DATE:

   10  /  08  /  10    

 
Name:          Thomas  R.  Howe                                                                              DOB:                  05/25/1981    
 
INITIAL PSYCHIATRIC EVALUATION

HISTORY OF PRESENT ILLNESS: 29 year-old mixed-race male patient

who presents with disorganized behavior and auditory/visual hallucinations. Pt was
poorly responsive to questions; appeared distracted, Pt stared into space and
occasionally left chair grabbing into air. Pt denied hx of MI or head injury.

Per Mother Report: Mother stated Pt became withdrawn and making bizarre comments
following head injury at age 16. Mother stated approx. 1 year after injury Pt admitted
seeing ghosts. Mother stated Pt getting worse in past year: talking to self, irrelevant
speech, appearing to look at invisible objects, increasingly withdrawn. Mother stated 2
days ago Pt wandered away from home and was found a few blocks away staring at an
office building. Mother stated Pt would not say why he left the house and spoke
irrelevantly. Mother stated she has urged Pt to seek psych. tx for years.

PAST PSYCHIATRIC HISTORY:

HOSPITALIZATION: none reported

OUTPATIENT TREATMENT: none reported

SUBSTANCE ABUSE: none reported

SUICIDE HISTORY: none reported

MEDICAL HISTORY:

MEDICATIONS: none

ALLERGY: none

FAMILY HISTORY OF MENTAL ILLNESS: Mother current outpatient tx for

depression; first dx d and tx d approximately 1975. Half-brother dx d with schizophrenia
approximately 2000.
PSYCHOSOCIAL HISTORY: (per mother)

DEVELOPMENTAL MILESTONES: as expected prior to head injury

EDUCATION: B student prior to head injury; struggled following hospitalization from

head injury; graduated H.S. 2001

WORK HISTORY: sporadic employment at part-time jobs

LEGAL HISTORY: no arrests in past decade

ABUSE HISTORY: denied; head injury from neighborhood attack at age 16

MENTAL STATUS EVALUATION:

-­‐ Appearance and Behavior: disheveled appearance, bizarre behavior
-­‐ Psychomotor activity: fluid; repetitive knee knocking
-­‐ Attitude: defensive, agitated
-­‐ Speech/Thought Process: irrelevant, illogical
-­‐ Mood: restricted
-­‐ Affect: restricted
-­‐ Suicidal ideas: denies (contracted for safety)
-­‐ Homicidal ideas: denies (contracted for safety)
-­‐ Hallucinations: denies but responsive to internal auditory and visual stimuli
-­‐ Delusions: denies
-­‐ Orientation: x4 time, place, person, circumstance
-­‐ Attention: poor due to internal stimuli
-­‐ Memory/Recent: intact Remote: intact
-­‐ Cognition: poor due to irrelevant speech
-­‐ Insight: limited Judgment: limited
-­‐ Impluse Control: moderate

DIAGNOSIS:
Axis I: Schizophrenia, Undifferentiated Type, Chronic

Axis II: Dx Deferred

Axis III: Head injury age 16
Axis IV: Deferred
Axis V: GAF = 45
TREATMENT PLAN:
M EDICATION M ANAGEM ENT : Given Rx Haldol, 2mg, to be taken twice daily

PSYCHOTHERAPY : Referral for outpatient therapy and outpatient psychiatric tx

for MI insight and medication management
OTHER : Assertive Community Tx (ACT Team) to be considered if Pt continues sx
denial and is medication non-compliant

Donald Randall, MD

DONALD RANDALL M.D.