How to: Case Summary and Report

Dear all,

Here is a what was written in the study guides on how to write a case summary and how to write a case report.

Each Case Summary shall contain the following:

1. The Patient’s Initials (not full name)

2. The Registration Number

3. The Dates of Admission and Discharge (if relevant)

4. The Date of Clerking

5. A brief account (150 to 175 words) of the patient’s clinical problem, i.e. the relevant history, physical findings, provisional/differential diagnoses, investigations with results, treatment and the outcome.

6. Discussion of 2 to 3 learning issues relevant to that patient, under the 8 IMU outcomes. Note: transcribing materials from the textbook or other sources is not considered a discussion, and no marks will awarded for this.

The final documentation must be:

1. on size A4 paper, typed single-spaced using font size 11 or 12, Times New Roman

2. in about 300 words in total (1 page)

Marking: Each case summary shall be assessed on the following criteria, namely:

1. precise and relevant

2. the relevance of the issues discussed to the case

3. the explanation provided for issues discussed is clear

Each Case Report shall contain the following:

1. The Patient’s Initial (not name)

2. The Registration Number

3. Dates of Admission and Discharge (if relevant)

4. Date of Clerking

5. A detailed account of the case, including the provisional and differential diagnoses, investigations done (with results) and management (treatment and outcome)

6. Include a discussion on one or more issues under the IMU outcomes, relevant to the case

7. Include illustrations, where appropriate (photographs, charts, graphs, tables, ECGs, references etc)

The final documentation must be:

1. on size A4 paper, typed double-spaced using font size 12, Times New Roman

2. in not more than 2000 words, in total

Marking: Each case report shall be assessed on the following criteria, namely:

1. The case (history & examination) is well documented

2. The differential & final diagnoses are well discussed

3. The management strategy chosen is appropriate

4. Overall discussion (treatment, prognosis, follow-ups)

Loads of love and cheer,
Zia