The Medical Internship: Your
The Medical Internship: Your
The Medical Internship: Your
• Interns are responsible for treating patients under appropriate supervision. They have to ensure
that their functions are carried in a good manner and more priority is given for the patient' s
safety.
• Check the patients while they are getting admitted or discharged and fill in the right details about
them. To order and interpret diagnostic tests is one of the duties which are carried by intern
doctors. They are the one who initiate and monitor the treatments given to the patients.
• Communication with patients and their relatives is essential. Intern doctors are the ones who
take responsibility for communicating with them and other hospital clients. These doctors also
attend meetings at their work place that are related to any particular complicated case.
• They co-operate with investigations, audit, or enquiries that are related to the provision of
health. They do take a daily round through all the patients for their regular check up and
assistance regarding any health issue.
Medicine
or elective
( Medicine )
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Medicine
Medicine
(1 October 2013 )
(1 October 2013 )
• Signature or stamp .
16 / 10/ 2012 The medical internship
Physician progress note
• Use SOAP format for physician progress note.
• Always start with seen with or end with plan
discussed with your seniors.
• Add any updates to patient condition or any
new ( lab or radiological )investigation
• Subjective :
Still c / o cough and yellow sputum but no more chest pain or SOB and no more vomiting
• Objective :
Tem ( 38 °C to 40 °C , BP 125 / 55 mmHg , HR 90 BPM ,RR 12 / m , O2 sat 99 % on 2 L Oxy ( was on 4 L )
Gen. exam : not pale or jaundice and no respiratory distress
Resp :normal chest expansion , dullness on the left lung base with reduced breath sound , bronchial
breathing and coarse crepitation
Rest of exam unremarkable
Labs : WBC 8 ( 14 on admission) , blood & sputum culture grew strept. Pneumonia that is pan-sensitive
• Assessment :
A 34 Y O M with CAP ( pneumococcal ) , responding to Abx therapy
• Plan :
Stop azithromycin and continue ceftriaxone
Stop IVF as patient has no more vomiting and tolerating oral intake
Encourage mobilization
Possible discharge tomorrow
Dr. AlRowaie
ID 59050
Patient seen with Dr.Arshad and agreed on the above plan Pager 3232
16 / 10/ 2012 The medical internship
16 Oct 2012
14:00
Admission order
• Admit to MMW under care of Dr Arshad , IM section
• Diagnosis : CAP others : DM , HTN
• Allergy : NKA
• Vital signs : Q 4-6 hours ( if DM add gluco check)
• Activity: As tolerated
• Diet : Regular
• Investigation: CBC , Electrolyte , LFT , blood and sputum G.S and culture , CXR ( done in
ER )
• Medication:
Oxy to keep sat above 94 %
IVF , D5NS @ 100 cc / hr
Paracetamol 500 mg every 6 hours PRN for pain and fever
Ceftriaxone 2 g IV OD
Azithromycin 500 mg OD for 3 days
Enoxaparin 60 mg subcut OD Dr. AlRowaie
ID 59050
16 / 10/ 2012 The medical internship Pager 3232
Discharge summary
• Patient demographic data
• Diagnosis ( discharge or admission diagnosis)
• Other Diagnoses :
• CC, HPI , PMH ,FH ,SH, Allergy and BT hx
• Systematic review
• Investigation ( labs , radiology , pathology etc )
• Hospital course
• Discharge medication
• Discharge plan Dr. AlRowaie
ID 59050
16 / 10/ 2012 The medical internship Pager 3232
Consultation
• Before calling, be sure you understand why
you’re calling a consult .
• Always start by introducing your self
• Never say we just wanted to get you on board.
• Never call the consultant directly .
• Prepare and document all related labs ,
investigations , reports , medication list .
• Reliable
• Bring energy and enthusiasm
• Dress well
• Balance self-sufficiency with asking questions
• Participate
• Stay flexible
• Pay attention to detail
• Network
16 / 10/ 2012 The medical internship
16 / 10/ 2012 The medical internship
Advices for successful internship