Wednesday, November 16, 2016


Do not choose your patients like you 
choose books from a bookshop!

 Do not write diagnoses like those shown above! Make sure your diagnoses reflect all the clinical information you have at that point.

The working diagnosis represents the information from history, physical examination and investigations. Where there is ambiguity, your diagnosis must reflect that uncertainty as shown in the diagnosis written on the right side.

The summary of your case report must be mix of both description and analysis. The introduction in your summary must reflect your understanding of your patient.

You can read below the summary written by a student. My comments are shown in italics.

The student introduces the patient and tells us about his presenting symptoms ............
Then the student tells us a little of the past history..........

Then a bit more of the past history and family history and then moves on to examination findings...

 More of the examination findings and then proceeds to inform the reader about the investigations....
More of the investigations is given, and then the reader is informed about how the patient was treated and what happened during admission.....

Critical evaluation of the above summary
The above summary is about an elderly man who has coronary artery disease, underwent coronary angioplasty with stent insertion many years ago, and then now presents with a myocardial infarction. The summary tells us how the patient presented, the initial error in the diagnosis and how the patient was treated, and how he responded to treatment. 

However, it does not tell us whether the patient has diabetes or hypertension or any renal disease. It does not tell us whether he needs to be referred for another coronary angiogram and why he was not given ACE inhibitors at the time of discharge. 

Please read how the same information has been rewritten into a summary with a lot more analysis and also see how the patient has been introduced......


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