Clinical Reasoning Form A. Client 1. What is the client's main problem? 2. What are the client’s main functional limitations? 3. What are the client’s expectations/goals for the consultation? B. Potential Diagnosis 1. Are the subjective findings consistent with an injury/condition? 2. List 3 provisional diagnoses and the subjective features supporting each 3. Which contraindications exist for assessment & treatment? Specify. C. Examination findings & interpretation 1. Outline the features and results of the objective assessment 11. Which objective features support or negate any additional diagnoses? 13. What are the main functional limitations? 14. What psychosocial, attitudinal or belief factors are relevant? 15. What further subjective or objective techniques would further test your hypotheses? 16. Might imaging modalities be indicated for this case? Justify your answer. D. Management 1. Describe and justify the initial treatment and summarise its immediate effect 2. What are the short term goals with this client? Include timeframes 3. What techniques do you propose to achieve these goals? 4. What outcome measures do you propose to measure short term treatment effect? 5. What are the long term goals with this client? Include timeframes. 6. What techniques do you propose to achieve these goals? 7. What outcome measures do you propose to measure the long term treatment effect? 8. What input from other health professionals will be helpful? E. Prognosis / Discharge planning 1. List the factors that indicate a favourable prognosis 2. List the factors that indicate an unfavourable prognosis 3. What would constitute a successful treatment outcome for this client? Thank you!
