1.1. Name of ship
1.2. Call sign
1.3. Date and time (GMT/UTC)
1.4. Course, speed, position
1.5.1. Port of destination is … and is … hours/days away
1.5.2. Nearest port is … and is … hours/days away
1.5.3. Other possible port is … and is … hours/days away
1.6 Local weather (if relevant)
2. Routine particulars about the patient
2.1. Surname of casualty
2.2. Other names of casualty
2.3. Rank
2.4. Job on board (occupation)
2.5. Age and sex
3. Particulars of the illness
3.1. When did the illness first begin?
3.2. How did the illness begin (suddenly, slowly, etc.)?
3.3. What did the patient first complain of?
3.4. List all his complaints and symptoms.
3.5. Describe the course of his present illness from the beginning to the present time.
3.6. Give any important past illness/operations/injuries
3.7. Give particulars of known illnesses that run in the family (family history).
3.8. Describe any social pursuits or occupations that may be important (social and occupational history).
3.9. List all medicines/tablets/drugs that the patient was taking before the present illness began and indicate the dose(s) and how often taken (see 6.1.)
3.10. Has the patient been taking any alcohol or do you think he is taking non-medicinal drugs?
4. Results of examination of the ill person
4.1. Temperature, pulse and respiration
4.2. Describe the general appearance of the patient
4.3. Describe the general appearance of the affected parts
4.4. What do you find on examination of the affected parts (swelling, tenderness, lack of movement, etc.)?
4.5. What tests have you done and with what result (urine, other)?
5. Diagnosis
5.1. What do you think is the diagnosis?
5.2. What other illnesses have you considered (differential diagnosis)?
6. Treatment
6.1. List ALL the medicines/tablets/drugs that the patient has taken or been given since the illness began and indicate the doses and the times given or how often given (see 3.9.). Do not use term “standard antibiotic treatment”. Name the antibiotic given.
6.2. How has the patient responded to the treatment given?
7. Problems
7.1. What problems are worrying you now?
7.2. What do you think you need to be advised on?