Case 5
Case 5
Part 1
Age: 66
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: Caucasian
Relationship Status: Married
Counseling Setting: Agency
Type of Counseling: Individual
Presenting Problem: Memory Loss
Diagnosis: Major Neurocognitive Disorder due to probable Alzheimer's disease
Presenting Problem: You are a counselor at a mental health agency and your client has been referred to you by his primary care physician due to some concerns with memory loss. The client, a 66 year-old Caucasian male, attends the session with his wife who expresses more concern than her husband. She states that lately her husband has been showing a gradual decline in his ability to carry out day to day tasks. He recently left the stove on for an hour after heating up some water to make tea. The client states that he has noticed that it takes him about a week to finish a crossword puzzle that used to take about an hour, and this increase in time has been steadily increasing over the past year. “I just can’t think of the words,” he states. The client’s wife says that the client has stopped doing crossword puzzles out of frustration and he has no longer been interested in reading, which has always been one of his favorite pastimes.
Mental Status Exam: The client comes to session well groomed with good hygiene. The client is oriented to person, place, and time. The client does not report a history of hallucinations or delusions. At the end of the session, the client is unable to recall three words that were mentioned to the client at the beginning of the session. The client grows frustrated in session when he cannot recall some details that his wife mentions. At numerous times, the client stares out the window while his wife talks to you.
Family History: The client is a father to six adult children and eighteen grandchildren. His oldest grandchild is about to graduate high school, and his youngest grandchild was just born at a hospital not far from your office. He recalls going to the hospital for each of their births, except the birth of Isaac, his grandson who was two years ago. Your client tells you the story about how his daughter was on a flight from Los Angeles to Des Moines when, all of a sudden, her water broke and she went into active labor while on the airplane. Luckily there was a gynecologist and a paramedic on board who safely delivered the baby. Your client shares that he doesn’t know what the “place of birth” says on his grandson’s birth certificate, but it should say “somewhere over the Rocky Mountains.” He regularly spends time with his grandchildren, and states that the family is planning to get together for his upcoming birthday.
Living Situation: The client lives with his wife. They have six grown children, who are all married with children. The client is retired and is dependent on his wife for transportation since losing his license 3 months ago due to transient memory loss.
Health History: The client’s doctor has ruled out cerebrovascular diseases via neuro-imaging and has made a preliminary diagnosis of Major Neurocognitive Disorder due to probable Alzheimer's disease. The client is otherwise in good health. The only factor that stands out in client’s health history is that the client’s father and grandfather were both diagnosed with Alzheimer’s disease before they died.
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Part 1
Age: 66
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: Caucasian
Relationship Status: Married
Counseling Setting: Agency
Type of Counseling: Individual
Presenting Problem: Memory Loss
Diagnosis: Major Neurocognitive Disorder due to probable Alzheimer's disease
Presenting Problem: You are a counselor at a mental health agency and your client has been referred to you by his primary care physician due to some concerns with memory loss. The client, a 66 year-old Caucasian male, attends the session with his wife who expresses more concern than her husband. She states that lately her husband has been showing a gradual decline in his ability to carry out day to day tasks. He recently left the stove on for an hour after heating up some water to make tea. The client states that he has noticed that it takes him about a week to finish a crossword puzzle that used to take about an hour, and this increase in time has been steadily increasing over the past year. “I just can’t think of the words,” he states. The client’s wife says that the client has stopped doing crossword puzzles out of frustration and he has no longer been interested in reading, which has always been one of his favorite pastimes.
Mental Status Exam: The client comes to session well groomed with good hygiene. The client is oriented to person, place, and time. The client does not report a history of hallucinations or delusions. At the end of the session, the client is unable to recall three words that were mentioned to the client at the beginning of the session. The client grows frustrated in session when he cannot recall some details that his wife mentions. At numerous times, the client stares out the window while his wife talks to you.
Family History: The client is a father to six adult children and eighteen grandchildren. His oldest grandchild is about to graduate high school, and his youngest grandchild was just born at a hospital not far from your office. He recalls going to the hospital for each of their births, except the birth of Isaac, his grandson who was two years ago. Your client tells you the story about how his daughter was on a flight from Los Angeles to Des Moines when, all of a sudden, her water broke and she went into active labor while on the airplane. Luckily there was a gynecologist and a paramedic on board who safely delivered the baby. Your client shares that he doesn’t know what the “place of birth” says on his grandson’s birth certificate, but it should say “somewhere over the Rocky Mountains.” He regularly spends time with his grandchildren, and states that the family is planning to get together for his upcoming birthday.
Living Situation: The client lives with his wife. They have six grown children, who are all married with children. The client is retired and is dependent on his wife for transportation since losing his license 3 months ago due to transient memory loss.
Health History: The client’s doctor has ruled out cerebrovascular diseases via neuro-imaging and has made a preliminary diagnosis of Major Neurocognitive Disorder due to probable Alzheimer's disease. The client is otherwise in good health. The only factor that stands out in client’s health history is that the client’s father and grandfather were both diagnosed with Alzheimer’s disease before they died.
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