CASE WRITE UP FOR FLOORS ROTATION

PEDIATRICS

A. Identifying Data
B. Chief Compliant – patient’s words (phrase or word only)
C. History of Present Illness –
 No bullet form, history should be placed in paragraph form
D. ROS - include only pertinent to case
E. Past Medical History
F. Birth History
G. Developmental History – if child is below 1 year old, start all developmental history from
birth (milestone and history is different)
H. Immunization History – state all immunization given at what age, do not just write NOT
at par per age
I. Family History
J. Social History
K. Stake holder analysis
L. Physical Examination – vital signs, anthropometrics, z score
M. Impression
N. Differentials – should be placed in paragraph form, no bullets and table form
O. Course in the wards – also in paragraph form , SOAP per day
P. Discussion – brief discussion pathophysiology management prognosis
Q. Public Health – Brief discussion
R. Drug Formulary
 Drugs used
 Dosages and Preparations
 Indications
 Contraindications
 Adverse effects
S. Reflection – consists of learnings, Takeaway from the case, and thoughts on how the
patient was managed
T. Please attach a Case Discussion Grading Sheet for grading