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 HERMOSA
June. In addition, her family physician, Dr. A prescribed Prozac. Hermosa indicated seeing a psychiatrist, whose name she could not recall, nineteen years ago for two years. She said that she was put on Seroquel because she was hearing things and couldn't sleep, but could not recall the dosage. Once everything became better, she was weaned off the medication.
Intake Date: April xxxx
PRESENTING PROBLEM: Hermosa indicated that since her husband died suddenly of a Myocardial Infarction (MI) on Christmas Day, two years ago, she has progressively become more and more depressed. During the week prior to this presentation, she indicated becoming progressively dysphoric, crying uncontrollably for several hours, and had suicidal thoughts of taking an overdose. The patient presented in the ER on a voluntary basis. She denied wanting to kill herself on admission to the ER.
MENTAL STATUS: Hermosa presented as a casually dressed, meticulously groomed woman who appeared her stated age of 43. She lay on her bed during the interview. She had a fixed, mood congruent expression on her face. Motor activity was normal. Mood was dysphoric. Affect was constricted. Speech was guarded and soft with some evidence of stuttering. Content was adequate, however. Thought processes were goal-directed, logical, and abstract. There was no evidence of delusions. Hermosa acknowledged auditory hallucinations in the form of two men sitting on her shoulder telling her self-depreciating thoughts.
PSYCHOLOGICAL DATA: Hermosa is a 43-year-old, Hispanic widowed female. Hermosa reports being of Christian faith. She completed her BS in Education and one semester in graduate school in Special Education. She has been voluntarily unemployed last year. She lives with her 1-year-old daughter who is a college student. She also has a son, age 20, who is a college student in California. She has two siblings. Digit span was 7 forward and 4 in reverse. She was unable to calculate serial 7's. Recent and remote memory appeared intact. Intelligence appeared above average. Hermosa was able to abstract similarities and proverbs with detail and accuracy. Ordinary social and personal judgment was appropriate. Hermosa's three wishes were that her family stays well, that she is able to get on with her life, and that she is close to her family and kids. Five years from now, Hermosa sees herself in graduate school, getting a living on campus in Indiana. Prior to being widowed, Hermosa was married twice. Her first marriage ended seventeen years ago, and she remarried four years later. Hermosa also has a brother, age 40, and a sister, age 38, both of whom live within a two-hour drive of Hermosa. Her father and mother, ages 69 and 65 respectively, are both retired and living within a four-hour drive of Hermosa. She would "feel better about myself, more secure, more confident."
MEDICAL HISTORY: Menses are irregular and accompanied by severe dysmenorrhea. Hermosa has had severe dysmenorrhea when she was not focused on getting pregnant. Her last menstrual period began last month. Hermosa has had two pregnancies and given birth to two children. She is allergic to spores, mold, dust, cigarette smoke, Penicillin, and Demerol. She has previously had hyposensitization shots which ended last June (History taken from ER chart).
SUICIDAL ASSESSMENT: Hermosa admitted to recurring thoughts about "taking an overdose and ending my life." She said that she would be better off dead, then she would no longer be in pain. Hermosa denied any concrete plan about taking an overdose, vis-à-vis the type of medication or the amount. Hermosa also denied intent. Hermosa admitted to a prior suicide attempt nineteen years ago, in which she took an overdose of Valium and Alcohol. Hermosa denied any other attempts.
HOMICIDAL ASSESSMENT: Hermosa denied any homicidal thoughts, plan, or intention. Hermosa denied any previous homicidal history.
SUBSTANCE ABUSE HISTORY: Hermosa denies consumption of alcohol/drugs.
PSYCHIATRIC HISTORY: Hermosa has been in outpatient individual psychotherapy with Dr. W since last year.
SUMMARY NOTE: Hermosa thought she has been depressed since her husband died suddenly of a Myocardial Infarction (MI) two years ago.