Psychiatric Social Report

Dr. Stephen B. Salazar Patient. Tu Anh Doa
5028 South Broadway, Age: 26 Exeter, NH 03833

Presenting Problem: This is a 26 year old Vietnamese males seen today at the request of the Department of Social Services Disability Evaluation Unit. Questions regarding mental status appearance simple repetitive tasks interests and daily activities and ability to relate and interact with public and coworkers were raised. The interview was conducted in the living room of the home in which he lives and has lived for the past three or four years. The claimant resides in the home with his mother and his 11 year old younger sister. His mother and an interpreter were present in the room during the interview. The interview lasted one hour. The claimant was very quiet and at some point hardly audible. He declined to answer questions quite often during the interview. Several times during the interview the mother interrupted and gave answers to him. He seemed to show pressure of speech and memory difficulties during the interview.

History: The history reveals that Mr. Dao was born in Hanoi Vietnam where he went to school up to eighth grade. At the eighth grade he dropped out and began to farm doing rice farming. At age 26 he moved to Exeter. After arriving in Exeter he worked in a restaurant which he cannot name as a dishwasher for two or three months but quit because the job in the first place was part time and temporary. He then worked for two years as a gardener and quit this job because heath problems and he was always feeling sick. He also worked for one or two months as a carpenter but he quit because he did not have money to buy the tools. In 1990 he was admitted to College Hospital where he had surgery and was in the hospital for one or two months during the winter of the year. He claims that the surgery was neurological although it could have been rather then on the brain an inner ear surgery due to vertigo and tinnitus problems. There is no history of any other hospitalization. The claimant is the older son of five children he has two sisters and two brothers they are all living in the United States.

Environment: The claimant he lived in his present house for one and a half years with his mother and 11 year old sister. He states that he wakes at8 or 9 am. He walks around in the yard for awhile and then he eats breakfast he does not eat lunch but he eats dinner. He said that during this time his appetite is good and he eats because he is hungry. Once a week he leaves the house to see a doctor who checks for the surgery and his neurological problem. He states that he had a ringing in the left ear which was partially a result to the surgery. He has not done any kind of work since the head surgery and he has not done anything around the house. He reports difficulty with memory. He rarely does anything with friends except when they come over to visit him and only leaves the house to walk around the yard or go to the doctor appointment. He is able to dress himself and bathe himself but does not do ant chores of any kind around the house. He states that his mother cooks for him and he never cooked for himself and he does not do anything around the yard either. His grooming showed him to be wearing a shirt slacks with no shoes or socks and he was cleaned shaven his hair styled and neatly brushed. He reports going to bed around 1 or 2am. Most of his day is spend listening to the radio and watching television. While showing that he could ambulate he had significant difficulty walking on his toes; he was unable to do this but he was able to walk on his heels and his gait appeared to be normal. There is no significant psychomotor retardation noted.