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Ben Case

Case Study of Ben, Part 2

Read the Case Study of Ben, Part 2.

Use the Case Study Response Guide to assist you in revisiting your diagnosis of Ben’s condition, incorporating this new information. In Section 4 of the response guide, address each of the following:

· In each of these scenarios, describe how the new information alters the picture presented in the original case study.

· Describe your new diagnostic hypotheses, and justify your conclusions.

· What further diagnostic evaluation do you believe is warranted?

Use the Case Study Response Guide to format your assignment.

Case Study Response Guide

Use this outline to structure your case assignments.
1. Case Summary
  • Provide a brief summary of what you have      learned about the individual reviewed in the case. Include information about the individual      in terms of demographics and general history, and the sources of that      information, and the reason that the individual was referred, and by      whom. 
  • Summarize any information you may have      about evaluations that have been conducted, including the results. 
2. Clinical Impression (Diagnosis)

Write the clinical impression in the DSM-5 format:

XXX.xx (Yyy.yy) Primary Diagnoses (list in order of salience).

(DSM-5 Code is first, as in XXX.xx, and ICD-10 codes next, in parentheses.)

OTHER FACTORS:

Use the V and Z codes, or simply appropriate descriptors to psychosocial and contextual factors of importance to the diagnostic case. These replace the DSM-IV-TR Axis IV & V used to address these concerns.

3. Recommendations 

Explain any recommendations for interventions, treatment, and/or disposition.

4. Questions

Address the specific questions that were asked in the instructions for this assignment.

Here is a sample assignment question and an appropriate brief response:

Question: Describe what further information you would need to accurately diagnose this case.

Response: To diagnose this case accurately, I would also need to review any pertinent medical records. I would want to interview this client’s mother, with whom he lives, to corroborate the clinical interview data supplied by the client, and to learn more about his developmental history. I would also want to…

 

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