SUCCESS ON THE WARDS

A student-to-student guide to getting the

most out of your third year:

NORTHWESTERN UNIVERSITY
F EINBERG S CHOOL OF M EDICINE
19TH EDITION
SUMMER 2008

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 YOU (hopefully):

CARTOON BY: MICHELLE AU

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TABLE OF CONTENTS

INTRODUCTION ........................................................................................... 3
THE WARD TEAM ......................................................................................... 4
WHAT IS JUNIOR YEAR? ..........................................................................5-6
Your Role .................................................................................................. 5
Daily Schedule ........................................................................................... 6
What to Keep in Your White Coat........................................................... 6
How You’re Evaluated.............................................................................. 6
RULES TO LIVE BY ..................................................................................7-10
BASIC CHARTING INFORMATION & TIPS......................................11-14
Documenting Laboratory Values ......................................................12-13
The H & P and SOAP Notes ............................................................13-14
THE CASE PRESENTATION ................................................................15-17
ADMISSION & DISCHARGE ................................................................18-19
Admission and Post-Op Orders ............................................................. 18
The Discharge Note ................................................................................ 19
Prescriptions............................................................................................ 19
THE ROTATIONS ...................................................................................20-42
Lay of the Land ....................................................................................... 20
Guide to the Patient Room................................................................20-21
Key People on the Floor....................................................................21-22
Suggested Pocketbooks........................................................................... 22
Medicine .............................................................................................23-27
Surgery ................................................................................................28-32
Obstetrics & Gynecology...................................................................32-39
Pediatrics ............................................................................................39-42
Psychiatry............................................................................................43-45
Neurology ...........................................................................................46-47
Primary Care ............................................................................................ 48
PATIENT PRIVACY ..................................................................................... 49
SAFETY ISSUES .......................................................................................50-52
Needle Sticks ......................................................................................50-51
Immunization .......................................................................................... 51
Security ...............................................................................................51-52
ABUSIVE BEHAVIOR.............................................................................52-53
CONCLUSION .............................................................................................. 54
APPENDIX: Abbreviations ......................................................................55-61
IMPORANT PHONE NUMBERS ............................................................... 62
NOTES.......................................................................................................63-64
 Special thanks to the following members of the class of 2009
for their contributions to this Guide:

Martin Buta
Catherine Chen
Brendan Connell
Sadiya Khan
Albert Kim
Michelle Lin
Melissa Marinelli
Ben Paul

And…to the numerous members of previous classes who originated this

guide and kept it up-to-date over the years.

The Ward Survival Guide is a student publication. We would like to

thank Dr. Amy Kontrick, Dr. James Rosenthal, Dr. Larry Cochard, Sarah
Sproule, and the Augusta Webster, MD, Office of Medical Education for
their support and guidance in this endeavor.

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 INTRODUCTION
Welcome to the nineteenth edition of the Ward Survival Guide!
The following year is guaranteed to be challenging, exciting, and
rewarding, and sometimes overwhelming, but we hope to ease a bit of the
confusion and worry with this little booklet.
You spent your first two years in the library and in the
classroom (or neither). At this point you are likely very excited to finally
enter the clinical phase of your training. With that excitement likely
comes a sinking feeling in the pit of your stomach that you have no clue
what you are doing. Rest assured, generations of medical students before
you have experienced that same feeling and have survived! But much like
learning how to swim, you will learn the most by simply jumping in. This
booklet will keep you afloat only temporarily; with time and experience
you will gain the confidence to fly on your own!
The upcoming clinical years of medical school will provide some
of the most influential and rewarding experiences of your life. You will
learn from and work alongside your peers, mentors, future colleagues,
and, most importantly your patients. Your experiences in these two years
will guide your decisions about the rest of your medical career. So make
sure to study hard, pay attention, have fun and, of course, keep this book
close at hand. Good luck!

The Class of 2009

If you have any suggestions for ICC or this guide, please contact Dr.
Amy Kontrick or Sarah Sproule so future classes may benefit.

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 THE WARD TEAM
The members of the team are described below. Students are an integral
member and may be most knowledgeable about a patient.

Attending Physician has completed a residency and possibly a fellowship

and is a member of the Northwestern faculty. Ultimately responsible for
the patient's care and will thus make or approve all major decisions.

Fellow has completed a residency program and is now in subspecialty

training, e.g. cardiology, vascular surgery, high-risk obstetrics, etc. As a
junior student, your contact with these individuals will occur in the setting
of a subspecialty consult clinic, operating room, or on rounds. Fellows
are, in general, exceptionally knowledgeable about their specialty and
slightly less overworked than residents. Thus, they make excellent
teachers.

Resident is anyone with more than one year of postgraduate training (PGY-
2+). Since attendings typically round once a day, the resident is in charge
of the daily work of the team. Besides helping the intern in managing the
team's patients, he or she is also primarily responsible for the education
of students. Clerkship evaluations are often solicited from residents.

Intern is in the first year of postgraduate training (PGY-1). The intern is

primarily responsible for the moment-to-moment patient care. You may
be paired with an intern who will work with you on the patients you are
assigned. The intern usually has many tasks to be completed through the
day, so any work you can do to help out will be greatly appreciated. In
return, they can show you the ropes around the hospital, teach you about
your patients, and offer a good evaluation of your performance to the
resident. Helping the intern with their work can be an excellent learning
experience.

Senior Student is a fourth year medical student who is taking an elective or

a sub-internship (Sub-I). He or she has the responsibilities of an intern
and is supervised by the resident. The 4 th year student will not be
responsible for your evaluation.

Junior Student You! Described fully on the next page.

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 WHAT IS JUNIOR YEAR?
The goal of the junior clerkships is to continue to teach you the clinical
skills of a physician and expose you to different fields. During the M1
and M2 years, you learned pathophysiology, problem solving, and patient
interaction skills. During the ward years you will learn how to integrate
and apply these skills toward actual patient care. This is a challenging
endeavor, but you will slowly improve as the year progresses.

You will frequently find that you lack knowledge of a particular disease
process or the skills to perform a certain procedure. Remember, you are
there are to learn, and nobody expects you to know everything already,
especially not at the beginning. In time, your clinical judgment, problem
solving skills, ability to manage patient issues, and self-confidence will
develop.

Your Role

Your first priority is to learn as much as possible. Reading is highly

encouraged and may be difficult during busy rotations. You should carry
something to read at all times since you never know when you might have
spare time!

Also, your presence during patient rounds, on the floor, in the operating
room, and at conferences exposes you to clinical faculty. These
individuals will serve as your mentors and have an obligation to teach you
over the course of your clinical rotations. Always remember that you are
a student who is paying tuition in exchange for the privilege of learning.

Your second priority is to help the team. You should write the daily
progress note, as well as orders on your patients if you are able to do so.
These steps will help organize your thoughts about your patients, force
you to think through a clinical plan, and ensure that you are up-to-date on
your patients. Student orders and notes always need to be cosigned, so an
occasional error is acceptable, but errors in your documentation are
still a part of the medical record. Learn from each error to better avoid
them in the future.

You should also help your team to accomplish the tasks necessary for
patient care. Taking a detailed history and physical (H&P), following up
laboratory results, getting films from radiology, or drawing blood
provides you with an opportunity to refine your clinical skills, gain more
patient care responsibilities, and help the whole team to finish their day’s
work earlier so that everyone can go home or have more time to teach
you.

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Daily Schedule

The routine varies with every rotation. On your first day, you should be
informed of the typical schedule, but it may take a few days to figure it
out. Often, the day begins with work rounds. You are responsible for
pre-rounding on all of your individual patients. This involves seeing the
patient and finding about all relevant new information including vitals, lab
results, etc. Afterwards, you will round with your team and see your
patients a second time. The team of house staff and students goes from
patient to patient talking about each patient's medical problems, present
condition, and plan for the day in regards to tests, therapies, procedures,
etc.

After rounds, you may go into the operating room, see your patients
individually, or coordinate their care. The rest of the day is spent in
attending rounds, conferences, lectures, writing SOAP notes, and
following up results. Efficiency is a good skill to learn and refine. You
must fit all of the unscheduled business around scheduled meetings and
conferences. At the end of the day, sign-out rounds are usually done to
update the team members and to let the on-call person know about each
patient.

What to Keep in Your White Coat

What to carry in your white coat will also vary slightly with every rotation.
At a minimum, you should carry a stethoscope, penlight, and reflex
hammer. For OB/GYN it’s nice to have a pregnancy wheel, which you
will receive at orientation. On Pediatrics, a developmental stage guide can
be helpful (found in Maxwell’s), and on Psych, bring the mini-mental
plaque that you were given during physical exam courses. As mentioned
before, ALWAYS have something to read!

However, try to hold yourself back from overfilling your pockets!

How You’re Evaluated

The specifics of how you are evaluated are different on each rotation and
should be explicitly explained to you on your first day. If they are not
explained, feel free to ask. In general, your evaluation will be based on
some combination of how you perform on the wards (your clinical
evaluation) and how you perform on the test at the end of the rotation
(the “shelf exam” and often a practical exam called an OSCE). The
“shelf” is a multiple-choice, nation-wide test that will have clinical-
vignette questions similar to those you saw on Step 1, although with
longer questions stems and a more clinical focus.

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RULES TO LIVE BY: THE TEN COMMANDMENTS
There are many unwritten laws in medicine, so here are some rules that
many students have found useful.

1. Remember that there is a person on the other end. During your clerkship,
you may begin to forget that the only reason we are here is because
there are patients. They deserve our time, help, and most
importantly our respect. Your patients are giving their bodies for
your education, and while you should be assertive in your desire to
learn, you must always keep in mind that the person who does a
procedure on or has an important conversation with a patient must
be the most appropriate team member, and it may not be the junior
student. Always treat patients the way that you would like to be
treated.

2. Enthusiasm. Be a happy worker. Residents and interns have a hard

life as it is, and behaving in a reluctant or uninterested manner will
make them invest less in your education. Try to have a positive
attitude and try to be an active member of the team. Generally, you
should learn something from the tasks that you do, but occasionally,
that may not be the case. One piece of advice you should keep in
mind throughout your medical education is that any task that must
be done for your patient should not be considered “scut.”

3. Assertiveness. Patients appreciate it if doctors say or do something

with certainty. With patients, explain what you are doing and why
you are doing it. Residents and attendings will appreciate confidence,
however it is good to be assertive without being aggressive or rude.
Talk clearly and enunciate. Actively volunteer to take a patient or to
present your patient. Every once in a while, ask yourself, "Am I
getting out of this rotation what I want? Am I being taught
enough?” Then speak up to change things if necessary. During
rounds or pimp sessions, volunteer answers if you know them, and
do so with confidence. (But always give the person to whom the
question is directed a chance to answer first!) A note of caution,
however: do not try to answer questions about patient data that you
do not know the answer to. It is better to say, “I don’t know” than to
give incorrect information about a patient.

4. Reading. Assertiveness is best when accompanied by knowledge. By

reading, you learn more and prepare yourself for rounds, patient
care, and exams. Although the wards experience can teach you a lot
that you can never learn from books, reading is essential. Start with
reading about your patients and the basics on each rotation, and then
move along to less common diseases.

5. Respect your fellow classmates. Learn with and not at the expense of
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 your colleagues. Never put down or show up another student.
Residents and attending can spot "brown-nosing" and back-stabbing
behavior easily. Remember: your classmates are your colleagues.
Like you, your peers are trying their best to do well and learn as
much as they can. Mutual respect will allow for a more pleasant
rather than painful experience and allow you to learn from one
another.

6. Have a good time. Despite the fact that medical students are "lowest
on the totem pole," you do not have to suffer. This is two years of
your life, and you have a right to learn as much as you can and to be
respected as a human being. Try to enjoy yourself and take care of
your health. Eat whenever you can. Sleep whenever you can. Always
carry around a granola or snack in your pocket. When you learn to
strike a perfect work-life balance, let the rest of us know how!

7. Be friendly with support staff, especially the nurses. Being nice to everyone
makes life much easier for you. At this point in your education,
nurses know a lot more than you do when it comes to the daily
routine of patient care. Introduce yourself to the nurse taking care
of your patients, and always turn to the nurse as a resource about
what happened overnight. Since you don’t get sign-out, this may be
your best chance to be prepared for rounds Better communication
means better care for your patients, and you will save time and
impress your residents.

8. Be on time. It may seem that no one will notice if you are late by a
few seconds or minutes, but punctuality and promptness are always
evaluated. Being late can only hurt you, so plan accordingly. Your
resident may consistently arrive late for morning rounds; do not
assume that you are allowed to do the same.

9. Ask questions. Asking many questions demonstrates interest and an

eagerness to learn. The questions you ask will reflect how much you
know. Make sure that the questions you ask show that you have
been doing your reading and try to avoid questions that could be
answered simply by reading a textbook. It is better, however, to
focus on clinical decision making skills and questions that can only
be answered by someone with experience. At the same time, do not
be afraid to ask some simple questions at appropriate times; they still
show interest.

10. Seek feedback. It is your responsibility to find out how your residents
and attendings regard you. You should not rely upon subtle hints
and body language. Rather, directly ask for feedback approximately
halfway in the rotation. Do not just ask how you are doing (you will
probably receive a vague, "You're doing fine."). Ask if there are any
specific things upon which you can improve, and in the remaining

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 time, improve on those things. Also, the more focused your
questions, the more constructive the feedback will be. (i.e. “Did I
present that patient in a concise and focused manner?” or “Can you
comment on my H&Ps?”)

ADDITIONAL RULES TO LIVE BY:

• Let your intern/resident know where you are at all times. Post a schedule of
your lectures and give them your pager number. This is a good idea
multiple reasons. First, part of your role is to give your intern a hand
with his/her work. Second, if they can't find you, they might assume
you are goofing off, or you may miss the chance to do a procedure.
Use your discretion to avoid annoying anyone, but check-in
occasionally to give them an idea of what you have been doing and to
offer to help.

• Work hard. Any boss you have had or will have appreciates hard
workers. Being a medical student, it is almost a given that you are a
hard worker. But the trick is to show that you are a hard worker.
Volunteer to take on an extra patient. Offer to stay a little longer at
the end of the day to help out. Always ask if there is anything else
you can do before you leave for the day.

• Take initiative. You can probably pass all of your rotations by doing
the minimum requirements. But if you are in the OR, or on the floor
anyway, why not make the most of the situation? Take an active role
in all aspects of your education. Volunteer to answer questions, and
offer any good ideas or plans that you have in your patients' care.
Occasionally bring in articles relevant to your patients' treatment
plan or disease.

• Know your patients better than anyone else. Know the most and be the
first one to know the latest word on your patient, which includes
pre-rounding, checking labs, and getting imaging studies when they
are performed. Your residents will appreciate you telling them the
latest developments on your patient and it makes you look like you
are “on top of things”. Cherish the opportunity to get to know your
patients—you will not have this much time to do so later in your
career.

• Appropriate humility. There is a time for everything. As a medical

student, you should show the appropriate due respect to the
residents and attendings who were once in your position. Do not try
to outsmart, embarrass, or correct them in the middle of conference.
Do not talk back; arrogance is never appreciated. Say “I don’t know”
if you really don’t know the answer. Be a team player.

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• Understand responsibilities and expectations. Your duties are usually well
explained in the clerkship syllabus at the beginning of each rotation,
but because each resident runs his or her team differently,
clarification may be needed. It is to your advantage to ask early in
the rotation. Miscommunication concerning student responsibilities
can be a source of unnecessary conflict.

• Be prepared to be on-call the first night. This is a possibility on some

rotations.

• Appearance and demeanor are important. Students are considered part of

the patient care team and are therefore expected to dress and act in a
manner suitable to a professional medical environment. Men are
expected to wear dress slacks and ties; women are expected to wear
modest dresses, skirts or slacks. Socks or pantyhose should always
be worn, and open-toe shoes are a JCAHO violation. Scrubs may be
acceptable if you are on-call. However, if in doubt, ask your
resident. Some attendings expect students to be dressed nicely and
clean- shaven (men) even if you’re post-call. How you dress may
depend upon which clerkship you are on, as for some rotations, you
may wear scrubs every day, whereas during others, they are never
permitted. Even on surgery business attire in the clinic is expected.
Most hospitals’ infection control regulations forbid you from wearing
scrubs outside the hospital.

• Prepare/practice for oral presentations. You will definitely be asked to

present for attending rounds. Usually, you will be warned ahead of
time when you will be presenting, but sometimes you will be told at
the last minute. Your oral presentation is your time to show what
and how much you know about your patient. This may be the only
way for your attending to evaluate you, in addition to what he or she
hears about you secondhand from your resident Do not memorize
your presentations word for word unless your attending tells you this
is required. Instead, have notes but do not rely too heavily on them.
Be prepared to answer any questions such as why a certain study was
ordered, etc.

• Efficiency is key . An attending/resident/intern appreciates an efficient,

organized medical student. Do not spend hours trying to determine the
liver span of your patient. Try to keep progress notes and presentations as
concise as possible (The H&P is the time to show your thought process).

• Remember Patient Confidentiality. Be careful about where you talk about

patients. Corridors, elevators, stairwells, Au Bon Pain, and other public
locations are inappropriate areas. There have been incidents in which patients’
families have complained to the hospital.

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BASIC CHARTING INFORMATION & TIPS
One of your duties will be writing the progress note and orders for the
patients you are following. The key issue to remember is that the
patient’s chart is a legal document. Thus, if you make a mistake, you
should cross out the mistake once, write “error” or “err” and initial it if
you are using paper charts. On the computer, write an addendum
correcting the error. You must sign your notes and orders and have them
cosigned by an intern or resident.

At the beginning of all written notes, remember to indicate which service

you represent and your individual status, e.g. “Neurology MS3 Progress
Note”. At the end of all notes and orders that you write, sign your name,
print your name, and indicate your status and pager number.

In the Assessment/Plan section of your notes, give your impression of

patient management and recommendations. However, always state them
as considerations unless you have discussed them with your team. For
example, “consider Celexa 20mg PO daily to treat major depression”;
never make statements that directly question the recommendations or
judgment of others.

The purpose of notes is to communicate. Write clearly and try not to use
abbreviations as they are rarely standardized.

Using Powerchart and Epic

Powerchart: You will get powerchart training and your ability to use it
will increase with time. Until then, here are a few pointers.

1. Use dot phrases! You will learn to create these in training and
they can save a lot of time. You can create these shortcuts for
different types of notes as well as for standard text within notes.
2. Use caution when copying notes from the previous day. This is a
ripe situation for errors, and while it saves time it is very
embarrassing if you do not proofread well. The assessment and
plan are particularly vulnerable, as it is easy to include an out-of-
date plan or incorrect numbers of days post-op or of antibiotics.
It is a liability to enter incorrect information in the medical
record.
3. Use the “NEW RESULTS” tab. This is a great way to find out
the most recent studies, labs, etc… that you might not even
know were ordered.

EPIC: You will be trained to use it there if you are doing rotations there.
At NMH it is most useful for reviewing patient charts to find out about
outpatient workups, care, and labs.

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The Electronic Medical Record

ƒ Your daily notes need to reflect that day’s updated information.

You are conveying information to others about the patient’s
hospital course. Be sure that your assessment and plan do not
differ too much from your teammates’.
ƒ SAVE, SAVE, SAVE, SAVE!! Losing a note is not something
you want to experience.
ƒ Dot phrases are your friend (available on PowerChart and Epic).
Try typing “.cbc_chem” or “.vitals” on PowerNote.
ƒ Always remember that the EMR is a legal document and is
permanent. Be accurate and respectful.

Please note the Augusta Webster, MD, Office of Medical Education Policy on the
Electronic Medical Record for students:

“It is never appropriate for a student to copy and paste elements of

another person’s H&P or patient care note into their own note and portray
it as their work. All information, other than structured data elements
contained within the medical record (vital signs, lab results, medication
records, etc) should reflect the student’s ability to gather and present
patient data. If a student copies and pastes their own note from a previous
day, it should reflect all relevant changes in the patient’s condition and
progression in their understanding/analysis of the patient’s underlying
disease process. Inappropriate copying and pasting of another person’s
work will be considered a transgression of the student code of conduct and
a professionalism form may be submitted to the Dean’s office.”

Documenting Laboratory Values

One of the most commonly ordered tests is the basic chemistry panel,
previously referred to as the ‘SMA-7’ or ‘Chem-7’, since it provides a
quick assessment of electrolytes, renal function, and serum glucose. The
following skeleton is used:

Na / Cl / BUN / Glucose
K \HCO 3 \ Cr \

Another common test is the complete blood count, which can be reported
in the following format:

WBC \_Hb_/ Platelets

/ Hct \

It is also recommended that you include the MCV and RDW to rule out
or help evaluate anemia as well as the differential if it was ordered.
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The traditional method to report arterial blood gas results is:

FiO 2 / pH / pCO 2 / pO 2 / HCO 3 / BE/ O 2 saturation

Frequently, the FiO2 is left out if the patient is on room air, and the
bicarbonate is appended to the end to help evaluate acid/base
disturbances.

Electrocardiographic results are not usually reported in a standard format

with slash marks as above, so it is best to label all intervals, often in the
following order:

Rhythm, rate, P-R interval / QRS interval / QT interval,

QRS and T wave axes, ST and T wave abnormalities,
Interpretation.

Formal EKG readings are typically available the next working day.

History and Physical (H&P)

One of the goals of your medical education is to become proficient at

writing H&Ps. You should periodically ask for feedback regarding your
write-ups from both your attendings and residents. Initially, your H&Ps
will be long and detailed in order to show your superiors how much you
know and understand about your patient. The assessment and plan is
your opportunity to demonstrate your thought process and show your
ability to create a differential. At the beginning, you may require some
support from your residents to organize this. Gradually, with your
growing knowledge, confidence and experience, your H&Ps will become
concise and efficient and you will be able to completely formulate
differentials on your own.

On Medicine you present the patient to the attending the day after you do
the exam and H&P. Some teams will allow you to work on an H&P
overnight and leave it unsigned until after presenting the patient to the
attending the next morning. Other teams will expect you to commit to a
plan before you leave for the night, using the daily progress note the next
day as a place for a more updated plan.

The SOAP Note

The purpose of the daily progress note is to document any significant

patient events, the patient’s current condition, and the current therapeutic
reasoning and plan. It improves communication between everyone
involved in the care of your patient. The most common method of
writing this note is using the SOAP format.

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 S - Subjective:
9 Any events overnight? (fever, emesis, bowel mvmt, etc.)
9 How the patient is feeling today, according to him/ her!
9 You may document patient care-related discussions, i.e.
informed consent, in this section as appropriate
O - Objective:
9 Vitals (Temp, HR, RR, BP, O2 sat)
9 Ins and Outs
9 Focused Physical Exam (Gen, Heart, Lungs, Abd, etc.)
9 Recent lab values and test results
A - Assessment:
9 Most important part of your note
9 Repeat one-liner except now, provide YOUR assessment:
i.e. “55yo man with hx of … who presented with …,
LIKELY DUE TO …”
9 It is okay to be wrong. This is where you show your team
your thought process and reasoning. [If you are uncertain,
you could ask your intern/ resident (prior to starting your
note) to run over your assessment with you and provide
feedback.]
9 On Medicine, it is important to include a justification of
your diagnosis or assessment. Explain why your patient’s
symptoms are consistent with your diagnosis, but also
include some possible reasons as to why it might be
unlikely.
P - Plan:
9 Typically organized by problems (ICU and Surgery may use
organ systems)
9 Start with pt’s chief complaint or most pressing issue, i.e.
“1) Chest pain.”
9 If not already discussed in Assessment, may include a
phrase or two as to likely etiology, i.e. “likely cardiac in
nature, given pt’s history.”
9 What you are going to do to address the problem, i.e. start/
continue meds, check labs, send X-rays, get Echo.

The basic format of a SOAP note is consistent between rotations however

there are subtle differences that you’ll need to keep in mind as you tailor
the SOAP note to each rotation. We’ve attempted to point out the major
differences in the examples that follow.

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 THE CASE PRESENTATION
This is often the only way your attendings and/ or senior residents will be
able to assess you. Even if this is not the case, the case presentation is
the basis upon which your peers form their first impression of your
clinical abilities. Presentation skills require experience and knowledge, so
don’t expect to nail it the first time. Throughout the year, you will learn
to formulate and convey a well-ordered, concise summary of the pertinent
clinical information.

Important tips:
1) Present in order. One of the most common criticisms of
student presentations is that they are “disorganized.” The
SOAP/ H&P format is a good standard to follow.
2) If Review of Systems is non-contributory, state “non-
contributory.” Otherwise, say “ROS remarkable for history
joint pain related to arthritis.” If it is relevant to the
patient’s chief complaint, it belongs in the HPI.
3) Offer YOUR assessment and plan. Be prepared to justify.
4) DO NOT READ. You may refer to notes while
presenting, but reading from the page is tedious for
everyone. Try highlighting important history/ labs
beforehand if you do plan to use notes.
5) State only pertinent information. This is a lose-lose
situation as a medical student because we often don’t know
what is pertinent and have been trained to err on the side
of thoroughness. Use your best judgment and learn from
your (and other students’!) mistakes.

Structure
In general, think of the presentation as a story. Or consider it a
persuasive essay where you are leading your listener to your thesis (a.k.a.
diagnosis).

HPI: Always start with your one-liner: patient’s name, age, race, and sex
followed by a statement of the chief complaint. If this person has a
relevant past medical history, you may also include these in your one-
liner. Otherwise, for a complicated patient, it is generally acceptable to
say “history of multiple medical problems.”

Continue with an abbreviated history of present illness, including

description of symptoms (OLDCARTS, you know the drill), chronologic
development of symptoms (state “two days prior to admission” instead of
the day of the week or date). Include pertinent positive findings, as well
as pertinent negatives.

For the past medical history, list all medical conditions which the patient
has had and elaborate on those with special relevance. When you reach
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medications, list ONLY the names, either generic or brand; if your
audience is interested in specific dosages, they will ask. The social and
family medical history can be condensed to relevant details “lives with
husband, employed as secretary, smokes one pack per day for last 20
years, no alcohol or illicits.” At this point, the audience has constructed
and narrowed down a differential diagnosis.

The physical exam should always begin with a description of the patient
and vital signs. Then, list the pertinent positive and negative findings in
their respective organ systems. Always include lungs, heart, and abdomen
(if normal, state: “heart regular, lungs clear, abdomen benign.”) Next, the
pertinent laboratory values and results from tests or procedures are
mentioned. By now, you should have hopefully led the audience to a
single diagnosis, so you can finish with a summary statement that
describes your management plan.

The following is provided as a very brief example, which should be

tailored to the clerkship and attending preferences:

Mr. Foley, a 53 year old, white male with a history of stage III
prostate cancer diagnosed 2 years ago s/p radical prostatectomy
with adjuvant radiation therapy, presents with lower back pain x
2 months. Pain began gradually 2 months ago without radiation
and has a severity of 8/10. Pain is on and off, and is worse at
night but independent of position. Pt has been taking Advil but
without relief. Denies history of trauma to area, change in
urination, change in bowel habits, weakness of proximal
muscles, fevers, and chills.

Past medical history is as described above. No known drug

allergies. Medications include bethanecol. Denies ethanol and
tobacco usage. Family history is noncontributory.

On physical exam, the patient is a cachectic male in no acute

distress. Vital signs are stable. Lungs clear, heart regular,
abdomen soft and nontender with palpable liver edge at 2 cm
below costal margin. Back: point tenderness over L4-L5.
Neuro: 5/5 strength throughout, sensation intact to light touch
bilaterally, (-) straight leg raise test. Basic chemistry panel and
CBC were within normal limits except for calcium of 11.5; alk
phos of 150. His most recent PSA\ was 10 one month ago,
increased from baseline of 5.

In summary, the patient is a 53 year old male with history of

prostate cancer and now presents with back pain. Given the
focal nature of the pain with elevated PSA, calcium, and alk
phos, it is likely this represents metastasis to the lumbar
vertebrae. The enlarged liver may represent liver metastasis.

16
 Our plan is to start Vicodin for the pain, obtain a bone scan to
evaluate for bone metastasis, and obtain abdominal CT to
evaluate liver metastasis.

Final Words of Advice

Your presentation should not be your H&P word for word. Your
attendings and residents can read, and if they wanted to hear every detail,
they would simply look at your note. Therefore, include ONLY
PERTINENT INFORMATION.

You may find it helpful to practice beforehand. Often doing so with your
peers is helpful, so that they can provide feedback (i.e. saying “um” or
“like” every other word). The more relaxed you sound when you present,
the more professional you will seem. Be careful of sounding overly
rehearsed. Remember that people will be listening to learn important
patient information, so it is part of your duty to your patient to keep them
engaged.

Do not expect your first presentation to be perfect. If it is, then

congratulations. If not, be sure to take constructive criticism with a smile
and remember the advice for your future presentations. If no helpful
critique is offered, you should approach your resident or attending at an
appropriate time, i.e. after rounds, to ask for feedback. Often, doing so
before rounds ensures that they will pay more attention and provide more
helpful and specific comments.

That said, each attending is unique. Many of the Medicine faculty

members want to hear a very thorough and well thought-out presentation,
in some cases with particular emphasis on certain sections such as the
social history. Other attendings may not be as interested in details and
will want you to get to the point. Do not take it personally if you are cut
off. Simply learn and adapt to each attending as you rotate. What one
attending specifically tells you to do may be another attending’s pet peeve.
While this is certainly frustrating, it is often unavoidable. Continue to do
your best and offer a complete, concise presentation.

17
 ADMISSION AND DISCHARGE
Admission Orders
With electronic medical records, it is unlikely that you will be writing
orders on the floor. However, you WILL BE EXPECTED TO WRITE
ORDERS (typed freehand, from memory) on the OSCE exam (for
Medicine, Surgery, etc.)

A good way to learn is to practice writing a set of orders for patients your
team is admitting, then have your intern/ resident take a look at them.
This will give you experience, as well as demonstrate that you are being
proactive about your learning. At CMH (if they are still using paper
records), residents write admission orders by hand, so you can volunteer
to help with these, especially on call!

There are numerous different mnemonics used. PICK ONE AND

STICK TO IT. Here, we use ADC VANDALISM.

Admit: 12 E, Attending: Dr. Shapiro, Intern: John Smith, pager # 5-

1234
Diagnosis: primary reason for admission, or if post-op
¾ “Chest pain” or “s/p laparoscopic appendectomy”
Condition: stable or not (of limited use, since you will often hear
that “a dead patient is stable”)
¾ “Stable, fair” or “critical” might be more descriptive
Vitals: how often? When to notify house officer?
¾ Vitals q6h per protocol. Please also check pulse ox. Call h.o. (house
officer) for T>100.5 <96, HR>120 <50, RR>20 <12,
BP>160/110 <90/60, O2sat <92%, glucose <70 >200, urine
output <300cc/8o
Allergies: self explanatory. Include reactions, if known.
¾ “Penicillin – rash/ swelling” or ‘NKDA”
Nursing orders: things that need to monitored/ checked
¾ Strict I/O q shift, daily weights, accu check qAM, Foley to gravity,
NG tube to LIWS (low intermittent wall suction), incentive
spirometer 10x/1o when awake, TEDs and SCDs while not
ambulating
Diet: self-explanatory.
¾ “NPO,” “general diet,” “clears,” “mechanical soft,” “TLC diet,”
“NPO after midnight” (for procedures)
Activity: typically ad lib, remember weight bearing for Ortho
¾ “Ad lib,” “up with assist,” “strict bed rest,” “OOB to chair,”
“NWB left leg” (no weight bearing)
Labs: specify, what, when, and for how long
¾ CBC, chem 7 + Ca, Mg qAM x 3d, LFTs and ESR now
IVF: type and infusion rate (impt for surgery, less so for others)
¾ “D 5 0.45 NS @ 125 cc/ o ,” or “Heplock IV” if none
Special Studies: diagnostic tests and consults
18
 i.e. CT scan of brain with and without infusion, CXR PA/LAT
Medications: 1) drug name (generic or trade)
2) dosage
3) administration route (PO, IM, SQ, PR)
4) frequency (Q day, QHS, BID, q 8 hrs, etc.)
¾ Pepcid 20 mg PO QHS
Colace 100 mg PO BID
Norco 325/ 75 1 tabs PO q4-6 hours PRN pain
***On SURGERY, when writing post-op orders, remember the following five
classes: pain meds, DVT prophylaxis, antibiotics, peptic ulcer prophylaxis,
patient’s home medications

The Discharge Note (The bane of house-staff paperwork. Ingratiate

yourself by volunteering to help with these.)

Admission Date:
Discharge Date:
Admission Diagnosis: Keep it general (i.e. Abdominal Pain)
Discharge Diagnosis:
Attending:
Referring Physician:
Procedures: include anything out of the ordinary (e.g. PPD)
Consults:
Complications:
Hospital Course: If the patient is complicated, the best way to
approach this is to organize it by problem/ organ system.
Condition at Discharge: “improved” (we hope!) If not stable or
good, explain.
Disposition: Discharged home, skilled nursing facility, etc.
Discharge Medications:
Instructions: Include please call your doctor if you experience any
concerning symptoms.
Follow up Plan:

Prescriptions

To prescribe outpatient meds, use prescription stationery when

discharging patients on medications. You can specify either a brand or
generic drug. Generics usually save the patient money and are required by the
Food and Drug Administration (FDA) to have 80% bioequivalence of the brand
name drug. You also want to write these numbers out in long hand, so they
cannot be altered.
John Q. Smith April 19, 2006

Toprol XL 100mg tablet

Sig: 1 tab PO QD
Disp: 30 (thirty)

May substitute: yes

Refills: none
19 A. Everhart, MS3/Dr. Neely
 THE ROTATIONS

Lay of the Land:

Navigating the hospitals can be confusing, and finding the results to a
particular test can take hours if you don’t know where to look. Some
commonly visited locations are as follows:

ƒ NMH
• 1 st Floor: Emergency Department and ED Radiology Reading
Room
• 3 rd Floor: Department of Medicine and Surgery Offices
• 4 th Floor: Neuroradiology reading room, Ultrasound, MRI, CT,
Radiology Film pickup window, GI Lab, Interventional
Radiology
• 5 th Floor: Primary surgical suites, post-op recovery rooms
• 6 th Floor: Resident lounge, Surgery resident room, Staff dining
room, Telecommunications office (for free pager batteries and
paging directory), Scrubs machine
• 7 th Floor: Laboratories, Auxiliary surgical suites (mostly
Transplant, Cardiothoracic, & ENT), EEG,
• 8 th Floor: Nuclear Medicine, Echocardiography, Cardiac
Catheterization Lab, Electrophysiology
• 9 th Floor: Dialysis
ƒ ENH
• Ground Floor: Radiology viewing rooms, nuclear medicine,
cardiac catheterization, outpatient clinics (Louis), ED
• 1st Floor: Outpatient labs (Louis), pathology, histology
• 2nd Floor: CCU (Louis)
• 3rd Floor: OR/Ambulatory Surgery, ICU, Pediatrics (Louis),
EDOU (Louis)
• 5th Floor: Psych (Louis)

Guide to the Patient Room:

A typical patient room contains several pieces of whirring, beeping, and
hissing equipment that may seem daunting at first. A basic understanding
of these devices will help you feel more comfortable.

• Bed: Modern hospital beds are surprisingly complicated. Here are a

few key points:
• The entire bed, and its head and tail, can each be raised and
lowered independently. The controls sit outside the bed rails.
There are also simplified controls inside the rails for patient use.
• The bed rails are released by a small lever underneath.

20
 • Falls are a serious hospital safety issue. If you raise the bed or
lower a rail, make sure to restore it to its original position
before leaving the room.
• Table: Can be adjusted to jut out directly over the bed. Used for
meals, and sometimes also as a workspace when doing procedures.
You can raise/lower it via the release lever on the side. Some
models have an expandable lower leaf or even a fold-out mirror.
• Remote control: Adjusts the TV and room lights. Can also call the
floor secretary, who can dispatch the patient's nurse.
• IV pump: Delivers continuous infusions of fluids and medications to
the patient at a set rate, which is indicated on a display. The infused
substances hang in bags above, which are labeled with the names of
the substance and the patient. The pump has a battery and sits on a
wheeled pole, which can be unplugged and taken to the bathroom (or
on a walk around the floor!)
• Tip #1: if the pump keeps beeping, this may mean that a bag is
empty and needs to be replaced, or that the tubing between the
pump and patient is kinked. Check for an obvious obstruction
(is the patient laying on the tubing?), and if none is found,
contact the patient's nurse. You can silence the beeping briefly
by pressing the yellow “Silence” button.
• Tip #2: if IV infusions are no longer needed, the tubing can be
disconnected with the IV catheter left in place (e.g., still in the
patient's arm), allowing the patient to walk around freely. The
remaining catheter is called a heparin lock (“hep-lock”) IV.
• Sequential compression devices (SCDs): Consists of a small machine
and two pneumatic compression sleeves. The machine sits near the
tail of the bed and periodically inflates/deflates the sleeves, which
are usually worn around the calves. This is an important safety
measure that helps prevent deep vein thrombosis (DVT), a frequent
complication in hospitalized patients.
• Thromboembolic devices (TEDs): This is a fancy name for tight
knee-high stockings that are worn around the calves. They also help
prevent DVT, and are often used in combination with SCDs.
• Nasal cannula: A pair of prongs that sit in the nose and deliver
supplemental oxygen (2-6 liters/minute). The tubing goes around
the ears and attaches to a port on the wall. Next to the port is a
gauge, which looks like a thermometer and measures the rate of
oxygen delivery (in L/min), and a knob that adjusts this rate.
• Face mask: Used for patients who require additional oxygen. It
comes in several varieties, which are beyond the scope of this text.

Key People On The Floor:

Medicine today is a team effort. Getting to know the other members can
help you stay on top of your patients, and will also make you look like a
star.

21
♦ Unit secretary: One of the most important people on the floor. Can
locate a patient's nurse, tell you where a patient has gone, help find a
piece of equipment, and otherwise make life easier in numerous
ways.
♦ Nurses: Are an invaluable source of information about your patients,
the floor, and the hospital in general. If you make an effort to keep
them informed about your team's plans, they will appreciate it.
Don't be afraid to ask them questions!
♦ Charge nurse: Manage most aspects of the floor. Among other
things, they supervise other nurses and stay on top of all patient
arrivals and departures.
♦ Nurse practitioners: Work with the medical team to manage a subset
of patients and help out with many other miscellaneous tasks.
♦ Social workers: Help with myriad social aspects of a hospital stay,
including coordinating social support services, obtaining funding,
locating housing for visiting families, and finding a place for patients
to go after they leave the hospital and helping them to get a ride
there.
♦ Case managers: Assist with discharge planning. They review medical
records daily and help determine whether a patient still needs to be
in the hospital, and if not, where they should go.
♦ Others: You may also encounter respiratory therapists, radiology
technicians, phlebotomists, nutritionists, hospital volunteers, and
many others. As usual, it pays to get to know them!

Suggested Pocketbooks for all rotations:

• ePocrates (PDA) or Tarascon Pocket Pharmacopoeia (Book): Medication
reference including indications, available dosing/form, and
generic/trade name cross referencing.
• Pocket Medicine (Massachusetts General Hospital): An excellent source of
reference on the wards. Great differential diagnosis, work-up, and
treatment plans in an efficient outline format. A must-have text for the
medicine rotation.
• Maxwell’s: Concise guide of normal lab values, etc, etc, etc.
• Optimizing Medication Use at NMH: standard pocket antimicrobial
reference guide. Updated annually. Copies available at NMH
Pharmacy.
• Northwestern Memorial Hospital Pager Directory: Contains pager and phone
numbers of attendings, residents, and labs. Free on 6th floor of Feinberg.
This info is also accessible via the computer or by dialing the operator.
• Keep this book in your pocket. Refer to abbreviations and phone
numbers often.

The NMH Pager Directory

Let your residents know that you can be paged through the general web-
texting site by your last name. When paging someone yourself, be sure to
leave a call back number and your pager number so that they can
22
reach you. Do not forget to be succinct and clear as to why you are
paging them. Here is an example:
Ann Smith, MS3
CB: 51333
Message here. Pager (249-1631)

MEDICINE

The medical student H&P is usually the most comprehensive and complete
H&P in the medical record, usually more so than the resident or attending
note. Remember that your note is part of the permanent medical record, so
document accurately and truthfully. One of the hardest parts of your junior year
will be accurately and efficiently performing a physical exam. We've tried to
provide you with the basic information that you should attempt to ascertain
with each H&P.

Medicine H&P:
CC: A few words on why the patient presents, usually a symptom such as
“arm pain for1-2 days.” Quote the patient if you can.
HPI: This part of the H&P should tell a story about the patient’s
symptoms. Try to maintain chronology, but don’t forget to include
significant past medical history. Also, don’t forget to state pertinent
demographic information (age/sex), OLDCARTS, and relevant Review
of Systems. Since most patients are admitted by way of the Emergency
Department, students often struggle with how and where to include
information obtained in the ED (e.g. CT scan). We’ve found that it
varies based on the attending, so your best bet is to take note of what
the attending wants and adjust your HPI accordingly. If a patient is
admitted for dehydration or hypovolemia, include the amount of fluid
the patient was given by bolus in the ED.
PMH/PSH: Specifically ask about major diseases (e.g. diabetes, heart
disease, HTN, stroke) and correlate to the medication list. Patients will
sometimes say they do not have any medical problems but are taking
thyroid replacement, diuretics, beta-blocker, and have an inhaler.
Another tip that is often helpful is to ask about TB exposure or old
PPD reactions in patients with undiagnosed pulmonary issues.
Meds: Medication name, dosage, route, and frequency. Before presenting
your patients to the attending, try to figure out why your patient is on
each and every one of his/her meds. You’ll likely be asked.
Allergies: Medication/Reaction. An upset stomach, for example, is
usually not a true allergy. It is therefore important to include the
reaction to the medication.
Family Hx: At a minimum, the patient’s mother, father, and siblings.
Remember to include ages and, if deceased, the cause of death. Also
include the age of diagnosis for diseases like cancer and MI.
Social Hx: Tobacco, EtOH, drug use, and sexual activity. Career. If
retired, include work history. Living situation (what kind of domicile
and with whom).
23
Physical Exam:
GEN: A&Ox? Pleasant? Cooperative? Sitting/laying? In distress?
VS: Temp (route), Pulse, RR, BP (at time of interview), orthostatics (if
thought to be hypovolemic)
HEENT: NCAT? PERRL? EOMI? Sclera anicteric? Oropharynx clear,
erythematous, or with exudate or lesions?
NECK: Neck supple? Thyromegaly? Lympadenopathy? JVD or bruits?
CHEST: Normal respiratory effort? Clear to percussion and auscultation?
Rales/rhonchi/wheezes?
CV: Regular rate & rhythm? PMI palpable? PMI location? Normal S1/S2?
No S3/S4, murmurs, rubs or gallops, or clicks?
ABD: BS normoactive? Soft? Non-tender? Non-distended?
Hepatosplenomegaly? Liver span/palpable?
PULSES: Normal? Without carotid, abdominal or femoral bruits?
EXT: Clubbing/cyanosis/edema? Full range of motion? No
fluctuation/crepitus?
NEURO: Mini-Mental if relevant. CN II- XII intact? Strength 5/5?
Reflexes 2/4? Coordination? Gross sensory?

Labs: Include CBC (with differential), chem 7, and other labs done in the
ED.
Imaging: X-rays, CT, MRI, US, EKG. Include your own assessment, not
just a copy-paste of the report.

A/P: The assessment and plan are usually the most difficult element of
the H&P for the junior student and are often wrong early in the
clerkship; this shouldn’t discourage you from putting something down
(Just put “CONSIDER” before each recommendation and you are
usually safe). Late in the clerkship you’ll be amazed at how often your
assessment and plan is correct. That said, in the assessment don’t
forget to include age/sex/race, an abbreviated restatement of the chief
complaint and HPI, and a ranked differential diagnosis based on
symptoms, signs, PEX, and other studies. For the plan: some
attendings want it systems based, while others prefer it problem based
(i.e. “CV” vs. “Chest Pain”). For organization purposes, it is helpful to
number each element of the plan. A common mistake in developing a
plan is to not include enough. Items commonly left out are: diet,
F/E/N, account for ALL medications, include any HELD medications,
TEDs/SCDs, DVT prophylaxis, ulcer prophylaxis, IV fluids, electrolyte
replacement, pending studies, disposition (where they are getting
admitted).

Medicine SOAP:

S: Include patient’s status, significant overnight events, pain control,

sleep, toleration of diet and brief ROS.

24
O: Vitals: Include the patient’s current temperature (Tc) as well as
maximum temperature in the last 24 hours (Tm), pulse (including range
over 24 h), blood pressure (range over 24 h), respiratory rate, and pulse
ox (on oxygen or room air). Ins and Outs should be recorded both
over past 24 h and for each 8 h shift.

PEX: As in H&P above, although is usually less detailed, more focused

and includes fewer organ systems.

Labs: Patients usually have daily CBCs (with differential) and basic
chemistry panels so it is helpful to date the labs. Don’t forget to follow
up on any pending labs from the previous day.

Imaging: Follow up on any pending imaging from the previous day. Use
your own assessment, not just a copy-paste of the report.

A: Very similar to the H&P, but perhaps less detailed. Be sure to include
any changes in your original assessment based on new labs, imaging, etc.

P: Again, similar to the H&P. A problem based or systems based

approaches are equally viable; do whatever works best for you. Any
notes written on patients in the MICU should be systems based and
always include every system (CV, PULM, RENAL/GU, NEURO,
ENDOCRINE, GI, F/E/N, PROPHYLAXIS, DISPOSITION).
Students commonly forget to reflect medications that were added,
discontinued or dosage changed. The “disposition” does not mean how
the patient is feeling. Instead, it is where the patient’s plans for
discharge are recorded. When in doubt, “discharge per attending” is
usually safe.

Recommended References, Textbooks and Pocketbooks:

• First-Aid for Medicine: This text provides a great summary of important
topics within medicine, and goes into just the right amount of detail.
Supplement this text with practice questions.
• Case Files: Internal Medicine: Contains 60 clinical cases with extended
discussions, clinical pearls and review questions. It creates a good
backbone for the entire clerkship.
• Pretest Medicine: Great question book; reviews major disciplines of
medicine with a nice question/explanation section—the key to success
in medicine is practice questions!
• MKSAP: Recommended by Dr. Neely; collection of patient cases with
questions; harder than expected for examination. If you like the Board
Simulator Series style of difficult questions, then MKSAP is for you.
• The Only EKG Book You'll Ever Need: Interpretation of EKGs is really
important, as it is a common “pimping point” by many attendings, and it is
expected that you know how to interpret them when you start on the wards!
This is a concise, well-organized EKG book.
• UpToDate: This website is the saving grace of the entire
25
 healthcare profession. It provides comprehensive, always pertinent,
information on diagnosis, management and treatment of nearly every
diagnosis you could think of, zebras included. An excellent for when
your attending asks you to present a topic to the team. It is available
only physically on campus (NMH/VA/Galter). Ask an M4 about a
sneaky way to get a 30 day trial to use for free at home.
• Pocket Medicine [Massachusetts General Hospital]: An excellent source
of reference on the wards. Great differential diagnosis, work-up, and
treatment plans in an efficient outline format. A must-have text for the
medicine rotation.

Other References and Textbooks:

• Blueprints in Medicine: Great to read early on in the rotation. Covers
all major diseases encountered with emphasis on differential diagnosis
and approach to chief complaints. Good quick review right before the
exam.
• Step Up To Medicine: A well-organized, comprehensive, very readable
text that blends a bullet-outline format with comprehensive paragraphs.
Contains x-rays, ECGs, mnemonics and “Quick Hit” pearls. A good
text to read throughout the clerkship.
• NMS Medicine: Well written and short enough to read during the
clerkship. Organized by system with easy to read chapters in outline
form. Practice questions are very similar to the exam.
• Dubin's Rapid Interpretation of EKG's: Widely recommended resource
since it provides a very good step-by-step method in approaching
EKGs, though simplistic.
• Harrison's Principles of Internal Medicine: The authority on Internal
Medicine. Very large, heavy, and full of information.
• Cecil Essentials of Medicine: Excellent tables and charts for understanding
pathophysiology. Not as useful for treatment reference.

Testing:
Shelf: The Medicine test is a shelf examination, consisting of 100
questions. Students over previous years have struggled with timing as
the stems to each question are usually long and take a while to digest.
Also keep in mind that most shelf exams have about 7 questions at the
very end that have 12 or so possible answers. Students often find these
questions tricky. The key to success seems to be doing plenty of
practice questions and starting to read early.
OSCE: The OSCE is an assessment of your clinical skills that usually
takes place on the last week of the clerkship. It consists of 4-6 stations
with standardized patients with corresponding computer stations, where
you will be expected to develop differentials, think about management,
and write admission orders.

Other Medicine tips and common pimp questions:

26
Reading a CXR: Deriving a Differential Causes of ESR >100: Hypercalcemia:
Airway Dx: Temporal Arteritis Calcium Overdose
Bones Metabolic Chronic Infxn (Osteo, Hyperparathyroidism
Cardiac silhouette Infectious SBE, TB, abscess) Iatrogenic (Thiazides)
Diaphragms Neoplastic Thyroiditis Metastasis/Milk Alkali
Effusions Traumatic Vasculitis Paget’s Dz
Fields Cardiovascular Multiple Myeloma Addisons’s Dz
Gastric bubble Allergic/Autoimmune Neoplasm (MM)
Hardware Neurologic Zollinger-Ellison
Drug Reaction Excess Vit D
Youth (Congenital) Excess Vit A
Sarcoidosis
Anion Gap Acidosis: Eosinophilia: Good Quality Sputum Cx: SLE:
Methanol Neoplasm <10 Epithelial Cells Serositis
Uremia Allergy >25 PMN’s Oral Apthous ulcers
DKA Asthma Arthritis
Paraldehyde Churg-Strauss Photosensitivity
INH/ Iatrogenic Parasites Blood (ITP, Hemolytic
Lactic Acid Anemia)
EtOH/Ethylene Renal Nephritis
Glycol ANA (almost always +)
Salicylates Immunology (dsDNA, anti-
Small Bowel Large Bowel Lower GI Bleeds: Sm, low C)
Obstruction: Obstruction: Hemorrhoids Neurologic (Lupus
Adhesions Cancer Diverticulosis Psychosis)
Bulges (hernia) Diverticulitis IBD Malar Rash
Cancer Volvulus Ischemic Bowel Discoid Rash
AVM’s
Ulcer
Proven Mortality Most common ECG Most common bone Emergent Dialysis:
Benefit in CHF: change in PE: mets: Acidosis\hypoAlbumin\Anor
Beta-blocker Sinus tachycardia Breast exia
ACE inhibitor Lung Electrolyte imbalance (inc K)
Spironolactone in Thyroid Ingested toxins
Class IV CHF Kidney Overload (volume)
Prostate Uremia with Sx (cns
(BLT with a Kosher changes)
Pickle)
Potassium repletion: Magnesium Repletion: IV Fluids (4:2:1 rule):
Goal = 4.0 Goal = 2.0 4ml/kg/hr for first 10kg
Every 10 mEq K will 2ml/kg/hr for second
raise serum K by 0.1 Each 1 g Mg will raise 10kg
serum Mg by 0.1-0.2 1ml/kg/hr for remaining
PO: K-Dur, can give kg
40-60 mEq at once Give IV in multiples of
IV: KCl 10 mEq IV 2g Shortcut for pts >60kg:
peripherally; need Weight in kg + 40 = cc/hr
central line to give
20 mEq

27
 SURGERY

Surgery H&P:
Usually, either the H&P will already be completed in the office prior to
surgery and found in the Epic note, or you can use the short H&P
forms/PowerNote found in PowerChart.
Each service will need different information. In general you need to focus on:
Brief HPI: why patient is having surgery, what type of surgery is being
done, left/right side
Past Surgical History: include any bad reactions to anesthesia
Past Medical History:
Hardware: i.e. artificial heart valves, artificial joints, etc.
Current Medications:
Drug Allergies: include reactions to the medication, e.g. hives

The Postoperative Note:

Pre-op diagnosis: Initial preoperative diagnosis
Post-op diagnosis: Final postoperative diagnosis (often “same”)
Procedure: What procedure was performed
Surgeon: Attending(s)
Assistants: Resident(s) and Student(s)
Anesthesia: Local, Regional, or General (GETA, MAC)
I.V. Fluids (IVF)**: Amount crystalloid and/or colloid in mL
Estimate Blood Loss (EBL)**: Minimal, or amount in mL
Urine output (UOP)**: No Foley or amount in mL
Drains: Type, location, and how much has drained
Findings: Gross pathology as well as significant normal findings
Specimen: What specimens were taken to the lab
Complications: i.e. “None” – Ask attending/resident before putting
down any complication other than “none”
Condition: Stable/unstable, intubation status
Disposition: Usually to recovery room, PACU, floor, etc.
**REMEMBER** Ask the anesthesiologist for IVF, EBL and UOP

Surgery SOAP:
S: Postoperative: Any acute events overnight, incisional pain, flatus,
hiccups (a sign of bowel obstruction), bowel movements, urination (if
no Foley), nausea/vomiting, fevers/chills/sweats, CP/SOB,
lightheadedness/dizziness, pain control (PO, IV, # of times PCA was
admin.), whether tolerating PO (if eating), and ambulation

O: Vitals: Tmax, Tcurrent, HR, RR, BP, Sa02 (if applicable)

I/Os: Total over past 24hrs
Urine Output: over past 24hrs in 8hrs intervals in chronological order
(i.e. “200/800/750 for total of 1750ml/24hrs”)
Drain Outputs: over past 24hrs in 8hr intervals, list each drain
separately

28
 PEX:
GEN: A&Ox3, NAD
CV: RRR, no m/r/g
ABD: soft, NT/ND, +/-BS
INCISION: c/d/i (clean/dry/intact), erythema/drainage, dressing in
place/removed, with steris/staples if present
EXT: no warmth, tenderness, edema (signs of DVT)

Labs, Imaging, Pathology Results, Other Studies, etc.

A/P: POD#__, s/p {procedure} for {reason}. AFVSS, patient is doing

___ (list how the patient is doing).
Day of Surgery is POD #0, next day is POD #1.
1. CV/Heme: HD (hemodynamically) stable by vitals/exam, HGB__.
2. Pulm: on __L NC, wean O2, encourage IS
3. GI: wait for return of bowel function, +/- flatus
4. GU: d/c foley? Good UOP? Voiding freely?
5. Pain: epidural, PCA, PO meds?
6. Prophy: SCDs/TEDs, ambulation, SubQ Heparin
7. FEN: IVF@__, diet (i.e. ADAT = advance diet as tolerated)
8. Path: pathology pending
9. Dispo: PT/OT?; continue inpatient management; per attending;
transfer to floor, etc.
10. Other: miscellaneous; monitor liver, check thyroid, endocrine, etc

Duties in the OR:

1. Bring the Patient In: Help anesthesia bring the patient to the OR
2. Move the Patient to the Table: Help move patient from bed to table
3. Remove Bed: once patient is on table, put bed in hallway
4. Put on TEDs/SCDs: ask nurse for these and put on patient
5. Help Drape/Position/Strap Down Patient:
6. Place Foley: Ask the nurse for the Foley, do this for them
7. Retract: expect to be the person retracting
8. Cut Suture: be ready with suture scissors when resident/attending is
suturing, on most sutures leave 1cm long suture tails
9. Retrieve Bed: when procedure is done, bring bed back in
10. Transport Patient: help transport patient to PACU, floor, etc.
11. Procedure Note: put in procedure note

Hints/Tips for Surgery:

1. Look at the OR schedule the DAY BEFORE: learn the operative
anatomy/pathophysiology of the surgery. It’s difficult to impress an
attending with your knowledge of anatomy, but not knowing it can look
quite bad. OR schedule can be found in PowerChart.
2. Expect to retract: this is not glamorous, but it will be your job.
3. Practice knot tying: If given the opportunity to tie in the OR, it is best
to be prepared: if you tie well, they will likely let you tie more.
4. Cutting suture, expect to get yelled at: Pay attention and be ready with

29
 suture scissors when asked to cut. If there is any doubt on where to cut
or how long to leave the tails: ASK. “There are three types of med
students: those who cut too long, those who cut too short, and those
who cut too slowly” – Surgery Attending.
5. Be Nice to Scrub/Circulating Nurses: Stay on their good side as they
can be very helpful at guiding you in the OR.
6. DO NOT touch instrument table: never touch the table, always ask the
nurse to pass you instruments
7. Observe Sterile Field: If you have any doubt whether or not you can
touch something, DO NOT TOUCH IT. When gowned and gloved and
not standing at the table, keep your hands above your waist and on
your abdomen at all times. If you do become contaminated for any
reason, tell someone.
8. Learn to place a Foley: This is a great way to help in the OR. The more
you help in the OR, the more the residents and attending will let you do
during the procedure.
9. General Surgery Call Tips: carry trauma/bandage scissors, for traumas
put in the trauma note, for consults put in the consult H&P.
10. Ordering Films: if you need to put in the order for films, you need to
give the Patient Name, MRN, Name of Study & Date, Series # and
Image #s (number range), Your Name and Pager #.

Recommended References Textbooks:

• Essentials of General Surgery/Essentials of Surgical Subspecialties:
Required textbooks for surgery rotation. Most find the general surgery
book concise and useful. Has adequate coverage of pathophysiology as
well as some anatomy and surgical technique, but lacks detail and depth
in many areas. The subspecialty text is probably less useful and much of
its information is adequately covered in review books.
• Surgical Recall: An excellent pocketbook for surgery rotation. Quick
and easy to read…read it over and over! Answers to many typical pimp
questions and many good mnemonics. An essential for the rotation and
very helpful for the tests.
• First Aid for Surgery: Excellent overview of general surgery topics.
Decent subspecialty coverage though lacks much detail.

Other References and Textbooks:

• BRS General Surgery and Surgical Subspecialties: Provide adequate
preparation for the shelf. Sometimes not detailed enough, but will have
good questions at the end of every chapter.
• Netter’s Atlas of Anatomy: Will suffice for all your anatomy needs.
Read the night before a surgery for a good anatomy review.
• Pretest Surgery: Decent preparation for the shelf, but it should be noted
that a number of the sections are of low-yield and not reflective of the
shelf exam. Answer explanations are great.
• Appleton and Lange: More than 1000 practice questions to prepare for
the shelf exam. Fairly challenging, but the answer explanations are often
not very thorough or helpful.
30
 • NMS Surgery Casebook: Several comprehensive case studies. A nice
alternative or supplement to practice questions and textbooks.
• Lange Case Files: Surgery: Good review for basic surgical principles
though often lacking detail.
• Learning Objectives with Answers: A large document created by M3 students
several years ago that consists of all of the surgery learning objectives that
generally circulates around the class every year. Be warned that in this
document some of the answers are good, some are very incomplete and non-
informative, and some are incorrect. Most often this document is used to
study for the midterm.

Testing/Grading:
There are 3 components to the final surgery grade: an OSCE, your clinical
evaluations, and a shelf. To get honors you must score above the class
average of your current surgery group on all three components. To get a
high-pass you must score above average in 2 of the 3 components. The
average for the clinical evaluations is around 7.1 and the average on the
shelf exam is usually in the high 60s to low 70s.
There is also a midterm, an in-house test that does contain some slides. It
is derived directly from the learning objectives and lectures. The average
on the test is usually between 50-60%. While the midterm does not
factor into honors/high-pass, it is used to calculate the overall grade to
determine pass vs. fail.

Post Op Fever: Compartment Anterior Mediastinal Mass (4

Wind - atelectasis, Syndrome: T's):
pneumonia Pain Thymoma
Water - UTI Paresthesia Terrible (T-cell) Lymphoma
Wound - Infection Pallor Teratoma
**Womb - endometritis, Paralysis Thyroid Goiter
uterine infxn (if C- Poikilothermia
Section) *NOT pulselessness*
Walking - DVT
Wonder-Drugs - Medications

31
Sepsis: Hematuria (ITS): Fistula that fails to close:
Systemic Inflammatory I - Infection High output
Response Syndrome - Infarction Intestinal destruction
(SIRS)= - Iatrogenic (drugs) Short segment
Temperature: ↑ or ↓ T - Trauma Foreign Body
Tachycardia - Tumor Radiation
Tachypnea - TB Infection
Leukopenia or S - Stone Epithelialization
Leukocytosis - Sickle cell Neoplasm
Hypotension - cystitis
Sepsis = SIRS + Infxn
Septic Shock = Sepsis
unresponsive to fluids
(must use pressors)
Appendicitis: Ascending Septic (Ascending) Cholangitis:
Rovsing’s Sign Cholangitis: Reynold’s Pentad –
Psoas Sign Charcot’s Triad – Charcot’s Triad
Obturator Sign Jaundice Hypotension
McBurney’s Sign Fever (with rigors) Altered Mental Status
RUQ Pain

OBSTETRICS & GYNECOLOGY:

Included are templates of relevant OB/GYN notes that can serve as
references throughout the rotation.

Obstetrics H&P:
CC: A few words on why the patient presents, usually a symptom such as
“my water broke.” Quote the patient if you can.
HPI: Start with age G_P_ _ _ _ @ *** of weeks dated by (LMP, US {at #
of weeks}, or both) admitted for: describe the reason for coming the
hospital as you would for other rotations, making sure to ask about
vaginal bleeding, contractions (frequency and intensity), loss of fluid,
and fetal movement.
Prenatal Course: Complications? Screening tests and their results?
Ultrasounds?
PMH: As per usual
PSH: Particularly any abdominal surgeries
POBHx: # of pregnancies; # of births (Term >37wk; Preterm 20-37wk;
Abortions/Miscarriages <20wk; Living); Ask about route of delivery,
duration of labor, size of baby, gender, and any complications.
Meds: As per usual
Allergies: As per usual
Social Hx: EtOH, Tobacco, other drugs.
Family Hx: History of birthing complications or birth defects, bleeding
diatheses.
PEX: VS:
GEN:
32
 CV:
LUNGS:
ABD: Gravid, NT, fundal height
EXT: Comment on edema
FHT (fetal heart tones): Baseline, long-term variability, accels,
decels, variables (describe the decel or variable) –you’ll learn
how to read these during the first few days on L&D.
TOCO (tocometer-measures uterine contractions): q***min;
level of Pit
SVE (sterile vaginal exam): Dilation/effacement/station (done
by the resident or attending; students write “deferred”)
Labs/Studies: Be sure to include GBS status, blood type, Ab status,
Hep B, RPR/VDRL, Rubella and HIV.

A/P: Age, G_P_ _ _ _ at *** of weeks dated by (LMP or US {at # of

weeks} or both) admitted for _____________.
1. Maternal Well Being (MWB: usually “reassuring”)
2. Fetal Well Being (FWB: usually “reassuring”)
3. Labor (Expectant management? Start Pit? AROM?)
4. Other issues (e.g. GBS, Gestational diabetes, etc.)

Labor SOAP Note: written every two hours while patient is laboring
S: In any pain? Feeling contractions?
O: VS:
FHT: Baseline, long-term variability, accels, decel, variables (describe
the decel or variable).
TOCO: q***min; level of Pit
SVE: Dilation/effacement/station (done by the resident or
attending; students write deferred).
A/P: Age, G_P_ _ _ _ @ *** weeks dated by (LMP or US # of weeks or
both?) in latent/active labor.
1. FWB: Reassuring.
2. MWB: How is the mother doing? Does she need pain meds?
Are pain meds helping her?
3. Labor: Cont pit if being used. Include any change in labor.
4. GBS status: If positive, then indicate antibiotic being given.

Delivery Note:
Procedure: NSVD/LFVD/OFVD/Primary LTCS/Repeat CS/Classical
CS
PreOp Dx: # of weeks IUP. # of hours in 2nd stage of labor. If C/S,
give reason why.
PostOp Dx: Same
Attending: ***
Asst: Resident and/or student present for delivery
Anesthesia: Typically CLE (epidural)
EBL: For C/S ask anesthesiologist

33
IVF: For C/S ask anesthesiologist
UOP: For C/S ask anesthesiologist
Findings: **Viable M/F infant. Weight. Apgars at 1 and 5 minutes. **
Placenta delivered via manual expression/extraction. Intact? 3 Vessel
Cord? Abnl? ** If C/S, note status of uterus, tubes, and ovaries
bilaterally.
Lacerations: If vaginal delivery, indicate the degree of laceration and
type of suture material used.
Specimen: Indicate if cord blood collected.
Complications: ***
Condition: Stable
Disposition: LDR (for vaginal deliveries) or RR (for C/S) with infant
Dictation: (Resident or attending does dictation)

Post Partum Progress Note for a Cesarean Section:

S: Ask about pain, diet (and if tolerating it), nausea, vomiting, flatus, voiding,
vaginal discharge, ambulation, and breastfeeding (and how it is going). Ask
about post partum birth control plans.
O: VS and I/O’s: Include UOP over 24hrs.
CV: RRR. no m/r/g
LUNGS: CTAB
ABD: +/- BS. Soft. Appropriately tender. ND. Uterus firm @ 1-
2cm +/- umbilicus. Be sure to have pt lying flat for abdominal exam
INCISION: c/d/i (clean, dry, intact)
EXT: Check edema/calf tenderness.
Labs: If POD #1.
A/P: Age, G_P_ _ _ _ at *** of weeks dated by (LMP or US {at # of
weeks} or both) POD # s/p (type of C/S). AFVSS. Adequate/good UOP.
List how patient is doing.
1. d/c foley
2. Advance diet to general
3. PO pain meds
4. HLIV (hep-lock IV)
5. Encourage ambulation
6. Check CBC
7. Lactation consultant PRN
**Remove bandage on POD #1**

POD #2: Continue above recommendations. Advance diet if not already on

general.
POD #3: Continue above recommendations.
**Staples are usually removed on POD #3 for TRANSVERSE INCISIONS
ONLY. If in doubt, ask your resident. Apply Benzoin and steri-strips
perpendicular to incision.

Post Partum Progress Note for a Vaginal Delivery:

S: Ask about pain, eating/drinking, nausea, vomiting, voiding, vaginal bleeding,
and breastfeeding (and how it is going). Ask about post partum birth control

34
 plans.
O: VS: I/Os (if they have been recorded).
GEN: A&OX3. NAD.
CV: RRR.
LUNGS: CTAB
ABD: +/- BS. Soft. Appropriately tender. ND. Uterus firm @ 1-
2cm +/- umbilicus. Be sure to have pt lying flat for abdominal exam.
EXT: Check for edema/calf tenderness.
A/P: PDD # s/p NSVD (or forceps assisted VD). AFVSS. Adequate/Good
UOP. List how patient is doing.
1. General diet
2. Encourage ambulation
3. Lactation consultant as needed
4. Post partum birth control plan

Gynecology OP Note:
Pre-Op Dx: ***
Post-Op Dx: ***
Procedure: ***
Surgeon: ***
Asst: Include resident(s) and medical student(s)
Anesthesia: Usually either GETA (general) or CLE (epidural)
EBL: Get from Anesthesiologist
IVF: Get from Anesthesiologist
UPO: Get from Anesthesiologist
Findings: From both exam under anesthesia and Intra-op findings
Specimen: What you found and where it went
Complications: ***
Condition: Stable to PACU
Dispo: ***
Dict: Resident or Attending will do

Gynecology SOAP Note:

S: Ask about pain control (on IV or PO meds), fever, nausea, vomiting, diet
(and if tolerating), flatus, voiding, CP, and SOB.
O: VS and UOP: If not in computer, be sure to ask nurse.
GEN: A&O. NAD.
CV: RRR. no m/r/g
LUNGS: CTAB.
ABD: Note +/- BS. Soft. ND. Appropriate tenderness.
INCISION: c/d/i. No erythema or drainage. (Remove bandage on
POD #1 unless specifically told not to.)
EXT: Note edema and +/- SCDs/TEDs
Labs/Studies: ***
A/P: POD # s/p (procedure) for (what reason). List how patient is doing.
AFVSS.

35
 1. FEN: IVF, diet
2. GU: d/c foley?
3. CV: Stable?
4. Pain: Change to PO meds?
5. Other medical problems and their tx
6. Path: Pending if not back yet. When back, print a copy for the
chart (if at Prentice).

Gynecology Discharge Instructions:

Admit Date: ***
D/C Date: ***
Procedure: ***
Meds: In pt’s language; Pts usually leave with:
Norco 10/325mg 1 PO Q4H prn for pain; Disp: 30 (no refills)
Motrin 600mg PO Q6H prn for pain; Disp: 30 (no refills)
FeSO4 325mg PO BID; Disp: 60 (3 refills)
Colace 100mg PO BID; Disp 60 (3 refills)
Stairs: As tolerated
Lifting: No more than 10-15lbs for 2-6wks
Diet: No restrictions
Driving: Not while taking pain meds (Norco)
Other: Call if: temp>100.5, uncontrolled pain, severe nausea or vomiting, or
with any questions. In case of questions or emergency call Dr *** at (the
phone number) or 911

**Be sure to fill out the appropriate D/C form and write out the
prescriptions. This is good to do on POD #0 to assist residents.

DUTIES ON OB:
Daytime
1. Check in with residents. Check the board for patients to pick up at the
beginning of the day.
2. Write H&Ps on new patients throughout the day.
3. Check on patients every 2 hours and write a labor progress note.
4. Work with nurse when patient is pushing.
5. Gown up promptly for delivery (always wear the blue-knee high boots!)
and be ready to be an active participant in the delivery (obviously attending
and patient dependent).
6. Follow patients to C/S or be willing to go to a C/S at any time during the
day.
Night Float
1. Largely the same as days in regards to picking up and following patients.
Hours are typically 5:30PM to 7AM.
2. If interested, go to the ER with the Gyne on-call resident.
3. Always have something to read on hand as nights can range from very busy
to very slow.

36
DUTIES ON GYNE:
In The OR
1. Check to see if the patient needs Abx. Fetch them if necessary (they will
show you where the pharmacy is on the first day).
2. Take bed out and help roll it back in.
3. Write your name on the board.
4. Pull your gloves.
5. Introduce yourself to the circulating and scrub nurses.
6. Put SCDs on the pt’s legs.
7. Exam under anesthesia with resident and/or attending.
8. Place foley and do thorough vaginal prep.
On The Floors
1. Daily SOAP notes and orders done and in chart by 6:30am so resident can
add addendum.
2. Take off bandage in AM of POD #1 unless specifically told not to. Leave
dressing for the resident to examine.
3. Check POD #1 CBC.
4. D/C instructions and scripts.
5. PostOp check and note.
6. PM checks (no note needed, but done to update team) – Diet changes?
Pain control? Voiding? Flatus? New orders?
7. Follow-up on pathology POD #1 or 2. Print copy to put in chart.

Commonly Used OB/GYNE Abbreviations:

Ab – abortion (included elective, DMPA – Depo-Provera

therapeutic, and miscarriages) DUB – dysfunctional uterine
AFVSS – afebrile, vital signs stable bleeding
ASC-H – atypical squamous cells EDC – est. date of confinement
cannot exclude high-grade EDD – est. date of delivery
intraepithelial lesion EFW – est. fetal weight
ASC-US – atypical squamous cells of EUA – exam under anesthesia
undetermined significance FAS – fetal alcohol syndrome
bHCG – beta human chorionic FF – fundus firm
gonadotropin FHT – fetal heart tracing
BPP – biophysical profile FM – fetal movement
BSO – bilateral salpingo- FSE – fetal scalp electrode
oophorectomy FT – full term
BV – bacterial vaginosis FTP – failure to progress
C/D/I – clean/dry/intact FWB – fetal well being
CKC – cold knife cone biopsy GA – gestational age
CLE – epidural GBS – grp B streptococcus
CPD – cephalopelvic disproportion GETA – general anesthesia
C/S – C-section GLT – glucose loading test
Ctx or Ucx – contractions GPs – Gravida (number of
D&C – dilatation & curettage pregnancies) and Para
D&E – dilatation & /evacuation (number of births in this

37
 order: Term, Preterm, PCOS – polycystic ovarian
Abortions, Living) syndrome
GTT – glucose tolerance test PID – pelvic inflammatory disease
HELLP – hemolysis, elevated LFTs, PIH – pregnancy induced HTN
low platelets POBH – past OB history
HPL – human placental lactogen POD – post op day (0=day of
HSG – hysterosalpingography surgery)
ICSI – intracytoplasmic sperm PP – post partum
injection PGYNEH – past GYNE history
IUFD – intrauterine fetal death Pit – pitocin
IUGR – intrauterine growth PPBC – post partum birth control
restricted PPROM – preterm premature
IUP – intrauterine pregnancy rupture of membranes
IUPC – intrauterine pressure PROM – premature rupture of
catheter membranes
LBW – low birth weight ROM – rupture of membranes
LEEP – loop electrosurgical excision RPR – rapid plasma reagin
procedure SAB – spontaneous abortion
LFVD/OFVD – forcep assisted SERM – selective estrogen receptor
vaginal delivery modulator
LGA – large for gestational age SGA – small for gestational age
LGV – lymphogranuloma venereum SUI – stress urinary incontinence
LMP – last menstrual period TAB – therapeutic abortion
LOF – loss of fluids (water breaking) TAH – total abdominal
LOT – left occiput transverse hysterectomy
LTCS – low transverse C-section TPAL – term, preterm, aborted,
LTL – laparoscopic tubal ligation living
LTV – long-term variability TVH – total vaginal hysterectomy
MAC – conscious sedation TOA – tubo-ovarian abscess
MSAFP – maternal serum AFP TOLAC – trial of labor after
MWB – maternal well being Cesarean
NRFT – nonreassuring fetal testing TOCO – tocometer (measures
NST – nonstress test frequency of contractions)
NSVD – normal spontaneous TSST – toxis shock syndrome toxin
vaginal delivery UPI – uteroplacental insufficiency
NT – nuchal translucency U/S – ultrasound
NTD – neural tube defect VBAC – vaginal birth after Cesarean
OCP – oral contraceptive pill VDRL – Venereal Disease Research
OCT – oxytocin challenge test Laboratory
PCOD – polycystic ovarian disease

Recommended References, Textbooks and Pocketbooks:

• Beckmann’s Obstetrics and Gynecology: Same book from SBM.
An easy and concise read with helpful tables, figures, and diagrams.
Helpful practice questions at the end of the book.
• Blueprints in Ob/Gyn: Good, concise, easy read. Adequate to prepare
you for the shelf.
38
 • First Aid—OB/GYN: Good preparation for the shelf.
• Obstetrical Pearls/Gynecologic Pearls: Great pocketbook.
Provides a concise summary of all of the major topics. Can be read
within a day at a moderate pace. Good to read day before starting
new block of either OB, GYN surgery, or clinics.
• Pre-Test OB/GYN: 500+ clinical questions structured after the
USMLE Step 2. Good practice for OB/GYN shelf exam.
• Case Files: OB/GYN: Excellent preparation for Shelf and OSCE.
For many students a must read. Case based, so easy to work
through.

Testing:
Shelf: 100 question shelf exam. 130 minutes to complete.
OSCE: Typically 6 stations:
• OB exam: evaluate a pregnant pt (fundal ht, FHT, due date, etc.)
• Gyne exam (know how to use speculum)
• Oral exam with an attending
• Internet research skills: answer a clinical question
• Review pt chart and write A/P
• Clinical identification: evaluate pictures and write A/P

PEDIATRICS:
Included are templates of relevant Peds notes that can serve as references
throughout the rotation.

Pediatric H&P:
CC:
HPI: "4mo boy/girl w/ PMH sign for *** presents with _______."
• Apply OLD CARTS
• How much is he drinking/eating/peeing/pooping? What does he eat
(BM = breast milk, formula)? How much and how often? Normal
for them? Last time they pooped, consistency?
• How much is he sleeping? More/less than usual? Is he easily
arousable? Is he more fussy than usual? Is he consolable? *Parents
throw around the words "lethargic" and "irritable" and "more fussy."
When we say a child is lethargic (and not easily arousable) or irritable
(and not consolable), we have to start thinking about meningitis - so
be careful with your terminology.
• Typically report on the ER course here, however some residents and
attendings may advise you to put that info in your A/P.
PMH: Ongoing medical problems? Hospitalizations? ER visits? Who is his
PMD? Hx of asthma/allergies/eczema? (Always ask about the three b/c they
always go together.) Immunizations up to date?
Meds: As per usual.
Allergies: As per usual.

39
Diet: Ask about if not yet obtained. BM? What kind of formula? How much,
how often?
BirthHx: Pregnancy: Full term? Complications? Prenatal care? Birth:
Complications? GBS status? Fevers? ABx? How long was stay in the
hospital? Did baby go home w/ mom?
Developmental Hx: Assess milestones. Ask parents, but observe as many as
you can (head lag, rolling over, grasp).
Social Hx: Who lives at home? Environment? Apt/house? Pets? Smokers?
Who does he spend time with during the day (care taker, day care, school,
etc)? Recent travel? Recent sick contacts?
Family Hx: Hx of asthma/allergies/eczema? Childhood diseases, genetic
disorders, cancer in family? (Parents/Grandparents/Sibs)
PEX:
VS: T/HR/RR/BP
GROWTH: Height/weight/head circumference (if<2yo)/BMI, and
corresponding percentiles (look at growth curves).
GEN: Describe what child is doing. Is he well-appearing/ill-
appearing? Crying? Consolable?
HEAD: NCAT (normocephalic/atraumatic), AFOSF (anterior
fontanelle open/soft/flat). If less than 2yo, assess anterior and
posterior fontanelles.
EYES: PERRL, EOMI, tear production, red reflex (looking for
retinoblastoma/cataracts/etc) with an ophthalmoscope. Don't worry
about looking at fundus.
EARS: TM intact? (have mom or dad help hold child’s arms down)
THROAT: OP clear? MMM? Erythema or exudates?
NECK: No LAD (a shotty node should be less than 1cm)
CV: RRR, nml S1S2, no m/r/g
LUNGS: CTAB, wheezes, nasal flaring, tracheal tugging, subcostal
retractions, accessory muscle use.
ABD: Soft, NTND, +/-BS, no HSM
BACK: Sacral dimple, +/- hair tuft
GU: Tanner Stage, nml ext genitalia (for males, circumcised penis,
testes descended bilaterally)
RECTAL: Anus patent
EXT: Good cap refill (<2cm) or WWP (warm and well-perfused), no
c/c/e.
SKIN: No rashes
NEURO: “Appropriate” usually good enough. MAEW (moves all
ext well). Can comment on tone/strength/reflexes (esp. sucking,
palmar grasp, Moro, Babinski... DTR's are less important unless
illness is something musculoskeletal or neuro in nature)
* Above PE is a fairly comprehensive list of what you should assess. Some
attendings/residents will not want/expect you to record such a detailed
exam, especially if findings are normal.
Lab/Studies: For cultures, always report as "NGTD x how many days" or
“pending.”

40
A/P: 4mo infant p/w ***. Discuss differential diagnosis (usually a paragraph
or several sentences) and then break down plan by system (may only have
main issue and FEN depending on level of complexity of patient). You may
commonly see POAL (PO ad lib) in the FEN section.

Pediatric SOAP:
S: What happened overnight - per mom, per nursing staff, per pt. Update on
main issue. Eating (tolerating PO? any emesis?), peeing, pooping.
O: VS:
ƒ Tmax for last 24hr - note other fever spikes (and when)
ƒ Tcurrent
ƒ HR + 24hr range
ƒ RR + 24hr range
ƒ BP + SBP range/DBP range over 24hr
ƒ O2 sat + 24hr range
ƒ Daily weight
ƒ I/Os 24hr total in (break down by IV/PO) over 24hr total out =
total up or down.
For example, 500 in (300 PO, 200 IV)/600 out = -100 down.
ƒ UOP: Look specifically at urine output (record as cc/kg/hr, >1
is nml) and stool output (record as cc/kg/day, <20 is nml).
PEX: GEN, HEENT, RESP, CV, ABD, EXT, NEURO
Labs: As above.
A/P: As above.

Commonly Used Peds Abbreviations:

ABC – apnea, bradycardia, IRDS – idiopathic respiratory
cyanosis distress syndrome
AFOF – anterior fontanelle open IVH – intraventricular hemorrhage
and flat LGA – large for gestational age
AGA – appropriate for gestational MAS – meconium aspiration
age syndrome
BPD – bronchopulmonary MR – mental retardation
dysplasia NB – newborn
CBG – capillary blood gases NBN – Newborn Nursery
CLD – chronic lung disease NEC – necrotizing enterocolitis
CPS – Child Protective Services NICU – Neonatal Intensive Care
ECMO – extracorporeal Unit
membrane oxygenation NNB – normal newborn
FAS – fetal alcohol syndrome OFC – Occipitofrontal
GBS – grp B streptococcus circumference
HMD – hyaline membrane disease PAL – Peripheral Alimentation
HMF – human milk fortifier Line
ICH – intracranial hemorrhage PDA – patent ductus arteriosus
IDM – infant of a diabetic mother PIE – pulmonary interstitial
IICU – Infant Intensive Care Unit emphysema
PKU – phenylketonuria
41
PTD – prior to delivery TORCH – (titers for)
PVL – periventricular toxoplasmosis, rubella,
leukomalacia cytomegalovirus, herpes
ROP – retinopathy of prematurity TTNB – transient tachypnea of
SGA – small for gestational age the newborn
SIDS – sudden infant death UAC – umbilical arterial catheter
syndrome UVC – umbilical venous catheter

Recommended References, Textbooks and Pocketbooks:

• The Harriet Lane Handbook: Classic pocketbook for the house
officer. A must-have if you are going into Pediatrics, although
usefulness for our level of education is questionable. One is usually
available on the floor for reference.
• Blueprints in Pediatrics: Extremely good overview of peds. Easy
read.
• Pediatric Articles: Provided by clerkship director on Blackboard.
Covers most relevant subjects in pediatrics, although some articles
are too detailed.
• Clipp Cases: Accessible via Blackboard. Covers peds topics in a
case-based manner. You are required to do about half of them.
Many students find them an excellent way to learn. Summary pages
included at the end of each case. Consider printing out these
summary pages and studying from them. Many students have felt
these were the most important study aid for the clerkship.
• Pretest Pediatrics: 500+ clinical questions structured after the
USMLE Step 2. Good practice for peds shelf exam.
• First Aid: Pediatrics: Some find this book too dense, others view it
as the only book they need.

Testing:
Shelf: 100 question shelf exam. 130 minutes to complete.

42
 PSYCHIATRY
Psychiatry H&P:
CC: Describe CC, as you would do with any H&P
HPI: Include age, sex, and history of psychiatric d/o. Include living situation,
employment, recent stressors and funding status if pertinent to the CC.
Psych ROS: -Assess mood (depression screen ask SIGECAPS;
mania/hypomania/mixed episodes ask DIGFAST)
-Assess anxiety (excessive worry, panic attacks, obsessions, compulsions,
social anxiety
-Assess psychosis (including A/VH, paranoia, delusions, disorganized
thinking/behavior)
-Assess functionality (missed work or unemployment, ADLs)
-Assess chemical dependency
-Pt’s subjective sense of cognition (concentration and memory)
Past Psych Hx:
-Previous inpatient hospitalizations – when, where, why
-Previous outpatient tx – therapist/psychiatrist and when last seen, meds
used, how long tx lasted, and if it was beneficial.
-Get written consent to speak with therapist if possible.
-Previous suicide attempts/aborted attempts/self-destructive behavior
(such as cutting)
Chem Dep:
-Current use of EtOH (CAGE screen), drugs (ask about specific drugs),
and tobacco – quantity, frequency, pattern of use, last use of each, triggers
for use.
-If positive drug abuse, ask about history of withdrawal seizures, DTs,
blackouts
-Be sure to ask when first used, if there have been periods of sobriety,
rehab/detox/AA/NA programs attended.
PMH: ask specifically about – seizure d/o, h/o head trauma and LOC, stroke,
in women with children ask about post partum depression
PSH:
Meds: List meds on prior to admission and while in hospital. List use of PRN
meds. Don’t forget herbal, over the counter meds and birth control
Allergies:
Family Hx: h/o depression, bipolar d/o, anxiety, “nervous breakdowns,”
psychosis, suicide attempts, psych hospitalizations, and pertinent family
medical hx.

43
Social Hx: Include living situation, significant others, social support system,
education level, employment status, source of income, legal problems,
abuse hx.

Mental Status Exam:

Vitals:
GEN – appearance relative to age, race, dress, hygiene, behavior, eye
contact, cooperativeness, alertness, orientation
SPEECH – rate (accelerated/slowed/normal), rhythm
(halting/hesitancy/stuttering), volume (loud/soft/normal), lack of
spontaneity? Hyperverbal?
PSYCHOMOTOR – psychomotor retardation or agitation, tremor, ataxia,
wheelchair bound.
MOOD – in the pt’s words.
AFFECT – objective sense of pt’s mood: range (constricted/full/labile),
intensity, mood congruent/incongruent?
THOUGHT CONTENT – passive or active SI, intent, plan, HI, A/VH,
paranoia, delusions, obsessions, ruminations, etc.
THOUGHT PROCESS – linear, focused and goal oriented? Disorganized,
flight of ideas/logical/illogical/tangential/circumstantial?
INSIGHT – poor/fair/good/excellent
JUDGEMENT – poor/fair/good/excellent. Is pt making good decisions
for themselves and others in their care?

MMSE – (mini mental) – use card from 1st year or pocket book.

Labs/Studies:

Assessment: Brief statement of overall impression.

Axis I: Primary psychiatric dx (major depressive d/o, somatization d/o,
panic d/o, schizophrenia, bipolar d/o)
Axis II: Personality d/o and mental retardation. (Don’t dx a personality
d/o for the first time in the hospital. It is not a dx that can be made in that
setting. Instead, always write “DEFERRED”.)
Axis III: Medical d/o
Axis IV: Psychosocial stressors (chronic mental illness, financial or
employment stressors, relationship strain)
Axis V: Global Assessment of Functioning – Found in DSM IV
Plan: Include med suggestions, suggestions for placement, suggestions for
additional consults, suggestions of how to deal with family, etc.

Psychiatry SOAP:
S: Events o/n. Use of PRN meds (found in MAR)
O: Vitals
GEN – appearance, race, dress, hygiene, behavior, eye contact,
cooperativeness, alertness, orientation

44
 SPEECH – rate (accelerated/slowed/normal), rhythm
(halting/hesitancy/stuttering), volume (loud/soft/normal), lack of
spontaneity? Hyperverbal?
PSYCHOMOTOR – psychomotor retardation or agitation, tremor, ataxia,
wheelchair bound.
MOOD – in the pt’s words.
AFFECT – objective sense of pt’s mood: range (constricted/full/labile),
intensity, mood congruent/incongruent?
THOUGHT CONTENT – passive or active SI, intent, plan, HI, A/VH,
paranoia, delusions, obsessions and ruminations
THOUGHT PROCESS – linear, focused and goal oriented?
Disorganized/scattered/logical/illogical/tangential/circumstantial?
INSIGHT – poor/fair/good/excellent
JUDGEMENT – poor/fair/good/excellent. Is pt making good decisions
for themselves and others in their care?

MMSE – (mini mental) – use card from 1st year.

Labs/Studies –

A/P: Brief impression.

-Med suggestions, placement suggestions, suggestions of additional consults, f/u
on outpatient treatment options.

References/Textbooks (Recommended books are checked):

• Stoudemire's Clinical Psychiatry for Medical Students: Should
already have this book from SBM. Extremely wordy, but it contains
all the necessary information.
• Diagnostic Statistical Manual IV: For those students who consider
Psych as a specialty, as well as those students on the Consultation-
Liaison service.
9 First-Aid for Psychiatry: Many students find this book as helpful for
psychiatry as the First-Aid for Medicine was during that rotation.
9 Pretest Psychiatry: Good questions in preparation for the shelf exam.
• NMS Psychiatry: Many students use the NMS series to read as the
clerkship progresses. To study for the final exam, NMS Psychiatry has
many useful questions.
• Psychiatry by Current Clinical Strategies Publishing: Excellent Pocketbook
with most of the information you’ll need for the shelf

Testing:
The Psychiatry exam is a 100 question shelf examination. This exam is
traditionally very difficult to finish due to long question stems.

Also, there is an OSCE with 2 patients that requires you to be document a

thorough mental status exam and formulate management plans.

Commonly Used Psych Abbreviations:

45
ADL – activities of daily living MR – mental retardation
A/VH – auditory or visual NA – narcotics anonymous
hallucinations SI – suicidal ideation
Chem Dep – chemical dependency SIGECAPS – sx of depression: Sleep
DIGFASST – sx of mania: (Inc or Dec), Interests (Dec), Guilt,
Distractibility, Irritability, Grandiosity, Energy (Dec), Concentration (Dec),
Flight of ideas, Activity (Inc), Speech Appetite (Inc or Dec), Psychomotor
(Pressured), Sleep, Thoughtlessness retardation/agitation, Suicide Ideation
HI – homicidal ideation

46
 NEUROLOGY
The responsibilities on this rotation vary depending on site between
Evanston and NMH. Services include stroke, consult, ER, and outpatient
offices. However, always be prepared with a reflex hammer, tuning fork,
MMSE, and a dermatome map.

Neurology H&P:
While this is very similar to a medicine note, there are some differences,
which will be highlighted below.

HPI: Pt is a _ yo right-handed/left-handed dominant M/F with a PMH

significant for (neurologic diseases) presenting with (chief complaint)

Physical Exam:
Gen: NAD
Lung: CTAB
CV: rrr, no mrg, no carotid bruits auscultated

Neuro Exam:
Mental Status: alert and oriented to person, place and time. Language and
speech are intact. Able to follow simple and complex commands.
CN I: not tested
CN II: Visual fields full to confrontation. Acuity grossly intact. Pupils equal
round and reactive to light.
CN III, IV, VI: EOM full without dyscongugate gaze, no nystagmus or ptosis
CN V: Mastication intact; facial sensation normal
CN VII: face symmetrical
CN VIII: hearing grossly intact to finger rub bilaterally
CN IX, X: Palate and uvula elevation midline
CN XI: 5/5 sternocleidomastoid and trapezius muscles symmetrically
CN XII: tongue protrudes midline and without atrophy or fasciculations.
Motor:
Strength 5/5 in upper and lower extremities bilaterally with no atrophy or
fasciculations. Tone is normal without tremor at rest, posture or intention. No
cogwheeling or rigidity. Palpation of muscles in LE bilaterally does not elicit
pain or discomfort.
Reflexes:
Normoactive, symmetrical reflex in upper and lower extremities in following
tested reflexes: biceps, triceps, supinator, patellar and achilles.
Babinksi flexor response bilaterally
Sensation:
Intact sensation to pinprick, light touch, vibration, proprioception
Coordination:
Rapidly alternating movements and finger to nose testing performed well and
without difficulty
Gait and Stance:

47
Normal gait and stance. Able to walk on heels, toes, and in tandem. Romberg
performed without sway.

Neurology SOAP:
S: similar to Med. SOAP
O: similar to Med. SOAP
Should include a full neurological exam like the following:
MSE (mental status exam)
o A&O x 3 (alert and oriented to person, place, and time)
o Mini mental 24/30 unable to recall 3 objects at 5 min
and unable to spell “world” backwards
CN (cranial nerves)
o Always document all CN as shown above in the H&P.
Usually not acceptable to write “II-XII intact”
Motor:
o 5/5 is normal
o Be sure to check for pronator drift and examine distal and
proximal muscle groups.
Reflex:
o 2+ is normal (scale 0-4, 0 =absent)
o Check biceps, triceps, brachioradialis, patellar and Achilles
o Assess Babinski (flexor response (toes down) is normal)
Coordination: Assess finger to nose, fast finger movements, rapid
alternating movements, heel to knee, Romberg
Sensory: Assess lt touch, pinprick, proprioception and temp.
Gait:
o Describe their gait
o Can they walk on the toes? Heels? In tandem?

A/P: similar to medicine SOAP

References/Textbooks (Recommended books are checked):

9 Clinical Neurology by Gelb: This is the recommended textbook by
the clerkship director. It is an easy read and we would recommend
reading the text twice in preparation for the exam.
• High Yield Neuroanatomy: Great review of neuroanatomy! Good
basis for neurological principles. Not always a necessary book, but
can definitely help with the basics.
• Pre-Test Neurology: If you like practice questions, then this book
isn’t bad; however it tends to have many detailed questions that will
likely not be assessed on the shelf exam.

Testing:
Like other clerkships, there is a shelf exam at the end of the rotation. 100
questions, with some long question stems. Also like other shelf exams,
this is thought to be a challenging test.

48
 PRIMARY CARE
You will have the option of working in a family medicine, pediatrics, or
internal medicine clinic, all of which will provide a different experience,
but with the same underlying principles of outpatient care. You may be
expected to travel, so be prepared to factor in commuting time. If you
have this rotation near the end of the year, think of it as a culmination of
all you have learned from previous clerkships and as a way to apply the
various skills you have picked up along the way. If you have this rotation
in the beginning of the year, use it as a refresher course for honing your
PEX skills, as you may be a little rusty after studying for Boards.

The format of your day will vary from clinic to clinic, but will be much
like any CSA exam you have taken. You may shadow your preceptor for
the first day or so, but make sure you express your wish to see patients on
your own. Because of the high volume of patients, you may end up
helping out your preceptor, but beware that if you take too long, you end
up slowing them down. Efficiency is the key (aka focused histories and
physicals). Become familiar with the patient’s chart beforehand and
always keep a look out for interesting patients, as you can present them
during Weekly Report.

There is an OSCE, but it does not contribute towards your grade. There
is no shelf exam, but rather an in-house test developed by the department.
Use this rotation as a way to brush up on physical exam skills and focus
your differentials. For example, if you are not comfortable with the
otoscopic exam, ask your patients if you can take a look at their ears (time
permitting).

References/Textbooks (Recommended books are checked):

• Primary Care Medicine: Excellent reference for the clerkship. Will
be lent to you on the first day of the rotation.
• Otherwise, same books as medicine!

Testing:
The final exam is departmental exam that is based on the recommended
reading and topics covered in lecture. Therefore, go to class, pay
attention and do the recommended reading. Also, don’t neglect the derm
module…there are a few questions (with pictures) from that module that
could be gimmies if you have studied. The test is about 75 questions and
traditionally has a very high mean.

49
PATIENT PRIVACY
Respect the privacy of patients at all times.

If you fail to protect the confidentiality of health information you are:

♦ Acting unethically and are breaking the law
♦ Undermining your relationship with the patient and that of other
caregivers (including the patient’s personal physician).
♦ Placing the medical school, hospital and yourself in legal jeopardy
which, depending on the severity of the violation, may include fines
and jail time.

Here are a few reminders regarding the basics:

♦ Patients have the right to know that the confidential information on
their medical record will not be disclosed without their permission
♦ Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- ensures that individuals moving from one health plan to another will
have continuity of coverage and that their privacy and the
confidentiality of their health information is protected.
♦ Look at charts or other printed or electronic medical records only if
you are assigned to be involved in that patient’s care (the so-called
need to know principle). So, if you hear that your former high school
principal is in the hospital and you are curious as to how she is doing,
it would be a violation for you to look at her medical records if you
are not involved in her care.
♦ Do not talk to anybody who is not involved in the patient’s care about
the case. Never disclose patient information without the patient’s
permission. If you are ever approached by somebody who asks you
about a case and you are not sure if you should tell them anything,
don’t! Check with an elder on your team.
♦ NEVER talk about patients in public places like elevators, hallways,
cafeterias, or anywhere else where somebody might overhear the
conversation. For all you know, the person standing in the corner of
the elevator is the patient’s boss who will overhear things that the
patient does not want him to know.
♦ NEVER talk to patients in front of others if you aren’t sure that the
patient wants them to overhear the conversation: For instance, it is
inappropriate to speak with a patient about his medical condition in a
crowded waiting room.
♦ Don’t throw papers with identifiable patient information into
unlocked trash bins or other containers. Special containers for such
confidential materials are available
♦ Be careful to turn off computer screens and log off programs that
contain patient information when you are finished. Don’t leave
diskettes or other sources containing patient information where others
might be able to look at them.
You will receive extensive instruction on the privacy regulations.
50
 SAFETY ISSUES
Needle Sticks

If stuck with a contaminated needle, or otherwise subjected to contamination by

bodily fluids from a patient, there is a small but very real risk of acquiring a
serious infection from the host. If such an incident does occur, you are
automatically excused from whatever you are doing. It is to your benefit to
report all incidents because, if necessary, you will need to prove that you were
infected during your training in order to claim the disability insurance offered
through the medical school. Remember that your health comes first.

Medical attention will include cleansing and treating any wound, obtaining both your
blood and the host blood for testing, and the provision of counsel on follow-up treatment and
testing. At the time of any potential contamination, you should excuse yourself
from the activity under way and immediately call or go to the site specified
below:

NMH Corporate Health 312-926-8282 If it is after hours or on a

weekend, the office will be closed, but an answering service will take your call
and will page the nurse on call.

RIC Corporate Health 312-926-8282 If it is after hours or on a

weekend, the office will be closed, but an answering service will take your call
and will page the nurse on call.

CMH Employee Health 3-2273 Needle Stick Pager (NAB

103)

ENH Emergency Room Emergency Room

VAL Emergency Room (HEU) Emergency Room (HEU)

VAW Employee Health (Room 1480) 569-7159 Needle Stick Hotline

If at a physician’s office or other site, you would still contact Corporate Health
at NMH.

While the exact reporting procedure varies from hospital to hospital, the first
step is to contact the appropriate person immediately. This individual deals with
such incidents on a routine basis. He or she can order testing of the patient and
you, provide counseling regarding the need and desirability of further testing or
treatment, and answer any questions you may have.

In order to minimize your risk of exposure, follow the universal

precautions. Wear gloves, eye protection, and facemask during
procedures. Treat all patients and bodily fluids as if they are infected. Wash
your hands frequently. Don’t recap needles, and dispose of all sharp objects
51
immediately after use. If you follow them consistently, they will become second
nature.

For your own information and for patients who ask, it is important to
differentiate between confidential and anonymous testing. Confidential testing
is done at a medical institution, and the result becomes part of the medical
record, which is available to insurance companies and may affect future
insurability. Anonymous testing is done by “neutral” organizations like Family
Planning and state/county health agencies, and only the patient will know the
result. Consider this issue before being tested.
You should not receive any bills for treatment, but if you do, send them to
Christopher Johnson
Director, Office of Risk Management
Northwestern University
2020 Ridge Avenue, #240
Evanston, IL 60208-4335

Phone: (847) 491-8518

Fax: (847) 467-7475
Email: [email protected]

Immunizations
PPD: Yearly PPD or CXR results are required at all hospitals. The
Office of Student Programs will periodically announce class PPD
placement by Student Health.
Tetanus: Shots must be on record within the last 10 years. Usually, this is
done on enrollment at FSoM.
Hepatitis B: This series of three shots is usually done during M1 year.
MMR: Documented proof of 2 doses is required.
Flu: Each year the flu kills thousands of people. Although it is unlikely
that you will die from this disease, you can suffer its effects as well as
transmit it to your sick patients. So, it is highly recommended that all
hospital personnel receive the yearly influenza vaccine. Most hospitals
offer the vaccine to their personnel. Students may not always receive
these benefits. The VA offer free flu shots to students rotating in late fall
or early winter. Children’s may also offer free flu shots if you are rotating
through peds in the late fall/early winter. The flu vaccine is also available
from Student Health for a nominal fee.

Security

As medical students, we have terrible hours; we come to the hospital early

in the morning and leave late at night. Those are also the times when
most crimes occur. Fortunately, students have been mostly spared from
these unpleasant events in the past.

To further reduce your risk of being a victim, be street smart. Stay in well
traveled areas and be alert of your surroundings. Look like you know
52
what you are doing. Do not carry or wear expensive jewelry or bulging
wallets. If you feel threatened, get attention by running and crying out
for help. Finally, if you have questions about the general safety of an
area, talk to the hospital personnel. Most likely, they have been working
at the hospital for several years and know the places you should avoid.

ABUSIVE BEHAVIOR

Over the past few years, a growing awareness of abusive behavior by

faculty, housestaff, and others toward medical students and junior
housestaff has appeared in the medical education literature. A
preponderance of the reported incidents occurred during the junior and
senior medical school years, when the difference in power is greatest.
While there is reason to believe that such incidents are relatively
infrequent during clerkships, they are not absent.

What is Abuse?
Abuse can be a subjective entity depending on the perceptions of the
victim. However, it is not the rare outburst of verbal invective, directed
at whoever happens to be nearby. Such events do happen and are
unpleasant, but are not intended to be abusive. However, recurring
comments of an insulting or demeaning nature directed intentionally
toward a specific person or group of people is abuse. So too is any
physical contact of a disciplinary or harassing nature, repeated requests
for the use of a student’s time to carry out personal tasks or errands, or
any threat of grade retribution as a penalty for action or inaction
unrelated to educational or patient duties. These are inappropriate and
unprofessional behaviors.

The Response
The issue of student abuse has been discussed at the Curriculum
Committee, Deans’ meetings, individual departmental meetings, and
housestaff orientation programs.

When an abusive situation arises, the student should first attempt to

confront the abuser and inform the senior resident if necessary. If the
abuse continues or if the student anticipates retribution, the student
should then approach the appropriate department representative with the
case. At the beginning of each clerkship, the director should identify
specific individuals that will accept reports of suspected incidents.
Furthermore, the incident(s) should be reported as soon as possible, so
that corrective actions can be made.

In addition, Dean Angela Nuzzarello (312-503-4318) and/or Dean John

X. Thomas (312-503-1691) should be alerted to any suspected incident.
This is particularly important if it is felt that a departmental authority
does not understand or does not want to be concerned with pursuing the
issue.

53
Also, be liberal with your utilization of the Student Senate. The members of the
Senate have been elected to represent the student voice and to serve as your
advocates when the opportunity arises. If at any time you feel that your
concerns as a student are not being heard, inform your senator.

Perspective
Student abuse is a rare, but sad reality that arises during the clinical years.
Every physician must do her part to interrupt the occasional pattern of
abusive attitudes. In another two years, you will be assuming the role of
an authority figure and the responsibility to be a role model for your
patients, students, and colleagues.

54
 CONCLUSION

Your junior year will be extremely interesting and may also be quite
challenging. You will see and do many things that you may never have
the chance to do again – deliver a baby, replace a knee, consider the best
anti-psychotic for a schizophrenic with auditory hallucinations, help a
child in DKA, give tPA to a stroke victim, and oh so much more.

It has frequently been said that a student’s experience is team-dependent.

Unfortunately, there is no standard of resident teaching as there is a
standard of medical care, but one can make the best of the situation. As
with any working environment and life in general, there can be personality
differences, prejudices, and unfair treatment. Although one should try to
resolve those conflicts as smoothly as possible, sometimes it is better to
simply accept such circumstances unless they qualify as abuse.

Remember, you are here to learn (and you are paying quite a large sum of
money to do so). While it is your right to be taught, it is also your duty to
help out as much as possible. Remember, if your resident is able to finish
all the floor work because you helped, there will more time for teaching.
When it comes to helping, this includes helping all members of your team,
even your peers. This will allow for a more enjoyable working
atmosphere.

In addition to learning more about medicine, you will hopefully learn

more about yourself. You will be exposed to many different situations
and people, and these experiences will help you grow as a person and
become a great doctor.

Have a great year and welcome to the wards!

55
APPENDIX: Abbreviations
The following represents a very extensive list of commonly and uncommonly used
abbreviations. After spending some time on the wards, these abbreviations will
become almost second nature.

T. one (used to substitute for AFB acid fast bacilli (think

numerical digit) tuberculosis)
T.T. two (used to substitute for afib atrial fibrillation
numerical digit) AFP alpha fetoprotein
T.T.T. three (used to substitute for AI aortic insufficiency
numerical digit) AKA above the knee amputation
a before (Latin: ante) ALL allergies; also acute
AAA abdominal aortic aneurysm lymphocytic leukemia
Ab antibody or abortion AMA against medical advice
Abx antibiotics (signing out of hospital)
Abd abdomen AML acute myelocytic (or
ABG arterial blood gas myelogenous) leukemia
ABI ankle brachial index ANA anti-nuclear antibody
a.c. before meals (Latin: ante AODM adult onset diabetes mellitis
cibum) AP anteroposterior
AC & BC air conduction and bone A+P auscultation and percussion
conduction of ear A/P assessment/plan
ACTH adrenocorticotropic aPPT activated partial
hormone thromboplastin time (PTT)
ADA diet American Diabetic appy appendectomy
Association diet AR aortic regurgitation
ADH anti-diuretic hormone ARDS adult respiratory distress
(vasopressin) syndrome
ADLS activities of daily living ARF acute renal failure
skills
ad lib at liberty

56
AROM artificial rupture of D5 5% dextrose in saline
membranes or active range solution
of D 5 LR 5% dextrose in lactated
motion
AS aortic stenosis ringer’s solution
D5W 5% dextrose in water
ASA acetylsalicyclic acid (aspirin)
ASAP as soon as possible D+C dilatation and curettage
ASD atrial septal defect d/c discontinue or discharge
AXR abdominal x-ray DCFS Department of Children and
B/L bilateral Family Services
c with D+E dilatation and evacuation
CA carcinoma DI diabetes insipidus
C/D/I clean/dry/intact (in regard DIC disseminated intravascular
to incisions) coagulation
CHF congestive heart failure DJD degenerative joint disease
CIS carcinoma in situ DKA diabetic ketoacidosis
CM costal margin or DM diabetes mellitus
cardiomegaly DNR do not resuscitate
CMH Children’s Memorial (supportive measures only)
Hospital DOA date of admission or dead
CMV cytomegalovirus on arrival
CN cranial nerve (** do not use **)
c/o complains of DOE dyspnea on exertion
coags coagulation factors (tested DM diabetes mellitus
with PT/PTT) DP dorsalis pedis artery
COPD chronic obstructive DPT diphtheria, pertussis, tetanus
pulmonary disease immunization
CP chest pain or cerebral palsy DT’s delirium tremens
CPAP continuous positive airway DTR deep tendon reflexes
pressure DUB dysfunctional uterine
CPM continue present bleeding
management DVT deep vein thrombosis
CRF chronic renal failure Dx diagnosis
CRI chronic renal insufficiency Dz disease
C+S culture and sensitivity EBL estimated blood loss
C-section cesarean section ECT electroconvulsive therapy
C/S cesarean section ECG electrocardiogram
CS chemstrips (measures serum EDC estimated date of
glucose) confinement (referring to
CSF cerebrospinal fluid pregnancy)
CSOM chronic suppurative otitis EEG electroencephalogram
media EFM external fetal monitor
CT computerized tomography EFW estimated fetal weight
CTA clear to auscultation (in lung EGD esophagogastroduodenoscopy
exam) EKG electrocardiogram
CV cardiovascular ELISA enzyme linked
CVA cerebral vascular accident immunoabsorbent assay
(stroke) EMG electromyogram
CVAT costovertebral angle ENT ear, nose, and throat
tenderness EOM extraocular movements
CVP central venous pressure EOMI extraocular movements
c/w consistent with intact
Cx culture EPS electrophysiological
CXR chest x-ray study/service

57
ERCP endoscopic retrograde GP gravidy (# preganancies),
cholecystopancreatogram parity (#
ESRD end stage renal disease births categorized as TPAL
ESR erythrocyte sedimentation - term, preterm, abortions,
rate living kisa hildren)
ESWL extracorporeal shock wave GSW gunshot wound
lithotripsy gt. or gtt. drop or drops (Latin: gutta)
ETT endotracheal tube GTT glucose tolerance test
EXT extremities GU genitourinary
FB foreign body GYN gynecology
FBS fasting blood sugar HA or h/a headache
f/c/s fevers/chills/sweats HAL hyperalimentation
FDP fibrin degradation products HAV Hepatitis A virus
(same as FSP) Hb hemoglobin
FDLMP first day last menstrual HBHC home based health care
period HBV Hepatitis B virus
F/E/N fluids, electrolytes, and HCG human chorionic
nutrition gonadotropin
FFP fresh frozen plasma Hct hematocrit
FH Family History HEENT head, eyes, ears, nose, throat
FHR fetal heart rate HEU Health Evaluation Unit (the
FHS fetal heart sounds VA’s ER)
FHT fetal heart tones Hgb hemoglobin
FIO 2 fraction of inspired oxygen H/H hemoglobin/hematocrit
FLK funny looking kid (**not H-J reflux hepato-jugular reflux
very professional**) HMD hyaline membrane disease
FM face mask h/o history of
FOB foot of bed H/O hemoccult
F.P. Family Planning H.O. house officer
FROM full range of motion HOB head of bed
FSH follicle stimulating hormone HOH hard of hearing
FSP fibrin split products (same hpf high power field (referring
as FDP) to microscope)
FT IUP full term intrauterine HPI history of present illness
pregnancy HR heart rate
FTA-Abs fluorescent treponemal h.s. bedtime (Latin: hora somni)
antibody absorption HSG hystosalpingogram
FTT failure to thrive HSM hepatosplenomegaly
f/u follow up HTN hypertension
FUO fever of unknown origin hx history
fx fracture ICU Intensive Care Unit
gb gallbladder I+D incision and drainage
GBM glioblastoma multiforme ID infectious disease
GC gonococcus IDDM insulin dependent diabetes
GDM gestational diabetes mellitus mellitus
GERD gastroesophageal reflux IFM internal fetal monitor
disease IM intramuscular
GI gastrointestinal, I+O or I/O fluid intake (e.g. IVF) and
gastroenterology output (e.g. urine, stool)
gm% grams per hundred IPPB intermittent positive
milliliters of serum pressure breathing
GOETT general oral endotracheal ITP idiopathic
tube thrombocytopenic purpura
IUD intrauterine device
IUFD intrauterine fetal death
58
IUGR intrauterine growth MCV mean corpuscular volume
retardation MD terrapins
IUP intrauterine pregnancy mg% milligrams per hundred
IV intravenous milliters
IVAC a type of infusion pump MI myocardial infarct or mitral
IVDA intravenous drug abuse insufficiency
IVDU intravenous drug use MICU medical intensive care unit
IVF IV fluids MMMI mucus membranes moist
IVP IV push or intravenous and intact
pyelogram MR mitral regurgitation
IVPB IV piggyback MRI magnetic resonance imaging
JODM juvenile onset diabetes MRSA methicillin resistant staph
mellitis aureus
JRA juvenile rheumatoid arthritis (think isolation)
JVD jugular venous distention MS mitral stenosis or multiple
KUB kidneys, ureters, bladder sclerosis
(referring to abdominal x- MSO 4 morphine
ray) MVC motor vehicle collision
L left MVI multivitamin
LAD left axis deviation or left MVP mitral valve prolapse
anterior descending artery NABS normoactive bowel sounds
LBBB left bundle branch block NAD no acute/apparent distress
LDH lactic dehydrogenase NC nasal cannula
LE lower extremity (leg) NC/AT normocephalic, atraumatic
LFT liver function tests (a normal head)
LGA large for gestational age NEC necrotizing enterocolitis
LH luteinizing hormone NG naso-gastric tube
LIH left inguinal hernia NICU neonatal or neurosurgical
LLE left lower extremity (left leg) intesive care unit
LLL left lower lobe (referring to NIDDM non-insulin dependent
lung) diabetic
LLQ left lower quadrant NKDA no known drug allergies
(referring to abdomen) nl normal
LMA laryngeal mask airway NMH Northwestern Memorial
LMP last menstrual period Hospital
LOL little old lady (**do not Ø no or none
use**) NPO nothing by mouth
LP lumbar puncture (Latin: nihil per os)
L/S lecithin/sphingomyelin ratio NS normal saline
LUE left upper extremity (left NSAID non-steroidal anti-
arm) inflammatory drug
LUL left upper lobe (referring to NSR normal sinus rhythm
lung) NSVD normal spontaneous vaginal
LVH left ventricular hypertrophy delivery
m/r/g murmurs/rubs/gallops NT nasotracheal (referring to
MAL mid-axillary line suctioning)
MAOI monoaminooxidase NTND nontender, nondistended
inhibitor NTG nitroglycerin
MAP mean arterial pressure n/v/d/c nausea/vomiting/
MCH mean corpuscular diarrhea/constipation
hemoglobin O 2 sat oxygen saturation
MCHC mean corpuscular
hemoglobin OB obstetrics
concentration OBS organic brain syndrome
MCL mid clavicular line OCP oral contraceptive pills
59
OCOR on call to the OR PND paroxysmal nocturnal
(referring to OR meds) dyspnea
OD right eye p.o. by mouth (latin: per os)
OM otitis media POD postoperative day (followed
OOB out of bed (referring to by a number)
activity) polys polymorphonuclear
o/p outpatient leukocytes
OPV oral polio vaccine post-op post-operative
OR operating room PP post-partum
os mouth PPTL post-partum tubal ligation
OS left eye PPD purified protein derivative
OT occupational therapy (for tuberculin test)
OTD out the door p.r. per rectum (suppository)
OU both eyes PRBC’s packed red blood cells
p after (Latin: post) prn when necessary (Latin: pro
P pulse re nata)
PA posterior-anterior PROM premature rupture of
PAC premature atrial contraction membrane or passive range
Pap smear Papanicolaou cytologic test of
PAS para-amino salicyclic acid motion
PAT paroxysmal atrial PSH past surgical history
tachycardia PSVT paroxysmal supraventricular
p.c. after meals (Latin: post tachycardia
cibum) PT physical therapy
PCA patient controlled analgesia PTCA percutaneous transluminal
PCN penicillin coronary angioplasty
PCO polycystic ovary ψ psychiatry
PDA patent ductus arteriosus pt patient
PDR Physician’s Desk Reference PT prothrombin time or
PE physical examination or posterior tibial artery
pulmonary PTA prior to admission
embolus PTH parathyroid hormone
PEEP positive end expiratory PTT partial thromboplastin time
pressure PUD peptic ulcer disease
PERL pupils equal and react to PVC premature ventricular
light contraction
PERRLA pupils equal, round, and q every (Latin: quaque)
react to qAM every morning
light & accommodation qhr or q° every hour
PFC persistent fetal circulation qhs at hour of sleep
PFT pulmonary function tests qD daily (Latin: quaque die)
PG prostaglandins qid four times per day
PH past history qMWF every Monday, Wednesday,
PI pulmonary insufficiency and Friday
PID pelvic inflammatory disease qod every other day
PKU phenylketonuria qPM every evening
Plt platelets q shift every nursing shift (usually
PMH past medical history every 8 hours)
PMI point of maximum impulse qwk every week
(referring to heart) R right
pmns polymorphonuclear RA rheumatoid arthritis
leukocytes RAI radioactive iodine
(i.e. neutrophils) RBBB right bundle branch block
PM&R Physical Medicine & RBC red blood count
Rehabilitation
60
r/c/g/m rubs, clicks, gallops, SMA sequential multiple analysis
murmurs (chemistry laboratory tests –
RDS respiratory distress usually sodium, potassium,
syndrome chloride, bicarbonate, BUN,
RDW red cell distribution width creatinine, and glucose)
REM rapid eye movement SOB shortness of breath
Rh Rhesus blood factor SOM serous otitis media
RHD rheumatic heart disease sono sonogram (ultrasound)
RIA radioimmunoassay s/p status post
RIH right inguinal hernia SP speech pathology
RLE right lower extremity (right sp gr specific gravity
leg) SQ subcutaneous
RLL right lower lobe (referring SROM spontaneous rupture of
to lung) membranes
RLQ right lower quadrant SSCP substernal chest pain
(referring to abdomen) STAT immediately (Latin: statim)
r/o rule out SVC service
ROC resident on call SVT supraventricular tachycardia
ROM range of motion T temperature
ROS review of systems T3 triiodothyronine
RPR rapid plasma reagent T 3 -RU triiodothyronine resin
(syphilis test)
RR Recovery Room uptake
T4 serum thyroxine
RRR regular rate and rhythm
(referring to heart) T+A tonsillectomy and
RT radiation therapy adenoidectomy
RTA renal tubular acidosis tab tablet (Latin: tabella)
RTC return to clinic TAH-BSO total abdominal
RUL right upper lobe (referring hysterectomy bilateral
to lung) salpingo-
RUE right upper extremity (right oophorectomy
arm) TB tuberculosis (think isolation)
RUQ right upper quadrant TBG thyroxine binding globulin
(referring to abdomen) TBS total body surface
RVH right ventricular T+C type and crossmatch
hypertrophy TCA tricyclic antidepressant
Rx prescription, treatment, or TCDB turn, cough, deep breath
therapy TENS transcutaneous electrical
s without (Latin: sine) nerve stimulator
SlS2 first and second heart TFT thyroid function tests
sounds TIA transient ischemic attack
SBE subacute bacterial tid three times a day (Latin: ter
endocarditis in die)
SBO small bowel obstruction TKO to keep open (referring to
SCM sternocleidomastoid IV rates)
sed rate sedimentation rate TL tubal ligation
SEM systolic ejection murmur TM tympanic membrane
SGA small for gestational age TMJ temporal mandibular joint
SH social history TOA tubal ovarian abscess
SICU surgical intensive care unit TORCH toxoplasmosis, other
sig label (latin: signa) (syphyllis), rubella, CMV,
SL sublingual (e.g. for herpes
nitroglycerin) tPA tissue plasminogen activator
SLE systemic lupus TPN total parenteral nutrition
erythematosis T+S type and screen
61
TSH thyroid stimulating hormone vfib ventricular fibrillation
TTP thrombotic VNA Visiting Nurse Association
thrombocytopenic purpura V/Q ventilation/perfussion
TUR transurethral resection VRE vancomycin-resistant
TURP transurethral resection of enterococcus (think
the prostate isolation)
Tx treatment VS vital signs
UA or U/A urinalysis VSD ventricular septal defect
UCLA bruins, baby VSS vital signs stable
UE upper extremity (arm) VT ventricular tachycardia
U/O urine output v-tach ventricular tachycardia
URI upper respiratory infection w+d warm and dry (referring to
U/S ultrasound skin)
UTC up to chair (referring to WBC white blood count
activity) WDWN well developed, well
UTI urinary tract infection nourished
VA Veterans’ Administration WNL within normal limits
VDRL serologic syphilis test w/c wheelchair
VF ventricular fibrillation w/u work up
Visual field XRT radiation therapy
VFFTC visual field full to ZE Zollinger-Ellison
confrontation

Add your own abbreviations:

62
NMH Helpful Phone Number (with thanks to Dr. David Neely)

Hospital Operator
Dial 5-1000 or 0 from an in house phone.

Imaging Locations
Echo Reading – Rm 8-216 XR Viewing – Rm 4-328
CT Body Viewing – Rm 4-546 MR Viewing – Rm 4-525
Ad-Thal Viewing/Nuclear Cardiology – 8-140
** After 5PM, go to ED viewing to go over films with radiologists

Important Phone Numbers

Pharmacy
Analgesic Dosing Service: 5-7246 (pager), 6-3382 (office)
Anticoagulation Dosing Service: 5-6548, 6-8670 (office)

Radiology Psych
Protocol CT: 6-5314 Chem Dep Inpt Consult: 6-8411
CT Scheduling: 6-6366 Psych Consult: 6-8411
IR: 6-5200
Feinberg MRI: 6-4333 GI/Renal
Neuroradiology: 6-5245 GI Lab: 6-2425
Inpatient Rads: 6-5105 Dialysis (inpatient): 6-1696
US (general): 6-7032
Labs
Cardiac Cytopathology: 6-7002
Cardiac arrest: 5-5555 Flow Cytometry Lab: 6-7360
Emergency hotline: 5-5555 Hematology: 6-3200
Cardiac Cath Lab: 6-5135 Histology: 6-2429
Cardiac Echo: 6-7483 Immunohistochem: 6-7872
Cardiac Stress Test: 6-8662 Micro: 6-3202
Cardiology pager: 5-7458 Surgical Path: 6-3211
Echo reports: 6-7483
Echo scheduling: 6-7483 Miscellaneous
EKG pager: 6-6935 Ethics consult: 6-3112
Nutrition (inpatient): 6-7437
Patient Services RIC: 238-6000
Case Management: 6-2272 13E Nursing Station: 6-2356
Social Work: 6-2060 13W Nursing Station: 6-2381
PT: 3229 14E Nursing Station: 6-2365
OT: 6-2526 14W Nursing Station: 6-2358

Add your own numbers:

63
Notes

63
Notes

64