Patient Note Entry Form

Patient Note
Examinee Instructions

HISTORY: Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives) relevant to this patient's problem(s).

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PHYSICAL EXAMINATION: Describe any positive and negative findings relevant to this patient's problem(s). Be careful to include only those parts of examination you performed in this encounter.

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DATA INTERPRETATION: Based on what you have learned from the history and the 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. Then, enter the positive or negative findings from the history and the physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)

Diagnosis #1

History Finding(s)

Physical Exam Finding(s)

Diagnosis #2

History Finding(s)

Physical Exam Finding(s)

Diagnosis #3

History Finding(s)

Physical Exam Finding(s)

Diagnostic Study/Studies

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Vital Signs

Temperature: 98.8°F (37.1°C)

Blood Pressure: 120/76 mm Hg

Heart Rate: 78/min

Respirations: 15/min

Instructions

Obtain a history pertinent to this patient's problem.
Perform a relevant physical examination (Do not perform a breast, pelvic/genital, corneal reflex, or rectal examination).
Discuss your impressions and any initial plans with the patient.
After leaving the room, complete your patient notes on the given form or computer.

Opening Scenario

Jason Morris, a 21-year-old male, has come to the student health clinic because he recently passed out while playing basketball.

USMLE ID	0-123-456-7	Badge ID	2
Room Number	2	Encounter	1

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Please await the proctor's instructions.