Psychiatry III Case Conference 1

1. Psychiatry IIICase Conference 1 III-B Cueto, Mary Anne Carol – Diaz, Mark Fernan

2. General Data L.M.P 35 y/o married Born Again Christian 2nd in a brood of 3 BS Nursing Graduate unemployed born & raised in Capiz admitted 1st time on April 4, 2005 Informants: Patient: 75% Husband: 85% Sister: 85%

3. Chief Complaint: insomnia, delusion of reference • According to patient: “ Pinaghihiwalayang family namin ng ministry.” According to husband: “ Hindi makatulog, minsannagbabasang bible mag-isa” “ Feeling nyapinagtutulungansiyang ministry” Personality Profile: Pre-morbid personality: “masinop, masayahin, sensitive” Morbid personality: “tahimik, kung anuanongsinasabi”

4. History of Present Illness 2001 * very active, sings in the choir 2004 * negative feelings towards members and ministry December 2005 * persistent negative feelings towards members and January ministry, delusion of reference 2005 * auditory hallucination, loss of appetite, reduced February sleep, negative feeling towards her husband 2005 * auditory hallucination, odd behavior, blank stares 1st wk March anxious

5. History of Present Illness 2005 * quiet, unresponsive 3rd wk March 2005* verbal aggression, delusion of reference March 25 2005 * felt guilty of what she said to the members, March 26delusion of persecution 2005 * neglected her chores and children, delusion March 27of persecution/anxiety 2005* singing songs, speaking incomprehensible words March 31

6. History of Present Illness 2005 * suspicious w/her surroundings April 1 * brought to Las Pinas Doctors Hospital * injected w/unrecalled medication * admitted @ USTH while sedated Review of Systems (-) Headache, loss of consciousness, convulsions (-) fever (+) anorexia , weight loss

7. FAMILY HISTORY (+) HPN – mother (+) stroke – mother (+) heart disease, PUD – father (+) alcohol dependence – father (?) nervous breakdown – great grandmother

8. PERSONAL HISTORY Non-smoker Non-alcoholic beverage drinker Denies use of any prohibited drugs

9. ANAMNESIS

10. PRENATAL AND PERINATAL HISTORY • Born to 23 y/o G2P1 (1001); NSD at home • By traditional birth attendant • No prenatal or postnatal complications • Neuro-developmental milestones at par with age

11. EARLY-MIDDLE CHILDHOOD • Lived with parents and three siblings • Family owns a small grocery store • Left in the care of the father, an alcoholic • Father had occasional fights with his wife • Patient admits his father had his “weaknesses” but was very affectionate and loving • Patient grew-up closer to her father and siblings

12. MIDDLE CHILDHOOD • Primary education at Malubog-lubog Elementary School in Capiz • Average student and had very few friends • 6th grade - father died which caused extreme sadness and felt that a big part of her was lost with the passing • Left in the care of the eldest sibling (Gina) • Gina confided of being overprotective of her younger siblings

13. ADOLESCENCE • Family Relationship • after father’s death, mother married a policeman • Siblings were against the marriage at first • Patient felt that the mother betrayed her father • According to the patient, she had a harmonious relationship with stepfather and stepsiblings • Stepfather did not impose himself on the stepchildren • was kind and approachable and was readily approachable when they need him

14. ADOLESCENCE • Social Relationships • Claimed to have a number of friends • stayed at home on weekends because mother would not allow her to go out with friends • School History • Attended high school in FLAIMER Christian Institute in Capiz • Wanted to take up AB Philosophy • forced by mother to take up BS Nursing • Graduated on time

15. ADOLESCENCE • Academic Achievement • failed Nursing Board Exams (1990) • failure due to “poor preparation” • Worked as an assistant nurse in a small clinic while waiting for the next board exams

16. YOUNG ADULTHOOD • took the boards in Manila and passed with high marks (1992) • Did not work at once because she was waiting for her petition from her maternal aunt to work in Germany • After some time worked as a ticketing supervisor at Ever Gotesco Cinema • Resigned after 2 months, thinking she was not ready to work yet • Learned that her petition was declined

17. YOUNG ADULTHOOD • 1993 - nurse in Capiz and resigned after 6 months • Felt bad in an incident when a patient deteriorated infront of her • According to sister: • Patient was pious and hardworking • Gave portion of salary to patients

18. YOUNG ADULTHOOD • 1994- went back to Manila and stayed with sister • Meaningful Long-term Relationship • met Norman and married him after two years (1996) - Stayed with husband’s family (Cavite) • After a few months, husband flew to Abu Dhabi • Patient got pregnant and went back to Capiz • Had difficult pregnancy - 1997 – CSD with her 1stchild (Paul Christian)

19. YOUNG ADULTHOOD • 1998 – went to Abu Dhabi with husband and had no difficulty in adjusting • Worked as sales clerk in a pharmacy • December 1999 – decided to return to Philippines due to 2nd pregnancy • 2000 – gave birth to second child (Patricia Lois) • Stayed with her mother, who sometimes helped out with her grandchildren • Longed for her husband

20. YOUNG ADULTHOOD • 2001 – returned to UAE with her children because of argument with mother • Was baptized to a ALL Nations FULL GOSPEL, a Born Again Christian group • Planned to work as a nurse however got pregnant with her 3rd child

21. WORK EXPERIENCE • First worked as an assistant nurse • Very little compensation while waiting for the next board exams • resigned to take 2nd board exam • Worked as Ticketing supervisor and resigned after 2 mos • Petition by her maternal aunt was declined by the German Embassy • 1998 - sales clerk in a pharmacy in Abu Dhabi • 1999 - resigned because of 2nd pregnancy • No difficulty adapting to new environment • No difficulty adjusting to new role as mother

22. FAMILY PROFILE • Cesar- father • Died of “heart attack” at 45 • An elementary graduate • Came from a well off family in Capiz • Alcoholic since 20 y/o • Drank gin (? amount) almost everyday usually alone or with friends • Patient regards him as loving and kind father • Patient claims she got her talent from him • He usually sang with her

23. FAMILY PROFILE • Minerva- mother • 58 y/o, elementary graduate • Strict disciplinarian in the family • Managed mini-grocery store with Cesar • Patient would have arguments with her

24. FAMILY PROFILE • Ricardo Delfin – stepfather • 60 y/o, retired policeman • Treated his stepchildren as his own • Takes care of Minerva very well

25. FAMILY PROFILE • Gina – sister • 38 y/o, BS Music undergraduate • Married, currently unemployed • Previously worked as a singer in Japan • Currently lives with husband and 5 children in Caloocan • Very close to the patient; patient’s confidant

26. FAMILY PROFILE • Julius- brother • 33 y/o, college undergraduate • Married with 2 children • Previously worked as a seafarer • Stays at Panitan, Capiz with their mother • Suffered stroke • Small business – selling prepaid cards

27. FAMILY PROFILE • Norman- husband • 38 y/o, aeronautics graduate • Trainer at Estilat Telecom Co. in UAE • Member of ALL Nations FULL GOSPEL for 10 years • Very loving and supportive husband and father

28. FAMILY PROFILE • Paul Christian – son • 8 y/o, Grade 2 student • Good relationship with parents and siblings • Has problems in school • Hyperactive and lazy to copy notes

29. FAMILY PROFILE • Patricia Lois – daughter • 5 y/o, Kinder II student • Very bright daughter • Consistent honor student • Has good relationship with parents and siblings

30. FAMILY PROFILE • Tim Albert- son • 2 y/o

31. Cesar 45 Ricardo Delfin 60 Minerva 58 4 1996 Gina 38 L 35 Norman 38 Julius 33 2 5 LEGEND Heart attack Stroke Tim Albert 2 Paul Christian 8 Patricia Lois 5 PUD HPN

32. Physical Examination essentially normal

33. Neurological Examination essentially normal

34. Mental Status Examination Looks appropriate for age Kept wearing pink blouse and black slacks Cooperative with good eye contact, answers appropriately No mannerisms and psychomotor agitation noted Euthymic mood with appropriate affect Claims that she has “discerning spirit” & the ministry is against her Conscious, oriented to time, place and person Memory is intact with good attention span Fair judgment and impulse control and poor insight

35. Salient Features 35 y/o Female Born again Christian Unemployed Preoccupation with at least 2 delusions (Jan-March2005) Auditory hallucination Aggressive/agitated behavior (March 2005) Avolition-apathy (3rd wk & 27 Mar)

36. Salient Features Incomprehensible speech Impaired social functioning Physiologic disturbance: anorexia and insomnia Family history: great grandmother had nervous breakdown Non-smoker, non-alcoholic, denies use of prohibited drugs Poor relation with mother

37. Salient Features Normal physical and neurologic exam Unremarkable general appearance , behaviour and psychomotor activty Euthymic mood with appropriate affect (+) Hallucinations & delusions Conscious, oriented, good memory and attention span Fair judgment and impulse control Poor insight

38. DIFFERENTIAL DIAGNOSIS

39. Major Depressive Disorder Bipolar Disorder Schizophrenia

40. DSM-IV-TR Diagnostic Criteria for Major Depressive Episode

44. DSM-IV-TR Diagnostic Criteria for Manic Episode

47. DSM-IV-TR Diagnostic Criteria for Hypomanic Episode

50. DSM-IV-TR Diagnostic Criteria for Schizophrenia