Transcript PSYCHIATRIC HISTORY OF MENTAL ILLNESS

PSYCHIATRIC
HISTORY OF
MENTAL ILLNESS
Synthesized by:
Katrina Kua
INFORMANTS
• Wife, A.R., 25 y/o.
• Wife’s homosexual friend and
housemate, Angel
• Patient
• Date history was obtained:
October 12, 2009
Chief Complaint
• Patient: “I need to get admitted
because I don’t want to hurt my
wife anymore.”
• Relatives: “Nagtatangka siyang
magpakamatay 4 na beses na.”
Personality Profile
• Pre-morbid: kind, sweet,
quiet, cheerful
• Morbid: nagwawala,
nang-aaway
History of Present Illness
Starting on the latter days of July upto present,
Aiza and Angel noticed behaviour changes in
Sophie. At first he will be extremely cranky when
Aiza is out working. He also has exaggerated
mood swings like when he was dancing happily
at first then suddenly would answer that he
speaks to himself because he is crazy. He would
also turn off all the lights and electricity and stay
in the dark.
History of Present Illness
• There was also a time when he was being sweet
to Aiza before she left to work and then would
suddenly tell her not to come back home again.
He also chased Aiza with a kitchen knife “let’s
finished what i’ve done in America!” then when
Angel saw him, he said, “okay, i’ll do it to myself,
then.” And then would graze the knife on his
belly. He would inflict superficial wounds using
scissors and a knife on his arms, saying, “it feels
good. You should try it.”
History of Present Illness
• He would also stay up at night and just watch Aiza sleep,
sometimes holding a knife. He would always throw fits when
Aiza leaves for work and would calm down when he sees
Angel saying, “i’ll come [calm] down if you give me your
dress.” He would calm down but would later throw fits again
and bash house furniture and wound his arms. He would also
threaten that he would attempt suicide and would even fake
overdosing his medications. He knows that what he’s doing is
wrong. He’d always say sorry and even tell Aiza to take a
vacation because she wouldn’t like his attitude during this
season but would still repeat to throw fits again. Due to the
events, Aiza consulted the VA and also to fix his pension
papers that is when Sophie admitted to Aiza that he was
previously diagnosed with manic-depressive disorder and
PTSD. This last 2 weeks, patient was noticed to be more
violent than usual.
ANAMNESIS (Past Personal
History)
- Remembrance of the past; accumulated data
concerning a psychiatric patient and the patient’s
background, including the family, previous
environment, experiences, and particular recollections,
for use in analyzing his condition. –
Birth and Early Development
• On June 29, 1946, patient was born to Doris
Mae Thompson and Willian Riggs via NSD at
Warrensberg, Illinois. The pregnancy was
wanted and expected. The delivery was
essentially normal w/o any complications. R.R.
was the 2nd child, the 1st son among the 4
siblings. The family lived averagely in the
suburb of Illinois.
Childhood
• Patient claims that since he was 3 y/o, he knew that he was a
woman trapped in a guy’s body and would want to wear dresses.
One time his father caught him wearing a dress and beat him
up. His parents disapproved of him being gay and told him that
they would disown him if he would continue to be like that.
Since then, patient would try to be manly around people but
would still try on dresses of his sisters when their parents are
not around. He said that his sisters didn’t mind him wearing
dresses and did not really care if he is gay. R.R. also did not like
school very much, because he was being bullied there. One time
patient was forced to eat a burger with a yucky concoction of
dressing by the school bully.
• In the young age of 17 he volunteered to serve his
country in the Vietnam War as a marine. He said that
he hated it there but would always volunteer because
it was his way of releasing his long suppressed energy
and also the benefits, the pension when he retires
attracted him. So he served the marine corps for 7
years from 1965-1972. He was a front liner during the
Vietnam War and went there 3 times, 13 months a
time. His main work was to call out aircrafts and take
care of dead bodies. He was a front liner in the war
but was wounded twice, one from a blast injury from
a grenade, another was a gunshot wound in his butt.
• He said that he volunteered himself frequently because
it was his way of channelling out his suppressed energy,
because ever since he was 3 y/o, he wanted to be a girl
and dresses like one but his parents would never allow
him and would get mad.
• He was much disciplined, stern, and focused and earned
the title of a sergeant. His main job there was with
equipments, calling aircrafts at the battlefield and taking
care of the dead bodies. He was really strict and stern
when handling his troupe. He even claims himself to be
wicked and even got reprimanded for being too wicked.
• On July 4th, patient commanded his men, Jerry, Bobby and
Frank to place their equipments back in their tank because
carrying their heavy equipment was bothersome and was
interfering with their work. At the same time that the
three were back in the tank, a grenade blasted their tank
with the 3 men in it, and he couldn’t do anything. R.R. felt
responsible for their death and says 3 men died because he
turned soft-hearted.
• He left the service on 1972 with a number of awards such
as purple heart, presidential unit citation awarded 3rd
marine division for service in Vietnam, Vietnam service
medal, republic of Vietnam campaign medal, national
defense service.
• R.R. got out of service in 1972. He went back to the States and tried
to look for his family, but he said that it was difficult to track them
because his siblings had families of their own by that time and
already lived in different places. He immediately wore women’s
clothes when he got out of service, because it made him feel good
and happy. Patient then lived on his own and got jobs at different
hotdogs and burger joints. Living alone was tough for him because
post-war, people would think badly about him when would find out
that he was part of Vietnam War where he killed people and babies.
• This made him feel very bad about himself. Since then, he did not like
to be in a crowd. He did not want to work or interact with people
and he could not deal with people standing behind his back. He
wants to work alone, that is why he took a job as truck driver and
lived in a trailer home where he could have good income and be
alone.
• Patient worked as a truck driver for 24 years
from 1975-1999. He was living alone in a
trailer and had a few “acquaintances” and
“flings.” He was very avoidant of people and
would easily get moody. Sometimes he would
be in road rage while driving his truck.
• On 1999, he got into an accident while driving his truck. He
claims to have crushed his cervical bones and was paralyzed from
neck down. He underwent an operation where they accessed his
spine through his neck and instilled fluid in his spine to straighten
them. While recuperating, he started to feel dormant and that’s
when he started to have flashbacks and auditory hallucinations
about the war. He would be okay for most of the time but would
go “crazy” during the months of July, August, and September. He
said that Frank, Bobby and Jerry would talk to him and tell him
that it’s okay and their death is not his fault. Hallucinations still
occur up till now. Sometimes, he also feels like he was back in the
war, there was even a time when he was running around with
butcher knife, and he was reliving his war experience. It was a
good thing that police got hold of him and that he did not hurt
anybody.
• After the accident, R.R. lost his job and his trailer
and started to live on the streets. He was jobless,
homeless, and sickly for about a year. A Good
Samaritan helped him get back on his feet and
even processed his pension plans. He was
pensioned around 3800 dollars per month since
then. On 2000, he got back to his feet and rented
a house in Michigan, got a car, and lived with his
pension money. He gained a lot of friends and
was popular with them especially when he
receives his monthly pension funds.
• In 2002-2003, patient started to live as a
woman. He would go out dressed as a woman
goes by the name of Allysa. Patient during this
time had suicidal ideations and attempted
suicide 3 times. He did this by drinking
nortriptyline overdose with whiskey. He also
tried to hang himself, and attempted to jump
off a building.
• On 2005, patient met Aiza through the internet in a chat room. He
jokingly told her that he is gay but then denied it. They got close
and he called her almost daily from then on. On that same year,
Aiza became his girlfriend. They started having a long distance
relationship through cyberspace.
• Aiza openly told him that she has a son named Raniel, at that time,
4 years old. He was glad about that, and told her that he was happy
to support her and her son. He gave her monthly support and gifts
for Raniel. He told her that he wants to marry her and would be
happy to adopt Raniel, since he couldn’t have a family in the States.
During this time, patient was in and out of the hospital frequently
because of his ailments. He had a heart attack thrice. He was
admitted several times due to his poorly controlled diabetes.
• On 2008, patient decided to live in the Philippines because
he did not like to live in the US anymore. He had no family,
and could not live the life he wants without being judged by
the people. He started using hormonal drugs such as
Provera and testosterone blockers and was planning to
have sex transplant; however, his co-morbiditites would not
allow him.
•
He planned to go to the Philippines, but then he got
sick again (was confined due to hyperosmotic nonketotic
coma. Lost consciousness while driving so his license was
taken after). Patient told Aiza that he wants to have a
female name when he goes to the Philippines, so she
named him Sophie. During that time, she was already
suspicious that he may really be gay.
• On January 2009, patient asked for a doctor’s
advice for hormone use and sex transplant but
was already using much drugs for about two
years. He at that time was living as a woman
and goes by the name of Allysa for 7 years
already and he was allowed to use hormones.
Marriage
On June 2009, Sophie went to the
Philippines and surprised Aiza and told
her to fetch him at the airport because
he will be living with her and her son
from then on. Sophie met Aiza
personally for the first time and
showed up at the airport wearing
men’s polo and slacks and high heels.
On June 24, 2009, they had a civil
wedding. They were living happily
together with Raniel, Aiza’s 10 y/o
son, Angel, their transvestite friend,
and they hired Ara, a gay caregiver for
him.
He continues to wear female clothes
when they go out. Aiza and R.R. live
happily and truly love each other
even if their relationship in
unconventional. They both admit that
they married more because of
companionship than intimacy.
Family History
R.R. grew up not close to his family,
particulary his father. When he got
out of the service, he tried to contact
his family but did not maintain regular
communication with them and lived
alone by himself since then.
Family History
• William Riggs • Doris Mae
Thompson Riggs
• Father of
patient. Patient • Mother of
disliked his
patient; died
father because
because of heart
when he was
ailment. Patient
young, his
not close to her
father caught
because she did
him wearing a
not approve of
dress and beat
him being gay
him up.
[transvestite].
Sherry Riggs
• Older sisister of patient. Patient
said that she did not mind him
wearing dresses. When he got
out of the service, he tried to
contact her but she already had
her own family and lived in a
different place. Patient keeps
her number and communicates
with her seldom.
• Bill Riggs
• Younger brother of
patient. Patient was
not close to him.
Patient said that his
brother died
because he was an
alcoholic and an
addict.
• Sandy Riggs
• Younger sister of patient.
Like Sandy, she did not
mind him wearing
dresses, even lends him
hers if he asks. When he
got out of the service, he
tried to contact her but
she already had her own
family and lived in a
different place.
Mental Status Exam Upon
Admission
(September 22, 2009)
Mental Status Exam
• Patient is fairly kempt, wearing purple polo shirt, and black doll
shoes.
• He is euthymic with appropriate affect.
• He spontaneously answers to cues of interviewer with normal
speed and rate.
• He is friendly, participative and conversant.
• Patient’s thought is relevant with clear cause and effect ideations.
• Patient expresses his transvestite lifestyle, his suicidal ideations and
his auditory hallucinations.
• Remote, recent and short-term memory intact.
• He is conscious, alert, and oriented as to time place and person.
• He has good judgment and insight.
Current Social Situation
The client is unemployed and residing in his wife’s
house at 717 Corcuerra St. Tondo, Manila
together with his Filipino wife of 3 months
named Aiza, 25 y/o, her son Raniel, 10 y/o, their
friend Angel, and his caregiver “Ara.” The patient
openly admits that he is a transvestite and
prefers to be called Sophie.
Current Social Situation
• His wife sings at a club, and works with her
friend Angel. She usually goes to work late in
the afternoon to the evening. He is always the
one left at home to play with Raniel. His
marital relationship started having problems in
July, when the client was acting up with manic,
aggressive and suicidal behaviour. It was in this
time that his sexual ideations and fantasies of
being a girl surfaced to a maximum extent.
MEDICAL HISTORY
OF PRESENT ILLNESS
Synthesized by: Katrina Kua
• Informant: wife, A.R., 25 y/o.
– Wife’s homosexual friend and housemate,
Angel
• Date history was obtained:
– September 22, 2009
• Chief Complaint:
– multiple trauma secondary to mauling
General Data
• Patient is Ronald Thompsom Riggs, a 63 y/o male,
right handed, Caucasian, who is a veteran war
sergeant currently residing at 717 Corcuerra St.
Tondo, Manila together with his Filipino wife of 3
months named AIza, 25 y/o, their friend Angel, and
his caregiver “Ara.” The patient openly admits that he
is a transvestite and prefers to be called Sophie.
Born on 6/29/1946 to Doris Mae Thompsom and
William Riggs at Warrensberg, Illinois. He is the
second child in a family of 6, with one older sister, a
younger brother and a younger sister.
History of Present Illness
• Known case PTSD and manic- depressive
(bipolar 1) disorder and anxiety disorder
• Had suicidal ideations and was previously
admitted in the US
• Irritable, violent and with suicidal ideations
during July-September; normal on different
months
• Allegedly attacked helper and latter fought
back and hit the patient with a plastic chair
• Patient suffered multiple lacerations
Narrative
• Two weeks prior to admission, patient was
noticed be more violent than usual. Starting
on the latter days of July upto present, Aiza
and Angel noticed behaviour changes in
Sophie. At first he will be extremely cranky
when Aiza is out working. He also has
exaggerated mood swings like when he was
dancing happily at first then suddenly would
answer that he speaks to himself because he
is crazy. He would also turn off all the lights
and electricity and stay in the dark.
Narrative
• There was also a time when he was being
sweet to Aiza before she left to work and
then would suddenly tell her not to come
back home again. He also chased Aiza with
a kitchen knife “let’s finished what i’ve done
in America!” then when Angel saw him, he
said, “okay, i’ll do it to myself, then.” And then
would graze the knife on his belly. He would
inflict superficial wounds using scissors and a
knife on his arms, saying, “It feels good. You
should try it.”
Narrative
• He would also stay up at night and just watch
Aiza sleep, sometimes holding a knife. He
would always throw fits when Aiza leaves for
work and would calm down when he sees
Angel saying, “I’ll calm down if you give me
your dress.” He would calm down but would
later throw fits again, bash house furniture
and wound his arms. He would also threaten
that he would attempt suicide and would
even fake overdosing his medications.
Narrative
• He knows that what he’s doing is wrong.
He’d always say sorry and even tell Aiza to
take a vacation because she wouldn’t like his
attitude during this season but would still
repeat to throw fits again. Due to the events
and also to fix his pension papers, Aiza
consulted the VA. This was the time when
Sophie admitted to Aiza that he was
previously diagnosed with manic-depressive
disorder and Post Traumatic Stress Disorder
(PTSD).
Past Medical History
•
•
•
•
HPN since 2000
DM type 2 since 2002
STROKE 1998
Myocardial Infarction (3 times, from
2005-2006)
• TRUCK ACCIDENT 1999
Family Medical History
• Mother – hypertensive
• Brother – alcoholism and illicit drug use
Personal and Social History
• 200 pack year history, started at 15 y/o
– 2001
• Occasional “dope” user 1975-1999
• Occasional alcohol drinker
• Retired US Marine Corps Veteran;
currently Unemployed
• Never had a wife in the US, Filipino
wife of 3 months is his first wife
Review of Systems:
• Decreased hearing on both ears
• With prosthesis and full dentures on
both upper and lower teeth (never wore
them in nurse-patient interactions)
Physical Examination Upon
Admission
• Vital signs as follows: 120/62 mmHg,
80 bpm, 19 bpm
• Pink palpebral conjunctiva, anicteric
sclera
• Warm moist skin
• With multiple lacerations on both arms
• With multiple long and superficial slash
marks in inner aspect of forearms
Neurologic Examination
• conscious, coherent, oriented to time,
place and person
• spontaneous eye opening
• follows commands
• spontaneously answers when asked
• can read and write
• intact remote and recent memory
Clinical Impression
• multiple physical injuries (superficial
abrasions and lacerations) secondary
to blunt physical trauma and selfinflicted wounds
• referral to dermatology, endocrine,
orthopaedic, and rehabilitation
medicine for co-morbidities
Katrina Kashmyr B. Kua,
SN/UST
Personal Data
• Interview Done and History Prepared by:
Katrina Kashmyr B. Kua
• Date Written: October 18, 2009
• Initials of Patient: R. T. R. “R.R.”
• Diagnosis to Consider: Axis I: to consider
Bipolar 1 Mood Disorder
• Information Obtained from: Patient
• Dates: October 5-6, 12-13, 2009
Personal Data
•
•
•
•
•
•
•
•
•
•
Hospital Number: 05-46-20
Date of Admission: September 22, 2009
Address: 717 Cercuerra Street, Tondo, Manila
Birthday: June 29, 1946
Place of Birth: Detroit, Illinois
Age: 63
Sex: Male
Civil Status: Married
Occupation: Retired US Marine Corps Veteran; currently Unemployed
Educational Attainment: First Year High School; took up a vocational
course in fashion design in Michigan for two years
• Religion: Roman Catholic
• Race: Caucasian
• Nationality: American
PATIENT’S PERCEPTIONS AND
EXPECTATIONS RELATED TO
ILLNESS/HOSPITALIZATION

(why he was brought to the hospital)
– Was brought to the hospital by wife and her
homosexual and transvestite (in the context of this
history, both adjectives will be referred to as “gay”)
friend due to multiple physical injuries (lacerations
and abrasions) secondary to blunt physical trauma
by the patient’s gay caregiver. “All along I thought I
was brought here to get my wounds treated. I didn’t
know at first why they were keeping me here and
taking away my rights. Rights to eat what I want, to
make calls, being told what to do and when to do
it, everything is taken away from me.”
PATIENT’S PERCEPTIONS AND
EXPECTATIONS RELATED TO
ILLNESS/HOSPITALIZATION

(what does he think caused him to get sick)
– “I have these wounds on my fingers, my foot
and my toes because of my diabetes.”
– “I had a stroke and heart attacks in the past. It’s
why I’ve been receiving physical therapy here.”
– “I do have a problem of having a very bad
temper. But don’t worry, I won’t hurt you.”
PATIENT’S PERCEPTIONS AND
EXPECTATIONS RELATED TO
ILLNESS/HOSPITALIZATION
(has being sick made any difference in his usual way of life?)
– “Yeah! I can’t do much, my rights are taken away from
me. I miss my wife, I miss the kid, Raniel even more.
With him I can play with! Because I’m the one left at
home, it’s usually just him and me. We’re very close, and
I miss him a lot.”
– “I’ve had this [diabetes] for a fairly long time now.
Because of it, I can’t go hungry cause’ I’ll get dizzy, and I
get wounds that take a long time to or never heal. It’s
the same now here [in the CC] as at home. Only here, I
get my shots of insulin. Ouch! And i have to eat almost
immediately after if I don’t want my blood sugar to get
low.”
PATIENT’S PERCEPTIONS AND
EXPECTATIONS RELATED TO
ILLNESS/HOSPITALIZATION


(has being sick made any difference in
his usual way of life?)
“Before I started therapy, I can only raise my
arms up until here (makes an effort to raise
his arms, and reaches only until his shoulder
level.). Now, I can go as high as this (makes
another effort to raise his arms, and this
time, reaches slightly over an inch higher
from his shoulders.).
PATIENT’S PERCEPTIONS AND
EXPECTATIONS RELATED TO
ILLNESS/HOSPITALIZATION

(what he expects will be done to him in the
hospital)
– “I still have my mental doctor to look forward to
seeing. He’s never around, they [the staff] tell
me. I’m stuck here, not knowing EXACTLY why
I’m here while he’s out playing golf (irritated and
dismayed expression). It’s been almost 30 days,
and I haven’t even seen my doctor. Is he a boy
or a girl? I don’t even know that much!”
PATIENT’S PERCEPTIONS AND
EXPECTATIONS RELATED TO
ILLNESS/HOSPITALIZATION

(what he expects will be done to him in the
hospital)
“Those who always keep seeing me are doctors
for my wounds, doctors for my diabetes, and
my therapists. I’m improving in controlling
and increasing my range [referring to his
motor activity, especially on his limbs]. I still
get my [insulin] shots, and my wounds are
constantly monitored and treated.”

PATIENT’S PERCEPTIONS AND
EXPECTATIONS RELATED TO
ILLNESS/HOSPITALIZATION
(how long he expects to be in the hospital)
– On October 6 (Tuesday): “My wife came by already.
You might not see me here tomorrow when you
return anymore (looking very happy, in an elevated
mood), because it’s either I go home tonight or early
tomorrow morning.”
– On October 12 (the following Monday): “I’m still here
(disappointed and frustrated, yet later, accepting
expression). I’ll be out on October 28th. They’re still
having the house fixed that’s suitable for me to live
in, according to my wife. She says the house has
been hit badly by the pesky typhoon and floods.”
PATIENT’S PERCEPTIONS AND
EXPECTATIONS RELATED TO
ILLNESS/HOSPITALIZATION
Patient lives with his wife, her 10 y/o
son, her gay friend, and his gay
caregiver in her house in Tondo, Manila.
 His wife and Raniel are the most
important people in his life. “They’re all
I have.”

PATIENT’S PERCEPTIONS AND
EXPECTATIONS RELATED TO
ILLNESS/HOSPITALIZATION

(visits)
– “My wife first visited me last night (October
5, Monday) since I signed my pension
papers 2 weeks ago. She visits me and
brings me things and my favourite food.”

(recreation)
– “I just stay at home to play with the kid. I
like designing, clothes [female’s], a lot. I’ve
done a few already, actually.”
PATIENT’S PERCEPTIONS AND
EXPECTATIONS RELATED TO
ILLNESS/HOSPITALIZATION

(getting along after leaving the hospital)
– “I will control my temper, and exercise what i’ve learned
from my previous anger management classes.”
– “I plan on putting up my own boutique, with my own
designs and style. I’ll include everything. From [women’s]
lingerie, panty hoses, especially the frilly and the lace-y
ones. It’s what I really want to do. One is never too old. I
plan on living here [in the Philippines] and work on that
business, can’t do that over there [in the US]. I have
nothing left and nothing to go back to over there
anymore.”
COMFORT and PAIN
• Claims to not experience pain in his self-inflicted, superficial
lacerations (slashes) on his forearms. “It feels good.” (straight
forward, satisfied expression.)
• No more pain felt in the dry and healing lacerations from his
blunt physical trauma.
• Claims sharp, throbbing pain on his affected toes and right foot
due to abrasions secondary to his diabetes and poor foot care.
(rated 4/10, 10 the most painful)
– due to this, client never goes barefooted and claims to exercise
hygienic foot practices.
• Pain on his foot and toes are bearable, and he is used to them.
SAFETY
• Client has difficulty rising up from bed, coupled with a grimaced
facial expression in his efforts to rise up.
– Gets dizzy,
– he knows it’s due to his medical condition and the side effects of the
medications he is taking.
– “That’s why I feel! I didn’t do it gradually, and I fell head first on the floor
beside my bed. I didn’t get seriously hurt, though. I’ve had much worse
[takes it that the student nurse understands that he is referring to his war
experience and his gay caregiver’s mauling him.] The staff was quick to help
me.”
• Exhibits a slow, limping gait on his right foot. Is wearing mary
jane (doll) shoes. Client bears the pain when walking, but is not
seen walking around a lot. He only walks to get from one place
to another around the Community Center (CC).
VISION
• Noted to have cloudy, gray eyes. “I can’t see well, and I can’t
read without my glasses. I don’t have any now, I broke the pair
I had with me. I was so angry, it was during the times when I
thought that my wife had abandoned me. So I took my glasses,
(demonstrates doing so while narrating) crushed them between
my hands until I’ve shattered it to pieces.”
• “I wish there was something else I could have broken in its
place, though. I would still have glasses now if there was.”
VISION
• “My diabetes is getting to my eyes. I can’t see very
well anymore. Although I can still see you, I can still
see colors and shapes. Details, I decipher fairly, like
the color and the material of your top. That’s a
Carmeuse. Most think it’s a maroon or a red. But it’s
actually a Carmeuse. Haha! You’re learning from me,
eh? (laughs, is looking happy)”
• “I haven’t had injuries or my vision impairment hasn’t
brought any casualties yet. I rise slowly now, and I
just focus on where I want to go.”
HEARING
• Claims to have poor hearing. His hearing aids were left at home.
• “I can only hear you from a close distance, and I can only listen
to one person at a time. If people talk simultaneously, I’ll lose
you.”
• Noted to frequently be asking the student-nurse to repeat what
she has said, saying “I’m sorry, say that again? I cannot hear
you.” And moves his ear closer to the student’s face before she
repeats her statement. Always happens in the social hall or along
the benches, especially when other people are around.” The
client asks statements that he did not hear be repeated to him.
REST AND SLEEP
• Is used to the ward by now. The noise from outside
does not bother him.
• Claims to be getting enough sleep, ranging from 5-7
or 8 hours.
• Claims that the side effects of sedation from some of
the medications he is taking do not affect him. He
rarely sleeps in the afternoon. “I’m not like the other
guys here that can sleep all day. I don’t feel the side
effects of the meds I’m taking.”
REST AND SLEEP
• sleeps with his pillow aligned vertically according to
his spine. “I’m comfortable this way, I prefer this.”
• “Rest is the only thing we can ever do on a regular
basis here! There’s nothing else to do, it’s pure
boredom. I don’t get visited that often, and I
understand that they’re preparing the house for me to
live in. It’s just that here, when our rights are taken
away, there’s nothing much to do but rest and sleep.”
REST AND SLEEP
• Noted to be taking very short naps in between
student-patient interactions and therapies.
Assumes the side-lying position, with his right
hand supporting his head. Wakes up after 5
minutes or so.
HYGIENE
• noted to be usually wearing a clean white shirt paired with clean,
strikingly colourful pajamas with mary janes (doll shoes)
• hair is usually kempt, already reaching the collarline.
• Looks rugged and unshaven.
• Never encountered with a foul odor. Client has no pungent
smell.
• Does a full body bathing in the evening.
• Does his morning care first thing in the morning (brushes his
teeth, combs his hair, washes his face)
• Brushes his teeth twice daily. Or if he ate sometime unpleasant
for him or has a strong flavour, brushes his teeth after meals.
HYGIENE
• Skin is fair and normally moist.
• With multiple long and superficial slash marks in inner
aspect of forearms
• With both individual and clustered dry, clotted
lacerations from the attack by his gay caregiver.
• With disseminated arthropod bites in all his limbs.
Bites are red macules with irregular and undefined
edges. Client claims not to be irritated very much, as
they do not itch or cause him pain very much.
HYGIENE
• Prior to admission, shaves his legs. His legs look very fair and
feel smooth. “The first time i shaved my legs after got out of the
service, my, it felt so good, I was so happy (accompanied by
reminiscent expression, with eyes closed and pleasant, dreamy
look.) Don’t tell them, I have a tweezer with me to use to pluck
the hair on my legs. Don’t tell them (animates this part with
furtive gestures, looks to the corners of his eyes and brings his
index finger to his mouth), because they might take it away like
what they did to my other stuff. It’s all I have left to keep my
legs clean and hair-free.”
• Wears a white shirt and thin pajamas because of the climate in
the Philippines. But claims to be coping fine. They have air
conditioning in his room at home.
FLUIDS AND NUTRITION (DIET)
on a diabetic diet.
Voices difficulty liking the food here.
“Don’t get me wrong, I mean I love the
Philippines, but I just can’t eat your
rice. I want hamburgers. French Fries.
I want them so bad. The food they
feed me here aren’t any good.”
“My wife brings me chicken and
hamburger. Lots of them (looks very
happy).”
FLUIDS AND NUTRITION (DIET)
On October 12, noted to appear thinner.
Patient claimed eating well with a
normal appetite. “Oh I eat my meals.”
Noted not to be prompt in getting his
food at chow time.
Eats very fast, just eats a small portion
(1/4, half or two thirds at most) of his
rice. Arrives as one of the latest in the
dining hall, and is one of the earliest to
leave.
Eats his vegetables, does not dislike
them, does not love them either.
FLUIDS AND NUTRITION (DIET)
Is so used to drinking his medications that
he swallows them without his teeth, and
without water. Mouth is empty after
mouth check.
Noted to drink only during meals, and uses
one glass for his medications (7-9
tablets).
Has a bottle of water on the side table of
his bed.
Claims to drink 7-10 glasses of water daily
FLUIDS AND NUTRITION (DIET)
Has full dentures for both upper and
lower set of teeth. Client prefers not
wearing them. Speech is not made
difficult for the patient.
ELIMINATION
•Usually moves his bowels in the morning. By the
time of BP checking at 8 or 10 am, he normally
scores 2(micturation):1(bowels)
•Moves his bowels once to twice daily. In the
morning and after meals.
•Does not strain, without difficulty and does not
pass loose stools. Soft and formed in consistency.
Foul-smelling and golden to brown in color.
•Urinates on urge. Straw to light yellow in color.
Usually urinates twice in the morning, twice to
thrice in the afternoon, and twice in the evening,
especially before going to bed.
OXYGENATION
No changes in breathing from home to the CC.
Pulse and respiratory rate upon admission are 80
bpm and 19 bpm, respectively.
PR and RR in the CC range from 61-83 bpm and
12-19 bpm, respectively.
No difficulty of breathing, assumes any position he
likes while on bed with no notable changes or
difficulty in breathing rate and exertion.
SEXUALITY
At home, he claims to be both the mother and the father to Raniel.
She sometimes does the domestic chores like washing clothes and
cleaning the house.
His wife leaves home and comes home only after work, so he is left
to be the mother and father of Raniel.
Claims that he and his wife are more of companions than intimate
partners.
He missed his wife a lot, claims to love her very much, and also her
son. He even misses the child more than his wife.
Only sees the child from the outside, jumping up and down so he
can see him. The patient cannot wait to be with his family again.
ALLERGIES
none claimed by the patient, and none in
medical history.
NURSES’ IMPRESSIONS AND SUGGESTIONS
The patient is observed as:
alert
homesick
initially angry when wife has not shown up or kept in touch for over
a week
cooperative
critical
quick to comprehend
intact judgment
insight labile and fluctuating, depending on topic
NURSES’ IMPRESSIONS AND SUGGESTIONS
seeks independence
seeks minimal support
oriented
conversational
expressive
suspicious about the wife when something does not “seem right” or
if he is curious about teh reason behind his wife’s acts.
Critical and judgmental towards the staff
MENTAL STATUS
EXAMINATION
Done and Prepared by:
Katrina Kashmyr B. Kua
Outline:
I. General Description
• Appearance
• Behaviour and Psychomotor Activity
• Attitude toward Examiner
II. Mood and Affect
• Mood
• Affect
III. Speech
IV. Perceptual Disturbance
V. Thought
• Process of Form of Thought
• Content of thought
VI. Sensorium and Cognition
• Alertness and Level of
Consciousness
• Orientation
• Memory
• Concentration and Attention
• Capacity to Read and Write
• Abstract Thinking
• Fund of Information and
Intelligence
VII. Impulse Control
VIII. Judgment and Insight
IX. Reliability
General Description: Appearance
Pleasant-looking
Looks calm in all of interactions, except in one
time when the patient got irritated by another
Usually has the “morning-just-got-out-of-bed” look
Clothing is appropriate for place and climate.
Claims that he wears a shirt and pajamas of thin
material because of the climate in the Philippines.
usually wearing a clean white shirt paired with
clean, strikingly colourful pajamas with mary
janes (doll shoes)
General Description: Appearance
Fairly kempt and combed, white and gray hair
already reaching the collar line
Looks rugged and unshaven.
Never encountered with a foul odor. Client
has no pungent smell.
With good, erect posture and a slight “beer
belly” mid-section
Neither primly effeminate or roughly
masculine
General Description: Appearance
Skin is fair and normally moist.
With multiple long and superficial slash marks in inner
aspect of forearms
With both individual and clustered dry, clotted
lacerations from the attack by his gay caregiver.
With disseminated arthropod bites in all his limbs.
Bites are red macules with irregular and undefined
edges. Client claims not to be irritated very much, as
they do not itch or cause him pain very much.
With slender, fair, smooth, and shaved legs.
The lower 2/3 of his legs have arthropod bites similar
in appearance as in his upper limbs.
General Description: Appearance
Acts younger than what is expected from his age.
Concerns are those that are normally dealt with at the
borderline between young and middle adulthood.
• The client jokes more, insight regarding things outside his
mood problem are intact, updated, and comprehensive, does
not give the usual impression that elders impart, like the
wisdom and the seriousness.
• His problems and issues can be likened to a young and
middle-aged adult where concerns are livelihood,
relationship, controlling of impulses, the task of intimacy vs.
Isolation, is in the stage of separating himself from others’
expectations and rules and can define morality in terms of
personal principles.
Answers are willingly and promptly elaborated when
asked (for most topics)
General Description:
Behaviour and Psychomotor Activity
Usually seen in one area only, with occasional
changes in position
Establishes good and consistent eye contact
Is verbally and facially expressive of his thoughts,
feelings, opinion and perceptions
Facial expressions are symmetrical
Observed to have wandering eyes when outside
the nurses’ station, as if looking for something,
waiting for something, and yearning to establish
eye contact
Seen scanning the environment when he is up
and around the nurses’ station
General Description:
Behaviour and Psychomotor Activity
 Walks in an evidently limping gait
 Has difficulty rising up from a sitting or lying
position. Also has difficulty sitting on the
floor from a standing position.
 Both upper limbs have diminished range or
motion. His arms can only be raised a couple
of inches maximum above his shoulders
General Description:
Behaviour and Psychomotor Activity
Would claim “I feel good when I slashed myself before
(closes eyes, clasps lips together, and makes a satisfied
facial expression), there was no pain.”
seen licking the glue that was used in art therapy
from his fingers and from the table
observed to be socially receptive to the staff and to
other patients
is generous with sharing his food to other patients
is careful with his movements, guides himself well in
walking and rising
likes to jokingly act out pain when his BP is being
taken
General Description:
Attitude toward Examiner
o Friendly
o Warm
o Conversive
o Cooperative
o Expressive on select, superficial and recent topics
o Follows commands
o Is very considerate and sensitive not to offend the
student nurse
o Trusts the student-nurse with information that he
does not divulge with the regular staff
Mood
Normally in a euthymic mood
Occasionally in an elevated mood when his
wife visits him the previous evening
Was in an agitated and dysphoric mood once
when he almost had an encounter with
another patient
Claims to have mood swings “they’re what I
need to control while I’m here, so I won’t
throw fits when I get out.”
Affect
Consistently exhibits appropriate/broad/full
affect
Emotional tone is always in harmony with the
accompanying idea, thought or speech.
Full range of emotions are appropriately expressed
SPEECH
• The client does not wear and prefers not to
wear his dentures. Even so, his speech is still
understandable most of the time
• Speaks in a soft, muffled voice
• Speaks spontaneously
• With good vocabulary
• Articulates well
• Speaks slang sometimes that the student
nurse asks it to be repeated
PERCEPTUAL DISTURBANCE
• Noted to display misperceptions when it
comes to his psychiatric condition
– Denies that he has/believe that he does not
have a mood disorder
– When given his meds with their
corresponding indication, verbalizes, “but I’m
not agitated!”
• Claims absence of any form of
hallucination
Process or Form of Thought
• exhibits reality testing for things and events
he cannot easily understand
– “... and she hasn’t showed up ever since. It’s just
natural and correct to assume that she
abandoned me and ran off with my money,
right?”
– “when I’m here, with no contacts from my wife or
anyone from the outside, I’m left here with
nothing to do but think about the possibilities,
right?”
– “if you allow people like him to take control and
manipulate and intimidate other people, he’ll
keep doing it, and that’s just not right.”
Process or Form of Thought
• Neologisms
– “bone-crushers” (referring to creditors)
• Perseveration
– Was present in the initial interaction about his
wife abandoning him
Content of thought
• Preoccupations and obsession
– Women’s clothes in detail, and related things
– Setting up a boutique of women’s clothes
• Suspiciousness
– Is suspicious towards staff and his wife
– Wife: that she abandoned him, ran off with his money,
plans to go to the CC outside visiting hours
– Staff: are hiding/covering up for the psychiatric doctor,
are keeping salient information about his care and
condition from him, sends his wife away when she
comes to visit, would not let him see her
– Staff are not attending to his needs and requests
Content of thought
• Ideas of reference
– inaccurate interpretation that general events
(such as the CC’s visiting hours) as personally
directed to him (the staff purposely do not
want him to see his wife)
– CC protocol are directed to taking away his
rights (telephone call, he can’t even contact
the US embassy to let them know he is
confined in the CC.)
Content of thought
• Delusion
– Has a fixed belief that he does not need mood stabilizers,
because he is “in well control.”
– Believes he was attacked by his gay caregiver
spontaneously, and that he did not provoke the latter to
do so.
– “I do not have a mental problem. I want to know the real
reason why I’m being held here in this “nuthouse.”
– “I never had the intention of killing myself as I was slashing
my arms. My wife never asked. Had she asked, I would
have told her.”
– Believes that the meds he’s taking “jacks up his memory, so
those I try to recall are remotely fuzzy.” (unable to recall
wife’s phone number)
SENSORIUM AND COGNITION:
Alertness and LOC
• Talks to the nurse when he is awake and
through with his morning routines;
therefore, is awake, conscious and
coherent in the content of his thoughts
and speech
• Reasonably alert (normally aware of
internal and external stimuli)
SENSORIUM AND COGNITION:
Orientation
• Oriented to time, place and person
– Recalls the student nurse and her name
– Knows where he is
– Knows where he lived prior to admission and
where he will be living upon discharge
– Is knowledgeable about the date and day
– Remembers how long and since when he has
been in the ward
SENSORIUM AND COGNITION:
Orientation
• Oriented to circumstance
– Knows he was confined upon the discretion
of his wife and their housemates
– Knows that he was there because his family
thinks that he has a mental condition
– “It’s my temper that needs work on, and I’m
getting to it. I’m applying what I learned from
my anger management classes back in the
U.S.”
SENSORIUM AND COGNITION:
Memory
• Immediate
– When asked 5 minutes later to remember some of the
lyrics from the song in Music therapy and lines from
the bibliography therapy, the client remembered.
• Recent
– Remembered the student nurse’s name the next
morning.
– Accounted for what he and his wife talked about
during her visit the previous evening
• Remote
– Cannot recall his wife’s phone number
– Cannot recall the exact date of the Vietnam war
SENSORIUM AND COGNITION:
Concentration and Attention
• able to follow instructions independently
when given one at a time during art therapy
• due to his hearing impairment, can only
concentrate on hearing one person at a time.
When there are interruptions such as noise or
simultaneous speaking of different people,
“I’ll lose you. [I won’t be able to catch what
you are saying anymore.]”
SENSORIUM AND COGNITION:
Concentration and Attention
• when in conversation with the student-nurse,
is not easily distracted by outside stimuli and
is able to go back to what he was previously
saying promptly and cohesively.
• Attention is directed as it is called for.
(interactions have ranged from 5 minutes to
an hour and 30 minutes)
• Mentally performed simple mathematical
equations
SENSORIUM AND COGNITION:
Capacity to Read and Write
• Has cloudy and nearly opaque, gray
pupils, thus the client has difficulty, though
is capable of reading.
• Can read when the letters are bold and
huge. A printed font size of 12 cannot be
read by him.
• Is able to write (his wife, her son’s and his
own name during art therapy)
SENSORIUM AND COGNITION:
Abstract Thinking
• The client is very good at making interpretations
about a situation or comment. Voices out his
opinions and understanding that are based on
facts.
• Gives explanations to cited proverbs.
– Example, “absence makes the heart grow fonder.”
– “a hungry man is an angry man” “A person who does
not get what he wants or needs is a frustrated person
and will be easily provoked to rage.”
– “Discretion is the better part of valor” “If you say
discretion is the better part of valor, you mean that
avoiding a dangerous or unpleasant situation is
sometimes the most sensible thing to do.”
SENSORIUM AND COGNITION:
Fund of Information and Intelligence
• How many weeks in a year?
• What do Filipinos celebrate the most in
one calendar year?
• What is the name of the noontime show
in ABS-CBN?
• Client is intelligent in the sense of
comprehending things (like his
medications, remembers what they are
for, some technicalities regarding his
diabetes)
IMPULSE CONTROL
 Exhibited good impulse control throughout the course
of his stay in the ward
 Avoids being near the patient that may aggravate him
 Filters and thinks before he acts
 Gauges the situation before acting
 Recalls what he learned from his anger management
classes in the US
 “right now I am in well control. I’ll just have to worry
about keeping it consistent when I get out. I’m going
to look for diversions. Fitness boxing is a good idea.
And I will devote my time to my family and my
boutique.”
JUDGMENT
• Occasionally exhibits poor judgment when
things do not turn out as planned or
expected, such as when his wife
“abandoned” him, or when she visited him
outside visiting hours. “Why she did that, I do
not know.” “Where she is and what her
intentions are, I don’t know.”
– Decision-making: “I’ll find her. And when I do, I’ll
kill her. (resolute)”
– Pre-admission: poor/impaired judgment. Was
impulsive
JUDGMENT
• During latter part of the interaction process
when his wife started visiting him again, “I
have no anger now. I love my wife. I can’t
wait to get out of here to be with them. I
have a lot of things to fix. First is my temper
control.”
• When it comes to interacting with staff,
doctors, and co-patients, he is very cautious
not to offend and careful to be in good terms
with them.
INSIGHT
• Initially, had limited insight because he believed that
he was “fine” and had no problems with his mood. He
was not agitated, he did not need mood stabilizers.
• Poor insight: “I don’t have a problem. It’s these
medications that give me the problem.” the
medications are the reason for his forgetting things,
they mess up with his head and memories.
• “How am I supposed to know the real reason why
they’re keeping me here when I haven’t seen or heard
from my doctor yet? He just gives me medications I
don’t need. As soon as the mental doctors comes to
examine me, I’ll have this all figured out, I won’t be so
anxious and kept in the dark. I’ll be fine.”
INSIGHT
• My wife just came by with a bank representative
that was peobably paid to do the job, get me to
sign papers to transfer my pension money, and
then disappeared after that. NO contact from the
staff. It’s been 7 days. She ran off with my money
and abandoned me. (in tears)”
• Later on, accepted and took responsibility for
keeping his mood and bad temper under control.
“I’ve been controlling my temper just fine. I
remember my anger management classes and
apply what I learn. I’m just worried about it when I
get to the outside. I don’t want to hurt my wife
anymore.”
RELIABILITY
• Fair. The client is the only informant for
the mental status exam.
• When it came to confirming the patient’s
statements with facts, both are congruent.
It was true that the wife came with a bank
representative (verified by nurse aids, the
staff nurse, and the unit supervisor).
END