Clerkship Case write-up Guidelines

Patients Profile: 1. Date, time and patient record number 2. Biographical data (patients name, age, marital status, sex, occupation) 3. Source and reliability of history Chief complaint: Briefly state the patients primary complaint(s), and indicate the duration. History of presenting complaint: (Listen, ask open-ended questions, and finally, specific questions to develop a description of all symptoms in chronological order.) 1. Onset-date and manner (gradual, sudden) 2. Characteristics-quality, severity, location, temporal relationships (continuous, intermittent), aggravating and relieving factors, and associated symptoms. 3. Course (continuous, progressive, intermittent) 4. Results of pertinent tests and therapies Past History: 1. Allergies/drug reactions 2. Current/recent medications 3. Concurrent medical problems 4. Previous injuries/illnesses/hospitalizations/surgeries 5. Growth and development/childhood diseases 6. Toxins and/or industrial exposures Family History: 1. Summary of ages and states of health or causes of death of immediate family 2. Family members with similar symptoms and signs 3. Presence of infectious and/or chronic diseases in family members Socioeconomic history: 1. Family unit (spouse, children, parents, siblings, other) 2. Personal background (education, occupation, travel, religion, dwelling) 3. Prevention (alcohol, drugs, tobacco, diet, exercise, hobbies, periodic health examinations, immunizations, sleep, stress,) Review of systems: Generalchange in weight, weakness, fatigue, fever, heat or cold intolerance Skincolor or texture changes, hair or nail changes, bleeding or bruising tendencies, change in mole(s) Head, Eyes, Ears, Nose, Sinuses, Mouth and Throatheadaches, dizziness, trauma, visual acuity, diplopia, infections, dental hygiene, auditory acuity, nasal obstruction, epistaxis, hoarseness Neckthyroid or lymph node enlargement, pain, stiffness Breastspain, masses, discharge

Respiratorycough, hemoptysis, wheezing, dyspnea, recurrent infection Cardiovascularchest pain (substernal pain, pressure or distress), orthopnea, edema, palpitations, hypertension Gastrointestinalabdominal pain, appetite, nausea, vomiting, dysphagia, hematemesis, jaundice, melena, change in bowel habits, constipation, diarrhea Urinaryfrequency, urgency, dysuria, hematuria, nocturia, incontinence, renal colic or stones Female reproductivemenstrual history, obstetrical history, contraceptive history, sexually transmitted diseases, pain, discharge, sexual history Male reproductivescrotal pain or masses, hernias, pain, discharge, genital lesions, contraceptive history, sexually transmitted diseases, sexual history Back and extremitiesjoint pain, stiffness, swelling; leg pain, edema, claudication; pack pain Neuropsychiatricsyncope, alterations of consciousness, convulsions, weakness, tremors, Physical Examination: VITAL SIGNS: temperature, pulse, respiratory rate, blood pressure, weight, height (orthostatic hypotension) GENERAL APPEARANCE: apparent health, developmental status, apparent physiologic age, habitus, nutrition, gross deformities, mental state and behavior, facies, posture SKIN: color, texture, moisture, turgor, eruptions, abnormalities of hair and nails (pallor, pigmentation, cyanosis, clubbing, edema, spider nevi, petechiae) HEAD: symmetry, deformities of cranium, face and scalp (tenderness, bruits) EYES: visual acuity, visual fields, extraocular movements, conjunctive, sclerae, cornea, pupils including size, shape, equality and reaction, ophthalmoscopic exam including lens, media, disks, retinal vessels and macula, tonometry (pallor, jaundice, proptosis, ptosis) EARS: hearing, acuity, auricles, canals, tympanic membranes (mastoid tenderness, discharge) NOSE: nasal mucosa and passages, septum, turbinates, transillumination of sinuses (tenderness over sinuses) MOUTH AND THROAT: breath, lips, buccal mucosa, salivary glands, gingiva, teeth, tongue, palate, tonsils, posterior pharynx, voice NECK: range of motion, thyroid, trachea, lymph nodes, carotid pulses (venous distension, abnormal arterial and venous pulsations, bruits, tracheal deviation) LYMPH NODES: cervical, supraclavicular, axillary, epitrochlear and inguinal nodes (enlargement, consistency, tenderness, and mobility) BREASTS: symmetry (nodules including size, consistency, tenderness, mobility, dimpling, nipple, discharge, and lymph nodes) THORAX AND LUNGS: configuration, symmetry, expansion, type of respiration, excursion of diaphragms, fremitus, resonance, breath sounds (refraction, labored breathing, prolonged expiration, cough, sputum, adventitious sounds including rales, wheezes, rhonchi, and rubs) CARDIOVASCULAR SYSTEM: precordial activity, apical impulse, size, rate, rhythm, heart sounds, abdominal aorta, peripheral arterial pulses including carotid, radial,

femoral, posterior tibial, and dorsalis pedis pulses (thrills, murmurs, friction rubs, bruits, central venous distension, abnormal venous pulsations) ABDOMEN: contour, bowel sounds, abdominal wall tone, palpable organs including liver, spleen, kidney, bladder, and uterus, liver span (scars, dilated veins, tenderness, rigidity, masses, distension ascites, pulsations, bruits) BACK AND EXTREMITIES: symmetry, range of motion, joints, peripheral arterial pulses, color, temperature (curvatures of spine, costovertebral angle tenderness, joint deformities, muscle tenderness, edema, ulcers, varicosities) NEUROLOGIC EXAM: cranial nerves, station, gait, coordination, sensory and motor systems, muscle stretch reflexes (paresthesias, weakness, muscle atrophy, fasciculation, spasticity, abnormal reflexes, tremors) GENITALIA: femaleexternal genitalia, vagina, cervix, cytology smear, fundus, adnexae, rectovaginal exam (vaginal discharge, tenderness) malepenis, scrotal contents (urethral discharge, hernias) RECTUM: Sphincter tone, prostate, test for occult blood (hemorrhoids, fissures, masses) MENTAL STATUS EXAM: affect, intellectual functions, thought content and processes, motor behaviorconsider patterns of adjustment, ability to handle life crises and behavior during the interview, attitude Summary:

Problem formulation with Plan: Problem list Biological Subjective (related history) Objective (relevant physical exam) Analysis (logical differential list) Plan (Diagnostic/Therapeu tic, patient education) Ask yourself questions

Psycholog ical

Social

Preventive

Ethical

Evidence based solution to clinical questions raised: (You can fill as many forms as you would like based on the number of questions asked) Formulate Clinical Question: (PICO format) Type of Question: Diagnosis, Therapy, Prognosis Patients: Intervention: Comparison Intervention: Outcome: Acquire Evidence (Search strategy) Key words used: Source of evidence: Primary (PubMed) Secondary (Cochrane, ACP journal club, Clinical evidence, Uptodate) Level of Evidence: Conclusion from Evidence: (Appraisal)

Applicability issues: 1- Patient related (personal preference, affordability, follow up)

2- Physician related (availability of options, risks-benefits, financial, shared decision making)

Final course of Action:

Grading scheme: Clinical case write up History: 1- General flow is logical 2- All relevant aspects covered 3- reveals thought process (logic, diagnosis, preventive aspects) Physical: 1- systematic Problem list: 1- arises logically 2- SOAP internally consistent 3- Learning needs identified EBM write up Formulate Clinical Question PICO Acquire Evidence (Search strategy) Conclusion from Evidence: (Appraisal) Applicability issues and final course of action Excellent Satisfactory Needs improvement