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CASE of BOB INTAKE DATE: November xxxx DEMOGRAPHIC DATA: This is a…
CASE of BOB INTAKE DATE: November xxxx DEMOGRAPHIC DATA: This is a voluntary intake for this 24 year old Jamaican male. Bob has had several psychiatric hospitalizations in the past. Bob has been married for 5 years. His wife, Rayona was born and raised in the United States. He has one son 5 years old and one daughter, 3 years old. Bob has had difficulty in jobs and has not been at any job longer than one year. Bob immigrated to the United States with his parents when he was 6 years old. CHIEF COMPLAINT: “My wife is complaining about my behavior. I do not see what the issue is”. HISTORY OF ILLNESS: Bob reports first seeking psychiatric treatment when he was sixteen years old. He was prescribed anti-depressants, but does not remember what kind. Since they helped his mood he remained on anti-depressants for four years. At twenty years old he attempted suicide after his wife threatened to leave him. He was hospitalized in a psychiatric unit for thirty days. At that time Bob was put on Depakote, with continued success for three years. He stopped taking the Depakote 1 years ago. In the previous September Bob returned to his psychiatrist because he was becoming depressed again, feeling sad, fearful and suicidal. He was given Trintellex. During the next few weeks Bob felt on top of the world. He then would have angry outbursts. His wife asked him to leave the home. He then took an overdose of Klonopin. More recently Rayona was getting concerned about their financial state because Bob would constantly be buying big items that they could not afford. They would have arguments about this all the time. Bob was rarely sleeping because he was up shopping at night on the Internet. This had no effect on his ability to work. SUBSTANCE USE HISTORY: At twenty one Bob began drinking. His use of alcohol continued increasingly until about 6 months ago. He reports never planning on drinking as much as he did but once he started he was compelled to drink until he passed out. He stopped drinking after attending outpatient treatment for 16 weeks. He began drinking in September again, Bob indicates, to cope with the marital difficulties. PSYCHOSOCIAL HISTORY: Bob reports growing up as uneventful. His mother separated from his father on several occasions. His mother made all the decisions and his father played a more passive role. Bob is the only child from his parents’ union. He has an older brother from his mother’s previous marriage. Bob does not have any contact with his brother. Bob was initially considered an underachiever in the early years of school. He had trouble being in fights with other kids because they used to make fun of his wrinkled clothes. Bob has no legal history. He worked in the family business through high school and college. He became a project coordinator at his next job. He stayed there six months years. MEDICAL HISTORY: Bob states he had the usual childhood vaccinations and no major illnesses as a child. He currently is physically fit and healthy. FAMILY ISSUES AND DYNAMICS: Bob reports that he is happy in his marriage and does not know why his wife has so much trouble with him. He believes his wife has become more distant from him over the past several years which he doesn’t like. Their fighting has increased. Bob reports his wife is frustrated with his lack of energy and fatigue which has, recently, been impacting their social life and activities with the children. MENTAL STATUS EXAM: Bob presents as a neatly dressed male who appears younger than his stated age. Facial expressions are appropriate to thought content. Motor activity is appropriate. Thoughts are logical and organized. There is no evidence of hallucinations or delusions. Bob admits to a history of suicidal ideation, gestures and attempts. His mood is depressed. During the interview Bob talked fast. Bob is oriented to time, place and person. His intelligence appears above average.
Submit your diagnosis for the client in the case. 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)
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.
