PSYCHIATRIC HISTORY OF MENTAL ILLNESS

1. PSYCHIATRIC HISTORY OF MENTAL ILLNESS  Synthesized by: Katrina Kua

2. INFORMANTS • Wife, A.R., 25 y/o. • Wife’s homosexual friend and housemate, Angel • Patient • Date history was obtained: October 12, 2009

3. Chief Complaint • Patient: “I need to get admitted because I don’t want to hurt my wife anymore.” • Relatives: “Nagtatangka siyang magpakamatay 4 na beses na.”

4. Personality Profile • Pre-morbid: kind, sweet, quiet, cheerful • Morbid: nagwawala, nang-aaway

5. History of Present Illness Starting on the latter days of July upto present, Aiza and Angel noticed behaviour changes in Sophie. At first he will be extremely cranky when Aiza is out working. He also has exaggerated mood swings like when he was dancing happily at first then suddenly would answer that he speaks to himself because he is crazy. He would also turn off all the lights and electricity and stay in the dark.

6. History of Present Illness • There was also a time when he was being sweet to Aiza before she left to work and then would suddenly tell her not to come back home again. He also chased Aiza with a kitchen knife “let’s finished what i’ve done in America!” then when Angel saw him, he said, “okay, i’ll do it to myself, then.” And then would graze the knife on his belly. He would inflict superficial wounds using scissors and a knife on his arms, saying, “it feels good. You should try it.”

7. History of Present Illness • He would also stay up at night and just watch Aiza sleep, sometimes holding a knife. He would always throw fits when Aiza leaves for work and would calm down when he sees Angel saying, “i’ll come [calm] down if you give me your dress.” He would calm down but would later throw fits again and bash house furniture and wound his arms. He would also threaten that he would attempt suicide and would even fake overdosing his medications. He knows that what he’s doing is wrong. He’d always say sorry and even tell Aiza to take a vacation because she wouldn’t like his attitude during this season but would still repeat to throw fits again. Due to the events, Aiza consulted the VA and also to fix his pension papers that is when Sophie admitted to Aiza that he was previously diagnosed with manic-depressive disorder and PTSD. This last 2 weeks, patient was noticed to be more violent than usual.

8. ANAMNESIS (Past Personal History) - Remembrance of the past; accumulated data concerning a psychiatric patient and the patient’s background, including the family, previous environment, experiences, and particular recollections, for use in analyzing his condition. –

9. Birth and Early Development • On June 29, 1946, patient was born to Doris Mae Thompson and Willian Riggs via NSD at Warrensberg, Illinois. The pregnancy was wanted and expected. The delivery was essentially normal w/o any complications. R.R. was the 2nd child, the 1st son among the 4 siblings. The family lived averagely in the suburb of Illinois.

10. Childhood • Patient claims that since he was 3 y/o, he knew that he was a woman trapped in a guy’s body and would want to wear dresses. One time his father caught him wearing a dress and beat him up. His parents disapproved of him being gay and told him that they would disown him if he would continue to be like that. Since then, patient would try to be manly around people but would still try on dresses of his sisters when their parents are not around. He said that his sisters didn’t mind him wearing dresses and did not really care if he is gay. R.R. also did not like school very much, because he was being bullied there. One time patient was forced to eat a burger with a yucky concoction of dressing by the school bully.

11. Social, Sexual and Occupational History • In the young age of 17 he volunteered to serve his country in the Vietnam War as a marine. He said that he hated it there but would always volunteer because it was his way of releasing his long suppressed energy and also the benefits, the pension when he retires attracted him. So he served the marine corps for 7 years from 1965-1972. He was a front liner during the Vietnam War and went there 3 times, 13 months a time. His main work was to call out aircrafts and take care of dead bodies. He was a front liner in the war but was wounded twice, one from a blast injury from a grenade, another was a gunshot wound in his butt.

12. Social, Sexual and Occupational History • He said that he volunteered himself frequently because it was his way of channelling out his suppressed energy, because ever since he was 3 y/o, he wanted to be a girl and dresses like one but his parents would never allow him and would get mad. • He was much disciplined, stern, and focused and earned the title of a sergeant. His main job there was with equipments, calling aircrafts at the battlefield and taking care of the dead bodies. He was really strict and stern when handling his troupe. He even claims himself to be wicked and even got reprimanded for being too wicked.

13. Social, Sexual and Occupational History • On July 4th, patient commanded his men, Jerry, Bobby and Frank to place their equipments back in their tank because carrying their heavy equipment was bothersome and was interfering with their work. At the same time that the three were back in the tank, a grenade blasted their tank with the 3 men in it, and he couldn’t do anything. R.R. felt responsible for their death and says 3 men died because he turned soft-hearted. • He left the service on 1972 with a number of awards such as purple heart, presidential unit citation awarded 3rd marine division for service in Vietnam, Vietnam service medal, republic of Vietnam campaign medal, national defense service.

14. Social, Sexual and Occupational History • R.R. got out of service in 1972. He went back to the States and tried to look for his family, but he said that it was difficult to track them because his siblings had families of their own by that time and already lived in different places. He immediately wore women’s clothes when he got out of service, because it made him feel good and happy. Patient then lived on his own and got jobs at different hotdogs and burger joints. Living alone was tough for him because post-war, people would think badly about him when would find out that he was part of Vietnam War where he killed people and babies. • This made him feel very bad about himself. Since then, he did not like to be in a crowd. He did not want to work or interact with people and he could not deal with people standing behind his back. He wants to work alone, that is why he took a job as truck driver and lived in a trailer home where he could have good income and be alone.

15. Social, Sexual and Occupational History • Patient worked as a truck driver for 24 years from 1975-1999. He was living alone in a trailer and had a few “acquaintances” and “flings.” He was very avoidant of people and would easily get moody. Sometimes he would be in road rage while driving his truck.

16. Social, Sexual and Occupational History • On 1999, he got into an accident while driving his truck. He claims to have crushed his cervical bones and was paralyzed from neck down. He underwent an operation where they accessed his spine through his neck and instilled fluid in his spine to straighten them. While recuperating, he started to feel dormant and that’s when he started to have flashbacks and auditory hallucinations about the war. He would be okay for most of the time but would go “crazy” during the months of July, August, and September. He said that Frank, Bobby and Jerry would talk to him and tell him that it’s okay and their death is not his fault. Hallucinations still occur up till now. Sometimes, he also feels like he was back in the war, there was even a time when he was running around with butcher knife, and he was reliving his war experience. It was a good thing that police got hold of him and that he did not hurt anybody.

17. Social, Sexual and Occupational History • After the accident, R.R. lost his job and his trailer and started to live on the streets. He was jobless, homeless, and sickly for about a year. A Good Samaritan helped him get back on his feet and even processed his pension plans. He was pensioned around 3800 dollars per month since then. On 2000, he got back to his feet and rented a house in Michigan, got a car, and lived with his pension money. He gained a lot of friends and was popular with them especially when he receives his monthly pension funds.

18. Social, Sexual and Occupational History • In 2002-2003, patient started to live as a woman. He would go out dressed as a woman goes by the name of Allysa. Patient during this time had suicidal ideations and attempted suicide 3 times. He did this by drinking nortriptyline overdose with whiskey. He also tried to hang himself, and attempted to jump off a building.

19. Social, Sexual and Occupational History • On 2005, patient met Aiza through the internet in a chat room. He jokingly told her that he is gay but then denied it. They got close and he called her almost daily from then on. On that same year, Aiza became his girlfriend. They started having a long distance relationship through cyberspace. • Aiza openly told him that she has a son named Raniel, at that time, 4 years old. He was glad about that, and told her that he was happy to support her and her son. He gave her monthly support and gifts for Raniel. He told her that he wants to marry her and would be happy to adopt Raniel, since he couldn’t have a family in the States. During this time, patient was in and out of the hospital frequently because of his ailments. He had a heart attack thrice. He was admitted several times due to his poorly controlled diabetes.

20. Social, Sexual and Occupational History • On 2008, patient decided to live in the Philippines because he did not like to live in the US anymore. He had no family, and could not live the life he wants without being judged by the people. He started using hormonal drugs such as Provera and testosterone blockers and was planning to have sex transplant; however, his co-morbiditites would not allow him. • He planned to go to the Philippines, but then he got sick again (was confined due to hyperosmoticnonketotic coma. Lost consciousness while driving so his license was taken after). Patient told Aiza that he wants to have a female name when he goes to the Philippines, so she named him Sophie. During that time, she was already suspicious that he may really be gay.

21. Social, Sexual and Occupational History • On January 2009, patient asked for a doctor’s advice for hormone use and sex transplant but was already using much drugs for about two years. He at that time was living as a woman and goes by the name of Allysa for 7 years already and he was allowed to use hormones.

22. Marriage

23. On June 2009, Sophie went to the Philippines and surprised Aiza and told her to fetch him at the airport because he will be living with her and her son from then on. Sophie met Aiza personally for the first time and showed up at the airport wearing men’s polo and slacks and high heels. On June 24, 2009, they had a civil wedding. They were living happily together with Raniel, Aiza’s 10 y/o son, Angel, their transvestite friend, and they hired Ara, a gay caregiver for him.

24. He continues to wear female clothes when they go out. Aiza and R.R. live happily and truly love each other even if their relationship in unconventional. They both admit that they married more because of companionship than intimacy.

25. Family History R.R. grew up not close to his family, particulary his father. When he got out of the service, he tried to contact his family but did not maintain regular communication with them and lived alone by himself since then.

26. Family History • William Riggs • Father of patient. Patient disliked his father because when he was young, his father caught him wearing a dress and beat him up. • Doris Mae Thompson Riggs • Mother of patient; died because of heart ailment. Patient not close to her because she did not approve of him being gay [transvestite].

27. Sherry Riggs • Older sisister of patient. Patient said that she did not mind him wearing dresses. When he got out of the service, he tried to contact her but she already had her own family and lived in a different place. Patient keeps her number and communicates with her seldom.

28. Bill Riggs • Younger brother of patient. Patient was not close to him. Patient said that his brother died because he was an alcoholic and an addict. • Sandy Riggs • Younger sister of patient. Like Sandy, she did not mind him wearing dresses, even lends him hers if he asks. When he got out of the service, he tried to contact her but she already had her own family and lived in a different place.

29. Mental Status Exam Upon Admission (September 22, 2009)

30. Mental Status Exam • Patient is fairly kempt, wearing purple polo shirt, and black doll shoes. • He is euthymic with appropriate affect. • He spontaneously answers to cues of interviewer with normal speed and rate. • He is friendly, participative and conversant. • Patient’s thought is relevant with clear cause and effect ideations. • Patient expresses his transvestite lifestyle, his suicidal ideations and his auditory hallucinations. • Remote, recent and short-term memory intact. • He is conscious, alert, and oriented as to time place and person. • He has good judgment and insight.

31. Current Social Situation The client is unemployed and residing in his wife’s house at 717 Corcuerra St. Tondo, Manila together with his Filipino wife of 3 months named Aiza, 25 y/o, her son Raniel, 10 y/o, their friend Angel, and his caregiver “Ara.” The patient openly admits that he is a transvestite and prefers to be called Sophie.

32. Current Social Situation • His wife sings at a club, and works with her friend Angel. She usually goes to work late in the afternoon to the evening. He is always the one left at home to play with Raniel. His marital relationship started having problems in July, when the client was acting up with manic, aggressive and suicidal behaviour. It was in this time that his sexual ideations and fantasies of being a girl surfaced to a maximum extent.

33. MEDICAL HISTORY OF PRESENT ILLNESS Synthesized by: Katrina Kua

34. Informant: wife, A.R., 25 y/o. • Wife’s homosexual friend and housemate, Angel • Date history was obtained: • September 22, 2009 • Chief Complaint: • multiple trauma secondary to mauling

35. General Data • Patient is Ronald Thompsom Riggs, a 63 y/o male, right handed, Caucasian, who is a veteran war sergeant currently residing at 717 Corcuerra St. Tondo, Manila together with his Filipino wife of 3 months named AIza, 25 y/o, their friend Angel, and his caregiver “Ara.” The patient openly admits that he is a transvestite and prefers to be called Sophie. Born on 6/29/1946 to Doris Mae Thompsom and William Riggs at Warrensberg, Illinois. He is the second child in a family of 6, with one older sister, a younger brother and a younger sister.

36. History of Present Illness • Known case PTSD and manic- depressive (bipolar 1) disorder and anxiety disorder • Had suicidal ideations and was previously admitted in the US • Irritable, violent and with suicidal ideations during July-September; normal on different months • Allegedly attacked helper and latter fought back and hit the patient with a plastic chair • Patient suffered multiple lacerations

37. Narrative • Two weeks prior to admission, patient was noticed be more violent than usual. Starting on the latter days of July upto present, Aiza and Angel noticed behaviour changes in Sophie. At first he will be extremely cranky when Aiza is out working. He also has exaggerated mood swings like when he was dancing happily at first then suddenly would answer that he speaks to himself because he is crazy. He would also turn off all the lights and electricity and stay in the dark.

38. Narrative • There was also a time when he was being sweet to Aiza before she left to work and then would suddenly tell her not to come back home again. He also chased Aiza with a kitchen knife “let’s finished what i’ve done in America!” then when Angel saw him, he said, “okay, i’ll do it to myself, then.” And then would graze the knife on his belly. He would inflict superficial wounds using scissors and a knife on his arms, saying, “It feels good. You should try it.”

39. Narrative • He would also stay up at night and just watch Aiza sleep, sometimes holding a knife. He would always throw fits when Aiza leaves for work and would calm down when he sees Angel saying, “I’ll calm down if you give me your dress.” He would calm down but would later throw fits again, bash house furniture and wound his arms. He would also threaten that he would attempt suicide and would even fake overdosing his medications.

40. Narrative • He knows that what he’s doing is wrong. He’d always say sorry and even tell Aiza to take a vacation because she wouldn’t like his attitude during this season but would still repeat to throw fits again. Due to the events and also to fix his pension papers, Aiza consulted the VA. This was the time when Sophie admitted to Aiza that he was previously diagnosed with manic-depressive disorder and Post Traumatic Stress Disorder (PTSD).

41. Past Medical History • HPN since 2000 • DM type 2 since 2002 • STROKE 1998 • Myocardial Infarction (3 times, from 2005-2006) • TRUCK ACCIDENT 1999

42. Family Medical History • Mother – hypertensive • Brother – alcoholism and illicit drug use

43. Personal and Social History • 200 pack year history, started at 15 y/o – 2001 • Occasional “dope” user 1975-1999 • Occasional alcohol drinker • Retired US Marine Corps Veteran; currently Unemployed • Never had a wife in the US, Filipino wife of 3 months is his first wife

44. Review of Systems: • Decreased hearing on both ears • With prosthesis and full dentures on both upper and lower teeth (never wore them in nurse-patient interactions)

45. Physical Examination Upon Admission • Vital signs as follows: 120/62 mmHg, 80 bpm, 19 bpm • Pink palpebral conjunctiva, anicteric sclera • Warm moist skin • With multiple lacerations on both arms • With multiple long and superficial slash marks in inner aspect of forearms

46. Neurologic Examination • conscious, coherent, oriented to time, place and person • spontaneous eye opening • follows commands • spontaneously answers when asked • can read and write • intact remote and recent memory

47. Clinical Impression • multiple physical injuries (superficial abrasions and lacerations) secondary to blunt physical trauma and self-inflicted wounds • referral to dermatology, endocrine, orthopaedic, and rehabilitation medicine for co-morbidities

48. NURSING HISTORY Katrina Kashmyr B. Kua, SN/UST

49. Personal Data • Interview Done and History Prepared by: Katrina Kashmyr B. Kua • Date Written: October 18, 2009 • Initials of Patient: R. T. R. “R.R.” • Diagnosis to Consider: Axis I: to consider Bipolar 1 Mood Disorder • Information Obtained from: Patient • Dates: October 5-6, 12-13, 2009

50. Personal Data • Hospital Number: 05-46-20 • Date of Admission: September 22, 2009 • Address: 717 Cercuerra Street, Tondo, Manila • Birthday: June 29, 1946 • Place of Birth: Detroit, Illinois • Age: 63 • Sex: Male • Civil Status: Married • Occupation: Retired US Marine Corps Veteran; currently Unemployed • Educational Attainment: First Year High School; took up a vocational course in fashion design in Michigan for two years • Religion: Roman Catholic • Race: Caucasian • Nationality: American