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CASE of KATLEGO
Intake Date: March 2021
IDENTIFYING/DEMOGRAPHIC DATA: This is a voluntary intake for this 53-year-old South African male. Katlego has been married for 29 years and has been separated from his wife for the past ten months. He has been living alone for the past five months. His wife and three sons live two blocks from him. Katlego has had difficulty in jobs and has not been at any job longer than three years.
CHIEF COMPLAINT/PRESENTING PROBLEM: “I miss my family and do not want to live without them”.
HISTORY OF PRESENT ILLNESS: In December 2020 Katlego returned to his psychiatrist because he was becoming depressed again, feeling sad, fearful and suicidal. He reported angry outbursts. His wife asked him to leave the home. He then took an overdose of Klonopin. In consultation with his wife, she reported getting continuously concerned about their financial state because Katlego would constantly be buying big items that they could not afford. They would have arguments about this all the time.
PAST PSYCHIATRIC HISTORY: Katlego has had several psychiatric hospitalizations in the past. Katlego reports first seeking psychiatric treatment when he was twenty-six years old. He was prescribed anti-depressants
?, but does not remember what kind. Since they helped his mood he remained on anti-depressants for several years. At thirty-four years old he attempted suicide n?>k after his wife and children left him. He was hospitalized in a psychiatric unit for thirty days. At that time Katlego was put on Depakote with continued successful results for several years, resulting in reconciliation. He stopped taking his medication in 2019.
SUBSTANCE USE HISTORY: In his late teens Katlego began drinking. His use of alcohol continued into his early thirties.
PAST MEDICAL HISTORY: Katlego states he currently takes Synthroid for a thyroid problem and this helps him keep his weight down.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Katlego reports growing up as tumultuous. His mother separated from his father on several occasions and sometimes would throw Katlego out of the house with the father. His mother made all the decisions and his father played a more passive role. Both parents would often have physical fights and Katlego would try to break up the fighting from as early as he can remember.
Katlego is the only child from his parents’ union. Katlego was initially considered an underachiever in the early years of school. He had trouble being in fights with other kids because they used to make fun of his wrinkled clothes.
Katlego has no legal history. He worked in the family business through high school and college. He became a project coordinator at his next job. He stayed there three years.
CURRENT FAMILY ISSUES AND DYNAMICS: Katlego was first married at age twenty one years old which ended in a quick divorce. Six months after his first divorce Katlego married again. They have two children. The first ten years of their marriage Katlego reports physically abusing his wife. He stopped the physical abuse when Mrs. Katlego asked for a divorce the first time. He believed his wife was becoming more distant from him over the past several years which he could not take. Their fighting increased, although he would not become physical with her now.
MENTAL STATUS EXAM:
Katlego presents as a neatly dressed male who appears younger than his stated age. His hair is a bit disheveled. His nails are neatly groomed. Facial expressions are appropriate to thought content. Motor activity is appropriate. Thoughts are logical and organized. There is no evidence of hallucinations. Katlego admits to a history of suicidal ideation, gestures and attempts. His mood is depressed. During the interview Katlego talked fast. Katlego is oriented to time, place and person. His intelligence appears above average.
Submit 2-3 page paper. In your write-up, Describe your case in 300-500 words.
· Identify the red flags in your case study to be further evaluated.
· Outline your and your partner’s plan for further research and consultation,
· Briefly summarize your case, highlighting the diagnostic symptoms seen in the case.
· Describe your decision-making process for identifying the key problems in the case and the differential eliminations for your case.
· Identify the diagnosis of the client in the case. Explain the diagnosis by providing the supporting DSM-5 criteria with specific examples of how your client met those criteria.
· Post a fully coded DSM-5 diagnosis. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may be a focus of clinical attention)
