Psychiatric Evaluation Clinician: Dr. Gerald Bruner Date: 17/ 03/ 2023 I. Identification, Chief Complaint, and Reason for Referral Raymond Babbitt Autistic Savant. Distress to any small changes, Sticks to routine (Change in routine terrifies him) repeating of words (Stereotypical) Raymond can not explain his emotions and explain his needs . ___________________________________________________________ II. History of the Present Illness Savant syndrome Diagnosed at the age of 18 – 20 Charge to the hospital when he was considered as harm to his 3 year old brother. Disturbed concentration Abnormal social approach reduced sharing of interests emotions. ________________________________________________________________ III. Past Psychiatric History non ____________________________________________________________ IV. Family History Father- died 1988 Mother- died on 5th -1-1965 ________________________________________________________________ V. Past Social and Developmental History 1. Education: Non 2. Family Relationships, Social Network, and Abuse History: Was Close to Father. Tried to burned his younger brother mistake by hot water by 3. Employment Record and/or Military History: Non 4. Legal Record: Non 5. Religious Background: Non ________________________________________________________________ VI Current Social History 1. Family Relationships and Other Interpersonal Factors: Close to Vern, his mentor at the hospital, considers him as his “Main Man. 2. Patient’s Strengths: He has a profound memory (history, numbers, counting cards) far beyond the capacity of his older brother. He is intelligent ________________________________________________________________ VII. General Medical History 1. Disorders: Non 2. Review of Systems: Non 3. Medications: non 4. Physician: Non 5. Allergies: Non ________________________________________________________________ VIII. Mental Status Examination 1. Appearance and Behavior: clean shaven Tilted neck, short hair (straight hair), no emotions, poor eye contact, fixated eyes, normal build 2. Speech: Rapid speech, repeated speech, late latency of response 3. Mood and Affect: its normal but anxious when there is change in routine 4. Thoughts: Random thoughts 5. Perception: Good perception 6. Cognition: Difficulty in adapting new places or sudden changes. 7. Insight: Unaware about his condition, that he is suffering from autism. ________________________________________________________________ IX. General Physical Examination (Non) ________________________________________________________________ X. DSM-5 Differential Diagnosis Autism Spectrum Disorder (DSM-5) (F84.0) (Stage II) A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following: 1. Deficits in social-emotional reciprocity 2. Deficits in nonverbal communicative behaviors used for social interaction (from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language) 3. Deficits in developing, maintaining, and understanding relationships (difficulties adjusting behavior to suit various social contexts). B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by the following: 1. Stereotyped or repetitive motor movements, use of objects, or speech 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior C. Symptoms present in the early developmental period D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability. With Level II Severity (requiring substantial support) ________________________________________________________________ XI. Narrative Summary and Formulation Raymond Babbitt Male Suffer from (chief complain) Distress to any small changes, sticks to routine (Change in routine terrifies him) repeating of words (Stereotypical) Raymond cannot explain his emotions and explain his needs. The starting or the beginning of the this complains was at the age of the 18-20 years’ old He Charged to the hospital when he was considered as harm to his 3-year-old brother. Was Close to Father. He tried to burned his younger brother by hot water by mistake Appearance and Behavior: clean shaven Tilted neck, short hair (straight hair), no emotions, poor eye contact, fixated eyes, normal build His diagnosed with autism spectrum disorder F84.0 (299.00)
