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The diagnosis should appear on one line in the following order. …
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)
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 months.
CASE STUDY
IDENTIFYING/DEMOGRAPHIC DATA: Ivander is a 19-year-old, biracial male who was raised in Hugo, Oklahoma. Ivander’s mom is Caucasian and his father is African American. Ivander is the only child from his parents union. Ivander is in his first year at college and lives on campus.
CHIEF COMPLAINT/PRESENTING PROBLEM: Ivander came into treatment due to his concern of a change in behavior. Ivander indicated that he was having a strange experience – “I went into another world. I heared people talking, but I couldn’t talk back. I couldn’t trust my roommate – I thought he was taking my food and hiding it”
HISTORY OF PRESENT ILLNESS: Ivander reports beginning to feel strange three weeks ago after the winter break. He reported hearing voices outside his window in the dorm. It was an angel’s voice calling his name. That is when he realized he cannot trust his roommate. He realized the roommate would put TV shows on that were referencing how Ivander was doing in his classes. His school papers were all over his room and he could not organize them the way he wants.
Ivander socializes with his classmates and is engaged in leisure activities. He feels better now and does not feel the same way but the experience made him very concerned.
PAST PSYCHIATRIC HISTORY: Ivander’s mom does not report any psychiatric issues with Ivander in the past. His behavior was a typical teenage behavior, video games, dressing unusual, thinking in a way that differs from his parents beliefs.
SUBSTANCE USE HISTORY: Ivander denies consumption of alcohol or illicit drugs. He denies ever using illicit drugs that were not prescribed to him. Ivander reports now that he thinks about it he is glad he never used drugs since drug dealers will kill their clients.
PAST MEDICAL HISTORY: Mother reports Ivander broke his arm at 7 years old. The arm healed successfully. Ivander had all his childhood shots, but she does recall her fear of his health early on when Ivander was 2 ½ weeks old he came down with a spring cold.
FAMILY MEDICAL AND PSYCHIATRIC HISTORY: There was no significant information about the family history.
CURRENT FAMILY ISSUES AND DYNAMICS: Ivander was able to indicate some history that was consistent with history taken from his mother.
MENTAL STATUS EXAM: Ivander was coherent during most of the interview. Ivander presented as a casually dressed, clean cut young man who looked his stated age. He has a fluctuating mood and an anxious expression on his face. Motor activity appeared fine. Mood was anxious and concerned. Speech was appropriate. His affect was inappropriate and at times blunted. He reported bizarre delusions and auditory hallucinations during that 3 week period. Ivander is oriented to time, place, and person. He was able to state the season. Ivander can name 3 different objects correctly (bed, apple, shoe). He needed to calculate 100 – 3 five times. Ivander denied suicidal or homicidal ideation.
