SOURCE AND RELIABILITY Patient: 90% CHIEF COMPLAINT Patient: "I feel extremely sad and anxious." HISTORY OF PRESENT ILLNESS Two years prior to consultation, while in her third year of nursing school, the patient, who had no previous psychiatric consultation or diagnosed psychiatric illness, gradually developed depressive symptoms characterized by persistent sadness, anhedonia, low energy, poor concentration, and excessive daytime sleepiness despite sleeping approximately 16 hours per day. She frequently fell asleep during classes, had difficulty sustaining attention, and occasionally left school without informing anyone. Her friends observed episodes during which she would stare blankly for prolonged periods, reportedly lasting up to four hours, after which she would abruptly leave school and return home. She gradually became socially withdrawn, stopped participating in study sessions with friends, skipped classes, developed poor appetite, and lost motivation to perform routine household chores. During the same period, she failed her first nursing examination, causing significant emotional distress, as she had previously been a high-achieving student academically. She also experienced interpersonal conflicts that resulted in the loss of several friendships, further worsening her depressive symptoms. A friend studying psychiatry advised her to seek psychiatric consultation; however, she did not pursue evaluation. She denied hallucinations, delusions, or other psychotic symptoms during this period. One year prior to consultation, her depressive symptoms persisted without significant improvement. She began experiencing intrusive internal urges repeatedly telling her to “do something,” although the commands were vague and not directed toward any specific act. She also developed recurrent suicidal ideation. On one occasion, she asked her friends to accompany her to the beach because she intended to allow herself to drift into the sea. Her friends recognized her suicidal intent, closely monitored her, and prevented any suicide attempt. During this period, she created a private social media account where she regularly documented her emotions and daily experiences as a coping mechanism. Despite the persistence of her symptoms, she still did not seek psychiatric consultation. Six months prior to consultation, her symptoms progressively worsened. She continued to experience persistent sadness accompanied by feelings of emptiness and worthlessness, poor appetite, and severe insomnia, sleeping only two to three hours each night. She developed recurrent thoughts of strangling herself and engaged in non-suicidal self-injurious behavior by making superficial cuts on both wrists with a blade without the intention of ending her life. Her friends noticed the injuries and provided emotional support, which temporarily helped her cope. She identified increasing academic demands and fear of failing nursing school as the primary stressors contributing to the worsening of her symptoms. One week prior to consultation, her condition further deteriorated. She described feeling “extremely sad” and emotionally overwhelmed, with worsening insomnia, often not falling asleep until around 4:00 AM. She developed command auditory hallucinations consisting of indistinct voices repeatedly instructing her to cut or wound herself. She also experienced recurrent thoughts of worthlessness, persistent urges to cut herself, recurrent thoughts of strangling herself, loss of motivation to attend school, emotional outbursts, irritability, and episodes of aggression. Her friends likewise observed prolonged episodes of blank staring and marked behavioral changes. On the day of consultation, because of persistent depressive symptoms accompanied by urges to engage in self-harm, severe insomnia, and the recent onset of auditory hallucinations, she sought psychiatric consultation for the first time at our institution OPD on july 15, 2026. PAST PSYCHIATRIC HISTORY The patient has no prior psychiatric symptoms observed. Had no psychiatric consultations or hospitalizations. Patient had no history of suicidal or homicidal thoughts process in the past. SUBSTANCE USE HISTORY The patient previously smoked approximately three cigarettes per day, with an estimated smoking history of 0.6 pack-year. Her last cigarette use was in March 2026. She drinks alcohol occasionally with friends, with her last alcohol intake occurring approximately one month prior to consultation. She denies any history of illicit drug use, gambling, or disordered eating behaviors. PAST MEDICAL HISTORY The patient denies any history of hypertension, diabetes mellitus, bronchial asthma, thyroid disease, arthritis, malignancy, or other chronic medical illnesses. She has never undergone surgery. She was previously hospitalized at Cebu City Medical Center during Grade 4 and Grade 9 for unrecalled illnesses. She denies any history of seizures, stroke, head trauma, or other neurologic disorders. Childhood immunizations were reportedly complete, including Pfizer COVID-19 vaccine (2 doses), Hepatitis B, and MMR vaccination. She reports no known food and drug allergies. FAMILY HISTORY The patient currently lives with her parents and is primarily cared for by her maternal aunt. Her father (56 years old) is a taxi driver with hypertension and diabetes mellitus. Her mother (40 years old) owns a small business and likewise has hypertension and diabetes mellitus. The patient describes herself as emotionally closer to her mother. She has four younger sisters: a 20-year-old college student taking Accountancy who lives seperately with father's aunt because of the patient used to behave aggressively to her and fighting daily ,a 13-year-old Grade 7 student, an 11-year-old Grade 6 student, and a 6-year-old Grade 1 student. There is no known family history of psychiatric illness, psychiatric consultation, or suicide DEVELOPMENTAL AND SOCIAL HISTORY Prenatal, Natal, and Postnatal History: The patient was born to a 27-year-old G5P5 (5005) mother via normal spontaneous vaginal delivery. The pregnancy was reportedly complicated by meconium-stained amniotic fluid. Her mother denied alcohol, cigarette, or illicit drug use during pregnancy. No significant perinatal complications or prolonged neonatal hospitalization were recalled. Early Childhood (0–3 years): The patient was primarily cared for by her parents and grandmother and was raised in a supportive family environment. Developmental milestones, including speech and independent walking, were reportedly attained at appropriate ages. No developmental delays or significant childhood illnesses were recalled. Middle Childhood (3–11 years): The patient started kindergarten at approximately five to six years of age and entered elementary school at seven years of age. She consistently performed well academically and frequently received academic honors. She actively participated in table tennis, badminton, volleyball, quiz competitions, poetry writing, and story-writing contests. She enjoyed reading and writing during this period. She experienced verbal bullying related to her family’s financial status and physical appearance, which occasionally led to physical altercations. She informed her mother about these incidents and eventually established better relationships with her peers. She denied absenteeism or significant behavioral problems. Later childhood to Adolescence (12 year or 18 year): The patient attended Don Vicente Rama Memorial National High School, where she maintained good academic performance and actively participated in badminton and tennis. She experienced cyberbullying by a classmate through Facebook, prompting her to distance herself from certain peers. During Grades 9 and 10, her family transferred residence. She described herself as emotionally sensitive and frequently sacrificed sleep to meet academic demands. She also reported emotional distress related to her father’s alcohol use, financial difficulties within the family, and episodes of physical abuse at home. During this period, she engaged in her first episode of non-suicidal self-injury by making superficial cuts on her wrist, which she denied was associated with suicidal intent. Despite these stressors, she maintained several close friendships and denied any romantic relationships. Adulthood The patient is currently a fourth-year nursing student (9th semester) at Cebu Institute of Technology-University. She previously worked night shifts in a call center while attending school, which contributed to sleep deprivation and increasing stress. She described herself as becoming increasingly hyper-independent and coping with problems through avoidance. During her third year of nursing school, after resigning from work, she experienced worsening depressive symptoms accompanied by racing thoughts, self-harm urges, insomnia, and eventually auditory hallucinations. Academic pressure , family problems remain as her primary stressor. MENTAL STATUS EXAMINATION The patient is a 22 year old young adult female who appears her stated age. She is awake, alert, and cooperative throughout the interview. She is fairly groomed and appropriately dressed. She maintains good eye contact and demonstrates no abnormal involuntary movements or psychomotor agitation. Her speech is well modulated with normal rate, rhythm, volume, and tone. Her mood is “sad” and mood-congruent affect. Her thought process is logical, linear, and goal-directed. Thought content is significant for feelings of worthlessness, urges to engage in self-harm.She reports command auditory hallucinations consisting of indistinct voices telling her to cut or wound herself, as well as tactile hallucinations described as sensations of insects crawling on her skin. She does not report visual hallucinations.She is oriented to time, place, and person. Attention and concentration are intact during the interview. Immediate, recent, and remote memory are grossly intact. Fund of knowledge is appropriate for her educational level. Abstract thinking is intact. Insight is Level V . PHYSICAL EXAMINATION BP: 110/80 mmHg RR: 19 cpm TEMP: 36.6 C HR: 92 bpm O2 sat: 99% at RA Ht: 165 cm Wt: 79 kg BMI: 29.0 kg/m2 PRIMARY IMPRESSION Persistent depressive disorder, with major depressive episodes,with current episode DIFFERENTIAL DIAGNOSIS PLEASE MAKE YOUR OWN PLAN PHARMACOTHERAPY: Escitalopram 10 mg/tab, ½ tab OD AM x 6 days , then 1 tab OD AM thereafter Olanzapine 10 mg/ tab, ½ tab OD HS NON-PHARMACOLOGICAL: Supportive therapy Psycoeducation Differtial diagnosis please