Written Case Reports

(Success Reports; Morbidity/Mortality Reports)

Format

Reporter:

Case History:

This is the case of (INITIALS), a (AGE)-year-old (SEX), who was admitted to (NAME OF HOSPITAL) for the (NO.) time on (DATE) for the chief complaint of (COMPLAINT).

(NARRATE HISTORY OF PATIENT'S PROBLEM OR CHIEF COMPLAINT.)

(Include only relevant data.)

(IF PAST, FAMILY, PERSONAL, AND MENSTRUAL HISTORY ARE NON-CONTRIBUTORY TO PATIENT'S CHIEF COMPLAINT, DO NOT INCLUDE THEM ANYMORE.)

Pertinent Physical Exam Findings on Admission/Referral:

• General condition:
• Vital signs:
• Head and Neck:
• Chest:
• Abdomen:
• Extremities:
• Others:

(Include schematic diagram as much as possible.)

(Include only pertinent positive and negative findings.)

Clinical Diagnosis:

(Reporter's clinical diagnosis based on above history and physical examination.)

(Give basis for diagnosis. Be specific. Be rational in supporting diagnosis.)

Paraclinical Diagnostic Procedures:

(Justify need, choice, and interpret findings.)

Treatment:

(Justify need and choice.)

Preoperative Preparations:

The Operation:

• Anesthesia:
• Position of patient:
• Prepped and draped:
• Incision (illustrate):
• Operative findings (illustrate):
• Operative maneuvers and procedures (illustrate):
• Drain or no drain (justify and specify type):
• Hemostasis:
• Irrigation or lavage:
• Correct sponge and instrument count:
• Wound closure or management (describe):
• Dressing:

  Summary of operations done:

Postop Course:

• Postop care
• Postop medicine
• When diet resumed
• When intravenous fluid discontinued
• Morbidity
• Management of morbidity
• Discharged/died
• Cause of morbidity/mortality
• Other relevant data

Follow-up care for nonmortality case (describe):

Final diagnosis (state):

Signature:

Date:

Written Case Reports as Learning Activities

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