Case presentation and history
criterion
(~200 words) Case presentation and history
Focus question: What are the key features of the patient’s presentation? Details to include: – Summarises most important features of the clinical symptoms and any relevant additional history, co-morbidity, treatments. Appropriately chooses not to discuss data that are irrelevant to the condition of interest.
(~300 words) Clinical assessment
Focus questions: What does the information provided say? What is particularly notable? Details to include: – Accurately summarises all findings of neuropsychiatric assessments and clinical investigations. Results are presented in an order logical to the examining doctors and unremarkable findings are effectively abridged. – Draws particular attention to unusual or noteworthy results with comparison to normal values if appropriate. This is done without any diagnostic interpretation.
(~400 words) Provisional hypothesis
Focus questions: What is a hypothesised diagnosis for the patient? What information is missing for differential diagnosis or confirmation of diagnosis? Details to include: – Proposes one or more provisional hypotheses that can explain the relevant clinical results. The rationale for this hypothesis is explained logically with accurate reference to relevant literature but avoiding a dry recital of textbook knowledge. – Suggests (with reasons) where the patient could be on the clinical staging model – Highlights the limitations of the reported assessment techniques and the extent to which these constrain a differential diagnosis or formulation.
(~300 words) Additional investigations
Focus question: What other assessments would be most valuable for diagnosis and why these assessments? Details to include: – Suggests additional assessments/investigative techniques that could be included to better resolve the diagnosis. – Shows an understanding of their relative strengths in characterising the condition in question. – Describes at least one potential finding from each of these assessments that would convincingly focus the diagnosis onto a specific disorder.
(~300 words) Treatment plan
Focus questions: What evidence-based treatment would you recommend for this patient? Describe both the treatment and the evidence for it (what mechanism is it working on?) Details to include: – Recommends a treatment plan appropriate to the most likely diagnosis, clinical stage and to the progression of the condition. – Demonstrates a thorough understanding of how such strategies relate to the pathology as supported by current, peer-reviewed evidence.
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