Case Presentation Format

The Case History Format includes the following sections

1. Demographic and identifying details

2. Chief complaints

3. Present History

4. Past History

5. Personal History

6. Family History

7. In women

a) Menstrual History 

b) Family Planning Status

c) Obstetric History

8. In children

a) Birth History

b) Postnatal care History

c) Immunization

d) Development History

9. Socio-economic History

10. Environmental History

11. Dietary History

12. Examination

a) General Examination

b) Systemic Examination

i) Respiratory System

ii) Cardiovascular System

iii) Alimentary System

iv) Central Nervous System

13. Case Summary

14. Provisional Diagnosis

15. Proposed Investigations

16. Management

a) Pharmacological Treatment

b) Non-Pharmacological Advice (Dietary history, Physical Activity, Environmental history, Follow up, etc..)