Internal medicine educational case history structure
Sections in the order expected by most academic departments. The generator uses this exact structure; if your department requires a specific format, upload it as a template.
- 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.
How an internal medicine case history differs from other subjects
An internal medicine case history (faculty therapy, hospital therapy, internal diseases) tests primarily clinical reasoning: from complaints and physical findings to syndromes, from syndromes to nosology, from nosology to treatment according to clinical guidelines. In surgery, the main focus is status localis and the operation, in infectious diseases it is the epidemiological history, while in internal medicine it is the logic of the diagnosis and how you account for comorbid conditions.
In faculty therapy, students usually follow a patient with a single leading disease in a typical clinical course, where the most important things are a complete classification and accurate formulation. In hospital therapy, the focus shifts to multimorbidity, differential diagnosis, and treatment selection when the patient has multiple diseases and medications interact with each other.
Which sections the department grades the strictest
- Justification of the diagnosis. Every statement is supported by a fact: a complaint, a physical examination finding, a lab value. The phrase "based on complaints, anamnesis, and physical examination" without listing specific facts will not receive credit.
- Formulation of the clinical diagnosis. Structure: main disease, complications of the main disease, comorbidities. For the main disease, all categories of the adopted classification must be indicated: stage and grade of hypertension and CV risk, functional class of angina pectoris, stage of chronic heart failure according to Strazhesko-Vasilenko, and functional class according to NYHA.
- Differential diagnosis. With 2–3 diseases that genuinely resemble your patient's case, based on specific features rather than generic textbook phrases.
- Treatment. Medications with doses, frequency, and justification in accordance with current clinical guidelines of the Russian Ministry of Health, non-pharmacological measures, and therapy goals: target BP, heart rate, LDL-C level.
What to add beyond the general layout
Particularly outstanding are the papers where clinical scales are calculated (CHA2DS2-VASc and HAS-BLED in atrial fibrillation, CURB-65 in pneumonia, GFR by CKD-EPI in renal assessment), the ECG is analyzed step by step, the follow-up notes show dynamics rather than repeating the same text, and the epicrisis concludes with post-discharge recommendations. It is convenient to calculate scales in the clinical scales section and cross-check controversial treatment points against clinical guidelines. The general procedure for working on a medical history case is discussed in the article on the medical history with a neural network.
Sample internal medicine case history: hypertension
Model example, the patient is fictional. Three sections where points are most frequently lost are shown.
Justification of the preliminary diagnosis
Patient N., 58 years old, complains of a pressing headache in the occipital region and tinnitus upon BP elevation up to 170/100 mmHg. Notes BP elevation for 6 years, takes antihypertensive drugs irregularly. Risk factors: male sex, age over 55, smoking (20 pack-years), obesity (BMI 31.2 kg/m², waist circumference 108 cm), early stroke in father (at age 54).
Objectively: BP 162/98 mmHg on both arms, HR 78 bpm, pulse regular. Apex beat enhanced, sustained, in the 5th intercostal space along the left midclavicular line; the left border of relative cardiac dullness is shifted to the left midclavicular line. Accent of the 2nd heart sound over the aorta.
Syndromes identified: arterial hypertension (BP 162/98 mmHg, corresponding to grade 2) and left ventricular hypertrophy (enhanced sustained apex beat, displacement of the left heart border, Sokolow-Lyon index of 38 mm on ECG). Target organ damage without associated clinical conditions corresponds to stage II, and the combination of stage II and grade 2 hypertension yields a high CV risk. Symptomatic hypertension remains to be ruled out, so the diagnosis is preliminary.
Formulation of the clinical diagnosis
Main disease: Stage II hypertension. Hypertension grade 2. Left ventricular hypertrophy. Dyslipidemia. Grade I obesity. CV risk 3 (high). Target BP <130/80 mmHg.
ICD-10 code: I11.9 (hypertensive heart disease without [congestive] heart failure).
If there is no heart and kidney damage, hypertension is coded as I10, and in the presence of CHF, I11.0 is used. The code must match what is written in the formulation.
Examination plan
- Complete blood count, urinalysis.
- Blood chemistry panel: creatinine with GFR calculation by CKD-EPI, potassium, sodium, fasting glucose, lipid profile (total cholesterol, LDL-C, HDL-C, triglycerides), uric acid.
- Albumin-to-creatinine ratio in a single-void urine sample.
- 12-lead ECG, echocardiography with left ventricular mass index calculation.
- Ambulatory blood pressure monitoring (ABPM), duplex scanning of brachiocephalic arteries, fundus examination.
Further in the treatment section, it is logical to justify the starting dual fixed-dose combination (a RAAS blocker with a dihydropyridine calcium channel blocker or with a thiazide/thiazide-like diuretic), non-pharmacological measures, and the decision on lipid-lowering therapy according to the cardiovascular risk category.
Common mistakes in internal medicine case histories
- Diagnosis without classification categories: "AH", "CHD", "CHF" without stage, grade, or functional class.
- Justification of the diagnosis reduced to a generic phrase instead of a list of specific complaints, findings, and numbers.
- Complications recorded as comorbidities, and comorbidities mixed up with the main disease.
- The differential diagnosis was made with diseases that the case does not resemble, or was copied from a textbook without reference to the patient.
- Treatment without doses, frequency, and justification, or using outdated regimens not found in current clinical guidelines.
- Figures do not match across sections: one BP value in the status, another in the progress notes, and a third in the epicrisis.
- Laboratory tests are presented without interpretation: the number is there, but there is no conclusion on which syndrome it confirms.
- Follow-up notes are copied from each other without showing the dynamics of complaints, BP, HR, and response to treatment.
- The identification section contains the patient's real full name, date of birth, or address instead of anonymized data.
Compile your internal medicine case history
The patient can be simulated for a specific condition, or you can upload your own clinical notes (text, handwritten photos, audio). Cross-checked with clinical guidelines, ICD-10 coding, and export to Word and PDF. 2 case histories per month for free.
Frequently asked questions
How to write an internal medicine case history?
Start with the patient care and examination: questioning, systemic physical examination, laboratory and instrumental findings. Then, identify the syndromes, justify the provisional diagnosis, formulate an examination plan, conduct a differential diagnosis, and state the clinical diagnosis according to the classification. Conclude the work with treatment based on clinical guidelines, progress notes, epicrisis, and references.
How does a case history in propedeutics of internal diseases differ from hospital therapy?
Propedeutics of internal diseases usually focuses on a single leading disease in a typical course, with the main emphasis on a complete classification and formulation of the diagnosis. Hospital therapy pays more attention to comorbidity, differential diagnosis, and treatment selection considering concomitant diseases and drug interactions.
Where can I find an example of an internal medicine case history?
The model example above shows what the justification, diagnosis formulation, and examination plan look like. It is risky to submit someone else's ready-made case history: instructors recognize standard texts, and during the defense, they ask questions about your patient. It is more reliable to use the example as a structural guideline and compile your own work based on your patient care notes.
Which diseases are most commonly chosen for an internal medicine case history?
Patients with hypertension, coronary artery disease, chronic heart failure, atrial fibrillation, pneumonia, COPD, bronchial asthma, peptic ulcer disease, liver cirrhosis, chronic pyelonephritis, rheumatoid arthritis, and type 2 diabetes mellitus are most frequently managed. The choice depends on the profile of the department where the rotation takes place.
Must the ICD-10 code be specified in a student internal medicine case history?
Most departments require the code after the clinical diagnosis formulation. The code must correspond to the formulation: for example, hypertension with left ventricular hypertrophy without CHF is coded as I11.9, while without heart and kidney damage it is I10.
Can an internal medicine case history be written using an AI?
You can use AI to figure things out and put together a draft, and you will defend the work yourself. The generator compiles a student case history following the internal medicine structure or your department's uploaded template based on your care notes (text, file, photo of handwritten notes, audio), checks the diagnosis and treatment against the Russian Ministry of Health clinical guidelines, assigns the ICD-10 code, and marks missing data as "not specified". Do not include the patient's real full name, date of birth, address, or insurance policy in the prompt: this is medical confidentiality (Art. 13 of Federal Law No. 323-FZ) and personal data (Federal Law No. 152-FZ), and the identification section must be anonymized. 2 case histories per month are available for free on any account, with another 5 on the "Maximum" plan.
Case histories for other subjects
How the generator works and how to check its output: case history with AI. All tools: AI for medical professionals.