Approach Clinical Problems- not on exam Flashcards
Systems approach
Is the cause of the problem: Cardio-vascular Respiratory GI Neurological Musculoskeletal GU Reproductive Endocrine Lymphatic
Etiology/ Epidemiology approach
Is the cause of the problem: Infectious/Inflammatory Neoplastic Metabolic Autoimmune Traumatic Congenital Degenerative Idiopathic/Iatrogenic
Order Writing: Pre- OP Orders
NPO after midnight
IV orders – type of fluids and rate
Meds – pre-op antibiotics, sedation
Labs – T & C, CBC, PT/PTT, electrolytes, BUN/Cr
Prep and shave area, antiseptic shower
Premedicate with _______ (usually ordered by anesthesia)
Foley catheter or have patient void
Example of Operative Note
Pre-op diagnosis Post-op diagnosis Procedure Surgeons and assistants Anesthesia and pain control Operative findings Specimens/frozens sent to pathology Drains/tubes/IV’s Estimated blood loss (EBL) in ml Fluids used in the procedure Tourniquet time (orthopedic cases) Complications Condition/disposition
Types of Chart Notes
Admission note Progress note Pre-Op note Operative note Post-Op note Procedure Note ICU note Off Service note Delivery note Discharge Summary note
Labs that go with these diagnoses:
Appendicitis Ectopic pregnancy Gastroenteritis Pancreatitis Cholecystitis/Cholelithiasis Gastritis/PUD IBS Cystitis PID Hepatitis Cancer-GI/GYN
Appendicitis – CT scan, ultrasound
Ectopic pregnancy – bHCG, ultrasound
Gastroenteritis – roto virus, stool C & S, stool O & P c. difficile toxin, other serology
Pancreatitis – amylase, lipase, CT scan
Cholecystitis/Cholelithiasis – CT scan, Ultrasound, HIDA
Gastritis/PUD – Endoscopy, H. pylori, serum gastrin
IBS/IBD - colonoscopy
Cystitis – UA, Urine C & S
PID – GU exam, GEN probe, CT Scan, ultrasound
Hepatitis – LFTs, Hepatitis profile
Cancer-GI/GYN – CT Scan, colonoscopy
Presenting Cases to an Attending
Aim for a 3-4 minute maximum presentation
Use notes, but maintain good eye contact with your listeners
Remember—the history is subjective (what the patient says) and the physical exam and labs are objective (what you observe)
Not everything is included in the oral presentation that will be present in your write-up. Be selective!
