Write-ups serve two purposes and thus fall into two types. For the medical record, the key is to be both complete and concise. For the tutor, a more expanded discussion of differential diagnosis is appropriate.
Format of the case presentation
1. Report the history, succinctly, in standard format:
- Chief complaint
- History of the present illness
- Past medical history
- Medications
- Medication allergies
- Social history
- Family history
- Review of systems (specify only pertinent positive and negative findings)
- Vital signs (specify)
- HEENT (acceptable to say "normal" or "unremarkable", if this is so)
- Neck
- Nodes
- Breasts (always include a breast exam for women on the medicine service)
- Chest
- Cardiovascular
- Abdomen
- Genitourinary
- Rectal
- Extremities
- Skin
- Neurologic
4. Summarize the case: this is important! The summary should include a few well-crafted sentences, perhaps 3-5 in all. A concise, accurate summary shows that you have grasped the essentials of the case and can distill the clinical data into its essence.
5. Assessment. In the assessment, you choose the most important one or two problems and discuss the differential diagnosis. Remember that the differential diagnosis should address the possible causes in the case at hand, not for the problem in general. For example, in a patient with acute fever, cough, rhonchi and pulmonary infiltrate, discuss pneumonia, not cough.
6. Plan. Outline your recommendations for diagnostic tests and therapy.
Tips for good case write-ups
- Resident notes in the medical record are often very terse
and plan-oriented. For example a resident note might read:
Impression: GI bleed
Plan: Colonoscopy
This is not appropriate for a student note, which should discuss possible causes of the GI bleed.
Impression: GI bleed. Differential diagnosis includes . . .
- Use of the primary medical literature is often useful—but
should be considered an adjunct to textbook reading, not a
substitute.
- Further details are described in Essential Skills in Clinical
Medicine.
