Patient Presentation

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Patient Presentation

Patients are often presented to supervising clinicians or on rounds.

One possible framework:

1. Patient’s name
2. Patient’s age/gender/occupation/social role/activity level
3. Presenting complaint(s)
4. History of presenting complaint (location, quality, quantity, chronology, aggravating/alleviating factors, previous treatment/investigations etc)
5. Pertinent history of other conditions
6. Family and social history if pertinent
7. Physical findings
8. Diagnostic tests
9. Concise problem synthesis
10. Diagnosis or differential diagnosis
11. Indications for further investigations
12. Prognosis
13. Treatment plan
14. How monitor treatment

For learners:
15. An educational plan/reflective statement to better understand the patient and their presenting complaint

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