AOA Survival Guide to the 2nd Year

Duke University School of MedicineAugust, 2008

Table of Contents

Chapter 1: The Basics- Introduction- The Basic Patient Workup- Definitions of Common Terms and Activities- How to Present- Pockets

Chapter 2: The Rotations- A typical day in:

o Medicineo Surgeryo Psychiatryo Family Medicineo Pediatricso OB-GYN

Chapter 3: Additional Information- Example Normal Physical Exam- Abbreviations

Chapter 4: Sample Progress Notes-Medicine-Surgery-Peds

CHAPTER 1: THE BASICS

IntroductionThe beginning of the clinical rotations is an exciting and stressful time, and there

is no adequate way to prepare yourself for 2nd year other than to jump in and be confident that you will figure things out as they come along. That said, this document is meant to serve as an introduction to the daily routines and expectations for each of your 2nd year rotations, and we hope that you will be able to refer back to this booklet throughout the year as you begin each new rotation.

As with any job, it is important to know your position within the Duke Medical Institution:

Your place in the hierarchy of Duke Medicine:

Chancellor Victor Dzau

Clinical Chairs

Attendings

Fellows

Residents

Interns

Nurses

Medical Students

The Basic Patient WorkupYou must shift your thinking from a disease orientation to a patient orientation. In

other words, instead of focusing on the manifestations of a given disease, while working up a patient you must focus on the symptoms and signs of your patient to try to determine which disease explains the patient’s problems and presentation. A basic patient work up will generally include the following:

1. Patient Profile:Name, age, sex, race, marital status, occupation, referring physician, hometown, etc.

2. Chief complaint:The primary problem according to the patient, and usually stated in the patient’s own words.

3. History:This includes both the history of the present illness in which you will characterize the patient’s subjective symptoms as accurately as possible with respect to location, radiation, severity, quality, duration, and alleviating and exacerbating factors. You will also elicit the patient’s past medical history.

4. Physical Examination:Here you will examine the patient for any signs of disease. Signs in contrast with symptoms are objective indicators of disease. For example, a patient may describe the symptom of shortness of breath and on examination you may note the sign of expiratory wheezing on auscultation of the lung fields. An example of a normal physical exam appears later in this document.

5. Laboratory Tests:To confirm or exclude diagnoses or to monitor progress.

6. Special Studies:Radiological studies, EEG, EMG, etc.

7. Assessment:Of the patient’s status and of likely diagnoses. This is the part of the workup where you describe your thought process of what may be occurring and why. As a medical student, this is a particularly important section as it should be the most accurate demonstration of your understanding of both the patient and the disease to your attending.

8. Plan:To narrow the differential diagnosis and to treat the patient.

At every point during this workup, you should try to keep in your mind the differential diagnosis of conditions that the patient might have. Then through your questioning of the patient’s symptoms, examination of the patient’s signs, careful ordering and analysis

of lab data and special studies, you should refine your differential diagnosis and develop and appropriate plan.

Definitions of Common Terms and ActivitiesPrerounding:Visiting your patient in the morning to check on their status overnight. Details will vary with rotation, but prerounding generally involves reviewing the medical and nursing charts for any overnight notes (check the progress notes and consults sections for any new notes), medication changes, new labs, vital sign changes i.e. Tmax (= max overnight temp), BP spikes, emesis, etc., then wake up your poor patient at whatever ungodly hour it happens to be. Interview your patient briefly and perform a pertinent, focused physical exam. On some rotations, you will be expected to write the progress note for your patient before work rounds. More about writing notes below and in the individual rotation sections.

Work rounds:Rounding with your team i.e. intern, resident, and other students, to interview, examine and write orders for patients. You will generally present your patients to your team, including your assessment and plan for the patient.

Attending rounds:This will vary greatly by rotation and by attending, but this is the opportunity for the attending to see the patients and approve the plan of their care in addition to teaching the residents and students. On medical rotations you will be expected to present to your attending and be pimped about your patient's medical conditions. On surgery, you will likely be pimped in the OR, and you may or may not present during attending rounds.

Evening rounds:Generally only on surgical rotations, attendings and or residents will round after the day's cases to check on patients' post op progress.

Admission History and Physical: H+PWhen a new patient is admitted to your service (especially on medicine and peds) and assigned to you, you are expected to take a complete medical history and perform a complete physical exam on him/her. There are admit H+P forms on the wards which contain the outline and order you should follow. Generally this will be:

CC: Chief complaintHPI: History of present illnessPMH: Past medical historyPSH: Past Surgical historySH: Social historyFH: Family historyROS: Review of systemsPEX: Physical Exam (with vital signs first)Labs:

Special Studies: (Xrays, EEGs, EKGs, etc.)Assessment:Plan:

A template of an admit H+P for your use can be found of the AOA 2nd Year Survival Website at: http://www.duke.edu/web/aoa/dusm.html although you should check with your particular team to see if it is ok for you to use the template; some teams frown on it.

Progress NotesOn most services, you will be expected to write the notes (and possibly orders) for your patients. You will follow the SOAP format:

- First, put the patient’s name and hospital day (HD) or post-op day (POD ___ from __________ [list surgery])

- S = Subjective – what the patient tells you that they are subjectively experiencing, e.g. nausea, vomiting, chest pain, appetite, etc.

- O = Objective – vital signs, physical exam, labs, radiology, etc- A = Assessment – of the patient’s condition, diagnosis, and progress- P = Plan – to treat the patient or further work them up.NOTE: Some services may prefer that you combine the Assessment and Plan in a problem based or organ based fashion, e.g. “1. Acute Renal Failure – Creatinine continues to be elevated above patient’s baseline. Will aggressively hydrate and discontinue NSAIDs. 2. Hypertension – Patient’s blood pressure remains well-controlled on current antihypertensive regimen. Will plan to continue current antihypertensive metoprolol.”

How to PresentYou will present your patients on work or attending rounds in this same general

order as the H+P and SOAP notes as described above, but rotations and attendings will vary in the detail they require. You will generally provide a full H+P presentation as described above on the morning following the admission of your patient. For each subsequent day you will present your patient in the SOAP format. It is important to keep your presentations pertinent, succinct and well organized. Some attendings will allow you to get away with simply reading your H+P's or notes to them in the conference room, whereas others will require you to present from memory without notes at the patient's bedside. This is a pain. However, it does force you to really know your patients and to organize your presentations well. It will be appreciated and will serve you well on every rotation if you are able to present your patients from memory, so learn to do it even if not required.

Tips regarding presentations:1. Memorize the abnormal findings:Once you get comfortable with the normal physical exam, you will be able to rattle of the normal findings easily—“Abdomen is soft, nontender, nondistended with no organomegaly or masses...” Then all you have to remember for your patient are any abnormal findings. The same is true for the review of systems. Often when presenting it is appropriate to just include the data that are relevant to your patient’s condition, the

“pertinent positives and negatives” e.g. for ROS and Labs for your patient. Nevertheless, you should still know and be able to answer questions from the attending about other details.

2. For complicated patients, it may be wise to divide your presentation into a problem-based format and present the history of each present problem separately.

3. Presenting patients at the bedside to your attending and team can be very anxiety provoking. If you are required to do so, tell your patient beforehand so that they aren’t caught off guard by having the intimate details of their lives told before a group of strangers. Also use discretion about which topics should be discussed outside of the room, for example with topics such as cancer or HIV when the patient does not yet realize that they could be a possibility. Also never try to wing or make up anything. If you don’t know something about the patient’s history, ask the patient, or admit that you don’t know it but will find out.

4. Be adaptable. Every attending will have different preferences for presentations. Try to learn your attending’s preferences early and accommodate them.

5. Be good to your patients. This goes without saying as you are caring for their health, but your patients can also help you out. When you are stuck presenting at the bedside with an ornery attending they can be your ally, and there is no better evaluation a medical student can receive than a patient’s comment to a resident or attending that they appreciated you.

6. Be assertive and do what you say you will do. Try to formulate a plan for your patient and write the orders for your resident to cosign. Ask questions if there is something that you don’t know, but do not ask questions to show off or that you could easily look up. If you say that you will do something, do it; your team and patients will depend on you. Be respectful to all of the workers in the hospital.

Pockets:With your crisp, short, little white coat you have been given the gift of many pockets. Generally, in these you should always have a copy of Maxwell's, your stethoscope, palm, a pen-light, pens, and something to write on. On your medicine rotation you will receive a copy of the Intern Survival Guide, which contains useful phone numbers, what tubes to use for different labs, common medications and doses, and a wealth of other very useful items. Once you receive this guide keep it in your pocket for all of your subsequent rotations. The intern survival guide is very useful.

Figure out some way to keep track of your patients on notecards, rounding sheets, or something similar so that you will have your patients' labs, medications, pending studies, etc. within reach. Additional items may be useful on specific rotations as discussed later.

CHAPTER 2: THE ROTATIONS

MedicineTypical day:6:30-7:30am

- Preround on your patients; write your progress notes and orders.7:30-9:30am

- Work rounds with team; present your patients to the team and discuss the plan for your patients.

9:30-11:30- Attending rounds, present your patients to the attending, and be prepared to

answer questions about your patients’ conditions and treatments.- Finish your notes and orders for your patients, and have the resident or intern

cosign them.12:00pm

- Noon conference.Afternoon

- Follow up on your patients’ labs and other studies, help out with discharges, etc.

- Lectures, Physical Diagnosis rounds etc.Call Night

- Admit patients, do full H+P, learn about your patients' conditions before attending rounds the following morning.

Tips for Medicine:- Try to be active in the plan of your patient by writing the orders and labs for your

patient and calling for consults if possible.- UpToDate is a great resource for reading about your patients' conditions and

planning treatment.- Help out your team by filling out discharge sheets and calling to arrange follow up

appointments.

Surgery:Typical day:5:00-6:00am

- Preround on your patients, focusing on pertinent aspects of history and physical. For example if they had abdominal surgery: are there +BS, are the passing flatus, have they had a bowel movement? Are they getting OOB (out of bed), what are their ins/outs, are they using the incentive spirometer, how does the wound look, etc?

6:00-7:00am - Work rounds.

7:30am-5:00pm

- In the OR. Surgical Recall is a very helpful book to have on hand to look up last minute information before or between cases...but...never let your attending know that you just looked up last minute info in Surgical Recall.

5:00pm-6:00pm - Evening rounds.

Call night- Hang out with the on-call intern and work up post-op fevers and the like.

Tips for Surgery:- Offer to write the Op note after the surgery.- Get your own gloves and gown and give them to the circulating nurse. Introduce

yourself to the nursing team. They can be your greatest allies on this rotation.- Be enthusiastic even if you are exhausted.

Psychiatry:Typical day (will vary by service):7:00-8:00am

- Preround on your patients, noting any changes in MSE (mental status exam).8:00-10:00am

- Work rounds; interview the patients with the resident and help write notes. 10:00am-12:00pm

- Attending rounds.Afternoon

- Help write discharge notes, see consults, etc.

Family Med:Typical day (will vary by location):8:00am

- Show up, and start seeing patients. Interview the patients, present in SOAP form and then see the patient with the attending.

- Offer to dictate if you want the experience.

Pediatrics:Typical Inpatient Day—very similar to Medicine:6:30-7:30am

- Preround on your patients; write your progress notes and orders.7:30-9:30am

- Work rounds with team; present your patients to the team and discuss the plan for your patients.

9:30-11:30- Attending rounds, present your patients to the attending, and be prepared to

answer questions about your patients’ conditions and treatments.- Finish your notes and orders for your patients, and have the resident or intern

cosign them.Afternoon

- Follow up on your patients’ labs and other studies, help out with discharges, etc.

- Lectures.Call Night

- Admit patients, do full H+P, learn about your patients' conditions before attending rounds the following morning.

Typical Outpatient Day:-Variable by outpatient clinic

Typical Newborn Nursery Day:6:00am

- Divide up the list of babies with your classmates, and see all of them collecting information regarding, feeds, weight changes, birth information etc.

7:30am - Attending rounds

Rest of the day- Play with the babies and go to deliveries with the Nursery intern

OB/GYN:Typical Labor and Delivery Day6:00am

- Pre-round. Divide up the list of post-partum moms with your classmates and see all of them asking questions such as about abdominal pain, vaginal bleeding, pain, resumption of bowel activities (esp. if C-section). Be sure to check the perineum if there was a vaginal delivery - attendings will expect you to do so.

7:00am - Attending rounds in the conference room.

Rest of the day- Go to clinic and see the prenatal patients, or stay in the labor and delivery

triage area with the intern/resident/midwives.- Help fill out discharge sheets.

Call night- Stay up; go to C-sections and deliveries.

Tips for Labor and Delivery:- With your classmates, keep an updated list with all of the patients on it. Have the on

call student run through the list during a slow part of the night around 5am and update the information for the new and old patients, so that the other students can just show up quickly preround without searching for all of that information.

Typical Day for GynOnc/GynBenign—very similar to Surgery:5:00-6:00am

- Preround on your patients, focusing on pertinent aspects of history and physical. For example if they had abdominal surgery are there

+BS, are the passing flatus, have they had a bowel movement? Are they getting OOB (out of bed), what are their ins/outs, are they using the incentive spirometer, how does the wound look, etc?

6:00-7:00am - Work rounds.

7:30am-5:00pm - In the OR.

5:00pm-6:00pm - Evening rounds.

Call night- Hang out with the on-call intern and work up post-op fevers and the

like.

CHAPTER 3: ADDITIONAL INFORMATION

Example Normal Physical Exam:This is an example of a normal physical exam. As you know from the Physical

Diagnosis course there are many more aspects of the physical exam which you may need to test; this simply provides the format for a typical, normal medical physical exam.

GEN: Vital Signs (120/70 BP 60 HR 14 RR 37 Temp)AOx3 (alert and oriented to person, place and time) NAD (no acute distress)

HEENT (head/eye/ear/nose/throat):NC/AT (normocephalic atraumatic)PERRLA (pupils equal round reactive to light and accommodation)Sclera anicteric EOMI (extraocular movements intact)O/P clear (oropharynx)MMM mucous membranes moistTongue pink and moist

Neck:SuppleØ thyromegalyØ LAD (lymphadenopathy)

CV:RRR (regular rate & rhythm) normal S1, S2Ø M/R/G (murmurs/rubs/gallops)

Chest/Back:CTAB (clear to auscultation bilaterally)Ø W/R/R (wheezes/rhonchi/rales)Ø CVA tenderness

ABD:S/NT/ND (soft/non-tender/non-distended)Ø R/G (rebounding/guarding)BS (bowel sounds)Ø massesØ HSM (hepatosplenomegaly)

EXT:Ø C/C/E (clubbing/cyanosis/edema)

Skin:WD (warm & dry)Ø visible lesionsØ Tenting/Normal Turgor

Neuro:Non-focalCN 2-12 intact (cranial nerves)

2+ DTR B/L (deep tendon reflexes)5/5 Strength bilaterally

Labs:

See the Intern Survival Guide for more information of normal lab values and recommendations.

Common Medical Notations:c = with s = withoutPRN = as needed p = afterNTE = not to exceedB = BL = B/L = bilateralc/o = complaining ofCP = chest painCa = cancerD/C = discharge or discontinueDx = diagnosisSx = SymptomTx = treatment or transplantRx = prescriptionHx = historyf/u = follow uph/o = history ofHA = headacheN/V = nausea/vomitingU/A = unrinalysis

VS = vital signsWNL = Within normal limits (be careful using this as some attendings take it to

mean “we never looked”)x = except

Frequency of Medications or Other Activities (i.e., labs, inspiratory spirometry, ambulation, etc.)Q = every QHS = at nightQAM = in morningBID = twice daily TID = three times daily QID = four times dailyBID, TID, and QID are not equivalent to q12h, q8h, or q6h

Route of MedicationsPO = by mouth NPO = nothing by mouthIV = intravenous SQ = subcutaneousPR = per rectum