NURSING HEALTH HISTORY

Personal Data: Mr. Roldan X is a 29 years old, male, was born on April 24,1975 at their province in San Nicolas, Banban, Tarlac. He is a Filipino, Catholic and still single. He lived together with his father, Mr. Danilo X, mother, Mrs. Milagros Y and his three siblings at #55 C Governor Antonio Carpio San Pedro, Santo Tomas, Batangas.

Patient was finished his high school at Batangas, and he took Computer course at University of Santo Tomas, Batangas first Year College.

Patient was admitted for the second time in National Center for Mental Health (NCMH) last September 01,2000 in the morning accompanied by his relatives with a complaint of unusual behavior.

Chief Complaint:
"Natatakot ako matulog, hindi ako makatulog, ayaw ko matulog." as stated by the client
“Hindi makatulog, lagging salita ng salita kahit walang kausap, minsan malungkot at tahimik, minsan naman ay nagsisigaw at nagbabasag ng kung anu-ano…”stated by his mother.

History of Present Illness:
Two years prior to admission, patient was brought to National Center for Mental Health with the referral of the University Santo Tomas Hospital and was confined fro three days.

He was discharge when the condition improved but the relatives were advised to have a home care to the patient. Patient was given Chlorpromazine 200 mg at bedtime, Biperiden HydroChloride PRN or as needed, and Lithium Carbonate 450mg twice a day.

Patient was advised to have follow-up every month and follow the medications given to him. But patient only had one follow-up which was last October, 1998 and no subsequent check-up done. Patient is poor compliant to medicines, too as reported by his mother. He was non-functioning and was tolerated at home.

Three days prior to admission, patient was noted to have impaired sleeping, in deep thoughts, with blank stares, talking to self, refused to take a bath and change clothes, keeps making sign of the cross and become assaultive. Hence, mother decided to bring again his son to NCMH for consultation and further management.

Patient Upon Admission
Patient is an adult male, wearing white shirt and maong pants. He is agitated and restless. Mood is dysphoric and affect is appropriate. He has blank stares and saying irrelevant things and words. He has looseness of association and tangentially. He admitted to auditory hallucination of “sex, coarse, angels and coding of angels” which started last 1996 until present. He keeps on saying in English language. He also admitted to thought racing and grandiose delusion. Patient was not oriented to time and place. He denies suicide ideation and saying “no way” whenever he ask him about suicidal attempts. Patient was noticed to have poor insights.

Patient was under rapid neuroleptization. He was given Haloperidol 10-20 BID and Biperiden Hydrochloride PRN x EPS. Electroconvulsive Therapy x 3 doses given in a week.

Patient is admitted to Acute Crisis Intervention Service I with an admitting vital signs of Blood pressure: 100/70mmHg; pulse rate 0f 86 beats/min.; afebrile, with a body temperature of 37 degree celcius and respiratory rate of 20 cycles per minute. He was diagnosed having Bipolar Affective Disorder, manic with Psychotic Features, unstable.

History of Previous Illness:
This condition started four years ago prior to admission. Patient was apparently well as a student when in 1996, he joined an activity group and went to the mountain for 6 months. When he arrived home, his family noticed him having impaired sleep, talking and laughing to self. He sometimes changes his mood to crying and depressives episodes. He had also shouting episodes and he is very assaultive. He throws glasses and other fragile decorations at home.

His mother, Milagros, decided to bring him at the University of Santo Tomas Hospital. The patient undergoes a series of exams and observations by different doctors and was admitted for eight times in the hospital. But the condition is getting worse and the hospital referred the patient to National Center For Mental health located at Mandaluyong City.
(-) seizures
(-) heart problem
(-) asthma
(-) ECT

Past Personal History:
Patient only had bottle-feeding during infancy. He had immunization and was born with no complication. His father is strict in disciplining his family.
Patient was sent in School and reach in College. He is very active in his school activity.
Patient loves playing basketball with his friends. He also wants going out with his friend.
The patient did not identify bonding within the family.
He used to join with his friends using marijuana during high school life.
He met a girl at the restaurant who really love him and had committed on him.
That girl is Ria Q.-that was according to patient’s mother.
Patient is the eldest of the three siblings. His relatives’ premorbid to him was “tahimik na bata”.
Patient use to smoke, Marlboro red, 1 pack per day. Patient was not noted to be an alcohol drinker

Family History:
Patient had positive mental illness pattern within their generation. His father’s brother was diagnosed to be have schizophrenia and deceased already. His grandmother in father side was noted to have mentally disorder but there is no proper intervention given. It was tolerated at home but there’s consultation done and was advise to consult on mental institution but the relatives prefer not to bring her to mental hospital, since, her behavior is controllable and manageable but noted to have deep thoughts and talking to herself occasionally.