Transcript Physical and Neurological Exam on Admission

GENERAL DATA
E.B., a 30 year old, right handed, single,
Filipino-American,
Roman
Catholic,
female, only child.
- She graduated from the University of
Maryland with a degree of BA in
government and politics.
- She was admitted for the first time at our
institution last March 25, 2009.
CHIEF COMPLAINT
According to the patient: “I’m undergoing a
change in my medications and I don’t
know how it might affect me”
According to the mother: “She couldn’t sleep
and she might get violent.”
PERSONALITY PROFILE
• Pre-morbid – loving, responsible, introvert,
hardworking, intelligent
• Morbid – “weird”, “hyperactive”, assaultive,
restless, boisterous
HISTORY OF PRESENT ILLNESS
1993
E.B was noted to lose weight, eat less, talk a
lot, physically abusive to her mother, and would
often break things in their house whenever she
would not get what she wants.
There was also an incident where she
grabbed the car’s steering wheel while Victoria
was driving. They both luckily escaped the
incident uninjured.
Victoria then brought E.B to Walter Reed
Army Center( adolescent clinic) where she was
diagnosed to have OPPOSITIONAL DEFIANT
DISORDER and was admitted for a month
Upon discharge, she was able to go back to
school and was able to finish her freshman
year.
1994
During E.B’s Junior year in high school,
she was noted to have “extreme
behaviors”.
She was noted to be crying and
shouting because of the pressures in
school since her mother wants her to
excel.
1995
E.B’s father died due to malignant
melanoma.
Because
of
this,
her
mother
transferred her to a public high school
because she could not afford to send her
to a private high school.
1996
After graduating from high school, EB
wanted to be away from her mother and to
have a life of her own.
She went to Buena Park in San Francisco
where she stayed with a friend.
She found work at the San Francisco Cookie
Company doing errands. After a few weeks
working at the cookie company, she went back
to Maryland because she could not afford the
cost of living in Buena Park.
She then worked as a cashier at HEX
Department store to save money for college.
However, her mother did not approve of her
job so she was forced to resign after 7 mos.
August
1997
E.B studied liberal arts at Montgometry
College in Maryland from 1997-1999.
She did not spend for her tuition fee since
she qualified for a scholarship because of her
good grades.
EB and her mother lived in a three room
apartment near her school. The third room
was occupied by a 64 year old Cuban man
named Hugo. Unknown to her mother, EB
had a secret affair with Hugo for more than a
year. He was EB’s first boyfriend and she was
deeply in love with him.
When her mother learned of her
relationship, she told EB to break up with
Hugo. EB then obeyed and broke up with
Hugo.
September
2000
EB took up government studies at the
University of Maryland; where she was
diligent, studious, and belonged to the top
of the class.
She finished her 1st and 2nd years in the
university with good grades and was a
part of the Dean’s List
April 2002
She was noted to be very talkative in her
class because of numerous things in her
mind.
She was pre-occupied that her co-workers
in the library were talking about her of the
thesis that she was working on.
She could also spend recklessly buying a
lot of things when she could not afford to buy it.
Her mother observed EB had the tendency to
shoplift things when she could not afford to buy
it.
She filed a leave of absence from the
university before her 3rd year because of her
hyperactive attitude.
She would go shopping for clothes and
jewelries maxing out her credit cards.
Dec 2002
She was approached by a man who told her
about how miserable and sick she looked.
Thereafter, she sought for a consult with
another psychiatrist. She was prescribed with
olanzapine 10 mg/tab
She took the drug compliantly and she has
improved with the medication
Jan 2003
Went back to UM and worked at McD’s to
pay for rent and other expenses
She eventually graduated from UM in August
2006
Oct 2006
Apr 2008
She worked at Aramark regional staffing in
Washington DC where she was to told that she
was going to be promoted soon. However, her
mother did not approve of her job, and so she
quitted.
EB’s mother decided that they will be going to the
Philippines due to EB’s frequent misundestanding
with her co-workers. EB did not want to go to the
Philippines but she agreed since she does not want
to disappoint her mother.
In the Philippines, she sought for another consult,
at NMCH, because her drug was running out.
Olanzapine was thereafter discontinued and she
was prescribed with quentiapine (100 mg)
Oct 31, 08
Together with her mother and an uncle, EB
went to a cemetery in Marikina; there, she was
again observed to be very talkative. While on
their way home, she ran out of the car because
she thought that there was a coup’d etat going
on. She then went to SM MOA where she spent
P14,000 for shopping.
After shopping, she stayed at an apartelle in
Quezon city for 3 days before going back to
their house on Kamuning.
Nov 4, 08
She opted to ba admitted at NCMH where
she was given lithium, quetiapine and
paliperidone
Dec 12, 08
She was discharged from NCMH with the same
medication.
She would still have hyperactivity episodes and
would always stay the gym so she would lose
weight,
Mar 23, 08
She experienced uncontrollable shaking of
her thighs and generalized body weakness.
She sought for another consult and was told
to discontinue paliperidone and was prescribed
with quetiapine and alprazolam
Mar 25, 08
EB ha a difficulty in sleeping and worried of
the
possible
effects
of
discontinuing
paliperidone; hence, her admission
SALIENT FEATURES
• 30 year old female
• Talks a lot because of numerous running ideas in her
mind
• Physically abusive to her mother
• Hyperactivity episodes
• Break things in the house whenever she would not get
what she wants
• Diagnosed to have oppositional deviant disorder in 1993
• Extreme behaviors in high school (1994) such as
shouting and crying.
• Would shoplift when she can not afford to buy the things
that she like
• Compulsion in buying things
• Preoccupied that her coworkers were talking about her
• Having thoughts of the occurence coup’d etat
Physical and Neurological Exam on Admission:
Essentially Normal
Mental Status Examination
 No abnormal mannerisms and posturing were noted.
 Mood was euthymic with appropriate affect.
 She had spontaneous speech and able to maintain good
eye contact.
 She denied hallucination and no delusions were elicited.
 There was no looseness of association and she was
able to answer questions appropriately.
 She verbalized her aggressive thoughts towards other
people.
 She is oriented to person, place and time
 Concentration, attention and memory were all intact.
 She was able to read, write, and was capable of abstract
thinking.
 Judgement was fair and she had an intellectual insight
about her condition.
Review of the Systems
• Unremarkable
Past Medical History
• Angiogram at the age of 10 due to
elevated BP
• (-) DM, cancer and TB
• (-) asthma, allergies
Family History
• (+) malignant melanona – father
• (+) hypertension – mother and maternal
grandparents
• (+) DM – maternal grandfather
• (-) stroke, asthma, allergies and
psychiatric dso
Past personal History
• Non smoker
• Non alcoholoc beverage drinker
• No elicit drug use
Family Profile
• Aladdin (+) – father
– Retired chef of the US navy
– Had a distant relationship with EB because of work
– EB would describe him as workaholic, disciplinarian
and supportive.
– He would always remind EB to work harder and to
excel in school.
– (1995) on EB’s senior yrs, he died of malignant
melanoma
– Was previously married; had a son 4 yrs older than
EB
Family Profile
• Victoria, 64 y/o
– Worked as a daycare teacher back in the US,
and currently unemployed; living with her
brother in Kamuning.
– Was the primary caregiver of EB
– Would often give EB some advice whenever
EB confides her problems.
– Would always give EB what she asks for, as
long as she could afford it
Family Profile
• Antonio 71 y/o widower
– Oldest brother of Victoria
– Owns the house where EB and her mother stays
– Has a limited interaction with EB since, EB would
always stay in her room whenever Antonio is around
• Francisco 60 y/o
– Youngest brother of Victoria
– Never married so he lives with his siblings
– Also has a limited relationship with EB
Family Profile
• Mila 35 y/o
– The household helper of the family for 7 yrs.
– Apparently has a relationship with Antonio to
whom she apparently has a child with.
• Jeremy 6 y/o
– The son of Mila
– Whom, EB thinks is her nephew