Instructions:
Read the vignette.
Summarize the applicable biopsychosocial and MSE information; use a narrative style that would be included in a formal report, although lists and bullet points may be appropriate.
Briefly summarize the differential diagnoses considered, including the rationale for ruling each out as a diagnosis. Have at least 3 differentials.
Write the full, properly formatted diagnosis, including applicable “other conditions that may be a focus of clinical attention” and their respective ICD-10 codes.
Summarize an assessment option, including a published instrument, that may be helpful in assessing for this disorder. You should have at least 1 peer-reviewed article to support this.
Summarize an intervention that has demonstrated efficacy in treating this disorder. You should have at least 1 peer-reviewed article to support this.
Summarize predisposing factors, across at least two domains, that may contribute to the development of this disorder and the prognosis for clients with this disorder. Be sure to consider this particular client’s experiences and characteristics to make the prognosis and predisposing factors specific (i.e., use specific information from the vignette to support why you think this may be a cause for this client). Should have at least 1 peer-reviewed article to support this information.
Additional notes:
The general format (headings, citations, etc.) should comply with APA; however, you are allowed to use bulleted lists or other formats to clearly convey your client’s information. A title page is not necessary.
You will need a minimum of 3 different peer-reviewed (non-DSM) articles, but you will likely need more.
It is important to be concise (your clinical teammates, judges, insurance companies, etc. will not be able to read volumes). You should be able to summarize the history and MSE in no more than 1-2 pages, and the differential diagnostic section and summary of disorder, assessment, and treatment, etc. should be summarized in 2 pages.
Writing should be formal and professional, free of errors and shorthand clinical “speak” (i.e., this should not be in a progress-note style with sentence fragments, abbreviations, etc.).
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