JMS Survival Guide 2010

8/11/2019 JMS Survival Guide 2010

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UTMB SOM MS-III Survival Guide


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Table of Contents

General Information

Welcome to 3rdyear!EvaluationsThe PaperChase

History & PhysicalConsultationsDischarge paperwork

Writing prescriptionsEpic TutorialMyUTMB TutorialViewing Radiographic Studies

Procedures

On-line ResourcesPeripheral IV AccessSterile Fields & ScrubbingSuturing/Wound Care


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The Rotations

Austin RotationsPsychiatrySurgeryOB/GYNInternal MedicineFamily MedicinePediatricsElectives:

Senior Neurology

Senior SurgeryEmergency MedicineMiscellaneous


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Welcome to your 3rdYear!!Congratulations on making it through the basic science years of medical school, and completing Step I!Your third year of medical school is an exciting time when you get to start assimilating all of theconcepts you have been studying into the development of differential diagnoses and treatment plans.

Here are a few things to consider as you being your clinical training:

Professionalism is extremely important. You are reminded about the important of professionalismfrequently during medical school, and most of the information seems like common sense.Unfortunately, every year, medical students make the same mistakes and drop the ball for theirclassmates and patients. Here are some common mistakes:

Just because they didnt say anything doesnt mean theres not a problem: You cannot count onsomeone else to tell you when there are problems with your professionalism. If you show up late onemorning, and nobody seems to notice, it does not mean that your tardiness was acceptable. If you are

the type of person who will test the boundaries to see what is acceptable, your faculty and residents willgive you all the rope you need to hang yourself. There is nothing malicious about this on their part. Theconcept of professionalism should be self-evident, and they are not going to spend their time dealingwith those basic issues.

If you are not early, you are late: Residents and attending will not tolerate tardiness. Everyoneunderstands that things come up occasionally that make it difficult to be punctual. It is a good idea toplan to get everywhere a few minutes earlier than you might normally arrive. This allows you to keepsome room in your schedule for unexpected delays

Responsibility: It is important to realize the importance of the tasks you are asked to complete. Even

tasks that seem unimportant can have significant consequences if they are not completed. Surgerieshave been delayed for over 30 minutes because someone failed to get a copy of the X-rays to theoperating room. This makes the attending surgeon, anesthesiologist, and residents all very unhappy.

Attendance: It is very inconsiderate to skip your clinical assignments. In most cases, you create morework for your classmates who are forced to cover your patients. Even if they say it is okay,it usuallyis not.

Be nice: Your interpersonal skills can be just as important as your knowledge base, or skill level. Thisis especially true early in your training. You dont needto hug or brown-nose everyone, but you shouldtreat everyone with respect. One faculty frequently tells students that nurses are the most important

people to impress on a clerkship. The reason is that the faculty and residents all get one vote on yourperformance, but the nurses will complain about you to everyone, or loudly sing your praises. Manystudents have been hurt by their poor treatment of support staff.


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Evaluations & GradingFrom here on out, a more significant portion of your grades will be based on subjective observations.Exams are still very important, but they tend to be responsible for a much lower percentage of youroverall grade. The exact weight of the various components used to calculate your grade is different

during each clerkship.

It is a good idea to find out who will be doing your evaluations, so that you can make sure the evaluatorsare aware of your efforts and are able to give you the recognition that you deserve. Consider thefollowing situation:

I had one rotation where I spent a great deal of time working with a senior resident, only to find outlater that the evaluations were done by the faculty, with very little input from the residents. I had spentvery little time with the faculty, so he didnt have enough information to give me anything more than a

mediocre evaluation.

In many rotations you can go over your evaluations at the end of the rotation and request evaluationsfrom residents and faculty with whom you had the most contact. Ask for additional evaluations. If youhave spent a lot of time working with a particular faculty or resident, ask them to complete an evaluationfor you. Dont put a lot of pressure on them. Even if they think you were great, an evaluation that you

hounded them about is not going to be as favorable as one that they were eager to complete.


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The Paper Chase

The History & Physical:

This is something that you should already have developed proficiency in. You know the basic format,but the residents and faculty in each clerkship may have different expectations. You are expected tohave the basics down, and learn the specifics on the rotations. A good rule of thumb is to try to find agood H&P to read on the first day of each new rotation. It will give you an idea of what is expected, andhopefully point out anything on which you need clarification.

Things can get a little more difficult with regard to the time frame you are expected work within. Inyour Practice of Medicine courses you were expected to go gather the information, then sit down andtype everything up and submit your H&P for critique within a few days of the patient encounter.Unfortunately, that is not reality. You will need to gather the information and either write the H&P asyou interview the patient, or immediately afterwards. With everyone now having access to Epic, yournotes are easily accessible for your residents and faculty to view. Epic does have spellcheck, butremember that it does not catch every misspelled word. Additionally, be wary of using any sort oftemplate unless given permission by your team.

Progress Notes (SOAP notes):Note: The idea is to see your patients and write your own note preferably before the residents havewritten their notes, but at least before looking at their notes. This is where you practice your clinical

thinking skills. You may be way off, but the great thing is, it doesnt matter. Faculty would much rather

you have a wrong assessment and plan than nothing at all. At least this shows youre putting some

thought into your patients.

General format to follow (adjustments should be made for the focus of the particular rotation):Subjective:Give a brief summary of what the patient reports over the previous 24 hours. Include anyimportant changes in the patients status.Objective:This section includes the vitals, ins/outs, physical exam, labs, radiology, & current meds.Assessment:You should give a brief assessment of the patients problems based on the above data.Plan:Detailed plan on how you want to address each of the patients problems that you mentionedabove. Include medication changes, labs, procedures, consults, discharge status, etc.

DISCHARGE SUMMARYTo be completed in EPIC.Note: TDC discharges are a little different. You have to know what type of unit the person is going to and his or her mode oftransportation. Additionally, every TDC patient going to an infirmary must have a MRIS (Medical Release Intensive

Supervision) formed filled out.Patient's Name:Chart Number:Date of Admission:Date of Discharge:Admitting Diagnosis:Discharge Diagnosis:Attending or Ward Team:

Surgical Procedures, Diagnostic Tests, Invasive Procedures:Brief History & Pertinent Physical Examination & Laboratory Data:Describe the course of the patient'sdisease up until the patient came to the hospital including physical exam & laboratory data.


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Hospital Course:Describe the course of the patient's illness while in the hospital; include evaluation,treatment, outcome of treatment, and medications given while in the hospital.Discharge Condition:Disposition:Where the patient will be going upon discharged (home, nursing home), and who will takecare of patient.Discharged Medications:List medications and instructions.Discharged Instructions & Follow-up Care:Date of return for follow-up care at clinic, diet, exercise.

Problem List:List all active and past problems.Copies:Send copies to attending physician, clinic, consultants and referring physician.


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Writing a PrescriptionYou are able to fill out the prescription for your faculty or resident, but you cannot sign the prescriptionyourself. Remember that all prescriptions go on water sealed paper.

Under Texas State Law, all prescriptions should have the following essential elements : Date of the order: Allows determination of the life of the prescription with regard to refills. Legend

drugs expire 1 year from the date of the original prescription. Controlled substances expire muchsooner.

Patient Name and Address:Date of birth is not required but is generally included. If the drug is prescribed for an animal, the species of the animal Name of the drug Strength of the drug Quantity of the drug Directions for use Intended use of the drug, unless practitioner feels indication is not in best interest of patient Practitioner Name, Address, Telephone number

Common Pitfalls

Avoid trailing decimals: 8.0 may be misinterpreted as 80. Use zeroes before leading decimals: .5 may be misinterpreted as 5, whereas 0.5 is less

likely to be misread.

Example Prescription

UTMB prescriptions often include a pager numberfor the signing physician.

You can also avoid some potential for errors by

writing out the number to be dispensed, as well asindicating the number numerically. This should

always be done with controlled substances. In theexample prescription, it would be easy to changethe 30 to an 80. It would be more difficult to

alter #30 (thirty). If you get into the habit of

doing this every time, you are less likely to forgetwhen it is important.


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Epic: a Medical Students Best Friend

The BasicsThis is the computer system everyone had to be tutored on before you started 3rd-year. On your firstday, you will be a little unfamiliar with it, but the more you use it Epic will be your best friend at

UTMB. Epic is accessible on any computer on the UTMB campus and UTMB outside clinics.**Austin has its own computer system**

The only good way to really learn the system is from someone who has already learned it. Ask a fourthyear or upper level resident to help you. Remember, the interns are new too (unless they went toUTMB), and they will be just as lost as you, probably more so. Also, don't wait until you are on call oreveryone is busy trying to admit patients. Ask someone to help you with the computer systems duringyour first rotation, when there is some down time (afternoons are usually slower than mornings for mostclerkships).

In the Hospital

Once you start a new rotation, create a new patient list for that rotation from the selected team you areon. (Most of the teams will already have an existing list and your residents will share it with you.) Youcan organize & create the patient list to show specific values that you need. Print the patient listeveryday(write on it to know what procedures are being done, what lab values do you need, whichpatients are going home, etc.) and possibly Rounds reports for your patients (this has all of the importantinfo: current meds & dosages, current orders, lab values, test results, etc.)

After you have selected a patient:

Snapshot: brief Past Med Hx & Meds

Patient Summary: Rounds reports

Chart Review: past Encounters/Notes, Standing orders

Results Review: all lab values & test results

Demographics: Contact info & Emergency contact

Historical Orders: Log of Complete/Incomplete orders

MAR: tracking of medication dosages & schedules

Make a List

Find Wherea Patient is

Find Patients onYour Team

ClickHereforRounds

Report


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In Clinics with EpicIf you are at a UTMB outside clinic, you can look up a doctors schedule (click on SCHEDULEandfind the clinics name) and review patient information before the patients come in. Click Review inorder to access a patients chart. This is a great way to know the past medical history, currentmedications, and the key reason why the patient is returning to the clinic (from Encounters in ChartReview).

MyCitrix: Accessing Epic from your V ERY OWN HOME(http://mycitrix.utmb.edu)Why go into the hospital if you just want to check on an updated lab value or see the number of patientsthat you currently have on your census? By accessing MyCitrixfrom home or anywhere, you can savetime by finding info quickly off-campus with access to all of the same features, such as Epic & otherprograms.

You must be able to download the ActiveX component to your computer in order to fully accessthe website.

This also gives you a way to access UpToDate from home. Go through the UTMB Homepagelink.

2n Select Department/Clinic

1s click Schedule

3r SelectDoctor
http://mycitrix.utmb.edu/http://mycitrix.utmb.edu/http://mycitrix.utmb.edu/http://mycitrix.utmb.edu/


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MyUTMB: a Medical Students other Best

Friend

The BasicsMyUTMB (http://my.utmb.edu)is also a website that medical students can access ANYWHERE. It hasall of the information that is accessible in EPIC along with some different features. If you haveproblems accessing MyUTMB, call technical support to make sure that you have access (your usualusername & password). Older information and other reports could be stored in here if not seen in Epic.However, lab info is not as printer-friendly compared to Epic.

MessageNet(must log-in to MyUTMB for access)This allows you to store peoples pager numbers, sort them intogroups, and (if they have alpha-pagers) text page people withimportant, brief info. No need to remember your classmates or

residents pager numbers. Plus, you can mass page people whenrounds are ready.

Webpaging(http://my.utmb.edu/webpage)If you just want to send a brief message and are not able to/do notwant to access MessageNet, you can webpage with the same amountof text page capability. This is accessible through iUTMB homepageas well.

iUTMB (http://www.utmb.edu/iutmb)This is the UTMB homepage for Faculty, Staff, and Students which

has links to pretty much everything mentioned above.
http://my.utmb.edu/http://my.utmb.edu/http://my.utmb.edu/http://my.utmb.edu/webpagehttp://my.utmb.edu/webpagehttp://my.utmb.edu/webpagehttp://www.utmb.edu/iutmbhttp://www.utmb.edu/iutmbhttp://www.utmb.edu/iutmbhttp://my.utmb.edu/webpagehttp://my.utmb.edu/


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Viewing Radiological Studies

What is PACS: PACS is the program that we use to view radiological images. It can be accessed at aPACS station in the hospital or at any computer through MyCitrix. It is important to realize that imagesshould ideally be viewed on the PACS stations located throughout UTMB. These viewing stations have

high resolution monitors. Images viewed on other computers may not have the appropriate resolutionand can lead to incorrect interpretations. The interpretation standard is to utilize the viewing stations.When you access PACS remotely (i.e., not through a viewing station), the program you will use is calledCentricity.

Accessing PACS: You must access the PACS system to view radiological images. The URL ishttps://pacs.utmb.edu. If you cannot remember the URL, it can be found easily through MyCitrix or theMyUTMB website. Simply access MyUTMB and access your patients records. Then open theRadiology folder within the frame on the left. Then click on Images. This will take you to a page thathas the link to the PACS system.

Logging In to PACS: PACS is configured to utilize the same username and password that you areassigned for email access. However, to access PACS, you must use the entire username, which is:utmb-users-m\email username.

Finding a Patient: Once you have logged into PACS, you should see a screen similar to the one below.There is a small icon that looks like a set of binoculars. If you move the mouse over this icon, a newscreen pops up where you can enter any parameters you would like to search. You can enter any of theparameters listed on this screen, although the Patient ID (the UH number), is the most specificparameter.
https://pacs.utmb.edu/https://pacs.utmb.edu/https://pacs.utmb.edu/


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Viewing the Images: Once you have queried a patient, you will be presented with a list of the availableimages. Just click on the study you wish to see. Once you select a study to view, you will seethumbnails of the images. Click on the thumbnail you wish to enlarge. Across the top of the screenthere will be navigation and viewing options. These allow you to move forward and backward throughthe images, as well as selecting the number of images to view per page. On the top of the screen youwill see the following icons:

Contrast: This icon allows you to adjust the contrast of the image. The easiest and probably mostpopular way to adjust the contrast is to simply hold down the right-button on the mouse while

moving the cursor over the image. What this is actually changing is too complicated to get into, butyou can play with it and learn to clarify what you are looking for.

Magnify: this allows you to zoom the image in or out. There is also a magnifying glass feature thatallows creates a pop-up window that you can move over the image with the mouse and works like a

magnifying glass.

ALWAYS LOOK AT YOUR PATIENTS RADIOLOGIC IMAGES YOURSELF! You may not knowhow to read x-rays and CTs yet, but the only way you learn is through practice, and some attendings willactually ask if you looked at it.


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ProceduresThis section is not meant to teach you how to perform any of these procedures. We are simply going toreview information that may be confusing or often overlooked. Additionally, this section providesresources that can be utilized for a more complete procedure review. If you have the luxury of knowing

ahead of time that you will be participating in a procedure, take a few minutes to review the procedureas completely as you can.

Excellent Procedure ResourcesYou can access Roberts: Clinical Procedures in Emergency Medicine, 4th ed. through MD Consult.Locate the main MD Consult page under Electronic Books section on thelibrarys website. From theMD Consult homepage, select Books from the tabs across the top of the page. Roberts is listedunder the emergency medicine textbooks.

Topics covered include: tracheal intubation, cricothyrotomy, thoracentesis, tube thoracostomy,defibrillation/cardioversion, cardiac pacing, pericardiocentesis, resuscitative thoracotomy, peripheral

and central venous access, arterial access, venous cutdown procedures, intraosseous infusions, woundclosure, incision and drainage, urethral catheterization, and many more!

Also, The New England Journal of Medicine has several videos demonstrating many types ofprocedures. You will see some of these during Clinical Skills week, but if you want a refresher, theycan be found athttp://content.nejm.org/misc/videos.dtl.

Peripheral IV AccessSome people will argue that there is no need for medical students to become proficient at establishingperipheral IVs. The problem with this argument arises when the nurses are unable to establish an IV.Here at UTMB, the team intern is called when the nurses are unable to get IV access on a patient. Most

nurses will allow you the first stick at starting an IV if you ask nicely. Take advantage of the opportunityto become proficient now!

Saline Lock Vs. Heparin Lock Vs. Peripheral IV: When establishing peripheral IV access you mustconsider the patients needs. If he/she is going to receive periodic medications, but does not otherwiserequire a continuous infusion, there is often no need to connect the patient to a bag of IV fluids. In thiscase, you can simply put a cap on the IV catheter after it has been inserted. Since the IV is not

attached to anything it is much more comfortable for the patient and less likely to be accidentallyremoved. If the IV catheter is capped in this manner, it needs to be flushed to minimize the chances ofthe catheter occluding with a clot. Unless told otherwise, you can flush a peripheral IV catheter with 3-5ml of normal saline after inserting. MAKE SURE that your vial is NORMAL SALINE, as often the

vials appear similar to different medications, which could be lethal if 3-5 ml were infused. SometimesHeparin is used. The difference between a Heparin Lock anda Saline Lock is simply the fluid thatis used for the flush. Everything else is the same. Beware that people sometimes incorrectly refer tosaline locks as heparin locks. It is a good idea to confirm things before flushing with heparin.

Sites to Avoid: Basically, try to avoid any IV site that is abnormal. Avoid areas with surgicalmanipulations, trauma, or infections. ABSOLUTELY avoid arms on the same side as a mastectomy, ordialysis access. It is also a good rule of thumb to start distally, and then work proximally whenevaluating potential IV sites. If you blow an IV in a patients antecubital fossa, and then establish one in
http://content.nejm.org/misc/videos.dtlhttp://content.nejm.org/misc/videos.dtlhttp://content.nejm.org/misc/videos.dtlhttp://content.nejm.org/misc/videos.dtl


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the back of his hand, there is a chance that your IV fluid will leak out of the more proximal puncturesite.

Sterile Fields & ScrubbingDuring your surgery rotation, and probably your OB/GYN rotation you will be doing plenty ofscrubbing in on cases. The surgery clerkship has an orientation to the OR where they will highlight theimportant topics, and there is also an OR manual found at:http://www.utmb.edu/surgery/clerks/ormanual.htmthat may be helpful.

Scrubbing:

1. Make sure before you start scrubbing that you have everything on you will need (especially yourmask and eye protection), and that it is comfortable because you wont be able to touch anything

afterwards.2. Generally, the first time you scrub in for the day, you should do a full scrub with the antibacterial

soap.a. Turn on the water and open the package containing the brush and nail cleaner.b. Clean under the nails and throw the nail cleaner away.c. Take the brush in one hand and wet with water and soap.

d. Scrub the nails of the opposite hand, followed by the fingers (treating each finger as four-sided). Then scrub up the arm to 2 inches above the elbow.

e. Switch hands and scrub the opposite arm in the same manner.f. Discard your brush and rinse off both arms making sure that the water runs down your

elbow and not off the ends of your hands. (Keep hands higher than elbow.)g. Enter OR carefully, making sure not to touch anything with your arms.h. This first scrub should take approximately 5 minutes.

3. Each subsequent time that you scrub during the day, people generally do a much faster scrubwith soap and water. They then dry off their hands and apply the alcohol solution to fingers,hands and arm making sure to not miss anywhere.

4. Once in the OR suite, most scrub nurses are great about helping you out as long as youre nice to

them, and dont touch any of theirsterile equipment. They will help you gown and glove.

Sterile Fields:Basically, the most important thing to remember is that you are sterile from your chest to the level of thesterile field, so this area should never touch anything else. Also no other area of your body should touchanything within the sterile field. As students, you will mostly be standing, watching and retracting sothere is usually no reason to be moving around the room. Therefore, just always remember to keep yourarms in front of you between your waist and chest.

Suturing/Wound CareYou will be closing wounds, mostly closing up after surgery, but you may also close traumatic wounds

in the emergency department as well.

Basic Principles for traumatic wounds:1. For all wounds do a good neurovascular exam to ensure that sensation and motor function are

intact.2. Tetanus status should be checked on all patients presenting with wounds.3. If there is a risk of foreign bodies being stuck in the wound plain film x-rays can be obtained.4. Wounds at high risk for infection (mammalian bites, oral wounds, plantar puncture wounds, etc.)

should receive antibiotics before any manipulation of the wound.
http://www.utmb.edu/surgery/clerks/ormanual.htmhttp://www.utmb.edu/surgery/clerks/ormanual.htmhttp://www.utmb.edu/surgery/clerks/ormanual.htm


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Steps for traumatic wound care:1. First, do a good neurovascular exam.2. Following the exam, give local anesthesia, usually lidocaine around entire wound. Insert the

needle through the already injured tissue at one end and inject a wheal of anesthetic. Then theneedle can be withdrawn and advanced all around the wound while injecting anesthetic.

3. Hemostasis is important for good wound visualization and cleaning. With most wounds,hemostasis can be achieved by applying direct pressure.

4. Remove any foreign bodies.5. Irrigate the wound with high pressure irrigation. There are many different methods for doing

this.6. Debridement may be necessary if there is dead tissue around the wound.

Wound closure:1. Classification of closure

a. Primary intentiondirect closure of wound using sutures, glue, etc. This is ideal, butshould not be done if the wound is obviously infected, or is at high risk of infection.

b. Secondary intentionused with infected wounds. Wound is left open and may be

covered with antibacterial ointment. Often, a wet-to-dry dressing will be used tocontinuously debride the top layer of tissue, which is usually dirty.

c. Tertiary intentionwound is closed after leaving open for a while and after wet-to-drydressings have established a clean bed of tissue.

2. In the OR, most wounds will be closed with primary intention.3. A thorough review of suturing techniques and types is beyond the scope of this survival guide,

but the Clinical Procedures in Emergency Medicine book found at MDConsult and referencedabove has an excellent explanation with many diagrams.


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Psychiatry

The ScheduleGenerally you have weekends off, unless you are on call.Spend time studying for the shelf. You have no excuse not tothis is one clerkship with adequate study

time.

Small Groups:Do the assigned reading: You will be tested on the material every time. The IRAT will evaluate yourmemory of the specific reading, not your understanding of the topic. Even if you have the material downcold, you will not do well if you skipped the reading. No other source will help you as much on theIRAT/GRAT as the assigned text.

Adult Psych InpatientResponsibilities will differ depending on where you are doing your inpatient portion at (St. Josephs, St.

Lukes, Jester, Austin, etc.) In general:

Before Rounds Duties include seeing your assigned patient and completing your notes. Making sure the team census is correct for morning rounds. Helpful hintfirst student to arriveprint census/rounds reports on all patients and a checkout

list (shows meds) for each student. Distribute the census/rounds reports to the assigned studentsalong with a checkout list. This will save everyone a lot of time.

After Rounds Update the census list in the afternoon. Help with complete discharge planning and paperwork. Call MHMR to schedule patients f/u visits and obtain records of new patients.

Patients appreciate just having someone to talk with when you arent busy doing other stuff.

Consult & Liaison C & L makes it worthwhile to pay the extra $50-odd for an alpha pager. You can study in the

library (or at home, depending on where you live) and the patients information gets sent to you

without you having to stop and find a phone. Rounds in the morning change locationdepending on which faculty member is attending that

day. Dont lose your first-day information about the faculty schedule. It is a good idea to pick up one of Dr. Averys AIDS packages in case you are asked to consult

for a patient with AIDSthat way you wont have to track him down to get one. The package isHUGE (it makes War & Peace look like a comic book) so be prepared to spend some quality

time filling it out. The added bonus of doing C&L early in the year is you get to learn your way around the

hospital. STUDY when you are not with a patient!!!


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Outpatient:There are several clinics where you may be assigned. In general, at most clinics your mainresponsibility is just shadowing the faculty and residents. The best way to excel in this portion ofpsychiatry is to pay attention, act interested, and ask good questions of those youre working with. Youcan pick up a lot of useful information during clinic if youre paying attention.

Textbooks:Student Recommendations:

Case Files Appleton and Lange Qs, First AidPsychiatry Clerkship Series: Psychiatry: A quick read that was useful for getting the main idea behind the

DSMIV criteria. I had a hard time memorizing the diagnostic criteria, and this book providedexamples that allowed me to get the feel for the different disorders. This book is not availablein the bookstore, but can be purchased online.

Pretest Psychiatry: Good basic questions. Skip theory section!

And again, make sure you read the weekly assignments from the assigned textbook!

Psychiatric HistoryIdentifying information- age, sex, marital status, raceChief complaint- reason for consultation, a direct quote from the patientHPI(History of Present Illness) - current symptoms, previous psychiatric symptoms and treatments,reason presenting now.Past Psych. History- previous and current psychiatric diagnoses, history of treatments (include bothoutpatient and inpatient), psychiatric medications, history of attempted suicides and potential lethality.Past Medical History- current and or previous medical problems with treatmentsFamily History- relatives with history of psychiatric disorders, suicide or attempts, alcohol or substanceabuseSocial History- source of income, level of education, relationship history, support network, individualsliving with patient, current alcohol or drug use, occupational history.Developmental History-family structure since childhood, relationships with parents, peers and siblings,developmental milestones, school performance.

Mental Status ExamGeneral Appearance and Behavior grooming, level of hygiene, clothing characteristics, unusualmovements, attitude, interactions with the interviewer, psychomotor activity (agitation or retardation),degree of eye contact.Affect- external range of expression (described in terms of quality, range and appropriateness). Typescould include flat, blunted, labile, and wide range.Mood- internal emotional tone of the patient: dysphoric euphoric, angry, anxious.Thought Process

Use of Language- quality and quantity of speech. Note tone and fluency here.Thought Content:

Hallucination -false sensory perceptions (auditory, visual, tactile, gustatory, olfactory) Delusions -fixed, false beliefs firmly held despite contradictory evidence

o Persecutory - others are trying to cause harm or spy with intent to cause harmo Erotomanic -false belief that a person of higher status is in love with the patient


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o Grandiose -false belief of inflated sense of self-wortho Somatic -false belief of having a physical defect

Illusions - misinterpretations of reality Derealization -feelings of unrealness involving the outer environment Depersonalization -feelings of unrealness (being outside of your own body)

Suicidal and Homicidal IdeationCognitive Evaluation

Level of Consciousness Orientation - person, place and date Attention and Concentration - repeat 5 digits backwards or spell world backwards Short-term memory - recall 3 objects after 5 minutes Fund of knowledge - name 5 presidents or historical date Calculations - subtract serial 7s, math problems (simple) Abstraction -proverb interpretation

Insight:ability of patient to display an understanding of his current problemJudgment:ability to make realistic decisions about everyday activitiesPhysical ExamDSM IV Multiaxial Assessment

Axis I: Clinical Disorders Axis II: Personality Disorders Axis III: Medical Conditions Axis IV: Psychosocial Problems Axis V: Global Assessment of Function (a number)

Plan of Treatment

Common Thought Disorders Pressured Speech - rapid speech, especially with manic disorders Poverty of speech - minimal responses Blocking - sudden cessation of speech Flight of ideas - accelerated thoughts that jump from idea to idea Loosening of Associations - illogical shifting between unrelated topics Tangentiality - thought which wanders from the original point Circumstantiality - unnecessary digression which gets to the point eventually Echolalia - echoing of words and phrases Neologisms - invention of new words by the patient Clanging -speech based on sound such as rhyming and punning rather than logical connections Perseveration - repetition of phrases or words in the flow of speech Ideas of Reference - interpreting unrelated events as having direct reference to the patient

Lab Evaluation of Psychiatric PatientCommonly includes: Chem - 7, CBC, LFTs, RPR (VDRL), Toxicology screening, Blood alcohol,medication levels, HIV


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Surgical ClerkshipTeam work is essential during surgery. Communicate on a daily basis with your fellow medical studentsto make sure that every surgery is covered by the appropriate amount of medical students (some needonly one, some need two), and every patient on the service is covered.

RoundingSurgery rounds are early! Youre basically expected to be there from 6 a.m. to 6 p.m.

You will be rounding with your Chief Resident more than with your attending. Ask what he/she wantsin a presentation.Important Information to Gather Each Morning:

Fever: always report the T-max, range of temperature, and time of Tmax. Ins and OutsBe specific & include each type (urine, drains, fistulas, etc.) Status of flatus AND Bowel movements Also remember to actually look at the incision/dressing

Textbooks:Student recommendations

Surgery Recall is a great book to carry with you and read before your surgeries for pimpingquestions.

Pestana Review Questions (e-mailed to you by the course coordinator)good overview of basics Surgery Case Files Underground Clinical Vignettes NMS for Surgery NMS Surgery CasebookSimilar to Case Files but more details, does not cover many surgical

subspecialties Pretest for Surgery- if you find that you like the pretest series, this one is helpful.

First Aid for Surgerytrauma portion

Basic Information: At the end of every day, check the Case book/OR schedule to see what surgeries are scheduled

for the next day; decide how to divide them up amongst the team. You are expected to know the local anatomy for your surgery and pathophysiology. (It doesnt

hurt to look up what is going to be done in the surgery) If you are on the trauma teamyou dont have the luxury of knowing what youll see- so you

might want to have an atlas in your bag- you dont have to carry it around, leave it in the callroom.

Be sure to let the scrub tech know you will be scrubbing in and ask if you should get your correct

size of gloves and gown. DO NOT ASSUME that they have your stuff. Usually they arentprepared for you/dont know your size, so just a good idea to keep a couple of pairs of sterilegloves in your size with you at all times. Always double glove for surgeries, especially thoseinvolving TDC inmates.

PAY ATTENTION during the information sessions at the beginning of surgerysteriletechnique, Foley and NG insertions are all things that you will need to know. Get someone towalk you through this on a patient early on, so it will be easy later on.

CLINIC DAYS are professional clothes days for everyone except the trauma team.


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General Surgery Team Codes for Order Entry: SURA for General A; SURB for General B For clinic, review your breast pathology, signs and symptoms, and tests. When you know your patient is going to be discharged, make sure to fill out the Discharge

Summary if your team wants you to help with these. If you have a patient who has been inhouse, having multiple procedures, its nota bad thing to get into the habit of filling out thedischarge sheet as you gowith each procedure & date so you wont have to go through thechart later to find this information.

Trauma Whether youre on the team for the month or trauma call, a lot of what youre doing is making

things run smoothly. Keep a study book in your pocketthere is a lot of down-time when you are waiting for patients

in the CT scanner, X-Ray, etc. When you are on trauma call you have the trauma pager. There is only one trauma pager

between all medical students. If you are a heavy sleeperlet your call partner sleep with thetrauma pager. If you are both heavy sleepers make sure you both sleep in the same call room andpray you dont sleep through it. It has been done. YOU DO NOT WANT THIS TO HAPPENTO YOU!!!

The trauma call room is on the third floor of the Trauma Center (above the E.R.) The doornumber is 123. The inside door codes are on the side of each lock (Thus they dont reallyfunction as a lockthey just delay entry of someone long enough for you to wake up and wipethe drool from your face)

For some reason, the phones in the Trauma Call rooms tend to get unplugged and moved around,so dont assume that the number on the phone itself is correct (especially if youve been waitingan awful long time for someone to return your page).

On trauma call, you will meet for the trauma meeting either in the morning or afternoon andexchange pager numbers and cell phone numbers with the residents then.

Usually for high-speed collisions and falls (the majority of traumas) you are going to want:o CXR (Chest X-Ray)o 3V C-Spine (3 view c-spine)o Pelviso Fortunately, if the team wants all of this they can now order a trauma panel on EPIC.

Any CT scans done in the trauma rooms have to be okayed by a radiologist before you canschedule them. The ER/Trauma Radiologist is usually in the Radiology reading room. ItsYOUR job to write up the request as the resident says they want to get a CT, take it to theRadiologist, let them write their code on the request, then take it to the CT Scanner.

If youre on the trauma team keep a 10 cc syringe in your pocket on rounds so you can pull outFoley catheters without searching one out. You can get these in the shock trauma rooms in theERwhile youre there, also grab some tape, because youll want that for changing dressings.

4X4s are also a good thing to have on youbut the packaged ones are easier to find on the floorthan in the ER. I always tried to have two packs on me, and replaced them as we used them. Ontrauma teamits still a good idea to have X-Ray & Consult forms on you at all times.

If the patient has a distracting injury - like a broken bone in the wrist, etc.then you dontclear the c-spine clinicallythere has to be good radiographic evidence that the C-spine is okaythat means if the 3-view c-spine is inadequate, youre going to have to do a CT.


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CRITICAL PARTS OF YOUR JOB ON TRAUMA TEAM or TRAUMA CALL: When the patient arrives and you are in the trauma call room, quickly go to the phone in the

trauma room, dial X-Ray (speed dial button) and tell them there is a trauma. Have your trauma shears readyyou cut the clothes off the patients so that the residents can

assess them. Foley catheters & NG tubesthis is your time to learn to put them in. (Dont worry you will

be shown how to do this in a group session at the beginning of trauma - PAY ATTENTION) Starting I.V.sIf patients come in by ambulance they generally already have at least onethe

nurses will start another quickly, so if you want to tryspeak fast. Dont pick an unstablepatientyou dont want to be delaying essential patient care but there will be plenty of stablepatients!

Check INQN for lab results for your patients (Most of the stat requests will be hand-delivered onlittle slips of paper by the nursesmake sure results get into the trauma sheet)

Photocopy the trauma sheets for the patient you want to present in the morningyoull be gladyou didalso, make sure you know WHY studies were done or not donebecause you may bethe person justifying decisions that werent yours.

Cardiothoracic Surgery Team Code: CTS Cardiothoracic surgery has a protocol book that they give you at the beginning of the rotation for

pre & post-operative care that explains all the preoperative work up and the postoperative ordersfor every post-operative day. This book should help you know what is going on.

Be careful about contamination with the bypass machine; there are always tubes and thingseverywhere and they ask you to move around sometimes from one side to the other. Rememberwhere your sterile field is & don't put your hands below your waist, rest them across your chestand keep your elbows in when walking around.

Also if you have a bad back or joints, take a Motrin before every thoracotomy because you willprobably be riding a retractor the whole time.

Would be helpful to review your cardiac output equations, know the pulmonary arterycatheter/Swan Ganz and what it measures, read about cardiopulmonary bypass surgery tounderstand the heart cannulations and the bypass machine.

Also for people that have been on the bypass machine in surgery when they are on the floor youare looking for them to diurese all that fluid out so pay attention to urine output, ankle edema,and daily weights! And listen to lungs for crackles, signs of fluid overload. You are looking forthem to get down to their admission weight. Always have those things in your notes and knowthem for rounds. Know which diuretic and how much they are on. Typically they need to get outof bed when they are stable, so ask the patients or look in the nurses notes to find out if theyve

been ambulating yet.

Vascular Surgery Learn your vascular anatomySERIOUSLYits not something you can fudge. On rounds,

o One team member better have the Doppler machine and jelly so that you are prepared toDoppler every patient.

o Know the DAILY values of PT, PTT, & INR, for any anti-coagulated patient (this will bealmost EVERY vascular patient)


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Surgical DocumentationFor Procedure purposes: We now enter procedure documentation through an online database (See

syllabus for website). Start early and keep track.

SURGICAL HISTORY AND PHYSICAL EXAMINATIONIdentifying Data:patient's name, age, race, sex; referring physician.Chief Complaint:Reason given by patient for seeking surgical care; place reason in "quotation marks."History of Present Illness (HPI):Describe the course of the patient's illness, including when it began, character of thesymptoms; pain onset (gradual or rapid), precise character of pain (constant, intermittent); other factors associated with pain(defecation, urination, eating, strenuous activities); location where the symptoms began; aggravating or alleviating factors,vomiting (characteristics, appearance, frequency, associated pain), change in bowel habits; bleeding, character of blood,(clots, bright or dark red), trauma; recent weight loss or anorexia; other related diseases; past diagnostic testing.Past Medical History (PMH):past diseases, all previous surgeries and indications; dates and types of procedures; seriousinjuries, hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma,myocardial infarction; hernia, gallstones.Medications:Allergies:Record the drug and the reactionFamily History:Medical problems in relatives. Family history of colonic polyposis, carcinomas, multiple endocrineneoplasia (MEN syndrome).Social History:Alcohol, smoking, drug usage.

REVIEW OF SYSTEMS (ROS):General:Weight gain or loss; appetite loss, fever, fatigue, night sweats.Head:Headaches, seizures.Eyes:Visual changes, diplopia, eye pain.Mouth & Throat:Dental disease, hoarseness, sore throat, pain, masses.Respiratory:Cough, shortness of breath, sputum.

Cardiovascular:Chest pain, orthopnea, dyspnea on exertion, claudication, extremity edema.Gastrointestinal:Dysphasia, abdominal pain, nausea, vomiting, hematemesis, melena (black tarry stools), hematochezia(bright red blood per rectum), constipation, bloody stool, change in bowel habit; hernia, hemorrhoids, gallstones.Genitourinary:Dysuria, frequency, hesitancy, hematuria, polyuria, discharge; impotence, prostate problems.Gynecological:Last menstrual period, breast masses.Skin:Easy bruising, bleeding tendencies.Lymphatics:Lymphadenopathy.

PHYSICAL EXAMINATIONVital Signs:Temperature, heart rate, respirations, blood pressure, weight.HEENT: Head, Eyes, Ears, Nose, ThroatNeck:Jugular venous distention (JVD), thyromegaly, masses, bruits; lymph nodes.Chest:Equal expansion; rhonchi, crackles, breath sounds.

Heart:Regular rate & rhythm (RRR), first & second heart sounds; murmurs (grade 1-6), pulses (graded 0-2+).Breast:Retractions, tenderness, lumps, nipple discharge, dimpling, gynecomastia; axillary nodes.Abdomen:contour (flat, scaphoid, obese, distended); scars, bowel sounds, tenderness, organomegaly, masses, liver span;splenomegaly, guarding, rebound, bruits; percussion note (tympanic), costovertebral angle tenderness (CVAT), inguinalmasses.Genitourinary:External lesions, hernias, scrotum, testicles, varicoceles.Extremities:Edema (grade 1-4+); cyanosis, clubbing, edema (CCE); pulses (radial ulnar, femoral, popliteal, posterior tibial,dorsalis pedis; simultaneous palpation of radial and femoral pulses), Homan's sign (dorsiflexion of foot elicits calftenderness).Rectal Exam:Sphincter tone, masses, hemorrhoids, fissures; guaiac test for occult blood; prostate masses.Neurological:Mental status; gait, strength (graded 0-5); deep tendon reflexes.


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LABS:Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine), CBC; X-rays, ECG (if older than 35 yrsor history of cardiovascular disease), urine analysis (UA), liver function tests, PT/PTT.

ASSESSMENT (Impression):Assign a number to each problem and discuss each problem separately.

PLAN:Describe surgical plans including preoperative testing, laboratory studies, medications, and antibiotics.

PREOPERATIVE NOTEPreoperative Diagnosis:Procedure Planned:Type of Anesthesia Planned:

Laboratory Data:Electrolytes, BUN, creatinine, CBC, PT/PTT, UA, EKG, Chest X-ray; type and screenfor blood or cross match if indicated; liver function tests, ABG.Risk Factors:Cardiovascular, pulmonary, hepatic, renal, coagulopathic, nutritional risk factors.Consent:Document explanation to patient of risk and benefits of procedure, and document patient'sinformed consent or guardian's consent and understanding of procedure.Allergies:Major Medical Problems:Medications:

BRIEF OPERATIVE NOTE(Written immediately after the procedure)Date of the Procedure:Preoperative Diagnosis:Postoperative Diagnosis:Procedure:Names of Surgeon and Assistant:Anesthesia:Estimated Blood Loss (EBL):Fluids and Blood Products Administered During Procedure:Specimens: Pathology specimens, cultures, blood samples.

POSTOPERATIVE NOTESubjective:Mental status & patient's subjective condition; pain control.Vital Signs:Temperature, blood pressure, pulse, respirations.Physical Exam:Chest and lungs; inspection of wound and surgical dressings; conditions of drains;characteristics and volume of output of drains.Labs:Impression:Plan:

PROBLEM-ORIENTED PROGRESS NOTEProblem List:Postoperative day number, antibiotic day number if applicable, hospital day number,hyperalimentation day number. List each surgical problem separately (status post-appendectomy,hypokalemia). Address each numbered problem daily in progress note.Subjective:Write how the patient feels in the patient's own words, and give observations about thepatient.Objective:Vital signs; physical exam for each system; thorough examination and description of wound;condition of dressings; purulent drainage, granulation tissue, erythema; condition of sutures, dehiscence;amount and color of drainage, laboratory data.Assessment:Evaluate each numbered problem separately.


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Plan:For each numbered problem, discuss any additional orders, surgical plans. Discuss changes in drugregimen or plans for discharge or transfer. Discuss conclusions of consultants.

DISCHARGE SUMMARYPatient's Name:Chart Number:Date of Admission:

Date of Discharge:Admitting Diagnosis:Discharge Diagnosis:Attending or Ward Team:

Surgical Procedures, Diagnostic Tests, Invasive Procedures:Brief History & Pertinent Physical Examination & Laboratory Data:Describe the course of the patient'sdisease up until the patient came to the hospital including physical exam & laboratory data.Hospital Course:Describe the course of the patient's illness while in the hospital. Include evaluation,treatment, outcome of treatment, and medications given while in the hospital.Discharge Condition:Describe improvement or deterioration in patient's condition.Disposition:Describe the situation to which the patient will be discharged (home, nursing home), andperson who will take care of patient.

Discharge Medications:List medications and instructions.Discharge Instructions & Follow-up Care:Date of return for follow-up care at clinic; diet, exercise.Problem List:List all active and past problems.Copies:Send copies to attending physician, clinic, consultants and referring physician.


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Obstetrics and GynecologyClerkship website:www.utmb.edu/obgyn/students/default.htm

Textbooks:

Required: Obstetrics and Gynecology for Medical Students (Beckman et al., required for EER 2ndyear) Obstetrical Pearls

Recommended by Faculty Obstetrics and Gynecology (Hacker et al) Obstetrics and Gynecology NMS Current Diagnosis and Treatment in Ob Gyn (Appleton & Lange) Williams Obstetrics

Student recommendations for the Shelf: Information resources: First Aid for OB/GYN, High Yield, Case Files, Blueprints

Practice questions: Case Files, Case Files, Case Files, Blueprints, Pre-test

OB/ Gyn General Schedule (6 weeks)

General Scheduleo 2 weeks of Labor & Delivery/Triageo 1 week of Antepartumo 1 week of Postpartumo 2 weeks of Clinico The OB/GYN rotations have varied from year to year so not all of the rotations below

may be applicable but are included to account for possible future changes.

Labor & Deliveryo Location: John Sealy 2nd flooro Combination of Nights and Days; Night Schedule: 5:30pm-7amo The rotation begins with the L&D team reviewing the boardo Students should split up C-sections and rounding on the L&D patientso Main responsibilities: Update the board, Assist in the OR, Conduct/assist in vaginal

deliverieso The Board

Each patient in the L&D floor documented on the board according to their L&Dstatus

Age, G-P- Status, Gestation, Dilation, Effacement, Station, Presentation,Estimated Fetal Weight, Additional notes

Students are generally responsible for making sure the information is current andcorrect.

o When you attend a delivery, C-section, tubal ligationjust about anythingget into thehabit of taking a patient sticker and writing on it: the procedure, and the resident/facultyyou worked with. At the time, you think youll remember these things but they start torun together after a while. This will help you TREMENDOUSLY when youre filling in

your procedure sheet.o Your L & D days are the least scheduled days. Dont wait around for something to

happenpick an intern or a resident and stick to them like glue. Im not kidding.
http://www.utmb.edu/obgyn/students/default.htmhttp://www.utmb.edu/obgyn/students/default.htmhttp://www.utmb.edu/obgyn/students/default.htmhttp://www.utmb.edu/obgyn/students/default.htm


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o I wish I had known that they want you to follow the interns around in L&D because theydon't tell you what to do and then if you just stand there waiting for someone to tell youthat you should be following a resident or intern around you get comments on yourevaluation that you were not a very enthusiastic student.

o If you want to deliver a babypick an upper year that is more likely to let you get handson experience than an intern, who still wants to get experience themselves.

o Show initiativeif you want to get hands on experience, dont stand back.

Clinico Outpatient Clinicso Typical Hours are 8:00 am-4:00 pm

Galveston clinics are either OB/Well-woman exams or Gynecology/Oncology Locations: Galveston, Texas City, Dickinson, Pearland, Angleton, Pasadena Call the clinic the week before your rotation to get directions to where to report You will shadow a resident, faculty, midwife, or nurse practitioner in clinic.

Antepartum & Postpartumo You will have one week of each.o Postpartum rounds early so the patients can be discharged as soon as possible. You

usually have to be there very early (5:30 am), but are done early, usually before noon.Basically, you pre-round on patients write a couple notes, and then round with theresidents and attending. Then youll follow up on labs, etc. that need to be done beforepatient discharge.

o Antepartum rounds later, after postpartum rounds. You usually arrive at 7:30 am and aredone early in the afternoon. Again, you pre-round on patients, write notes, and thenround with the team.

o These are good rotations to study on, as youll have some down time and a light schedulefor the most part.

Endocrine / Reproductiono In addition to clinic responsibilities, students are expected to attend Endocrine

Conferences / Clinic dispersed throughout the week as assigned in the schedule.o Follow the directions in the course syllabus as for the schedule. It is easy to miss

something.o Know the recommendations for cancer screening for women for menopause clinico Review the fertility drugs from your Endo knowledge before you go to patient conference

these may come up.o Chart review: Most of the time you wont get to see the patients you are assigned to look

up. However, you still need to know the information, because you will be asked about itin conference. Pay attention to other peoples presentations in the morning you mayend up seeing their patients

Gynecologyo Location: John Sealy 9

thflooro Schedule: See patients on the wards in the morning, Attend clinic/OR in the afternoonso Use your free time to study. In GYN you are generally supposed to split clinic daysso

you have the morning or the afternoon off - study for the shelf.o Try to see as many different operations as you can and read the sections in the text on the

problems involved on the day you see the surgerymore will stick with you this way.This is also true of GYN ONC, L&D, and REI

Oncologyo Location: John Sealy 9

thflooro Schedule: Ward rounds in the morning, Clinic/ OR in the afternoon


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o The residents are really good at coaching you what you should and shouldnt say andtake their advice. If you say the patient is anemichave the H./H values because he mayask. Dont be too narrative, just state problem, workup, solution. Hell ask you if he

wants details. Still, dont go on at length, hell cut you off if you talk too long.

o Dysplasia Clinic: The goal is to be prepared for the team to see about 30 patients between 9:00 and

12:00, and these visits are very procedure intensive, (Paps, Colposcopy, Biopsies(BX) Endocervical Curettage (ECC), LEEPs)

All the charts on these patients are divided up between the team members in theconference

Review the chartfind out the pertinent HPI for the patient Each person summarizes the HPI for the patient and suggests plan of action. The

team agrees or tells you what the plan is In clinic, you go in and see patients, explain the plan to them, answer questions

(as you can), and get any relevant updates before the residents get in to see them. Review the algorithms for management of the abnormal Pap smear

Grading Components:o Resident Evaluationso Small Group Facilitator Evaluationso NBME Shelfo Team Learning Activity Quizzeso Bonus pointsLecture attendance

OB/ Gyn Required Skills Card(you will need to have these skills observed and signed by faculty)o Bimanual pelvic examo Vaginal speculum examo Pap test/endocervical cuff cultureso Interpret a fetal monitor stripo Spontaneous vaginal deliveryo Various others

Small Group PresentationsHistorically, these presentations have had a significant impact on grades. They can be just enough topush you over the top if you are right at the break point between grades.It is a good idea to pick OB topics for OB facilitators and GYN topics for GYN facilitators.

Oral PresentationCase presentation of an obstetric or gynecologic patient You can present any patient you followed on service

Presentation should be done from memory Formal H&P write-up of the case presented should be turned in to your small group faculty


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Internal Medicine

The BasicsCarry some sort of pocketbook with you at all times to look things up in a hurry.

http://www.medfools.com has a great printout chart for you to keep patient vitals, checklist, etc. inorder. Keep a couple of them with you on the wards. My residents would even steal a copy to keeptheir tasks in order too.

TextbooksStudent Recommended:

Pretest Medicine, Lange Case Files, Step-Up to Medicine MKSAP for Students Pocket Medicine is a popular pocket handbook St. Francis guide for Inpatient medicine - great for the OSCE (There is currently no OSCE for

IM, but the information is included for when the OSCE is begun again.)

Know the differential diagnoses for abdominal pain, chest pain, shortness of breath, etc. Reviewthese several times; it is invaluable for IM and future rotations.

Washington Manual or Ferri Guide as a PDA resource for learning about yourpatients problemswhile you write your notes

NMS for Medicinedenser than some of the other resources. Blueprints may be too superficial Strong References: Cecils, Harrisons, Langes Current Medical Diagnosis and Treatment, and

especially Up to Date.

Clerkship StructureThe clerkship is 3 months long with each student serving on a different service each month. Usually,

each student spends one month on a general inpatient service and one on a consult service. The thirdmonth may be spent on another general inpatient ward, a specialty inpatient ward, or at an outpatientclinic.

Inpatient WardsMost general inpatient teams consist of an attending, an upper level resident, 2-3 interns, 2-4 medicalstudents and a social worker. How the team runs really depends on the attending and upper levelresident. The role of the attending is to basically run rounds and do a little teaching while seeing thepatients. Some attendings really enjoy teaching and will hold outside lectures for students, while otherswill limit teaching to quizzing the students during rounds. The upper level resident delegatesresponsibility to the team members. They are the ones who will have the greatest impact on a students

experience. The interns and the students on the service carry out the work delegated by the resident andattending. It is their responsibility to make sure there are no loose ends with any of the patients. Thesocial worker takes care of discharge planning and funding for patients.

Consult ServicesThe teams on the consult services are set up similarly to the inpatient wards, except that the fellow runsthe team and delegates responsibilities. There is some variability to the way the different teams work.In general, the student will be given a consult, either at a morning meeting or by getting a page duringthe day. The student will see the patient and write the consult- basically a full H&P focused to the
http://www.medfools.com/http://www.medfools.com/http://www.medfools.com/


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problems for which the team is being consulted. The team will then meet to round and all consultedpatients are then seen.

TDCThe TDC teams run basically the same way as the free world inpatients teams run. The only differenceis that there may or may not be a social worker assigned to each team. The pathology in TDC is alsoquite different than the free world. There is also one team in the TDC that is specifically designated forinfectious diseases such as HIV. Be aware of what you can and cannot bring into the TDC. The list ofacceptable items is very small, so it is best to go in with as little as possible. If you are assigned to aTDC month, you will be given a list of prohibited items.

Before RoundsCheck team's censusPrint rounds reports (for some attendings)

3 vs. 7 days Standard format vs. include all (other orders, radiology, etc.) Make sure you ask your attending which type of rounds reports her or she prefers, some want

everything and some want only medications.Check labs in Epic

Labs received but pending Lab results

Check vital signs / nursing notes (teal chart, mostly in Epic) Record Temp, BP, Pulse, Resp I/Os

Check patient charts (gray charts, but mostly on Epic) Progress notes Consults Lab / test / procedure results

See patients Immediately notify doctor if patient has altered mental status or is unresponsive!!! Do a focused Hx & PE Strip drains, check wounds, etc. Report to interns / residents

Report ALL patient changes / problems to house staff BEFORE, NOT DURING faculty rounds!!!

Decide on management (labs, meds, etc.)Prepare presentations

Notes can be used during rounds ... But try to present from memory as much as possible Save notes from previous days (for reference, writing D/C summaries, etc.)

Write progress notes Some doctors prefer that notes be written after rounds Some doctors prefer that notes be started before rounds but allow for them to be finished after

rounds Some doctors want notes done before rounds Update and print census for team (if applicable)


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Rounds

Some teams do table rounds first, meaning theyll talk about the patients first (discuss whathappened overnight, review labs, form a plan for that patient such as discharge, continuetreatment, alter treatment, etc.) After table rounds, the team will physically go room to room.

Internists like ranges reported on vitals. Report blood pressure as 140-200 / 70-110 instead140/70

Medicine is all about trends. When charting labs, it is helpful to record what the previous valueswere. Chart review is essential in working up a patient. Important things to look for in a chart:

o Old EKGs (for comparison)o Discharge summarieso Medicationso Operative noteso Cath reportso Pathology summarieso Baseline labs

Patient presentation is generally in a SOAP format. New patients are presented with an abbreviated history and physical. When rounds are over with the entire team, you may meet again with the intern and resident to

go over the game plan for the rest of the day. Your job is to follow up on labs that were pendingand record them as an addendum in the progress notes. Additional duties may include phoninghospital departments like CT, MRI, nuclear medicine, hyperbaric or special procedures to seewhen your patients procedure will be done. You want to make sure that the ball is not dropped

and that the department has your patient on its schedule to do the test or procedure. Another thing you might be involved with is discharging patients and helping the intern with the

paperwork associated with this. Most of the above work is completed by early to mid afternoon so you may find yourself with

extra time to study and hang around the unit or the room where your team meets for report. Someteams make afternoon rounds so you may find yourself busy all day long.

Medicine H & Ps

Dont fall behind.

Do your first 1 or 2 in the first week and wait for feedback. Often, they give you things to changeand you should make those changes on subsequent write-ups. Dont give your attending 3 or 4H&Ps in the last week of the rotation, they wont appreciate it, and you have no time to adjust

your H&Ps to the feedback you receive.

Do them on the computer and learn the art of cut a paste

CallCall is not overnightyou stop accepting new patients in the early evening and you usually stop seeingnew patients usually around 10 PM. Grab your patients to do your H&P early if you want to go home ata decent time.


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Family Medicine

The Basics: Covers healthcare from the womb to the tomb (sorry, couldnt let that one go) No rounds, nice schedule, only the occasional weekend. Try to enjoy it.

Take the web cases seriously. Your answers are sent to the faculty, so keep them professional. For any question on alternative medicine, check out Health Notes via UTMB library

(http://library.utmb.edu/HealthNotes) If youre interested in doing moreproceduresor delivering babiesASK. You will get more

out of the experience if youre setting your own learning objectives Patient education and preventive medicine are important. You will spend more time asking

about lifestyle, diet, etc. than you have in any other rotation.

Textbooks:Student recommended to take to the OSCE

There is currently no OSCE for the FM rotation, but this information is included in case the

OSCE is brought back in the future. The Family Practice Text: the one you check-out for the clerkship. GOOD to take to the OSCE.

Use these books throughout the clerkship. If you are not familiar with how they or organizedand what information is found in each resource it will take too long to find the information youneed.

Current Diagnosis or any good up to date reference you like best Pocket Medicine Sierpinas book on Complementary and Alternative Medicine Preventive Medicine Screening:

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat3.section.10513Tables are available at thebottom of the right-sided column that has extensive screening recommendations by age group.

This is useful to print out and take to the OSCE. Case Files (most likely a case will reflect one of your standardized patients)

Student Recommendations for the Exam The exam is difficult. Other than the specific recommendations here, it would be a good idea to

review Step II focused resources. NMS Questions for Family Practice: Available for loan from the clerkship office. Seems to be

universally recommended. New Case Files for Family Medicine: good review of several topics for a short rotation (1

month)
http://library.utmb.edu/HealthNoteshttp://library.utmb.edu/HealthNoteshttp://library.utmb.edu/HealthNoteshttp://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat3.section.10513http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat3.section.10513http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat3.section.10513http://library.utmb.edu/HealthNotes


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Pediatrics

The Basics Generally a good schedule. Try to do your written H&Ps as early in the rotation as possible.

Do your observed H&P whenever an upper level offers, which might be early in the rotation.You dont want to be part of the scramble at the end trying finish this.

The big topics are developmental milestones, nutrition, safety, immunizations, and viral vs.bacterial illnesses.

Textbooks:Student Recommended:

Blueprints for Peds Case Files Appleton and Lange Questions Pretest

Call Inpatient call: generally about 1x per week. To get the most out of it, give your pager number to

both the intern and the upper level on call. Then stick to them like glue to maximize your chanceto see and do stuff.

For call in the nursery, you are generally done at 10 pm. Specialty call is generally taken with theinpatient team unless you are on PICU or ISCU. Then you will take it with the residents in thatunit.

Inpatient: Morning report starts at 8 everyday and you are required to go unless you are in the nursery or in

ISCU. You need to have seen your patients and written a note before morning report. The afternoon usually involves family meetings or other odds and ends.

Nursery: Lots of paperwork, but the babies are fun to work with. You will need to arrive between 6:30 and 7:30 a.m. to do mommy visits, record vitals on all the

babies, update the census, and see as many babies as you can on your own to present. All of thisis explicitly explained in the syllabus.

After rounds you will do more mommy visits, help with charting, or do whatever else is needed. The nurse practitioners are very friendly and helpful if you have questions. They like to teach. The afternoon is usually spent updating labs and the census, playing with the babies, or going to

the stand to assess a newborn. You can also spend anytime you wish up in the transition nursery examining babies. If you like

hands-on, this is a good place to be.


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Ins and Outs Ins: For babies, do this in cc/kg/d and cal/kg/day (if on formula). If breastfeeding, record how

long the baby nurses on each breast, and how often. Outs: Urine cc/kg/hr (to 1 decimal point X.X cc/kg/hr), Bowel Movementshow many and

describe if pertinent, Emesis Record changes in weight as well as the current daily weight

Use the following table to convert milliliters into calories

FormulaCalorie Conversion Factor

(Calories in formula/30cc)

Enfamil/Similac w Iron/Lactofree (20 cal/oz) 0.67

Enfamil or Similac 22 or Neosure 0.73

Enfamil or Similac 24 0.8

Pregestamil/Alimentum/Nutramigen (20 cal/oz) 0.67

Kindercal (30 ca/oz.) 1.Breast milk (20 cal/oz) 0.67

For the pediatric History and Physical Write-ups, dont forget to refer to the example that they providein the syllabus.


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ElectivesListed below are various electives that medical students can take during 3rdyear. Neurology, SeniorSurgery, and Emergency Medicine are ones that everyone is required to take before they graduate, so itis great to complete them sometime in 3rdyear to give you more time 4thyear.

In General:Try to schedule a senior elective during your third year elective month. This allows for a more flexible 4th year(to set up away rotations, AI's, etc.) and allows you to knock out a required course early. However, there are afew reasons to go ahead and do a non-required elective during your 3rd year:

a. Try out a field that youreconsidering but that you won't get to experience during your required 3rdyear rotations - i.e. radiology, derm, anesthesia, etc.b. Travel to another city/country for an electivec. Set up a research project with a particular faculty/lab or you want to continue a project that has alreadybeen established. Remember, you need to get research approved before you can earn credit for a rotation.

Andthere are some reasons NOT to do a particular elective during your 3rd year:Ex. - Even if you know you want to do pediatrics (or IM/OB/GYN/psych/surg, whatever), don't do a pedi

elective "just because" you think you should. You will get ample time to get all the experience you need duringyour clerkship. This is a good situation where a 4th year rotation would be good to do during 3rd year.Additional advice: try to do a rotation over the Christmas month. For the most part, people are pretty flexibleand you will still have time off for Christmas and New Year's. (Again this is very rotational specific.) If yourfamily lives far away, try to set up an away rotation in their city.

Senior Neurology (required before graduation):This course is 4 weeks with 1 week in Geriatrics, 1 week on wards/inpatient, 1 week on Neuro consult, and 1week of Neuro clinic. No call; weekends & holidays off. Good rotation to have if you want a break or need extratime for other things. If you are interested in neuro, tell all of the doctors so that they will recognize you for aneuro award at the end of the year.

Suggested Readings:

Boards & Wards - Neurology section Any resource (for Step 2 study material) with a neurology section Look through First Aid Step 1 to remind yourself of neuro pathologies (seizures, strokes, ) The chief resident gave the students a review shortly before the real test. This might change if the NBME

test is integrated.

Lectures

Stated in the schedule. Usually will be in the morning (8:00am) or lunchtime (Noon). However,Wednesdays are busy because they squeeze in grand rounds, neuropathology, and radiology rounds in themornings as well.

Recommendations During rotation:

Geriatricsyou will take a brief test on the first day, and then take the same test again on Thursday (to seeif you learned anything over the past week). You will be given a couple articles on delirium & dementia,

which you will discuss with one of the Geriatric fellows on Thursday. On Monday, Tuesday, andWednesday, you will be assigned to work in a geriatric clinic (ACE Unit/10thfloor, Santa Fe Clinic,Retirement home).

Inpatient/Wards: You pretty much follow the resident to the various neurology patients in the hospital.Assess for strokes, seizures, paralysis, etc. You will be assigned 1-2 patients, and rounds will either be in themorning or at 1:00pm in the afternoon (depends on faculty).

Neuro Adult clinicyou will be busy, busy, busy. Pick up a patients chart and enter the room (do not askfor the residents permission). Inform your resident of what you found, go in together, and then get theblessing from the faculty (usual clinic proceedings)

Neuro Pedi cliniclike the adult clinic, but with less patients. Lots of seizures


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Neuro Consultcome in at 8:00am to see if there are any new consults. If assigned a new patient, you willsee the patient first, then page/inform your assigned resident. If you do not have a new patient, check on theprevious consult patients that have not been signed-off. Then, wait in the consult room or the student loungeon the 9thfloor to be paged for new consults. You will present new consults in afternoon rounds (the facultyfor consult is the same for Inpatient/Wards. After the Inpatient/Wards team is done with their rounding, thenyou will round for the consult patients).

Senior Surgery (required before graduation)1) Course structure- You will be assigned a surgery service based on preference although many people

do not get what they want: Dr. Mileski does not want you doing a service that you were on for the junior rotation.Really you just participate in the required clinical/OR duties of the service - it's just an additional surgery monthwithout the shelf exam at the end.

2) Required activities- Participate in the service activities, trauma call 2-3 times during the month asassigned, autopsy experience: you will be paged to participate in one autopsy during the month-you are notifiedthe day of the autopsy and given an orientation to what you need to do that day. The autopsy day is pretty easy,just show up - there is an autopsy report that is required to pass the course. The format of the report and anexample will be given to you.

3)Grading- grading if based entirely on evaluations and whether or not you complete the senior project.The project is optional but if you do not complete it you can not make above a passing grade. If you choose to do

the project you can either high pass or honor the course based on the quality of your project and evaluations. Theproject consists of a literature review of any topic you pick (basically you summarize 10 articles and drawconclusions about medical practice based on your review).

4) Recommended readings- nothing5) General advice- have a good attitude. Look at this as another surgery month instead of a month to do

as little as possible. In the past the seniors have used this course as a vacation month and Mileski is not lettingthat fly anymore. So, just try to enjoy the fact that there is no shelf to worry about and if you just show up andcomplete the required activities it will be fine. Obviously, if you want to do surgery it might be a good idea tocomplete the project.

Senior Emergency Medicine (required before graduation) Generally a good rotation that consists of 12hr shifts (6 day shifts, 6 night shifts), 1 ambulance ride shift and

1 poison control shift. Always remember your shift card!!! And get them signed!!!! This is the way they know you attended shifts.

You sign up for shifts prior to rotation, but you are allowed to switch shifts (make sure you tell Martha, thecoordinator)

ER is great for allowing you to do procedures, pick and choose patients that interest you, and that you thinkyou will be able to do procedures (sutures, vaginal exams, line-placement, etc.).

There is a procedure card that you must complete. You must get signatures for 15 procedures (many can berepeated) such as IV placement, laceration repair, etc.

The physicians working in the ER are great at letting you get involved as much as you want, and you get towork directly with them often. When presenting make sure you keep things to the point, while not skimpingtoo much on the details. Make sure you get the HPI and a focused physical. They also want you to get thePMH, FH, & ROS, as these are the only things you can actually enter on Epic.

Basically, just act interested, volunteer to see patients and do procedures, and things will go great.

Clinical Dermatology Rotation (not required but very informative and not as time-demanding) Best book is Dermatology Secrets. Otherwise, they have a great library in the derm clinic. Get involved in aproject if you are interested.

.


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Appendices

History & Physical Template: A Template for the JMS H&P. Please make copies to help you outline

your H&Ps.


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Date/time: JMS History and Physical PCP:Chief Complaint: Al lergies:

H istory of Present I ll ness:

PMH:

Medications:

Family H istory:Father: Mother: Siblings: Other:

Social H istory:Lives in: Tobacco: Etoh:

IVDA: Blood transfusions: Tattoos:

Review of Systems:

1. General: Fever Chills Night sweats Weight change

2. HEENT: Tinnitus Decreased hearing Blurred vision Diplopia HA

Epistaxis Rhinorrhea Congestion Sore throat Hemoptysis3. Chest: Shortness of breath PND Orthopnea Dyspnea on exertion Cough

4. Cardiovascular: Chest pain Pleurisy Palpitations

5. Abdomen/GI : Pain Constipation Diarrhea Melena Hematochezia BRBPR

6. Extremity: Pain Swelling Claudication7. Skin: Rash Pruritus

8. Neurological: Dysarthria Coordination Balance Syncope

9. Musculoskeletal: Joint pain Weakness Swelling10. Geni tourinary: Increased frequency Dysuria Hematuria Foul odor Pain11. Hematological: Bleeding Bruising Recurrent infections


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Physical Exam: Temp Resp HR O2 sat BP

General:

HEENT:

Neck:

CV:

Chest:

Abd:

Ext:

Neuro:

Skin:

Rectal: Cal AST Tn

Labs: MCV Phos ALT CK

Diff: Mag AP MB

RDW GGT Alb BNP

baseline Hgb: baseli ne Cr: TSH Amyl L ip

EKG: UA: PT

CXR: INR

Other: PTT

Documents

JMS Survival Guide 2010