures: He did not show any gestures while he was talking.

Facial Expressions: He smiles appropriately once in a while during our

conversation.

Older or Young for Age: He looks appropriate for his age.

Have you been more or less active than usual? No

Motoric Behavior: He moves normally, he does not have ataxia, dyslexia,

hyperactivity, flexibility.
Emotional Appearance: The patient seems depressed.

Voice: The patient has whispered speech.

Attitude Toward the Interview:

He seems shy and will not look at me straight in the eye. He is defensive but
cooperative.

Mood: The patient has a gloomy and depressed mood. He does not have
thought of harming himself.

Affect: The patient has appropriate content.

Speech: The patient has spontaneous speech. He does not have dysartria
upon saying Methodist Episcopalian.

Perceptual Disorder:

The patient told me he does not hear any voices, does not have strange
experiences in sleep and does not have strange smells.

Thought Content:

He does not feel that people wants to harm him, does not have special
powers, no one is trying to influence him, does not have strange body
sensations, does not have thoughts that he cannot get out of his mind, does
not think about the end of the world, and people cannot read his mind. But,
the T.V. is talking to him. He does not have any fantasies or dream.

When I asked him about the meaning of the proverb “Nasa Diyos ang Awa
nasa tao ang Gawa” he responded “ Hindi ko alam.”

Sensorium:

Level of Consciousness: The patient is alert, confused, and clouded. He is

oriented to time, person and place.

Memory:

Where were you Born? He told me that his mother told him he is born in their
house in Bicutan.

When is you birthday? He tol me December 18, but he cannot recall what
year.
Where did you study? He said Daang Hari Elementary School

Rcent Recall:

Where were you yesterday? “ Andito pa din”

What did you eat last night? “Isdang Bangus”

Immediate memory: He was able to count six digits forward and backward.

3 non related items and tested for five minutes: He forgot.

Concentrations and Calculations:

Count 1-10: able

Simple Calculation: was not able to answer correctly

Information & Intelligence:

Name some vegetable: He answered, amapalaya, gabi, lanka, beans, togue.

Philippine Presidents: He answered, Marcos, Jose Rizal, Andress Bonifacio,

Manuel Roxas, Emilio Jacinto, and Manuel Quezon.

Judgement:

What will you do if you find an envelope in a taxi stamped addressed and
sealed? He said he will not meddle with it because it belongs to someone
else.

Insight Level:

Do you think you have a Problem? He answered “wala”

Do you think you need help? He said “Hindi, gusto ko na nga umuwe.”

What are your plans for the future? He said “Ganon pa rin, maglalaba at
papasok sa school, miss ko na pumasok sa school eh”.
 MULTI AXIAL DIAGNOSTIC SYSTEM

AXIS 1:

Schizophrenia

AXIS 2: Obsessive Compulsive Disorder, Antisocial Personality Disorder

AXIS 3: Obesity

AXIS 4: Lack of an adequate support system

AXIS 5: