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Mental Health Status Exam - Case Study Example

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Summary
Dale, an Irish-American, aged fifty-five years old is a male client whose condition (which his brother refers to as ‘sadness’) compels him to seek for clinical intervention. They traced the center through a referral system they found on the internet. He was escorted by his…
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Mental Health Status Exam
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Mental Health Status Exam Client’s Clinician’s Name:
Client’s Date of Birth: Date of Evaluation:
Client’s Age
Dale, an Irish-American, aged fifty-five years old is a male client whose condition (which his brother refers to as ‘sadness’) compels him to seek for clinical intervention. They traced the center through a referral system they found on the internet. He was escorted by his brother Todd, who identified some unusual psychological tendencies prompting them to seek for help. They made enquiries and booked for an appointment via telephone. The interview sessions were conducted at the clinic.
Physically, Dale is a relatively tall, immaculately dressed man. The client indicated based on the observation of his dressing that he has not had any problems with self-care. The assessor and the client (Dale) managed to build a rapport that enabled an effective interaction. The client was willfully opened up and cooperated with the assessor in providing sufficient information about his condition.
Throughout the assessment, Dale is confident while he narrates the story of his life. It is clear to see that he is oriented to time, place and self. He accurately recounts detailed information about his past. Both his long term and short term memories are functional. He can integrate information and connect the past with the present. His speech is articulate and lucid. He has a typical speech volume and rhythm. No speech impediments can be detected in his communication.
The client demonstrated tearful moods and affect that were characterized by a sense of ill-fated feelings. His choice of words indicated he was in deep anger. His face could depict the despondency he was in. Dale, however, does not exhibit any abnormal motor movements. He is seated uprightly and maintains eye-contact with the assessor. No unusual psychomotor movements were observed.
The client’s thought processes and perceptions are of great concern. Although Dale reports he has never attempted suicide in the past, he is currently preoccupied with these thoughts. He candidly admits that he cannot get his mind off the suicidal thoughts. He indicates he is successful in his business career but cannot help control his fluctuating moods that recently inflated. He has a history of depression and this seem to be affecting him up to now. Dale stays indoors for considerable periods and this exposes him to deep suicidal thoughts. The client, however, does not demonstrate any signs of hallucinations or delusions.
DSM IV Classification
Axis I: Bipolar I Disorder
Axis II: None
Axis III: High Blood Pressure
Axis IV: Recent divorce, social isolation.
Axis V: 40
Recommendations
Recommendations
Rationale
i.) It is recommended that Dale be referred to a psychiatric/ clinical-psychological therapy.
ii.) It is recommended that Dale be taken through Cognitive Behavioral Therapy (CBT).
iii.) It is recommended that the client seek proper examination and medication for high blood pressure.
i.) The assessment conducted indicates Dale has fluctuating moods that have existed for mildly several years (shifting from depressive to hypomanic moods) hence the need for treatment.
ii.) The client has shown suicidal tendencies and CBT would help him restructure his thoughts as well as behavior.
iii) The client has medications for HBP which indicates the existence of a serious medical condition.
Assessing for Competence
Client is enthusiastic about his business.
He recognizes he has a problem.
The client is cooperative and willing to adjust. Read More
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