aoa survival guide to the 2nd year[1]

8/14/2019 AOA Survival Guide to the 2nd Year[1]

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AOA Survival Guide to the2nd Year

Duke University School of MedicineAugust, 2008


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CHAPTER 1: THE BASICS

IntroductionThe beginning of the clinical rotations is an exciting and stressful time, and there

is no adequate way to prepare yourself for 2nd year other than to jump in and be

confident that you will figure things out as they come along. That said, this document ismeant to serve as an introduction to the daily routines and expectations for each of your 2nd year rotations, and we hope that you will be able to refer back to this bookletthroughout the year as you begin each new rotation.

As with any job, it is important to know your position within the Duke Medical Institution:

Your place in the hierarchy of Duke Medicine:

Chancellor Victor Dzau

Clinical Chairs

Attendings

Fellows

Residents

Interns

Nurses

Medical Students


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The Basic Patient WorkupYou must shift your thinking from a disease orientation to a patient orientation. In

other words, instead of focusing on the manifestations of a given disease, while workingup a patient you must focus on the symptoms and signs of your patient to try todetermine which disease explains the patients problems and presentation. A basic

patient work up will generally include the following:1. Patient Profile:Name, age, sex, race, marital status, occupation, referring physician, hometown, etc.

2. Chief complaint:The primary problem according to the patient, and usually stated in the patients ownwords.

3. History:This includes both the history of the present illness in which you will characterize the

patients subjective symptoms as accurately as possible with respect to location,radiation, severity, quality, duration, and alleviating and exacerbating factors. You willalso elicit the patients past medical history.

4. Physical Examination:Here you will examine the patient for any signs of disease. Signs in contrast withsymptoms are objective indicators of disease. For example, a patient may describe thesymptom of shortness of breath and on examination you may note the sign of expiratorywheezing on auscultation of the lung fields. An example of a normal physical examappears later in this document.

5. Laboratory Tests:To confirm or exclude diagnoses or to monitor progress.

6. Special Studies:Radiological studies, EEG, EMG, etc.

7. Assessment:Of the patients status and of likely diagnoses. This is the part of the workup where youdescribe your thought process of what may be occurring and why. As a medicalstudent, this is a particularly important section as it should be the most accuratedemonstration of your understanding of both the patient and the disease to your attending.

8. Plan:To narrow the differential diagnosis and to treat the patient.

At every point during this workup, you should try to keep in your mind the differentialdiagnosis of conditions that the patient might have. Then through your questioning of the patients symptoms, examination of the patients signs, careful ordering and analysis


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of lab data and special studies, you should refine your differential diagnosis and developand appropriate plan.

Definitions of Common Terms and ActivitiesPrerounding:

Visiting your patient in the morning to check on their status overnight. Details will varywith rotation, but prerounding generally involves reviewing the medical and nursingcharts for any overnight notes (check the progress notes and consults sections for anynew notes), medication changes, new labs, vital sign changes i.e. Tmax (= maxovernight temp), BP spikes, emesis, etc., then wake up your poor patient at whatever ungodly hour it happens to be. Interview your patient briefly and perform a pertinent,focused physical exam. On some rotations, you will be expected to write the progressnote for your patient before work rounds. More about writing notes below and in theindividual rotation sections.

Work rounds:

Rounding with your team i.e. intern, resident, and other students, to interview, examineand write orders for patients. You will generally present your patients to your team,including your assessment and plan for the patient.

Attending rounds:This will vary greatly by rotation and by attending, but this is the opportunity for theattending to see the patients and approve the plan of their care in addition to teachingthe residents and students. On medical rotations you will be expected to present toyour attending and be pimped about your patient's medical conditions. On surgery, youwill likely be pimped in the OR, and you may or may not present during attendingrounds.

Evening rounds:Generally only on surgical rotations, attendings and or residents will round after theday's cases to check on patients' post op progress.

Admission History and Physical: H+PWhen a new patient is admitted to your service (especially on medicine and peds) andassigned to you, you are expected to take a complete medical history and perform acomplete physical exam on him/her. There are admit H+P forms on the wards whichcontain the outline and order you should follow. Generally this will be:

CC: Chief complaintHPI: History of present illnessPMH: Past medical historyPSH: Past Surgical historySH: Social historyFH: Family historyROS: Review of systemsPEX: Physical Exam (with vital signs first)Labs:


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Special Studies: (Xrays, EEGs, EKGs, etc.)Assessment:Plan:

A template of an admit H+P for your use can be found of the AOA 2nd Year SurvivalWebsite at: http://www.duke.edu/web/aoa/dusm.html although you should check with

your particular team to see if it is ok for you to use the template; some teams frown onit.

Progress NotesOn most services, you will be expected to write the notes (and possibly orders) for your patients. You will follow the SOAP format:

- First, put the patients name and hospital day (HD) or post-op day (POD ___ from __________ [list surgery])

- S = Subjective what the patient tells you that they are subjectivelyexperiencing, e.g. nausea, vomiting, chest pain, appetite, etc.

- O = Objective vital signs, physical exam, labs, radiology, etc

- A = Assessment of the patients condition, diagnosis, and progress- P = Plan to treat the patient or further work them up.NOTE: Some services may prefer that you combine the Assessment and Plan ina problem based or organ based fashion, e.g. 1. Acute Renal Failure Creatinine continues to be elevated above patients baseline. Will aggressivelyhydrate and discontinue NSAIDs. 2. Hypertension Patients blood pressureremains well-controlled on current antihypertensive regimen. Will plan tocontinue current antihypertensive metoprolol.

How to PresentYou will present your patients on work or attending rounds in this same general

order as the H+P and SOAP notes as described above, but rotations and attendings willvary in the detail they require. You will generally provide a full H+P presentation asdescribed above on the morning following the admission of your patient. For eachsubsequent day you will present your patient in the SOAP format. It is important tokeep your presentations pertinent, succinct and well organized. Some attendings willallow you to get away with simply reading your H+P's or notes to them in the conferenceroom, whereas others will require you to present from memory without notes at thepatient's bedside. This is a pain. However, it does force you to really know your patients and to organize your presentations well. It will be appreciated and will serveyou well on every rotation if you are able to present your patients from memory, so learnto do it even if not required.

Tips regarding presentations:1. Memorize the abnormal findings:Once you get comfortable with the normal physical exam, you will be able to rattle of thenormal findings easilyAbdomen is soft, nontender, nondistended with noorganomegaly or masses... Then all you have to remember for your patient are anyabnormal findings. The same is true for the review of systems. Often when presenting itis appropriate to just include the data that are relevant to your patients condition, the
http://www.duke.edu/web/aoa/dusm.htmlhttp://www.duke.edu/web/aoa/dusm.html


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pertinent positives and negatives e.g. for ROS and Labs for your patient.Nevertheless, you should still know and be able to answer questions from the attendingabout other details.

2. For complicated patients, it may be wise to divide your presentation into a problem-

based format and present the history of each present problem separately.3. Presenting patients at the bedside to your attending and team can be very anxietyprovoking. If you are required to do so, tell your patient beforehand so that they arentcaught off guard by having the intimate details of their lives told before a group of strangers. Also use discretion about which topics should be discussed outside of theroom, for example with topics such as cancer or HIV when the patient does not yetrealize that they could be a possibility. Also never try to wing or make up anything. If you dont know something about the patients history, ask the patient, or admit that youdont know it but will find out.

4. Be adaptable. Every attending will have different preferences for presentations. Tryto learn your attendings preferences early and accommodate them.

5. Be good to your patients. This goes without saying as you are caring for their health,but your patients can also help you out. When you are stuck presenting at the bedsidewith an ornery attending they can be your ally, and there is no better evaluation amedical student can receive than a patients comment to a resident or attending thatthey appreciated you.

6. Be assertive and do what you say you will do. Try to formulate a plan for your patientand write the orders for your resident to cosign. Ask questions if there is something thatyou dont know, but do not ask questions to show off or that you could easily look up. If you say that you will do something, do it; your team and patients will depend on you.Be respectful to all of the workers in the hospital.

Pockets:With your crisp, short, little white coat you have been given the gift of many pockets.Generally, in these you should always have a copy of Maxwell's, your stethoscope,palm, a pen-light, pens, and something to write on. On your medicine rotation you willreceive a copy of the Intern Survival Guide, which contains useful phone numbers, whattubes to use for different labs, common medications and doses, and a wealth of other very useful items. Once you receive this guide keep it in your pocket for all of your subsequent rotations. A version of the guide available as a Word document on the AOA2nd Year Survival Website, and where it can be downloaded onto your palm viaDocumentsToGo. The intern survival guide is very useful.

Figure out some way to keep track of your patients on notecards, rounding sheets, or something similar so that you will have your patients' labs, medications, pendingstudies, etc. within reach. Additional items may be useful on specific rotations asdiscussed later.


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CHAPTER 2: THE ROTATIONS

Medicine

Typical day:6:30-7:30am- Preround on your patients; write your progress notes and orders.

7:30-9:30am- Work rounds with team; present your patients to the team and discuss the

plan for your patients.9:30-11:30

- Attending rounds, present your patients to the attending, and be prepared toanswer questions about your patients conditions and treatments.

- Finish your notes and orders for your patients, and have the resident or interncosign them.

12:00pm- Noon conference.Afternoon

- Follow up on your patients labs and other studies, help out with discharges,etc.

- Lectures, Physical Diagnosis rounds etc.Call Night

- Admit patients, do full H+P, learn about your patients' conditions beforeattending rounds the following morning.

Tips for Medicine:- Try to be active in the plan of your patient by writing the orders and labs for your

patient and calling for consults if possible.- UpToDate is a great resource for reading about your patients' conditions and

planning treatment.- Help out your team by filling out discharge sheets and calling to arrange follow up

appointments.

Surgery:Typical day:5:00-6:00am

- Preround on your patients, focusing on pertinent aspects of history andphysical. For example if they had abdominal surgery: are there +BS, are thepassing flatus, have they had a bowel movement? Are they getting OOB (outof bed), what are their ins/outs, are they using the incentive spirometer, howdoes the wound look, etc?

6:00-7:00am- Work rounds.

7:30am-5:00pm


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- In the OR. Surgical Recall is a very helpful book to have on hand to look uplast minute information before or between cases...but...never let your attending know that you just looked up last minute info in Surgical Recall.

5:00pm-6:00pm- Evening rounds.

Call night- Hang out with the on-call intern and work up post-op fevers and the like.

Tips for Surgery:- Offer to write the Op note after the surgery.- Get your own gloves and gown and give them to the circulating nurse. Introduce

yourself to the nursing team. They can be your greatest allies on this rotation.- Be enthusiastic even if you are exhausted.

Psychiatry:Typical day (will vary by service):

7:00-8:00am- Preround on your patients, noting any changes in MSE (mental status exam).8:00-10:00am

- Work rounds; interview the patients with the resident and help write notes.10:00am-12:00pm

- Attending rounds.Afternoon

- Help write discharge notes, see consults, etc.

Family Med:Typical day (will vary by location):8:00am

- Show up, and start seeing patients. Interview the patients, present in SOAPform and then see the patient with the attending.

- Offer to dictate if you want the experience.

Pediatrics:Typical Inpatient Dayvery similar to Medicine:6:30-7:30am

- Preround on your patients; write your progress notes and orders.7:30-9:30am

- Work rounds with team; present your patients to the team and discuss theplan for your patients.

9:30-11:30- Attending rounds, present your patients to the attending, and be prepared to

answer questions about your patients conditions and treatments.- Finish your notes and orders for your patients, and have the resident or intern

cosign them.Afternoon


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- Follow up on your patients labs and other studies, help out with discharges,etc.

- Lectures.Call Night

- Admit patients, do full H+P, learn about your patients' conditions before

attending rounds the following morning.Typical Outpatient Day:-Variable by outpatient clinic

Typical Newborn Nursery Day:6:00am

- Divide up the list of babies with your classmates, and see all of themcollecting information regarding, feeds, weight changes, birth information etc.

7:30am- Attending rounds

Rest of the day- Play with the babies and go to deliveries with the Nursery intern

OB/GYN:Typical Labor and Delivery Day6:00am

- Pre-round. Divide up the list of post-partum moms with your classmates andsee all of them asking questions such as about abdominal pain, vaginalbleeding, pain, resumption of bowel activities (esp. if C-section). Be sure tocheck the perineum if there was a vaginal delivery - attendings will expect youto do so.

7:00am- Attending rounds in the conference room.

Rest of the day- Go to clinic and see the prenatal patients, or stay in the labor and delivery

triage area with the intern/resident/midwives.- Help fill out discharge sheets.

Call night- Stay up; go to C-sections and deliveries.

Tips for Labor and Delivery:- With your classmates, keep an updated list with all of the patients on it. Have the on

call student run through the list during a slow part of the night around 5am andupdate the information for the new and old patients, so that the other students can

just show up quickly preround without searching for all of that information .

Typical Day for GynOnc/GynBenignvery similar to Surgery:5:00-6:00am

- Preround on your patients, focusing on pertinent aspects of historyand physical. For example if they had abdominal surgery are there


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+BS, are the passing flatus, have they had a bowel movement?Are they getting OOB (out of bed), what are their ins/outs, are theyusing the incentive spirometer, how does the wound look, etc?

6:00-7:00am- Work rounds.

7:30am-5:00pm - In the OR.5:00pm-6:00pm

- Evening rounds.Call night

- Hang out with the on-call intern and work up post-op fevers and thelike.


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CHAPTER 3: ADDITIONAL INFORMATION

Example Normal Physical Exam:This is an example of a normal physical exam. As you know from the Physical

Diagnosis course there are many more aspects of the physical exam which you mayneed to test; this simply provides the format for a typical, normal medical physical exam.

GEN:Vital Signs (120/70 BP 60 HR 14 RR 37 Temp)AOx3 (alert and oriented to person, place and time)NAD (no acute distress)

HEENT (head/eye/ear/nose/throat):NC/AT (normocephalic atraumatic)PERRLA (pupils equal round reactive to light and accommodation)Sclera anicteric

EOMI (extraocular movements intact)O/P clear (oropharynx)MMM mucous membranes moistTongue pink and moist

Neck:Supple thyromegaly LAD (lymphadenopathy)

CV:RRR (regular rate & rhythm) normal S1, S2 M/R/G (murmurs/rubs/gallops)

Chest/Back:CTAB (clear to auscultation bilaterally) W/R/R (wheezes/rhonchi/rales) CVA tenderness

ABD:S/NT/ND (soft/non-tender/non-distended) R/G (rebounding/guarding)BS (bowel sounds) masses HSM (hepatosplenomegaly)

EXT: C/C/E (clubbing/cyanosis/edema)

Skin:WD (warm & dry) visible lesions Tenting/Normal Turgor

Neuro:Non-focalCN 2-12 intact (cranial nerves)


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2+ DTR B/L (deep tendon reflexes)5/5 Strength bilaterally

Labs:

See the Intern Survival Guide for more information of normal lab values andrecommendations.

Common Medical Notations:c = withs = withoutPRN = as neededp = after NTE = not to exceedB = BL = B/L = bilateralc/o = complaining of CP = chest painCa = cancer D/C = discharge or discontinueDx = diagnosisSx = SymptomTx = treatment or transplantRx = prescriptionHx = historyf/u = follow uph/o = history of HA = headacheN/V = nausea/vomitingU/A = unrinalysis


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VS = vital signsWNL = Within normal limits (be careful using this as some attendings take it to

mean we never looked)x = except

Frequency of Medications or Other Activities (i.e., labs, inspiratory spirometry,ambulation, etc.)Q = everyQHS = at nightQAM = in morningBID = twice dailyTID = three times dailyQID = four times dailyBID, TID, and QID are not equivalent to q12h, q8h, or q6h

Route of Medications

PO = by mouthNPO = nothing by mouthIV = intravenousSQ = subcutaneousPR = per rectum


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