| Purpose:
Sample of computerized Integrated Summary report for psychiatric inpatients. |
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Mississippi State Hospital
| BLDG NUMBER : 99 Sam Stone, M.D. DATE OF ADMISSION: 7/19/99 DATE OF BIRTH: 8/16/85 IDENTIFICATION AND PRESENTING PROBLEM: This 14-year/2-month-old black male
8th-grader from Somewhere County presents for his first Oak Circle Center Adolescent Unit
admission, committed through Chancery Court due to problems including recent aggressive
behavior and noncompliance with outpatient treatment. The patient’s chief complaint
at the time of admission is: "I got a temper problem...all my life." Information
available upon admission reveals clinical symptoms including: "mood swings";
decreased sleep (especially trouble initiating); decreased concentration; some increased
crying (though not currently); threatening statements and gestures; and disregard for
rules and authority. FAMILY AND SOCIAL FACTORS: Information concerning the patient’s social history was obtained through interview with patient, interview with his parents, and admission paperwork. John was born in Somewhere, MS, and raised there by his natural parents. He is the third child born to Fred and Ethyl Smith. Mr. Smith has two children from a previous relationship. In 1991, the Smiths adopted two of their nieces, Lucy (13 y/o) and Lucrecia (12 y/o). The patient lives with his parents, 14 y/o brother (Robert), Lucia, and Lucrecia. John’s father works as an auto mechanic and his mother runs a carpet cleaning shop out of their home. No history of emotional, sexual, or physical abuse is reported. The family lives in a small town in North Mississippi. The community and is perceived by the patient as average in socio-economic status. John reports having poor relationships with teachers and other authority figures. Ms. Smith reported hat John was disrespectful of his teachers. The patient describes himself as being socially outgoing but participating in few extracurricular activities. John is currently described as normally affiliative. A preference is reported for social interests over solitary activities. The patient tends to interact primarily with same age peers and displays an age-appropriate range of recreational interests. There is no reported history of arrests or other legal problems for this patient. John
is on probation for fighting at school. Upon discharge from OCC, the patient will be on
probation for one year. John is not known to have been involved in organized
"gang" activity. There is no known history of substance abuse. John admits to
smoking cigarettes. Further details of this patient’s social history will be
available on the Social Service Plan in the medical records. SCHOOL PERFORMANCE: Information concerning John’s educational history was provided by an interview with Fred and Ethyl Smith (patient’s parents) and a review of school records (including the cumulative folder). The student was last enrolled in the Somewhere School District and attended the Somewhere alternative school for the 7th grade. John is not eligible for special education services. Prior to admission his special needs were being addressed through participation in the alternative school. The patient has been a disciplinary problem at school, as evidenced by reports of breaking rules, disruptive behaviors, not completing school work, and talking back/defying authority figures. Ms. Smith denies that John has been physically aggressive at school. She states that he will do his homework but will not return it to school. Prior disciplinary actions taken by the school have included suspensions (for excessive tardiness and smoking). Other factors which may have affected this child’s education include tardiness which has led to suspensions. A review of John’s grade averages reveals F’s at the present time. Grades have declined since the 6th grade. Ms. Smith attributes much of his problems to changing to the middle school for the 6th grade. Test data available in the education records at Lakeside School include results from annual group achievement tests. Results of these tests reveal low average to high average skills. The parent’s educational and career goals for the patient were not disclosed.
John’s personal educational and career goals include a career as a mechanic. Further
details concerning John’s educational program will be available in the medical chart
and in school records. EMOTIONAL, BEHAVIORAL AND COGNITIVE FACTORS: Information concerning the patient’s mental health history was obtained by interview with the patient’s mother, interview with the patient’s father, review of commitment papers, and review of available medical records. There is no family history of mental illness. The first reports of behavioral or emotional problems for John occurred at age eight.. At that time identified problems included difficulty controling "his attitude and temper." The primary etiology for these initial problems appears to have been his move to middle school. There was no therapeutic intervention at that time. The identified problems have become progressively worse over time and additional problems have surfaced. These additional problems include anger outbursts, lying, stealing, fighting, and multiple suspension. Therapeutic interventions have included treatment by a mental health center therapist
(Sherman Williams). Details of these interventions will be available in the patient’s
medical records. The patient has not participated in psychological evaluation in the past.
Based on all available information, the primary reason for the decision to commit the
patient at this time appears to be problems controlling his temper, focusing on schoolwork
and fighting at school. This preliminary review suggests that strengths/skills which may
influence the choice of treatment for this patient include supportive parents,
is"outgoing", enjoys music, art, fishing and swimming. BIO-MEDICAL FACTORS: Review of medical history reveals no history of major medical illness or injury. Review of current status reveals no ongoing treatment for any illness. The patient’s vital signs at the time of admission include: temperature 98, pulse 88, respiration 20, and blood pressure 122/84. His height is 5'4 3/4" and his weight is 114 pounds. The patient is taking no medications at the time of admission. John has no known allergies to any medications, food, or other substances. Admission physical exam is within normal limits. Cardiovascular and respiratory exams are within normal limits. Neurological exam reveals CN II-XII within normal limits. Cerebellar function is grossly intact. Muscle tone is good and without cogwheeling; motor exam is unremarkable. Admission laboratory is pending at this time. See the patient’s medical chart for additional details. CURRENT MENTAL STATUS: Mental Status Examination reveals a well-developed
well-nourished 14-year/2-month-old black male whose appearance is consistent with his
stated age. The patient is alert upon interview. Orientation is intact for person, time
(except for missing exact date by one day), and place. He is casually dressed and groomed
in hospital scrubs. Eye contact is minimal, with patient leaning back to stare at ceiling
at times. His mood is "sad," with patient trying to concealed his anxious and
restricted affect. Speech is coherent and goal-directed. The patient denies
hallucinations, delusions, or paranoia. He denies current suicidal or homicidal ideation.
Memory functions are grossly intact with respect to immediate and remote recall of
information. Intelligence grossly appears to be somewhat below average. His level of
insight appears to be poor, as evidenced by limited understanding of the significance of
his problems. Judgment appears poor to history, but intact to formal testing. Proverb
interpretation is abstract. Two of the three "fantasy" wishes are somewhat
grandiose. PHYSICIAN'S PRELIMINARY DIAGNOSTIC IMPRESSION: AXIS I: 1. r/o Depressive Disorder NOS vs Bipolar Disorder NOS AXIS II: no diagnosis AXIS III: no diagnosis AXIS IV: moderate - conflicts with peers, academic problems, presence in household AXIS V: GAF 30/50
IDENTIFIED PROBLEMS AND PRELIMINARY TREATMENT PLANS:
TREATMENT TEAM SIGNATURES __________________________
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