Case Presentation and Discussion
Format

(Name of Student)

Case Presentation

Present Database

General Data

Minimum: Initials of patient, age, sex
As needed: Occupation, residence, religion

Chief Complaint
History of Present Illness/Condition
As needed:

Past Medical History
Personal Social History
Obstetrical and Gynecological History

Physical Examination

Case Discussion

Must include the following 4 parts:
I. Clinical Diagnosis
II. Paraclinical Diagnostic Procedures
III. Treatment
IV. Prevention and Health Promotion

I. Clinical Diagnosis

1. Identify data from database which can serve as cues for a clinical diagnosis.

Age/Sex
Symptoms
Signs

2. Based on pattern recognition and prevalence, decide on the primary and secondary diagnoses. Primary diagnosis is what you think is the most likely diagnosis and secondary diagnosis is the closest second.

Primary Clinical Diagnosis:
Secondary Clinical Diagnosis:

3. Illustrate/explain how you arrive to the primary and secondary clinical diagnoses.

Use the clinical diagnostic processes of pattern recognition and prevalence.
Use algorithm as much as possible.
Use pathophysiology to support your primary and secondary clinical diagnoses.

II. Paraclinical Diagnostic Procedures

1. Restate your primary and secondary clinical diagnosis.
2. Decide on whether you need a paraclinical diagnostic procedure or not.

If YES, why? If NO, why?
Use the processes of certainty and proposed treatment of your primary and secondary diagnoses as basis.

Certainty*

Treatment Modality

Primary diagnosis

Secondary diagnosis

*Place figures such as 10%, 50%, 70% certain and basis of certainty, whether based on signs, symptoms, and prevalence or just on symptoms and prevalence or just prevalence.
 **If you decide you don't need a paraclinical diagnostic procedure, proceed to TREATMENT.

3. If you decide to go for a paraclinical diagnostic procedure, select one from at least two procedures that may be done. Use the following table:

Benefit

Risk

Cost

Availability

Diagnostic Procedure 1

Diagnostic Procedure 2

4. After selecting one paraclinical diagnostic procedure, briefly describe how it is done and what will be the result that will firm up your diagnosis.
5. Present the paraclinical diagnostic procedure(s) that were done on the patient starting with the one that you are recommending. Then, interpret the results.

III. Treatment

1. State your pretreatment diagnosis - both primary and secondary.
2. State the goals of treatment for the primary diagnosis.
3. Decide on the treatment modality.

Benefit

Risk

Cost

Availability

Nonoperative

Operative

4. Decide how you evaluate the result or outcome of your proposed treatment.
5. If data are available, present the treatment procedures done on the patient and their outcome.

IV. Prevention and Health Promotion

1. State your final diagnosis.
2. Briefly describe how you will advice patient on prevention of the disease and health promotion.

Use pathophysiology.
Advice on screening.
Advice on early detection.

V. References

Evaluation Criteria:

BCCM