CC (chief complaint): D.C. came to the clinic and said he was sad, unhappy, worried, and scared of losing his partner. I think my girlfriend is cheating on me with another guy and wants to leave me for him.
HPI: DC is a 26-year-old African American male who complained of being depressed, anxious, and fearful of losing his partner when he visited the clinic. The patient suspected his partner of infidelity. He said he knows of several strange and suspicious phone calls his girlfriend has received. He said the caller, talks to his girlfriend more than once, but she said it was a colleague in the same office, and all the calls were for work. The patient said he did not believe her because this was how problems arose in his last relationship, which ended up falling apart. His ex-wife denied it every time he asked her about it, but she eventually ended the marriage and began dating a church member.
The patient said he was worried that his suspicions would soon be proven to be true. When his ex-wife left him in 2018, he said the relationship was over. Going through this cycle again gives me a lot of anxiety and fear. It takes me a while to function and adjust to a new person or relationship after a breakup, which is why I fear finding myself in such stage again. It is hard for me to love someone because I do not know if they will love me the same way. The patient said that when he lost his ex-girlfriend the last time, he did not talk to anyone for almost 12 months. I only talked to close family members and avoided extended family and friends, he said. I do not think I am ready for this. The writer asked the patient what is relationship is with family, friends and colleague at work? Patient stated he finds it hard to trust people he meets because the always judge me and misunderstand whatever I say, unless you prove I can trust you.
Past Psychiatric History:
General Statement After witnessing the 2017 shooting of his bedmate in Baltimore due to gang violence. He said, At the time, he refused medication; no medication was prescribed, but he did get psychotherapy. Before his friends condition improved, the patient said he had flashbacks of lying in a pool of blood for a long time. The patient is mentally unbalanced, and even a significant mental irritation may trigger a breakdown.
Hospitalizations: The patient denies any previous hospitalizations.
Medication trials: Denies taking any prescription medications.
Psychotherapy or Previous Psychiatric Diagnosis: When his friend was shot in 2017, he sought treatment and was later diagnosed with PTSD and depression.
Substance Current Use and History: The patient denies prior or present substance abuse.
Family Psychiatric/Substance Use History: He has no history of substance addiction in the family, but mother had been previously diagnosed with major depressive disorder.
Psychosocial History: The patient is a 26-year-old African American born and raised in Baltimore. The patient today lives independently, has a degree in information technology, and works for Google. He is currently in a relationship. He has one sister and two brothers in his family. He added that his parents lavished him with affection, provided him with a good upbringing, and that he and his siblings were not permitted to do all those other children and adolescents did. I am thankful for it anyhow, he remarked.
Diagnosis is Paranoid personality disorder
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