UNIVERSITY OF KANSAS
SCHOOL OF MEDICINE
KANSAS CITY
CLINICAL STUDENT
ORIENTATION MANUAL
2005-2006
SPONSORED BY:
THE UNIVERSITY OF KANSAS ALPHA CHAPTER
ALPHA OMEGA ALPHA NATIONAL HONOR SOCIETY
Original Author:
Curtis R. Maslen, M.D., 1985
With contributions from the classes of
1990, 1992, 1995, 1996, 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006
Alpha Omega Alpha
Kansas Alpha Chapter
Alpha Omega Alpha is the only national honor medical society in the world. National Alpha Omega Alpha was established in 1902 at the College of Physicians and Surgeons in Chicago, with the Kansas Alpha Chapter receiving its charter in 1931. Its raison d'etre can be expressed in a phrase: to recognize and perpetuate excellence in the medical profession. As stated in the society's constitution, "Alpha Omega Alpha is organized for educational purposes exclusively and not for profit, and its aims shall be the promotion of scholarship and research in medical schools, the encouragement of a high standard of character and conduct among medical students and graduates, and recognition of high attainment in medical science, practice, and related fields."
To fulfill the role it has set for itself, Alpha Omega Alpha elects outstanding medical students, graduates, alumni, faculty and honorary members to its ranks and offers its membership important national programs such as: Alpha Omega Alpha Visiting Professorships, a quarterly journal - The Pharos, Student Research Fellowships, and two Distinguished Teaching Awards in collaboration with the Association of American Medical Colleges. In addition to national programs, the Kansas Alpha Chapter has several local programs which include: The William Root Lecture Series, the KUMC Clinical Student Orientation Manual, and Residency Information programs.
Election to Alpha Omega Alpha is a distinction that accompanies a physician throughout his or her career. Especially for the younger physician, the society provides a forum for the exchange of ideas as well as a source of valuable contacts. Members can be elected as students, house officers, alumni, or faculty of an affiliated institution, or by virtue of distinguished achievement in any field related to medicine, on an honorary basis.
Elections in the first four categories are carried out by the individual chapters. Chapters elect undergraduate members from students in their last two years of medical school. Scholastic excellence is a key criterion, but not the only one for election; integrity, capacity for leadership, compassion and fairness in dealing with one's colleagues are also to be considered. Students who are in the top academic quartile of their class are eligible for election, but the number elected may not exceed one-sixth of the graduating class. The Alpha Chapter at the University of Kansas has two separate elections in which undergraduates may be voted into Alpha Omega Alpha. The first opportunity is in the Spring at the end of junior clinical clerkships when the top 12.5% of undergraduates are eligible, and the second opportunity for election is during the Fall of the senior year clerkships when the top quartile is eligible. The students elected to the society are men and women who have compiled the requisite high academic standing and who, in the judgment of the members of the local chapter, have shown promise of becoming leaders in their profession. As noted above, opportunities exist for later election to the society of those not selected as undergraduates.
Respectfully,
Spencer Eagan
Kansas Chapter President, 2005-2006
Welcome to your clinical years! This orientation manual represents an attempt to assist in the transition from basic sciences to the wards and to make that transition as painless as possible. It is full of information that most of us wished we would have had access to BEFORE starting clinics. Since each person's medical school experience is unique, it does not pretend to foresee everything that will be encountered on the clinical wards. It does, however, present the kind of information that we would have liked to have seen before we suffixed our names with MS3 for the first time, and we believe that it will be useful to most of you. Depending on your previous experiences, some of the material in this manual may be obvious. Nevertheless, since the first several weeks of clinics can, to a greater or lesser extent, be spent "learning the ropes", we present this material in hopes that it will help you to spend less time "on the ropes" and more time with "the important stuff."
This manual represents an attempt by medical students to help other medical students in the transition from the basic science classrooms to the clinical wards. It is our hope that this manual will prove to be useful, and not only that it will be continued from year to year, but also that it will be improved upon through your experiences. We ask you, therefore, to critically evaluate the information provided in this manual as you progress through the first several months of clinics, make note of important topics which were omitted as well as information which was unnecessarily included, and use that evaluation to modify this orientation manual so that it will be of even greater benefit to the class of 2008.
The following is a discussion of how the clinical student fits into the picture. Since much of the transition from basic science student to clinical student concerns itself with figuring out just exactly what it is that one is supposed to be doing on the wards, this section concerns itself with outlining some of the basic responsibilities and expectations placed on the clinical student. It should be noted first of all that student responsibilities vary tremendously from clerkship to clerkship, service to service, and attending to attending. Therefore, clinical students are well advised to define, as clearly as possible, their responsibilities early on in each rotation by consulting with the residents and attending physician. When new situations arise, "it never hurts to ask".
More specifically, a list of clinical students' responsibilities usually includes charting progress notes, doing admission H&P's, writing orders on the chart, attending rounds, lectures, and conferences, presenting patients to residents and attendings, studying when they have time, and, of course, "scut work". Order writing is the most variable of these since on some services you will be expected to write virtually all of the patient care orders, while on other services your attempt to do so may result in the loss of life or limb. The specifics of writing orders, charting progress notes, and a few basic items of scut work are discussed later on in this manual. Scut work, as we're sure you've already heard, includes such things as drawing blood, filling out requisitions, consults, and a multitude of other paperwork, inserting foley catheters, starting IV's, placing NG tubes, and virtually anything else that residents or attendings insist that you do as they wave your clinical evaluation form over your head. For virtually all clerkships, being enthusiastic and helpful is the single most important thing one can do to maximize learning and enjoyment on the service.
Really Important Phone Numbers: KU Pathology x1180
KU Laboratory x1700
* Always dial an 8 KU Radiology reports x 7551, then # 1,1111111,
pt# before all extensions.
5 goes to the previous report filed.
3 rewinds 5-10 seconds
7 fast forwards 5-10 seconds
Note: can look at films on --- KU Radiology online: Pulse, click on pts, then
Vista Imaging System, which is on most computers.
clinical dept, radiology, then pt info, log on: tcao,
password medline
VARadiology reports x7301, then #1, resident pager, 11(or 13 for MRI), pts last four
KU paging system 9-917, then number
VA paging system 86, then number, then function 3
KU operator 0, or x5000
KU medical records x2454
KCVA 816-4700
To put in consult at KU: Fill out request form. Call operator and ask for the number to put in a consult for whatever service you need. Call the number and have available the pt's name, age, room # and hospital #, attending, resident and pager #, and the reason for consult. This is all done on the computer at the VA.
To find an old chart at KU: Charts are supposed to come to the floors with the pts. Unfortunately, that doesn't always happen. Your best shot is to go to medical records yourself (ground floor, in the hall between cafeteria and main elevators) and request the chart. Be sure to take the pt's medical record number! If you are really nice to the med records people, your life will be much easier. By the way, all records are computerized at the VA.
Checking out X-rays at KU: Radiology jackets are available in the film library/reading room on the second floor of the main hospital. Go to the window and fill out the white request form. If you will be taking the jacket with you, you must also fill out a yellow or blue card with the name, number, and your service name. You must fill out a separate card for every jacket checked out. If you need to look at your patient's daily films, go to Inpatient Radiology and ask to look at inpatient rollo. If patient is coming from ED, check there first.
KU -6:30am to 8:00pm
VA - 8:00am to 2:30pm
As you will find, reading time is valuable during a clinical rotation. You will need to select textbooks which are both accurate and complete yet readable in the relatively short time in which a clerkship lasts.
The following list of books and comments is compiled to help you make a selection as well as to inform you about what is available. Also, see the book section for each rotation for recommendations on specific courses. Before you purchase a textbook, which you feel you may not use after you have finished your rotation, it is recommended that you check with the clerkship's education coordinator to see if you can get required texts from them on "loan". Some departments have limited copies available which you can use while you are on their rotation. The counseling center has many review books that can be checked out free. Also check with your big sib or classmates who have taken the rotation already to get other recommendations.
First a few general comments:
1. Select books you feel you can read cover-to-cover during the one to three months of a rotation. It is important to get an overall view of a particular clinical rotation. Your goal is not to become a world authority on Hematology or Gastroenterology during the two-month medicine rotation. You need to get the whole picture.
2. Once you have selected a book - read it. Don't attempt to read several different books on specialized areas. Basically, pick one book.
3. Use major textbooks (Harrison's, etc.) when it is necessary to have more detail. When you want to read about a specific problem on one of your patients - Harrison's and other references are usually easy to find on the floors. The easiest reference to be used is Uptodate. It has an icon on all desktops in the hospital. It is great to use to look up information prior to rounds.
4. NMS review books as well as other review books are available to check out from the Learning Resources Office, Room 4006 Student Center (588-4688), at no charge. This is an excellent resource to save you $$.
5. Use the library. Many excellent reference books and atlases can be found there. Many of them can be checked out. If a desired book is not there, encourage the department to place one on reserve.
6. Read about your patients - Know their problems.
7. Do Appleton and Lange review questions in addition to book reading.
GENERAL ESSENTIALS - The first 3 items are must have's.
1. Guides to Antimicrobial Therapy, Sanford. A must. You can usually get a free copy from a professional pharmaceutical representative.
2. Pocket Pharmacopoeia, Tarascon. Updated every year. Essential for writing orders and looking up meds.
3. Quick Medical Reference, Maxwell. Easy place to get common things- everything from note writing and drug levels to dermatomes and mental status exam. Little too.
4. EpocratesRx Clinical Drug Reference - over 2,600 drugs and tables, including adult and peds indications and dosing, contraindictions/cautions, adverse reations, mechanism of action, formularies, black box safety information and pricing. One can run a multi-drug check for up to 30 drugs (www.epocrates.com). FREE
5. EpocratesID Infectious Disease - access comprehensive information on over 300 diagnoses, including more than 350 bugs and over 250 drugs (similar to Sanfords Guide to Antimicrobial Therapy) (www.epocrates.com). FREE
6. MedMath - a free medical calculator designed for rapid calculation of more than 20 common equations and formulas used in adult internal medicine
(http://smi-web.stanford.edu/people/pcheng/medmath ).
Additionally, a website with a large list of PDA resources for the medical student can be found at (www.library.ualberta.ca/subject/index.cfm ).
Title of course: Surgery
Course Director: Chris Haller, MD, x3254
Course Coordinator: Jonya Rakoski, x3173 Office: 5th floor Sudler
On the first day- Meet: 560 Eaton (5th floor Sudler) 8 a.m.
Bring: White Coat, note pad.
Attire: Professional attire is standard, and is required in all clinics and classes.
Entrance to OR locker is accessed by calling on phone at door. Scrubs are checked out using the Auto Valet cards in OR, though students are only allowed ONE pair
at a time. This has become a pain, and it may be easier to get your own. Long hair should be pulled back.
Helpful stuff: At some point during the rotation, fill your pockets with the
following: Trauma scissors, tape, 4 X 4 gauze, note cards. You will spend one month
on a general service and one month in a specialty.
Main OR Desk (core) x2880 PACU x2100 Same Day Surgery x2141
Books:
Loaned by the Surgery department:
Books most of the group used to study:
Helpful Books:
1. Sabiston: The Harrison's of Surgery. Somewhat more physiologic than Schwartz and a little more difficult to read.
2. Atlas of Surgical Operations: by Zollinger: Excellent for understanding specific surgeries or for making drawings for Dr. Thomas. Expensive; look in the library. (can be found in resident room on Unit 51)
3. Schwartz: A medicine textbook for surgeons; used by many; recommended by the Surgery department; a reference book.
4. Fluids and Electrolytes for the Surgical Patient y Pastana: Excellent book; lots of pictures, easy to interpret diagrams, explains well acid/base disorder; worthwhile purchase.
5. Manual of Surgical Therapeutics: The surgery version of the Wash manual; good info on fluid and electrolytes.
6. Companion Handbook to Schwartz: Similar to Companion Harrison's; worth the money if you will use it.
Hours: Expect to arrive at the hospital between 5:00 and 6:00a.m. Surgeries are usually scheduled to begin at 7:30am. Be prepared to leave the hospital between 6:00 and 8:00 pm. Unlike Medicine, you will not be leaving early on your post-call day.
Rounds: Most services round sometime between 6:00 and 7:00a.m., but some will expect you to come see your patient before rounds. Allow 30-60 for this "pre-rounding" time, especially at the beginning of the rotation. Afternoon post-op rounds may be held by trauma on general services (usually not on specialty services). Take the initiative to see your patients prior to post-op rounds.
Weekends: If you are not on call, you will come for morning rounds and usually be done before noon. The on call team will handle emergency surgeries during the weekend. There are no elective surgeries on the weekends. You will have to take call on weekends.
Call schedule: Depends on the # of students, usually every 4-6th night. You will only be on call while on KU's general surgery rotation (3 times during the rotation). While on call, your team will cover the trauma room. Page the intern on call, and you will follow him for the night. There is no call room, so if it is slow, you will probably be sent home.
Call Room location/ code: At KUMC, KC VA, and Leavenworth VA there are no call rooms. No call is taken at the VA's.
Grading System; 90/80/70
50% Clinical Evals., 15% presentation and 35% Final USMLE-style exam. Evaluations are done by attending and Chief Residents.
Writing Notes:
Daily Notes:
1. Keep them short, no longer than length of pen
2. Include Post-Operation day number (ie POD#3)
3. Include the number of days on Antibiotics (ciprofloxin #5)
4. Vitals including intake/output (I/O) and drain output
Pre-Op Note:
As a surgery student, it may be your responsibility to write pre-op notes before a patient goes to surgery. The pre-op note provides a brief yet concise description of what is wrong with your patient, what surgical procedure is planned, who plans to do it, and any historical information or findings that are pertinent to the surgical procedure.
1. Notes should be completed the day before a patient is scheduled to go to the OR.
2. Arrive in Same Day Surgery when your patient arrives and page the intern. Stay with your patient until they are taken to the OR.
Pre-Op Note
Hx: This 48yo WF c NIDDM presented 3/24/84 c 2 day Hx of RUQ pain. Outpatient sono revealed nonvisulaized gall bladder, and pippida scan was c/w cholecystitis.
Pre Op Dx: Cholecystitis
Planned Procedure: Cholecystectomy
Surgeons: Dr. Smith/Dr. Jones/Yours Truly MS3
Labs: (List pre-op CBC, Platelet Count, PT/PTT, ASTRA, etc. using the laboratory shorthand mentioned above.)
CXR: Normal chest
EKG: NSR, rate 80, nonspecific ST-T changes
Current Meds: Tavist-1 prn
Blood: 2 U PRBCs typed, crossed, and available
Consent: Signed and on chart
Post-Op Note:
You may also be responsible for writing post op notes on your patients immediately following surgery. Since the post op note is written while the patient is still in the recovery room, you will either have to memorize its format or bring Maxwells along with a pen, and your ID badge, with you in your surgical scrubs. The following sample post op note is self-explanatory. (Most surgeons write the post-op note on the computer and print it out immediately after the case).
Post Op Note
Pre Op Dx: Cholecystitis
Post Op Dx: Same
Procedure: Cholecystectomy
Surgeons: Dr. Smith/Dr. Jones/Yours Truly MS3
Findings: Cholelithiasis, cholecystitis
Anesthesia: GETA(General endotracheal, spinal, local, epidural, etc.)
Fluids: 500cc D5LR (list here the amount and type of fluids given dur-ing the procedure, eg. NS, blood, albumin, etc. You can find this by looking on the anesthesiology record or by asking the anesthesiologist or surgical nurse.)
EBL: 50cc (This is the estimated blood loss during the procedure, as shown on the anesthesiologist's record.)
Tubes/Drains: NG to low intermittent sxn, T-tube in RUQ
Specimens: Gall bladder sent to surgical pathology
Complications: None
Condition: To RR in (good, fair, stable, poor, critical) condition
Post-Op Orders:
Take initiative and offer to write the post-op orders. Ask the resident for their format and follow that format throughout the month long rotation. Although the ADC VAN Dissel (see admit order page) mnemonic can be used to write post op orders, you might find the following format equally useful and match much less cumbersome.
Post-Op Orders
1) Procedure: (eg. S/P cholecystectomy)
2) Allergies: (eg. NKA )
3) Disposition: (eg. Return to 5120 when stable, admit to ICU, etc.)
4) Vital Signs: ( This determines how often vitals will be taken after the patient leaves
the RR, eg. Vitals Q15 minx 8, Q30 min x4, Q4 hrs x 6, then Q shift.)
5) Diet: (eg NPO, advance diet as tolerated, etc.)
6) Activity: (eg. Bedrest, bedrest c BRP, etc.)
7) Tubes/Drains: (eg. NG to low intermitten Gomco, foley to DD, etc)
8) Resp. Care: (eg.TC&DB Q2 hrs x 24 hrs, incentive spirometry, 02, etc.)
9) Meds: (eg. Reorder patient's pre op meds if appropriate,
Antibiotics, IV fluids, etc.)
10) Call HO if: (eg. Call HO for temp >38.5)
Remarks: Residents and Staff appreciate initiative. This means being an active seeker of knowledge. Things you can do to help the team include: search for path reports and x-ray, print extra copies of rounds reports, gather charts before or after rounds, and recognize that the flow of information is from you to the intern, intern to the chief resident, and Chief to the Attendings. It is recommended to be in surgery or with your residents when not in lecture (don't say you have lecture when you don't). Also, it is considerate when scrubbing out of a surgery for lecture to always check back after lecture to make sure the surgery has ended or you are excused to go home.
Title of course: Neuro-Psychiatry
Course Director: Psychiatry: William Gabrielli, MD/PhD, x6401
Neurology: Heather Anderson, MD, x2330
Course Coordinator: Lesley Leive, x6401 Office 1st floor Olathe Pavilion-1006
Paula Mengel, x6996, Landon Center on Aging
On the first day: Meet: Room 1020 Olathe Pavilion (Olathe is down the main corridor past Delp; it's the section of the hospital across the street from Kirmayer)
Helpful stuff: This is a fun 2 months. You can also learn a lot, but also have some time off to breathe! If you have this rotation early on in 3rd year, then be advised that you will have more time off during these 8 weeks than on other rotations. So either just enjoy the increased time and flexibility or use it wisely! This is a good clerkship to aim for an A! The clerkship is divided into different combinations of clinical experience in Psych and Neurology. This will include:
Sites-
Books:
Books we actually used to study:
1. High Yield Psychiatry by Fadem & Simring- Williams & Wilkins. Quick read and covers most of the material. (all you really need).
2. Blueprints of Psychiatry: also a quick read, but covers most of the material.
3. Psychiatry by Appleton and LANGE - question and answer book that is a good supplement to NMS.
Helpful books: (not usually necessary unless you plan to do psychiatry)
1. NMS Review; Required text; covers personality disorders and child psych in addition to reviewing the field. The shortest of all NMS books- easy to get through.
2. Psychiatry Recall by Fadem & Simring - W & W
1. The DSM IV is a good reference and can be found in most psych depts as well as the library.
2. Psychiatric Diagnosis by Goodwin: Recommended by the psych dept.
3. Psychiatry by Tomb; A good pocket sized review of the field. Can often get free from drug reps.
4. Pocket Handbook of Clinical Psychiatry, Kaplan and Sadock.
5. *Aminoff - borrow if necessary for Neurology, Clinical Neuro
Hours: Rounds- Will vary depending on if you are at the VA or KU. At the VA, the three teams usually round at different times, such as 8:30 a.m., 11 a.m. or even 1p.m. depending on the attending. You usually need to allot 30-45 minutes to see your patients before rounds. KU rounds are usually not before 8:00 a.m.
Typical Day: Usually about 7:30 a.m. (roughly, maybe earlier) until about 4 or 5 p.m. Maybe longer if very busy on inpatient Psych at KU.
Weekends: Probably not, but there is a chance. If you are at the VA you can be almost sure you won't have any weekends. Students on KU Adult psych. usually had to alternate weekends to be there.
Call schedule: Everyone will be on call twice during the clerkship. All call is taken at KU regardless if you are at the VA at that time. The call is usually with the PLS (psych. liaison service in the ER), and is from 6 p.m. to 10 p.m. Sometimes there will be NO patients at all (you might be sent to read) or could be busy with multiple psych patients in the ER).
Grading System: 90/80/70/60. Based on clinical evals, neuro paper, oral exam (a case presentation), and the shelf test. Opportunity exists for extra credit paper (2% of total grade).
· For Neurology, remember to include all aspects of complete Neuro exam in the objective portion
(cranial nerves, strength, sensation, tone, reflexes, cerebellar function, gait, etc.)
· For Psych, the objective part of your note should include:
*Mood/Affect, Speech/Thought, Insight/Judgment
Attention/Concentration, Hallucinations, Suicidal or Homicidal ideation
*Assessment will include Axis (I, II, III, IV, V) - you will learn all about this part of the
psych assessment
Title of course: Medicine
Course Director: Amy O'Brien-Ladner, M.D., x 6405
Course coordinator: Karen Reeves, x3833 Office: 1012 Wescoe
On the first day: Meet: 4050 Wescoe
Bring: White coat, stethoscope, penlight, ID badge, notepad
Helpful stuff: Blank note cards are a great way to keep track of patient info.
Dress: Professional attire is required.
Books:
Books most of the group used to study:
Other helpful references:
5. Practical Guide to the Care of Medical Patient, by Fred Ferri. A pocket-sized handbook like Wash Manual, but with more procedures. Many residents and students prefer the Wash Manual. Neither is essential.
6. Medical Manual of Therapeutics (also known as the Wash manual): A good book well liked by residents; as a third year student you probably won't use it much.
7. Companion Handbook to Harrison's: Contains a lot of information in a short, concise, readable form; nice to have with you at the morning lectures.
8. Book of Lists by Dr. Greenberger: Great for coming up with a differential diagnosis.
9. Rapid Interpretation of EKG's by Dubin: Great for learning EKG's; you can read it in one day.
10. Merck Manual of Diagnosis and Therapy: Excellent investment.
11. Medicine, Fishman
Required text (but not really):
1. Cecil's Essentials of Medicine, fourth edition: This is the required text and the one from which assigned readings are taken. Provides readable discussions of major topics, but includes too much material to read in 2 months. It is also too sparse to serve as a good reference. Reasonable price.
Reference Texts:
1. Harrison's Principles of Internal Medicine: An excellent reference, the Gold Standard. It is big and expensive, but you will be able to use it during many rotations. Often available in residents' rooms, and always in the library. A worthwhile purchase if you can afford it.
Hours: Expect hours to be about 6:00 a.m. to 6:00 p.m., with occasional earlier days. Morning report is at 8 a.m. in 4050 Wescoe or Sudler for Grand Rounds. Attendance strongly encouraged.
Rounds: KNOW WHAT IS GOING ON WITH YOUR PATIENTS!
Be sure to read about your patient's diseases because that is where most of the questions during rounds will come from. Rounds usually occur in the morning. They frequently last most of the morning. Most services require that you come in before rounds to see your patients (6:30 or 7:00). Notes may or may not have to be written before rounds - just ask the residents on your team.
Weekends: Students are required to see their patients every day. However, most services will provide you one day off a weekend, or allow one student to cover all the patients so the other students can be off. Students are usually allowed to leave the hospital on weekends after rounding and writing note/orders.
Call Schedule: Most teams are on call every 4th or 5th night, but sometimes it is more frequent. Students are usually required to stay. Usually each student picks an intern and takes all call with that intern. It is a good idea to ask about call responsibilities on the first or second day of a clerkship.
Call room location/code: KU: 4th floor Bell, just inside the lobby of the MICU. (ie. Unit 44) Code 243.
VA: 11th floor East Hall. Code 543
Units: Medicine floors are on 4 and 5.
Grading System:
Your grade will be based on the following: Clinical evals 60 pts (30 ea month)
Shelf Test 40 pts
Total 100 pts
88% has been a superior, with grades falling at 70, 60, 50, and 40 thereafter. The medicine department is very clear that they will review point totals and set new cutoffs if necessary, so these numbers are approximate.
Writing Notes: Daily notes on the Medicine services are written in SOAP format. It deserves mention that Medicine notes are usually fairly long, as patients typically have multiple problems. Students are also responsible for writing H&P's on all new patients.
Orders: The student is usually responsible for writing orders on his/her pts both @ KUMC and the VA. A resident must co-sign all student orders. Therefore, students should take the responsibility to make sure that their orders are co-signed in a timely manner so as not to delay patient care.
Remarks: The Basic Medicine clerkship is one which students often consider the most valuable. It is a good place to learn the basics about the presentations and management of human diseases. The amount of material that falls under this heading is vast, so it is important not to get weighed down with obscure facts. The best learning experiences (and the best test scores!) will come to those who learn broad principles of Internal Medicine while on this rotation, and read, read, read.
Title of course: Obstetrics and Gynecology
Course Director: Mary Duff, MD, x3244
Course Coordinator: Valorie Dodd, x6274, Office 3009 Wescoe
On the first day-Meet: OB/GYN Library on 3rd Floor Wescoe
Bring: White coat, note cards, and ID card for labor and delivery access will be provided.
Helpful stuff: At some point you should acquire a gestational wheel. HOWEVER, don't purchase one - you can usually get one from a drug rep. or on Labor & Delivery.
Books:
Books most of the group used:
Hours: Rounds: Start about 6:45 a.m. at the latest. You will be expected to pre-round and have your notes written before rounds.
Weekends: Yes. Students are expected to round and write notes on weekend days. Most services will allow several students to cover all of the patients so that everyone gets at least a few weekend days off.
Call schedule: Subject to change with each group. Usually there is only one student on call for OB and one for Gyn per night. Therefore, the frequency of your call depends on how many students there are on your particular rotation. Generally, there are plenty of students so call is not as frequent as other rotations. (every 3rd to 6th nights). Students will be involved in all deliveries of babies.
Call room location/code: Call rooms are located in the west hallway on the way to Unit 51. The code is 423. A shower is available in the locker room in Labor & Delivery. There are 2 call rooms.
Grading System: 90/80/70
25% Ob evals, 25% Gyn Evals, 10% Gyn-Onc Evals, 10% Mid-term, 30% USMLE-style exam. Every resident and staff receives an evaluation form regarding each student. If the resident/staff feels that they know you well enough through clinics, surgeries, ward, or on-call they will evaluate you. Occasionally, however, students receive evaluations from resident/staff that they hardly worked with. The point is, be prepared for every interaction.
How to present a patient: Ms.________is a ___year old G__P__LC__(race)____ female with an EDC of ___(date)_____based on (LMP or Sono).
Ms. Jones is a 34 yo G5P4 LC4 white female with an EDC of June 18, 2002 by a 12 week sono.
Questions to Ask Antepartum Patients (about ready to have a child)
Fetal Movement? Vaginal Discharge/Bleeding? Leakage of Fluid?
Cramping or Contraction? Edema? Especially facial edema.
Headaches? Blurring of the vision?
Writing Notes:
Vaginal Delivery
Postpartum Day #1 *Pt may go home if>24 hours post delivery if she is afebrile. Check cbc Hb
Postpartum Day #2 Pt goes home if afebrile
*Check and report: birth control plan
breast or bottle feeding
Postpartum Hgb/Hct
Rubella immune status: if non-immune, pt needs Rubella injection prior to discharge
VDRO
Blood Type: if Rh-, Aby scree-, and infant Rh+ pt needs Rhogam injection prior to discharge
Any culture results or pending
Discharge orders *Follow up: in _____ clinic in 6 weeks
*Activity: no tampons, douching or intercourse x 4 weeks
*Diet: regular
RTC: if temp>101, foul smelling discharge, severe abdominal pain, bleeding more than a pad an hour
Discharge Meds *Motrin 800 mg 1 po q 8 hrs prn pain, #30; no refills
*Colace 100 mg 1 po BID #60; no refills
*if Hgb<10.0, FeSO4 6 weeks worth; no refills
Hgb9.0-10.0, FeSO4 325mg 1po q day with meals
Hgb<9.0, FeSO4 325mg 1 po BID with meals
*if breast feeding, PNV 1 po q day #100; 5 refills
C-Section
Post-op Day #1 *remove surgical bandage before rounds (if on > 2 hrs)
*Orders Ambulate QID
D/C Foley
Heplock IV
Clear liquids
Check cbc
*Meds D/C IM pain meds
Motrin 600 mg1po q 6 hrs prn pain, do not exceed 4 in 24 hrs
Tyl #3 1-2 po q 4-6 hrs prn pain
Colace 100 mg po BIC
Post op Day #2 *advanced diet if tolerated clear liquids well
Post op Day #3 *remove staples and steri-strip just prior to discharge
*ask about plans for birth control, breast or bottle feeding
*Pt to go home
Discharge Orders *follow-up in _______ clinic in 4 weeks
*activity: no tampons, douching, or intercourse x 4 weeks
*diet: regular
*RTC: if temp > 101, foul smelling discharge, severe abdominal pain, or bleeding > 1 pad per hour
Discharge Meds *Tylenol #3 1-2 po q 4-6 hrs prn pain #30, no refills
*Motrin 600 mg 2 po q 4-6 hrs prn pain #30, no refills
*Colace 100 mg 1 po BIC #60, no refills
*if Hgb <10.0, ReSO4 6 weeks worth; no refills
Hgb 9.0-10.0, FeSO4 325 mg 1 po BID with meals
Hgb <9.0, FeSO4 325 mg 1 po BID with meals
*if breast feeding, PNV 1 po q day #100; 5 refills
Title of Course: Pediatrics
Course Director: Stephen Smith, M.D., x6340, 3032 Delp
Course Coordinator: Benito Berardo, x6310, 2010 Miller Building
On the first day: Meet: 2001 Miller at 8 a.m.
Bring: Pen light
Helpful stuff: 1. - The CDU has copies of note cards with developmental milestones.
2. - Take copies of the clinic sheets for each age group. Read.
Locations: Peds floor - Unit 55 Bell Hospital.
Clinics - Miller building, 1st floor. Tunnel between main elevators and cafeteria.
Peds ICU - 1st floor, main hospital. Take escalator to one. Turn right to end of hall.
NICU - Unit 56. Main elevators to 5th floor. Past mother baby on Unit 56.
Lockers - Bottom floor of Miller building. Assigned at orientation
Full-Term Nursery - Unit 56
Books:
Books provided by the clerkship:
1. Rudolph's Fundamentals of Pediatrics, 3rd edition, 2002, Appleton & Lange - Too long to get through during a 6 week clerkship. Use this textbook as a reference.
2. Blackwell's Underground Clinical Vignettes, 2002, Blackwell Publishing - Excellent, concise set of vignettes. Not comprehensive, but good to read when you have a few minutes of downtime.
3. Blueprint Q&A Step 2 - Decent question book. Benito has several copies of this on reserve.
Required Textbook (not provided):
1. Blueprints in Pediatrics, 3rd edition, 2003, Blackwell Publishing- Simply written with lots of good information. This is the book Dr. Smith recommends for students to read.
Other options:
6. NMS Review: Some consider it helpful for boards. Outline format. Long.
Optional/Borrow
Hours: You will spend two weeks on inpatient (PICU or Floor), 1 week nursery or NICU, one week in specialty clinics, one week in urgent care clinics, and one week in community. Clinics are usually 8-5 and rarely require weekend time. Inpatient requires more time, and services have students come in both weekend days. Weekends usually consist of seeing patients, rounding, and writing notes (home by noon if all goes well). You will only be on call during the two weeks of inpatient care.
Rounds: Vary on inpatient, usually a.m. rounds. No rounds in clinics.
Weekends: Mornings while inpatient. Rare while in clinics
Call schedule: Every 3rd or 4th night while on inpatient.
Call room location/ code: Inside Unit 56. Share call room with intern.
Grading System: Curved but based on the following system : Sup 90-100
High Sat 83- 89
Sat 77- 82
Low Sat 70- 76
Unsat 0- 69
Clinical Evaluations are worth 50%, (note: you are not graded during your subspecialty week) and the shelf exam is worth 50%. The shelf is considered to be fairly difficult. However, Dr. Smith does an excellent job of preparing you for the exam. Make sure that you attend his Q&A sessions. The topics that he covers tend to be very high yield for the exam. Additionally, try to do all the questions that he hands out during the rotation as the questions have been known to show up on the shelf. Finally, in addition to reading Blueprints, you should make the effort of doing a question book (Pretest, Blueprints Q&A or Appleton & Lange) during the rotation.
Writing Notes: Clinic notes will vary. Most attendings like a brief S.O.A.P. note with a targeted H&P. Inpatient notes will consist of initial History and Physicals on new patients, and daily S.O.A.P notes as progress notes on established patients. Notes in the PICU and NICU are system-based.
Remarks: This rotation is a whirl-wind tour of pediatrics. There is much to be learned in each of the clinical settings, and the attendings are usually very good at teaching and directing students. Ask lots of questions. No one will expect you to come in an expert. Finally, have fun!! Play with the kids. This is the one opportunity you will have in med school when someone encourages you to be child-like.
Title of Course: Ambulatory Medicine/Geriatrics and Family Practice
Course Directors: Ambulatory/Geriatrics: Dr. Rauf/Dr. Swagerty
Family Medicine: Dr. Chumley and Dr. Dobbie
Course Coordinators: Ambulatory/Geriatrics: Karen Reeves x6051
Sandra Scott x1490
Family Medicine: Ryan Murray x1996
On the first day: Meet: check email notifications
Bring: white coat, stethoscope, and anything you might use in an outpatient med clinic
Helpful stuff: Pharmacopia, Sanford's Guide to Antimicrobials, Maxwell's, PDA drug programs
Books we used: (These are good for preparing for the Family Shelf and the Ambulatory portion of
Amb./Geriatrics in-house exam. Study the Geriatrics web modules for the Geriatric
portion of the Amb./Geriatrics exam. Medicine review books are also helpful.)
1. Blueprints of Family Medicine - Good outpatient overview.
2. Blueprints of Medicine - Good Medicine overview, lacks Pediatrics and OB/GYN info.
3. NMS Family Medicine - Question book.
4. Family Practice Bard Review Book - Expensive, past students have recommended buying this if you plan on doing FP.
5. Essentials of Family Medicine (required text) - Most students did not use this book to study.
6. Many students also read over any pertinent sections of Boards and Wards and Step 2 Secrets review books.
Hours: Rounds - most students on these services will not ever round on inpatients
Weekends - rarely/never
Call: None
Daily hours, in general, are variable for each student based on assigned preceptors and
community experience location. Especially during Ambulatory/Geriatrics, each student
may have many preceptors each week and a varied combination of different preceptors each
half day. Certain days will be assigned for lectures. A schedule will be distributed.
Grading System: Family Practice Ambulatory Medicine/Geriatrics
50% Clinical evals 27.5% Ambulatory Evals
(25% Preceptor) 27.5% Geriatrics Evals
(15% Student Clinic) 20% In-house exam
(5% Community Clinic) 10% Web-Modules
(5% Standardized pt/ 5% Standardized Pt./Clinical skills session
Clinical skills session) 5% Participation in Small Groups
25% Shelf exam raw score 5% Palm-based patient logs
20% COPC presentation
5% Participation in case-based discussions
Grading Breakdown: FM: Sup. 89.5-100 Amb./Geriatrics: Sup. >88%
HS 79.5-89.4 HS 78.6-87.9
Sat. 69.5-79.4 Sat. 72-78.5
F<69.5 LS 66-71.9
F <65.9
A note about COPC: Students will participate in a Community Oriented Primary Care project which involves creating/continuing an intervention with an area vulnerable population and giving two presentations to your class. The grading for this counts toward both the Family Medicine grade and the Amb./Geratrics grade. As of the writing of this booklet, the exact nature of the COPC project and its contribution to the grades may be in flux, and the above grading information may be out-of-date. Direct any COPC questions to Diana Carter x1987.
Writing Notes:
Clinic Notes: most are in the SOAP format - see later text. However, the student may have contact with multiple attendings, especially during the ambulatory part of this rotation, and
should verify with each attending what format he/she prefers for the student notes. Some attendings may want full H&P's, some may want SOAP notes and some may have a fill-in-the
blank type of form for the student to use, which will be the case a lot of the time in private practice settings.
Outpatient Prescription Writing:
From time to time, you will be called upon to write outpatient prescriptions. The
outpatient prescription includes the name of the drug, form in which it is to be dispensed,
amount to be dispensed (Disp), patient instructions (Sig), number of refills, and signed by
a resident or attending.
Outpatient Prescription Example:
Name (Augmentin 875 mg)
Disp #(20)
Sig: (1 po BID x 10 days)
Refills: 0
**************************************************************************************
A note about resident work hours vs. medical student work hours:
In July 2003, the federal government passed legislation that restricted the number of hours that residents are required to work. The rules are basically no more that 24 hours per shift and no more than 80 hours per week, although there are a few exceptions. This has been a big change affecting how many services operate in the hospital. Many physicians are frustrated by the new rules as they often place greater burden on the rest of the team. As a medical student it is necessary to understand that these rules do not apply to you. Just because you were on-call with a resident the night before does not mean that you are free to go at noon when the resident leaves. There is a lot of variability between the services but it is very important to never assume that you are going to leave early post-call. This is especially relevant during peds, surgery, OB and medicine rotations.
It is important for the new clinical clerk to be aware of some of the important issues regarding chart work. The first is WRITE CLEARLY! The second is anything you enter into a patient's chart has the potential to be used as a reference which may help to guide the patient's future health management. It is also a legal document which may become public record if used in court. It is absolutely imperative that clinical clerks do not write anything in the chart which is not true or not actually observed by you personally. If you are going to include information which was observed by others (i.e. a physical finding noted in the residents notes, but not by you) you must include this as part of your note. If you simply do not have time to fully examine a patient before 5:00 a.m. OBGYN rounds, you should probably not include this in your note. It is also unacceptable to photocopy any portion of a patient's record (including your History and Physicals once they are in the chart), as this is a breech in patient confidentiality. It is always a good idea to "ask before you do", and this will come in handy throughout your career in medicine.
A topic not discussed elsewhere in the manual is the responsibility of presenting patients to residents and attendings. The verbal presentation of a patient proceeds in the same order as the admission H&P, from chief complaint through clinical impression and plan. The object of presenting a patient is to communicate enough pertinent information about the patient that someone who does not know the patient will be adequately informed and satisfied. The key words here are, of course, "pertinent" and "enough". We know you're tired of hearing this already, but what is "pertinent" and what is "enough" varies so much that it is meaningless to attempt to define it. Some attendings are satisfied with the patient's name, age, sex, and chief complaint, interrupt you shortly thereafter, and scurry off to the patient's room because you were taking too long. Other attendings expect you to recite the patient's entire history and physical from beginning to end in elaborate detail, and they will wait very patiently as you do so.
One way of beginning a presentation of an H&P is the following: "Mr. Doe is a 45 year old white male with a history of COPD, angina and an inferior MI in the past, who now presents with angina of increasing severity and duration". The first statement of the presentation is the most important and by including the pertinent past history gives the attending and others present a brief synopsis of the patient's status. In general, it is wise to present only the pertinent findings in the H&P - laboratory work, x-rays, EKG, etc. Nevertheless, the most important piece of your presentation is the clinical impression and plan for the patient. This is where the attending will be able to assess your clinical expertise.
Further complicating any attempt to describe the art of presenting patients is the fact that some attendings will allow you to read your presentation directly from your admission write-up, others will allow you to carry 3x5 note cards for presentations, and still others, thankfully a minority, expect you to present your patients entirely from memory. Unfortunately, the latter category of attendings also usually happen to be the ones who insist that your patients are presented in elaborate detail. In the final analysis, you just have to get a feeling for what is pertinent and what is not, what is excessive and what is enough, and what your particular attending expects. The best thing to do is to ask your resident what to expect before you come under the gun, although occasionally attending physicians may actually tell you what they want. The importance of figuring out what is expected of you with regard to patient presentation resides in the fact that a good portion of your clinical evaluation by the attending physicians may be determined by your skill at presenting patients to them, since they are likely to observe you doing that more than they will see you doing anything else. To repeat the basic rule of thumb, therefore, "it never hurts to ask".
Subjective:
This part of the S.O.A.P. note should briefly describe how the patient feels and any complaints he/she might have. Analogous to the chief complaint portion of a History and Physical, it should be stated in the patient's own words whenever possible. It should also contain, when pertinent, your own subjective observations about the patient, for example, his/her general mental state or appearance.
Objective:
This part of the S.O.A.P. note lists objective data including current vital signs, pertinent physical exam findings (which always includes cardiovascular, pulmonary and abdominal exam and only the other physical findings which are pertinent to that patient), and laboratory results. Some attendings like to have pertinent laboratory values circled, others do not. Check with your individual residents.
Assessment:
In this part of the S.O.A.P. note, each of the patient's medical problems is listed, generally in descending order of importance, and basically conforming to the list which you generated in your admission H&P, with the addition, of course, of those problems which have developed or have been discovered since the patient was admitted. Each listed problem is updated according to evaluation of the current objective data which you listed under "Objective". In this problem-oriented format, the number of each problem is retained throughout the patient's hospitalization, with new problems added to the list as they arise and problems deleted from the list as they are resolved.
Plan:
In this part of the S.O.A.P. note, diagnostic and therapeutic plans are listed as they apply to the patient's current problems and in the same order. Included are any new medications or diagnostic procedures which are added, changes or additions to nursing orders, and plans for discharge or transfer. Your responsibilities as a clinical student will include knowing your patient's current problem list, gathering and knowing the results of all diagnostic procedures, knowing the current status of all therapeutic interventions, and compiling all of this information into a problem oriented progress note in the S.O.A.P. format which you will record on the chart daily for all of your patients.
The following is an example of such a progress note:
S. "I feel just great today". The patient is without complaints this morning and appears much less SOB.
O. P.E.VITALS: BP 136/82 s orthostatic change, P80, RR18, T 37.0,
HEENT: unchanged
NECK: s JVD
CHEST: Fine insp. rales in post. bases, scattered insp. rhonchi., exp. phase prolonged, but decreased use of accessory muscles.
ABD: Obese, BS present, nontender to palpation, s HSM or masses
NEURO: CN II-XII intact, sensory, cerebellar, and motor exams WNL, DTR's 2+ and bilat. =. No tremors, seizure activity, or asterixis, patient is alert and oriented c intact short-term memory.
EXTR: s clubbing, cyanosis or edema.
LABS:
141 108 14
______ _________ ________< 89 See CBC with Diff
4.0 26 1.0
sputum culture - neg. @ 24 hrs.
stools occult blood positive 7.37/42/84 on 21/NC
4 units PRBC's typed and cross matched
Upper GI endoscopy revealed diffuse, erosive gastritis
A. 1) GI bleed. Stable further blood loss, although stools remain heme. +.
EGD revealed erosive gastritis as probable source of blood loss.
2) COPD. The patient's pulmonary status continues to improve, c improved air exchange by P.E. and improved ABGs. Sputum cult. neg. so far.
3) Probable alcoholism. Patient continues s evidence of acute withdrawal.
P.
1) Continue Tagamet and antacids, monitor the patient's Hb, and continue to Guiac stools. 4 units PRBCs typed and crossed.
2) Continue Alupent aerosols, 02 at 21/NC, and IV Aminophylline. Taper Solumedrol and continue to monitor ABGs.
3) Thiamine IM, monitor for sx of ETOH withdrawal c Librium use as indicated. Transfer to ADTU when #1 and #2 are stable.
Laboratory Shorthand:
The following are examples of a common way to record lab values in a patient's chart:
Chem 7 (Must order individually at KCVA)
Sodium Chloride BUN
__________ _____________ ______________< Glucose
Potassium C02 Creatinine
ABG
ph/pC02/p02, FI02, method of delivery
CBC with differential
Segs/bands/lymphs/monos/basos/eos Ca TP AlkP
PO4 Alb AST
U.A. TB Chol
WBC> HgB <Plt
Hct
MCV/rdw
BASIC LABS - RANGES OF NORMALS
Na Cl BUN
137-147 98-110 8-20
<Glucose
K CO2 Cr
3.7-5.0 21-30 0.5-1.2
Ca 9.0-11.0 Albumin 3.5-5.0 Tot. Prot. 6.0-8.0 Chol <200
P 2.0-4.0 Tot. Bili. 0.2-1.0 AST 7-56
Mg 1.4-2.3 Alk. Phos 25-110 ALT 7-40
Hgb
12.0 - 16.5 MCV 80-100
WBC> <Plt RDW 11-15
4.5-11.0 150-400 MCH 26-34
Hct
36-50
PTT 23.5-34.5
PT 11.0-13.5
ABG's pH 7.35-7.45
pO2 80-90
pCO2 33-48
On-Service and Off-Service Notes:*
Some services will ask you to write On-Service notes on your first day. This note includes a brief history of illness and review of hospital course to date, as well as pertinent labs and results of studies. Off-Service notes are similar and should include all events up to the day you are leaving the service. These notes are considered common courtesy to your fellow students who will be coming onto the service following you. If you are not asked to write these notes, you should extend the courtesy of information to your peers in person.
*(Most services do not require these)
ORDER WRITING
Your responsibilities as a clinical student will include writing orders on your patients for admission, discharge, transfers, and daily changes in medications, therapies, and diagnostic procedures. The extent to which you are responsible for order writing will vary from service to service, attending to attending, and resident to resident. On some services, you will be encouraged and expected to write every order for your patients, while on other services you may not be allowed to write orders at all. The usual case is somewhere between these two extremes, and you will be sharing the responsibility of writing orders with your resident. It is a good idea to find out at the beginning of a clinical rotation what your resident's expectations are in this regard, since your aggressiveness in writing orders on your patients is frequently a factor in your clinical evaluation by the residents. Furthermore, it is much easier to keep track of what is going on with your patients if you yourself wrote the order for their care.
It is always a good idea to write orders clearly, number each order individually, include the date and time in which the order was written, and always sign your name legibly.
The nursing staff will not follow through with student orders until they have been co-signed by a resident or attending. It is also your responsibility, therefore, to see that the orders which you have written are co-signed in a timely fashion so that they can be carried out in a timely manner.
Admission Orders (ADC VAN DISSEL): Maxwell has a great (short) example.
The following format is useful for writing admission orders and is easy to remember using the mnemonic ADC VAN DISSEL. With some minor alterations, it is also useful for writing transfer and postoperative orders. The mnemonic stands for Admit, Diagnosis, Condition, Vital signs, Activity, Nursing procedures, Diet, Intake and output, Specific drugs, Symptomatic drugs, Extras, and Labs. Many physicians and residents have their own system for order writing. Find one that works best for you, is easy to remember and includes all of the important information/orders.
1. Admit: Floor, team, house officer, attending, etc. For instance, admit to 44C ICU, Med I Service, Dr. Smith H.O., Beeper #2222
2. Diagnosis: The diagnosis may be specific, for example acute appendicitis, or may be a symptomatic diagnosis if a specific diagnosis is not yet known, for instance, abdominal pain. For postoperative orders, include the surgical procedure which was performed, for instance, appendectomy. Always include under diagnosis the patient's allergies or lack of known allergies, for instance NKDA or allergic to penicillin.
3. Condition: The patient's condition on admission, transfer, or post-operatively is noted here as stable, critical, etc. Vital signs: This is technically part of nursing procedures, but is written separately by convention.
4. Vitals: Refers to the frequency with which the nursing staff will monitor and record the temperature, blood pressure, pulse, and respirations of the patient. Other specific monitoring, such as weight, CVP, PCWP, CO, neurologic signs, etc. should also be listed here. For instance, Vitals: Q1hr., daily weights, Swan-Ganz measurements Q shift.
5. Activity: This describes the activities allowed for the patient, for instance, up ad lib, bed rest, bathroom privileges, bedside commode, ambulate TID, up in chair QID, limited visitation, etc.
6. Allergies: List any drug allergies, and what reaction accompanies each (i.e. rash).
7. Nursing procedures: This consists of a variety of items including, but not limited to the following:
Bed position: For instance, elevate HOB 30 degrees, Trendelenburg position, etc.
Preps: This generally refers to preoperative patients and includes, for instance, bowel preps, surgical preps, showers, etc.
Dressing changes and wound care.
Respiratory care: Although respiratory care is generally provided by Respiratory Therapy rather than nursing, Respiratory Therapy orders that do not include medications are often included here, for instance, PD&C (percussion and postural drainage), TC&DB (turn cough and deep breathe), incentive spirometry, nasotracheal suctioning, etc.
Notify house officer if: This establishes parameters in vital signs beyond which nursing will notify the
patient's resident for further orders, for instance, notify HO for temp 38, systolic BP 90,
PCWP 20, etc.
8. Diet: NPO, regular, mechanical soft, clear liquid, 1600 cal ADA, 2 gm sodium restriction, tube feedings, protein restricted, etc.
9. Intake and output: This includes the frequency with which nursing will monitor and record I&O as well as any tubes, drains, or lines the patient might have, for instance:
Record hourly I&O
NG tube to low intermittent suction
Foley catheter to dependent drainage
Hemovac, surgical drains, chest tubes
Endotracheal tubes, arterial lines, central venous lines
10. Specific drugs: This includes all medications to be given on a specific schedule, for instance, antibiotics, diuretics, cardiovascular drugs, etc. Also include allergies to medications. IV orders include simply the type of IV solution and the rate at which it is to be infused, for instance, D5 1/2NS TRA 50 cc/hr. When the patient has both central and peripheral lines, these are specified separately, for example, D5 1/2NS TRA TKO via peripheral line and D5 1/2NS TRA 100 cc/hr via central line. Inpatient medication orders are written with the name of the drug, dosage, route of administration, and frequency of administration specified, for instance, Digoxin 0.125 mg PO Qday.
11. Symptomatic drugs: This includes all drugs to be given on a pm basis, for instance, pain meds, laxatives, sedatives, etc.
12. Extras: This includes any diagnostic procedures to be performed, for instance, EKG, chest x-ray, CT scan, sonogram, etc.
13. Labs: Blood tests, urinalysis, etc. These can be one-time orders for admission lab work or can be standing orders for continuous monitoring, for example, daily CBC.
Discharge Orders:
At KUMC a standard form is used for all discharges. At the KCVA you use the same order form for discharges as you do for your other orders. Discharge orders should include the following basic information. (Note: most of the discharge paperwork will now be completed on the computer, but the information provided here still holds).
1. Discharge: Give location patient will be going after leaving hospital (i.e. home, nursing home). Specify what date and time.
2. Follow-up Care: Include with whom, when and what time. (i.e. Patient to follow-up with Dr. Meyer in Family Practice outpatient clinic, on Tuesday 7/23/05 at 1:00). You will usually need to call to set these up.
3. Discharge medications: When you are writing discharge orders, medication orders are written like outpatient prescriptions, and therefore include the name of the drug, form in which it is to be dispensed, amount to be dispensed, patient instructions, and number of refills, for instance, Ampicillin, 250 mg capsules, Disp:#40, Sig: 1 cap PO QID until gone, Refills: 0
ABBREVIATIONS
Below are some of the more commonly encountered abbreviations. Some abbreviations are not approved by the University of Kansas Medical Center regulations for use in the body of a patient's chart. These abbreviations, nevertheless, show up quite frequently on the charts, and it is nice to know what they mean. (The KUMC Formulary is published annually and has a complete listing of approved abbreviations, which clinicians are to use in charts.) These are free to medical students in the inpatient pharmacy.
INSTRUCTIONS
a (with a line over it) before
ac before meals
ad lib as often as desired
ASAP as soon as possible
bid twice a day
BRP bathroom privileges
c (with a line over it) with
FSBS finger stick blood sugar
gtts drops
HOB head of bed
qhs at bedtime
IM intramuscular, given intramuscularly
IV intravenous, given intravenously
KOR keep open rate
KVO keep vein open
mmol millimole
NPO nothing by mouth
OOB out of bed
pc after meals
pg picogram
po by mouth, given orally
pr by rectum, given rectally
prn as needed
q every
qd every day
qh every hour
qhs at bedtime
qid four times a day
qod every other day
q6h every six hours
s without
sig label
SL sublingual
s/p status post
SQ subcutaneous, given subcutaneously
STAT immediately
tid three times a day
TKO to keep open
v.o. verbal order
wnl within normal limits
TRO to run over
TRA to run at
DESCRIPTION AND DIAGNOSIS
AAA abdominal aortic aneurysm
A&B apnea and bradycardia
A-aDO2 A-a gradient
A-a gradient alveolar to arterial gradient
AAS acute abdominal series
AB antibody, abortion, or antibiotic
A/BI ankle brachial index
ABD abdomen
ABG arterial blood gas
ACLS advanced cardiac life support
ACTH adrenocorticotropic hormone
ADC VAN DISSEL mnemonic for Admit, Diagnosis, Condition, Vitals, Activity,
Nursing procedures, Die, Ins and outs, Specific drugs,
Symptomatic drugs, Extras, Labs
ADH antidiuretic hormone
AEIOU TIPS mnemonic for Alcohol, Encephalopathy, Insulin, Opiates,
Uremia, Trauma, Infection, Psychiatric Syncope afebrile,
aortofemoral, or atrial fibrillation
AFB acid-fast bacilli
AFP alpha-fetoprotein
AI aortic insufficiency
AKA above-the-knee amputation
ALL acute lymphocytic leukemia
AML acute myelogenous leukemia
AOB alcohol on breath
AP anteroposterior, abdominal-perineal
ARDS adult respiratory distress syndrome
AS aortic stenosis
ASCVD atherosclerotic cardiovascular disease
ASD atrial septal defect
AO antistreptolysin O
AV atrioventricular
A-V arteriovenous
A-VO2 arteriovenous oxygen
BI&II Billroth I and II
BBB bundle branch block
BE barium enema
BKA below-the-knee amputation
BMR basal metabolic rate
BP blood pressure
BPH benign prostatic hypertrophy
BRBPR bright red blood per rectum
BS breath sounds
BSC bedside Commmode
BS&O bilateral salpingo-oophorectomy
BUN blood urea nitrogen
BW body weight
bx biopsy
CA cancer
CABG coronary artery bypass graft
CAD coronary artery disease
CT computerized axial tomography
C&S culture and sensitivity
CBC complete blood count
CC chief complaint
CCU clean-catch urine or cardiac care unit
CEA carcinoembryonic antigen
CHF congestive heart failure
CHO complex carbohydrate
CI cardiac index
CML chronic myelogenous leukemia
CMV cytomegalovirus
CN cranial nerves
CNS central nervous system
CO cardiac output
C/O complaining of
COPD chronic obstructive pulmonary disease
CPAP continuous positive airway pressure
CPK creatinine phosphokinase
CPR cardiopulmonary resuscitation
CrCl creatinine clearance
CRP C-reactive protein
CSF cerebrospinal fluid
CTA clear to ausculation
CVA cerebrovascular accident or costovertebral angle
CVP central venous pressure
CXR chest x-ray
DC discontinue, discharge
D&C dilation and curretage
DDX differential diagnosis
D5LR 5% dextrose in lactated Ringer's solution
D5W 5% dextrose in water
DIC disseminated intravascular coagulation
DKA diabetic ketoacidosis
DOA dead on arrival
DOE dyspnea on exertion
DPL diagnostic peritoneal lavage
DPT diphtheria, pertussis, tetanus
DTR deep tendon reflexes
DVT deep venous thrombosis
DX diagnosis
EBL estimated blood loss
ECG electrocardiogram
ECT electroconvulsive therapy
EDC estimated date of confinement
EOMI extraoccular muscles intact
ESR erythrocyte sedimentation rate
ET endotracheal
ETOH ethanol
EUA examination under anesthesia
FBS fasting blood sugar
FEV1 forced expiratory volume-I second
FHT fetal heart tones
FFP fresh frozen plasma
FRC functional residual capacity
FTA-ABS fluorescent treponemal antibody-absorbed
F/U follow-up
FUO fever of unknown origin
FVC forced vital capacity
Fx fracture
G gravida
GC gonorrhea (gonococcus)
GFR glomerular filtration rate
GI gastrointestinal
GSW gunshot wound
GTT glucose tolerance test
GU genitourinary
GXT graded exercise tolerance (cardiac stress test)
HAA hepatitis-associated antigen
HBsAg hepatitis B surface antigen
HCG human chorionic gonadotropin
HCT hematocrit
HEENT head, ears, eyes, nose and throat
Hgb hemoglobin
H/H hemoglobin/hematocrit
HIAA 5-hydrozyidoleacetic acid
HJR hepatojugular reflux
HPR high power field
HPI history of present illness
HR heart rate
Hx history
I&D incision and drainage
I&O intake and output
ICU intensive care unit
ID identification
IDDM insulin dependent diabetes mellitus
IHSS idiopathic hypertrophic subaortic stenosis
IM intramuscular
IMV intermittent mandatory ventilation
IPPB intermittent positive pressure breathing
ITP idiopathic thrombocytopenic purpura
IUP intrauterine pregnancy
IVC intravenous cholangiogram
IVP intravenous pyelogram
JVD jugular venous distention
KUB kidneys, ureters, and bladder
LAD left axis deviation or left anterior descending
LAE left atrial enlargement
LAP left atrial pressure or leukocyte alkaline phosphatase
LC living children
LDH lactate dehydrogenase
LLL left lower lobe
LMP last menstrual period
LP lumbar puncture
LPN licensed practical nurse
LUL left upper lobe
LUQ left upper quadrant
LVEDP left ventricular end diastolic pressure
LVH left ventricular hypertrophy
MAO monoamine oxidase
MAP mean arterial blood pressure
MAST military (medical) anti-shock trousers
MBT maternal blood type
MCH mean cell hemoglobin
MCHC mean cell hemoglobin concentration
MVC mean cell volume
MI myocardial infarction or mitral insufficiency
MLE midline episiotomy
MMM mucous membranes moist
MMR measles, mumps, rubella
MS morphine sulfate or mitral stenosis
MVA motor vehicle accident
MVI multivitamin injection
NAACP mnemonic for Neoplasm, Allergy, Adison's disease, Collagen-vascular diseases, Parasites
NABS Normal Active Bowel Sounds
NAD no active disease/no acute distress
NAVEL mnemonic for Nerve, Artery, Vein, Empty space, Lymphatic
NC/AT normmocephalic/atraumatic
NED no evidence of disease
NERD no evidence of return disease
NG nasogastric
NIDDM non-insulin dependent diabetes mellitus
NKA no known allergies
NKDA no known drug allergies
NRM no regular medicines
NS normal saline or neurosurgery
NSR normal sinus rhythm
NT nasotracheal
OB obstretrics
OCG oral cholecystogram
OD oculus dextra - right eye, overdose
OM otitis media
OP oropharynx
OPV oral polio vaccine
OR operating room
ORIF open reduction internal fixation
OS left eye
OU both eyes
P para
PA posteroanterior
PAC premature article contraction
pAO2 alveolar oxygen
paO2 peripheral arterial oxygen content
PAP pulmonary artery pressure
PAT paroxysmal atrial tachycardia
P&PD percussion and postural drainage
P&C panendoscopy and cystocopy
PCWP pulmonary capillary wedge pressure
PDA patent ductus arteriosis
PDR Physicians Desk Reference
PE pulmonary embolus
PEEP positive end expiratory pressure
PERRLA pupils equal, round, and reactive to light and accommodation
PFT pulmonary function tests
PI pulmonic insufficiency
PID pelvic inflammatory disease
PKU phenylketonuria
PMH past medical history
PMN polymorphonuclear leukocye (neutrophil)
PND paroxysmal nocturnal dyspnea
POD post op day
PP postprandial
PPD purified protein derivative
PRBC packed red blood cells
PS pulmonic stenosis
PT prothrombin time, physical therapy
Pt patient
PTH parathyroid hormone
PTHC percutaneous transhepatic cholangiogram
PTT partial thromoplastin time
PUD peptic ulcer disease
PVC premature ventriculare contraction
PVD peripheral vascular disease
PZI protamine zinc insulin
Q mathematical symbol for flow
RA rheumatoid arthritis
RAD right axis deviation
RAE right artrial enlargement
RAP right artrial pressure
RBBB right bundle branch block
RBC red blood cell (erythrocyte)
RDA recommended dietary allowance
RDW red cell distribution width
RIA radioimmunoassay
RLL right lower lobe
RLQ right lower quadrant
RML right middle lobe
RNA ribonucleic acid
R/O rule out
ROM range of motion
ROS review of systems
RRR regular rate and rhythm
RT rubella titer, respiratory therapy
RTA renal tubular acidosis
RTC return to clinic
RU resin uptake
RUG retrograde urethrogram
RUL right upper lobe
RUQ right upper quadrant
RV residual volume
RVH right ventricular hypertrophy
Rx prescription, treatment
SA sinoatrial
Sab spontaneous abortion
SBE subacute bacterial endocarditis
SBFT small bowel followthrough
SBS short bowel syndrome
SCr serum creatinine
SG Swan-Ganz
SGGT serum gamma-glutamyl transaminase
SGOTG serum glutamic-oxaloacetic transaminase
SGPT serum glutamic-pyruvic transaminase
SIADH syndrome of inappropriate ADH
SIMV synchronous intermittent mandatory ventilation
SLE systemic lupus erythematosis
SOAP mnemonic for Subjective, Objective, Assessment, Plan
SOB short of breath
SVD spontaneous vaginal delivery
SQ subcutaneous
SX symptoms
Tab therapeutic abortion
T&C type and cross
TAH type and hold
TB tuberculosis
TBG thryroid binding globulin
TBLC term birth, living child
TC&DB turn, cough, and deep breath
TIA transient ischemia attack
TIBC total iron binding capacity
TKO to keep open
TLP total lung capacity
TNTC too numerous to count
TORCH toxoplama, rubella, cytomegalovirus, herpes virus
TPN total parenteral nutrition
TPR total peripheral resistance
TSH thyroid stimulating hormone
TTP thrombotic thrombocytopenic purpura
TU tuberculin units
TURBT TUR bladder tumors
TURP transurethral resection of the prostate
TV tidal volume
TVH total vaginal hysterectomy
Tx treatment
UA urinalysis
UGI upper gastrointestinal
URI upper respiratory tract infection
US ultrasound
UTI urinary tract infection
UUN urinary urea nitrogen
VBG Venous Blood Gas
VC vital capacity
VCUG voiding cystourethrogram
VMA vanillymandelic acid
V/Q ventilation-perfusion
VSD ventricular septal defect
VSS vital signs stable
WB whole blood
WBC white blood cell or white blood cell count
WD well-developed
WF white female
WM white male
WN well-nourished
WNL within normal limits
W/U work-up
Yo years old
MISCELLANEOUS WARD SURVIVAL INFORMATION
Telephone Use:
At the desk on every nursing unit, you will find a list of telephone extensions. This is a large sheet taped to the counter top next to at least one of the telephones. If you don't find the number you need on this list, you can either ask the Unit Secretary or call the hospital operator (Dial "0") and ask him/her. You probably already know that to reach an in-hospital number you need only to dial "8" and the four-digit extension, and to reach an out-of-hospital number, you need to dial"9" followed by the outside telephone number. Not all lines in the hospital "dial out", so if you can't dial out on the line you are using, try another line or try another phone.
To call a CODE BLUE, dial extension 5656. Tell the code blue operator the nursing unit (and room number, assuming the code is in a room) of the code, the extension from which you are calling, your name, and whether the person is an adult or pediatric patient. It is a good idea to wait for the code blue operator to hang up before you do, so that if he/she needs further information, you will not have hung up on them in your haste.
To call a CODE RED (fire), dial extension 5656. Tell the code blue operator the nursing unit and extension from which you are calling, your name, the nature of the fire, and its location as precisely as possible. It is important to tell the operator the nature of the fire, since if you just smell smoke or hear the alarm going off, he/she will take one course of action, whereas if you actually see flames, he/she will take an entirely different course of action. Again, wait for the operator to hang up before you do.
Paging System:
Most of the residents and attendings at KU carry computer pagers. To page someone with a computer beeper, wait for the telephone dial tone, press 9-917 then the extension number which you want the person you are paging to call, hit the # key and hang up the phone.
To use VA beepers dial 86, wait for a new dial tone and then dial in the 3 digit pager number.
Follow other instructions for voice pager as listed above.
Requisitions and Other Paperwork:
In addition to the chartwork outlined previously, you will find yourself responsible for filling out a variety of lab menus, x-ray requisitions, consult forms, etc. It would require more space than is available here to describe all of these forms and requisitions. Therefore, only a few comments on the subject will be made here and the rest can be left for you to discover as you go along.
First of all, the Unit Secretary is your life-line when it comes to paperwork of all kinds. He/she will be able to tell you which form needs to be filled out, how to fill it out, where to find it, where to send it when you're done, which of the many requisitions, forms and menus are your responsibility, and which ones are his/her responsibility. One item of paperwork that will always be your responsibility is the consult form.
A consult form is simply the paperwork involved when the patient's primary physician requests an opinion from other physicians regarding that patient's treatment. For instance, you might consult Dermatology regarding that funny rash your patient developed, or you might consult Surgery when your Medicine patient develops acute appendicitis. The consult form includes some basic patient data, as well as a brief clinical history pertinent to whatever physician or specialty you are consulting. Again, you will get a feel for what to include here as you go along.
After you fill out the consult form, unless you "call in the consult", nothing will happen. The list of hospital extensions on every unit also includes a list of consult numbers. If you can't find the number of the consult service you need to call, ask the Unit Secretary or call the hospital operator (Dial "O") and ask him/her. When you call the consult number, the secretary on the other end of the line will ask you for some information: Pt name, MR#, Room #, Service, Attending, Resident, Resident's pager #, and a BRIEF reason for the consult, after which he/she will inform the consult team. After the consult team sees your patient, they will write their comments and suggestions on the consult form that you filled out.
VA versus KU Labs:
A final note about scut work at KU versus the VA, specifically about the difference in their clinical laboratories, is in order. It is essential to remind yourself that the clinical labs at these two institutions are staffed by completely different personnel, are equipped with completely different biomedical machinery, and, not surprisingly therefore, often do things quite differently.
This is especially important after you have spent a month or two at KU, have gotten used to the scut work routine there, and then find yourself starting a new rotation at the VA. If you allow yourself to go on autopilot without knowing some of the VA's idiosyncrasies, it won't be long before you find yourself having to re-draw a specimen of blood because you put it in the wrong colored tube, didn't get enough blood to satisfy the lab techs (even though you obtained twice the amount required at KU), etc. The VA lab publishes a Laboratory Service Manual which gives you general information about the lab, a section about how to fill out requisitions, a list of what tube and how much blood is required for different tests, and much more. You should go to the lab and ask them for a copy of the manual. The docs write most lab orders and they will specify tube colors if you look up the orders. You don't need to worry. You can do as much or little as you want at the VA. Ask and you shall receive.
GOOD LUCK WITH CLINICS!!!!
Telephone Directory
Burn Center (6th floor Wescoe Pavilion)...................X6540
Emergency Room (G501 KU Hospital).................X6500
Family Medicine (G601 KU Hospital).................. X4350
OB/GYN
52, 5 SE............................X5250
56, Mother/Baby..........................X5650
54, Delivery Room..........................X5450
54, Surgicenter GYN......................X5457
Newborn Nursery (Full Term)....................X6387
Neonatal ICU...............................X6350
Intensive Care Units
Medicine 44A........................X4450
Medicine 44B.........................X4454
Medicine 44C............................X4458
Neurosurgical ICU.......................X1551
Pediatrics..........................X6363
Surgery 26C...........................X2750
Surgery 28B...........................X2850
Neonatal.......................... X5670/6350
Medicine
4 Eaton.............................X6069
4 Delp Pavilion.........................X6065
42 SE.............................X4250
43 CW...........................X4350
46 NE............................X4650
44 A Medicine ICU......................X4450
44 B Medicine ICU......................X4454
44 C Medicine ICU......................X4458
Pediatrics
5 Delp Pavilion Infant and Toddlers...................X6360
5 Delp Pavilion School Age/Adolescence.............X6352
28 A ICU Pediatrics.......................X6363
Psychiatry
2 Olathe Pavilion.........................X6450
3 Olathe
Pavilion.........................X6455
Radiology (2nd floor KU Hospital)
Film Library...........................X6812
Roentgenology Division.......................X6850
Surgery and Bedside X-ray......................X6852
Ultra Sound (Sonography).......................X6861
Radiology Central Dictation (KUMC)................X3067
(punch in Patient ID #; then punch in 666666 for Resident ID #)
Radiology Central Dictation (VAMC).............861-4700 X7301
(punch 11 for chest x-ray and 13 for MRI)
3 Delp Pavilion.........................X2048
15 A Neurosurgery ICU........................X1550
15 B NW...........................X1555
15 C NE............................X1552
41 SW............................X4150
45 NW...........................X4550
51 SW............................X5150
55 NW...........................X5550
21 PACU..........................X2100
26 C Surgery ICU CTS......................X2750
28 B Surgery ICU.........................X2850
Burn Unit.............................X6540
Other Important Numbers:
Medical Student Records and Registration.............X6594
USMLE Registration.......................X5261
Clinical Schedules, Away Electives.....................X5261
Grades............................X6594
Student Fees and Health Insurance................. ..X6591
Student Immunization Records.......................X1941
Student Financial Aid.......................X5170
GPA and Class Rank........................X5261
VA Medical Center (Kansas City).................861-4700
Useful Websites
1. Pub Med: http://www.ncbi.nlm.nih.gov/PubMed/
3. MDConsult:www.mdconsult.com
4. OB/GYN.net (use for u/s images) www.obgyn.net
This booklet brought to you
through the courtesy of the
K.U. Medical Center Bookstore
Visit us online at and
check out our "Best Price Guarantee".
Bookstore Hours of Operation:
Monday Thru Friday 7:30 am - 5:30 pm
Saturday 9:00 am - 1:00 pm
(June & July, we close at 5:00 pm)
Need information, service
or want to place an order?
General Information 588-2537
Textbooks & Instruments 588-2542
Supplies & Gift Items 588-2543
Medical Apparel & Clothing 588-2494
©
The University of Kansas Medical Center