DEPARTMENT OF INTERNAL MEDICINE

ORIENTATION PACKAGE FOR CLERKS

HEALTH SCIENCES CENTRE CLINICAL TEACHING UNIT ROTATION

820 Sherbrook Street Winnipeg, Manitoba R3A 1R9

Revision: Contact:

March 2011 Janet Labarre, Education Coordinator 787-8696 /jlabarre2@hsc.mb.ca

DEPARTMENT OF INTERNAL MEDICINE

CLERKS' SCHEDULE

Monday
0715 0830 Assess Patients

Tuesday
0715 0830 Assess Patients

Wednesday
0715 0830 Assess Patients

Thursday
0715 0830 Assess Patients

Friday
0715 0830 Assess Patients

0800-0900 HSC Grand Rounds (Theatre A)

0800-0900 SBGH Grand Rounds (These may be linked to GH 404 e.g. M & M rounds) 0830 1100 Ward Rounds 0900 1100 Ward Rounds 0830 1100 Ward Rounds

0830 1100 Ward Rounds

0900 1100 Ward Rounds

1100-1200 Attending Teaching

1100-1200 Attending Teaching

1100-1200 Attending Teaching

1100-1200 Attending Teaching

1100-1200 Attending Teaching

1200 1300 Medicine Clerkship Tutorial Series

(GH404)

1200 1300 Medicine Clerkship Tutorial Series

(GH404)

1200 1300 Medicine Clerkship Tutorial Series

(GH404)

1200 1300 Medicine Clerkship Tutorial Series

(GH404)

*Clerkship Tutorial sessions linked *Clerkship Tutorial sessions linked *Clerkship Tutorial sessions *Clerkship Tutorial sessions to HSC, VGH and GGH via to HSC, VGH and GGH via linked to HSC, VGH and GGH via linked to HSC, VGH and GGH via MBTelehealth MBTelehealth MBTelehealth MBTelehealth

**NOTE: check Clerkship Tutorial schedule if session is booked for a particular day

1300 - 1330 X-Ray Rounds

1300 - 1330 X-Ray Rounds

1300 - 1330 X-Ray Rounds

1300 - 1330 X-Ray Rounds

1300 - 1330 X-Ray Rounds

1330 - 1630 Service Work

1330 - 1630 Service Work

1330 - 1630 Service Work

1330 - 1630 Service Work

1330 - 1630 Service Work

1630 - finish Sign Out Rounds

1630 - finish Sign Out Rounds

1630 - finish Sign Out Rounds

1630 - finish Sign Out Rounds

1630 - finish Sign Out Rounds

INTRODUCTION
Welcome to your Internal Medicine rotation at HSC. By the time you have received this package, you will have already been assigned to one of the three Clinical Teaching Units (CTU's) designated A, D and H Medicine. A CTU is comprised of a ward resident, 1 - 2 PGY-1s, and 1 - 2 medical students. Each unit also has a service chief. If you have any concerns that cannot be resolved with your current resident, do not hesitate to discuss this with the service chief accountable for your particular service or with Dr. Nick Hajidiacos, director for clerkship for Internal Medicine. Your service chiefs are as follows:

A medicine Dr. Jon Bellas D medicine Dr. Kiraninder Lamba H medicine Dr. Ken Van Ameyde

The primary responsibility of any intern or clerk on the CTU is to satisfy the educational objectives for the rotation by providing care for the medical patient with as much (or as little) help as needed from the resident or the attending physician involved. A PGY-1 is responsible for the care of approximately 10 patients at any one time on average. Clinical clerks are expected to be responsible for no more than 5 patients at any given time. Each member of the housestaff is expected to assess all of his/her patients on a daily basis in preparation for Morning Rounds with the residents. In addition, it is expected that the housestaff will formulate a problem list and potential solutions to the new or ongoing management issues of the patients with which they are involved. Lastly, the housestaff are responsible for daily written documentation of the progress of their assigned patients in a concise, problem oriented fashion. Your notes will be evaluated on an ongoing basis by the resident and attending physicians and critiqued as needed.

DEPARTMENT OF INTERNAL MEDICINE

ATTENDANCE, ON-CALL, TIME OFF
ATTENDANCE
Students must be present on the wards during the dates of their rotations as indicated in their timetables. Students failing to attend may be reported to the Associate Dean, Undergraduate Medical Education who will inform the COE clinical. Each student will receive a warning from the deans office. If this warning is ignored, then the students attendance record will be considered by the COE Clinical and the student may be failed for the time missed. (Please refer to the University of Manitoba, Undergraduate Calendar for a complete list of evaluation regulations.) Recognizing that periodic absence is unavoidable, you must do the following: 1. Notify either Dr. N. Hajidiacos (paging 787-2071) or Janet Labarre (787-8696) and your CTU resident (through paging). If the absence occurs on a weekend day or Monday of a long weekend, you must notify the screening medical resident on call (again through paging). An absence of more than one day will require a doctors certificate. The Department of Internal Medicine will determine if make-up time is required.

2.

Complete the short absence form that is kept in 260 Brodie and return it to the receptionist. If you cant fill out the form in advance, make sure you do it as soon after as possible.

ON-CALL
Clinical medicine is best learned by active experience in the care of patients at the hospital bedside or in the office. This experience should include on-call, often overnight duty, but too easily the purpose of the students clerkship education is overlooked in the inevitable service demands of patient care on clinical teaching units. The following are the regulations of the clerkship. The clerkship director, or delegate, together with the undergraduate committee of the Department must ensure that these regulations are met: During any period of attachment of a department, the on-call for a clinical clerk must not be more frequent than 1 in 4 overnight stay in the hospital. If a period is subdivided into separate rotations, then the on-call frequency for each part must not be more than 1 in 4. If a more frequent on-call rota is demanded by a department then the clerk must not spend the night in the hospital, ie., they must leave by 11:00 p.m. When a clerk, for exceptional circumstances such as illness of another clerk or absence of another clerk for internship interviews, has to be on-call more frequently than 1 in 4 then they must have nights off to bring the average back to 1 in 4 allowed. Clinical clerks must not be on hospital service duty for more than 26 hours continuously. Thus the clinical clerk who has spent on-call night in the hospital must sign over their cases to the next on-call person during the morning work round by 10 am on weekdays and 11 am on weekends.
Students will not be placed on-call the night prior to their National Board examination. Students will not be placed on-call the last evening/night of their rotation. However, the rotation does not end with the exam and students are expected to return to their rotation after the exam unless their supervisor specifically tells them otherwise.

STATUTORY HOLIDAYS
When a clinical clerk is on duty for a statutory holiday then they must be given a day off during the period in which the statutory holiday occurred. Statutory holiday substitute days off may not be carried over to another period in another department. This is in accordance with the PARIM contract.

THE WARDS
The wards at the Health Sciences Centre are geographical. This means that all your patients will be on your respective ward (ie: A medicine is on A4). There are two exceptions:

1) High Observation Unit This unit is physically located on H7 and is a 6-bed unit. This unit is reserved for very sick
patients who require intensive nursing care and observation. Any service can admit to this unit and your service will have on average 1 to 2 patients there at any one time. Pages from this unit (phone numbers 73751, 73752) should be answered immediately.

2) B3 B3 is located on the third floor and is a ten-bed unit. This is the only medical ward with
telemetry. Any service can admit to this ward.

CTU DAILY STRUCTURE

A weekly schedule is enclosed in this package which outlines the rounds and activities of the housestaff on a day-to-day basis. Morning Assessment Each morning prior to the arrival of the medical resident, the housestaff are responsible for assessing the patients assigned to them. This involves reviewing the chart and liaising with the on-call resident to learn of any events which transpired during the night. While seeing your patients you should be preparing a problem list for each patient to present to the resident during morning rounds. In addition, active problems should be well thought through and an attempt should be made to formulate a decision as to the cause of the problem as well as plan for its management. Many trainees find it helpful to arrive with enough time to complete their progress notes prior to rounds. This may help you organize your problem list and plan for each patient. IMPORTANT: You must arrive with sufficient time to see all the patients assigned to you. It is not acceptable for patients not to be assessed prior to morning rounds.

Morning Rounds Morning Rounds usually begin at 8.30 am with the exception of days when there are grand rounds prior, when they will begin at 9.00 am. These are designed to be walk rounds, with the entire team seeing patients at the bedside and deciding the plan for the day. Rounds are attended by the house-staff, the charge-nurse or CRN for the ward and one of the two attending physicians. There is usually a pharmacist as well who can be an invaluable resource for questions of medication choice, dosing and side effects. The attending physician is there as a resource only. The responsibility for running rounds belongs to the ward resident. There are several purposes to walk rounds. First, seeing the patients each day allows all the housestaff to familiarize themselves with the people they will be responsible for on-call. Secondly, this

provides trainees with an opportunity to present their patients issues and plans to the ward resident. Thirdly, these are work rounds. All orders should be written during rounds, and all requisitions completed in order to ensure nothing is missed and treatment plans are enacted as early as possible during the day. As before, the role of each member of the housestaff is to provide a concise problem list with potential management schemes for their patients. It is vitally important to learn to be organized so that rounds can run smoothly and efficiently and each team member gets the most learning and benefit from them. Of note, is that in order to ensure the post-call individual leaves by 10 am, the team will see his/her patients first and then return to the rest of the patients. Attending Teaching There is protected teaching time each day from 11.00 am to 12.00 pm. The attending may choose to teach at the bedside or present a didactic session on a core topic. Attendance at these sessions is mandatory for all house-staff who are not post-call. Xray rounds Depending on the number of studies to be reviewed these may or may not be held on a daily basis. Typically, new imaging from the previous 24-hours is reviewed with the ward resident for the purposes of teaching. Each ward has an x-ray viewer and access to the Impax system. Afternoons From 1300 - 1630 is the time for the housestaff to follow-up on their patients as well as to complete the daily progress notes on their patients. This is also an opportunity to review any of the more critically ill patients and deal with any new admissions. A history and physical exam with an assessment and plan should be performed on all new patients and documented in the chart. These can be reviewed at the sign-out rounds. Sign-Out Rounds This is the final rounds of the day and is meant to be a concise description of any new events during the day as well as an outline of potential problem patients. This is critical for the member of the housestaff on call that evening. The duration of these rounds should be no longer than 30 minutes and is not meant to be a repeat of Morning Rounds. You should be there to provide relevant updates on your patients as well as to notify the on-call individual of any issues or results that need to be followedup over the course of the evening/night.

Other Rounds As outlined in the weekly schedule provided, there are Grand Rounds held twice per week. These take place on Tuesday (linked from HSC) and Thursday (held at SBGH) at 8 am and last approximately one hour. You are invited to be at these rounds and may need to arrive on the wards extra early to see your patients in order to be prepared for Morning Rounds. Unless acute issues on the ward detain you, attendance is expected. Summer emergency rounds are held in the TV link room. These rounds are held in July and August and cover a variety of core and on-call topics.

For the clerks there are also mandatory Clerkship Tutorials which are linked to the other teaching sites using the MB Telehealth equipment. These are a vital component of the individualized teaching provided for the medical students. Students are expected to be covered for ward pages by their intern and resident colleagues during this protected teaching time.

ON CALL
Call will not exceed 1 night in 4 on average over the course of the rotation. During call you will be responsible for the patients on your service and will be the first person called for any problems that arise. Ward Calls If it is an emergency or you do not feel comfortable with the situation call for help immediately. Otherwise, you are expected to assess the situation and patient, make a plan and call the resident to review the plan and co-sign your orders. Although Clinical Clerks take call on their own, there is always back up available. The screening medical resident (SMR) is in-house at all times and should be the first person you call. If you have more questions or there has been a significant change in a patients status the attending physicians are always available and should be paged. In case of a cardiac arrest or respiratory failure you can call a Code Blue without consulting SMR. Also of note is that other staff can call Medical 25s (medical emergencies) or Code Blues, and you should attend any that occur on your ward. You may be able to assist in a number of ways such as providing background information on the patient to the code team. Also these are good opportunities to see ACLS and acute care in action. Admissions During call you are responsible for any new admissions that come to the ward. You are not expected to see patients who are still in the emergency room or re-assessment area. You should do a full history and physical on each new admission, ensure all appropriate medications, investigations and consults are ordered, and formulate your own problem list and plan to present on rounds the next day. All admission history and physicals should be reviewed with the screening or senior medical resident. Weekends/Holidays Call shifts start at 9.00 am on weekends and holidays. You and the post-call individual are responsible for signing over events of the night before and distributing the patients between yourselves. Typically the person coming on to call will take more of the patients to see/write notes on. On weekends or statutory holidays, the person on call is responsible for rounding by himself/herself on the patients on their service. Each patient should be seen and a brief note written updating the chart with any significant changes to the patient status or treatment plan. Post-call Post-call you are expected to leave by 10 am on weekdays and 11 am on weekends to comply with the 26-h maximum shift length. The ward resident and team will see your group of patients first to permit this. You are responsible for writing notes on your patients prior to leaving for the day. If there are investigations etc to follow up during the day

Call requests Call requests are to be submitted to the Chief Medical Residents (cmr@cc.umanitoba.ca) before the 1st Monday of the previous call schedule. NB: the call schedule is produced each month and is based on the residents rotation schedule. Leave for conferences etc. must be applied for through the Undergraduate office.

ADMISSIONS, DISCHARGES AND NON-TEACHING PATIENTS

Admissions usually come from the emergency department but may also come from clinician offices. All teaching patients will be admitted under one of the two attending physicians for the ward. The only exception to this rule are dialysis patients who may be admitted under the nephrologist. Housestaff should be notified of any admissions by the attending and/or screening medical resident. When the patient is clinically stable he/she may be made "non-teaching". Such patients are then the responsibility of the attending physician, if there is an emergency, however, housestaff may be reinvolved.

EVALUATIONS
General Knowledge This will be assessed at the end of the clerks rotation using the National Board Examination. Failure would mean that the examination would have to be rewritten at a later date as per UGME rules. Clinical Skills and Attitudes This evaluation is the responsibility of the service chief. They will discuss your performance with the attendings, resident and nursing staff you have worked with on the ward. During your rotation, all housestaff will receive a midpoint evaluation and a final evaluation. It will be the Service Chief or his/her designate who will determine a passing or failing evaluation after discussions with the above noted staff. But, ultimately, the final decision lies with the Undergraduate Committee, Department of Medicine and the Committee of Examiners. Failure will usually lead to a remedial rotation scheduled as per UGME rules, the duration of which is at the discretion of the Internal Medicine Undergraduate Committee.

GENERAL INFORMATION
Clerks' Orders All clerks' orders must be written and co-signed by a PGY-1, resident or attending staff person prior to the order being carried out. It is the responsibility of the clerk and not the nursing staff or the ward clerk to ensure that this occurs. Clerks are not allowed to co-sign verbal orders even when this has been discussed with a licensed physician; the order must be physically signed (or given as a verbal order to a nurse) by a licensed physician. Urgent Calls A "25" call implies a medical emergency which can range from a fall to impending respiratory arrest. If you are called as a "25" to the ward you must leave what you are doing and get to the ward. There should be no delay in calling the resident. A "code blue" implies a respiratory or cardiac arrest. You should attend all "code blues" called by your ward to help the ICU team with any procedures and to provide key information about the patient to the ICU staff who are the first response team for a "code blue" in the Hospital. Non-Teaching Patients Any patient who is a potential candidate to be made non-teaching should be discussed with the ward resident prior to broaching it with the attending physician. Once they are non-teaching you will no longer be involved in their care. Venipuncture There is a venipuncture team. Consequently, there is no need to draw blood on your patients. Still, the experience of venipuncture may be useful. You should take the opportunity to gain experience in the technique with the patients you are looking after. You may be required to draw blood for some stat blood work.

Blood Gases A respiratory therapist is available during the day for elective arterial blood gas measurements and emergently if housestaff are unable to get a sample. In general, however, medical students are encouraged to do as many of these themselves as they are able. The ward resident, screening medical resident and/or attendings are all willing and available to teach you the procedure. ECG's These are available 24 hours a day. Hospital Library The Neil John Maclean Library is available on campus and you should already be familiar with its rules regarding access. Call Rooms Call rooms are located in the same building as the PARIM lounge. Each call room is equipped with a telephone. Wake-up calls can be obtained through paging. The key is located on the ward and one of the team members or other residents will show you the room on your first day.

DEPARTMENT OF MEDICINE WORK ROUNDS Guidelines for CTU Rounds

A.
TIME:

WEEKDAY MORNING ROUNDS

Monday to Friday 0830 hours to 1030 hours Main desk of the CTU.

STARTING LOCATION:

PERSONNEL:

Resident, PGY-1s, Clerks Charge nurse and/or bedside nurses. Attending Physician Pharmacist (may or may not be present depending on staffing) Rounds should be held at the bedside, not in the conference rooms. a) Clinical assessment skills b) Patient involvement c) Development of interactive skills talking with patients/families. 1. Patient Care Housestaff must present the patient's problems to the team in a concise and organized fashion, organized from most to least important. For each problem the intern or clerk should convey the relevant subjective and objective data as well as a proposed plan of action. 2. Teaching Practical skills in the assessment and management of patients is acquired on work rounds. Housestaff will also learn about time management, the roles of the different members of a multidisciplinary health team, and develop skills in communication with co-workers and patients. More comprehensive approaches to clinical problems are learned through other formats (attending rounds, seminars, tutorials, etc.). 3. Evaluation The clinical problem-solving skills, knowledge base, organization and presentation skills of junior housestaff (clerks, PGY-1s) will be evaluated on the work rounds by the resident. The resident's comments will contribute to the consensus evaluation completed by the Service Chief (or designate) and reviewed with each housestaff member. In turn the resident's organization and teaching skills will be assessed on the work rounds. Golden Rules: 1. The thoughts and observations of all members of the team should be

FORMAT:

GOALS:

solicited and valued.

2. Housestaff must be on time. This means that they must arrive early
enough to have assessed all their patients by the start of work rounds.

3. Housestaff must thoroughly evaluate their patients prior to work rounds.

This includes: (a) eliciting any new relevant history, (b) examining patients, (c) gathering new data on vital signs, problems and investigations from the chart and co-workers (eg. nurses, "on-call" physician, problem "clip-board", etc.,) and (d) formulating a plan for investigation/treatment to present to the team.

4. The ward resident is responsible for running rounds and directing

patient care plans. Attending Physicians are present at rounds to act as a resource and observer.

5. Orders and requisitions should be completed during work rounds, not

left for later in the day.

B.

WEEKEND MORNING ROUNDS

It is expected that every patient is reviewed on weekends and that an appropriate progress note is written. Housestaff will meet at 0900 hours to discuss problems and sign over patients. It is understood that the post-call individual has (or will) see their share of the patients and write up progress notes before leaving the hospital. It is expected that the post-call individual leaving comply with the 26 hour rule. The on-call and post-call individuals are responsible for dividing the patients to ensure all are seen each day. When a clinical clerk is on-call the screening medical resident or senior medical resident will be available to co-sign orders and review admissions if the attending physician is not present.

C.

SIGN-OUT ROUNDS

PURPOSE The purpose of sign-out rounds is to convey important new patient information in order to:

a) b)
FORMAT

Decide whether any action needs to be taken that evening. Provide the on-call intern/clerk with sufficient data to handle new problems that may arise. 1. These rounds must be short and "to-the-point" 2. Usually held in a conference room.

Useful Resources/Reading
This package contains:

1. 2. 3. 4. 5.

A list of core topics Recommended resources A cheat-sheet of common medications and doses A sample H & P and Progress Note Sheets you can use to organize your patient data etc.

1. CORE TOPICS IN INTERNAL MEDICINE

The following topics are considered Core reading during your Internal Medicine rotation. Clerks are strongly advised to review these areas prior to the National Board Examination. You are also expected to read around cases that you have encountered on the CTU's and in the clinics. The recommended reference is Cecil's Essentials of Medicine. 1. Management of the acute MI and the post-MI patient 2. Congestive Heart Failure 3. Arrhythmias 4. Hypertension - Primary and Secondary Causes 5. Cardiac Risk factors - Smoking/Obesity/Hyperlipidemia 6. Diabetes Mellitus 7. Thyroid Dysfunction and Nodules 8. Approach to Jaundice 9. Peptic Ulcer Disease and Dyspepsia 10. DVT and Pulmonary Embolism 11. Approach to Anemia 12. Pneumonia 13. Kidney Stones and Urinary Tract Infections 14. Infections of the Nervous System 15. Acid-base and Electrolyte Disturbances 16. Renal Failure: acute and chronic 17. Dementia and Coma 18. TIA and CVA 19. COPD and Asthma 20. Monoarthritis and Polyarthritis 21. DKA and HHS 22. Soft tissue infections 23. Febrile neutropenia/oncologic emergencies 24. Alcohol associated diseases: cirrhosis, withdrawal, neurological syndromes 25. Upper and lower GIB

26. End-of-life issues and palliative care

2. READING
It is neither recommended or expected that you purchase the books mentioned below. Most are available in the library or through their on-line resources. You may, however, find it beneficial to purchase one or more books as resources. Those that are particularly recommended are starred and italicized. a) General a. The recommended reference is Cecil's Essentials of Medicine*. This is a reliable, comprehensive overview of the important topics in Internal Medicine. b. For more detail you may want to consult either Harrisons Principles of Internal Medicine 17e or Cecil Textbook of Medicine 20 e. b) Physical Exam a. Talley and OConnor: Clinical Examination: A systematic guide to physical diagnosis.* b. McGee: Evidence Based Physical Diagnosis c) On-call a. Pocket Medicine: The MGH Handbook of Internal Medicine* b. Uptodate.com -- this is available through the U of M Health Sciences Library to anyone with a library ID and password. It can be very useful for specific questions of investigation and treatment but is too detailed to be a primary resource for medical student learning. d) Specific topic reviews a. Any of the above references b. Review articles from core journals (e.g. NEJM, JAMA, Lancet, Archives of Internal Medicine) which can be found using the Health Sciences Library and Pubmed.

3. USEFUL MEDICATIONS AND DOSES

NB: dosing given for normal renal function Analgesics: acetaminophen 325-625 mg PO q4h prn (max 4g/24h) ibuprofen 200-400 mg PO q6h prn (max 1200 mg/24h) naproxen 250 mg PO TID or 500 mg PO BID morphine 2.5-5 mg IV/subcut or 5-10 mg PO hydromorphone 0.5-1 mg IV/subcut or 1-2 mg PO fentanyl 12.5-25 mcg subling/IV Antibiotics: cephalexin 500 mg PO QID cefazolin 1-2 g IV q8h ceftriaxone 1-2 g IV q24h cefotaxime 1g IV q8h ciprofloxacin 500 mg PO BID ciprofloxacin 400 mg IV q12h levofloxacin 500-750 mg IV/PO q24h azithromycin 500 mg on the 1st day then 250 mg x 4 days PO/IV piperacillin-tazobactam 3.375 g IV q6h metronidazole 500 mg PO/IV q8h amoxicillin-clavulanate 500 mg PO TID Anti-emetics: dimenhydrinate 25-50 mg PO/IV q4-6h metoclopramide 10 mg PO/IV q6h domperidone 10 mg PO ac meals

Bowel medications: docusate sodium 100 mg PO BID or 200 mg PO daily, should use regularly senokot 1-2 tabs PO at hs lactulose 15-60 cc PO per dose bisacodyl 5-10 mg PO or 10 mg PR

Anticoagulation: DVT prophylaxis: unfractionated heparin 5000 units subcut BID

in bigger patients can use TID dosing or 7500 units BID dalteparin 5000 units subcut daily DVT treatment: UFH 80 units/kg bolus and 18 units/kg infusion. Dalteparin 200 IU/kg q24h ACS treatment: enoxaparin 1mg/kg subcut q12h UFH 60 units/kg bolus (max. 4000 units) and 12 units/kg/h infusion (max. 1000 units/h)

4. SAMPLE HISTORY AND PHYSICAL

ID: 78 presents with several weeks of worsening dyspnea. HPI: The patient presented to the ER with a 2-3 week history of progressively worsening shortness of breath on exertion. Prior to this was able to walk several blocks without a rest, but now cannot make it to the bathroom without severe dyspnea. Also has noticed some orthopnea. No PND. Describes increasing pedal edema over the same time period. Coughing at night. No sputum. No fevers/chills/nightsweats. No chest pain. No change in medications. No previous history of the same. Normal urine output. Review of systems: Dark stools intermittent for the last 3 months. Nil else. Past Medical History: 1. Ischemic heart disease: MI 2009, had angiogram and stents placed at that time. No chest pain since. 2. Hypertension: controlled on metoprolol, ramipril 3. Dyslipidemia: on atorvastatin, doesnt know when last checked 4. Gout: last flare about 6 months ago 5. BPH: on alpha-blocker 6. Remote smoker: 20 pack years, quit 5 years ago Medications prior to admission: ASA 81 mg PO daily metoprolol 25 mg PO BID nifedipine XL 20 mg PO daily clopidogrel 75 mg PO daily atorvastatin 40 mg PO daily ramipril 2.5 mg PO daily allopurinol 300 mg PO daily Allergies: NKDA Social: No drugs. Retired. Lives with wife in assisted living complex. FHx: Non-contributory

O/E: HR 135 irregularly irregular BP 145/65 RR 24 91% RA 95% 2L NP Afebrile JVP 7cm ASA. 2+ pitting edema to the knees bilaterally. + AJR No carotid bruits. Normal carotid impulse. Normal heart sounds. 2/6 systolic murmur at ULSB, no radiation. Abdomen soft, non-tender, no mass, no HSM. Peripheral pulses palpable in all extremities. Some stasis dermatitis to lower shins. Power 5/5 in all limbs. Normal sensation to pin-prick and light touch. PERL. Normal EOM. No facial droop. No tongue deviation. Reflexes normal throughout. Finger-to-nose and RAM normal. Labs: Hb 115 MCV 72 WBC 7.0 Plt 275 Na 129 Cl 104 TCO2 20 K 4.2 Urea 13 Creatinine 75 CK 55 67 TnT 0.02 0.02 INR 1.0 alb 29 Liver enzymes normal. Imaging: ECG: incomplete LBBB (not new), sinus rhythm, inferior Q waves. No change from previous. CXR: bilateral pleural effusions, bilateral interstitial infiltrates, +fluid in fissure -- consistent with pulmonary edema. Issues: 1. Dyspnea physical exam and investigations consistent with CHF no evidence of pneumonia or obstructive lung disease needs IV diuresis: will start at 40 mg IV furosemide and will titrate to a goal of 0.5 - 1 kg weight loss per day will follow ins and outs, daily weights and monitor oxygen saturation

 sodium restricted diet evaluation of ejection fraction -- will discuss with team with regards to Echo vs MUGA 2. Atrial fibrillation no previous diagnosis of the same but given lack of palpitations ?chronic needs improved rate control, but likely to be difficult due to acute CHF also meets criteria for anticoagulation (CHADS 3) but given anemia and history of melena, would worry about increased risk of bleeding increase beta blocker after diuresis started, goal HR 60-70 will need anticoagulation in longterm Echo 3. Anemia Hb 115 with low MCV = microcytic anemia most likely iron deficiency will send iron studies and check LDH to rule out hemolysis history of black stools is concerning for a GI source of blood loss given active CHF and no ongoing bleeding will plan for endoscopy later in the admission or as an outpatient consult GI type and screen transfusion trigger 90 given IHD and CHF monitor CBC daily 3. Hyponatremia hypervolemic hyponatremia most likely due to CHF not in a dangerous range will R/A after diuresis to ensure improving monitor lytes 4. HTN BP slightly above target range, likely due to volume overload at home is on two different antihypertensives at low doses would simplify regimen and maximize one medication before adding a second because of his presentation the most useful of the medications would be ramipril d/c nifedipine (especially as it can cause fluid retention) and titrate ramipril as tolerated monitor Cr and K target <140/90 or lower if tolerated 5. Gout no current symptoms continue home meds 6. DVT prophylaxis on heparin 5000 units subcut BID

7. Disposition patient wishes full codes no anticipated barriers to discharge, but as patient has some home care will notify of admission

Sample Progress Note:

Date: 13/June/20XX Time: 7.00 am 78 y.o. male admitted with shortness of breath due to congestive heart failure. Feeling better today. His breathing has improved and he thinks there is less pedal edema. No new complaints. O/E: HR 90 irreg. BP 140/70 RR 18 91% RA 98% 2L NP Afebrile JVP 5cm ASA Decreased edema Bibasilar crackles, no wheeze. U/O 1700 cc, 24-hour balance: -350 cc Wt: 0.3 kg Hb 116 Na 130 Cl 103 TCO2 22 K 4.2 Urea 11 Creatinine 73 Issues: 1. CHF MUGA showed EF 38%, Echo pending for today patient losing weight but quite slowly electrolytes and Cr stable increase lasix to 40 mg IV BID x 48 h then R/A continue to follow I/O and weights increase ramipril to 5 mg daily to decrease afterload 2. Atrial fibrillation rate improved with diuresis and increased beta blocker no hypotension only received one higher metoprolol dose, will plan to increase tomorrow if still out of target range awaiting scope before start anticoagulation, discussed with patient 3. Anemia: Hb stable, no melena or hematochezia GI has seen and will scope as inpatient when HF better controlled PPI started (oral) as per GI recommendations 4. Hyponatremia

 improving continue to monitor 5. Disposition mobilizing independently but still requiring oxygen and on IV diuresis so no plans to d/c HC aware of admission PT have signed off

Helpful tips for H & P

1. Where to get information (apart from the patient) a. The old chart -- if it isnt there ask for it. If the patient has not been admitted to that hospital before but is well known to another one, ask for those records. Particularly useful are: old H & Ps, discharge summaries, case summaries from family physician or specialist (e.g. nephrologist). b. GP offices are usually able to send over recent lab work very quickly and this can be invaluable for providing baselines c. Medication bubble packs or lists are better than the DPIN (the latter should be reviewed with the patient, or if they are not able to help their pharmacy can give you the dosages etc) d. Family members 2. How to organize it efficiently on the page and when presenting a. Dont repeat yourself (i.e. the chief complaint and ID should be just that and should not include a litany of the patients past medical history) b. Take as much room as you need -- leaving spaces between paragraphs will make it easier to read for you and others. c. Consider putting the past medical history before the HPI as it gives a better background for those listening. d. Present only the relevant details (sorting out which are relevant is one of the skills you should be learning). Dont worry about missing something the first few times, the ward resident will prompt you for missing information, and its the only way to learn. 3. How to get as much learning out of the experience as you can a. Take all the teaching opportunities offered you, both formal and informal. b. Review all your history and physicals with the ward resident, senior or screening medical resident, or the attending. This gives you one-on-one teaching and invaluable feedback that you can apply to the next patient you see. c. Pay attention on rounds. d. Show up to codes, medical 25s and get involved in acute situations on the ward. e. Ask questions. f. Read around your patients, not just for the exam. Youll be surprised how much more sticks when it applies to someone youre taking care of. And it will help you take better care of the patient.