case study

Bert

You see Bert in an outpatient clinic as a favor to his husband, Ernie. Ernie is a psychiatric nurse practitioner and asked you to please conduct an assessment on Bert as a favor. Bert and Ernie have been married for five years, and during this time, Ernie has noticed some behavior that concerns him. Upon meeting you, Bert rolls his eyes, smiles, and says, "Only for Ernie would I do this."Bert is a 30-year-old White male who works as a manager at the local branch of a national bank.

Bert grew up with a loving mother and father, who passed away in a car accident when Bert was in college. Bert reports that he has never used drugs and drinks only socially. Bert has a younger sister, Abby, who lives across the country and whom he sees very little. Bert and Ernie

have a border collie named Grouch, and Bert is very involved with Grouch's dog agility training. There are no known medical issues.

Ernie says he's concerned because Bert often seems "down in the dumps." Bert agrees that he often feels sad and that during those times, he sleeps for only a few hours and then has trouble going back to sleep; he feels tired during the day. Bert reports that playing with Grouch helps his mood, but it seems that often, he feels "blah." Bert and Ernie agree that Grouch is a comfort during these times, but Bert feels guilty that usually, he can't muster the energy to practice agility with Grouch. The couple has noticed (and looks forward to) the times when Bert feels better, seemingly every couple of months. Ernie describes Bert as a "ray of sunshine" during those times. Bert states that he feels full of life and energy during these times. Bert reports that even Grouch enjoys

these times because the dog agility training is in full force.

Ernie gets very serious toward the end of your meeting and talks about how he and Bert are planning on adopting a child, but adoption agencies have expressed concern about Bert's mood. This finding has been devastating for the couple and is why they're here to see you today.

After reviewing the designated case, answer the following questions:

PLEASE USE DSM 5

1. Does the case meet the criteria for the DSM-5?

a. The justification should begin with “meets the diagnostic criteria for _____ as evidenced by...” with a clear description of the symptoms that warrant the diagnosis.

b. You will use specific information from the case to justify your diagnosis and match it to the diagnostic criteria. Each criterion that is met will be followed by details from the case that illustrates that criterion.

c. You also need to provide at least one z-code ("Other Condition that May Be the Focus of Clinical Attention) for the case.

2. What are the psychosocial issues facing the client?

3. What are the client’s strengths and resources?

4. What further assessment issues do you have with the client?

a. Include a brief rationale for the assessment that you’d like to do, followed by the specific areas of assessment that are based on the client's presentation of symptomatology.

5. What initial treatment goals do you have for the client? These treatment goals should be based on the literature and have an evidence-base, which means you need to reference the information that you provide here. They should also be specific to the case information and the diagnosis. For example, saying that the client will attend therapy sessions is too generic as this would be true for all the cases that we review.

Your case review is due by Saturday of this module. Plan to spend about 2-3 hours on this assignment. However, keep in mind that this is just an estimate and may take you more or less time depending on your grasp of the readings and content.

Before submitting your review, refer to the rubric for this assignment, which can be found below.

Rubric

Case Review Rubric

Case Review Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeDSM Criteria	2 to >1.5 pts A Diagnosis is complete and accurate. Justification is given for the diagnosis with clarity, accuracy, and depth. Appropriate z- codes are included. 1.5 to >1.0 pts B Diagnosis is complete and accurate. Justification is somewhat unclear or lacks depth of understanding or z- codes are missing. 1 to >0.5 pts C Diagnosis is incomplete or the justification is inaccurate or unclear, and z-codes are missing. 0.5 to >0 pts D/F Diagnosis is incomplete and the justification is inaccurate or unclear, and z- codes are missing.	2 pts
This criterion is linked to a Learning OutcomePsychosocial Issues	2 to >1.5 pts A Several psychosocial issues are accurately identified and written with clarity. 1.5 to >1.0 pts B Several psychosocial issues are identified but are somewhat unclear. 1 to >0.5 pts C One or two psychosocial issues are identified and written with clarity. 0.5 to >0 pts D/F Psychosocial issues are not accurately identified.	2 pts
This criterion is linked to a Learning OutcomeStrengths	2 to >1.5 pts A Several strengths are accurately identified and written with clarity. 1.5 to >1.0 pts B Several strengths are identified but are somewhat unclear. 1 to >0.5 pts C One or two strengths are identified and written with clarity. 0.5 to >0 pts D/F Strengths are not accurately identified.	2 pts
This criterion is linked to a Learning OutcomeFurther Assessment	2 to >1.5 pts A Several issues are identified for further assessment and written with clarity. 1.5 to >1.0 pts B Several issues are identified for further assessment but are somewhat unclear. 1 to >0.5 pts C One or two issues are identified for further assessment and written with clarity. 0.5 to >0 pts D/F Issues for further assessment are not accurately identified.	2 pts
This criterion is linked to a Learning OutcomeTreatment Goals	2 to >1.5 pts A Several initial goals are identified for the client and written in a clear, concise, specific, and objective manner. 1.5 to >1.0 pts B Several initial goals are identified for the client but are somewhat unclear, non-specific, or lack objectivity. 1 to >0.5 pts C One or two initial goals are identified for the client and written in a clear, specific, concise, and objective manner. 0.5 to >0 pts D/F Initial goals for the client are not accurately identified.	2 pts
Total Points: 10

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