Presenting a patient

Question 1

Parts to include for subjective history

Answer 1

Patient age, race, sex, pmhx

OPQRST

Question 2

Parts to include for Objective part of history

Answer 2

Vitals, labs, Physical exam (general, CV, Respiratory, GI, Neuro)

Question 3

Parts to include for Assessment

Answer 3

Summarize patient in 1 sentence
Differential
Problem list and workup to rule things in and out
Fluid, diet, DVT, precautions

Question 4

Parts to include for Disposition

Answer 4

Admit to __
Dx
or hold in er etc