Case Study of Ben: Part 2

Mental Status Evaluation (MSE) Checklist

1. Appearance a. Physical Appearance. Client appears stated age, appears older, or appears younger, hairstyle, fingernails, and so on. b. Dress. Appropriate, clean, pressed, wrinkled, disheveled, and so on. c. Hygiene. Clean, well groomed, presence of body odor, and so on. 2. Behavior and Mannerisms a. Gait limping, slow, hurried, and so on. b. Posture. Slumped or rigid. c. Eye Contact.d. Mannerisms. Foot tapping, eye blinking, hand rolling, head nodding, and so on. 3. Attitude a. Toward Interviewer. b. Toward Treatment. c. Toward Others. 4. Mood and Affect a. Mood. Sad, elated, happy, bored, and so on. b. Affect. Outward expression of mood such as smiling, frowning, crying, or laughing. c. Appropriateness. Does the affect match the mood and the situation? 5. Speech a. Quantity. Talkative, poverty of speech, and so on. b. Quality. Circumlocution, monotonous, loquacious, loud, and so on. c. Rate of Production. Mumbles, slow production, pressured speech, and so on. 6. Perceptual Disturbances a. Hallucinations. False perceptions. b. Illusions. Misperceptions of reality.

7. Thought a. Thought Content. Delusions, obsessions, phobias, suicidal ideation, homicidal ideation, and so on. b. Thought Processes. Flight of ideas, poverty of thought, relevancy, and so on. 8. Sensorium and Cognition a. Alertness. Awareness of surroundings, goal-directed thinking, responding to the environment, and so on. b. Orientation. Person, place, time, and situation. c. Memory and Concentration. Remote, recent past, recent, and immediate recall. d. Abstract Thinking. Conceptual thinking, ability to understand abstract ideas, ability to use inductive and deductive reasoning. e. Intellect and Fund of Knowledge basic knowledge and intelligence. 9. Impulse Control a. Sexual. Ability or lack of ability to control sexual impulses. b. Physical. Ability or lack of ability to control physical impulses such as hitting, biting, or yelling. c. Social. Ability or lack of ability to control social impulses. 10. Judgment and Insight a. Social Judgment. Awareness of others, empathy, social decision making, and so on. b. Insight. Awareness and understanding of one’s mental illness, insight into cause, effect, and course of illness. c. Reliability. Is the client a good source of information, is he or she honest, aware, and able to report to the therapist his or her daily happenings?

Unit 6 assignment

Case Study of Ben, Part 2

Read the Case Study of Ben, Part 2.

Use the Case Study Response Guide to assist you in revisiting your diagnosis of Ben’s condition, incorporating this new information. In Section 4 of the response guide, address each of the following:

· In each of these scenarios, describe how the new information alters the picture presented in the original case study.

· Describe your new diagnostic hypotheses, and justify your conclusions.

· What further diagnostic evaluation do you believe is warranted?

Use the Case Study Response Guide to format your assignment.

Case Study Response Guide

Use this outline to structure your case assignments.

1. Case Summary

 

1. Provide a brief summary of what you have learned about the individual reviewed in the case. Include information about the individual in terms of demographics and general history, and the sources of that information, and the reason that the individual was referred, and by whom. Case Study of Ben: Part 2

1. Summarize any information you may have about evaluations that have been conducted, including the results.

 

1. Clinical Impression (Diagnosis)

Write the clinical impression in the DSM-5 format:

XXX.xx (Yyy.yy) Primary Diagnoses (list in order of salience).

(DSM-5 Code is first, as in XXX.xx, and ICD-10 codes next, in parentheses.)

 

OTHER FACTORS:

 

Use the V and Z codes, or simply appropriate descriptors to psychosocial and contextual factors of importance to the diagnostic case. These replace the DSM-IV-TR Axis IV & V used to address these concerns.

1. Recommendations

Explain any recommendations for interventions, treatment, and/or disposition.

1. Questions

Address the specific questions that were asked in the instructions for this assignment.

Here is a sample assignment question and an appropriate brief response:

Question: Describe what further information you would need to accurately diagnose this case.

Response: To diagnose this case accurately, I would also need to review any pertinent medical records. I would want to interview this client’s mother, with whom he lives, to corroborate the clinical interview data supplied by the client, and to learn more about his developmental history. I would also want to…

 

 

 

Case Study of Ben (Part One)

Ben is a 46-year-old computer scientist at a large university. In recent weeks, his wife has noticed that he has been “different.” He is being seen on your service at the local hospital, where you are asked to evaluate him.

Ben is a hostile interviewee. He does not want to talk to you, and has made it clear that he is here against his will. In recent weeks, according to his wife, Cindy, he has been moody, irritable, and increasingly inappropriate in his actions and comments. For instance, Cindy tells you that last Friday night at a neighborhood party, he went up to an attractive young neighbor and, after asking if she was having as good a time as he was, put his hand on her breast. She reacted furiously, and Ben seemed surprised at her reaction. The young woman’s husband pushed Ben away, and Ben became furious and struck the man. Cindy is embarrassed and says Ben has never been like this before now. In the past, she says, he has always been kind and respectful, “even a little shy.”

Yesterday morning, Ben began to eat his breakfast cereal with his fingers. Cindy says he left for work much later than usual and seemed to be having a hard time organizing his briefcase, his keys, and so on. “Lately, he has been making all kinds of plans and then just not following through on them, which is so unlike him. He has always been real careful, real well-organized, and when Ben makes plans, he always keeps them.” But yesterday, after Ben left the car running in the driveway and took the bus to work, Cindy became alarmed. She called their family doctor, who sent Ben to the hospital for this evaluation.

Cindy says nothing has happened to Ben that might explain his change. Ben admits he has had lots of work stress lately, “because of my goddamn boss’s stupidity.” He is surly. He snaps at his wife, “What do you mean, nothing has happened? You idiot, what about that asshole boss of mine?” His wife is embarrassed at his crude language. When you ask Ben if anything else has gone wrong lately that might explain his irritability, he snaps, “Isn’t that enough?” but then considers the question. He starts to speak, then seems distracted by something on your bookshelf and shrugs his answer off.

Cindy mentions that about six months ago, Ben was in an auto accident in which his car rear-ended the vehicle in front of him. Ben, who was a passenger, hit his head on the rear-view mirror. Ben was taken to the emergency room for an X-ray, which had negative findings. Cindy was instructed to monitor him for 24 to 48 hours for any signs of brain injury, but nothing appeared. Other than a slight headache, Ben was his normal self the next day. The irritability and erratic behavior did not start until about five days ago, nearly six and a half months after the accident. No other traumas were noted.

Ben works 50 hours a week for a software company, earning about $130,000 per year. He has always had excellent reviews and never missed a promotion. He is close friends with many coworkers and always had a lot of friends. He is still close with a number of his high school and college friends, and frequently calls old neighbors on the telephone. “Everybody likes Ben,” says Cindy. “That is why I was so shocked by what he did last Friday and by how he’s started swearing and acting so . . . gross.”

Cindy and Ben met and married about 23 years ago. It is the first marriage for both of them, and Cindy says it has always been a good marriage. “We had some fights a few years ago, a kind of rough spot. Everybody goes through that. I think Ben got a bit over involved with one of the women at work, but we got through that okay. That was maybe 10, 11 years ago.” Ben laughs and says, “Over involved? I wish I’d a stuck it to her, goddamn it! She was something!” His tone is lecherous.

Cindy says there has never been any separations or talk of divorce. “Nothing was ever that troubling; just a few arguments,” she says. Their sex life has always been fine, and they have “lots of fun” when they go out together, which they have done weekly, until last Friday.

Ben did very well in high school and college, earning nearly straight As and a spot on the Dean’s list nine times in college. He graduated with honors and landed the best job out of anyone in his class. His parents are still alive, living in Arizona. Neither is in great health, but there is nothing seriously wrong. Ben and Cindy travel to Phoenix to see them twice a year and everyone gets along well. Cindy says she has heard no particularly bad stories about Ben’s childhood, and he agrees. He is still close with his only brother, who is three years older. At this point, Ben stands up and asks you who you are and why you are here. You explain, and he seems relieved. He had seemed slightly anxious. You inquire, but he waves you off.

Cindy says Ben had had a couple of glasses of wine at the party, but he has not had a drink since Friday night. Usually, he drinks two or three glasses of wine on a weekend, and perhaps one glass each evening with dinner. He has never had a drinking problem, according to Cindy. Ben refuses to answer, but a check of his medical records later confirms Cindy’s information.

Ben also has had a remarkably healthy life. Except for a tonsillectomy when he was nine and the surgical removal of an impacted wisdom tooth, Ben has had no injuries, no illnesses, and no accidents resulting in any health problems. He takes no medication, not even aspirin. He does not get headaches. He is not overweight; in fact, he jogs four miles each day and feels in good health, he says. He smirks briefly at you and says, “You could use a few miles a day, Doc.” When Cindy reacts, he snaps at her, “Oh, get with it, baby!”

 

Case Study of Ben, Part Two

Instructions: Use this scenario for u06a1 Case Study of Ben, Part Two, after completing your discussion posting in u06d2 Case Study of Ben, Part One.

Part 2

You ponder the case of Ben, and conclude that you have more questions than answers.

You again interview Ben and his wife, Cindy. In the course of this second interview, you learn the following:

Both corroborate that Ben has never had symptoms like this before. Cindy has spoken to Ben’s siblings, and they corroborate that nothing like this ever occurred in their knowledge of him. They also report no known history of mental health problems in Ben’s family. Case Study of Ben: Part 2

Ben’s medical evaluation after the car accident was cut short. Ben’s employer was in the middle of changing insurers, the new insurer had all sorts of obstructionist pre-authorization requirements, and Ben gave up trying to hassle it out with them after he felt better. Also, the physician who initially evaluated Ben transferred to another facility. Before she left, she told Ben that he really needed to follow through and get the other tests. Ben never did, and the replacement physician never contacted Ben for follow-up as promised. It is clear that Ben fell through the cracks medically.

In the six months since the head injury, Ben has had two incidents of nosebleeds for no clear reason. These occurred at the same time as some of his oddest behavior. One of the nosebleeds was unusually profuse. Ben was unwilling to see a doctor.

Cindy reports that Ben has a number of times apparently smelled things that were not there. He once spent three hours cleaning his car, saying there was a foul odor. She smelled nothing. Another time, they had a big argument when she served a large salad for dinner. He insisted that he smelled grilling bratwurst, his favorite food, and wanted bratwurst instead. She had not grilled any bratwurst, and she smelled nothing like that.

Cindy reported that on a number of occasions in the last few months, Ben seemed to be having difficulty finding words, and he has recently used words in odd ways that he never did previously.

Cindy also reports that Ben’s judgment has been episodically off in many ways. Ben has always managed their retirement portfolio, and has been a conservative investor, taking few risks. She recently learned that he sold some of their reliable Johnson & Johnson stock, and instead bought shares of “Fooled you once, shame on me” corporation, which specializes in starting tropical fruit farms in North Dakota. When she asked him why, he replied that they both like tropical fruit, so it is a sure thing.

Finally, you learn that in the accident, Ben hit the rear view mirror where the nose, forehead, and eye sockets come together. He had a dark spot under the surface of his skin for a few months after that. You could only really see it in a certain light, but it was there. Case Study of Ben: Part 2