NS5346 Advanced Health Assessment

A case report is a research design where an unusual finding or rare condition is described in a detailed report of clinical findings, clinical course, and patient prognosis supported by evidence-based literature. In this assessment you will undertake a modified version of a case report addressing the following,

1.Describe the differential/actual diagnosis and how it aligns to the patient history and physical examination 

2.Identify an actual clinical case that challenges your current skills and knowledge using ONE of the following scenarios as the basis of your case report,  

a.a disease aetiology unfamiliar to you,

b.a patient with an unusual clinical presentation,

c.a patient whose diagnosis of the illness/disease was challenging. 

PROCESS

Pre task

1.Obtain consent from your workplace to undertake this assessment task 

2.Secure a preceptor (senior clinical nurse/ educator or medical officer) to evaluate your competence.

3.Obtain consent from a patient to undertake a patient history and focused physical examination. Use the Mini-CEX form* to record the patient consent

4.Inform your workplace and patient that information gathered will be de-identified

Gathering Data

Once you have selected the case type and have selected your patient complete the following tasks

1.Complete a patient history through your preferred interview techniques

2.Conduct a focused physical examination (Mini-CEX). Your preceptor will evaluate your competence level using the Mini CEX form*

3.Collect other relevant information such as lab results, imaging, patient progress notes.