By Day 7
Submit 2- to 3, in which you complete both parts outlined below:
Part I: Diagnostic Summ and MSE
Provide a diagnostic summ of the client, Carl. Include:
- Identifying Data/Client demographics
- Chief complaint/Presenting Problem
- Present illness
- Past psychiatric illness
- Substance use history
- Past medical history
- Family history
- Mental Status Ex (Be professional and concise for all nine areas)
- 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, 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?
Support Part II with citations/references. The DSM 5 and case study do not need to be cited. Utilize the other course readings to support your response.