Sample Case Reports

Sample Case Report

For the Counseling Intuition Exam, the following is a case report example:

Counselor: Roberta Jones, Charlotte, N.C.

Client Name: Elizabeth Smith
Age: 44
Presenting Problem: Depression related to long-standing marital distress, with physical and verbal abuse

Dates Seen: January 10, 2003; January 17, 2003; February 1, 2003

Counseling Technique used:
Natal and Marital Archetypal wheels with interpretation.

The client realized after these sessions that she was continuing a Rescuer and Victim role that has plagued her most of her life. She reported on February 15, 2003 that she had removed herself to a halfway house for abused women and was seeking a divorce.
I contacted her on October 19, 2003 for follow-up; she has completed her divorce and feels free of depression.

A copy of this form was sent to her for signature and returned.

Client Signature:
I agree that the above report is accurate.

Signed: Elizabeth Smith, 1708 S. Third Ave, Charlotte, N.C. 28201
October 22, 2003

Sample Case Report

The Medial Intuition Exam will consist of 40 cases which must be diagnosed using this format:

C. Norman Shealy, M.D., Ph.D.

DO EITHER A or B & C If you feel comfortable that you know the specific disease, JUST do A. Otherwise, give the location and the cause of the problem.

A. Specific Disease

B. Physical Location of significant disorder:

  1. Brain
  2. Head: eyes, ears, nose, mouth, tongue, teeth, sinuses
  3. Neck: thyroid, parathyroid, esophagus, bronchi
  4. Chest: heart, lungs, esophagus, aorta, ribs, breasts
  5. Abdomen: stomach, liver, spleen, pancreas, small intestine, large intestine, kidneys, adrenals
  6. Spine: cervical, thoracic, lumbar, sacral
  7. Pelvis: bladder, rectum, pelvic bones
  8. Reproductive organs: uterus, ovaries, fallopian tubes, vagina, external genitalia or prostate, testes, penis
  9. Legs: thighs, calves, feet
  10. Arms: shoulders, upper arms, hands
  11. Skin
  12. Immune system: deficient, allergies, acute or chronic infection, cancer, autoimmune, white blood cells, antibodies, lymph system
  13. Chemical system: electrolytes, general chemistry, neurochemistry, neurochemical, hormonal
  14. Electrical system: epilepsy, hyperactive, imbalanced
  15. Spinal cord
  16. Peripheral nerves
  17. Autonomic nervous system
  18. Blood vessels: veins, arteries, capillaries
  19. Systemic: non-specific, high blood pressure, generalized biochemical
  20. Skeletal: spine, skull, pelvis, arm, leg, ribs
  21. Muscular: specific muscles, generalized muscular
  22. Other – Describe

C. Type of disorder:

  1. Addiction
  2. Autoimmune
  3. Benign tumor
  4. Biochemical, metabolic
  5. Degenerative
  6. Electrical
  7. Endocrine
  8. Hematologic
  9. Hereditary/congenital
  10. Immunological
  11. Infectious: bacterial, viral, fungal, protozoan, amoebic
  12. Inflammatory
  13. Psychological/emotional/spiritual (experiences, traumas, personal issues) serious
  14. Malignant tumor
  15. Surgical
  16. Traumatic
  17. Vascular