medical assessment
...am pt shows no signs of recovery after 7 years of treatment. Family History: PT family was both physicaly and verbaly abusive to the pt throughout his childhood. Pt father was an alchoholic and drug user. Abuse history: PT was a victim of child abuse from his father who sexually abused him over a period of several years. Substance abuse: Pt say that the only drug he abused was marijuana, and some alchohol abuse. There was no period of remesion of pt abuse pt state he has continuasly used throughout his life. Social Data: Pt has family that frequently sends him money but do not visit him. Pt states that he is very wealthy on the outside. Pt has no interest in any speritual affiliation. Pt state that he owned his own trucking buisness and sold drugs for a living on the outside. Appearance: Pt is well groomed and well kept. The pt takes showers as frequenly as possibe, pt hygiene is in perfect shape, the pt is tall and a attractive man. pt hair is well kept and trimmed. Clothes are ironed and pressed and in knew shape. The pt is well spoken and seems to be very educated from the use of words and dielect. Affect and Mood: The pt seems to be in a happy mood, with no signs of saddness to be seen. Pt states that he sleeps very well and keeps very busy. Pt always has something going on such as writing reading or teaching other pt different things. Behavior: The pt is very interactive with the younger population of the hospital. He says that he has three boyfriends in the area. The pt can be very argumentative at times he beliieves that he is better that everyone else and should be treated as such. Thought Processes: The pt is very absessive when it comes to his personal things. He likes to have everything just one way, and if it is not how he wants it then he will ge very angry. The pt is not suicidal and shows no signs of ever trying. The pt dose not like to be around large numbers of people, he likes to stay in smaller groups so that he can maintain control of them. Speech pattern: The pt speeks very elequently and has a very educated manor. He is a very munipulative person and trys to see where your shortcomings are so that he can capitlaize on them. Pt can relate to others in many different ways so he has a lot of respect from the groups. Symtpoms: Pt state that he hears voices thoughout the day and the night. Pt also says that he has multiple personalities, seven to be exact. He says that he cant remember anything when they come out and that they just act on their own. Pt also says that he has hallucinations, that he sees the devil all the time. The pt will get very angry if his envirnment is out of his liking, becomes very agitated and aggressive. Todays most important issue for the pt: The pt says that the most important issue for him today is trying to clean up his living area and get the rest of his roomates to work with him. Therapeutic communication summary Opened ended questions: Do you know why you are in here or do you forget? pt says that he remmembers what he did but has trouble controling his feeling about the situation. He says that he thinks his other personalities forced him to do these things. do you think growing up the way you did had anything to do with your troubled lifestyle or do you think it would have happend anyway? pt state that he believes that somewhere he just decided it was easyer to be someone else so he would not have do deal with things ...