Assignment: Conducting a Diagnostic Interview With a Mental Status Exam

CASE of CARLOS R.

 

INTAKE DATE: May 2019

 

IDENTIFYING/DEMOGRAPHIC DATA: Carlos is a 7 year old male in the third grade. He lives in Houston, Texas with his parents. He is the only child to two parents, both of whom have completed post-graduate education. His parents are originally from Guatemala and relocated to the United States when Carlos was 6 months old for job opportunities. Carlos is an intelligent and caring young boy who presents with significant potential to excel academically.

      

CHIEF COMPLAINT/PRESENTING PROBLEM: Carlos was referred for an evaluation because his parents and teacher indicate that Carlos is restless, and often requires reminders to help him stay on task. He is described as "constantly running around" and presenting with difficulties listening and following instructions.

 

HISTORY OF PRESENT ILLNESS: Carlos enjoys spending time with his friends, and participating in physical activities such as swimming, running and skating. He also enjoys participating in social events, and is often invited to play dates and birthday parties. While Carlos interacts well with peers his own age, his parents believe he is easily led and influenced by others. Carlos does get upset when he does not receive recognition or feels that he has been ignored. His teacher notes that he sometimes acts 'socially immature', and that he often demonstrates attention-seeking behavior.

Carlos has difficulty focusing and sitting still in class. He is able to 'hyper focus' on some activities of interest however he often has difficulty sustaining his attention at school. Carlos has been known to blurt out answers and interrupts other students in the classroom. His mother reports difficulties at home with following routines and remembering instructions. His parents describe emotional reactivity as well as confrontational behaviors demonstrated both at home and at school. His teacher notes that Carlos is defiant towards listening to instructions, but generally interacts well with his peers. He is easily frustrated and emotionally impulsive - Carlos has had several incidents of hitting, crying outbursts, and inappropriate behavior. Behavioral concerns with aggression, lying, arguments, and disruptive behavior were noted in his pre-school program at age 4. Each school year since teachers have reported incidents in the classroom.

PAST PSYCHIATRIC HISTORY: This is the first evaluation for Carlos. It is noteworthy that he did not know his address or home phone number, could not print his surname, and recognized only a few pre-primer words.

SUBSTANCE USE HISTORY: None reported

PAST MEDICAL HISTORY: Carlos has been vaccinated with all the needed vaccinations to attend school. There is no noteworthy illnesses to report.

 

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Carlos’ parents report some history of mental illness in the family. His maternal grandmother was diagnosed with depression. Carlos has always had challenges falling asleep, and sometimes finds that he wakes up in the middle of the night. When he wakes up he finds that he has a difficult time getting back to sleep - sometimes staying awake for as long as an hour and a half.

MENTAL STATUS EXAM: Carlos is age appropriate in size and structure. His appearance is clean and neat. Carlos is an active child and interacts with his parents appropriately. There does not appear to be any underlying overtones between the parents and Carlos. Carlos did not have any problems separating from his parents when being interviewed. Speech is appropriate for child’s age. Carlos’ mood is in normal range and congruent with his mood. Affect was appropriate. There were no hallucinations or delusions. There were some challenges with Carlos’ judgment and insight.