CASE OF RALPH

INTAKE DATE: May xxxx

DEMOGRAPHIC DATA:

This is a voluntary admission for this 32-year-old Caucasian male. This is Ralph's first psychiatric hospitalization. Ralph has been married for 6 years and lives with his husband, Richie, and son. Ralph has a two-year degree in nursing and works as an RN. Religious affiliation is agnostic.

CHIEF COMPLAINT:

"My life is spiraling out of control. I do not want to lose my family".

HISTORY OF ILLNESS:

This admission was precipitated by Ralph's increased depression with passive suicidal ideation in the past three months prior to admission. Ralph has had a past history of alcohol binges and these binges are intensified when there is a need for coping mechanisms in times of stress. Ralph was starting vacation from work just prior to admission and recognized that if he did not come to the hospital for treatment of depression and alcoholism, he worried he would have a serious alcohol binge. Ralph reports that in the past three months, he has experienced sad mood, fearfulness, and passive suicidal ideation. He denies a specific suicidal plan. Ralph's husband reports that during the past three months prior to admission, Ralph made a verbal suicidal threat.

Ralph reports he has been increasingly withdrawn/non-communicative. His motivation has decreased, and he finds himself "sitting around and not interested in doing chores at home". He reports decreased concentration at work and increased distractibility. Ralph has experienced increased irritability, decreased self-esteem, and feelings of guilt/self-blame. There is no change in appetite, but Ralph reports an intentional weight loss of 20 pounds in the last 5 months with dieting. Ralph states that for many years he hasn't really slept ever since he worked double shifts when requested. Ralph reports his normal sleep pattern for many years has been generally three hours of unbroken sleep. Ralph reports past history of euphoria, although his husband reports to the intake worker having observed periods when Ralph's mood is elevated; then in the next few hours, Ralph appears out of control with poor impulse control, increased arguing, temper tantrums and alleged shoving and pushing him and his son. After this, Ralph feels tired and ends up sleeping more than average.

Ralph denies suicidal ideation at the present time while in the evaluation unit.

Ralph reports a history of some alcohol binges in the past. He began drinking beer eleven years agoafter he turned 21 years old. Ralph reports that until two years prior to admission, his pattern of drinking was to get drunk with his social group approximately twice per month. He denies a history of blackouts. He admits to the alcohol binges and heavy use of cocaine (snorting and freebasing on weekends) in the past. Ralph received a charge of driving while intoxicated in March, 7 years ago, and had lost his driver's license for six months. Ralph reports using alcohol as a coping mechanism for stress (reporting that he will only drink on weekends now).

PAST PSYCHIATRIC HISTORY:

Ralph was seen on an outpatient basis by Dr. S for a period of two months prior to admission. He was being seen for individual counseling because of depression. Dr. S recently referred Ralph for inpatient rehabilitation.

MEDICAL HISTORY:

Four years ago, Ralph sustained a head injury when he hit his head on a coffee table. Ralph had a past history of fractured toes with pins being inserted in the third and fourth digits of his right foot after an accident in which he crushed his foot at work. Ralph denies a past history of seizures.

Ralph has had a weight loss of approximately 20 pounds secondary to dieting. Ralph is allergic to Codeine.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY:

Father and grandfather have a history of cardiovascular disease and alcoholism.

PSYCHOSOCIAL AND DEVELOPMENTAL HISTORY:

Ralph reports that while growing up his parents maintained a satisfactory relationship. Father reportedly worked nights and slept during the day. Ralph did not have much contact with his father but now enjoys a close relationship with him. He states he has always had his parent's support.

During Ralph's school years, he reports he was an underachiever in elementary school. He denies having had a history of discipline problems or hyperactivity. He states he did well in high school and earned grades of A's and B's. Ralph played football in HS. After completing high school, Ralph furthered his education and earned his license as a registered nurse. He states he graduated at the top of his class from nursing school.

Ralphhas been married for 6 years. Ralph and his husband have one adopted son, age 4. Ralph states he feelsinvested as a parent and feels close to his son.

Leisure time activities Ralph has enjoyed in the past include playing softball, reading, playing poker, and watching football.His husband has complained that he is doing less of that now since he is drinking more.Ralph states he has several close friends.

CURRENT FAMILY ISSUES AND DYNAMICS:

Ralph's husband reports that Ralph's difficulties began to get worse a few months ago due to Ralph's increasingly erratic behavior. Husband states that Ralph has been suffering from mood swings where he is "very up" and feeling great, firm in his direction, and then within the next few hours, he is often out of control, arguing, throwing temper tantrums, pushing and shoving, and becoming verbally abusive.

Husband states Ralph has been drinking for several years in the amount of a 12-pack of beer per day plus shots of hard liquor. Although Ralph reported he has been using cocaine on and off for about two years, his husband states he does not think that Ralph is presently using cocaine. At one point, after threats from his husband, Ralph told him that he had gone to a clinic for outpatient rehabilitation, but he did not believe him.

Husband describes Ralph as "extremely depressed" now and says Ralph states, "Life is over...I wish I was dead...everything I touch turns to garbage. The husband adds that Ralph suffers from poor self-esteem, lack of sleep, and an extremely boastful attitude. In terms of strengths, he is a good father, compassionate, creative, and can be an outstanding person.

The husband reports Ralph always had a bad relationship with his mother. Ralph is close to his father who is reported to have an alcohol problem and was allegedly loud and intimidating.

MENTAL STATUS:

Ralph presents as a casually dressed male who appears his stated age of 32. The posture is relaxed. Facial expressions are appropriate to thought content. Motor activity is appropriate. Speech is clear and thereareno speech impediments noted. Thoughts are logical and organized. There is no evidence of delusions or hallucinations. Ralph admits to a recent history of passive suicidal ideation without a plan but denies suicidal or homicidal ideation at the present time. Ralph admits to a history of decreased need for sleep but denies euphoric episodes. His husband has observed a history of notable mood swings. No manic-like symptoms were observed at the time of this examination.

On formal mental status examination, Ralph is found to be oriented to three spheres. The fund of knowledge is appropriate to the educational level. Recent and remotememory appearintact. Ralph was able to calculate serial 7's. In response to three wishes, Ralph replied "I wish that my marriage was better, that my son would be happy, and that someone would give me a million dollars."

Question :

• Explain how you support the diagnosis by specifically identifying the criteria from the case study.
  • Describe in detail how the client's symptoms match up with the specific diagnostic criteria for the disorder (or all the disorders) that you finally selected for the client. You do not need to repeat the diagnostic code in the explanation.
• Identify the differential diagnosis you considered.
• Explain why you excluded this diagnosis/diagnosis.
• Explain the specific factors of culture that are or may be relevant to the case and the diagnosis, which may include the cultural concepts of distress.
• Explain why you chose the Z codes you have for this client.
  • Remember: When using Z codes, stay focused on the psychosocial and environmental impact on the client within the last 12 months.

***Dear Tutor, the first part of the post is the full case study of Ralph (Case study). The second part of the post is the questions that need to be addressed. Thank you. References well be appreciated .