IDENTIFYING AND DEMOGRAPHIC OF DATA

To prepare:

  • Read the case provided by your instructor for this week’s Discussion and identify relevant symptoms and factors. You may want to make a simple list of the symptoms and facts of the case to help you focus on patterns.
  • Read the Morrison (2014) selection. Focus on Figure 1.1, “The Roadmap for Diagnosis,” to guide your decision making. https://bookshelf.vitalsource.com/#/books/9781462513567/epubcfi/6/24%5B%3Bvnd.vst.idref%3Dchapter1%5D!/4/2/4/2/2%400:0
  • Identify four clinical diagnoses relevant to the client that you will consider as part of narrowing down your choices. Be prepared to explain in a concise statement why you ruled three of them out.
  • Confirm whether any codes have changed by checking this website: American Psychiatric Association. (2017, October 1). Changes to ICD-10-CM codes for DSM-5 diagnoses. Washington, DC: Author. Retrieved from https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5/coding-updates

Post a 300- to 500-word response in which you address the following:

  • Provide a full DSM-5 diagnosis of the client. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may be a focus of clinical attention). Keep in mind a diagnosis covers the most recent 12 months.
  • Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.
  • Identify which four diagnoses you initially considered in the case of the client, using the DSM-5 diagnostic criteria to explain why you selected these four items. In one or two sentences each, explain why three of these diagnoses were excluded.
  • Explain any obvious eliminations that could be made from within the neurodevelopmental spectrum.
  • Describe in detail how the client’s symptoms match up with the specific diagnostic criteria for the primary disorder that you finally selected for him. Note two other relevant DSM-5 criteria for that illness from the sections on “diagnostic features” and “development and course” that fit this case.

CASE of PABLO

INTAKE DATE: May 2020

IDENTIFYING/DEMOGRAPHIC DATA:  Pablo is a 7 year old male in the third grade.  He lives in Houston, Texas with his parents.  He is the only child to two parents, both of whom have completed post-graduate education.  His parents are originally from Guatemala and relocated to the United States when Pablo was 6 months old for job opportunities.  Pablo is an intelligent and caring young boy who presents with significant potential to excel academically.

CHIEF COMPLAINT/PRESENTING PROBLEM:  Pablo was referred for an evaluation because his parents and teacher indicate that Pablo is restless, and often requires reminders to help him stay on task. He is described as “constantly running around” and presenting with difficulties listening and following instructions.

HISTORY OF PRESENT ILLNESS:  Pablo enjoys spending time with his friends, and participating in physical activities such as swimming, running and skating. He also enjoys participating in social events, and is often invited to play dates and birthday parties.  While Pablo interacts well with peers his own age, his parents believe he is easily led and influenced by others. Pablo does get upset when he does not receive recognition or feels that he has been ignored.  His teacher notes that he sometimes acts ‘socially immature’, and that he often demonstrates attention-seeking behavior.

Pablo has difficulty focusing and sitting still in class. He is able to ‘hyper focus’ on some activities of interest however he often has difficulty sustaining his attention at school. Pablo has been known to blurt out answers and interrupts other students in the classroom. His mother reports difficulties at home with following routines and remembering instructions. His parents describe emotional reactivity as well as confrontational behaviors demonstrated both at home and at school. His teacher notes that Pablo is defiant towards listening to instructions, but generally interacts well with his peers. He is easily frustrated and emotionally impulsive – Pablo has had several incidents of hitting, crying outbursts, and inappropriate behavior. Behavioral concerns with aggression, lying, arguments, and disruptive behavior were noted in his pre-school program at age 4.  Each school year since, teachers have reported incidents in the classroom.

Pablo has always had challenges falling asleep, and sometimes finds that he wakes up in the middle of the night. When he wakes up he finds that he has a difficult time getting back to sleep – sometimes staying awake for as long as an hour and a half.

PAST PSYCHIATRIC HISTORY:  This is the first evaluation for Pablo.  It is noteworthy that he did not know his address or home phone number, could not print his surname, and recognized only a few pre-primer words.

SUBSTANCE USE HISTORY:  None reported

PAST MEDICAL HISTORY:  Pablo has been vaccinated with all the needed vaccinations to attend school.  There is no noteworthy illnesses to report.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY:  Pablo’ parents report some history of mental illness in the family.  His maternal grandmother was diagnosed with depression.

MENTAL STATUS EXAM:  Pablo is age appropriate in size and structure.  His appearance is clean and neat.  Pablo is an active child and interacts with his parents appropriately.  There does not appear to be any underlying overtones between the parents and Pablo.  Pablo did not have any problems separating from his parents when being interviewed.  Speech is appropriate for child’s age.  Pablo’ mood is in normal range and congruent with his mood.  Affect was appropriate.  There were no hallucinations or delusions.  There were some challenges with Pablo’ judgment and insight.


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