The Pre-Clerkship Guide

Preface v
Contributors vi
Reviewers xii
Abbreviations xix
I. HISTORY, PHYSICAL EXAMINATION, AND NOTES 1
1 History and Physical Examination: Medicine 1
Sarah L. Rhoads; Burton Hui Shen; Sean Sanker
2 History and Physical Examination: Surgery 5
Vinay Rao
3 History and Physical Examination: Obstetrics and Gynecology 10
Merima Ruhotina; Roxanne A. Vrees
4 History and Physical Examination: Pediatrics 15
Sean Sanker; Sarah L. Rhoads; Burton Hui Shen
5 History and Physical Examination: Neurology 21
Vincent Angelo LaBarbera; Linda C. Wendell
6 History and Physical Examination: Psychiatry 29
Danielle Stern
7 History and Physical Examination: Family Medicine 37
David Anthony
8 Genitourinary and Rectal Examinations 40
Leanne L. Free; Dayna Burrell
9 Progress Note: Medicine 46
Kate Cahill
10 Progress Note: Surgery 48
Vinay Rao
11 Progress Note: Obstetrics and Gynecology 51
Michael Cohen; Dayna Burrell
12 Progress Note: Pediatrics 57
Marie Lidia Carillo; Jessica Dietz Daley; Katherine Mason
13 Progress Note: Neurology 61
Alina D. Bayer; Linda C. Wendell
14 Progress Note: Psychiatry 65
Sarah R. Magaziner
15 Follow-Up Visit: Family Medicine 67
CONTENTS Admission/Transfer Orders 69
Molly G. Curtis; Erica Y. Chung
Hospital Discharge Summary 72
Madeleine W. Elia; Erica Y. Chung
Preoperative Note 75
Jeremy Dressler; Beth Ann Ryder
Operative Note 77
Jeremy Dressler; Beth Ann Ryder
Postoperative Note 80
Jeremy Dressler; Beth Ann Ryder
Procedure Note 82
Pooja Aysola
Vaginal and Cesarean Section Delivery Notes 83
Merima Ruhotina; Roxanne A. Vrees
Postpartum Note 86
Erin M. Cleary
II. ORAL PRESENTATIONS 89
New Patient Oral Presentation: Medicine 89
Sarah L. Rhoads; Burton Hui Shen; Sean Sanker
New Patient Oral Presentation: Surgery 92
Vinay Rao
New Patient Oral Presentation: Obstetrics and Gynecology 96
Renee Ross Eger
New Patient Oral Presentation: Pediatrics 105
Sean Sanker; Sarah L. Rhoads; Burton Hui Shen
New Patient Oral Presentation: Neurology 108
Mayra Montalvo; Linda C. Wendell
New Patient Oral Presentation: Psychiatry 111
Paul Wallace
New Patient Oral Presentation: Family Medicine 116
David Anthony; Andrea Arena
Progress Note Oral Presentation: Medicine 118
Tovah Bass Tripp
Progress Note Oral Presentation: Surgery 120
Vinay Rao
Progress Note Oral Presentation: Obstetrics and Gynecology 124
Chelsy Caren
Progress Note Oral Presentation: Pediatrics 129
Jessica Dietz Daley; Marie Lidia Carillo36 Progress Note Oral Presentation: Psychiatry 134
Carmen Kilpatrick
37 Progress Note Oral Presentation: Family Medicine 136
David Anthony; Andrea Arena
III. ELECTRONIC MEDICAL RECORDS 138
38 Electronic Health Records (EHR) Basics 138
Ross W. Hilliard
39 Placing Orders 140
Ross W. Hilliard
40 Writing Prescriptions 143
Ross W. Hilliard
IV. PROCEDURES 146
41 Informed Consent 146
Erica Lash; Mary Bess Ledoux
42 Electrocardiogram Basics 149
Armon Ayandeh
43 Chest X- Rays 157
Elizabeth Wei; Erica Y . Chung
44 Blood Pressure Measurement 163
Danielle Halpern
45 Infection Control Precautions 168
James Tanch
46 HEPA Mask 172
Shaan Ali Ahmed
47 Scrubbing Into Surgery 173
Andrew Varone; Michael Connolly
48 Cardiopulmonary Resuscitation 175
Armon Ayandeh
49 Bag and Mask Ventilation 178
Pooja Aysola
50 Basic Life Support and Advanced Cardiovascular Life Support 180
Elizabeth Sutton
51 Trauma 183
Andrew Varone; Michael Connolly
52 Pediatric Advanced Life Support 187
Sarah Spencer Welsh; Katherine Mason
53 Intubation Basics 197 Ultrasound Basics 204
Nehal Al-Sadhan; Kristin Helena Dwyer
Point- of-Care Ultrasound 209
Nehal Al-Sadhan; Kristin Helena Dwyer
IV Placement 214
Danielle Halpern
Local Anesthesia 218
Travis L. Hase; Rory Merritt
Nasogastric Tube Placement and Removal 221
Danielle Halpern
Surgical Drain Removal 225
Andrew Varone; Michael Connolly
Venipuncture 227
Danielle Halpern
Arterial Blood Gas 230
Armon Ayandeh
Urinary Catheterization 234
Mary Bess Ledoux; Erica Lash
Suturing and Knot Tying 238
Thomas Ross
Lumbar Puncture 246
Matthew Czar Taon
Delivering a Baby: Key Maneuvers and Steps of a Vaginal and Cesarean
Section Delivery 250
Merima Ruhotina; Roxanne A. Vrees
Casting 253
Walter Klyce
V. COMMUNICATION 257
Delivering Bad News 257
Linda C. Wendell
Patient Advocacy and Health Equity 259
Katherine Rand; Angela Y . Zhang
VI. HOW TO ANSWER CLINICAL QUESTIONS—CLINICAL
RESOURCES 265
How to Answer Clinical Questions: Medicine 265
Burton Hui Shen; Sean Sanker
How to Answer Clinical Questions: Surgery 267
Andrew Varone; Michael Connolly71 How to Answer Clinical Questions: Obstetrics and Gynecology 268
Merima Ruhotina; Roxanne A. Vrees
72 How to Answer Clinical Questions: Pediatrics 269
Carly Dru Schmidt; Katherine Mason
73 How to Answer Clinical Questions: Neurology 272
Julie L. Roth; Jonathan F. Cahill
74 How to Answer Clinical Questions: Psychiatry 276
Katherine Cicolello
75 How to Answer Clinical Questions: Family Medicine 283
David Anthony; Andrea Arena
VII. QUICK REFERENCES 286
76 Vital Signs 286
Dhairyasheel Sandeep Ghosalkar
77 Common Cardiac Rhythms 290
Elizabeth Sutton
78 Cardiopulmonary Values 295
Sarita Warrier
79 Assessing Fluid Status 297
Alexander Hung Tran
80 ACLS: Cardiac Arrest 300
Rory Merritt; Brian Clyne
81 ACLS: Immediate Post–Cardiac Arrest Care 303
Seth Clark
82 ACLS: Acute Coronary Syndrome 305
Seth Clark
83 ACLS: Adult Bradycardia 307
Rory Merritt; Brian Clyne
84 ACLS: Adult Tachycardia With Pulse 310
Seth Clark
85 ACLS: Suspected Stroke 312
Chelsea Ann Boyd
86 National Institute of Health Stroke Scale 314
Chelsea Ann Boyd
87 Normal Laboratory Values 319
Tovah Bass Tripp
88 Serum Drug Levels 324
Sarita Warrier
89 Daily Body Fluids 327
Sarita Warrier Helpful Equations 330
Sara Heejung Park
Unit Conversions 339
Danielle Halpern
Apgar Scoring 341
Burton Hui Shen; Sean Sanker; Sarah L. Rhoads
Estimated Date of Delivery 343
Michael H. Sisitsky
Glucose Tolerance Values 346
Tovah Bass Tripp
Developmental Milestones 348
Matthew Lorenz; Alison Riese
Pediatric Immunizations 352
Danielle Halpern; Alison Riese
Further Reading 357
Index 369