Reading Template ATSI Case


GENERAL INSTRUCTIONS

  • You have 15 minutes to the complete the tasks listed below for this case
  • You will have to manage your own time
  • A patient record summary is provided for your information
  • Perform the following tasks:
  1. Take a history from the patient.
  2. Explain your differential diagnosis to the patient.
  3. Explain which bedside tests and further investigations you would like to perform and why?
  4. Explore any other concerns the patient may have and counsel him appropriately.

PATIENT RECORD SUMMARY

Patient details

Name:         James Smith

Age:           58 years

Indigenous status:         Aboriginal

Allergies and adverse reactions

Current medications

Past history

Social history          Nil recorded

Family history         Nil recorded

Smoking                   Nil recorded

Alcohol                     Nil recorded

Immunisation and preventive activities

Nil recorded

SCENARIO

You are in a rural clinic. You have never met James before. He is of ATSI heritage.


Task ListPatient Problem List
>>> Rapport = Light social history <<<
Hx
DDx
Ix – bedside + formal
ICE
>>> Follow up and safety <<<
James 58yo male ATSI NFI
History (PRoMPF STOPI)DDx (PROMPT Model)
Presenting – SCR ODT EAS PT
RoS + Red Flags
Meds ? NKA
PHx
FHx
SHx
THx
O&G = ED, LUTS
Psych
Immunisation + Preventative
VINDICATED MEN
ExaminationInvestigations
XXXBedside
Formal
ManagementFollow Up & Safety Netting

Opportunistic immunisation, IHD, CKD, …
Manage Identified Issues
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