Download Clinical case analysis and more Schemes and Mind Maps History in PDF only on Docsity! Clinical case analysis Case submission template 63 02 The Royal Australian College of General Practitioners Ltd Page 1 of 6 Date Participant name Patient Information Take care to avoid including any details that could identify the patient. Patient Information: Age Male Female Brief description of the initial presentation Include relevant sociocultural and occupational details. Clinical information gathering and interpretation History Focused, structured, appropriate to the patient’s presentation. Include all relevant information in note form. Physical Examination Focused, systematic and appropriate to the patient’s presentation. Include only relevant positive and negative findings in note form. Include the mental state examination findings, ( if performed). PEP Clinical case analysis rating The Royal Australian College of General Practitioners Ltd Page 2 of 6 63 02 Assessment and screening tools Include the outcomes of any assessment or screening tools used (for example Kessler Psychological Distress Scale or Mini Mental State Examination) Surgery tests performed and the results Investigations and results Refer to guidelines to ensure that testing is appropriate. Making a diagnosis, decision making and reasoning Using the ‘Murtagh’ diagnostic model as a guide. What is the most likely diagnosis and WHY? Outline in note form any other diagnoses considered and why. PEP Clinical case analysis rating The Royal Australian College of General Practitioners Ltd Page 5 of 6 63 02 What screening and prevention strategies did you implement for this patient, if any? Why? Were there any public health considerations? General practice systems and regulatory requirements General practice systems and regulatory requirements Were there any concerns or issues relating to patient confidentiality? Consider mandatory/voluntary reporting requirements. What did you need to take into consideration with regards to informed consent? Were there any ethical/medico-legal considerations for this case? Fitness to drive, medical reports, death certificate etc. Outcome What was the outcome of this case? PEP Clinical case analysis rating The Royal Australian College of General Practitioners Ltd Page 6 of 6 63 02 Reflections What are the 3 things that you have learnt from this case? References
