MEDICAL STUDENT HANDBOOK ST. BARNABAS HOSPITALDepartment Of Family Practice 3rd Avenue and 183rd St. Bronx, N.Y. 10457
Revised March 3, 2007 Reviewed: 2002 |
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Medical Student Handbook
TABLE OF CONTENTS |
MEDICAL STUDENT CLERKSHIP IN FAMILY PRACTICEST. BARNABAS HOSPITAL
Men: * Dress shirt and a tie are required. * Dress slacks or white pants are required. * JEANS ARE UNACCEPTABLE. * Comfortable shoes or solid color sneakers (white, black, gray or beige) should be worn.
Women: * A dress, or a blouse and a skirt, or a blouse and dress slacks are required. * JEANS ARE UNACCEPTABLE. * Comfortable shoes or solid color sneakers (as above) should be worn. Please note: Due to OSHA regulations, open-toed shoes or sandals are inappropriate.
All: * A clean, neat white lab coat is required while on duty. * You are required to visibly wear your ID badge at all times while at the Fordham Plaza Clinic or St. Barnabas Hospital grounds. * You are expected to dress neatly, and provide a competent and professional appearance at all times while you are on duty.
FAMILY PRACTICE CLINIC
A. New Patient (never been seen in Clinic Before)
1. Obtain Chart from Chart Rack.
2. Call patient and introduce yourself.
3. Obtain complete History and record on appropriate form in Chart. Fill in Health Maintenance Form.
4. Perform thorough Physical Examination with emphasis on problem areas. Record findings. If a portion of the Physical Examination needs to be deferred to the next visit (i.e. pelvic exam), it should be noted as such on the form. Structural exams should be done as part of a complete physical and the proper form is to be completed.
5. The student should formulate his/her own Assessment and Plan. Note it on a scrap paper if necessary. DO NOT record it on the H & P form at this point. Discuss the case and your findings with your supervising resident. He/She may re-interview and/or re-examine the patient. At this point, you and the resident will discuss the case with the Preceptor. A diagnosis with a treatment plan will be reached.
6. Record Assessment and Plan.
7. Complete any necessary paper work.
* Prescriptions * X-ray requests * Test requests * Follow-up appointment requests * Medication list * Problem list * Complete billing form
8. Have Preceptor review and sign appropriate papers.
9. Give chart to Discharge Nurse along with verbal instructions for special requests.
B. Patient previously seen in Clinic:
1. Review * Medication List * Last progress note * Problem list * Lab and test results
15. Interview Patient * Review medications * Have patient explain how they take the medications * Ask about side effects * Investigate any new problems
16. Examine Patient
17. Start writing SOAP note. Formulate Assessment and Plan, but DO NOT record until after discussing the case with first the supervising resident, and then the Preceptor.
18. Complete steps 6 through 9 as those for New Patients.
Abundant evidence documents that the majority of deaths among Americans below age 65 are preventable, many through interventions best provided in a clinician’s office. Primary care clinicians play a key role in screening for many preventable illnesses and conditions. The information contained in this section will be useful as you rotate through the St. Barnabas Department of Family Practice, as well as in your future career. The health problems you will address are extensive and are seen every day by primary care providers: cardiovascular and infectious diseases, cancers, immunizations, etc. Of equal importance, however, is the clinician’s role in counseling patients to change unhealthful behaviors related to diet, smoking, and sexually transmitted diseases. The evidence based information will be crucial you as you build your career and grow as a professional. The recommendations reviewed are based on the Guide to Clinical Preventive Services, the culmination of information, debate and synthesis of critical comment from experts compiled by the U.S. Preventive Services Task Force.
Regularly Updated Evidence Based Screening Guidelines from the U.S. Preventive Task Force are available on our Departmental web site via hyperlink to the U.S.P.S.T.F. at the following address: www.stbarnabashospital.org Select Family Practice once on the hospital website. Please refer to this website for the latest evidence based comprehensive screening guidelines.
As future osteopathic physicians, you are trained not only in the traditional medical theories, but also in an applied principle called osteopathic manipulative medicine. It is the philosophy of osteopathy, which makes you unique. Therefore, the issue of preventative medicine must never omit the importance of the screening musculoskeletal examination. The information in this handout regarding the structural examination was obtained by the 1997 edition of Foundations For Osteopathic Medicine published under the auspices of the American Osteopathic Association.
Screening Using The Structural Examination
The structural examination may be used as a screening of all key areas of the musculoskeletal system, which includes screening for possible viscerosomatic reflexes causing dysfunction. Using the screening examination may assist in formulating a plan in order to provide osteopathic manipulative therapy for a patient with significant somatic dysfunction. When performing a screening structural examination, it is necessary to only do a minimal examination unless there is some indication for seeking additional data (e.g., pain, specific musculoskeletal complaints). The osteopathic screening examination should not exceed more than 3-5 minutes, and it should be incorporated with the other aspects of the history and physical examination. The American Osteopathic Association defines a musculoskeletal screening to include examination in three positions, incorporating inspection, palpation, and regional and segmental motion testing of the spine and pelvis. Major findings of the extremities are to be included as well. It is imperative to document findings of: 1. the anteroposterior curves 2. the lateral curves 3. any limitations of motion 4. any muscular findings (e.g., hypertonicity or spasm) 5. tenderness
When interviewing a patient, it is possible that the history will draw attention to specific areas of potential somatic dysfunction, including areas of viscerosomatic reflexes. Although this is meant as a screening tool, keep in mind that an adequate examination will reveal significant findings necessary to make an accurate diagnosis. Therefore, all pertinent positive and negative findings should be recorded with the end product being documentation of all areas examined and appropriate diagnoses made. The form included in this handout is for documentation purposes only and does not specify a particular sequence. Its purpose is to assure that portions of the examination are less likely to be inadvertently omitted. * * *
Studies have suggested that 90% of the time the diagnosis can be obtained from the history alone.
General advice on history taking:1) Speak to the intelligence level of your patient not over them.2) Show empathy and interest in your dialogue.3) Allow them the opportunity to speak freely and ask questions.4) If they go off on tangents then redirect them with statements like “I will get to that a little later in our discussion but right now lets get back to what you were saying about”5) Maintain eye contact and do not invade the patients space.6) Keep in mind and respect cultural nuances that may not be readily apparent or that you may not be used too.7) Be yourself and genuine rather than trying to be someone your not and the patient will have more respect for you.8) Don’t stereotype or make rash assumptions in your interview.Date and TimeSource: Identify the person providing the history. Patient, family members name, translators name, EMS sheet.
Reliability: A comment on the quality of the reliability of the person providing the history. Reliable, unreliable, confused, incoherent incomprehensible, irrelevant etc.
Subjective:
Chief Complaint: A brief statement of why the patient is here, E.R., Office, Hospital? Should be in patients own words and in quotation.
History of the Present Illness/Chief Complaint (HPI): A summary of the events and symptoms over the course of the developing illness. If pain is the symptom you can include mnemonics NLDOCAT or OPQRST. Also if not pain can include elements of the mnemonics i.e. Onset, Duration Aggravating/Alleviating factors. Should also include selective system reviews extracted from the comprehensive Review Of Systems(ROS) pertinent to the presenting complaint. That is, if the chief complaint were abdominal pain than either of the mnemonics above would apply and the GI systems review should be incorporated in the HPI. The HPI gives many physicians in training difficulty. It will develop and improve over the course of your career as you better understand the various symptom manifestations of disease which can draw symptoms from many of the various systems within the comprehensive ROS. For example abdominal pain may manifest with joint pain and a skin rash which might prompt the knowledgeable physician to include the symptoms from the Skin and Rheumatologic systems reviews routinely.
Can include an update on past medical history, past surgical history, allergies, medications, social history, and family history especially if it has been some time since the last visit.
Objective:
Perform either a focused or more extensive physical examination based on the your clinical judgement and the presenting complaint. See H&P for details of Physical examination.
Assessment/Plan:
Labs (can use accepted shorthand notational schematic representation)
Special studies: EKG, PFT, XRAY, CT, MRI, Ultrasound, Stress Test results.
Generate a problem and/or diagnosis list.
Numbered problems listed with differential diagnosis, or rule outs followed by planned tests and treatment strategies to determine etiology.
Numbered diagnosis listed followed by planned testing and treatment strategies. * * *
Sample History and Physical Examination
Studies have suggested that 90% of the time the diagnosis can be obtained from the history alone.
General advice on history taking:
1) Speak to the intelligence level of your patient not over them.
2) Show empathy and interest in your dialogue.
3) Allow them the opportunity to speak freely and ask questions.
4) If they go off on tangents then redirect them with statements like “I will get to that a little later in our discussion but right now lets get back to what you were saying about”
5) Maintain eye contact and do not invade the patients space.
6) Keep in mind and respect cultural nuances that may not be readily apparent or that you may not be used too.
7) Be yourself and genuine rather than trying to be someone your not and the patient will have more respect for you.
8) Don’t stereotype or make rash assumptions in your interview.Date and TimeSource: Identify the person providing the history. Patient, family members name, translators name, EMS sheet.
Reliability: A comment on the quality of the reliability of the person providing the history. Reliable, unreliable, confused, incoherent incomprehensible, irrelevant etc.
Chief Complaint: A brief statement of why the patient is here, E.R., Office, Hospital? Should be in patients own words and in quotation.
History of the Present Illness/Chief Complaint (HPI): A summary of the events and symptoms over the course of the developing illness. If pain is the symptom you can include mnemonics NLDOCAT or OPQRST. Also if not pain can include elements of the mnemonics i.e. Onset, Duration Aggravating/Alleviating factors. Should also include selective system reviews extracted from the comprehensive Review of Systems (ROS) pertinent to the presenting complaint. That is, if the chief complaint were abdominal pain than either of the mnemonics above would apply and the GI systems review should be incorporated in the HPI. The HPI gives many physicians in training difficulty. It will develop and improve over the course of your career as you better understand the various symptom manifestations of disease which can draw symptoms from many of the various systems within the comprehensive ROS. For example abdominal pain may manifest with joint pain and a skin rash which might prompt the knowledgeable physician to include the symptoms from the Skin and Rheumatologic systems reviews routinely.
Past Medical History: You may want to site examples i.e. Heart disease, Asthma, Diabetes High Blood Pressure. Denies. When possible include date or number of years diagnosed.
Past Surgical History: You may want to site examples i.e. Tonsillectomy, Cholecystectomy, Appendectomy, Cesarean section. When possible include date or number of years respective surgey was performed. No history of Operations or transfusions.
Allergies: No known drug allergies and no known environmental or food related allergies. Pets.
Medications: Include dosage, frequency, when started and discontinued. Ask specifically about oral contraceptives and Vitamins and Herbs since some people do not consider these to be drugs. Over the counter medications used?
Family History: Generally we are interested in first degree relatives of patient, father, mother, sisters, brothers, and children but can be expanded to include second degree relatives. Use a genogram.
Occupational History: Ask specifically about work environments that may have contributed to the disease process i.e. lifting, toxic exposure, repetitive trauma etc.
Travel History: Destinations, Dates, Activities, Diet.
Diet History: Quality, type, frequency, and variety (5 food groups represented?) of meals ingested.
Social History: Start by informing the patient that the questions to follow are asked of everyone that we are not selective in whom we discuss these subjects with. Alcohol, tobacco, caffeine and drugs ( How much, how often, route and when last used?) Michigan Cage questionnaire, # pack-years. Sexual history should be included here specifically # of partners, history of sexually transmitted diseases. HIV testing.
Review of Systems: This is used to bring out any other symptoms in which the patient may not feel is connected and therefore failed to bring up in the HPI. If a particular pertinent system review was used in the HPI it does not need to be included here again. This also gives many Physicians in training difficult since some patients seem to identify “too many” symptoms. Leaving the doctor with a list of problems a whole page long. With each problem having its own differential diagnosis and needing to be addressed this task can be daunting. Therefore, prior to starting tell the patient that “I am about to name a variety of symptoms like headache, rash, and diarrhea among others. I am not asking if you ever had these symptoms before in your life. I am only asking if you have these symptoms presently or if this is a symptom that is recurrent, that seems to come back frequently again and again? Is this a symptom you have been enduring for a long time that doesn’t seem to be going away? Then begin. The patient may need to be reminded of your instructions during the course of the Review of Systems.
General Review of Systems: The patient has been in good health without any recent significant changes in weight, and appetite. The patient further denies any fever, night sweats, chills, fatigue.
HEENT: Head: Denies headache (cephalgia), head trauma, hair loss (alopecia). Eyes: Denies recent changes in vision including blurry vision, double vision, (diplopia), red eyes eye discharge, loss of vision/eyeglasses, itchy teary eyes, or eye pain or eye discharge. Ears: Denies any hearing loss, ear discharge (otorrhea), pain (otalgia), ringing or humming in the ears (tinnitus), does the room spin?(vertigo) Nose: Denies nose bleeds (epistaxis), discharge (rhinorrhea), loss of smell (anosmia), post nasal drip. Throat: Denies sore throat (odynophagia), trouble swallowing (dysphagia), change in voice, snoring.
Skin: Denies rashes, itching (pruritis), or growths.
Cardiovascular: Denies chest pain, palpitations, shortness of breath (dyspnea), leg swelling (edema), trouble breathing when lying down or waking up at night short of breath (orthopnea, and paroxysmal nocturnal dyspnea respectively), buttock or leg pain when walking or sitting.
Pulmonary: Denies shortness of breath (dyspnea), cough, phlegm, coughing up blood (hemoptysis), wheezing, pain on inhalation (pleurisy).
Breasts: Denies lumps (masses), nipple discharge, pain.
Gastrointestinal: Denies abdominal pain, heartburn, nausea, vomiting, diarrhea, bloody vomitus (hematemesis), constipation, bright red blood from rectum (hematochezia), black tarry stools (melena), hemorrhoids, belching (flatulence).
Genitourinary: Denies burning during urination (dysuria), excessive frequent urination (frequency), intense painful urge to urinate (urgency), excessive waking at night (nocturia), bloody urine (hematuria), excessive quantities of urine (polyuria), passing air while urinating (pneumaturia), foul smelling urine. Male: Denies discharge from penis, testicular lumps. Female: Menarche, regular/irregular, duration, flow consistency heavy (menorrhagia), bleeding between periods (metrorrhagia), first day of last menstrual period, Parity/Obstetric history.
Neurological: Denies loss of consciousness (syncope), uncontrolled shaking (tremors), dizziness, numbness loss of feeling, pins and needles sensation/burning (paresthesia), loss of strength, loss of coordination/trouble maintaining balance.
Musculoskeletal: Denies joint pain, stiffness, swelling, and limitation in movement. Denies backache.
Metabolic: Denies constant or excessive thirst or hunger (polydipsia, polyphagia), excessive discomfort when exposed to cold or heat, dizziness upon standing or sitting up (orthostatic symptoms), shakiness/agitation/dizzy if skips meals.
Hematologic: Denies unexplained bruising or bleeding.
Physical Examination:
General: This is a XX year old well appearing, well nourished, caucasian male in no acute distress. He is alert awake and oriented to person place and time.
Vital Signs: Temperature and route, Pulse and quality, Respiration rate and pattern, Blood Pressure.
Head: Normocephalic without trauma and with normal hair distribution pattern.
Eyes: Pupils equally reactive to light and accommodation bilateral (PERLA bilateral).
Ears: External auditory canals are patent and clear. Tympanic membranes are without effusion, erythema, or loss of landmarks or immobility.
Nose: Nasal septum is midline, without deviation or perforation. Nares are free of congestion rhinorrhea, or epistaxis.
Mouth and Throat: Adequate oral hygiene is apparent. No inflammation or exudative discharge is apparent in the oropharynx, and tongue is midline.
Neck: No evidence of thyromegaly, cervical lymphadenopathy, or bruits. Full cervical range of motion with midline trachea.
Skin: Warm and dry to palpation, and without rashes, palor, or lesions. Anicteric.
Cardiovascular: Regular heart rate and rhythm without murmur. Normal S1 and S2 present without splitting. No S3 or S4. Nondisplaced PMI no palpable thrills.
Pulmonary: Thorax is symmetrical with normal excursion. Normal Percussion bilaterally. Bilateral lung sounds are clear throughout with no evidence of wheezing, rhonchi, rales, or rubs. Normal inspiratory and expiratory phases.
Breasts: Both breasts are free of masses, nipple discharge, skin retractions, and tenderness to palpation.
Abdomen: Abdomen is flat. Bowels sounds are present in four quadrants without abdominal bruits. Abdomen is without tenderness to palpation, and there is no rebound, rigidity, or guarding. No masses, organomegaly.
Genital: Male: Bilateral descended testes are noted without masses or lesions. No penile discharge. Female: No lesions or masses are noted. No chandeliers sign, or uterine enlargement are noted.
Rectal: No hemorrhoids are observed or rectal masses palpated. Sphincter tone is normal.
Neurological: Cranial Nerves II through XII are grossly without focal localizing signs. Deep tendon reflexes are symmetrical bilaterally in the upper and lower extremities measuring +2.
Extremities: No evidence of clubbing, cyanosis, or edema. Dorsalis pedis and Posterior tibial arteries are palpable bilaterally. Color and temperature are appropriate. Homans sign is negative bilaterally.
Osteopathic structural examination: Full range of motion is noted. No lordosis, kyphosis, or scoliosis. Standing and seated flexion tests are normal. No paravertebral asymmetry, rigidity, tenderness or spasm is noted. Muscle strength is 5/5 for upper and lower extremities bilaterally.
Labs (can use accepted shorthand notational schematic representation)
Special studies: EKG, PFT, XRAY, CT, MRI, Ultrasound, Stress Test results.
Assessment/Plan:
Generate a problem and/or diagnosis list.
Numbered problems listed with differential diagnosis, or rule outs followed by planned tests and treatment strategies to determine etiology. Numbered diagnosis listed followed by planned testing and treatment strategies.
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