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The Unofficial Clinical Clerkship Survival Guide: University of Louisville School of Medicine
The Unofficial Clinical Clerkship Survival Guide: University of Louisville School of Medicine
Table Of Contents
General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Parking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Food and Dining Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Scrubs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Evaluations and Shelf Exams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Patient Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Computer Access and Electronic Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Prescription Writing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
White Coat Essentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Third Year Track Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
8-week Clerkships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
6-week Clerkships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Neurology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Elective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Values, Calculations, and Commonly Asked Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Example Notes and Oral Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Internal Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
General Information
This section is entirely dedicated to the general information that spans all of your third year of medical school and is not
necessarily related to an individual clerkship. Topics include parking, on-campus free dining, attire, clerkship evaluations, shelf
exam, patient logs, etc. More specific information pertaining to each of the individual clerkships can be found under its own
section. Read at length or flip back for reference as questions arise!
Parking
University of Louisville Hospital
University Garage: If you have around $400 burning a hole in your pocket, go for renewing your parking pass to the
620 Garage, but keep in mind you may not be doing all of your rotations at University Hospital. This garage offers
1,711 parking spaces for faculty, staff, and students, and is ID card protected for safe access.
HSC Parking Office: 414 East Chestnut Street
Hours: 8:00am - 4:00 pm, Monday-Friday, Closed 1:00pm - 2:00pm for lunch
Phone: (502) 852-5111
Free Parking: Students often park along Muhammad Ali Blvd, starting at Clay St (in front of the 620 Garage) and
ending at Jackson St; there is also free street parking along S. Hancock, Marshall Street, and Clay St. Please be prudent
and keep safety in mind as you walk to and from your car during early morning and late night hours. On weekends,
there is free parking at the UL hospital garage (on the corner of S. Hancock and E. Madison St, next to the pedestrian
crosswalk). Metered parking is also available (most now payable by credit card). Metered spaces are free after 6PM
Monday Saturday and all day Sunday.
Norton Hospital and Kosair Childrens Hospital:
Students get free parking at a lot adjacent to the L&N credit union (on the corner of
nd
Chestnut St and 2 St) while on a rotation at these locations. Students on a rotation at
Kosair can obtain a pass for the hospital parking garage by going to the parking office on
the first floor of the Medical Towers South (the blue building on the right after you pass
Norton Hospital on the corner of Gray and Floyd Street, heading towards Broadway). Go
in the double doors that face Gray Street and go to the right, following signs directing
you to the Parking Office. Also, parking at Kosairss garage (214 Abraham Flexner Way )is
free on the weekends!
st
Jewish HospitalDoctors lounge in the Rudd Heart and Lung center, 1 floor. Serves continental breakfast, a full
lunch, as well as a soft drink and espresso machine. Dont miss Taco Wednesdays! Often, your resident will give you
their door code or let you in to get to the grub.
Norton HospitalDoctors Lounge2nd floor Norton Hospital, across from escalators. A full breakfast and lunch are
served daily, with snacks available throughout the day. Relive your childhood dreams of chocolate milk with your
cereal. Badge access required, so have your resident let you in. Technically this is just for attendings, so opt to sit on
the couches and not at the tables if space is tight!
Kosair Hospital Doctors Lounge 1st floor of Kosairs; have your resident point it out, as it may be hidden. Your
badge should give you access to cereal, juice, fruit, peanut butter, crackers and a soda machine.
University HospitalAlthough there are no meals provided, the pre-op doctors lounge does provide bagels and
donuts in the morning (they go quick!), as well as access to a soft drink machine (broken about 20% of the time). You
can almost always find at least peanut butter and crackers here or in pre-op when you are looking for quick food
between cases. While on inpatient wards, most patient floors have access to the nutrition room, stocked with milk,
ice cream, soda, peanut butter, and crackers.
Scrubs
In general, wearing scrubs is limited to time in the OR, on-call days for inpatient medicine and pediatrics, and on Labor and
Delivery during your OBGYN rotation. During L&D, it is recommended that you come to the hospital in business attire and
change into scrubs in the locker rooms (3rd floor on L&D). It is always best to check with your resident teams about any dress
code for rounds. On Surgery, you should never wear scrubs to the Department of Surgery offices (2nd floor ACB)wear clinic
attire with your white coat. The location of scrubs will vary among locations and services, so check with your resident teams or
ask a nurse where you can find scrubs. Just a few pearls be conservative with your scrubs; go a size up if you need to and
dont be a hero. Ladies, small tops are hard to come by, so most prefer to wear a t-shirt or tank top underneath these oversized
scrub tops.
Patient Care - Taking an effective history, physical exam skills, generating a differential diagnoses, creating a
problem list, generating a treatment plan
Interpersonal and Communication Skills - Spoken and written communication, oral presentation skills
Professionalism Honor and integrity, responsibility and accountability, caring and compassion, and respect
Finally, your evaluator will have the opportunity to write Overall Comments. These comments will be the real meat
and potatoes of what appears in your Medical Student Performance Evaluation (MSPE) lettera summary of your
overall clinical performance during each of your rotations as a third year. The MSPE letter is a large part of your
application for residency, so it is important that it reflects your true performance. These evaluations are completed
using New Innovations.
Evaluation pearls: Very rarely will a clinical evaluation keep a student from honoringif you show up, work hard, and
are respectful, you should do just fine. If you are consistently not honoring because of your clinical evaluations (i.e.
honors on the shelf but not the clerkship), this is something worth talking about. Pediatrics tends to be a little more
difficult as their cutoff for clinical performance for honors is higher than most other clerkships.
Student Evaluation of the Rotation, Residents, and Attending:
Be sure to fill out your evaluations of the residents and attendings using New Innovations. You are often assigned
residents and attendings to evaluate at the end of your rotation-- constructive feedback (not overly negative) is
crucial to improving the experience for others. These evaluations are reviewed and can be used as a means for
positive change. Any serious issues or urgent concerns should be addressed sooner rather than later; utilize your
Track Captains, residents or anyone else you trust or to hear your concerns. Student mistreatment is taken very
seriously, so speak up should you feel uncertain or uncomfortable about an issue. Once the rotation ends, you will
receive an evaluation from Paul Klein to provide feedback on the rotation itself. This is a good time to offer up
suggestions to improve the way the clerkship operates (and it is anonymous!). Both the Clerkship Directors and the
Educational Policy Committee (EPC) review the survey results and comments to monitor the quality of the experience
and provide feedback for changes as needed.
Shelf Exams:
Each of the third-year clerkships concludes with a shelf exam, typically administered on the last morning of the clerkship. A
shelf exam is a clerkship-specific standardized test developed by the NBME that medical schools purchase to gauge how their
students perform on a national level. The exam is generally 2.5 hours long and consists of 100 questions. At the University of
Louisville, this exam is a generally a hefty portion of the final grade, ranging from 40-50%, depending on the clerkship, and is
graded on a curve with respect to percentiles. In order to receive honors for a clerkship you MUST receive a raw score
equivalent to the 75th national percentile (which hovers around a raw score of 80-85/100) or above -- no exceptions. In essence,
you must honor the shelf to honor the rotation. A passing grade involves a raw score of greater than the 4th percentile. If in the
course of your third year you fail a single shelf exam, you may retake that shelf exam. However, if you fail more than one shelf
exam, then you may have to remediate the entire course. While the school pays for you take the first shelf exam, if you fail a
shelf you will pay to retake the exam. Resources for each clerkship are listed under their respective sessions.
ONLINEMEDED.ORG has a series of free videos that review clerkship and NBME shelf content.
Patient Tracking
You are required to log each of your core clinical clerkships (with the exception of your time on Elective) in a case log located
on New-innovations. Each of the core clinical clerkships has a list of required clinical diagnoses that you must see or learn
about during the course of the rotation. New Innovations will allow you to log your patient with their corresponding diagnosis
obviously not every patient fits the exact descriptors, so think big-picture if you do not find the exact diagnoses you are looking
EMR System
University: NetAccess, Synapse, Allscripts, Cerner
Norton and Kosair: EPIC
VA EMR
VA fingerprinting and ID services
University Hospital:
Inpatient: NetAccess (health information) and Synapse (Imaging)
Login information will be provided to you by email from Tonya Hockenbury ([email protected]), Administrative
Assistant from the Office for Medical Education. Accessed through myapps.ulh.org. IT help number 502-588-0411 for
problems with access (i.e. when your username and password expire for the 10th time). NetAccess will provide you
with daily patient information, such as labs and ins/out, and some discharge summaries and operative reports.
However, at UL every patient also has a paper chart located on his or her respective hospital floor. Synapse is the
system used to access imaging, such as x-rays, CTs, and MRIs.
Outpatient: Allscripts
Prescription Writing
2 Pens (always have more than oneyou are bound to lose one or your resident/attending will ask for a pen)
Small Notebook
Stethoscope
Reflex Hammer
Optional: Pocket Medicine (amazon.com for $20), iPad mini or other tablet
For Rounds, a foldable White coat clipboard (found on amazon.com) can be very handy for helping stay organized.
Professionalism
Overall, your third year will be a much different experience than your pre-clinical years, so prepare yourself for a fun and
exciting change! That being said, the amount of responsibility that the third year brings can initially be a shock, but with time it
will be a great transition to what you will be doing for the rest of your life!
With the transition to clinical work, the concept of professionalism and teamwork becomes even more crucial. You will be a
member of the patient care team, and you must keep in mind that you are representing not only the University of Louisville,
but also the medical profession. Always be mindful of your team as well as your peers. Avoid criticizing students openly to
others, and particularly in front of residents or attendingsthey are now your colleagues and not just your classmates.
If you notice repeat or gross lapses in professionalism by your peers, there are many resources at your disposal. Sometimes
professionalism issues call for tough conversationsif you feel comfortable and are in a position to have that talk, please do so.
If not, you can address professionalism concerns with your Track Captain and through the anonymous submission of an Early
Concern Note (ECN). Keep in mind that ECNs are confidential, low-stakes, and are only reviewed by the student-only Honor and
Professionalism Advocacy Council (HPAC). For more information, see: http://louisville.edu/medicine/studentaffairs/studentservices/hpac
To submit an ECN directly, see:
https://louisville.edu/medicine/acl_users/credentials_cookie_auth/require_login?came_from=http%3A//louisville.edu/medicin
e/studentaffairs/ecn
This is a valuable tool in preventing professionalism issues from reaching the point of being detrimental in a Deans letter (the
MSPE) and can go a long way in helping correct professionalism issues early.
8-week Clerkships:
Surgery
Jewish Hospital Offers 4 weeks of general surgery, as well as 2 weeks of cardiothoracic surgery and transplant
surgery which most students find very interesting and enjoyable. A good balance of slow and busy, and usually
students find they have plenty of time to study. Call is at Jewish.
Kosair/VA Kosair offers an abundance of cases that are far different from the other general surgery experiences,
and may appeal to those interested in pediatrics. Pediatric surgery questions are less numerous on both the shelf and
oral exam, but some students report being able to be more hands on as compared to other surgery rotations. VA
balances OR cases with time spent in clinic, and provides great exposure to bread-and-butter general surgery cases,
as well as exposure to thoracic and vascular cases. As with everything at the VA, things run a little slower but this
translates to a little more study time. Call is split between Kosair (while on Peds surgery) and UL Trauma (while on VA)
Norton Hospital Comprised of 4 weeks of general surgery. Norton also houses the 2 week subspecialty optios of of
Colorectal Surgery, Surgical Oncology, and Vascular. This is a very busy service with a high patient volume, but the
exposure to numerous cases may appeal to those interested in surgery. Call is at Nortons.
UL Hospital Includes 4 weeks of trauma surgery, which may appeal to those interested in surgery or ER. Students
will also be assigned to either 4 weeks of elective surgery, which students find as a good balance to trauma as they
have more time to study on elective, or 4 weeks of surgical oncology and vascular surgery, which are both busy and
interesting services that may appeal to students pursuing surgery. Call is with UL Trauma.
Madisonville All 8 weeks are spent at Baptist Health in Madisonville, and students have a different lecture series
and call schedule. Most of the time is spent working directly with attendings, which may allow for more teaching
Wards (4 weeks) Students are assigned to teams at either UL or the VA. As with most things at the VA, things tend to
run a little slower but hours are slightly shorter.
GI Somewhat longer hours, but a great experience for those interested in the field and/or a more procedural
experience. You will see patients in the morning, observe procedures and see consults in the afternoon.
Cardiology - Both VA and UL involves seeing patients and writing notes. VA hours are slightly shorter, but all sites are
reportedly a great opportunity for those interested.
Pulmonary Consult Generally a lighter patient load with moderate hours and plenty of study time.
Endocrinology - Service covers four different hospitals and students will be asked to attend rounds and see patient,
but generally will not write notes. Among the longest hours on medicine (8-6), but very rewarding and well-liked by al
students that understand the time commitment. Avoid scheduling this subspecialty close to shelf exam time for study
purposes.
Nephrology Sites at Jewish, VA, and ULH. VA and ULH see lighter to moderate hours, while Jewish is among the
heaviest of the specialties in hours (7-7 many days). All the locations have been reported to be a good experience.
Infectious Diseases Sites at Jewish and UL. Also Bone and Joint ID team available at both Jewish and UL. You will see
patients in the morning, round with and attending, and will stick around campus for consults in the afternoon. Some
services also have clinic in the afternoon at the VA.
Hematology/Oncology Hours are extremely variable based on the attending and your teams fellow/resident.
Clinic attendance is encouraged once a week. You will see patients in the morning or afternoon, depending on the
attending.
Neurology: 2 weeks on inpatient and 2 weeks on outpatient. You can rank your preferred locations in the electives.
Inpatient:
Jewish General - This is one of the busier services but provides students with a great opportunity to see a wide variety of
neurological diseases.
Child Neuro - This is one of the most demanding inpatient services for neurology, but students see a wide variety of very
unique cases and learn a tremendous amount from the faculty. Child neuro is split with one week on inpatient and one on
outpatient. You will work one weekend day, but this also counts as your call day for the rotation.
ULH Stroke - Hours vary with attendings and patient volume. In general, the start time is earlier than most services, but
students are finished in the afternoon.
ULH General - Hours are similar to ULH Stroke. Students are expected to see a patient and write a note but are not always
asked to present during rounds.
Outpatient:
Child Neuro - Hours are typically 8-4PM. Some attendings will have you see patients and write notes, while others will
have you shadow and be helpful to the resident. Child Neuro assignment is 2 weeks long with one week spent on inpatient
and the other on outpatient.
Private Practice You are assigned to work with a community neurologist with each experience varying based on your
attending. In general, however, the hours are reasonable and the neurologists you work with are very helpful.
HCOC-Outpatient Clinic- Located in the Healthcare Outpatient Care Building (HCOC). Students are paired with different
attendings each day. Students usually start around 8:30AM and finish around 4:00PM, depending on the patient load.
Elective: scheduled on a different basis, please look for emails from your leadership or Sherri Gary for scheduling information.
6-week Clerkships:
Psychiatry:
Child Psych Excellent hours, but one-on-one patient interaction can be limited due to the nature of the service. Students
are generally happy with their experience here and often more enjoyable for those interested in pediatrics.
Emergency Psych- and ACB This rotation entails more dedicated hours, but the residents and attendings offer you
significant autonomy with a lot of patient contact. Pace can be hectic with patients that are potentially dangerous,
however security is always present and is a good environment for those that thrive in an ER environment. You will also get
this experience as part of your call assignment while on the psychiatry clerkship. The other half of this assignment is a
slower-paced outpatient experience at the ACB.
Norton Consult This is a consultation serve for medical in-patients with concomitant psychiatric symptoms. This rotation
offers good hours (8 to 4/5), with excellent patient contact, lots of autonomy, and responsibility. Most students feel
integral in actual patient care as the attendings and residents on this service listen to your suggestions and even let you
put in orders.
Norton Inpatient Unit Wide variety of diagnoses, excellent patient contact, with moderate autonomy.
ULH Inpatient UnitWide variety of illnesses and you are more likely to see those that are seriously ill as primary
admissions are made mainly through Emergency Psych.
ULH Consult ServiceThis service sometimes has limited patient censuses, but this also gives you lots of opportunity to
study.
VA Inpatient/Outpatient Hours consistently 8:00AM-4:30PM. This rotation offers significant autonomy with your own
patient load and one-on-one interaction with the attending. 5 weeks on inpatient VA-psych with 1 week on the inpatient
substance abuse treatment floor. You will present at Journal Club, write notes on your patients every day and will get used
to giving oral presentations.
Gynecologic oncologyvery interesting and demanding cases, but with significant hours and would be a good choice if
interested in surgery.
Benign gynecologic surgeryshorter hours than gyn/onc with more emphasis on hysterectomies and minimally-invasive
surgeries.
ODSUoutpatient surgery with short hours but less interesting/significant cases than the others. Will see procedures
including polyp removal and other procedures.
Urogynecologyprocedures for pelvic organ prolapses and urinary incontinence. May work at several different hospitals,
but a very interesting experience.
Pediatrics:
Stonestreet Clinic: A lot of one-on-one time with attendings, where they emphasize patient interaction rather than EMR
proficiency. It is an off-campus site ( 20-30 min drive) and you will see a more rural patient population.
Eastern Parkway Clinic: Located at the Kosair Charities Building on Eastern Parkway. You will experience nearly one-onone student/attending time, with lots of individual teaching. However, there may not be as many patients to see (8-10 per
half day), and cases may be less acute. Many Spanish-speaking patients, and a great opportunity to utilize medical Spanish.
Children and Youth Clinic (C&Y): Located on campus, next to nursing building. Heavy patient load as this clinic recently
absorbed what was UL Broadway Pediatrics. Attendings are kind, helpful, and most interested in helping students learn
brief lectures Tuesday and Thursday morning. However there are several students assigned to this at the site at a time, so
time with each attending can be limited.
Family Medicine:
Both the Newburg and Cardinal Station clinics are very similar and just vary by physical location. You will spend 2 weeks at
either of the clinic sites, then 4 weeks at your AHEC site (scheduled separately; be sure to attend AHEC fair for locations.
10
General Surgery
Welcome to surgery! It is easy to imagine this as a rotation you will spend all of your time in the OR (and you will spend many
hours there), but there is much more to surgery than operating. You will also spend a good deal of your time seeing consults,
assessing whether or not the patient needs surgery, performing bedside procedures (central lines), and making sure your
patients recover well postoperatively.
Surgery generates most of its patients through either previous clinic visits when the surgery was planned months or weeks in
advance, such as for elective cases, or through inpatient consultations or the ER where the patient is scheduled for surgery in
the upcoming minutes, hours, or days. Prior to surgery the patient is taken to Pre-Op where consent is obtained and the
anesthesia team performs their assessment in preparation for sedation. Once ready for the OR, the patient is rolled back and
prepped for surgery. After surgery, the patient is taken to the PACU where they are monitored while waking from anesthesia,
and eventually transported to their hospital room for postoperative management on the floor. The surgery team then follows
the patient until ready for discharge and will subsequently schedule the patient for outpatient follow up appointments.
This rotation is a total of 8 weeks. You will spend 4 weeks on a general surgery or trauma service and 4 weeks on a subspecialty
service(s), sometimes further divided into 2-week services. The patient population is largely adult, however, you may manage
pediatric patients if you are assigned to Kosair Childrens Hospital pediatric surgery service. Some of the common diagnoses you
will encounter include bowel obstructions, hernias, appendicitis, and gallbladder disease. The learning curve for surgery is
steep. Not only will you be expected to know the diagnosis and indications for surgery, you will also likely be questioned on
complications, anatomy, imaging, etc. This is a fast-paced rotation with long hours, so be prepared to dive in and get your
hands dirty!
Length of Rotation: 8 weeks
Locations:
University of Louisville Hospital (ULH)
530 S. Jackson St
Louisville, KY, 40202
Norton Hospital
200 E. Chestnut St.
Louisville, KY 40202
Jewish Hospital
200 Abraham Flexner Way
Louisville, KY 40202
Baptist Health
900 Hospital Drive
Madisonville, KY 42431
Important Contacts:
Clerkship Director: Dr. Sheldon Bond
Pediatric Surgery
[email protected]
(502)629-8630
11
Trauma Surgery (ULH) Cares for patients that present to the ER and need urgent or emergent surgical
evaluation and management. You will be responding to Room 9s (often Level I traumas!) and other consults in
the ER.
General VA (VAMC) The general surgery service at the VA. You will also have exposure to vascular and thoracic
cases.
Pediatric Surgery (KCH) Cares for pediatric surgery patients at KHC. This is a very busy service, as you will
manage consults and trauma calls in addition to previously scheduled surgeries.
2-week rotations
Colorectal Surgery (Norton Hospital) Manages patients needing surgery involving the colon or rectum. Offers a
great deal of exposure to colorectal cancer.
Vascular Surgery (Norton Hospital) Manages patients with vascular diseases that need surgical repair. This
service offers abundant OR time, with cases such as amputations, fistulizations, AAA repairs, and
catheterizations.
Surgical Oncology (UL, Norton, and, Jewish Hospital) Manages patients with cancerous tumors. This is a very
busy service, and you will see cases such as mastectomies, melanoma wide-local excisions, and Whipple
procedures.
Transplant Surgery (Jewish Hospital) Manages patients undergoing lung, liver, or kidney transplants.
Thoracic Surgery (Jewish Hospital) Cares for patients undergoing surgeries of the chest. Cases include
bronchoscopies and esophageal reconstructions.
Off-campus 8-week rotation: Madisonville (8 weeks, Baptist Health) Comprised of a 4-week general surgery
rotation, and 2 2-week rotations in orthopedic and vascular surgery. You will see a wide variety of cases on this
rotation, and spend more time working directly with attendings.
Grades and Assignments
Clinical Evaluations 30%
Quizzes 20% (3 total)
Shelf Exam 30%
12
13
On Trauma Service at UL: Your task as a student is making sure the patient-note templates are current with your
teams list (Trauma 1 or Trauma 2). This means that you have a paper note with your patients sticker in the top right
corner, the HPI is current and accurate (include blanks for HD# and POD#), the medication list is updated, etc. You
should have these templates updated and ready for your pre-rounding team (generally the interns). Once they have
completed their notes, the upper level will go over them, add their plan, and then you create the final days note
packet with enough copies for everyone on the team. You may be expected to pre-round and present 1-2 patients,
depending on which service you are assigned to and the expectations from your residents/attending. Just ask! Finally,
if you go to see a consult or room 9, grab a Trauma H&P and get started! The resident will ask the questions and
perform an exam; write as they talk. If you are on call, you can also get a template prepped and ready if you know the
patient is likely going to surgery/getting admitted. This will make the work easier in the mornings for those students
on the day shift. This can be a high-stress and busy service for the residents, so find ways to be helpful and they will
reciprocate by allowing you to be more hands on in the OR or with procedures.
The Oral Exam:
Surgery is the only rotation with an oral exam. The oral exam sounds terrifying, but most people leave feeling that it went much
better than expected. On the last Friday of your 8-week rotation, you will meet in the General Surgery Department (2nd floor,
ACB) for your oral exam. The exam consists of 3-4 clinical scenarios that you will work through step-by-step, and be expected to
list differential diagnoses, interpret imaging results, state the next step in treatment, etc. You will have one or two surgery
attendings or residents proctoring your exam, and it will last 20-30 minutes.
This sounds extremely intimidating on the first day of your surgery rotation, but by the end of the eight weeks you
will be more than prepared. The last two lectures before the oral exam will be devoted to the Gaar Sessions. These are two
four-hour sessions where Dr. Gaar presents the 10-15 possible cases you may be given in your exam. He will work through each
case in an oral-exam format, and he will cover any and every question that you could possibly be asked in your exam. Old
manuscripts of the Gaar Sessions from previous years are circulating, and are very useful for studying.
Most Common Study Resources:
Dr. Pestanas Surgery Notes Read through this multiple times before the shelf exam.
Surgical Recall More helpful for time spent in the hospital as it includes practical information as well as material you
may be pimped on. Also helpful for the oral exam.
Essentials of General Surgery by Peter Lawrence Textbook that can be helpful to cover high-yield topics for
presentation, work-up, and surgical options. Directed toward high yield and big picture material.
Toronto Notes, General Surgery Section bullet point information in dx and management of surgical diseases
14
Internal Medicine
Internal Medicine is a broad field composed of primary care internists and a variety of subspecialties that deal with adult
patients and their illnesses, most commonly in the inpatient setting but also outside the hospital in each of the Internal
Medicine subspecialty fields. Internal Medicine diagnoses are quite diverse, spanning every organ system. Some of the most
common include pneumonia, kidney disease, diabetes and metabolic diseases, hypertension and cardiac disease; the internist
functions as the primary care giver in the hospital for most of these patients. Some Internal Medicine teams are also consulted
by the surgical teams to co-manage complex patients before and after surgery.
Internal Medicine is an eight week clerkship organized into two four-week blocks: 4 weeks of general Internal
Medicine ward work and 4 weeks further subdivided into two separate Internal Medicine subspecialties. Both assignments
involve seeing new patient consults or admissions, writing a note, forming a differential diagnosis, constructing a plan with a
subsequent workup, and presenting that information to an attending and your resident team. During the rotation, students
attend weekly didactic sessions, daily Noon report, and weekly Grand Rounds. You will also be expected to complete two
graded clinical exercises called mini-CEXs in addition to the midclerkship evaluation (ungraded) and your final clinical
evaluations.
Length of Rotation: 8 Weeks (4 weeks of general IM wards, 4 weeks divided into two subspecialties)
Locations:
University Hospital
530 S Jackson St
Louisville, KY 40202
Jewish Hospital
200 Abraham Flexner Way
Louisville, KY 40202
Louisville VA Medical Center
800 Zorn Ave
Louisville, KY 40206
Important Contacts:
Clerkship Director: Dr. Kristan Milam
[email protected]
Clerkship Co-Director: Dr. Monalisa Tailor
(502) 852-3637
[email protected]
Didactics: All medical student didactics are weekly and mandatory, regardless of your clerkship assignment location.
While on IM wards at either the VA or UL there is a daily Noon Conference that is also required. Grand Rounds is a
weekly requirement, though this is often broadcasted to the VA.
15
NBME Shelf Exam 30% (Minimum of 4th percentile to pass; actual raw score varies depending on the time of the
year. Like all other clerkships, you much honor the shelf to honor the clerkship, which is above the 75% percentile).
SIMPLE Online Cases 15% (Completion of all 15 cases earns full credit)
http://www.med-u.org/simple
or
http://app.med-u.org/player/app/homepage.html
(2) Mini-CEX - Two clinical exercises graded by residents. . One mini-CEX will focus on medical interviewing skills and
the other mini-CEX will focus on physical examination. These exercises must be supervised by an attending, fellow,
or upper-level resident to meet the requirement. Does not count in overall grade, but must completed to pass.
Required Diagnoses/Patient Log: Log your patients on New Innovations to complete required diagnoses
The Wards:
On wards, an Internal Medicine team is usually composed of one to two medical students, two interns and one upper level
resident. Each team is divided up by colors: White, Red, Green, and Purple. No team is harder or easier than the others, as your
workload is mostly dependent on your residents and your attending assignment. The upper level is responsible for admitting
patients, handling transfers from the ICU, managing consults, and overall organization of the team. The interns primarily serve
as the workhorses who place orders, make phone calls, and take pages. All members of the team will break up the patient list
and see each patient individually before the attending arrives. Often times the upper-level will see every patient on the list,
though the interns split the list to manage the details of the patients care. Occasionally a pharmacist and a teaching resident
will also round with the team.
As a medical student, the day begins anywhere between 5:30 7:00 AM with pre-rounding, where you will see the 1-3 patients
assigned to you by your team. This usually takes place before or concurrently with the interns. Keep in mind that your prerounding time will vary based on your level of experience/efficiency, the number of patients you have, whether or not your
team accepted Night Float patients that morning, and the overall expectations from your team. You will write your own note
(hand-written at UL and typed at the VA), forming your own differential diagnosis followed by a plan. Once you have given your
case some thought and constructed your plan, students should discuss their patients briefly with their residents, helping to
finalize the presentation and plan proposed to the attending. They like to see that you have thought about the case and
management plans before asking questionsit shows that you are taking ownership of your patient and youre trying to
independently formulate a treatment plan based on your clinical assessment. Next, the attending arrives and begins to round,
which simply consists of a patient presentation, with students expected to present each patient they have seen that morning.
The expectations during rounds can vary dramatically between attendings, therefore asking a resident what a particular
16
UL Heme/Onc
UL Gastroenterology
UL Pulmonology
The subspecialty rotations are opportunities to explore the more specific fields of Internal Medicine (see list of available
subspecialties below). Each of these specialties share a similar team structure to wards, except the team is smaller, your upper
level is often a fellow, and many specialties do not admit their own patients, therefore acting only as a consult service to the
primary medicine team. Pre-rounding and rounding is similar to wards, though the focus is usually narrowed to only include
issues pertaining to that specialty. Most subspecialties will have both inpatient ward work and some clinic days. Clinic on some
services is mandatory (ID), while it can be optional for others (Endocrine, Heme/Onc). As always, clinic attire is business casual
with white coat.
The hours and work expectations seen on subspecialty depend not only on the site but also on the attending. In general, VA
rotations tend to be lighter than others, particularly on Cardiology and Renal. Infectious Disease at the VA and at University
tends to be a little longer and you will be asked to stay and wait for afternoon consults. Bone and Joint infectious Disease is
characteristically hit-or-miss but oftentimes works fewer hours than the general ID team. Hematology-Oncology can be a very
relaxed rotation or very time consuming, depending on the attending. The most difficult rotations have reportedly been Renal
at Jewish and Endocrine. Endocrine is a unique rotation in that students will cover all four major hospitals, often requiring
rounding at each location for a larger portion of the day than most other subspecialties. Students on this rotation do learn a lot
and have great experiences so long as you know what youre in for! Renal at Jewish involves rounding twice, once during the
morning and once in the afternoon, leading to the longer hours. Despite the longer hours, students have said both are excellent
for learning their respective area.
As compared to ward work, the hours on subspecialty are often shorter. For this reason, some students will request ward work
first, leaving subspecialty for the last four weeks to pack in a little more studying. The exception is with Endocrinebe sure you
dont have Endocrine scheduled during your last two weeks on IM, as it will interfere with studying for the shelf. Ultimately, half
of your track will do ward work followed by subspecialty or subspecialty then wards some argue there is no real difference in
strategy, so dont fret either way.
How to Shine: As with any third year rotation, attitude plays a huge role in success. Be willing to volunteer to write H&Ps, ask
your residents questions when they are free, offer to go medical-record hunting, and try to read the latest on Up-to-Date for
each topic so that you are prepared for discussion. Take extra time forming a differential diagnosis and be able to talk through
which diagnosis is more likely versus which are not and why. More so than many of your other rotations, the Internal Medicine
teams practice evidence based medicine, so whenever you can bring up new articles (print it out if you can!) or major clinical
trials on why things are conducted the way they are, that is something that will help prove you did look up information as it
related to your patient the night before. This is by no means a daily or even weekly requirement, but if you can find a tactful
17
World QBank (1359 questions) Excellent example of questions, though the subjects tend to be VERY specific. Should
be your primary source of questions for the shelf. Start early, as this is the largest question section on the Qbank and
the shelf creeps up quicker than you think!
Step Up to Medicine Best overall review for the shelf. Many students shoot to read this at least two times before
the shelf. This can also be very useful when studying for Step 2 CK.
Emma Rhamahis Review This 2 hour video is a must; most people watch it during the last week of studying to
brush up on high-yield topics. You can speed up the video to make it shorter.
http://som.uthscsa.edu/StudentAffairs/documents/HighYieldInternalMedicinecompatibleversion.pdf
MKSAP questions Not a great representation for the shelf, but the explanation are a great way to learn the
concepts and process of medicine. Consider this a secondary question resource.
Pocket Medicine (The Massachusetts General Hospital Handbook of Internal Medicine) Marc S. Sabatine; The
Washington Manual, Lippincott-Raven- Great resources for looking up quick information while on wards, but not a
great tool for studying for the shelf. Use as a quick reference guide.
NBME clinical mastery tests - Two 50 question tests that are $20 each. Best example of the questions faced on the
exam. Use more as a gauge of progress later on than as a study tool. Note: test 1 tends to be easier than the shelf,
while test 2 is more representative. Not often utilized by most students, but it can be a resource if you learn best by
example
18
Neurology
The field of Neurology encompasses a variable patient population and spans all ages, as well as inpatient and outpatient
services. Strokes, headaches, seizures, and altered mental status are among the most common diagnoses in inpatient
neurology; for each of these, identifying the underlying cause can drastically change the treatment options and prognosis for
the patient. In the outpatient setting, neurologists follow patients who tend to have a more chronic component to their disease
state. While diagnoses such as headaches and seizures are still common among outpatients, the role of the neurologist for
these patients is focused more on the ongoing treatment than the underlying cause with the best management commonly
achieved through long-term follow-up. As a student, you will experience neurology in both the inpatient and outpatient
environment, gaining an understanding of the variety of disease states that are most commonly encountered in the field. By the
end of the rotation, you will be a master of the ever-challenging neuro exam.
Length of Rotation: 4 weeks (2 weeks spent at two different locations, most commonly with 2 weeks of inpatient and 2 weeks
of outpatient).
Locations:
Inpatient:
University Hospital (Stroke, Inpatient)
530 S Jackson St
Louisville, KY 40202
Outpatient:
Louisville VA Medical Center
800 Zorn Ave, Louisville, KY 40206
Dr. Greg Smiths Office: A505
Community Neurologists
Dr. Rukmaiah Bhupalams Office: 1169
Eastern Parkway Suite 1126
Important Contacts:
Clerkship Director: Michael A. Haboubi, DO
[email protected]
Didactics: All lectures for the Neurology rotation are held on orientation day. This is important to account for because it is much
easier to put off studying through this short four-week rotation. Dont underestimate the Neurology shelfit is oftentimes one
of the more challenging shelf exams.
Grand Rounds: 8:00 - 9:00AM on Thursdays, located in the Nursing Building, however location may be subject to change. It is
required that students on the Health Sciences Campus attend Grand Rounds. Be sure to sign in! Those on outpatient service
with community neurologists are not required to attend Grand Rounds during those weeks.
19
Logistics: This is a four-week rotation divided into two different two-week assignments that cover inpatient and outpatient
Neurology.
Hours: Generally, hours are 8:00AM - 5:00PM for most locations with weekends off (**Peds Neuro works 1 weekend)
Call: Every student will take in-house call one time during their inpatient rotation
o UofL General Neurology call from 4:00PM 8:00PM on a weekday
Contact the resident or attending that is on call to setup the time and place to meet
Pediatric Neurology
This is a two-week experience with one week spent on the inpatient service and one week spent on the outpatient
service (clinic). Hours are usually 8:00AM 5:00PM but may vary depending on the attending physician. Pediatric
Neurology inpatient hours are sometimes longer and it is required that you work one weekend, but the overall clinical
experience is one of the best.
Overall, this rotation is very popular with students given the patient population, wide variety of diagnoses, and the
high quality of the clinical faculty in Pediatric Neurology. Namely, Dr. Vinay Puri, Chief of Child Neurology and Vice
Chair of Neurology, is often cited as one of the major strengths of the rotation.
Contact: Miranda S. Der Ohanian, Pediatric Neurology Administrative Assistant
502-588-3673
[email protected]
Inpatient The location for this assignment is Kosair Childrens Hospital. Of the inpatient locations, this can
be one of the most demanding of your time. However, students on this rotation have excellent experiences
and always praise the quality of the teaching by the faculty. Hours here are a little more demanding
expect to arrive around 7:00AM to pre-round. You will write notes on all of your patients (usually 2-3 while
on service) using EPIC. The residents and NPs will give you a heads up on the time you will round the next
day. Be prepared to present your findings on the neuro exam. Dont forget your penlight, reflex hammer,
and stethoscope. Both residents and attendings are most interested in helping you learn and perfect both
the neuro exam and the presentation of the neuro exam.
Outpatient The location for this assignment is Kosair Childrens Foundation Building (the 5 th floor of the
Chase building across from Kosair). As a student you will see the patient and his/her parents before the
attendingsometimes with a resident and other times on your own. Be sure to get a thorough H&P for new
patients. Like on inpatient, residents and attendings are most interested in helping you learn and perfect
the neuro exam. Outpatient notes are done using AllScripts; not every attending expects you to write notes,
but ask ahead of time.
UofL Stroke
The location for this assignment is UofL Hospital. Report to the Stroke ICU on the 9 th Floor and be prepared for
rounding by 8:00AM. Start time varies depending on the attending, but expect to get to the hospital sometime
between 6:45AM and 7:00AM so that you have time to see your patient and write a note in the chart before rounds
start. Students may finish before 5:00PM depending on the attending and volume of patients.
Jewish Consult
The location for this assignment is Jewish Hospital. Students should expect to arrive between 6:30AM and 7:00AM in
order to see their patients and prepare for rounds, which usually begin around 9:00AM. Generally, you meet with
your residents at 7:00AM once the pager switches over to get new consults. You will be assigned patients/new
consults to see and the resident will often let you see them independently. Get a good history and do a thorough
physical exam with ample attention to the neuro exam. Note writing isnt required, but if you type your notes in a
word doc and print them off for the resident to reference for their note, you get major bonus points. Often you will
20
Show up on time and be enthusiastic about learning. Come prepared: reflex hammer, penlight, and your stethoscope!
Know as much as you can about your patients (recent imaging and labs, etc.)
Offer to help the residents with anything that could make their lives easier
Be a team player
Master the neuro exam from top to bottom. Practice on each of your patients, going in the same order every time, to
perfect your approach and to become more efficient.
No matter how well you do on the wards, honoring often comes down to the shelf exam. Neurology is a short fourweek rotation, so dont put off your studying until the last week!
Most Common Study Resources:
Case Files
Blueprints
Pretest
First Aid
21
Elective
This four week period is very much a what you put into it is what you will get out. It can be the perfect opportunity to help
you decide your ultimate career choice, solicit letters of recommendation, and get to know faculty and staff in the specialty of
your choice, or conversely offer a time for rest and relaxation in-between clerkships. The third year elective time can be utilized
in a variety of different ways as outlined by the diagram below. Career Exploration and Clinical Electives are completely
optional and will be discussed in detail below. You may also opt to use your elective time for vacation, Step 2 studying, or
independent research (i.e. continue working on current research or join a new project of interest).
Career Exploration:
Career exploration is an opportunity for you to shadow faculty in a field of your interest without the stress of tests
and evaluations. If you are unsure about your future field, the career exploration path is affords you a hassle-free
way to further investigate your interests. Students who take this elective will be given 1 to 4 weeks of credit toward
the required elective time in the fourth year, depending on the amount of time you decide to commit to your career
exploration time.
22
Clinical Electives:
Clinical electives are pre-made, university-approved rotations that allow students to rotate through certain
subspecialties or work with specific patient populations. The clinical elective provides some students with the
opportunity to spend more time (outside the core rotations) with faculty in departments of interest. The evaluations
provided by these rotations may be important to gain if you are attempting to match in a subspecialty. For instance, if
you are interested in hand surgery and you find that there is a third year elective at the hand institute, it may be
advantageous to take that rotation during your elective time.
To see whats available, visit this link, https://netapps.louisville.edu/MECourseCatalog/Catalog.aspx
Select a field of interest and press submit to see courses offered. Make sure the description of the course you are
interested in includes the text: THIRD YEAR ELECTIVE. Be sure to pay attention to the prerequisites to each elective.
In the past, some electives have required you complete your surgery or internal medicine core rotations before you
are eligible to participate in the elective.
If you would like to participate in a clinical elective send an email to Sherri Gary, listing the elective title and dates for
the elective. This request must be submitted at least 4 weeks in advance.
III.
Research
This four-week period is an ideal time to focus on new or ongoing research projects. Certain programs, such as the
Distinction in Research Track, have elective research requirements that are often fulfilled during this time. Again, not
all four weeks are required to count towards researchyou can opt to do a week or two of research with a clinical
experience or vacation time built into the remaining weeks.
If you are interested in participating in research during your elective time, please contact Sherri Gary for further
instructions.
IV.
23
Outpatient:
UofL Health Care Outpatient Center
401 E Chestnut St
th
Outpatient Clinic is on the 4 Floor
Important Contacts:
Clerkship Director: Sara Petruska, MD
Office: 502-291-6257
Email: [email protected]
Didactics:
Orientation and Wednesday lectures with different members of faculty covering a range of OBGYN-related topics are
nd
in the Bridge Conference room, located in the OBGYN Education Office on the 2 floor walkway between the ACB and
ULH. Attendance is required and a sign-in sheet is present, but under certain circumstnaces absences may be excused
(unique procedure, your patient is mid-deliver, etc.) and are explained during orientation.
Small Group sessions: Attending physicians lead discussions on various cases that are provided in the orientation
packet. These cases require reading beforehand to allow for student participation and discussion. Following the
discussion, a short quiz will be administered for a grade. Small group schedules vary depending on the attending and
will be given at orientation.
Grand Rounds: Friday from 1-2 PM in the ACB auditorium, near the cafeteria. Attendance is required, sign-in sheets
are present, and food is not provided.
24
OBGYN Assignments
Labor and Delivery
ULH 3rd Floor. All students will complete this two-week rotation, with one week of day shift (5:30AM to 5:30PM) and
one week of night shift (5:30PM to 7AM). Each week will be five shifts, unless you are on the first week or the last
week. Three third year students will be on each shift. Scrubs are located in a closet on L and D, which is down the LEFT
rd
hallway after entering the door across from the elevators with your hospital ID on the 3 floor. Do not allow people
to follow you into the secure doorway. Men and women lockers are near the entrance of the floor.
On days, arrive with enough time to change and be at the postpartum wing, located down the RIGHT hall after
entering the secure door, by 5:30 AM. Morning duties include splitting up postpartum patients with a blue label
(meaning vaginal delivery) among the students. You will preround on the patient and ask questions regarding
postpartum care, which should only last about 5 minutes. Relevant questions are included in a blank postpartum note
that is in the patients chart. DO NOT fill out a blank note in the chart. Only residents will do this. You may make
copies of a blank note with the name blocked out to help guide your interview. Other information on the postpartum
note includes labs, which may be gathered from NetAccess or WatchChild, the EMR used on the floor. After youve
gathered information from the patient and the EMR, see which resident is going to see your patient and provide them
with the information youve already gathered, and see the patient with them. You are also responsible for writing
discharge prescriptions for patients. Prescription pads and stamps are located at the Nurses station. Specific
information regarding prescriptions is included in the orientation packet. On nights, students meet in the L and D at
5:30 PM. Those on Nights will also meet on the postpartum wing at 5:30 AM and are responsible for patients with a
red label (meaning Cesarean deliver). Patients who have had C-sections also receive an extra prescription for pain
medication. Patients who are postpartum vaginal deliveries are discharged 2 days after delivery; Cesarean section
patients are discharged 3 days after delivery. Patients with a purple label are private and are not rounded on by
students, but prescriptions for these patients can still be written. Once all the prescriptions are written for all patients
being discharged, bring them to morning report in the library to be signed by a resident. Both shifts attend morning
report for hand-off. Following hand-off, students on nights are dismissed, and students on days stay for morning topic
discussion.
After morning report one student will round with the Maternal Fetal Medicine attending, while the other two begin
on L and D. Patients who are in labor may be distributed among the students. Students should introduce themselves
to the patient if they are going to participate in the delivery. When the resident who is covering your patient checks
on the patient, ask to follow them so that you can also keep track of the patients cervical dilation and station.
Students should not perform pelvic exams unsupervised. Make sure to know where shoe covers, facemasks, and
sterile gloves are located; also know how to properly gown and glove so when a delivery is happening you can quickly
prepare. For vaginal deliveries, students are expected to have a delivery during which their hands are on the baby, in
addition to delivering the placenta and drawing cord blood. This will be practiced in the Sim Labs. C-sections will be
performed in the OR, which is located on the same floor. Following a delivery or C-Section, students are responsible
for filling out the Baby Book as well as the Placenta Registry Form. Ask a resident how to complete this. Also during
L and D, students must triage patients. Pregnant patients with acute issues (membrane rupture, decreased fetal
movement, extremity swelling, etc.) are assessed through triage. Students must keep an eye out to see when patients
enter triage and quickly perform an H and P as shown below. Present the patient to the intern or an available resident
along with your assessment and plan. This should all happen as quickly as possible.
Private Practice:
Private Practice is a two-week rotation, and student experiences vary depending on their preceptor. It may consist of
outpatient OBGYN care, private practice obstetrics, or private practice surgeries. Most students work from 8 AM to 5
PM and have weekends off.
Surgical Assignment:
Surgery is a two-week assignment, and student experiences vary depending on preceptor and assigned unit, which
includes Urology/Gynecology, Benign Gynecology, Gynecology Oncology, and One Day Surgery Unit (ODSU). Be in
25
One-Day Surgery will typically have 1 student working with a resident, and outpatient procedures include Essure
placement, hysterectomy, and tubal ligation. The hours are generally lighter on this assignment. Surgeries are
performed in the HCOC.
Benign Gyn will consist of two students at ULH working with Dr. Pasic and Dr. Biscette, an intern and chief
resident. Procedures include laparoscopic/robot-assisted/open hysterectomies, oophorectomies, and benign
ovarian tumor removals. A resident will inform you where to report and send the procedure schedule on Sunday.
Students are responsible to pre-round on a post-op patient, write a note, and present for rounds usually at 6:45
AM. Hours can vary depending on surgery scheduling and types of procedures.
Uro/Gyn will consist of two students on rotation and procedures including pelvic organ prolapse, urinary
incontinence, and overactive bladder, which may be performed laparoscopically or robotically. Hours on
Uro/Gyn also vary.
Gyn Onc normally has 2-3 students who will see procedures involving cancer of the female genital tract. Hours
are regular, depending on number and complexity of cases. For people interested in surgery, this can be the
most rewarding part of the rotation. Students are responsible for pre-rounding on patients, writing notes, and
presenting patients on rounds on 6th Floor South. The surgery schedule will be given out on your first day, and
you should contact a resident the day before to find out what time to show up for pre-rounding.
Continuity Clinic:
Continuity Clinic consists of 2 shifts of outpatient care at the Womens Health Clinic on the 4th floor of HCOC. Students
are assigned a resident for an afternoon or morning of clinic. This will allow you to follow the longitudinal care
involved in OBGYN. Resident assignments and scheduled clinic days for students are listed in the orientation packet.
Before seeing a patient in clinic ask your resident to help you adjust your history and physical to the patient. For
example, pregnant patients will have different histories depending on their gestational age, and gynecologic patients
may present for check ups or acute problems.
Grades and Assignments
Attire
rd
L and D scrubs are located in a closet on the 3 floor and Locker Rooms are also on the 3 floor
Private Practice will vary depending on your attending and what they are doing. Days of clinic require professional
attire, but wear scrubs if you are performing procedures. If working at a private hospital, wear professional attire to
the hospital and change into the hospital scrubs in the locker room.
Surgical Assignment ask a resident you are working with what would be appropriate
How to Shine:
The first step to doing well on any rotation is to understand how you fit into the treatment team and knowing the expectations
from your Attending and Resident physicians. This will allow you to be more proactive in your learning as well as assist the
team. The orientation packet and syllabus has a lot of helpful information. Asking students who have been on the rotation what
was expected of them and having a designated time for transition of care and a walkthrough of the important locations and
resources is always helpful.
26
BluePrints OBGYN is a very extensive read, but has all the important information and more.
Case Files presents a case and a few pages of relevant topics followed by questions
27
Pediatrics
Pediatrics focuses on the health and well being of infants, children, adolescents, and young adults, ranging 1 day old to 17 years
old. The clerkship is divided into two parts: inpatient and outpatient. Outpatient pediatrics mainly consists of well child checks
and acute care visits. These visits are important for immunization updates, checking growth curves, surveying developmental
milestones, providing anticipatory guidance, and much more. In addition, patients visit the outpatient clinics for acute issues
and monitoring chronic diseases, such as for asthma checkup or exacerbation, rashes, diarrhea, sore throat, cough, and fever.
Inpatient is considerably different as compared to outpatient in both work environment and the condition of the patients.
These patients can be quite sick, making their care more complex. The patients you will see on inpatient service will vary
greatly depending on the time of year you are on service. For example, asthma exacerbations are common in the summer and
fall, while upper respiratory infections and bronchiolitis and are common in the winter (i.e. RSV season).
Length of Rotation: 6 weeks (3 weeks inpatient, 3 weeks outpatient)
Locations:
Inpatient:
Kosair Children's Hospital, Medical Education
Office K609
231 E. Chestnut St.
Louisville, KY 40202
Outpatient:
Children and Youth Clinic
555 S. Floyd St.
Louisville, KY 40202
Stonestreet Clinic
9702 Stonestreet Rd. Ste. #100
Louisville, KY 40272
Didactics:
Student Didactics: Wednesdays, 2:00PM 4:00PM
Location: KCH, Room 605 (Office of Medical Education - Morning Report conference room
Orientation to the Pediatrics clerkship is held on the first Monday of the rotation. Clerkship information will be
discussed, followed by several lectures by UL pediatricians about history taking, physical exam, and immunizations.
Beginning the second week of rotation, Wednesday afternoons are set aside for quizzes and lectures. Quizzes are
based on mandatory online CLIPP (3 cases/week) cases (found at med-u.org) that students are to complete each
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Happy Half-Hour: Every Tuesday and Thursday at 1:15 PM, typically in 6 floor lecture room. This will cover highyield board material and include board style questions, and attendance is mandatory for all students on inpatient.
Grand Rounds: Fridays, 8:00AM-9:00AM
Location: Wade Mountz Auditorium, located on 2nd floor of Norton Hospital
Students should sit near the back. Breakfast is served in the adjacent room from 7:30-8:00AM. Attendance is
required, sign in sheets will be present, but those at Stonestreet can watch by video conference although technical
difficulties commonly occur.
Assignments
Inpatient
Students rotate on inpatient pediatrics at Kosairs Childrens Hospital for 3 weeks. The Residents Room, Morning
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report, Medical Education Office, and a computer lab are all located on the 6 Floor. The computer lab is near the
elevators and for the students when the Residents Room is busy. The service is split up into teams of different colors.
One large team color consists of two teams (i.e. Red 1 and Red 2) that share one attending. Each smaller team is
made up of a single upper level, an intern, and one to two medical students. Medical students are only assigned JFK
(Just For Kids) patients. You will be assigned 1-3 patients while on inpatientstart with one and get to know your
patients well.
Typical day is like on inpatient:
o
o
o
Pre-rounding: 6:30-8:00AM. Read notes from overnight on EPIC. Record vitals, labs. Check on the patients
and perform a physical exam (wake the patient if he/she is asleep). Check with the nurses to see if anything
important happened overnight, and remember to always be kind and courteous to the nurses. The nurses
change shifts at 7:00AM, so it would be ideal to get there for an update from the night nurse before she/he
leaves. You need to have your notes done by 8:00AM-arrive at whatever time you need to in order
accomplish this (i.e. can vary with patient load, how quickly you write notes, etc.). You will assign your notes
to the attending for their review. It may be helpful to print off your note and the patients H&P in the
morning, as you will often go off of this information when you present your patient during patient-centered
rounds.
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Morning report: 8:00-8:45AM. Report to the classroom on 6 floor of Kosair for a lecture or case
presentation given by one of the chief residents or attendings. All residents and students on the inpatient
service attend. You are expected to see your patients and have notes finished by this time.
Checkout: 8:45-9:15AM. Patients who were admitted overnight are handed off to your team.
Rounds: 9:15- 11AM-ish. All patients are seen with your team and attending. You are expected to present
the patients who you saw in the morning, including your assessment and plan. Use your pre-written note or
a printed H&P to help guide your presentation. Use these only as a guide and quick reference for vitals and
lab values. Try to not read directly off of your paper or notes and be confident in your presentation. It
doesnt feel natural at first, but the more you do it the better you feel!
Patient-centered rounds: On this rotation part of your presentations will take place in the room
with the patient, the patients family, and your entire team. The idea is to keep everyone involved
in the childs care on the same page. Because of this, avoid medical jargon (i.e. dyspnea= difficulty
breathing, hematuria= blood in urine) and try to narrate your presentation as a story, maintaining
eye contact and speaking to both the treatment team and the family. Occasionally before patientcenter rounds some attending ask for a brief presentation including your plan outside the
patients room.
Noon conference 12:00-1:00PM. Noon conference is not technically required, but the best advice is to
follow what your resident does. If they are there, then you should be, too! Some of these lectures are
helpful for the shelf and may even serve food! Check your schedule and ask your residents if there is a
conference.
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Work/Reading time: 1:00-4:00PM. Follow up on your assigned tasks as outlined during rounds, pending
results, consults, procedures, new admissions, etc. during this time. If things are dead, ask the infamous is
there anything else I can help you with or use your down time to prepare for the shelf exam.
Checkout: 4:00PM. You and your residents sit down with the call team for final checkout. Once youve
made it through the list, you may leave if you are not on call.
**Depending on which team you assigned to, you may also have specialty rounds (i.e. Yellow
team will have Nephrology and Neurology rounds daily if the residents have patients on that
service.) Sometimes is can be easy to zone out during these rounds if your patient isnt being
addressed, but try your best to pay attention.
Call days: 3:00-8:00PM, Q4: Your team will accept new admissions along with one other team. It is typically a busy
night of taking full H and Ps, so get food before it starts. You cannot take a call day as your one day off for the week.
Try to be in attendance on post-call days so that you can present the patients that you see while on call.
Weekends: No morning report. Check out at 8:00-8:30 am. Confirm with resident. Divide the weekend days between
you and the other student (if applicable), as you may only take off one day per week and the pediatric coordinators
prefer that your day off be on a weekend day.
Again, students get 2 days off during your 3 weeks on inpatient. Days off should only be taken on the weekends and
should be discussed with the upper level on the first day of the rotation and coordinated with the other student on
your team. You may not take call days off, and most attendings prefer that you are present on post-call days to
present the new patients you helped to admit.
Inpatient Requirements: (checklist is provided)
Outpatient
The outpatient rotation is 3 weeks long and will take place at one of the following three clinic sites: C&Y clinic, Eastern
Parkway clinic, or the Stonestreet clinic. Start time is generally between 8:30-9:00AM, depending on your clinical site,
and days typically run until about 4:00-5:00PM. The C&Y and Broadway clinic are convenient located near downtown,
however the Stonestreet clinic is about 20 miles (30 minutes) south of Louisville, near Valley Station. Student at C&Y
and Eastern Parkway with occasionally have 30-minute lectures over high-yield topics on Tuesday and Thursday
mornings before seeing patients. The outpatient experience is Monday Friday and does not require you to work
weekends.
All note taking is through the Allscripts EMR, which provides a default layout for documentation Use the templates to
guide your interview and questions, but do not get bogged down by all the options and avoid only talking to the
computer screen should you attempt to type and ask questions at the same time.
During your outpatient experience, you will spend one week of mornings in the Newborn Nursery at UL Hospital (3rd
Floor) in order to learn a proper newborn physical exam and practice it on newborns. Dr. Larry Wasser runs the
newborn nursery and is an excellent teacher. Each student will prepare a brief presentation over a topic of your
choice to present to Dr. Wasser, the residents, and the students on Newborn Nursery that week. It is very laid back
and this tends to be a very low-key week during your pediatrics experience.
You will also spend one half-day at the Home of The Innocents (1100 E. Market Street Louisville, KY 40206). During
this time you will round with the attending and sometimes a resident on kids with chronic debilitating diseases. It can
be a very humbling and inspiring experience. http://www.homeoftheinnocents.org/
Outpatient Assignment Locations
C & Y Clinic This tends to be a very busy clinic with many residents, 4-5 attendings, and a healthy patient load.
It is located on campus, next to the Nursing School, so it is easy to get to and less of a hassle when trying to
30
navigate back to Kosairs for lectures, Grand Rounds, etc. Take it upon yourself to grab a laptop for access to
Allscripts and dive in to start seeing patients. While busy with good volume, there can sometimes be many
students and residents, so you may have to double-up.
Stonestreet Clinic The advantage to this site is essentially one-on-one interaction with the attendings.
Depending on your attending, there tends to be less emphasis on EMR and more on the overall patient
interaction and oral presentation. Take it upon yourself to grab a laptop (always check it out!) for access to
Allscripts and an otoscope once you get to clinic. Pair up with attending and see how they best prefer their work
flow, and then dive in to start seeing patients. Sometimes residents arrive in the afternoons for their own clinic
patients and you may be asked to surrender your laptop. Keep in mind that the Stonestreet Clinic is located 20
miles (30 minutes) south of downtown.
ULP Eastern Parkway Clinic Students notoriously get a lot of one-on-one interaction with the attendings at this
clinic site, however, there are fewer patients with usually 8-10 patients per half day. This clinic is about 3 miles
(10 minutes) from downtown.
Outpatient Requirements
Prescription writing
Demonstrate appropriate professional behavior commensurate with the role of a physician and abide by the
rules and policies of the Department of Pediatrics, and of the facilities in which you work.
Patient logs/evaluations - Maintain and submit the logs at the end of the block along with evaluations of your
supervisors and clinical assignments.
Clinical performance - Achieve a "composite" MINIMUM score of 70% for each clinical assignment in the
Clerkship
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As is true for all rotations, be on time and be interested! Your body language can show your attending a lot.
Never complain! Be aware that residents get there earlier and will stay later than you.
There is usually no need to look at your phone in front of an attending unless he/she asks you to look up something
on the spot. If you want to look up a information while rounds, indicate you are using your phone or tablet for that
purpose (so that they dont assume you are texting!) some attendings prefer that you avoid technology entirely, so
just feel it out.
READ ABOUT YOUR PATIENTS. This is a great way to learn and impresses attendings. You carry very few patients
intentionallyso that you can know and understand their case inside and out.
If an attending asks you a general or pimp question that you do not know, be honest but tell them you can find the
answer and look it up when time allows.
When rounding, try to correlate what you have learned based on the patient case. This can also be a good time to
present any literature you have come across that could influence treatment plan. As always, be tactful and avoid
looking like a show-off.
Dont quiz, interrupt, or spit/punch/wet-hilly (and all other things common sense) attendings, residents, or fellow
students, but feel free to ask the attending questions when appropriate.
Do not answer questions directed to other students unless the conversation has been opened to the group. Similarly,
avoid jumping to answer every question when rounding as a teameveryone needs an opportunity to participate.
Be confident during your presentations on rounds by maintaining eye contact with your attending as you present and
also by avoiding the need to rely on your paper notes to narrative the presentation. If you are shy or uncertain of your
treatment plan, seek out the residents and ask if you can practice your presentation with them before rounds,
ensuring that your Assessment/Plan is appropriate. Your notes and presentations will improve with time and
experience, which will ultimately translate to better evaluations.
Talk to the nursesbe kind, courteous, and helpful when opportunities arise. Befriending the nurses can make your
job much easier. Being rude or inconsiderate is a quick way to make enemies and it is sure to make your job harder.
Common Study Resources
Case Files. Some love it; others hate it. Useful to read the cases related to assigned patients.
BluePrints is good for a quick overview of a topic you are unfamiliar with. However, it is much too superficial for what
you need to know for the shelf
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Family Medicine
Family medicine provides continuous and comprehensive care to any patient, including chronic disease management, acute
health management, and preventive care. It is the primary resource patients will have for their everyday health. Mostly, Family
Medicine practices will manage hypertension, diabetes mellitus, COPD, hyperlipidemia and many will also cover pediatrics and
OBGYN care in rural areas. Health maintenance visits are common and include medication checks, screening tools, and
immunizations.
The clerkship is six weeks long, with two weeks at one of two clinics in Louisville (Cardinal Station or Newburg) and four weeks
at an AHEC (Area Health Education Center) rural site. Students may request AHEC sites, especially those from underserved parts
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of the state, but there are no guarantees. On the Friday of the 6 week, students will take the 2.5-hour, 100-question Family
Medicine Shelf Exam.
Length of Rotation: 6 weeks (2 weeks in Louisville and 4 weeks AHEC)
Locations:
Cardinal Station Clinic
215 Central Avenue, Suite 100
Louisville, KY 40208
Phone: 502-588-8720
Newburg Clinic
1941 Bishop Lane, Suite 900
Louisville, KY 40218
Phone: 502-588-2500
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34
School presentation (does not include simple Q&A at your high school)
Jail or prison health care visit with health care provider, civic group presentation, substance abuse treatment
facility visit with health care provider
Points
Clinical Components
o Summative Evaluation from AHEC preceptor
320
o Mid-Clerkship assessments
15
o Formative feedback cards
5
o Summative evaluations from DFGM clinical
150
sites
o Chronic disease documentation sheet
20
Examination components
o Successful standardized patient exams
50
o Final written exam
300
o fmCases quiz
80
Additional components
o Service learning project
50
o Nutrition-FFQ
10
TOTAL
1000
Passing requires >70% of total points and >4th %ile on Shelf. Honors
requires >93% points and >75%ile on Shelf Exam. Specifics for Honors and
Passing are explained in orientation and in the syllabus.
Attire: SP attire (business casual) with white coat is expected every day. Scrubs are not worn on this rotation.
Commonly Asked Questions
AHEC: Many students from Kentucky who are not from Louisville like to go to areas closer to home. The Louisville
area and Northern Kentucky tend to be the most popular locations and are tough to get. Physician availability varies.
You can work with a family physician at a location you like, but it needs to be approved by the clerkship director. If
you are not from an underserved area, the clerkship coordinator will encourage you to go elsewhere.
Louisville clinics: The expectations at AHEC and the UofL Clinics vary. Some AHEC preceptors strictly have students
shadow them because they see many patients in one day and patient presentations need to be very quick. The UofL
clinics are teaching sites, allowing for more practice with independent history taking, presentation skill development,
and formative feedback. Some AHEC preceptors will want to know what your assessment and plan for a patient might
be, and some may not. However, at the UofL clinics, residents and attending physicians expect you to develop a
differential and potential plan for the patients you see. Its important to realize that the information used heavily in
clinic may not reflect equally on the Shelf exam. For example, knowing the screening guidelines and immunization
schedules are important for every patient you see in clinic, but there are few questions on this topic on the Shelf
exam. Make sure to be thorough in your studying as explained below.
Shelf exam: This is a very challenging Shelf exam, despite relatively light hours. There are not any specific UWorld
questions, which is a resource used for other clerkships. However, there are free questions available through
AAFP.org. The key is to identify the study resource you want to use and stick with it throughout the rotation (see
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Case Files: 55 commonly tested cases on the shelf exam, with explanations of each case, other possible diagnoses and
important take home points. Each case is also followed by 3-6 multiple choice or matching questions with answers
and explanations that follow.
Blueprints: More of a text based format that reviews commonly tested topics in family medicine.
Pretest: 500 questions and explanations that review common family medicine topics. Do not get bogged down by
some of the more obscure specifics of some explanations.
Family Medicine Question Resources at AAFP.org: After going to the AAFP website, navigate to CME (link at top of
page) and under Find AAFP CME by Topic click on Board Review Preparation. Scroll to the bottom of the next
page and click on Board Review Questions, which will then require you to register. NOTE that this registration takes
time to approve, so register early in the rotation even if you dont plan to start doing questions until later. These
questions are a good review, but are meant for the Family Medicine Boards not the Shelf, so keep that in mind.
Step-Up to Medicine (Ambulatory Care section only): Approximately 80 pages that covers outpatient care, guidelines
to chronic diseases, and first and second-line treatment options for common diagnoses, such as hypertension,
hyperlipidemia, etc. Relatively quick read covers high-yield topics.
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Psychiatry
Psychiatry is the field of medicine that focuses on treating diseases of dysfunction in cognition and behavior and their
associated pathology. This clerkship consists of treating patients of all ages, including children, with a wide variety of social and
medical backgrounds that may contribute to their diseases. You will learn to effectively utilize the mental status exam to
evaluate patients. Hours at the different sites vary, but students will always have weekends off. Common diagnoses include
anxiety disorders, mood disorders, PTSD, substance abuse, personality disorders, delirium, and dementia. The clerkship is 6
weeks and divided into 4 weeks at a primary site and 2 weeks at a secondary site, except for those at the VA. The various sites
are Emergency Psychiatry Services at ULH, Psychiatry Inpatient at ULH or Norton Hospital, Psychiatry Consult at ULH or Norton
Hospital, Child Psychiatry Inpatient at Norton Hospital, and Child Psychiatry Outpatient at the Bingham Clinic, and Psychiatry at
Veterans Affairs Medical Center.
Length of Rotation: 6 weeks (Primary site 4 week rotation and Secondary site - 2 week rotation)
Locations:
Emergency Psychiatry, ULH Inpatient, ULH Consult
University Hospital
530 S Jackson St
Louisville, KY 40202
EPS 1st Floor
ULH Inpatient 5th Floor, East
Veterans Affairs Medical Center
800 Zorn Avenue
Louisville, KY 40206
VAMC Psych 7N Floor
Didactics: All didactic lectures led by faculty occur on the first 3 days of the clerkship, and clinical rotations begin on the first
Wednesday morning, followed by the last lecture in the afternoon.
Professor Rounds: Wednesdays, 12:00 1:00PM
Students are scheduled to lead an interactive case presentation with a faculty member from 12:00 PM to 1:00 PM.
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38
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Clinical Evaluations completed by Attending Physicians and Residents are worth 100/250 points
Reflective writing assignment (1-2 pages, double spaced) is worth 20/250 points
SP Exercise is worth 20/250 points
Interview evaluation form completed by Attending Physician or Resident is worth 10/250 points
NBME Shelf Exam is worth 100/250 points
th
Honors will be considered for >75 percentile on the shelf exam and 90% clinical grade.
Pass will be given with a minimum of 70% on clinical evaluations and >4th percentile on the shelf exam.
Attire
All services recommend against neckties, necklaces, and other low hanging jewelry for safety reasons
EPS Scrubs and white coat are acceptable
Other services Clinic attire and white coat
How to Shine
The first step to doing well on any rotation is to understand how you fit into the treatment team and knowing the expectations
from your Attending and Resident physicians. This will allow you to be more proactive in your learning as well as assist the
team. Sensitivity and empathy go a long way when interacting with a patient, and understanding patient cues will help you
gather information that other people may not, residents and attendings included. Especially on Psychiatry, there is a chance
that patients will be poor historians, so getting corroborating information from family members or medication lists from their
pharmacy can help build a more accurate history. On the other hand, recognizing that patients may be more honest without
family in the room will also help you learn more about them. Arrive early when prerounding on a patient and realize that you
may be the one person on the medical team that they talk to the most, so be vocal during rounds and provide your own
assessment and plan during your presentation. Show your enthusiasm by volunteering to see consults, doing prescreens, calling
outside hospitals or pharmacies, and other tasks that improve the teams efficiency.
Common Study Resources
First Aid for Psychiatry Clerkship is well organized review of all tested topics, including mental status exam
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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics
2 Peripheral IVs
2 Chest tubes
1 Endotrachial tube
1 Nasogastric tube
1 Foley catheter
Burns: Estimating the Total Body Surface Area (TBSA) The rule of 9s
Head 9%
Upper extremity 9%
Back 18%
Palm 1%
Burns: Fluid Resuscitation
Internal Medicine
SIRS Two or more of the following:
pO2 < 60 mm Hg
pO2 decrease or pCO2 increase by 10 mm Hg from baseline (takeaway point check baselines when possible
especially if the patient has known COPD!)
Next are the lab values, specifically. You much know and interpret when electrolytes are low and how to correct them.
Na Complex workup involved for both hypo- and hypernatremia. Step-up or Pocket medicine have good algorithms.
Know this is a WATER problem, not an issue of too much or too little sodium.
Symptoms include:
o arrhythmias,
o muscular weakness and cramps,
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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics
o decreased deep tendon reflexes,
o polyuria, polydipsia
o ,nausea and vomiting.
Replacement treatment
o K should be replaced orally with 10 mEq of KCl increasing K levels by 0.1 mEq/L.
o IV can be used in severe (K < 2.5) or patients unable to take oral KCl. Maximum infusion rate is 10
mEq/hour in peripheral line or 20 mEq/hour in a central line.
Patients commonly complain of pain during infusion, so it the less preferred method.
Hyperkalemia is
Refers to a K > 5
Symptoms include:
o Arrhythmia: look for peaked T waves, QRS widening, PR interval prolongation, loss of P waves
on ECG
o Muscle weakness and (rarely) flaccid paralysis
o Decreased deep tendon reflexes
o Respiratory failure
o Nausea/vomiting, intestinal colic, diarrhea
Treatment
o First therapy is IV calcium gluconate to stabilize myocardial membrane potential, thus
reducing the likelihood of arrhythmia.
o Glucose and insulin can also be administered for immediate treatment
o Kayexelate can also be used to reduce K but its much slower acting
o Hemodialysis remains the most effective and rapid way to lower K. Usually only seen in
patient with extreme renal failure.
Ca Correct your Ca for albumin [0.8x(4-Alb)]+Ca= Corrected Ca level
BUN/Cr: Used primarily as a measure of kidney function
Acute Kidney Injury Determined by the RIFLE criteria
Risk: 1.5 increase in serum creatinine or GFR by 25% or urine output of <0.5 mL/kg/hour for 6 hours
Injury: Two fold increase in serum creatinine or GFR decrease by 50% or urine output of <0.5 mL/kg/hour
for 12 hours
Failure: Three fold increase in serum creatinine or GFR decrease by 75% or urine output of <0.5 mL/kg/hour
for 24 hours or anuria for 12 hours
Loss: complete loss of kidney function for greater than 4 weeks
ESRD: Complete loss of kidney function for more than 3 months
Prerenal failure
Most common Cause of AKI is a decrease in systemic arterial blood volume or renal perfusion
Etiologies: CHF, Hypovolemia, Hypotension, Renal arterial obstruction,
Lab findings:
o BUN/Cr >20:1
o Increased urine osmolality (>500 mOsm/kg)
o Decreased urine Na (<20 with FENa <1%)
o Hyaline Casts
Renal Failure
Kidney tissue is damaged resulting in an inability to concentrate urine
Etiologies: Acute Tubular Necrosis, Glomerular disease, Vascular disease, Acute Interstitial Nephritis
Lab Findings
o BUN/Cr <20:1, closer to 10:1
o Increased urine Na (>40 mEq/L with FENa >2% to 3%)
o Decreased urine osmolality (<350 mOsm/kg)
o Abnormal UA with different sediment depending on etiology
Postrenal Failure
Least common cause of AKI result of downstream occlusion of urine flow
Etiology: Urethral obstruction (BPH), Nephrolithiasis, Obstructing Neoplasm, Retroperitoneal fibrosis
Can appear to look like ATN if obstruction persists.
Bicarb: Acid-base returns! You need an ABG to accurately determine whether there is an actual acid base disturbance
(no pH otherwise!). If there is an anion gap metabolic acidosis remember A CAT MUDPILES!
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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics
43
Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics
Many internal medicine physicians use scores to determine the severity of a given disease. You should know the components of
these scores and use a calculator to determine them when on rounds. High yield examples include:
Pneumonia: CURB-65 or Pneumonia Severity Index
Points
3.0
3.0
1.5
1.5
1.5
1.0
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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics
Malignancy (on treatment or treated in last 6 months)
Score
<2 points
2-6 points
> 6 points
1.0
Category
Low probability
Moderate probability
High Probabiliyt
Diabetes (1 pts)
Risk of CVA in first two days following TIA:
0-3 = 1% risk
Stroke Risk
Low probability
Moderate Probability
High Probabiliy
Therapy
Aspirin
Warfarin or Aspirin
Warfarin (INR 2-3)
Neurology
Steps of the Neuro Exam: Be sure to follow this same sequence EVERY time you perform the neuro examit will help you learn
it and will also serve as the order in which you present your patients neuro exam findings during oral presentations.
1. Mental Status Exam can be as simple as orientation to person/place/time or as involved as the Mini Mental Status Exam
it all depends on the intention and relevance of this exam for your patient. Overall, you will test orientation (person, place,
date), registration (naming an object, repeating), attention and calculation (WORLD backwards), Recall, and Language (No ifs,
ands, or buts, following commands)
Link for MMSE - http://www.mountsinai.on.ca/care/psych/on-call-resources/on-call-resources/mmse.pdf
2. Cranial Nerves:
Link for Cranial Nerve Exam: https://www.youtube.com/watch?v=G6FZR64Cq9U
CN I
Olfactory Nerves
Smell: Not commonly tested
CN II
Optic Nerve
Vision: Test visual acuity with Snellen chart, visual field by holding up
numbers or wiggling fingers
CN III
Oculomotor Nerve
Eye Movement: Pupillary light reflex (CN II and III)
CN IV
Trochlear Nerve
Eye Movement: make The Big H with their eyes following your finger to
test the Superior Oblique muscle
CN V
Trigeminal Nerve
Facial Sensation: Test facial sensation in the distribution of the three
branches of CN V
CN VI
Abducens Nerve
Eye Movement: Make The Big H with their eyes following your finger to
test the Lateral Rectus muscle
CN VII Facial Nerve
Facial expression: Test for symmetric facial expression
CN
Vestibulocochlear Nerve
Hearing: Test hearing by rubbing fingers together close to the outer ear
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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics
VIII
CN IX
Glossopharyngeal Nerve
CN X
CN XI
Vagus Nerve
Accessory Nerve
CN XII
Hypoglossal Nerve
with eyes closed. Sensorineural vs. conductive hearing loss can be tested
using tuning fork (Weber/Rinne)
Oral sensation, taste, and salivation: Check for symmetric palate elevation
(both CN IX, X)
Check for symmetric palate elevation (both CN IX, X)
Shoulder elevation and head turning: Test shoulder shrug and head turning
for symmetrical strength
Tongue movement: Check for atrophy & deviation of tongue to one side
3. Motor Exam test for symmetrical strength in each joint of the upper and lower extremities
*5/5 normal strength
*4/5 movement against some resistance
*3/5 movement against gravity
*2/5 movement possible but not against gravity
*1/5 muscle contraction but no movement
*0/5 no muscle contraction
4. Reflexes test triceps, biceps, brachioradialis, patella, and Achilles
+4 markedly hyperactive with clonus
+3 increased but normal
+2 normal
+1 present with reinforcement
+0 absent
5. Sensory Exam test fine touch, pain/temp, and position sense in upper and lower extremities
6. Coordination and Gait
*Assess rapid alternating movements, finger-to-nose, and heel-to-shin
*Observe patient as he/she walks normally, on their toes, and on their heels
Pediatrics
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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics
mL/kg/h
First 10 kg
Second 10 kg
Each additional kg
Ex: 25 kg
Ex: 17 kg
Psychiatry
Know the components of the mental status exam, as this is important in interviewing patients.
Understand the AXIS system and review the diagnostic criteria for mood disorders (depressive disorder, anxiety disorder,
bipolar disorder), schizophrenia, personality disorders, and dementia vs. delirium are commonly asked topics.
When interviewing patients, make sure to ask about suicidal and homicidal ideation (if they have a plan or a weapon), learn
to ask for a comprehensive substance abuse history (when did they last use a substance, specific amount of substance, how
long theyve used a drug, difficulty quitting), obtain a thorough social history (support system, risky behavior). Many of
these topics can be sensitive and difficult to talk about but they are important in the treatment of patients.
Psychiatry involves various medications and side effects, so be sure to know the different generic and brand names of
benzodiazepines, 1st gen and 2nd gen antipsychotics, and antidepressants.
When studying for the shelf, learn management principles. Recognizing disease is important, but the exam will often ask
what is the next step in treatment. Keep in mind that the pathology you see on a rotation may not be equally reflected by
the topics on the shelf, so be sure to study the other topics in psychiatry.
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98
4.3
26
0.8
9.4
12.4
176
37.2
Physical Exam:
GEN NAD, sitting up in bed.
HEENT NG tube in place and to suction. Bilious content in container.
CV RRR
LUNGS CTAB
ABD Mildly distended, appropriate tenderness near incision site. Incision is clean, dry, and non-erythematous. 1-2 cc
of serosanguinous drainage on 4x4 dressing.
EXT: Peripheral IV in place, SVTs in place
A: Post-op day 1 for ex-lap with SBR for SBO.
P:
1. Post-op for SBR Await bowel function. Continue maintenance fluids. Remain NPO. Keep NG to suction. ABD XR
tomorrow morning.
2. Pain Continue Norco PRN.
3. DVT prophylaxis Continue LMWH and SVTs. Have patient OOB and ambulating today.
Oral Presentation for above Progress Note
Patient is 45 yo lady, HD#2, POD #1 ex-lap with SBR and LOA for SBO. No events overnight. Pain is well controlled with Norco.
Currently NPO. No N/V. No flatulence or BM. Has not ambulated since surgery.
Vitals are normal and stable. UO was 600, 600, not recorded over the past 24 hours. NG tube output was 450, 220, not
recorded and bilious in color. Physical exam was benign except for a mildly distended abdomen. Incision was clean and dry.
Assessment is patient is post-op day 1 for small bowel resection for small bowel obstruction, doing well since surgery.
Plan is to await bowel function continue maintenance fluids and LMWH, remain NPO, and keep NG to suction. Encourage
ambulation today. ABD XR tomorrow morning.
Internal Medicine
History and Physical Example
HPI: Mr. Smith is a 65 y/o M with past medical history of atrial fibrillation who presents to the emergency department with a
two-week history of progressive shortness of air and chest palpitations. The patient noted his difficultly breathing has now
worsened to the point he cannot climb a flight of stairs without needing to sit. In the past few days, he also recalled being
awoken from sleep, gasping for air and has noticed that his shoes no longer fit. Today the shortness of air was accompanied
with a feeling like my heart was going to beat out of my chest.
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RR: 15
BP: 146/86
T: 98.2
Pox: 90%
Lab values:
144
103
13
4.4
27
1.1
213
6.5
12.3*
224
36.9
AST
ALT
Alk Phos
Ca
Albumin
31
17
100
8.9
3.7
Total
Protein
7.6
Pro BNP
Troponins
11000*
0.0712*
Diagnostic Tests
ECG: Shows atrial fibrillation with rapid ventricular rate of 126. Q waves in left lateral leads, with no ST depression or
elevation.
Chest X-ray: Bilateral plural effusions, much larger on the right side.
Assessment and Plan: Mr Smith is 65 yo M who presents with progressive shortness of breath over two weeks duration with
new onset of chest palpitations. On chest x-ray he was found to have evidence of bilateral plural effusions, much larger on the
right side.
Shortness of Breath: Ddx includes: new onset congestive heart failure, myocardial infarction, anemia, pneumonia, COPD
Congestive heart failure Most likely due progressive course with history of heart disease and bilateral
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RR: 14
BP: 136/82
T: 98.7
Pox: 94%
Lab values:
141
96
20
4.1
29
1.2
103
7.3
11.7*
35.1
206
Diagnostic Tests:
Echocardiogram (Two days prior): Ejection fraction of 35% with no diastolic dysfunction.
Thoracentesis results: 1200 cc of straw colored fluid was removed; Protein ratio of 0.42 and LDH ratio of 0.45
A/P: Pt is 65 yo M with history of MI and afib presents with new onset systolic heart failure resulting in progressive dypnea and
afib with RVR.
1)
2)
3)
4)
New onset systolic HF - Echo showed EF of 35%. Clinical presentation consistent with new onset systolic heart failure
resulting in dyspnea.
CHA2DS2-VASc score of 4 indicates need to begin warfarin therapy wth goal INR of 2-3.
Right-sided plural effusion - 1200 cc of straw colored fluid was removed with Protein ratio of 0.42 and LDH ratio of
0.45. Consistent with transudate per Lights criteria and clinical presentation of heart failure
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Neurology
History and Physical Example:
Chief Complaint The patient is a 25 year old, right-handed female who complains of severe, throbbing headaches.
History of Present Illness The patient states that the headaches began when she was in high school, and she experiences
these headaches 1-2 times per month. The pain is usually one-sided and feels like it is behind her eye and lasts anywhere
from 8 to 24 hours. Occasionally, she has noticed flashes of light in the periphery of her visual fields in the moments preceding
a headache. During the headache, she complains of severe nausea and reports vomiting during at least one episode. She cannot
determine anything that seems to trigger the headaches and says that lying down in a dark room and taking a nap is about the
only thing that helps her symptoms. She has tried taking Advil, Tylenol, and Excedrin for the headaches, but they only provide
marginal relief.
Past Medical History no significant medical diagnoses
Past Surgical History appendectomy (8 years ago)
Family History Mother experiences similar headaches
Social History drinks alcohol occasionally, does not smoke or use illicit drugs
Medications Fexofenadine 10mg for seasonal allergies
Review of Systems She has no headache at the time of presentation and denies fever, chills, nausea, vomiting, diarrhea, and
abdominal pain.
Physical Exam:
Vital Signs T 98.9, Pulse 74, RR 16, BP 128/82
General Patient is a well-appearing 25yo, right-hand dominant, white female
HEENT NCAT, MMM, EOMI, no papilledema
Cardiovascular RRR, normal S1 and S2, no JVD,
Pulmonary CTAB, no W/R/R, symmetrical expansion
Abdominal Soft, non-tender, not distended, normal bowel sounds x4
Neuro:
Mental Status AAOx3, speech is fluent and clear, good comprehension, repetition, and naming, able
to recall 3/3 objects after 5 minutes
Cranial Nerves
o CN II visual fields intact without disturbance, PERRLA
o CN III, IV, VI EOMI with no deviation
o CN V facial sensation is intact and symmetric x3
o CN VII facial expression is symmetric
o CN VIII hearing is unimpaired
o CN IX, X symmetrical palate elevation
o CN XI symmetrical strength on head turning and shoulder shrug
o CN XII tongue is midline with no atrophy or fasciculations
Motor strength is 5/5 in upper and lower extremities bilaterally
Reflexes 2+ and symmetric at the triceps, biceps, brachioradialis, and patella
Sensory light touch, pinprick, and position senses are intact and symmetric in upper and lower
extremities
Coordination rapid alternating movements intact, no dysmetria on heel-to-shin, absent Romberg sign
Assessment/Plan:
The patient is a 25yo WF with a 5+ year of debilitating headaches that occur 1-2 times per month. Her symptoms and the
pattern of her headaches are highly suggestive of migraine headaches. Other diagnoses that could explain her headaches are
tension headaches, pseudotumor cerebri, and brain tumor. The quality of her headaches is not consistent with tension
headaches as she feels a throbbing pain instead of the classical band-like tension associated with tension headaches.
Pseudotumor cerebri is unlikely do to a normal fundoscopic exam. Brain tumors would more likely present with a constant,
progressively worsening headache instead of the episodic headaches that the patient experiences.
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Pediatrics
Inpatient
History & Physical Example
CC: Kiddo Jones is a previously healthy 3 yo boy who is admitted at the request of their primary care physician for a
high fever and suspected meningitis. The patients mother is the source of the history.
HPI: The patient was healthy until he developed some congestion and a fever yesterday. The fever initially was
controlled with Tylenol until the middle of last night when the temperature remained at 103F despite a Tylenol dose.
The patients mother contacted their primary care provider, Dr.Smith, this morning and was subsequently seen in
their office. By this time the child had developed lethargy, appearing weak and having decreased muscle tone, and
the physician stated he appeared dehydrated. Dr. Smith was concerned about the potential of meningitis and sent the
child and mother directly to the hospital. The mother states that the childs condition has remained stable since they
left Dr. Smiths office. The mother states that he has not eaten or drank much since the onset of symptoms yesterday.
He has had no urine output since yesterday evening. She denies any diarrhea or vomiting. Aside from the congestion,
the mother denies any other symptoms, including cough, ear pain, sore throat, or excessive nasal or conjunctival
discharge. The mother is unaware of any sick contacts; however, the patient does attend daycare 3 times a week.
The mother believes he is up-to-date on all immunizations. The patient has had two ear infections in the past but no
other known infections or illnesses. The mother admits to smoking around the patient and in the house. She denies
any recent travel with the patient or known TB exposures. The mother is concerned that her son picked up an
infection from another child at daycare.
PMHx: Two episodes of otitis media resolved with antibiotics, last course was 6 months ago.
Surgical Hx: None
Maternal OB and Birth history: Nulliparous prior to conception. Prenatal care throughout pregnancy. All maternal
screening tests were negative, including GBS. Delivered at 39W2D. Spontaneous vaginal delivery was uneventful. The
mother did not smoke, drink, or use recreational drugs during the pregnancy. Newborn screen was negative.
Growth and Development:
Last well child check was at 24 months. Due for next well child exam in a few weeks. Has been told that he is meeting
milestones appropriately. Sat unaided by 6 months and could walk at 15 months. He was speaking at least 2 words by
12 months. By 2 years he was brushing his teeth and clothing himself.
Allergies: NKDA
Meds: None
Health Maintenance:
1. Screening tests: Lead screen negative at age 12 And 24 months.
2. Exposures:
a. Mother smokes in home
b. No pets
3. Sleep: Generally sleeps well getting 10-12 hours per night
4. Diet: Enjoys fruits and vegetables. Eats chicken and rarely red meat.
5. Immunizations: up to date per the mother. MCIR in patient chart confirms immunizations through 24 months of
age.
Social History: The patient lives with his mother and father. His father works outside the home full-time and his
mother works outside of the home part-time. He attends daycare 3 days per week. He is occasionally watched by his
maternal grandmother.
Family History:
1. Father: Alive and well at age 32yo
2. Mother: seasonal allergies, age 32yo
3. Maternal grandmother: breast cancer diagnosed at age 67yo, alive at age 71yo
4. Paternal grandfather: passed away from MI at age 72yo
No family history of diabetes, blood dyscrasias, bleeding disorders, or cardiac, renal, or liver disorders.
Review of Systems:
-Constitutional: As above.
-Skin: No history of rashes, eczema, excessive bruising, or skin lesions.
-Eyes: No eye discharge or pain, excessive tearing, or itchiness.
-Ears: No problems with hearing. No ear pain or drainage.
-Nose: As above.
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Family Medicine
History and Physical Example:
HPI: Includes chief complaint, location and radiation (if applicable), onset and frequency of symptoms, alleviating/aggravating
factors, and associated symptoms.
Example: Jim Smith is a 35 y/o WM (white male) who presents today with cough and rhinorrhea for the past 5 days. He states
that his symptoms have gotten worse since their onset and occur throughout the day. Exertion seems to make things worse and
he has tried drinking hot beverages, which have not helped. He denies any associated symptoms.
PMH: Include any significant medical conditions or hospital visits
Example: COPD
PSH: Include any significant surgeries
Example: Tonsillectomy as an adolescent for recurrent pharyngitis
Medications: Include any prescription or over-the-counter medications and supplements
Example: Albuterol PRN (as needed)
Allergies: Include any drug allergies (NKDA = no known drug allergies)
Example: Allergy to sulfa derivatives
Social History: Include alcoholic drinking history (how long, how many drinks per week, how long sober), smoking history (how
many packs per day, how long has he/she been smoking), illicit drug use, living situation (who do they live with, where do they
live, any sick contacts), and educational/employment status
Example: Drinks around 1-2 beers/night. Smokes 1ppd for the past 15 years. Denies any illicit drugs. Lives with wife and two
children (one son, one daughter) at home; his son recently had a viral URI (upper respiratory tract infection). He graduated high
school and currently works for the USPS.
FMH: Include any significant family history of diseases (often will have to prompt patients by asking specifically about heart
disease, high blood pressure, stroke, diabetes, or lung disease)
Example: Mother and father both had high blood pressure and maternal grandmother died of a stroke.
Oral Presentation example for above H&P:
Example: Jim Smith is a 35 y/o WM (white male) with a history of COPD who presents today with cough and rhinorrhea for the
past 5 days. He states that his symptoms have gotten worse since their onset and occur throughout the day. Exertion seems to
make things worse and he has tried drinking hot beverages, which have not helped. He treats his COPD with albuterol PRN and
his son had a recent URI.
Developing an assessment and plan are also important. While some attendings or residents may ask for one, be sure to
volunteer your thoughts regardless.
Psychiatry
History and Physical
HPI: C.P. is a 44 yo F who presented to the hospital c/o auditory hallucinations and increasing depression and
paranoia. Pt reports increasing depression for the past month. Started hearing voices recently - they are men's voices
and this really scared her. She feels very scared all the time - thinks that people have been following her and someone
made the hand gesture of a gun towards her. Reports that people have been following her for 3 years. She has moved
to multiple different apartments (and a different state - thought this was happening in Georgia too) but believes
these people are going to hurt her or her son. Pt reports that her son is not worried about it and doesn't seem
concerned. He is now becoming fed up with her. Pt reports that her son is "tired of dealing" with her and that she
"gets on his nerves." Pt is tearful on and off throughout the interview. Has high anxiety. Has called the police multiple
times about the cars she believes are following her. Says she has been on the same meds for years Seroquel 1000 mg
and Zoloft 100 mg. These havent been changed anytime recently. They are being prescribed by her PCP.
Past Psych Hx: Admitted to Norton Hospital in 2005 for Opiate overdose. Dx Bipolar and Opiate Dependence. Seen at
Seven Counties from 2004-05. PCP Dr. Gray has been prescribing her medication for her.
Substance Abuse Hx: Denies any recreational drugs. Denies overusing her pain medications but there has been
concern in the past for that. Sees pain management. Alcohol- 1-2 glasses of wine per week.
Medical Hx: Asthma, HTN, HLD
Surgical Hx: None
Social History: Grew up in Louisville. Has an older brother. Graduated from high school and got an Associates Degree
in Business. Has a 24 yr old son. Had received disability in the past but currently has been working as a CNA in a
Nursing Home. Was living with her son in an apartment but they just moved in with her mother. Smokes 1 ppd for
past 20 years, drinks 1-2 glasses of wine per week, denies cocaine, heroin, amphetamine, opioid, marijuana abuse.
Family Hx: Depression in mother and paternal aunt.
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