Mrs

New Jersey Medical School Class of 2005 Books To Bedside Information Packet July 1-2, 2003 Schedule of Events Dr. Ruiz and Class of 2004 SOAP Notes and Presentations 8:30 – 9:00 am Breakfast and odds & ends Members of the Class of 9:00 – 9:05 am 2004 Welcome to Third Year 4:30 – 6:00 pm SFHCC Russell T. Joffe, MD, Night Coordinator Dean NJMS Training 9:05 - 9:15am Administrative For SFHCC participants Orientation only Robin Schroeder, MD Assoc. Dean for Student Affairs 9:15 – 9:30am Books to Bedside: An Overview Lisa Lovas ‘04 9:30 – 10:30am Legal Aspects of Medical Records and Charting Linda Boyd, MD Assoc. Professor, Family Med 10:30 – 11:00am Student Harassment/Abuse Beverly Delaney, MD Members of Class of 2004 11:00 – 12:00pm Careers in Medicine Dr. Schroeder 12:00 – 1:30pm Lunch and Viewing of Wit 1:30 – 4:30pm Workshops Chest X Ray Dr. Schroeder, Radiologist EKG Dr. Atkins, Assoc. Prof. Medicine Suturing and Knot Tying Schedule of Events Tuesday, July 1, 2003 Wednesday, July 2, 2003 8:30 – 9:00 am Non-traditional student breakfast 9:00 – 9:15 am A Student Perspective Valerie Fitzhugh ‘04 9:15 – 10:00 am Needlestick Precautions Dr. Schroeder Jennifer Jacobs ‘04 10:00 – 10:45am Professionalism Gaines M. Mimms, MD Associate Professor Pediatrics Pediatric Clerkship Director Morristown Memorial Hospital 10:45 – 11:45am Tours of University Hospital Class of 2004 11:45 – 1:15 pm Lunch with Fourth Years Class of 2004 1:15 – 2:45pm Student Clinician Ceremony Presented by the Gold Foundation 2:45 pm Reception in the Grand Foyer The Arnold P. Gold Foundation has chosen New Jersey Medical School as one of several schools in the country to receive support for this student organized clinical transition program. This program is designed to give incoming third year medical students practical information for a smooth transition into their clinical careers, while reminding them of the humanistic aspects of this endeavor. The students and faculty are grateful to the Gold Foundation for its continued support of this event and their dedication to the importance of humanism in medicine. Schedule of Events Plan for Workshop Sessions Group assignments are listed on the next page! Each session is 40 minutes long with a 5 minute move time! Session 1 1:45 – 2:25pm Session 2 2:30 – 3:10pm Session 3 3:15 – 3:55pm Session 4 4:00 – 4:40pm Find your group and follow the schedule below. SOAP Notes and Presentations are split into your FIRST clerkship so be sure to go to the right room listed below! Group A 1. SOAP Notes and Presentations Medicine: B540a Presentations Peds: B540b Ob Gyn: B540c Psych: B540d 2. Chest X Ray B540e/f 3. Suturing and Knot Tying 4. EKG B609b/c 4. Group C 1. Suturing and Knot Tying B540e/f 2. EKG B609b/c 2. 3. SOAP Notes and Presentations Medicine: B540a Presentations Peds: B540b Surgery: B540c Family Medicine: B540d 4. Chest X Ray B540 e/f B540d Group B 1. EKG B609b/c 2. SOAP Notes and Medicine: B540a Peds: B540b Ob Gyn: B540c Psych: B540 3. Chest X Ray B540e/f Suturing and Knot Tying Group D 1. Chest X Ray Suturing and Knot Tying 3. EKG B609b/c 4. SOAP Notes and Medicine: B540a Peds: B540b Surgery: B540c Family Medicine: Schedule of Events Groups for Workshop Sessions Group A Ahmed Rashed Anand Swaminathan Andrea Adams Ankoor Shah David Ospital Gem Ashby Gregory Sugalski Henry Chen Jaime Morales Jason Maggi Jeffrey Peretz Jennifer Hendi Jessica Reid Joana Emmolo Kapil Rajwani Katherine Zamecki Kathleen Swayne Kevin Munjal Leni Gonzalez Mansi Kanuga Maya Capoor Michael Arcaro Michael Docktor Michael Shirazi Neetu Chahil Nicole Fox Nicole Tully Nitin Patel Oluwaseum Akeju Ravi Shah Rerjane Guerrier Reza Karimi Richie Martinez Ritu Sharma Sarah Desoky Sarah White Steven Milo Susan Alsmarai Tashelle Samuels Vimal Patel Vincent Tamuzza William Min Group B Aarati Malliah Ahsanuddin Ahmad Alireza Sedarat Amy Palmieri Amy Skversky Anthony Sifonios Benita Rice Candyce DeLoatch Christopher Hoyte Cristobal Beiro Elliot DeHaan Emily Freilich Geoffrey Nosker Hubert Bitner Iona O'Neil Dunne James Chen Jason Hauptman Jason Schaechter Jeani John Jeffery VanGelderen Jennifer Valentine John Paul Tutela Joshua Reimer Justin Vadaparampil Kathleen Rossy Kathryn Whalen Mark Weinstein Marni Kriegel Mayank Mathur Mei Yung Chan Michael Pollock Natasha Dwamena Radhika Siriki Robyn Banio Sandhya Murthy Sanghyun Lee Shipra Bansal Sumit Shah Thomas Murphy Timothy Grau Tina Cocuzza Tobechukwu Onugha Group C Aarti Patel Adil Ali Ahdev Kuppusamy Alycia Lunga Aphrodite Zimmerman Arun Agarwal Catherine Theo Chaim Gofman Christina Rivera Clare Hack Danielle Brandman Deborah Caruso Deepta Vasudev Derek Culnan Dipti Parikh Elizabeth Marshall Erik Hoy Faisal Mahmood Francelle Fanfan Gauri Tilak Gloria Seo Humaira Chaudhry Jennifer Scarpone Jessica Lucero Jose Zevallos Joseph Ciccone Kenneth Bono Kulpreet Sahota Matthew Hosler Michael Kasper Michael Preziosi Natasha Chinn Raj Yalamanchili Raul Paterl Ray Ryan Santos Robert Kwon Ronniel Mercado Roshni Alli Sridaran Narayanan Steven Ghanny Sumathy Rajamanickam Vincent Syers Group D Adam Fechner Adam Suslak Alex Merkulov Anthony Rosania Arielle Fenig Benjamin Freeman Benjamin No Brenden Grubbs Catherine Lynch Daniel Simon Danielle Butler David Hudesman Dorothy Sippo Ezra Berkowitz Faisal Siddiqi Geroge Sandau Ginger Wey Heather Jeney Helen Bellete Jaime Green Jennifer Crow John Castillo Kenneth Nisch Kim Randolph Lindsey Sternberg Marcin Szember Mark Arcaro Matthew Wolenski Michael Anana Michael Link Neil Lee Parag Desai Raj Munshi Selvi Rengasami Shabbir Naqvi Shefali Parikh Susan Kim Terrence Curran Timothy Johnson Walson Metzger Schedule of Events A Friendly Guide to Books that Will Help You as You Enter Your Third Year  Internal Medicine 1. NMS Medicine This is an excellent resource for medicine. It‟s more complete than blueprints, so if you‟re a serious reader, this is definitely the book for you. It‟s a review text, but it takes a while to read, so if you choose to use this, start early. 2. Blueprints in Medicine This is also an excellent resource, because let‟s face it, when you‟re doing your month at UH, you will be tired, and therefore will never want to read when you go home at night. Therefore, you‟re going to need a resource that will give you a good amount of information and not leave you hanging at shelf time. This is that book. Most people get through it 2-3 times over the course of the rotation, which is a testament to its readability. 3. PreTest Medicine An excellent resource for questions. Because the chapters are split by system or specialty, it allows you to figure out where you‟re weak before the shelf, and than way you can go back and review those areas. The book contains 500 questions with explanations. 4. Appleton and Lange Question Book, Medicine Again, an excellent resource. The book contains over 1000 questions with explanations that re very good for shelf prep. It definitely prepares you for some of the trickier questions on the medicine shelf. 5. Rapid Interpretation of EKGs (Dubin) This book should be read early in the medicine rotation, especially if you‟re not at UH first, because people are going to ask you to read EKGs throughout the entire rotation. This book requires you to fill in the blanks, but that forces you to learn what is being taught. 6. Cecil’s Essentials of Medicine Most of you bought this text during ICS, so you already know a bit about it. This book is good for preparing any presentations you may have to do during the rotation. It is also excellent for reading up on your patients, as you will be expected to know everything about every condition your patients have. You should not try to read this book cover to cover because you will not have time! 7. Practical Guide to the Care of the Medical Patient This is the Ferri book that many people will be carrying in their pockets. It‟s very useful, especially in the first half of the year when everything seems really new. The only real drawback to the book is that it‟s a little heavy in comparison to most of the things you will carry in your white coat. Books To Get 8. High Yield Internal Medicine This is a very quick read, and is very useful to cram in that last minute knowledge a couple of days before the medicine shelf. Some people use it all clerkship long which isn‟t a bad way to go either. 9. Mastering the OSCE/CSAE If you want to survive the medicine OSCE, you must have this book. It‟s useless for the peds, Ob, family med, and psych OSCEs, but for medicine it is an absolute gem. Since Dr. Reteguiz wrote the book, and she writes the medicine OSCE, it‟s in your best interest to use the book. It‟s very good practice for what she looks for on the exam. Psychiatry 1. PreTest Psychiatry Another very good question source. This book has particularly good questions in its psychopharmacology section. Like all other pretest books, it has 500 questions with explanations at the end of each chapter. 2. Blueprints in Psychiatry This is a decent choice, but recommended only after reading more comprehensive sources first (High Yield Psych is actually more comprehensive than this). This book is only 81 pages, so if you like „em short, this is definitely the one for you. 3. Appleton and Lange Question Book, Psychiatry This is the shortest of the A&L books, with only approximately 800 questions. However, there are explanations at the end of every chapter, and it is good prep for the psych shelf. 4. Psychiatry for Medical Students (Waldinger) This is the yellow textbook that you didn‟t read for the first two years of psychiatry. The text is pretty useful in the third year, especially if you want comprehensive coverage of many of the important areas of psych, such as mood disorders and psychopharmacology. If you haven‟t bought the text by now, borrow a copy from a friend. 5. High Yield Psychiatry An excellent resource for the psych shelf, written by Drs. Fadem and Simring. Most students get by just reading this book and doing questions, so if there was one must have read for psych, this is probably it. Family Medicine 1. Essentials of Family Medicine This is the required text for the rotation. There is a departmental exam that comes from this book. The grading for the teaching OSCEs is also based on this book. Bottom line: read it, and do the included CD, whether you want to or not. You‟ll do much better in family medicine for it. Books To Get 2. Appleton and Lange Question Book, Family Medicine In addition to the family medicine departmental exam, there is also a shelf exam that you‟ll have to take. This is a really good resource for the exam. The only problem is actually finding time to do the questions, as you‟ll be busy with a paper, two OSCEs, and another exam to study for. General Surgery 1. Surgery Recall This is an excellent resource for prepping the night before a case. For some reason, a lot of what the surgeons like to pimp med students on comes out of this book. The 3rd edition of the book hit bookstores in 2003 (if you‟re dying for a brand spanking new book). This book can be very repetitive, and is not ideal reading for the surgery shelf (which is pretty hard). 2. Appleton and Lange Question Book, Surgery With over 1000 questions, this book is an excellent resource for the surgery shelf. There are explanations for every question, so your time spent answering the questions does not go in vain and you learn from your mistakes. 3. Essentials of General Surgery This is a textbook, but if you want to understand the aspects of the care of a surgical patient as well as what goes on in the OR, this is a good read. Each chapter has questions at the end which are comparable to shelf type questions. If you‟re going to read this one cover to cover, you‟ll need to start really early in the rotation (especially since surgery has been shortened). Pediatrics 1. Blueprints in Pediatrics This is a review book with pretty decent coverage of all the important topics in peds. With all the write-ups and the ethics paper to do, you may not have time to read much more than this. This is a good read for shelf prep (and in peds you will definitely need good shelf prep). 2. NMS Pediatrics A much more detailed book with a bullet point type format, different from Blueprints. You can‟t read the whole thing, but when used with the “high yield” list given to you by the pediatric department, it is a great resource for shelf prep. 3. Appleton and Lange Question Book, Pediatrics This book is a must have for the peds shelf. It has over 1000 questions with explanations, again meaning that you‟ll learn a lot from doing the work. Some of the questions are very hard, but since the peds shelf is no walk in the park, you‟ll be very ready by the time you‟re done with this book. 4. PreTest Pediatrics If you didn‟t get enough questions from Appleton and Lange, this is another good book to have on hand. There are 500 questions, and explanations are provided for them. Books To Get 5. Harriet Lane Handbook for Pediatrics This is a very nice resource to have on the floors, as it has answers to many of the questions you‟ll run into on the wards. Most people who are going into peds are going to buy their own and cherish it, so if you‟re friends with one of those people, try to borrow theirs (given they don‟t have peds at the same time as you). If you‟re not going into peds, it‟s not worth the buy, because you‟ll never use it again. Obstetrics and Gynecology 1. Essentials of Obstetrics and Gynecology (Hacker and Moore) This is a textbook, but an excellent one for ob/gyn. It lays a very basic foundation for everything you will see with your patients. If you like reading textbooks, or even if you don‟t, this one is highly recommended, and you can read it cover to cover within a short period of time. 2. High Yield Obstetrics and Gynecology This is an excellent book. Every patient has patient snapshots which are very similar to scenarios you could see on the shelf exam. If you have a good understanding of the material in this book, you‟re on your way to a good shelf grade! 3. Appleton and Lange Question Book, Obstetrics and Gynecology Same spiel- excellent for shelf prep. 1000 questions with explanations at the end of each chapter. 4. Blueprints in Obstetrics and Gynecology Another very good book in the blueprints series. A little more in depth than High Yield. A good read in that you may be too tired to read other longer books. Be careful with this one, as we found some mistakes in the last edition. Comprehensive 1. NMS Step 2 Review Book This is a very good comprehensive question book which covers Medicine, Psych, Peds, Ob, and Surgery. There is a section in the back of the book that tells you which questions correspond to which subject area in each of the 5 tests. This is another must have. 2. First Aid for the Wards This is a good resource to read a few days before you start a new rotation. It will give you a feel as to what to look out for as well as what not to do. It also tells you what equipment will be useful to carry in your white coat. Very informative. 3. First Aid for the USMLE Step 2 The format is a little different than that of First Aid for the USMLE Step 1, but it‟s good to start using and taking notes during each clerkship in your third year so that you have an excellent resource when it comes down to studying for Step 2 at some point in your fourth year. Books To Get 4. Boards and Wards Another very good resource. It contains information for all 6 clerkships that you will take this year as well as some fourth year topics, such as neurology and ophthalmology. It‟s god for use for the USMLE Steps 2 and 3, and contains good high yield topics for study as well as for floor prep. Definitely worth the investment. 5. Prescription for the Boards This book is in the same vein as First Aid for the USMLE Step 2, but takes more of a systems approach, and also covers some third and fourth year rotations. It‟s also good to start using and taking notes in during your third year so it‟s ready for your Step 2 study as a fourth year. We hope this guide will be useful for you! Review it before each clerkship and try to pick out which books are best for you (especially in something like medicine which has a lot of good choices). Best of luck to you in your third year!!! Books To Get What to Put in Your White Coat Must haves… Name Tag disappear) Stethoscope Pharmacopia/epocrates Stanford guide/e-pocrates Maxwell’s Reflex hammer Pen light Several Pens (they tend to Good to haves… Otoscope (or at least the specula)…especially for Peds Calculator…especially to calculate Peds medication dosages Alcohol swabs…especially to clean your stethoscope in Peds Trauma Shears…especially for Surgery Tape and gauze…especially for Surgery and OB/Gyn Small notebook PDA Pocket Books like Ferri’s Guide for Medicine, Harriet Lane for Peds (see books guide for more information) Stickers for Pediatrics Supplies Heme occult developer and cards…these are often impossible to find! Turnoquets…these are always hard to find! Band aids Tongue depressor White Coat Vacutaner Snacks…graham crackers and granola bars work great! Never carry needles or syringes in your coat or store them in your locker! White Coat SOAP NOTES AND PRESENTATIONS General Tips 1. Always date and time your notes! 2. Always sign your notes (Jane Smith, MSIII)! 3. Make sure your resident and/or attending sees your note…you want feedback and you want them to see your stuff! Remember, they are grading you in the end and why bother writing notes if you are not going to learn from them! 4. Be aggressive about presenting. Often the interns and residents are so busy they forget the patient they are about to present is yours. Simply remind them; a good suggestion is to remind them while you are walking over to the next room; of course, be tactful. 5. Present with confidence…stand up straight, look people in the eyes, don‟t read right off a piece of paper. All these things help make you look like you know exactly what you are doing…even if you don‟t! 6. The key is to really know your patient. As a student, you are probably only going to follow 1-3 patients, so you‟ll have time to get to know them! Just by knowing your patients, you will really shine! And by learning as much as you can about your patients, you learn as much as you can about the subject as well. It is the best way to study for exams. 7. Never lie! Never tell a resident or attending that you did something you did not do. Never make up lab values or vital signs. Simply say, “I‟m sorry…I did not do that” or “I don‟t know”. People will respect you a lot more than if you are caught making something up! 8. Have fun! This is what you have been waiting for. You are finally going to be doing some real medicine. Relax and enjoy it. SOAP Notes and Presentations Internal Medicine Sample patient… Mrs. I. B. Wheezy is an obese 63 year old AA female, past medical history significant for hypertension, CAD (cardiac catheterization and stent placement 4 months ago), type 2 DM (diagnosed 7 years ago), who presented to the UH ER one day ago with acute lobar pneumonia after coughing up copious amounts of yellow-green sputum for 2 days PTA and experiencing fevers, chills, shortness of breath, and pleuritic chest pain. She has never smoked, drinks socially (1-2 drinks per month), denies illicit drug use, and lives at home with her husband and two grandkids (7 and 9). She is currently sexually monogamous HIV test performed one year ago was negative. She has not traveled recently and denies sick contacts. She used to work as an executive assistant, but is now retired. She denies recent exposure to TB or previous TB infection. At the time of admission she was febrile, tachycardic, tachypneic, O2 sat 91% on RA, and random blood glucose level 253. She was admitted to H green and placed on levofloxacin 500mg IV QD, fosinopril (Monopril)10 mg PO QD, metoprolol (Lopressor) 150mg PO QD, metformin (Glucophage) 500mg PO BID, enoxaparin (Lovenox) 40mg SQ QD, lansoprazole (Prevacid) 15mg QD, and sliding scale insulin coverage. You find the patient in bed sleeping and wake her easily. Over the past 24 hours the patient has felt better, but continued to cough up about ½ cup of yellow-green mucous, although less so than the day PTA. She did not cough up blood, but her coughing did wake her. She is not having shortness of breath. She is not nauseous, and has not vomited. She is not having diarrhea and has moved her bowels once since admission. She is not having any dysuria, frequency, or urgency. She spiked to 101.8 at 3:00 am and given tylenol, currently 99.4. Finger sticks 168 (2u), 184 (2u), 252 (6u), 168 (2u), HR 88-102, RR 18-20, BP 138146/74-86, O2 sat 97% on 2 L O2. Her exam is significant for decreased air entry throughout, crackles over LLL(up to 10 cm from base), scattered expiratory wheezes. Labs: Na: 138, K: 3.8, Cl: 105, HCO3: 24, BUN: 16, Creat: 1.1 Glu: 170 Ca: 8.8, Mg: 1.8, PO4: 2.2, WBC: 18.8, Hgb: 13.8, Hct: 45.5, Plt: 368, N: 85, L: 11, M: 2, E: .4 Urine Cx negative, Blood cultures x 2 NGTD, sputum culture: pending Internal Medicine SOAP Note The SOAP Note… July 1, 2003 7:15 am MS III PN HD # 2 Problem List 1)LLL Pneumonia 2) HTN 3) CAD 4) Type 2 DM 5) DVT prophylaxis 6) GI prophylaxis 7) obesity Meds 1)levofloxacin 500 IV QD 2)fosinopril 10 PO QD 3)metoprolol 150 PO QD 4)metformin 500 PO BID 5)enoxaparin 40 SQ QD 6) lansoprazole 15 PO QD 7) sliding scale with humolog insulin 8) acetaminophen PO Q 6 hr PRN pain S: Pt states she feels better but could not sleep much last night secondary to coughing. States she is still coughing up yellow-green sputum, about ½ cup since 8:00 pm. Denies hemoptysis, SOB and pleuritic chest pain. Denies F/C/N/V/D/CP/ orthopnea/PND. Tolerating PO, ambulating well to BR. O: Gen: 67 y.o. obese AAF in NAD, lying in bed asleep, easily arousible Vit: Tmax: 101.8 (currently 99.4); BP: 138-146/74-86; P: 88-102; R: 18-20; O2 sat 97% on 2L O2; FS: 168 (2u), 184 (2u), 252 (6u), 168 (2u) Chest: decreased air entry b/l, (+)scattered expiratory wheezes, (+) crackles @ L base up 10 cm, (-) rhonchi CV: RRR, (+) S1/S2, (-) M/R/G, (-) JVD Abd: soft, ND/NT, (+) BS x 4, (-) masses/organomegaly Ext: (-) C/C/E, peripheral pulses 2+ b/l Labs: 138 105 16 ----------------------3.8 24 1.1 8.8 1.8 2.2 170 18.8 13.8 45.5 N:85 L:11 M:2 E: .4 Urine Cx: (-) Sputum Cx: pending Blood Cx x 2: NGTD 368 A/P: 67 yo obese AAF with PHx of asthma, HTN, CAD, Type 2 DM, with acute community-acquired bacterial pneumonia. 1)Pneumonia: Pt feeling better, crackles remain on exam over LLL. Day # 1 of levoquin. Spiked fever last pm. and was given Tylenol by nurse, will consider med change if patient continues to spike after 2-3 days on medication. Currently afebrile on Tylenol. WBC’s 18.8 this am, decreased from admission. Sputum Cx pending -continue levoquin IV 500 2) HTN: Pt’s BP well controlled on Monopril and Lopressor. -continue current meds 3)CAD: Pt denies CP/SOB/orthopnea/PND since admission. 4)Type 2 DM: Pt’s BS have been elevated since admission, needed 12 units of insulin coverage over the last 24 hours. Will consider increasing dose of metoprolol, or adding secretagogue if blood sugar remains elevated today 5)DVT prophylaxis: continue Lovenox 40 sq 6)GI prophylaxis: continue Prevacid 15 Internal Medicine SOAP Note Pediatrics The story… The date is Monday, 8/13/03. Jessica is a 10y.o. WF (white female) with a PMH (past medical history) significant for mild persistent asthma (no past hospital admissions or intubations) who was admitted to the hospital yesterday. The admission note states she started having trouble breathing after playing basketball in the heat of the day. Her mom gave her a neb (nebulizer) treatment of albuterol and atrovent (ipritroprium bromide), and after she did not improve, she brought the child into the ER. In the ER, Jessica was noted to be in a great deal of distress, using her accessory muscles to breath, with poor air movement into and out of the lungs. She had an audible wheeze and was unable to complete a sentence without catching her breath. O2 sats (the little thing on her finger) were around 92-93%. Chest x-ray was ordered, and showed no infiltrate or abnormality. Her only abnormalities on physical exam were her pulmonary findings (HEENT WNL), along with dry mucus membranes and cap refill > 2 sec. She was afebrile with slight tachycardia. She was given two additional treatments of albuterol and atrovent, with little improvement in the ER. She was also given a 50mg dose of prednisone. Since she did not improve (PEFR (peak expiratory flow rate) improved < 10%), she was given a diagnosis of status asthmaticus and admitted to the floor. Jessica was also noted to be slightly tachycardic with slightly dry mucus membranes and cap refill approx. 2.5 sec (5% dehydrated). That night, Jessica was noted by the night float resident to be in only mild distress with a slightly audible wheeze. She complained of chest pain diffusely, but generally her SOB (shortness of breath) had improved from the afternoon. She was started on albuterol and atrovent neb treatments Q4 hours and 50mg doses of prednisone Q6 hours. She also began receiving D5W1/4NS @ 50cc hr. Labs were ordered for this morning and included a CBC, SMA7, and ABG. Pt consistently denied any NVD, fever, chills, rash, or night sweats. She denied cough, rhinnorhea, ear pain, or throat pain. She denied any bowel or urinary issues. It is now Monday morning and you are asked to see this patient and be prepared to present to the attending. After reviewing the chart, you go into the patient’s room. She is lying in bed. Questions you want to ask… How are you feeling this morning? How’s your breathing? Do you feel like you could walk around without SOB? Any chest pain this morning? Any chills, runny nose, cough? Nausea, vomiting, diarrhea? Physical Exam You Want to Do… Observe patient (do they look like they are in distress?) Make sure patient is oriented Check patient’s mucus membranes and cap refill Listen to heart Listen to lungs Abdomen exam Look for clubbing, cyanosis, or edema in extremeties Pediatric SOAP Note SOAP Note… 8/13/03 7:30am MSIII Progress Note Problem List 1. Status Asthmaticus 2. 5% Dehydration Medications Atrovent Albuterol Prednisone D5W1/4NS @ 55cc/hr S: Pt seen this morning lying comfortably in bed. Pt has oxygen mask over nose and mouth. Pt states she is feeling better this morning. Breathing has improved; pt states she can walk around without SOB. Pt denies CP, chills, rhinnorhea, cough, rash, urinary issues, or NVD. Pt received 6 nebulizer treatments yesterday and one so far today. O: vs: T = 98.7 P = 82 R = 18 BP = 95/60 O2sat=97% General : AAO x 3 NAD HEENT: mucus membranes moist Heart : RRR S1S2+ no m/r/g Lungs: + expiratory wheeze noted, good airflow, no retractions, no abdominal breathing Abdomen: soft, nt, nd BS+ Extremeties: no c/c/e capillary refill < 2 sec Labs: \ 13.3 / 140 | 101 | 6 / 15.3 ------------ 430 ------------------- 130 / 37.5 \ 3.0 | 23 | .3 \ ABG: 7.35/60.2/37/22 A/P: 10yo WF with PMH of mild persistent asthma admitted with status asthmaticus and 5% dehydration. 1. Status Asthmaticus - pt is currently improving; last ABG WNL - change Q4 hour nebulizer treatments of atrovent/albuterol to Q6 albuterol alone - continue taper down prednisone - d/c oxygen; continue to monitor O2 sats; consider restart O2 if below 95% - continue peak flow measurements - consider PFT’s before discharge - make outpatient appointment for follow up care 2. 5% Dehydration - mucus membranes are moist, pt is not tachycardic, and cap refill < 2sec - d/c IVF - continue to monitor patient for further signs of dehydration 3. Elevated WBC count/elevated platelets/elevated glucose/hypokalemia - most likely secondary to stress and steroids/B agonist use - repeat CBC and SMA7 in am Pediatric SOAP Note Presenting for peds… Presenting for peds in similar to the way you would present in medicine. You begin with: “This patient is a 10 year-old white female who was admitted on Sunday for status asthmaticus and mild dehydration.” This gives your attending or resident a little intro into a patient they may not remember all too well. You then give your subjective findings (almost exactly as you have written in your SOAP note). You continue: “Vital signs for this patient are…” “On physical exam, patient was noted to have…” “Labs today…” Once you have finished your subjective and objective findings, you continue on to your assessment. “This is a 10yo WF with status asthmaticus and mild dehydration who is clinically improving on both issues. She also had an increased WBC, platelet, and glucose level today, which appears to simply be from stress and the use of steroids.” Then, your plan: “The plan for this patient is to…” Pediatric SOAP Note Psychiatry The story… Michelle Robinson is a 38-year-old African American female who was admitted to the hospital four days ago for a drug overdose. A note was found by her side and the overdose was ruled an attempted suicide. After two days of medical treatment, she was transferred to the inpatient psych unit. Her H&P was completed by the medical team. Today you will pick up this patient. It is your task to write a SOAP note on her and present the patient to your attending. 1. Subjective  This is the part where the patient gives you subjective data as to how they’re doing on this particular day.  For psych, the most important thing to find out is whether or not the patient wants to hurt himself or someone else on the floor.  Ask the patient about mood.  Ask how they’re tolerating their meds (they will all be on something).  Ask them how they slept the night before (you would be surprised how poorly most psych inpatients sleep).  Ask them if they’ve heard and voices commanding them to do things or saying things about them that no one else seems to hear (auditory hallucinations) or if they’ve had any visions (visual hallucinations).  Ask about any delusions they might have (i.e. the bank has my inpatient psych records [bizarre] versus my wife is sleeping with the parish priest [non-bizarre])  This would be a good time to make a mental note of the patient’s general appearance, as well as how they answer questions, their speech, and how they interact with you. WHY? Because… 2. Objective  In most specialties, this would be the physical exam. In psychiatry, it’s the Mental Status Exam, which is not the same as the Mini Mental State Exam  Covers 8 areas: general, speech, mood, affect, thought process, thought content, impulse control, and insight and judgment.  General: Tell about the patient’s appearance. Does he/she look his/her age? How is the patient dressed? Are they neat or disheveled? Is s/he making good eye contact with you?  Speech: Is it rapid or slow? Are pitch and intensity changes appropriate? Is the speech pressured?  Mood: Is the patient depressed, euphoric, or manic?  Affect: This is your assessment of the patient’s mood. If the patient says s/he’s down and s/he’s acting like it, then mood and affect are said to be congruent. If the patient says s/he feels like a million bucks, but acts depressed, then the mood and affect are incongruent.  Thought process: This is how the patient answers your questions. Linear is when the patient answers your questions directly. Circumstantial is when the patient goes around your point but eventually gets back to the answer to the question. Tangential is when the patient goes off on some topic related to the answer to the question asked. Flight of ideas is a series of related ideas that may have initially been an attempt to answer your question. Loose associations are jumbles of ideas that have no relation to each other and make no sense. Ideas of reference are when people think that shows on TV are about them or when spilled milk on the Psychiatry SOAP Note table has a meaning only they can see. Ideas of grandiosity are when the patient thinks s/he is someone important, like God.  Thought content: Here’s where you note if the patient has hallucinations, delusions, and suicidal/homicidal ideations.  Impulse control: How comfortable do you feel with the patient? Do you think s/he can handle him/herself, or do you think s/he will jump across the table to strangle you?  Insight and judgment: What does the patient understand about his or her illness? Does s/he even realize that s/he is sick? What is the patient’s decision making capacity?  Labs: Rarely seen in psych, unless the patient is taking lithium or valproic acid to control their bipolar disorder or you suspect neuroleptic malignant syndrome in someone who has been taking antipsychotics. In that case, levels have to be drawn every few days (roughly every four) to make sure levels are therapeutic, especially with lithium, which has a very narrow therapeutic index. 3. Assessment  This is what you think of your patient on this particular day. 4. Plan  Here’s what you want to do for your patient.  Do medications need to be adjusted?  Do medications need to be added?  Do labs need to be drawn?  Is the patient imminently dangerous to anyone and need to be placed on continuous observation?  Does the patient get privileges for good behavior?  Use the MSE to guide you.  Most importantly, when do you think the patient might go home? Questions you want to ask… Do you have any intention on harming yourself or others? How are you feeling today? How are you tolerating your medications? How did you sleep last night? Have you heard any voices commanding you to do anything or saying anything about you. Have you had any visions? Are you having any delusions? Psychiatry SOAP Note The SOAP Note… Subjective: The patient is a 38 year old African American female who was admitted to the floor 2 days ago after two days of medical treatment following a suicide attempt. She states that she has no intention on harming herself or others, and she is feeling a bit down because she cannot believe she did something to almost end her life. She is tolerating her medications well, although she is not sleeping well. Pt denies hallucinations and delusions at this time. Objective: MSE: Gen: The pt is a 38 year old female who appears as her stated age. She is dressed in a hospital gown. Her hair is neatly groomed. She makes good eye contact with the MS III. Speech: Fluent and intelligible. Changes in pitch and intensity are appropriate. Speech is not pressured. Mood: Pt states that she is feeling down as above. Affect: Affect is congruent with mood. Thought Process: The patient answers questions linearly. Thought Content: The patient denies hallucinations, delusions, and suicidal/homicidal ideation. Impulse control: The patient displays good impulse control at this time. Insight and judgment: The patient displays fair insight and judgment into her condition. No labs were drawn this am on this patient. Assessment: The pt is a 38 year old African American female who appears to be in no acute distress at this time. Plan: 1. Continue patient on Lexapro 10mg PO QHS for depressive symptoms. 2. Consider starting Trazadone 50mg to aid in patient’s sleep. 3. Consider continuing observation for one more day to be certain that patient is past her suicidal phase. 4. Continue to interact with this patient. Psychiatry SOAP Note Family Medicine The Story… A.B. is a 50 year old African American female. She has been coming to you every six months for the past 5 years after being diagnosed with hypertension. Initially, the patient tried dietary and lifestyle modifications for 6 months without a decrease in hypertension. She is currently taking hydrochlorothiazide to control her hypertension. She is slightly overweight and smokes 1 pack of cigarettes per day for the past 30 years. What do you want to ask? 1. Any symptoms? Headaches, blurred vision, palpitations, chest pain, dizziness, numbness, tingling? 2. Past medical history? 3. Medication use? Do you need refills? Compliance? 4. Diet? 5. Tobacco use? How much? How long? 6. Illicit drug use? 7. Alcohol use? 8. Exercise? 9. Stresses in life? Employment, family, illnesses? 10. Family history? 11. Additional risk factors? Known cholesterol? Diabetes/last blood sugar test? What do you want to do on physical exam? 1. BP in both arms. ***Make sure you use the correct size cuff to avoid false measurements. 2. BP sitting and standing. 3. Ophthalmoscopic examination- look for arteriolar narrowing, AV nicking, exudates. 4. Listen to heart in all for places. Palpate PMI. 5. Listen to abdomen with stethoscope for bruits. Palpate abdomen to determine kidney size. 6. Feel for peripheral pulses bilaterally. 7. Listen to lungs in back and FRONT. Secondary Causes of HTN: 1. Cushings- hirsutism, facial plethora, truncal obesity, headache, acne. 2. Pheochromocytoma- headache, palpitations, diaphoresis. 3. Renal artery stenosis. 4. Hyperaldosteronism. 5. Polycystic kidney disease. 6. Coarctation of the aorta. 7. Hyperparathyroidism. 8. Thyroid disease. 9. Acromegaly. Risk Factors: 1. Hyperlipidemia. 2. Diabetes mellitus. 3. Medications- OCP, estrogens. 4. Family history- cardiac, hyperlipidemia. 5. Tobacco, cocaine use, alcohol use, diet, stress. Family Medicine SOAP Note The SOAP Note… S/ Patient denies any chest pain, headaches, blurred vision, palpitations, dizziness, numbness, tingling, and lightheadedness. Patient has been compliant with HCTZ and experiences no side effects from medication. Patient has decreased amount of smoking to ½ pack per day, but has not changed diet and continues to eat regular amount of salt, fat, and cholesterol. Patient ambulates around house and 1 block to and from bus station, but does not engage in regular exercise. Patient denies any new stresses in life and does not take any other medications (besides HCTZ) including herbal, vitamins, or OCP. O/ Vitals- BP- 145/90 R= 16 P= 80 T= 98.6F Gen- WN/WD slightly overweight AAF sitting in chair in NAD. HEENT- AT/NC, PERRLA, no papilledema, hemorrhage, AV nicking, or exudates observed, EOM I., no carotid bruits b/l, no JVD noted, no thyroidomegaly. Chest- CTA b/l, no wheezes, rales, rhonchi noted. CVS- RRR, +S1 +S2, no murmurs, gallops, rubs appreciated, PMI palpated within normal range. Abd- soft, NT, ND, +BS, no hepatosplenomegaly or masses noted, liver span 8cm, no bruits auscultated. Ext- no clubbing, cyanosis, edema, DP pulses +2 b/l. Neuro- AAOx3. A/ 50 year old AAF with history significant for hypertension for 5 years. Currently controlled with HCTZ. No symptoms at present. P/ 1. Hypertension a. Continue diuretic. b. Assess patient for other risk factors for CAD- hyperlipidemia, diabetes (obtain fasting lipid levels and blood glucose measurements). c. Order CBC, electrolytes (glucose, potassium, creatinine, BUN). d. Obtain UA to look for protein and/or blood. e. Council patient on smoking cessation, healthy diet, and exercise program. f. Follow up in 6 months. 2. Preventive care a. Baseline EKG. b. Refer for mammography. c. Refer for sigmoidoscopy/colonoscopy. d. Continue care with gyn and annual pap smears. What might labs look like? \ 13.3 15.3 -----------/ 37.5 U/A / 430 \ 140 | 101 | 6 / ------------------- 130 3.0 | 23 | .3 \ 7.115/1.10/clear/negative protein, glucose, ketones Family Medicine SOAP Note General Surgery The patient is a 26 y/o WM (white male) who presented on 8/9/03 evening with a 3 day h/o (history of) abdominal pain. The pain began in the lower abdomen and was described as diffuse. Over the next day the pain moved into the RLQ (right lower quadrant) and had stayed there until yesterday. In the a.m. of the day of admission the pain seemed to have resolved but then became quite severe by evening and the patient came to the hospital. The patient has had multiple episodes of vomiting x 2 days. The patient has had no appetite and taken nothing PO (per os) for 2 days. Over the past 2 days he reports a temp of 101.2. The patient denied any diarrhea, bloody stools, symptoms of PUD (peptic ulcer disease), dysuria, urgency, frequency, hematuria, SOB, or cough. The patient had pyloric stenosis at 6 months which was repaired surgically with pyloromyotomy. The patient has NKDA (no known drug allergies). The patient takes no medications. He does not smoke cigarettes, drink EtoH, or use illicit drugs. The patient’s father had appendicitis when he was 16 y/o. On admission the patient’s vitals were 145/72, 98, 21, 102.4. The patient appeared to be in mild distress but was lying very still in the bed. Bowel sounds were present but diminished. The patient’s abdomen was rigid with involuntary guarding and rebound tenderness. There was RLQ point tenderness. Obturator and psoas were negative. Lungs were CTA B/L (clear to auscultation bilaterally), Heart with RRR (regular rate and rhythm), no palpable hernias B/L. Labs showed WBC 14,000 with 10 bands, Hemoglobin 14.3, Hct 41.6, platelets 450,000. Na 140, K 3.9, Cl 101, CO2 22 (=HCO3), BUN 33, Creat 1.2. Urinalysis showed mild hematuria and pyuria. CT scan of abdomen showed appendiceal diameter of 8 cm and periappendiceal fluid suggestive of appendicitis. The patient was started on IV drip and taken STAT to OR for appendectomy at 10pm. The patient had a ruptured, gangrenous appy in the OR which was excised and the pus was drained. Postoperatively, the patient was started on Zosyn and Clindamycin and a Morphine PCA. The patient was made NPO (nothing per os) and the foley placed at surgery was left in place. The wound was left open and covered with a sterile dressing. The patient was admitted to the floor at 1am. You were on call last night, evaluated this patient in the ER and helped with the appendectomy in the OR. It is now 6 am and you must see this patient and write a SOAP note. You need to present this patient at morning rounds to your attending and residents. You are the only one who has had contact with the patient. General Surgery SOAP Note SOAP Note… 8/10/03 6:10 a.m. MSIII PN (progress note) Surgery Problem List 1 s/p (status/post) ruptured appy Medications 1 Zosyn Day #1 2 Clindamycin Day #1 3 Morphine PCA (patient controlled analgesic) (S) Pt lying in bed in NAD (no apparent distress). C/O (complains of) mild incisional tenderness and diffuse abdominal discomfort. Pt also complains of some discomfort when taking deep breathes. Pt has incentive spirometer at bedside but has not used it. Pt denies flatus/BM. No N/V (nausea/vomiting), no SOB. (O) Tmax = 101.3 @6am P = 77 I/O 1000/450 over 8 hours R = 15 BP = 115/70 O2sat=99% Heart : RRR Lungs: CTA B/L Abdomen: BS- mild incisional tenderness, dressing C/D/I (clean/dry/intact) GU-foley in place, no gross hematuria Labs: \ 13.2 / 16.3 ------------ 448 / 39.8 \ 141 | 102 | 6 / ------------------- 88 3.8 | 24 | .5 \ A/P: 26 y/o male s/p ruptured appy. POD #1 (post operative day). Stable. -cont zosyn and clindamycin (usually until pt has normal WBC and is afebrile, ambulating, and eating a regular diet) -cont morphine PCA (after a few days if the pt is using the pump less and tolerating the pain better, pain meds can be switched to oral, i.e. percocet) -pt instructed to use incentive spirometer Qhour (every hour) when awake (to prevent atelectesis) -cont NPO (most surgeons wait for signs of bowel function, i.e. flatus, bowel sounds, BM, before challenging with clear diet) **Complications to always keep in mind are pelvic and liver abscess. This must be considered if the pt is still spiking with a white count a week after the surgery. After every surgery it is useful to write down the complications of the surgery so you can make a quick assessment in the a.m. when you see the pt. General Surgery SOAP Note Obstetrics and Gynecology Prenatal Care Visit:(* = Good for GYN as well) S(Subjective) O(Objective) Age* Vitals*esp. Blood pressure Gravidy – G* Weight gain Parity – P* Urine protein & glucose Last Menstrual Period – Fetal Heart Rate – FHR LMP* (@6-8wks) Estimated Date of Fetal Movement -FM Confinement – EDC Fundal Height – FH (empty Estimated Gestational Age bladder – EGA @16-18wks) Document any patient Fetal Position – (@26complaints – c/o* 28wks) Risk Assessment for: Physical exam in pregnancy Pre-Term Labor (vaginal bleeding-VB, 1st visit: leaking of fluid from vagina - Breast Full and tender – Rupture of - Cervix Soft Membranes(ROM), (Goodell’s Sign), abdominal pain, congested and contractions-ctx) cyanotic (Chadwick’s Sign)) Infection (fever, chills, burning with - Cervix and uterine urination) body feel like two separate Pre-eclampsia (blurred vision, scotoma, organs on headache, rapid weight gain bimanual (Hegar’s ) or edema) Lab results: Fetal Compromise CBC: (pronounced decrease in WBC \Hemoglobin/ Plts frequency or intensity of / Hematocrit \ fetal movement) MVC: Mean corpuscular Volume RDW: Red Cell Distribution Width SMA7 Na Cl BUN_/ Glu K HCO3 Creatin\ Mg Coagulation Profile PT/PTT/INR or _PT_/INR PTT \ A(Assessment) Diagnosis/Problem list* Nagele’s Rule for expected date of delivery: (LMP +7days) – 3 months Precise knowledge of the ae of the fetus is imperative for ideal obstetrical management thus unit is in weeks of gestation completed. Ex: 33 completed weeks and 3 days = 33 3/7 weeks. Transvaginal Ultrasound most accurate means of estimating gestational age especially before 12 weeks. (16-20 weeks) Ultrasonagraphy not routinely done unless indicated: - Uncertain date of LMP - Family Hx of congenital anomalies P(Plan) Plan for each diagnosis/problem* Date of return visit: (monthly until 28 wks, bimonthly until 36 weeks, weekly thereafter) Routine Prenatal Labs: 1st Visit (Type & Screeen-T&S, Complete Blood Count-CBC, Pap smear, Rubella, VDRLsyphilis, Urine Analysis-UA for protein, glucose, & microscopic exam, Urine Culture-cx, BbsAg, HIV, PPD, Gonorrhea GC/Chlamydia, discuss genetic screening-chorionic villus sampling - CVS vs. amniocentesis) 15-20 weeks gestation (Offer Maternal Serum fetoprotein – MSAFP or “Triple Screen” – AFP, unconjugated estriol, free -HCG) 18-20 weeks gestation (Ultrasound if indicated) 24-28 weeks gestation (1 hour glucose challenge testGCT) 28 –30 weeks gestattion (RhoGam administration if indicated – must have prior negative antibody screen, ) 28-32 weeks gestation (Repeat VDRL in high risk patients) 35-37 weeks gestation Group B Strep culture – GBS cx, Repeat CBC) OB/Gyn SOAP Note The SOAP Note… Gynecology S: 24 y/o G3P2012, LMP 2 weeks ago, complains of an offensive vaginal discharge. She states that the discharge is thin, white and foul smelling. She especially notices the odor after sex or after taking a bath. She is in a monogamous relationship for past 2 years. She reports no vulvar pruritis or soreness and denies urinary symptoms, F/C (fever/chills) O: 98.8-110/70-88-15 Lungs: CTA b/l CV: RRR, nl S1/S2, (-) m/r/g/ Abd: Soft, NT, ND, (+) BS x 4 quads, no palpable masses SVE: Homogenous, grayish-white, watery discharge coating vaginal walls that yields a fishy odor, (-) inflammation. Labs: pH 5.5, (+) KOH whiff test, (+) clue cells on wet mount Bacterial Vaginosis - Metronidazole vaginal gel (Metro-Gel) 0.75%, one applicator (5g) PV(per vagina) BID(twice a day) x 5 days - Schedule regular GYN visit in 6 months. A: P: OB/Gyn SOAP Note Labor & Delivery (L&D) – History & Physical (bolded items are OB additions to standard H & P) HPI: 25 yo G4p2012, LMP 6/9/02, EDC 3/16/03 @ 39W3d presents w/ c/o ctx x 5hrs w/ increasing frequency and intensity, occurring q 5 min. Denies LOF(Leakage of fluid) ROM, VB, reports active FM. PNC(Pre-Natal Care): HUMC Clinic, 1st visit @11 + wks x 14 visits PNL(Pre Natal Labs): A+/Ab-, RI (rubella immunization), VI (varicela immunization), RPR NR(Non-reactive), HbsAG (-), HIV NR, Pap WNL, GCT = 109, HbEP (hemoglobin electrophoresis) WNL (within normal limits), Urine cx (-), GC/Chlam(-), GBS(+). POBHx: G1 – 1995 - TOP(termination of pregnancy)-8 weeks G2 - July ’99 - 40 weeks-NSVD(normal spontaneous vaginal delivery) – male –7lbs6oz-no comp(complications)-HUMC G3 – Dec ’01 – 39 weeks –NSVD – female – 7lbs 10 oz- no comp –HUMC PGYNHx: Menarche @ 12, Cycle 28days, Menses 5 days. PMHx: Asthma – diagnosed during childhood; last exacerbation 2 years ago PSHx: D& C (Dilation and Curettage) x1 Appendectomy - @16 Meds: PNV (pre-natal vitamins) ALL: NKDA(no known drug allergies SHx: (+)tobacco - 10 pack years, quit for pregnancies; denies EtOh and illicit drug use FHx: (+) DM (MGM); (+)HTN (father and mother), (-) h/o endometrial/ovarian/cervical/breast cancer O HEENT:NC/AT, EOMI, (-) oropharyngeal lesions, neck supple, (-) thyromegaly/thyroid nodules Lungs: CTA b/l CV: RRR nl S1/S2, -m/r/g Abd: Soft, NT, gravid, FH= 39cm, Leopold’s – vtx (vertex) Ext: Warm, dry, 1+ pitting pretibial edema b/l; (-) calf tenderness. SVE(speculum vaginal exam): 4/90/-2/vtx/Intact (dilation in cm/effacement %,station/position/membranes) FHR: BL(baseline) = 120s, (+) LTV, reactive to 150’s, (-) decals Toco(contractions): q 3-5 minutes A: 1) IUP(intra uterine pregnancy) @ 39+ wks 2) Active labor 3)GBS(+)) 4)H/O Asthma – stable, not requiring meds P: - Admit to LD - Routine labs(CBC, T&S) - IV hydration - NPO (not per oral) except ice chips - GBS prophylaxis w/ IV Ampicilllin - Reexamine in 2hrs. Pitocin augmentation if indicated - Anticipate NSVD OB/Gyn SOAP Note Good Luck and Enjoy!