!"#$% '(!) *(+(* , -!"( .)/0(1$ (+!*1!

0/23 42)#

-*/3/-!* (3-2130() #251*( .((6 7 81*' 9: 7;<=
"015(30 3!#(> ??????????????????????????????????????? (+!*1!0(5 @'> ??????????????????????
YL7 CASE WRITE UP CHECK LIST

Maximum
Score
Students
Score
Description of the person/patient
2

Full Name, Gender, Birthdate, Literacy level, Occupation, Civil status, Place of
origin, Race, Informant - Reliability
History of presenting condition
14

Chief complaint, History of present illness (6 pts), Review of system (1 pt)
Past Medical Hx (1 pt), Birth / Maternal / Menstrual Hx (1 pt), Immunization
Hx (1 pt), Nutritional Hx (1 pt), Developmental Hx (1 pt), Family History (1
pt), Temporal profile (1 pt)
Result of Physical Examination
10

Vital Signs (1 pt), Anthropometrics / Nutritional Status (1 pt) , Overall
Condition (in distress/not), HEENT, Chest wall/Breasts, Lungs, Heart, Upper
Extremities, Abdomen/Inguinal Areas, Perineum/Rectal/Vaginal, Lower
Extremities (8 pts)
Describe the patient's psycho-socio-religious context
7

Religion, Religion of Spouse/Children, Pertinent personal beliefs, Pertinent
family Traditions , Social Influence and Convictions, Alcohol Intake or abuse,
Use of prohibited drugs, Sexual preference, Size of family/ Number of
Children, Number of Dependents (extended family), Previous psychological
problems, Anti-social behavior/ convictions, Main source of living, Place and
nature of dwelling, Intact/dissipated family/OFW, Income per month
NOTE: Stakeholder Analysis (4pts)
Pre-work-up discussion leading to a clinical impression & differential
diagnosis/es
25

Salient features, pertinent positive and negative findings, Literature Review to
support impression, Statement of differential diagnosis/es, Ruling out the
differential diagnosis/es
Explain pathophysiology of clinical impression 10
Rationalization of diagnostic work-up

10


Pertinent laboratory tests, Pertinent ancillary procedures, Interpretation of
results, Rationale for diagnostic tests
Principles of management of the clinical problem

5

Definitive Management, Supportive/adjuvant/palliative management, Review
of pertinent literature
Management and Discussion of psycho- socio-religious problem/s

3


Prognosis
4

Expected outcome with intervention, Expected outcome w/o intervention
Expected subsequent intervention/s in case, of failure of therapy
Preventive measures

10

Prevention of clinical problem, Prevention of related psycho-socio-religious
problem/s
TOTAL

100