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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 months.
CASE of SHANA Intake Date: January xxxx IDENTIFYING/DEMOGRAPHIC DATA: Shana is a 32 year old, single African American female, with no siblings. Shana reports never being married. She works full time at the library.
CHIEF COMPLAINT/PRESENTING PROBLEM: Shana reported having sudden attacks and feeling anxious. She described feelings coming over her so quickly where her heart was pounding and she couldn’t breath. Recently when shopping, she wanted to just run out of the store when this happened, she was so dizzy she wanted to vomit. She even stopped going to the library.
HISTORY OF PRESENT ILLNESS: Sharice notes “I like people but I don’t deal well with them. I never seem to meet a lot of people. I guess I have always been this way. I remember rarely inviting other kids to my birthday parties. “I didn’t think they really wanted to come”. Shana described feeling anxiety and panic over the past three weeks when she was assigned a new boss. She believes her work is unsatisfactory and feels very dissatisfied with her job. She doesn’t like the anxiety she is now experiencing. Over the past two years her other boss would cover up for her mistakes, when her concentration was off and she couldn’t make a decision. She may need to quit her job. She cannot believe that she gets accommodations at work. She cannot figure out why.
PAST PSYCHIATRIC HISTORY: Sharice initially started psychiatric treatment at 18 years old after her mother complained about her depressed mood and lack of social activity. She just lost all interest in trying to do things because it just did not work. Sharice believes she is just not the type that has a lot of energy for things. She states she did not know how to go about being social. After several years she finally admitted to her mother that she always thought about killing herself. At 25 she made a suicide attempt by drinking a glass of wine and taking valium. She describes being unsure how much valium she needed, so she took half a pill. She remembers being upset because her fingers bled because she would pull the extra skin off by her nails, and then her nail would look terrible. Everything was “going haywire” at that time. Her energy was “zapped”, she did not want to try and build her social circle, her sleeping and eating habits got worse. At this time, Sharice was admitted to a psychiatric unit for thirty days. Shana reports being involved in psychotherapy previously, over a ten year period. She would attend one session, then never go back. There was only one social worker that she stayed with for any length of time. Shana states she enters treatment when she feels anxious or depressed. Most of the time her mother would bring her to the first session. She has been prescribed Prozac and Paxil in the past – ten years ago and five years ago, respectively. Sharice reports both medications helped “somewhat” but did not really help much.
SUBSTANCE USE HISTORY: About one year after discharge from the psychiatric hospital Shana’s depressive symptoms were still present so she started drinking at home. Her drinking increased so much over that one year that she knew it was contributing to her depression. Shana’s mother confronted her about the drinking and brought Shana for alcohol treatment. She completed outpatient treatment and slowly began attending AA meetings. She states she is a recovering alcoholic for five years. Shana denies any other drug use. She has never had a sponsor, and does not attend any AA functions other than a meeting. Presently she attends one AA meeting a week. It is on a Friday afternoon during lunch time. Shana reports always enjoying this meeting in the past because all three attendees get a chance to talk if they want. Over the last two years, Shana reports losing interest even in attending this AA meeting, but she goes because they serve lunch.
MEDICAL HISTORY: Shana had her tonsils removed at 8 years old. She denies any other distinguishing medical problems. Shana has used Paxil and Prozac in the past, when her anxiety became overwhelming. She stopped her Paxil three years ago because she felt better.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Her parents were divorced when she was 11 years old. Shana resides with her mother in Austin, TX. Shana describes her relationship with her mother as “very close”. She does worry about disappointing her mother since mom, for as long as she can remember, complained about Shana being depressed all the time.
CURRENT FAMILY ISSUES AND DYNAMICS: Shana reports never having many friends because of her relationship with her mother. She believes if she moved out of her house she would be able to increase her social circle. Sharice reports having a boyfriend in college, who she knew since childhood but she didn’t know really how to be a girlfriend. She stopped taking his phone calls. She remembers going to the movies with him a few times. Sharice reports being unsure how to act on a date. Sharice would like to get married and have children.
MENTAL STATUS EXAM: Shana presented in a very plain non descript manner with no makeup. She was dressed appropriately in casual attire, a skirt and blouse. She apologized for not wearing makeup, but she described herself as being unable to be like other woman who know how to put makeup on. Shana spoke in almost a whisper, with very flat affect. She states her concentration is definitely affected by her lack of sleep since she wakes up every couple of hours. She sees herself as more irritable than ever, even her mother commented on her irritability. Shana states she also is feeling some muscle tension. She denies homicidal ideation. When asked about suicidal ideation Sharice responded “You mean right now, or this moment, no, but they are there. I don’t think I’ll ever kill myself, but you never know, do you?”.
