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

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, 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.

CASE of MARIANA

Intake Date: October xxxx

DEMOGRAPHIC DATA:

Mariana is a24-year old single Hispanic woman. She has lived in a group home for the mentally ill for the past 2 years. She was born in Puerto Rico and moved to Michigan with her mother when she was 4 years old.

PRESENTING PROBLEM:

Mariana presented in the ER having been brought in by her mother and a friend. Mariana indicated that she was having one of her "anxiety attacksit's like a seizure, I feel so dizzy, I go into another world, I can hear people talking but I can't talk back." When this happens, Mariana reports she starts sweating, starts choking wants to throw up. Mariana was incoherent during most of the interview.

MEDICAL HISTORY:

An examination by a neurologist revealed mild cognitive impairment, difficulty with balance and a slight gait ataxia. A CT scan showed a mild enlargement of the lateral cerebral ventricles. No specific neurologic disorder was diagnosed (information derived from the ER chart).

SUBSTANCE ABUSE HISTORY:

Mariana denies consumption of alcohol or illicit drugs. She denies ever using chemicals that were not prescribed to her.

FAMILY HISTORY:

Her mother lives in a bordering town, her father left the family when she was 3 years old. Mariana has no siblings. Mariana stated she was adopted when she was 2 years old, although her mother claimed that is her biological child. Mother said that Mariana was not mentally retarded.

PSYCHIATRIC HISTORY:

Mariana has been hospitalized 8 times at a State Hospital during the past 5 years. She had been picked up several times by the police for "talking in public" and each time she was sent to the State Hospital. Mariana was unsure of her diagnosis. She indicated that she takes Zyprexa but was unable to indicate her dosage. Mariana actually denied being under any current psychiatric care. She claims to be mentally retarded. She indicated that "I have always been in special education classes."

She was able to indicate some history that was inconsistent with history taken from her mother. She first became ill when she was 16. Mariana has become progressively isolated from friends and family since 16, and during the past 5 years has been unable to work or tend adequately to her personal needs.

MENTAL STATUS:

Mariana presented as a casually dressed, unwashed woman with an extremely disagreeable body odor. She lay on her bed in restraints during the interview protecting her from harming herself or others. She had a fluctuating mood and an anxious expression on her face. Motor activity appeared agitated. Mood was anxious alternating with hostility and depression. Speech was pressured at times and inappropriately loud. Her affect was inappropriate and at times blunted. Thought processes were at times incoherent and at times displayed a marked loosening of associations. She also displayed bizarre delusions and verbal hallucinations.

"I see my mother, who committed suicide, it's like having her alive again. I see little balloons out there, like two beach balls. At the group home I felt possessed. I felt that a demon was trying to come into my body. I felt that tricks were being played on me in my room. God said I was a slut, that I married the devil. I thought I was pregnant, I am going to have the devil's baby."

Mariana was disoriented in three spheres (time, place, and person). Concentration was markedly impaired. Digit span was unobtainable. She was unable to calculate serial 7's. Recent and remote memory was not discernible. Mariana was unable to abstract similarities and proverbs. Ordinary social and personal judgment was inappropriate. Her three wishes were that "my balloons stay floating, that the devil leaves me, that Jesus hates my mother."

Her wishes for 5 years from now were unobtainable.

SUICIDAL ASSESSMENT:Unable to ascertain.

HOMICIDAL ASSESSMENT: Unable to ascertain.