Case Study #2: The Most Difficult Case: Involving a case where there was an unusual presentation or it was difficult to reach a diagnosis. The written report: The case study written report should include the following: Background Information: • Subjective Data: all relevant components, include in depth information related to Family and Social, particularly related to age group • Objective Data: Physical exam findings, test results, measurements • Assessment: Provide at least 5 differential diagnoses (sometimes you may have more) – explain why this dx was ruled-in or a potential dx or ruled-out; list the supporting evidence from the H&PE findings. Was one diagnosis was reached, what was it and why? Include at least two red flag items • Plan: Include rationale for the treatment plan.◦ Treatment: Including OTC or Rx medications, therapies, other care, include potential use of non-traditional therapies if they apply. Please discuss the different medications that might be considered for this diagnosis, and the pros and cons of each. Reference at least one research study, and at least one guideline. ◦ Management Plan to include diagnostic studies, procedures, etc if you are trying to rulein or rule-out potential diagnoses. ◦ Education: Health teaching, anticipatory guidance (often guided by Red Flag signs and symptoms) ◦ Follow-up, i.e. When to see client again or have phone contact; consider liability issues ◦ Referral- i.e. to an agency, specialist physician, etc, if applicable. Include rationale for the treatment plan. • Evaluation –What was the outcome? What did or did not work and what future care was projected/planned? • Identify whether or not there are clinical guidelines for the diagnosis reached, whether or not these were used to plan treatment. The written report should be no longer than 3 – 5 pages (single spaced)- you may list or bullet the Subjective and Objective findings instead of doing as paragraphs. References – 3 at a minimum: from a textbook, a guideline, and an article. Remember these are case studies to help you learn. Do not pick the easiest case study
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