DEPARTMENT OF ANAESTHESIOLOGY & INTENSIVE CARE

UNIVERSITI KEBANGSAAN MALAYSIA

CASE WRITE-UP
STUDENT NAME:
MATRIC NO:

YEAR / GROUP:

SUPERVISOR:

ASSESSMENT OF ANAESTHESIOLOGY CASE WRITE-UP:

Core Clinical Component
History

/10

Examination

/5

Description of Anaesthetic
Technique
Post-Operative Management

/10

Investigation

/5

Discussion

/10

Pre-medication

/5

References

/5

Plan of Anaesthesia

/5

/5

Professionalism
Communication issues

/5

Ethical issues

/5

Reflection of the case

- lifelong learning
- professional judgement

Spiritual issues/complementary
medicine

/5

Critical thinking

MARKS FOR CORE CLINICAL COMPONENT

MARKS FOR PROFESSIONALISM COMPONENT

TOTAL SCORE

/10
/10
/5

/ 60
/ 40
/ 100

PATIENT IDENTIFICATION
DATA
Name:
Gender:

Age:
Registration Number:

Date of admission:

Race:

Date of operation:

DIAGNOSIS:
___________________________________________________________________________________________
OPERATION:
___________________________________________________________________________________________
___________________________________________________________________________________________
ELECTIVE/EMERGENCY: ____________________

MAIN COMPLAINTS:

PRE-OPERATIVE ASSESSMENT:
History of Presenting Complaint:

Past medical History:

Drug History:

Any Known Allergy:

Past Surgical History:

Past Anaesthetic History:

RELEVANT PHYSICAL EXAMINATION:

General:

Cardiovascular:

Airway:

Respiratory:

Relevant Examinations of Other Systems:

RELEVANT INVESTIGATIONS:
Blood Results:

Imaging:

Other Relevant Investigations:

PREMEDICATION:

PLAN OF ANAESTHESIA:

DESCRIPTION OF ANAESTHETIC TECHNIQUE:

POST-OPERATIVE MANAGEMENT:

DISCUSSION:
Identify Problems In Order of Priority:

Explain How the Problems are Solved:

Other Aspects of Discussion:

COMMUNICATION ISSUES:

ETHICAL ISSUES:

SPIRITUAL ISSUES

REFLECTION OF THE CASE What have you learnt from this case?

LIST OF REFERENCES:
Please list a minimum of 3 relevant to the above case.
1.
2.
3.
4.
5.

_____________________________________________________________________________
10