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 sig
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)
Then, in 1–2 pages, 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.
- Remember: When using Z codes, stay focused on the psychosocial and environmental impact on the client within the last 12 months.
CASE of VICTOR
INTAKE DATE: August xxxx
IDENTIFYING/DEMOGRAPHIC DATA: Victor is a 24 year old Brazilian male. Victor’s religion is Catholic. He is single and attending the University of Maine for his Masters Degree in Finance. Victor was born and raised in Sao Paulo, Brazil and came to the United States 2 years ago.
CHIEF COMPLAINT/PRESENTING PROBLEM: Over the past three months Victor reported he had auditory hallucinations of an angel’s voice. Victor had thoughts about killing his roommate by suffocation – claiming that he heard fireflies tell him the roommate is influenced by Satan.
HISTORY OF PRESENT ILLNESS: In the last several months, Victor began to become socially withdrawn (keeping himself in his room), losing his concentration and feeling depressed. He showed signs of disorganized thought. Victor began spending his time browsing and chatting in Facebook about God and UFO’s. He would spend too much time online until he passed out. His sleep patterns became inconsistent which led him to feeling fatigued all day.
PAST PSYCHIATRIC HISTORY: Victor denies any past psychiatric history.
SUBSTANCE USE HISTORY: Victor denies any use of illicit drugs. He does report occasional use of alcohol. He has been drunk as a teenager but prefers not to indulge that much.
PAST MEDICAL HISTORY: Victor had been admitted to a Hospital six weeks ago for treatment as his wrist was injured due to a suicide attempt.
FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Victor is the second from five siblings. One of his family members has mental illness (schizophrenia), but would not identify the family member.
CURRENT FAMILY ISSUES AND DYNAMICS (OPTIONAL): Victor attends school for finance. His family continues to reside in Brazil. His parents are very supportive of his attendance at an American school. Victor is able to socialize with other students and professors. He did engage in leisure activity such as surfing the Internet, keeping his room tidy, doing household activity such as washing clothes, and kitchen preparation. That has reduced a lot over the past couple of months.
MENTAL STATUS EXAM: Victor appeared disheveled with poor hygiene. He was properly attired with hospital attire and had adequate eye contact. Victor was able to cooperate during the interview. There were some signs of anhedonia. He raised his voice at one time during the interview. His mood was irritable with upset speech. Thoughts were preoccupied with persecutory delusions. Perceptions showed auditory hallucinations. He was oriented: able to state person, place and time correctly. His short-term memory was intact: able to retrieve games rule. His long term memory was good: able to recall previous history. Insight was good.
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