Harborview Medicine 665 Outpatient Student Responsibilities

Student Responsibilities

Attend all scheduled clinics and teaching activities.

Enthusiastic educational attitude.

Professional demeanor and cooperative attitude toward all staff and patients.

In Student Follow-Up, Adult Medicine Walk-In and DESC see 2-4 patients per session, present to the attending (see below for outline of clinic presentations), and initiate management. Your history and exam should be directed toward the problems of the day, but you should be aware of the full problem list and all medications taken. The attending will review the history and physical examination, help you formulate a treatment plan, and give you specific feedback regarding your efforts. Write-ups should be completed within 24 hours (see below for suggested format for clinic notes).

Follow-up. Before a patient leaves clinic, review how they will learn of lab results and when they should return to clinic. When appropriate, you should follow-up test results over the phone or schedule patients back to see you again.

Prepare for case discussions, including review of suggested references, prior to each didactic session with Dr. Baggett.

Arrange to ride with Medic-One once during the rotation. Call Carol Barton at 386-1483 to arrange. Make sure to wear your white coat.

No on-call or weekend responsibilities are scheduled.

If you would like to work on phlebotomy skills, you may join HMC ward phlebotomists as they make morning rounds on Monday or Tuesday. Contact Victor Green (744-3451).

Have fun! Contact Dr. Baggett (pager 680-0115, email baggettt@u.washington.edu) or Dr. Terasaki (pager 680-0543, email terasaki@u.washington.edu) immediately if you need help solving any problems!

Suggested Outline for Clinic Presentations

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

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

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

Give an efficient, problem-based history, exam, and plan

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

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

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

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

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

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

Get feedback

Any suggestions for me?

Suggested Format for Clinic Notes

ID: Briefly frame the patient and purpose of the visit: 55 yo male with back pain.

PCP

Problem List: List all active problems and pertinent past medical history.

Hypertension.
Hyperlipidemia, 6/03 total cholesterol 300, HDL 45, LDL 190, Trig 150.
CAD, s/p MI 5/00, thallium study 9/01 negative.
Tobacco use.
Health care maintenance: tetanus shot 5/99, colonoscopy 4/01 normal.

Medications: List meds with doses.

Allergies: List reaction.

Current Concerns: Concise histories of problems addressed.

Problem 1: Back pain: Pt developed low back pain 2 days ago while moving furniture. He denies numbness/tingling in his legs, no lower extremity weakness, no incontinence of urine or stool. He has not been taking any medications. etc.
Problem 2: etc.

Exam: Detailed descriptions of exam performed that day, always include vitals and general statement.

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

Assessment and Plan: For each problem, discuss differential diagnosis, your management rationale and plan. List your plan in bullet form so that it can be easily read. Please clarify your plans for follow up.