UTMB SOM MS-III Survival Guide

Table of Contents

General Information
Welcome to 3
rd
year!
Evaluations
The Paper Chase
History & Physical
Consultations
Discharge paperwork
Writing prescriptions
Epic Tutorial
MyUTMB Tutorial
Viewing Radiographic Studies

Procedures
On-line Resources
Peripheral IV Access
Sterile Fields & Scrubbing
Suturing/Wound Care

The Rotations
Austin Rotations
Psychiatry
Surgery
OB/GYN
Internal Medicine
Family Medicine
Pediatrics
Electives:
Senior Neurology
Senior Surgery
Emergency Medicine
Miscellaneous




Welcome to your 3
rd
Year!!
Congratulations on making it through the basic science years of medical school, and completing Step I!
Your third year of medical school is an exciting time when you get to start assimilating all of the
concepts you have been studying into the development of differential diagnoses and treatment plans.

Here are a few things to consider as you being your clinical training:

Professionalism is extremely important. You are reminded about the important of professionalism
frequently during medical school, and most of the information seems like common sense.
Unfortunately, every year, medical students make the same mistakes and drop the ball for their
classmates and patients. Here are some common mistakes:

Just because they didnt say anything doesnt mean theres not a problem: You cannot count on
someone else to tell you when there are problems with your professionalism. If you show up late one
morning, and nobody seems to notice, it does not mean that your tardiness was acceptable. If you are
the type of person who will test the boundaries to see what is acceptable, your faculty and residents will
give you all the rope you need to hang yourself. There is nothing malicious about this on their part. The
concept of professionalism should be self-evident, and they are not going to spend their time dealing
with those basic issues.

If you are not early, you are late: Residents and attending will not tolerate tardiness. Everyone
understands that things come up occasionally that make it difficult to be punctual. It is a good idea to
plan to get everywhere a few minutes earlier than you might normally arrive. This allows you to keep
some room in your schedule for unexpected delays

Responsibility: It is important to realize the importance of the tasks you are asked to complete. Even
tasks that seem unimportant can have significant consequences if they are not completed. Surgeries
have been delayed for over 30 minutes because someone failed to get a copy of the X-rays to the
operating room. This makes the attending surgeon, anesthesiologist, and residents all very unhappy.

Attendance: It is very inconsiderate to skip your clinical assignments. In most cases, you create more
work for your classmates who are forced to cover your patients. Even if they say it is okay, it usually
is not.

Be nice: Your interpersonal skills can be just as important as your knowledge base, or skill level. This
is especially true early in your training. You dont need to hug or brown-nose everyone, but you should
treat everyone with respect. One faculty frequently tells students that nurses are the most important
people to impress on a clerkship. The reason is that the faculty and residents all get one vote on your
performance, but the nurses will complain about you to everyone, or loudly sing your praises. Many
students have been hurt by their poor treatment of support staff.

Evaluations & Grading
From here on out, a more significant portion of your grades will be based on subjective observations.
Exams are still very important, but they tend to be responsible for a much lower percentage of your
overall grade. The exact weight of the various components used to calculate your grade is different
during each clerkship.

It is a good idea to find out who will be doing your evaluations, so that you can make sure the evaluators
are aware of your efforts and are able to give you the recognition that you deserve. Consider the
following situation:

I had one rotation where I spent a great deal of time working with a senior resident, only to find out
later that the evaluations were done by the faculty, with very little input from the residents. I had spent
very little time with the faculty, so he didnt have enough information to give me anything more than a
mediocre evaluation.

In many rotations you can go over your evaluations at the end of the rotation and request evaluations
from residents and faculty with whom you had the most contact. Ask for additional evaluations. If you
have spent a lot of time working with a particular faculty or resident, ask them to complete an evaluation
for you. Dont put a lot of pressure on them. Even if they think you were great, an evaluation that you
hounded them about is not going to be as favorable as one that they were eager to complete.
The Paper Chase

The History & Physical:

This is something that you should already have developed proficiency in. You know the basic format,
but the residents and faculty in each clerkship may have different expectations. You are expected to
have the basics down, and learn the specifics on the rotations. A good rule of thumb is to try to find a
good H&P to read on the first day of each new rotation. It will give you an idea of what is expected, and
hopefully point out anything on which you need clarification.

Things can get a little more difficult with regard to the time frame you are expected work within. In
your Practice of Medicine courses you were expected to go gather the information, then sit down and
type everything up and submit your H&P for critique within a few days of the patient encounter.
Unfortunately, that is not reality. You will need to gather the information and either write the H&P as
you interview the patient, or immediately afterwards. With everyone now having access to Epic, your
notes are easily accessible for your residents and faculty to view. Epic does have spellcheck, but
remember that it does not catch every misspelled word. Additionally, be wary of using any sort of
template unless given permission by your team.

Progress Notes (SOAP notes):
Note: The idea is to see your patients and write your own note preferably before the residents have
written their notes, but at least before looking at their notes. This is where you practice your clinical
thinking skills. You may be way off, but the great thing is, it doesnt matter. Faculty would much rather
you have a wrong assessment and plan than nothing at all. At least this shows youre putting some
thought into your patients.

General format to follow (adjustments should be made for the focus of the particular rotation):
Subjective: Give a brief summary of what the patient reports over the previous 24 hours. Include any
important changes in the patients status.
Objective: This section includes the vitals, ins/outs, physical exam, labs, radiology, & current meds.
Assessment: You should give a brief assessment of the patients problems based on the above data.
Plan: Detailed plan on how you want to address each of the patients problems that you mentioned
above. Include medication changes, labs, procedures, consults, discharge status, etc.

DISCHARGE SUMMARY
To be completed in EPIC.
Note: TDC discharges are a little different. You have to know what type of unit the person is going to and his or her mode of
transportation. Additionally, every TDC patient going to an infirmary must have a MRIS (Medical Release Intensive
Supervision) formed filled out.
Patient's Name:
Chart Number:
Date of Admission:
Date of Discharge:
Admitting Diagnosis:
Discharge Diagnosis:
Attending or Ward Team:
Surgical Procedures, Diagnostic Tests, Invasive Procedures:
Brief History & Pertinent Physical Examination & Laboratory Data: Describe the course of the patient's
disease up until the patient came to the hospital including physical exam & laboratory data.
Hospital Course: Describe the course of the patient's illness while in the hospital; include evaluation,
treatment, outcome of treatment, and medications given while in the hospital.
Discharge Condition:
Disposition: Where the patient will be going upon discharged (home, nursing home), and who will take
care of patient.
Discharged Medications: List medications and instructions.
Discharged Instructions & Follow-up Care: Date of return for follow-up care at clinic, diet, exercise.
Problem List: List all active and past problems.
Copies: Send copies to attending physician, clinic, consultants and referring physician.

Writing a Prescription
You are able to fill out the prescription for your faculty or resident, but you cannot sign the prescription
yourself. Remember that all prescriptions go on water sealed paper.

Under Texas State Law, all prescriptions should have the following essential elements:
Date of the order: Allows determination of the life of the prescription with regard to refills. Legend
drugs expire 1 year from the date of the original prescription. Controlled substances expire much
sooner.
Patient Name and Address: Date of birth is not required but is generally included.
If the drug is prescribed for an animal, the species of the animal
Name of the drug
Strength of the drug
Quantity of the drug
Directions for use
Intended use of the drug, unless practitioner feels indication is not in best interest of patient
Practitioner Name, Address, Telephone number

Common Pitfalls
Avoid trailing decimals: 8.0 may be misinterpreted as 80.
Use zeroes before leading decimals: .5 may be misinterpreted as 5, whereas 0.5 is less
likely to be misread.


Example Prescription

UTMB prescriptions often include a pager number
for the signing physician.

You can also avoid some potential for errors by
writing out the number to be dispensed, as well as
indicating the number numerically. This should
always be done with controlled substances. In the
example prescription, it would be easy to change
the 30 to an 80. It would be more difficult to
alter #30 (thirty). If you get into the habit of
doing this every time, you are less likely to forget
when it is important.
Epic: a Medical Students Best Friend
The Basics
This is the computer system everyone had to be tutored on before you started 3
rd
-year. On your first
day, you will be a little unfamiliar with it, but the more you use it Epic will be your best friend at
UTMB. Epic is accessible on any computer on the UTMB campus and UTMB outside clinics.
**Austin has its own computer system**

The only good way to really learn the system is from someone who has already learned it. Ask a fourth
year or upper level resident to help you. Remember, the interns are new too (unless they went to
UTMB), and they will be just as lost as you, probably more so. Also, don't wait until you are on call or
everyone is busy trying to admit patients. Ask someone to help you with the computer systems during
your first rotation, when there is some down time (afternoons are usually slower than mornings for most
clerkships).

In the Hospital
Once you start a new rotation, create a new patient list for that rotation from the selected team you are
on. (Most of the teams will already have an existing list and your residents will share it with you.) You
can organize & create the patient list to show specific values that you need. Print the patient list
everyday (write on it to know what procedures are being done, what lab values do you need, which
patients are going home, etc.) and possibly Rounds reports for your patients (this has all of the important
info: current meds & dosages, current orders, lab values, test results, etc.)

After you have selected a patient:


Snapshot: brief Past Med Hx & Meds

Patient Summary: Rounds reports

Chart Review: past Encounters/Notes, Standing orders

Results Review: all lab values & test results

Demographics: Contact info & Emergency contact

Historical Orders: Log of Complete/Incomplete orders

MAR: tracking of medication dosages & schedules

Make a List
Find Where
a Patient is
Find Patients on
Your Team
Click
Here
for
Rounds
Report
In Clinics with Epic
If you are at a UTMB outside clinic, you can look up a doctors schedule (click on SCHEDULE and
find the clinics name) and review patient information before the patients come in. Click Review in
order to access a patients chart. This is a great way to know the past medical history, current
medications, and the key reason why the patient is returning to the clinic (from Encounters in Chart
Review).
MyCitrix: Accessing Epic from your VERY OWN HOME
(http://mycitrix.utmb.edu)
Why go into the hospital if you just want to check on an updated lab value or see the number of patients
that you currently have on your census? By accessing MyCitrix from home or anywhere, you can save
time by finding info quickly off-campus with access to all of the same features, such as Epic & other
programs.
You must be able to download the ActiveX component to your computer in order to fully access
the website.
This also gives you a way to access UpToDate from home. Go through the UTMB Homepage
link.



2
nd
Select Department/Clinic
1
st
click Schedule
3
rd
Select
Doctor
MyUTMB: a Medical Students other Best
Friend
The Basics
MyUTMB (http://my.utmb.edu) is also a website that medical students can access ANYWHERE. It has
all of the information that is accessible in EPIC along with some different features. If you have
problems accessing MyUTMB, call technical support to make sure that you have access (your usual
username & password). Older information and other reports could be stored in here if not seen in Epic.
However, lab info is not as printer-friendly compared to Epic.

MessageNet (must log-in to MyUTMB for access)
This allows you to store peoples pager numbers, sort them into
groups, and (if they have alpha-pagers) text page people with
important, brief info. No need to remember your classmates or
residents pager numbers. Plus, you can mass page people when
rounds are ready.

Webpaging (http://my.utmb.edu/webpage)
If you just want to send a brief message and are not able to/do not
want to access MessageNet, you can webpage with the same amount
of text page capability. This is accessible through iUTMB homepage
as well.

iUTMB (http://www.utmb.edu/iutmb)
This is the UTMB homepage for Faculty, Staff, and Students which
has links to pretty much everything mentioned above.






Viewing Radiological Studies

What is PACS: PACS is the program that we use to view radiological images. It can be accessed at a
PACS station in the hospital or at any computer through MyCitrix. It is important to realize that images
should ideally be viewed on the PACS stations located throughout UTMB. These viewing stations have
high resolution monitors. Images viewed on other computers may not have the appropriate resolution
and can lead to incorrect interpretations. The interpretation standard is to utilize the viewing stations.
When you access PACS remotely (i.e., not through a viewing station), the program you will use is called
Centricity.

Accessing PACS: You must access the PACS system to view radiological images. The URL is
https://pacs.utmb.edu. If you cannot remember the URL, it can be found easily through MyCitrix or the
MyUTMB website. Simply access MyUTMB and access your patients records. Then open the
Radiology folder within the frame on the left. Then click on Images. This will take you to a page that
has the link to the PACS system.

Logging In to PACS: PACS is configured to utilize the same username and password that you are
assigned for email access. However, to access PACS, you must use the entire username, which is:
utmb-users-m\email username.

Finding a Patient: Once you have logged into PACS, you should see a screen similar to the one below.
There is a small icon that looks like a set of binoculars. If you move the mouse over this icon, a new
screen pops up where you can enter any parameters you would like to search. You can enter any of the
parameters listed on this screen, although the Patient ID (the UH number), is the most specific
parameter.













Viewing the Images: Once you have queried a patient, you will be presented with a list of the available
images. Just click on the study you wish to see. Once you select a study to view, you will see
thumbnails of the images. Click on the thumbnail you wish to enlarge. Across the top of the screen
there will be navigation and viewing options. These allow you to move forward and backward through
the images, as well as selecting the number of images to view per page. On the top of the screen you
will see the following icons:



Contrast: This icon allows you to adjust the contrast of the image. The easiest and probably most
popular way to adjust the contrast is to simply hold down the right-button on the mouse while
moving the cursor over the image. What this is actually changing is too complicated to get into, but
you can play with it and learn to clarify what you are looking for.

Magnify: this allows you to zoom the image in or out. There is also a magnifying glass feature that
allows creates a pop-up window that you can move over the image with the mouse and works like a
magnifying glass.




ALWAYS LOOK AT YOUR PATIENTS RADIOLOGIC IMAGES YOURSELF! You may not know
how to read x-rays and CTs yet, but the only way you learn is through practice, and some attendings will
actually ask if you looked at it.











Procedures
This section is not meant to teach you how to perform any of these procedures. We are simply going to
review information that may be confusing or often overlooked. Additionally, this section provides
resources that can be utilized for a more complete procedure review. If you have the luxury of knowing
ahead of time that you will be participating in a procedure, take a few minutes to review the procedure
as completely as you can.

Excellent Procedure Resources
You can access Roberts: Clinical Procedures in Emergency Medicine, 4th ed. through MD Consult.
Locate the main MD Consult page under Electronic Books section on the librarys website. From the
MD Consult homepage, select Books from the tabs across the top of the page. Roberts is listed
under the emergency medicine textbooks.

Topics covered include: tracheal intubation, cricothyrotomy, thoracentesis, tube thoracostomy,
defibrillation/cardioversion, cardiac pacing, pericardiocentesis, resuscitative thoracotomy, peripheral
and central venous access, arterial access, venous cutdown procedures, intraosseous infusions, wound
closure, incision and drainage, urethral catheterization, and many more!

Also, The New England Journal of Medicine has several videos demonstrating many types of
procedures. You will see some of these during Clinical Skills week, but if you want a refresher, they
can be found at http://content.nejm.org/misc/videos.dtl.

Peripheral IV Access
Some people will argue that there is no need for medical students to become proficient at establishing
peripheral IVs. The problem with this argument arises when the nurses are unable to establish an IV.
Here at UTMB, the team intern is called when the nurses are unable to get IV access on a patient. Most
nurses will allow you the first stick at starting an IV if you ask nicely. Take advantage of the opportunity
to become proficient now!

Saline Lock Vs. Heparin Lock Vs. Peripheral IV: When establishing peripheral IV access you must
consider the patients needs. If he/she is going to receive periodic medications, but does not otherwise
require a continuous infusion, there is often no need to connect the patient to a bag of IV fluids. In this
case, you can simply put a cap on the IV catheter after it has been inserted. Since the IV is not
attached to anything it is much more comfortable for the patient and less likely to be accidentally
removed. If the IV catheter is capped in this manner, it needs to be flushed to minimize the chances of
the catheter occluding with a clot. Unless told otherwise, you can flush a peripheral IV catheter with 3-5
ml of normal saline after inserting. MAKE SURE that your vial is NORMAL SALINE, as often the
vials appear similar to different medications, which could be lethal if 3-5 ml were infused. Sometimes
Heparin is used. The difference between a Heparin Lock and a Saline Lock is simply the fluid that
is used for the flush. Everything else is the same. Beware that people sometimes incorrectly refer to
saline locks as heparin locks. It is a good idea to confirm things before flushing with heparin.

Sites to Avoid: Basically, try to avoid any IV site that is abnormal. Avoid areas with surgical
manipulations, trauma, or infections. ABSOLUTELY avoid arms on the same side as a mastectomy, or
dialysis access. It is also a good rule of thumb to start distally, and then work proximally when
evaluating potential IV sites. If you blow an IV in a patients antecubital fossa, and then establish one in
the back of his hand, there is a chance that your IV fluid will leak out of the more proximal puncture
site.

Sterile Fields & Scrubbing
During your surgery rotation, and probably your OB/GYN rotation you will be doing plenty of
scrubbing in on cases. The surgery clerkship has an orientation to the OR where they will highlight the
important topics, and there is also an OR manual found at:
http://www.utmb.edu/surgery/clerks/ormanual.htm that may be helpful.

Scrubbing:
1. Make sure before you start scrubbing that you have everything on you will need (especially your
mask and eye protection), and that it is comfortable because you wont be able to touch anything
afterwards.
2. Generally, the first time you scrub in for the day, you should do a full scrub with the antibacterial
soap.
a. Turn on the water and open the package containing the brush and nail cleaner.
b. Clean under the nails and throw the nail cleaner away.
c. Take the brush in one hand and wet with water and soap.
d. Scrub the nails of the opposite hand, followed by the fingers (treating each finger as four-
sided). Then scrub up the arm to 2 inches above the elbow.
e. Switch hands and scrub the opposite arm in the same manner.
f. Discard your brush and rinse off both arms making sure that the water runs down your
elbow and not off the ends of your hands. (Keep hands higher than elbow.)
g. Enter OR carefully, making sure not to touch anything with your arms.
h. This first scrub should take approximately 5 minutes.
3. Each subsequent time that you scrub during the day, people generally do a much faster scrub
with soap and water. They then dry off their hands and apply the alcohol solution to fingers,
hands and arm making sure to not miss anywhere.
4. Once in the OR suite, most scrub nurses are great about helping you out as long as youre nice to
them, and dont touch any of their sterile equipment. They will help you gown and glove.

Sterile Fields:
Basically, the most important thing to remember is that you are sterile from your chest to the level of the
sterile field, so this area should never touch anything else. Also no other area of your body should touch
anything within the sterile field. As students, you will mostly be standing, watching and retracting so
there is usually no reason to be moving around the room. Therefore, just always remember to keep your
arms in front of you between your waist and chest.

Suturing/Wound Care
You will be closing wounds, mostly closing up after surgery, but you may also close traumatic wounds
in the emergency department as well.

Basic Principles for traumatic wounds:
1. For all wounds do a good neurovascular exam to ensure that sensation and motor function are
intact.
2. Tetanus status should be checked on all patients presenting with wounds.
3. If there is a risk of foreign bodies being stuck in the wound plain film x-rays can be obtained.
4. Wounds at high risk for infection (mammalian bites, oral wounds, plantar puncture wounds, etc.)
should receive antibiotics before any manipulation of the wound.

Steps for traumatic wound care:
1. First, do a good neurovascular exam.
2. Following the exam, give local anesthesia, usually lidocaine around entire wound. Insert the
needle through the already injured tissue at one end and inject a wheal of anesthetic. Then the
needle can be withdrawn and advanced all around the wound while injecting anesthetic.
3. Hemostasis is important for good wound visualization and cleaning. With most wounds,
hemostasis can be achieved by applying direct pressure.
4. Remove any foreign bodies.
5. Irrigate the wound with high pressure irrigation. There are many different methods for doing
this.
6. Debridement may be necessary if there is dead tissue around the wound.

Wound closure:
1. Classification of closure
a. Primary intention direct closure of wound using sutures, glue, etc. This is ideal, but
should not be done if the wound is obviously infected, or is at high risk of infection.
b. Secondary intention used with infected wounds. Wound is left open and may be
covered with antibacterial ointment. Often, a wet-to-dry dressing will be used to
continuously debride the top layer of tissue, which is usually dirty.
c. Tertiary intention wound is closed after leaving open for a while and after wet-to-dry
dressings have established a clean bed of tissue.
2. In the OR, most wounds will be closed with primary intention.
3. A thorough review of suturing techniques and types is beyond the scope of this survival guide,
but the Clinical Procedures in Emergency Medicine book found at MDConsult and referenced
above has an excellent explanation with many diagrams.


Austin Rotations
The Basics
You will receive your own materials when you go there. It is a minority of the class that actually is
allowed to go, and each rotation there puts their own booklet together; it is very self-explanatory. In
Austin, you will be told what to expect/do, and everyone is very good about that since there are less
students.

Adrienne Thompson (acthomps@utmb.edu) is your best source of information while you are in Austin!
Don't hesitate to ask her questions and if she can't answer them, she is awesome at helping you find
answers.

The parking shuttle is not such a bad deal. Rather than curse its distance away from the hospital, just
utilize it and you will never have trouble finding parking.

The Brackenridge staff is not used to having students around as much as they are at UTMB. Make every
effort to participate in anything you can, as they are happy to teach when you show interest.

The housing that UTMB provides is very reasonable. You can share the rooms with people that you
know (4 of you), so it can be just like college all over again. If you do not want to stay there, keep in
mind which classmates are living in Austin in case they can offer to crash at their place for a month or
so.

The best part: more things to do. If you think you might get bored, do not worry. Everyone will be in
touch with whom all is in Austin, so going out is a nice break and a good change of scenery. Plus, you
can make some stronger friendships or new friends in the class while in Austin since it is a fair distance
away from UTMB.

Yes, you will be busier on some rotations due to the lack of residents, but you are able to perform more
duties and procedures, so it can help you in the long run. The commute back to Galveston for OSCEs
and shelf exams is not too much of a hassle because you can touch base with the Galveston people while
you get back into town. In 3rd year, everyone is so busy; many people have not seen each other in a
long time. Whether you are in Austin or Galveston, your fellow classmates will want to hear how things
have been going.



Psychiatry
The Schedule
Generally you have weekends off, unless you are on call.
Spend time studying for the shelf. You have no excuse not to this is one clerkship with adequate study
time.

Small Groups:
Do the assigned reading: You will be tested on the material every time. The IRAT will evaluate your
memory of the specific reading, not your understanding of the topic. Even if you have the material down
cold, you will not do well if you skipped the reading. No other source will help you as much on the
IRAT/GRAT as the assigned text.

Adult Psych Inpatient
Responsibilities will differ depending on where you are doing your inpatient portion at (St. Josephs, St.
Lukes, Jester, Austin, etc.) In general:

Before Rounds
Duties include seeing your assigned patient and completing your notes.
Making sure the team census is correct for morning rounds.
Helpful hint first student to arrive print census/rounds reports on all patients and a checkout
list (shows meds) for each student. Distribute the census/rounds reports to the assigned students
along with a checkout list. This will save everyone a lot of time.
After Rounds
Update the census list in the afternoon.
Help with complete discharge planning and paperwork.
Call MHMR to schedule patients f/u visits and obtain records of new patients.
Patients appreciate just having someone to talk with when you arent busy doing other stuff.

Consult & Liaison
C & L makes it worthwhile to pay the extra $50-odd for an alpha pager. You can study in the
library (or at home, depending on where you live) and the patients information gets sent to you
without you having to stop and find a phone.
Rounds in the morning change location depending on which faculty member is attending that
day. Dont lose your first-day information about the faculty schedule.
It is a good idea to pick up one of Dr. Averys AIDS packages in case you are asked to consult
for a patient with AIDS that way you wont have to track him down to get one. The package is
HUGE (it makes War & Peace look like a comic book) so be prepared to spend some quality
time filling it out.
The added bonus of doing C&L early in the year is you get to learn your way around the
hospital.
STUDY when you are not with a patient!!!

Outpatient:
There are several clinics where you may be assigned. In general, at most clinics your main
responsibility is just shadowing the faculty and residents. The best way to excel in this portion of
psychiatry is to pay attention, act interested, and ask good questions of those youre working with. You
can pick up a lot of useful information during clinic if youre paying attention.

Textbooks:
Student Recommendations:
Case Files
Appleton and Lange Qs,
First Aid Psychiatry
Clerkship Series: Psychiatry: A quick read that was useful for getting the main idea behind the
DSMIV criteria. I had a hard time memorizing the diagnostic criteria, and this book provided
examples that allowed me to get the feel for the different disorders. This book is not available
in the bookstore, but can be purchased online.
Pretest Psychiatry: Good basic questions. Skip theory section!

And again, make sure you read the weekly assignments from the assigned textbook!

Psychiatric History
Identifying information - age, sex, marital status, race
Chief complaint - reason for consultation, a direct quote from the patient
HPI (History of Present Illness) - current symptoms, previous psychiatric symptoms and treatments,
reason presenting now.
Past Psych. History - previous and current psychiatric diagnoses, history of treatments (include both
outpatient and inpatient), psychiatric medications, history of attempted suicides and potential lethality.
Past Medical History - current and or previous medical problems with treatments
Family History - relatives with history of psychiatric disorders, suicide or attempts, alcohol or substance
abuse
Social History - source of income, level of education, relationship history, support network, individuals
living with patient, current alcohol or drug use, occupational history.
Developmental History -family structure since childhood, relationships with parents, peers and siblings,
developmental milestones, school performance.

Mental Status Exam
General Appearance and Behavior grooming, level of hygiene, clothing characteristics, unusual
movements, attitude, interactions with the interviewer, psychomotor activity (agitation or retardation),
degree of eye contact.
Affect - external range of expression (described in terms of quality, range and appropriateness). Types
could include flat, blunted, labile, and wide range.
Mood - internal emotional tone of the patient: dysphoric euphoric, angry, anxious.
Thought Process
Use of Language - quality and quantity of speech. Note tone and fluency here.
Thought Content:
Hallucination -false sensory perceptions (auditory, visual, tactile, gustatory, olfactory)
Delusions -fixed, false beliefs firmly held despite contradictory evidence
o Persecutory - others are trying to cause harm or spy with intent to cause harm
o Erotomanic -false belief that a person of higher status is in love with the patient
o Grandiose -false belief of inflated sense of self-worth
o Somatic -false belief of having a physical defect
Illusions - misinterpretations of reality
Derealization -feelings of unrealness involving the outer environment
Depersonalization -feelings of unrealness (being outside of your own body)
Suicidal and Homicidal Ideation
Cognitive Evaluation
Level of Consciousness
Orientation - person, place and date
Attention and Concentration - repeat 5 digits backwards or spell world backwards
Short-term memory - recall 3 objects after 5 minutes
Fund of knowledge - name 5 presidents or historical date
Calculations - subtract serial 7s, math problems (simple)
Abstraction -proverb interpretation
Insight: ability of patient to display an understanding of his current problem
Judgment: ability to make realistic decisions about everyday activities
Physical Exam
DSM IV Multiaxial Assessment
Axis I: Clinical Disorders
Axis II: Personality Disorders
Axis III: Medical Conditions
Axis IV: Psychosocial Problems
Axis V: Global Assessment of Function (a number)
Plan of Treatment

Common Thought Disorders
Pressured Speech - rapid speech, especially with manic disorders
Poverty of speech - minimal responses
Blocking - sudden cessation of speech
Flight of ideas - accelerated thoughts that jump from idea to idea
Loosening of Associations - illogical shifting between unrelated topics
Tangentiality - thought which wanders from the original point
Circumstantiality - unnecessary digression which gets to the point eventually
Echolalia - echoing of words and phrases
Neologisms - invention of new words by the patient
Clanging -speech based on sound such as rhyming and punning rather than logical connections
Perseveration - repetition of phrases or words in the flow of speech
Ideas of Reference - interpreting unrelated events as having direct reference to the patient

Lab Evaluation of Psychiatric Patient
Commonly includes: Chem - 7, CBC, LFTs, RPR (VDRL), Toxicology screening, Blood alcohol,
medication levels, HIV
Surgical Clerkship

Team work is essential during surgery. Communicate on a daily basis with your fellow medical students
to make sure that every surgery is covered by the appropriate amount of medical students (some need
only one, some need two), and every patient on the service is covered.

Rounding
Surgery rounds are early! Youre basically expected to be there from 6 a.m. to 6 p.m.
You will be rounding with your Chief Resident more than with your attending. Ask what he/she wants
in a presentation.
Important Information to Gather Each Morning:
Fever: always report the T-max, range of temperature, and time of Tmax.
Ins and Outs Be specific & include each type (urine, drains, fistulas, etc.)
Status of flatus AND Bowel movements
Also remember to actually look at the incision/dressing

Textbooks:
Student recommendations
Surgery Recall is a great book to carry with you and read before your surgeries for pimping
questions.
Pestana Review Questions (e-mailed to you by the course coordinator) good overview of basics
Surgery Case Files
Underground Clinical Vignettes
NMS for Surgery
NMS Surgery Casebook Similar to Case Files but more details, does not cover many surgical
subspecialties
Pretest for Surgery- if you find that you like the pretest series, this one is helpful.
First Aid for Surgery trauma portion

Basic Information:
At the end of every day, check the Case book/OR schedule to see what surgeries are scheduled
for the next day; decide how to divide them up amongst the team.
You are expected to know the local anatomy for your surgery and pathophysiology. (It doesnt
hurt to look up what is going to be done in the surgery)
If you are on the trauma team you dont have the luxury of knowing what youll see- so you
might want to have an atlas in your bag- you dont have to carry it around, leave it in the call
room.
Be sure to let the scrub tech know you will be scrubbing in and ask if you should get your correct
size of gloves and gown. DO NOT ASSUME that they have your stuff. Usually they arent
prepared for you/dont know your size, so just a good idea to keep a couple of pairs of sterile
gloves in your size with you at all times. Always double glove for surgeries, especially those
involving TDC inmates.
PAY ATTENTION during the information sessions at the beginning of surgery sterile
technique, Foley and NG insertions are all things that you will need to know. Get someone to
walk you through this on a patient early on, so it will be easy later on.
CLINIC DAYS are professional clothes days for everyone except the trauma team.

General Surgery
Team Codes for Order Entry: SURA for General A; SURB for General B
For clinic, review your breast pathology, signs and symptoms, and tests.
When you know your patient is going to be discharged, make sure to fill out the Discharge
Summary if your team wants you to help with these. If you have a patient who has been in
house, having multiple procedures, its not a bad thing to get into the habit of filling out the
discharge sheet as you go with each procedure & date so you wont have to go through the
chart later to find this information.

Trauma
Whether youre on the team for the month or trauma call, a lot of what youre doing is making
things run smoothly.
Keep a study book in your pocket there is a lot of down-time when you are waiting for patients
in the CT scanner, X-Ray, etc.
When you are on trauma call you have the trauma pager. There is only one trauma pager
between all medical students. If you are a heavy sleeper let your call partner sleep with the
trauma pager. If you are both heavy sleepers make sure you both sleep in the same call room and
pray you dont sleep through it. It has been done. YOU DO NOT WANT THIS TO HAPPEN
TO YOU!!!
The trauma call room is on the third floor of the Trauma Center (above the E.R.) The door
number is 123. The inside door codes are on the side of each lock (Thus they dont really
function as a lock they just delay entry of someone long enough for you to wake up and wipe
the drool from your face)
For some reason, the phones in the Trauma Call rooms tend to get unplugged and moved around,
so dont assume that the number on the phone itself is correct (especially if youve been waiting
an awful long time for someone to return your page).
On trauma call, you will meet for the trauma meeting either in the morning or afternoon and
exchange pager numbers and cell phone numbers with the residents then.
Usually for high-speed collisions and falls (the majority of traumas) you are going to want:
o CXR (Chest X-Ray)
o 3V C-Spine (3 view c-spine)
o Pelvis
o Fortunately, if the team wants all of this they can now order a trauma panel on EPIC.
Any CT scans done in the trauma rooms have to be okayed by a radiologist before you can
schedule them. The ER/Trauma Radiologist is usually in the Radiology reading room. Its
YOUR job to write up the request as the resident says they want to get a CT, take it to the
Radiologist, let them write their code on the request, then take it to the CT Scanner.
If youre on the trauma team keep a 10 cc syringe in your pocket on rounds so you can pull out
Foley catheters without searching one out. You can get these in the shock trauma rooms in the
ER while youre there, also grab some tape, because youll want that for changing dressings.
4X4s are also a good thing to have on you but the packaged ones are easier to find on the floor
than in the ER. I always tried to have two packs on me, and replaced them as we used them. On
trauma team its still a good idea to have X-Ray & Consult forms on you at all times.
If the patient has a distracting injury - like a broken bone in the wrist, etc. then you dont
clear the c-spine clinically there has to be good radiographic evidence that the C-spine is okay
that means if the 3-view c-spine is inadequate, youre going to have to do a CT.


CRITICAL PARTS OF YOUR JOB ON TRAUMA TEAM or TRAUMA CALL:
When the patient arrives and you are in the trauma call room, quickly go to the phone in the
trauma room, dial X-Ray (speed dial button) and tell them there is a trauma.
Have your trauma shears ready you cut the clothes off the patients so that the residents can
assess them.
Foley catheters & NG tubes this is your time to learn to put them in. (Dont worry you will
be shown how to do this in a group session at the beginning of trauma - PAY ATTENTION)
Starting I.V.s If patients come in by ambulance they generally already have at least one the
nurses will start another quickly, so if you want to try speak fast. Dont pick an unstable
patient you dont want to be delaying essential patient care but there will be plenty of stable
patients!
Check INQN for lab results for your patients (Most of the stat requests will be hand-delivered on
little slips of paper by the nurses make sure results get into the trauma sheet)
Photocopy the trauma sheets for the patient you want to present in the morning youll be glad
you did also, make sure you know WHY studies were done or not done because you may be
the person justifying decisions that werent yours.

Cardiothoracic Surgery
Team Code: CTS
Cardiothoracic surgery has a protocol book that they give you at the beginning of the rotation for
pre & post-operative care that explains all the preoperative work up and the postoperative orders
for every post-operative day. This book should help you know what is going on.
Be careful about contamination with the bypass machine; there are always tubes and things
everywhere and they ask you to move around sometimes from one side to the other. Remember
where your sterile field is & don't put your hands below your waist, rest them across your chest
and keep your elbows in when walking around.
Also if you have a bad back or joints, take a Motrin before every thoracotomy because you will
probably be riding a retractor the whole time.
Would be helpful to review your cardiac output equations, know the pulmonary artery
catheter/Swan Ganz and what it measures, read about cardiopulmonary bypass surgery to
understand the heart cannulations and the bypass machine.
Also for people that have been on the bypass machine in surgery when they are on the floor you
are looking for them to diurese all that fluid out so pay attention to urine output, ankle edema,
and daily weights! And listen to lungs for crackles, signs of fluid overload. You are looking for
them to get down to their admission weight. Always have those things in your notes and know
them for rounds. Know which diuretic and how much they are on. Typically they need to get out
of bed when they are stable, so ask the patients or look in the nurses notes to find out if theyve
been ambulating yet.


Vascular Surgery
Learn your vascular anatomy SERIOUSLY its not something you can fudge.
On rounds,
o One team member better have the Doppler machine and jelly so that you are prepared to
Doppler every patient.
o Know the DAILY values of PT, PTT, & INR, for any anti-coagulated patient (this will be
almost EVERY vascular patient)
o Know where to feel pulses femoral, dorsalis pedis, popliteal, posterior tibial. On
rounds if you feel a pulse, great. If you find the popliteal easily its probably an
aneurysm. If you dont feel a pulse- the patients pulse is probably not palpable.
Read the packet of studies that the faculty gives to you. READ THEM.
Wear safety goggles when removing stitches on any anti-coagulated patient.
On the first clinic day, be polite and ask one of the nurses in clinic to show you:
o How to use the Doppler
o How to put on a UNABOOT
o How to fill out pre-op packets

Transplant Surgery
The progress notes are done on a special form; labs are checked every morning and recorded on
the form, along with all the meds that patient is on. The easiest place to find the meds is on the
MAR form in the nursing folder. Make sure you write down the doses on the
immunosuppressant meds. They will be CSA (Neoral), mycophenolate (CellCept), FK506
(tacrolimus or Prograf), and a steroid, usually prednisone or Solu Medrol.
Get to know Melissa. Shes the team pharmacist and your best friend for information on
immunosuppressant medications.
Every patient that has had a transplant needs a door chart that is updated every day. Make sure
that all immunosuppressants and antimicrobials that the patient is on are on the door chart, as
well as drug levels, like FK or CSA (which are drawn every morning)
Try to get in on a lot of vascular access cases, because you get to do more sewing, if you want to.
Most transplants dont actually happen during the daytime hours. If you want really want to see a
transplant, make sure your attendings have your pager/phone numbers to be able to get a hold of
you should the opportunity arise.

Burns Surgery
Be sure to include todays PE, although not a space for it on the form, any recent labs, and most
recent x-ray results.
Youre allowed to leave for class and often dont have to return.
Youre able to split weekends but will be required to see all of your patients and those of the
other student for whom you are covering. This means getting here much earlier on the weekend
so that you have time.
Discharge planning meeting is multidisciplinary and can be interesting or very boring.
Depending on your residents you may be required to stay or you may be excused to go to the
OR.
After rounds, you can go to OR everyday or help with odds and ends on the floor placing back
skin, removing staples, applying amnion, etc.
If no surgeries are going on, there can be lots of down time to sit on the floor and study good
just to show your face. Usually not a good idea to leave completely, unless for class or small
group.


Surgical Documentation
For Procedure purposes: We now enter procedure documentation through an online database (See
syllabus for website). Start early and keep track.

SURGICAL HISTORY AND PHYSICAL EXAMINATION
Identifying Data: patient's name, age, race, sex; referring physician.
Chief Complaint: Reason given by patient for seeking surgical care; place reason in "quotation marks."
History of Present Illness (HPI): Describe the course of the patient's illness, including when it began, character of the
symptoms; pain onset (gradual or rapid), precise character of pain (constant, intermittent); other factors associated with pain
(defecation, urination, eating, strenuous activities); location where the symptoms began; aggravating or alleviating factors,
vomiting (characteristics, appearance, frequency, associated pain), change in bowel habits; bleeding, character of blood,
(clots, bright or dark red), trauma; recent weight loss or anorexia; other related diseases; past diagnostic testing.
Past Medical History (PMH): past diseases, all previous surgeries and indications; dates and types of procedures; serious
injuries, hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma,
myocardial infarction; hernia, gallstones.
Medications:
Allergies: Record the drug and the reaction
Family History: Medical problems in relatives. Family history of colonic polyposis, carcinomas, multiple endocrine
neoplasia (MEN syndrome).
Social History: Alcohol, smoking, drug usage.

REVIEW OF SYSTEMS (ROS):
General: Weight gain or loss; appetite loss, fever, fatigue, night sweats.
Head: Headaches, seizures.
Eyes: Visual changes, diplopia, eye pain.
Mouth & Throat: Dental disease, hoarseness, sore throat, pain, masses.
Respiratory: Cough, shortness of breath, sputum.
Cardiovascular: Chest pain, orthopnea, dyspnea on exertion, claudication, extremity edema.
Gastrointestinal: Dysphasia, abdominal pain, nausea, vomiting, hematemesis, melena (black tarry stools), hematochezia
(bright red blood per rectum), constipation, bloody stool, change in bowel habit; hernia, hemorrhoids, gallstones.
Genitourinary: Dysuria, frequency, hesitancy, hematuria, polyuria, discharge; impotence, prostate problems.
Gynecological: Last menstrual period, breast masses.
Skin: Easy bruising, bleeding tendencies.
Lymphatics: Lymphadenopathy.

PHYSICAL EXAMINATION
Vital Signs: Temperature, heart rate, respirations, blood pressure, weight.
HEENT: Head, Eyes, Ears, Nose, Throat
Neck: Jugular venous distention (JVD), thyromegaly, masses, bruits; lymph nodes.
Chest: Equal expansion; rhonchi, crackles, breath sounds.
Heart: Regular rate & rhythm (RRR), first & second heart sounds; murmurs (grade 1-6), pulses (graded 0-2+).
Breast: Retractions, tenderness, lumps, nipple discharge, dimpling, gynecomastia; axillary nodes.
Abdomen: contour (flat, scaphoid, obese, distended); scars, bowel sounds, tenderness, organomegaly, masses, liver span;
splenomegaly, guarding, rebound, bruits; percussion note (tympanic), costovertebral angle tenderness (CVAT), inguinal
masses.
Genitourinary: External lesions, hernias, scrotum, testicles, varicoceles.
Extremities: Edema (grade 1-4+); cyanosis, clubbing, edema (CCE); pulses (radial ulnar, femoral, popliteal, posterior tibial,
dorsalis pedis; simultaneous palpation of radial and femoral pulses), Homan's sign (dorsiflexion of foot elicits calf
tenderness).
Rectal Exam: Sphincter tone, masses, hemorrhoids, fissures; guaiac test for occult blood; prostate masses.
Neurological: Mental status; gait, strength (graded 0-5); deep tendon reflexes.

LABS: Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine), CBC; X-rays, ECG (if older than 35 yrs
or history of cardiovascular disease), urine analysis (UA), liver function tests, PT/PTT.

ASSESSMENT (Impression): Assign a number to each problem and discuss each problem separately.

PLAN: Describe surgical plans including preoperative testing, laboratory studies, medications, and antibiotics.

PREOPERATIVE NOTE
Preoperative Diagnosis:
Procedure Planned:
Type of Anesthesia Planned:
Laboratory Data: Electrolytes, BUN, creatinine, CBC, PT/PTT, UA, EKG, Chest X-ray; type and screen
for blood or cross match if indicated; liver function tests, ABG.
Risk Factors: Cardiovascular, pulmonary, hepatic, renal, coagulopathic, nutritional risk factors.
Consent: Document explanation to patient of risk and benefits of procedure, and document patient's
informed consent or guardian's consent and understanding of procedure.
Allergies:
Major Medical Problems:
Medications:

BRIEF OPERATIVE NOTE
(Written immediately after the procedure)
Date of the Procedure:
Preoperative Diagnosis:
Postoperative Diagnosis:
Procedure:
Names of Surgeon and Assistant:
Anesthesia:
Estimated Blood Loss (EBL):
Fluids and Blood Products Administered During Procedure:
Specimens: Pathology specimens, cultures, blood samples.

POSTOPERATIVE NOTE
Subjective: Mental status & patient's subjective condition; pain control.
Vital Signs: Temperature, blood pressure, pulse, respirations.
Physical Exam: Chest and lungs; inspection of wound and surgical dressings; conditions of drains;
characteristics and volume of output of drains.
Labs:
Impression:
Plan:

PROBLEM-ORIENTED PROGRESS NOTE
Problem List: Postoperative day number, antibiotic day number if applicable, hospital day number,
hyperalimentation day number. List each surgical problem separately (status post-appendectomy,
hypokalemia). Address each numbered problem daily in progress note.
Subjective: Write how the patient feels in the patient's own words, and give observations about the
patient.
Objective: Vital signs; physical exam for each system; thorough examination and description of wound;
condition of dressings; purulent drainage, granulation tissue, erythema; condition of sutures, dehiscence;
amount and color of drainage, laboratory data.
Assessment: Evaluate each numbered problem separately.
Plan: For each numbered problem, discuss any additional orders, surgical plans. Discuss changes in drug
regimen or plans for discharge or transfer. Discuss conclusions of consultants.

DISCHARGE SUMMARY
Patient's Name:
Chart Number:
Date of Admission:
Date of Discharge:
Admitting Diagnosis:
Discharge Diagnosis:
Attending or Ward Team:
Surgical Procedures, Diagnostic Tests, Invasive Procedures:
Brief History & Pertinent Physical Examination & Laboratory Data: Describe the course of the patient's
disease up until the patient came to the hospital including physical exam & laboratory data.
Hospital Course: Describe the course of the patient's illness while in the hospital. Include evaluation,
treatment, outcome of treatment, and medications given while in the hospital.
Discharge Condition: Describe improvement or deterioration in patient's condition.
Disposition: Describe the situation to which the patient will be discharged (home, nursing home), and
person who will take care of patient.
Discharge Medications: List medications and instructions.
Discharge Instructions & Follow-up Care: Date of return for follow-up care at clinic; diet, exercise.
Problem List: List all active and past problems.
Copies: Send copies to attending physician, clinic, consultants and referring physician.


Obstetrics and Gynecology
Clerkship website: www.utmb.edu/obgyn/students/default.htm

Textbooks:

Required:
Obstetrics and Gynecology for Medical Students (Beckman et al., required for EER 2
nd
year)
Obstetrical Pearls
Recommended by Faculty
Obstetrics and Gynecology (Hacker et al)
Obstetrics and Gynecology NMS
Current Diagnosis and Treatment in Ob Gyn (Appleton & Lange)
Williams Obstetrics
Student recommendations for the Shelf:
Information resources: First Aid for OB/GYN, High Yield, Case Files, Blueprints
Practice questions: Case Files, Case Files, Case Files, Blueprints, Pre-test

OB/ Gyn General Schedule (6 weeks)
General Schedule
o 2 weeks of Labor & Delivery/Triage
o 1 week of Antepartum
o 1 week of Postpartum
o 2 weeks of Clinic
o The OB/GYN rotations have varied from year to year so not all of the rotations below
may be applicable but are included to account for possible future changes.
Labor & Delivery
o Location: John Sealy 2
nd
floor
o Combination of Nights and Days; Night Schedule: 5:30pm-7am
o The rotation begins with the L&D team reviewing the board
o Students should split up C-sections and rounding on the L&D patients
o Main responsibilities: Update the board, Assist in the OR, Conduct/assist in vaginal
deliveries
o The Board
Each patient in the L&D floor documented on the board according to their L&D
status
Age, G-P- Status, Gestation, Dilation, Effacement, Station, Presentation,
Estimated Fetal Weight, Additional notes
Students are generally responsible for making sure the information is current and
correct.
o When you attend a delivery, C-section, tubal ligation just about anything get into the
habit of taking a patient sticker and writing on it: the procedure, and the resident/faculty
you worked with. At the time, you think youll remember these things but they start to
run together after a while. This will help you TREMENDOUSLY when youre filling in
your procedure sheet.
o Your L & D days are the least scheduled days. Dont wait around for something to
happen pick an intern or a resident and stick to them like glue. Im not kidding.
o I wish I had known that they want you to follow the interns around in L&D because they
don't tell you what to do and then if you just stand there waiting for someone to tell you
that you should be following a resident or intern around you get comments on your
evaluation that you were not a very enthusiastic student.
o If you want to deliver a baby pick an upper year that is more likely to let you get hands
on experience than an intern, who still wants to get experience themselves.
o Show initiative if you want to get hands on experience, dont stand back.
Clinic
o Outpatient Clinics
o Typical Hours are 8:00 am-4:00 pm
Galveston clinics are either OB/Well-woman exams or Gynecology/Oncology
Locations: Galveston, Texas City, Dickinson, Pearland, Angleton, Pasadena
Call the clinic the week before your rotation to get directions to where to report
You will shadow a resident, faculty, midwife, or nurse practitioner in clinic.
Antepartum & Postpartum
o You will have one week of each.
o Postpartum rounds early so the patients can be discharged as soon as possible. You
usually have to be there very early (5:30 am), but are done early, usually before noon.
Basically, you pre-round on patients write a couple notes, and then round with the
residents and attending. Then youll follow up on labs, etc. that need to be done before
patient discharge.
o Antepartum rounds later, after postpartum rounds. You usually arrive at 7:30 am and are
done early in the afternoon. Again, you pre-round on patients, write notes, and then
round with the team.
o These are good rotations to study on, as youll have some down time and a light schedule
for the most part.
Endocrine / Reproduction
o In addition to clinic responsibilities, students are expected to attend Endocrine
Conferences / Clinic dispersed throughout the week as assigned in the schedule.
o Follow the directions in the course syllabus as for the schedule. It is easy to miss
something.
o Know the recommendations for cancer screening for women for menopause clinic
o Review the fertility drugs from your Endo knowledge before you go to patient conference
these may come up.
o Chart review: Most of the time you wont get to see the patients you are assigned to look
up. However, you still need to know the information, because you will be asked about it
in conference. Pay attention to other peoples presentations in the morning you may
end up seeing their patients
Gynecology
o Location: John Sealy 9
th
floor
o Schedule: See patients on the wards in the morning, Attend clinic/OR in the afternoons
o Use your free time to study. In GYN you are generally supposed to split clinic days so
you have the morning or the afternoon off - study for the shelf.
o Try to see as many different operations as you can and read the sections in the text on the
problems involved on the day you see the surgery more will stick with you this way.
This is also true of GYN ONC, L&D, and REI
Oncology
o Location: John Sealy 9
th
floor
o Schedule: Ward rounds in the morning, Clinic/ OR in the afternoon
o The residents are really good at coaching you what you should and shouldnt say and
take their advice. If you say the patient is anemic have the H./H values because he may
ask. Dont be too narrative, just state problem, workup, solution. Hell ask you if he
wants details. Still, dont go on at length, hell cut you off if you talk too long.
o Dysplasia Clinic:
The goal is to be prepared for the team to see about 30 patients between 9:00 and
12:00, and these visits are very procedure intensive, (Paps, Colposcopy, Biopsies
(BX) Endocervical Curettage (ECC), LEEPs)
All the charts on these patients are divided up between the team members in the
conference
Review the chart find out the pertinent HPI for the patient
Each person summarizes the HPI for the patient and suggests plan of action. The
team agrees or tells you what the plan is
In clinic, you go in and see patients, explain the plan to them, answer questions
(as you can), and get any relevant updates before the residents get in to see them.
Review the algorithms for management of the abnormal Pap smear


Grading Components:
o Resident Evaluations
o Small Group Facilitator Evaluations
o NBME Shelf
o Team Learning Activity Quizzes
o Bonus points Lecture attendance

OB/ Gyn Required Skills Card (you will need to have these skills observed and signed by faculty)
o Bimanual pelvic exam
o Vaginal speculum exam
o Pap test/endocervical cuff cultures
o Interpret a fetal monitor strip
o Spontaneous vaginal delivery
o Various others

Small Group Presentations
Historically, these presentations have had a significant impact on grades. They can be just enough to
push you over the top if you are right at the break point between grades.
It is a good idea to pick OB topics for OB facilitators and GYN topics for GYN facilitators.

Oral Presentation Case presentation of an obstetric or gynecologic patient
You can present any patient you followed on service
Presentation should be done from memory
Formal H&P write-up of the case presented should be turned in to your small group faculty

Internal Medicine

The Basics
Carry some sort of pocketbook with you at all times to look things up in a hurry.
http://www.medfools.com has a great printout chart for you to keep patient vitals, checklist, etc. in
order. Keep a couple of them with you on the wards. My residents would even steal a copy to keep
their tasks in order too.

Textbooks
Student Recommended:
Pretest Medicine, Lange Case Files, Step-Up to Medicine
MKSAP for Students
Pocket Medicine is a popular pocket handbook
St. Francis guide for Inpatient medicine - great for the OSCE (There is currently no OSCE for
IM, but the information is included for when the OSCE is begun again.)
Know the differential diagnoses for abdominal pain, chest pain, shortness of breath, etc. Review
these several times; it is invaluable for IM and future rotations.
Washington Manual or Ferri Guide as a PDA resource for learning about your patients problems
while you write your notes
NMS for Medicine denser than some of the other resources.
Blueprints may be too superficial
Strong References: Cecils, Harrisons, Langes Current Medical Diagnosis and Treatment, and
especially Up to Date.

Clerkship Structure
The clerkship is 3 months long with each student serving on a different service each month. Usually,
each student spends one month on a general inpatient service and one on a consult service. The third
month may be spent on another general inpatient ward, a specialty inpatient ward, or at an outpatient
clinic.

Inpatient Wards
Most general inpatient teams consist of an attending, an upper level resident, 2-3 interns, 2-4 medical
students and a social worker. How the team runs really depends on the attending and upper level
resident. The role of the attending is to basically run rounds and do a little teaching while seeing the
patients. Some attendings really enjoy teaching and will hold outside lectures for students, while others
will limit teaching to quizzing the students during rounds. The upper level resident delegates
responsibility to the team members. They are the ones who will have the greatest impact on a students
experience. The interns and the students on the service carry out the work delegated by the resident and
attending. It is their responsibility to make sure there are no loose ends with any of the patients. The
social worker takes care of discharge planning and funding for patients.

Consult Services
The teams on the consult services are set up similarly to the inpatient wards, except that the fellow runs
the team and delegates responsibilities. There is some variability to the way the different teams work.
In general, the student will be given a consult, either at a morning meeting or by getting a page during
the day. The student will see the patient and write the consult- basically a full H&P focused to the
problems for which the team is being consulted. The team will then meet to round and all consulted
patients are then seen.

TDC
The TDC teams run basically the same way as the free world inpatients teams run. The only difference
is that there may or may not be a social worker assigned to each team. The pathology in TDC is also
quite different than the free world. There is also one team in the TDC that is specifically designated for
infectious diseases such as HIV. Be aware of what you can and cannot bring into the TDC. The list of
acceptable items is very small, so it is best to go in with as little as possible. If you are assigned to a
TDC month, you will be given a list of prohibited items.


Before Rounds
Check team's census
Print rounds reports (for some attendings)
3 vs. 7 days
Standard format vs. include all (other orders, radiology, etc.)
Make sure you ask your attending which type of rounds reports her or she prefers, some want
everything and some want only medications.
Check labs in Epic
Labs received but pending
Lab results
Check vital signs / nursing notes (teal chart, mostly in Epic)
Record Temp, BP, Pulse, Resp
I/Os
Check patient charts (gray charts, but mostly on Epic)
Progress notes
Consults
Lab / test / procedure results
See patients
Immediately notify doctor if patient has altered mental status or is unresponsive!!!
Do a focused Hx & PE
Strip drains, check wounds, etc.
Report to interns / residents
Report ALL patient changes / problems to house staff BEFORE, NOT DURING faculty rounds!!!
Decide on management (labs, meds, etc.)
Prepare presentations
Notes can be used during rounds ...
But try to present from memory as much as possible
Save notes from previous days (for reference, writing D/C summaries, etc.)
Write progress notes
Some doctors prefer that notes be written after rounds
Some doctors prefer that notes be started before rounds but allow for them to be finished after
rounds
Some doctors want notes done before rounds
Update and print census for team (if applicable)
Rounds
Some teams do table rounds first, meaning theyll talk about the patients first (discuss what
happened overnight, review labs, form a plan for that patient such as discharge, continue
treatment, alter treatment, etc.) After table rounds, the team will physically go room to room.
Internists like ranges reported on vitals. Report blood pressure as 140-200 / 70-110 instead
140/70
Medicine is all about trends. When charting labs, it is helpful to record what the previous values
were.
Chart review is essential in working up a patient.
Important things to look for in a chart:
o Old EKGs (for comparison)
o Discharge summaries
o Medications
o Operative notes
o Cath reports
o Pathology summaries
o Baseline labs
Patient presentation is generally in a SOAP format.
New patients are presented with an abbreviated history and physical.
When rounds are over with the entire team, you may meet again with the intern and resident to
go over the game plan for the rest of the day. Your job is to follow up on labs that were pending
and record them as an addendum in the progress notes. Additional duties may include phoning
hospital departments like CT, MRI, nuclear medicine, hyperbaric or special procedures to see
when your patients procedure will be done. You want to make sure that the ball is not dropped
and that the department has your patient on its schedule to do the test or procedure.
Another thing you might be involved with is discharging patients and helping the intern with the
paperwork associated with this.
Most of the above work is completed by early to mid afternoon so you may find yourself with
extra time to study and hang around the unit or the room where your team meets for report. Some
teams make afternoon rounds so you may find yourself busy all day long.

Medicine H & Ps
Dont fall behind.
Do your first 1 or 2 in the first week and wait for feedback. Often, they give you things to change
and you should make those changes on subsequent write-ups. Dont give your attending 3 or 4
H&Ps in the last week of the rotation, they wont appreciate it, and you have no time to adjust
your H&Ps to the feedback you receive.
Do them on the computer and learn the art of cut a paste

Call
Call is not overnight you stop accepting new patients in the early evening and you usually stop seeing
new patients usually around 10 PM. Grab your patients to do your H&P early if you want to go home at
a decent time.

Family Medicine
The Basics:
Covers healthcare from the womb to the tomb (sorry, couldnt let that one go)
No rounds, nice schedule, only the occasional weekend. Try to enjoy it.
Take the web cases seriously. Your answers are sent to the faculty, so keep them professional.
For any question on alternative medicine, check out Health Notes via UTMB library
(http://library.utmb.edu/HealthNotes)
If youre interested in doing more procedures or delivering babies ASK. You will get more
out of the experience if youre setting your own learning objectives
Patient education and preventive medicine are important. You will spend more time asking
about lifestyle, diet, etc. than you have in any other rotation.

Textbooks:
Student recommended to take to the OSCE
There is currently no OSCE for the FM rotation, but this information is included in case the
OSCE is brought back in the future.
The Family Practice Text: the one you check-out for the clerkship. GOOD to take to the OSCE.
Use these books throughout the clerkship. If you are not familiar with how they or organized
and what information is found in each resource it will take too long to find the information you
need.
Current Diagnosis or any good up to date reference you like best
Pocket Medicine
Sierpinas book on Complementary and Alternative Medicine
Preventive Medicine Screening:
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat3.section.10513 Tables are available at the
bottom of the right-sided column that has extensive screening recommendations by age group.
This is useful to print out and take to the OSCE.
Case Files (most likely a case will reflect one of your standardized patients)
Student Recommendations for the Exam
The exam is difficult. Other than the specific recommendations here, it would be a good idea to
review Step II focused resources.
NMS Questions for Family Practice: Available for loan from the clerkship office. Seems to be
universally recommended.
New Case Files for Family Medicine: good review of several topics for a short rotation (1
month)

Pediatrics
The Basics
Generally a good schedule.
Try to do your written H&Ps as early in the rotation as possible.
Do your observed H&P whenever an upper level offers, which might be early in the rotation.
You dont want to be part of the scramble at the end trying finish this.
The big topics are developmental milestones, nutrition, safety, immunizations, and viral vs.
bacterial illnesses.

Textbooks:
Student Recommended:
Blueprints for Peds
Case Files
Appleton and Lange Questions
Pretest

Call
Inpatient call: generally about 1x per week. To get the most out of it, give your pager number to
both the intern and the upper level on call. Then stick to them like glue to maximize your chance
to see and do stuff.
For call in the nursery, you are generally done at 10 pm. Specialty call is generally taken with the
inpatient team unless you are on PICU or ISCU. Then you will take it with the residents in that
unit.

Inpatient:
Morning report starts at 8 everyday and you are required to go unless you are in the nursery or in
ISCU. You need to have seen your patients and written a note before morning report.
The afternoon usually involves family meetings or other odds and ends.

Nursery:
Lots of paperwork, but the babies are fun to work with.
You will need to arrive between 6:30 and 7:30 a.m. to do mommy visits, record vitals on all the
babies, update the census, and see as many babies as you can on your own to present. All of this
is explicitly explained in the syllabus.
After rounds you will do more mommy visits, help with charting, or do whatever else is needed.
The nurse practitioners are very friendly and helpful if you have questions. They like to teach.
The afternoon is usually spent updating labs and the census, playing with the babies, or going to
the stand to assess a newborn.
You can also spend anytime you wish up in the transition nursery examining babies. If you like
hands-on, this is a good place to be.





In s and Out s
Ins: For babies, do this in cc/kg/d and cal/kg/day (if on formula). If breastfeeding, record how
long the baby nurses on each breast, and how often.
Outs: Urine cc/kg/hr (to 1 decimal point X.X cc/kg/hr), Bowel Movements how many and
describe if pertinent, Emesis
Record changes in weight as well as the current daily weight

Use the following table to convert milliliters into calories

Formula
Calorie Conversion Factor
(Calories in formula/30cc)
Enfamil/Similac w Iron/Lactofree (20 cal/oz) 0.67
Enfamil or Similac 22 or Neosure 0.73
Enfamil or Similac 24 0.8
Pregestamil/Alimentum/Nutramigen (20 cal/oz) 0.67
Kindercal (30 ca/oz.) 1.
Breast milk (20 cal/oz) 0.67

For the pediatric History and Physical Write-ups, dont forget to refer to the example that they provide
in the syllabus.



Electives
Listed below are various electives that medical students can take during 3
rd
year. Neurology, Senior
Surgery, and Emergency Medicine are ones that everyone is required to take before they graduate, so it
is great to complete them sometime in 3
rd
year to give you more time 4
th
year.

In General:
Try to schedule a senior elective during your third year elective month. This allows for a more flexible 4th year
(to set up away rotations, AI's, etc.) and allows you to knock out a required course early. However, there are a
few reasons to go ahead and do a non-required elective during your 3rd year:
a. Try out a field that youre considering but that you won't get to experience during your required 3rd
year rotations - i.e. radiology, derm, anesthesia, etc.
b. Travel to another city/country for an elective
c. Set up a research project with a particular faculty/lab or you want to continue a project that has already
been established. Remember, you need to get research approved before you can earn credit for a rotation.
And there are some reasons NOT to do a particular elective during your 3rd year:
Ex. - Even if you know you want to do pediatrics (or IM/OB/GYN/psych/surg, whatever), don't do a pedi
elective "just because" you think you should. You will get ample time to get all the experience you need during
your clerkship. This is a good situation where a 4th year rotation would be good to do during 3rd year.
Additional advice: try to do a rotation over the Christmas month. For the most part, people are pretty flexible
and you will still have time off for Christmas and New Year's. (Again this is very rotational specific.) If your
family lives far away, try to set up an away rotation in their city.

Senior Neurology (required before graduation):
This course is 4 weeks with 1 week in Geriatrics, 1 week on wards/inpatient, 1 week on Neuro consult, and 1
week of Neuro clinic. No call; weekends & holidays off. Good rotation to have if you want a break or need extra
time for other things. If you are interested in neuro, tell all of the doctors so that they will recognize you for a
neuro award at the end of the year.
Suggested Readings:
Boards & Wards - Neurology section
Any resource (for Step 2 study material) with a neurology section
Look through First Aid Step 1 to remind yourself of neuro pathologies (seizures, strokes, )
The chief resident gave the students a review shortly before the real test. This might change if the NBME
test is integrated.
Lectures
Stated in the schedule. Usually will be in the morning (8:00am) or lunchtime (Noon). However,
Wednesdays are busy because they squeeze in grand rounds, neuropathology, and radiology rounds in the
mornings as well.
Recommendations During rotation:
Geriatrics you will take a brief test on the first day, and then take the same test again on Thursday (to see
if you learned anything over the past week). You will be given a couple articles on delirium & dementia,
which you will discuss with one of the Geriatric fellows on Thursday. On Monday, Tuesday, and
Wednesday, you will be assigned to work in a geriatric clinic (ACE Unit/10
th
floor, Santa Fe Clinic,
Retirement home).
Inpatient/Wards: You pretty much follow the resident to the various neurology patients in the hospital.
Assess for strokes, seizures, paralysis, etc. You will be assigned 1-2 patients, and rounds will either be in the
morning or at 1:00pm in the afternoon (depends on faculty).
Neuro Adult clinic you will be busy, busy, busy. Pick up a patients chart and enter the room (do not ask
for the residents permission). Inform your resident of what you found, go in together, and then get the
blessing from the faculty (usual clinic proceedings)
Neuro Pedi clinic like the adult clinic, but with less patients. Lots of seizures
Neuro Consult come in at 8:00am to see if there are any new consults. If assigned a new patient, you will
see the patient first, then page/inform your assigned resident. If you do not have a new patient, check on the
previous consult patients that have not been signed-off. Then, wait in the consult room or the student lounge
on the 9
th
floor to be paged for new consults. You will present new consults in afternoon rounds (the faculty
for consult is the same for Inpatient/Wards. After the Inpatient/Wards team is done with their rounding, then
you will round for the consult patients).

Senior Surgery (required before graduation)
1) Course structure- You will be assigned a surgery service based on preference although many people
do not get what they want: Dr. Mileski does not want you doing a service that you were on for the junior rotation.
Really you just participate in the required clinical/OR duties of the service - it's just an additional surgery month
without the shelf exam at the end.
2) Required activities- Participate in the service activities, trauma call 2-3 times during the month as
assigned, autopsy experience: you will be paged to participate in one autopsy during the month-you are notified
the day of the autopsy and given an orientation to what you need to do that day. The autopsy day is pretty easy,
just show up - there is an autopsy report that is required to pass the course. The format of the report and an
example will be given to you.
3) Grading- grading if based entirely on evaluations and whether or not you complete the senior project.
The project is optional but if you do not complete it you can not make above a passing grade. If you choose to do
the project you can either high pass or honor the course based on the quality of your project and evaluations. The
project consists of a literature review of any topic you pick (basically you summarize 10 articles and draw
conclusions about medical practice based on your review).
4) Recommended readings - nothing
5) General advice- have a good attitude. Look at this as another surgery month instead of a month to do
as little as possible. In the past the seniors have used this course as a vacation month and Mileski is not letting
that fly anymore. So, just try to enjoy the fact that there is no shelf to worry about and if you just show up and
complete the required activities it will be fine. Obviously, if you want to do surgery it might be a good idea to
complete the project.

Senior Emergency Medicine (required before graduation)
Generally a good rotation that consists of 12hr shifts (6 day shifts, 6 night shifts), 1 ambulance ride shift and
1 poison control shift.
Always remember your shift card!!! And get them signed!!!! This is the way they know you attended shifts.
You sign up for shifts prior to rotation, but you are allowed to switch shifts (make sure you tell Martha, the
coordinator)
ER is great for allowing you to do procedures, pick and choose patients that interest you, and that you think
you will be able to do procedures (sutures, vaginal exams, line-placement, etc.).
There is a procedure card that you must complete. You must get signatures for 15 procedures (many can be
repeated) such as IV placement, laceration repair, etc.
The physicians working in the ER are great at letting you get involved as much as you want, and you get to
work directly with them often. When presenting make sure you keep things to the point, while not skimping
too much on the details. Make sure you get the HPI and a focused physical. They also want you to get the
PMH, FH, & ROS, as these are the only things you can actually enter on Epic.
Basically, just act interested, volunteer to see patients and do procedures, and things will go great.

Clinical Dermatology Rotation (not required but very informative and not as time-demanding)
Best book is Dermatology Secrets. Otherwise, they have a great library in the derm clinic. Get involved in a
project if you are interested.
.
Appendices

History & Physical Template: A Template for the JMS H&P. Please make copies to help you outline
your H&Ps.



Date/time: J MS History and Physical PCP:
Chief Complaint: Allergies:
History of Present I llness:














PMH:


Medications:





Family History: Father: Mother: Siblings: Other:
Social History: Lives in: Tobacco: Etoh:
IVDA: Blood transfusions: Tattoos:
Review of Systems:
1. General: Fever Chills Night sweats Weight change
2. HEENT: Tinnitus Decreased hearing Blurred vision Diplopia HA
Epistaxis Rhinorrhea Congestion Sore throat Hemoptysis
3. Chest: Shortness of breath PND Orthopnea Dyspnea on exertion Cough
4. Cardiovascular: Chest pain Pleurisy Palpitations
5. Abdomen/GI : Pain Constipation Diarrhea Melena Hematochezia BRBPR
6. Extremity: Pain Swelling Claudication
7. Skin: Rash Pruritus
8. Neurological: Dysarthria Coordination Balance Syncope
9. Musculoskeletal: Joint pain Weakness Swelling
10. Genitourinary: Increased frequency Dysuria Hematuria Foul odor Pain
11. Hematological: Bleeding Bruising Recurrent infections

Physical Exam: Temp Resp HR O2 sat BP
General:
HEENT:
Neck:
CV:
Chest:
Abd:
Ext:
Neuro:
Skin:
Rectal: Cal AST Tn
Labs: MCV Phos ALT CK
Diff: Mag AP MB
RDW GGT Alb BNP
baseline Hgb: baseline Cr: TSH Amyl Lip
EKG: UA: PT
CXR: I NR
Other: PTT