BPD
Criteria Clinical Notes
Subjective CC: Patient presents with complaints of recent self-harm, feelings of
Include chief boredom, and frustration with current living situation
complaint, subjective HPI: Mr. Rice is a 37-year-old African American male who presented
information from the to the clinic for a wrist infection. He reported that injury occurred as a
patient, names and result of his impulsive act of breaking a window during a party at the
relations of others fraternity he was living in. He reported dissatisfaction with his living
present in the arrangements at the fraternity, and being left out and lonely most of
interview, and basic the time. Mr. Rice reported consuming alcohol during social events,
demographic and attributed that to his boredom, the self-centered fraternity
information of the brothers, and the lack of meaningful connections. Mr. Rice stated he
patient. HPI, Past has a history of self-harm, few suicide attempts such as the severe
Medical and burns self-inflicted at the age of seventeen or eighteen. He stated
Psychiatric History, that he needs more meaningful social interactions and intellectual
Social History. engagement, which he feels he lacks in the fraternity setting. Mr.
Rice reported he met a woman named Miss Murray at a bus stop
and felt a connection with her, and would like to move in with her for
companionship and stimulating conversations.
Past Psychiatric History:
• General statement: reports that he has been under
psychiatric treatment prior to this evaluation, and previously
sought help for mental health concerns but without success.
• Current Caregivers: none
• Hospitalization history: Mr. Rice’s history of seeking
psychiatric care, previous severe medical hospitalizations,
and mentions of self-harm and suicidal ideation indicate a
complex mental health background that may include past
psychiatric hospitalizations.
• Medication history: He has no prior history of psychiatric
medications.
• Psychotherapy/Previous Pychiatric Diagnosis: He had seen
psychiatrists in different cities, but he expressed
dissatisfaction with the psychiatric care he received in the
past because it did not improved his mental health. He
moved to his current area in search of a decent psychiatrist
because of its reputation as a supportive mental health
community, but he is not currently in contact with any mental
health specialists. Mr. Rice stated that he attempted suicide
on multiple occasions, which may warrant hospitalization if
he were to present with severe suicidal ideation or behaviors
, in the future.
Substance Current use: Reports ocassional alcohol use but denies
cigarette smoking, or other illicit drugs.
Family Pyschiatric history: Mr. Rice does not mention any psychiatric
history of his parents or other family members during the interview.
This lack of information makes it difficult to assess whether there is a
genetic or familial predisposition to mental health conditions.
Social history: Mr. Rice indicates that during the first three years of
his life, he was hospitalized due to a congenital heart condition, and
his family lived a hundred miles away from the hospital. This
suggests that while he had parents their involvement during that time
may have been limited due to the distance and circumstances. He
has a history of feelings of being an outsider, which he also
experienced growing up and attending school. Recently, Mr. Rice
lived in a fraternity, where he described himself as an "honorary
member." He felt disconnected from other members and found the
environment unfulfilling and boring. He had some work experience,
mentioning a short stint as a short-order cook that he left due to
physical pain from scar tissue on his chest.
Past Medical history:. He has a history of hospitalizations and
complications during early childhood due to congenital heart
conditions, which has contributed to his feelings of isolation
throughout his life.
Past Surgical history:. Burn Injury: He mentioned being burned on
his chest when he was seventeen or eighteen years old due to
pouring gasoline and then lighting it. This incident resulted in
significant burns that required hospitalization for almost a year.
Congenital Heart Condition: Mr. Rice also referenced having a
congenital heart condition that involved complications requiring
surgery during his early childhood. He spent the first three years of
his life in the hospital due to this condition and the associated
complications, suggesting multiple medical interventions, including
surgeries.
Medications: Mr. Rice noted a lack of effective treatment from past
psychiatrists, which may have included medications, but he did not
detail any specific psychiatric medications. Mr. Rice was prescribed
Amoxicillin for the wrist infection.
Allergies: No food allergies. No seasonal allergies. Drugs:Penicillin
(reaction: rash)
Spiritual history: none
Primary Care Physician: Patient does not see a physician regularly.
ROS:
General : Mr. Rice denies fever, generalized weakness, or chills.
Criteria Clinical Notes
Subjective CC: Patient presents with complaints of recent self-harm, feelings of
Include chief boredom, and frustration with current living situation
complaint, subjective HPI: Mr. Rice is a 37-year-old African American male who presented
information from the to the clinic for a wrist infection. He reported that injury occurred as a
patient, names and result of his impulsive act of breaking a window during a party at the
relations of others fraternity he was living in. He reported dissatisfaction with his living
present in the arrangements at the fraternity, and being left out and lonely most of
interview, and basic the time. Mr. Rice reported consuming alcohol during social events,
demographic and attributed that to his boredom, the self-centered fraternity
information of the brothers, and the lack of meaningful connections. Mr. Rice stated he
patient. HPI, Past has a history of self-harm, few suicide attempts such as the severe
Medical and burns self-inflicted at the age of seventeen or eighteen. He stated
Psychiatric History, that he needs more meaningful social interactions and intellectual
Social History. engagement, which he feels he lacks in the fraternity setting. Mr.
Rice reported he met a woman named Miss Murray at a bus stop
and felt a connection with her, and would like to move in with her for
companionship and stimulating conversations.
Past Psychiatric History:
• General statement: reports that he has been under
psychiatric treatment prior to this evaluation, and previously
sought help for mental health concerns but without success.
• Current Caregivers: none
• Hospitalization history: Mr. Rice’s history of seeking
psychiatric care, previous severe medical hospitalizations,
and mentions of self-harm and suicidal ideation indicate a
complex mental health background that may include past
psychiatric hospitalizations.
• Medication history: He has no prior history of psychiatric
medications.
• Psychotherapy/Previous Pychiatric Diagnosis: He had seen
psychiatrists in different cities, but he expressed
dissatisfaction with the psychiatric care he received in the
past because it did not improved his mental health. He
moved to his current area in search of a decent psychiatrist
because of its reputation as a supportive mental health
community, but he is not currently in contact with any mental
health specialists. Mr. Rice stated that he attempted suicide
on multiple occasions, which may warrant hospitalization if
he were to present with severe suicidal ideation or behaviors
, in the future.
Substance Current use: Reports ocassional alcohol use but denies
cigarette smoking, or other illicit drugs.
Family Pyschiatric history: Mr. Rice does not mention any psychiatric
history of his parents or other family members during the interview.
This lack of information makes it difficult to assess whether there is a
genetic or familial predisposition to mental health conditions.
Social history: Mr. Rice indicates that during the first three years of
his life, he was hospitalized due to a congenital heart condition, and
his family lived a hundred miles away from the hospital. This
suggests that while he had parents their involvement during that time
may have been limited due to the distance and circumstances. He
has a history of feelings of being an outsider, which he also
experienced growing up and attending school. Recently, Mr. Rice
lived in a fraternity, where he described himself as an "honorary
member." He felt disconnected from other members and found the
environment unfulfilling and boring. He had some work experience,
mentioning a short stint as a short-order cook that he left due to
physical pain from scar tissue on his chest.
Past Medical history:. He has a history of hospitalizations and
complications during early childhood due to congenital heart
conditions, which has contributed to his feelings of isolation
throughout his life.
Past Surgical history:. Burn Injury: He mentioned being burned on
his chest when he was seventeen or eighteen years old due to
pouring gasoline and then lighting it. This incident resulted in
significant burns that required hospitalization for almost a year.
Congenital Heart Condition: Mr. Rice also referenced having a
congenital heart condition that involved complications requiring
surgery during his early childhood. He spent the first three years of
his life in the hospital due to this condition and the associated
complications, suggesting multiple medical interventions, including
surgeries.
Medications: Mr. Rice noted a lack of effective treatment from past
psychiatrists, which may have included medications, but he did not
detail any specific psychiatric medications. Mr. Rice was prescribed
Amoxicillin for the wrist infection.
Allergies: No food allergies. No seasonal allergies. Drugs:Penicillin
(reaction: rash)
Spiritual history: none
Primary Care Physician: Patient does not see a physician regularly.
ROS:
General : Mr. Rice denies fever, generalized weakness, or chills.
