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- Demographic information of the patient
- Chief complain.
- History of present illness. Fallowing the mnemonic old chart: Onset/Location/Duration/Character/Alleviating-Aggravating factors/Temporal pattern/Severity. Additional symptoms and previous treatment if known.
- Medical history: PMH, FMH, SMH.
- Social history, employment, habits, physical activity, allergies and medications taken. For these six elements include a concise statement about the impact of such findings for potential outcomes with in-text citations as required.
- Review of systems.
- As part the objective component include: Vital signs, body measurements.
- Physical examination with pertinent normal findings, normal variations and abnormalities. Characterization of pain or discomfort (if present) and psychological status.
- Completed or known diagnostic tests with results supporting or ruling outa medical diagnosis.
- Diagnosis. Include a rationale and in-text citation supporting your diagnosis. Are there possible etiologies? What’s the reasoning behind it?(Include citations as required).
- Differential diagnosis. Include three ruled out diagnoses with in-text citations supporting your ideas.
- Treatment with rationales per therapeutic option. Describe the goals, priorities and education provided. Include a citation per therapeutic option and education.
- New orders for diagnostic testing. Include rationale and one citation per order.
- Follow ups and referrals if required.
- Finish the case with a paragraph justifying a theoretical perspective supporting your management approach