Describe the Nature of the complaint, including location, intensity, and associated symptoms.
Describe the History of the complaint, including details of the time and circumstances of the onset. Also, the evolution of the complaint.
Describe the Relieving and aggravating factors.
Patient history.
Family history.
Summarize the Results of the Physical Examination.
List Tests/diagnostics that are ordered. (Do make it relevant to the condition;)
List Diagnosis
Give some possible treatments. (Assume the patient lives long enough for treatment.)
Give the general Prognosis. for this kind of condition
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