CLIENT CASE STUDY REPORT

I. IDENTIFYING INFORMATION

NAME JUAN PEDRO G. DELA CRUZ

NICKNAME JUAN
BIRTHDAY JUNE 27, 1990
GENDER MALE
EDUCATIONAL ATTAINMENT COLLEGE GRADUATE
CIVIL STATUS SINGLE
PARENTS MARIA DELA CRUZ (MOTHER/INFORMANT)
PEPITO DELA CRUZ (FATHER)

II. REASON FOR REFERRAL

- Constantly fidgeting (“Hindi mapakali sa isang pwesto”)

- Mumbles to himself (“Bumubulong-bulong mag-isa”)
- Easily gets angry
- Talks incoherently (“Paiba-iba ang sinasabi na di naman maintindihan”)
- Does not take a bath, sleep, or eat

III. HISTORY OF PRESENT ILLNESS/CONDITION

March 2012 - Juan was a graduating college student. His mother said that he
was frequently busy that he would often forego sleeping or
eating just to complete his requirements. A few weeks before his
thesis defense, his mother often caught him staring blankly into
space (“naging parang tulala po sya”).

July 2012 - After graduation, Juan’s mother allowed him to forego applying
for a job so he could recover from the stress of his academics;
thus, he stayed mostly at home. However, his behaviors
continued and he became even more lethargic. At times, he
would lock himself inside his room and would stare out his
window as if looking for something (“Lagi pong nakatitig sa
bintana na para bang may inaabangan.”). He also did not join
the family during mealtimes. During nights, his brother reported
that Juan stayed up and did not go to sleep.

January 2013 - Juan’s behaviors worsened. He was frequently seen staring at

the window and whispering to himself. When asked who he was
speaking to, he would claim he was just coordinating with a
colleague, even though he was not employed. As such, the
family took him to see a psychiatrist who diagnosed him with
“Major Depressive Disorder”. He was prescribed with Sertraline
which, according to his mother, helped him sleep at night. He
continued his psychiatric consultations every month.

June 2013 - Despite having improvements in his sleep, he continued to be

listless. He no longer mumbled to himself; instead, he was now
 clearly observed to be speaking to someone that the family
could not perceive. He would walk around the house saying
nonsensical things (“Lakad nang lakad tapos kung anu-ano
pinagsasabi di naman namin maintindihan.”). Upon consulting
with his psychiatrist, his diagnosis was changed to
“Schizophrenia” and he was given new medications such as
Rivotril and Risperidone. He continued to have consultations
with his psychiatrist every month.

July 2014 - Juan’s mother reported that he was already functional. He was
accepted as a clerk in their baranggay hall where he is in charge
of inventory and filing. He also got along well with his
colleagues; thus, his doctor reduced his medication.

October 2014 - One of the clients of the baranggay shouted at him and called
him a derogatory name (“Nasigawan po sya nung isang nag-
iinquire at sinabihan syang baliw daw sya”). Since then, he
became extremely preoccupied with other people’s opinions and
would accuse others of saying bad things behind his back even
though this was not true. His doctor increased his dosage to
manage his symptoms.

November 2014 - Juan eventually lost his job at the baranggay due to the
resumption of his symptoms. He stayed at home again but
would help out in the household chores. He continued to see his
doctor and take his medications.

IV. RELEVANT BACKGROUND (pre- and post-natal, childhood, adolescence, and

adulthood)

Juan is the youngest of four children. According to his mother, Juan was an
unplanned pregnancy as she was already planning on getting a tubal ligation at the
time she conceived Juan. She had regular consultations with her obstetrician-
gynecologist and also took prenatal vitamins.

Juan was born via emergency caesarean section due to his mother’s
preeclampsia. Upon birth, he was found to have cord coil which was untangled
immediately. Despite the circumstances of his birth, he was deemed to be healthy
by his pediatrician.

He had complete immunizations and only incurred typical illnesses such as

coughs, colds, and fever. He was able to walk independently by the age of two.
However, his speech was slightly delayed and was only able to speak fluently when
he was already four years old. The family did not seek professional consultations
regarding this delay as he was able to outgrow it eventually.

Juan was an average student who obtained satisfactory grades. He had some
difficulty in Mathematics but still got passing marks. He was also able to establish
friendships with his classmates. For college, he chose to follow the footsteps of his
older brother who was an engineer. Juan took up BS Electronics and
Communications Engineering. His mother claimed that he was still an average
student although his transcripts reflected that he failed three of his major subjects
when he was in the junior year level. His mother also reported that it was during
this time that he became a bit reclusive with his classmates. She suspected that he
was probably just ashamed of his failing grades.

His symptoms started after graduating from college. Presently, he is living with
his parents and one of his sisters. His fairly socially competent and can tend to his
own needs independently. He also participates in house chores regularly. He spends
most of his time watching television, playing video games, and accompanying his
mother in running errands. He has only held one job but had to resign due to a
relapse. His family has not allowed him to look for another job due to their concerns
that it might cause a relapse again. Though generally asymptomatic, Juan has been
occasionally observed to be laughing by himself and prefers to be alone.

V. EDUCATIONAL HISTORY

Level Name of School School Year Academic

Performance
Preschool Giving Tree Day 1994-1996 Good
Care Center
Elementary St. Bernadette 1996-2001 Good
School for Boys
High School St. Bernadette 2001-2006 Good but with
School for Boys difficulty in Math
College (BS Our Lady of Divine 2006-2012 Failed three major
Electrical and Mercy Catholic subjects during
Communications College third year
Engineering)

Juan was reported to be an average student. He obtained passing marks and

was diligent in accomplishing his homework and projects. He did not have any
behavioral difficulties and cooperated with his teachers and classmates. He also had
a steady group of friends whom he always hung out with at school and at home.

In college, Juan decided to take up BS ECE so he could become an engineer like

his oldest brother. According to his mother, one of Juan’s brothers tried to dissuade
him because of his apparent difficulty in Mathematics during high school. However,
Juan was adamant and said that he can finish the course regardless of the possible
difficulties. As such, his family supported his decision.

During the first two years of his collegiate career, Juan performed satisfactorily.
However, when he got more major subjects, he started to have difficulty. At home,
he was notably anxious when studying and his sister once claimed she saw him
sobbing into his notebook. His eldest brother, who was an engineer, offered to help
him but he refused. He said he could do it by himself.
 He failed three of his major subjects and was placed on probation. His siblings
insisted on helping him with his schoolwork to keep him from failing again. Juan
allowed them to help but would sometimes become frustrated when he could not
understand what his brothers were teaching him. In one incident, he even accused
one of his brothers of intentionally teaching him the wrong solutions (“Sabi po nya
sinasadya ko daw siyang maliin.”).

Despite his difficulties, he eventually graduated with a degree in BS ECE. Due to

the onset of his symptoms, he was not able to prepare for the board licensure
exams and has not taken the test as of this writing.

VI. OCCUPATIONAL HISTORY

Name of Job Years of Reason for Quality of

Company Title/Designatio Service Leaving Performan
(recent to n ce
previous)
Privet Drive Part-time Clerk August 2013- Relapse Fair
Baranggay Hall (MWF only) November
2014

Once his symptoms stabilized, Juan’s sister helped him apply for a part-time job
at their baranggay hall. He was hired and scheduled to work on Mondays,
Wednesday, and Fridays. He earned a minimum wage.

Juan’s main tasks were taking inventory of the supplies and donations from the
baranggay’s benefactors. He was also in charge of filing the paperwork and
documentations in the baranggay. According to his supervisors, he was a diligent
employee. He was quiet but did all of his tasks conscientiously. Reportedly, his co-
workers were sad that he had to leave the job because he was well-liked in the
baranggay hall.

His family found it best to keep Juan at home so he could fully recover. They
stated that they will allow him to return to work if he wishes, provided that he
obtains clearance from his doctor. There is currently no plans for Juan to take the
board exams.

VII. FAMILY COMPOSITION

Name of Family Relationship Occupation Quality of

Member/s Relationships
Pepito Dela Cruz Father Hardware Store Positive
Proprietor
Maria Dela Cruz Mother Housewife Close, positive
Teodoro Dela Cruz Brother Engineer Positive
 Jaime Dela Cruz Brother Call Center Agent Positive
Melba Dela Cruz Sister Data Analyst Close, positive
Juan Pedro Dela Client None --
Cruz

Juan has a generally positive relationship with his family members. He is closest
with his mother and sister as they usually assist him with his needs. He presently
still lives in the family home with his parents and sister. The family owns a hardware
store located three blocks from their home which Juan’s father manages. His two
brothers live on their own but visit him as often as they could. They usually take him
to the mall and buy him whatever they want.

In terms of family history, his mother recalled that one of her distant uncles also
had a mental illness, though she could not recall the actual diagnosis. On Juan’s
paternal side, he is also said to have a second cousin with Autism Spectrum
Disorder.

VIII. MARITAL BACKGROUND

Name of Family Relationship Occupation Quality of

Member/s Relationships

NOT APPLICABLE

IX. CLINICAL IMPRESSION

Juan is a 28 year-old male who has been diagnosed with Schizophrenia. He

presents symptoms of hallucination, incoherent speech, poor adaptive functioning,
and intense mood shifts over a period of eight years. He is regularly consulting with
a psychiatrist and is managed on daily doses of Risperidone.

His symptoms may have been triggered by the stress he experienced during his
last few years in college which he could not manage properly. Such may have also
triggered his relapse while partially employed since it was also the time when his
doctor attempted to reduce his medications. Likewise, family history of mental
health conditions may have also been a factor in the development of his present
condition.

X. RECOMMENDATIONS

 Juan should continue attending consultations with his psychiatrist. The family
should also consider the recommendations that the doctor may suggest in
order to ensure his continuous progress.
  At home, Juan should be given productive activities that would allow him to
hone his competency and possibly even prepare him for future employment.
The family may consider the following tasks:
o Assign him with regular house chores that he should complete on a
daily basis. Such chores should be matched with his present
competency. Raise the level of difficulty once he has already mastered
the task.
o Allow him to help with the family business at least once or twice a
week. This would enable him to practice his social skills as he
interacts with other people.

 Juan may also be enrolled in a technical vocational program which could help
him develop practical skills that he could use for future employment. Despite
his condition, the family should still encourage Juan to be a productive and
independent adult so he could be well-equipped to take care of himself in
the future.

Prepared by:

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