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Internship & Residency
Admitting Patients
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Dr. Karl Newman
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Dr. Karl Newman, Q Fever!'s I&R
correspondent, is on vacation this issue.
Instead of his usual column, we present the following
helpful template, designed and used by Dr. Karl himself, to help you while:
Admitting Patients.
INTERN ADMIT NOTE
CC: __________ pain for 10 days
Body part
HPI: Pt is a __________ year old ________ ________
# btw 50-200 Ethnicity Occupation
with a PMHx significant for ________, ________, and
Rare Dz. Common Dz.
__________ who was in his/her usual state of _________
insect(pl.) Adjective
health until 10 days ago when patient ___________ a
Active verb-past tense
bottle of __________, after which time pt. began to
Chemical element
notice ______ smelling bowel movements associated with
adjective
__________ vomitus and profound __________. Pt called
color ROS complaint
his/her ___________, who recommended over-the-counter
occupation
___________. Patient then developed increased production
Chemo drug
of __________ smelling ___________ and presented to the
adjective Body fluid
_______________ for evaluation. The patient denies
Hospital Location
__________ pain or __________ discharge.
Body part Body part
PMHx: As above
Social Hx: Occasional _______. Lives with _________.
Vice 70's sitcom actor
Sexually active with _________; practices safe sex
Superhero
using _________ for protection.
Noun (pl.)
Allergies:__________
Any four letters
Meds: 1) Extract of __________ to affected area bid
Animal
2) __________ enema po bid
Any type of fluid
3) ___________ PR qid
Any medication
Fam Hx: Unknown (Pt. Raised by wild __________)
Animal (pl.)
PE: Looks __________, but __________
Adjective Adjective
Exam: Refused
Labs: Significant only for hyper_________-emia and
Chemical element
__________ __________ cells on peripheral blood smear.
Color Noun
CXR: No infiltrates or __________
Noun (pl.)
A/P: Patient presents with perplexing diagnosis of
__________ vs. _________
Psych Dx Rare Dx
1) __________ IV x 1 stat
Herbal remedy
2) Urgent __________ of __________
Radiology test Part of anatomy
3) Follow CBC, _________, _________ analysis q6h
Bizarre lab test Fluid
5) Observe __________ for signs/sxs of __________
Adverb Emotion
6) Case discussed with __________
Current events figure
7) Code status: patient is __________
Any 3-letter abbrev.
Just
tell 'em Dr. Karl sent ya!
Karl
Newman, MD is a second-year resident in Internal Medicine.
The views expressed in this article to not necessarily represent those
of Q Fever!, its editors, or its writers.
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