Use shorthand where possible and approved medical abbreviations. Avoid redundancy and irrelevant information. 2. Provide a differential diagnosis (minimum of 3) which might explain the patient’s chief complaint along with a brief statement of pathophysiology for each. 3. Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis. 4. Rank the differential in order of most likely to least likely. 5. Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be supported with an evidence-based medicine (EBM) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must also support this decision with EBM evidence.
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