SURVIVING CLERKSHIP

Tips to the Ward and Exam Questions FIRST EDITION AUTHORS: Paul Healey ’00 & Rupinder Sahsi ‘00 SECOND EDITION AUTHORS: Darren Cargill ‘03 & George Kim ‘03 THIRD EDITION AUTHORS: Mark Matsos ’04, Tomas Jimenez ’04 FOURTH EDITION Author: Jesse Shantz ‘05, Sumon Chakrabarti ‘05 FIFTH EDITION- Kris Croome ‘06 SIXTH EDITION – Mike Zettler ‘10
The vast majority of the work for this “Clerkship Survival Guide” was done by my predecessors listed above. All I’ve done is to edit the particulars have changed over the years in medical school: the organization of rotations, the format of exams, and the on-call responsibilities of clerks. The truly important things, however, don’t change. I think this survival guide is most useful for these kinds of things; like how to assess patients and write notes and orders, how to interact with your team, and how to stay human in medicine. I hope it’s useful. Enjoy clerkship! Sincerely, Mike PS. There is one section that could be changed but hasn’t: the online resources and PDA/smartphone section. My feeling is that this information changes too quickly to pass down between classes, and I would completely unqualified to write about it. My only suggestion would be to talk to people who do or do not use various systems to get their opinions.

"Never let formal education get in the way of your learning." -Mark Twain "The student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end." -Sir William Osler, 1905

CONTENTS
Preface: Rupi’s Rules of Clerkship A Guide To Useful Books For Clerkship Must-Have Books Strongly Recommended Useful Books Online Resources A Few Notes for PalmOS Users Useful Sites Useful Software An Approach to the Many Types of Rounds Guide To Writing Notes Admission Note format Progress Note format The Discharge Dictation Format and Discharge Summary Guide to Writing Orders Approach To Admission/Transfer Orders Ordering Drugs and Writing Prescriptions Common Order Pitfalls Sample Orders Frequently Used Abbreviations The LHSC/SJHC Paging System at a Glance Rotation Tips Distilled
Medicine Rotation Surgery Rotation Paeds Rotation Family Medicine Rotation Psych Rotation OB/GYN Rotation

Never piss people senior to you. Don’t get the patient’s bed dirty. You can’t go wrong by going to see the patient. you clean up the mess. 2) make sure the chart is handy. b) have the suture scissors ready BEFORE you’re told to cut. Eat when you can Sleep when you can F#@& when you can Never lie to your senior Never let them see you eating or sleeping. your consultant will steal it. Never buy an expensive pen. Never skip a teaching session. it will come back to haunt you. Know when you’re over your head. Never upstage your colleagues.* Never pass up free food. You never know who’s listening. Nobody likes a miserable clerk. you can’t find a fever. You never know who’s listening. Get a life! . Nobody ever gets in shit for showing up on time. potentially going home/taking a break/getting a meal… don’t think about it… THANK THEM AND BUGGER OFF! When a code is called. no matter how good you think you’ll look. maybe. If you don’t take a temperature. and they’ll make you look good. c) suck the smoke Never fudge a finding. give yourself 30 seconds to wake up before slurring your speech into the telephone) Don’t try to be a hero. or it won’t be free for long. Take your pulse first* (in a panic situation. You make a mess. 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 26) 27) 28) 29) 30) 31) 32) 33) 34) 35) 36) 37) 38) Never stand when you can sit. Never sit when you can lie down.” Make your seniors look good. I’d love to do that rectal exam for you. Caffeine is your friend. 3) fight the urge to run around screaming “whatdoIdowhatdoIdowhatdoIdo…” Never miss any rounds sponsored by a drug company (FREE STUFF) You’re no good to anyone if you’re still asleep (when you’re paged in the middle of the night. make sure you’re calmed down and thinking clearly) If anyone suggests. hints. If you enjoy your free time. Never talk about patients in public areas. never spend any of it within line of site of the nursing station. Know your patient better than anyone else does. Follow the chain of command. If you’re scrubbed in a) make sure the field is well lit. Read something every day. Never talk about staff in public areas. or alludes to you possibly. A must read. clerks traditionally have three roles 1) get the gawkers out of the room. “Sure. or it will inevitably show up all over your exam. Medicine is a team sport. particularly part way through your Medicine rotation.RUPI’S RULES OF CLERKSHIP from “The House of God” by Samuel Shem. When nature calls. especially at rounds. make sure you’re listening. Be a team player.

Only limitation is that they only carry 1-2 copies of each book. It is advisable to tailor your purchases/acquisitions to the amount of time you will actually spend (all good intentions aside) reading during your clerkship. you’ll be better with infectious diseases than most residents (and some consultants!). some not so good. § Contains almost all the drugs you will be ordering. Most medical students already have a wide assortment that will serve them well. ~ $50 § The Washington Manual of Therapeutics. their indications. and their CANADIAN dosages. it very well could be. § PalmOS Users may substitute for epocrates (be warned it is does not have all Canadian drugs) or purchase a subscription for the Palm version of Tarascon (see below for option to get free access) § While extremely comprehensive. The following is a partial list and is by no means comprehensive. In addition. Strongly Recommended One of the following for Medicine: (but still very useful beyond your Medicine rotation) § Care of the Medical Patient. ~ $40 § On-Call: Surgery. The books you buy will be strongly influenced by what specialty you decide to enter. The Toronto Notes: MCCQE (Printed Yearly) ~ $110 through Bookstore § This is a handy reference. the next best thing to a faceto-face conversation with an Infectious Disease specialist. each rotation will present you with a list of their own departmental recommendations – some good. ~$60 § The Oxford Handbook of Clinical Medicine. ~$45 For Surgery: § Current diagnosis and treatment in Surgery ~$90 § Surgical Recall § Contains lots of questions you will be asked in the OR Useful Books One of the following for taking call: § On-Call: Principles & Protocols. ~ $40 § On-Call: Medicine ~ $40 . if you are hesitant about paying money for new books before getting a good look at them. make a point of knowing where to find the nearest CPS on each rotation for uncommon indications or for the few drugs that are not listed. if any. and use it well. but is in point form and therefore better for review than learning § LOOK OUT FOR ERRORS!!! If something seems wrong. try searching the UWO library system. Also remember. Must-Have Books Tarascon Pocket Pharmacopeia (Printed Yearly). The Sanford Guide to Antimicrobial Therapy (Printed Yearly) § This small reference book is authoritative for bugs and antibiotics. § It may seem cryptic at first.A GUIDE TO USEFUL BOOKS FOR CLERKSHIP The decision of what books to buy in Clerkship is a controversial one. but if you learn to use it. § Infections are relevant everywhere (except Psychiatry I guess). as well as your method of studying.

As well.com o Medical news. everybody’s favorite PCL tool). don’t bother paying for this feature. ~$40 each § The Mosby “Crash Course” Series – an easy read.ca o included with your CMA membership is online access to MD Consult (yes.org o Quick search of a large library of handy review articles CMA Osler .com o Complete guide to Ortho (with tons of spelling mistake) Emedicine – www. by specialty ~ $Variable § NMS Review Series. online textbooks by medical professionals for medical professionals The Merck Manual Online – www. you can be sure that a PalmOS unit with less than 8MB may not have enough memory to run many of the larger medical software packages.www. § § § § § A FEW NOTES FOR PALM-OS USERS It is difficult to give definitive advice on the different models or applications because of the rapid rate of change in this area. Some useful sites for this include: § § American Academy of Family Physicians – www.com o Full text of the handy Merck Manual available online Google – www. § Clinical Microbiology Made Ridiculously Simple – If you have a hard time wrapping your head around antibiotics and bugs. § Pocket Medicine (Massachussets General Hospital Handbook of Internal Medicine) – 6 ring binder full of quick info for internal medicine.com o The ultimate Internet search engine. and you will likely find it even more useful in clinical practice than in the pre-clinical years. reliable. wireless internet access. ~ $85 § Harrison’s Principles of Internal Medicine. ~ $45 § The Intern’s Pocket Survival Guide (also a version for Surgical Interns) – $11 § Essentials of Clinical Examination Handbook – a concise guide from U of T.wheelessonline. by specialty ~ $Variable § Cecil’s Essentials of Internal Medicine. very efficient.) Series. Being able to access online information quickly is a good skill to polish. try to tailor your model to your needs. Try to get your hands on a physical copy of the publication before you buy. this may give you a head start One of the best resources for finding really good books is your resident(s). articles. ~ $135 § The Recall (Paeds Recall.com o Free.medscape.merck.cma. however. Some of the newer ones have a camera. to make sure it’s both at your level and something you might actually have time/inclination to read.emedicine.google.Other handy references both for being on the wards and at-home reading: § The Lange Series of Books. Also. Medicine Recall. or even a cell phone. Frequently. and a medical student section full of handy resources Wheeless Orthopedics – www. ONLINE RESOURCES Most of your clerkship will be spent in centers with ready access to the internet. a keyboard. If you are never going to hook into a wireless network. as well as OVID online access to a ton of full text journals (ensure you have your CMA number) Medscape – www. etc. this can act as a surrogate textbook in lieu of carrying your entire medical library with you in your lab coat. but somewhat simplistic.aafp. Blazing fast. See what they would suggest. a cellphone may be .

and even Powerpoint.handheldmed.a respectable medical section. you can get a one month subscription every month) § 5 Minute Clinical Consult – good for a quick check up on a topic. So. don’t stress – the software is out there you only have to look a little harder! . The only way to know if a program might be useful to you is to simply try it. There is a huge variety of software available for PalmOS. Be sure to ask clerks. and even consultants if they have anything you might find useful.healthypalmpilot.com .mobile medical content.tarascon.handy to have. but rather a supplement to stir up memories of forgotten topics from first and second year. with many useful non-medical programs. but be sure you have the option to turn it off while the Palm is on as cellular use is not allowed in the hospitals.com . It is possible to get a one month free subscription at http://www. With such programs as Word. § Merck Manual – the electronic version of the book we’ve all come to know § TealDoc/TealInfo – useful for accessing many medical databases/publications FEWER NOTES FOR POCKET PC USERS While PalmOS owned the medical market.a FREE constantly updated guide to antibiotic therapy (note – some have had some difficulty loading this on their palm) § www. featuring the PocketClinician Library.an extensive database of programs with software reviews § www. Useful Medical Software § Epocrates – Free pharmacopeia that contains drug dosages. § www. recently there has been a trend towards newer Pocket PCs based on a Windows platform. Many useful programs.cfm . such as MedMath.palmgear. 5MCC.com/ (if you sign up for a new email address every month. Excel. one can type documents on your handheld (easier if you have a keypad) or even make a presentation without worrying about where you will find a laptop. elective students. can be beamed from one Palm to another. adverse reactions.com . residents. Not a substitute for a brain. though much of it tends to be quite specialized. More and more of the software is becoming available for the Pocket PC and it is only a matter of time until those are circulating around the class. Useful Sites § www. This allows for more compatibility between PCs and handheld devices. and Dorland’s are the three most useful programs.the only place to get THE most useful PalmOS drug book – FREE! § http://hopkins-abxguide. This is changing. and it is possible to BUY the Pocket PC version of 5MCC (free versions floating around the class are for PalmOS ONLY right now) as well as register for the Tarascon Pocket PC version. Quite helpful before a “pimping” session. contraindications (does not contain Canadian trade names) § Tarascon Pharmacopeia – same as the pocket guide but saves you carrying around the book. however. § Dorland’s Dictionary – useful for quick reference of some of the more obscure medical terminology and acronyms § Medmath – does common medical calculations including BMI.com . To date I have found that ePocrates/Tarascon (whichever you prefer).org/download_center/download_center. There is also some free software floating around. A-a gradient etc. Skyscape programs like the 5 Minute Clinical Consult (5MCC) series are available if you find someone who has a copy of the CD-ROM. The only down side is that the majority of the medical software is for PalmOS. for those of you with a Pocket PC.epocrates.

after. residents only). NEVER EVER show someone up (aka Pimping). as the consultant/chief resident will usually ask you a question of two regarding the status and plan for your patient. These rounds – like site rounds. Clerks Role – Know your assigned patients. and dinner all at 16:30). and dealing with any issues left over from the evening and making plans for the day. often with social work and PT/OT. the resident you are with may say for you to show up tomorrow at 7:00am for “rounds”. Answer questions with certainty if you’re certain. residents in the middle. Make sure you know their medical issues. lunch. Usually residents are asked questions but the occasional clerk will get one. Gen. speak briefly with the nurses or the resident on call about the previous night’s issues. In general when a resident asks to meet you somewhere – especially in the morning – DON’T BE LATE. current labwork and investigations and plan forwards and backwards before rounds. For this reason. grab the patient’s charts when going in to see them. and length (ortho rounds = 10-15 patients in 30-45 minutes vs. eat your muffin and pay attention to what’s being said as it may turn up during the days discussion in the OR. on the ward. the plan for the day. or instead of patient rounds. write orders and flag the chart. While rounds vary somewhat from specialty to specialty with regards to who is present (residents and staff vs. write progress notes and orders. . In general. 2) Team Rounds – a staple of medicine.this involves seeing all of the patients assigned to your team (there is usually a team list on powerchart) with the residents and clerks +\. the main forms of rounds are: 1) Patient Rounds . any changes overnight. you not only need to know your own patients. quickly. All teams from all sites in a specialty meet and discuss case presentations or other topics. push the chart rack down the hall. 3) Site Rounds – Usually held after patient rounds or at lunch-time. Clerks Role – read around the topic of the day. and the overall plan. keep up with team as you move from patient to patient. Otherwise. During your Medicine and Pediatric (CTU) rotations you will be given the responsibility of following your own patients. write a progress note (SOAP format explained later). This may occur either before. Surg is notorious for having breakfast. All teams at a certain site meet to discuss patients (as in mortality and morbidity [M&M] rounds). In addition.consultant. You meet with the team and go over patient progress. it is a good idea to be aware when the residents switch services .often the clinical clerks will be the only remaining members of a Medicine team and you may be responsible for handing over a roster of 25 patients to a new set of residents during rounds. medicine rounds = 10-20 patients in 2-5 (or more) hours. NEVER pimp someone out. Clerks Role – show up 10 minutes early to print out the team list. When food is available show up early to avoid interrupting the flow of rounds if possible. Medicine is somewhat more civilized given the prolonged duration of rounding vs surgery – there is always a break at 12:00 for lunch rounds during your medicine rotation. round on patients. but also pay attention in rounds so that you have some knowledge of all patients under your team’s care (this will also help when you’re on call). If you know the answer to a question asked of someone else and they obviously don’t know the answer wait until you are asked or the group is asked to answer. grab the patients bedside chart containing vital signs. Know their meds. or discuss a topic (ID for example). and be prepared to answer questions. etc.are somewhat hierarchical with consultants sitting up front. Questions are usually asked of the clerks in this setting. and clerks at the back. Say “I don’t know” if you don’t know the answer.An Approach to the Many Types of ‘Rounds’ There are different types of “rounds”. and management plans. if you happen to be the clinical clerk on Medicine or Pediatrics (CTU) near the end of a month. 4) Grand Rounds – Usually held weekly or monthly. drink your free coffee. Again. and get to the OR (note that there is usually no time for breakfast so eat before coming to the hospital. discuss case presentations. Your first day. Residents generally will allow only exactly enough time to get a patient list.

format. It should have a patient ID. lab vales are usually recorded in symbol format. You will likely want to leave this section blank until you discuss the patient with your senior – but make sure you are at least thinking about what you would write. your notes will be very brief. In time you will recognize the range of normal values. Begin at the head and work your way down describing your findings by system. Always begin by listing the vital signs (HR. The next section is History of the Present Illness. Surgical progress notes are very brief and no more than 4-5 lines. Then use the S. The next sections are Assessment and Plan. geographical location. This should not be more than 2 sentences and usually has age. Surgery admission notes are rarely more than 1 page. medicine admission notes should be 2-4 pages depending on the complexity of the patient. O is objective which encompasses your physical exam. The admission note and the progress note. This is what you go to medical school for so don’t expect to be able to fill it in right away. Next comes the Problem List or Past Medical/Surgical/Obstetrical/Gynecologic History. Here is an example of a standard surgical progress note. To further complicate things. Start from head to toe and write your physical exam findings. Try to list the problems in order of importance. As a general rule. Medications should be next in the note. Instead examine the medication bottles if they have brought them. We will go into more detail by specialty later but here are some general principles to remember. The demands of these notes vary with the specialty you are on. You should list them with dosage and frequency. You will catch onto the important things. Most people will put past surgeries under the inactive problem list. Orthopedics and Neurology also require handedness in this section. S is subjective and includes how the patient is feeling – occasionally. alcohol and drugs. this will vary according to the service. Always consult the old chart before seeing the patient. it will help to speed up your history. Stick to history. This comes with time as you learn what is and isn’t important. Admission Notes The admission note always follows the same format with the order altered depending on your preference. symbols and acronyms to distill the HPI into a more practical form. . problem list and medications. BP. The rest can be listed anyway you chose. This section is important because it will put the rest of your note into context. The first section is the Patient ID section. Don’t forget ECG and x-ray results. RR. Temp. The common formats are listed below. Most people will use brief sentences. Physical Examination is the next section. 70% will not know. occupation. Don’t waste a lot of time on exact dates. The visit list under patient information in powerchart is also a useful resource for past medical history. Remember to put in pertinent negatives. In the Allergy section list the patients “allergies” and always describe the reaction they had. do not put any physical exam findings or lab results in this section unless they are crucial to the story. Saturation). For Surgery. You should also cover Family Hx and Social Hx.O. The next section is the Lab Results. The assessment should contain the diagnoses and the plan should have a numbered approach outlining what you will do. Progress notes in medicine should likely be from ¾ to 1 page long. In notes. Back pain in someone with a recent cancer history is far more important than back pain in a healthy person. check the old chart or call the patient’s pharmacy.P. Don’t waste time asking the patient what medications they are taking. the symbols are not written in stone and people will often put the values in different spots. WBC HgB Plt Na Cl K HCO 3 BUN Gluc Creat These are the common lab values. A is assessment and will change based on S & O. Contrary to the new curriculum these should be very very short – stick to what is pertinent to the patient’s immediate management including smoking. Progress Notes Again.GUIDE TO NOTE WRITING There are two basic notes that you will write. When you are asked to see a patient in emergency most of the bloodwork will already have been done. sex.usually written very quickly during morning rounds. it may be worthwhile to quote the patient’s own words. labs and imaging. An important part of clerkship is learning the screening physical exam. P is plan. For medicine your note will be a slightly scaled down version of your admission note. The problems can be listed in two columns: active and inactive. duration of illness and tentative diagnosis.A.

etc. φ BM feels hungry O/ AVSS (Tmax = 37. you will learn that the discharge summaries in each patient’s old chart can be your very best friend. make sure you get it the first few times you dictate. 2000 under Dr. 2000. However.under which service + consultant Date of Discharge Date of Dictation Admitting Diagnosis / Reason for Admission Problem List (if more than one. “new paragraph” while dictating or your note will be transcribed as one long sentence. Copies of this dictation to go to the chart. so avoid eating or chewing gum during dictations. The Ward Clerks on each floor have a sheet with detailed instructions on how the dictation system works. and . dictating a discharge summary on patient John Doe. Discharged September 6. Signed John Jacob Hingleheimerschmidt. new issues procedures. patient # 11015555. complications) Disposition (to home. your must say “period”. dictating on behalf of Dr. Frankenstein. and (other physicians directly involved in the patient’s care for this problem… not every doctor they see!). dictated if the patient has been in hospital >6 days – in order to ensure that future medical caregivers have quick access to the information they need. Don’t lose your dictation ID#. Mark” good pain control with PCA + flatus. Make sure to return the favour. rewind. to the patient’s family physician Dr. Thank you. Frankenstein. Internal Medicine. clinical clerk meds three. Patient Identification (include date of birth and patient identification #) Date of Admission . it can be a pain to retrieve when you’re in a rush. nursing home. Follow Up and other Special Medical Instructions If dictating: “end dictation. to Dr. Be sure to speak clearly.78 yo Γ POD #2 right hemicolectomy S/ “I slept pretty well last night Dr. response. clinical clerk meds three. If dictating.” Each chart has a form which has to be filled out upon discharge. or different from RFA) Past Medical History (if extensive or important) Patient Presentation = Admitting History and Physical (pertinent details only) Course in Hospital (include treatment. on corkboards. “This is John Jacob Jingleheimerschmidt. Patient admitted to Internal Medicine at Victoria Hospital on September 1. which will contain most of the information contained above. “comma”. Remember you can always pause. London Health Sciences Centre – Victoria Campus. it is a good idea to fill out the form first as a rough guide for your dictated material. Once you navigate through the various menus your dictation would sound like this. abdo soft φ distended stable advance to clear fluids D/C PCA and switch to Tylenol #3 1-2 tabs q4-6h prn A/P The Discharge Dictation Format and Discharge Summary When a patient leaves your service. but there are often instruction sheets taped on walls next to phones. listen to yourself. spell out your words after saying them (ie: hiatus – H I A T U S – hernia).2) good U/O incision + BS. You may want to write out your first Discharge Summary before you dictate it. A few quick notes on the dictation process. Don’t be afraid to use numbered lists where appropriate – they are actually the preferred format for things like the Problem List and Discharge Medications. it is important to ensure that an adequate discharge summary is written – or more often. After a few middle-of-the-night complicated admissions. Hyde (address if needed). Frankenstein FRCP(C). You’ll quickly learn the to navigate the dictations system. When in doubt. Don’t worry about “uhms” and “aaahs” in between your text – the dictation service employs trained professionals. mention home care) Discharge Medications List these with dose and frequency of administration.

GUIDE TO WRITING ORDERS One of your common duties as a clerk will be to write orders on your patients. Temperature will be checked every 8 or 12 hours. q12h (at shift changes). If you’re writing orders on rounds. which are one big sheet). your dictations will quickly get briefer. If there is a particularly sick patient more frequent vitals may be necessary (VS q6h.” 99% of the time you will write AAT. have to be cosigned by a licensed physician (resident or consultant).) If special parameters should be monitored regularly (ie: postural vitals). or BR with BRP (Bed Rest with Bathroom Priviledges). VSR means the nurses will check vitals in the usual routine for this hospital or a particular floor. At London hospitals the form has two halves: the left half is for non-medication orders and the right is for medication orders. being transferred to a new service. put the date and time in the appropriate spot. DIAGNOSIS This is what you suspect they have. Don’t forget to sign your name with M3. BP. each with a place for you to sign at the bottom. Microbiology. Activity. etc. All orders are written on the order forms in the chart. Admit to Gold team under Dr. ice cream) and Dysphagia Diet. If you think critically about what you’ve done. Generally HR. Lower GI Bleed DIET The most common order you will write is DAT (Diet as Tolerated). and remember that you are dictating confidential patient information. These are usually located in the front of the chart and have a purple edge. a septic 82 year old patient with confusion could be approached this way. Vital Signs. Investigations. Cardiac Diet. Diagnosis. via your “Message Centre” on PowerChart. or FWB (Feather Weight Bearing). Drugs ADMIT Usually you will write: Admit to (your service) under (your consultant today and your team) Eg. done faster. It’s a good idea to review your dictations as soon as possible after completing them. Approach To Admission/Transfer Orders Most people use the AD DAVID mnemonic: Admit. AAT. All orders (even for tylenol. Consults. Larocque. be sure to specify. Diet. get it done right away so you don’t have to drag a resident back to the ward and so the patient can get their medication or test sooner. A simple approach is to remember there are five basic investigation areas: Imaging. or a urine dip). INVESTIGATIONS This is the largest section you will write. Other common diets you will order are: Diabetic Diet. Elevate Lt leg. Post-surgery patients will often have sips to DAT written so that the nurses can decide when to also recovering patients to eat. This section requires an approach of it’s own. If you’re on your own while writing orders. Biochemistry. so make sure you have the appropriate degree of privacy. and more useful to others. Patients who are mostly sedentary might have ambulation orders added to this section: “Up In Chair tid” “Ambulate bid. This is also a good time to indicate if you want any limbs elevated etc.correct mistakes if you have to. VS q4h. In general it will be bigger than all the other sections combined. Obstetrics will sometimes use BR. Work in a quiet area. The sheets are divided into 3 horizontal sections (except for initial admission orders. . Full Fluids (Includes pudding. VITAL SIGNS The most common order is VSR (Vital Signs Routine). Eg. For each investigation start from the head and work down keeping in mind your patients disease. Here are the general principles to writing orders with more specifics to come. RR. Orthopedics will use abbreviations like NWB (Non Weight Bearing). Any patient being admitted to hospital. (Acute Renal Failure. or having management changed must have orders. Patients who might need surgery should be NPO (Nothing by Mouth). O2 sat. but this is not always the case when the patient has had bowel surgery. don’t forget to ask a resident to co-sign them when they’re available. Congestive Heart Failure) Eg. Clear Fluids. Hematology. For example. ACTIVITY The most common order is AAT (Activity As Tolerated). NWB Lt leg.

A must have book for clerkship is Tarascon Pocket Pharmacopeia. Start out with IV fluid orders. Formal prescriptions have the following structure: Date Patient name and Address – stamped with the blue card . a patient who can’t take anything by mouth due to nausea or impending surgery can’t take pills. The investigations to order will come with experience. Microscopy. For this section just remember all the things you can culture: CSF. For example. CSF protein and glucose Microbiology: Urine R&M/C&S (Routine Tests. especially if the patient is not able to drink. diuretics. PTT/INR + + 2+ 2+ Biochemistry: Daily Electrolytes (Na . Sputum. Daily Creatinine. prokinetics. Use the 4-2-1 rule (as described later). Blood The above is not a complete list but simply an approach. nausea and pain. They will likely need an IV but may also need antibiotics. For the present. Pee (IV fluids. present & future. Abbreviation PO IV SL PR IM Meaning By Mouth Intravenous Sublingual By Rectum Intramuscular Abbreviation OD qD q h SC Meaning Once Daily Every Day Every Hours Subcutaneous Abbreviation BID TID QID PRN qhs Meaning Twice daily 3 times daily 4 times daily As needed At Bedtime Prescriptions written to be filled outside the hospital use the same abbreviations but a slightly different format. Neurology?. Feces. Begin by ordering all the medications the patient is already on (the past). It is an American program though and some Canadian drugs names are not in it (ex. Poop (bowel routine). Exercise judgment as to which ones the patient still needs. PE (anticoagulation). culture & sensitivity. Gravol or dimenhydrinate). You cannot possibly know every drug dose but you will come to know the ones you commonly use. K . anti-arrythmics and so on. Pus (antimicrobials). Daily Urea. think about what the patient needs right now. EKG Consults: Social Work. Chest X-ray. Culture.Cl . It has almost every drug and it’s common indications and dosages (PalmOS users should consider epocrates which has the same information plus a little more). Below. A simple approach is past. Pus from wounds. A good mnemonic for this is to make sure you’ve addressed the “Patient P’s” – Problems (specific medical issues). common medication abbreviations are listed. sleeplessness. Mg . Puke (anti-nauseants. Sensitivity). Psych (don’t forget about DTs when on medicine!). The basic format is as follows: DRUG Lasix Clarithromycin Ativan Tylenol #3 DOSE 40 mg 500 mg 0. antacids). Urine. DRUGS This is also a big section. electrolytes). glucose.q q q q q Imaging: CT head. Ordering Drugs and Writing Prescriptions Drugs have a specific nomenclature that you need to follow. Infectious Diseases? Hematology: Daily CBC with Differential. Pain (analgesia). Also. CSF from Lumbar Puncture for gram stain. HCO3 ). PO4 . The pharmacist can be your savior as clerks frequently make drug mistakes. For the future try to anticipate what the patient might need.5 mg 1-2 tablets ROUTE IV PO SL PO FREQUENCY q12h BID qhs prn q6h prn DURATION/AMT X 10 days 20 tablets 15 Tablets In London hospitals these are written on the right side of the orders page. Ca . Pillow (sedation). a bleeding patient doesn’t need Aspirin or Coumadin. Remember to press hard as a carbon copy is made and this copy goes to pharmacy. Think about DVT prophylaxis. diuretics. Blood Cultures. Previous Meds. CSF cell count.

dosage. Italics would not be written and are only for your explanation. These flags sometimes vary depending on the ward/hospital you are in. The U. Subscription (Instructions to the pharmacist) Where you specify the quantity to be dispensed and any other special information. if at all unclear from the inscription. Regardless. § Prescribers should not use vague instructions (“take as directed”) as the sole direction for use. Nurses cannot carry out orders unless the patient is properly identified. Do Not Repeat Dr. The term “units” should be spelled out rather than abbreviated as “U. Remember to think ahead. You are making a carbon copy that will be used by pharmacy.Inscription (The Rx the appears in the corner. MD. Sign the orders and put the date and time or there may be a delay in carrying them out. 5. They may vary by colour . Anticipate problems with pain. If the orders are important. make sure to ask someone. A terminal or trailing zero should never be used after a decimal.yellow/red/white. Signa = “write”) is often used here. § All prescription orders should be written using the metric system except therapies that use standard units such as insulin and vitamins. sometimes when you least expect it. If pharmacy can’t read your orders it’s hard for them. Sample Orders To demonstrate a typical set of orders let’s assume we have a 63 year old man with bright red blood per rectum earlier in the day. sleeplessness and hydration. Mistakes in dosing usually result from bad penmanship and short forms. Signature (Instructions to the patient) Basically what you want written on the bottle. A simple order written at admission can save you or someone else a call at 2:00am.P. Always remember to write the patient’s name in the upper right-hand corner of the order sheet or stamp that corner with the patient’s blue card.” § The medication order should include drug name. Orders are fairly constant between services and this list should be a good framework for whatever rotation you’re on. The abbreviation S: (Sig. § Prescribers should avoid potentially confusing abbreviations or Latin directions for use. make sure they are seen by the ward clerk right away. Don’t abuse words like “now” or “stat” – check with your resident about these if you are unsure If you are unsure about your orders in any way. Press hard on the order sheets. 8. Pharmacy will catch your mistakes more than anyone else so do them a favour. Refill Information (number of refills. Remember to ALWAYS bring your pharmacopia with you – you will use it in every rotation. 6. route and frequency of administration. Ontario (1) Lasix 40mg PO OD Mitte: 14(fourteen) 40mg tablets Sig: One capsule by mouth daily (2) Ventolin MDI two puffs qid prn Mitte: One MDI Sig: Two inhaled puffs as needed with onset of asthmatic symptoms. London. and by inscription – clerk/orders etc… Make sure to ask which flag to use. 4. short for recipe or “take thou”) Each drug. 9. or no repeats… ALWAYS REMEMBER THIS) Prescriber’s Signature September 1. 2. and dosage form § A leading zero should always precede a decimal expression of less than one. Assume he is currently not bleeding and his hemoglobin in 65. 3. Write Clearly. “for cough”) unless inappropriate. The abbreviation M: (Mitte = “dispense”) is often used here. 7. . 2000 Patient: Mr. exact metric weight or concentration.S. makes the following recommendations for avoiding prescription errors: § All prescription documents must be legible. § Prescription orders should include a brief notation of purpose (eg. Common Order Pitfalls 1. Jinglehiemerschmidt. always remember to pull up the “Doctor’s Orders” flag in the chart. John Doe Address: 1234 Western Avenue.

) Alert MD if Urine output < 90cc over 3 hrs (Low urine output is a measure of hydration status) Stool Chart (Nurse will examine stool and write finding on chart) Keep 2 units Group & Crossed at all times Daily Labs: CBC.Admit to CTU-2 medicine under Dr. BUN/CR. Smith Diagnosis: Lower GI Bleed NPO (may take PO meds with sips). Lytes. CCAC consult Saline lock second IV Transfuse 2 units of cross-matched PRBC (packed red cells) over 2 hrs st nd with 20 mg Lasix between 1 & 2 Unit Pharmacy Medications 2 large bore IV’s (14 or 16 gauge) IV D5W/. NG etc. Blood Sugar Blood Urea Nitrogen Complains Of Coronary Artery Bypass Graft Common Bile Duct Clear Fluids Chest Pain Cerebral Vascular Accident Cardiovascular Disease Central Venous Pressure Chest X Ray Discharge/Discontinue Dextrose 5% in Water Diet As Tolerated Deep Venous Thrombosis EBL EF EGD ERCP FF FFP F/U FWB GCS I&D IABP IHD IVF L/E LAT LGI LR NAD NEOM NG NPO NS NSR NWB NVC Estimated Blood Loss Ejection Fraction Esophagogastroduodenoscopy Endoscopic Retrograde CholangioPancreatography Full Fluids Fresh Frozen Plasma Follow Up Featherweight Bearing Glasgow Coma Scale Incision and Drainage Intra Aortic Balloon Pump Ischemic Heart Disease Intravenous Fluids Lower Extremity Lateral Lower Gastrointestinal Lactated Ringer’s No Apparent Distress Normal Extraocular Movements Nasogastric Nothing Per Os Normal Saline (0. AAT VSR Foley Catheter Accurate Ins & Outs (Nurse to monitor fluids in through IV & Mouth and fluids out in urine.45 NS with 20 meq KCL @ 125 cc/hr Ranitidine 150 mg PO BID Enalapril 20mg PO OD Tylenol pl 1-2 tabs q6h prn ECASA 325mg PO OD (HOLD) Ativan 0. PTT. Breath Sounds. 3 views of the abdomen GI consult in am. INR EKG.9%) Normal Sinus Rhythm Nonweight Bearing No Voiced Complaints .5mg SL qhs prn Standard bowel prep as per GI FREQUENTLY USED ABBREVIATIONS AAT ABG AKA AMA AP AXR BE BKA BRBPR BRwBRP BS BUN C/O CABG CBD CF CP CVA CVD CVP CXR D/C D5W DAT DVT Activity as Tolerated Arterial Blood Gas Above Knee Amputation Against Medical Advice Antero-Posterior Abdominal X-Ray Barium Enema Below Knee Amputation Bright Red Blood Per Rectum Bed Rest with Bathroom Priviledges Bowel Sounds.

and the status of the pager. key in your numeric message and the # key. You should receive a confirmation of your page.OB OOB ORIF Fixation PA PEEP PERRL PICC PRBC PTCA PUD PVD R/A Occult Blood Out of Bed Open Reduction and Internal Posterio-Anterior Positive End Expiratory Pressure Pupils Equal and Reactive to Light Peripherally Inserted Central Catheter Packed Red Blood Cells Percutaneous Transluminal Coronary Angioplasty Peptic Ulcer Disease Peripheral Vascular Disease Reassess RL RTC SBO SIADH SOB SOBOE TEE Tmax TPN U/E UGI UO UTI VSR Ringer’s Lactate Return to Clinic Small Bowel Obstruction Syndrome of Inappropriate Antidiuretic Hormone Shortness of Breath Shortness of Breath on Exertion Transesophageal Echocardiography Maximum Temperature Total Parenteral Nutrition Upper Extremity Upper Gastrointestinal Urine Output Urinary Tract Infection Vital Signs Routine Quick Reference to the LHSC/SJHC Paging System TO PAGE A PAGER In hospital: Dial the 5-digit pager number (1+old 4 digit number) directly Out of Hospital: Dial 685-8500. but during the personal greeting you can press [*4] to initiate a “personal conference call. press [**] to hear the name of the party trying to get in touch with you. If you are paged in this manner. There are full instructions available at each hospital. press [3]. THE CALL CONNECT SYSTEM You can page someone and remain on hold until they answer. sign over pagers. After connecting. Dial YOUR 5-digit pager number. The procedure is similar to making a normal page. They’re worth consulting. After the tone. When the person your are paging connects. To correct a page before you send it. Your message will be erased and you will be prompted to enter a new one. and enabling/disabling your pager. To accept. with detailed instructions on the above as well as how to record greetings. press [***]. listen to the greeting. enter the 5 digit number + the # key.” Speak your name when prompted and press the [#] key. you will hear a tone and you will be connected. During the personal greeting. . your pager will display “U” and your five digit pager number (ie: U12345).

4. junior residents (PGY-1 internal medicine). you call the resident back and together you will assess the patient. and any procedures/special tests/changes in status/discharge planning that are going to happen that day or soon. social work). then after you’ve seen them and you’ve done the directed history and decided what labs to order. It’s the longest single rotation of the entire year. and admissions. these will take a little longer. and you can really learn a lot from them. Old charts are the best starting point on an admission. There is a lot of work involved in dealing with general internal medicine patients. The residents also help by asking other questions you have left out. but you can’t rest on that…if you also reinforce your teaching with reading. off-service junior residents (often anaesthesia. After that you will be able to take a directed history and physical and order some labs. Be prepared by knowing what has happened to your patient since the last set of rounds. If the patient is going to be admitted. Weekend rounds are usually done with the consultant on call… find out what time. PT. nurses specific to your patient. You can learn a lot from them…they know all of the important questions. to difficulty breathing or chest pain. Afternoon rounds are usually a quick handover to the person on call: give them the highlights. They aren’t too far above clerk level. neurology. your fellow clerks. . You will learn a lot on this rotation: not only about internal medicine problems. You will get a lot of teaching. and a bit of reading the night before will prepare you for questions and add to your understanding. practice. speech-language pathology. Admissions involve a lot of work. CTU is a chance to work with allied health professions (OT. Your resident will give you the highlights of the patient you have to go see. and the resident calls admitting to get a bed. PT.Medicine Every clerk has 6 weeks of CTU on their schedule. Who you will meet Your consultant --. but take your time and you will really develop your history and physical skills. and you will present the issues and results of the past few days to your team. These occur just about every morning and every lunchtime… free food! This is also a good rotation to develop your skills of critical appraisal. On Call CTU call is the hardest of clerkship. and be prepared to work through every patient on the team fairly quickly. senior resident (PGY-3 Internal). elective students. you each write a note for the chart. the first day that you have a new consultant. psychiatry. and can explain their reasoning to you. pharmacist. consulting service residents and consultants (PGY-2. but about situations that will come up no matter what specialty you train in. OT. Morning rounds are not at an unreasonable hour. you have to be pro-active. Teaching Rounds Morning and lunch teaching rounds give you a chance to eat and learn a bit. and feedback. Floor calls will be anything from Tylenol or sleeping pill orders. You have two responsibilities: floor calls. 5 internal medicine). social work. usually after teaching rounds (but go to teaching rounds!). but to get the most out of the experience. you will come out with great diagnostic skills. key problems that each patient has. and anything that MIGHT come up overnight that might require a clerk being called. Get some articles that describe the current topics in common diseases.internist (either general or subspecialty). Rounding is the time when your knowledge will be used. pharmacy. You can even apply what you find to your patients. and the floor charge nurses. and family medicine – usually PGY-1). then one of you writes the orders. Rounding Most of the work you do will involve following 2-6 patients and knowing everything that goes on with them. or the first day of the rotation.

Medications 1. Constant LLQ Pain 3/10 w/ ∅ radiation. Last hospitalization Sept 99. ∅fever. +BS(Bowel Sounds). Last meal 2300 yesterday. ∅ bleeding problems. T=37. Awoke from sleep w/ LLQ (Left Lower Quadrant) crampy pain. ∅S3/S4. T & A (Tonsillectomy & Adenoidectomy) HPI 65 yo M w/ 3 episodes of BRBPR in 24 hrs. BRBPR 2. Gait Normal . Ranitidine 150 mg PO BID 3. ∅masses NEURO: Alert & Oriented x3 (person. Ventolin MDI 1 to 2 puffs QID PRN 5. Cerebellar Testing Normal. ∅ melena. ON presenting today with 1 day hx of BRBPR. Never had pain previous. Prostate Soft Mildly enlarged. ∅chills. Loose stools last 2 wks but ∅ blood. mild expiratory wheezes. ∅rebound tenderness. ∅ abd distention. ∅ N&V(Nausea & Vomiting). ∅ crackles. ∅ dysphagia. 3. ∅ LOC (loss of consciousness). ∅ indrawing CVS: N S1S2. ∅ peripheral edema. ∅night sweats. Osteoarthritis – Affecting knees and low back 5. BRB present. ∅ scars. ORIF (open reduction internal fixation) R wrist 7. ∅ jaundice/cyanosis RESP: Good BS bilaterally. ECASA 325mg PO OD x 5 yrs 2. ∅lymphadenopathy. ∅masses/organomegaly. Sat 96% on RA. Normal tympany RECTAL: Normal Tone. Grade II/VI systolic murmur heard best at apex. Normal Tone. ∅ CP (Chest Pain). Mildly tender LLQ.Sample Admission Note: Medicine This would be a typical note for our previous case of BRBPR (bright red blood per rectum). Allergies Morphine – GI Upset Pencillin – Rash Family Hx Father Colon CA 56 Physical Examination: HR 90. 2 episodes since @ 0600 and 1100. at urging of wife. 40 pack/year smoker Married w/ 3 grown children. 136/80 standing. Reflexes 2+ in all limbs and symmetric. conjunctiva pale thyroid grossly N. Large bowel mvmt mixed with BRB “45 cupfuls”. Patient ID: 65 yo retired carpenter from Chatham. Decreasing energy last 2 mos. Atrovent MDI 2 puffs QID Social History 1-2 ETOH per month. JVP 3cm ABD: Soft.11 Normal. First epsiode 0200 last night. CN 2-9. COPD – 3 hospitalizations for exacerbations in last 5 yrs. ∅weight loss. Strength 5+ in all muscle groups. place. PPP (peripheral pulses palpable). + Aspirin use x 5 yrs. Problem List: 1. Tylenol #3 1-2 tabs PO OD 4. and time). Biliary Colic – 3-4 episodes per year 4. GERD 6. @ 1300 with c/o “weak & dizzy”. RR 22. BP = 140/86 lying.10. 1-2 ETOH per month. Presented to ER.0 HEENT: Mucous membranes dry.

1 65 7. Normal Axis. Diverticuli Left colon CXR: Normal Cardiac Silhouette. consults. 2. respite. It’s never too early to think about long-term planning. Diverticulosis 2.4/PO2=96/PCO2=37/HCO3=23 Cardiac Enzymes: CK 85 & Troponin I < 0. Be there. pharmacists. Being a team player can make everyone’s experience better.5 123 MCV INR / PTT = 1. Mildly dehydrated DDx: 1. Your consultants are busy. If you get called. teaching sessions. lunch rounds. They are generally available at some point every day. and a senior.0 250 4. go see the patient. They usually have clinics. OTs. Transfuse 2 units PRBC 4. It is a team experience --. Volvulus Plan 1. RTs. ∅ dilated bowel loops. You can learn a lot of the nuts and bolts of medicine from them. ∅ ST-T changes Assessment Stable 65 yo man with 1 day Hx of BRBPR. Whether that’s discharge home. Talk to the nurses. Keep on top of your patients. PTs --. Admit to Medicine 2. Rehydrate (2 large bore IV’s) 3. or palliative care.they have lots of experience and can draw on it to help you (and your patients). Be there for morning rounds.2 Cap Gas: pH=7. Keep 4 units grouped & crossed @ all times 3. 5. procedures.Labs 139 97 4. often an off-service junior. keep track of their lab results. call them. Angiodysplasia 3.0 23 12. . or other services to run in addition to their weeks on team. See them every day (unless you are post-call). 4. surgery. nursing home. talk to their nurses and see what’s happening. 6. and bounce questions off them when you are concerned about a patient or encounter something new. Take advantage of it when you can. GI consult for Endoscopy Tomorrow The short version: 1. Talk to your residents: usually you will have at least one junior. CCAC care at home.1/60 93 Calcium = 2. but different from almost any other you’ll have in clerkship. Colon Ca 4. There will always be a resident on call with you: if you get stuck at any time during the night.05 Imaging: 3 views Abdomen: ∅ free air.like CTU on Paeds. rehab. Clear Lung Fields EKG: Normal Sinus Rhythm @ 86 bpm.04 Albumin = 35 ALT = 15 AST = 20 Group & Type = O+ GGT = 20 Alk Phos = 60 Lactate = 1. and they are really good teachers. 3.

and it’s easy to fall asleep if you get lost. Patient ID: 65 yo male presenting today with 1 day hx of BRBPR. You will have quite a bit of responsibility on this rotation. There are call rooms for your Gen. Don’t be afraid to start writing orders for the admission without your resident. Teaching Rounds Clerk teaching is really good in surgery. Tylenol #3 1-2 tabs PO OD 4. it’s their job. Consults will be phoned to the resident./Thoracics Rotations. 40 pack/year smoker PSHx Appendectomy (1999) Cholecystectomy (1986) Allergies Morphine – GI Upset Pencillin – Rash Family Hx Father Colon CA 56 . That includes helping with rounds in the early morning (ie writing notes on patients). COPD Medications 1. You go home and return if you need to see someone. Rounds Rounds are fast. Sit at the back for grand rounds. Atrovent MDI 2 puffs QID Social History 1-2 ETOH per month. and you’re expected to keep pace with the notes in the morning. Sometimes this can leave clerks feeling overwhelmed and alone. The best way to get a lot out of these sessions is to read the night before. but your resident is always there to help you out in a bind. The Surgery Admission Note This is a comparison to the medicine admission note for the same problem. You may also be in the OR if you have a really sick patient overnight. just skim a concise text or get previous student’s notes. There is often a schedule of topics. and they will often call you and tell you to see the patient and call them when you’re done. It’s good to read up since the material may be over your head. ECASA 325mg PO OD x 5 yrs 2. Ortho. seeing patients in the ER. this has varied a lot recently. See the example below for an idea of the minimal content of a surgical progress note. Plastics. Just know your limits and stretch your wings a bit. If you know the content of the lecture you’ll look good for the consultant and learn more in the process.Surgery The surgery rotation really gives you a chance to become a part of a team and feel like you’re “making a difference” in the hospital. consulting on the wards and taking care of problems on the ward. PMHx CHF. On Call You may be responsible for fielding calls from the floor. Ranitidine 150 mg PO BID 3. Don’t be afraid to call them. It’s a good chance to develop your own skills and learn from your mistakes. You don’t have to read a textbook’s worth of information. Urology are all home call. Ventolin MDI 1 to 2 puffs QID PRN 5. You will see the residents get grilled and you don’t want to be in the line of fire. Surg. depending on policy and the nursing staff.

∅night sweats.4/PO2=96/PCO2=37/HCO3=23 Cardiac Enzymes: CK 85 & Troponin I < 0. ∅ crackles. Mildly dehydrated DDx: 1. Rehydrate (2 large bore IV’s) 3. ∅chills. @ 1300 with c/o “weak & dizzy”. RR 22. Large bowel mmt mixed with BRB “4-5 cupfuls”.HPI 3 episodes of BRBPR in 24 hrs. Admit to Surg team 2 2. 136/80 standing. POD#1 No new complaints.2 Cap Gas: pH=7.0 250 4. Prostate Soft Mildly enlarged. Surg. Mildly tender LLQ. ∅masses Labs 139 97 4.04 Albumin = 35 ALT = 15 AST = 20 Group & Type = O+ GGT = 20 Alk Phos = 60 Lactate = 1. ∅rebound tenderness. ∅ dysphagia. Decreasing energy last 2 mos. ∅ CP (Chest Pain). Presented to ER. ∅weight loss. Diverticulosis 2. Awoke from sleep w/ LLQ (Left Lower Quadrant) crampy pain. ∅ abd distention. ∅ ST-T changes Assessment Stable 65 yo man with 1 day Hx of BRBPR. Physical Examination: HR 90. ∅ peripheral edema. PPPX4 (peripheral pulses palpable) ABD: Soft. ∅fever.0 RESP: Good BS bilaterally. T=37. ∅ scars.1/60 93 Calcium = 2.1 65 7.5 Imaging: 3 views Abdomen: ∅ free air. Volvulus Plan 1. ∅ dilated bowel loops. Clear Lung Fields EKG: Normal Sinus Rhythm @ 86 bpm. Never had pain previous. BS+ Wound clean and dry . Last meal 2300 yesterday. ∅ bleeding problems. ∅S3/S4. +BS(Bowel Sounds). For colonoscopy tomorrow The Surgery Progress Note Date/time Gen. Sat 100% on RA. + Aspirin use x 5 yrs. non-tender. ∅ melena.5 123 MCV INR / PTT = 1. BRB present. at urging of wife. 2 episodes since @ 0600 and 1100. ∅ LOC (loss of consciousness). mild expiratory wheezes.0 23 12. First epsiode 0200 last night. BP = 140/86 lying. ∅ N&V(Nausea & Vomiting). +flatus. Diverticuli Left colon CXR: Normal Cardiac Silhouette. Loose stools last 2 wks but ∅ blood. No BM O/E: AVSS Abdo soft. ∅ indrawing CVS: N S1S2. Transfuse 2 units PRBC 4. ∅masses/organomegaly. Normal tympany RECTAL: Normal Tone. Keep 4 units grouped & crossed @ all times 3. Constant LLQ Pain 3/10 w/ ∅ radiation. Normal Axis. Colon Ca 4. 1-2 ETOH per month. Angiodysplasia 3.

Your help with this is appreciated.Plan: Advance diet Mobilize Continue to follow The Surgical OR Note In surgery. Some consultants/residents prefer to write these brief notes for themselves. but not as detailed. The format is similar to that of the operative note. This is the only record of the operative procedure between the operation and when the dictation service finally distributes your consultant’s detailed operative note. but at the very least you should know the format. what was done.OR Note Pre-op Dx: cholecystitis Post-op Dx: same Procedure: laparoscopic cholecystectomy Surgeon: Dr. and how was the patient after the fact. Who was there. (resident) PGY _/ (clerk) M3 Anesthesia: GA by ETT (general anesthesia by endotracheal tube). especially if you aren’t scrubbed in on the case. Most of the time it is the clerk’s job to write this note. Below is a sample: Sept 1/00 – 2300h . Dr. Procedure notes should be added to the clinical record after anything significant is done to the patient (eg. (staff) Assistants: Dr. what did you find. you will also be required to write OR notes. ___ Findings: none Specimens: gallbladder EBL: minimal Complications:None Drains: None counts correct Disposition: To PACU in stable condition. . Suturing in the ER).

this “step back” can be pretty frustrating. If you know the kid is going to be cranky then the best bet is to go for where the money is on exam. feet > hands (mother unable to put patient’s shoes on) φ diarrhea φ vomiting φ cough φ recent travel φ sick contacts PMHx: previously healthy Meds: φ Allergies: NKDA Perinatal Hx: uncomplicated pregnancy SVD at term 8 lbs. Apgars 8/9 φ resusc. but when they cry they can ruin your day. more advanced compared to siblings Immunization Hx: uTD MMR given March 14 Feeding Hx: 8 to 12 oz. visit to family MD à prescribed Amoxil for ?scarlet fever May 6-10: continued fever. If you don’t learn a lot of pediatric medicine you will at least come out better prepared for parenting. You need to be prepared to make kids cry. You may feel like you don’t have a lot of responsibility. There are various topics presented in an afternoon. in hosp. but that just allows you lots of time to think about your patients. homo milk by cup per day. Remember. and if you can read about every case that you see to make the experience more rewarding. meats.5 C) May 5: onset of bilateral. Sample Admission Note: Pediatrics ID: 18 mo Ε previously well CC: fever x 8 days HPI: May 4: onset of fever (38. they have a short memory. Just know your patients and you’ll be fine. conjunctivitis resolved today: bilateral hand and foot swelling. decreased fluid intake. Development: appropriate. Teaching Rounds These can be good and bad. and the hospital seems like torture when you have to wait and you are ill. Your exam should be from least uncomfortable to most uncomfortable (finish up with throat and ears). Some lectures are didactic and others are interactive. Residents in this rotation (Peds CTU) can be pretty protective of their kids. increasing irritability. Pediatric Emergency This is a great opportunity to see a lot of different issues arising in the care of children. Make sure that you take the time to follow the patients while they are in the department. Still. necessary φ antibiotics φ significant jaundice discharged home with mom after 36 hers. good intake of all other foods incl.Paediatrics Kids are funny! They will make this rotation fun. Go straight for the part that you think is causing the problem. They can’t understand why you’re doing whatever you are doing. 4 oz. decreased appetite. Rounds These are much like medicine rounds. non-purulent conjunctivitis and generalized erythematous rash. fruits and vegetables .

cap. PPP. φ masses GU: normal external genitalia DERM: generalized erythematous maculopapular rash. well perfused RESP: good A/E bilaterally.8 kg (50 %ile) th Length: 83 cm (75 %ile) th HC: 47 cm (50 %ile) VS: T = 39. φ crackles.2 C ax. IV 2/3 1/3 with 20 mEq KCl/L @ 50 cc/hr 3. refill < 2 sec.2 Cl:32 Polys: 9.FHx: SHx: Paternal aunt: congenital deafness Maternal grandfather: osteogenesis imperfecta lives in Oshawa with mom. + red reflex. Admit to ward 2. esp. BP 70/P HEENT: ant. φ ulcers.3 Monos: 0. in groin palmar and pedal erythema bilaterally φ peeling of fingertips MSK: generalized non-pitting edema of feet > hands φ dactylitis NEURO: PERRL. generalized cervical Lymphadenopathy neck supple CVS: N S1S2.4 Plt: 486 ALP 430 AST 86 ALT 42 N sinus rhythm. IV Ig 5.8 EKG: Hb: 126 WBC: 16. 34 asthma 32 healthy O/E: 5 irritable. RR 36/min. φ conjunctivitis lips and tongue swollen/erythemaatous.. 2+ bilaterally Investigations: Na: 126 K: 4. dad and two sisters mom stays at home with children dad works as computer programmer lots of family supports φ financial concerns ! consang. soft. φ wheezes ABDO: + BS. φ ST changes Imp: 18 mo Ε previously well. φ S3 S4. Fontanelle closed. φ toxic 18 mo th healthy Weight: 10.8 Lymphs: 4. reflexes symmetrical. Rheumatology consult 6. N TM’s. presents with 8 day Hx of fever and 4/5 criteria for Kawasaki disease Plan: 1. High dose ASA 4. HR 140. non-tender. Echocardiogram tomorrow . φ HSmegaly.

Your treatment will be both chemical and cognitive. not interested in psychiatry. etc. Rounds Student #1: You will get to talk to the patients and find out how they are progressing. #2: Depending on how interested you are in psychiatry. the more you get involved. low humility.Family Medicine Family is a pretty laid-back rotation. as well as by speaking with other students. but try to interview as much as possible. There often isn’t a lot to do depending on the size of your team. One order you will see on this rotation is passes to leave the hospital. but it’s really easy. Some students find that their ping-pong game improves during the rotation. you can always ask to work with other consultants as long as you do a little detective work. OR. This is a nice pace. Since consultants have an interest your clinical experience may be slanted to several diagnoses. and you can do more interesting stuff. Sitting around interviewing inpatients at a long-term care facility can be comainducing. superior fashion sense. In London you are responsible for presenting on a topic of your choice after your two week rotation. There also isn’t a lot of resident contact so the consultant will do most of the teaching. Acute care is more exciting. as well as with individual psychiatrists. In London the academic clinics see less patients (1 per 15min). as well as giving you more interesting work. Student #2: This is where you follow patients’ progress. as this is more difficult than it sounds. especially when you can interview. emerg. There is an exam. Do your best to present your cases in an organized fashion. Some are good and others aren’t. It will show you how varied family can be. It’s intimidating at first.. the more interesting it is. high humility. depending on your site. given that your interviews will not progress in a linear fashion. This is a breeze. This format can vary quite a bit from site to site. Days tend to be longer and busier in the rural portion. A general . you can choose to play a larger or smaller role. Student #2: ONLY interested in psychiatry. This is the way patients slowly re-enter society after admission. Psychiatry: A Two-headed perspective Introduction: Student #1: Generally keen medical student. as psychiatry offers the BEST opportunity to develop interview skills that will be useful when dealing with patients (especially the difficult ones) on ANY service. thus increasing the likelihood that they’ll do more teaching. otherwise lukewarm keen-ness. so show some initiative. It’s also the way they get caffeine and nicotine. #1: This is a very consultant-dependent rotation. Moral of the story: Sitting back and just doing the bare minimum may likely be far more boring than taking charge and initiative. poor fashion sense. Showing interest will endear you to staff and residents. On the rural portion of the rotation you may spend time in the office. IMHO. If you feel like you’re getting a tunnel-view due to the staff you work with.

The diagnosis will guide your decision to admit – if they’re psychotic. they need to come in. Only several of them are interactive. based on a case write-up in emerg. and other pertinent positives in family/medical/social history will make it more thorough. Include their ID. depending on what they’ll want from you. and ALWAYS be sure to rule out psychosis (hallucinations. then they shouldn’t come in. depending on how much time you want to spend in rounds. The only purposes of the interview are to decide if the patient should stay or go home and to gather information laid out on a form. Follow the patient’s progress in hospital – how have they improved/worsened subjectively/staff reports (look at chart first!). If they’re borderline with chronic suicidality and no new plans. If they’re depressed. or a little handbook.g. etc… Multiaxial diagnosis: DSM stuff – you’ll learn this from books and such. and most important details (e. and likely will regress and do worse if they come in to hospital. hallucinations. which can be skirted by using a DSM palm program. Don’t worry. you will look REALLY organized. forensic history (VERY important!) Mental Status Exam – NEVER forget about suicidal and homicidal ideation! Impression: A paragraph or so to summarize the patients presentation. E. etc…). Here’s a general outline: ID: Include patient’s age/name/marital status/source of income/how they presented to hospital/Form status/competency status. and unable to care for themselves. You need to ask diagnostic questions in relation to the main +/. Critical is that you show here the basis of your reasoning on whether to admit or not. psych history. You will be called to see patients in the emergency department as they are referred. E. If you can get good at summarizing patients like this. CC. You can leave out some information. Past psych Hx: Past Medical Hx Meds/Allergies Smoking/EtOH/Substance history (important!) Family History Social history: marriage. brief psych history.g. CC HPI – not only what has led them up to this point. Here are some things that you might want to ask about: 1. ambulance. etc…) . Student #2: You will be performing a comprehensive interview. you’ll look like a pro star. but cover the topics to be seen on the exam. ask questions about depression (MSIGECAPS). but useful sometimes). as that is the summary of the patients’ situation. if you can remember to always mention how someone presented (e. On the floor: Student #2: When following patients on an inpatient ward. their risk to themselves/others.g.outline is shown below under On call. as well as commonly related illnesses.associated mental illnesses in order to make your diagnosis. childhood stuff (can usually gloss over. At the least. Sometimes the lectures are interesting. This requires some memorization of DSM criteria. as this is ALL important. OCD. Teaching Rounds These are variable. such as GAD. actively suicidal/homicidal. psychotic features. suicidal ideation. it takes time before you can get a good handle on what exactly needs to be asked. ideas of reference – also covered in the Mental status exam). sometimes it’s hard to determine what you want to do with an interview (usually done every day). No treatment is started in the ER. but their symptoms in relation to specific mental illness. but mostly they are not very useful. self. Adding CC. an HPI. On Call Student #1: You are in-house (required to stay in the hospital) until midnight. police). delusions.g. asking about old/new symptoms (e. you should prepare a good impression. delusions. This information is CRUCIAL.g.

What you need to know may vary from consultant to consultant. Even if you don’t find it interesting. and treating them with respect. so chances are you will too as long as you keep an open mind. and you feel that your patient would benefit from this. especially if they’re psychotic Check their insight and judgement – e. and give you a better evaluation if they think you really want to be there. Discuss treatment – goals. as they can play an important role. Even surgery keeners have enjoyed their psych rotations. If your social workers are really good at doing cognitive behaviour therapy. their own objectives. If you have an approach before seeing someone. This should apply to ALL of your clerkship rotations. Despite some obscure questions. General survival tips: Student #2: 1. bipolar. and suggest services/alternative housing/addictions counseling/etc…. and something quite different from anything else in medicine. they might change from involuntary to voluntary status. They won’t mind too much if you know the most basic stuff. it makes remembering which questions to ask MUCH easier. There doesn’t seem to be a pattern to the questions they ask. Tell them you want to keep an open mind if they ask you. Show interest. speak to them. so make sure that if you know anything. teach you more. and it’s hard to remember to ask it all) Cover their understanding of why they’re in hospital – this may change during the course of their hospitalization. depression. 6. You’ll see MUCH more patients with schizophrenia. you have a HUGE potential in psychiatry to do a whole lot of good (IMHO. and followup notes. Enjoy psych. and lots of them lose out on services that would be really beneficial. Be flexible if you want to shine. others about their area of research. If you can look out for your patients. its still fairly easy compared to Medicine.g. by following your patients. If you know this bare minimum. easy call. 6. 5. The Exam – What to expect (student #1) The exam is taken from a bank of questions. Ask questions about information missing in the original assessment (there is a LOT of vital data. but you’ll make a huge difference in helping someone get better. The more you make an effort to enjoy psychiatry (or any rotation for that matter). the new patient write-up (see emerg note). 4. side effects. unless the staff/resident wishes to customize your learning to your specialty of choice. know these conditions. 3. antidepressants. Get to know the affiliated health staff. anticonvulsants. and less stressful. Also. Some groups had questions about sleep disorders. look forward to getting off early. 3. but this is often untrue. study the medications that are used to treat these conditions (typical/atypical antipsychotics. which is a pain). Showing up on time and not being a total asshat will almost guarantee a pass in everything. 2. Get to know the format of the mental status exam. No matter where you’re located. 5. not only will you look like a superstar. while others focus on the DSM diagnoses.2. more than any other specialty). or don’t if you just want to pass. Prioritize your studying by what you’ll be experiencing on the ward. others somatoform and conversion . anxiolytics). patient’s beliefs in efficacy. and borderline personality disorder than anything else. Study the big money conditions first. Some are all about the pharmacology (including side effects. People will automatically treat you better. even if you have to fake it. etc… Discuss long term follow-up: Critical for discharge planning. you should get by most of your rotation. The exam has a history of poorly written or off-the-wall questions. This is the only thing that you should really look at before starting your rotation (unless you know nothing. but the rotation director is making serious attempts to improve it. then refer to #1 4. the better time you’ll have. if this is improving. People often assume that someone else is following the patients’ care.

Student #2: For questions below. anxiety. Below is a guide for studying. Atypical antipsychotics (newer agents.disorders. more popular than typicals). Basically. if you understand depression. bipolar and their treatment as well as Axis II and suicidality you have learned a great deal from this rotation. know that neuroleptic = typical antipsychotic = dopamine receptor antagonist. are NOT neuroleptic (definition – causes movement disorder) Obstetrics and Gynecology . psychosis. but the exam is often a bit of a surprise.

WARM THE SPECULUM UNDER TAP WATER. don't feel shy about stepping back and not participating. it is often also a time when all the residents and students who will be attending the O.R. By having both of you in the room. Those clerks in London will have fewer opportunities.e. particularly women who have already had children. will be more than happy to coach you through the process (particularly at LHSC. will consent to having the student be part of the examination process. ITS AMAZING HOW FAR YOU'LL GET WHEN YOU BRIEFLY TELL THE PATIENT WHAT YOU WILL BE DOING AS YOU ARE DOING IT IE "I'M GOING TO INSERT THE SPECULUM NOW. once the patient has been put to sleep). where 95% of the births are “low risk”). it is equally important that students do not just skip this important part of the clinical examination. On the gyne surgery part of the rotation. as the new residents will have just started and they are quite keen to do all the deliveries. That being said. Deliveries are the gold star of this rotation – particularly for those students not interested in pursuing OB/GYN as a future career.R.At the start of your OB/GYN rotation. Your best bet as a clerk is to talk to one of the senior OB residents when you are on with them in the DR and tell them that you’d like to do as many deliveries as possible – often these residents are bored of the whole delivery process. as this will likely be one of the few opportunities to learn this skill. Often the consultant will want to confirm your findings and it is awkward and inconsiderate to ask a patient if you can repeat a pelvic examination. However.BUT CHECK TO MAKE SURE IT ISN'T REQUIRED TO BE COMPLETELY STERILE FIRST. It is important that clerks become accustomed to the speculum and bimanual exam. IF YOU CAN. IT MAY FEEL A BIT COLD AND WET" ALSO. Many students (particularly male students) often comment that they feel intimidated of this whole examination process following this session. also perform the bimanual exam. a better tactic is to get to the o. it is often standard practice for a bimanual pelvic exam to be performed in the O. the patient need only go through this process once. if you feel this way. you should be provided with a small pink booklet. During the second year OB/GYN clinical method session there is much “hoopla” surrounding this often awkward and anxiety ridden part of the clinical exam (for both patient and medical student alike!).. While it is very important to be cognoscente of the feelings of your patients (remember FIFE!).. If you feel at all uncomfortable examining a patient who is not awake and/or whom you have not met before and therefore who has not consented to you performing an exam. originally published by the class of 2001 – this contains all the important orders for various situations you will find yourself in during this rotation. particularly those clerks starting OB in the last block of clerkship. You will find that the majority of patients. In these situations you may have to be somewhat aggressive in order to have your opportunity. A brief note also regarding the pelvic exam. and if it is a routine birth. Students in Windsor will have numerous opportunities for deliveries as no residents are present (some Meds ‘04 clerks delivered close to 40 children during their rotation). prior to surgery (i.r with time to spare so that you can . it is always important to: (1) ASK PERMISSION OF THE PATIENT (2) ONLY DO A SPECULUM/BIMANUAL EXAM IF THE CONSULTANT OR RESIDENT IS PRESENT IN THE ROOM WITH YOU! (3) SPEAK TO THE PATIENT AS YOU ARE PERFORMING THE EXAM. While this is often done by the gyne surgeon in order to better delineate the anatomy he/she will be dealing w/ in the surgery.

2) Be sensitive also if a new mom has her baby in the neonatal intensive care unit. On Call Obstetrics call consists of admitting patients for labour and delivery and following them while they are progressing through labour. so don’t count on a great sleep. If you want to get the most out of your night on call. A good idea is to also swing by the nicu and ask the staff how baby x is doing. Key things to ask your post-op gyne patient about: her pain. ask if they would mind you assisting and offer to do the admission history. check the labs on the computer (especially post-op hemoglobin). Ask the nurse to tell you when she will be performing the next cervical check so that you can do one at the same time. Generally. Listen to the chest. This can be very busy. The sessions are case-based and are best prepared for using old notes or a succinct review text. is she drinking/eating. You are also asked to take care of floor stuff such as post-op complications and general problems. defer to the neonatalogists. be sensitive when entering a room like this :i. Another good tip: get involved in deliveries done by family doctors. you may be asked to help out. how her sleep was. Two important sensitivity points to mention: 1) You will sometimes notice on the postpartum ward that a door to a patient room has a small crocheted colourful butterfly on the door. If the delivery suite is busy.meet the patient before she has been wheeled into the room and put to sleep. esp pod #1. You will then be joined by the resident who will want you to present the patients status to them. This means there will be just you and the GP and this often means you will get more hands on experience. The more times you peek your head into the birthing room to see how your patient's labour is progressing. If you do not feel comfortable answering mom's questions re the status of her newborn. is she having any flatus. Gyne call requires you see patients in emerg. These patients are not seen by the obstetrical service unless a complication develops. which may include more opportunity in doing deliveries.e. . Check the wound dressing and pad for bleeding. At this time you can ask her permission to participate in the pre-surgery examination. and decide their proper treatment. don't ask how the baby is doing. the more comfortable she and the other staff will be about letting you take more responisiblity during the delivery. Thus. Rounds Note that some residents will want you to get to the ward some time before they do in the morning and "pre-round" on the patients. it is not considered great form to rush in when a patient is 10cm dilated and ready to push and expect to be allowed to do the delivery if you have not even so much as introduced yourself to the patient prior to this point. The same applies for post-c-section ob patients. This symbol denotes a perinatal loss. Introduce yourself to the GP. and thus the ob residents are not usually involved in the case. Look at the vitals record. make sure you follow the patients closely. Teaching Rounds Most lectures are interactive and relevant to what you need to know on the wards and for the exam.

mother: HTN SHx: married. φ PIH (pregnancy induced HTN) φ GDM(Gestational Diabestes Mellitus) φ bleeding φ infections MSS (maternal serum screening)–ve GBS (Group B strep) +ve (February 18/00) last U/S @ 18 weeks – OK rec’d Rhogam Dec 14/99 OBHx: 1996: SA (spontaneous abortion) @ 12 wks.Sample Admission Note: OB/GYN Labour & Delivery ID: 29 yo G3P1A1. soft. station –2. GBS + RFA: SROM (Spontaneous Rupture of Membranes) HPI: pt. no decel’s 6 O/E: Imp: 29 yo G3P1A1 presents with SROM in active labour Plan: 1. NAD VS: afebrile. φ heart disease φ asthma φ coagulopathy Meds: prenatal vitamins Allergies: NKDA FHx: father: DM Type II. SROM at 13:00 – gush of clear fluid with continued leaking. A neg. labour:16 hrs. Ampicillin 2g IV now. 6 cm dilated. bleeding x 4-5 days. contractions now q 5-6 minutes. LOA FHR: baseline 130-135/min. D&C 1997: pregnancy complicated by PIH. regular 28-day cycles. baby active. BP 120/75 CVS: S1S2. + accel’s. EDC March 7. Gr II/VI SEM best heard @ LSB. noticed lower abdominal pain radiating to back at 09:30 today. moderate variability. works as administration assistant husband: 32 yo. φ Hx of STD’s. HR 88 reg. live Γ infant. no peripheral edema. IUD (1997-1999) PMHx: healthy. GA. then 1g IV q6h for GBS prophylaxis . Admit to L&D 2. PPP RESP: good A/E bilaterally. SVD (standard vaginal delivery) 1999: current pregnancy GynHx: onset of menses @ age 14. φ S3 S4. φ crackles φ wheezes NEURO: reflexes symmetrical. GA 38 wks. 2000. 2+ bilaterally ABDO: vertex engaged V/E: cervix mid-anterior. chemical engineer φ smoking φ EtOH φ street drugs diaphoretic. RR 20/min. frequent yeast infections esp. no bleeding. with antibiotic use contraception: BCP (1991 – 1995). 80% effaced. 1 minute in duration Course During Pregancy: uneventful pregnancy.

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