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files (2)AppendixK_CasePresentationForm.pdf
kellycase1.docx
AppendixK_CasePresentationForm.pdf
Graduate School of Professional Psychology University of St. Thomas APPENDIX K: CLINICAL CASE PRESENTATION FORMAT - Option #1
You are required to delete/remove ALL identifying information about a client from the case description and recording sample. Your instructor may require you to play a segment of the counseling session during the case presentation. Client description: In most cases, include the client’s age, race, ethnic background, gender, sexual orientation, and relationship / marital status. Include other information only if it is relevant to the case and to your questions about it. However, be aware of the need to preserve the client’s confidentiality. Consider carefully whether the client could be identified by what you disclose. Examples of other potentially relevant information include: psychiatric medications, ability/disability, occupation, education, religious affiliation, family constellation, medical issues, and previous treatment. You may have additional information available in the event that it is requested by your faculty practicum instructor/consultant or colleague. Presenting and other identified problems, clinical impressions, diagnosis: This section includes both the client’s conceptualization of his or her or their concerns as well as yours. Your interpretations of the dynamics you observe could be included. Background / history: Provide a brief summary of the client’s significant life experiences and his or her or their feelings / responses to them. This section might include information about abuse or other traumatic experiences; chemical use or abuse; social history and support system; and family history, as well as other pertinent history. Summary of treatment to date: Describe the issues that have been addressed with this client, any interventions you have made, and your assessment of their effectiveness. You must also complete a Treatment Plan associated with this client; use the Minnesota Universal Outpatient Mental Health-Chemical Health Authorization Form. Goals, objectives, and strategies: List the general, agreed upon goals, the related objectives identified by you and the client, and any strategies you’ve developed to achieve them. For example, a goal may be for a given client to have better relationships with people in authority at work. An objective could be to respond to criticism with more openness and less defensiveness and dread. A related strategy might be to actively solicit feedback about work performances. Your goals for this consultation / supervision: Identify the specific questions or issues about which you would like to receive feedback. Be aware that it is not uncommon for a faculty practicum instructor/consultant and/or colleagues to raise additional issues that you may not have identified. Additional information: Include anything that you believe is relevant that does not fit easily into any of the other sections. Your impressions of the client’s responses to you, your personal responses to the client (transference and counter-transference), client’s strengths and limitations, etc.
See next page for a different option to complete this assignment
APPENDIX K: CLINICAL CASE PRESENTATION FORMAT - Option #2 You are required to delete/remove ALL identifying information about a client from the case description and recording sample. Your instructor may require you to play a segment of the counseling session during the case presentation.
Background Information Client description: In most cases, include the client’s age, race, ethnic background, gender, sexual orientation, ability/disability, and relationship status. However, be aware of the need to preserve the client’s confidentiality. Consider carefully whether the client could be identified by what you disclose. Include other information only if it is relevant to the case and to your questions about it. Examples of other potentially relevant information include: occupation, education, religious affiliation, sexual orientation, family constellation, medical issues, and previous treatment. Have additional information available in the event that your faculty practicum instructor/consultant or colleague requests it. Presenting and other identified problems This section includes the client’s view of his or her concerns. History: Provide a brief summary of the client’s significant developmental experiences and his or her feelings/responses to them. This section might include information about abuse or other traumatic experiences; chemical use or abuse; social history and support system; and family history, as well as other pertinent history.
Conceptualization
Clinical impressions, cultural formulation, diagnosis: In your conceptualization, describe your understanding of the client’s presenting issue within the client’s cultural context. Begin using relevant theory or empirical resources to frame your understanding. Reflections: In this section, include your impression of your client’s responses to you, personal responses to the client, and moments between you two that you thought impacted the therapeutic process.
See next page for more information about Option #2
APPENDIX K: CLINICAL CASE PRESENTATION FORMAT
Option #2 (continued)
Treatment Planning List the general, agreed-upon goals, the related objectives identified by you and the client, and any strategies you’ve developed to achieve them. For example, a goal may be for a given client to have better relationships with people in authority at work. An objective could be to respond to criticism with more openness and less defensiveness and dread. A related strategy might be to actively solicit feedback about work performances. Goals: Expected Outcome & Prognosis* ☐ Return to normal functioning ☐ Relieve acute symptoms, return to baseline functioning ☐ Expect improvement, anticipate less than normal functioning ☐ Maintain current status/prevent deterioration Treatment Objectives* For each objective, provide the following information:
• Measurable Objective: • Intervention/Method/Strategy for Achieving Objective • Progress to Date: N-New Objective, 1-Much Worse, 2-Somehwat Worse, 3-No Change,
4-Slight Improvement, 5-Great Improvement, R-Resolved • Resolution Date (if applicable)
Consultation Goals
Identify the specific questions or issues about which you would like to receive feedback. Be aware that it is not uncommon for a faculty practicum instructor/consultant or colleagues to raise additional issues that you have not identified. *Format follows Minnesota’s Universal Outpatient Mental Health/Chemical Health Authorization Form
kellycase1.docx
CHIEF COMPLAINT: Patient is a 14 yo. female who presents today for evaluation of possible eating disorder.
HISTORY OF PRESENT ILLNESS:
Kelly presents today with her mother, I had the opportunity to speak with the patient alone and then with their parent alone. We then came together at the end of today's assessment to discuss findings and recommendations.
Kelly states she wanted to change her body shape and size about 3 months ago. Her mother states she started talking about how specific foods with make her "fat" several months ago, but was still eating. About 3 mo ago, she started restricting her intake. She started avoiding sugar and didn't have cake on her birthday or her mom's birthday. There are more arguments around food at home. She has lost ~15# in 3 months.
Kelly states she is feeling tor-"I don't want my organs to shut down like my mom says they will, but I also don't want to eat more and gain weight". Kelly hasn't had a period in 2 months.
Kelly has been struggling with depression. She was seen in the ER in March 2022 for suicidal ideation, but was discharged. Mood has been improved since starting sertraline.
EATING BEHAVIORS:
Overeating/Emotional Eating/Binge Eating: Maybe once or twice recently
Purging: No
Chewing and spitting: No
Restricting food/under-eating: restricting intake
Vegetarian/Vegan: No
Compulsive or excessive exercise: 3-4/wk for 40-50 min. Motivated by wanting to lose more weight.
Diet pills/supplements/weight loss programs: No
iding Food: No xcessively Picky Eater: No axative use: No
ercent of the day the patient spends thinking about food, weight and/or body image: 50-74%- should you really eating this? Maybe you shouldn't eat all of this?
NEIGHT HISTORY:
Surrent weight:. 44.5 kg (98 lb 1.7 oz) (25 %, Source: CDC (Girls, 2-20 Years))
Current height: 1.661 m (5' 5.39" (79 %, Source: CDC (Girls, 2-20 Years))
Highest weight: 112 lb on 3/30/22.
Lowest weight: 98 lb current.
PAST MEDICAL HISTORY:
Past Medical History
Problem List
PAST HOSPITALIZATIONS/SURGERIES/MEDICAL ILLNESSES:
Past Surgical History
CURRENT MEDICATIONS:
Depression. Taking sertraline with improvement in symptoms.
Psychiatric hospitalizations: No. ER visit for SI 3/2022.
Self-harm: N
Suicide attempts: N
Columbia - Suicide Severity Rating Scale (C-SSRS) Score
Wish to be dead
1. In the past month, have you wished you were dead or could go to sleep and not wake up?
Yes
Suicidal Thoughts
2. In the past month, have you had any actual thoughts of killing yourself?
No
Suicide Behavior
6. Have you ever done anything, started to do anything, or prepared to do anything to end your life?
No
Risk Score: LOW
Risk Assessment
Risk Factors: History of mental health diagnosis and Anorexia nervosa (vs other eating disorder diagnosis)
Protective Factors: Family and community support and Close observation by family or friends
Suicide Risk Summary
Based on the patient's current responses to the C-SSRS, risk and protective factors, and current mental status exam, suicide risk is deemed to be: LOW. The following actions have been taken: Crisis intervention numbers were provided.
FAMILY HISTORY:
Mother with hx of depression and anxiety. Father with history of anxiety. Sister with history of depression and anxiety.
Family history of depression, anxiety, bipolar affective disorder, other mental illness, alcoholism, drug abuse, suicide attempts or eating disorders is otherwise negative.
SOCIAL HISTORY:
Kelly lives with her parents and older sister in MN. She is close with her family. She will be going into 9th grade- she is anxious about going to high school. She attended a small middle school- 11 students, rigorous. Mom states she would compare herself- not smart enough, not thin enough. She plays the violin.
Mom works at OT in a school
History of Legal Problems: no
Religious or spiritual beliefs impacting service preferences: n/a
Alcohol: N
Tobacco: N
Drug use: N
Caffeine: N
REVIEW OF SYSTEMS: Please see scanned intake form.
Menstrual history:
Patient's last menstrual period was 05/25/2022 (approximate).
12/2022 09:20 Progress Notes Initial Evaluation
Height: 166.1 cm (5' 5.39")
Weight: 44.5 kg (98 lb 1.7 oz)
Estimated body mass index is 16.13 kg/m? as calculated from the following.
Height as of this encounter: 1.661 m (5 5.39").
Weight as of this encounter: 44.5 kg (98 lb 1.7 oz).
GENERAL: Patient alert and oriented, in no acute distress. Cooperative throughout examination.
SKIN: Clear, warm, dry. No rashes. No suspicious lesions.
HEENT: Atraumatic, normocephalic skull. PERRLA. Oropharynx clear. No exudates. Dentition satisfactory.
NECK: Supple, without adenopathy or thyromegaly. No parotid or submandibular gland enlargement noted.
HEART: Regular rate and rhythm. Normal S1/S2. No murmurs, clicks, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally. Normal effort, No wheezes, rales, or rhonchi.
ABDOMEN: Soft, nontender, active bowel sounds, no hepatosplenomegaly or other masses. Nondistended.
EXTREMITIES: No lower extremity edema. No acrocyanosis. Hands and feet warm to touch. Well formed. Moves all extremities equally.
NEUROLOGIC: No focal neurologic deficits. Normal gait.
PSYCHIATRIC: Alert and oriented × 3. Speech volume and pat§r normal. Thought processes coherent and logical.
Normal insight. Judgment intact. No suicidal or homicidal ideations.
EKG: Tracing from today was performed and was independently reviewed. It showed a HR of 66 bpm and QT interval of 419 msec. The EKG was read as: NSR, early repolarization
LABORATORY: Labs ordered and results are pending
ASSESSMENT:
Anorexia nervosa, restricting type - restriction of intake and ~15# with loss over the last 3 mo. Discussed with pt's mother it is very positive that it was caught so early. Pt has some insight into the dangerous results of restricting intake and wants to avoid these on some level.
Discussed outpatient FBT as the treatment recommendation. Overview provided, signed up for Jumpstart for tonight. If not making progress, will consider HLOC, however parent seems capable and quite motivated to engage in FBT..
Secondary amenorrhea
Depressive disorder
PLAN:
Patient will be admitted to the Park Nicollet Melrose Institute eating disorder treatment programs in level OP.
Patient is considered to be medically compromised, but stable today and interventions will be directed to medical stability monitoring, reduction of eating disorder symptoms, and it improved nutrition. Education regarding medical complications of eating disorders will be provided for the patient, family, and/or support individuals.
Outpatient eating disorder treatment with medical doctor, registered dietitian, and licensed psychologist is recommended for the purpose of medical monitoring, nutrition counseling, and psychotherapy. Goals of curriculum based treatment program include weight restoration, weight stabilization, symptom interruption, medical stabilization, nutrition education, stabilization of eating patterns, and education with family.
Social History:
The patient currently lives with mother, father, and sister.
The patient is currently employed: No. Will be a freshman at Roseville HS
Food and Security
Within the past 12 months, were you worried that your food would run out before you had money to buy more? No Within the past 12 months, has food you purchased run out and you didn't have money to get more? No Barriers to Recovery: None
Weight History/Patterns: May started reducing the amount of food she was eating each day and exercising more ofte cut back on sugar based foods
"Did not want to be obese"
Was weighing self 1-2 times per day
Does not currently have access to a scale
Current Height and Weight:
08/01/22: 1.661 m (5'5.39") (79 %)*
* Growth percentiles are based on CDC (Girls, 2-20 Years) data.m
GOALS OF TREATMENT:
Medical stabilization: Yes
Weight restoration: Yes
Weiaht stabilization Yes
Allergies
Problems imm/inj/.
7/12/2022 09:20 Progress Notes Initial Evaluation
Symptom interruption: Yes
Nutrition education: Yes
Stabilization of eating patterns: Yes
Education with family: Yes
CONSULTATIONS:
Psychiatry: For evaluation of psychiatric comorbidities and use of psychotropic medications No
Physical therapy: PT consult for Evaluation of physical performance, functional limitations and exercise instruction with home program: No
Occupational therapy: For evaluation of life skills and safety: No
Chemical Dependency: For Substance abuse issues: No
This plan was discussed with the patient and her family (mother), who verbalized understanding.
Melrose Medical Doctor IT Objectives/Interventions
This patient is considered to be medically compromised, but acutely stable today and interventions will be directed to medical stability monitoring, a reduction of eating disorder symptoms and improved nutrition. Education regarding medical complications of eating disorders will be provided for the patient, family and support individuals".
Total time 90 min spent obtaining comprehensive history, performing exam, preparing plan of care, counseling/educating patient, coordinating care and documenting today's visit.
Diagnoses:
1. Anorexia nervosa, restricting type
2. Depressive disorder
Other mental health diagnoses: N/A
Target problems/ Symptoms/Needs as identified in DA:
Eating Disorder Symptoms: restricting and compulsive and excessive exercise
Psychiatric Symptoms
Depression: sad and low energy
Anxiety: Worry
Risk Factors: N/A
Needs/vulnerabilities: N/a
Strengths: Engaged in school, Good family/social support system, Has access to treatment, and Treatment compliant
Patient's identified recovery goals): "I want to eat on my own with my friends which means I need to change my whole mind set"
Goals: Expected Outcome & Prognosis:
Return to normal functioning
Treatment Plan Objectives: (List objectives directed at reducing symptoms and impairment in functioning, need to be measureable.)
Eating Disorder
GOAL
OBJECTIVE
INTERVENTION
IRAFTIAR
Target Resolution
S
Goals: Expected Outcome & Prognosis:
Return to normal functioning
Treatment Plan Objectives: (List objectives directed at reducing symptoms and impairment in functioning, need to be measureable.)
Eating Disorder
GOAL
Target Resolution
Date
8/22/2023
Eating Disorder.
Exercise in moderation
OBJECTIVE
INTERVENTION
METHODS
Objective: Patient will
CBT-E and FBT
eat three (3) meals and three (3) snacks per day. Patient will identify three (3) coping skills for ED triggers/symptom urges. Patient to
complete self-monitoring record to assist in identifying triggers fas eating disorder symptoms. Patient will discuss triggers for Symptom use and identify coping skills at leach session.
Treatment Details.
Type of Service (duration): 90834 Psychotherapy 45 minutes
Frequency: Weekly W
Duration of Treatment: 5 months
Family/Support System Involvement: Family/Support System will be involved in treatment: Family sessions.
Session 1 as family session
Group guidelines were reviewed, including confidentiality. Verbal consent was obtained.
Skills/ Strategies/ Topics discussed: This one time group therapy session focused on introducing parents to Family-Based Treatment (FBT. Didactic portion focused on educating parents about eating disorders, FBT, and the concept of agnosticism. Charged parents with task of refeeding and recommended goal of 3 meals and 3 snacks. Addressed common questions such as "What?" and "How much?" to feed my child. Explained and encouraged monitoring of meals and other ED behaviors. Broadly explained treatment goals, with a focus on weight restoration and WR. Covered considerations in parents preparing for and prioritizing FBT at home, including work, school, and mobilizing support systems. Questions and concerns were addressed.
Objectives met per I TP: Increase parental skill use and increase support.
Participation: Shares information, shares emotions, listens to others, gives feedback, accepts feedback.
Session #
Assessment and Plan:
1. Anorexia nervosa, restricting type - weight is up almost a pound.
Continue providing 3 meals and 3 snacks. Discussed needing to increase pt's overall intake- pt's mom is looking forward to RD appt this week to get more guidance. Encouraged pt's mom to ask husband for support.
1. Secondary amenorrhea - expect resumption with weight restoration.
2. Depressive disorder
The following plan was discussed and agreed upon with the patient:
. Continue to work on developing and utilizing healthy coping skills and moving away from the eating disorder.
•Encouraged pt to follow up with all treatment providers
Follow up with psychiatry for ongoing medication management
. Continue to update team as needed.
.. Follow up in 1-2 weeks, or sooner prn.
Total time 32 min spent reviewing previous labs, reviewing provider notes from multidisciplinary team, performing exa preparing plan of care, counseling/educating patient, coordinating care and documenting today's visit.
Session #
VISIT:
Kelly is here with her Mom, Sara today for FBT. Met with Sara individually and she reports things are going well at home. Some resistance to specific foods (I.e. yogurt) but eventually she is eating. She has a call into the school to figure out where Kelly can eat lunch and last week they did a tour of the school. Mom shared it may be difficult to make future appointments at the MG location once school starts due to the commute and video visits don't work. Expressed my concern with the lag time of school starting and Kelly not starting with her new therapist until November. Mom said she would look at their schedule and see if there is anything they could do.
Met with Kelly and she denies restricting but admits the urges are very big right now. Her ED thoughts are heightened when she eating and then "screaming" at her afterwards. Unable to identify specific thoughts. Discussed coping skills to begin reframing her thoughts. Also using distraction at when she is eating with music, tv, conversation, etc. Encouraged her to track her thoughts at least once per day so we can begin to counteract/reframe.
PRESENTING PROBLEMS/SYMPTOMS:
She presents with Anorexia Nervosa (AN). Symptoms include restricting and over-focus on shape/weight.
MENTAL STATUS EXAM:
Mood: anxious
Affect: mood-congruent
Appearance: age appropriate
Tonic Scores:
Melrose Tonic last three scores:
8/22/2022
Session #
Patient's progress in treatment:
Weight increase - weight remains stable. Within 1# of GW. Discussed adding more consistent snacks daily to increase caloric intake or increasing portions at meals.
Restricting: Frequency -- mom continues to plate/portion meals. Options are given to patient for snacks generally.
Adhering to meal plan - 3 meals/1-2 snacks.
Eating Disorder thoughts - patient shared she no longer wants her eating disorder and noticed a decrease in thoughts " a couple of months ago". Reported she no longer sees the benefit of it and it takes too much to maintain.
Poor body image
Patient's response/participation in today's session: Patient was engaged in session.
Family's response/participation in today's session: Mom shared progress since starting treatment, in phase 2. Shared hopes for patient and places in which patient may be struggling.
Family's support plan: eating meals together and cooking, prepping, serving meals
Patient's Treatment Goals: Increase regular or scheduled eating patterns
Weight increase
Improve readiness and commitment to treatment
Increase effective use of coping strategies
Decrease eating disorder thoughts
Express thoughts and feelings
Maintain progress in recovery from eating disorder
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