Investigations Summary
A professional Internal Medicine template for healthcare professionals.
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OVERALL_INSTRUCTIONS
[Categorize all investigations into the above sections.] [For each blood test and imaging date, list all of them under 'All investigations' and also categorize them below.] [Separate lab and imaging entries by date of event.] [For lab results, start entry with date, e.g., 'Jan5, 2025: Na132, K5.0'.] [For CBC reports, include only the WBC, Hg, MCV, PLT values, and only include eosinophils, neutrophils, lymphocyte counts if they are abnormal] [Use abbreviations for names of blood tests.] [Double asterisk (**) for abnormal/outside of range results.] [For imaging results, start with type of imaging test then date, e.g., 'CT-chest Jan5, 2025'.] [Do not include any sections other than those listed.] [This note is only used to summarize investigations from data copy and pasted or screenshot into here.]
All investigations
[For each blood test date, list all labs performed on that date in the following format:] [DATE: labs] [Example: Jan5, 2025: Na132, K5.0, Cr1.2, HbA1c6.5] [Double asterisk (**) any abnormal/outside of range results.] [Each date should have its own entry.] [All labs listed here should also be categorized below.] [For imaging results, start with type of imaging test then date, e.g., 'CT-chest Jan5, 2025'.] [For imaging, copy and paste verbatim the radiologist's summary/conclusion and add pertinent positives from the body of the report not mentioned in the summary but do not include any unremarkable or normal findings.]
Cardiac related
[For each relevant date, list cardiac-related labs in the following format:] [DATE: BNP/NTpBNP, hsTrop, TSH, etc] [Double asterisk (**) any abnormal/outside of range results.] [For each CT-chest performed, use the following format:] [CT-chest (DATE):] [list only results related to the coronary artery or heart] [Example: CT-chest Jan5, 2025: coronary artery calcification]
Diabetes related
[For each relevant date, list diabetes-related labs in the following format:] [DATE: fasting glucose, HbA1c, etc] [Double asterisk (**) any abnormal/outside of range results.]
Lipids related
[For each relevant date, list lipid-related labs in the following format:] [DATE: TC, HDL, LDL, non-HDL TC, TG, apoB, lp(a), TSH, etc] [Double asterisk (**) any abnormal/outside of range results.] [For each CT performed, use the following format:] [CT body part (DATE):] [list only results related to arteries] [Example: CT-abd Jan5, 2025: iliac artery stenosis]
Renal related
[For each relevant date, list renal-related labs in the following format:] [DATE: Na, K, Cl, CO2, Cr, eGFR, Ca, sPEP, uPEP, UA, urine ACR, ANA, ENA, dsDNA, ANCA, C3, C4, CRP, HepB (sAg+/-, sAb+/-, cAb+/-), HepC (Ab+/-), HIV+/-, cryoglobulin, ASOT Ab, anti-GBM Ab] [Double asterisk (**) any abnormal/outside of range results.] [For each CT or ultrasound performed, use the following format:] [imaging test type (DATE):] [list only results related to kidney or urinary tract system] [Example: renal U/S Jan5, 2025: hydronephrosis of left kidney]
Hypertension related
[For each relevant date, list hypertension-related labs in the following format:] [DATE: Ca, TSH, UA, urine ACR, aldo, renin, aldo/renin ratio, post-dexamethasone AM cortisol] [For 24hr urine, use: 24hr urine DATE: Cr, metanephrines, catecholamines, free-cortisol, protein] [Double asterisk (**) any abnormal/outside of range results.]
Liver related
[For each relevant date, list liver-related labs in the following format:] [DATE: PLT, TBili, ALT, AST, ALP, GGT, ANA, ENA, AMA, ASMA, IgG, anti-TTG, CRP, ferritin, iron sat, ceruloplasmin, A1-AT, HepA, HepB (sAg+/-, sAb+/-, cAb+/-, eAb+/-, eAg+/-, DNA), HepC (Ab+/-, RNA), AFP] [Double asterisk (**) any abnormal/outside of range results.] [For each CT or ultrasound performed, use the following format:] [imaging test type (DATE):] [list only results related to liver or biliary system or spleen] [Example: Abd U/S Jan5, 2025: fatty liver, splenomegaly 15cm]
Hematology related
[For each relevant date, list hematology-related labs in the following format:] [DATE: WBC, Hg, MCV, PLT, retics, smear, ferritin, B12, copper, zinc, LDH, haptoglobin, TSH, sPEP, uPEP, Ca, SFLC ratio, CRP, ANA, ENA, dsDNA, C3, C4, RF, anti-CCP, ANCA, TBili, ALT, AST, ALP, GGT, UA, HepB (sAg+/-, sAb+/-, cAb+/-), HepC (Ab+/-), HIV+/-, INR, PTT] [Double asterisk (**) any abnormal/outside of range results.] [For each CT or ultrasound performed, use the following format:] [imaging test type (DATE):] [list only results related to abnormal lymphadenopathy, liver or spleen] [Example: CT-chest+abd Jan5, 2025: mediastinal lymphadenopathy, splenomegaly 15cm]
Others
[For each relevant date, list any investigations not included in the above categories in the following format:] [DATE: test/results] [Double asterisk (**) any abnormal/outside of range results.]
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