CASE REPORT

Blok elektif

dr. Rita Murnikusumawatie Sp.M

dokter

residen Koass

Laporan kasus mendeskripsikan seorang pasien,

kasus klinis yang tidak umum ditemukan atau
suatu metode penatalaksanaan pasien yang
baru atau lebih baik daripada standar yang
dipergunakan

PASIEN

Di-anamnesis
Di-periksa
Di-diagnosis
Di-terapi
di rawat

Kasus pendek /
panjang

Pengetahuan dan skill

berkembang

Tepat bertanggungjawab

BIDANG
KEPEMINATAN
GERIATRI
DRUG ABUSED
PALLIATIVE CARE
DOMESTIC VIOLENCE
Observational study
Expert opinion, clinical experience

TSTRATEGI PEMBUATAN CASE REPORT

BLOK ELEKTIF
Patient with
problem

CASE
REPORT

Discussion
( the title)

Formulate
in answerable
question

Search
Literature

Medical students:
(Background question)
What
What
What
What
What

is the disease?
is the cause?
are symptoms & signs?
is the treatment?
are the complications?

CONTOH

KEKERASAN DALAM
RUMAH TANGGA
MACAM MACAM KEKERASAN ?
( PSIKIS, SEKSUAL, FISIK DLL )
PASIEN ( SUAMI, ISTRI ATAU
ANAK ?)
RIWAYAT MASA LALU YANG
TERKAIT SAAT INI
FAKTOR PENYEBAB ? / AKIBAT ? /
TERAPI ?
ANALISA KASUS
HUBUNGAN DENGAN
AGAMA

FAKTOR FAKTOR
PENYEBAB KDRT
PENDIDIKAN
PENDIDIKAN
RIWAYAT
RIWAYATMASA
MASA
KECIL
KECIL

EKONOMI
EKONOMI

FAKTOR
FAKTORFAKTOR
FAKTOR
TERKAIT
TERKAIT
ANGGOTA
ANGGOTA
KELUARGA
KELUARGAYANG
YANG
SAKIT
SAKIT

LINGKUNGAN
LINGKUNGAN

PERLAKUAN
PERLAKUANDARI
DARI
PASANGAN
PASANGAN

PENYUSUNAN CASE
REPORT BLOK ELEKTIF

I. COVER
JUDUL
NAMA PENYUSUN & NIM
BIDANG KEPEMINATAN
NAMA TUTOR

II. ABSTRACT
Introduction and objective
Case report
Discussion
Conclusion

III. INTRODUCTION /
BACKGROUND
Describe the subject matter.
State the purpose of the case report.
Provide background information.
Provide pertinent definitions

 List the patients medication history

before admission and throughout the
case report
Ensure that the medication history
includes herbals, vaccines, depot
injections, and nonprescription
medications, and state that the
patient was asked for this history

 Introduce the patient case to the reader

Make the introduction brief and less
than three paragraphs

IV. CASE PRESENTATION

Describe the case in a narrative form
Provide patient demographics (age, sex,
height, weight, race, occupation)
Avoid patient identifiers (date of birth, initials)

 Describe the patients complaint

List the patients present illness
List the patients medical history
List the patients family history
List the patients social history

List each drugs name, strength, dosage

form, route, and dates of administration
Verify the patients medication

 Provide the patients dietary history

Provide pertinent findings on physical
examination ( medical record)
Provide pertinent laboratory values that support
the case
Provide the reference range for laboratory
values that are not widely known or established
List the completed diagnostic procedures that
are pertinent and support the case (medical
record)

 Provide the results of the diagnostic procedures

Provide photographs of histopathology,
roentgenograms, electrocardiograms,
skin manifestations, or anatomy as they
relate to the case
Obtain permission from the patient to use the
patients photographs, or follow institutional
guidelines

 Provide the patients events in chronological

order
Ensure a causal relationship
Ensure that the patient case presentation
provides enough detail for the reader to
establish the cases validity

V. DISCUSSION
Compare and contrast the case report with
the literature review.
Explain or justify the similarities and differences
between the case report and the literature
List the limitations of the case report and
describe their relevance
Establish the causal relationship

VI. CONCLUSION AND SUGGESTION

Provide a justified conclusion
Describe how the information learned
applies to ones own practice
List opportunities for research
Ensure that this section is brief and does
not exceed one paragraph.

SUSUNAN CASE REPORT

SAMPUL DEPAN
ABSTRAK
PENDAHULUAN /
LATAR BELAKANG
PRESENTASI KASUS
DISKUSI
KESIMPULAN DAN
SARAN
DAFTAR PUSTAKA