INSTRUCTIONS
For this Benchmark Case Presentation Paper Assignment, you will create a case presentation to review, diagnose and provide treatment recommendations for.
Part 1
Step 1: Choosing the Diagnosis
In the Quiz: Case Presentation Topic for Instructor Approval, you will submit your request for the diagnosis on which you will base your case presentation. You must receive written approval from your professor to proceed with the case presentation. You will need to provide the full name and ICD 10 code for the diagnosis you are requesting, including any specifiers. Once you receive approval, you can begin to construct your case.
Step 2: Writing the Benchmark Case Presentation Paper Assignment
For this case presentation the following sections are to be organized using Level 1 and Level 2 APA headings:
Basic Case Summary
Identifying Information (approximately ½ page)
This section needs to include the following information exactly as listed here:
Date of initial assessment:
Client’s Name:
Employment Status:
School Status:
Age:
Gender:
Race/ Ethnicity:
Marital Status:
Presenting Concern: (This is the client’s reason for referral and should be 2-3 sentences, phrased as a client quote, that explains why they are meeting with you)
Presenting Concern (primary section, approximately 2 pages)
This section needs to include a description of the client’s situation, signs of the symptoms of the disorder they are experiencing, how the signs of the symptoms are affecting major areas of life (relationships, employment, school, spiritual, physical health, recreation/ enjoyment in life, etc.…). This section should be told in narrative style, including client quotes. In this section you need to make sure to connect most of the symptoms in the DSM of the disorder by presenting corresponding signs (client report) of the symptoms. If you choose, you can throw in a few signs of symptoms that do not directly relate to the diagnosis, but make sure you do not present a second diagnosis.
This section should be clearly worded and sound like something you would expect a client to report. It should not be a listing of symptoms from the DSM; rather, how a client would represent their experience of the symptoms.
Example of language not to include in this section:
DSM: Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).
Example of language to include in this section:
“I feel so sad all the time. Sad, empty and I cry at the drop of a hat. I have been at lunch with two different people since this started and I started crying uncontrollably, which was pretty embarrassing. I have never cried in public like that. And it just happened! This has been going on every day for about eight weeks… but it feels like it has been going on for years and I am starting to worry I will never feel happy or hopeful again.”
Not all signs of symptoms to support the diagnosis must be in this section, but there must be a strong foundation for the diagnosis. You can scatter a few of the needed signs of the symptoms in the next section or cover them all in this section.
History (approximately 2 pages)
Below are points to include in your Case Presentation Paper Assignment. Please use Level 2 APA headings to organize this section. The required information is as follows:
Family
Information about spouse, children, others living in the home. Client’s perception of the home environment and relationships within the family. Critical family incidents may be included.
Client’s Physical Health
A statement of the client’s significant health history, current treatment, and medications.
Occupational History
Client’s current occupational functioning, history of work problems and reason for change.
Substance Use History
Description of client’s alcohol/drug use, patterns of use, and last use; as well as how often client uses and how much.
Spiritual Information
Does client believe in God? Attend church? What role does religious affiliation play in the client’s life? Are spiritual resources or issues important to client? How does client describe God? What is the state of the client’s spiritual awareness?
Cultural/ Social Justice Factors
Does the client have any factors such as acculturation, discrimination, etc. that impact the client and may be source of signs, symptoms? How would the client explain the problem from their cultural lens?
Barriers to Treatment/Success
Are there personality factors, stages of change influences, or contextual/ cultural/ social justice/ motivational factors that would influence the success of treatment?
**Optional Information (if directly related to the diagnosis)
Family of Origin
Parents and siblings; client’s perception of the home environment and relationships within the family; critical family incidents may be included.
Educational History
Description of pertinent information in relation to educational background
Sexual Adjustment
Current status, significant problems or disturbances in functioning, alternate lifestyles
Other Pertinent Data
Provide any other data points not captured from the sections above such as signs, symptoms, severity, onset, conditions, context that provide a clearer picture for the development and discernment of the diagnosis as well as client insight and motivation to treatment.
Mental Status Exam (approximately 1 page)
This section should be a very brief overview of initial observations, perceptions, and impressions of the case presentation. Very briefly remark on anything that would support the diagnosis you are presenting (for depression you might comment on sadness, flat affect or tearfulness…).
The following are required to be in the mental status exam:
o Presenting Appearance
o Basic Grooming and Hygiene
o Interpersonal Characteristics and Approach to Evaluation
o Speech
o Eye Contact
o Expressive Language
o Receptive Language
o Orientation
o Alertness
o Coherence
o Concentration/ Attention
o Thought Processes
o Hallucinations and Delusions
o Judgement/ Insight
o Intellectual Ability
o Mood
o Affect
o Suicidal and Homicidal Ideation
o Risk of Violence
Please review the supplemental materials for this assignment in the Helpful Information for Writing the Mental Status Exam document, which includes a list with more detail about the terms you must use. You can include language from this list as appropriate.
Answer Key (1/2 to 1 page)
As part of this Case Presentation Paper Assignment, you will provide an answer key, to confirm that you have intentionally provided adequate information to support your diagnosis. This Answer Key will include the chart indicating your client meets all the criteria for the chosen DSM-5-TR disorder. Be sure to include the full name and ICD 10 code for the diagnosis.
DSM-5-TR Diagnostic Criteria: disorder name and code number Client’s Reported Symptoms:
Criterion A:
Criterion B:
Criterion C:
Criterion D:
Criterion E:
Criterion F:
Treatment Recommendations (approximately 1 page)
Two treatment recommendations: Choose what you think is the most important issue to address in the case and provide two treatment recommendation. You will need two peer reviewed journal article that are not more than 10 years old to support your recommendation. Please make sure you provide a recommendation that counseling focused- what would you as a counselor do with this client in your office. Any case management (medication evaluation, etc.…) can be noted but does not suffice as the treatment recommendation.
The Treatment Recommendations will be the final section of the Case Presentation Paper Assignment.
