History of Present Illness:
A 33 year old male is brought to the psychiatric department bypolice 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 theman putting an arm around his girlfriend. The pt. states thathe immediately became ‘ENRAGED” and began to screamobscenities. The shouting quickly escalated into a full blownbar brawl, and the police intervened when the patient wrappedhis hands around the man’s throat and pinned him against thebar.The pt. admits to numerous incidents of this nature and hasfound himself in fights several times each year since lateadolescence. Two months ago, he was arrested for smashing acar window with a baseball bat when the man “cut him off” onthe highway. He was also fired from several jobs in his late20’s due to his “hot temper” with coworkers who were tryingto “slight him”. The pt. believes that his actions are sometimesunreasonable, but the combination of heightened energy,racing thoughts, and anger makes his urges nearly impossibleto resist.The pts. girlfriend states that he is a fun loving and charmingman between episodes but starts arguments with herapproximately twice a week. She claims that during his verbalattacks he will often make demeaning and devaluing remarksabout her. On several occasions he has broken her personalbelongings during trivial arguments. The pt. acknowledgesthat he regrets these episodes, but they usually subside withina half hour and provide an instant sense of relief.Past Psychiatric History:No psychiatric history or past use of psychiatric medications isreported. The pt. denies symptoms of a mood disorder. Headmits to 1 or 2 alcoholic drinks per week and a history ofmarijuana experimentation in his late teens.Mental Status Exam:The pt. appears well built and sharply dressed and looks hisstated age. He is awake, alert and oriented in all spheres.Behavior is appropriate, and eye contact is good. Speech isclear and coherent with normal rate, rhythm, and volume.Mood is euthymic, and affect is full. Thought process is logicaland goal directed. Thought content does not include delusions,ideas of reference, paranoid ideation, suicidal, or homicidalideation. Impulse control is poor, as noted by his recentviolent outbursts. Insight is limited because he does notrecognize the maladaptive nature of his behavior. Judgment isimpaired, as evidenced by his inability to behave in asociallyaccepted ways. Reliability is fair.Labs:Na = 141, K=4.2, Chloride=106, carbon dioxide =23, blood ureanitrogen=9, creatinine=0.6, glucose=91.Blood alcohol level and urine tox are negative.Diagnostic Testing:CT of the head shows no sign of mass, lesion or bleeding.Electroencephalogram is unremarkable without signs ofslowing or seizure foci.
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