Harbieto, Celso

48 y.o
Male
December 03, 1969
Roman Catholic
Filipino
Consolacion, Cebu
Date HISTORY Findings Assessment and
Plan
05/19/18 Informant: mother and patient Patient was stained A:
Reliability: 85% for both respectively by his blood with a P:
Resident couple of blood
in charge: A case of C.H., 48 yr old male,residing in dropo n his neck Meds:
Dr. Consolacion, Cebu, born December 03, collar. Was wearing 1.
Calmerin 1969, single, filipino, roman catholic. a red shirt, black
pants and black cap
Intern in Chief Complaint: and slippers. Was
Charge: “pa injection ko” as verbalized by poorply groomed.
Goyenec the patient. He had a lacerated
he, right lower eyelid
Marichell History of Present Illness: about less than a
e Several hours prior to consult, centimeter in lenth
patient was drinking hard liquir with but was actively
local friends away from home. When he bleeding. With right
went home to sleep, there was an lower orbital
ongoing wedding/party and still many hematoma. Patient
people were around. After awhile he was calm and
awoke to the sound of mutiple stones talked in a good
being thrown on the ceiling, as claimed moderate voice
by the patient but this information was with good rate and
denied by the mother who was also at the rhythm. No
venue. So the patient went out to the mannerisms were
crowd and started yelling the everybody noted and could
saying “and kutsilyo! And kutsilyo!”. His keep eye contact.
mother was worried maybe the patient Was sleepy during
get a knife and might hurt someone. - the later part of the
especially the husband who was the interview and keep
pastor which was mention by the patient asking for an
earlier, that he hated because he accused injection. Was
the pastor of laughing at him but this oriented to self,
information was also denied by the time and place.
mother saying, “namadlong raman sad Intact remote
ang pastor”. The patients relatives memort but por
quickly scolded him saying, “hilom recent memory.
diha!” this provoked the patient more and When asked who is
he started making more of a commotion. the current
The patient somehow got a hold of a president he answer
piece of wood which angered the crowd “Ferdinand
more until one of his nephew punched Marcus”. Denied
him in the face. This prompted the any auditory or
mother to call the police where visual
subsequently the patient was blottered halluciantions. Was
and after was brought by the mother to not mathematically
this institution. challenged and was
able to distinguish
Past Psychiatric, Substance Abuse and different colors.
Medical History
21/22 years prior to consult, patient was
brought to VSMMC for the first time for
hitting his mother with a piece of Wood
due to controlled anger which the details
were already hard to recal, as claimed by
the mother. Patient was admitted for 3
days with unrecalled diagnosis.
Prescribed with haloperidol which was
maintain for roughly one year with por
compliance due to unavailability of
medication.
In 1995, mother claims he was depressed
because his girlfriend broke up with him
which rendered him unable to converse
properly and had loss of appetite. This
was consulted with a doctor but the
physicians diagnosis was unrecalled.
2 years prior to consult, patient was
brought back to VSMMC Psychiatric
Ward for getting involved in a brawl
which he started. Details were unclear as
to what caused the brawl or what
provoked the patient to start a fight.
Claimed he was admited for three days
and was discharge because “ma storya
naman siya og tarong”, as verbalized by
the mother.
Patient admitted to using only marijuana
in college but his mother claimed it
started way back in high school. Patient
claimed he stopped using around year
1995 when was started working as San
Miguel.
Patient had removal of his appendix. S/P
Appendectomy (2003). No other
hospitalization nor other surgeries.

Family History
Father is deceased back in 2000
due to stroke, mother still alive, claims
thy had another realtive, the patients
grandfather on his fathers side that was
also a the same as the patient. No know
heredofanilial diseases.

Personal and Social History

Patient was born to a 25 year old
mother, OB score of G8P8 (8008). His
the 2nd out of 8 siblings. Patient was a
planned pregnancy, and delivered via
normal spontaneous delivery but was
immediately admitted for 18 days due to
diarrea as claimed by mother.
Elementary days were normal as claimed
by the mother, saying he was ok
academically, but was secretive. Doesn’t
talk much about his experiences in school
or his friends. High school was far better
says the mother, stating he was much
socialized. Did not repeat any years and
graduated with his starting batch.
Reached first year college, nautical,
when his mother decided to he stopped
school because he stopped going in going
to class to hang with his friends ang
smoke marijuana. Since then, patient
spends his time at home or roaming
around their town, or walking for 30
minutes to an hour to his cousins place
where he claims had more activites going
on like people playing volleyball or his
cousins would be drinking. Deceased
father; 2000 due to stroke. Mother claims
patient has good relation with all of
siblings and relatives.