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)

• 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.

USE THE CASE STUDY BELOW

CASE of ALEYDA

INTAKE DATE: April xxxx

IDENTIFYING/DEMOGRAPHIC DATA: Aleyda is a 31-year-old single, Cuban female. She lives by herself in Phoenix, Arizona. Her family lives in Miami, Florida. She is employed as a librarian at the University.

CHIEF COMPLAINT/PRESENTING PROBLEM: Aleyda states she is troubled by fatigue. She always feels tired and doesn't sleep well, often waking up early. She does not find pleasure in life and "just exists." She wants to enjoy life more but has some challenges making friends and having the energy to go out.

HISTORY OF PRESENT ILLNESS: Aleyda states her interest in usual activities has been declining for several years now, although she really never had a lot of energy like others. She reports she is missing work due to fatigue. She finds herself unable to make decisions.

PAST MEDICAL AND PSYCHIATRIC HISTORY: Aleyda has no significant past medical or psychiatric history and takes no regular medications. She does note that her troubled sleeping habits and malaise have persisted for as long as she can remember.

SUBSTANCE USE HISTORY: She denies using alcohol abusively. She denies any drug use at all. She does drink on occasion but has never been inebriated.

CURRENT FAMILY ISSUES AND DYNAMICS: Aleyda reports she has never been married and has dated somewhat. She would like to be married and have children. All her family live in Florida but she got this great job at the university which prompted her move. She has a great relationship with all her family.

MENTAL STATUS EXAM: Aleyda is cooperative, alert, and oriented to time, place, and person. She denies delusions or hallucinations and her thoughts are goal-directed and logical. Aleyda appears to have some psychomotor slowing. She denies current suicidal ideation or homicidal ideation. Aleyda states she has feelings of hopelessness and has no future direction set for her.