What are the essential components to include when writing a casesheet as a doctor?

How to Write a Medical Case Sheet: Essential Components and Structure

A well-structured medical case sheet should follow established guidelines like the SCARE checklist, which provides a comprehensive framework for documenting patient information, clinical findings, diagnostic assessments, interventions, and outcomes to ensure optimal patient care and clinical documentation. 1

Essential Components of a Medical Case Sheet

Title and Patient Identification

• Include a clear title that describes the focus area (presentation, diagnosis, technique, or outcome) 1
• Document de-identified demographic details including age, sex, ethnicity, and occupation 1

Patient Information

• Record the presenting complaint and mode of presentation (ambulance, walk-in, referral) 1
• Document past medical and surgical history with relevant outcomes from previous interventions 1
• Include medication history, allergies, psychosocial history (smoking, alcohol, drugs), and family history with relevant genetic information 1

Clinical Findings

• Document relevant physical examination findings systematically 1
• Include clinical photographs where relevant and with proper consent 1
• Record vital signs and pertinent positive and negative findings 1

Timeline

• Present the sequence of events in chronological order 1, 2
• Document any delays between presentation and intervention 1
• Consider using a table or figure to clarify complex timelines 1

Diagnostic Assessment

• Detail all diagnostic methods used (physical exam, laboratory testing, imaging, histopathology) 1
• Document diagnostic reasoning and differential diagnoses considered 1
• Include prognostic characteristics when applicable (e.g., tumor staging) 1
• Record diagnostic challenges encountered (access, financial, cultural barriers) 1

Therapeutic Intervention

• Describe pre-intervention considerations and patient optimization measures 1
• Detail interventions performed (pharmacologic, surgical, etc.) and reasoning behind treatment choices 1, 2
• For surgical cases, include specific details on anesthesia, positioning, equipment, and techniques 1
• Document the operator's experience level and any modifications to standard approaches 1

Follow-up and Outcomes

• Report clinician-assessed and patient-reported outcomes with specific time periods 1
• Document complications or adverse events in detail, including how they were managed 1
• Include future surveillance requirements when applicable 1

Example Scenario: 45-year-old Male with Acute Appendicitis

Title and Patient Identification

Case Report: Acute Appendicitis with Peritonitis in a 45-year-old Male

• Patient: 45-year-old male, Caucasian, office worker, BMI 27 1

Patient Information

• Presenting Complaint: Patient presented to Emergency Department with 24-hour history of right lower quadrant abdominal pain that began periumbilically, associated with nausea, vomiting, and anorexia 1
• Mode of Presentation: Self-referred to Emergency Department 1
• Past Medical History: Hypertension (diagnosed 5 years ago), well-controlled on medication 1
• Past Surgical History: Tonsillectomy at age 12, no complications 1
• Medication History: Lisinopril 10mg daily 1
• Allergies: No known drug allergies 1
• Social History: Non-smoker, occasional alcohol consumption (2-3 drinks weekly), no recreational drugs 1
• Family History: Father with history of colon cancer at age 65 1

Clinical Findings

• Vital Signs: Temperature 38.2°C, HR 102/min, BP 135/85 mmHg, RR 18/min, SpO2 98% on room air 1
• Abdominal Examination: Tenderness and guarding in right lower quadrant, positive rebound tenderness, positive Rovsing's sign 1
• Other Systems: Cardiovascular and respiratory examinations unremarkable 1

Timeline

• Day 1,8 AM: Onset of periumbilical pain
• Day 1,6 PM: Pain migrated to right lower quadrant, developed nausea and vomiting
• Day 2 AM: Presented to Emergency Department
• Day 2,4 AM: Laboratory and imaging studies completed
• Day 2,8 AM: Surgery performed 1, 2

Diagnostic Assessment

• Laboratory Studies: WBC 15,500/μL with left shift, CRP 85 mg/L 1
• Imaging: Abdominal CT scan showed inflamed appendix (11mm diameter) with surrounding fluid and fat stranding 1
• Differential Diagnoses: Acute appendicitis, mesenteric adenitis, cecal diverticulitis, terminal ileitis, ureterolithiasis 1
• Final Diagnosis: Acute appendicitis with localized peritonitis 1

Therapeutic Intervention

• Pre-operative Management: IV fluids (normal saline 1L), IV antibiotics (ceftriaxone 2g and metronidazole 500mg) 1, 3
• Surgical Procedure: Laparoscopic appendectomy under general anesthesia 1
• Operative Findings: Inflamed, gangrenous appendix with localized purulent fluid in right iliac fossa 1
• Technical Details: Standard three-port technique, appendix base secured with endoloop, specimen removed in retrieval bag 1
• Post-operative Care: Continued IV antibiotics for 24 hours, then oral antibiotics for 5 days 1

Follow-up and Outcomes

• Hospital Course: Uneventful recovery, discharged on post-operative day 2 1
• Histopathology: Confirmed acute suppurative appendicitis with transmural inflammation and early gangrene 1
• Follow-up Visit: Two weeks post-discharge, patient fully recovered with well-healed wounds 1
• Complications: None 1

Common Pitfalls to Avoid

• Disorganized Documentation: Always present information in a logical, chronological order to avoid confusion 2
• Incomplete History: Ensure all relevant past medical, surgical, and medication histories are documented 1
• Inadequate Physical Examination: Document all pertinent positive and negative findings 1
• Missing Differential Diagnoses: Always include your diagnostic reasoning and alternatives considered 1
• Poor Documentation of Interventions: Detail all treatments provided and their rationale 1
• Lack of Follow-up Information: Document outcomes and any complications that occurred 1
• Omitting Patient Perspective: When appropriate, include the patient's perspective on the treatment received 1