3rd Year: The Chronicles of the Shortcoat

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3rd Year The Chronicles of the Shortcoat

• Alpha Omega Alpha

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Pre-Rounds

• Pre-round
• Vitals On the clipboard or soft chart in the
  Wallaroo by the patients room
• Labs/Imaging OACIS
• Radiology dictation line 2-6062
• SOAP Note Big (hard) chart in the Wallaroo or at
  the nurses station

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Rotations Inpatient

• Medicine
• Long notes
• Big Assessment/Plan
• Surgery
• Short presentations
• Vitals, I/O, bowel movements or passing gas
• Remove bandage only on/after POD2
• OB/GYN
• LD
• Big four (any exam room visit) Contractions?
  Vaginal bleeding? Loss of fluid? Is the baby
  moving?
• Fetal status (FHT, variability, etc.)
• GYN, GYN-ONC, or Post-partum
• Lochia greater or less than menses?
• Otherwise like surgery note

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Rotations Inpatient

• Pediatrics
• Similar to medicine note
• Psych
• Appearance --Behavior
• Speech --Motor
• Affect --Mood
• Thought content/process
• Perceptions
• Judgment/Insight
• Suicidal/homicidal ideation, hallucinations

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SOAP Notes Medicine

• S No SOB/CP overnight. 3 pillow orthopnea
  (improved from 4 at admission). Pt feels swelling
  in feet has improved but still has to elevate
  legs frequently. Pt walked halls s difficulty but
  did not tolerate steps.
• O T98.6 Tm99.3 HR87 RR14 bp114/69-129/78
  I/O1800cc/4500cc FSBS 178-223
• PE Gen AO x 3, in NAD HEENT PERRL, EOMI
  CV RRR, S3 present, no m/r/g, 2 PE to mild
  calf (B) Resp CTAB x mild crackles _at_ bases
  (B), breathing symm c normal effort Abd
  s/nt/nd, NABS, no HSMeg, no palpable masses MS
  MAEW, 5/5 strength UE/LE(B) Neuro CN II-XII
  intact, normal sensation to LT/pressure/temp (B),
  two-point discrimination intact, gait normal,
  patellar and brachiorad DTRs 2/4 (B) Psych
  affect mood congruent and appropriate
• Labs CBC, BMP or CMP Rad XR, CT, Echo, etc.
• A/P 68 yo WM c CHF, HTN and DMII admitted for ?
  edema and DOE
• 1. CHF previously class II but pt now
  symptomatic c mild exertion echo scheduled today
  to eval EF/cardiac fxn pt on appropriate CHF
  regimen at home will continue aggressive
  diuresis c Lasix and consider addition of
  digitalis at this time cont low Na diet
• 2. HTN currently on Lasix, BB and ACEI c good
  control, cont home meds
• 3. DMII on glucophage at home c FSBS in 250-300
  range on SSI c FSBS 178-223 in house will
  consult DM Ed to educate pt on diet/exercise as
  well as recommend more appropriate home regimen
  cont Q6H FSBS

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SOAP Notes Surgery

• Pain well controlled on PO meds. voiding
  flatus/- stool. Tolerating clears s N/V.
  Ambulating well.
• O T97.9 Tm101.0 HR79 RR16 bp 104/67-123/78 I/O
  2300/2150
• PE Incision c/d/i, no erythema CV RRR, no
  m/r/g Resp CTAB c poor effort, mild crackles c
  deep insp Abd s/nd, appropriately tender,
  NABS, ostomy site clean c gas in bag
• Labs
  Rad
• A/P 65 yo AAF s/p partial colectomy c Hartmanns
  pouch temporary colostomy
• 1. Pain well controlled, cont PO meds
• 2. Diet pt tolerating clears c flatus/BS, will
  advance to full liquids and re-eval for bowel
  activity before adv to reg diet
• 3. LG Fever likely due to atelectasis, pt to
  use IS Q1H will get CBC and monitor for other
  s/s of infection
• 4. Dispo pt ambulating s difficulty, plan to
  d/c home c Home Health services tomorrow will
  see in 2 weeks for post-op visit, will schedule
  re-anastamosis in 3-4 months

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SOAP Notes OB/GYN

• Good examples of post-partum notes on OB/Gyn
  website
• Vaginal delivery and C/Section differ
• Access to website through WebCT while on rotation
• LD Q2H progress notes for women in labor
• Vitals include Fetal Heart Tones/Rate
  (FHT)/variability contractions/tocometry (e.g.
  Q4-5min) found on monitors at bedside
• PE includes most recent cervical check
• If pre-eclamptic or r/o (HTN and protein on
  urine dip), watch for labs on OACIS (UA, Liver
  enzymes, 24 hr urine, platelets) and s/s (severe
  headache, vision changes)
• If on Magnesium (MGSO4), monitor DTRs and RR
  closely for s/s of toxicity
• Always give a womans Gs and Ps and weeks
  gestation 24 yo G5, P3, A1 _at_ 23 5/7 wga

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SOAP Notes Peds

• Like Medicine notes except
• Subjective largely dependent on parents
• Ins Outs recorded as cc/kg (ins) and cc/kg/hr
  (outs) in younger kids for babies on formula,
  give Kcal/kg
• On Physical Exam
• Do parts of exam requiring silence FIRST
  (especially if child is still asleep)
• Much of the exam can be done while playing with
  the child be creative! parents and patients
  will be much happier

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SOAP Notes Psych

• Physical exam is Mental Status Exam (MSE)
  different from MMSE
• Appearance (well groomed), Behavior
  (cooperative), Speech (pressured), Motor
  (repetitive rocking motions), Mood (whatever
  patient says), Affect (mood incongruent),
  Thought content (SI/HI, hallucinations), Thought
  process (flight of ideas, tangential),
  Perceptions (seeing or hearing things?), Judgment
  (decision making capabilities), Insight (aware of
  illness?)
• DO NOT forget to ask about Suicidal/Homicidal
  Ideations (SI/HI)
• Labs are usually drawn only to monitor drug
  levels or other effects of drugs (e.g. bone
  marrow suppression)
• Otherwise, SOAP notes are similar to other
  services

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Abbreviations

• PERRLA Pupils equal, round, react to light and
  accomodation
• EOMI Extra-ocular motions intact
• RRR regular rate and rhythm
• CTAB clear to auscultation bilaterally
• S/NT/ND, NABS Soft, non-tender, non-distended,
  normal active bowel sounds
• MAEW Moves all extremities well
• DTR Deep tendon reflexes
• QDay Every day BID Twice a day
• TID Three times a day QID Four times a day
• QOD Every other day Q6H/Q6 Every 6 hours
• QAC Before meals QAM/PM At morning/night
• Prn As needed for (e.g. prn pain)
• c with s without x except

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Rounds

• Rounds Game time
• Make a copy of your SOAP note (do not take notes
  out of the chart)
• Present in order of your SOAP note or HP
• Try to go by memory as much as possible
• After rounds
• Write orders
• Is there anything I can do to help you?

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Writing a Prescription

• First Line - Medication
• Ex Ibuprofen 800mg
• Second Line Instructions
• Ex Sig 1 tab Q6H prn pain
• Drugs like antibiotics wont have a prn
  indication
• Third Line - Amount to dispense
• Ex 30 or Disp 30
• Some people put QS for quantity sufficient, but
  never do this as a medical student
• Remember, if prescribing a controlled substance,
  spell the number out (Ex 30 thirty)

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Get Pimped? Go to MUSC Library Clinical Resources

• Up to Date
• MD Consult
• E Medicine
• PubMed
• Articles not necessarily covered in Up to Date
• InfoRetriever for PDA
• Guidelines, etc.

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Books you may want
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Your enemies
Push Alarm Silence
Mute or On/Off
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Call rooms 1st Floor CSB
Code 354
Down the hall from the CSB elevators, next to
Bronchoscopy. Several beds, separate room
available for women.
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8th Floor Call Rooms
Gen Medicine Call Room
Medicine Subspecialty Call Room
Codes?
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Other call rooms

• Psych
• 2nd Floor Charleston Medical Hospital (above ER)
• VA
• 2nd Floor follow the signs for Specialty Clinics

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Peds ER 1st Floor MUH
Peds ER
CSB exit to Jonathan Lucas St.
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ER 1st Floor MUH
Adult ER
Starbucks
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ICUs 4th 6th Floor MUH
STICU
CSB
Surgical ICU and Ped Cardiology ICU on 4th Floor
MUH MICU on 6th Floor MUH
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OR 4th Floor Childrens Hospital
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Labor and Delivery 5th Floor MUH
Scrub Machine
Student Cave
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Scrub Machines

• 5th Floor MUH on LD
• 4th Floor Childrens Hospital OR locker rooms
• Rutledge Tower 1st Floor Behind OR

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Elevators
D Elevators Floors 1-10 Radiology 3rd Floor
Access
Gold Elevators Floors 1-10, Except 3rd
Restroom
Freight Elevators Next to D elevators
Emergency elevators Key access only