7/28/2019 Blank Patient Note for step2cs

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Step 2 Clinical Skills Patient Note Doctor Case

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

Physical Examination: Indicate only pertinent positive and negative findings related to the patients chiefcomplaint.

Differential Diagnosis: In order of likelihood (with Diagnostic Workup: List immediate plans (up to1 being the most likely), list up to 5 potential or 5) for further diagnostic workup:possible diagnoses for this patients presentation

(in many cases, fewer than 5 diagnoses are likely):

1. 1.

2. 2.

3. 3.

4. 4.

5. 5.