Provide three differential diagnosis similar diagnosis but not diagnosis repeated in a different way. eg do not put lumbar strain and back strain. From your differential come up with a : Final diagnosis with rationale.

Subjective information

CC chief complaint in patient works

HPI : OLDCART focus on the reason for the visit

PMHx

Social Surgery

Allergy Immunization

ROS pertinent to HPI

Objective : Include vital signs detail physical findings pertaining to the system been covered and any associated system.

Assessment : Three differential diagnosis similar diagnosis but not diagnosis repeated in a different way. eg do not put lumbar strain and back strain. From your differential come up with a :

Final diagnosis with rationale

Plan: Teaching, medication referral diagnostic test etc.

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