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Anatomy of A Case Write-Up DI
Anatomy of A Case Write-Up DI
Writer
Date and Time, Alpert Medical Student Year 1 (AMS 1)
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.
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.
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.
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).