In our discussions, you had the ability to consider the theoretical concepts of integrating assessment, diagnosis, and treatment. For the case presentation assignments in this course, you will apply the theoretical to the clients you are working on in your practicum.
You will identify one client from your current clinical experience and prepare a case presentation in MS Word addressing the following areas.
NOTE: No identifying information should be used. No initials of first/last names should be included. This assignment demands complete anonymity. Simply state the patient’s age/gender (for example: “Today I am presenting the case of 48-year-old male…)
I recommend reading the grading rubric so that you will know in detail how you will be graded for this assignment.
Your presentation should include the following elements:
- Chief Complaint and History of Present Illness (worth 10 points)
- Collateral Information Obtained (10 points)
- Client Assessment (10 points)
- Cultural Considerations (10 points)
- Developmental Considerations (10 points)
- Differential Diagnosis and Pathophysiologic Explanation (10 points)
- Case Formulation (10 points)
- Treatment Plan (20 points)
- Legal and Ethical Issues (10 points)
The chief complaint is that the patient has been experiencing suicidal thoughts, and she keeps repeating phrases such as I will “blow my head off”, “burn the house down,” and “I am going to be dead, and I have a plan.”
In the follow-up visit, the patient refused medical help from doctors, did not take medications properly, did not bathe regularly, watched YouTube for 16+ hours a day, and was paranoid about people coming after her.
The patient’s daughter confirms the information on the MIW form is true. She adds that her mother had a recent behavior outburst but won’t accept it.
The daughter also produces videos she took with her phone when her mother was threatening to shoot herself and burn the house. APA