Diagnosis evidence and reasoning

Case Study Format

There may be 2-3 diagnoses in each case.

No more than 2 pages maximum in addition to title page and references

Diagnoses = 20 points

Reasoning/evidence = 20 points; APA Format & Writing = 10 points

You want your case to be well organized and well written to be sure that the information you include is easily identified and followed by your reader. The following can be used as section headings to help you organize the paper:

· Brief overview of relevant symptoms from case

· Diagnosis 1

· Diagnosis 1 evidence and reasoning

· Diagnosis 2

· Diagnosis 2 evidence and reasoning


Brief overview of relevant symptoms from case

· Dylan, 15-year-old high school student

· Referred to psychiatrist for stress caused by car wreck

· Doesn’t sleep well due to accident

· Awakes in the middle of the night with heart racing, and visuals of oncoming headlights

· Have trouble concentrating

· Gets anxious when his parents proceed to drive out of the driveway or cross intersection

· Refuses to practice driving

· Short tempered with his family and friends

· becomes irritated when being asked about his stress

· poor performance in school

Additional symptoms after seeing psychiatrist:

· hated being jumpy around loud noises

· can’t escape the image of his injured and unresponsive friend

· angry at the other driver in the wreck

· feels embarrassed and disappointed for being reluctant to practice driving

· witnessed the near drowning of one his sisters

· during this time, it’s the anniversary of his grandfather’s death

List Diagnosis 1: (ICD & DSM diagnoses)

F 43.0 Acute stress disorder (Acute reaction to stress)

Diagnosis 1 Reasoning/Evidence

· recurrent dreams about the car wreck (awakes in the middle of the night from dreams about oncoming car head lights)

· irritable behavior; unable to concentrate (Short tempered with his family and friends; poor performance in school; doesn’t like to talk to his family about the wreck)

· difficulty falling and staying asleep (wakes up in the middle of the night)

· distressing memories about the wreck (walked out the movies because the sound was too loud; can’t escape vision of his injured and unresponsive friend


List Diagnosis 2: (ICD & DSM diagnoses)

F51.5 Nightmare disorder

Diagnosis 2 Reasoning/Evidence

· heart racing (often awakes in the middle of the night with his heart racing, visualizing oncoming traffic)