Case study: patient consultation, history taking and the completion of a physical assessment
The summative written case study (2500 words) is based on one patient case study. This will involve a patient consultation, history taking and the completion of a physical assessment,
and is reflective in nature. The medical model will be used and should include a history taking section and written physical examination section. Consultation models will be critically appraised, and one will be selected (e.g., Calgary-Cambridge model) to guide the structure of the assignment.
• Critically evaluate recognised consultation models, select and use a model to guide the health interview, obtaining subjective health data; including patient’s presenting complaint, history of present illness, past medical history, family medical history and social history.
• Document and synthesize subjective and objective health data within each body system, using appropriate medical terminology. Analyze positive/ negative findings recognizing any red flags and using clinical reasoning skills to explore possible differential diagnosis.
