Annex IV

POST GRADUATE INSTITUTE OF MEDICINE

UNIVERSITYOF COLOMBO, SRI LANKA
INSERVICE TRAINING ASSESSMENT
MD Paediatrics

Case Based Discussion (CBD)

Trainee’s name:

Date of assessment (dd/mm/yyyy):

Training Centre:

1 2 3 4
Year of training:

Clinical setting: OPD/Clinic In-patient Acute Admission Neonates

Clinical problem: Respiratory CVS GI CNS Neonates Development Emergency

Focus of Clinical Encounter: History Examination Diagnosis Management Discussion

Other (Please specify):

__________________________________________________________________________________

Please insert a brief clinical summary of the case below (e.g. 3 year old with prolonged febrile seizure
and developmental delay):

Please grade the below areas using the given scale:

50