Medicine Patient Name MR Number DOB Date Time

Medicine Patient Name MR Number DOB Date Time General Medicine Daily Note MSIII S: 24 hour events… Patient’s subjective assessment of symptoms associated with current hospitalization. Important ROS include: CP, SOB, N/V, Fever/Chills, PAIN Assessment. O: Vitals: Tmax / Tcurrent / bp / hr / resp / O 2 sats /accucheck I/O: last 8 hr- ‘in” (PO, IV)/ “outs” (urine, stool) last 24 hr- ‘in” (PO, IV)/ “outs” (urine, stool) Labs: Meds: Exam: GEN: HEENT: CV: PULM: ABD: EXT: NEURO: GU: A/P: Can be organized by problems or by systems. Either way, address the status of each of the pt’s problems – stable vs worsening vs improving. Discuss possible etiologies for a problem if a diagnosis has not been made. Include any changes in meds, tests or labs to order, and plans for discharge. Things to Know: • Be prepared to discuss your patients’ problems in depth – pathophysiology, diagnosis, different treatments, etc. • Put thought into your assessment and plan in your H & P’s and in daily progress notes. • Do some reading to help you develop a complete and thorough differential diagnosis. • Don’t be afraid to ask questions. Attendings appreciate good, thoughtful questions. Books: • The Washington Manual of Therapeutics (can fit in your pocket) • Harrison’s Principles of Internal Medicine (big book-lots of details or little book-less detailed) • EKG Books (either Dubin or Thaler) from IPM 2 • Pocket Medicine by Sabatine (black small 3 -ring with good synopses) • Blueprints in Medicine (good overview, not detailed) • Up to Date and Harrison’s Online for (quick refs on the floors) • Class notes (high-yield for the exam)