Assignment: Conducting a Diagnostic Interview With a Mental Status Exam

CASE PRESENTATION – Case of Edward

 

INTAKE DATE: August 2019

 

IDENTIFYING/DEMOGRAPHIC DATA: Edward is a 24 year old Caucasian English male. Edward’s religion is Protestant. He is single and attending the University of Maine for his Masters Degree in Finance. Edward was born and raised in Liverpool, England and came to the United States 2 years ago.

   

CHIEF COMPLAINT/PRESENTING PROBLEM: Over the past three months Edward reported he had auditory hallucinations of an angel’s voice, suspiciousness, ideas of reference and hostility, and moderately severe conceptual disorganization. Patient tried to kill his roommate by suffocation - claiming that he heard fireflies tell him the roommate is influenced by Satan.

HISTORY OF PRESENT ILLNESS: In the last several weeks, Edward began to become socially withdrawn (keeping himself in his room), had signs of disorganized speech & thought. Edward began spending his time browsing and chatting in Facebook about God and UFO’s. He would spend too much time online until he passed out.

PAST PSYCHIATRIC HISTORY: Edward denies any past psychiatric history.

SUBSTANCE USE HISTORY: Edward denies any use of illicit drugs. He does report occasional use of alcohol. He has been drunk as a teenager but prefers not to indulge that much.

PAST MEDICAL HISTORY: Edward had been admitted to a Hospital to get treatment as his wrist was injured due to a suicide attempt, six weeks ago.

 

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Edward is the second from five siblings. One of his family members has mental illness (schizophrenia), but would not identify the family member.

CURRENT FAMILY ISSUES AND DYNAMICS (OPTIONAL): Edward attends school for finance. His family continues to reside in England. His parents are very supportive of his attendance at an American school. Edward is able to socialize with other students and professors. He engages in leisure activity such as surfing the Internet, keeps his room tidy, doing household activity such as washing clothes, and kitchen preparation.

 MENTAL STATUS EXAM: Edward appeared disheveled with poor hygiene. He was properly attired with hospital attire and had adequate eye contact. Edward was able to cooperate during interview. There were some signs of anhedonia, inappropriate behavior. He raised his voice at one time during the interview. His mood was irritable with upset speech. He was not coherent at times. Sometimes there appeared irrelevant talk. Thoughts were preoccupied with obsessions, and persecutory delusions. Perceptions showed auditory hallucinations. He was oriented: able to state person, place and time correctly. His short term memory was intact: able to retrieve games rule. His long term memory was good: able to recall previous history. Insight was good.