Analysis of the Mental Status Exam

The sign of an effective clinician is the ability to identify the criteria that distinguish the diagnosis from any other possibility (otherwise known as a differential diagnosis). An ambiguous clinical diagnosis can lead to a faulty course of treatment and hurt the client more than it helps. In this Assignment, using the DSM-5 and all of the skills you have acquired to date, you assess a client.

This is a culmination of learning from all the weeks covered so far.

 

To prepare:Use a differential diagnosis process and analysis of the Mental Status Exam in The Case of L to determine if the case meets the criteria for a clinical diagnosis.

Then by Sunday night, Please submit a 4 to 5 page paper in which you:

• Provide the full DSM-5 diagnosis. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may need clinical attention).
• Explain the full diagnosis, matching the symptoms of the case to the criteria for any diagnoses used.
• Identify 23 of the close differentials that you considered for the case and have ruled out. Concisely explain why these conditions were considered but eliminated.
• Identify the assessments you recommend to validate treatment. Explain the rationale behind choosing the assessment instruments to support, clarify, or track treatment progress for the diagnosis.
• Explain your recommendations for initial resources and treatment. Use scholarly resources to support your evidence-based treatment recommendations.
• Explain how you took cultural factors and diversity into account when making the assessment and recommending interventions.
• Identify client strengths, and explain how you would utilize strengths throughout treatment.
• Identify specific knowledge or skills you would need to obtain to effectively treat this client, and provide a plan on how you will do so.

 

CASE OF LUCIA

INTAKE DATE: May 2018

IDENTIFYING/DEMOGRAPHIC DATA:Lucia is a 53-years-old Hispanic female. She has two adult sons, aged 27 and 24, who both live with her. She works full time as an executive secretary. Lucia has a live in boyfriend, Tomaz. They have been together 8 years.

CHIEF COMPLAINT/PRESENTING PROBLEM: I am in constant physical pain every day and can hardly walk and move. Even at night when I am in bed I am always in pain. Lucia reports that even in the few moments the pain eases it is difficult for her to get sleep.

HISTORY OF PRESENT ILLNESS: Lucia has been suffering from physical pain for the past 18 months. She has been to many doctors for help. Lucia has been very concerned about her illness and wants to understand the causes of this pain. There has never been an accurate diagnosis. She has been given medication and steroids with no relief of her physical pain. Most recently, she had a full evaluation at the Mayo Clinical which had inconclusive results. One doctor at the Mayo clinic suggested she seek individual counseling, hoping this will help her physically as well. Lucias reports her anxiety is so high now with all the stress she is under.

PAST PSYCHIATRIC HISTORY: Lucia denies any past psychiatric history for herself. The only significant family history is her older brothers diagnosis of Intellectual Disability.

SUBSTANCE USE HISTORY: Lucia reports drinking socially and very minimally. There is no evidence of substance use disorders in her family.

PAST MEDICAL HISTORY: Lucia has been ailing over the past 18 months with unidentified pain. There were no previous significant medical issues in her past.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Lucia is the third child of four from her parents union. She has an older sister, a brother, and a younger sister. Her brother was diagnosed with intellectual disability from a young age. The familys focus has always been on taking care of her older brother. Her father died 6 years ago. Lucia lost her mother to dementia 6 months earlier than this intake. With the death of her mother, the responsibility of her brother has now been transferred to Lucia and her two sisters. Lucia reports feeling responsible for her extended family and needs to be involved with their issues. She recalls growing up and always feeling not worthy to be part of the family. She is hoping that the family would value her more than she believes they do.

CURRENT FAMILY ISSUES AND DYNAMICS: Lucia divorced 17 years ago after 12 years of marriage. The marriage was tumultuous. Her husband was addicted to pornography and had several affairs. Lucia denies any physical abuse but reports a lot of emotional abuse that she sustained from her husband. Lucia maintained the family house after the divorce but had very little money to support the household and her two sons. Lucias financial issues continued to increase her stress over the years.

Eight years ago, Lucia began a romantic relationship with Tomaz after a long term work friendship. Tomaz divorced nine years ago. Lucia believed she was finally happy in a relationship. Tomaz moved into her home soon after their romantic relationship began. Tomaz promised he would take care of her financially for the rest of her life.

Four years ago, Tomaz was diagnosed with terminal cancer. Following the diagnosis, Tomaz became a spendthrift and purchased very large items such as trucks, motorcycles, and ATVs. Lucia was feeling increased stress with the loss of her mother, the burden of care taking her brother, Tomazs diagnosis and his increased spending of his money. She always found herself fatigued due to this stress.

MENTAL STATUS EXAM: Lucia presented as a casually dressed, meticulously groomed woman who appeared her stated age of 53. She had a fixed, mood congruent expression on her face. Motor activity was normal. Mood appeared depressed and was dysphoric. Affect was constricted. Speech was guarded and soft, content was adequate. Thought processes were goal-directed, logical but at times distracted. There was no evidence of delusions. Lucia was oriented to time, place, and person. During the intake, Lucias thoughts would jump around. She noted that over the past several months she has had an inability to concentrate at work. Digit span was 7 forward and 4 in reverse. She was unable to calculate serial 7’s. Recent and remote memory appeared intact. Intelligence appeared above average and fund of knowledge was excellent. All factual questions were answered correctly. Lucia was able to abstract similarities and proverbs with detail and accuracy. Ordinary social and personal judgment was appropriate.

 

Required Readings

Morrison, J. (2014).Diagnosis made easier(2nd ed.). New York, NY: Guilford Press.
Chapter 15, Diagnosing Substance Misuse and Other Addictions (pp. 238250)

Optional Resources

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