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Psychiatric Evaluation

DEMOGRAPHIC INFORMATION

IDENTIFYING INFORMATION: The patient named JJ is a male patient aged 21 years African America. He is a soldier, brought to the psychiatric center by colleagues and his parents as a referral patient from the military clinic. His colleagues reports that the patient has violent behavior towards other soldiers, and he has shown changes in personality and characters. These occurrences started about one month ago when he joined military service after release from training as a new recruit.

SUBJECTIVE DATA

CC: JJ states that, “I am absolutely fine and I do not know why I have been brought here.”

HISTORY OF PRESENT ILLNESS: (SUBJECTIVE) 

After release from military training four months ago, JJ visited his home. His parents noted a change of behavior different from how he behaved before joining military one year ago. Before joining the military, he was shy and timid, but the parents reported that he now appears more confident and concessionary indicated that he is going to be the best soldier in the United States. He also showed forgetful behavior to an extent of forgetting where he kept his personal belongings. JJ was once returned home by police after he had strayed far from home and he did not know how he got at that place. After release from training, he was posted for military duties where his colleagues who were with him at the training camp reported that he appeared outgoing and passionate contrary to his usual behavior. ROS: He has shown loss of weight and he has a slight head trauma that occurred during military training. RESPIRATORY: The patient does not report any difficulty in breathing. CARDIOVASCULAR: Denies any chest pain. NEUROLOGICAL: JJ denies any loss of feelings and coordination. PSYCHOLOGICAL: Depressed and anxious

PAST PSYCHIATRIC HISTORY:

The patient has never had any psychological disorder as reported by the parents. He has never been hospitalized for any psychological disorder. JJ has never had any suicide attempt or self-harm intentions in the past. Denies past depression or anxiety.

 PREVIOUS PSYCHIATRIC MEDICATIONS: 

JJ has never taken any previous psychiatric medications.     

CURRENT MEDICATIONS:

Clozapine (Clozaril) 12.5mg twice per day

SUBSTANCE USE/ ADDICTIVE BEHAVIORS: 

The patient denies current use of any drug. However, he used to occasionally take alcohol one year ago but stopped after joining military. He took a maximum of 5 bottles of 500ml beer per week. His parent reports that he has never been addict of any drug.

FAMILY PSYCHIATRIC HISTORY: 

His 75 years grandmother was diagnosed with dementia five years ago. She has been taking donepezil for the last five years without any signs of improvement. In essence, her condition is worsening.

Parents and siblings have never reported any psychiatric disorder.

MEDICAL HISTORY:  

The patient experienced a slight head injury six months ago during a military training session. The injury was not serious, although it left a scar at the back of the head. He was treated at the military clinic and discharged. Computerized tomography (CT) scan did not show any abnormalities. JJ has no history of surgery. No chronic illness and denies any allergies. Electrocardiogram (ECG) report showed normal sinus rhythm. Full psychological battery ruled out occurrence of any cognitive impairment.

PSYCHOSOCIAL:  

The patient is experiencing problems at work. He tends to be violent to his colleagues. He is also having problems with his seniors as he tend to forget some of the military procedures.

JJ had a normal childhood development. Although he was shy, he was usually happy and most of the time in jovial mood especially in presence of familiar people. His mother had a full term pregnancy. He is a Christian and the highest level of education is high school.

Born and raised where/by whom/siblings/relationship status: He was born in African and moved to America at the age of 14 years. He has two siblings; a sister aged 24 years and a brother aged 16 years. He was brought up by his two parents in a stable family.

Education/performance: He was an average student in school.

Living situation: He was living with his family until he moved to military barracks about one year and three months ago.

Marriage/relationships: He is not married, but the parents indicates that he has a girlfriend who is now complaining that he has changed.

Children: The patient has no children.

Employment: He is a soldier in American defense forces. 

Legal: He has no history of crime and he has never been jailed.

Abuse: He was physically and sexually abus

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