Name: Morton, Charles Age: 22 years old Sex: Male Occupation: Student Date of Interview: June 1, 2010 Identifying Information: The client is a 22-year-old white male who is presently a full-time student a large Midwestern University. Currently, he lives alone in an apartment and works part-time at a local grocery store. Chief Complaint: The client reports that he has experienced symptoms of depression “off and on” for the past year. These symptoms include depressed mood, appetite disturbance but no significant weight loss, sleep disturbance (early morning awakening), fatigue, feelings of worthlessness, and difficulty concentrating. All these symptoms have been present nearly every day over the last two weeks. About one year ago, the client reports, a long-standing romantic relationship of four years ended. Following this break-up, the client reports that he became increasingly withdrawn and, in addition to some of the symptoms noted above, experienced several crying spells. Although his adjustment to this event became better as time progressed, the client reports that the break-up “shook” his confidence and led to a decrease in the number of social activities he engaged in. Further, he reports that he has not dated since. Last semester, the client transferred to this university from a community college in another Midwestern location. He reports that the move was difficult both emotionally and academically. Specifically, being away from his hometown, family, and friends has led him to feel more isolated and dysphoric. Further, his grades last semester reportedly suffered. He reports that his grades dropped from A’s in his previous school to C’s at this university. Toward the end of the last semester, he developed an increasing number of depressive symptoms. Past Treatment History: The client reports that he has not previously sought out psychological or psychiatric treatment. Medical History: No significant medical history was reported. Substance Use/Abuse: The client denies any current symptoms substance abuse or dependence. He has “tried” marijuana on three occasions in the past but denies current use. He reports drinking on average 3 to 4 cans of beer per week. Medication: The client reports that he is not currently taking any medications. Family History: Both the client’s biological parents are living, and he has one brother (age 20) and one sister (age 26). The client reports that his mother suffers from depression and has received out-patient treatment on numerous occasions. Further, he reports that his maternal grandfather was diagnosed with depression. No substance use problems among family members were noted. Suicidal/Homicidal Ideation: The client denied any current or past suicidal or homicidal ideation, intent or action. Mental Status: The client was well-groomed, cooperative, and dressed appropriately. He was alert and oriented in all spheres. His mood and affect were dysphoric. His speck was clear, coherent, and goal-directed. Some attention and concentration difficulties were noted. Further, his immediate memory was mildly impaired. No evidence of formal though disorder, delusions, hallucinations, or suicidal/homicidal ideation. His insight and judgement appear to be fair. Diagnostic Impression: 1. AXIS I? Justify. 2. AXIS II? Justify. 3. AXIS III? Justify. 4. AXIS IV? Justify. 5. AXIS V: GAF = 50 (current) 6. What recommendations can you give? Provide only 1 S.M.A.R.T, personal and practical recommendations. Make sure to justify your recommendation.
Name: Morton, Charles
Age: 22 years old
Sex: Male
Occupation: Student
Date of Interview: June 1, 2010
Identifying Information: The client is a 22-year-old white male who is presently a full-time student a large Midwestern University. Currently, he lives alone in an apartment and works part-time at a local grocery store.
Chief Complaint: The client reports that he has experienced symptoms of depression “off and on” for the past year. These symptoms include depressed mood, appetite disturbance but no significant weight loss, sleep disturbance (early morning awakening), fatigue, feelings of worthlessness, and difficulty concentrating. All these symptoms have been present nearly every day over the last two weeks.
About one year ago, the client reports, a long-standing romantic relationship of four years ended. Following this break-up, the client reports that he became increasingly withdrawn and, in addition to some of the symptoms noted above, experienced several crying spells. Although his adjustment to this event became better as time progressed, the client reports that the break-up “shook” his confidence and led to a decrease in the number of social activities he engaged in. Further, he reports that he has not dated since.
Last semester, the client transferred to this university from a community college in another Midwestern location. He reports that the move was difficult both emotionally and academically. Specifically, being away from his hometown, family, and friends has led him to feel more isolated and dysphoric. Further, his grades last semester reportedly suffered. He reports that his grades dropped from A’s in his previous school to C’s at this university. Toward the end of the last semester, he developed an increasing number of depressive symptoms.
Past Treatment History: The client reports that he has not previously sought out psychological or psychiatric treatment.
Medical History: No significant medical history was reported.
Substance Use/Abuse: The client denies any current symptoms substance abuse or dependence. He has “tried” marijuana on three occasions in the past but denies current use. He reports drinking on average 3 to 4 cans of beer per week.
Medication: The client reports that he is not currently taking any medications.
Family History: Both the client’s biological parents are living, and he has one brother (age 20) and one sister (age 26). The client reports that his mother suffers from depression and has received out-patient treatment on numerous occasions. Further, he reports that his maternal grandfather was diagnosed with depression. No substance use problems among family members were noted.
Suicidal/Homicidal Ideation: The client denied any current or past suicidal or homicidal ideation, intent or action.
Mental Status: The client was well-groomed, cooperative, and dressed appropriately. He was alert and oriented in all spheres. His mood and affect were dysphoric. His speck was clear, coherent, and goal-directed. Some attention and concentration difficulties were noted. Further, his immediate memory was mildly impaired. No evidence of formal though disorder, delusions, hallucinations, or suicidal/homicidal ideation. His insight and judgement appear to be fair.
Diagnostic Impression:
1. AXIS I? Justify.
2. AXIS II? Justify.
3. AXIS III? Justify.
4. AXIS IV? Justify.
5. AXIS V: GAF = 50 (current)
6. What recommendations can you give? Provide only 1 S.M.A.R.T, personal and practical recommendations. Make sure to justify your recommendation.
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