Anatomy of a Case Write-up

Patient Demographic Data

Patient name (“Patient X” for Doctoring) and medical record number (not for Doctoring)

Writer
Date and Time, Alpert Medical Student Year 1 (AMS 1)

Source and Reliability of Information

State the source of the data (ex. patient, parent), the reliability of information, and
whether the history was obtained with the assistance of a medical interpreter.

Chief Complaint (CC)

State the patient’s most bothersome symptom, ideally in the patient’s own words.

History of Present Illness (HPI)

The HPI is the most important part of the history and is written in narrative form. Record the
chronology of symptoms and events. Over time, you will learn to frame your narrative in a way
that leads your audience to the same conclusions you are considering.

Open with the patient profile— name, age, sex—and an overview of the pertinent cardinal
features (OPQRST). Then record the pertinent positive and negative Review of Systems (ROS).
Begin by considering the ROS of the same organ system as the CC. Over time, you will learn to
include symptoms from other systems. Next, record the positive and negative secondary data,
such as past medical history, habits (ex. exercise, diet, substance use), life stressors, etc. Finally,
include the patient’s perspective, disability or functional status, and existing support systems.

Past Medical History (PMH)

The past medical history is a longitudinal record of what has happened to the patient since
birth. It is usually presented in tabular form.

Childhood Illnesses: include childhood infections

Adult Illnesses: current and past illnesses. For chronic illness, include duration or diagnosis date,
management, level of control, related complications, and recent testing.
Hospitalizations: medical or psychiatric, including reason and dates.
Surgical History: procedure and date. Include obstetric history here (GPML – Gravida (#
pregnancies), Parity (# deliveries), Miscarriages (# miscarriages), Living (# living children).
Current Medications: Include generic/trade name and dosing schedule. Also mention
contraceptives, over-the-counter, herbal, and alternative medications/therapies.
Allergies: name allergies to medication (include type of reaction), food, and environment

Family History (FH)

Include information about the age and health (or cause of death) of parents, siblings and children.
Describe any other illnesses that have affected multiple family members.

Social History (SH)

The social history provides information about the patient’s schooling, career, religion, social
supports, and substance use. It may provide insight into patient behaviors. It can be written in
narrative or tabular form and should include the following information:

Living arrangements: who is at home with the patient, pets, how things are going.
Family relationships and social support: list sources of support
Education: highest level achieved
Occupation: satisfaction, hazardous exposures
Substance use: tobacco, drugs, alcohol. Inquire about current and/or past use, including usual and
maximal amount used daily/weekly, years of use, complications, CAGE
Life stressors: deaths, divorce, moves, illness, job loss
Finances: note access to food, housing, health resources and supplies
Nutrition: note BMI, changes in weight, goal weight, # daily meals, variety, servings of fruits
and vegetables, fat content
Physical activity: type, frequency, and duration
Abuse: past or current physical, emotional, or sexual abuse
Safety: Seat belt use, helmets, fire extinguishers, safe gun storage, etc.
Sexual History (often included in social history, or may be a separate section): sexual activity,
number and gender of current and lifetime sexual partners, use of contraception and STI
protection, history of STIs, HIV testing, and concerns about sexual dysfunction. It can be written
in narrative or tabular form.

Review of Systems (ROS)

Includes past and present symptoms. It is usually recorded in tabular form. Within each
category, list positive symptoms before negative responses.

Physical Examination (PE)

Includes vital signs, observations about the patient and the examination of organ systems.
Interpretations should be deferred to the assessment section of the case write-up.

Begin with vital signs (heart rate and rhythm, blood pressure (include patient’s position, arm,
reading, cuff size), temperature, respiratory rate, weight, height, and BMI. Follow this with
general appearance (whether patient is well-appearing, appearing stated age, or in distress).
The remainder of the physical exam is documented by organ system.

Labs and Imaging

Include relevant studies (not copied directly from the medical record for Doctoring).

Assessment/Formulation Statement
The assessment is a summary of the patient’s clinical presentation. The assessment may begin
with a formulation statement; a sample template for this may be found in the “Student Guide to
Case Write-Ups” document.

Plan
Includes a plan of action to address the patient’s problem list (not required for Doctoring).