Out-Patient Department Case

1. Out-Patient Department Case Block 5A

2. The Case of EDG History

3. General Data • E.D.G • 56 year old, Female • Married • Roman Catholic • Resident of Valenzuela City

4. Chief Complaint “Nalulungkot at Nalilito”

5. History of Present Illness EGD, a known hypertensive with good activities of daily living, is apparently well until…

6. History of Present Illness • 4 years PTC • EDG discovered her diabetic husband’s infidelity, felt depressed and angry towards her husband. • Forced her husband to leave their house and filed a legal separation but still cries every night and minimal effect on her job. • Felt guilty when she found out that her husband had stroke. • She feels that if she had forgiven her husband, it would not have happened.

7. History of Present Illness • 3 years PTC • She welcomed her husband due to his medical condition and appease her feeling of guilt. • She devoted her time taking care of her husband. • She continued to feel bouts of depression associated with easy fatigability but (-) insomia, poor concentration, anorexia. • EDG had consultations and rehabilitations in PGH due to LBP and myofascial pain syndrome

8. History of Present Illness • 3 years PTC • Husband had changes in attitude and behavior secondary to s/p stroke leading to family conflicts. • Eldest son run away due to frequent heated arguments with father and oftentimes against EDG. • Daughter, 2nd Child, eloped due to feeling of neglect and eventually got pregnant. • Youngest son, had difficulty in studies and run away from home for about a week. • EDG felt so depressed and tried to win back her children, but only the eldest and youngest went back.

9. History of Present Illness • 2 years PTC • Her husband died of second episode of stroke. • She partly blame her eldest son’s strict and often inconsiderate adherence to husband’s management. • Eldest son decided to finally live independently. • EDG’s depressive bouts now associated with difficulty in initiating sleep, depressed most of the day and had frequent crying spells whenever alone, but with no suicidal ideation.

10. History of Present Illness • 2 years PTC • To meet their financial needs, EDG worked as project head to sales in a realty. • At work, she is aloof most of the time and increased irritability whenever mistakes are committed. • There was an episode that she confronted her workmates due to heard rumors about her but eventually settled their conflicts.

11. History of Present Illness • 1 year PTC • Due to her depressive bouts and follow-up on her medical condition • She changed residency as per advised by her M.D. but with minimal improvement on her depression. • She now lives with youngest son, college student. • She is alone most of the time and feels that no one is there to listen to her problems and even accomplishments at work.

12. History of Present Illness • 1 year PTC • She also is anxious in sharing her current state even o her closest friends. • Her only coping mechanism is to keep herself busy at work and at home. • She also finds joy in seeing her grand son once in awhile. • She never had a good conversation with her eldest son.

13. Review of Systems • (-) weight and appetite changes, fever • No GI, GU, hematologic, endocrinologic, dermatologic and OB-Gyne complaints. • (+) eye itchiness/stinging, occasional dyspnea, chest pain, cervical spine pain, low back pain, occasional difficulty in concentrating, headache, and nausea, generalized weakness and easy fatigability.

14. Past Medical Illness • Hypertension Stage II, controlled • Maintained on Losartan 50mg, 1 tab OD • MPS, bilateral trapezius, rhomboids, paraspinal, and paralumbar • Maintained on Eperisone 50g, 1 tab OD, discontinued • Dry Ice Syndrome & Uveitis, resolved • Nodular Non-toxic Goiter s/p partial thyroidectomy • Myoma uteri, s/p THBSO • s/p appendectomy • Dyslipidemia • Maintained of 40 mg simvastatin

15. Family Medical History

16. Obstetric and Gynecologic History • Menarche at 11 y/o, RMI • Menopause at 45 y/o (surgical, THBSO) • G4P4 (4003) • All children delivered via NSVD, no feto-maternal complications • 4th child died at 21 days after delivery, cause of death unknown, EDG did not recall any inappropriate mood and behavior changes

17. Psychiatric Symptoms • No previous perceptual disturbance such as hallucinations and delusions • Manic episode: irritability but appropriate to circumstance, • (-) physical restlessness, increased talkativeness, foolhardy/reckless behavior, distractibility • Anxiety • (-) discrete episode of intense fear or discomfort, autonomic arousal symptoms • No suicidal behavior, mental reatrdation. Substance abuse

18. Psychiatric History • Previous consultations • 2009 to a Psychiatrist an psychologist immediately after death of husband due to depressive bouts • No consult to guidance counselors, religious leaders and fold healers because of her feeling of pride. • Interventions • Psychotherapy, 2008, had 1 session conducted by FMC residents due to husband’s stroke and rebelliousness of children.

19. Personal & Social History • Family Information • Parents are legally married. • Father has children outside marriage. • Patient currently lives with youngest child, John Carl, in a rented house.

20. Personal & Social History • Family Dynamics • Eldest child, Jose • Started supporting the patient financially since he started working. • Offered some emotional support by calling but has kept his distance. • Middle child, Jobelle-lain • Malambing but strong-headed. • Offered only some emotional support. • No financial support. • Youngest, John Carl • Still studying. • Patient’s caretaker.

21. Personal & Social History • Family Dynamics • Grandson, Cyrus • Source of joy for the patient. • Father, Jose • Lives with sons and daughters. • No financial and emotional support. • Siblings • Patient supports siblings financially. • No emotional support because of distance.

22. Personal & Social History • Community Information • Patient gets support from: • Local government • Meds • Health care professionals

23. Personal & Social History • Nonsmoker, non-alcoholic beverage drinker • No use of illicit drugs • Caffeine Intake • Previously 4 cups per day but curren;ty limit herself to 1 cup of decaffeinated coffee • History of “Mogadonroche” intake, once in college to stay awake to study

24. Anamnesis • Adolescence and Early Adulthood • Avoided relationships with the opposite sex. • Focused on studies. • Had difficulty finding the best course. • Father wanted Political Science. • Secretly took Nursing. • Was discovered. Father scolded her and threatened to stop financial support. • Decided to leave home. • Returned only when mother died; she continued studying.

25. Anamnesis • Adolescence and Early Adulthood • Discovered father’s infidelity but did not feel any strong emotion about it. • First worked as a government employee (admin assistant) at 17 years of age.

26. Anamnesis • Adulthood • Met soon-to-be husband in a conference in Pangasinan. • Wed in a Born-again church. Also had a civil marriage. • Had first son after 8 years. Daughter and son followed after every 2 years.

27. Anamnesis • Family Life • Early years: well-off and sufficiently provided for by husband who worked abroad. • Financial strain when husband forced to return home (DM, nephropathy). • Husband’s attitude and behavior changed. • More irritable, angry, violent/aggressive, alcohol-dependent.

28. Anamnesis • Infancy and Childhood • Born to a 24-year-old G2P1 (1001), SVD. • Breastfed up to 2 months. • Developmental milestones at par with age. • Playful and friendly, especially with boys. • Tomboyish at times. • Preferred boy’s games. • Excelled in academics due to strict upbringing. • Frequent transfer of residences and schools. • Because of father’s nature of work. • Easily adapts to changes.

29. The Case of EDG Physical Examination

30. The Case of EDG Primary ImpressioN

31. The Case of EDG Differential DIAGNOSES

32. The Case of EDG MULTi-AXIAL DIAGNOSIS

33. The Case of EDG Management