Redacted Anthology: Psychiatric Evaluation

Medical Restricted

Montana Health Department

Division of Mental Health Services

 

Identification of Patient:

  • Fifteen years old
  • Caucasian male
  • Single
  • First year high school student
  • Lives at home with both parents (married) and two sisters (ages six and ten)

 

Referral Source: Dr. Delfino Cordez, MD (through the inquisition of the patient’s parents)

 

Sources of Information:

  • Karen Stowe and Mark Stowe (the patient’s parents)
  • Karen, an accountant, and Mark, an architect, both appear to be reliable sources of information.
  • Several phone calls with Karen lasting from one half to a full hour in the month prior to the first assessment of the patient.
  • One half-hour interview with both Karen and Mark in office one week prior to the first assessment of the patient.
  • Medical records
  • This is the patient’s third evaluation.

 

Chief Complaint: The patient states that he does not need to be evaluated. When asked to explain, the patient says that he is “still fine” and otherwise remains silent. The patient has again been brought to this facility for a third evaluation by his parents for worsening behavioral changes including irritability and anger, a decline in school performance, insomnia, a withdrawal from normal activities and social relationships, failure to eat, and an unhealthy obsession with a new video game. Noticeably small changes at home began in November with mild mood swings and reclusive inclinations. The severe effects of poor school performance, malnutrition, a propensity for violence, lack of sleep, memory loss, and the fixation on the game began to emerge at the end of the month of December and only seem to have increased over this month of January.

 

History of Present Illness: The patient has been receiving services at this facility over the past two months under my care. Historically, he has found that he is often distracted and unable to focus for long periods of time. His parents relate that they became aware of this struggle and lack of ability to concentrate when he was ten years old. After many conferences with the patient’s elementary and middle school teachers, the patient’s parents finally had him tested for attention deficit hyperactivity disorder. Symptoms of poor school performance, minimal motivation, absentmindedness, and the inability to remain actively engaged and involved in day-to-day actives have greatly improved with treatment that began in October 2010. The patient has had no troubles for five years. However, suddenly the patient’s medication does not seem to slow the arrival of both old and new problems as of November 2015. The patient is often not present mentally. He seems far away and disconnected from the conversation or task at hand. This detachment and disinterest has been increasing with time. It began with decisions to forgo simple social outings with friends and has developed to include weekly school absences, a refusal to join the family for gatherings during the Christmas holidays, and the confinement of himself to his room. Food has not only become unappetizing, but also recently toxic. The patient either chooses not to eat or involuntarily regurgitates all that he consumes. The patient has lost twelve pounds since the last evaluation two and a half weeks ago. The patient’s parents report that the dark circles under his eyes and his lifeless demeanor and appearance stem from insomnia and malnutrition. Over the months the patient’s sleep has diminished from four hours a night, to two hours a night, to now around four hours per week. The patient’s parents convey that he spends all of his time and sleepless nights alone in his room either playing his game or staring at it in silence. Symptoms of verbal aggression began with minor incidents at school. These incidents have now escalated to encompass fits of uncontrollable physical violence and verbal threats that exist in all aspects of daily life. The patient “does not become angry, he becomes infuriated at anything….with everything,” Karen said. According to the patient’s parents, violent behavior is most common when in connection to the game and namely, attempts to confiscate it from the patient. The patient also exhibits periods of memory loss. The patient often disappears anywhere from hours to days at a time. Upon return, the patient reports that he “never left [his] bedroom.” The patient claims that he has “been upstairs playing [his] game the whole time.” However, the patient’s shoes, clothing, and documented history of credit card charges imply otherwise. Review of symptoms suggests something greater than the return of an attention deficit hyperactivity disorder. The symptoms of the patient suggest that something in his life has changed. An unidentified stimulus has generated the sudden onset of such behaviors.

 

Psychiatric History: The patient has never been hospitalized for a psychiatric purpose. The patient was diagnosed with attention deficit hyperactivity disorder in October 2010 at the age of ten by Dr. Samantha Brock, MD of Riverside Medical.

 

Substance Abuse History: NONE

 

Medical History: See History of Present Illness. Ongoing nausea, upset stomach, vomiting since the end of November 2015. The patient suffered from a broken wrist and two broken fingers from a bicycle accident in June 2007 (age seven). No reports of head trauma or seizures.

 

Surgeries: Adenoids and Tonsils Removed August 2003 (age three)

 

Allergies: NONE

 

Current Medications: Prescription – Vyvanse 30 mg daily (a.m.)

 

Family Medical History: The patient’s paternal grandfather diagnosed with lung cancer at age sixty-five. The patient’s father suffers from hypertension. No family history of heart disease or diabetes. No family history of psychiatric disorders.

 

Spiritual Beliefs: Christian

 

Employment: Student

 

Legal: No legal problems.

 

Hobbies: The patient plays baseball and likes to be outdoors (prior to the problems that emerged in November 2015). “Now all he wants to do is play that game. I’m not even sure where he got it or who gave it to him. He has never shown an interest in video games until this one came along,” reported Karen.

 

Education: The patient’s parents relate that the patient is (was) very social. He had many friends and was always well liked. He never had any problems with anyone. He had a good relationship with all of his teachers. The patient’s parents reported that the patient did not always make straight A’s, but he never made below a B+ (until now). “He had to work for his grades. But that’s what is important to note. He always worked for it. He usually puts all his effort, every ounce of his being, into everything he does. Now he doesn’t seem to care about anything. Not school, not his friends, not even his own health,” said Mark.

 

Mental Status Examination: The patient is five minutes late to his appointment. According to the patient’s parents, the patient refused to get in the car. The patient locked himself inside his room and barricaded his door with his bed. It is reported that the patient violently screamed and threatened to injure his parents when they finally managed to open his door. “Once I finally got a hold of his thrashing arms, I noticed that he was foaming at the mouth. He was uncontrollable. He was shaking from the anger. His cheeks were red, his back was wet with sweat, and he was hot to the touch. When I looked into his eyes, I didn’t recognize my son anymore,” explained Mark. The patient is unclean. His unwashed and thinning hair is dark with grease, his body emits a foul odor, and his fingernails are uncut and yellow with bacteria. His clothes hang two sizes too big off of his small and continually shrinking frame. The patient’s pale and weak demeanor ages his young body. The patient is not cooperative and does not maintain good eye contact. He is not alert. When he is not looking at his hands, mumbling in anger, he stares through me, only seeing the thoughts in his head. The patient’s gaze often scans the room, back and forth, as if he is watching a very different scene unfold. He is distant. His reactions and speech are slow. It seems that a response is only generated after the question is repeated for the third time. The patient’s educational history reveals that his intelligence is above average. However, he offers little explanation and insight when asked for interpretations of various pictures, readings, or questions. When asked why, the patient often responds: “I don’t know or I don’t care.” Although the patient displays a good short-term memory when asked to recall a series of phrases previously stated, the patient denies any memory of purchasing batteries four days ago. The patient denies any behavioral changes, mood swings, irritability, and physical transformation. As questions about the video game begin, the patient once again becomes fidgety. The patient finally discloses that he found the game in his backpack at school on October 31, 2015. When asked about the need and desire he has to play the game, the patient quickly shouts, “I have to. I have to play it. I have to play.” The escalation from a calm and detached disposition to one of rage is noted to both occur more quickly and with more intensity each successive evaluation.

 

Clinical Impression: The patient is a fifteen year-old Caucasian male with no family history of any psychiatric disorders. He has no history of substance or family abuse. The patient benefited from the treatment for attention deficit hyperactivity disorder in October 2010. Although medical treatment has been successful, the patient now displays troubling symptoms in addition to and greater than that of attention deficit hyperactivity disorder.

 

Diagnoses:

  • AXIS I: Rule out PTSD. Rule out Bipolar Disorder. Rule out Panic Disorder. Rule out Depression.
  • AXIS II: Rule out Borderline Personality Disorder
  • AXIS III: History of attention deficit hyperactivity disorder.
  • AXIS IV: Psychosocial Stressors: The patient’s behavioral changes began after he acquired the new game. The patient’s obsession to the game is the catalyst to his arising problems.
  • AXIS V: GAF: 11. Declining with time.

 

Prognosis: Good, if the patient adheres to treatment. The patient will continue to display physical, mental, and emotional degradation without the correct assistance from his treatment plan.

 

Treatment Plan: The patient is to return to this facility for evaluations every week. We will check the patients weight and blood pressure. We will examine the patient’s alertness, mental presence, response time, cooperation, judgment, and emotional stability. We have discussed treatment options for the patient’s parents to implement at home regarding the video game. We also have discussed hospitalization.

 

Dr. Brett Boline

3 January 2015

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