Case Analysis

NU665C – Week 15 Case Study Analysis

For this assignment, you will apply what you have learned during the course to develop and present a case and treatment plan for a fictional or real client encountered in clinical practice. Your case analysis will be completed in three sections totaling five to seven pages (excluding title page and references) and will be graded using the case study grading rubric.

Part A: Clinical Assessment

1. Record your client assessment, diagnosis (medical and psychiatric differentials), medical and psychiatric history and psychosocial factors that impact the case. This information should be presented in the same format as your Wheeler (2014) textbook’s Sample Clinical Assessment Form, found on pages 143–145. The link is below, pages 54-56.

2. Conclude Part A with a one-page description of this fictional patient, including all the relevant information outlined in the clinical assessment form as well as relevant and realistic information acquired from your research. Refer to the APA  Clinical Practice Guidelines .

Part B: Therapy Session

You will design a therapy session for your client based on his or her preceding clinical assessment. Part B of your assignment will be assessed on your demonstration of proper therapeutic communication. The empathy demonstrated should be consistent with the following operational definition: Empathy is a critical tool for establishing a trusting therapeutic relationship. Rather than parrot back what your client has said, good empathy reflects the thoughts and feelings of your client and notes the importance of what has been communicated. In doing so, it invites the client to self-explore. Empathic feedback avoids “why” questions. When appropriately relayed in a tentative manner, good therapeutic empathy also gives the client a chance to redirect or correct what the counselor has said.

Your session transcript should:

· Use your personal experiences to replicate realistic patient responses as well as clinical responses.

· Be a written transcript of more than 2,100 words (at least 15 minutes in length).

· Evidence empathic feedback that adheres to the operational definition of empathy in the counselor’s responses to most of the client’s remarks.

Part C: Therapeutic Intervention

Much of the information you learn through your research can help inform the development of your patient. Research evidence-based interventions involving both psychopharmacological and nonpharmacological services to individuals who have been assessed in a mental health setting.

There should be three to five evidence-based articles and interventions that encompass both medication and non-medication modalities. Be sure to include two different therapeutic approaches when discussing non-medication interventions. For example, when selecting therapeutic approaches, you can select client-centered and cognitive behavioral therapy.

wheelers-assessment-docx (1)


Sample Assessment Form


Identifying Data

Name of Client:




DOB: Age:

Sex: Sexual Preference:

Marital Status:




Religious Preference:

Client-Identified Problem (Client’s Own Words) and Referral Source

1. History of current illness

A. Stressors and symptoms: include current stressors and detailed chronologic history of symptoms for each diagnosis on axes I and Il. Detail current substance abuse and the amount and pattern of use.

B. Recent suicide or homicide ideation or behavior: include all ideation, gestures, attempts, presence or absence of hopelessness, and extent of actions or plans in the past month.

2. Psychiatric history

A. Episodes and treatment: describe previous episodes of current disorder and all other disorders, including treatment modalities such as hospitalizaüon, psychotherapy, and medications and their dosages.

B. History of tauma: list the 10 most significant traumas. Do a timeline, and rate the disturbance for each event on a scale of 0 to 10; you can also ask for significant positive and negative events in the person’s life. Administer the Impact of Events Scale and Dissociative Experiences Scale if trauma is suspected or reported.

C. History of violence To self:

To others:

To property:

3. Psychiatric review of systems: circle all relevant symptoms, and add any not listed

A. Mood: sadness, tearfulness, depressed mood, irritability, fatigue, lethargy, anergia, anhedonia, sleep changes, appetite changes, decreased libido, hopelessness, helplessness, worthlessness, suicide ideation, homicide ideation, spending sprees, increased energy or acüvity, decreased need for sleep, increased libido, pressured speech, tangentiality, and flight of ideas.


B. Anxiety: anxious mood, excessive worry, shortness of breath, heart palpitations, panic attacks, sweating, flushing, hyperventilation, sense of impending doom, fear of death or collapse, cold/clammy skin, and tingling sensations in extremities.

C. Thought disorder: auditory or visual hallucinations, other hallucinations, ideas of reference, paranoia, delusions, thought insertion, thought blocking, thought broadcasting, flight of ideas, hyper-religiosity, tangentiality, looseness of associaüons, and bizarre behavior.

4, Drug and alcohol history

A. Episodes and treatment: describe previous episodes of current disorder and all other disorders, including modalities such as hospitalizaüon, psychotherapy, and medications and their dosages. B. Substance abuse profile:

Substance Current Amount Date Last Used
Alcohol (use CAGE if abuse suspected but denied)    
Tetrahydrocannabinol (THC)    
Cocaine, crack, speed    
LSD, mescaline, psilocybin    
Barbiturates, other sedatives    
Caffeine, tobacco    
Over-the-counter drugs, herbal medications    

5. Medical history: List significant past illnesses, surgeries, or hospitalizations A. Primary care physician:

B. Allergies:

C. Medications: use the table to document:

Current Medication Dosage Taken as Prescribed?
    Yes No

6. Psychosocial history

A. Education:

B. Family relationships, social relationships, and abuse history:

C. Employment record and military history:

D. Religious background, belief system, or meaning framework:

E. Client’s strengths: include client resources and how client self-soothes and manages stress.

7. Family history

A. Genogram:


Assessment of suicide or violence risk:


Admit to:



Refer to:


Referred for:

Physical examination

Individual psychotherapy

Psychological testing

Group psychotherapy

Hospitalization tions

Support group

Community support program services

Diagnostic summary:

Axis Diagnoses, Factors, or Status Codes Alternatives to Rule Out
l. Clinical psychiatric syndromes 2.


Il. Personality and specific development disorders 2.


Ill. Medical problems 2.


IV. Psychosocial stressors* 2.


V. Global assessment of functioning (GAF) Current GAF

Highest GAF in past year

*Prioritize and rank severity: 1, none; 2, mild; 3, moderate; 4, severe; 5, extreme; 6, catastrophic; 7, unspecified.  

Clinician’s signature:


Location of assessment:

Adapted from Shea, S. C. (1998). Psychiatric interviewing: The art of understanding (2nd ed.). Philadelphia: W. B. Saunders.

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