Module: OPHTHALMOLOGY

UNIVERSITI KEBANGSAAN MALAYSIA

CASE WRITE-UP

STUDENT NAME:

MATRIC NO: YEAR / GROUP:

SUPERVISOR:

ASSESSMENT OF Ophthalmology:
Core Clinical Component

History /10 Prognosis & Outcome /5

Physical Examination /10 Case Summary /5

Investigation /5 Discussion /10

Diagnosis/Differential Diagnosis /5 References /5

Identify problems, management, and /5

progress of patient

Professionalism
Communication Issue /10 Reflection of the case:
Ethical Issues /5 -Lifelong learning /5
-Professional Judgment /5
Spiritual Issues / Complementary Medicine /5 Critical thinking /10

MARKS FOR CORE CLINICAL COMPONENT: /60

MARKS FOR PROFESSIONALISM COMPONENT: /40

OBSTETRICS AND GYNAECOLOGY

INTERNAL MEDICINE
 PATIENT IDENTIFICATION
DATA

Name: Age:

Gender: Registration Number: Race:

Religion: Marital Status: Occupation:

Informants:

Date of admission: Date of clerking:

MAIN COMPLAINTS/ REASON FOR REFERRAL:

HISTORY OF PRESENTING ILLNESS:

PAST MEDICAL HISTORY:

PAST SURGICAL HISTORY:

DRUG HISTORY

FAMILY HISTORY:

SOCIAL HISTORY:

PHYSICAL EXAMINATION
GENERAL PHYSICAL EXAMINTION

SYSTEMIC OPHTHALMIC EXAMINATION

SYSTEMIC EXAMINATION:

PROVISIONAL & DIFFERENTIAL DIAGNOSES:

(Discussion & supporting evidence)

OUTLINE RELEVANT INVESTIGATION DONE, WITH REASONS

STATE RESULTS OF INVESTIGATIONS DONE SO FAR, WITH YOUR

INTERPRETATIONS:
IDENTIFY PROBLEMS, MANAGEMENT, AND PROGRESS OF PATIENT

PROGNOSIS & OUTCOME

DISCHARGE/ CLINICAL SUMMARY:

DISCUSSION

LIST OF REFERENCES:
Please list a minimum of 3 recent articles pertaining to the above case.

1.

2.

3.

4.

5.____________________________________________________________________________

PROFESSIONALISM COMPONENT – REFLECTION OF THE CASE

1. COMMUNICATION ISSUES:

2. ETHICAL ISSUES:

3. SPIRITUAL ISSUES/ COMPLEMENTARY MEDICINE / CULTURAL ISSUES

4. REFLECTION OF THE CASES

CRITICAL THINKING