ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
Current Medical Student Manual
This is an updated generic version of a 5th Pathway Program students Manual, for when that
program was active at Pascack Valley Hospital, prior to its closing November 2007. It is stripped
of the particulars of Pascack Valley Hospital where the program was conducted, and is presented
for informational purposes only.
Dear incoming students,
This manual is the start of larger manual that will introduce you to the opportunities and
obligations of your upcoming stay here. It’s recommend you study it thoroughly, and, realizing its
limited nature, make ready with any questions you may have, as well as suggestions you may
have for its improvement. We wish to keep such questions in a FAQ file that will be attached
below.
Though Valley Hospital is not a formal teaching affiliate, there are at times various As a teaching
affiliate of the New York Medical College, we host several levels of trainees from various sources,
so that you need to identify yourself, in conversations and in your notes, at all times:
High School students from local and New York state schools
Pre-medical college students that are part of the Stewart F. Alexander Premedical student
program
5th pathway Program students such as yourselves
PGY-2, 3, 4 residents in surgery and Obstetrics
House doctors in Medicine
Full time attending staff on call in Pediatrics
For Medical Students: You will be assigned a schedule of activities, the order of which you may
have some input into. In each activity there will be specific assignments of a student to their
mentor, in a variety of setting. You need to always be very clear about requirements of these
assignments, and about notifying responsible parties if you are going to be late or unable to
attend at any particular time, as your presence and contribution is being counted upon.
Your responsibilities will match those of 3rd and 4th year medical students; that is to say, you will
be expected to do the following:
Work up admissions by interviewing and examining the patients, prepare a complete history and
physical and follow them through their inpatient stay and write daily progress notes, with
particular emphasis on:
--history,
--physical findings,
--problems/diagnosis list, and
--diagnostic and treatment plans—
these are the key items. Your written notes should be neat and readable, and as they may
become part of the patient’s medical record, should accurately reflect the ongoing of the patient
and the opinions of the treating team. This means you must communicate with the patient and
responsible parties ahead of time about the contents, as well as being responsible for having
them reviewed, amended if necessary, and cosigned by your mentor or an appropriate substitute.
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
Only after they are signed may these notes become part of the chart, so I recommend you write
them on a fresh new page and put a line through the remainder of the page.
Similarly, you will perform histories and physical in the clinic or ER setting, and prepare
appropriate notes.
You must remember that you must submit copies of 3 complete history and physicals or similar
comprehensive notes per rotation to be able to get a proper evaluation or recommendation. This
cannot be overemphasized.
You are encouraged to perform bedside procedures in a supervised setting and are required to
keep a log of all the procedures you have performed, any complications encountered, or any
complication you have otherwise observed elsewhere or helped manage, and have each entry
countersigned by the supervising mentor.
Below is a list of bedside procedures you are allowed to perform, and the appropriate level of
supervising mentor you must employ. These mentors are expected to be beside you when
obtaining consent, performing the procedure and when informing the patient of the results
afterwards and formulating post-procedure orders, as may be indicated:
procedure
Rectal Exams
IV insertions
# that you need to
perform supervised
before you do one
independently
10
4
NG tube insertions
Foley
Venipuncture
Hanging blood
products
ABG
4
4
4
All the time
Pelvic exams
PAP smears
10
10
Appropriate mentor
Resident, MD,
Technician, RN,
Resident, MD,
RN, Resident, MD
RN, Resident, MD
RN, Resident, MD
RN,
Resident, MD,
Technician
Resident, MD, trained
nurse/clinician
Having the roster ready at hand assures that items get listed and co-signed, and allows you to
proceed solo in areas you have shown expertise. It is also an invaluable tool for you to show the
supervising team or mentor of what you have been capable of in the past and build their
confidence in you, so that they will count on you in the future when occasion arise for further
procedures to be performed.
Preparation for working on the medical wards:
Working on the medical wards, needless to say, will be one of the most demanding things you
will be asked to do. The better you are prepared for it, the better you will meet those demands
and the more you will get out of it personally and professionally. Again, the better you are
prepared, the more you will be able to show everyone your competence, the more you will be
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
included in the process of the ward, which will teach you exponentially more, and increase your
confidence. Not to mention, the better your evaluations will be.
Preparation can be divided into several aspects:
1. Organization.
2. Fund of knowledge.
3. Procedural skills.
Organization--is crucial to remaining efficient in integrating large amounts of relevant
information, as well making yourself an efficient house staff that can be counted on. This is also
crucial factor in patient care safety. Having a clip board and at least a sheet of paper that is
organized in a useful fashion will help you keep all the details you need straight and keep you
from missing or forgetting about items that need to get done. Samples in Appendix AD.
Fund of knowledge—there is no substitute for knowing things, so you need to read a lot, each
day, to cover the basics. You will need to do this in addition to your studying for exams.
Speaking from experience, it’s best to read about current cases as much as possible, as this both
helps you treat that case better as well as help you retain what you read. Additionally, it always
helps to have some notes and references available close to you in a portable form, such as what
we used to call colloquially “a peripheral brain”. Increasingly this is taking the form of PDA’s. It
also helps to read ahead if possible, though this is difficult to accomplish on rotations, because it
is best to read within the rotation while you are in it.
Procedural skills—this refers to bedside procedures performed by trainee housestaff, (usually
interns) as well as special tests and procedures performed by specialty services in the hospital.
there is nothing as useful as an Intern that can arrange for or perform procedures well without
much help. there is nothing worse, however, then an intern who does not understand the right
time or way to perform a procedure or who misinterprets results or cannot recognize a
complication or how to deal with a complication of a procedure. In a community hospital we do
not offer a large number of opportunities for students to perform procedures. However, you are
expected to use the ample time and opportunity to read and learn about common bedside and
special procedures, understand indications for procedures, and to become knowledgeable about
the complications and their management.
A partial list of Specialty procedures that you should be intimately familiar with, and additional
relevant resources:
Chest X-ray: both AP and PA and lateral X-ray of the chest
ER
Lumbosacral spine X-rays
ER
Skull series, cross table laterals of the neck
Common fractures and dislocations—hip, shoulder, hand/wrist,
ER
lumbosacral
Upper GI series
Barium enemas
Gastroscopy
Colonoscopy
Fiberoptic laryngoscopy
Fiberoptic Bronchoscopy
CT of head, chest, abdomen and pelvis
Angiograms—diagnostic and therapeutic
Cardiac cath
CT guided abscess drainage
GI service
GI service
GI service
GI service
ENT service
Pulmonary service
radiology
Special procedures
Cardiac Cath lab
CT
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
Bone scan
PET scan
Lung Scan and pulmonary CTA for pulmonary emboli
Venous Doppler of the LE’s for DVT
Sonogram of RUQ, pelvis, kidneys, pregnancy
EKG
PFT’s
Nuclear medicine
Nuclear medicine
Nuclear medicine/CT
ultrasound
ultrasound
Dubin’s EKG, cardiology
Pulmonary lab
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
Some basic knowledge will serve you well and increase confidence of others in your abilities. This
includes knowing the lingo, the set up, the way to get things done:
KNOWLEDGE: know what you don’t know---and catch up
i.e. how to order and interpret common tests: CXR, other X-rays, CT scans,
EKG –Dubin’s Rapid EKG diagnosis
CBC’s, metabolic profiles, ABG’s, lipid profiles
Thyroid profiles,
Hepatitis tests
HIV testing
Cardiac enzymes
Urinalysis
Cultures and sensitivities
Drug brand names, dosages –the Sanford Guide to antimicrobial therapy, yearly updates
A yearly updated copy of the PDR is available on each floor
Basic antibiotic coverage issues
LINGO: generally same in all of US, but may different from subspecialty to subspecialty—reading
ahead and looking and asking for it will help you a lot.
Certain situations:
Patient presentation—detailed vs. brief
CXR
CT scans
Procedures
Sign-outs
SET UP: esp. rules of engagement with service and private patient for that respective
department,
--physical set—
--prompt attendance and letting someone know where you are if you are away from your
station
Way to get things done:
List of essential phone numbers,
How to order tests
List of key personnel
Location of key equipment
The hours when rounds or other academic activities require your attendance or attention
The order of things:
there is an order by which care is rendered to and documentation is maintained on
hospital patients, and you as students participate in most aspects, as long as your notes are
countersigned. Examples follow after the list:
1.
History and Physical: the process by which the admitting complaint, and
relevant morbidity are obtained and documented. This evaluation leads to an organized list of
problems, from which is formulated a list of diagnostic possibilities and a diagnostic and or
therapeutic plan.
2.
admission orders: by offering the private attending in the ER to help write the
admitting orders, or observe their computer entries, you will gain insight into this most important
function.
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
3.
Daily chart notes: similar to an H&P, but smaller in scope, focused on the
active problems, in a SOAP format.
4.
Discharge notes, instructions, summary and attestations—all done on the
day of discharge of the patient from the hospital.
Samples of these documents are in the first several appendices.
Dress code: official—no jeans, no sneakers,
When in doubt, and to those asking my own opinion, I try and ask them to stand in front of a
mirror and consider the following: what impression are you trying to make today ?
I would suggest that you and your dress should match your demeanor and your purpose here--you are here to learn, to be both an observer and examiner of the patients and to be the patient’s
conduit of information to the rest of the staff. The more everything about you says to the patients
and staff “I am here to learn, and be of service” the more you will be given to do, and the more
you will learn. This is true in life as well as in PVH. The corollary is also true--Anyone who feels
their dress or demeanor should reflect some other, ulterior motive, such as peace in the world,
getting a man/woman, or invited to the next dance, or pot party, has got to believe that that
attempt will be noticed. Indeed it will be noticed, but will not lead to more learning---rather it’s
going to impede interaction with staff, confidence in you, and therefore your learning.
My recommendations?
men:
shirt, tie, (bowties are more functional but ostentatious (I would suggest tie clips instead)
slacks, shoes, loafers, clogs
white jacket
women:
much more variety can be considered, but I would suggest
avoiding low necklines, bare shoulders or mid-drift, hip huggers, additional jewelry or accessories
beyond a belt needed to hold up pants, and or 1-2 simple additional items.
White jacket.
I cannot overemphasize the following final comments:
Always wear your badge prominently displayed, so your name and your status can easily be
discerned. You may introduce yourself as medical students, and an attending may choose to
use the term student doctor.
You must maintain patient and staff confidentiality. Please become familiar with the hospital’s
HIPAA policy, and realize that as soon as you graduate, wherever you will be, there will be a
(hopefully) similar policy in effect. In private practice you will have to formulate your own policy.
OK—let’s hear those questions and comments !
Alexander Biener, MD
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
Addendum:
Another part of your experience will be visiting the private physicians in their private practice
offices. You should be paying attention to the differences between the conduct of medical
delivery in the office setting as opposed to the hospital setting and the variety of styles this can be
performed under.
Particularly you want to take a look at the chart organization, which should include the following
items:
-to facilitate communications particularly if there is more than one practitioner in a particular
practice. Using in the front of the chart there will be a list, a problems list, diagnosis list,
allergies and medications. Usually following that will be either history and physicals or
some intake information that describes the patient fully. Thereafter there will be the chart
notes as well as, and the correspondence or the material that the patient brings in.
-thereafter there is often a section containing correspondence from other doctors about the
patient, thereafter a section of laboratory tests, x-rays and EKG’s.
-thereafter a section containing charts relevant to hospital admissions.
-thereafter one often finds any old charts from other doctors, and a section on insurance
and billing.
-often a prominent part of the chart would also be listed patient’s immunizations to date and
in many adult internal medicine practices also will be a flow sheet for routine care which
you should become intimately familiar with.
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
APPENDIX A
A useful template for an adult female history and physical:
Chief Complaint:
simple restatement of main complaint of the patient
History of Present Illness:
detailed accounting of complaint, its nature, description and
severity, timing of onset, and any changes in description and or severity, mitigating and
aggravating factors, and any associated symptoms.
Also note any attempts to alleviate the symptoms, medicines tried, tests done, or relevant prior
history .
Thereafter any additional symptoms that may have bearing on the above but which likely
represent a separate disease or body system.
Thereafter any highly relevant social, family or travel or exposure history.
Past Medical History: all relevant major medical disorders
Denies Diabetes, Hypertension, ASHD, vascular, thyroid, renal, or liver disorders.
Past Surgical History: Denies surgery
SOME PUT HERE ACCIDENDTS , INJURIES,
Medications:
name, dose, route, when taken
I ALSO KEEP A LIST OF PREVIOUSLY TAKEN MEDS
Allergies:
any drug, environmental and food allergies
Family History:
No family history of diabetes, cardiovascular, thyroid, renal, liver, gallbladder disease, osteoporosis, Alzheimer’s
disease, cancer.
Social History:
marital status, family and community supports available, next of kin
type of dwelling, any obstacles to an older person such as stairs.
Whether smoking, drinking.
Relevant travel, job, exposures
Review of Systems: Constitutional:
Head:
Denies fever, sweats, chills, alteration of weight, appetite or
sleep.
Denies headache or trauma.
Eyes: Denies eye pain, discharge, diplopia, altered vision.
Ears: Denies ear pain, discharge, altered hearing, or tinnitus.
Nose: Denies runny/stuffy nose, sinusitis, polyps, altered smell.
Mouth: Denies toothache, lesions, tongue swelling, pain.
Throat: Denies soreness, hoarseness, Odynophagia, Dysphagia,
Neck: Denies neck stiffness, pain, lumps, goiter.
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
Cardiovascular: Denies chest pains, SOB, DOE, PND, orthopnea, pedal edema, dizziness, palpitations, arrhythmia,
claudication, heart attack or murmur, rheumatic fever, abnormal EKG or chest X-ray.
Respiratory: Denies pleuritic chest pains, cough, expectoration, dyspnea, Pneumonia, wheezing, Asthma, Bronchitis,
COPD.
Gastrointestinal:
Denies Abdominal pains, distention, pyrosis, dyspepsia, dysphagia, nausea, vomiting, early
satiety, bloating, gaseousness, diarrhea, constipation, hematemesis, melena, BRBPR, Jaundice, Pruritus, clay
colored stools, dark urine, ulcers, gallstones, polyps, hemorrhoids.
Genitourinary: Denies dysuria, frequency, hematuria, nocturia, discharge, flank pain, incontinence, hesitancy,
decreased stream, kidney stones, tumor.
Musculoskeletal:
Denies fractures, Injuries, inflammation, joint pains, stiffness, myalgia.
Integumentary (skin/breast):
Denies rash, Pruritus, lesions, breast lumps, nipple discharge.
Neurological: Denies head trauma or headache, dizziness, vertigo, alteration in vision, paralysis, paresthesia, seizure,
strokes.
Psychiatric:
Denies mental illness, depression, anxiety, difficulty coping or sleeping.
Endocrine: Denies goiter, dry, or sweaty or pigmented skin, voice change, hirsutism, cold intolerance, heat
intolerance, tremor, polyphagia, polyuria, polydipsia, hair or shoe size changes.
Hematologic/Lymphatic:
Denies anemia, transfusions, lymphadenopathy, easy bruiseability, prolonged bleeding.
Allergic/Immunologic: Denies allergies to iodine or shellfish, hayfever, frequent sinusitis or pneumonia, eczema,
asthma, Poison Ivy rash.
Gynecological:
No spotting, fibroids, hot flashes.
PHYSICAL EXAM: Healthy well nourished female in no distress. Height = 5’-”, Weight = 1 lb. blood
pressure = 120/80, respirations = 16 bpm and unlabored, pulse = 70 and regular, Temperature 98.0 F oral.
Head:
atraumatic, normocephalic, with normal eyes, white sclera, pink conjunctiva. External ear canals
and tympanic membranes are clear with normal light reflex. The throat is clear and non-injected.
The teeth are normal and the tongue well papillated.
Fundi:
Neck:
Neck is supple, and without lymphadenopathy, thyromegaly, bruits or jugular venous distention.
The carotid upstrokes are 2+/2+.
Chest:
The lungs are clear to auscultation and percussion. Symmetrical inspiratory excursion and no
scoliosis or other deformity.
Breasts:
Without masses, tenderness, or discharge from the nipples. The axillae are clear.
Cardiovascular: The skin is warm and pink; Heart Sounds are normal, no murmur or gallop, heave or
lift. Heart borders and point of maximal impact are normal.
Abdomen: Benign, soft and non-distended, with normoactive bowel sounds. There is no succussion
splash, hepatosplenomegaly, masses, hernias, spider angiomata, palmar erythema, venous pattern
or caput medusa, or icterus.
Rectal:
clear ampulla--stool is brown and guaiac negative.
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
Female Genitalia:
Back:
normal vulva and introitus. On Bimanual exam a normal uterus and clear adnexa.
exam shows no deformity or spinous or costovertebral angle tenderness.
Extremities:
There is no clubbing, cyanosis, edema, varicose veins. Nails normal.
Peripheral pulses 2+ and bilaterally symmetrical.
Neurological: Cranial Nerves 2-12 are intact. Motor strength is 5/5 in all 4 limbs, without drift, and
sensation is intact to pin prick and fine touch. DTR’s are normal—
Visual fields are normal to confrontation
Vibratory and kinesthetic senses are preserved in the fingers and toes, and finger-to-nose and Heel-to-shin
tests are normal. There is no disdiadokokinesis or Rhomberg’s sign.
Psychiatric: She is alert and oriented to person, time and place and mental status is clear. She exhibits
appropriate concern and normal range of affect, normal memory and judgment and cerebral
functions.
Hematologic/Lymphatic:
Skin:
Free of bruises, petecchiae, telangiectasias, or lymphadenopathy.
There is no rash, skin lesion, hyperpigmentation, or scarring.
a/p
CHF/diuretics
Chest pain/rule out AMI
ASSESSMENT if you are the primary
If you are a consultant: IMPRESSION:
year old female with:
Principal problems, with relevant differential diagnosis, comes first,
Relevant or active additional problems, follow, each with their own differential diagnosis.
Thereafter additional though inactive problems or diagnoses.
Please note—a differential is the most crucial construct at your stage—only state a diagnosis if
that is the principal reason the patient comes under your care and there is no doubt about
it.
Plan If you are the primary
Recommendations if you are the consultant:
as much as you can
this is the next most important construct for you—do
Pneumovax if indicated, flu shot in season
If female:
GYN exam, PAP smear, breast self exams, & Mammography if not done
If male:
PSA,
Signature/cosignature
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
APPENDIX B
Admission Orders:
A
D
V
A
C
A
N
D
I
S
S
L
E
N
Admit to _____ floor/monitored bed/ICU/observation unit
Dx:
(I prefer to list all important diagnoses, especially those that would impact in case of an
emergency care or code)
VS:
VS qshift, qd, WA,
Allergies/Reaction:
NKA, NKDA,
Condition:
Critical, guarded, Stable
Activity:
OOB, bedrest w/ BRP’s with assist
Nursing:
Foley to BSD, turn q2h, dressing, cultures this or that,
Diet:
regular, npo, low fat, low sodium, fluid restrictions, etc.
IV:
heplock vs. IV of ½ normal saline or normal saline or D5W,
Without supplements, or with , e.g. 10 mEq KCl /L
Specific medications: medications for their specific conditions
Medications for their chronic specific conditions that will be continued if
not contraindicated
Subjective medications: Tylenol 650 mg po/pr q4h prn fever or pain
MOM 30 cc po qd if no bm (unless renal impairment)
Ambien 5-10 mg po qhs prn (unless high risk fall)
Mylanta 30 cc po q2h prn pyrosis (unless renal impairment)
PCA,
Labs: CBC, Complete Metabolic Profile daily, amylase/Lipase, etc.
Exams: serial EKG’s, Echocardiogram, X-rays, EEG,
Next step in work up—consults, dietary/PT evaluation, patient teaching for diabetes, wound
dressings, etc., discharge planning,
Please note that PVH and many other hospital have now formalized these into order sets called
critical pathways—we have several, for CHF, pneumonia, GI bleed, total hips and knees, and you
should become familiar with them.
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
APPENDIX C
Some useful inpatient order templates:
HERE IS a useful template for insulin coverage schedule:
Fingersticks qid and glucose coverage schedule as follows:
HUMULIN-R U-100 INJ, 3 U, SC, IF BLOOD SUGAR 180-240
HUMULIN-R U-100 INJ, 5 U,SCD, IF BLOOD SUGAR 241-300
HUMULIN-R U-100 INJ, 7 U,SC, IF BLOOD SUGAR 301-350
HUMULIN-R U-100 INJ, 9 U,SC, IF BLOOD SUGAR 351-400
HUMULIN-R U-100 INJ, 11 U,SC, IF BLOOD SUGAR 401-450
HUMULIN-R U-100 INJ,15 U,SC, IF BLOOD SUGAR >450,
IF >450 NOTIFY DR., IF <65 NOTIFY DR.
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
APPENDIX D
Some useful formats for Daily notes:
Daily Medical Student Hospital Note on medical floor:
MEDICINE--Medical Student Note
SUBJECTIVE: (any changes in patient’s chief complaints, any new complaints)( summarize
important events, such as patient fell, nurses report agitation, had multiple bloody stools, etc.)
Review of Systems: Constitutional/Head & Neck/Cardiovascular/ Respiratory/ Gastrointestinal/
Genitourinary/Musculoskeletal/skin/Neuro/Endocrine/ Hematologic otherwise unchanged since
last note.
OBJECTIVE: bp = , pulse = , RR = , Temp. = ,
HEAD & NECK: wnl.
CHEST: chest clear to auscultation and percussion.
CARDIOVASCULAR: S1 S2 wnl. No murmur or gallop.
ABDOMEN:
Soft, non-distended, benign, normoactive bowel sounds,
EXTREMITIES: No clubbing , cyanosis, or edema, calf tenderness.
NEUROLOGICAL: nonfocal, MS intact.
SKIN:
No rash, phlebitis, or new skin lesion.
LABORATORY:
X-RAY:
STUDIES:
ASSESSMENT:
year old with:
(Problems/diagnoses –most important one first,
all current ones,
may mention important inactive ones.)
PLAN: (consider addressing them in the order of the diagnoses above)
(Signature)/(printed name)/5th pathway
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
APPENDIX E
Discharge procedure:
Once a decision is made to discharge a patient, and the patient has agreed, and demonstrates
that all discharge planes can be met by them and or their friends and family, the nursing staff is
notified via an order in the chart, as well as discharge planners, and or social workers, as the
need arises. The student, housestaff, or attending then—
1.
write a brief discharge note in the chart, and
2.
write out or use the TDS computer to print out, discharge instructions.
3.
In addition, the resident or attending will dictate a discharge summary, summarizing the
admission, and
4.
sign an abbreviated synopsis called the attending attestation on the face sheet that starts
the hospital billing cycle.
a useful mnemonic for a discharge chart note is the “6 D’s”:
Date of admission
Date of discharge
Diagnoses relevant to this admission
Discharge medications
Discharge instructions
Disposition
Dictating the DISCHARGE SUMMARY:-- this is a document expected to be placed in chart after
any hospital discharge –-at PVH it is usually dictated at the end of the admission, but in TCC
there is an abbreviated form which can be filled in. At other institutions there may be forms or
other formats.
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
APPENDIX F
Here follows another more formal discharge summary format:
ADMISSION DATE:
DISCHARGE DATE:
FINAL DIAGNOSES:
1.
principal diagnosis that occassioned the admission
2.
other active diagnoses
3.
inactive but important diagnoses
PROCEDURES:
1.
all diagnostic and surgical procedures
2.
blood transfusions,
3.
therapeutic procedures, taps, I&D,
4.
wound care, IV antibiotics,
HOSPITAL COURSE:
A chronological narrative of events, with brief explanations of events, in which you can
incorporate all the procedures mentioned above,
LABORATORY TESTS AND STUDIES:
Listing of values of relevant and salient lab tests and discharge lab values.
DISCHARGE MEDICATIONS:
DISCHARGE INSTRUCTIONS:
Any instructions, need for follow up labs and procedures, doctor visits, consults
DISPOSITION:
Where the patient is going to and who will be caring for them,
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
APPENDIX G
Some Useful discharge instructions templates:
For gastroenteritis:
I believe you have a viral gastroenteritis. If you have fever, worse pain, severe
diarrhea or vomiting get back to me.
For now stay on a BRAT diet:
B-R-A-T--
Boiled chicken
Rice, Rice water
Apple Sauce
Weak Tea and Toast
Eat sparingly, and drink lots of fluids, especially Gatorade. When you feel better
you can start eating regularly but be careful with dairy products, as you ability to
digest them may take a while. Please call in 1-2 days or whenever worse.
Also See the ER sheets for standard discharge protocols for some common symptoms and
problems such as fever, abdominal pains, head injuries, kidney stones.
There are an increasing number of other standard discharge instruction in our hospital as well as
in those that you will be visiting. Inquire.
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
APPENDIX H
Useful data to have at hand once you start ambulatory care rotations in your residency:
Routine care in the office
Primary care consideration in the office
Cancer screening
Carviovascular risk factor screening and modifications
Immunizations
Osteoporosis screening
Smoking cessation
Mental health
Mini-Mental status Exam: Knows her name, location, address,
Knows the president, day, month, year
Calculates quarters and nickels in a dollar
Spells WORLD forwards and backwards
Remembers 3 out of 3 objects 5 minutes later.
Counts backwards in three’s to _____.
Screening for mental health disorders
Dealing with the mentally ill/neurotic
Legal considerations
malpractice
Work flow
The office as a political platform
Important differentials—
Appendicitis,
Meningitis,
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
APPENDIX AA
Here are some resources that have proven useful over the years:
(* essential resources you should own,
**available in PVH library)
*Bates, Barbara, Physical diagnosis, ** new version in library, 2 other books available, an
absolute essential resource you have to read in your first weeks here and know cover to cover.
DeGowin, Elmer L. and DeGowin, Richard L. Diagnostic Examination. Macmillan Publishing Co.,
Inc., this classic is updated every several years. Either this or Bates’ Physical diagnosis are an
essential beginning for your year.
Walker, H. Kenneth et al. Clinical Methods: The History, Physical and Laboratory Examinations.
Volume 1 and 2. Butterworth Publishers. 1976, still very current, copies in my office.
*Harrison’s Textbook of Medicine**
*Cecil’s Textbook of Medicine**
*Current Medical Diagnosis & Treatment, updated yearly**
*Washington Manual,** come large pocket sized spiral, and PDA versions, an essential guide for
medical house staff, and should be part of everyone’s early reading and a constant companion in
the hospital.
The Harriet Lane Handbook, The Johns Hopkins Hospital, small pocket sized but very detailed
guide to data, used universally by pediatric house staff.
Maxwell’s Quick medical reference, @ www.maxwellbooks.com, dozen+ pages of essentials in
pocket size.
The Scut Monkey,
Gilbert, David N. et al. The Sanford Guide to Antimicrobial Therapy. Updated yearly, copies
often available in my office.
Eknoyan, Garabed. Medical Procedures Manual. Year Book Medical Publishers, 1981. single
copy available in my office.
Differential diagnosis in Medicine,
The Brown book of Laboratory tests and their interpretation
* Dubin’s EKG interpretation**—still the easiest book for EKG self teaching.
*Marriott, practical electrocardiography**—where you go to once you have read Dubin’s EKG
interpretation, to complete your necessary skill level.
Another text now in the library--- under REFERENCE.
Philip Buttaravoli and Thomas Stair,
Minor Emergencies, Splinters to Fractures,
Mosby 2000 ISBN0-323-00756-2. 525 pages
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
–
you can find a copy in the ER express; Heavily diagramed, well organized and at your
level
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
APPENDIX AC
rotation specific resources you might consider:
Psychiatry:
Kaplan, Saddock, _________________________
Pediatrics:
Nelson’s
Surgery:
Cope’s differntial diagnosis of the abdomen
Ob/Gyn:
Danforth’s Ob/Gyn
ER:
EMERGENCY MEDICINE text by ______, copy in ER.
Ent:
Neurology:
**Scheinberg, An introduction to diagnosis and management of common
neurological disorders,
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ALEXANDER BIENER, M.D., P.A.
595 CHESTNUT RIDGE ROAD, Suite #6
WOODCLIFF LAKE, NJ 07677
Tel. (201) 505-9595
Diplomate, American Board of Internal Medicine and Gastroenterology
FAX: (201) 505-9474
APPENDIX AD
A useful template for a clip board or index card patient file to carry on rounds, especially as an
intern: much of this is written and maintained in shorthand, modified/individualized to the
situation, tweaked as needed, and a new Xerox copy made each day off those items that do not
vary.
Name age sex MR #
Main Dx
Other Dx
Allergies:
Rx:
Work up/plan
Important tel. #’s,
Na /_Cl /gluc_/ Creatinine
plts \Hb_/ WBC, differential
K+ /CO2/ BUN\
/Hct\
liver profile, other labs,
MCV
[ ] boxes for any pending X-rays ____result
[ ] boxes for any pending tests_______
[ ] to do list____
[ ] for any pending result, report _______
[ ] to do list____
Name age sex MR #
Main Dx
Other Dx
Allergies:
Rx:
Work up/plan
Important tel. #’s,
Na /_Cl /gluc_/ Creatinine
plts \Hb_/ WBC, differential
K+ /CO2/ BUN\
/Hct\
liver profile, other labs,
MCV
[ ] boxes for any pending X-rays ____result
[ ] boxes for any pending tests_______
[ ] to do list____
[ ] for any pending result, report _______
[ ] to do list____
Name age sex MR #
Main Dx
Other Dx
Allergies:
Rx:
Work up/plan
Important tel. #’s,
Na /_Cl /gluc_/ Creatinine
plts \Hb_/ WBC, differential
K+ /CO2/ BUN\
/Hct\
liver profile, other labs,
MCV
[ ] boxes for any pending X-rays ____result
[ ] boxes for any pending tests_______
[ ] to do list____
[ ] for any pending result, report _______
[ ] to do list____
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