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 patient's chief complaint.
DIFFERENTIAL DIAGNOSIS - In order of likelihood (with 1 being
the most likely), list up to 5 potential or possible diagnoses for
this patient's presentation (in many cases, fewer than 5
diagnoses are likely):
DIAGNOSTIC WORKUP - List immediate plans (up to 5) for further