a -year-old with a -year-old with medical student presentation name of student date and time
TRANSCRIPT
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A -Year-Old with
Medical Student Presentation
Name of StudentDate and time
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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?)
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Past History
Past Medical History:– diagnoses– complications/sequelae/progression– current management and status
Surgical History– Reason if appropriate
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Medications and Allergies
Current Medications– Dosages, OTC meds., alternative
therapies– Immunizations– Hormone replacement, aspirin, calcium– Devices– Nutritional supplements
Allergies: Note specific reactions
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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
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Family History
Cancer Hypertension Heart disease Diabetes Other relevant diseases Illness similar to present illness
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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)
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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
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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
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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
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Physical Examination
Vital signs and General Appearance Blood pressure (standing/lying if
indicated) Temperature Pulse Respiratory Rate Oximetry on _____ Height and weight (if appropriate)
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Physical Examination Head / Face /Ears / Nose / Mouth
/Neck
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Physical Examination Chest
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Physical Examination Abdomen
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Physical Examination Neuromuscular
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Physical Examination Rectal and Genitalia
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Physical Examination
Osteopathic structural examination
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Differential Diagnosis
What is the differential diagnosis of this patient’s problem based on symptoms and signs?
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Differential Diagnosis
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What Testing is Indicated?
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Test Results
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Discussion of Disease Process
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Discussion of Management
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References
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Questions
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