AOA Survival Guide to the 2nd Year

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					AOA Survival Guide to the
       2nd Year




       Duke University School of Medicine
                 August, 2008
                                Table of Contents

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

Chapter 2: The Rotations
      - A typical day in:
         o Medicine
         o Surgery
         o Psychiatry
         o Family Medicine
         o Pediatrics
         o OB-GYN

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

Chapter 4: Sample Progress Notes
      -Medicine
      -Surgery
      -Peds
                               CHAPTER 1: THE BASICS

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

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

                    Your place in the hierarchy of Duke Medicine:


                 Chancellor Victor Dzau

                               Clinical Chairs

                                    Attendings

                                        Fellows

                                       Residents

                                          Interns


                                           Nurses



                                        Medical Students
The Basic Patient Workup
       You must shift your thinking from a disease orientation to a patient orientation. In
other words, instead of focusing on the manifestations of a given disease, while working
up a patient you must focus on the symptoms and signs of your patient to try to
determine which disease explains the patient’s problems and presentation. A basic
patient work up will generally include the following:

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

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

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

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

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

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

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

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

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

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

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

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

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

Admission History and Physical: H+P
When a new patient is admitted to your service (especially on medicine and peds) and
assigned to you, you are expected to take a complete medical history and perform a
complete physical exam on him/her. There are admit H+P forms on the wards which
contain the outline and order you should follow. Generally this will be:
       CC: Chief complaint
       HPI: History of present illness
       PMH: Past medical history
       PSH: Past Surgical history
       SH: Social history
       FH: Family history
       ROS: Review of systems
       PEX: Physical Exam (with vital signs first)
       Labs:
      Special Studies: (Xrays, EEGs, EKGs, etc.)
      Assessment:
      Plan:
A template of an admit H+P for your use can be found of the AOA 2nd Year Survival
Website at: http://www.duke.edu/web/aoa/dusm.html although you should check with
your particular team to see if it is ok for you to use the template; some teams frown on
it.

Progress Notes
On most services, you will be expected to write the notes (and possibly orders) for your
patients. You will follow the SOAP format:
       - First, put the patient’s name and hospital day (HD) or post-op day (POD ___
          from __________ [list surgery])
       - S = Subjective – what the patient tells you that they are subjectively
          experiencing, e.g. nausea, vomiting, chest pain, appetite, etc.
       - O = Objective – vital signs, physical exam, labs, radiology, etc
       - A = Assessment – of the patient’s condition, diagnosis, and progress
       - P = Plan – to treat the patient or further work them up.
       NOTE: Some services may prefer that you combine the Assessment and Plan in
       a problem based or organ based fashion, e.g. ―1. Acute Renal Failure –
       Creatinine continues to be elevated above patient’s baseline. Will aggressively
       hydrate and discontinue NSAIDs. 2. Hypertension – Patient’s blood pressure
       remains well-controlled on current antihypertensive regimen. Will plan to
       continue current antihypertensive metoprolol.‖

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

Tips regarding presentations:
1. Memorize the abnormal findings:
Once you get comfortable with the normal physical exam, you will be able to rattle of the
normal findings easily—―Abdomen is soft, nontender, nondistended with no
organomegaly or masses...‖ Then all you have to remember for your patient are any
abnormal findings. The same is true for the review of systems. Often when presenting it
is appropriate to just include the data that are relevant to your patient’s condition, the
―pertinent positives and negatives‖ e.g. for ROS and Labs for your patient.
Nevertheless, you should still know and be able to answer questions from the attending
about other details.

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

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

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

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

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

Pockets:
With your crisp, short, little white coat you have been given the gift of many pockets.
Generally, in these you should always have a copy of Maxwell's, your stethoscope,
palm, a pen-light, pens, and something to write on. On your medicine rotation you will
receive a copy of the Intern Survival Guide, which contains useful phone numbers, what
tubes to use for different labs, common medications and doses, and a wealth of other
very useful items. Once you receive this guide keep it in your pocket for all of your
subsequent rotations. A version of the guide available as a Word document on the AOA
2nd Year Survival Website, and where it can be downloaded onto your palm via
DocumentsToGo. The intern survival guide is very useful.

Figure out some way to keep track of your patients on notecards, rounding sheets, or
something similar so that you will have your patients' labs, medications, pending
studies, etc. within reach. Additional items may be useful on specific rotations as
discussed later.
                           CHAPTER 2: THE ROTATIONS


Medicine
Typical day:
6:30-7:30am
       - Preround on your patients; write your progress notes and orders.
7:30-9:30am
       - Work rounds with team; present your patients to the team and discuss the
           plan for your patients.
9:30-11:30
       - Attending rounds, present your patients to the attending, and be prepared to
           answer questions about your patients’ conditions and treatments.
       - Finish your notes and orders for your patients, and have the resident or intern
           cosign them.
12:00pm
       - Noon conference.
Afternoon
       - Follow up on your patients’ labs and other studies, help out with discharges,
           etc.
       - Lectures, Physical Diagnosis rounds etc.
Call Night
       - Admit patients, do full H+P, learn about your patients' conditions before
           attending rounds the following morning.

Tips for Medicine:
- Try to be active in the plan of your patient by writing the orders and labs for your
   patient and calling for consults if possible.
- UpToDate is a great resource for reading about your patients' conditions and
   planning treatment.
- Help out your team by filling out discharge sheets and calling to arrange follow up
   appointments.

Surgery:
Typical day:
5:00-6:00am
       - Preround on your patients, focusing on pertinent aspects of history and
          physical. For example if they had abdominal surgery: are there +BS, are the
          passing flatus, have they had a bowel movement? Are they getting OOB (out
          of bed), what are their ins/outs, are they using the incentive spirometer, how
          does the wound look, etc?
6:00-7:00am
       - Work rounds.
7:30am-5:00pm
      -    In the OR. Surgical Recall is a very helpful book to have on hand to look up
           last minute information before or between cases...but...never let your
           attending know that you just looked up last minute info in Surgical Recall.
5:00pm-6:00pm
       - Evening rounds.
Call night
       - Hang out with the on-call intern and work up post-op fevers and the like.

Tips for Surgery:
- Offer to write the Op note after the surgery.
- Get your own gloves and gown and give them to the circulating nurse. Introduce
   yourself to the nursing team. They can be your greatest allies on this rotation.
- Be enthusiastic even if you are exhausted.

Psychiatry:
Typical day (will vary by service):
7:00-8:00am
       - Preround on your patients, noting any changes in MSE (mental status exam).
8:00-10:00am
       - Work rounds; interview the patients with the resident and help write notes.
10:00am-12:00pm
       - Attending rounds.
Afternoon
       - Help write discharge notes, see consults, etc.

Family Med:
Typical day (will vary by location):
8:00am
      - Show up, and start seeing patients. Interview the patients, present in SOAP
          form and then see the patient with the attending.
      - Offer to dictate if you want the experience.

Pediatrics:
Typical Inpatient Day—very similar to Medicine:
6:30-7:30am
       - Preround on your patients; write your progress notes and orders.
7:30-9:30am
       - Work rounds with team; present your patients to the team and discuss the
          plan for your patients.
9:30-11:30
       - Attending rounds, present your patients to the attending, and be prepared to
          answer questions about your patients’ conditions and treatments.
       - Finish your notes and orders for your patients, and have the resident or intern
          cosign them.
Afternoon
       -   Follow up on your patients’ labs and other studies, help out with discharges,
           etc.
       -   Lectures.
Call Night
       - Admit patients, do full H+P, learn about your patients' conditions before
           attending rounds the following morning.

Typical Outpatient Day:
-Variable by outpatient clinic

Typical Newborn Nursery Day:
6:00am
       - Divide up the list of babies with your classmates, and see all of them
          collecting information regarding, feeds, weight changes, birth information etc.
7:30am
       - Attending rounds
Rest of the day
       - Play with the babies and go to deliveries with the Nursery intern

OB/GYN:
Typical Labor and Delivery Day
6:00am
       - Pre-round. Divide up the list of post-partum moms with your classmates and
           see all of them asking questions such as about abdominal pain, vaginal
           bleeding, pain, resumption of bowel activities (esp. if C-section). Be sure to
           check the perineum if there was a vaginal delivery - attendings will expect you
           to do so.
7:00am
       - Attending rounds in the conference room.
Rest of the day
       - Go to clinic and see the prenatal patients, or stay in the labor and delivery
           triage area with the intern/resident/midwives.
       - Help fill out discharge sheets.
Call night
       - Stay up; go to C-sections and deliveries.

Tips for Labor and Delivery:
- With your classmates, keep an updated list with all of the patients on it. Have the on
   call student run through the list during a slow part of the night around 5am and
   update the information for the new and old patients, so that the other students can
   just show up quickly preround without searching for all of that information.

Typical Day for GynOnc/GynBenign—very similar to Surgery:
5:00-6:00am
                 - Preround on your patients, focusing on pertinent aspects of history
                   and physical. For example if they had abdominal surgery are there
                    +BS, are the passing flatus, have they had a bowel movement?
                    Are they getting OOB (out of bed), what are their ins/outs, are they
                    using the incentive spirometer, how does the wound look, etc?
6:00-7:00am
                -   Work rounds.
7:30am-5:00pm
                -   In the OR.
5:00pm-6:00pm
                -   Evening rounds.
Call night
                -   Hang out with the on-call intern and work up post-op fevers and the
                    like.
                      CHAPTER 3: ADDITIONAL INFORMATION

Example Normal Physical Exam:
      This is an example of a normal physical exam. As you know from the Physical
Diagnosis course there are many more aspects of the physical exam which you may
need to test; this simply provides the format for a typical, normal medical physical exam.

GEN:
       Vital Signs (120/70 BP 60 HR 14 RR 37 Temp)
       AOx3 (alert and oriented to person, place and time)
       NAD (no acute distress)
HEENT (head/eye/ear/nose/throat):
       NC/AT (normocephalic atraumatic)
       PERRLA (pupils equal round reactive to light and accommodation)
       Sclera anicteric
       EOMI (extraocular movements intact)
       O/P clear (oropharynx)
       MMM mucous membranes moist
       Tongue pink and moist
Neck:
       Supple
       Ø thyromegaly
       Ø LAD (lymphadenopathy)
CV:
       RRR (regular rate & rhythm) normal S1, S2
       Ø M/R/G (murmurs/rubs/gallops)
Chest/Back:
       CTAB (clear to auscultation bilaterally)
       Ø W/R/R (wheezes/rhonchi/rales)
       Ø CVA tenderness
ABD:
       S/NT/ND (soft/non-tender/non-distended)
       Ø R/G (rebounding/guarding)
       BS (bowel sounds)
       Ø masses
       Ø HSM (hepatosplenomegaly)
EXT:
       Ø C/C/E (clubbing/cyanosis/edema)
Skin:
       WD (warm & dry)
       Ø visible lesions
       Ø Tenting/Normal Turgor
Neuro:
       Non-focal
       CN 2-12 intact (cranial nerves)
        2+ DTR B/L (deep tendon reflexes)
        5/5 Strength bilaterally

Labs:




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

Common Medical Notations:
c = with
s = without
PRN = as needed
p = after
NTE = not to exceed
B = BL = B/L = bilateral
c/o = complaining of
CP = chest pain
Ca = cancer
D/C = discharge or discontinue
Dx = diagnosis
Sx = Symptom
Tx = treatment or transplant
Rx = prescription
Hx = history
f/u = follow up
h/o = history of
HA = headache
N/V = nausea/vomiting
U/A = unrinalysis
VS = vital signs
WNL = Within normal limits (be careful using this as some attendings take it to
       mean ―we never looked‖)
x = except

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

Route of Medications
PO = by mouth
NPO = nothing by mouth
IV = intravenous
SQ = subcutaneous
PR = per rectum