Presenting New Patients to Your Attending (Mark D. Siegel, md/12-2014) Chief Complaint



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Presenting New Patients to Your Attending (Mark D. Siegel, MD/12-2014)



  • Chief Complaint

    • Host: age, gender, key identifying facts (pertinent medical history, job)

    • Reason for admission (patient’s words or key problem)

  • Source of Information

  • History of Present Illness

  • Past Medical History (detail varies with pertinence)

  • Medications (prescribed, over the counter, supplements, and alternatives)

  • Social History

    • Work, hobbies (especially something interesting)

    • Habits (alcohol, cigarettes, drugs)

    • Sexual history

    • Travel history

    • Living situation (where, with whom)

  • Family History (relevant findings only)

  • Review of Systems (relevant findings only)

  • Physical Exam (Detail may vary w/clinical needs and attending expectations)

  • Diagnostic Studies (details may vary w/clinical needs and attending’s expectations)

    • Blood Work

    • Urinalysis

    • EKG

    • Imaging studies

    • Other

  • Summary (salient points)

  • Impression

    • Differential diagnosis

    • Weigh pros and cons of reasonable diagnostic possibilities

  • Plan by Issue

    • Work up (consultations, diagnostic testing)

    • Treatment





Presenting New Patients to Your Attending (Mark D. Siegel, MD/12-2014)



  • Chief Complaint

    • Host: age, gender, key identifying facts (pertinent medical history, job)

    • Reason for admission (patient’s words or key problem)

  • Source of Information

  • History of Present Illness

    • Begins with usual state of health

    • Orderly Progression

    • Pertinent negatives

    • Culmination in admission (emergency room course, prior hospital course)

  • Past Medical History (detail varies with pertinence)

  • Medications (prescribed, over the counter, supplements, and alternatives)

  • Social History

    • Work, hobbies (especially something interesting)

    • Habits (alcohol, cigarettes, drugs)

    • Sexual history

    • Travel history

    • Living situation (where, with whom)

  • Family History (relevant findings only)

  • Review of Systems (relevant findings only)

  • Physical Exam (Detail may vary w/clinical needs and attending expectations)

    • General Appearance

    • Vital Signs

    • Physical Findings

  • Diagnostic Studies (details may vary w/clinical needs and attending’s expectations)

    • Blood Work

    • Urinalysis

    • EKG

    • Imaging studies

    • Other

  • Summary (salient points)

  • Impression

    • Differential diagnosis

    • Weigh pros and cons of reasonable diagnostic possibilities

  • Plan by Issue

    • Work up (consultations, diagnostic testing)

    • Treatment





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