Haiguslugu gastroenteroloogias 4

Instructions for the Academic Case History in Internal Medicine for 4th Year Medical Students

The academic case history shall be compiled by the student on the basis of individual examination of the patient. The student must include information that he/she has obtained by examining his/her patient, information regarding the patient´s clinical history and information required through discussion with his/her supervisor. The student shall compile his/her work on the basis of medical literature and format it according to the rules of a traditional academic case history. Compared to the academic case history in internal medicine propaedeutics, the aim of this case history is to make an accurate clinical diagnosis and to plan treatment accordingly.

These requirements form the basis for the academic case history. Different subspecialities may make amendments/changes to it and students must take those specific requirements into account. Every subspeciality with their supervisors will specify the exact conditions regarding the academic case history within their field.
1. Title Page

The title page must include the name of the hospital, patient´s initials, sex and age, time of hospitalization and clinical diagnosis (in Latin). The clinical diagnosis consists of the main disease(s), accompanying disease(s) and complications of the disease(s).

2. Anamnesis/History

Anamnesis is the information that originates from an earlier time in the patient´s life and regards the patient´s health problem as a whole. The anamnesis helps guide diagnostics and treatment of the patient.

Presenting Complaints

This should include all chief complaints, symptoms and signs of the disease.