Medical College Alpha Omega Alpha
Guide to the Clinical Years
Each morning during rounds you will be expected to present patients you have been following. Try to listen closely to the intern or resident presenting in order to get a feel for pertinent information and points to note. Here is a sample presentation for a patient with pneumonia:
Mr. M. is a 54 y/o white male with a past medical history of diabetes on Glipizide and a 20 pack-year smoking history who was admitted yesterday with a fever of 102, shaking chills, shortness of breath, and a cough productive of yellow-green sputum. This morning he noted continued cough, again productive but with no hemoptysis. Also noted was shortness of breath and a fever with chills overnight. Patient noted pleuritic chest pain that is improving this morning. No dysuria and last bowel movement was 2 days ago. AM temp was 100.2 with a Tmax of 102.6, blood pressure 128/82 ranging from 115-130 over 72-84, respirations 20, moderately labored and heart rate 98. Pulse ox 98% on 4L nasal cannula and he was 1.7 liters in and 2.2 liters out over 24 hours. Exam was positive for right lower lobe dullness to percussion, increased tactile fremitus on the right, and bronchial breath sounds with fine crackles over the right lung base posteriorly. No wheezing or rubs. Otherwise, the patient was not cyanotic and had a regular rate and rhythm. White count was 23.5 with 90% neutrophils. At 0500, ABG was 7.46/30/52/84% on room air. House officer was called and patient was placed on 4L oxygen via nasal cannula. Chest x-ray from late last night revealed extensive consolidation of the right lower lobe without pleural effusion; left lung was clear. Sputum revealed numerous gram positive diplococci with polys. Blood cultures pending. Electrolytes and am Accucheck were within normal limits. The patient likely has pneumonia due to Streptococcus pneumoniae. Today's plan is to continue the ceftriaxone (he is on day one), continue 4L oxygen with pulse ox monitoring and re-examine later on this afternoon.
Some things to always include: patient’s age, pertinent past medical history, hospital day, and reason for admission. Next, give a brief description of the overnight course. For physical exam, begin with vitals and pertinent negatives and positives. Add in labs or studies as you see fit. Conclude with your assessment and plan. Students often find that writing their SOAP notes early helps them organize the morning presentation during rounds because you are essentially giving an abbreviated version of the progress note to the team.
Admitting patients will be one of your daily tasks on almost every service of your third year. The following is an example of admission orders.
Mnemonic: ADV CAAN DIML
Admit to 6 Southwest, Dr. Smith's Service
Diagnosis: S/P TAH/BSO
Vitals: q1h x 2, then q2h x 2, then q4h
Activity: OOB (out of bed) as tolerated
Nursing: Foley to gravity, SCD’s (Compression Boots)
Diet: Clear liquids as tolerated
IVF: D5LR @ 120 cc/hr, decrease to 80 cc/hr in am
Meds: Percocet 1-2 tabs po q4-6h prn, Tylenol 325 mg po q6h prn, PCA (patient controlled analgesia.) see attached (usually on a separate sheet in chart), Maalox 30 cc po q6h prn
Labs: CBC in am
- Maxwell Quick Medical Reference - a great quick reference for template notes and exams.
- Epocrates - the most commonly used Palm-based drug reference. There is also an infectious disease program from the same company. Both are FREE, and are wonderful clinical references. This is what most people use their palm pilot for.
- The Sanford Guide to Antimicrobial Therapy - is helpful to carry for everyday anti-microbial look-up.
- Facts and Formulas - is a wonderful reference for formulas, graphs and charts.
- Pocket Survival Guide - series is available for surgery, internal medicine, and OB/GYN. It is good for template notes, but also useful for the respective field.
Last revised: 6/08