Patient Name:

_______________________________
MRN: ___________________________

Date: ____________

Time: _________

Infectious Diseases Consultation

Requested by: ____________________________________________

Reason for consult: _______________________________________________________________________________

Patient seen & examined with Attending Dr. ________________ Patient seen by Dr. ___________________ only
Teaching Physician
Key Findings

Chief complaint:

HPI: C1&2=1, C3-C5=4+

History of Present Illness:

History unobtainable. Reason: _________________________________________

Page 1 of 5

Patient Name:

_______________________________
MRN: ___________________________

Teaching Physician
Key Findings

Infectious Diseases Consultation

Past Medical History:

PMH/FamHx/SocHx:
C3=1of3, C4&5=3of3

Allergies:

Family History:

Social History:

Illicit drugs:

Occupation:

HIV risk factors:

Alcohol:
Tobacco:
Antimicrobial Drugs

Travel:
Dose/Route

Date start

Date stop

Page 2 of 5

Patient Name:

_______________________________
MRN: ___________________________

Infectious Diseases Consultation

Teaching Physician
Key Findings

Other medications:

C2=prob pert, C3=prob pert + 2,

C4&5=10+

Review of Systems (check if done, circle abnormal):

C1=affected body area/system

C2=affected+other symptomatic/
related system
C4&5>8

___ General
___ Eyes - poor vision, pain
___ ENT - sore throat, pain, runny nose, hearing prob,
dysphagia
___ CV - pain, palpitations, hypo/hypertension
___ Resp dyspnea, cough, tachypnea
___ GI pain, nausea, vomiting, diarrhea, constipation
___ GU - pain, bleeding, incontinent, nocturia, odor
___ Muscle - myalgias, arthralgias, weakness

Physical Exam (9alone=normal, if abnormal write results)

Const
Eyes

ENT/
Neck

Resp
CV

GI
GU

Ht___________ Wt____________ __General

__Conjunctivae, lids, pupils & irises
__External canals & TM
__Nasal mucosa, septum & turbinate
__Lips, gums, teeth
__Oropharynx, oral mucosa, salivary glands
__Hard/soft palate, tongue, tonsils, post. pharynx
__Thyroid
__Neck
__Resp effort
__Lung percussion & auscultation
__Palpation & auscultation of heart
__Carotid art __Abd aorta
__Fem arteries
__Pedal pulses
__Abdomen note masses or tenderness
__Liver & spleen
__Anus, perineum, rectum, sphincter tone
__Scrotal contents
__Penis
__Rectal exam/prostate gland/FOBT
__Lymph nodes in 2 or more areas

Skin

__Palpate skin & SQ tissue

Neuro

Psych

Abnormal Findings

BP_____/_____ P_______ R______ T_______

Lymp

Musc/
Skel

___ Skin - rash, pain, abscess, mass

___ Psych - fatigue, insomnia, mood
problems, depression, crying
___ Endocrine - hot flashes
___ Hem/Lymph fevers, chills,
swelling, night sweats
___ Immunologic/Allergies:

__Gait & station

__Digits, nails
__Joints, bones, muscles
__ROM, Stability __Muscle strength & tone
__Cranial nerves note deficits
__DTRs
__Sensation
__ Judgment & insight
__Orientation to time place, person
__Recent & remote memory __Mood & affect

Page 3 of 5

Patient Name:

_______________________________
MRN: ___________________________

Teaching Physician
Key Findings

Infectious Diseases Consultation

Laboratory & Radiology Data

Cultures (site/date/results)

Page 4 of 5

Patient Name:

_______________________________
MRN: ___________________________

Teaching Physician
Key Findings

Infectious Diseases Consultation

Diagnoses (include all non-infectious diseases diagnoses)

Data reviewed
&/or labs rec.:
Labs rev/rec
Radiology
tests rev/rec
Medicine
tests rev/rec
Discussed
results w/
performing
MD
Independent
review of
image,
tracing or
specimen
Obtained old
records &/or
history from
person other
than pt
Reviewed/
summarized
old records
&/or
obtained hx
from person
other than pt

Patient met criteria for:

Septicemia
+ blood culture & fever (or other symptoms)
Sepsis
+blood culture & >2 SIRS criteria
Severe sepsis
>2 SIRS criteria with organ dysfunction
Septic shock
Severe sepsis w/ hypotension & vital organs
deprived of adequate blood supply

SIRS Criteria:
T>100.4 or <96.8
WBC>12k or <4k
P>90
RR>20 or pCO2<32

Recommendations

Risk &/or
morbidity
mortality:
Low
Moderate
High

______________________________________

___________________________________

__________

____________________

Signature: Fellow; Resident; Student

Printed name
VCU ID#
Date
Teaching Physician Assessment:
I have interviewed & examined the patient & confirmed/revised the history, examination, assessment & plan as noted
in the margin. Please see residents notes for details.
________________________________
Attending Physician Signature

____________________________
Attending Physician Name (printed)

_________
VCU ID #

________________
Date
Page 5 of 5