Patient Notes

Date:
Student Name:
Patient Number:
   

HISTORY Include significant positives and negatives from history of present illness, past medical history, review of system(s), social history, family history, medications and allergies.

 


PHYSICAL EXAMINATION - Describe any positive and negative findings relevant to this patient's problem(s). Be careful to include only those parts of the examination you performed in this encounter.

DIFFERENTIAL DIAGNOSIS/Assessments - Data Interpretation: Based on what you have learned from the history and physical examination, list a minimum of 3 diagnoses that might explain this patient's complaint(s). List your diagnoses from most to least likely. Then enter the positive or negative findings from the history and the physical examination (if present) that support each diagnosis.

 

Diagnosis #1

History Finding(s)

Physical Exam Finding(s)

Diagnosis #2

History Finding(s)

Physical Exam Finding(s)

Diagnosis #3

History Finding(s)

Physical Exam Finding(s)

Diagnosis #4

History Finding(s)

Physical Exam Finding(s)

Diagnosis #5

History Finding(s)

Physical Exam Finding(s)

DIAGNOSTIC WORKUP/PLAN - List immediate plans (up to 5) for further diagnostic workup:
1.
2.
3.
4.
5.
 

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