Description
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
NB : please don,t forget Reference page
Unformatted Attachment Preview
CASE of CHUCK
Intake Date: August xxxx
IDENTIFYING/DEMOGRAPHIC DATA: Chuck (31) and Helen (28) are a
married Caucasian couple who live with their sons, Mark (10) and Louis (8), in a
two-bedroom condominium in a middle-class neighborhood. Chuck is an Afghan
War veteran and employed as a human resources assistant for the military and
Helen is a special education teacher in a local elementary school. Chuck is
physically fit, but an injury he sustained in combat sometimes limits his ability to
use his left hand. Helen is in good physical condition and has recently found out
that she is pregnant with their third child.
CHIEF COMPLAINT/PRESENTING PROBLEM: Chuck stated that he came
for services only because his wife had threatened to leave him if he did not get
help. Helen was particularly concerned about his drinking and lack of involvement
in his sons’ lives. She told him his drinking had gotten out of control and was
making him mean and distant. Chuck’s expressed fear of losing his job and his
family if he did not get help.
HISTORY OF PRESENT ILLNESS: Chuck said that since his return to civilian
life 10 months ago he had experienced difficulty sleeping, heart palpitations, and
moodiness. He described being proud to join the army and deployed and described
himself as upbeat and happy prior to his deployments. He felt that he had to
“change” to stay alive there. Chuck works in an office with civilians and military
personnel and mostly gets along with people in the office. Chuck tended to keep to
himself and said he sometimes felt pressured to be more communicative and social.
He is very worried that Helen would leave him. He said he had never seen her so
angry before and saw she was at her limit with him and his behaviors. Chuck said
he thinks he is “going crazy”. He expressed concern that he would never feel
“normal” again and said that when he drank alcohol, his symptoms and the
intensity of his emotions eased. He talked about always feeling “ready to go.” He
said he was exhausted from being always alert and looking for potential problems
around him, always feeling on edge and every sound seemed to startle him when
he was not drinking. Chuck stated he often thinks about what happened “over
there” but tries to push it out of his mind. The night is the worst time for Chuck, as
he has terrible recurring nightmares of one particular event. He said he wakes
up shaking and sweating most nights. He then said drinking was the one thing that
seemed to give him a little relief.
PAST PSYCHIATRIC HISTORY: Chuck admits to cycles of hyperarousal and
avoidance, including his lack of sleep and irritability and the isolation.
SUBSTANCE USE HISTORY: As teenagers, Chuck and Helen used marijuana
and drank. Neither uses marijuana now but they still drink. Helen drinks socially
and has one or two drinks over the weekend. Chuck reported he has four to five
drinks in the evenings during the week and eight to ten drinks on Saturdays and
Sundays. Chuck admitted to drinking heavily nearly every day. Chuck spends his
evenings on the couch drinking beer and watching TV or playing video games.
PAST MEDICAL HISTORY: Chuck had previously visited his primary care
physician, Dr. Zoe, where he was given a prescription of Paxil to help reduce his
symptoms of anxiety and depression. Dr. Zoe recommended that he get ongoing
treatment.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC:
Chuck’s parents are deceased, and he has a sister who lives outside London. He
and his sister are not very close but do talk twice a year. Helen is an only child, and
her mother lives in the area but offers little support. Her mother never approved of
Helen marrying Chuck and thinks Helen needs to deal with their problems on her
own.
CURRENT FAMILY ISSUES AND DYNAMICS: There is no criminal history
reported. The couple has some friends, but due to Chuck’s recent behaviors, they
have slowly isolated themselves. Chuck stated he and his wife had been fighting a
lot and that he drank to take the edge off and to help him sleep, saying, “Nights are
the hardest.” Chuck admits he is not engaged with his sons at all and he keeps to
himself when he is at home. He gave some examples of having a “hair-trigger
temper” with his sons, especially if they surprised him inadvertently.
With Chuck’s permission, a collateral contact was made by phone with Helen to
elicit her concerns and perspective. Helen talked about wanting to be able to
communicate with Chuck without feeling that she was “nagging him” or fearful
that she was making him withdraw and that she would “trigger his anger.” She said
that she avoided asking him things or talking to him for fear it would “set him off”
and make him retreat to the basement on his own. As it stood, she did not think she
could talk with Chuck about her concerns. She told him she missed
socializing with friends and having family outings and felt isolated during their
confrontation. She reported that during the fight it came out that Chuck told her
that just keeping his intrusive thoughts at bay took all the energy he could
muster. Seeing friends and making small talk was not something he felt he could
do right now. Helen admitted that she did not know that socializing affected him
that way nor that loud noises, open spaces, and green lights triggered intrusive
memories
MENTAL STATUS EXAM: Chuck was well-groomed but appeared somewhat
guarded and anxious. He was coherent and articulate. Speech was at a normal rate,
although the pace was noted to accelerate when he approached or discussed
disturbing content. He denied depression but admitted anxiety and hyperarousal in
situations, such as when strangers stand close to him in check-out lines. His affect
was somewhat constricted but appropriate to content. His thought process was
coherent and linear. He denied all suicidal and homicidal ideations but admitted
that if startled “not much thought happens” between the event and his aggression
responses. He had no psychotic symptoms, delusions, or hallucinations. He had
reasonable insight, was well oriented, and seemed to have average intelligence.
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