Part I: Diagnostic Summary and MSE

Provide a diagnostic summary of the client, Carl. Within this summary include:

• Identifying Data/Client demographics
• Chief complaint/Presenting Problem
• Present illness
• Past psychiatric illness
• Substance use history
• Past medical history
• Family history
• Mental Status Exam (Be professional and concise for all nine areas)
  • Appearance
  • Behavior or psychomotor activity
  • Attitudes toward the interviewer or examiner
  • Affect and mood
  • Speech and thought
  • Perceptual disturbances
  • Orientation and consciousness
  • Memory and intelligence
  • Reliability, judgment, and insight

Psychopathology For Social Work

PART 1: DIAGNOSTIC SUMMARY AND MSE

Based on the client’s demographics, Carl is eighteen years of age, a Caucasian, and of the male gender. The overall assumption, in this case, is that the client resides in Montana. After witnessing strange conduct and “odd ideations” from the client, his teachers and vocational trainers consigned him for a routine check-up after seeing peculiar behavior and “odd ideations” from the client. Besides, there are no records on past psychiatric illnesses or past medical history for the client. The client also failed to mention whether he had a history of substance abuse. Nevertheless, he briefly said that he and his acquaintances sometimes did indulge in substance use. The client also mentioned that he at several points helped his allies whenever they were drunk or influenced by drug and substance use. On family history, there was a brief moment when the client mentioned the death of his mother. He also said that he frequently changed his last name based on the individual his mother was seeing at that time. The client also mentioned how his mother was involved in multiple relations with both genders (Inc & Sons, 2014).

Mental Status Exam

Appearance: Appearance is among the key domains in a mental status exam (MedLecturesMadeEasy, 2017). Therefore, based on the client’s appearance, he seems to be within the age bracket that he pinpointed. He is not over/underweight, and on the examination day, he had cargo pants and a t-shirt. His “dirty blonde hair was tied back. Based on his facial appearance, the client had “dark circles” below his eyes, an apparent indication of lack of sleep, and “poor sleeping tendencies.” Generally, Carl was clean and nicely clad.

Behavior or psychomotor activity: Based on the client’s behavior, he gestured numerous times when talking. However, his eye contact was on point throughout. The client was also continuously fidgeting and readjusting himself on the chair respective of how challenging the questions he was asked were to answer. When responding to mental health queries, he was quite anxious. His breathing was labored, and he constantly blew his nose while clearing his throat.  

Attitudes toward the interviewer or examiner: During the MSE, the client was quite polite and obliging. Besides, he utilized humor to react to questions while simultaneously displaying a high engagement level. He also pointed out that he watched his language throughout the session.

Affect and mood: The client pointed out that he was quite calm throughout the process. Besides, his mood was a five out of a possible ten. The rationale behind this was that the clients’ moods varied based on the day. The client was quite happy on the day the interview was carried out, but he was quite unhappy the day before that.

Speech and thought: In instances where the client was reacting to questions that he could not significantly comprehend, it was quite evident that his voice turned out shaky, and he became quite anxious. Most questions were also answered with extra detail.

Perceptual disturbances: The client claimed that he had thoughts constantly seizing his mind. When asked about the compulsive thoughts he encounters, the client claimed that such thoughts existed in the millions. He also claimed that he saw ghosts. The obsessive thoughts running through his head entailed memories, songs, and voices. He prevented such thoughts by establishing even stronger ones within his mind that acted as a shield. Carl also claimed that he regularly engages with the voices within his mind while relating them to imaginary friends.

Orientation and consciousness: The client offered numerous names and was quite uncertain of the date. The client also claimed the season was spring, even though there was still snow.

Memory and intelligence: The client’s memory and intelligence were normal and okay across the entire process. All the necessary information that had to be remembered was.

Reliability, judgment, and insight: The client acknowledges that he is responsible for the numerous voices within his head. Besides, his judgment is impartial based on how he responded to questions. On relatively important subjects, the client was not quite concerned.

Part 2: Analysis of MSE

“Identify any areas in your MSE that require follow-up data collection.”

The areas requiring follow-up entail accessing Carl’s medical and psychiatric history, which are significant in psychiatry (Sarin et al., 2018). Additional information about the client’s family is also vital. A follow-up on the voices the client experiences coupled with the obsessive thoughts would also be beneficial. There is also the need to gauge the client’s speech.

“Explain how using the cross-cutting measure would add to the information gathered.”

The “cross-cutting measure” would be significant in establishing an inclusive mental health test considering it would bring about attention that wouldn’t be appropriate for any different diagnostic criteria. It assists the relevant experts in tracing clients’ conditions to investigate their treatment responses and severity (Clarke & Kuhl, 2014).

“Do Carl’s answers add to your ability to diagnose him in any specific way? Why or why not?”

The answers provided by the client, Carl, do not add to my ability to conduct a diagnosis since the information was not sufficient enough. Thus, a more comprehensive assessment is needed since the answers from the evaluation were quite insufficient.

“Would you discuss a possible diagnosis with Carl at this point in time? Why?”

It would not be possible to discuss a prospective diagnosis with the client, considering that the information acquired from the client’s assessment is inconclusive. The critical information valuable for a diagnosis is not present.