Patient is a 37 year old male, admitted to the hospital:
Alert, oriented to time, space and person. Short- and long-term memory intact, slightly distractible attention, and briefer concentration.
Slightly neglected appearance, casual dress, sporadic eye contact, adequate posture. Moderate psychomotor restlessness with pacing. Speech with normal rate and tone, lower volume, without pressure.
Seemingly irritated but cooperative behavior. History of hostile impulses. No suicidal or homicidal ideations.
Labile affect, mostly congruent to thought content. Anxious and irritable mood.
Auditory and kinaesthetic sensory-perceptual halucinations are verbalized a few times during the interview. Diffusion of thought, loose associations, minimal tangentiality. Ideas of reference, reading phenomena, and marked delusions of control and harm can be explored. Average judgement, poor insight.
Verbalized marked craving.
Moderate level initial insomnia and fragmented sleep.
Appetite undisturbed.
