Mental Diagnostic Evaluation Summary

31 y/o AA male patient seen today for psychiatric-mental health assessment. He is awake, alert and oriented x4. He is calm, cooperative and follows commands during assessment. The patient reports he is depressed, difficulty sleeping and nightmares at night. The patient explained his depression is as a result of deep thinking from a news he received two days ago from his elder brother that his mother is ill. Stressors identified by the patient include losing his job a week ago before the news about his mother; his wife is 6-months pregnant with their first child, who currently works part-time at her present job; patient relates difficulty paying monthly bills and inability to provide adequately for his family as a man. The patient denies mood swings, suicidal/homicidal thoughts and ideation. Patient reports his spouse is at work at the moment and he does not want to put stress on his wife due to her current condition. Patient denies been hospitalized for depression or psychiatric illness; and denies family history of mental illness. Patient reports he is seeking help because he does not like feeling this way using terms of “helpless and loss of worth from his spouse”. Patient reports he needs help with his depression and nightmares before his current condition get out of hands and ruined his marriage.

Clinical Assessment=According to our book, the term Clinical assessment generally refers to applying assessment procedures to (a) diagnose a mental disorder, (b) develop a plan of intervention, (c)monitor progress in counseling, and (d) evaluate counseling outcome. (Drummond, 2010). Clinical assessment has been the method used when diagnosing and planning treatment for a patient. The first step is evaluating the individual in order to obtain information and figure out what is wrong. Counselors, conduct this assessment to develop and adhere a plan of intervention, monitor clients progress, and ensue all information are interpreted and understood.

Under 38 C.F.R. § 4.130, Diagnostic Code 9411, a 50 percent schedular rating is said to be appropriate when there is evidence of occupational and social impairment due to a variety of symptoms such as, flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing effective work and social relationships. Given that our veteran was reported by the VA psychiatrist as exhibiting symptoms of memory impairment, difficulty in establishing relationships, and twice-weekly panic attacks, it is clear that a 50 percent rating should be given for the time frame

Client has had one year of mental health treatment while he was being treated in the VA rehab hospital for his injuries. He did not have a diagnosis of PTSD during this mental health treatment.

He has been diagnosed with Persistent Depression Disorder, which is self-reported to have gotten worse since the TBI. The veteran has attempted to make appointments with a psychologist at the VA, but he reports that those appointments have been canceled. He wears hearing aids and has a knee injury, which he will have surgery on in the future.

The main purpose of the ensuing evaluation is to determine if Ms. Tyler is competent to stand trial for accused crimes, and needs to be evaluated for criminal responsibility. She exhibits signs of mental illness; further investigation via a mental status assessment is required.

Client continues to deny any mental health issues, but on 4/11/2016, she met with Dr. Shuster and an initial psychiatric evaluation was completed and the client was diagnosed with Axis 1: PTSD (Post traumatic stress disorder) F43.10 (Primary), rule out symptoms off. She was refer to participate in individual mental health treatment. Client reported she went for mental health assessment at Woodhull Hospital client need to submit medical documents.

When looking at initial assessment of the patient's history, I was not able to get hold of her psychiatrist who could provide more details of what the patient has undergoing and give proper justification of what she was diagnosed with instead of PTSD. However, the assessment discovered that the main symptoms of persistent intrusive ideas of abuse, indifference, isolation, increased anger, lack of sleep and poor hyper-vigilance. The patient's general mood which was recorded earlier before the initial assessment indicated a lot of hopes about the future (patient is optimistic). In addition, the mental assessment which was being conducted for her as initial part of case management at HUD-VASH, she wanted more treatment to be offered to her even after the end of the first assessment process. During the first psychiatric

Ms.D. is independent and lives alone in her home, however, she reports difficulty remembering to carry out or terminate activities. She reports that she has forgotten to turn off the sink twice this year and flooded her apartment both times. The Functional Activities Questionnaire was chosen to inquire about her safety and the other activities in her life. Next, the Berg Balance Scale was used to highlight Ms. D.’s risk of falling noted by her “furniture-walking”, foot drop, and failed hip replacement. She carries a cane with her but often walks in the senior center without using it. Also, Ms. D. reports difficulty walking in the community and states that she needs a break every five steps due to fatigue. Lastly, the Modified Mini-Mental State Exam was chosen to determine Ms. D.’s cognitive impairment level, if any, and to rule-out Alzheimer’s Disease. As her chief complaint, Ms. D. reports often forgetting the names of people, places, and things. As mentioned before, she has forgotten to turn off her sink and flooded her apartment

E.S. had a complex case because he was not only grieving the loss of his son but he soon thereafter was grieving the loss of his grandson. The grieving process appeared to be quite tough for E.S. since his family unit had been torn apart (some lived in Los Angeles, while others lived in Chicago). Since his children come from different wives it was hard for E.S. to navigate the family unit upon the loss of one of his sons. He mentioned that it was difficult to talk with the boy’s mother in this time of grief “ because she would start crying and I just couldn’t handle that.” It appears that he felt inadequate for not being the support that his ex-wife needed. This veteran did present signs of depression and grief. E.S. attended a Bereavement Group in Building 500 at the West Los Angeles VA. Before I was forced to terminate with E.S., I found out that he was on three different types of medications. He was prescribed an antidepressant (Zoloft), medication for his blood pressure, and medication for his cholesterol. While he was on this combination of medications, this veteran reported thoughts of suicide. Veteran confirmed that the suicidal thoughts stemmed from his anti-depressant (Zoloft), and once he stopped taking the Zoloft and

HYPOTHESIS: The patient had general difficulty completing thought trends. He denied any hallu-cinations or delusions, but his guardedness would indicate possible paranoid ideation with possible unsys-temized persecutory delusional system. He felt there was some type of conspiracy against him to place him at Sweetwater Home Board and Care. He was unable to recognize and appreciate his medical and mental cir-cumstances appropriately and respond to them in an appropriate manner. Judgement was impaired since the patient could not make medical or financial decisions in his best interest. I do not feel that he knows the ex-tent of his medical illnesses or his financial situation. The patient was disoriented to time, person and place.

This case pertains to a 27-year-old male named Josh of undisclosed ethnicity who just three months ago witnessed a horrific, senseless accident which resulted in the death of his fiancée. He is suffering from a tragic, irreplaceable loss and is displaying symptoms of posttraumatic stress disorder (PTSD).

It is evident from Thomas’s case that he presents “textbook” symptomology of PTSD. It is reported that Thomas currently seeks medical care at a VA clinic and complains of both back and neck pain which frustrates him because he seems to feel that he is being misdiagnosed due to the fact that no physical anomalies are present. The VA clinicians are taking themselves off the hook by transferring blame onto Thomas claiming, “that it’s all in (his) head.” Thomas’s case file reveals that he possesses some cognitive deficits and claims to have been suicidal in the past.

He was in active duty and multiple times in 2008 he suffered brain trauma (missile attacks and a vehicle impacted the left side of his head; he was wearing a helmet). He received treatment at the Traumatic Brain Injury and Concussion Clinic and received mental health therapy. He suffered changes in his personality, developed intellectual problems, had recurrent nightmares about being in Iraq, had panic attacks, and had difficulty being around others. He also had physical limitations because of back pain. He took multiple medications, including psychotropics and medicines for pain control. The claimant had traumatic brain injury, post-traumatic stress disorder, and cognitive disorder secondary to brain injury. Because of his condition, he was incapable of even low stress

Clients that are considered intellectual disability are defined as individuals whom IQ are below 70. They usually have substantial difficulties in adaptive behaviors and daily living skills such as self-care, communication and community involvement. (CDDH, 2014) Ian has an IQ 55 which means depending on educational opportunities he may learn to read and write. Ian was the ability to develop and maintain vital relationships along with participating in diverse activities while contributing to his family and communities. He has proven to be moderately self-sufficient. He is employed part-time with own apartment. Although he has proven that he able to sustain himself, he has also stated to Samantha that he has been having problem remembering things lately and has