Reference no: EM133803088

Question

Discuss each differential and whether or which of the MSE data and alcohol and substance use history adds to your diagnostic reasoning, enabling you to have more confidence in a particular primary diagnosis or differentials. Differentials: alcohol use disorder, generalized anxiety disorder, major depressive disorder, bipolar disorder, insomnia, substance induced mood disorder MENTAL STATUS EXAM: Appearance: Caucasian male who appears older than stated age. Wearing blue jeans and a hoodie with clean tennis shoes. Wears long hair and a beard that is slightly unkempt. Appears well nourished. Behavior/Motor: Mild fidgeting Mood: Euthymic Affect: Full range; appropriate to Mood Thought Process: Logical & Coherent Psychosis: No Evidence of psychosis Thought Content: No evidence of obsessions, No SI or HI, or ruminations Speech: Somewhat rapid in rate, normal tone and rhythm Alert & Oriented to person, place, time and situation Concentration/Attn: Good Memory: Recent: Intact Remote: Intact Insight: Good Judgment: Fair Fund of Knowledge: Intact Risk: Homicidal Thoughts: Denies Concern: Low If yes to suicidal thoughts: Plan: Intent: Means: Deterrent: Alcohol and Substance Use History; Habits: He reports his first use of alcohol at 15 years of age. He consumes alcohol five days a week up to 1/5 of a bottle of vodka, and as little as 4 shots or 2 beers. Client's longest period of abstinence has been two days, which occurred in the past two months. While in college, he successfully stopped drinking alcohol for 4 months. First use of marijuana at 18 years of age, with last use 6 weeks ago. From the ages of 19-22 years, he smoked marijuana 3-4 times a day. He first used powder cocaine at 21 years of age and would use 1 gram per sitting every 6 months, with last use 4 years ago. He used mushrooms twice at 19 years of age. He stopped due to having a "bad dream." He smokes 1 pack of cigarettes per week. He sometimes will use a Monster drink for energy once a week but never after 2 pm due to sleep disturbance.