• Family history pertaining to parents, grandparents, and siblings: illnesses, predispositions, and genetic factors • Medication history: current prescription medications with dosages, schedules, and adherence; over -the- counter medications; herbal and supplemental remedies; past medications as indicated; and medication reactions • Pertinent social history: occupation, tobacco, alcohol, and drug use; current life situation, financial and emotional support; and sexual history as appropriate • Review of health maintenance practices, including exercise, safety device use, and preventive care • Complementary and alternative therapies • Pertinent review of systems • Interval history for chronic illness, including progression, regression, or stabilization Physical Examination The student should be able to perform appropriate complete and focused physical examinations on patients of any age or gender in any medical setting, demonstrating: • A complete, well-organized, and appropriately sequenced physical examination • Proper use of required physical examination equipment • Ability to communicate with patients of any age and in any setting in a clear, jargon- free manner • Attention to patient safety and comfort throughout the examination • Recognition of normal and abnormal findings across the lifes pan • Clear, concise communication of physical examination findings to peers and supervisors Differential Diagnosis and Treatment Plan Formulation The student should be able to develop an appropriate differential diagnosis and diagnostic impression for each patient, demonstrating: • Sound clinical judgment in differential diagnosis formulation, with at least three diagnostic possibilities discussed • Ability to synthesize historical, physical, and diagnostic data into a coherent treatment plan • Effective written and oral communication of diagnostic impressions and treatment plans • Maintenance of a complete, up-to-date patient problem list with appropriate ICD-10 codes • Appropriate referrals for further evaluation and services
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