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.
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CASE of KATLEGO
Intake Date: March xxxx
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 two
years ago.
SUBSTANCE USE HISTORY: In his late teens Katlego began drinking. His
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:
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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.
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