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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