CASE REPORT

Patient Initials: Student Name and ID: Hospital No: Age:

No: Gender:

Prior information
Selected information available to you at the start of the consultation

History
All relevant information gathered from the patient about the presenting illness, co-existing problems, current treatment, significant past medical history and the social and family background. The patients view of the nature of the problem and their expectations for treatment.

Analysis of history
The most likely single cause of the presentation, other possible causes and reasons for these choices. The selected signs looked for on examination to help decide the cause.

Examination
All findings from the selective examination, positive and negative

Analysis of features in the history and examination

Reasons for your choice of the cause of the patients problem(s) and any other cause that still needs to be considered at this stage

Formulation of the patients problem(s)

Encapsulate this in physical, psychological and social terms (the triple diagnosis)

Management

Outcome
A description of the progress of the patient as far as possible. This should include consideration of further issues to be resolved. Where appropriate you should contact by telephone patients if you do not seen them at a subsequent consultation

Evidence based care and issues for research

A consideration of the evidence base that supports the diagnosis and management of the patients problem(s)

Commentary
A commentary on issues of health care delivery, ethical issues or disability relevant to the patient and/or problem

Impact on your learning

Describe what you have learnt from this case and how this will affect your future learning