1
Identification
- Name, age, sex, occupation
- Date of admission
- Presenting from
2
Presenting Complaint
- In patient's own words
- Duration
3
History of Presenting Illness
- Onset, duration, progression
- Aggravating / relieving factors
- Associated symptoms
- Treatment received so far
4
Systemic Review
- CVS, RS, GI, GU, CNS, MSK, skin
5
Past History
- Medical, surgical, transfusion, allergies
6
Drug History
- Current, adherence, OTC, herbal
7
Family History
- First-degree relatives, hereditary conditions
8
Social History
- Smoking, alcohol, drugs
- Occupation, housing, support
9
Examination
- General, vitals
- System-wise findings
10
Summary & Differentials
- 3-line summary
- Top 3 differentials with reasoning
11
Investigations & Plan
- Bedside, bloods, imaging, special
- Management plan
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