The attending physician will ask the patient’s permission to have the student present their case. Report any new finding, laboratory tests, diagnostic procedures and changes in medications.Briefly review the present illness, physical examination and admitting diagnosis.The follow-up presentation differs from the presentation of a new patient.It is an abridged presentation, perhaps referencing major patient issues that have been previously presented, but focusing on new information about these issues and/or what has changed. Be sure to know why things are being done since you will be asked.Then, state what you plan to do for the patient, including labs.The assessment and plan should include what you think is wrong and, briefly, why.Only give pertinent positives and negatives. The Review of Systems (ROS) is often left out, as anything important was in the History of Present Illness (HPI). Next give important Past Medical History (PMH), Past Surgical History (PSH), etc.Give the chief complaint and a brief and pertinent History of Present Illness (HPI).New patients get the traditional History and Physical Exam (H&PE) with assessment and plan.
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