HEADQUARTERS

ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND

VICTORIANO LUNA MEDICAL CENTER

DEPARTMENT OF MENTAL HEALTH AND BEHAVIORAL SCIENCES

V Luna Avenue, Quezon City

NARRATIVE SUMMMARY
NAME BACO, TRUEMAN ALMAZAR RANK/BOS SGT/ PA
AGE/SEX/DOB 38/M/ 15 SEPTEMBER 1980 REG.NO. 195722
GENERALIZED ANXIETY
INITIAL DATE OF
DISORDER, IN REMISSION 04 June 2019
DIAGNOSIS ADMISSION
FOR REPROFILING
FINAL NO PSYCHOPATHOLOGY DATE OF
12 July 2019
DIAGNOSIS DURING TIME OF ADMISSION DISCHARGE

CHIEF COMPLAINT:
According to the patient: “For reprofiling po sir, para maayos po serbisyo ko”
According to medical tag: “Generalized Anxiety Disorder”.

HISTORY OF PRESENT ILLNESS:

Patient was previously admitted last 27 February 2018 - 07 December 2018 as a case of Generalized
Anxiety Disorder and was discharged EDRD with P3. He returned to unit and resumed intel duties occasionally given
night duties and was not able to wield a firearm. No recurrence of uncontrolled anxiety, sleep disturbance, difficulty
concentrating, irritability, being easily fatigue or muscle tension. No suicide or homicide ideations. No perceptual
disturbance or hallucinating behavior observed. Patient returned for reprofiling hence this admission.

MENTAL STATUS EXAMINATION UPON ADMISSION:

Patient seen and examined as an adult male, looks appropriate for 38 year old of age. Fairly kempt, medium
built, average height, cooperative, relatively fair with eye contact; no tic or mannerisms. Euthymic mood, congruent
affect. Spontaneous, normoproductive speech with moderate rate and volume of voice; no perceptual disturbance;
goal – oriented; “ok naman po ako, nakikita niyo naman at saka matitingnan naman ng mga kasama ko sa batalyon ”;
“sir baka pwede humingi ng pabor na magpalipat ng unit”; no suicide or homicidal ideation; no delusion noted;
oriented to 3 spheres; intact memory, fair abstract thinking, attention span; fair judgement; fair insight to current
condition.

PHYSICAL EXAMINATION UPON ADMISSION:

General Survery Conscious, coherent. Not in Cardiorespiratory distress.
Vital signs BP: 130/90 mmHg HR: 60 bpm RR: 20 cpm Temp: 36.5 C
Skin Skin is brown, warm to touch, moist with good skin turgor, with capillary refill time <2sec
HEENT Anicteric sclerae, pink palpebral conjunctivae, no nasoaural discharge, no
tonsillopharyngeal congestion, no cervical lymphadenopathy
Chest/Lung Symmetrical chest expansion, no retractions, no lagging, clear breath sounds
Heart Adynamic precordium, nor mal rate, regular rhythms, no murmurs
Abdomen Flabby abdomen, soft, normoactive bowel sounds, nontender, no masses
Extremities Grossly normal extremities, no edema, no pallor, full and equal pulses on both extremities
Neurological Cerebrum: Conscious, coherent, oriented to 3 spheres
Cranial Nerves:
I. Intact sense of smell
II. 3 mm pupils equally reactive to light
III, IV, VI. Intact EOM, follows movement of focus object
VII. no facial asymmetry, able to close eyelids, raise eyebrows, puff cheeks
VIII. Intact gross hearing
IX, X. (+) Gag reflex, able to swallow
XI. Able to shrug shoulders
XII. Tongue at midline upon protrusion
Motor: Good muscle tone, 5/5 in all extremities
Sensory: 100% on all extremities
Cerebellum: Normal gait and stance, no involuntary movements

AFP Core Values: Honor, Service, Patriotism

LABORATORY EXAMINATIONS:

HEMATOLOGY
CLINICAL CHEMISTRY
CBC RESULTS SERUM ELECTROLYTES
Cholesterol 5.14
Hemoglobin 166g/L Sodium 138.1
mmol/l
Hematocrit 0.46 Creatinine 102.03 mmol/L
RBC Count 5.81x10^12/L umol/l Potassium 3.85
WBC Count 8.50x10^9/L SGOT 25 U/L mmol/L
Chloride 100
DIFF SGPT 41.2 U/L
mmol/L
COUNT Glucose 4.93 Ionized 1.14
Segmenters 0.44 mmol/l Calcium mmol/L
Lymphocyte 0.43 HDL- 0.91 Ionized 0.41
s Cholesterol mmol/l Magnesium mmol/L
Eosinophils 0.07 LDL- 3.67
Monocytes 0.05 Cholesterol mmol/l
Basophils 0.01 Triglycerides 3.90
mmol/l
MCV 80 fL
BUN 4.83
MCH 29 pg mmol/l
MCHC 36 g/dL
RDW 12.31
Platelet Ct 222x10^9
Bloot Type AB+

URINALYSIS
MACROSCOPIC MICROSCOPIC
RESULTS N.V. RESULTS N.V.
COLOR YELLOW YELLOW RBC 0-1/ hpf 0-2/HPF
TRANSPARENCY SLIGHTLY SLIGHTLY PUS CELLS 0-2/ hpf 0-2/HPF
TURBID TURBID
REACTION 6.0 4.0 – 7.0 BACTERIA
SP GRAVITY 1.030 1.015 – 1.025 EPITHELIAL rare FEW
SUGAR NEGATIVE NEGATIVE CRYSTALS
PROTEIN NEGATIVE NEGATIVE MUCUS Many FEW
THREADS
AMORPHOUS Moderate FEW
URATES
AMORPHOUS FEW
PHOSPHATES
CASTS OTHERS
HYALINE MICRAL TEST
FINELY PREGNANCY
REGULAR TEST
COARSELY RBC
GRANULAR MORPHOLOGY
WAXY

HbSAg Non Reactive

RPR Non Reactive
UDA Negative

12L ECG: Sinus rhythm, Nonspecific ST-T wave changes; intraventricular conduction delay

Course in the Ward:

Patient was admitted to ACU on June 04, 2019. Consent for admission and management secured. Caffeine-
free diet. Vital signs were monitored q shift. Diagnostics done were CBC c PC, Blood Typing, UA, UDA, FBS, BUN,
CREA, SGOT, SGPT, NA, K, TL, TO, LDL, HDL, HbSAg, RPR/VLDL, CXR (PA), 12L ECG. Medications given were
Vitamin B complex 1 tab OD, and Ascorbic acid 500 mg tab 1 tab OD after negative UDA result. Patient was for ESH
precaution. Patient performed battery of psychological exam.
On the 7th hospital day, patient is still for close monitoring.
On the 16th hospital day, patient noted to have difficulty of sleep. Patient was given Diphenhydramine 50
mg/cap, 1 cap PRN if with difficulty of sleeping.

AFP Core Values: Honor, Service, Patriotism

 On the 18th hospital day, patient was transferred to open ward – ward A. Reprofiling done. Still for close
monitoring.
On the 19 hospital day, patient still with difficulty of sleeping. Patient was advised for sleep hygiene. Still for
close monitoring.
On the 22nd hospital day, patient has 6 hours of sleep and with good appetite. Still for close monitoring.
On the 29th hospital day, patient stated that he has occasional difficulty of sleeping and verbalized his
request for unit transfer.
On the 30th hospital day, patient still with difficulty of sleeping hence given with Quetiapine 25 mg/ tab, 1 tab.
On the 36th hospital day, patient advised for EDRD on 12th of July 2019.

MENTAL STATUS EXAMINATION ON DISCHARGE:

Patient was seen and examined as an adult male, looks appropriate for age, medium built, well kempt and
groomed, clad in blue hospital uniform; Cooperative, with good eye contact; No tics nor mannerisms noted;
Spontaneous normoproductive speech, with moderate tone and volume; Euthymic mood with congruent affect;
Thought process is coherent and goal-directed; No perceptual and auditory disturbances; No persecutory delusion;
No suicidal or homicidal ideation; Oriented to time, place and person. Has intact immediate, recent and remote
memory. Patient exhibits good impulse control; Has fair insight and judgment.

DISPOSITION: EDRD Effective 12 July 2019

Condition: Stable
Profile: P2

MAJ ROLLO/FUENTES/CHAN/CPT AGUILAR/GERONIMO/CPT AGNABO/ COMENDADOR/ CPT

PLUMA/ P2LT VILLAPANDO/P2LT LUMANOG/ CPT PORTE
Consultants/ Residents-in-charge

AFP Core Values: Honor, Service, Patriotism