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, 2
Patient Demographics and Identification
- Full name, date of birth, age, sex, race/ethnicity including birthplace and parents' places of origin 2
- Years in current country of residence, primary language, handedness 2
- Education level, occupation, literacy status 2
- Living situation, type of residence, marital status, level of independence 2
- Contact person information for emergency and informant purposes 2
Chief Complaint and History of Present Illness
- Time last known well - establish exact timing using creative questioning with time anchors 3
- Presenting symptoms with detailed characterization: onset, duration, quality, severity, location, radiation, aggravating/alleviating factors, associated symptoms 1, 4
- Temporal progression of symptoms and any changes in pattern 3
- Related symptoms that may have been missed in initial questioning 4
- Impact on daily activities and quality of life 2
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 2, 3
- Cerebrovascular disease: stroke (hemorrhagic or ischemic), transient ischemic attack, carotid endarterectomy 2, 3
- Metabolic conditions: diabetes mellitus, hypertension, hyperlipidemia 2, 3
- Other conditions: migraine, sleep disorders, sickle-cell anemia, hypercoagulable states, deep-vein thrombosis, pulmonary embolus, chronic infections (periodontal disease, bronchitis), autoimmune diseases, renal disease 2
- Surgical history including any cognitive difficulties arising after surgery 2
- 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, 5
- Over-the-counter drugs including supplements 1, 5
- Herbal and alternative remedies 1, 5
- Previous antiretroviral therapy if applicable, with thorough documentation 1
- Recent medication changes or discontinuations 5
- Adherence assessment from patient, family, or general practitioner 5
Allergy and Adverse Reaction History
- Drug allergies with specific documentation of: drug name, dose, exact reaction suffered, temporal relation to drug exposure 5
- Previous drug intolerances with detailed descriptions 5
- Susceptibility factors for adverse reactions 5
Family History
- First-degree relatives: strokes, vascular disease including myocardial infarction, dementia, neurological diseases 2
- Age at death for deceased relatives 2
- Age of disease onset for affected relatives 2
Social History
- Tobacco use: current and lifetime exposure including second-hand smoke 2
- Alcohol consumption: quantity, frequency, pattern 2
- Recreational drug use: specific substances and routes of administration 1, 4
- 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 2
- Environmental exposures: pesticides, occupational hazards 2
- 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 2
- Neurological: gait problems, tremor, balance issues, swallowing difficulties, incontinence, pseudobulbar affect 2
- Cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, dermatologic systems 1
Physical Examination
- Vital signs: blood pressure (including orthostatic measurements), heart rate, respiratory rate, temperature, oxygen saturation 2, 3
- Anthropometrics: height, weight, body mass index, waist circumference 2
- Ankle-brachial index for vascular assessment 2
- Vision and hearing screening 2, 3
- NIH Stroke Scale (NIHSS) for patients with cerebrovascular history or symptoms 2, 3
- Neurological examination: level of consciousness, cranial nerves, motor strength, reflexes, Babinski signs, gait assessment 2, 3
- Cardiovascular examination: heart sounds, murmurs, peripheral pulses 3
- 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 3
- 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 6
Documentation Quality Elements
- Clear, concise language avoiding ambiguity 7
- Standardized terminology for reproducibility 7
- Photo or video documentation when relevant 7
- Electronic format with structured data fields 8
- Conclusion and recommendations clearly stated 7
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 4
- Incomplete medication reconciliation - pharmacists obtain better medication histories than physicians 5
- Inadequate screening for substance use - while physicians frequently screen for smoking and alcohol, they rarely ask about recreational drug use 1, 4
- Failure to document temporal relationships for allergies and adverse reactions 5
- Overlooking informant sources when patient history is unreliable 2, 5