BPD
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:
•
General statement: reports that he has been under
psychiatric treatment prior to this evaluation, and previously
sought help for mental health concerns but without success.
•
Current Caregivers: none
•
Hospitalization history: Mr. Rice’s history of seeking
psychiatric care, previous severe medical hospitalizations,
and mentions of self-harm and suicidal ideation indicate a
complex mental health background that may include past
psychiatric hospitalizations.
•
Medication history: He has no prior history of psychiatric
medications.
•
Psychotherapy/Previous Pychiatric Diagnosis: He had seen
psychiatrists in different cities, but he expressed
dissatisfaction with the psychiatric care he received in the
past because it did not improved his mental health. He
moved to his current area in search of a decent psychiatrist
because of its reputation as a supportive mental health
community, but he is not currently in contact with any mental
health specialists. Mr. Rice stated that he attempted suicide
on multiple occasions, which may warrant hospitalization if
he were to present with severe suicidal ideation or behaviors
Include chief
complaint, subjective
information from the
patient, names and
relations of others
present in the
interview, and basic
demographic
information of the
patient. HPI, Past
Medical and
Psychiatric History,
Social History.
