Name, age, gender, how they were brought to the hospital and their chief
complaint:
________________________________________________________________________________
List with a list of 6 differentials that could cause the chief complaint. Order them
from most likely for the given age and gender to least likely. Search on up-to-date
using IMC computer.
Differential #1: Differential #2:
Differential #3: Differential #4:
Differential #5: Differential #6:
HPI:
If chief complaint is pain then use mnemonic LIQROPDFCSAAA described below to
obtain the HPI. Record responses. Consider which differential each answer is a
pertinent positive or negative for.
Location: Intensity:
Quality: Radiation:
Onset: Progression:
Duration: Frequency:
Chronicity: Setting:
Alleviation: Aggravation:
Associated symptoms:
If chief complaint is non-pain in nature, then use OPDFCSAAA described below to
obtain the HPI. Record responses. Consider which differential each answer is a
pertinent positive or negative for.
Onset: Progression:
Duration: Frequency:
Chronicity Setting:
Alleviation factors: Aggravation factors:
Associated symptoms:
For each differential search and write down the supporting history, vital signs,
physical examination, labs and imaging typically expected in that differential. Then
beside each, write + if present in your patient, -ve if not present. Write down N/A if
that lab test or imaging test or procedure has not been ordered.
Lastly, write down what next step in management you would take to rule in or rule
out that differential, if any at all.
