PART TWO OF THE COMPREHENSIVE CASE STUDY
Differentials: Three differential diagnoses including pertinent patient presentation/symptoms that should be considered and must be plausible to match the patient presentation. The student should write in detail WHY they thought the patient met this criterion using the previous information presented in part one and how the diagnosis was ruled out. The final diagnosis should NOT be included in the differential.
DSM-5 Final Diagnosis with ICD-10 Code: What is the rationale for the diagnosis? The student should write in detail the rationale that describes the specific symptomatology that qualifies the clinical presentation to be identified as the DSM-5 diagnosis, including diagnostic specifiers.
Formulating the Treatment Strategy
EBP: Review an Evidence-Based Practice article referring to this patient with this particular diagnosis, treatment, or medication (summarize the study, include a rating of the article, (citation for the rating scale & put the article and rating scale in your references), instruments utilized, relevant findings.
Measurement of patient progress and Assessment Tools: List 2-3 measures that could be utilized for this patient in the future to measure their progress. Include the name of the test, information about reliability & validity, score ranges, meaning of high vs low scores, how often the instrument should be administered, and patient score is assessed during evaluation. Mnemonic devices, such as “SIGECAPS” are not published/validated tests.
Psychopharmacology: Medication with dose-instructions listed, pharmacodynamics, and pharmacokinetics. A detailed explanation is provided for the choice of this medication over other medications in the same category.
Diagnostic tests: Diagnostic tests that are specific to the case are described with the rationale. Lab/Diagnostic template in Appendix A below. List each test separately and provide the rationale (CBC is separated by each test – hemoglobin, hematocrit, etc and what abnormals could mean and the possible connection to a psychiatric diagnosis if applicable.
Psychotherapy: List 2 or more theoretical orientations which could be used in the treatment of this patient and give 3-4 sentences describing each theoretical orientation and why the treatment could be beneficial. Such options could include Interpersonal, psychodynamic, EMDR, Rogerian, CBT, Jungian, etc. Use references other than Sadler or Wheeler.
Psychoeducation: Pertinent information regarding aftercare, legal issues, health promotion such as diet, medical, psychological testing, medications, diagnosis, black box warnings, and educational websites
Follow-up: Instructions to the patient for follow-up visits, emergency access, or diagnostics. Include safety measures if indicated.
References: APA format and writing