A Day in the Life
of an MS3
Capstone I - May 27, 2008
First, some basics…
The Call Cycle
Round we go
The first day . . .
You are a superstar
MS3 on your first day
of your Medicine
Your team is “on-call”
Your senior turns to
you and your intern
There’s a new admit
You’re off to the ER!
Your New Patient
ID: 63 yo woman 2 wks s/p thoracic
laminectomy, presenting with 1 hour of
pleuritic chest pain.
Hot Tip # 1
Clipboard like device-
MI, PE, PNA, GERD,
Spasm . . .
Taking a History
HPI: Pt was in her USOH, complicated by mild COPD
until 1 hour prior to presentation when while watching
tv she developed acute dyspnea and sharp L sided
chest pain radiating to her L arm and jaw, worse with
inspiration and exertion. Pain is 8/10. Pt denies
nausea, diaphoresis, palpitations, leg pain or edema.
Still taking a history
ROS: Per HPI, pt denies nausea, diaphoresis, palpitations, leg pain or
edema. Don’t forget all systems!
PMH/PSH: COPD, OA, Depression, Allergic rhinitis, GERD, Recent
Medications: Ipratropium, Citalopram, Lansoprazole,
Salmeterol/Fluticasone Inhaled , Fluticasone nasal spray
FH: Father died from MI, age 72. Mother with CVA in her early 70’s.
Strong family history of hypertension.
Social: Patient has been a cigarette smoker since age 19. Reports that
she has quit, but also admits that she had a cigarette this morning. She
denies any alcohol or other drug use.
O: One hour PTA
Q: Sharp pain
R: Radiates to left arm and jaw
A: Aggravated by inspiration and exertion
A: Not alleviated by anything
A: Patient attributes the pain to “her
VITALS: P:110, R:20, BP:119/85, O2 sat 96% on 2L.
GENERAL: Patient is sitting up, appearing dyspneic and in pain.
HEENT: The head is atraumatic. PERRLA. EOMI. There is no nasal discharge. Oropharynx is clear without
visible lesions. Moist mucous membranes.
CHEST: CTAB without any crackles, wheezes or rhonchi. Pain not reproducible with palpation.
CV: Tachycardia, regular rhythm, Normal S1 and S2. No murmurs, rubs or gallops.
ABDOMEN: Soft, NT/ND without palpable HSM.
BACK: There is a healing midline scar in the mid to lower thoracic region without overlying erythema,
swelling or exudate.
EXT: Warm and well perfused with brisk capillary refill. No clubbing, cyanosis or edema. There is no
tenderness to palpation of the calves bilaterally.
NEURO: Patient is alert and oriented. Cranial nerves are intact and strength is symmetric upper and lower
Hot Tip #2
Admitting the patient
Look up records, labs, studies
References to help with diagnosis and
Reviewing the medical
record . . .
Look up your patient in the electronic medical
Orca-Harborview, UW, Children’s
If applicable, call primary care provider to notify
that patient is being admitted and to gather
Na | Cl | BUN / Glucose WBC\Hg /PLT
K | Bicarb | Cr \ /HCT\
141 | 102 | 13 / 90 5.4\11.3/544
4.1 | 25 | 0.6 \ /34\
Ca++ 9.7, Mg 2.1
Cardiac Enzymes Negative x1
ECG: Tachycardia, rate 110, no specific ST or T-wave
Revisiting our Differential
Confirm suspicion of PE with CT-PA- Computed
Tomography with Pulmonary Angiogram
But we can’t get the CT-PA right away so let’s
admit her to the hospital in the meantime . . .
Admit to Medicine
Diagnosis: Pulmonary Embolism
Vitals: per routine
Activity: OOB TID with assistance
Nursing: Call HO if HR>110, <50, T>38.5, BP>180/110, <100/40, RR>20, <6
IV fluids: None
Ipratropium MDI 2-3 puffs inhaled TID
Salmeterol/Fluticasone MDI 1 dose inhaled BID
Citalopram 20mg PO q day
Lansoprazole 20mg PO q day
Labs: Troponin I, CK, CKMB x2 @ 2400 and 0600
Special: TEDs and SCDs, Consult PT
Code Status: Full Code (be sure to discuss with patient)
Hot tip #3
Now that your patient is admitted, how do
you keep track of her information?
Notecards, patient tracking templates
Copies of H&P write-up and daily notes
Make a “To-Do” list with boxes to be
checked off, consult this list frequently!
□ Check CT results
□ Follow-up cardiac enzymes
□ Consult PT
□ Call SNF for discharge planning
□ Call PCP
And 2 hours later . . .
right segmental and
Diagnosis of PE is confirmed by CT-PA
Try suggesting a treatment plan to your
resident, consult references for help
Start patient on heparin drip per protocol,
transition to warfarin once therapeutic
Hot tip #4
Be an active learner and
Read as much as possible about your
patient’s diagnosis and treatment options
Come up with questions about your
patient’s disease and bring in primary
literature addressing those questions to
share with the team
Before going to sleep
Check in on patient
Follow up additional labs/studies
Write up the H&P
Practice presentation! Don’t be afraid to
practice with your residents . . .
The Next Morning
Set your alarm so that
you wake up with time to:
Freshen up (bring your
Start progress notes for
patients (if possible)
Eat and hydrate (critical)
Help your team with any
Hot tip # 5 - Prerounding
Goal is to check in on patient and gather the
Recent vitals and trend for relevant vitals
Focused physical exam
Current labs and study results from overnight
Come up with a one line assessment and
Leave plenty of time in your morning schedule
for these tasks!
Tips to be a stellar student
Attitude is everything
Be on time
Embrace new experiences
Be okay with not knowing and not being
Don’t make excuses; Don’t complain
Laugh at yourself
Take care of yourself
That’s all folks . . .
Enjoy patient care!
Don’t be afraid to ask for help!