Introductory statement (one-liner):
This is a (age) year old (male/female) with a past medical history of (only pertinent PMHx) who presents to the emergency department today with an (acute/chronic/# day history of) history of (worsening/improving) (chief complaint).
HPI
- OPQRSTU
- Describe if relevant
- Stool
- Cough
- Urine
- Pain
- Include any pertinent positives or negatives within the HPI story (ROS).
- Include any relevant family history (diabetes, ACS, etc.) here as well
- Include any relevant prior surgeries here
- Include medications, smoking history, alcohol history here if relevant
- What happened that convinced the patient to come come to the emergency department today?
- When did they first experience their CC?
- From the first time they experienced the CC until now, what happened?
- Have they been hospitalized in the past for issues related to CC? What happened then and what was the diagnosis?
Physical exam findings and investigations
- Vital signs
- Only pertinent physical exam findings
- Only pertinent labs and imaging if any
Impression and plan
Repeat one-liner:
In summary, this is a (age) year old (male/female) with a past medical history of (only pertinent PMHx) who presents to the emergency department today with an (acute/chronic/# day history of) history of (worsening/improving) (chief complaint).
Include most relevant symptoms, results from labs and imaging (do not repeat everything you said above)
On the differential, the most harmful etiologies include (cause #1), (cause #2), (cause #3). #1 is possible because of the (your reasons), but is less likely because of (other reasons). #2 is possible because of the (your reasons), but is less likely because of (other reasons). #3 is possible because of the (your reasons), but is less likely because of (other reasons). In my view, the most likely cause is #4 because of (your reasons).
Diagnosis: The plan moving forward will be lab/imaging #1 to rule out/evaluate #1, lab/imaging #2 to rule out/evaluate #2, etc.
Symptom relief: In regards to his pain, I would like to give him (your plan for pain). In regards to his nausea, I would like to give him (your plan for nausea). In regards to (any other symptomatic issue), I would like to provide him (symptomatic relief while we investigate underlying cause).
Disposition: Finally, in regards to disposition, I would like to consult internal medicine (or another service) and get him admitted OR if the investigations are clear discharge him home