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SURVIVING CLERKSHIP

Tips to the Ward and Exam Questions FIRST EDITION AUTHORS: Paul Healey 00 & Rupinder Sahsi 00 SECOND EDITION AUTHORS: Darren Cargill 03 & George Kim 03 THIRD EDITION AUTHORS: Mark Matsos 04, Tomas Jimenez 04 FOURTH EDITION Author: Jesse Shantz 05, Sumon Chakrabarti 05 FIFTH EDITION- Kris Croome 06 SIXTH EDITION Mike Zettler 10
The vast majority of the work for this Clerkship Survival Guide was done by my predecessors listed above. All Ive done is to edit the particulars have changed over the years in medical school: the organization of rotations, the format of exams, and the on-call responsibilities of clerks. The truly important things, however, dont change. I think this survival guide is most useful for these kinds of things; like how to assess patients and write notes and orders, how to interact with your team, and how to stay human in medicine. I hope its useful. Enjoy clerkship! Sincerely, Mike PS. There is one section that could be changed but hasnt: the online resources and PDA/smartphone section. My feeling is that this information changes too quickly to pass down between classes, and I would completely unqualified to write about it. My only suggestion would be to talk to people who do or do not use various systems to get their opinions.

"Never let formal education get in the way of your learning." -Mark Twain "The student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end." -Sir William Osler, 1905

CONTENTS
Preface: Rupis Rules of Clerkship A Guide To Useful Books For Clerkship Must-Have Books Strongly Recommended Useful Books Online Resources A Few Notes for PalmOS Users Useful Sites Useful Software An Approach to the Many Types of Rounds Guide To Writing Notes Admission Note format Progress Note format The Discharge Dictation Format and Discharge Summary Guide to Writing Orders Approach To Admission/Transfer Orders Ordering Drugs and Writing Prescriptions Common Order Pitfalls Sample Orders Frequently Used Abbreviations The LHSC/SJHC Paging System at a Glance Rotation Tips Distilled
Medicine Rotation Surgery Rotation Paeds Rotation Family Medicine Rotation Psych Rotation OB/GYN Rotation

RUPIS RULES OF CLERKSHIP from The House of God by Samuel Shem. A must read, particularly part way through your Medicine rotation. 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 26) 27) 28) 29) 30) 31) 32) 33) 34) 35) 36) 37) 38) Never stand when you can sit. Never sit when you can lie down. Eat when you can Sleep when you can F#@& when you can Never lie to your senior Never let them see you eating or sleeping. If you enjoy your free time, never spend any of it within line of site of the nursing station, or it wont be free for long. Never buy an expensive pen, your consultant will steal it. Nobody ever gets in shit for showing up on time. When nature calls, make sure youre listening. You cant go wrong by going to see the patient. Know your patient better than anyone else does. Caffeine is your friend. Medicine is a team sport. Be a team player. If you dont take a temperature, you cant find a fever.* Never pass up free food. Never skip a teaching session, or it will inevitably show up all over your exam. Dont get the patients bed dirty. Nobody likes a miserable clerk. Never upstage your colleagues, especially at rounds, no matter how good you think youll look. If youre scrubbed in a) make sure the field is well lit, b) have the suture scissors ready BEFORE youre told to cut, c) suck the smoke Never fudge a finding. Never piss people senior to you, it will come back to haunt you. Read something every day. Follow the chain of command. Take your pulse first* (in a panic situation, make sure youre calmed down and thinking clearly) If anyone suggests, hints, or alludes to you possibly, maybe, potentially going home/taking a break/getting a meal dont think about it THANK THEM AND BUGGER OFF! When a code is called, clerks traditionally have three roles 1) get the gawkers out of the room, 2) make sure the chart is handy, 3) fight the urge to run around screaming whatdoIdowhatdoIdowhatdoIdo Never miss any rounds sponsored by a drug company (FREE STUFF) Youre no good to anyone if youre still asleep (when youre paged in the middle of the night, give yourself 30 seconds to wake up before slurring your speech into the telephone) Dont try to be a hero. Know when youre over your head. Never talk about patients in public areas. You never know whos listening. Never talk about staff in public areas. You never know whos listening. Sure, Id love to do that rectal exam for you. Make your seniors look good, and theyll make you look good. You make a mess, you clean up the mess. Get a life!

A GUIDE TO USEFUL BOOKS FOR CLERKSHIP


The decision of what books to buy in Clerkship is a controversial one. Most medical students already have a wide assortment that will serve them well. The following is a partial list and is by no means comprehensive. The books you buy will be strongly influenced by what specialty you decide to enter. It is advisable to tailor your purchases/acquisitions to the amount of time you will actually spend (all good intentions aside) reading during your clerkship, as well as your method of studying. In addition, each rotation will present you with a list of their own departmental recommendations some good, some not so good. Also remember, if you are hesitant about paying money for new books before getting a good look at them, try searching the UWO library system. Only limitation is that they only carry 1-2 copies of each book, if any.

Must-Have Books
Tarascon Pocket Pharmacopeia (Printed Yearly), Contains almost all the drugs you will be ordering, their indications, and their CANADIAN dosages. PalmOS Users may substitute for epocrates (be warned it is does not have all Canadian drugs) or purchase a subscription for the Palm version of Tarascon (see below for option to get free access) While extremely comprehensive, make a point of knowing where to find the nearest CPS on each rotation for uncommon indications or for the few drugs that are not listed. The Toronto Notes: MCCQE (Printed Yearly) ~ $110 through Bookstore This is a handy reference, but is in point form and therefore better for review than learning LOOK OUT FOR ERRORS!!! If something seems wrong, it very well could be. The Sanford Guide to Antimicrobial Therapy (Printed Yearly) This small reference book is authoritative for bugs and antibiotics; the next best thing to a faceto-face conversation with an Infectious Disease specialist. It may seem cryptic at first, but if you learn to use it, and use it well, youll be better with infectious diseases than most residents (and some consultants!). Infections are relevant everywhere (except Psychiatry I guess). Strongly Recommended One of the following for Medicine: (but still very useful beyond your Medicine rotation) Care of the Medical Patient, ~ $50 The Washington Manual of Therapeutics, ~$60 The Oxford Handbook of Clinical Medicine, ~$45 For Surgery: Current diagnosis and treatment in Surgery ~$90 Surgical Recall Contains lots of questions you will be asked in the OR Useful Books One of the following for taking call: On-Call: Principles & Protocols, ~ $40 On-Call: Surgery, ~ $40 On-Call: Medicine ~ $40

Other handy references both for being on the wards and at-home reading: The Lange Series of Books, by specialty ~ $Variable NMS Review Series, by specialty ~ $Variable Cecils Essentials of Internal Medicine, ~ $85 Harrisons Principles of Internal Medicine, ~ $135 The Recall (Paeds Recall, Medicine Recall, etc.) Series, ~$40 each The Mosby Crash Course Series an easy read, but somewhat simplistic. ~ $45 The Interns Pocket Survival Guide (also a version for Surgical Interns) $11 Essentials of Clinical Examination Handbook a concise guide from U of T. Pocket Medicine (Massachussets General Hospital Handbook of Internal Medicine) 6 ring binder full of quick info for internal medicine. Clinical Microbiology Made Ridiculously Simple If you have a hard time wrapping your head around antibiotics and bugs, this may give you a head start One of the best resources for finding really good books is your resident(s). See what they would suggest. Try to get your hands on a physical copy of the publication before you buy, to make sure its both at your level and something you might actually have time/inclination to read.

ONLINE RESOURCES
Most of your clerkship will be spent in centers with ready access to the internet. Frequently, this can act as a surrogate textbook in lieu of carrying your entire medical library with you in your lab coat. Being able to access online information quickly is a good skill to polish, and you will likely find it even more useful in clinical practice than in the pre-clinical years. Some useful sites for this include: American Academy of Family Physicians www.aafp.org o Quick search of a large library of handy review articles CMA Osler - www.cma.ca o included with your CMA membership is online access to MD Consult (yes, everybodys favorite PCL tool), as well as OVID online access to a ton of full text journals (ensure you have your CMA number) Medscape www.medscape.com o Medical news, articles, and a medical student section full of handy resources Wheeless Orthopedics www.wheelessonline.com o Complete guide to Ortho (with tons of spelling mistake) Emedicine www.emedicine.com o Free, reliable, online textbooks by medical professionals for medical professionals The Merck Manual Online www.merck.com o Full text of the handy Merck Manual available online Google www.google.com o The ultimate Internet search engine. Blazing fast, very efficient.

A FEW NOTES FOR PALM-OS USERS


It is difficult to give definitive advice on the different models or applications because of the rapid rate of change in this area, however, you can be sure that a PalmOS unit with less than 8MB may not have enough memory to run many of the larger medical software packages. Also, try to tailor your model to your needs. Some of the newer ones have a camera, a keyboard, wireless internet access, or even a cell phone. If you are never going to hook into a wireless network, dont bother paying for this feature. As well, a cellphone may be

handy to have, but be sure you have the option to turn it off while the Palm is on as cellular use is not allowed in the hospitals. There is a huge variety of software available for PalmOS, though much of it tends to be quite specialized. The only way to know if a program might be useful to you is to simply try it. There is also some free software floating around. Skyscape programs like the 5 Minute Clinical Consult (5MCC) series are available if you find someone who has a copy of the CD-ROM. Many useful programs, such as MedMath, can be beamed from one Palm to another. Be sure to ask clerks, elective students, residents, and even consultants if they have anything you might find useful. To date I have found that ePocrates/Tarascon (whichever you prefer), 5MCC, and Dorlands are the three most useful programs. Useful Sites www.epocrates.com - the only place to get THE most useful PalmOS drug book FREE! http://hopkins-abxguide.org/download_center/download_center.cfm - a FREE constantly updated guide to antibiotic therapy (note some have had some difficulty loading this on their palm) www.healthypalmpilot.com - an extensive database of programs with software reviews www.handheldmed.com - mobile medical content, featuring the PocketClinician Library. www.palmgear.com - a respectable medical section, with many useful non-medical programs. Useful Medical Software Epocrates Free pharmacopeia that contains drug dosages, adverse reactions, contraindications (does not contain Canadian trade names) Tarascon Pharmacopeia same as the pocket guide but saves you carrying around the book. It is possible to get a one month free subscription at http://www.tarascon.com/ (if you sign up for a new email address every month, you can get a one month subscription every month) 5 Minute Clinical Consult good for a quick check up on a topic. Not a substitute for a brain, but rather a supplement to stir up memories of forgotten topics from first and second year. Quite helpful before a pimping session. Dorlands Dictionary useful for quick reference of some of the more obscure medical terminology and acronyms Medmath does common medical calculations including BMI, A-a gradient etc. Merck Manual the electronic version of the book weve all come to know TealDoc/TealInfo useful for accessing many medical databases/publications

FEWER NOTES FOR POCKET PC USERS


While PalmOS owned the medical market, recently there has been a trend towards newer Pocket PCs based on a Windows platform. This allows for more compatibility between PCs and handheld devices. With such programs as Word, Excel, and even Powerpoint, one can type documents on your handheld (easier if you have a keypad) or even make a presentation without worrying about where you will find a laptop. The only down side is that the majority of the medical software is for PalmOS. This is changing, however, and it is possible to BUY the Pocket PC version of 5MCC (free versions floating around the class are for PalmOS ONLY right now) as well as register for the Tarascon Pocket PC version. More and more of the software is becoming available for the Pocket PC and it is only a matter of time until those are circulating around the class. So, for those of you with a Pocket PC, dont stress the software is out there you only have to look a little harder!

An Approach to the Many Types of Rounds


There are different types of rounds. Your first day, the resident you are with may say for you to show up tomorrow at 7:00am for rounds. While rounds vary somewhat from specialty to specialty with regards to who is present (residents and staff vs. residents only), and length (ortho rounds = 10-15 patients in 30-45 minutes vs. medicine rounds = 10-20 patients in 2-5 (or more) hours. In general, the main forms of rounds are: 1) Patient Rounds - this involves seeing all of the patients assigned to your team (there is usually a team list on powerchart) with the residents and clerks +\- consultant, and dealing with any issues left over from the evening and making plans for the day. Clerks Role show up 10 minutes early to print out the team list, keep up with team as you move from patient to patient, push the chart rack down the hall, grab the patients charts when going in to see them, grab the patients bedside chart containing vital signs, quickly, write a progress note (SOAP format explained later), write orders and flag the chart. During your Medicine and Pediatric (CTU) rotations you will be given the responsibility of following your own patients. Make sure you know their medical issues, current labwork and investigations and plan forwards and backwards before rounds, as the consultant/chief resident will usually ask you a question of two regarding the status and plan for your patient. In addition, if you happen to be the clinical clerk on Medicine or Pediatrics (CTU) near the end of a month, it is a good idea to be aware when the residents switch services - often the clinical clerks will be the only remaining members of a Medicine team and you may be responsible for handing over a roster of 25 patients to a new set of residents during rounds. For this reason, you not only need to know your own patients, but also pay attention in rounds so that you have some knowledge of all patients under your teams care (this will also help when youre on call). 2) Team Rounds a staple of medicine, often with social work and PT/OT. You meet with the team and go over patient progress, and management plans. This may occur either before, after, or instead of patient rounds. Clerks Role Know your assigned patients. Know their meds, any changes overnight, the plan for the day, and the overall plan. 3) Site Rounds Usually held after patient rounds or at lunch-time. All teams at a certain site meet to discuss patients (as in mortality and morbidity [M&M] rounds), discuss case presentations, or discuss a topic (ID for example). Questions are usually asked of the clerks in this setting. Clerks Role read around the topic of the day, and be prepared to answer questions. Say I dont know if you dont know the answer. NEVER EVER show someone up (aka Pimping). If you know the answer to a question asked of someone else and they obviously dont know the answer wait until you are asked or the group is asked to answer. When food is available show up early to avoid interrupting the flow of rounds if possible. 4) Grand Rounds Usually held weekly or monthly. All teams from all sites in a specialty meet and discuss case presentations or other topics. These rounds like site rounds- are somewhat hierarchical with consultants sitting up front, residents in the middle, and clerks at the back. Usually residents are asked questions but the occasional clerk will get one. Again, NEVER pimp someone out. Answer questions with certainty if youre certain. Otherwise, drink your free coffee, eat your muffin and pay attention to whats being said as it may turn up during the days discussion in the OR, on the ward, etc. In general when a resident asks to meet you somewhere especially in the morning DONT BE LATE. Residents generally will allow only exactly enough time to get a patient list, speak briefly with the nurses or the resident on call about the previous nights issues, round on patients, write progress notes and orders, and get to the OR (note that there is usually no time for breakfast so eat before coming to the hospital; Gen. Surg is notorious for having breakfast, lunch, and dinner all at 16:30). Medicine is somewhat more civilized given the prolonged duration of rounding vs surgery there is always a break at 12:00 for lunch rounds during your medicine rotation.

GUIDE TO NOTE WRITING


There are two basic notes that you will write. The admission note and the progress note. The demands of these notes vary with the specialty you are on. As a general rule, medicine admission notes should be 2-4 pages depending on the complexity of the patient. Surgery admission notes are rarely more than 1 page. Progress notes in medicine should likely be from to 1 page long. Surgical progress notes are very brief and no more than 4-5 lines. We will go into more detail by specialty later but here are some general principles to remember.

Admission Notes
The admission note always follows the same format with the order altered depending on your preference. Always consult the old chart before seeing the patient, it will help to speed up your history. The visit list under patient information in powerchart is also a useful resource for past medical history. The first section is the Patient ID section. This should not be more than 2 sentences and usually has age, sex, occupation, geographical location, duration of illness and tentative diagnosis. Orthopedics and Neurology also require handedness in this section. Next comes the Problem List or Past Medical/Surgical/Obstetrical/Gynecologic History. This section is important because it will put the rest of your note into context. Back pain in someone with a recent cancer history is far more important than back pain in a healthy person. The problems can be listed in two columns: active and inactive. Try to list the problems in order of importance. Most people will put past surgeries under the inactive problem list. Dont waste a lot of time on exact dates. Medications should be next in the note. You should list them with dosage and frequency. Dont waste time asking the patient what medications they are taking, 70% will not know. Instead examine the medication bottles if they have brought them, check the old chart or call the patients pharmacy. In the Allergy section list the patients allergies and always describe the reaction they had. You should also cover Family Hx and Social Hx. Contrary to the new curriculum these should be very very short stick to what is pertinent to the patients immediate management including smoking, alcohol and drugs. The next section is History of the Present Illness. Most people will use brief sentences, symbols and acronyms to distill the HPI into a more practical form. Remember to put in pertinent negatives. Stick to history, do not put any physical exam findings or lab results in this section unless they are crucial to the story. Physical Examination is the next section. Always begin by listing the vital signs (HR, RR, Temp, BP, Saturation). Start from head to toe and write your physical exam findings. An important part of clerkship is learning the screening physical exam. This comes with time as you learn what is and isnt important. Begin at the head and work your way down describing your findings by system. The next section is the Lab Results. When you are asked to see a patient in emergency most of the bloodwork will already have been done. In notes, lab vales are usually recorded in symbol format. The common formats are listed below. To further complicate things, the symbols are not written in stone and people will often put the values in different spots. In time you will recognize the range of normal values.

WBC HgB Plt

Na Cl

K HCO 3

BUN Gluc Creat

These are the common lab values. The rest can be listed anyway you chose. Dont forget ECG and x-ray results. The next sections are Assessment and Plan. This is what you go to medical school for so dont expect to be able to fill it in right away. You will likely want to leave this section blank until you discuss the patient with your senior but make sure you are at least thinking about what you would write. The assessment should contain the diagnoses and the plan should have a numbered approach outlining what you will do.

Progress Notes
Again, this will vary according to the service. For medicine your note will be a slightly scaled down version of your admission note. It should have a patient ID, problem list and medications. Then use the S.O.A.P. format. S is subjective and includes how the patient is feeling occasionally, it may be worthwhile to quote the patients own words. O is objective which encompasses your physical exam, labs and imaging. A is assessment and will change based on S & O. P is plan. For Surgery, your notes will be very brief- usually written very quickly during morning rounds. You will catch onto the important things. Here is an example of a standard surgical progress note.

78 yo POD #2 right hemicolectomy S/ I slept pretty well last night Dr. Mark good pain control with PCA + flatus, BM feels hungry O/ AVSS (Tmax = 37.2) good U/O incision + BS, abdo soft distended stable advance to clear fluids D/C PCA and switch to Tylenol #3 1-2 tabs q4-6h prn

A/P

The Discharge Dictation Format and Discharge Summary


When a patient leaves your service, it is important to ensure that an adequate discharge summary is written or more often, dictated if the patient has been in hospital >6 days in order to ensure that future medical caregivers have quick access to the information they need. After a few middle-of-the-night complicated admissions, you will learn that the discharge summaries in each patients old chart can be your very best friend. Make sure to return the favour. The Ward Clerks on each floor have a sheet with detailed instructions on how the dictation system works, make sure you get it the first few times you dictate. Youll quickly learn the to navigate the dictations system, but there are often instruction sheets taped on walls next to phones, on corkboards, etc. Dont lose your dictation ID#, it can be a pain to retrieve when youre in a rush. Once you navigate through the various menus your dictation would sound like this. This is John Jacob Jingleheimerschmidt, clinical clerk meds three, dictating a discharge summary on patient John Doe, patient # 11015555. Patient admitted to Internal Medicine at Victoria Hospital on September 1, 2000 under Dr. Frankenstein. Discharged September 6, 2000. Copies of this dictation to go to the chart, to Dr. Frankenstein, to the patients family physician Dr. Hyde (address if needed), and (other physicians directly involved in the patients care for this problem not every doctor they see!). Patient Identification (include date of birth and patient identification #) Date of Admission - under which service + consultant Date of Discharge Date of Dictation Admitting Diagnosis / Reason for Admission Problem List (if more than one, or different from RFA) Past Medical History (if extensive or important) Patient Presentation = Admitting History and Physical (pertinent details only) Course in Hospital (include treatment, response, new issues procedures, complications) Disposition (to home, nursing home, mention home care) Discharge Medications List these with dose and frequency of administration. Follow Up and other Special Medical Instructions If dictating: end dictation. Signed John Jacob Hingleheimerschmidt, clinical clerk meds three, dictating on behalf of Dr. Frankenstein FRCP(C), Internal Medicine, London Health Sciences Centre Victoria Campus. Thank you. Each chart has a form which has to be filled out upon discharge, which will contain most of the information contained above. If dictating, it is a good idea to fill out the form first as a rough guide for your dictated material. You may want to write out your first Discharge Summary before you dictate it. Dont be afraid to use numbered lists where appropriate they are actually the preferred format for things like the Problem List and Discharge Medications. A few quick notes on the dictation process. Be sure to speak clearly, so avoid eating or chewing gum during dictations. Dont worry about uhms and aaahs in between your text the dictation service employs trained professionals. However, your must say period, comma, new paragraph while dictating or your note will be transcribed as one long sentence. When in doubt, spell out your words after saying them (ie: hiatus H I A T U S hernia). Remember you can always pause, rewind, listen to yourself, and

correct mistakes if you have to. Work in a quiet area, and remember that you are dictating confidential patient information, so make sure you have the appropriate degree of privacy. Its a good idea to review your dictations as soon as possible after completing them, via your Message Centre on PowerChart. If you think critically about what youve done, your dictations will quickly get briefer, done faster, and more useful to others.

GUIDE TO WRITING ORDERS


One of your common duties as a clerk will be to write orders on your patients. Any patient being admitted to hospital, being transferred to a new service, or having management changed must have orders. All orders are written on the order forms in the chart. These are usually located in the front of the chart and have a purple edge. At London hospitals the form has two halves: the left half is for non-medication orders and the right is for medication orders. The sheets are divided into 3 horizontal sections (except for initial admission orders, which are one big sheet), each with a place for you to sign at the bottom. Dont forget to sign your name with M3, put the date and time in the appropriate spot. All orders (even for tylenol, or a urine dip), have to be cosigned by a licensed physician (resident or consultant). If youre writing orders on rounds, get it done right away so you dont have to drag a resident back to the ward and so the patient can get their medication or test sooner. If youre on your own while writing orders, dont forget to ask a resident to co-sign them when theyre available. Here are the general principles to writing orders with more specifics to come.

Approach To Admission/Transfer Orders Most people use the AD DAVID mnemonic: Admit, Diagnosis, Diet, Activity, Vital Signs, Investigations, Drugs ADMIT
Usually you will write: Admit to (your service) under (your consultant today and your team)

Eg. Admit to Gold team under Dr. Larocque. DIAGNOSIS


This is what you suspect they have. (Acute Renal Failure, Congestive Heart Failure) Eg. Lower GI Bleed

DIET
The most common order you will write is DAT (Diet as Tolerated). Patients who might need surgery should be NPO (Nothing by Mouth). Other common diets you will order are: Diabetic Diet, Cardiac Diet, Clear Fluids, Full Fluids (Includes pudding, ice cream) and Dysphagia Diet. Post-surgery patients will often have sips to DAT written so that the nurses can decide when to also recovering patients to eat, but this is not always the case when the patient has had bowel surgery.

ACTIVITY
The most common order is AAT (Activity As Tolerated). Orthopedics will use abbreviations like NWB (Non Weight Bearing), or FWB (Feather Weight Bearing). Obstetrics will sometimes use BR, or BR with BRP (Bed Rest with Bathroom Priviledges). Patients who are mostly sedentary might have ambulation orders added to this section: Up In Chair tid Ambulate bid. 99% of the time you will write AAT. This is also a good time to indicate if you want any limbs elevated etc. Eg. AAT, NWB Lt leg, Elevate Lt leg.

VITAL SIGNS
The most common order is VSR (Vital Signs Routine). VSR means the nurses will check vitals in the usual routine for this hospital or a particular floor, q12h (at shift changes). Generally HR, RR, BP, O2 sat, Temperature will be checked every 8 or 12 hours. If there is a particularly sick patient more frequent vitals may be necessary (VS q6h, VS q4h, etc.) If special parameters should be monitored regularly (ie: postural vitals), be sure to specify.

INVESTIGATIONS
This is the largest section you will write. In general it will be bigger than all the other sections combined. This section requires an approach of its own. A simple approach is to remember there are five basic investigation areas: Imaging, Consults, Hematology, Biochemistry, Microbiology. For each investigation start from the head and work down keeping in mind your patients disease. For example, a septic 82 year old patient with confusion could be approached this way.

q q q q q

Imaging: CT head, Chest X-ray, EKG Consults: Social Work, Neurology?, Infectious Diseases? Hematology: Daily CBC with Differential, PTT/INR + + 2+ 2+ Biochemistry: Daily Electrolytes (Na , K ,Cl , HCO3 ), Daily Urea, Daily Creatinine, Ca , Mg , PO4 , glucose, CSF cell count, CSF protein and glucose Microbiology: Urine R&M/C&S (Routine Tests, Microscopy, Culture, Sensitivity), Blood Cultures, CSF from Lumbar Puncture for gram stain, culture & sensitivity. For this section just remember all the things you can culture: CSF, Sputum, Urine, Feces, Pus from wounds, Blood

The above is not a complete list but simply an approach. The investigations to order will come with experience.

DRUGS
This is also a big section. Start out with IV fluid orders, especially if the patient is not able to drink. Use the 4-2-1 rule (as described later). A simple approach is past, present & future. Begin by ordering all the medications the patient is already on (the past). Exercise judgment as to which ones the patient still needs. For example, a bleeding patient doesnt need Aspirin or Coumadin. Also, a patient who cant take anything by mouth due to nausea or impending surgery cant take pills. For the present, think about what the patient needs right now. They will likely need an IV but may also need antibiotics, diuretics, anti-arrythmics and so on. For the future try to anticipate what the patient might need. Think about DVT prophylaxis, sleeplessness, nausea and pain. A good mnemonic for this is to make sure youve addressed the Patient Ps Problems (specific medical issues), Pain (analgesia), Pus (antimicrobials), Puke (anti-nauseants, prokinetics, antacids), Pee (IV fluids, diuretics, electrolytes), Poop (bowel routine), Pillow (sedation), PE (anticoagulation), Psych (dont forget about DTs when on medicine!), Previous Meds.

Ordering Drugs and Writing Prescriptions


Drugs have a specific nomenclature that you need to follow. The basic format is as follows: DRUG Lasix Clarithromycin Ativan Tylenol #3 DOSE 40 mg 500 mg 0.5 mg 1-2 tablets ROUTE IV PO SL PO FREQUENCY q12h BID qhs prn q6h prn DURATION/AMT X 10 days 20 tablets 15 Tablets

In London hospitals these are written on the right side of the orders page. Remember to press hard as a carbon copy is made and this copy goes to pharmacy. The pharmacist can be your savior as clerks frequently make drug mistakes. You cannot possibly know every drug dose but you will come to know the ones you commonly use. A must have book for clerkship is Tarascon Pocket Pharmacopeia. It has almost every drug and its common indications and dosages (PalmOS users should consider epocrates which has the same information plus a little more). It is an American program though and some Canadian drugs names are not in it (ex. Gravol or dimenhydrinate). Below, common medication abbreviations are listed.

Abbreviation PO IV SL PR IM

Meaning By Mouth Intravenous Sublingual By Rectum Intramuscular

Abbreviation OD qD q h SC

Meaning Once Daily Every Day Every Hours Subcutaneous

Abbreviation BID TID QID PRN qhs

Meaning Twice daily 3 times daily 4 times daily As needed At Bedtime

Prescriptions written to be filled outside the hospital use the same abbreviations but a slightly different format. Formal prescriptions have the following structure:

Date Patient name and Address stamped with the blue card

Inscription (The Rx the appears in the corner, short for recipe or take thou)
Each drug, dosage, route and frequency of administration.

Subscription (Instructions to the pharmacist)


Where you specify the quantity to be dispensed and any other special information. The abbreviation M: (Mitte = dispense) is often used here. Signature (Instructions to the patient) Basically what you want written on the bottle, if at all unclear from the inscription. The abbreviation S: (Sig, Signa = write) is often used here. Refill Information (number of refills, or no repeats ALWAYS REMEMBER THIS)

Prescribers Signature
September 1, 2000 Patient: Mr. John Doe Address: 1234 Western Avenue, London, Ontario (1) Lasix 40mg PO OD Mitte: 14(fourteen) 40mg tablets Sig: One capsule by mouth daily (2) Ventolin MDI two puffs qid prn Mitte: One MDI Sig: Two inhaled puffs as needed with onset of asthmatic symptoms. Do Not Repeat Dr. Jinglehiemerschmidt, MD. The U.S.P. makes the following recommendations for avoiding prescription errors: All prescription documents must be legible. All prescription orders should be written using the metric system except therapies that use standard units such as insulin and vitamins. The term units should be spelled out rather than abbreviated as U. The medication order should include drug name, exact metric weight or concentration, and dosage form A leading zero should always precede a decimal expression of less than one. A terminal or trailing zero should never be used after a decimal. Prescription orders should include a brief notation of purpose (eg. for cough) unless inappropriate. Prescribers should not use vague instructions (take as directed) as the sole direction for use. Prescribers should avoid potentially confusing abbreviations or Latin directions for use.

Common Order Pitfalls


1. 2. 3. 4. 5. 6. 7. 8. 9. Always remember to write the patients name in the upper right-hand corner of the order sheet or stamp that corner with the patients blue card. Nurses cannot carry out orders unless the patient is properly identified. Write Clearly. Mistakes in dosing usually result from bad penmanship and short forms. Remember to think ahead. Anticipate problems with pain, sleeplessness and hydration. A simple order written at admission can save you or someone else a call at 2:00am. Press hard on the order sheets. You are making a carbon copy that will be used by pharmacy. If pharmacy cant read your orders its hard for them. Pharmacy will catch your mistakes more than anyone else so do them a favour. Sign the orders and put the date and time or there may be a delay in carrying them out. If the orders are important, make sure they are seen by the ward clerk right away. Regardless, always remember to pull up the Doctors Orders flag in the chart. These flags sometimes vary depending on the ward/hospital you are in. They may vary by colour - yellow/red/white, and by inscription clerk/orders etc Make sure to ask which flag to use. Dont abuse words like now or stat check with your resident about these if you are unsure If you are unsure about your orders in any way, make sure to ask someone. Remember to ALWAYS bring your pharmacopia with you you will use it in every rotation, sometimes when you least expect it.

Sample Orders
To demonstrate a typical set of orders lets assume we have a 63 year old man with bright red blood per rectum earlier in the day. Assume he is currently not bleeding and his hemoglobin in 65. Italics would not be written and are only for your explanation. Orders are fairly constant between services and this list should be a good framework for whatever rotation youre on.

Admit to CTU-2 medicine under Dr. Smith Diagnosis: Lower GI Bleed NPO (may take PO meds with sips), AAT VSR Foley Catheter Accurate Ins & Outs (Nurse to monitor fluids in through IV & Mouth and fluids out in urine, NG etc.) Alert MD if Urine output < 90cc over 3 hrs (Low urine output is a measure of hydration status) Stool Chart (Nurse will examine stool and write finding on chart) Keep 2 units Group & Crossed at all times Daily Labs: CBC, BUN/CR, Lytes, PTT, INR EKG, 3 views of the abdomen GI consult in am, CCAC consult Saline lock second IV Transfuse 2 units of cross-matched PRBC (packed red cells) over 2 hrs st nd with 20 mg Lasix between 1 & 2 Unit

Pharmacy Medications 2 large bore IVs (14 or 16 gauge) IV D5W/.45 NS with 20 meq KCL @ 125 cc/hr Ranitidine 150 mg PO BID Enalapril 20mg PO OD Tylenol pl 1-2 tabs q6h prn ECASA 325mg PO OD (HOLD) Ativan 0.5mg SL qhs prn Standard bowel prep as per GI

FREQUENTLY USED ABBREVIATIONS


AAT ABG AKA AMA AP AXR BE BKA BRBPR BRwBRP BS BUN C/O CABG CBD CF CP CVA CVD CVP CXR D/C D5W DAT DVT Activity as Tolerated Arterial Blood Gas Above Knee Amputation Against Medical Advice Antero-Posterior Abdominal X-Ray Barium Enema Below Knee Amputation Bright Red Blood Per Rectum Bed Rest with Bathroom Priviledges Bowel Sounds, Breath Sounds, Blood Sugar Blood Urea Nitrogen Complains Of Coronary Artery Bypass Graft Common Bile Duct Clear Fluids Chest Pain Cerebral Vascular Accident Cardiovascular Disease Central Venous Pressure Chest X Ray Discharge/Discontinue Dextrose 5% in Water Diet As Tolerated Deep Venous Thrombosis EBL EF EGD ERCP FF FFP F/U FWB GCS I&D IABP IHD IVF L/E LAT LGI LR NAD NEOM NG NPO NS NSR NWB NVC Estimated Blood Loss Ejection Fraction Esophagogastroduodenoscopy Endoscopic Retrograde CholangioPancreatography Full Fluids Fresh Frozen Plasma Follow Up Featherweight Bearing Glasgow Coma Scale Incision and Drainage Intra Aortic Balloon Pump Ischemic Heart Disease Intravenous Fluids Lower Extremity Lateral Lower Gastrointestinal Lactated Ringers No Apparent Distress Normal Extraocular Movements Nasogastric Nothing Per Os Normal Saline (0.9%) Normal Sinus Rhythm Nonweight Bearing No Voiced Complaints

OB OOB ORIF Fixation PA PEEP PERRL PICC PRBC PTCA PUD PVD R/A

Occult Blood Out of Bed Open Reduction and Internal Posterio-Anterior Positive End Expiratory Pressure Pupils Equal and Reactive to Light Peripherally Inserted Central Catheter Packed Red Blood Cells Percutaneous Transluminal Coronary Angioplasty Peptic Ulcer Disease Peripheral Vascular Disease Reassess

RL RTC SBO SIADH SOB SOBOE TEE Tmax TPN U/E UGI UO UTI VSR

Ringers Lactate Return to Clinic Small Bowel Obstruction Syndrome of Inappropriate Antidiuretic Hormone Shortness of Breath Shortness of Breath on Exertion Transesophageal Echocardiography Maximum Temperature Total Parenteral Nutrition Upper Extremity Upper Gastrointestinal Urine Output Urinary Tract Infection Vital Signs Routine

Quick Reference to the LHSC/SJHC Paging System TO PAGE A PAGER


In hospital: Dial the 5-digit pager number (1+old 4 digit number) directly Out of Hospital: Dial 685-8500, enter the 5 digit number + the # key. After connecting, listen to the greeting, and the status of the pager. After the tone, key in your numeric message and the # key. You should receive a confirmation of your page. To correct a page before you send it, press [***]. Your message will be erased and you will be prompted to enter a new one.

THE CALL CONNECT SYSTEM


You can page someone and remain on hold until they answer. The procedure is similar to making a normal page, but during the personal greeting you can press [*4] to initiate a personal conference call. Speak your name when prompted and press the [#] key. When the person your are paging connects, you will hear a tone and you will be connected. If you are paged in this manner, your pager will display U and your five digit pager number (ie: U12345). Dial YOUR 5-digit pager number. During the personal greeting, press [**] to hear the name of the party trying to get in touch with you. To accept, press [3]. There are full instructions available at each hospital, with detailed instructions on the above as well as how to record greetings, sign over pagers, and enabling/disabling your pager. Theyre worth consulting.

Medicine
Every clerk has 6 weeks of CTU on their schedule. Its the longest single rotation of the entire year. You will learn a lot on this rotation: not only about internal medicine problems, but about situations that will come up no matter what specialty you train in. There is a lot of work involved in dealing with general internal medicine patients, but to get the most out of the experience, you have to be pro-active. You will get a lot of teaching, but you cant rest on thatif you also reinforce your teaching with reading, practice, and feedback, you will come out with great diagnostic skills. CTU is a chance to work with allied health professions (OT, PT, pharmacy, social work), and you can really learn a lot from them. Rounding Most of the work you do will involve following 2-6 patients and knowing everything that goes on with them. Rounding is the time when your knowledge will be used, and you will present the issues and results of the past few days to your team. Morning rounds are not at an unreasonable hour, usually after teaching rounds (but go to teaching rounds!); the first day that you have a new consultant, or the first day of the rotation, these will take a little longer. Be prepared by knowing what has happened to your patient since the last set of rounds, and any procedures/special tests/changes in status/discharge planning that are going to happen that day or soon. Afternoon rounds are usually a quick handover to the person on call: give them the highlights, key problems that each patient has, and anything that MIGHT come up overnight that might require a clerk being called. Weekend rounds are usually done with the consultant on call find out what time, and be prepared to work through every patient on the team fairly quickly. Teaching Rounds Morning and lunch teaching rounds give you a chance to eat and learn a bit. They arent too far above clerk level, and a bit of reading the night before will prepare you for questions and add to your understanding. These occur just about every morning and every lunchtime free food! This is also a good rotation to develop your skills of critical appraisal. Get some articles that describe the current topics in common diseases. You can even apply what you find to your patients. Who you will meet Your consultant --- internist (either general or subspecialty); senior resident (PGY-3 Internal); off-service junior residents (often anaesthesia, neurology, psychiatry, and family medicine usually PGY-1); junior residents (PGY-1 internal medicine), elective students, your fellow clerks; pharmacist, social work, OT, PT, speech-language pathology; consulting service residents and consultants (PGY-2, 4, 5 internal medicine); nurses specific to your patient, and the floor charge nurses. On Call CTU call is the hardest of clerkship. You have two responsibilities: floor calls, and admissions. Floor calls will be anything from Tylenol or sleeping pill orders, to difficulty breathing or chest pain. Admissions involve a lot of work, but take your time and you will really develop your history and physical skills. Old charts are the best starting point on an admission. After that you will be able to take a directed history and physical and order some labs. Your resident will give you the highlights of the patient you have to go see, then after youve seen them and youve done the directed history and decided what labs to order, you call the resident back and together you will assess the patient. The residents also help by asking other questions you have left out. You can learn a lot from themthey know all of the important questions, and can explain their reasoning to you. If the patient is going to be admitted, then one of you writes the orders, you each write a note for the chart, and the resident calls admitting to get a bed.

Sample Admission Note: Medicine


This would be a typical note for our previous case of BRBPR (bright red blood per rectum). Patient ID: 65 yo retired carpenter from Chatham, ON presenting today with 1 day hx of BRBPR. Problem List: 1. BRBPR 2. COPD 3 hospitalizations for exacerbations in last 5 yrs. Last hospitalization Sept 99. 3. Biliary Colic 3-4 episodes per year 4. Osteoarthritis Affecting knees and low back 5. GERD 6. ORIF (open reduction internal fixation) R wrist 7. T & A (Tonsillectomy & Adenoidectomy) HPI 65 yo M w/ 3 episodes of BRBPR in 24 hrs. First epsiode 0200 last night. Awoke from sleep w/ LLQ (Left Lower Quadrant) crampy pain. Large bowel mvmt mixed with BRB 45 cupfuls. N&V(Nausea & Vomiting), dysphagia. Constant LLQ Pain 3/10 w/ radiation. Never had pain previous. abd distention. Loose stools last 2 wks but blood. melena. 2 episodes since @ 0600 and 1100. Presented to ER, at urging of wife, @ 1300 with c/o weak & dizzy. LOC (loss of consciousness). CP (Chest Pain). fever, chills, night sweats, weight loss. Decreasing energy last 2 mos. bleeding problems. + Aspirin use x 5 yrs. 1-2 ETOH per month. Last meal 2300 yesterday. Medications 1. ECASA 325mg PO OD x 5 yrs 2. Ranitidine 150 mg PO BID 3. Tylenol #3 1-2 tabs PO OD 4. Ventolin MDI 1 to 2 puffs QID PRN 5. Atrovent MDI 2 puffs QID Social History 1-2 ETOH per month. 40 pack/year smoker Married w/ 3 grown children. Allergies Morphine GI Upset Pencillin Rash

Family Hx Father Colon CA 56

Physical Examination: HR 90, RR 22, BP = 140/86 lying, 136/80 standing, Sat 96% on RA, T=37.0 HEENT: Mucous membranes dry, lymphadenopathy, conjunctiva pale thyroid grossly N, jaundice/cyanosis RESP: Good BS bilaterally, mild expiratory wheezes, crackles, indrawing CVS: N S1S2, S3/S4, Grade II/VI systolic murmur heard best at apex, peripheral edema, PPP (peripheral pulses palpable), JVP 3cm ABD: Soft, Mildly tender LLQ, rebound tenderness, masses/organomegaly, +BS(Bowel Sounds), scars, Normal tympany RECTAL: Normal Tone, Prostate Soft Mildly enlarged, BRB present, masses NEURO: Alert & Oriented x3 (person, place, and time), CN 2-9,10,11 Normal, Reflexes 2+ in all limbs and symmetric, Strength 5+ in all muscle groups, Normal Tone, Cerebellar Testing Normal, Gait Normal

Labs

139 97

4.0 23

12.1

65 7.0
250

4.5 123

MCV INR / PTT = 1.1/60 93 Calcium = 2.04 Albumin = 35 ALT = 15 AST = 20 Group & Type = O+ GGT = 20 Alk Phos = 60 Lactate = 1.2 Cap Gas: pH=7.4/PO2=96/PCO2=37/HCO3=23 Cardiac Enzymes: CK 85 & Troponin I < 0.05

Imaging: 3 views Abdomen: free air, dilated bowel loops, Diverticuli Left colon CXR: Normal Cardiac Silhouette, Clear Lung Fields EKG: Normal Sinus Rhythm @ 86 bpm, Normal Axis, ST-T changes Assessment Stable 65 yo man with 1 day Hx of BRBPR. Mildly dehydrated DDx: 1. Diverticulosis 2. Angiodysplasia 3. Colon Ca 4. Volvulus Plan 1. Admit to Medicine 2. Rehydrate (2 large bore IVs) 3. Keep 4 units grouped & crossed @ all times 3. Transfuse 2 units PRBC 4. GI consult for Endoscopy Tomorrow

The short version: 1. Be there. Be there for morning rounds, lunch rounds, teaching sessions. If you get called, go see the patient. 2. Its never too early to think about long-term planning. Whether thats discharge home, surgery, procedures, CCAC care at home, nursing home, respite, rehab, or palliative care. 3. Keep on top of your patients. See them every day (unless you are post-call), keep track of their lab results, talk to their nurses and see whats happening. 4. Talk to your residents: usually you will have at least one junior, often an off-service junior, and a senior. You can learn a lot of the nuts and bolts of medicine from them, and bounce questions off them when you are concerned about a patient or encounter something new. There will always be a resident on call with you: if you get stuck at any time during the night, call them. Talk to the nurses, pharmacists, RTs, OTs, PTs --- they have lots of experience and can draw on it to help you (and your patients). 5. Your consultants are busy. They usually have clinics, consults, or other services to run in addition to their weeks on team. They are generally available at some point every day, and they are really good teachers. Take advantage of it when you can. 6. It is a team experience --- like CTU on Paeds, but different from almost any other youll have in clerkship. Being a team player can make everyones experience better.

Surgery
The surgery rotation really gives you a chance to become a part of a team and feel like youre making a difference in the hospital. You will have quite a bit of responsibility on this rotation. That includes helping with rounds in the early morning (ie writing notes on patients), seeing patients in the ER, consulting on the wards and taking care of problems on the ward. Sometimes this can leave clerks feeling overwhelmed and alone, but your resident is always there to help you out in a bind, its their job. Dont be afraid to call them. Just know your limits and stretch your wings a bit. Rounds Rounds are fast, and youre expected to keep pace with the notes in the morning. See the example below for an idea of the minimal content of a surgical progress note. Teaching Rounds Clerk teaching is really good in surgery. The best way to get a lot out of these sessions is to read the night before. You dont have to read a textbooks worth of information, just skim a concise text or get previous students notes. If you know the content of the lecture youll look good for the consultant and learn more in the process. Sit at the back for grand rounds. You will see the residents get grilled and you dont want to be in the line of fire. There is often a schedule of topics. Its good to read up since the material may be over your head, and its easy to fall asleep if you get lost. On Call You may be responsible for fielding calls from the floor; this has varied a lot recently, depending on policy and the nursing staff. Consults will be phoned to the resident, and they will often call you and tell you to see the patient and call them when youre done. Dont be afraid to start writing orders for the admission without your resident. Its a good chance to develop your own skills and learn from your mistakes. You may also be in the OR if you have a really sick patient overnight. There are call rooms for your Gen. Surg./Thoracics Rotations. Plastics, Ortho, Urology are all home call. You go home and return if you need to see someone.

The Surgery Admission Note This is a comparison to the medicine admission note for the same problem.
Patient ID: 65 yo male presenting today with 1 day hx of BRBPR. PMHx CHF, COPD Medications 1. ECASA 325mg PO OD x 5 yrs 2. Ranitidine 150 mg PO BID 3. Tylenol #3 1-2 tabs PO OD 4. Ventolin MDI 1 to 2 puffs QID PRN 5. Atrovent MDI 2 puffs QID Social History 1-2 ETOH per month. 40 pack/year smoker PSHx Appendectomy (1999) Cholecystectomy (1986) Allergies Morphine GI Upset Pencillin Rash

Family Hx Father Colon CA 56

HPI 3 episodes of BRBPR in 24 hrs. First epsiode 0200 last night. Awoke from sleep w/ LLQ (Left Lower Quadrant) crampy pain. Large bowel mmt mixed with BRB 4-5 cupfuls. N&V(Nausea & Vomiting), dysphagia. Constant LLQ Pain 3/10 w/ radiation. Never had pain previous. abd distention. Loose stools last 2 wks but blood. melena. 2 episodes since @ 0600 and 1100. Presented to ER, at urging of wife, @ 1300 with c/o weak & dizzy. LOC (loss of consciousness). CP (Chest Pain). fever, chills, night sweats, weight loss. Decreasing energy last 2 mos. bleeding problems. + Aspirin use x 5 yrs. 1-2 ETOH per month. Last meal 2300 yesterday. Physical Examination: HR 90, RR 22, BP = 140/86 lying, 136/80 standing, Sat 100% on RA, T=37.0 RESP: Good BS bilaterally, mild expiratory wheezes, crackles, indrawing CVS: N S1S2, S3/S4, peripheral edema, PPPX4 (peripheral pulses palpable) ABD: Soft, Mildly tender LLQ, rebound tenderness, masses/organomegaly, +BS(Bowel Sounds), scars, Normal tympany RECTAL: Normal Tone, Prostate Soft Mildly enlarged, BRB present, masses Labs

139 97

4.0 23

12.1

65 7.0
250

4.5 123

MCV INR / PTT = 1.1/60 93 Calcium = 2.04 Albumin = 35 ALT = 15 AST = 20 Group & Type = O+ GGT = 20 Alk Phos = 60 Lactate = 1.2 Cap Gas: pH=7.4/PO2=96/PCO2=37/HCO3=23 Cardiac Enzymes: CK 85 & Troponin I < 0.5

Imaging: 3 views Abdomen: free air, dilated bowel loops, Diverticuli Left colon CXR: Normal Cardiac Silhouette, Clear Lung Fields EKG: Normal Sinus Rhythm @ 86 bpm, Normal Axis, ST-T changes Assessment Stable 65 yo man with 1 day Hx of BRBPR. Mildly dehydrated DDx: 1. Diverticulosis 2. Angiodysplasia 3. Colon Ca 4. Volvulus Plan 1. Admit to Surg team 2 2. Rehydrate (2 large bore IVs) 3. Keep 4 units grouped & crossed @ all times 3. Transfuse 2 units PRBC 4. For colonoscopy tomorrow

The Surgery Progress Note


Date/time Gen. Surg. POD#1 No new complaints, +flatus, No BM O/E: AVSS Abdo soft, non-tender, BS+ Wound clean and dry

Plan: Advance diet Mobilize Continue to follow

The Surgical OR Note


In surgery, you will also be required to write OR notes. This is the only record of the operative procedure between the operation and when the dictation service finally distributes your consultants detailed operative note. Some consultants/residents prefer to write these brief notes for themselves, but at the very least you should know the format. Most of the time it is the clerks job to write this note, especially if you arent scrubbed in on the case. Your help with this is appreciated. Below is a sample: Sept 1/00 2300h - OR Note Pre-op Dx: cholecystitis Post-op Dx: same Procedure: laparoscopic cholecystectomy Surgeon: Dr. (staff) Assistants: Dr. (resident) PGY _/ (clerk) M3 Anesthesia: GA by ETT (general anesthesia by endotracheal tube), Dr. ___ Findings: none Specimens: gallbladder EBL: minimal Complications:None Drains: None counts correct Disposition: To PACU in stable condition. Procedure notes should be added to the clinical record after anything significant is done to the patient (eg. Suturing in the ER). The format is similar to that of the operative note, but not as detailed. Who was there, what was done, what did you find, and how was the patient after the fact.

Paediatrics
Kids are funny! They will make this rotation fun, but when they cry they can ruin your day. You need to be prepared to make kids cry. They cant understand why youre doing whatever you are doing, and the hospital seems like torture when you have to wait and you are ill. Remember, they have a short memory. Your exam should be from least uncomfortable to most uncomfortable (finish up with throat and ears). If you know the kid is going to be cranky then the best bet is to go for where the money is on exam. Go straight for the part that you think is causing the problem. Residents in this rotation (Peds CTU) can be pretty protective of their kids. You may feel like you dont have a lot of responsibility, but that just allows you lots of time to think about your patients. Still, this step back can be pretty frustrating. Rounds These are much like medicine rounds. Just know your patients and youll be fine. Teaching Rounds These can be good and bad. There are various topics presented in an afternoon. Some lectures are didactic and others are interactive. Pediatric Emergency This is a great opportunity to see a lot of different issues arising in the care of children. If you dont learn a lot of pediatric medicine you will at least come out better prepared for parenting. Make sure that you take the time to follow the patients while they are in the department, and if you can read about every case that you see to make the experience more rewarding.

Sample Admission Note: Pediatrics


ID: 18 mo previously well CC: fever x 8 days HPI: May 4: onset of fever (38.5 C) May 5: onset of bilateral, non-purulent conjunctivitis and generalized erythematous rash; visit to family MD prescribed Amoxil for ?scarlet fever May 6-10: continued fever, increasing irritability, decreased appetite, decreased fluid intake, conjunctivitis resolved today: bilateral hand and foot swelling, feet > hands (mother unable to put patients shoes on) diarrhea vomiting cough recent travel sick contacts PMHx: previously healthy Meds: Allergies: NKDA Perinatal Hx: uncomplicated pregnancy SVD at term 8 lbs. 4 oz. Apgars 8/9 resusc. necessary antibiotics significant jaundice discharged home with mom after 36 hers. in hosp.

Development: appropriate; more advanced compared to siblings Immunization Hx: uTD MMR given March 14 Feeding Hx: 8 to 12 oz. homo milk by cup per day; good intake of all other foods incl. meats, fruits and vegetables

FHx: SHx:

Paternal aunt: congenital deafness Maternal grandfather: osteogenesis imperfecta lives in Oshawa with mom, dad and two sisters mom stays at home with children dad works as computer programmer lots of family supports financial concerns

! consang.

34 asthma

32 healthy

O/E:

5 irritable, toxic 18 mo th healthy Weight: 10.8 kg (50 %ile) th Length: 83 cm (75 %ile) th HC: 47 cm (50 %ile) VS: T = 39.2 C ax, HR 140, RR 36/min, BP 70/P HEENT: ant. Fontanelle closed, N TMs, + red reflex, conjunctivitis lips and tongue swollen/erythemaatous, ulcers, generalized cervical Lymphadenopathy neck supple CVS: N S1S2, S3 S4, PPP, cap. refill < 2 sec., well perfused RESP: good A/E bilaterally, crackles, wheezes ABDO: + BS, soft, non-tender, HSmegaly, masses GU: normal external genitalia DERM: generalized erythematous maculopapular rash, esp. in groin palmar and pedal erythema bilaterally peeling of fingertips MSK: generalized non-pitting edema of feet > hands dactylitis NEURO: PERRL, reflexes symmetrical, 2+ bilaterally

Investigations:

Na: 126 K: 4.2 Cl:32 Polys: 9.8 Lymphs: 4.3 Monos: 0.8 EKG:

Hb: 126 WBC: 16.4 Plt: 486 ALP 430 AST 86 ALT 42

N sinus rhythm, ST changes

Imp: 18 mo previously well, presents with 8 day Hx of fever and 4/5 criteria for Kawasaki disease Plan: 1. Admit to ward 2. IV 2/3 1/3 with 20 mEq KCl/L @ 50 cc/hr 3. High dose ASA 4. IV Ig 5. Rheumatology consult 6. Echocardiogram tomorrow

Family Medicine
Family is a pretty laid-back rotation. There is an exam, but its really easy. In London you are responsible for presenting on a topic of your choice after your two week rotation. This is a breeze. On the rural portion of the rotation you may spend time in the office, emerg., OR, etc. It will show you how varied family can be. Days tend to be longer and busier in the rural portion. In London the academic clinics see less patients (1 per 15min). This is a nice pace.

Psychiatry: A Two-headed perspective Introduction: Student #1: Generally keen medical student, not interested in psychiatry, poor fashion sense, high humility. Student #2: ONLY interested in psychiatry, otherwise lukewarm keen-ness, superior fashion sense, low humility.
#1: This is a very consultant-dependent rotation. Some are good and others arent. There often isnt a lot to do depending on the size of your team. Some students find that their ping-pong game improves during the rotation. There also isnt a lot of resident contact so the consultant will do most of the teaching. Since consultants have an interest your clinical experience may be slanted to several diagnoses. #2: Depending on how interested you are in psychiatry, you can choose to play a larger or smaller role, depending on your site. IMHO, as well as by speaking with other students, the more you get involved, the more interesting it is. Sitting around interviewing inpatients at a long-term care facility can be comainducing, so show some initiative, and you can do more interesting stuff. Acute care is more exciting, especially when you can interview. Its intimidating at first, but try to interview as much as possible, as psychiatry offers the BEST opportunity to develop interview skills that will be useful when dealing with patients (especially the difficult ones) on ANY service. If you feel like youre getting a tunnel-view due to the staff you work with, you can always ask to work with other consultants as long as you do a little detective work. Moral of the story: Sitting back and just doing the bare minimum may likely be far more boring than taking charge and initiative. Showing interest will endear you to staff and residents, thus increasing the likelihood that theyll do more teaching, as well as giving you more interesting work. Rounds Student #1: You will get to talk to the patients and find out how they are progressing. Your treatment will be both chemical and cognitive. One order you will see on this rotation is passes to leave the hospital. This is the way patients slowly re-enter society after admission. Its also the way they get caffeine and nicotine. Student #2: This is where you follow patients progress. This format can vary quite a bit from site to site, as well as with individual psychiatrists. Do your best to present your cases in an organized fashion, as this is more difficult than it sounds, given that your interviews will not progress in a linear fashion. A general

outline is shown below under On call, based on a case write-up in emerg. You can leave out some information, depending on how much time you want to spend in rounds. At the least, you should prepare a good impression, as that is the summary of the patients situation. Adding CC, an HPI, psych history, and other pertinent positives in family/medical/social history will make it more thorough, depending on what theyll want from you. Teaching Rounds These are variable, but cover the topics to be seen on the exam. Sometimes the lectures are interesting, but mostly they are not very useful. Only several of them are interactive. On Call Student #1: You are in-house (required to stay in the hospital) until midnight. You will be called to see patients in the emergency department as they are referred. The only purposes of the interview are to decide if the patient should stay or go home and to gather information laid out on a form. No treatment is started in the ER. Student #2: You will be performing a comprehensive interview. Heres a general outline: ID: Include patients age/name/marital status/source of income/how they presented to hospital/Form status/competency status. This information is CRUCIAL. E.g. if you can remember to always mention how someone presented (e.g. ambulance, self, police), you will look REALLY organized, as this is ALL important. CC HPI not only what has led them up to this point, but their symptoms in relation to specific mental illness. E.g. If theyre depressed, ask questions about depression (MSIGECAPS), as well as commonly related illnesses, such as GAD, OCD, and ALWAYS be sure to rule out psychosis (hallucinations, delusions, ideas of reference also covered in the Mental status exam). Past psych Hx: Past Medical Hx Meds/Allergies Smoking/EtOH/Substance history (important!) Family History Social history: marriage, childhood stuff (can usually gloss over, but useful sometimes), forensic history (VERY important!) Mental Status Exam NEVER forget about suicidal and homicidal ideation! Impression: A paragraph or so to summarize the patients presentation. Include their ID, brief psych history, CC, and most important details (e.g. actively suicidal/homicidal, psychotic features, etc). If you can get good at summarizing patients like this, youll look like a pro star. Critical is that you show here the basis of your reasoning on whether to admit or not, their risk to themselves/others, etc Multiaxial diagnosis: DSM stuff youll learn this from books and such. You need to ask diagnostic questions in relation to the main +/- associated mental illnesses in order to make your diagnosis. This requires some memorization of DSM criteria, which can be skirted by using a DSM palm program, or a little handbook. The diagnosis will guide your decision to admit if theyre psychotic, and unable to care for themselves, they need to come in. If theyre borderline with chronic suicidality and no new plans, then they shouldnt come in, and likely will regress and do worse if they come in to hospital. On the floor: Student #2: When following patients on an inpatient ward, sometimes its hard to determine what you want to do with an interview (usually done every day). Dont worry, it takes time before you can get a good handle on what exactly needs to be asked. Here are some things that you might want to ask about: 1. Follow the patients progress in hospital how have they improved/worsened subjectively/staff reports (look at chart first!), asking about old/new symptoms (e.g. suicidal ideation, hallucinations, delusions, etc)

2. 3. 4. 5. 6.

Ask questions about information missing in the original assessment (there is a LOT of vital data, and its hard to remember to ask it all) Cover their understanding of why theyre in hospital this may change during the course of their hospitalization, especially if theyre psychotic Check their insight and judgement e.g. if this is improving, they might change from involuntary to voluntary status. Discuss treatment goals, side effects, patients beliefs in efficacy, their own objectives, etc Discuss long term follow-up: Critical for discharge planning.

Get to know the affiliated health staff, as they can play an important role. If your social workers are really good at doing cognitive behaviour therapy, and you feel that your patient would benefit from this, speak to them. People often assume that someone else is following the patients care, but this is often untrue, and lots of them lose out on services that would be really beneficial. If you can look out for your patients, and suggest services/alternative housing/addictions counseling/etc, not only will you look like a superstar, but youll make a huge difference in helping someone get better. No matter where youre located, you have a HUGE potential in psychiatry to do a whole lot of good (IMHO, more than any other specialty), by following your patients, and treating them with respect. General survival tips: Student #2: 1. Study the big money conditions first. Youll see MUCH more patients with schizophrenia, bipolar, depression, and borderline personality disorder than anything else, so make sure that if you know anything, know these conditions. Prioritize your studying by what youll be experiencing on the ward. Also, study the medications that are used to treat these conditions (typical/atypical antipsychotics, anticonvulsants, antidepressants, anxiolytics). If you know this bare minimum, you should get by most of your rotation. 2. Show interest, even if you have to fake it. Tell them you want to keep an open mind if they ask you, unless the staff/resident wishes to customize your learning to your specialty of choice. This should apply to ALL of your clerkship rotations. People will automatically treat you better, teach you more, and give you a better evaluation if they think you really want to be there. Showing up on time and not being a total asshat will almost guarantee a pass in everything. 3. Get to know the format of the mental status exam, the new patient write-up (see emerg note), and followup notes. If you have an approach before seeing someone, it makes remembering which questions to ask MUCH easier, and less stressful. This is the only thing that you should really look at before starting your rotation (unless you know nothing, then refer to #1 4. The exam has a history of poorly written or off-the-wall questions, but the rotation director is making serious attempts to improve it. Despite some obscure questions, its still fairly easy compared to Medicine. 5. What you need to know may vary from consultant to consultant. Some are all about the pharmacology (including side effects, which is a pain), others about their area of research, while others focus on the DSM diagnoses. Be flexible if you want to shine, or dont if you just want to pass. They wont mind too much if you know the most basic stuff. 6. Enjoy psych. Even if you dont find it interesting, look forward to getting off early, easy call, and something quite different from anything else in medicine. The more you make an effort to enjoy psychiatry (or any rotation for that matter), the better time youll have. Even surgery keeners have enjoyed their psych rotations, so chances are you will too as long as you keep an open mind. The Exam What to expect (student #1)

The exam is taken from a bank of questions. There doesnt seem to be a pattern to the questions they ask. Some groups had questions about sleep disorders, others somatoform and conversion

disorders. Basically, if you understand depression, anxiety, psychosis, bipolar and their treatment as well as Axis II and suicidality you have learned a great deal from this rotation. Below is a guide for studying, but the exam is often a bit of a surprise. Student #2: For questions below, know that neuroleptic = typical antipsychotic = dopamine receptor antagonist. Atypical antipsychotics (newer agents, more popular than typicals), are NOT neuroleptic (definition causes movement disorder)

Obstetrics and Gynecology

At the start of your OB/GYN rotation, you should be provided with a small pink booklet, originally published by the class of 2001 this contains all the important orders for various situations you will find yourself in during this rotation. Deliveries are the gold star of this rotation particularly for those students not interested in pursuing OB/GYN as a future career, as this will likely be one of the few opportunities to learn this skill. Students in Windsor will have numerous opportunities for deliveries as no residents are present (some Meds 04 clerks delivered close to 40 children during their rotation). Those clerks in London will have fewer opportunities, particularly those clerks starting OB in the last block of clerkship, as the new residents will have just started and they are quite keen to do all the deliveries. In these situations you may have to be somewhat aggressive in order to have your opportunity. Your best bet as a clerk is to talk to one of the senior OB residents when you are on with them in the DR and tell them that youd like to do as many deliveries as possible often these residents are bored of the whole delivery process, and if it is a routine birth, will be more than happy to coach you through the process (particularly at LHSC, where 95% of the births are low risk). A brief note also regarding the pelvic exam. It is important that clerks become accustomed to the speculum and bimanual exam. During the second year OB/GYN clinical method session there is much hoopla surrounding this often awkward and anxiety ridden part of the clinical exam (for both patient and medical student alike!). Many students (particularly male students) often comment that they feel intimidated of this whole examination process following this session. While it is very important to be cognoscente of the feelings of your patients (remember FIFE!), it is equally important that students do not just skip this important part of the clinical examination. That being said, it is always important to: (1) ASK PERMISSION OF THE PATIENT (2) ONLY DO A SPECULUM/BIMANUAL EXAM IF THE CONSULTANT OR RESIDENT IS PRESENT IN THE ROOM WITH YOU! (3) SPEAK TO THE PATIENT AS YOU ARE PERFORMING THE EXAM. ITS AMAZING HOW FAR YOU'LL GET WHEN YOU BRIEFLY TELL THE PATIENT WHAT YOU WILL BE DOING AS YOU ARE DOING IT IE "I'M GOING TO INSERT THE SPECULUM NOW. IT MAY FEEL A BIT COLD AND WET" ALSO, IF YOU CAN, WARM THE SPECULUM UNDER TAP WATER...BUT CHECK TO MAKE SURE IT ISN'T REQUIRED TO BE COMPLETELY STERILE FIRST. Often the consultant will want to confirm your findings and it is awkward and inconsiderate to ask a patient if you can repeat a pelvic examination. By having both of you in the room, the patient need only go through this process once. You will find that the majority of patients, particularly women who have already had children, will consent to having the student be part of the examination process. On the gyne surgery part of the rotation, it is often standard practice for a bimanual pelvic exam to be performed in the O.R. prior to surgery (i.e. once the patient has been put to sleep). While this is often done by the gyne surgeon in order to better delineate the anatomy he/she will be dealing w/ in the surgery, it is often also a time when all the residents and students who will be attending the O.R. also perform the bimanual exam. If you feel at all uncomfortable examining a patient who is not awake and/or whom you have not met before and therefore who has not consented to you performing an exam, don't feel shy about stepping back and not participating. However, if you feel this way, a better tactic is to get to the o.r with time to spare so that you can

meet the patient before she has been wheeled into the room and put to sleep. At this time you can ask her permission to participate in the pre-surgery examination. Rounds Note that some residents will want you to get to the ward some time before they do in the morning and "pre-round" on the patients. You will then be joined by the resident who will want you to present the patients status to them. Key things to ask your post-op gyne patient about: her pain, how her sleep was, is she having any flatus, is she drinking/eating. Look at the vitals record, check the labs on the computer (especially post-op hemoglobin). Check the wound dressing and pad for bleeding. Listen to the chest, esp pod #1. The same applies for post-c-section ob patients. Two important sensitivity points to mention: 1) You will sometimes notice on the postpartum ward that a door to a patient room has a small crocheted colourful butterfly on the door. This symbol denotes a perinatal loss. Thus, be sensitive when entering a room like this :i.e. don't ask how the baby is doing. 2) Be sensitive also if a new mom has her baby in the neonatal intensive care unit. A good idea is to also swing by the nicu and ask the staff how baby x is doing. If you do not feel comfortable answering mom's questions re the status of her newborn, defer to the neonatalogists.

Teaching Rounds Most lectures are interactive and relevant to what you need to know on the wards and for the exam. The sessions are case-based and are best prepared for using old notes or a succinct review text. On Call Obstetrics call consists of admitting patients for labour and delivery and following them while they are progressing through labour. This can be very busy, so dont count on a great sleep. If you want to get the most out of your night on call, which may include more opportunity in doing deliveries, make sure you follow the patients closely. Ask the nurse to tell you when she will be performing the next cervical check so that you can do one at the same time. The more times you peek your head into the birthing room to see how your patient's labour is progressing, the more comfortable she and the other staff will be about letting you take more responisiblity during the delivery. Generally, it is not considered great form to rush in when a patient is 10cm dilated and ready to push and expect to be allowed to do the delivery if you have not even so much as introduced yourself to the patient prior to this point. Another good tip: get involved in deliveries done by family doctors. These patients are not seen by the obstetrical service unless a complication develops, and thus the ob residents are not usually involved in the case. This means there will be just you and the GP and this often means you will get more hands on experience. Introduce yourself to the GP, ask if they would mind you assisting and offer to do the admission history. Gyne call requires you see patients in emerg. and decide their proper treatment. You are also asked to take care of floor stuff such as post-op complications and general problems. If the delivery suite is busy, you may be asked to help out.

Sample Admission Note: OB/GYN Labour & Delivery


ID: 29 yo G3P1A1, EDC March 7, 2000, GA 38 wks, A neg, GBS + RFA: SROM (Spontaneous Rupture of Membranes) HPI: pt. noticed lower abdominal pain radiating to back at 09:30 today; SROM at 13:00 gush of clear fluid with continued leaking; no bleeding, baby active; contractions now q 5-6 minutes, 1 minute in duration Course During Pregancy: uneventful pregnancy; PIH (pregnancy induced HTN) GDM(Gestational Diabestes Mellitus) bleeding infections MSS (maternal serum screening)ve GBS (Group B strep) +ve (February 18/00) last U/S @ 18 weeks OK recd Rhogam Dec 14/99 OBHx: 1996: SA (spontaneous abortion) @ 12 wks. GA; D&C 1997: pregnancy complicated by PIH, live infant, labour:16 hrs, SVD (standard vaginal delivery) 1999: current pregnancy GynHx: onset of menses @ age 14, regular 28-day cycles, bleeding x 4-5 days; Hx of STDs; frequent yeast infections esp. with antibiotic use contraception: BCP (1991 1995); IUD (1997-1999) PMHx: healthy; heart disease asthma coagulopathy Meds: prenatal vitamins Allergies: NKDA FHx: father: DM Type II; mother: HTN SHx: married, works as administration assistant husband: 32 yo, chemical engineer smoking EtOH street drugs diaphoretic, NAD VS: afebrile, HR 88 reg, RR 20/min, BP 120/75 CVS: S1S2, S3 S4, Gr II/VI SEM best heard @ LSB; no peripheral edema; PPP RESP: good A/E bilaterally, crackles wheezes NEURO: reflexes symmetrical, 2+ bilaterally ABDO: vertex engaged V/E: cervix mid-anterior, soft, 80% effaced, 6 cm dilated, station 2, LOA FHR: baseline 130-135/min, moderate variability, + accels, no decels
6

O/E:

Imp: 29 yo G3P1A1 presents with SROM in active labour Plan: 1. Admit to L&D 2. Ampicillin 2g IV now, then 1g IV q6h for GBS prophylaxis

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