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  • Case Report Guide

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    Khai
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    Patient presented to Hospital / GP with a New problem / Follow up / Emergency. Interesting aspect of the Patient s perspective.

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    Patient presented to Hospital / GP with a New problem / Follow up / Emergency. Interesting aspect of the Patient s perspective.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    10 views1 page

    Case Report Guide

    Uploaded by

    Khai
    Patient presented to Hospital / GP with a New problem / Follow up / Emergency. Interesting aspect of the Patient s perspective.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Case Report Guide

    1. Location of consultation
    Hospital/ GP

    2. Type of presentation
    Routine/ New problem/ Follow up/ Emergency

    3. Patient details
    Initials, gender, age

    4. Presenting complaint
    One sentence only

    5. HOPC
    Details of PC
    Review of other symptoms associated with that particular system

    6. Past medical/ Surgical history

    7. Medications/ Allergies

    8. Family History

    9. Social history
    Occupation
    Smoking (cigarettes per day @ day x no. of years smoking)
    Alcohol (units per week)
    Illicit drugs
    Living circumstances
    Marital status

    10. Relevant findings on clinical exam

    11. Summary – 2,3 sentences

    12. Patient’s perspective on illness

    13. Interesting aspect of case

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