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Sample Case
Report
Sample Medical
Diagnosis
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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.
Outcome:
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
Date:
October 22, 2003
Sample Case Report
The Medial Intuition Exam will consist of 40 cases which must be diagnosed using this format:
CRITERIA FOR MEDICAL DIAGNOSES
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:
- Brain
- Head: eyes, ears, nose, mouth, tongue, teeth, sinuses
- Neck: thyroid, parathyroid, esophagus, bronchi
- Chest: heart, lungs, esophagus, aorta, ribs, breasts
- Abdomen: stomach, liver, spleen, pancreas, small intestine, large intestine, kidneys, adrenals
- Spine: cervical, thoracic, lumbar, sacral
- Pelvis: bladder, rectum, pelvic bones
- Reproductive organs: uterus, ovaries, fallopian tubes, vagina, external genitalia or prostate, testes, penis
- Legs: thighs, calves, feet
- Arms: shoulders, upper arms, hands
- Skin
- Immune system: deficient, allergies, acute or chronic infection, cancer, autoimmune, white blood cells, antibodies, lymph system
- Chemical system: electrolytes, general chemistry, neurochemistry, neurochemical, hormonal
- Electrical system: epilepsy, hyperactive, imbalanced
- Spinal cord
- Peripheral nerves
- Autonomic nervous system
- Blood vessels: veins, arteries, capillaries
- Systemic: non-specific, high blood pressure, generalized biochemical
- Skeletal: spine, skull, pelvis, arm, leg, ribs
- Muscular: specific muscles, generalized muscular
- Other - Describe
C. Type of disorder:
- Addiction
- Autoimmune
- Benign tumor
- Biochemical, metabolic
- Degenerative
- Electrical
- Endocrine
- Hematologic
- Hereditary/congenital
- Immunological
- Infectious: bacterial, viral, fungal, protozoan, amoebic
- Inflammatory
- Psychological/emotional/spiritual (experiences, traumas, personal issues) serious
- Malignant tumor
- Surgical
- Traumatic
- Vascular
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