Long case structure and its components and summary

StructureL ong case structure and conponents

1. MD Medicine Dr. Sudheera Fernando
General introduction
- Age
- Town – distance to hospital
- About patient to get an
impression whom I’m presenting



PMH:
DM
HT
IHD
Renal disease
Liver disease
TB
Malignancy history
Not to miss
1. History of fall
2. History or contact of TB
3. Myopathy
4. Anaemia
5. Osteoporosis
6. ICU admission
7. Erectile dysfunction
Investigations not to missed
1. CT
2. Endoscopy –
broncho/UGIE/LGIE/ERCP
3. Biopsy – bone
marrow/skin/liver/kidney/other
Presenting complain:
Should be clear and short



PSH:
LRT
LSCS
TAH
any other
Allergies:
Drug
Food
Plaster
For female:
Menarche/menopause
LRMP
IUCD
History of presenting complain





Family history:
DM/HT/IHD
Sudden death
Young disease
Malignancy
Vaccinations:
specially in immunocompromised
and splenectomy patients
- Pneumococcal
- Influenza
- HIB
Travel history:
Foreign
Endemic areas
Risk sexual behavior
IV drug abuse
Disease progression in
chronological order
- Onset
- Duration
- Diagnosis
- Outside investigations
- Relapses
- Hospital admission – No
- ICU admission
- Treatment/ Special drugs
- Compliance
- Insight of the disease
Drug history:
- OHD/Insulin
- Antihypertensive
- Ca
2+
supplementation
- PREDNISOLONE
- THYROXINE
- Other immune suppression
- ALENDRONATE/ annual
bisphosphonate
- Iron treatment
- WARFARIN

Social history:
- Activity of daily living
- Barriers
- Care givers
- Depression/ psychological
- Education level
- Financial/income
- Sexual habits/risks
- Habits – smoking/alcohol
- Insight
- Compliance/ concerns
- Expectations

Special investigations:
ANA/RF
HRCT
Angiogram - Retroviral screening
MRI
EEG
U1RNP
Lung function test
X-rays
Echocardiogram
Fluid aspiration –
pleural/joint/abdomen