COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION

Hispanic Male
18 year old
New client started last week
He is a new client seen for intake client assessment.

dx:
r/o OCD
r/o sexual disorder
r/o eating disorder
r/o anxiety
r/o trauma/PTSD

Presenting problem:
– masturbation (w/o receiving pleasure)
– pornography’s use, for 6 years
-moderate mental health symptoms
-family hx of mental illness (mother and brother)

Medical issue:
“Under-eating “, however client denies eating disorder

Social:
currently in college, studding to be a pastor
not employed
will be transferring to university upcoming Fall, hoping to find a job

not in a relationship
had a girlfriend in HS, however things ended “bad” per client. He is currently has anxiety of meeting his ex-gf in university, he is afraid to speak with her.

the therapist asked the client what he meant by “under-eating”?
– client states he does not eat enough, he goes to gym, but he couldn’t finish his plate.
-client states he sets a timer on his phone, to see how much time it takes for him to prepare food. He states that usually it takes him a very long time to prep meals. After he finishes his meal, he sets the timer for 45 min and then goes back to eat.
– regular meal plate consists of: 6 eggs, steak, mushrooms, etc. client reports he only eats half of the plate
– client reports he has his routine with setting up timer/eating, and if he does not follow his routine, he feels like “poop”
-client reports that he has remembered that with previous therapist they has to work a lot on negative self talk

Family:
Grew up in Long Beach, California then moved to Riverside
Step-sister (sharing same dad)
Brother (older brother) 25 y.o

School:
reports he has been bullied in 2-4 grade, by a female classmate that he went to pre-school together. Client reports she was gossiping about him, but nothing physical.
He reports this girl was making sexually inappropriate comments about her breast, and sexual comments in general.

Older brother as a trigger:
Patient reports his older brother, introduced him to sexual topics, before he was ready to process. He reports that he did not understand or knew anything about sex, however, because his classmates and friends were all talking about it, he just had to do it, to fit in

Mother and father:
Client states he was surrounded by love and respect at his house. Mother and father provided everything he needs, and reports he can freely speak to them on any subject.

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