Third Year Internal Medicine Clerkship
2015 - 2016
Syllabus
Department of Internal Medicine
Quillen College of Medicine
East Tennessee State University
Dr. Charles A. Stuart
Interim Chair, Department of Internal Medicine
Dr. Aaysha Kapila – Course Director
Dr. Rupal Shah – Co-Director
Yvette Font
Clerkship Coordinator
(rev. 9/22)
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2015 – 2016 JUNIOR INTERNAL MEDICINE CLERKSHIP SYLLABUS
CONTACT INFORMATION
WELCOME
A. Importance of clerkship
B. Clerkship Goals
C. Clerkship Objectives
ROLES AND RESPONSIBILITIES
A. Assessment of Student
B. Assessment of Faculty and Course
C. Faculty Responsibilities
D. Student Responsibilities
E. Documentation of Required Experiences
F. Clerkship Specific Procedures/Patient Log
G. Professional Expectations for Students
H. Social Networking
I. Policy on HIPPA Training, Violations and Disciplinary Actions
J. Medical Student Duty Hours
K. Student Illness
L. Student Absences
M. Inclement Weather Policy
N. Appropriate Dress
O. Identification Badges
P. Student Contact Phone Numbers
SCHEDULES
A. Clerkship Site Assignments
B. Student Education Conferences
C. Quiz schedule
D. Department of Medicine Grand Rounds
E. Cardiac Rehabilitation
ASSESSMENTS
A. Clerkship Grading
B. Clerkship Grade Scale
C. NBME Exam Policy
D. Student Computer Usage During Electronically Administered
Quizzes/Exams Policy
TIPS FOR LEARNING
A. Top 10 Ways to Excel on the Internal Medicine Clerkship
LEARNING RESOURCES
A. Textbooks for reading
B. References and Materials (Optional)
C. Student Procedures for Special Services (ADA)
D. Tutoring
E. Counseling
APPENDICES
A. History and Physical Template
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B. COM Intuitional Objectives
C. Entrustable Professional Activities
JR. INTERNAL MEDICINE CLERKSHIP
Dr. Aaysha Kapila: Course Director: 423-224-8425 (beeper) kapilaa@etsu.edu
Yvette Font: Clerkship Coordinator, 423-439-6381 font@etsu.edu
Johnson City Medical Center
VA Medical Center
Holston Valley Medical Center
Bristol Regional Medical Center
Academic Affairs
Ms. Tawana Holland
Ms. Anetha Wright
Ms. Rita Forrester
Ms. Jane Lipscomb
Ms Cathy Peeples
423-431-6431
423-926-1171 ext. 7358
423-224-5075
423-844-6650
423-439-6311
WELCOME!
Welcome to the Junior Medicine Clerkship. We hope you will enjoy the time you share with us. We are
proud of our reputation as dedicated medical educators and hope you enjoy the knowledge and
experience you will gain while rotating with the Department of Internal Medicine.
The Junior Clerkship experience in Internal Medicine consists of six weeks of inpatient medicine divided
into two three week rotations at two of our three sites: VA Medical Center, Johnson City Medical Center or
Holston Valley Medical Center. This will provide you the opportunity to experience different hospital
settings.
A.
Importance of this course
During this six-week clerkship, you will acquire fundamental skills, reinforce and expand your knowledge,
and develop personally and professionally. We hope that this experience inspires you to learn and
experience more of what Internal Medicine has to offer. Internists care for a broad spectrum of patients,
ranging in age from adolescents to the ever-growing elderly population. While expanding your medical
knowledge, you will also be solidifying basic clinical skills such as patient interviewing, physical
examination, and communication through case presentations and written documentation. This time is
also a major opportunity to improve more advanced skills such as physical diagnosis, clinical reasoning,
and developing physician-patient relationships.
B.
Clerkship Goals
The Internal Medicine curriculum goals are to assist students in acquiring a foundation of knowledge
regarding the practice of medicine, and assist students in mastering basic interpersonal skills relevant to
the management of patients with medical illness.
1. Student will develop a solid foundation of medical knowledge regarding the care and
management of patients presenting with a variety of medical diseases. This will include
formulating a diagnosis, patient care plan, medical diagnostic procedures, adherence to
evidence-based guidelines and follow up care that includes both medical and psychological
support.
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2. Students will effectively participate as team members while maintaining a professional demeanor
that includes communication with fellow students, residents, attending physicians and patient’s
family members.
C.
Clerkship Objectives:
Course / Clerkship Objectives:
At the conclusion of this rotation the
student will be able to:
Meets EPAsee
appendix B
Educational
Method(s)
gather a history and perform a physical
examination incorporating ethical, social,
and diversity perspectives to provide
culturally competent health care.
prioritize a differential diagnosis following a
clinical encounter for common conditions
seen in Internal Medicine.
EPA 1
Clinical
Experienceinpatient
EPA 2
Clinical
Experienceinpatient
recommend and interpret common
diagnostic and screening tests for
conditions frequently seen in Internal
Medicine.
EPA 3
-Clinical
Experienceinpatient;
- Conference
document and discuss orders for common
conditions seen in Internal Medicine.
EPA 4
appropriately write prescriptions by
recognizing and avoiding errors utilizing
information resources to place the correct
order/perscription and maximize therapeutic
benefit and safety for patients
document a clinical encounter in the patient
record (electronic or written format)
EPA 4
Clinical
Experienceinpatient
Clinical
Experienceinpatient
provide an accurate and concise oral
presentation of a clinical encounter of a
patient in the inpatient setting
form clinical questions and retrieve
evidence to advance patient care
EPA 6
give or receive a patient handover to
transition care responsibility in an inpatient
setting
demonstrate the ability to collaborate as a
member of an interprofessional team in an
inpatient setting
EPA 8
recognize a patient requiring urgent or
EPA 10
EPA 5
EPA 7
EPA 9
Assessment
Method(s)
-Clinical
Documentation
Review;
-Participation
-Clinical
Documentation
Review;
-Exam-Institutionally
Developed-writtem;
-Exam-Nationally
Normed/Subject
-Clinical
Documentation
Review;
-Exam-Institutionally
Developed-writtem;
-Exam-Nationally
Normed/Subject
-Clinical
Documentation
Review
Clinical
Documentation
Review
Clinical
Experienceinpatient
Clinical
Experienceinpatient
-Clinical
Experienceinpatient;
-Self-directed
learning
Clinical
Experienceinpatient
Clinical
Experienceinpatient
Clinical
Documentation
Review
Oral Patient
Presentation
-Clinical
-Participation;
-Clinical
Documentation
Review;
-Oral Patient
Presentation
Participation
Participation
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emergent care
demonstrate knowledge of the elements
necessary for informed consent for tests
and procedures and impact on
patient/family
perform required Clerkship and College of
Medicine procedures under direct
supervision.
demonstrate an understanding of system
based practice and the students role in a
culture of patient safety and continuous
quality improvement
2.
Experienceinpatient;
-Conference
Clinical
Experienceinpatient
-Exam-Nationally
Normed/Subject
EPA 12
-Demonstration;
-Preceptorship
EPA 13
Clinical
Experienceinpatient
-Participation;
-Clinical Performance
Checklist
-Participation;
-Exam-Nationally
Normed/Subject
EPA 11
-Participation;
- Exam-Nationally
Normed/Subject
ROLES AND RESPONSIBILITIES IN LEARNING
A. COM: ASSESSMENT OF STUDENT
The clerkship director and coordinator manage the assessment process for all the clerkship students.
QCOM uses an on-line assessment system, New Innovations (NI), to assess each student’s performance.
Individual faculty assessment of each student will be combined into the Clerkship Director’s final
composite assessment form for each student. The final composite will contain faculty comments and the
final course grade. Students will be notified when their final assessment is available in NI to view. This
should be approximately 3 weeks following the conclusion of the clerkship. Final grades will be posted
into the ETSU Banner system and become the official grade for the student’s transcript.
An integral part of the assessment process is the Mid-clerkship Review with the clerkship director which
all students will have. It is the student’s responsibility to complete their portion of the Mid-Clerkship
Review form and to arrange for a faculty member they have worked closely with during the clerkship to
review and complete the faculty portion of the form prior to the Mid-Clerkship Review. During the Midclerkship Review the clerkship director will review and discuss the completed form with the student. The
completed form will remain with the Clerkship throughout the rotation. The Mid-Clerkship Review form
can be found in the Administrative Forms folder in New Innovations under my Favorites/Department
Manuals or it may be provided to the student by the clerkship coordinator. The Mid-Clerkship Review
form can be found in the Administrative Forms folder in New Innovations under Intranet or it may be
provided to the student by the clerkship coordinator.
B. COM: EVALUATION OF FACULTY AND COURSE
The on-line system is also used for the students to evaluate the faculty and the course. This evaluation
tool is used to provide information to the clerkship administration about the teaching/learning process with
the intent of improving learning. Student feedback is essential for curriculum planning. Students will be
notified electronically when these required evaluations are available to complete. Timely completion of
evaluations is required. Individual clerkships may also request students to evaluate its’ Resident
Physicians using the on-line system, also with the intent of improving learning.
C. FACULTY RESPONSIBILITIES:
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Observe each student perform components of a history and physical exam on a patient some
time during their inpatient rotation. During the inpatient rotation a strong emphasis on the
development of clinical skills is a necessity.
Review student’s histories and physical exams to include assessments and plans.
Review the written record and assess that the student is able to present each case succinctly.
(Students at the VA will write notes in Word Document so that the notes can be cut and pasted if
needed by residents or attendings to insert into the patient record.)
Submit an assessment via New Innovations of each student after the completion of the ward
rotation.
D. STUDENT RESPONSIBILITIES:
1. Attend Orientation at 8 a.m. on first Monday of the clerkship. This is a live interactive orientation
conducted by one of the co-clerkship directors and coordinator, which is designed to outline the
course and expectations as well as tips on how to succeed. Included in the orientation will be a
discussion regarding professionalism and its vitality in medicine.
2. Admit at least 12 patients during the 6 week ward service. Perform a complete history and
physical exam on these patients. Assist the PGY-1 with entering admission orders into the
hospital order entry system. Leave history, physical exam and assessment on patients chart to be
countersigned by the attendings. Copies of the H&P should be made and submitted to the
attending for critique. An H&P template will be emailed to you for assistance with structure and
content. In addition, one formal H&P will be submitted to the clerkship office for review and
evaluation. It will be counted as 10% of your total grade.
3. Write daily progress (SOAP) notes on patients you are covering to be co-signed by attendings.
Each student will be responsible for two patients while on rotation during any one given time.
4. Attend morning report and/or attending rounds daily and be prepared for patient presentations or
admission H&P’s from the previous night.
5. Take Overnight call – no more than 1 in 7 days (average over 6 weeks) If you are assigned to the
VAMC you will be expected to take one week of night float. Students should be aware that night
float begins on Sunday night at 7 p.m. and ends Friday morning at 7 a.m. STUDENTS MAY
WEAR SCRUBS DURING THE WEEK OF NIGHT FLOAT AT WELL AS NIGHTS ON CALL AT
JCMCH OR HOLSTON VALLEY. STUDENTS AT ALL SITES MAY STOP TAKING FLOOR
CALLS AND ADMISSIONS AT MIDNIGHT ON NIGHTS PRIOR TO QUIZ DATES. PLEASE
COMMUNICATE WITH YOUR ATTENDINGS AND SENIOR RESIDENTS.
6. Maintain a professional demeanor that includes communication with fellow students, residents,
faculty, staff and patient’s family members.
7. Attend Student Education Conference each Thursday afternoon from 1-5 p.m. in VAMC, Bldg 1.
8. Complete a comprehensive patient interview followed by a case presentation with their assigned
attending who will assess a grade. Grading forms will be distributed at orientation and can also
be obtained online in New Innovations. This grade will count as 15% of their overall clerkship
grade.
9. Complete a patient log (hard copy) as well as enter in New Innovations. At mid-rotation the
student must review the log with his or her attending to make sure the requirements are being
met. Any deficiencies must be noted and completed by the end of the rotation.
10. Complete a Mid-Clerkship Self-Assessment. During the Mid-clerkship Review the clerkship
director will review and discuss the completed form, accomplishment and documentation of
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required procedures and/or patient types, and duty hours issues with the student. The MidClerkship Review form can be found in the Administrative Forms folder in New Innovations under
Intranet or it may be provided to the student by the clerkship coordinator.
11. Complete an assessment of the faculty and clerkship at the end of the rotation. Student input is
instrumental to creating a positive experience for students. Student responses are taken into
consideration by each department.
12. Access: http://www.etsu.edu/com/intmed/educationprograms/juniormed/lecture.aspx
The prerecorded lectures can also be retrieved by accessing the Department of Internal Medicine
website – “clerkships” – “junior medicine” – “student lecture series”
E. COM: DOCUMENTATION OF REQUIRED EXPERIENCES
Required College of Medicine Procedures and Clerkship Specific Procedures and/or Patient Types LCME
Accreditation standard ED-2 requires that core clinical requirements are identified for all students to
accomplish. This has been done at both the clerkship level and the College of Medicine level. Students
are expected to demonstrate performance (not observing or assisting) the following procedures by the
end their M3 year in order to graduate from the Quillen College of Medicine.
Class of 2016 Required College of Medicine Procedures
2015-16 Quillen College of Medicine Required Procedures
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QCOM: Arterial puncture - perform (also Surgery Clerkship requirement)
QCOM: Aseptic technique-demonstrate (also Surgery Clerkship requirement)
QCOM: Bacterial culture-collect, perform and interpret results (also Surgery Clerkship
requirement)
QCOM: EKG-perform
QCOM: Foley catheter- perform insertion (also Surgery Clerkship requirement)
QCOM: Glucose test finger stick-perform and interpret (also Community Medicine & RPCT
Clerkship requirement)
QCOM: Injection-intramuscular -perform (also Family Medicine & RPCT Clerkship requirement)
QCOM: Injections-subcutaneous - perform
QCOM: KOH Prep-perform (OB Clerkship requirement)
QCOM: Nasogastric tube insertion - perform (also Surgery Clerkship requirement)
QCOM: Pap smear-perform (also OB Clerkship requirement)
QCOM: Prostate Exam-perform
QCOM: Spirometry-perform and interpret results (also Community Medicine & RPCT Clerkship
requirement)
QCOM: Stool guaiac testing-perform
QCOM: Suturing-successfully demonstrate (also Surgery & OB Clerkship requirements)
QCOM: Tube Thoracotomy (live or in sim lab) (also Surgery Clerkship requirement)
QCOM: Urine clean catch - instruct patient and obtain (also Community Medicine & RPCT
clerkship requirement)
QCOM: Urine dipstick test-perform & interpret results (also Community Medicine & RPCT
clerkship requirement)
QCOM: Venipuncture - perform (also Surgery Clerkship requirement)
QCOM: Wet mount-perform (Wet prep, GBS, FFN requirement for OB clerkship)
The above procedures can to be performed any time during the M3 year and documented into New
Innovations under the Global setting in the Case Logger, however please note some are also Clerkship
requirements and must be accomplished during that specific clerkship.
F. Clerkship Specific Procedures Patient Log
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Each clerkship has also identified required and/or suggested procedures to be performed and/or patient
types for all students to experience during the clerkship. Clerkship specific procedures/patient types are
also to be documented in New Innovations, indicating if they observed, assisted or performed a skill and
where the experience occurred. Required procedures must be “performed”. Only those procedures
documented as “performed,” not observed or assisted, will count toward meeting the requirements.
Students are to document all clerkship identified experiences in the Case Logger module of New
Innovations by the end of the clerkship. Only the electronic log will be accepted as evidence of meeting
the requirements. The ability to log diagnosis or procedures into New Innovations closes at midnight the
last Friday of the clerkship rotation. Those students who do not document in New Innovation
accomplishing all clerkship specific required procedures/patient types by the end of the clerkship will have
their final numeric grade lowered by 5%.
2015-16 Internal Medicine Required Procedures
# Required
Interpret a Gram stain
1
Interpret an EKG
Interpret and report urinalysis results
1
1
Perform a complete history and physical
Read and interpret a peripheral blood smear
12
1
Encouraged Diagnosis
Abdominal Pain
Anemia
Alcohol/ Drug Related Problem
Arthritis
Bleeding Disorder
Coronary Artery Disease
Diabetes
Gastrointestinal Bleeding
Hepatitis
Hypertension
Neuromuscular Disease
Pleural Effusion
COPD/Asthma
CVA
Electrolyte Abnormality
Heart Failure
HIV
Lung Nodule/Mass
Pancreatitis
Pneumonia
Renal Failure
Thyroid Disorder
Vasculitis
Syncope/Arrhythmia
Urinary Tract Infection
Clerkships must provide students with adequate exposure to a variety of learning opportunities. If a
student is having difficulty in securing an opportunity to perform a required procedure or see a required
patient type they should request assistance from the clerkship director, preceptors, residents or fellow
students in identifying opportunities. If the student is still not able to secure a required procedure
experience they should inform the clerkship director and request to complete in a simulated environment.
It is the student’s responsibility to be proactive in seeking out the identified required educational
experiences. A clerkship may provide the student a paper copy of the required experiences specific to
that clerkship and require that each accomplished experience be validated by the observing faculty. This
documentation assures the requirements of the clerkship are met by each student and builds the
student’s portfolio. A single observer cannot validate all of a student’s documentation. Students are
expected to enter their documentation at least weekly into New Innovations and document at least 1/3 of
the required clerkship procedures/patient types by the clerkship midpoint. Students’ progress will be
monitored by the Clerkship Director and Coordinator in addition to Academic Affairs.
G. COM: PROFESSIONAL EXPECTATIONS FOR STUDENTS
Student behavior is expected to be professional in all areas at all times.
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Professionalism
Students shall demonstrate the behaviors befitting an ethical professional at all times.
Students shall:
 exhibit respect, compassion, humility, altruism, duty, and honesty with patients, patient’s families,
staff, faculty, members of the healthcare team, fellow students, and themselves.
 be punctual, reliable, and conscientious in completing academic and patient care responsibilities.
 recognize limitations in knowledge and pursue appropriate activities to effectively address
learning needs.
 demonstrate personal accountability and admit professional mistakes.
 adhere to legal and ethical principles related to patient consent and confidentiality.
 demonstrate awareness and sensitivity to age, gender, race, ethnicity, culture, spiritual beliefs,
socioeconomic background, family support, sexual orientation, and healthcare beliefs in
interactions with others.
 demonstrate professionalism in dress, hygiene, and demeanor.
 utilize appropriate boundaries within the patient/physician relationship.
For the vast majority of students these expectations are natural and intuitively known. However, a limited
number of specific unprofessional behaviors are identified below. Of course, it is impossible to delineate
each and every aspect of professionalism. Consequently, the final decision of what constitutes
unprofessional behavior lies with faculty preceptors and the clerkship director. Faculty preceptors may
report any unprofessional actions of concern on their assessment of student form or to the clerkship
director prior to the end of the rotation. The student may be assigned a grade of R, which requires a
review by the Student Promotions Committee. Students many fail a clerkship based solely on
unprofessional behavior.
Examples of Unprofessional Behavior Include:
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Absence from duty without excuse.
Substance abuse either on duty or off duty which effects performance while on duty (in addition, legal
or criminal action, will be dealt with as an infraction of professional behavior).
False witness in any statement in a chart or document related to the practice of medicine.
Failure to safeguard patient’s rights.
Willful neglect of patients.
Expressions of prejudice in any form (this includes verbal comments or behaviors expressing
prejudice based on age, sex, sexual orientation, race, religion, nationality, origin, or disability).
Inappropriate personal behavior in professional settings including abusive language, unprofessional
appearance or sexual misconduct.
Use of patient's chart or record for any purpose other than rendering health care (i.e., criticism of
colleagues, demeaning remarks toward the patients).
Non-compliance with HIPAA guidelines (Refer to QCOM’s HIPAA and Social Medical Policies for
additional information.)
Acute or chronic neglect of professional/educational schedule.
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Failure to comply with the hospital or clinic bylaws.
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Willful failure to comply with the reasonable professional directions of an attending physician or
faculty preceptor.
Texting or sleeping during didactic, clinical or laboratory activities.
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H. COM: Social Networking Guidelines
The Quillen College of Medicine recommends that students exercise caution in using social networking
sites such as Facebook, MySpace, and Twitter. Items that represent unprofessional behavior posted by
students on such networking sites are not in the best interest of the University or Quillen College of
Medicine and may result in disciplinary action up to and including termination.
Students are expected to exhibit a high degree of professionalism and personal integrity consistent with
the pursuit of excellence in the conduct of his or her responsibilities. They must avoid identifying their
connection to the University or QCOM if their online activities are inconsistent with University and QCOM
values or could negatively impact the University's or College of Medicine’s reputation.
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If using social networking sites, students should use a personal e-mail address as their primary
means of identification. Their University e-mail address should be used in accordance with university
policy: http://www.etsu.edu/oit/policies/acceptableuse.aspx#Intro . Students who use these websites
must be aware of the critical importance of privatizing their websites so that only trustworthy friends
have access to the websites/applications.
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In posting information on personal social networking sites, students must not present themselves as
an official representative or spokesperson for the college of medicine, any affiliated hospital or clinic,
or the University. Patient privacy must be maintained and confidential or proprietary information about
the University or hospitals must not be shared online. Patient information is protected under the
Health Insurance Portability and Accountability Act (HIPAA). Students have an ethical and legal
obligation to safeguard protected health information and posting or e-mailing patient photographs is a
violation of the HIPPA statute.
I.
COM: Policy on Student HIPAA Training, Violations and Disciplinary Action
The Health Insurance Portability and Accountability Act (HIPAA) is federal legislation which protects the
health information of individuals. Medical students will routinely be exposed to Protected Health
Information (PHI) during clinical rotations.
As part of their orientation to medical school students will receive HIPAA training which will be periodically
updated.
HIPAA violations can result in significant federal penalties for both individuals and
organizations. Quillen College of Medicine regards HIPAA violations as serious offenses.
Discussion of patient cases in educational conferences and among students for educational purposes is
not a HIPAA violation. However, if such PHI was disseminated beyond these settings, it would likely be a
HIPAA violation. Use of PHI in research requires approval of an Institutional Review Board (IRB).
Medical students who do not know if a particular use of PHI is appropriate should ask their supervisor.
Level of
Violation
Examples of HIPAA Violations
(these are not inclusive)
Review and
Minimum
Disciplinary Action
Level I
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Level II
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Level II
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Unauthorized copying of medical
records
Leaving PHI in a public area
Discussing PHI in a non-secure
area
Posting PHI on any social
networking site
Removing medical records from a
hospital or clinic without proper
authority
Unapproved accessing of PHI when
the student is not involved in the
care of the particular patient
Intentional assisting another person
in gaining unauthorized access to
PHI
Inappropriate sharing of
ID/Password with another person
Removing medical records from a
hospital or clinic without proper
authority
Unapproved accessing of PHI when
Verbal counseling
Written warning in student’s permanent file
and Retraining
Multiple careless Level I violations shall be
subject to progressive disciplinary action
which may include a failing grade in the
course/clerkship and/or dismissal from
QCOM
 Verbal counseling
 Written reprimand in student’s file
and Retraining
 A single incident may result in suspension,
a failing grade in the course/clerkship
and/or
dismissal from QCOM
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Verbal counseling
Written reprimand in student’s file
and Retraining
A single incident may result in suspension,
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Level III
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the student is not involved in the
care of the particular patient
Intentional assisting another person
in gaining unauthorized access to
PHI
Inappropriate sharing of
ID/Password with another person
Disclosure or abusive use of PHI
Tampering with or unauthorized
destruction of information
Unauthorized delivery of PHI to any
third party
a failing grade in the course/clerkship
and/or
dismissal from QCOM
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Immediate dismissal
Violations should be reported to the Executive Associate Dean for Academic Affairs immediately for
consideration by the Student Promotions Committee which will make an action recommendation. The
student may appeal the recommendation of the Student Promotions Committee to the Executive
Associate Dean for Academic Affairs. Final determination will be made by the Dean based on the
committee’s recommendation.
J. COM: MEDICAL STUDENT DUTY HOURS
Medical student assignments, including the nature and content of activities and the number of duty hours
required, must be determined by the educational value of the assignment. All assignments must provide
meaningful educational value. Excessive work hours and fatigue can impact medical student learning just
as it impacts patient care.
1. Duty hours consist of hours required
 In hospital or clinic/office.
 In didactic education (lectures, conferences, etc.).
 In any mandatory educational activity.
2. At home call is not included in duty hours determinations.
3. Student study at home is not counted as duty hours.
4. Medical student duty hours should not exceed on average 80 hours / week.
5. IN-HOUSE NIGHT CALL is permitted under the following conditions:
 Is a valuable educational experience. Facilitates being a member of healthcare team.
 Adequate rest facilities available in hospital.
 Occurs no more frequently than once every week.
 Call will not precede day of an exam or quiz.
 If student feels fatigued after the call, he/she is to be excused for an appropriate length of
time from rounds, classes, etc. Any didactic materials should be made available to the
student. It is the responsibility of the student to effectively communicate with team members
regarding their need for a period of post-call rest.
 The student should not leave normal student responsibilities without such communication.
 Hours of in-house call count toward 80 hours total.
Students are to log their duty hours weekly into New Innovations for each clerkship period for
documentation purposes. Duty hour compliance will be monitored by Academic Affairs on a periodic
basis. Students who feel they are consistently expected to work more than 80 hours per week should
notify the clerkship director. If the issue is not resolved the student should contact the Executive
Associate Dean for Academic Affairs.
K. COM: STUDENT ILLNESS
In the event of illness, the student must contact on the day of absence the preceptor/resident they are
assigned to work with that day. The student is to update the Clerkship Coordinator upon their return to
work.
L. COM: STUDENT ABSENCES
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During Jr. Clerkship rotations there is no annual leave / time off. Students will work the schedule of the
location they are assigned to during the clerkship. ETSU COM Administrative office closures do not
necessitate student time off. All requests for absence from the clerkship rotation must be requested in
advance on the Request for Leave form prior to the date(s) needed for justifiable circumstances. The
Request for Leave form is located in the Administrative Forms folder in NI, on the Intranet. Additional call
may be required for time away for other approved educational activities. All absences will be reported on
the final composite assessment completed by the clerkship. No Requests for Leave will be granted for
scheduled exam times.
M. COM: INCLEMENT WEATHER POLICY
The official radio station for reporting the status of classes and other activities of the College of Medicine
during inclement weather is WETS-FM 89.5. All students - including all medical students - are to govern
themselves according to the status as reported by this station for the University. In the event of missed
classes due to inclement weather, makeup classes may be required on Saturdays.
N. COM: APPROPRIATE DRESS
It is the consensus of the faculty and administration of the Quillen College of Medicine that students
should maintain a neat, clean personal appearance and dress in a professional manner at all times. Since
students are intimately involved with patients and members of the health care team, wearing reasonable
clothing and avoiding extremes of dress is imperative. Individual clerkships may have more specific
criteria.
GUIDELINES:
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All students shall wear their white lab coats, unless the department indicates otherwise.
General attire must be clean and neat at all times.
Appropriate attire is considered to be dress shirts, dresses, pantsuits, blouses, skirts, sport coats,
dress slacks, and shirts with collars.
Jeans, tennis shoes, shorts, skirts three inches of more above the knee, tube tops, low cut tank
tops, t-shirts, midriff tops, sundresses without a jacket or blazer, see-through and low cut blouses,
sweatpants, sweatshirts, and leather attire are considered inappropriate attire.
When patient care responsibilities necessitate physical contact do not wear large bulky jewelry or
jewelry that may inadvertently cause injury to patients.
Hair should be neatly arranged in such a manner that it does not fall on patients and cannot be
grabbed by a patient. Facial hair should be neatly groomed to present a professional image.
Perfume, cologne, or other fragrance products should be moderately used to avoid being
offensive or causing discomfort to others.
Undergarments should not be visible through outer clothing.
OSHA requires that shoes must be closed-toed in the patient care areas (no flip-flops or sandals).
Shoes should be of reasonable height and comfortable enough for the student to be able to
respond to any type of emergency in a healthcare setting.
Visible body piercing must be conservative and jewelry must be small in size.
CDC requires that fingernails be kept clean and short for patient care and for the proper fit of
gloves or other protective equipment. Artificial Nails are not permitted.
Scrubs need to be covered when leaving patient care areas.
COMPLIANCE:
All students are expected to comply with these guidelines. If a faculty preceptor deems the student’s attire
is inappropriate, the student will be counseled appropriately and may be sent home to correct attire
before returning to their duties.
O. COM: IDENTIFICATION BADGES
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Students are to wear their College of Medicine Identification badges at all times while on any
clinical rotation.
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Students are to wear their hospital issued identification badge at all times during any clinical
rotation which requires the student to be present in that particular facility.
o It is the student’s responsibility to keep their VA credentials current in accordance with
VA policy during their M3 and M4 year. Students may not participation in any rotation
occurring at the VAMC without a valid VAMC identification badge.
P. COM: STUDENT CONTACT PHONE NUMBERS
The student is responsible for providing a local area code contact phone number or pager number for use
by rotation coordinators. If contact information has changed, the change should be made in Banner,
which will update information in New Innovations.
3. SCHEDULES
A. CLERKSHIP SITE ASSIGNMENTS are posted in New Innovations for each rotation and
distributed at clerkship orientation.
B. STUDENT EDUCATION CONFERENCE (SEC)
The SEC or Academic Half Day will be held each Thursday afternoon in an effort to help bolster medical
knowledge as well as help students develop their medical management skills. Faculty and residents will
be responsible for facilitating each session that will consist of up to date audio lectures followed by a
“Washington Manual” review session. The class will culminate in a case conference
Week 1:
Week 1.
Week 2:
Week 2:
Week 3:
Week 4:
C.
CHF, ACS, A fib, EKG’s
Asthma, COPD
Fever/Infection
DVT/PE
CVA/Seizure Disorder
DKA
QUIZ SCHEDULE:
Week 2:
Week 3:
Week 4:
Week 5:
Cardio and Pulmonary
Hematology and ID (midterm review forms due)
Gastroenterology and Neurology
Endocrine and Nephrology (written H&P’s due)
D. DEPARTMENT OF MEDICINE “GRAND ROUNDS” CONFERENCE
Every Tuesday at 8 a.m. at the Votaw Auditorium located at the ETSU Physicians and Associates
building there is “Grand Rounds.”
Please inquire with your attending at each specific training site
regarding attendance. If you are directed to attend the “Grand Rounds” then you will report back to your
respective sites following its conclusion at 9 a.m.
E. CARDIAC REHABILITATION
As a component of Internal Medicine, students will attend a lecture given by Dr. Timir Paul –
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ETSU Physicians, Cardiologist. The goals of cardiac rehabilitation lecture are to introduce the student to
how rehabilitation can improve patient functioning through:
 reduction, modification and/or elimination of the health risks associated with chronic disease, and
 restoration, maintain and/or improvement of the patient's physical function and quality of life.
4. ASSESSMENTS
A. CLERKSHIP GRADING – The Clerkship graded activities and NBME exam policy are under
revision and will be distributed as soon as available.
Item
weight
Faculty observation
35%
Quizzes
20%
Graded H&Ps
10%
NBME
35%
Your final grade will be based on a 100 point scale. There is no certain score you have to achieve on the
NBME exam, however, performing well on it helps your chances of obtaining the highest possible grade.
Students are excused from clinical duties the day before the NBME end of course exam and the day of
the exam.
Faculty Observations: Individual faculty assessments based on observation of each student will be
combined into the final composite assessment form for each student. The final composite containing
faculty comments and ratings are the basis of this component of the final grade. Particular focus will be
on student’s clinical acumen while on the inpatient service.
History & Physical Examination: The written H&P is due by week 5 (during the Student Education
Conference on Thursday.) The H&P will be graded and returned to each student prior to the final quiz.
This H&P should be formal and legibly written or typed. The H&P should be as detailed as possible
particularly in the assessment and plan section. Points will be deducted if: 1) the chief complaint is
omitted, 2) the assessment and plan is not appropriately detailed, including differential diagnosis, or 3) an
explanation of reasoning is missing. The template to be used can be found in the Appendix.
*Please remember that the mid-term review does not count toward your final grade but serves only as a
tool to help gauge progress at the mid-point of the rotation.
B. COM: CLERKSHIP GRADE SCALE
A=100-90 (Excellent) B=89-80 (Good) C=79-70 (Adequate) D= below 70 (Remediate part of the course)
F=Below 70 (After attempted remediation = repeat the course) I=Incomplete R=Review by Student
Promotions Committee
For Specialties Clerkship only: P (Pass) =70 and above F=Below 70 (Repeat the course).
Any grade less than a C requires a deficiency grade sheet to be submitted to the COM Registrar’s office
outlining the issues and remediation plan. All will be discussed at the next regularly scheduled Student
Promotions Committee meeting.
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D = Requires review and approval of the remediation plan by the Student Promotions Committee.
A “D “ grade indicates that in the judgment of the course faculty, an additional period of prescribed
remediation (assuming no deficiencies in other courses), if successfully completed, will qualify a student
for a grade of C*. If a grade of D is not successfully remediated in the time period allotted by the faculty
and/or the Student Promotions Committee, a grade of F will be assigned.
I = Incomplete, requires completion of work within 12 months or grade will automatically be changed to
an F. A grade of “I” may be given in cases wherein students, for an acceptable reason, have been unable
to complete all of the required work in a course. An incomplete grade must be removed within twelve
months after it has occurred or it will automatically be changed to F. If the student removes the
incomplete within the time period, the instructor may assign any appropriate grade according to the
quality of the work completed for the entire course.
R =Review by Student Promotions Committee; If for some appropriate reason a course faculty wishes to
insure that the performance of a student is discussed at a Student Promotions Committee (SPC)
meeting, a grade of R (review) may be assigned. Following the consideration by the SPC, the R will be
changed to the appropriate grade.
C. COM: NBME EXAMINATION POLICY
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NBME End of clerkship exams will be administered the last day of the clerkship. Specific time
and location information will be provided by each clerkship.
If a student is not present at the announced location and time the exam is to begin, that student
will have to make special arrangements to take the exam at another time/location and will receive
a grade of “I” for the rotation. No Requests for Leave will be granted for scheduled exam
times.
Students must bring a laptop computer with Ethernet capability and related cables for the exam.
The exam cannot be taken wirelessly.
No food or drinks of any type are permitted in the exam area.
Books, all electronic devices, including cell phones, and other personal items, including baseball
caps, are not permitted in the exam area. These items should be left at home, in lockers or cars.
Examinations will be proctored by staff and/or faculty from the department responsible for
administering the examination.
Students will be required to sign in. ETSU ID cards are required.
Students may leave the room to attend to personal needs. They may not remove any items from
the exam room and may not talk with classmates while out of the room.
D. COM: STUDENT COMPUTER USAGE DURING ELECTRONICALLY
ADMINISTERED QUIZZES/ EXAMS POLICY
This policy has been developed to address the problem of students appearing for computer administered
quizzes or exams without a laptop computer that meets the specifications set forth in the QCOM Student
Catalog.
Every student is responsible for having a functioning laptop computer that meets these
specifications. Currently, mobile devices (e.g., iPads) are not compatible with the testing environment.
Any student who experiences computer problems should meet with the IT Manager (Daniel McLellan) to
attempt to resolve the problem in advance of a scheduled quiz/exam. It is understood that some technical
issues may not be resolved and that last minute issues may arise. If a student experiences issues
immediately prior to the quiz/exam, they should bring their laptop to the quiz/exam for examination by the
IT Manager. Only those students who contact the IT Manager no later than the day prior to the quiz/exam
for a known problem, or who present their malfunctioning laptop the day of the quiz/exam, or who
experience technical issues during the quiz/exam will be provided a laptop for the quiz/exam by the
College of Medicine.
Failure to adhere to this policy will result in consequences related to both the grade assigned and
professionalism assessment. The student’s quiz/exam score will be reduced by 10 points and a
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Professionalism Report form will be submitted for any student who requests use of a College of Medicine
computer but had failed to contact the IT Manager prior to the quiz/exam day or to present their
malfunctioning laptop the day of the quiz/exam.
5.TIPS FOR LEARNING
TOP 10 WAYS TO EXCEL ON THE INTERNAL MEDICINE CLERKSHIP
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Find out what your preceptors expect of you. Meet and try to exceed their expectations.
Go the extra mile for your patients. You will benefit as much as they will.
Go the extra mile for your team. Additional learning will follow.
Read consistently and deeply. Include what you learn in your discussions with your team and in
your notes.
Follow through on every assigned task.
Ask good questions.
Educate your team members about what you learn whenever possible.
Speak up – share your thoughts in teaching sessions, share your opinions about your patients’
care, constructively discuss observations about how to improve the education you are receiving
and the systems around you.
Actively reflect on your experience.
The more you put in, the more you will get out.
 Be caring and conscientious and strive to deliver outstanding quality to your patients as you learn
as much as you can from every experience.
 Treat every member of the health care team, the clerkship team, and every patient with respect.
 Answer your pager and email in a reasonable time frame.
 Make sure your handwriting is legible and ensure every note includes your name, role, and pager.
 Adapt and be professional. An open mind is expected.
 Be pro-active – seek out learning opportunities.
 Ask questions.
 Be flexible – each day will be different.
6. LEARNING RESOURCES
A. Textbooks for Reading: all are available for loan during the clerkship and can
be obtained from the office of the Clerkship Secretary
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Dr. Berk’s Pre-Test Medicine: Self-Assessment and Review
Harrison’s Principles of Internal
Step Up To Medicine
Cecil’s Essentials of Medicine – 7th Edition
Bates History and Physical Examination – 11th Edition
B. References and Materials to read: (Optional)
Balady GJ, Williams MA, Ades PA, et al. Core Components of Cardiac
Rehabilitation/Secondary Prevention Programs: 2007 Update: A Scientific Statement from the
American Heart Association and AACVPR. Journal of Cardiopulmonary Rehabilitation and
Prevention. 2007;27:121-129.
Balady GJ et al. Core components of cardiac rehabilitation/secondary prevention programs:
2007 update: Circulation. 2007;115(20):2675-2682.
N.K. Wenger. Current Status of Cardiac Rehabilitation. Journal of the American College of
Cardiology. 51(2008), pp. 1619–1631.
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Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship Between Cardiac
Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly
Medicare Beneficiaries. Circulation. 121(2010); pp 63-70.
Suaya JA, Stason WB, Ades PA, et al. Cardiac Rehabilitation and Survival in Older Coronary
Patients. J. Am. Coll. Cardiol. 2009;54;25-33.
Geol K, Lennon RJ, Tilbury RT et al, Impact of Cardiac Rehabilitation on Mortality Following
Percutaneous Coronary Intervention. Circulation. 2011;123:2344-2352.
Many books are available from our COM Library portal at http://www.etsu.edu/medlib.,
including board review resources. Appropriate use of electronic material is governed by
copyright and Intellectual Property Laws.
C. COM: STUDENT PROCEDURES FOR SPECIAL SERVICES (ADA)
ABSENT A LETTER FROM DISABILITY SERVICES, STUDENTS ARE NOT
ELIGIBLE FOR ACCOMMODATION
It is the policy of ETSU to accommodate students with disabilities, pursuant to federal law, state law and
the University’s commitment to equal educational access. Any student with a disability who needs
accommodations, for example arrangement for examinations or seating placement, should inform the
instructor at the beginning of the course. All students seeking accommodation for disabilities are to
contact Ms. Linda Gibson, M.Ed., Director, ADA Coordinator for Disability Services at East Tennessee
State University (439-8346). Faculty accommodation forms are provided to students through Disability
Services in the D. P. Culp center, Suite A.
D. COM: TUTORING
The Office of Student Affairs will make tutors available to any QCOM student. Contact Student Affairs at
439-2037.
E. COM: COUNSELING
Confidential academic and personal counseling are available through the Professional and Academic
Resource Center – PARC (Mr. Phil Steffey, 232-0275 or pager 854-0342.)
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APPENDIX A
IM H&P TEMPLATE
APPENDIX B:
BULLETED LIST OF EXPECTED BEHAVIORS FOR PRE-ENTRUSTABLE AND
ENTRUSTABLE LEARNERS
LINK TO COLLEGE OF MEDICINE INSTUTIONAL OBJECTIVES
HTTP://WWW.ETSU.EDU/COM/MSEC/DOCUMENTS/INSTITUTIONALEDUCATIONALOBJEC
TIVES_LATESTVERSION.PDF
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INTERNAL MEDICINE HISTORY AND PHYSICAL TEMPLATE
Identifying Data
Name, Date of Birth, Account number (dictation identifying information as required by site)
Primary care doctor
Chief Complaint: (in patient’s own words)
History of Present Illness (HPI)
Course
Onset
Duration
Intensity
Exacerbating factors
Remitting Factors
Signs and symptoms associated
From whom information obtained
Last meal
Under the influence of drugs or alcohol
Poor historian/Good historian
Other pertinent info for example:
If cardiovascular: risk factors- obesity, htn, hpl, family
history, smoking, diabetes, male >45yo
Past Medical History
Childhood and Adult diseases (medical, surgical, ob-gyn, psych)
Blood transfusion history (antibodies?- if known)
Hospitalizations
Past Surgical History
Prior surgery types, complications, approximate date
Current Medications
Name, dosage and whether adherent, last time taken, recent adjustments or additions, include over the
counter vitamins and minerals
Allergies
Drugs, contrast media, latex, foods (include the reaction to differentiate adverse reaction from allergy)
Social/Sexual History
Social: Smoking (pk-yr history), ETOH, caffeine, substance abuse, education level, occupation (current and
past), marital status, children, lifestyle (activity level, eating habits), religion, type of support from family, living
environment, recent changes
Sexual: Sexual orientation (if applicable) menstruation information for females, ED for males? birth
information, contraception, libido, symptoms/issues
Special Needs Assessment
Sleep assessment- sleep apnea screen (use CPAP? daytime sleepiness)
Hearing aid- does patient have hearing aid or difficulty hearing- has with them?
Vision- does patient wear glasses- have with them?
Does patient use cane or walker prior to hospitalization?
Fallen in the past year?
Depression screen- SIGECAPS
Pain Management- have pain normally, how controlled/ problems with requiring additional medications,
any signs of abuse/dependence (loss of family support, legal issues,
Dysphagia screen-Problems with choking or swallowing prior to hospitalization?
Chronic Foley- last time changed
Oxygen requirements- Home oxygen? Continuous? Nocturnal?
Reading comprehension- literacy level, problems with reading
Review of Systems (in patient terms)
GENERAL/CONSTITUTIONAL: overall general health changes, fever, chills, fatigue, weakness, changes in
sleep, sweats, appetite changes, weight gain or weight loss.
HEAD, EYES, EARS, NOSE AND THROAT:
Head- headache, trauma, migraines
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Eyes –pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling
that something is in the eye, vision correction issue.
Ears, nose, mouth and throat. -Ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry
sinuses, sinusitis, post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry
mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant feeling of a need to
clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or throat, food sticking in
throat when swallows or painful swallowing, new lumps or bumps in neck/thyroid area noted
CARDIOVASCULAR: chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation,
shortness of breath, difficulty breathing at night, swollen legs or feet, heart murmurs, high blood pressure, cramps
in his legs with walking, pain in his feet or toes at night or varicose veins.
RESPIRATORY: chronic dry cough, coughing up blood, coughing up mucus (purulent? Amount?), waking at
night coughing or choking, repeated pneumonias, wheezing or night sweats, occupational exposures, TB
history/testing, pain with deep breath, shortness of breath, fast breathing.
GASTROINTESTINAL: decreased appetite, nausea, vomiting, vomiting blood or coffee ground material,
heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow skin, generalized itching,
diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids, colonoscopy and results
GENITOURINARY: difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky
urine, frequent need to urinate, urgency, needing to urinate frequently at night, inability to hold the urine,
discharge from the penis, kidney stones, rash or ulcers, sexual difficulties, impotence or prostate trouble, exposure
to sexually transmitted diseases, abnormal PAP smears, changes in menstruation or bleeding, discharge, pain with
intercourse
MUSCULOSKELETAL: arm, buttock, thigh or calf cramps, joint or muscle pain. Muscle weakness or
tenderness. Joint swelling, neck pain, back pain or major orthopedic injuries, limited movement in any joints
SKIN AND BREASTS: easy bruising, skin redness, skin rash, hives, sensitivity to sun exposure, tightness,
nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple
discharge.
NEUROLOGIC: headache changes, dizziness, fainting, lightheadedness, muscle spasm, loss of
consciousness, sensitivity, tingling or pain in the hands and feet or memory loss, seizures, shaking/tremor,
problems with speech.
PSYCHIATRIC: depression, thoughts of suicide? nervousness, panic attacks, attention problems,
hallucinations (visual or auditory), delusions, substance abuse, not sleeping for >3 days, and if so reason, changes
in personality, previous treatment for psychiatric issues
ENDOCRINE: intolerance to hot or cold temperature, flushing, fingernail changes, increased thirst,
increased urination, increased salt intake or decreased sexual desire.
HEMATOLOGIC/LYMPHATIC: anemia, pallor, bleeding tendency or clotting tendency, lumps or bumps
neck, armpits or groin area
Physical Examination
General Appearance
Development Nourishment Body habitus Deformities Attention to grooming Comprehension
and language skills (also noted in history)
Vital signs
Temperature, height and weight (if question repeat) Respiration Pulse – regular, irregular or
irregularly irregular (as in atrial fibrillation – A fib) Blood pressure (BP) – both arms - check for orthostatic
hypotension by taking blood pressure with patient sitting - (if orthostatic hypotension considered-obtain BP lying,
sitting, standing and in legs (if coarc aorta considered)
HEENT
Head
Shape, scars and size
Eyes
External eye structures-Visual acuity – use pocket-sized visual cards, color chart Extra ocular
movements (EOM) and convergence
Pupillary light reflex (direct and consensual) and accommodation Visual
fields by confrontation Ophthalmoscopy
Ears
External canals-Gross hearing (rub fingers together next to ears) Weber test – place tuning
fork in middle of forehead
Rinne test – place tuning fork behind ear on mastoid process Otoscopy – look
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at tympanic membrane
Nose
External nares (polyps, condition of mucosa), turbinates, septum (deviation from the
Center – from fracture) Sinuses (tap them for tenderness, particularly over the maxillary sinus)
Throat
Lips (pale – anemia, cold sore – viral infection)
Buccal mucosa (pale – anemia)
Gingiva (gums) – bleeding, hypertrophy (thick and swollen due to taking Dilantin)
Teeth –
presence, state of repair, dentures
Hard and soft palates – clefts, masses
Tonsils – (red, swollen
with exudates – tonsillitis)
Floor of mouth – (ranula – stone in duct of sub maxillary gland)
Gag
reflex
Neck
Scars, masses
Anterior and posterior cervical nodes
Carotid artery pulse (also, auscultate for a
bruit first)
Observe jugular vein for distention (increased jugular venous pressure – JVP)
Check for
tracheal position in midline and for free movement of trachea
Palpate thyroid gland for enlargement and
nodules
Chest
Anterior
Inspect sternum (marked central depression of sternum – pectus excavatum, pigeon
breast – pectus carinatum)
Inspect ribs (point tenderness – fracture of rib)
Inspect for scars
and for symmetrical movement of chest wall with breathing Palpate for symmetrical movement of chest wall on
breathing and for tactile fremitus
Percussion for resonance, dullness, flatness, tympany Auscultation for
breath sounds
Posterior Inspect for scars, contour, symmetrical motion on breathing, shape and appearance
Palpate for symmetrical motion on breathing and for tactile fremitus
Percussion for resonance,
dullness, flatness, tympany and for movement of diaphragm on both sides
Auscultation – breath sounds,
rales (crepitations), egophony, bronchophony, whispered pectoriloquy and rubs
Breasts
Inspect and palpate Dimpling of skin (peau d’orange – cancer) Tenderness – infection All quadrants
and tail process of Spence Axillary nodes, areolae
-Discharge (galactorrhea, blood and pus)
Chest wall pain – very tender costchondral junctions (Tsetse’s Syndrome)
Heart
Sitting and lying down (examine all 4 areas – mitral, tricuspid, pulmonary, and aortic) Inspect – scars
(midsternal scar – CABG), pulsations
Palpate – Point of maximal impulse (PMI), heaves, thrills, lifts
Auscultate - heart sounds, rubs, gallops (S3 and S4) and murmurs
Location refers to where the heart murmur is usually auscultated best. There are four places on the anterior chest wall to listen for
heart murmurs; each of the locations roughly corresponds to a specific part of the heart and should be auscultated with the patient lying
supine. The four locations are:
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Aortic region - the 2nd right intercostal space.
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Pulmonic region - the 2nd left intercostal spaces.
•
Tricuspid region - the 5th left intercostal space.
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Mitral region - the 5th left mid-clavicular intercostal space.
Additional maneuvers can be performed for additional auscultation:
• Left lateral decubitus. With the patient sitting upright, with the patient leaning forward and exhaling.
Radiation refers to where the sound of the murmur radiates. The general rule of thumb is that the sound radiates in the direction of
the blood flow.
Intensity refers to the loudness of the murmur, and is graded according to the Levine scale, from 1 to 6
1.
The murmur is only audible on listening carefully for some time.
2.
The murmur is faint but immediately audible on placing the stethoscope on the chest.
3.
A loud murmur readily audible but with no palpable thrill.
4.
A loud murmur with a palpable thrill.
5.
A loud murmur with a palpable thrill. The murmur is so loud that it is audible with only the rim of the stethoscope touching the
chest.
6.
A loud murmur with a palpable thrill. The murmur is audible with the stethoscope not touching the chest but lifted just off it.
Pitch may be low, medium or high and is determined by whether it can be auscultated best with the bell or diaphragm of a
stethoscope.
Quality refers to unusual characteristics of a murmur, such as blowing, harsh, rumbling or musical.
A mnemonic to remember what characteristics to look for when listening to murmurs is SCRIPT: Site, Configuration (shape),
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Radiation, Intensity, Pitch and quality, and Timing in the cardiac cycle.
The use of two simple mnemonics may help differentiate systolic and diastolic murmurs; PASS and PAID. Pulmonary and aortic
stenoses are systolic while pulmonary and aortic insufficiencies (regurgitation) are diastolic. Mitral and tricuspid defects are opposite.
Abdomen-Lying flat
Inspect – scars, masses, contour, venous pattern
Auscultate – bowel sounds, bruits Percussion – all
four quadrants – if pain elicited in any quadrant be gentle on palpation so as not to have the patient suffer
unnecessary pain Palpate and percussion (a) Superficial and deep palpation (all 4 quadrants) (b) Liver and Spleen
for consistency and size (c) Hepato-jugular reflex (d) Shifting dullness (e) Fluid wave (f) Masses and hernias –
include inguinal area
Rectal exam-sphincter tone, rashes, hemorrhoids? obvious bleeding amount, or occult blood testing
results
Genitourinary
Peripheral vascular
Palpate Carotid pulse – also auscultate for a bruit first
Radial pulse
Femoral pulse – also
auscultate for bruit
Popliteal pulse Dorsalis pedis (DP) pulse Posterior tibial (PT) pulse
Musculoskeletal
Inspect and palpate
Bones, joints and spine
CVA tenderness
Sacroiliac tenderness Sacral
edema -Muscle atrophy, muscle strength Tenderness, warmth, swelling and redness of joints, as well as for
stability and also for whether a joint effusion is present Range of motion (ROM) of joints (perform only if there is a
joint problem)
– elbows – wrists – fingers Chest – spine (thoracic and lumbar) kyphosis, scoliosis
Hips – knees – ankles
Neurologic
Mental status Level of consciousness
Orientation to time (date), place (where are you?), and
person (your name)
Memory - remember 3 words (recent memory), well-known past event (remote
memory) Insight and judgment – reaction to a simple problem Affect – emotional response to an
event
Intellectual ability – series of 7s (100 – 7)
Speech, language and comprehension
(a) Aphasia – acquired disturbance of language
1. Motor – expressive
2. Sensory – receptive
(b) Dysarthria – disturbance of speech due to problems with articulation of sounds
(MMSE) or SLUMS exam – used in geriatric patients
Cranial nerves I – not tested
II – visual acuity, visual fields by confrontation (already done under Eyes)
III, IV and VI – extra-ocular movements (EOM), light reflex (direct and consensual), nystagmus
(already done under Eyes)
V – sensory and motor of face
(a) Sensory – test ophthalmic, maxillary and mandibular divisions
(b) Motor – ask patient to bite down hard – feel contraction of masseter muscles
VII – smile, ask patient to close eyes tightly and don’t let you open them, wrinkle
Forehead (bilaterally innervated)
VIII – hearing, Weber and Rinne tests (already done under Ears)
IX – X – gag reflex (already done under Throat)
XI – shrug shoulders – palpate both trapezii muscles and feel contraction, push chin against
Examiner’s fingers of one hand and examiner feels contraction of sternocleidomastoid
Muscles with his other hand
XII – stick out tongue – it should be in midline; if to either side, it points to the side of the l
Lesion (already done under Throat)
Motor system
Test muscle strength and resistance to passive motion (part of Musculoskeletal
Examination, but fits in here much better)
Reflexes – biceps, triceps, brachioradialis, knee jerk (KJ),
ankle jerk (AJ)
Babinski reflex
Inspect for (a) Tremor - involuntary shaking (b) Fasciculations - irregular,
involuntary muscle twitching (c) Spasticity – involuntary increased muscle tone with progressive stretching of
muscle (d) Rigidity – involuntary increased muscle tone throughout range of motion of
muscle (e) Atrophy - loss of muscle mass (f) Flaccidity – floppiness of muscle (g) Chorea – involuntary
twisting and writhing motion (h) Myoclonus – involuntary shock-like motion of muscles with extreme twisting
of joints (i) Dystonia–involuntary, persistent, fixed contraction of muscle
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Sensory system Pain and temperature (use sharp side of pin)
Light touch (use dull side of pin)
(NB – pain and light touch are performed together on hands and lower forearm as
well as on feet and lower leg) Two-point discrimination Position sense and vibration (testing posterior
or dorsal column) – hold lateral aspects
of both great toes and both thumbs and move up and down – ask patient to close eyes
and identify movement as up or down
Romberg test – stand with feet together, arms stretched
forward, eyes open and have
patient close eyes (be careful to be ready to catch patient if patient begins to fall) – if patient losses
balance or sways with eyes open, cerebellar disease is probably present; if this occurs with eyes closed, but not
when eyes are open, then position sense is impaired
Cerebellum
Finger to nose test - eyes open (if eyes closed, testing position sense)
Heel to
knee (shin) – eyes open (if eyes closed, testing position sense)
Alternating movements
Gait Posture-Walking – normally, on toes, on heels and in tandem
Assessment and Plan
The assessment starts with a summary statement. In the summary statement, put foreground issues first
(i.e. presenting complaint and important findings from your history, physical, and data sections) and then state the
background issues (age, pertinent past medical history). The assessment should include a discussion of the
differential diagnosis and your clinical reasoning. Divide your differential diagnosis into categories of “likely”, “less
likely”, “less likely but immediately life-threatening”, and “unlikely” diagnoses. . List the most likely diagnoses
first. As you weigh your differential diagnosis, you should support your reasoning with findings from your history,
physical, and work-up, and information you gathered from your reading. The assessment is a discussion of your
patient, NOT a reiteration of your reading. This is your opportunity to show how you are thinking about a case.
References should be used for every patient and noted at the end of your write-up.
All problem lists in the History and Physical should be problem-based, not organ system-based, In some
cases, the problem will be a symptom (abdominal pain); in other cases, when a diagnosis is established by the data
you have already collected, it will be a diagnosis (pancreatitis). For example, the headers for your discussion in the
problem list would be:
1. Pancreatitis or Abdominal Pain not Gastrointestinal- abdominal pain
Or
1. Pneumonia not Respiratory/Pulmonary- shortness of breath or pneumonia
The goal is as you progress through the hospitalization you will be able to further reason out the possible
differential diagnosis listed initially in your assessment and develop a firm diagnosis by discharge. Each day you can
discuss what aspects of the initial assessment are no longer valid and continue to refine
Each medication should have a problem associated with it. If it is stable and not going to impact the
hospitalization, it does not need to be carried through as a problem on daily SOAP notes. These should include only
the active problems being treated.
A plan/intervention should be developed under each problem listed. If it is stable and no intervention
required, document this information
Code Status includes any discussion information and who was present for decision, living will?
Prophylaxis- DVT and GI (if not needed for either document reason)
Disposition- planned disposition of patient at time of discharge
Immunization Status: up to date on immunizations?
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