GENERAL PROFILE

Personal Profile

Name: D
Age: 67 years old
Sex: Female
Birth date: December 22, 1950
Marital status: Widowed
Occupation: None
Address: Tinoc, Poblacion, Ifugao
Religion: Roman Catholic

Chief Complaint:

Admission Diagnosis:

T/C Bipolar Affective Disorder, Current Episode: Manic

History of Present Illness:

Patient D had shown symptoms of altered mentation in 2013. Because of this, she was admitted
to a certain psychiatric facility. She was able to control her symptoms and was doing fine until her
brother died last December 2016. This triggered her symptoms to resurface, and was diagnosed with
T/C Bipolar Affective Disorder with a current episode of manic.

Past Medical History:

Patient had hypertension and diverticulitis. She had been follow up till now at Outpatient
department.

Social and Environment History:

Patient D is a resident of Poblacion Tinoc, Ifugao, she lives with her two daughters.
Their place is not congested and weather is most often warm.

Patient graduated Bachelor of Science in Commerce but currently unemployed.

 Family history

? age ? age
(Vehicular Accident) (Pneumonia)

73 71 ? age ? age
A and W A and W DM DM
67 ? age
Pneumonia HPN
HPN Unknown
Diverticulosis cause of death

35 33 32 30 23
A/W A/W A/W A/W A/w

Genogram Key
= Female
= Male
or = Deceased
A and W= Alive and Well
(Cause of Death)
= Client

Patient is the youngest of five siblings, considering their third child who died on due to
pneumonia and DM. Among his siblings, the fourth child is diagnosed of hypertension and DM.
Moreover, their mother died of pneumonia at unknown age, while their father died of vehicular
accident. In addition, his husband died due to unknown cause. They had five children, two males and
three females, with no known illness.
 PHYSICAL EXAMINATION

The physical examination of patient D was initially performed during her admission at Roseville
Rehabilitation Complex Corporation on February 12, 2018 at 1:00 PM by the physicians and staff nurses.
We then performed an assessment on February 20-24, 2018, during our three day rotation.

General Survey

Upon observation, patient D is conscious, disoriented, and alert. She has difficulty in following
commands and instructions and able to answer questions with flight of ideas and perseveration. Her
body is symmetric with no injuries, fractures, and deformities.
Initial vital signs taken during the shift are as follows: blood pressure of 110/70 mmHg, pulse
rate of 82 bpm, respiratory rate of 18 cpm, temperature of 36.5 degrees Celsius, and an oxygen
saturation of 97%.

HEENT

Patient D’s head is symmetric, normocephalic in size, with no lesions, abrasions, and wounds.
She has a black and white, short hair, which is evenly distributed over scalp. Her scalp is mobile and non-
tender. She has no episodes of dizziness.
Her face is symmetrical and facial expressions are sometimes not appropriate. When asked to
smile, his nasolabial folds are proportionate. No lesions or abnormal movements were observed.
Her eyes are symmetric, with white sclera and pink, palpebral conjunctiva. His eyelashes and
eyebrows are evenly distributed. His pupils are at 2-3 mm, equally reactive to light and accommodation.
She does not wear any corrective lenses.
Her ears are symmetrical and equally aligned to the eyes. No redness, lesions, or drainage were
observed. She has a grossly equal hearing, with no difficulty of hearing and no ringing in the ears noted.
Her nose is symmetrical, with no lesions observed. There are no deviations and flaring noted.
Her nasal mucosa is pink, moist, with no lesions or discharges.
She has pink, moist lips, with no lesions observed. She has pink, moist oral mucosa, with no
lesions noted. Her tongue is pink, moist, and intact. Often drool with white foamy saliva. With dentures
noted.
She does not experience any difficulty and pain in swallowing. She has an intact gag and swallow
reflex. No masses and enlarged lymph nodes were palpated in his neck.
Respiratory System
Patient D has no complaints of difficulty and shortness of breath. Her lungs symmetrically
expand, with respiratory rates ranging from 17 cpm to 22 cpm. No masses, and crepitus were noted
during palpation. No abnormal breath sounds were heard during auscultation.

Cardiovascular System
Patient D’s average blood pressure ranges from 110/60 mmHg to 150/100 mmHg. Her pulse
rates range from 70 bpm to 95 bpm. No bruits and abnormal heart sounds were heard upon
auscultation.

Gastrointestinal System

Patient D’s abdomen is flat and symmetrical, with no lesions, scars, and hernias noted. She has
normally active bowel sounds of seven clicks per minute. No borborygmi, bruits, hums, or rubs noted.
No masses and tenderness were palpated. She defecates every other day.

Genito-urinary System

Patient D has no complaints of painful, scanty, or frequent urination. She urinated once during
the shift.

Motor – Musculoskeletal System

Patient D has shuffling gait. Her muscle strength was evaluated graded as follows: right arm –
5/5, left arm – 5/5, right leg – 5/5, left leg – 5/5. She requires moderate supervision in performing
activities of daily living such as walking and going to the bathroom.

Sensory – Neurologic System

Patient D is conscious, alert, and disoriented, with GCS of 15. She has no difficulty in recalling
memory when assessed. She has difficulty in following commands and instructions. She is able to read
and draw. Pupils are at 2-3 mm, equal, round and reactive to light and accommodation. Gag and
swallow reflexes of the patient is present and sense of taste is intact.
She was able to determine shape, smoothness and coarseness of an object placed to his palm
such as a key, and coin. Her deep tendon reflexes were graded as follows: right arm – 3+, right hand –
3+, left arm – 3+, left hand – 3+, right leg – 3+, right foot – 3+, left leg – 3+, and left foot – 2+.
Integumentary System

Upon observation, Patient D has no lesions, wounds, deformities or other damage to his skin
integrity. However, there were presences of varicosities on her both legs. Her skin is brown and warm to
touch with poor turgor (2-3 sec). She has pale cuticles, and trimmed nails with a capillary refill of 1-2
seconds. She has a black and white hair, which is evenly distributed over scalp. Her scalp is mobile and
non-tender.

Mental Status Examination

Patient D is well dressed appropriately and neatly. She is generally clean with unusual odors. She
speaks Ilocano, Filipino and English rapidly. She has unusual behavior and unusual movements such as
presence of tantrums and akathesia. She has flight of ideas, perseveration and circumstantial. She has
no signs of mutism, echolalia, neologism, verbigeration and pressured speech. She does not experience
any hallucinations, illusions, delusions, depersonalization, obsession, compulsions, preoccupation,
phobias and fantasies. She has labile affect but does not experience elation, depression, disassociation,
apathy and incongruence. She is not oriented in three phases, has short attention span, and has jumbled
memories.