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PAO - PSOPRS - Dr Jorge G. Camara Memorial
CLINICOPATHOLOGIC CONFERENCE CASE SUBMISSION FORM

DIAGNOSIS/TITLE OF CASE:


MAIN/ CORRESPONDING AUTHOR:
Last Name (Family or Surname)


First Name


Middle Name


AFFILIATION (e.g., University, Department):


Email Address:


Postal/ Mail Address:


Telephone Number:


CO-AUTHORS: (No more than 2 co-authors can be entered)
Last Name


First Name


Middle Name


I. Case Report Selection/ Reson for Presentation, Important Feature(s):
Please "Fill in" the blanks in the tables below, if applicable. This will facilitate the collection of information to create a case report. Following the steps below will also tend to maximize the quality and minimize the time spent preparing a presentation.

1. What is the most interesting about this case to you?

2. An initial review of the literature indicates that the case is significant because:

3. The unexpected including a new association between a disease and symptoms; between previously unrelated symptoms or findings, or a new disease or syndrome and treatment:

4. A surprising event in the course of diagnosis or treating a patient which may have wider implications:

5. Events which raise questions about the possible cause, or course of treatment, of a disease or condition or increase or decrease the occurrence of an adverse effect resulting from a Surgical procedure:

6. Unique or rare features of a disease particularly if they impacted on Surgical treatment:

7. Exceptional extensions or approaches to Surgical treatment.

II. Case Description: The following analysis of the elements of a case description is based on the paper by Illes & Piepho (1996). If you fill in the following, it will be easier to write up the case.
General description of patient: Focus on the information that is not most directly relevant to the point that you are trying to make. Summarize other information as "unremarkable" or "within normal limits" etc.

1. Patient demographics (age, sex, weight, height, race):

2. Chief complaint:

3. History of condition, relevant other surgical history:

4.History (Social, family):

5. Historical laboratory and other test results:

6. History course:

III. Patient's Condition: Summarize only the most relevant aspects of the patient's condition.

1. Incidence of condition:

2. Etiology:

3. Pathophysiology:

4. Typical course of the condition:

5. Clinical symptomatology:

6. Laboratory and other test findings:

7. Prognosis:

8. Complications:

9. Sequelae:

10. Quality of life implications (short and long term):

11. Basic rationale for the diagnosis:

IV. Treatment Description: Describe in adequate detail the course of treatment

1. Standard Treatment/ Classical or typical surgical treatment:

2. Surgical treatment in this case:

3. Desired therapeutic endpoints:

4. Reactions to treatment:

5. Adverse events:

6. Efficacy of treatment (short and long term):

V. Discussion: Conservatively present the implications of the above information.

1. The best explanation for what occurred is (with citations):

2. Some possible alternative explanations are (with citations):

3. Reason/s why alternative explanation/s is/are less likely:

4. The main clinical implication/s of this case is/are:

5. The main support for the clinical implications is (with citations):

6. Additional research is needed on:

7. Recommendations for treating similar cases in the future are: