MEDICAL WRITTEN CASE STUDIES (WRITE-UPS)Iriana Hammel MD FACP

GOALS AND OBJECTIVESThe written case presentation serves as both a learning tool for the student and an evaluation of the student. As a learning tool it provides the student with the opportunity to not only perform a history and physical but to integrate the data as they provide an assessment and plan. It provides the learners with a mechanism to review established medical resources which in turn can be applied to the patient for clinical presentation, diagnosis and treatment. As an evaluation tool it provides the educator a tool that assesses critical thinking, basic medical knowledge, organization ability, and professionalism in meeting course assignments.

SECTION 1 SPECIFIC REQUIREMENTS FOR WRITE-UPS

WRITE-UP ASSIGNMENT #1 ( GRADED)Interview as a group a standardized patient based on a given chief complaint (OSCE station format) and write the HPI and A&P after the encounter. You will be provided with the abnormal PE and pertinent lab findings. This will serve a dual purpose of familiarizing yourselves with the most difficult parts of a write-up and see an example of a OSCE station. Peer review and grading of this assignment under attending supervision.

ASSIGNMENT #2 FORMAL WRITE-UP (GRADED) You are a primary care physician evaluating a new patient and writing a complete H&P, preceded by a title page and an abstract and followed by a discussion and references

SUBJECTIVE (CC, HPI, PMH, PSH,ALLERGIES, MEDS, SOCIAL HX, FAMILY HX, ROS) Elicit historical data inclusive of all key components of a medical history: HPI should be focused on the chief complaint and the system it belongs to (ex: if the cc is chest pain then you need to report in HPI all of patients cardiovascular symptoms or lack of). If your patient has no complaints, then your chief complaint becomes the evaluation of a system with significant pathology for your patient (example: CC: Patient seen for an evaluation of the cardiovascular system).

OBJECTIVE (PE and LABS)Perform a complete physical examination with specific attention to pertinent positive and negative findings. The write-up must include a CBC and renal function (including calculated creatinine clearance, using Cockroft - Gault equation) and electrolytes (BMP) in the lab section of the paper. Include any other labs or diagnostic tests that are pertinent to your reason for visit. All abnormal lab values should be discussed briefly in the A&P section (under a diagnosis, such as anemia of chronic disease) and further on (more detailed) in the discussion section.

ASSESSMENT AND PLANIntegrate information obtained from the patient into an organized problem list. You must include all newly found patient complaints, all pre-existing medical problems, and abnormal physical examination and laboratory findings in the assessment. The plan should address all diagnoses included in the assessment and should involve medications, further diagnostic interventions, nutrition, behavioral interventions or any other appropriate interventions. Review current treatment and its successes or failures, as well as proposed new therapies and diagnostic evaluations.

OTHER INSTRUCTIONSReview the guidelines provided in the AICM Written Case Study Evaluation Form, posted on E-College. DO NOT include any patient names/identifiers in your paper. Inclusion of any identifiers may result in getting NO credit for your paper. Initials may be used instead. Student name and banner ID should be listed on every page of the write up. ! Note:

The examples that you will see were taken word for word from papers written by your colleagues (have not been edited), so they are not perfect, but meet the requirements stated in this presentation . Therefore, those students were given excellent grades and hopefully will serve as good examples for other students to follow in their footsteps.

SECTION 2: GUIDELINES FOR EACH COMPONENT OF THE H&P

FORMAT1. Title page 2. Abstract 3. Source of information and statement of reliability 4. Chief complaint 5. HPI 6. PMH (with separate headingsfor Obstetrical History and Preventative Medicine and Immunizations)

7. PSH (Past Surgical Hx)

8. Allergies 9. Medications 10. Social HX 11. Family HX 12. ROS 13. PE 14. Labs 15. A&P 16. Discussion 17. References

TITLE PAGE (1) Example 1:

Hunt for The Brown October (Name) (Date)

TITLE PAGE (2)Example 2:

Pull Up a Stool: A GI Story of Ins, Outs and the Plumbing in Between (Name) (Date)

ABSTRACTProvide 2-3 sentences that highlight the most interesting and significant aspects of the case Include at least a statement about why the primary issue presented is important to medical providers in the US and/or the world Include 2-3 statements about what the medical literature reflects about the topic The length of the abstract should be approximately 300 words, excluding conjunctions and prepositions

ABSTRACT - EXAMPLEM.F. is a 90 year-old Caucasian woman with multiple gastrointestinal complaints, and a host of associated comorbidities. Chief among them is a myelodysplastic syndrome. At present, MF is mostly well-controlled through physical, pharmacological, and nutritional management. She is able to perform most I/ADLs with modest assistance, and by her own account is remarkably fortunate to have the health she does. MF represents an excellent snapshot of the predicament healthcare providers encounter when treating the geriatric population. Myriad disease processes, a medication list that contraindicates itself with each subsequent malady, little if any research to support a drugs use in this cohort, and extremely limited resources on the part of the patient and practitioner.

ABSTRACT - EXAMPLE (contd)While more aggressive therapy certainly exists for almost every problem one might find in this cohort, cost-benefit analysis almost always skews toward conservative, empiric treatment for both financial and health reasons. Transplants, exploratory surgeries, and aggressive pharmacological therapy become much more devastating as a patient advances in years. It has always been assumed that a given studys results will extrapolate to older geriatrics, in lieu of actual data. This partly stems from the fact that it becomes more difficult to enroll, keep, and treat older participants, and partly because they almost never meet the inclusion criteria because of comorbidities. This case seeks to highlight such management strategy, while serving as an open call to the research community to design and implement studies to better serve an increasingly aging population, comobidities and all.

SOURCE OF INFORMATION AND STATEMENT OF RELIABILITYPlease list the source for the information you are providing ( patient, chart, family, nursing staff). State whether or not the patient is a reliable source of information and, if not, why not (Example: Mrs. M.L. is not a reliable historian due to advanced cognitive impairment)

CHIEF COMPLAINT (CC)Statement which succinctly describes symptoms or problem/problems for which patient is being seen Reason for the encounter Focus on pertinent systems Whenever possible use patients own words in the chief complaint, without using quotation marks If your patient is seen for an evaluation of a system (CVS for example) and does not have a specific complaint related to that particular system, then your CC will be: Patient seen for an evaluation of the CVS system

HISTORY OF PRESENT ILLNESS (HPI)Chronological description of how the present illness developed over time from first sign/symptom to now: location, severity, duration, timing, context , quality, alleviating/aggravating factors, associated S/S Relevant aspects of PMH (such as history of prior MI in a patient with chest pain) and Social Hx (such as tobacco abuse) should be included in HPI if they contribute to painting the appropriate picture

Include any and all questions (and patients answers) pertinent to the evaluated system Your questions should correlate with patients CC and current diagnoses( for example, in a patient with a h/o CHF you should ask about edema and dyspnea on exertion/at rest).

HPI - EXAMPLEM.F. is a 90 year-old Caucasian female examined at the Nursing Home on July 8 for the continued care of gastrointestinal complaints. She is currently in no acute distress, but complains of chronic melena, rectal hemorrhoids, and maybe some weight loss. She is also chronically anemic and suffers from a myelodysplastic syndrome. She reports melena, and attributes it to her black pill. Upon further questioning, both she and her nurse reported the classic description of melena, (black, smelly, firm) but it should be noted that MF receives ferrous sulfate daily and EPO injections monthly for the anemia. She reports one stool daily, which is usually firm and medium to large-sized. She is continent of bowels and bladder, but requires assistance with ambulation and toileting. MF has stage III prolapsed internal hemorrhoids that can occasionally be manually reduced. She typically experiences no pain with these unless she or her caregivers clean her rectum too vigorously, which also causes them to rupture and bleed. Proctosol HC 2.5% cream is applied topically twice daily and relieves any discomfort she might have.

HPI - EXAMPLE (contd)Additionally, MF sits on a pressure-relieving cushion in her wheelchair and is assisted with active positioning throughout the course of her day. MF has a long history of weight loss. She reported losing weight shortly after admission, and related that to the change in diet. She got used to the food and her weight stabilized over the next few months. She reports a mild recent weight loss, but could not quantify it. She reports a good appetite, and that she enjoys most food provided her. She denies anorexia or early satiety, and eats seventy percent of her meals, according to her nurse. She wears full dentures on upper and lower teeth, and reports that they are well-maintained and are appropriately sized. She complains of infrequent xerostomia but denies pain or ulcers in oral cavity. MF denies dysphagia or odynophagia, reflux, epigastric pain, and abdominal pain. She further denies nausea, retching, vomiting, diarrhea, or constipation. MF has no known family history of gastrointestinal malignancy, inflammatory or ischemic bowel disease, liver disease, or colon polyps.

PAST MEDICAL HISTORY1. List all past and chronic illnesses, hospitalizations, injuries (provide dates when possible; if not available, please state: dates not available) 2. Obstetrical History 3. Preventative medicine and immunizations: include dates of vaccinations, recommended screening tests (state if done or not done - with dates, when available )

PAST SURGICAL HISTORYList surgeries (with dates, when available)

ALLERGIESInclude meds, food and environmental; state type of reaction

MEDICATIONComplete list with doses and frequency

SOCIAL HISTORYSmoking/substance abuse/alcohol Education Occupation Safety practices Marital status and family relationships Hobbies/favorite activities DPOA Code status, if known Sexual history, if appropriate Religion

SOCIAL HISTORY - EXAMPLEMF was born and raised in the mid-Michigan area, and reports a happy relationship with her parents and siblings as a child. She attended school through high school, and subsequently worked as a store clerk in various department stores until she was married. After that, she frequently cared for friends and neighbors in their homes when they were ill. She is a widow of eight years, following the death of her husband. They were married sixty years, and she reports that their relationship was strong and happy. They adopted three children, two boys and a girl who still live in the area, and visit occasionally with their families. She is a practicing Lutheran, and enjoys singing and socializing with friends. She has never abused alcohol or illicit drugs, and denies any tobacco use. MFs son acts as her patient advocate, and assists in medical decisions, and he acts under a durable power of attorney. She denies any legal problems at this time.

FAMILY HISTORYPertinent family illnesses (diseases with a genetic component) Ages and causes of death (if unknown, please state so) of grandparents, parents, siblings and children, if applicable. Include at least a statement about h/o CAD, DM, malignancy in any family members.

REVIEW OF SYSTEMS (ROS)Used to identify symptoms Pertinent negatives (use: patient denies)and positives (use: patient complains of) Inventory of body systems Complete: all body systems; use Bates as guideline

Add pertinent information to your patient: some questions may be more pertinent to a geriatric patient (e.g. vision/ hearing impairments or urinary incontinence, mobility and cognitive impairments etc) than to a young adult

REVIEW OF SYSTEMS (ROS)General HEENT: Head/Eyes/Ears/Nose/Mouth/Throat (separate heading for each one, please) Neck Breasts Cardiac Respiratory Gastrointestinal Urinary Genital Peripheral vascular Musculoskeletal Skin Neurological Psychiatric Endocrine Hematologic/lymphatic

ROS - EXAMPLEGeneral: Patient denies any recent change in energy level or sleep. She thinks she has lost some weight since admission, but cannot say how much. No fever, chills, night sweats Skin: MF denies rashes, ecchymoses, lesions, and pruritus. She complains of pale skin. Head: Patient denies headaches, dizziness hair loss, or scalp pain. Eyes: She denies pain, pruritus, discharge or xeropthalmia. MF states she wears corrective lenses for daily use, but denies focal visual deficits or recent vision loss. Ears: She denies pain, discharge, hearing loss or tinnitus. Nose/Sinuses: Patient denies difficulty breathing, discharge, and pain. She complains of occasional congestion due to season allergies. Oral: MF denies bleeding gums, pain, and ulcerations in mouth. She wears dentures daily, and reports that they are properly fitting. Neck: Patient denies neck stiffness, pain, masses or nodules.

ROS - EXAMPLE (contd)Breasts: Denies pain, masses, nodules and recent changes of breast shape. Respiratory: She noted dyspnea on exertion, such as walking distances of 100 and the occasional cough when she has a cold. Denies pain on respiration or wheezing. Cardiovascular: Patient denies any palpitations, chest pain, dyspnea on exertion, orthopnea or PND Gastrointestinal: see HPI Genito-Urinary: Patient urinates approximately three to four times daily. Currently denies dysuria, urinary frequency, and incontinence. Endocrine: Patient denies any change in energy or in hair distribution and texture. She noted mild weight loss. No heat/cold intolerance. Denies polyuria, polydypsia, polyphagia. Hematologic/Lymphatic: Patient denies ecchymoses, masses, or nodules .

ROS - EXAMPLE (contd)Musculoskeletal: States she is unable to stand without assistance, and walks with an aluminum walker. MF also complains of weakness in her right upper extremity and poor range of motion due to an injury sustained in a fall five years previous. She rates the pain as 6/10 when in pain, controlled with BioFreeze application twice daily. She also complains of low to mid back pain, which has been resolving with the introduction of a new wheelchair. When acutely painful, she rates it as 8/10, and states her baseline is 0-3/10. Nervous System: She denied any headaches, diplopia, anosmia, or loss of taste. She experiences numbness and paresthesias in her hands bilaterally. Psychiatric: Patient reports positive attitude, currently denies feeling sad or depressed, delusions, and suicidal ideation.

PHYSICAL EXAMINATIONPerform a complete physical examination with specific attention to pertinent positive and negative findings. Document your PE findings, including pertinent negative findings, in an organized and concise fashion, preferably bullet format. List your findings in a head-to-toe fashion (in a typical H&P format) Review Bates Guide to Physical Exam

LABSInclude at least the patients CBC and BMP (which includes Renal function and electrolytes) in each write-up. If the CBC and BMP are WNL, you need to include another lab result pertinent to the system you are discussing. If there is no other pertinent lab in the chart, please include a discussion regarding possible pathological findings in BMP and/ or CBC due to patients condition/ meds. Any labs documented in the lab section of the paper that are ABNORMAL need to be discussed both in the A&P (briefly) AND in the Discussion section (more detailed). Once you have encountered an abnormal lab, you need to go back to your HPI or ROS (whichever is applicable) and include the appropriate questions in order to clarify this particular diagnosis.

ASSESSMENT AND PLAN (A&P)A=assessment (putting the data gathered in the subjectiveand objective portions of the H&P together to form diagnoses of what the problems may be) Put A & P together when possible as flows/logical/faster and easier to read Prioritize your diagnoses, starting the list with the most serious/life threatening (usually coinciding with your CC) Be sure that you have the data in your exam to support the diagnosis you use Save the detailed information about the diagnosis in question for the Discussion section and be concise in your A&P: if this is a chronic condition, you need to state if compensated/controlled or decompensated/uncontrolled, state the goal of treatment (according to what guidelines) and assess whether the patient is at goal or not. Also list stage of disease if applicable. If this is a new symptom/problem, please give presumed etiology and 1-2 differential diagnoses.

ASSESSMENT AND PLANList investigations needed to confirm your diagnosis Make a plan of pharmacological and non-pharmacological intervention Be sure to recognize that your patients are individuals and decide whether following a guideline would be the best choice for that particular patient (e.g.: Restricting salt for a 35 yo AA male with uncontrolled HTN versus an 89 yo Caucasian female with history of weight loss/debility and average SBP in 140s)

Use medical terms only and formulate actual diagnoses as components of your assessment Include all pre-existing conditions that are chronic (even those for which your patient may not be undergoing treatment at this time) and all the newly found problems (diagnoses)

A&P - EXAMPLE1. H/o GI Bleed: MF may currently be having an active occult GI bleed. Oral ferrous sulfate can darken the stool and appear as melena. The two negative FOBTs may be accurate if this is the case. She has had consistently low hemoglobin, hematocrit, and iron level despite long-term treatment, which may be due to the fact that she receives Erythropoietin for her anemia of chronic disease and this leads to increased iron consumption (to increase erythropoesis). Given her advanced age, and relative lack of overt symptoms, continue to monitor for now, in conjunction with hematology/oncology service. Consider colonoscopy/EGD for a definitive diagnosis, or in case of acute bleed or sudden drop in H&H.

A&P - EXAMPLE (contd)2. Weight loss: MFs weight has decreased to 129.4 pounds, which is a 5% percent from 11/08, and decreased 14% from admission in 2005. She has a history poor appetite when feeling depressed, and may be related to the Celexa, which is anorexigen. Consider performing a GDS and changing to another antidepressant. The weight loss could also be the result of her myelodysplastic syndrome or other occult malignancy and further workup may be necessary. Encourage healthy eating habits, assist where necessary. When possible, tailor diet to patients preference. Continue physical therapy, encourage assisted walking, regular exercise and group activities to improve her depression and/or appetite.

A&P - EXAMPLE (contd)3. Rectal hemorrhoids: MF has chronic stage III prolapsed hemorrhoids. Continue Proctosol HC cream twice daily. Educate patient and assist with cleaning techniques as necessary. Soft medicated wipes would likely be beneficial. Surgery is not likely a solution; given her age and comorbidities, the risks would likely outweigh the benefits. Manual reduction has been successful in the past, and may be an option. IRC previously stopped acute hematochezia, but was ineffective at reducing the hemorrhoids. Continue active positioning, and pressure relieving chair cushion. Ensure patient does not become constipated. Encourage ambulation as tolerated.

A&P - EXAMPLE (contd)4. Chronic anemia secondary to myelodysplastic syndrome: MF has a normochromic, normocytic anemia consistent with anemia of chronic disease. She has a decreased hemoglobin and hematocrit despite continued EPO injections. Total serum iron is also low despite daily ferrous sulfate therapy, which may indicative of blood loss. Complicating the picture, the patient has a history of GI bleed. However, two previous FOBTs were negative. That may be of little value, as this test has a low sensitivity. She may have a combination of blood loss and ineffective erythropoesis secondary to the myelodsyplastic syndrome. Continue to monitor CBC and Iron levels monthly per Heme/Onc. Continue Procrit (EPO) and ferrous sulfate. Monitor renal function with metabolic panel if EPO appears ineffective. Continue to ambulate and exercise as tolerated to prevent constipation that can be associated with iron therapy. Maintain and encourage diet and fluids as tolerated.

DISCUSSIONReview of medical textbooks and articles related to your patients diagnoses and how the medical literature applies to your patient (focus primarily on medical textbooks and less on journal articles). Include AT LEAST 2 conditions pertinent to the system AND the abnormal labs . The topics included in the discussion need to correlate with the abstract and the system covered in the HPI Length should be 2- 4 pages; points will be deducted for shorter or longer length than specified.

REFERENCESYou need to review and cite in your references at least 2 widely-accepted medical textbooks. The other 3 references can be articles, preferably review articles from reputable medical journals. At least one article should be included in references. Web sites are not acceptable to be listed as references.