Right now I happen to be on the hospital internal medicine service, which in a nutshell means that I am assigned a handful of patients to round on each morning before the attending physician comes for the “official” rounds. What this means for me, as a medical student, is that I must see each patient, see how they’re doing, do a focused physical exam, find the chart (which is a whole other topic), dig through the chart and figure out what the sub-specialists are doing/thinking, and then write a note summarizing everything. This note is written in a standardized form called a SOAP note.
7:00AM – Arrive at the hospital.
My work day begins bright and early at 0700. Typically, I arrive 5 minutes late because every day I tell myself that I can make up the time by driving fast. For some reason I think I’ll be more rested if I sleep five minutes later — it makes sense at 6:00am anyways. Once I get to the hospital I head into the back entrance and take the stairs to the second floor. Usually the other medical student on the service is already there and has a list of the day’s patients waiting for me. About this time the internal medicine resident on my team is overhead paging “Student Doctor John V, please call 7507″. The three of us then begin the process of dividing up the patients. We usually try to keep some semblance of continuity of care going, thus any patients I saw the day before I will see again. This works best for the patient and the students/residents. As a student, I typically have at least 2-3 GOMERS assigned to me on any given day. The other 2-3 patients assigned to me can vary from good cases to baker-acted nutjobs to patients who make you want to poke your eyeballs out and everyone in between. After I get my patient assignments, I check to see how many new patients I have. For each new patient I print out a handy worksheet from medfools.com that helps me keep track of the patient’s medical history, history of current hospitalization, medications, orders, complaints, etc.
7:15AM – Head up to rehab
I try to hit the rehab floor first. They physical therapists like to start pulling patients out of their rooms for physical / occupational therapy at about 8am. This means that if I get upstairs too late I have to interrupt what is usually a group physical therapy so I can interview and examine the patient in front of the group. The patients usually don’t mind but you can feel the hate radiating off the physical therapists whenever this happens.
The problem with the rehab floor is two-fold. First, the charts are usually no where to be found. There is a chart rack behind the main nurses station that the charts are supposed to be in when they’re not being used, but usually the charts are AWOL somewhere out on the floor (the floor is a term we use to refer to any part of that floor other than the nurses station — not the literal ground). The second problem with the rehab floor is that the vital signs are never, ever done and/or chartted by the nurses yet. This means I have to leave that part of my note blank and come back later in the morning to fill those in.
Rehab patients are usually quick and straightforward. Unfortunately they’re often in a lot of pain and many of them are very depressed (imagine being stuck on a hospital floor for 6 weeks while you relearn to feed yourself after a stroke). Medically, the patients are usually easy cases. To be cleared to go up to the rehab floor, you first have to be deemed medically stable. For the most part, on the rehab floor we just manage anticoagulent therapy, blood pressure, and sugars. Each case takes me about 10 minutes to see the patient and 10-15 minutes to write my note (unless something is out of the ordinary). My recommendations are almost identical from patient to patient, day to day:
“(1) Continue to monitor ________
(2) CPTx (continue present treatment)
(3) DWA (discuss with attending) – Dr. Smith”
Dr. Smith / John V., MS IV
7:55AM – Head downstairs to the medical floors
The medical floors are a whole different beast. For one, there are all sorts of techs, nurses, aids, students, interns, residents, fellows, and attendings hustling and bustling about in the morning. The first and most important thing you need to know as a medical student is the hierarchy of medicine. Obviously anybody above your rank has first rights to the chart, and anyone below your rank will usually give the chart up for you. The nice thing about being a medical student is that you’re acting as an extension of the resident, who is acting as an extension of the attending. So nurses, aids, techs, etc. usually will let you have the chart so you can go on about your work. However, if an intern, resident, fellow, or attending has the chart — tough luck. You just have to come back and hope some other physician doesn’t have it.
Once I get the chart, I dig into the orders, medications, and progress notes sections. My job as a student is to know absolutely every test, every specialist, every opinion, every medication, literally everything that is going on with a patient and that has changed with the patient overnight. Sounds easy, right? Unfortunately this often involves interpreting the hand-writing of the other physicians on the case, as well as spending an inordinate amount of time reading CT and x-ray reports and figuring out who ordered what test and what the result was exactly. I usually spend about 20 minutes with the chart and the lab results on the computer before I even think about seeing the patient. I usually try to assimilate this into some sort of loosely connected picture in my brain before I see the patient so I can efficiently talk to the patient, answer his/her questions, provide basic information, ask relevant questions, and do a focused physical exam.
Actually seeing and examining the patient is the quickest and easiest part of the whole process. I usually spend about 5-10 minutes talking to the patient. After I finish the interview I run through my standard schtick “Any chest pain, palpitations, diaphoresis, shortness of breath, nausea, vomitting, diarrhea, fevers, chills, abdominal pain, leg pain?” The physical exam is pretty standard for most patients, with attention to specific systems depending on why the patient is in the hospital. Every patient gets a basic cardiovascular, pulmonary, abdominal, and extremety physical exam. After the physical I wrap up the interview, answer any questions, and head out to find an open table to write up my note.
The day to day hospital notes by physicians (called progress notes) are usually written in a standard format — though some attendings ignore and/or modify this format to their pleasing. The standard format is called a “SOAP” note — s for subjective, o for objective, a for assessment, p for plan. These notes are hand-written in my hospital. In the subjective portion you write a basic subjective narrative of what’s going on with the patient. This portion is usually a bit flexible as sometimes objective data (such as # of stools passed yesterday, etc.) is included. The objective portion is where I write my physical exam results and any lab results. The assessment where you list any and all relevant diagnoses in order of relevance to your specialty. The plan section is self-explanatory.
Here’s a sample SOAP note:
S – Patient seen and examined. No new complaints / concerns. Continues to complain of pain in left shoulder and “tailbone”; describes pain as 5/10 nonradiating intermittent stabbing worse with movement. Also continues to complain of decreased appetite and fatigue. Participating in physical therapy. + BM last night. Denies CP/SOB, n/v/d, f/c. Asking when she can go home.
O – Vitals: P – 68; R – 18; BP – 112/65; T – 97.9
General: AAO x3 (alert and oriented to person, place, time), NAD (no apparent distress)
CV (cardiovascular) – RRR (regular rate and rhythm), S1S2 (specific heart sounds) noted without m/r/g (murmurs, rubs, gallops)
Pulm (pulmonary) – CTAB (clear to auscultation bilaterally), no r/r/w (rhonchi, rales, wheezes), no conversational dyspnea, adequate respiratory effort
Abd (abdomen) – soft, NT/ND (non-tender, non-distented), +BSx4 (positive bowel sounds in all four quadrants)
Ext (extremities) – no c/c/e (cyanosis, clubbing, edema), negative homan’s sign
A – (1) status post ground level fall and left shoulder fracture
(2) Hypertension – well controlled
(3) Paroxysmal atrial fibrillation
(4) Coronary artery disease – stable
(5) History of CVA (stroke)
P – (1) Continue blood pressure monitoring
(2) Fall precautions
(3) Continue rehab
(4) Discuss with attending – Dr. Smith
– Dr. Smith / John V., MS IV
After I’ve written my note I make a copy of it to carry with me so that I can answer any questions my attending has later in the day. I repeat this process about 3-4 times, depending on how many patients I need to see.
12:45PM – Scramble to lunch
….to be continued