Here are the excerpts of the medical records that is circulating in the internet.
History of Present Illness: The patient is a 36-year old single male with a history of profuse salivation and labile moods since his childhood. He was observed to be sleeping excessively, disoriented and confusing family and household member’s name. When interviewed at the time of psychiatric assessment, the patient said he had difficulty in speech, poor concentration, impaired thinking and melancholia brought about by the stresses of his work and the break-up with his flight attendant girlfriend. He also claimed he felt clumsy and uncoordinated. He also describes what appeared to be a deep sense of foreboding and feeling that the “world was coming to an end.”
1. Psychomotor retardation
2. Slowed gait and activity
3. Lack of initiative
6. Lack of self-confidence
7. Lack of sexual interest
Substance Abuse History:
* Smoker = Yes, up to two (2) packs a day
* Drugs = Yes, teen-age experimentation with Marijuana and various pills
* ETOH = Yes, solitary drinker
The Psychologist conducting the interviews noticed that the patient would occasionally walk slowly and aimlessly around the room when being interviewed. He appeared inattentive, vague, non-spontaneous and detached in interactions, but passively followed simple commands. He appeared disoriented. There was some difficulty in communicating due to his deep depression and melancholia. On mental state examination, he was a lanky man of medium height who was mildly psychomotor retarded with a latency of verbal replies, and a slowness of movement. He was preoccupied with his inner thoughts, brooded and felt melancholy. He appeared quite elevated and irritable when he spoke of the loss he was feeling when he recounted his relationship with his girlfriend. He expressed a poorly-formed grandiose delusion that the world was ending and described feelings of foreboding but no disturbance in any other sensory modality. The patient was oriented in person and place, with only very mild impairment of time. Attention and concentration deficits were evident, though much in the slightest and confirmed on formal testing that he had minor difficulty in counting down by seven from 100 and could not readily spell some words backwards. Registration and short term memory were intact on testing but he was often distracted and distant. There was evidence of dysphagia, mild difficulty with three-step commands, concretism and trial-constructional dyspraxia (he could not copy complex diagrams). No confabulation or remote memory deficits were identified. His Mini-Mental State Examination (MMSE) score totaled 28/30. No cognitive impairments. He denied being in need of medical assistance and explained his presence in the school as being due to his sister’s concerns, but did not appear suspicious of possible motives or irritated by his presence in the department. He denied that he had any cognitive deficits. He said he required medication and dietary modification, but did not accept medication offered in fact requiring detailed explanation on why the medication had to be taken.
In as much as the patient exhibits the following symptoms (1) Depressed mood (i.e. feeling sad and empty) most of the day for 10 days, (2) Markedly diminished interest on pleasure in almost all activities (including lack of sexual interest) most of the day for 10 days, (3) A noticeable fluctuation of appetite most of the day for 10 days, (4) Psychomotor agitation or retardation (i.e. increased restlessness) most of the day for 10 days, (5) A diminished ability to concentrate ordering on indecisiveness most of the day for 10 days, (6) Insomia nearly everyday, (7) Fatigue nearly everyday , And (8) a feeling of foreboding everyday. He is diagnosed as suffering from Major Depressive Disorder.