Assignment task: 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:
1. Explain how you support the diagnosis by specifically identifying the criteria from the case study.
2. 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.
3. Identify the differential diagnosis you considered.
4. Explain why you excluded this diagnosis/diagnoses.
5. 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.
6. 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 STUART
IDENTIFYING/DEMOGRAPHIC DATA: Stuart is a 19-year-old, biracial male who was raised in Hugo, Oklahoma. Stuart's mom is Caucasian and his father is African American. Stuart has 3 siblings all younger than him. Stuart is in his first year at college and lives on campus.
CHIEF COMPLAINT/PRESENTING PROBLEM: Stuart presented in the emergency room (ER) having been brought in by his mother and a friend. Stuart indicated that he was having a strange experience - "I go into another world. I can hear people talking, but I can't talk back. I can no longer trust my roommate - he is taking my food and hiding it"
HISTORY OF PRESENT ILLNESS: Stuart reports beginning to feel strange one month after he started school in August. He reports hearing voices outside his window in the dorm. It was an angel's voice calling his name. That is when he realized he cannot trust his roommate. He realized the roommate would put TV shows on that were referencing how Stuart was doing in his classes. His school papers were all over his room and he could not organize them the way he wants. At times, the fireflies outside told him about his roommate.
In high school, Stuart socialized with his classmates and was engaged in leisure activities. He went to the senior prom and enjoyed the summer prior to college. Since coming to college, Stuart's roommate reports Stuart was socially withdrawn.
PAST PSYCHIATRIC HISTORY: Stuart's mom does not report any psychiatric issues with Stuart in the past. His behavior was a typical teenage behavior, video games, dressing unusual, thinking in a way that differs from his parents beliefs.
SUBSTANCE USE HISTORY: Stuart denies consumption of alcohol or illicit drugs. He denies ever using chemicals that were not prescribed to him. Stuart reports now that he thinks about it he is glad he never used drugs since drug dealers will kill their clients.
PAST MEDICAL HISTORY: Mother reports Stuart broke his arm at 7 years old. The arm healed successfully. Stuart had all his childhood shots, but she does recall her fear of his health early on when Stuart was 2 ½ weeks old he came down with a spring cold.
FAMILY MEDICAL AND PSYCHIATRIC HISTORY: There was no significant information about the family history.
CURRENT FAMILY ISSUES AND DYNAMICS: Stuart was incoherent during most of the interview. He was able to indicate some history that was inconsistent with history taken from his mother. Mother indicated that Stuart was picked up several times within the past two months by campus police for "talking in public".
MENTAL STATUS EXAM: Stuart presented as a casually dressed, unwashed young man. He has a fluctuating mood and an anxious expression on his face. Motor activity appeared agitated. Mood was anxious alternating with hostility and depression. Speech was pressured at times and inappropriately loud. His affect was inappropriate and at times blunted. Stuart's thought processes were at times incoherent and at times displayed a marked loosening of associations. He also reported bizarre delusions and auditory hallucinations. Stuart's wishes for 5 years from now were unobtainable. Stuart is oriented to time, place, and person. He was able to state the season. Stuart can name 3 different objects correctly (bed, apple, shoe). He needed to calculate 100 - 3 five times.
SUICIDAL/HOMICIDAL ASSESSMENT: Unable to ascertain.