UTMB SOM MS-III Survival Guide
Table of Contents General Information
Welcome to 3rd year! Evaluations Chase” “The Paper C History & Physical Consultations Discharge paperwork Writing prescriptions Epic Tutorial MyUTMB Tutorial Viewing Radiographic Studies Procedures
On-line Resources Peripheral IV Access Sterile Fields & Scrubbing Suturing/Wound Care
Table of Contents General Information
Welcome to 3rd year! Evaluations Chase” “The Paper C History & Physical Consultations Discharge paperwork Writing prescriptions Epic Tutorial MyUTMB Tutorial Viewing Radiographic Studies Procedures
On-line Resources Peripheral IV Access Sterile Fields & Scrubbing Suturing/Wound Care
The Rotations
Austin Rotations Psychiatry Surgery OB/GYN Internal Medicine Family Medicine Pediatrics Electives: Senior Neurology Senior Surgery Emergency Medicine Miscellaneous
Welcome to your 3 rd Year!! Congratulations on making it through the basic b asic science years of medical school, and a nd completing Step I! Your third year of medical school is an exciting time when you get to start assimilating all of the concepts you have been studying into the development of differential diagnoses and treatment plans. Here are a few things to consider con sider as you being your clinical training: Professionalism is extremely extremely important. You are reminded about the important of professionalism frequently during medical school, and most of the information seems like common sense. Unfortunately, every year, medical students make the same mistakes and drop the ball for their classmates and patients. patients. Here are some some common mistakes: “Just because they didn’t say anything doesn’t mean there’s not a problem”: You cannot count on someone else to tell you when there are problems with your professionalism. If you show up late one morning, and nobody seems to notice, it does not mean that your tardiness tardiness was acceptable. If you are the type of person who will test the boundaries to see what is acceptable, your faculty and residents will give you all the the rope you need to hang yourself. There is nothing malicious about this on their part. The concept of professionalism should be self-evident, and they are not going to spend their time dealing with those basic issues.
tolerate tardiness. tardiness. Everyone “If you are not early, you are late”: Residents and attending will not tolerate understands that things come up occasionally occasionally that make it difficult to be punctual. It is a good idea to plan to get everywhere a few minutes earlier than you might normally arrive. This allows you to keep some room in your schedule for unexpected delays realize the importance of the tasks you you are asked to complete. Even Responsibility: It is important to realize tasks that seem unimportant can have significant consequences if they are not completed. Surgeries have been delayed for over 30 minutes because someone failed to get a copy of the X-rays to the operating room. This makes the attending surgeon, anesthesiologist, anesthesiologist, and residents all very unhappy. cases, you create more Attendance: It is very inconsiderate to skip your clinical assignments. In most cases, work for your classmates classmates who are forced to cover your your patients. Even if they say it is “okay”, it usually is not. skills can be just as important important as your your knowledge base, or skill skill level. This Be nice: Your interpersonal skills is especially true early in your training. You don’t need to hug or brown-nose everyone, but you should treat everyone with respect. One faculty frequently tells tells students that nurses nurses are the most important important people to impress on a clerkship. The reason is that the faculty and residents all get “one vote” on your performance, but the nurses will complain about you to everyone, or loudly sing your praises. Many students have been hurt by their poor po or treatment of support staff.
Evaluations & Grading From here on out, a more significant portion of your grades will be based on subjective observations. Exams are still very important, but they tend to be responsible for a much lower percentage of your overall grade. The exact weight of the various components used to calculate your grade is different during each clerkship. It is a good idea to find out who will be doing your evaluations, so that you can make sure the evaluators are aware of your efforts and are able to give you the recognition that you deserve. Consider the following situation: “I had one rotation where I spent a great deal of time working with a senior resident, only to find out later that the evaluations were done by the faculty, with very little input from the residents. I had spent very little time with the faculty, so he didn’t have enough information to give me an ything more than a mediocre evaluation.”
In many rotations you can go over your evaluations at the end of the rotation and request evaluations from residents and faculty with whom you had the most contact. Ask for additional evaluations. If you have spent a lot of time working with a particular faculty or resident, ask them to complete an evaluation for you. Don’t put a lot of pressure on them. Even if they think you were great, an evaluation that you hounded them about is not going to be as favorable as one that they were eager to complete.
The Paper Chase The History & Physical : This is something that you should already have developed proficiency in. You know the basic format, but the residents and faculty in each clerkship may have different expectations. You are expected to have the basics down, and learn the specifics on the rotations. A good rule of thumb is to try to find a good H&P to read on the first day of each new rotation. It will give you an idea of what is expected, and hopefully point out anything on which you need clarification. Things can get a little more difficult with regard to the time frame you are expected work within. In your Practice of Medicine courses you were expected to go gather the information, then sit down and type everything up and submit your H&P for critique within a few da ys of the patient encounter. Unfortunately, that is not reality. You will need to gather the information and either write the H&P as you interview the patient, or immediately afterwards. With everyone now having access to Epic, your notes are easily accessible for your residents and faculty to view. Epic does have spellcheck, but remember that it does not catch every misspelled word. Additionally, be wary of using any sort of template unless given permission by your team.
Progress Notes (SOA P notes): Note: The idea is to see your patients and write your own note preferably before the residents have written their notes, but at least before looking at their notes. This is where you practice your clinical thinking skills. Y ou may be way off, but the great thing is, it doesn’t matter. Faculty would much rather you have a wrong assessment and plan than nothing at all. At least this shows you’re putting some thought into your patients. General format to follow (adjustments should be made for the focus of the particular rotation): ubjective: Give a brief summary of what the patient reports over the previous 24 hours. Include any S important changes in the patient’s status. bjective: This section includes the vitals, ins/outs, physical exam, labs, radiology, & current meds. O A ssessment: You should give a brief assessment of the patient’s problems based on the above data. P lan: Detailed plan on how you want to address each of the patient’s problems that you mentioned above. Include medication changes, labs, procedures, consults, discharge status, etc.
DISCHA RGE SUMMA RY To be completed in EPIC. Note: TDC discharges are a little different. You have to know what type of unit the person is going to and his or her mode of transportation. Additionally, every TDC patient going to an infirmary must have a MRIS (Medical Release Intensive Supervision) formed filled out. Patient's Name: Chart Number: Date of Admission: Date of Discharge: Admitting Diagnosis: Discharge Diagnosis: Attending or Ward Team: Surgical Procedures, Diagnostic Tests, Invasive Procedures : Brief History & Pertinent Physical Examination & Laboratory Data: Describe the course of the patient's
disease up until the patient came to the hospital including physical exam & laboratory data.
Hospital Course: Describe
the course of the patient's illness while in the hospital; include evaluation, treatment, outcome of treatment, and medications given while in the hospital. Discharge Condition: Disposition: Where the
patient will be going upon discharged (home, nursing home), and who will take
care of patient. Discharged Medications: List medications and instructions. Discharged Instructions & Follow-up Care: Date of return for follow-up care at clinic, diet, Problem List: List all active and past problems. Copies: Send copies to attending physician, clinic, consultants and referring physician.
exercise.
Writing a Prescription You are able to fill out the prescription for your faculty or resident, but you cannot sign the prescription yourself. Remember that all prescriptions go on water sealed paper. Under Texas State Law, all prescriptions should have the following essential elements : Date of the order: Allows determination of the life of the prescription with regard to refills. Legend drugs expire 1 year from the date of the original prescription. Controlled substances expire much sooner. Patient Name and Address: Date of birth is not required but is generally included. If the drug is prescribed for an animal, the species of the animal Name of the drug Strength of the drug Quantity of the drug Directions for use Intended use of the drug, unless practitioner feels indication is not in best interest of patient Practitioner Name, Address, Telephone number Common Pitfalls Avoid tr ailing decimals: “8.0” may be misinterpreted as “80”. Use zeroes before leading decimals: “.5” may be misinterpreted as “5”, whereas “0.5” is less likely to be misread.
Example Prescription
UTMB prescriptions often include a pager number for the signing physician. You can also avoid some potential for errors by writing out the number to be dispensed, as well as indicating the number numerically. This should always be done with controlled substances. In the example prescription, it would be easy to change the “30” to an “80”. It would be more difficult to alter “#30 (thirty)”. If you get into the habit of doing this every time, you are less likely to forget when it is important.
Epic: a Medical Student’s Best Friend The Basics This is the computer system everyone had to be tutored on before you started 3rd-year. On your first day, you will be a little unfamiliar with it, but the more you use it Epic will be your best friend at UTMB. Epic is accessible on any computer on the UTMB campus and UTMB outside clinics. **Austin has its own computer system** The only good way to really learn the system is from someone who has already learned it. Ask a fourth year or upper level resident to help you. Remember, the interns are new too (unless they went to UTMB), and they will be just as lost as you, probably more so. Also, don't wait until you are on call or everyone is busy trying to admit patients. Ask someone to help you with the computer systems during your first rotation, when there is some down time (afternoons are usually slower than mornings for most clerkships).
In the Hospital Once you start a new rotation, create a new patient list for that rotation from the selected te am you are on. (Most of the teams will already have an existing list and your residents will share it with you.) You can organize & create the patient list to show specific values that you need. Print the patient list everyday (write on it to know what procedures are being done, what lab values do you need, which patients are going home, etc.) and possibly Rounds reports for your patients (this has all of the important info: current meds & dosages, current orders, lab values, test results, etc.) After you have selected a patient:
Snapshot : brief Past Med Hx & Meds
Click Here for Rounds Report
Make a List
Find Where a Patient is
Patient Summary : Rounds reports Chart Review: past Encounters/Notes, Standing orders Results Review : all lab values & test results Demographics : Contact info & Emergency contact Historical Orders : Log of Complete/Incomplete orders MAR : tracking of medication dosages & schedules
Find Patients on Your Team
In Clinics with Epic If you are at a UTMB outside clinic, you can look up a doctor’s schedule (click on SCHEDULE and find the clinic’s name) and review patient information before the patients come in. Click “Review” in order to access a patient’s chart. This is a great way to know the past medical history, current medications, and the key reason why the patient is returning to the clinic (from “Encounters” in Chart Review). 1s click Schedule
3r Select Doctor
2n Select Department/Clinic
MyCitrix: A ccessing Epic from your V ERY OWN HO ME (http://mycitrix.utmb.edu) Why go into the hospital if you just want to check on an updated lab value or see the number of patients that you currently have on your census? By accessing MyCitrix from home or anywhere, you can save time by finding info quickly off-campus with access to all of the same features, such as Epic & other programs. You must be able to download the ActiveX component to your computer in order to fully access the website. This also gives you a way to access UpToDate from home. Go through the “UTMB Homepage” link.
MyUTMB: a Medical Student’s other Best Friend The Basics MyUTMB (http://my.utmb.edu) is also a website that medical students can access ANYWHERE. It has all of the information that is accessible in EPIC along with some different features. If you have problems accessing MyUTMB, call technical support to make sure that you have access (your usual username & password). Older information and other reports could be stored in here if not seen in Epic. However, lab info is not as printer-friendly compared to Epic. MessageNet (must log-in to MyUTMB for access) This allows you to store people’s pager numbers, sort them into groups, and (if they have alpha-pagers) text page people with important, brief info. No need to remember your classmates or resident’s pager numbers. Plus, you can mass page people when rounds are ready. Webpaging (http://my.utmb.edu/webpage) If you just want to send a brief message and are not able to/do not want to access MessageNet, you can webpage with the same amount of text page capability. This is accessible through iUTMB homepage as well. iUTMB ( http://www.utmb.edu/iutmb) This is the UTMB homepage for Faculty, Staff, and Students which has links to pretty much everything mentioned above.
Viewing Radiological Studies What is PA CS: PACS is the program that we use to view radiological images. It can be accessed at a PACS station in the hospital or at any computer through MyCitrix. It is important to realize that images should ideally be viewed on the PACS stations located throughout UTMB. These viewing stations have high resolution monitors. Images viewed on other computers may not have the appropriate resolution and can lead to incorrect interpretations. The interpretation standard is to utilize the viewing stations. When you access PACS remotely (i.e., not through a viewing station), the program you will use is called “Centricity”. A ccessing PA CS: You must access the PACS system to view radiological images. The URL is https://pacs.utmb.edu. If you cannot remember the URL, it can be found easily through MyCitrix or the MyUTMB website. Simply access MyUTMB and access your patient’s recor ds. Then open the Radiology folder within the frame on the left. Then click on “Images”. This will take you to a page that has the link to the PACS system. Logging In to PA CS: PACS is configured to utilize the same username and password that you are assigned for email access. However, to access PACS, you must use the entire username, which is: utmb-users-m\email username. Finding a Patient: Once you have logged into PACS, you should see a screen similar to the one below. There is a small icon that looks like a set of binoculars. If you move the mouse over this icon, a new screen pops up where you can enter any parameters you would like to search. You can enter any of the parameters listed on this screen, although the “Patient ID” (the UH number ), is the most specific parameter.
Viewing the Images: Once you have queried a patient, you will be presented with a list of the available images. Just click on the study you wish to see. Once you select a study to view, you will see thumbnails of the images. Click on the thumbnail you wish to enlarge. Across the top of the screen there will be navigation and viewing options. These allow you to move forward and backward through the images, as well as selecting the number of images to view per page. On the top of the screen you will see the following icons:
Contrast : This icon allows you to adjust the contrast of the image. The easiest and probably most popular way to adjust the contrast is to simply hold down the right-button on the mouse while moving the cursor over the image . What this is actually changing is too complicated to get into, but you can play with it and learn to clarify what you are looking for. Magnify: this allows you to zoom the image in or out. There is also a magnifying glass feature that allows creates a pop-up window that you can move over the image with the mouse and works like a magnifying glass.
ALWAYS LOOK AT YOUR PATIENTS RADIOLOGIC IMAGES YOURSELF! You may not know how to read x-rays and CTs yet, but the only way you learn is through practice, and some attendings will actually ask if you looked at it.
Procedures This section is not meant to teach you how to perform any of these procedures. We are simply going to review information that may be confusing or often overlooked. Additionally, this section provides resources that can be utilized for a more complete procedure review. If you have the luxury of knowing ahead of time that you will be participating in a procedure, take a few minutes to review the procedure as completely as you can.
Excellent Procedure Resources You can access Roberts: Clinical Procedures in Emergency Medicine, 4th ed. through MD Consult. Locate the main MD Consult page under “Electronic Books” section on the library’s website. From the MD Consult homepage, select “Books” from the tabs across the top of the page. “Robert’s” is listed under the emergency medicine textbooks. Topics covered include: tracheal intubation, cricothyrotomy, thoracentesis, tube thoracostomy, defibrillation/cardioversion, cardiac pacing, pericardiocentesis, resuscitative thoracotomy, peripheral and central venous access, arterial access, venous cutdown procedures, intraosseous infusions, wound closure, incision and drainage, urethral catheterization, and many more! Also, The New England Journal of Medicine has several videos demonstrating many types of procedures. You will see some of these during Clinical Skills week, but if you want a refresher, they can be found at http://content.nejm.org/misc/videos.dtl.
Peripheral IV A ccess Some people will argue that there is no need for medical students to become proficient at establishing peripheral IVs. The problem with this argument arises when the nurses are unable to establish an IV. Here at UTMB, the team intern is called when the nurses are unable to get IV access on a patient. Most nurses will allow you the first stick at starting an IV if you ask nicely. Take advantage of the opportunity to become proficient now! Saline Lock Vs. Heparin Lock Vs. Peripheral IV: When establishing peripheral IV access you must consider the patient’s needs. If he/she is going to receive periodic medications, but does not otherwise require a continuous infusion, there is often no need to connect the patient to a bag of IV fluids. In this case, you can simply put a “cap” on the IV catheter after it has been inserted. Since the IV is not attached to anything it is much more comfortable for the patient and less likely to be accidentally removed. If the IV catheter is capped in this manner, it needs to be flushed to minimize the chances of the catheter occluding with a clot. Unless told otherwise, you can flush a peripheral IV catheter with 3-5 ml of normal saline after inserting. MAKE SURE that your vial is NORMAL SALINE, as often the vials appear similar to different medications, which could be lethal if 3-5 ml were infused. Sometimes Heparin is used. The difference between a “Heparin Lock” anda “Saline Lock” is simply the fluid that is used for the flush. Everything else is the same. Beware that people sometimes incorrectly refer to “saline locks” as “heparin locks”. It is a good idea to confirm things before flushing with heparin. Sites to Avoid: Basically, try to avoid any IV site that is abnormal. Avoid areas with surgical manipulations, trauma, or infections. ABSOLUTELY avoid arms on the same side as a mastectomy, or dialysis access. It is also a good rule of thumb to start distally, and then work proximally when evaluating potential IV sites. If you blow an IV in a patient’s antecubital fossa, and then establish one in
the back of his hand, there is a chance that your IV fluid will leak out of the more proximal puncture site. Sterile Fields & Scrubbing During your surgery rotation, and probably your OB/GYN rotation you will be doing plenty of scrubbing in on cases. The surgery clerkship has an orientation to the OR where they will highlight the important topics, and there is also an OR manual found at: http://www.utmb.edu/surgery/clerks/ormanual.htm that may be helpful. Scrubbing: 1. Make sure before you start scrubbing that you have everything on you will need (especially your mask and eye protection), and that it is comfortable because you won’t be able to touch anything afterwards. 2. Generally, the first time you scrub in for the day, you should do a full scrub with the antibacterial soap. a. Turn on the water and open the package containing the brush and nail cleaner. b. Clean under the nails and throw the nail cleaner away. c. Take the brush in one hand and wet with water and soap. d. Scrub the nails of the opposite hand, followed by the fingers (treating each finger as foursided). Then scrub up the arm to 2 inches above the elbow. e. Switch hands and scrub the opposite arm in the same manner. f. Discard your brush and rinse off both arms making sure that the water runs down your elbow and not off the ends of your hands. (Keep hands higher than elbow.) g. Enter OR carefully, making sure not to touch anything with your arms. h. This first scrub should take approximately 5 minutes. 3. Each subsequent time that you scrub during the day, people generally do a much faster scrub with soap and water. They then dry off their hands and apply the alcohol solution to fingers, hands and arm making sure to not miss anywhere. 4. Once in the OR suite, most scrub nurses are great about helping you out as long as you’re nice to them, and don’t touch any of their sterile equipment. They will help you gown and glove. Sterile Fields: Basically, the most important thing to remember is that you a re sterile from your chest to the level of the sterile field, so this area should never touch anything else. Also no other area of your body should touch anything within the sterile field. As students, you will mostly be standing, watching and retracting so there is usually no reason to be moving around the room. Therefore, just always remember to keep your arms in front of you between your waist and chest.
Suturing/Wound Care You will be closing wounds, mostly closing up after surgery, but you may also close traumatic wounds in the emergency department as well. Basic Principles for traumatic wounds: 1. For all wounds do a good neurovascular exam to ensure that sensation and motor function are intact. 2. Tetanus status should be checked on all patients presenting with wounds. 3. If there is a risk of foreign bodies being stuck in the wound plain film x-rays can be obtained. 4. Wounds at high risk for infection (mammalian bites, oral wounds, plantar puncture wounds, etc.) should receive antibiotics before any manipulation of the wound.
Steps for traumatic wound care: 1. First, do a good neurovascular exam. 2. Following the exam, give local anesthesia, usually lidocaine around entire wound. Insert the needle through the already injured tissue at one end and inject a wheal of anesthetic. Then the needle can be withdrawn and advanced all around the wound while injecting anesthetic. 3. Hemostasis is important for good wound visualization and cleaning. With most wounds, hemostasis can be achieved by applying direct pressure. 4. Remove any foreign bodies. 5. Irrigate the wound with high pressure irrigation. There are many different methods for doing this. 6. Debridement may be necessary if there is dead tissue around the wound. Wound closure: 1. Classification of closure a. Primary intention – direct closure of wound using sutures, glue, etc. This is ideal, but should not be done if the wound is obviously infected, or is at high risk of infection. b. Secondary intention – used with infected wounds. Wound is left open and may be covered with antibacterial ointment. Often, a wet-to-dry dressing will be used to continuously debride the top layer of tissue, which is usually dirty. c. Tertiary intention – wound is closed after leaving open for a while and after wet-to-dry dressings have established a clean bed of tissue. 2. In the OR, most wounds will be closed with primary intention. 3. A thorough review of suturing techniques and types is beyond the scope of this survival guide, but the Clinical Procedures in Emergency Medicine book found at MDConsult and referenced above has an excellent explanation with many diagrams.
Austin Rotations The Basics You will receive your own materials when you go there. It is a minority of the class that actually is allowed to go, and each rotation there puts their own booklet together; it is very self-explanatory. In Austin, you will be told what to expect/do, and everyone is very good about that since there are less students. Adrienne Thompson (
[email protected]) is your best source of information while you are in Austin! Don't hesitate to ask her questions and if she can't answer them, she is awesome at helping you find answers. The parking shuttle is not such a bad deal. Rather than curse its distance away from the hospital, just utilize it and you will never have trouble finding parking. The Brackenridge staff is not used to having students around as much as they are at UTMB. Make every effort to participate in anything you can, as they are happy to teach when you show interest. The housing that UTMB provides is very reasonable. You can share the rooms with people that you know (4 of you), so it can be just like college all over again. If you do not want to stay there, keep in mind which classmates are living in Austin in case they can offer to crash at their place for a month or so. The best part: more things to do. If you think you might get bored, do not worry. Everyone will be in touch with whom all is in Austin, so going out is a nice break and a good change of scenery. Plus, you can make some stronger friendships or new friends in the class while in Austin since it is a fair distance away from UTMB. Yes, you will be busier on some rotations due to the lack of residents, but you are able to perform more duties and procedures, so it can help you in the long run. The commute back to Galveston for OSCE’s and shelf exams is not too much of a hassle because you can touch base with the Galveston people while you get back into town. In 3rd year, everyone is so busy; many people have not seen each other in a long time. Whether you are in Austin or Galveston, your fellow classmates will want to hear how things have been going.
Psychiatry The Schedule Generally you have weekends off, unless you are on call. Spend time studying for the shelf. You have no excuse not to – this is one clerkship with adequate study time. Small Groups: Do the assigned reading: You will be tested on the material every time. The IRAT will evaluate your memory of the specific reading, not your understanding of the topic. Even if you have the material down cold, you will not do well if you skipped the reading. No other source will help you as much on the IRAT/GRAT as the assigned text. A dult Psych – Inpatient Responsibilities will differ depending on where you are doin g your inpatient portion at (St. Joseph’s, St. Luke’s, Jester, Austin, etc.) In general: Before Rounds Duties include seeing your assigned patient and completing your notes. Making sure the team census is correct for morning rounds. Helpful hint – first student to arrive – print census/rounds reports on all patients and a checkout list (shows meds) for each student. Distribute the census/rounds reports to the assigned students along with a checkout list. This will save everyone a lot of time. After Rounds Update the census list in the afternoon. Help with complete discharge planning and paperwork. Call MHMR to schedule patients’ f/u visits and obtain records of new p atients. Patients appreciate just having someone to talk with when you aren’t busy doing other stuff.
Consult & Liaison C & L makes it worthwhile to pay the extra $50-odd for an alpha pager. You can study in the library (or at home, depending on where you live) and the patient’s information gets sent to you – without you having to stop and find a phone. Rounds in the morning change location – depending on which faculty member is attending that day. Don’t lose your first-day information about the faculty schedule. It is a good idea to pick up one of Dr. Avery’s AIDS packages in case you are asked to consult for a patient with AIDS – that way you won’t have to track him down to get one. The package is HUGE (it makes War & Peace look like a comic book) so be prepared to spend some quality time filling it out. The added bonus of doing C&L early in the year is you get to learn your way around the hospital. STUDY when you are not with a patient!!!
Outpatient: There are several clinics where you may be assigned. In general, at most clinics your main responsibility is just shadowing the faculty and residents. The best way to excel in this portion of psychiatry is to pay attention, act interested, and ask good questions of those you’re working with. You can pick up a lot of useful information during clinic if you’re paying attention. Textbooks: Student Recommendations: Case Files Appleton and Lange Q’s, First Aid – Psychiatry Clerkship Series: Psychiatry: A quick read that was useful for getting the main idea behind the DSMIV criteria. I had a hard time memorizing the diagnostic criteria, and this book provided examples that allowed me to get the “feel” for the different disorders. This book is not available in the bookstore, but can be purchased online. Pretest Psychiatry: Good basic questions. Skip theory section! And again, make sure you read the weekly assignments from the assigned textbook!
Psychiatric History Identifying information - age, sex, marital status, race Chief complaint - reason for consultation, a direct quote from the patient HPI (History of Present Illness) - current symptoms, previous psychiatric
symptoms and treatments,
reason presenting now. Past Psych. History - previous and current psychiatric diagnoses, history of treatments (include both outpatient and inpatient), psychiatric medications, history of attempted suicides and potential lethality. Past Medical History - current and or previous medical problems with treatments Family History - relatives with history of psychiatric disorders, suicide or attempts, alcohol or substance abuse Social History - source of income, level of education, relationship history, support network, individuals living with patient, current alcohol or drug use, occupational history. Developmental History -family structure since childhood, relationships with parents, peers and siblings, developmental milestones, school performance.
Mental Status Exam grooming, level of hygiene, clothing characteristics, unusual movements, attitude, interactions with the interviewer, psychomotor activity (agitation or retardation), degree of eye contact. Affect - external range of expression (described in terms of quality, range and appropriateness). Types could include flat, blunted, labile, and wide range. Mood - internal emotional tone of the patient: dysphoric euphoric, angry, anxious. General Appearance and Behavior
Thought Process Use of Language Thought Content :
quality and quantity of speech. Note tone and fluency here.
Hallucination -false sensory perceptions (auditory, visual, tactile, gustatory, olfactory) Delusions -fixed, false beliefs firmly held despite contradictory evidence Persecutory - others are trying to cause harm or spy with intent to cause harm o Erotomanic -false belief that a person of higher status is in love with the patient o
Grandiose -false belief of inflated sense of self-worth Somatic -false belief of having a physical defect o Illusions - misinterpretations of reality Derealization -feelings of unrealness involving the outer environment Depersonalization -feelings of unrealness (being outside of your own bo dy) o
Suicidal and Homicidal Ideation Cognitive Evaluation
Level of Consciousness Orientation - person, place and date Attention and Concentration - repeat 5 digits backwards or spell “world” backwards Short-term memory - recall 3 objects after 5 minutes Fund of knowledge - name 5 presidents or historical date Calculations - subtract serial 7’s, math problems (simple) Abstraction -proverb interpretation Insight: ability of patient to display an understanding of his current problem Judgment: ability to make realistic decisions about everyday activities
Physical Exam DSM IV Multiaxial Assessment
Axis I: Clinical Disorders Axis II: Personality Disorders Axis III: Medical Conditions Axis IV: Psychosocial Problems Axis V: Global Assessment of Function (a number)
Plan of Treatment
Common Thought Disorders Pressured Speech - rapid speech, especially with manic disorders Poverty of speech - minimal responses Blocking - sudden cessation of speech Flight of ideas - accelerated thoughts that jump from idea to idea Loosening of Associations - illogical shifting between unrelated topics Tangentiality - thought which wanders from the original point Circumstantiality - unnecessary digression which gets to the point eventually Echolalia - echoing of words and phrases Neologisms - invention of new words by the patient Clanging -speech based on sound such as rhyming and punning rather than logical connections Perseveration - repetition of phrases or words in the flow of speech Ideas of Reference - interpreting unrelated events as having direct reference to the patient Lab Evaluation of Psychiatric Patient Commonly includes: Chem - 7, CBC, LFTs, RPR (VDRL), Toxicology screening, Blood alcohol, medication levels, HIV
Surgical Clerkship Team work is essential during surgery. Communicate on a daily basis with your fellow medical students to make sure that every surgery is covered by the appropriate amount of medical students (some need only one, some need two), and every patient on the service is covered.
Rounding Surgery rounds are early! You’re basically expected to be there from 6 a.m. to 6 p.m. You will be rounding with your Chief Resident more than with your attending. Ask what he/she wants in a presentation. Important Information to Gather Each Morning: Fever: always report the T-max, range of temperature, and time of Tmax. Ins and Outs – Be specific & include each type (urine, drains, fistulas, etc.) Status of flatus AND Bowel movements Also remember to actually look at the incision/dressing Textbooks: Student recommendations Surgery Recall is a great book to carry with you and read before your surgeries for “pimping” questions. Pestana Review Questions (e-mailed to you by the course coordinator) – good overview of basics Surgery Case Files Underground Clinical Vignettes NMS for Surgery NMS Surgery Casebook – Similar to Case Files but more details, does not cover many surgical subspecialties Pretest for Surgery- if you find that you like the pretest series, this one is helpful. First Aid for Surgery – trauma portion Basic Information: At the end of every day, check the Case book/OR schedule to see what surgeries are scheduled for the next day; decide how to divide them up amongst the team. You are expected to know the local anatomy for your surgery and pathophysiology. (It doesn’t hurt to look up what is going to be done in the surgery) If you are on the trauma team – you don’t have the luxury of knowing what you’ll see- so you might want to have an atlas in your bag- you don’t have to carry it around, leave it in the call room. Be sure to let the scrub tech know you will be scrubbing in and ask if you should get your correct size of gloves and gown. DO NOT ASSUME that they have your stuff. Usually they aren’t prepared for you/don’t know your size, so just a good idea to keep a couple of pairs of sterile gloves in your size with you at all times. Always double glove for surgeries, especially those involving TDC inmates. PAY ATTENTION during the information sessions at the beginning of surgery – sterile technique, Foley and NG insertions are all things that you will need to know. Get someone to walk you through this on a patient early on, so it will be easy later on. CLINIC DAYS are professional clothes days for everyone except the trauma team.
General Surgery Team Codes for Order Entry: SURA for General A; SURB for General B For clinic, review your breast pathology, signs and symptoms, and tests. When you know your patient is going to be discharged, make sure to fill out the Discharge Summary if your team wants you to help with these. If you have a patient who has been in house, having multiple procedures, it’s not a bad thing to get into the habit of filling out the discharge sheet as you go – with each procedure & date so you won’t have to go through the chart later to find this information. Trauma Whether you’re on the team for the month or trauma call, a lot of what you’re doing is making things run smoothly. Keep a study book in your pocket – there is a lot of down-time when you are waiting for patients in the CT scanner, X-Ray, etc. When you are on trauma call you have the trauma pager. There is only one trauma pager between all medical students. If you are a heavy sleeper – let your call partner sleep with the trauma pager. If you are both heavy sleepers make sure you both sleep in the same call room and pray you don’t sleep through it. It has been done. YOU DO NOT WANT THIS TO HAPPEN TO YOU!!! The trauma call room is on the third floor of the Trauma Center (above the E.R.) The door number is 123. The inside door codes are on the side of each lock (Thus they don’t really function as a lock – they just delay entry of someone long enough for you to wake up and wipe the drool from your face) For some reason, the phones in the Trauma Call rooms tend to get unplugged and moved around, so don’t assume that the number on the phone itself is correct (especially if you’ve been waiting an awful long time for someone to return your page). On trauma call, you will meet for the trauma meeting either in the morning or afternoon and exchange pager numbers and cell phone numbers with the residents then. Usually for high-speed collisions and falls (the majority of traumas) you are going to want: CXR (Chest X-Ray) o 3V C-Spine (3 view c-spine) o Pelvis o Fortunately, if the team wants all of this they can now order a trauma panel on EPIC. o Any CT scans done in the trauma rooms have to be “okayed” by a radiologist before you can schedule them. The ER/Trauma Radiologist is usually in the Radiology reading room. It’s YOUR job to write up the request as the resident says they want to get a CT, take it to the Radiologist, let them write their code on the request, then take it to the CT Scanner. If you’re on the trauma team keep a 10 cc syringe in your pocket on rounds so you can pull out Foley catheters without searching one out. You can get these in the shock trauma rooms in the ER – while you’re there, also grab some tape, because you’ll want that for changing dressings. 4X4s are also a good thing to have on you – but the packaged ones are easier to find on the floor than in the ER. I always tried to have two packs on me, and replaced them as we used them. On trauma team – its still a good idea to have X-Ray & Consult forms on you at all times. If the patient has a “distracting injury” - like a broken bone in the wrist, etc. – then you don’t clear the c-spine clinically – there has to be good radiographic evidence that the C-spine is okay – that means if the 3-view c-spine is inadequate, you’re going to have to do a CT.
CRITICAL PARTS OF YOUR JOB ON TRAUMA TEAM or TRAUMA CALL: When the patient arrives and you are in the trauma call room, quickly go to the phone in the trauma room, dial X-Ray (speed dial button) and tell them there is a trauma. Have your trauma shears ready – you cut the clothes off the patients so that the residents can assess them. Foley catheters & NG tubes – this is your time to learn to put them in. (Don’t worry – you will be shown how to do this in a group session at the beginning of trauma - PAY ATTENTION) Starting I.V.s – If patients come in by ambulance they generally already have at least one – the nurses will start another quickly, so if you want to try – speak fast. Don’t pick an unstable patient – you don’t want to be delaying essential patient care – but there will be plenty of stable patients! Check INQN for lab results for your patients (Most of the stat requests will be hand-delivered on little slips of paper by the nurses – make sure results get into the trauma sheet) Photocopy the trauma sheets for the patient you want to present in the morning – you’ll be glad you did – also, make sure you know WHY studies were done or not done – because you may be the person justifying decisions that weren’t yours.
Cardiothoracic Surgery Team Code: CTS Cardiothoracic surgery has a protocol book that they give you at the beginning of the rotation for pre & post-operative care that explains all the preoperative work up and the postoperative orders for every post-operative day. This book should help you know what is going on. Be careful about contamination with the bypass machine; there are always tubes and things everywhere and they ask you to move around sometimes from one side to the other. Remember where your sterile field is & don't put your hands below your waist, rest them across your chest and keep your elbows in when walking around. Also if you have a bad back or joints, take a Motrin before every thoracotomy because you will probably be riding a retractor the whole time. Would be helpful to review your cardiac output equations, know the pulmonary artery catheter/Swan Ganz and what it measures, read about cardiopulmonary bypass surgery to understand the heart cannulations and the bypass machine. Also for people that have been on the bypass machine in surgery when they are on the floor you are looking for them to diurese all that fluid out so pay attention to urine output, ankle edema, and daily weights! And listen to lungs for crackles, signs of fluid overload. You are looking for them to get down to their admission weight. Always have those things in your notes and know them for rounds. Know which diuretic and how much they are on. Typically they need to get out of bed when they are stable, so ask the patients or look in the nurses notes to find out if they’ve been ambulating yet.
Vascular Surgery Learn your vascular anatomy – SERIOUSLY – it’s not something you can fudge. On rounds, One team member better have the Doppler machine and jelly so that you are prepared to o Doppler every patient. Know the DAILY values of PT, PTT, & INR, for any anti-coagulated patient (this will be o almost EVERY vascular patient)
Know where to feel pulses – femoral, dorsalis pedis, popliteal, posterior tibial. On rounds – if you feel a pulse, great. If you find the popliteal easily – it’s probably an aneurysm. If you don’t feel a pulse- the patient’s pulse is probably not palpable. Read the packet of studies that the faculty gives to you. READ THEM. Wear safety goggles when removing stitches on any anti-coagulated patient. On the first clinic day, be polite and ask one of the nurses in clinic to show you: How to use the Doppler o o How to put on a UNABOOT How to fill out pre-op packets o o
Transplant Surgery The progress notes are done on a special form; labs are checked every morning and recorded on the form, along with all the meds that patient is on. The easiest place to find the meds is on the MAR form in the nursing folder. Make sure you write down the doses on the immunosuppressant meds. They will be CSA (Neoral), mycophenolate (CellCept), FK506 (tacrolimus or Prograf), and a steroid, usually prednisone or Solu Medrol. Get to know Melissa. She’s the team pharmacist and your best friend for information on immunosuppressant medications. Every patient that has had a transplant needs a door chart that is updated every day. Make sure that all immunosuppressants and antimicrobials that the patient is on are on the door chart, as well as drug levels, like FK or CSA (which are drawn every morning) Try to get in on a lot of vascular access cases, because you get to do more sewing, if you want to. Most transplants don’t actually happen during the daytime hours. If you want really want to see a transplant, make sure your attendings have your pager/phone numbers to be able to get a hold of you should the opportunity arise. Burns Surgery Be sure to include today’s PE, although not a space for it on the form, any recent labs, and most recent x-ray results. You’re allowed to leave for class and often don’t have to return. You’re able to split weekends but will be required to see all of your patients and those of the other student for whom you are covering. This means getting here much earlier on the weekend so that you have time. Discharge planning meeting is multidisciplinary and can be interesting or very boring. Depending on your residents you may be required to stay or you may be excused to go to the OR. After rounds, you can go to OR everyday or help with odds and ends on the floor – placing back skin, removing staples, applying amnion, etc. If no surgeries are going on, there can be lots of down time to sit on the floor and study – good just to show your face. Usually not a good idea to leave completely, unless for class or small group.
Surgical Documentation For Procedure purposes: We now enter procedure documentation through an online database (See syllabus for website). Start early and keep track.
SURGICAL HISTORY AND PHYSICAL EXA MIN A TIO N Identifying Data: patient's name, age, race, sex; referring physician. Chief Complaint: Reason given by patient for seeking surgical care; place reason in "quotation marks." History of Present Illness (HPI): Describe the course of the patient's illness, including when it began, character of the symptoms; pain onset (gradual or rapid), precise character of pain (constant, intermittent); other factors associated with pain (defecation, urination, eating, strenuous activities); location where the symptoms began; aggravating or alleviating factors, vomiting (characteristics, appearance, frequency, associated pain), change in bowel habit s; bleeding, character of blood, (clots, bright or dark red), trauma; recent weight loss or anorexia; other related diseases; past diagnostic testing. Past Medical History (PMH): past diseases, all previous surgeries and indications; d ates and types of procedures; serious injuries, hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma, myocardial infarction; hernia, gallstones. Medications: Allergies: Record the drug and the reaction Family History: Medical problems in relatives. Family history of colonic polyposis, carcinomas, multiple endocrine neoplasia (MEN syndrome). Social History: Alcohol, smoking, drug usage.
REVIEW OF SYSTEMS (ROS): General: Weight gain or loss; appetite loss, fever, fatigue, night sweats. Head: Headaches, seizures. Eyes: Visual changes, diplopia, eye pain. Mouth & Throat: Dental disease, hoarseness, sore throat, pain, masses. Respiratory: Cough, shortness of breath, sputum. Cardiovascular: Chest pain, orthopnea, dyspnea on exertion, claudication, extremity edema. Gastrointestinal: Dysphasia, abdominal pain, nausea, vomiting, hematemesis, melena (black tarry stools), hematochezia (bright red blood per rectum), constipation, bloody stool, change in bowel habit; hernia, hemorrhoids, gallstones. Genitourinary: Dysuria, frequency, hesitancy, hematuria, polyuria, discharge; impotence, prostate problems. Gynecological: Last menstrual period, breast masses. Skin: Easy bruising, bleeding tendencies. Lymphatics: Lymphadenopathy.
PHYSICAL EXAMINATION Vital Signs: Temperature, heart rate, respirations, blood pressure, weight. HEENT: Head, Eyes, Ears, Nose, Throat Neck: Jugular venous distention (JVD), thyromegaly, masses, bruits; lymph nodes. Chest: Equal expansion; rhonchi, crackles, breath sounds. Heart: Regular rate & rhythm (RRR), first & second heart sounds; murmurs (grade 1 -6), pulses (graded 0-2+). Breast: Retractions, tenderness, lumps, nipple discharge, dimpling, gynecomastia; axillary nodes. Abdomen: contour (flat, scaphoid, obese, distended); scars, bowel sounds, tenderness, organomegaly, masses, liver span; splenomegaly, guarding, rebound, bruits; percussion note (tympanic), costovertebral angle t enderness (CVAT), inguinal masses. Genitourinary: External lesions, hernias, scrotum, testicles, varicoceles. Extremities: Edema (grade 1-4+); cyanosis, clubbing, edema (CCE); p ulses (radial ulnar, femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial and femoral pulses), Homan's sign (dorsiflexion of foot elicits cal f tenderness). Rectal Exam: Sphincter tone, masses, hemorrhoids, fissures; guaiac test for occult blood; prostate masses. Neurological: Mental status; gait, strength (graded 0-5); deep tendon reflexes.
LABS: Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine), CBC; X-rays, ECG (if older than 35 yrs or history of cardiovascular disease), urine analysis (UA), liver function tests, PT/PTT. ASSESSMENT (Impression): Assign a number to each problem and discuss each problem separately. PLAN: Describe surgical plans including preoperative testing, laboratory studies, medications, and antibiotics.
PREOPERA TIVE NOTE Preoperative Diagnosis: Procedure Planned: Type of Anesthesia Planned: Laboratory Data: Electrolytes,
BUN, creatinine, CBC, PT/PTT, UA, EKG, Chest X-ray; type and screen for blood or cross match if indicated; liver function tests, ABG. Risk Factors: Cardiovascular, pulmonary, hepatic, renal, coagulopathic, nutritional risk factors. Consent: Document explanation to patient of risk and benefits of procedure, and document patient's informed consent or guardian's consent and understanding of procedure. Allergies: Major Medical Problems: Medications:
BRIEF OPERA TIVE NOTE (Written immediately after the procedure) Date of the Procedure: Preoperative Diagnosis: Postoperative Diagnosis: Procedure: Names of Surgeon and Assistant: Anesthesia: Estimated Blood Loss (EBL): Fluids and Blood Products Administered During Procedure: Specimens: Pathology specimens, cultures, blood samples.
POSTO PERA TIVE NOTE Subjective: Mental status & patient's subjective condition; pain control. Vital Signs: Temperature, blood pressure, pulse, respirations. Physical Exam: Chest and lungs; inspection of wound and surgical dressings; conditions of drains; characteristics and volume of output of drains. Labs: Impression: Plan:
PROBLEM-O RIENTED PROGRESS NOTE Problem List: Postoperative day number, antibiotic day number if applicable, hospital day number, hyperalimentation day number. List each surgical problem separately (status post-appendectomy, hypokalemia). Address each numbered problem daily in progress note. Subjective: Write how the patient feels in the patient's own words, and give observations about the patient. Objective: Vital signs; physical exam for each system; thorough examination and description of wound; condition of dressings; purulent drainage, granulation tissue, erythema; condition o f sutures, dehiscence; amount and color of drainage, laboratory data. Assessment: Evaluate each numbered problem separately.
Plan: For
each numbered problem, discuss any additional orders, surgical plans. Discuss changes in drug regimen or plans for discharge or transfer. Discuss conclusions of consultants.
DISCHA RGE SUMMA RY Patient's Name: Chart Number: Date of Admission: Date of Discharge: Admitting Diagnosis: Discharge Diagnosis: Attending or Ward Team: Surgical Procedures, Diagnostic Tests, Invasive Procedures : Brief History & Pertinent Physical Examination & Laboratory Data: Describe
the course of the patient's disease up until the patient came to the hospital including physical exam & laboratory data. Hospital Course: Describe the course of the patient's illness while in the hospital. Include evaluation, treatment, outcome of treatment, and medications given while in the hospital. Discharge Condition: Describe improvement or deterioration in patient's condition. Disposition: Describe the situation to which the patient will be discharged (home, nursing home), and person who will take care of patient. Discharge Medications: List medications and instructions. Discharge Instructions & Follow-up Care: Date of return for follow-up care at clinic; diet, exercise. Problem List: List all active and past problems. Copies: Send copies to attending physician, clinic, consultants and referring physician.
Obstetrics and Gynecology Clerkship website: www.utmb.edu/obgyn/students/default.htm
Textbooks: Required: nd Obstetrics and Gynecology for Medical Students (Beckman et al., required for EER 2 year) Obstetrical Pearls Recommended by Faculty Obstetrics and Gynecology (Hacker et al) Obstetrics and Gynecology NMS Current Diagnosis and Treatment in Ob Gyn (Appleton & Lange) Williams Obstetrics Student recommendations for the Shelf: Information resources: First Aid for OB/GYN, High Yield, Case Files, Blueprints Practice questions: Case Files, Case Files, Case Files, Blueprints, Pre-test
OB/ Gyn General Schedule (6 weeks) General Schedule 2 weeks of Labor & Delivery/Triage o 1 week of Antepartum o 1 week of Postpartum o 2 weeks of Clinic o o The OB/GYN rotations have varied from year to year so not all of the rotations below may be applicable but are included to account for possible future changes. Labor & Delivery Location: John Sealy 2nd floor o o Combination of Nights and Days; Night Schedule: 5:30pm-7am The rotation begins with the L&D team reviewing the board o Students should split up C-sections and rounding on the L&D patients o Main responsibilities: Update the board, Assist in the OR, Conduct/assist in vaginal o deliveries The Board o Each patient in the L&D floor documented on the board according to their L&D status Age, G-P- Status, Gestation, Dilation, Effacement, Station, Presentation, Estimated Fetal Weight, Additional notes Students are generally responsible for making sure the information is current and correct. When you attend a delivery, C-section, tubal ligation – just about anything – get into the o habit of taking a patient sticker and writing on it: the procedure, and the resident/faculty you worked with. At the time, you think you’ll remember these things but they start to run together after a while. This will help you TREMENDOUSLY when you’re filling in your procedure sheet. o Your L & D days are the least scheduled days. Don’t wait around for something to happen – pick an intern or a resident and stick to them like glue. I’m not kidding.
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Outpatient Clinics Typical Hours are 8:00 am-4:00 pm o Galveston clinics are either OB/Well-woman exams or Gynecology/Oncology Locations: Galveston, Texas City, Dickinson, Pearland, Angleton, Pasadena Call the clinic the week before your rotation to get directions to where to report You will shadow a resident, faculty, midwife, or nurse practitioner in clinic. Antepartum & Postpartum You will have one week of each. o Postpartum rounds early so the patients can be discharged as soon as possible. You o usually have to be there very early (5:30 am), but are done early, usually before noon. Basically, you pre-round on patients write a couple notes, and then round with the residents and attending. Then you’ll follow up on labs, etc. that need to be done before patient discharge. Antepartum rounds later, after postpartum rounds. You usually arrive at 7:30 am and are o done early in the afternoon. Again, you pre-round on patients, write notes, and then round with the team. These are good rotations to study on, as you’ll have some down time and a light schedule o for the most part. Endocrine / Reproduction In addition to clinic responsibilities, students are expected to attend Endocrine o Conferences / Clinic dispersed throughout the week as assigned in the schedule. Follow the directions in the course syllabus as for the schedule. It is easy to miss o something. Know the recommendations for cancer screening for women for menopause clinic o Review the fertility drugs from your Endo knowledge before you go to patient conference o – these may come up. Chart review: Most of the time you won’t get to see the patients you are assigned to look o up. However, you still need to know the information, because you will be asked about it in conference. Pay attention to other people’s presentations in the morning – you may end up seeing “their” patients Gynecology Location: John Sealy 9th floor o Schedule: See patients on the wards in the morning, Attend clinic/OR in the afternoons o o Use your free time to study. In GYN you are generally supposed to split clinic days – so you have the morning or the afternoon off - study for the shelf. Try to see as many different operations as you can and read the sections in the text on the o problems involved on the day you see the surgery – more will stick with you this way. This is also true of GYN ONC, L&D, and REI Oncology Location: John Sealy 9th floor o o Schedule: Ward rounds in the morning, Clinic/ OR in the afternoon o
“I wish I had known that they want you to follow the interns around in L&D because they don't tell you what to do and then if you just stand there waiting for someone to tell you that you should be following a resident or intern around you get comments on your evaluation that you were not a very enthusiastic student.” If you want to deliver a baby – pick an upper year that is more likely to let you get hands on experience than an intern, who still wants to get experience themselves. Show initiative – if you want to get hands on experience, don’t stand back.
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The residents are really good at coaching you what you should and shouldn’t say – and take their advice. If you say the patient is anemic – have the H./H values because he may ask. Don’t be too narrative, just state problem, workup, solution. He’ll ask you if he wants details. Still, don’t go on at length, he’ll cut you off if you talk too long. Dysplasia Clinic: The goal is to be prepared for the team to see about 30 patients between 9:00 and 12:00, and these visits are very procedure intensive, (Paps, Colposcopy, Biopsies (BX) Endocervical Curettage (ECC), LEEPs) All the charts on these patients are divided up between the team members in the conference Review the chart – find out the pertinent HPI for the patient Each person summarizes the HPI for the patient and suggests plan of action. The team agrees or tells you what the plan is In clinic, you go in and see patients, explain the plan to them, answer questions (as you can), and get any relevant updates before the residents get in to see them. Review the algorithms for management of the abnormal Pap smear
Grading Components: o Resident Evaluations Small Group Facilitator Evaluations o o NBME Shelf o Team Learning Activity Quizzes Bonus points – Lecture attendance o OB/ Gyn Required Skills Card (you will need to have these skills observed and signed by faculty) Bimanual pelvic exam o o Vaginal speculum exam Pap test/endocervical cuff cultures o Interpret a fetal monitor strip o Spontaneous vaginal delivery o Various others o Small Group Presentations Historically, these presentations have had a significant impact on grades. They can be just enough to push you over the top if you are right at the break point between grades. It is a good idea to pick OB topics for OB facilitators and GYN topics for GYN facilitators. Oral Presentation – Case presentation of an obstetric or gynecologic patient You can present any patient you followed on service Presentation should be done from memory Formal H&P write-up of the case presented should be turned in to your small group faculty
Internal Medicine The Basics Carry some sort of pocketbook with you at all times to look things up in a hurry. http://www.medfools.com has a great printout chart for you to keep patient vitals, checklist, etc. in order. Keep a couple of them with you on the wards. My residents would even steal a copy to keep their tasks in order too. Textbooks Student Recommended: Pretest Medicine, Lange Case Files, Step-Up to Medicine MKSAP for Students Pocket Medicine is a popular pocket handbook St. Francis guide for Inpatient medicine - great for the OSCE (There is currently no OSCE for IM, but the information is included for when the OSCE is begun again.) Know the differential diagnoses for abdominal pain, chest pain, shortness of breath, etc. Review these several times; it is invaluable for IM and future rotations. Washington Manual or Ferri Guide as a PDA resource for learning about your patients’ problems while you write your notes NMS for Medicine – denser than some of the other resources. Blueprints may be too superficial Strong References: Cecil’s, Harrison’s, Lange’s Current Medical Diagnosis and Treatment, and especially Up to Date. Clerkship Structure The clerkship is 3 months long with each student serving on a different service each month. Usually, each student spends one month on a general inpatient service and one on a consult service. The third month may be spent on another general inpatient ward, a specialty inpatient ward, or at an outpatient clinic. Inpatient Wards Most general inpatient teams consist of an attending, an upper level resident, 2-3 interns, 2-4 medical students and a social worker. How the team runs really depends on the attending and upper level resident. The role of the attending is to basically run rounds and do a little teaching while seeing the patients. Some attendings really enjoy teaching and will hold outside lectures for students, while others will limit teaching to quizzing the students during rounds. The upper level resident delegates responsibility to the team members. They are the ones who will have the greatest impact on a student’s experience. The interns and the students on the service carry out the work delegated by the resident and attending. It is their responsibility to make sure there are no loose ends with any of the patients. The social worker takes care of discharge planning and funding for patients. Consult Services The teams on the consult services are set up similarly to the inpatient wards, except that the fellow runs the team and delegates responsibilities. There is some variability to the way the different teams work. In general, the student will be given a consult, either at a morning meeting or by getting a page during the day. The student will see the patient and write the consult- basically a full H&P focused to the
problems for which the team is being consulted. The team will then meet to round and all consulted patients are then seen. TDC The TDC teams run basically the same way as the free world inpatients teams run. The only difference is that there may or may not be a social worker assigned to each team. The pathology in TDC is also quite different than the free world. There is also one team in the TDC that is specifically designated for infectious diseases such as HIV. Be aware of what you can and cannot bring into the TDC. The list of acceptable items is very small, so it is best to go in with as little as possible. If you are assigned to a TDC month, you will be given a list of prohibited items.
Before Rounds Check team's census Print rounds reports (for some attendings) 3 vs. 7 days Standard format vs. include all (other orders, radiology, etc.) Make sure you ask your attending which type of rounds reports her or she prefers, some want everything and some want only medications. Check labs in Epic Labs received but pending Lab results Check vital signs / nursing notes (teal chart, mostly in Epic) Record Temp, BP, Pulse, Resp I/O’s Check patient charts (gray charts, but mostly on Epic) Progress notes Consults Lab / test / procedure results See patients Immediately notify doctor if patient has altered mental status or is unresponsive!!! Do a focused Hx & PE Strip drains, check wounds, etc. Report to interns / residents Report ALL patient changes / problems to house staff BEFORE, NOT DURING faculty rounds!!! Decide on management (labs, meds, etc.) Prepare presentations Notes can be used during rounds ... But tr y to present fr om memory as much as possible Save notes from previous days (for reference, writing D/C summaries, etc.) Write progress notes Some doctors prefer that notes be written after rounds Some doctors prefer that notes be started before rounds but allow for them to be finished after rounds Some doctors want notes done before rounds Update and print census for team (if applicable)
Rounds Some teams do table rounds first, meaning the y’ll talk about the patients first (discuss what happened overnight, review labs, form a plan for that patient such as discharge, continue treatment, alter treatment, etc.) After table rounds, the team will physically go room to room. Internists like ranges reported on vitals. Report blood pressure as 140-200 / 70-110 instead 140/70 Medicine is all about trends. When charting labs, it is helpful to record what the previous values were. Chart review is essential in working up a patient. Important things to look for in a chart: Old EKG’s (for comparison) o Discharge summaries o o Medications Operative notes o Cath reports o Pathology summaries o o Baseline labs Patient presentation is generally in a SOAP format. New patients are presented with an abbreviated history and physical. When rounds are over with the entire team, you may meet again with the intern and resident to go over the game plan for the rest of the day. Your job is to follow up on labs that were pending and record them as an addendum in the progress notes. Additional duties may include phoning hospital departments like CT, MRI, nuclear medicine, hyperbaric or special procedures to see when your patient’s procedure will be done. You want to make sure that the ball is not dropped and that the department has your patient on its schedule to do the test or procedure. Another thing you might be involved with is discharging patients and helping the intern with the paperwork associated with this. Most of the above work is completed by early to mid afternoon so you may find yourself with extra time to study and hang around the unit or the room where your team meets for report. Some teams make afternoon rounds so you may find yourself busy all day long. Medicine H & Ps Don’t fall behind . Do your first 1 or 2 in the first week and wait for feedback. Often, they give you things to change and you should make those changes on subsequent write-ups. Don’t give your attending 3 or 4 H&P’s in the last week of the rotation, the y won’t appreciate it, and you have no time to adjust your H&P’s to the feedback you receive. Do them on the computer and learn the art of cut a paste
Call Call is not overnight – you stop accepting new patients in the early evening and you usually stop seeing new patients usually around 10 PM. Grab your patients to do your H&P early if you want to go home at a decent time.
Family Medicine The Basics: Covers healthcare “from the womb to the tomb” (sorry, couldn’t let that one go) No rounds, nice schedule, only the occasional weekend. Try to enjoy it. Take the web cases seriously . Your answers are sent to the faculty, so keep them professional. For any question on alternative medicine, check out Health Notes via UTMB library (http://library.utmb.edu/HealthNotes) If you’re interested in doing more procedures – or delivering babies – ASK. You will get more out of the experience if you’re setting your own learning objectives Patient education and preventive medicine are important. You will spend more time asking about lifestyle, diet, etc. than you have in any other rotation. Textbooks: Student recommended to take to the OSCE There is currently no OSCE for the FM rotation, but this information is included in case the OSCE is brought back in the future. The Family Practice Text: the one you check-out for the clerkship. GOOD to take to the OSCE. Use these books throughout the clerkship. If you are not familiar with how they or organized and what information is found in each resource it will take too long to find the information you need. Current Diagnosis or any good up to date reference you like best Pocket Medicine Sierpina’s book on Complementary and Alternative Medicine Preventive Medicine Screening: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat3.section.10513 Tables are available at the bottom of the right-sided column that has extensive screening recommendations by age group. This is useful to print out and take to the OSCE. Case Files (most likely a case will reflect one of your standardized patients) Student Recommendations for the Exam The exam is difficult. Other than the specific recommendations here, it would be a good idea to review Step II focused resources. NMS Questions for Family Practice: Available for loan from the clerkship office. Seems to be universally recommended. New Case Files for Family Medicine: good review of several topics for a short rotation (1 month)
Pediatrics The Basics Generally a good schedule. Try to do your written H&Ps as early in the rotation as possible. Do your observed H&P whenever an upper level offers, which might be early in the rotation. You don’t want to be part of the scramble at the end trying finish this. The big topics are developmental milestones, nutrition, safety, immunizations, and viral vs. bacterial illnesses. Textbooks: Student Recommended: Blueprints for Peds Case Files Appleton and Lange Questions Pretest Call
Inpatient call: generally about 1x per week. To get the most out of it, give your pager number to both the intern and the upper level on call. Then stick to them like glue to maximize your chance to see and do stuff. For call in the nursery, you are generally done at 10 pm. Specialty call is generally taken with the inpatient team unless you are on PICU or ISCU. Then you will take it with the residents in that unit.
Inpatient: Morning report starts at 8 everyday and you are required to go unless you are in the nursery or in ISCU. You need to have seen your patients and written a note before morning report. The afternoon usually involves family meetings or other odds and ends. Nursery: Lots of paperwork, but the babies are fun to work with. You will need to arrive between 6:30 and 7:30 a.m. to do mommy visits, record vitals on all the babies, update the census, and see as many babies as you can on your own to present. All of this is explicitly explained in the syllabus. After rounds you will do more mommy visits, help with charting, or do whatever else is needed. The nurse practitioners are very friendly and helpful if you have questions. They like to teach. The afternoon is usually spent updating labs and the census, playing with the babies, or going to the stand to assess a newborn. You can also spend anytime you wish up in the transition nursery examining babies. If you like hands-on, this is a good place to be.
In’ s and Out ’ s
In’s: For babies, do this in cc/kg/d and cal/kg/day (if on formula). If breastfeeding, record how long the baby nurses on each breast, and how often. Out’s: Urine cc/kg/hr (to 1 decimal point X.X cc/kg/hr), Bowel Movements – how many and describe if pertinent, Emesis Record changes in weight as well as the current daily weight
Use the following table to convert milliliters into calories
Formula
Enfamil/Similac w Iron/Lactofree (20 cal/oz) Enfamil or Similac 22 or Neosure Enfamil or Similac 24 Pregestamil/Alimentum/Nutramigen (20 cal/oz) Kindercal (30 ca/oz.) Breast milk (20 cal/oz)
Calorie Conversion Factor (Calories in formula/30cc) 0.67 0.73 0.8 0.67 1. 0.67
For the pediatric History and Physical Write-ups, don’t forget to refer to the example that they provide in the syllabus.
Electives Listed below are various electives that medical students can take during 3rd year. Neurology, Senior Surgery, and Emergency Medicine are ones that everyone is required to take before they graduate, so it is great to complete them sometime in 3 rd year to give you more time 4th year.
In General: Try to schedule a senior elective during your third year elective month. This allows for a more flexible 4th year (to set up away rotations, AI's, etc.) and allows you to knock out a required course early. However, there are a few reasons to go ahead and do a non-required elective during your 3rd year: a. Try out a field that y ou’re considering but that you won't get to experience during your required 3rd year rotations - i.e. radiology, derm, anesthesia, etc. b. Travel to another city/country for an elective c. Set up a research project with a particular faculty/lab or you want to continue a project that has already been established. Remember, you need to get research approved before you can earn credit for a rotation. And there are some reasons NOT to do a particular elective during your 3rd year: Ex. - Even if you know you want to do pediatrics (or IM/OB/GYN/psych/surg, whatever), don't do a pedi elective "just because" you think you should. You will get ample time to get all the experience you need during your clerkship. This is a good situation where a 4th year rotation would be good to do during 3rd year. Additional advice: try to do a rotation over the Christmas month. For the most part, people are pretty flexible and you will still have time off for Christmas and New Year's. (Again this is very rotational specific.) If your family lives far away, try to set up an away rotation in their city.
Senior Neurology (required before graduation): This course is 4 weeks with 1 week in Geriatrics, 1 week on wards/inpatient, 1 week on Neuro consult, and 1 week of Neuro clinic. No call; weekends & holidays off. Good rotation to have if you want a break or need extra time for other things. If you are interested in neuro, tell all of the doctors so that they will recognize you for a neuro award at the end of the year. Suggested Readings: Boards & Wards - Neurology section Any resource (for Step 2 study material) with a neurology section Look through First Aid Step 1 to remind yourself of neuro pathologies (seizures, strokes, ) The chief resident gave the students a review shortly before the real test. This might change if the NBME test is integrated. Lectures Stated in the schedule. Usually will be in the morning (8:00am) or lunchtime (Noon). However, Wednesdays are busy because they squeeze in grand rounds, neuropathology, and radiology rounds in the mornings as well. Recommendations During rotation: Geriatrics – you will take a brief test on the first day, and then take the same test again on Thursday (to see if you learned anything over the past week). You will be given a couple articles on delirium & dementia, which you will discuss with one of the Geriatric fellows on Thursday. On Monday, Tuesday, and Wednesday, you will be assigned to work in a geriatric clinic (ACE Unit/10 th floor, Santa Fe Clinic, Retirement home). Inpatient/Wards: You pretty much follow the resident to the various neurology patients in the hospital. Assess for strokes, seizures, paralysis, etc. You will be assigned 1-2 patients, and rounds will either be in the morning or at 1:00pm in the afternoon (depends on faculty). Neuro Adult clinic – you will be busy, busy, busy. Pick up a patient’s chart and enter the room (do not ask for the resident’s permission). Inform your resident of what you found, go in together, and then get the blessing from the faculty (usual clinic proceedings) Neuro Pedi clinic – like the adult clinic, but with less patients. Lots of seizures
Neuro Consult – come in at 8:00am to see if there are any new consults. If assigned a new patient, you will
see the patient first, then page/inform your assigned resident. If you do not have a new patient, check on the previous consult patients that have not been signed-off. Then, wait in the consult room or the student lounge on the 9th floor to be paged for new consults. You will present new consults in afternoon rounds (the faculty for consult is the same for Inpatient/Wards. After the Inpatient/Wards team is done with their rounding, then you will round for the consult patients).
Senior Surgery (required before graduation) 1) Course structure- You will be assigned a surgery service based on preference although many people do not get what they want: Dr. Mileski does not want you doing a service that you were on for the junior rotation. Really you just participate in the required clinical/OR duties of the service - it's just an additional surgery month without the shelf exam at the end. 2) Required activities- Participate in the service activities, trauma call 2-3 times during the month as assigned, autopsy experience: you will be paged to participate in one autopsy during the month-you are notified the day of the autopsy and given an orientation to what you need to do that day. The autopsy day is pretty easy, just show up - there is an autopsy report that is required to pass the course. The format of the report and an example will be given to you. 3) Grading- grading if based entirely on evaluations and whether or not you complete the senior project. The project is optional but if you do not complete it you can not make above a passing grade. If you choose to do the project you can either high pass or honor the course based on the quality of your project and evaluations. The project consists of a literature review of any topic you pick (basically you summarize 10 articles and draw conclusions about medical practice based on your review). 4) Recommended readings - nothing 5) General advice- have a good attitude. Look at this as another surgery month instead of a month to do as little as possible. In the past the seniors have used this course as a vacation month and Mileski is not letting that fly anymore. So, just try to enjoy the fact that there is no shelf to worry about and if you just show up and complete the required activities it will be fine. Obviously, if you want to do surgery it might be a good idea to complete the project.
Senior Emergency Medicine (required before graduation)
Generally a good rotation that consists of 12hr shifts (6 day shifts, 6 night shifts), 1 ambulance ride shift and 1 poison control shift. Always remember your shift card!!! And get them signed!!!! This is the way they know you attended shifts. You sign up for shifts prior to rotation, but you are allowed to switch shifts (make sure you tell Martha, the coordinator) ER is great for allowing you to do procedures, pick and choose patients that interest you, and that you think you will be able to do procedures (sutures, vaginal exams, line-placement, etc.). There is a procedure card that you must complete. You must get signatures for 15 procedures (many can be repeated) such as IV placement, laceration repair, etc. The physicians working in the ER are great at letting you get involved as much as you want, and you get to work directly with them often. When presenting make sure you keep things to the point, while not skimping too much on the details. Make sure you get the HPI and a focused physical. They also want you to get the PMH, FH, & ROS, as these are the only things you can actually enter on Epic. Basically, just act interested, volunteer to see patients and do procedures, and things will go great.
Clinical Dermatology Rotation (not required but very informative and not as time-demanding) Best book is Dermatology Secrets. Otherwise, they have a great library in the derm clinic. Get involved in a project if you are interested.
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Appendices History & Physical Template: A Template for the JMS H&P. Please make copies to help you outline your H&Ps.
Date/time: Chief Complaint:
JM S H istor y and Physical
PCP: Al lergies:
H istory of Present I ll ness:
PMH:
M edications:
F amily H istory: Father: Social H istory: Lives in:
IVDA: Review of Systems: 1. General: Fever 2. HEENT: Tinnitus
Mother: Tobacco: Blood transfusions:
Siblings:
Other: Etoh: Tattoos:
Chills Night sweats Weight change Decreased hearing Blurred vision Diplopia Epistaxis Rhinorrhea Congestion Sore throat Hemoptysis PND Orthopnea Dyspnea on exertion 3. Chest: Shortness of breath Pleurisy Palpitations 4. Cardiovascular: Chest pain Constipation Diarrhea Melena Hematochezia 5. Abdomen/GI : Pain 6. Extremity: Pain Swelling Claudication Pruritus 7. Skin: Rash Dysarthria ∆Coordination ∆Balance Syncope 8. Neurological: : Joint pain Weakness Swelling 9. M usculoskeletal 10. Geni touri nary: Increased frequency Dysuria Hematuria Foul odor Bruising Recurrent infections 11. Hematological: Bleeding
HA Cough BRBPR
Pain
