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