PCP: Note name of PCP and whether or not they are in regular care
ID/ Chief Complaint: include age, gender, language (if not English) and geographic ancestry, as well as what led the patient to seek medical attention. Identify whether the patient has decision-making capacity and, if not, who the decision-maker is.
History of Present Illness: Includes all details pertinent to patient’s presenting complaint, including pertinent ROS, relevant PMH and any ancillary information obtained from family/eyewitnesses/nursing home staff.
Past Medical History: List most relevant history first, including both past medical/surgical/psych history. Include chart review and details of significant past studies. For Peds include birth/ immunizations/ developmental history. For Ob-Gyn include pregnancies, birth hx. For primary care include health care maintenance (immunizations, cancer screening, cholesterol).
Medicines: Complete list and dosing of patient’s current outpatient medications including OTC drugs and supplements. Use generic names of drugs.
Social: Include tobacco/alcohol/drug use, home situation, previous/current employment. Include sexual history, work exposures, and travel history when relevant.
Family: Pertinent or unusual family history, particularly those with a genetic basis.
ROS: Any complaints that were not included in HPI.
Exam: Include vitals (may include ER + Floor findings for hospitalized patients if significant differences noted) and a general description of patient’s appearance. Initial exam should be comprehensive, but presentation should include only pertinent positives/negatives.
Labs/Studies: Significant positives/negatives from both blood work and diagnostic imaging. Include past labs if helpful to follow trends.
Assessment/Plan: Briefly Summarize case, touching on pertinent points from chief complaint/HPI/past/ social history, significant physical and diagnostic findings. Then, outline what you think is going on to explain the above, narrowing your differential to the 2-3 most likely diagnoses. Analyze the differential by comparing and contrasting the possibilities- using key features of the problem and evidence. Describe your Plan for management including treatments or further diagnostic work-up. After the chief complaint/problem has been dealt with, then address other issues in order of importance.
Questions: Probe the attending/ resident by asking questions about uncertainties or difficulties. Be prepared to answer questions from other team members, including multidisciplinary members (PCP, RN, Case Manager, Pharmacist, etc).
Select: Choose a case-related issue for your self-study and be prepared to discuss what you learned the following day.