Case Summary #2

Overview: This assignment enables practice with assessment and differential diagnosis via application of the DSM 5 criteria and use of theoretical case conceptualization skills.

Purpose:. This assignment provides students with an opportunity to utilize case conceptualization and differential diagnosis skills through application to a scenario. This mirrors field work and is designed to strengthen these skills via practice and feedback.

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The case summary reflects your assessment process and strategy, and initial diagnostic impressions. Using the WHO Model, DSM 5 and other course materials and content, prepare a case summary of the information presented in a sample vignette of your choosing.

Vignettes are provided “Case Vignettes”. For educational purposes, sample vignettes do not include all the information necessary to complete an assessment. Therefore, you may elaborate on existing information (i.e. background demographics) and/or add additional information not provided in the sample vignette (i.e. health status, previous treatment response, mental status, social system, etc.). However, it is not permissible to change any original case information or the intent of the original version. Remember, this is very familiar to how the individuals we work with present to us; there is often missing information and part of our job is to recognize what other information we need and seek it out.

Read each section below, carefully considering the prompts. Use the bolded guiding questions below as headers (exclude the accompanying information) and respond to each question. (APA formatting).

Required sections:
1. Presenting Concerns: Concisely summarize the nature of the presenting problem. Describe your conceptualization of this case using information from the case vignette, client’s understanding of themselves and the presenting problem(s), social and environmental factors, strengths, coping strategies, and clinical observation. Include data such as client’s identifying information, reason for visit/referral, strengths, health status, social support, previous treatment, and primary concerns.
2. Salient Symptoms: Among all of the information presented in the case vignette, discern the most salient symptoms. Identify the most salient symptoms, including information such as when and where symptoms occur, timeline for onset, duration, and intensity, and any antecedents or consequences. Consider the client’s current life situation including intrapersonal issues (mental status, developmental considerations, cognitive/behavioral/emotional/physiologic factors, client roles, etc.). Remember to consider impact on functionality as you articulate what a ‘symptom’ is.
3. Diagnostic Impression: Consider the continuum of reasonable possible diagnoses that may apply to this case and list at least three of your considerations. Write the complete name (no abbreviations) of each of the diagnoses, with their proper numeric coding.
4. Diagnostic Follow Up: Identify what you will need to monitor, how you might proceed to refine the diagnosis.
5. Strengths and Resources: Describe strengths and resources within and around this client. Consider the client’s context and social support networks.
6. Trauma and Stressors: Note the trauma informed considerations you are making in this case, including how you might incorporate the principles of trauma informed care in the initial assessment and diagnostic process.
7. Recommendations: Provide a minimum of two initial treatment recommendations and justify these.
8. Student needs: This portion of the assignment is ungraded, but gives you a chance to give feedback on what you did well and to ask for any specific feedback you would like during grading or to identify where you are struggling with the content.

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