Initial Report:

Patient #47 was referred for psychiatric evaluation by family counselor, due to increased concern for the patient's well being, and the safety of those around the patient. 

Patient is a female of average build. Patient's appearance is disheveled, hair unbrushed, clothing unkempt. Patient has continued to be co-operative, but has displayed mistrust of staff. No current acts of aggression displayed. Mistrusting behaviors include avoidance of eye contact, minimal verbal response, and agitation at physical contact. Possible fear of physical touch. When patient does speak, it is with a soft but clear voice. No intellectual concerns at this time.

Patient seems to have persecutory thoughts towards staff, and care givers at home. Patient also expresses somatic thoughts toward the patient's bodily appearance, specifically toward facial and sexual vanity, and weight. Patient is guarded when asked about her own thoughts, but has admitted to acts of self mutilation and thoughts of suicide. Patient confirmed she does not have a plan for suicide. 

Family counselor has confirmed presence of auditory, visual, and tactile hallucinations. Counselor also confirmed depersonalization perception, and occasional flightiness of thought process. Counselor confirms that patient's care givers believe the patient to be withdrawn and showing a loss of interest in daily activities.

Note patient uses terms "depressed" and "anxious" when asked to describe current mood, and seems constricted in verbal response. 

Possible diagnosis to examine: depressive disassociation, body dismorphia, depression/anxiety disorder.

Patient would benefit from pharmaceutical therapy, and consistent counseling.

Doctor's Initials:           HRD                

Date:      11/15/2008