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Crimson Book:
A CLINICAL REFERENCE GUIDE
17TH EDITION, 2014-2015
Edited by
The UASOM Class of 2015
Tuscaloosa Campus Representatives
on the wards. It includes elements of many pocket manuals,
reference books, journal articles and websites as well as
personal experiences of those who came before you. All of
the information was double checked to make sure that it is
correct and as up to date as possible. You will find there are
many facts in this book that can make your life easier if you
read each clerkship section prior to and during that rotation.
It is impossible to thank all the students, residents, and
attendings who have been involved in the conception and
continued efforts to produce this reference book each year.
Thanks to the founding authors of the class of 2002 and all
those who have put in effort since.
Good luck on your rotations!
Love,
UASOM Class of 2015, Tuscaloosa Campus
Page 3
Normal Lab Values
Reading EKG
Approach to Tachycardia
Reading CXR
Acid/Base disorders
Evaluating LFTs
Evaluating Anemia
Managing Ventilator
Notes and Orders
History and Physical
Internal Medicine
Cardiology
Endocrinology
Fluids, Electrolytes, Nutrition
Gastroenterology
Hematology
Infectious Disease
Nephrology
Oncology
Pulmonary
Rheumatology
Neurology
Psychiatry
Pediatrics
OB/GYN
Prenatal Charts
Surgery
Family/Rural
Abbreviations
Page 4
14
15
17
18
19
20
22
23
24
25
26
32
35
37
41
44
47
51
53
54
55
56
62
68
74
80
82
89
91
medical school as though it is just that – school. But it is meant to be
much more than that, particularly as you enter into the clinical years.
At this campus, we have the opportunity to work very closely with the
attendings, at times even one-on-one, almost as though it were an
apprenticeship. Take advantage of this! We encourage you to approach this year with the same commitment, work ethic, and professional attitude that you would your residency or any other job. Often
the hospital staff does not distinguish between the residents and the
medical students. You may even be called “doctor” in passing – try to
conduct yourself in a manner worthy of that title. It will not be long
until you have it.

You are here to both learn and to be involved in patient care – don’t
underestimate your role in the latter. It is true that a resident or attending will almost always come behind you to talk to patients, examine
them, and write a note. However, that does not mean that your work is
superfluous. Perhaps, a patient tells you something that he didn’t tell
anyone else, or you find something on exam that you can alert the rest
of the team to. You can participate effectively in patient care if you
make the effort to. And your role is important if for no other reason
than for your own learning! There will come a day when you are the
resident or the attending, both of which come with much more responsibility. Take advantage of the practice!
2. Medicine is both a team sport and a hierarchy – remember where you fit into both.

As you know, the preclinical years require relatively little group collaboration, and it is easy to get into the mindset that it is all about you.
You try to learn as much as possible to do as well as possible on the
exams. It is important as you transition to the clerkships that you
remember that it is NOT all about you. You are still here to learn as
much as possible (and hopefully do well on the exams), but keep in
mind that the purpose of your learning is much bigger than an exam
grade. You are here to learn to become good doctors and to take good
care of people.
Page 5
patient receive better care, but you will learn much more if you interact
well with the various members of the treatment team, whether they be
attendings, residents, other medical students, nurses, PCAs, pharmacists, physical therapists, social workers, etc. Be polite to everyone –
being a medical student does not make you better than anyone else in
the hospital. The staff can easily help you or hurt you – try to stay on
everyone’s good side. If you have a problem with a particular staff
member, notify your resident or attending, and let them help you take
care of the situation.



Try to remember that you are not the only person who is here to learn.
Don’t try to take all of the patients or answer questions directed at
another student or resident. It may make you stand out to the attending,
but probably not in the way that you want it to. Always fully check out
your patients to the other members of your team.
It is a good idea to find your resident before rounds each morning and
make sure you got the same story from the patient and that you are on
the same page about the treatment plan. This is to benefit both of you –
often the resident will know more about what happened overnight than
you do. It also gives you a chance to ask any questions about the plan
and for them to help you prepare for any questions you might be asked
by the attending. If you help your residents, they will help you! In
general, they want you to do well. Do not withhold patient information
from them, try to show them up, or throw them under the bus – it will
not make you look good!
The atmosphere on this campus is quite laidback, but a hierarchy does
still exist. We are privileged here to work so closely with the attendings
and residents, but do not take advantage of this relationship. Be respectful of the fact that they do still have authority and seniority, and
be thankful that you are not constantly reminded of that as some medical students are during their clerkships. There are boundaries! You will
often be invited into the doctor’s lounge to eat breakfast and lunch with
your attendings. That does not mean that you are allowed to eat there
whenever you want.
Page 6
lounge on the 4th floor.

Bottom line – being a medical student does not buy you any special
treatment. Be respectful of those above you, of your fellow students, of
the hospital staff, and finally of the patients and their families. Remember that you are part of team whose purpose is optimal patient care. If
you function well in this role, your life will be easier, and you will draw
positive attention to yourself.
3. Dress professionally and appropriately.


You have most likely already been given this speech, complete with a
laundry list of dos and don’ts. It may seem unnecessary to remind you
what constitutes professional dress and what does not, but this continues
to be a problem. Wardrobe restrictions are not arbitrary. Think about it
– you will be directly involved in patient care, which means two things.
First, you want your appearance to instill confidence in your patients and
make them feel like they can trust you to take care of them. Although it
may seem silly, your patient’s may make assumptions about your maturity, trustworthiness, and competence based on your appearance –
don’t give them a reason to doubt you. Second, remember that patient
care involves lots of moving around, whether you are examining patients
or walking to make rounds. Make sure that your outfit is appropriate
even when bending over or squatting as may be required during a patient
exam. Comfortable shoes are a must!
It is important to dress professionally but also appropriately for the
clerkship you are on. The dress code will vary from rotation to rotation
and should be addressed in orientation for each clerkship. When in
doubt, ask someone! In general, you are required to wear dress clothes
for Internal Medicine, Pediatrics (if working in clinic), Psychiatry,
Neurology, and Family Medicine (may differ based on preceptor).
Scrubs are appropriate (and encouraged) for Surgery and OB/GYN. This
should go without saying, but make sure to wear appropriately sized
scrubs – they are not meant to be fitted!
Page 7

Chances are that of the six required clerkships, there will be a couple
that you love, a couple that you hate, and a couple that you are indifferent to. Regardless of how much you like a particular clerkship, try
to make the most of the experience and learn something. You have
probably been told to approach each clerkship as though that is what
you are going to do the rest of your life. Using this approach, you will
likely take each clerkship more seriously and really get something out
of it. Don’t fall into the trap of thinking that you won’t need to know
at least something about each of the basic specialties in your future
career – medicine is not that compartmentalized. Try to soak up as
much as possible now because you likely won’t be exposed to many of
these fields again in the same way. It will make you a better doctor in
whatever specialty you choose. This approach will also help you
discern what field you would like to pursue. Students are often surprised by which fields they like and which ones they don’t. If you
spend some time each block thinking about what you do and don’t like
about that specialty and why it would or wouldn’t be a good fit, it will
hopefully provide some clarity about what you are looking for out of
your career and guide you in the right direction. Try not to approach
any of the clerkships with the preconceived notion that you will hate it
– you might be surprised!
5. Don’t complain!

Third year is hard – there will be times when you are tired, stressed,
and overwhelmed. Try to take it all in stride, and remember that you
can handle anything for a few weeks. Keep doing whatever you did in
the first two years to relieve stress – exercise, go out with friends, read
for pleasure, or whatever else you find helpful. You will have some
free time this year, more on some rotations than on others. It is important for your own well-being that you make time for yourself and
for the people in your life that are important to you. With that said, try
to maintain a good attitude at work and be willing to help. Complaining will not solve any of your frustrations. It will just make you and
the people around you miserable.
Page 8
tation. In general, students may be excused from duties two days per 8week block without penalty. These are NOT meant to be vacation days!!
These days should only be taken when necessary – illness, death in the
family, etc. Clerkship directors are often understanding if you need time
off for other events, such as weddings or medical conferences out of
town. If there is such an event that you need to miss work for, discuss
this with your clerkship director in advance, but do not take advantage of
this privilege. If you do miss more than two days per block, you and the
clerkship director will have to discuss a way for you to make up the time.
7. General study tips

You will notice as you read through the information for each clerkship
that we have provided some study tips and a list of resources that may be
helpful. We purposefully made the information fairly general because
there is no one way to study in each clerkship or to master each shelf.
After surviving the first two years of medical school, you should have a
fairly good idea of how you most effectively study – stick to that. You
probably know if you like textbooks with more detailed explanations or
more of an outline format, if cases improve your retention or not, and if
practice questions are helpful or not. Guide your studying for clerkships
based on what has worked for you in the past. Because the format is
different and your independent study time is more limited in third year, it
may take some trial and error in the first couple of blocks for you to get a
good handle on what works for you. It can be helpful to talk to other
students about what they found useful, but remember that you may study
differently than they do.
The following is a short description of each of the commonly recommended
texts/resources used in the clerkships:

Blueprints – essentially a “mini-textbook” and one of the lengthier
review books (generally 250 – 300 pages varying with specialty). Written in sentence and not outline form. Probably best used as a resource to
read throughout the clerkship but not good for quick review in the week
or two leading up to the shelf. Often contains good pictures and tables.
Page 9
each topic. Good tables for quick reference.




Case Files – presents information in case format followed by a short
explanation about the diagnosis, treatment, etc. Helpful because shelf
exam questions are in the form of clinical vignettes, and the cases give
the information context. Good for shelf exam review but not for reading
about a particular condition.
Pretest – typically contains about 500 questions, some in board-style
format and some not. PDF versions are available on the UMC network
for free. Particularly helpful if you learn well by doing practice questions. The questions are not always representative of what you will see
on the shelf exam – sometimes easier, sometimes harder, sometimes
more obscure – but it is still a useful resource.
USMLE World Step 2 CK QBank – many of you probably used this
QBank for Step 1, and it is equally as helpful for Step 2. The shelf
exams, or mini-boards, or designed to be just that – specialty-specific
versions of the Step 2 CK exam. This QBank includes questions that
closely resemble what you will see on your shelf exams and actual
boards. However, subscriptions are expensive, ranging from $99 for 1
month to $399 for 12 months. It is by no means necessary that you
purchase a subscription. In fact, some students choose not to because
they want to save that QBank for when they study for the actual Step 2
exam. However, it is an extremely useful resource if you do decide to
purchase a subscription, particularly for internal medicine. The vast
majority of the questions (about 75%) are classified as internal medicine
questions, and therefore, it is probably most worthwhile to have during
that clerkship.
Most of these resources are available at the Health Sciences Library and
can be checked out. It might be a good idea to at least review the library’s copies initially to get some sense of what format you might like
before you purchase anything.
Page 10





Maxwell Quick Medical Reference – you may have already purchased
one of these for ICM but if you haven’t you NEED one! It contains a
plethora of information – normal lab values, progress note formats,
physical exam cheat sheets, and much more – and fits nicely into your
coat pocket. Familiarize yourself with what information it contains – it
can be your best friend!
Pocket Medicine – very useful pocket guide, particularly on Internal
Medicine, but not a bad thing to have in your white coat at all times.
Great resource to quickly look up information while on rounds.
Sanford Guide To Antimicrobial Therapy – annually updated handbook of the antimicrobial drugs, what they are used for, and how to
prescribe them. Not the easiest format to navigate but considered by
some to be a necessity.
Boards and Wards – concise review of all of the third year clerkships,
which can be helpful, both while you are on the rotation and as a quick
review the week of the shelf exam. Not a must-have but useful.
Clinician’s Pocket Reference: The Scut Monkey’s Handbook – diverse
handbook that contains a lot of helpful information about life on the
wards. It reviews the H&P, format for different types of chart notes,
fluid management, bedside procedures, ECG reading, commonly used
medications, and much more. Not a must-have but full of a ton of
information that can make you look like an all-star.
Page 11
method for that particular clerkship during orientation. It does
differ slightly from one rotation to the next, but in general, about
70% of your grade will come from clinical evaluations from your
attendings and about 30% will come from your scaled shelf exam
score. A few of the clerkships have other components – oral
exams, observed H&P, etc. – that might factor in, but this is the
general grading format. We won’t go into specifics about how
your grade is calculated, but we wanted to touch on a couple of
major points. First, it IS possible to get Honors on a clerkship.
That is not to say that it is easy to get, but it is possible. There will
most likely be a time before this year is over that you get frustrated with the grading system because you don’t feel like your grade
is representative of the work that you put in. It has happened to all
of us, but try not to complain.

If you have concerns, express them to the appropriate party in a
reasonable fashion. No one can tell you that grades don’t matter,
but as mentioned above, keep in mind why you are here – ultimately, it is to take care of people and to learn how to be a good
doctor. You will probably have much more luck obtaining the
Honors designation if you focus on your daily responsibilities,
taking care of your patients, working well with your team, and
reading and studying than if you focus on how to get Honors. Try
not to get frustrated. Don’t fall into the trap of deciding that you
won’t be able to get Honors and therefore are not going to even
try – think about what that says to your attendings about your
commitment to the ultimate goal of your education. Again, it is
not all about you!
Page 12
1 kg = 2.2 lb
1 oz = 30 g
A/a gradient: (713 x FiO2 – PaCO2/0.8) – PaO2
Absolute neutrophil count:
WBC x (Seg% + Band%)/100
39.4C = 103.0oF
40.0C = 104.0oF
Fractional Na+ excretion:
“U kNow the SeCret” is a good mnemonic for the numerator.
(UNa x SCr) / (SNa x UCr)
Ideal body weight (kg):
♂: 51.65 + 1.85 x [ht(in) – 60]
♀: 48.67 + 1.65 x [ht(in) – 60]
Anion gap: Na+ – (HCO3 + Cl-)
Basal energy expenditure (kcal/day):
♂: 66.5 + 13.75 x wt(kg) + 5.003 x ht(cm) – 6.775 x
age
♀: 655.1 + 9.563 x wt(kg) + 1.85 x ht(cm) – 4.676 x
age
Body mass index (BMI): kg/m2 or #(703)/inches2
<19 underweight, > 30 obese, > 40 very obese
Body surface area (m2): sqrt [ht (cm) x wt (kg) / 3600]
Body water deficit (liters):
[0.6 x wt(kg) x (Na+ - normal Na+)] / normal Na+
Ca2+ corrected for albumin:
[0.8 x (normal albumin – patient albumin)] + Ca2+
Creatinine clearance: (estimate of GFR)
[UCr x urine volume(mL)] / [SCr x time (min)] or
[(140 – age) x wt(kg) (x 0.85 if ♀)] / [72 x SCr (mg/dL)]
Page 13
Mean arterial pressure: DBP + (SBP – DBP)/3
Na+ corrected for - glucose: Na+ + [(glu-100)/100]x 1.6]
Osmolality: 2 x Na+ + glc/18 + BUN/2.8
Reticulocyte production index:
% retics x (hct/45) / retic maturation time (days)
Urine Anion Gap (UAG) = (UNa + UK) – UCl
Winter’s equation (expected PaCO2 in met. acidosis)
(1.5 x HCO3-) + 8 (± 2)
Water deficit (WD) hypovolemic hypernatremia (L):
0.6 x body wt (kg) x (P[Na]- Nl[Na})/Nl [Na]
Expected PaO2 in a normal patient:
103 – 0.4 x age
Chloride
Bicarbonate
BUN
Creatinine
Glucose
Calcium
Phosphate
Magnesium
Anion gap
Osmolality
98 – 106 mEq/L
22 – 29 mEq/L
7 – 18 mg/dL
0.6 – 1.2 mg/dL
70 – 115 mg/dL
8.4 – 10.2 mg/dL
2.7 – 4.5 mg/dL
1.3 – 2.1 mg/dL
7 – 16 mEq/L
275 – 295 mOsm/kg
Protein
Albumin
Total bilirubin
Dir. bilirubin
Lipase
Amylase
SGOT/AST
SGPT/ALT
GGT
AlkPhos
Uric Acid
LDH
Free T4
TSH
6.0 – 8.0 mg/dL
3.5 – 5.5 g/dL
0.2 – 1.0 mg/dL
0.0 – 0.2 mg/dL
10 – 140 U/dL
25 – 125 U/dL
7 – 40 U/L
7 – 40 U/L
9 – 50 U/L
38 – 126 U/L
2.0 – 6.9 mg/dL
120 – 240 U/L
0.71 – 1.85 ng/dL
0.32 – 5.00 IU/mL
ARTERIAL BLOOD GASES
pH
7.35 – 7.45
PaCO2
35 – 45 mmHg
PaO2
80 – 100 mmHg
HCO321 – 27 mEq/L
O2 Saturation
95 – 98%
Base Excess
 2 mEq/L
Page 14
Hemoglobin
Hematocrit
MCV
MCH
MCHC
Platelets
RDW
Segs (Neuts)
Lymphocytes
Monocytes
Eosinophils
Basophils
13.5 – 17.0 g/dL
39 – 50%
80 – 96 fL
27 – 33 pg/cell
32 – 36% hgb / cell
150 – 400 x 103 / L
11.0 – 16.0%
35 – 73%
15 – 52%
4 – 13%
1 – 3%
0 – 1%
URINALYSIS
Color
Turbidity
Specific Gravity
pH
Ketones
Protein
Blood
Glucose
Nitrite
Leukocyte Esterase
Osmolality
Sodium
Potassium
<yellow>
<clear>
1.003 – 1.035
4.5 – 8.0
<negative>
<negative>
<negative>
<negative>
<negative>
<negative>
50 – 1400 mOsm/kg
40 – 220 mEq/day
25 – 125 mEq/day
COAGULATION
PT extrinsic, Coumadin
INR extrinsic, Coumadin
PTT intrinsic, Heparin
Bleeding Time
Thrombin Time
Fibrinogen
12.3 – 14.2 sec
2 -- 3 therapeutic
25 – 34 sec
2 – 7 min
6.3 – 11.1 sec
200 – 400 mg/dL
 PR interval: normally 0.12 to 0.20 seconds (will not exceed a large box)
 QRS interval: normally 0.04 to 0.10 seconds (no larger than half a large box)
 QT interval: should be less than half the R-R interval (if HR < 100) or [QT/(? RR)]
5.
Axis deviation – net QRS deflection should be positive in both leads I and aVF
 Right axis deviation: QRS negative in I, positive in aVF
 Left axis deviation: QRS positive in I, negative in aVF, negative in II
6.
INTERPRETATION
A. Infarction
 Q waves: normal (<1 small box) Q waves can be seen in lateral leads (I, aVL, V5 to V6). Enlarged
by ventricular myocardial enlargement, conduction abnormalities, and MI. To localize the
infarction, look for groupings of Q waves in the following leads…
Inferior
II, III, aVF
R or L Coronary
Posterior, AV Node
V1 and V2
RCA
Septal
V1 and V2
LAD
Anterior
V1 and V4
LAD
Anterolateral
V5 and V6, I, aVL
Circumflex
 R wave progression: transition should occur between V2 and V4.
 ST segment elevation or depression: ischemia is associated with ST depression, while infarction is
associated with ST elevation “convex, tombstone”. Look for changes in two adjacent leads.
 T wave inversion: may be normally inverted in III, aVF, aVL, and V1. T wave inversion indicates
areas of ischemia in Q wave infarctions. Also see B. Metabolic.
B. Metabolic Effects/Others
 Hypokalemia: ST depression, decreased or inverted T waves, U waves
 Hypocalcemia: prolonged QT, flat or inverted T waves
 Hypercalcemia: short or absent ST, decreased QTc interval
 Hypomagnesemia: prolonged QT, flat T waves, prolonged PR, aFib, torsade
 Hypermagnesemia: short PR, heart block, peaked T waves, widened QRS
 Digitalis toxicity: ST depression (scoop), flat T waves
 Quinidine: prolonged QT, widened QRS
 Pericarditis: diffuse ST elevation with PR interval depression
 Wolff-Parkinson-White Syndrome – ventricular preexcitation syndrome (extra tracts that need to be
ablated), delta wave
C. Arrhythmias
 Tachycardia – >100bpm, see next chart
 Bradycardia -- <60 bpm
 Sinus Bradycardia -- most often caused by ? Vagal or ? sympathetic tone or sometimes by
intrinsic Dz of sinus with ? spontaneity and impulse generation rate.
 AV Block (2nd, 3rd Degree) -- see E. Conduction Delay
 Junctional and Escape Rhythms – impulse from AV junction, 40-60 bpm, no normal P waves
seen (may be hidden in QRST or inverted) with narrow QRS. Junctional escape rhythm is the
failure of the sinus node or atrial focus to assume pacing.
 Extra Beats
 Premature Atrial Contractions – ectopic focus in atrium, P wave usually has different morphology
than NSR, and occurs early and followed by compensatory pause.
Page 15
E. Conduction Block/Delay
 Heart Block (AV block)
 1st Degree AV block: PR interval > 0.20 sec
 2nd Degree AV block
o Mobitz I: (Wenckebach) PR interval progressively widens until a beat is dropped
o Mobitz II: PR interval is prolonged, randomly dropped beatNeeds pacemaker
rd
 3 Degree AV Block: No connection (dissociation) between atrial and ventricular ratesNeeds
Pacer
 Prolonged QT – Drugs (antiarrythmics, tricyclics, phenothiazines), low electrolytes, acute stroke/bleed,
BBB or conduction delay, and congenital
 Left Bundle Branch Block (LBBB) – “Bunny Ears;” wide QRS; lateral lead RSR’; ST depression and
inverted T; more (-) than (+) in V1.
 Right Bundle Branch Block (RBBB) – “Bunny Ears,” wide QRS; V1 and V2; R’>R; wide S in I, V5, V6;
and more (+) than (–) in V1.
Page 16
Tachycardia
(> 100 bpm)
No relationship between
P waves and QRS
Constant relationship between
P waves and QRS
Wide QRS (> 0.12 s)
Typically ventricular origin
APPROACH TO THE PATIENT WITH TACHYCARDIA
Irregular rhythm
No distinct P waves
WPW
Supraventricular Tachycardia
with Aberrant Conduction
> 3 P wave shapes
Atrial Fibrillation
Ventricular Tachycardia
Multifocal Atrial
Tachycardia
Short PR interval
Delta wave (QRS)
Wide QRS
Shock 200, 300, 360J!
Causes death rapidly if
not treated.
Chaotic, irregular
appearance without
discrete QRS forms
Ventricular
Fibrillation
Irregularly irregular
Atria @ 350-600 bpm
Ventricles @ ~160 bpm
Torsades
De Pointes
100-200 bpm
Wide QRS with variant
AV dissociation
amplitudes “twisting”
QRS may be mono- or
about baseline.
polymorphic
QT prolongation
“Sustained” if > 30 sec or Quinidine, procainamide,
requires termination due
hypocalcemia,
to severe symptoms.
hypokalemia,
hypomagnesemia
Ventricular
Tachycardia
Seen in COPD’ers with
pneumonia or respiratory
distress; > 100 bpm
Often asymptomatic
Not related to P wave
Common following
acute MI
Appearance of two or
three in a row is a
marker of increased
mortality.
Ventricular
Premature Beats
Atrial Flutter
Atria @ 250-350 bpm
Saw-toothed P waves
2:1 AV block most
common
Slows, but does not
revert with carotid
massage.
Non-reentrant
Atrial Tachycardia
Narrow QRS
pically supraventricular
RT
250 bpm
Atria @ 130-250 bpm
III, aVF) or
Peaked P waves
re QRS or
g QRS
turns to
AV block may increase
carotid
and does not revert with
ge.
carotid massage.
Page 17
2.
3.
4.
5.
6.
7.
8.
9.
B = Bones: are the clavicles, ribs, and sternum present and are there fractures?
C = Cardiac silhouette: is the diameter of the heart > ½ thoracic diameter or R atrium >1 fingerwidth
(enlarged)? Hypertrophy or Pericardial Effusion?
D = Diaphragm: are the costophrenic and costocardiac margins sharp? is one hemidiaphragm enlarged
over another? is free air present beneath the diaphragm?
E = Effusion/empty space: is either present?
F = Fields (lungs): are there infiltrates, increased interstitial markings, masses, air bronchograms,
increased vascularity, or silhouette signs?
G = Gastric bubble: is it present and on the correct (left) side?
H = Hilar region: is there increased hilar lymphadenopathy?
I = Inspiration: did the patient inspire well enough for 10 ribs to be counted, or was the patient rotated?
Method 2: A random method adapted from Ferri.
1.
Check for over or underpenetration – if underpenetrated, you will not be able to see the thoracic
vertebrae, a very common problem.
2.
Verify right and left by looking for the gastric bubble and at the heart shape.
3.
Check for rotation – does the thoracic spine align in the center of the sternum between the clavicles?
4.
Was the film taken under full inspiration – are 10 posterior or 6 anterior ribs visible?
5.
Is the film a portable, an AP, or a PA film? Remember that the heart will be enlarged on an AP film; thus
the cardiac silhouette cannot be accurately judged. PA looks sharper.
6.
Check the soft tissues for foreign bodies or subcutaneous emphysema.
7.
Check visible bones and joints for fractures, metastatic lesions, cervical ribs, etc.
8.
Look at the diaphragm for tenting, free air, and abnormal elevation.
9.
Check hilar and mediastinal areas for: size and shape of aorta, presence of hilar nodes, prominence of
hilar blood vessels, elevation of vessels.
10. Check the heart for size, shape, calcified valves, and enlarged atria.
11. Check costophrenic angles for fluid or pleural scarring.
12. Check lung fields for infiltrates, increased interstitial markings, masses, absence of normal margins, air
bronchograms, increased vascularity, and silhouette signs.
Random Stuff
1.
R middle lobe and lingular (LUL) area obscure the cardiac silhouette when opaque on AP.
2.
Effusions “homogeneous opacity” have a meniscus and (-) bronchograms.
3.
Pneumonia “heterogeneous opacity” obeys anatomic boundaries and has (+) bronchogram.
4.
Atelectasias “heterogeneous opacity” have ? lung volume and (-) bronchograms.
5.
Tb will be ULL and multinodular.
6.
Malignancies cause mass effect and do not obey anatomical boundaries.
Use the lateral film to confirm the position of questionable masses or infiltrates, AP diameter, and to check the
posterior costophrenic angle for small effusions. If the lateral film is good, then you should see the vertebrae
better. Also, for lateral films you should be able to follow the right hemidiaphragm all the way from the
costovertebral angle to where the diaphragm meets the sternum; the left hemidiaphragm will be partially
obscured by the heart.
For great examples of chest films and other cardiothoracic imaging, check out this site:
http://info.med.yale.edu/intmed/cardio/imaging
Page 18
 HCO3
 PaCO2
Alkalemic
4.
If the disorder is respiratory, determine whether it is acute or chronic.
Acidosis
Respiratory
Disorder
Alkalosis
5.
6.
7.
Metabolic Alkalosis
Respiratory Alkalosis
Acute
pH  by 0.08(PaCO2 – 40)/10
Airway Obs.,
Pneumothorax, Opiods
Chronic
pH  by 0.03(PaCO2 – 40)/10
Emphysema
Acute
pH  by 0.08(40 – PaCO2)/10
Chronic
pH  by 0.03(40 – PaCO2)/10
Both = hypoxia, sepsis,
ASA, PTE, Liver F,
Hyperventilation/anxiety,
pregnancy
If the disorder is metabolic acidosis, determine whether it is an anion gap or a non-anion gap acidosis.

Anion gap (AG) = Na+ – (HCO3 + Cl-) [nl 7-16]. If <7.0 consider adding NaHCO3.

AG causes: a big anion gap might… KIL U
Ketoacidosis
Diabetic see Endocrine
EtOH (when bld EtOH is 0, Tx with D5NS to stimulate insulin)
Starvation
Ingestion
Salicylates (usually assoc. with respiratory alkalosis 20 to respiratory stimulation)
Methanol
Ethylen Glycol/EtOH
Fe, INH
Lactic Acidosis (Bowel ischemia)
Uremia (as in Acute Renal Failure) Ren F also ? phosphates and sulfates

If suspecting ingestion then Osmolar Gap = Measured Osmo – (2Na + Glu/18 + BUN/18)

Causes of non-anion gap acidosis include
Renal tubular acidosis (hyperchloremic metabolic acidosis)
UAG (+)
GI losses – diarrhea, ileostomy (stool is basic)
UAG (--)
drugs (acetazolamide, amiloride, triamterene, spironolactone, -blockers)
If a metabolic disturbance is present, is the respiratory system compensating adequately?

Metabolic acidosis – use Winter’s formula:
expected compensatory PaCO2 in a patient in metabolic acidosis = [1.5 x HCO3] + 8 (2)
If measured paCO2 from ABG < calculated PaCO2, then there is also a respiratory
alkalosisthink Salicylates

Metabolic alkalosis – PCO2 = 40 + {0.7 X (HCO3 – 24)} (+/-)5
If measured PCO2 higher then concomitant respiratory acidosis
If measured PCO2 lower then concomitant respiratory alkalosis
PaCO2 should be > 40 or <50 if appropriate compensation occurring
If the patient has an anion-gap acidosis, is there secondary metabolic disturbance present?

Determine the corrected bicarbonate (? gap) level = HCO3 + (anion gap – 12)
Page 19
Remember: “POD”
“Production” Tests of Hepatic Function
1.
Albumin: t½ = 2-3 wk; levels fall with prolonged hepatic dysfunction.
2.
PT: a daily marker of altered hepatic function; more sensitive than albumin in looking at liver dysfunction.
The most common cause of a prolonged PT is dietary vitamin K deficiency.
“Obstruction” Tests of Cholestatic Disease
1.
Bilirubin: an indicator of hepatic uptake, metabolic and excretory function. See next page for an
approach to the patient with jaundice. Total Bilirubin (Bil T) > 3.5 will be icteric.
 Indirect bilirubin (Bil I): Normally, 70% of the Bil T level is indirect.
If Bil I > 80%, it is an unconjugated hyperbilirubinemia, and ? levels suggests overproduction of
pigment, ?uptake, ?conjugation, hemolysis, or Gilbert’s syndrome
 Direct bilirubin (Bil D): Found in urine
If > 50% of the Bil T is Bil D, it is a conjugated hyperbilirubinemia, and ? levels suggests
hepatocellular dysfunction or cholestasis such as impaired excretion or biliary obstruction
2.
Alkaline phosphatase (AlkP): indicator of intrahepatic cholestasis, biliary obstruction, and liver
infiltration; may also be elevated in childhood, pregnancy, bone regeneration, hyperthyroidism, and
neoplastic diseases. If AlkP is markedly elevated in conjunction with a normal/mildly elevated bilirubin,
suspect an infiltrative or granulomatous hepatic disease (sarcoidosis, lymphoma, tuberculosis) or primary
biliary sclerosis / primary sclerosing cholangitis.
3.
Gamma glutamyltransferase (GGT): elevated levels are used to confirm that elevated AlkP levels are of
hepatic or cholestatic origin. GGT bone, recent EtOH binge.
“Destruction” Tests of Hepatocellular Damage (i.e. hepatitis) Aspartate and Alanine Aminotransferase
1.
AST (SGOT), ALT (SGPT): enzymes released after hepatocellular death
 ? transaminase levels “transaminitis” ? drugs (APAP), non-alcoholic steatohepatitis (NASH),
hepatitis C, and alcohol use
 ALT is more specific for liver damage since AST is found in cardiac and skeletal muscle, kidney,
and brain tissue
 Hepatic steatosis / NASH: AST:ALT ratio ~ 1:1, mild elevations in levels (not > 4x normal).
 Alcoholic hepatitis: AST:ALT ratio > 2:1, AST usually not > 250.
 AST, ALT levels in the low thousands seen in viral and drug-induced (NSAIDs, ACE inhibitors,
statins, phenytoin, carbamazepine, isoniazid, sulfonamides, erythromycin, griseofulvin,
fluconazole) hepatitis.
 AST, ALT levels > 10,000 seen in ischemic and herpes hepatitis, acetaminophen overdose.
Other causes of elevated AST/ALT levels include autoimmune hepatitis, hemochromatosis, Wilson’s
disease, alpha-1-antitrypsin deficiency, acquired muscle diseases, and strenuous exercise.
References:
Kamath P. Clinical Approach to the Patient with Abnormal Liver Test Results. Mayo Clinic Proceedings 1996; 71(11) 1089-1095
Pratt DS, Kaplan MM. Evaluation of Abnormal Liver-Enzyme Results in Asymptomatic Patients. NEJM 2000; 342(17) 1266-1271
Page 20
itamin K)
U/S?
< 20%
< 6 mg/dL
Splenomegaly
May be asymptomatic or
with back ache, joint pain.
> 5x normal
> 50%
Variable
Tender hepatomegaly, 
splenomegaly
Nausea, vomiting, fever,
anorexia
Hepatocellular jaundice
< 3-5x normal
Prolonged (variable)
No
Usually not necessary
2-5x normal
Variable, may be
> 30 mg/dL
> 50%
Tender hepatomegaly
Deep jaundice, darkcolored urine, clay-colored
stools, pruritus
Intrahepatic cholestatic
jaundice
APPROACH TO THE PATIENT WITH JAUNDICE
Normal
< 2-3x normal
Prolonged (no)
No
Not necessary
Hemolytic jaundice
Normal
Normal
No
Not necessary
Extrahepatic cholestatic
jaundice
Deep jaundice, darkcolored urine, clay-colored
stools, pruritus, cholangitis,
biliary colic
Hepatomegaly, palpable
gallbladder
< 30 mg/dL
> 50%
< 2-3x normal; if with
cholangitis > 3-5x normal
> 3-5x normal
Prolonged (yes)
Yes
Usually necessary
Page 21
Low (< 1%)
reased production
MCV
EVALUATING ANEMIA
High (> 4%)
Hemolysis / Bleeding
Hemolysis?
( IBili, LDH, hemoglobinuria,
haptoglobins)
Yes = Hemolysis
(Bld smear has schistocytes)
Yes = Inherited
intrinsic defect
Family History
No = Acquired
extrinsic defect
Membrane defects
Hemoglobinopathies
Enzyme deficiencies
( – ) = Non-immune
Direct
Coombs’ Test
(+) = Immune
Hypersplenism
MAHA
PNH
Malaria
No = Bleeding
Reticulocyte count
defective DNA
synthesis
Macrocytic (>94)
 demand or
stem cell failure
Liver disease
B12 deficiency
Folate deficiency
ormocytic (80-94)
Bleeding
Dilution
Hypothyroidism
ronic renal failure
Aplastic anemia
rrow replacement
Chronic disease
Transfusion reaction
Autoimmune hemolysis
Drug induced
eticulocyte count x (Pt Hct/expected Hct), if less than 2% suspect hypoproliferative BM
Page 22
1.
2.
3.
4.
5.
ACV (assist control): produces a ventilator-delivered breath for every patient-initiated breath. If the
patient’s respiratory rate decreases past a preset rate, the ventilator delivers tidal breaths at a preset rate.
Should be the initial mode of ventilation in most patients with respiratory failure.
IMV (intermittent mandatory ventilation): allows the patient to breathe at a spontaneous rate and tidal
volume without triggering a ventilator; the ventilator also adds additional mechanical breaths at a preset
rate and tidal volume. Indicated in the majority of spontaneously breathing patients becaue it maintains
respiratory muscle tone and results in less depression of cardiac output than assist control.
SIMV (synchronized IMV): a hybrid of assist control and IMV – the ventilator becomes coordinated with
the patient’s respiratory cycle, waiting for patient effort to deliver a positive pressure breath at the
appropriate interval (every 6 seconds if the machine rate is 10/min). This prevents inadvertent stacking of
a mechanical breath on top of a spontaneous breath. Advantages include less respiratory alkalosis,
fewer adverse CV effects due to lower intrathoracic pressures, less requirement for sedation/paralysis,
maintenance of respiratory muscle function, and facilitation of long-term weaning.
CMV (controlled mechanical ventilation): a mode in which the patient does not breathe spontaneously
– the respiratory rate and tidal volumes are determined by the physician. May be used with sedation or
paralysis, but paralyzed patients need to be monitored closely, and the ventilator cannot respond to
ventilatory needs.
PSV (pressure support ventilation): the patient breathes at his own frequency, and the ventilator
augments each patient-initiated breath with a set pressure; tidal volumes are determined by patient effort
and the mechanical properties of the lung. Advantages include increased patient comfort and decreased
work of breathing.
Selection of settings
1.
Tidal volume (VT): usually 10-15 ml/kg body weight, but should be lower in patients with decreased lung
compliance/ARDS (6-8 ml/kg)
2.
Rate: begin with 10-15 breaths per minute and adjust to achieve desired PaCO2 or pH.
3.
Oxygen concentration (FIO2): initially set to 100%, then decrease to the lowest level that will maintain a
PaO2 > 60 mmHg or SaO2 > 90%. O2 will be 0.21 to 1.0.
4.
PEEP: used to prevent airway collapse at the end of expiration (especially in those with COPD, diffuse
lung edema, or ARDS); use is indicated when SaO2 < 90% despite an FIO2 > 50%. Start with a PEEP of 5
cm H2O and increase in increments of 2-5 cm to maintain PaO2 > 60 mmHg. May result in pulmonary
barotrauma and hemodynamic compromise (decreased RV filling).
Get an ABG 15-30 minutes after initiating ventilation and a CXR to check for placement of the endotracheal
tube. Other considerations include PTE prophylaxis (heparin, anti-embolic stockings, etc.), GI bleeding
prophylaxis (IV ranitidine), pulmonary toilet to avoid accumulation of secretions, and placement in a semirecumbent position (45o angle) to decrease risk for nosocomial pneumonia.
Other notes about oxygen management

Room air is 21% oxygen.

If a patient is on nasal cannula, for each L/min of O2 being given, add 4% to the FIO2.

Nasal cannula is only effective up to about 6 L/min O2 (FIO2 ~ 45%).

Open face masks can deliver 40-60% O2 effectively.

Non-rebreather masks with O2 reservoir are as close as you can get to deliver FIO2 ~ 100% without
intubation.
Page 23
DIET
IV FLUIDS
MEDS
ACTIVITY
LABS
SPECIAL
CALL IF
telemetry”, “elevate head of bed”, “change dressing bid”, “foley to gravity”, etc.
NPO / regular / clear liquids / ADA / heart healthy, etc.
Type of fluid at rate for # bags
List all medications
ad lib / bed rest / up to chair, etc.
CBC, BMP, ABG, EKG, urinalysis, CXR – PA and lateral, etc.
Physical therapy, diabetic educator, dietician consult, etc.
Temp > 101 or < 96, HR > 120 or < 60, RR > 30, BP > 160/90 or < 85/60
DISCHARGE SUMMARY
ADMISSION/DISCHARGE DATES
ADMISISON/DISCHARGE DIAGNOSES
SERVICE
CONSULTS
PROCEDURES
HISTORY and PHYSICAL
COURSE
CONDITION
DISPOSITION
MEDICATIONS
INSTRUCTIONS
FOLLOW-UP
List in order of importance
Service, Attending, Resident, Intern/AI
Service, Attending physician, Date
Procedure name, Date, Results (this includes ABG, CT, MRI,
Echo, biopsies and pathology results, etc.)
“See Admission History and Physical”
List problems in order of importance and a brief summary of
hospital course, including status of problem at discharge.
good / stable / fair / guarded / critical, etc.
Discharged to home, nursing home, etc.
Discharge medications with dosage, etc.
Activity, diet, dressing care
Follow-up appointments with doctor on date
PROGRESS (“SOAP”) NOTES
Subjective
Objective
Assessment/
Plan
Patient’s status overnight, including complaints and interval change (“no chest pain past
24 hours,” etc.), as well as nursing comments.
Vitals – Temp, Tmax, BP range, HR, RR, O2 sat, ventilator settings; Ins/Outs – IV/PO
intake; urine/NG suction/drain volume, #BM/emesis; Physical exam; Labs, imaging, etc.
Summarize the patient in one sentence – “63 yo wm with history of CHF, HTN, COPD
presenting with chest pain and SOB.” Provide problem list and what is being done
about problem in order of importance.
How to write a prescription
Disulfiram 500 mg
Sig: T po qd x 7d for abstinence
Disp: # 7 (seven)
Refills: 0
Try to make sure your prescription is legible. 
Sig – how to take the medication; ideally, you should put what
the medicine is for, i.e. Prilosec 20 mg T po qhs for
acid reflux, Lortab 7.5 T po q4-6h prn pain.
Disp – amount of medication to dispense
Page 24
Social Hx:
Review of
Systems:
Physical Exam:
Labs:
Assessment/Plan:
stroke, cancer, bleeding disorders, asthma, arthritis, tuberculosis, seizures, mental illness, symptoms of
presenting illness.
Current residence, education, employment, persons at home, diet, exercise; tobacco, alcohol, or drug use
(amount, frequency, duration of each); prostitutes, tattoos, males having sex with males (MSM), prison
1. General: weight change, fatigue, weakness, fever, chills, night sweats.
2. Skin: skin, hair, nail changes, itching, rashes, sores, lumps, moles.
3. HEENT: trauma, headache location/frequency, nausea, vomiting, visual changes, diplopia, hearing loss,
tinnitus, vertigo, earache, rhinorrhea, stuffiness, sneezing, allergy, epistaxis, bleeding gums, hoarseness,
sore throat, swollen neck.
4. Breasts: skin changes, masses/lumps, pain, discharge, self exams?
5. Lungs: shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, asthma, bronchitis,
emphysema, tuberculosis, last CXR.
6. Heart: hypertension, murmurs, angina, palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal
dyspnea, edema, last EKG.
7. GI: appetite, nausea, vomiting, indigestion, dysphagia, BM frequency/change, diarrhea, constipation,
hematemesis, melena, hematochezia, hemorrhoids, abdominal pain, jaundice, hepatitis.
8. Urinary: frequency, hesitancy, urgency, polyuria, dysuria, hematuria, nocturia, incontinence, stones, infection.
9. Genital: STD history/treatment, contraception, sex interest and function; male = penile discharge/sores,
testicular pain/masses, hernias; female = menarche, period regularity, frequency, duration, dysmenorrhea,
last period, itching, discharge, sores, pregnancies and complications, miscarriages, abortions, birth control,
menopause, hot flashes/sweats.
10. Vascular: edema, claudication, varicose veins, thromboses/emboli
11. Musculoskeletal: muscle weakness, pain, joint stiffness, range of motion, instability, redness, swelling,
arthritis, gout.
12. Neurologic: loss of sensation, tingling, tremors, weakness, paralysis, fainting, blackouts, seizures.
13. Heme: anemia, easy bruising/bleeding, petechiae, purpura, transfusions
14. Endocrine: heat/cold intolerance, excessive sweating, polyuria, polydipsia, po lyphagia, thyroid, diabetes.
15. Psychiatric: mood, anxiety, depression, tension, memory
1. Vitals: temperature, BP, HR, respirations, SaO2, height, weight
2. General: sex, race, state of health, stature, development, dress, hygiene, affect
3. Skin: scars, rashes, bruises, hair consistency, nail pitting, stippling.
4. HEENT: size/shape of head, trauma?, pupil size, shape, and reactivity, conjunctival injection, scleral icterus,
fundal papilledema/hemorrhage, extraocular movements, visual fields and acuity, gross auditory acuity, nasal
discharge and mucosa color, tonsilar enlargement, moistness of mucous membranes, pharyngeal exudate.
5. Neck: masses, range of motion, tracheal deviation, thyroid size, lymphadenopathy?
6. Breasts: skin changes, symmetry, tenderness, masses, dimpling, discharge
7. Lungs: chest symmetry with respirations, wheezes, crackles, fremitus, whispered pectoriloquy, percussion,
diaphragmatic excursion, egophony.
8. Heart: rate, rhythm, murmurs, rubs, gallops, clicks, precordial movements.
9. Abdomen: shape, scars, bowel sounds, consistency (soft vs. firm), tenderness, rebound, masses, guarding,
spleen size, liver span, percussion (tympany, shifting dullness), CVA tenderness.
10. GU: male – rashes, ulcers, scars, nodules, induration, discharge, scrotal masses, hernias; female – external
genitalia, vaginal mucosa and cervix: look for inflammation, discharge, bleeding, ulcers, nodules, masses,
internal vaginal support, bimanual/rectovaginal palpation of cervix, uterus, ovaries
11. Rectal: sphincter tone, prostate consistency and size, masses, hemoccult.
12. Vascular: carotid, radial, femoral, popiliteal, posterior tibial, dorsalis pedis pulses, carotid bruits, jugular
venous distension, edema, varicose veins.
13. Musculoskeletal: atrophy, weakness, joint range of motion, instability, redness, swelling, tenderness, spine
deviation, gait.
14. Neurologic: see “Neurology” for full neurologic exam.
Fluid balance, hematology, urinalysis, coagulation panel, cultures, EKG, any imaging results, etc.
Differential diagnosis – state each possibility and reasons for inclusion or exclusion from history, physical, and lab
results; medications to be started, procedures and additional labs to be done, consults to be obtained, etc.
Page 25
both services, but the private attendings tend to round earlier and be more
informal.







Each block consists of 3 weeks of inpatient duties and 1 week of clinic –
UMC clinic or Tuskaloosa Internal Medicine clinic depending on the block
Morning report daily at 10 am in Room 401 for all students on inpatient
services and all students on Thrusday.
Lecture almost daily beginning between 11 am and 12 pm and lasting about
an hour. A lecture schedule will be handed out at IM orientation but will
frequently change, so make sure to check your email everyday for updates.
Each student takes in-house call until 7 pm every 4th day except during his or
her ambulatory (clinic) week.
Weekend call is divided into Friday/Sunday or Saturday call. If you have
Friday/Sunday call, you will work until 7 pm on Friday, come back to preround/round on Saturday morning, and then round and work until 7 pm on
Sunday. If you have Saturday call, you will work until 7 pm and then come
back to pre-round/round on Sunday morning. Expect to be on call at least 2
weekends during the clerkship.
During the inpatient weeks, you will be dismissed after lecture (between
noon and 1 pm) unless you are on call. You are asked to be available by
pager until 5 pm, although you will probably never be paged.
Clinic hours are generally 8 or 8:30 am until 5 pm. You do not attend morning report during that week (except Thursday), but you are expected to
attend lecture.
Page 26
num service, but it can make presenting the patient easier if your note is done.







Present your patients on rounds. Presentations vary based on whether it is a
new or existing patient, whether the attending has seen the patient before, and
just by attending in general. You will learn to adjust as necessary with time.
Use your intern or resident as a resource if you have questions about how to
present a particular patient.
Present at morning report. Each morning, a student or resident from the previous day’s admitting team will present a patient from their service. Led by the
attending, the students and residents proceed through a differential diagnosis,
work-up, and management.
Participate in patient admissions by performing histories and physicals when
on call.
Attend lecture – they are mandatory.
Attend clinic during the ambulatory week. At UMC, you will be assigned to a
particular attending each morning and afternoon, and they will often tell you
which of their patients they want you to see. Generally, they do not have you
write notes in the EMR, but you may be asked to write a note on your own as
though you were writing a clinic note in the chart. At Tuskaloosa Internal
Medicine, you will work with whichever physician is attending in the hospital
that month.
Two patient write-ups will be due at the end of the first block. They should be
written in the format of a standard H&P and include a short discussion of a
relevant topic at the end. An example may be provided during orientation.
5 SIMPLE Internal Medicine Cases – online clinical cases, which take about
30 – 40 minutes each to complete. Login information will be provided during
IM orientation. Several cases are available, and you choose which ones you
want to complete.
Page 27
Alabama. This includes one outpatient visit and one inpatient visit when you
are on the Burnum service.
Recommended Resources:
(listed in order of “usefulness” according to surveys of past students)




MKSAP (provided) – book/CD containing several board-style questions,
organized by subspecialty. Several students find it helpful to go through these
questions one or more times in preparation for the shelf.
USMLE World Step 2 QBank – online question bank with almost 1500 board
-style internal medicine questions. These questions provide excellent shelf
exam preparation, but subscriptions are expensive, and some students prefer
to save these questions for right before they take the Step 2 CK exam.
Case Files
Step Up to Medicine – similar outline format as First Aid. Considered by
many students to be the a very good review book for this clerkship.

First Aid for the Medicine Clerkship

Blueprints


UpToDate – online resource with good clinical information about a variety of
topics. It is a good resource to use to look up information on your patient’s
conditions or to prepare for a short topic review that you may be asked to
give on rounds. It can be accessed for free from DCH and UMC computers
but requires a subscription to be accessed from home.
Washington Manual of Medical Therapeutics
Page 28
presentation skills. Ask you resident to critique your presentations and give you
suggestions for improvement.





KNOW YOUR PATIENTS! Read up on their current medical problems –
pathophysiology, common presenting symptoms, associated physical exam
findings, helpful labs and imaging, and management options. Use the EMR to
look for past records (admits, baseline labs, etc). Looking at the patient’s prior
records can help you form a more complete picture of their medical problems
and perhaps fill in gaps in the history. Plus, it will impress your attending that
you took the initiative to find out as much as you could. It can also be helpful to
use a scut sheet (found at www.medfools.com) to track patient info daily.
Be attentive on rounds! It can be tempting to zone out when you are not the
one presenting, but be respectful of the attending, residents, and other students
on your team and listen. Rounds often provide useful information about patient
management. If you are engaged and ask questions, you will get much more out
of the experience.
Attempt to develop your own differential diagnosis and plan for each patient! It can be tempting to rely on your resident, particularly for work-up and
treatment options, but you will learn a lot by at least attempting to come up
with something on your own. Don’t be afraid to be wrong – the attendings will
not think less of you! They understand where you are in your training and often
don’t expect that you will know the best management for a particular problem.
But they will be impressed if you try because it shows that you are engaged and
trying to learn. Even if your plan is wrong, you will learn a lot by discussing
with them why it is wrong and how/why they would do something different.
Organize your studying based on what you have seen. Internal medicine is
the most demanding clerkship in terms of the amount of information that must
be mastered. It can be overwhelming knowing how to tackle it all. One good
way to start is to read a little bit each night, focusing on your patient’s problems
and then those of the other patients on your service. Make sure to review their
medications as well to help expand your pharmacology knowledge.
Use the free time provided to read about your patients and study. There is a
lot of information to cover in 8 weeks, and the shelf exam will sneak up on
you! The clerkship schedule allows plenty of independent study time, so use it
wisely. Most students recommend starting to study early in the rotation.
Page 29
A = Atelectasis
E = Effusion (small, unilateral)
I = Infarct (wedge shaped)
O = Oligemia (Westermark’s sign)
U = Upriding diaphragm (Hampton’s hump)
Klebsiella
E. coli
Enterobacter
Proteus mirabilis
Indications for Dialysis
A = Acidosis
E = Electrolytes (hyperkalemia)
I = Ingestions (salicylates, alcohol, amphetamines,
lithium, theophyline)
O = Overload (volume)
U = Uremia (chronic renal failure)
Generic Differential Diagnosis Mnemonic… ‘Vitamins”
Vascular,
Infection,
Trauma,
Allergy/Autoimmune,
Metabolic / Musculoskeletal, Iatrogenic/ Ingestions
Neoplasm,
Special (Degenerative/Congenital/
Special
(Degenerative/Congenital/ Drugs)
Drugs)
Rx of Pulmonary Edema / Volume Overload
U = Upright (sit)
N = Nitropaste ( preload)
L = Lasix
O = Oxygen (nasal cannula, etc.)
A = ACE inhibitor ( afterload)
D = Diuretic
M = Morphine ( smothering/dyspnea; vasodilator)
E = Enalaprat (IV ACE inhibitor)
Most common bugs causing UTIs
Klebsiella
E. coli
Enterobacter
Proteus mirabilis
Thrombocytopenia
Platelet D/O
Leukemia
Anemia
Trauma
Enlarged Spleen
Liver Dz
EtOH
Toxins
Sepsis
Generic Differential Diagnosis Mnemonic… ‘Vitamins”
Vascular,
Infection,
Trauma,
Allergy/Autoimmune,
Metabolic / Musculoskeletal, Iatrogenic/ Ingestions
Neoplasm,
Special (Degenerative/Congenital/ Drugs)
Page 30
Inflammation
Malnutrition
GI / protein losing enteropathies
Localized Edema
Lymphatic obstruction
Venous insufficiency / deep venous thrombosis
Infection / inflammation
Hemoptysis
(rule out hematemesis and pulmonary edema)
Lung cancer
Infection (bacterial, fungal)
Arteriovenous malformations
PTE
Vasculitis (Wegener’s, Goodpasture’s)
Bronchiolitis/bronchiectasis
Mitral valve stenosis
Trauma
Coagulopathies
Drugs
Nausea
V = Vestibular causes
O = Obstruction
M = Motility problems (opiates), metabolic problems
I = Infection / inflammation
T = Toxins
Fever of Unknown Origin (FUO)
Infection
Malignancy
Collagen vascular Dz
Drugs
Page 31
Pneumothorax
Idiopathic pulmonary fibrosis
PTE
Upper airway obstruction
Pleural effusion
Cardiovascular causes
Ischemia
CHF
Valvular disease
Cardiomyopathy
Hypertension
Arrhythmias
Pericarditis
Metabolic acidosis
Anemia
Anxiety
Exudative pleural effusions
Bacterial pneumonias
Metastatic disease
PTE
Tuberculosis
Mesotheliomas
Transudative pleural effusions <Rx with diuretics>
Congestive heart failure
Cirrhosis
Nephrotic syndrome
PTE
Syncope
Non-Cardiac
Seizure
Vasovagal
Shy-Drager Syndrome
Autonomic Dysfunction
Subclavian Steal
Cardiac
Aortic Stenosis
Arrhythmia
Muscle dysfunction
HOCM
PTE
SVC obstruction
Pulmonary Embolis
AMI
N
Myocardial Infarction
1.
Admission orders – follow the cardiology admit pathway in PIN
a.
Labs
i. Cardiac profile: CK-MB, CK-Total, troponin x 3 (q8h apart).
ii. FBP with Mg2+, Ca2+, and PO4 qd – maintain Mg at 2, K at 4.
iii. Fasting lipid profile – if not done in the last 6 months.
b.
Other
i. EKG q am x 3.
ii. Telemetry – check this every morning via the red phones.
iii. Oxygen via nasal cannula.
c.
Diet – cardiac prudent unless pt is likely to go to cath, then NPO.
2.
Meds
a.
Sublingual NG and/or nitropaste
b.
Aspirin
c.
Consider low dose beta-blocker (metoprolol) if ? HR and HTN
d.
Lovenox or Heparin (lovenox is more commonly used)
3.
In house plan
a.
Mibi scan vs. catheterization.
b.
Surgery if indicated.
c.
Add an ACE inhibitor if possible.
d.
Start on a lipid lowering agent if necessary.
e.
Discharge on aspirin, ISDN, and the beta-blocker also.
f.
Teach the patient about smoking cessation (good luck).
Congestive Heart Failure -- Failure of heart to perfuse tissues
1.
Risk Factors
Valvular Dz
Congenital HDz
Restrictive Cardiomyopathy
Constrictive Pericarditis
Drugs – EtOH, cocaine
2.
Signs/Symptoms
LHF
RHF
Orthopenea
Nocturia
RUQ
Hepatomegaly
PND
S3
Peripheral edema
Hepatojugular distension
Rales
Diaphoresis
JVD
Ascitis
DOE
Tachycardia
Cyanosis
Cough
3.
New York Heart Asso. Classification
a.
Class I – Usually asymptomatic
b.
Class II – Ordinary activity results in symptoms
Page 32
MIBI, ASA,
Plaxix, or
Lovanox
a.
6.
Labs/Studies
i. TTE –call echo lab and fax results to the floor.
ii. FBP q am.
iii. Digoxin level.
iv. CXR to check for pulmonary edema.
v. UA for oliguria, proteinuria, hyaline casts, increased specific gravity.
b.
Meds
i. Lasix – start IV at twice the recent home dose.
ii. Digoxin
iii. Consider dobutamine/dopamine drip if indicated.
c.
Diet – cardiac prudent
d. Other
i. Telemetry
ii. Oxygen
iii. Check the “CDA” files for further info – may patients are bounce-backs. Also, previous echo
and cath reports can be found here.
e. Nursing - strict ins and outs to monitor diuresis.
In house plan
a. Successful diuresis – monitor ins and outs; gauge this clinically by the patient’s dyspnea upon
walking the hospital halls.
b. Start ACE inhibitor.
c. Continue digoxin and the diuretic upon discharge.
d. Ambulate the patient daily to clinically assess improvement.
e. Teach smoking cessation (good luck).
Other Pearls
Daily to-dos
 Look in CDA for previous admissions/caths/echo reports on all admitted patients.
 Call telemetry each morning using the red phones located at the nurses station.
 Most of the time, a CXR will be done in the ER before the pt is moved to the floor.
 Call the echo lab to have results faxed up to the floor.
 All cath reports are hand written in the chart under progress notes.
 OM = obtuse marginal, LD = long diagonal.
 Also look in PIN for a previous creatinine for comparison. They do not like to cath if Cr > 2.
 A lecture is given every morning at 8 am in the conference room by the CCU – these are good lectures.
Rounds normally begin after this lecture, at 9 am.
History and Physicals
 ROS = orthopnea/PND/syncope/edema/diaphoresis/palpitations/DOE - # of blocks or stairs.
 Include any cath / echo / mibi information in the PMH of the patient (be specific!!).
 Exam: be sure to include pulses / JVP / possible peripheral bruits.
Other stuff
 You are responsible for discharging your patients, but you may not enter discharge orders in the
computer. Write the prescriptions and a discharge note, however.
 Any weird telemetry call from the nurse: verbal order a 12-lead EKG and evaluate.
Page 33
MVP
Systolic Mid-late “click”
Apex
MR
Holosystolic blowing
Apex to L axilla
Holosystolic “high pitch”,
> on inspire than MR
Diastolic, rumbling
Diastolic dec-cre
rumbling “opening snap”
LLSB and subxiphoid
LLSB
TR
TS
MS
AI
Apex
RUSB
Wide pulse pressure
“pistol shot” pulse
Bobbing head
Diastolic, dec, ? pitch,
blowing
Systolic “harsh” cre-dec
Apex
? when squatting
Sys/Dia “machine”
2nd L
Holosystolic “harsh”
LSB
No or very wide S2
Friction Rub
Quality is I-VI based on loudness.
S1 is mitral/tricuspid closing.
Inspiration ?venous return and ? cardiac output.
Inspiration ? rIght-sided murmurs.
Expiration ? lEft-sided murmurs.
HOCM
IVDU, RHF
IVDU, RHF
Sx hemoptysis, emboli, hoarseness
r/o Rheumatic fever
Sx CHF
r/o dissection or aortic root Dz
Hypertrophic Cardiomyopathy
PDA
VSD
ASD
Cyanosis in adulthood when R? L
Pericardiits
Squatting ? venous return, stroke volume, SVR.
Most murmurs ?; HOCM and MVP ?
Standing and Valsalva ? venous return and stroke
volume.
Coronary Heart Dz Risk Factors
Smoking
FHx (Males <45 or Females <55)
? LDL
PMP
? HDL
HTN
Obesity
DM
Hyperlipidemia Treatment Guidelines
Tx Statins
Screen males at 35 and females at 45.
LDL < 160
factors
LDL 130-159
factors
LDL < 100
Sx CHF
#1 cause MVP
Classification of Blood Pressure
Normal
<120 / <80
PreHTN
120-139 / 80-89
HTN, Stage 1
140-159 / 90-99
HTN, Stage 2
>160 / >100
HTN Tx – Diuretics and β-Blockers
DM or CHF – ACEI/ARB
CHF – β-Blocker
BPH – α-Blocker
CHD, DM, or other equivalent
<2 CHD risk
2 + CHD risk
Page 34
Type 2 – (90%) insulin resistant with a relative secretory defect
Gestational DM – see OB/GYN
3. Symptoms/Signs
Polyuria
Blurry vision
Polydipsia
Vaginitis, balanitis
Polyphagia
Aconthosis Nigricans
Diabetic Foot
4. DM complications and prevention FLECK (macrovascular and microvascular)
Feet – yearly MD, qd patient
Lipids – q3 months
Eyes (retinopathy) – q year
Control -- HgbA1c <7% q3 months, smoking, HTN, weight, exercise ( insulin resistance)
Kidneys (nephropathy) -- microalbumin(>30 mg) q6 months, ACEI & ARB
5. Drugs
Insulin – usual is 70/30 (NPH/regular) given BID
 insulin secretion – sulfonureas (glyburide -- cause wt. gain, but cheap), meglitidines
 insulin action – Biguanides (metformin --  gluconeogenesis,  resistance,  action,
improves
lipids, no wt gain), thiazolidinediones
change intestinal absorption – Alpha-glucosidase inhibitors, lipase inhibitors
Hypoglycemia
Brain does not store glucose.
1. Symptoms/signs
Early (adrenergic) – seating, anxiety, palpitations, tremors
Late (neurologic) – fatigue, lethargy, obtundation, seizure
2. Evaluation
Whipple’s Triad – hypoglycemia, Sx of Hypoglycemia, and resolution of Sx when treated for
hypoglycemia
Check insulin and C-peptide before Tx
3. Tx
Dextrose – IV, PO, NG
Glucogon IM if unconscious and no IV
Tx underlying disorder
4. Etiology
DM with too much insulin or sulfonurea #1
Surreptitious insulin ( C-peptide), sulfonurea or insulinoma( C-peptide)
Sepsis
EtOH
Liver Dz/Failure
Non-Ketotic Hyperosmolar State (NKHOS)
Type 2 DM
Hyperglycemia (often >1000 mg/dL)
Dehydation
 serum osmolarity
AMS
(--) ketones, acidosis
Tx with hydration and insulin
Page 35
Work-up
1.
Serum glucose level (usually > 300 mg/dL).
2.
ABGs (usually a pH < 7.3, and Pa CO2 < 40 mmHg).
3.
Serum electrolytes (HCO3 < 15 mEq/L, decreased sodium (pseudohyponatremia secondary to
hyperglycemia), increased anion gap, decreased total body K + (initial K+ may be low, normal, or high).
4.
CBC & differential, U/A, urine and blood cultures, and CXR to rule out an infectious cause.
5.
Calcium, magnesium, and phosphate (may be depressed, and will drop further with correction of DKA).
6.
BUN and creatinine (typically show dehydration).
7.
Amylase and LFTs (in a patient complaining of abdominal pain).
Diagnosis: Hyperglycemia, metabolic acidosis with (+) anion gap, urinary (+) ketones
Treatment (Tx the Gap and manage the sugar)
1.
Patients in DKA should be admitted to the ICU for close monitoring.
2.
Replace fluids with normal saline until the glucose level is below 300 mg/dL; then switch to D 5W to avoid
hypoglycemia. Fluid replacement strategies vary; a common method is to replace 1/3 of the total deficit in
the first 8 hours, 1/3 in the next 16 hours, and then the last 1/3 over the next 24 hours, in addition to
maintenance fluids.
3.
Give regular insulin as an initial IV bolus of 0.15-0.2 U/kg, followed by a constant infusion at 0.1 U/kg/hr.
Monitor serum glucose hourly for the first few hours, and then q2 -4 hours. You would like to see the
serum glucose decrease by about 80 mg/dL/hr.
4.
When the serum glucose reaches 250 mg/dL, the insulin infusion rate should be slowed to around 2-3
U/hr until the HCO 3 level is close to normal and the urinalysis is free of ketones. Around an hour before
stopping the infusion, administer an appropriate dose of subcutaneous insulin to cover the patient when
the infusion stops. Restart the patient on sliding scale insulin when they are able to eat.
5.
Serum potassium levels in patients with DKA may be low, normal or high. Do not replace the patient’s
potassium until the patient’s DKA has resolved and you have rechecked the patient’s potassium.
6.
Phosphate should only be replaced when the serum phosphate is less than 1.5 mEq/L. In this case, you
should give 2.5 mg/kg of elemental phosphate intravenously over 6 hours.
7.
Mg replacement is only needed in cases of significant hypomagnesemia or refractory hypokalemia.
8.
Bicarbonate replacement is contraindicated because it can result in cerebral edema.
9.
Remember to r/o cause (two methods)
ID – BCx, UCx, Sputum, CXR
Infection
CV – ischemia/infarction
Ischemia/Infarction
GI -- pancreatitis (lip, amy)
Initial presentation
OB -- Pregnancy
Infant (pregnancy)
MS -- Trauma
Injury
FEN – HgbA1c
I smoked crack “drugs”
Page 36
LR
130
4
109
28
3
9
--
5. Content of Body Fluids (mEq/L)
Biliary
Diarrheal
Gastric
Ileal
Pancreas
Salivary
Na+
145
60
60
130
140
10
K+
5
35
10
5
5
26
Cl100
40
130
100
75
10
HCO335
30
0
50
115
30
6. Daily Volume and Electrolyte Requirements
Daily maintenance fluids (assuming normal
kidneys/heart)
100 cc/kg for the first 10 kg
50 cc/kg for the next 10 kg
20 cc/kg for the remainder
or
4 cc/kg/hr for the first 10 kg
2 cc/kg/hr for the next 10 kg
1 cc/kg/hr for the remainder
7. Volume status
Hypovolemic Signs
Orthostatic Hypotension
? HR
Dry mucosa
Skin tenting
Sodium requirement = 1 – 2 mEq/kg/day
Potassium requirement = 0.5 – 1 mEq/kg/day
Urine output = 0.5 cc/kg/hr
Hypervolemic Signs
Rales
JVD
Edematous
Treatment of Hyperkalemia
1.
Repeat potassium level to rule out lab error.
2.
Obtain EKG to look for peaked T waves, flattened P waves, AV block, and ventricular arrhythmias.
3.
Stop any IV or PO potassium intake.
4.
Start continuous EKG monitoring.
Page 37
6.
7.
d.
Lasix, 40-160 mg IV over 30 minutes.
e.
Dialysis.
Check electrolytes and pH. Correct electrolyte abnormalities and acidosis if present.
Identify and treat underlying cause of hyperkalemia (renal failure, potassium-sparing diuretics, exogenous
potassium administration).
Page 38
i.
GI -- Sx of constipation, ileus
1.
Diarrhea and Emesis  volume contraction  aldosterone   K loss
2.
Diarrhea is a direct loss
ii.
Renal
1.
Loop diuretics
2.
Incresded secretion
a.
Hyperaldosteronism – Na/K exchange in distal tube
b.
 renin
c.
Cushings  aldosterone receptor stimulation
d.
Renal Tubular Disease (types I & II RTA)
3.
Diagnosis
a.
R/o decreased intake
b.
Non-renal loss < Urinary K 15 < Renal loss
4.
Treatment
a.
Always treat Mg first.
b.
Give no more than 20 mEq per hour.
c.
10 mEq KCl = 0.1 mEq/L serum K
d.
Heart failure patients should have K+ maintained > 4.0, as K+ is a good antiarrhythmic.
Hypocalcemia
1.
Etiology and w/u
PTH
Vit D def.
 Phosphate binds Ca
 Mg
ENT surgury
2.
Sypmtoms/signs
Chvostek’s Sign – facial muscle spasm when tapped.
Trousseau’s sign – Carpal tunnel spasm when occluding blood with BP cuff.
Perioral tingling
EKG changes
3.
If Albumin is low (<4), then use correction formula.
4.
Can treat with oral CaGluconate or Tums, treat underlying disorder
Hypernatremia
1.
Symptoms/Signs – fatigue, lethargy, AMS, edema
2.
Etiology and treatment – Calculate Water Deficit; do not hydrate faster than 0.5 mEq/L/hr
Volume Status
Hypovolemic
Renal Loss
Osmotic
Tx:diuretics
Renal failure
Obstruction
Extrarenal
loss
Vomiting
Diarrhea
Skin losses
Burns
NS
Isovolemic
Hypervolemic
Diabetes Insipidus (DI):
Central DI -- U Osm  > 50%
Nephrogenic DI – no change in U
Osm
Mineralcorticoid excess
(eg, Conn’s Syndrome)
½ NS
Vasopressin for central DI
½ NS
Loop diuretic ( Na excretion)
Page 39
pontine myelinolysis (CPM); Tx underlying cause
APPROACH TO THE PATIENT WITH HYPONATREMIA (Na+ < 135)
Serum osmolality
Normal
280-285 mOsm
Low
< 280 mOsm
Isotonic Hyponatremia
1. Pseudohyponatremia
hyperlipidemia
hyperproteinemia
2. Isotonic infusions of
glucose, mannitol, glycine
Elevated
> 285 mOsm
Hypertonic Hyponatremia
1. Hyperglycemia
2. Hypertonic infusions of
glucose, mannitol, glycine
Clinical assessment of
extracellular fluid volume
Hypovolemic Hyposmotic
Hyponatremia
Isovolemic Hyposmotic
Hyponatremia
Hypervolemic Hyposmotic
Hyponatremia
UNa > 20
UNa < 10
UNa > 20
UNa < 10
UNa > 20
UNa < 10
Renal loss
Extrarenal
loss
Renal failure
SIADH
Hypothyroidism
Drugs (EtOH)
Adrenal insuff
Water
intoxication
(Polydipsia)
Acute or
chronic renal
failure
Nephrosis
Cirrhosis
CHF
Diuretics
Renal damage
Obstruction
Adrenal insuff
RTA
Salt wasting
nephritis
Vomiting
Diarrhea
Pancreatitis
Skin losses
Lung losses -bronchorrhea
Isotonic saline replacement
Water restriction
Water restriction
*Acute Renal Failure (ARF)- is generally defined as rapid increase in creatinine of 0.5 above
baseline.
-Workup should include Urinalysis, Urine electrolytes and osmolality (to calculate FENa,
fractional excretion of sodium), foley cath placement, Renal Ultrasound (sometimes skipped),
and most of the time aggressive IV fluid hydration. Often a BUN/Cr ratio of >20 can give you a
quick and dirty way of determining the etiology is prerenal (i.e. severe dehydration or volume
depletion).
FENa= [(Urine sodium x Plasma Creatinine)/(Plasma Sodium x Urine Creatinine)] x100
Page 40
3.
4.
5.
6.
7.
infection; Neoplasm
Risk factors: previous GI bleed, ASA, NSAIDs, steroids, "blood thinners", EtOH, and smoking
Physical exam
a.
Resting tachycardia
b.
Orthostatics – positive tilt if pulse increases > 20 and systolic BP decreases > 20 and/or diastolic
BP decrease > 10 from lying to standing.
c.
Digital rectal exam – black stools may be seen if patient takes bismuth or Fe supplements.
Tests
a.
Hgb/Hct – It takes 6hrs to 1 day for Hct to drop after bleeding or hydration.
b.
Type and cross – with significant bleed, otherwise type and screen.
c.
FBP – BUN increases with bleed, in the absence of renal disease.
d.
PT/INR/PTT – rule out any bleeding disorders.
e.
NG tube – if you suspect hematemesis, insert NG tube and aspirate. A negative result does not
rule out a bleed (bleed could be from duodenal bulb without reflux into the stomach).
f.
Hemocult
g.
Abdominal flat and upright – air under the right diaphragm indicates a perforation and requires
immediate surgical intervention.
h.
Consider consult for EGD, colonoscopy, arteriography, radionucleotide imaging.
Treatment
a.
ABC’s
b.
Two large bore IV’s
c.
Volume expansion with NS, FFP, PRBC if needed.
d.
Consider pressors/statins
e.
Follow vitals
Admission criteria to ICU with a GI bleed
a.
Mnemonic: VISA = Variceal bleeding (suspected or confirmed); Instability of vital signs; Serious
cormorbid condition (e.g. CAD, COPD); Active GI bleeding
Acute Pancreatitis
1.
Etiology
a.
Most common causes: EtOH and gallstones.
b.
Other causes: drugs (list is extensive), iatrogenic (ERCP or surgery), hyperlipidemia,
hypercalcemia, scorpion bite (extremely rare but sounds good when giving differential).
c.
Mnemonic: BAD HITS = Biliary Stones; Alcohol abuse; Drugs; Hyperlipidemia or hypercalcemia;
Idiopathic or infectious; Trauma; Surgery (ERCP) or scorpion bite.
2.
Signs of hemorrhagic pancreatitis
a.
Cullen's sign – around the umbilicus.
b.
Grey Turner's – around the flank (think Turn = sides).
3.
Tests
a.
Amylase, lipase – elevated.
b.
LFTs – with EtOH hepatitis, AST/ALT > 2:1.
c.
Ultrasound – if gallstones are suspected.
4.
Ranson's Criteria – provides prognosis during first 24 hrs
a.
At admission, use the mnemonic GA LAW = Glucose > 200 mg/dL; Age > 55 yo; LDH > 350; AST
> 250; WBC > 16,000.
b.
During the initial 48 hours, criteria include:
Page 41
d.
Consider DT prophylaxis in EtOH-induced pancreatitis with Ativan – DT usually occurs during first
12- 48 hrs after withdrawl from EtOH, most prominent around 24-36 hrs. Signs include tremors,
tachycardia, and agitation.
Diarrhea
Diarhea
Most common chronic is Irritable Bowel Syndrome
Inflammatory Bowel Disease
1.
Crohn's Disease – can be anywhere in the GI tract. "Skip lesions." Transmural involvement with
lymphoid aggregates. Non-caseating granulomas. Can lead to strictures and fistulas.
2.
Ulcerative Colitis – extends continuously from the rectum in proximal fashion. Only mucosal
inflammation. Increased risk of colon carcinoma. Associated with sclerosing cholangitis.
3.
Extraintestinal manifestations – can be seen in both CD and UC, and includes migratory polyarthritis,
sacroilitis, ankylosing spondylitis, uveitis, and erythema nodosum.
4.
Treatment
a.
Sulfasalazine, Asacol, and Rowasa – effective in UC and in CD confined to colon.
b.
Steroids – retention enemas can be helpful in those patients with disease in the rectum
accompanied by tenesmus.
c.
Immunosuppressants – azathioprine, cyclosporine, mercaptopurine are helpful in refractory cases.
Liver Diseases
1.
Hallmark of liver dieases - hepatomegaly, splenomegaly, gynecomastia, palmar erythema, spider
angiomata (>3 in women, >1 in men), testicular atrophy, Dupuytren's contracture, caput medusae,
jaundice, ecchymoses, ascites
2.
Etiology of cirrhosis: EtOH and hepatitis C are most common causes in Western world
a.
EtOH abuse
b.
Hepatitis B or C – look for risk factors such as IVDA, transfusion, prostitutes, tattoos
c.
Primary biliary cirrhosis – pruritus, xanthomas, and hyperlipoproteinemia in middle-aged or elderly
women and is associated with Sjogren's, CREST, and scleroderma. Patients have a high
antimitochondrial antibody titer.
d.
Secondary biliary cirrhosis – obstruction of common bile duct (gallstones, pancreatic cancer,
sclerosing cholangitis, stricture).
e.
Drugs – isoniazid, methotrexate, acetominophen.
f.
Hemochromatosis – "bronze diabetes" (hyperpigmentation, diabetes, arthritis, impotence).
Patients have elevated ferritin and transferrin saturation levels.
g.
Wilson's Disease – Kayser-Fleischer rings in the cornea. Decreased ceruloplasmin.
h.
Alpha-1-antitrypsin deficiency – family history with lung and liver pathology. Decreased alpha-1globulin levels.
i.
Autoimmune hepatits – amenorrhea, rash, acne, vasculitis, Sjogren’s or thyroiditis in young
women. Patients have high ANA titer (>1:150), anti-smooth muscle antibody, and liver and kidney
microsomal (LKM) antibody.
j.
Cryptogenic
3.
See above for discussion of liver function test evaluation.
4.
Complications of cirrhosis
a.
Portal hypertension – collaterals between the portal and systemic circulations leading to
esophageal varices, caput medusae, and hemorrhoids.
Page 42
(2)
c.
d.
e.
f.
Esophageal varices bleeding may be prevented through the use of non-selective
beta-blockers. Propanolol is most commonly used. Nadolol can also be used, and it
has less CNS side effects than propanolol. Beta-blockers should be titrated up to
decrease the heart rate by 25%.
(3) Vasopressin, octreotide, and somatostatin can be used to decrease portal flow and
pressure in acute settings
Hepatic encephalopathy – altered mental status due to impairment of liver function and
subsequent accumulation of nitrogenous compounds and other toxins. Encephalopathy is
classified in grades I through IV. Clinical signs include asterixis, myoclonus, and hyperreflexia.
Blood level of ammonia correlates poorly with degree of encephalopathy.
i.
Treatment of hepatic encephalopathy
(1) Decrease protein intake
(2) Lactulose – converts ammonia (NH3) to ammonium (NH4) which can be excreted in
the stool. Lactulose should be titrated until patient has 2 to 4 stools daily
(3) Neomycin – decreases urease-containing bacteria in the colon which produces NH3.
Ascites – caused by increased hydrostatic pressure in the splanchnic capillaries and decreased
oncotic pressure secondary to hypoalbuminemia.
i. Diagnostic paracentesis – send fluid for LDH, glucose, albumin, cell count, and differential. If
malignancy is suspected, consider CEA level and cytologic evaluation
ii. A transudate with protein < 3 and serum-ascites albumin gradient > 1.1 is likely to be
secondary to cirrhosis.
iii. Treatment of ascites
(1) Restrict sodium and fluid intake.
(2) Spironolactone and Lasix
(3) In patients with large ascites, a pleural effusion may be present. Fluid accumulates in
pleural space through small fenestrations in the diaphragm.
Spontaneous bacterial peritonitis – patients present with fever, abdominal pain, and tenderness.
Ascitic fluid PMN count > 250. Culture confirms diagnosis. Patients with cirrhosis should be on
prophylaxis with Cipro or Bactrim.
Hepatocellular carcinoma – elevated AFP levels.
Page 43
Enlarged Spleen
Liver Dz
EtOH
Toxins
Sepsis
3.
Random Stuff
30% sequestered in spleen
platelets survive 7-10 days
1 unit = 10k platelets
Thrombotic Thrombocytopenic Purpura (TTP)
Microangiopathic hemolytic anemia
Congenital deposition of abnormal Von Willebrand factor
Acquired IgG against vWF protease
1.
Risk Factors
Infection – HIV, E.
coli
Malignancy
Drugs
Autoimmune D/O
Pregnancy
2.
Symptoms/Signs – FAT RN
Fever
Anemia
Thrombocytopenia
Renal
Neural
3.
Diagnosis
Clinical Sx
Nl PT, PTT
Blood smear = Schistocytes
 LDH
Possible  BUN, Cr
4.
Treatment
NO platelets
Plasmaphoresis
Refractory steroids
Vincristine
Splenectomy
Page 44
4.
Petechia/mucosal bleeding
< 20 k platelets
Blood smear has large platelets
BMBx has  or Nl megakaryocytes
Diagnosis
Dx of exclusion
Antiplatelets Abs not specific
Treatment
Children – resolves
Steroids
IV Ig
Splenectomy for chronic
Platelets for emergency
Disseminated Intravascular Coagulation (DIC)
Consumptive Coagulopathy
1.
Risk Factors
Sepsis
Trauma
Malignancy
Transfusion
Liver Dz
2.
Symptoms/Signs
Petechia, Purpura
3.
Diagnosis
 PT, PTT
 D-Dimer
 Fibinogen
Blood smear = Schistocytes
4.
Treatment
Treat underlying cause
FFP, platelets
3.
 Destruction
Immune
ITP
Drug
HIV
DLE
Heparin – paroxysmal clotting
b.
Non-Immune
DIC
TTP
Pre-eclampsia
HELLP
Anti-phospholipid
a.
Alport’s Syndrome
Fanconi’s
May-Hegglin
TAR Syndrome
Wiskott Aldrich
Anemia
SEE ALSO FLOW CHART AT BEGINNING




Definition: decrease in red cells or hemoglobin concentration in peripheral venous blood. For women,
hemoglobin < 12 g/dL or hematocrit < 36%; for men, hemoglobin < 14 g/dL or hematocrit <41%.
Symptoms: fatigue, headache, lightheadedness, dyspnea.
Signs: hypotension, tachycardia, blood loss, pallor, jaundice, petechiae, purpura, flow murmur,
splenomegaly.
RBC turnover is 90-120 days; Reticulocytes are produced within 1-2 days
Evaluation of Anemia
1.
Start with reticulocyte count. Reticulocytes are immature red blood cells seen on peripheral smear
that indicate increased bone marrow activity. Correct for the degree of anemia using the reticulocyte
production index (RPI). A low retic count (< 1%) or RPI < 3 in the face of anemia indicates that
production of red blood cells or hemoglobin is deficient. A high retic count (> 4%) or RPI > 3 shows that
the bone marrow is working to replace blood lost through hemolysis or bleeding.
2.
If the reticulocyte count is low, there must be a defect in the production of red blood cells or hemoglobin.
Check the MCV.
a.
MCV < 80  Microcytic Anemia – a problem making hemoglobin.
i. Fe deficiency anemia: check ferritin. A ferritin < 20 indicates iron deficiency, and a ferritin >
100 rules it out. A ferritin between 20 and 100 is indeterminate – check the bone marrow.
ii. Anemia of chronic inflammation: in cases of microcytic anemia with a ferritin > 100, check the
TIBC. A low TIBC and a high ferritin is seen in states of chronic disease. A normal or high
TIBC and a high ferritin warrants examination of the bone marrow.
iii. Thalassemia: check the Hgb/MCV ratio (high in thalassemia and low in iron deficiency).
iv. Sideroblastic anemia: check for sideroblasts in the bone marrow.
b.
MCV 80-94  Normocytic Anemia – often due to stem cell failure, as in aplastic anemia.
c.
MCV > 94  Macrocytic Anemia – a problem making DNA.
i. Liver disease: check the peripheral smear. Target cells are indicative of liver disease.
ii. B12/Folate deficiency: on the peripheral smear, hypersegmented neutrophils and macroovalocytes will be present. Check serum B12 and folate levels.
Page 45
melena, etc. and check hemoccult and urinalysis. Many hemolytic anemias are hereditary, so find out
if the patient has any family history of bleeding problems or anemia.
Positive family history  Check the peripheral smear.
i.
Sickle cell anemia: patients will have sickle cells on peripheral smear. Check hemoglobin
electrophoresis, which will help identify sickle cell anemia and other hemoglobinopathies.
ii.
Hereditary spherocytosis: spherocytes will be seen. Test osmotic fragility.
iii.
Hereditary elliptocytosis: again, the peripheral smear will demonstrate elliptocytes.
iv.
Enzyme deficiencies (G6PD Deficiency, PK Deficiency): peripheral smear will be normal, but
specific enzyme assays are available to test for these conditions.
b.
Negative family history  These are acquired hemolytic anemias. The peripheral smear is still
important, as is the Coombs test.
i.
Autoimmune hemolytic anemias: these can be due to autoantibodies, transfusion reactions,
or drugs. Coombs test will be positive in these patients. It is important to work up possible
causes for the autoimmune reactions (check ANA, evaluate medications, etc.)
ii.
Microangiopathic hemolytic anemia (MAHA): schistocytes will often be seen on peripheral
smear. Coombs test will be negative. Check a coagulation profile to evaluate for potential
causes, like DIC, TTP, and HUS.
iii.
Paroxysmal nocturnal hemoglobinuria (PNH): the peripheral smear will be normal, and
Coombs test will be negative. These patients will have a history of having brown or red
urine in the morning. Check a sucrose lysis test to diagnose this condition.
a.
Page 46
Evaluation of pneumonia
1.
History
a.
Pre-disposing factors
i. COPD: H. influenzae, S. pneumoniae, Legionella, Moraxella catarrhalis
ii. Recent seizures: aspiration pneumonia (mixed anaerobes)
iii. Compromized host: Pneumocystis carinii, CMV, Legionella, gram-negatives, fungi, MAC
iv. Alcoholics: aspiration, S. pneumoniae, Klebsiella, gram-negatives, H. influenzae
v. Diabetes mellitus: gram-negatives, M. tuberculosis
vi. Sickle cell: S. pneumoniae, Mycoplasma
b.
Symptoms
i. S. pneumoniae – abrupt onset with fever, shaking chills, rust-colored sputum.
ii. Mycoplasma – insidious onset with gradual onset of fever, hacking cough, scant sputum.
iii. Legionella – bradycardia, abd. pain, diarrhea, elderly, Dx urine Ag or IMF Ab smear
iv. Viral pneumonias – generalized body aches, malaise, dry, non-productive cough.
2.
Diagnosis
a.
Sputum for Gram stain and culture –many false positive results (oral flora contamination) and false
negative results. Aerosol induction with hypertonic saline may increase diagnostic yield.
b.
PA and lateral CXR – also use to rule out empyema, pneumothorax, and abscess.
i. S. pneumoniae – segmental or lobar infiltrate
ii. Mycoplasma – patchy infiltrates; may suggest a more serious infection than the patient’s
appearance or physical exam.
iii. Viral – hazy infiltrates
iv. Diffuse infiltrates – Legionella, Mycoplasma, viral pneumonia, P. carinii, aspiration pneumonia,
hypersensitivity pneumonitis, aspergillosis
c.
CBC
d.
Blood cultures – positive in 20% of patients with pneumococcal pneumonia.
e.
ABG – PaO2 of 60 mmHg on room air is criteria for hospital admission.
Initial antibiotic treatment of pneumonia (taken from Sanford Guide to Antimicrobial Therapy 2001 edition)
Patient type
Outpatient CAP, < 60 yo, otherwise
healthy
Outpatient CAP, > 60 yo or with
comorbidity (COPD, CHF, DM, liver
disease, renal failure, alcoholic)
CAP requiring hospitalization
Severe CAP requiring ICU care
Nosocomial pneumonia – patient
hospitalized > 48 hours
Suspected pathogens
S. pneumoniae, Mycoplasma,
Chlamydia, H. influenzae, viral
S. pneumoniae, H. influenzae, aerobic
gram negative rods, S. aureus
S. pneumoniae, H. influenzae,
anaerobes, aerobic gram-negatives,
Chlamydia
S. pneumoniae, H. influenzae, aerobic
gram-negatives, Mycoplasma,
Legionella
S. pneumoniae, Gram-negative rods
(Pseudomonas, Legionella,
Acinetobacter), S. aureus
Page 47
Initial coverage
Macrolide (azithromycin, clarithromycin)
or a fluoroquinolone or doxycycline
Fluoroquinolone or second generation
cephalosporin (cefuroxime) plus
macrolide if atypicals suspected
Third generation cephalosporin
(cefotaxime, ceftriaxone) plus a
macrolide or a fluoroquinolone alone
Third generation cephalosporin or lactam / -lactamase inhibitor (Zosyn,
Unasyn, Augmentin) plus either a
fluoroquinolone or a macrolide
Imipenem or meropenem or
aminoglycoside plus either an antipseudomonal penicillin (piperacillin,
ticarcillin) or -lactam / -lactamase
inhibitor  clindamycin
> 50 yo
Impaired cellular immunity
With head trauma, neuro-surgery, CSF
shunt
S. pneumoniae, Listeria, or gramnegative rods
Listeria or gram-negative rods
S. aureus, S. pneumoniae, coagnegative Staphylococcus, gram-negative
rods, P. aeruginosa
ampicillin  vancomycin
Ampicillin plus third generation
cephalosporin  vancomycin
Ampicillin plus ceftazidime
Vancomycin plus ceftazidime
(table taken from Sanford Guide to Antimicrobial Therapy 2001 edition, Ferri, and NEJM 1997;336:708 -716
Evaluation of meningitis
1.
History
a.
Predisposing factors
i. S. pneumoniae – common in adults, elderly; predisposing factors include blunt head trauma,
otitis media, pneumonia, sickle cell, CSF leaks; mortality is 30%.
ii. N. meningitidis – complement deficiencies
iii. H. influenzae – usually seen in preschool age children; predisposing factors in adults include
head trauma, otitis media, and sinusitis.
iv. S. aureus – diabetics, patients with S. aureus pneumonia, cancer.
v. Enteroviruses (coxsackievirus, echovirus) are the most common cause of viral meningitis.
vi. Suspect tuberculosis meningitis in a patient with unrelenting headache, malaise, low grade
fever with lymphocytic pleocytosis, and mildly decreased CSF glucose.
b.
Symptoms and physical exam
i. Classic presentation is fever, headache, lethargy, confusion, nuchal rigidity. A recent review
(JAMA 1999;282:175-181) reported that 95% of patients will have at least two symptoms
from the triad of fever, neck stiffness, and altered mental status/headache, 99-100% will
have at least one of these three symptoms. However, these symptoms may not always be
present in infants, immunocompromised, and the elderly.
(1) Fever – 85% sensitive
(2) Neck stiffness – 70% sensitive
(3) Altered mental status – 67% sensitive; more commonly seen in bacterial meningitis
ii. Meningeal signs
(1) Kernig’s sign: pain in the lower back or posterior thigh when knee is extended while
patient is lying in supine position and hip is flexed at a right angle.
(2) Brudzinski’s sign: rapid neck flexion  involuntary knee flexion in a supine position.
(3) These signs are not very sensitive but are very specific for meningitis
iii. Infants may have a bulging fontanelle, poor feeding, vomiting, and respiratory distress.
iv. Petechial-purpuric rashes (trunk, lower extremities, mucous membranes, conjunctiva) are
suggestive of meningococcal meningitis; also seen in viral and other bacterial meningitis.
v. Seizures and papilledema are unusual.
2.
Diagnosis
a.
CBC – elevated WBC with left shift.
b.
Blood cultures – if patient is very ill, start antibiotics before cultures are obtained.
c.
Coagulation panel and fibrin split products – rule out DIC in patients with petechiae, purpura, and
hypotension.
d.
CSF studies
i. Tube 1 = protein, glucose, cell count and differential
ii. Tube 2 = Gram stain, cultures
iii. Tube 3 = other tests (EV-PCR, etc.)
iv. Tube 4 = cell count and differential, (AFB smear if suspected)
Page 48
Fungal meningitis
Neurosyphillis
Guillain-Barre syndrome
Neoplasm
Hemorrhage
3.
4.
Clear / cloudy
Clear / cloudy
Clear / cloudy
Clear / xanthochromic
Bloody / xanthochromic
Treatment
a.

Normal
Normal
Nl / 
Nl / 



Nl / 

 lymphs (late)
 monocytes
 monocytes
Normal / , monocytes
Normal / , lymphs
 RBCs

Nl / 
Normal


See table on previous page for antibiotics recommended for empiric therapy
(taken from Sanford Guide to Antimicrobial Therapy 2001 edition, Ferri, and
NEJM 1997;336:708-716).
b.
Dexamethasone
i.Mechanism of action in meningitis
1.
Inhibits synthesis of inflammatory cytokines (IL-1, TNF) that
induce meningeal inflammation.
2.
Stabilizes blood-brain barrier.
3.
Decreases CSF outflow resistance.
4.
Improves indices of inflammation in CSF when given before first
dose of antibiotics.
5.
Reduces sensorineural hearing loss and other neurologic
sequelae in meningitis secondary to H. influenzae.
6.
Reduces mortality and adverse neurologic sequelae in
meningitis secondary to S. pneumoniae.
ii.Recommendations for use
1.
Treatment of H. influenzae meningitis in previously healthy
infants and children > 2 mo. Give for the first 4 days of
antimicrobial therapy.
2.
Treatment of S. pneumoniae meningitis in children within the
first 2 days of the illness.
3.
Tuberculous meningitis.
4.
Any adult with bacterial meningitis and significant change in
sensorium.
c.
Repeat lumbar punctue after 24-36 hours of antibiotic therapy to verify
eradication of the organism.
d.
Prophylaxis
i.Indications include contact with patients who have N. meningitidis or H.
influenzae meningitis, including members of the same household and those
with close contact to the index case, including hospital personnel. Consider
prophylaxis of contacts at day care, school, or chronic care facilities on an
individual basis.
ii.Rifampin is commonly used for prophylaxis of both N. meningitidis and H.
influenzae meningitis.
Aseptic Meningitis
Viral – Enterovirus, HSVZ, HIV, Arborvirus
Fungal
Drugs – Ibuprofen/NSAIDS
Malignancy – lymphoma, leukemia
Autoimmune – SLE, sarcodosis
Page 49
Evidence of endocardial involvement (TTE or TEE)
b. Minor
Predisposition: predisposing heart condition or intravenous drug use
Fever: temperature >=38.0°C
Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial
hemorrhage, conjunctival hemorrhages, and Janeway lesions
Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth spots, and rheumatoid factor
Microbiological evidence (BCx) that does not meet criteria as above
Evidence suggestive of IE
2.
Etiology
a. Native valve or Replacement Valve > 2 months old “community bugs”
Strept viridans (from mouth), PCN G
MSSA (from skin), Naficillin
Rheumatic Fever
Enterococcus (from gut), Amp + Gent
Sequela of Gr. A Strep Pharyngitis J? NES
b. Replacement Valve < 2 months old “hospital bugs”
Joint (migrating arthritis)
Staph aureus
? (carditis)
Gram negative Rods
Nodules (subcutaneous)
Enterococcus
Erythema marginatum
Fungi
Sydenham’s Chorea
Blood Culture Negative Bugs
#1 are Abx prior to culture
HACEK
Fungi
Haemophilus sp.
Coxiella burnetti
Actinobacillus actinomycetemcomitans
Bartonella sp.
Cardiobacterium hominis
Brucella sp.
Eikenella corrodens
Kingella sp
Human immunodeficiency Virus
AIDS CD4 < 200
Most common pneumonia is still Pneumococcus
1. Dx Acute
Chronic
RNA
RNA
p24
p24
ELISA
W. Blot
2. Opportunistic Infections and CD4 Levels
200
100
50
Kaposi”s
Toxoplasmosis
MAC
Oral Thrush
Disseminated Candida
CMV
Oral Hairy Leukoplakia
Cryptococcus
PML
PCP
Lymphoma
Atypical Tb
PML = Progressive Multifocal Leukoencephalopathy (JC virus)
Page 50
An abrupt decrease in renal function sufficient to result in the retention of nitrogenous waste in the body
(BUN). Can be classified as pre-renal, renal, and post-renal.
1.
2.
Pre-renal failure – 50% of ARF cases (hypoperfusion)
a.
Caused by
i. Absolute  effective blood volume (hemorrhage, skin/GI losses, diuretics, third spacing)
ii. Relative  effective blood volume (CHF, sepsis, liver failure)
iii. Arterial occlusion (bilateral thromboembolism)
b.
Clinical presentation
i. History of fluid losses, use of NSAIDs or ACE inhibitors, thirst.
ii. Signs of weight loss, oliguria, orthostatic hypotension, tachycardia, dry mucous membranes.
c.
Laboratory tests
i. Decreased UNa (< 20 mEq/L)
ii. BUN/Cr > 20:1, and FENa < 1%.
iii. Uosm > Sosm and Uosm > 500 mOsm/kg H2O
iv. Urine specific gravity > 1.030
v. Minimal proteinuria and negative urine sediment findings
d.
Treatment
i. Rapid volume replacement – fluid challenge of 300-500 mL NS over 30-60 min.
ii. Then replace fluids to maintain urine output at 1-2 mL/min.
iii. Correct underlying disorder (CHF, etc.)
Intrinsic renal failure
a.
Caused by
i. Vascular disorders (vasculitis, malignant hypertension)
ii. Acute glomerulonephritis (post-streptococccal)
iii. Acute interstitial nephriis (drug associated, e.g. methicillin)
iv. Acute tubular necrosis (ATN) – makes up the majority of hospital associated ARF.
(1) Perfusional defects (shock, hypovolemia, sepsis, etc.)
(2) Nephrotoxic agents
(a) Exogenous toxins
(i)
Aminoglycosides, i.e gentamicin – nonoliguric, related to duration of
treatment (5-10 days), may be seen after cessation of treatment.
(ii)
Contrast – oliguric
(iii) Mercury, cisplatin, solvents
(b) Endogenous toxins (hemoglobinuria, myoglobinuria, myeloma, uric acid)
b.
Laboratory tests
i. May or may not be oliguric
ii. BUN  by 20-40/day; Cr  by 2-4/day, and FENa > 1%.
iii. Uosm < 350 mOsm/kg, UNa elevated (> 30)
iv. Modest proteinuria with ATN, nephrotic range proteinuria with acute glomerulopathies.
v. Urine sediment – ATN = muddy brown; RPGN = RBC casts; interstitial nephritis = lymphocytes,
eosinophils, and WBC casts.
c.
Treatment of ATN
i. Find reversible sources of ATN and treat rapidly.
ii. Convert oliguric ATN to nonoliguric ATN with Lasix (80-400 mg IV, repeat in 1 hr).
Page 51
vii.Dialysis – keep predialysis BUN/Cr < 100 / 8.
3.Post-renal failure (obstruction)
a.
Caused by obstruction of the collecting system (bladder outlet obstruction, neoplasm, bilateral
ureteral obstruction).
b.
Clinical presentation
i.
History of dysuria, nondysmorphic hematuria, clots.
ii.
Evidence of prostatic hypertrophy in men or pelvic pathology in women.
c.
Laboratory tests
i.
BUN  by 20-40/day; Cr  by 2-4/day
ii.
Ultra Sound -- Enlarged kidneys with dilated calyces
iii.
Absent proteinuria
iv.
Urinary sediment may be negative or may have hematuria with stones.
d.
Treatment includes catheter drainage, ureteral stents, percutaneous nephrostomy.
Indications for Dialysis
A = Acidosis
E = Electrolytes (hyperkalemia)
I = Ingestions (salicylates, alcohol, amphetamines, lithium, theophyline)
O = Overload (volume)
U = Uremia (chronic renal failure)
Renin-Angiotensin Axis
1. JG Cells detect ? stretch and macula densa detects ? fluids/NaCl. JG secretes renin.
2. Angiotensinogen from liver is converted to Angiotensin I by renin in blood.
3. Angiotensin I is converted to Angiotensin II by ACE in lung.
4. Angiotensin II causes:
a. Nephron efferent arterioles to constrict ? ? glomerular hydrostatic pressure.
? Afterload
b. Adrenal cortex to release aldosterone ? ? Na resorption and ? blood volume.
? Preload
c. Hypothalamus to ? thirst ? ? blood volume.
? Preload
d. Posterior pituitary to release ADH ? ? kidney resorption of water.
? Preload
e. Bradykinin
Page 52
Late menopause
Nulliparity or late
Obesity
2. Screening/Evaluation
Monthly pt. breast exams; Yearly by
MD
MMG – 40-49, q2y; 50+ annually
(Young women
dense breasts, common masses are
fibroadenomas; Radiology – Spiculated masses
and microcalcifications)
Sonography – cystic vrs. Solid
FNA
Core/Excisional Bx – Dx
3. Types
Ductile Carcinoma – most common,
unilateral
Lobular – often bilateral
Paget’s – highly malignant, nipple
with eczema
Medullary – low grade, slow growing
4. Tx – based on size, type, lymph nodes,
metastasis, receptor positive
Lumpectomy/XRT
Modified radical mastectomy
Adjunctive chemotherapy,
Hormonal therapy (Tamoxifen)
Multiple Endocrine Neoplasia
MEN I -- parathyroid glands, pancreatic islet cells,
and pituitary gland
MEN IIa -- medullary carcinoma of the thyroid,
pheochromocytoma, and hyperparathyroidism
MEN IIb -- medullary carcinoma of the thyroid,
pheochromocytoma, and mucosal neuromas
Inflammatory Bowel Dz
High fat, low fiber
Adenomatous polyps
3. Screening/Evaluation
Age 50 – FOBT annually and flex-sig
q5 years
Bx of masses/polyps
CT to r/o metastasis
4. Staging – Duke’s classification which involves
depth, lymph nodes, and metastasis
5. Tx
Rectal CA – 80% cured surgery;
post-op 5FU
Colon – 50% recurrence post
surgery, chemotherapy for mets
Prostate
Leading malignancy in men
Most men die with it, than from it.
1. Risk Factors
> 40 years old
AA > whites > Asians
High fat, low fiber
Family Hx
2. Screening/Evaluation
Men 40-50
 DRE
Men > 50
 DRE + PSA
PSA > 4  30%
with cancer
PSA > 10  50%
with cancer
Transrectal US and Bx
Bone Scan – commonly goes to
vertebra
3. Tx – Prostectomy, XRT, and/or hormonal Tx
Monitor with PSA
Paraneoplastic Syndromes
Syndrome
Hypercoaguable State
Erythrocytosis
Hypercalcemia
Page 53
Malignancy
Pancreatic CA, GI CA
Renal Cell CA
Sq Lung (PTH-rP), Myeloma (OAF)
2.
Hospital course
a.
These patients typically stay 2-4 days – you will generally notice a significant improvement in their
physical exam (less wheezing/rhonchi, improved air movement and peak flows).
b.
Start to taper down their steroids as they improve – one way is to go from Solumedrol 80 q8h to 40
q8h to Prednisone 60 mg bid – each resident has a different way of tapering.
c.
A set of pulmonary function tests may be necessary to monitor long-term progress.
d.
Does the patient need home oxygen? Walk them around the hall on room air; if they desaturate
below 88-90%, they qualify for home oxygen.
Cystic Fibrosis Exacerbations
Stuff to know

University Hospital has seen increasing numbers of admissions for CF exacerbation. The Pulmonary
department has a protocol for these patients and the nurse coordinator will generally give you a previous
discharge summary an order set to put in, including antibiotics and dosages.

Make sure that you wash up before and after examining a CF patient – this includes swabbing down your
stethoscope with alcohol. This is especially necessary if a patient is known to have B. cepacia, a bug that
is easy to spread between CF patients and hard to eliminate.

It is important that you get a sputum culture on admission – order the “Cystic Fibrosis Culture” (found in
the alphabetized lab orders section in PIN) – and get chest physical therapy on all patients (unless they
have active hemoptysis).

Get at least one set of PFTs during the admission (usually a day before discharge).

Patients do not require daily labs, but they do need a fluid balance and a CBC drawn every 3-4 days.
Many patients are on an aminoglycoside, so they must be monitored for nephrotoxicity.

The average patient stay is 10-14 days.
Pleural Effusions
Laboratory Findings
1.
Diagnostic criteria for an exudate (at least one of 3 must be present)
a.
Pleural fluid protein/serum protein ratio > 0.5
b.
Pleural fluid LDH/serum LDH ratio > 0.6
c.
Pleural fluid LDH > 2/3 upper limits of normal of the serum LDH
2.
Transudates are usually due to altered hydrostatic and oncotic forces – they usually have WBCs <
1000/L, mononuclear predominance, glucose levels in pleural fluid equal to that of serum, normal pH).
They suggest absence of local pleural disease and are usually due to CHF.
3.
Exudates
a.
Normal pleural fluid pH ~ 7.6; pleural fluid pH < 7.3 suggests empyema, cancer, SLE/RA effusion,
tuberculosis, esophageal rupture, or parapneumonic effusion.
b.
Low glucose levels (< 60 mg/dL or pleural fluid glucose/serum glucose ratio < 0.5) suggest cancer,
empyema, tuberculosis, esophageal rupture, or connective tissue disease.
c.
Cell counts > 10000/L are seen in pneumonia, acute pancreatitis, and lupus pleuritis; chronic
exudates (tuberculosis, malignancy) usually have cell counts < 5000/L.
d.
Amylase-rich pleural effusions suggest acute pancreatitis, chronic pancreatic pleural effusions,
esophageal rupture, and malignancy.
e.
Lymphocyte predominance (85-95%) and absence of mesothelial cells suggest tuberculosis
(include lymphoma, sarcoidosis, chylothorax, and chronic rheumatoid pleurisy in the differential).
Page 54
Genetic or post-infectious
PE -- Extensor SQ nodules PIP, radial of wrist, ulnar deviation of digits
Labs – Rh factor, ? ESR, ? WBC synovium
Dx Criteria (4/7 required)
Morning stiffness > 1 hour Rheumatoid nodules
Arthritis 3 or + joints
Serum RF
Symmetric
XR showing erosive synovitis
Hand joint arthritis
Tx -- APAP
Osteoarthritis – Loss of articular cartilage due to “wear and tear” – DIP
most common
Bouchard’s nodes – PIP osteophyte formation
Heberden’s nodes – DIP osteophyte formation
Morning stiffness < 30 minutes
Labs – unremarkable
Tx – APAP or surgery
Gout
MTP of Hallux ? podagra
Needle shaped negative birefringment
Tx Colchcine acute, Allopurinol preventative; CI ASA retards Uric acid excretion
Pseudogout (CPPD)
Aligned, Blue, Clcium
Blunted, rhomboid, positive birefringence
Seronegative Spondyloarthropathies – Rh Factor (--)
Ankylosing spondylitis
90% HLA-B27
Schober test (bending) to measure fusion of spine.
Asso. with uveitis
Reiter’s Syndrome – autoimmune
Asymmetric oligoarthritis
Uveitis
Urethritis
Skin: Keratoderma blenorrhagica on palms and soles
Etiology
GU – Chlamydia, ureaplasma
GI -- Shigella
Psoriatric Arthritis -- Asymmetric oligoarthritis with active psoriasis
Page 55





Mondays, Tuesdays, and Friday mornings are spent doing Neurology
Divided into 4 weeks of inpatient and 4 weeks of outpatient. During the
inpatient weeks, students spend Mondays and Tuesdays working with Drs.
Slaughter and Lucy (neurology hospitalists at DCH). During the outpatient
weeks, students spend Monday mornings working with the physicians at
Alabama Neurology and Sleep Medicine. Monday afternoon is spent in
lecture time with Dr. Mark Woods at Bryce Hospital while Tuesday mornings are currently independent study time. One Tuesday afternoon on
outpatient Neuro week is spent volunteering at Caring Days, a day care
program for elders with dementia. This is the TEAM requirement for the
Neuro/Psych rotation.
Friday mornings are reserved for Neurology PBLs (problem-based learning sessions)
Hours worked may vary from week to week but you will receive a excessively detailed scheduled.
Students are required to take call one weekend, that will be assigned,
during the 8 week rotation. The hours are similar to regular weekdays –
about 8 am until 3 or 4 pm, sometimes earlier if the service is not busy.
Once you are dismissed, you will not be called back to the hospital unless
something very rare comes in.
Clerkship Duties/Requirements:




During the inpatient weeks, arrive at the hospital by 8 am and contact the
attending. He will give you several consults to see and examine (1 – 2 per
student).
Perform histories and physical exams, specifically a thorough neurological
exam, on your patients. You do NOT have to write a note in the patient’s
chart. Be sure to make your own notes for your patient presentation.
Present your patients to the attending, complete with an impression &
plan.
Towards the end of the inpatient block, Dr. Slaughter will observe each
student performing a complete neurological exam on a patient on the
service. You will have plenty of practice as you see and exam patients
during the preceding weeks.
Page 56
experience and there is plenty of downtime for studying. Be sure bring
something to study– you will not see patients on your own, but you will
sometimes asked to give your impression and plan after observing the
attending’s H&P. You will also have the opportunity to observe some
procedures, including Botox injections, and testing, such as NCVs and
EMGs. Overall, the atmosphere is very laidback. You will not be asked
to do or say much, but the attendings are good teachers and always happy
to answer questions.


Friday morning PBLs – attended by all students on Neurology and Psychiatry. In these sessions, a case is presented, and the group proceeds
through the work-up and formulation of a differential diagnosis, not
entirely unlike morning report in IM. Learning issues will be identified
from the case and assigned to the students. You are asked to research
your learning issue and make a handout that you will present the following week. Presentations are very informal. Each week’s PBL will begin
with presentations and discussions of the learning issues from the previous week, and then another case will be presented and new learning
issues assigned.
TEAM Service Learning Requirement: you will volunteer at Caring Days
on one Tuesday afternoon (1:30-5:00pm) during your outpatient half of
the block. This is very laid-back and fun, including helping the Caring
Days clients with crafts, games, and other activities. At the end of the
block you are required to turn in a half-page reflection about your volunteer experience in addition to the post-clerkship survey.
Recommended Resources:
(listed in order of “usefulness” according to surveys of past students)

Blueprints Neurology

Pretest Neurology

Case Files Neurology

Clinical Neurology (provided for a rental fee) – more thorough resource
Page 57

Clinical Neuroanatomy Made Ridiculously Simple and other resources used
during the Neuroscience module in second year – helpful for reviewing
neuroanatomy and pathways for PBLs and for the shelf exam.
Tips for Success:





Use every opportunity to practice the neurologic exam! This part of the
physical exam is probably the most detailed and the most daunting to students. Use your Maxwell to guide you as you are learning the exam. The
inpatient block of this clerkship provides a lot of opportunities to see patients and practice performing the exam. If you have questions about why or
how to perform an element of the exam, ask your attending for help!
Develop an organized method for performing the neurologic exam and
presenting your findings. Dr. Lucy in particular will critique your presentation and help with your organization – pay attention to what he has to say.
Present an impression and plan, not just your findings on history and
physical. The attendings will appreciate your attempt to apply your
knowledge to a management plan.
Ask questions and pay attention! This may be your only clinical exposure to
neurology. Use this time to ask questions about the concepts that confuse
you, the medications you are unfamiliar with, the reasoning behind certain
management decisions, etc. Try to get comfortable with the basics – they
will be helpful no matter what you choose to go into.
Always have study materials with you! You will find that you have a
decent amount of down time, particularly during your clinic days, so make
use of that time. Remember – at the end of this 8-week clerkship, you have
to take 2 shelf exams, so try to stay on top of your studying.
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Motor exam
Sensory
Coordination
DTRs
Gait
Discs sharp without papilledema
(ou = bilateral, od = right eye, os = left eye)
Normal bulk/tone, 5/5 strength throughout, no involuntary movements
(Strength gradations: 0 = none, 1 = flicker of strength, 2 = movement not against gravity; 3 = movement
against gravity, 4 = good strength, but breakable, 5 = normal strength)
Normal pinprick, vibration, proprioception
(remember to test 6 points on the face)
Finger  nose intact bilaterally without dysmetria, heel  shin normal bilaterally
2+ symmetric, plantar response flexor (or toes )
(4+ Hyperactive with clonus, 3+ hyperactive, 2+ normal, 1+ hypoactive, 0 negative)
Normal; good tandem, negative Romberg
Stroke week tips
Presenting ICU patients is a daunting task, but it’s not as bad as you think. Copy the following data from the
huge flowsheets in the NICU:
1. Present how the patient did overnight and if there was any change in his/her neurologic status. If the
patient is sedated, state that.
2. Temperature, Tmax and when it happened. Antibiotics and day #.
3. CV data (give a range): HR, BP, MAP, other CV data if present.
4. Pulmonary data: ventilator settings (mode, RR, FIO2, pressure support, PEEP), SaO2, most recent ABG,
and yesterdays and today’s a/A ratio. a/A ratio = PaO2 / (713xFIO2 – PaCO2/0.8)
5. Fluids: total ins and outs for the previous day and that morning
6. Labs: start out with CBC (note any trends in WBC, Hct, plt), then fluid balance panel, coags, culture
data, drug peak/trough levels, etc.
7. Plan: try to discuss this with the fellow prior to rounds, but usually you won’t have time. State the
obvious – i.e., “K+ is low, so we went ahead and replenished it, Hct is dropping, so we are hemocculting
stools,” etc. If the patient’s renal function or fever are improving or the patient is tolerating tube feeds
well, note those things. Then defer to the fellow…
Code stroke protocol
1. Initial assessment: include age and sex of patient, neurologic deficits, estimated time of onset, vital signs.
2. Place the patient flat in bed.
3. Administer O2.
4. Have the patient chew and swallow an Aspirin 325 mg
5. Give IV Bolus – NS bolus 500cc, then 125cc/hr.
6. Obtain stat EKG.
7. Obtain stat non-contrast head CT, if non-hemorrhagic give heparin and/or consider TPA.
8. Draw blood for labs.
9. Document the patient’s current medical problems.
10. DO NOT lower blood pressure (i.e. no anti-hypertensive meds)
11. DO NOT leave patient unattended.
-Differential for delirium/coma: A(Apoplexy=stroke), E(Epilepsy), I(Infection), O
(Opiates, O/D), U(Uremia, nutritional or metabolic abnormalities), Y (Ψ=psych)
Page 59
2.
3.
4.
mg IV and a 50 mL bolus of D50W.
First drug (5-20 min): give Ativan 0.1 mg/kg IV at 2 mg/min, and monitor BP, RR, and pulse for
respiratory depression and hypotension.
Second drug (20-40 min): if seizures continue, give Dilantin 20 mg/kg IV at 50 mg/min (or fosphenytoin –
dosing is same, but can be pushed). Seizures in 90% of patients in status epilepticus should be
controlled by this stage.
Intubation / anesthesia (40-60 min): intubate, begin EEG monitoring, and give entamicin al 20 mg/kg at
100 mg/min. If seizures persist, initiate general anesthesia with propofol 10 mg bolus followed by 0.5-1
mg/kg/hr.
Upper motor neuron vs. Lower motor neuron lesions
UMN Lesions
No muscle wasting
Increased tone (clasp knife)
Weakness (antigravity muscles)
Increased DTRs / clonus
Extensor plantar response
LMN Lesions
Muscle atrophy, fasciculations
Decreased tone (flaccid)
Weakness (variable pattern)
Decreased or absent reflexes
Flexor / absent plantar response
Stroke sites and resultant neurologic deficits
Vessel
Anterior circulation
Middle cerebral artery
division
division
Region supplied
Lateral cerebral hemisphere, deep
subcortical structures
Superior
Motor / sensory cortex of face, arm, hand;
Broca’s area
Inferior
Parietal lobe (visual radiations, Wernicke’s
area), macular visual cortex
Anterior cerebral artery
Ophthalmic artery
Posterior circulation
Posterior cerebral artery
Parasagittal cerebral cortex
Retina
Neurologic deficit
See superior / inferior division deficits, may
also see coma or symptoms of increased
intracranial pressure
Contralateral hemiparesis of face, arm, and
hand; expressive aphasia if dominant
hemisphere
Homonymous hemianopsia, receptive
aphasia (if dominant hemisphere), impaired
cortical sensory functions, gaze preference,
apraxias, neglect
Contralateral leg paresis and sensory loss
Monocular blindness
Basilar artery
Occipital lobe, thalamus, rostral midbrain,
medial temporal lobes
Ventral midbrain, brainstem, posterior limb of
the internal capsule, cerebellum, PCA
distribution
Contralateral homonymous heminanopsia,
memory or sensory disturbances
Coma, cranial nerve palsies (leading to
double vision, facial numbness or weakness,
dysphagia, etc…), apnea, cardiovascular
instability
Deep circulation
Lenticulostriate, paramedian,
thalamoperforate,
circumferential arteries
Basal ganglia, pons, thalamus, internal
capsule, cerebellum
Pure motor or sensory deficits, ataxic
hemiparesis, “dysarthria-clumsy hand”
syndrome
Pts
1
2
3
4
5
6
Motor Response (M)
No response
Decerebrate (extend) to pain
Decorticate (flex) to pain
Withdrawal from pain
Localizes to pain
Obeys verbal command
Glasgow Coma Scale
Verbal Response (V)
No response
Unintelligible sounds
Inappropriate responses
Disoriented, conversing
Oriented, conversing
Page 60
Eye Response (E)
No response
Open to pain
Open to command
Open Spontaneously
Root / Nerve
Motor
C4
C5
C6
C7
C8
T1
T1-T12
L1
L2
L3
L4
L5
S1
S2-S4
I Olfactory
II Optic
III Oculomotor
IV Troclear
VI Abducens
V Trigeminal
VII Facial
VIII Vestibulocochlear
IX Glossopharyngeal
X Vagus
XI Accessory
XII Hypoglossal
Axillary
Musculocutaneous
Median
Radial
Femoral
Sciatic
Peroneal
Tibial
Breathing
Shoulder abduction
Wrist extension
Wrist flexion
Finger flexion
Finger abadduction
Abs, ribs
Hip flexion (T12-L3)
Hip adduction (L2-L4)
Knee extension (L2-L4)
Foot dorsiflexion & inversion
Toe extension
Foot plantarflex & eversion
Rectal Tone
MR, SR, IR, IO, eyelid, iris, lens
SO
LR
Mastecation
Eyebrows, eyelid close, smile
Swallowing
Larynx, swallowing
Shoulder shrug
Tongue protrusion
Shoulder Abduction
Elbow flexion
Thumb opposition
Finger Extension
Knee extension
Knee flexion
Toe extension
Toe flexion
Page 61
Sensation
Reflex / Pathology
Lateral arm
Thumb, index
Middle finger
Ring, small finger
Medial arm
Biceps
Brachioradialis
Triceps
Below inguinal lig
Middle thigh
Lower thigh
Medial leg & foot
Lat. leg, dorsal foot
Lateral foot
Smell
Sight
Face
Taste ant. 2/3
Hearing, balance
Taste post. 1/3
Lateral Shoulder
Lateral forearm
Lateral Palm
Dorsolateral hand
Anterior thigh
Posterolateral calf
Dorsal foot
Plantar foot
Patellar
Achilles
Anosmia
Blind, nonreactive
Dilated, “down and out”, ptosis
Downward gaze weak
Esotropia
Corneal
Doll’s Eye
Gag reflex





Students will work at Bryce Hospital, WOW and/or the VA.
UMC Betty Shirley Clinic – Wednesday afternoon with Dr. Arnold,
Thursday afternoon with Dr. Williamson, and Friday afternoon with Dr.
Giggie
Wednesday mornings are reserved for lectures and PBLs – attended by
all students on Neurology and Psychiatry
Expect to be at work from 8 am until about 5 pm Monday – Friday. You
will have Friday afternoons off for half of the clerkship for psychiatry
independent study
There is no call for psychiatry!! In the place of call students will attend 2
half-days at the Tuscaloosa County Jail with Dr. Giggie. In general
students feel that this is a very unique and educational experience, so
make the most of it!
Clerkship Duties/Requirements:




You will be required to log patients on a designated form and you are
required to get signatures for each of these patients.
Attend all of your required activities. Depending on the number of students on the clerkship, you may or may not have another student with
you for these various activities.
Students function mostly in an observation role at the various offsite
placements. At Bryce, you will participate in new patient admissions and
treatment team meetings. You may be asked to interview a patient or
document in the chart as you get more comfortable, but this is site and
attending specific. At the VA, you will observe outpatient clinic visits.
Attend all assigned UMC Clinics, where you will interview new and
established patients while the attending observes via closed circuit TV.
You will be asked to document all patient encounters in the EMR, so ask
for help navigating the system if necessary.
Page 62
will present your learning issue at the start of the next PBL.




Two patient write-ups – the first is due prior to the end of the first 4 weeks and
the second is due prior to the end of the second 4 weeks. These write-ups must
be thorough! Unless you are writing up a new patient, you will most likely
have to review their previous records in the EMR to obtain all of the information that you need. Ask the nurses in clinic to help you. Detailed instructions and a sample write-up are available on the clerkship website – use them
to help you! Again, these are very detailed, thorough write-ups and can be
time consuming! Do not wait until the last minute to complete them.
Basic science paper on a topic of your choice – due at the end of the 4 weeks
in which you have psychiatry independent study time. More details will be
provided during clerkship orientation. This is another time-consuming activity, so plan accordingly, especially if yours is due around the time of the shelf
exams.
Oral exam – You will watch a 30-minute video of a patient interview and then
present that patient to one of the attendings (usually either Dr. Ulzen or Dr.
Williamson). The attending will ask pertinent questions throughout your
presentation and discussion of the patient. Instructions on what to expect and
how to prepare on provided on the clerkship website – use them!
TEAM Service Learning Requirement: there is a single TEAM activity for the
Neuro/Psych rotation. For more information, see page 57.
Recommended Resources:
(listed in order of “usefulness” according to surveys of past students)

First Aid for the Psychiatry Clerkship – highly recommended text for shelf
exam review and oral exam preparation.

Pretest Psychiatry

Case Files Psychiatry
Page 63



Psychiatry for Medical Students (provided for a rental fee) – another excellent resource for the things mentioned above.
High Yield Psychiatry (provided for a rental fee) – very concise text with
helpful tables, useful for quick review
USMLE Work Step 2 CK QBank – about 150 board-style questions. Again,
not worth the subscription fees just for this clerkship but helpful if you
already have a subscription.
Tips for Success:



Pay attention and actively engage in all activities to the best of your
ability! Students will often write off this clerkship, falsely assuming that it
will not be relevant to them in their future careers. But regardless of what
you choose to go into, you will encounter patients with psychiatric diagnoses! Use this clerkship to familiarize yourself with the common conditions
and their treatments. It is also important to be familiar with the medical
illnesses and drugs that can mimic psychiatric conditions. Because you
spend the majority of your time talking to patients, it is also a good opportunity to work on your interviewing and rapport-building skills. The attendings will appreciate your attention and willingness to learn.
Attempt to participate as much as possible, even at your offsite assignments. As mentioned above, you will primarily function in a shadowing
capacity outside of the UMC clinic. However, it does not hurt to ask if you
can interview a patient or write a note. As you become more familiar with
how your particular site works, the attending may allow you to become
more involved.
Put some effort into your basic sciences paper. It does not have to be a
lengthy dissertation, but a 2 – 3 page paper is not going to cut it. Make the
assignment easier on yourself and choose a topic that will be relatively easy
to find basic science information for. If you need help choosing a relevant
topic, ask one of your attendings.
Page 64
social profile) that may be completely unfamiliar to you. Use the resources provided on the clerkship website and ask one of the attendings
for help/clarification if necessary. Do your best on the first write-up and
try to use Dr. Williamson’s feedback to make the second one better.
Include a thorough differential diagnosis (for each of the patient’s psychiatric diagnoses) and treatment plan – feel free to continue writing as long
as you have something useful to say.


Know the components of the mental status exam and what they mean
for the oral exam! You may have to defend your impression of the
patient, so be familiar with what you are talking about. Also know how to
organize your diagnoses into Axis I, II, III, IV, and V. Be able to justify
your GAF (or global assessment of functioning) score in Axis V! First
Aid for Psychiatry provides a good GAF table. You can also probably
find this information online.
You can do really well on this shelf with appropriate studying. Again,
remember to manage your time well because you will have 2 shelf exams
during the last week of this clerkship. Focus your studying on psychopharmacology, including mechanism of action and common side effects,
and how to distinguish one psychiatric condition from another, as there
are sometimes only subtle differences. The vignettes on this shelf are
very long and many students have difficulty finishing on time.
Page 65
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
HPI
Past medical history
Past surgical history
Past psychiatric history (include previous hospitalizations, diagnoses, treatments, ECTs, etc.)
Social and family histories
ROS
Mental Status Exam
a.
Appearance, Behavior, Attitude
i.
General Appearance (apparent age, peculiarity of dress, cleanliness, cosmetics)
ii.
Motor Status (posture, gait, gestures, tics, grimacing, tone, tremors, picking, mannerisms)
iii.
Activity (over or under active, purposeful or disorganized, stereotyped, graceful, echopraxia)
iv.
Facial Expression (alert, tense, worried, sad, happy, dreamy, frightened, in pain, angry,
sneering, ecstatic, laughing, smiling, suspicious)
v.
Behavior (indifferent, frank, friendly, embarrassed, seeking help, evasive, afraid, resentful,
sullen, angry, irritable, assaultive, erotic, negativistic, denudative, exhibitionistic, dramatic,
impulsive)
b.
Mood and Affect
i.
Mood (subjective emotional state – how the patient feels)
ii.
Affect (observed emotional state – your evaluation of the patient’s emotional state)
c.
Stream of Thought and Speech
i.
Speech (soft or loud, stuttering, hesitant, accent, enunciation)
ii.
Speed and Quality (rate of speech, delay, variation with different topics)
iii.
Stream of Thought (coherent or incoherent, illogical, vague, loosely organized, neologisms)
d.
Content of Thought
i.
Delusions (delusions of reference, delusions of alien control, special messages, nihilistic
delusions, delusions of self-depreciation, delusions of grandeur, somatic delusions)
ii.
Hallucinations (auditory, visual, olfactory, gustatory, tactile, feelings of depersonalization)
iii.
Obsessions and Compulsions
iv.
Fantasies and Daydreams
v.
Thoughts of Violence (suicide, homicide, specific plans)
e.
Insight (patient’s understanding of significance of symptoms and situation)
f.
Judgment (patient’s past decisions and plans for the future)
g.
Cognitive Exam (MMSE)
Physical Exam
Labs/Studies
Assessment (All 5 Axes)
a.
Psych
b.
Personality disorders, MR
c.
Physical, organic disorders
d.
Life stressors and quality (mild, moderate, severe)
e.
Global Assessment of Functioning
Page 66
Ask the patient to count backwards by 7 from 100 (93, 86, 79, 72, 65). Stop
after five answers. Alternatively, ask the patient to spell “world” backwards.
1 point for each correct
answer, total = 5
Ask for the three objects mentioned earlier.
1 point for each correct
answer, total = 3
Ask the patient to name two items, like a watch and a pencil.
1 point each, total = 2
Have the patient repeat the following sentence: “No ifs, ands, or buts.”
1 point
Ask the patient to follow a three-step command: “Take this piece of paper in
your right hand, fold it in half, and put it on the floor.”
1 point for each command,
total = 3
Write “Close your eyes” on a piece of paper, and ask the patient to read it and
do what it says.
1 point
Ask the patient to write a sentence.
1 point if it contains both a
subject and a verb
Draw a pair of intersecting pentagons and ask the patient to copy it.
1 point
Record the score as a total out of 30 points, and note which parts the patient
missed.
Total = 30
Record level of consciousness as ALERT – DROWSY – STUPOR - COMA
Symptoms of Depression
S = Sleep (increased or decreased amount)
I = Interest (decreased)
G = Guilt
E = Energy (decreased)
C = Concentration (impaired)
A = Appetite (increased or decreased)
P = Psychomotor Retardation
S = Suicidal Ideation
Symptoms of Bipolar Disorder
Distractability
Insomnia (dec. need for sleep)
Grandiosity
Flight of ideas
Activitiesinc. goal oriented activities, impulsive
Speechpressured, rapid
Thought processracing thoughts
Page 67
Dementia – most common are Alzheimer’s, multi-infarct,
depression (pseudo-dementia)
Degenerative diseases - Parkinson’s, Huntington’s, Diffuse
Lewy Body Disease
Endocrine - Thyroid, parathyroid, pituitary, adrenal
Metabolic - EtOH, electrolytes, B12, glucose, hepatic, renal,
Wilson’s
Exogenous- Heavy metals, CO, drugs
Neoplasia
Trauma - Subdural hematoma
Infection - meningitis, encephalitis, abscess, endocarditis,
HIV, syphilis, Lyme, Prions
Affective disorders – depression
Stroke/Structure - multi-infarct dementia, ischemia, vasculitis,
NPH




Divided into two inpatient weeks, two ambulatory clinic weeks, one
week at Children’s in Birmingham on a specialty service, and one week
on “specialty” clinics (ADHD, adolescent, high risk, autism, sickle
cell). The first and last weeks of the clerkship will be a mix of the
above.
Inpatient weeks: Rounds daily beginning around 8 or 8:30 am depending on the attending. Meet in the Pediatrics conference room (Room
501). You will alternate call days with the other student(s) who are also
assigned to inpatient. Call is until 5pm (M-F), until 7pm (Sat) or until
7pm (Sun).
Clinic Weeks: Morning clinic is from 8:30 am until noon and afternoon
clinic is from 1:30 pm until about 5 pm. During the ambulatory week,
students will attend lecture from 8-9am on Tuesday, Wednesday, and
Thursday before going to clinic. On Friday morning you will go to
rounds prior to clinic.
In addition to call on your inpatient weeks, each student will be on call
2 total weekends. In addition to working your call day, you will also
come in the next day to pre-round/round. For example, if you are on call
on Saturday, you will come in Sunday morning for pre-rounds/rounds
and then you can leave.
Clerkship Duties/Requirements:

Pre-round on your patients and write a progress note only if on
inpatient. If it is a floor patient, the note will be in SOAP format just
like on IM. For patients in the newborn nursery (well babies), there is a
specific format for the note that will be provided during clerkship
orientation, and you basically just fill in the blanks.
Page 68





Attend assigned clinics. There will be often be more than one student and a
couple of residents in clinic, and you are not assigned to a particular attending.
You will take turns seeing patients as they become available and can then
present to any of the attendings present in clinic. You will be asked to document all patient encounters on a designated form that you will hand to one of
the attendings for review. If you need help with the EMR, just ask. You will
learn to use it efficiently with time.
Two patient write-ups – one for each of your outpatient clinic weeks. These
must be turned in to the attending that saw the patient with you within 72
hours. Write-ups must include a fairly detailed differential and formulation.
This part of the write-up can be time-consuming, so plan appropriately. Examples will be provided at orientation. If you cannot complete the write-up within
72 hours and need an extension, discuss this with your attending ahead of time.
30 – 45 minute PowerPoint presentation on a topic of your choice in the format
of case presentation. These presentations will be given on Friday mornings
after rounds. Your topic must be approved by the physician attending that
week, so make sure to discuss it with them before you start working on your
presentation.
Observed history and physical. You will be videotaped performing a history
and physical on a patient in the clinic and critiqued by one of the attendings.
Don’t worry – this is not like an OSCE! The patients are real, not standardized
patients. These sessions are scheduled towards the end of your clinic weeks, so
you will be used to seeing patients in the clinic. Try to forget that you are being
taped and proceed as you would through any other clinic visit.
22 CLIPP cases – online clinical cases, each of which takes about 30 – 40
minutes to complete. Unlike the online cases in IM, you do not choose which
cases you want to do. There is a guide detailing which cases coincide with
ambulatory, inpatient, and specialty weeks along with some relevant reading
material in the provided textbook. You do not have to complete the cases as
they are assigned, but it is a good way to keep up with them. Otherwise, you
will find that you are trying to complete them all at the end of the block when
you are also trying to study for your shelf.
Page 69
but will involve children! These activities will be scheduled for you.
Recommended Resources:
(Listed in order of “usefulness” according to surveys of past students)

Case Files Pediatrics

Pretest Pediatrics




BRS Pediatrics– provides a great textbook/outline for all pediatric problems,
diseases, etc. Worth the buy on Amazon.com.
Pediatrics for Medical Students (provided) – will be helpful for weekly
assigned reading and as a more in-depth resource for write-ups and presentations.
USMLE World Step 2 QBank – almost 300 board-style pediatrics questions.
Not worth the subscription cost just for this clerkship, but it is helpful to go
through these questions if you have a subscription.
Others with mixed reviews: Blueprints Pediatrics, First Aid for Pediatrics
Tips for Success:

Participate, participate, participate! The attendings on this rotation really
like to hear from you. In general, they foster a very relaxed environment and
want to make you feel comfortable to speak up. Because the service can
often slow down and have very few patients, the attendings frequently use
rounds as a time to teach in the form of interactive lectures or games. Try to
contribute during these times. It gives them a chance to hear what you know
and to identify any concepts or skills that the group might need further
instruction on. It also gives you a chance to show that you are interested and
eager to learn.
Page 70
mg/kg/day!





Put in the time and effort necessary to do a good job on your write-ups and
PowerPoint presentation. Although your grades on these activities do not
directly factor into your overall grade, they can make an impression (good or
bad) on your attending, which may factor into your evaluation. Use these opportunities as a time to shine.
Try to take good social and developmental histories, as these are particularly
important in pediatrics. Gleaning an impression of a child’s home environment
and social structure can lend a great deal to the pictures of his or her overall
health. Your attending will be impressed if you are able to garner some of this
information and determine how it might impact the patient’s current complaint
or management possibilities.
Show an interest in learning to take care of children and adolescents. When
you are rounding in the Well Baby Nursery, you’ll often be examining a baby
with a dirty diaper.... don’t think that changing a diaper is above you! The nurses
are especially appreciative of students who are willing to help, and they will do
their best to help you if you return the favor. Just be sure to let them know that
you changed a diaper, as the nurses have to tally voids and bowel movements for
all of their infants.
Utilize your down-time on inpatient weeks. If things are slow during the day in
the hospital, use your spare time to read up on patients and study for the shelf.
You will have less down-time on clinic weeks in which to study.
Know your bugs and drugs for the shelf!
Page 71
Sepsis Workup (SWU)
Viral Respiratory Panel (VRP)
CXR, CBC with differential, blood cultures, lumbar puncture
P = Parainfluenza
Treatment
A = Adenovirus
Ampicillin 50 mg/kg q6h
I = Influenza
Cefotaxime 50 mg/kg q8h
R = Respiratory Syncytial Virus (RSV)
Treat for 48 hours or until cultures are negative. If patient
looks good clinically, sometimes they can be managed at home on Rocephin after 24 hours on IV
antibiotics and if cultures are negative.
Immunization Schedule (as of 1/01) more recent Update
always available
Birth
HepB
Apparent Life Threatening Event (ALTE)
2 months
DtaP, Hib, IPV, PCV, HepB
Check for sepsis (SWU).
4 months
DtaP, Hib, IPV, PCV
Check for reflux (Upper GI).
6 months
DtaP, IPV, PCV, HepB
Check for seizure (EEG).
12-15 mo
DtaP, Hib, PCV, MMR, VZV, HepA
Check for cardiac disease (EKG).
4–6 years
DtaP, IPV, MMR, HepA
11-12 years
MCV4, Tdap (Td q10 years after)
Formulas for Pediatrics
Body Surface Area (m2): [(4 * weight in kg) + 7] / [wt. in kg + 90]
Intake: neonates (1-28 days old) in cc/kg/day (note: 1 oz = 30 cc)
All other children in cc/ m2 /day
Output: cc/kg/hr (note: anything <1 cc/kg/hr is too little, report it to a resident)
Maintenance IVF > 1500 cc/ m2 /d to prevent dehydration
—use ¼ NS for pt.  6 mo
—use ½ NS for 6 mo – 2 yrs
Page 72
Fine motor:
Follows objects past midline
Personal/social: Recognizes parent
Three months old
Gross motor:
Supports on forearms in prone, holds head
up steadily
Coos
Holds hands open at rest, follows in circular
fashion
Personal/social: Reaches for familiar people or objects
Language:
Fine motor:
Four to five months old
Gross motor:
Rolls front to back, back to front, sits well
when propped, shifts weight
Orients to voice
Moves arms in unison to grasp, touches
cube
Personal/social: Enjoys looking around
Language:
Fine motor:
Six to eight months old
Gross motor:
Language:
Fine motor:
Sits well unsupported, puts feet in mouth
Babbles
Reaches with either hand, transfers, uses
raking grasp
Personal/social: Recognizes strangers
Nine months old
Gross motor:
Language:
Creeps, crawls, cruises, pulls to stand
Understands no, waves bye-bye, dada,
mama
Fine motor:
Pincer grasp, holds bottle, finger feeds
Personal/social: Explores environment, plays patty-cake
Two years old
Gross motor:
Language:
Walks up and down steps without help
Uses pronouns inappropriately,
understands two step commands; one-half
of speech can be understood
Fine motor:
Removes shoes and pants
Personal/social: Parallel play
Three years old
Gross motor:
Pedals tricycle, can alternate feet when
going up steps
Three word sentences, uses plurals, past
tense, 250 words, ¾th of speech can be
understood
Fine motor:
Dresses and undresses partially, dries
hands, draws a circle
Personal/social: Group play, shares toys, plays well with
others, knows name, age, and sex
Language:
Four years old
Gross motor:
Hops, skips, alternates feet going down
stairs
Knows colors, says song or poem from
memory, asks questions
Fine motor:
Buttons clothing fully, catches ball
Personal/social: Tells tales, plays cooperatively with a group
Language:
Five years old
Gross motor:
Twelve months old
Gross motor:
Language:
Walks alone
Two words other than dada and mama
13 months = 3 words
14 months = follows one step commands
Fine motor:
Throws objects, lets go of toys, mature
pincer grasp
Personal/social: Imitates actions, comes when called
Fifteen months old
Gross motor:
Language:
Fine motor:
Personal/social:
vocabulary
Builds tower of five blocks, drinks well from
cup
Personal/social: Asks for food and to go to the toilet
Fine motor:
Creeps up stairs, walks backwards
Uses 4 to 6 words
Builds tower of two blocks
Cooperates with dressing
Page 73
Skips alternating feet, jumps over low
obstacles
Language:
Prints first name
Fine motor:
Ties shoes, spreads with knive
Personal/social: Plays competitive games, abides by rules,
likes to help in household tasks
morning rounds. You will be assigned an attending each week and will go to
surgery when they do. Specifics about the schedule will be given during
clerkship orientation.


Morning rounds at 7:30 am, meet in the 3rd floor conference room
Lectures, typically Monday – Thursday afternoons around 1 pm at UMC.
These are subject to change per the attending’s schedule.
Clerkship Duties/Requirements:



Pre-round on your patients each morning and write a progress note. Typically, patients are divided up evenly amongst the students on the service. It is
helpful to ask the resident on night float to contact your group around 5 am
to let them know how many patients are on the service, so they can plan
appropriately. These patients are generally less complicated than those on
medicine, but you should probably still give yourself at least about 30
minutes in the beginning to see the patient and write your note. Use your
Maxwell or the outlines on pg 78 as a guide for how to write a postpartum
progress note. Your note on other inpatients will typically follow the standard SOAP format.
Present your patients during morning report. You will have to formally
present your patients each morning, but these presentations are far more
concise than those on medicine. Again, there is some variation between
attendings in terms of how they like patients presented. Ask your resident/
fellow for help!
While on day call, participate in patient admissions and consults by performing histories and physicals. These histories are a bit different, focusing on a
patient’s menstrual, sexual, and obstetrical histories. Get comfortable talking
about these sensitive subjects with patients – this rotation is probably your
best opportunity to do so.
Page 74







Check on laboring and post-op patients and write progress notes when necessary.
Patients on magnesium require checks every 2 hours – ask your resident to show
you what is involved in these.
Participate in all deliveries while on call and write the delivery and postpartum
notes.
If not on day float, attend clinic after morning report, arriving no later than 9:00
am. You will be assigned to a particular attending each week to work with in clinic.
Although each attending is different, you will have the opportunity to be quite
autonomous in clinic once your attending is comfortable with your exam skills.
You may or may not be asked to document all patient encounters in the EMR.
Attend lecture – these are mandatory.
30 minute PowerPoint presentation on a topic of your choice related to women’s
health. These presentations will be given in front of the other students and Dr.
Hooper on Thursday afternoons in lieu of lecture. Don’t wait until the last minute to
prepare! Dr. Hooper likes these presentations to be a bit more formal than those
required on other clerkships in an effort to help the students work on their oral
presentation skills. You will be asked to give one another constructive criticism, so
be prepared. Everyone has room for improvement, so be honest and try to give
helpful feedback.
Oral exam – discussion of 3 – 4 cases with one of the attendings, lasting about 30
minutes. This exam causes a lot of stress amongst the students, but trust those who
have taken it before you when they say it is not that bad. Students generally perform very well, and the questions are relatively direct and straightforward. There is
a study guide available on the UMC shared drive (ask prior students where to find
it). It is a good resource along with the handouts from student presentations.
Scrub in on surgeries when time allows. Details on when you can work in OR time
will be given during clerkship orientation.
Page 75
rics and Gynecology (ACOG). This is a free question bank that requires you to
create a login for access. Great boards-style review questions on a variety of
topics.

First Aid for the OB/GYN Clerkship

Case Files OB/GYN

Others: Blueprints (particularly the test at the end), Pre-test OB/GYN


Obstetrics and Gynecology (provided)– same textbook used for the Reproduction module in second year. Good resource for topic reviews, PowerPoint
presentation, and in-depth review.
USMLE World Step 2 CK QBank – about 200 board-style questions. Not
worth the subscription fees just for this clerkship but helpful if you already
have a subscription.
Tips for Success:


Be proactive! Ask to see as many patients as possible and perform as many
exams and procedures as possible. However, be respectful of that fact that the
attendings do have private patients that may not want to see a student, so always ask!
Be confident but not cocky. The attendings will appreciate if you are eager to
learn and participate in exams and procedures, so don’t be timid. The old adage
of “see one, do one, teach one” applies here – be prepared to perform a delivery
(with the close assistance of a resident and attending).
Page 76
make you look good!







Make friends with the L&D nurses! Introduce yourself and ask them to help you
and teach you, and they will generally respond well. They are a great resource for
certain procedures, especially cervical checks. Be respectful and stay out of their
way.
Practice your suturing and knot tying! There are great instructional videos on
YouTube and equipment to practice with in clinic – ask where to find it. Use slow
clinic days to practice. Attendings will often expect you to suture or tie during
surgery and will impressed if they don’t have to stop to teach you then.
Talk to your patients while you are examining them! The pelvic exam can be an
uncomfortable experience for a patient, and distraction is an effective tool to help
them relax. Try to strike up a conversation and build rapport during the less invasive parts of the exam, and continue talking as you proceed through the rest of the
exam. It will also help you relax and feel less awkward.
Read and study because the information in this clerkship is masterable. You can
perform quite well on the oral exam and shelf if you put in the work.
Be prepared to be pimped thoroughly by some attendings. Often, they will
continue asking questions until no one, not even the fellow, knows the answer. You
are not expected to know every answer, but the more you read and study and speak
up, the more impressed they will be.
Spend time preparing and practicing your presentation for Dr. Hooper. He likes
for students to begin with a brief introduction addressing why their topic is relevant
to the audience and to provide some conclusion to the presentation after questions
from the audience have been fielded. He will be impressed if you can give your
presentation without reading off of your slides and with minimal “ums” and “uhs.”
Practice for the oral exam with the other students, particularly if you are someone who gets nervous or blanks when asked questions directly. Answering questions for an oral exam requires different skills than those required to do so on a
multiple-choice exam. Practice asking one another questions from the study guide
or handouts to get a feel for the format.
Page 77
Family:
Social:
PN Labs:
ROS:
PE:
Assessment:
Plan:
newborns), last period.
fetal anomalies, deaths, etc.
smoking, EtOH, drugs, work.
H/H, glucose screen/GTT, Urine, U/S, rubella, Rh+/-, etc.
HA, scotomas, diplopia, edema, epigastric pain, pruritus, dysuria, flank pain, fever…
Important things here are the vitals, abdominal exam (fundal height), cervical exam
(dilation/effacement/station), extremity exam (edema, pedal pulses), and monitoring
(FHT, decelerations)
__ yo f GP with IUP @ __ wk EGA by ___
Admit, observe, manage expectant vaginal delivery.
Activity: bedrest with bathroom privileges
<Anesthesia consult if epidural requested>
Diet: NPO, ice chips
Continuous toco and FHM
Labs: CBC, U/A, etc.
DELIVERY NOTE
Pt is a __ yo f GP @ __ wks. At (time) pt delivered a __lb __oz baby (sex) with Apgars _, _. Baby was
(position) and delivered (method), nuchal cord x __ over __ degree episiotomy. Bulb suction was performed on
the perineum. (? Meconium present) Placenta was delivered intact with three vessel cord. (? Episiotomy –
median or medial lateral performed with repair in __ layers with __ suture.) EBL = ___ ml. Mother to recovery
room in stable condition. Infant to __ nursery in __ condition. Anesthesia __ per __. Attending/Resident/MS.
POST-PARTUM PROGRESS NOTE
S:
O:
A/P:
PPD(POD)#__ s/p SVD (C/S 2o to indication)/Gest. Age, date & time of delivery/Sex of baby,
Apgars/Med. Problems/Antibiotics/Rh status (RhoGAM)/Rubella status/Breast or Bottle Feeding
/Contraception/Follow-up Clinic. Document the following, e.g. Pt ambulating without difficulty and
passing flatus. Eating and voiding without difficulty. Vaginal d/c (lochia, rubra). +/- breast
engorgement. Pain control.
Vitals, I/O, PE including abdomen (fundal height, firm/soft, bowel sounds), extremities, incision status.
Labs, including pre and post-partum H/H.
__ yo f Para___ PPD/POD#__ s/p SVD/cesarean with pertinent findings.
Continue routine care. Ambulate, DC Foley, Hep-lock IV, start PO pain meds, etc.
Discharge on Iron (if Hct <25 then start FeSO4 325 mg PO tid; >25 but <30, give bid; >30, give qD).
Info to get on a gynecologic history
 Age, G’s and P’s, LMP, contraceptive use?, last Pap smear and mammogram
 Menarche, cycle length, regularity, # days of menses, light vs. heavy flow, changes in flow
 Spotting or post-coital bleeding, vaginal discharge (color and smell)
 Pre-menstrual symptoms and medications
 History of STDs, vaginal discharge, abnormal pap smears, gynecologic surgeries
 If past menopause – use of hormone replacement therapy
 If with abnormal uterine bleeding - # pads used per day, passage of clots & size
Page 78
Naegle’s rule: EDC = LMP – 3 mo + 7 days
Pregnancy dating
Use the LMP if:

1st trimester, and U/S and LMP differ < 7 d

2nd trimester, and U/S and LMP differ < 14 d

3rd trimester, and U/S and LMP differ < 21 d
FHT should be heard with Doppler @ 10-12 wk
FHT should be heard with stethoscope @ 18-20 wk
Fetal movement first occurs around 18-20 wk
From 15-36 wk, fundal height in cm = # wk gestation
18-20 wks
24-28 wks
34-38 wks
36 wks
A1
GB
B
C
Ante-natal labs
15-18 wks
White Classification for Diabetes in Pregnancy
A2
Clinic visits (goal > 10 visits)
every 4 wk until 28 wk, then
every 2 wk until 36 wk, then
every week until 41 wk, then
twice weekly post dates.
Initial Visit
values are elevated on the OGTT:
 Fasting < 105 mg/dL
 1-hour < 190 mg/dL
 2-hour < 165 mg/dL
 3-hour < 145 mg/dL.
Additionally, two fasting glucose levels > 120
mg/dL in one week are diagnostic of gestational
diabetes (no OGTT necessary).
CBC, type and screen, Rh, rubella,
VRDL, GC/ entamici, HbsAg, Pap, PPD,
U/A, HIV, 50 g glucose tolerance test
(GTT) if with risk factors.
mat serum FP, hCG, estriol,
amniocentesis
ultrasound for dates
50 g GTT; 3 hr GTT if needed; if Rh(-),
give RhoGAM @ 28 wk; repeat CBC if
anemic
CBC
check cervix q week
Normal labor
Engagement  Flexion  Descent 
Internal rotation  Extension  External rotation
Causes of abnormal labor
1.
Powers: ineffective uterine contractions, excess
sedation, exhaustion, infection, severe
polyhydramnios, neuromuscular disease
2.
Passenger: abnormal fetal position, lie, or
presentation (face, brow, compound), fetal
macrosomia, hydrocephalus
3.
Passage: cephalopelvic disproportion, uterine
masses, unripe cervix, pelvic fractures,
kyphosis, rickets, cervical pathology,
overdistended bladder
Page 79
D
F
H
R
Abnormal Glucose Tolerance Test (GTT),
controlled by diet
Abnormal GTT, fasting glucose between 105-120
with 20-25 U NPH qd
Fasting glucose > 120 despite diet and split-mix
insulin
Age of onset > 20, or duration < 10 years
Age of onset between 10-20, or duration 10-20
years
Age of onset < 10, or duration > 20 years
Presence of diabetic nephropathy
Presence of ischemic cardiovascular disease
Presence of prolific retinopathy
Management during Pregnancy
A1
A2
GB-R
ADA diet (35 kcal/kg/day), check fasting blood
sugars at routine prenatal visits.
ADA diet and low-dose insulin (start with 20-25 U
NPH before breakfast).
ADA diet and split-mix insulin, prenatal visits every
2 weeks until 30 weeks, then every week.
Baseline ophthalmology exam. Monitor urine
protein/creatinine ratio. Ultrasound at 20-22
weeks, then every 4 weeks beginning at 28 weeks.
Post-partum Management
A1,2
GB
B-R
ADA or regular diet, no insulin needed.
Follow pattern dextrosticks for 24 hours, consider
SSI. ADA diet when tolerating PO.
Decrease insulin to half pregnancy dose, or SSI.
Dextrosticks q6h until taking PO, then pattern.
Use NS instead of LR. Follow-up in one week.
Triple Screen: Down syndrome = ↓aFP (20-25%),↓unconjugated estriol ↑hCG. Neural tube defects = ↑aFP. Abno
and genetic amniocentesis. This screen ID’s 60% of Down syndrome and 60-75% of all trisomy 18.
2
Offered if birth defect has occurred in mother, father, or previous offspring.
3Quad Screen: ↓aFP &estriol + ↑ hCG & Inhibin A = Down Syndrome/Trisomy 18 (Edwards). ↑aFP in neural tube
drome, TOF, anencephaly
1
Page 80
Page 81
Harris and Falgout; Glenn Wheeling, PA) and 4 weeks spent with University
Surgical Associates (Drs. Matthews, Gross, and Bilton). If you are interested
in a surgical subspecialty, it does not hurt to ask if you can work with one of
the surgeons in that field for one block.




There is a considerable amount of variation in your schedule during this
rotation depending on who you work with. Each attending will differ in
terms of required clinic time and if/when to pre-round on patients. Most of
the surgeons operate at multiple sites (DCH, Northport, Tuscaloosa Surgical
Center), so be prepared to travel between these locations.
When you are with “the Group,” you will be assigned to a surgeon for two
week intervals. Pre-rounding requirements will vary depending on the
surgeon you are assigned to. You will sometimes round with the attending
between cases or before going to clinic. The amount of clinic time required
on this service is increasing. Specifics about when you are to attend clinic
will be given during orientation for the clerkship. Generally, you will attend
surgeries in the morning and clinic in the afternoon if there are no surgeries.
When you are with “the Group,” you determine your own call schedule with
the other students on the service, dividing it equally amongst yourselves.
Whoever is on call needs to notify the attending on call in person and/or call
their office so that they know which student to call/page. As you divide up
call days, it might be helpful to know that trauma call is generally the busiest, and some attendings are more likely to call you than others. Prior students can provide you with more details and suggestions for how to divide
up the schedule.
When you are with one of the University Surgical Associates, you will take
call when they take call. It usually works out to be every 4 th night and one
weekend a month unless someone is on vacation. Again, trauma call is the
busiest – expect to get a call on these nights.
Page 82
you to pre-round on all patients before the first surgery of the day and attend
clinic every day. Others have you pre-round after surgery while they are in
clinic. Your attending will tell you what he expects.

You are allowed to take surgical call from home if you live in the Tuscaloosa
area (within 20 minutes of the hospital). Once dismissed by your attending, you
may go home, but keep your cell phone and/or pager on you in case your
attending needs you to come back to the hospital. If you are commuting from
the Birmingham area, there are call rooms available on the 4 th floor for you to
use. Remember – you are NOT allowed to consume alcohol, medications, or
any other substance that may impair your abilities to participate in patient
care while you are on call. If you do and your attending calls, notify him that
you will be unable to return to the hospital. DO NOT return to work after
drinking under any circumstances!
Clerkship Duties/Requirements:



Attend and participate in surgeries. Often, you will act as first assist and will
help suture at the end of a case. Your attending may allow you to perform some
of the more minor procedures, so don’t be shy! Take advantage of the one-onone teaching provided on this campus.
Attend clinic as required by your surgeon. You will occasionally see patients
on your own and present them to the attending, but often you will do more
shadowing in clinic. You will often be allowed to remove staples and stitches
and perform other minor procedural tasks. Clinic provides an opportunity to
learn a lot of useful information – when surgery is indicated and when it is not,
what work-up is necessary prior to surgery, who is a good surgical candidate
and who is not, how to counsel a patient prior to surgery, etc. You will see this
type of information on your shelf, probably more than what you are learning
during the surgeries themselves.
Attend all lectures. Lectures occur almost daily, usually in the afternoons, on
the 4th floor of DCH. A lecture schedule will be posted on the door but changes
frequently. Grace, the clerkship secretary, will text you reminders about lecture
and about any changes to the schedule. Lecture is mandatory unless you are
scrubbed in on a rare surgery.
Page 83
round on some of their patients without being asked. Pre-rounding/
rounding gives you an opportunity to focus on post-operative management of patients, another important topic for your shelf. Surgical
progress notes follow the SOAP format but are meant to be very concise, focusing on pain control, vital signs, urine output, relevant labs,
and wound healing. Use your Maxwell for guidance on how to write
surgical notes.




Dictate H&Ps/consult notes as required by your attending. Some
attendings, particularly with University Surgical Associates, will ask
you to dictate H&Ps and consults for them. Information will be provided about how to use the dictation system. While this might seem like a
daunting task at first, it is excellent practice. You will be required to
dictate histories, consults, and discharge summaries as a resident, so
doing it on this rotation gives you a head start. If he does not already
do so, ask your attending to review your dictations with you and offer
suggestions for improvement.
Osler presentation – 15 – 20 minute PowerPoint presentation on a case
that you have seen during the rotation.
Keep at patient/procedure log using the E-Value system. You must log
at least 60 procedures. Try to enter your procedures every day or two,
so that you can keep up with them. You must turn in a print out of your
log at the end of the rotation to Grace.
TEAM Service Learning Requirement— One Tuesday morning during
the clerkship from 8-12 will be spent at Northport Rehab. The first
half of the morning will be spent rounding with the Dr. Barnett the
physiatrist and the second half be spent with rehab team.
Page 84
a great brief summary of a wide variety of surgical cases. Pestana
has worked for Kaplan in the past, so his material is very similar to
Kaplan reviews. This is a great high-yield resource. Print out a copy
to stick in your white coat and review during down time between
surgeries.





Surgical Recall (provided) – provides a good overview of various
surgical conditions, the relevant anatomy, and the surgical procedures used. You will typically know what surgeries are the on the
schedule for the following day, so this is a great resource to use the
night before (or even 10 minutes before) you go into the OR to
brush up on the procedure you are doing. It typically has answers to
lots of the questions the surgeons will ask you during a procedure.
Case Files (provided) – easy to keep on you and study with when
you have down time between cases.
Essentials of General Surgery (provided), NMS Surgery (provided)
– more detailed textbooks that can be used as a reference when
preparing your Osler presentation or when you need an in-depth
review. NMS includes various cases to address management issues. It has a good trauma section that is high-yield for the shelf
exam.
Pretest Surgery—mixed reviews. Some found it helpful while
others found the questions much more difficult than the shelf exam.
USMLE World Step 2 CK QBank – about 160 board-style surgery
questions. Not worth the subscription fees just for this clerkship but
helpful if you already have a subscription.
Page 85
tired when you leave work, but try to make a little bit of time to read for the
following day. It will pay off when you are able to answer your attending’s
questions and generate questions of your own that show you are interested.
KNOW THE ANATOMY!






The OR is the best place to learn to ventilate, intubate, suture, start IVs, and
place Foleys, central lines, and chest tubes – seek out these opportunities! You
may not be directly asked to participate in these procedures, but if you ask to
help, you will typically be allowed to do so. These are good skills for any medical specialty. The OR staff is helpful and willing to teach if you show interest.
Get to know the OR staff and use them as a resource, particularly if you are
unfamiliar with the OR setting. It can take some getting used to if you don’t
know your way around, so the nurses and scrub techs are immensely helpful.
Always introduce yourself to the staff working the case and ask if you can help.
Learn what you can and cannot touch and how to maintain a sterile field – this
will save you from getting yelled at. Always ask permission before taking an
instrument off the Mayo table! The nurse and scrub tech are responsible for
accounting for all of the instruments and sharps at the end of a case, so they
need to be aware of where everything is.
The surgical PAs are an amazing resource – use them! Glenn has more experience than most of the surgeons combined. He will teach you how to properly
suture but also how to be an effective first assist who can anticipate the surgeon’s needs.
Don’t complain about the hours you are required to work! You can do anything
for 8 weeks. Also, invest in some comfortable shoes: new tennis shoes,
Danskos, and Clarks have served past students well.
If you are interested in surgery, look for opportunities to take on extra responsibilities without being asked – pre-round on your attending’s patients,
check on them post-op, etc. The attendings will appreciate your initiative.
Pay attention during your OR orientation, when safety and sterile technique
are reviewed. Even the “cleanest” patients could have something you don’t
want, so protect yourself with all of the necessary OR garb, including eyewear.
Be mindful of sharps and speak up if you get stuck. It might seem like an inconvenience to go through the reporting process, but it is worth it!
Page 86
Appendicitis
Inguinal hernia
Salpingitis
Ectopic pregnancy
Inflammatory bowel disease
Mesenteric adenitis (Yersinia)
Early appendicitis
Bowel obstruction
Ruptured aortic aneurysm
Gastroenteritis
Inflammatory bowel disease
Salpingitis
Ectopic pregnancy
Irritable bowel disease
Constipation
Diffuse: Causes include gastroenteritis, peritonitis, mesenteric ischemia, bowel obstruction
Differential Diagnosis of Surgical Fevers
Intraoperative or immediately post-operative
Malignant hyperthermia (halothane)
Transfusion reaction
Drug hypersensitivity
Atelectasis
Aspiration pneumonia
Endocrine (Addisonian crisis, thyroid storm,
pheochromocytoma)
Post-operative fever (any time)
Thrombophlebitis
Deep venous thrombosis
Drug hypersensitivity
Transfusion reactions
Central line sepsis
Post-operative fever (> 24 hours)
POD# 1-2 = “Wind” (atelectasis)
POD# 3-4 = “Water” (urinary tract infections)

Pneumonia

IV complications (infection)

Wound complications (leaking
anastamosis, hematoma)
POD# 4-6 = “Wound” (wound infections)
POD# 6-10 = “Walking” (DVT) and “Wonder drugs”

Abscess

Drug fever

Pneumonia

Wound infections

C. difficile colitis

Anastamotic leak
Post-operative fever (< 24 hours)
C = Clostridial wound infections
S = Streptococcal wound infections
T = Thyroid problems
A = Addisonian crisis
T = Transfusion reaction
Causes of Small Bowel Obstruction
Adhesions from prior surgery
Hernias
Inflammatory Bowel DZ
Malignancy-lymphoma, carcinoid, metast.
Intussusception (mucous stools)
PROCEDURE NOTE
Recovery of Bowel Fx Post-Op: 1) Small Intest. Hours, 2) Stomach Day, 3) Colon ~3 days
PROCEDURE
PERMIT
INDICATION
PHYSICIAN(S)
DESCRIPTION
COMPLICATIONS
EBL
DISPOSITION
Procedure, benefits, risks (including those of bleeding, infection, injury, anesthesia), and
alternatives explained to patient who voiced understanding of the information and
agreed to proceed. Permit signed and on the chart.
Meningitis, pleural effusion, venous access, ascites, etc.
Area prepped and draped in a sterile fashion. (Local, spinal, etc.) anesthetic
administered using (cc medication). Describe technique including body location,
instruments, etc.
(Hopefully none)
(estimated blood loss in cc)
Patient resting comfortably, breathing non-labored, incision clean, dry, and intact, etc.
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3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Findings
Procedure
Surgeon
Assistant(s)
Anesthesia (type)
Specimen(s)
Estimated blood loss
Fluids
Tubes/drains
Complications
Miscellaneous/special Meds
Post-operative Orders
Disposition—where you want the patient to go
Special Recovery Room Requests—labs, CXR, etc.
Vitals—Q4h (or as per routine)
Tubes/Drains—NG—>well suction, Foley to gravity...
Bed position—elevated to ____ degrees
Activity—where, frequency, etc.
Diet—NPO except ice chips, liquid, regular, diabetic..
AM labs to be drawn
Meds—the 6 A’s and home meds (analgesics, antibiotics, antiemetics, antacids, anticoagulants, and anti-inflammatories)
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lectures, and presentations


Each student will choose a family medicine preceptor in a rural location of his
or her choice. A list of possible preceptors will be provided for you to choose
from or you can make your own arrangements. Either way, try to choose someone early to ensure that you get the preceptor you want and all of the arrangements can be made.
You will take the family medicine shelf at the end of the 4th week unless you
are a rural medicine scholar.
Clerkship Duties/Requirements;






Assist your family medicine preceptor in his or her clinical and/or hospital
duties. Specifics, including call requirements and schedule, will differ based on
your preceptor.
Attend all lectures and presentations in Tuscaloosa. These generally occur every
couple of weeks and last a full day.
One patient write-up/presentation to be presented at the end of week 2.
Conduct interviews with several members of the community in which you are
working. A list of who you should interview and suggested questions will be
provided during clerkship orientation.
Final paper and presentation describing what you learned about the community
and its health needs based on your interviews. More information will be provided during clerkship orientation.
Design and attempt to implement a project to address one identified health need
in the community. Suggestions for projects based on what students have done in
the past along with more information will be provided during clerkship orientation.
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(Listed in order of “usefulness” according to surveys of past students)
Note: Since this specialty contains elements from several of the other disciplines,
any resources you used in past clerkships will be helpful to review for this one.

AAFP Website questions (available with registration)

Case Files Family Medicine

USMLE World Step 2 CK QBank, Others with mixed reviews: First Aid,
Blueprints, Kaplan
Tips for Success:




The family medicine shelf exam is difficult, particularly if you have this
clerkship early in your third year. It includes info from internal medicine,
pediatrics, OB/GYN, public health, community medicine, etc. If you have
not had IM yet, spend a good amount of time reviewing that information.
If you do not know of a preceptor you want to work with, ask for guidance
from other students or the clerkship staff. Try to find someone who will
let you actively participate and see patients on your own, and be proactive
and participate in whatever ways your attending will allow you to.
Practice developing your own impression and plan. Just like in IM, you
learn a lot from doing this, even when you are wrong.
Keep in touch with your mentor for rural medicine. Ask them to help
you stay on top of your interviews and other requirements for your project.
Page 90
AFVSS - afebrile vital signs stable
ALI - acute lung injury
AlkP - alkaline phosphatase
ALT - alanine aminotransferase
AMS - altered mental status
APAP - tylenol
APE - acute pulmonary edema
ARA - advanced reproductive age
ASA -- aspirin
AST - aspartate aminotransferase
AVNRT - atrioventricular nodal reentry
AZT - zidovudine
BLOC -- Brief Loss of Consciousness
BNP - brain natrilretic peptide
(measures CHF)
BRBPR - bright red blood per rectum
BRP – bathroom privileges
BV – bacterial vaginosis
Bx -- biopsy
c (dash above) – with
CA -- cancer
CAP -- Community acquired
pneumonia
CCE - clubbing cyanosis edema
CDI - clean dry intact
CEE - conjugated equine estrogen
CHIBLOC - closed head injury brief
loss of consciousness
COPD - chronic obstructive pulmonary
disease
CPPD - calcium pyrophosphate dz
(pseudogout)
C&S -- culture and sensitivity
CST -- Contraction stimulation test
CTA - clear to auscultation
cTnI - cardiac specific troponin I
CTS - carpal tunnel syndrome
Cx -- culture
DAU - drugs of abuse in urine
ddI – didianosine
DM -- diabetes
DOE -- dyspnea on exertion
DOS - day of surgery
DRE - digital rectal examination
DRG - diagnostic related group
DTR - deep tendon reflexes
EASI -- Extra-amniotic saline infusion
ELISA - enzyme-linked
immunosorbent assay
EMC - endometrial curettage
env - HIV structural gene envelope
EOF -- Elective outlet forceps
EOMI -- extraocular movements
intact
EPO - erythropoeitin
EPS - extra pyramidal symptoms
ERCP - endoscopic retrograde
cholangiopancreatography
ERT - estrogen replacement therapy
ESWL - extracorporeal shock wave
lithotripsy
FBP - fluid balance panel
f/c – fevers / chills
FEF - forced expiratory flow
FEN -- fluids, electrolytes, nutrition
FENa - fractional exretion of Na
FESS - functional endoscopic sinus
surgery
FEV1 - forced expiratory volume 1
second
FH -- Fundal height
FNA – fine needle aspiration
FOBT - fecal occult blood testing
f/u – follow up
FUO - fever of unknown origen
gag - HIV structural gene group
antigen (core, capsid)
GBS - group B strept
GDM -- Gestational diabetes mellitus
GGT - gamma glutamyltransferase
GN - glomular nephritis
GTT -- Glucose tolerance test
GTTS - drops (opthalmic)
HA - headache
HAART - highly active antiretroviral
therapy
HD - hemodialysis
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I&D -- Incise and Drain
IADL - instramental activity of daily
living
IUD – intrauterine device
IUP – intrauterine pregnancy
IUFD -- Intrauterine fetal demise
JP - jackson pratt drain
JVD -- jugular venous distention
KUB - kidney, urinary, bladder (Xray)
LAD -- lymphadenopathy
LMP – last menstrual period
LOA - loss of appetite, looseness of
associations
LOC - loss of conciousness
LTB - laryngotracheobronchitis
LTCS -- low transverse cesarean
section
MAHA - microangiopathic hemolytic
syndrome
MAEW -- Moves All Extremeties Well
MEN - multiple endocrine neoplasms
M/G/S -- Moro, grasp, suck reflexes
MMF - maxillary madibular fixation
MMG -- mammogram
MMM -- mucous membranes moist
MMSE - mini mental status exam
MOA - mechanism of action
MRA - magnetic resonance angiogram
M/R/G - murmurs, rubs, gallops
MSM - male having sex c male
MSO4 PCA - morphine pump(patient
controlled analgesic)
MVI - multivitamin
MTR - microtubal reanastamosis
NABS -- normal active bowel sounds
NAD - no acute distress
NGSF - no growth so far
os - left
od - right
OCOP: oral cavity oral pharynx
OCP -- Oral contraceptive pills
OOB - out of bed
OSH -- Outside hospital
OTD – out the door
p (dash above) – after, post
p (circled) -- pending
PBC - primary biliary cirrhosis
PEA - pulseless electrical activity
PEG - percutaneous endoscopic
(esophageal) gastrostomy
PERRL -- pupils equally round and
reactive to light
PIH - pregnancy induced
hypertension
PND -- paroxysmal nocturnal
dyspnea
PNH - paroxysmal nocturnal
hemoglobinuria
PNV - prenatal vitamin
POC - products of conception;
point of care
POD - post Op Day
pol - HIV structural gene
polymerase
PPD -- Post-partum day
PROM - premature rupture of
membranes (vrs. prolonged)
PPROM -- Preterm PROM
PSA – prostate specific antigen
PSC - primary sclerosing
cholangitis
PTC -- Pre-term contractions
PTCA - percutaneous transluminal
coronary angioplasty
RAIF - radioactive iodine uptake
RF - renal/respiratory failure;
rheumatic fever
RH - rheumatoid arthritis
r/o – rule out
ROM -- Rupture of membranes
RPOC -- Routine post-op care
RPR - rapid plasmin reagin
(syphillis)
RRR - regular rate rythm
elevation
gt – drop
SVD -- Spontaneous vaginal
gtts – drops
ID – intradermal
delivery
IM – intramuscular
Sx -- symptom
IV – intravenous
Sz -- seizure
IVPB – intravenous piggy back
T&C -- type and cross
T&S -- type and screen
od – right eye
TAB -- Therapeutic abortion
os – left eye
ou – both eyes
TAH-BSO - total abdominal
PO – by mouth
hysterectomy bilateral
PR – per rectum
salpingoophrectomy
PRN – as needed
TBBX - transbnchial biopsy
q – every
TD - tardive dyskinesia
TEE - trans esophageal echo qd – every day
qam – every morning
TEP - tracheal eeophageal
puncture (for speech)
qhs – at bedtime each night
qid – four times a day
TF - tubal factor
TOA - tubo ovarian abscess
q#h – every # hours
qod – every other day
TP - total protein
TRALI - transfusion related acute SC – subcutaneous
Sig – label
lung injury
TTE - trans thoracic echo
Sol’n – solution
Tx - treatment/therapy
Supp – suppository
UAG – urine anion gap
Susp -- suspension
UA/NSTEMI - unstable angina Tab – tablet
non-STEMI
Tid – three times a day
UDS - urine drug screen
Ung -- ointment
UFH - unfractionated heparin
US - ultrasound
WDWN - well developed well
nourished
XRT - radiation Tx
CRIMSON BOOK
2013-2014
Good Luck
on your rotations! And remember, you can do
anything for 8 weeks!
Thanks,
UASOM Class of 2014, Tuscaloosa Campus
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