Haiguslugu gastroenteroloogias 4



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Academic Case History 27.02.2017

6. Course of Disease (Decursus morbi)

The student must summarize the period during which he/she clinically observed the patient. Decursus morbi is to be presented as dated journal entries. If necessary, charts for monitoring changes in temperature, blood pressure, diuresis and fluid volume are submitted.


7. Clinical Diagnosis

The student will present the clinical diagnosis which is based on gathered clinical information: anamnesis, objective examination, the results of laboratory and instrumental examination. Disease severity and other specifications traditionally included in the diagnosis or specifications arising from the nature of the subspeciality have to be mentioned. Students must explain in detail why that particular form of disease can be diagnosed, which clinical facts support it and how to assess the severity of the disease. It is important to use medical literature when providing explanations. Describe any diagnostic contradictions that might occur and provide an explanation for test results which do not support the final clinical diagnosis. Students should also elaborate why the aforementioned does not rebut the clinical diagnosis. Same applies for complications of the main disease. Accompanying diseases should be mentioned and provided only with a brief explanation since they are not the focal point of this academic case history.



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