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

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

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 DIEGO

INTAKE DATE: September xxxx

IDENTIFYING/DEMOGRAPHIC DATA: Diego is 15 years old, Cuban Hispanic male in tenth grade. He lives with his parents in Miami, Florida, who immigrated to the United States 16 years ago. He has a younger brother who is 9 years old.

CHIEF COMPLAINT/PRESENTING PROBLEM: Diego's parents are concerned about Diego's school work. They believe his intellect level is higher than his grades indicate. Diego has had challenges with his school work for several years and his parents chose to work with him at home, even hiring private tutors. Diego would become easily distracted with the tutor as well They are more concerned now since the grades have not increased and he is in high school and will be heading towards college soon.

HISTORY OF PRESENT ILLNESS: Diego has struggled in school since the third grade. He is now in serious academic trouble. After a psycho-educational evaluation at school, it was found that he had above-average intellectual ability. From the third grade Diego had difficulty keeping up with assignments and completing his work each year. While he comprehends the material, he didn't retain what he read. He appeared to understand lectures, but he couldn't organize his thoughts well enough to write them down on paper. "I just stare at the page and nothing comes out," he said. Adding to these difficulties was the fact that he often forgot to make a note of assignments and "just couldn't get organized".

If he did at sometime remember to write down his homework, he would misplace the paper he wrote on. Diego's mom worries that Diego is intentionally not remembering these tasks because of her parenting and blames herself. Mom was so happy to have her children in the United States, she believes she overindulged him.

Diego has no behavioral challenges in school and has never been disciplined in anyway by the teachers or principal. He is reported to be nice to others as well as helpful and does have several friends in his class. Diego does bring home report cards that seemingly fail to reflect his intelligence. His work remains unfinished, even if he knows the answer when called on in class.

PAST PSYCHIATRIC HISTORY: Diego's parents are from Cuba. Mom is concerned thatthese behaviors might be interpreted as indicating a poorly raised child whose behavior could be modified by parental discipline. Diego's parents have tried all kinds of ways to help their child focus on school work. When nothing changed, even though the parents are embarrassed, they chose to seek outside help.

SUBSTANCE USE HISTORY: Diego denies any use of drugs or alcohol.

PAST MEDICAL HISTORY: Diego has been fairly healthy throughout his life. He had normal childhood illnesses.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: This is a Cuban family which adheres to the behaviors and parenting of their culture. There is no reported psychiatric history in the family.

CURRENT FAMILY ISSUES AND DYNAMICS: The parents report running a strict Cuban household. Both children are required to do household chores daily. Diego's parents get worried when Diego is assigned chores and forgets to do them or gets distracted when doing the chores and doesn't finish. His parents are concerned that Diego stresses about trying to please his parents over the failing school grades. The parents are not comfortable bringing Diego in for an evaluation but they were referred by the school system.

MENTAL STATUS EXAM: Diegopresents as a casually dressed teenager who appears his stated age of 15. He is a bit anxious during the interview. His affect is appropriate but gets saddened about disappointing his parents. Motor activity is appropriate. Speech is clear. At times during the interview, he lost his train of thought, got distracted and had to be redirected to the subject. There is no evidence of delusions or hallucinations. Diego's intelligence appears above average. He is oriented to time, place, and person and denies suicidal or homicidal ideation.