Case Submission Form

for Group Discussion & Input

Project ECHO programs are intended to be a community of collaborative learning. A great way to expand your knowledge and experience is to share new or unusual cases and learn from the group's expertise. In turn your expertise and experience can help another fellow address one of their cases.


Although this form is collecting a lot of information, not all of it is needed to pose your question to the group. Beyond identifying your question for the ECHO faculty; its purpose is to help organize your thoughts and case details so that you can confidently respond to clarifying questions during the group discussion.


When presenting your case in the ECHO session, you will want to have a few slides of the case details as a visual resource for the group discussion - i.e. test results, images, medications etc. The conversation is the most important part of this process!


Above all please ensure that all patient information shared is anonymized to protect patient confidentiality.

Presenter Information

* Presenter Name and PGY level
0/250
* Presenter Email
0/250
* Presenter Institution
0/250

Case Details

* Reason for referral
0/250
* HPI - History of Present Illness: Outline the current illness details without revealing personal patient information.
0/500
* Other Relevant History: List any past medical, surgical, family and social history. For example - Parental hip fracture for osteoporosis
0/500
* Medications: List any medications that may cause skeletal harm or prior osteoporosis treatment (date, duration)
0/250
* Physical Exam: List any relevant findings. For example: Skeletal deformities
0/500
* Laboratory Tests: List any test and results. For example Calcium, phosphorus, Alk phos, BUN, creatinine, PTH, PTHRP, Serum C telopeptide, P1NP (Procollagen Type 1 Intact N-Terminal Propeptide)
0/500
* Imaging: List any imaging test or scans collected. For example - Xrays, MRI/CT scan, Bone density: BMD, T score/Z score.
0/250

ECHO Discussion

* What is your clinical question(s) regarding this case that you would like to pose to the group for their input?
0/250

Thank you for sharing a case for the group discussion. A member of the ECHO faculty will contact you in the next week or so regarding next steps.