Sanjeet Patel, M.D.

Talk to the student leaving your service
 Logistics
 when and where
 patient list
 what are the med/surg issues
 anything interesting during the case
 Expectations
 who pimps?
 what do they pimp about
 what forms do they use, how do you fill it out
 what was deemed “helpful”
 Tips or advice

Prepare for anything

Professional Attire unless you are IN THE OR
 Clinics
 ALL conferences
 AM rounds
Always bring scrubs
Clean white coat

Think about how you want to be perceived
Medical student vs. physician-in-training

Stethoscope around neck
Backpack on rounds
Scruff
Hats
Strong cologne
Long fingernails
Long fingernails
Strong perfume

Attending
Fellow
Senior
Resident
Junior
Resident
Intern
MS III
Each person plays a vital role

Watch what the intern does or doesn ’ t do
 Organizing information
 Presenting at rounds
 Making decisions
 Talking to patients
You will soon be in his or her shoes
 BUT! do not tell a patient something you dont
 know; or worse something they didnt know...

Pre-rounds: 5:30 AM
Rounds: 6 – 6:30 / 7AM
Preop / Breakfast / Conference 7AM
OR 7:30 AM / Clinic 8 AM
Afternoon rounds 1 – 6 PM
Go home / On-Call

Arrive at the hospital early
See and examine your patients
Check and record vitals & I/Os
Look through chart
 Notes from previous day
 Orders (overnight events, new meds)
 Review MAR every day
Ask RN or on-call resident about issues

Know/record all pertinent information
 Initial H&P (including PMH, PSH, Meds, etc)
 Preop and postop course
 Salient events
5 x 7 index cards (Watch the R3)
Printed patient info sheets

Daily information on floor patients

Daily information on ICU patients

SOAP format
Concise
Try to come up with your own assessment and plan
Finish note before you leave for the AM
 DO NOT keep notes in your pocket
 Notes must be co-signed by resident

BE ON TIME!
Pay attention to everyone & everything
Present your patients
Be helpful
 Change dressings : if rounding either have
 whats needed in your hand or do it yours
 Gather charts
Be engaged

Patient name
HD/POD # for procedure/diagnosis
Antibiotic name and day #
Diet
Overnight events
Subjective
Objective
Assessment and plan

Name:
Post-op day:
Procedure/Dx:
Antibiotics:
Diet:
“ Mr. Smith is post-op day #1 from sigmoid colectomy for diverticulitis.
Cefoxitin day 2.
NPO.
”

MAJOR events only
Be concise
“ The patient had an unwitnessed fall while attempting to get out of bed. He said he fell on his left side. Neurological and musculoskeletal exams have been unchanged from baseline. CT of the head was unremarkable.
”
“ No events overnight.
”

Relevant information or complaints that the patient tells you
“ The patient ’ s pain has improved after his PCA was discontinued yesterday. The patient ambulated twice without difficulty.
The patient passed flatus, but did not have a bowel movement. He has been nauseated all day but did not vomit.
”

Temperature
T max and T current
Blood pressure
Range & Current
Pulse
Range & Current
“ Vitals: Tmax 100.4, current 98.6.
120-175/65-95, currently
110/65.
80-115, currently 76.
RR
Range & Current
14-18.
O2 sat
Range & Current
Supplemental O2
O2 sat 94-96% on 2L nasal canula.
”

Temperature
T max and T current
Blood pressure
Range & Current
20-175/5-95
10-115.
Pulse
Range & Current
RR
Range & Current
“ Vitals: Tmax 100.4,
14-68.
“fine.
”
O2 sat
Range & Current
Supplemental O2

Total first, then breakdown
“ I/Os 2050 in and 1980 out.
Ins
 IVF (type & rate)
 TPN
 PO
 Tube feeds (type & rate)
For ins, 1800 was IV fluid
(75 cc/hr D5 ½ NS) and
250 was PO.
Outs
 Urine
 BM
 Drains (amt & kind)
 NG tube (amt & kind)
 Chest tube (amt & kind)
For outs, 1800 was urine.
JP #1 put out 75 cc of serosanguinous fluid and
JP#2 put out 105 cc of bilious fluid.
”

Total first, then breakdown
“ I/Os 2050 in and 80 out.
Ins
 IVF (type & rate)
 TPN
 PO
 Tube feeds (type & rate)
For ins, 1800 was IV fluid
(75 cc/hr D5 ½ NS) and nothing recorded was
PO.
Outs
 Urine
 BM
 Drains (amt & kind)
 NG tube (amt & kind)
 Chest tube (amt & kind)
For outs, 80 was urine. nothing else was recorded Dr. Hines.
”

Do a full focused physical exam daily
Present only pertinent positives & negatives
ALWAYS examine the wound carefully
 Remove post-op dressings on POD #2, then change every day
 Monitor for erythema, warmth, drainage
“ Exam was significant for rhonchi throughout both lung fields.
Bowel sounds are absent.
Abdomen is somewhat distended and tympanic.
The wound is clean and dry.
”

AM labs often not back before rounds
Know shorthand for recording labs:
Always look at films yourself before you read the radiologists report

This is your best opportunity for thinking and learning.
Think in terms of systems so you will never forget anything.
You can come up with an incorrect assessment and a terrible plan, but you will be a step ahead of the student who can ’ t come up with one at all.

Is the patient awake?
Is pain controlled?
Is blood pressure controlled?
How is the heart rate?
Are there preop cardiovascular problems that should be addressed?

If the patient is on a ventilator:


Can the vent settings be weaned?
Can the patient be extubated?
If the patient is on supplemental O2:
 Can this be weaned off?
Is the patient using an incentive spirometer, really is the patient using IS??????
Is he/she receiving chest physiotherapy?

Is the UOP adequate?
Has the foley been removed?
Is the patient febrile?
Is the WBC elevated?
Are there any culture results back yet?
Can any antibiotics be stopped?

Wind, POD1-2, atelectasis*, aspiration, pna
Water, POD3-5, UTI
Walking, POD4-6, DVT or PE
Wound, POD5-7, wound infxn
Wonder drugs, drug fever

Is the hematocrit stable?
Are platelets & coags normal?
Is blood glucose well controlled?

Are the bowels working yet?
 Can the NGT be removed?
 Is the patient passing gas or having BMs?
Is the diet appropriate?
Do electrolytes need to be replaced?
(Ca, Mag, Phos, K)
Can the IV be heplocked?
How are the nutritional parameters?
(albumin, prealbumin)

Is the patient ambulating?
Is PT/OT needed?
GI prophylaxis:
 H2 blocker or PPI
DVT prophylaxis:
 SCDs or sub-Q lovenox or heparin

IV placement/blood draws
Nasogastric tube placement
Foley Catheter placement
Wet-to-dry dressing changes/Wound care
Stripping of JP drains
Pulling JP drains or chest tubes
Suturing (simple interrupted or subcuticular)
Knot tying (two handed throws)
Incision and drainage of abscess

Find out what cases you will scrub in on
Read – Focus on:
 Indications for surgery
 Disease process
 Anatomy
Know your patient

All patients need pre-op H&P & consent
Help the residents with the H&P
Introduce yourself to the patient
Examine the patient (if appropriate)
Record H&P on your patient info sheets – this is now your patient!

Introduce yourself to all OR staff, especially the circulating and scrub nurses
Pull your own gloves & give to scrub nurse
Write your name on the whiteboard
Ask questions at APPROPRIATE times
Cause as little interruption as possible

If H&P is < 30 days but >24 hours old
Focus on appropriateness for the OR:
 What surgery? Appropriate indication?
 Cardiac/medical workup complete
 History (CVA,CHF, MI, Valvular), DM, Cr > 2.0
 Consents signed & patient understands?
 Likelihood of blood transfusion?
Is there a current type and screen?
Is blood ordered and on call to OR?
Is blood consent signed?

Diagnosis:
Planned Procedure:
Surgeon:
Labs:
CXR/Other tests:
EKG:
Blood:
Consent:

Diagnosis: Acute cholecystitis
Planned Procedure: Laparoscopic versus open cholecystectomy
Surgeon: Dr. Schmit
Labs: LFTs, CBC, Electrolytes
CXR/Other tests: Ultrasound results
EKG: (If done)
Blood: Pt has active type and screen
Consent: Procedure and blood consents signed and in chart.

Pre-Op Diagnosis:
Post-Op Diagnosis:
Procedure:
Attending Surgeon:
Assistant Surgeons:
Anesthesia:
Intravenous Fluids:
Estimated Blood Loss:
Urine Output:
Specimen:
Drain:
Complications:
Condition:

Pre-Op Diagnosis: Right inguinal hernia
Post-Op Diagnosis: Direct right inguinal hernia
Procedure: Repair of right inguinal hernia with mesh
Attending Surgeon: Dr. Charles Chandler
Assistant Surgeons: List resident and med student
Anesthesia: LMA + local
Intravenous Fluids: 500 ml LR
Estimated Blood Loss: Minimal
Urine Output: None
Specimen: Hernia sac
Drain: None
Complications: None (probably but ask resident)
Condition: Stable to PACU

Usually 3-4 hours after OR
Review PACU notes and vitals
Review any post-op labs or imaging
Like a focused SOAP note:
 Pain controlled?
 Vital signs stable?
 Bleeding or drainage on dressing?
 Has patient urinated?
 Drain output and characterization?

Dress professionally and be on time
Go see and examine patients, then present to attending or resident
Be efficient
Like morning presentations, be concise
Try to formulate an assessment & plan
Write a note to be cosigned

Follow up on studies and labs
Check in with the on-call resident
Get vitals and I/Os for the day
See your patient before rounds – sometimes they can tell you more information than anything else!

Usually once per week
Work with the on-call intern/resident
Always bring your own work to do
No call prior to busy clinic days
Excellent opportunity to see consults and learn to make your own decisions

1 review book
For your patients
 Disease process
 Treatment Options
 Surgical Options
1 textbook
For your exams
Systematic, scheduled topic review

Don ’ t disappear
 Sleeping in the call room doesn ’ t count as being there
 Your teammates will quickly tire of having to answer the question, “ Where ’ s
<insert name>?
”
© 2003-2004 Michelle Au http://www.theunderweardrawer.homestead.com

READ!
 Every day
 About your patients
 About your cases
© 2003-2004 Michelle Au http://www.theunderweardrawer.homestead.com