Clerkship Survival Guide 7.2015.pdf

The Unofficial Clinical Clerkship Survival Guide University of Louisville School of Medicine

Brought to you by the Class of 2016 Track Captains and the Organization of Student Representatives (OSR) Authors Eric Kreps - General Information and Track Selection Alexandra Healy - General Surgery Eric Poulos - Internal Medicine John Wehry - Neurology Anne Hayes - Elective Chris Hamann - Obstetrics and Gynecology Evan Rhea - Pediatrics Gerald Cheadle - Family Medicine Catey Harwell - Editor Rudra Pampati - Editor Allison M. Hunter - Editor

Table Of Contents General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Parking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Food and Dining Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Scrubs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Evaluations and Shelf Exams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Patient Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Computer Access and Electronic Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Prescription Writing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 White Coat Essentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Third Year Track Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 8-week Clerkships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 6-week Clerkships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Neurology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Elective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Values, Calculations, and Commonly Asked Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Example Notes and Oral Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Internal Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

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Clinical Clerkship Survival Guide: General Information By Eric Kreps

General Information This section is entirely dedicated to the general information that spans all of your third year of medical school and is not necessarily related to an individual clerkship. Topics include parking, on-campus free dining, attire, clerkship evaluations, shelf exam, patient logs, etc. More specific information pertaining to each of the individual clerkships can be found under its own section. Read at length or flip back for reference as questions arise!

Parking University of Louisville Hospital  University Garage: If you have around $400 burning a hole in your pocket, go for renewing your parking pass to the 620 Garage, but keep in mind you may not be doing all of your rotations at University Hospital. This garage offers 1,711 parking spaces for faculty, staff, and students, and is ID card protected for safe access. HSC Parking Office: 414 East Chestnut Street Hours: 8:00am - 4:00 pm, Monday-Friday, Closed 1:00pm - 2:00pm for lunch Phone: (502) 852-5111  Free Parking: Students often park along Muhammad Ali Blvd, starting at Clay St (in front of the 620 Garage) and ending at Jackson St; there is also free street parking along S. Hancock, Marshall Street, and Clay St. Please be prudent and keep safety in mind as you walk to and from your car during early morning and late night hours. On weekends, there is free parking at the UL hospital garage (on the corner of S. Hancock and E. Madison St, next to the pedestrian crosswalk). Metered parking is also available (most now payable by credit card). Metered spaces are free after 6PM Monday – Saturday and all day Sunday. Norton Hospital and Kosair Children’s Hospital: Students get free parking at a lot adjacent to the L&N credit union (on the corner of nd Chestnut St and 2 St) while on a rotation at these locations. Students on a rotation at Kosair can obtain a pass for the hospital parking garage by going to the parking office on the first floor of the Medical Towers South (the blue building on the right after you pass Norton Hospital on the corner of Gray and Floyd Street, heading towards Broadway). Go in the double doors that face Gray Street and go to the right, following signs directing you to the Parking Office. Also, parking at Kosairs’s garage (214 Abraham Flexner Way )is free on the weekends!

Jewish Hospital Garage: Parking pass to the Jewish hospital garage (249 East Muhammad Ali Boulevard) can be obtained from the 5th floor of the Outpatient Care Center attached to the garage. VA Hospital: Parking is available in front of the VA Hospital. Good news: no passes needed! Bad news: many spaces are reserved for just patients and the others fill up very quickly in the morning - it can be difficult to find a spot after 8:30AM! The best advice is to get there early (before 7:50AM). You can park at the Ramada Inn on Zorn Avenue (numbered spots only) or at the Lebanese American Supper Club parking lot off River Road behind the Ramada. A marked VA shuttle will arrive every 15 20 minutes to transport you to and from the VA Medical Center between 6:15AM and 6:00PM. Escort Service: The UofL police department can pick you up from any on-campus location and escort you to your vehicle within 4 blocks of campus if you call 502-852-6111. This is especially useful when it is late and you feel uncomfortable walking to your car.

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Clinical Clerkship Survival Guide: General Information By Eric Kreps

Food and Dining Options Eat for free! Each hospital has its own unique dining options, however this information covers the sustenance that is free of charge only.  

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Jewish Hospital—Doctor’s lounge in the Rudd Heart and Lung center, 1 floor. Serves continental breakfast, a full lunch, as well as a soft drink and espresso machine. Don’t miss Taco Wednesdays! Often, your resident will give you their door code or let you in to get to the grub. Norton Hospital—Doctor’s Lounge—2nd floor Norton Hospital, across from escalators. A full breakfast and lunch are served daily, with snacks available throughout the day. Relive your childhood dreams of chocolate milk with your cereal. Badge access required, so have your resident let you in. Technically this is just for attendings, so opt to sit on the couches and not at the tables if space is tight! Kosair Hospital – Doctor’s Lounge – 1st floor of Kosair’s; have your resident point it out, as it may be hidden. Your badge should give you access to cereal, juice, fruit, peanut butter, crackers and a soda machine. University Hospital—Although there are no meals provided, the pre-op doctors lounge does provide bagels and donuts in the morning (they go quick!), as well as access to a soft drink machine (broken about 20% of the time). You can almost always find at least peanut butter and crackers here or in pre-op when you are looking for quick food between cases. While on inpatient wards, most patient floors have access to the nutrition room, stocked with milk, ice cream, soda, peanut butter, and crackers.

Scrubs In general, wearing scrubs is limited to time in the OR, on-call days for inpatient medicine and pediatrics, and on Labor and Delivery during your OBGYN rotation. During L&D, it is recommended that you come to the hospital in business attire and change into scrubs in the locker rooms (3rd floor on L&D). It is always best to check with your resident teams about any dress code for rounds. On Surgery, you should never wear scrubs to the Department of Surgery offices (2nd floor ACB)—wear clinic attire with your white coat. The location of scrubs will vary among locations and services, so check with your resident teams or ask a nurse where you can find scrubs. Just a few pearls – be conservative with your scrubs; go a size up if you need to and don’t be a hero. Ladies, small tops are hard to come by, so most prefer to wear a t-shirt or tank top underneath these oversized scrub tops.

Evaluations and Shelf Exams Evaluations: The seemingly subjective evaluation of your clerkship performance is perhaps one of the most unique and important parts of third year to understand. For the first time your grade depends not only on how well you study and perform on exams, but how well you communicate, interact, and work as a member of a team. The intangibles of professionalism, emotional intelligence, and reading social situations will come in handy. The mainstays of responsibility, hard work, and punctuality will serve you well, so be on your best behavior and prepare to shine as you transition from the classroom to the clinic. Clinical Evaluation of the Student: Your student evaluation will be made up of one ungraded midclerkship evaluation and several graded clinical evaluations. First, you will be evaluated at the midpoint of each rotation (midclerkship evaluation). This consists of formal, ungraded feedback from an attending using either a paper form or the tool on New Innovations (method is clerkship specific). This is a way to gauge your performance before final graded evaluations, that way if there is significant room for improvement, then you will have time to cover ground before it really counts! The final evaluations at the end of the clerkship are graded and are the main component of your final clinical evaluation grade. Keep in mind, that no matter how well you perform on your clinical evaluations, you cannot honor a

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Clinical Clerkship Survival Guide: General Information By Eric Kreps clerkship without honoring the shelf exam. Both residents and attendings will evaluate you during each of your rotations. You will be evaluated on the following:  Patient Care - Taking an effective history, physical exam skills, generating a differential diagnoses, creating a problem list, generating a treatment plan  Medical Knowledge - Integration of basic sciences, application of clinical sciences)  Interpersonal and Communication Skills - Spoken and written communication, oral presentation skills  Systems-Based Practice - Teamwork, skills in evidence-based medicine  Professionalism –Honor and integrity, responsibility and accountability, caring and compassion, and respect Finally, your evaluator will have the opportunity to write “Overall Comments.” These comments will be the real meat and potatoes of what appears in your Medical Student Performance Evaluation (MSPE) letter—a summary of your overall clinical performance during each of your rotations as a third year. The MSPE letter is a large part of your application for residency, so it is important that it reflects your true performance. These evaluations are completed using New Innovations. Evaluation pearls: Very rarely will a clinical evaluation keep a student from honoring—if you show up, work hard, and are respectful, you should do just fine. If you are consistently not honoring because of your clinical evaluations (i.e. honors on the shelf but not the clerkship), this is something worth talking about. Pediatrics tends to be a little more difficult as their cutoff for clinical performance for honors is higher than most other clerkships. Student Evaluation of the Rotation, Residents, and Attending: Be sure to fill out your evaluations of the residents and attendings using New Innovations. You are often assigned residents and attendings to evaluate at the end of your rotation-- constructive feedback (not overly negative) is crucial to improving the experience for others. These evaluations are reviewed and can be used as a means for positive change. Any serious issues or urgent concerns should be addressed sooner rather than later; utilize your Track Captains, residents or anyone else you trust or to hear your concerns. Student mistreatment is taken very seriously, so speak up should you feel uncertain or uncomfortable about an issue. Once the rotation ends, you will receive an evaluation from Paul Klein to provide feedback on the rotation itself. This is a good time to offer up suggestions to improve the way the clerkship operates (and it is anonymous!). Both the Clerkship Directors and the Educational Policy Committee (EPC) review the survey results and comments to monitor the quality of the experience and provide feedback for changes as needed. Shelf Exams: Each of the third-year clerkships concludes with a “shelf exam,” typically administered on the last morning of the clerkship. A shelf exam is a clerkship-specific standardized test developed by the NBME that medical schools purchase to gauge how their students perform on a national level. The exam is generally 2.5 hours long and consists of 100 questions. At the University of Louisville, this exam is a generally a hefty portion of the final grade, ranging from 40-50%, depending on the clerkship, and is graded on a curve with respect to percentiles. In order to receive honors for a clerkship you MUST receive a raw score equivalent to the 75th national percentile (which hovers around a raw score of 80-85/100) or above -- no exceptions. In essence, you must honor the shelf to honor the rotation. A passing grade involves a raw score of greater than the 4th percentile. If in the course of your third year you fail a single shelf exam, you may retake that shelf exam. However, if you fail more than one shelf exam, then you may have to remediate the entire course. While the school pays for you take the first shelf exam, if you fail a shelf you will pay to retake the exam. Resources for each clerkship are listed under their respective sessions. ONLINEMEDED.ORG has a series of free videos that review clerkship and NBME shelf content.

Patient Tracking You are required to log each of your core clinical clerkships (with the exception of your time on Elective) in a “case log” located on New-innovations. Each of the core clinical clerkships has a list of required clinical diagnoses that you must see or learn about during the course of the rotation. New Innovations will allow you to log your patient with their corresponding diagnosis— obviously not every patient fits the exact descriptors, so think big-picture if you do not find the exact diagnoses you are looking

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Clinical Clerkship Survival Guide: General Information By Eric Kreps for. Students are now expected to log patients on a weekly basis. A portion of your grade will be dependent on your completion of patient logs. Though the process can seem tedious, it serves an important role: the New Innovations system allows the Office of Medical Education and the accrediting body of all medical schools (LCME) to follow the type and number of patients you are seeing to ensure comparability across all clinical sites (this is important for accreditation!). Also, make sure you have fulfilled the required number of clinical diagnoses for each clerkship by running a “requirements summary” in New Innovations.

Computer Access and Electronic Medical Records Pay close attention to your emails at the end of your second year, as you will be receiving log-in information for up to six different electronic medical record (EMR) systems that you will need access to during your clerkship experience. These systems include: Allscripts (UL outpatient), EPIC (Norton and Kosair), Cerner (Jewish Hospital), NetAccess (UL inpatient), Synapse (UL imaging), and last but not least the infamous VA EMR system. Both University systems, (Allscripts and NetAccess) can be accessed from your own computer/tablet through installation of the Citrix receiver software on your device. Detailed instructions, including info on installation of Citrix, can be found from the emails sent from the Office of Medical Education. How to access EPIC and Allscripts from your home computer. 1. For Allscripts, the link is https://citrix.ulp.org 2. For EPIC, the link is https://myresources.nortonhealthcare.org 3. It may ask you to install some software. Let it. 4. Login with your respective ID and you should come to the familiar screen with the links to "AHS - Live" or "Hyperspace PRD" How to access EPIC and Allscripts from your iPad. 1. Go to the app store and download the free app called "Citrix Receiver". 2. After the app is installed go to the respective link (Allscripts = https://citrix.ulp.org, EPIC = https://myresources.nortonhealthcare.org) 3. Sign in and select your respective EHR ("AHS - Live" or "Hyperspace PRD"). 4. This will bring up a screen with a file asking how you want to open it. You should have a button that reads "Open with Receiver". 5. This should launch the app and bring you to the login screen. One word of warning: the interface is a bit clunky and takes a few minutes to get adjusted. It is more useful for reading notes and patient data than trying to write notes.

EMR System University: NetAccess, Synapse, Allscripts, Cerner Norton and Kosair: EPIC VA EMR VA fingerprinting and ID services

Help Contact Number (502) 588-0411 (502)-629-8911 Help Desk Extension – 55491 (502) 287-5983

University Hospital: Inpatient: NetAccess (health information) and Synapse (Imaging) Login information will be provided to you by email from Tonya Hockenbury ([email protected]), Administrative Assistant from the Office for Medical Education. Accessed through myapps.ulh.org. IT help number 502-588-0411 for problems with access (i.e. when your username and password expire for the 10th time). NetAccess will provide you with daily patient information, such as labs and ins/out, and some discharge summaries and operative reports. However, at UL every patient also has a paper chart located on his or her respective hospital floor. Synapse is the system used to access imaging, such as x-rays, CTs, and MRIs. Outpatient: Allscripts

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Clinical Clerkship Survival Guide: General Information By Eric Kreps Login information will be issued through a sketchy “encrypted” email from Martin Kaelin ([email protected]) in late June. Follow the directions to access your login information. The same email will include information on how to install the Citrix receiver required to launch the EHR. Training for Allscripts is provided during orientation on Blackboard. Again, the helpdesk number is 502-588-0411. Write it down. Save it. You will need it. This system provides all notes from the outpatient experience, incorporating all outpatient providers from the UL network. It is often slow and “crashes” more than you might consider reasonable, so be patient and help the clinic keep moving by seeing patients and writing paper notes should technology issues arise. University Wifi Access: In order to access the wifi at university hospital the following credentials are used Network: guest Username: wifiguest Password: use the following format: yearmoguest (ie for December 2017, use 201712guest) Norton and Kosair Hospital: EPIC rd Everyone will be required to attend one 4-hour training session for formal EPIC training, held at Norton Hospital during the 3 year orientation week. At the time of training you will receive your login information and password, so make sure you WRITE YOUR LOGIN INFO DOWN AT THE TIME OF TOUR TRAINING! If you are unable able to get remote access to EPIC from your device (iPad or home computer), call the EPIC helpdesk at 502629-8911. Having access at home makes it easier to ready about patients, however it is not very functional for writing notes or anything other than information output. Once you get the remote access, you can log onto EPIC from myresources.nortonhealthcare.org, then launch the secure connection from the Citrix receiver. As the sole source of patient information for both Nortons and Kosairs, this system is the most comprehensive and should be the easiest to navigate. Jewish Hospital: Cerner Orientation will be provided at your specific site at Jewish Hospital; any login information will be provided to you prior to your start date. The site to log on is webapps.catholichealth.net. Training videos can be found at http://www.chionecare.net/cernerphysician-training-videos/. If you have any questions feel free to call the IT desk at 502-588-0411. VA Hospital: The one and only All students will be required to complete VA processing, as they will eventually rotate through the VA. If you are rotating at the VA first, start this process 4 weeks prior to your start date. This process will be long and drawn out and something is bound to go wrong-- be patient and plan ahead. Setting up your access to the VA EHR is a multi-step and complicated process, and detailed instructions will be sent out via Tonya Hockenbury ([email protected]). The best advice is to start early (4 weeks prior), call ahead to make sure the photo and fingerprinting system is working, and avoid the lunch hour. There are just a few steps to this process: 1. Find the packet available on Blackboard and fill out the paperwork; fax one of the indicated forms to VAMC. 2. Go to VAMC, turn in the rest of the paperwork, get fingerprinted, and get pictures for your ID badge. Submit the necessary paperwork (4 weeks prior to start date). **The camera, finger print device, and web site are not reliable and are down frequently. If you want to make sure that everything is up you can call Randy in the office where they take your photo and finger prints at 502-287-5983. 3. Complete online training modules 4. Return to VAMC, sign on to computer, get computer access, get email, and pick up your ID badge (call ahead to make sure it’s ready!) A key point is that even after you get everything set up at the VA computer system, after 90 days of inactivity your password will expire, and you will need to call the national helpdesk (also in Tonya’s email) to have new access codes sent to you. VA Help Desk Extension – 55491.

Prescription Writing

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Clinical Clerkship Survival Guide: General Information By Eric Kreps One common task of medical students is writing out prescription medications by hand for practice, to then have the senior resident sign. Some common abbreviations are used for the frequency of the medications, including QAM (morning), QHS (nightly), Q4H (every 4 hours), Q8H (every 8 hours), BID (twice daily), or TID (three times daily). Also, some medications can be “PRN” (as needed) for [a symptom]. Writing this out, say for administration of an antipyretic, would be “Q6H PRN fever.”

White Coat Essentials One important aspect of third year is the application of your physical exam skills with respect to patient care. Particularly critical for physical exam and note taking are your stethoscope, at least 2 pens, and a notepad. Your stethoscope bell can double for a reflex hammer, but an actual reflex hammer and a pen light are recommended for your neurology rotation.  2 Pens (always have more than one—you are bound to lose one or your resident/attending will ask for a pen)  Small Notebook  Maxwell Quick Medical Reference (amazon.com for $6 or bookstore for $8)  Stethoscope  Reflex Hammer  Optional: Pocket Medicine (amazon.com for $20), iPad mini or other tablet  For Rounds, a foldable “White coat clipboard” (found on amazon.com) can be very handy for helping stay organized.

Professionalism Overall, your third year will be a much different experience than your pre-clinical years, so prepare yourself for a fun and exciting change! That being said, the amount of responsibility that the third year brings can initially be a shock, but with time it will be a great transition to what you will be doing for the rest of your life! With the transition to clinical work, the concept of professionalism and teamwork becomes even more crucial. You will be a member of the patient care team, and you must keep in mind that you are representing not only the University of Louisville, but also the medical profession. Always be mindful of your team as well as your peers. Avoid criticizing students openly to others, and particularly in front of residents or attendings—they are now your colleagues and not just your classmates.

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Clinical Clerkship Survival Guide: General Information By Eric Kreps

If you notice repeat or gross lapses in professionalism by your peers, there are many resources at your disposal. Sometimes professionalism issues call for tough conversations—if you feel comfortable and are in a position to have that talk, please do so. If not, you can address professionalism concerns with your Track Captain and through the anonymous submission of an Early Concern Note (ECN). Keep in mind that ECNs are confidential, low-stakes, and are only reviewed by the student-only Honor and Professionalism Advocacy Council (HPAC). For more information, see: http://louisville.edu/medicine/studentaffairs/studentservices/hpac To submit an ECN directly, see: https://louisville.edu/medicine/acl_users/credentials_cookie_auth/require_login?came_from=http%3A//louisville.edu/medicin e/studentaffairs/ecn This is a valuable tool in preventing professionalism issues from reaching the point of being detrimental in a Dean’s letter (the MSPE) and can go a long way in helping correct professionalism issues early.

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Clinical Clerkship Survival Guide: Track Selection By Eric Kreps

Third Year Track Selection Your third year of medical school at ULSOM will consist of 7 core clerkships broken down into one semester of 8-week rotations and one semester of 6-week rotations, starting in July and running through the following June. The 8-week rotations consists of Surgery, Internal Medicine, Neurology (4wk)/Elective time (4wk), while the 6-week rotations include Family Medicine, Obstetrics and Gynecology (OBGYN), Pediatrics, and Psychiatry. More detailed information pertaining to each of the 6 and 8week clerkships can be found as individual chapters in the Clerkship Survival Guide. The following information is meant to provide you with an overview of the track selection process, as well as provide you with information that should be considered as you begin to map your third year schedule. Although the track selection process might at first seem to be a daunting task, it really is a very manageable process and will provide you with a roadmap to your first clinical year as a medical student. You will be making your track selection using NewInnovations, a web-based service that is used to manage the clerkship selection process in a way that makes organized, fair, and efficient. To select a “track” essentially means that you will be choosing the order in which you will experience each of the third year clerkships. First, you must decide to schedule either the 8-week rotations (Surgery/Neuro 4wk-Elective 4wk/Internal Medicine) or 6-week rotations (family med/OBGyn/Peds/Psych) first. When it comes to scheduling, be sure to take your career plans, personal interests, and the seasons and into consideration. For example if you are sure that you are interested in Surgery, it might be wise to avoid scheduling that rotation first as you will likely be inexperienced. Also, coming off Internal Medicine in early summer might have you better refreshed for Step 2, etc. Be sure to keep in mind the different experiences that you will find on the clerkships given the time of year (example trauma season in warmer months for Surgery, RSV and flu season during winter months for Pediatrics, etc.). Ultimately all students will complete each of the core clerkships, and some would argue that timing and sequence does not matter. Seek out the advice from upper classmen and your advisor to make the decision that works best for you! After you determine the order of 6 vs. the 8-week rotations, you can then begin to consider the clerkship sequence and rank your preferences for location/subspecialty for each rotation. There are several options to choose from, so read the following for a VERY brief overview of each of the selections options you will find when using New Innovations (please look at each clerkship within the packet for more details!).

8-week Clerkships: Surgery  Jewish Hospital – Offers 4 weeks of general surgery, as well as 2 weeks of cardiothoracic surgery and transplant surgery which most students find very interesting and enjoyable. A good balance of slow and busy, and usually students find they have plenty of time to study. Call is at Jewish.  Kosair/VA – Kosair offers an abundance of cases that are far different from the other general surgery experiences, and may appeal to those interested in pediatrics. Pediatric surgery questions are less numerous on both the shelf and oral exam, but some students report being able to be more “hands on” as compared to other surgery rotations. VA balances OR cases with time spent in clinic, and provides great exposure to bread-and-butter general surgery cases, as well as exposure to thoracic and vascular cases. As with everything at the VA, things run a little slower but this translates to a little more study time. Call is split between Kosair (while on Peds surgery) and UL Trauma (while on VA)  Norton Hospital – Comprised of 4 weeks of general surgery. Norton also houses the 2 week subspecialty optios of of Colorectal Surgery, Surgical Oncology, and Vascular. This is a very busy service with a high patient volume, but the exposure to numerous cases may appeal to those interested in surgery. Call is at Nortons.  UL Hospital – Includes 4 weeks of trauma surgery, which may appeal to those interested in surgery or ER. Students will also be assigned to either 4 weeks of elective surgery, which students find as a good balance to trauma as they have more time to study on elective, or 4 weeks of surgical oncology and vascular surgery, which are both busy and interesting services that may appeal to students pursuing surgery. Call is with UL Trauma.  Madisonville – All 8 weeks are spent at Baptist Health in Madisonville, and students have a different lecture series and call schedule. Most of the time is spent working directly with attendings, which may allow for more teaching

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Clinical Clerkship Survival Guide: Track Selection By Eric Kreps moments and first-assists. Students that go to Madisonville all report a positive experience: call is home-call and you have some weekends off; more didactic and committed study time; more hands-on with more time spend directly with attendings only (1 UL resident spends time at this site at a time). If you are interested in pursuing surgery for residency, however, this does prevent you from meeting and working with faculty members and residents involved with the UL program. Internal Medicine: 4 weeks on wards and 4 weeks on subspecialty, with the subspecialty month split between two subspecialties (i.e. 2 weeks of Cards and 2 weeks of GI). Generally speaking, inpatient Internal Medicine wards tend to carry primary patients, while most subspecialty services are consult services.  Wards (4 weeks)– Students are assigned to teams at either UL or the VA. As with most things at the VA, things tend to run a little slower but hours are slightly shorter.  GI – Somewhat longer hours, but a great experience for those interested in the field and/or a more procedural experience. You will see patients in the morning, observe procedures and see consults in the afternoon.  Cardiology - Both VA and UL involves seeing patients and writing notes. VA hours are slightly shorter, but all sites are reportedly a great opportunity for those interested.  Pulmonary Consult –Generally a lighter patient load with moderate hours and plenty of study time.  Endocrinology - Service covers four different hospitals and students will be asked to attend rounds and see patient, but generally will not write notes. Among the longest hours on medicine (8-6), but very rewarding and well-liked by al students that understand the time commitment. Avoid scheduling this subspecialty close to shelf exam time for study purposes.  Nephrology – Sites at Jewish, VA, and ULH. VA and ULH see lighter to moderate hours, while Jewish is among the heaviest of the specialties in hours (7-7 many days). All the locations have been reported to be a good experience.  Infectious Diseases – Sites at Jewish and UL. Also Bone and Joint ID team available at both Jewish and UL. You will see patients in the morning, round with and attending, and will stick around campus for consults in the afternoon. Some services also have clinic in the afternoon at the VA.  Hematology/Oncology – Hours are extremely variable based on the attending and your team’s fellow/resident. Clinic attendance is encouraged once a week. You will see patients in the morning or afternoon, depending on the attending. Neurology: 2 weeks on inpatient and 2 weeks on outpatient. You can rank your preferred locations in the electives. Inpatient:  Jewish General - This is one of the busier services but provides students with a great opportunity to see a wide variety of neurological diseases.  Child Neuro - This is one of the most demanding inpatient services for neurology, but students see a wide variety of very unique cases and learn a tremendous amount from the faculty. Child neuro is split with one week on inpatient and one on outpatient. You will work one weekend day, but this also counts as your “call” day for the rotation.  ULH Stroke - Hours vary with attendings and patient volume. In general, the start time is earlier than most services, but students are finished in the afternoon.  ULH General - Hours are similar to ULH Stroke. Students are expected to see a patient and write a note but are not always asked to present during rounds. Outpatient:   

Child Neuro - Hours are typically 8-4PM. Some attendings will have you see patients and write notes, while others will have you shadow and be helpful to the resident. Child Neuro assignment is 2 weeks long with one week spent on inpatient and the other on outpatient. Private Practice – You are assigned to work with a community neurologist with each experience varying based on your attending. In general, however, the hours are reasonable and the neurologists you work with are very helpful. HCOC-Outpatient Clinic- Located in the Healthcare Outpatient Care Building (HCOC). Students are paired with different attendings each day. Students usually start around 8:30AM and finish around 4:00PM, depending on the patient load.

Elective: scheduled on a different basis, please look for emails from your leadership or Sherri Gary for scheduling information.

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Clinical Clerkship Survival Guide: Track Selection By Eric Kreps

6-week Clerkships: Psychiatry:  



   

Child Psych – Excellent hours, but one-on-one patient interaction can be limited due to the nature of the service. Students are generally happy with their experience here and often more enjoyable for those interested in pediatrics. Emergency Psych- and ACB – This rotation entails more dedicated hours, but the residents and attendings offer you significant autonomy with a lot of patient contact. Pace can be hectic with patients that are potentially dangerous, however security is always present and is a good environment for those that thrive in an ER environment. You will also get this experience as part of your call assignment while on the psychiatry clerkship. The other half of this assignment is a slower-paced outpatient experience at the ACB. Norton Consult – This is a consultation serve for medical in-patients with concomitant psychiatric symptoms. This rotation offers good hours (8 to 4/5), with excellent patient contact, lots of autonomy, and responsibility. Most students feel integral in actual patient care as the attendings and residents on this service listen to your suggestions and even let you put in orders. Norton Inpatient Unit – Wide variety of diagnoses, excellent patient contact, with moderate autonomy. ULH Inpatient Unit—Wide variety of illnesses and you are more likely to see those that are seriously ill as primary admissions are made mainly through Emergency Psych. ULH Consult Service—This service sometimes has limited patient censuses, but this also gives you lots of opportunity to study. VA Inpatient/Outpatient – Hours consistently 8:00AM-4:30PM. This rotation offers significant autonomy with your own patient load and one-on-one interaction with the attending. 5 weeks on inpatient VA-psych with 1 week on the inpatient substance abuse treatment floor. You will present at Journal Club, write notes on your patients every day and will get used to giving oral presentations.

Obstetrics and Gynecology: 2 weeks of private practice, 2 weeks of surgical subspecialty and 2 weeks of Labor and Delivery. The electives you may choose are in the surgical subspecialty:    

Gynecologic oncology—very interesting and demanding cases, but with significant hours and would be a good choice if interested in surgery. Benign gynecologic surgery—shorter hours than gyn/onc with more emphasis on hysterectomies and minimally-invasive surgeries. ODSU—outpatient surgery with short hours but less interesting/significant cases than the others. Will see procedures including polyp removal and other procedures. Urogynecology—procedures for pelvic organ prolapses and urinary incontinence. May work at several different hospitals, but a very interesting experience.

Pediatrics:   

Stonestreet Clinic: A lot of one-on-one time with attendings, where they emphasize patient interaction rather than EMR proficiency. It is an off-campus site ( 20-30 min drive) and you will see a more rural patient population. Eastern Parkway Clinic: Located at the Kosair Charities Building on Eastern Parkway. You will experience nearly one-onone student/attending time, with lots of individual teaching. However, there may not be as many patients to see (8-10 per half day), and cases may be less acute. Many Spanish-speaking patients, and a great opportunity to utilize medical Spanish. Children and Youth Clinic (C&Y): Located on campus, next to nursing building. Heavy patient load as this clinic recently absorbed what was UL Broadway Pediatrics. Attendings are kind, helpful, and most interested in helping students learn brief lectures Tuesday and Thursday morning. However there are several students assigned to this at the site at a time, so time with each attending can be limited.

Family Medicine: Both the Newburg and Cardinal Station clinics are very similar and just vary by physical location. You will spend 2 weeks at either of the clinic sites, then 4 weeks at your AHEC site (scheduled separately; be sure to attend AHEC fair for locations.

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Clinical Clerkship Survival Guide: General Surgery By Alexandra Healy

General Surgery Welcome to surgery! It is easy to imagine this as a rotation you will spend all of your time in the OR (and you will spend many hours there), but there is much more to surgery than operating. You will also spend a good deal of your time seeing consults, assessing whether or not the patient needs surgery, performing bedside procedures (central lines), and making sure your patients recover well postoperatively. Surgery generates most of its patients through either previous clinic visits when the surgery was planned months or weeks in advance, such as for elective cases, or through inpatient consultations or the ER where the patient is scheduled for surgery in the upcoming minutes, hours, or days. Prior to surgery the patient is taken to Pre-Op where consent is obtained and the anesthesia team performs their assessment in preparation for sedation. Once ready for the OR, the patient is rolled back and prepped for surgery. After surgery, the patient is taken to the PACU where they are monitored while waking from anesthesia, and eventually transported to their hospital room for postoperative management on the floor. The surgery team then follows the patient until ready for discharge and will subsequently schedule the patient for outpatient follow up appointments. This rotation is a total of 8 weeks. You will spend 4 weeks on a general surgery or trauma service and 4 weeks on a subspecialty service(s), sometimes further divided into 2-week services. The patient population is largely adult, however, you may manage pediatric patients if you are assigned to Kosair Children’s Hospital pediatric surgery service. Some of the common diagnoses you will encounter include bowel obstructions, hernias, appendicitis, and gallbladder disease. The learning curve for surgery is steep. Not only will you be expected to know the diagnosis and indications for surgery, you will also likely be questioned on complications, anatomy, imaging, etc. This is a fast-paced rotation with long hours, so be prepared to dive in and get your hands dirty! Length of Rotation: 8 weeks Locations: University of Louisville Hospital (ULH) 530 S. Jackson St Louisville, KY, 40202

Kosair Children’s Hospital (KCH) 231 E. Chestnut St Louisville, KY 40202

Norton Hospital 200 E. Chestnut St. Louisville, KY 40202

VA Medical Center (VAMC) 800 Zorn Avenue Louisville, KY 40206

Jewish Hospital 200 Abraham Flexner Way Louisville, KY 40202

Baptist Health 900 Hospital Drive Madisonville, KY 42431

Important Contacts: Clerkship Director: Dr. Sheldon Bond Pediatric Surgery [email protected] (502)629-8630

Department Chairman: Dr. Kelly McMasters Surgical Oncology [email protected] (502)852-5447

Student Contact and Clerkship Coordinator: Brenda Dawson [email protected] (502)852-5676

Residency Director: Dr. William Cheadle General Surgery [email protected] (502)852-5675

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Clinical Clerkship Survival Guide: General Surgery By Alexandra Healy Didactics: All didactic sessions are required for this clerkship, and they take attendance very seriously! Always be prompt, arriving 5-10 minutes before lectures begin. As with everything in surgery—if you are on time, you are late! Business attire with your white coat for all lectures—do not wear scrubs to Grand Rounds or into the General Surgery Department offices (more on attire later!) Weekly Student Didactics: Wednesday 1:00-5:00PM rd Location: Hagan Library, ACB 3 Floor in the General Surgery Department offices Grand Rounds: Friday 7:00 – 10:00AM Location: ACB Auditorium in the ACB Basement ** Grand Rounds is required even on post-call days. Drink lots of coffee these days! Polk Rounds: ULH - Monday 7:00-8:00AM Location: SICU **Mandatory for those on services at UL VA – Tuesday 7:00 – 8:00AM Location: SICU **Mandatory for all those on service at the VA General Surgery Assignments 4-week rotations  Trauma Surgery (ULH) – Cares for patients that present to the ER and need urgent or emergent surgical evaluation and management. You will be responding to Room 9’s (often Level I traumas!) and other consults in the ER.  Elective Surgery (ULH) – The general surgery service at ULH.  General VA (VAMC) – The general surgery service at the VA. You will also have exposure to vascular and thoracic cases.  Pediatric Surgery (KCH) – Cares for pediatric surgery patients at KHC. This is a very busy service, as you will manage consults and trauma calls in addition to previously scheduled surgeries. 2-week rotations     

Colorectal Surgery (Norton Hospital) – Manages patients needing surgery involving the colon or rectum. Offers a great deal of exposure to colorectal cancer. Vascular Surgery (Norton Hospital) – Manages patients with vascular diseases that need surgical repair. This service offers abundant OR time, with cases such as amputations, fistulizations, AAA repairs, and catheterizations. Surgical Oncology (UL, Norton, and, Jewish Hospital) – Manages patients with cancerous tumors. This is a very busy service, and you will see cases such as mastectomies, melanoma wide-local excisions, and Whipple procedures. Transplant Surgery (Jewish Hospital) – Manages patients undergoing lung, liver, or kidney transplants. Thoracic Surgery (Jewish Hospital) – Cares for patients undergoing surgeries of the chest. Cases include bronchoscopies and esophageal reconstructions.

Off-campus 8-week rotation: Madisonville (8 weeks, Baptist Health) – Comprised of a 4-week general surgery rotation, and 2 2-week rotations in orthopedic and vascular surgery. You will see a wide variety of cases on this rotation, and spend more time working directly with attendings. Grades and Assignments Clinical Evaluations – 30% Quizzes – 20% (3 total) Shelf Exam – 30%

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Clinical Clerkship Survival Guide: General Surgery By Alexandra Healy Oral Exam – 20% Online Cases – Not graded, but part of LCME requirements Surgical Technique Checklist – Must complete prior to end of rotation Required Diagnoses/Patient Log – Must complete prior to end of rotation Attire: Always wear business attire when entering the Department of Surgery (ACB, 2nd Floor), Polk Rounds, or attending Grand Rounds. This includes shirt and tie for men, knee-length dresses/skirts or pants for women. A general rule of thumb is to keep an extra change of dress clothes in your car at all times, for instances when you forget you need to change into business attire later in the day. Check with your team about clinic days and what attire is expected. On most other days you may wear scrubs to the hospital. Each hospital has its own supply of scrubs, usually located in the locker room. If you are assigned to the VA you will be given a ScrubX card and allowed to checkout two pairs of scrubs at a time. You must wear the VA scrubs on days you will be scrubbing into surgery. How to Shine: This is the most hands-on rotation you will have, and it’s important that you take advantage of it. Always be willing and prepared to jump in and help. In the OR this means anticipating where you can be most useful, such as using the suction to grab smoke at they use the Bovi, asking for the scissors as they begin to close, and transferring the patient to and from the bed. Outside the OR this means running errands, putting on gloves when doing a bedside procedure, changing dressings, etc. When in doubt, put on gloves so you are available for assistance should it be needed. In addition, confidence is key. Always speak with confidence when you present or answer a question, even if you aren’t entirely sure of yourself. A few other ways to shine – Before the OR: There should be a student present in every case. Before surgeries begin each day, divide the scheduled cases between you and the other students on your team and decide who is scrubbing in on what. Read up on your patient, the surgeries you are scrubbing in on, and know the anatomy involved. Know your patient and know why they are having surgery. Some surgeons ask—what’s the most important question of the day? The answer: Why are we here? Read the HPI and look at any imaging the patient may have had. In addition, it may be helpful to get to know the scrub team, the anesthesia team, and the other ancillary staff members that could make your life easier. This is team- and location-dependent, but if you get to know the anesthesia resident well, and stay with your patient from pre-op to the OR, they may be willing to teach you techniques like inserting IVs, induction, and intubation. In the OR: Keep tabs on when your patient arrives to the OR. Pick out your gloves, and your resident’s gloves if you know their size, and introduce yourself to the OR tech well before surgery. Also, write your name and year in medical school on the dry erase board—it helps the staff identify who you are and your role immediately. Help the OR staff with moving the patient to the table, positioning the patient, shaving body hair, applying betadine to the area being operated on, etc. Always pay attention and be prepared to do your part during surgery. If you hear the attending or resident ask for the retractor, be ready to hold it. If they begin to close, ask for the scissors and be ready to cut. After surgery, help the OR staff transfer the patient back to the bed. Stay with the patient until they are delivered to the PACU. The OR is like a dance—a lot goes unsaid and it’s up to you to anticipate the pace, tone, and next move; predict their needs, as well as when it is an appropriate time to ask questions or, arguably more important, when to stay quiet. This finesse comes with time and close observation, but the keen student will catch on quickly as the rotation progresses. During Rounds: You should be seeing 2-4 patients each day. Show up early enough to see your patients (often around 5:00AM) and write notes on each of them. Your team rounding will be highly variable, based on your service and your resident team. Surgery can be very hierarchical, so if you have a question, go to the first person ahead of you (i.e. ask the intern before you go to the chief). There is a high volume of patients and very little time before surgery begins in the morning. It is important that you take the initiative and jump in when the team gets to your patient. Make your presentations succinct and present with confidence. Always have an assessment and plan for your patient. On Call: Being on call means you are working from your report time to approximately 8:00 AM the next day – generally more than 24 hours. Call nights can be exhausting, but it’s important that you don’t complain or make it obvious that you want to go to sleep. Often it is just you and a resident working call night. In the event that you become swamped, try to help out your resident. Respond to their pages if you can; get started on the H&Ps for consults; ask for ways to be helpful. When all of the work is done, and there are no cases going, then it is okay to go to the call room.

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Clinical Clerkship Survival Guide: General Surgery By Alexandra Healy

On Trauma Service at UL: Your task as a student is making sure the patient-note templates are current with your team’s list (Trauma 1 or Trauma 2). This means that you have a paper note with your patient’s sticker in the top right corner, the HPI is current and accurate (include blanks for HD# and POD#), the medication list is updated, etc. You should have these templates updated and ready for your pre-rounding team (generally the interns). Once they have completed their notes, the upper level will go over them, add their plan, and then you create the final day’s note packet with enough copies for everyone on the team. You may be expected to pre-round and present 1-2 patients, depending on which service you are assigned to and the expectations from your residents/attending. Just ask! Finally, if you go to see a consult or room 9, grab a Trauma H&P and get started! The resident will ask the questions and perform an exam; write as they talk. If you are on call, you can also get a template prepped and ready if you know the patient is likely going to surgery/getting admitted. This will make the work easier in the mornings for those students on the day shift. This can be a high-stress and busy service for the residents, so find ways to be helpful and they will reciprocate by allowing you to be more hands on in the OR or with procedures. The Oral Exam: Surgery is the only rotation with an oral exam. The oral exam sounds terrifying, but most people leave feeling that it went much better than expected. On the last Friday of your 8-week rotation, you will meet in the General Surgery Department (2nd floor, ACB) for your oral exam. The exam consists of 3-4 clinical scenarios that you will work through step-by-step, and be expected to list differential diagnoses, interpret imaging results, state the next step in treatment, etc. You will have one or two surgery attendings or residents proctoring your exam, and it will last 20-30 minutes. This sounds extremely intimidating on the first day of your surgery rotation, but by the end of the eight weeks you will be more than prepared. The last two lectures before the oral exam will be devoted to the “Gaar Sessions.” These are two four-hour sessions where Dr. Gaar presents the 10-15 possible cases you may be given in your exam. He will work through each case in an oral-exam format, and he will cover any and every question that you could possibly be asked in your exam. Old manuscripts of the “Gaar Sessions” from previous years are circulating, and are very useful for studying. Most Common Study Resources:  UWorld QBank (147 questions) – Shelf exam preparation.  Emma Rhamahi’s Review – A 2-hour review for the shelf exam. o Video: http://atsvid.uthscsa.edu/Mediasite/Play/60089c931cca4bcabb76bf8f2c883b09 o Powerpoint: http://som.uthscsa.edu/StudentAffairs/documents/High_Yield_Surgery_Compatible_Version.pdf – A quick 2-hour review for the shelf exam. o ** Some students often review the Internal Medicine presentation as well; a lot of medicine shows up on the General Surgery shelf, so look alive!  Dr. Pestana’s Surgery Notes – Read through this multiple times before the shelf exam.  Case Files Surgery –Lecture, quiz, and shelf exam preparation.  NMS Surgery – Quiz and shelf exam preparation.  Surgical Recall – More helpful for time spent in the hospital as it includes practical information as well as material you may be pimped on. Also helpful for the oral exam.  Essentials of General Surgery by Peter Lawrence – Textbook that can be helpful to cover high-yield topics for presentation, work-up, and surgical options. Directed toward high yield and big picture material.  Toronto Notes, General Surgery Section – bullet point information in dx and management of surgical diseases

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Clinical Clerkship Survival Guide: Internal Medicine By Eric Poulos

Internal Medicine Internal Medicine is a broad field composed of primary care internists and a variety of subspecialties that deal with adult patients and their illnesses, most commonly in the inpatient setting but also outside the hospital in each of the Internal Medicine subspecialty fields. Internal Medicine diagnoses are quite diverse, spanning every organ system. Some of the most common include pneumonia, kidney disease, diabetes and metabolic diseases, hypertension and cardiac disease; the internist functions as the primary care giver in the hospital for most of these patients. Some Internal Medicine teams are also consulted by the surgical teams to co-manage complex patients before and after surgery. Internal Medicine is an eight week clerkship organized into two four-week blocks: 4 weeks of general Internal Medicine ward work and 4 weeks further subdivided into two separate Internal Medicine subspecialties. Both assignments involve seeing new patient consults or admissions, writing a note, forming a differential diagnosis, constructing a plan with a subsequent workup, and presenting that information to an attending and your resident team. During the rotation, students attend weekly didactic sessions, daily Noon report, and weekly Grand Rounds. You will also be expected to complete two graded clinical exercises called mini-CEX’s in addition to the midclerkship evaluation (ungraded) and your final clinical evaluations. Length of Rotation: 8 Weeks (4 weeks of general IM wards, 4 weeks divided into two subspecialties) Locations: University Hospital 530 S Jackson St Louisville, KY 40202 Jewish Hospital 200 Abraham Flexner Way Louisville, KY 40202 Louisville VA Medical Center 800 Zorn Ave Louisville, KY 40206 Important Contacts: Clerkship Director: Dr. Kristan Milam [email protected] Clerkship Co-Director: Dr. Monalisa Tailor (502) 852-3637 [email protected]

Department Chairman: Dr. Jesse Roman Dr. Roman’s Secretary: Ms. Sherry Hertel [email protected]

Student Contact: Missy Klotz (502) 852-7945 [email protected]

Residency Director: Dr. Jennifer Kuch [email protected]

Didactics: All medical student didactics are weekly and mandatory, regardless of your clerkship assignment location. While on IM wards at either the VA or UL there is a daily Noon Conference that is also required. Grand Rounds is a weekly requirement, though this is often broadcasted to the VA.

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Clinical Clerkship Survival Guide: Internal Medicine By Eric Poulos Weekly medical student didactics: Thursdays, 12:00PM-2:30PM** Specific times may vary so check the schedule or ask your track captain. These sessions include “Meet the Professor” rounds and teaching by the Chief residents over topics such as “Reading EKGs”, “Reading Chest x-rays”, and “ABG interpretation/acid-base disorders” rd Location: Medicine Conference Room (ACB-3 floor) Noon Report (VA): 12:00PM – 1:00PM Monday - Friday Location: Room D010 Noon Report (UL): 12:00PM – 1:00PM Mondays, Tuesdays, and Fridays Location: ACB, Community Conference (basement) Grand Rounds: 8:00AM – 9:00AM, Thursdays Location: ACB auditorium (basement) Grades and Assignments:  Clinical Evaluations – 40% (minimum of 70% to pass)  NBME Shelf Exam – 30% (Minimum of 4th percentile to pass; actual raw score varies depending on the time of the year. Like all other clerkships, you much honor the shelf to honor the clerkship, which is above the 75% percentile).  SIMPLE Online Cases – 15% (Completion of all 15 cases earns full credit) http://www.med-u.org/simple or http://app.med-u.org/player/app/homepage.html  EKG Quiz – 5% (20 question quiz)  (2) Mini-CEX - Two clinical exercises graded by residents. . One mini-CEX will focus on medical interviewing skills and the other mini-CEX will focus on physical examination. These exercises must be supervised by an attending, fellow, or upper-level resident to meet the requirement. Does not count in overall grade, but must completed to pass.  Required Diagnoses/Patient Log: – Log your patients on New Innovations to complete required diagnoses The Wards: On wards, an Internal Medicine team is usually composed of one to two medical students, two interns and one upper level resident. Each team is divided up by colors: White, Red, Green, and Purple. No team is harder or easier than the others, as your workload is mostly dependent on your residents and your attending assignment. The upper level is responsible for admitting patients, handling transfers from the ICU, managing consults, and overall organization of the team. The interns primarily serve as the workhorses who place orders, make phone calls, and take pages. All members of the team will break up the patient list and see each patient individually before the attending arrives. Often times the upper-level will see every patient on the list, though the interns split the list to manage the details of the patients’ care. Occasionally a pharmacist and a teaching resident will also round with the team. As a medical student, the day begins anywhere between 5:30 – 7:00 AM with pre-rounding, where you will see the 1-3 patients assigned to you by your team. This usually takes place before or concurrently with the interns. Keep in mind that your prerounding time will vary based on your level of experience/efficiency, the number of patients you have, whether or not your team accepted Night Float patients that morning, and the overall expectations from your team. You will write your own note (hand-written at UL and typed at the VA), forming your own differential diagnosis followed by a plan. Once you have given your case some thought and constructed your plan, students should discuss their patients briefly with their residents, helping to finalize the presentation and plan proposed to the attending. They like to see that you have thought about the case and management plans before asking questions—it shows that you are taking ownership of your patient and you’re trying to independently formulate a treatment plan based on your clinical assessment. Next, the attending arrives and begins to round, which simply consists of a patient presentation, with students expected to present each patient they have seen that morning. The expectations during rounds can vary dramatically between attendings, therefore asking a resident what a particular

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Clinical Clerkship Survival Guide: Internal Medicine By Eric Poulos physician expects during the first few days is very important. After rounds, the team breaks off to place orders, make phone calls to social services, or if they are on call, see patients needing attention in the emergency department. Medical students are expected to work an average of 6 days per week with hours, usually ranging from 7:00AM to 4:00PM, depending on your pre-rounding responsibilities, team’s patient load, and the overall working dynamics of your team. VA students tend to have shorter hours (usually end by 2) than ULH students (usually end anywhere between 2:00PM – 5:00PM). th Students are expected to take call from 7:00 AM until at least 7:00 PM every 4 day with their team. During call, students will see new patients in the emergency department and will be asked to conduct and write a full history physical, including a differential diagnosis and plan. Your call days are a good time to knock out both your history taking and physical exam miniCEXs! Attire is mostly business casual with your white coat, however you are allowed to wear scrubs on your call days, post-call days, and on the weekends. Finally, students on wards must attend Noon Report on Mondays, Tuesdays, and Fridays, which are usually short case presentations that are didactic in nature. Be sure to sign in to get credit. Subspecialty: The available 2-week Internal Medicine subspecialty options are as follows:  Renal (Jewish, UL, VA)  Cardiology (Jewish, UL, VA)  UL Heme/Onc  Endocrine (One service covers all hospitals)  General Infectious Disease (UL and VA)  UL Gastroenterology  Bone and Joint Infectious Disease (UL, VA)  Medicine Intensive Care Unit (UL, VA)  UL Pulmonology The subspecialty rotations are opportunities to explore the more specific fields of Internal Medicine (see list of available subspecialties below). Each of these specialties share a similar team structure to wards, except the team is smaller, your upper level is often a fellow, and many specialties do not admit their own patients, therefore acting only as a consult service to the primary medicine team. Pre-rounding and rounding is similar to wards, though the focus is usually narrowed to only include issues pertaining to that specialty. Most subspecialties will have both inpatient ward work and some clinic days. Clinic on some services is mandatory (ID), while it can be optional for others (Endocrine, Heme/Onc). As always, clinic attire is business casual with white coat. The hours and work expectations seen on subspecialty depend not only on the site but also on the attending. In general, VA rotations tend to be lighter than others, particularly on Cardiology and Renal. Infectious Disease at the VA and at University tends to be a little longer and you will be asked to stay and wait for afternoon consults. Bone and Joint infectious Disease is characteristically hit-or-miss but oftentimes works fewer hours than the general ID team. Hematology-Oncology can be a very relaxed rotation or very time consuming, depending on the attending. The most difficult rotations have reportedly been Renal at Jewish and Endocrine. Endocrine is a unique rotation in that students will cover all four major hospitals, often requiring rounding at each location for a larger portion of the day than most other subspecialties. Students on this rotation do learn a lot and have great experiences so long as you know what you’re in for! Renal at Jewish involves rounding twice, once during the morning and once in the afternoon, leading to the longer hours. Despite the longer hours, students have said both are excellent for learning their respective area. As compared to ward work, the hours on subspecialty are often shorter. For this reason, some students will request ward work first, leaving subspecialty for the last four weeks to pack in a little more studying. The exception is with Endocrine—be sure you don’t have Endocrine scheduled during your last two weeks on IM, as it will interfere with studying for the shelf. Ultimately, half of your track will do ward work followed by subspecialty or subspecialty then wards – some argue there is no real difference in strategy, so don’t fret either way. How to Shine: As with any third year rotation, attitude plays a huge role in success. Be willing to volunteer to write H&P’s, ask your residents questions when they are free, offer to go medical-record hunting, and try to read the latest on Up-to-Date for each topic so that you are prepared for discussion. Take extra time forming a differential diagnosis and be able to talk through which diagnosis is more likely versus which are not and why. More so than many of your other rotations, the Internal Medicine teams practice evidence based medicine, so whenever you can bring up new articles (print it out if you can!) or major clinical trials on why things are conducted the way they are, that is something that will help prove you did look up information as it related to your patient the night before. This is by no means a daily or even weekly requirement, but if you can find a tactful

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Clinical Clerkship Survival Guide: Internal Medicine By Eric Poulos way to insert your review of the literature into the patient’s care, it can certainly take you a long way. Last, this is very much a TEAM rotation—be a team player and find ways to be helpful along the way. In terms of shelf preparation, start studying and do UWORLD questions IMMEDIATELY. There is too much information to begin to master everything in 8 weeks, but it is possible to get a good grasp on most things with a consistent approach. Most Common Study Resources:  World QBank (1359 questions) – Excellent example of questions, though the subjects tend to be VERY specific. Should be your primary source of questions for the shelf. Start early, as this is the largest question section on the Qbank and the shelf creeps up quicker than you think!  Step Up to Medicine – Best overall review for the shelf. Many students shoot to read this at least two times before the shelf. This can also be very useful when studying for Step 2 CK.  Emma Rhamahi’s Review – This 2 hour video is a must; most people watch it during the last week of studying to brush up on high-yield topics. You can speed up the video to make it shorter. http://som.uthscsa.edu/StudentAffairs/documents/HighYieldInternalMedicinecompatibleversion.pdf  MKSAP questions – Not a great representation for the shelf, but the explanation are a great way to learn the concepts and process of medicine. Consider this a secondary question resource.  Pocket Medicine (The Massachusetts General Hospital Handbook of Internal Medicine) Marc S. Sabatine; The Washington Manual, Lippincott-Raven- Great resources for looking up quick information while on wards, but not a great tool for studying for the shelf. Use as a quick reference guide.  NBME clinical mastery tests - Two 50 question tests that are $20 each. Best example of the questions faced on the exam. Use more as a gauge of progress later on than as a study tool. Note: test 1 tends to be easier than the shelf, while test 2 is more representative. Not often utilized by most students, but it can be a resource if you learn best by example

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Clinical Clerkship Survival Guide: Neurology By John Wehry

Neurology The field of Neurology encompasses a variable patient population and spans all ages, as well as inpatient and outpatient services. Strokes, headaches, seizures, and altered mental status are among the most common diagnoses in inpatient neurology; for each of these, identifying the underlying cause can drastically change the treatment options and prognosis for the patient. In the outpatient setting, neurologists follow patients who tend to have a more chronic component to their disease state. While diagnoses such as headaches and seizures are still common among outpatients, the role of the neurologist for these patients is focused more on the ongoing treatment than the underlying cause with the best management commonly achieved through long-term follow-up. As a student, you will experience neurology in both the inpatient and outpatient environment, gaining an understanding of the variety of disease states that are most commonly encountered in the field. By the end of the rotation, you will be a master of the ever-challenging neuro exam. Length of Rotation: 4 weeks (2 weeks spent at two different locations, most commonly with 2 weeks of inpatient and 2 weeks of outpatient). Locations: Inpatient: University Hospital (Stroke, Inpatient) 530 S Jackson St Louisville, KY 40202

Outpatient: Louisville VA Medical Center 800 Zorn Ave, Louisville, KY 40206 Dr. Greg Smith’s Office: A505

Jewish Hospital (General Consult Service) 200 Abraham Flexner Way Louisville, KY 40202

Community Neurologists Dr. Rukmaiah Bhupalam’s Office: 1169 Eastern Parkway Suite 1126

Kosair Children’s Hospital (Pediatric) 231 E Chestnut St Louisville, KY 40202

Dr. Michael Alt’s Office: 2934 Breckenridge Lane Suite #2 Louisville, KY 40220 Children's Hospital Foundation Building 601 S Floyd St, Suite 500 Louisville, KY 40202

Important Contacts: Clerkship Director: Michael A. Haboubi, DO [email protected]

Program Coordinator Asst: Dominique Hurt (502) 852-8426 [email protected]

Student Contact: Connie Elgan (502) 852-6328 [email protected]

Department Chairman: Kerri Remmel, MD (502) 852-6990 [email protected]

Didactics: All lectures for the Neurology rotation are held on orientation day. This is important to account for because it is much easier to put off studying through this short four-week rotation. Don’t underestimate the Neurology shelf—it is oftentimes one of the more challenging shelf exams. Grand Rounds: 8:00 - 9:00AM on Thursdays, located in the Nursing Building, however location may be subject to change. It is required that students on the Health Sciences Campus attend Grand Rounds. Be sure to sign in! Those on outpatient service with community neurologists are not required to attend Grand Rounds during those weeks.

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Clinical Clerkship Survival Guide: Neurology By John Wehry Clinical Neurology Assignments:  Logistics: This is a four-week rotation divided into two different two-week assignments that cover inpatient and outpatient Neurology.  Dress: Business casual clothes and your white coat.  Hours: Generally, hours are 8:00AM - 5:00PM for most locations with weekends off (**Peds Neuro works 1 weekend)  Call: Every student will take in-house call one time during their inpatient rotation o UofL General Neurology call – from 4:00PM – 8:00PM on a weekday  Contact the resident that is on call to arrange a meeting place o Kosair Pediatric Neurology call – weekend morning (~8:00AM until finished rounding)  Contact the resident or attending that is on call to setup the time and place to meet Pediatric Neurology This is a two-week experience with one week spent on the inpatient service and one week spent on the outpatient service (clinic). Hours are usually 8:00AM – 5:00PM but may vary depending on the attending physician. Pediatric Neurology inpatient hours are sometimes longer and it is required that you work one weekend, but the overall clinical experience is one of the best. Overall, this rotation is very popular with students given the patient population, wide variety of diagnoses, and the high quality of the clinical faculty in Pediatric Neurology. Namely, Dr. Vinay Puri, Chief of Child Neurology and Vice Chair of Neurology, is often cited as one of the major strengths of the rotation. Contact: Miranda S. Der Ohanian, Pediatric Neurology Administrative Assistant 502-588-3673 [email protected] Inpatient – The location for this assignment is Kosair Children’s Hospital. Of the inpatient locations, this can be one of the most demanding of your time. However, students on this rotation have excellent experiences and always praise the quality of the teaching by the faculty. Hours here are a little more demanding— expect to arrive around 7:00AM to pre-round. You will write notes on all of your patients (usually 2-3 while on service) using EPIC. The residents and NPs will give you a heads up on the time you will round the next day. Be prepared to present your findings on the neuro exam. Don’t forget your penlight, reflex hammer, and stethoscope. Both residents and attendings are most interested in helping you learn and perfect both the neuro exam and the presentation of the neuro exam. Outpatient – The location for this assignment is Kosair Children’s Foundation Building (the 5 th floor of the Chase building across from Kosair). As a student you will see the patient and his/her parents before the attending—sometimes with a resident and other times on your own. Be sure to get a thorough H&P for new patients. Like on inpatient, residents and attendings are most interested in helping you learn and perfect the neuro exam. Outpatient notes are done using AllScripts; not every attending expects you to write notes, but ask ahead of time. UofL Stroke The location for this assignment is UofL Hospital. Report to the Stroke ICU on the 9 th Floor and be prepared for rounding by 8:00AM. Start time varies depending on the attending, but expect to get to the hospital sometime between 6:45AM and 7:00AM so that you have time to see your patient and write a note in the chart before rounds start. Students may finish before 5:00PM depending on the attending and volume of patients. Jewish Consult The location for this assignment is Jewish Hospital. Students should expect to arrive between 6:30AM and 7:00AM in order to see their patients and prepare for rounds, which usually begin around 9:00AM. Generally, you meet with your residents at 7:00AM once the pager “switches” over to get new consults. You will be assigned patients/new consults to see and the resident will often let you see them independently. Get a good history and do a thorough physical exam with ample attention to the neuro exam. Note writing isn’t required, but if you type your notes in a word doc and print them off for the resident to reference for their note, you get major bonus points. Often you will

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Clinical Clerkship Survival Guide: Neurology By John Wehry present your patient to both the resident and the attending. This service is covered by a variety of attendings and often you won’t work with the same one more than 2-3 days, so if you find one that you “gel” with ask him/her upfront for an evaluation. By the end of this rotation you will perfect the H&P, the neuro exam, and oral presentations. Obviously the level of your involvement will vary based on your own interest and the hands-on/handsoff nature of your residents. Because Jewish is a private hospital and many attendings/service are not in-house, the resident neurology service can sometimes get the shaft with consults—such is life in the practice of medicine so work every patient up as though they were a blank slate! Private Practice Dr. Rukmaiah Bhupalam’s Office 1169 Eastern Parkway, Suite 1126 Hours are usually 8:00AM – 5:00PM with Tuesday mornings off for studying. Dr. Bhupalam works at a slower pace, however he expects students to take a good HPI from patients and then present to him before going into the room together to evaluate the patient. He tries to get students to see as many different patients as possible, and he does a good job of teaching in a way that is easy to understand. He spends some time at Norton Audubon doing sleep medicine and EMG. Dr. Michael Alt’s Office 2934 Breckenridge Lane Suite #2. Students usually report to Dr. Alt’s office by 8:30AM when he starts to see patients. He is very nice and laid back, but expects students to be willing to learn, ask questions, and be engaged. Be involved, interested, and enthusiastic. Dr. Greg Smith’s Office VA Hospital, 5th floor. From the main elevators, walk to the left and then turn right when the hallway begins. Dr. Smith’s office will be one of the first few doors on the left. He is very interactive with students and will teach you how to interpret several imaging studies, which will be helpful down the road. The mornings are usually filled with clinic time, and he often does EMGs in the afternoon. You will not be required to get to the hospital before 8:00AM and will not leave later than 5:00PM. Grades and Assignments:  Clinical Evaluations (40%) – completed on New Innovations o Mid-clerkship Evaluations are required for completion of the clerkship but do not contribute to the Clinical Evaluations grade.  Shelf Exam (40%)  Standardized Patient/Lumbar Puncture Simulation (20%) o Students will have the opportunity to practice the SP/LP simulation before the date of their exam. o Students are able to retake the SP/LP simulation one time to improve their score.  Required Diagnoses/Patient Log – completed on New Innovations How to Shine:  Show up on time and be enthusiastic about learning. Come prepared: reflex hammer, penlight, and your stethoscope!  Know as much as you can about your patients (recent imaging and labs, etc.)  Offer to help the residents with anything that could make their lives easier  Be a team player  Master the neuro exam from top to bottom. Practice on each of your patients, going in the same order every time, to perfect your approach and to become more efficient.  No matter how well you do on the wards, honoring often comes down to the shelf exam. Neurology is a short fourweek rotation, so don’t put off your studying until the last week! Most Common Study Resources:  World QBank (172)  Case Files  Blueprints  Pretest  First Aid

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Clinical Clerkship Survival Guide: Elective By Anne Hayes

Elective This four week period is very much a “what you put into it is what you will get out.” It can be the perfect opportunity to help you decide your ultimate career choice, solicit letters of recommendation, and get to know faculty and staff in the specialty of your choice, or conversely offer a time for rest and relaxation in-between clerkships. The third year elective time can be utilized in a variety of different ways as outlined by the diagram below. Career Exploration and Clinical Electives are completely optional and will be discussed in detail below. You may also opt to use your elective time for vacation, Step 2 studying, or independent research (i.e. continue working on current research or join a new project of interest).

Length of Rotation: 4 weeks Many clinical electives will require a commitment of at least two weeks. You may choose to do two clinical electives (two weeks each), one two week elective with two weeks of research, or one three week elective with one week of vacation etc. A career exploration has a minimum commitment of one week. Overall, there is a lot of flexibility with how you split the four weeks of elective time. You are not required to use all four weeks, however keep in mind that any time you spend in clinical electives or career exploring will contribute toward your required 4th year elective hours (22 weeks). Making Arrangements: You are responsible for setting up your elective time, however the personnel in Student Affairs can help you navigate the process. You should start making arrangements 2-3 months ahead of time to ensure availability. You can solicit advice from your Advisory Dean, current physicians or researchers, your mentor(s), or other students. Below is the contact name and email address for personnel in Student Affairs that can help you, too! Sherri Gary, Senior Academic Coordinator [email protected] Kim Holsclaw, Senior Program Coordinator [email protected] Micheal Keibler, Visiting Student and Elective Coordinator [email protected] Grades: Clinical Electives vs. Career Exploration One difference between clinical electives and career exploration is how you are evaluated/graded. Students are required to write a one-page reflective paper after completing a career exploration. Once the paper has been submitted to Student Affairs, the student will receive a grade of “Pass” and no evaluation is included in the MSPE (residency application letter). If a student completes a “Clinical Elective” the student is truly evaluated by their attending and receives a numerical grade. The comments from the clinical elective evaluation will appear in the MSPE. I.

Career Exploration: Career exploration is an opportunity for you to shadow faculty in a field of your interest without the stress of tests and evaluations. If you are unsure about your future field, the career exploration path is affords you a hassle-free way to further investigate your interests. Students who take this elective will be given 1 to 4 weeks of credit toward the required elective time in the fourth year, depending on the amount of time you decide to commit to your career exploration time.

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Clinical Clerkship Survival Guide: Elective By Anne Hayes If you are interested in completing a career exploration with a UL department, please send an email to Michael Keibler, listing the dates of your exploration and the desired field. If there is a particular physician or service you are interested in shadowing, also include this information in your email. This request must be submitted at least 4 weeks in advance. If Mr. Keibler is unable to accommodate your requests, consider contacting the physician or department directly, as there may be alternative shadowing opportunities outside the main avenues. Please be professional with all requests! You may also complete this experience with non-UofL faculty. This includes physicians out of the state. The student will need to make arrangements with the outside physician, and then send an email to Sherri Gary, with the name, address, type of practice and the dates of the experience at least 2 weeks in advance of starting. At the end of your experience, you will email Kim Holsclaw, a one-page reflective paper over what you gained from the rotation. You will be contacted with more information on this assignment after you sign up for the career exploration elective. II.

Clinical Electives: Clinical electives are pre-made, university-approved rotations that allow students to rotate through certain subspecialties or work with specific patient populations. The clinical elective provides some students with the opportunity to spend more time (outside the core rotations) with faculty in departments of interest. The evaluations provided by these rotations may be important to gain if you are attempting to match in a subspecialty. For instance, if you are interested in hand surgery and you find that there is a third year elective at the hand institute, it may be advantageous to take that rotation during your elective time. To see what’s available, visit this link, https://netapps.louisville.edu/MECourseCatalog/Catalog.aspx Select a field of interest and press submit to see courses offered. Make sure the description of the course you are interested in includes the text: THIRD YEAR ELECTIVE. Be sure to pay attention to the prerequisites to each elective. In the past, some electives have required you complete your surgery or internal medicine core rotations before you are eligible to participate in the elective. If you would like to participate in a clinical elective send an email to Sherri Gary, listing the elective title and dates for the elective. This request must be submitted at least 4 weeks in advance.

III.

Research This four-week period is an ideal time to focus on new or ongoing research projects. Certain programs, such as the Distinction in Research Track, have elective research requirements that are often fulfilled during this time. Again, not all four weeks are required to count towards research—you can opt to do a week or two of research with a clinical experience or vacation time built into the remaining weeks. If you are interested in participating in research during your elective time, please contact Sherri Gary for further instructions.

IV.

Vacation and Miscellaneous Third year can be a stressful time! Oftentimes students will use one week of elective time for vacationand use the remaining three weeks for clinical or research experiences. Others will dedicate the full four weeks to planned time off—you decide! You are NOT required to inform the school that you are using this time for vacation, ENJOY! If the four-week elective time falls in May or June, some students consider using this period to study for Step 2s: Clinical Skills (CS) and/or Clinical Knowledge (CK). Most students recommend 1-2 weeks of study time for CS and 2-4 th weeks of study time for CK, so this could certainly be of benefit if you are planning on doing away rotations during 4 year and need your scores early. It is not recommended that you sit for CS without passing the CSE-3 (Basically Step 2 CS practice exam) hosted by Carrie Bohnert ([email protected]) through the Standardized Patient Program. It is also not recommended that you sit for CK without completing the 7 core clinical clerkships.

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Clinical Clerkship Survival Guide: OBGYN By Chris Hamann

Obstetrics and Gynecology Obstetrics focuses on pregnancy, childbirth, and postpartum care. Gynecology focuses on pathology of the female reproductive system. This clerkship is a combination of primary care, surgery, and medicine for women of all ages. Each rotation will provide a different aspect of care, and common diagnoses include pregnancy and associated complications, tumors of the reproductive tract, sexually transmitted infections, among many others. This clerkship is six weeks, with 2 weeks of L and D, 2 weeks of private practice, and 2 weeks of a surgical rotation (benign gynecology, gynecology oncology, urology/gynecology, or one-day surgery). Length of Rotation: 6 weeks (3 rotations of 2 weeks each) Locations: Inpatient: University Hospital 530 S Jackson St Louisville, KY 40202

Outpatient: UofL Health Care Outpatient Center 401 E Chestnut St th Outpatient Clinic is on the 4 Floor

OBGYN education office: Second floor walkway between the Ambulatory Care building (ACB) and ULH. On orientation, signs will be posted to direct you. This is where the bridge conference room for orientation and lectures are. L and D, Lockers, and the Library: 3rd Floor Gynecology Oncology: 6th Floor, South Surgery and Pre-op: 2nd Floor

Important Contacts: Clerkship Director: Sara Petruska, MD Office: 502-291-6257 Email: [email protected]

Department Chair: Sharmila Makhija, MD

Clerkship Coordinator: Susan Jackson Office: 502-561-7449 Email: [email protected]

Residency Program Director: Jennifer Hamm, MD

Didactics: Orientation and Wednesday lectures with different members of faculty covering a range of OBGYN-related topics are nd in the Bridge Conference room, located in the OBGYN Education Office on the 2 floor walkway between the ACB and ULH. Attendance is required and a sign-in sheet is present, but under certain circumstnaces absences may be excused (unique procedure, your patient is mid-deliver, etc.) and are explained during orientation. Small Group sessions: Attending physicians lead discussions on various cases that are provided in the orientation packet. These cases require reading beforehand to allow for student participation and discussion. Following the discussion, a short quiz will be administered for a grade. Small group schedules vary depending on the attending and will be given at orientation. Grand Rounds: Friday from 1-2 PM in the ACB auditorium, near the cafeteria. Attendance is required, sign-in sheets are present, and food is not provided.

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Clinical Clerkship Survival Guide: OBGYN By Chris Hamann

OBGYN Assignments Labor and Delivery ULH 3rd Floor. All students will complete this two-week rotation, with one week of day shift (5:30AM to 5:30PM) and one week of night shift (5:30PM to 7AM). Each week will be five shifts, unless you are on the first week or the last week. Three third year students will be on each shift. Scrubs are located in a closet on L and D, which is down the LEFT rd hallway after entering the door across from the elevators with your hospital ID on the 3 floor. Do not allow people to follow you into the secure doorway. Men and women lockers are near the entrance of the floor. On days, arrive with enough time to change and be at the postpartum wing, located down the RIGHT hall after entering the secure door, by 5:30 AM. Morning duties include splitting up postpartum patients with a blue label (meaning vaginal delivery) among the students. You will preround on the patient and ask questions regarding postpartum care, which should only last about 5 minutes. Relevant questions are included in a blank postpartum note that is in the patient’s chart. DO NOT fill out a blank note in the chart. Only residents will do this. You may make copies of a blank note with the name blocked out to help guide your interview. Other information on the postpartum note includes labs, which may be gathered from NetAccess or WatchChild, the EMR used on the floor. After you’ve gathered information from the patient and the EMR, see which resident is going to see your patient and provide them with the information you’ve already gathered, and see the patient with them. You are also responsible for writing discharge prescriptions for patients. Prescription pads and stamps are located at the Nurse’s station. Specific information regarding prescriptions is included in the orientation packet. On nights, students meet in the L and D at 5:30 PM. Those on Nights will also meet on the postpartum wing at 5:30 AM and are responsible for patients with a red label (meaning Cesarean deliver). Patients who have had C-sections also receive an extra prescription for pain medication. Patients who are postpartum vaginal deliveries are discharged 2 days after delivery; Cesarean section patients are discharged 3 days after delivery. Patients with a purple label are private and are not rounded on by students, but prescriptions for these patients can still be written. Once all the prescriptions are written for all patients being discharged, bring them to morning report in the library to be signed by a resident. Both shifts attend morning report for hand-off. Following hand-off, students on nights are dismissed, and students on days stay for morning topic discussion. After morning report one student will round with the Maternal Fetal Medicine attending, while the other two begin on L and D. Patients who are in labor may be distributed among the students. Students should introduce themselves to the patient if they are going to participate in the delivery. When the resident who is covering your patient checks on the patient, ask to follow them so that you can also keep track of the patient’s cervical dilation and station. Students should not perform pelvic exams unsupervised. Make sure to know where shoe covers, facemasks, and sterile gloves are located; also know how to properly gown and glove so when a delivery is happening you can quickly prepare. For vaginal deliveries, students are expected to have a delivery during which their hands are on the baby, in addition to delivering the placenta and drawing cord blood. This will be practiced in the Sim Labs. C-sections will be performed in the OR, which is located on the same floor. Following a delivery or C-Section, students are responsible for filling out “the Baby Book” as well as the Placenta Registry Form. Ask a resident how to complete this. Also during L and D, students must triage patients. Pregnant patients with acute issues (membrane rupture, decreased fetal movement, extremity swelling, etc.) are assessed through triage. Students must keep an eye out to see when patients enter triage and quickly perform an H and P as shown below. Present the patient to the intern or an available resident along with your assessment and plan. This should all happen as quickly as possible. Private Practice: Private Practice is a two-week rotation, and student experiences vary depending on their preceptor. It may consist of outpatient OBGYN care, private practice obstetrics, or private practice surgeries. Most students work from 8 AM to 5 PM and have weekends off. Surgical Assignment: Surgery is a two-week assignment, and student experiences vary depending on preceptor and assigned unit, which includes Urology/Gynecology, Benign Gynecology, Gynecology Oncology, and One Day Surgery Unit (ODSU). Be in

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Clinical Clerkship Survival Guide: OBGYN By Chris Hamann contact with your assigned residents to determine where to meet them and when. Some surgeries you will be expected to scrub in and others you will only observe. Learn proper technique and protocol.  One-Day Surgery will typically have 1 student working with a resident, and outpatient procedures include Essure placement, hysterectomy, and tubal ligation. The hours are generally lighter on this assignment. Surgeries are performed in the HCOC.  Benign Gyn will consist of two students at ULH working with Dr. Pasic and Dr. Biscette, an intern and chief resident. Procedures include laparoscopic/robot-assisted/open hysterectomies, oophorectomies, and benign ovarian tumor removals. A resident will inform you where to report and send the procedure schedule on Sunday. Students are responsible to pre-round on a post-op patient, write a note, and present for rounds usually at 6:45 AM. Hours can vary depending on surgery scheduling and types of procedures.  Uro/Gyn will consist of two students on rotation and procedures including pelvic organ prolapse, urinary incontinence, and overactive bladder, which may be performed laparoscopically or robotically. Hours on Uro/Gyn also vary.  Gyn Onc normally has 2-3 students who will see procedures involving cancer of the female genital tract. Hours are regular, depending on number and complexity of cases. For people interested in surgery, this can be the most rewarding part of the rotation. Students are responsible for pre-rounding on patients, writing notes, and presenting patients on rounds on 6th Floor South. The surgery schedule will be given out on your first day, and you should contact a resident the day before to find out what time to show up for pre-rounding. Continuity Clinic: Continuity Clinic consists of 2 shifts of outpatient care at the Women’s Health Clinic on the 4th floor of HCOC. Students are assigned a resident for an afternoon or morning of clinic. This will allow you to follow the longitudinal care involved in OBGYN. Resident assignments and scheduled clinic days for students are listed in the orientation packet. Before seeing a patient in clinic ask your resident to help you adjust your history and physical to the patient. For example, pregnant patients will have different histories depending on their gestational age, and gynecologic patients may present for check ups or acute problems. Grades and Assignments         

Attire   

Clinical Evaluations completed by Attending Physicians and Residents (70%), Breakdown: Private, 10% Continuity Clinic, 10% L and D Days, 10% L and D Nights, 10% Surgical Assignment, 10% Small Group and Case Quizzes, 20% NBME Shelf Exam (30%) th Honors will be considered for >75 percentile on the shelf exam and 90% clinical grade. Pass will be given with a th minimum of 70% on clinical evaluations and >4 percentile on the shelf exam. rd

rd

L and D – scrubs are located in a closet on the 3 floor and Locker Rooms are also on the 3 floor Private Practice – will vary depending on your attending and what they are doing. Days of clinic require professional attire, but wear scrubs if you are performing procedures. If working at a private hospital, wear professional attire to the hospital and change into the hospital scrubs in the locker room. Surgical Assignment – ask a resident you are working with what would be appropriate

How to Shine: The first step to doing well on any rotation is to understand how you fit into the treatment team and knowing the expectations from your Attending and Resident physicians. This will allow you to be more proactive in your learning as well as assist the team. The orientation packet and syllabus has a lot of helpful information. Asking students who have been on the rotation what was expected of them and having a designated time for transition of care and a walkthrough of the important locations and resources is always helpful.

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Clinical Clerkship Survival Guide: OBGYN By Chris Hamann Show up early especially when you have questions regarding your role so you can still perform them on time as expected. Most importantly, keep a positive attitude. A 14-hour night shift may be your longest shift so far, but remember, the residents are working longer shifts and can be sensitive to complaining. Show your enthusiasm for learning and do what you can to make their shifts easier. Impressing attending physicians requires enthusiasm and a genuine interest in your patient’s care. Show them that you’ve studied a disease, or learned about new evidence in regards to a treatment algorithm, but always respect their judgment. The OR requires astute self-awareness. Knowing the proper technique to scrub in, properly dry off, gown, and glove require practice and have patience when asking the scrub technician to assist you. Once you’re comfortable with your own presence in the OR, you can learn the basic techniques of surgery. Nurses, technicians, and surgical assistants can be incredibly helpful for you to maximize your learning experience and deliver care to the patient. Common Study Resources  UWorld QBANK (~213 Questions)  APGO https://www.apgo.org/student/320-uwise-index.html (540 questions), these questions are helpful in learning management of diseases. Some questions may be more in depth than necessary. It is still a very helpful resource.  BluePrints OBGYN is a very extensive read, but has all the important information and more.  Case Files presents a case and a few pages of relevant topics followed by questions

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Clinical Clerkship Survival Guide: Pediatrics By Evan Rhea

Pediatrics Pediatrics focuses on the health and well being of infants, children, adolescents, and young adults, ranging 1 day old to 17 years old. The clerkship is divided into two parts: inpatient and outpatient. Outpatient pediatrics mainly consists of well child checks and acute care visits. These visits are important for immunization updates, checking growth curves, surveying developmental milestones, providing anticipatory guidance, and much more. In addition, patients visit the outpatient clinics for acute issues and monitoring chronic diseases, such as for asthma checkup or exacerbation, rashes, diarrhea, “sore throat”, cough, and fever. Inpatient is considerably different as compared to outpatient in both work environment and the condition of the patients. These patients can be quite sick, making their care more complex. The patients you will see on inpatient service will vary greatly depending on the time of year you are on service. For example, asthma exacerbations are common in the summer and fall, while upper respiratory infections and bronchiolitis and are common in the winter (i.e. RSV season). Length of Rotation: 6 weeks (3 weeks inpatient, 3 weeks outpatient) Locations: Inpatient: Kosair Children's Hospital, Medical Education Office K609 231 E. Chestnut St. Louisville, KY 40202

Outpatient: Children and Youth Clinic 555 S. Floyd St. Louisville, KY 40202 Stonestreet Clinic 9702 Stonestreet Rd. Ste. #100 Louisville, KY 40272

Didactics and Grand Rounds: Wade Mountz Auditorium nd Norton Hospital, 2 Floor

Eastern Parkway Clinic 982 Eastern Parkway Louisville, KY 40217 **A parking pass is available to students on pediatrics. This will give you access to an open-air lot on 2nd & Chestnut Streets (behind the L & N credit union). You must obtain this pass from Norton Healthcare Parking, located on the first floor of Medical Towers South at the corner of Floyd & Gray Streets. This pass does not give you access to the Kosair garage. Important Contacts: Clerkship Director: Olivia Mittel, MD Office: 502-629-8828 [email protected] Assistant Directors: Gerald Lee, MD, and Jennifer Thompson, MD

Department Chair: Gerard Rabalais, MD

Clerkship Coordinator: Debbie Vanderhoof K609, Kosair Children’s Hospital (6 East) Office: 502-629-8819 [email protected]

Residency Director: Kimberly Boland, MD

Didactics: Student Didactics: Wednesdays, 2:00PM – 4:00PM Location: KCH, Room 605 (Office of Medical Education - Morning Report conference room Orientation to the Pediatrics clerkship is held on the first Monday of the rotation. Clerkship information will be discussed, followed by several lectures by UL pediatricians about history taking, physical exam, and immunizations. Beginning the second week of rotation, Wednesday afternoons are set aside for quizzes and lectures. Quizzes are based on mandatory online CLIPP (3 cases/week) cases (found at med-u.org) that students are to complete each

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Clinical Clerkship Survival Guide: Pediatrics By Evan Rhea week. These cases are time-consuming (30 minutes 1 hour per case), so do not wait until Tuesday to do them. The quizzes are typically not “high-yield” for the shelf, but necessary to do well in the clerkship. After the CLIPP quiz and discussion are lectures where clinicians cover high-yield topics in pediatrics. th

“Happy Half-Hour”: Every Tuesday and Thursday at 1:15 PM, typically in 6 floor lecture room. This will cover highyield board material and include board style questions, and attendance is mandatory for all students on inpatient. Grand Rounds: Fridays, 8:00AM-9:00AM Location: Wade Mountz Auditorium, located on 2nd floor of Norton Hospital Students should sit near the back. Breakfast is served in the adjacent room from 7:30-8:00AM. Attendance is required, sign in sheets will be present, but those at Stonestreet can watch by video conference although technical difficulties commonly occur. Assignments Inpatient Students rotate on inpatient pediatrics at Kosair’s Children’s Hospital for 3 weeks. The Residents’ Room, Morning th report, Medical Education Office, and a computer lab are all located on the 6 Floor. The computer lab is near the elevators and for the students when the Residents’ Room is busy. The service is split up into teams of different colors. One large team color consists of two teams (i.e. Red 1 and Red 2) that share one attending. Each smaller team is made up of a single upper level, an intern, and one to two medical students. Medical students are only assigned JFK (Just For Kids) patients. You will be assigned 1-3 patients while on inpatient—start with one and get to know your patients well. Typical day is like on inpatient: o

o

o o

Pre-rounding: 6:30-8:00AM. Read notes from overnight on EPIC. Record vitals, labs. Check on the patients and perform a physical exam (wake the patient if he/she is asleep). Check with the nurses to see if anything important happened overnight, and remember to always be kind and courteous to the nurses. The nurses change shifts at 7:00AM, so it would be ideal to get there for an update from the night nurse before she/he leaves. You need to have your notes done by 8:00AM-arrive at whatever time you need to in order accomplish this (i.e. can vary with patient load, how quickly you write notes, etc.). You will assign your notes to the attending for their review. It may be helpful to print off your note and the patient’s H&P in the morning, as you will often go off of this information when you present your patient during patient-centered rounds. th Morning report: 8:00-8:45AM. Report to the classroom on 6 floor of Kosair for a lecture or case presentation given by one of the chief residents or attendings. All residents and students on the inpatient service attend. You are expected to see your patients and have notes finished by this time. Checkout: 8:45-9:15AM. Patients who were admitted overnight are handed off to your team. Rounds: 9:15- 11AM-ish. All patients are seen with your team and attending. You are expected to present the patients who you saw in the morning, including your assessment and plan. Use your pre-written note or a printed H&P to help guide your presentation. Use these only as a guide and quick reference for vitals and lab values. Try to not read directly off of your paper or notes and be confident in your presentation. It doesn’t feel natural at first, but the more you do it the better you feel! Patient-centered rounds: On this rotation part of your presentations will take place in the room with the patient, the patient’s family, and your entire team. The idea is to keep everyone involved in the child’s care on the same page. Because of this, avoid medical jargon (i.e. dyspnea= difficulty breathing, hematuria= blood in urine) and try to narrate your presentation as a story, maintaining eye contact and speaking to both the treatment team and the family. Occasionally before patientcenter rounds some attending ask for a brief presentation including your plan outside the patient’s room.

o

Noon conference 12:00-1:00PM. Noon conference is not technically required, but the best advice is to follow what your resident does. If they are there, then you should be, too! Some of these lectures are helpful for the shelf and may even serve food! Check your schedule and ask your residents if there is a conference.

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Clinical Clerkship Survival Guide: Pediatrics By Evan Rhea o

o

Work/Reading time: 1:00-4:00PM. Follow up on your assigned tasks as outlined during rounds, pending results, consults, procedures, new admissions, etc. during this time. If things are dead, ask the infamous “is there anything else I can help you with” or use your down time to prepare for the shelf exam. Checkout: 4:00PM. You and your residents sit down with the call team for final checkout. Once you’ve made it through the list, you may leave if you are not on call. **Depending on which team you assigned to, you may also have specialty rounds (i.e. Yellow team will have Nephrology and Neurology rounds daily if the residents have patients on that service.) Sometimes is can be easy to zone out during these rounds if your patient isn’t being addressed, but try your best to pay attention.

Call days: 3:00-8:00PM, Q4: Your team will accept new admissions along with one other team. It is typically a busy night of taking full H and Ps, so get food before it starts. You cannot take a call day as your one day off for the week. Try to be in attendance on post-call days so that you can present the patients that you see while on call. Weekends: No morning report. Check out at 8:00-8:30 am. Confirm with resident. Divide the weekend days between you and the other student (if applicable), as you may only take off one day per week and the pediatric coordinators prefer that your day off be on a weekend day. Again, students get 2 days off during your 3 weeks on inpatient. Days off should only be taken on the weekends and should be discussed with the upper level on the first day of the rotation and coordinated with the other student on your team. You may not take call days off, and most attendings prefer that you are present on post-call days to present the new patients you helped to admit. Inpatient Requirements: (checklist is provided)  Topic presentation with team  Review 1 H & P with an Attending  Review 1 Discharge Summary with an Attending  Happy Half-Hour attendance

Outpatient The outpatient rotation is 3 weeks long and will take place at one of the following three clinic sites: C&Y clinic, Eastern Parkway clinic, or the Stonestreet clinic. Start time is generally between 8:30-9:00AM, depending on your clinical site, and days typically run until about 4:00-5:00PM. The C&Y and Broadway clinic are convenient located near downtown, however the Stonestreet clinic is about 20 miles (30 minutes) south of Louisville, near Valley Station. Student at C&Y and Eastern Parkway with occasionally have 30-minute lectures over high-yield topics on Tuesday and Thursday mornings before seeing patients. The outpatient experience is Monday – Friday and does not require you to work weekends. All note taking is through the Allscripts EMR, which provides a default layout for documentation Use the templates to guide your interview and questions, but do not get bogged down by all the options and avoid only talking to the computer screen should you attempt to type and ask questions at the same time. During your outpatient experience, you will spend one week of mornings in the Newborn Nursery at UL Hospital (3rd Floor) in order to learn a proper newborn physical exam and practice it on newborns. Dr. Larry Wasser runs the newborn nursery and is an excellent teacher. Each student will prepare a brief presentation over a topic of your choice to present to Dr. Wasser, the residents, and the students on Newborn Nursery that week. It is very laid back and this tends to be a very low-key week during your pediatrics experience. You will also spend one half-day at the Home of The Innocents (1100 E. Market Street Louisville, KY 40206). During this time you will round with the attending and sometimes a resident on kids with chronic debilitating diseases. It can be a very humbling and inspiring experience. http://www.homeoftheinnocents.org/ Outpatient Assignment Locations  C & Y Clinic – This tends to be a very busy clinic with many residents, 4-5 attendings, and a healthy patient load. It is located on campus, next to the Nursing School, so it is easy to get to and less of a hassle when trying to

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Clinical Clerkship Survival Guide: Pediatrics By Evan Rhea



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navigate back to Kosairs for lectures, Grand Rounds, etc. Take it upon yourself to grab a laptop for access to Allscripts and dive in to start seeing patients. While busy with good volume, there can sometimes be many students and residents, so you may have to double-up. Stonestreet Clinic – The advantage to this site is essentially one-on-one interaction with the attendings. Depending on your attending, there tends to be less emphasis on EMR and more on the overall patient interaction and oral presentation. Take it upon yourself to grab a laptop (always check it out!) for access to Allscripts and an otoscope once you get to clinic. Pair up with attending and see how they best prefer their work flow, and then dive in to start seeing patients. Sometimes residents arrive in the afternoons for their own clinic patients and you may be asked to surrender your laptop. Keep in mind that the Stonestreet Clinic is located 20 miles (30 minutes) south of downtown. ULP Eastern Parkway Clinic – Students notoriously get a lot of one-on-one interaction with the attendings at this clinic site, however, there are fewer patients with usually 8-10 patients per half day. This clinic is about 3 miles (10 minutes) from downtown.

Outpatient Requirements  Review note with attending  Prescription writing  Newborn nursery presentation  Home of the Innocence experience Grades and Assignments Clinical Evaluations - 50% NBME Shelf Exam 35% CLIPP 12% - 4% for completion of the cases and 8% for the CLIPP quiz graded performance SP/SIM Encounters 3% In order to pass this course, the student must meet EACH of the following requirements:  Demonstrate appropriate professional behavior commensurate with the role of a physician and abide by the rules and policies of the Department of Pediatrics, and of the facilities in which you work.  Attend all clinical activities.  Accept and meet all clinical responsibilities, including night call.  Patient logs/evaluations - Maintain and submit the logs at the end of the block along with evaluations of your supervisors and clinical assignments.  Clinical performance - Achieve a "composite" MINIMUM score of 70% for each clinical assignment in the Clerkship  NBME Shelf Exam - Achieve a MINIMUM of the 4th percentile.  OVERALL NUMERICAL COURSE SCORE - Achieve a MINIMUM COMBINED SCORE OF 70. In order to honor the course: Minimum criteria for HONORS are: overall numerical score of 93% or above, in addition to a raw score > 80 on the NBME. By the end of the 6 weeks, you will need to submit the following: o Inpatient:  1 Clinical Encounter Feedback Tool  1 Mid-block Report/ Core Competency Checklist o Outpatient:  1 Clinical Encounter Feedback Tool  1 Mid-block Report/ Core Competency Checklist *Review orientation packet for a more detailed list of course requirements. Attire: Students are expected to wear business-casual/SP attire, including white coat for inpatient and outpatient. Invest in some comfortable shoes, as you are on your feed a good amount! On inpatient, scrubs can be worn on call days, post-call days, and weekends only.

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Clinical Clerkship Survival Guide: Pediatrics By Evan Rhea How to Shine  As is true for all rotations, be on time and be interested! Your body language can show your attending a lot.  Never complain! Be aware that residents get there earlier and will stay later than you.  There is usually no need to look at your phone in front of an attending unless he/she asks you to look up something on the spot. If you want to look up a information while rounds, indicate you are using your phone or tablet for that purpose (so that they don’t assume you are texting!) —some attendings prefer that you avoid technology entirely, so just feel it out.  READ ABOUT YOUR PATIENTS. This is a great way to learn and impresses attendings. You carry very few patients intentionally—so that you can know and understand their case inside and out.  If an attending asks you a general or pimp question that you do not know, be honest but tell them you can find the answer and look it up when time allows.  When rounding, try to correlate what you have learned based on the patient case. This can also be a good time to present any literature you have come across that could influence treatment plan. As always, be tactful and avoid looking like a show-off.  Don’t quiz, interrupt, or spit/punch/wet-hilly (and all other things common sense) attendings, residents, or fellow students, but feel free to ask the attending questions when appropriate.  Do not answer questions directed to other students unless the conversation has been opened to the group. Similarly, avoid jumping to answer every question when rounding as a team—everyone needs an opportunity to participate.  Be confident during your presentations on rounds by maintaining eye contact with your attending as you present and also by avoiding the need to rely on your paper notes to narrative the presentation. If you are shy or uncertain of your treatment plan, seek out the residents and ask if you can practice your presentation with them before rounds, ensuring that your Assessment/Plan is appropriate. Your notes and presentations will improve with time and experience, which will ultimately translate to better evaluations.  Talk to the nurses—be kind, courteous, and helpful when opportunities arise. Befriending the nurses can make your job much easier. Being rude or inconsiderate is a quick way to make enemies and it is sure to make your job harder. Common Study Resources  World QBank (354 questions)- great questions- a must do!  Emma Rhamahi’s Review (http://som.uthscsa.edu/StudentAffairs/thirdyear.asp) is a great shelf exam review lecture (video & slides). Hits a lot of high yield material. Recommend watching this lecture a day or two before the shelf exam after you have covered all the material.  Case Files. Some love it; others hate it. Useful to read the cases related to assigned patients.  BluePrints is good for a quick overview of a topic you are unfamiliar with. However, it is much too superficial for what you need to know for the shelf

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Clinical Clerkship Survival Guide: Family Medicine By Gerald Cheadle

Family Medicine Family medicine provides continuous and comprehensive care to any patient, including chronic disease management, acute health management, and preventive care. It is the primary resource patients will have for their everyday health. Mostly, Family Medicine practices will manage hypertension, diabetes mellitus, COPD, hyperlipidemia and many will also cover pediatrics and OBGYN care in rural areas. Health maintenance visits are common and include medication checks, screening tools, and immunizations. The clerkship is six weeks long, with two weeks at one of two clinics in Louisville (Cardinal Station or Newburg) and four weeks at an AHEC (Area Health Education Center) rural site. Students may request AHEC sites, especially those from underserved parts th of the state, but there are no guarantees. On the Friday of the 6 week, students will take the 2.5-hour, 100-question Family Medicine Shelf Exam. Length of Rotation: 6 weeks (2 weeks in Louisville and 4 weeks AHEC) Locations: Cardinal Station Clinic 215 Central Avenue, Suite 100 Louisville, KY 40208 Phone: 502-588-8720

Newburg Clinic 1941 Bishop Lane, Suite 900 Louisville, KY 40218 Phone: 502-588-2500

Dept of Family and Geriatric Medicine Suite 690, Rudd Heart and Lung Center 201 Abraham Flexner Way Louisville, KY 40202

Med Center One 2nd Floor 501 E. Broadway Louisville, KY 40202

Bottigheimer Auditorium (Grand Rounds) Ground Floor Jewish Hospital 200 Abraham Flexner Way Important Contacts: Clerkship Director Dr. Donna Roberts Email: [email protected] Clerkship Coordinator Anne Loop Email: [email protected] Office: 502-852-5314 Fax: 502-852-7142 (for AHEC preceptor evaluations) Department Chairman: Dr. Diane Harper, MD, MPH, MS Residency Director: Dr. Jonathan Becker (Sports Medicine) Didactics: Orientation is the first day of your rotation, during which the Clerkship Coordinator and the Director will go over graded assignments and schedules. This will be followed by a few lectures. Dress in SP attire with your white coat. After orientation, some students will report to clinic and others will drive to their AHEC site. Always refer to the syllabus or schedule that is given to you by the clerkship coordinator, as lectures are subject to change. After week 2, there will be a quiz covering topics from assigned FMCases (from med-u.org) on that Friday. Lectures will follow the quiz. After week 4, there will be another quiz covering the FMCases and more lectures. Check your schedule for the location (Rudd Heart and Lung Center or Med Center One) and timing of the quizzes and lectures. Every student on AHEC will come back for Friday lectures and quiz halfway through their 4-week rotation, leaving the site on Thursday.

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Clinical Clerkship Survival Guide: Family Medicine By Gerald Cheadle FMCASES on Med-U.org: Online, interactive cases that can be accessed through med-u.org. You will need to register to gain access. There will be several cases assigned throughout the rotation with two short quizzes on the Fridays of weeks 2 and 4. The cases cover specific topics and do take time, so plan accordingly and study other materials. Grand Rounds: Grand Rounds are held in the Bottigheimer Auditorium in Jewish Hospital at 7:30 AM. Students rotating at UofL Sites are expected to attend, while students on AHEC will only attend Grand Rounds midway through their rotation, prior to FMCase quizzes and lectures. SP Encounter: There are two standardized patient cases (one is a phone case) that will help prepare you for the CSE-3 exam and the Step 2 Clinical Skills (CS) exam. Following each of the patient encounters, you will write a note using the same template utilized by the Step 2 CS exam. The encounters are pass/fail and give you time to work on managing a full H&P and writing a SOAP note. This is an opportunity to get feedback and adjust your technique for Step 2 CS. Assignments Louisville Site: This rotation lasts 2 weeks (either the first two weeks or last two weeks). Students will complete this rotation at either Cardinal Station or Newburg Clinic. During these two weeks, you will work directly with UofL Family Medicine faculty and residents. You will rotate for a total of 11 half days over 2 weeks with weekends off. You will mostly have half days, but some days will be full (you will get your schedule during orientation; everyone’s will be different). Half days are either 8am-12pm or 1pm-5pm. During your rotation time, you will work with one specific resident or attending each shift, scheduled ahead of time. You will need to have five of ten formative feedback cards filled out by a resident or attending. These formative feedback cards are feedback on a specific part of your performance (for example, a progress note, presentation skills, professionalism, etc.). AHEC: This rotation is 4 weeks, and takes place at any of the affiliated AHEC locations across the state of Kentucky. During 2nd year, there will be an AHEC fair during which you can get information about each regional location. At that time, you will then fill out a fact sheet with your top 3 AHEC area choices. You will usually find out your rotation location a few weeks before you begin the Family Medicine Clerkship, but this may vary. Once assigned, you will need to email your preceptor and/or anyone else in his/her office that will help you set up living arrangements (you may find your own or they may help you). If you have a particular location and/or preceptor in mind, particularly if you can provide your own housing, it is important to indicate those connections or preferences on the fact sheet mentioned above. You will be reimbursed $480.00 if you will be living at your AHEC rotation location; if you are commuting, you will not be reimbursed. Often times if you are from a more populous area in Kentucky (Lexington, NKY, etc.), you will be assigned to a more rural area across the state. There are always exceptions to this, and if there are special circumstances in which you need to stay close to Louisville, the Clerkship Director will often work with you to find the best AHEC match. Please note the Northeast AHEC is reserved only for students with special situations that require him or her to remain close to home. The most common accepted reasons are having young children or a newborn and pregnancy. Contact Dr. Roberts or Anne Loop if you feel you need to remain closer to home. Community Service Project: This is a community project that you will complete while on your AHEC rotation. You should discuss this with your AHEC preceptor when you arrive on the first day. After completion, you will write a reflection paper that includes a description of the project, what happened during the project, the impact of the project on the community, and how it may affect you in your future practice. The paper must be ½ to one page in

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Clinical Clerkship Survival Guide: Family Medicine By Gerald Cheadle length. The key is to decide on a project with your preceptor early on and make sure it is an acceptable project with the Clerkship Director. The entirety of this project is very subjective, so don’t stress too much; everyone is able to complete the assignment and most find it rewarding as it is a unique way to learn more about the AHEC community. Examples of previous projects include:  Home Visit with a physician or another health care provider  Scheduled activity with clients at a Senior Day Center  School presentation (does not include simple Q&A at your high school)  Jail or prison health care visit with health care provider, civic group presentation, substance abuse treatment facility visit with health care provider  Hospice Home Visit with Hospice staff. Grades and Assignments NOTE: Subject to change based on the syllabus that you are given at the start of the rotation 

Points Clinical Components o Summative Evaluation from AHEC preceptor 320 o Mid-Clerkship assessments 15 o Formative feedback cards 5 o Summative evaluations from DFGM clinical 150 sites o Chronic disease documentation sheet 20  Examination components o Successful standardized patient exams 50 o Final written exam 300 o fmCases quiz 80  Additional components o Service learning project 50 o Nutrition-FFQ 10 TOTAL 1000 Passing requires >70% of total points and >4th %ile on Shelf. Honors requires >93% points and >75%ile on Shelf Exam. Specifics for Honors and Passing are explained in orientation and in the syllabus. Attire: SP attire (business casual) with white coat is expected every day. Scrubs are not worn on this rotation. Commonly Asked Questions AHEC: Many students from Kentucky who are not from Louisville like to go to areas closer to home. The Louisville area and Northern Kentucky tend to be the most popular locations and are tough to get. Physician availability varies. You can work with a family physician at a location you like, but it needs to be approved by the clerkship director. If you are not from an underserved area, the clerkship coordinator will encourage you to go elsewhere. Louisville clinics: The expectations at AHEC and the UofL Clinics vary. Some AHEC preceptors strictly have students shadow them because they see many patients in one day and patient presentations need to be very quick. The UofL clinics are teaching sites, allowing for more practice with independent history taking, presentation skill development, and formative feedback. Some AHEC preceptors will want to know what your assessment and plan for a patient might be, and some may not. However, at the UofL clinics, residents and attending physicians expect you to develop a differential and potential plan for the patients you see. It’s important to realize that the information used heavily in clinic may not reflect equally on the Shelf exam. For example, knowing the screening guidelines and immunization schedules are important for every patient you see in clinic, but there are few questions on this topic on the Shelf exam. Make sure to be thorough in your studying as explained below. Shelf exam: This is a very challenging Shelf exam, despite relatively light hours. There are not any specific UWorld questions, which is a resource used for other clerkships. However, there are free questions available through AAFP.org. The key is to identify the study resource you want to use and stick with it throughout the rotation (see

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Clinical Clerkship Survival Guide: Family Medicine By Gerald Cheadle Common Study Resources). Getting through Case Files, Pretest, or Blueprints is much more high yield than going through all of the FMCases. Course requirements: There are many requirements for this rotation, so stay on top of your assignments. The syllabus and orientation packet contain a detailed outline and schedule that will help you keep track of your progress and missing assignments. How to Shine: Show a good work ethic and be a team player. Try to identify small tasks that make things run more smoothly for your resident or attending; these can be as simple as having a chart pulled up or printing off a prescription for your patient. If they have more time, they will be able to teach you more. Be efficient, but take your time with every patient you see, especially during this rotation. Most of your interactions will be in an outpatient/clinic setting, where things typically run a little slower. Go through the full history and physical and then take time to connect with your patient. Residents and attendings will notice when a patient has had a good interaction with a student. Do your best to come up with an assessment and plan with at least three differential diagnoses. This will show that you are thinking critically about the patient. This may be difficult at first, but attendings and residents know this. If you make a good attempt and explain your thought process, they will take notice. If it’s clear what might be wrong with a patient and isn’t grave news, counsel them on what you’re thinking. Residents and attendings will appreciate this, especially if you give accurate counseling, as it expedites the visit. Practice makes this easier, but learning about common presentations and appropriate diagnostics and presenting this information succinctly in regards to a specific patient will make a great impression. Don’t complain about slow days or busy days. Residents and attendings are working longer hours than you. Be smart about asking when your day is done. Sometimes things get busy and preceptors forget to dismiss you. Ask your residents if there is anything else you can do to help; this is an innocuous way to remind them to dismiss you. Common Study Resources: Try to identify one or two resources that work best for you and stick with them throughout the clerkship. Combined with a good work ethic in the clinic, each of these resources should cover enough material to do well on the Shelf exam. Also if Case Files or BluePrints worked for one rotation, it’s likely to work for this rotation. Generally students say that the Family Medicine Shelf covers many of the same things seen on Step 1 with the addition of treatment options.    

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Case Files: 55 commonly tested cases on the shelf exam, with explanations of each case, other possible diagnoses and important take home points. Each case is also followed by 3-6 multiple choice or matching questions with answers and explanations that follow. Blueprints: More of a text based format that reviews commonly tested topics in family medicine. Pretest: 500 questions and explanations that review common family medicine topics. Do not get bogged down by some of the more obscure specifics of some explanations. Family Medicine Question Resources at AAFP.org: After going to the AAFP website, navigate to CME (link at top of page) and under “Find AAFP CME by Topic” click on “Board Review Preparation”. Scroll to the bottom of the next page and click on “Board Review Questions”, which will then require you to register. NOTE that this registration takes time to approve, so register early in the rotation even if you don’t plan to start doing questions until later. These questions are a good review, but are meant for the Family Medicine Boards not the Shelf, so keep that in mind. Step-Up to Medicine (Ambulatory Care section only): Approximately 80 pages that covers outpatient care, guidelines to chronic diseases, and first and second-line treatment options for common diagnoses, such as hypertension, hyperlipidemia, etc. Relatively quick read covers high-yield topics.

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Clinical Clerkship Survival Guide: Psychiatry By Kirk Akaydin

Psychiatry Psychiatry is the field of medicine that focuses on treating diseases of dysfunction in cognition and behavior and their associated pathology. This clerkship consists of treating patients of all ages, including children, with a wide variety of social and medical backgrounds that may contribute to their diseases. You will learn to effectively utilize the mental status exam to evaluate patients. Hours at the different sites vary, but students will always have weekends off. Common diagnoses include anxiety disorders, mood disorders, PTSD, substance abuse, personality disorders, delirium, and dementia. The clerkship is 6 weeks and divided into 4 weeks at a primary site and 2 weeks at a secondary site, except for those at the VA. The various sites are Emergency Psychiatry Services at ULH, Psychiatry Inpatient at ULH or Norton Hospital, Psychiatry Consult at ULH or Norton Hospital, Child Psychiatry Inpatient at Norton Hospital, and Child Psychiatry Outpatient at the Bingham Clinic, and Psychiatry at Veterans Affairs Medical Center. Length of Rotation: 6 weeks (Primary site – 4 week rotation and Secondary site - 2 week rotation) Locations: Emergency Psychiatry, ULH Inpatient, ULH Consult University Hospital 530 S Jackson St Louisville, KY 40202 EPS – 1st Floor ULH Inpatient – 5th Floor, East Veterans Affairs Medical Center 800 Zorn Avenue Louisville, KY 40206 VAMC Psych – 7N Floor

Norton Inpatient, Norton Consult, Child Psychiatry: Norton Hospital 200 E Chestnut St Louisville, KY 40202 Norton Inpatient – 6th Floor, East Child Outpatient – Bingham Clinic, 2nd Floor Child Inpatient – 6C Ackerly Unit *Norton and ULH Consult work throughout the respective hospitals and meeting location primarily depend on the Attending Physicians and Residents.

Electroconvulsive therapy at St. Mary’s OP Surgery Center (1 day experience) 4414 Churchman Avenue Louisville, KY 40215 Important Contacts: Clerkship Director: Dr. Theodore Feldmann (502) 852-5431 (Psych Med Ed Office) Email: [email protected]

EPS – Dr. Christina Terrell Norton Consult – Dr. Robert Friarson VAMC – Dr. Jennifer Bowman and Dr. David Howerton Child Inpatient Psych – Dr. Jennifer Le

Clerkship Coordinator: Miranda Sloan (502) 852-5431 (Psych Med Ed Office) Email: [email protected] Department Chair: Allan Tasman, MD Residency Program Director: Sarah Johnson, MD

Didactics: All didactic lectures led by faculty occur on the first 3 days of the clerkship, and clinical rotations begin on the first Wednesday morning, followed by the last lecture in the afternoon. Professor Rounds: Wednesdays, 12:00 – 1:00PM Students are scheduled to lead an interactive case presentation with a faculty member from 12:00 PM to 1:00 PM.

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Clinical Clerkship Survival Guide: Psychiatry By Kirk Akaydin Grand Rounds: Thursday, from 11:30-1 PM in the ACB auditorium, near the cafeteria. Attendance is required, sign-in sheets are present, and food is not provided. Assignments All students are assigned to a primary site for 4 weeks followed by a secondary site for 2 weeks. The exceptions are: Emergency Psychiatry Services, who will remain at EPS the entire 6 weeks with some half days at ULH Inpatient; Child Psychiatry, who will spend three afternoons per week at the Bingham Outpatient clinic; and the VA, who spend the full 6 week at the VA hospital. Furthermore, all students are required to take 3 EPS Call shifts from 5:30 to midnight, 2 nights of the weekday and one on the weekend. Those assigned to EPS are required to take 2 night shifts on the weekend. Emergency Psychiatry Services at ULH (6 weeks, half days at ULH Inpatient Psych) Emergency Psychiatry Services is Monday through Friday from 8 AM to 5 PM. It is a separate part of the Emergency st Department at ULH located on the 1 floor and directly straight past the information desk at the main entrance of the hospital. EPS is dedicated to evaluate patients who either volunteer themselves for psychiatric evaluation and possible admission or are brought in by the police for mental illness or drug intoxication and the endangerment of themselves or others. Patients may also be brought in on a Mental Inquest Warrant, which may be filed by anyone (family, friend, or acquaintance), is approved by a judge, and legally requires a Psychiatrist to evaluate the patient before they can be released from the hospital. Patients are often suicidal, severely addicted to drugs, or mentally unstable. The treatment team consists of an Attending Physician, a resident physician, a social worker, representatives from local mental health services, and 1-2 students. Students are responsible for prescreening patients for past medical history and medications and to assess for any acute issues that may need to be immediately addressed. Prescreen forms will be available after the nurses and Physician’s Assistant have entered the patients’ information into the Tsystem, which is the EMR for all emergency services and accessible to students assigned to the service. Prescreens can be difficult as the patient may inappropriately respond or verbally aggressive. Stay close to the entrance of the interview rooms, so if you feel threatened you can quickly and easily exit the room. After the prescreen, students present the patients to the resident and/or attending with their potential assessment and plan, and the patient is added to the list of patients to evaluate by the entire treatment team. After the evaluation, which may be led by a student at the attending’s suggestion, the team will decide to discharge, hold, or admit the patient, which requires a physical examination performed by the students. EPS can be a very busy and exciting service with reactive or unstable patients and requires students to maintain a certain degree of composure in possibly uncomfortable situations. You will adequately learn how to diagnose patients as well as learn about local mental health services for patients. In addition to EPS shifts, students will spend some half days on ULH Inpatient Psych, outlined in the schedule. Veterans Affairs Medical Center (6 weeks) VA Psychiatry consists of 5 weeks of inpatient psychiatry and 1 week of consult or substance abuse treatment. Hours are generally Monday thru Friday 8 AM to 4:30 PM depending on the census. Students are expected to preround on their patients and pick up new admits. While prerounding, it is important to find out about events overnight and the clinical histories of newly admitted patients. You will have the opportunity to present your patient(s) to the treatment team at 9 AM, so arrive early enough to allow yourself time to preround. The treatment team consists of the Attending Physician, social workers, other patient advocates, and 2-3 students. Patients with updated treatment plans may be interviewed and reevaluated. Afterwards, the team will round on the inpatient floor. Students will be expected to write a SOAP note for their patients in the VA system, which will be cosigned by the Attending. It’s important to initiate the VA EMR process as soon as possible due to the slow turnaround and processing time. Each Wednesday, there will be a Journal Club attending by Psych faculty and residents. Each student will present on a preapproved topic for 30 minutes during one of the Journal Club meetings. The last week of the rotation can either be spent working with the Physician Assistants taking Psych consults or you can opt to rotate in Substance Abuse Treatment clinic. The VA does not have great parking space, so arriving before 7:45 AM you have a greater chance at finding a parking spot near the VA. There is also a shuttle from the lot across from the Mellwood Arts Center. The VA cafeteria does not have many options and there are not many lunch places nearby, so students are encouraged to pack their own lunch, and they will have access to a fridge and microwave. Child Psychiatry (6 weeks, 3 half days per week at Bingham Outpatient Clinic)

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Clinical Clerkship Survival Guide: Psychiatry By Kirk Akaydin Child Psychiatry has both an inpatient and outpatient clinic component. Inpatient-only days last from 8 AM to 3 th PM and those days with outpatient last from 8 AM to 5 PM. The Inpatient floor is located on 6 Floor Ackerly Unit of nd Norton Hospital (6C) and the Bingham OP Clinic is located on the 2 floor of Norton Hospital. Students attend th morning rounds on the 6 floor, during which the night team passes off the patient list to the morning team, which consists of Dr. Le, the attending, a fellow, a resident, social workers, therapists, and 2-3 students. During rounds, students have the opportunity to provide input on the patients that they’ve seen. There is no pre-rounding on patients. Following rounds, students will see their current patients and write a progress note and pick up new admits and write an H and P. Students can help by getting collateral information from family members and doing physical rd exams on the new admits. EMR is through EPIC, and all students will undergo EPIC training before 3 year. Notes for Psychiatry are different than usual medical notes and the attending will provide a template. Following rounds, students will have the opportunity to participate in daily activities with the children, including art/theater/music therapy, group therapy with the chaplain, or attend family sessions with the social workers. There are also special occasions, like zoo day when the zoo brings animals or dog therapy day. Rotations in outpatient clinic is three days per week from 1 PM to 5 PM. Students work with one attending or fellow and are expected to see patients with the physician and discuss the cases with them. They also have the opportunity to attend therapy sessions as well. Dr. Lohr has Autism clinic that is a great experience for many students. Norton Inpatient and Consult (4 weeks on Inpatient, 2 weeks on Consult, or vice versa) Norton Inpatient may be the primary site and 4 weeks in length with Norton Consult as the secondary site and 2 weeks in length or vice versa. Norton Inpatient is on 6th Floor East and has 20 beds. Hours are from 8 AM to 3 PM, and usually 2 students are on the service. Students are expected to preround on their patients before 8 AM and have notes completed and signed by the attending at the end of the day. EMR is through EPIC. Students must also update the med list, which shows the patients, respective diagnoses, and medications/allergies, and make copies for the entire team by 8 AM. Morning conference is at 8 AM, during which the night nurses update the residents, attending, and students on any overnight events. Residents also give patient updates with student input and treatment plans are also determined during this time. Following morning conference, the team will round and students can work on their notes. At the end of the day, students are expected to update the med list again and faxing it to EPS. Norton Consult consists of evaluating patients that are admitted to medical or surgical floors for psychiatric illnesses, commonly post-op delirium, dementia, or mood disorders. Hours are usually 8 AM to 4 PM. Students meet with the residents in the Norton’s Physician Lounge to split up the patient list. The lounge is on the 2nd floor of Norton’s, accessible without a badge ID via the library, which is down the left hallway near the parking garage at the top of the escalators. From 8 AM to 12:55 PM, students will preround on the patients assigned to them and are expected to present the patient on rounds. Consult notes will be written in EPIC and are expected to be signed by the end of the day. Students and residents will reconvene in the doctor’s lounge at 12:55 PM to round with Dr. Frierson until 4 PM. ULH Inpatient and Consult (4 weeks on Inpatient, 2 weeks on Consult, or vice versa) Contributions by Kevin Murray ULH Inpatient may be the primary site and 4 weeks in length with ULH Consult at the secondary site and 2 weeks in th length or vice versa. ULH Inpatient is on 5 Floor East and is a locked unit, requiring students to buzz in and out. Hours are generally from 8 AM to 2 PM. Students are expected to preround on patients and have some of their progress note (vitals, sleep hours, medications given, etc) completed in time for rounds at 8 AM. From 9 – 10 AM, attendings, residents, nurses, social workers, and students meet to discuss care plans for each patient. Students are expected to give input on their patient’s care. Afterwards, the team completes rounds and students may complete their progress notes and have them reviewed by the residents. Students also write prescriptions for patients being discharged and retrieve outside hospital records. Following a lunch break, students may interview and examine newly admitted patients and write H&Ps and present the patients for feedback. Aside from learning about various psych topics from residents, there are also group therapy sessions that students may participate in to understand various treatment options. Dog therapy sessions are on Wednesday afternoons. th ULH Psych Consult office is on the 5 floor and hours are typically 8 AM to 4 PM. Students are expected to preround on patients and have progress notes written and ready to present by 8 AM on rounds. Following rounds, students and residents communicate with the primary team for new consults and interview patients. Students may write the H&P and present the patient to the attending. Students are required to stay until 4 PM for new consults, but there is time to study during downtime.

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Clinical Clerkship Survival Guide: Psychiatry By Kirk Akaydin Grades and Assignments     

Clinical Evaluations completed by Attending Physicians and Residents are worth 100/250 points Reflective writing assignment (1-2 pages, double spaced) is worth 20/250 points SP Exercise is worth 20/250 points Interview evaluation form completed by Attending Physician or Resident is worth 10/250 points NBME Shelf Exam is worth 100/250 points th

Honors will be considered for >75 percentile on the shelf exam and 90% clinical grade. Pass will be given with a minimum of 70% on clinical evaluations and >4th percentile on the shelf exam. Attire All services recommend against neckties, necklaces, and other low hanging jewelry for safety reasons EPS – Scrubs and white coat are acceptable Other services – Clinic attire and white coat How to Shine The first step to doing well on any rotation is to understand how you fit into the treatment team and knowing the expectations from your Attending and Resident physicians. This will allow you to be more proactive in your learning as well as assist the team. Sensitivity and empathy go a long way when interacting with a patient, and understanding patient cues will help you gather information that other people may not, residents and attendings included. Especially on Psychiatry, there is a chance that patients will be poor historians, so getting corroborating information from family members or medication lists from their pharmacy can help build a more accurate history. On the other hand, recognizing that patients may be more honest without family in the room will also help you learn more about them. Arrive early when prerounding on a patient and realize that you may be the one person on the medical team that they talk to the most, so be vocal during rounds and provide your own assessment and plan during your presentation. Show your enthusiasm by volunteering to see consults, doing prescreens, calling outside hospitals or pharmacies, and other tasks that improve the team’s efficiency. Common Study Resources  UWorld QBANK (150 Questions)  Case Files (60 cases and in-depth review)  First Aid for Psychiatry Clerkship is well organized review of all tested topics, including mental status exam  Emma Holliday Ramahi’s Review http://som.uthscsa.edu/StudentAffairs/thirdyear.asp

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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics

Values, Calculations, and Commonly Asked Topics General Surgery The 7 Tubes of Surgery –  2 Peripheral IVs  2 Chest tubes  1 Endotrachial tube  1 Nasogastric tube  1 Foley catheter Burns: Estimating the Total Body Surface Area (TBSA) – “The rule of 9’s”  Head – 9%  Upper extremity – 9%  Lower Extremity – 18%  Trunk (front) – 18%  Back – 18%  Palm – 1% Burns: Fluid Resuscitation –  Ringer’s Lactate 2-4 cc x Body Weight (kg) x TBSA Burn  Give ½ of this in the first 8 hours Glasgow Coma Scale (GCS) –

Internal Medicine SIRS – Two or more of the following:  Temp > 38°C or <36°C  Respiratory Rate > 20 breaths/min or PCO2 < 32 mm Hg  WBC > 12,000 or <4,000 or >10% bands  Heart Rate > 90 bpm Sepsis – SIRS plus a source (i.e. pneumonia or open wound) Severe Sepsis – Sepsis plus end organ damage (acute kidney injury plus sepsis) Septic Shock – Sepsis plus hypotension. Acute Respiratory Failure – One of the following:  pO2 < 60 mm Hg  pCO2 < 50 mm Hg and pH >7.35  P/F ratio (pO2/FIO2) <300  pO2 decrease or pCO2 increase by 10 mm Hg from baseline (takeaway point  check baselines when possible especially if the patient has known COPD!) Next are the lab values, specifically. You much know and interpret when electrolytes are low and how to correct them. Na – Complex workup involved for both hypo- and hypernatremia. Step-up or Pocket medicine have good algorithms. Know this is a WATER problem, not an issue of too much or too little sodium.  Do not correct Na faster that 12 meq/24 hrs or risk neurological damage K – Potassium levels are very important and differ if they are high or low. Hypokalemia  K <3.5, though symptoms do not begin until <3.0.  Symptoms include: o arrhythmias, o muscular weakness and cramps,

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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics o decreased deep tendon reflexes, o polyuria, polydipsia o ,nausea and vomiting.  Replacement treatment o K should be replaced orally with 10 mEq of KCl increasing K levels by 0.1 mEq/L. o IV can be used in severe (K < 2.5) or patients unable to take oral KCl. Maximum infusion rate is 10 mEq/hour in peripheral line or 20 mEq/hour in a central line.  Patients commonly complain of pain during infusion, so it the less preferred method. Hyperkalemia is  Refers to a K > 5  Symptoms include: o Arrhythmia: look for peaked T waves, QRS widening, PR interval prolongation, loss of P waves on ECG o Muscle weakness and (rarely) flaccid paralysis o Decreased deep tendon reflexes o Respiratory failure o Nausea/vomiting, intestinal colic, diarrhea  Treatment o First therapy is IV calcium gluconate to stabilize myocardial membrane potential, thus reducing the likelihood of arrhythmia. o Glucose and insulin can also be administered for immediate treatment o Kayexelate can also be used to reduce K but its much slower acting o Hemodialysis remains the most effective and rapid way to lower K. Usually only seen in patient with extreme renal failure. Ca – Correct your Ca for albumin  [0.8x(4-Alb)]+Ca= Corrected Ca level BUN/Cr: Used primarily as a measure of kidney function Acute Kidney Injury – Determined by the RIFLE criteria  Risk: 1.5 increase in serum creatinine or GFR by 25% or urine output of <0.5 mL/kg/hour for 6 hours  Injury: Two fold increase in serum creatinine or GFR decrease by 50% or urine output of <0.5 mL/kg/hour for 12 hours  Failure: Three fold increase in serum creatinine or GFR decrease by 75% or urine output of <0.5 mL/kg/hour for 24 hours or anuria for 12 hours  Loss: complete loss of kidney function for greater than 4 weeks  ESRD: Complete loss of kidney function for more than 3 months Prerenal failure  Most common Cause of AKI – is a decrease in systemic arterial blood volume or renal perfusion  Etiologies: CHF, Hypovolemia, Hypotension, Renal arterial obstruction,  Lab findings: o BUN/Cr >20:1 o Increased urine osmolality (>500 mOsm/kg) o Decreased urine Na (<20 with FENa <1%) o Hyaline Casts Renal Failure  Kidney tissue is damaged resulting in an inability to concentrate urine  Etiologies: Acute Tubular Necrosis, Glomerular disease, Vascular disease, Acute Interstitial Nephritis  Lab Findings o BUN/Cr <20:1, closer to 10:1 o Increased urine Na (>40 mEq/L with FENa >2% to 3%) o Decreased urine osmolality (<350 mOsm/kg) o Abnormal UA with different sediment depending on etiology Postrenal Failure  Least common cause of AKI – result of downstream occlusion of urine flow  Etiology: Urethral obstruction (BPH), Nephrolithiasis, Obstructing Neoplasm, Retroperitoneal fibrosis  Can appear to look like ATN if obstruction persists. Bicarb: Acid-base returns! You need an ABG to accurately determine whether there is an actual acid base disturbance (no pH otherwise!). If there is an anion gap metabolic acidosis remember A CAT MUDPILES!

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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics

Hgb/Hct: Usually in a 1:3 ratio.  The normal value for Hgb is above 13.5 g/dL in men and 12 g/dL in women. This correlates to a Hct >41 in men and Hct >36.0 in women. o A patient with lower values is considered anemic.  Severe anemia requiring transfusion occurs at Hgb~7-8.  Transfusion in acute bleeding/surgery should occur at Hgb <10.  1U pRBC = increase of 1 Hgb/3Hct. Glucose: Know the last 3 glucose readings.  SSI is a bad way to manage diabetes, so always find out home insulin requirements if possible.  If blood sugar appears poorly controlled in a long-term patient on SSI, calculate total insulin requirement based on what was given for a single day in the hospital and use half that dose of a long acting insulin qhs (at night).  Example algorithm for care of diabetes in an non-acute setting:

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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics

Many internal medicine physicians use scores to determine the severity of a given disease. You should know the components of these scores and use a calculator to determine them when on rounds. High yield examples include: Pneumonia: CURB-65 or Pneumonia Severity Index

Pleural Effusion: Light’s Criteria determines exudate vs. transudate  Pleural Fluid is exudate if: o Protein level in pleural fluid divided by level in serum is less than 0.5 o Lactate dehydrogenase level in pleural fluid divided by level in serum is greater than 0.6 o Lactate dehydrogenase level in pleural fluid is more than two-thirds the upper limit of the normal level in serum Pancreatitis: Ranson’s Criteria or Apache-II (FYI if you have Dr. Moffet he will tell you Ranson’s criteria does NOT predict mortality despite what books will say).  Ranson’s Criteria Present on Admission Developing During the First 48 Hours Age > 55 years Hematocrit fail > 10% WBC > 16,000 BUN increase > 8 mg/dL Blood glucose > 200 mg/mL Serum calcium < 8 mg/dl Serum LDH > 350 I.U./L Arterial oxygen saturation < 60 mm Hg SGOT (AST) > 250 I.U./L Base deficit > 4 mEg/L Estimated fluid sequestration > 600 mL Score of 0-2: Minimal mortality Score of 3-5: 10% - 20% Score > 5: more than 50% mortality with more systemic complications Pulmonary Embolism – Wells score Variable Clinical Signs and symptoms of DVT An alternative diagnosis is less likely than PE HR > 100 beats per minute Immobilization or surgery in previous 4 weeks Previous DVT/PE Hemoptysis

Points 3.0 3.0 1.5 1.5 1.5 1.0

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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics Malignancy (on treatment or treated in last 6 months) Score <2 points 2-6 points > 6 points

1.0

Category Low probability Moderate probability High Probabiliyt

Risk of stroke in 1st 2 days post TIA: ABCD2 Criteria  Age: greater that or equal to 60 (1 pt)  Blood Pressure: SBP > 140 or DBP > 90 (1pt)  Clinical Features: Focal Weakness (2 pts) or speech impairment (1 pt)  Duration of symptoms: > 60 minutes (2 pts) or < 59 minutes (1 pt)  Diabetes (1 pts) Risk of CVA in first two days following TIA:  0-3 = 1% risk  4-5 = 4.1% risk  6-7 = 8.1% risk Risk of stroke in pts with afib – CHADS2 score  determines anticoagulation needs Variable Points Previous Stroke or TIA 2.0 Age > or = 75 years 1.0 Hypertension 1.5 Diabetes mellitus 1.5 Heart Failure 1.5 Score 0 1 points > 6 points

Stroke Risk Low probability Moderate Probability High Probabiliy

Therapy Aspirin Warfarin or Aspirin Warfarin (INR 2-3)

Neurology Steps of the Neuro Exam: Be sure to follow this same sequence EVERY time you perform the neuro exam—it will help you learn it and will also serve as the order in which you present your patient’s neuro exam findings during oral presentations. 1. Mental Status Exam – can be as simple as orientation to person/place/time or as involved as the Mini Mental Status Exam— it all depends on the intention and relevance of this exam for your patient. Overall, you will test orientation (person, place, date), registration (naming an object, repeating), attention and calculation (WORLD backwards), Recall, and Language (“No ifs, ands, or buts,” following commands) Link for MMSE - http://www.mountsinai.on.ca/care/psych/on-call-resources/on-call-resources/mmse.pdf 2. Cranial Nerves: Link for Cranial Nerve Exam: https://www.youtube.com/watch?v=G6FZR64Cq9U CN I Olfactory Nerves Smell: Not commonly tested CN II Optic Nerve Vision: Test visual acuity with Snellen chart, visual field by holding up numbers or wiggling fingers CN III Oculomotor Nerve Eye Movement: Pupillary light reflex (CN II and III) CN IV Trochlear Nerve Eye Movement: make “The Big H” with their eyes following your finger to test the Superior Oblique muscle CN V Trigeminal Nerve Facial Sensation: Test facial sensation in the distribution of the three branches of CN V CN VI Abducens Nerve Eye Movement: Make “The Big H” with their eyes following your finger to test the Lateral Rectus muscle CN VII Facial Nerve Facial expression: Test for symmetric facial expression CN Vestibulocochlear Nerve Hearing: Test hearing by rubbing fingers together close to the outer ear

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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics VIII CN IX

Glossopharyngeal Nerve

CN X CN XI

Vagus Nerve Accessory Nerve

CN XII

Hypoglossal Nerve

with eyes closed. Sensorineural vs. conductive hearing loss can be tested using tuning fork (Weber/Rinne) Oral sensation, taste, and salivation: Check for symmetric palate elevation (both CN IX, X) Check for symmetric palate elevation (both CN IX, X) Shoulder elevation and head turning: Test shoulder shrug and head turning for symmetrical strength Tongue movement: Check for atrophy & deviation of tongue to one side

3. Motor Exam – test for symmetrical strength in each joint of the upper and lower extremities *5/5 – normal strength *4/5 – movement against some resistance *3/5 – movement against gravity *2/5 – movement possible but not against gravity *1/5 – muscle contraction but no movement *0/5 – no muscle contraction 4. Reflexes – test triceps, biceps, brachioradialis, patella, and Achilles +4 – markedly hyperactive with clonus +3 – increased but normal +2 – normal +1 – present with reinforcement +0 – absent 5. Sensory Exam – test fine touch, pain/temp, and position sense in upper and lower extremities 6. Coordination and Gait *Assess rapid alternating movements, finger-to-nose, and heel-to-shin *Observe patient as he/she walks normally, on their toes, and on their heels

Obstetrics and Gynecology Gs and Ps for OB patients. G stands for gravida and is the number of times a woman has been pregnant. This includes stillbirths and abortions. Thus a woman who has delivered twins, is currently not pregnant, and otherwise never been pregnant is a G1. P stands for para. This can be reported in two formats. The extended format of TPAL stands for Term deliveries, Preterm deliveries, Abortus (includes spontaneous and induced), and Living Children. If the woman with twins had them prematurely, she would be a G1P0102. The abbreviated P sums term, premature, and abortus deliveries. A pregnant woman who has had one previous delivery would be a G2P1. Abbreviations are commonly used. Try to keep up with the terminology so that you can communicate effectively. Review pelvic anatomy and relations of structures. The structural, vascular, and nervous support to the female reproductive tract and relation to abdominal structures are very important to know during surgeries. Learning the physiology of pregnancy as well as the potential complications and pathophysiology is very important. The screenings and recommendations for pregnant patients at various gestational ages are also important and can be found on pregnancy wheels provided by the department or available on a smart phone. When studying for the shelf, learn management principles. Recognizing the pathology is important, but the exam will often ask what is the next step in treatment. Keep in mind that the time you spend on a rotation may not be equally reflected by the shelf, so be sure to also study the subjects outside your rotation.

Pediatrics     

CDC Pediatric Developmental Milestones: http://www.cdc.gov/ncbddd/actearly/milestones/ Epocrates smartphone app is highly recommended for dosing, interactions, mechanism of action, and includes useful calculators (i.e. BMI, pediatric maintenance fluids). Medscape provides brief approaches to diseases and treatments. UpToDate can provide detailed evidence based medicine. (Various EBM tools will be presented at orientation). Immunization schedule are on Maxwell’s Reference. Asthma severity charts can also help and are attached.

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Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics

Pediatric Maintenance fluids: Weight

mL/kg/h

First 10 kg

4

Second 10 kg

2

Each additional kg

1

Ex: 25 kg

4(10) + 2(10) + 1(5) = 65 mL/hr

Ex: 17 kg

4(10) + 2(7) = 54 mL/hr

Normal Heart Rate Newborn 93-154 1-2 mo 121-179 1-2 yo 89-151 5-7 yo 65-133 Teen 60-120 Normal Respiratory Rate Newborn 40-60 1-2 yo 22-30 4-5 yo 20-24 Teen 12-20 Normal Blood Pressure (based on age and height) 1 yo <104/56 3 yo <105/63 7 yo <112/72 16 yo <126/80

Psychiatry   

 

Know the components of the mental status exam, as this is important in interviewing patients. Understand the AXIS system and review the diagnostic criteria for mood disorders (depressive disorder, anxiety disorder, bipolar disorder), schizophrenia, personality disorders, and dementia vs. delirium are commonly asked topics. When interviewing patients, make sure to ask about suicidal and homicidal ideation (if they have a plan or a weapon), learn to ask for a comprehensive substance abuse history (when did they last use a substance, specific amount of substance, how long they’ve used a drug, difficulty quitting), obtain a thorough social history (support system, risky behavior). Many of these topics can be sensitive and difficult to talk about but they are important in the treatment of patients. Psychiatry involves various medications and side effects, so be sure to know the different generic and brand names of benzodiazepines, 1st gen and 2nd gen antipsychotics, and antidepressants. When studying for the shelf, learn management principles. Recognizing disease is important, but the exam will often ask what is the next step in treatment. Keep in mind that the pathology you see on a rotation may not be equally reflected by the topics on the shelf, so be sure to study the other topics in psychiatry.

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations

Example Notes and Oral Presentations General Surgery History and Physical Example HPI: Patient is a 45 yo lady (always use gentleman or lady) who presents to the ED with a 4-day history of abdominal bloating accompanied by abdominal pain, obstipation, nausea, and vomiting. She describes her abdominal pain as diffuse and says the quality alternates between dull and sharp. She began experiencing NV yesterday and has had 3 episodes of non-bloody, bilious emesis in the last 24 hours. She is unable to take anything by mouth, as this aggravates her symptoms. Patient’s last BM was 5 days ago, and has not experienced flatulence since then. She denies fever, fatigue, weight loss, or diarrhea. PMH: Significant for HTN. Denies history of GERD, gallbladder disease, inflammatory bowel disease, colon cancer. PSH: Tonsillectomy at age 6, Appendectomy at age 24. Allergies: Penicillin Meds: Lisinopril Family History: Father died of MI at age 64. Mother has history of HTN, T2DM. No family history of gallbladder disease, IBD, colon cancer. Social History: Works as a sales associate. Lives at home with her husband. No smoking history. Drinks one glass of wine per week. ROS: Constitutional – No fever, fatigue, weight loss Skin – No rashes, jaundice HEENT – No HA, dizziness, vision changes, hearing loss, tinnitus, rhinorrhea, mouth sores, pharyngitis Resp – No dyspnea, cough, chest pain CV – No angina, palpitations GI – As stated in HPI GU – No changes in urinary frequency, dysuria, hematuria Endocrine – No DM, thyroid disease Physical Exam: Vitals – T: 99.0F HR: 89 RR: 16 BP: 134/86 O2: 99% GEN – Overweight female, mildly distressed, AOx4 HEENT – EOMI, PERRLA, no icterus, mucous membranes dry, no LAD CV – RRR, S1 and S2 heard, no murmurs LUNGS – CTAB, no crackles or wheezes ABD – Significant distention, old appendectomy scar present, absent bowel sounds, diffuse tenderness to light palpation, no peritoneal signs, no hepatomegaly or splenomegaly, no hernia EXT – No jaundice, erythema, edema Assessment/Plan: 1. Abdominal distention/pain – -DDx of mechanical small bowel obstruction vs large bowel obstruction due to colonic neoplasm vs gallstone ileus vs incarcerated hernia -Clinical presentation along with PSH of appendectomy supports small bowel obstruction due to adhesions -Absence of colon cancer in family history, plus absence of constitutional symptoms does not support large bowel obstruction due to colonic neoplasm -Absence of diarrhea or fever and no PMH of IBD does not support IBD. -Absence of history of gallbladder disease does not support gallstone ileus -Absence of hernia on physical exam does not support incarcerated hernia -Establish IV access, begin Ringer’s Lactate and LMWH -Insert NG tube and put to suction -CBC and CMP -Abdominal XR -If XR suggestive of SBO, will likely send to OR for exploratory laparotomy Oral Presentation example for above H&P – The patient is a 45 yo lady with a 4-day history of abdominal bloating accompanied by diffuse abdominal pain, obstipation, nausea, and bilious emesis. She denies fever, fatigue, weight loss, or diarrhea. Her last BM was 5 days ago. She is unable to take anything by mouth as this exacerbates her symptoms. Her PMH is remarkable for HTN for which she is taking lisinopril. She has

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations no history of GERD, gallbladder disease, inflammatory bowel disease, or colon cancer. Her past surgical history is remarkable for appendectomy at age 24. No family history of gallbladder disease, IBD, or colon cancer. ROS is negative. Vitals are normal. Physical exam is remarkable for appendectomy scar, abdominal distention, diffuse abdominal tenderness on light palpation, and absent bowel sounds. My assessment includes a differential diagnosis of SBO due to adhesions vs obstruction due to colonic neoplasm vs IBD vs gallstone ileus vs incarcerated hernia. SBO is the most suggestive diagnosis given the clinical presentation and PSH of appendectomy. Lack of constitutional symptoms nor family history of colon cancer does not support colonic neoplasm, absence of diarrhea does not suggest IBD, absence of gallbladder disease does not support gallstone ileus, absence of hernia on physical exam does not support incarcerated hernia. My plan is to begin Ringer’s Lactate and LMWH, insert an NG tube and set to suction, obtain a CBC and CMP, and get an abdominal XR. If XR is suggestive of SBO, plan to go to the OR for exploratory laparotomy. Progress Note Example (SOAP Format) – S: Patient is 45 yo lady, HD#2, POD #1 for ex-lap with small bowel resection and lysis of adhesions for SBO. No overnight events. Some abdominal pain, but reports pain meds provide relief. Sleeping comfortably. Currently on Norco PRN. Remains NPO. No N/V. No flatulence or BM. Not ambulating. O: Tmax: 98.9 HR: 78 RR:18 BP: 128/74 O2: 98% UO: 600/600/NR NG: 450 cc/220 cc/NR Labs: 136 98 16

98

4.3

26

0.8

9.4

12.4

176

37.2

Physical Exam: GEN – NAD, sitting up in bed. HEENT – NG tube in place and to suction. Bilious content in container. CV – RRR LUNGS – CTAB ABD – Mildly distended, appropriate tenderness near incision site. Incision is clean, dry, and non-erythematous. 1-2 cc of serosanguinous drainage on 4x4 dressing. EXT: Peripheral IV in place, SVTs in place A: Post-op day 1 for ex-lap with SBR for SBO. P: 1. Post-op for SBR – Await bowel function. Continue maintenance fluids. Remain NPO. Keep NG to suction. ABD XR tomorrow morning. 2. Pain – Continue Norco PRN. 3. DVT prophylaxis – Continue LMWH and SVTs. Have patient OOB and ambulating today. Oral Presentation for above Progress Note – Patient is 45 yo lady, HD#2, POD #1 ex-lap with SBR and LOA for SBO. No events overnight. Pain is well controlled with Norco. Currently NPO. No N/V. No flatulence or BM. Has not ambulated since surgery. Vitals are normal and stable. UO was 600, 600, not recorded over the past 24 hours. NG tube output was 450, 220, not recorded and bilious in color. Physical exam was benign except for a mildly distended abdomen. Incision was clean and dry. Assessment is patient is post-op day 1 for small bowel resection for small bowel obstruction, doing well since surgery. Plan is to await bowel function – continue maintenance fluids and LMWH, remain NPO, and keep NG to suction. Encourage ambulation today. ABD XR tomorrow morning.

Internal Medicine History and Physical Example – HPI: Mr. Smith is a 65 y/o M with past medical history of atrial fibrillation who presents to the emergency department with a two-week history of progressive shortness of air and chest palpitations. The patient noted his difficultly breathing has now worsened to the point he cannot climb a flight of stairs without needing to sit. In the past few days, he also recalled being awoken from sleep, gasping for air and has noticed that his shoes no longer fit. Today the shortness of air was accompanied with a feeling “like my heart was going to beat out of my chest.”

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations Currently, the patient has difficultly breathing at rest with a continued rapid heart rate. He says he must sit up to breath effectively but denies any dizziness, fever or chest pain. He has never had symptoms like these before but states that he had a myocardial infarction five years ago, from which he recovered completely, though during a follow up he was diagnosed with new onset atrial fibrillation for which he is currently taking metoprolol. He denies any recent illnesses, ROS: General: does not have fever, chills or fatique Eyes: Does not have vision changes, diplopia, or floaters Cardiac: has paranoctural dyspnea; has orthopnea, does not have chest pain Pulm: has dypnea, cough. No hemoptysis GI: Does not have nausea, vomiting or diarrhea GU: Does not have dysuria or hematuria Skin: Does not have rashes or ulcers present at admission Extremities: Has edema Neuro: Does not have numbness, tingling or weaknes Musculoskeletal: Does not have joint pain All other systems reviewed and are negative. Past Medical History: MI five years prior; atrial fibrillation diagnosed four years ago; insulin dependent type II diabetes Past Surgical History: Appendectomy at 20. Family History: Father died of MI at age 68; Diabetes (Mother). Social History: Smoker for 30 pack/years; quit 15 years ago; denies EtOH, illicit drugs; Lives at home with wife. Current Medications: Metoprolol 50 mg BID, Atorvastatin 40 mg PO daily, Aspirin 81 mg PO daily Allergies: Penicillin (broke out in a rash) Vital Signs: HR: 134

RR: 15

BP: 146/86

T: 98.2

Pox: 90%

PE: General: In distress, laboring to breathe; A/O X 3 HEENT: EOMI, PERRLA, No LAD, Neck supple; JVD present Pulm: Crackles bilaterally; Dull to percussion on right side; No tactile fremitus Card: Fast, irregularly irregular rhythm. Normal S1,S2 with S3 present. GI: 2+ Bowl sounds; NT, ND. Skin: No rash, petechiae or ecchymosis. 2+ edema in legs bilaterally. Neuro: CN II-XII intact; no motor or sensory weakness on examination.

Lab values:

144

103

13

4.4

27

1.1

213

6.5

12.3*

224

36.9

AST

ALT

Alk Phos

Ca

Albumin

31

17

100

8.9

3.7

Total Protein 7.6

Pro BNP

Troponins

11000*

0.0712*

Diagnostic Tests ECG: Shows atrial fibrillation with rapid ventricular rate of 126. Q waves in left lateral leads, with no ST depression or elevation. Chest X-ray: Bilateral plural effusions, much larger on the right side. Assessment and Plan: Mr Smith is 65 yo M who presents with progressive shortness of breath over two weeks duration with new onset of chest palpitations. On chest x-ray he was found to have evidence of bilateral plural effusions, much larger on the right side. Shortness of Breath: Ddx includes: new onset congestive heart failure, myocardial infarction, anemia, pneumonia, COPD Congestive heart failure Most likely due progressive course with history of heart disease and bilateral

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations plural effusions in the absence of fever or chest pain. unlikely due to normal ECG and clinical course. Mildly elevated troponins can occur in CHF Anemia Patient hemoglobin slightly low but not exceptionally low enough to cause the clinical symptoms described. Pneumonia No fever or leukocytosis make this less likely COPD Patient has normal breath sounds, but does have a positive history of smoking and difficulty breathing  Order an Echo to assess for heart function  Continue monitoring troponins to trend levels  Add lasix 40 mg BID to diuresis plural effusion  No indication for thoracentesis at this time. Afib with rapid ventricular rate (RVR)  Increase metoprolol to 100 mg BID.  Monitor with telemetry  Start enoxaparin – discuss restarting of warfarin while in the hospital Diabetes - Patient has a history of type-II diabetes not currently treated with medication. Glucose was elevated to 213 on presentation  Begin SSI and continue to monitor blood glucose. Myocardial infarction

Oral Presentation example for above H&P Mr. Smith is a 65 yo M with a history of MI and afib presents to the emergency department with a two week history of progressive shortness of breath with recent onset of chest palpitations but no associated chest pain. On presentation, he said the symptoms began last week and now he has unable to walk up the stairs. He notes orthopnea and paroxysmal nocturnal dyspnea that have worsened over the past two weeks. He denies any fevers, chills, dizziness or nausea and vomiting associated with these symptoms. His past medical history is also significant for type-2 diabetes that has been managed by diet. His MI occurred five years ago and his afib was diagnosed shortly thereafter at a follow-up appointment for which he has received metoprolol 50 mg BID. Other medications include Atorvastatin 40 mg PO daily and Aspirin 81 mg PO daily. He has never been on anticoagulation for his afib due to fears of bleeding. He was a previous smoker for 30 pack years before quitting 15 years ago, but denied alcohol or illicit drug use. His only known allergy is penicillin. On physical examination, his was dyspneic and in distress. His HEENT examination was significant for moderate JVD. His cardiac examination was significant for an irregularly irregular rhythm with rapid rate and an S3. Examination of his lungs showed crackles bilaterally with reduced breath sounds, dullness to percussion and decreased tactile fremitus on the lower right. His abdomen was non-tender and non-distended with normal bowel sounds, while his skin examination was significant for 1+ edema in his legs bilaterally. Vital Signs were significant for tachycardia at 134 with a normal respiratory rate at 15. He was afebrile with a temperature of 98.2 and had a slightly elevated blood pressure of 146/86. For lab values, his electrolytes were within normal limits, though his glucose was elevated at 213. His white count was not elevated at 6.5, though his hemoglobin was mildly depressed at 12.3. His troponins were mildly elevated on presentation at 0.06 and his Pro-BNP was elevated at 11,000. Studies done on the emergency department included an ECG, which showed afib with rapid ventricular rate of 126 and a chest x-ray that demonstrated bilaterally plural effusions, much larger on the right. In summary, Mr. Smith a 65 yo M with past medical history of MI and afib presenting with two weeks course of progressive dyspnea and afib with rapid ventricular rate. The differential diagnosis for his dyspnea includes new onset heart failure, myocardial infarction, anemia, and COPD. At this time, his subacute course of development, lack of chest pain, and normal ECG with a chest X-ray showing bilateral pleural effusions make new onset heart failure most likely. I want order an echocardiogram and begin him on lasix 40 mg BID for diuresis of his plural effusion before considering thoracentesis. Because his troponins were elevated on presentation, we should continue to monitor them q6h until return to normal. For his afib with RVR we should increased his metoprolol to 100 mg BID and monitor on telemetry. Finally, for his diabetes we should begin glucose checks with sliding scale insulin while in the hospital. This presentation can change dramatically depending on attending preference. In general, try to be succinct but through as possible. Some attendings will require you to read all lab values while some only want pertinent positives or negatives, but the important point is to interpret what you are given, not just to read numbers from a page. Also, be careful with stating physical exam findings are “normal.” Since you are a medical student, they may ask you to expand upon that so be prepared to say exactly what you mean by normal.

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations Progress Note Example (SOAP Format)  After three days in the hospital S: Pt is 60 yo M HD #3 with h/o MI and afib presented with shortness of air and afib with RVR >120 now suffering from new onset systolic heart failure. Thoracentesis was performed yesterday for removal a residual right-sided plural effusion, evacuating approximately 10mL of clear fluid. Today, pt is feeling better, reporting improved breathing with some shortness of air only on exertion and less overall malaise. He denies fever, dizziness and chest pain. He states he talked with cardiology yesterday and understands he will need medical management for his new-onset heart failure. O: Vital Signs: HR 90

RR: 14

BP: 136/82

T: 98.7

Pox: 94%

PE: General: NAD; A/O X 3 HEENT: EOMI, PERRLA, No LAD, Neck supple Pulm: Diminished crackles bilaterally, Card: Irregularly irregular rhythm. Normal S1,S2 with S3 present. GI: 2+ Bowl sounds; NT, ND. Skin: No rash, petechiae or ecchymosis. 1+ edema in legs bilaterally. Neuro: CN II-XII grossly intact with no focal deficits on exam; no motor or sensory weakness on examination. Medications: Metoprolol 100 mg BID; Aspirin 81 mg PO daily, Atorvastatin 40 mg PO daily, Enoxaparin, Furosemide 40 mg BID

Lab values:

141

96

20

4.1

29

1.2

103

7.3

11.7* 35.1

206

Serum LDH: 626 Serum Prot: 7.7 Plural LDH: 284 Plural Prot: 3.3

Diagnostic Tests: Echocardiogram (Two days prior): Ejection fraction of 35% with no diastolic dysfunction. Thoracentesis results: 1200 cc of straw colored fluid was removed; Protein ratio of 0.42 and LDH ratio of 0.45 A/P: Pt is 65 yo M with history of MI and afib presents with new onset systolic heart failure resulting in progressive dypnea and afib with RVR. 1)

2)

3)

4)

New onset systolic HF - Echo showed EF of 35%. Clinical presentation consistent with new onset systolic heart failure resulting in dyspnea.  Lower Furosemide to 20 mg BID; add ACE inhibitor Afib with RVR - Well controlled with rates 80-90 on telemetry  Continue metoprolol 100 mg BID  CHA2DS2-VASc score of 4 indicates need to begin warfarin therapy wth goal INR of 2-3. Right-sided plural effusion - 1200 cc of straw colored fluid was removed with Protein ratio of 0.42 and LDH ratio of 0.45. Consistent with transudate per Light’s criteria and clinical presentation of heart failure  Monitor cultures for bacterial growth Diabetes - Pt glucose well controlled on SSI during inpatient stay with glucose at 106 this morning. Continue SSI for remainder of hospitalization.

Oral Presentation for above Progress Note: Mr. Smith is the 65 y/o M with new onset heart failure and afib with RVR. Yesterday he had his thoracentesis and today he is feeling much better with reduced dyspnea and overall malaise. He has denied any fevers or chest pain. Vital Signs are within normal limits with his telemetry showing rates of 80-90 overnight. His electrolytes are also within normal limits and his latest glucose readings have been 136, 109, and 106 respectively. His hemoglobin remains mildly decreased at 11.7, with the remainder of his CBC unremarkable. Preliminary lab work up of his plural fluid shows protein ratio of 0.42 and LDH ratio of 0.45 with no organisms growing on initial cultures. For assessment and plan this is 65 y/o M with new onset heart failure resulting in progressive dyspnea with bilateral plural effusions. For his new onset systolic heart failure, the patient can have his furosemide lowered to 20 mg BID with the addition of an ACE inhibitor. He will need to follow up with cardiology outpatient. His afib with RVR is now rate controlled with metoprolol 100 mg BID with telemetry showing rates between 80 to 90. With his new onset systolic HF, his CHA2D2-VASc score

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations is 4 which indicates a need to begin anticoagulation with goal INR of 2-3. Thoracentesis yesterday of residual right sided plural effusion showed 1200 cc of straw color fluid with protein ratio of 0.42 and LDH ratio of 0.45 indicating it is a transudate by Light’s criteria and is consistent with systolic heart failure as its likely etiology. Finally, his diabetes has been well controlled with SSI in the hospital with glucose readings. We will continue SSI for the remainder of his hospital stay.

Neurology History and Physical Example: Chief Complaint – The patient is a 25 year old, right-handed female who complains of severe, throbbing headaches. History of Present Illness – The patient states that the headaches began when she was in high school, and she experiences these headaches 1-2 times per month. The pain is usually one-sided and feels like it is “behind her eye” and lasts anywhere from 8 to 24 hours. Occasionally, she has noticed flashes of light in the periphery of her visual fields in the moments preceding a headache. During the headache, she complains of severe nausea and reports vomiting during at least one episode. She cannot determine anything that seems to trigger the headaches and says that lying down in a dark room and taking a nap is about the only thing that helps her symptoms. She has tried taking Advil, Tylenol, and Excedrin for the headaches, but they only provide marginal relief. Past Medical History – no significant medical diagnoses Past Surgical History – appendectomy (8 years ago) Family History – Mother experiences similar headaches Social History – drinks alcohol occasionally, does not smoke or use illicit drugs Medications – Fexofenadine 10mg for seasonal allergies Review of Systems – She has no headache at the time of presentation and denies fever, chills, nausea, vomiting, diarrhea, and abdominal pain. Physical Exam: Vital Signs – T 98.9, Pulse 74, RR 16, BP 128/82 General – Patient is a well-appearing 25yo, right-hand dominant, white female HEENT – NCAT, MMM, EOMI, no papilledema Cardiovascular – RRR, normal S1 and S2, no JVD, Pulmonary – CTAB, no W/R/R, symmetrical expansion Abdominal – Soft, non-tender, not distended, normal bowel sounds x4 Neuro: Mental Status – AAOx3, speech is fluent and clear, good comprehension, repetition, and naming, able to recall 3/3 objects after 5 minutes Cranial Nerves o CN II – visual fields intact without disturbance, PERRLA o CN III, IV, VI – EOMI with no deviation o CN V – facial sensation is intact and symmetric x3 o CN VII – facial expression is symmetric o CN VIII – hearing is unimpaired o CN IX, X – symmetrical palate elevation o CN XI – symmetrical strength on head turning and shoulder shrug o CN XII – tongue is midline with no atrophy or fasciculations Motor – strength is 5/5 in upper and lower extremities bilaterally Reflexes – 2+ and symmetric at the triceps, biceps, brachioradialis, and patella Sensory – light touch, pinprick, and position senses are intact and symmetric in upper and lower extremities Coordination – rapid alternating movements intact, no dysmetria on heel-to-shin, absent Romberg sign Assessment/Plan: The patient is a 25yo WF with a 5+ year of debilitating headaches that occur 1-2 times per month. Her symptoms and the pattern of her headaches are highly suggestive of migraine headaches. Other diagnoses that could explain her headaches are tension headaches, pseudotumor cerebri, and brain tumor. The quality of her headaches is not consistent with tension headaches as she feels a throbbing pain instead of the classical band-like tension associated with tension headaches. Pseudotumor cerebri is unlikely do to a normal fundoscopic exam. Brain tumors would more likely present with a constant, progressively worsening headache instead of the episodic headaches that the patient experiences.

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations The plan for the patient is to start her on sumatriptan with instructions to take the medication as soon as she believes that she is about to have a migraine. She should follow up with us in clinic if the sumatriptan therapy is unsuccessful in providing relief of her symptoms. Oral Presentation example for above H&P: Miss X is a 25yo white female with no significant PMH who presents with a 5+ year history of severe, episodic, and one-sided headaches that sits behind the eye. The headaches occur 1-2 times per month and usually last for 8 to 24 hours. She describes throbbing and pounding sensations associated with the headache which is usually unilateral in nature. Occasionally, she notices visual disturbances preceding the onset of the headache, which she describes as “flashes of light” at the periphery of her visual field. She experiences intense nausea and has vomited while she was having a headache. Nothing seems to trigger these headaches, and she only finds relief by laying down in a dark, quiet room. She has no significant past medical history, and her only surgery was an appendectomy 8 years ago. Her mother has experienced similar headaches, but the rest of her family history is unremarkable. She drinks alcohol occasionally but does not use tobacco or any illicit drugs. Her only regular medication is fexofenadine, which she takes for seasonal allergies. She has tried treating her headaches with Advil, Tylenol, and Excedrin but has had only marginal relief. Review of systems did not produce any pertinent positives or negatives, and her physical exam was unremarkable. She is awake, alert, and oriented to person, place, and time. Her speech is fluent, and she has good comprehension, repetition, and naming. She was able to recall 3/3 objects after 5 minutes. There were no disturbances of her visual fields, and her pupils were equally round and reactive to light and accommodation. Extraocular eye movements were symmetrical and showed no deficits. Her facial sensation and expressions were intact and symmetrical. Hearing was unimpaired. Palate elevation, shoulder shrug, and head turn were all symmetrical. Strength was 5/5 in both upper and lower extremities. Reflexes were 2+ at the triceps, biceps, brachioradialis, and patella. Sensation of light touch, pinprick, and position were intact and symmetrical. Rapid alternating movements were intact, and she had no dysmetria on heel-to-shin. My assessment is that this patient is most likely suffering from migraine headaches based on the symptoms that the patient describes and the pattern of her headaches. The best treatment for her would be an abortive medication such as sumatriptan, which she could take at the first sign of a headache in order to prevent its progression. *Some attendings will always want you to give results for the full neuro exam during your presentation but others may not (just be plan on presenting this information, and the attending will let you know if they want a more concise presentation) *For the inpatient setting, be sure to include vital signs, lab results, and imaging studies in your presentation

Obstetrics and Gynecology Labor and Delivery Triage History and Physical Example – ID: 30yo G3P1101 @ 39+2 weeks by LMP (last menstrual period) c/w (confirmed with) 20 wk U/S (ultrasound) CC: contractions HPI: Pt presents to triage with c/o (complaint of) contractions for one day, increasing in frequency and intensity. (+) FM (fetal movement), LOF (loss of fluid), no VB (Vaginal Bleeding), no Vag D/C (discharge), denies HA (headache), denies N/V (nausea, vomiting). Prenatal care at ??? clinic. Last clinic visit, next clinic visit, last cervical dilation measurement (not you doing it) Ultrasound? PNC (prenatal complications): Complicated by Obesity, tobacco, C/G, GBS PNL (prenatal labs): ABO blood type, HbsAg, HIV, Pap,GBS, 1 hour glucose, Gonorrhea/Chlamydia Past OB: year, how many weeks, baby’s sex, weight, vaginal vs C-section, complications Past GYN: history of STI, treated or not, hx of abnormal Paps Past Medical History: HTN, DM, seizures Past Surgical History: Medications: Allergies: Social: Tobacco, Alcohol, other drugs, supplements, support at home Family History: Birth defects? Sickle Cell? Cancer, other diseases Review of Systems: Contractions, fetal movement, loss of fluid, vaginal bleeding, vaginal discharge, headache, nausea, vomiting, vision changes, swelling Physical Exam: -Vitals: Blood Pressure, Heart Rate, O2 Stats, Temp -HEENT, Cardiovascular, Lungs, Abdomen, Fundal Height, Extremities-Edema, reflexes Toco: contractions q five min Fetal Heart Tones: 150s reactive.

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations DO NOT PERFORM PELVIC EXAM OR CERVICAL CHECK WITHOUT SUPERVISION Pelvic: Fern (-) Pool (-) Nitrazine(-) Cervix: 3cm/80%/-2 (dilation/effacement/station) A/P 30 yo G3P1101 @39+2 weeks by LMP c/w 20 wk U/S 1) Active Labor admit to L&D 2) Anticipate SVD Oral Presentation example for above H&P Ms. First Name, Last Name is 30 y/o G3P1101 at 39w2d by LMP consistent with a 20 week ultrasound presenting with a one day history of uterine contractions. She denies loss of fluid or vaginal bleeding. She reports active fetal movement. Pregnancy has been complicated by: Obesity, tobacco, Chlamydia or Gonorrhea, GBS It is always a good idea to have more information in you note than you verbally present so you can answer questions if additional information is asked. Also be sure to talk about loss of fluid, blood, fetal movement, and contractions. Postpartum (NSVD and C-section) Note Example (SOAP Format) Date, time S) Pt. doing well, scant lochia, mild cramping, tolerating regular diet, ambulating, pain well controlled, had bowl movement since delivery. PPD# O) VS: CV: Lungs: Abd: Soft, Fundus (at/above/below) umbilicus Extremities: +1 edema bilaterally, Labs: Pre-delivery CBC Post delivery CBC A/P 1) O+, RPR-NR, HepB-, VI, RI 2) Breast Feeding 3) Declines Circumcision for infant 4) Birth control plan Remember to use a blank postpartum note to guide your interview and gather information for the resident. Private Practice – Students do not usually write notes Surgical Assignment The OR – learn how to properly scrub in, gown, and glove while remaining sterile. When drying your hands, always keep your hands up and only move the towel down. Always wear a mask, shoe covers, and hair net before entering the OR area. Watch for the RED LINE. Post-Op Progress Note Example (SOAP Format) Date Med Student Note POD# S) Pt. feels well, pain controlled, denies N/V, denies CP, SOB, positive Time Flatus, denies BM, denies . Ambulating well and tolerating clear diet. O) Vitals: BP, P, RR, T, T max (last 24 hrs) HEENT: PERRLA, EOMI CV: RRR, no murmur Lungs: CTAB no rhonchi, rales, or wheezing Abd: soft, non-tender, non-distended, bowl sounds heard, Incision C/D/I, JP Drain X2 Defer Pelvic examination Extremities: comment on edema and reflexes I/O: 8hr- 875/350 24hr- 1950/1204 JP Drain- 20 cc/8hr Labs: A/P: 42 yo AA female s/p TAH/BSO 20 to left benign ovarian mass. Awaiting path 1. HTN- Controlled on HCTZ 2. Pain- Well controlled 3. Diet- Tolerating clears 4. Ambulating well 5. Incisions dry and intact

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations

Pediatrics Inpatient History & Physical Example CC: Kiddo Jones is a previously healthy 3 yo boy who is admitted at the request of their primary care physician for a high fever and suspected meningitis. The patient’s mother is the source of the history. HPI: The patient was healthy until he developed some congestion and a fever yesterday. The fever initially was controlled with Tylenol until the middle of last night when the temperature remained at 103F despite a Tylenol dose. The patient’s mother contacted their primary care provider, Dr.Smith, this morning and was subsequently seen in their office. By this time the child had developed lethargy, appearing weak and having decreased muscle tone, and the physician stated he appeared dehydrated. Dr. Smith was concerned about the potential of meningitis and sent the child and mother directly to the hospital. The mother states that the child’s condition has remained stable since they left Dr. Smith’s office. The mother states that he has not eaten or drank much since the onset of symptoms yesterday. He has had no urine output since yesterday evening. She denies any diarrhea or vomiting. Aside from the congestion, the mother denies any other symptoms, including cough, ear pain, sore throat, or excessive nasal or conjunctival discharge. The mother is unaware of any sick contacts; however, the patient does attend daycare 3 times a week. The mother believes he is up-to-date on all immunizations. The patient has had two ear infections in the past but no other known infections or illnesses. The mother admits to smoking around the patient and in the house. She denies any recent travel with the patient or known TB exposures. The mother is concerned that her son picked up an infection from another child at daycare. PMHx: Two episodes of otitis media resolved with antibiotics, last course was 6 months ago. Surgical Hx: None Maternal OB and Birth history: Nulliparous prior to conception. Prenatal care throughout pregnancy. All maternal screening tests were negative, including GBS. Delivered at 39W2D. Spontaneous vaginal delivery was uneventful. The mother did not smoke, drink, or use recreational drugs during the pregnancy. Newborn screen was negative. Growth and Development: Last well child check was at 24 months. Due for next well child exam in a few weeks. Has been told that he is meeting milestones appropriately. Sat unaided by 6 months and could walk at 15 months. He was speaking at least 2 words by 12 months. By 2 years he was brushing his teeth and clothing himself. Allergies: NKDA Meds: None Health Maintenance: 1. Screening tests: Lead screen negative at age 12 And 24 months. 2. Exposures: a. Mother smokes in home b. No pets 3. Sleep: Generally sleeps well getting 10-12 hours per night 4. Diet: Enjoys fruits and vegetables. Eats chicken and rarely red meat. 5. Immunizations: up to date per the mother. MCIR in patient chart confirms immunizations through 24 months of age. Social History: The patient lives with his mother and father. His father works outside the home full-time and his mother works outside of the home part-time. He attends daycare 3 days per week. He is occasionally watched by his maternal grandmother. Family History: 1. Father: Alive and well at age 32yo 2. Mother: seasonal allergies, age 32yo 3. Maternal grandmother: breast cancer diagnosed at age 67yo, alive at age 71yo 4. Paternal grandfather: passed away from MI at age 72yo No family history of diabetes, blood dyscrasias, bleeding disorders, or cardiac, renal, or liver disorders. Review of Systems: -Constitutional: As above. -Skin: No history of rashes, eczema, excessive bruising, or skin lesions. -Eyes: No eye discharge or pain, excessive tearing, or itchiness. -Ears: No problems with hearing. No ear pain or drainage. -Nose: As above.

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations -Mouth and throat: No history of dental caries. No oral mucosa inflammation or lesions. -Neck: No history of pain -Respiratory: No cough or wheezing. -Cardiac: No history of murmur, syncope, cyanosis, or palpitations. -GI: As above. -GU: No history of UTI. No dysuria or hematuria. -Musculoskeletal: No history of fracture, myalgias or arthralgias. -CNS: No difficulty with gait or balance. No history of seizures, automatisms, or tremors. No history of headaches. -Endocrine: No excessive thirst or urination. No history of heat or cold intolerance. Physical Exam: Vitals: Temp: 103.0 F oral, Tmax 103.2 @ 08:30. Last Tylenol dose was 4 hours ago. Pulse: 120 regular [89-128] Resp: 32/minute O2 Sat: 98% on room air BP: 85/52 [78-110/48-60] Weight: 16.5 kg (90th percentile) Height: 96 cm (65th percentile) BMI: 17.9 (85th percentile) General: Appears lethargic and ill. Skin: No visible lesions or rashes. No jaundice. Head: Normocephalic, atraumatic. Eyes: No conjunctival injection or excessive tearing. PERRL. Fundoscopic exam does not show any papilledema. Ears: TMs are erythematous and bulging bilaterally and immobile. No discharge or drainage is noted in the external canals. Nose: Nasal mucosa is dry and mildly erythematous. No purulent discharge or blood. Mouth and throat: Oral mucosa is dry but without lesions. Gums appear healthy. Oropharynx is hyperemic but without exudate. Neck: There is palpable cervical lymphadenopathy. Rigidity is present with positive Brudzinski’s sign. Respiratory: CTABL. No wheezes, rhonchi, or crackles. No assessory muscle use. CV: Tachycardia. RRR, no murmurs or gallops. Abd: Bowel sounds are present. Nontender, nondistended. The spleen and liver are unpalpable. Musculoskeletal: Positive Kernig’s sign. No edema or digital clubbing. Assessment: Kiddo Jones is a 3 yo male with possible bacterial vs. aspectic meningitis. He was healthy until yesterday when he developed congestion and fever. The fever continued to increase and the patient became lethargic over the past 24 hours. This morning he was seen by his primary care provider who was concerned about meningitis and requested hospitalization. Current temperature is 103.0F. 1) Meningitis is the suspected cause of the fever. This is the most likely diagnosis given his high fevers, the rapid onset of symptoms, and his positive signs of meningeal irritation. Possible causes of meningitis include both viral and bacterial organisms. Potential sources of infection include, urinary tract infection, otitis media, or other upper respiratory infection, and direct extension from disruption of surrounding skin. 2) Dehydration: the patient has had no oral intake in the past 24 hours and his oral mucosa is dry. Additionally, he has had no urine output since yesterday evening (18 hours). Plan: Draw the following labs: CBC including WBC differential with bands, electrolytes, urinalysis, and blood cultures. Chest x-ray is ordered. We will perform an LP measuring WBCs, protein, and glucose. We will examine the CSF for bacteria, perform cultures and sensitivity, and run PCR for herpes simplex virus. We will give a NS fluid bolus at 20ml/kg to correct an stimated 6% total body volume deficit. Then run 1/4NS for maintenance at 50ml/hour. We will begin empiric treatment with IV Vancomycin and Claforan and IV acyclovir. Tylenol every 4-6 hours for fever. We will perform regular patient status and neuro checks for any changes such as a decrease in mental status,onset of seizures, or worsening fever. Oral Presentation for above H&P Kiddo Jones is a 3 yo male with possible bacterial vs. aspectic meningitis. He was healthy until yesterday when he developed congestion and fever. The fever continued to increase and the patient became lethargic over the past 24 hours. This morning he was seen by his primary care provider who was concerned about meningitis and requested hospitalization. Current temperature is 103.0F. Tmax 103.2 at 08:30. Minimal po intake and urine output. Mom

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations denies diarrhea or vomiting. Kiddo was possibly exposed to sick contacts at day care, which he attends 3x/week. Upto-date on immunizations. Non-contributory past medical and surgical history. Delivered at term, uncomplicated SVD. No allergies and not one any medication. ROS positive for weakness and fatigue. Denies other symptoms. On exam, temp is 103.0 and Kiddo appears lethargic and ill. There is palpable cervical lymphadenopathy. Rigidity is present with positive Brudzinski’s sign. Lungs CTAB, heart RRR no murmurs, abdomen non-distended, non-tender with positive bowel sounds. My assessment is that Kiddo Jones is a 3 yo male with suspected meningitis. This is the most likely diagnosis given his high fevers, the rapid onset of symptoms, and his positive signs of meningeal irritation. Possible causes of meningitis include both viral and bacterial organisms. Potential sources of infection include, urinary tract infection, otitis media, or other upper respiratory infection, and direct extension from disruption of surrounding skin. My plan is to draw a CBC including WBC differential with bands, electrolytes, urinalysis, and blood cultures. Perform spinal tap to test spinal fluid. We will begin empiric treatment with IV Vancomycin and Claforan and IV acyclovir. Tylenol every 4-6 hours for fever. Start IV fluids. We will perform regular patient status and neuro checks for any changes such as a decrease in mental tatus,onset of seizures, or worsening fever. Progress Note Example (SOAP Format) Introductory phrase: (a way of briefing the group: name, age, CC, working diagnosis) “Timmy is a 3 yo patient admitted with rash and fever found to have Kawasaki Disease” Subjective: (Sum up what the parents would have told you. Common things to mention in your subjective sections: Report any relevant pain, BM and urination, what kind of diet and how they are tolerating it, and if they are ambulating.) Objective: (Vitals, physical exam, labs, radiology) Ranges are good for temperature, O2 saturations, and BP but probably not needed for RR if all were normal…check with your resident. Physical Exam: Report pertinent exam. Don’t need to report deep tendon reflexes every day for every patient. What is helpful is comparing todays exam with previous exam. Labs: With a progress note, just present the labs that were drawn since the last time you presented the patient and how certain values are trending (i.e. Hb in a patient who was anemic) -but know all of the previous labs if asked. Radiology: Same as above with labs. No need to present initial x-rays on hospital day 12. If a malignancy found, do not report this in front of the family. Assessment: Repeat the introductory phrase (name, age, CC, if still no certain diagnosis, list differential diagnosis.) Plan: Some residents and attending like to merge the assessment and plan and some do them separate. Also, some like to do a numbered plan with most pertinent problems first and others do a system-based plan. I find that the system-based plan is more useful when a patient has issues with more than two or three systems. Use judgement with this (don’t do a system-based plan for a kid having an asthma exacerbation and no other problems) and ask your resident when unsure. Example Progress note: Timmy is a 3 yo patient admitted with rash and fever found to have Kawasaki Disease. S: Overnight Timmy’s rash has improved, although he has had some skin peeling from his finger tips. He had one fever overnight, treated with Tylenol. He has been able to eat and drink well, peeing and pooping normal. O: Vitals: Temps ranged from 97.6-101.2. Tmax at 03:30. Pulse 78, RR 16, oxygen saturation 98% on room air. Physical Exam: Timmy was resting comfortably this morning. His oropharynx is erythemetous, with cracking of his lips. Neck swelling present but decreased from yesterday. His lungs sound clear bilaterally. His heart is regular in rhythym, with a 2/6 systolic ejection murmur over the left upper sterna border. His abdomen is soft and non-tender with positive bowel sounds. His rash has improved, and now confined to just his trunk. Labs: WBC 12.6 down from 14.0, Hb 13.2, platelets 207k A/P: Timmy is a 3 yo patient admitted yesterday with rash and fever found to have Kawasaki Disease. He received IVIG yesterday evening as well as aspirin and tolerated both of those treatments well. Currently afebrile but had a Tmax of 101.2 at 03:30. His rash and neck swelling have reduced significantly. My plan is to monitor until Timmy has been without a fever for 12 hours. If all other symptoms have remained stable or improved at this time, he can be discharged. Oral Presentation for above Progress Note Timmy is a 3 yo patient admitted with rash and fever found to have Kawasaki Disease. Overnight Timmy’s rash has improved, although he has had some skin peeling from his finger tips. He had one fever overnight (101.2 @ 03:30), treated with Tylenol. He has been able to eat and drink well, peeing and pooping normal. On exam his oropharynx is

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations erythematous, with cracking of his lips. Neck swelling present but decreased from yesterday. His rash has improved, and now confined to just his trunk. Rest of exam WNL. His WBC count is down to 12.6 from 14.0. My assessment is Timmy is a 3 yo patient with Kawasaki Disease. He received IVIG yesterday evening as well as aspirin and tolerated both of those treatments well. Currently afebrile but had a Tmax of 101.2 at 03:30. His rash and neck swelling have reduced significantly. My plan is to monitor until Timmy has been without a fever for 12 hours. If all other symptoms have remained stable or improved at this time, he can be discharged. Outpatient Well Child Check SOAP Note 05/29/12 (Date) 0900 (Time) S: 4 month old male presents for well baby visit Concerns: No concerns since last visit Diet: Several bottles of Similac with iron per day, no solids (ask about fluoride and vitamin supplementation) Development: Normal Denver – babbles and coos, smiles, laughs, holds head up, rolls from front to back, raises body on hands, grasps rattle, recognizes parent’s voice Bowel/Bladder: BMs x 2 per day, soft, slightly formed stool, no straining, no blood, 6-8 wet diapers per day (toilet training after 21 months) Sleep: Sleeps in crib in own room on his back, wakes once per night for bottle Dental: No teeth. (if a child has a tooth it should be brushed, should see dentist at age 3) Safety: Rear facing car seat in the back seat, sleeps on back, (+) smoke and carbon monoxide detectors (helmet use, gun safety, pet safety) Immunizations: Up to date, needs DTaP (diptheria, tetanus and acellular pertussis), Hib (haemophilus influenzae type B), IPV (inactivated poliovirus), PCV (pneumococcal) For adolescents: Drugs/alcohol/tobacco, sexual activity, after-school activities, hours of screen time (TV and computer), school, depression/self-esteem O: Length: 25in, Weight: 14lbs 8oz, Head Circumference: 16.5in, Pulse: 130 Gen: Awake, alert, no acute distress, smiling HEENT: Anterior fontanelle open, flat and soft (AFOFS), normal cephalic atraumatic (NCAT), (+) red reflexes bilaterally, follows past midline, (-) strabismus, pupils equal round and reactive to light (PERRL), normal tympanic membranes B/L, inferior turbinates slightly pale and boggy, throat clear Neck: Supple, (-) lymphadenopathy (LAD) Skin: (-) rashes, (-) mongolian spots CV: regular rate and rhythm, (+) S1S2, (-) murmurs, equal radial and femoral pulses Resp: CTA B/L, (-) wheezes/rhonchi/rales Abd: Soft, (+) bowel sounds, NT, ND, (-) masses, (-) hepatosplenomegaly Ext: normal range of motion (ROM), (-) Ortolani, (-) Barlow Neuro: (+) Moro reflex, (+) grasping reflex, (+) stepping reflex A/P: 4 month old male presents for well baby visit. No new complaints. 1. Diet: add cereal and then pureed fruits/veggies, only add one new food per week to gauge tolerance 2. Safety: discussed ‘child proofing’ the house (hot liquids, sharp objects, outlets, cords, etc.) as baby is becoming more mobile 3. Immunizations: Received DTaP, IPV, Hib, PVC today 4. Return in 2 months Oral Presentation for above Well Child Check Pt is a 4 mo. male here today for a well child check. No complaints since last visit and no interval history. He is feeding well with Similac with iron (several bottles/day); no solids yet. 2 soft BM/day and 6-8 wet diapers/day. Sleeping in crib on back. He is meeting appropriate gross motor, fine motor, language, and social developmental milestones. Home and automobile anticipatory guidance were discussed. Pt is onschedule with immunizations and needs 4 month shots today. Pt is in 50% for height and weight. Physical exam was normal in all systems. My assessment is that this is a 4 month old male here for a well baby visit and no new complaints. Add cereal to diet and then pureed fruits/veggies, only add one new food per week to gauge tolerance. Discuss ‘child proofing’ the house (hot liquids, sharp objects, outlets,cords, etc.) as baby is becoming more mobile. Received DTaP, IPV, Hib, PVC immunizations today. Return in 2 months.

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations

Family Medicine History and Physical Example: HPI: Includes chief complaint, location and radiation (if applicable), onset and frequency of symptoms, alleviating/aggravating factors, and associated symptoms. Example: Jim Smith is a 35 y/o WM (white male) who presents today with cough and rhinorrhea for the past 5 days. He states that his symptoms have gotten worse since their onset and occur throughout the day. Exertion seems to make things worse and he has tried drinking hot beverages, which have not helped. He denies any associated symptoms. PMH: Include any significant medical conditions or hospital visits Example: COPD PSH: Include any significant surgeries Example: Tonsillectomy as an adolescent for recurrent pharyngitis Medications: Include any prescription or over-the-counter medications and supplements Example: Albuterol PRN (as needed) Allergies: Include any drug allergies (NKDA = no known drug allergies) Example: Allergy to sulfa derivatives Social History: Include alcoholic drinking history (how long, how many drinks per week, how long sober), smoking history (how many packs per day, how long has he/she been smoking), illicit drug use, living situation (who do they live with, where do they live, any sick contacts), and educational/employment status Example: Drinks around 1-2 beers/night. Smokes 1ppd for the past 15 years. Denies any illicit drugs. Lives with wife and two children (one son, one daughter) at home; his son recently had a viral URI (upper respiratory tract infection). He graduated high school and currently works for the USPS. FMH: Include any significant family history of diseases (often will have to prompt patients by asking specifically about heart disease, high blood pressure, stroke, diabetes, or lung disease) Example: Mother and father both had high blood pressure and maternal grandmother died of a stroke. Oral Presentation example for above H&P: Example: Jim Smith is a 35 y/o WM (white male) with a history of COPD who presents today with cough and rhinorrhea for the past 5 days. He states that his symptoms have gotten worse since their onset and occur throughout the day. Exertion seems to make things worse and he has tried drinking hot beverages, which have not helped. He treats his COPD with albuterol PRN and his son had a recent URI. Developing an assessment and plan are also important. While some attendings or residents may ask for one, be sure to volunteer your thoughts regardless.

Psychiatry History and Physical HPI: C.P. is a 44 yo F who presented to the hospital c/o auditory hallucinations and increasing depression and paranoia. Pt reports increasing depression for the past month. Started hearing voices recently - they are men's voices and this really scared her. She feels very scared all the time - thinks that people have been following her and someone made the hand gesture of a gun towards her. Reports that people have been following her for 3 years. She has moved to multiple different apartments (and a different state - thought this was happening in Georgia too) but believes these people are going to hurt her or her son. Pt reports that her son is not worried about it and doesn't seem concerned. He is now becoming fed up with her. Pt reports that her son is "tired of dealing" with her and that she "gets on his nerves." Pt is tearful on and off throughout the interview. Has high anxiety. Has called the police multiple times about the cars she believes are following her. Says she has been on the same meds for years Seroquel 1000 mg and Zoloft 100 mg. These haven’t been changed anytime recently. They are being prescribed by her PCP. Past Psych Hx: Admitted to Norton Hospital in 2005 for Opiate overdose. Dx Bipolar and Opiate Dependence. Seen at Seven Counties from 2004-05. PCP Dr. Gray has been prescribing her medication for her. Substance Abuse Hx: Denies any recreational drugs. Denies overusing her pain medications but there has been concern in the past for that. Sees pain management. Alcohol- 1-2 glasses of wine per week. Medical Hx: Asthma, HTN, HLD Surgical Hx: None Social History: Grew up in Louisville. Has an older brother. Graduated from high school and got an Associates Degree in Business. Has a 24 yr old son. Had received disability in the past but currently has been working as a CNA in a Nursing Home. Was living with her son in an apartment but they just moved in with her mother. Smokes 1 ppd for past 20 years, drinks 1-2 glasses of wine per week, denies cocaine, heroin, amphetamine, opioid, marijuana abuse. Family Hx: Depression in mother and paternal aunt.

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations Home Meds: Alprazolam (Xanax) 0.25 mg PRN sleep; Hydrocodone-Acetaminophen 7.5-300 mg PRN pain, Quetiapine (Seroquel XR), 400 mg BID, Sertraline (Zoloft) 100 mg daily Current Inpt Meds: Haloperidol (Haldol) 2 mg daily, Sertraline (Zoloft) 50 mg BID, Baclofen (Lioresal) 20 mg daily, Nicotine (Nicoderm CQ) 14 mg (1 patch) daily, Quetiapine (Seroquel XR) 800 mg daily Allergies: NKDA ROS: Constitutional: Negative for fever and chills. HENT: Negative for sore throat, neck pain and neck stiffness. Eyes: Negative for redness and visual disturbance. Respiratory: Negative for shortness of breath and stridor. Cardiovascular: Negative for chest pain, palpitations and leg swelling. Gastrointestinal: Negative for nausea, vomiting, abdominal pain, diarrhea, blood in stool and abdominal distention. Genitourinary: Negative for difficulty urinating. Musculoskeletal: Negative for joint swelling. Skin: Negative for rash. Neurological: Negative for speech difficulty, weakness and numbness. Psychiatric/Behavioral: Positive for hallucinations (auditory), changes in sleep, and decreased concentration. Psychiatric Review Of Systems: No appetite and weight changes. Poor sleep, low energy, decreased interest and pleasure, anxiety, of guilt and hopelessness, suicidal ideation Physical Exam: PE: T 97.9 HR 70 BP 96/62 RR 16 General: Alert, cooperative, no distress, appears stated age Head: Normocephalic, without obvious abnormality, atraumatic Eyes: PERRL, conjunctiva/corneas clear, EOM's intact Ears: Normal external ear canals, both ears Nose: Nares normal, septum midline, mucosa normal, no drainage or sinus tenderness Throat: Lips, mucosa, and tongue normal; teeth and gums normal Neck: Supple, trachea midline; thyroid: no enlargement/tenderness/nodules; no carotid bruit or JVD Back: Symmetric, no curvature, ROM normal, no CVA tenderness Lungs: Clear to auscultation bilaterally, respirations unlabored Chest Wall: No tenderness or deformity Heart: Regular rate and rhythm, S1 and S2 normal, no murmur, rub or gallop Abdomen: Soft, non-tender, bowel sounds active all four quadrants, no masses, no organomegaly Extremities: Extremities normal, atraumatic, no cyanosis or edema Pulses: 2+ and symmetric all extremities Skin: Skin color, texture, turgor normal, no rashes or lesions Lymph Nodes: Cervical, supraclavicular, and axillary nodes normal Neurologic: CNII-XII intact, normal strength, sensation and reflexes throughout Mental Status Evaluation: Appearance: Groomed, clean, appropriately dressed Behavior: Restless and fidgety Speech: Normal tone, speed, volume, and language Mood: Anxious and depressed Affect: Labile Thought Process: Logical, goal-directed Thought Content: Delusions, Auditory Hallucinations Sensorium: Awake, alert, oriented to person, place, time Cognition: No cognitive defects noted Insight: Impaired Judgment: Impaired SI/HI: Suicidal ideation without a plan Assessment/Plan: Axis I: Major Depression, recurrent with psychotic features; r/o delusional disorder Axis II: Deferred Axis III: Asthma, HTN, HLD

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations Axis IV: economic problems, housing problems and other psychosocial or environmental problems Axis V: 11-20 some danger of hurting self or others possible OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication. Plan: 1. Admit to 6E for safety and stabilization 2. Encourage group and therapeutic activities 3. Seroquel 800 mg qhs 4. Add Haldol 2 mg daily, may increase if seroquel isn't treating the psychosis adequately 5. Increase Zoloft to 150 mg - has been on for long time but no dosage adjustments 6. Suicide precautions Oral Presentation: C.P. is a 44yo female w hx of Bipolar dz and opiate overdose attempt who presents with worsening depression, paranoia and auditory hallucinations for several months that are stressing her relationship with her son, with whom she currently lives. She has taken Seroquel 1000mg and Zoloft 100mg for several years through her psychiatrist at Seven Counties. Pt also takes Xanax 0.25mg and Norco at home. Patient smokes 1 PPD, reports occasional alcohol and denies recreational drugs. Family Hx significant for MDD in mother and paternal aunt. ROS positive for poor sleep, depressed mood and concentration, feelings of anxiety and guilt and suicidal ideation without a specific plan. No change in appetite, bowel or bladder habits, and no recent illness symptoms. On exam, vital signs were T 97.9 HR 70 BP 96/62 RR 16. Pupils equal, round, reactive to light and accommodation. CN’s 2 through 12 grossly intact, LCAB, RRR, radial pulses 2+ bilaterally, no cyanosis or edema, no focal neural deficits appreciated. On Mental Status Examination, pt appeared stated age, was awake alert and oriented to person, place, time, and circumstances. She was restless, mood congruent with labile affect, exhibited perseveration, and seemed to have limited insight into nature of her illness. My assessment is: Axis I: Recurrent MDD with psychotic features; DDx includes delusional disorder, schizophrenia. Axis II: none at this time. Axis III: Asthma, HTN, HLD Axis IV: economic problems, social problems, environmental problems Axis V: 40 for inability to carry on daily functions My plan would be to admit to inpatient for safety and stabilization, encourage therapeutic milieu, continue home Seroquel for sleep, increase Zoloft to 150mg for active depression, add Haldol 2mg for psychosis, and suicide watch. Progress Notes S: This morning patient was doing better. Alert, Oriented, sitting in chair. C/o of residual memory problems, does not remember working with PT yesterday. Still very poor sleep. Does not want seroquel since 25 mg "zonked me out", felt very drowsy the entire next day. Interested in trying something else. Related other sources of stress in her life including several family relationships. Still cries everyday thinking about her husband. Their wedding anniversary is coming up on Sun 9/21. She plans to spend the day with her son, and her daughter made reservations for Vincenzo's the Saturday before. Pt relates dreaming about husband every night, sometimes about his death, and often wakes crying out for him, describes the experiences as unpleasant. Denies flashbacks or other nightmares. In other history, pt was sole caregiver for grandson for 8 yrs until he was admitted to Brooklawn in October 2013 for conduct disorder. No complaints of pain at this time. Anxiety persists and may be getting a little worse. Denies CP, SOB, NVD. Meds: Budesonide-formoterol 2 puff daily, Clonidine 0.1 mg PO daily, Hydralazine 25 mg PO daily, insulin detemir 10 units subcutaneous QHS, verapamil 240 mg PO QHS O: T 98.8 HR 85 BP 141/80 RR 18 Gen: NAD, sitting up watching TV. CV: RRR, S1S2 nml, no G/M/R’s, radial pulses 2+ Bil, no edema. Pulm: CTAB Abd: Soft, NTND, +BS MSE: Appearance: Gowned, ear-rings, glasses, slippers, watch Behavior: Calm, cooperative, congenial, responsive, but became agitated discussing stressors. Speech/Lang: Normal volume/rate. Good articulation. No perseveration or echolalia. Mood: sad Affect: Sad, emotionally labile Thought Ps: linear, goal-oriented. Thought Ct: No SI/HI/HA Orientation: A, A, oriented to P P T C Memory: Not formally tested.

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Clinical Clerkship Survival Guide: Example Notes and Oral Presentations Conc/Attn: normal Fund of Kn: Not formally tested. Insight: Fair, recognizes depression but may underestimate severity Judgment: Fair Labs: 05:58 - Glucose 256 (Elevated) Assessment Axis I: MDD; Bereavement; resolving delirium due to infx. Axis II: No diagnosis Axis III: UTI; PMHx includes DM2, HTN, HLD, spondylolisthesis, glaucoma Axis IV: Unsafe home environment dt late husband's hoarding, significant family and social stressors. Axis V: 41-50, serious symptoms. Pt’s personal psychiatrist came to visit today and has requested transfer to 6East Plan Defer management to pt's psychiatrist. Admit to 6East per primary psychiatrist’s request, and sign off psych consult. Oral Presentation: C.E. is a 76 yr/o female w hx of DM2 and depression who presents with confusion for 3 days now and being treated for UTI. Home meds duloxetine and quetiapine were stopped. Psychiatry was consulted for AMS and meds evaluation. Consult Day 2. This morning pt is feeling better but did not remember doing physical therapy yesterday. Relates several social stressors that occupy her thoughts and disturb her sleep. Did not sleep well last night but does not want Seroquel due to side effects. Denies new or worsening Sx. Vitals were T 98.8 HR 85 BP 141/80 RR 18 PE was unremarkable. On mental status exam, she was generally calm and cooperative but became intermittently agitated when discussing specific social relationships. Mood is sad, with congruent, appropriate affect. Denies SI/HI. No meds changes since yesterday. My assessment is Axis I: MDD with superimposed Bereavement; resolving delirium due to infx. Axis II: No diagnosis Axis III: UTI; PMHx includes DM2, HTN, HLD, spondylolisthesis, glaucoma Axis IV: Unsafe home environment dt late husband's hoarding, significant family and social stressors. Axis V: 41-50 for serious stressors. My plan would be to d/c Seroquel and start trazodone for sleep. Patient’s psychiatrist has requested transfer to 6East, so consult will sign off at that point

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