Assignment 2: Comprehensive Psychiatric Evaluation Note And Patient Case Presentation

Case study3

Chief complaint “she drives me insane, all she does in nag me”

HPI: Patient is a married caucasion male referred to therapy by his wife. The patient’s wife has

recently threatened divorce, claiming his anger is out of control. He has been married for 7 years.

Patient states that his relationship was great for the first 2 years. Over the last 5 years, he has

gotten increasingly inpatient and agitated with his wife. Him and his wife have been living

separately for the last 6 months. The patient started having angry violent outbursts 6 months ago,

almost daily. After the outburst, the patient leaves and stays in his brother’s guest house. When he

would return home the next morning, his wife would confront his behavior and disappearance,

and the outburst would start over. The patient reports that the family has gone through 5 cell

phones this year because he throws them on the ground and stomps on them during the outburst.

He also screams with such intensity that he is unintelligible. Upon leaving the house, he

slammed the sliding glass door so hard that the glass shattered. Since the marital issues, his wife

has been maintaining their live/work business solely while raising their son who is 18 months.

He spends most hours of the day at his brother’s guest house unable to resolve the longstanding

conflict with his wife. He denies emotional/behavioral problems prior to 5 years ago.

Past Psychiatric History:

● Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History: Infrequent social drinker, 2-3 beers. Heavy use of

caffeine, 6+ cups daily. Smokes “dabs” daily, 1 gram per day. Denies using hallucinogens,

opioids, sedatives, hypnotics, anxiolytics, nicotine or stimulants.

Family Psychiatric/Substance Use History: None provided

Psychosocial History: Patient was born and raised in Reno, NV by his biological parents. He

has one older brother. After the passing of both his parents, he and his brother inherited the house

and resided there together through adulthood. His brother moved out after his wife moved in 7

years ago. He describes his childhood as “great”. He is a highschool graduate, taking normal

classes. After highschool he attended a trade school and started working as an electrician. He

gave up his trade after meeting his wife and opened up an art/jewelry gallery on their property.

No religious preference. He has no criminal background, but police have been sent to the

residence on multiple occasions due to disturbances on the property. Warnings have been issued.

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