CASE of CARLOS R. INTAKE DATE: May 2019 IDENTIFYING/DEMOGRAPHIC DATA: Carlos is a 7 year old male in the third grade. He lives in Houston, Texas with his parents. He is the only child to two parents, both of whom have completed post-graduate education. His parents are originally from Guatemala and relocated to the United States when Carlos was 6 months old for job opportunities. Carlos is an intelligent and caring young boy who presents with significant potential to excel academically. CHIEF COMPLAINT/PRESENTING PROBLEM: Carlos was referred for an evaluation becausehis parents and teacher indicate that Carlos is restless, and often requires reminders to help him stay on task. He is described as "constantly running around" and presenting with difficulties listening and following instructions. HISTORY OF PRESENT ILLNESS: Carlos enjoys spending time with his friends, and participating in physical activities such as swimming, running and skating. He also enjoys participating in social events, and is often invited to play dates and birthday parties. While Carlos interacts well with peers his own age, his parents believe he is easily led and influenced by others. Carlos does get upset when he does not receive recognition or feels that he has been ignored. His teacher notes that he sometimes acts 'socially immature', and that he often demonstrates attention-seeking behavior. Carlos has difficulty focusing and sitting still in class. He is able to 'hyper focus' on some activities of interest however he often has difficulty sustaining his attention at school. Carlos has been known to blurt out answers and interrupts other students in the classroom. His mother reports difficulties at home with following routines and remembering instructions. His parents describe emotional reactivity as well as confrontational behaviors demonstrated both at home and at school. His teacher notes that Carlos is defiant towards listening to instructions, but generally interacts well with his peers. He is easily frustrated and emotionally impulsive - Carlos has had several incidents of hitting, crying outbursts, and inappropriate behavior. Behavioral concerns with aggression, lying, arguments, and disruptive behavior were noted in his pre-school program at age 4. Each school year since teachers have reported incidents in the classroom. PAST PSYCHIATRIC HISTORY: This is the first evaluation for Carlos.It is noteworthy that he did not know his address or home phone number, could not print his surname, and recognized only a few pre-primer words. SUBSTANCE USE HISTORY: None reported PAST MEDICAL HISTORY: Carlos has been vaccinated with all the needed vaccinations to attend school. There is no noteworthy illnesses to report. FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Carlos’ parents report some history of mental illness in the family. His maternal grandmother was diagnosed with depression. Carlos has always had challenges falling asleep, and sometimes find ...

1. CASE of CARLOS R.
INTAKE DATE: May 2019
IDENTIFYING/DEMOGRAPHIC DATA: Carlos is a 7 year old
male in the third grade. He lives in Houston, Texas with his
parents. He is the only child to two parents, both of whom have
completed post-graduate education. His parents are originally
from Guatemala and relocated to the United States when Carlos
was 6 months old for job opportunities. Carlos is an intelligent
and caring young boy who presents with significant potential to
excel academically.
CHIEF COMPLAINT/PRESENTING PROBLEM: Carlos was
referred for an evaluation becausehis parents and teacher
indicate that Carlos is restless, and often requires reminders to
help him stay on task. He is described as "constantly running
around" and presenting with difficulties listening and following
instructions.
HISTORY OF PRESENT ILLNESS: Carlos enjoys spending
time with his friends, and participating in physical activities
such as swimming, running and skating. He also enjoys
participating in social events, and is often invited to play dates
and birthday parties. While Carlos interacts well with peers his
own age, his parents believe he is easily led and influenced by
others. Carlos does get upset when he does not receive
recognition or feels that he has been ignored. His teacher notes
that he sometimes acts 'socially immature', and that he often
demonstrates attention-seeking behavior.
Carlos has difficulty focusing and sitting still in class. He is
able to 'hyper focus' on some activities of interest however he
often has difficulty sustaining his attention at school. Carlos has
been known to blurt out answers and interrupts other students in

2. the classroom. His mother reports difficulties at home with
following routines and remembering instructions. His parents
describe emotional reactivity as well as confrontational
behaviors demonstrated both at home and at school. His teacher
notes that Carlos is defiant towards listening to instructions, but
generally interacts well with his peers. He is easily frustrated
and emotionally impulsive - Carlos has had several incidents of
hitting, crying outbursts, and inappropriate behavior. Behavioral
concerns with aggression, lying, arguments, and disruptive
behavior were noted in his pre-school program at age 4. Each
school year since teachers have reported incidents in the
classroom.
PAST PSYCHIATRIC HISTORY: This is the first evaluation
for Carlos.It is noteworthy that he did not know his address or
home phone number, could not print his surname, and
recognized only a few pre-primer words.
SUBSTANCE USE HISTORY: None reported
PAST MEDICAL HISTORY: Carlos has been vaccinated with
all the needed vaccinations to attend school. There is no
noteworthy illnesses to report.
FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Carlos’
parents report some history of mental illness in the family. His
maternal grandmother was diagnosed with depression. Carlos
has always had challenges falling asleep, and sometimes finds
that he wakes up in the middle of the night. When he wakes up
he finds that he has a difficult time getting back to sleep -
sometimes staying awake for as long as an hour and a half.
MENTAL STATUS EXAM: Carlos is age appropriate in size
and structure. His appearance is clean and neat. Carlos is an
active child and interacts with his parents appropriately. There
does not appear to be any underlying overtones between the

3. parents and Carlos. Carlos did not have any problems
separating from his parents when being interviewed. Speech is
appropriate for child’s age. Carlos’ mood is in normal range
and congruent with his mood. Affect was appropriate. There
were no hallucinations or delusions. There were some
challenges with Carlos’ judgment and insight.
CASE PRESENTATION – Case of Edward
INTAKE DATE: August 2019
IDENTIFYING/DEMOGRAPHIC DATA: Edward is a 24 year
old Caucasian English male. Edward’s religion is Protestant.
He is single and attending the University of Maine for his
Masters Degree in Finance. Edward was born and raised in
Liverpool, England and came to the United States 2 years ago.
CHIEF COMPLAINT/PRESENTING PROBLEM: Over the past
three monthsEdward reported he had auditory hallucinations of
an angel’s voice, suspiciousness, ideas of reference and
hostility, and moderately severe conceptual disorganization.
Patient tried to kill his roommate by suffocation - claiming that
he heard fireflies tell him the roommate is influenced by Satan.
HISTORY OF PRESENT ILLNESS: In the last several
weeks,Edward began to become socially withdrawn (keeping
himself in his room), had signs of disorganized speech &
thought. Edward began spending his time browsing and
chatting in Facebook about God and UFO’s. He would spend
too much time online until he passed out.
PAST PSYCHIATRIC HISTORY: Edward denies any past
psychiatric history.

4. SUBSTANCE USE HISTORY: Edward denies any use of illicit
drugs. He does report occasional use of alcohol. He has been
drunk as a teenager but prefers not to indulge that much.
PAST MEDICAL HISTORY: Edward had been admitted to a
Hospital to get treatment as his wrist was injured due to a
suicide attempt, six weeks ago.
FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Edward
is the second from five siblings. One of his family members has
mental illness (schizophrenia), but would not identify the family
member.
CURRENT FAMILY ISSUES AND DYNAMICS (OPTIONAL):
Edward attends school for finance. His family continues to
reside in England. His parents are very supportive of his
attendance at an American school. Edward is able to socialize
with other students and professors. He engages in leisure
activity such as surfing the Internet, keeps his room tidy, doing
household activity such as washing clothes, and kitchen
preparation.
MENTAL STATUS EXAM: Edward appeared disheveled with
poor hygiene. He was properly attired with hospital attire and
had adequate eye contact. Edward was able to cooperate during
interview. There were some signs of anhedonia, inappropriate
behavior. He raised his voice at one time during the interview.
His mood was irritable with upset speech. He was not coherent
at times. Sometimes there appeared irrelevant talk. Thoughts
were preoccupied with obsessions, and persecutory delusions.
Perceptions showed auditory hallucinations. He was oriented:
able to state person, place and time correctly. His short term
memory was intact: able to retrieve games rule. His long term
memory was good: able to recall previous history. Insight was
good.

5. CASE PRESENTATION – F
INTAKE DATE: May 2019
IDENTIFYING/DEMOGRAPHIC DATA:
This is a voluntary admission for this 32 year old Black
male. This is F’s first psychiatric hospitalization. F has been
married for 13 years and has been separated from his wife for
the past three months. He has currently been living with his
sister. His family residence is in Nashville, TN where his wife,
two daughters and son reside. F graduated high school then
attended a technical school for computers. In the past, F
worked for seven years at the front desk of a hotel. For the past
three years F has been employed at a local print shop. Religious
affiliation is agnostic.
CHIEF COMPLAINT/PRESENTING PROBLEM:
"I need to learn to deal with my wife wanting a divorce."
HISTORY OF PRESENT ILLNESS:
This admission was precipitated by F’s increased depression
with passive suicidal ideation in the past three months prior to
admission. He identifies a major stressor of his wife and three
children leaving him three months prior to admission. F has had
a past history of alcohol binges but only drinks periodically
now when there is a need for coping mechanisms in times of
stress. F was starting vacation from work just prior to admission
and recognized that if he did not come to the hospital he did not
know what would happen. F reports that in the past three
months since separating from his wife, he has experienced sad
mood, fearfulness, and passive suicidal ideation. He denies a
specific suicidal plan. Wife reports that during these past three
months prior to admission, F made a verbal suicide threat.
F reports he has been increasingly withdrawn/non-
communicative. His motivation has decreased and he finds
himself "sitting around and not interested in doing chores at

6. home". He reports decreased concentration at work and
increased distractibility. F has experienced increased
irritability, decreased self esteem, and feelings of guilt/self
blame. There is no change in appetite. F states for many years
he doesn’t sleep, having a past history of working double shifts
when requested. F reports his normal sleep pattern for many
years has been generally three hours of unbroken sleep. He then
feels tired and ends up sleeping more than his average
pattern. Wife reports he has not been violent with her since
they have been separated.
F denies suicidal ideation at the present time while on the
evaluation unit.
PAST PSYCHIATRIC HISTORY:
F was seen on an outpatient basis by Dr. S, for a period of
two months prior to admission. He was being seen for
individual counseling because of the marital problems and
depression. Dr. S recently referred F for inpatient treatment
SUBSTANCE USE HISTORY:
F reports a history of some alcohol binges in the past. He
began drinking beer in 2008. His pattern of drinking was to get
drunk with his social group approximately twice per month. He
denies a history of blackouts. He admits to the alcohol binges in
the past. Since his marital breakup, F reports using alcohol as a
coping mechanism for stress (reporting that he will only drink
on weekends now but doesn’t get drunk).
PAST MEDICAL HISTORY:
F reports having been involved in a motor vehicle accident
with loss of consciousness in 2004. He states he has no memory
of the accident. F had a past history of fractured toes with pins
being inserted in the third and fourth digits in his right foot
after an accident in which he crushed his foot playing sports. F
denies a past history of seizures.
F smokes approximately two packs of cigarettes per day. F is

7. allergic to Codeine.
FAMILY MEDICAL AND PSYCHIATRIC HISTORY:
Father and grandfather have a history of cardiovascular
disease.
F reports that while growing up his parents maintained a
satisfactory relationship. Father reportedly worked nights and
slept during the day. F did not have much contact with his
father but now enjoys a close relationship with his father. He
states he has always had his parents support.
During F’s school years, he reports he was an underachiever
in elementary school. He denies having had a history of
discipline problems or hyperactivity. He states he did well in
high school and earned grades of A’s and B’s. F played football
in HS.
F has been married for 13 years and has recently been
separated for the past three months. F and his wife have three
children including a daughter, age 12, a daughter, age 8, and a
son age 7. F states he feels very invested as a parent and feels
close to his children.
Leisure time activities F has enjoyed in the past include
playing softball, skiing, reading, playing poker, and watching
football. His wife has complained that he is doing less of that
now. F states he has several close friends.
CURRENT FAMILY ISSUES AND DYNAMICS:
Wife reports that F’s difficulties began to get worse a few
months ago when she decided to move out of the house due to
F’s increasing erratic behavior. She moved into her parents’
house and F is living with his sister. Wife states that F has been
suffering from mood swings. At one point, after threats from
his wife, F told her that he had gone to a clinic for outpatient
rehabilitation, but she did not believe him.
Wife describes F as "extremely depressed" now and says F
states, "life is over…I wish I was dead…don’t send the kids
over to visit because I don’t want them to find my dead

8. body…everything I touch turns to garbage. Wife adds that F
suffers from poor self esteem, lack of sleep and an extremely
boastful attitude. On the positive side he is a good father,
compassionate, creative, and could be an outstanding person.
Wife reports F always had a bad relationship with his
mother. F is close to his father who is reported to have an
alcohol problem and was allegedly loud and intimidating.
F is currently employed by his wife’s father. F states he has
financial problems now due to paying for counseling and child
support.
MENTAL STATUS EXAM:
F presents as a casually dressed male who appears his stated
age of 32. Posture is relaxed. Facial expressions are appropriate
to thought content. Motor activity is appropriate. Speech is
clear and there are no speech impediments noted. Thoughts are
logical and organized. There is no evidence of delusions or
hallucinations, which F denies. F admits to a recent history of
passive suicidal ideation without a plan, but denies suicidal or
homicidal ideation at the present time. His wife has observed a
history of notable mood swings. No manic-like symptoms are
observed at the time of this examination.
On formal mental status examination, F is found to be
oriented to three spheres. Fund of knowledge is appropriate to
educational level. Recent and remote memory appear intact. F
was able to calculate serial 7’s. In response to three wishes, F
replied "I wish that my marriage would work out and that my
kids would be happy and that someone would give me a million
dollars.”
1
3
Dr. Diane Rullo CASE of Sigmund
INTAKE DATE: FEBRUARY 2019

9. DEMOGRAPHIC DATA:
This is a voluntary intake for this 53 year old Jewish male.
Sigmund has had several psychiatric hospitalizations in the past.
Sigmund has been married for 29 years and has been separated
from his wife for the past ten months. He has been living alone
for the past five months. His wife and three daughters live two
blocks from him. Sigmund has had difficulty in jobs and has
not been at any job longer than three years.
CHIEF COMPLAINT:
"I miss my family and do not want to live without them".
HISTORY OF ILLNESS:
Sigmund reports first seeking psychiatric treatment when he
was sixteen years old. He was prescribed anti-depressants, but
does not remember what kind. Since they helped his mood he
remained on anti-depressants for several years. In his late teens
he began drinking. His use of alcohol continued into his early
thirties. At thirty four years old he attempted suicide after his
wife and children left him. He was hospitalized in a psychiatric
unit for thirty days. At that time Sigmund was put on lithium,
with continued successful results for several years, resulting in
reconciliation.
In December 2018 Sigmund returned to his psychiatrist
because he was becoming depressed again, feeling sad, fearful
and suicidal. He was given Parnate. Soon after, both Sigmund
and the psychiatrist did not think this was working very well
and the psychiatrist added Ritalin to his medication regiment.
During the next three months Sigmund felt on top of the world
sometimes lasting for 10 days. He then would have angry
outbursts. His wife asked him to leave the home. He then took
an overdose of Klonopin. Sigmund was then prescribed ECT
(shock treatment). Sigmund returned home after the shock
treatment but reported that it was an inhumane experience and
felt anger towards his wife believing she forced him to receive
ECT to return home.

10. Sigmund continued on anti-depressants and lithium. Mrs.
Sigmund was getting continuously concerned about their
financial state because Sigmund would constantly be buying big
items that they could not afford. They would have arguments
about this all the time. By the end of August he was asked to
leave his home again because he used pills as a suicidal gesture.
He began drinking again to cope with the separation. This use
and behavior continued up to his current presentation for intake.
PSYCHOSOCIAL HISTORY:
Sigmund reports growing up as tumultuous. His mother beat
him and would lock him out of the house when she became
angry. His mother separated from his father on several
occasions and sometimes would throw Sigmund out of the house
with the father. His mother made all the decisions and his
father played a more passive role. Both parents would often
have physical fights and Sigmund would try to break up the
fighting from as early as he can remember.
Sigmund is the only child from his parents union. He has an
older brother from his mother's previous marriage. Sigmund
does not have any contact with his brother. Sigmund was
initially considered an underachiever in the early years of
school. He had trouble being in fights with other kids because
they use to make fun of his wrinkled clothes. Sigmund always
wanted to be a doctor. He spent the following five years after
college graduation taking courses but never completed his
graduate studies.
Sigmund has no legal history. He worked in the family
business through high school and college. He became a project
coordinator at his next job. He stayed there three years.
MEDICAL HISTORY:
Sigmund states he currently takes Synthroid for a thyroid
problem and this helps him keep his weight down.
FAMILY ISSUES AND DYNAMICS:

11. Sigmund was first married at age twenty one years old. He
reports not loving his first wife but liked the stability of her
family and asked her to marry him. They spent one year
together. He physically abused her from the beginning of their
marriage. Mrs. Sigmund the first had an affair that ended the
marriage. Mrs. Sigmund reports Sigmund had spoken to her
several times about getting involved with other men for sexual
pleasure with his knowledge and she states she just followed
through with his wishes. They had no children.
Six months after his first divorce Sigmund married again.
He reports not loving his second wife but thought it was better
to be married. The second Mrs. Sigmund had one child from a
previous marriage who Sigmund adopted. They had two other
children.
The first ten years of their marriage Sigmund reports
physically abusing his wife. He reports hitting the oldest child
once. He stopped the physical abuse when Mrs. Sigmund asked
for a divorce the first time. Sigmund reports he always wants
people around him. He believed his wife was becoming more
distant from him over the past several years which he could not
take. Their fighting increased, although he would not become
physical with her now.
MENTAL STATUS EXAM:
Sigmund presents as a neatly dressed male who appears
younger than his stated age. His hair is a bit disheveled. His
nails are neatly groomed. Facial expressions are appropriate to
thought content. Motor activity is appropriate. Thoughts are
logical and organized. There is no evidence of hallucinations.
Sigmund admits to a history of suicidal ideation, gestures and
attempts. His mood is depressed. During the interview
Sigmund talked fast. Sigmund is oriented to time, place and
person. His intelligence appears above average.
Case D
Dr. Rullo

12. CASE PRESENTATION - Darien
Intake Date: November 2018
Identifying Information:
A 27 year old African-American, male student was referred
for a psychiatric consultation after a workup for gastrointestinal
distress proved negative. Darien has consulted his family
physician after months of feeling bloated and nauseated in
anticipation of certain distressing events and circumstances.
History of Present Illness:
Darien described 3 years of “anxiety attacks” accompanied
by palpitations, shortness of breath, hot flashes, sweating and
parathesias, in addition to abdominal discomfort. Their onset
was clearly traced to a blind date arranged by a close friend.
On the way with his friend to pick up the girl he suddenly felt
extreme nausea and was forced to pull the car off to the side of
the road. He got out for a breath of fresh air and promptly
vomited. Although his friend forced him to go through with
the date, Darien was extremely nervous and preoccupied
throughout, took his date home immediately after the movie was
over and sped away without even walking her to the door.
Darien has continued to think about this situation and feels
down when thinking of what happened in the past. Over the
past several months his mood is low and he has had trouble
staying asleep at night. Although he had previously been shy
around girls, following this incident, Darien panicked at the
thought of a date. There were girls to whom he felt attracted,
but whenever he brought himself to even consider asking one
out, he became symptomatic. The anticipation generalized so
that he became anxious going to local basketball games, bars
and concerts with friends because he might see girls he was
interested in meeting, talking to or dating. He frequently felt
like staying home but forced himself with the help of some peer
pressure to go out at least "with the boys." More recently he
does not even want to do that. He finds himself staying home

13. more and eating to relax himself.
As he neared completion of his MSW program he had to go
for job interviews, these began to cause anticipatory anxiety.
He described feeling "trapped" in the interview with "no way
out." He then developed a fear of talking on the phone to
people to arrange appointments for interviews or follow-ups.
He was hired by a large municipal welfare agency and stayed
mostly to himself on the job. His telephone fear extended to
conversations with clients. Darien finds himself being more
challenged now because he is forgetting things at work and is
having difficulty focusing.