Question
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123TR321
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: 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.”
