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Friday, April 19, 2019

Importance Of Assessing For Medical Factors - Case Example


By: SOPHIA F. DZIEGIELEWSKI

In a comprehensive diagnostic assessment, the importance of examining complicating or interacting
medical conditions cannot be underestimated. Consider this example.

Late one night, a client who was extremely unkempt, delusional, and paranoid was brought to the emergency room. He reported bizarre delusions: Demons had invaded his teeth and were trying to capture his mind.

The client had a past history of schizophrenia and often reported persecutory auditory hallucinations. This time, however, the delusions he was reporting were extreme compared with previous presentations. He was so convinced that demons were inside his mouth that he had started to tear at his gums with his fingers in an attempt to get at the demons inside.

In his state of poor hygiene and malnourishment, it was not hard to see how he had managed to remove most of his teeth from his mouth, ripping them out with his fingers. Immediately on admission, a physical exam was ordered, along with an X-ray of his teeth to see the extent of the damage he had created by ripping the teeth from his mouth.

The X-ray revealed that the client had an extensive sinus infection and made it obvious how much pain the untreated infection was causing. The pressure the sinus discharge placed on the roots of his teeth was causing him extensive pain and heightening the paranoid delusion of demons occupying his teeth. Once the sinus infection was treated, the severity of the paranoid delusions subsided.

As can be seen in this example, it is critical that medical issues, especially when clients present with extreme signs and symptoms, be clearly assessed and documented as part of the comprehensive
diagnostic assessment process.

References

SOPHIA F. DZIEGIELEWSK, 2015, DSM-5TM in Action, by John Wiley & Sons, Inc.

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