Student Responsibilities

• Attend all scheduled clinics and teaching activities.
• Enthusiastic educational attitude.
• Professional demeanor and cooperative attitude toward all staff and patients.
• In Student Follow-Up, Adult Medicine Walk-In and DESC see 2-4 patients per session, present to the attending (see below for outline of clinic presentations), and initiate management. Your history and exam should be directed toward the problems of the day, but you should be aware of the full problem list and all medications taken. The attending will review the history and physical examination, help you formulate a treatment plan, and give you specific feedback regarding your efforts. Write-ups should be completed within 24 hours (see below for suggested format for clinic notes).
• Follow-up. Before a patient leaves clinic, review how they will learn of lab results and when they should return to clinic. When appropriate, you should follow-up test results over the phone or schedule patients back to see you again.
• Prepare for case discussions, including review of suggested references, prior to each didactic session with the Chief Resident.
• Arrange to ride with Medic-One once during the rotation. Call Carol Barton at 386-1483 to arrange. Make sure to wear your white coat.
• No on-call or weekend responsibilities are scheduled.
• If you would like to work on phlebotomy skills, you may join HMC ward phlebotomists as they make morning rounds on Monday or Tuesday. Contact Victor Green (744-3451).
• Have fun! Contact Dr. Babcock (pager 680-1819, email babcock@uw.edu) or Dr. Terasaki (pager 680-0543, email terasaki@uw.edu) immediately if you need help solving any problems!

Suggested Outline for Clinic Presentations

In clinic, your presentations should clarify the issues you discussed and your plan for each. Be certain to let your attending know how they might help you most. One popular and effective format is as follows:

1. Frame the patient and identify a question that you want the attending to address:

   Mr. K is a 45-year-old man with diabetes, hypertension, and depression. He is here for a new lesion on his leg and for a blood pressure check. I’d like you to look at his leg with me, and I need your thoughts on his BP. His PCP is Dr. Sheffield.

2. Give an efficient, problem-based history, exam, and plan:

   Problem #1: Leg lesion. He noticed this lesion a few months ago, and it’s gradually grown. He doesn’t recall injuring himself, and it’s non-tender and not itchy. He has not had fever or chills.

   Problem #2: Blood pressure. He’s had hypertension for 5 years, and it had been well controlled until recently when his medication doses have had to be increased. He’s currently taking atenolol 50 mg, hydrochlorothiazide 25 mg, and lisinopril 20 mg. He does not drink and has always been compliant with his medications. Now his pressures at home range from 140s to 150s over 90s. He denies chest pain, SOB, orthopnea, headache, edema.

   In clinic today, his pressure is 152/92 and pulse is 54, his temp is 37. He appears well. I do not hear a murmur, no JVD and his lungs are clear. There is no edema. I hear a bruit over the right femoral artery. On his right anterior shin he has a smooth, shiny, well-demarcated plaque with central atrophy and telangiectasia. The surrounding leg and skin are normal in appearance and sensation is intact.

   My assessment by problem:
   #1: Leg lesion: Because he’s diabetic, I was originally concerned about infection, but there are no signs or symptoms of that. I am not certain what this is. Could you look at it with me?

   #2: Hypertension: I am concerned that he might be developing renovascular disease, and I’d like to order a renal artery duplex. I also think that his BP is above his goal and that we should adjust his medications.

   Other issues: We didn’t talk about his diabetes today. I’d like to schedule an appointment for follow-up in 2 weeks to go over that and his test results.

3. Get Feedback

Any suggestions for me?

Suggested Format for Clinic Notes

When reviewing your clinic notes, a reader should be able to rapidly identify your patient’s problems, medications, and management plan. With the exception of the Assessment & Plan section, clinic notes are generally much more concise than ward notes.

There are two basic formats for clinic notes:

1. Full History & Physical: used for patients who are new to the clinic or specialty. Similar to inpatient admission notes, it includes HPI, PMH, FH, SH and a complete ROS.
2. Modified SOAP note: used for patients who have been seen previously in the clinic, regardless if this is your first time meeting the patient. This will be >95% of the notes written during your outpatient clerkship.

The following is an example of a clinic note in the modified SOAP format with the basic components.

ID/CC: 55 year old gentleman with acute back pain.

In addition to the patient’s primary concern or focus of the visit, the ID/CC should include the age, gender, and other active and relevant problems. While language and ethnicity can provide valuable information in “framing” the patient, race identifiers are rarely clinically important and should be omitted.

PCP: Dr. Sheffield

Current Concerns:

Problem 1: Back pain: Pt developed low back pain 2 days ago while moving furniture. He denies numbness/tingling in his legs, no lower extremity weakness, no incontinence of urine or stool. No f/c/s. He has not been taking any medications for this problem. No history of cancer or steroid use.

Problem 2: Hypertension… etc

The “S” of the SOAP note, this section is a concise, problem-based history of the concerns discussed. New problems require a chronology of the events leading up to today’s presentation (including location, duration and timing, severity, quality, associated symptoms, relieving and exacerbating factors, and impact on their functionality). Pertinent positives and negatives should reflect your differential diagnosis. The reader, by this point in the note, will have mentally generated their own list of possible diagnoses based on the chief complaint and chronology; it is your job to provide the relevant information (e.g. associated symptoms, risk factors and exposures) to help the reader to narrow down their differential diagnosis. It is also helpful to note the patient’s perception of the cause of the problem. For known chronic diseases, you should provide a status update and response to previously prescribed interventions, if any. In this context, the pertinent positive/negatives should include possible complications from the disease process or from the therapy. For example, in the case of a patient with long standing diabetes, it would be important to report the presence or absence of blurred vision, polyuria, polydipsia, chest pain, feet tingling, and hypoglycemic symptoms.

Problem List:

1. Hypertension.
2. Hyperlipidemia, 6/09 total cholesterol 300, HDL 45, LDL 190, Trig 150.
3. CAD, s/p MI 5/00, thallium study 9/01 negative.
4. Tobacco use.
5. Health care maintenance: tetanus shot 5/99, colonoscopy 4/01 normal.

What is the purpose of the ‘problem list’? Many providers view it as tool to keep track of the patient’s active problems over months and years. If meticulously maintained after each visit, the Problem List can save the provider from having to do a time-consuming chart review with subsequent visits. It is also valuable to other providers (consulting, interim follow-up, and admitting services) in providing an accurate snap-shot of the patient’s current issues. The scope, level of detail, and style of the Problem List vary widely between providers.

Medications:

• Aspirin 81mg po qday
• Enalapril 10mg po qday
• Simvastatin 40mg po qhs
• Colchicine 0.6mg po qday
• Tylenol 500mg po qid prn pain
• Ginko biloba (OTC) one capsule qday

Beware of the automatically imported list in the electronic medical record. How can one be certain of the accuracy of this list? How was this list generated? Is it directly linked with the dispensing pharmacy? Who last updated it? An accurate medication list is crucial to providing care and the only way of knowing what the patient is actually taking is by directly asking him or her. Make sure to note whether the medication list you’ve included has been verified/reconciled with the patient at this visit.

Alleriges:

Sulfa drugs cause rash

Be sure to list the reaction.

Physical Exam:

Vitals: t 36.8, BP 155/92 (manually 148/90), HR 86, RR 12, Pox 99% on RA
General: NAD, pleasant, talkative.
Back: FROM, able to touch toes. Mild palpation in the lumbar paraspinous muscles on the left side. Spinous processes are non-tender. Negative straight leg test.
GU: deferred.
MSK: 5/5 strength in the bilateral quads, hamstrings, and calf muscles. Able to stand from squatting position without difficulty.
Neuro: A&O. Normal stance and gait. Grossly normal sensation of the bilateral lower legs and feet to light touch.

The objective section includes a description of the exam performed on that day. Always include vitals and general statement. Be sure that the scope of your exam encompasses your differential diagnosis. For example, if the patient’s chief complaint is acute chest pain and you are considering the possibility of several diagnoses including pulmonary embolism, it would be especially important to report a detailed description of the cardiac and pulmonary exam as well as the presence or absence of lower extremity edema.

Results:Summarize key results if relevant (labs, imaging studies, pathology).

Assessment and Plan:

1. Acute low back pain. The DDx for LBP includes muscular spasm, degenerative joint disease, disc herniation with sciatica, compression fractures, spinal abscess, cancer, and ankylosing spondylitis. Given the acute onset and the absence of trauma, risk factors for osteoporosis, concerning neurologic findings, or infectious symptoms, it would appear that his LBP is uncomplicated and mostly likely due to muscular spasm from heavy lifting. This would be expected to be self-limited with most people recovering by 6 weeks. There is no role for imaging at this point.

Plan:


• a. Advised to maintain near nrl activity level; avoid bedrest
• b. Referred to PT
• c. Rx: Naproxen 500mg po bid prn; advised to buy OTC bengay cream
2. Hypertension. Poorly controlled despite adherence to medication.

Plan:


• a. Increase enalapril to 20mg po qday
• b. Brief counseling to stop smoking (contemplative). Quit-line info given.
• c. Return in 1 week for basic metabolic panel. Pt given lab slip.
3. Health care maintenance: Did not have time to address today. Next time: needs a Td booster shot.

Follow-up: return to med student clinic in 4 weeks to reassess LBP and recheck BP.

The assessment and plan is your opportunity to demonstrate your fund of knowledge, problem-solving skills and ability to communicate clearly. For new problems, list your differential diagnosis and briefly discuss how the available data supports or refutes each possibility. What is the most likely diagnosis? If, however, at the end of the visit, there is still diagnostic uncertainty among the remaining possibilities, then you should discuss your plan to further evaluate the problem (imaging, labs, watchful waiting, etc.)
For established chronic problems, you should start with stating the status or trend since the last encounter. Are there any complications from the disease process or adverse effects from the therapy? (Depending on the severity, these complications may warrant their own section and discussion).
With each problem, you should provide your plan in bullet format so that it can be easily read. Please clarify your plan for follow-up. Finally, the note should conclude with the intended time frame for the next follow-up visit.
One last suggestion: ask for ongoing feedback on your clinic notes!