Identifying Data Patient RB, 29/M/S Roman Catholic From Obando, Bulacan
Admitted at SOJR due to CPI, with ruptured lens, post traumatic cataract OD and CPI with hyphema OS. Referred to Psychiatry due to a previous diagnosis of Schizophrenia, type unkown (NCMH, 2004) CC: hindi makakita; kung hindi rin lang lilinaw ang paningin mabuti pang mabulag na
History of Present illness 3 weeks PTC the patient noted foreign body sensation on and severe pruritus of both eyes. He noted some sand-like particles in both his eyes after looking at the mirror. He tried to remove the particles using a needle causing him to poke both eyes resulting to blurring. The patient felt scared and was anxious to tell his family about what happened because he knew that they did not have enough funds for the treatment.
He was also afraid that they won’t bring him to the hospital to be treated. He thus kept the situation to himself and as blurring progressed he felt more scared but did not tell his family. Instead the patient just went to sleep.
One day after the injury the patient suddenly claimed that he could no longer see. He was then rushed to PGH and was admitted at SOJR.
Past Medical History (+) child hood asthma Was hospitalized at a local hospital in bulacan in 2004 after suffering minor head injury (laceration at the occipital region) sec to fall from a height of ~20 feet – (allegedly no X-ray/CT scan done only cleaning and suturing of laceration done)
Past Psychiatric History Diagnosed with Schizophrenia, type unknown in 2004 (jas please insert your part here, how long after the injury, initial presenting symptoms and management for the admissions in 2004 and 2007) @ NCMH
3 rd admission, Oct 2009 The patient stopped taking his meds (Carbamazepine) thinking that he was already well. He started having had auditory hallucinations again telling him that his mother was noisy and that he had to shut the noise up. He was more irritable and was more frequently seen with blank stares. When his mother asked him to drink his meds he threw a piece of wood towards her prompting them to bring the patient back to NCMH
Family Medical and Psychiatric Hx (+) DM- father and (+) asthma – sister (+) Brief psychotic disorder - father – >30 years ago – Still maintained with unrecalled anti-psychotic meds regularly administered by his wife
Anamnesis The patient was born full term via SVD to a then G2P1 motherin Samar with no FMC. It was a wanted pregnancy. He was the 2 nd in a a brood of 3. He is closest to his eldest sibling who is now married but is still living with them together with her husband and is currently 4 months pregnant. The patient expressed that he was saddened by the fact that he couldn’t talk to her as much as she used to.
He also expressed that he is sad that he might not be able to see his nephew when he is born bec of what happened to him. The patient’s father works as a construction worker and his mother a s a volunteer of a foundation called ‘Mother Leaders’. The patient remembers his father as the main disciplinarian of the family but he stated
That his father never resorted to violence to discipline them The patient was described to be very active and friendly as a child. And he liked to play outside. The patient grew up in Bulacan where he lived with his entire family after being born.
In school –his performance was noted to be average. He finished highschool but wasn’t able to proceed to college due to financial constraints. He wanted to go into the Military but his only choice was to do it in Cebu and he did not want to be far from his family so he just decided to not go to college.
He used to work as a contractual construction worker and also as a ‘bantay’in a bakery near their house. This was before he was admitted in 2009. After the patient was discharged he just stayed at home and helps with household chores.
Mental Status Exam (April 25) The patient was seen dressed in a clean yellow hospital gown with a surgical cap and booties. The patient was about to be wheeled into the OR that day. The patient was in a sad mood with appropriate affect. His speech was spontaneous with slow rate normal volume and clear
The patient is filled with thoughts of his condition and the possible failure of surgery. He stated that if the surgery couldn’t afford him to get his normal vision back then he would rather just go blind because he said that they did not have enough money to cover for the expenses anyway. He is worried that his family will run out of resources because of his condition.
The patient also stated that if he had a gun it would be ok for him to just shoot himself and die. The patient did not have any auditory or visual hallucinations nor delusions. He was oriented to three spheres and was coherent. He had good insight on his illness and his psychiatric illness. Intact Judgement.
Multiaxial diagnosis Axis I – Schizophrenia, undifferentiated type Axis II – Defer for now Axis III – OD, CPI with ruptured lens, post traumatic cataract; OS, CPI with Hyphema Axis IV – GMC, Financial Constraints, Axis V – GAF 41 - 50