INTAKE DATE: August xxxx
Diagnosis:
F32.3 Major Depressive Disorder, single episode with mood congruent psychotic
features
Z60.0 Phase of Life Problem
IDENTIFYING/DEMOGRAPHIC DATA: Eliazer is a 24-year-old Brazilian
male. Eliazer’s religion is Catholic. He is single and attending the University of
Maine for his master’s degree in finance. Eliazer was born and raised in Sao Paulo,
Brazil and came to the United States 2 years ago.
CHIEF COMPLAINT/PRESENTING PROBLEM: Over the past three months
Eliazer reported he hear angel’s voice during the day and more so at night. Eliazer
had thoughts about killing 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 months, Eliazer began to
become socially withdrawn (keeping himself in his room), losing his concentration
and feeling depressed. He showed signs of difficulty organizing his thinking by
shifting from one topic to another in discussions with no logical connection.
Eliazer began spending his time browsing and chatting in Facebook about God and
UFO’s. He would spend a lot of time online until he passed out. His sleep patterns
became inconsistent which led him to feeling fatigued all day.
PAST PSYCHIATRIC HISTORY: Eliazer denies any past psychiatric history.
SUBSTANCE USE HISTORY: Eliazer 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: Eliazer had been admitted to a hospital six weeks
ago for treatment as his wrist was injured due to a suicide attempt.
FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Eliazer is the second of
five siblings. One of his family members has schizophrenia but would not identify
the family member.