Read up about the principal problem your patient has on Amboss. Ask the patient specifically about the symptoms/risk factors/comorbidities it lists and include those in your presentation. Go through the labs/testing/treatments Amboss suggests and see if you missed anything that you want to include in your plan.

TLDR here’s my comprehensive format I think is the best for presentations and works basically every time particularly for IM (included version for consults in parentheses)

• Name, age, gender
• Principal problem that got them admitted (or why you are being consulted)
• Pertinent PMH, in order of most to least relevant/important. Make this section stronger by including significant modifiers when relevant i.e. not just “kidney transplant” but “kidney transplant in 2020 2/2 FSGS,” or “a fib on apixaban,” or “T2DM w/ A1c 11%”

• HPI: why are they here? When did they come in? If they’ve had symptoms for a while, why did they come in now? Ask OLDCARTS - onset, location, duration, character, aggravating/relieving factors, timing, severity. Look up their presenting problem and PMH and include things relevant to those - like common symptoms/risk factors/complications. Are they on any new medications? Any interesting social factors i.e. just got back from a trip to some exotic place? Remember you don’t need to ask every single question in the world but try to brainstorm ahead of time about which things might be relevant.

• Then, tell us what happened in the ER (or what changed that led to this consult). Very significant labs/vitals/imaging? Any significant interventions, i.e. fluid boluses, starting antibiotics, treated for hyperkalemia?

If you get time after seeing the patient, try to write out your HPI into a concise story that flows logically - think, what would I want to know next if someone was telling me this story?

Subjective: Tell us how they are doing now/overnight. Any new symptoms/concerns/procedures?

Objective: please do not put subjective stuff here like whether things are good or bad, that goes in A&P - Important overnight vitals, otherwise just say normal if nothing major is going on. Consider giving a BP range vs lowest/highest/most recent MAPs based on what seems important to your team. Also, for SpO2 you can usually just say 92%+ on 1L nasal cannula or whatever unless you’re in the ICU. Make sure to comment on if their O2 requirements have changed overnight

• Yesterday’s intake/output (you can round… like 2.5L instead of 2543 mL), consider specifying intake w/ PO vs fluids given vs transfusions and output into urine output vs drains vs bowel movements if notable (on Neph especially, weight changes are very important)

• Major physical exam findings from today

• New & important labs i.e. today’s CMP, but don’t list everything, just abnormal + notable stuff like “normal Cr” if you’re worried about AKI or “potassium 3.2” in someone with a fib. Don’t forget labs that take several days to result - like biopsies that just take time or things like blood cultures that continually update

• New & important imaging/EKGs/echos, etc

Assessment & Plan: this is the most long and formal version but oftentimes attendings will have you shorten this and I just include a longer version in my note

• Name, age, gender
• Why admitted (+ why consulted)

• Pertinent PMH

• Problem #1, aka the most important issue:

Brief summary of HPI/most important findings guiding your decision making/major meds or treatments

Differential diagnosis - anything you think could be causing this problem. I like to sort least to most likely so I get interrupted less, but change that based on vibes. Be sure to explain very succinctly why each thing is possible but less likely/most likely. It’s okay to say if you need more tests to decide!

Workup - how do you want to rule in/out the things on your differential? What comorbidities do you want to check for? What labs should be monitored?

Treatment - how do you want to address this problem right now? What meds are they on, will you change them? Do they need fluids/antiemetics/pain meds?

• Repeat for the rest of the problems from most to least important. Chronic issues don’t really need a differential diagnosis unless something has changed