Talampas, Crisanto J. Psychiatry Clinical Clerk History and Mental Status Examination

TALAMPAS, CRISANTO J.
Psychiatry
Clinical Clerk
HISTORY AND MENTAL STATUS EXAMINATION
GENERAL DATA:
This is the case of Jane, a 20-year-old, female, single, fourth year BS Biology student, Born
Again Christian, Filipino, born on January 14, 1998, in Cabanatuan City, currently residing in Aurora
Hill, Baguio City.
PRESENTING COMPLAINT:
The patient stated that she “is anxious most of the time” and “feels that she no longer has the will to live.”
INFORMANT:
The patient is the informant herself.
RELIABILITY: 95%
Premorbid personality:
The patient describes herself as being introverted, shy, and timid. She does not get easily
comfortable with new people and being in a huge crowd makes her anxious and that her “social battery
gets easily drained” during such situations.
HISTORY OF PRESENT ILLNESS:

The patient entered university. She claims that she was apparently well during those times—she
always attends worship services, study with friends, and goes out with them to have fun from time to
time. During her first year in college (3 years PTC), she met her worship leader for whom she became
very close to. Because of her dedication to her faith, she always attends Sunday service and even
participates in a religious club at school wherein her worship leader is also her orgmate. She claims that
because they were always together, they became too close that she developed feelings for her. The patient
claims that these feelings were reciprocated as the time goes by. However, their relationship was kept
secret since it is against the teachings of their church and same-sex relationships are frowned upon and
are “considered as sinful”. Due to this secret, the patient became anxious as she did not want anyone to
know that she has a relationship with someone of the same sex. She and her now-girlfriend always goes
out together and people barely noticed their closeness until her college friends started to joke around,
asking her if she has feelings for her worship leader since they are mostly seen together despite being on
different year levels. This made the patient more anxious, so she decided to keep her distance from her
friends. She felt that her friends were talking about her and her “worship leader” behind her back.
During her second year in college (2 years PTC), a room in her dormitory was vacated and her girlfriend
decided to move in. She claims that because of this, they became “closer than ever”. However, she felt
that through time, her girlfriend was being cold to her. When she confronted her, her girlfriend told her
that she could no longer keep being in a relationship with her since she was lying to her parents, and even
to the church. The patient said that this made her depressed. She felt that she lost motivation in studying.
She barely goes to church anymore claiming that it is because the people at church were “hypocrites” and
that “they do not practice what they preach” since, according to her, there are so many closeted same-sex
relationships in church, some are even worship leaders, but they still insist on preaching that same-sex
relationship was sinful. During this time, her “ex” still lived at the same dormitory but on a different
room. She claims that they remained friends. However, she felt that her ex was being “unfair” since she
would go to her room to talk to her whenever she’s sad and this would sometimes lead to “intimacy” but
she also claims that she could not freely enter her ex’s room as she would get mad and would often throw
her out of the room. According to the patient, this caused her anxiety levels to increase as well as her
depression. When asked why she did not seek professional help during this time, she said that “she was
not ready to talk to anyone regarding this matter, so she just kept this for herself.
The patient claims that she and her ex remained friends even until her ex graduated from college. Her ex
entered med school in Vigan City. Her absence made the patient so sad since she was used to her being
around. She claims that she no longer has someone to confide into whenever she felt stressed and anxious
because of school. The patient claimed that this led to a significant decline in her academic performance
because, for the first time in her life, she failed a subject and she had to retake it. She also claims that this
worsened her anxiety since the professor teaching the subject was a “terror” and she would often yell at
students who seems unprepared during class presentations. Not having someone to talk to, she claims that
this made her more depressed. During this time, she started hanging out with some of her friends wherein
she learned how to drink alcohol and even smoke. She claims that this gradually worsened to the point
where she would drink with her friends during their breaks. She claims that this went on until before the
pandemic (1 year PTC).
When the pandemic emerged, and Baguio was on lockdown, she claims that she was not able to go home
to her family in Nueva Ecija since she initially thought that the class suspension would eventually be
lifted after a month or two. However, she lockdown got implemented and travels going in and out of the
city was banned. She claims that she was left alone in her dormitory. She claims that she had a hard time
coping during this time since she has no one with her to talk to except for the frequent calls of her parents.
She claims that there were times that she felt emotionless and that she had suicidal ideations. She also
claims that during her “dark times”, she felt that she no longer has a purpose on continuing to live.
However, she denies of suicidal attempts since she claims that she does not want to get physically
harmed. 6 months PTC, the patient claims that her ex-girlfriend, whom she remained to be friends with,
blocked her. She thought that this might be her way of “getting away from temptation.” The patient
claims that she had a very difficult time getting out of bed to do schoolwork. She claims that she is not
motivated in answering or doing her requirements. Most of the time, she just crams her schoolwork
whenever they are due. She claims that there were also times when she would just not mind doing her
requirements. This went on until 1 week PTC where her friend talked to her and insisted that she seeks
professional help since her friend was worried that she might do something that she would regret. She
initially brushed off her friend’s suggestion until 3 days PTC where she felt that her symptoms were
getting worse and that the suicidal ideations became more frequent. She claims that during this time, she
already feels lightheadedness and palpitations whenever she gets anxious. The patient claims that this
made her really consider going to a private psychiatrist. The patient promised to seek consult as soon as
possible.
PAST MEDICAL HISTORY:

Patient was diagnosed with Dengue fever in 2019 for which she was admitted at the SLU-
Hospital of the Sacred Heart and Urinary Tract Infection on the same year and was treated with an
unrecalled antibiotic. She denies any history of hypertension, DM, cerebrovascular disease, kidney
disease, thyroid disease, nor cancer. She has no known allergy to food or medications and denies any
history of trauma or any psychiatric disorders.
FAMILY HISTORY AND FAMILY PROFILE:

The patient grew up in Cabanatuan City where she has lived most of her life with her parents and
2 younger sisters until she went to Baguio to study college. Her family is very religious and would always
go to church every Sunday.
DV, 48M, father, college graduate, owner, and manager of a private accounting firm, who she
describes as very loving, very hardworking, and would provide their family’s needs. Patient also
described him as very nurturing and would make her laugh whenever she gets sad.
AV, 46F, college graduate, co-owner, and co-manager of their accounting firm, described by the
patient to be gentle, loving, and caring. She was also described to be very religious and would insist for
her daughters to always attend Sunday service with her.
Siblings:
Patient
SV, 18 F, Second year Accounting Student
RV, 15 F, Senior High School Student
SUBSTANCE HISTORY
Patient is a 1-pack-year smoker, occasional alcohol beverage drinker, does not gamble and does
not use prohibited drugs.
REVIEW OF SYSTEMS:
General: (+) fatigue, (-) weight change, (-) fever, (-) chills, (-) diaphoresis, (-) dizziness, (-) body
weakness
Integumentary: (-) rash, (-) sores, (-) hives,
Head and Neck: (-) headache, (-) trauma, (-) pain, (-) stiffness
Eyes: (-) pain, (-) diplopia, (-) visual dysfunction, (-) dryness, (-) redness, (-) tearing
Ears: (-) difficulty hearing, (-) tinnitus, (-) pain, (-) discharge
Nose: (-) epistaxis, (-) discharge, (-) smell dysfunction, (-) sneezing
Mouth: (-) soreness, (-) hoarseness, (-) cyanosis, (-) change in tone of voice, (-) poor oral care
Respiratory: (-) cough, (-) dyspnea, (-) hemoptysis, (-) cyanosis, (-) wheezing, (-) occupational exposure,
(-) TB exposure
Cardiac: (-) chest pains/ discomfort, (-) orthopnea, (-) dyspnea, (-) paroxysmal nocturnal dyspnea, (+)
palpitation, (+) undue fatigue, (-) edema, (-) cyanosis, (-) syncope, (-) hypertension
Vascular: (-) intermittent claudicating, (-) leg cramps
Gastrointestinal: (-) vomiting, (-) nausea, (-) dysphagia, (-) hematemesis, (-) indigestion, (-) melena,
(-)hematochezia, (-) heartburn, (-) abdominal pain, (-) abdominal distention, (-) jaundice, (-) diarrhea, (-)
constipation, (-) change in bowel habits
Renal and Urinary: (-) dysuria, (-) hematuria, (-) incontinence, (-) urinary frequency
Musculoskeletal: (-) muscle pains, (-) joint pains, (-) cramps, (-) weakness, (-) stiffness, (-) Hx of trauma,
(-) limitation of motion, (-) backache
Hematological: (-) anemia, (-) excessive bleeding, (-) easy bruising
Endocrine and Metabolic: (-) heat/cold intolerance, (-) weight change, (-) excessive sweating, (-)
polydipsia,(-)polyphagia, (-) polyuria
Nervous System: (-) headache, (-) syncope, (-) seizures, (-) left or right sided weakness, (-) head trauma,
(+) sleep disorder, (-) coordination problem,
Psychiatric/Emotional: (+) anxiety, (-) loss of control/violence, (+) change in behavior, (+) depression (+)
insomnia (-) nervousness, (-) memory change, (-) substance abuse (+) alcohol consumption
MENTAL STATUS EXAMINATION:

Seen and examined a female adult patient who appeared as her apparent age, with good grooming
and good hygiene. She was wearing a green shirt with clean glasses, face mask and face shield. Patient
was jittery throughout the interview and MSE, which may suggest anxiousness. The patient has normal
gait. Patient is cooperative and has fair eye contact. She had a normal rate, volume, and pattern of speech
with appropriate tone of voice. The patient had a broad range of affect throughout the. She denies having
any hallucinations. Patient had a linear and clear thought process and claims to have suicidal ideations.
She has good insight and judgement. Patient is conscious, coherent, and alert, oriented in 3 spheres.
Disclaimer: This is an actual case of a patient. However, as per her request, the interviewer changed her
name for the patient’s privacy.

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Talampas, Crisanto J. Psychiatry Clinical Clerk History and Mental Status Examination

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TALAMPAS, CRISANTO J.

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

FAMILY HISTORY AND FAMILY PROFILE:

MENTAL STATUS EXAMINATION:

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