CDD WORKSHEET

PART II

1. Name: MENDOZA, Andrian Ornillo Rank: PFC AFPSN: 909281 BOS: PA

2. Date of enlistment: Total Year in Service: 6 years
3. Date of Previous Hospitalization: ETE:
4. Date of Present Hospitalization: 19 September 2018

5. History of Present Illness

Chief complaint: According to the patient’s companion, “parang naging makakalimutin sya,
di na niya makilala yung mga tao”

3 weeks prior to admission, the patient claimed “nadedepress ako, masakit sa loob ko” after
being scolded and humiliated at work and was called “bobo” in front of his colleagues when he
submitted an unfinished file at work. The patient’s wife claimed that after that incident, the patient
started experiencing headaches. From then on, he was constantly reprimanded at work which caused
increased severity and episodes of headaches. No medications were taken. No consult done.

5 days prior to admission, the patient started having muscle pains associated with body malaise
and persistent headache which was described as severe “sobrang sakit”. Bioflu was taken every 6 hours
which prompted temporary relief of symptoms. No consult done.

4 days prior to admission, the patient had undocumented fever and vomiting previously
ingested food, approximately 4 episodes still associated with headache and muscle pains. He was
advised by his godfather to have his health checked at the hospital but opted to go to a “manghihilot”
but still no relief of symptoms. The patient was then noticed to be asleep most of the time.

2 days prior to admission, still with undocumented fever, headache and muscle pains. The
patient’s wife claimed that the patient cannot recognize her and their own son. When asked if he was
just kidding, he just lay in bed and slept.

Few hours prior to admission, the patient’s companion noticed that he was sometimes
unresponsive when called and when asked with questions, his answers were unrelated to the topic or
just responds with “maganda naman ‘yun” or “maayos naman ‘yun”. He was unable to recognize his
colleagues and was noticed to be indifferent. Persistence of symptoms prompted consult hence,
admission.

6. Physical Examination on Admission

General Survery: conscious, incoherent, not oriented to time, person and place
Vital Signs: BP: 110/70 mmHg, PR: 89 bpm, RR:20 cpm, T:36.7 O2 sat: 98%
Skin: (-) jaundice, (-) pallor, (-) erythema, (-) rash
HEENT: anicteric sclera, pink palpebral conjunctivae, (-) neck mass, (-) hoarseness of voice
Chest and Lungs: equal chest expansion, clear breath sounds, no retractions
Heart: Adynamic Precordium, normal rate, regular rhythm, no murmurs
Abdomen: Flat, Normoactive bowel sounds, soft, non-tender
Extremities: no gross deformities, Full equal pulses, CRT <2s

7. Mental Status Examination

Patient was seen and examined, adult male, appearance appropriate for age at 26 years old,
wearing a gray shorts and a plain shirt, well-groomed and well kempt. Patient is uncooperative, poor
eye contact, with mannerism noted (constant nodding). Normoproductive speech with soft tone, with
word salad. Euthymic mood with appropriate and congruent with affect. Patient has irrelevant and
disorganized flow of thinking. Patient had no auditory and visual hallucinations. He is not oriented to
person, place and time. Patient has poor concentration. The patient’s recent, immediate and remote
memory are all impaired. Patient has poor judgement and poor insight to illness during the
examination.

8. Course in the Ward

The patient was admitted to ACU temporarily. Consent for admission and management was
secured. Vital sign were monitored every 8 hours and were recorded. The patient was advised to have
caffeine-free diet. Appropriate diagnostics were done such as CBC with PC, Blood typing, UA with
UDA, FBS, Creatinine, BUN, BUA, SGPT, SGOT, RPR/VDRL, CXR-PA, and 12 Lead ECG..
Medications given were: Risperidone 1mg/tab ODHS, Vitamin C 500mg/tab 1 tab OD after UDA,
Vitamin B Complex 1 tab OD. Escape-Suicide-Homicide Precaution.
 On the 5th day of hospital stay, the patient was noted to have good sleep, good appetite,
euthymic mood with congruent affect and normoproductive speech. Risperidone was held temporarily.
Present management continued and the patient still for observation.
On the 19th day of hospital stay, the patient was noted to have good sleep and good appetite, also
with no subjective complaints. He was then transferred to Ward B. Family therapy was advised and
present management continued.
On the 23rd day of hospital stay, the patient verbalized that he was unable to sleep well,
Diphenhydramine 50mg/cap 1 cap PRN was given for difficulty of initiating sleep.
On the 28th day of hospital stay, the patient still unable to initiate sleep, Diphenhydramine was
changed to Quetiapine 25mg/tab ODHS as medication.
On the 29th day of hospital stay, the patient complained of cough for 2 days mostly occurring at
night, physical examination showed erythematous tonsils and clear breath sounds. No antibiotics were
given however, he was advised to increase oral fluid intake and to take note if there’s persistence of
symptoms. No fever noted.
During the interim, the patient had no subjective complaints with stable vital signs. Present
management continued.
On the 111th day of hospital stay, the patient had occasional auditory hallucinations as
verbalized by the patient that an adult male called his name “Mendo” and had difficulty of maintaining
sleep. Quetiapine was increased to 100mg/tab 1 tab ODHS.
On the 118th day of hospital stay, the patient was for CDD.
During the interim, the patient had no subjective complaints with stable vital signs. Present
management continued. The patient was monitored closely and was referred accordingly. Still for CDD
Processing.
 CDD WORKSHEET

PART III

Name: MENDOZA, Andrian Ornillo Rank: PFC AFPSN: 909281 BOS:PA

Date of Enlistment: Total Year in Service: 6 years

9. Laboratory Examination

CBC 19 Sept 2018 URINALYSIS 19 June 2019

Hemoglobin 160 Color Straw
RBC 6.25 Clarity Clear
WBC 9.90 Specific Gravity 1.010
Segmenters 0.56 pH 6.5
Lymphocytes 0.34 Protein Negative
Eosinophils 0.01 Glucose Negative
Monocytes 0.08 RBC 0-1/HPF
Basophils 0.01 Pus cells 0-1/HPF
MCV 78 Epithelial cells Rare
MCH 26 Amorphous Urates Rare
MCHC 33
RDW 9.78
APC 298
Blood Type O positive

Clinical Chemistry 20 Sept 2018

ALT 33.5 U/L
AST 30.6 U/L
Creatinine 95.79 umol/L
 Cholesterol 5.67 mmol/L (H)
Glucose 5.00 mmol/L
HDL 0.67 mmol/L
LDL 4.93 mmol/L (H)
Triglycerides 1.78
Uric Acid 657.24 umol/L (H)
BUN 6.25

Immunology (20 September 2018)

Syphilis: 0.11 (NONREACTIVE)
Drug Testing (10 October 2018)
Methamphetamine: Negative
Tetrahydrocannabinol: Negative

10. Chest X-ray (03 OCT 2018)

Lungs are clear
Heart is not Enlarged
Aorta is not dilated
Diaphragm and sulci are intact
The rest of the visualized chest Structures are unremarkable
Remarks: NO SIGNIFICANT CHEST FINDINGS
11. ECG (03 October 2018)
Sinus Bradycardia
Non Specific ST-T Wave Changes
Intra Ventricular Conduction Delay
.
12. Treatment
Quetiapine 100 mg/tab 1 tab ODHS
Vitamin C 500mg/tab 1 tab OD
Vitamin B Complex 1 tab OD
12. Psychological Examination Result:
13. Diagnosis: T/C Brief Psychotic Disorder
14. Remarks: For CDD
Head, Department of MHBS