MEDICAL WRITTEN CASE

STUDIES
(WRITE-UPS)

Iriana Hammel MD FACP

 GOALS AND OBJECTIVES
„ The written case presentation serves as both a learning tool
for the student and an evaluation of the student.
„ As a learning tool it provides the student with the
opportunity to not only perform a history and physical but
to integrate the data as they provide an assessment and
plan. It provides the learners with a mechanism to review
established medical resources which in turn can be applied
to the patient for clinical presentation, diagnosis and
treatment.
„ As an evaluation tool it provides the educator a tool that
assesses critical thinking, basic medical knowledge,
organization ability, and professionalism in meeting course
assignments.
 SECTION 1

SPECIFIC REQUIREMENTS FOR

WRITE-UPS
 WRITE-UP ASSIGNMENT #1
( GRADED)
„ Interview as a group a standardized patient based
on a given chief complaint (OSCE station format)
and write the HPI and A&P after the encounter.
You will be provided with the abnormal PE and
pertinent lab findings. This will serve a dual
purpose of familiarizing yourselves with the most
difficult parts of a write-up and see an example of a
OSCE station.
„ Peer review and grading of this assignment under
attending supervision.
 ASSIGNMENT #2
FORMAL WRITE-UP
(GRADED)

You are a primary care physician evaluating

a new patient and writing a complete H&P,
preceded by a title page and an abstract and
followed by a discussion and references
 SUBJECTIVE (CC, HPI, PMH, PSH,
ALLERGIES, MEDS, SOCIAL HX, FAMILY HX,
ROS)
ƒ Elicit historical data inclusive of all key
components of a medical history:
ƒ HPI should be focused on the chief complaint
and the system it belongs to (ex: if the cc is chest
pain then you need to report in HPI all of
patient’s cardiovascular symptoms or lack of). If
your patient has no complaints, then your chief
complaint becomes the evaluation of a system
with significant pathology for your patient
(example: CC: Patient seen for an evaluation of
the cardiovascular system).
 OBJECTIVE (PE and LABS)
ƒ Perform a complete physical examination with
specific attention to pertinent positive and
negative findings.
ƒ The write-up must include a CBC and renal
function (including calculated creatinine
clearance, using Cockroft - Gault equation) and
electrolytes (BMP) in the lab section of the
paper.
ƒ Include any other labs or diagnostic tests that are
pertinent to your reason for visit.
ƒ All abnormal lab values should be discussed
briefly in the A&P section (under a diagnosis,
such as “anemia of chronic disease”) and further
on (more detailed) in the discussion section.
 ASSESSMENT AND PLAN
ƒ Integrate information obtained from the patient
into an organized problem list.
ƒ You must include all newly found patient
complaints, all pre-existing medical problems, and
abnormal physical examination and laboratory
findings in the assessment.
ƒ The plan should address all diagnoses included in
the assessment and should involve medications,
further diagnostic interventions, nutrition,
behavioral interventions or any other appropriate
interventions.
ƒ Review current treatment and its successes or
failures, as well as proposed new therapies and
diagnostic evaluations.
 OTHER INSTRUCTIONS
ƒ Review the guidelines provided in the AICM Written Case
Study Evaluation Form, posted on E-College.
ƒ DO NOT include any patient names/identifiers in your
paper. Inclusion of any identifiers may result in getting NO
credit for your paper. Initials may be used instead.
ƒ Student name and banner ID should be listed on every page
of the write up.

! Note:
The examples that you will see were taken “word for word “
from papers written by your colleagues (have not been
edited), so they are not “perfect”, but meet the requirements
stated in this presentation . Therefore, those students were
given excellent grades and hopefully will serve as good
examples for other students to follow in their footsteps.
 SECTION 2:

GUIDELINES FOR EACH COMPONENT

OF THE H&P
 FORMAT

1. Title page 8. Allergies

2. Abstract 9. Medications
3. Source of information and 10. Social HX
statement of reliability 11. Family HX
4. Chief complaint 12. ROS
5. HPI 13. PE
6. PMH (with separate headings 14. Labs
for Obstetrical History and 15. A&P
Preventative Medicine and
Immunizations) 16. Discussion
7. PSH (Past Surgical Hx) 17. References
 TITLE PAGE (1)
Example 1:

Hunt for The Brown October

(Name)
(Date)
 TITLE PAGE (2)

Example 2:

Pull Up a Stool: A GI Story of “Ins”, “Outs”

and the “Plumbing” in Between
(Name)
(Date)
 ABSTRACT

ƒ Provide 2-3 sentences that highlight the most

interesting and significant aspects of the case
ƒ Include at least a statement about why the primary
issue presented is important to medical providers
in the US and/or the world
ƒ Include 2-3 statements about what the medical
literature reflects about the topic
ƒ The length of the abstract should be approximately
300 words, excluding conjunctions and
prepositions
 ABSTRACT - EXAMPLE

M.F. is a 90 year-old Caucasian woman with multiple

gastrointestinal complaints, and a host of associated
comorbidities. Chief among them is a myelodysplastic syndrome.
At present, MF is mostly well-controlled through physical,
pharmacological, and nutritional management. She is able to
perform most I/ADLs with modest assistance, and by her own
account is remarkably “fortunate” to have the health she does.
MF represents an excellent snapshot of the predicament
healthcare providers encounter when treating the geriatric
population. Myriad disease processes, a medication list that
contraindicates itself with each subsequent malady, little if any
research to support a drug’s use in this cohort, and extremely
limited resources on the part of the patient and practitioner.
 ABSTRACT - EXAMPLE (cont’d)

While more aggressive therapy certainly exists for almost every

problem one might find in this cohort, cost-benefit analysis
almost always skews toward conservative, empiric treatment for
both financial and health reasons. Transplants, exploratory
surgeries, and aggressive pharmacological therapy become much
more devastating as a patient advances in years.
It has always been assumed that a given study’s results will
extrapolate to older geriatrics, in lieu of actual data. This partly
stems from the fact that it becomes more difficult to enroll,
keep, and treat older participants, and partly because they almost
never meet the inclusion criteria because of comorbidities. This
case seeks to highlight such management strategy, while serving
as an open call to the research community to design and
implement studies to better serve an increasingly aging
population, comobidities and all.
 SOURCE OF INFORMATION AND
STATEMENT OF RELIABILITY

ƒ Please list the source for the information you are

providing ( patient, chart, family, nursing staff).

ƒ State whether or not the patient is a reliable source

of information and, if not, why not
(Example: Mrs. M.L. is not a reliable historian due
to advanced cognitive impairment)
 CHIEF COMPLAINT (CC)
ƒ Statement which succinctly describes symptoms
or problem/problems for which patient is being
seen
ƒ Reason for the encounter
ƒ Focus on pertinent systems
ƒ Whenever possible use patient’s own words in
the chief complaint, without using quotation
marks
ƒ If your patient is seen for an evaluation of a
system (CVS for example) and does not have a
specific complaint related to that particular
system, then your CC will be: Patient seen for an
evaluation of the CVS system
 HISTORY OF PRESENT ILLNESS (HPI)
ƒ Chronological description of how the present illness
developed over time from first sign/symptom to now:
location, severity, duration, timing, context , quality,
alleviating/aggravating factors, associated S/S

ƒ Relevant aspects of PMH (such as history of prior MI in a

patient with chest pain) and Social Hx (such as tobacco
abuse) should be included in HPI if they contribute to
“painting” the appropriate picture

ƒ Include any and all questions (and patient’s answers)

pertinent to the evaluated system

ƒ Your questions should correlate with patient’s CC and

current diagnoses( for example, in a patient with a h/o
CHF you should ask about edema and dyspnea on
exertion/at rest).
 HPI - EXAMPLE
M.F. is a 90 year-old Caucasian female examined at the Nursing
Home on July 8 for the continued care of gastrointestinal complaints.
She is currently in no acute distress, but complains of chronic melena,
rectal hemorrhoids, and “maybe some weight loss.” She is also
chronically anemic and suffers from a myelodysplastic syndrome. She
reports melena, and attributes it to her “black pill.” Upon further
questioning, both she and her nurse reported the classic description
of melena, (black, smelly, firm) but it should be noted that MF
receives ferrous sulfate daily and EPO injections monthly for the
anemia. She reports one stool daily, which is usually firm and medium
to large-sized. She is continent of bowels and bladder, but requires
assistance with ambulation and toileting. MF has stage III prolapsed
internal hemorrhoids that can “occasionally” be manually reduced.
She typically experiences no pain with these unless she or her
caregivers clean her rectum too vigorously, which also causes them to
rupture and bleed. Proctosol HC 2.5% cream is applied topically
twice daily and relieves any discomfort she might have.
 HPI - EXAMPLE (cont’d)
Additionally, MF sits on a pressure-relieving cushion in her
wheelchair and is assisted with active positioning throughout the
course of her day. MF has a long history of weight loss. She
reported losing weight shortly after admission, and related that to
the change in diet. She “got used to the food” and her weight
stabilized over the next few months. She reports a mild recent
weight loss, but could not quantify it. She reports a good
appetite, and that she enjoys most food provided her. She denies
anorexia or early satiety, and eats “seventy percent of her meals,”
according to her nurse. She wears full dentures on upper and
lower teeth, and reports that they are well-maintained and are
appropriately sized. She complains of infrequent xerostomia but
denies pain or ulcers in oral cavity. MF denies dysphagia or
odynophagia, reflux, epigastric pain, and abdominal pain. She
further denies nausea, retching, vomiting, diarrhea, or
constipation. MF has no known family history of gastrointestinal
malignancy, inflammatory or ischemic bowel disease, liver
disease, or colon polyps.
PAST MEDICAL HISTORY
1. List all past and chronic illnesses, hospitalizations, injuries
(provide dates when possible; if not available, please state:
dates not available)
2. Obstetrical History
3. Preventative medicine and immunizations: include dates of
vaccinations, recommended screening tests (state if done or
not done - with dates, when available )
PAST SURGICAL HISTORY
List surgeries (with dates, when available)
ALLERGIES
Include meds, food and environmental; state type of
reaction
MEDICATION
Complete list with doses and frequency
 SOCIAL HISTORY
ƒ Smoking/substance abuse/alcohol
ƒ Education
ƒ Occupation
ƒ Safety practices
ƒ Marital status and family relationships
ƒ Hobbies/favorite activities
ƒ DPOA
ƒ Code status, if known
ƒ Sexual history, if appropriate
ƒ Religion
 SOCIAL HISTORY - EXAMPLE
MF was born and raised in the mid-Michigan area, and reports a happy
relationship with her parents and siblings as a child. She attended school
through high school, and subsequently worked as a store clerk in various
department stores until she was married. After that, she frequently cared
for friends and neighbors in their homes when they were ill. She is a
widow of eight years, following the death of her husband. They were
married sixty years, and she reports that their relationship was strong and
happy. They adopted three children, two boys and a girl who still live in
the area, and visit occasionally with their families. She is a practicing
Lutheran, and enjoys singing and socializing with friends. She has never
abused alcohol or illicit drugs, and denies any tobacco use. MF’s son acts
as her patient advocate, and assists in medical decisions, and he acts
under a durable power of attorney. She denies any legal problems at this
time.
 FAMILY HISTORY

ƒ Pertinent family illnesses (diseases with a genetic

component)
ƒ Ages and causes of death (if unknown, please state
so) of grandparents, parents, siblings and children,
if applicable.
ƒ Include at least a statement about h/o CAD, DM,
malignancy in any family members.
 REVIEW OF SYSTEMS (ROS)

ƒ Used to identify symptoms

ƒ Pertinent negatives (use: patient denies…)and
positives (use: patient complains of…)
ƒ Inventory of body systems
ƒ Complete: all body systems; use Bates as guideline
ƒ Add pertinent information to your patient: some
questions may be more pertinent to a geriatric
patient (e.g. vision/ hearing impairments or
urinary incontinence, mobility and cognitive
impairments etc) than to a young adult
 REVIEW OF SYSTEMS (ROS)
ƒ General
ƒ HEENT: Head/Eyes/Ears/Nose/Mouth/Throat (separate heading for
each one, please)
ƒ Neck
ƒ Breasts
ƒ Cardiac
ƒ Respiratory
ƒ Gastrointestinal
ƒ Urinary
ƒ Genital
ƒ Peripheral vascular
ƒ Musculoskeletal
ƒ Skin
ƒ Neurological
ƒ Psychiatric
ƒ Endocrine
ƒ Hematologic/lymphatic
 ROS - EXAMPLE
ƒ General: Patient denies any recent change in energy level or sleep.
She thinks she has lost “some weight” since admission, but cannot
say how much. No fever, chills, night sweats
ƒ Skin: MF denies rashes, ecchymoses, lesions, and pruritus. She
complains of pale skin.
ƒ Head: Patient denies headaches, dizziness hair loss, or scalp pain.
ƒ Eyes: She denies pain, pruritus, discharge or xeropthalmia. MF
states she wears corrective lenses for daily use, but denies focal
visual deficits or recent vision loss.
ƒ Ears: She denies pain, discharge, hearing loss or tinnitus.
ƒ Nose/Sinuses: Patient denies difficulty breathing, discharge, and
pain. She complains of occasional congestion due to season
allergies.
ƒ Oral: MF denies bleeding gums, pain, and ulcerations in mouth.
She wears dentures daily, and reports that they are properly fitting.
ƒ Neck: Patient denies neck stiffness, pain, masses or nodules.
 ROS - EXAMPLE (cont’d)
ƒ Breasts: Denies pain, masses, nodules and recent changes of
breast shape.
ƒ Respiratory: She noted dyspnea on exertion, such as walking
distances of 100 and the occasional cough when she has a cold.
Denies pain on respiration or wheezing.
ƒ Cardiovascular: Patient denies any palpitations, chest pain,
dyspnea on exertion, orthopnea or PND
ƒ Gastrointestinal: see HPI
ƒ Genito-Urinary: Patient urinates approximately three to four
times daily. Currently denies dysuria, urinary frequency, and
incontinence.
ƒ Endocrine: Patient denies any change in energy or in hair
distribution and texture. She noted mild weight loss. No
heat/cold intolerance. Denies polyuria, polydypsia, polyphagia.
ƒ Hematologic/Lymphatic: Patient denies ecchymoses, masses,
or nodules .
 ROS - EXAMPLE (cont’d)
ƒ Musculoskeletal: States she is unable to stand without
assistance, and walks with an aluminum walker. MF also
complains of weakness in her right upper extremity and poor
range of motion due to an injury sustained in a fall five years
previous. She rates the pain as 6/10 when in pain, controlled
with BioFreeze application twice daily. She also complains of low
to mid back pain, which has been resolving with the introduction
of a new wheelchair. When acutely painful, she rates it as 8/10,
and states her baseline is 0-3/10.
ƒ Nervous System: She denied any headaches, diplopia, anosmia,
or loss of taste. She experiences numbness and paresthesias in
her hands bilaterally.
ƒ Psychiatric: Patient reports positive attitude, currently denies
feeling sad or depressed, delusions, and suicidal ideation.
 PHYSICAL EXAMINATION

ƒ Perform a complete physical examination with

specific attention to pertinent positive and negative
findings.

ƒ Document your PE findings, including pertinent

negative findings, in an organized and concise
fashion, preferably “bullet format”.

ƒ List your findings in a head-to-toe fashion (in a

typical H&P format)

ƒ Review Bates Guide to Physical Exam

 LABS
ƒ Include at least the patient’s CBC and BMP (which
includes Renal function and electrolytes) in each write-up.
If the CBC and BMP are WNL, you need to include
another lab result pertinent to the system you are
discussing. If there is no other pertinent lab in the chart,
please include a discussion regarding possible pathological
findings in BMP and/ or CBC due to patient’s condition/
meds.
ƒ Any labs documented in the lab section of the paper that
are ABNORMAL need to be discussed both in the A&P
(briefly) AND in the Discussion section (more detailed).
ƒ Once you have encountered an abnormal lab, you need to
go back to your HPI or ROS (whichever is applicable) and
include the appropriate questions in order to clarify this
particular diagnosis.
 ASSESSMENT AND PLAN (A&P)
ƒ A=assessment (putting the data gathered in the subjective
and objective portions of the H&P together to form
diagnoses of what the problems may be)
ƒ Put A & P together when possible as flows/logical/faster
and easier to read
ƒ Prioritize your diagnoses, starting the list with the most
serious/life threatening (usually coinciding with your CC)
ƒ Be sure that you have the data in your exam to support the
diagnosis you use
ƒ Save the detailed information about the diagnosis in
question for the “Discussion” section and be concise in
your A&P: if this is a chronic condition, you need to state if
compensated/controlled or decompensated/uncontrolled,
state the goal of treatment (according to what guidelines)
and assess whether the patient is at goal or not. Also list
stage of disease if applicable. If this is a new
symptom/problem, please give presumed etiology and 1-2
differential diagnoses.
 ASSESSMENT AND PLAN
ƒ List investigations needed to confirm your diagnosis
ƒ Make a plan of pharmacological and non-pharmacological
intervention
ƒ Be sure to recognize that your patients are individuals and
decide whether following a guideline would be the best
choice for that particular patient (e.g.: Restricting salt for a
35 yo AA male with uncontrolled HTN versus an 89 yo
Caucasian female with history of weight loss/debility and
average SBP in 140’s)
ƒ Use medical terms only and formulate actual diagnoses as
components of your assessment
ƒ Include all pre-existing conditions that are chronic (even
those for which your patient may not be undergoing
treatment at this time) and all the newly found problems
(diagnoses)
 A&P - EXAMPLE

1. H/o GI Bleed:
MF may currently be having an active occult GI bleed. Oral
ferrous sulfate can darken the stool and appear as melena.
The two negative FOBTs may be accurate if this is the
case. She has had consistently low hemoglobin, hematocrit,
and iron level despite long-term treatment, which may be
due to the fact that she receives Erythropoietin for her
anemia of chronic disease and this leads to increased iron
consumption (to increase erythropoesis). Given her
advanced age, and relative lack of overt symptoms,
continue to monitor for now, in conjunction with
hematology/oncology service. Consider
colonoscopy/EGD for a definitive diagnosis, or in case of
acute bleed or sudden drop in H&H.
 A&P - EXAMPLE (cont’d)

2. Weight loss:
MF’s weight has decreased to 129.4 pounds, which is a 5%
percent from 11/08, and decreased 14% from admission in
2005. She has a history poor appetite when feeling depressed,
and may be related to the Celexa, which is anorexigen. Consider
performing a GDS and changing to another antidepressant. The
weight loss could also be the result of her myelodysplastic
syndrome or other occult malignancy and further workup may
be necessary. Encourage healthy eating habits, assist where
necessary. When possible, tailor diet to patient’s preference.
Continue physical therapy, encourage assisted walking, regular
exercise and group activities to improve her depression and/or
appetite.
 A&P - EXAMPLE (cont’d)

3. Rectal hemorrhoids:
MF has chronic stage III prolapsed hemorrhoids. Continue
Proctosol HC cream twice daily. Educate patient and assist with
cleaning techniques as necessary. Soft medicated wipes would
likely be beneficial. Surgery is not likely a solution; given her age
and comorbidities, the risks would likely outweigh the benefits.
Manual reduction has been successful in the past, and may be an
option. IRC previously stopped acute hematochezia, but was
ineffective at reducing the hemorrhoids. Continue active
positioning, and pressure relieving chair cushion. Ensure patient
does not become constipated. Encourage ambulation as
tolerated.
 A&P - EXAMPLE (cont’d)
4. Chronic anemia secondary to myelodysplastic syndrome:
MF has a normochromic, normocytic anemia consistent with
anemia of chronic disease. She has a decreased hemoglobin
and hematocrit despite continued EPO injections. Total serum
iron is also low despite daily ferrous sulfate therapy, which
may indicative of blood loss. Complicating the picture, the
patient has a history of GI bleed. However, two previous
FOBTs were negative. That may be of little value, as this test
has a low sensitivity. She may have a combination of blood
loss and ineffective erythropoesis secondary to the
myelodsyplastic syndrome. Continue to monitor CBC and
Iron levels monthly per Heme/Onc. Continue Procrit (EPO)
and ferrous sulfate. Monitor renal function with metabolic
panel if EPO appears ineffective. Continue to ambulate and
exercise as tolerated to prevent constipation that can be
associated with iron therapy. Maintain and encourage diet and
fluids as tolerated.
 DISCUSSION
ƒ Review of medical textbooks and articles related to
your patient’s diagnoses and how the medical
literature applies to your patient (focus primarily
on medical textbooks and less on journal articles).
ƒ Include AT LEAST 2 conditions pertinent to the
system AND the abnormal labs .
ƒ The topics included in the discussion need to
correlate with the abstract and the system covered
in the HPI
ƒ Length should be 2- 4 pages; points will be
deducted for shorter or longer length than
specified.
 REFERENCES
ƒ You need to review and cite in your references
at least 2 widely-accepted medical textbooks.

ƒ The other 3 references can be articles, preferably

review articles from reputable medical journals. At
least one article should be included in references.

ƒ Web sites are not acceptable to be listed as

references.