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Diagnostic Case Study Health, Medicine, Nursing Case Study (Case Study Sample)


There are two options.
Option 1- if you have a client who are available to give a diagnosis with mental illnesses at your filed practicum, you can use your own client.

Option 2- 2 case vignettes will be provided, and you will select one case for the assignment.

· You are a new assigned clinical social worker (you will regard yourself as the treating therapist and not have to refer your client to another clinician considering they already have a treating psychiatrist and other resources, support group, medical providers and specialists to treat their health issues if any).

· You will discuss and respond to the following questions. Please incorporate course literature i.e. DSM-5, Corcoran & Walsh, as well as other literature you would find applicable to support your clinical reasoning.

Bio-Psycho-Social assessment- If applicable, provide as much information as possible
(1) Personal info (age, gender, employment, etc.)
(2) Life span issues (childhood and present)
(3) Family history
(4) Medical and mental health history
(5) Diversity
(6) Protective and risk factors
(7) Current Individual coping
(1) Your Diagnosis based on DSM-5
(2) Brief description of how client’s symptoms meet identified criteria
Provide a differential diagnosis
Discussion of comorbidity and similar mental disorders ruled out
Justification of primary and differential diagnoses: Copy the diagnostic criteria, in bold. Then write a very brief description of how this client’s symptoms meet these criteria.
· Example: “More talkative than usual or pressure to keep talking. Mr. B talks non-stop for the duration of the interview. He will not be interrupted by clinician. He talks in a tangential manner about the most recent basketball game.”
· Remaining questions, if needed: When referring to differential diagnoses, list questions you still have or information that you still need to acquire to be able to rule in or rule out these diagnoses. This may be the remaining diagnostic criteria that client has not yet met. There may be additional questions that you have.
· Provide V-codes
List questions you still have, or information needed to rule in or rule out these diagnoses
Identify and discuss 2 relevant assessment tools that could have used for diagnosis and evaluate progress of the client. Discuss strengths and weaknesses of the assessment tools including validity and reliability.
Discuss 2 empirically sound clinical interventions for the client. Please use the description below. Please consider the following
(1) In establishing your clinical work with your selected client, what models of therapy will you incorporate to gain a therapeutic alliance? Please consider their primary diagnosis and what is evidence based to support your approach.
(2) What special considerations, as the treating therapist, will you have to be mindful of in treating your client’s diagnosis? (Risk factors, risky behaviors, challenging behaviors comorbid diagnosis).
7. Developing a treatment plan. Please refer to your textbook.
(1) I hope goals and objectives are SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) for your client. Use the resource provided in class as a model to develop. From the case scenario, who would you include from the client’s life in developing this Safety Plan?
(2) With regard to the development of a solid treatment plan and client’s goals, how would you help develop short term and long-term goals for the client considering their limitations (cognitive, decision making, chronic condition)?
8. What questions would you want to raise with your clinical supervisor about this client that can help you be the best clinical social worker for them.


Diagnostic Case Study: Lucy Johnson
Institution Affiliation
Bio-Psycho-Social assessment
The client in question is Lucy Johnson, a 15-year-old 10th grader residing in Virginia's rural area. She lives with her mother, her elder sister Terry and younger sister Sally. Lucy's father resides in Florida is barely seen in Virginia. Her mother works at the hosiery. She also has a 19-year-old boyfriend, Joe.
Her leisure and fun activities include reading, cycling in the woods, swimming, and camping. Lucy is a happy, outgoing person who exhibits affection for her family and friends. She is a brilliant student and performs exceptionally in Math, science, and literature. Lately, she has manifested a change in character and ardent truancy and deteriorating performance in school.
Lucy has been going through challenges at home, which have subjected her to depression. She cannot enjoy her fun activities and appears to be in a foul mood for the better part of the day. The interview unearthed that Lucy bared the burden of worrying about her elder sister's welfare, her mother promiscuity, and financial instability, as well as her younger sister's somewhat wayward trends. Besides, she has started smoking pot with her boyfriend, Joe. The amalgamation of these elements has subjected her to a drastic change in behavior, which has had detrimental effects on her mental health.

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