The Unofficial Clinical Clerkship Survival Guide

The Unofficial Clinical Clerkship Survival Guide
University of Louisville School of Medicine
Brought to you by the Class of 2016 Track Captains and the

Organization of Student Representatives (OSR)
Authors
Eric Kreps - General Information and Track Selection
Alexandra Healy - General Surgery
Eric Poulos - Internal Medicine
John Wehry - Neurology
Anne Hayes - Elective
Chris Hamann - Obstetrics and Gynecology
Evan Rhea - Pediatrics
Gerald Cheadle - Family Medicine
Catey Harwell - Editor
Rudra Pampati - Editor
Allison M. Hunter - Editor
Table Of Contents
General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Parking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Food and Dining Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Scrubs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Evaluations and Shelf Exams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Patient Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Computer Access and Electronic Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Prescription Writing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
White Coat Essentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Third Year Track Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
8-week Clerkships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
6-week Clerkships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Neurology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Elective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Values, Calculations, and Commonly Asked Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Example Notes and Oral Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Internal Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
The University of Louisville School of Medicines Unofficial
Clinical Clerkship Survival Guide: General Information

By Eric Kreps
General Information
This section is entirely dedicated to the general information that spans all of your third year of medical school and is not
necessarily related to an individual clerkship. Topics include parking, on-campus free dining, attire, clerkship evaluations, shelf
exam, patient logs, etc. More specific information pertaining to each of the individual clerkships can be found under its own
section. Read at length or flip back for reference as questions arise!
Parking
University of Louisville Hospital
University Garage: If you have around $400 burning a hole in your pocket, go for renewing your parking pass to the
620 Garage, but keep in mind you may not be doing all of your rotations at University Hospital. This garage offers
1,711 parking spaces for faculty, staff, and students, and is ID card protected for safe access.
HSC Parking Office: 414 East Chestnut Street
Hours: 8:00am - 4:00 pm, Monday-Friday, Closed 1:00pm - 2:00pm for lunch
Phone: (502) 852-5111
Free Parking: Students often park along Muhammad Ali Blvd, starting at Clay St (in front of the 620 Garage) and
ending at Jackson St; there is also free street parking along S. Hancock, Marshall Street, and Clay St. Please be prudent
and keep safety in mind as you walk to and from your car during early morning and late night hours. On weekends,
there is free parking at the UL hospital garage (on the corner of S. Hancock and E. Madison St, next to the pedestrian
crosswalk). Metered parking is also available (most now payable by credit card). Metered spaces are free after 6PM
Monday Saturday and all day Sunday.
Norton Hospital and Kosair Childrens Hospital:
Students get free parking at a lot adjacent to the L&N credit union (on the corner of
nd
Chestnut St and 2 St) while on a rotation at these locations. Students on a rotation at
Kosair can obtain a pass for the hospital parking garage by going to the parking office on
the first floor of the Medical Towers South (the blue building on the right after you pass
Norton Hospital on the corner of Gray and Floyd Street, heading towards Broadway). Go
in the double doors that face Gray Street and go to the right, following signs directing
you to the Parking Office. Also, parking at Kosairss garage (214 Abraham Flexner Way )is
free on the weekends!
Jewish Hospital Garage:

Parking pass to the Jewish hospital garage (249 East Muhammad Ali Boulevard) can be obtained from the 5th floor of the
Outpatient Care Center attached to the garage.
VA Hospital:
Parking is available in front of the VA Hospital. Good news: no passes needed! Bad news: many spaces are reserved for just
patients and the others fill up very quickly in the morning - it can be difficult to find a spot after 8:30AM! The best advice is
to get there early (before 7:50AM). You can park at the Ramada Inn on Zorn Avenue (numbered spots only) or at the
Lebanese American Supper Club parking lot off River Road behind the Ramada. A marked VA shuttle will arrive every 15 20 minutes to transport you to and from the VA Medical Center between 6:15AM and 6:00PM.
Escort Service: The UofL police department can pick you up from any on-campus location and escort you to your vehicle
within 4 blocks of campus if you call 502-852-6111. This is especially useful when it is late and you feel uncomfortable
walking to your car.

By Eric Kreps
Food and Dining Options

Eat for free! Each hospital has its own unique dining options, however this information covers the sustenance that is free of
charge only.
st
Jewish HospitalDoctors lounge in the Rudd Heart and Lung center, 1 floor. Serves continental breakfast, a full
lunch, as well as a soft drink and espresso machine. Dont miss Taco Wednesdays! Often, your resident will give you
their door code or let you in to get to the grub.
Norton HospitalDoctors Lounge2nd floor Norton Hospital, across from escalators. A full breakfast and lunch are
served daily, with snacks available throughout the day. Relive your childhood dreams of chocolate milk with your
cereal. Badge access required, so have your resident let you in. Technically this is just for attendings, so opt to sit on
the couches and not at the tables if space is tight!
Kosair Hospital Doctors Lounge 1st floor of Kosairs; have your resident point it out, as it may be hidden. Your
badge should give you access to cereal, juice, fruit, peanut butter, crackers and a soda machine.
University HospitalAlthough there are no meals provided, the pre-op doctors lounge does provide bagels and
donuts in the morning (they go quick!), as well as access to a soft drink machine (broken about 20% of the time). You
can almost always find at least peanut butter and crackers here or in pre-op when you are looking for quick food
between cases. While on inpatient wards, most patient floors have access to the nutrition room, stocked with milk,
ice cream, soda, peanut butter, and crackers.
Scrubs
In general, wearing scrubs is limited to time in the OR, on-call days for inpatient medicine and pediatrics, and on Labor and
Delivery during your OBGYN rotation. During L&D, it is recommended that you come to the hospital in business attire and
change into scrubs in the locker rooms (3rd floor on L&D). It is always best to check with your resident teams about any dress
code for rounds. On Surgery, you should never wear scrubs to the Department of Surgery offices (2nd floor ACB)wear clinic
attire with your white coat. The location of scrubs will vary among locations and services, so check with your resident teams or
ask a nurse where you can find scrubs. Just a few pearls be conservative with your scrubs; go a size up if you need to and
dont be a hero. Ladies, small tops are hard to come by, so most prefer to wear a t-shirt or tank top underneath these oversized
scrub tops.
Evaluations and Shelf Exams

Evaluations:
The seemingly subjective evaluation of your clerkship performance is perhaps one of the most unique and important parts of
third year to understand. For the first time your grade depends not only on how well you study and perform on exams, but how
well you communicate, interact, and work as a member of a team. The intangibles of professionalism, emotional intelligence,
and reading social situations will come in handy. The mainstays of responsibility, hard work, and punctuality will serve you well,
so be on your best behavior and prepare to shine as you transition from the classroom to the clinic.
Clinical Evaluation of the Student:
Your student evaluation will be made up of one ungraded midclerkship evaluation and several graded clinical
evaluations.
First, you will be evaluated at the midpoint of each rotation (midclerkship evaluation). This consists of formal,
ungraded feedback from an attending using either a paper form or the tool on New Innovations (method is clerkship
specific). This is a way to gauge your performance before final graded evaluations, that way if there is significant room
for improvement, then you will have time to cover ground before it really counts!
The final evaluations at the end of the clerkship are graded and are the main component of your final clinical
evaluation grade. Keep in mind, that no matter how well you perform on your clinical evaluations, you cannot honor a

By Eric Kreps
clerkship without honoring the shelf exam. Both residents and attendings will evaluate you during each of your
rotations. You will be evaluated on the following:
Patient Care - Taking an effective history, physical exam skills, generating a differential diagnoses, creating a
problem list, generating a treatment plan
Medical Knowledge - Integration of basic sciences, application of clinical sciences)
Interpersonal and Communication Skills - Spoken and written communication, oral presentation skills
Systems-Based Practice - Teamwork, skills in evidence-based medicine
Professionalism Honor and integrity, responsibility and accountability, caring and compassion, and respect
Finally, your evaluator will have the opportunity to write Overall Comments. These comments will be the real meat
and potatoes of what appears in your Medical Student Performance Evaluation (MSPE) lettera summary of your
overall clinical performance during each of your rotations as a third year. The MSPE letter is a large part of your
application for residency, so it is important that it reflects your true performance. These evaluations are completed
using New Innovations.
Evaluation pearls: Very rarely will a clinical evaluation keep a student from honoringif you show up, work hard, and
are respectful, you should do just fine. If you are consistently not honoring because of your clinical evaluations (i.e.
honors on the shelf but not the clerkship), this is something worth talking about. Pediatrics tends to be a little more
difficult as their cutoff for clinical performance for honors is higher than most other clerkships.
Student Evaluation of the Rotation, Residents, and Attending:
Be sure to fill out your evaluations of the residents and attendings using New Innovations. You are often assigned
residents and attendings to evaluate at the end of your rotation-- constructive feedback (not overly negative) is
crucial to improving the experience for others. These evaluations are reviewed and can be used as a means for
positive change. Any serious issues or urgent concerns should be addressed sooner rather than later; utilize your
Track Captains, residents or anyone else you trust or to hear your concerns. Student mistreatment is taken very
seriously, so speak up should you feel uncertain or uncomfortable about an issue. Once the rotation ends, you will
receive an evaluation from Paul Klein to provide feedback on the rotation itself. This is a good time to offer up
suggestions to improve the way the clerkship operates (and it is anonymous!). Both the Clerkship Directors and the
Educational Policy Committee (EPC) review the survey results and comments to monitor the quality of the experience
and provide feedback for changes as needed.
Shelf Exams:
Each of the third-year clerkships concludes with a shelf exam, typically administered on the last morning of the clerkship. A
shelf exam is a clerkship-specific standardized test developed by the NBME that medical schools purchase to gauge how their
students perform on a national level. The exam is generally 2.5 hours long and consists of 100 questions. At the University of
Louisville, this exam is a generally a hefty portion of the final grade, ranging from 40-50%, depending on the clerkship, and is
graded on a curve with respect to percentiles. In order to receive honors for a clerkship you MUST receive a raw score
equivalent to the 75th national percentile (which hovers around a raw score of 80-85/100) or above -- no exceptions. In essence,
you must honor the shelf to honor the rotation. A passing grade involves a raw score of greater than the 4th percentile. If in the
course of your third year you fail a single shelf exam, you may retake that shelf exam. However, if you fail more than one shelf
exam, then you may have to remediate the entire course. While the school pays for you take the first shelf exam, if you fail a
shelf you will pay to retake the exam. Resources for each clerkship are listed under their respective sessions.
ONLINEMEDED.ORG has a series of free videos that review clerkship and NBME shelf content.
Patient Tracking
You are required to log each of your core clinical clerkships (with the exception of your time on Elective) in a case log located
on New-innovations. Each of the core clinical clerkships has a list of required clinical diagnoses that you must see or learn
about during the course of the rotation. New Innovations will allow you to log your patient with their corresponding diagnosis
obviously not every patient fits the exact descriptors, so think big-picture if you do not find the exact diagnoses you are looking

By Eric Kreps
for. Students are now expected to log patients on a weekly basis. A portion of your grade will be dependent on your completion
of patient logs.
Though the process can seem tedious, it serves an important role: the New Innovations system allows the Office of Medical
Education and the accrediting body of all medical schools (LCME) to follow the type and number of patients you are seeing to
ensure comparability across all clinical sites (this is important for accreditation!). Also, make sure you have fulfilled the required
number of clinical diagnoses for each clerkship by running a requirements summary in New Innovations.
Computer Access and Electronic Medical Records

Pay close attention to your emails at the end of your second year, as you will be receiving log-in information for up to six
different electronic medical record (EMR) systems that you will need access to during your clerkship experience. These
systems include: Allscripts (UL outpatient), EPIC (Norton and Kosair), Cerner (Jewish Hospital), NetAccess (UL inpatient),
Synapse (UL imaging), and last but not least the infamous VA EMR system.
Both University systems, (Allscripts and NetAccess) can be accessed from your own computer/tablet through installation of the
Citrix receiver software on your device. Detailed instructions, including info on installation of Citrix, can be found from the
emails sent from the Office of Medical Education.
How to access EPIC and Allscripts from your home computer.
1. For Allscripts, the link is https://citrix.ulp.org
2. For EPIC, the link is https://myresources.nortonhealthcare.org
3. It may ask you to install some software. Let it.
4. Login with your respective ID and you should come to the familiar screen with the
links to "AHS - Live" or "Hyperspace PRD"
How to access EPIC and Allscripts from your iPad.
1. Go to the app store and download the free app called "Citrix Receiver".
2. After the app is installed go to the respective link (Allscripts = https://citrix.ulp.org,
EPIC = https://myresources.nortonhealthcare.org)
3. Sign in and select your respective EHR ("AHS - Live" or "Hyperspace PRD").
4. This will bring up a screen with a file asking how you want to open it. You should have
a button that reads "Open with Receiver".
5. This should launch the app and bring you to the login screen.
One word of warning: the interface is a bit clunky and takes a few minutes to get
adjusted. It is more useful for reading notes and patient data than trying to write notes.
EMR System
University: NetAccess, Synapse, Allscripts, Cerner
Norton and Kosair: EPIC
VA EMR
VA fingerprinting and ID services
Help Contact Number

(502) 588-0411
(502)-629-8911
Help Desk Extension 55491
(502) 287-5983
University Hospital:
Inpatient: NetAccess (health information) and Synapse (Imaging)
Login information will be provided to you by email from Tonya Hockenbury (tlhock01@louisville.edu), Administrative
Assistant from the Office for Medical Education. Accessed through myapps.ulh.org. IT help number 502-588-0411 for
problems with access (i.e. when your username and password expire for the 10th time). NetAccess will provide you
with daily patient information, such as labs and ins/out, and some discharge summaries and operative reports.
However, at UL every patient also has a paper chart located on his or her respective hospital floor. Synapse is the
system used to access imaging, such as x-rays, CTs, and MRIs.
Outpatient: Allscripts

By Eric Kreps
Login information will be issued through a sketchy encrypted email from Martin Kaelin (martin.kaelin@ulp.org) in
late June. Follow the directions to access your login information. The same email will include information on how to
install the Citrix receiver required to launch the EHR. Training for Allscripts is provided during orientation on
Blackboard. Again, the helpdesk number is 502-588-0411. Write it down. Save it. You will need it. This system
provides all notes from the outpatient experience, incorporating all outpatient providers from the UL network. It is
often slow and crashes more than you might consider reasonable, so be patient and help the clinic keep moving by
seeing patients and writing paper notes should technology issues arise.
University Wifi Access: In order to access the wifi at university hospital the following credentials are used
Network: guest
Username: wifiguest
Password: use the following format: yearmoguest (ie for December 2017, use 201712guest)
Norton and Kosair Hospital: EPIC
rd
Everyone will be required to attend one 4-hour training session for formal EPIC training, held at Norton Hospital during the 3
year orientation week. At the time of training you will receive your login information and password, so make sure you WRITE
YOUR LOGIN INFO DOWN AT THE TIME OF TOUR TRAINING!
If you are unable able to get remote access to EPIC from your device (iPad or home computer), call the EPIC helpdesk at 502629-8911. Having access at home makes it easier to ready about patients, however it is not very functional for writing notes or
anything other than information output. Once you get the remote access, you can log onto EPIC from
myresources.nortonhealthcare.org, then launch the secure connection from the Citrix receiver. As the sole source of patient
information for both Nortons and Kosairs, this system is the most comprehensive and should be the easiest to navigate.
Jewish Hospital: Cerner
Orientation will be provided at your specific site at Jewish Hospital; any login information will be provided to you prior to your
start date. The site to log on is webapps.catholichealth.net. Training videos can be found at http://www.chionecare.net/cernerphysician-training-videos/. If you have any questions feel free to call the IT desk at 502-588-0411.
VA Hospital: The one and only
All students will be required to complete VA processing, as they will eventually rotate through the VA. If you are rotating at the
VA first, start this process 4 weeks prior to your start date. This process will be long and drawn out and something is bound to
go wrong-- be patient and plan ahead. Setting up your access to the VA EHR is a multi-step and complicated process, and
detailed instructions will be sent out via Tonya Hockenbury (tlhock01@louisville.edu). The best advice is to start early (4 weeks
prior), call ahead to make sure the photo and fingerprinting system is working, and avoid the lunch hour.
There are just a few steps to this process:
1. Find the packet available on Blackboard and fill out the paperwork; fax one of the indicated forms to VAMC.
2. Go to VAMC, turn in the rest of the paperwork, get fingerprinted, and get pictures for your ID badge. Submit the necessary
paperwork (4 weeks prior to start date).
**The camera, finger print device, and web site are not reliable and are down frequently. If you want to make sure
that everything is up you can call Randy in the office where they take your photo and finger prints at 502-287-5983.
3. Complete online training modules
4. Return to VAMC, sign on to computer, get computer access, get email, and pick up your ID badge (call ahead to make sure its
ready!)
A key point is that even after you get everything set up at the VA computer system, after 90 days of inactivity your password
will expire, and you will need to call the national helpdesk (also in Tonyas email) to have new access codes sent to you. VA Help
Desk Extension 55491.
Prescription Writing

By Eric Kreps
One common task of medical students is writing out prescription medications by hand for practice, to then have the senior
resident sign. Some common abbreviations are used for the frequency of the medications, including QAM (morning), QHS
(nightly), Q4H (every 4 hours), Q8H (every 8 hours), BID (twice daily), or TID (three times daily). Also, some medications can be
PRN (as needed) for [a symptom]. Writing this out, say for administration of an antipyretic, would be Q6H PRN fever.
White Coat Essentials

One important aspect of third year is the application of your physical exam skills with respect to patient care. Particularly
critical for physical exam and note taking are your stethoscope, at least 2 pens, and a notepad. Your stethoscope bell can
double for a reflex hammer, but an actual reflex hammer and a pen light are recommended for your neurology rotation.
2 Pens (always have more than oneyou are bound to lose one or your resident/attending will ask for a pen)
Small Notebook
Maxwell Quick Medical Reference (amazon.com for $6 or bookstore for $8)
Stethoscope
Reflex Hammer
Optional: Pocket Medicine (amazon.com for $20), iPad mini or other tablet
For Rounds, a foldable White coat clipboard (found on amazon.com) can be very handy for helping stay organized.
Professionalism
Overall, your third year will be a much different experience than your pre-clinical years, so prepare yourself for a fun and
exciting change! That being said, the amount of responsibility that the third year brings can initially be a shock, but with time it
will be a great transition to what you will be doing for the rest of your life!
With the transition to clinical work, the concept of professionalism and teamwork becomes even more crucial. You will be a
member of the patient care team, and you must keep in mind that you are representing not only the University of Louisville,
but also the medical profession. Always be mindful of your team as well as your peers. Avoid criticizing students openly to
others, and particularly in front of residents or attendingsthey are now your colleagues and not just your classmates.

By Eric Kreps
If you notice repeat or gross lapses in professionalism by your peers, there are many resources at your disposal. Sometimes
professionalism issues call for tough conversationsif you feel comfortable and are in a position to have that talk, please do so.
If not, you can address professionalism concerns with your Track Captain and through the anonymous submission of an Early
Concern Note (ECN). Keep in mind that ECNs are confidential, low-stakes, and are only reviewed by the student-only Honor and
Professionalism Advocacy Council (HPAC). For more information, see: http://louisville.edu/medicine/studentaffairs/studentservices/hpac
To submit an ECN directly, see:
https://louisville.edu/medicine/acl_users/credentials_cookie_auth/require_login?came_from=http%3A//louisville.edu/medicin
e/studentaffairs/ecn
This is a valuable tool in preventing professionalism issues from reaching the point of being detrimental in a Deans letter (the
MSPE) and can go a long way in helping correct professionalism issues early.
Clinical Clerkship Survival Guide: Track Selection

By Eric Kreps
Third Year Track Selection

Your third year of medical school at ULSOM will consist of 7 core clerkships broken down into one semester of 8-week rotations
and one semester of 6-week rotations, starting in July and running through the following June. The 8-week rotations consists of
Surgery, Internal Medicine, Neurology (4wk)/Elective time (4wk), while the 6-week rotations include Family Medicine,
Obstetrics and Gynecology (OBGYN), Pediatrics, and Psychiatry. More detailed information pertaining to each of the 6 and 8week clerkships can be found as individual chapters in the Clerkship Survival Guide. The following information is meant to
provide you with an overview of the track selection process, as well as provide you with information that should be considered
as you begin to map your third year schedule.
Although the track selection process might at first seem to be a daunting task, it really is a very manageable process and will
provide you with a roadmap to your first clinical year as a medical student. You will be making your track selection using NewInnovations, a web-based service that is used to manage the clerkship selection process in a way that makes organized, fair,
and efficient.
To select a track essentially means that you will be choosing the order in which you will experience each of the third year
clerkships. First, you must decide to schedule either the 8-week rotations (Surgery/Neuro 4wk-Elective 4wk/Internal Medicine)
or 6-week rotations (family med/OBGyn/Peds/Psych) first. When it comes to scheduling, be sure to take your career plans,
personal interests, and the seasons and into consideration. For example if you are sure that you are interested in Surgery, it
might be wise to avoid scheduling that rotation first as you will likely be inexperienced. Also, coming off Internal Medicine in
early summer might have you better refreshed for Step 2, etc. Be sure to keep in mind the different experiences that you will
find on the clerkships given the time of year (example trauma season in warmer months for Surgery, RSV and flu season during
winter months for Pediatrics, etc.). Ultimately all students will complete each of the core clerkships, and some would argue that
timing and sequence does not matter. Seek out the advice from upper classmen and your advisor to make the decision that
works best for you!
After you determine the order of 6 vs. the 8-week rotations, you can then begin to consider the clerkship sequence and rank
your preferences for location/subspecialty for each rotation. There are several options to choose from, so read the following for
a VERY brief overview of each of the selections options you will find when using New Innovations (please look at each clerkship
within the packet for more details!).
8-week Clerkships:
Surgery
Jewish Hospital Offers 4 weeks of general surgery, as well as 2 weeks of cardiothoracic surgery and transplant
surgery which most students find very interesting and enjoyable. A good balance of slow and busy, and usually
students find they have plenty of time to study. Call is at Jewish.
Kosair/VA Kosair offers an abundance of cases that are far different from the other general surgery experiences,
and may appeal to those interested in pediatrics. Pediatric surgery questions are less numerous on both the shelf and
oral exam, but some students report being able to be more hands on as compared to other surgery rotations. VA
balances OR cases with time spent in clinic, and provides great exposure to bread-and-butter general surgery cases,
as well as exposure to thoracic and vascular cases. As with everything at the VA, things run a little slower but this
translates to a little more study time. Call is split between Kosair (while on Peds surgery) and UL Trauma (while on VA)
Norton Hospital Comprised of 4 weeks of general surgery. Norton also houses the 2 week subspecialty optios of of
Colorectal Surgery, Surgical Oncology, and Vascular. This is a very busy service with a high patient volume, but the
exposure to numerous cases may appeal to those interested in surgery. Call is at Nortons.
UL Hospital Includes 4 weeks of trauma surgery, which may appeal to those interested in surgery or ER. Students
will also be assigned to either 4 weeks of elective surgery, which students find as a good balance to trauma as they
have more time to study on elective, or 4 weeks of surgical oncology and vascular surgery, which are both busy and
interesting services that may appeal to students pursuing surgery. Call is with UL Trauma.
Madisonville All 8 weeks are spent at Baptist Health in Madisonville, and students have a different lecture series
and call schedule. Most of the time is spent working directly with attendings, which may allow for more teaching

By Eric Kreps
moments and first-assists. Students that go to Madisonville all report a positive experience: call is home-call and you
have some weekends off; more didactic and committed study time; more hands-on with more time spend directly
with attendings only (1 UL resident spends time at this site at a time). If you are interested in pursuing surgery for
residency, however, this does prevent you from meeting and working with faculty members and residents involved
with the UL program.
Internal Medicine: 4 weeks on wards and 4 weeks on subspecialty, with the subspecialty month split between two
subspecialties (i.e. 2 weeks of Cards and 2 weeks of GI). Generally speaking, inpatient Internal Medicine wards tend to carry
primary patients, while most subspecialty services are consult services.
Wards (4 weeks) Students are assigned to teams at either UL or the VA. As with most things at the VA, things tend to
run a little slower but hours are slightly shorter.
GI Somewhat longer hours, but a great experience for those interested in the field and/or a more procedural
experience. You will see patients in the morning, observe procedures and see consults in the afternoon.
Cardiology - Both VA and UL involves seeing patients and writing notes. VA hours are slightly shorter, but all sites are
reportedly a great opportunity for those interested.
Pulmonary Consult Generally a lighter patient load with moderate hours and plenty of study time.
Endocrinology - Service covers four different hospitals and students will be asked to attend rounds and see patient,
but generally will not write notes. Among the longest hours on medicine (8-6), but very rewarding and well-liked by al
students that understand the time commitment. Avoid scheduling this subspecialty close to shelf exam time for study
purposes.
Nephrology Sites at Jewish, VA, and ULH. VA and ULH see lighter to moderate hours, while Jewish is among the
heaviest of the specialties in hours (7-7 many days). All the locations have been reported to be a good experience.
Infectious Diseases Sites at Jewish and UL. Also Bone and Joint ID team available at both Jewish and UL. You will see
patients in the morning, round with and attending, and will stick around campus for consults in the afternoon. Some
services also have clinic in the afternoon at the VA.
Hematology/Oncology Hours are extremely variable based on the attending and your teams fellow/resident.
Clinic attendance is encouraged once a week. You will see patients in the morning or afternoon, depending on the
attending.
Neurology: 2 weeks on inpatient and 2 weeks on outpatient. You can rank your preferred locations in the electives.
Inpatient:
Jewish General - This is one of the busier services but provides students with a great opportunity to see a wide variety of
neurological diseases.
Child Neuro - This is one of the most demanding inpatient services for neurology, but students see a wide variety of very
unique cases and learn a tremendous amount from the faculty. Child neuro is split with one week on inpatient and one on
outpatient. You will work one weekend day, but this also counts as your call day for the rotation.
ULH Stroke - Hours vary with attendings and patient volume. In general, the start time is earlier than most services, but
students are finished in the afternoon.
ULH General - Hours are similar to ULH Stroke. Students are expected to see a patient and write a note but are not always
asked to present during rounds.
Outpatient:
Child Neuro - Hours are typically 8-4PM. Some attendings will have you see patients and write notes, while others will
have you shadow and be helpful to the resident. Child Neuro assignment is 2 weeks long with one week spent on inpatient
and the other on outpatient.
Private Practice You are assigned to work with a community neurologist with each experience varying based on your
attending. In general, however, the hours are reasonable and the neurologists you work with are very helpful.
HCOC-Outpatient Clinic- Located in the Healthcare Outpatient Care Building (HCOC). Students are paired with different
attendings each day. Students usually start around 8:30AM and finish around 4:00PM, depending on the patient load.
Elective: scheduled on a different basis, please look for emails from your leadership or Sherri Gary for scheduling information.

By Eric Kreps
6-week Clerkships:
Psychiatry:
Child Psych Excellent hours, but one-on-one patient interaction can be limited due to the nature of the service. Students
are generally happy with their experience here and often more enjoyable for those interested in pediatrics.
Emergency Psych- and ACB This rotation entails more dedicated hours, but the residents and attendings offer you
significant autonomy with a lot of patient contact. Pace can be hectic with patients that are potentially dangerous,
however security is always present and is a good environment for those that thrive in an ER environment. You will also get
this experience as part of your call assignment while on the psychiatry clerkship. The other half of this assignment is a
slower-paced outpatient experience at the ACB.
Norton Consult This is a consultation serve for medical in-patients with concomitant psychiatric symptoms. This rotation
offers good hours (8 to 4/5), with excellent patient contact, lots of autonomy, and responsibility. Most students feel
integral in actual patient care as the attendings and residents on this service listen to your suggestions and even let you
put in orders.
Norton Inpatient Unit Wide variety of diagnoses, excellent patient contact, with moderate autonomy.
ULH Inpatient UnitWide variety of illnesses and you are more likely to see those that are seriously ill as primary
admissions are made mainly through Emergency Psych.
ULH Consult ServiceThis service sometimes has limited patient censuses, but this also gives you lots of opportunity to
study.
VA Inpatient/Outpatient Hours consistently 8:00AM-4:30PM. This rotation offers significant autonomy with your own
patient load and one-on-one interaction with the attending. 5 weeks on inpatient VA-psych with 1 week on the inpatient
substance abuse treatment floor. You will present at Journal Club, write notes on your patients every day and will get used
to giving oral presentations.
Obstetrics and Gynecology:

2 weeks of private practice, 2 weeks of surgical subspecialty and 2 weeks of Labor and Delivery. The electives you may choose
are in the surgical subspecialty:
Gynecologic oncologyvery interesting and demanding cases, but with significant hours and would be a good choice if
interested in surgery.
Benign gynecologic surgeryshorter hours than gyn/onc with more emphasis on hysterectomies and minimally-invasive
surgeries.
ODSUoutpatient surgery with short hours but less interesting/significant cases than the others. Will see procedures
including polyp removal and other procedures.
Urogynecologyprocedures for pelvic organ prolapses and urinary incontinence. May work at several different hospitals,
but a very interesting experience.
Pediatrics:
Stonestreet Clinic: A lot of one-on-one time with attendings, where they emphasize patient interaction rather than EMR
proficiency. It is an off-campus site ( 20-30 min drive) and you will see a more rural patient population.
Eastern Parkway Clinic: Located at the Kosair Charities Building on Eastern Parkway. You will experience nearly one-onone student/attending time, with lots of individual teaching. However, there may not be as many patients to see (8-10 per
half day), and cases may be less acute. Many Spanish-speaking patients, and a great opportunity to utilize medical Spanish.
Children and Youth Clinic (C&Y): Located on campus, next to nursing building. Heavy patient load as this clinic recently
absorbed what was UL Broadway Pediatrics. Attendings are kind, helpful, and most interested in helping students learn
brief lectures Tuesday and Thursday morning. However there are several students assigned to this at the site at a time, so
time with each attending can be limited.
Family Medicine:
Both the Newburg and Cardinal Station clinics are very similar and just vary by physical location. You will spend 2 weeks at
either of the clinic sites, then 4 weeks at your AHEC site (scheduled separately; be sure to attend AHEC fair for locations.
10
Clinical Clerkship Survival Guide: General Surgery

By Alexandra Healy
General Surgery
Welcome to surgery! It is easy to imagine this as a rotation you will spend all of your time in the OR (and you will spend many
hours there), but there is much more to surgery than operating. You will also spend a good deal of your time seeing consults,
assessing whether or not the patient needs surgery, performing bedside procedures (central lines), and making sure your
patients recover well postoperatively.
Surgery generates most of its patients through either previous clinic visits when the surgery was planned months or weeks in
advance, such as for elective cases, or through inpatient consultations or the ER where the patient is scheduled for surgery in
the upcoming minutes, hours, or days. Prior to surgery the patient is taken to Pre-Op where consent is obtained and the
anesthesia team performs their assessment in preparation for sedation. Once ready for the OR, the patient is rolled back and
prepped for surgery. After surgery, the patient is taken to the PACU where they are monitored while waking from anesthesia,
and eventually transported to their hospital room for postoperative management on the floor. The surgery team then follows
the patient until ready for discharge and will subsequently schedule the patient for outpatient follow up appointments.
This rotation is a total of 8 weeks. You will spend 4 weeks on a general surgery or trauma service and 4 weeks on a subspecialty
service(s), sometimes further divided into 2-week services. The patient population is largely adult, however, you may manage
pediatric patients if you are assigned to Kosair Childrens Hospital pediatric surgery service. Some of the common diagnoses you
will encounter include bowel obstructions, hernias, appendicitis, and gallbladder disease. The learning curve for surgery is
steep. Not only will you be expected to know the diagnosis and indications for surgery, you will also likely be questioned on
complications, anatomy, imaging, etc. This is a fast-paced rotation with long hours, so be prepared to dive in and get your
hands dirty!
Length of Rotation: 8 weeks
Locations:
University of Louisville Hospital (ULH)
530 S. Jackson St
Louisville, KY, 40202
Kosair Childrens Hospital (KCH)

231 E. Chestnut St
Louisville, KY 40202
Norton Hospital
200 E. Chestnut St.
VA Medical Center (VAMC)

800 Zorn Avenue
Jewish Hospital
200 Abraham Flexner Way
Baptist Health
900 Hospital Drive
Madisonville, KY 42431
Important Contacts:
Clerkship Director: Dr. Sheldon Bond
Pediatric Surgery
sheldon.bond@louisville.edu
(502)629-8630
Department Chairman: Dr. Kelly McMasters

Surgical Oncology
kelly.mcmasters@louisville.edu
(502)852-5447
Student Contact and Clerkship Coordinator:

Brenda Dawson
brenda.dawson.1@louisville.edu
(502)852-5676
Residency Director: Dr. William Cheadle

General Surgery
william.cheadle@louisville.edu
(502)852-5675
11

By Alexandra Healy
Didactics: All didactic sessions are required for this clerkship, and they take attendance very seriously! Always be prompt,
arriving 5-10 minutes before lectures begin. As with everything in surgeryif you are on time, you are late! Business attire with
your white coat for all lecturesdo not wear scrubs to Grand Rounds or into the General Surgery Department offices (more on
attire later!)
Weekly Student Didactics: Wednesday 1:00-5:00PM
rd
Location: Hagan Library, ACB 3 Floor in the General Surgery Department offices
Grand Rounds: Friday 7:00 10:00AM
Location: ACB Auditorium in the ACB Basement
** Grand Rounds is required even on post-call days. Drink lots of coffee these days!
Polk Rounds:
ULH - Monday 7:00-8:00AM
Location: SICU
**Mandatory for those on services at UL
VA Tuesday 7:00 8:00AM
Location: SICU
**Mandatory for all those on service at the VA
General Surgery Assignments
4-week rotations
Trauma Surgery (ULH) Cares for patients that present to the ER and need urgent or emergent surgical
evaluation and management. You will be responding to Room 9s (often Level I traumas!) and other consults in
the ER.
Elective Surgery (ULH) The general surgery service at ULH.
General VA (VAMC) The general surgery service at the VA. You will also have exposure to vascular and thoracic
cases.
Pediatric Surgery (KCH) Cares for pediatric surgery patients at KHC. This is a very busy service, as you will
manage consults and trauma calls in addition to previously scheduled surgeries.
2-week rotations
Colorectal Surgery (Norton Hospital) Manages patients needing surgery involving the colon or rectum. Offers a
great deal of exposure to colorectal cancer.
Vascular Surgery (Norton Hospital) Manages patients with vascular diseases that need surgical repair. This
service offers abundant OR time, with cases such as amputations, fistulizations, AAA repairs, and
catheterizations.
Surgical Oncology (UL, Norton, and, Jewish Hospital) Manages patients with cancerous tumors. This is a very
busy service, and you will see cases such as mastectomies, melanoma wide-local excisions, and Whipple
procedures.
Transplant Surgery (Jewish Hospital) Manages patients undergoing lung, liver, or kidney transplants.
Thoracic Surgery (Jewish Hospital) Cares for patients undergoing surgeries of the chest. Cases include
bronchoscopies and esophageal reconstructions.
Off-campus 8-week rotation: Madisonville (8 weeks, Baptist Health) Comprised of a 4-week general surgery
rotation, and 2 2-week rotations in orthopedic and vascular surgery. You will see a wide variety of cases on this
rotation, and spend more time working directly with attendings.
Grades and Assignments
Clinical Evaluations 30%
Quizzes 20% (3 total)
Shelf Exam 30%
12

By Alexandra Healy
Oral Exam 20%
Online Cases Not graded, but part of LCME requirements
Surgical Technique Checklist Must complete prior to end of rotation
Required Diagnoses/Patient Log Must complete prior to end of rotation
Attire: Always wear business attire when entering the Department of Surgery (ACB, 2nd Floor), Polk Rounds, or attending Grand
Rounds. This includes shirt and tie for men, knee-length dresses/skirts or pants for women. A general rule of thumb is to keep
an extra change of dress clothes in your car at all times, for instances when you forget you need to change into business attire
later in the day. Check with your team about clinic days and what attire is expected. On most other days you may wear scrubs
to the hospital. Each hospital has its own supply of scrubs, usually located in the locker room. If you are assigned to the VA you
will be given a ScrubX card and allowed to checkout two pairs of scrubs at a time. You must wear the VA scrubs on days you will
be scrubbing into surgery.
How to Shine: This is the most hands-on rotation you will have, and its important that you take advantage of it. Always be
willing and prepared to jump in and help. In the OR this means anticipating where you can be most useful, such as using the
suction to grab smoke at they use the Bovi, asking for the scissors as they begin to close, and transferring the patient to and
from the bed. Outside the OR this means running errands, putting on gloves when doing a bedside procedure, changing
dressings, etc. When in doubt, put on gloves so you are available for assistance should it be needed. In addition, confidence is
key. Always speak with confidence when you present or answer a question, even if you arent entirely sure of yourself. A few
other ways to shine
Before the OR: There should be a student present in every case. Before surgeries begin each day, divide the
scheduled cases between you and the other students on your team and decide who is scrubbing in on what. Read up
on your patient, the surgeries you are scrubbing in on, and know the anatomy involved. Know your patient and know
why they are having surgery. Some surgeons askwhats the most important question of the day? The answer: Why
are we here? Read the HPI and look at any imaging the patient may have had. In addition, it may be helpful to get to
know the scrub team, the anesthesia team, and the other ancillary staff members that could make your life easier.
This is team- and location-dependent, but if you get to know the anesthesia resident well, and stay with your patient
from pre-op to the OR, they may be willing to teach you techniques like inserting IVs, induction, and intubation.
In the OR: Keep tabs on when your patient arrives to the OR. Pick out your gloves, and your residents gloves if you
know their size, and introduce yourself to the OR tech well before surgery. Also, write your name and year in medical
school on the dry erase boardit helps the staff identify who you are and your role immediately. Help the OR staff
with moving the patient to the table, positioning the patient, shaving body hair, applying betadine to the area being
operated on, etc. Always pay attention and be prepared to do your part during surgery. If you hear the attending or
resident ask for the retractor, be ready to hold it. If they begin to close, ask for the scissors and be ready to cut. After
surgery, help the OR staff transfer the patient back to the bed. Stay with the patient until they are delivered to the
PACU. The OR is like a dancea lot goes unsaid and its up to you to anticipate the pace, tone, and next move; predict
their needs, as well as when it is an appropriate time to ask questions or, arguably more important, when to stay
quiet. This finesse comes with time and close observation, but the keen student will catch on quickly as the rotation
progresses.
During Rounds: You should be seeing 2-4 patients each day. Show up early enough to see your patients (often around
5:00AM) and write notes on each of them. Your team rounding will be highly variable, based on your service and your
resident team. Surgery can be very hierarchical, so if you have a question, go to the first person ahead of you (i.e. ask
the intern before you go to the chief). There is a high volume of patients and very little time before surgery begins in
the morning. It is important that you take the initiative and jump in when the team gets to your patient. Make your
presentations succinct and present with confidence. Always have an assessment and plan for your patient.
On Call: Being on call means you are working from your report time to approximately 8:00 AM the next day
generally more than 24 hours. Call nights can be exhausting, but its important that you dont complain or make it
obvious that you want to go to sleep. Often it is just you and a resident working call night. In the event that you
become swamped, try to help out your resident. Respond to their pages if you can; get started on the H&Ps for
consults; ask for ways to be helpful. When all of the work is done, and there are no cases going, then it is okay to go
to the call room.
13

By Alexandra Healy
On Trauma Service at UL: Your task as a student is making sure the patient-note templates are current with your
teams list (Trauma 1 or Trauma 2). This means that you have a paper note with your patients sticker in the top right
corner, the HPI is current and accurate (include blanks for HD# and POD#), the medication list is updated, etc. You
should have these templates updated and ready for your pre-rounding team (generally the interns). Once they have
completed their notes, the upper level will go over them, add their plan, and then you create the final days note
packet with enough copies for everyone on the team. You may be expected to pre-round and present 1-2 patients,
depending on which service you are assigned to and the expectations from your residents/attending. Just ask! Finally,
if you go to see a consult or room 9, grab a Trauma H&P and get started! The resident will ask the questions and
perform an exam; write as they talk. If you are on call, you can also get a template prepped and ready if you know the
patient is likely going to surgery/getting admitted. This will make the work easier in the mornings for those students
on the day shift. This can be a high-stress and busy service for the residents, so find ways to be helpful and they will
reciprocate by allowing you to be more hands on in the OR or with procedures.
The Oral Exam:
Surgery is the only rotation with an oral exam. The oral exam sounds terrifying, but most people leave feeling that it went much
better than expected. On the last Friday of your 8-week rotation, you will meet in the General Surgery Department (2nd floor,
ACB) for your oral exam. The exam consists of 3-4 clinical scenarios that you will work through step-by-step, and be expected to
list differential diagnoses, interpret imaging results, state the next step in treatment, etc. You will have one or two surgery
attendings or residents proctoring your exam, and it will last 20-30 minutes.
This sounds extremely intimidating on the first day of your surgery rotation, but by the end of the eight weeks you
will be more than prepared. The last two lectures before the oral exam will be devoted to the Gaar Sessions. These are two
four-hour sessions where Dr. Gaar presents the 10-15 possible cases you may be given in your exam. He will work through each
case in an oral-exam format, and he will cover any and every question that you could possibly be asked in your exam. Old
manuscripts of the Gaar Sessions from previous years are circulating, and are very useful for studying.
Most Common Study Resources:
UWorld QBank (147 questions) Shelf exam preparation.
Emma Rhamahis Review A 2-hour review for the shelf exam.

o Video: http://atsvid.uthscsa.edu/Mediasite/Play/60089c931cca4bcabb76bf8f2c883b09
o Powerpoint:
http://som.uthscsa.edu/StudentAffairs/documents/High_Yield_Surgery_Compatible_Version.pdf A quick
2-hour review for the shelf exam.
o ** Some students often review the Internal Medicine presentation as well; a lot of medicine shows up on
the General Surgery shelf, so look alive!
Dr. Pestanas Surgery Notes Read through this multiple times before the shelf exam.
Case Files Surgery Lecture, quiz, and shelf exam preparation.
NMS Surgery Quiz and shelf exam preparation.
Surgical Recall More helpful for time spent in the hospital as it includes practical information as well as material you
may be pimped on. Also helpful for the oral exam.
Essentials of General Surgery by Peter Lawrence Textbook that can be helpful to cover high-yield topics for
presentation, work-up, and surgical options. Directed toward high yield and big picture material.
Toronto Notes, General Surgery Section bullet point information in dx and management of surgical diseases
14
Clinical Clerkship Survival Guide: Internal Medicine

By Eric Poulos
Internal Medicine
Internal Medicine is a broad field composed of primary care internists and a variety of subspecialties that deal with adult
patients and their illnesses, most commonly in the inpatient setting but also outside the hospital in each of the Internal
Medicine subspecialty fields. Internal Medicine diagnoses are quite diverse, spanning every organ system. Some of the most
common include pneumonia, kidney disease, diabetes and metabolic diseases, hypertension and cardiac disease; the internist
functions as the primary care giver in the hospital for most of these patients. Some Internal Medicine teams are also consulted
by the surgical teams to co-manage complex patients before and after surgery.
Internal Medicine is an eight week clerkship organized into two four-week blocks: 4 weeks of general Internal
Medicine ward work and 4 weeks further subdivided into two separate Internal Medicine subspecialties. Both assignments
involve seeing new patient consults or admissions, writing a note, forming a differential diagnosis, constructing a plan with a
subsequent workup, and presenting that information to an attending and your resident team. During the rotation, students
attend weekly didactic sessions, daily Noon report, and weekly Grand Rounds. You will also be expected to complete two
graded clinical exercises called mini-CEXs in addition to the midclerkship evaluation (ungraded) and your final clinical
evaluations.
Length of Rotation: 8 Weeks (4 weeks of general IM wards, 4 weeks divided into two subspecialties)
Locations:
University Hospital
530 S Jackson St
Jewish Hospital
Louisville VA Medical Center
800 Zorn Ave
Important Contacts:
Clerkship Director: Dr. Kristan Milam
kamila01@louisville.edu
Clerkship Co-Director: Dr. Monalisa Tailor
(502) 852-3637
mmtail01@louisville.edu
Department Chairman: Dr. Jesse Roman

Dr. Romans Secretary: Ms. Sherry Hertel
sherry.hertel@louisville.edu
Student Contact: Missy Klotz

(502) 852-7945
kmklot01@louisville.edu
Residency Director: Dr. Jennifer Kuch

jennifer.koch@louisville.edu
Didactics: All medical student didactics are weekly and mandatory, regardless of your clerkship assignment location.
While on IM wards at either the VA or UL there is a daily Noon Conference that is also required. Grand Rounds is a
weekly requirement, though this is often broadcasted to the VA.
15

By Eric Poulos
Weekly medical student didactics:
Thursdays, 12:00PM-2:30PM** Specific times may vary so check the schedule or ask your track captain.
These sessions include Meet the Professor rounds and teaching by the Chief residents over topics such as Reading
EKGs, Reading Chest x-rays, and ABG interpretation/acid-base disorders
rd
Location: Medicine Conference Room (ACB-3 floor)
Noon Report (VA):
12:00PM 1:00PM
Monday - Friday
Location: Room D010
Noon Report (UL):
12:00PM 1:00PM
Mondays, Tuesdays, and Fridays
Location: ACB, Community Conference (basement)
Grand Rounds:
8:00AM 9:00AM, Thursdays
Location: ACB auditorium (basement)
Grades and Assignments:
Clinical Evaluations 40% (minimum of 70% to pass)
NBME Shelf Exam 30% (Minimum of 4th percentile to pass; actual raw score varies depending on the time of the
year. Like all other clerkships, you much honor the shelf to honor the clerkship, which is above the 75% percentile).
SIMPLE Online Cases 15% (Completion of all 15 cases earns full credit)
http://www.med-u.org/simple
or
http://app.med-u.org/player/app/homepage.html
EKG Quiz 5% (20 question quiz)
(2) Mini-CEX - Two clinical exercises graded by residents. . One mini-CEX will focus on medical interviewing skills and
the other mini-CEX will focus on physical examination. These exercises must be supervised by an attending, fellow,
or upper-level resident to meet the requirement. Does not count in overall grade, but must completed to pass.
Required Diagnoses/Patient Log: Log your patients on New Innovations to complete required diagnoses
The Wards:
On wards, an Internal Medicine team is usually composed of one to two medical students, two interns and one upper level
resident. Each team is divided up by colors: White, Red, Green, and Purple. No team is harder or easier than the others, as your
workload is mostly dependent on your residents and your attending assignment. The upper level is responsible for admitting
patients, handling transfers from the ICU, managing consults, and overall organization of the team. The interns primarily serve
as the workhorses who place orders, make phone calls, and take pages. All members of the team will break up the patient list
and see each patient individually before the attending arrives. Often times the upper-level will see every patient on the list,
though the interns split the list to manage the details of the patients care. Occasionally a pharmacist and a teaching resident
will also round with the team.
As a medical student, the day begins anywhere between 5:30 7:00 AM with pre-rounding, where you will see the 1-3 patients
assigned to you by your team. This usually takes place before or concurrently with the interns. Keep in mind that your prerounding time will vary based on your level of experience/efficiency, the number of patients you have, whether or not your
team accepted Night Float patients that morning, and the overall expectations from your team. You will write your own note
(hand-written at UL and typed at the VA), forming your own differential diagnosis followed by a plan. Once you have given your
case some thought and constructed your plan, students should discuss their patients briefly with their residents, helping to
finalize the presentation and plan proposed to the attending. They like to see that you have thought about the case and
management plans before asking questionsit shows that you are taking ownership of your patient and youre trying to
independently formulate a treatment plan based on your clinical assessment. Next, the attending arrives and begins to round,
which simply consists of a patient presentation, with students expected to present each patient they have seen that morning.
The expectations during rounds can vary dramatically between attendings, therefore asking a resident what a particular
16

By Eric Poulos
physician expects during the first few days is very important. After rounds, the team breaks off to place orders, make phone
calls to social services, or if they are on call, see patients needing attention in the emergency department.
Medical students are expected to work an average of 6 days per week with hours, usually ranging from 7:00AM to 4:00PM,
depending on your pre-rounding responsibilities, teams patient load, and the overall working dynamics of your team. VA
students tend to have shorter hours (usually end by 2) than ULH students (usually end anywhere between 2:00PM 5:00PM).
th
Students are expected to take call from 7:00 AM until at least 7:00 PM every 4 day with their team. During call, students will
see new patients in the emergency department and will be asked to conduct and write a full history physical, including a
differential diagnosis and plan. Your call days are a good time to knock out both your history taking and physical exam miniCEXs! Attire is mostly business casual with your white coat, however you are allowed to wear scrubs on your call days, post-call
days, and on the weekends. Finally, students on wards must attend Noon Report on Mondays, Tuesdays, and Fridays, which are
usually short case presentations that are didactic in nature. Be sure to sign in to get credit.
Subspecialty:
The available 2-week Internal Medicine subspecialty options are as follows:
Renal (Jewish, UL, VA)
Cardiology (Jewish, UL, VA)
UL Heme/Onc
Endocrine (One service covers all hospitals)
General Infectious Disease (UL and VA)
UL Gastroenterology
Bone and Joint Infectious Disease (UL, VA)
Medicine Intensive Care Unit (UL, VA)
UL Pulmonology
The subspecialty rotations are opportunities to explore the more specific fields of Internal Medicine (see list of available
subspecialties below). Each of these specialties share a similar team structure to wards, except the team is smaller, your upper
level is often a fellow, and many specialties do not admit their own patients, therefore acting only as a consult service to the
primary medicine team. Pre-rounding and rounding is similar to wards, though the focus is usually narrowed to only include
issues pertaining to that specialty. Most subspecialties will have both inpatient ward work and some clinic days. Clinic on some
services is mandatory (ID), while it can be optional for others (Endocrine, Heme/Onc). As always, clinic attire is business casual
with white coat.
The hours and work expectations seen on subspecialty depend not only on the site but also on the attending. In general, VA
rotations tend to be lighter than others, particularly on Cardiology and Renal. Infectious Disease at the VA and at University
tends to be a little longer and you will be asked to stay and wait for afternoon consults. Bone and Joint infectious Disease is
characteristically hit-or-miss but oftentimes works fewer hours than the general ID team. Hematology-Oncology can be a very
relaxed rotation or very time consuming, depending on the attending. The most difficult rotations have reportedly been Renal
at Jewish and Endocrine. Endocrine is a unique rotation in that students will cover all four major hospitals, often requiring
rounding at each location for a larger portion of the day than most other subspecialties. Students on this rotation do learn a lot
and have great experiences so long as you know what youre in for! Renal at Jewish involves rounding twice, once during the
morning and once in the afternoon, leading to the longer hours. Despite the longer hours, students have said both are excellent
for learning their respective area.
As compared to ward work, the hours on subspecialty are often shorter. For this reason, some students will request ward work
first, leaving subspecialty for the last four weeks to pack in a little more studying. The exception is with Endocrinebe sure you
dont have Endocrine scheduled during your last two weeks on IM, as it will interfere with studying for the shelf. Ultimately, half
of your track will do ward work followed by subspecialty or subspecialty then wards some argue there is no real difference in
strategy, so dont fret either way.
How to Shine: As with any third year rotation, attitude plays a huge role in success. Be willing to volunteer to write H&Ps, ask
your residents questions when they are free, offer to go medical-record hunting, and try to read the latest on Up-to-Date for
each topic so that you are prepared for discussion. Take extra time forming a differential diagnosis and be able to talk through
which diagnosis is more likely versus which are not and why. More so than many of your other rotations, the Internal Medicine
teams practice evidence based medicine, so whenever you can bring up new articles (print it out if you can!) or major clinical
trials on why things are conducted the way they are, that is something that will help prove you did look up information as it
related to your patient the night before. This is by no means a daily or even weekly requirement, but if you can find a tactful
17

By Eric Poulos
way to insert your review of the literature into the patients care, it can certainly take you a long way. Last, this is very much a
TEAM rotationbe a team player and find ways to be helpful along the way.
In terms of shelf preparation, start studying and do UWORLD questions IMMEDIATELY. There is too much information to begin
to master everything in 8 weeks, but it is possible to get a good grasp on most things with a consistent approach.
World QBank (1359 questions) Excellent example of questions, though the subjects tend to be VERY specific. Should
be your primary source of questions for the shelf. Start early, as this is the largest question section on the Qbank and
the shelf creeps up quicker than you think!
Step Up to Medicine Best overall review for the shelf. Many students shoot to read this at least two times before
the shelf. This can also be very useful when studying for Step 2 CK.
Emma Rhamahis Review This 2 hour video is a must; most people watch it during the last week of studying to
brush up on high-yield topics. You can speed up the video to make it shorter.
http://som.uthscsa.edu/StudentAffairs/documents/HighYieldInternalMedicinecompatibleversion.pdf
MKSAP questions Not a great representation for the shelf, but the explanation are a great way to learn the
concepts and process of medicine. Consider this a secondary question resource.
Pocket Medicine (The Massachusetts General Hospital Handbook of Internal Medicine) Marc S. Sabatine; The
Washington Manual, Lippincott-Raven- Great resources for looking up quick information while on wards, but not a
great tool for studying for the shelf. Use as a quick reference guide.
NBME clinical mastery tests - Two 50 question tests that are $20 each. Best example of the questions faced on the
exam. Use more as a gauge of progress later on than as a study tool. Note: test 1 tends to be easier than the shelf,
while test 2 is more representative. Not often utilized by most students, but it can be a resource if you learn best by
example
18
Clinical Clerkship Survival Guide: Neurology

By John Wehry
Neurology
The field of Neurology encompasses a variable patient population and spans all ages, as well as inpatient and outpatient
services. Strokes, headaches, seizures, and altered mental status are among the most common diagnoses in inpatient
neurology; for each of these, identifying the underlying cause can drastically change the treatment options and prognosis for
the patient. In the outpatient setting, neurologists follow patients who tend to have a more chronic component to their disease
state. While diagnoses such as headaches and seizures are still common among outpatients, the role of the neurologist for
these patients is focused more on the ongoing treatment than the underlying cause with the best management commonly
achieved through long-term follow-up. As a student, you will experience neurology in both the inpatient and outpatient
environment, gaining an understanding of the variety of disease states that are most commonly encountered in the field. By the
end of the rotation, you will be a master of the ever-challenging neuro exam.
Length of Rotation: 4 weeks (2 weeks spent at two different locations, most commonly with 2 weeks of inpatient and 2 weeks
of outpatient).
Locations:
Inpatient:
University Hospital (Stroke, Inpatient)
530 S Jackson St
Outpatient:
Louisville VA Medical Center
800 Zorn Ave, Louisville, KY 40206
Dr. Greg Smiths Office: A505
Jewish Hospital (General Consult Service)

Community Neurologists
Dr. Rukmaiah Bhupalams Office: 1169
Eastern Parkway Suite 1126
Kosair Childrens Hospital (Pediatric)

231 E Chestnut St
Dr. Michael Alts Office:

2934 Breckenridge Lane Suite #2
Children's Hospital Foundation Building
601 S Floyd St, Suite 500
Important Contacts:
Clerkship Director: Michael A. Haboubi, DO
mahabo01@louisville.edu
Program Coordinator Asst: Dominique Hurt

(502) 852-8426
d0walk01@louisville.edu
Student Contact: Connie Elgan

(502) 852-6328
connie.elgan@louisville.edu
Department Chairman: Kerri Remmel, MD

(502) 852-6990
kerri.remmel@louisville.edu
Didactics: All lectures for the Neurology rotation are held on orientation day. This is important to account for because it is much
easier to put off studying through this short four-week rotation. Dont underestimate the Neurology shelfit is oftentimes one
of the more challenging shelf exams.
Grand Rounds: 8:00 - 9:00AM on Thursdays, located in the Nursing Building, however location may be subject to change. It is
required that students on the Health Sciences Campus attend Grand Rounds. Be sure to sign in! Those on outpatient service
with community neurologists are not required to attend Grand Rounds during those weeks.
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By John Wehry
Clinical Neurology Assignments:
Logistics: This is a four-week rotation divided into two different two-week assignments that cover inpatient and outpatient
Neurology.
Dress: Business casual clothes and your white coat.
Hours: Generally, hours are 8:00AM - 5:00PM for most locations with weekends off (**Peds Neuro works 1 weekend)
Call: Every student will take in-house call one time during their inpatient rotation
o UofL General Neurology call from 4:00PM 8:00PM on a weekday
Contact the resident that is on call to arrange a meeting place

o Kosair Pediatric Neurology call weekend morning (~8:00AM until finished rounding)
Contact the resident or attending that is on call to setup the time and place to meet
Pediatric Neurology
This is a two-week experience with one week spent on the inpatient service and one week spent on the outpatient
service (clinic). Hours are usually 8:00AM 5:00PM but may vary depending on the attending physician. Pediatric
Neurology inpatient hours are sometimes longer and it is required that you work one weekend, but the overall clinical
experience is one of the best.
Overall, this rotation is very popular with students given the patient population, wide variety of diagnoses, and the
high quality of the clinical faculty in Pediatric Neurology. Namely, Dr. Vinay Puri, Chief of Child Neurology and Vice
Chair of Neurology, is often cited as one of the major strengths of the rotation.
Contact: Miranda S. Der Ohanian, Pediatric Neurology Administrative Assistant
502-588-3673
miranda.derohanian@ulp.org
Inpatient The location for this assignment is Kosair Childrens Hospital. Of the inpatient locations, this can
be one of the most demanding of your time. However, students on this rotation have excellent experiences
and always praise the quality of the teaching by the faculty. Hours here are a little more demanding
expect to arrive around 7:00AM to pre-round. You will write notes on all of your patients (usually 2-3 while
on service) using EPIC. The residents and NPs will give you a heads up on the time you will round the next
day. Be prepared to present your findings on the neuro exam. Dont forget your penlight, reflex hammer,
and stethoscope. Both residents and attendings are most interested in helping you learn and perfect both
the neuro exam and the presentation of the neuro exam.
Outpatient The location for this assignment is Kosair Childrens Foundation Building (the 5 th floor of the
Chase building across from Kosair). As a student you will see the patient and his/her parents before the
attendingsometimes with a resident and other times on your own. Be sure to get a thorough H&P for new
patients. Like on inpatient, residents and attendings are most interested in helping you learn and perfect
the neuro exam. Outpatient notes are done using AllScripts; not every attending expects you to write notes,
but ask ahead of time.
UofL Stroke
The location for this assignment is UofL Hospital. Report to the Stroke ICU on the 9 th Floor and be prepared for
rounding by 8:00AM. Start time varies depending on the attending, but expect to get to the hospital sometime
between 6:45AM and 7:00AM so that you have time to see your patient and write a note in the chart before rounds
start. Students may finish before 5:00PM depending on the attending and volume of patients.
Jewish Consult
The location for this assignment is Jewish Hospital. Students should expect to arrive between 6:30AM and 7:00AM in
order to see their patients and prepare for rounds, which usually begin around 9:00AM. Generally, you meet with
your residents at 7:00AM once the pager switches over to get new consults. You will be assigned patients/new
consults to see and the resident will often let you see them independently. Get a good history and do a thorough
physical exam with ample attention to the neuro exam. Note writing isnt required, but if you type your notes in a
word doc and print them off for the resident to reference for their note, you get major bonus points. Often you will
20

By John Wehry
present your patient to both the resident and the attending. This service is covered by a variety of attendings and
often you wont work with the same one more than 2-3 days, so if you find one that you gel with ask him/her
upfront for an evaluation. By the end of this rotation you will perfect the H&P, the neuro exam, and oral
presentations. Obviously the level of your involvement will vary based on your own interest and the hands-on/handsoff nature of your residents. Because Jewish is a private hospital and many attendings/service are not in-house, the
resident neurology service can sometimes get the shaft with consultssuch is life in the practice of medicine so work
every patient up as though they were a blank slate!
Private Practice
Dr. Rukmaiah Bhupalams Office
1169 Eastern Parkway, Suite 1126
Hours are usually 8:00AM 5:00PM with Tuesday mornings off for studying. Dr. Bhupalam works at a slower pace,
however he expects students to take a good HPI from patients and then present to him before going into the room
together to evaluate the patient. He tries to get students to see as many different patients as possible, and he does a
good job of teaching in a way that is easy to understand. He spends some time at Norton Audubon doing sleep
medicine and EMG.
Dr. Michael Alts Office
2934 Breckenridge Lane Suite #2.
Students usually report to Dr. Alts office by 8:30AM when he starts to see patients. He is very nice and laid back, but
expects students to be willing to learn, ask questions, and be engaged. Be involved, interested, and enthusiastic.
Dr. Greg Smiths Office
VA Hospital, 5th floor. From the main elevators, walk to the left and then turn right when the hallway begins. Dr.
Smiths office will be one of the first few doors on the left.
He is very interactive with students and will teach you how to interpret several imaging studies, which will be helpful
down the road. The mornings are usually filled with clinic time, and he often does EMGs in the afternoon. You will not
be required to get to the hospital before 8:00AM and will not leave later than 5:00PM.
Grades and Assignments:
Clinical Evaluations (40%) completed on New Innovations

o Mid-clerkship Evaluations are required for completion of the clerkship but do not contribute to the Clinical
Evaluations grade.
Shelf Exam (40%)
Standardized Patient/Lumbar Puncture Simulation (20%)

o Students will have the opportunity to practice the SP/LP simulation before the date of their exam.
o Students are able to retake the SP/LP simulation one time to improve their score.
Required Diagnoses/Patient Log completed on New Innovations

How to Shine:
Show up on time and be enthusiastic about learning. Come prepared: reflex hammer, penlight, and your stethoscope!
Know as much as you can about your patients (recent imaging and labs, etc.)
Offer to help the residents with anything that could make their lives easier
Be a team player
Master the neuro exam from top to bottom. Practice on each of your patients, going in the same order every time, to
perfect your approach and to become more efficient.
No matter how well you do on the wards, honoring often comes down to the shelf exam. Neurology is a short fourweek rotation, so dont put off your studying until the last week!
World QBank (172)
Case Files
Blueprints
Pretest
First Aid
21
Clinical Clerkship Survival Guide: Elective

By Anne Hayes
Elective
This four week period is very much a what you put into it is what you will get out. It can be the perfect opportunity to help
you decide your ultimate career choice, solicit letters of recommendation, and get to know faculty and staff in the specialty of
your choice, or conversely offer a time for rest and relaxation in-between clerkships. The third year elective time can be utilized
in a variety of different ways as outlined by the diagram below. Career Exploration and Clinical Electives are completely
optional and will be discussed in detail below. You may also opt to use your elective time for vacation, Step 2 studying, or
independent research (i.e. continue working on current research or join a new project of interest).
Length of Rotation: 4 weeks

Many clinical electives will require a commitment of at least two weeks. You may choose to do two clinical electives (two
weeks each), one two week elective with two weeks of research, or one three week elective with one week of vacation etc. A
career exploration has a minimum commitment of one week. Overall, there is a lot of flexibility with how you split the four
weeks of elective time. You are not required to use all four weeks, however keep in mind that any time you spend in clinical
electives or career exploring will contribute toward your required 4th year elective hours (22 weeks).
Making Arrangements:
You are responsible for setting up your elective time, however the personnel in Student Affairs can help you navigate the
process. You should start making arrangements 2-3 months ahead of time to ensure availability. You can solicit advice from
your Advisory Dean, current physicians or researchers, your mentor(s), or other students. Below is the contact name and email
address for personnel in Student Affairs that can help you, too!
Sherri Gary, Senior Academic Coordinator
sherri.gary@louisville.edu
Kim Holsclaw, Senior Program Coordinator
kim.holsclaw@louisville.edu
Micheal Keibler, Visiting Student and Elective Coordinator
michael.keibler@louisville.edu
Grades: Clinical Electives vs. Career Exploration
One difference between clinical electives and career exploration is how you are evaluated/graded. Students are required to
write a one-page reflective paper after completing a career exploration. Once the paper has been submitted to Student
Affairs, the student will receive a grade of Pass and no evaluation is included in the MSPE (residency application letter). If a
student completes a Clinical Elective the student is truly evaluated by their attending and receives a numerical grade. The
comments from the clinical elective evaluation will appear in the MSPE.
I.
Career Exploration:
Career exploration is an opportunity for you to shadow faculty in a field of your interest without the stress of tests
and evaluations. If you are unsure about your future field, the career exploration path is affords you a hassle-free
way to further investigate your interests. Students who take this elective will be given 1 to 4 weeks of credit toward
the required elective time in the fourth year, depending on the amount of time you decide to commit to your career
exploration time.
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Clinical Clerkship Survival Guide: Elective

By Anne Hayes
If you are interested in completing a career exploration with a UL department, please send an email to Michael
Keibler, listing the dates of your exploration and the desired field. If there is a particular physician or service you are
interested in shadowing, also include this information in your email. This request must be submitted at least 4 weeks
in advance. If Mr. Keibler is unable to accommodate your requests, consider contacting the physician or department
directly, as there may be alternative shadowing opportunities outside the main avenues. Please be professional with
all requests!
You may also complete this experience with non-UofL faculty. This includes physicians out of the state. The student
will need to make arrangements with the outside physician, and then send an email to Sherri Gary, with the name,
address, type of practice and the dates of the experience at least 2 weeks in advance of starting.
At the end of your experience, you will email Kim Holsclaw, a one-page reflective paper over what you gained from
the rotation. You will be contacted with more information on this assignment after you sign up for the career
exploration elective.
II.
Clinical Electives:
Clinical electives are pre-made, university-approved rotations that allow students to rotate through certain
subspecialties or work with specific patient populations. The clinical elective provides some students with the
opportunity to spend more time (outside the core rotations) with faculty in departments of interest. The evaluations
provided by these rotations may be important to gain if you are attempting to match in a subspecialty. For instance, if
you are interested in hand surgery and you find that there is a third year elective at the hand institute, it may be
advantageous to take that rotation during your elective time.
To see whats available, visit this link, https://netapps.louisville.edu/MECourseCatalog/Catalog.aspx
Select a field of interest and press submit to see courses offered. Make sure the description of the course you are
interested in includes the text: THIRD YEAR ELECTIVE. Be sure to pay attention to the prerequisites to each elective.
In the past, some electives have required you complete your surgery or internal medicine core rotations before you
are eligible to participate in the elective.
If you would like to participate in a clinical elective send an email to Sherri Gary, listing the elective title and dates for
the elective. This request must be submitted at least 4 weeks in advance.
III.
Research
This four-week period is an ideal time to focus on new or ongoing research projects. Certain programs, such as the
Distinction in Research Track, have elective research requirements that are often fulfilled during this time. Again, not
all four weeks are required to count towards researchyou can opt to do a week or two of research with a clinical
experience or vacation time built into the remaining weeks.
If you are interested in participating in research during your elective time, please contact Sherri Gary for further
instructions.
IV.
Vacation and Miscellaneous

Third year can be a stressful time! Oftentimes students will use one week of elective time for vacationand use the
remaining three weeks for clinical or research experiences. Others will dedicate the full four weeks to planned time
offyou decide! You are NOT required to inform the school that you are using this time for vacation, ENJOY!
If the four-week elective time falls in May or June, some students consider using this period to study for Step 2s:
Clinical Skills (CS) and/or Clinical Knowledge (CK). Most students recommend 1-2 weeks of study time for CS and 2-4
th
weeks of study time for CK, so this could certainly be of benefit if you are planning on doing away rotations during 4
year and need your scores early. It is not recommended that you sit for CS without passing the CSE-3 (Basically Step
2 CS practice exam) hosted by Carrie Bohnert (carrie.bohnert@louisville.edu) through the Standardized Patient
Program. It is also not recommended that you sit for CK without completing the 7 core clinical clerkships.
23
Clinical Clerkship Survival Guide: OBGYN

By Chris Hamann
Obstetrics and Gynecology

Obstetrics focuses on pregnancy, childbirth, and postpartum care. Gynecology focuses on pathology of the female reproductive
system. This clerkship is a combination of primary care, surgery, and medicine for women of all ages. Each rotation will provide
a different aspect of care, and common diagnoses include pregnancy and associated complications, tumors of the reproductive
tract, sexually transmitted infections, among many others. This clerkship is six weeks, with 2 weeks of L and D, 2 weeks of
private practice, and 2 weeks of a surgical rotation (benign gynecology, gynecology oncology, urology/gynecology, or one-day
surgery).
Length of Rotation: 6 weeks (3 rotations of 2 weeks each)
Locations:
Inpatient:
University Hospital
530 S Jackson St
Outpatient:
UofL Health Care Outpatient Center
401 E Chestnut St
th
Outpatient Clinic is on the 4 Floor
OBGYN education office:

Second floor walkway between the Ambulatory
Care building (ACB) and ULH. On orientation,
signs will be posted to direct you. This is where
the bridge conference room for orientation and
lectures are.
L and D, Lockers, and the Library: 3rd Floor
Gynecology Oncology: 6th Floor, South
Surgery and Pre-op: 2nd Floor
Important Contacts:
Clerkship Director: Sara Petruska, MD
Office: 502-291-6257
Email: sepetr02@louisville.edu
Department Chair: Sharmila Makhija, MD
Clerkship Coordinator: Susan Jackson

Office: 502-561-7449
Email: skjack04@louisville.edu
Residency Program Director: Jennifer Hamm, MD
Didactics:
Orientation and Wednesday lectures with different members of faculty covering a range of OBGYN-related topics are
nd
in the Bridge Conference room, located in the OBGYN Education Office on the 2 floor walkway between the ACB and
ULH. Attendance is required and a sign-in sheet is present, but under certain circumstnaces absences may be excused
(unique procedure, your patient is mid-deliver, etc.) and are explained during orientation.
Small Group sessions: Attending physicians lead discussions on various cases that are provided in the orientation
packet. These cases require reading beforehand to allow for student participation and discussion. Following the
discussion, a short quiz will be administered for a grade. Small group schedules vary depending on the attending and
will be given at orientation.
Grand Rounds: Friday from 1-2 PM in the ACB auditorium, near the cafeteria. Attendance is required, sign-in sheets
are present, and food is not provided.
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By Chris Hamann
OBGYN Assignments
Labor and Delivery
ULH 3rd Floor. All students will complete this two-week rotation, with one week of day shift (5:30AM to 5:30PM) and
one week of night shift (5:30PM to 7AM). Each week will be five shifts, unless you are on the first week or the last
week. Three third year students will be on each shift. Scrubs are located in a closet on L and D, which is down the LEFT
rd
hallway after entering the door across from the elevators with your hospital ID on the 3 floor. Do not allow people
to follow you into the secure doorway. Men and women lockers are near the entrance of the floor.
On days, arrive with enough time to change and be at the postpartum wing, located down the RIGHT hall after
entering the secure door, by 5:30 AM. Morning duties include splitting up postpartum patients with a blue label
(meaning vaginal delivery) among the students. You will preround on the patient and ask questions regarding
postpartum care, which should only last about 5 minutes. Relevant questions are included in a blank postpartum note
that is in the patients chart. DO NOT fill out a blank note in the chart. Only residents will do this. You may make
copies of a blank note with the name blocked out to help guide your interview. Other information on the postpartum
note includes labs, which may be gathered from NetAccess or WatchChild, the EMR used on the floor. After youve
gathered information from the patient and the EMR, see which resident is going to see your patient and provide them
with the information youve already gathered, and see the patient with them. You are also responsible for writing
discharge prescriptions for patients. Prescription pads and stamps are located at the Nurses station. Specific
information regarding prescriptions is included in the orientation packet. On nights, students meet in the L and D at
5:30 PM. Those on Nights will also meet on the postpartum wing at 5:30 AM and are responsible for patients with a
red label (meaning Cesarean deliver). Patients who have had C-sections also receive an extra prescription for pain
medication. Patients who are postpartum vaginal deliveries are discharged 2 days after delivery; Cesarean section
patients are discharged 3 days after delivery. Patients with a purple label are private and are not rounded on by
students, but prescriptions for these patients can still be written. Once all the prescriptions are written for all patients
being discharged, bring them to morning report in the library to be signed by a resident. Both shifts attend morning
report for hand-off. Following hand-off, students on nights are dismissed, and students on days stay for morning topic
discussion.
After morning report one student will round with the Maternal Fetal Medicine attending, while the other two begin
on L and D. Patients who are in labor may be distributed among the students. Students should introduce themselves
to the patient if they are going to participate in the delivery. When the resident who is covering your patient checks
on the patient, ask to follow them so that you can also keep track of the patients cervical dilation and station.
Students should not perform pelvic exams unsupervised. Make sure to know where shoe covers, facemasks, and
sterile gloves are located; also know how to properly gown and glove so when a delivery is happening you can quickly
prepare. For vaginal deliveries, students are expected to have a delivery during which their hands are on the baby, in
addition to delivering the placenta and drawing cord blood. This will be practiced in the Sim Labs. C-sections will be
performed in the OR, which is located on the same floor. Following a delivery or C-Section, students are responsible
for filling out the Baby Book as well as the Placenta Registry Form. Ask a resident how to complete this. Also during
L and D, students must triage patients. Pregnant patients with acute issues (membrane rupture, decreased fetal
movement, extremity swelling, etc.) are assessed through triage. Students must keep an eye out to see when patients
enter triage and quickly perform an H and P as shown below. Present the patient to the intern or an available resident
along with your assessment and plan. This should all happen as quickly as possible.
Private Practice:
Private Practice is a two-week rotation, and student experiences vary depending on their preceptor. It may consist of
outpatient OBGYN care, private practice obstetrics, or private practice surgeries. Most students work from 8 AM to 5
PM and have weekends off.
Surgical Assignment:
Surgery is a two-week assignment, and student experiences vary depending on preceptor and assigned unit, which
includes Urology/Gynecology, Benign Gynecology, Gynecology Oncology, and One Day Surgery Unit (ODSU). Be in
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By Chris Hamann
contact with your assigned residents to determine where to meet them and when. Some surgeries you will be
expected to scrub in and others you will only observe. Learn proper technique and protocol.
One-Day Surgery will typically have 1 student working with a resident, and outpatient procedures include Essure
placement, hysterectomy, and tubal ligation. The hours are generally lighter on this assignment. Surgeries are
performed in the HCOC.
Benign Gyn will consist of two students at ULH working with Dr. Pasic and Dr. Biscette, an intern and chief
resident. Procedures include laparoscopic/robot-assisted/open hysterectomies, oophorectomies, and benign
ovarian tumor removals. A resident will inform you where to report and send the procedure schedule on Sunday.
Students are responsible to pre-round on a post-op patient, write a note, and present for rounds usually at 6:45
AM. Hours can vary depending on surgery scheduling and types of procedures.
Uro/Gyn will consist of two students on rotation and procedures including pelvic organ prolapse, urinary
incontinence, and overactive bladder, which may be performed laparoscopically or robotically. Hours on
Uro/Gyn also vary.
Gyn Onc normally has 2-3 students who will see procedures involving cancer of the female genital tract. Hours
are regular, depending on number and complexity of cases. For people interested in surgery, this can be the
most rewarding part of the rotation. Students are responsible for pre-rounding on patients, writing notes, and
presenting patients on rounds on 6th Floor South. The surgery schedule will be given out on your first day, and
you should contact a resident the day before to find out what time to show up for pre-rounding.
Continuity Clinic:
Continuity Clinic consists of 2 shifts of outpatient care at the Womens Health Clinic on the 4th floor of HCOC. Students
are assigned a resident for an afternoon or morning of clinic. This will allow you to follow the longitudinal care
involved in OBGYN. Resident assignments and scheduled clinic days for students are listed in the orientation packet.
Before seeing a patient in clinic ask your resident to help you adjust your history and physical to the patient. For
example, pregnant patients will have different histories depending on their gestational age, and gynecologic patients
may present for check ups or acute problems.
Attire
Clinical Evaluations completed by Attending Physicians and Residents (70%), Breakdown:

Private, 10%
Continuity Clinic, 10%
L and D Days, 10%
L and D Nights, 10%
Surgical Assignment, 10%
Small Group and Case Quizzes, 20%
NBME Shelf Exam (30%)
th
Honors will be considered for >75 percentile on the shelf exam and 90% clinical grade. Pass will be given with a
th
minimum of 70% on clinical evaluations and >4 percentile on the shelf exam.
rd
rd
L and D scrubs are located in a closet on the 3 floor and Locker Rooms are also on the 3 floor
Private Practice will vary depending on your attending and what they are doing. Days of clinic require professional
attire, but wear scrubs if you are performing procedures. If working at a private hospital, wear professional attire to
the hospital and change into the hospital scrubs in the locker room.
Surgical Assignment ask a resident you are working with what would be appropriate
How to Shine:
The first step to doing well on any rotation is to understand how you fit into the treatment team and knowing the expectations
from your Attending and Resident physicians. This will allow you to be more proactive in your learning as well as assist the
team. The orientation packet and syllabus has a lot of helpful information. Asking students who have been on the rotation what
was expected of them and having a designated time for transition of care and a walkthrough of the important locations and
resources is always helpful.
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By Chris Hamann
Show up early especially when you have questions regarding your role so you can still perform them on time as expected. Most
importantly, keep a positive attitude. A 14-hour night shift may be your longest shift so far, but remember, the residents are
working longer shifts and can be sensitive to complaining. Show your enthusiasm for learning and do what you can to make
their shifts easier. Impressing attending physicians requires enthusiasm and a genuine interest in your patients care. Show
them that youve studied a disease, or learned about new evidence in regards to a treatment algorithm, but always respect
their judgment.
The OR requires astute self-awareness. Knowing the proper technique to scrub in, properly dry off, gown, and glove require
practice and have patience when asking the scrub technician to assist you. Once youre comfortable with your own presence in
the OR, you can learn the basic techniques of surgery. Nurses, technicians, and surgical assistants can be incredibly helpful for
you to maximize your learning experience and deliver care to the patient.
Common Study Resources
UWorld QBANK (~213 Questions)
APGO https://www.apgo.org/student/320-uwise-index.html (540 questions), these questions are helpful in learning

management of diseases. Some questions may be more in depth than necessary. It is still a very helpful resource.
BluePrints OBGYN is a very extensive read, but has all the important information and more.
Case Files presents a case and a few pages of relevant topics followed by questions
27
Clinical Clerkship Survival Guide: Pediatrics

By Evan Rhea
Pediatrics
Pediatrics focuses on the health and well being of infants, children, adolescents, and young adults, ranging 1 day old to 17 years
old. The clerkship is divided into two parts: inpatient and outpatient. Outpatient pediatrics mainly consists of well child checks
and acute care visits. These visits are important for immunization updates, checking growth curves, surveying developmental
milestones, providing anticipatory guidance, and much more. In addition, patients visit the outpatient clinics for acute issues
and monitoring chronic diseases, such as for asthma checkup or exacerbation, rashes, diarrhea, sore throat, cough, and fever.
Inpatient is considerably different as compared to outpatient in both work environment and the condition of the patients.
These patients can be quite sick, making their care more complex. The patients you will see on inpatient service will vary
greatly depending on the time of year you are on service. For example, asthma exacerbations are common in the summer and
fall, while upper respiratory infections and bronchiolitis and are common in the winter (i.e. RSV season).
Length of Rotation: 6 weeks (3 weeks inpatient, 3 weeks outpatient)
Locations:
Inpatient:
Kosair Children's Hospital, Medical Education
Office K609
231 E. Chestnut St.
Outpatient:
Children and Youth Clinic
555 S. Floyd St.
Stonestreet Clinic
9702 Stonestreet Rd. Ste. #100
Didactics and Grand Rounds:

Wade Mountz Auditorium
nd
Norton Hospital, 2 Floor
Eastern Parkway Clinic

982 Eastern Parkway
**A parking pass is available to students on pediatrics. This will give you access to an open-air lot on 2nd & Chestnut Streets
(behind the L & N credit union). You must obtain this pass from Norton Healthcare Parking, located on the first floor of Medical
Towers South at the corner of Floyd & Gray Streets. This pass does not give you access to the Kosair garage.
Important Contacts:
Clerkship Director: Olivia Mittel, MD
Office: 502-629-8828
olivia.mittel@louisville.edu
Assistant Directors: Gerald Lee, MD, and Jennifer
Thompson, MD
Department Chair: Gerard Rabalais, MD
Clerkship Coordinator: Debbie Vanderhoof

K609, Kosair Childrens Hospital (6 East)
Office: 502-629-8819
Deborah.vanderhoof@nortonhealthcare.org
Residency Director: Kimberly Boland, MD
Didactics:
Student Didactics: Wednesdays, 2:00PM 4:00PM
Location: KCH, Room 605 (Office of Medical Education - Morning Report conference room
Orientation to the Pediatrics clerkship is held on the first Monday of the rotation. Clerkship information will be
discussed, followed by several lectures by UL pediatricians about history taking, physical exam, and immunizations.
Beginning the second week of rotation, Wednesday afternoons are set aside for quizzes and lectures. Quizzes are
based on mandatory online CLIPP (3 cases/week) cases (found at med-u.org) that students are to complete each
28

By Evan Rhea
week. These cases are time-consuming (30 minutes 1 hour per case), so do not wait until Tuesday to do them. The
quizzes are typically not high-yield for the shelf, but necessary to do well in the clerkship. After the CLIPP quiz and
discussion are lectures where clinicians cover high-yield topics in pediatrics.
th
Happy Half-Hour: Every Tuesday and Thursday at 1:15 PM, typically in 6 floor lecture room. This will cover highyield board material and include board style questions, and attendance is mandatory for all students on inpatient.
Grand Rounds: Fridays, 8:00AM-9:00AM
Location: Wade Mountz Auditorium, located on 2nd floor of Norton Hospital
Students should sit near the back. Breakfast is served in the adjacent room from 7:30-8:00AM. Attendance is
required, sign in sheets will be present, but those at Stonestreet can watch by video conference although technical
difficulties commonly occur.
Assignments
Inpatient
Students rotate on inpatient pediatrics at Kosairs Childrens Hospital for 3 weeks. The Residents Room, Morning
th
report, Medical Education Office, and a computer lab are all located on the 6 Floor. The computer lab is near the
elevators and for the students when the Residents Room is busy. The service is split up into teams of different colors.
One large team color consists of two teams (i.e. Red 1 and Red 2) that share one attending. Each smaller team is
made up of a single upper level, an intern, and one to two medical students. Medical students are only assigned JFK
(Just For Kids) patients. You will be assigned 1-3 patients while on inpatientstart with one and get to know your
patients well.
Typical day is like on inpatient:
o
o
o
Pre-rounding: 6:30-8:00AM. Read notes from overnight on EPIC. Record vitals, labs. Check on the patients
and perform a physical exam (wake the patient if he/she is asleep). Check with the nurses to see if anything
important happened overnight, and remember to always be kind and courteous to the nurses. The nurses
change shifts at 7:00AM, so it would be ideal to get there for an update from the night nurse before she/he
leaves. You need to have your notes done by 8:00AM-arrive at whatever time you need to in order
accomplish this (i.e. can vary with patient load, how quickly you write notes, etc.). You will assign your notes
to the attending for their review. It may be helpful to print off your note and the patients H&P in the
morning, as you will often go off of this information when you present your patient during patient-centered
rounds.
th
Morning report: 8:00-8:45AM. Report to the classroom on 6 floor of Kosair for a lecture or case
presentation given by one of the chief residents or attendings. All residents and students on the inpatient
service attend. You are expected to see your patients and have notes finished by this time.
Checkout: 8:45-9:15AM. Patients who were admitted overnight are handed off to your team.
Rounds: 9:15- 11AM-ish. All patients are seen with your team and attending. You are expected to present
the patients who you saw in the morning, including your assessment and plan. Use your pre-written note or
a printed H&P to help guide your presentation. Use these only as a guide and quick reference for vitals and
lab values. Try to not read directly off of your paper or notes and be confident in your presentation. It
doesnt feel natural at first, but the more you do it the better you feel!
Patient-centered rounds: On this rotation part of your presentations will take place in the room
with the patient, the patients family, and your entire team. The idea is to keep everyone involved
in the childs care on the same page. Because of this, avoid medical jargon (i.e. dyspnea= difficulty
breathing, hematuria= blood in urine) and try to narrate your presentation as a story, maintaining
eye contact and speaking to both the treatment team and the family. Occasionally before patientcenter rounds some attending ask for a brief presentation including your plan outside the
patients room.
Noon conference 12:00-1:00PM. Noon conference is not technically required, but the best advice is to
follow what your resident does. If they are there, then you should be, too! Some of these lectures are
helpful for the shelf and may even serve food! Check your schedule and ask your residents if there is a
conference.
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By Evan Rhea
o
Work/Reading time: 1:00-4:00PM. Follow up on your assigned tasks as outlined during rounds, pending
results, consults, procedures, new admissions, etc. during this time. If things are dead, ask the infamous is
there anything else I can help you with or use your down time to prepare for the shelf exam.
Checkout: 4:00PM. You and your residents sit down with the call team for final checkout. Once youve
made it through the list, you may leave if you are not on call.
**Depending on which team you assigned to, you may also have specialty rounds (i.e. Yellow
team will have Nephrology and Neurology rounds daily if the residents have patients on that
service.) Sometimes is can be easy to zone out during these rounds if your patient isnt being
addressed, but try your best to pay attention.
Call days: 3:00-8:00PM, Q4: Your team will accept new admissions along with one other team. It is typically a busy
night of taking full H and Ps, so get food before it starts. You cannot take a call day as your one day off for the week.
Try to be in attendance on post-call days so that you can present the patients that you see while on call.
Weekends: No morning report. Check out at 8:00-8:30 am. Confirm with resident. Divide the weekend days between
you and the other student (if applicable), as you may only take off one day per week and the pediatric coordinators
prefer that your day off be on a weekend day.
Again, students get 2 days off during your 3 weeks on inpatient. Days off should only be taken on the weekends and
should be discussed with the upper level on the first day of the rotation and coordinated with the other student on
your team. You may not take call days off, and most attendings prefer that you are present on post-call days to
present the new patients you helped to admit.
Inpatient Requirements: (checklist is provided)
Topic presentation with team
Review 1 H & P with an Attending
Review 1 Discharge Summary with an Attending
Happy Half-Hour attendance
Outpatient
The outpatient rotation is 3 weeks long and will take place at one of the following three clinic sites: C&Y clinic, Eastern
Parkway clinic, or the Stonestreet clinic. Start time is generally between 8:30-9:00AM, depending on your clinical site,
and days typically run until about 4:00-5:00PM. The C&Y and Broadway clinic are convenient located near downtown,
however the Stonestreet clinic is about 20 miles (30 minutes) south of Louisville, near Valley Station. Student at C&Y
and Eastern Parkway with occasionally have 30-minute lectures over high-yield topics on Tuesday and Thursday
mornings before seeing patients. The outpatient experience is Monday Friday and does not require you to work
weekends.
All note taking is through the Allscripts EMR, which provides a default layout for documentation Use the templates to
guide your interview and questions, but do not get bogged down by all the options and avoid only talking to the
computer screen should you attempt to type and ask questions at the same time.
During your outpatient experience, you will spend one week of mornings in the Newborn Nursery at UL Hospital (3rd
Floor) in order to learn a proper newborn physical exam and practice it on newborns. Dr. Larry Wasser runs the
newborn nursery and is an excellent teacher. Each student will prepare a brief presentation over a topic of your
choice to present to Dr. Wasser, the residents, and the students on Newborn Nursery that week. It is very laid back
and this tends to be a very low-key week during your pediatrics experience.
You will also spend one half-day at the Home of The Innocents (1100 E. Market Street Louisville, KY 40206). During
this time you will round with the attending and sometimes a resident on kids with chronic debilitating diseases. It can
be a very humbling and inspiring experience. http://www.homeoftheinnocents.org/
Outpatient Assignment Locations
C & Y Clinic This tends to be a very busy clinic with many residents, 4-5 attendings, and a healthy patient load.
It is located on campus, next to the Nursing School, so it is easy to get to and less of a hassle when trying to
30

By Evan Rhea
navigate back to Kosairs for lectures, Grand Rounds, etc. Take it upon yourself to grab a laptop for access to
Allscripts and dive in to start seeing patients. While busy with good volume, there can sometimes be many
students and residents, so you may have to double-up.
Stonestreet Clinic The advantage to this site is essentially one-on-one interaction with the attendings.
Depending on your attending, there tends to be less emphasis on EMR and more on the overall patient
interaction and oral presentation. Take it upon yourself to grab a laptop (always check it out!) for access to
Allscripts and an otoscope once you get to clinic. Pair up with attending and see how they best prefer their work
flow, and then dive in to start seeing patients. Sometimes residents arrive in the afternoons for their own clinic
patients and you may be asked to surrender your laptop. Keep in mind that the Stonestreet Clinic is located 20
miles (30 minutes) south of downtown.
ULP Eastern Parkway Clinic Students notoriously get a lot of one-on-one interaction with the attendings at this
clinic site, however, there are fewer patients with usually 8-10 patients per half day. This clinic is about 3 miles
(10 minutes) from downtown.
Outpatient Requirements
Review note with attending
Prescription writing
Newborn nursery presentation
Home of the Innocence experience

Clinical Evaluations - 50%
NBME Shelf Exam 35%
CLIPP 12% - 4% for completion of the cases and 8% for the CLIPP quiz graded performance
SP/SIM Encounters 3%
In order to pass this course, the student must meet EACH of the following requirements:
Demonstrate appropriate professional behavior commensurate with the role of a physician and abide by the
rules and policies of the Department of Pediatrics, and of the facilities in which you work.
Attend all clinical activities.
Accept and meet all clinical responsibilities, including night call.
Patient logs/evaluations - Maintain and submit the logs at the end of the block along with evaluations of your
supervisors and clinical assignments.
Clinical performance - Achieve a "composite" MINIMUM score of 70% for each clinical assignment in the
Clerkship
NBME Shelf Exam - Achieve a MINIMUM of the 4th percentile.
OVERALL NUMERICAL COURSE SCORE - Achieve a MINIMUM COMBINED SCORE OF 70.

In order to honor the course: Minimum criteria for HONORS are: overall numerical score of 93% or above, in addition to a raw
score > 80 on the NBME.
By the end of the 6 weeks, you will need to submit the following:
o Inpatient:
1 Clinical Encounter Feedback Tool
1 Mid-block Report/ Core Competency Checklist

o Outpatient:
1 Clinical Encounter Feedback Tool
1 Mid-block Report/ Core Competency Checklist

*Review orientation packet for a more detailed list of course requirements.
Attire: Students are expected to wear business-casual/SP attire, including white coat for inpatient and outpatient. Invest in
some comfortable shoes, as you are on your feed a good amount! On inpatient, scrubs can be worn on call days, post-call days,
and weekends only.
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By Evan Rhea
How to Shine
As is true for all rotations, be on time and be interested! Your body language can show your attending a lot.
Never complain! Be aware that residents get there earlier and will stay later than you.
There is usually no need to look at your phone in front of an attending unless he/she asks you to look up something
on the spot. If you want to look up a information while rounds, indicate you are using your phone or tablet for that
purpose (so that they dont assume you are texting!) some attendings prefer that you avoid technology entirely, so
just feel it out.
READ ABOUT YOUR PATIENTS. This is a great way to learn and impresses attendings. You carry very few patients
intentionallyso that you can know and understand their case inside and out.
If an attending asks you a general or pimp question that you do not know, be honest but tell them you can find the
answer and look it up when time allows.
When rounding, try to correlate what you have learned based on the patient case. This can also be a good time to
present any literature you have come across that could influence treatment plan. As always, be tactful and avoid
looking like a show-off.
Dont quiz, interrupt, or spit/punch/wet-hilly (and all other things common sense) attendings, residents, or fellow
students, but feel free to ask the attending questions when appropriate.
Do not answer questions directed to other students unless the conversation has been opened to the group. Similarly,
avoid jumping to answer every question when rounding as a teameveryone needs an opportunity to participate.
Be confident during your presentations on rounds by maintaining eye contact with your attending as you present and
also by avoiding the need to rely on your paper notes to narrative the presentation. If you are shy or uncertain of your
treatment plan, seek out the residents and ask if you can practice your presentation with them before rounds,
ensuring that your Assessment/Plan is appropriate. Your notes and presentations will improve with time and
experience, which will ultimately translate to better evaluations.
Talk to the nursesbe kind, courteous, and helpful when opportunities arise. Befriending the nurses can make your
job much easier. Being rude or inconsiderate is a quick way to make enemies and it is sure to make your job harder.
World QBank (354 questions)- great questions- a must do!
Emma Rhamahis Review (http://som.uthscsa.edu/StudentAffairs/thirdyear.asp) is a great shelf exam review lecture

(video & slides). Hits a lot of high yield material. Recommend watching this lecture a day or two before the shelf exam
after you have covered all the material.
Case Files. Some love it; others hate it. Useful to read the cases related to assigned patients.
BluePrints is good for a quick overview of a topic you are unfamiliar with. However, it is much too superficial for what
you need to know for the shelf
32
Clinical Clerkship Survival Guide: Family Medicine

By Gerald Cheadle
Family Medicine
Family medicine provides continuous and comprehensive care to any patient, including chronic disease management, acute
health management, and preventive care. It is the primary resource patients will have for their everyday health. Mostly, Family
Medicine practices will manage hypertension, diabetes mellitus, COPD, hyperlipidemia and many will also cover pediatrics and
OBGYN care in rural areas. Health maintenance visits are common and include medication checks, screening tools, and
immunizations.
The clerkship is six weeks long, with two weeks at one of two clinics in Louisville (Cardinal Station or Newburg) and four weeks
at an AHEC (Area Health Education Center) rural site. Students may request AHEC sites, especially those from underserved parts
th
of the state, but there are no guarantees. On the Friday of the 6 week, students will take the 2.5-hour, 100-question Family
Medicine Shelf Exam.
Length of Rotation: 6 weeks (2 weeks in Louisville and 4 weeks AHEC)
Locations:
Cardinal Station Clinic
215 Central Avenue, Suite 100
Phone: 502-588-8720
Newburg Clinic
1941 Bishop Lane, Suite 900
Phone: 502-588-2500
Dept of Family and Geriatric Medicine

Suite 690, Rudd Heart and Lung Center
Med Center One

2nd Floor
501 E. Broadway
Bottigheimer Auditorium (Grand Rounds)

Ground Floor Jewish Hospital
Important Contacts:
Clerkship Director
Dr. Donna Roberts
Email: dmrob01@louisville.edu
Clerkship Coordinator
Anne Loop
Email: ajloop01@louisville.edu
Office: 502-852-5314
Fax: 502-852-7142 (for AHEC preceptor evaluations)
Department Chairman: Dr. Diane Harper, MD, MPH, MS
Residency Director: Dr. Jonathan Becker (Sports Medicine)
Didactics:
Orientation is the first day of your rotation, during which the Clerkship Coordinator and the Director will go over graded
assignments and schedules. This will be followed by a few lectures. Dress in SP attire with your white coat. After orientation,
some students will report to clinic and others will drive to their AHEC site. Always refer to the syllabus or schedule that is given
to you by the clerkship coordinator, as lectures are subject to change.
After week 2, there will be a quiz covering topics from assigned FMCases (from med-u.org) on that Friday. Lectures will follow
the quiz. After week 4, there will be another quiz covering the FMCases and more lectures. Check your schedule for the location
(Rudd Heart and Lung Center or Med Center One) and timing of the quizzes and lectures. Every student on AHEC will come back
for Friday lectures and quiz halfway through their 4-week rotation, leaving the site on Thursday.
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By Gerald Cheadle
FMCASES on Med-U.org: Online, interactive cases that can be accessed through med-u.org. You will need to register to gain
access. There will be several cases assigned throughout the rotation with two short quizzes on the Fridays of weeks 2 and 4. The
cases cover specific topics and do take time, so plan accordingly and study other materials.
Grand Rounds: Grand Rounds are held in the Bottigheimer Auditorium in Jewish Hospital at 7:30 AM. Students rotating at UofL
Sites are expected to attend, while students on AHEC will only attend Grand Rounds midway through their rotation, prior to
FMCase quizzes and lectures.
SP Encounter: There are two standardized patient cases (one is a phone case) that will help prepare you for the CSE-3 exam and
the Step 2 Clinical Skills (CS) exam. Following each of the patient encounters, you will write a note using the same template
utilized by the Step 2 CS exam. The encounters are pass/fail and give you time to work on managing a full H&P and writing a
SOAP note. This is an opportunity to get feedback and adjust your technique for Step 2 CS.
Assignments
Louisville Site: This rotation lasts 2 weeks (either the first two weeks or last two weeks). Students will complete this
rotation at either Cardinal Station or Newburg Clinic. During these two weeks, you will work directly with UofL Family
Medicine faculty and residents. You will rotate for a total of 11 half days over 2 weeks with weekends off. You will
mostly have half days, but some days will be full (you will get your schedule during orientation; everyones will be
different). Half days are either 8am-12pm or 1pm-5pm. During your rotation time, you will work with one specific
resident or attending each shift, scheduled ahead of time. You will need to have five of ten formative feedback cards
filled out by a resident or attending. These formative feedback cards are feedback on a specific part of your
performance (for example, a progress note, presentation skills, professionalism, etc.).
AHEC: This rotation is 4 weeks, and takes place at any of the affiliated AHEC locations across the state of Kentucky.
During 2nd year, there will be an AHEC fair during which you can get information about each regional location. At that
time, you will then fill out a fact sheet with your top 3 AHEC area choices. You will usually find out your rotation
location a few weeks before you begin the Family Medicine Clerkship, but this may vary. Once assigned, you will need
to email your preceptor and/or anyone else in his/her office that will help you set up living arrangements (you may
find your own or they may help
you).
If you have a particular location
and/or preceptor in mind,
particularly if you can provide your
own housing, it is important to
indicate those connections or
preferences on the fact sheet
mentioned above. You will be
reimbursed $480.00 if you will be
living at your AHEC rotation
location; if you are commuting, you
will not be reimbursed.
Often times if you are from a more
populous area in Kentucky
(Lexington, NKY, etc.), you will be
assigned to a more rural area across the state. There are always exceptions to this, and if there are special
circumstances in which you need to stay close to Louisville, the Clerkship Director will often work with you to find the
best AHEC match. Please note the Northeast AHEC is reserved only for students with special situations that require
him or her to remain close to home. The most common accepted reasons are having young children or a newborn and
pregnancy. Contact Dr. Roberts or Anne Loop if you feel you need to remain closer to home.
Community Service Project: This is a community project that you will complete while on your AHEC rotation. You
should discuss this with your AHEC preceptor when you arrive on the first day. After completion, you will write a
reflection paper that includes a description of the project, what happened during the project, the impact of the
project on the community, and how it may affect you in your future practice. The paper must be to one page in
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By Gerald Cheadle
length. The key is to decide on a project with your preceptor early on and make sure it is an acceptable project with
the Clerkship Director. The entirety of this project is very subjective, so dont stress too much; everyone is able to
complete the assignment and most find it rewarding as it is a unique way to learn more about the AHEC community.
Examples of previous projects include:
Home Visit with a physician or another health care provider
Scheduled activity with clients at a Senior Day Center
School presentation (does not include simple Q&A at your high school)
Jail or prison health care visit with health care provider, civic group presentation, substance abuse treatment
facility visit with health care provider
Hospice Home Visit with Hospice staff.

NOTE: Subject to change based on the syllabus that you are given at the start of the rotation
Points
Clinical Components
o Summative Evaluation from AHEC preceptor
320
o Mid-Clerkship assessments
15
o Formative feedback cards
5
o Summative evaluations from DFGM clinical
150
sites
o Chronic disease documentation sheet
20
Examination components
o Successful standardized patient exams
50
o Final written exam
300
o fmCases quiz
80
Additional components
o Service learning project
50
o Nutrition-FFQ
10
TOTAL
1000
Passing requires >70% of total points and >4th %ile on Shelf. Honors
requires >93% points and >75%ile on Shelf Exam. Specifics for Honors and
Passing are explained in orientation and in the syllabus.
Attire: SP attire (business casual) with white coat is expected every day. Scrubs are not worn on this rotation.
Commonly Asked Questions
AHEC: Many students from Kentucky who are not from Louisville like to go to areas closer to home. The Louisville
area and Northern Kentucky tend to be the most popular locations and are tough to get. Physician availability varies.
You can work with a family physician at a location you like, but it needs to be approved by the clerkship director. If
you are not from an underserved area, the clerkship coordinator will encourage you to go elsewhere.
Louisville clinics: The expectations at AHEC and the UofL Clinics vary. Some AHEC preceptors strictly have students
shadow them because they see many patients in one day and patient presentations need to be very quick. The UofL
clinics are teaching sites, allowing for more practice with independent history taking, presentation skill development,
and formative feedback. Some AHEC preceptors will want to know what your assessment and plan for a patient might
be, and some may not. However, at the UofL clinics, residents and attending physicians expect you to develop a
differential and potential plan for the patients you see. Its important to realize that the information used heavily in
clinic may not reflect equally on the Shelf exam. For example, knowing the screening guidelines and immunization
schedules are important for every patient you see in clinic, but there are few questions on this topic on the Shelf
exam. Make sure to be thorough in your studying as explained below.
Shelf exam: This is a very challenging Shelf exam, despite relatively light hours. There are not any specific UWorld
questions, which is a resource used for other clerkships. However, there are free questions available through
AAFP.org. The key is to identify the study resource you want to use and stick with it throughout the rotation (see
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By Gerald Cheadle
Common Study Resources). Getting through Case Files, Pretest, or Blueprints is much more high yield than going
through all of the FMCases.
Course requirements: There are many requirements for this rotation, so stay on top of your assignments. The
syllabus and orientation packet contain a detailed outline and schedule that will help you keep track of your progress
and missing assignments.
How to Shine:
Show a good work ethic and be a team player. Try to identify small tasks that make things run more smoothly for your resident
or attending; these can be as simple as having a chart pulled up or printing off a prescription for your patient. If they have more
time, they will be able to teach you more. Be efficient, but take your time with every patient you see, especially during this
rotation. Most of your interactions will be in an outpatient/clinic setting, where things typically run a little slower. Go through
the full history and physical and then take time to connect with your patient. Residents and attendings will notice when a
patient has had a good interaction with a student. Do your best to come up with an assessment and plan with at least three
differential diagnoses. This will show that you are thinking critically about the patient. This may be difficult at first, but
attendings and residents know this. If you make a good attempt and explain your thought process, they will take notice. If its
clear what might be wrong with a patient and isnt grave news, counsel them on what youre thinking. Residents and attendings
will appreciate this, especially if you give accurate counseling, as it expedites the visit. Practice makes this easier, but learning
about common presentations and appropriate diagnostics and presenting this information succinctly in regards to a specific
patient will make a great impression.
Dont complain about slow days or busy days. Residents and attendings are working longer hours than you. Be smart about
asking when your day is done. Sometimes things get busy and preceptors forget to dismiss you. Ask your residents if there is
anything else you can do to help; this is an innocuous way to remind them to dismiss you.
Common Study Resources: Try to identify one or two resources that work best for you and stick with them throughout the
clerkship. Combined with a good work ethic in the clinic, each of these resources should cover enough material to do well on
the Shelf exam. Also if Case Files or BluePrints worked for one rotation, its likely to work for this rotation. Generally students
say that the Family Medicine Shelf covers many of the same things seen on Step 1 with the addition of treatment options.
Case Files: 55 commonly tested cases on the shelf exam, with explanations of each case, other possible diagnoses and
important take home points. Each case is also followed by 3-6 multiple choice or matching questions with answers
and explanations that follow.
Blueprints: More of a text based format that reviews commonly tested topics in family medicine.
Pretest: 500 questions and explanations that review common family medicine topics. Do not get bogged down by
some of the more obscure specifics of some explanations.
Family Medicine Question Resources at AAFP.org: After going to the AAFP website, navigate to CME (link at top of
page) and under Find AAFP CME by Topic click on Board Review Preparation. Scroll to the bottom of the next
page and click on Board Review Questions, which will then require you to register. NOTE that this registration takes
time to approve, so register early in the rotation even if you dont plan to start doing questions until later. These
questions are a good review, but are meant for the Family Medicine Boards not the Shelf, so keep that in mind.
Step-Up to Medicine (Ambulatory Care section only): Approximately 80 pages that covers outpatient care, guidelines
to chronic diseases, and first and second-line treatment options for common diagnoses, such as hypertension,
hyperlipidemia, etc. Relatively quick read covers high-yield topics.
36
Clinical Clerkship Survival Guide: Psychiatry

By Kirk Akaydin
Psychiatry
Psychiatry is the field of medicine that focuses on treating diseases of dysfunction in cognition and behavior and their
associated pathology. This clerkship consists of treating patients of all ages, including children, with a wide variety of social and
medical backgrounds that may contribute to their diseases. You will learn to effectively utilize the mental status exam to
evaluate patients. Hours at the different sites vary, but students will always have weekends off. Common diagnoses include
anxiety disorders, mood disorders, PTSD, substance abuse, personality disorders, delirium, and dementia. The clerkship is 6
weeks and divided into 4 weeks at a primary site and 2 weeks at a secondary site, except for those at the VA. The various sites
are Emergency Psychiatry Services at ULH, Psychiatry Inpatient at ULH or Norton Hospital, Psychiatry Consult at ULH or Norton
Hospital, Child Psychiatry Inpatient at Norton Hospital, and Child Psychiatry Outpatient at the Bingham Clinic, and Psychiatry at
Veterans Affairs Medical Center.
Length of Rotation: 6 weeks (Primary site 4 week rotation and Secondary site - 2 week rotation)
Locations:
Emergency Psychiatry, ULH Inpatient, ULH Consult
University Hospital
530 S Jackson St
EPS 1st Floor
ULH Inpatient 5th Floor, East
Veterans Affairs Medical Center
800 Zorn Avenue
VAMC Psych 7N Floor
Norton Inpatient, Norton Consult, Child Psychiatry:

Norton Hospital
200 E Chestnut St
Norton Inpatient 6th Floor, East
Child Outpatient Bingham Clinic, 2nd Floor
Child Inpatient 6C Ackerly Unit
*Norton and ULH Consult work throughout the respective
hospitals and meeting location primarily depend on the
Attending Physicians and Residents.
Electroconvulsive therapy at St. Marys OP Surgery Center

(1 day experience)
4414 Churchman Avenue
Important Contacts:
Clerkship Director: Dr. Theodore Feldmann
(502) 852-5431 (Psych Med Ed Office)
Email: tbfeld01@louisville.edu
EPS Dr. Christina Terrell

Norton Consult Dr. Robert Friarson
VAMC Dr. Jennifer Bowman and Dr. David Howerton
Child Inpatient Psych Dr. Jennifer Le
Clerkship Coordinator: Miranda Sloan

(502) 852-5431 (Psych Med Ed Office)
Email: miranda.sloan@louisville.edu
Department Chair: Allan Tasman, MD
Residency Program Director: Sarah Johnson, MD
Didactics: All didactic lectures led by faculty occur on the first 3 days of the clerkship, and clinical rotations begin on the first
Wednesday morning, followed by the last lecture in the afternoon.
Professor Rounds: Wednesdays, 12:00 1:00PM
Students are scheduled to lead an interactive case presentation with a faculty member from 12:00 PM to 1:00 PM.
37

By Kirk Akaydin
Grand Rounds: Thursday, from 11:30-1 PM in the ACB auditorium, near the cafeteria.
Attendance is required, sign-in sheets are present, and food is not provided.
Assignments
All students are assigned to a primary site for 4 weeks followed by a secondary site for 2 weeks. The exceptions are: Emergency
Psychiatry Services, who will remain at EPS the entire 6 weeks with some half days at ULH Inpatient; Child Psychiatry, who will
spend three afternoons per week at the Bingham Outpatient clinic; and the VA, who spend the full 6 week at the VA hospital.
Furthermore, all students are required to take 3 EPS Call shifts from 5:30 to midnight, 2 nights of the weekday and one on the
weekend. Those assigned to EPS are required to take 2 night shifts on the weekend.
Emergency Psychiatry Services at ULH (6 weeks, half days at ULH Inpatient Psych)
Emergency Psychiatry Services is Monday through Friday from 8 AM to 5 PM. It is a separate part of the Emergency
st
Department at ULH located on the 1 floor and directly straight past the information desk at the main entrance of the
hospital. EPS is dedicated to evaluate patients who either volunteer themselves for psychiatric evaluation and
possible admission or are brought in by the police for mental illness or drug intoxication and the endangerment of
themselves or others. Patients may also be brought in on a Mental Inquest Warrant, which may be filed by anyone
(family, friend, or acquaintance), is approved by a judge, and legally requires a Psychiatrist to evaluate the patient
before they can be released from the hospital. Patients are often suicidal, severely addicted to drugs, or mentally
unstable.
The treatment team consists of an Attending Physician, a resident physician, a social worker, representatives from
local mental health services, and 1-2 students. Students are responsible for prescreening patients for past medical
history and medications and to assess for any acute issues that may need to be immediately addressed. Prescreen
forms will be available after the nurses and Physicians Assistant have entered the patients information into the Tsystem, which is the EMR for all emergency services and accessible to students assigned to the service. Prescreens
can be difficult as the patient may inappropriately respond or verbally aggressive. Stay close to the entrance of the
interview rooms, so if you feel threatened you can quickly and easily exit the room. After the prescreen, students
present the patients to the resident and/or attending with their potential assessment and plan, and the patient is
added to the list of patients to evaluate by the entire treatment team. After the evaluation, which may be led by a
student at the attendings suggestion, the team will decide to discharge, hold, or admit the patient, which requires a
physical examination performed by the students. EPS can be a very busy and exciting service with reactive or unstable
patients and requires students to maintain a certain degree of composure in possibly uncomfortable situations. You
will adequately learn how to diagnose patients as well as learn about local mental health services for patients. In
addition to EPS shifts, students will spend some half days on ULH Inpatient Psych, outlined in the schedule.
Veterans Affairs Medical Center (6 weeks)
VA Psychiatry consists of 5 weeks of inpatient psychiatry and 1 week of consult or substance abuse treatment. Hours
are generally Monday thru Friday 8 AM to 4:30 PM depending on the census. Students are expected to preround on
their patients and pick up new admits. While prerounding, it is important to find out about events overnight and the
clinical histories of newly admitted patients. You will have the opportunity to present your patient(s) to the treatment
team at 9 AM, so arrive early enough to allow yourself time to preround. The treatment team consists of the
Attending Physician, social workers, other patient advocates, and 2-3 students. Patients with updated treatment plans
may be interviewed and reevaluated. Afterwards, the team will round on the inpatient floor. Students will be
expected to write a SOAP note for their patients in the VA system, which will be cosigned by the Attending. Its
important to initiate the VA EMR process as soon as possible due to the slow turnaround and processing time. Each
Wednesday, there will be a Journal Club attending by Psych faculty and residents. Each student will present on a
preapproved topic for 30 minutes during one of the Journal Club meetings. The last week of the rotation can either be
spent working with the Physician Assistants taking Psych consults or you can opt to rotate in Substance Abuse
Treatment clinic. The VA does not have great parking space, so arriving before 7:45 AM you have a greater chance at
finding a parking spot near the VA. There is also a shuttle from the lot across from the Mellwood Arts Center. The VA
cafeteria does not have many options and there are not many lunch places nearby, so students are encouraged to
pack their own lunch, and they will have access to a fridge and microwave.
Child Psychiatry (6 weeks, 3 half days per week at Bingham Outpatient Clinic)
38

By Kirk Akaydin
Child Psychiatry has both an inpatient and outpatient clinic component. Inpatient-only days last from 8 AM to 3
th
PM and those days with outpatient last from 8 AM to 5 PM. The Inpatient floor is located on 6 Floor Ackerly Unit of
nd
Norton Hospital (6C) and the Bingham OP Clinic is located on the 2 floor of Norton Hospital. Students attend
th
morning rounds on the 6 floor, during which the night team passes off the patient list to the morning team, which
consists of Dr. Le, the attending, a fellow, a resident, social workers, therapists, and 2-3 students. During rounds,
students have the opportunity to provide input on the patients that theyve seen. There is no pre-rounding on
patients. Following rounds, students will see their current patients and write a progress note and pick up new admits
and write an H and P. Students can help by getting collateral information from family members and doing physical
rd
exams on the new admits. EMR is through EPIC, and all students will undergo EPIC training before 3 year. Notes for
Psychiatry are different than usual medical notes and the attending will provide a template. Following rounds,
students will have the opportunity to participate in daily activities with the children, including
art/theater/music therapy, group therapy with the chaplain, or attend family sessions with the social workers. There
are also special occasions, like zoo day when the zoo brings animals or dog therapy day. Rotations in outpatient clinic
is three days per week from 1 PM to 5 PM. Students work with one attending or fellow and are expected to see
patients with the physician and discuss the cases with them. They also have the opportunity to attend therapy
sessions as well. Dr. Lohr has Autism clinic that is a great experience for many students.
Norton Inpatient and Consult (4 weeks on Inpatient, 2 weeks on Consult, or vice versa)
Norton Inpatient may be the primary site and 4 weeks in length with Norton Consult as the secondary site and 2
weeks in length or vice versa. Norton Inpatient is on 6th Floor East and has 20 beds. Hours are from 8 AM to 3 PM, and
usually 2 students are on the service. Students are expected to preround on their patients before 8 AM and have
notes completed and signed by the attending at the end of the day. EMR is through EPIC. Students must also update
the med list, which shows the patients, respective diagnoses, and medications/allergies, and make copies for the
entire team by 8 AM. Morning conference is at 8 AM, during which the night nurses update the residents, attending,
and students on any overnight events. Residents also give patient updates with student input and treatment plans are
also determined during this time. Following morning conference, the team will round and students can work on their
notes. At the end of the day, students are expected to update the med list again and faxing it to EPS.
Norton Consult consists of evaluating patients that are admitted to medical or surgical floors for psychiatric illnesses,
commonly post-op delirium, dementia, or mood disorders. Hours are usually 8 AM to 4 PM. Students meet with the
residents in the Nortons Physician Lounge to split up the patient list. The lounge is on the 2nd floor of Nortons,
accessible without a badge ID via the library, which is down the left hallway near the parking garage at the top of the
escalators. From 8 AM to 12:55 PM, students will preround on the patients assigned to them and are expected to
present the patient on rounds. Consult notes will be written in EPIC and are expected to be signed by the end of the
day. Students and residents will reconvene in the doctors lounge at 12:55 PM to round with Dr. Frierson until 4 PM.
ULH Inpatient and Consult (4 weeks on Inpatient, 2 weeks on Consult, or vice versa)
Contributions by Kevin Murray
ULH Inpatient may be the primary site and 4 weeks in length with ULH Consult at the secondary site and 2 weeks in
th
length or vice versa. ULH Inpatient is on 5 Floor East and is a locked unit, requiring students to buzz in and out.
Hours are generally from 8 AM to 2 PM. Students are expected to preround on patients and have some of their
progress note (vitals, sleep hours, medications given, etc) completed in time for rounds at 8 AM. From 9 10 AM,
attendings, residents, nurses, social workers, and students meet to discuss care plans for each patient. Students are
expected to give input on their patients care. Afterwards, the team completes rounds and students may complete
their progress notes and have them reviewed by the residents. Students also write prescriptions for patients being
discharged and retrieve outside hospital records. Following a lunch break, students may interview and examine newly
admitted patients and write H&Ps and present the patients for feedback. Aside from learning about various psych
topics from residents, there are also group therapy sessions that students may participate in to understand various
treatment options. Dog therapy sessions are on Wednesday afternoons.
th
ULH Psych Consult office is on the 5 floor and hours are typically 8 AM to 4 PM. Students are expected to preround
on patients and have progress notes written and ready to present by 8 AM on rounds. Following rounds, students and
residents communicate with the primary team for new consults and interview patients. Students may write the H&P
and present the patient to the attending. Students are required to stay until 4 PM for new consults, but there is time
to study during downtime.
39

By Kirk Akaydin
Clinical Evaluations completed by Attending Physicians and Residents are worth 100/250 points
Reflective writing assignment (1-2 pages, double spaced) is worth 20/250 points
SP Exercise is worth 20/250 points
Interview evaluation form completed by Attending Physician or Resident is worth 10/250 points
NBME Shelf Exam is worth 100/250 points
th
Honors will be considered for >75 percentile on the shelf exam and 90% clinical grade.
Pass will be given with a minimum of 70% on clinical evaluations and >4th percentile on the shelf exam.
Attire
All services recommend against neckties, necklaces, and other low hanging jewelry for safety reasons
EPS Scrubs and white coat are acceptable
Other services Clinic attire and white coat
How to Shine
The first step to doing well on any rotation is to understand how you fit into the treatment team and knowing the expectations
from your Attending and Resident physicians. This will allow you to be more proactive in your learning as well as assist the
team. Sensitivity and empathy go a long way when interacting with a patient, and understanding patient cues will help you
gather information that other people may not, residents and attendings included. Especially on Psychiatry, there is a chance
that patients will be poor historians, so getting corroborating information from family members or medication lists from their
pharmacy can help build a more accurate history. On the other hand, recognizing that patients may be more honest without
family in the room will also help you learn more about them. Arrive early when prerounding on a patient and realize that you
may be the one person on the medical team that they talk to the most, so be vocal during rounds and provide your own
assessment and plan during your presentation. Show your enthusiasm by volunteering to see consults, doing prescreens, calling
outside hospitals or pharmacies, and other tasks that improve the teams efficiency.
UWorld QBANK (150 Questions)
Case Files (60 cases and in-depth review)
First Aid for Psychiatry Clerkship is well organized review of all tested topics, including mental status exam
Emma Holliday Ramahis Review http://som.uthscsa.edu/StudentAffairs/thirdyear.asp
40
Clinical Clerkship Survival Guide: Values, Calculations, and Commonly Asked Topics
Values, Calculations, and Commonly Asked Topics

General Surgery
The 7 Tubes of Surgery
2 Peripheral IVs
2 Chest tubes
1 Endotrachial tube
1 Nasogastric tube
1 Foley catheter
Burns: Estimating the Total Body Surface Area (TBSA) The rule of 9s
Head 9%
Upper extremity 9%
Lower Extremity 18%
Trunk (front) 18%
Back 18%
Palm 1%
Burns: Fluid Resuscitation
Ringers Lactate 2-4 cc x Body Weight (kg) x TBSA Burn
Give of this in the first 8 hours

Glasgow Coma Scale (GCS)
Internal Medicine
SIRS Two or more of the following:
Temp > 38C or <36C
Respiratory Rate > 20 breaths/min or PCO2 < 32 mm Hg
WBC > 12,000 or <4,000 or >10% bands
Heart Rate > 90 bpm

Sepsis SIRS plus a source (i.e. pneumonia or open wound)
Severe Sepsis Sepsis plus end organ damage (acute kidney injury plus sepsis)
Septic Shock Sepsis plus hypotension.
Acute Respiratory Failure One of the following:
pO2 < 60 mm Hg
pCO2 < 50 mm Hg and pH >7.35
P/F ratio (pO2/FIO2) <300
pO2 decrease or pCO2 increase by 10 mm Hg from baseline (takeaway point check baselines when possible
especially if the patient has known COPD!)
Next are the lab values, specifically. You much know and interpret when electrolytes are low and how to correct them.
Na Complex workup involved for both hypo- and hypernatremia. Step-up or Pocket medicine have good algorithms.
Know this is a WATER problem, not an issue of too much or too little sodium.
Do not correct Na faster that 12 meq/24 hrs or risk neurological damage

K Potassium levels are very important and differ if they are high or low.
Hypokalemia
K <3.5, though symptoms do not begin until <3.0.
Symptoms include:
o arrhythmias,
o muscular weakness and cramps,
41
o decreased deep tendon reflexes,
o polyuria, polydipsia
o ,nausea and vomiting.
Replacement treatment
o K should be replaced orally with 10 mEq of KCl increasing K levels by 0.1 mEq/L.
o IV can be used in severe (K < 2.5) or patients unable to take oral KCl. Maximum infusion rate is 10
mEq/hour in peripheral line or 20 mEq/hour in a central line.
Patients commonly complain of pain during infusion, so it the less preferred method.
Hyperkalemia is
Refers to a K > 5
Symptoms include:
o Arrhythmia: look for peaked T waves, QRS widening, PR interval prolongation, loss of P waves
on ECG
o Muscle weakness and (rarely) flaccid paralysis
o Decreased deep tendon reflexes
o Respiratory failure
o Nausea/vomiting, intestinal colic, diarrhea
Treatment
o First therapy is IV calcium gluconate to stabilize myocardial membrane potential, thus
reducing the likelihood of arrhythmia.
o Glucose and insulin can also be administered for immediate treatment
o Kayexelate can also be used to reduce K but its much slower acting
o Hemodialysis remains the most effective and rapid way to lower K. Usually only seen in
patient with extreme renal failure.
Ca Correct your Ca for albumin [0.8x(4-Alb)]+Ca= Corrected Ca level
BUN/Cr: Used primarily as a measure of kidney function
Acute Kidney Injury Determined by the RIFLE criteria
Risk: 1.5 increase in serum creatinine or GFR by 25% or urine output of <0.5 mL/kg/hour for 6 hours
Injury: Two fold increase in serum creatinine or GFR decrease by 50% or urine output of <0.5 mL/kg/hour
for 12 hours
Failure: Three fold increase in serum creatinine or GFR decrease by 75% or urine output of <0.5 mL/kg/hour
for 24 hours or anuria for 12 hours
Loss: complete loss of kidney function for greater than 4 weeks
ESRD: Complete loss of kidney function for more than 3 months
Prerenal failure
Most common Cause of AKI is a decrease in systemic arterial blood volume or renal perfusion
Etiologies: CHF, Hypovolemia, Hypotension, Renal arterial obstruction,
Lab findings:
o BUN/Cr >20:1
o Increased urine osmolality (>500 mOsm/kg)
o Decreased urine Na (<20 with FENa <1%)
o Hyaline Casts
Renal Failure
Kidney tissue is damaged resulting in an inability to concentrate urine
Etiologies: Acute Tubular Necrosis, Glomerular disease, Vascular disease, Acute Interstitial Nephritis
Lab Findings
o BUN/Cr <20:1, closer to 10:1
o Increased urine Na (>40 mEq/L with FENa >2% to 3%)
o Decreased urine osmolality (<350 mOsm/kg)
o Abnormal UA with different sediment depending on etiology
Postrenal Failure
Least common cause of AKI result of downstream occlusion of urine flow
Etiology: Urethral obstruction (BPH), Nephrolithiasis, Obstructing Neoplasm, Retroperitoneal fibrosis
Can appear to look like ATN if obstruction persists.
Bicarb: Acid-base returns! You need an ABG to accurately determine whether there is an actual acid base disturbance
(no pH otherwise!). If there is an anion gap metabolic acidosis remember A CAT MUDPILES!
42
Hgb/Hct: Usually in a 1:3 ratio.

The normal value for Hgb is above 13.5 g/dL in men and 12 g/dL in women. This correlates to a Hct >41 in
men and Hct >36.0 in women.
o A patient with lower values is considered anemic.
Severe anemia requiring transfusion occurs at Hgb~7-8.
Transfusion in acute bleeding/surgery should occur at Hgb <10.
1U pRBC = increase of 1 Hgb/3Hct.
Glucose: Know the last 3 glucose readings.
SSI is a bad way to manage diabetes, so always find out home insulin requirements if possible.
If blood sugar appears poorly controlled in a long-term patient on SSI, calculate total insulin requirement
based on what was given for a single day in the hospital and use half that dose of a long acting insulin
qhs (at night).
Example algorithm for care of diabetes in an non-acute setting:
43
Many internal medicine physicians use scores to determine the severity of a given disease. You should know the components of
these scores and use a calculator to determine them when on rounds. High yield examples include:
Pneumonia: CURB-65 or Pneumonia Severity Index
Pleural Effusion: Lights Criteria determines exudate vs. transudate

Pleural Fluid is exudate if:
o Protein level in pleural fluid divided by level in serum is less than 0.5
o Lactate dehydrogenase level in pleural fluid divided by level in serum is greater than 0.6
o Lactate dehydrogenase level in pleural fluid is more than two-thirds the upper limit of the normal
level in serum
Pancreatitis: Ransons Criteria or Apache-II (FYI if you have Dr. Moffet he will tell you Ransons criteria does NOT
predict mortality despite what books will say).
Ransons Criteria
Present on Admission
Developing During the First 48 Hours
Age > 55 years
Hematocrit fail > 10%
WBC > 16,000
BUN increase > 8 mg/dL
Blood glucose > 200 mg/mL
Serum calcium < 8 mg/dl
Serum LDH > 350 I.U./L
Arterial oxygen saturation < 60 mm Hg
SGOT (AST) > 250 I.U./L
Base deficit > 4 mEg/L
Estimated fluid sequestration > 600 mL
Score of 0-2: Minimal mortality
Score of 3-5: 10% - 20%
Score > 5: more than 50% mortality with more systemic complications
Pulmonary Embolism Wells score
Variable
Clinical Signs and symptoms of DVT
An alternative diagnosis is less likely than PE
HR > 100 beats per minute
Immobilization or surgery in previous 4 weeks
Previous DVT/PE
Hemoptysis
Points
3.0
3.0
1.5
1.5
1.5
1.0
44
Malignancy (on treatment or treated in last 6 months)
Score
<2 points
2-6 points
> 6 points
1.0
Category
Low probability
Moderate probability
High Probabiliyt
Risk of stroke in 1st 2 days post TIA: ABCD2

Criteria
Age: greater that or equal to 60 (1 pt)
Blood Pressure: SBP > 140 or DBP > 90 (1pt)
Clinical Features: Focal Weakness (2 pts) or speech impairment (1 pt)
Duration of symptoms: > 60 minutes (2 pts) or < 59 minutes (1 pt)
Diabetes (1 pts)
Risk of CVA in first two days following TIA:
0-3 = 1% risk
4-5 = 4.1% risk
6-7 = 8.1% risk

Risk of stroke in pts with afib CHADS2 score determines anticoagulation needs
Variable
Points
Previous Stroke or TIA
2.0
Age > or = 75 years
1.0
Hypertension
1.5
Diabetes mellitus
1.5
Heart Failure
1.5
Score
0
1 points
> 6 points
Stroke Risk
Low probability
Moderate Probability
High Probabiliy
Therapy
Aspirin
Warfarin or Aspirin
Warfarin (INR 2-3)
Neurology
Steps of the Neuro Exam: Be sure to follow this same sequence EVERY time you perform the neuro examit will help you learn
it and will also serve as the order in which you present your patients neuro exam findings during oral presentations.
1. Mental Status Exam can be as simple as orientation to person/place/time or as involved as the Mini Mental Status Exam
it all depends on the intention and relevance of this exam for your patient. Overall, you will test orientation (person, place,
date), registration (naming an object, repeating), attention and calculation (WORLD backwards), Recall, and Language (No ifs,
ands, or buts, following commands)
Link for MMSE - http://www.mountsinai.on.ca/care/psych/on-call-resources/on-call-resources/mmse.pdf
2. Cranial Nerves:
Link for Cranial Nerve Exam: https://www.youtube.com/watch?v=G6FZR64Cq9U
CN I
Olfactory Nerves
Smell: Not commonly tested
CN II
Optic Nerve
Vision: Test visual acuity with Snellen chart, visual field by holding up
numbers or wiggling fingers
CN III
Oculomotor Nerve
Eye Movement: Pupillary light reflex (CN II and III)
CN IV
Trochlear Nerve
Eye Movement: make The Big H with their eyes following your finger to
test the Superior Oblique muscle
CN V
Trigeminal Nerve
Facial Sensation: Test facial sensation in the distribution of the three
branches of CN V
CN VI
Abducens Nerve
Eye Movement: Make The Big H with their eyes following your finger to
test the Lateral Rectus muscle
CN VII Facial Nerve
Facial expression: Test for symmetric facial expression
CN
Vestibulocochlear Nerve
Hearing: Test hearing by rubbing fingers together close to the outer ear
45
VIII
CN IX
Glossopharyngeal Nerve
CN X
CN XI
Vagus Nerve
Accessory Nerve
CN XII
Hypoglossal Nerve
with eyes closed. Sensorineural vs. conductive hearing loss can be tested
using tuning fork (Weber/Rinne)
Oral sensation, taste, and salivation: Check for symmetric palate elevation
(both CN IX, X)
Check for symmetric palate elevation (both CN IX, X)
Shoulder elevation and head turning: Test shoulder shrug and head turning
for symmetrical strength
Tongue movement: Check for atrophy & deviation of tongue to one side
3. Motor Exam test for symmetrical strength in each joint of the upper and lower extremities
*5/5 normal strength
*4/5 movement against some resistance
*3/5 movement against gravity
*2/5 movement possible but not against gravity
*1/5 muscle contraction but no movement
*0/5 no muscle contraction
4. Reflexes test triceps, biceps, brachioradialis, patella, and Achilles
+4 markedly hyperactive with clonus
+3 increased but normal
+2 normal
+1 present with reinforcement
+0 absent
5. Sensory Exam test fine touch, pain/temp, and position sense in upper and lower extremities
6. Coordination and Gait
*Assess rapid alternating movements, finger-to-nose, and heel-to-shin
*Observe patient as he/she walks normally, on their toes, and on their heels

Gs and Ps for OB patients. G stands for gravida and is the number of times a woman has been pregnant. This includes stillbirths
and abortions. Thus a woman who has delivered twins, is currently not pregnant, and otherwise never been pregnant is a G1. P
stands for para. This can be reported in two formats. The extended format of TPAL stands for Term deliveries, Preterm
deliveries, Abortus (includes spontaneous and induced), and Living Children. If the woman with twins had them prematurely,
she would be a G1P0102. The abbreviated P sums term, premature, and abortus deliveries. A pregnant woman who has had
one previous delivery would be a G2P1. Abbreviations are commonly used. Try to keep up with the terminology so that you can
communicate effectively.
Review pelvic anatomy and relations of structures. The structural, vascular, and nervous support to the female reproductive
tract and relation to abdominal structures are very important to know during surgeries. Learning the physiology of pregnancy as
well as the potential complications and pathophysiology is very important. The screenings and recommendations for pregnant
patients at various gestational ages are also important and can be found on pregnancy wheels provided by the department or
available on a smart phone.
When studying for the shelf, learn management principles. Recognizing the pathology is important, but the exam will often ask
what is the next step in treatment. Keep in mind that the time you spend on a rotation may not be equally reflected by the
shelf, so be sure to also study the subjects outside your rotation.
Pediatrics
CDC Pediatric Developmental Milestones: http://www.cdc.gov/ncbddd/actearly/milestones/

Epocrates smartphone app is highly recommended for dosing, interactions, mechanism of action, and includes useful
calculators (i.e. BMI, pediatric maintenance fluids).
Medscape provides brief approaches to diseases and treatments.
UpToDate can provide detailed evidence based medicine. (Various EBM tools will be presented at orientation).
Immunization schedule are on Maxwells Reference. Asthma severity charts can also help and are attached.
46
Pediatric Maintenance fluids:

Weight
mL/kg/h
First 10 kg
Second 10 kg
Each additional kg
Ex: 25 kg
4(10) + 2(10) + 1(5) = 65 mL/hr
Ex: 17 kg
4(10) + 2(7) = 54 mL/hr
Normal Heart Rate

Newborn
93-154
1-2 mo
121-179
1-2 yo
89-151
5-7 yo
65-133
Teen
60-120
Normal Respiratory Rate
Newborn
40-60
1-2 yo
22-30
4-5 yo
20-24
Teen
12-20
Normal Blood Pressure (based on age and height)
1 yo
<104/56
3 yo
<105/63
7 yo
<112/72
16 yo
<126/80
Psychiatry
Know the components of the mental status exam, as this is important in interviewing patients.
Understand the AXIS system and review the diagnostic criteria for mood disorders (depressive disorder, anxiety disorder,
bipolar disorder), schizophrenia, personality disorders, and dementia vs. delirium are commonly asked topics.
When interviewing patients, make sure to ask about suicidal and homicidal ideation (if they have a plan or a weapon), learn
to ask for a comprehensive substance abuse history (when did they last use a substance, specific amount of substance, how
long theyve used a drug, difficulty quitting), obtain a thorough social history (support system, risky behavior). Many of
these topics can be sensitive and difficult to talk about but they are important in the treatment of patients.
Psychiatry involves various medications and side effects, so be sure to know the different generic and brand names of
benzodiazepines, 1st gen and 2nd gen antipsychotics, and antidepressants.
When studying for the shelf, learn management principles. Recognizing disease is important, but the exam will often ask
what is the next step in treatment. Keep in mind that the pathology you see on a rotation may not be equally reflected by
the topics on the shelf, so be sure to study the other topics in psychiatry.
47
Clinical Clerkship Survival Guide: Example Notes and Oral Presentations
Example Notes and Oral Presentations

General Surgery
History and Physical Example
HPI: Patient is a 45 yo lady (always use gentleman or lady) who presents to the ED with a 4-day history of abdominal bloating
accompanied by abdominal pain, obstipation, nausea, and vomiting. She describes her abdominal pain as diffuse and says the
quality alternates between dull and sharp. She began experiencing NV yesterday and has had 3 episodes of non-bloody, bilious
emesis in the last 24 hours. She is unable to take anything by mouth, as this aggravates her symptoms. Patients last BM was 5
days ago, and has not experienced flatulence since then. She denies fever, fatigue, weight loss, or diarrhea.
PMH: Significant for HTN. Denies history of GERD, gallbladder disease, inflammatory bowel disease, colon cancer.
PSH: Tonsillectomy at age 6, Appendectomy at age 24.
Allergies: Penicillin
Meds: Lisinopril
Family History: Father died of MI at age 64. Mother has history of HTN, T2DM. No family history of gallbladder disease, IBD,
colon cancer.
Social History: Works as a sales associate. Lives at home with her husband. No smoking history. Drinks one glass of wine per
week.
ROS:
Constitutional No fever, fatigue, weight loss
Skin No rashes, jaundice
HEENT No HA, dizziness, vision changes, hearing loss, tinnitus, rhinorrhea, mouth sores, pharyngitis
Resp No dyspnea, cough, chest pain
CV No angina, palpitations
GI As stated in HPI
GU No changes in urinary frequency, dysuria, hematuria
Endocrine No DM, thyroid disease
Physical Exam:
Vitals T: 99.0F HR: 89 RR: 16 BP: 134/86 O2: 99%
GEN Overweight female, mildly distressed, AOx4
HEENT EOMI, PERRLA, no icterus, mucous membranes dry, no LAD
CV RRR, S1 and S2 heard, no murmurs
LUNGS CTAB, no crackles or wheezes
ABD Significant distention, old appendectomy scar present, absent bowel sounds, diffuse tenderness to light
palpation, no peritoneal signs, no hepatomegaly or splenomegaly, no hernia
EXT No jaundice, erythema, edema
Assessment/Plan:
1. Abdominal distention/pain
-DDx of mechanical small bowel obstruction vs large bowel obstruction due to colonic neoplasm vs gallstone ileus vs
incarcerated hernia
-Clinical presentation along with PSH of appendectomy supports small bowel obstruction due to adhesions
-Absence of colon cancer in family history, plus absence of constitutional symptoms does not support large bowel
obstruction due to colonic neoplasm
-Absence of diarrhea or fever and no PMH of IBD does not support IBD.
-Absence of history of gallbladder disease does not support gallstone ileus
-Absence of hernia on physical exam does not support incarcerated hernia
-Establish IV access, begin Ringers Lactate and LMWH
-Insert NG tube and put to suction
-CBC and CMP
-Abdominal XR
-If XR suggestive of SBO, will likely send to OR for exploratory laparotomy
Oral Presentation example for above H&P
The patient is a 45 yo lady with a 4-day history of abdominal bloating accompanied by diffuse abdominal pain, obstipation,
nausea, and bilious emesis. She denies fever, fatigue, weight loss, or diarrhea. Her last BM was 5 days ago. She is unable to take
anything by mouth as this exacerbates her symptoms. Her PMH is remarkable for HTN for which she is taking lisinopril. She has
48

no history of GERD, gallbladder disease, inflammatory bowel disease, or colon cancer. Her past surgical history is remarkable for
appendectomy at age 24. No family history of gallbladder disease, IBD, or colon cancer. ROS is negative. Vitals are normal.
Physical exam is remarkable for appendectomy scar, abdominal distention, diffuse abdominal tenderness on light palpation,
and absent bowel sounds. My assessment includes a differential diagnosis of SBO due to adhesions vs obstruction due to
colonic neoplasm vs IBD vs gallstone ileus vs incarcerated hernia. SBO is the most suggestive diagnosis given the clinical
presentation and PSH of appendectomy.
Lack of constitutional symptoms nor family history of colon cancer does not support colonic neoplasm, absence of diarrhea
does not suggest IBD, absence of gallbladder disease does not support gallstone ileus, absence of hernia on physical exam does
not support incarcerated hernia. My plan is to begin Ringers Lactate and LMWH, insert an NG tube and set to suction, obtain a
CBC and CMP, and get an abdominal XR. If XR is suggestive of SBO, plan to go to the OR for exploratory laparotomy.
Progress Note Example (SOAP Format)
S: Patient is 45 yo lady, HD#2, POD #1 for ex-lap with small bowel resection and lysis of adhesions for SBO. No overnight events.
Some abdominal pain, but reports pain meds provide relief. Sleeping comfortably. Currently on Norco PRN. Remains NPO. No
N/V. No flatulence or BM. Not ambulating.
O: Tmax: 98.9 HR: 78 RR:18 BP: 128/74 O2: 98%
UO: 600/600/NR
NG: 450 cc/220 cc/NR
Labs:
136 98 16
98
4.3
26
0.8
9.4
12.4
176
37.2
Physical Exam:
GEN NAD, sitting up in bed.
HEENT NG tube in place and to suction. Bilious content in container.
CV RRR
LUNGS CTAB
ABD Mildly distended, appropriate tenderness near incision site. Incision is clean, dry, and non-erythematous. 1-2 cc
of serosanguinous drainage on 4x4 dressing.
EXT: Peripheral IV in place, SVTs in place
A: Post-op day 1 for ex-lap with SBR for SBO.
P:
1. Post-op for SBR Await bowel function. Continue maintenance fluids. Remain NPO. Keep NG to suction. ABD XR
tomorrow morning.
2. Pain Continue Norco PRN.
3. DVT prophylaxis Continue LMWH and SVTs. Have patient OOB and ambulating today.
Oral Presentation for above Progress Note
Patient is 45 yo lady, HD#2, POD #1 ex-lap with SBR and LOA for SBO. No events overnight. Pain is well controlled with Norco.
Currently NPO. No N/V. No flatulence or BM. Has not ambulated since surgery.
Vitals are normal and stable. UO was 600, 600, not recorded over the past 24 hours. NG tube output was 450, 220, not
recorded and bilious in color. Physical exam was benign except for a mildly distended abdomen. Incision was clean and dry.
Assessment is patient is post-op day 1 for small bowel resection for small bowel obstruction, doing well since surgery.
Plan is to await bowel function continue maintenance fluids and LMWH, remain NPO, and keep NG to suction. Encourage
ambulation today. ABD XR tomorrow morning.
Internal Medicine
History and Physical Example
HPI: Mr. Smith is a 65 y/o M with past medical history of atrial fibrillation who presents to the emergency department with a
two-week history of progressive shortness of air and chest palpitations. The patient noted his difficultly breathing has now
worsened to the point he cannot climb a flight of stairs without needing to sit. In the past few days, he also recalled being
awoken from sleep, gasping for air and has noticed that his shoes no longer fit. Today the shortness of air was accompanied
with a feeling like my heart was going to beat out of my chest.
49

Currently, the patient has difficultly breathing at rest with a continued rapid heart rate. He says he must sit up to breath
effectively but denies any dizziness, fever or chest pain. He has never had symptoms like these before but states that he had a
myocardial infarction five years ago, from which he recovered completely, though during a follow up he was diagnosed with
new onset atrial fibrillation for which he is currently taking metoprolol. He denies any recent illnesses,
ROS: General: does not have fever, chills or fatique
Eyes: Does not have vision changes, diplopia, or floaters
Cardiac: has paranoctural dyspnea; has orthopnea, does not have chest pain
Pulm: has dypnea, cough. No hemoptysis
GI: Does not have nausea, vomiting or diarrhea
GU: Does not have dysuria or hematuria
Skin: Does not have rashes or ulcers present at admission
Extremities: Has edema
Neuro: Does not have numbness, tingling or weaknes
Musculoskeletal: Does not have joint pain
All other systems reviewed and are negative.
Past Medical History: MI five years prior; atrial fibrillation diagnosed four years ago; insulin dependent type II diabetes
Past Surgical History: Appendectomy at 20.
Family History: Father died of MI at age 68; Diabetes (Mother).
Social History: Smoker for 30 pack/years; quit 15 years ago; denies EtOH, illicit drugs; Lives at home with wife.
Current Medications: Metoprolol 50 mg BID, Atorvastatin 40 mg PO daily, Aspirin 81 mg PO daily
Allergies: Penicillin (broke out in a rash)
Vital Signs: HR: 134
RR: 15
BP: 146/86
T: 98.2
Pox: 90%
PE: General: In distress, laboring to breathe; A/O X 3

HEENT: EOMI, PERRLA, No LAD, Neck supple; JVD present
Pulm: Crackles bilaterally; Dull to percussion on right side; No tactile fremitus
Card: Fast, irregularly irregular rhythm. Normal S1,S2 with S3 present.
GI: 2+ Bowl sounds; NT, ND.
Skin: No rash, petechiae or ecchymosis. 2+ edema in legs bilaterally.
Neuro: CN II-XII intact; no motor or sensory weakness on examination.
Lab values:
144
103
13
4.4
27
1.1
213
6.5
12.3*
224
36.9
AST
ALT
Alk Phos
Ca
Albumin
31
17
100
8.9
3.7
Total
Protein
7.6
Pro BNP
Troponins
11000*
0.0712*
Diagnostic Tests
ECG: Shows atrial fibrillation with rapid ventricular rate of 126. Q waves in left lateral leads, with no ST depression or
elevation.
Chest X-ray: Bilateral plural effusions, much larger on the right side.
Assessment and Plan: Mr Smith is 65 yo M who presents with progressive shortness of breath over two weeks duration with
new onset of chest palpitations. On chest x-ray he was found to have evidence of bilateral plural effusions, much larger on the
right side.
Shortness of Breath: Ddx includes: new onset congestive heart failure, myocardial infarction, anemia, pneumonia, COPD
Congestive heart failure Most likely due progressive course with history of heart disease and bilateral
50

plural effusions in the absence of fever or chest pain.
unlikely due to normal ECG and clinical course. Mildly elevated troponins can
occur in CHF
Anemia
Patient hemoglobin slightly low but not exceptionally low enough to cause the
clinical symptoms described.
Pneumonia
No fever or leukocytosis make this less likely
COPD
Patient has normal breath sounds, but does have a positive history of smoking
and difficulty breathing
Order an Echo to assess for heart function
Continue monitoring troponins to trend levels
Add lasix 40 mg BID to diuresis plural effusion
No indication for thoracentesis at this time.

Afib with rapid ventricular rate (RVR)
Increase metoprolol to 100 mg BID.
Monitor with telemetry
Start enoxaparin discuss restarting of warfarin while in the hospital

Diabetes - Patient has a history of type-II diabetes not currently treated with medication. Glucose was elevated to 213 on
presentation
Begin SSI and continue to monitor blood glucose.

Myocardial infarction

Mr. Smith is a 65 yo M with a history of MI and afib presents to the emergency department with a two week history of
progressive shortness of breath with recent onset of chest palpitations but no associated chest pain. On presentation, he said
the symptoms began last week and now he has unable to walk up the stairs. He notes orthopnea and paroxysmal nocturnal
dyspnea that have worsened over the past two weeks. He denies any fevers, chills, dizziness or nausea and vomiting associated
with these symptoms.
His past medical history is also significant for type-2 diabetes that has been managed by diet. His MI occurred five years ago and
his afib was diagnosed shortly thereafter at a follow-up appointment for which he has received metoprolol 50 mg BID. Other
medications include Atorvastatin 40 mg PO daily and Aspirin 81 mg PO daily. He has never been on anticoagulation for his afib
due to fears of bleeding. He was a previous smoker for 30 pack years before quitting 15 years ago, but denied alcohol or illicit
drug use. His only known allergy is penicillin.
On physical examination, his was dyspneic and in distress. His HEENT examination was significant for moderate JVD. His cardiac
examination was significant for an irregularly irregular rhythm with rapid rate and an S3. Examination of his lungs showed
crackles bilaterally with reduced breath sounds, dullness to percussion and decreased tactile fremitus on the lower right. His
abdomen was non-tender and non-distended with normal bowel sounds, while his skin examination was significant for 1+
edema in his legs bilaterally.
Vital Signs were significant for tachycardia at 134 with a normal respiratory rate at 15. He was afebrile with a temperature of
98.2 and had a slightly elevated blood pressure of 146/86. For lab values, his electrolytes were within normal limits, though his
glucose was elevated at 213. His white count was not elevated at 6.5, though his hemoglobin was mildly depressed at 12.3. His
troponins were mildly elevated on presentation at 0.06 and his Pro-BNP was elevated at 11,000. Studies done on the
emergency department included an ECG, which showed afib with rapid ventricular rate of 126 and a chest x-ray that
demonstrated bilaterally plural effusions, much larger on the right.
In summary, Mr. Smith a 65 yo M with past medical history of MI and afib presenting with two weeks course of progressive
dyspnea and afib with rapid ventricular rate. The differential diagnosis for his dyspnea includes new onset heart failure,
myocardial infarction, anemia, and COPD. At this time, his subacute course of development, lack of chest pain, and normal ECG
with a chest X-ray showing bilateral pleural effusions make new onset heart failure most likely. I want order an echocardiogram
and begin him on lasix 40 mg BID for diuresis of his plural effusion before considering thoracentesis. Because his troponins were
elevated on presentation, we should continue to monitor them q6h until return to normal. For his afib with RVR we should
increased his metoprolol to 100 mg BID and monitor on telemetry. Finally, for his diabetes we should begin glucose checks with
sliding scale insulin while in the hospital.
This presentation can change dramatically depending on attending preference. In general, try to be succinct but through as
possible. Some attendings will require you to read all lab values while some only want pertinent positives or negatives, but the
important point is to interpret what you are given, not just to read numbers from a page. Also, be careful with stating physical
exam findings are normal. Since you are a medical student, they may ask you to expand upon that so be prepared to say
exactly what you mean by normal.
51

Progress Note Example (SOAP Format) After three days in the hospital
S: Pt is 60 yo M HD #3 with h/o MI and afib presented with shortness of air and afib with RVR >120 now suffering from new
onset systolic heart failure. Thoracentesis was performed yesterday for removal a residual right-sided plural effusion,
evacuating approximately 10mL of clear fluid.
Today, pt is feeling better, reporting improved breathing with some shortness of air only on exertion and less overall malaise.
He denies fever, dizziness and chest pain. He states he talked with cardiology yesterday and understands he will need medical
management for his new-onset heart failure.
O: Vital Signs: HR 90
RR: 14
BP: 136/82
T: 98.7
Pox: 94%
PE: General: NAD; A/O X 3

HEENT: EOMI, PERRLA, No LAD, Neck supple
Pulm: Diminished crackles bilaterally,
Card: Irregularly irregular rhythm. Normal S1,S2 with S3 present.
GI: 2+ Bowl sounds; NT, ND.
Skin: No rash, petechiae or ecchymosis. 1+ edema in legs bilaterally.
Neuro: CN II-XII grossly intact with no focal deficits on exam; no motor or sensory weakness on examination.
Medications: Metoprolol 100 mg BID; Aspirin 81 mg PO daily, Atorvastatin 40 mg PO daily, Enoxaparin, Furosemide 40 mg BID
Lab values:
141
96
20
4.1
29
1.2
103
7.3
11.7*
35.1
206
Serum LDH: 626

Serum Prot: 7.7
Plural LDH: 284
Plural Prot: 3.3
Diagnostic Tests:
Echocardiogram (Two days prior): Ejection fraction of 35% with no diastolic dysfunction.
Thoracentesis results: 1200 cc of straw colored fluid was removed; Protein ratio of 0.42 and LDH ratio of 0.45
A/P: Pt is 65 yo M with history of MI and afib presents with new onset systolic heart failure resulting in progressive dypnea and
afib with RVR.
1)
2)
3)
4)
New onset systolic HF - Echo showed EF of 35%. Clinical presentation consistent with new onset systolic heart failure
resulting in dyspnea.
Lower Furosemide to 20 mg BID; add ACE inhibitor

Afib with RVR - Well controlled with rates 80-90 on telemetry
Continue metoprolol 100 mg BID
CHA2DS2-VASc score of 4 indicates need to begin warfarin therapy wth goal INR of 2-3.
Right-sided plural effusion - 1200 cc of straw colored fluid was removed with Protein ratio of 0.42 and LDH ratio of
0.45. Consistent with transudate per Lights criteria and clinical presentation of heart failure
Monitor cultures for bacterial growth

Diabetes - Pt glucose well controlled on SSI during inpatient stay with glucose at 106 this morning. Continue SSI for
remainder of hospitalization.
Oral Presentation for above Progress Note:

Mr. Smith is the 65 y/o M with new onset heart failure and afib with RVR. Yesterday he had his thoracentesis and
today he is feeling much better with reduced dyspnea and overall malaise. He has denied any fevers or chest pain.
Vital Signs are within normal limits with his telemetry showing rates of 80-90 overnight. His electrolytes are also
within normal limits and his latest glucose readings have been 136, 109, and 106 respectively. His hemoglobin remains mildly
decreased at 11.7, with the remainder of his CBC unremarkable. Preliminary lab work up of his plural fluid shows protein ratio
of 0.42 and LDH ratio of 0.45 with no organisms growing on initial cultures.
For assessment and plan this is 65 y/o M with new onset heart failure resulting in progressive dyspnea with bilateral
plural effusions. For his new onset systolic heart failure, the patient can have his furosemide lowered to 20 mg BID with the
addition of an ACE inhibitor. He will need to follow up with cardiology outpatient. His afib with RVR is now rate controlled with
metoprolol 100 mg BID with telemetry showing rates between 80 to 90. With his new onset systolic HF, his CHA2D2-VASc score
52

is 4 which indicates a need to begin anticoagulation with goal INR of 2-3. Thoracentesis yesterday of residual right sided plural
effusion showed 1200 cc of straw color fluid with protein ratio of 0.42 and LDH ratio of 0.45 indicating it is a transudate by
Lights criteria and is consistent with systolic heart failure as its likely etiology. Finally, his diabetes has been well controlled with
SSI in the hospital with glucose readings. We will continue SSI for the remainder of his hospital stay.
Neurology
History and Physical Example:
Chief Complaint The patient is a 25 year old, right-handed female who complains of severe, throbbing headaches.
History of Present Illness The patient states that the headaches began when she was in high school, and she experiences
these headaches 1-2 times per month. The pain is usually one-sided and feels like it is behind her eye and lasts anywhere
from 8 to 24 hours. Occasionally, she has noticed flashes of light in the periphery of her visual fields in the moments preceding
a headache. During the headache, she complains of severe nausea and reports vomiting during at least one episode. She cannot
determine anything that seems to trigger the headaches and says that lying down in a dark room and taking a nap is about the
only thing that helps her symptoms. She has tried taking Advil, Tylenol, and Excedrin for the headaches, but they only provide
marginal relief.
Past Medical History no significant medical diagnoses
Past Surgical History appendectomy (8 years ago)
Family History Mother experiences similar headaches
Social History drinks alcohol occasionally, does not smoke or use illicit drugs
Medications Fexofenadine 10mg for seasonal allergies
Review of Systems She has no headache at the time of presentation and denies fever, chills, nausea, vomiting, diarrhea, and
abdominal pain.
Physical Exam:
Vital Signs T 98.9, Pulse 74, RR 16, BP 128/82
General Patient is a well-appearing 25yo, right-hand dominant, white female
HEENT NCAT, MMM, EOMI, no papilledema
Cardiovascular RRR, normal S1 and S2, no JVD,
Pulmonary CTAB, no W/R/R, symmetrical expansion
Abdominal Soft, non-tender, not distended, normal bowel sounds x4
Neuro:
Mental Status AAOx3, speech is fluent and clear, good comprehension, repetition, and naming, able
to recall 3/3 objects after 5 minutes
Cranial Nerves
o CN II visual fields intact without disturbance, PERRLA
o CN III, IV, VI EOMI with no deviation
o CN V facial sensation is intact and symmetric x3
o CN VII facial expression is symmetric
o CN VIII hearing is unimpaired
o CN IX, X symmetrical palate elevation
o CN XI symmetrical strength on head turning and shoulder shrug
o CN XII tongue is midline with no atrophy or fasciculations
Motor strength is 5/5 in upper and lower extremities bilaterally
Reflexes 2+ and symmetric at the triceps, biceps, brachioradialis, and patella
Sensory light touch, pinprick, and position senses are intact and symmetric in upper and lower
extremities
Coordination rapid alternating movements intact, no dysmetria on heel-to-shin, absent Romberg sign
Assessment/Plan:
The patient is a 25yo WF with a 5+ year of debilitating headaches that occur 1-2 times per month. Her symptoms and the
pattern of her headaches are highly suggestive of migraine headaches. Other diagnoses that could explain her headaches are
tension headaches, pseudotumor cerebri, and brain tumor. The quality of her headaches is not consistent with tension
headaches as she feels a throbbing pain instead of the classical band-like tension associated with tension headaches.
Pseudotumor cerebri is unlikely do to a normal fundoscopic exam. Brain tumors would more likely present with a constant,
progressively worsening headache instead of the episodic headaches that the patient experiences.
53

The plan for the patient is to start her on sumatriptan with instructions to take the medication as soon as she believes that she
is about to have a migraine. She should follow up with us in clinic if the sumatriptan therapy is unsuccessful in providing relief of
her symptoms.
Oral Presentation example for above H&P:
Miss X is a 25yo white female with no significant PMH who presents with a 5+ year history of severe, episodic, and
one-sided headaches that sits behind the eye. The headaches occur 1-2 times per month and usually last for 8 to 24 hours. She
describes throbbing and pounding sensations associated with the headache which is usually unilateral in nature. Occasionally,
she notices visual disturbances preceding the onset of the headache, which she describes as flashes of light at the periphery
of her visual field. She experiences intense nausea and has vomited while she was having a headache. Nothing seems to trigger
these headaches, and she only finds relief by laying down in a dark, quiet room. She has no significant past medical history, and
her only surgery was an appendectomy 8 years ago. Her mother has experienced similar headaches, but the rest of her family
history is unremarkable. She drinks alcohol occasionally but does not use tobacco or any illicit drugs. Her only regular
medication is fexofenadine, which she takes for seasonal allergies. She has tried treating her headaches with Advil, Tylenol, and
Excedrin but has had only marginal relief.
Review of systems did not produce any pertinent positives or negatives, and her physical exam was unremarkable.
She is awake, alert, and oriented to person, place, and time. Her speech is fluent, and she has good comprehension, repetition,
and naming. She was able to recall 3/3 objects after 5 minutes. There were no disturbances of her visual fields, and her pupils
were equally round and reactive to light and accommodation. Extraocular eye movements were symmetrical and showed no
deficits. Her facial sensation and expressions were intact and symmetrical. Hearing was unimpaired. Palate elevation, shoulder
shrug, and head turn were all symmetrical. Strength was 5/5 in both upper and lower extremities. Reflexes were 2+ at the
triceps, biceps, brachioradialis, and patella. Sensation of light touch, pinprick, and position were intact and symmetrical. Rapid
alternating movements were intact, and she had no dysmetria on heel-to-shin.
My assessment is that this patient is most likely suffering from migraine headaches based on the symptoms that the
patient describes and the pattern of her headaches. The best treatment for her would be an abortive medication such as
sumatriptan, which she could take at the first sign of a headache in order to prevent its progression.
*Some attendings will always want you to give results for the full neuro exam during your presentation but others may not (just
be plan on presenting this information, and the attending will let you know if they want a more concise presentation)
*For the inpatient setting, be sure to include vital signs, lab results, and imaging studies in your presentation

Labor and Delivery
Triage History and Physical Example
ID: 30yo G3P1101 @ 39+2 weeks by LMP (last menstrual period) c/w (confirmed with) 20 wk U/S (ultrasound)
CC: contractions
HPI: Pt presents to triage with c/o (complaint of) contractions for one day, increasing in frequency and intensity. (+)
FM (fetal movement), LOF (loss of fluid), no VB (Vaginal Bleeding), no Vag D/C (discharge), denies HA (headache),
denies N/V (nausea, vomiting). Prenatal care at ??? clinic. Last clinic visit, next clinic visit, last cervical dilation
measurement (not you doing it) Ultrasound?
PNC (prenatal complications): Complicated by Obesity, tobacco, C/G, GBS
PNL (prenatal labs): ABO blood type, HbsAg, HIV, Pap,GBS, 1 hour glucose, Gonorrhea/Chlamydia
Past OB: year, how many weeks, babys sex, weight, vaginal vs C-section, complications
Past GYN: history of STI, treated or not, hx of abnormal Paps
Past Medical History: HTN, DM, seizures
Past Surgical History:
Medications:
Allergies:
Social: Tobacco, Alcohol, other drugs, supplements, support at home
Family History: Birth defects? Sickle Cell? Cancer, other diseases
Review of Systems: Contractions, fetal movement, loss of fluid, vaginal bleeding, vaginal discharge, headache, nausea,
vomiting, vision changes, swelling
Physical Exam:
-Vitals: Blood Pressure, Heart Rate, O2 Stats, Temp
-HEENT, Cardiovascular, Lungs, Abdomen, Fundal Height, Extremities-Edema, reflexes
Toco: contractions q five min
Fetal Heart Tones: 150s reactive.
54

DO NOT PERFORM PELVIC EXAM OR CERVICAL CHECK WITHOUT SUPERVISION
Pelvic: Fern (-) Pool (-) Nitrazine(-)
Cervix: 3cm/80%/-2 (dilation/effacement/station)
A/P
30 yo G3P1101 @39+2 weeks by LMP c/w 20 wk U/S
1) Active Labor admit to L&D
2) Anticipate SVD
Ms. First Name, Last Name is 30 y/o G3P1101 at 39w2d by LMP consistent with a 20 week ultrasound presenting with
a one day history of uterine contractions. She denies loss of fluid or vaginal bleeding. She reports active fetal
movement. Pregnancy has been complicated by: Obesity, tobacco, Chlamydia or Gonorrhea, GBS
It is always a good idea to have more information in you note than you verbally present so you can answer questions
if additional information is asked. Also be sure to talk about loss of fluid, blood, fetal movement, and contractions.
Postpartum (NSVD and C-section) Note Example (SOAP Format)
Date, time
S) Pt. doing well, scant lochia, mild cramping, tolerating regular diet, ambulating, pain well
controlled, had bowl movement since delivery.
PPD#
O) VS:
CV:
Lungs:
Abd: Soft, Fundus (at/above/below) umbilicus
Extremities: +1 edema bilaterally,
Labs: Pre-delivery CBC Post delivery CBC
A/P
1) O+, RPR-NR, HepB-, VI, RI
2) Breast Feeding
3) Declines Circumcision for infant
4) Birth control plan
Remember to use a blank postpartum note to guide your interview and gather information for the resident.
Private Practice Students do not usually write notes
Surgical Assignment
The OR learn how to properly scrub in, gown, and glove while remaining sterile. When drying your hands, always
keep your hands up and only move the towel down. Always wear a mask, shoe covers, and hair net before entering
the OR area. Watch for the RED LINE.
Post-Op Progress Note Example (SOAP Format)
Date
Med Student Note
POD#
S) Pt. feels well, pain controlled, denies N/V, denies CP, SOB, positive
Time
Flatus, denies BM, denies . Ambulating well and tolerating clear diet.
O) Vitals: BP, P, RR, T, T max (last 24 hrs)
HEENT: PERRLA, EOMI
CV: RRR, no murmur
Lungs: CTAB no rhonchi, rales, or wheezing
Abd: soft, non-tender, non-distended, bowl sounds heard, Incision C/D/I, JP Drain X2
Defer Pelvic examination
Extremities: comment on edema and reflexes
I/O: 8hr- 875/350 24hr- 1950/1204 JP Drain- 20 cc/8hr
Labs:
A/P: 42 yo AA female s/p TAH/BSO 20 to left benign ovarian mass. Awaiting path
1. HTN- Controlled on HCTZ
2. Pain- Well controlled
3. Diet- Tolerating clears
4. Ambulating well
5. Incisions dry and intact
55
Pediatrics
Inpatient
History & Physical Example
CC: Kiddo Jones is a previously healthy 3 yo boy who is admitted at the request of their primary care physician for a
high fever and suspected meningitis. The patients mother is the source of the history.
HPI: The patient was healthy until he developed some congestion and a fever yesterday. The fever initially was
controlled with Tylenol until the middle of last night when the temperature remained at 103F despite a Tylenol dose.
The patients mother contacted their primary care provider, Dr.Smith, this morning and was subsequently seen in
their office. By this time the child had developed lethargy, appearing weak and having decreased muscle tone, and
the physician stated he appeared dehydrated. Dr. Smith was concerned about the potential of meningitis and sent the
child and mother directly to the hospital. The mother states that the childs condition has remained stable since they
left Dr. Smiths office. The mother states that he has not eaten or drank much since the onset of symptoms yesterday.
He has had no urine output since yesterday evening. She denies any diarrhea or vomiting. Aside from the congestion,
the mother denies any other symptoms, including cough, ear pain, sore throat, or excessive nasal or conjunctival
discharge. The mother is unaware of any sick contacts; however, the patient does attend daycare 3 times a week.
The mother believes he is up-to-date on all immunizations. The patient has had two ear infections in the past but no
other known infections or illnesses. The mother admits to smoking around the patient and in the house. She denies
any recent travel with the patient or known TB exposures. The mother is concerned that her son picked up an
infection from another child at daycare.
PMHx: Two episodes of otitis media resolved with antibiotics, last course was 6 months ago.
Surgical Hx: None
Maternal OB and Birth history: Nulliparous prior to conception. Prenatal care throughout pregnancy. All maternal
screening tests were negative, including GBS. Delivered at 39W2D. Spontaneous vaginal delivery was uneventful. The
mother did not smoke, drink, or use recreational drugs during the pregnancy. Newborn screen was negative.
Growth and Development:
Last well child check was at 24 months. Due for next well child exam in a few weeks. Has been told that he is meeting
milestones appropriately. Sat unaided by 6 months and could walk at 15 months. He was speaking at least 2 words by
12 months. By 2 years he was brushing his teeth and clothing himself.
Allergies: NKDA
Meds: None
Health Maintenance:
1. Screening tests: Lead screen negative at age 12 And 24 months.
2. Exposures:
a. Mother smokes in home
b. No pets
3. Sleep: Generally sleeps well getting 10-12 hours per night
4. Diet: Enjoys fruits and vegetables. Eats chicken and rarely red meat.
5. Immunizations: up to date per the mother. MCIR in patient chart confirms immunizations through 24 months of
age.
Social History: The patient lives with his mother and father. His father works outside the home full-time and his
mother works outside of the home part-time. He attends daycare 3 days per week. He is occasionally watched by his
maternal grandmother.
Family History:
1. Father: Alive and well at age 32yo
2. Mother: seasonal allergies, age 32yo
3. Maternal grandmother: breast cancer diagnosed at age 67yo, alive at age 71yo
4. Paternal grandfather: passed away from MI at age 72yo
No family history of diabetes, blood dyscrasias, bleeding disorders, or cardiac, renal, or liver disorders.
Review of Systems:
-Constitutional: As above.
-Skin: No history of rashes, eczema, excessive bruising, or skin lesions.
-Eyes: No eye discharge or pain, excessive tearing, or itchiness.
-Ears: No problems with hearing. No ear pain or drainage.
-Nose: As above.
56

-Mouth and throat: No history of dental caries. No oral mucosa inflammation or lesions.
-Neck: No history of pain
-Respiratory: No cough or wheezing.
-Cardiac: No history of murmur, syncope, cyanosis, or palpitations.
-GI: As above.
-GU: No history of UTI. No dysuria or hematuria.
-Musculoskeletal: No history of fracture, myalgias or arthralgias.
-CNS: No difficulty with gait or balance. No history of seizures, automatisms, or tremors. No history of headaches.
-Endocrine: No excessive thirst or urination. No history of heat or cold intolerance.
Physical Exam:
Vitals:
Temp: 103.0 F oral, Tmax 103.2 @ 08:30. Last Tylenol dose was 4 hours ago.
Pulse: 120 regular [89-128]
Resp: 32/minute
O2 Sat: 98% on room air
BP: 85/52 [78-110/48-60]
Weight: 16.5 kg (90th percentile)
Height: 96 cm (65th percentile)
BMI: 17.9 (85th percentile)
General: Appears lethargic and ill.
Skin: No visible lesions or rashes. No jaundice.
Head: Normocephalic, atraumatic.
Eyes: No conjunctival injection or excessive tearing. PERRL. Fundoscopic exam does not show any papilledema.
Ears: TMs are erythematous and bulging bilaterally and immobile. No discharge or drainage is noted in the external
canals.
Nose: Nasal mucosa is dry and mildly erythematous. No purulent discharge or blood.
Mouth and throat: Oral mucosa is dry but without lesions. Gums appear healthy. Oropharynx is hyperemic but
without exudate.
Neck: There is palpable cervical lymphadenopathy. Rigidity is present with positive Brudzinskis sign.
Respiratory: CTABL. No wheezes, rhonchi, or crackles. No assessory muscle use.
CV: Tachycardia. RRR, no murmurs or gallops.
Abd: Bowel sounds are present. Nontender, nondistended. The spleen and liver are unpalpable.
Musculoskeletal: Positive Kernigs sign. No edema or digital clubbing.
Assessment: Kiddo Jones is a 3 yo male with possible bacterial vs. aspectic meningitis. He was healthy until yesterday
when he developed congestion and fever. The fever continued to increase and the patient became lethargic over the
past 24 hours. This morning he was seen by his primary care provider who was concerned about meningitis and
requested hospitalization. Current temperature is 103.0F.
1) Meningitis is the suspected cause of the fever. This is the most likely diagnosis given his high fevers, the rapid onset
of symptoms, and his positive signs of meningeal irritation. Possible causes of meningitis include both viral and
bacterial organisms. Potential sources of infection include, urinary tract infection, otitis media, or other upper
respiratory infection, and direct extension from disruption of surrounding skin.
2) Dehydration: the patient has had no oral intake in the past 24 hours and his oral mucosa is dry. Additionally, he has
had no urine output since yesterday evening (18 hours).
Plan: Draw the following labs: CBC including WBC differential with bands, electrolytes, urinalysis, and blood cultures.
Chest x-ray is ordered. We will perform an LP measuring WBCs, protein, and glucose. We will examine the CSF for
bacteria, perform cultures and sensitivity, and run PCR for herpes simplex virus. We will give a NS fluid bolus at
20ml/kg to correct an stimated 6% total body volume deficit. Then run 1/4NS for maintenance at 50ml/hour. We will
begin empiric treatment with IV Vancomycin and Claforan and IV acyclovir. Tylenol every 4-6 hours
for fever. We will perform regular patient status and neuro checks for any changes such as a decrease in mental
status,onset of seizures, or worsening fever.
Oral Presentation for above H&P
Kiddo Jones is a 3 yo male with possible bacterial vs. aspectic meningitis. He was healthy until yesterday when he
developed congestion and fever. The fever continued to increase and the patient became lethargic over the past 24
hours. This morning he was seen by his primary care provider who was concerned about meningitis and requested
hospitalization. Current temperature is 103.0F. Tmax 103.2 at 08:30. Minimal po intake and urine output. Mom
57

denies diarrhea or vomiting. Kiddo was possibly exposed to sick contacts at day care, which he attends 3x/week. Upto-date on immunizations.
Non-contributory past medical and surgical history. Delivered at term, uncomplicated SVD. No allergies and not one
any medication.
ROS positive for weakness and fatigue. Denies other symptoms. On exam, temp is 103.0 and Kiddo appears lethargic
and ill. There is palpable cervical lymphadenopathy. Rigidity is present with positive Brudzinskis sign. Lungs CTAB,
heart RRR no murmurs, abdomen non-distended, non-tender with positive bowel sounds.
My assessment is that Kiddo Jones is a 3 yo male with suspected meningitis. This is the most likely diagnosis given his
high fevers, the rapid onset of symptoms, and his positive signs of meningeal irritation. Possible causes of meningitis
include both viral and bacterial organisms. Potential sources of infection include, urinary tract infection, otitis media,
or other upper respiratory infection, and direct extension from disruption of surrounding skin.
My plan is to draw a CBC including WBC differential with bands, electrolytes, urinalysis, and blood cultures. Perform
spinal tap to test spinal fluid. We will begin empiric treatment with IV Vancomycin and Claforan and IV acyclovir.
Tylenol every 4-6 hours for fever. Start IV fluids. We will perform regular patient status and neuro checks for any
changes such as a decrease in mental tatus,onset of seizures, or worsening fever.
Progress Note Example (SOAP Format)
Introductory phrase: (a way of briefing the group: name, age, CC, working diagnosis)
Timmy is a 3 yo patient admitted with rash and fever found to have Kawasaki Disease
Subjective: (Sum up what the parents would have told you. Common things to mention in your subjective sections:
Report any relevant pain, BM and urination, what kind of diet and how they are tolerating it, and if they are
ambulating.)
Objective: (Vitals, physical exam, labs, radiology)
Ranges are good for temperature, O2 saturations, and BP but probably not needed for RR if all were normalcheck
with your resident.
Physical Exam: Report pertinent exam. Dont need to report deep tendon reflexes every day for every patient. What is
helpful is comparing todays exam with previous exam. Labs: With a progress note, just present the labs that were
drawn since the last time you presented the patient and how certain values are trending (i.e. Hb in a patient who was
anemic) -but know all of the previous labs if asked.
Radiology: Same as above with labs. No need to present initial x-rays on hospital day 12. If a malignancy found, do not
report this in front of the family.
Assessment: Repeat the introductory phrase (name, age, CC, if still no certain diagnosis, list differential diagnosis.)
Plan: Some residents and attending like to merge the assessment and plan and some do them separate. Also, some
like to do a numbered plan with most pertinent problems first and others do a system-based plan. I find that the
system-based plan is more useful when a patient has issues with more than two or three systems. Use judgement
with this (dont do a system-based plan for a kid having an asthma exacerbation and no other problems) and ask your
resident when unsure.
Example Progress note:
Timmy is a 3 yo patient admitted with rash and fever found to have Kawasaki Disease.
S: Overnight Timmys rash has improved, although he has had some skin peeling from his finger tips. He had one fever
overnight, treated with Tylenol. He has been able to eat and drink well, peeing and pooping normal.
O: Vitals: Temps ranged from 97.6-101.2. Tmax at 03:30. Pulse 78, RR 16, oxygen saturation 98% on room air.
Physical Exam: Timmy was resting comfortably this morning. His oropharynx is erythemetous, with cracking of his lips.
Neck swelling present but decreased from yesterday. His lungs sound clear bilaterally. His heart is regular in rhythym,
with a 2/6 systolic ejection murmur over the left upper sterna border. His abdomen is soft and non-tender with
positive bowel sounds. His rash has improved, and now confined to just his trunk.
Labs: WBC 12.6 down from 14.0, Hb 13.2, platelets 207k
A/P: Timmy is a 3 yo patient admitted yesterday with rash and fever found to have Kawasaki Disease. He received
IVIG yesterday evening as well as aspirin and tolerated both of those treatments well. Currently afebrile but had a
Tmax of 101.2 at 03:30. His rash and neck swelling have reduced significantly. My plan is to monitor until Timmy has
been without a fever for 12 hours. If all other symptoms have remained stable or improved at this time, he can be
discharged.
Oral Presentation for above Progress Note
Timmy is a 3 yo patient admitted with rash and fever found to have Kawasaki Disease. Overnight Timmys rash has
improved, although he has had some skin peeling from his finger tips. He had one fever overnight (101.2 @ 03:30),
treated with Tylenol. He has been able to eat and drink well, peeing and pooping normal. On exam his oropharynx is
58

erythematous, with cracking of his lips. Neck swelling present but decreased from yesterday. His rash has improved,
and now confined to just his trunk. Rest of exam WNL. His WBC count is down to 12.6 from 14.0. My assessment is
Timmy is a 3 yo patient with Kawasaki Disease. He received IVIG yesterday evening as well as aspirin and tolerated
both of those treatments well. Currently afebrile but had a Tmax of 101.2 at 03:30. His rash and neck swelling have
reduced significantly. My plan is to monitor until Timmy has been without a fever for 12 hours. If all other symptoms
have remained stable or improved at this time, he can be discharged.
Outpatient
Well Child Check SOAP Note
05/29/12 (Date) 0900 (Time)
S: 4 month old male presents for well baby visit
Concerns: No concerns since last visit
Diet: Several bottles of Similac with iron per day, no solids (ask about fluoride and vitamin supplementation)
Development: Normal Denver babbles and coos, smiles, laughs, holds head up, rolls from front to back, raises body
on hands, grasps rattle, recognizes parents voice
Bowel/Bladder: BMs x 2 per day, soft, slightly formed stool, no straining, no blood, 6-8 wet diapers per day (toilet
training after 21 months)
Sleep: Sleeps in crib in own room on his back, wakes once per night for bottle
Dental: No teeth. (if a child has a tooth it should be brushed, should see dentist at age 3)
Safety: Rear facing car seat in the back seat, sleeps on back, (+) smoke and carbon monoxide detectors (helmet use,
gun safety, pet safety)
Immunizations: Up to date, needs DTaP (diptheria, tetanus and acellular pertussis), Hib (haemophilus influenzae type
B), IPV (inactivated poliovirus), PCV (pneumococcal)
For adolescents: Drugs/alcohol/tobacco, sexual activity, after-school activities, hours of screen time (TV and
computer), school, depression/self-esteem
O: Length: 25in, Weight: 14lbs 8oz, Head Circumference: 16.5in, Pulse: 130
Gen: Awake, alert, no acute distress, smiling
HEENT: Anterior fontanelle open, flat and soft (AFOFS), normal cephalic atraumatic (NCAT), (+) red reflexes bilaterally,
follows past midline, (-) strabismus, pupils equal round and reactive to light (PERRL), normal tympanic membranes
B/L, inferior turbinates slightly pale and boggy, throat clear
Neck: Supple, (-) lymphadenopathy (LAD)
Skin: (-) rashes, (-) mongolian spots
CV: regular rate and rhythm, (+) S1S2, (-) murmurs, equal radial and femoral pulses
Resp: CTA B/L, (-) wheezes/rhonchi/rales
Abd: Soft, (+) bowel sounds, NT, ND, (-) masses, (-) hepatosplenomegaly
Ext: normal range of motion (ROM), (-) Ortolani, (-) Barlow
Neuro: (+) Moro reflex, (+) grasping reflex, (+) stepping reflex
A/P: 4 month old male presents for well baby visit. No new complaints.
1. Diet: add cereal and then pureed fruits/veggies, only add one new food per
week to gauge tolerance
2. Safety: discussed child proofing the house (hot liquids, sharp objects, outlets,
cords, etc.) as baby is becoming more mobile
3. Immunizations: Received DTaP, IPV, Hib, PVC today
4. Return in 2 months
Oral Presentation for above Well Child Check
Pt is a 4 mo. male here today for a well child check. No complaints since last visit and no interval history. He
is feeding well with Similac with iron (several bottles/day); no solids yet. 2 soft BM/day and 6-8 wet
diapers/day. Sleeping in crib on back. He is meeting appropriate gross motor, fine motor, language, and
social developmental milestones. Home and automobile anticipatory guidance were discussed. Pt is onschedule with immunizations and needs 4 month shots today. Pt is in 50% for height and weight. Physical
exam was normal in all systems. My assessment is that this is a 4 month old male here for a well baby visit
and no new complaints. Add cereal to diet and then pureed fruits/veggies, only add one new food per week
to gauge tolerance. Discuss child proofing the house (hot liquids, sharp objects, outlets,cords, etc.) as baby
is becoming more mobile. Received DTaP, IPV, Hib, PVC immunizations today. Return in 2 months.
59
Family Medicine
History and Physical Example:
HPI: Includes chief complaint, location and radiation (if applicable), onset and frequency of symptoms, alleviating/aggravating
factors, and associated symptoms.
Example: Jim Smith is a 35 y/o WM (white male) who presents today with cough and rhinorrhea for the past 5 days. He states
that his symptoms have gotten worse since their onset and occur throughout the day. Exertion seems to make things worse and
he has tried drinking hot beverages, which have not helped. He denies any associated symptoms.
PMH: Include any significant medical conditions or hospital visits
Example: COPD
PSH: Include any significant surgeries
Example: Tonsillectomy as an adolescent for recurrent pharyngitis
Medications: Include any prescription or over-the-counter medications and supplements
Example: Albuterol PRN (as needed)
Allergies: Include any drug allergies (NKDA = no known drug allergies)
Example: Allergy to sulfa derivatives
Social History: Include alcoholic drinking history (how long, how many drinks per week, how long sober), smoking history (how
many packs per day, how long has he/she been smoking), illicit drug use, living situation (who do they live with, where do they
live, any sick contacts), and educational/employment status
Example: Drinks around 1-2 beers/night. Smokes 1ppd for the past 15 years. Denies any illicit drugs. Lives with wife and two
children (one son, one daughter) at home; his son recently had a viral URI (upper respiratory tract infection). He graduated high
school and currently works for the USPS.
FMH: Include any significant family history of diseases (often will have to prompt patients by asking specifically about heart
disease, high blood pressure, stroke, diabetes, or lung disease)
Example: Mother and father both had high blood pressure and maternal grandmother died of a stroke.
Oral Presentation example for above H&P:
Example: Jim Smith is a 35 y/o WM (white male) with a history of COPD who presents today with cough and rhinorrhea for the
past 5 days. He states that his symptoms have gotten worse since their onset and occur throughout the day. Exertion seems to
make things worse and he has tried drinking hot beverages, which have not helped. He treats his COPD with albuterol PRN and
his son had a recent URI.
Developing an assessment and plan are also important. While some attendings or residents may ask for one, be sure to
volunteer your thoughts regardless.
Psychiatry
History and Physical
HPI: C.P. is a 44 yo F who presented to the hospital c/o auditory hallucinations and increasing depression and
paranoia. Pt reports increasing depression for the past month. Started hearing voices recently - they are men's voices
and this really scared her. She feels very scared all the time - thinks that people have been following her and someone
made the hand gesture of a gun towards her. Reports that people have been following her for 3 years. She has moved
to multiple different apartments (and a different state - thought this was happening in Georgia too) but believes
these people are going to hurt her or her son. Pt reports that her son is not worried about it and doesn't seem
concerned. He is now becoming fed up with her. Pt reports that her son is "tired of dealing" with her and that she
"gets on his nerves." Pt is tearful on and off throughout the interview. Has high anxiety. Has called the police multiple
times about the cars she believes are following her. Says she has been on the same meds for years Seroquel 1000 mg
and Zoloft 100 mg. These havent been changed anytime recently. They are being prescribed by her PCP.
Past Psych Hx: Admitted to Norton Hospital in 2005 for Opiate overdose. Dx Bipolar and Opiate Dependence. Seen at
Seven Counties from 2004-05. PCP Dr. Gray has been prescribing her medication for her.
Substance Abuse Hx: Denies any recreational drugs. Denies overusing her pain medications but there has been
concern in the past for that. Sees pain management. Alcohol- 1-2 glasses of wine per week.
Medical Hx: Asthma, HTN, HLD
Surgical Hx: None
Social History: Grew up in Louisville. Has an older brother. Graduated from high school and got an Associates Degree
in Business. Has a 24 yr old son. Had received disability in the past but currently has been working as a CNA in a
Nursing Home. Was living with her son in an apartment but they just moved in with her mother. Smokes 1 ppd for
past 20 years, drinks 1-2 glasses of wine per week, denies cocaine, heroin, amphetamine, opioid, marijuana abuse.
Family Hx: Depression in mother and paternal aunt.
60

Home Meds: Alprazolam (Xanax) 0.25 mg PRN sleep; Hydrocodone-Acetaminophen 7.5-300 mg PRN pain, Quetiapine
(Seroquel XR), 400 mg BID, Sertraline (Zoloft) 100 mg daily
Current Inpt Meds: Haloperidol (Haldol) 2 mg daily, Sertraline (Zoloft) 50 mg BID, Baclofen (Lioresal) 20 mg daily,
Nicotine (Nicoderm CQ) 14 mg (1 patch) daily, Quetiapine (Seroquel XR) 800 mg daily
Allergies: NKDA
ROS:
Constitutional: Negative for fever and chills.
HENT: Negative for sore throat, neck pain and neck stiffness.
Eyes: Negative for redness and visual disturbance.
Respiratory: Negative for shortness of breath and stridor.
Cardiovascular: Negative for chest pain, palpitations and leg swelling.
Gastrointestinal: Negative for nausea, vomiting, abdominal pain, diarrhea, blood in stool and abdominal distention.
Genitourinary: Negative for difficulty urinating.
Musculoskeletal: Negative for joint swelling.
Skin: Negative for rash.
Neurological: Negative for speech difficulty, weakness and numbness.
Psychiatric/Behavioral: Positive for hallucinations (auditory), changes in sleep, and decreased concentration.
Psychiatric Review Of Systems:
No appetite and weight changes.
Poor sleep, low energy, decreased interest and pleasure, anxiety, of guilt and hopelessness, suicidal ideation
Physical Exam:
PE: T 97.9 HR 70 BP 96/62 RR 16
General: Alert, cooperative, no distress, appears stated age
Head: Normocephalic, without obvious abnormality, atraumatic
Eyes: PERRL, conjunctiva/corneas clear, EOM's intact
Ears: Normal external ear canals, both ears
Nose: Nares normal, septum midline, mucosa normal, no drainage or sinus tenderness
Throat: Lips, mucosa, and tongue normal; teeth and gums normal
Neck: Supple, trachea midline; thyroid: no enlargement/tenderness/nodules; no carotid bruit or JVD
Back: Symmetric, no curvature, ROM normal, no CVA tenderness
Lungs: Clear to auscultation bilaterally, respirations unlabored
Chest Wall: No tenderness or deformity
Heart: Regular rate and rhythm, S1 and S2 normal, no murmur, rub or gallop
Abdomen: Soft, non-tender, bowel sounds active all four quadrants, no masses, no organomegaly
Extremities: Extremities normal, atraumatic, no cyanosis or edema
Pulses: 2+ and symmetric all extremities
Skin: Skin color, texture, turgor normal, no rashes or lesions
Lymph Nodes: Cervical, supraclavicular, and axillary nodes normal
Neurologic: CNII-XII intact, normal strength, sensation and reflexes throughout
Mental Status Evaluation:
Appearance: Groomed, clean, appropriately dressed
Behavior: Restless and fidgety
Speech: Normal tone, speed, volume, and language
Mood: Anxious and depressed
Affect: Labile
Thought Process: Logical, goal-directed
Thought Content: Delusions, Auditory Hallucinations
Sensorium: Awake, alert, oriented to person, place, time
Cognition: No cognitive defects noted
Insight: Impaired
Judgment: Impaired
SI/HI: Suicidal ideation without a plan
Assessment/Plan:
Axis I: Major Depression, recurrent with psychotic features; r/o delusional disorder
Axis II: Deferred
Axis III: Asthma, HTN, HLD
61

Axis IV: economic problems, housing problems and other psychosocial or environmental problems
Axis V: 11-20 some danger of hurting self or others possible OR occasionally fails to maintain minimal personal
hygiene OR gross impairment in communication.
Plan:
1. Admit to 6E for safety and stabilization
2. Encourage group and therapeutic activities
3. Seroquel 800 mg qhs
4. Add Haldol 2 mg daily, may increase if seroquel isn't treating the psychosis adequately
5. Increase Zoloft to 150 mg - has been on for long time but no dosage adjustments
6. Suicide precautions
Oral Presentation: C.P. is a 44yo female w hx of Bipolar dz and opiate overdose attempt who presents with worsening
depression, paranoia and auditory hallucinations for several months that are stressing her relationship with her son,
with whom she currently lives. She has taken Seroquel 1000mg and Zoloft 100mg for several years through her
psychiatrist at Seven Counties. Pt also takes Xanax 0.25mg and Norco at home. Patient smokes 1 PPD, reports
occasional alcohol and denies recreational drugs. Family Hx significant for MDD in mother and paternal aunt. ROS
positive for poor sleep, depressed mood and concentration, feelings of anxiety and guilt and suicidal ideation without
a specific plan. No change in appetite, bowel or bladder habits, and no recent illness symptoms.
On exam, vital signs were T 97.9 HR 70 BP 96/62 RR 16. Pupils equal, round, reactive to light and accommodation.
CNs 2 through 12 grossly intact, LCAB, RRR, radial pulses 2+ bilaterally, no cyanosis or edema, no focal neural deficits
appreciated. On Mental Status Examination, pt appeared stated age, was awake alert and oriented to person, place,
time, and circumstances. She was restless, mood congruent with labile affect, exhibited perseveration, and seemed
to have limited insight into nature of her illness.
My assessment is:
Axis I: Recurrent MDD with psychotic features; DDx includes delusional disorder, schizophrenia.
Axis II: none at this time.
Axis III: Asthma, HTN, HLD
Axis IV: economic problems, social problems, environmental problems
Axis V: 40 for inability to carry on daily functions
My plan would be to admit to inpatient for safety and stabilization, encourage therapeutic milieu, continue home
Seroquel for sleep, increase Zoloft to 150mg for active depression, add Haldol 2mg for psychosis, and suicide watch.
Progress Notes
S: This morning patient was doing better. Alert, Oriented, sitting in chair. C/o of residual memory problems, does not
remember working with PT yesterday. Still very poor sleep. Does not want seroquel since 25 mg "zonked me out", felt
very drowsy the entire next day. Interested in trying something else. Related other sources of stress in her life
including several family relationships. Still cries everyday thinking about her husband. Their wedding anniversary is
coming up on Sun 9/21. She plans to spend the day with her son, and her daughter made reservations for Vincenzo's
the Saturday before. Pt relates dreaming about husband every night, sometimes about his death, and often wakes
crying out for him, describes the experiences as unpleasant. Denies flashbacks or other nightmares. In other history,
pt was sole caregiver for grandson for 8 yrs until he was admitted to Brooklawn in October 2013 for conduct disorder.
No complaints of pain at this time. Anxiety persists and may be getting a little worse. Denies CP, SOB, NVD.
Meds: Budesonide-formoterol 2 puff daily, Clonidine 0.1 mg PO daily, Hydralazine 25 mg PO daily, insulin detemir 10
units subcutaneous QHS, verapamil 240 mg PO QHS
O:
T 98.8 HR 85 BP 141/80 RR 18
Gen: NAD, sitting up watching TV.
CV: RRR, S1S2 nml, no G/M/Rs, radial pulses 2+ Bil, no edema.
Pulm: CTAB
Abd: Soft, NTND, +BS
MSE: Appearance: Gowned, ear-rings, glasses, slippers, watch
Behavior: Calm, cooperative, congenial, responsive, but became agitated discussing stressors.
Speech/Lang: Normal volume/rate. Good articulation. No perseveration or echolalia.
Mood: sad
Affect: Sad, emotionally labile
Thought Ps: linear, goal-oriented.
Thought Ct: No SI/HI/HA
Orientation: A, A, oriented to P P T C
Memory: Not formally tested.
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Conc/Attn: normal
Fund of Kn: Not formally tested.
Insight: Fair, recognizes depression but may underestimate severity
Judgment: Fair
Labs: 05:58 - Glucose 256 (Elevated)
Assessment
Axis I: MDD; Bereavement; resolving delirium due to infx.
Axis II: No diagnosis
Axis III: UTI; PMHx includes DM2, HTN, HLD, spondylolisthesis, glaucoma
Axis IV: Unsafe home environment dt late husband's hoarding, significant family and social stressors.
Axis V: 41-50, serious symptoms.
Pts personal psychiatrist came to visit today and has requested transfer to 6East
Plan
Defer management to pt's psychiatrist. Admit to 6East per primary psychiatrists request, and sign off psych consult.
Oral Presentation: C.E. is a 76 yr/o female w hx of DM2 and depression who presents with confusion for 3 days now
and being treated for UTI. Home meds duloxetine and quetiapine were stopped.
Psychiatry was consulted for AMS and meds evaluation. Consult Day 2.
This morning pt is feeling better but did not remember doing physical therapy yesterday. Relates several social
stressors that occupy her thoughts and disturb her sleep. Did not sleep well last night but does not want Seroquel due
to side effects. Denies new or worsening Sx.
Vitals were T 98.8 HR 85 BP 141/80 RR 18
PE was unremarkable. On mental status exam, she was generally calm and cooperative but became intermittently
agitated when discussing specific social relationships. Mood is sad, with congruent, appropriate affect. Denies SI/HI.
No meds changes since yesterday.
My assessment is
Axis I: MDD with superimposed Bereavement; resolving delirium due to infx.
Axis II: No diagnosis
Axis III: UTI; PMHx includes DM2, HTN, HLD, spondylolisthesis, glaucoma
Axis IV: Unsafe home environment dt late husband's hoarding, significant family and social stressors.
Axis V: 41-50 for serious stressors.
My plan would be to d/c Seroquel and start trazodone for sleep. Patients psychiatrist has requested transfer to
6East, so consult will sign off at that point
63

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The Unofficial Clinical Clerkship Survival Guide

University of Louisville School of Medicine

Brought to you by the Class of 2016 Track Captains and the

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Clinical Clerkship Survival Guide: General Information

Jewish Hospital Garage:

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Clinical Clerkship Survival Guide: General Information

Food and Dining Options

Evaluations and Shelf Exams

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Clinical Clerkship Survival Guide: General Information

Medical Knowledge - Integration of basic sciences, application of clinical sciences)

Systems-Based Practice - Teamwork, skills in evidence-based medicine

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Clinical Clerkship Survival Guide: General Information

Computer Access and Electronic Medical Records

Help Contact Number

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Clinical Clerkship Survival Guide: General Information

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Clinical Clerkship Survival Guide: General Information

White Coat Essentials

Maxwell Quick Medical Reference (amazon.com for $6 or bookstore for $8)

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Clinical Clerkship Survival Guide: General Information

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Clinical Clerkship Survival Guide: Track Selection

Third Year Track Selection

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Clinical Clerkship Survival Guide: Track Selection

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Clinical Clerkship Survival Guide: Track Selection

Obstetrics and Gynecology:

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Clinical Clerkship Survival Guide: General Surgery

Kosair Childrens Hospital (KCH)

VA Medical Center (VAMC)

Department Chairman: Dr. Kelly McMasters

Student Contact and Clerkship Coordinator:

Residency Director: Dr. William Cheadle

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Clinical Clerkship Survival Guide: General Surgery

Elective Surgery (ULH) The general surgery service at ULH.

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Clinical Clerkship Survival Guide: General Surgery

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Clinical Clerkship Survival Guide: General Surgery

UWorld QBank (147 questions) Shelf exam preparation.

Emma Rhamahis Review A 2-hour review for the shelf exam.

Case Files Surgery Lecture, quiz, and shelf exam preparation.

NMS Surgery Quiz and shelf exam preparation.

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Clinical Clerkship Survival Guide: Internal Medicine

Department Chairman: Dr. Jesse Roman

Student Contact: Missy Klotz

Residency Director: Dr. Jennifer Kuch

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Clinical Clerkship Survival Guide: Internal Medicine

Clinical Evaluations 40% (minimum of 70% to pass)

EKG Quiz 5% (20 question quiz)

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