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Guidelines for Write-Ups


Principles

The purpose of the write-up is


To record your patient's story in a concise and well-organized manner.
To demonstrate your clinical reasoning and decision making to other providers
To demonstrate your fund of knowledge and problem solving skills.
Although there is no single authority on write-ups, these guidelines will help you avoid
common mistakes. Further specific feedback from your teachers will illustrate the
diversity of styles used in the successful write-up.
The Length and Structure

The overall length should be 3-5 pages. Here is a suggested detail for each component of
the write up:
Source of Information (1/2 line)
Chief Complaint (1-2 line)
History of Present Illness (1/2 to 1 page)
Past Medical History (list)
Family History (5 lines)
Social History (5-10 lines)
ROS (1/4-1/2 page)
Physical Examination (1/2-11/2 pages)
Laboratory (1/4-1/2 page)
Assessment/Plan (1-11/2 pages)
History of Present Illness (HPI): The history of present illness can be viewed as a hypothesis generating
statement. The first paragraph should make clear to the reader the primary hypothesis (or hypotheses) that one
is considering as an explanation of the patients presenting complaint(s). The second paragraph should make
clear to the reader the alternative hypotheses that one is considering by means of providing additional pertinent
negatives / positives that may alternatively explain the patients presenting complaint(s).
The following is a basic structure of the HPI.

The Topic Sentence


The topic sentence should begin with identifying information. Include the patient's
Age
Sex
Country of origin or race if relevant
Other social/demographic info if relevant
Other active and relevant medical problems
- no more than four
- must be critical to understanding the chief complaint or will influence the management
of the patient
Summary of the chief complaint
Good examples
''Mr. Jones is a 54 yo man with a history of a recent umbilical hernia repair who presents
with nausea, vomiting, and abdominal pain.''
(acute and latent complications arise from prior abdominal surgery)
''Mrs Evans is a 62 yo woman with diabetes and steroid dependent COPD who presents
with dysuria and hematuria.''
(diabetes and lung disease will require active management in the hospital)
Bad Example
''Mr. Smith is a 45 yo man with a remote history of diverticulitis who presents with a
swollen leg.''
(diverticulitis is neither active nor relevant and belongs in the PMH)
Chronology
Next describe the story chronologically. If you believe that the chief complaint (chest
pain) may be the direct extension of his ongoing chronic problem (recurrent PE's s/p leg
trauma), then begin the HPI with the chronic problem.
''Mr. Womack is a 45 yo man with a history of recurrent pulmonary emboli (PE) who
presents with chest pain. Two years prior to admission, he suffered a compound femur
fracture from a motor vehicle accident. He course was complicated by a PE. He since has
been treated with coumadin and has demonstrated noncompliance with the medication
leading to two subsequent admissions for PE. He was in his usual state of health until,...''
Sufficient Detail
Pay attention to detail. The well-characterized history includes
Setting of the complaint
Intermittent/constant
Progressive/stable or improving
Any prior episodes
Duration
Aggravating or alleviating features
Associated symptoms

''...He was in his usual state of health until today when, while sitting in a chair, he
developed the abrupt onset of a diffuse left anterior chest pain without radiation,
associated with shortness of breath. The pain was 5/10, described as sharp and constant.
It was unaffected by position.''
Pertinent Negatives

Include pertinent negatives so that the reader is influenced to think in terms of your
differential diagnosis.
''...There was no fever, cough, sputum, chest pressure, nausea, vomiting, bloating, or
hematemesis. He has no prior history of trauma to the chest, prior coronary artery disease
or anxiety.''
The pertinent negatives reflect the differential diagnosis. Other causes of chest pain to
consider in this case are pneumonia (fever, cough, sputum), coronary artery disease
(radiating chest pressure, nausea), peptic ulcer disease (nausea, vomiting, hematemesis),
anxiety or musculoskelatal disease.
Only negative statements belong in the pertinent negatives section. If you discover that
your patient has not been taking his coumadin, you would tell the story chronologically.
''... He has not been taking his coumadin over the last three weeks. He was in his usual
state of health until today when...''
If Evaluated Elsewhere and Transferred to Your Service

Key events from outside evaluations are placed in the concluding remarks of the HPI.
''...Because these symptoms did not improve and were similar to prior PE's that he
experienced, he went to his local physician who hospitalized him at St. Mary's Hospital.
Evaluation there revealed a swollen left lower extremity, a sub-therapeutic prothrombin
time and a moderate probability VQ scan. He was given the diagnosis of PE and
transferred to our hospital for further evaluation.''
Relevant data collected before your evaluation (or the Emergency Department
evaluation) even if it includes physical findings and labs, belongs in the concluding
remarks of the HPI. Alternatively, this data may be incorporated into the chronology for
the patients HPI if it is relevant to the story and helps build the hypothesis being
constructed in the first paragraph.
Past Medical History

Include all medical problems (active or remote). We suggest that you order the problems
outline the problems from the most pertinent to the least pertinent to the issues of the
current illness.
1. Recurrent PE's, see HPI
2. Noncompliance with coumadin, see HPI
3. MVA with left leg fracture
4. Cellulitis, group A streptococcal bactermia, no recurrences
5. Appendectomy*,
6. T&A as a child*
If Mr. Womack was admitted for lower abdominal pain with a differential including
small bowel obstruction, then the appendectomy would take higher priority in the PMH
listing and be mentioned in the HPI.
* You may list prior surgeries in a separate section or record them in order of pertinence
to the current presentation with the other medical problems
Certain diseases require listing of pertinent positives and negatives in the PMH. Your
residents can assist you.
1. COPD: diagnosed 1995, never required steroids, never intubated, hospitalized x 2 for
exacerbations in ( ) and ( ), ( ) PFTs FEV1 1.8L, FEV1/FVC 0.65.
2. DM: diagnosed 1997, oral hypoglycemics, Hgb A1C 1999 8.2, no micro- or macro-
vascular complications known.
3. CAD: s/p PTCA of LAD 1998, angina equivalent is chest pressure with exertion, 2
NTG tabs a month, cath 2000: 70% LAD stenosis, 30% circumflex stenosis, no wall
motion abnormalities (or last echo showed,...)
Other items to include in the Past Medical History, as taught in physical diagnosis:
medications (record doses)
allergies (list reaction experienced)
substance abuse
transfusions
substance abuse
childhood illnesses and immunizations if pertinent
Family History

Construct a family tree. Specify whether there is a family history of DM, HTN, cancer,
heart disease, or illness similar to the HPI.
Social History

Include social support, occupation, education, travel, and sexual history.


Review of Systems

Listing, rather than using subject and verbs, is preferred. Remember, pertinent positive
and negative symptoms dealing with the present illness belong in the HPI, not the ROS.
Physical Examination

Listing, rather than using subjects and verbs, is preferred.


Laboratory Data

A commonly used order is:


Electrolytes
CBC
Urinalysis
CXR
EKG
Microbiology
Other
Assessment and Plan

When the differential is unknown


State the problem, which usually is a symptom, sign, or abnormal laboratory result or
diagnosis. List a differential diagnosis. State which diagnosis is most likely and why,
drawing from the information from your recorded history and physical. State why other
diagnoses in the differential are less likely. Discuss the plan. ''I favor the diagnosis of PE
because,... I believe that pneumonia is less likely given the CXR,...''
When the differential is known
Your discussion should focus on causes of the condition or controversies in management.
Your resident or attending can assist you in tailoring the discussion to meet your learning
needs.
When the patient has multiple problems to discuss
Again, your resident or attending can help you to determine how to organize you're A&P.
For example, you have a patient with COPD, pneumonia, and uncontrolled DM. Since
you have had many patients with COPD exacerbation, you decide not to discuss COPD.
Instead, you argue that the pneumonia likely led to the COPD exacerbation and
uncontrolled glucose readings, then you expand your discussion with a review of
pneumonia pathogens in this population. You conclude with your plans to pursue further
diagnosis (sputum culture) and provide therapy (bronchodilators, antibiotics, IVF's, and
insulin).
Common Mistakes

Pertinent Negatives are Omitted - This section is difficult and requires that we thoroughly
understand the differential diagnosis of our patient's complaint.
Related complaints are discussed separately in the HPI - A patent with expanding ascites
may experience simultaneous dyspnea, abdominal pain, and edema. To discuss these
three symptoms as separate problems in the HPI is a mistake. Ask for direction from your
resident or attending if you are unsure whether symptoms are related.
Long narrative descriptions of physical signs - use listing, omit subjects and verbs.
Inattention to detail - A ''soft systolic ejection murmur'' is inferior to ''a 1/6 midsystolic
murmur at the left sternal border, without radiation that decreases with Valsalva.''
List of unfamiliar abbreviations - When in doubt spell out the word.
Recording a diagnosis instead of a finding in the physical exam - Writing ''findings
consistent with RLL pneumonia'' is inferior to ''right posterior base with increased
fremitus, dullness to percussion and bronchial breath sounds.''
Incomplete Assessment and Plan - ''Hematemesis - probably varices. Plan T&C 4 units, 2
16g IV's, consult GI'' is only appropriate when you are an experienced house officer on a
busy call night. As a third year clerk, you should become a scholar on your patient's
problems and demonstrate this in your assessment, discussing a complete differential
diagnosis, separating likely from unlikely diagnoses, and emphasizing a reason behind
your plan.

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