Conducting a Diagnostic Interview with a Mental Health Status Exam
Master of Social Work, Walden University
SOCW 6090: Psychopathology and Diagnosis for Social Work Practice
Conducting a Diagnostic Interview with a Mental Health Status Exam
14:51:32 GMT -05:00
, Identifying Data/Client Demographics
Carl Dunn is a 19-year-old Caucasian male. He resides in Darby, Montana. Carl is a student at
Trapper Keep Job Corps.
Chief complaint/Presenting Problem
Carl's presenting problems are bizarre behavior and odd ideation.
Present illness
Carl's present illnesses are obsessive thoughts and hallucinations as he hears and sees things that
are not there.
Past psychiatric illness
Past psychiatric illness was not discussed.
Past medical history
Past medical history was not discussed.
Family history
Carl reports that his mom dated several men and women during his childhood, and he "had quite
a few different names growing up." Carl also mentioned that he had family members that were
practicing Wiccans. Additional family history was not discussed.
Mental Status Exam
Carl presents as a casually dressed young man of average build and appears to be his age of 19
years old. Carl's hair was in a middle-part ponytail, and he had dark circles around his eyes
which could be a result of lack of sleep. He wore a brown shirt, khaki pants, and black tennis
shoes to the interview and appeared to be appropriately groomed. The client demonstrated
appropriate eye contact with the clinician and displayed a polite and cooperative attitude in
answering all questions. The client also displayed his sense of humor by making jokes to the
clinician based on some of the questions. Carl's speech was clear and fluid. The client's affect
14:51:32 GMT -05:00
Master of Social Work, Walden University
SOCW 6090: Psychopathology and Diagnosis for Social Work Practice
Conducting a Diagnostic Interview with a Mental Health Status Exam
14:51:32 GMT -05:00
, Identifying Data/Client Demographics
Carl Dunn is a 19-year-old Caucasian male. He resides in Darby, Montana. Carl is a student at
Trapper Keep Job Corps.
Chief complaint/Presenting Problem
Carl's presenting problems are bizarre behavior and odd ideation.
Present illness
Carl's present illnesses are obsessive thoughts and hallucinations as he hears and sees things that
are not there.
Past psychiatric illness
Past psychiatric illness was not discussed.
Past medical history
Past medical history was not discussed.
Family history
Carl reports that his mom dated several men and women during his childhood, and he "had quite
a few different names growing up." Carl also mentioned that he had family members that were
practicing Wiccans. Additional family history was not discussed.
Mental Status Exam
Carl presents as a casually dressed young man of average build and appears to be his age of 19
years old. Carl's hair was in a middle-part ponytail, and he had dark circles around his eyes
which could be a result of lack of sleep. He wore a brown shirt, khaki pants, and black tennis
shoes to the interview and appeared to be appropriately groomed. The client demonstrated
appropriate eye contact with the clinician and displayed a polite and cooperative attitude in
answering all questions. The client also displayed his sense of humor by making jokes to the
clinician based on some of the questions. Carl's speech was clear and fluid. The client's affect
14:51:32 GMT -05:00
