



Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
CC: Patient presents with complaints of recent self-harm, feelings of boredom, and frustration with current living situation HPI: Mr. Rice is a 37-year-old African American male who presented to the clinic for a wrist infection. He reported that injury occurred as a result of his impulsive act of breaking a window during a party at the fraternity he was living in. He reported dissatisfaction with his living arrangements at the fraternity, and being left out and lonely most of the time. Mr. Rice reported consuming alcohol during social events, and attributed that to his boredom, the self-centered fraternity brothers, and the lack of meaningful connections. Mr. Rice stated he has a history of self-harm, few suicide attempts such as the severe burns self-inflicted at the age of seventeen or eighteen. He stated that he needs more meaningful social interactions and intellectual engagement, which he feels he lacks in the fraternity setting. Mr.
Typology: Study Guides, Projects, Research
1 / 6
This page cannot be seen from the preview
Don't miss anything!
Criteria Clinical Notes Subjective CC : Patient presents with complaints of recent self-harm, feelings of boredom, and frustration with current living situation HPI : Mr. Rice is a 37 - year-old African American male who presented to the clinic for a wrist infection. He reported that injury occurred as a result of his impulsive act of breaking a window during a party at the fraternity he was living in. He reported dissatisfaction with his living arrangements at the fraternity, and being left out and lonely most of the time. Mr. Rice reported consuming alcohol during social events, and attributed that to his boredom, the self-centered fraternity brothers, and the lack of meaningful connections. Mr. Rice stated he has a history of self-harm, few suicide attempts such as the severe burns self-inflicted at the age of seventeen or eighteen. He stated that he needs more meaningful social interactions and intellectual engagement, which he feels he lacks in the fraternity setting. Mr. Rice reported he met a woman named Miss Murray at a bus stop and felt a connection with her, and would like to move in with her for companionship and stimulating conversations. Past Psychiatric History :
in the future. Substance Current use : Reports ocassional alcohol use but denies cigarette smoking, or other illicit drugs. Family Pyschiatric history : Mr. Rice does not mention any psychiatric history of his parents or other family members during the interview. This lack of information makes it difficult to assess whether there is a genetic or familial predisposition to mental health conditions. Social history : Mr. Rice indicates that during the first three years of his life, he was hospitalized due to a congenital heart condition, and his family lived a hundred miles away from the hospital. This suggests that while he had parents their involvement during that time may have been limited due to the distance and circumstances. He has a history of feelings of being an outsider, which he also experienced growing up and attending school. Recently, Mr. Rice lived in a fraternity, where he described himself as an "honorary member." He felt disconnected from other members and found the environment unfulfilling and boring. He had some work experience, mentioning a short stint as a short-order cook that he left due to physical pain from scar tissue on his chest. Past Medical history :. He has a history of hospitalizations and complications during early childhood due to congenital heart conditions, which has contributed to his feelings of isolation throughout his life. Past Surgical history :. Burn Injury : He mentioned being burned on his chest when he was seventeen or eighteen years old due to pouring gasoline and then lighting it. This incident resulted in significant burns that required hospitalization for almost a year. Congenital Heart Condition : Mr. Rice also referenced having a congenital heart condition that involved complications requiring surgery during his early childhood. He spent the first three years of his life in the hospital due to this condition and the associated complications, suggesting multiple medical interventions, including surgeries. Medications : Mr. Rice noted a lack of effective treatment from past psychiatrists, which may have included medications, but he did not detail any specific psychiatric medications. Mr. Rice was prescribed Amoxicillin for the wrist infection. Allergies : No food allergies. No seasonal allergies. Drugs:Penicillin (reaction: rash) Spiritual history : none Primary Care Physician : Patient does not see a physician regularly.
General : Mr. Rice denies fever, generalized weakness, or chills.
ruminations about the past, self-harm, and a longing for connection. No current suicidal ideation was noted during the discussion. He is alert and oriented x 4, with no memory deficits. Denies hallucinations or delusions but but his ability to maintain a coherent train of thought appears impaired during emotionally charged discussions. Mr. Rice demonstrated limited insight into his condition, as evidenced by impulsive behaviors (e.g., breaking a window resulting in injury) and the self-destructive thoughts surrounding his living situation and social interactions. Assessment Borderline personality disorder (F60.3)
DSM-5 as a response to stressors that leads to clinically significant emotional or behavioral symptoms and is categorized as a stressor- related disorder. He reports feelings of boredom, frustration, and dissatisfaction with his life, resulting in an impulsive behavior (breaking a window and cutting his wrist) and past suicide attempts indicates potential emotional or behavioral responses to the stressor. Major Depressive Disorder F60. DSM-5 Criteria for MDD includes 5 or more of the following symptoms: depressed mood, loss of interest or pleasure, weight loss/gain, sleep disturbances, psychomotor agitation/retardation, feelings of worthlessness or guilt, diminished concentration, or fatigue. Additionally, symptoms can include suicidal ideation. Plan Treatment /Plan The treatment plan for Mr. Rice includes: