Remember specific formats can vary for different courses or situations (such as NBME-CS). The following is a comprehensive example- for a specific case be much more focused (see "First Aid" book).
CC. "tired all the time"
HPI: 38 year old white woman complaining of increasing fatigue over about 4months. Feels tired all day, decreased interest in usual activities, less able to complete routine tasks, and generally slowed up. Sleeping more than previously (now approximately 9 pm to 7:30 am) but does not feel rested. Does not wake during night or nap during day. No recent acute illnesses. No precipitating events for fatigue. Family, friends and co-workers are criticizing her for low performance of usual activities and negative attitude. Is not aware of other major symptoms. Is concerned "something is wrong" but can't specify a particular concern.
PMH: Denies previous serious illness or surgery. Hospitalization for childbirth x3. G3P3 LC3.
Denies prescription medication. Takes daily multivitamin for last month. No regular use of OTC, herbal or other supplements. Tylenol @ 1-4 per month for shoulder/neck pains or headaches. Recently tried Metamucil for constipation.
No drug or other allergies
Unsure of immunization status. No recent influenza, tetanus. Last physical/pelvic/Pap about 3 years ago. No other screening. Does not do BSE. Contraception by husband's vasectomy.
SH: Smoked ½ ppd from age 16-22. Drinks <2 glasses wine /month, no use of illicit substances
Part-time teacher's aide in special education class (3 mornings per week). Currently not doing well at work, can't keep up with the stress.
Lives with husband and children. Family complaining about her lack of energy. Reduced housekeeping, cooking, and family activities. No regular exercise.
Stressed by family and work situation and ongoing financial concerns for family.
FH: Parents alive. Father 61 hypertension. Mother 59 type 2 diabetes, obesity. Sister 35 obesity, infertility. Brother 33 no health problems. Husband and children healthy.
Obesity, diabetes in several family members. No known cancer, strokes, heart disease
RoS: Denies chest pain, dyspnea on exercise/at night, swelling ankles, cough or wheeze
Appetite reduced but eating more and gained about 10 lbs in 2-3 months. No abdominal pain, nausea, vomiting, indigestion. Constipated recently with fair response to Metamucil. No dark or bloody stools.
Has vague mild headache 1-2 per week, rarely need Tylenol. Vision may be less acute, hearing normal, no dizziness, often feels faint but never passed out, generally feels weaker than previously, no change in sensation, no tingling, numbness. Feet and hands felt colder than usual recently.
Increase in vague muscle aches esp. in shoulders and neck. No joint symptoms
Menarche aged 13, regular cycles 3-4/28 without cramps, clots or intermenstrual bleeding/spotting. LMP last week heavier than usual. Sexually monogamous with husband but libido greatly reduced. No discharge, genital lesions, dyspareunia, pelvic pain.
Less interested in "fun" but denies depression, hopelessness, anxiety.
Skin and hair may be drier than usual
PHYSICAL EXAM (Objective)
Vitals: 120/75, 60 reg, 980 (36.7), resp 12, weight 158lbs. ht. 64 inches
General: Looks older than age, overweight, well groomed, pale. Concerned but not in pain or distress. Intelligent and cooperative.
Head: atraumatic, normocephalic, EOMI, PERRLA. Mucosae moist
Neck : Supple with no masses/tenderness/lymph nodes. Normal thyroid
Chest:. Normal appearance of chest
Lungs clear to auscultation , vesicular breath sounds, no rales, rhonchi, rubs
PMI not displaced. RRR 60 beats/min. Normal S1,S2. no murmurs
Abdomen: Mildly obese, no scars, active bowel sounds. Soft, no tenderness, masses, hepatosplenomegly on palpation.
Extremities: feet cool, no ankle edema, peripheral pulses present and equal
CNS. Alert, oriented, appropriate behavior, good recall of information, appropriate affect and speech. Normal gait.
Cranial nerves II-XII intact. Fundi normal
Strength 5/5 bilaterally in extremities. Light touch and pin prick sensation intact
DTR slow return in knees and ankles. Babinski down bilaterally. Romebrg normal
Breast/Genital exam: deferred
Differential Diagnosis (Assessment)
In most situations the priority order is important - used to assess your clinical reasoning
Diagnostic Workup (One component of Plan)
Diagnostic strategy must match differential to rule conditions in or out. Can include non-lab tests such as screening tools and "sensitive" exams
Management Plan (not in USML-CS)