SOAP note guidance from APM
You have learned that the complete patient database contains the patient history, physical examination, all relevant/known investigative data, and importantly, the assessment and plan. . . . Remember that the function of the medical record is to communicate with yourself, and to communicate with others on the health care team. That goes for your assessment […]
CONSULT Mnemonic Card
Tap each letter to view the mnemonic. C O N S U L T Contact the consultant courteously. Caller’s name, training level, team, “I am requesting a CONSULT please….” Orient. Patient name. Medical record number (MRN). Floor and bed. Code status. Narrow question. Ask a focused question regarding diagnosis (workup, procedures) and/or management (treatments, pre-op). […]
Resources
Resource Collections
Checklist for Consulting Surgery
download this checklist For emergent consultations (i.e.: surgical emergencies that require immediate beside surgical intervention/presence), best to page the surgical consultant with the specific needs and the patient’s location (e.g., tension pneumothorax, surgical airway). Necessary for urgent and routine consultations Brief patient summary sentence: 74 y.o. man with acute cholecystitis, septic shock Clinical question: Should […]
Transition to Clerkship Resources
There is a variety of resources here—different ones will be relevant for different patients whom you encounter in Wesford. Medication Reconciliation Demonstration How to write orders Illness script Normal reference ranges for lab values during pregnancy Ob/gyn tools Pediatric reference ranges How to use SimCapture EMR/EHR EMR/EHR login information Please use Chrome See our tech […]
Practice Cases
Patient 1: Joanna—I’m back on the ship Tap the arrow to view the case.A 51-year-old professor returns from a 2-week cruise to Alaska. The next morning, she calls your office to schedule a telemedicine visit. She tells you that she woke up, got out of bed, and then became “dizzy” and fell backward onto the […]
Case Study 4: My World Is Spinning
Case study 4: Min—My world is spinning Tap the image to view the case. A 62-year-old woman comes to see you about repeated episodes of spinning vertigo over five days, which gradually improved. Today (day 7), she gets 15–45 seconds of vertigo brought on by movement such as rolling over in bed. She denies tinnitus, […]
Case Study 3: I Passed Out
Case study 3: Frank—I passed out Tap the image to view the case. A 62-year-old man with a history of cluster headaches and MI comes to the office because he has increasing dizziness. He passed out yesterday while walking. Past smoker, quit 5 years ago. Brother had an MI at 55. Question Check your answer […]
Case Study 2: Dizzy Doing Dishes
Case study 2: Opal—Dizzy doing dishes Tap the image to view the case. A 72-year-old woman passed out when she turned her head to answer a question from her son while reaching to get dishes from a high cupboard. She felt dizzy for a few seconds before she lost consciousness. No chest pain. No known […]
Case Study 1: Bug Bite While Swimming
Case study 1: Jeremy—Bug bite while swimming Tap the arrow to view the case.A previously healthy, athletic 40-year-old man is brought in by ambulance. He is hypotensive after collapsing. While he was swimming, he was bitten by a large fly or bee on the forehead and bled from the bite. He suddenly felt unwell and […]