Submit your diagnosis for the client in the case. Follow the guidelines below.

CASE of VICTOR

 

INTAKE DATE: August xxxx

IDENTIFYING/DEMOGRAPHIC DATA: Victor is a 24 year old Brazilian male. Victor’s religion is Catholic. He is single and attending the University of Maine for his Masters Degree in Finance. Victor was born and raised in Sao Paulo, Brazil and came to the United States 2 years ago.

   

CHIEF COMPLAINT/PRESENTING PROBLEM: Over the past three months Victor reported he had auditory hallucinations of an angel’s voice. Victor had thoughts about killing 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HISTORY OF PRESENT ILLNESS: In the last several months, Victor began to become socially withdrawn (keeping himself in his room), losing his concentration and feeling depressed. He showed signs of disorganized thought. Victor 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. His sleep patterns became inconsistent which led him to feeling fatigued all day.

PAST PSYCHIATRIC HISTORY: Victor denies any past psychiatric history.

SUBSTANCE USE HISTORY: Victor 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: Victor had been admitted to a Hospital six weeks ago for treatment as his wrist was injured due to a suicide attempt.

 

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Victor 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): Victor attends school for finance. His family continues to reside in Brazil. His parents are very supportive of his attendance at an American school. Victor is able to socialize with other students and professors. He did engage in leisure activity such as surfing the Internet, keeping his room tidy, doing household activity such as washing clothes, and kitchen preparation. That has reduced a lot over the past couple of months.

MENTAL STATUS EXAM: Victor appeared disheveled with poor hygiene. He was properly attired with hospital attire and had adequate eye contact. Victor was able to cooperate during the interview. There were some signs of anhedonia. He raised his voice at one time during the interview. His mood was irritable with upset speech. Thoughts were preoccupied with 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.