COUC 546
Benchmark Case Presentation Paper Assignment Instructions
Overview
This assignment is designed to help you make application of course content to a counseling situation. In this assignment you will have the opportunity to create a clinical case, identify and prioritize key issues involved, consider and clarify relevant diagnostic issues and formulate treatment recommendations that are most likely to be helpful to the client. This assignment will directly apply to your work in COUC 667 and with clients when you begin practicum.
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
At the end of Module 3: Week 3 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 APA headings:
Identifying Information
This section needs to include the following information exactly as listed here:
Name
Age
Gender
Race/ Ethnicity
Marital Status
Reason for referral (this is to be 2-3 sentences, phrased as a client quote, that explains why they are meeting with you)
Presenting Problem (primary section, 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 effecting 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, but be how a client would represent their experience of the symptoms: signs of the symptoms
Example:
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).
Client report: 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 (2 pages)
Below are points to include in your Case presentation. This section should be 200 – 350 words maximum. Please use Level 2 APA headings to organize this section.
Required Information:
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: 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 (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:
Presenting Appearance
Basic Grooming and Hygiene
Interpersonal Characteristics and Approach to Evaluation
Speech
Eye Contact
Expressive Language
Receptive Language
Orientation
Alertness
Coherence
Concentration/ Attention
Thought Processes
Hallucinations and Delusions
Judgement/ Insight
Intellectual Ability
Mood
Affect
Suicidal and Homicidal Ideation
Risk of Violence
At the end of the instructions is a list with more detail about the terms you must use. You can add from the list below if appropriate.
Treatment recommendations (1 page)
Two treatment recommendation: 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.
Answer Key (1 page)
As part of this 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, in bullet points:
Diagnosis that includes full name and ICD 10 code
Key Issues in order of importance
All the signs of symptoms presented in the case presentation
Any signs of symptoms that where presented but not part of the diagnosis
The answer key will be the final section of the Assignment
This paper should be 8-10 pages long, excluding the title page and reference page. Use current APA format. This assignment does not require an abstract.
This assignment requires a minimum of 2 resources from peer reviewed journals that are less than 10 years old. You may use textbooks, but they will not count towards the two required resources. You may not use web site or other non-professional literature.
Note: Your assignment will be checked for originality via the Turnitin plagiarism tool.
MENTAL STATUS EXAM
The Mental Status Exam is the basis for understanding the client’s presentation and beginning to conceptualize their current functioning into a diagnosis. At first, this might seem overwhelming and time consuming, but it is not difficult to do. It can generally be done in a few minutes as the vast majority of this information is obtained through your careful observations of the client during the intake interview. This is why developing your observation skills is important.
APPEARANCE
Presenting Appearance, including sex, chronological and apparent age, ethnicity, apparent height and weight (average, stocky, healthy, petite), any physical deformities (hearing impaired, injured and bandaged right hand)
Basic Grooming and Hygiene, dress and whether it was appropriate attire for the weather, for a doctor’s interview, accessories like glasses or a cane
Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), work speed, any noteworthy mannerisms or gestures
MANNER & APPROACH
Interpersonal Characteristics and Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, shows subdued mistrust and hostility, excessive shyness)
Behavioral Approach (distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing)
Speech (normal rate and volume, pressured, slow, accent, enunciation quality, loud, quiet, impoverished)
Eye Contact (makes, avoids, seems hesitant to make eye contact)
Expressive Language (no problems expressing self, circumstantial and tangential responses, anomia, difficulties finding words, misuse of words in a low-vocabulary-skills way, misuse of words in a bizarre-thinking-processes way, echolalia or perseveration, mumbling)
Note if English is not the primary language here and comment on their command of the language
Receptive Language (normal, able to comprehend questions, difficulty understanding questions)
Recall and Memory (could explain recent and past events in their personal history, recalls three words (e.g., Cadillac, zebra, and purple) immediately after two rehearsals, and then again five minutes later (five minutes is how long it takes for information to move from short-term to long term memory). If they cannot, you can prompt them (e.g., “Was the first one a kind of tree, color, or car? A car, OK was it a Camaro, Continental, or Cadillac?”)
ORIENTATION, ALERTNESS, & THOUGHT PROCESSES
Orientation (person, place, time, presidents, your name)
Alertness (sleepy, alert, tired for working late, dull and uninterested, highly distractible)
Coherence (responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow)
Concentration and Attention (based on Digit Span and attention to your questions, serial 7’s or 3’s (count backwards from 100 to 50 by 7’s or 3’s), naming the days of the week or months of the year in reverse order, spelling their last name, or the ABC’s backwards)
Thought Processes (could/could not recall the plot of a favorite movie or book logically, difficult to understand line of reasoning, showed loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization)
Hallucinations and Delusions (presence, absence, denied visual but admitted olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications)
Judgment and Insight (based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong)
Intellectual Ability (roughly average, above average, or below average based on answers to questions like “name last four presidents” or “who is the governor of the state?” or “what is the capitol of the state?” or “what direction does the sun set?,” etc…)
Abstraction Skills that are based on proverbs and sayings (“What do people mean when they say…”), similarities (“How are a ______ and a ______ alike? Different?”), and giving both definitions for word (“What are two different meanings for ‘right,’ ‘bit,’ and ‘left?’”)
MOOD & AFFECT
Mood or how they feel most days (happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry)
Affect or how they felt at a given moment (comments can include range of emotions like broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation and facial expressions, pessimistic, optimistic) as well as inappropriate signs (began dancing in the office, verbally threatened examiner, cried while discussing a happy event and cannot explain why) or consider the weather, which varies slightly from day to day
Rapport (easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset)
Facial and Emotional Expressions (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful when discussing such and such)
Suicidal and Homicidal Ideation (ideation but no plan or intent, clear/unclear plan but no intent, ideation coupled with clear plan and intent to carry it out)
Risk for Violence (fair, low, high, uncertain, effected by substance use)
Impulsivity (low medium, high, effected by substance use)
Anxiety (note level of anxiety, any behaviors that indicated anxiety, ways they handled it)
Defense Mechanisms observed
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