***Anson's Psychiatric Evaluation***
by Jean
SERIES: Anson's Journal.
DISCLAIMER: All characters used here and alluded to belong to Alliance and their respective owners.
SUMMARY: Anson's Psychiatric Evaluation
BETA: Dr. Ruthless
THANKS: To Dr. Ruthless for role-playing Anson to answer my questions.
NOTES: Anson clammed up on me this week, so instead of a journal entry I thought I would do his psychiatric evaluation. I had to do these on most of the patients that were admitted to the hospital that I was rotating at. I used my perceptions of Anson from the Maloney episode, plus Dr. Ruthless and I did some role-playing with her as Anson and me as Dr. Linasp. I am not saying that the diagnosis I came up with is correct, just my interpretations. Any questions, feel free to ask. And if you disagree, please let me know, I would like to see what y'all think.
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IDENTIFYING DATA: Patient is a 33 year-old, divorced, Caucasian male referred to Bryce State Hospital, by the Los Angeles County Courts, for psychiatric confinement until a time that patient is no longer a threat to self or others, but not to be less than 1 year.
CHIEF COMPLAINT: Patient states that he is here because he can't keep his temper and that he is "disturbed".
HISTORY OF PRESENT ILLNESS: Patient was admitted to Bryce State Psychiatric Hospital by Los Angeles County Courts because of a hostage situation in which the patient took numerous hostages in a psychiatric ward. Patient was arrested for fleeing the scene of an accident. He then took the arresting officer's gun and then proceeded to take hostages. Patient also is alleged to have killed a police officer in Florida.
PAST PSYCHIATRIC HISTORY: Patient states that he was placed in a psychiatric hospital for a "couple of months" when he was a kid because he was "difficult". He does not recall his length of stay or what medications he was on.
FAMILY/EDUCATIONAL/SOCIAL HISTORY: Patient is divorced with an 8-year-old daughter. He was married for approximately 5 years. Patient has a history of being in foster homes after the death of his mother when he was 7. Patient denies any abuse. Patient states that he did not complete high school, but did obtain his GED. He served in the Marines for 3 years and was in the stockade for approximately 1 more year. He was discharged after that. He was currently working as a construction worker.
MEDICAL HISTORY: Patient denies any drug allergies. Patient is on no current medications. He denies any significant medical problems.
SUBSTANCE USE HISTORY: Patient admits to an occasional beer. He states that he smoked marijuana in the past with last use being three years ago.
MENTAL STATUS:
APPEARANCE/COOPERATION/RELIABILITY: Patient is casually dressed. Patient is openly hostile. Patient is a fair historian.
AFFECT/MOOD: Mood is resentful. Affect is appropriate.
SPEECH/THOUGHT PROCESS: Speech is pressured. Thought process is goal directed. There is no loosening or association, tangentiality or circumferentiality. No flight of ideas.
THOUGHT CONTENT: Patient is awake, alert, and oriented to person, place and time. There are no suicidal or homicidal ideations. No obsessions, compulsions, or delusions. There are some references to self in third person.
INSIGHT/JUDGEMENT: Insight is poor. Judgement is poor.
ADMITTING DIAGNOSIS:
AXIS I: Post-Traumatic Stress Disorder; Adjustment Disorder; r/o Panic Disorder; r/o Bipolar Disorder; r/o alcohol dependency.
AXIS II: Deferred
AXIS III: None
AXIS IV: Chronic on-going stressors: death of mother, divorce, current legal issues.
AXIS V: Current GAF: 20; Highest GAF in past year: 50
PRELIMINARY TREATMENT PLAN:
1. Maintain patient in safe, in-patient environment.
2. Psychotropic medications: Risperdal 3 mg, Prozac 40 mg.
3. History and Physical, Routine Lab Work
4. Urine Drug Screen.
5. Group, One on One, Recreational, Art, Music, Occupational Therapy.
ESTIMATED LENGTH OF STAY: 5 years.
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