The diagnosis should appear on one line in the following order.

Diagnose the client

Note: Do not include the plus sign in your diagnosis. Instead, the indicated items should be 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)

Next

Explain how you support the diagnosis by specifically identifyin the criteria from the case study

Describe in detail how the clients symptoms match up with the specific diagnostic creiter for all the disorder that you finally selected for the client. NOTE: You do not need to repeat the diagnostic code in the discussion.

Identify the differential diagnosis you considered

Please provide an in depth explanation of 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 PRESENTATION -LESTER

Intake Date:August xxxx

IDENTIFYING/DEMOGRAPHIC DATA: Lester is a 28 year old African American male who is presently an inmate at the XYZ prison facility.

CHIEF COMPLAINT/PRESENTING PROBLEM: He is having difficulty adjusting to the prison facility because of the close proximity to other inmates. He says there are "people" in Texas who are trying to kill him and that anyone who has a tattoo is a member of their "army". He says he has seen their "soldiers" outside his cell at night and he is terrified that he will be hurt. When his fear becomes too great he begins to scream and will not stop. He will tear off his clothes and smear his feces on the wall.

HISTORY OF PRESENT ILLNESS: At the time of his last outburst he was transferred to a special unit in the prison that works with mentally ill inmates and was stabilized on Resperidol. Upon stabilization he was returned to the general population and was able to function for approximately a month. He was pleased that he finally does not need a lot of sleep so the "soldiers" will stay away from him. He then began to demonstrate the same hallucinations and delusions but this time it did not bother him as much. Lester now believes he is feeling better and is looking forward to pulling his life together and getting a better education. He still fights with inmates who he considers "marked" as soldiers. Lester believes he is powerful and can fight like Muhammad Ali so he is much less frightened on the unit now.

PAST PSYCHIATRIC HISTORY:He has a history of being arrested for petty offenses, but a year ago he was arrested for breaking into a small appliance repair shop and destroying some of the equipment he found there. He says that he broke into the store because he was homeless and he needed shelter from the cold, but he became frightened that the government could see him and were tracking him through some of the equipment in the store so he set fire to it.

SUBSTANCE USE HISTORY:He says he has used drugs, but has never been addicted because he never had enough money to get addicted. He started smoking marijuana at 12 years old. He used crack, heroin, and fentanyl in the past.

PAST MEDICAL HISTORY: Lester grew up in the inner city with a lot of gang activity around him. Due to these circumstances Lester did not get medical attention growing up.

FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC:

Lester was placed in foster care at birth. He was unadoptable because his mother was in and out of psychiatric hospitals. He was raised in foster care and still has a good relationship with the woman who fostered him as an adolescent. He had trouble in school and has never been able to hold down a job. He lost contact with his foster mother for a few years after he was emancipated and when he surfaced again he was homeless and unable to say where he had been.

CURRENT FAMILY ISSUES AND DYNAMICS: Lester has some contact again with his foster mom and biological mom. He has not seen either for a long time.

MENTAL STATUS EXAM: Lester spoke about people being after him so he has trouble sleeping, claiming he needs to protect himself. He is cooperative, alert, and oriented to time, place, and person. He appears to be very anxious and agitated and has inappropriate affect. His personal appearance is disheveled. He denies current suicidal ideation or homicidal ideation. Lester has markedly peculiar behavior, abnormal affect, unusual speech, bizarre ideas, and strange perceptual experiences. He has made statements such as "I think tough gangs are funny because they beat down people." While saying this, he laughed loudly. At times throughout the intake Lester was so talkative it was very hard to interrupt.