Personal Case Formulation

Personal Case Formulation


Case Study    

Mr Sam Kwon is a 74-year-old man (Medical Record Number (MRN) 684421). He was brought in by paramedics with right-sided hemi-paralysis, aphasia and facial drooping. He has a history of hypertension, congestive cardiac failure, and type 2 diabetes mellitus.

He takes oral hypoglycaemic agents. He has also smoked a pack of cigarettes a day for approximately 40 years. His observations were as follows:

Temperature Heart rate Respiration rate Blood pressure SpO2
36.8°C 98bpm 24/per minute 140/105mmHg 96% (room air)


A CT scan without contrast suggested a probable left cerebrovascular accident, with increased density in the left middle and cerebral artery and possible early signs of oedema.

From these results, it is expected that Mr Kwon may also be experiencing homonymous hemianopia, but communication is difficult at this stage.

As he is aphasic he requires a communication board, however, he can answer with a head nod to closed questions.

Mr Kwon’s BGL is 9.4mmol/L. He has basal crackles and has been placed on oxygen at 2L/min via nasal prongs. A swallow review has been booked for today; meanwhile he remains nil by mouth.

The time of the incident is currently unknown as his family have been out since early morning and did not find him until late last night.

The team were unable to dissolve the clot. Mr Kwon requires q2h turns, he has an IV catheter in situ and is receiving crystalloid fluids. He also requires q2h BGL tests at this stage he is for review later today.

Task Details

  1. Analyse and interpret the assessment findings for Mr Kwon.

In this address and discuss each assessment findings of him and explain the pathophysiology behind this symptom associated with the brain injury happened in the left middle and cerebral artery and other diseases. Do not write the general pathophysiology or something. Just explanation associated with the case study and the symptoms pathophysiology.

You must have knowledge about the location of the artery in brain and what are the symptoms develop when any damage happened to that specific area.

Describe the signs and symptoms and behind the rationales about the signs and symptoms.

Regarding the connection between BGL and stroke in disease progression.

Why is having basal crackles (mainly associated with immobility or swallowing difficultly or chances of aspiration peumonia ) you have to explain more with a proper literature finding. Why is for review for swallowing (associated with CVA).

The time of incident is unknown. Family was out since early morning. The initial management of stroke was not established within the time frame as per the stroke protocols. So explain about the importance of door to needle time in stroke( which was nt happened on this case) so they cannot dissolve the clot(thrombolysis)

The writer needs to write in master level instead of writing in general. Please explain everything in detail.

Why he needs q2h turns (immobility and need change of position to prevent bed sore and pressure injury)

Why he is on specific iv fluids ( he cannot swallow, and he is nil by mouth) explanation. Literature about Stroke protocol are there for the iv fluids. Why he is on crystalloids? its used for stroke patient. I need clear explanation about that too.

  1. Based on your analysis and interpretation, develop an interprofessional care and management plan for Mr Kwan. In your plan, address:
    1. Ethical and legal implications
    2. Person-centred care
    3. Health promotion strategies.

I want a specific care management plan for the case study.

Address all the professional involved in his management plan and what they do to improve his health.

ROLES examples you can add more according to the case

Doctors, nurses, dietician, neuro psychologist, occupational therapist, physio therapists, psychologist, speech therapists, pharmacists

Explain this with your points you already mentioned by addressing as per the 3 same headings but it should be as interprofessional care management plan for Mr Kwan. As per Australian heath care system.


Support your plan with current evidence-based literature. I need around 18- 20 references minimum to support all the evidences.


Don’t worry about the discharge plan. Just write about two answers in the 2000 words limit.


  1. Over the next 14 days, Mr Kwon’s condition improves to a point where the doctor is happy to discharge him home.  His gait is steady and unaided, his speech has improved but still slurred. He has recovered some movement on his right side and it is likely a deficit will remain.  With this new information and your initial notes about his lifestyle/history, develop a discharge plan.  Complete the attached discharge plan form.

Justify your discharge plan decisions with reference to the literature.

Assessment Criteria

You will be assessed on your ability to:

  1. Identify and analyse key case findings and draw logical conclusions. (30)
  2. Develop and prioritise care strategies that flow from your analysis. (30)
  3. Explain your decisions in a clear and logical way. (20)
  4. Incorporate relevant ideas from the literature in your writing that support your argument. (10)
  5. Use academic English, grammatically correct sentences and APA style for references. (10)


0 replies

Leave a Reply

Want to join the discussion?
Feel free to contribute!

Leave a Reply