Read the case about Emily (see presentation section, then module 4). Write up an initial assessment of your client including you final diagnosis and any relevant V codes that further illustrate Emily’s current circumstances. Assess your client in terms of what you have learned thus far. You will clearly explain your reasoning for your diagnosis and V codes and will include rule outs you made for the diagnosis. Be sure to clearly label what is your rule out and what is your final diagnosis. An example of the rule outs is attached. You are not discussing the treatment plan and interventions (that is for your Signature Assignment) however; you should clearly discuss the symptoms and other details from the case to come up with an evaluation and assessment of this client. Explain your reasoning for each rule out you give and of course, indicate for your final diagnosis and V codes your reasoning for choosing this final diagnosis. Always support your thoughts with professional sources throughout the paper. The Case Assignment should be 5-8 pages in length (double spaced, size 12 font). Include a title page with your name, date, class name, and the title of your paper. Paper must contain at least 2 professional sources. Note that this case will be used again for your Signature Assignment but in much greater depth. Outline of case assignment: Assessment of the case: Here you would include the symptoms and other details from the case to come up with an evaluation and assessment of this client. Of course, information on your rule outs and final diagnosis will come up in this section. This is where you would use information from professional sources to support your case. This is in paragraph form. To Rule Out: (this is in bulleted format like below) 294.11 Dementia of the Alzheimer’s Type with Behavioral Disturbance, Late Onset – This progresses slowly and I would need to know when the memory loss and behavioral symptoms began. I would also need to know if there was a family history since late onset cases have a genetic component. 296.22 Major Depressive Disorder, Single Episode with Melancholic Features – Clara’s depression is not known, we do not know if she was active and has discontinued hobbies, clubs or socializing, we do not know if she has lost weight, is having problems sleeping, has low energy, feelings of worthlessness, or inappropriate guilt. 331.0 Alzheimer’s – Some common symptoms of Alzheimer’s that Clara is showing are: à Memory loss – She is having problems remembering things. à Problems doing familiar tasks – Left gas on stove and unlit. à Poor or decreased judgment – Left gas on stove and unlit. à Changes in personality – Ben is angry and impatient with her and this could be because of her changes in personality. What are some questions you may ask or further information you need from client to make these rule outs more clear… (keep this short) I would ask Clara about Ben’s anger and impatience with her. This might be signs of elder abuse. If there seems to be significant reason to believe there is elder abuse, I would have to report the elder abuse immediately. I would also ask Clara about her thoughts about suicide. Because she has left the gas on the stove unlit there is suspicion of an attempt at suicide. If she admits to suicide, I can place a 5150 hold on her. Final Diagnosis including specifies, severity, and relevant V codes. Hint: there are several V codes for Emily here, look at the DSM V manual under the “other conditions that may be a focus of clinical attention.” Here you would explain why you gave her this diagnosis and any relevant V codes. Make sure you are using professional sources and citing in APA format.
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