Chief Complaint (CC)
The opening statement should give an overview of the patient, age, sex, reason for visit and the duration of the complaint. Give marital status, race, or occupation if relevant. If your patient has a history of a major medical problem that bears strongly on the understanding of the present illness, include it.
History of Present Illness (HPI)
This will be very similar to your written HPI. Present the most important problem first. If there is more than one problem, treat each separately. Present the information chronologically. over one system before going onto the next. Characterize the chief complaint – quality, severity, location, duration, progression, and include pertinent negatives. Items from the ROS that are unrelated to the present problem may be mentioned in passing unless you are doing a very formal presentation. When you do your first patient presentation you may be expected to go into detail.
Review of Systems (ROS)
Most of the ROS is incorporated at the end of the HPI. Items that are unrelated to the present problem may be briefly mentioned.
Past Medical History (PMH)
Discuss other past medical history that bears directly on the current medical problem.
Past Surgical History
Provide names of procedures, approximate dates, indications, any relevant findings or complications, and pathology reports, if applicable.
Present all current medications along with dosage, route and frequency. For the follow-up presentation just give any changes in medication.
Smoking and Alcohol (and any other substance abuse)
Note frequency and duration.
Home, environment, work status and sexual history.
Note particular family history of genetically based diseases.
Physical Exam/Labs/Other Tests
Include all significant abnormal findings and any normal findings that contribute to the diagnosis. Give a brief, general description of the patient including physical appearance. Then describe vital signs touching on each major system. Try to find out in advance how thorough you need to be for your presentation. There are times when you will be expected to give more detail on each physical finding, labs and other test results.
Assessment and Plan
Give a summary of the important aspects of the history, physical exam and formulate the differential diagnosis. Make sure to read up on the patient’s case by doing a search of the literature.
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