HOSPITAL COURSE
Dewayne was admitted to the SGHC Adolescent Unit in May 2022 and he is going through evaluations from the following disciplines: psychiatry, psychology, somatic medicine, nursing, social work, recreational therapy, and occupational therapy.
Mental status on admission:
Dewayne was awake and alert during the interview process. He was oriented to place, time, and person based on his ability to correctly state today’s month, today’s year, the name of “crazy hospital” and his DOB. He was wearing detention-issued clothes and shoes. He had fair personal hygiene and grooming. He appeared younger than his biological age based on his short stature and slim body. His gait was stable and he did not appear having any abnormal muscle movement (AIMS was zero). Initially, Dewayne was oppositional by refusing to comply with wearing a mask, using profanity at security officers and glaring at staff members. However, after receiving as- needed (PRN) medication for agitation, he started engaging in the interview properly and his demeanor was calm with intermittent eye contact.
Dewayne’s speech was regular rate and rhythm without any difficulties with articulation. His thought process was goal directed and linear without any disorganization. He denied experiencing any thoughts to harm self or others (Suicide Behaviors Questionnaire- Revised Plus 2, SBQR-2 was 3). He denied paranoia or ideas of reference. However, he exhibited behavior that would indicate hypervigilance based on him constantly assessing any threats around him and not liking to have anyone where his back is facing. He did not appear having any perceptual disturbances and denied experiencing any hallucination.
