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Dec 16, 2022


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IDENTIFYING/DEMOGRAPHIC DATA: Mateo 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 Mateo was 6 months old for job opportunities. Mateo is an intelligent and caring young boy who presents with significant potential to excel academically.
CHIEF COMPLAINT/PRESENTING PROBLEM: Mateo was referred for an evaluation because his parents and teacher indicate that Mateo 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: Mateo 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 Mateo interacts well with peers his own age, his parents believe he is easily led and influenced by others. Mateo 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.
Mateo 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. Mateo 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 Mateo is defiant towards listening to instructions, but generally interacts well with his peers. He is easily frustrated and emotionally impulsive – Mateo 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.
PAST PSYCHIATRIC HISTORY: This is the first evaluation for Mateo. 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.
PAST MEDICAL HISTORY: Mateo has been vaccinated with all the needed vaccinations to attend school. There is no noteworthy illnesses to report.
FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Mateo’ parents report some history of mental illness in the family. His maternal grandmother was diagnosed with depression. Mateo 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.
MENTAL STATUS EXAM: Mateo is age appropriate in size and structure. His appearance is clean and neat. Mateo is an active child and interacts with his parents appropriately. There does not appear to be any underlying overtones between the parents and Mateo. Mateo did not have any problems separating from his parents when being interviewed. Speech is appropriate for child’s age. Mateo’ mood is in normal range and congruent with his mood. Affect was appropriate. There were no hallucinations or delusions. There were some challenges with Mateo’s judgment and insight.
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 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 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.


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