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Published online by Cambridge University Press: 19 October 2021
Patient evaluation on intake
• Patient #1
– 60-year-old man with a chief complaint of “being angry and down”
• Patient #2
– 15-year-old girl with a chief complaint of “everything sucks”
• Patient #1 states that he was involved in a fracas at work, was pushed down the stairs, and was in a coma for a week
• Patient #2 states that she has been having a difficult time at home and at school
Psychiatric history
• Patient #1 had been without any psychiatric issues until his head injury. He states his symptoms developed after this
• Patient #2 states that she has gradually become more emotionally labile, depressed, and anxious over the last one to two years
• Patient #1 has not been able to go back to work at all due to his depression, amotivation, and anger management problems
• Patient #2 has been absent from school due to her inability to get up and get ready for school
• Patient #1 admits to full syndrome MDD
– He has passive suicidal thoughts that there is “not much to life” and he “wouldn’t mind if he didn’t wake up”
– Admits to poor focus, concentration, and amotivation as chief Complaints
• He states that little things make him angry quickly
– Experiences road rage and followed fellow drivers after Incidents
• He states that he was never like this prior to his accident
– Denies PTSD-related avoidance, flashbacks, or nightmares as he does not remember the accident due to his head injury and coma
– Is tense and hyperaroused most of the time
• He has relatively few friends as most were colleagues at his previous job. He is at home more and not motivated to leave his home
• Patient #2 admits to full MDD symptoms
– Has suicidal thoughts that occur more when stressed
– Admits to having an inability to focus, poor concentration, and lack of enjoyment as chief complaints
• She states that “little things make her angry quickly”
– She is afraid that going to school puts her in situations where she may strike out and get into fights, even though this has never been her social pattern
– She has friends but feels disenfranchised from them
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