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)
  • 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, 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.