Introduction/Chief Complaint/Story of Presentation

Mr./Mrs. [name] is a [age]-year-old [gender] who presents

today in [general condition]. They came in with several
concerns: They complain of [brief description of chief
complaint 1]. Additionally, they mentioned [brief description of
CC 2]. And lastly, [brief description of CC 3]. These
symptoms began [duration] ago while the patient was [brief
context, e.g., doing what?] They mention that [CC 1] has
been [worse/better/stable] since it started, while [CC 2, CC 3,
etc.] has [progressed in what manner]. [CC1, CC2, etc.] is
worse with [aggravating factor] and better with [alleviating
factor]. Additionally, they have experienced [associated
symptoms with each CC]:
1. [relevant symptom 1]
2. [relevant symptom 2]
3. [relevant symptom 3]
4. [relevant symptom 4]
5. [relevant symptom 5]

Relevant Medical History (If Pertinent)

Regarding their medical history, they have a history of
[relevant medical conditions]. Medications include [list of
medications], and they are allergic to [list of allergens].
Social Context
Socially, our patient is a [occupation] and resides [alone/with
family/homeless/other]. There might be factors like [relevant
lifestyle factors: tobacco, alcohol, recreational drug use] that
could be impacting their condition.

Physical Exam
Upon physical exam, I observed [relevant physical findings
for CC1, CC 2, etc.].
• Cardiovascular
• Pulmonary
• GI
• Neuro
• MSK
• Skin
[Diagnostic tests] were done which should [findings].
Differential Diagnosis
My initial thoughts on the possible diagnoses for [CC1, CC2,
etc.] include:
1. [PD 1: most likely] because [reasoning]
2. [PD 2: life-threatening] because [reasoning]
3. [PD 3: 2nd most likely] because [reasoning]
4. [PD 4: 3rd most likely] because [reasoning]
5. [PD 5: least likely] because [reasoning]
Plan
For my plan, I would like to [for each CC]:
• Start/continue the patient on [treatment] to [end goal]
• Obtain [imaging/tests] for further evaluation of
[differential]
• Consult [relevant specialty] for their perspective on
[].
• At this point in time, I would recommend that the
patient be [discharged/admitted/observed] pending
[lab/diagnosis tests].
Wrap-Up
Is there anything specific you would like to add or any
feedback on my presentation of this case?