Description
Review the case study for this week.
Start by familiarizing yourself with the disorders from the DSM-5-TR found in the Learning Resources this Week.
Look within the noted sections for symptoms, behaviors, or other features the client presents within the case study.
If some of the symptoms in the case study cause you to suspect an additional disorder, then research any of the previous disorders covered so far in the course.
This mirrors real social work practice where you follow the symptoms.
Review the correct format for how to write the diagnosis noted below. Be sure to use this format.
Remember: When using Z codes, stay focused on the psychosocial and environmental impact on the client within the last 12 months.
BY DAY 7
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
Unformatted Attachment Preview
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CASE of KATLEGO
Intake Date: March xxxx
Diagnosis:
F31.4 Bipolar I Disorder, most recent episode depressed, severe, depressive
episode with mixed features
Z63.5 Disruption of Family by Separation or Divorce
Z56.9 Other Problem Related to Employment
IDENTIFYING/DEMOGRAPHIC DATA: This is a voluntary intake for this
53-year-old South African male. Katlego has been married for 29 years and has
been separated from his wife for the past ten months. He has been living alone for
the past five months. His wife and three sons live two blocks from him. Katlego
has had difficulty in jobs and has not been at any job longer than three years.
CHIEF COMPLAINT/PRESENTING PROBLEM: “I miss my family and do
not want to live without them”.
HISTORY OF PRESENT ILLNESS: Three months earlier, in December
Katlego returned to his psychiatrist because he was becoming depressed again,
feeling sad, fearful and suicidal. He reported angry outbursts. His wife asked him
to leave the home. He then took an overdose of Klonopin. In consultation with his
wife, she reported getting continuously concerned about their financial state
because Katlego would constantly be buying big items that they could not afford.
They would have arguments about this all the time.
PAST PSYCHIATRIC HISTORY: Katlego has had several psychiatric
hospitalizations in the past. Katlego reports first seeking psychiatric treatment
when he was twenty-six years old. He was prescribed anti-depressants, but does
not remember what kind. Since they helped his mood he remained on antidepressants for several years. At thirty-four years old he attempted suicide after
his wife and children left him. He was hospitalized in a psychiatric unit for thirty
days. At that time Katlego was put on Depakote with continued successful results
for several years, resulting in reconciliation. He stopped taking his medication in
two years ago.
SUBSTANCE USE HISTORY: In his late teens Katlego began drinking. His
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use of alcohol continued into his early thirties.
PAST MEDICAL HISTORY: Katlego states he currently takes Synthroid for a
thyroid problem and this helps him keep his weight down.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC:
Katlego reports growing up as tumultuous. His mother separated from his father on
several occasions and sometimes would throw Katlego out of the house with the
father. His mother made all the decisions and his father played a more passive
role. Both parents would often have physical fights and Katlego would try to break
up the fighting from as early as he can remember.
Katlego is the only child from his parents’ union. Katlego 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.
Katlego 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 three years.
CURRENT FAMILY ISSUES AND DYNAMICS:
Katlego was first married
at age twenty one years old which ended in a quick divorce. Six months after his
first divorce Katlego married again. They have two children. The first ten years of
their marriage Katlego reports physically abusing his wife. He stopped the
physical abuse when Mrs. Katlego asked for a divorce the first time. He believed
his wife was becoming more distant from him over the past several years which he
could not take. Their fighting increased, although he would not become physical
with her now.
MENTAL STATUS EXAM:
Katlego presents as a neatly dressed male who appears younger than his stated
age. His hair is a bit disheveled. His nails are neatly groomed. Facial expressions
are appropriate to thought content. Motor activity is appropriate. Thoughts are
logical and organized. There is no evidence of hallucinations. Katlego admits to a
history of suicidal ideation, gestures and attempts. His mood is depressed. During
the interview Katlego talked fast. Katlego is oriented to time, place and person.
His intelligence appears above average.
Diagnosis Explanation:
F31.4 Bipolar I Disorder, most recent episode depressed, severe, depressive
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episode with mixed features
Z63.5 Disruption of Family by Separation or Divorce
Z56.9 Other Problem Related to Employment
Some Notes:
With mixed features
1 elevated expansive mood
3 more talkative than usual or pressure to keep talking
6 unrestrained buying sprees
Since there is a history of depression and mania – noted by the fact that they were
previously diagnosed and medication was successful confirms the diagnosis. This
time the depression is apparent. The use of drugs and alcohol may play a factor
but his use began after his initial diagnosis. This would need to continually be
evaluated as well. He may meet criteria for alcohol or drug use disorder.
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Case of IKE
Intake Date: November xxxx
IDENTIFYING/DEMOGRAPHIC DATA: Ike is a 27 year old AfricanAmerican, male student. He returned to school for his Masters in Social Work
degree. Ike is ready to graduate and will soon be working in the field. He is the
youngest in his family and the only one to graduate from college. He lives on
campus in graduate housing.
CHIEF COMPLAINT/PRESENTING PROBLEM: Ike was referred for a
psychiatric consultation after a workup for gastrointestinal distress proved
negative. Ike has consulted his family physician after months of feeling bloated
and nauseated in anticipation of certain distressing events and circumstances.
HISTORY OF PRESENT ILLNESS: Ike described the past 3 years of anxiety
attacks accompanied by palpitations, shortness of breath, hot flashes, sweating and
parathesias, in addition to abdominal discomfort. The symptoms’ onset was
clearly traced to a blind date arranged by a close friend. On the way to pick up the
girl with his friend, he suddenly felt extreme nausea and was forced to pull the car
off to the side of the road got out for a breath of fresh air and promptly vomited.
Although his friend forced him to go through with the date, Ike was extremely
nervous and preoccupied throughout, took his date home immediately after the
movie was over, and sped away without even walking her to the door. He
frequently felt like staying home but forced himself with the help of some peer
pressure to go out at least “with the boys.”
As he is nearing the completion of his MSW program he is going job interviews,
which began to cause anticipatory anxiety. Ike finds himself reducing some of his
anxiety by scratching his head and playing with his hair. He describes feeling
“trapped” in interviews with “no way out.” He is now developing a fear of talking
on the phone to people to arrange interviews or follow-ups. He is a bit
embarrassed as well since some of his hair has gone missing and he has taken to
wearing hats to cover up the spots. He realizes he needs to find other ways to calm
himself down. He has the opportunity to be hired by a large municipal welfare
agency where he is completing his internship. He found himself staying mostly to
himself lately. Ike senses his fear is now extending to conversations with clients.
PAST PSYCHIATRIC HISTORY: Although he had previously been shy
around girls, following this incident, Ike panicked at the thought of a date. There
were girls to whom he felt attracted, but whenever he brought himself to even
consider asking one out, he became symptomatic. The anticipation generalized so
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that he became anxious going to local basketball games, bars and concerts with
friends because he might see girls he was interested in meeting, talking to, or
dating.
SUBSTANCE USE HISTORY: Ike reports drinking with his friends on
occasions. He denies drug use. Ike states he tried marijuana once with his friends
but did not like it. Ike considers himself a social drinker and often is the
designated driver.
PAST MEDICAL HISTORY: Ike had a workup for gastrointestinal distress
which proved negative. Ike has feelings of being bloated and nauseated in
anticipation of certain distressing events and circumstances.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Ike
reports no significant illness in his family either medically or psychiatrically.
CURRENT FAMILY ISSUES AND DYNAMICS: None reported
MENTAL STATUS EXAM: Ike is a casually dressed but neatly groomed male
who appeared his stated age. He was anxious with mildly pressured speech, which
was fluent, coherent and could be interrupted. There was no evidence of
psychosis, paranoid ideation, delusions, or form of thought disorder. There was no
looseness of association, flight of ideas, or ideas of reference. His affect was full
range. Ike denied suicidal and homicidal ideation.
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