Use the information provided in the PDF as an “EXAMPLE”. You must use the word temple file and tailor it to your patient and their diagnosis. Using this template will make it very easy to learn the things needed in the note and help you not forget to put something or lose points due to incorrect format or missing information. The Chief Complaint, Patient info, HPI, Plan section, and references must all be of your own work and The Main Areas of Focus that will be checked for plagiarism is Chief Complain, History of Present Illness (HPI), Assessment with Rationale and Explanation, and the Plan. All of this should be in your own words and not copy-pasted from a past note or website or book. There should be minimum likeness noted by turn it in software in these areas. The Objective and Subjective information can be from a template (Standard Documentation) and will only be looked at for content and not for plagiarism. So if you are past 50% and the above main areas of focus sections are clear and minimum then you are ok. You can resubmit as many times but after 3 it takes up to 24 hours to get turn it in a score. This is a made-up patient, so review your diagnosis and have the patient have the standard presentation, objective and subjective symptoms that would typically present and adjust them on

the given template. It is important to note that this assignment requires a deep understanding of medical terminology and diagnostic processes.

Patient Information:

Name: [Patient Name]
Age: [Patient Age]
Gender: [Patient Gender]
Date of Admission: [Date of Admission]
Date of Birth: [Date of Birth]
Room Number: [Room Number]
Medical Record Number: [Medical Record Number]
Allergies: [Patient Allergies]
Primary Care Physician: [Primary Care Physician]
Consulting Physician: [Consulting Physician]

Chief Complaint:

The patient presents with [specific complaint(s)].

History of Present Illness (HPI):

The patient reports [details of how and when the symptoms started, their severity, progression, and any associated factors]. The symptoms are [describe the symptoms in detail]. The patient has tried [mention any self-medication or treatments undertaken by the patient] with partial/no relief. The patient denies any history of similar symptoms in the past.

Review of Systems (ROS):

1. Constitutional: [List constitutional symptoms]
2. Cardiovascular: [List cardiovascular symptoms]
3. Respiratory: [List respiratory symptoms]
4. Gastrointestinal: [List gastrointestinal symptoms]
5. Genitourinary: [List genitourinary symptoms]
6. Musculoskeletal: [List musculoskeletal symptoms]
7. Neurological: [List neurological symptoms]
8. Hematologic/Lymphatic: [List hematological/lymphatic symptoms]
9. Endocrine: [List endocrine symptoms]
10. Integumentary: [List integumentary symptoms]
11. Psychiatric: [List psychiatric symptoms]
12. Allergic/Immunologic: [List allergic/immunologic symptoms]

Assessment and Plan:

1. Differential Diagnosis:
– [List possible differential diagnoses based on the symptoms reported by the patient]
– [Provide a brief explanation for each potential diagnosis]

2. Working Diagnosis:
– [State the working diagnosis based on the patient’s history, physical examination, and any relevant test results]

3. Investigations:
– [List any laboratory tests, imaging studies, or additional investigations ordered or recommended for further evaluation of the working diagnosis]
– [Provide a rationale for each investigation]

4. Treatment Plan:
– [Describe the proposed treatment plan for the patient]
– [Mention any medications prescribed, dose, frequency, and duration]
– [Include any non-pharmacological interventions, lifestyle modifications, or referrals]

5. Patient Education:
– [Outline the key points to be discussed with the patient regarding their diagnosis, treatment options, potential complications, and follow-up]
– [Provide information about resources for further education]

6. Follow-up Plan:
– [Specify the date and manner of follow-up]
– [Indicate any expectations for improvement or resolution of symptoms]

References:

List any references consulted for this case study in a standardized format, such as AMA or APA style.

Please note that this is a generic example of a medical note template, and the specific details of the patient’s case should be adjusted accordingly. The objective and subjective information can be obtained from a standard documentation template, but the Chief Complaint, History of Present Illness (HPI), Assessment with Rationale and Explanation, and the Plan sections should be written in your own words to avoid plagiarism. The aim of this assignment is to demonstrate your understanding of the medical case and the thought process behind diagnosis and treatment decisions.