Internal Medicine Patient Introduction Template
A comprehensive internal medicine introduction should systematically capture demographics, chief complaint with temporal details, complete medical and medication history, family and social history, review of systems, and physical examination findings in a structured format that prioritizes diagnostic accuracy and patient safety. 1
Patient Demographics and Identification
- Full name, date of birth, age, sex, race/ethnicity including birthplace and parents' places of origin 1
- Years in current country of residence, primary language, handedness 1
- Education level, occupation, literacy status 1
- Living situation, type of residence, marital status, level of independence 1
- Contact person information for emergency and informant purposes 1
Chief Complaint and History of Present Illness
- Time last known well - establish exact timing using creative questioning with time anchors 2
- Presenting symptoms with detailed characterization: onset, duration, quality, severity, location, radiation, aggravating/alleviating factors, associated symptoms 1, 3
- Temporal progression of symptoms and any changes in pattern 2
- Related symptoms that may have been missed in initial questioning 3
- Impact on daily activities and quality of life 1
Past Medical History
- Cardiovascular disease: myocardial infarction, arrhythmia/atrial fibrillation, angioplasty, stent, coronary artery bypass graft, valvular surgery, pacemaker, congestive heart failure, angina, peripheral artery disease 1, 2
- Cerebrovascular disease: stroke (hemorrhagic or ischemic), transient ischemic attack, carotid endarterectomy 1, 2
- Metabolic conditions: diabetes mellitus, hypertension, hyperlipidemia 1, 2
- Other conditions: migraine, sleep disorders, sickle-cell anemia, hypercoagulable states, deep-vein thrombosis, pulmonary embolus, chronic infections (periodontal disease, bronchitis), autoimmune diseases, renal disease 1
- Surgical history including any cognitive difficulties arising after surgery 1
- Date of diagnosis for chronic conditions and approximate date of onset when determinable 1
Medication History
- All prescription medications with exact names, doses, frequencies, and duration of use 1
- Over-the-counter drugs including supplements 1
- Herbal and alternative remedies 1
- Previous antiretroviral therapy if applicable, with thorough documentation 1
- Recent medication changes or discontinuations 1
- Adherence assessment from patient, family, or general practitioner 1
Allergy and Adverse Reaction History
- Drug allergies with specific documentation of: drug name, dose, exact reaction suffered, temporal relation to drug exposure 1
- Previous drug intolerances with detailed descriptions 1
- Susceptibility factors for adverse reactions 1
Family History
- First-degree relatives: strokes, vascular disease including myocardial infarction, dementia, neurological diseases 1
- Age at death for deceased relatives 1
- Age of disease onset for affected relatives 1
Social History
- Tobacco use: current and lifetime exposure including second-hand smoke 1
- Alcohol consumption: quantity, frequency, pattern 1
- Recreational drug use: specific substances and routes of administration 1, 3
- Sexual history: number of partners, types of sexual activity, condom use, partner HIV status 1
- Injection drug use: sharing of needles, syringes, or other equipment 1
- Diet and lifestyle factors 1
- Environmental exposures: pesticides, occupational hazards 1
- Depression screening using direct questions or validated tools 1
- Domestic violence assessment 1
Review of Systems
- Cognitive and behavioral symptoms: memory changes, mood alterations, personality changes 1
- Neurological: gait problems, tremor, balance issues, swallowing difficulties, incontinence, pseudobulbar affect 1
- Cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, dermatologic systems 1
Physical Examination
- Vital signs: blood pressure (including orthostatic measurements), heart rate, respiratory rate, temperature, oxygen saturation 1, 2
- Anthropometrics: height, weight, body mass index, waist circumference 1
- Ankle-brachial index for vascular assessment 1
- Vision and hearing screening 1, 2
- NIH Stroke Scale (NIHSS) for patients with cerebrovascular history or symptoms 1, 2
- Neurological examination: level of consciousness, cranial nerves, motor strength, reflexes, Babinski signs, gait assessment 1, 2
- Cardiovascular examination: heart sounds, murmurs, peripheral pulses 2
- Complete system-based examination relevant to chief complaint 1
Assessment and Plan
- Problem list with prioritization based on acuity and impact on morbidity/mortality 1
- Differential diagnosis for each active problem 2
- Diagnostic workup planned with rationale 1
- Therapeutic interventions with specific medications, doses, and monitoring plans 1
- Follow-up plan: timing of next visit, parameters for urgent return 1
- Patient education provided and comprehension verified 1
Documentation Quality Elements
- Clear, concise language avoiding ambiguity 1
- Standardized terminology for reproducibility 1
- Photo or video documentation when relevant 1
- Electronic format with structured data fields 1
- Conclusion and recommendations clearly stated 1
Common Pitfalls to Avoid
- Missing related symptoms beyond the chief complaint - physicians frequently obtain information about presenting symptoms but miss important related symptoms and medical history 3
- Incomplete medication reconciliation - pharmacists obtain better medication histories than physicians 1
- Inadequate screening for substance use - while physicians frequently screen for smoking and alcohol, they rarely ask about recreational drug use 1, 3
- Failure to document temporal relationships for allergies and adverse reactions 1
- Overlooking informant sources when patient history is unreliable 1