Assignment Instructions/ Description
Assignment: Diagnosis of Somatic Symptom and Related Disorders
According to the World Health Organization (2022):
is the process of assigning a code from a classification to represent a clinical concept for a specific purpose. Coding rules must be incorporated in the classification to achieve consistency of coding and comparability of coded data over time and place. (1.1.2 Classification, para. 2)
You have practiced diagnosing mental disorders many times in this course to help strengthen your skills in communicating a client�s mental health status. One of the goals of continued practice, and one of the most important parts of a diagnosis, is articulating the diagnosis in a way that can be understood by practitioners in many disciplines over time.
With each practice diagnosis, you also focused on how the client presented�their behaviors, symptoms, and recent history.
Reference: World Health Organization. (2022). ICD-11 reference guide (draft): International classification of diseases for mortality and morbidity statistics (11th rev.). https://icdcdn.who.int/icd11referenceguide/en/html/index.html
Note: Remember that symptoms can occur in many disorders. As a result, all disorders in the DSM-5-TR covered up until this point may factor into your diagnosis (for example as a possible additional disorder you diagnose).
To Prepare
Review the case study for this week.
Start by familiarizing yourself with the disorders from the DSM-5-TR found in the Learning Resources this Week.
Look within the noted sections for symptoms, behaviors, or other features the client presents within the case study.
If some of the symptoms in the case study cause you to suspect an additional disorder, then research any of the previous disorders covered so far in the course.
This mirrors real social work practice where you follow the symptoms.
Review the correct format for how to write the diagnosis noted below. Be sure to use this format.
Remember: When using Z codes, stay focused on the psychosocial and environmental impact on the client within the last 12 months.
By Day 5
Submit your diagnosis for the client in the case. Follow the guidelines below.
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)
Then, in 1�2 pages, respond to the following:
Explain how you support the 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.
Week 11 � CASE PRESENTATION � SANTIAGO � Diagnosis: 1 F code and 4 Z codes
Intake Date: July xxxx ?
IDENTIFYING/DEMOGRAPHIC DATA: Santiago is an 11 year-old Hispanic male who lives with his grandmother and mother Sofia in Nogales, Arizona. Santiago�s father has not been in his life over the past two years.
CHIEF COMPLAINT/PRESENTING PROBLEM: Two years ago Santiago stopped talking and lost his hearing and sigh. The medical doctors cannot find any physical reasons for his challenges. After many visits to doctors they decided to bring Santiago to a clinical social worker.
HISTORY OF PRESENT ILLNESS: Santiago and his family live in a gang ridden area in Nogales. Sofia�s husband Juan was protecting Sofia from being attacked by a gang leader and Santiago watched his father shoot the gang leader as he was attempting to attack Sofia. When Sofia and Juan realized that Santiago saw this, they feared for his life and worried he may say something about this murder. Sofia violently shook Santiago telling him he did not see or hear anything. Two months later Santiago lost his sense of hearing, seeing, and speaking.
PAST PSYCHIATRIC HISTORY: This is the first psychiatric visit for Santiago.
SUBSTANCE USE HISTORY: There is no reported substance use for Santiago.
PAST MEDICAL HISTORY: Santiago had wellness checks from the time he was born. There were no medical issues other the normal childhood illnesses.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: No reported medical or psychiatric family issues.
CURRENT FAMILY ISSUES AND DYNAMICS: Santiago was a good student up to 9 years old. His parents helped Santiago stay focused on his studies, wanting more for him outside the neighborhood. Since Sofia�s mother was elderly and ailing they were not prepared to leave the area yet but had future plans of doing that. Santiago has never been in trouble at school or at home. His parents have kept him isolated, with few friends, due to their worry about Santiago getting involved with gang activity.
After the death of the gang leader Juan decided to leave the area to protect his family. At this point it is unknown if Juan is alive or not.
Santiago does not engage with others, including his mother and grandmother. He only responds to a man on the street who plays the guitar in the street for money. Sofia and Santiago encounter this man when they go to the bodega. Santiago likes to just sit there but they typically do not stay long since Sofia fears the neighborhood.
Santiago is no longer in school.
MENTAL STATUS EXAM: The social worker was unable to do a full mental status exam with Santiago since he was mostly catatonic.