UNIVERSITY OF TORONTO

FACULTY OF MEDICINE

SURVIVING CLERKSHIP
A PRACTICAL GUIDE
EIGHTEENTH EDITION 2019

Editors:
Jordan Lewis, Chris Adams-McGavin & Rohan Philip
Class of 2T0

Associate Editors:
Hetshree Joshi and Maham Bushra

Sponsored by:
MD Financial Management
Previous Editors
SEVENTEETH EDITION, 2018
Robin Mawson & Juliet Shao (IT9)
SIXTEENTH EDITION, 2017
Linda Chow & Roland Xu (1T8)
FIFTEENTH EDITION, 2016
Dhruvin Hirpara, Narayan Chattergoon & Marcus Tan (1T7)
FOURTEENTH EDITION, 2015
Pavel Ketov, Alex Wasserman & Jason Woodfine (1T6)
THIRTEENTH EDITION, 2014
Hassan Masoom, Mohammed, Sabri Attia & Nadia Salvo (1T5)
TWELFTH EDITION, 2013
Anthony La Delfa, Erin Thomas Wong (1T4)
ELEVENTH EDITION, 2012
Dahlia Balaban, Erin Spicer (1T3)
TENTH EDITION, 2011
Corey Boimer, Marcus Miller (1T2)
NINTH EDITION, 2010
Alex Cheng, Faazil Kassam (1T1)
EIGHTH EDITION, 2009
Emilie Lam, Akash Patel (1T0)
SEVENTH EDITION, 2008
Emilie Lam, Akash Patel (1T0)
SIXTH EDITION, 2007
Tony Tam, Taryn Simms, Nam Le, Amol Verma (OT9)
FIFTH EDITION, 2006
Charles Kassardjian, June Lee (OT8)
FOURTH EDITION, 2004 (reprint)
THIRD EDITION, 2003
Adam Fleming (OT4)
SECOND EDITION, 2001
Sharmistha Mishra, Evan Propst, Darren Yuen (OT2)
FIRST EDITION, 2000
Jane Vetiska (OT1)

2 / 120 University of Toronto, 2017

Dear 2T1 Clinical Clerks,
The Office of Health Professions Student Affairs (OHPSA) is your confidential,
neutral, safe space for support around your learning environment. Some of the
services offered in house include:

- Personal Counselling
- Career Counselling/advising
- Academic Coaching and support
- Support for Leaves of Absences

We also focus on wellness and mental health and are your go-to place for
everything match/CaRMS. If we don't have what you need in house, we will link
you to other supports within the MD Program, the University, and/or the
community. This could include Accessibility Services, financial support,
housing, harassment and diversity matters, and medical/mental health
services, as examples. Whatever it is, we're with you.

Learn more about us by calling 416-978-2764, emailing ohpsa.reception or

looking at our website www.md.utoronto.ca/OHPSA. Stop in or book an
appointment with us at http://www.md.utoronto.ca/content/book-
appointment.

Our regular office hours are Monday - Friday 9:00am-5:00pm but you can also
book after hours appointments at either St. George or Mississauga. Note our
new downtown location as of July 1, 2018 is Naylor Building, 3rd floor, 6
Queen's Park Cres (north-west side of University and College)

The OHPSA team

Surviving Clerkship: A Practical Guide 3 / 120

TABLE OF CONTENTS
Address from OHPSA……………………………………………………………………………… 3
Table of Contents ............................................................................................ 4
Introduction ..................................................................................................... 6
General Tips for Success in Clerkship ............................................................. 8
Writing Notes ................................................................................................. 10
A. The Admission Note ............................................................................ 10
B. The Progress Note ............................................................................... 13
C. The Surgical O.R. Note......................................................................... 14
D. The Procedure Note ............................................................................ 14
E. The Discharge Summary ...................................................................... 14
F. Dictating ............................................................................................... 15
How to Read a Chart ..................................................................................... 17
Writing Orders and Prescriptions ................................................................. 18
A. Admission/Transfer Orders ................................................................ 18
B. Common Order Pitfalls ........................................................................ 22
C. Ordering Medications ......................................................................... 23
D. Writing Prescriptions .......................................................................... 23
Requesting a Consultation ............................................................................ 25
Anaesthesia .................................................................................................... 27
Dermatology .................................................................................................. 30
Emergency Medicine ..................................................................................... 32
Family Medicine ............................................................................................ 38
Medicine ........................................................................................................ 42
Obstetrics and Gynecology ........................................................................... 50
Ophthalmology .............................................................................................. 62
Otolaryngology – Head and Neck Surgery ................................................... 64
Paediatrics ...................................................................................................... 67
Psychiatry ....................................................................................................... 73
Surgery ........................................................................................................... 84
Appendix A: Other Useful Stuff .................................................................... 97
Appendix B: Frequently Used Abbreviations ............................................... 98
Appendix C: Useful Resources for Clerkship.............................................. 102

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Appendix D: Fitzgerald Academy ............................................................... 104
St. Michael’s Hospital (SMH) ................................................................ 104
Appendix E: Mississauga Academy of Medicine ....................................... 106
Credit Valley Hospital (CVH) ................................................................. 106
Mississauga Hospital (M Site) ............................................................... 107
Queensway Health Centre (Q Site) ...................................................... 108
Travelling Between Sites - Shuttle Bus Services .................................. 109
Appendix F: Peters-Boyd Academy ............................................................ 110
Sunnybrook Hospital ............................................................................. 110
Women’s College Hospital .................................................................... 113
North York General Hospital……………………………………………………………113
Appendix G: Wightman-Berris Academy ................................................... 115
Mt. Sinai (MSH) ...................................................................................... 115
University Health Network ................................................................... 116
General Info for WB Academy .............................................................. 117
Appendix H: Frequently Used Conversions ............................................... 119

Surviving Clerkship: A Practical Guide 5 / 120

INTRODUCTION
This booklet is meant to provide you with a concise guide to the clerkship
experience, as well as tips and suggestions passed on from previous years.
It is an unofficial student-led guide. We have done our best to ensure that
the information in the guide is accurate but may change as the course
structure is updated, especially evaluation/call/schedule details.
The useful resources section is meant as a list of resources only. Guideline
websites are very useful and are always free. We have included costs and
names of a variety of textbooks, however you are NOT, by any means,
required to purchase ANY of these books. Each course has official online
and/or printed resources, which cover the mandatory topics.
We would like to thank the original creators of this guide, as well as the
many people who have provided content since its inception.
We would also like to thank MD Management for generously funding the
publication of this booklet.
We wish you the best of luck in clerkship and hope that you find this guide
useful in your journey!

- The Surviving Clerkship Team

6 / 120 University of Toronto, 2018

If you have any questions about clerkship or specific rotations please
contact your Clerkship Reps or Course Reps listed below:
2T1 Clerkship Reps: Hetshree Joshi
Maham Bushra
Anaesthesia Dong An

Dermatology Matt Ladda

Electives Adriana Dekirmendijian

Jason Zhou

Emergency David Wiercigroch

Family Medicine Alicia Roy

Shivani Patel

Medicine Jeff Smallbone

Sofia Solar-Cafaggi

Obstetrics/Gynaecology Tommy Hana

Julia Hollingsworth

Ophthalmology Ruben Kalaichandran

Otolaryngology Gianluca Sampieri

Paediatrics Kimberly Young

Linlei Ye

Psychiatry Jimmy Tan

Shaoyuan (Randi) Wang

Surgery Lucshman Raveendran

Saly Halawa

TTC / TTR / Portfolio Darby Little

Surviving Clerkship: A Practical Guide 7 / 120

GENERAL TIPS FOR SUCCESS IN CLERKSHIP
1. Always, always be ON TIME – this is the easiest way to impress. Failing
to do so is also the easiest way to stand out and annoy everyone who
has to wait for you.
2. INTRODUCE yourself. Make sure you always take the opportunity to
introduce yourself to all your patients, staff, residents, and allied
health professionals. It’s very easy to become invisible in clerkship.
3. Always be COURTEOUS to the allied health professionals. Read their
notes and learn from them. You’d be surprised where your name pops
up and how quickly students can earn a reputation – good or bad.
You can make notes of names in your phone.
4. When you get PIMPED by your staff or resident, always go back to
first principles and organize your answer in the form of an approach.
For example, for acute kidney injury, think about pre-renal, renal and
post-renal causes.
5. Show INITIATIVE! If you can look up something on your own, look it up
before asking a question. It will show initiative and will save you from
asking “dumb” questions (e.g. “What’s the operation today?” could be
answered by looking in the patient’s chart).
6. Be ANTICIPATORY.
i. Know your patients better than your resident does and keep on
top of all their investigations, issues, and discharge planning.
ii. Begin writing notes before being asked to (e.g. OR notes, chart
notes, discharge notes, prescriptions, lab requisitions).
iii. Take a focused history when you meet a patient.
iv. In surgery: make sure the field is well lit, have suture scissors
ready before being told to cut and suck the smoke/blood.
7. Always carry something to READ in your pocket. Clerkship is busy. Use
your downtime during the day to learn and catch up on studying.
8. Create ME time. It’s easy to become overwhelmed by clerkship and to
give up on things you enjoy in order to catch up with readings,

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 studying and work. Create time for family, friends and a hobby or two
– they’ll keep you from burning out.
9. NEVER FUDGE a finding or an answer to a history question. You can
endanger patients and you’ll lose all trust.
10. NEVER UPSTAGE colleagues (especially at rounds) no matter how
good you think you’ll look.
11. NEVER TALK about patients (or staff) in public areas. It is
unprofessional and you never know who is listening.
12. ASK FOR HELP. You’ll be embarking on a journey packed full of new,
exciting and challenging experiences. Don’t be afraid to ask your
colleagues, residents or staff for help when you need it.
13. VITALS – they’re called vitals for a reason. Pay attention to them! If
the patient appears to be deteriorating (e.g. vitals worsening), call
your resident ASAP and ASK FOR HELP! Never be afraid to ask for
help.
14. USEFUL RESOURCES FOR ANY CLERKSHIP ROTATION. The following
are a list of books that many students find helpful across all the
different rotations. You should preview resources before you buy to
ensure they fit with your personal learning style. More specific books
for each rotation are listed later (also see APPENDIX C for more
resources).
• Toronto Notes
• OnlineMedEd.org
• Tarascon’s Pharmacopoeia (ultimate drug booklet)
• Up To Date –available through U of T Library
• DynaMed – available through OMA as a phone app
• BMJ Clinical Evidence – for therapeutics (evidence based
summaries with links to articles/RCTs)

Go to the comprehensive website: https://meded.utoronto.ca. It has

links to all the courses including lecture notes, announcements, schedules,
and resources.

Surviving Clerkship: A Practical Guide 9 / 120

WRITING NOTES
The two most common notes you will write are the “Admission Note” and
the “Progress Note”. The length and complexity of these notes vary
depending on the rotation. As a general rule:
Admission Note Progress Note
Medicine 2 – 5 pages 1 page
Surgery 1 – 2 pages No more than a few
lines

A. The Admission Note

The admission note generally follows the same format, although some
staff will have their own preferences (e.g. some prefer the PMHx before
the HPI). If available, try to look at an old chart before seeing a patient – it
will help to speed up your history. See specific rotation sections for
sample notes.
Service, Date, Time
Patient ID
No more than 2 sentences, containing name, age, sex, marital/living status
and occupation (+ L/R handedness if on neurosurgery/neurology!)
Reason for Referral or Chief Complaint (CC)
Include BOTH the CC (why the patient came in) and RFR (why the
emergency staff referred them) when applicable. List in one line the
patient’s complaints in their own words, including the duration of each of
these complaints.
Past Medical History (PMHx)/Problem List
This section is important because it will put the rest of your note into
context. For example, back pain in someone with a recent cancer history is
far more important than in a healthy person. The problems may be listed
in two columns: active and inactive. Try to list the problems in order of
importance and relevance to the CC. Most people will put past surgeries

10 / 120 University of Toronto, 2018

under the inactive problem list. Don’t waste a lot of time on exact dates if
those surgeries are unrelated to the Chief Complaint. On the other hand,
make sure to get the dates for surgeries related to the Chief Complaint.
Medications
Always list their current meds with dosage, frequency and compliance.
Ask about “pills,” “drops,” & “creams”. If patients don’t know, examine
any medication bottles they have with them, or check their old chart.
Write down the name and phone number of their pharmacy. The ward
pharmacists will have an easier time verifying the medication. Ask women
if they are taking the birth control pill or HRT. Also, ask about vitamins,
herbal medicines, and over-the-counter drugs.
Allergies
List “allergies”, including medications, food, environmental, etc., and
describe the type of reaction they had. If they do not have any allergies,
write “NKDA” (no known drug allergies).
History of Present Illness (HPI)
Be diligent when taking the history. A good history can often lead to a
diagnosis. Most people will use brief sentences, symbols, and acronyms to
distil the HPI into a more useable form. A general rule is to provide a brief
description of baseline status at the beginning. Next, include pertinent
positives. After this, it is always important to list the pertinent negatives
to rule out other causes of the patient’s complaints. This demonstrates
that you are developing a differential diagnosis. Stick to the history; do
not put any physical exam findings or lab results in this section unless they
are crucial to the story.
LOP3QRSTUVW: Location; Onset; Progression; Palliating; Provoking;
Quality; Radiation; Severity; Timing; How has it affected U?; Déja Vu?;
What do you think it is?
Family Hx and Social Hx
Should be short – stick to what is pertinent to the patient’s immediate
management (exceptions include psychiatry, where it will be longer).

Surviving Clerkship: A Practical Guide 11 / 120

Include IADLs and ADLs if relevant, and any other information that may
affect the discharge plan.
Physical Examination
Always begin by listing vital signs (VS): HR, RR, Temp, BP, O2 Sat. If
relevant, include important physical signs from a previous exam in
comparison to the findings you elicited on your exam (e.g. an asthma
patient’s VS taken by the emergency physician prior to receiving
salbutamol/ipratropium, and then the VS you take as a medicine clerk
afterwards). Begin at the head and work your way down describing your
findings by system. Always perform and write out your physical exam in
the same way – this will make sure you don’t forget anything. An
important part of clerkship is learning the screening physical exam. This
comes with time as you learn what is and isn’t important.
Investigations
Generally, you should divide your “Investigations” section into Labs,
Imaging (X-ray, U/S, etc.), and Miscellaneous (e.g. ECG, EEG, etc.). In chart
notes, lab values are usually recorded in symbol format. The common
formats are listed below (they may differ). To further complicate things,
the formats are not written in stone and people will often put the values
in different spots. In time you will recognize the range of normal values.

Hb ALT
Urea
Na K ALP
WBC Plt Glc AST INR
Cl HCO3 Cr Alb
MCV Bili

* Based on Sunnybrook & Women’s College labs, ALWAYS refer to ranges listed on the specific
result you might be looking at.

Assessment and Plan

You may want to leave this section blank until you discuss the patient with
your senior resident – but make sure you are at least thinking about what
you would write. It is important for you to develop a problem list (if the
patient has multiple problems), and a differential diagnosis for each

12 / 120 University of Toronto, 2018

 problem (listed from the ‘most likely’ to the ‘least likely’) for each
problem. This is the hardest section to come up with on your own, but
with time you will develop a sense of what the plan should be – the plan
should be a numbered list of actions listed under each problem. This
section is where you will have a chance to demonstrate your skills as a
clerk so ALWAYS present it, even if you’re not sure about your
conclusions.

B. The Progress Note

The “SOAP” format is the standard outline for both medical and surgical
progress notes. Title the note as “CC3 Progress Note” and ALWAYS write
the date and time.
Subjective: How the patient feels (i.e. current symptoms) and
what has changed since the previous note.
Objective: Your findings (what the patient is doing, how they
look, physical exam findings, labs, imaging).
Assessment: What the new findings mean and progress made.
Plan: Any changes in management, investigations or
orders that need to be done.
Medicine: A scaled-down version of the admission note. Use SOAP but
also include the current problem list and current meds. Use the problem
list as your “agenda” for the day (i.e. what must be done for the patient).
Surgery: Very brief. Usually written very quickly during morning rounds.
See the Surgery section for a sample.
WBC = 4-11 x109 Eq/L Na = 135-147 mmol/L
Hb = Male 140-174 g/L K = 3.5-5.0 mmol/L
= Female 115-165 g/L HCO3 = 22-30 mmol/L
Plt = 150-400 x 109 Eq/L Cl- = 96-108 mmol/L
Urea = 3.0-7.0 mmol/L Glucose = 4.0-8.0 mmol/L (random)
Creat = Male 62-115 umol/L
= Female 35-97 umol/L
Always watch for the units given! (e.g. glucose 1 mmol/L = 18.02 mg/dL)

Surviving Clerkship: A Practical Guide 13 / 120

C. The Surgical O.R. Note
You will be required to write an OR note at the end of each surgery. It is
the only record of the OR procedure between the operation and when the
dictation service finally distributes your consultant’s detailed operative
note. See the Surgery section for a sample.

D. The Procedure Note

Procedure Notes should be added to the chart after any procedure is
performed on the patient (e.g. bone marrow aspiration, thoracentesis,
LP). The format is similar to the OR note, but not as detailed.
Sample
Procedure: Abdominal paracentesis
Your Name (CC3) / Dr. Resident
2L of fluid was drained from the abdomen under local anesthetic
(list concentration)
No complications. Procedure was well-tolerated.
If a device was added, add a line for lot # and series #
Post-procedure vital signs: BP: 120/60, HR: 72

E. The Discharge Summary

When a patient leaves your service, a discharge summary is written in
order to ensure that future medical caregivers have quick access to the
information they need. Many hospitals have their own templates or online
discharge summaries for you to fill out. You will learn the specific way
your particular team prefers to structure discharge summaries. Start these
early and update them regularly. After a few middle-of-the-night complex
admissions, you will see that a good previous discharge summary can
make life a lot easier.
• Patient Identification: Name, date of birth, MRN.
• Recipients: Make sure that the family doctor and any specialists
involved in the patient’s care receive a copy.

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 • Date of Admission: Under which service and consultant.
• Date of Discharge: Date and length of stay.
• Admitting Diagnosis: Working diagnosis.
• Discharge Diagnosis: Final diagnosis.
• Patient Presentation: Admitting H&P (pertinent details only).
• Problem List: List of identified issues.
• Investigations: Pertinent lab, radiologic or other findings.
• Course in Hospital: The meat of the note. Include treatments,
responses, new issues, procedures, and complications. It’s a good
idea to organize this section into a problem list so it’s easy to follow.
• Disposition: To home, nursing home, with or without home care.
• Discharge Medications: Write which medications are being
discontinued, which medications were modified, and new
medications. Mistakes are often made by lack of communication.
• Discharge Instructions: Be specific about activity level, diet, wound
care, symptoms and signs to report or seek care for (e.g. “call Dr. X if
…”, “go to ER if …”). Anticipate new medication side effects.
• Follow-ups: State EXACTLY what you would like the GP to do – phone
GP if care has been complex or significant follow-up is needed. For
Appointments: write out the doctor, specialty, contact info,
appointment location, and time. If patient is to schedule the
appointment, make sure to include timeframe and method of
communication (e.g. “You are to arrange appointment with Dr. X. at
Hospital Y in 2 weeks by calling 555-5555”).

F. Dictating
As the year progresses, you may be asked to dictate discharge summaries
or clinic visit notes. Each hospital has their own dictating system, which
usually consists of an extension number and a set of numbers that allow
you to pause, rewind, etc. As a clerk, you may not have your own “user
code” but staff or residents are usually more than happy to give you theirs
so that you can gain experience dictating – a very important skill! Again,
there is a lot of variability in how this is done.

Surviving Clerkship: A Practical Guide 15 / 120

Sample Dictation
A general format clinic note dictated as a letter to the family physician:
“This is Clark Kent (spell K-E-N-T), clinical clerk, dictating a general
surgery clinic note on patient John Doe (D-O-E), patient # J0995555.
Copies to the chart, to Dr. Kryptonite, and to the patient’s family
physician Dr. Lane of 55 University Avenue, Toronto, Ontario M5G
1X8.”
“Dear Dr. Lane...I had the pleasure of seeing Mr. Doe in Dr. Kryptonite’s
general surgery clinic today (period) As you know (comma) he is a 63-
year old gentleman with a history of ....
(Include a concise review of history, assessment, and current
management plan)”
“Yours sincerely (comma) Clark Kent (comma) clinical clerk for Dr.
Kryptonite FRCP(C).
End of dictation.”

Be sure to copy down the reference number somewhere in the chart that
is quoted to you at the end of the dictation.
Don’t worry about “uhms” and “aahs” in between your text – the
dictation service employs trained professionals and they will not include
these in the final dictated note. However, you MUST say “period”,
“comma”, “new paragraph” while dictating or your note will be
transcribed as one long sentence. When in doubt, spell out your words
after saying them (e.g. hiatus [H-I-A-T-U-S] – hernia). Remember you can
always pause, rewind, listen to yourself, and correct mistakes (usually by
using the phone dial pad) Ask your residents about the dictation dialpad
commands. Work in a quiet area, and remember that you are dictating
confidential patient information, so make sure you have the appropriate
degree of privacy.

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HOW TO READ A CHART
Reading a chart may seem like an easy thing to do, but you can get easily
bogged down in the details. A good approach to reading a chart can save
you a great deal of time and frustration but your approach will depend on
the situation.
Inpatient
• Read the admission note first. This will give you a good summary of
the patient’s status at the time of admission.
• Read the last note made by the most senior person on your service
(e.g. medicine, general surgery, etc.). This will give you an idea of the
most important issues for your patient from the perspective of the
service that you are on.
• If orders are paper-based, read the last orders to give you a better
idea of current management.
• Read the last progress note. This will give you an idea of the patient’s
current status.
• Check the patient’s vital signs, medications, intake/output (esp. for
surgery services), and scan the nurses’ note.
Outpatient (e.g. clinic)
• Most family practice clinics will have a summary sheet for the patient
at or near the front of the chart. This will give you a quick summary of
the patient’s status and past medical history.
• Read the last note made in the chart. Often, patients will be seen for a
problem and will be asked to follow up in the clinic at a later date.
This gives you a sense of why the patient is in clinic today.

Surviving Clerkship: A Practical Guide 17 / 120

WRITING ORDERS AND PRESCRIPTIONS
One of your common duties as a clerk will be to write orders on your
patients. Any patient being admitted to hospital, being transferred to a
new service, or having their management changed must have orders.
Orders are generally hand-written on the order forms in the chart,
although some sites have undergone the transition to electronic order
entry. Do NOT forget to sign your name with your rank (i.e. CC3)! Always
include the date and time, and try to number your order items. Generally,
your orders will not be carried out unless they are co-signed by your
resident or staff. Nurses may accept your orders for minor things such as
blood work or x-rays, but it is good practice to review ALL orders with an
MD.

A. Admission/Transfer Orders
Most people use the “AD DAVIIDD” mnemonic. Some services and
hospitals use standardized admission order sheets so you can just check
off your orders – verify with your Resident whether this is used.
Standardized order sheets are nice for speed, but they prevent you from
learning and getting used to orders. Make sure you study and would be
able to write the orders from memory.
It is always a good idea to ask yourself WHY each of the checkboxes exists
on the standardized orders. Ask you residents if you are unsure
Admit: Admit to <your service> under <your consultant today>
(E.g. Admit to D4 Team medicine under Dr. X.)
Diagnosis: This is what you suspect they have (e.g. Acute Renal Failure,
Congestive Heart Failure).
Diet: DAT – diet as tolerated (no restrictions)
NPO – nothing by mouth (if going for surgery/procedures)
**Don’t let patients stay NPO longer than necessary!!!
Sips Only – usually if coming off surgery/bowel obstruction

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 Clear Fluids – includes ginger-ale, apple juice
Full Fluids – includes pudding, ice cream
Advancing Diet – NPO to sips to clear fluids to full fluids to DAT
Diabetic Diet – also indicate Calories (1800 Kcal, 2200 Kcal)
Cardiac Diet
Dysphagia Diet
Activity: AAT – Activity as Tolerated (will use 99% of time)
NWB – Non-Weight bearing (Ortho)
FWB – Full Weight bearing (Ortho)
BR – Bed Rest (OB)
BR with BRP – Bed Rest with Bathroom Privileges (OB)
Others – sedentary patients might have ambulation orders,
e.g. “Up in Chair TID”, “Ambulate BID”
Vital Signs: (HR, RR, BP, O2 Saturation, Temperature)
Ask yourself if all vitals need to be done and how frequently?
VSR – Vital Signs Routine (q 8-12 hours, i.e. q shift)
Others – more frequent if patient v. sick (vs q6h, etc.)
– Special parameters (e.g. postural VS, neuro vitals
q1h)
Monitor (not really vitals, but a good place for this)
– Accurate Ins & Outs (surgery, volume status pts.)
– Daily weights (e.g. renal failure, edema, infants)
Investigations: This is the largest section you will write. A simple approach
is to remember that there are five basic areas of investigation: Imaging,
Consults, Cells (Hematology/Cytology), Bugs (Microbiology) and
Biochemistry. For each investigation start from the head and work down
keeping in mind your patient’s disease. Avoid standing orders and if you
need daily investigations specify number of days (e.g. “daily CBC x3 days”).
• Imaging: X-ray, CT, MRI, ultrasound, nuclear, echo, ECG
• Consults: Social Work, SLP, PT, OT, neurology, etc.
• Cells: CBC + diff, PTT/INR, immunology, cytology, CSF cell count

Surviving Clerkship: A Practical Guide 19 / 120

 • Bugs: For this section remember all the things you can culture:
blood, urine, feces, saliva, CSF, pus from wounds; urine
R&M/C&S, gram stain for CSF
• Biochemistry: Electrolytes (Na +, K+, Cl-, HCO3-), Urea,
Creatinine, Ca2+, Mg2+, PO4-, glucose, CSF protein and glucose

IVs: Solution (D5W, 2/3+1/3, NS, Ringers), Rate (cc/hr), Additives (e.g. KCl)
Drugs: This is also a big section. A simple approach is “Past, Present &
Future”. Begin by ordering all the medications the patient is already on
(‘the Past’). Exercise judgment as to which ones the patient still needs. For
example, a bleeding patient doesn’t need aspirin or warfarin. For the
Present, think about what the patient needs right now. They will likely
need an IV but may also need antibiotics, diuretics, anti-arrhythmics and
so on. For the Future try to anticipate what the patient might need. Think
about DVT prophylaxis, sleeplessness, nausea and pain.
Diabetics and DVTs: Accu-cheks, sliding scales, and heparin!
• Mnemonic: Make sure you’ve addressed the “10 Patient P’s”
Problem specific medical issues
Pain: analgesia
Pus: antimicrobials
Puke: anti-emetics, prokinetics, antacids
Pee: IV fluids, diuretics, electrolytes
Poop: bowel routine
Pillow: sedation
PE anticoagulation (e.g. heparin 5000 units sc bid)
Psych: don’t forget about the DTs (delirium tremens) when on
medicine!
Previous Meds
• Alternatively, think of the “7 A’s”
Analgesics Anti-emetics
Antibiotics Anti-inflammatory
Anti-coagulants Autologous (own meds from
Anti-constipation (laxatives) before admission)

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Sample Order
To demonstrate a typical set of orders let’s assume we have a 70 y.o. M
with bright red blood per rectum. This is only an example as different
hospitals and individual staff will have their own specific preferences.
1. Admit to Medicine (14 Cardinal Carter Wing) under Dr. X
2. Dx: Lower GI Bleed
3. NPO (may take PO meds with sips), AAT, VSR
4. Foley Catheter
5. Accurate Ins & Outs
6. Alert MD if U/O < 90cc over 3 hrs
7. Daily Labs x 3 days: CBC, BUN/Cr, lytes, PTT, INR
8. ECG, 3 views of the abdomen
9. GI consult in am
10. Standard bowel prep
11. 2 large bore IV’s (14 or 16 gauge)
12. 1st IV: NS with 20 mEq KCl/L @ 125 cc/hr
13. Saline lock second IV
14. Transfuse 2 units of cross-matched PRBC over 2 hrs with 20 mg
furosemide between 1st & 2nd unit
15. ECASA 325mg PO daily (HOLD)
16. Ranitidine 150 mg PO BID
17. Ativan 0.5mg SL QHS PRN
18. Tylenol plain 1-2 tabs q6h PRN

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B. Common Order Pitfalls
1. Name, Hospital #: Always remember to write the patient’s name in the
upper right-hand corner of the order sheet or stamp that corner with the
patient’s hospital card. Nurses cannot carry out orders unless the patient is
properly identified.
2. Date and Time: Needed to carry out the orders and helps clarify the
sequence in which care is delivered to patients.
3. Allergies: Always remember to write in the allergies or NKDA on EVERY
page!
4. Write Clearly: Hours of work (interviewing, examining, reviewing, and
counselling) can be undone in the few seconds it takes to write an illegible
order that is misinterpreted. Dosing mistakes usually result from bad
penmanship and improper short forms.
• Always use prefix zeros but never use unnecessary or trailing zeroes,
i.e. “.1 mg” (bad), “0.1 mg” (better). “10.0 mg” (bad), “10 mg” (better).
Use “mcg” for microgram doses.
• Try to avoid abbreviations, e.g. OD means “once daily” and also
means, “right eye”.
5. Remember to think ahead: Anticipate problems with regards to pain,
sleeplessness and hydration. It may be worthwhile to order prn meds for
pain, constipation, nausea, and sleepiness at the time of admission. A
simple order written at admission can save you or someone else a call at 2
am.
6. Press hard on the order sheets: You are making a carbon copy that will be
used by pharmacy. Pharmacy will catch your mistakes more than anyone
else so do them a favour.
7. Sign the orders with your name, rank, and pager number so that orders
can be clarified if necessary.
8. If the orders are important, ensure they are seen by the ward clerk or
nurse right away. Regardless, always remember to pull up the “Doctor’s
Orders” flag in the chart.
9. Don’t abuse words like “now” or “stat” – check with your resident.
10. If you are unsure about your orders in any way, make sure to ask
someone.

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C. Ordering Medications
Format and Nomenclature
Drug Dose Route Frequency Duration/Amt
Lasix 40 mg IV q12h
Clarithromycin 500mg PO BID X 10 days
Ativan 0.5 mg SL qhs prn 20 tablets
Tylenol #3 1-2 tablets PO q6h prn 15 tablets

These doses and routes are for illustration only, so check them before
writing orders. You cannot possibly know every drug dose, but you will
come to know those that are commonly used. It is extremely helpful to
have a pocket book with drug dosages. See Useful Resources for Clerkship.
Common Medication Abbreviations
PO By Mouth od Once Daily Q_h Every _ Hours
IV Intravenous daily Once Daily PRN As Needed
SC Subcutaneous BID 2x Daily qhs At Bedtime
SL Sublingual TID 3x Daily ac Before Meals
PR Per Rectum QID 4x Daily qw Every Week
IM Intramuscular

D. Writing Prescriptions
Prescriptions for outside the hospital use the same abbreviations, but with
a slightly different format. Formal prescriptions have the following
structure:
Date
Patient name and Address and/or Date of Birth
• Write out or stamp directly with patient’s hospital card (do not use
stamped stickers)
• Script should have two pieces of information identifying the patient
(patient’s name + address or DOB)

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Inscription (Rx is short for “recipe” or “take thou”)
• Also called the body of the prescription
• Provide the drug name, dosage, route and if relevant the
formulation/dosage form (e.g. suspension, syrup, tablet, etc.)
Subscription (Instructions to the pharmacist)
• Specify the quantity to be dispensed and any special information
• The abbreviation M: (Mitte = “dispense”) is often used here
• For narcotics, write out the amount to be dispensed, e.g. “30 (thirty)”
Signature (Instructions to the patient)
• What you want written on the bottle, to clarify the inscription
• The abbreviation S: (Sig, Signa = “write”) is often used here (e.g.
“apply sparingly to affected area QID”)
Refill Information (# refills, or NO repeats...ALWAYS remember this)
Prescriber’s Signature
(Your signature AND a co-signature from your resident/staff)
*Benzodiazepines and Narcotics
If you are prescribing a benzodiazepine or a narcotic (which are now
controlled substances) you must include a patient ID number (such as an
OHIP number) as well as the physician’s CPSO number. Ask for help if
you’re not sure what you need to do, so that the pharmacy doesn’t have
to call you later to let you know that the prescription was invalid.
Sample Prescription
Date: September 1, 2004
Patient: Mr. John Doe
Address: 1 King’s College Circle
(1) Lasix 40mg PO daily
M: 14 tablets, NO repeats
(2) Fucidin Ointment
M: 30 g, NO repeats
Sig: Apply sparingly to affected area TID
Dr. Ian Taylor

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All prescriptions require a doctor’s signature! If you write a script, sign
your name but then remember to have your resident/staff CO-SIGN it.
For all prescriptions, put a line through any blank space at the bottom so
that the patient cannot add their own medications to the list

REQUESTING A CONSULTATION
Consults are arranged when your team needs an expert opinion (e.g. a
patient admitted under medicine develops acute abdominal pain and a
general surgery consult is requested to find out if it’s a surgical problem).
The details of requesting a consult will vary slightly, but here is a quick,
general approach. Remember to write the order for a consult in the chart
and call it in yourself (check with your resident or staff the first time, as
some services do not permit/expect clerks to request consults).
• Page the RESIDENT on-call that day for the service you need
• Introduce yourself and let them know that you would
appreciate a consultation on your patient
• Give the consultant a brief history of the patient
• Always have a question. Clearly state WHY the consultation is
being requested i.e. “Please assess for condition X / please rule
out condition X” OR “Please advise on the management of
condition X”
• State the level of urgency
• Have the chart handy so that you can answer questions
regarding blood work, specific dates, hospital number, etc.
• You may want to ask the consultant to page you once they
have seen the patient or you can communicate through the
chart
• You may choose to write a brief consult request note on the
CONSULT sheets

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Sample Consult: (if verbal, BE BRIEF & TO THE POINT)
ID: name, age, service admitted under, floor & bed #.
RA: Admitted to service for the following: ______
Reason for Consult:
(1) To answer the following questions: ______
(2) To help manage the following medical conditions or findings: _____
PMH: list of the relevant history.
HPI: This HPI has to do with the reason for the consult. For example,
the patient may have been admitted for pyelonephritis, and on
investigation, was found to have an incidental finding of an adrenal
mass. Tell the consultant the HPI of the adrenal mass. Include relevant
symptoms, labs, etc.
FH, Social Hx: If relevant to the consultant

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ANAESTHESIA
Outline of Rotation
• 2-week rotation
• 2 simulation days at Sunnybrook (usually Day 2 and Day 9)
• 8 mandatory e-modules (two simulation day modules must be
completed before the corresponding sessions)
Useful Resources
• Course manual on Elentra
• Anaesthesia for Medical Students is a comprehensive
companion to the emails (copy available on Elentra)
• Ottawa Anesthesia Primer – for those wishing further reading
at a medical student level
Preparation before the Rotation
• Read the course manual on Elentra!
• Review basic cardiac and respiratory physiology, and narcotic
equivalencies
• Learn about:
• Preoperative assessment (ASA scoring system & Mallampati
scoring system)
• Drugs and common dosages, different types of lines, epidural
vs. spinal
• Basic induction, maintenance, and emergence
• Basic airway management (including airway assessment, which
you should complete on each patient)
• Pain management
• If you are interested in specific areas of anaesthesia (i.e. IV
insertion, OB, pain management, etc.) and if they are available
at your assigned hospital, contact your site coordinator early so
they can organize specific ORs for you
Typical Day
• Ensure that you arrive at the OR on time – typically 07:30

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 • Assist in the OR throughout the day – typically there will be 2-6
cases depending on the type of cases
• Patients are typically outside the OR, or in the preoperative
area prior to the start of the case – try to help complete the
preoperative assessment sheet and the physical exam before
the patient is brought into the OR
• Post-op, assist in transfer of patient to PACU and record post-
op vitals on arrival at PACU
• May have a day rotation on the Pain Service or Preadmission
Clinic
Call
• Generally, NO CALL, but some evening shifts optional
depending on your hospital. Volunteer to be on call with the
site lead if you are gunning for anesthesia. You also learn a lot
on call.
• Evening shifts = ER cases and L&D
General Tips
• Review Pre-operative Assessment and Airway Management in
the Anaesthesia Clerkship Manual on Elentra prior to starting –
really helps!
• On Day 1 – familiarize yourself with the drugs that your
particular hospital uses (take stickers!)
• Let your preceptor know if you are just starting your rotation,
they will often teach your basic skills (setting up a saline bag,
piggy-backing a second bag, etc.) and useful tips!
• Know basic OR protocol
• Check the OR schedule the day before and familiarize yourself
with the cases (you will be assigned to an OR)
• Always introduce yourself to the patient outside the OR or
before induction of anesthesia
• Always introduce yourself to the nurses – they are critical to a
positive rotation
• Take the initiative to fill out the anaesthesia record

28 / 120 University of Toronto, 2018

 • There will be downtime in the OR so go in prepared with
questions
• Be proactive – ask to prepare meds, push meds, place lines,
and do intubations
• Purchase a comfortable pair of shoes – these will be handy for
other rotations too (Surgery, Ob/Gyn). Ideally water proof.
• Dress code is scrubs for the OR. If you are cold, ask a nurse for
an OR gown. Do not bring your own sweater into the OR or
wear full sleeve shirts under the scrubs.
• Do not bring personal bags or handbags into the OR, you are
welcome to bring a notebook or an iPad into the OR.
• All valuables should be kept on one’s person. Everything else
should be placed in secure lockers where provided.
Examination
• MCQ
• Short answer questions
• Key concept questions (choose 4 from a list of approx. 10
options)
• Review “topics for discussions”, e-modules and course manual
• Only need to know drug dosing for ACLS medications
Evaluation
• Written evaluation – 60% [1.5h exam - 40% MCQ, 60% SAQ]
• Clinical evaluation – 40%
Contact Information
• 2T1 Anaesthesia Representative (Dong An)

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DERMATOLOGY
Outline of Rotation
• Four elements comprise the rotation, all during TTC:
• 1) Patient viewing day – a full day consisting of 12 patient,
clinical or procedural stations, each 12 min, facilitated by staff
dermatologists or senior dermatology residents
• 2) Online modules – 2 orientation modules and 10 clinical
modules with 3 short questions after each module
• 3) Clinical note – one of the stations during patient viewing day
will require a focused H&P for a patient who comes in for a skin
check. The following station will be a rest station to provide
time to edit/complete a clinical note, which is submitted at the
end of the day. Note: This station is done as a group, but each
member must submit a separate note.
• 4) Written exam – 40 MCQ, 1-hour exam, includes photos
Useful Resources
• Dermatology syllabus on Elentra
• Online atlas (link on Elentra)
• Optional modules on Elentra
• http://dermnetnz.org
Preparation before the Rotation
• Review the course material from Dermatology week in pre-
clerkship
• Review the course website on Elentra
• Review taking a dermatological history and performing a full
skin exam
Call
• No call
Sample Note
• ID: age, gender, ethnicity, occupation, +/- drug plan

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 • HPI: OPPQRST – Onset; Position (location), Persistent vs.
intermittent; Qualifying factors – pruritus, pain, burning;
Relieving and aggravating factors; Systemic symptoms – fever,
weight loss, arthralgias, GI symptoms; Treatments – prior
investigations and/or treatment(s)
• Past medical history and family history of dermatologic (and
other medical) problems, medications, allergies, exposures
• Physical exam: P-SCALLDA - Skin Phototype; Size of lesion(s);
Colour of lesion(s); Arrangement of lesion(s); Location of
lesion(s); Lesion morphology – primary and secondary;
Distribution; Always check nails, hair, mucous membranes,
intertriginous regions
General Tips
• Do not spend an excessive amount of time taking a history
prior to the physical exam as some symptoms may be better
elucidated after seeing the lesion
• This rotation is very short! Stay engaged during patient viewing
day and use it as an opportunity to ask your station preceptors
questions
• Go into this rotation with the mindset that dermatology is
relevant to your learning and WILL come up on family
medicine, pediatrics, internal medicine, etc.
Examination
• Written exam – 1h x 40 MCQ (80%)
• Clinical note – completed during patient viewing day (20%)
• When studying, refer to the mandatory modules on Elentra
(HIGH YIELD), online atlas (link provided in Elentra) in addition
to the course syllabus – you will need to be able to recognize
the common dermatological presentations; pictures are often
on the exam
Contact Information
2T1 Dermatology Representative (Matt Ladda)

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EMERGENCY MEDICINE
Emergency Medicine is an extremely broad specialty and one that will be
applicable to your career regardless of what path you choose. Whether
you are receiving a consult or advising a patient to go to the emergency
department, being familiar with what is and is not possible in the
emergency department is key. Emergency Medicine is fun and emergency
physicians are some of the most interesting, funny and accomplished
people you will meet – so make the most of this rotation!
Outline of Rotation
• Starts with a 3-day intensive crash course that includes
interactive seminars and hands-on workshops on airways,
chest pain, cardiac dysrhythmias, ED radiology, wound care,
toxicology, trauma, and splinting
• Subsequently, you will have 3.5 weeks of clinical time
• Expect to work two weekends and up to three night shifts
during the rotation
• You will be scheduled for approximately 14 shifts and it is
expected that missed shifts be rescheduled
• Each clerk is assigned 1-2 preceptors for at least 50% of their
shifts
• You will be working with a variety of staff physicians during
your rotation, all of whom play a role in your evaluation
Useful Resources
• Course Manual: The ABCs of Emergency Medicine
• Tintinalli, Judith. Emergency Medicine: A Comprehensive
Study Guide. ~ $230
• Dubin, Dale. Rapid Interpretation of EKGs. ~$50
Preparation before the Rotation
• Since Emergency Medicine is such a broad field, your reading
needs to be equally broad

32 / 120 University of Toronto, 2018

 • Before you get overwhelmed, remember that the goal for you
is not to nail the diagnosis every time but to have a good
approach to the common presenting complaints and to have a
healthy differential diagnosis:

Step 1: Download the course manual, The ABCs of Emergency

Medicine, from Elentra
• Reading this manual will provide you with practical information for
managing ER patients and will function as a useful reference. Exam
questions are taken directly from the manual and the seminar
material.
• The book has a couple of chapters on the “The Symptom Pursuit
Approach”. Try to thoroughly review these chapters before starting
your clinical work. That way you won’t be lost on your first day.

Step 2: Buy a pocket book

• Keep track of the patients you’ve seen, and what
investigations/treatments are pending before their discharge
• Keep track of things you want to read up on.
• Write down summary answers in the pocketbook. That way if you
see the same case again, you don’t have to run around trying to
find a free computer.

Step 3: Other common things you should learn (that will make you
look like a superstar)
• Familiarize yourself with the resuscitation chapters with a focus on
knowing how to clear a C-Spine and the common C-Spine
Precautions
• Canadian CT Head Rules
• The Ottawa Foot, Ankle and Knee Rules
• Know how to do simple interrupted sutures
• Know how to read ECGs (especially for MI, WPW, Afib, etc.)
• Basic chest X-ray interpretations
• Common meds for common problems (e.g. STI, CHF, asthma)
• Other great resources:

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 • See the Emergency Medicine course page on Elentra where
you will find contact info, seminar schedules/notes, and the
clerkship handbook which contains course info and a list of
objectives
Typical Day
• The schedule varies – you may work the day, afternoon, or
night shift (generally 8 hour shifts at most hospitals)
• You will be linked with several nurses
• With the assistance/supervision of a nurse, you should
perform the following procedures: IVs, venipunctures, Foley
catheters, NG tubes, and ECGs
• You may perform other procedures under the supervision of
RTs or the orthopaedic technicians, as available
Call
• No call
Sample Case Presentation
An Emergency Medicine case presentation is very different from an
Internal Medicine or Family Medicine case presentation. From experience,
most physicians have recommended the following order:
• Patient’s Name, Age, and Sex (e.g. Mr. Al Capone, 67M)
• Chief Complaint (e.g. Chest pain)
• PMHx: State the PMHx before the HPI only if it is relevant to the
current presentation (e.g. Hx. of MI x 2, DMII and CAD)
• HPI: State the relevant positives supporting your diagnosis first (e.g.
8/10 retrosternal chest pain with radiation to the left shoulder and
associated with nausea, vomiting, dyspnea and diaphoresis), then
state the pertinent negatives (e.g. I don’t think this patient has a PE
because there was no calf swelling or tenderness, hemoptysis, or risk
factors)
• Physical exam: ALWAYS present the vitals and the general state of the
patient first, followed by the relevant physical exams – in the ER, you
have to learn to be focused so do NOT do a knee exam on someone

34 / 120 University of Toronto, 2018

 who presents with chest pain as it does not matter if they have
arthritis!
• Pertinent labs and imaging: in the ER, nurses will often order blood
work even before you see the patient, so be aware of these results
• Your Impression, Working Diagnosis, and Differential (e.g. M.I. or less
likely causes such as pericarditis, aortic dissection or PE)
• Assessment and Plans: Summarize what you think is the working
diagnosis and any investigations which may help to narrow the
differential
• NOTE: If the patient has presented to the hospital before, review their
old notes before presenting as this can add significant value to your
presentation
General Tips
• The most appropriate dress code is scrubs, though white coats can be
worn over scrubs or business casual dress if desired
• Try to find your supervisor and ask him or her if it’s okay for you to
start seeing patients – this may not always be possible if the staff is
with a patient
• You will see many different presentations during this rotation and you
are not expected to know how to approach each one specifically – it is
recommended that you have a good approach to the following “bread
and butter” scenarios: “dizziness”, failure to cope in the elderly, fall,
headache, chest pain, shortness of breath, abdominal pain
(male/female specific), vaginal bleeding in pregnancy, altered level of
consciousness, allergic reaction, seizure, and shock
• You will be seeing some sick patients – if you are worried about a
patient or a person’s condition deteriorates during your assessment,
find your staff physician immediately
• Ask your staff how long they expect you to spend with each patient
and how they want you to present the patient – staff can have very
different expectations and knowing this beforehand can make life
much easier for both of you

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• When approaching a diagnosis, it is important to think in broad
categories (e.g. GI, GU, CVS, MSK), and have a systematic approach so
you do not miss important findings
• Vitals are called vitals for a reason
• Before seeing the patient, ensure that you review all the
patient’s vitals since they first were seen by medical personnel
• If any vital signs are unstable, let your staff know immediately
before you assess the patient – immediate intervention may
be needed
• If there are non-urgent abnormalities, record them in your
assessment and circle them so you remember to discuss them
with staff – all abnormal vitals should be repeated when you
see the patient
• Remember that there are 5 vital signs: BP, HR, RR, T, SaO2
• Have a general idea of how to interpret ECGs – ER docs are
asked to review these constantly
• Have a plan in place for your patient after you see them:
• Investigations you want ordered
• The differential diagnosis
• The patient’s disposition (home versus admission). Who would
you refer them to?
• Are there programs in the hospital that could help this patient
at home (e.g. CCAC, Geriatric Outreach Team)?
• Reading around cases is important in Emergency Medicine – if
you have Internet access, use eMedicine or UpToDate to
further your understanding on the topic while you are
between patients
• Some ERs have a computerized method to track the time a
patient waits to be seen by specific people – ask your
supervisor whether or not they want you to help keep track of
this information
• Learn how to do simple interrupted stitches and instrument
tie reasonably well before or during the rotation

36 / 120 University of Toronto, 2018

 • Remember to ask to eat if you are hungry – ER shifts can be
very busy, and you need to take care of yourself
• Be very nice to the Emergency Nurses – they can really help
you if you’re interested in doing simple procedures like
starting IVs, obtaining blood samples, bandaging wounds, etc.
Examination
• 1-hour written exam. MCQ, short answers and key feature
questions based on content of course manual and seminars
Evaluation
• Written exam (50%)
• Clinical evaluation (50%)
• Shift evaluation forms filled out by the staff supervisor at the
end of each shift – in total there should be ~13 shift cards
• Observed history and physical
• Your preceptor will provide mid-rotation feedback and should
review your Case Logs progress at the same time
Contact Information
2T1 Emergency Medicine Representative (David Wiercigroch)

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FAMILY MEDICINE
Outline of Rotation
• 6-week rotation
• The first two days consists of centralized core seminars downtown.
• The six weeks are spent at your assigned Family Medicine clinic. You
may have seminars with the other students at your site during these
weeks. You will have mandatory e-modules to complete, which cover
core topics in Family Medicine.
Useful Resources
• American Family Physician Website: very good practice guidelines for
classic Family Medicine problems (access through U of T library).
• Canadian Practice Guidelines: http://www.cma.ca/cpgs/
• Canadian Task Force on Preventive Health Care: practice guidelines on
medical screening (www.canadiantaskforce.ca/)
• DFCM Open: one-page primers on common presentations
(www.dfcmopen.com)
• The Hub: created by Dr. Azi Moaveni, useful resources for common
Family Medicine topics (http://thehub.utoronto.ca/family/)
Preparation before the Rotation
• Scan the Family Medicine chapter in Toronto Notes.
• Get comfortable with general approaches to common issues: e.g.
Hypertension, common infections, diabetes management, chest pain,
abdominal pain, back pain, etc.
• Review your head-to-toe physical exam skills.
• Be familiar with up to date screening guidelines (breast/colon/cervical
cancer, lipids, diabetes, etc.) and immunization schedules.
Typical Day
• Generally, clinics begin at 9:00 am and finish by 5:00 pm (varies by
site). You will typically be assigned to 2-3 preceptors, depending on
your site. You will see patients throughout the day, taking histories,
performing physicals, and assisting with procedures.

38 / 120 University of Toronto, 2018

• Occasionally, you may have shifts during the evening or on weekends
depending on your preceptor’s schedule.
• Some preceptors may also work in other specialty clinics (e.g. sports
medicine, geriatrics, etc.) or do Obstetrics/Emergency shifts.
Call
• Varies by site: some sites have mandatory ER or Obstetrics shifts.
Sample Note
• “SOAP” note: see page 8 for details.
General Tips
• On your first day, ask your preceptor to explain the charting system
they use in the office. With electronic records, it is often helpful to
learn how to use time saving functions like inserting standardized
forms (e.g. Rourke, annual health exam form) or stamps.
• Most charts have a cumulative patient profile (CPP). Before you see a
patient for the first time, scan the CPP quickly for an overview of their
medical problems, meds, FHx, SHx, and screening exams.
• Every time you see a patient, try to write the “assessment” and “plan”
part of your SOAP note before you review with your staff. This is great
practice and forces you to create a clear management strategy on
your own.
• Try and see as many different patient problems as you can. In
academic centres, the staff physicians may have more narrow scopes
of practice, so try and work with a few different preceptors to get
exposure to a larger spectrum of patients and issues.
• Do as many procedures as you can (pelvic exams, Paps,
immunizations, ear syringing, cryotherapy, punch biopsies, etc.). If
you express an interest in doing these things, your preceptor is more
likely to let you try!
• Ask your preceptor to let you write the requisitions and the
prescriptions. It is good practice and it will save your preceptor time.
• Know the practice guidelines published by the CMAJ on common
clinical presentations. Decision making in Family Medicine largely
relies on these evidence-based guidelines.

Surviving Clerkship: A Practical Guide 39 / 120

• Use periodic health exams as an opportunity to practice different
physical examination skills (e.g. fundoscopy). The more “normal”
findings that you’re exposed to will help you better recognize
abnormal pathology in the future.
• Also take the opportunity to practice counselling patients on a variety
of health topics (e.g. exercise, smoking, diet, etc.)
• For Periodic Health Exams:
• Ask about changes in their typical symptoms for their chronic
condition(s).
• Record full functional inquiry and focus on education and health
promotion (sun safety, seatbelt use, water safety)
• ALWAYS ask about new meds or changes in chronic meds. Ask
about over the counter (OTC) meds and herbals also.
• Some EMR systems have stamps for Periodic Health Exams – if
yours does, this can be useful for guiding your history and
physical.
• During well child/well baby visits, record developmental milestones.
Use the Rourke record and/or Nipissing checklist.
• Start thinking about your academic project topic sooner rather than
later. Basing your presentation on a clinical encounter you had will
make the whole process easier.
Examination
• Written exam is during the last week of the rotation.
• Make sure you study the seminar material from the first week, review
topics of the Hub and topics taught in your hospital-based seminars.
Evaluation
• Clinical Evaluation - 35%
• Evidence-Based or Advocacy Project [presentation and write-up] -
15%
• Written exam – 34% [SAQ + key features]
• Clinical Evaluation Exercises (FM-CEX) [4 observed H&Ps] - 16%

40 / 120 University of Toronto, 2018

FM-CEX
• Each FM-CEX is an observed history and physical by your preceptor
that is graded using a standard evaluation form; you have to do one
per week in weeks 2-5 (each worth 4%). You will see all of your CEX
marks at your final evaluation with the Hospital Program Director.

Contact Information
• 2T1 Family Medicine Representatives (Alicia Roy & Shivani Patel)

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MEDICINE
Outline of Rotation
• See Elantra for full details on scheduling, evaluations, and to
find the Orange Book with suggested study topics.
• 8 weeks of Team Medicine with 4-6 ambulatory half days
scheduled between weeks 2 and 7 (site-specific with a fair bit
of variation between sites, pre-assigned, and covering 2-3 sub-
specialties).
• The rotation starts with 2 days of didactic teaching on
common topics in Internal Medicine. These are high-yield
topics that you will see many times on the wards.
• Each site will also have site-specific longitudinal seminar
series, ECG reading and radiology seminars over the course of
the rotation.
• Typically, each hospital has 4 teams, each with a staff
internist, senior resident (PGY-2 or PGY-3), 2-3 interns (PGY-1),
3rd year clerk(s), +/- elective students. Additionally, there is
usually a fifth (Hospitalist) team that does not include clerks,
whose purpose is to consult in the ER during the daytime
hours, so the other teams do not have to.
• Each student is assigned a preceptor to provide informal
feedback and teaching, and to observe your evaluated H&P.
Useful Resources
• Official textbook: Cecil Essentials of Medicine by Andreoli –
~$80
• Useful resources:
• Pocket Medicine: The Massachusetts General Hospital
Handbook of Internal Medicine – ~$65
• Approach to Internal Medicine by Hui (similar to Pocket
Medicine, but Canadian)

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Preparation before the Rotation
• Look through the course website and the Orange Book manual
on Elentra
• Read about the approaches to common presenting
complaints: chest pain, cough, shortness of breath, decreased
level of consciousness, weakness and abdominal pain. Other
important common problems are listed in the curriculum
outline in the Orange Book.
• Develop an approach to interpreting common investigations:
CXR, ECG, PFT, ABG, joint aspirate, CSF, urinalysis/microscopy,
CBC/lytes
• Come prepared (instruments, scrubs)! You will be assigned
patients on the first day and may be on-call the first night.
Typical Day
• 8–9 am Morning Report (some sites have this later in the
day, a few times a week, or do not have it at all): The clerk or
intern presents an interesting/challenging case and the staff
poses questions to the students to facilitate learning/solving
the case.
• Rounds with staff: How often and how long depends on staff.
Also round on the new patients received on-call previous
night.
• Bullet rounds: Rounds with interdisciplinary team
(PT/OT/Pharmacy/SW/RN/RD/CCAC). Management/discharge
planning is discussed during these rounds
• Clinical care: See patients in order from most sick > those
needing discharge > least sick
• Relevant Hx and P/E (ask staff or resident how to focus)
• Write progress note (SOAP format)
• Order/follow up on labs/imaging/consults
• Review plan with senior resident
• Lunchtime rounds: Daily presentations on various topics. All
teaching, including lunchtime rounds, will vary be site. Site
directors will inform you of your teaching schedule.

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 • Teaching: Site and team dependent. The afternoon is also
often used to round on patients or provide clinical care.
• Typically leave by 5:30 - 6:30 pm
• There is gradually increased responsibility on the ward with
students being expected to care for more patients each week
of their rotation.
Call
• Approximately 1 in 4 (including alternating weekends). The
pattern for call days is: Mon-Fri-Sun-Thu-Tue-Sat-Wed
(repeating depending on your start date).
• Students will take overnight call taking consults from the ER
(typically 1-3 per night). There is gradually increasing
responsibility (e.g., covering ward issues typically in week 4) as
the rotation progresses.
• For any consult, find out from your resident the location of the
patient and whether the patient is stable or not. Go eyeball
the patient to double check that the patient is still stable (e.g.
vitals ok, on a monitor), and review previous records (e.g. old
d/c notes, EM note, and already-ordered labs) before formally
going to see the patient.
• Write a full admission note (see example below) and review it
with the senior resident upon completion. Time to review
varies, so use it productively (e.g., study/read around
case/create a management plan).
• Formal presentation to staff/team in the morning followed by
rounding on all new admits. The post call day ends at 10 am.
Maximum time in hospital on call is 26hrs.
Sample Admission Note
1. ID: Age, sex, came from home/institution/street, arrived by
EMS/walk-in/cab. If neuro case, include handedness. Note any
limitations in collecting information (i.e. non-reliable historian).
2. CC and RFR: Include BOTH the CC (why the patient came in) and RFR
(why the emergency staff referred them to Internal Medicine).

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3. PMHx: Present the most pertinent part of the PMHx first. Number
PMHx items from most to least important and report in that order.
Flesh out directly relevant PMHx, including signs/symptoms, any
previous W/U (work-up), disease course, major events, Rx,
compliance to Rx, recent changes in Rx, complications, and F/U
including date last seen by F/U MD.
4. Meds: from patient, family, pharmacist, FamMD or Electronic Health
Record (MiSYS, Soarian, etc.). Rx, dose, route, compliance and when
prescribed.
5. Allergies: include patient reaction
6. HPI: OP3QR2ST2 for all presenting complaints. Begin with onset of
symptoms and proceed chronologically (e.g., course in ER). Discuss
pertinent positives, pertinent negatives, risk factors, constitutional
symptoms. Calculate risk scores where relevant (e.g., PORT, TIMI,
Well’s etc.).
7. SocHx: ADL, iADL, Smoke (how long, how much) / EtOH (how much,
what, how long) / Drugs (IV or not), immigration hx, sexual history,
education & work hx, home & home care.
8. Code Status: Including details on interventions (e.g. chest
compressions, intubation, ICU admission).
9. FamHx: where relevant. Ask about health issues in parents, siblings,
and kids. Ask about FamHx of cancer, CAD, DM, and autoimmune as
appropriate.
10. (ROS): Non-pertinent ROS not listed in the HPI. Often non-relevant
ROS is simply stated as: additional ROS unremarkable.
11. ER Management: Include vitals at triage to the ER, and what was done
for management before medicine was consulted
12. Physical Exam
General Appearance: well or unwell + conditions (i.e. O2 mask, IV w/
meds, etc.).
Other possible descriptors: obtunded, agitated, respiratory distress,
disheveled.
VS: BP (both arms if cardiac pt.), HR (note regular/irregular etc.), RR,
Temp, O2 Sat, pain and pain control. If indicated: orthostatic VS. GCS.
All vitals should be when you visited the patient, not at triage.

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 Cardio: JVP, apex, heart sounds (S1-S4), murmurs. If indicated: bruits,
peripheral swelling.
Resp: inspection (obvious abnormalities), auscultation. If indicated:
percussion, palpation, clubbing.
Abdo: bowel sounds, percussion, palpation, peritoneal signs. If
indicated: organomegaly, CVA tenderness, signs of liver disease, DRE.
Other as indicated: Neuro, MMSE, PVE, MSK, Derm, Ascites, HEENT,
Thyroid, etc.
13. Ix: CBC, lytes, extended lytes (Total calcium, albumin, phosphate and
magnesium), other blood/biochem, ECG, then imaging. If there are
any abnormalities in the CBC, report the MCV and WBC differential. If
current abnormal lab value, make reference to baseline lab values if
available. Circle abnormal results in your notes.
14. Impression: 3-4 summarizing statements including ID, CC, pertinent
findings on Hx, P/E, and Ix. Include working DDx and rationalization.
This section can be organized into issues.
15. Plan: Should address specific issues in impression. Come up with a
problem list. Always remember to include discharge/disposition in
the plan. e.g.:
1) Acute renal failure – DDx, Ix, Tx
2) L knee pain – DDx, Ix, Tx, PT/OT to see
3) Disposition – home when ambulating and Cr stabilized. CCAC to
see.
General Tips
• You should know your patients best. Stay up to date with their
status, concerns, investigation/results, allied health, and
discharge planning.
• Speak up! Make sure you advocate for your patients at
interdisciplinary and team rounds.
• Create an issue/problem list for each patient and a list of
things to do for each patient daily (templates available for
download, e.g. ‘Medfools’).
• Update the team list daily and ask on the first day where the
team list can be edited/printed from (e.g. in EPR).

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 • When you admit a patient, stamp 2 stickers with the patient’s
hospital card – for your staff and senior resident.
• If your patient needs other services (allied health, consults,
imaging, etc.), try to get this arranged as early as possible. All
consults should be made in the morning to ensure the patient
is seen on that day.
• “ALC” means “Alternate Level of Care”, these patients are
awaiting placement and therefore, by definition, should not
have daily blood work or investigations for you to follow. Try
to see these patients briefly every day and do a formal
assessment every 2-3 days.
• When taking over an already-admitted patient, READ THE
CHART! The admission note is usually the most helpful place
to start. Never take what’s in the chart for granted – if you’re
not convinced the diagnosis or management plan is adequate,
consider starting a new workup yourself and ask your resident
about it.
• Check medication orders daily – you’ll be surprised at what
doesn’t get done, despite things being ordered. If you suspect
that there was a medication error, check the Medication
Administration Record (MAR) to assess what your patient has
been given.
• Consider whether your patients require blood work for the
next day and ensure that you place orders before you leave
the hospital.
• A few things to consider on a daily basis that can improve
patient comfort: Need for Foley? D/C if possible; current diet –
can it be advanced or should they stay NPO, etc.
• Discharge planning should start on the day of admission. D/C
summaries should be started early and updated regularly.
• If someone else will be taking over the care of your patient,
write a ‘Transfer of Care Note’ in the chart on the patient’s
course in hospital. This allows a more seamless transfer of
care to the next team member.

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 • Your approach can be based on any categorization scheme
(e.g. anatomy, organ system) – just be systematic!
• Read around topics listed in Appendices 1 and 2 in the Internal
Medicine clerkship curriculum outline (orange manual).
• You will pick up a LOT of random information and clinical
pearls during your rotation. DO NOT try to chase around all of
these clinical pearl tidbits that you hear about every day, just
file them away on a notepad reserved for clinical pearls.
Incorporate them when you come across reading about
relevant examinable topics.
Examination
• Written Exam – 2.5h MCQ, SAQ covering all subspecialties in
IM (30%)
• Clinical Ward performance (30%)
• Ambulatory Clinic evaluation (10%)
• Observed Hx & Px (formative)
• Patient Centered Care Assignment (formative)
• EBM Presentation (5%)
• OSCE - 8 stations (25%)
• 3 standardized patients (Hx only, PEx only, or both)
• 3 clinical vignette stations (one-on-one with a staff, as you go
through a case and outline history, physical exam, DDx,
investigations, management, etc.)
• 2 written stations (CXR and ECG interpretation)
Evaluation
Measure Timing Contribution to Mark
Observed Hx and Px By end of Week 3 Credit / No Credit
Written Exam Week 6 30%
EBM Assignment Week 7/8 5%
PCC Assignment Week 8 Credit/No Credit
OSCE Week 8 25%
Ward Evaluation Ongoing 30%
Ambulatory Clinics Ongoing 10%

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 Case Logs / Ongoing Credit/ No Credit
Professionalism

• *Anticipate the marking scheme to change slightly as this has

not been confirmed yet!
• You must pass both the OSCE and written exam individually to
pass the course.
Contact Information
2T1 Medicine Representatives (Jeff Smallbone & Sofia Solar-Cafaggi)

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OBSTETRICS AND GYNECOLOGY
Outline of Rotation
• 6-week rotation
• Site-specific seminars (each day covers a syllabus topic)
Useful Resources
• Course Syllabus – large compilation of articles and staff-generated
summaries. Very detailed, highly applicable information.
• Essentials of Obstetrics & Gynecology by Hacker & Moore. ~$80
• A must-have for Ob/Gyn keeners, used for the LMCC questions
and highly recommended by the teaching staff.
• Easy to read and great for understanding concepts.
• Also found at hospital libraries.
• Toronto Notes
Preparation before the Rotation
Read at minimum:
• Hx & PE sections (Toronto Notes, Clinical Exam Handbook)
• Progress of Normal Labour, Fetal Heart Tracing in case you are
on call on your first day (Toronto Notes is sufficient)
• Review the course website on Elentra
Typical Day
Gyne
• Round at 7:00 am with Gyne team on in-patients
• Arrive ~15-20 minutes earlier to set up the charts and write
down all vitals (with time taken), urine output, most recent
bloodwork
• Arrange for necessary consults
• Check imaging and blood work on each patient and then
inform the senior resident
• OR +/- academic rounds for the rest of the day
• Usually finish around 5:00 pm

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Labour & Delivery
• Rounding on all complicated vaginal/C-section deliveries (exact
time depends on the site)
• Go to L&D floor, do admissions, triage, follow patients through
L&D
• Usually finish by 5:30 (on-call clerk arrives at 5:00 pm)
Clinics
• Staff dependent, usually start between 8:30-9:00 am (after seminar).
• Some clinics are outside the main hospital building. Ask site
supervisor or check CPSO for locations.
Seminars
• usually every day from 7:30-8:30 or 8:00-9:00 am depending on site.
These are mandatory to attend unless you are post-call.
Call
• 1 in 4-6 overnight call
• Responsible for L&D admissions, deliveries, ER consults, and ward
problems
• Prepare charts (vitals, hgb) for postpartum rounds and help round
• Go home after handover (8 am on weekdays, 9 am on the weekend)
TRIAGE/ADMISSION NOTE TO L&D – Sample
A condensed list to consider when assessing all OB patients, especially
in triage:
1. Fetal Movements
2. Per Vaginal (PV) blood loss (amount and pain, Rh?)
3. Contractions
4. Ruptured membranes?
5. Infectious symptoms (fever, pain) & GBS status
6. Complications in pregnancy (bleeding, u/s abnormalities,
infections, GDM, HTN)
Date and Time
ID: age, GxPx, GA, EDC, GBS, Rh status
CC: contractions, bleeding, leaking fluid, ¯ fetal movement
HPI: ctx time, leaking fluid, bleeding, fetal movement

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 Hx of pregnancy: antenatal screening (bloodwork inc. blood type/Rh
status and serology, genetic screening, anatomy U/S and other U/Ss,
GDM test, GBS result), twins, HTN, infection
OBHx: outcomes of each pregnancy (SA, TA, term/premature,
vaginal/C/S, size of babies, length of labours, complications)
PMHx: routine problem list; HTN, DM, asthma
PSHx: surgeries
Meds: dose and route of admin
Allergies: include reaction
O/E: FHR assessment (baseline FHR, variability, accels/decels,
tocometer contractions)
Position of baby | palpable contractions?
Sterile speculum exam (with resident): nitrazine test, pooling
amniotic fluid, ferning, fetal fibronectin
Vaginal exam (with resident): membrane status | cervix
(effacement, dilatation, position, presentation)
Other relevant features depending upon chief complaint
Investigations:
SROM? (nitrazine, ferning)
Preterm Labour? (fetal fibronectin, cervical length on US),
Fetal status? (U/S BPP)
Impression:
Primip or multip in active labour (or not in active labour) for
admission (or discharge). Try to decide if the pt is in labour BEFORE
you go to the resident.
Plan:
Discharge or admit (if admitting, consider: ARM, oxytocin, epidural,
GBS prophylaxis)
L&D ADMISSION ORDERS – Sample
Date and Time
Admission to L&D under Dr. _______
Diagnosis: Active vs. latent phase labour, antenatal hemorrhage, etc.
Diet – usually as tolerated, but beware of other circumstances
Activity – same as diet

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 Vitals – VSR and fetal heart rate monitoring (if concerned about well-
being, use continuous; otherwise intermittent is sufficient)
IV solution – Ringer’s Lactate/Normal Saline @ 125 cc/hr
Oxytocin (if required) as per hospital policy
Investigations: CBC, group and screen, others if necessary
Drugs: ?Epidural + ? Abx if GBS+
OB PROGRESS NOTE (L & D) – Sample
Date and Time
Subjective: Analgesia: epidural?
Coping?
Contractions – frequency, strength
Oxytocin? Dose?
Exam: FHR assessment (baseline, variability, accels/decels,
tocometer contractions) Cervix (effacement, dilatation,
station, presentation) Fluid quality
Impression: Progress or not, reassuring fetal status or not
Plan: Continue monitoring progress + FHR, ↑ Oxytocin, call for epidural
DELIVERY NOTE (L & D) – Sample
Date and Time
Type of delivery: SVD, vacuum, forceps, C/S
Obstetrician
Assistants
Anaesthesia: epidural, local
Placenta: spontaneous or manual removal, intact, 3 vessels
Laceration/Episiotomy: degree, repaired with XX suture
Infant: live-born male/female child, birth-weight, APGARs
Blood Loss
Counts correct
POSTPARTUM PROGRESS NOTE (Post-Delivery Days 1 & 2 etc.)
Date, Time and Postpartum Day # (PPD)
Type of delivery (SVD, forceps, vacuum, C/S), provide reason for C/S
(repeat, breech, dystocia, non-reassuring FH tracing)
Vitals: “VSS, afeb”

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 Subjective:
lochia (normal is like a period or less, increased, clots), pain
control, voiding, flatus, BM, breastfeeding (Y/N), diet (fluids, DAT),
ambulating
Objective:
Abdo exam – fundus firm at umbilicus
Incision – clean & dry / discharge / drains (amt draining, quality)
Periphery – calves tender, swollen, etc.
Chest exam – prn only (i.e. having chest pain, etc.)
Labs - HgB, WBC
Assessment: Well (or differential diagnosis if problem exists)
Plan: Discharge plan, HgB, mobilize, advance diet
Special tests: CBC, CXR, US, CT, leg Dopplers
GYNE OR Note – Sample
Date + PPP SAFE DISC + Disposition
Date and Time
Procedure
Pre-op diagnosis
Post-op diagnosis (“same” if same as pre-op Dx)
Surgeon, Assistants (residents, clerks)
Anesthesia
Findings à you will learn how to fill this section out with experience,
ask your resident/staff the first few times you do it
Estimated blood loss (EBL)
Drains à do they have any? (Chest tube, Foley, Peritoneal Drain)
Ins and Outs: Total Urine Output (UO) and Fluid through IV (usually
RL or NS)
Specimen: Whatever was sent to pathology (if anything)
Complications/Counts correct?
Disposition à usually “Stable, to PACU”

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GYNE PROGRESS NOTE (ward note) – Sample
Date and Time
Post-op Day (POD) # (or Hospital Day # if not post-op)
Procedure or diagnosis
Subjective:
Pain (controlled? Via PCA or po analgesia, what dose?)
Diet (NPO, fluids, DAT)
Flatus
Voiding (spontaneously, or to Foley) – urine output
Vaginal bleeding: pads count, clots (if appropriate)
Symptoms of hypovolemia (dizzy, lightheaded, SOB, chest pain)
Screen for DVT/PE (CP, SOB, unilateral leg pain)
Objective:
Vitals: “VSS, afeb” i.e. < 38.0
Chest: lungs clear (or not…)
Abdo exam: soft, guarding, tender
Incision: clean & dry / discharge / drains in place (amt draining,
quality of fluid)
Periphery: calves tender, swollen
Labs: HgB, WBC
Assessment: Well POD # (or differential diagnosis if problem exists)
Plan: Advance diet, ambulate, d/c Foley, home
Special tests: CBC, CXR, US, CT, leg Doppler’s
ER CONSULT NOTE - Sample
Date and time
Reason for Referral
ID: XX year old gravida X para XX
HPI OP3Q2R2ST2 - briefly describe main symptom
Past Gyne Hx: LMP (cycle length - e.g. 28days) | contraception |
surgeries | similar problem in past (menarche is not
very relevant in ER)
Past ObHx: outcome of all pregnancies (SVD or C/S), including
complications (may omit if irrelevant)

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 PMHx: Routine problem list. Remember to get details on
serious medical problems if patient is elderly (see
Internal Medicine notes).
PSHx: surgeries, esp. previous abdo surgery.
Meds: Dose and route
Allergies: note what reaction occurs with allergy
Last Meal: (if pt may go to OR)
SocHx/FamHx: FamHx of gyne problems or cancers. Others as
indicated.
O/E: Vitals - (postural if bleeding may be an issue – e.g.
ectopic, DUB)
Abdo - soft | tender | guarding | peritoneal signs |
scars
Chest - lungs | heart sounds | murmurs?
Pelvic - speculum and bimanual (only to be done with
resident)
Investigations: CBC | PTT/INR | Cross & Type | beta-HCG (R/O
pregnancy) | Imaging: Ultrasound / CT (as indicated)
Assessment: Differential Diagnosis and working Dx.
Plan: Enumerated list: more investigations, home, admit,
refer, treatment etc.
GYNE CLINIC NOTE – Sample and Common Scenarios
ID: __ year old gravida ___ para ___
CC:
HPI: OPQRST+UVW + associated symptoms:
• If amenorrhea, primary or secondary? Ask about nutritional
deprivation/increased exercise, double vision/headache, sense of
smell, nipple discharge, short stature/webbed neck, signs of
virilization, hx of radiation/chemotherapy, etc.
• If abnormal uterine bleeding (AUB), ask about signs of
hyperandrogenism (hirsutism, acne), signs of perimenopause (hot
flashes, insomnia, urogenital atrophy, mood disturbance), hx of
blood dyscrasia (vWD, platelet abnormality), hx of thyroid
abnormality? etc.

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 • If dysmenorrhea, ask about dyschezia, dyspareunia (when is it
painful – at insertion, midvaginal or deep?), dysuria, hx of
intrauterine procedures, hx of PID, IUD, etc.
• If infertility, ask about prior reproductive function of each partner,
menstrual cyclicity, coital technique, hx of
PID/endometriosis/surgery, hx of undescended
testes/varicocele/hernia repair, etc.
• If pelvic pain/mass, first r/o pregnancy, then acute vs. chronic?
Ask about sinister symptoms (weight loss, increase abdo girth,
constitutional symptoms, bowel/bladder symptoms), dyspareunia,
symptoms of STI (fevers, chills, discharge?), hx of previous sexual
abuse/assault, hx of uterine prolapse?
• If vaginal discharge/pruritus, ask about discharge (colour, amount,
nature, odour), irritating symptoms, dysuria/dyspareunia, skin
lesions, product use (soaps, tampons, recent Abx)?
Past Gyn Hx: LMP (certain, regular, cycle length), contraception
Sexual Hx (as indicated): number of partners,
men/women/both, new partners, unprotected sex
Age of menarche/ thelarche/ adrenarche/ menopause
Last pap (hx of abn results?) à colposcopy, LEEP, etc.
Hx of STI or STI symptoms STI (cervicitis, PID à any
Rx?)
Hx of hormone replacement (unopposed estrogen?)
Previous gyne procedures or abdominal surgeries
Past Ob Hx: outcome of pregnancy, complications
PMHx/PSHx: problem list / surgeries
Fam/SocHx: hx of ovarian/breast cancer | known BRCA? | Abuse
screen (as indicated)
Meds: Dose and route
Allergies: Allergen and reaction.
O/E: Vitals (postural if concern of major bleeding)
Chest: lungs | heart sounds | murmurs?
Abdo: soft | tender | guarding | peritoneal signs |
scars

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 Pelvic (only to be done with resident or staff)
Speculum: external genitalia | vaginal walls | cervix
(d/c, lesions)
Bimanual Examà cervical motion tenderness | uterus
(shape, size, orientation, tenderness, mobility) |
adnexal mass
Investigations:
• CBC | PTT/INR | beta-HCG (Cross & Type if major bleed)
• W/U for abnormal bleeding: TSH, PRL, FSH, LH, 17-OH prog., DHEA
• W/U for postmenopausal bleeding: pap smear, vaginal/cervical
biopsy, endometrial biopsy +/- hysteroscopy and D&C, pelvic US
(Abn > 5mm)
• W/U for dysmenorrhea: pelvic US, CT
• W/U for infertility: day 3 FSH (N < 10), prolactin, TSH, PCOS
workup, US for ovarian reserve, tests of tubal patency (HSG),
semen analysis
• W/U for pelvic mass: pelvic US, CT
Assessment: Differential Diagnosis and working Dx.
Plan: More investigations, home, admit, refer, Rx, etc.
Rotation Specific Do’s & Don’ts:
General Tips
• Anytime you start with a service, ASK your resident/staff about what
your responsibilities are.
• Be very nice to the nurses. They can TEACH you a lot on this service.
• Volunteer to take blood and put in IVs - this rotation can be a good
opportunity to practice these skills.
• Eat, sit and sleep when you can.
• When on L&D, introduce yourself to every patient that is covered by
your team so that if you have the opportunity to assist in their
delivery, you will be prepared.
• Bring food when on-call. Not many food outlets are open at 3 am.

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• Seminars are at your hospital and are very well done. Exam topics
come from these seminars, but extra details in the syllabus are
sometimes testable. Try to read the syllabus chapter the night before.
• Do a little reading most nights and you will be fine for the exams.
Practice talking aloud in preparation for the oral exam.
• Never complete a pelvic exam without supervision.
OR Tips
• Introduce yourself to the staff and residents when you enter the OR if
you come late (which you often are after morning seminar). Write
your name and level (CC3) on the whiteboard.
• Read the chart before meeting the patient if possible. Otherwise, read
it before scrubbing in. Know the case - focus on anatomy (including
vascular supply) and the specific condition; general principles of the
surgery are important but less so.
• Meet the patient before they go to the OR. Ensure that permission
has been obtained regarding any examinations that may be
conducted on the patient while under GA. If in doubt, ask their
permission yourself. Explain that a pelvic exam might be conducted in
order to help improve your future care of patients. Thank them in
advance for their part in helping make you a better doctor (because
that is what they are doing!).
• Often during elective C-sections, the partner (or support person) is
just waiting to be admitted to the procedure room. If you have the
time, it’s appreciated when you take a few moments to introduce
yourself and talk with him/her.
• Determine if you are scrubbing in. If so, let the OR nurses know and
find your correct glove size and an extra gown if needed.
• Wear easy to clean shoes (e.g. Crocs) OR shoe covers.
• Write the OR note and post-op orders. Ask your resident to co-sign
your orders.
• Practice knot tying and suturing – ask for sutures from the OR to
practice with.
• Volunteer to clean up and transfer the patient at the end of the case.

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Labour & Delivery Tips
• Introduce yourself to the patient as soon as you get to the floor (the
earlier in labour the better).
• Introduce yourself to the nurse in charge of patient. Put your name &
pager # alongside the patient and the staff’s name on the main board.
Ask the nurse to page you when the patient starts pushing or hang
around the nurse’s station when you have a free moment
• Go with your resident for the reassessments of the patient. Try to be
there for the entire ‘pushing’ stage of active labour.
• Assess the fetal monitoring yourself for practice.
• You should be doing most of the delivery of the baby and placenta
(with guidance from the resident/staff). If you aren’t doing this, ASK
to do more with each delivery.
• ASK to get practice at examining for cervical dilation & effacement,
help with the assessments of patients who have epidurals. Once you
are better at it and can do it faster, the resident may then have you
assess patients not on epidurals. It is very important to learn this skill!
• When taking cord blood make sure you:
• Clamp the cord proximally before withdrawing the needle to
avoid blood spurting from the cord
• Keep your fingers on the side of the cord to avoid a needle stick
injury
• Know if it’s the artery or vein! Label appropriately.
• Help the nurses clean up.
• Don’t reveal the sex of the baby unless the parents wish to know.
• Don’t talk about ‘bad medical stuff’ in front of patients. They may
become worried you are talking about them!
• Always ask how the family members are related (congratulating the
new grandmother when she’s actually a new aunt is avoidable).
• If patient comes in with vaginal bleeding, make sure you ask
about recent cervical exams and sexual intercourse.
Ward (Gyne, High Risk) Tips
• Ask the resident what your responsibilities are.

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• To get the most out of the ward experience, read the chart on each of
the patients and know their current status – it makes for a good
learning experience. If you can follow a few patients it is even better.
• Do all the admissions (write the admission notes and orders).
• Don’t just leave if there is nothing going on – tell your resident that
you have finished the work and ask if you can help with anything else.
Inform him/her where you are going if there isn’t anything else to do
at the moment. Page him/her at the end of the day to say you are
done your work and going home if he/she hasn’t told you to do so
already.
Examination
• Written exam, MCQ and short answer
• Based exclusively on content found in the syllabus provided
• Structured oral exam
• 4 case-scenarios; you are asked about assessment and
management of typical cases (e.g. pre-eclampsia, post-partum
hemorrhage, ectopic pregnancy, etc.) Generally, 2 OB topics
and 2 Gyne topics.
Evaluation
• Clinical evaluation (33%) - At least 10 daily encounter forms (7-8 by
staff and 2-3 by residents) that you work with in clinic, OR or on-call.
3-4 forms should be submitted by the midterm evaluation. Try to get
an encounter form from every significant interaction. All of the forms
are used for the final clinical evaluation.
• Written exam (33%)
• As long as you know the manual well you should be set for this
exam.
• Oral exam (33%)
• Observed H&P Form (CR/NC)
• Case Logs Requirements (CR/NC)
• Professionalism Evaluation (CR/NC)
Contact Information
• 2T1 Ob/Gyn Representatives (Julia Hollingsworth & Tommy Hana)

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OPHTHALMOLOGY
Outline of the Rotation
• 1-week rotation, consisting of half/full-day clinics and 1 half-day of OR
• The Ophthalmology course has mostly online lectures. Pediatric
Ophthalmology will take place on the Friday (or Thursday if it is the
week of the exam) at the Hospital for Sick Children
Useful Resources
• Course syllabus
• Elentra
• Harper, R.A. (ed). Basic Ophthalmology. American Academy of
Ophthalmology. 9th Edition. ~$50. This is a very basic review text
geared towards general practice and other non-ophthalmologic
specialties.
Preparation before the Rotation
• Start reviewing the material on Elentra before your clinics. This will
give you a head start on the terminology
• Direct fundoscopy (using direct ophthalmoscope)
• To gain confidence with this skill, make sure you start by
examining a dilated pupil
• A few basic points on how to get a good view of the optic disc:
angle of approach (15 degrees temporal), match the eye you
are looking at (e.g. your right eye to patient’s right eye), make
sure the patient is focusing on a point at the distance and you
aren’t obstructing their view, and get close. Otherwise, it’s all
about practice
• Slit Lamp Exam (anterior segment exam)
• Know the eye anatomy in cross section – this guides you when
you are focusing your slit lamp for various parts of the eye
• Be familiar with the notations for clinic notes (Toronto Notes
Ophthalmology section)

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Typical Day
• Clinics start around 9 am, usually finish by 5-6 pm
• Clinical time split between private offices and hospital clinics,
depending on academy
• Some clinics tend to be more of a shadowing experience if you
are not proactive about asking to participate! Try to use the
ophthalmoscope/slit lamp with as many patients as you can
• Hospitals will have teaching scopes which are very helpful for
getting feedback
• If clerks are interested in taking call or spending time in the OR,
they can arrange this with their site coordinator
No call – unless you’re interested. If so, then ask the residents!
General Tips
• Take advantage of practice time in clinic & become familiar with the
slit lamp, the direct ophthalmoscope, lid eversion, and eye patching.
These are the critical skills to be learned during the rotation - they
apply to general practice and will definitely show up on the exam!
• Some sites recommend that you bring an ophthalmoscope. Try to
borrow one if you don’t have one and need it for clinic. Be sure to
charge it beforehand!
Examination
• Written exam on the same day as OHNS and Anaesthesia at the
end of Week 4 of the Anes/OHNS/Ophtho/ER block.
• MCQs and short answers – know the online cases notes well
• There will likely be a few images to be identified on the exam.
These will be taken from the online notes
Evaluation
• Clinical evaluation (35%)
• Written exam (65%) – 1h duration
Contact Information
2T1 Ophthalmology Representative (Ruben Kalaichandran)

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OTOLARYNGOLOGY – HEAD AND NECK SURGERY
Outline of the Rotation
• 1-week rotation
• Depending on the order of your grab bag rotations, a Friday afternoon
of your 2-week ENT/Ophtho block is reserved for teaching at Sick Kids
and will consist of:
• Paediatric seminars – 1 hour
• Audiology Lecture – 1 hour
• OtoSIM seminar session – 1 hour
Useful Resources
• CPC2 notes
• Course lecture notes and eCases on Elentra, sample exam questions
placed on Elentra. Recap of the Head and Neck Exams:
http://www.entnet.org/EducationAndResearch/The-ENT-EXAM.cfm
• Site specific clerkship handbooks:
http://www.otolaryngology.utoronto.ca/undergraduate/clerkship1/cl
ekship_handbooks.htm
• Otic reference library: www.hawkelibrary.com
• Baylor College of Medicine: http://www.bcm.edu/oto/gr-archive
• Otolaryngology Houston: http://www.ghorayeb.com/pictures.html
• Martindale's The "Virtual" Medical Centre:
http://www.martindalecenter.com/MedicalAudio_2_C.html
• Canadian Society of Otolaryngology - Head and Neck Surgery website:
www.entcanada.org and follow the link for 'Undergraduate
Education'.
• Lee, KJ (ed). Essential Otolaryngology: head & neck surgery, and
Pasha, R. Otolaryngology: head & neck surgery: clinical reference
guide. Both useful as references and are available from the U of T
libraries (Gerstein and Sunnybrook, respectively).
• Toronto Notes

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Preparation before the Rotation
• Reading ahead the preceding weekend or reviewing your CPC2 notes
will help you get the most out of this experience. Reviewing the
physical exam from ICE (or the link above is recommended).
• The syllabus has been thoroughly updated to include notes on Elentra
that can be reviewed before the start of the rotation.
• Visit the course website on Elentra for useful case studies and other
course information.
• Students will get an email from the Department of Otolaryngology –
Head & Neck Surgery regarding their assigned hospital that will
provide details as to where and when to meet on the first day and the
schedule for the week.

Typical Day
• Clinics begin at 8-9 am depending on your site. A few sites will require
you to round on patients on the ward with the residents (typically
start at 7 am).
• The Department of Otolaryngology has put considerable effort into
ensuring that most students are placed in the community. Refer to
Elentra/departmental website (see link above) for the clerkship site
handbook with information about each site including TTC and driving
directions, office locations and contact information.
• Every effort is made to get clerks time in the OR. Speak to your
residents/staff as early as possible if you would like this opportunity
and it has not been scheduled for you.
Call
• No call.
General Tips
• Take advantage of practice time in clinic and become familiar with
nose packing, otoscopy and simple examination instruments. OtoSim,
an otoscopy simulation system, should be available at all sites.
• Exam questions are from the online lecture notes and the audiology
lecture given on Friday. Make sure you focus on these!

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Examination
• 1.5 hour written exam (55 MCQs). Questions are taken directly from
notes. Learn general statistics and risk factors (e.g. most common
thyroid cancer), common things, “what a family doctor would be
expected to know”. Sample questions can be found on Elentra.
Evaluation
• Clinical Evaluation (20%)
• Written Exam (80%) – 1.5h x 55 MCQ
• Case logs: A completed case log summary is required and must be
submitted to the invigilator at the written examination on the last day
of the rotation.
Contact Information
• 2T1 Otolaryngology Representative (Gianluca Sampieri)

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PAEDIATRICS
Outline of Rotation
• 6 weeks at community hospital OR 3 weeks at SickKids (Ward or
Emerg) + 3 weeks at a community office
• 2 days of interactive seminars in the first week
• Depending on site, there are neonatal seminars scheduled.
Useful Resources
• Paeds On-The-Go Handbook: condensed, pocket-sized version of the
syllabus. Provided to students. Everything in it is testable. Great study
guide!
• Course Syllabus: Available on Elentra. Good source of information for
reading around your cases. Don’t feel like you need to know
everything – intended to supplement your clinical experience.
• CLIPP cases: Online interactive paediatrics cases. Each takes 40min-
1hr to complete. A great study resource with printable summaries. All
31 together cover most curriculum requirements. Very high yield for
the exams!
• You must complete 15 CLIPP cases to pass the rotation.
• Textbooks:
• Nelson’s Textbook of Pediatrics: Good source for paeds to read
around cases.
• Goldbloom’s Pediatric Clinical Skills: Physical exam only.
Excellent newborn, ophtho, neuro exams and developmental
milestones chart.
• Handbooks: useful for DDx, when on-call/ER
• Paeds On-The-Go Handbook of Paediatric Essentials
• Mosby’s Care of Pediatric Patient
• Paediatric Emergency Care
• Prasad Pocket Pediatrics
• HSC Formulary
Preparation before the Rotation
• ICE handbook, Pre-Clerkship notes

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• Review pediatric physical exams
• Review immunization schedule
Typical Day
HSC ward (7D, 7B, or short-stay/Streamlined Care Unit) –
brief orientation on the first day
• Start at 7:30 – get handover/new patients from the on-call team.
• Responsible for around 3-4 patients. Daily patient care assigned by
staff/senior resident. Includes seeing patients, writing progress notes,
arranging consults, reviewing labs, etc.
• Family-centred rounds on all patients with the team, then put in
computer orders that need to be done (don't forget to have written
orders co-signed) and write progress notes on your patients. Update
ward list during the day.
• Start discharge summary soon after the patient is admitted. Be sure
the patient is removed from active patient list once discharged.
Arrange to review your progress notes with your senior resident.
• Various 1-hour educational rounds during day (schedule will be given
out at start of rotation).
• All teams have hand-over @ 5 pm to on-call team.
• Home by 6 pm when not on-call.
• Three overnight call shifts (Thursday + Saturday or Friday + Sunday of
one weekend + one other weeknight) during the three weeks @ HSC.
Computer system: (1) KIDCARE – the computer system used @ HSC for all
orders, labs, and investigations. (2) PACS – the imaging system where
reports & images are viewed. Passwords/training are obtained during your
first week.
Community hospital
• Very dependent on different sites and supervisors
• Some sites have ER call or after-hours clinics to attend

Emergency at HSC
• Shift work (some overnight)

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• Separate ER teaching seminars (Thursday morning 8 am - 1 pm, even
if post-shift), includes mock codes at simulation centre (525 University
Ave.)
• There is an orientation for students starting in the ER to learn how to
use the EPR and ER online patient list system (EDIS)
• Brief history (as opposed to detailed Pediatric ward history) to be
documented. Focus primarily on CC/HPI bringing in relevant past
medical history, meds/allergies, social history, and family history. A
detailed developmental, pregnancy/birth, immunization, or
feeding/dietary history may not be needed (unless relevant).
• Brief physical exam to be documented on the ER chart. Given the case
presentation, ensure that the most necessary exams are performed
first whereas others may be left for later or omitted.
Call
• Site dependent
• No more than 1 in 4
PAEDIATRICS ADMISSION NOTE – Sample
ID: 18-month-old male, previously healthy & normal
development
CC: fever x 8 days
HPI: May 4: onset of fever (38.5 C)
May 5: onset of bilateral, non-purulent conjunctivitis and
generalized erythematous rash; visit to family MD ––>
prescribed Amoxil for ?scarlet fever
May 6-10: continued fever, increasing irritability, decreased
appetite, decreased fluid intake, conjunctivitis resolved
today: bilateral hand and foot swelling, feet > hands
(mother unable to put patient’s shoes on)
Ø diarrhea Ø vomiting Ø cough
Ø recent travel
Ø sick contacts
PMHx: previously healthy
Meds: Ø Allergies: NKDA

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 Perinatal Hx: uncomplicated pregnancy
SVD at term
8 lbs. 4 oz.
Apgars 8/9
Ø resus or antibiotics necessary
Ø significant jaundice
discharged home with mom after 36 hrs. in hosp.
Development: appropriate; more advanced compared to siblings
Immunization Hx: UTD (up to date); MMR given March 14
Feeding Hx: 8 to 12 oz. homo milk by cup per day; good intake of
all other foods incl. meats, fruits and vegetables
FHx: Paternal aunt: congenital deafness
Maternal grandfather: osteogenesis imperfecta
SHx: lives in Oshawa with mom, dad and two sisters
mom stays at home with children
dad works as computer programmer
lots of family supports
Ø financial concerns
O/E: VS: T = 39.2 C ax, HR 140, RR 36/min, BP 70/P irritable, Ø toxic
W:10.8 kg (50th %ile); L:83 cm (75th %ile); HC:47 cm (50th %ile)
HEENT: ant. Fontanelle closed, N TM’s, + red reflex, Ø
conjunctivitis, lips and tongue swollen/ erythematous, Ø ulcers,
generalized cervical lymphadenopathy, neck supple
CVS: N S1S2, Ø S3 S4, PPP, cap. refill < 2 sec., well perfused
RESP: good A/E bilaterally, Ø crackles, Ø wheezes
ABDO: +BS, soft, non-tender, Ø HSM, Ø masses
GU: normal external genitalia
DERM: generalized erythematous maculopapular rash, esp. in
groin; palmar and pedal erythema bilaterally, Ø peeling of
fingertips
MSK: generalized non-pitting edema of feet > hands, Ø dactylitis
NEURO: PERRL, reflexes symmetrical, 2+ bilaterally
Ix: Na: 126 Hb: 126 Polys: 9.8 ALP 430
K: 4.2 WBC: 16.4 Lymphs: 4.3 AST 86

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 Cl:32 Plt: 486 Monos: 0.8 ALT 42
EKG: N sinus rhythm, Ø ST changes
Imp: 18 mo male previously well, presents with 8-day Hx of fever
and 4/5 criteria for Kawasaki disease
Plan: 1. Admit to ward __ under Dr. Staff
2. IV 2/3 1/3 with 20 mEq KCl/L @ 50 cc/hr
3. High dose ASA
4. IV Ig
5. Rheumatology consult
6. Echocardiogram tomorrow
Note: The SOAP format used for both medical and surgical progress notes
is used for paediatric progress notes.
General Tips
• Don’t need a paediatric stethoscope
• Have a small (cleanable!) toy that you can attach to your stethoscope
to distract kids or bring stickers to give away
• If a child looks sick, tell someone right away – they can deteriorate
quickly!
• Kids are not just little adults – this can affect case presentation, DDx,
and treatment
• Age of child – tailor your approach (e.g. infant, pre-school/school-
aged child, adolescent)
• Pay attention to medication dosing by weight – have your calculator
handy
• Earning trust – you are a stranger in a strange environment so take
time for your patient to become comfortable with you
• Parent and child – patient history will often have to be obtained from
parents depending on the patient age; keep in mind privacy issues at
all ages and confidentiality in older patients
Tips for presenting a case to staff on ER:
• Prior to meeting with staff, organize H+P into a brief 1-2 minute
snapshot to present, including only the relevant details (not a
medicine case presentation).
• Consider relevant tests (if needed) and treatments.

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• After discussion, typically the staff will review the patient with you at
the bedside and talk with the parent(s).
• Complete all necessary notation on the chart and begin to prepare
discharge sheet (with documented diagnosis, discharge meds,
discharge instructions, and follow-up instructions) to eliminate added
paperwork at the end of shift.
Examination
• On last Friday of rotation
• MCQ, short answer and key feature
• Review seminars, Paeds On-The-Go Handbook, CLIPP cases
• MCQs are based on CLIPP cases
Evaluation
• Clinical evaluation (50%)
• Ward/Community: done by staff (with resident input)
• HSC ER – Cards filled out by each supervisor at shift – averaged
by site supervisor
• Written exam (50%)
• Case Log (credit/no credit): review with staff at midway point
(completed form)
• Observed H&P (credit/no credit)
• CLIPP cases (credit/ no credit): 10 in total must be completed
Contact Information
• 2T1 Paediatrics Course Representatives
(Kimberly Young & Linlei Ye)

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PSYCHIATRY
Outline of Rotation
• Two 3-week blocks in different areas of psychiatry – Inpatient, Consult
Liaison/Medical Psychiatry, ACT team/Emergency Psychiatry, Geriatric
Psychiatry.
• For each block you will be assigned a preceptor. You will work closely
with this preceptor and any resident on the team. Ask your preceptor
what your role is, as a clerk, at the beginning of the block. You will
often see the patient first and then present the case to the resident or
staff.
• Each hospital will have a Personality Disorders Course run by
residents and Interviewing Skills sessions on site. These are very
useful for your everyday duties and are also high yield for the exam
and OSCE!
• One day of core seminars take place in the 1st week. PLUS, you will
have 2 hours per week for “guided” self study over the first 5 weeks
of the rotation
• The OSCE and written exam are on the same day in the final week at a
centralized site.
• You will be responsible for writing up a narrative medicine
assignment. Your first preceptor will grade it. It is due at the end of
the rotation.
• There will be 2-3 Child Psychiatry half-days over the rotation, which
may be off-site (e.g. CAMH, HSC, Hincks-Dellcrest Centre).
Useful Resources
• Psychiatry Handbook: compiled and provided by the undergraduate
committee. Available for free on Elantra.
• Black D.W & Andreasen, N.C. Introductory Textbook of Psychiatry.
Sixth Edition, 2014. (REQUIRED TEXT)
• Best resource to study from, exam questions are based on
information from this book. Contains descriptions of psychiatric
disorders and DSM-V diagnostic criteria

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• Zimmerman, M. Interview Guide for Evaluating DSM-V Psychiatric
Disorders and the Mental Status Examination.
• Pocket book, useful to develop clinical/interviewing skills ~$11
• Diagnostic Criteria from DSM-V Pocket version of DSM-V ~$20
• Goldbloom, D. (ed) Psychiatric Clinical Skills – focusing on clinical
assessment, user-friendly with good teaching pearls ~$54
Preparation before the Rotation
• Read Interviewing and Assessment (Chap 2) of Andreasen text
• Review Mental Status Exam (MSE)
• Review the course website on Elentra
Typical Day
• Inpatient Psychiatry
• Morning report (review patients and management plans with inter-
professional team) – starts around 8-9 am
• Round on patients (interview patients and write progress notes) –
either alone or with resident/staff
• Day ends by around 5-6 pm
• Emergency
• Morning report from 8-9 am
• Assess patients as they are referred to Psych ER (complete history and
MSE, then review with staff)
• Meet with clerk crisis clinic patient – if applicable
• Hand-over to on-call team at 5 pm (review current patients)
• Consultation Liaison (CL)/Medical Psychiatry
• Meet with preceptor – usually at 8:30 or 9:00 am
• Round on patients being followed (on non-psych wards)
• Complete new consults (history and MSE), and review with staff
• Day ends by around 4-6 pm
Call
• Depends on your site, primarily in Psychiatric Emergency Room.
• Starts at 5 pm, officially ends at 11:00 pm.
• Return for morning report/hand-over the next day (8-9 am).

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• You will be expected to stay the full day post-call.
Psychiatric Assessment (Overview)
1. ID: name | age | marital status | living situation | source of income |
reliability of patient as a historian
2. CC/RFR: patient’s subjective complaint and duration (or the specific
reason for the consult)
3. HPI: onset | duration | time course | symptoms | previous episodes |
stressors/triggers | supports | relevant ψ functional inquiry
4. Ψ Functional Inquiry
• Mood: Depression: MSIGECAPS
• Has there been a period of 2 weeks or more when you’ve been
feeling down, depressed or hopeless? Have you lost interest in
things that usually give you pleasure?
• Mania: GSTPAID
• Have you had a period of a week or more when you felt the
opposite of depressed? When your mood was abnormally good,
where you were extremely talkative, had a lot of energy and
didn’t need to sleep but still felt rested?
• Anxiety: BESKIM (GAD), STUDENTS fear the 3Cs (Panic Disorder),
TRAUMA (PTSD)
• Do you consider yourself a worrier? Do you worry more days
than not? Do you experience sudden attacks of anxiety
accompanied by physical symptoms?
• Psychosis:
• Do you ever hear things that other people can’t hear?
• Do you ever see things that other people can’t see?
• Do you think that some people are out to hurt you?
• Do you feel as if you have any special powers or abilities?
• Does the TV, radio or newspaper carry messages that are
intended directly for you?

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 • Organic: substances (see below), dementia (MMSE/MOCA)
5. PψHx: psychiatric hospitalizations | psychiatric contacts | psychiatric
medications | forensic history
6. Safety: suicidal/homicidal ideation | previous attempts | suicide plan
| lethality | supports | children in the home
7. Substances: substance abuse/dependence | last used | known
complications (e.g. DTs, seizures) | HIV, hepatitis | IV drug use
8. Meds: current and previous psychiatric medications | effectiveness |
compliance | all other medications
9. Allergies: allergens and reactions
10. FHx: psychiatric family history (include age and effective medications)
| general medical FHx
11. PMHx: problem list of general medical conditions
12. Past Personal History: education | occupation | relationships |
supports
13. MSE: see below
14. Impression: summary, risk (SI/HI), need for hospitalization,
certifiability, capacity for Rx
15. Multi-axial Assessment: (no longer part of DSM but still used)
Axis I – DSM-V clinical disorders
Axis II – personality disorders and developmental disability
Axis III – general medical conditions that are relevant to the current
mental state
Axis IV – psychosocial and environmental issues relevant to
presentation
Axis V – global assessment of functioning (GAF 0-100)
16. Plan: add or alter medication | behavioural interventions | admit |
discharge. ALWAYS make a plan (even if you’re not sure), ALWAYS
include risk assessment and rationale for admit/discharge
Inpatient Assessments & Notes
• When you first meet the patient, you may be required to do a full
psychiatric history. After that you can use the SOAP method:
ID age | admitting diagnosis if applicable

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Subjective what the patient reports they are experiencing | thoughts
| perceptions | psychiatric functional inquiry
Objective MSE
Assessment impression | multi-axial assessment | interventions that
have been attempted | effectiveness of Rx |
Plan add or alter medication | behavioural interventions |
discharge planning
Mental Status Examination (MSE)
The MSE is essentially the physical exam for psychiatry. The included
mnemonics are useful for remembering components of the MSE.
Appearance age (chronological/appeared) | alertness |
& Behaviour cooperativeness |
dress | grooming | ASEPTIC
distinguishing features Appearance and behaviour
| eye contact | Speech
abnormal movements Emotion (affect and mood)
Speech rate | rhythm | Perception
volume | spontaneity Thought content and process
Insight and judgment
Mood patient’s report
Cognition
(subjective, use their
exact words) | quantify (/10)
Affect examiner’s report (objective) | quality | range (full,
restricted, blunted, flat) | appropriateness to thought
content | intensity
Thought suicidal/homicidal

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Content ideation | ideas/themes |
preoccupations, ruminations | ABC STAMP
obsessions | magical thinking | LICKER
ideas of reference | overvalued
ideas | first rank symptoms Appearance
(TW/TI/TB) | delusions Behaviour
Thought logic | coherence stream (goal- Cooperation
directed, tangential,
Process circumstantial, loosening of Speech
associations, flight of ideas, word Thought content, thought
salad) process
Perception hallucinations | illusions | Affect
depersonalization/ derealisation Mood
Insight patient’s awareness and Perception
understanding of their illness
(give an example e.g. insight poor- Level of consciousness
believes delusions and Insight
hallucinations are due to Cognition
breathing problem) Knowledge base
Endings (suicidal/homicidal)
Judgment patient’s ability to understand the Reliability
outcome of their behaviour and
act accordingly (give an example
e.g. judgment poor- stopped taking medications despite
acknowledging their beneficial effects)
Cognition MMSE or MOCA (if applicable) | alertness and orientation
to time, place, and person

FOLSTEIN MINI-MENTAL STATUS EXAM

Name:___________________________ Date:____________________
Age:____ LOC: alert/drowsy/stupor/coma Examiner:______________
1. Orientation
Year /1 Country /1

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 Season /1 Province /1
Month /1 City /1
Day /1 Hospital /1
Date /1 Floor/Ward /1
/5 /5
2. Immediate Recall: Repeat: Car, Ball, Tree /3
trials until learned: ___ (remind them you’ll ask them to repeat it later)
3. Attention/Concentration
Serial 7s 100 or spell “WORLD” backwards
93 /1
86 /1
79 /1
72 /1
65 /1
/5
5. Delayed Recall: Car, Ball, Tree /3
6. Language
Repeat “No ifs, ands, or buts” /1
Name watch & pen /2
Read “Close your eyes” and do what it says /1
Write a complete sentence /1
Copy design (intersecting pentagons) /1
Take paper with right hand, /1
...fold in half, /1
...and place it on the table /1
/9

TOTAL /30
Psychiatry Discharge Summary
• Ask your staff/resident for a discharge summary template
• Keep it brief, objective, and factual
• Focus on course in hospital and disposition planning

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Clinical Resources
• Most inpatient units and psychiatry emergency services have a social
worker that works as a discharge planner. The social worker has
comprehensive knowledge of all the services available in the area for
patients with mental health issues.
• Toronto has a book similar to a phone book called: The Blue Book:
Directory of Community Services in Toronto. Dial 2-1-1 and a
counsellor will answer the phone 24 hours a day, 7 days a week. Also
see 211toronto.ca.
• Additional community/clinical support programs are often hospital
and regional specific – ask your residents if you need to contact a
specific service.
General Tips
• Interview patients on your own to prepare for the OSCE. Be proactive
- let the residents know you want to take responsibility.
• Always ask about suicidal/homicidal ideation/safety.
• Memorize the common drugs, the basics of the mechanisms by which
they work, and the common and serious side effects. When
interviewing patients, ask about drug side effects and whether
medication is making a difference to specific symptoms.
• When writing notes in ER, include the patient’s social situation and
how they presented in the identifying data (e.g. 23 y.o. male, patient
of Dr. X, brought to ER by girlfriend, accounting student at U of T, lives
with parents).
• Mental Health Forms (e.g. Form 1) can be printed from
http://www.health.gov.on.ca/en/public/forms/mental_fm.aspx
• Be familiar with all components of the MSE.
• Memorize the Folstein MMSE. Introduce it tactfully; e.g. “I’m now
going to ask you some questions to give me an idea of how your
memory and concentration are today.” Another useful test is the
Montreal Cognitive Assessment or MOCA
(http://www.mocatest.org/).

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• Remember that your own safety is your number one priority. Don’t
be afraid to ask for help. You can always leave the room and go back
later when the patient is more cooperative.
• Start reading in the first week and follow the course outline. For
example, the first week is on mood disorders, so read the chapter(s)
on mood disorders.
• Keep on top of your observed history taking! You must complete 6
observed histories through the rotation, half of which have to be with
staff (which can be hard to get done on short notice due to time
constraints).
• Start the narrative medicine assignment early. You will have a seminar
within the first few weeks that goes into what will be expected in it.
This seminar is also a component of the assignment.
Examination
• Find someone who you can practice timed interviews with. The OSCE
is very different from any other rotation and the best way to prepare
is practice, practice, and practice!
• Practice redirecting and interrupting difficult patients - you may need
to interrupt, using their name, and remind them what you’re there to
accomplish and why it’s important. This skill has been commonly
tested on the OSCE.
• For the OSCE and in general, empathy is extremely important. You
may want to use techniques such as summarizing and paraphrasing to
convey to your patient that you have heard what they have said.
• READ THE TEXTBOOK! A few of the questions on the exam may ask for
even more detail than the handbook provides.
• Study the syllabus and lecture notes, as exam questions may be taken
from this information as well.
OSCE Tips
• The OSCE consists of 4 x 15-minute stations. Three stations are
typically 11 minutes with the patient, followed by 4 minutes of a post-
encounter probe with the examiner. There is one modified OSCE
station where you spend 15 minutes with the examiner only.

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• Read the scenario carefully and make sure you do what it asks. You
have 2 minutes to read the stem before you enter the room – write
down important points, DDx, important things to ask (e.g. SI, HI,
safety, MSIGECAPS, other useful acronyms). Do an MMSE if indicated
(e.g. suspected dementia, cognitive impairment from a medical
condition, such as HIV).
• When you enter the room, give the examiner your stickers, wash your
hands, and greet your patient.
• Introduce yourself and your level of education to the patient.
• Do not speak to the examiner – they are not allowed to speak to you
during the interview.
• Look at the patient and comment on unusual things they are wearing
or holding. This shows the patient that you are interested in their
interests, and it may help guide your interview and diagnosis.
• You may wish to jot down brief notes to remind you of what you’ve
covered. Do not write too much as it will slow down the interview.
• Use lay terms when speaking with patients. Save the medical lingo for
the examiner if they ask you for a differential after the encounter.
• Introduce new parts of the interview - this will help you to organize
your thoughts and let the patient and examiner to know where you
are going (e.g. “Now, I would like to learn more about your social
situation.”)
• Folstein MMSE - Some patients may feel that certain questions are
patronizing. You may wish to introduce it with, “I am now going to ask
you some questions that I ask everyone who comes into the hospital.”
• In children screen for ADHD, ODD, CD, psychosomatic illness,
milestones, abuse, and ask who disciplines the child. Say that you’d
like to interview the parents and teachers for collateral information.
• For geriatric patients, screen for dementia, delirium, and depression.
• Pay attention to your patient’s emotions, behaviour and responses
throughout the interview – they can guide you to be more
empathetic.
• If you feel that you are getting stuck, move on. In a brief focused
interview, it is better to touch on many topics than to explore few.

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• If the patient wants to leave the room do not physically restrain them;
remain calm and ask them if they will return. Tell them that if they do
not return, and it is indicated, you will be required to complete a
Form 1 that will require them to remain in hospital for up to 72 hours
for evaluation.
• If the patient has active suicidal or homicidal ideation, admission
should be seriously considered.
• Use the last minute to conclude the interview. This is more important
than trying to fill in small details that you may have missed. If you
finish the interview early, try not to sit in silence - ask more questions.
• The marker will have a long checklist to score your performance on
content and process. Do not get worried if the marker is not checking
things off – they may just do so at the end of the encounter.
Content (the content checklists vary in length/detail)
Process:a) Nonverbal communication /5
b) Verbal communication /5
c) Organization /5
d) Empathy /5
Evaluation
• Clinical evaluation (40%)
• Collaboration between supervisors from your 2 blocks (including input
from residents and allied health)
• Narrative reflective competence (10%)
• OSCE (25%) - 3 OSCEs + 1 Modified OSCE
• Written exam (25%) - done the day of the OSCE at a centralized
location
• 40 MCQs and 5 short answer
• Feedback on exam performance is provided on the last day of week 6
Contact Information
• 2T1 Psychiatry Representatives
(Jimmy Tan & Shaoyuan (Randi) Wang)

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SURGERY
Outline of Rotation
• 8-week rotation that is organized as follows:
• The first week is “Prelude to Surgery” where you will receive
hands-on seminars and problem-based learning sessions on
core surgical topics and an introduction to surgical skills. Based
on clerkship committee meetings, for the 2T1s this week has
been revamped based on student feedback with more
emphasis on hands-on training in person (and didactic learning
independently).
• The last week includes one day of paediatric seminars and the
remainder, for written and oral exam preparation. Attendance
is mandatory for both weeks.
• The 6 weeks in between are divided into 2 blocks, each 3
weeks. One of which must be General Surgery, the other based
on student ranking and matching.
• Each student is assigned to a staff surgeon preceptor for each block
for supervision and evaluation.
• Keep in mind that every academy has a Surgical Education Office that
is there to assist you and guide you through the rotation.
Useful Resources
• NMS Surgery Text & Handbook: Each student is provided a copy to
borrow free of charge from the Surgery coordinators. It is very helpful
for the written exam.
• Pestana, C. Dr. Pestana’s surgery notes – Top 180 vignettes for the
surgical wards. Kaplan medical. Very helpful for the exam.
• Kao, L and Lee, T. Surgery Pre-Test. ~ $32 (A good study aid for the
written exam.)
• Blackbourne, Lorne H. Surgical Recall. ~ $50 (This is a book of “quiz
questions” common in the surgical setting. Useful for studying.)
• Doherty, Gerard M. Current Surgical Diagnosis & Treatment. ~ $92 (A
good general reference for all surgical specialties.)

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• Textbook/atlas/app of medical anatomy (Netter’s, Grant’s, etc.)
• Sherris, DA, and Kern, EB. Essential Surgical Skills. ~ $55 (Picture book
on basic surgical skills such as draping, suturing, and knot tying.)
• Toy, Liu & Campbell. Case Files: Surgery. ~$35 (Contains common
cases in many surgical specialities; great for the oral exam.)
Preparation before the Rotation
• Read the applicable section to your sub-rotation in the provided NMS
textbook and handbook the weekend before you start that sub-
rotation.
• Check out the surgical clerkship webpage on Elentra.
• Read the Technical Skills information on the website prior to starting
the “Crash Course in Surgery”.
• Buy a pocket notebook that can be written in on the run!
• Contact the staff / chief resident / administrative assistant a few days
before the start of each sub rotation to introduce yourself and ask
where and what time to meet on your first day.
Typical Day
• Start at 6:15-7:00 am to round on your team’s ward/ICU patients.
• Arrive 5-15 min early and get patient charts ready. Print out
patient lists for each member of your team. Check the notes
for anything that happened overnight. Check labs, vitals,
ins/outs, new orders. Only if your resident asks you to, record
this in each chart and set up a SOAP note for rounding.
• This is typical for General Surgery but may not apply on other
services; check with your resident.
• Take turns writing SOAP notes in charts with other clerks on
your team to help your team round quickly. Be aware of team
dynamics (i.e. each clerk should able to contribute equally,
regardless of interest in the field).
• Quick progress notes are written as you round – be ready to
write down whatever your senior says.
• On some services, you may be asked to round independently
on patients and review later. Always ask if you’re not sure.

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 • You will need to return to the floor later in the day (or even
several times per day) to deal with any outstanding ward issues
or developments.
• You may or may not be directly responsible for specific patients
like on Internal Medicine. Most commonly the collective team
takes care of all the team’s patients on the floor and ICU.
Therefore, make sure you know all of the patients admitted
under your service/team well.
• After morning rounds, you will go to one of several places, typically
the OR, teaching rounds, clinic, etc. Usually the schedule changes
frequently and it’s best to ask your resident or site admin person.
• In the OR, your role will vary. You should always try to help out
with preparatory work for the patient (e.g. moving them to the
OR table, helping residents with draping, foley insertion, etc.).
Write your name on the board and your glove size(s). If you
know which residents and staff are in the room, do the same
for them.
• If you are not sure how to do something, ASK. The last thing
you want to do is “wing it” and have it be wrong, only for
everyone else to have to re-do it. The same goes for after the
case ends.
• During the operation, your role will vary as well. Make it known
that you are interested in participating and your staff will try to
accommodate you as appropriate. Be aware that the residents
and fellows are also there to learn (albeit to learn skills of a
different level).
• Staff and residents often ask you questions during the
operation. The most common questions are anatomy-related,
so know this in advance. They will also often ask about the
procedure being done. To help prepare for this, check the OR
desk for the next day’s procedures before you go home each
night. Some staff may not ask you questions or engage as
much. If you want to show interest, ask intelligent questions,

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 timed correctly that show you are following the procedure and
can anticipate next steps.
• Always try your hand at writing the post-op note. Even just
setting up the headings and filling in what you know will help
out the residents.
• In clinic, you will see patients and review with your staff. It is to
your advantage to learn to dictate well, succinctly, and clearly
during clinic.
• In any surgical case, if you can demonstrate that you are able
to perform some skill, people will be more inclined to let you
do more and more. Bon the staff and resident you have, and if
it is okay, ask the scrub nurse for instruments before they are
needed (i.e. picking up scissors while the surgeon is tying a
knot). Always ask the nurse for instruments and do not take
them directly from the tray, even if it is right in front of you.
• Your (non-call) days end after whatever afternoon activity you are
doing ends. For OR days, they typically end before 5 pm. However,
you are expected to remain with the residents and deal with any
outstanding post-op or ward issues, etc. Clinic days vary depending on
scheduling. Never head home without checking with your resident.
• Staff are aware that duty hours apply: maximum 12hrs/day or 26hrs
consecutive if on call. They often do not know your call schedule or
when you arrived in the morning. If you are approaching your duty
hours, let a resident or staff know. This can be extremely difficult
given the power dynamic: if your duty hours are not being respected
you can tell the site lead and ask them to send a message to all
preceptors for anonymity (they are on your side)!
• Clinics (new patients and outpatient follow-ups) often start at 8 or 9
am; OR’s start at anywhere from 7:30-8 am – be on time to meet the
patient prior to them entering the OR and so that you don’t miss
opportunities to practice technical skills! (i.e. Foley insertion)
• Sometimes you round with staff in the afternoon.
• Usually finish between 4:30 and 6:00 pm.

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Call
• Usually 1 day in 4 (including 1 weekend day per rotation, so 2
weekend days per month).
• While on-call: consults in ER (after a consult, take 2 stickers with you
for the staff and write when you saw the patient and name of
referring physician), assist in OR on emergency cases, assessment in
trauma cases (SMH/SBK/Sick Kids).
• Home after morning rounds and helping team wrap up any loose ends
(discharge summaries, ordering consults, etc.).
• Some sites will allow you to set your own call schedule with the
residents. If possible, it would be best if you did your call when your
staff is also on call, to get more exposure to him/her.
• Be aware that call nights, particularly at busier sites, are a great
opportunity to get more hands-on experience, as there are fewer
residents/fellows/etc. around overnight to do any emergency cases or
other urgent work.
• At some sites, you may be listed as first call. Always confirm with your
on-call resident regarding how the call shift will be run. The resident
may choose to page you with consults from the ER or other floors,
which you will see yourself and then review with your resident. It is
also possible that you will be expected to field calls first and then
touch base with your supervising resident to determine who will deal
with each issue as they arise. Be prepared to check in with the OR
desk to see when your next case will run if there are cases pending,
and if you are at SMH/SBK/Sick Kids, make sure you inform your
resident/TTL (Trauma Team Leader) to call you for the trauma cases in
the OR and trauma room.
Sample Post-op OR Note – write in patient’s chart after each surgery
*Keep in mind that some staff/residents may ask you to document it
differently. Not all headings below apply to every surgery.
Sept 1/11, 23:00 OR Note
Surgeon: Dr. (staff)
Assistants: Dr. (resident) PGY _/ (clerk) CC_
Anesthesia: General Anaesthesia by ETT, Dr. (anaesthetist)

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 Pre-op Dx: appendicitis
Post-op Dx: perforated appendicitis
Procedure: laparoscopic appendectomy
Estimated Blood Loss (EBL): 150cc (check suction container/ask
anaesthesia)
Findings: none
Specimens: appendix
Complications: none
Counts: correct
Drains: none (i.e. JP, Foley, NG, etc.)
Disposition: to recovery room (PACU) in stable condition
Sample Post-Op Orders (Use “AD DAVIIID” mnemonic)
Sept 1/11, 13:00 Post-Op Orders
Admit: to Ortho Ward 7C under Dr. (staff)
Diagnosis: post-op hip replacement
Diet: sips to ice chips to DAT (Diet As Tolerated)
Activity: AAT (Activity As Tolerated), up in chair, etc.
Vitals: Vital Signs Routine (VSR)/q2h if more concerned
I.V.*: 2/3 D5W + 1/3 NS + 20 mEq KCI/L @ 100cc/hr
Ins and Outs: Please measure precise in’s and out’s
Investigations: CBC, lytes, BUN, Cr. Accuchecks if diabetic.
Drugs: Analgesia: Morphine 5-10 mg SC q3h prn
Tylenol #3 1-2 tabs PO q4h prn
Antibiotic: Ancef 1g IV q8h x24hr
Anticoagulation: Enoxaparin 40mg SC OD
Bowel routine: Colace 100 mg BID with DAT
Antiemetic: Gravol 25-50 mg PO/IV q4h prn
Anti-inflammatory
Patient’s own meds from before admission
* Use the “4-2-1 rule”: 4cc/kg 1st 10kg, 2cc/kg next 10kg, 1cc/kg after
Ask resident for specifics regarding orders for their specialty.
Sample Surgery Progress Note (SOAP note)
ID: 78 yr male POD (post op day) #2 - right hemicolectomy

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 S/ (subjective assessment) good pain control with PCA (Patient
Controlled Analgesia) + flatus, Ø BM yet post-op; feels
hungry
O/ (objective assessment) AVSS (Tmax = 37.2) (Afebrile, Vital
Signs Stable i.e. BP, HR, RR)
good U/O (Urine Output) / suprapubic catheter drained
1200cc
incision ü (incision is clean)/ wound CDI (clean, dry, intact)
BS+, abdo soft, Ø distended
A/P (assessment and plan) - stable
- advance to clear fluids
- D/C PCA and switch to Tylenol #3 1-2 tabs q4-6h prn
- family meeting today re: disposition
Sample Consult Note
ID: 40yr male construction worker previously well
CC/RFR: Abdo pain ?appendicitis or hepatitis
HPI:
a. pain—use OPQRSTUVW from ICE
b. nausea/vomiting, last meal, character of vomitus
c. gas/bowel movements
d. bleeding?
e. fever/chills/sweats/weight loss, other constitutional
symptoms
f. pruritis/jaundice/dark urine/pale stools/etc.
Past medical/surgical Hx
Meds
Allergies
Physical exam:
a. vitals—specific numbers, not just AVSS here
b. focused exam, including quick cardio and resp exams
Labs, imaging
Impression and plan: come up with something and review with the
resident. Don’t worry if you’re wrong – the residents are
there to teach you too!

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Sample Admission orders: similar to post-op orders
Sept 1/11, 13:00 Admission Orders
Admit: to (Surgical service) under Dr. (staff)
Diagnosis: e.g. appendicitis, septic arthritis of R knee
Diet: (NPO if need surgery soon)
Activity: AAT (Activity As Tolerated), up in chair, etc.
Vitals: Vital Signs: specify frequency
I.V.*: 2/3 D5W + 1/3 NS + 20 mEq KCI/L @ 100cc/hr
Ins and Outs: Please measure precise in’s and out’s
Investigations: CBC, lytes, BUN, Cr. Accuchecks if diabetic.
Drugs: Analgesia: Morphine 5-10 mg SC q3h prn
Tylenol #3 1-2 tabs PO q4h prn
Antibiotic: Ancef 1g IV q8h x24hr
Anticoagulation: Enoxaparin 40mg SC OD
Bowel routine: Colace 100 mg BID with DAT
Antiemetic: Gravol 25-50 mg PO/IV q4h prn
Anti-inflammatory
Patient’s own meds from before admission
* Use the “4-2-1 rule”: 4cc/kg 1st 10kg, 2cc/kg next 10kg, 1cc/kg after
Ask resident for specifics regarding orders for their specialty.

General Tips
• ALWAYS BE FIVE MINUTES EARLY FOR EVERYTHING! Surgery teams
are very busy, and scheduling is very tight. This will have an impact on
both your experience and your evaluations.
• Try to attend as many of your supervising surgeon’s OR’s and clinics
as possible, so they can get to know you, assess your progress, and
tailor your experience to your interests. If you need to be away, be
sure to inform your supervisor ahead of time. Seek feedback from
them and more importantly, realize when they are giving you non-
formative feedback. Keeping the above in mind, don’t be afraid to
‘drop-in’ on other OR’s and clinics (if there is room) to explore the
specialty and areas of interest. This is best organized with the help of

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 your senior resident. Getting the most out of your surgery rotation is
on you – be proactive in arranging clinics and ORs.
• While you are in a patient room during morning rounds, read the
chart of the next patient on the list so that you will be able to quickly
comment on the vital signs, in’s & out’s, etc.
• Volunteer to be the scribe of daily ward rounds notes and pay careful
attention to what your resident evaluates each morning.
• Check the next day’s OR schedule and try to review the procedure,
the anatomy involved, possible complications, etc., so that you can
anticipate the next moves and be able to answer questions.
• Ask your resident(s) early on if you’re not sure of how things work at
your site. Often there is already an established role for the clerk at
morning rounds and it’s best for everyone if you learn this fast.
• Be proactive; ask to learn procedures and do things. People are
usually happy to try to accommodate you if the situation permits. You
will gain a lot more from your rotation this way.
• Work with the residents and the other clerks to divide up work and
experiences fairly; expect to help out with some of the “Scut."

Common ward work and general tips:

• Requesting consults from other services, checking lab work and
imaging, dealing with ward issues, and writing discharge
summaries.
• ER consults and patient assessments when you are on-call.
• Get enough sleep, wear comfortable shoes, and always carry food.
• If residents, fellows, or staff offer you a break or tell you to go home,
DO IT. Likewise, if there are too many learners in an OR, don’t be
afraid to ask to step out and study – but stay nearby and available!
• Be respectful and courteous to nurses and all healthcare workers in
the OR and on the wards:
• Introduce yourself and write your name/level of training/glove
size on the OR whiteboard.
• Pull out your gloves for the RN in the OR, offer to put in Foley
catheters (once comfortable doing so), etc.

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 • Clean up after your procedures. Never leave sharps out!
• If you feel ill or too tired to contribute or be safe in the OR, tell your
supervisor and step out.
• NEVER fake/lie about a finding; it’s always best to be honest and
admit when you don’t know something
• Cooperate with the other clerks on your team to ensure equal access
to scrubbing-in, etc. Make sure you don’t try to ‘out do’ them by
showing up earlier than them, etc. You will only make yourself look
bad! Agree on a clerk start time and stick to it.
• When doing a physical or a procedure, make sure that both YOU and
the PATIENT are comfortable with the arrangement and setting.
• Practice tying one-handed knots when you can; all you need is thread.
You’ll learn how to do so during the Crash course. If you’re scrubbed
and not doing much, ask for a tie and practice tying knots (just make
sure you’re still following the operation and not in the way).
Competency in this will certainly impress and incline others to let you
do more.
Receiving requests from the wards (e.g. from RNs)
• On the phone:
• Patient name/MRN/location
• What is the issue?
• Current vitals – ask for it if not available
• When you go see the patient:
• Reason for admission
• What procedure was done, if any
• What was the condition at AM rounds?
• Eyeball the patient: stable or not?
• If unstable, get help and ABCs
• Take BRIEF history of the new complaint
• Do a BRIEF and FOCUSED physical exam + vitals
• Make a plan and review with your resident

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Preparation for OR days – know these BEFORE going into the OR
• What procedure and why? You can find an OR list the night before
from:
• The surgical ward nursing station
• The OR front desk
• Your supervisor’s office
• Past medical history
• Possible complications
• Patient allergies
In the OR
• You must wear: Mask, cap, scrubs, OR-appropriate shoes (closed toe,
ideally waterproof) or shoe covers. Optional (but recommended): eye
protection (face shield, goggles etc.)
• NO lab coats past the OR front desk
• NO extra bags etc. in the OR. Avoid bringing things you can’t fit
in your pockets.
• Bring a pen to write notes and orders.
• Scrub-in only after you have ASKED the STAFF if it is okay to do so.
Sometimes it is better to not scrub to see more; this is your staff’s
discretion.
• Ensure the RNs have a gown for you and your gloves ready
• Scrub properly – they will show you during lecture week
• Don’t forget to “turn yourself” to tie the waist-cord on the
gown
• Most common clerk tasks: adjust lighting; cutting sutures; suctioning;
retracting; suturing/stapling/other wound closure; maintaining sterile
technique.
• You are encouraged to ask questions WHEN APPROPRIATE. Use your
judgement, e.g. if there is a nicked aorta that is bleeding profusely
and everyone is scrambling to deal with it, do not ask questions then!
In Clinic
• New patients: <10 minutes

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 • Read the referral note – what is the chief complaint, and what
investigations have been done?
• Take a brief and focused history
• Do a focused physical exam
• Come up with a differential diagnosis and plan
• Review with your staff: keep this CONCISE. They will ask you
questions if you are missing something, and they will fill in
remaining gaps with the patient themselves. Surgeons do NOT
want case presentations the way internists and psychiatrists
do!
• Post-op follow-up patients (very quick visit):
• Read the chart and find out what happened and when
• Review pathology findings
• Review most recent clinic visit
• Take a brief interim history
• Do a brief focused physical exam, paying attention to possible
post-op complications
• Write a SOAP note and present to your staff CONCISELY.
Consults
• On the phone, get the following:
• Patient name/MRN/location/gender
• Reason for referral
• Stable or not? Most recent vitals. Is this urgent?
• Think of a plan.

• Consider AMPLE history if urgent OR:

• Allergies
• Meds
• PMHx
• Last meal
• Events leading up to current problem (i.e. focused)
• If in the ER: read emergency notes and past records.

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Examination
• Common things are common; know common complaints. Some are
covered in the seminar series, but this is not complete. Treat it as an
introduction.
• You are expected to read beyond the material given.
• The material on the website may not be the same as what
lecturers present; however, the content will be similar. Faculty
are encouraged to go through cases in their lectures.
• Major topics are General Surgery, Urology, Neurosurgery,
Orthopaedic, Thoracic, Cardiac, Vascular and Plastic Surgery.
• Start EARLY as there is a lot of material to know.
• Use the NMS study guide and casebook provided by the faculty
for your exam.
• Use clinic visits and consults as practice for your oral exam.
• For the exam, read Pestana’s first, then read “Surgery, a case-
based approach” by De Virgilio and do pre-test questions last.
Evaluation
• Final grade is based on the written exam, structured oral exam, and
clinical/ward evaluation. Each component is weighted equally (33%)
• Mastery Exercise – 50-75 questions over 2h
• Oral exam – 2 stations, 20 minutes each (not necessarily in
consecutive order). Part 1 will be a focused H&P relevant to the
patient’s primary problem and then present a summary of your
findings to the examiner. Part 2 will be 3 structured oral exam
questions
• To pass the course, you must pass both the oral and written exam and
receive a passing grade (60%) on the ward evaluation.
• You will also have centralized OSCEs that will include surgical stations
among other disciplines as part of your overall clerkship
Contact Information
• 2T1 Surgery Representatives (Lucshman Raveendran & Saly Halawa)

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APPENDIX A: OTHER USEFUL STUFF
The Doctor’s Letter of Condolence
The New England Journal of Medicine, April 12, 2001 Vol. 344, No. 15
A letter of condolence from a doctor may have a special meaning for a
family in mourning. It may help the family as they move through the
natural phases of grief. It may also help to alleviate some of the
physician’s personal feelings of grief or distress about the event. A letter
of condolence appears to be more effective than a telephone call, for it
enables the family to reread your words at their own leisure. Obviously,
the condolence letter is meant to be genuine, and so the purpose of the
following outline is merely to assist you in your writing.
• Avoid superficial attempts such as “it was meant to be”, or “I know how
you feel”.
• To avoid the issue of legal liability, the letter should focus on the
sadness of the death, rather than revisit the clinical details of the
illness.
• Begin the letter with a direct expression of sorrow, such as: “I am
writing to send you my condolences on the death of your husband.”
• Try to include a personal memory of the patient and something about
the patient’s family or work, such as devotion to family, courage during
the illness, or speak of the patient’s character traits that left an
impression on you. This will help to bring the letter to life.
• Explain that it was a privilege to participate in the patient’s care
• Point out the comfort the patient received from the family’s love.
• Conclude with a few words of support to let the family know your
thoughts are with them.

“After a patient dies, when we all feel helpless, the best care we can
provide is our expression of concern and sympathy in a letter of
condolence”
– Susanna E. Bedell, NEJM 2001

Surviving Clerkship: A Practical Guide 97 / 120

APPENDIX B: FREQUENTLY USED ABBREVIATIONS
A BS Bowel Sounds, Breath
Sounds, Blood Sugar
AAT Activity as Tolerated
ABG Arterial Blood Gas BUN Blood Urea Nitrogen
A/E Air Entry C
AGUS Atypical Glandular CABG Coronary Artery Bypass
Epithelium of Graft
Undetermined CAD Coronary Artery
Significance Disease
AKA Above Knee CBD Common Bile Duct
Amputation CF Clear Fluids
ALP Alkaline Phosphatase C/O Complains Of
AMA Against Medical Advice CP Chest Pain / Cerebral
AP Antero-Posterior Palsy
ARM Artificial Rupture of CPAP Continuous Positive
Membranes Airway Pressure
ASA Above Sternal Angle CVA Cerebral Vascular
ASCUS Atypical Squamous Accident
Cells of Undetermined CVD Cardiovascular Disease
Significance CVP Central Venous
AVSS Afebrile, Vital Signs Pressure
Stable CXR Chest X Ray
AXR Abdominal X-Ray C&S Culture and Sensitivity
B D
BCP Birth Control Pill D/C Discharge / Discontinue
BE Barium Enema D5W Dextrose 5% in Water
BKA Below Knee D10W Dextrose 10% in Water
Amputation DAT Diet As Tolerated
BRBPR Bright Red Blood Per DKA Diabetic Ketoacidosis
Rectum DVT Deep Venous
BRwBRP Bed Rest with Thrombosis
Bathroom Privileges DNR Do Not Resuscitate

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DT’s Delirium Tremens HSIL High-grade Squamous
Intraepithelial Lesion
E
EBL Estimated Blood Loss I
EBM Expressed Breast Milk I&D Incision and Drainage
EDC Estimated Date of I&O Ins and Outs
Confinement (Due IUGR Intrauterine Growth
Date) Retardation
ECASA Enteric Coated IVF Intravenous Fluids
Acetylsalicylic Acid L
EF Ejection Fraction L/E Lower Extremity
EGD Esophagogastro-
LAT Lateral
duodenoscopy
LBW Low Birth Weight
EOM Extra-ocular LGIB Lower Gastrointestinal
Movements
Bleed
ERCP Endoscopic Retrograde
LOC Loss of Consciousness /
Cholangio- Level of Consciousness
Pancreatography
LP Lumbar Puncture
ETT Endotracheal Tube
LR Lactated Ringer’s
F LSB Left Sternal Border
FF Full Fluids LSIL Low-Grade Squamous
FHR Fetal Heart Rate Intraepithelial Lesion
FFP Fresh Frozen Plasma M
FWB Featherweight Bearing
MAR Medication
G Administration Record
GA General Anaesthesia MSS Maternal Serum Screen
GBS Group B Strep N
GCS Glasgow Coma Scale NAD No Apparent/Acute
GDM Gestational Diabetes
Distress; No
Mellitus
abnormality detected
H NG Nasogastric
HC Head Circumference NKDA No Known Drug
HBD Had Been Drinking Allergies
HS Heart Sounds

Surviving Clerkship: A Practical Guide 99 / 120

NPO Nil Per Os (nothing by PIH Pregnancy Induced
mouth) Hypertension
NS Normal Saline (0.9%) PO Per Os
NSR Normal Sinus Rhythm POD Post-Operative Day
N&V Nausea and Vomiting PPP Peripheral Pulses
NWB Non-Weight Bearing Present/Palpable
O PR Per Rectum
OA Osteoarthritis PRBC Packed Red Blood Cells
PROM Premature Rupture of
OB Occult Blood
Membranes
OCP Oral Contraceptive Pill
OD Right Eye (don’t use for PTA Prior to Admission
PTL Preterm Labour
“once daily” – write
PTCA Percutaneous
“daily” or “qd”)
O/E On Examination Transluminal Coronary
Angioplasty
OGD Oesophago-
PUD Peptic Ulcer Disease
gastroduodenoscopy
O&P Ova and Parasites PVD Peripheral Vascular
Disease
ORIF Open Reduction and
Internal Fixation R
OS Left Eye RA Rheumatoid Arthritis
O x3 Oriented to (1) Person RFA Reason for Assessment
(2) Time and (3) Place RFC Reason for Consultation
P RFR Reason for Referral
RL Ringer’s Lactate
PCA Patient Controlled
R&M Routine and
Anaesthesia
PE Pulmonary Embolus Microscopy
PEEP Positive End Expiratory S
Pressure SA Spontaneous Abortion
PERRLA Pupils Equal, Round and SBO Small Bowel
Reactive to Light & Obstruction
Accommodation SEM Systolic Ejection
PICC Peripherally Inserted Murmur
Central Catheter

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SIADH Syndrome of Tmax Maximum Temperature
Inappropriate TPN Total Parenteral
Antidiuretic Hormone Nutrition
SLE Systemic Lupus TKVO To Keep Vein Open
Erythematosus TFI Total Fluid Intake
SOB Shortness of Breath U
SOBOE Shortness of Breath on UA Urinalysis
Exertion U/E Upper Extremity
SR Sinus Rhythm
UGIB Upper Gastrointestinal
SROM Spontaneous Rupture
Bleed
of Membranes U/O Urine Output
SVD Spontaneous Vaginal
U/S Ultrasound
Delivery
UTD Up To Date
T UTI Urinary Tract Infection
TA Therapeutic Abortion V
T&A Tonsillectomy and VBAC Vaginal Birth After
Adenoidectomy
Caesarian section
TEE Transesophageal
VSR Vital Signs Routine
Echocardiography VSS Vitals Signs Stable
TTE Transthoracic
Echocardiography W
WDW When Drinking Well

Surviving Clerkship: A Practical Guide 101 / 120

APPENDIX C: USEFUL RESOURCES FOR CLERKSHIP
The decision of what books to buy in Clerkship is a controversial one.
Different people have different learning styles, and your learning style
should guide the resources you use. The following is by no means a
comprehensive list. The books you buy will be strongly influenced by the
specialty you decide to enter. It is advisable to tailor your
purchases/acquisitions to the amount of time you will actually spend (all
good intentions aside) reading during your clerkship, as well as your
method of studying. In addition, each rotation will present you with a list
of their own departmental recommendations – some good, some not so
good.
Recommended Books:
• The Toronto Notes, $95 if purchased directly from UofT, $135 if
purchased at the UofT Bookstore.
• Tarascon Pocket Pharmacopeia (Updated Yearly), ~$15
o Contains almost all the drugs you will be ordering, their
indications, and their dosages.
o Smartphone users may substitute Medscape or Epocrates
(may not have all the Canadian drugs), Lexicomp, or the
mobile version of the Tarascon book.
o Make a point of knowing where to find the nearest CPS on
each rotation for the few drugs that are not listed.
• A pocket book for Medicine, such as the Massachusetts General
Hospital Handbook of Internal Medicine (very useful beyond your
Medicine rotation).
Other Useful Books
• On-Call: Principles & Protocols ~$50
• On-Call: Surgery, or Medicine ~$50
• U of T’s Essentials of Clinical Examination Handbook
• Clinical Examination by Talley & O’Connor
• The Sanford Guide to Antimicrobial Therapy ~ $15
• The Recall Series (Surgery Recall, Medicine Recall, etc.) ~$40ea.

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 • The Lange Series of Books, by specialty
• NMS Review Series, by specialty
• Cecil’s Essentials of Internal Medicine, ~ $90
• Harrison’s Principles of Internal Medicine, ~ $190
**One of the best resources for finding really good books is your residents
or 4th year clerks. See what they suggest. Try to get your hands on a
physical copy of the publication before you buying to ensure it’s both at
your level and something you will actually have the time/inclination to
read.
Online Resources
Most of your clerkship will be spent in centers with readily available
Internet access. Frequently, this can act as a surrogate textbook in lieu of
carrying your entire medical library with you in your lab coat. Being able to
access online information quickly is a good skill to have, and you will find it
even more useful in clinical practice than in the pre-clinical years. Some
useful sites for this include:
• Up to Date
o Available to UofT students through the Library
o Excellent resource – many residents use it!
• American Academy of Family Physicians – www.aafp.org
o Quick search of a large library of handy review articles
• Medscape – www.medscape.com
o Medical news, articles, and medical student section
• eMedicine – www.emedicine.com
o Free, reliable, online textbooks for medical professionals
• The Merck Manual Online – www.merck.com
o Full text of the handy Merck Manual available online
• New England Journal of Medicine www.nejm.com
o Free full text articles with login
• Useful forms, such as for Psychiatry –
o www.gov.on.ca/health/english/forms/forms_cat.html

Surviving Clerkship: A Practical Guide 103 / 120

APPENDIX D: FITZGERALD ACADEMY

St. Michael’s Hospital (SMH)

Frequently Called Numbers
Main ............................................................................................ 416-864-6060
Locating .................................................................................................... x5431
Switchboard ..................................................................................................... 0
Locating .................................................................................................... x5431
Core Lab ................................................................................................... x5082
Hematology ........................................................................................ x5125
Biochemistry ...................................................................................... x2459
Microbiology ...................................................................................... x5381
Cytology .............................................................................................. x5850
Film Library .............................................................................................. x5662
CT Scan ..................................................................................................... x5663
Student Centre.....................................................................................x5700
Department Locations
• B2-Cardinal Carter: Radiology (MRI)
• 2-Queen: Haematology/Oncology
• 4-Queen: Palliative Care
• 6-Queen: Respirology
• 3-Cardinal Carter: Radiology (film library, X-ray, CT scan)
• 4-Cardinal Carter: Med/Surg ICU, CVICU, ambulatory clinics
• 5-Cardinal Carter: ORs, Cystoscopy
• 7-Cardinal Carter: Cardiology/CV Surg
• 8-Cardinal Carter: ENT, Nephrology/Urology
• 9-Cardinal Carter: Orthopedics, TNICU
• 14-Cardinal Carter: Medicine
• 15-Cardinal Carter: Gyne/Post-partum ward, L&D
• 16-Cardinal Carter: Plastics/Gen Surg/GI
• 17-Cardinal Carter: Psychiatry

104 / 120 University of Toronto, 2018

Call Rooms
• Medicine and Surgery (8 Bond)
o The easiest way to get to 8-Bond is to go through 7-CC and
follow the signs to the CCU. Just before you get to the door
for the CCU there will be a door for a staircase that only
goes up one flight, to the 8th floor. This will take you to the
call rooms
o Obtain card access from security (Cardinal Carter lobby)
after 5 pm during your call. Each call room has a bed, desk,
and telephone
o Bathrooms with shower, computer, kitchen are shared
o Call rooms 42 and 43 are for medicine clerks only
• Ob/Gyn
o Separate call room on 15-Cardinal Carter
o No booking necessary
Telephones
• Dial “9” for an outside line, including when paging
• Dial direct with 4-digit extension number
• If you are paged to a 4-digit extension number and are not in the
hospital, dial 416-864-xxxx
• Call locating (x5431) if you need to page someone
• Call switchboard (0) for a direct extension of a dept/office
Miscellaneous
• Access the Li Ka Shing (LKS) building from the main hospital via
the underground tunnel or the above ground walkway at 3-Shuter
• Get replacement pager batteries from IT (4 Shuter) or Med Ed
(LKS 5th floor)
• Student Lounge is located on 6 Shuter, accessible via Shuter North
elevators only
• Clerks have a reserved set of lockers in the general locker room in
the LKS
• Printing is available at the Health Sciences Library (LKS 3rd floor)
• Student centre website for any queries: studencentre.smh.ca

Surviving Clerkship: A Practical Guide 105 / 120

APPENDIX E: MISSISSAUGA ACADEMY OF MEDICINE

Credit Valley Hospital (CVH)

Frequently Called Extension Numbers
Locating .................................................................................................... x4466
Security..................................................................................................... x3974
Phone for deaf in ER ................................................................................ x4476
Outpatient Specimen Collection ............................................................ x5441
Medical Imaging ...................................................................................... x4517
Film Library .............................................................................................. x2685
Emergency ............................................................................................... x4141
Pharmacy ................................................................................................. x1614
Laboratory ................................................................................................ x2696
Library....................................................................................................... x2411
Medical Education ................................................................................... x4365
Ethicist………………………………………………………………………………………………...
x4482
Call Rooms
• Rooms located on 1C
• Access the rooms with your hospital ID badge
• Call rooms available on a first-come, first-served basis
Student Lounge: 1st floor, C-wing; use hospital ID badge (ASCM lounge)
Printer available here.
Medical Education Offices: 1F
Scrub Machines: one in the ER (near diagnostic imaging) and one outside
the ORs on 3G (across from 3C). There is also another machine on the L&D
floor (3A), but only really accessible during OBGYN rotation.
Parking: Monthly student passes should be bought at Trillium and security
at CVH will activate for site access. As of 2018, this was the cheapest
method of obtaining parking at all sites.

106 / 120 University of Toronto, 2018

Intranet
The iCare homepage has many useful resources including:
• SCM (vitals, investigations, clinical documents, med
reconciliation)
• Meditech (investigations, old notes and mox)
• UptoDate
• ECGs
• Impax (radiology)
• Order sets and clinical protocols
• PRO and REACH viewers (records from other hospitals)
• ChartMaxx (scanned documents from previous visits)

Mississauga Hospital (M Site)

Frequently Called Extension Numbers
Main Switchboard ....................................................................................x7533
Locating ...........................................................................................x7557/2222
Security .....................................................................................................x7394
Medical Imaging (Bookings) ....................................................................x7384
CT...............................................................................................................x3860
Film Library .....................................................................................x7296/7285
Emergency (Main desk) .................................................................x7600/7613
ER Admitting .............................................................................................x2241
Pharmacy ..................................................................................................x7475
Laboratory (Office) ...................................................................................x7297
Library .......................................................................................................x7394
Blood Bank ................................................................................................x7520
Pathology ..................................................................................................x7297
Ethicist.......................................................................................................x3083
Call Rooms
• Rooms located on ground floor of the J Wing – behind the parking
‘pay-station’
• Access the rooms with your hospital ID badge

Surviving Clerkship: A Practical Guide 107 / 120

 • Call rooms available on a first-come, first-served basis
• Please use the ‘occupied’ signage when using the room
Scrub Machines: Outside surgery on 2nd floor; another one in the CT
hallway beside emerg on main floor
Student Lounge: 7th floor, Clinical Administration (CA) Building (ASCM
lounge)
Medical Education Offices: 7th floor CA building
Parking: Monthly student passes can be bought at the parking office
located in the North end of the parking structure at M site. This pass will
also work in the North Staff parking lot at Q site.
Intranet
The iCare homepage has many useful resources including:
• SCM (vitals, investigations, clinical documents, med
reconciliation)
• Meditech (investigations, old notes and mox)
• UptoDate
• ECGs
• Impax (radiology)
• Order sets and clinical protocols
• PRO and REACH viewers (records from other hospitals)
• ChartMaxx (scanned documents from previous visits)

Queensway Health Centre (Q Site)

Frequently Called Extension Numbers
Main Switchboard ................................................................................... x7533
Locating .......................................................................................... x7557/2222
Security..................................................................................................... x7394
Parking
Monthly student passes can be bought at the parking office located in the
North end of the parking structure at M site. This pass will also work in the
North Staff parking lot at Q site.

108 / 120 University of Toronto, 2018

Scrub Machines
In the day surgery area on the main floor
Changerooms and Lockers
Basement below the ORs

Travelling Between Sites - Shuttle Bus Services

You can pick up a copy of the bus schedule at the main lobby information
desks at each location. Or find it online at:
http://trilliumhealthpartners.ca/ineed/directions/Pages/default.aspx
Designated Shuttle Bus Stops:
• Mississauga Hospital:
1. Main entrance
2. West wing entrance
3. Emergency/Family Care entrance
• Queensway Health Centre:
1. Urgent Care Centre
2. Appleton 160 building
• Credit Valley Hospital:
1. Main Entrance
2. PRCC entrance

Surviving Clerkship: A Practical Guide 109 / 120

APPENDIX F: PETERS-BOYD ACADEMY

Sunnybrook Health Sciences Centre

Sunnybrook Hospital Campus (2075 Bayview Av.)
Frequently Called Extension Numbers
Main Switchboard ...................................................................... 416-480-6100
Locating .................................................................................................... x4244
Paging
From inside the hospital ...................................................................... x744
From outside the hospital .................................................... 416-480-5744
Cardiac Arrest .......................................................................................... x5555
Security Office
Secretary............................................................................................. x4601
Security Officer .................................................................................. x4589
Occupational Health ................................................................................ x4175
Medical Education Office
Margaret Chung (E313a) ................................................................... x4273
Sonya Boston (E313b)........................................................................ x4274
Norma Armas-Lewis........................................................................x5962
Admitting ................................................................................................. x4407
Biochemistry ............................................................................................ x4646
Blood Bank ............................................................................................... x4051
Cardiac Cath Lab ...................................................................................... x4880
CT Scan Booking....................................................................................... x4343
MRI Scan Booking .................................................................................... x6177
Ultrasound Booking ................................................................................. x6130
Medical Imaging ...................................................................................... x7515
Emergency ............................................................................................... x4207
Endoscopy Suite ...................................................................................... x4005
Family Practice Unit................................................................................. x4930
MacDonald Library (EG-29)..................................................................... x4562
OR Reception ........................................................................................... x4239
Pathology ................................................................................................. x4600
Social Work .............................................................................................. x4477
Thromboembolic Team ........................................................................... x8170

110 / 120 University of Toronto, 2018

Department Locations
• BG Emergency (Zones: green, blue, purple, orange)
• A1-20 Family Practice
• M1-202 Ophthalmology
• M1-102 Otolaryngology
• FG-46 Psychiatry
• H1-71 General Surgery
Photo ID Badges: Badges issued in first year are valid until graduation.
Contact Norma (E319) for more information.
Call Rooms
• Surgery (H367-H369): key safe mounted outside the rooms, the
code will be changed and provided at the start of each rotation.
• Medicine
o H303: Key safe codes provided to registered students by
Margaret (E3-13a)
• OB/GYN: access managed by department (obgyn@sunnybrook.ca)
Student Lounge: 3rd floor, E-wing, E3-09
Lockers: Assigned during orientation. Locker room (JG02)
Pagers & SunnyCare access: Information provided during orientation.
Access is valid until graduation. Contact Margaret (E313) with questions.
Food: M1 Second Cup is open 24/7, M1 cafeteria is open until 7:00pm
every day. Check Sunnybrook website for other locations/hours.
Transportation
• TTC (2 routes): bus #11 to/from Davisville station OR bus #124
to/from Lawrence station
• Driving: monthly and weekly parking passes available for medical
students (Parking office CG-01). Need photo ID badge to purchase
a pass.
• Shuttle: Sunnybrook-CNIB-Holland Orthopedic-Women’s College
o Shuttles run Monday – Friday only
o Main stop located outside H Wing

Surviving Clerkship: A Practical Guide 111 / 120

 Southbound Northbound
Bus Bayview HOAC WCH HOAC Bayview
2 5:30am 5:50 6:00 6:05 6:30
1 5:45 6:05 6:15 6:20 6:45
2 6:30 6:50 7:00 7:05 7:30
1 6:45 7:05 7:15 7:20 7:50
2 7:30 7:50 8:00 8:05 8:25
1 8:00 8:20 8:30 8:35 9:00
2 8:25 8:50 9:00 - 9:15 9:20 9:45
1 9:15 9:35 9:45 9:50 10:15
2 9:45 10:05 10:15 10:20 10:45
1 10:15 10:35 10:45 10:50 11:15
2 10:45 11:05 11:15 11:20 11:45
1 11:15 11:35 11:45 11:50 12:15
2 11:45 12:05 12:15 12:20 12:45
1 12:15 12:35 12:45 12:50 1:15
2 12:45 1:05 1:15 1:20 1:45
1 1:15 1:35 1:45 1:50 2:15
2 1:45 2:05 2:15 2:20 2:45
1 2:15 2:35 2:45 2:50 3:15
2 2:45 3:05 3:15 - 3:35 3:40 4:05
1 3:35 4:00 4:10 4:15 4:50
2 4:05 4:35 4:45 4:50 5:35
1 4:50 5:20 5:30 5:35 6:15
2 5:35 6:10 6:20 6:25 7:00
1 6:15 6:40 6:50 6:55 7:30
2 7:00 7:25 7:30 7:35 8:00pm
*This schedule does not include CNIB stop times (between Bayview &
HOAC in both directions).

112 / 120 University of Toronto, 2018

Women’s College Hospital
Frequently Called Extension Numbers
Main Switchboard ...................................................................... 416-323-6400
Locating .....................................................................................................x4141
Cardiac Arrest ...........................................................................................x5555
Security .....................................................................................................x6090
Medical Education Office........................................................... 416-323-6044
Admitting ..................................................................................................x6075
Biochemistry .............................................................................................x6289
Blood Bank ................................................................................................x6294
Ultrasound booking..................................................................................x6160
Film Library ...............................................................................................x6081
Emergency ................................................................................................x6300
Family Practice Unit .................................................................................x6060
Homecare .................................................................................................x6199
Medical Library ........................................................................... 416-323-6036
Pathology ..................................................................................................x6140
Social Work ...............................................................................................x6150
Photo ID Badge: Security office located in main lobby.
Computer Access: Apply for a user ID with Med Ed (Room 2438 within
Education Suite 2406).

North York General Hospital

Frequently Called Extension Numbers
Main Switchboard ...................................................................... 416-756-6000
Locating .....................................................................................................x6002
Security .....................................................................................................x6049
Medical Education Office.........................................................................x6929
Ultrasound booking..................................................................................x6176
Emergency ................................................................................................x6001
Family Practice Unit .................................................................................x6980

Surviving Clerkship: A Practical Guide 113 / 120

Photo ID Badges: Obtained from Centre For Education (6N-630) at the
start of your rotation. Must be returned at the end of rotation or you will
be charged a fee.
Call Rooms: Room 6N-629
Student Lounge: Room 6N-629
Lockers: Located within room 6N-629. To be assigned for the duration of
rotations at NYGH.
Pagers: Obtained from Centre For Education (6N-630), batteries available
during office hours (7AM-4PM). Pagers from other sites can also be used,
contact Locating at ext. 6002.
Food: Tim Hortons on 1st floor, West lobby is open 24/7. Check NYGH
website for other locations/hours.
Transportation
• TTC: Take Line 4 to Leslie Station, follow signs on platform for
Hospital. Turn right when exiting on Leslie St. and hospital will be
across the street.
• Driving: Staff parking rate is available to clerks, contact the
parking office in the parking garage.

114 / 120 University of Toronto, 2018

APPENDIX G: WIGHTMAN-BERRIS ACADEMY
To call another WB hospital the following prefix is used before the
extension:
Mt Sinai ...........................................................................................................17
TWH.................................................................................................................13
TGH ..................................................................................................................14
PMH .................................................................................................................16
MaRS ...............................................................................................................18

Mt. Sinai (MSH)

Frequently Called Extension Numbers
Main ............................................................................................ 416-586-4800
Switchboard ......................................................................................................0
Locating .....................................................................................................x5133
Medical Imaging .......................................................................................x4411
Med Ed Office .................................................................................x5989/8389
Department Locations
• 12, 17 (ward) Medicine
• 5 Radiology (film library, X-ray, CT scan)
• 18 Med/Surg ICU
• 16 CCU
• 14 General Surgery
• 10 Post-partum ward
• 11 Gynaecology
• 7 Labour & Delivery, High Risk In-Patient OB
• 5 OR
• 4 Ophthalmology
• 4/11 ENT
• 11 Orthopaedics
Call Rooms
• General Surgery – 5th floor (OR area), code given

Surviving Clerkship: A Practical Guide 115 / 120

 • OB/Gyne – 16th floor, code given
• Medicine – 15th floor, code given
Computer Systems
• POWERCHART: Check results (labs, micro, imaging reports),
orders can be entered but must be co-signed by MD.
• E-FILM: Medical imaging & reports (XR, CT, MRI, etc.). All imaging
should be on the system.
• FetL Link: Obstetrics monitoring system for documenting the
progress of labour and fetal health.

University Health Network

Frequently Called Extension Numbers
Toronto General Toronto Western
Main 416-340-4800 416-603-2581
Switchboard 0 0
Locating x3155 x5111
Medical Imaging x3365 x5871
Med Ed Office x4162 x5924/6403
Computer Systems
EPR
• ID, password, course required (can do in Sept, same as with TWH)
• Orders (labs, investigations), results (labs, imaging reports)
E-film: Medical imaging. Reports can be found on E-film and EPR.
Toronto General Hospital Site Specific Information
Department Locations
• 13&14 Eaton Medicine
• 1 Radiology (film library, X-ray, CT scan)
• 10 NCSB Med/Surg ICU
• 2 CCU
• 9 Eaton General Surgery
• 8 Eaton Psych

116 / 120 University of Toronto, 2018

 • 2 NCSB OR
• 7 ENT
• 3 NCSB Uniform exchange
Call Rooms
• General Surgery – 5th floor NCSB, code given
• Medicine – 5th floor NCSB, key to be signed found in binder by 13
Eaton nursing station
Toronto Western Hospital Site Specific Information
Department Locations
• 8 Medicine
• 3 Radiology (film library, X-ray, CT scan)
• 5 Med/Surg ICU
• 3 CCU
• 8 General Surgery
• 2 OR
• 6/7 Ophthalmology
• 2/5 Neurosurgery/Neurosurgery &Trauma ICU, Orthopaedics
Call Rooms
• Medicine/Neurosurgery – 8th floor, code given
• All others – basement, key given by department

General Info for WB Academy

Telephones
• Dial “9” to get an outside line, including when paging someone
• Dial direct with 4-digit extension number
• Call locating if you need to page someone
• Call switchboard (0) if you need a direct extension for a
dept/office

Surviving Clerkship: A Practical Guide 117 / 120

Pagers: Replace your pager batteries from Med Ed offices
MRN numbers: This is patient identification number. ALWAYS have this
number with you when retrieving lab work from the computer, when
requesting films from the film library, or when arranging for a consult
Photocopy Cards: Pick up from your home hospital library (500 free
copies). Accepted by all three hospitals.
Hints on Finding X-rays and CT films
• First check on the E-Film system. If not found, call the film library
(MRN # handy) and determine if hardcopy available
• If a film is not in the film library, check the following places:
• Radiology reading rooms, CT scanner room, ED, wards
UHN Shuttle Bus Service
Daily shuttle bus service between TGH and TWH is available M-F
Leaving From TWH: Leonard Street Entrance
0630h 0700h 0730h 0800h
0815h and every 15 minutes until 1700h
1730h and every 30 minutes until last bus at 2000h
Leaving From TGH: 585 University Avenue Entrance
0645h 0715h 0745h 0815h
0830h and every 15 minutes until 1715h
1745h and every 30 minutes until last bus at 2015h
Late-night bites:
TGH: Tim Horton’s (Open until midnight on weekdays), Subway (open until
11 pm), Mega Wraps and Hero Burger (Open until 10 pm)
TWH: Druxy’s (9 pm), Tim Horton’s (10 pm), McDonald’s and Tim Horton’s
at Bathurst and Dundas (24 hrs)
Refer to WB website for the full list of restaurant options within UHN and
in the area.

118 / 120 University of Toronto, 2018

APPENDIX H: FREQUENTLY USED CONVERSIONS
Remember:
100 mL = 1 dL 1 mcg/L = 1 ng/mL 1 mmol/L = 1 mEq/L for electrolytes

Lab Value convert from conversion factor convert to

Albumin g/L x 0.1 g/dL
Ammonia µmol/L x 1.703 µg/dL
Bilirubin µmol/L x 0.0585 mg/dL
Calcium mmol/L x 4.008 mg/dL
Cholesterol mmol/L x 38.66 mg/dL
Copper µmol/L x 6.354 µg/dL
Creatinine mmol/L x 11.3 mg/dL
Cyanide µmol/mL x 0.026 µg/mL
Glucose mmol/L x 18.02 mg/dL
Iron µmol/L x 5.585 µg/dL
Lactate mmol/L x 8.904 mg/dL
Lead µmol/L x 20.72 µg/dL
Lipase µkat/L x 60 IU/L
Magnesium mmol/L x 2.432 mg/dL
Osmolality mmol/kg x1 mOsm/kg•H2O
pCO2 mm x 0.1317 kPa
Phosphate mmol/L x 3.098 mg/dL
pO2 mm X 0.1317 0.1317
Thyroxine nmol/L x 0.078 µg/dL
Urea mmol/L x 6.006 mg/dL
Uric acid mmol/L x 16.81 mg/dL
Zinc µmol/L x 6.538 µg/dL

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NOTES

120 / 120 University of Toronto, 2018