Table 1.
Case information | Patient's name: | Gender: | Gender: | |||||
Clinical setting: | Age: | T: | ||||||
Chief complaint: | Height: | HR: | ||||||
Weight: | RR: | |||||||
CATEGORY: HPI | ||||||||
1 | Chief complaint | Description? | ||||||
2 | Pain scale? | |||||||
3 | Onset | When did it begin? | ||||||
4 | How did it begin? | |||||||
5 | Progression | Better, worse, same? | ||||||
6 | Mitigating factors | What makes it better? | ||||||
7 | What makes it worse? | |||||||
8 | Associated symptoms? | |||||||
9 | History of previous occurrence (details)? | |||||||
10 | Pertinent other | Allergies to medications? | ||||||
Current medications? | ||||||||
12 | Past medical history? | |||||||
13 | Family history? | |||||||
14 | Social history (smoking, alcohol, drugs)? | |||||||
15 | Other | |||||||
CATEGORY: Physical exam | ||||||||
16 | Neurologic | |||||||
17 | HEENT | |||||||
18 | Chest, heart & lungs | |||||||
19 | Abdominal | |||||||
20 | Female breast & GU (& rectal) | |||||||
21 | Male GU (& rectal) | |||||||
22 | Musculoskeletal | General | ||||||
23 | Upper extremities | |||||||
24 | Lower extremities | |||||||
25 | Lab findings | |||||||
26 | Other diagnostics | |||||||
27 | Radiographic procedures | |||||||
What is the best diagnosis/etiological agent for this pastient's disease? | ||||||||
Potential diagnoses Rule each In or Out | Answer A | |||||||
Answer B | ||||||||
Answer C | ||||||||
Answer D | ||||||||
Answer E |