Identifying information: 45 year old Caucasian male accompanied by his wife.
Setting: Outpatient mental health clinic.
Chief Complaint/Reason for visit: “I have just been working too long of hours…I stopped for a drink and because I was so tired my driving was not that
best. I got pulled over by the police.”
History of Present Illness: JS states he has scheduled an appointment because his wife told him “I have to get help or she is out of here.” He makes it
clear that he doesn’t see that there are any real issues. His wife relates that last week he had been pulled over for erratic driving, failed the breath
analysis test, and has a court hearing coming up. He admits to drinking “2 or 3 drinks” a night. He relates he used to “just drink on weekends but over
the last year or two work has just gotten to be so rough if I don’t drink I don’t sleep.” Since being stopped by the police he has not had a drink for
the past 2 days. When pressed, he reports he has difficulty remembering what exactly he was doing prior to being stopped by the police. JS’s wife tells
you she has become more and more concerned with JS. She believes his drinking is out of control and is worried about his functioning. She reports he
has been having more angry outbursts, general irritability and mood swings.
Past Psych Hx: JS has never been hospitalized or received any prior mental health or substance abuse treatment.
Past Medical Hx: JS reports a recent hospitalization following a motor vehicle accident, and it was discovered that his “bleeding time was off.” He
reports he is not on any current medications and denies any known health problems.
Family/Social Hx: JS has been married to his current wife for the last 10 years. He reports that he was married briefly right out of college but the
marriage didn’t last. Both of JS’s parents are deceased; his father from “liver disease”, and mother from a heart attack.
Family Psychiatric Hx: JS denies any family history of psychiatric illness.
Substance Use Hx: JS reports he had his first drink at age 15 yrs and experimented with drugs, “mostly pot but occasionally coke” during college and
young adult years.
Review Of Systems: Negative except for mild nausea, headaches, feeling shaky, some perspiration on his forehead.
Physical Exam: BP 147/92, P98, HT 71” WT, 215 lbs
Mental Status Exam:
Appearance: JS is dressed in clean clothes. There is perspiration on his forehead.
Behavior: He sits leaning forward and he continually jiggles his legs. There is a slight tremor of his hand when he reaching for a paper. Eye contact
Speech: pressured at times
Mood: JS relates that he is nervous, and states “I just want to get this over with.”
Thought Process: Linear, organized.
Thought Content: Logical, no hallucinations or delusional content. Denies suicidal or homicidal ideation.
Cognition: Alert. He has poor memory of recent events. Remote memory grossly intact. Decreased concentration as evidenced by difficulty completing
Insight: Appears to lack awareness of the extent of his problem.
Judgment: Appears impaired about his drinking.
Case conceptualization (20 points)
Using your Carlat& DSM5 texts and other relevant sources to develop your clinical impression.
1. Create a concept map, table, or decision tree to help you identify all relevant psychiatric and medical conditions you would consider for this
individual. Include the DSM5 criteria for psychiatric diagnoses.
2. From the above, create a prioritized list of your top 3 differential psychiatric diagnoses, starting with the primary working diagnosis (your
answer), include the ICD 10 diagnostic code for each diagnosis. Explain your thinking process on what factors you considered that led you to select your
primary diagnosis, and other possible diagnoses.
3. List 2 most pertinent interview questions for each of the 3 differential psychiatric diagnoses that you need to ask to rule in or rule out that
4. List 2 most pertinent differential medical conditions you would consider for this individual. Provide a brief list of symptoms that support your
5. List any pertinent laboratory tests or screening tools you might use to help you rule in or rule out your top 3 differential diagnoses and a concise
For questions 1-5, provide text/reference, page number (in APA style) where you found the information to support your thinking. Use your own words,
limit any direct quotes to no more than 1-2 phrases.
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