Overview
i uploaded a powerpoint of my friend so you can follow the same order, but with a case of antisocial patient. I will add some information about a case that you can use, also you can add more information too.
Patient is a 18-year-old male with a history of DMDD, ADHD, cannabis use disorder, Tobacco use disorder, Unspecified anxiety disorder, who was admitted to the CCSU involuntary via PC due to increasingly aggressive and combative with others. Today, upon evaluation, the patient presents in his bedroom getting up, continues on 2 to 1 sitter for safety, accompanied by MHTs working with the patient, at the interview time patient presents with flat affect, frustrated and somewhat cooperative, minimizing his actions. Patient cited "I`m alright". Patient informed that "I do not want to talk about the incident happened yesterday ... in the middle of the night I blew my nose, and it started bleeding, and now it`s still bleeding ... I had a conversation with my mom during the weekend". Patient reports appropriate sleep pattern and good appetite. Patient exhibits selective/restrictive social interactions for his behavior conditions. At the time of interview, no evidence of delusional thought content and/or mental preoccupations. Denies auditory and visual hallucinations or any other perceptual disturbances. Denies suicidal and homicidal ideation; no plan, intent, and/or target. Undersigned encouraged participation in individual psychotherapy and/or groups. Per nursing staff, patient is taking care of ADLs; received an ETO with mechanical and medication (Olanzapine 10 mg; IM), after unsuccessful deescalation techniques when patient not following unit rules and regulations, being verbally and physically aggressive towards staff members where the law enforcement intervened. Patient is adherent with medication(s), without reported/visible (related) side effects. Client denies having access to firearms or any other lethal means. Patient reports the following substance(s): - Previous experience(s) with: "Weed over a year" HEALTH: Undersigned requested pediatric follow-up from nursing service. Per medical chart, no DCF holds. VITAL SIGNS: Vitals Date: 11/10/2025 Vitals Time: 07:20 AM Blood Pressure: 140/85 Position: Sitting Pulse: 86 bpm Respiratory: 20 bpm Temperature: 97.8 Fahrenheit MENTAL STATUS EXAM: Orientation: Alert, awake, and oriented X3. General Appearance: Appears stated age/ Obesity/ Long hair style blond (Dyed) and natural black/ Old scar on right wrist and forearm. Interview Behavior: Upon evaluation, the patient presents in his bedroom getting up, continues on 2 to 1 sitter for safety, accompanied by MHTs working with the patient, at the interview time patient presents with flat affect, frustrated and somewhat cooperative, minimizing his actions. Eye Contact: Fair to good, intermittent/episodic. Speech: Clear and comprehensible, with normal tone, and normal rate. Mood: "Alright" Affect: Flat. Insight: Limited to fair. Judgement: Fair. Attention/Concentration: Fair to good; fair to good. Memory: No gross deficits, appears largely intact. Thought Process: Coherent, linear, and overall organized. No evidence of disorganization. Thought Content: No delusions and/or mental preoccupations elicited/noted. See below for perceptual disturbances and suicidal/homicidal ideation. Perceptual Disturbances: Denies any/all hallucinations, including A/V. Suicidal/Homicidal Ideation: Denies suicidal and homicidal ideation. AIMS: N/A or 0 (none). DIAGNOSES: Disruptive mood dysregulation disorder Attention-deficit hyperactivity disorder, combined type Anxiety disorder, unspecified Tobacco use disorder, mild Cannabis use disorder, severe Childhood obesity CURRENT PSYCHOTROPIC MEDICATIONS: ESCITALOPRAM 20 MG; Daily at Bedtime GUANFACINE HCL 4 MG ER; Daily at bedtime. SEROQUEL 400 MG; Daily at Bedtime. BENADRYL 25 mg; daily twice a day. CURRENT MEDICATIONS FOR MEDICAL CONDITIONS: None. LABS: Report from 11/10/2025 - Serology: WNL except the following altered value(s): Glucose: 123; B/C ratio: 103.0; Cholesterol: 170; Triglycerides: 172; HDL Cholest: 44.0; Direct LDL: 112; Non-HDL-Choles: 126; T4: 0.50. - Urine: WNL. - Toxicology/drug screen: Negative.
Medical/Surgical Hx Type of Medical Involvement: Surgery Describe: navel hernia Year: 5/6 years old Family Medical Hx Family Member: Father Note Serious Illnesses or Conditions: dyslipidemia Legal History Type of Legal Involvement: Arrested Date: 5-2-2024 Describe: spit in teachers face, swung at her/ battery, court 6/21/24 Legal History Type of Legal Involvement: Arrested Date: June 2024 Describe: Hit teacher, Development Assessment for a minor: Yes Developmental Milestones: Normal Concerns Regarding Walking or Motor Coordination: Yes Describe Concerns: Mother reports client did not walk until age 1.5 years Concerns Regarding Fine Motor Coordination: No Concerns Regarding Speech or Language Acquisition: No Concerns Regarding Bladder or Bowel Control, Including Bed-Wetting: No Concerns Regarding Current Eating Habits: Yes Describe Concerns: Increased appetite Concerns Regarding Current Sleeping Habits: Yes Describe Concerns : Interrupted sleep due to breathing Concerns Regarding Social Interaction with Caregivers or Peers: Yes Describe Concerns: History of physical aggression toward peers Relevant Family Psychiatric and Substance Abuse HX Relevant Family Psychiatric and/or Substance Abuse History: As per electronic health records review. "Mother reports a history of schizophrenia/ Schizoaffective disorder? and substance use (crack cocaine) on his paternal side. Patient's father, paternal grandfather, and three paternal uncles are diagnosed with schizophrenia. Mother uses marijuana for medicinal purposes. Younger brother diagnoses with autism."