curvature of the spine causing muscle spasms in his lower back.Limitations: NoneMood: No history of depression or mania.Sleep: Occasional nightmares (2 to 3 times monthly).Appetite: No problems.Sexual function: N/A History of lost consciousness: Has passed out while drinking.Hospitalization: Twice for pneumonia.Medication: NoneAlcohol/drug use: Heavy use of marijuana and frequent useof alcohol. Has also experimented with narcotics which were stolen from his mother. Hallucinogens, including "acid" and "shrooms". He is also a pack-a-day cigarette smoker.Observations and BehaviorsAttitude: Good rapport during interview, very cooperative,frank, and open.Appearance: Unremarkable.Motor: Posture slumped, seemed nervous, a little agitated,but held eye contact.Speech: Adequate and average.Language: Good vocabulary, normal.Attention: Adequate.Memory: Could not remember exact year his brother died. Otherwise, memory seemed fine, with accurate detail.Mood: No depression or mania. Has had occasional thoughts of suicide, but never attempted. In the past has had anger-management problem, and saw a therapist (after complaints by teachers) from 1987 to 1990.Affect: Appropriate and normal.Self-appraisal: Adequate.Insight: Consistent with abilities.Judgment: Adequate.Thoughts: Appropriate to content, no phobias, obsessions, etc.Perception: Normal.Attitude towards illness: Recognizes he has a problem, but doesn't see it as serious, therefore is not very motivated to fix, or work on the problem.DiagnosisAxis I: Substance abuse, particularly alcohol and cannabis, bordering on substance dependence.Axis II: N/AAxis III: Curvature of the spine.Axis IV: Mother with significant psychological problems combined with AODA issues due to death of oldest son.Axis V: 90Support for diagnosis Substance abuse-Despite being caught numerous times for drinking and drug use, and suffering the resulting consequences, "Kurt" refuses to abstain fr...
