1. Demographic Information of The Patient ( NAME, GENDER, AGE, RACE)
2. Chief Complaint:
3. History Of Present Illness: Onset/Location/Duration/Character/Alleviating-Aggravating factors/Temporal pattern/Severity. Additional symptoms and previous treatment if known.
4.Past Medical History
5.“Family Medical history:
6.“Surgical Medical history:
7.Review of systems and Physical Examination : HHENT, NEURO, CARDIO RESP, GI, GU, MUSCULOSKELETAL.
8. As part the objective component include: Vital signs, body measurements.
10.Main Diagnosis with explanation of what it is:
11.Mention 3 Differentials Diagnosis with citation
12.Treatment: If medication include route, dose and frequency ( Describe the goals, priorities and education provided. Include a citation per therapeutic option and education.)
13. New orders for diagnostic testing. Include rationale and one citation per order.
14.Follow up and Referrals
15. Rational Paragraph justifying a theoretical perspective supporting your management approach.
16. References ( No older that 5 years)
APA Style 6th Edition
NO PLAGIARISM AT ALL MUST HAVE LESS THAN 6 % OR WILL HAVE A FAIL GRADE
NEED IT FOR MONDAY JANUARY 24, 2022 EARLY IN THE MORNING
DONY NEED TO BE EXTENSIVE BUT NEED TO FILL OUT EACH SECTION CORRECTLY.