Global Medical UCLA Sarah Kim & Kevin Lloyd

 SUBJECTIVE  OBJECTIVE  ASSESMENT  PLAN

 First, introduce yourself!  Obtain basic info  Past medical history (PMH)  Social life  Chief complaint (secondary complaint)  Vitals (objective)  Temperature  Pulse Rate  Blood Pressure

 History of present illness (HPI):  Onset  Location  Duration  Characteristics  Aggravating factors  Relieving factors  Severity

 Inspection/Observation  General, eyes, ears/nose/throat (ENT), cardiovascular (CV), respiratory, gastrointestinal, muscular, skin, neurology, psychology  Auscultation  Palpation  Percussion

 Discussion of case  Assessment  Preliminary diagnosis presented to attending physicians  Plan/Treatment  Prescribe medication  PREVENTATIVE ADVICE!  Rx  Doctor’s prescription