History of Present Illness
Bernardo, Claire L. BSCP 4-1
I. Identifying Data The subject’s subject’s name is Johna Paula B. Landeros, a 19-year 19 -year old female, who was born as a Roman th Catholic. She is single and she’s a 4 year student taking up BS in Clinical Psychology. She resides at 149 Masipag Street, brgy. Tanza, Navotas city. When she needs help in case of emergency, the first person who is usually notified is her mother, Aurora B. Landeros. The subject was brought here on Friday, June 27, 2014, 5:20 in the afternoon. The subject was calm and was in good spirit when she first came here. She didn’t refuse when told that she is going to be interviewed. She looked comfortable and fine. II. Chief Complaints According to the subject:
“Nahihirapan ako makipagkaibigan sa iba. Natatakot ako ako ma judge agad”
According to the mother:
“Nai-intimidate “Nai-intimidate sa kanya yung mga tao kasi tahimik, parang mahirap i-approach” i-approach”
According to her high school friend:
“Ang hirap niya ipakilala sa ibang tao kasi laging nahihiya”
III. History of Present Illness To determine the etiology of the subject’s problem, obtaining an accurate history should be the first step. The history of the subject’s present illness will create a basis for the diagnosis made. This includes relevant information and greater understanding of the subject and her illness. 12 years prior to consultation, the subject started to go to school and every time she does, she would not want to let go of her mother especially that her mother was pregnant with her younger sister that time. She wants her mother to stay with her at the school until the class ends. 11 years prior to consultation, the subject tried to go out of the house and play with their neighbor’s children. But she was beaten by her father when he saw her trying to go out. After that incident, she was rarely seen going g oing out of the house to play wit h the other kids. 10 years prior to consultation, the subject went to Bulacan for a vacation at her aunt’s house and she was not accompanied by her mother that time. When she was there, her aunt would always check everything she does if she was doing them all right. She gets reprimanded right away when she does wrong things. Every night before she goes to sleep, she cries because she would always thought that without her mother, everything that she does is always wrong. The subject would always think, “ kapag wala si mama, feeling ko wala kong nagagawang tama.” tama.” 9 years prior to consultation, the subject was in the fourth grade during this time. And she was fat back then. She said that she started being conscious about it because she was being laughed at by her classmates about her weight.
8 years prior to consultation, the subject has always been studious since she started schooling. th st And when she reached 5 grade, she ranked 1 in her class. The teachers were always comparing her to her other classmates and she thinks that she doesn’t deserve to be the top of her class. She said, “Kasi di naman ako madalas magrecite kasi nahihiya ako, kaya baka di ko naman deserve maging top 1” 7 years prior to consultation, the subject would always make friends but most of the time, she chooses the wrong kind of friends and she would always end up being left out within their group. She can’t relate to them. That was when she started to have a hard time making friends; she feels that there was something wrong with her. The subject said, “Kaya di akko magaling makipagfriends na rin pagdating nung high school ako. Sobrang bilang lang sila”. 6 years prior to consultation, since the subject was doing great at school, she was transferred to st the star section from 1 year to 4 year high school. But the subject did not adjust very well to her surroundings. She felt that everyone was very competitive and smart. She felt inferior to them. She said, “feeling ko di ako makakasurvive don”. 5 years prior to consultation, the subject was in third year high school, and they were encouraged to join extracurricular activities like dancing and acting, but the subject would always refuse to join because she thinks that her classmates were all better than her. She said, “unless grades na talaga ang nakasalalay, sumasali ako”. 4 years prior to consultation, the subject told that her school was always the top choice when there are competitions in research. Despite of her having ideas, she sometimes don’t share it with others because she sees her classmates as smart and that their topics have the greater chance to be approved than her. 3 years prior to consultation, the subject has entered another phase of her life, she now is in the college level, new people, new environment, and a lot of adjustments to do again. Since the subject has a hard time approaching people, she was a hard time making friends again. Like for instance, in the organization where she joined, she was having second thoughts in revealing her true self to people she do not really know. 2 years prior to consultation, the subject was not just finding it hard to make friends with her classmates but also with the classmates of her friends in college. The subject always feels like they are rich, and she might be judged based on her status and they might think she was feeling close to them. “Yung mga rich kids, baka kasi judgmental sila tas isipin feeling close ako”. 1 year prior to consultation, the subject was invited by her friend’s debut. And her friend was asking her to join the intermission subject, where she initially agreed on. But when told that she will be with her friend’s other college friends, she backed out, reasoning the she was shy to have an intermission number with people she’s not close with. 11 months prior to consultation, two of the subject’s friends became family heads in the org she joined it. She was repeatedly invited to events. Even though her friends will be in the activities, she still avoids having interpersonal contacts with people. She said, “baka malef -out lang naman ako. Lagi kasing ganon. Di ko alam kung mukha ba akong mahirap i-approach”.
10 months prior to consultation, the subject has always been preoccupied with being rejected, crticitized or judged by people. There this time when she wants somebody to come with her to buy a gift for her mother but she was shy to ask, she said, “baka di lang naman sila sumama, e di nangyari, ako na lang tuloy mag isa bumili”. rd
9 months prior to consultation, the subject was now in 3 year college, and they have research as part of their curriculum. Since thesis making requires having random people take the questionnaires, the subject took a long time before she was able to be have the questionnaires answered. “Nahiya ako magtanong sa kanila kasi nga random, so they can either agree or disagree to take the exam”. 8 months prior to consultation, the subject attended a birthday of her schoolmate. The celebrants have more guests from college and the subject noticed that it seems she was only talking to them. She felt left out again because she doesn’t know how to introduce a topic to them. 6 months prior to consultation, the subject and her cousins bonded over a jamming session. She feels inadequate seeing her cousins playing guitar, drums and piano, while she on the other hand, does not know how to play any musical instruments. 5 months prior to consultation, the subject was given a flier to join their college newspaper, but with all the screening and interview needed to be passed, the subject did not continue to apply for it. She said, “gusto ko talaga magapply as writer, kaso baka di ako matanggap kasi di ako magaling magsalita pagdating sa mga interview”. 4 months prior to consultation, it can be observed that the subject always feels inadequate and inferior of others. For instance, when she was told by her cousin to try out for badminton, she rejected because she feels they already know the game better than her and she said “larong kalye lang kasi alam ko e baka di ako makapasok so di ako sumali”. 3 months prior to consultation, the subject met their neighbor who was a psych graduate, there were so much talking going on about their course, and at one point the subject just had to stop and hold back because she was preoccupied in the thinking that what her saying might be already wrong and her neighbor might be scrutinizing everything she say in her mind. 2 months prior to consultation, the subject and her cousins went trailbiking in Bulacan. She was reluctant at first because she doesn’t know who will be joining them. The subject said “ang galling nila. Kahit bako bako yung daan or mataas or mababa, tas ako di makasabay”. Then after a week the team invited them again and she pretended that she was not well. The subject does not want to get embarrass again. 1 month prior to consultation, the subject was embarrassed during her aunt’s birthday, when she and her sister compete in a singing challenge. Her sister was good and the competition between them ended up with them making fun at her. “tumatawa rin ako pero deep inside, sobrang nakakahiya” 1 week prior to consultation, there was a new neighbor where the subject resides who has the same age as hers. Her mother would always talk to him and she wants her to meet the neighbor and to make friends with him. But since the subject has interpersonal issues, she was nervous at the thought of talking to him, she barely knows him and she doesn’t know how to start a conversation and break the awkward feelings toward each other.
IV. Personal History A. Pre-Natal Data The subject was born when her mother was 26 years of age. She was their first born. During the pregnancy, the mother experiences spasms at times and massage was her remedy. The mother also experiences frequent headaches and her doctor advises her to only take a rest and medications. There was no infectious or non-infectious disease the mother had when she was pregnant. The mother has O blood type and there were no allergic reactions on the part of the mother. The nutrition of their family was okay during that time; the doctor prescribed the mother to have a healthy diet, mo nthly check up, and to take vitamins. There were neither drugs nor alcohol intake from the mother when she was pregnant with the subject. There were some emotional factors that the mother had which might have an effect to the subject, her mother has always been shy towards her in-laws. “Pag wala si papa, feeling daw ni mama wala siyang kakampi, tas di raw siya kumakain”. B. First Year of Life and Infant Feeding The subject had a painless, normal birth but the mother had a difficulty protruding the subject because she was big during that time. She was delivered in a clinic, by a midwife, Florencia Calapano. The subject was breast-fed by the mother until she has reached one month old. The mother said that the sucking process was satisfactory. And after a month from birth, the subject started to be bottle-fed under her mother’s supervision. Her mother has no job, and her whole time was devoted to the subject. She was always being carried by her parents. Also, the subject’s mother carries her when she was being fed. There were no times when the subject refused to suck or fed. The subject was not abandoned by the mother during the time of feeding. The subject’s parents were always the one who take care of her. They were being patient and watchful to the subject. The subject vomits at times but the doctor said that it was common for babies so the mother did not take any medications. There was no any circumstance when the subject became irritable after feeding. The subject was also given food regularly by the mother; she was not busy to neglect the feeding hours of the subject. The subject weaned after she was a month old because her mother does not have enough milk. The subject did not refuse to eat after she was being introduced to formula milk. Her mother did not even give her an artificial rubber nipple to adjust. The subject was not considered to be an abandoned infant since her mother has no job and was full time in taking care of her. The subject used to have diarrhea during this year of her life when her teeth was starting to erupt. There was also no thumb sucking, lips biting or nails biting made by th e subject during this time.
As a child, the subject’s mother noticed at 3 to 4 months that she was able to fix her eyes towards the person around and look or follow them by the eyes. She also started to be sensitive and respond to sound, voice or approach of anybody. She started playing with an object at 6 months but learn to grasp them by fingers at 5 months. She began rolling at 4 months, began sitting at 8 months, began standing without help at 9 months, began walking at 10 months, and began running, climbing and jumping when she was 11-14 months. The subject also had her first eruption of teeth at 7 months old. She also utters her first word, “papa” at 8 months. She started saying phrases and sentences when she was 1 to 2 years of age. The subject started singing at 4 years old. At 3 years old, the subject was exposed with other children to play. At 4 to 5 months old, the subject started to babble. And she was able to utter simple words like papa and mama when she was about 11 to 12 months old, though she was still having speech defect (bulol). C. Two to Three Years of Life During the second year of the subject’s life, the subject was intentionally bowel and urinates anywhere but she would always tell her parents first. She never wore a diaper; she would always ask her parents if she can go to the comfort room to urinate or bowel. The subject did not find pleasure in playing with her feces or urine. The parents were not strict in toilettraining the subject. When she does it the wrong way, she was being reprimanded in a gently manner and she gets it right away. The subject was neither stubborn nor resistive in complying with the rules of toilet training. She experiences diarrhea every time a tooth would erupt. The subject, during this stage have revealed outburst of temperament, her mother said, “pag hindi nakukuha yung gusto; hindi din matiis, binibigay din”. The subject was stubborn during this year of life; she doesn’t want anyone except her mother to take care of her, and instead of crying alone, her mother would allow her to go anywhere she goes. Though stubborn, the subject was not a destructive kind of child. She was just importunate, just like any kind of child who has the same age as hers. When there are times the subject was really beyond just being importunate, she was verbally disciplined by her parents. She was not punished physically. During this stage, the subject’s speech has been greatly improved. She can already speak straight sentences and phrases. She was even reading newspapers as what her mother said.