How to do a writeup
Dr Lina Choong
A case writeup explores the characteristics of the patient who has a problem/problems
which leads to a consultation or hospitalisation and how it is diagnosed and managed. It
covers the breadth of the basic sciences (anatomy, physiology, pathology, microbiology etc)
to understand the linkages of a medical condition starting from its predisposing conditions,
leading up to the presentation and which diagnosis best fits the picture. It is a reflection of
all these processes to capture your understanding of the subject.
The first clinical year of the Medical Student’s path generally focuses more on diagnosis.
However, he is expected to know the aims of management in common conditions.
1. Enumerate the facts of the case
- Patient’s Gender/Age/Ethnicity
- Chief Complaint
- Relevant History
o Include relevant past medical history and chronic medications
o Drug Allergy
o Social History
o Other relevant history
- Relevant Physical Examination
- Other relevant Information which may include:
o Lab tests already available at the first consultation or initial clerking
o Imaging tests
o Other tests
2. Develop a problem list and enumerate the various conditions you need to address
during the course of his admission or if ambulatory (ongoing consultations)
eg.
1 Chief complaint
- Differential Diagnosis 1
- Differential Diagnosis 2
- Differential Diagnosis 3
etc
2. Other medical conditions
a.
b.
c.
etc
Please do this list first before proceeding to discuss the conditions
3. Rank the differential diagnosis of the chief complaint from the most likely to least
likely? Under each condition, you should state why this is likely or less likely using
the facts from Item 1 (history, physical and lab findings or imaging). Where relevant,
include the severity of the condition and how it is derived eg scoring system.
For a case that has been worked up, you should use the relevant investigations to
rule-in or rule-out a condition. Where an investigation is pending, state how it is
expected to help in the differential diagnosis
4. Are the background or other acute conditions which are active, require management
and can impact on the patient’s health. Explain how that may be.
5. What are your management aims and plan for the patient? Explain the purpose of
each aim.
6 How would you gauge the response or progress of the patient? What monitoring
should be performed?
Where possible use the actual progress of the patient as illustration
7 What learning points have you obtained from this case. List and discuss at least
three.
Updated 4/6/2021
