Internal Medicine Consult (Source)

• Date/Time:
• Attending Name:
• ID: (age, gender, whether from home, nursing home, retirement home, etc)
• RFR: Reason for Referral
• PMHX: Past Medical History
• Meds:
• 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.)
• FHx: Family history
• ROS: Review of systems
• O/E: On examination
• Ix: Investigations (including bloodwork, x-rays, EKG, imaging. 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 ______.
• Plan
  • Problem 1 - most important
  1. Action 1
  • ⋮