Toxicology
Overview: You’re on a consult service with 5 Toxicologists (Russ Kerns, Michael Buehler,
Christine Murphy, Marsha Ford, and Anna Dulaney (PharmD)). Work weeks are typically <40h
in the hospital, but there is a lot of reading and outside work to do, so make out a schedule and
start early in the month to tackle it all. Have your ipad on hand for downtime. MEB 2nd floor is
a good place to hang out and study. Keller’s study guide is really helpful (available under
toxicology rotation on compendium). Lots of teaching during the weekdays.
Cerner Notes to have on Day 1:
 Progress notes are just basic SOAP notes.
 Revised Dr. Murphy H&P Consultation note template (see below)
Cerner Order Sets: none, you just make recommendations and rarely order anything
Service List: none, just get the MRNs from CPC or attending
Schedule:
In General:
 Call CPC between 6:45-7am every morning to find out if there are any consults to be
seen. If yes, they’ll given you basic info and tell you what time the attending wants to
meet to round.
 If no patients, go to CPC at 8-9am to do follow-ups.
 On call (24h 7a-7a) every other day and two weekends during the month (Fri 7a – Mon
7a)
Life Planning:
 Can take vacation, moonlight, or have a baby this month—schedule is very flexible and
accommodating
 Set your schedule with co-rotators and Kerns at the beginning of the month.
 Also have 5-7 back-up shifts, try to arrange these on the same day as your tox call days to
maximize days off
 No Thank You Bob Shifts
Schedule Interpretation:
 If patient to be seen: whenever the attending wants to meet, likely teaching afterwards
 If no patients to be seen: CPC between 8-9am for follow-ups and teaching
 M-F: generally 9ish til whenever you’re done (usually by 1pm)
 Call days 7a-7a—stay sober and in town, have your cell phone or pager on
 Weekends: if you’re not on call, stay out of the hospital; if you’re on call, round on any
patients when the attending wants to meet
 Wicked Wednesday = toxicology conference from 9a-12p in MEB 2nd floor conf room;
Nerd out time to talk about recent tox deaths, do weekly journal club, present outlines
and presentations and go on random tox tangents.
In General Time is spent between:
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Seeing consults at CMC
Teaching time (usually in MEB after rounding, everyone teaches except Ford)
Carolinas Poison Center to do phone call follow-ups (“CPC” – near airport)
On your own reading and studying
Wicked Wednesday toxicology conference
You’ll be responsible for:
 2-3 journal articles to present during the month
 2 outlines (2 pg on a toxin)
 One 45 min end of the month presentation on a specific tox subject/question (they’ll give
you a list of forbidden topics)
 Final exam at the end of the month on the required readings
MISC: You’re expected to see all of the consults and write the notes. The toxicologist on call
will get in touch with you (cell phone or pager, your preference) when there is a consult to see.
You can pre-round on them and get their note started, but they really don’t care if you have seen
them beforehand as long as you can present and discuss their case. No orders, just
recommendations as the consult team. Average 0-3 patients on the service at a time, but this can
greatly vary.
Numbers:
Kerns: 704-936-6349 | Buehler: 704-609-4375 | Murphy: 804-647-8560 | Poison Center: 704355-4000
Important things to remember when writing toxicology notes. . . .
Initial H&P is a “CONSULTATION REPORT” with a title of Toxicology Consultation. Subsequent progress
notes are “PHYSICIAN PROGRESS NOTES” with title of Toxicology Progress Note
- Must include: Requesting attending (who wants the consult must be attending name) Reason for
consultation
- ROS (and you must list this out individually
- Physical exam with current vitals, vent settings Medical decision making
- this includes labs, imaging results, ekg results and what happened at OSH
- Assessment/Plan
- rough discussion of what is going on or why constellation of symptoms not consistent with some
type of intoxication Recommendations
- bulleted or numbered specific recommendations
****Please see H&P template below
Revised Dr. Murphy H&P Consultation note template:
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Toxicology Consultation
Physician Requesting Consult: (Must be attending name)
Physician Completing Consult:
Reason for Consult:
CC:
HPI:
Meds:
Allergies:
Medical History:
Surgical History:
Social Hx:
Family Hx:
Environmental History: (work, hobbies, well/city water, type of heat, etc)
ROS: (must list this out individually)
Gen: No fever, weight loss
CV: No cp, palpitations
Resp: No wheezing, sob, orthopnea
MSK: No joint pain, myalgias.
Skin: No rashes, no yellowing of skin
Abd: No abdominal pain, no nausea, vomiting, diarrhea.
Neuro: No focal weakness or slurred speech
Psych: Denies suicidal ideations, depression.
HEENT: No vision changes, change in color of eyes, sore throat, rhinorrhea, ear pain, epistaxis.
GU: No vaginal discharge, dysuria, hematuria.
Endocrine: No polydypsia, polyuria.
Heme: No easy bruising or bleeding.
Physical Exam:
VS:
General: NAD, WDWN
HEENT:
Head: NC, AT
Eyes: Pupils equal, round, reactive to light. EOMI fully without nystagmus on direct
testing. EOMI are spontaneously intact. Conjunctiva are pink. Sclera are nonicteric.
Nose: Nares patent, septum midline.
Mouth: Tongue is midline, MMM, normal dentition. OP is clear with no exudates or
erythema.
Neck: Supple, no signs of meningismus. No carotid bruits. No JVD.
CV: Regular rate. No M/G/R. 2+ pulses equal bilaterally. No peripheral edema.
Resp: CTA B with no W/R/R. Equal breath sounds bilaterally and equal chest expansion.
Abd: Soft, ND. Normal active bowel sounds. No tenderness on palpation. No HSM.
MSK: FROM all 4 extremities spontaneously without deformity or guarding.
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Skin: Warm and dry. No rashes or lesions noted.
Back: Normal musculature. No step offs, crepitus or tenderness to palpation of vertebral bodies
of the cervical, thoracic, or lumbar spine.
Neuro: Alert and oriented x3. Face is symmetric, tongue is midline without
fasciculation. Strength is 5/5 and equal bilaterally in the upper and lower extremities. Normal
sensation to light touch throughout all 4 extremities. Normal speech. Normal gait. No truncal
ataxia. Normal finger to nose, heel to shin, and no pronator drift on direct testing. Reflexes 2+
bilateral patella, biceps and brachioradialis, no myoclonus elicited.
Psych: Normal mood and affect. Cooperative. Not suicidal or homicidal.
Assessment and Recommendations:
We have reviewed with patient the plan for care. Understanding and agreement to plan was
acknowledged. All questions were answered to the best of our ability. We greatly appreciate the
opportunity to participate in the care of this patient. We will continue to follow the patient at this
time. Please call the Carolinas Poison Center with any additional questions at 704-355-4000.
You can ask to speak to the toxicologist on call at any time.
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