COMMUNITY & SOCIAL PSYCHIATRY

Parco, Matthew DavidTan, Jaesser

Joanne Robes GuevaraAge: 34

Birthday: April 10, 1977 (Sta. Cruz, Manila)

Religion: Roman Catholic

Nationality: Filipino

Chief Complaint: “Leg Edema”

Informant: Anita Robes

History of Present IllnessPatient is a known case of Schizophrenia

diagnosed for more than 15 years already. Patient was admitted on and off in various care homes.

7 days prior to consult, patient had leg edema which was noticeable at the end of the day, accompanied by decrease in weight and poor oral intake.

Patient was referred to internist in the care home, and was advised work-up and revision of medications. Patient opted to transfer to the Medical City for further management.

Past Medical History, Family Medical History

Review of Systems: Weight loss, edema, hallucinations

Past Medical History: Unremarkable.Allergic to fish.Past Psychiatric History: Diagnosed to have

Schizophrenia 15 years ago. No substance use or abuse documented.

Family Medical History: Unremarkable

Personal and Social History

Patient was the eldest of four kids born via NSD in Chinese General Hospital to a well-off family, whose main business interests are in the petroleum industry.

Patient was described to be well-loved by her grandparents.

Her parents regularly fought, owing to the father’s being a womanizer – and the patient frequently sees her mother being physically abused by her father.

During Pre-School, patient was supervised by grandparents and maids. She was described as sweet and responsible, albeit spoiled. Her parents were very busy during those years, and she looked after her siblings.

During Elementary, patient’s house was robbed by their houseboy, with her neck being strangled. No counseling or help was sought.

In College, she took BS HRM, Siena College. During her first two years, her grandparents regularly drove her from Bulacan to QC. On her third year, she had her own car. It was during that time when her mom noticed her being socially withdrawn and irritable. She also got into numerous fistfights and troubles with her schoolmates.

Her mother would scold her about her changing behavior, but she would simply pack some clothes and drove anywhere out of town. It was also during that time when her grandfather died, and she opted to move to the USA, where she worked as a cashier and had her first serious relationship.

Six years ago (28 y/o), patient’s family got bankrupt and they were forced to move to a smaller house, which again resulted to the social withdrawal and irritability of the patient.

Consult with psychiatrist suggested admission, but her mother simply sent her off to her aunt.

Episodes of agitation eventually led the mom to have her confined in Grace Halfway House, where she was started on antipsychotics. She was discharged after her agitation subsided.

Up to present, patient is confined “on and off” during periods of agitation.

Physical ExaminationHEENT

Anicteric sclerae, pink palpebral conjunctiva, nose midline, tongue midline, no facial or oral deformities. No TPC. No CLAD.

Cardiopulmonary Clear breath sounds. Equal chest expansion. No rales,

rhonchi, or wheezes. Adynamic precordium. Normal rate and regular rhythm.

No murmurs.

Abdomen Normoactive bowel sounds. No masses, tenderness, or

organomegaly.

Extremities Full and equal pulses. Edema, grade III (bilateral). Pink skin.

Good turgor.

Neurologic I: intact II: 2-3 mm ERBTL III, IV, VI: full EOMs V: intact VII: intact VIII: intact IX, X: intact XI: intact XII: intact

Mental State ExaminationPatient is an adult Filipino female with fair skin

and cachectic look. She was fairly kempt with disheveled hair, in T shirt, jeans, and fleece jackets. She had a small built and stature, and looks appropriate for chronological age. Patient was curled in a fetal position, and was restless in bed. There is Grade III pitting edema on bilateral lower extremities.

Wearing her pink flip-flops showed band markings in her edematous feet. Patient has clear and spontaneous speech. There are loose associations and occasional tangentiality. Denies hallucinations or delusions. Desires to go back to her care home, where she has lots of friends. Poor insight.

Multi-Axial DiagnosisAxis I: Schizophrenia, Paranoid type

Axis II: Defer

Axis III: Edema, grade III, bilateral lower extremities

Axis IV: Relationship stressors (parents)

Axis V: 21-30

PlanClonazepam, 2 mg/tab, ½ BID

Olanzapine, 5 mg/tab, 1 tab or

Olanzapine, 5 mg/IM for agitation and/or refusal to take medications.

Diagnostic Work-ups Increased cholesterol, HDL, LDL, MCV, Neutrophil Decreased Hgb, Hct, RBC, WBCNormal BUN, Creatinine, Uric Acid, Na, K, Cl, Ca,

Glucose, SGOT, SGPT

Principles of Community Psychiatry

Commitment to mental health needs of population.

Service

Long-term Care

Case Management

Community Participation

Consultation

Evaluation and Research

Least Restrictive Alternatives