John Ryan Almagro, 25, has a history of mental illness dating back to age 10. He has been diagnosed with manic depression, bipolar I disorder, and now is suspected to have schizophrenia. His symptoms include delusions, disorganized behavior, and negative symptoms. He has a history of poor compliance with medications and substance abuse. His condition has worsened over time and now prevents him from working.
John Ryan Almagro, 25, has a history of mental illness dating back to age 10. He has been diagnosed with manic depression, bipolar I disorder, and now is suspected to have schizophrenia. His symptoms include delusions, disorganized behavior, and negative symptoms. He has a history of poor compliance with medications and substance abuse. His condition has worsened over time and now prevents him from working.
John Ryan Almagro, 25, has a history of mental illness dating back to age 10. He has been diagnosed with manic depression, bipolar I disorder, and now is suspected to have schizophrenia. His symptoms include delusions, disorganized behavior, and negative symptoms. He has a history of poor compliance with medications and substance abuse. His condition has worsened over time and now prevents him from working.
John Ryan Almagro, 25, has a history of mental illness dating back to age 10. He has been diagnosed with manic depression, bipolar I disorder, and now is suspected to have schizophrenia. His symptoms include delusions, disorganized behavior, and negative symptoms. He has a history of poor compliance with medications and substance abuse. His condition has worsened over time and now prevents him from working.
IDENTIFYING DATA Name: John Ryan Almagro Sex: Male Age: 25 years old Birthdate: March 12, 1988 Civil status: Single Ethnicity: Filipino Location: Sucat, Paranaque Religion: Roman Catholic Educational attainment: 2 nd year college
CHIEF COMPLAINT
According to brother: di na ma-control sa bahay Gusto lagi lumabas ng bahay tapos pag ayaw payagan nagagalit.
According to patient: di ko alam, di ko nga alam kung bakit ako andito eh HISTORY OF PRESENT ILLNESS 15 years PTA (1999): Patient was allegedly diagnosed with Manic Depression at the age of 10. His fathers first family didnt treat him well and he had feelings of resentment towards his siblings from his fathers first family because they werent treating him like a brother. Medications were given with allegedly poor compliance to medication due to financial constraints, where the patient would seldom take his medications.
6 years PTA (2008): Patients mother died due to sepsis. He then had a recurring episode of depression because he was really close with his mother (he confides everything with her and he spends most of his time with her). According to patients brother: grabe yung depress niya depress na depress siya to the point where he wouldnt eat, he would lock himself in his room and he wouldn't speak much. Symptoms exhibited were insomnia, anorexia and weight loss. It was around this time he started to smoke excessively.
4 years PTA (2010): Patient was diagnosed with Bipolar I Disorder. Symptoms exhibited were violence, talking to himself, auditory hallucinations (which were identified as bulong), restlessness, no appetite, suicidal ideations, hurting himself and insomnia. He was also smoking excessively during this time. He was brought to a psychologist and received therapy for a year.
3 years PTA (2011): Patients family had decided to bring him to a psychiatric facility (rehab) in Cebu where he was admitted twice. He was allegedly hyper and he often talks to himself before but then after rehab he allegedly became very sluggish (naging sluggish yung galaw physically and mentally).
About a few weeks PTA (end of January 2014): Patient returned to Manila then had a check up on February 2014 at Perpetual Help, Las Pias (sister: kung pwede matignan) About a few days PTA (February 2014): Patient was insisting on leaving the house (umaakyat ng bakod, binabalak baklasin yung gate) his family let him leave the house since he was observed for about a week and he was coming back home. But then he started to panic (naging nerbyoso) and he started to become scared of the people living with him (nilalayuan) so his family didnt let him go out. He then started to accuse the people his living with, gusto niyo ko i-isolate, gusto niyo ako ikulong. Pinagtutulungan niyo ako and whenever they wouldnt let him out he would throw a fit.
4 days PTA (February 2014): Patient went out of the house and wandered alone. He said he just wanted to get out of their house so he was allowed to. He was found 3 days after in front of their village gate and was brought home with wounds (dry) and bruises all over his body. When asked about what happened patient would state that he couldnt remember. His family then decided to bring him to the emergency room. Patient insisted that he had no problem and that he was okay. His brother was sharing some stories when he decided to ask the patient about what happened and the patient suddenly remember everything and said that he was beaten near the Domestic Airport while he was wandering around. (wala naman ako ginagawa sa kanila) Patient is currently admitted to PGH Ward 7 and is currently exhibits delusions, disorganized behaviour and negative symptoms. His condition has stopped her from being able to work.
PAST PSYCHIATRIC HISTORY 1999 2010 2011 2014 Patient was allegedly diagnosed with Manic Depression. Symptoms were not stated although medications were said to be given with allegedly poor compliance to medication. Patient was diagnosed with Bipolar I disorder. Symptoms exhibited were violence, talking to himself, auditory hallucinations (which were identified as bulong), restlessness, no appetite, suicidal ideations, hurting himself and insomnia. Maintained on valproic acid and olanzapine with allegedly poor compliance to medication. Patient was brought to a psychiatric facility in Cebu because they werent able to control him anymore. (nagwawala) Patient was brought to PGH Ward 7 after leaving for a about 3 days and came back with wound and bruises on him. Used to take on valproic acid and olanzapine but now maintained on Aripriprazole 15mg/tab 1 tab ODHS and Haloperidol 5mg/mL 1mL + Diphenhydramine 50mg/mL IM for severe agitation or refusal to take medications. PAST MEDICAL HISTORY History of asthma Suffers from slipped disc Has skin allergy loratadine and co-amoxiclav (ointment) Neverundergone any surgeries Not afflicted by any neurological conditions. No history of diabetes, hypertension, and the like.
PERSONAL HISTORY Born the 12 th of March 1988 normal spontaneous vaginal delivery no complications or developmental delays reported. Eldest of 4 on his fathers 2 nd family. Reported to have close family relationships and even with the first family. but his brother stated that parang asot pusa sila ng father namin hes really close with his mom and ate. Hes only close with his brother (3 rd out of 4) whenever they play computer games. his youngest brother was his favourite but the youngest brother doesnt like him. Childhood: described as friendly said to have episodes of being depressed He was also said to be envied by his siblings from his fathers first family. He was a below average student but was able to reach 1 st year college couldnt finish a course he kept on shifting Unemployed No criminal record During Free time: plays video games, read books (mostly about mythology) and watch anime. Smoker= over 1 pack/day Drink occasionally (2-3 bottles) But reported to have had a lot of alcoholic beverages in his house in Cebu. His family and close friends are very supportive and encourage treatment. Currently lives with his brother, two cousins and a friend but when he gets discharged he would be living with 3 people (kakilala) from Cebu, a friend and his brother (3 rd ). FAMILY HISTORY Father: Salvador P. Almagro retired pilot Mother: Rosalinda S. Almagro Died = sepsis There is no family history of psychiatric illness other than his mom being allegedly depressed. Father: hypertension
MENTAL STATUS EXAMINATION General appearance and behavior He is seen half-lying on the bed during the interview. Observed to have very slow gait. He has fair grooming and wears clothing appropriate for age and gender. His expression was flat. He does not maintain good eye contact. Able to follow commands.
Speech and language He was apathetic but cooperative and had a flat expression during the interview. Responses were kept short. No evidence of stuttering or vocal tics
Mood and Affect. He displayed flat affect during the interview He was also apathetic. showed no interest, enthusiasm, or concern
Perception, Thought and Cognition Thoughts circulated on wanting to go home Denied presence of hallucinations and delusions He answered after about 30secs to a minute He is able to understand English Language skills are at par with educational attainment Denied suicide attempt Although his brother once mentioned he tried to commit suicide before and smoking was also his way of killing himself.
Orientation Oriented in place. Oriented in year, month and day of the week except exact date and time. Oriented in person.
Memory Recent Memory Good He remembered the meds he was supposed to take. Remote Memory Good He was able to answer where Jose Rizal was shot and where hes from. Immediate Memory Good He was able to repeat the 3 items I asked him to repeat during MMSE. (paru-paro, lamesa at mansanas)
Impulse control Fair Judgment Fair Judgment Asked what he would do if he found a stamped envelope on the street with the address and he said ihuhulog ko sa P.O. Box Asked what he would do if he was in a movie thetre and he smelled smoke and he answered didiretso ako sa fire exit Insight to Illness Poor di ko alam kung bakit ako andito sabi ng doctor may bipolar daw ako wala ako bipolar, manic depression lang Reliability Poor There were instances where he would answer after long periods of time (ranging from 30secs to a minute)
MINI-MENTAL STATUS EXAMINATION Oriented in place year, month and day of the week except exact date and time Registers information well Has good attention and calculation Immediate recall was Good Was able to understand and follow commands. Overall score is 27/30, which is within the range of normal (23-30). DIAGNOSIS Although he was diagnosed Bipolar I with Psychotic features we think that he might actually have Schizophrenia (unspecified).
Criterion A: met because Hallucinations (auditory) and Delusions (Grandiose, persecutory), disorganized behaviour, and Negative symptoms are present. Criterion B: met because he stopped working even after he got out of rehab. Criterion C is met because the duration of disturbance has been at least 6 months. Criterion E is met because the disturbance not due to substance.
DIFFERENTIAL DIAGNOSIS Ruled-in Ruled-out Bipolar I Disorder with psychotic features Mood disturbances present with psychotic features. He still has psychotic features even without mood disturbances. Schizoaffective Disorder Mood disturbances present together with psychotic features. Mood Symptoms are not present majority of the time. Brief Psychotic Disorder Symptoms present for over 6 months. PROGNOSIS: POOR + - Supportive family and friends. Poor insight to illness. Cannot be totally controlled by family. History of poor compliance to medications due to financial constraints BIOPSYCHOSOCIAL FORMULATION Predisposing Precipitating Perpetuating Bio Non-compliance to medication Psycho Distress from problems summing up. Trauma: gone for three days and got beaten up Denying delusions observed. Distress from not getting what he wants. Social Relationship with father and siblings (1 st family). Mothers Death. Social stigma. COMPREHENSIVE TREATMENT PLAN Short Term Long Term Educate patient regarding Illness. Encourage patient to participate in occupational therapy to improve motor skills. Clarify other precipitating factors to help in decreasing the chance of relapse in the future. The patient, family and friends must be educated about the factors to be able to manage the condition better. Continuation of good compliance with medication to ensure that the condition is alleviated and possible relapse is decreased Encourage the patient to continue consulting his doctors. Re-educate patient and relatives about the condition and contributing factors. Support Groups.