A -Year-Old with Medical Student Presentation

Name of StudentDate and time

Chief Complaint and History of Present Illness

Concise statement of chief complaint Quality/Location/radiation/severity Chronology – onset, timing, duration,

frequency, changes over time Aggravating/alleviating factors Associated symptoms Pertinent risk factors Attributions (what does patient think is

causing the problem?)

2

Past History Past Medical History:

– diagnoses– complications/sequelae/progression– current management and status

Surgical History– Reason if appropriate

3

Medications and Allergies Current Medications

– Dosages, OTC meds., alternative therapies

– Immunizations– Hormone replacement, aspirin, calcium– Devices– Nutritional supplements

Allergies: Note specific reactions

4

Social History Tobacco, alcohol, drug, and caffeine Exercise/diet Travel /exposures HIV risk factors Occupation and current living

situation– Seat belts use, smoke alarms, helmet

use, and gun safety Social cultural/ethnic background Screening examinations

5

Family History Cancer Hypertension Heart disease Diabetes Other relevant diseases Illness similar to present illness

6

Reproductive/Sexual History Sexually active Contraception; STD prevention and

STD Menarche (age) Menses Menopause (age) Pregnancies; abortions: spontaneous;

full-term, premature, living (Para Gravida format)

7

Review of Systems General: Fever; sweats; weight change;

energy level Skin: Rashes; pruritus; lumps or lesions HEENT:

– Headache; trauma, vision; glasses; diplopia; inflammation; pain; hearing; tinnitus; vertigo; pain, epistaxis; obstruction; drainage; dental care; dentures; sores; sore throat

Breasts: Lumps; discharge; pain; swelling Respiratory: Dyspnea; pleuritic pain;

cough; sputum; wheezing; asthma; hemoptysis; cyanosis; snoring; apnea; TB exposure; PPD

8

Review of Systems Cardiovascular: Chest pain; dyspnea-various

types, orthopnea; edema; palpitations; claudication

Gastrointestinal: Appetite; dysphagia/odynophagia; heartburn; nausea/vomiting/diarrhea; constipation; change in bowel habits; hemorrhoids; jaundice; hematemesis/melena/hematochezia

Genitourinary: Dysuria; nocturia; hematuria; frequency; urgency; hesitancy; incontinence; discharge

Musculoskeletal: Joint/back pain; swelling; stiffness; deformity; muscle aches

9

Review of Systems Neurological: Dizziness; syncope; loss of

coordination; weakness; memory changes; seizures; paresthesias

Psychiatric: Depression; sleep disturbance; anorexia; anhedonia; suicidal/homicidal ideation; anxiety; eating disorders; hallucination; delusions; behavioral changes

Hematologic: Anemia; easy bruising; heavy bleeding

Endocrine: Polyuria; polydipsia; heat/cold intolerance

Functional Status (optional): Activities of Daily Living: bathing; ambulating; toileting; transfer; eating; dressing

10

Physical ExaminationVital signs and General Appearance Blood pressure (standing/lying if

indicated) Temperature Pulse Respiratory Rate Oximetry on _____ Height and weight (if appropriate)

11

Physical Examination Head / Face /Ears / Nose / Mouth

/Neck

12

Physical Examination Chest

13

Physical Examination Abdomen

14

Physical Examination Neuromuscular

15

Physical Examination Rectal and Genitalia

16

Physical Examination Osteopathic structural examination

17

Differential Diagnosis What is the differential diagnosis of

this patient’s problem based on symptoms and signs?

18

Differential Diagnosis

19

What Testing is Indicated?

20

Test Results

Discussion of Disease Process

22

Discussion of Management

23

References

24

Questions

25