Patient History Quiz on Psychiatric Cases

Patient History

• Patient Name: Sherdina Antoine
• Age: 29
• Sex: Female
• Marital Status: Single
• Occupation: HR Manager at Jolly's Pharmacy Ltd.
• Income: $75,000 annually
• Address: St. Aroment, Roseau, Dominica
• Date of Admission: September 25, 2023
• Hospital Number: 71532
• Psychiatric Ward: DCFH APU
• Informant: Patient is of age.

Chief Complaint

• Patient reports piercing headache and constant shivers, along with "hearing things."

History of Present Illness

• Duration: 2 weeks
• Mode of Onset: Abrupt
• Course: Fluctuating
• Precipitating Factors: Stress from work, repeatedly slamming head on objects to stop "voices."
• Aggravating Factors: Repeatedly slamming head on objects, leading to physical wounds.
• Relieving Factors: Pain medication and sleeping pills.
• Other Symptoms: Impaired sleep schedule, due to nightmares, loss of appetite.
• Recent Head Injury: Sustained due to repeatedly slamming head on work desk.

Symptoms of Illness

• Auditory hallucinations
• Frenzied movement
• Nail biting
• Episodic headaches
• Symptoms noted by colleagues 2 weeks prior.

Treatment

• Patient started taking Ibuprofen and antibiotics 2 weeks prior, but hasn't taken any medication recently.

Past Surgical/Medical Illness

• Sustained head injury.
• Medication: Naproxen.

Past Psychiatric History

• No prior hospitalizations for mental disorders.
• First time clinical psychiatric case.

Family History

• Orphaned: Patient is currently orphaned. Parental figure passed away in the past year.
• No hereditary illnesses: No known hereditary illnesses in family.
• Substance abuse: Patient admits to occupational stress causing alcohol and illegal drug abuse (cocaine & ecstasy).

Personal History

• Perinatal history: Nil
• Childhood history: Raised by mother, artificial feeding, age 1 at weaning, normal development, no behavioural or emotional problems (age 1 year 6 months able to toilet independently).
• Educational history: Started formal education at 2 years old, finished at a mature age (23 years). Holds an Associate's and Bachelor's Degree in Management with first-class honors. Professional relationship with teachers, no grand relationship with peers, no school phobia, perfect attendance, no learning disabilities. Employed, pursuing Master's degree. Attended primary, secondary school and tertiary at Dominica State College and Midwestern State University.
• Played with classmates: Rarely played unless compulsory.
• Emotional problems: Nil during adolescence
• Puberty: 13 years of age. No anxiety related to puberty changes.
• **Menarche:**12 years old
• Cycle: Normal cycle and normal flow
• Obstetrical history: Nil
• Occupation: Assistant HR to HR manager. Stated job as appropriate to qualifications and interests.
• Current Job Satisfaction: The job involved maintaining good working relationships for a period of time, before becoming strained.

Current Social Situation

• Lives alone: With no other home circumstances noted.
• Household income: EC $6250.00
• Financial stability: Patient poses no financial instability.
• Cultural and religious activities: Patient lacks the energy for cultural and religious events. No social support system.
• Church service attendance: Approximate yearly church service attendance is 12 times per year.
• Relationship with parents: Stated relationship is strained.

Personal Relationships

• Stated introverted personality impacting interpersonal relationships with friends and colleagues; strained.

Use of Leisure Time

• Enjoys reading, kayaking, poetry, especially slam poetry events.

Predominant Mood

• Optimistic but prone to anxiety.
• Patient's reaction to stressful life events is introverted and non-sharing with others.

Attitude to Self and Others

• Fluctuating self-confidence level.
• High self-criticism and self-consciousness.
• Thoughtful of others but has low self-appraisal of abilities.
• Helpful personality.

Attitude to Work and Responsibilities

• Good decision-making, responsible, tries to be flexible
• Catholic-Christian faith.
• Spaces out/loses focus at times.

Habits

• Irregular eating and sleep patterns

Frequent use of Drugs

• Frequent use of drugs worsens during withdrawals.

Diagnosis

• Drug-induced Schizophrenia (probable)

Medications

• Benzodiazepines and antipsychotics prescribed.

Referring Physician

• Dr. Dolapo Oladapo