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Intake Date: March 2021

IDENTIFYING/DEMOGRAPHIC DATA: This is a voluntary intake for this 53-year-old South African male. Katlego has been married for 29 years and has been separated from his wife for the past ten months. He has been living alone for the past five months. His wife and three sons live two blocks from him. Katlego has had difficulty in jobs and has not been at any job longer than three years.

CHIEF COMPLAINT/PRESENTING PROBLEM: “I miss my family and do not want to live without them”.

HISTORY OF PRESENT ILLNESS: In December 2020 Katlego returned to his psychiatrist because he was becoming depressed again, feeling sad, fearful and suicidal. He reported angry outbursts. His wife asked him to leave the home. He then took an overdose of Klonopin. In consultation with his wife, she reported getting continuously concerned about their financial state because Katlego would constantly be buying big items that they could not afford. They would have arguments about this all the time.

PAST PSYCHIATRIC HISTORY: Katlego has had several psychiatric hospitalizations in the past. Katlego reports first seeking psychiatric treatment when he was twenty-six years old. He was prescribed anti-depressants
?, but does not remember what kind. Since they helped his mood he remained on anti-depressants for several years. At thirty-four years old he attempted suicide n?>k after his wife and children left him. He was hospitalized in a psychiatric unit for thirty days. At that time Katlego was put on Depakote with continued successful results for several years, resulting in reconciliation. He stopped taking his medication in 2019.

SUBSTANCE USE HISTORY: In his late teens Katlego began drinking. His use of alcohol continued into his early thirties.

PAST MEDICAL HISTORY: Katlego states he currently takes Synthroid for a thyroid problem and this helps him keep his weight down.

FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Katlego reports growing up as tumultuous. His mother separated from his father on several occasions and sometimes would throw Katlego out of the house with the father. His mother made all the decisions and his father played a more passive role. Both parents would often have physical fights and Katlego would try to break up the fighting from as early as he can remember.

Katlego is the only child from his parents’ union. Katlego was initially considered an underachiever in the early years of school. He had trouble being in fights with other kids because they used to make fun of his wrinkled clothes.
Katlego has no legal history. He worked in the family business through high school and college. He became a project coordinator at his next job. He stayed there three years.

CURRENT FAMILY ISSUES AND DYNAMICS: Katlego was first married at age twenty one years old which ended in a quick divorce. Six months after his first divorce Katle



Applying Differential Diagnosis
· 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.

I will diagnose Alim with the following differential
F84.0 autism spectrum disorder
F70-F79 Intellectual disability

F90.1 Attention-deficit predominately hyperactive/impulsive presentation
F91.8 Other Specified Disruptive, Impulse-Control, and Conduct Disorder

Z62.820 Parent-child relational problem
Z62.891 Sibling relational problem

312.89 (F91.8) Other Specified Disruptive, Impulse-Control, and Conduct Disorders

Autism Spectrum Disorder

The selected condition is an autism spectrum disorder, a mental illness listed under the DSM-5 diagnosis model. Alim meets criteria A. He has persistent deficits in social-emotional interaction ranging from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions and absence of interest in peers. Alim’s intellectual disability meets criteria A, B, and C. He has a deficit in intellectual functioning and adaptive functioning that fails to meet developmental and sociocultural standards for personal independence and social responsibility. Deficiency in adaptive functioning limits his daily life, such as communication, social participation, and independent living.  His hyperactivity and impulsiveness increase his ability to interrupt class with his comments, struggle with school, have no friends, and often meltdown when he does not get his way. Besides, his ADHD limits his ability to focus and increases his disruptive behaviors.
The ICD-10 codes are F84.0. Alim’s attitudes towards his mother when his lunch is packed differently within his lunch box for school and kicking and hitting and trying to suffocate his siblings indicate the Z codes for Z62.820 and Z62.898. The signs and symptoms Alim in the case study perfectly align with the description and diagnosis of the condition. The criteria used in the diagnosis process include interference of the occupational, educational or social functioning of a period exceeding six weeks.

Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.
F84.0 autism spectrum disorder- Alim has a persistent manifestation of deficits in social interactions and communication and deficits in social, emotional connection, and reciprocity. For example, the ability to engage with others and share thoughts and feelings. During the interview with the school social worker for mental disorders, Alim is reported to have abnormalities in maintaining eye contact and facial expressions, tick-talked manneris

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