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write the diagnostic Code + Name + Specifier (appears on its own…
write the diagnostic Code + Name + Specifier (appears on its own first line)
Z code (appears on its own line next with its name written next to the code):
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/diagnoses.
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 month
CASE of MICHAEL
Intake Date: October XXXX
IDENTIFYING/DEMOGRAPHIC DATA: Michael is a 27-year-old African American male. He is single and lives by himself in low-income housing. He is currently looking for a job.
CHIEF COMPLAINT/PRESENTING PROBLEM: Michael has been concerned for the past 3 years of becoming ill. His father died at 25 years old and Michael is afraid he would follow in those footsteps. He worries if he gets any pain or aches in his body. He was very worried about contracting Covid 19 but never did. He worries every year about getting the flu but will not take vaccines thinking they will promote the illness that they are supposed to combat.
HISTORY OF PRESENT ILLNESS: When Michael became close to the age that his dad died his worry began. His sleeping habits have become erratic over the past three years. His mood is down and he feels hopeless especially since doctors have not diagnosed any physical illness. Michael fears getting physically ill.
PAST PSYCHIATRIC HISTORY: Michael has not been to any psychiatrist or therapist until this intake.
SUBSTANCE USE HISTORY: Michael states he drinks periodically but does not get drunk. He fears that he would lose his senses and maybe get ill if he is not clear thinking.
PAST MEDICAL HISTORY: Michael has been to several doctors over the past three years he does not even remember all of them. He is so concerned over possibly getting sick and they tell him that he is misreading any physical cues.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Michaels’ dad died very young. He was not in good shape and had a heart attack at 25 years old. Michael’s mom is ill and takes a lot of medication.
CURRENT FAMILY ISSUES AND DYNAMICS: Michael does have contact with his mother. He knows she is ill and he tries to be in touch as much as possible. Michael does not have any siblings.
MENTAL STATUS EXAM: Michael was uncomfortable throughout the interview. Michael’s judgement is poor. He showed signs of depression. Michael is oriented to time place and person. He denies suicidal ideation. There are no perceptual disturbances reported.
