- 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.
Intake Date: October xxxx
IDENTIFYING/DEMOGRAPHIC DATA: Sampaguita is a 29-year-old female from the Philippines. She is employed as a nurse at a local hospital. She lives by herself in an apartment close to where she works.
CHIEF COMPLAINT/PRESENTING PROBLEM: Sampaguita was referred to treatment by her primary care physician.
HISTORY OF PRESENT ILLNESS: Sampaguita had unusual and dramatic presentation of symptoms that defy any conventional medical understanding. When other symptoms resolved new emergence of other unusual symptoms would present themselves. Her primary care physician then referred her for therapy.
PAST PSYCHIATRIC HISTORY: Sampaguita presented in the ER 5 years ago after an overdose. Sampaguita reported that she has had repeated overdoses and has slashed her wrist several times since she was 16 years old.
SUBSTANCE USE HISTORY: Sampaguita reports use of many different drugs. She does not obtain them from the street but sneaks them from the hospital that she works at. It was suspected that the use of these drugs were to promote illness at noted in the PCP notes.
PAST MEDICAL HISTORY: The report from her primary care indicated Sampaguita was always eager to undergo procedures or testing or to recount symptoms. She was reluctant to give access to collateral sources of information (i.e., refusing to sign releases of information or to give contact information for doctors). Since her parents are in the medical field the physician was able to obtain a release form for the parents. There was an extensive medical history including multiple drug allergies. She seemed to have the ability to forecast unusual progression of symptoms or unusual response to treatment. Sampaguita was very angry about the referral and wondered why her PCP was abandoning her.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Sampaguita’s parents integrated from the Philippines when she was 2 years old. Both parents are doctors and very successful. Sampaguita has two younger sisters, 27 and 25 years old. The three girls were raised by different nannies throughout their lives since their parents were very busy building the radiologist business. There were several different nannies since several were found to be abusive. The parents were rarely around and paid very little attention to the three girls. There were 3 or 4 times that Sampaguita ended up being hospitalized when she was very young. She found hospital workers (e.g., doctors, nurses, and hospital workers) to be loving and caring and never wanted to leave the hospital to return home.
CURRENT FAMILY ISSUES AND DYNAMICS: Sampaguita’s parents are very concerned about Sampaguita’s illnesses since they do not see any present illness. In one of Sampaguita hospitalizations she was found to be carrying a list of symptoms of several disorders in her handbag. Her parents did believe that Sampaguita was able to simulate, induce, and aggravate her illnesses. The parents report Sampaguita being very moody since she was a teenager and always causing havoc in the family. Sampaguita has been in several relationships and is promiscuous but they are always short term and very volatile. There were several times she told her partners she was pregnant which never turned out to be true.
MENTAL STATUS EXAM: Sampaguita is a well dressed 29-year-old who looks younger than her stated age. There were no perceptual disturbances noted. She was very cooperative in the intake, describing all her physical symptoms that did not look apparent to the social worker. Her mental state was normal. Sampaguita has a very poor self-image or sense of self. She was oriented to time, place, and person.
