History of Present Illness:
A 33 year old male is brought to the psychiatric department by
police after he attacked another man in a bar and threatened to
“rip (your) throat out with (my) bare hands”. The pt.
apparently returned from the restroom in the bar to find the
man putting an arm around his girlfriend. The pt. states that
he immediately became ‘ENRAGED” and began to scream
obscenities. The shouting quickly escalated into a full blown
bar brawl, and the police intervened when the patient wrapped
his hands around the man’s throat and pinned him against the
The pt. admits to numerous incidents of this nature and has
found himself in fights several times each year since late
adolescence. Two months ago, he was arrested for smashing a
car window with a baseball bat when the man “cut him off” on
the highway. He was also fired from several jobs in his late
20’s due to his “hot temper” with coworkers who were trying
to “slight him”. The pt. believes that his actions are sometimes
unreasonable, but the combination of heightened energy,
racing thoughts, and anger makes his urges nearly impossible
The pts. girlfriend states that he is a fun loving and charming
man between episodes but starts arguments with her
approximately twice a week. She claims that during his verbal
attacks he will often make demeaning and devaluing remarks
about her. On several occasions he has broken her personal
belongings during trivial arguments. The pt. acknowledges
that he regrets these episodes, but they usually subside within
a half hour and provide an instant sense of relief.
Past Psychiatric History:
No psychiatric history or past use of psychiatric medications is
reported. The pt. denies symptoms of a mood disorder. He
admits to 1 or 2 alcoholic drinks per week and a history of
marijuana experimentation in his late teens.
Mental Status Exam:
The pt. appears well built and sharply dressed and looks his
stated age. He is awake, alert and oriented in all spheres.
Behavior is appropriate, and eye contact is good. Speech is
clear and coherent with normal rate, rhythm, and volume.
Mood is euthymic, and affect is full. Thought process is logical
and goal directed. Thought content does not include delusions,
ideas of reference, paranoid ideation, suicidal, or homicidal
ideation. Impulse control is poor, as noted by his recent
violent outbursts. Insight is limited because he does not
recognize the maladaptive nature of his behavior. Judgment is
impaired, as evidenced by his inability to behave in asocially
accepted ways. Reliability is fair.
Na = 141, K=4.2, Chloride=106, carbon dioxide =23, blood urea
nitrogen=9, creatinine=0.6, glucose=91.
Blood alcohol level and urine tox are negative.
CT of the head shows no sign of mass, lesion or bleeding.
Electroencephalogram is unremarkable without signs of
slowing or seizure foci.
- Any differential diagnoses (Include a short line indicating why each one should be considered for the case)
- Your diagnosis and reasoning (Please include the time consideration for differentiating adjustment disorders from PTSD). Also, discuss the difference between an Oppositional defiant disorder and Conduct disorder.
- Any additional questions you would have asked to obtain more information.
- Medication recommendations along with your rationale. Please discuss side effects vs benefits vs risks for all medications that are recommended.
- Any labs and why they may be indicated (Include labs to rule out any organic causes of aggression)
- Screener scales or diagnostic tools that may be beneficial
- Additional resources to give (Therapy modalities, support groups, activities, etc.) Do not forget a hotline number and support group.