General structure of a student case history
The framework is nearly identical across all departments in Russian medical universities: patient identification data, chief complaints, history of present illness (anamnesis morbi), past medical history (anamnesis vitae), physical examination (status praesens) by system, preliminary diagnosis, diagnostic plan and results, differential diagnosis, clinical diagnosis, etiology and pathogenesis, treatment, daily progress notes, epicrisis, prognosis, and references. Below is this structure as used by the generator (illustrated using internal medicine).
- 1General patient data
Age (not date of birth), gender, occupation/profession (omit organization name), date and time of admission, department, referral source/delivery method, referring facility diagnosis, admission diagnosis. Do not include full name, address, or document numbers: use "Patient N."
- 2Complaints
Chief complaints with details (localization, character, intensity, radiation, duration, triggers, and relieving factors) along with general symptoms; complaints upon admission and at the time of examination.
- 3History of the present illness (Anamnesis morbi)
Onset and progression, initial symptoms, clinical course, previous medical consultations, prior diagnostic tests and treatments before admission along with their efficacy, as well as the reason and circumstances of hospitalization.
- 4Past Medical History (Anamnesis vitae)
- Brief biographical data, living conditions, and dietary habits
Birthplace and upbringing, education, housing and living conditions, dietary habits, physical activity.
- Occupational history
Profession, length of service, working conditions, occupational hazards (without naming the organization).
- Past medical history, surgeries, injuries
Childhood infections, chronic diseases, surgeries, trauma, tuberculosis, viral hepatitis, STIs, blood transfusions (with reactions).
- Bad habits
Smoking (duration, pack-years), alcohol (frequency, quantity), illicit drug use.
- Medication history
Regular medications taken by the patient (name, dose, frequency).
- Allergic history
Drug, food, and household allergen intolerance; type of reaction.
- Epidemiological history
Contact with infectious patients, travel outside the region/country over the past 6 months, parenteral interventions, bites, dietary history, contact with animals.
- Family history
First-degree relatives' medical history (CVD, diabetes mellitus, oncology, tuberculosis, psychiatric conditions).
- Obstetric and gynecological history
For women: menarche, menstrual cycle characteristics, menopause, pregnancies/childbirth/abortions.
- Insurance history
Certificate of incapacity for work (duration), disability group.
- 5Objective examination (Status praesens objectivus)
- General physical examination
General condition, level of consciousness, body position, physique, body type, height, body weight, BMI, body temperature; skin and visible mucous membranes, subcutaneous adipose tissue, edema, lymph nodes, muscles, bones, joints.
- Respiratory system
Chest inspection, respiratory rate, palpation (resistance, vocal fremitus), comparative and topographical percussion, auscultation (breath sounds, rales, crepitation, pleural friction rub), bronchophony, SpO2.
- Cardiovascular system
Inspection of the heart and neck vessels, apex beat, boundaries of relative cardiac dullness, auscultation (heart sounds, murmurs), pulse (rate, rhythm, volume, tension), blood pressure on both arms, peripheral arterial pulsation.
- Digestive system
Oral cavity, tongue, abdomen (inspection, superficial and deep palpation according to Obraztsov-Strazhesko, percussion, auscultation), liver dimensions according to Kurlov, gallbladder (symptoms), spleen, stool.
- Urinary system
Lumbar region inspection, kidney palpation, tapping sign (Pasternatsky's sign), urination, diuresis.
- Endocrine system
Thyroid gland (palpation, eye signs), subcutaneous fat distribution, secondary sexual characteristics.
- Nervous system and sense organs
Consciousness, orientation, sleep, memory, meningeal signs, focal symptoms, reflexes, vision, hearing.
- 6Preliminary diagnosis and its rationale
Identify syndromes based on complaints, history, and objective data, justify each; formulate a preliminary diagnosis.
- 7Examination plan
Laboratory and instrumental studies and consultations with the purpose of each: according to clinical guidelines of the Russian Ministry of Health (mandatory and as indicated).
- 8Results of laboratory and instrumental studies
All available results with dates (in a table where appropriate) and interpretation: what is normal, what is abnormal, and what it means. Unperformed/missing studies should be listed as "no data".
- 9Differential diagnosis
At least 2–3 diseases with a similar presentation: for each, common features and differences used to rule it out (based on this patient's data).
- 10Clinical diagnosis and its rationale
Formulation according to the classification from clinical guidelines and ICD-10 (code): underlying disease, complications of the underlying disease, comorbid conditions; rationale for each component.
- 11Etiology and pathogenesis
Etiology and pathogenesis of the disease in general and applied to this patient (risk factors, mechanisms of syndrome development).
- 12Treatment and its rationale
Regime, diet (table), non-pharmacological treatment, pharmacotherapy: drug (INN), dose, route, frequency, duration, and justification with reference to clinical guidelines; At the end: prescriptions in Latin (Rp.: … D. S. …) for 2–3 main drugs.
- 13Observation notes
prescriptions).
- 14Stage (discharge) epicrisis
Briefly: patient, age, date of admission, reason for admission, main examination results, clinical diagnosis, treatment performed and its effect, condition at the end of curation, recommendations.
- 15Prognosis and recommendations
Prognosis for life, for recovery, for working capacity (with justification); discharge recommendations and follow-up care according to clinical guidelines.
- 16References
formatted according to GOST R 7.0.100-2018.
Compile a case history using the structured format
From patient care notes (text, manuscript photo, audio) or based on the disease alone. Cross-checked with Russian Ministry of Health clinical guidelines, ICD-10 code, Latin prescriptions, export to Word and PDF. 2 case histories per month free of charge.
Frequently asked questions
How to write an academic case history?
Start with your department's template and gather patient care data: complaints, history of present illness, objective status by organ systems. Next, identify syndromes, justify the provisional diagnosis, outline an examination plan based on clinical guidelines, perform differential diagnosis, and formulate the clinical diagnosis with an ICD-10 code.
How do case histories differ across various medical subjects?
The general framework is identical, but specialized sections differ: local status and operative report in surgery, pediatric history and vaccinations in pediatrics, obstetric status in obstetrics, neurological status and topical diagnosis in neurology, epidemiological history and anti-epidemic measures in infectious diseases.
Can you write a medical case history using a neural network?
An academic one, yes: the generator will assemble a document according to your department's template from your care notes or disease name (simulating a patient), cross-check the diagnosis and treatment with clinical guidelines, and assign an ICD-10 code. You must read and understand the draft, as you will be the one defending the case history.
Where can I find my department's case history template?
It is usually provided by the department or found in the methodological guide. You can upload your department's template to the generator or use one already uploaded by other participants.
Detailed guide: how to write an academic case history using AI. Other tools: AI for healthcare professionals.