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When international patients prepare for medical care in China, the most commonly overlooked task isn’t “which records to bring” — it’s how to organize those records into a summary a specialist can absorb in 15 minutes. The difference between handing over 50 pages of unorganized reports versus 1 page of structured summary backed by 50 pages of supporting material is whether the specialist can make a meaningful judgment within your appointment window. This article provides an internationally standard Case Summary template, three real disease-type examples, and the eight rules that distinguish effective summaries from ineffective ones.
Why “15 Minutes” Is the Threshold That Matters
Chinese specialists’ actual working pace:
- Standard outpatient appointment: 5–15 minutes per patient (high-intensity flow)
- International Medical Department (IMD) appointment: 30–60 minutes per patient (already a generous allocation)
- Multidisciplinary Team (MDT) consultation: 30–90 minutes per case (multiple specialists present simultaneously)
International patients pay IMD premium fees, which in theory buy 30–60 minutes of physician time. But if the specialist needs to spend 20 minutes of that flipping through unfiltered 50-page records, the time actually available for diagnosis and treatment discussion shrinks to 10–40 minutes.
The value of a structured Case Summary is that it lets the specialist absorb your complete clinical picture in the first 15 minutes, then dedicate the remaining appointment time entirely to what you care about most — treatment options, surgical risk, expected outcomes.
Internationally Standard Case Summary Structure
A well-formed Case Summary fits on 1–2 pages of A4, with the following 12 standard fields:
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CASE SUMMARY
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1. PATIENT DEMOGRAPHICS
Name: [Full name]
Sex: [M/F]
DOB: [Date of birth]
Nationality: [Country]
Contact: [Phone / email]
2. CHIEF COMPLAINT (1–2 sentences)
[e.g.: Stage III lung adenocarcinoma,
currently on 2nd-line osimertinib, seeking
second opinion on adjuvant immunotherapy]
3. HISTORY OF PRESENT ILLNESS
[Chronological, 5–10 bullet points]
• 2024-01: First presented with persistent cough...
• 2024-02: CT scan revealed 3.2 cm RUL mass...
• 2024-03: Biopsy confirmed adenocarcinoma...
• [Continue in date order]
4. PAST MEDICAL HISTORY
• Hypertension, diagnosed 2019, on amlodipine
• Type 2 diabetes, diagnosed 2022, on metformin
• [One condition per line]
5. SURGICAL HISTORY
• [Year] · [Procedure] · [Hospital / Surgeon]
• [If none: write "None"]
6. FAMILY HISTORY
[Focus on hereditary conditions]
• Father: lung cancer, deceased age 68
• Mother: alive, healthy
• Siblings: 1 brother, healthy
7. CURRENT MEDICATIONS
[Format: Generic (Brand) | Dose | Frequency]
• Osimertinib (Tagrisso) | 80 mg | once daily
• Amlodipine | 5 mg | once daily
• Metformin | 500 mg | twice daily
8. ALLERGIES
• Penicillin (rash)
• No known food allergies
9. KEY LAB RESULTS (most recent month)
[Tabular format]
Date | Test | Result | Reference
2025-04-15 | Hemoglobin | 11.2 g/dL | 12-16
2025-04-15 | WBC | 4.5 | 4-10
2025-04-15 | CEA (tumor) | 8.3 ng/mL | <5
2025-04-15 | EGFR mutation | T790M+ | -
10. KEY IMAGING FINDINGS
[Date + study + key finding]
• 2025-04-10 · CT chest: RUL mass decreased
from 3.2 cm to 2.4 cm, no new lesions
• 2025-04-10 · PET-CT: SUV max 5.2 (down from 9.1)
11. CURRENT DIAGNOSIS
Stage III (T2N2M0) lung adenocarcinoma
EGFR T790M mutation positive
On 2nd-line osimertinib (12 months)
12. SPECIFIC QUESTIONS
[State 1–3 answerable questions]
a. Is adjuvant immunotherapy recommended
given current response to osimertinib?
b. If yes, which combination protocol?
c. What is the expected 3-year survival
with vs without immunotherapy?
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Example 1: Oncology Patient Case Summary (the most common international patient profile)
CASE SUMMARY
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Name: Maria Rodriguez · F · DOB 1968-03-22
Nationality: Spain · Contact: +34-xxx-xxx-xxxx
CHIEF COMPLAINT:
Stage IIA invasive ductal breast carcinoma,
ER+/PR+/HER2-, status post-lumpectomy and
adjuvant radiation, seeking second opinion
on extended endocrine therapy duration.
HISTORY OF PRESENT ILLNESS:
• 2024-08: Screening mammogram revealed
1.8 cm RUQ mass, BI-RADS 5
• 2024-09: Core biopsy confirmed invasive
ductal carcinoma, Grade 2
• 2024-10: Lumpectomy + sentinel lymph node
biopsy; 1/2 nodes positive
• 2024-11 to 2025-01: Adjuvant radiation
therapy (50 Gy in 25 fractions)
• 2025-02: Started tamoxifen 20 mg daily
• 2025-05: Currently considering AI switch
vs continuation of tamoxifen
PAST MEDICAL HISTORY:
• Hypertension on losartan 50 mg
• Hyperlipidemia on atorvastatin 20 mg
SURGICAL HISTORY:
• 2024-10 · Lumpectomy + SLNB · Hospital
Universitario La Paz, Madrid · Dr. Garcia
FAMILY HISTORY:
• Mother: breast cancer at age 62
• Maternal aunt: breast cancer at age 55
• BRCA testing: negative
CURRENT MEDICATIONS:
• Tamoxifen | 20 mg | once daily
• Losartan | 50 mg | once daily
• Atorvastatin | 20 mg | once daily
• Calcium + Vit D | standard dose | daily
ALLERGIES: NKA (no known allergies)
KEY LAB RESULTS:
Date | Test | Result | Reference
2025-04-20 | Estradiol | 28 pg/mL | postmenop
2025-04-20 | FSH | 62 mIU/mL | postmenop
2025-04-20 | CA 15-3 | 22 U/mL | <31
2025-04-20 | LFTs | Normal | -
KEY IMAGING FINDINGS:
• 2025-04-15 · Mammogram: No recurrence
• 2025-04-15 · Bone density: T-score -1.8
(osteopenia in lumbar spine)
CURRENT DIAGNOSIS:
Stage IIA (T2N1M0) invasive ductal carcinoma
ER 95%+/PR 80%+/HER2 negative (FISH negative)
Ki-67: 18%
Status: Post-lumpectomy + adjuvant RT,
3 months on tamoxifen
SPECIFIC QUESTIONS:
1. Should I switch from tamoxifen to an
aromatase inhibitor (anastrozole/letrozole)
given my postmenopausal status?
2. Recommended total duration of endocrine
therapy: 5 vs 7 vs 10 years?
3. Should ovarian suppression be added?
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Example 2: Cardiovascular Patient Case Summary
CASE SUMMARY
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Name: Ahmed Al-Hassan · M · DOB 1972-11-15
Nationality: UAE · Contact: +971-xx-xxx-xxxx
CHIEF COMPLAINT:
Severe symptomatic aortic stenosis, evaluating
TAVI vs SAVR in China given unique anatomy
(bicuspid valve + small annulus).
HISTORY OF PRESENT ILLNESS:
• 2023-11: Onset of exertional dyspnea
• 2024-02: Echocardiogram showed AV peak
velocity 4.8 m/s, mean gradient 58 mmHg
• 2024-03: Cardiac MRI confirmed bicuspid
aortic valve with severe stenosis
• 2024-04: Coronary angiogram showed
non-obstructive CAD
• 2024-06: Initial TAVI consultation in Dubai
declined due to small annulus (18 mm) +
bicuspid anatomy
• 2025-04: Seeking 2nd opinion in China
PAST MEDICAL HISTORY:
• Hypertension since 2018
• Hyperlipidemia
• Bicuspid aortic valve (congenital)
SURGICAL HISTORY: None
FAMILY HISTORY:
• Father: died of AAA rupture at age 70
• Mother: alive, hypertension only
• Brother: bicuspid aortic valve, well
CURRENT MEDICATIONS:
• Bisoprolol | 5 mg | once daily
• Amlodipine | 5 mg | once daily
• Rosuvastatin | 10 mg | once daily
• Aspirin | 81 mg | once daily
ALLERGIES: NKA
KEY LAB RESULTS:
Date | Test | Result | Reference
2025-04-01 | Cr | 1.0 mg/dL | 0.7-1.3
2025-04-01 | NT-proBNP | 850 pg/mL | <125
2025-04-01 | HbA1c | 5.4% | <6.5
2025-04-01 | LDL | 88 mg/dL | <100
KEY IMAGING FINDINGS:
• 2025-03-15 · Echo: AV peak velocity 5.1
m/s, mean gradient 65 mmHg, AVA 0.7 cm²
• 2025-03-15 · Cardiac CT: Annulus 18 mm,
bicuspid valve (type 1, R-L fusion),
moderate calcification
• 2025-03-15 · Coronary CT: Mild LAD disease,
no obstruction
CURRENT DIAGNOSIS:
Severe symptomatic aortic stenosis
(NYHA Class II–III)
Bicuspid aortic valve, type 1 (R-L fusion)
Small aortic annulus (18 mm)
Hypertension, Hyperlipidemia
SPECIFIC QUESTIONS:
1. Given small annulus + bicuspid anatomy,
is TAVI feasible in your center?
2. If TAVI not advisable, what is your
SAVR experience with bicuspid valve?
3. Recommended valve type (mechanical vs
bioprosthetic) given my age (52)?
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Example 3: Complex Orthopedic Patient Case Summary
CASE SUMMARY
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Name: David Chen · M · DOB 1958-06-30
Nationality: USA · Contact: +1-xxx-xxx-xxxx
CHIEF COMPLAINT:
Failed left total hip arthroplasty (2 prior
revisions), evaluating 3rd revision in China.
HISTORY OF PRESENT ILLNESS:
• 2008: First left THA (primary), USA
• 2017: 1st revision THA due to acetabular
loosening, USA
• 2022: 2nd revision THA due to instability
+ dislocation, USA
• 2024-08: Onset of progressive groin pain
+ leg shortening (current 2 cm)
• 2024-12: X-ray showed prosthesis subsidence
+ acetabular bone loss (Paprosky type IIIA)
• 2025-03: US surgeons declined 3rd revision;
recommended hip resection arthroplasty
(Girdlestone)
• 2025-05: Seeking 2nd opinion in China
PAST MEDICAL HISTORY:
• Type 2 diabetes (HbA1c 6.8)
• Hypertension
• Mild COPD (FEV1 70% predicted)
• Prior smoker, quit 2010
SURGICAL HISTORY:
• 2008 · Left primary THA · Mayo Clinic
• 2017 · Left revision THA · Mayo Clinic
• 2022 · Left revision THA · HSS
FAMILY HISTORY: Non-contributory
CURRENT MEDICATIONS:
• Metformin | 1000 mg | twice daily
• Lisinopril | 20 mg | once daily
• Tiotropium | 18 mcg | inhaled daily
• Acetaminophen | 1000 mg | as needed
ALLERGIES: Sulfa (rash)
KEY LAB RESULTS:
Date | Test | Result | Reference
2025-04-25 | Hemoglobin | 13.5 g/dL | 13-17
2025-04-25 | ESR | 32 mm/h | <20
2025-04-25 | CRP | 1.8 mg/L | <5
2025-04-25 | HbA1c | 6.8% | <6.5
KEY IMAGING FINDINGS:
• 2025-04-20 · X-ray pelvis: Acetabular
component subsidence 8 mm, Paprosky IIIA
• 2025-04-20 · CT pelvis: Acetabular bone
loss with discontinuity, femoral component
intact
CURRENT DIAGNOSIS:
Failed left THA (2nd revision)
Paprosky Type IIIA acetabular bone loss
Leg length discrepancy: 2 cm shortening
DM, HTN, COPD (mild)
SPECIFIC QUESTIONS:
1. Is 3rd revision THA feasible with custom
acetabular component (3D-printed)?
2. If feasible, what is your team's experience
with Paprosky IIIA reconstruction?
3. Alternative options if revision fails
(Girdlestone vs hip fusion)?
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The Eight Rules of an Effective Case Summary
Rule 1: Maximum 1–2 pages of A4 A “summary” longer than two pages stops being a summary. The whole purpose is to let the specialist skip the 50 pages of supporting material and grasp the case immediately. If your draft exceeds two pages, you’re including too much detail — push that detail into supporting documents and tighten the summary.
Rule 2: End with 1–3 specific, answerable questions The “Specific Questions” section is the most important part of the entire Case Summary. A summary without a clear question = a specialist who doesn’t know what you actually want = 30 minutes potentially spent on the wrong discussion. “I’d like your opinion” is not an effective question. Effective questions are answerable: Should I have surgery? Which procedure? What timing?
Rule 3: Chronological order for History of Present Illness; checklist format for medications, allergies, and family history The HPI should read forward in time (onset → present). Medications, allergies, and family history should be in clean list format. Mixing the two formats slows the reader down.
Rule 4: Use generic name + brand name for medications Chinese physicians are familiar with generic names (osimertinib), but brand names (Tagrisso) can speed recognition. Include both.
Rule 5: Tabular format for lab results Lab results scattered through prose paragraphs are rarely read in detail. Use a table: Date | Test | Result | Reference range.
Rule 6: Clinical language, not narrative Case Summary is physician-to-physician communication and should use clinical language and objective data. Emotion, concern, and personal experience should be communicated to your coordination team — not to appear in the Case Summary. “I feel anxious about…” and “I’m worried that…” don’t belong in this document.
Rule 7: Include the most recent data Imaging from 3 months ago and labs from 6 months ago have minimal diagnostic value. Your Case Summary should include key data from the most recent month. If your most recent imaging is older, schedule a follow-up before submitting the summary.
Rule 8: End with a References section pointing to supporting documents The Case Summary should close with a “References” section telling the specialist exactly where to find each piece of supporting material: which DICOM disc holds the imaging, which envelope contains the pathology slides, which PDF holds the detailed chemotherapy records. This lets the specialist drill into specific data efficiently when needed.
Language Selection for the Case Summary
English: all major Chinese IMDs read English Case Summaries fluently. English is the recommended primary version.
Chinese-English bilingual: for complex cases, a side-by-side version (English on the left, Chinese on the right) lets Chinese-native physicians scan quickly as well.
Chinese only: not recommended unless you’re certain the receiving physician has limited English. Using English actually makes it easier for the specialist to cite international guidelines.
Translation quality: use a professional medical translation service (see Article 7) rather than self-translation, which often gets medical terminology wrong.
How to Submit Your Case Summary to a Chinese Hospital
Via IMD email: all major Tier-3A IMDs accept PDF Case Summaries by email. Recommended practice: paste the Case Summary in the email body and attach the PDF version.
Via a coordination service: if working through MedCareInChina or a similar service, they can polish the Case Summary for you — experienced coordination services typically have their own templates and translation teams.
Submit before you arrive: ideal practice is to submit the Case Summary 1–2 weeks before arriving in China. This gives the IMD specialist time to review the case in advance, so the in-person visit can move directly into treatment discussion.
Common Questions
I don’t have a medical background — can I write something like this? Yes. The template is designed for non-medical patients. Best practice: draft it yourself using the template, then have your home physician review and revise before finalizing.
My home doctor doesn’t follow my care closely — what then? A coordination service can help draft it. MedCareInChina’s Pathway Scan service includes drafting a standardized Case Summary based on the materials you provide.
Is a Case Summary the same as a Physician Referral Letter? Not quite. A referral letter is shorter and focused on the handoff itself (“I’m transferring this patient to your care”). A Case Summary is a detailed clinical synopsis. Complex cases benefit from both.
How often should the Case Summary be updated? Every time there’s a significant clinical update — new imaging results, new treatment response, new diagnosis. Recommended practice: update before each Chinese IMD appointment.
Is referencing imaging and pathology in the Case Summary enough? No. The Case Summary is the synopsis; the actual DICOM imaging and physical pathology slides still need to be prepared per the checklist in Article 7.
Bottom Line
An effective Case Summary = 1–2 pages + 12 standard fields + clear specific questions.
Its core value: enables a Chinese specialist to absorb your complete clinical picture in 15 minutes, freeing the rest of your appointment for the conversation about treatment options that matters most to you.
The most common errors: too much information (becomes a full record again) + no clear questions (specialist doesn’t know what you actually want).
If you’d like help drafting your own Case Summary, the Pathway Scan service includes generating a standardized Case Summary from the materials you provide.
→ Send your case to hello@medcareinchina.com
See Service & Refund Policy and Medical Disclaimer for service boundaries.
Sources
- International standard structure for medical case summaries — Synthesized from medical literature on case reports and medical referral letter conventions, referencing the case report standards used by BMJ Case Reports, NEJM, and the American Journal of Medicine. https://casereports.bmj.com/
- Chinese IMD pre-booking and record submission workflows — Public information on PUMC IMS, Shanghai Ruijin IMD, and Shanghai Huashan HIMC pre-booking flows. https://www.pumch.cn/department_ims/detail/28388.html ; https://www.rjh.com.cn/2018RJPortal/txylbjzx/sy/index.shtml
- Multidisciplinary Team (MDT) consultation standards — National Health Commission regulations on multidisciplinary diagnostic and treatment management.
- Professional medical translation standards — Referenced from sources in Article 7 regarding translation agency credentials.
