Documenting the patient encounter

I am a [clinical role, e.g., pediatrician, family medicine physician, resident] seeing a [age]-year-old [gender] with [chief complaint] and [key symptoms] in the [clinic / ED / hospital]. Write a concise but thorough clinical note including: History of present illness; Relevant past history and medications; Focused physical exam; Assessment with differential; Plan (diagnostics, treatment, and follow-up). Format it the way it would appear in a real chart.