GENERAL INFORMATION FOR ALL CLERKSHIPS

ADMISSION ORDERS - ADC VAAN DIMLS (Post op orders too)
Admit:
Unit, Team, Attending, Resident, Intern, Student
Diagnosis: Reason for admission, working diagnoses (pancreatitis, MI)
Condition: Satisfactory, serious, guarded, critical, etc.
Vitals: Frequency (per routine); specify telemetry, neuro checks, O2 sats
Allergies: Indicate drug and nature of allergic reaction
Activity: Ad lib or as tolerated, up in chair, ambulate TID, BR w/ BRP
Nursing: I&O's, daily weights, bedside spirometry, wound care and dressing changes, drains (Foley to gravity). Call HO for T>38.5,HR>110, <60, SBP >160, < 90, RR> 30, < 8, UOP < 30 cc/hr
Diet: Regular, ADA, low salt, clear liquids, soft foods diet, NPO, advance as tolerated
IV: Fluids Indicate solution, additives, volume, and rate of flow, e.g. D51/2NS w/ 20 mEq KCl at 100cc/hr. Heplock with q shift flush, TKO = to keep open. If multiple lines or lumens are present, write a separate order for each
Meds: Name, dose, route, and frequency for all scheduled and PRNs
Labs: CBC, Chem 7, etc. Also include ECG and imaging.
Special: For orders that do not fall into above categories

ADMISSION NOTE
ID/CC:
One sentence describing patient and reason for admission
Problem List
HPI:
Don't forget pertinent + and -, relevant social and family hx
PMH: Medical and surgical history, diagnoses, and dates
Meds: Usually list outpatient meds
Allergies
Family Hx
Social Hx
ROS
PE
Labs
Imaging
Assessment:
Approach either by list of problems or by organ system. For each problem, include a differential diagnosis and brief explanation.
Plan: Again, by list of problems or by organ system. Consider further diagnostic measures and treatment. Include labs, meds, consults, procedures, etc.

DAILY PROGRESS NOTE
Date/Time, Service, MS3 Note
ID: Identify patient, include HD#, abx day#, POD#
E: Events (overnight pt had episodes of hypoxia)
S: Subjective - complaints, events, symptoms, pain
O: VS, weight, I&O, PE, labs, imaging
A: Assessment
P: Plan

DISCHARGE ORDERS
D/C:
To home, nursing home, SNF, etc.
Diagnoses: #1_____, #2_____, #3________
D/C Meds: Include length of continuation
Diet: Include if special considerations (ADA, NPO before surgery)
Activity: Note restrictions for work, sports, bathing or showering, weight-bearing
Follow-up: Include MD, clinic, date, time for appts, dressing changes, labs

DISCHARGE SUMMARY
Date of admission
Date of discharge
Admission / Discharge diagnoses
H&P, procedures, consults
Admission medications
Hospital course:
List by diagnoses/system or by time course
D/C medications
Disposition:
Nursing home, SNF, rehab
Follow-up: Appointments, instructions

PROCEDURE NOTE
Date/Time
Procedure:
Paracentesis, chest tube placement, etc.
Permit: Explained to pt by ___, indications/risks discussed, questions answered
Indication: Ascites, concern for meningitis, etc.
Labs: Include INR, CBC, or creatinine if relevant
Physician(s):
Description: Area prepped and draped in a sterile fashion. (Describe the anesthetic used and how it was administered). Describe technique including instruments, body location, type of needles and suture used, etc. Also include any relevant findings.
Specimens: Cultures and/or labs sent, specimens sent to pathology, etc.
Complications:
Estimated Blood Loss: None, minimal, amount in cc
Disposition: Pt alert, oriented, and resting; breating nonlabored; neurovascularly intact; incision clean, dry, and intact, etc.

WRITING PRESCRIPTIONS
Write neatly. Include patient's name, allergies, medication name, strength, and dosing.
Sig: Frequency of administration
Disp: Amount to dispense
Date/Time
Patient Name
Allergies:
NKDA
Medication: Furosemide 40 mg
Sig: 1 PO bid
Disp: #60
Refills__2__
Signature

SIGNING NOTES
Give your name, MS3, pager number, and leave room for the co-signer.

PRESENTING A PATIENT (From Dr. McGee's guidelines)
1. Concisely present relevant information from the history, PE and labs/imaging to demonstrate your understanding of the patient's condition and approach to initial management. Strive for 4-5 minutes (less on surgery) and a memorized presentation, except for lab values.
2. Include major presenting symptoms, pertinent positives/negatives, and work-up of complaint prior to hospital admission in HPI.
3. Avoid repetition, disorganization, and editorial comments. Practice before you present.
Format:

  1. ID/CC
  2. HPI
  3. Other active medical problems
  4. Meds/allergies/substance use/pertinent social history. Do not present ROS (pertinent +/- belong in HPI, rest of ROS is left out)
  5. PE, including vital signs. Can do relevant positives/negatives or full PE, depending on situation and team preference
  6. Labs, imaging. Compare to prior if available
  7. Assessment/plan/hospital course to date

ICU PRESENTATION
ID/CC, HD#
24-hour events:
Changes in management, big events
Subjective: Rare because patients are usually intubated
Lines: Know number of days each has been in
Drips and rate: Pressors, diuetic, sedatives, etc.
Antibiotics: Drug and day#
Vitals: Tmax, Tcurrent, BP range, HR range, RR, SaO2
Ventilator settings: Mode, TV, actual RR, set RR, FiO2, PEEP
Weaning parameters: RR, TV, NIF, minute ventilation, RSBI
ABG: pH / pCO2 / pO2, HCO3 / SaO2
Swan data: CVP / PAP / Wedge / Cardiac Output & Index / SVR
I&O: 24-hour volumes (have breakdown of each in case asked)
Drains
PE:
Pertinent findings
Labs / micro: Follow trends and have info available if important
Imaging: Usually CXR plus any other studies
Assessment & Plan by System: For each system, state problem and how you plan to treat or fix it. If there are no issues, state “Stable, no issues”.
Neuro
Resp / Pulm
CV
GI
Renal
Heme
ID
FEN
Prophylaxis
Endocrine
Disposition
Code Status

IMMUNIZATIONS
You must be current with all immunizations to participate in 3rd and 4th year clerkships. This includes an annual TB test and all immunizations required by the School of Medicine. Many sites outside of Seattle require you to provide results of your most recent TB test, so it is wise to carry a copy with you. Contact myshots@u.washington.edu for more information.

UNIVERSAL PRECAUTIONS
1. Hand washing: Essential. Wash hands before and after leaving a patient room, after performing procedures, after eating or using restroom, and after removing gloves.
2. Gloves: Use when contact with body fluids is anticipated. Change gloves and wash hands between patients.
3. Gowns: Used to cover skin or clothing that may become soiled with body fluids or substance during a procedure.
4. Eye protection/mask: Use whenever there is a risk of splashing or spraying of body fluids into mouth, nose, or eyes. Also use for airborne diseases (TB, pertussis)
5. Isolation: Used for patients with active TB, primary varicella, measles, mumps, rubella.
6. Sharps: Do not recap contaminated needles. Discard sharps in appropriate containers. Take care when passing sharps and inform others of sharp location to prevent accidental injury or needle sticks.

EXPOSURE PROCEDURES
If exposed to blood/body fluids, immediately:
1. Remove soiled clothing and wash exposed area with soap and water.
2. Notify attending physician, resident, or site coordinator.
3. Note the severity and type of exposure and likelihood that patient is at risk for HIV infection.
4. If you have questions about your exposure or believe you are a candidate for the antiretroviral post-exposure prophylaxis protocol, call these numbers:
In Seattle:
UWMC Campus Health Services (206) 598-4848 7:30am to 4 pm M-F
Or MEDCON 1-800-326-5300
Or UWMC Emergency Department (206) 598-4000
Outside of Seattle:
Call MEDCON or UWMC Emergency Department
If you have additional questions, call Doug Paauw, M.D., at (206) 598-6190 (pager)
5. Request venous blood from the source patient to be sent for HIV/HBV antibody testing. Follow rules/regulations of the hospital/clinic/state for HIV counseling and testing. Have a venous blood sample drawn from yourself and store. No specific storage procedures are necessary. If test result from source patient is positive for HIV, have your blood tested.

EQUATIONS
Nephrology
Anion Gap = Na - [Cl + HCO3] Nml 12 +/- 2

Urine Anion Gap = UNa + UK - UCl

Delta Gap = (AG-12) + HCO3
>30 = metabolic alkalosis
<23 = non-AG metabolic acidosis

Creatinine Clearance = Urine creatinine mg/dL x urine volume mL/day / Plasma creatinine mg/dL x 1440 min/day

Creatinine Clearance =____140 - age(yrs)____ x weight kg (x 0.85 if woman) / Serum creatinine mg/dL x 72

FeNa = Urine Na x Plasma Cr x 100 / Urine Cr x Plasma Na

Calculated serum osmolarity = (2 x Na) + BUN / 2.8 + Glu / 18 + EtOH / 4.6

Osmolal Gap = measured osm - calculated osm
>10 think about methanol, ethylene glycol, sorbitol, mannitol

Total Body Water = lean body mass (kg) x 0.6 (male) or 0.5 (female)

Free Water Deficit = 0.4 x lean body weight x [plasma Na - 1] / 140

Corrected Sodium (hyperglycemia) = measured Na + [(glu-100) x 1.6 / 100]

Corrected Calcium (hypoalbumin) = ì Ca 0.8mg/dL for every 1g/dL ì in Alb. below 4.0

Predicted Acid-Base Compensations
Acute Resp. Acidosis HCO3 up 1 for every 10 increase in pCO2
Chronic Resp. Acidosis HCO3 up 3-4 for every 10 increase in pCO2
Acute Resp. Alkalosis HCO3 down 2 for every 10 decrease in pCO2
Chronic Resp. Alkalosis HCO3 down 4-5 for every 10 decrease in pCO2
Metabolic Acidosis predicted CO2 = 1.5(HCO3) + 8 ± 2
Metabolic Alkalosis pCO2 = 0.6(HCO3) + 40

Cardiology
MAP = [SBP + (2xDBP)] / 3

SVR = 80 x [MAP - RA pressure] / Cardiac output L/min

PVR = 80 x [mean PA pressure - mean PCWP] / Cardiac output L/min

Cardiac Output (CO) = HR x SV (Nl 4-8 L/min)

Cardiac Index (CI) = CO / BSA (Nl 2.5-4.0 L/min)

BSA= sqrt [ht in cm x wt in kg] / 3600

Pulmonary
PAO2 = (Pb-PH2O) x FiO2 - (PaCO2 x 1.25)
At sea level, room air = 150 - (PaCO2 x 1.25)

(A - a) gradient = PAO2 - PaO2

Tidal Volume (Vt) = Vd (dead space) + Va (alveolar space)

Dead Space = PaCO2 - PeCO2 / PaCO2

Minute ventilation (Ve) = 0.863 x Vco2 (mL/min) / PaCO2 x (1 - Vd/Vt)

Static compliance = _______Vt____________ / Pplateau - Pend expiration

Misc
Corrected Reticulocyte count = (%retic / 2) x (Hgb / nml Hgb)

BMI = weight in kg / height (m2)

Disease + Disease -
Test + A (True positive) B (False positive)
Test - C (False negative) D (True negative)

Sensitivity = A / A + C
Specificity = D / B + D
PPV = A / A + B
NPV = D / C + D

CONVERSIONS
Temp Conversion
Celsius Fahrenheit
34.0 93.2
35.0 95.0
36.0 96.8
37.0 98.6
38.0 100.4
39.0 102.2
40.0 104.0
41.0 105.8
42.0 107.6

F = (1.8 x C) + 32
C = (F - 32) / 1.8

Unit Conversions
1 inch = 2.54 cm 1 cm = 0.394 inches
1 foot = 0.305 m 1 m = 3.291 ft
1 fl oz = 30 mL 1 ml = 0.0338 fl oz
1 gal = 3.79 L 1 L = 0.264 gal
1 tsp = 5 mL 1 Tbsp = 15 ml
1 oz = 30 g 1 gram = 0.0352 oz
1 lb = 0.45 kg 1 kg = 2.2 l

PHYSICAL SIGNS AND EPONYMS
Argyll-Robertson pupil: Small, irregular, unequal pupils that do not react to light but react to accommodation
Babinski's sign: Extension of big toe (toes upgoing) with stimulation of plantar surface
Battle's sign: Ecchymosis behind ear, associated with basilar skull fractures
Bell's palsy: Lower motor neuron lesion of the facial nerve affecting upper and lower face
Bisferiens pulse: Double-peaked pulse in severe aortic insufficiency
Bouchard's nodes: Hard, non-tender nodules on dorsolateral aspects of PIP joints. Associated with osteoarthritis
Brudzinski's sign: Flexion of the neck causes hips to flex. Seen in meningitis
Cheynes-Stokes respirations: Repeating cycles of gradual increase in depth of breathing followed by gradual decrease to apnea. Seen with CNS disorders, uremia.
Chvostek's signs: Tapping of facial nerve causes facial spasm in hypocalcemia
Cullen's sign: Ecchymosis around the umbilicus associated with retroperitoneal bleeding
Doll's eyes: Conjugated movement of eyes in one direction as the head is briskly moved in the other direction. Tests oculocephalic reflex in comatose patients.
Dupuytren's contracture: Contracture of the 4th and 5th digits due to proliferation of fibrous tissue of palmar fascia. Seen in alcoholics, individuals with seizure
Grey-Turner's sign: Ecchymosis at the flank associated with retroperitoneal bleeding
Heberden's nodes: Hard, non-tender nodules of the dorsolateral aspects of the DIP joints seen in osteoarthritis
Hegar's sign: Softening of the distal uterus, seen in early pregnancy
Hoffman sign or reflex: Flicking of the volar surface of the distal phalanx causes fingers to flex. Associated with pyramidal tract disease.
Homan's sign: Calf pain with forceful dorsiflexion of the foot. Seen with DVT.
Horner's syndrome: Unilateral miosis, ptosis, anhidrosis. Due to destruction of the unilateral superior cervical ganglion (lung carcinoma)
Janeway lesion: Erythematous or hemorrhagic lesions on palms, soles in subacute bacterial endocarditis
Kernig's sign: Extension of leg from flexed position elicits pain. Seen in meningitis
Kussmaul respirations: Deep, rapid respiratory pattern seen in DKA, coma
Levine's sign: Clenched fist over chest describing chest pain. Assoc. with angina, acute MI.
Marcus-Gunn pupil: Dilation of the pupils with swinging flashlight test. Due to unilateral optic nerve disease.
McBurney's point: Point located 1/3 of the distance between ASIS and umbilicus. Tenderness associated with acute appendicitis
Moro reflex: Abduction of the hips and extension of the arms when infant's head/upper body are suddenly dropped several inches. Normal reflex in infancy.
Murphy's sign: Severe pain and inspiratory arrest with RUQ palpation. Seen in cholecystitis.
Obturator sign: Flexion and lateral rotation of the thigh elicits pain. Seen in appendicitis and pelvic abscess.
Osler's nodes: Tender, red, raised lesions on hands or feet. Seen in subacute bacterial endocarditis.
Pancoast's syndrome: Carcinoma of the apex of lung resulting in arm or shoulder pain from involvement of brachial plexus and Horner's syndrome from involvement of superior cervical ganglion.
Phalen test: Flexion of wrists by opposing dorsum of hands against each other. Positive test results in pain and tingling in the distribution of the median nerve.
Psoas sign: Extension and elevation of the right leg produces pain when psoas muscle is inflamed in appendicitis.
Pulsus alternans: Fluctuation of the pulse pressure with every other beat. Seen in aortic stenosis and congestive heart failure.
Quickne's sign: Alternating blushing and blanching of the fingernail bed following light compression. Seen in chronic aortic insufficiency.
Rovsig's sign: Pain in the right lower quadrant with deep LLQ palpation. Seen in appendicitis.
Traube's sign: Booming or pistol shot sounds heard over the femoral arteries in chronic aortic insufficiency
Trousseau's sign: Carpal spasm produced by inflating blood pressure cuff around arm above systolic pressure in hypocalcemia
Virchow node: Palpable left supraclavicular lymph node associated with GI neoplasm.

ABBREVIATIONS
A
A before
AAA abdominal aortic aneurysm
AAO alert and oriented
Ab abortion
Abd abdomen
ABG arterial blood gas
Abx antibiotics
AC before meals
ACE angiotensin converting enzyme
ACL anterior cruciate ligament
ACLS advanced cardiac life support
ACTH adrenocorticotropic hormone
AD right ear (auris dexter)
ADAT advance diet as tolerated
ADH antidiuretic hormone
Ad lib as desired
ADL activities of daily living
AFP alpha fetoprotein
A fib atrial fibrillation
Atx atelectasis
AKA above knee amputation
AOB alcohol on breath
AP anteroposterior
ARDS acute resp. distress synd
ALL acute lymphocytic leukemia
ALT alanine aminotransferase
AMA advance maternal age
against medical advice
AML acute myelogenous leukemia
APAP acetaminophen
APD afferent pupillary defect
AS left ear (auris sinistra)
Aortic stenosis
ASD atrial septal defect
AST aspartate aminotransferase
AT atraumatic
AU both ears (auris uterque)
AV arteriovenous
Atrioventricular

B
BAER brainstem auditory evoked response
BAL blood alcohol level
brochioalveolar lavage
BBB blood brain barrier
BCC basal cell carcinoma
BE barium enema
BID twice a day (bis in die)
BiPAP bilevel positive airway pressure
BKA below knee amputation
BM bowel movement
BMP basic metabolic panel
BS bowels sounds, breath sounds
BSA body surface area
BUN blood urea nitrogen
Bx biopsy

C
c with
Ca cancer
CABG coronary artery bypass graft
CAD coronary artery disease
CBC complete blood count
CBD common bile duct
CCU coronary care unit
C/D/I clean, dry, intact
CEA carcinoembryonic antigen
CHD common hepatic duct
CHF congestive heart failure
CLL chronic lymphocytic leukemia
CML chronic myelongenous leukem
CN cranial nerves
CNS central nervous system
C/O complaints of
COPD chronic obstructive pulm dis
CP cerebral palsy
CPAP continuous positive airway pressure
CPS child protective services
CRF chronic renal failure
C/S Caesarean section
CSF cerebrospinal fluid
CT computed tomography, chest tube
CVA cerebrovascular accident
CVP central venous pressure
c/w consistent with
CXR chest xray
CTA clear to auscultation

D
D/C discontinue, discharge
D&C dilatation and curettage
DI diabetes insipidus
DM diabetes mellitus
D/O disorder
DOB date of birth
DT's delirium tremens
DTRs deep tendon reflexes
DVT deep venous thrombosis
D/W discussed with
Dx diagnosis
Dz disease

E
EBL estimated blood loss
ECMO extracorporeal membrane oxygenation
ECG electrocardiogram
EMG electromyogram
EOMI extraocular movements intact
ERCP endoscopic retrograde cholangiopancreatography
ESLD end stage liver disease
ESR erthrocyte sedimentation rate
ESRD end stage renal disease

F
FBS fasting blood sugar
FENa fractional excretion of Na
FHT fetal heart tones
F/U follow-up
FUO fever of unknown origin

G
GC gonorrhea
GER gastroesophageal reflux
GFR glomerular filtration rate
GI gastrointestinal
GSW gunshot wound
GTT glucose tolerance test
Gtts drops/IV drip
GU genitourinary

H
HD hospital day
H&H hematocrit and hemoglobin
Hct hematocrit
Hgb hemoglobin
HPF high power field
HS at bedtime (hora somni)
HTN hypertension
Hx history

I
ICU intensive care unit
IMV intermittent mandatory vent
INR international normalized ratio
I&O ins and outs (fluids)
IV intravenous
IVC inferior vena cava
IVDU intravenous drug use
IVP intravenous pyelogram

J
JP Jackson-Pratt drain
JVD jugulovenous distention

K
KUB kidneys, ureter, bladder

L
LAD left ant. descending (coronary)
Lap laparoscopic, laparotomy
LCA left coronary artery
LDH lactate dehydrogenase
LDL low density lipoprotein
LE lower extremity
LFT liver function test
LLL left lower lobe
LLQ left lower quadrant
LMP last menstrual period
LPF low power field
LP lumbar puncture
LUL left upper lobe
LUQ left upper quadrant

M
Mb myoglobin
MCC motorcycle crash
MCH mean cell hemoglobin
MCHC mean cell hemoglobin conc.
MCL medial collateral ligament
MCV mean cell volume
MI myocardial infarction
M&M morbidity and mortality
MRI magnetic resonance imaging
MVC motor vehicle crash

N
NAD no acute distress
NCAT normocephalic, atraumatic
NGT nasogastric tube
NIF negative inspiratory force
NKDA no known drug allergies
NOS not otherwise specified
NPO nothing by mouth (nulla per os)
NT nontender
N/V nausea, vomiting

O
OD right eye (oc dexter), overdose
OGT orogastric tube
OR operating room
ORIF open reduction internal fixation
OS left eye (ocular sinistre)
OT occupational therapy
OU both eyes (oculus uterque)

P
PA posteroanterior
PAC premature atrial contractions
PAT paroxysmal atrial tachycardia
p after (post)
PC after meals (post cibum)
PCL posterior cruciate ligament
PCP primary care provider
PE pulmonary embolus
PEA pulseless electrical activity
PEEP positive end-expiratory pressure
PID pelvic inflammatory disease
PFT pulmonary function test
POD post-op day
PPD purified protein derivative (Tb)
PPV positive pressure ventilation
PRN as required (pro re nata)
PSH past surgical history
PT prothrombin time, physical therapy
PTA prior to admission
PTCA percutaneous transluminal coronary angioplasty
PTT partial thromboplastin time
PTX pneumothorax
PVC premature ventricular contraction

Q
QD every day (quaque die)
QH every hour (quaque hora)
QHS every bedtime (qh somni)
QID four times a day (quarter in die)
QN every night (quaque nox)

R
RBF renal blood flow
RCA right coronary artery
Rh rhesus (Rh blood group)
RLL right lower lobe
RLQ right lower quadrant
RML right middle lobe
R/O rule out
RRR regular rate and rhythm
RT respiratory therapy
RUG retrograde urethrogram
Rx prescription

S
s without (sine)
SA sinoatrial
SAB spontaneous abortion
SBE subacute bacterial endocarditis
SBO small bowel obstruction
SCC squamous cell carcinoma
SLE systemic lupus erythematosus
SNF skilled nursing facility
SOB shortness of breath
S/P status post
SPEP serum protein electrophoresis
SQ subcutaneous
S/S signs and symptoms
Stat immediately (statim)
STH said to have
STHB said to have been
SVC superior vena cava
SVT supraventricular tachycardia
Sx symptoms
Sz seizure

T
T&A tonsillectomy and adenoidectomy
TAH total abdominal hysterectomy
TEE transesophageal echocardiogram
TEN toxic epidermal necrolysis
TIA transient ischemic attack
TID three times a day (ter in die)
TKO to keep open
TNM tumor, nodes, metastasis
TPA tissue plasminogen activator
TPN total parenteral nutrition
TSH thyroid stimulating hormone
TTE transthoracic echocardiogram
TURP transurethral resection of prostate
TV tidal volume
TVH total vaginal hysterectomy
Tx treatment

U
UA urinalysis
UOP urine output
UPEP urine protein electrophoresis
U/S ultrasound
UTI urinary tract infection
VXWYZ
VA visual acuity
VF visual fields, v fib
VS vital signs
VSS vital signs stable
VSD ventricular septal defect
VT ventricular tachycardia
WNL within normal limits
YO year old