Case Report Guide

1. Location of consultation
Hospital

2. Type of presentation
Emergency

3. Patient details
TC, male, 75

4. Presenting complaint
Passed out at home

5. HOPC
Patient just passed out when sitting in his house. This has happened several occasions before.

6. Past medical/ Surgical history

History of depression, affective disorder, schizophrenia, hypercholesterolemia, recurrent penile
candida, benign prostatic hyperplasia, backpain (secondary to secondary disc bulge and
narrowing of disc space), haemorrhoids

7. Medications/ Allergies
 Effexor (225mg)
 Zyprexa (10mg then 2.5mg)
 Rivanol (0.5mg)
 Inegy (simvastatin and ezetimibe) -10/20mg
 Omnexel prolonged release (400mg)

8. Family History

9. Social history
Retired. Used to work as security guard, psychiatry nurse
Alcohol (units per week)
Cigarettes
Living circumstances
Single

10. Relevant findings on clinical exam

Patient has a pacemaker inserted. On auscultation, ejection systolic murmur was heard loudest
at lower sternal area.

11. Patient’s perspective on illness

He thought that his depression may be due to failure to fulfil his ambition to become a dentist.

12. Interesting aspect of case

Patient was able to explain his condition very well as he used to work as a psychiatry nurse
before.