Case Assignment
Read the Case of Emily (refer to Presentation Section, then Module 4).
Use critical thinking skills to understand the information in the
prompt. Assess your client using what you have learned so far in
class. Write up an initial assessment of your client.
Formatting:
The entire Case Assignment should be 5-8 pages in length. You
must use the APA format. Please see the Purdue Owl Website
for any APA formatting questions.
Use the seven (7) headers listed below.
Use at least two professional sources
Support your thoughts with professional sources throughout
the paper.
Use the following as headers for your paper (use bolded words only):
Introduction: Introduce what you will be writing about in your
paper.
Assessment: Include the symptoms and other details from the
case to come up with an evaluation and assessment of this
client. Information supporting your provisional diagnoses and
final diagnosis can come up in this section. This is where you
would use information from professional sources to support
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your case.
Provisional Diagnoses (other possible diagnoses that the client
might meet criteria for): You will prove/disprove reasons why
these diagnoses fit or does not fit Emily. Please list a minimum
of two provisional diagnoses and a maximum of four
provisional diagnoses. For example, you may share that Client
X displays F02.81 Alzheimer’s Disease with behavioral
disturbance. State why this disorder does/does not fit Client X.
Clearly explain your reasoning.
Zcodes: Look at the DSM 5: “Other conditions that may be a
focus of clinical attention.” Choose between one to five Zcodes
for Emily. Include the code and name (i.e. V60.2 Extreme
Poverty). Please state why these codes are relevant to Emily.
This may be a bulleted section.
Questions: What further information do you need to make a
proper diagnosis/provisional diagnoses? Include questions
you would ask Emily in order to diagnose her properly. This
section may be written in bullet form. For example, “how long
has your depression persisted?” or “Was there any time in
your life that you did not feel depressed?”
Final Diagnosis: Choose only one diagnosis. Include diagnosis
code, name, specifiers, and severity. State why you chose this
diagnosis for Emily. Clearly explain your reasoning. Reminder:
Do not use Axis I, II, III, IV, and V to diagnose (that was the
format for DSM IV-TR and is no longer necessary today).
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Conclusion: Provide a summary of your assessment of Emily.
You are not discussing the treatment plan and interventions in this
paper (that is for your Signature Assignment). However, you should
clearly discuss symptoms and other details from the case to come up
with an assessment/evaluation of this client.
Note: You will use this Case Assignment as a foundation for your
Signature Assignment.
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