Question
Answered step-by-step
CommodoreCaterpillar2553
Follow the guidelines below. The diagnosis should appear on one…
Follow the guidelines below.
The diagnosis should appear on one line in the following order.
Note: Do not include the plus sign in your diagnosis. Instead, write the indicated items next to each other.
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)
Then, respond to the following:
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.
Case Study:
CASE PRESENTATION – ANNIE
Intake Date: July xxxx
IDENTIFYING/DEMOGRAPHIC DATA: Annie is a White female, 29 years
old who lives in Oregon with her husband Dwayne and four sons. She has been
married 12 years. She is a homemaker and does not work outside the home.
Annie and Dwayne own several mini golf locations throughout Oregon.
CHIEF COMPLAINT/PRESENTING PROBLEM: One evening the family
was attending a Christian event – a bon fire party at the beach and Annie
unexpectedly was nowhere to be found. Soon after she was located further down
on the beach unconscious. Annie was brought to the hospital. There were no signs
of physical trauma. When Annie awakened, she could not recall the incident, what
happened, or anything about who she is. She was unable to remember her husband
or children. The hospital did a full evaluation for head trauma but found none.
Annie has been having difficulty adjusting to the role of wife and mother. She
does not recall how she was in both roles previously.
HISTORY OF PRESENT ILLNESS: Annie experienced a seemingly traumatic
event while at a community function at the beach. From the incident she seems to
have forgotten who she is. After a complete medical workup there is no evidence
of organic brain dysfunction. The situation has caused Annie a lot of emotional
distress.
PAST PSYCHIATRIC HISTORY: Annie has never had a history of psychiatric
treatment.
SUBSTANCE USE HISTORY: Annie drinks socially. She denies any drug use.
Her husband Dwayne concurs that Annie is not a big drinker and drinks on
occasion. He has never seen Annie intoxicated.
PAST MEDICAL HISTORY: Annie has yearly physicals. There has never been
any concern with medical issues. Annie at times has painful menstrual periods but
not on a monthly basis.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Annie
comes from a more affluent family. She met Dwayne in high school when the
football teams were competing each other. She has been with Dwayne ever since.
Her parents did not approve of Dwayne since he was Black. Annie has very little
contact with her family even though her marriage to Dwayne has proven to be very
successful.
CURRENT FAMILY ISSUES AND DYNAMICS: Annie continues her role as
wife and mother but is having difficulty adjusting to it. She is very distressed that
she cannot remember her past. The doctors have told Annie that her memory
probably will come back suddenly. Annie stays isolated now since she cannot
remember her past with all her social activities and friends. Annie was very
involved with her children’s school and church activities.
MENTAL STATUS EXAM: Annie is not oriented to time, place or person
from the past. She is oriented to what she has been told since the incident on the
beach. She could do serial 7’s and all memory tests. Short term memory, since
the incident is adequate but long-term memory is lost. Concentration is not
impaired. Patient denies homicide and suicide ideation. Her affect is flat and
mood dysphoric. Annie indicates her sleep is impacted, sometimes waking up and
worrying. When asked how she sees herself in five years, she said “hopefully with
my memory back, only healthier.”
