INFECTIOUS DISEASES - ID WEEK 2019
SMH 402 MR
University of Rochester
Strong Memorial Hospital
Highland Hospital
INFECTIOUS DISEASES
CONSULTATION
DATE:_____________ TIME:______________ Consult requested by Dr.________________________________
Consulted for: ____________________________________________________________________________
History of Presenting Illness: ___________________________________________________________________________________________________
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PHYSICAL EXAMINATION
|SYSTEM |Normal |FINDINGS |
|VITALS: BP________ P_________ T________ R_______ O2 Sat________ |
|General: |
|Head, ENT | | |
|Eyes | | |
|Lymph Nodes | | |
|Respiratory | | |
|Cardiovascular | | |
|Gastrointestinal | | |
|GU | | |
|Musculoskeletal | | |
|Skin | | |
|Neuro & Psych | | |
|Other | |
SMH 402 MR
University of Rochester
Strong Memorial Hospital
INFECTIOUS DISEASES
CONSULTATION (2nd sheet)
OTHER DATA:___________________________________________________________________________________
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ASSESSMENT + RECOMMENDATIONS: _________________________________________________
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SIGNATURE:_____________________PRINT:_______________________ PAGER # 51616-_______
ID ATTENDING CONSULT NOTE:______________________________________________________________
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ID Attending Attestation:
( I have interviewed and examined this patient and reviewed pertinent history, lab data, and imaging results.
( I have reviewed detailed consult note of ID Resident/Fellow (Dr. ___________________Date:_____________)
( I concur with his/her HPI, exam, PMHx, Family Hx, Social Hx, ROS, assessment & plan, except as otherwise noted.
SIGNATURE:_____________________PRINT:_______________________ PAGER #: 51616-______[pic]
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Inpatient
Outpatient
ED
STAMP
History from: Patient Family Med record
Neg Pos ROS
[pic] [pic] Wt loss, fatigue, fever ______
[pic] [pic] ENT___________________
[pic] [pic] Eye____________________
[pic] [pic] Resp___________________
[pic] [pic] CV____________________
[pic] [pic] GI: ____________________
[pic] [pic] GU: ___________________
[pic] [pic] S楫㩮张彟彟彟彟彟彟彟彟ൟ 祌灭㩨张彟彟彟彟彟彟彟ൟ 畍歳汥›彟彟彟彟彟彟彟ൟ 敎牵㩯张彟彟彟彟彟彟彟彟čĠ倠獹档›彟彟彟彟彟彟彟彟ൟ 湅潤›彟彟彟彟彟彟彟彟彟č删协渠来攠捸灥⁴獡渠瑯摥愠潢敶☠䠠䥐敌敶ⴴ‵潣獮汵㩴†〱佒ⱓ漠佒⁓敮硥散瑰愠潮整㭤倠⁅⬸猠獹整獭※䡆⬠匠⁈䵐⁈漨潤畣敭瑮甠潮瑢楡慮汢⥥ 倠䡍䡆䡓佒⁓湵扯慴湩扡敬ഠ畤潴ഺ不†夠उउउ䵐硈čĠ䐠彍彟彟彟彟彟彟彟彟彟彟kin: __________________
[pic] [pic] Lymph: ________________
[pic] [pic] Mus-skel: _______________
[pic] [pic] Neuro: _________________
[pic] [pic] Pysch: _________________
[pic] [pic] Endo: __________________
[pic] ROS neg except as noted above & HPI
Level 4-5 consult: 10+ ROS, or ROS neg except as noted; PE 8+ systems; FH + SH + PMH (or document unobtainable)
[pic] PMH, FH, SH, ROS unobtainable
due to:
N Y PMHx
[pic] [pic] DM______________________
[pic] [pic] Cancer _____________________
[pic] [pic] ESRD____________________
Other:
FAMILY HX
Not relevant to current dx
N Y
[pic] [pic] TB___________________
[pic] [pic] other signif ID_________
Other:
N Y SOCIAL HX
[pic] [pic] Tobacco________
[pic] [pic] Alcohol_________
[pic] [pic] Ilicit drugs_______
[pic] [pic] Travel___________
[pic] [pic] Animals: _________
Occupation:____________
Other:
Patient name:_____________________________________ MRN:_____________________
Antibiotics (Start-Stop) and Pertinent MEDICATIONS:
Adverse Drug Experiences:
N Y
[pic] [pic] To Meds:
Neg Pos ROS
[pic] [pic] Wt loss, fatigue__________
[pic] [pic] ENT___________________
[pic] [pic] Eye____________________
[pic] [pic] Resp___________________
[pic] [pic] CV____________________
[pic] [pic] GI: ____________________
[pic] [pic] GU: ___________________
[pic] [pic] Skin: __________________
[pic] [pic] Lymph: ________________
[pic] [pic] Mus-skel: _______________
[pic] [pic] Neuro: _________________
[pic] [pic] Pysch: _________________
[pic] [pic] Endo: __________________
[pic] ROS neg except as noted above & HPI
N Y SOCIAL HX Occupation:____________
[pic] [pic] Tobacco________ Other:
[pic] [pic] Alcohol_________
[pic] [pic] Ilicit drugs_______
[pic] [pic] Travel___________
[pic] [pic] Animals: _________
MICRO:
UA:
Seg:
Band:
Lymph:
Mono:
Eos:
STAMP
IMAGING::
STAMP if separate sheet
DATE:
TIME:
Imaging or micro specimens independently reviewed by ID Attending.
Results reviewed w/ pathologist or microbiologist:_________________
Case discussed with another provider (MD, NP):________________
|Attend | | |21 |22 |23 |
|Consult |51 |52 |53 |54 |55 |
|Chief Comp |yes |yes |yes |yes |yes |
|HPI elements |1-3 |1-3 |4 |4 |4 |
|PMH, FH, SH |0 |0 |1/3 |3/3 |3/3 |
|ROS |0 |1 |2-9 |10+ |10+ |
|PE systems |1 |2-7 |2-7 |8+ |8+ |
|Complexity |min |min |lo |mod |hi |
HI = > 2 of the following: 1) serious illness (risk to life or bodily fx), 2) dx tests recommended, 3) independently reviewed xrays, OR old records summarized in note (d/c sum, outpt notes, labs from prior admit or OSH), OR reviewed test results with pathologist or microbiologist, OR hx from family, OR discussed case with another provider. MOD = less than above, but acute illness/injury w/ systemic sx or complications, exacerbation chr onic illness, >1 chronic illness, or complications of therapy.
Form 6/15/06
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