Tracy Pendarvis

RCLS 245 -Messina

ICF WRITE UP
February 24, 2016
Below is my assessment of pseudo-in patient client, Jason P., whose primary
diagnosis is Anorexia Nervosa. I have described other related factors that are
involved in his disorder. In this ICF WRITE UP I will use the following format and
detail the case using: Three Body Function codes; three Activities and Participation
codes and two Environmental codes and the relevancy to this patient with these
clinical diagnoses. All codes are located in the ICF Handbook. (Porter & Burlingame,
2010)
Client Jason P. presents as a 24 years old male student, Montana native and devout
Catholic who attends Gonzaga University in Spokane, Washington.

His focus of

study is Theology and he plans to enter The Society of Jesus (Jesuits) of the Oregon
Province following the completion of his sophomore year at GU. Jason was admitted
to Deaconess Hospital presenting symptoms of dehydration, malnutrition, as his
was 15% less than his normal body weight. (National Eating Disorder Association ,
2016) and possible metabolic deterioration within the endocrine system. (Porter &
Burlingame, 2010)

Further evaluation led to a preliminary clinical diagnosis of

Anorexia Nervosa. (Porter & Burlingame, 2010) Jason presents an atypical case of
the disorder. His symptoms are post adolescent and he is in the minority as only
25% of the male population have Anorexia per the Diagnostic Statistical Manual Edition 5, otherwise known as the DSM -5 (American Psychiatric Association, 2014)
and as a man with eating disorder even more likely to elude detection. (National
Eating Disorder Association , 2016) Other factors which may have may lead to his
disorder include: 1) Being sexually abused and groomed as a young child by an
elder male in his family repeatedly until the age of 11 when the elder stated to

Jason he was no longer interested because Jason had become too mature and too
fat for his liking. 2) Jason possessed homosexual tendencies as early as age 10
which he perceived as taboo in nature because of his spiritual faith as a Catholic. 3)
He saw himself as unattractive and sexually unappealing because he was too fat.
Jason began a strict regimen of diet and limiting food intake beginning at age 11
and continued until age 16. During a confession with a Catholic priest, at age 16,
Jason asked forgiveness for his taboo thoughts of homosexuality. Jason was
counseled by the priest that his feelings were not abnormal and many other men
had such tendencies. He encouraged Jason to look at religious vocations or careers
where his sexuality would not be a focus. The validation from this priest encouraged
Jason to research the vocation of priesthood within the Catholic faith, hoping that
his homosexual tendencies might be concealed or masked under the vocation of
being a priest, as well as enhance the love he had for God, his love of music and
singing. At age 16 embraced his love of music and found it to be his solace when he
became stressed. Jasons obsessive compulsive behavior along with his irrational
view of his body image were less psychologically invasive for three years as he
focused his direction for his future goals to attain a vocation to the priesthood. In
his second semester as a freshman at GU Jason began a sexual relationship with a
male professor who was in a heterosexual marriage. The professor abruptly broke
off the relationship citing Jason wasnt his type. This led to an aggressive relapse of
irrational body image thoughts, compulsive exercise, limited food intake and other
subsequent anorexia nervosa behaviors so severe in began to affect his endocrine
system- presenting itself as possible Hypothyroidism (Porter & Burlingame, 2010)
and Cardiovascular issues primarily related to the heart. It was these symptoms that
finally led his voluntary admission to the Inpatient Eating Disorder Unit at

Deaconess for a primary diagnosis of Anorexia Nervosa. (Porter & Burlingame,

2010)
Per the patients primary physical assessment and write up made by The Treatment
Team a (Treatment) Plan was created along with an ICF write up by this CTRS. The
ICF Write Up is as follows and takes under considerable precautions to the amount
of physical exercise which will be allowed until further evaluations regarding the
endocrine and cardiovascular related issues:
Body Function code 1: s4108.2.7. O Structure of the Cardiovascular
System Others Specified the concern after further review of a CT scan that Jason
has a buildup of fluid around the pericardium of the heart. Further tests reveal that
the heart is abnormally smaller than within clinical ratios.

The first indication

malnutrition has clearly affected his heart muscle. Thus, the first qualifier of 2
indicating a moderate impairment to the heart, a 2 nd qualifier of 7 to indicate there
is qualitative fluid around the structure of the heart within the pericardium. and 3 rd
qualifier indicating that the location of the impairment is on more than one area.
Body Function Code 2 is b598.3.8.0 Function of the Digestive System
indicating there is possible diagnosis of Hyperthyroidism which explains the
feelings of fatigue, insomnia heart palpitations, feelings of anxiousness. The first
qualifier indicates there is moderate impairment with a second qualifier to not be
specified until further evaluation can be made by a Cardiologist. The indication is
that this is a secondary reaction to the malnourished state. Nonetheless, the
physicians want to make sure the possible Hyperthyroidism was not the primary
diagnosis and resulted in the other symptoms of anorexia, anxiety and heart

palpitations to be present. Further evaluation by the primary physician will confirm

the validity of the code.
Body function code 3 is b1801.3 referencing the patients clinical diagnosis of
anorexia nervosa with regards to body image distortions was initially measured as
severe.

Though it is the least physically detrimental ailment, it is clearly the most

important aspect with regards to the patients diagnosis of Anorexia Nervosa. Most
Notably the psychological distorted thoughts and compulsive behavior that led to
the patients original clinical diagnosis of Anorexia Nervosa. I have included a
qualifier of 3 to be a moderate (bordering on severe) impairment to the patients
ability to see himself as anything other than obese.
An and P code 1 is d2408.3 References Jasons ability to handle stress and other
psychological demands. Jason uses his compulsive tendencies to ease his anxiety
levels of test taking, relationships, and everyday stressors. Jason will over exercise,
restrict his food intake and do what it takes to be an overachiever in school. It has
led to complete exhaustion. The goal is to have Jason recover physically from his
compromised state and then work on the tactics to deal with stress in a manageable
way. Also overcome his past abuse as inferred in qualifier .3 indicating a level of
severe difficulty. This will be addressed further with the Treatment Team and their
individual treatment plan.
An and P code 2 is d7400.3 references the problems Jason suffers with regards to
complex interpersonal interactions in terminating relationships that are either
destructive in behavior and or in the best interest of his well-being to terminate
such relationships in accordance to the rules our society deems the norm. This is
specifically referring to the relationship with the married professor, not referencing

his Homosexuality. This classification was coded in reference also to the sexual
abuse piece listed in the beginning stages of Jasons life through puberty.

The

effects have left Jason severely inept of having a healthy and meaningful romantic
relationship as well as proper formal adult male relationships.
An and P code 3 d7603.3 references the sexual molestation and grooming of
Jasons male extended family member and how it inflicted Jason during his early
prepubescent and pubescent years. It will be the responsibility of the Treatment
Team to address and teach Jason healthy behaviors to overcome his past and not let
it affect his future relationships.
Environmental Code 1 is e.1100.3 directly relates to the primary clinical
diagnosis of Anorexia. Under this specific code, Food for personal consumption,
Jason was evaluated to be severely impacted with his desire to starve himself to
death. Food is a basic human need and without a healthy and sustainable amount of
food body functions are harmed.(Porter & Burlingame, 2010) Thus the .3 qualifier is
noted.
Environmental Code 2 is e1458+3 describes the aspect of Products and
technology for the practice of religion or spirituality. An added qualifier of +3 to the
assessment indicates Jasons use of the Catholic Music song book to be his solace
and ways to console himself.

Jason plays the guitar and often will soothe his

anxieties of life issues and school by playing the guitar and singing hymns from the
song book.
Environmental Code 3 e1400+3 references a Product and Technology for culture,
recreation and sport. Jasons guitar would classify as this product of culture and
recreation that directly facilitates a positive aspect of life. Here he does not obsess

or think negatively when playing the guitar. Since the age of 9 when he taught
himself how to play the guitar, he has used it as his escape from the anxiety and
stressors. It is his soothing mechanism.
This write up addresses the initial assessment of patient Jason P. and his initial
clinical diagnosis made by the Deaconess Eating Disorder Treatment Team for
admission to the Deaconess Eating disorder unit and the initial assessment of this
CTRS, Tracy Pendarvis.
A follow up intervention plan will be assessed in 48 hours to give Jason. and the
Treatment Team time to analyze and assess the tests, clinical work ups, scans and
scoring of the Beck Depression Inventory Test and State Trait Anxiety Inventory.
(Porter & Burlingame, 2010) The plan will incorporate the Eating Disorder Team
protocol as well as an individualized treatment plan for Jason in his post hospital
outpatient care.

A complete health insurance audit will be completed within the

following days to ensure Jason has the coverage needed to receive the most
complete and therapeutic treatment for his recovery.

Bibliography
American Psychiatric Association. (2014). DSM-5. Washington DC : American
Psychiatric Publishing .
National Eating Disorder Association . (2016, 02 20). National Eating Disorder
Organization. Retrieved from NEDA feeding hope :
http://www.nationaleatingdisorders.org/anorexia-nervosa
Porter, H. R., & Burlingame, J. (2010). Recreational Therapy Handbook of Practice.