Report the history, succinctly, in standard format:

Chief complaint History of the present illness Past medical history Medications Medication allergies Social history Family history Review of systems (specify only pertinent positive and negative findings)

2. Describe the physical examination, succinctly, in standard format:

Vital signs (specify) HEENT (acceptable to say "normal" or "unremarkable", if this is so) Neck Nodes Breasts (always include a breast exam for women on the medicine service) Chest Cardiovascular Abdomen Genitourinary Rectal Extremities Skin Neurologic

3. Report the basic laboratory data

4. Summarize the case: this is important! The summary should include a few well-crafted sentences, perhaps 3-5 in all. A concise, accurate summary shows that you have grasped the essentials of the case and can distill the clinical data into its essence. 5. Assessment. In the assessment, you choose the most important one or two problems and discuss the differential diagnosis. Remember that the differential diagnosis should address the possible causes in the case at hand, not for the problem in general. For example, in a patient with acute fever, cough, rhonchi and pulmonary infiltrate, discuss pneumonia, not cough. 6. Plan. Outline your recommendations for diagnostic tests and therapy.