Out-Patient Department Case

Out-Patient Department Case

Block 5A

HISTORYThe Case of EDG

General Data

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

Chief Complaint

“Nalulungkot at Nalilito”

History of Present Illness

EGD, a known hypertensive with good activities of daily living, is apparently well

until…


• 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.


• 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


• 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.


• 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.


• 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.


• 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.


• 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.

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.

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

Family Medical History

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

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

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.

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.


• 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.


• 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.


• Community Information– Patient gets support from:• Local government

– Meds• Health care professionals


• 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 “Mogadon roche” intake, once in

college to stay awake to study

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.

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.

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.

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.

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.

PHYSICAL EXAMINATIONThe Case of EDG

PRIMARY IMPRESSIONThe Case of EDG

DIFFERENTIAL DIAGNOSESThe Case of EDG

MULTI-AXIAL DIAGNOSISThe Case of EDG

MANAGEMENTThe Case of EDG

Documents

Out-Patient Department Case