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INTERNAL MEDICINE
Savannah
CLERKSHIP MANUAL
CLASS OF 2016
(7/28/2014 to 7/10/2015)
Table of Contents
Key Contacts ................................................................................. Page 3
Course Objectives ......................................................................... Page 4
Numbers & Kinds of Patients ....................................................... Page 6
Evaluations/Clerkship Evaluation ................................................. Page 10
Remediation/Failure to meet evaluation standards ....................... Page 18
Attendance Policy/Absences ......................................................... Page 19
Failure to meet attendance requirements ...................................... Page 19
Inpatient service responsibilities/On-call expectations ................ Page 20
Outpatient service responsibilities ................................................ Page 22
H&P workups ................................................................................ Page 27
Duty hour expectations/Curriculum .............................................. Page 30
Curriculum .................................................................................... Page 31
Important Dates & Information .................................................... Page 32
Physical Findings .......................................................................... Page 34
Clerkship syllabus ......................................................................... Page 35
Mission, Vision, Goals .................................................................. Page 36
Grading Information ..................................................................... Page 37
Work hours/Procedure Log ........................................................... Page 39
On Call Holiday Schedule ............................................................ Page 41
Appendix………………………………………………………. Page 44
Page | 2
INTERNAL MEDICINE ACADEMIC YEAR 2014-2015
CLASS OF 2016
JUNIOR MEDICINE CLERKSHIP DESCRIPTION
Welcome to the Internal Medicine Clerkship!
The following are the key faculty and staff who are responsible for the Clerkship.
Academic Chair: Steven Carpenter, MD
Phone: (912) 350-8372; E-mail: [email protected]
Clerkship Director: J. David Baxter, MD
Phone: (912) 350-8372; E-mail: [email protected]
Year 3 Program Director: J. David Baxter, MD
Phone: (912) 350-8372; E-mail: [email protected]
Clerkship Coordinator: Sandra Simmons
Phone: (912) 350-8372; E-mail: [email protected]
Mailing Address:
Department of Internal Medicine
Memorial University Medical Center
4700 Waters Avenue
Savannah, GA 31404
Office Address:
Department of Internal Medicine Education
Center for Internal Medicine
1101 Lexington Avenue
Savannah, GA 31404
Chief Residents
2014-2015
NAMES
PAGERS
Eddy Gutierrez, MD 3rd Yr.
8965
Margaret McCormack, MD 3rd Yr.
8767
Page | 3
THE COURSE OBJECTIVES OF THE CLERKSHIP ARE AS FOLLOWS:
The student will be able to…….
1. Obtain a complete and accurate medical history including asking how recently patient has
undergone appropriate screening studies.
2. Obtain an accurate social/health promotion history including asking about alcohol,
tobacco, exercise, etc.
3. Perform and record a complete and accurate physical.
4. Review laboratory tests and radiological studies and interpret possible causes and effects.
5. Develop an accurate assessment, workable problem list and differential diagnosis on each
new patient.
6. Suggest an appropriate therapeutic plan that includes pharmacological agents and
therapeutic diagnostic studies.
7. Recognize and prioritize problems in the form of a problem list.
8. Review pertinent literature to expand your knowledge and understand the natural history
of the disease process and determine the efficacy of traditional and nontraditional
therapies.
9. Communicate effectively in oral and written form.
10. Use electronic data retrieval systems (MD CONSULT, PUB MED, HARRISONS, UP
TO DATE)
11. Recognize and maintain professional conduct.
12. Be active in the role as part of the multidisciplinary team including nurses, social
workers, colleagues, patients, and families.
13. Recognize the ethical and medical issues in patient documentation, confidentiality issues.
14. Discuss patient issues consistent with HIPAA privacy regulations.
15. Recognize situations where biopsychosocial determinants have impact on health and
disease and identify ways to maximize therapy and safe discharge that takes into account
these issues.
16. Identify most appropriate tests in any patient encounter based on documented sensitivity
and specificity and adequately explain decision process to team.
Page | 4
17. Rapidly identify life-threatening emergencies and notify team of same in a timely
fashion.
18. Interact with patients in a manner that respects individual diversity (including religious,
racial, ethnic, sexual orientation, etc.) differences.
19. Interact with patients in a courteous, caring, empathetic manner using standard good
courtesy practice (including active listening, reflective listening, not interrupting, not
judging, etc.)
20. Recognize normal structure and function of normal body systems and recognize
alterations of these body systems in the diseased state.
21. The student will be able to identify an assortment of physical findings as listed in the
student manual via the provided website and be responsible for the content of that
website to be tested on the exit exam at the end of the fourth year.
22. Analyze clinical experiences and scientific information and use this information to
improve clinical experience through reflective writing.
23. Participate in an OSCE at mid-rotation and receive feedback on performance by faculty
mentor.
24. The student will learn to recognize common pathological conditions/findings using
diagnostic imaging studies appropriate for the clerkship.
Your own patients are the focus of developing these skills and your contact with them is the center of your
curriculum.
Page | 5
Number and Kind of Patients
Students Should Encounter During Internal Medicine Clerkship
Cardiovascular System
Encounter
Required
Minimum
Heart Failure
2
Coronary
1
Artery Disease
Hypertension
3
Endocrinology and Metabolism
Encounter
Required
Minimum
Diabetes
4
Mellitus
Lipid disorders 3
Thyroid
1
diseases
Gastroenterology and Hepatology
Encounter
Required
Minimum
Gastrointestinal 1
Bleeding
PUD/GERD
1
Liver diseases
1
Hematology and Oncology
Encounter
Required
Minimum
Anemia
1
Cancer
1
Infectious Diseases
Encounter
Required
Minimum
HIV infection
1
Skin and Soft
1
tissue infection
Nephrology
Encounter
Renal failure
Required
Minimum
1
Level of Care *
I/P
O/P
I or II
I
X or
X or
X
X
I or II
X or
X
Level of Care *
I/P
O/P
I or II
X or
X
I or II
I or II
X or
X or
X
X
Level of Care *
I/P
O/P
I or II
X
I or II
I or II
X
X
Level of Care *
I/P
O/P
I or II
I
X or
X
X
Level of Care *
I/P
O/P
I or II
I or II
X or
X
X
Level of Care *
I/P
O/P
I
X
Page | 6
Neurology
Encounter
Stroke
Required
Minimum
1
Preventive Medicine
Encounter
Required
Minimum
Adult
1
Preventive Care
Psychiatric/Psychosocial disorder
Encounter
Required
Minimum
Depression
1
Substance
2
Abuse
Pulmonary Medicine
Encounter
Required
Minimum
Obstructive
3
Airway
Diseases
Pneumonia
1
Symptoms
Encounter
Required
Minimum
1
Level of Care *
I/P
I or II
X
Level of Care *
I/P
I
O/P
O/P
X
Level of Care *
I/P
O/P
I
I or II
X or
X
X
Level of Care *
I/P
O/P
I or II
X or
X
I or II
X
Level of Care *
I/P
Altered Mental
I or II
Status
Chest pain
1
II
Dyspnea
1
II
Cough
1
II
Abdominal pain 1
I or II
Rash
1
II
Back pain
1
I or II
Joint
1
I or II
pain/swelling
Headache
1
I or II
Dysuria
1
I or II
Fever
1
II
* Level of Care:
I = Perform under supervision
II = Assist with evaluation/treatment
III = Observe
O/P
X
X
X or
X or
X or
X or
X or
X or
X or
X or
X
X
X
X
X
X
X
X
X
Page | 7
If the student does not meet minimum requirement of numbers and kinds of patients,
they will receive an incomplete in clinical encounters (I-CE) and the means to complete
this requirement will be at the discretion of the clerkship director.
THE STUDENT IS REQUIRED TO LET THE CLERKSHIP COORDINATOR KNOW AT
LEAST 2 WEEKS PRIOR TO THE END OF THE ROTATION IF THEY HAVE NOT
MET THE MINIMUM PATIENT ENCOUNTERS.
Complete list of procedures for clinical clerks by December of the
third year – those marked in red are required while on IM
1) Venipuncture (5)
2) Intravenous catheter placement (5) (complete on I.M.)
3) Arterial blood sample for blood gas determination (observe) (complete on I.M.)
4) Injection
i) Intradermal
ii) Subcutaneous
iii) Intramuscular
5) Incision and drainage of superficial abscess
6) Heel and finger stick blood sample
7) Local anesthetic injection
8) ACLS certification (complete on I.M.)
9) Skin biopsy
i) Punch
ii) Shave
iii) Fusiform
10) Simple skin closure
11) Suture removal
12) Intradermal skin test with interpretation
13) Cerumen removal
14) Eye irrigation, foreign body removal and fluorescein staining
15) Nasogastric tube placement
16) Endotracheal intubation demonstrated on a model
17) Bladder catheterization and Foley catheter placement
18) Joint aspiration/injection
19) Lumbar puncture
20) Arterial line placement
Page | 8
STUDENT EXPECTATIONS - CLASS OF 2016
1.
You will see your patients before rounds and inform the intern of any developments.
2.
During rounds, you are expected to collect the charts as the team rounds.
3.
You will be expected to present your patient at rounds.
4.
5.
You will be expected to pick up at least three (3) new patients during call day and present
them the next morning at ward rounds.
You are still expected to see your old patients that day.
6.
You should go to every admission – this is for your benefit and to help the team.
7.
Your goal during the rotation is to learn physical signs and patient symptoms with
correlating disease state and development of differential diagnosis – the more you do –
the more you learn. Internal Medicine is the foundation for all medicine and it is what is
mostly tested on your future boards – Step 2 and Step 3.
8.
Typical (non-call) day – Come in at 7:00 a.m. See your patients, write your notes and
round with your team. Please print out a team list (the interns will show you how). Be
prepared to present them. Know labs, radiological results and medication list. You
should know how to write a SOAP note. Make sure the Team Leader goes over your
SOAP notes the first week (see Appendix). You can write orders and have the intern cosign them. Go to lectures when scheduled.
9.
Typical (call) day – Come in at 7:00 a.m. Let both your intern and resident know you are
here. If they don’t know you are here, they won’t call you with an admission. See your
old patients and write notes. Go to lectures and let the team know when you are gone and
when you come back. No overnight call. Do not leave before your team leaves
10.
On Saturday and Sunday, come in at 7:00 AM.
11.
Week of Nights start on Monday at 7 p.m. until roughly 7 a.m. for five (5) nights. On
Monday night, page the Senior Resident on Nights. Students are excused from all
lectures during the day this week only. This is a great opportunity to get your H and P's
done. You can admit 1-3 patients a night. I recommend that you present at least one (1)
patient every day at morning sign out. If possible, the patient will be followed by
another medical student on the day shift. You are ACLS certified and should respond
ASAP to any and all codes. If you are approved, the Week of Nights Policy will be
provided to you prior to your start.
ONLY 1 STUDENT ALLOWED ON NIGHT FLOAT AT A TIME. It is suggested you do
them the first four weeks of your eight-week inpatient experience.
Page | 9
The monthly Inpatient Ward Evaluations and multi-weekly Student Teaching Rounds lecture
evaluations are completed within the MUSM One 45 computer software program. The mid-term
and final evaluations are completed BOTH on paper and in the ONE45 computer system.
The forms provided in this manual reflect the items being evaluated.
ALTERNATE INSTRUCTIONS OF HOW TO COMPLETE STR
EVALUATION FORMS IN ONE45
1.
Log in to ONE45
2.
Go to “To Dos”
3.
Click on Choose a New Form To Complete
4.
Select form: Student Teaching Rounds Lecture
5.
Select speaker’s name
6.
Select date of lecture
7.
Click submit then you will see please confirm, then click submit again
8.
Type in the speaker’s name on the form
9.
Type in the speaker’s topic on the form
10.
Select the date of the lecture from the drop down box
11.
Complete the evaluation and include comments
12.
Click submit
As this form will remain in your ONE45 inbox to complete after each
lecture, please be sure to complete it after the end of the lecture.
Page | 10
Internal Medicine Clerkship Rotation
Student Evaluation of Faculty/Resident/Intern
Faculty/Resident/Intern/Backup Name:
Evaluator’s Name:
Rotation Period:
«Faculty_Name»
«Student_Name»
«BegDate» to «EndDate»
Please evaluate your faculty/resident/intern’s performance during this rotation utilizing the
following scale:
4 = Outstanding
3 = Above Average
2 = Average
1 = Below Average 0 = Unacceptable
All individual responses will be kept CONFIDENTIAL. Composite summary data will be
provided to faculty in an ANONYMOUS format. Place a check mark in the appropriate box for
each area:
0
1
2
3
4
Unacceptable
Below
Average
Average
Above
Average
Outstanding
Medical Knowledge
Professional Attitude
Teaching Skills
Availability to you during rotation
Value of teaching sessions on rounds
Comments or suggestions for improvement:
Please return NO LATER THAN END OF MONTH to Clerkship Coordinator.
THANK YOU!
UPDATED: 6/28/2012
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Page | 12
Internal Medicine Clerkship Rotation
Student Teaching Rounds Faculty Weekly Evaluation
Faculty Name:
Evaluator:
Topic:
Date:
Please evaluate the attending listed above that lectured during this rotation utilizing the following
scale:
4 = Outstanding 3 = Above Average
2 = Average
1 = Below Average
0 = Unacceptable
All individual responses will be kept CONFIDENTIAL. Composite summary data will be
provided to faculty in an ANONYMOUS format. Place a check mark in the appropriate box for
each area:
0
Unacceptable
1
2
3
4
Below average
Average
Above Average
Outstanding
Attitude towards teaching





Medical knowledge





Professionalism





Overall quality of session





Value of teaching sessions





Comments or suggestions for improvement:
Please return form to Clerkship Coordinator’s mailbox at end of rotation. THANK YOU!!!
UPDATED: 6/11/2007
Page | 13
14
15
Internal Medicine 3RD Year Clerkship
MID-TERM STUDENT EVALUATION
Class of 2016
Student:
Clerkship Rotation: Internal Medicine
Clerkship Dates: Beginning:
Ending:
Midterm date:
Extra 2 points at midterm:
H&P’s:
Patient Encounters:
Reflective Writing Entries:
A.
Rotation:
Yes
No
Absences:
STR evaluations completed
Overall assessment of student’s performance:
________________________________________________________________
________________________________________________________________
B.
Narrative describing student’s performance:
a. Knowledge:
b. Skills:
c. Attitude:
d. Professionalism including STR attendance :
C.
CLERKSHIP DIRECTOR’S COMMENTS:
________________________________________________________________
________________________________________________________________
STUDENT’S COMMENTS:
________________________________________________________________
________________________________________________________________
(Use other side if needed)
Clerkship Director:
(J. David Baxter, MD)
_______________
Signature
Student:
Signature
16
INTERNAL MEDICINE FINAL EVALUATION OF CLERKSHIP
1. Were your educational goals met on your IM clerkship? If not, please explain.
____ Yes
____ No
__________________________________________________________________
__________________________________________________________________
2. Please describe the quality of teaching by the faculty and residents. If overt
weaknesses notice, please describe.
_________________________________________________________________
_________________________________________________________________
3. Were you given a mid-term evaluation?
______ Yes
______ No
4. Did the faculty and residents give you feedback on your performance
throughout the rotation?
______ Yes
______ No
If so, was it helpful?
______ Yes
______ No
5. What could the department of IM have done differently to make your educational
experience more productive?
_
6. List 5 strengths noted in the department.
_
7. List 5 weaknesses noted in the department.
_
17
Performance/Evaluation – Appeals Committee on Students
Mercer University School of Medicine’s grading system is a pass/fail grading system for
the Third Year Clerkship rotations. This means that you will not be compared to your
colleagues until the final Dean’s letter. This letter will have a bar graph, which will
represent the distribution of your class in each clerkship.
The total percentage that can be obtained in IM is 100, so your final numerical grade is
the percentage you achieved out of 100. The minimal percentage needed to pass is
65. If for some reason you do not agree with your calculated total score, you may file a
complaint to the appeals committee. Your appeal must be submitted in writing one week
prior to the meeting day so members of the committee will have time to prepare to hear
your case. They will review your file in detail and notify you with their final decision.
Remediation Policy/Effect of failure to meet evaluation standards
* All remediation must be completed within 6 months of completion of the 3rd year
curriculum. *
If student fails to obtain a total of 65% during the rotation, the student must remediate for
one month.
If a medical student fails the shelf test on the first attempt, they will be given an
incomplete for the rotation until that time that the shelf test is retaken. If they pass the
shelf on the second attempt, they will pass the rotation. If however, they should fail the
repeat shelf, they will receive a failure grade for the rotation and they will be required to
retake the rotation in its entirety and will be assigned to a faculty member for close
monitoring.
If the student should fail the ward or clinical experience, but pass the shelf test, they will
be given an incomplete until which time they remediate one month of clinical wards with
a specified attending. The student will be monitored closely and given as much
guidance as needed. They will take call, keep a logbook of cases, be assigned to an
inpatient ward team, attend conferences, and take the shelf test. They must receive
satisfactory evaluations from faculty and residents to complete remediation, earning less
than a cumulative score of 3.0; they will be required to repeat the internal medicine
clerkship in its entirety. The student should receive an average of 3.0 on their
cumulative clinical performance.
If student fails the shelf and clinical, the student fails the clerkship and must
repeat the entire Internal Medicine rotation.
18
Policy on Attendance/Absences
Procedure for reporting/requesting absences
Effect of failure to meet attendance requirements
Policy:
A 100% attendance is expected by all students on rotation. You are expected to participate in all
scheduled activities. As clinical and educational activities arise, other activities may be scheduled. You
should keep the hours from 7:00am to 5:00 pm available for clinical, educational, and academic
activities even if nothing is scheduled. Significant absences or tardiness constitute a lack of
professionalism and will be dealt with as such.
The Clerkship Director may request a letter from the student’s physician if the student misses more than
two (2) days or at the clerkship director’s discretion.
Generally, excused absences are granted for sickness, death in the family, or a Mercer sanctioned
educational meeting with prior approval.
All unexcused absences will require remediation at the Clerkship Director’s discretion.
*Making up call: If for any reason you will miss a call day – you will be required to make that day up.
No switching call days between teams. You must stay on your team and remain on call with your
team. The day that the call day will be made up will be at the direction and discretion of the Clerkship
Director.
Procedure for reporting/requesting absences:
An advanced written request should be submitted to the Clerkship Director via the Clerkship
Coordinator for all absences. The written request can be in the form of an e-mail. All absences should
occur with full knowledge and permission of the Clerkship Director via the Clerkship Coordinator and
Attending Physician of your team. If you are working on your outpatient weeks, absences should occur
with full knowledge and permission of the Clerkship Coordinator and Resident/Attending Physician you
are assigned to work with during that time.
If you are unexpectedly ill or have an emergency that requires you to be absent, you MUST notify the
clerkship coordinator and the attending and/or resident of the service that you are currently working on.
*All absences during the rotation will be reported to Leigh Anne Kirkland, Student Coordinator at the
end of each rotation. *
Effect of failure to meet attendance requirements:
If a student misses four (4) or more days of the rotation due to excused or unexcused absences, an
incomplete for the rotation will be given and an appropriate remediation experience will be required.
The time of the remediation will be at Christmas Break or before the beginning of the Fourth Year or at
the clerkship director’s discretion. If the students miss five (5) days or more, a one-week remediation
will be mandatory.
19
SERVICE RESPONSIBILITIES
YOU SHOULD ALWAYS BE AVAILABLE BY PAGER.
PLEASE KEEP YOUR PAGER ON AT ALL TIMES!
INPATIENT RESPONSIBILITIES - Inpatient Service (8 weeks – two 4 week blocks)
1.
2.
3.
4.
5.
6.
7.
8.
You will be assigned to one of five (5) primary care residency teams composed of one second/third year
resident and one first year resident.
You will be assigned one (1) to three (3) new patients per call day. However, it is anticipated that the
student will continue to accompany his/her team during the remainder of the on-call day so that he/she
will be exposed to further patient evaluations, clinical decisions, etc. The student must turn in one
complete “graded” history and physical per week on a new patient to the Internal Medicine Clerkship
Coordinator.
Call occurs every fifth (5th) night on Internal Medicine teams; therefore, during a four-week block on the
Internal Medicine rotation, you will be on call seven (7) times. All medical residents on Internal
Medicine teams have four (4) total days off per 28-day block. You will follow the same schedule as the
residents on your team allowing you to have four (4) days off during the 28-day rotation. Student call
rooms are available.
You will attend Morning Report on Monday, Tuesday and Thursday, in the 4th Floor Resident’s
Conference Room. You will also attend the Performance Improvement Conference on Wednesday
mornings in the Hospital’s Conference Room (see Lunch Conference schedule for locations). You will
attend Grand Rounds at 8:00 am on Fridays in the Medical Education Auditorium. You will attend Lunch
Conference daily at 12:30 pm in Conference Room C. (Check conference calendar for any time/location
changes.)
You will attend the following student tutorial sessions with Dr. Leighton, Dr. David Baxter or other
faculty members:
(a) Monday: EKG sessions (check lecture schedule) held in Center for Internal Medicine
(b) Tuesday: Clinical Reasoning/CS2 Prep
(c) Wednesday & Thursday: Student tutorial with Attending Physician in 4th Floor Resident’s Room
in the Hospital (Room #4119) as scheduled.
You will round with the team attending and residents daily.
You should be prepared to present your patients each day on rounds. Try to limit your presentation to 2-3
minutes. Always give minimal review of admitting information, (e.g., patient is a 65 year-old female with
heart failure and to date we had diuresed 15 lbs.)
Students must return any departmental property to The Center for Internal Medicine office on the last day
of the rotation between 9:00 am-3:00 pm.
Please check student mailboxes weekly for any correspondence. Student mailboxes are located in the
Resident’s Room at the Center for Internal Medicine, 1101 Lexington Avenue.
All resident call, conference changes can be viewed in Memorial’s New Innovations computer
scheduling software.
You are expected to KEEP A LOG OF ALL PATIENTS THAT YOU HAVE
ACTIVELY FOLLOWED & ENTER THEM INTO THE PATIENT TRACKING
DATABASE.
***ALL SOAP notes are to be reviewed by the senior resident or attending daily. Notes
should be kept in the chart and are a part of the patient’s permanent medical record. Joint
Commission requires each page of your SOAP notes to have “IM – “color team,” signature,
date, and time 100% of the time on EVERY page you do in the medical record.
ONLY 1 STUDENT ALLOWED ON NIGHT FLOAT AT A TIME.
20
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21
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22
OUTPATIENT RESPONSIBILITIES
(4 weeks off call)
Outpatient Service (4 weeks) – No call during this time



No call Saturday, Sunday prior to beginning clinic week
Take call Friday, Saturday, Sunday of clinic week before you begin on inpatient wards
All schedule changes must go through Clerkship Coordinator before changes are made!
1. On the first day of the rotation, you will attend an Internal Medicine Department Orientation with the
Clerkship Director (Check your “Welcome” letter for exact location.)
2. Students on the Outpatient/Ambulatory rotations will then go to their assigned Outpatient/Ambulatory
assigned location immediately following Orientation. The contact person is listed for each location and
you will be given information for that office. (See information sheet.)
3. The student must attend teaching sessions as outlined under #5 of Inpatient Rotation Responsibilities.
4. Students attend Grand Rounds at 8:00 am on Fridays and Lunch Conference at 12:30 pm daily at
Memorial University Medical Center. (Check Conference Calendar for time/location changes.)
5. If the private attending is out of the office for illness, vacation, day off, etc., the student should be
assigned to the attending’s partner. If no attending is available, the student will follow one of
Memorial’s Department of Internal Medicine inpatient ward team until the assigned physician returns.
6. “Principles of Ambulatory Medicine” textbook is available in the Health Sciences Library.
7. On the last day of the rotation, the student should return any items borrowed from the Internal Medicine
Office between 9:00 am and 3:00 pm.
8. Please be sure to check student mailboxes weekly for any correspondence. Student mailboxes are
located in the Resident’s Room in the Center for Internal Medicine.
9. Do not forget to log patient encounters in one45. Please keep a copy of your encounters and
procedures.
 All conference changes can be viewed in Memorial’s New Innovations computer scheduling software.
Directions will be given to you for the following Outpatient/Ambulatory locations prior to the rotation:
OUTPATIENT/AMBULATORY CONTACT or DESIGNEE
Chatham Medical Associates
Ashley Fuller
PHONE NUMBER
912-350-7500
Dr. Yulianty Kusuma
Internal Medicine of Savannah
Dr. Steven Corse
Optim Medical Associates
Dr. Ali Rahimi
RTR Medical Group
Curtis V. Cooper Primary
Health Care Center
Dr. Kusuma
912-349-6624
Amy
912-443-4272
Tim
912-927-8887
Nurse Supervisor
912-527-1100
YOU SHOULD ALWAYS BE AVAILABLE BY PAGER.
PLEASE KEEP YOUR PAGER ON AND WITH YOU AT ALL TIMES!
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24
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25
STUDENT RESOURCES
References for Internal Medicine Residents and Medical Students
Dr. Desh Nepal, Assistant Professor of Medicine, Mercer University School of
Medicine – Savannah Campus has developed a website to help students and
residents. Access Dr. Nepal’s website at:
http://imreference.com
The sections you will review are:
o Physical Examination (found on main page)
o Hospital Patient Management (Skills and Strategy (found on main page)
o Medical Students Page (go to Search box)
Stanford Medicine
Stanford Medicine 25 website. To access this website go online to:
http://stanfordmedicine25.stanford.edu.
“Primer to the Internal Medicine Clerkship” Second Edition (handout)
Mercer University Blackboard
Mercer University Blackboard page has links that you may access various
teaching files throughout the rotation under the Savannah Campus folder. To
access blackboard go online to: https://bb-mercer.blackboard.com/ and enter
your username and password. Contact the Clerkship Coordinator if you have any
questions.
INSTRUCTIONS HOW TO ACCESS PHYSICAL FINDINGS WEBSITE
A physical findings website has been developed for students, which contain a number of physical
findings & physical exam maneuvers. All of the information on the physical findings website will be
"fair game" for the fourth year exit exam. While on Internal Medicine, students are responsible for
learning the content of the material on the website. The website address is provided below along with
proper log in directions. Please see the Clerkship Director with any questions.
The login for the physical findings website is as follows:
1.
Click INTERNAL MEDICINE PHYSICAL FINDINGS to access website
http://medicine.mercer.edu/Departments/Internal%20Medicine/clerk_int_intro/physicalfindings
2.
Username: Your MUID Number
3.
Password: Your date of birth in this format YYMMDD
26
History and Physicals/Work Ups
Call days – You are expected to work up 3-4 new patients on call day. You will still need to see other patients
even if you do not fully work them up with the team. Write ups should be between 3-4 typed pages, or 4-6
handwritten pages and must include a chief complaint, history of present illness, PMH, PSH, Medication, FH, SH,
ROS, PE, Labs, Assessment and Plan. H&Ps must be turned into the Clerkship Coordinator within 72 hours (3
days) of completion. They will be distributed to the attending physician for review. The attending physician
must review them with you. A typed copy of the H&P should follow the style using the template below. This is
only a guide. See the appendix for appropriate workup. Example of format is below.
STUDENT FIRST AND LAST NAME
Internal Medicine Team: A, B, C or D
Attending Physician: ___________
H&P #_ __
Page __ of ___
(This information should be provided on each typed page)
Pt Identifiers: Last name, First name
DOB: mm/dd/yyyy
Date & Time of Admission: mm/dd/yyyy, ~1800h
CC:
HPI:
PMH:
PSH:
MEDS:
ALLERGIES:
FH:
SH:
ROS:
Gen:
Derm:
Head:
Eyes:
Ears:
Nose:
Throat:
CV:
Pulm:
GI:
GU:
MS:
Neuro:
Heme:
Endo:
Psych:
27
MRN: 098xxxxxx
PE: Vital Signs T ___ P ___ R____ BP ___/____ O2 Sat _____, BMI _____
Gen:
Head:
Face:
Eyes:
Ears:
Nose:
Neck:
Mouth:
Heart:
Resp:
Abdomen:
GU:
Neuro:
Skin:
Extremities:
OLD LABS:
LAB DATA:
A/P
1.

DDx:

DDx:
2.
STUDENT NAME, MS III
Beeper xxxx
28
Record Keeping
SOAP Notes should be written on each patient daily and include patient information that
occurred within the past 24 hours. SOAP note style is appropriate with current labs and vitals.
A total of (4) four SOAP notes must be submitted to the attending for review & credit.
Presentations
Students should be prepared to present their patients each morning on rounds. An effort should
be made to make your presentation organized and without the use of notes. (This will take time
so personal notes are acceptable early on in rotation). Try to limit presentation to 2-3 minutes.
Always give minimal review of admitting information – i.e., Patient is 65yo F admitted for
CHF and to date we have diuresed 15 lbs.
Procedures
Students are welcome to perform procedures with residents or attending. Be sure to document
the procedures on your log within ONE45.
Other Responsibilities
 Report to all code blues when your team is on call.
 Assist residents in accumulation of data, labs, old records
 You are NOT responsible for carrying more than 3-4 patients.
 You are to act professionally AT ALL TIMES (Lab coats to be worn at all times).
 You are to work with patients in a respectful, compassionate, empathetic manner.
 You are expected to be PUNCTUAL and DEPENDABLE.
 You are to prepare and participate in ALL educational opportunities.
 You are expected to attend all conferences UNLESS you are post call. Particularly
attend student morning report out of respect for your peers.
 You are not to text during lectures!
 You are expected to KEEP A LOG OF ALL PATIENTS that you have
ACTIVELY followed. DO NOT FORGET TO DOCUMENT PROCEDURES!
PROFESSIONALISM
 It is paramount that the highest level of professional conduct be maintained at all
times.
 BEWARE OF IDLE TALK ABOUT CASES ON THE WARDS, CONFERENCE
ROOMS, ELEVATORS, CAFETERIA, etc.
 Pages/beeps should be returned promptly and courteously.
 You are not to text or use cell phone in any manner during any of the lectures!
 Lack of professionalism is a failable offense.
KNOWLEDGE BASE
 Reading is fundamental to your learning. It is advised that you read on ALL of your
clinical encounters in addition to CORE readings.

Work on Differential Diagnoses. This supports what you have been reading.
29
Clarification of Medical Student Duty / Rules for the Third Year Clerkships
Mercer University School of Medicine
80 Hour week rule: Students will work no more than 80 hours a week averaged over a four-week
block. This begins on the first day of the rotation and starts again on the first Monday of the next four
weeks. Students will work no more than 110% (88 hours) in any one week.
24 Hour Rule: Saturday call makes it impossible to guarantee 24 hours off every week. Students
should have four 24-hour periods off every 4 weeks and not go more than 2 consecutive weeks without
24 hours off.
30 Hour Rule: Students should not be “on call” or involved in inpatient care activities for more than
30 consecutive hours. Significant, group educational activities may take place beyond the 30 hours but
not for more than 36 total hours.
You will be keeping track of this on your weekly work hour form. Be sure to make yourself a
photocopy of the weekly work hour form before turning it in each week.
REMINDER
ALL WEEKLY HOURS LOGS MUST BE TURNED IN BY THE DAY OF
YOUR LAST STUDENT TEACHING ROUNDS LECTURE SESSION!
30
STUDENT TEACHING ROUNDS LECTURE TOPICS
Atherosclerotic Heart Disease
Heart Failure
Basic Arrhythmias
Hypertension & Lipids
How to be a successful clerk
Developing a differential diagnosis for
Chest Pain
Developing a differential diagnosis for
Shortness of Breath
Dermatology
Thyroid
Diabetes
Neurology
End of Life & Medical Futility
Death Certificates
Acute Kidney Injury/Renal Emergencies
Acid Base
Intro to Infectious Disease
HIV/AIDS & Antiretroviral agents
HIV
Antibiotics & ID Cases
Pneumonia
(Rheumatology)
RA, SLE, GOUT, CPPD, OA, OSTEOPOROSIS
Anemia
Deep Vein Thombosis
Pulmonology
Pulmonary Case Presentation
w/radiographic review
Gastroenterology
Biostatistics
Medical Jeopardy
31
THIRD YEAR CLERKSHIP REQUIRED
! Important Information !

♦ ACLS mandatory class
8-H&P’s
♦ 4-SOAP notes
♦ 10 Journaling Entries
♦12 weekly work hour logs ♦ OSCE video session
Shelf Test
♦ MUSM “One45” computerized system for patient log including procedures & evaluations
ACLS
JULY 2014
Rotation I
7/28/2014 – 10/17/2014
Rotation II
10/20/2014 – 1/23/2015
Rotation III
1/26/2015 – 4/17/2015
Rotation IV
4/20/2015 – 7/10/2015
H & P’s and
4 SOAP
NOTES
*Due 2 wks
prior to end of
rotation
Shelf Test
9/8/14
10/2/14
10/17/2014
12/1/14
1/8/15
1/23/2015
3/9/15
4/2/15
4/17/2015
6/1/15
6/25/15
7/10/2015
OSCE’s
(wk 7 of rotation)
JULY 2014
JULY 2014
JULY 2014
JULY 2014
Last day of
rotation
Students on Outpatient rotation the first four (4) weeks of the 12-week rotation: the deadline for
H & P submittal is one week prior to the end of the Outpatient rotation.
Current ACLS certification is a prerequisite for rotating on the Ward teams at Memorial
University Medical Center in Savannah. Failing to pass the ACLS certification will delay your
rotation start date on the Wards. (Starting on Ambulatory without current ACLS certification is
at the discretion of the Clerkship or Assistant Clerkship Director).
Observed Standardized patient Clinical Exam (OSCE) – Mid-Rotation
Exam will be held in Savannah. Details regarding student arrival time at the Old Transport
Building – Clinical Skills Area will be provided to you prior to the Exam.
32
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33
Journaling Project Entries – Total of 10 entries are required
Learning is more than the accumulation of facts; it includes personal growth, interpersonal
interactions, communication and professionalism. As a third year student you will encounter
things you have never experienced before. This journaling project is a way to reflect on your
experience and to learn from it.
You will be required to submit online journal entries via the Mercer Blackboard Webpage. Ten
(10) entries are required in all. Each entry should be a reflection on an experience you had
during that week. This could be an interaction with a resident physician, attending physician,
peer, patient, ancillary staff person or any significant experience that happened during that
week. Each entry should be at least a paragraph and should include:



A description of the experience.
How the event affected you.
What you learned from it.
Examples would include:
 death of a patient
 a conflict with a peer
 a mistake you made
 an ethical dilemma
 a disagreement with an attending or a resident
 a patient that you particularly liked
 an encounter with a nurse
 Anything that affected you emotionally or that makes you reflect on what it means
to be a doctor.
You are expected to check and review the Mercer Internal Medicine Savannah
Blackboard site for useful handouts, educational videos, and practice shelf exams. A
communication blog is up on the site as an open forum for the rotation as well as useful
links to assist in your educational experience.
INSTRUCTIONS ON HOW TO LOG ON TO BLACKBOARD WEBSITE
1.
2.
3.
4.
5.
https://bb-mercer.blackboard.com
Log in – User name (Mercer ID #) and Password (Student’s Date Of Birth
in the form of YYMMDD)
CLERKSHIP JOURNALING – CLKSHP JOURNALING
Class of 2016-Savannah campus
Create New Entry
"Feel free to follow Dr. Steven Carpenter and Dr. Tim Connelly on
Twitter for regular short bursts of useful medical knowledge and
High Yield USMLE facts and concepts"
34
INTERNAL MEDICINE THIRD YEAR CLERKSHIP SYLLABUS
Internal Medicine is a 12-week rotation (8 weeks Inpatient, 4 weeks Outpatient).
The clerkship is designed to give you increasing responsibility in patient care within the hospital wards
and outpatient clinics.
The overall goal of the clerkship is growing independence. The majority of your learning comes
through personal experience so, DO NOT BE A BYSTANDER. Your willingness to go out on a limb
and take risks is expected. We expect “Thinking Outside The Box.”
Your evaluation will be based on the RIME method. Each step is a synthesis of knowledge, skill, and
attitudes.
REPORTER: Can work professionally with patients and staff and accurately gather and clearly
communicate the clinical facts on your patient and with the proper terminology (this takes basic
knowledge of what is important, plus the skill and reliability to do it consistently).
INTERPRETER: At a basic level, you must identify and prioritize new problems as they arise. The
next step is to offer a differential diagnosis. Success is offering at least three reasonable possibilities
for new problems and giving your reasons. (You won’t always have the “right” answer.) This step
takes growing knowledge, skill in selecting clinical facts and seeing yourself as part of the intellectual
process.
MANAGER: This step takes even more knowledge, and more confidence, plus the skill to select
among options with your own patient, to be “proactive” rather than simply “reactive.” Generally, your
diagnostic plan should include three appropriate test options and your therapeutic plan should offer
three possible therapies. Always state your own preference (you don’t have to be correct).
EDUCATOR: Ultimately, your ability to help patients means an openness to new knowledge and
depends on your skill in identifying questions that cannot be answered from textbooks. Are you able
to cite the evidence that new therapies and tests are worthwhile?
35
MISSION STATEMENT FOR THE JUNIOR CLERKSHIPS
MERCER UNIVERSITY SCHOOL OF MEDICINE
Mission
The mission of the junior clerkships is to prepare broadly students for the practice of clinical medicine
by facilitating their acquisition of the knowledge, behaviors, skills, and attitudes necessary for the
compassionate and competent care of patients.
Vision
Our vision is to create lifelong learners who embody the stated values of MUSM (collaboration,
compassion, competence, excellence, integrity, respect and honesty, and service) and who have a
commitment to meeting the health care needs of Georgia.
Goals
Our goal is that students will be able to evaluate effectively a patient by performing an appropriate
history and physical that facilitates differential diagnosis and the developing of a treatment plan.
Our goal is to ensure students obtain the core knowledge considered necessary for the practice of
medicine.
Our goal is to socialize medical students into the best of the culture of medicine such that they develop
an enduring commitment to the care of patients.
36
GRADING GRID for INTERNAL MEDICINE
The total grade is a sum of four components:
10 - Journaling Entries
8 - Written History & Physicals and 4-SOAP notes
Ward Performance
Shelf Test
Journaling Entry Project – 10%
(Pass =10;
10%
10%
40%
40%
100% or 104% if bonus earned
Fail = 9 or lower)
Written History & Physical and SOAP notes - 10% (8 H&Ps; 4 sets of SOAP notes)
Must Turn in 8 H&Ps and 4 SOAP notes – Each will be critiqued by the ward attending physicians.
The physician will look for improvement in documentation skills and broadening of assessment and
plan. This is a formative exercise. It is at the discretion of the director or the ward attending physician
if all or portions of the H&P need to be redone. Maximum credit is given if all 8 H&Ps and 4 sets of
SOAP notes are turned in. No pre-printed forms accepted!
NO PARTIAL CREDIT WILL BE GIVEN!
Shelf Test - 40%
(Pass = 59% or higher; Fail = 58% or lower)_
Ward Performance - 40%
(Pass = 56% or higher; Fail = 55% or lower)

Knowledge Base
This score assesses the following four areas:
●Communication Skills/Presentation Skills

●Attitude
Problem Solving Skills/DDX
The ward performance evaluations are converted to a numerical score. The actual grade is the
average sum of all scores. The maximum obtainable score in this area is 4.0, which will result
in a maximum of 40% in this area.
1. Students who are required to remediate any component of a clerkship (with the
exception of incomplete clinical encounters-ICE) may not do so during a subsequent
clerkship.
2. All remediation events must be completed within 8 weeks of the end of Year III.
Students will not be allowed to enter Year 4 until all remediation events are successfully
completed.
3. Students who fail to complete remediation within 8 weeks will be required to go before
the SAPC.
37
An additional 2 bonus points will be given if weekly work hour logs, procedures, numbers & kinds, student
teaching rounds lecture evaluations, and H&Ps are up to date at the mid-term of the rotation. To be eligible to
earn the extra two bonus points at mid-term, the following minimum requirement must be met:
 4 weekly work hour logs to include weeks 1-4 of the rotation
 ½ of the required procedures and numbers & kinds entered into MUSM One45 system
 3 journal entries entered into the Blackboard system to include weeks 2-4 of rotation
 Student Teaching Rounds Lecture evaluations in One45 from weeks 1-5 of rotation
 1 H&P although 4 H&Ps would be desired
An additional 2 bonus points will be given if weekly work hour logs, procedures, numbers & kinds, journal entries,
student teaching rounds lecture evaluations and H&Ps are completed by week 11 of the rotation. A total of 4
bonus points can be earned. If any of these components are missing, your grade may be withheld until
completion of missing component.
Minimum Score on Shelf Exam = 59%
Each student will be given a grade of pass, fail, or incomplete at the end of the rotation.
PASS – Minimal level of Competency
In order to obtain a passing grade in Internal Medicine all evaluations must be satisfactory or better,
the shelf exam must be passed and a cumulative score must be equal to or greater than 65%.
The breakdown for final grades at the end of the year as per the Clerkship Committee and the
Curriculum Committee are as follows:
PASS
FAIL
Numerical Score in Dean’s Letter
MINIMUM CUMULATIVE PERCENTAGE FOR
PASSING MEDICINE ROTATION IS 65
38
Weekly Work Hours/Procedure Log Form: - (Form shown on next page)
The weekly work hours/procedure log form shows your accountability and responsibility of your
medicine clerkship activities and procedures for the rotation. In the first section to the left, you will
see the heading DATE/# HRS WORKED. Beside each day of the week, write the date along with the
total number of hours you worked on that day provided underneath the date.
In the middle section underneath the heading TIME OF DAY WORKED provide the hours you were
actually here, i.e., 8:00a.m. – 4:30 p.m. If during this time you completed your night float call, have
the night float resident that you worked with to sign their name in the night float name box.
In the right side section, write any procedures you performed on that day. Remember this information
must also be entered into the ONE45 computer system as well as on this procedure log form.
In the bottom section, circle the correct box if you worked inpatient or outpatient and which team you
worked with during that week. You must also total your own hours and provide your signature as
well as printed name in the box provided. Don’t forget to circle the appropriate week number of the
rotation. You must turn in at least one log sheet for each of the twelve weeks that you are on the
rotation. The Clerkship Director and Clerkship Coordinator will review your work.
Your signature shows you are attesting that the information you have submitted is true to the best of
your knowledge. It is suggested that you keep a photocopy of each weekly log form that you turn in
for your own records.
Please note: If your hours are not totaled or if you do not provide your signature and printed name at
the bottom of the form or if you do not circle the appropriate week number, the form will be returned
to you in order for you to complete each of these tasks.
*Students are required to enter all patient encounters into the MUSM “One45” software at the
medical school. The deadline to enter the information is the Saturday after the Shelf Exam.*
39
MERCER UNIVERSITY SCHOOL OF MEDICINE
Department of Internal Medicine Junior Medical Students
WEEKLY WORK HOURS/PROCEDURE LOG FORM
DATE/# HRS WORKED
TIME OF DAY WORKED
PROCEDURE(S) PERFORMED
MON
AM
to
Night float name if applicable:
Number of hours:
DATE/# HRS WORKED
PM
TIME OF DAY WORKED
PROCEDURE(S) PERFORMED
TUES
AM
to
Night float name if applicable:
Number of hours:
DATE/# HRS WORKED
PM
TIME OF DAY WORKED
PROCEDURE(S) PERFORMED
WED
AM
to
Night float name if applicable:
Number of hours:
DATE/# HRS WORKED
PM
TIME OF DAY WORKED
PROCEDURE(S) PERFORMED
THURS
AM
to
Night float name if applicable:
Number of hours
DATE/# HRS WORKED
PM
TIME OF DAY WORKED
PROCEDURE(S) PERFORMED
FRI
AM
to
Night float name if applicable:
Number of hours:
DATE/# HRS WORKED
PM
TIME OF DAY WORKED
PROCEDURE(S) PERFORMED
SAT
AM
to
Night float name if applicable:
Number of hours:
DATE/# HRS WORKED
PM
TIME OF DAY WORKED
PROCEDURE(S) PERFORMED
SUN
AM
to
PM
Night float name if applicable:
Number of hours:
Please circle the proper category for this week. Enter the grand total work hours. Student Signature REQUIRED
INPATIENT TEAM –
A
B
C
D
Outpt – Endo; Neuro; Cardio; Nephro; ID; or Ambulatory
GRAND TOTAL HOURS FOR THE WEEK:
Student Signature required:
Print Student Name:
Please circle correct week #:
1
2
3
4
5
40
6
7
8
9
10
11
12
HOLIDAY SCHEDULE FOR BEING ON CALL
Students will be off beginning at 6pm the night before the holiday until 6am the morning after the
holiday.
Example:
Memorial Day (Monday)
Sunday @ 6pm the students are off and will return to work on Tuesday @ 6am
CALL SCHEDULE AROUND OSCE
On the day prior to the OSCE, if the student is on wards and on call, the student will leave at 6:00pm.
After the OSCE, students will resume their regular schedule.
CALL SCHEDULE AT THE END OF THE ROTATION
If the student is working on wards during the last four (4) weeks of the rotation, the student’s last day
of call is the Saturday prior to the end of the rotation. Your call will end at 6:00 pm. Your patient
responsibilities will end on the Wednesday afternoon of week 12 of the rotation after Core Conference.
MERCER UNIVERSITY SCHOOL OF MEDICINE HOLIDAYS
Labor Day
Mon. Sept. 1, 2014
Thanksgiving
Thurs. Nov. 27, 2014 & Fri. Nov. 28, 2014
Christmas Break
Sat. Dec. 20, 2014 – Sun. Jan. 4, 2015
Martin Luther King, Jr. Day
Mon. Jan. 19, 2015
Good Friday
Memorial Day Holiday
Independence Day Holiday
Fri. Apr. 3, 2015
Mon. May 25, 2015
Friday July 3, 2015
41
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42
-MERCER UNIVERSITY SCHOOL of MEDICINESteven Carpenter, M.D., Internal Medicine Academic Chair
J. David Baxter, M.D., Internal Medicine Clerkship Director
Sandra Simmons, Internal Medicine Clerkship Coordinator
OSCE VIDEO PRESENTATION REVIEW
Rotation Dates:
Today’s date:
OSCE VIDEO PRESENTATION REVIEW
OSCE Mentor:
Student Name:
OSCE Mentor Signature:
Student Signature:
The OSCE video presentation recorded by above named student has been reviewed and discussed with
the student by the above named OSCE mentor.
43
APPENDIX
Review of Soap Note Charting
and
An excellent example of a complete H&P
44
45
46
47
48
PROGRESS NOTE
Include the date and perhaps the time. Give the number and name of the problem followed by:
S.
(Subjective)
The patient’s report
O.
(Objective)
The clinician’s observations
A.
(Assessment) The clinician’s interpretation of what is going on
P.
(Plan)
Further plans, diagnostic, therapeutic or educational
Please see below for an excellent example of a complete H&P. This is a good template to follow. We
need to do a better job of documentation and discussion of differential diagnoses and assessment and
plan. The mark of a good Internist is the length of the differential diagnoses. This will also protect
you medico-legally and allow you higher code of billing when you go into private practice.
49
HISTORY AND PHYSICAL EXAM
CC: " Shortness of breath and leg swelling. Chest Pain"
HPI: This 49-year-old African American Male was seen and examined in the Emergency Room at
3:00pm. He complains of shortness of breath, leg swelling, and chest pain. The chest pain is located sub
sternally and describes it as “pressure" like with radiation to the left jaw. On a pain scale he grades the
pain as a 10/10. This began as he came down the steps of his house this morning around 7:00am. The pain
lasted 10 minutes. He took a sublingual NTG which provided no. relief. The onset of the chest pain was
sudden. He denied any associated symptoms such as diaphoresis, fever, chills, nausea, vomiting,
dizziness, orLOC. There were no alleviating factors. Rest did improve his chest pain somewhat. The chest
pain is similar to that of his MI in 2001.
The patient also noticed his legs swelling up to his knees for the past 3 days. This has progressively gotten
worse. The leg swelling was of sudden onset. He h~d a cough . with yellow sputum production associated
with his leg swelling. He denied wheezing, hemoptysis, pleuritic chest pain. He noticed DOE with only 510 steps. He also has PND and 3 pillow orthopnea during the past 3 days which have gotten worse too.
The patient has shortness of breath for the past 3 days with the onset of his leg edema. The shortness of
breath is at rest and with physical activity. This is progressively getting worse. This is similar to his CHF
in 2001. Despite his Lasix at home, the SOB and leg edema are worse.
PMH: HTN 2000
Heart Failure 2001 . MI 2001, normal
Cath
PSH: Appendectomy
Cardiac Cath 2001, normal
MEDS: Aspirin 81 mg po q day Coreg 6.25 mg
po bid Lasix 80 mg po bid
50
ALG:NKA
FH: Father died MI age 46
Mother died MI age S5
BrotherHTN
SOCIAL: Smoking 1 PPD for 30 years ( Quit 1 month ago)
Denies Alcoholic beverages, IVDU
Did try Cocaine years ago
Married, lives in Hawkinsville, GA
Eats low salt diet
Works as a Music Minister
ROS:
Head: Negative for trautiia,surgery, loss of consciousness
Face: Negative for surgery, Bell's Palsy
Neck: Negative for surgery, trauma, thyroid disease,discdisease Eyes:
Negative for cataracts, RO, glaucoma, glasses
Ears: Negative for surgery, hearing loss, Perforations
Nose: Negative for sinusitis, allergies,. surgery, epistaxis
Throat: Negative for surgery, trauma, tonsillitis, thrush .
CV: Positive for chest pain, shortness of breath, leg edema, past MI Lungs:
Positive for shortness of breath, cough; dyspnea -on excertion Abdomen:
Negative forHH, PUD, hepatitis, colitis, BRBPR, GB disease. MS: Negative
for OA, RA, Gout, surgery
Neuro; Negative for surgery, LOC, AD, MS, paralysis, LBP
Skin: Negative for eczema, psoriasis, BCe, SCC
Immuno: Negative for recurrent bacterial infections
Heme: Negative for dyscrasias,.blood loss, transfusions
Psych: Negative for bipolar, depression, schizophrenia
PE: Vital Signs T 97.2, P91, R 20, BP llSnS 02 Sat 100% NRB
.
GeneraljPleasant, cooperative, some mild respiratory distress, well developed, Obese,
answering all my query
Head: Normocephalic, atraumatic, hair appears normal
Face: Symmetric, eN 5-7 intact, no drooping, no TMJ click, no sinus
tenderness
51
Eyes; Good D&C O.U., EOMI, no icterus, no sub-conj hemm. Fundus
\Vithout hemm, no papilledema
Ears: Normal pinnae, TM without inj, pus, holes
Nose: Patent nares, no nasal discharge, nasal septum midline
Neck: Good ROM, good carotid pulses, no carotid bruits. Positive JVD at 30
Degrees, positive HJR, no lymphadenopathy
Oro: Patent, no inj, pus, exudates. Tongue midline, moist, dentition good CV: RRR,
S1 and S2. No murmurs. Positive S3 gallop, no S4. PMI displaced
6th ICS mid axillary line, no thrills, rubs
.
Resp: No tenderness with palpation of thorax, no signs of HZV. Positive rales Both
lung bases, no rhonchi, no wheezing. Positive dullness to percussion Both lung
bases.
GI: Obese. Positive bowel sounds all quad, no tenderness, masses, guarding.
Hemoccult negative. No organomegaly, no costoverterbral angle tenderness· MS:
No joint redness, swelling, crepitus. No muscle atrophy
Neuro: Speech is clear. Awake and Alert. Answering all my query. CN 2-12
Grossly intact. 5/5 motor function to upper ext. and lower ext.
DTR 2+ UEILE. No sensory loss with light touch. Tongue midline Without
fasiculations. No paralysis, flaccidity noted. Babinski negative Cerebellar
function intact, no pronator drift
Skin: No g~oss rashes, cyanosis, clubbing
Extremities: 3+ pitting edema bit. Ankles up to knees •. No pre-sacral edema
Moving aU 4 ext. well
..
Vascular: Good pulses at carotids, radial, femoral, DP, PTalll-2+
. Good cap. Refill, calfs soft bit Positive for some brawny edema
Bilateral lower extremities
Psych: Normal mood and affect
OLD DATA: No old records found in computer system
LAB DATA: MBA < 10
Glue 104, BUN 13, CR 1.2, Na 137, K3.8, CL 101, C02 28, AG 8, Ca 9.6,
ALP 81, AST 35, AL T 23, Mg 23, BNP 699
CBC 8.9, Hgb 18.1; HCT 53.2, PL T 229,000, MCV 91.8, TC 116, TG 42, HDL 20,
LDL 88 PT 123, INR 0.91, PIT 27.7
UDS: Positive Cocaine
UA: > 300 protein, small bili, Occ. Bacteria
ABG: 7.39/55.6/40/34/6/73%/ FI02 21 %
EKG: Wide complex tachycardia
CXR: Cardiomegaly, Bilateral Pulmonary Edema; Cephalization
ITA Chest: No signs of PE. Right pleural effusion present
52
AlP: 49 year old African American Male with HIO MI, CAD now with:
1.O Shortness of Breath
DnX: Heart Failure, MI, Ischemia, pneumonia, valvular disease,
congenital heart anomaly, volume overload
1.l Congestive Heart Failure Consider Cocaine induced Cardiomyopathy
• Prior history of MI, will consider cardiac cath to evaluate for new
ischemia
 Pulmonary Edema evident by increased· JVD; increased markings on
CXR, generous pitting edema, enlarged heart on CXR

..
Start IV Natr~or2mcgIKg IV bolus, then 0.01 mcglKglmin IV·
Infusion. Monitor UP closely for hypotension
• Start Lasix 40 mg IV q 12 hours
• Daily weights and record. Strict I&O;s'
• Low salt diet less than 2 grams
• Daily CXR, repeat port. CXR tonight
• Bedside 2D Echo now. Dr. James/Hudson to read
• Consult Cardiology
1.2 Pulmonary Embolism

Unlikely in view of negative CTA Chest
However, will provide DVT prophylaxis
53
.
1.3 Anemia• Unlikely cause of Shortness of breath in view of adequate Hemoglobin
2.0 Chest Pain• DDX:Acute coronary syndrome, PE,
Tension pneumothorax, Aortic Dissection,
Pleurisy, Anxiety, GERD, esophagitis
2.1
Acute Coronary Syndrome-
.12 Lead EKG does not reveal any acute changes to suggest .
ischemia or infarction. Will monitor EKG x 3
 Cardiac biomarkers are not elevated, will monitor 3 sets, 8 hours
Apart. This makes MI or ischemia unlikely
• . Morphine 2-3 mg IV every 5 minutes PRN chest pain. Call MD .
If 3 doses are given. Oxygen 100% NRB to keep 02 &.at > 91 %
NTG patch transdermalliow. Aspirin 325 mg chewed now.
Lipitor 80 mg po now
.
.
2.2 Pneumothorax
This is unlikely in view of negative CTA Chest and no radiography
evidence on CXR
2.3 Herpes Zoster Virus-
• No evidence of vesicular lesions noted on thorax during inspection
2.4 Pneumonia

No signs of pneumonia on CXR
Patient not febrile, no leukocytosis
. 2.5 Valvular Heart Disease-
54

No clinical past history of rheumatic, scadet fever, to suggest
any valvular pathology or congenital anomoly
3.0 Wide Complex Tachycardia:) in ER• DDX: WPW, A V re-entry tachycardia, V-Tech
• Monitor now shows NSR
• Consider EP study. Will consult EP cardiologist
4.0 Hypoxemia Consider Respiratory Acidosis by ABG
 Consider Congestive Heart Failure.
Will monitor 02 saturation and consider need for BIP AP
Will require out-patient sleep study in view of his high BMI
and consideration of OSA
5.0 Cocaine positive UDS• Will get Psych Liason Consult
6.0 Nicotine Abuse Will encourage and counsil on quitting
 Offer Nicoderm patch as out-patient .
7.0 Obesity• Very high BMI
55
 Will involve nutritionist to get on proper diet plan
 Sleep study to access OSA as cause of hypoxemia
John Doe, M.D.
Beeper # xxxx
56
USMLE® : Test Content & Practice Materials
Page 1of 2
Common Abbreviations for the Patient Note
Note: This is not intended to be a complete list of acceptable abbreviations, but rather represents the
types of common abbreviations that may be used on the patient note. There is no need to use
abbreviations on the patient note; if you are in doubt about the correct abbreviation, write it out.
yo
m
f
b
w
L
R
hx
hlo
cia
NL
WNL
o
+
-
Abd
AIDS
AP
BUN
CABG
CBC
CCU
cig
CHF
COPD
CPR
CT
CVA
CVP
CXR
DM
DTR
ECG
ED
EMT
ENT
EOM
year-old
male
female
black
white
left
right
history
history of
complaining of
normal limits
within normal limits
without or no
positive
negative
abdomen
acquired immune deficiency syndrome
anteroposterior
blood urea nitrogen
coronary artery bypass grafting
complete blood count
cardiac care unit
cigarettes
congestive heart failure
chronic obstructive pulmonary disease
cardiopulmonary resuscitation computed
tomography cerebrovascular accident
central venous pressure
chest x-ray
diabetes mellitus
deep tendon reflexes
electrocardiogram
emergency department
emergency medical technician
ears, nose, and throat
extraocular muscles
alcohol
ETOH
http://www.usmle.org/Examinations/step2/cs/content/abbreviations.html
5/12/2009
USMLE® : Test Content & Practice Materials
Ext
extremities
FH
family history
GI
gastrointestinal
GU
genitourinary
HEENT
head, eyes, ears, nose, and throat
HIV
human immunodeficiency virus
HTN
hypertension
IV
intramuscularly
JVD
KUB
LMP
LP
MI
MRI
MVA
Neuro
NIDDM
NKA
NKDA
NSR PA
PERLA
po
PT
PTT
RBC
SH
intravenously
jugular venous distention
kidney, ureter, and bladder
last menstrual period
lumbar puncture
myocardial infarction
magnetic resonance imaging
motor vehicle accident
neurologic 0
non-insulin-dependent diabetes mellitus
no known allergies
no known drug allergy
normal sinus rhythm
posteroanterior
pupils equal, react to light and accommodation
orally
prothrombin time
partial thromboplastin time
red blood cells
TIA
social history
U/A
transient ischemic attack
URI
urinalysis
WBC
upper respiratory tract infection
white blood cells
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