|
|
 |
|
|
|
|
 |
|
|
|
Psychological Evaluation of Mason G Eckhart
Laura Varady, PhD
I.D.: Mason Grey Eckhart is a 48 year old divorced white male with no past psychiatric history.
Chief Complaint: Depressed mood after a severe health reversal
History of Present Illness: Following a work-related incident that left him immunocompromised, M.E. reports suffering from decreased sleep, decreased energy, decreased appetite, and moderately depressed mood. He also admits to some difficulty with concentration. However, he remains focused on his daily job, and has been able to perform his duties competently. He denies having feelings of guilt/anxiety/hopelessness, racing thoughts, suicidal ideation/intent, or hallucinations/delusions, obsessions/compulsions.
Past Psychiatric History: None.
Family Psychiatric History: Mother—depression, committed suicide. The patient is unsure of whether she was being treated or had ever been hospitalized for her depression.
Medications: Exo-skin, vitamin supplements, blood product infusions to offset bone marrow destruction
Medication Allergies: None
Social/Developmental History:
Birth/Development: M.E. and his identical twin Marcus Aaron were born 6/6/62 in a marine base hospital to Captain Conner Doyle Eckhart and Marilyn Thompson Eckhart. Though a multiple birth, it was a normal, uncomplicated vaginal delivery. M.E. and his brother reached all developmental milestones on time, there were no major infant illnesses.
Early Family Life: M.E. describes his father, a marine psychiatrist in Washington D.C., as "distant," and "a strict disciplinarian." He recalls a traumatic childhood incident where his father locked him in a ward with his patients for a weekend as punishment for some misdeed. M.E. had minimal contact with his father over the years as he attended military school and grew into adulthood. His father died of a stroke.
The patient recalls being closer to his mother while he was young, but felt betrayed when she committed suicide before his teen years, "leaving me solely in my father's custody." He denies any history of physical or sexual abuse.
M.E. was also close to his twin, Marcus, who accidentally drowned at the age of eight. The patient refuses to talk about the circumstances of this incident, which has clearly impacted his psychological development.
Education: M.E. maintained a status of top tenth percentile at his military academy and studied military law at West Point. Extracurricular activities included track, rowing, and skeet shooting.
Employment: M.E. joined the Bureau directly from West Point and advanced rank quickly. He began working at Genomex in the 1980's, and now maintains a high-ranking position. He describes his work persona as private, efficient, and dedicated, with a singular attention to detail. His main goals in life are all career-related.
Relationships: M.E. is currently divorced after a 6 year marriage to Jacqueline LaPort Eckhart. From this marriage, he has a son Grey, and twin daughters Michele and Deidre, with whom he has had little contact since the divorce. He denies any serious romantic relationships since the divorce, and is currently sexually inactive. M.E. has no close friendships.
Religion/Spirituality: None.
Mental Status Exam:
Appearance: The patient is a white male who appears his stated age. He is thin, but well-groomed with straight posture. He maintains a reserved but polite attitude towards the interviewer.
Speech: Soft-spoken, normal rate and rhythm. The patient gives full and complete answers without mumbling, dysarthria, stuttering, or syntax abnormalities.
Behavior: Appropriate eye contact. No tremor, tics, or odd positions noted. Normal psychomotor activity.
Mood: The patient describes his present mood as “fine.”
Affect: Reserved, somewhat restricted affect. Mood congruent, and appropriate to present situation.
Perception: The patient denies hallucinations, illusions, or dissociations
Thought Content: The patient denies suicidal, homicidal, or paranoid thoughts
Thought Process: Goal directed, relevant, logical and coherent
Cognitive: 30/30 on Folstein Mini Mental Exam
Judgment: Good
Insight: The patient is fully aware of his present condition and reasons behind it.
Assessment and Plan:
Axis I (Psychiatric illness): Mild-Moderate Situational depression status post suffering a major illness
Axis II (Personality disorder, mental retardation): None
Axis III (Medical illness): Immunologic compromise
Axis IV (Psychosocial stressors): Medical illness, traumatic childhood events, stressful work environment
Axis V (GAF 0-100): 85 at present, 90 in the past year
M.E. suffers from mild-moderate situational depression without suicidal ideation, manic symptoms, anxiety, or psychotic features. He is presently stable, and his mood disturbance has not affected his judgment or ability to work. I am worried only that he appears to have no real support structure in place to help him deal with his present medical condition. His main coping strategy appears to be intensifying his focus on his work. Since the patient has refused medication to improve his sleep and concentration, I have recommended weekly-biweekly counseling sessions as he deems necessary.
Lexajesse
|
|
|
|
|
The Sun Never Sets on PureMX.net
|
|
