On the internal medicine service, you may be consulted (asked) by other services such as emergency or surgery to evaluate a patient and either give recommendations, or to see whether this patient should be admitted (and therefore cared for) up to the appropriate floor, under your service’s care.
Allergies: to drugs, and describe the type of reaction (whether GI irritation, rash, or anaphylaxis)
HPI: history of presenting illness; this includes prior to hospital and in hospital
SHx: Social history, this includes smoking, alcohol use, recreational drug use, and relevant social circumstances (e.g. housing, support, involved health care professionals like social work, case worker, etc.)
Impression: (Age)___ (male/female)____ with a PMHx of ____, presents to this hospital’s ER on (date)____ with (symptoms)___, (signs)_____, and (relevant investigations)____. Therefore this patient has the diagnosis (Dx)___ and the differential diagnosis (DDx) includes ______.
Problem List (the most important part)
1. (Dx above) – Etiology Status Severity Anatomy Physiology Complications Plan
2. 2nd Problem – Etiology Status Severity Anatomy Physiology Complications Plan
3. 3rd Problem – Etiology Status Severity Anatomy Physiology Complications Plan