Case Presentation
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
PART II: ANALYSIS OF MSE
After completing Part I of the Assignment, provide an analysis and demonstrate critical thought (supported by references) in your response to the following:
- Identify any areas in your MSE that require follow-up data collection.
- Explain how using the cross-cutting measure would add to the information gathered.
- Do Carl’s answers add to your ability to diagnose him in any specific way? Why or why not?
- Would you discuss a possible diagnosis with Carl at this point in time? Why?
SAMPLE ASSIGNMENT