THE BOOK

2016

Class of 2018

THE BOOK
Edition XXXII

2016

A Medical Students Guide

To The Universe

REPRODUCED FROM THE BOOK I EDITION

As the many years before us have done...

we too are bestowing on to you
the highly guarded dare we say treasured secrets of

the book:

your guide to a successful 3rd year

Let the book be your oracle
for it knows things...
before you even ask...
Love the book, worship the book,
caress its virgin white pages.
Well, at least read it
at some point prior to rotations.
Every morning
take the time to take a good look at yourself
and say, Man, I look good...
Know it is more than just a white coat it is your entrance way
into a very sacred place of our patients lives

Revised by:
Christine Savilo
Hilary McCrary
Year 3 Class Reps

With input from the Class of 2017

and all those before us

Preface To The First Edition

Monday morning, June 20, 1983. 8:00 am. The Beginning of Third Year.
Arriving on the wards, faced with workups, orders, labs and rounds, we
found ourselves disoriented, bewildered, lost and completely unprepared for
Clinical Medicine. Later when we
figured out (through trial and error) how to survive on the wards,
we decided that our initial shock was totally unnecessary. It was
out of that frustration and anger that The Book was born. The
Book is a collection of our own personal list of Things We Wish
Wed Known In The Beginning. We are convinced that if we had known
these tidbits of information, our lives would have been
infinitely easier. In the sincere hope that our experience may
benefit other neophyte third year students, were giving you
Those Pearls We Wish Wed Had.

Copyright by Howard and Patty, 1984

2nd through 31st Editions, 1985-2016

No rights reserved. This book protected only by the Howard and

Patty copyright. Any part of this book may be reproduced in any
form, by any means (we encourage you to do so!), as long as it
is used for the sole purpose of enhancing medical education or
alleviating fears and anxieties of other medical students.

Contents
6 Part I: Welcome
7 How to use this Book
8 Your First Day
18 Part II: Clerkships
19 Internal Medicine
31 Surgery
37 Surgical Subspecialties
39 Obstetrics and Gynecology
47 Pediatrics
51 Family Medicine
53 Psychiatry
57 Neurology
60 The Shelf
64 Part III: How To Be a Third Year
73 The Admission Note
74 The Assessment and Plan
81 Presentations
87 Progress Notes
93 Understanding Prescriptions
95 The On-Call Night
98 Procedures
99 Code Blue
100 The Unit
105 Other Hospital Services
108 Part IV: General Information
121 Part V: Appendices
122 Common Notes
132 Abbreviations

Edition XXXI - Part I

Welcome
So, youre starting third year soon ... Worried? Scared? Excited? Heard lots
of third year medical student jokes? Think your life is over? The part of
your life that involved going to the rec center in the middle of the day is
over. So is the part about sitting in lecture for six hours. And so is the part
about you being a regurgomatic, with useless medical and non-medical trivia
occupying far too much brain space in that oh-so crowded hippocampal
formation. When July rolls around youll be transformed from a USMLE
Step I Test-taker to a Junior Clerk. Youll examine live patients rather than
cadavers. And hold peoples hands rather than their nutmeg livers.
This book was written by third year students who have experienced what you
are about to begin. We want you to have the benefit of knowledge that we
sweated, bled, and puked (or were puked upon) to obtain. We agree there is
much to be said about having good survival skills. We think you can not
only survive, but you can SUCCEED! You are entering a system that may at
times protect you, elevate you, and teach you, as well as humiliate you, work
you, and basically tire you out. You have in your hands the combined pearls
of each College of Medicine Class, designed to give you a head start, so you
wont be paralyzed with fright, anxiety, and nervousness. Thinking back to
the beginning of third year, we did not fully (or even partially!) understand
how to chart, what to chart, when to chart, what our responsibilities were,
and hundreds of other little details. The good news is that we do now, and
you will too.
Things have changed over the years. Generalists are in demand. Hospitals
are fighting for potential residents. Medical student abuse is no longer an
accepted rite of passage into the health care profession (though you may
need to remind a few of your attendings of this important point). Whether
you earned one honors grade or ten, we know from experience everyone can
excel during their first clinical year. This includes you! This edition will
provide tips on every rotation, to guide you through an experience you
cannot only live with but also enjoy!
Sit back the weekend before you start third year, grab this book while
catching some rays out near the pool, and glance over the section about your
first rotation. We recommend you read about the particular rotation youre
starting and review the chapters on How to be a third year MEDICAL
STUDENT. Dont wait until you are a savvy fourth year editing The Book
to realize just how much it has to offer. Keep THE BOOK, read about

rotations before they start. Carry THE BOOK around for quick reference.
We honestly hope this endeavor makes third year more rewarding for you.

How to use this Book:

Clerkship Descriptions
Here youll find brief descriptions of the rotations you will experience your
third year. There is information specific to each clerkship, as well as helpful
hints. There is information about sites you will work during specific
clerkships. The best advice we have to offer regarding good sites is dont
take too much advice. The reasons for liking or disliking sites vary, and can
be transient (My intern was a jerk, I couldnt get along with the nurses on
my teams floor, I got sick a lot). What someone disliked about a site may
be right up your alley, or it may have completely changed when you get
there. Most residents rotate just like you will, and attending physicians
change. Youll hear experiences described as team dependent, and most
are. A great attending, resident, and intern make a great team. Bad ones
dont, and combinations of the above create a range. Most of us have
rotations comfortably on the positive side of the continuum. Think about the
experience you want, do a little work, and youll get it. Weve tried to give
you some observations of the sites, as well as specific constructive ways to
get the most out of each site and to make your experiences more enjoyable.
How to be a third-year
Here are answers to questions including What will my day be like? What
do I do on Call? How do I present my patient to the team?
Tips
Consider everything a tip, a suggestion or idea we came up with during
third year (usually on the day or two before the rotation ended!).
Pearl Books
These are lists of references (mostly paperbacks and handbooks) many of us
have found extremely helpful. While there is no substitute for a reference
textbook, these are books that have saved many lives (our own included!).
Reference texts are standard, easily borrowed or checked out, so wont be
listed here. Remember, these are only suggestions - you need not buy all or
any of them! In fact, try to find a buddy on another track so you can trade
off books. Also, many rotations provide books, so check before purchasing
your own.

Blast from the Past

Mostly for entertainment value, and to remind you that medical school has
gotten a little better, we dredged up an early edition of The Book and have
included some quotes in here. These may or may not be clearly labeled, but
we are not to be held responsible for what transpired here at the UA during
the crazy 80s.
Copy Me!
These are specially marked pages intended to be removed, or copied and
carried around with you. We realize with all you have to carry around, it is
helpful to have only what you need. We found it helpful to reduce the size
(with the appropriate copier) and attach info to an index card. This makes it
easy to have the information at your fingertips.

First Day of Third Year

Tip: In most rotations the first day is reserved for orientation, but some
require you to actually start on the first day. This may include being on-call!

What to Bring

Name Badge (if you already have one, otherwise you will get one
on the first day).
For the VA, you need to complete a background check at least 2
weeks before starting-they require 2 forms of ID and fingerprinting.
Pager (This is for your Surgery rotation. Learn how it works before
day 1 and make sure you know your number its on the back)
Maxwells Quick Reference (available in the bookstore)
Drug info resource (PDA programs such as Epocrates or a Pocket
Pharmacopoeia, MicroMedex is what the pharm guys use)
appropriate dress (whatever that is. It varies for each rotation and
attending)
CLEAN white coat
stethoscope
3 x 5 note cards or small book to jot notes
at least one decent black pen

Optional:

clinical manual (e.g. Ferri manual, scut monkeys handbook, Pocket

Medicine which is amazing)
breath mints/ toothbrush (maybe this should not be optional!)
Snacks. Lots of snacks.
extra pens- we lose them all the time
calculator (endlessly useful)
PDA (download free versions of Epocrates, Merck manual, and/or
DynaMed (available through the library), as well as numerous
calculators (Qx Calculate) and other quick references
penlight
reflex hammer
tuning fork

What to bring if you are on-call the first day

You will be changing into scrubs, but dress nice for your first day anyway

comfortable shoes and socks (this is worth a major investment we

recommend Dansko)
toothbrush/toothpaste
if you insist on good grooming while on call, bring clean underwear
and shower stuff; most people dont bother.
reading material
munchies/pocket snacks (important to survival protein items
especially valuable)
small alarm clock/watch/cell phone with alarm (new pagers with
alarms set on vibrate mode are ideal)
a comfy light jacket... the longer you stay up the colder you feel

What You Will Be Doing

On your first day, find your intern or resident the clerkship coordinator or
chief resident will help you with this. Since you are new to the clinical side
of things, you will hang out (translation: follow) with your intern/resident
until you get the hang of things. It is in your best interest to make this period
as short as possible, plan on at least a day or two on the very first rotation.
Dont be surprised if your resident hands you a chart and shows you to your
first patient. Be ready to jump right in, but dont worry if this doesnt
happen. Be happy you may have found an actual teacher.
Pretty simple? Its easy to feel very overwhelmed the first day, but know
you wont be the only one! Relax, explain it is your first day/week of third
year, and people will work with you until you become comfortable with
what youre doing. How long will this take? Usually 1-2 weeks. The nice
thing is that you wont realize until later in the year how out of it you were at
the beginning. Just be enthusiastic, volunteer to do lots of stuff; you will be
excellent, and you will learn more in one month than you have in 2 years!
Once you get the hang of things, you will generally be responsible for
obtaining H&Ps (alone or with residents), writing notes, and presenting to
the attending (all skills which you will quickly become efficient with a little
time and practice).
A good recommendation is to ask fellow classmates what each rotation is
like and what they expect from the students. Obviously, this will become
more apparent as the year progresses. Use your class or the class above you
as resources.

On The Wards
Safety: Yours and the Patients
We cant emphasize this enough: Take care of yourself. Dont expose
yourself or your patients to unnecessary risks because you are in a hurry.
Wash hands frequently, using gloves where indicated, and wear other
protection (shoe covers, face shields) when indicated. Take the extra time.
This is part of the care you give your patients (and yourself), and they will
appreciate it. In clinics, wash hands in front of every patient before you
examine them. They DO take note of this! One last thing.... in certain
situations you may feel pressure to conform, by foregoing certain kinds of

10

protection. Weve seen entire groups of residents in trouble for this. There is
a written policy for procedures following blood/body fluid exposure. You
should already have signed this form. When it comes to safety, do only what
you think is prudent, then do it again, because you will live with the
consequences.

Disagreements
If something doesnt make sense (or seems wrong), or if you make an error,
definitely speak up. Do so by politely asking a member of your team for the
reasoning. Either they will recognize an error or provide an explanation.
Residents generally appreciate polite reminders for things such as writing
orders for meds/tests/etc. If you notice you made an error, admit to it,
apologize, and help correct it if needed.
By all means, speak your mind (including disagreeing) with anyone
concerning work-ups, diagnoses, or treatments; but follow a few simple rules
and life will be easier:

Be tactful! Theres no need to make anyone else look inadequate,

inferior, stupid, etc. Do that and youll live to regret it. Tact is
crucial crucial! (get the message?). Remember, attendings and
residents have been through the same training, and have probably
already asked the same questions you are asking.
Be able to defend your position (with references if possible in
triplicate!).
Dont air your gripes in front of attending before you take it up with
the house staff. The interns, residents, etc. may be wrong, but if you
point that out to all (in front of the attending), your team will hate
you, and your life will be unhappy (at best).
Air your complaints with the person with whom you are having
trouble. Tell everyone else first, and youll make the problem 10
times worse.
Talk about problems when they occur!! Suffering through six
twelve weeks because of a correctable problem (which most are),
and youll have no one to blame but yourself. It is not worth the
pain. The clerkship coordinators are excellent resources for
trouble shooting, and are accessible.
Above all, be prepared to be treated as the little medical student.
Not that this is always the case, but as they say, prepare for the
worst, and anything else is a nice surprise.

11

Dress Code
http://medicine.arizona.edu/form/student-dress-code-com

For women, dresses, skirts, or slacks are fine. For men, ties are expected, but
are discouraged in both Peds and Psychiatry (they can be lethal weapons in
the hands of patients). A good rule is to dress conservatively for the first few
days, while you notice what kind of attire your team wears. If the female
residents are wearing skirts at or below knee length, save your above-theknee skirts for another rotation, or better yet, for happy hour! The same is
true for sleeveless blouses/sweaters for women. Never wear open-toed shoes
(OSHA rules, baby!) unless you have seen your fellow team members doing
so. Even then, have a pair of closed toed shoes in your car, just in case.
Again, dress is team (and Attending!) dependent. Never acceptable: jeans,
T-shirts, shorts, swimming suits, or bare feet. Just use common sense, and
notice how the rest of the team dresses. Comfortable shoes are a must since
you may end up standing most of the day and/or running around large
hospitals, and going up and down stairs.
Question: When is it cool to wear scrubs around the hospital? All the time
when on Trauma Surgery or Labor & Delivery; for all other rotations only if
on-call or post-call and when scrubbed in for surgery (of course). Its always
ok to ask if you can wear scrubs!
Note: On your surgery rotation you may be expected to wear professional
attire for morning rounds even on surgery days.

Scrubbing in on a Surgery Case

Scrub training generally occurred the first day of any surgery or OB/GYN
Clerkship; now it is part of Transitions block. If instructed to scrub before
training has occurred, notify someone it is your first time. Hopefully that
person is nice enough to explain the process. Always, always, always
introduce yourself to the nurses and scrubs techs, even if it seems
awkward.
If you have never experienced scrubbing in, you are in for quite an event!
You will likely begin by being invited to attend a surgery or procedure.
Remember the following rules, as they may make the difference between life
and death:

12

Remember to enter the OR before you scrub with a mask on.

INTRODUCE YOURSELF to the scrub nurse (he/she will make or
break your experience... get on his/her good side) and the circulator,
ask if you can get gloves and a gown for yourself or for others.
Write your name and MSIII on the white board.
Never end your scrub before the attending or house staff. The
correct amount of time to scrub? Longer than anyone and
everyone above you in rank!
TOUCH NOTHING UNTIL YOU ARE GLOVED!
Always wait to gown up last.
Watch the scrub nurse for directions, and listen to what he/she
instructs. Others may tell you differently, but scrub nurses run the
show.
If you scrub in on multiple surgeries and stay in the PACU/PRR
between cases, you do not have to completely scrub in again for
future cases. You can simply use the gelbut remember sterile
technique in every case! Ask a scrub nurse or your intern if you are
confused or are not comfortable with scrubbing.
DO NOT FORGET EYE PROTECTION! Put it on along with your
mask before you start to scrub. YOUR FACE/MASK IS NOT
STERILE. Let your nose run or eye itch. But DO NOT touch
your face mask or head, or you will not be sterile.
Things that are helpful for medical students to do in the OR and will
get you major points with your residents/attendings: moving the bed
in or out of the room, putting on SCDs, helping move the patient,
and grabbing warm blankets.

Punctuality
Be on time! Lateness will incur wrath, and do more harm than many other
faults. This holds true even if your interns, residents and attending
physicians are late. Be punctual for all rounds, meetings and conferences.
Playing hooky is highly discouraged.

Be a Team Player NO SCOOPING!

Dont correct/criticize/pimp/scoop fellow students. We are all in this
together, and making a colleague look bad will do nothing to enhance your
own standing on the team. Fellow students are often the best resources,
especially for questions you are too embarrassed to ask the team.

13

By scooping we mean answering a question directed to one of your

colleagues (by an attending or resident). Some may also call this throwing
someone under the bus. This can be tempting, but resist! Murphys Law:
they always ask other student questions you know, and ask you the questions
you dont.
If your classmate misses an answer, you will usually be asked, so be patient.
Its encouraged to whisper/give covert hand signals to your classmate, of
course. Sometimes its good to restrain yourself and let a classmate shine!
Attending and residents are always aware of how you interact with the team.
Not only will this keep classmates from wanting to kill you, but they will be
much more likely to help you out when you need them, and believe us, you
will need them!!!
By criticizing, we mean commenting on the performance of a colleague to
your attending/resident. By the way, it is inappropriate for residents or
attendings to talk negatively about your colleagues to you. Remember If
you cant say anything nice, dont say anything at all! The corollary to this
is that its always O.K. to pay compliments to classmates and to others. This
can make a rough day more bearable. Support each other!
The sad reality, and unspoken truth, is that third year is the end of many
friendships. It may not be the people you think. The atmosphere is intense,
competition is high, and after a few weeks you will wonder who these people
are. Many say the third year brings out the worst in people. The good news is
that by mid-fourth year, many lost friendships are rebuilt (or so we hear).
Our advice to you is do your best to avoid the above-mentioned behavior,
and work to keep friendships alive in third year. Third year can be a lonely
place, but friends can help make it bearable. You might even make new
friends from former classmates.

GENERAL GUIDELINES FOR THIRD YEAR SUCCESS

(Revised from the Clinical Orientation Handbook, UCLA,1985)

The habits developed now will remain with you throughout your
career. It is worthwhile to take time to learn it and do it right.
Presentations and write-ups are the two most important aspects of

14

performance on the wards. Get into good habits, and practice them
NOW!

Dont assume its not your place to do something until you are told
it isnt. No one should get upset at a student for being enthusiastic
and eager to participate.

If you dont know, ASK! The person you ask is just as important as
when and how you ask. USE YOUR OWN DISCRETION.
Sometimes it is more prudent to look things up yourself, or ask a
compatriot. These moments will be apparent.

At the beginning of each clerkship, think about objectives youd

like to accomplish. Residents may even ask about your goals while
on the clerkship, so its best to have a few in mind. Its easy to get
so wrapped up in paperwork and minutia that you neglect the
primary learning experience. Remember: you are paying for this.

Your experience does not have to be limited to assigned patients. If

you hear of a patient with interesting findings, ask the attending
(and your classmate if its her/his patient no scooping,
remember?) if you may see the patient. Likewise, if you have an
interesting or unusual patient, share this with fellow students
(assuming, of course, that the patient has agreed). This is a very
informal, non-threatening way to learn a great deal.

NEVER forget you are part of a team. Teamwork makes everyones

job easier.

Nurses are an important part of the team. They are invaluable

sources of information and should always be treated with the utmost
respect. They have more power to make you miserable than you
realize. Dont forget to introduce yourself to nurses and other
medical staff. This will pay off in the end. Also, ask the night nurse
how the patient was overnight. They provide lots of useful
information!

The most important key to survive a busy clerkship is

ORGANIZATION. Carefully plan your patient visits, charting, and
scut. This minimizes the hours spent in the hospital, and miles you
put on your feet. Items that may help you get organized include a

15

clipboard to keep track of scut lists, lab results, etc., a pocket-size

date book, and 3x5 cards containing pertinent information on each
patient.

Some students develop their own data cards, organized to their style
of data collection, thought, organization, or presentation (places for
vitals, labs etc.) for each hospital day. Medfools.com has helpful
downloads of scut sheets.

Know your patient! This includes history, medical problems,

physical findings, lab data, medications, vital signs, etc. You wont
be asked about everything, but whatever you are asked, you should
know (if you want to look good).We recommend being the first to
know recent labs/radiology results.

Take care of yourself. Eat well and get adequate sleep. Take
advantage of the Wellness Center in the hospital. Youre here to
learn, but you cant do it well if youre in worse shape than your
patients! If you dont like the Wellness Center, or are tired of being
at Banner University Medical Center-Tucson Campus, find
somewhere else to exercise. Your body and mind will thank you!

Brown-nosing in any blatant form is unnecessary. Attendings,

residents, and interns have been down the same path, and can easily
spot these tactics. They possibly tried them themselves! Although
some form of social tact is necessary, blatant ass-kissers gain
negative reputations, which follow them throughout 3rd year.
Beware!

Remember that you get out of it what you put into it. Its possible
to get through many clerkships with minimal effort, but you will
learn a minimal amount. Dont forget that somewhere down the
line attendings will expect that you have learned basic principles
during clerkships. Put in the effort! If you do, you will be rewarded
with chances to do more in your clerkship and earn the respect of
your team. The key to succeeding in clerkships is to show interest,
effort, and enthusiasm to learn. Believe us, you dont have to know
all the answers to do well.

Although you may know exactly what field you plan to enter upon
graduation, it is advisable to use tact when considering with whom

16

you share this information. Some attendings and residents limit

their teaching once they learn you are not entering their field. The
best advice is to treat each rotation as if you are going into it, in
order to maximize the overall experience.

Dont stand around; always have a book to read (or pretend to)
when waiting on your resident. No one likes knowing people are
waiting on them.

If you have a significant other, call that person on your call nights.

Dont hoard resources. If you find a review book you like, stick to
it. Many students have made the mistake to try to get through too
many review books. Pick one and know it well (with the caveat you
need a question source, too if it doesnt have it in there).

Study for the shelf exam. Study for the shelf exam. Study for the
shelf exam. While you may perform well on a rotation, without a
strong shelf exam score, you will miss out on the coveted Honors
grade.

17

The Book
XXXII

Part II

Clerkships

ENTERING THE TWILIGHT ZONE

Read some of this section now, then pull out The Book at the
beginning of each rotation to refresh your memory as to what to
expect, what to study, which books are recommended, and miscellaneous
tricks of each trade.

18

Internal Medicine
Clerkship Director: Amy Sussman, MD (520) 626-6371
Email: asussman@deptofmed.arizona.edu
Coordinator: Lucy Contreras (520) 626-1574
Email: lcontrer@emailarizona.edu or lucia@deptofmed.arizona.edu
VAMC: Stephanie Velarde (602) 222-6436
Stephanie.Velarde@va.gov
Eternal Medicine: 12 weeks of differential diagnoses, eight+ page H&Ps,
hours of attending rounds, codes, and hopefully, integration of a little basic
science knowledge. Youll learn more about medicine in general in this
clerkship than in the remainder of medical school. Obviously thats a lot of
material. Youll use much of what youve learned in Basic Sciences (You
thought you could forget that? Guess again, my friend!) and put it to
practical use in Internal Medicine. Internal Medicine is intense, but youll
learn more about diagnostic, therapeutic, and presentation skills in this
clerkship than any other.

Teams
Inpatient Internal Medicine at the various hospitals is usually divided into
teams. At most sites, there are 4-5 teams. It doesnt matter what team youre
on since every team gets very different types of patients. Depending on the
attending (cardiologist vs rheumatologist), you may see more of a certain
type of patient, or be expected to know more about that aspect of a patient
than if you were on a different team, so beware! Since it is their area of
expertise, they will pimp you on those topics. Fortunately or unfortunately,
you will find in other rotations the quality of your experience is dependent
on the character of your team. Medicine is notorious for this condition, and
there is nothing you can do to change it (we have tried). We can only wish
you good luck.
Each team consists of an attending as described above, one or two residents,
one or two interns, and a third year clerk (thats you). Sometimes, youll
have a sub-intern, a 4th year student acting in an intern capacity doing a
Sub-I.

19

Typical Day
Your typical day will start out at 6:00-8:00 am when youll do Pre-rounds,
either by yourself or with your intern or resident. Most teams will combine
pre-rounds with Work rounds. See Part III about these parts of your day.
Always ask your resident when you start, what is expected of you on rounds,
as the sites have a tremendous amount of variation. Following your work
rounds (where you and/or your intern will write progress notes and orders or
schedule tests for that day), you attempt to obtain your patients most recent
lab work in time to present the patients at attending rounds. Attending
rounds usually last between one and five hours, after which you run for
lunch because if you dont get it now, you may not have time for it later. If
no lunch is possible, ALWAYS carry a snack in your pocket. At some of the
sites, you will do pre-rounds/work-rounds by yourself - only call your
resident if you have a question about something.

Responsibilities
Youll usually carry between one and four patients at a time. This is no
problem with some organizations. The number of admissions you take on a
call night is really up to you, but usually not more than 2. Residents are
usually really great about letting you get some study time in or excusing you.
If they tell you to go, just do it.).

H&P
Your medicine work-up is defined in one word complete. Youll do a
complete history and physical (H&P). (See Appendices for details.) With
old charts available, you will soon learn they can be a wealth of information;
however, a word of caution: be sure to verify the history (by asking the
patient, checking old tests, etc.) This serves two purposes: 1) you will look
good when your attending asks something like when/how a patient received
a particular diagnosis, and 2) it avoids propagating errors caused by someone
elses poor history taking. It is to your advantage to read through the old
chart (which is on computer at UMC and the VA). If nothing else, look at the
previous discharge summaries (See Part V). Once the patient is tucked-in
(admit note and orders written), youll want to sit down and read, read, read.
Then, you just might go for an article search. Resources include
EMEDICINE and MEDLINE available in the AHSC library and at just
about every other hospital library except the VA which has UpToDate. To
login to their website you have to pay; however, if you Google emedicine
and whatever disease you are looking for, you can get past it.

20

UpToDate and MDConsult are excellent resources, currently available

through the library and at most hospitals. Depending on your attending,
UptoDate and MDConsult may be as bad in their eyes as Wikipedia is. In
these cases, consider using AccessMedicine or go directly to primary
literature, which are all accessible through the AHSL website. DynaMed,
accessible under AHSL databases, is a great evidence-based resource. Try to
obtain an article or two regarding your patients disease and its treatment youll look stellar if you do this consistently.

Tip: Some attendings are more into the library action than others. Try to get
the feel of your attending at the beginning, as to what is expected of you.
Researching current articles is more an issue at BUMC-T Campus than at the
other sites. It is the way most of us will actually learn out there, in the real
world, so start the habit now! At some sites the attending or residents
might ask students to research a topic relevant to a particular patient on the
service, and then give a brief presentation during rounds. This is intended to
facilitate learning, they are happy with a couple minutes of discussion and
perhaps a short handout.
From all this information, youll proceed to write up your patient, including
your assessment and plan (A&P) which is the most emphasized portion of
the write-up in medicine. Students are to have the Database in the chart
within 24 hours, and the A&P within 48. If you are to present the patient the
next day, which is usually the case, you better do the whole thing in 24 hours
(ask your attending on the first day what she/he wants). Other possible notes
to write include Procedure Notes and Discharge Summaries (see appendices
Part V). When finished, you should be prepared to present this patient to
your attending the next day, and be able to answer any questions asked.
Sounds simple, doesnt it? Dont worry. You will become comfortable with
all of this near the end of your rotation (smile).

Call
The call schedule depends on location. Many teams (not all) let students go
home on call night after working up your one hit (aka new patient admit).
However, for internal medicine, they have a night float team who you sign
out to after your long call day. You do not stay the night with them! GO
HOME. Long call days can last anywhere between 12-16 hours. Be prepared
with snacks, coffee and food. In general, non-call days end anywhere from
11am to 9 pm; 3-5 pm is the norm, but it varies with both your team
personalities and the number of patients belonging to your team. Study when

21

you have down time. Long call days can get busy for residents (especially
when they are covering other teams patient in the afternoon). Be patient
with the interns at this point! Take initiative and take care of the patients you
are following for them. Take down time to ask how you can help. If there is
nothing to do, study near them... something will come up. In general, ask the
residents or your attending to go over certain topics about a patient. Dont be
afraid to ask questions.
Tip: You will soon find out that I-med usually does NOT involve any work
in the intensive care unit (the exception to this is the Tucson VAMC). You
may request this or be assigned to it depending on availability at UMC.
Good teams will teach you a lot, and even let you do some procedures. This
varies by site; so ask your ward residents if this is a good idea.
In addition to all the above, there is a core curriculum which consists of
required lectures and conferences. YOU ARE REQUIRED TO ATTEND
ALL ACADEMIC LECTURES FOR MED STUDENTS. You are not
required to attend the resident lectures at the VA, although most people do.
If you go, make sure your caffeine stores are sufficient.

Inpatient Sites-Tucson:
Veterans Administration Medical Center (6th Ave. and Ajo Way): Good
Luck-your team can make your rotation at the VA an incredible experience.
The attendings are incredible here and love to teach for the most part. You
will be able to do more procedures at the VA and have more responsibility.
As a med student you document the notes and H&Ps on the computer. The
patient load is usually 2-5. You will be an indispensable part of your team.
One of the greatest aspects of the VA is its team rooms where you will spend
a lot of your time hanging out with your residents. There is a fridge and
microwave at your disposal, which you will absolutely want to take
advantage of because VA CAFETERIA FOOD SUCKS also on the
weekends the VA cafeteria is closed so bring food on the weekends.
BUMC-T Campus (1501 North Campbell): Attend sign-out in the morning
to get your new patients. The night team will present them to you. BE
READY to write MRN, name, and HPI down quickly! Teams range from
extremely friendly to extremely anal and downright badgering. This is
probably the busiest site in terms of workload and hours. Patient load is 2-4.
It is very helpful to the team to call the consults for your patients. Talk to
your resident and ask if you can do this for them. (If you do, make sure you

22

have a QUESTION for the consulting service and know your patient with his
chart open while you are on the phone. They will ask specific questions.)
Here is where many of us decided to hate or love medicine.
Dr. Goldmans MICU rounds review EKGs, Xrays, relevant labs on current
ICU patients. A lot of good teaching occurs at this conference. A wise
student would be well-versed in EKGs (once again we recommend Dubin)
before attempting to present a patient at Goldman rounds. If you do, another
word to the wise - be BRIEF. If its longer than 30 seconds, its too long!
DR. GOLDMAN WILL ASK FOR A JOKE!!! BE PREPARED TO HAVE
ONE READY!!!!! VERY IMPORTANT. Dr. Goldman will tease you and
always challenge you, but he is good-humored and harmless! BE STRONG!
BUMC-S Campus: On a general day of medicine at South Campus you can
expect to work 11-14 hours, six days a week. Students are expected to arrive
at 6am sharp for patient sign-out from the night team. You'll then proceed to
round on your own patients (usually between 2 and 4), after which you will
meet to discuss/round with the rest of the team and your attending. Be
prepared to present your own patients and err on the side of being thorough
and detailed rather than short-and-sweet. The afternoon will be spent
admitting patients until 5 or 6pm. Make sure to read up on whatever
conditions/medications/etc. pertain to your patients so that you are prepared
to answer questions (and know what is going on!) The cafeteria is only open
certain hours of the day and the food isn't the greatest, so it is often helpful to
bring your own lunch. One way to really impress your team is to take
initiative and help out with the more menial, trivial tasks (making copy of
the nursing numbers for each resident, calling the pharmacy to check a
patient's medication list if there is a discrepancy, etc.). The residents and
attendings at south campus are very knowledgeable and you can be certain
you will learn a lot while on your rotation there!

Outpatient Sites-Tucson
The choice is Banner University Medical Center-Tucson Campus, VA, or
Banner University Medical Center-South Campus. At all locations you will
see patients, present them to the attending or chief resident, then be asked for
your assessment and plan. You quickly learn that taking an hour to interview
and examine a patient in a busy clinic is considered poor formalthough it
may happen if you get a train wreck (see Jargon) with no chart. The
number of patients seen in a day ranges from one or two to 10-15. At some

23

sites lunch is provided by the ubiquitous drug reps (see disclaimer about
this).
Another favorite of the clinics is the opportunity to do follow-up. This can be
exciting if you have done inpatient first, with outpatient to follow, and want
to see the patient you discharged at a later date. The hours are great,
although most agree that after four weeks, the walls do start to close in a
little. Most students use this month to do a bulk of their reading and studying
for the exam. Many students try to weasel their way into having this rotation
last; but it really doesnt matter there is so much material that one needs to
study for the entire 3 months to do well.
On Wednesday you will have a half day at your clinic, and then drive to
Banner University Health Center-Main Campus for grand rounds, and a
Humanities and EKG lecture in the afternoon. Weekends are entirely free
this month!!!!! Use them for fun, regaining sanity and study! Some Tips on
looking good in clinic:

Dont sit and brood over the patient chart when given to you. Read
up a little, especially the last clinic note and
problem List, if
the patient isnt new. This will tell you what to look for during the
exam. Then just go see the patient. Many clinics like efficient
students who do not waste time.

Youre not expected to know exactly whats going on with your

patient, and you may not have a clue. But, do have a differential in
mind when presenting your patient, even if you only know one
process that could cause the problem. At your stage, its taken for
granted that you know how to do a good H&P; venture some
thoughts on the patients condition and treatment and include them
in your presentation before the attending cuts you off (and they will
try!). The key here is not to pause between giving the HPI, PE, and
Assessment and Plan. Smile and stay focused!

Do not wait for the nurse, tech, etc. to perform simple tasks your
attending might want information on during your presentation. (I.e.
patient with N/V/D, the attending will want to know if the patient is
orthostatic.) Orthos, vitals, Pulse Ox, etc. are things you are quite
capable of doing yourself, so you will have the answers when
questioned. No reason to say well, I asked the nurse to do it!

24

Note: always recheck a high BP or fast pulse rate yourself for

confirmation.

You are encouraged to read about your patient while you wait to
present. Attendings appreciate a desire to learn if they see this
consistently.

Before you leave for the day ask your attending, Do you have any
interesting patients for me to see, or is there anything you would
like help with before I leave? This demonstrates you are motivated
and enthusiastic - youll learn quickly that 3rd year is a bit of a
game of politics: play well and win.

Internal Medicine Exam

The exam is an exam to behold. Its a National Board. The best that can be
said is that it is challenging. It can be passed, and some will even get
honors. See The Nitty-Gritty below for tips on studying for this sucker.
Everyone has his own strategy for the exam (if you have one that works
well, stick to it!), but remember to keep your pace up if you want to finish it helps to do the matching questions at the end first. If you do enough
practice questions, you will recognize keywords and likely be able to answer
questions after skimming each case presentation.
You do have to get honors on the exam, as well as stellar evaluations on at
least 6 evaluators (attendings and residents above PGY-1) in order to get that
gleaming H on the transcript. Honors on the evaluations is totally dependent
upon how your classmates do, as usually the top 20-25% of your cohort will
be eligible for honors. (Disclaimer: this does not translate to you throwing
people under the busthats a great way to get a terrible evaluation!) Please
note that you will be evaluated by everyone. Even if you work with them on
a short basis. Be kind and helpful even if they arent. Choose one reference
book, for example, First Aid or Step Up to Medicine. Start reading your
book of choice during your 2nd week - youll get through it and do well
on the exam. MKSAP IS THE BEST RESOURCE. IT IS A MUST! This is
also a great rotation to use your U-World subscription forif you have a
couple minutes, do a couple questions on your phone!
If you can get through Step-Up to Medicine, U-World and MKSAP, you will
hit this goal.

25

The following list of stuff is probably not used by most, but some people in
previous classes have found it helpful. It is pretty comprehensive for the
basics you need to know.

Review for Internal Medicine

Cardiology
Review Wiggers diagram for AS/AR, MS/MR
Know all the murmurs
Review MVP & HOCM (hypertrophic obstructive cardiomyopathy)
SBE (findings, presentation, treatment)
EKGs - not really emphasized
Arrhythmias - principally A-Fib, V-Fib, V-tach, SVT, including
treatment
Pulmonary
Asthma - especially ABGs in each stage
COPD
ABGs
Pulmonary Embolus - causes, diagnoses (V/Q vs. Angiogram),
treatment
TB - drugs and their side effects
Interstitial lung disease
Lung CA - types, treatment, prognosis, predisposing factors
Pneumonia - bugs, drugs, manifestations in IVDUT, HIV disease
Anaphylaxis - how to recognize and treat
Pneumothorax - manifestations and causes
Rheumatology
Osteoarthritis, Rheumatoid Arthritis (where, how they present)
Crystal arthropathies (gout, pseudogout)
Sero-negative spondyloarthropathies
CREST - what is it?
SLE - general criteria
Arthritis - GC, Reiters, psoriatic (differentiate the main types)
Immune reactions - types, characteristics
Polymyositis/Dermatomyositis - what are they?

26

Endocrinology
Hypo and hyper Ca++ (causes, diff. dx)
Hypo and hyperthyroid, parathyroid, and adrenal. Drugs used
to treat and their side effects.
Diff dx hyperaldosteronism (see Harrisons)
Diff dx Cushings (list in Harrisons)
Acromegaly - what causes it, what does it look like
Prolactinoma
Hypertension - secondary causes and manifestations. Know
pheochromocytosis.
Diabetes mellitus - presentation, long-term complications
Given levels of FSH, LH and Prolactin, be able to differentiate
atrophic vaginitis, Turners Syndrome, PCO, anorexia, testicular
feminization
MEN syndromes
GI

Renal

Esophageal - spasm, stricture, PSS, achalasia, cancer, reflux diff

dx by hx
LFTs - significance in hepatitis (ETOH vs viral)
PUD - dx, tx, Zollinger-Ellison
Malabsorption - types, w/u, sprue, Crohns vs. U.C.
Diarrhea
Pancreatitis chronic and acute - presentation, labs
Colon/Pancreas/Stomach Ca - dx, prognosis (incl. colon polyps)
Hemochromatosis

Acid base metabolic/respiratory alkalosis/acidosis

SIADH - when do you see this? dx, tx
Na/K - causes, consequences of too much or too little
Glomerulonephropathies - basic types
ATN vs dehydration
Anion gap - clinical use
Diabetes Insipidus - causes, nephrogenic vs. central, treatment

27

Neurology (Yes, there is neuro on this exam - dont forget!)

Stroke - right hemisphere stroke, left sided paralysis
Guillain Barre-presentation and CSF findings
ALS (presentation, pathology)
Thiamine deficiency - Korsakoffs/Wernickes, ETOH abuse
Multiple Sclerosis - diagnosis.
UMN vs. LMN Sx (hint: ALS has both of these)
Dermatology
Psoriasis
Tinea
Eczema/Atopy
Lichen Planus
HIV manifestations, HSV
Look at the Derm pictures in Harrisons!
Infectious Disease
Sepsis and DIC - how to recognize it
Mononucleosis (clinical picture, labs)
Toxins and organisms
STDs - GC, syphilis, herpes, etc.
Inflammatory diarrhea - C.dificile/Campylobacter/travelers
diarrhea
Vaginal candidiasis - diagnosis and treatment
HIV disease - GI, Pulmonary, CNS manifestations - more and
more emphasized!
Cocci - not really big on the test - more of a regional thing.
TB - atypical presentations (see note about HIV above)

Ophthalmology
Fundoscopic findings in:
HTN
DM
Hematology
Leukemia
Lymphoma
Multiple Myeloma
Anemia - types, causes, lab findings, w/u

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Hemolytic Anemia secondary to certain drugs (including G6PD

deficiency)
G6PD deficiency
Coagulation disorders (Hemophilia vs. Von-Willebrands a
common trick question)

Oncology
Selected CA - Breast, prostate, colon, lung, pancreas
Metastatic w/u
DIC, paraneoplastic syndromes
Chemotherapy - only the most common drugs and their well known
side effects (e.g.: bleomycin, pulmonary toxicity; adriamycin,
cardiomyopathies, etc.)
Recommended screening protocols for Breast, Cervical, Colon,
and Prostate Cancers.
All in all, Internal Medicine is the essence of third year. It is possibly your
most important clerkship in terms of building a foundation for further
practice. Youll learn much in these 12 weeks. Most students do enjoy it, get
something out of it, pass it, and, yes, may actually even go into Internal
Medicine! Remember, you have three, 4-week blocks, and they are all very
different. If the first month doesnt agree with you, be patient!

Study Guides: (Read for wards; Quiz Qs for exam prep)

MSKAP: Lots of hard questions, excellent practice for the exam,
fabulous answer explanations. Questions are much more challenging than
Pre-Test, a fairly good tool to see if you have truly mastered a topic. Style
and level of difficulty similar to actual exam. The questions are also
available on CD-ROM.
First Aid for Medicine: a new popular choice. Somewhere between
Blueprints and NMS in terms of details. A good source for the types of
questions you will be asked during wards and the test. If possible, read this
book throughout the clerkship, and then flip through it the day before the
exam to refresh your memory.
Blueprints: Highly recommended 30 min review of topics, not enough to
honor exam though. This resource is wordier and takes a long time to read.
Blueprints Casefiles: Some swear by it. Quick and easy to get through for
the basics.

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Pocket Medicine: MGH Handbook of Internal Medicine (3rd Ed, Sep

07~ $45 for pocket sized 6 ring binder book). Worth the investment.
Case Files- excellent case-based study resource.
Step up to Medicine: many people like this book, but it is a hefty one. So
again if you start early, you will get through it all and do well on the exam.
Its a STEP UP style book, but shockingly more detailed than the STEP 1
book. It actually is fatter than the Step 1 version of the series. There is even
a question section at the end.
Saint-Francis Guide to Inpatient Medicine: This is one of the best kept
secrets! This book not only fits into your pocket but is truly a great resource
to read at night. If you choose to use this book, it is entirely possible (and
advised) to get through it at least once before the exam. You will be
thankful.
Pre-Test: Medicine: Excellent preparation for the NBME exam. Questions
written in NBME format, tricks and all. You cant go wrong with this book;
but the questions are easier than those on the actual exam.
Rapid Interpretation of EKGs (Dubin): First line of attack in learning to
interpret those ubiquitous squigglies. A programmed text that is simple to
use and packed with information. Essential. Essential. Essential. Borrow it if
you dont want to buy it, but read it. Youll be sorry if you dont...
Manual of Medical Therapeutics: (a.k.a. The Washington Manual).
Widely used, excellent reference that focuses on therapy. A classic youll
buy sooner or later. This sucker fits into your white coat pocket - very key!

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Surgery
Clerkship Director: Rebecca Viscusi, M.D. Room 4327D,
Phone 626-4441 or 626-3678, Cell: 307-5530, Pager: 4153, Fax 626-7785
Email: rviscusi@surgery.arizona.edu
Clerkship Coordinator: Debbie Sherrow 626-3972 Fax: 626-4334,
Room 4327
Email: dsherrow@surgery.arizona.edu
Surgery seems to consist of three things: surgery, pimping, and very short
presentations. In Medicine, you sit and figure out exactly to the smallest
detail what the disease process is. In surgery you admit the patient, usually
with a diagnosis already made, prepare the patient for surgery, surgerize, do
post-op care, and discharge the patient. The write-ups are not as extensive,
the A&Ps are fairly short, the progress notes are angstroms in length, and
rounds are frequently shorter than Medicine.
Your day starts out quite early - anywhere between 5-5:30 am. You do your
own pre-rounds, paying special attention to vital signs (Temperature in
particular current and max,), and I&Os. On some services you will be
required to write all these values out for each patient, so plan your morning
accordingly. You will be required to see between 2-4 patients, depending on
the weight of the service. Choose your number wisely though. One good
presentation weighs a lot more than three terrible presentations. If you do not
have time to see your patients, DO NOT LIE. Be honest; it will serve you
well and will show integrity. See the Copy Me page for a detailed
description of your pre-rounds.
Usually work rounds begin about 6:00 a.m. This involves walking from
patient to patient, very briefly presenting said patients. Following rounds,
you go to surgery. Youll always scrub in for your patients operations
(remember always scrub a little longer than your attendings and residents),
and occasionally watch patients of the other students. During surgery your
job, whether or not you want to accept it, is to hold retractors (and to do
anything and everything else you are told to do). Yes, four years of college,
two plus of medical school and there you are, holding retractors. The art of
retractor holding is actually very refined (its in the wrist). Good students
will review the differential diagnosis of acute surgical abdomen in their
minds while holding the retractors. Honor students will do the above and
answer pimp questions during the operation. Failing students will fall asleep
and drop their glasses in the wound (bad, very bad). Pay attention when

31

youre retracting. Your job is to maintain surgical suite exposure for the
surgeon. If you move or obstruct the view, someone will bark at you.
Youll probably be yelled at anyway; so be prepared. Be patient. Dont take
anything personally. Be ready for some sore shoulders!

The OR
Your first scrub! What do you do with those freshly sterilized hands?
While waiting for the team to gather around the patient, you may fold your
arms across your chest. Never let your hands below your waist! Once youre
in place around the patient, you should rest your hands on any sterile (blue)
surface. A pair of visible free hands near the field will remind the surgery
team that youre available to help. Scissors may be slapped in your hand these are to cut suture. Keep a sharp eye out for surgeons tying knots. When
theyre done, theyll pull both strands together and expect you to cut the
excess immediately. Rhythm is key. You should cut approximately 1 cm
above the knot - the surgeon will criticize your distance to the knot - adapt
accordingly. In the OR, Med Students suck. Literally! Grab the plastic
suction tube (the surgeons call it the sucker; boy, are they creative) and
suck up blood, irrigation fluid, and even stool, to keep the field clear. Good
students will also suck air when the bovey is in use. Students can also
sponge; ask the scrub tech for 2x2s to sponge up said fluids.
Lets talk about OR pimping. FIRST: they will ask you anatomy and
structures. If you get this right, congrats- you are on to round 2. Next will be
function and pathology. Passed that? Nice work! They tend to ask questions
until you get one wrong. If you dont knowdont guess. Just say you arent
sure. Also, ANSWER WITH AUTHORITY IF YOU KNOW THE
ANSWER. They will get annoyed if you stutter around with umms and
hmm PO form Why? Because surgeons are usually impatient creatures.
Also, when you get asked a question, dont answer with another question.
TRAUMA!! >8-0
Three weeks. You can do it. But here are some tips on surviving. 28 Hour
call, but NEVER longer. With an intense pimping lecture at the last hour. Be
prepared with coffee. It will be a game of finding your team almost
always. SO to succeed arrive EARLY, but no earlier than you are allowed to.
Duty hours are a huge deal on this part of the rotation, so do not violate.
Days are divided into pre-call, call, and post-call. Lather rinse repeat. Precall days, your day will be about 8:00 to 4:00 or if you are lucky, earlier.
These are the days your team will perform scheduled surgeries. Call days are

32

the dreaded 28 hour days where everything hits the fan. Post-call days are
the day afteryou will be free after noon or sometimes immediately after
sign-out.
THE TEAM EXPECTS one med student to be in EVERY surgery (some
teams wants both med students in the room if there are no other cases).
(But they wont tell you when they are, ha ha. So, you are welcome Your
first puzzle is now solved.) Pre-round on your patients (usually 2) and write
the notes. Then attend the conference in the basement. Then your team will
round on the patients quickly. Dont be afraid to ask to go to a surgery even
if you miss rounds... they expect you to do that. Get the phone numbers of all
team members on the first day so you can be in contact with them if you lose
the team. Check in the trauma bay or second floor Diamonds Center if you
cant find anyone. Study down there if you can because the med student
pagers are a few minutes later than attendings and residents. This means that
if you are elsewhere and get a trauma page you are already late so RUN.
Final thoughts.. eat when you can, sleep when and where you can, and sit
when you can. Be proactive and ask to do simple procedures. Be prepared
for surgeries. KNOW THE case, patient, and anatomy at the very least.
Phew, ok, its a lot, but only three weeks. You can do anything for three
weeks. Keep your head up and your friends close for frequent hugs. It will be
over soon.

Suturing
If you plan to get some REAL action in the OR, you will want to practice
knot tying and suturing. There are practice boards for this purpose
consisting of rubber tubing and some hooks, which you can ask for in the
surgery office. OB-GYN tends to have a couple floating around, too. In any
event, get yourself some suture, and ask a resident to show you one-handed
and two-handed ties. These take practice! MAKE SURE YOU CAN DO IT
WITH BOTH HANDS. And if youre serious, youll want to start as soon as
the rotation begins. What you can do is tie some suture to your scrubs and
practice as you walk around the hospital. Many residents are willing to teach
you suturing, then let you close the wound, but only if you ask OR if you
have proven yourself by being attentive and answering questions during the
case. Be sure to practice knot tying before you are in the OR. On your
surgery rotation, two-handed ties should be used almost without exception!
Students get to participate in a suturing lab.
Another peculiarity to surgery: if a belly full of rotting bowel or a floor
covered with blood doesnt make you woozy, nothing will. Dont worry; its

33

happened to the best of us. Key things to remember-if you start feeling weak
or sick, just say that you need to scrub out, hand off your retractors, and sit
for a while (also an acceptable out if you must get to a bathroom or face
certain explosion). Surgeons do not need medical students - a sad but true
fact - and will generally do fine in our absence. If you dont manage to get
out before you go to the ground feeling diaphoretic and weak, just sit straight
down on the floor - you may get laughed at a bit, but its better than falling
into the wound or smacking your skull on that hard OR floor. Reminder: eat
breakfast no matter how rushed you may think you are!
Surgery can last anywhere from a couple of hours to all day; in some cases,
well into the night - particularly with vascular surgery cases. Eat breakfast!
Following surgery you write your notes (although this is theoretically better
done in the morning before surgeries - hence, the obscene morning hours),
change dressings, and do your scut. You often need to tell nurses you want to
be involved in dressing changes. Otherwise they do it themselves, and you
must undo everything to get a glance at the wound. The nurses can teach you
tons about the art of dressing and taping wounds. Its believed there will be a
gallery opening soon on this very topic. Take advantage.
Schedules: Surgery lasts 6 weeks; you will do three weeks of Trauma and
three weeks of General, HPB/Transplant, Minimally Invasive/Robotic
Surgery, Private Practice, or Vascular. Therefore, some people will have 6
weeks of General. Dr. Schilling was in the military and does vascular
surgery, dialysis catheters. Dr. Robertson is a private practice general
surgeon. HE IS THE BEST TEACHER EVER. Taught by Dr. Rappaport
back in the day. You are lucky if you get him. Debbie has the information on
getting the schedule you want. Do your best to schedule a private practice
rotation along with any of the others. These are laid back and afford lots of
time to study. Do not do two of the following: Vascular, Trauma, VA
General Surg, Pediatric Surgery. One is fine, two is way too busy.

Didactic Sessions and Lab Schedule are on Wednesdays with the

exception of orientation, which takes place the first 2-days of the
rotation.

Surgery Clerkship rotation consists of one six-week General

Surgery rotation, divided into two three-week rotations. One 3week rotation/service will be on the Trauma/Acute Care Surgery
service at Banner University Medical Center Tucson and the other

34

3-week rotation/service will be on another rotation within the

Department of Surgery, Private Practice (Tucson and Rural sites).

Dr. Viscusi, Clerkship Director, creates the Trauma call schedule

for students when they are on Trauma/Acute Care Surgery. The
Chiefs on the other services create the students schedule.

Notes particular to surgery include the pre-op note, the post-op note, and the
procedure note. Examples of these are found in the Reference section. Life
will be a tiny bit easier if you memorize the note formats, carry around the
appropriate Copy Me page, or look in Maxwells until they become second
nature (and they will). Finally, dont forget to review the anatomy pertinent
to cases you will be scrubbing in on!

Sites - Tucson:
Southern Arizona VA Health Care System (SAVAHCS) SAVAHCS might be a little over-rated in terms of students getting to
participate much in the OR, but the consensus is still more OR time than at
BUMC-T Campus. Students were satisfied with their opportunity to suture
and close on every case. This has the longest hours of any rotation during the
third year. No kids or women, patients tend to be older men.
BUMC-T- Campus There are five surgery teams at BUMC-T Campus: trauma, HPB/Transplant,
minimally invasive/robotic surgery, vascular and surgical oncology.
Variable free time on the trauma service - use it wisely. Few procedures,
especially on trauma. Teams put in equal amount of time. Equal amounts of
surgery clinic time as well; however, it is easy to avoid clinic on the trauma
service.

Surgery Exam
Surgery is a shelf exam. It is a shelf exam like no other! It does, however,
have a good deal of medicine on it. You must Honor both clinically and on
the exam to get Honors. Also, be prepared for none of your attendings to
actually DO your evaluations; so be nice to your residents (though they
might not do your evals either).. Most of your study materials will be
provided by the surgery department: surgical recall, an awesome packet of
vignettes, and some other stuff. Other recommended books below

35

Grades
Surgery is one rotation where you are really judged more on your enthusiasm
and willingness to work than on your knowledge base. So, if your chief tells
you there is perirectal abscess drainage in room 5 that you should scrub in
on, the correct answer is Im all over it, you hot sexy chief!
Additionally, this year they added an OSCE exam worth 10% of your grade
and a suture exam worth 5% of your grade DO NOT STRESS ABOUT
THESE! Everyone does fine. It will help your grade if anything.

Study Guides
Pearl Books: Surgery (several of these can be checked out from Debbie)
Dr. Pestanas Surgery Notes These are a must read before the shelf exam.
You can get through them pretty quick. They are especially helpful for the
surgical subspecialty questions you did not have much exposure to during
the clerkship.
Blueprints Nice overview of surgeries by organ system, but much too
elementary for the exam.
Surgical Recall Great for memorizing quick facts before cases or rounds.
You will be able to answer most pimp questions by reviewing this. Do not
study this for the test! Only for wards.
High Yield Gross Anatomy A familiar friend from Step 1 for many folks,
this skinny book is a godsend! Its absolutely ideal for reading during the 10
minutes before a case that you forgot to read (but that wont EVER happen)
or the dreaded Young Doctor - theres been a change in the schedule ...
Surgical Secrets (Abernathy). A must-have, especially if you only have 2
minutes before lecture.
Essentials of General Surgery (Lawrence) The official book of the surgery
rotation. A basic, straightforward introduction to surgery. Lightweight and
user-friendly. Exam questions have been known to lurk in these pages. For
the especially time-deficient, focus on chapters dealing with the GI tract.
The trauma chapter is very helpful.

36

Anatomy (Netter) Drag out that Netters from your first year anatomy
course and review blood supply innervation and muscles in the body area of
your procedure.
NMS Another great review book. Gives you different answers depending on
the scenario. Great way to prepare for shelf exam questions.

Surgical Subspecialties
Students chose ONE subspecialty and do that for 3 weeks. Above all, just
remember to get what YOU want out of this time. The options available
include Urology, Peds Surgery, Neurosurgery, Ortho, CT, Anesthesia,
Plastics, Ophtho and Otolaryngology.
Anesthesia The happiest doctors in the hospital. Procedures include lots
of intubations and starting lines! Great experience with lots of learning and
nice hours; the rotation is what you make of it, but if you show interest, all
the residents and attendings welcome student involvement.
Urology Known to be the funniest guys in the hospital. People really do
rave about it. No exam at the end. Are you down with DRE, yeah you know
me!!!
Orthopedics These folks have the best tools in the hospital-drills, drills,
and more drills! Easy test at the end.
Plastics where surgery and style come together in their most beautiful
forms. Excellent rotation with lots involvement and teaching. Unfortunately,
the plastics program at UA is virtually non-existent. If you can find a private
practice person to shadow, it can be very valuable. Otherwise, maybe pick
something else.
Otolaryngology If you like the fine details of the face and neck this
rotation is for you! The faculty in this department are notoriously fun and
you will learn a ton on this rotation. They will expect you to have top notch
presentations and know the anatomy so be prepared!

37

Copy Me!
Surgery pre-Rounds
From The Book, Edition X
UNIVERSITY OF ARIZONA COLLEGE OF MEDICINE, 1993
Check Vitals: HR, Temp max, Temp, Input/Output (categorize all input and
output, i.e. input = IV, po, meds, epidural, etc. and output = urine, NG tube,
JP drain, etc.) Wt., Fingerstick blood glucose, Guiacs on bedside clipboard.
Check Patient: S: Have you passed any gas? Any BMs? Any pain?
Pain medicine helping? Hows your appetite? How did you sleep last
night?
o
o
o
o
o

Auscultate heart, lungs, bowel sounds

Abdominal exam (be gentle if theyre post-op)
Extremity exam (look for pedal edema)
Wound Check (get dressing supplies ready for changes before
rounds) Also: Incisions, drains, lines, ostomy sites (red? swollen?
discharge?) Do not look at wound until 48 hours after surgery.
Examine other body parts involved in pts etiology.

Labs: Most current labs. Yesterdays labs arent really helpful unless your
team isnt aware of them yet. Know whether certain abnormal values are
increasing or decreasing from previous days. If you want to impress your
team, memorize todays labs.
Xray: Results of any imaging studies (call the dictation line-youll need a
residents access code to listen to the radiology report). Always look at the
scan yourself even if you dont have a clue how to read it!
Meds: Know what medications the patient takes. Know what antibiotics the
patient is receiving and how many days the patient has received them so far.
See Appendices for samples of notes

38

Obstetrics and Gynecology

Clerkship Director: Tucson: Heather Reed, M.D. (520) 626-7414 or
Email: hreed@email.arizona.edu
Clerkship Coordinator: Julie Tary (520) 626-7414
Email: jtary@obgyn.arizona.edu
Outreach Director: Amy Mitchell, M.D., (520) 626-7414
E-mail: amymitchell@obgyn.arizona.edu
Obstetrics and Gynecology is a clerkship in a class all its own. You are
usually caring for young, healthy patients. You may have a fair amount of
responsibility, get to do procedures on your own, deliver babies, and
participate in some surgery. In addition, in this clerkship youll rarely have
trouble making a diagnosis. Patients usually present appearing pregnant,
feeling pregnant, wanting to get pregnant, or never ever wanting to be
pregnant again.
As in most other clerkships, youll start off with a week- long orientation:
Welcome to OB-GYN. In this clerkship grades are based on knowledge and
technical skill. Therefore, when you are delivering babies, you are not to
drop them. There is a brief demonstration on scrubbing/sterile gown/glove
techniques. While this works well in theory, you will learn that there are
only a few seconds between the warning that mom wants to push and the
arrival of the bouncing baby, often not much time for perfect sterile
technique. If, as you are racing to the delivery room, you should happen to
spill a glass of water and get your fingertips wet, you will probably be
considered sufficiently scrubbed. Usually there IS time to wear a gown,
gloves, and mask with a fluid shield. On OB, you will be sprayed by 3-5
different body fluids per day, so dont skip the shield. We also highly
recommend a pair of comfortable shoes. If you value your shoes, always
wear shoe coverings during a delivery. Many students have found the feel of
amniotic fluid between their toes to be a bit too much. Plan for this each
time you are part of a delivery and it will become second nature. This is a
part of OSHA (Occupational Safety and Health Administration) regulations
that have been mandated for your safety. Dont take unnecessary risks - it
isnt worth it!

39

Some general advice for OB

Know where your intern is at all times when youre on call if they go
somewhere, follow them even if they are going to the bathroom (JK).
If a babys about to pop, the intern may not have time to call you. If youre
not present you could miss a delivery. Soon youll be able to judge how
close a mother is to delivery, which will make things easier. NEVER turn
your back on the perineum when the patient has completely dilated to 10 cm!
If so, you may just miss the delivery! The only sure way to be present for
overnight deliveries is to stay up all night, on the floor, where you can hear
the yelling, even if nobody pages you.

Tips:
Get to know the nurses who work your shift. They are typically your lifeline
to deliveries and are fantastic resources. Leave your pager number with the
nurse attending to each of your laboring patients. Ask that the nurse page
you whenever they page the resident! Many med students have missed a
delivery when the resident forgot to call them. Let the nurse know you would
like to do the cervical checks, but remember not to check a patient after
SROM (spontaneous rupture of membranes for beginners), without asking
your intern or resident. Be sure to give the nurses your pager #. If they like
you, you will be called when things start moving, if not... NOT.
The clerkship director will give you an OB survival guide at the beginning
of the rotation that is very useful, with all the note types and other great info
included. Since many of the cases in OB are relatively routine, the write-ups
are fairly standard. This includes admission notes, delivery notes,
postpartum notes, and discharge papers. The residents will be impressed with
you if you do this, whereas they will laugh at you if you write a medicinestyle H&P. See the attached Copy Me pages or use the format used by the
residents in your rotation.
As in surgery, practice knot-tying. If you dont know how yet, ask! The
residents will be happy to show you how. The one-handed tie is used more
often in OB compared to the surgery rotation. Be on time, polite, and
enthusiastic; the residents really notice and it makes a difference in how they
treat you. You can always get extra suture from the scrub techs in the OR if
you want extra practice.

40

Always work hard if for no other reason than the fact you have six weeks of
OB during the entirety of medical school (including general information
gathered in the first two years). Of all the people who fail USMLE Step 3 a
large number fail because of the OB/Gyn sections.
When youre on deck always keep a pair (or 2) of your size gloves in your
pocket because odds are the nurse wont have time to get you a pair in the
middle of a delivery.
What to wear: scrubs are the standard uniform with the possible exception of
when youre in clinic. Also, dont tuck in the shirt of your scrubs. You may
want to look tidy, but in all actuality this really just gives the fluids an all
access pass to your pants and chonies. DONT DO IT! Also wear shoes that
you are comfortable getting bodily fluids on - He he.
No matter what part of the rotation you are on, read during any down time
during the day or do UWise questions. By the time you get home at night the
last thing you will want to do is school work, and youd probably fall asleep
on it anyway.
The ACOG textbook for this rotation has fairly short chapters, a ton of useful
information that is easy to read and absorb for a textbook, and more helpful
than many of the others they give you. Lectures tend to be far more
interactive than other clerkship lectures throughout the year. Make sure you
do the reading so you dont look completely clueless.

Sites-Tucson
Banner University Medical Center Tucson Campus
Students divide themselves into 3 groups in which they spend 3 weeks on
OB and 3 week of GYN (either benign GYN or GYN-ONC). You will have
6 calls, 2 on weekends. Hours are 8 hour shifts during OB and team
dependent during GYN and GYN-ONC. The days tend to be longer on
GYN-ONC. On OB you are in clinic every morning and on Tuesday
through Friday afternoons (Tuesday and Thursday afternoons are spent at the
St. Elizabeth Clinic. Bring a Spanish/English dictionary if you are not
bilingual). Basically, you will spend all day in OB Clinic, unless you are on
call, then you are on the deck admitting patients and catching babies.
Dont check cervix without intern being present. On GYN, students are in
clinic in the afternoons, with the rest of the time for surgery, rounds, and
studying. Generally speaking, at BUMC-T Campus youll see a lot of highrisk patients on OB. Dont expect as much direct involvement in surgery as

41

you had, or will have, in general surgery. You will learn more by showing
interest.
The main complaint at BUMC-T Campus is there are fewer deliveries than
other sites, but most students get to do 2 to 10 on their own. Be assertive!
BUMC-T Campus usually affords students more GYN experience than the
other sites, so students usually become proficient at the pelvic exam. It
doesnt hurt to ask private attendings if you can assist if things are slow.
Many times they will let you do the delivery if the patient doesnt mind.
BUMC-T Campus also now has a great staff of midwives who are eager to
teach a few alternative techniques for managing women in labor. Work with
them, and they may also let you do their deliveries on occasion.

OB Exam
This shelf is bread and butter; if you know your basics like the back of your
hand, you will do well. Dont spend too much time about extremely rare
cases.
The final is an NBME exam which is challenging but passable; they give
you 20 more minutes than other Shelf exams. Its helpful on any Shelf to
start with the last 5-10 questions and then do the rest because the last 5-10
questions are the ones with 10 answer options and are easier to do at the
beginning of the test than at the end.
Get in as much studying as you can, using lecture notes, handouts, and the
books you may have. You may actually get the day off before this exam. The
OB department will loan you all the books you need, so dont buy any. Most
students are satisfied with NMS as their primary reference.
YOU MUST DO THE UWISE QUESTIONS!!!! You will have access as a
student. The shelf is written by the people who write these questions, so they
are extremely high yield. The companion text book by ACOG given to you
by the clerkship is helpful to clarify certain points. It is not necessary to read
it all.

Pearl Books OB-GYN:

Obstetrical Pearls, A Practical Guide for the Efficient Resident
(Benson). ESSENTIAL. READ THIS BOOK BEFORE YOU START THE
ROTATION. The hours it takes to read it will be invaluable!! Borrow or

42

buy it. An excellent practical guide to being on the OBGYN rotation. Some
sites will lend it to you.
PRE-TEST - Obstetrics and Gynecology Great overview of OB-GYN.
Helpful for the NBME exam.
NMS and Board Review Series: also helpful for exam prep. NMS can be
borrowed from the OB office.
Blueprints is also a good resource for a review book.

Copy Me! OB/GYN history and physical

H&P for Labor and Delivery, actual format
ID/HPI: Patient is a 24 y.o. G2PlOOl African-American female with an
EDC of 07/05/93 by U/S (07/06/93 by L.M.P). Gestational Age is 39 3/7
weeks. Patient presents with uncomfortable contractions since 06/30/93 at q
10 minutes. Patient presented to triage today with painful contractions (ctxs)
q 4'. Patient denies any SROM (spontaneous rupture of membranes), bloody
show, h/a (headache), epigastric pain, edema, visual changes, N/V/ F/C.
Patient intends to bottle (vs. breast) feed. Pediatrician is Dr. Moreno.
(Optional: Birth control method used during conception, pregnancy was
planned/unplanned). You may add a paragraph here describing any
significant complications during the pregnancy.
Prenatal Hx: First prenatal visit on 01/05/93 at 16 weeks gestation. Patient
received prenatal care at the office of Dr. Mary King. Ultrasound was
performed at 18 and 24 weeks and demonstrated a singleton fetus without
abnormalities. Patient was diagnosed with a yeast infection which resolved
with administration of Metronidazole ointment on 3/23/93.
Labs: Blood Type A pos, H&H 14.3/41.9 on 5/25/93. Antibody screen neg.,
G.C. neg, RPR non-reactive, Chlamydia neg., Rubella reactive, Pap smear
negative, HBsAg neg., Glucola 89, serum AFP not performed.
Amniocentesis not performed.
OB Hx:
(1) 1990 - S.V.D. of an 8# 4.5 oz. male at 40 weeks gestation, without
complications. Midline episiotomy performed.
(2) Current

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GYN Hx: No history of abnormal Pap smears. Denies any history of STDs
(you will want to specifically ask patient if shes had chlamydia, syphilis,
gonorrhea, HPV, trichomonas, or exposure to HIV).
PMH : Denies Asthma, DM, HTN, Immunological deficiencies, Cancer
Allergies: NKDA
Meds: PNV (Prenatal vitamins) with Fe 325 mg QD
Past Surgical Hx: Appendectomy, 1988, St. Josephs Hospital, Phoenix,
Arizona
Fam Hx: Maternal grandmother with Breast Cancer, otherwise no
significant family history. Denies fam hx of DM, immunological deficiency,
HTN, CHD, twins, mental illness, stillborn births, or congenital or
chromosomal anomalies.
Soc Hx: Denies TOB, Denies ETOH, 1 cup coffee QD. Patient is married x
3 years. At Maricopa always ask about hx of sexual abuse, drugs.
ROS: Denies chest pain, visual changes, HA, edema, N/V/F/C, calf pain,
back pain.
PE: A WDWN African-American Female with apparent discomfort during
contractions.
BP 11 6/71 HR 77
HEENT No thyromegaly
Breasts: Not engorged
Lungs: CTA Bilateral
Heart: Sl and S2 normal, without murmur, gallop, or rub
FHt 38 cm. Leopolds with vertex position. FHTs 150s and reactive.
Ctxs q 4-5 min.
VE: 6/80%/O (thats 6 cm dilated, 80% effaced, 0 station - always ask
a resident or nurse to check after you)
Ext: No edema, calf tenderness. DTRs 2/4 bilat patellar (Dont forget
DTRs!), no clonus.
A/P: TIUP 39 3/7 weeks with ctxs x 1 day and no SROM.
(1) Admit to L&D with monitoring
(2) Expectant management ( youll write this A LOT)
(3) Consider artificial rupture of membranes (this is not always indicated)
(4) Discussed with Dr. Montis

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Prenatal H&P - Initial visit

This H&P is similar to the one above, with the exception that you wont be
as rushed as you are in Labor and Delivery. The HPI is essentially the same;
you may want to ask the patient about things like low back pain, constipation
(iron in prenatal vitamins is a major culprit), visual changes, vaginal
discharge, and headaches. In the Gyn history, ask about age at menarche,
information about menstrual periods (length, regularity or lack thereof, days
of heavy/light flow). You will also want a more complete sexual history,
including number of partners, whether they are men, women, or both and
STDs. One way to elicit accurate information about STDs is to ask, Have
you ever had any bumps, rashes, sores, ulcers, etc.. Under Social History,
get information about occupation. Your physical is much more complete,
and the clinic may have a form for you to fill out. Determine pre-gestational
weight. You will be performing a pap and pelvic on the first visit. You will
perform a thorough breast exam, as many women receive their primary care
at these visits. Remember DATING (of the pregnancy that is) IS KEY!
ALWAYS recalculate dates on every prenatal visit, even if gestational dates
are listed in the chart!

Copy Me! OB/GYN delivery Note

OB/GYN Post partum note
A controlled spontaneous vaginal delivery of a viable male/female infant,
weight 6 pounds 1 0 oz, apgars 9/9 to a G5P5 woman. Bulb suction on the
perineum. Anterior shoulder was delivered without difficulty. Clear
amniotic fluid. Spontaneous expulsion (or manual extraction) of an intact
placenta with a 3VC (3 vessel cord make sure there are 3 vessels in the cord
- a 2VC is associated with abnormalities 18% of the time). Uterus was firm
to palpation and hemostasis was achieved. Cervix, vagina, and side walls
inspected and intact with no tears appreciated. Attending Dr. X present for
entire delivery (important to write this last part!).
Episiotomy repaired with 3-0 vicryl. EBL 300 cc. No other complications.
Blood type is A pos. Rubella reactive. Delivered by Joseph Montes, M.D.
and Mary Falls, MSIII.
NOTE: Certain residents/attendings prefer different formats. Refer to your
OB/GYN orientation packet for different formats.

45

Post Partum Note

I.D.: [Age] [Race] Female G- P - - - - estimated gestational ageThis is a regular SOAP note, but you need to pay special attention to:
o Level of uterine fundus (in relation to umbilicus)
o Is the uterus firm (i.e., contracted down)?
o Lochia (this is the postpartum bleeding) - quality and quant.
o Episiotomy - intact? edematous?
o HCT
o LE edema/tenderness (for DVTs) - review Homans sign calf.
o Rubella status, Blood type (Does the mother need Rhogam?)
o F/U care and discharge instructions (ask your resident)
o Ask about contraception, breast/bottle feeding

46

Pediatrics
Clerkship Director: Ziad Shehab, M.D. (520) 626-6507 or 626-4657
Pager (520) 531-2717, Email: zshehab@email.arizona.edu
Clerkship Coordinator Sr: Stephanie Samson (520) 626-4657
Email: ssamson@peds.arizona.edu
Program Coordinator: Claudia Jimenez (520) 626-7944
E-mail: claudiaj@peds.arizona.edu

Pediatrics is NOT internal medicine for little adults! In the clinic, you will
see upper respiratory infections, viral infections, diarrhea, well-baby checks,
and worried moms and dads (the #1 diagnosis in peds). In the hospital, its
more congenital anomalies, cystic fibrosis, meningitis, quite a bit of asthma,
a few strangely placed objects, and (unfortunately), cancer. Usually, its
quite satisfying because sick kids get well and do so remarkably quickly.
You will get used to admitting a five-week-old infant with a congenital
anomaly, a sternal notch-to-xyphoid surgical scar, in congestive heart failure,
and sending him home a week or two later, smiling and happy. All in all, its
likely true that if your patient doesnt have Otitis Media, hell have
undiagnosed Otitis Media. Pediatrics is a great rotation to brush up on your
write-up and presentation skills, as patients usually only present with one
problem, as opposed to adult medicine with 10-15 chronic illnesses.
Your clerkship starts off with a one hour orientation, where youll be told,
Dont examine a kids mouth first. The minute you put your tongue blade
in, hell clamp down his teeth (or gums) and youll sit in a tug-of-war for the
next half hour. Following your orientation, you either go to the wards or to
the clinics for the first three weeks. Although you have no control, there is a
distinct advantage having clinic second: more study time just before the
exam. Youll be using your calculator in your phone or apps that help you
figure our pediatric drug dosing. All pediatric drugs are calculated in mgs or
ccs per Kg. Hand tailored prescribing is much easier late in the day (or
night) with a little hand-held calculator/computer.

47

TipsNumber 1- PHYSICAL EXAM. Always begin your physical exam with

auscultation of the heart and abdomen. It is much easier to assess both prior
to the child screaming from the rest of the exam. Attendings always look for
this. Get the kid and family comfortable before you examine the kid.
Sometimes the physical exam will be in the parents arms. Thats ok for
most of it. They are your allies. They will help you restrain them later. OK,
you listened and looked at rashes. Have a toy or something to distract the kid
while you push on the belly/ hips. Next are the ears. THEY HATE THIS.
Watch a resident do it first. Most of the time the kid will start crying.
Congrats! Now take this opportunity to look in the mouth and palate!!! NO
tongue depressor needed!
Number 2- try using the little pocket Pharmacopoeia for drug prescribing. It
has a great section on pediatric drug dosing. If you want to get a handbook,
the Harriet Lane Handbook is the pediatric bible. With fancy technology you
can find lots of apps that do the same as these books.
Number 3- 99% of students get sick on this rotation whether it be an
upper respiratory tract infection or, even worse, a GI tract bug. It is okay to
want to be dedicated and never miss a day of school, but remember, dont
jeopardize the health of the kids! Your attending will be happy if you stay
home rather than giving diarrhea to the house staff and the patients! People
will tell you different strategies to avoid getting sick...none of them really
work! So just be prepared!

Sites - Tucson
The clinics are located at Banner University Medical Center-Tucson
Campus, North Hills, and Banner University Medical Center-South
Campus, the wards are at Banner University Medical Center-Tucson
Campus and TMC. The schedule is arranged so that you will do either
your clinic time or ward time at the University. So be ready to smile A
LOT.
Pediatric wards are very similar to Internal Medicine wards. The hours are
around 6:00am to 6:00pm, with 2 required evening calls until 11pm and one
weekend day call. Expect to be there all 12 hours during your inpatient
wards, so bring a book to study when there is downtime. The patient load
ranges from one to five. Youll become familiar with the usual problems
among hospitalized children (dehydration, seizures, pneumonia, etc.), as well

48

as some of the less common problems. Bring a book to study when there is
down time, but always stay in sight of the residents!
Clinics at Banner University Medical Center Tucson Campus, N.H. and
Banner University Medical Center-South Campus are typical of most
clinics. Youll see your share of otitis media, UTIs, URIs, diarrhea, and
others. Days go from 8am to 3-5pm with no call. The nice thing about the
Pediatrics rotation is that you are not required to move the clinic. While
sometimes you can take your time seeing and discussing your patients
without worrying about how backlogged the clinic is, you should be aware
of how many patients are being seen by the residents or faculty. You dont
want to be the reason why a patient goes home because they were not seen in
time.
The exception to this is North Hills. Believe it or not, they want you to stop,
study, and learn. In addition, there are two unique opportunities while on
outpatient. One is that you will spend one week in the newborn nursery. A
second is that you can go to outlying clinics such as Casa de los Ninos or El
Rio, if you arrange this with Stephanie Samson. El Rio is incredible, so I
highly recommend that you request this as outpatient.

PEDS EXAM
The test is a shelf exam. This test is all over the place in terms of topics. This
shelf has the longest vignettes, so do your best at reading quickly and
reading with a purpose. Reading with a purpose means read the question
at the end of the vignette, then go back and read the paragraph...its a great
time saver. Study the objectives given to you (this is where most of the test
comes from) as well as the things you see or hear about (otitis, diarrhea,
otitis, C.F, otitis, etc.). Go to the lectures, and dont panic. Some say this is
the hardest shelf, even harder than medicine. Study your butt off.

Pearl Books Pediatrics

Pretest: Excellent practice questions, especially micro related. This is a must
read for the shelf exam. It really helps fill in the blanks of blueprints and first
aid!
Harriet Lanes Handbook. All the pediatric interns carry one. A gold-mine
of pediatric information - practical and up-to-date.

49

Blueprints and 1st Aid: Both great references. Pick one and memorize the
crap out of it
Casefiles: Covers every major topic youll need to know. It lacks detail, but
will serve as a great outline if combined with another source, i.e. Blueprints
of 1st Aid.

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Family Medicine
Clerkship Director: Krista Sunderman, M.D. (520) 626-7824
Email: kristas@email.arizona.edu
Clerkship Coordinator: Rosalind Fair (520) 626-7865
Website: www.fcm.arizona.edu
Family Medicine is always busy. There is a wide range of patients, from
healthy babies to geriatric patients with heart disease, from orthopedics and
psychiatry to obstetrics/gynecology. Its also laid back and the people are
extremely nice. You should be aware that because this experience is so
diverse, with a large number of sites, the quality of your rotation will vary
dramatically.

EXCEPTIONS
The clerkship will begin with an orientation which is just one day. You will
meet the different attendings of the program and receive a brief history of the
specialty. Your role in the clerkship will be to see 8-20 patients a day (most
see 10 to 12) in a clinic format. However this really depends on your site.
Some places will restrict you to seeing about 4 patients total. Most
importantly clarify this with your preceptor. You will obtain a chief
complaint and pertinent history, doing a focused physical, and presenting
each patient to your attending. Youll get to the point where youll be able to
make most diagnoses fairly easily, and describe the treatment to your patient
even before you present to the attending. Youll write a short note in the
patients chart, write prescriptions, perform venipunctures, pelvic exams,
take cultures, give injections, and a lot of other fun things.
Hours are generally 8-9am to 5-6pm, no nights, weekends, or call during the
rotation. An exception to this is the Safford Experience during which you
will do call, and follow your patients in the hospital! This will be
appreciated in comparison to schedules on some other rotations. Think of
Family Medicine as a kinder, gentler introduction to third year, a much
needed breather, or an easy cruise into fourth year. The curious thing is
that when you finish the rotation you may realize you just learned the most
diverse collection of facts ever in your third year, and you became nearly
functional (SMILE).

51

Experiences at the different sites tend to vary. At some, youll get to

deliver babies. At some, youll work with only one or two attendings,
while at others youll work with residents and interns. Many have their own
small labs, where youll do your own cultures and urinalysis. Youll have
every weekend and holiday off. YEAH!!!!!! Some sites also offer
opportunities for home visits, and/or seeing patients in nursing homes.

Lectures
Attendance and participation at lectures is required AND graded.
Evaluation of participation, however, is subjective. Group dynamics
may work for or against you. Some student groups set up their own note
service, in which participating students outline/summarize two or three
lectures. You will have lecture the first day of the clerkship, and then return
for more lectures during week 3 of the clerkship THATS IT! This is the
great thing about this clerkship, is you go to your site and dont come back a
lot.

Exam
This is a shelf exam. Use the AAFP website and request access to the board
review questions there are hundreds on there. If you do all those you
should be set. The exam also covers MSS materials, so review your
shoulders and knees!
In essence, Family Practice is laid back, and most of all, fairly fun. The only
criticism we have heard is that sometimes the expectations are vague and the
overall course is less organized than others. But overall, its a great, unique
rotation. Do not be afraid to seek clarification, to know what exactly is
expected of you, and to ask for feedback.

Please refer to the following website for all FCM site information:
www.fcm.arizona.edu/predoc/clerkship

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Psychiatry
Clerkship Director: Clerkship Director: Barry Morenz M.D. (520) 626-6325
Email: bmorenz@email.arizona.edu
Clerkship Coordinator: Karina Latimer (520) 626-6812
Email: klatimer@psychiatry.arizona.edu
What you can say about psychiatry is that your goal is to become
comfortable with the mad, the strong, the depressed, and the bizarre. This is
easier for some than others. Try to keep an open mind, and youll do better.
Remember, there is a TON of psych in every field, even surgery.
In most places you will talk to each of your patients at least once a day.
Many students find this difficult at first, but Dr. Racy will give you a handy
guide to the art of Psychiatric conversation. One good guideline: just be a
good listener. You can talk about anything you want - moon beams, why the
CIA is after your patient, and why God doesnt smoke. Dont bother to try
to convince them that President Obama has nothing personal against them.
Your goal is to simply understand psychiatric illness, the manifestations,
presentations, and treatments. You are required to keep up with patient
progress by writing your progress notes, do admission work-ups, including
full physical exams on admission only (not so easy in a paranoid
schizophrenic), and administer Mental Status Exams. Your presence on the
ward contributes to the overall atmosphere meaning if patients can see
normalcy and social gatherings on the ward, they may be tempted to join. So
please, act professionally!
Some sites have attending rounds, consisting of the attending, resident,
yourself, the nurse and social worker assigned to your team, and possibly a
psychology intern. In attending rounds, you present your patients and
describe the plan of action. This includes things like, should we get a court
case scheduled to keep the patient in this unit? and how do you convince a
patient with mania, who thinks life is great, is excited, in love with
everything, and has endless energy, to take medications that will make him
or her calm down and be depressed like the rest of us? Attending rounds
tend to be informal; you are usually given a good deal of responsibility.
Several other conferences are scheduled during the week, most notably Racy
Rounds (Thursday afternoons at present). Here the amazing Dr. Racy
interviews a patient in front of the students. Youll learn a lot about
interviewing and maneuvering patients lines of thought. They are excellent

53

and should always be attended. Call at all of the locations is three-six times
during the entire six weeks. Call is from home, but dont expect to be
home during this time, as psych call is very, very busy at nighttime! Each
clerkship location offers a different exposure to psychiatry.

Wow! Thats a huge purse!

One final caveat: if you become familiar with the DSM-V manual, youll
find that theres a psychiatric diagnosis for almost every behavior youve
ever noticed about yourself. After analyzing yourself and all your
classmates, you may become severely worried about your mental health. We
want you to know that weve all done the same thing, and realized later we
were perfectly sane!

Sites -Tucson
Veterans Administration Medical Center
The days here are full, from 8-5. Many of the same pathologies are seen at
other facilities, with the addition of Post-Traumatic Stress Disorder and Drug
Withdrawal. There is a lot of Internal Medicine among VA Psychiatric
patients. The rotation is 3 weeks of inpatient (Ward 5) and 3 weeks of either
consult, outpatient clinic, or geriatric psych. On Ward 5 you will follow 3-4
patients at a time. Students are an integral part of the treatment teams on
Ward 5. You will have a good deal of responsibility for your patients; your
team will take your ideas and suggestions seriously. The atmosphere is
community oriented and casual (no lab coat, tie is optional). At the VA, you
will also have the opportunity to learn to dictate discharge summaries. The
staff is fun and helpful. Whos afraid of the big bad Wolfe?
Banner University Medical Center Tucson Campus
The inpatient unit at BUMC-T Campus is probably the best teaching among
the Tucson sites. The service is split between consult, Southern Arizona
Mental Health Crisis Center (outpatient short hours), Sonora Behavioral
Health (adolescent), and inpatient (variable hours). On the consult service,
you will follow the resident and attending as they address psychiatric
problems of medical, surgical, obstetrical patients, etc. You will work hard
while at BUMC-T Campus, your hours for four of your six weeks will truly
be 8 to 5, but you will take away a great deal from the experience.

54

BUMC-S Campus
Expect to be at the site all day, you will likely be busy and stay that way. As
always, your schedule depends on your attending, and some give students
more free time than others. Your patients are all adults only who exhibit
interesting pathology. At BUMC-S Campus you get the real deal, no
manipulating the system for a place to sleep, just people being petitioned for
psychiatric care. You will definitely get a rich experience with quite a few
interesting stories.

PSYCH EXAM:
The Psych exam is a shelf exam and is fairly difficult. There are many
questions about psych diagnoses and psych meds, as they relate to other
medical diagnoses, so dont forget about the rest of medicine in general. If
you do the Lange questions and know Psych First Aid inside and out, you
will honor the shelf In conclusion, Psych is laid-back, fun, and sometimes
bizarre. Youll laugh a lot, feel a lot, and do some deep thinking about
yourself.

Pearl Books Psychiatry:

Lange Q&A - Great practice questions and explanations. A must do if
you want to honor the shelf.

First Aid for Psychiatry - the Psych office loans you a copy! Yippee for
free borrowed stuff!
Pre-Test for Psychiatry - pretty helpful. Same as all the other pretest
books.
Psychiatry For the House Officer Toomb. Everything you need to know
about Psychiatry is in this little blue lifesaver.
Complete Handbook of Clinical Psychiatry-Kaplan and Saddock. An
excellent reference, especially if you have any interest in going into Psych.
Introduction Textbook of Psychiatry- Andreasen and Black. Same book
used in second year SBS. Many students only used this book to study. It is a
RACY RECOMMENDS and can be checked out ($48 deposit) from the
Psych office.

55

*** Also the Case Files books should be highly recommended for each
rotation. They havent let me down yet. ***

** They give you all the books to borrow the first day!**

56

NEUROLOGY
Clerkship Director, Tucson: Wendy Kulin, M.D. (520) 626-3894
Clerkship Coordinator: Tammie Anderson, room 3204B, (520) 626-7159
Email: tammiea@neurology.arizona.edu
Neurology is neuroscience in Technicolor. You will have TIAs in THX,
along with seizures, strokes, neuromuscular disorders, meningitis, and
dementia in surround sound. Your schedule and intensity depends on your
resident, attending, and site. There are many subspecialties within Neurology
like Peds/Neuro, Neuro/Psych and Neuro/Med, if you are interested.
Neuro is a quick rotation. Only three weeks with a shelf exam at the end.
Every free chance you get try and study!!!! They go by really fast.

Tucson
Banner University Medical Center- Tucson Campus
The rotation is divided into three one week blocks. One week you will be on
outpatient. You will be going to various outpatient neurology clinics around
Tucson each with a different specialty from seizures, to neuromuscular
disorders, to general to migraines. Whatever week you have this take
advantage, because this is the most amount of time you will have to study.
One week you will be on the general neurology service and the other week
you will be on the stroke service. These are like any other inpatient services.
You will be expected to follow 1-4 patients, write notes and present them on
rounds. During these weeks, you will be expected to work one weekend day
and two night calls where you are admitting until 9 pm. During the three
weeks, even if you are on outpatient, you are expected to come to Morning
Report at 7 am where the residents go over the cases from the night before
and have a lecture BE ON TIME! Occasionally you will have to sign in
with the time you arrived.

NEURO EXAM
In years past this was a department exam. Now it is a shelf exam like almost
every other rotation. Three weeks is a very short amount of time to study for
an exam, so take advantage of any down time on wards. Pick a study aid and
stick to it. First aid, Step up to Medicine neurology questions are gold for the
basics. The books below are just bonuses helping you to get that coveted
honors.

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Pearl Books Neurology

The neurology office provides lots of written material/book.
PRETEST Neurology. Designed to prepare you for NBME type tests.
May help for the written exam.
Clinical Neuroanatomy Made Ridiculously Simple (Goldberg). You
may have this left over from neurosciences. If you dont, get it. Its concise
and relevant and heaven knows youve got no time to waste on the three
week neurology clerkship.
Neurology for the House Officer (Weiner, Levitt). A superb adjunct
to the syllabus they provide. This also fits in your pocket.
The Human Brain Jack Nolte. Ahhh yes - and you thought you were
finished with this bad boy book.
Manual for Neurology Clerkship-Barrow Neurological institute, (Robert
Fisher, M.D.); FREE - Get a copy of this from your colleagues doing Neuro
at BNI. Its a concise review with sample cases and answers at the end.
Excellent.
Books provided in Phoenix (BGSMC): Introduction to Clinical Neurology
by Gelb, and Lange Clinical Neurology.

Other stuff to bring

The Queens square is preferred by most attendings.

Safety pins - You will use these to test sensory perception (i.e., pin
prick sensation). Remember to use a new one for every patient, and
dispose of pins in the sharps container in every room.
Tuning fork: Optimally, a 512 Hz for hearing and a 128 Hz for
vibration sense, but a 256 Hz will do for both.
Reflex hammer - of utmost importance.

Copy Me! Neurology progress note

S: Just like all your other notes - a description in patients own words of how
they are feeling. Ask specifically if patient has noticed any new neurological
deficits especially in a CVA patient.

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O:

Vital Signs
Heart
Lungs
Abdomen
Musculoskeletal
Any new findings
Neuro:
Mental Status: Alert and Oriented? Serial 7s, Folsteins
MME, etc
Cranial Nerves: II-XII, include hearing and visual acuity
Motor: tone/strength, fasciculations, spasticity, rigidity,
(check for cogwheeling with Parkinsons disease0
Sensory: light touch/pin prick, vibration, proprioception,
stereognosis
DTRs
Babinski (plantar reflex)
Cerebellar: Finger to nose, Heel to Shin, Romberg, Gait
Remember to check for evolving deficits (e.g. a visual field cut)
daily!
Labs: CSF tap? MRA/MRI/CT findings? Angiogram findings?

A/P: Neuro status - changed/unchanged? New deficits? More diagnostic

tests indicated? Medication changes?

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THE SHELF
Dont panic. They arent as bad as they seem.....okay, some of them are!
These tests are 2 hours and 45 minutes each and are comprised of 110
vignette style questions. Usually the best way to attack the questions is to
read the question stem first, then read the vignette so you are reading with a
purpose. There are MANY different resources, only the individual can
really decide what is going to be best for him/her. Most people would
recommend using some sort of question set that mimics the Shelf each
rotation, so you can get some practice at the test before the actual test day.
Each rotation section in this book has recommendations for that specific
shelf.
It has been a common experience that the shelf exam is what separates the
high pass from the honors. Many students do well clinically,
demonstrating enthusiasm through the ability to work and learn on the floor.
The challenge of the third year is setting time aside to study additional
material which may not be relevant to the patients you are currently seeing
each and every day.
Practice questions are favored by many students, however a good text
resource provides great foundation before testing your knowledge.
Below is a list of pearl books recommended by students, and data from the
2016 class on which resources they found the most beneficial to their shelf
performance.
Continuing UWorld subscriptions and NBME practice tests have been the
most common methods for computer based practice questions.

PEARL BOOKS
The PRE-TEST series. What the NMS series was to the 1970s, this is
to the 2000s. We really like this series. Excellent preparation for all
NBME exams administered throughout third year. Loaded with pimps
youll get on the wards. The key is to read the answers to ALL the
questions, even the ones you get right. Only disadvantage: the books lack
indexes in case you need to look something up quick. Buy parts of the set
and share with your classmates. Available as pdf files for free download
from previous classes. Some say going through this book twice over the
course of the clerkship is golden!

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The NMS series. The entire series is fairly new, up to date and
comprehensive. NMS is controversial and somewhat overrated in our
opinion - not what the modern med student uses. If you like lists of facts
thrown out at you, these books are for you.
Clinicians Pocket Reference, Sixth Edition The Scut Monkey
Handbook (Gomella, Braen, Olding). A gold mine of information
useful in any clerkship. It saves a lot of time. Includes info on chart
work, orders, procedures, scut, differential diagnoses, lab tests, blood
gases, fluids and lytes, suturing, EKG reading, critical care, emergencies,
drugs.
Manual of Medical Therapeutics (The Washington Manual).
Considered to be the interns bible, this book is probably easiest to just
borrow from interns/friends at this point in time - youll want to purchase
the most current one when you are an intern.
Medical Knowledge Self-Assessment Program (MKSAP)
This is a question-based comprehensive review of the Internal Medicine
clerkship. Students can access a student account through the American
College of Physicians. Highly recommended for more clinical based
questions for your IM shelf exam.
Case Files- highly recommended for all rotations. Provide case-based
discussion of common topics.
The House of God (Shem). A great book. Takes about 2 days to read.
Where lots of medical jargon comes from. Itll make you laugh and cry,
and by the end of the third year, youll know its all true.
Optional
Bedside Diagnostic Examination (DeGowin and DeGowin). A lot of
people buy this, but we dont know how many actually use it. Pocket-sized,
this covers everything you could ever want to know about physical exams,
from the basic cardiac exam to such things as Trendelenburgs sign and
the yellow nail syndrome. A fascinating reference.

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2016 Shelf Exam Resource Data

We surveyed our classmates at the end of our third year asking which
resources were the most helpful to their success on the shelf exams. Below
each clerkship we have listed the top 3 most commonly used resources and
the consensus best resource.
Internal Medicine
- UWorld
- MKSAP
- Step Up to Medicine (textbook)
Most helpful: MKSAP
Surgery
- Pestanas Surgery Notes
- UWorld
- NBME Practice Test
Most helpful: this was the most varied, without a single source providing a
majority benefit. One consensus, however, is that Dr. Rappaports lectures
are exceedingly helpful. Remember there is quite a bit of medicine on this
one.
OB/GYN
- Uwise Questions (provided by clerkship)
- Uworld
- ACOG textbook (provided by clerkship)
Most helpful: Uwise questions
Pediatrics
- Pretest
- Uworld
- CLIPP cases (provided by clerkship)
Most helpful: varied. Provided textbook and CLIPP cases

Family Medicine
- Pretest
- Case Files
- IM Ambulatory review
Most helpful: 2016 was the first year we took the NBME exam. We felt this
was the least predictable shelf exam and there is little confidence in

62

suggesting any resource, but students have had success using the materials
listed above. Personal preference on this one.
Psychiatry
- The Lange Q&A and First Aid textbooks (provided)
- UWorld
- NBME Practice test
Most helpful: provided textbooks
Neurology
- UWorld
- Pretest
- Neuro SAE assessment exam (clerkship provided)
Most helpful: Neuro SAE exam

63

The Book
Edition XXXII

Part III

How to Be a Third Year

Medical Student

64

A Day in The Life (a.k.a.: what youll actually be doing). You are about
to begin a very different portion of your medical training: out of the pan
and into the fire. The change in focus may be overwhelming at times.
Forget skipping lecture. You are now THE MEDICAL STUDENT. And
with this title come a number of expectations, frustrations, and overall
incredible experiences. You will laugh, the toughest of you will cry, you will
make friends and enemies, but above all you will learn more in 6 months
than you have for the past 6 years (no kidding). Above all, be prepared to be
lost. Initially you will have absolutely no idea of what is expected of you,
and in this regard we can be of no help because EVERY team expects a
different role. Know that we have all felt what you will feel; we all made do,
made attempts to figure out just what the heck this attending wants, and
ultimately survived. In a few months the idea of survival will be a
comforting notion; so remember: we all survived the experience, and
developed a level of pride in our mastery of being THE MEDICAL
STUDENT. Hopefully, the following will give you hints so you will look
like youre in control, while you are desperately attempting to define your
role.

The Parts Of Your Routine Explained

Pre-rounds
This means student-rounds to you. Dont panic! We will describe exactly
what to do. When should you come in? Come in early enough to be ready
for work rounds. If you are paired with a classmate in your rotation its nice
to coordinate with them for when to come in. Youll be ready when you have
examined your patients, read overnight notes and orders in the chart, and
reviewed labs at the very least. If you have 10 patients (which you probably
never will have), you will need to come in earlier than if you have 2 patients.
Depending on your rotation this could range from 1-3 hours prior to
rounding with your team.
REALITY CHECK- This translates into your coming in at 4 to 5am for
some rotations- the good news is as you develop your skills youll need less
time.
The point of pre-rounds is that you will be asked by your residents and /or
attendings what is going on with your patient(s), and you better know!!
Things you will usually be pimped on are vital signs, recent lab results,
procedures, and consults. It will help to make a list of your patients, and
write down pertinent notes about them. At the VA simply make a printout of

65

your patients labs, and jot down notes on the side. Better yet, have your note
mostly written, and print them out. This is a double edged sword, though.
While its nice to have your note printed out, dont read off of it!
Now that we have EMR you can even access the chart from home. Find out
what routine works best for and stick to it.
Orders: Look to see if new orders or lab orders are on the chart since
yesterday. This is important: the on-call team watching your patient is not
going to tell you that your patient had a seizure during the night.
Progress Notes At least skim every note written since your last note. Try
not to ignore nurses notes, as they often are the most complete, and often
provide information for the S of the SOAP notes. Never define subjective
information by the prior notes... ask the patient.
Consultations: Read any notes left by a consulting service. This may
include the GI service recommendation on how to handle your patients
black stools, or the Neuro service recommendation how to handle your
patients mental status changes. This is information you and your team need.
Labs, X-rays, and results/reports you may not have seen yet. Know what
labs and X-rays were ordered, which ones have results pending. For X-rays,
you may have to plan ahead to check them yourself if results arent
available. Ask a radiology resident or attending to help you interpret them.
RTAS at BUMC-T Campus is helpful for the most recent XRAY report,
694 -5840.
Now, see your patients. Say, Good morning, how are you feeling? and
listen to the answer! Do a limited physical exam, noting the general
condition, then focus on the pertinent: in an asthmatic patient, listen to the
lungs, your resident wont care about their ear exam; in a patient with a
necrotic leg ulcer, look at the ulcer, dont waste time percussing his liver
span. Also, note presence/absence of drains, IVs, foleys, etc. and their
respective in-going and out-going contents. Then say, See you later (its
true - you will), exit quickly, go to the next patient. At most hospitals vital
signs sheet is on a clipboard in the patient room. Be sure to note BP, P,
Resp, and Temp (note oral, rectal, axillary), AND Tmax! Plus, know Ins,
Outs and weight - if not charted, ask the nurse for them. If nothing is
available and you have time, do them yourself.

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Always know if a patient is febrile. The most important thing is the

maximum temperature in the past 24 hours (Tmax). Know what vital sign is
crucial; e.g., you better have the latest BP on a patient admitted with
hypertensive crisis, weight if patient in CHF or a renal overload, RR if in
COPD exacerbation, etc.
What you will notice is that you are gathering information you need to write
daily progress notes. Once you are proficient, you will find it efficient to
write the note then and there, so you dont have to worry about it later. Your
residents will love you if you do this consistently (some may require it).
Some residents want to wait until after work rounds, so you can go over the
assessment and plan together. Ask if this is the case. The key is to obtain
important info without wasting time; youll see what this means when you
follow several patients before 6:30 am work rounds. Remember: orders,
progress notes, consults, labs, vitals, and see the patient.
Note: This does not hold true for ICU patients. See The Unit.

Work Rounds
The house staff (residents, interns, students) may round as a team on all
patients first thing in the morning. The purpose is to see what happened
overnight, and to figure out what must be done that day. Follow the team;
their routine will quickly become apparent (or it will be drilled into you). By
the way, if someone asks about an aspect of your patient that you dont know
(or forgot to check), say, I dont know. Do not ever make something up!
Its tempting, but not worth it. Your patient is far more important than your
ego or the ego of your team.

Attending Rounds
Usually later in the morning, like 7am in Internal Medicine and ending
sometime before dinner, unpredictable in Surgery (i.e., Dr Neal just called,
he wants to round in 10 minutes), the whole team meets with the attending
to: 1) present new patients; 2) discuss old patients; 3) have academic
discussions/ lectures/talks- in other words PIMP, PIMP, PIMP. Know your
patients! Be able to give accurate follow-up, have the most current labs
available. If the resident might say nonchalantly, Oh, Dr. so-and- so is
coming on rounds with us today and we assume this means rounds as usual
with the attending tagging along - no big deal, right? Wrong! This is a clue
you should be ready to give a full presentation, including chief complaint,
history of present illness, etc. This is not a guarantee, but be ready. On
attending rounds nothing is more embarrassing than to be unprepared. And

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yes, since youre wondering, your presentation skills do account for much of
your evaluation. The key things the attending wants to know are: who is this
patient, how did this patient end up here, what did we find out since the
patient arrived, what are we doing about it, and when is the patient leaving.
If you can address all those questions in 60 seconds or less, youre all set.
To tell you the truth, the success of your presentation is primarily based on
the attendings and/or residents moods. If you blow it, tomorrow is another
day

Conferences/Lectures
Conferences are meant for house staff, students and are usually pretty low
key. Yes, you have to go, and no, you cant leave early. Lectures (or Core
Curriculum as its sometimes called) are meant for students, and may
require advance preparation; however, weve usually gotten by without any.
One helpful hint: since lectures are usually given by attendings on your
service, many students think they can pick up a few extra brownie points by
being first to answer a question given to the group by the lecturer. FALSE!
Your evaluation has nothing to do with how you perform in lecture. The
lecturer does not keep score, and will probably not remember anything
anyone says. You may be perceived as annoying to your classmates, as well
as the lecturer. Relax, chime in when you have something to offer, but be
gracious and let everyone shine (you all will). Finally, most clerkships
expect you to drop whatever you are doing to attend lecture. Many of us
have found this to be difficult, but in actuality, your residents and attendings
will understand.
It is important to make every effort to attend lecture. There may be days
when you need to be excused for illness or emergency, but plan to attend
otherwise.

Clinics
Some services have these, either in the morning or the afternoon. Youll be
informed of your duties. Beware: We have been told by attendings in a
clinic to Just go in and say hi to the patient while Im seeing Mrs. Jones,
only to find out the attending wanted us to do a full history and physical
regarding the patients complaint! Dont get caught short-handed; do a
directed work-up of the patients problem no matter what the attending says.

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Heres a quick run-down of what info you need:

HPI (remember OPQRSTADA!)
PERTINENT FamHx,
PMHx
Soc HX
ROS
LIMITED EXAM (USUALLY including heart, lungs, ankles for
edema, abdomen) and a more thorough exam of the specific area
causing the problem).

Work
This is the most ambiguous part of your day, the part you will probably like
best (you can be your own boss). The lack of structure may be hard to get
used to. The best analogy is that its like having many small errands to run
around the hospital, as opposed to sitting down at a desk to work. Work
means making sure that progress notes are written (and that means one
progress note per day on your patients). Start doing this from day one.
Keeping up-to-date on what is going on includes tracking down test results,
arranging consults, wound dressing changes, etc. It may also include helping
out your residents, working-up new admissions if on call, or helping
members of your team do their work. If there is none of this to do, and you
need to stick around for rounds or something, you can (1) accompany your
patient to a procedure to check it out - i.e., echocardiogram or fluoroscopic
exam in X-ray; (2) read about your patient to get ready for rounds; or (3)
sleep/eat/relax/watch The Simpsons. If you want to be a real stud, ask
your intern or resident if you can follow him/her around. If its someone you
relate well with, you may get lots of impromptu teaching this way.

Check-Out
Before you leave check out with your intern or resident. Heres what to
say: Im done with my work. Heres whats happening with my patients. Is
there anything else going on today? Is there anything I can do to help you
out? Courtesy will save you time and hassles. They may be able to give
you the latest info on your patients before you leave - after all the
MEDICAL STUDENT is always the last to know. It is bad form to leave
without checking out.

Before you Leave

Each day before you leave the hospital, here is a pipe dream that you can run
through. The following checklist helps make sure youve done everything.

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You can probably leave if:

Progress notes are all written
New patients are (at least partially) worked up: old charts
reviewed, H&P completed
All CXRs and EKGs and labs/tests seen or reviewed and
dealt with as necessary
Your scut work is done (is it ever done?)
Rounds are over
Youve checked out with your intern and resident
Youre not on call that night
You remember where you live.. is it at the hospital????
When these are done, make a mad dash for the door before something else
comes up. Remember, the trick is to get your work done, sign out, and then
be OTD ASAP! This is commonly referred to as the 30 second rule.
When told by your intern or resident that you can leave, you have 30 seconds
to get out of sight before something else comes up, requiring you to stay
longer. Beware - this really happens. Remember, the longer you stay, the
longer you stay!

THE PATIENT CHART (Get your degree in Form-ology!)

Before going into what your contribution to the chart is, well first describe
what the chart is, and why it exists. First of all, the chart is a legal, binding
record of the patients hospital course, the course of the disease, as well as
orders, tests, and procedures done on the patient, and the results.
We now have EPIC at BUMC and most other sites have EMR for inpatient
services. You will most likely get your user name and password on the first
day (if you don't already have access). Sometimes you will have to call the
help desk on occasion, and be given a random password that has been passed
around. Note: if you are going to be putting orders in, YOU should be the
one logged in. Having a resident or intern log you in to write orders can lead
to a sticky situation - be advised.
At BUMC-T and BUMC-S, we have medical student notes or as we call it
Epic for kids. This means these notes cannot be billed. Feel free to write
notes for practice, but know that they will not be used for patient care. Its
nice for the attendings to see you are writing notes, and in some cases its the
only way for residents and faculty to see you are doing things.

70

At the VA, youll have access to CPRS, where you can write notes and
change the author to your resident. Thus you will be able to directly help
with note writing.
At TMC, its also Epic for Kids. However, you can share notes with your
residents so useful findings in the history or assessment can be very helpful
for your team.

WHAT IS A WORK-UP ANYHOW?

One of the most common phrases youll hear in the next year is Go ahead
and work up this patient. If youre like many of us at the beginning of third
year, you may be a little unsure of what this means. What do you do and
how do you go about it? How does it differ from my preceptor work-ups?
Well, not much. Before we go into detail, let us translate: Work-up =
History and Physical + pertinent labs and diagnostic studies to rule out a
differential and come to a diagnosis.
Perhaps the greatest time-saving tip that we can offer is to stress how crucial
past notes can be. Before you even consider looking at the patient, you
should have thoroughly investigated notes in the EMR system. No one
considers this cheating; it is essential to get a feel for your patient before you
begin. One caveat, though, is that old records can be wrong. Be sure to
double check everything with the patient.
The best place to start is with the most recent Discharge Summary.. In
addition to details of the patients most recent medical admission, it should
contain information on PMHx, SHx, etc. Take copious notes from this, as
these details can be placed on note cards or on the Data Base. Theoretically,
if you have completed these tasks in an efficient manner, you can complete
an entire patient interview with 90% of the time devoted to the CC/HPI and
only 10% spent confirming past medical issues. It is imperative to carefully
reconfirm important facts, such as medications, allergies, or data regarding
the HPI.

The History and Physical

So what do you do with the patient? To begin with, do a history and
physical, just like youve been taught, and just like youve been
practicing.For your first few H & Ps, you may want to examine the patient
along with the intern. Be sure to spend a few minutes in the beginning
introducing yourself, explaining your role, and establishing rapport with the

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patient. This does not mean you should whine, grovel, or apologize for being
a medical student! Most patients are more than willing to be seen by you
when you explain your position. One way to handle this is to include a
phrase such as, Hello, Im Alex Miller, one of the medical students on the
general surgery team. Ill be in to see you every day and will be helping care
for you while you are here. Id like to ask you some questions and examine
you. Id be happy to answer any questions that you have, or find out
answers which I dont know yet, so please feel free to ask. Once youve done
your H&P, record it on the appropriate form (a data base or progress note).
Be sure to bring up physical exam findings you are unsure of so you can
learn for the next time.

Labs and Diagnostic Studies

Obtain all labs ordered on the patient; determine what they mean, and why
they were ordered. These are recorded in the database. Look at all X-rays,
EKGs, or other studies done on the patient. Of course, you dont know how
to read these things! So grab a cardiologist, radiologist, intern, or any
available knowledgeable person to help you.

Summary:

Chart Review
History and Physical
Labs
Imaging (X-Rays, CT, MRI)
EKG
Any other studies
Assessment and Plan
Write it all down
Youre OTD

See page 74 for information about the assessment and plan.

Never hesitate to read the intern and residents notes. Its best to do this after
you finish your work-up, so you can see if everyone agrees. If they noticed
something you didnt, this will give you a chance to go back, look again at
the patient, the labs, the CXR, or whatever. Do not fall into the habit of
reading their notes before you do a work-up; you wont learn as much that
way

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THE ADMISSION NOTE

The admission note is an introduction to the patient, the disease, presenting
manifestations, past medical and surgical history, as well as family and
social history.
It is documentation of how the patient first presented to you. All second
year medical students have written Admission Notes. You may not have
realized it, but all the write-ups you did for your mentors were your own
little admission notes. Therefore, we wont go into great detail describing
what youve already learned. The admission note consists of history and
physical, assessment, and overall plans.
Patient Identification: [Name of patient] is a [age] year old [race, sex] with
[previous major illness] (if known) referred from (transferred from) [hospital
(physicians)]. Many attendings want this in the first sentence of the HPI, not
a separate section.
Chief Complaint: Describe in one short phrase, in the patients own words,
(e.g., patients do not complain of dyspareunia complicated by sporadic
hematochezic episodes!) the current problem.
History of Present Illness: Describe in your words (medical terminology)
the course of the present illness, including when patient last felt well, how
and when the problem began, onset characteristics, location, character,
intensity, duration, aggravating and alleviating factors, associated symptoms,
previous treatment and diagnostic tests done, pertinent positives and
negatives, related illnesses, and risk factors (Some attendings want the HPI
done in a Problem Oriented format. If this is the case, merely separate each
problem and write a pertinent HPI for each one).
Medications: Drugs and dosages.
Allergies: Including reactions to each one.
Past Medical History: All prior hospitalizations for medical or surgical
problems. Any serious illness not requiring hospitalization. All trauma, ER
visits, and chronic diseases the patient has. Any significant procedures,
including blood transfusions. Any h/o infectious diseases. You can add,
Have you ever been laid up in bed, unable to go to school or work, for any
period of time? For what reason?

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Family History: A family tree is very useful here. Always ask for ages,
living status, and diseases of siblings, children, parents, and grandparents. If
there is a prevalent disease that runs in a family you may list cousins, aunts,
uncles, dogs, fish, birds, etc.
Social History: Habits including tobacco (pk/yrs, when quit) alcohol
(amount, # yrs), drugs (IV, sharing needles, etc.), sexual history (especially
HIV risks), living status, (married, divorced), other significant social facts
you think may contribute to the care of this patient. Some things in the social
hx may actually pertain to the chief complaint and must be detailed in the
HPI.
Review of Systems All information remotely pertinent to the chief
complaint must be detailed in the HPI. The ROS is reserved for descriptions
of significant pathology entirely unrelated to the disease at hand. Quite often,
however, the ROS is not substantial and can be summarized as noncontributory or consistent with HPI.
Physical Exam Vital signs and remainders of exam. You better know how
to do this by now! If you feel a little stumped, just look at the patient... Ears,
eyes, nose, mouth - everything is in front of you. Start at the top and work
your way down!
Labs Procedures, X-Rays: Other studies if done or pending.
Assessment/Plans: This is just as important as your HPI, if not more so Use
your own judgment, do not merely copy your resident or interns assessment.
Just think, if you come up with something they missed, its HONORS CITY!
OK, weve been promising to tell you about this part. The waiting is
over...

ASSESSMENT AND PLAN

After working with your preceptor, you are no doubt getting comfortable
with your H&P skills. Your residents and attendings will usually assume you
can do a quality H&P, and judge you on your assessment and plan.
This section is always problematic for a student new to the wards. Two
questions invariably come up: How do I know what the problem with the
patient is? What if I say its one thing and Im wrong?

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And here are your answers: As a third year student, you will not be expected
to know exactly what disease process is at work in your patient. What you
can do is come up with several options of what it could be. Use information
that you read about to point out specific tests or H&P findings that support
or do not support each option. If you dont know where to start, there are
several books that will give you a list of possible diagnoses for specific
symptoms and lab abnormalities.
Look up something about each of the possibilities to determine if your
patients presentation is consistent with what you read about. Remember
there is a spectrum of disease, so your patient may have Kawasaki
Syndrome, but not manifest all the classical findings. This is why you use
wording like this could possibly be... or this is consistent with... In the
final judgment, you will want to say something like This is most likely...
Notice that this does not commit you to a specific diagnosis, but
demonstrates you have thought about the case, and have a clue about whats
going on. What you are doing is going through on paper the same process
that your attending is going through in his or her head. This is a valuable
skill you will learn this year.
The fear of being totally off the mark will always be with you. It is
ALWAYS better to venture a guess. This holds true in your write-ups,
progress notes, and in outpatient clinics (especially outpatient clinics!)
Failure to do so will demonstrate that you have not thought about the case.
If you have any support at all for your diagnosis, you will not go wrong. For
example, if you venture that your patient with epigastric pain may have
esophageal reflux, due to the facts that he/she has (1) pain lasting longer than
30 minutes and (2) pain that is relieved with antacids and an upright posture
versus angina, you will have a formulated a reasonable diagnostic possibility
whether or not this is proved to be true on further testing. The key is that you
showed to your team that you know what causes reflux, and could sort this
out from other causes of epigastric pain.
One more final note before we move on to examples: Some attending will
try to help you out by offering a list of diagnostic possibilities. You might
get this information in therapy progress notes from your team. It is good to
use your team as a resource, but you will not score any brownie points by
relying on others consistently. Develop your own lists; discuss them with
your team. Try and get your two cents in before you are told what is going
on. Do this and you will look stellar!

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How about some examples? First, from the new medical student who doesnt
know what an assessment and plan should look like:
A- Left inguinal indirect hernia.
P- Surgical repair of left inguinal hernia, with possible resection
of necrotic bowel.
Whats wrong with this A&P? Well, what are the findings that the patient
has that makes a hernia a possibility? What else could cause similar
symptoms in a patient like this? Could someone pick up just the assessment
and plan on this patient and figure out what was going on? Not likely. This
assessment and plan makes it look like someone was told what was wrong
with the patient and took their word for it without any investigation.
__________________________
Ok, following is a better assessment and plan:
___________________________

Assessment
Patient admitted for surgical evaluation of adenocarcinoma of prostate.

Problem List
1.
2.
3.
4.
5.
6.
7.
8.

History of cystoprostatectomy following diagnosis of transitional

cell carcinoma of bladder.
History of preoperative radiation therapy with ensuing radiation
colitis.
Elevated Prostate Specific Antigen Marker, discovered In 1991.
Ultrasound with transrectal biopsy demonstrated adenocarcinoma of
prostate.
Negative Bone Scan performed on 3/27/93.
Patient completely asymptomatic, with a negative review of
symptoms,
except for occasional suprapubic pain in RLQ. ROS negative for
paraneoplastic syndromes.
Physical exam essentially negative. No abdominal masses or rectal
masses palpated.

Differential:
Elevated PSA demonstrates residual prostate tissue, as PSA is not found in
any other tissues. PSA level is not necessarily indicative of neoplastic

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transformation of prostate, although PSA levels greater than 10 ng/ml have

been found in 59% of men with extracapsular prostatic neoplasia. Biopsy
provides definitive diagnosis of adenocarcinoma of prostate. Without any
demonstrable symptomatology or physical findings, there is no other
compatible diagnosis.

Plan:
Without evidence of metastatic disease, the options for Mr. Johnson include
surgical prostatectomy and hormonal ablation via surgical or pharmaceutical
intervention. Mr. Johnson has already received a significant amount of pelvic
radiation, precluding this type of treatment which ordinarily might be
indicated at this time. Prostatectomy, assuming stage A disease, results in
disease free survival at five years of 93%, 85% with stage B disease.
Hormonal ablation results in 40% of patients having regression of disease,
40% of patients having stabilization, and 20% of patients having continued
growth. Side effects, including hot flashes and psychological trauma, are
associated with hormonal ablation therapy.
Given the option, Mr. Johnson has elected for surgical exploration and
possible resection, as he is most concerned about being disease free so that
he can care for his wife, who is ill at this time with COPD.

Is the above A&P better? Does it let the reader know exactly what you are
thinking and why? YES! All right, just one more, this time from internal
medicine:

ASSESSMENT
PROBLEM LIST AND ASSESSMENT
1. Bacteremia: based upon blood culture lab result. However, it is likely that
there is a collection error or skin contamination was present at the time of
collection, since Strep viridans is normally present on skin. It is also possible
that the patient was inoculated at some point in the last several weeks either
through fever blisters or through several ulcerations on the dorsum of his
hands. It is also possible that, in light of patients occupation, which involves
working around antibiotic-fed cattle, that he was inoculated with an atypical
strain of streptococcus.
A common cause of bacteremia is urinary tract infection, and in this patient
with chronic prostatitis, a low grade infection might be seeding the
bloodstream. In this case, a group D streptococcus would be responsible. The

77

strain isolated would also likely be resistant to Nitrofurantoin, which patient

has been taking chronically for approximately 40 years.
2. Head pain, tenderness over temporal region of scalp, edema,
erythema, loss of appetite, anorexia, and fevers: There are many possibilities
to explain the patients symptoms. Clinically, this resembles Giant Cell
Arteritis. GCA presents with fever of unknown origin in 15% of patients. In
addition, a headache is seen in 60% of patients, and fatigue and anorexia are
the most common presenting symptoms. The mean age at presentation is 70
years, with GCA being twice as common in women. Patients Westergren
sed rate is also compatible with GCA. In 1/3 of patients; however, elevation
in LFTs is seen, and a mild to moderate normochromic anemia may also be
seen in some patients, neither of which this patient has. Jaw claudication is
almost pathognomonic for GCA, but patient denies this. ANA or
Rheumatoid Factor should be negative in patients with GCA.
In addition, leukocyte counts and differential counts are usually normal. The
patients WBC count is slightly elevated, although there are only 5% bands
present. Finally, there is some anecdotal association between influenza
vaccine administration and GCA in elderly populations, and patient received
a vaccination approximately 4 weeks before presentation. Another related
entity would be polymyalgia rheumatica. PMR is more common than GCA
and is seen in 40-60% of GCA patients. GCA is seen in 0 to 80% of PMR
patients. This patient does not appear to have any of the classic symptoms of
myalgia in the deltoid and hip regions. In addition, the physical findings of
the head are more indicative of GCA. Wegeners Granulomatosis can
present in a fashion similar to GCA. Wegeners, however, usually includes
respiratory symptoms. An antineutrophil cytoplasmic antibody titer can be
performed to rule this out. It is important to note that as GCA is a sterile
inflammation, it is not associated with bacteremia. Assuming that the blood
culture examination was performed correctly, this would strongly suggest an
infectious etiology.
INFECTIOUS CAUSES: Most compatible with patients symptoms would
be a cellulitis or erysipelas, both of which can be caused by a strain of
Streptococcus pyogenes. Erysipelas, in particular, does cause constitutional
symptoms and can result in septicemia. Lymphadenopathy should also be
present, but that is not the case in this patient. In addition, patient denies any
injury or incision in his scalp, and a left shift in his WBC should be seen.
Other possibilities, which are less probable, include a sinusitis, most
common organism being Streptococcus pneumoniae. Patient denies

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mucopurulent discharge or sinus pain or respiratory symptoms, and plain

film X-rays are negative for an acute process. A left shift in WBC is usually
present in acute sinusitis. A chronic sinusitis is possible with the same
offending organisms in addition to anaerobes. Mucormycosis is seen in
poorly controlled diabetics and presents as a necrotizing sinus infection
and spreads progressively to the CNS. This is not compatible with patients
physical findings. Varicella Zoster reemergence would most likely be
unilateral and would not cause bacteremia. In consideration of patients
occupation, several unlikely causes might be considered: Leptospira
interrogans infection, common in farm workers, which is acquired through
animal urine, and presents with fever, chills, headache, muscle pain, and
bacteremia. In its most severe form (Wells disease), a vasculitis may also
develop. Penicillin treatment is effective only in the first few days. Fewer
than 100 cases are reported annually in the United States. Also, Brucellosis,
which is acquired by drinking unpasteurized dairy products, should be
included. Brucellosis presents with undulating fever and drenching night
sweats, which patient denies.
3. Chronic Prostatitis with chronic Nitrofurantoin administration: Patient
denies any acute exacerbation of irritative voiding symptoms. This will
affect the profile of organisms colonizing the patients GI tract and GU tract.
4. Diabetes Mellitus Type II
5. Prostate Cancer: as diagnosed by trans-rectal biopsy. Metastases with
lytic lesions in the skull causing an osteomyelitis are unlikely, as prostatic
metastases are usually osteoblastic.

PLAN
1. Repeat blood culture. Administer Penicillin G empirically. Await
sensitivities and adjust antibiotic as necessary. Attempt to establish a source
of bacteremia. This may include urine culture, sinus drainage and culture, or
prostatic massage with urine culture.
2. Temporal artery biopsy to be performed. This is to attempt to diagnose
GCA definitively, as well as to establish the need for long term prednisone
therapy in this patient. ANCA to be performed to rule out Wegeners
Granulomatosis. GCA may be followed in the laboratory by obtaining
Westergren sedimentation rates. An infectious disease consult will be
obtained for evaluation of the cause and nature of any potential Infection.

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3. Pulmonary function tests to be performed as Nitrofurantoin can cause

pulmonary fibrosis. Will continue on antibiotic administration during the
admission.
4. With prednisone administration, patient may require injectable insulin.
Endocrinology will be consulted regarding this. In addition, patient
education will be necessary.
5. To be followed by Dr. Gyori of the Urology Section.
________________________________
Holy cow! The previous example is a BUMC-T Campus A&P and is, by
definition, anal; but it is complete and will definitely earn you an honors
grade, if thats what youre after. One thing you should notice: in the
significant findings section the stage is set for the differential - for example,
the mention of the lack of palate necrosis is used later to make the diagnosis
of mucormycosis unlikely. This is done to show that you knew what to look
for during the workup. Can anyone know before working up a patient what
to look for in a host of diseases? No way! What you will do is whatever you
can think of doing, read about all the possibilities, then GO BACK and
check the things that are pertinent to the processes you are considering. You
can even go back and check the patient the next day if you want to. Your
team and your patients will appreciate your thoroughness. Remember that
your objective is not to be right on the first try but to come up with
reasonable conclusions after examination and study, and this is what being a
clinician is all about!
You will probably want to attempt to do one write-up like the last one early
in your rotation, just to establish yourself among your team as capable. If
you decide to do an A&P like the first one we showed you, go for it, but
were not going to tell you we told you so if you get reamed for it. As the
year goes on, you will do assessment and plans that are somewhere in
between the examples we showed you. As you progress toward internship,
your A&P will look more like the first example, but you should always strive
to justify your diagnoses at least in a few sentences.
Finally, while it is true that surgical write-ups tend to be shorter and require
less of a differential or discussion, your surgical attendings still will want an
assessment and plan more like the last 2 examples than the first one. Yes,
this isnt reality-but you arent a real doctor yet either!

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Orders
Admit orders are written for any patient on admission (of course), post-op, or
when the patient is transferred to another floor or service. Many services
(i.e., OB-GYN) have pre-printed forms that involve checking of some boxes.
When starting from scratch - heres what to do:
A.D.C. Vandalism:
ADMIT: to floor, service, docs. If transient admission (i.e., to recovery
room), may add then to floor when stable. Also write the attending,
resident, and intern.
DIAGNOSIS: medical/surgical problem (s/p appendectomy, r/o MI)
CONDITION: stable, guarded, etc. There are definitions for these. Ask
your intern or resident.
VITAL SIGNS: how often, include weights.
ALLERGIES: to medications, radiographic dyes, specific foods
NURSING PROCEDURES: bed position, preps (enemas, scrubs),
respiratory care, wound care, sp. gravity on urine, etc. Nurses record I&Os,
IV fluids, PO intake, as well as urine, GI, drain and NG tube output, if you
ask nicely.
DIET: NPO, reg. diet, liquid diet.
ACTIVITY: bed rest, ad lib, or OOB (out of bed) 3x/Day
LABS: CBC, renal battery q A.M., CBC stat and qod.
IVFs: e.g. D51/2NS at 120cc/hr
SYMPTOMATIC DRUGS: PRN for pain, nausea, insomnia, emesis,
itching (see below for more specifics).
MEDICATIONS: antibiotics, insulin, etc.
EXTRAS: EKG, CXR
PARAMETERS: call house officer for T>38.5, BP<90/60 or >180/11 0,
RR>25 or <1 5, Pulse>l 20 or <60.
Depending on the service, also include Ted Hose (or SCDs), and Incentive
spirometry at the bedside.

PRESENTATIONS
The following are the various parts which need to be included in any formal
presentation you give (and generally should be recited in this order). Note give pertinent only, do not include all info!!
The patients name, identifying information, and chief complaint.

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All this information must be included in the very first sentence you utter. If it
isnt, youll immediately be interrupted and asked to supply it. This part is
not tough! Its the old, Madeline Jones is a 54 year old diabetic Caucasian
female who presented to the ER last night complaining of a sudden onset of
crushing, sub-sternal chest pain. Notice that in one sentence youve given
the patients name, age, sex, ethnicity, the time and circumstances of her
arrival at the hospital, her presenting symptom, and an important adjective
(diabetic). Easy, right? No? OK, well give you a few more examples.
John Macias is an 8 year old Mexican-American boy admitted
from the clinic with a two hour history of fever, chills, and
obtundation and clinic LP showing gram negative rods in his CSF.
Mary Whitworth is a 28 year old African American female, 3
months pregnant, who was admitted for complaints of nausea,
cramping and fever following a black widow spider bite to her left
leg.
You get the idea now. NOTE!!! Many attendings like to hear pertinent and
significant medical history in the first line!

HPI
History of the Present Illness (HPI). This is where you expound on the chief
complaint, giving all pertinent positives and negatives, OPQRSTADA style.
Getting back to Madeline Jones chest pain, you might continue your
presentation with: Ms. Jones was at home walking up the stairs (onset)
when she experienced a sudden onset (time factor) of severe (severity),
crushing (quality) sub-sternal (position) and jaw pain (radiation),
accompanied by shortness of breath and anxiety (associated symptoms) and
unrelieved by nitroglycerin or rest (alleviating and aggravating).
She called out to her son who found her sitting down on the stairs
clutching her chest and looking like a ghost (info from witnesses). The son
immediately called the ambulance and the patient was brought here to the
Emergency Room. Now, even though this is the HPI, you need to include
relevant PMH, SH, FH and any other history that applies, especially any
results of past cardiac studies. Cardiac catheterization performed 7/92
demonstrated an 80% LAD lesion, 75% stenosis of the RCA, and complete
occlusion of the diagonals. Ejection Fraction was 36%.

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You would continue, Ms. Jones has a history of two prior MIs, in 1976 and
in 1980, with hospitalizations in Denver. She underwent a CABG in
September of 1980, also in Denver, for three vessel disease and has been
doing well since that time. Her cardiac cath in 7/92 showed...
note: When giving the HPI for conditions with known risk factors, including
MI and CVA (stroke), it is important to mention these here.
She has a 50-pack year smoking history, denies alcohol use, has been
diagnosed with diabetes mellitus type I since age 20, and has a strong family
history of heart disease, with a father and two brothers suffering fatal MIs
before age 60. She also admits to being hypertensive.
Current medications include nitroglycerin sl prn, which she uses 1, about
once a week, ASA prn for headaches, insulin 30u NPH q am, and a water
pill for hypertension which she takes about once a week. Youve given all
her meds, mentioning how much, how often, and how compliant she is.

Problem List
At this point (or even before the HPI) if the patient has a ton of medical
problems, you may want to include a brief list of them. This becomes
particularly relevant at the VA, where patients tend to have multiple
diagnoses. For example, Patient is a 79 year old Caucasian male who was
admitted with a 3 day history of fever, chills, coughing, and increasing
sputum production with a left lower lobe infiltrate on CXR. His problems
(heres your list!) include COPD, CHF, PUD, alcoholism, diabetes with
retinopathy, neuropathy, nephropathy, gout, and disseminated prostatic
carcinoma. You now have a completely different initial picture than if
youd merely presented the patient as a 79 year old with pneumonia. All
those diagnoses in your problem list are considered highly relevant.

Past Medical History

This is where you give the rest of the history that does not directly relate to
the patients current problem. Getting back to Madeline Jones, you might
say, Ms. Jones past medical history is significant for cholecystectomy at
age 40, and pneumonia with a one week hospitalization last year. She is a G6
P5 SAB1, (gravida 6 with five living children and one miscarriage, or
spontaneous abortion) who had a TAH (total abdominal hysterectomy)
after her last delivery at age 38. Since we already heard about her diabetes
and cardiac disease, you dont have to repeat it all. Do include a history of
allergies here.

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Family History
Most attendings will be happy with relevant FHx only. The fact that Ms.
Jones has a positive history of heart disease is relevant; the fact that her sister
broke her left wrist during a fight at age twelve is not. So you might say
Ms. Jones family history is significant for diabetes in her maternal
grandmother and one child, strokes in two aunts, and the cardiac disease
already mentioned. If there is nothing significant here, a simple family
history is noncontributory will suffice.

Social History
Attendings vary more widely on what they want to hear in this section than
any other! Some want only the bare minimum, which usually means
smoking, drinking, high risk sexual behavior, and illicit drugs; those
attendings couldnt care less whether their patients mother is dying, her
children are junkies, or the family lives in the bus depot. On the other hand,
some want to know it all. Your best bet is to know as much as possible about
the social history (in case youre asked), but only present what you feel is
crucial.
For example, Ms. Jones social history is remarkable for a 50 pack-year
smoking history. She denies a history of alcohol or recreational drug use,
including IV drugs. She currently resides in a trailer with her husband, her
19 year old son, and her invalid mother-in-law, whom she cares for 24 hours
a day (stress). If the attending wants to know more, she/he will ask.

Review of Systems
Remember the multitude of ROS questions (Short of breath? Pain on
urination? Swollen joints?). Here is where you present additional
complaints. You should also include pertinent negatives. Ms. Jones ROS
was positive for a decreased exercise tolerance over the past year, and
arthritis in her hands. Make it short; most attendings do not want to hear
all the negatives.

Physical Exam
This is where you tell them what you saw, heard, and felt. Some attendings
will want only the positives - e.g., if you dont mention the neurological
exam, it is assumed that you did it and found no abnormalities. Some
attendings want a detailed description with all positive, negative, and
questionable findings. Again, when in doubt, know the full detailed exam (in
case youre asked), but present an abbreviated account only. For example,

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On physical examination Ms. Jones is an obese, anxious, dyspneic

Caucasian woman, appearing much older than her stated age, who was
initially in severe distress, clutching her chest and moaning. Notice that in
one sentence, youve painted a fairly graphic picture of what the patient
looked like; remember this is essential since the attending has never seen the
patient. After your general statement, give a quick synopsis of the rest: vital
signs, HEENT, chest, cardiovascular, abd, extremities, and neuro.
Remember to be brief, mentioning only positives and pertinent negatives.
For example, Vital signs included an oral temp of 38.0, P 110, BP 130/70,
and respiratory rate of 32. HEENT was remarkable for a severe diabetic
retinopathy with cotton wool exudates, neovascularization and
microaneurysms.
Neck was without bruits. Head was atraumatic. Its important since she
might have hit her head when she fell. Notice how you dont mention normal
TMs, normal oral mucosa, or freckles. Lungs were clear in the upper lobes
with scattered bi-basilar crackles. Maybe shes developing some CHF,
maybe she has pneumonia? Breasts were without masses; cardiovascular
exam revealed no precordial impulses, a well localized PMI at the fifth
intercostal space. Sl and S2 were normal with no gallops, rubs, murmurs, or
clicks noted. There were no carotid or femoral bruits, pulses were all equal
and symmetrical, and no edema of her extremities was noted. She was
tachycardic to 120. Youre right, this is long and detailed, but its also the
organ were currently most concerned with. Had Mrs. Jones come in with a
broken ankle, we might well have said simply that the cardiovascular exam
was benign. Abdominal exam was unremarkable, with a liver span of 6 cm,
no palpable spleen or masses, no bruits, and active bowel sounds. A simple
abdomen was benign would probably suffice. Extremities were within
normal limits and neurological exam was non-focal. This means you did the
entire neuro exam and, if asked, you would be able to tell the attending all
about the patients cranial nerves, DTRs, muscle strength, etc. Most wont
ask. Notice that you didnt do a rectal exam; MI patients dont get rectals for
fear of a vasovagal response causing an extension of the infarct-- just a
bonus for you!

Lab Results
This is where you recite all the lab values obtained on the patient since
admission. Again, some attendings want only abnormal values; its best to
ask. If they only want the abnormals, you can say, Ms. Jones CBC and
diff, electrolytes, urinalysis, PT, and PTT were all normal. Always give the
value of lab results directly responsible for diagnosis, even if they are

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normal. In Ms. Jones case, be sure to know what the CPK, MB fraction,
LDH, and SGOT are (cardiac injury panel, as youll learn). Give the
attending these values, even if they are within normal limits at this point!!!
Also include results of Ms. Jones CXR and, for heavens sake, know what
her EKG showed (get someone to help you read it)!
So, for this whole section you might say, Ms. Jones had a normal CBC,
diff, lytes, clotting studies, and U/A. Her CPK was 400 with MB fraction
1O%, LDH 200 with isoenzymes pending, and SGOT 40. Her CXR showed
no acute disease and was without cardiomegaly, infiltrates, or pulmonary
edema. Her EKG showed a normal sinus rhythm @ 100 beats/min with ST
elevations in leads II, III, and AVF and reciprocal ST depression in the
anterior leads.

Special Studies
This includes any special X-rays, scans, or studies done on the patient. Ms.
Jones probably didnt have any. Had she come in with symptoms of a renal
calculus, she may have had an IVP; if a stroke was suspected, she may have
had a CT scan, etc.

Assessment & Plan

Heres where your reading, research, and thinking come into play. Tell the
attending what you think and why Ms. Jones is pretty straightforward. Ms.
Jones was admitted to rule out an MI. With EKG changes and an elevated
CPK with an increased MB fraction, shes ruled in for an inferior MI.
Most patients wont be as clear cut, so youd better think in advance about
why Mr. Gomezs crit is only 30, or why Mr. Maces left flank hurts. Be
sure to have a lengthy, but reasonable, differential diagnosis. Even in Ms.
Jones case, MIs are not always this clear cut, so be sure to know the
differential diagnosis of chest pain and how to distinguish all the possibilities
(see the assessment and plan).
Now that the attending knows what the patient complained of, what you
observed, what the lab told you, and what you think the problem is, hell
want to know what you did about it and what else you plan to do. Ms. Jones
was admitted to the ICU, given 02 at 2L by nasal cannula, given a 75mg
bolus of lidocaine and started on a drip at 2 mg/min, given Morphine Sulfate
until pain was relieved, and started on heparin. CPK, LDH, SGOT and
isoenzymes are ordered for the next three days. Include anticipated plans, if
appropriate.

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OK, so youve got the initial presentation down. This will be similar for
every service but will be MUCH shorter for surgery and OB/GYN. The most
important part of the surgery presentation is the HPI and past histories. On
the surgical service, you will mostly be doing presentations where you
update your team about patient post-op. It is basically in the form of a
progress note synopsis.
And heres an example: This is Ms. Jones, post-op day 2 status-post
cholecystectomy, intra-operative cholangiogram, and T tube placement.
She is afebrile today with the remainder of her vital signs stable. Her intake
over the last 24 hours was 2800 cc, output 2500 cc, of which 75 was from
the T tube and was bilious in appearance. Her physical exam remains
unchanged with mild incisional pain, wound intact without erythema or
induration or change. Her postop crit is 33%; her WBC is 8000 with no left
shift. Overall, she is doing fine. The plans for today are...
Always know new lab values, if available (frequently they arent in
the early morning, except on Unit patients), and present abnormal labs.
A COUPLE OF GENERAL RULES TO REMEMBER ABOUT
PRESENTATIONS
Its legal (and recommended!!) to practice in front of the mirror, to
fellow students, silently to yourself, to your dog...
The key to a good presentation is organization (running through
the above checklist is a good beginning).
Be concise, relevant, and brief.
You need to know all about the patient, but you do not need to say
all you know!
If you get interrupted by the residents or attending dont get
flustered! It will happen (especially on trauma surgery). Just move
on to the next patient!
Avoid pausing as much as possible - pauses give residents and
attendings the opportunity to cut you off and can make you look
less polished. Once you start, dont stop!

PROGRESS NOTES
Since you now know what the chart is made up of and more or less what an
admission note is made up of, lets get into your daily contribution. As
mentioned earlier, one of your main functions is to write the progress notes
each day on each patient. You want to try to get them in as early in the day
as possible so that others who read the chart during the day will know whats

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going on with your patient, and what the plan for the day is. It is important to
have at least thought about your A&P before rounds, so you can discuss it. If
your plan is dependent on a procedure or lab values, figure out a tentative
assessment. If youre really confident, you can basically write your entire
note when you pre-round in the morning adding an addendum later in the
day if your plan is dependent upon pending labs, procedures, or your
attending.
Your progress notes are Problem-Oriented. Youll list each problem at the
beginning of each note. Attempt to give each problem a number in order of
importance but keep the numbers consistent - even if a problem was defined
and numbered at a prior admission. When a problem is resolved, or is stable,
word it as such. Only then may you delete it from your progress note (it
should still be listed in the Problem List). Each problem is to be evaluated
by the SOAP method.
Whats the point? When we first started third year we robotically wrote these
chart notes without really knowing how they impacted patient care. Well, the
point is, as the principle care-giver (or pseudo care-givers we are), the
progress note documents the patients condition from day to day. It
demonstrates that someone IS taking care of the patient, that the patient was
checked today and the patients condition evaluated. The assessment and
plan are key parts of the progress note because they indicate how the patient
is doing overall and what needs to be done to get the patient well - and
discharged!
There are several ways to write your notes, each following the same basic
format - the SOAP method. Your actual notes will differ from service to
service - we will try and include examples of all of those notes.
Write legibly, be succinct and precise, base assessment and plans on your
own evaluation (along with that of your team), and your interns, residents,
and attendings will love you.

Parts of your progress note explained

Heading: This includes the date, time, what the note is (i.e., MSPN,
Addendum with new Lab Results, etc.), and the day of the hospital stay
this is (HD#5) or postoperative day (POD#5). It is helpful to write
current meds and dosages and day of meds (e.g., Day 3/7 of Antibiotic X) in
the margin in the heading or to the left of the objective section. It is
generally prudent to know that your patient is going on Day 17 of

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Gentamycin or that he/ shes on Digitalis plus potassium supplements. Some

thorough residents like IVFs written in the left margin with rate and day of
line noted (e.g., IVF - D5 1/2 NS at 700 cc/hr, day 3).
S Subjective: Data obtained from the patient, e.g., doing well, passing gas,
having bowel movements, severe lower abdominal pain, excruciating substernal, crushing chest pain associated with shortness of breath and
diaphoresis, as well as, I dont want a medical student touching me. The
nursing notes are often helpful in summarizing what happened overnight.
O Objective: Usually includes your general picture of the patient. Included
under Objective is your physical exam, vital signs, temperature, ins and outs,
TPN monitoring, and all other objective data you can find on your patient.
In your physical exam, just limit it to the appropriate organ systems for each
disease, e.g., you dont have to do an otoscopic exam on a patient with
appendicitis.
Youll soon learn that the entire head and neck exam can usually be
described as WITHIN NORMAL LIMITS. Beware, though. Some
attendings think that WNL means We Never Looked and will hammer you
for writing it down. Be sure to include all lab, procedure, and consult results
in this section. Basically, all new information you have obtained that day
goes in this section.
A Assessment: This is your assessment of whats going on. For instance, if
your subjective said dysuria, frequency and urgency, and your objective
said Urine Culture - 100,000 E. Coli per ml, you can safely say in your
assessment that this patient has a urinary tract infection. This is your chance
to diagnose!! Sometimes, especially in Internal Medicine, each patient will
have several problems, and each problem should be assessed separately.
This will be described in the example.
P Plan: This is self-explanatory, your plan based on your assessment. As in
the above example youd say treat patient with antibiotic. Some short cuts
in this section include going to physicians orders and seeing what your
interns plans are - what he/she ordered already. Its always good if your
plan and the interns plans correspond to each other. Note: Expect questions
regarding your plans: e.g., which antibiotic?, why?, what are you
treating?

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Sample progress note: Internal Medicine

07/10/93
0730
MSPN HD (HOSPITAL DAY) # 3
PROBLEM LIST:
1. DVT (deep venous thrombosis)
2. GUAIAC POSITIVE STOOLS
3. H/O (history of) PARANOID SCHIZOPHRENIA
S: PATIENT DESCRIBES RT CALF PAIN AND SWELLING, WORSE
AT NIGHT. OTHERWISE DOING WELL, DENIES BRIGHT RED
BLOOD PER RECTUM, ABDOMINAL PAIN, CONSTIPATION OR
DIARRHEA. (Note how, in your subjective, youve asked the patient
specific questions regarding his medical problems). DENIES N/V/F/C
(nausea, vomiting, fever, chills).
O: VS: BP 140/80; HR 92; Tc 37.4, T Max 38.2 (at 0400), RR 24
WT 78 Kg (+ 0.5 KG SINCE ADMISSION)
I/Os: INTAKE: IV - D5 1/2 NS 2500cc (or oral intake, other 500cc
TPN, MEDS)
OUTPUT: URINE 2,000cc (OR BLOOD, NG TUBE , STOOL,
DRAINS, EMESIS)
It is also important to characterize all outputs - for example, ng output can be
described as bilious, sanguinous, clear, etc.
PE:
GENERAL - PT SHOWS EVIDENCE OF DETERIORATING MENTAL
STATUS WITH THOUGHT PROCESS DISTURBANCES, ALTHOUGH
WITHOUT HALLUCINATIONS OR DELUSIONS.
LUNGS CTAP (clear to asucultation and palpation).
CV - S1 & S2 NORMAL, GR II/VI SEM AT LSB (UNCHANGED), NO
GALLOPS OR RUBS.
ABD - + BS, SOFT, NON-TENDER, NON-DISTENDED, NO REBOUND
OR GUARDING.

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RECTAL - RECTAL VAULT WITHOUT LESIONS OR MASSES,

GOOD SPHINCTER TONE, GUAIAC POSITIVE STOOLS. SMALL
EXTERNAL HEMORRHOID SEEN AT 0300.
EXTREM. - Rt LOWER EXTREMITY - Circ. 35 CM., RYTHEMATOUS,
EDEMATOUS. CORD PALPATED. (+) HOMANS SIGN.
Lt LOWER EXTREMITY - CIRC. 28 cm. (-) HOMANS SIGN.
LABS:
WBC 12.4 (52 Polys/16 Bands/20 Lymphs/2 Monos)
H/H 12.1/36.3
PT/PTT - 14.2 / 35.4
Na+ Cl- BUN /
---------------------Glucose
K+ HCO3 Cr \

\Hgb/
WCB-------Platelets
/Hct\

PROCEDURES:
CXR - NO ACUTE DISEASE.
IMPEDANCE PLETHYSMOGRAPHY - EVIDENCE OF LARGE DVT IN
Rt LOWER CALF.
CONSULTS
HEMATOLOGY - SUGGESTS CONTINUED USE OF HEPARIN,
SWITCHING TO COUMADIN IN THREE DAYS WHEN PTT IS 25.
ASSESSMENT AND PLAN: HD#3
1: DVT
A: PT SHOWS OBJECTIVE EVIDENCE OF A LARGE DVT IN Rt
LOWER CALF BY IMPEDANCE PLETHYSMOGRAPHY. CALF
CIRCUMFERENCE AND SYMPTOMATOLOGY INDICATE
WORSENING OF PROCESS.
P: CONTINUE HEPARIN AT DOSE. CONTINUE DAILY PT/PTT.
WILL MONITOR PT/PTT UNTIL 1 1/2 TIMES NORMAL.
2: GUAIAC POSITIVE STOOLS
A: ACTIVELY BLEEDING HEMORRHOID NOT SEEN ON
ADMISSION EXAM, BUT IS MOST LIKELY CAUSE OF GUAIAC POS.
STOOL.
P: WILL GET BE (barium enema) TO R/O DIVERTICULI OR MASSES.
3: H/O PARANOID SCHIZOPHRENIA

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A: PT SEEMS TO BE DECOMPENSATING. MOST LIKELY

SECONDARY TO REFUSAL TO TAKE PSYCH. MEDS.
P: ENCOURAGE USE OF MEDICATIONS. CONSIDER PSYCHIATRIC
CONSULTATION.
R. FARINA, MSIII
-------------This is a fairly complete, long note on an average medicine patient with only
three problems. It is somewhat more complete than what youll need to do,
since everyday youll put in only some of the included information, rather
than including it all in one day as in the above. Note how all the basic
information is in this one note, without extraneous information, e.g., who
cares that he just bought a new Toyota - it doesnt need to be on the chart.
In essence, if anyone came to look at your note, he/she would be able to find:
1) Why and how long this person has been in the hospital, 2) How
he/shes doing and/or progressing, and 3) What youre doing about each
problem.
--------------------Sample Progress note: Surgery
07/01/93 MSPN-POD 2 (post-operative day #2).
S/P CHOLECYSTECTOMY
0800
S: DOING WELL, C/O MINIMAL INCISIONAL PAIN, + FLATUS, NO
BM YET
0: VSS (VITAL SIGNS STABLE), AFEB (TMAX 372, Now 370), HR 80,
BP 135/7O, RR 16
I/0 - 2800cc/2400cc + 26cc (T-TUBE) LAST 24 HOURS
SEROSANGUINOUS DRAINAGE FROM JP TUBE AND BILIARY
FLUID FROM T-TUBE.
PE: LUNGS: CTA BILAT
CV: S1 AND S2 NL, WITHOUT MURMURS, GALLOP, OR RUB.
ABD: + BS, SOFT, NON-TENDER, NON-DISTENDED
INCISION: WELL HEALED WITHOUT ERYTHEMA, INDURATION,
OR DISCHARGE.
LABS - WBC - 10.5 WITHOUT A LEFT SHIFT

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H/H - 11.2 / 33.6

A: STABLE, POD #2, S/P CHOLECYSTECTOMY, WITH EVIDENCE
OF RETURN OF BOWEL FUNCTION.
P: ADVANCE TO CLEAR LIQUID DIET. D/C (discontinue) IV WHEN
TOLERATING CLEARS. CONTINUE WOUND CARE. WILL PULL JP
WHEN D/C(discharge) LESS THAN 25 cc/24 HOURS.
N. Dunnevant, MSIII
-----------------See, much more simple. As the year progresses, youll find that your
medicine notes are beginning to look like surgery notes. Ob-Gyn, peds, and
neuro notes all follow along the same format. Get used to it; youll be
writing thousands in the next few years.

UNDERSTANDING PRESCRIPTIONS
Writing medication orders and prescriptions is a topic not covered in any
basic science course. Unfortunately residents and attendings are frequently
under the assumption that we know at least the basics. Therefore, we feel it
is important to cover the general principles of medication orders.
Things that need to be included in an inpatient medication order are:
Name of the drug, dosage, instructions for dispensing, route of
administration, dosing frequency.
For an outpatient prescription, you include all the above information, plus
the total amount of medication to be dispensed, and the number of refills, if
any. It is relatively common to give a patient a one month supply of drug,
except narcotics and most psychiatric medications, where a 1-2 week supply
is given. ALL controlled substances (i.e. narcotics) require physicians DEA
number or hospital DEA and Resident tag on number.
Inpatient Medication Orders Examples
CHLORDIAZEPOXIDE 25 MG PO TID This means 25 mg of Chlordiazepoxide by mouth 3 times per day.
GENTAMICIN 100 MG IV q l 2' Means 100 mg of Gent every 12 hours.

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ACETAMINOPHEN 325 MG 2 TABS PO q 4-6' PRN PAIN

Means Two 325 mg tablets of Acetaminophen by mouth every 4 to 6 hours
as needed for pain.
NPH INSULIN 30 U SQ qAM AND 20 u SQ qPM -

Means 30 units of Insulin subcutaneously each morning and 20 units

subcutaneously each evening.
NOTE - Try and get into the habit of using generic names only.
VERY IMPORTANT: If you are uncertain what strength/dosage form a
medication comes in, DONT GUESS! Either look it up, or call the
pharmacy. It saves time and frustration in the long run.
PEARL - Get the recent edition of the Pocket Pharmacopeia in the
bookstore. It fits into the breast pocket of your lab coat or scrubs. All house
staff carry them for quick reference.
Outpatient Prescriptions - Examples
On a prescription blank, include all of the above information, plus the
number of refills and the amount of medicine to be dispensed (written as
dispense #).
Rx: AMOXICILLIN 250 MG, #40 (forty) [dont forget to write out the
number of pills] SIG: 1 TAB PO BID X 10 DAYS FOR AIRWAY
INFECTION.
Rx: AMITRYPTILINE 150 MG #14 (fourteen) SIG: 1 PO PHS FOR
DEPRESSION.
For the patients benefit, it is useful to write the reason for the medication in
lay terms as part of the instructions, i.e., for airway infection in the first
one above and for depression in the second example. This is especially
helpful for patients who take multiple medications.

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THE ON-CALL NIGHT

Yikes! Being on call invariably hits people as a
shock/surprise/disaster/delightful learning opportunity or just another rite-ofpassage. You WILL end up being on-call many times during your clinical
life and you WILL spend the night at the hospital. Fortunately, being on-call
turns out to be an excellent learning opportunity for us. Here are some
details:
Every service has its own call schedule. This varies from every third night to
every sixth. Most schedules are every fourth or fifth. Services differ in the
composition of the call team. Sometimes, the whole team stays (resident,
interns, all medical students). Other times, teams are divided so that medical
students rotate call (e.g., if there are four students on your team, you will be
on-call every fourth night.). On some services the call is short, meaning
you dont stay all night, only until 11pm or so. On other services, long call
means you stay all night. In some cases your call schedule will be
determined before you begin the service. Other times it will be left up to the
students to arrange.
On a practical level, here are some facts you ought to know about call. First,
realize (and be prepared for) the fact that, when you show up for your first
rotation, bright and early Monday morning, some of you wont be going
home Monday night. Instead, youll work all day Monday, some portion of
Monday night, all day Tuesday, and still maybe not get home in time for
5:00pm dinner Tuesday night. You might not be told in advance, either, who
will take Monday night call; actually in most rotations, its left up to the
students to decide. You can call the clerkship office before the rotation starts.
They may already have your call days scheduled. It is a good idea to keep a
toothbrush in your bag at all times.
What about your call schedule? Most residents have the student they know
best do more procedures. The best way to get to know someone better is to
work with that person longer. Try to schedule your call with the same
interns/residents each time. If you meet a resident with whom you really get
along, try to change your schedule so you can work with that person a night
or two.
Dont bother bringing your comfy pajamas; youll be wearing scrubs, the
uniform of call. Yes, you need scrubs, so you ought to know where to get
them. At most hospitals, theyre available from the O.R. Dont worry - youll
be shown where to get some. If not, ask. Never leave the VA in or with a

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pair of their scrubs; getting caught allegedly means an automatic $75 Federal
Fine, but weve all walked out of the VA in broad daylight in scrubs and no
one has been fined yet. For greater comfort, you can wear a T-shirt under
your scrubs it adds a little coverage to those plunging neck-lines.. It just
depends on the service what is acceptable. Surgery requires both top and
bottom or you get kicked out of the OR!
Sleeping arrangements are always a source of interest, so well fill you in.
Its nice to know in advance, so it doesnt shock either you or your S.O., that
youll be sleeping with one to three people in a tiny little room. Yes, call
rooms are dinky with one to two bunks that sleep two to four people.
Remember dorms? They were bigger. Most are connected to a bathroom,
and many also have a shower. Some also have a desk, a television, or
lockers. We have yet to see one that doesnt have lumpy beds and hard
pillows. Medical students occasionally sleep with the intern (ahem, in the
same room with the intern only). Residents often have a separate room (the
attending is home in his/her own bed). Beware, if there arent enough beds to
go around, guess who needs to go find a quiet couch? Luckily there are bunk
beds in the mail room but there is no guarantee of clean sheets (grab em
before you go all the way down there).
A word about sleeping etiquette. Medical students get the top bunk; interns
(if they sleep at all) sleep on the bottom. It is nothing like ER or Chicago
Hope. It is not a big party with everyone making out. (Thank goodness,
because most people forget to brush their teeth on-call anyway!!)
Eating on-call should be arranged in advance. Either bring enough food to
last you (refrigerators are available) or bring enough money to buy what you
need. However, $11 will be added to your meal card for every call night
scheduled. When you are up at 2am you will be hungry and the cafeteria
will likely be closed. Call is NOT the time to diet! At the VA, your dinner
and breakfast are on the house when youre on-call, as is lunch on the
weekends. VA food is not, however, considered gourmet. You must get to
the cafeteria between 7-8am for breakfast or 5-6pm for dinner. A minute too
early or too late and they wont let you in. TIP: At the VA, if you think you
might be late, CALL the cafeteria. They will graciously hold a meal for you
for exactly 30 minutes (no longer). The key is to not miss a meal. Therefore,
pack lots of snacks or even a dinner.

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What you do on-call varies. Most of the acutely ill and trauma patients will
come in at night, so this is where you stand a good chance of learning a lot of
medicine. Usually, you stick with the intern, seeing new admissions, doing
procedures, and sometimes covering other teams patients. At the VA, if
youre on Internal Medicine youll have your own beeper, so your intern and
team can contact you. You also attend codes, work-up new patients, study, or
write orientation manuals for the class behind you.
Our advice is basically to be visible during your call nights. It doesnt
behoove you to spend the whole night sleeping, especially when your team is
running around taking care of sick patients. On the other hand, if your intern
and resident have called it a night, no one will be left awake that will know
that youre asleep. The wonderful thing about call is that because there are
less people around looking over your shoulder, you have much more
opportunity to do procedures and get some real hands-on training.
Try and stick with someone youre comfortable working with, and be
assertive. At 3:00 in the morning, theyre less likely to argue with you about
whether or not you can put in an arterial line.
TIP - A technique we really like is the 20 minute head-start. Ask for this
from your resident when he/she gets an ER or floor call at night (only when
you know the patient is stable, of course) so you can get experience working
up acute problems on your own.
And a word about the morning post-call: if you dont have an alarm, get up
when the intern does and face a whole new day! You can also call the
operator for a call at a certain hour (if you are near a phone). Post-call you
do your work (see your patients; write progress notes), you usually dont
pick up any new patients, and unless you have clinics to attend, you can wear
your scrubs all day if you wish (thus proclaiming to the world that you are
post-call and therefore, by definition, tired, grumpy, and NOT to messed
with or hassled in any way).
Since you cant avoid call, use it! It is usually fun, with many fewer people
around. Night crews tend to be more patient, pleasant, and let you do more.
Students usually do and learn more on their call nights than all the days on
their rotations.

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PROCEDURES
The primary question students ask is: How can I get to do a procedure?
The most important thing to remember is Ask and you shall receive!
Usually no one will ask you if you want to do something. Just by asking you
may find your intern very enthusiastic in wanting to help you learn a new
technique/procedure, but dont be demanding. A little good-natured
pestering will usually get you what you want. If the answer is No or youre
unsure about asking, just ask if you can watch the procedure. This shows
motivation and initiative, and your team might get the hint you want to do
next time. A key issue is trust.
If this is your first time working with a resident/intern she/he may want you
to watch the first one. What you can do is try and be on-call with the same
people so that they can get to know you. Remember, your prime
opportunities for procedures are when you are on-call.
What kinds of things can med students do?
For sure
Drawing Blood: venipunctures, femoral sticks, ABGs
Starting IVs (be sure to let nurses know if you want to do it).
Foley Catheters
NG Tubes
Electrocardiograms
Injections
Closing subcutaneous layer in surgery
Delivering babies
More Risky, but Definitely Do-Able
Paracentesis
Arterial Lines
Lumbar Puncture
Thoracentesis
Closing fascia layer in surgery

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If youre lucky
Starting a central line
Chest tubes
Swan-Ganz catheter insertion
Bone marrow biopsy
Opening incision in surgery case
Intubation
Amniotomy
Vacuum extraction or forceps delivery
Try to watch
angiography, cardiac catheterization, bronchoscopy, cystoscopy,
nephrostomy tube placement, myelogram, echocardiogram, fluoroscopic
exams in radiology, GI Endoscopy, lithotripsy.

CODE BLUE
Code Blue! You will have the option to do these on Medicine, Peds, OB, and
Surgery. One of the most exhilarating/traumatic experiences of being on the
wards is participating in a code arrest. There is an indescribable feeling that
comes over you when the thrill of the code beeper goes off, and you run
through the hospital (the only time you are allowed to run) while visitors and
patients move out of your way knowing that youre off to a genuine
emergency. Once youre there, the balance between life and death stares you
straight in the eye.
Sounds awesome, doesnt it? And thats exactly the way it is. The problem
is, as a medical student, you never are quite sure what youre supposed to do.
This section will attempt to make you feel comfortable during a code, and
have an active part in it. First of all, how do you know when one is called?
All hospitals have different systems, but all codes are announced in two
methods. They are announced on the overhead page system and in the beeper
system. A code beeper is a special one that only goes off for a code. For
example, a code will be called over the PA system as Code Blue, Third
Floor North. At the same time, the code beeper will give of one long, loud
beep, and relay the same message. Your resident or intern carries the code
beeper, so either youll hear the code called from them, or youll hear it
overhead. If a code occurs at night, youll hear it from your intern since
youll be sleeping in the same room. At BUMC-T Campus, codes are not
announced overhead, so stick with your team or ask them to have someone
page you if one is called.

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In any case, you run to the location given. What should you do? Dont just
stand there, do something! The first procedure of any code arrest is to take
your own pulse (see House of God, Rules of the House of God). Then, if
youre the first one there or one of the first - think CPR. Remember the
ABCs? Make sure the patient has an airway. If not, make sure she/he gets
one. Next comes breathing, then circulation. This should take 10 seconds.
Dont feel that since youre just a medical student you shouldnt get in the
way. Most of the time its the medical student who is expected to do the
compressions. Other parts you may need to play in a code include:
o
o

Bagging the patient.

Starting lines - peripheral (as many as possible - dont stop at one
IV! and big ones 14-18 gauge)
o Drawing gases - femoral artery sticks for blood gases.
o Drawing labs - venipuncture.
o Compressions - remember, one one-thousand, two one thousand...it
may sound gruesome, but if you dont feel ribs cracking, youre not
going hard enough, 8 cm depth is the rule. Remember cadence
another one bites the dust song to get the right rate!
o Get the patients chart - important, but often overlooked.
o You dont have to know what drugs need be called for, but do try to
get a feel for whats going on, and why its being done.
o Charting events, drugs given, and the time each event happens
.
Try to do as much as you can. During a code, nobody will ask you to do
something; have the initiative to start by yourself or youll miss everything.
Remember nothing you do to this patient (e.g., missing a femoral stick 10
times or cracking a rib) is worse than the state she/he is in at that point.
Usually there are 2-10 doctors present, pharmacy, radiology, and tons of
nurses all to help out, so it can be overwhelming.

THE UNIT
Intensive Care
For most third year medical students the first exposure to the intensive care
unit (a.k.a. the ICU, the unit) is difficult at best, terrifying at worst. All
those lines! tubes! monitors with their beeps, blips, flashing lights, and
alarms! Even worse, all those numbers vital signs, labs, blood gases, Swan
readings, arterial line readings, central line readings, meds going in, body
fluids coming out - and all of it recorded every hour. You should know
before you begin to stress out, at BUMC-T Campus third year students only
take care of unit patients during surgery rotations, and during Internal

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Medicine at the VA. Intensive care unit experience is not a core part of any
other rotations.
Therefore, the unit gets its own section in our manual! Well try to address a
few basic concepts to introduce you to the unit and, to make your initial
experience there less traumatic. Our unit pearls will include: 1) who can
help; 2) what machines are hooked up to most unit patients; 3) where to find
the hard data youre supposed to know about your patients; 4) how to write a
complete, concise, organized progress note on a unit patient.
Who Can Help
THE NURSES - Most ICU nurses respond helpfully to a medical student
who says, This is my first unit patient. Will you please explain the set-up to
me?
THE UNIT ASSISTANT - They know where things are - e.g., the ECG
machine, blood gas syringes, lab slips, charts, etc.
YOUR INTERN AND RESIDENT - Keep bugging them to explain things
(but not during codes or other crises).

The Machines and Gadgets of the ICU

Even in the ICU, there are a limited number of machines that can be
connected to the body. The major ones are the following:
Cardiac monitor: three round sticky discs on the patients chest with wires
coming off them provide a continuous rhythm strip - a constant tracing of
the heart activity on a monitor above the patients bed. In addition, many
unit players have a 12-lead EKG done daily.
Arterial line: Also known as an art line or an A-line, this is an IV
catheter in an artery (usually radial) that provides a continuous BP reading
and a tracing on the same monitor. Arterial blood gases can be drawn
directly from it.
IVs: All unit players have at least a couple of peripheral lines for fluids,
meds, etc.
Central lines: IVs that go into central veins (subclavian, jugular).
Swan Ganz: a bright yellow catheter threaded through a central neck vein
into the heart and pulmonary artery, used for monitoring a patients
hemodynamic status. They are too complicated to explain here, but theyre

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important enough for you to make a concerted effort to understand them. A

great summary can be found in the Scut Monkeys Handbook.
Respirator: The noisy breathing machine also known as a ventilator. Dont
change the settings on the respirator (only respiratory therapy can do that and
the staff will be sure to hassle you if you do it). Do make sure you know
what the settings are, including TV (tidal volume), FiO2 (fraction of inspired
oxygen), rate and mode, PEEP (positive end expiratory pressure), and
pressure support. Get somebody to explain them to you. And when giving
report, always give ABG values that correspond to and agree with the vent
settings.
Foley: an indwelling catheter connecting the bladder to a collection bag. It
provides an accurate assessment of hourly urinary output.
Chest tube: a big fat tube inserted into the thorax to drain fluid, air, blood,
etc. from the pleural space.
Nasogastric (NG) tube: goes through the nose down into the stomach and is
either for draining things out (as with a GI bleed or a postop patient whose
bowels are not functioning) or for putting things in (feeding the patient).
Dobhoff Tube: Small version of NG tube that actually sits in the duodenum.
Used for feeding when you want to bypass the stomach.
Oxygen: If they arent on a respirator, many unit patients are on oxygen by
way of face mask or nasal cannula.
TPN line: since most unit patients are NPO, many will be receiving total
parenteral nutrition through a central line, to maintain nutritional
requirements.
Other drains: Patients may have a variety of these, including abdominal and
incisional drains. Follow the tube to the patient to find out where its coming
from. You can usually find out the origin by the OP-Note if it is not apparent
from the patient.
Drips: Unit players can be on a variety of drips, strong medications that
must be dripped into the patient constantly via an IV line. They may be
needed to maintain blood pressure (dopamine), or urine output (furosemide),
or something else. Drips are for real sick people.

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Data Collection
Every unit player has mounds of data collected and recorded hourly, and all
of it can be found on the flow sheet. The flow sheet is a poster sized sheet of
paper that contains most of the information youll need to know. It can be
found directly outside the patients room. FIND IT! YOU NEED IT! Spend
some time familiarizing yourself with the flow sheet and how to read it. In
general, it contains the following data: vital signs, daily weights, I&Os
(inputs and outputs from all sources), Swan-Ganz readings, labs, ABGs,
daily rhythm strips, and medications. Under how to write a note, youll be
told how to organize all those numbers.
The chart is the other important data source. Its main usefulness is in looking
at: 1) the orders-recent orders will often tell you about recent events; 2) labsknow whats ordered so youll know what to look up; 3) progress notes from
other people - including RT, consults, and, most useful of all, nurses.

HOW TO WRITE AN ICU NOTE

Like all patients, unit players need a daily progress note detailing what
happened since your last note, and what you plan to do with the patient.
Unlike other patients, unit players require collection, synthesis, and concise
recording of a tremendous amount of information in every note. Here is a
way to write ICU notes. Review the Critical Care Billing Progress Notes,
found where all unit forms are kept. They are helpful at compiling large
amounts of info on one sheet of paper.
ICU PROGRESS NOTE
General rules: Be complete, be organized, be concise, be consistent,
give ranges of values rather than one value.
-----------ICU Note Example #1
07/05/93 0800
MSPN POD 5 s/p exploratory laparotomy, appendectomy
S: Pt c/o minimal incisional pain. Denies passing flatus. Communicating
via writing.
O: General: alert, oriented, intubated white male with ng tube to LCS (low
constant suction), foley to gravity, Rt subclavian line, Lt radial
art line, swan-ganz, abdominal drains to LCS. VS: Tmax 39.0 at 2300 last
evening, cultures sent for blood, urine, sputum, wound. Tylenol given x3 t-

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Tmax 39.0 (2400 hrs), 38.3 currently, last Tylenol (0600). P:100-125, no
rhythm abnormalities (if abn: type, duration, how treated, if now present)
BP:100-110/50-60 maintained on Da 4 mcg/kg/min. R:12, TV-1000cc FiO240%, IMV-1 2, PEEP-5 0600.
ABGs: 82/97%/51/7.37127
Fluids: 3045cc IN TPN at 50 cc/hr
Aminophylline at 16cc/hr
Lasix at 9cc/hr 1800 out (1450 out urine, 300 out ng, 50 out drain)
WT: 66.7 KG (up.4 kg from yesterday)
Swan readings: pas-38 map-80 ra-14
pad-29 svr-860, pawp -1 8-20 co -5.40

PE:
HEENT:
Lungs:
CV:
Abd:
Extremities:
Neuro:
(be sure to note changes from yesterday)
MEDS:
Aminophylline drip at 16 cc/hr Lasix drip at 9 cc/hr
DA at 4 mcg/Kg/min
Ticarcillin 39 IV a 40
Gentamycin 80 mg IV a 80
Bronkosal .4 cc/4 cc NS a 60
Digitalis 0. 1 25 MG OD
LABS:
Give all the days labs, making sure to note the time they were done.
Include CBC, renal battery, pt, ptt, platelets, gentamycin levels, theo
levels, etc. Also, its good to give an idea as to the progression of values over
the day, e.g., ABGs.
Culture results: blood cultures (-) x 2 from 3 D ago urine C & S pending
sputum c & s pending
CXR: Left lower L013E infiltrate unchanged; pulm edema slightly improved
EKG: NSR AT 100. No change from admission EKG.

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A/P: Give your assessment of the patients status usually by listing

problems. For example:
1. RESPIRATORY:
2. CARDIOVASCULAR:
3. GASTROINTESTINAL:
4. NUTRITIONAL:
5. INFECTIONS:
6. ETC.
P: Put what you plan to do with the patient - try and venture some thoughts
on this, but dont hesitate to talk to your intern or resident if you need some
ideas.
P. Petlin, MSIII
---------------An excellent example of this commonly used method of writing progress
notes can be found in the Clinicians Pocket Reference (a.k.a. the scut
monkeys handbook), page 206 (sixth edition).
One last comment about the ICU. Its confusing, its difficult, its
frustrating, but you will learn more medicine (or surgery, or whatever) by
taking care of one really sick unit player than you could ever hope to learn
from a floor full of regular patients. Enjoy the unit - its a gold mine!

OTHER HOSPITAL SERVICES

Dietetic Service
The goal of the Dietetic Service is to provide optimal nutritional care to
patients. The dietitians interpret nutritional assessment data and develop and
document nutritional care plans. You can usually page an R.D. (registered
dietician) with questions about diet orders for your patient. They are also
helpful at determining TPN formulas and calculations.
Pharmacy- Some hospitals have clinical pharmacists, either on ward teams,
or available for consults. They are excellent resources for drugs, dosing,
interactions, etc.

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Social Work Service

Social Work services are available to all patients. Patients should be referred
to the social worker as soon as the physician becomes aware that they have
social or emotional problems related to their illness, or that there may be
problems involving planning for their release and post-hospital adjustment,
such as homelessness. The social worker can be of particular value in the
following types of cases:

Patients concerned about personal or family problems that

exacerbate the illness or impede treatment.
Patients unable to perform the activities of daily living.
Patients whose living or work patterns may need to be changed due
to their illness.
Terminal patients who need assistance in accepting their illness
and/or assistance in arranging their affairs.

Dont underestimate the need for this service! Often what seems like a
common procedure (colostomy) is tragic and disfiguring in the patients
eyes. These are real issues that be helped by calling the social worker
assigned to the floor. Most will appreciate your concern for the patients
well-being. Each medicine team has its own social worker assigned to them.
Radiology Service
Radiology Service is set up to handle the diagnostic imaging needs of the
hospital. In addition, interventional radiology now allows certain procedures
to be done with ct/ultrasound/fluoro guidance without having to use the
operating room. You should stay on top of the exams your patient has while
he/she is in the hospital, and for ICU patients you should be as up-to-date as
possible. This may mean going to radiology to review films with a
radiologist. However, it is always good to call and check on RTAS (6945840) which will give you the dictation of the most recent film, but first,
look at the films yourself and make your own assessment before getting the
experts opinion. Other things you need to know: be as polite as possible
to the radiology staff, as this is one of the busiest departments in the hospital.
Never remove films from the department without telling a member of the
radiology staff.

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Pathology Service
No matter what hospital or service, the Pathology Department can be an
invaluable complement to your education. It is worth your while to review
histo slides of your patients resected mass, or even your patients peripheral
blood smear, with a pathologist or pathology resident. Most are glad youre
interested, and will teach you lots. Its also nice to see some clinical
correlation with the hundreds of disease processes you saw in basic sciences.

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The Book
XXXII

Part IV

General Information

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UA AFFILIATED HOSPITALS GENERAL INFORMATION

Hospitals are whole communities unto themselves, and whether or not you
like it, you will become a permanent resident for the next year. Here is
some helpful info about the hospitals we all rotate through.
(1)Banner University Medical Center-Main Campus
1501 North Campbell Avenue, Tucson
Given the long time association with the College of Medicine, sometimes it
is easy for a student to be brushed off as just another med student. This is
not universal, so do your best to remember peoples names and be as polite
as possible. BUMC-T Campus is supposedly benign for a university
hospital, and you will have access to many great resources that College of
Medicine affords - the Learning Resource Center, the AHSC Library, etc.
BUMC-T Campus is beginning to think more of medical students as
evidenced by on-call meal cards. Telephone Number (520) 694-0111.
Paging operator (520) 694-6000.
Pagers
Digital pagers usually given when on-call, for whole rotation when on
Trauma surgery or Psychiatry Consult Service. Dial 80 from within the
hospital to page. Call 694-4480 from outside the hospital to page.
Hospital Computer System
Sunrise is taking over for the old system, Keystone. You went through
training class and got a password in April as part of Patient Care Skills in
PCM. It has all the labs, imaging, vitals, discharge summaries, etc. Call
information services to sign up. For radiology reports, you can call the
RTAS system at 694-5840.
Parking
BUMC-T- Campus does not provide on-site parking for year medical
students; so keep your UA permit. Zone 1 permits can be obtained from UA
Parking & Transportation (626-7275).
Places to Hide
Student Rec Room, AHS Library, Teaching and Learning Center basically
anywhere in the basic sciences building.

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Where to use EMAIL

Student mailroom, Information Technology Center, 2nd floor, AHS
Library, Computer Learning Center.
(2)Veterans Administration Medical Center - Tucson
Most students spend at least one clerkship in their third year at the VA
hospital. It is an experience to behold; it is where many of your stories of
medical school will come from, and it also is where youll receive most of
your technical experience. Students are very well integrated into VA
activities, much more so than at BUMC-T Campus. Youll probably take
care of more patients, be on call more often, and get less sleep. Most
students, however, find they learn more medicine in general at the VA than
any other hospital. The call rooms are the best of any hospital. Its also good
experience to work at the VA during your third year because most residency
programs have a VA as one of their teaching facilities, and all VAs are alike.
Telephone number (520) 792-1450 (be prepared to let it ring for a while ....)
note that unlike other hospitals, you cannot reach a given extension directly
by calling 792-xxxx. You must go through the operator if calling from
outside the hospital.
Pagers
You will be given the code pager by your classmate who was on call
the prior night for Medicine and Surgery. To page your intern or
resident, dial 5555 from within the hospital to page in the VA, or dial
4444 if you are at the VA paging a Banner University Health Center-Main
Campus #.
Hospital Computer System
The BEST and most efficient of all the hospitals. Make sure you get your
own access code. Getting labs are easy, and by using the RES function,
you can program in all your patients and get a customized lab printout every
morning that you can use during rounds. Also, VAMC has a great EMAIL
system. Just type MAIL from any prompt at any terminal, and you can send
or receive messages to or from anyone (including your fellow students) at
the VA.You can also receive messages from the outside world by having
them sent to your address in the following format: Last name, First
name@TUCSON.VA.GOV. Be sure to take advantage of Up To Date
while at the VA, as it is a free and invaluable resource.

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Library Resources - small, but available 24 hours a day. Ask your resident
for the code to get in. No Medline available.
Parking
On lot near the Ajo entrance. Plenty of spaces available.
Places to Hide
Patients bedside - most dont have much family and appreciate the
company.
Where to use EMAIL
The VA library has a terminal for medical students to use 24 hours a day.
This is for two-way communication. To RECEIVE E-MAIL or send EMAIL within the VA ONLY, you can use any terminal in the hospital - just
type MAIL from any computer prompt. Every team room and clinic exam
room has a computer for VA computer charting. You can access the internet
from all of these computers.
Places to Hide
If its a nice day, there are some places to sit outside. Avoid the snipers,
though. Theres a TV room on the main floor by the soda machines. Ask a
resident for the access code.
Where to use EMAIL
Terminal located in Room 12 of the Outpatient Clinics, during clinic hours
only. A permanent EMAIL terminal is being set up at press time. Ask the
staff for help.

MENTAL HEALTH
Just a note regarding your mental health. At some point in your medical
school career (most often during third year), you may find yourself
overwhelmed, depressed, or wondering why youre here. Every year, there
are students who question whether they really want to be doctors. Others
question whether they are capable of being good (or even adequate!) doctors.
You may find yourself needing help with these questions, or just wanting
someone to talk to (besides a classmate, spouse, or parent). We strongly
recommend that you seek out the services listed here that are available to
help you. These people WANT to help; they have a special interest in
helping medical students (youd be surprised how many of your classmates
are smart enough to take advantage of them).

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Larry Moher, M.D. - Very safe place to talk. Will see you as often as
desired, or assist in referring you to someone else. Drop-in or make an
appointment. Offices: Family Practice Office Building, 1450 N. Cherry
Office phone: 626-7435 or pager 1283.
Student Mental Health - on main campus. Marian Binder, Hal Crawford
and others have been very helpful to a number of students. Phone: 6213334. They can also refer you to other professionals after an initial
evaluation.
John Racy, M.D. and the Psychiatry department are willing to see students
for short courses of treatment without charge. Also a very safe place. Call
Dr. Racys office: 626-6351.
Mental Health (Phoenix)- Dr. Charlton always offers to talk to students and
the friendly Phoenix staff would likely assist in finding any needed
resources.
Also in Phoenix, ASU Student Health offers mental health counseling.
They can help in finding counseling resources, as well.

SUCCESS SECTION
When we started to write this section, it occurred to us that we all have
different definitions of success during our first clinical year. For some, it is
the maximum number honors grades possible. For others it is finding a
balance between personal and professional life. And for some of us, it is just
maintaining our sanity! With that in mind, we hope to give you some advice
in each of the areas. You need not follow our advice to succeed; you will
anyway!
Grading
Usually, from 20-40% of your grade may be determined by some objective
measures, i.e. the shelf exam. The rest will come from subjective evaluations
by your residents and clinical faculty. The criteria used in each rotation are
different; they will be explained to you when you start each rotation, and
many times you will exit the orientation confused. If you are ever unclear
what those criteria are, just ask! The common things people judge you on are
usually: motivation to learn, enthusiasm, professional and ethical behavior,
knowledge base, and technical skills. At the end of the evaluations, a
judgment is usually made regarding your potential to become a house

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officer. Weve never understood that part, because were all going to be
house officers anyway.
Although in some rotations your residents will have a lot of input into your
final grade, it is customary that the attending physician on most services has
the final say. Sometimes the attending will ask the residents how you are
doing, however. Times when you will be watched critically are work rounds
and attending rounds - so make sure you work on your presentations. The
other aspect of your work that will be judged is your write-ups/admission
notes, and especially your assessment and plans. You may occasionally be
judged by the quality of your progress notes as well. Your day to day
interactions with house staff and attending physicians may also be taken into
account in fact, the way you communicate with your team will probably set
the tone of your evaluation, no matter how well you do in the other areas, so
try and get along! This is the political side of third year. Areas where you
will probably not be judged critically include student lectures and your
history and physical, although some house officers may observe you and
take this into account.
It is often difficult to estimate how you are doing in a rotation of course we
all strive to be our best in all areas, but most attending physicians will
compare you to other medical students they have worked with. This does not
mean that you must compete for the grade you desire by any means. It is
possible (and it often happens) ALL students in a particular group get an
excellent evaluation in a rotation. So how do you find out what distinguishes
an average student from an honors student? ASK! The best time is a few
weeks into the rotation, when you have gotten the basics down and are ready
to work on specific skills. Dont feel embarrassed about stating your goals.
For example, you may ask your attending or chief resident, I would like to
do as well as I can in this rotation because I am considering this specialty as
a career; do you have any suggestions for me concerning things I can do to
get the most out of this experience? Even if you are not considering that
specific specialty you should still talk to your resident or attending about
their expectations, and let them know you are always open to suggestions for
improvement. Often, an attending is simply not aware that you are interested
in an honors grade and assumes that you are doing the minimum just to get
by. Often, your team assumes that medical students egos are too fragile to
take constructive criticism, so it helps to get the point across that you are
amenable to suggestions for improvement.

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You should know that an honors grade in a clinical rotation is quite an

achievement. Therefore, an expectation of honors in every clerkship is
probably unrealistic. It is helpful to earn honors in a rotation you are
considering as a career, but the grade need not be the end of all your pursuits
third year. Your written evaluation is very important. In fact, it is very
possible that you could get an excellent letter of recommendation from an
attending physician in a rotation in which you earned a pass, and vice
versa. A good end to work toward, we think, is improvement in your clinical
skills. This is what will get you where you want to go. And by striving for
improvement, your team will notice you as a hard worker. Remember, the
key is communication!
Feedback
Get in the habit of asking for feedback. Official College of Medicine Policy
is that all students must get feedback from the rotation halfway through. Not
all rotations do this, and most give you bogus feedback like youre doing
fine. I wouldnt change a thing. What you should do if regular feedback is
not scheduled is to ask your chief resident or other person who will be
evaluating you two questions, How am I doing? and How can I
Improve? This is hard to do, we know, and may get you a bogus response,
but youll regret it if you have to face a poor evaluation based on behaviors
that you could have corrected earlier in the rotation. We have tried to help
you in this area by suggesting to the clerkships what we would like to see in
terms of feedback (see the appendix). Some of the clerkships already do a
fantastic job at this and can really help make your rotation an excellent
learning experience.
Your family
At this point, we should paraphrase Dr Racy who says, Medical school is
urgent, but your children are important. Your time commitment in third
year is variable. For surgery it may be 5:00 in the morning to 8:00 PM on
non-call days and, of course, all night on call days. For the most part,
though, you will be working from about 7:30 to 4:00 each day that you are
not on call. When you are assigned to clinic, your hours will be better. It
isnt that bad, really. You will often have free weekends, even on surgery
(and if you believe that....). Some students manage to see their families by
meeting them for dinner at the cafeteria of the hospital where they are
working. At the VA, there is a very nice courtyard where you can sit and
chat. This works for some students and rotations better than others, so dont
be surprised if its just a little impossible for your significant other to come
out to the VA every night youre on call. Nobody needs to tell you that your

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time is at a premium. Any given classmate whos been in your shoes has
some coping mechanisms that worked for her/him.
A note to parents: see if you can work out a system whereby you trade
babysitting time so you can get out of the house. Golden weekends, the
ones between rotations where theres no call and nobody can touch you, may
not be a good time to do this, but perhaps students on less intense rotations
can help out those on the more time-intensive ones and vice-versa. An
informal system thats not too large might work best.
Your sanity
Its not easy for us to give you advice in this area. We all have different
coping mechanisms that work well for us. You will definitely interact with
individuals burned out on medicine, who seem to feel their attitude is the
best way to protect themselves. The best thing we can tell you is to seek out
some role models in your travels - whether it be an attending physician, a
house-officer, another student, or another individual outside of medicine. Try
to maintain contact with these individuals and discuss some of the things you
have seen on the wards or in the clinic so you can put them in perspective.
You also have resources in Tucson and Phoenix that you can use to help you
evaluate your experiences critically. See mental health.

MORE SUCCESS TIPS

Cant Quite Measure Up..
When youre on your first rotation, keep in mind that you have just replaced
a student at the end of their third year, who has no doubt impressed the hell
out of his/her residents. Residents and attendings dont keep track of what
part of the year you are in, so remind them at appropriate times that this is
your first rotation. Your expectations will then be lowered and you will be
under less pressure to not screw up.
The other thing you will hear a lot of throughout your year is the following:
The student that just finished the rotation before you was excellent; we
loved having him/her. They did better than any student weve ever worked
with. While we are no doubt happy to hear positive things about our
Classmates, sometimes we get a sinking feeling, like were starting with the
deck stacked against us. How will we ever be as good? We wanted to pass
on what we discovered: the house officers on the rotation you just left are
probably saying the same things about you. The other thing we discovered is
that, indirectly, your whole class is being complimented, and you should
accept the statement as such.

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We highly recommend that you let your classmates know the positive
comments that were said about them - give them a call as soon as you can
and tell them. This can really make someone feel better who is starting a new
rotation, and when weve done this, it has turned out that the student was
never told anything about how they did when they were actually on the
rotation!
Sweat equity
What weve all discovered is more than anything, you are judged as a person
rather than on your knowledge during your clinical year. The hardworking,
enthusiastic, always smiling third-year will always get better evaluations
than the domineering, defensive, bookworm. Be people-oriented, work to
get along with others as best you can.
No matter how hard you think youre working, remember your interns and
residents are working harder. This knowledge will keep you from doing or
saying something that may make others perceive you as unmotivated or,
even worse, lazy.
Work your butt off the first week of every rotation. First impressions are
everything. Taking every patient in sight and working tirelessly for five days
will create confidence in you by your team. In turn, that will allow you to
take it easy in successive weeks of the rotation without shaking your positive
first impression. Then again, dont be a hound and hang over the shoulder of
your resident/intern if they tell you to get out of here. Rather, say Are you
sure there isnt anything I can do to help? Theyll say no, you look like
you are interested, and you still get to leave.
Hide-and-Go-Seek
Find a place to hide. These are places in the hospitals where you can make
phone calls, study, or just relax, even for a few minutes. For the sake of
appearances, dont use the call room for this purpose too often. Think about
how it looks for the resident to be running around the hospital getting work
done to find you in the call room, leisurely watching The Price is Right. A
particularly good hiding place is your patients bedside! You cant make
calls from there or study, but you can escape the madness of the wards,
engage in some stimulating conversation, and even catch a sitcom or two
with your patient.

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The corollary to the above tip is to be visible also. Its good for your team to
see you at work; hiding is for when youre not working. So if youre reading,
working on an H&P or spending time with a patient (you can be hiding in
this case, but it still may look like youre working) in the open, this will add
to your reputation as a hard worker. Some students have received
comments in their evaluations that they were never around. If you are
going to take off to read (or go hide) - tell them youre going to read, let
someone know, and let them know how they can reach you if you are
needed either with a telephone extension or pager number.
Pharmaceutical Detail Persons
It youre not familiar with Detail Men/Women yet, you will be. Also
referred to as Drug Reps, these individuals are responsible for educating
medical professionals about the pharmaceuticals produced by the
corporations they represent. Among other activities, this may include
sponsoring various educational programs with free lunches, textbooks, and
smaller items like pens and notepads, all displaying a certain drug trade
name.
We dont include a discussion of detail persons here to argue the ethics of
accepting free gifts from drug companies; this is a choice that you have
already made or will make in the course of your career. We DO want to
emphasize the fact that you do have a choice. This means you do not have to
partake in a drug luncheon just because your attendings, your residents,
and even your fellow students are indulging, and the cafeteria is 10 minutes
away. You are always allowed to excuse yourself, make a trip to the
cafeteria, and then rejoin your peers for lunch. NO ONE can ever force you
to accept anything from a pharmaceutical corporation no matter the
perceived educational values. One last thought: if you are really on the fence
about this, it may help to realize that in the long run, the money you save
from a free drug lunch here and there really doesnt add up to much. At
hospitals in Phoenix where the food is free anyway it adds up to nothing!
There are medical students who cant get enough freebies and others who
have been able to totally divest themselves of pharmaceutical marketing
money without difficulty. Either way, the choice is yours!
National Conferences/Meetings
Many of you will need to attend national meetings or conferences (e.g.
American Medical Association, American Medical Student Association,
Specialty/Research Conferences) during your third year. The question
always comes up: Can I get time off from my rotation to go to X

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meeting? The answer, almost without exception, is yes! Remember that

as a student you are not ultimately responsible for patient care, so most
teams can function fine without you. The key in asking for time off is to ask
respectfully! Instead of asking the clerkship coordinator Can I have next
weekend off to go to X conference? you should say, I will be going to X
conference next weekend; what arrangements do I have to make? The
clerkship may ask you to submit in writing a description of the conference
you are attending and reasons why you are going.
You should get approval for your time off before the clerkship starts, if
possible. In addition, you should let your residents know early that you will
be taking a few days off, so that they can plan ahead. Finally your attendance
at a conference should not affect your evaluation in any way, if you gain
prior approval from the clerkship. Rarely, residents have put negative
comments on students evaluations in reference to them taking vacations
while on the service. Make sure you check your evaluations when they are
received by the clerkship office; comments like this will be disregarded in
your final evaluation. The great majority of residents are sympathetic,
though, and will encourage you to take as much time as you need.

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NOTES FROM THE ASSOCIATE DEANS

The following is from the College of Medicine Administration.
From Dr. Violet Siwik, Interim Asst. Dean.
Abuse
The Code of Conduct for Professional Relationships in the College of
Medicine was passed by the Student Council and the Faculty (copy of the
full text of this document is available on the Student Affairs web site:
www.medicine.arizona.edu/studentaffairs ) It states that faculty, students,
residents and fellows will:
1. Act honorably in all endeavors
2. Respect others
3. Never commit an act of physical violence (except in self-defense);
sexually abuse or harass, discriminate on the basis of gender, race,
ethnicity or sexual orientation; threaten to harm or verbally abuse
4. Report violations of this code to the appropriate authorities.
What acts should the student consider abuse?
Abuse can be defined as to treat in a harmful, injurious, or offensive way; to
attack in words; to speak insultingly, harshly, and unjustly to or about a
person. Students should not tolerate any form of physical violence (hitting,
kicking, pushing, etc.), sexual abuse or harassment (unwanted sexual
advances, sexist slurs), blatant discrimination based on race, ethnic
background, or sexual preference, verbal abuse, being threatened with harm
or receiving retribution for actions taken in reporting such incidents.
What constitutes sexual or ethnic discrimination?
Discrimination is to be denied opportunity on the basis of factors unrelated
to level of training, such as gender race, ethnic background, or sexual
preference.
How should a student handle abuse in an acute situation?
First, if the student feels their physical safety is in jeopardy, they must
remove themselves from the situation and contact appropriate authorities.
Second, for all forms of suspected abuse the students should feel free to
contact Dean of Student Affairs (626-6216) as soon after the situation as
possible to discuss available options

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What will happen when a student reports abuse?

No actions will be taken unless approved by the student, except when it
involves the physical safety of others.
Grading
What are the relevant C.O.M. policies concerning grading during the clinical
science years?
Clinical science courses are required to conform to the Honors, Pass, Fail
grading system. Each course determines what constitutes each of the grades.
Uniformly, clerkship grades are based on a combination of clinical
evaluations and a written final examination. They differ, however, in the
weight given to each and whether additional activities (i.e., problem solving
sessions, physical examination techniques, etc.) are included. The course
directors submit a final evaluation form that includes not only the grade but a
narrative description of your performance. The narratives can be quite
extensive, or very short, but usually include direct quotes from the attendings
and residents with whom you worked.
At the end of the third year, all students are required to pass the Observed
Structured Clinical Examination (OSCE). The exam is a practical test of
your clinical skills and is administered over a series of days in June. You
will be scheduled for this exam by the Clinical & Professional Skills office.
Students who fail the exam are given remedial help to address their
weaknesses prior to graduation.

What should a student do if they feel they are graded unfairly?

Students who feel that they received an unfair grade should address their
concerns first to the clerkship directors. If they are not satisfied at this level,
they can appeal to the appropriate Department Head and finally the Dean.
Dean of Student Affairs is available for consultation at any point in this
process.

120

The Book
Edition XXXII

Part V

Appendices

121

COMMON NOTES
Along with daily progress notes and admission notes, most rotations, include
other notes, as well. These include discharge summary notes, pre-op notes,
post-op notes and procedure notes. Writing orders is also expected on many
services
The purpose of this section is to provide a basic format for the notes you will
write on various rotations. Keep these handy!

Admit orders: Remember ADC Vandiml or ADC Vandalism

1) Admit: floor, room, team, attending, residents
2) Diagnosis: list in order of priority
3) Condition: good, stable, fair, guarded, etc.
4) Vitals: q4hrs, q shift, routine, etc.
5) Activity: ad lib, bed rest, up to chair, ambulate with assist, etc.
6) Nursing orders: parameters, i.e. BP, RR, PR, Temp, UO
7) Diet: regular, ADA (diabetic/low sodium/clear liquid/NPO, etc.
8) Ins & Outs: strict, routine, ad lib, etc.
IV fluids: D%NS to run at 120 ml/hr, etc.
Drains: Foley to gravity, NG T to intermittent suction, etc.
9) Meds
10) Labs

Pre-Op Note
l) Pre-op Diagnosis
2) Procedure planned
3) Indications for procedure
4) Lab results
5) CXR
6) EKG
7) Blood - type and crossed for 2 U PRBC
8) Orders - written, in chart
9) Permit - Procedure described to patient, along with risks& benefits
explained.
10) Consent signed, witnessed, and in chart.

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Post-Op Note
l) Pre-op Dx
2) Post-Op Dx
3) Procedure
4) Surgeons (in order): surgeon, 1st assistant, 2nd assistant, medical student)
5) Attending - even if not present
6) Findings - very briefly describe findings of operation (10 cm of colon
removed)
7) Anesthesia - type used (e.g., GET= general endotracheal).
8) Fluids required - ask anesthesia what and how much
9) EBL (estimated blood loss) - type and location - again, check the
anesthesia record, state urine output here also
10) Specimens - what, from where, where sent
11) Complications
12) Drains
13) Disposition/Condition - Patient tolerated procedure well, sent to recovery
room in stable condition.

Procedure Note
This is written after any procedure, e.g., LP, central line placement.
1) Procedure
2) Indications
3) Operation
4) Anesthesia
5) Positioning of patient
6) Description of procedure
7) Findings
8) EBL
9) Complications
10) Permit/Consent - signed/in chart
11) Disposition - pt. tolerated procedure well and ordered to remain supine
4-6 hrs.

Discharge Summary Note

This is often on a preprinted form.
1) Date of admission
2) Date of discharge
3) Admitting dx
4) Discharge dx
5) Attending and service to which pt. was admitted
6) Procedures done and indications

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7) Brief HPI
8) Hospital Course
9) Discharge Meds
10) Disposition
11) D/C Instructions and follow-up

Delivery Note:
On (delivery date, time) this (age, race) female under (epidural, pudendal,
local, no) anesthesia delivered a viable (male, female) infant weighing
(weight) with APGAR scores of (0-1 0) and (0-1 0) at 1 and 5 minutes.
Delivery was via (SVD, LTCT) to a sterile field (nuchal cord reduced).
Infant was bulb suctioned at (perineum, delivery). Cord clamped and cut
and infant handed to waiting (Pediatrician, nurse). Cord blood sent for
analysis. Placenta with (2-3) vessel cord delivered (spontaneously with
manual extraction) at (time). (Uterus, cervix, vagina, rectum) explored and
(midline episiotomy nth degree laceration, uterus and abdominal incision)
repaired in a normal fashion with (type) suture and (anesthesia). EBL
(amount). Patient taken to RR in stable condition. Infant taken to NBN in
stable condition.
Dr. (name) attending.
Note SVD=spontaneous vaginal delivery, LTCT=low transverse C-section,
RR=recovery room, NBN=newborn nursery.

Postpartum note:
S: patient comments or complaints, nursing comments
CHECK pain control, breast tenderness, quantity of vaginal bleeding,
urination, flatus, bowel movements, lower extremity swelling, ambulation,
breast or bottle feeding, birth control type.
0: Vitals, Ins/Outs
Exam: Breath sounds, bowel sounds, fundal height, consistency,
Incision/episiotomy condition, lower extremity edema.
Meds: Birth control, pain med, iron, vitamins, stool softener
Labs: CBC, Rh status
A: Assessments based on data above
P: Medication change, lab tests, procedures, consults, discharge.

APGAR scoring exam:

Appearance
2 Entire body pink

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1 Pink body with blue extremities

0 Entire body blue or pale
Pulse
2 >100 beats/min
1 <100 beats/min
0 Absent
Grimace
2 Cough, sneeze, or vigorous cry
1 Grimace or slight cry
0 No response
Activity
2 Active Movement
1 Some Movement
0 Limp. Motionless
Respirations
2 Strong, crying
1 Slow, irregular
0 Absent

CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS

(OPQRSTADA) Chronological order of onset, position, quality, radiation,
severity, timing and duration of symptoms, aggravating and alleviating
factors, associated symptoms, self- treatment, relevant laboratory values,
pertinent negatives.
It helps to think of the HPI as a story line of the patients problem. Begin at
the beginning as in, the patient describes herself as completely well prior
to..., and end with the patient is being admitted for further evaluation for
possible...

PAST MEDICAL HISTORY

General health; medications (names, dose, frequency, duration, reason for
taking, compliance, availability); date, type, outcome, complications of
childhood illnesses (measles, mumps, rubella, whooping cough, chicken
pox, rheumatic fever, scarlet fever, polio); adult illnesses; accidents/
injuries; hospitalizations not already listed; immunizations, screening
tests.

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PAST SURGICAL HISTORY

Operation date, type, reason, outcome, blood transfusions, complications.

FAMILY HISTORY
Age, health/death of parents, siblings, spouse/significant other, children.
Check for diabetes, heart disease, pulmonary disease, kidney disease,
bleeding disorders, cancer, mental illness or symptoms of presenting illness.

SOCIAL HISTORY
Birthplace, education, employment, relationships, persons at home, hobbies,
diet exercise.

HIGH RISK BEHAVIORS

Always check alcohol, tobacco, and drugs of abuse. For pregnant women
check caffeine consumption.

REVIEW OF SYSTEMS

General: weight change, fatigue, weakness, fever, chills, night

sweats.
Skin: Skin, hair, nail changes, itching, rashes, sores, lumps, moles
Head: Headache location, frequency pain type, N/V, visual sx.
Eyes: glasses, contact lenses, blurriness, tearing, itching, acute
visual loss
Ears: hearing loss, tinnitus, vertigo, discharge, earache
Nose, Sinuses: rhinorrhea, stuffiness, sneezing, itching, allergy,
epistaxis
Mouth, Throat, Neck: bleeding gums, hoarseness, sore throat,
swelling
Breasts: skin changes, masses, lumps, pain, discharge, self-exam
Respiratory: shortness of breath, wheeze, cough, sputum,
hemoptysis
Cardiac: hypertension, murmurs, angina, palpitations, dyspnea on
exertion, orthopnea, paroxysmal nocturnal dyspnea, edema, last
EKG
GI: appetite, N/V, indigestion, dysphagia, bowel movement
frequency/change, stool color, diarrhea, constipation, bleeding
(hematemesis, hemorrhoids, melena or hematechezia), abdominal
pain, jaundice, hepatitis
Urinary: frequency, hesitancy, urgency, polyuria, dysuria,
hematuria, nocturia, incontinence, stones, infection

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Genital: Male: penile discharge or sores, testicular pain or masses,

hernias; Female menarche, period regularity, frequency, duration,
dysmenorrhea, LMP, itching, discharge, sores, pregnancies and
complications, miscarriages/abortions, birth control, menopause,
hot flashes/ sweats; general STD history/ treatment, sex interest,
function, problems
Vascular: leg edema, claudication, varicose veins, thromboses,
emboli
Musculoskeletal: muscle weakness, pain, joint stiffness, range of
motion, instability, redness, swelling, arthritis, gout.
Neurologic: loss of sensation/ numbness, tingling, tremors,
weakness/paralysis, fainting/blackouts, seizures
Hematologic: anemia, easy bruising/bleeding, petechiae, purpura,
transfusions
Endocrine: heat/cold intolerance, excessive sweating, polyuria,
polydipsia, polyphagia, thyroid problems, diabetes
Psychiatric: mood, anxiety, depression, tension, memory

CRANIAL NERVE EXAM

I Olfactory -smell
II Optic - visual acuity/fields
III, IV, VI - Oculomotor, Trochlear, Abducens eyelid opening; extraocular
movements (IV superior oblique, VI lateral rectus; III all others), direct and
consensual pupillary light reflexes
V Trigeminal - (Vl ophthalmic, V2 maxillary, V3 mandibular) Corneal
reflex, facial sensation, jaw opening, bite strength.
VII Facial - eyebrow raise, eyelid close, smile, pucker, taste
VIII Vestibulocochlear - auditory acuity of each ear Rinne (air v bone
conduction) and Weber (lateralizing) tests.
Oculocephalic reflex (dolls eye maneuver), oculovestibular reflex (ear canal
caloric stimulation)
IX, X Glossopharyngeal, \/agus - palate elevation, gag reflex, phonation
XII hypoglossal - tongue protrusion and strength on lateral deviation

FOLSTEIN MINI MENTAL STATUS EXAM

Maximum Score = 30
5
What time is it? (year, season, date, day, month)
5
Where are we? (state, county town, hospital, floor)
3
Test giver names 3 objects, 1 second to say each.

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5
3
2
1
3
1
2

Ask patient to repeat all 3. Give 1 point for each correct

answer. Repeat 3 objects until patient learns them. Note
number of trials to learn.
Serial 7s from 100 to 5 answers (93, 86, 79, 72, 65) or spell
WORLD backwards.
Ask for 3 objects above
Test giver points to pencil and watch, and patient name them
Repeat the following; No ifs, ands, or buts.
Follow 3 step command; Take the paper in your right hand,
fold it in half, put it on the floor.
Read and obey the following: CLOSE YOUR EYES.
Copy design

GLASCOW COMA SCALE

Eye response (E)
4 Opens spontaneously
3 Opens to verbal command
2 Opens to pain
1 No response
Verbal Response (V)
5 Oriented, converses
4 Disoriented, converses
3 Inappropriate responses
2 Incomprehensible sounds
1 No response
Motor response (M)
6 Obeys verbal command
5 Localizes to pain
4 Withdraw from pain
3 Decorticates (flex) to pain
2 Decerebrate (extend) to pain
1 No response
Jargon
Although jargon tends to vary with the service, hospital, and house staff,
some of it is pretty standard (and unavoidable - so you might as well be
familiar with it). Note: Not all pretty, but medicine can be like that.
A crash - A patient who was stable at one time and now.
A great case - A patient you admit with either: 1) lots of problems; 2) one
interesting or unusual problem; 3) a mystery problem. A great

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case usually means a lot of work, staying up all night, and learning
things youll never forget!
A rule out - This refers to a patient usually admitted with chest pain, EKG
changes, etc. in whom you need to rule out a myocardial
infarction, noted on the chart as an r/o MI. So you follow a
certain protocol to figure out whether he or she has had a heart
attack or not. Meanwhile the patient is treated like he/shes had one.
AHSC - Arizona Health Sciences Center, BUMC-T Campus, The U All names for BUMC-T Campus
ALC - Refers to the patient you want to discharge. Stands for a la casa.
Blade - The surgeon; also can refer to the knife itself.
Bounce, Bounce-Back - A patient who is discharged only to return and be
readmitted a short time later often bounces right back to your
service.
Case - Another way of referring to a patient and his/her disease process, as in
What a good case.
Cold steel is the truth -A surgical hymn
CYA - Cover your ass. Legal medicine is now a reality
Curbside - To get an unofficial consult in the hallway from a specialist or
other service without filling out all the paperwork.
DPB - Discharge per basement (the patient didnt make it).
FOBIGMI - What a 4th year says to a pain-in-the-butt attending after Match
Day. Initials stand for F. Off Buddy, I Got My Internship!
Fascinoma -A fascinating case.
Flea - What docs on other services call the internal medicine docs.
Supposedly comes from the observation that a flea is always the last
thing to leave a dead body.
GI Rounds - Another way of saying dinner time.
GOMER - Get Outta My Emergency Room. This, sadly, refers to patients,
usually from nursing homes, who are completely dependent.
GOMERS never die, they just get sicker (see House of God,
Rules of the House of God). Also, GOMERE, for females.
Hit - An admission to your service (often heard in the context of We had a
busy call night - twelve hits! or by an elated resident No hit
today!)
Horrendioma -A disgusting appearing mass taken out of an abdomen.
Joes, Joes Place, Eat at Joes - All terms for St. Josephs
Hospital in Phoenix...
Masses - Lung, abdominal, or other masses without diagnosis are initially
referred to by many other names. In order of increasing size, a mass
may be called a ditzel, zit, booger, doodad, glitch, goober, snird,

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thing-a-ma-bob, thinga-ma-jig, squame ball (lung only), goomba,

honker or, for a really big mass, WHAMBA.
Nothing heals like stainless steel -A battle cry of surgeons.
Offending - A particularly obnoxious attending.
OTD - Your goal by the end of a long day stands for out the door.
OOH - Out of here - the goal for every ER patient, ASAP.
RSPAZ - Refers to RTAS, The X-ray reporting system at BUMC-T
Campus
S/P Snap - describes a patient who has had a psychotic break (new episode).
Smith and Wesson consult - What you may wish to order for some of your
more difficult or obnoxious patients.
Some dude syndrome - Seen on surgery especially in the ER at 3am. When
you ask the patient who shot, stabbed or mutilated him, the answer
is always some dude.
Strong Work - An often overused phrase; listen to the tone, as it may be
either a compliment or sarcastic criticism of your performance.
Stud - Thats you! (STUD-ent) Not all interns and residents refer to medical
students this way, but be aware.
Sundowning - Lots of older patients get more and more confused as the day
goes on and by nightfall are often completely disoriented.
Supratentorial - Means the problem is all in their head.
Surgerize - The art of surgery - to perform surgery.
Tern - The Intern.
The Service - Includes all the patients under your care. Theres your
residents service, which are all the patients hes responsible for; the
interns service, a subset of the residents service. When theres
more than one intern; your service is all the patients you admit,
work-up, and write daily progress notes on.
Train wreck - A very sick patient with many medical problems a medical
students nightmare.
Turf - A turf to... means youre transferring a patient from your service to
someone elses - e.g., you admit a patient to your medicine service
and discover he needs an operation, so you turf him to surgery. A
turf from... means a patient from someone elses service is being
transferred to you - e.g., the patient someone else admits to their
surgery service for repair of his hernia has an MI (heart attack!) and
gets turfed from surgery to your medicine service (more common
than the former).
Unit player - A patient in the intensive care unit.
VA, The VA Spa, or simply, The VA - All refer to the Veterans
Administration Hospital.

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Vitamin H - Haldol
Vitamin L - Lasix or Librium
Vitamin V - Valium.
WNL - Within normal limits. Often means we never looked...
Z-Rounds - The last time you see your patients at night when youre on call,
before going to sleep. Also refers to boring attending rounds/grand
rounds. On Pediatrics, these are called tuck-ins.

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ABBREVIATIONS
The following are commonly used abbreviations often seen in notes
and orders:
alert and oriented x 3 (to time, place, person)
abdominal aortic aneurysm. (also referred to as a triple-A)
Antibody, Abortion
acute bacterial endocarditis
arterial blood gas
before meals (ante cibum)
as tolerated/as often as desired
antidiuretic hormone
afebrile
acid-fast bacillus (usually used to mean AFB stain to
look for TB)
AFP
alpha-fetoprotein
AHCCCS Arizona Health Care Cost Containment System
AI
aortic insufficiency
AKA above knee amputation
ALL
acute lymphocytic leukemia
ALS
amyotrophic lateral sclerosis
ALT
alanine aminotransferase (same as SGPT)
AMA against medical advice
AML acute myeloblastic leukemia
ANA anti-nuclear antibody
AOM acute otitis media
AP
anteropostero
AR
aortic regurgitation
AROM artificial rupture of membranes
ARF
acute renal failure
AS
aortic stenosis; left ear
ASAP as soon as possible
ASA
aspirin (acetylsalicylic acid)
ASD
atrial septal defect
AST
aspartic aminotransferase (same as SGOT)
ATN
acute tubular necrosis
AT/NC atraumatic/normocephalic
AVM arteriovenous malformation
AVR aortic valve replacement
BCC
basal cell carcinoma
BE
barium enema
A&Ox3
AAA
AB
ABE
ABG
ac
ad lib
ADH
AF
AFB

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bid
twice a day
BKA below knee amputation
BM
bowel movement; bone marrow
BRBPR bright red blood per rectum
BPH
benign prostatic hypertrophy
BPM beats per minute; breaths per minute
BPP
biophysical profile (used in OB/Gyn)
BRP
bath room privileges
BS
bowel sounds; breath sounds; blood sugar; barium swallow
BSO
bilateral salpingo-oophorectomy
BTB
breakthrough bleeding
Bx
biopsy
c
with
C&S
culture and sensitivity
Ca
cancer, calcium
c/o
complaining of or complains of
CABG coronary artery bypass graft
CAD coronary artery disease
CAPD continual ambulatory peritoneal dialysis
CBC
complete blood count
cc
chief complaint
CCU
coronary care unit; clean catch urine
C/C/E clubbing, cyanosis, edema
CEA
carcinoembryonic antigen
CF
cystic fibrosis
CHF
congestive heart failure
CIN
cervical intraepithelial neoplasia
cis
carcinoma in situ
CLL
chronic lymphocytic leukemia
CML chronic myelogenous leukemia
CMV cytomegalovirus
CN
cranial nerve
COPD chronic obstructive pulmonary disease
COR
heart
CP
chest pain; cerebral palsy
CPAP continuous positive airway pressure
CPK; CK creatinine phosphokinase
CRF
chronic renal failure
CT
chest tube, cardiothoracic, computed tomography
CTA
clear to auscultation
CVA costovertebral angle; cerebrovascular accident (read: stroke)

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CXR
chest X-ray
D5LR dextrose 5% in lactated ringers solution
D5NS dextrose 5% in normal saline
D/C
discharge, discontinue
D&C dilation and curettage
DA
dopamine
DDx
differential diagnosis
DI
diabetes insipidus
DIP
distal interphalangeal (joint)
DJD
degenerative joint disease (note: osteoarthritis used more now)
DKA diabetic ketoacidosis
DLco diffusing capacity of carbon monoxide in lungs
DM
diabetes mellitus
DNP/DNS do not publish/do not show, patients name will not appear on the
door
DNI
do not intubate
DNR do not resuscitate at all
DOA dead on arrival
DOE
dyspnea on exertion
DST
dexamethasone suppression test
DPL
diagnostic peritoneal lavage
DTP
diphtheria, tetanus toxoid, pertussis vaccine
DTR
deep tendon reflex
DVT
deep venous thrombosis
Dx
diagnosis
Dz
disease
EBL
estimated blood loss
EBV
Epstein-Barr virus
ECG
electrocardiogram
ECT
electroconvulsive (shock) therapy
EDC
expected date of confinement (i.e., date of delivery of baby)
EEG
electroencephalogram
EF
ejection fraction
EGBUS external genitalia, Bartholins, urethra, Skenes glands
EJ
external jugular
EKG
electrocardiogram
EMG electromyelogram
EOMI extraocular movements intact
ERCP endoscopic retrograde cholangiopancreatography
ESR
erythrocyte sedimentation rate
ETT
endotracheal tube

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EUA
F/U
FBS
FEF
FEV1
FFP
FH
FiO2
FLK

exam under anesthesia

follow-up
fasting blood sugar
forced expiratory flow
forced expiratory flow at one second
fresh frozen plasma
family history
fraction of inspired oxygen
funny looking kid; not appropriate in the medical
record
FM
face mask
FOS
full of stool (not in regard to your attending)
FRC
functional residual capacity
FS
fingerstick
FTA-ABS fluorescent treponemal antibody absorption
FTN
finger-to-nose
FTT
failure to thrive
FUO
fever of unknown origin
FVC
forced vital capacity
fx
fracture
GC
gonococcus
GETT general, endotracheal tube (refers to anesthesia)
G-P
gravida, para (pregnancies, deliveries)
GSW gun shot wound
GTT
glucose tolerance test
GU
genitourinary
gtts
drops; drip (gutta)
H/H
Hct/Hgb
HA
headache
HAV hepatitis A virus
HBcAg hepatitis B core antigen
HBIG hepatitis B immune globulin
HBsAg hepatitis B surface antigen
HCG human chorionic gonadotropin
Hct
hematocrit
HCTZ hydrochlorothiazide
HD
hospital day 0, Hodgkins disease
HDL
high density lipoprotein
HEENT head, eyes, ears, nose, throat
Hgb
hemoglobin
HJR
hepatojugular reflex

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HIV
human immunodeficiency virus
HLA
histocompatibility locus antigen
HO
house officer
HOB head of bed
HOCM hypertrophic obstructive cardiomyopathy (same as IHSS)
HPL
human placental lactogen
HR
heart rate
hs at bed time (stands for hour of sleep)
HSM hepatosplenomegaly
HSV
herpes simplex virus
HTN
hypertension
HTS
heel to shin test
I&D
incision and drainage
I&O
intake and output
IDDM insulin dependent diabetes mellitus (Type I DM is the more
accepted term)
IHSS Idiopathic hypertrophic subaortic stenosis (same as HOCM)
IJ
internal jugular
IT
intrathecal
IM
intramuscular
imv
intermittent minute ventilation
INH
isoniazid
INO
internuclear ophthalmaplegia
ITP
idiopathic thrombocyopenic purpura
IUD
intrauterine device
IUGR intrauterine growth retardation
IV
intravenous
IVC
intravenous cholecystogram, inferior vena cava
IVF
intravenous fluid
IVP
intravenous pyelogram
jp
Jackson-Pratt (a type of drain)
JVD
jugular venous distension
JVP
jugular venous pressure
KCl
potassium chloride
KUB kidneys, ureters, bladder (another way of saying Abdominal XRay)
KVO keep vein open
LAD
left axis deviation; left anterior descending (coronary artery)
LBBB left bundle branch block
LCM left costal margin
LCS
low constant suction

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LD
lethal dose; loading dose; lactate dehydrogenase
LDH
lactate dehydrogenase
LDL
low density lipoprotein
LE
lower extremity
LFTs liver function tests
LGIB lower gastrointestinal bleed
LLQ
left lower quadrant
LLSB left lower sternal border
LMP
last menstrual period (usually means the first day of the LMP)
LOA
left occiput anterior
LOC
loss of consciousness; level of consciousness
LOP
left occiput posterior
LP
lumbar puncture
LPN
licensed practical nurse
LR
actated Ringers (solution)
L/S
ratio lecithin/sphingomyelin ratio
LSU
life support unit (name for the VA Emergency Room)
LUL
left upper lobe
LUQ
left upper quadrant
LVEDP left ventricular end diastolic pressure
LVEDV left ventricular end diastolic volume
LVH
left ventricular hypertrophy
m.
murmur
mai
mycobacterium avium-intracellularae
MAC minimum alveolar concentration
MAO monoamine oxidase
MAP mean aortic pressure
MAST military antishock trousers
MCH mean corpuscular hemoglobin
MCHC mean corpuscular hemoglobin concentration
MCP metacarpophalangeal joint)
MCV mean corpuscular volume
Mets
metastases
MgSO4 magnesium sulfate
MGUS monoclonal gammopathy of unknown significance
MI
myocardial infarction
MIAN medical intern admission note
MICU medical intensive care unit
MMR measles, mumps, rubella (vaccination)
MOM milk of magnesia

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MR

mental retardation; metabolic rate; mitral regurgitation; measles,

rubella
MRAN medical resident admission note
MRI
magnetic resonance imaging
Ms
morphine sulfate; mitral stenosis; multiple sclerosis; mental status;
musculoskeletal
MSE
mental status exam
MVA motor vehicle accident
MVC motor vehicle collision (theres no such thing as an accident)
MVP mitral valve prolapse
MVR mitral valve regurgitation
MSPN medical student progress note
NAD no apparent/acute distress
N/V/F/C nausea, vomiting, fever, chills
nc
nasal cannula
NC/AT normocephalic/atraumatic
nd
non-distended
NG
nasogastric
NIDDM non-insulin dependent diabetes mellitus (Type II DM is more
accepted term)
NKA no known allergies
NKDA no known drug allergies
NKMA no known medical allergies
Nl
normal
NPH
neutral prolamine Hagedorn (type of insulin); normal pressure
hydrocephalus
NPO
nothing by mouth
NS
normal saline
NSAID non-steroidal anti-inflammatory
NSR
normal sinus rhythm
NSVD normal spontaneous vaginal delivery
NSSTTWs nonspecific ST, T wave changes
NST
non-stress test (used in OB/Gyn)
Nt
nontender; nasotracheal
NTG
nitroglycerin
nt/nd
nontender, nondistended
OA
osteoarthritis
OB
occult blood; obstetrics
OCP
oral contraceptive pills
OD
right eye (remember - derecho is right in Spanish!); overdose
OKN optokinetic nystagmus

138

OOB
OM
OPV
OR
OS
Ox3
ou
p&pd
PA
PACU
Pap
PC
PCN
PCW
PCXR
PDA
PE

out of bed
otitis media
oral polio vaccine
operating room
left eye
oriented to person, place, and time (times 3)
both eyes or either eye
percussion and postural drainage
pernicious anemia, posteroantero
post anesthesia care unit (same as recovery room, post-op area)
Papanicolaou (vaginal smear for cancer)
after meals
penicillin
pulmonary capillary wedge pressure
portable chest x-ray
patent ductus arteriosus
physical exam; pulmonary embolism or pulmonary edema; pleural
effusion
PEEP positive end expiratory pressure
PERRL pupils equal, round, reactive to light PERRLA pupils equal, round,
reactive to light and accommodation
PFTs pulmonary function tests
PICA posterior inferior cerebellar artery
PID
pelvic inflammatory disease
PIP
proximal interphalangeal joint)
PKU
phenylketonuria
PND
paroxysmal nocturnal dyspnea
PO
by mouth (per os)
POD
post-operative day
pp
post-prandial
PPD
purified protein derivative (TB skin test)
PPN
peripheral parenteral nutrition
pr
per rectum
PROM premature rupture of membranes
pRBCs packed red blood cells
prn
as needed
PT
prothrombin time; posterior tibial (pulse); physical
PTA
prior to admission
PTCA percutaneous coronary angioplasty
PTH
parathyroid hormone
PTT
partial thromboplastin time

139

PUD
PVC
PVD
PWP
q
q4.
qam
qd
qhs
qid
qod
qpm
R/M/G
RA
RAE
RAMs
RAN
RBBB
RCM
RDA
RF
RHD
RLL
RLQ
R/O
ROM
RPN
RPR
RR
RRR
RSV
RTA
RTC
RUL
RUQ
RV
RVH
Rx
s
SA
SAB

peptic ulcer disease

premature ventricular contraction
peripheral vascular disease
pulmonary wedge pressure
each
every four hours
each morning
each day
each bedtime (hour of sleep)
four times a day
every other day
each evening
rubs/murmurs/gallops
rheumatoid arthritis; right atrium
right atrial enlargement
rapid alternating movements
resident admit note
right bundle branch block
right costal margin
recommended daily allowance
rheumatic fever; rheumatoid factor
rheumatic heart disease
right lower lobe
right lower quadrant
rule out
range of motion; rupture of membranes
resident progress note
rapid plasma reagin (test for syphilis)
respiratory rate; recovery room
regular rate and rhythm
respiratory syncitial virus
renal tubular acidosis
return to clinic
right upper lobe
right upper quadrant
right ventricle
right ventricle hypertrophy
prescription pharmaceuticals
without
sinoatrial
spontaneous abortion

140

SBE
subacute bacterial endocarditis
SBO
small bowel obstruction
SC
subcutaneous
SCC
squamous cell carcinoma
SEM
systolic ejection murmur
SGOT serum glutamic oxaloacetic transaminase (same as AST)
SGPT serum glutamic pyruvic transaminase (same as ALT)
SIADH syndrome of inappropriate secretion of ADH
SICU surgical intensive care unit
Sig:
indicating instructions to take medicine as follows (signa)
SL
sublingual
SLE
systemic lupus erythematosus
SOB
shortness of breath
S/P
status post (e.g., S/P cardiac arrest, S/P hysterectomy, etc.)
SPEP serum protein electrophoresis
SQ
subcutaneous
SROM spontaneous rupture of membranes
SSPE subacute sclerosing panencephalitis
SSS
scalded skin syndrome
STAT immediately, if not sooner!!
STD
sexually transmitted disease
sv
stroke volume; supraventricular
SVT
supraventricular tachycardia
Sx
symptoms
Sz
seizure
T
temperature
Tmax highest temperature (usually within last 24 hours)
Tab
therapeutic abortion
T&A tonsillectomy and adenoidectomy
T&C
type and cross match
TAH/BSO total abdominal hysterectomy/bilateral salpingoophorectomy
TB
tuberculosis
TBG
thyroxine binding globulin
TBW total body weight; total body water
TENS transcutaneous electrical nerve stimulation
TFT
thyroid function test
TIA
transient ischemic attack
TIBC total iron binding capacity
tid
three times a day
TKO
to keep open (IV at a slow rate)
TLC
total lung capacity; (tender loving care)

141

TLE
temporal lobe epilepsy
TM
tympanic membrane
TMJ
temporomandibular joint
TNTC too numerous to count
TOB
tobacco
TOPV trivalent oral polio vaccine
TPN
total parenteral nutrition
Tr
trace
TS
tricuspid stenosis
TSS
toxic shock syndrome
TTP
thrombotic thrombocytopenic purpura
TURBT transurethral resection of bladder tumor
TURP transurethral resection of the prostate
TV
tidal volume
Tx
treatment; transplant
u
units (as in Insulin)
UA
urinalysis; uric acid
UCD usual childhood diseases
UE
upper extremity
UGI
upper gastrointestinal (x-ray series)
URI
upper respiratory infection
U/S, US ultrasound
UTI
urinary tract infection
VD
venereal disease
VDRL syphilis test ( Venereal Disease Research Laboratory)
VF
ventricular fibrillation
VLDL very low density lipoprotein
VMA vanillymandelic acid
VSS
vital signs stable
VT
ventricular tachycardia
vzv
varicella zoster virus
WBC white blood count
wnl
within normal limits (or we never looked)
wnwd well nourished, well developed (overused)
WPW Wolff-Parkinson-White syndrome
W/U
workup
x
except
XRT
x-ray therapy
yo
years old
ZE
Zollinger-Ellison syndrome

142

NOTES
aka info you want your class reps to include next year!

143

The End!

144