PRMLE3 Patient Notes
10:00
Information
History
Describe the history you just obtained form this patient. Include only information (pertinent positives and negatives) relevant to this patient's problem(s)
Physical Examination
Describe any positive and negative findings relevant to this patient's problem(s). Be careful to include only those parts of the examination you performed in this encounter.
Data Interpretation
Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. The, enter the positive or negative findings from the history and the physical examination (if present) that supports each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory test, imaging, ECG, etc.