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The document outlines the basic steps in taking a case history, including collecting identifying information, understanding the presenting problem, and evaluating past and current mental health issues. It emphasizes the importance of the Mental Status Examination (MSE) in assessing a client's psychological functioning and planning treatment. Additionally, it provides examples of questions for evaluating attention, concentration, memory, and abstract thinking, and discusses how to handle client discomfort during the assessment process.

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Psyheal A place of acceptance
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3 views

Assignmenttt

The document outlines the basic steps in taking a case history, including collecting identifying information, understanding the presenting problem, and evaluating past and current mental health issues. It emphasizes the importance of the Mental Status Examination (MSE) in assessing a client's psychological functioning and planning treatment. Additionally, it provides examples of questions for evaluating attention, concentration, memory, and abstract thinking, and discusses how to handle client discomfort during the assessment process.

Uploaded by

Psyheal A place of acceptance
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Assignment

1. What are the basic steps in case history?

The basic steps in taking a case history follows a systematic format to get a detailed
understanding of the client’s background and current issues.

1. Identifying Information: Collecting basic details, Like name, age, gender, occupation, and
contact information.

2. Presenting Problem: Understanding the main reason the client has come. This is in the client's
own words.

3. History of Present Illness: Getting the timeline and details about when the problem began, how
it progressed, and any previous attempts at solving it.

4. Past Psychiatric History: Inquiring about any past mental health issues, treatments, or
hospitalizations.

5. Medical History: Collecting information on the client’s physical health, including current
medications and any past medical conditions.

6. Family History: details about mental or physical health conditions in the family that may be
relevant to the current situation.

7. Personal History: This covers developmental milestones, education, work, relationships, and
significant life events.

8. Social History: Details of the client’s social support, relationships, and living conditions.

9. Substance Use: seeing if the client uses substances like alcohol or drugs and how this might
affect their mental health.

10. Mental Status Examination (MSE): Evaluating the client's current mental state, including
mood, thought process, behavior, etc.

2. Why is mental status examination an essential part, and what is the purpose?

The Mental Status Examination is important because it gives a glimpse of a client’s psychological
functioning at that particular moment. It helps in identifying any abnormalities in cognition, mood,
behavior, or perception. The MSE helps in diagnosing mental health conditions and planning
treatment. It gives information into how the client perceives themselves, others, and the world
around them. By evaluating areas like appearance, speech, thought process, and cognitive
functions, the MSE serves as an essential tool for mental health professionals to understand both
the nature and severity of a client’s mental health concerns.

3. Give your own set of questions that you would ask from the client in MSE (attention,
concentration, memory, abstract thinking).

Attention:

 "Can you count backward from 100?"

 "Please name the months of the year in reverse order."

Concentration:

 "I am going to say 6 words, and I want you to repeat them back to me in the same order."

 "Can you spell the word 'LARGE' backward?"

Memory:

 "Can you tell me what you had for lunch this afternoon?"

 "Do you remember the 5 words I asked you to recall earlier?"

 "What were you doing 3 years ago?"

Abstract Thinking:

 "What do you think it means when people say, ‘The early bird catches the worm’?"

 "If you see breeze, what might you expect is happening?"

These questions help address different cognitive functions and give a clearer picture of how the
client processes and retains information, along with their ability to think critically.

4. If the client feels uncomfortable and is not ready to answer certain questions, what will be
your move and how will you deal with the client?

If a client becomes uncomfortable or hesitant to answer certain questions, my first move would be
to understand their feelings and create a safe, non-judgmental space for them. I will reassure them
by saying, “I understand that some of these questions may be uncomfortable. You are free to pass
any questions or come back to them when you feel ready.” It’s important to show empathy and
avoid pushing them, as this could create a barrier in the therapeutic relationship. I would also offer
to revisit those questions after some time or explore less sensitive topics to help them feel more
comfortable before getting into more personal matters. Building trust and rapport is the key, so I
would respect their boundaries and work at their pace.

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