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Mental Status exam for Uncle Sam

MENTAL HEALTH EVALUATION
CONFIDENTIAL

Client Name: Uncle Sam
(A.K.A. Samuel Wilson)

Case #: 741776

Referent: John Q. Public

Date of Birth: 07/04/1775

Age: 239

Date of Report: 07/04/2014

Mental Health Consultant (retired): Robert Weimar, M.S.

Assessment Techniques: Intake Interview
Clinical Interview
Mental Status Examination
Records Reviewed: Food Stamp “E.A.-US”
Historical Image of Lord Kitchener

Collateral Source: Brother Jonathan (A.K.A. Johnny Reb).

Presenting Complaints: PTSD, extreme fatigue, phase of life problem, obesity

Uncle Sam indicates that he has been in every major war since the War of 1812. Now he feels tired, worn out and is wondering what he is going to do as he joins the rank of his country's senior citizens. He also finds himself gaining weight.

Relevant History:

Developmental History:
No prenatal drug or alcohol exposures were reported. No developmental delays are known. No childhood accidents, injuries or childhood surgeries are reported. The Client makes no allegations regarding childhood abuse; however he states while growing up some pancakes and some onions were always replaced with “lasses cakes that were given to the young ones.”

Living Situation:
The client is a mature single man whose permanent address is given only as Washington DC. He has never married. The client had two sisters and one brother. He states that his sister, Columbia also resides in Washington DC and has duties atop of the United States Capitol; he states that sometimes she is confused with another person known as Freedom. He states that the last time he saw his sister was in Chicago in 1893 in Jackson Park where he describes some kind of exposition. The client's other sister whose name was Liberty apparently moved to Hollywood in the 1920s but lost favor with the family when she became a model for one of the motion picture companies. The client's brother, Jonathan, moved to the South and was often referred to by his nickname “Johnny Reb.”

Educational History:
The client was not proud to say that he ranked 17th in his education class. But as he ages he feels that he is slipping especially when he compares himself with some neighbors from Finland and South Korea. He really felt that he should have done better in school with his teachers.

Work History:
Client states that his first job was in 1916 when he is working doing promotional work for a publication called Leslies's Weekly. In our interview he points straight at me and says, “Don’t you remember I did a poster in 1917 where I said, 'I want you.'” He also indicates he worked in Troy, New York for a meat packer; the contractor was Mr. Albert Anderson whose packaged meat was under the label “E.A.- U.S.” The Client indicates that he was in each of the U.S. armed services and saw numerous tours of duty overseas. He states that his PTSD symptoms are from particularly haunting remembrances of his military involvement in Bosnia and Somalia. He reports a particularly bad memory of a Battle of Mogadishu in which he was riding in a Blackhawk helicopter.

Medical History:
Despite his numerous tours of duty in the military and despite his advanced years he is in particularly fair general health; however, he joins one in three senior citizens that are now overweight and finds himself more sedentary in his lifestyle and he has to watch his sugar intake. He reports that he has gained about 24 lbs recently. He seems pleased that he is living in the healthiest metropolitan area of the country that being Washington DC., but he is sometimes worried about his safety in the inner city. He indicates that his medical needs had been cared for by Dr. Walter Reed. Once while traveling in the Midwest he became ill in Rochester, Minnesota and was seen by a father-son medical team by the name of Mayo.

The client is of average height being 5 ft.9 in. and his weight is 195 lbs. His waist circumference is almost 40 in. and he is gaining weight apparently due to his more sedentary lifestyle and sugar intake.

Mental Health History:
The Client indicates that he has emotional problems that have interfered with his work. He states that over the years his stamina has diminished some. He voices concern about his symptoms of post-traumatic stress disorder. While his experience in Bosnia and Somalia are particularly haunting for him his most recent tours of duty in Afghanistan and Iraq were also problemsome. He finds himself particularly frustrated with increased symptoms when he views recent news accounts about political uprisings and continued insurgents in Iraq. In the interview he expresses anger at partisan politics which he states is now being been played out in the nation's capitol. He indicates that as an impressionable youth in his younger years he was part of the original Tea Party in Boston but he has become somewhat disconcerted about present politicians who are using the name “Tea Party” to support their own reelections. He remembers a particularly solemn time when he accompanied the presidential train from Washington DC to Gettysburg, Pennsylvania; he was on guard duty on the train and remembers being asked by Lincoln whether people would know how many years were in “four score.” Today, Uncle Sam expresses frustration and some trepidation that he now has been on a waiting list with the Veterans Administration for some time and has difficulty seeing the same physician or psychiatrist on any regular basis. He indicates he last saw an old Army psychiatrist from Texas, Dr. Paul Hill, who told him that he would not make a gurney case out of the walking wounded. Uncle Sam also feels that he has been over-medicated over the years even when he was a child and placed on Ritalin.

Medications:
The Client did not bring medications of his evaluation but states that he is taking Oxycodone, Lipitor, Lisinopril, Synthroid, Prilosec, Azthromycin, Amoxicillin and Metformin. (These are apparently the most frequently prescribed medicines in the world.)

Alcohol and Drug History:
Uncle Sam indicates that his consumption of alcohol has declined over time and he estimates he consumes about 2.31 gal. of alcohol per year. The client has never been arrested for driving under the influence and has never been in treatment for a drug or alcohol problem.

Legal History:
Uncle Sam cringed at the question if he had been arrested. He gives no history of legal charges or arrests; however, he remembers a particularly cold night when he was just an adolescent in which he was helping row General Washington across the Delaware River. He states that he asked kindly if the general would please take a seat as when he stood up the boat was liable to tip over. He states he tried to make a joke and told the general that he didn't think that his wooden teeth would keep him afloat if he fell in. The General apparently didn't take too kindly to his remarks and Uncle Sam found himself almost on charges for insubordination for his remarks.

Current Functioning/ADL’s:
He indicates that the time he gets up “at the dawn's early light”and the time that he goes to sleep vary. He is gaining weight as he spends more of his time than ever watching television during the day. He estimates that he gets about eight hours of sleep in a 24-hour period. The client indicates that lately he's been needing prompts and reminders to finish tasks but usually when he starts a task he will complete it. He reports leaving some unfinished business Iraq and Korea.

What Client Is Able To Do:
The client is able to get dressed, bathe, shave and brush his teeth. The client indicates he is capable of managing medicines himself. He could call a doctor to schedule appointment however he doesn't know how to reach Dr. Paul Hil, his Army psychiatrist anymore. The client can call a pharmacy if he had questions regarding medicines. He will attend appointments by himself. He is capable of preparing a full meal. He can prepare himself a light meal consisting of sandwiches. He can use the stove, oven, microwave, coffee pot and crock pot. He will clean up after himself in the kitchen including wiping up countries and tabletops. Sometimes he washes dishes. The client can do laundry. He knows the correct amount of bleach and laundry detergent to add to a washer. The client can dust, sweep, mop, make his bed, take out trash and straighten the house. He instill capable of pushing a mower and using a riding lawnmower. The client can do gardening, trim bushes and pull weeds. He's capable of using a cell phone. He does more testing although it is harder on his eyesight. The client indicates that he has a computer and can accesses social network sites and do general internet searches. The client indicates that he does not play on any game systems; he states that he leaves that to NORAD and the Air Force. He can operate a VCR or DVR. He watches television for 4 hours per day. He states that he eats out at a restaurant proximately five times a week. He is able to place his own order for food. He will go shopping at Wal-Mart, grocery stores, gas stations and malls. He shops at least once a week and will shop for less than one hour at a time. He indicates that he can manage his own money with the help of the Office of the Budget and that he can count change, pay bills and balance a bank account although he finds himself still running into high debt.

What Client Is Unable To Do:
Despite his claims of PTSD and fatigue the client indicates that he can do most household tasks and chores.

Social Functioning:
He indicates that he has not visited his brothers or sisters recently. He states that he sees his sister, Liberty, quite frequently when he is watching old movies as she had become the model for a particular motion picture company. He indicates they still get along fine and he will attend family functions on holidays and special occasions--particularly on the Fourth of July. He does tend to children and feels that no child should be left behind. He is somewhat irregular in his church attendance. He presented a list of numerous social clubs and organizations that he belongs. He indicates that he is an honorary member of most. He reports that he has several friends who live around the world. Lately he has been communicating with them by telephone and internet. When asked what he does for fun he claims he enjoys going to a concert in the park, going camping, taking a hike in the woods, going swimming or fishing. He enjoys having a picnic with a friend and visiting museums. He indicates he likes playing board games. As a boy he used to build sand castles when he went to the beach. He likes having Bar-B-Q particularly on the Fourth of July. He finds fireworks displays exhilarating. He enjoys going kayaking and bird watching; he will ride a bike and sometimes go to the local zoo. He states lately that he was cleaning out his house said maybe planning a garage sale.
Client’s portrayal of his ADL’s is a realistic portrayal of his abilities. His ADL information suggests both concentration and goal directed behavior. The information has been fairly accurately reported. He can understand, remember and carry out simple directions and most household tasks with adequate persistence, concentration and pace. Client reports he can structure and execute his day with some prompts or reminders from Congress or the President.

Collateral Source:
Brother Jonathan (A.K.A. Johnny Reb), Uncle Sam's brother states, "I'm still upset with my brother over what he did during the War of Northern Aggression..Also I'm upset with him with all those come-to-visit folk that came to Dixie after the war. Sometimes I just have to ignore my brother and just look away -- look way--look away. I guess I'm resigned myself to live and die in Dixie."

Mental Status and Behavioral Observations:
The client presented as a mature single man who is well groomed wearing a goatee. His hair was gray. He indicates that he has recently gained some weight. He was formally dressed in a blue jacket with red bow tie and striped red and white pants. He seems a little over dressed in our interview tonight. His dress appeared somewhat formal as he carried a white top hat which had a broad hatband that was the same color blue as his jacket with white large stars on the hatband. Despite some dark circles under his eyes as he alleges fatigue he both stood erect and he walked into the interview without assistance. He appeared alert and cooperative. Somewhat disconcerting today is that he caused a disturbance in our waiting room area when he replaced our rather subdued music with John Philip Sousa marches and handed out small American flags and had other clients even those who had been using walkers or canes to begin marching around the waiting room area and our hall. The client's eye contact was unwavering. Rapport was developed. His motor activity during the interview was calm and orderly. His speech patterns were normal, spontaneous and articulate. He said he could both say and see and was looking forward to the fireworks display later today of the rockets red glare and bombs bursting in air. He sleeps through the night and is awakened by the dawns early light. His attitude was somewhat aloof. His eye contact was unwavering and almost a glare. Content of his speech was somewhat formal in content. His mood was neutral; his affect was euthymic. His range of affect appeared broad. His energy level was somewhat diminished but he seemed to perk up after listening to the John Philip Sousa music that he had put on while in our waiting room. His thought processing was spontaneous and logical and relevant. His thought content was adequate and he did not seem to have any negative pre-occupations. Although he did express some religious preoccupation when he said, “My eyes at seeing the glory of the coming of the Lord.” He did express a some worry regarding the huddled masses yearning to breathe free and the wretched refuse from another teeming shore, the homeless and the tempest-tossed.

He was oriented to person, place, time and situation. He was alert and was able to follow simple directions as well as detailed directions. He was able to state the days of the week and the months of the year skipping every other month. He was able to invert the ZIP code for Washington DC. He was able to do serial seven calculations. He persisted at all tasks. His pace was good. He sustained attention. He was able to remember three objects after immediate presentation and also after about 15 minutes. He appeared to be handling the stress of our intake process, interviews and mental status exam today. When his interview was over the client was heard shouting, “Glory, glory hallelujah!

Validity Statement:
Client appeared to have suffered from some posttraumatic experiences; he presents today without meeting full criteria for post-traumatic stress disorder. He was a fair informant and was honest and forthright in his presentation. He did not appear to exaggerate, promote or embellish his symptomatology.

Diagnostic Impressions:

V62.89 (Z60.0) Phase of Life Problem
V69.9 (Z72.9) Problem Related to Life Style.
V62.22 (Z91.82) Personal History of Military Deployment

Summary and Conclusions:
Uncle Sam is a mature single man who gives his age as at least 239 years old. He presents with a phase of life problem, a problem related to life style and a personal history of military deployment. Client presents fairly well in today's evaluation and does not meet all criteria for post-traumatic stress disorder. His portrayal of symptoms and his activities of daily living are considered a valid representation of his current level of functioning. The client continues working in Washington DC. Based on his past work experience he appears to have adequate if not significant ability to handle stressful situations. In today's evaluation he adequately handled the stress of our intake process, interviews and mental status exam. Overall, prognosis for continued stability in mental health is good.

Thank you for this interesting referral. Should you have any questions, concerns or comments regarding this report, please do not hesitate to contact me.

Robert Weimar, M.S.
Clinical Hypnotist and Retired Mental Health Consultant

HAPPY FOURTH OF JULY