GRAY MATTER a collection of clinical facts for students at The University of Texas Medical School at Houston

Transcription

1 1 GRAY MATTER 2015 a collection of clinical facts for students at The University of Texas Medical School at Houston Originally produced and graciously shared by Baylor College of Medicine Office of Student Affairs Edited by: UTMSH Office of Student Affairs

2 2 Welcome to the 11th edition of Gray Matter, a clinical handbook for The University of Texas Medical School at Houston students first conceived by Mark Edelman and David Savage at Baylor College of Medicine. It is hoped that this collection of practical information will be useful during your clinical assignments. Please address any corrections or suggestions to: ms-graymatter@uth.tmc.edu Revised 6/15

3 TABLE OF CONTENTS 3 PHONE DIRECTORIES... 4 UT-H... 4 Texas Medical Center & other important numbers HCPC... 5 Hermann... 5 LBJ MD Anderson Ben Taub/Texas Children s/va... 8 St. Joseph... 8 HOLIDAY POLICY... 9 CLINICAL ROTATION SCHEDULE NEEDLESTICK POLICIES & PROCEDURES CCCE EXAM POLICY ON APPROPRIATE STUDENT TREATMENT DUTY HOURS POLICY ORDERS HISTORY & PHYSICAL Heart sounds SURGERY NOTES Progress Notes Surgical Notes Operative Note Procedure Note Discharge Summary LABOR & DELIVERY H&P Delivery Notes PEDI NOTES APGAR Score Neonatal/Birth H&P Primitive Reflexes of Infancy Pediatric H&P Estimating Body Surface Area in Children Abridged Denver Chart PSYCHIATRIC HISTORY ABBREVIATED NEUROLOGIC EXAM Mini Mental Status Exam Glasgow Coma Scale Cranial Nerves, Motor, Cerebellar, Sensory, Gait Dermatomes PROCEDURES EKG INTERPRETATION NORMAL LAB VALUES DIAGNOSTIC PARAMETERS Body Mass Index (BMI) NORMAL PHYSIOLOGIC VALUES FLUIDS & ELECTROLYTES MEDICAL SPANISH HEALTH CARE RESOURCES FOR THE HOMELESS METABOLIC ROUNDS CAREER CONSIDERATIONS EMR Log-in Information... 62

4 4 UNIVERSITY OF TEXAS MEDICAL SCHOOL AT HOUSTON (713) EMERGENCY 911 or 4357 (HELP) SECURITY 911 or 4357 (HELP) POLICE (non-emergency) (713) NEEDLESTICK HOTLINE (713) Student Affairs Margaret C. McNeese, M.D Sheela Lahoti, M.D Yolanda Clay Bell (parking) Pat Caver Steve Jones (schedules) Jamie Munsinger Kara Ramirez Kendall McKee Yvette Pinales Kisha Kohl Karla Trochez Fax Student Health UTPB Suite 130 Student Counseling Registrar: Brenda Powers Fax Financial Aid Fax Admissions Alumni Relations Auxiliary Enterprises Bookstore (8:30 AM-5 PM M-F) Cashier s Window/Bursar UCT (8AM-5PM M-F) Educational Programs Office Graduate Medical Education I.D. Badge Replacement (Cashier s Window) I.D. Badge Activation (Student Affairs) Learning Resource Center (LRC) Library - TMC Mon-Th 7 AM-10 PM Friday 7 AM-9 PM Saturday 9 AM-5 PM Sunday 1 PM-8 PM Online Catalog (computer) TexSearch (computer) Quick Copy (Med School) Rec Center (Knight Road) Risk Management Office Security Escorts PHONE DIRECTORIES Clerkship contacts Family Medicine Barbara.J.David@uth.tmc.edu Geriatrics Orit.Clarke@uth.tmc.edu Internal Medicine Venettea.Mitchell@uth.tmc.edu Obstetrics/Gynecology Yaki.B.Bryant@uth.tmc.edu (MHH) Clarissa.J.Spraberry@uth.tmc.edu (LBJ) vyacouby@houstonmethodist.org (St. Joseph) Pediatrics Deborah.Hernandez@uth.tmc.edu Psychiatry Kristi.D.Rowell@uth.tmc.edu Surgery Amber.J.McNutt@uth.tmc.edu Neurology Jennifer.Tremont@uth.tmc.edu APC/RCC/RTR Dawn.C.Morvant@uth.tmc.edu CCCE Marcy.Hamburger@uth.tmc.edu UT-H Clinics Cardiology Dermatology Endocrinology Family Practice General Medicine General Surgery Infectious Diseases Nephrology Neurology Neurosurgery Ob/Gyn Orthopaedics Otolrhinoaryngology Pediatrics Plastic Surgery Pulmonary Rheumatology Women s Health Center TEXAS MEDICAL CENTER AND OTHER IMPORTANT NUMBERS Child Abuse Hotline (rpt within 24 hrs) (800)

5 PHONE DIRECTORIES (continued) 5 City Health Dept Interventional Radiology Houston Area Women s Center Labor and Delivery Information (Houston) Laboratory Services (4-LABS) Information (TMC) Medical Intensive Care (MICU) Metro Bus Route Info Medical Intermediate Care (MIMU) Southeast Poison Control Ctr Medical Records TMC Brown Lot Office (Car Trouble) Fax TMC Credit and Collections MRI-Radiology TMC Cust. Svc. (Garage #2) Neonatal Intensive Care (NICU) TMC Police (Garage #2) Neonatal Level II Nursery TWU Neuroscience Unit UT Physicians Referral (888) Nuclear Medicine Reportable Diseases (800) Nursery (Well Baby) Pharmacy Central (Cullen) HCPC, HERMANN-TMC, ST. JOSEPH, LBJ, and MDA HCPC (713) Main 5000/5050 Admissions 3883 Lab/EKG 8621, 7854 Medical Records 7888 Pharmacy 8610 Security 8686 Unit 1B C 4710/4810 1D 4816/5016 1E B C D E B C D E 4835 MEMORIAL HERMANN - TMC (713)70 Main Hospital Admissions CT Scan Cardiac Care Unit (CCU) Cardiovascular ICU (CVICU) Care 4 EMR Help Desk Central Supply Consults call and request to be transferred Day Surgery EEG Emergency Center (Triage) Eye Center General Medicine (Cullen 5W), (Cullen 5E) Surgery Satellite (OR Pharmacy) Pharmacy - Pedi Ortho Trauma Pedi Intensive Care (PICU) Radiology Radiology-Pedi Recovery (PACU) Resident Paging alternate in Hermann Surgical Intermediate Care (SIMU) Social Work Shock Trauma ICU (STICU) A&B Surgery (Control Desk) Translator / Pager (inside) LBJ (713)56... Main Hospital (713) Page operator HCHD Administration HCHD Computer Help (713)-566-HELP UT Chief of Staff Nursing Administration Legal Affairs-UT (713) Security EMERGENCY NUMBERS FIRE CONDITION A Code & Conditions Admitting Office Business Office , Alcohol/Drug Abuse Counselor Audiologist , Bed Control Biomedical Technician , Chemotherapy Clinic

6 6 Discharge Planning Coordinator Women and Children Services Med, Surg, Ortho and Renal Obstetrics & Gynecology , Oncology Pediatrics Primary Medicine Clinic (4C) Surgery, General Surgery, Jail Surgery, Ophthalmology Surgery, Oral and Maxillofacial (only MWF) Surgery, Orthopedics (only MTh) Surgery, Otolaryngology/ENT (only TTh) Surgery, Plastics , Callroom Repairs/Maintenance Cardiology Department , Cashier Central (employee) Discharge Emergency Center OB/Gyn Chaplain Clinics Internal Medicine Midwifery Surgery, Urology Dietician EMERGENCY CENTER (Adult) Discharge Front Desk , Holding , Registration Suture Room Chemotherapy Triage EMERGENCY CENTER (Pediatrics) ECHO Cardiograms , EEG EKG GI Engineering (reporting maintenance) Housekeeping Infection Control IR IT Help Desk LABORATORY/PATHOLOGY Anatomical Pathology Bood Bank Bone Marrow Chemistry , , Cytology PHONE DIRECTORIES (continued) Fine Needle Aspirates Hematology , Histology , Micro , Lab Administration , Reports , Residents Room Serology (Ben Taub) Specimen Collection , STAT Lab TB Urinalysis LBJ Information Medical Records Charts pulled for completion Patient charts Fax Nuclear Medicine NURSING STATIONS 2A (Pediatrics) B (Surgical Post OB/GYN) C (OB/GYN Clinic) A (Med/Surg) B (Surg/Ortho) C (IMU) A (Medicine) B (Chemotherapy) B (Dialysis) C (Primary Medicine Clinic) Obstetrics and Gynecology Birthing Center Labor and Delivery Midwives B Perinatal Testing/Genetic Counselor Residents Lounge Triage Occupational Therapy Operating Room OR Director OR Front Desk , OR # OR # OR # OR # OR # OR # OR Nurse Manager OR Holding/SDSU , OR Materials Manager OR Post Scheduling MICU

7 PACU , PACU/SDSU Nurse Manager Sterile Processing Manager Ophthalmology Clinic Oral and Maxillofacial Surgery Oral Surgery Clinic Oral Surgery Front Desk Ortho clinic Pediatrics Chief Resident Chief, Community & Gen Pediatrics Clinic Emergency Center In-Patient (Nursing Unit 4A) Director, Newborn Service , Newborn Nursery NICU Pharmacy Director Drug Information Center (Ben Taub) In-Patient 3 rd floor satellite , IV Room , Out-Patient , Physical Therapy Operations Manager PT & OT Physician Services Psychiatry Consults Pulmonary Function Test Radiology (reading rooms in back) Reading Room CT Dictation Line Instructions: select #1, Doctor,2,000 MRN File Room Mammogram MRI Nuclear Medicine , Special Procedures Ultrasound X-ray Rehabilitation Services Operations Manager Occupational Therapy Physical Therapy Respiratory Therapy Risk Manag/Legal Affairs-UT (713) Social Services Speech/Language Pathologist Stress Testing (Cardiology) Translator/Interpreter , PHONE DIRECTORIES (continued) MD ANDERSON (713)79 General Information Cardiology Cytology/FNA Cytopathology Division of Medicine Division of Surgery Emergency Center General Oncology GI Center Head and Neck Imaging: CT/nuclear / Inpt. Routine Lab Stat Lab Leukemia/Bioimmunity Center Lymphoma/Myeloma Medical Records Fax Nursing Stations 3 Purple E Purple W Purple E Purple W Purple E Purple W PACU Purple E Purple E Purple E Purple E Purple E Purple E Purple E Purple E Green SW(Pedi Tx Rm) Green NW Green NE Green SE Green SW Green NW Green NE Green SE Green SW Green NW Green NE Green SE Green SW Green NW Green NE Green SE

8 8 ICU Pod A/B/C ICU Pod D/E Operator Page Operator Pathology , Pedi Pharmacy Surgery Check-In OR Social Work Translator After Hours TEXAS CHILDREN S (832) VA HOSPITAL (713) PHONE DIRECTORIES (continued) Labor and Delivery (713) nd floor, MGJ Bldg NICU (713) st floor, MGJ Bldg Family Birth Center (713) rd floor, MGJ Bldg Women s Surgery Unit (713) th floor, SKS Bldg Antepartum Unit (713) th floor, MGJ Bldg *From in house, for numbers beginning with 756, 757, 657, or 356, only the last four digits of the telephone number need to be dialed. For local calls dial 9 + local number. Dial 0 for the Hospital Operator and 1111 for the Page Operator. ST. JOSEPH *(713) Administration (713) Help Desk (713) Main Laboratory (713) ext 1557 Radiology (713) Dictation line 7499 Instructions: #111111, MRN Physical Therapy (713) Surgery (713) Medical Records (713) Pharmacy 6 GWS (713) ext 1070 Security Dispatch (713) ext 1313 Social Work/Case Management (713) Graduate Medical Education: Director (713) Resident Study Room (713) Coordinator FP Prog (713) Coordinator Ob/Gyn Prog (713) Coordin. Plastic Surg Prog (713) Coordinator Trans Prog (713) Patient Care Units: ICU (713) th floor Pavillion Rehab (713) rd floor, GWS Bldg SNF (713) th floor, GWS Bldg 5 Main Med/Surg Floor (713) th floor, GWS Bldg 6 Main Telemetry Floor (713) th floor, GWS bldg 8 Main Medical Floor (713) th floor, GWS Bldg BEN TAUB (713) Medical Records Fax

9 HOLIDAY POLICY Holiday Policy for Third-Year Students Students are excused from their clinical duties for the following holidays: July 4 Labor Day Thanksgiving Day Friday after Thanksgiving Memorial Day 9 Students will be excused at the end of their assigned duties the day before the holiday and are expected to report for duty the morning after the holiday. These days will be considered your day off for the week when you are on an in-patient ward service. Holiday Policy for Fourth-Year Students Students are excused from their clinical duties for the following holidays: July 4 Labor Day Thanksgiving Day Friday after Thanksgiving Christmas Eve Christmas Day New Year s Day Match Day Memorial Day Students will be excused at the end of their assigned duties the day before the holiday and are expected to report for duty the morning after the holiday. USEFUL WEB SITES Am I On (Call schedule for Internal Medicine at LBJ and Hermann) Harrison s Online HCHD Medical Records HAM-TMC Library MD Consult Memorial Hermann Online Check-out Sheet National Guideline Clearinghouse Office of Student Affairs (for first-time Hermann patients that have been to LBJ or Ben Taub) One45 Tracking System Guide to clinical clerkships used to complete evaluations and log patient encounters, clinical skills, clinical procedures, and duty hours. Use your UTHSC-H user ID and password to log in. Contact the Help Desk at if you have difficulty accessing the system. PubMed Resident Pager Service (passwords: uthpeds, uthim) Student Pages DynaMed

10 CLINICAL ROTATION SCHEDULE

11 NEEDLESTICK POLICIES & PROCEDURES 11 UT Student Health Services operates a Needlestick Hotline 24 hours a day, 7 days a week to expedite your treatment in case of needlestick or body fluid exposure. Regardless of the hospital or clinic where you are working, the procedure is the same. You should have a Needlestick sticker on the back of your student identification badge. If you sustain a needlestick or have an accidental exposure to bloodborne pathogens... page (713) 500-OUCH 24 hours a day Do NOT go to the nearest emergency room. Your page will be answered promptly, and you will receive specific instructions and information. After you page the hotline, remain by the phone but do not use it or your call cannot be returned. Most calls will be answered within 5-10 minutes. You will be asked to give a detailed description of the incident. Your baseline labs will be checked, as well as the labs on your source patient. Then you will be counseled on your overall risk, and if treatment is necessary. You will be given follow-up labs at defined intervals over the next 6 months to a year. The costs associated with the Needlestick Hotline (your laboratory work and medications) are covered by the medical school. However, if you choose not to follow the Needlestick Hotline procedure and see your own physician (private or through an emergency department, for example), you will be personally responsible for all costs, and these will not be reimbursed by UT Student Health Services. If you have any questions, please call the clinic at (713) , or stop by UT Student Health Services, which is located in the UT Professional Building, Suite 1010.

12 12 CCCE EXAM/POLICY ON APPROPRIATE STUDENT TREATMENT CCCE EXAM The CCCE is a standardized patient examination composed of seven patient encounters and one simulation station with different scenarios. The exam assesses a student s clinical skills. History taking, physical examination, communication/ interpersonal skills and problem solving management skills are all included. The purpose of the exam is: - To provide students with a comprehensive and valid assessment of their clinical skills, following the completion of all required third-year clerkships, and to target areas of deficiency. - To provide students with practice for the USMLE Step II clinical performance exam required by the National Board of Medical Examiners. - To gather overall class data on student clinical skills. This information is used to address student needs by implementing curriculum and training changes. Exam Format The exam format is similar to that of the USMLE exam. It is comprised of seven student/ pa tient encounters with one simulation station with different scenarios and post encounter exercises. Seven of the patient encounters including the simulation station are 15 minutes in length. One case is 40 minutes in length. Students have ten minutes between cases, during which time they are required to answer multiple choice questions or write a SOAP Note related to the case and complete a case evaluation. POLICY ON APPROPRIATE STUDENT TREATMENT I. Standards for Conduct in the Teacher-Learner Relationship The academic environment, particularly in medical education, requires civility from all participants, regardless of role or level, and a particular respect for the values of professionalism, ethics, and humanism in the practice of medicine. The relationship between teacher and learner is based on mutual respect and trust. Faculty must respect students level of knowledge and skills, which students have the responsibility to represent honestly to faculty. Faculty are obligated to evaluate students work fairly and honestly, without discrimination based on gender, ethnicity, national origin, sexual orientation, religious beliefs, disability or veteran status. Faculty have a duty not only to promote growth of the intellect but at the same time to model the qualities of candor, compassion, perseverance, diligence, humility, and respect for all human beings. Because this policy pertains to students as learners, references to teachers or faculty shall also include residents and fellows in their teaching and supervisory role with regard to students. Examples of unacceptable behavior include, but are not limited to: Physical or sexual harassment or abuse Discrimination or harassment based on race, gender, age, ethnicity, national origin, religion, sexual orientation, veteran status or disability Speaking in disparaging ways about an individual including humor that demeans an individual or a group

13 POLICY ON APPROPRIATE STUDENT TREATMENT (continued) 13 Requesting or requiring students to engage in illegal or inappropriate activities or unethical practices Loss of personal civility, such as shouting, displays of temper, publicly or privately abusing, belittling, or humiliating a student Use of grading or other forms of evaluation in a punitive or retaliatory manner. Students are also expected to maintain the same high standards of conduct in their relationships with faculty, residents, support staff, and fellow students. II. Procedures for Reporting and Investigating Violations Students enrolled in the Medical School (or Medical School portion of the M.D./Ph.D. program) should report abuse or mistreatment to the Associate Dean for Student Affairs, or they may contact the Human Resources Department or the UTHealth Compliance Hotline (which permits anonymous reports and/or complaints). UTHealth policies concerning misconduct by faculty and staff, including allegations of discrimination (including harassment) and retaliation, are outlined in the Handbook of Operating Procedures (HOOP). Relevant policies that can be found at htm include Policies 39, 59, 108,109, 183 and 186. The Associate Dean for Student Affairs will advise and assist the student in following applicable procedures of the institution. III. Dissemination and Education In order to make sure that faculty, residents, fellows, and students are aware of the Policy on Appropriate Student Treatment, several mechanisms for dissemination will be used. The Policy will be added to the Medical School website on the main student, faculty, and house staff web pages. A paper copy of the Policy will be provided to current house staff and fellows and given to new house staff during orientation. A paper copy of the Policy will be provided to current students, and thereafter to entering students at orientation. The policy will be reviewed and discussed at orientation for entering students and at the third-year orientation. A paper copy of the Policy will be provided to faculty and distributed at faculty orientations. Department Chairs and Directors will be responsible for ensuring that the Policy is discussed at departmental/division meetings. Each course director, clerkship director and/or Program Director will be responsible for providing a paper or electronic copy of the Policy to their respective teaching faculty and to all students at the start of each course, clerkship or rotation. To report student mistreatment, call: or

14 14 DUTY HOURS POLICY U.T. Medical School at Houston Duty Hours Policy for Medical Students on Clinical Clerkships Approved by the Curriculum Committee on March 16, 2011 for implementation effective June 27, Clerkships must provide students with adequate time for individual study, sleep and relaxation. The following policies set forth the acceptable amount of time that clerkships may require of students. Duty hours include inpatient and outpatient clinical activities and scheduled academic exercises such as conferences and lectures that are related to the clerkship. I. Total duty hours must not exceed 80 hours per week, averaged over a fourweek period. II. Call will be scheduled to coincide with the attending and resident team. III. Duty hour periods in the hospital will not exceed 28 consecutive hours. IV. In each month the clerkship will provide each student with four individual 24-hour periods free from any required clinical or educational activities. Clerkship directors are responsible for overseeing this policy.

15 ORDERS ADMISSION ORDERS (Remember ABC VANDALISM ) Admit to: (floor, service, MD) Diagnosis: (Because) Condition: (good, fair, poor, critical, guarded) Vital Signs: (q shift, q 4h, per routine, etc.) Allergies: Nursing: (I&O s, daily weights, turn patient q 4h, etc.) Diet: (regular, clear or full liquid, 4 g Na, low or hi protein, ADA calories, etc.) Activity: (ad lib, bedrest with/without bathroom privileges, OOB tid, etc.) Labs: (also x-rays, EKG s, etc.) IV Fluids: (type, added KCl, rate) Studies: (CXR, MRI, CT, EKG, EEG, etc.) Meds: Call house officer if T>101, BP>170/110 or <90/50, HR>120 or <50 15 PRE-OP ORDERS Diagnosis: Procedure planned: Labs: (lytes, CBC, PT/PTT, UA, amylase if applicable) CXR EKG (if > 35 yo or h/o heart disease) Type and crossmatch Prep and shave surgical field NPO after midnight Void on call to OR Foley catheter (if indicated) Consent form signed and on chart History and Physical on chart DISCHARGE ORDERS (Remember 4DCAF ) Discharge: when and to where Diagnosis: Discharge Medications: (also need to fill out prescriptions) Diet: Condition: (eg. good) Activity: (eg. ad lib with 6 weeks pelvic rest for postpartum patients) Follow up: (eg. return to clinic in 1 week) Call MD for (where and when) PRESCRIPTION WRITING Patient s name, address, age Date Rx: (drug name, strength, type) Sig: (quantity, route, frequency, any other instructions) Disp #: (amount to be dispensed) Refills? Substitutions? M.D. Signature

16 16 HISTORY & PHYSICAL INTRODUCTORY SENTENCE This sentence should include the number of hospital admissions or clinic visits followed by the patient s age, race, parity, sex, occupation, and the patient s chief complaint or complaints (C.C.) in his/her own words. SOURCE Source of history, assessment of reliability. PRESENT ILLNESS The present illness should be told in chronological sequence with reference to calendar date or time prior to admission, outlining the course of the illness from its beginning. Expound on each symptom thoroughly and its course. Previous treatment and hospitalizations should be noted; identify all significant medications received. Items of past medical history, family history, occupational history or social history that might have a bearing on the present illness should be included. Any symptoms suggested by the clinical picture which are not present should be noted and denied, i.e. pertinent negatives. PAST MEDICAL HISTORY General Health: Patient s general health throughout life. Childhood Health: General health and development. Note important deviations. Also, specifically mention acute febrile illnesses of childhood. Medical Illnesses: List and/or describe all illnesses requiring hospitalizations or a physician s care. Give dates. Note past blood transfusions. Operations and Injuries: Describe briefly and date each operation. Identify the hospital and surgeon, if known. Give dates of severe lacerations, head trauma, sprains, broken bones, or gunshot wounds. Describe sequelae. Medications: List all prescription and OTC medications including dosages and frequency. Allergies and Immunizations: Record all known allergies, specifically allergies to drugs and type of allergic reaction. Remark on the state of immunization of the patient. FAMILY HISTORY Ask about diseases in parents, siblings, and children including present age, age at death, and the cause of death where applicable. Specific diseases to be asked about are: cancer, diabetes, gout, TB, bleeding disorders, arthritis, anemia, hypertension, migraine headaches, allergies, mental or nervous disorders, diseases of the cardiovascular system, congenital defects in children, SIDS, or consanguinity. PERSONAL AND SOCIAL HISTORY Inquire about: alcohol use (quantity and type), smoking (how much, how long), unusual drug habits, occupation, economic status, leisure activities, home, family and marital history. REVIEW OF SYSTEMS Skin: moisture, temperature, color, texture, changes in hair or nails, itching, rashes, lesions Head: headache, head injury Eyes: vision, glasses, pain, photophobia, proptosis, diplopia, scotomata, lacrimation, inflammation, infection, discharge

17 HISTORY & PHYSICAL (continued) 17 Ears: hearing acuity, pain, tinnitus,vertigo, infection, discharge Nose: head colds, discharge, epistaxis, obstruction, sinus pain, anosmia Mouth & Throat: lesions in mouth, tongue or lips, pain in mouth or tongue, condition of teeth and gums, sore throats, postnasal discharge, speech difficulty, hoarseness Neck: stiffness, pain, limitations of motion, goiter, swelling Breasts (both sexes): pain, swelling, discharge, masses Respiratory: cough sputum (character, amount), hemoptysis, chills, fever, night sweats, dyspnea, wheezing, asthma, pain, pleurisy, bronchitis, pneumonia CVS: cyanosis, exertional dyspnea, paroxysmal nocturnal dyspnea, edema, palpitations, irregular rhythm, precordial pain (character, radiation, duration, location; relation to exercise, posture, eating, effect of medication), known hypertension, heart disease, or lipid disorder, claudication, varicose veins, phlebitis GI: appetite, food intolerance, dysphagia, belching, water-brash, heart-burn, sour stomach, nausea, vomiting, hematemesis, rectal pain, hemorrhoids, jaundice, hernia, gas (flatus, belching, borborygmis), change in bowel habits (regularity, frequency, laxative use), stools (color, consistency, size, shape, odor, bloody or tarry), epigastric distress (rel. to meals, relief by antacids, belching or food), abdominal pain (loc. & radiation; sharp, knife-like, colicky, dull, aching, gnawing; constant or intermittent; severity; relationship to eating, defecation, urination or menstruation; relieved by belching, vomiting, doubling up, defecation, urination, enema or drugs) GU: dysuria, urgency, frequency, nocturia, polyuria, incontinence, hesitancy, dribbling, size of stream, retention, oliguria, anuria, smoky urine, hematuria, pyuria, back or CVA pain, history of UTI, stones or gravel, gonorrhea and syphilis by name or symptoms OB-GYN: age of menarche, menses (freq., regularity, duration, amount, dysmenorrhea, recent changes in cycle, passage of clots, intermenstrual bleeding/metrorrhagia), menopause (spontaneous or surgical, date, complications subsequent vaginal bleeding), vaginal discharge, genital lesions, infertility, past use of birth control pills, pregnancies (number, abortions, complications, vaginal or cesarian, weight of babies) Bones, Joints, Muscles: pain, tenderness, swelling, stiffness limitations of movement, previous injuries and deformities Endocrine: general (weight change, easy fatigability, behavioral changes), diabetes (polyuria, polydipsia, infections), change in size of features, hands, feet, impotence, decrease in libido, change in body hair or distribution, thyroid disease (goiter, heat or cold intolerance, sweating, exophthalmos, tremor, skin and hair changes) Neurological: syncope, convulsions, unconsciousness, dizziness, vertigo, ataxia, tremor, weakness, paralysis, incoordination, pain, numbness, paresthesias, difficulty with speech or swallowing, difficulty with bladder or bowel control, localized or generalized symptoms Psychiatric: rapid changes in mood, memory loss, phobias, hallucinations, antisocial behavior, sleep disturbances, previous emotional illness and treatment PHYSICAL EXAMINATION General: A brief sentence to characterize the overall appearance of the patient including body habitus, muscular development, nutrition, and whether the patient appears to be of stated age, acutely ill, in acute distress, pain, dyspneic, coughing, etc. Vital Signs: ht, wt, (% iles and FOC in pediatrics), temp, blood pressure (which arm and whether supine, sitting, or standing), pulse, and respiration.

18 18 HISTORY & PHYSICAL (continued) Skin: hands, nails, hair; color, pigmentation, texture, moisture, temperature, and lesions. Lymph nodes posterior auricular, submaxillary, cervical, epitrochlear, axillary, and inguinal. Decubitus ulcers Grade I = superficial Grade III = muscle exposed Grade II = subcutaneous Grade IV = bone exposed Head: symmetry, deformities, skull size, scars, tenderness, tumors, or lesions. Eyes: visual acuity (OD=right eye; OS=left eye) and fields, exophthalmos, EOM, nystagmus, strabismus, inflammation, discharge, conjunctivae, sclera, corneal scars, opacity, ulcerations, arcus. Iris (iridectomy or lesions). Pupil size, regularity, equality, and reaction to light and accomodation (PERRLA). Lens (cataract, or dislocation). Fundi: disc (color, margins, cupping, and papilledema); vessels (size, tortuosity, AV nicking); hemorrhages, exudates, or lesions. Ears: hearing acuity, symmetry, tenderness, discharge, perforation, tophi; Weber and Rinne test results. Nose: deformity, septal deviation or perforation, obstruction, mucosa (discharge, bleeding, polyps), sinuses. Mouth and Throat: lips and mucous membranes (colors, lesions), tongue (size, color, papillae, lesions). Teeth and gums. Soft Palate. Uvula. Tonsils and pharynx (inflammation, exudate, and tonsillar size). Neck: symmetry, scars, ROM, stiffness, tenderness; thyroid (size, symmetry, nodules, and tenderness); trachea midline; level of jugular venous pressure, carotid pulses, bruits; masses. Spine: curvature, symmetry, mobility, tenderness. Chest: shape, symmetry, respiratory excursions, AP diameter, masses, tenderness, fremitus, percussion, rales, rhonchi, breath sounds, egophony ( e-to-a change), whispered pectoriloquy ( ninety-nine ), wheezes, friction rubs. Heart: heart sounds** (see page 19), rhythm, precordial heave or thrill, PMI location and character, pulsations, enlargement, murmurs (intensity, timing, location, and radiation), rubs and gallops. Breast: shape, symmetry, retractions, discharge, ulceration, masses, tenderness, scars. Abdomen: contour, scars, striae, venous pattern, abnormal movements; auscultation for bowel sounds (frequency and character) and bruits; percussion for liver and splenic dullness, ascites (shifting dullness); palpation for liver, spleen, kidneys, bladder, colon, masses, aortic pulsations; CVA tenderness, abdominal tenderness (direct and rebound), guarding, hernias, femoral pulses, lymphadenopathy. Genitalia: Male size and development of penis and testes, hydrocoele, varicocoele, masses, discharge, lesions. Female External genitalia, Bartholin s glands, uretheral orifice, clitoris, cystocoele, rectocoele, prolapse, vaginal or cervical discharge, lesions, bleeding, cervix, uterus, adnexae, or masses (note size, location, mobility, and tenderness), Pap smear. Rectal: hemorrhoids, fissures, ulcerations, bleeding, sphincter tone, masses, tenderness, prostate, stool color, stool for occult blood test. Extremities: atrophy, tremor, cyanosis, clubbing, edema, redness, tenderness, limitation of joint motion, deformities, pulses (normal is 2+ and equal bilaterally). Neurological: (see pages 32-34) mental status, behavior, alertness, orientation, mood, memory (recent and remote), speech; gait, Rhomberg, cranial nerve function, muscle (coordination, strength, tremor, abnormal movements), sensation (light touch, pin prick, temperature, position, vibration, two point discrimination), reflexes (abdominalis, cremasteric, biceps, triceps, radials, Hoffman, patellar, Achilles, plantar), clonus. Stick figures are helpful for reflexes.

19 HISTORY & PHYSICAL (continued) SUMMARY One or two sentences that contain only those points of the history and physical which contribute directly to the establishment of a diagnosis. 19 PROBLEM LIST Numbered in order of importance, include date of entry. IMPRESSION List of tentative diagnosis based on the history and physical exam to explain the problems noted under the problem list. This section should express your impressions diagnostically as to possible explanations for the problems found and most importantly why you feel these diagnoses should be considered. Likewise, reasons you feel certain disease processes are operative should also be discussed. PLAN Record all planned diagnostic and therapeutic procedures and plan for education of the patient based on the problem list generated. This format for history and physical exams is modeled after the Baylor College of Medicine Publication Guidelines: Medical, History and Physical Examination Writeup (1/83) **Heart Sounds S1: Loud: MS, short PR, hyperkinetic heart, thin chest wall Soft: Long PR, heart failure, MR, thick chest wall, emphysema S2: Nl: A2 before P2 with h splitting on inspiration Loud A2: Systemic HTN Widened spitting: RBBB, PS, MR Soft A2: AS Fixed splitting: ASD Loud P2: Pulmonary HTN Narrow splitting: Pulmonary HTN Soft P3: PS Paradoxical splitting: (narrows w/ respiration) AS, LBBB,CHF S3: Best heard w/ bell at apex and follows S2; LV failure, vol overload, nl in children S4: Best heard w/ bell at apex and precedes S1; AS, HTN, IHSS, CAD Ejection click: High pitch following S1; dilation of aortic root or pulmonary artery, AS, PS Opening Snap: High-pitched, follows S2, at L sternal border and apex in MS Midsystolic Clicks: Lower L sternal border in MVP Murmur grading: I=Faintest audible; heard only w/ special effort II=Faint, but easily audible III=Moderately loud IV=Loud; assoc w/ a thrill V=Very loud; + thrill; may be heard w/ stethoscope off chest VI=Max loudness; heard without a stethoscope Systolic murmurs: Lesion Type Valsalva HandGrip Squat Stand AS Crecendo MR Holosystolic VSD Holosystolic MVP Late systolic IHSS Harsh, diamond shaped Diastolic Murmurs: Early: Aortic or Pulmonary Regurgitation Mid-to-Late: MS, TS, mitral myxoma Continuous: PDA, AV fistula, Aortopulmonary septal defect

20 20 SURGERY NOTES PROGRESS/SOAP NOTE (GENERAL) Hospital day # Postop day # Antibiotic day # Subjective: how the patient feels, new complaints, continuing complaints, dizziness, pain, bowel movement, flatus, nausea, vomiting, etc. Objective: Vital signs PE by system including any surgical wounds Labs Shorthand for laboratory values: Chem-7 (SMA-7) NA K Cl HCO 3 BUN Cr Glucose CBC WBC Hgb Hct Some people switch MCV/MCH/MCHC WBC with platelets platelets segs/bands/lymphs/monos/basos/eos LFTs Alb. T. Prot. ALT AST D. Bili. T. Bili. Alk. Phos. Studies (CXR, MRI, EEG, etc.) Assessment: List each problem and its current status, eg #1 IDDM still poorly control, patient doesn t understand disease #2 HTN well controlled on current meds Plan: What are you going to do?, eg: #1 increase insulin to 30 units NPH q am, will contact diabetic teaching for education #2 continue current meds and doses PROGRESS NOTE (ICU) System oriented. Objective, assessment and plan done for each system in turn. Vitals (can include weight, growth esp. if pedi) Meds: list all medications pt is on Systems: Remember you have 11 systems in alphabetical order and you ll do great: A/B: airway, breathing, vent settings, apneic episodes, ABGs, po2 (pulse ox), etc. CVS: heart, pulses CNS ( Da brain ): F/E/N: fluids/electrolytes/nutrition (incl I+O s, TPN and residuals, Chem 7/lytes) GI: abdominal exam, pertinent studies, BM s, flatus, guaiac Heme: jaundice, CBC with differential, PT/PTT, etc. ID: infectious disease (include antibiotics, peak/trough levels, fever status, etc.)

21 SURGERY NOTES (continued) 21 Joints/Bones/Muscles: Kidney: Lines: List each and # of days it has been in place, whether local erythema, etc. Skin: rashes, decubitus ulcers (grade? see page 16) OPERATIVE NOTE Date of procedure: Procedure performed: Pre-op diagnosis: Post-op diagnosis: Surgeon: Assistant(s): Type of anesthesia: Anesthesiologist: Pump Time (if applicable): Clamp Time (if applicable): Findings: Specimen(s): Tubes/drains: (NG, ETT, Foley, wound drains) EBL: estimated blood loss, ask anesthesiologist Fluids in: type and amount Fluids out: eg. urine output, NG drainage Complications: (if not none, a resident/attending should be writing this note) Pt s condition/disposition (e.g., pt transfered to RR awake, extubated and stable) COMMON SURGICAL NOTES Admission/Pre-op H & P CC: (Chief complaint) HPI: (History of Present Illness) PSHx: (Past surgical history) PMHx: (Past medical history) - esp. clotting disorders Medications: types and dosage Allergies: FH: (Family history) Family members w/clotting disorders or anesthesia reactions SH: (Social history) tobacco, ETOH, street drug, caregivers, home, occupation ROS: esp fevers, chills, night sweats, weight loss, URI, GI, dysuria, bruising/bleeding Physical exam: Vitals, Wt: General: HEENT: Ears, sclera, conjunctiva, mouth, throat, lymph nodes, thyroid CV: Regular rate and rhythm? S1S2, murmurs Lungs: Auscultation, +/- percussion Abdomen: Bowel sounds, soft vs. vol/involuntary guarding, distention, tenderness GU: hernias, rashes, lesions Rectal: tone, masses, hemoccult Extremities: edema, rashes, lesions Neuro: Mental status, CN II-XII, gross motor, gross sensory, DTR s Labs: Most likely UA, CBC and Chem 7, +/- coags (PT, PTT), +/- Type & Cross or Type & Screen, +/- platelet count

22 22 SURGERY NOTES (continued) CXR: Depends on age and risk factors. EKG: Depends on age and risk factors Assessment: Be brief, i.e. 67 year-old diabetic male with right inguinal hernia. Plan: Be brief, i.e. admit to 6 Jones, HH orange team. Hernia repair on 1/28/04. Consider medical co-morbidities and whether cardiac stress testing or medical clearance is necessary. Admission Orders (Post-op) Admit to: Ward #, team, attending, Resident, Intern, Med Student. Include pager numbers. Diagnosis: S/P (status post ) procedure. Give disease process not actual diagnosis. Condition: stable, fair, critical Vitals: Vitals q 1/2/4/6 h. Also include neuro checks, O 2 sats, etc. if needed. Activity: OOB(out of bed) ad lib/with assistance, BR with BRP (Bed rest with bathroom privileges), Strict BR, ambulate with assistance TID, etc. Allergies: Specific or NKDA (no known drug allergies) Nursing: -Daily wts., I & O s (ins and outs) -DVT prophylaxis: Teds/ pneumoboots -incentive spirometer 10 puffs q 1h while awake -wound care -Drains/tubes: -Foley to gravity -NGT to low constant suction -Flush NGT with 30cc NS q shift -JP drain to bulb suction -Accucheck q h if diabetic Diet: NPO, clears, full liquids, advance as tolerated, diabetic, cardiac, etc. IVF: LR, NS, or D5 ½ cc/h (use LR and NS for fluid loss and 3rd spacing typically for 24h post-op. Use D5 ½ NS +/-KOH for maintenance fluid) Meds: -Pre-op medications (order all that pt should use in hospital) -Pain: MSO4 (morphine), Percocet, Tylenol 3, PCA (patient controlled analgesia) -Stool softener, particularly if giving narcotics (i.e. docusate sodium) -Antibiotic (if pre-op/intra-op antibiotics need continuing) -Ulcer prophylaxis: ranitidine, cimetidine, lansoprazole, omeprazole -DVT prophylaxis: SQ heparin, or low molecular weight heparin. -Other Labs: AM labs (CBC, Chem 7, etc.) Extra: -Call HO (house officer) T>38.5, P>100or <50, SBP>160 or <110, DBP> 100 or <50, RR > 30, Urine output <60cc in 2h. -Telemetry, CXR, EKG, etc. Operative Note The med student can write this in the OR or PACU immediately after the operation is finished. You can start the note before surgery. Pre-op Diagnosis: (i.e. Right inguinal hernia) Post-op Diagnosis: (i.e. Right inguinal hernia) Procedure: (i.e. Right inguinal herniorrhaphy) Surgeon: (list attending, residents, and med students)

23 SURGERY NOTES (continued) Anesthesia: (i.e. general, local, epidural, spinal) IVF: List amount and type of fluids administered during operation. (check with anesthesia) EBL: (estimated blood loss - check with anesthesia) Blood products: list amount and type administered. Urine output: (check with anesthesia) Drains: indicate placement Specimens: what was sent to pathology? Complications: Clear with attending before writing a complication. Findings: Pathology encountered, structural abnormalities Disposition: To PACU in stable condition, To ICU/SICU in critical condition. 23 Post-op Note The post-op note is written in the chart within several hours after the patient arrives on the floor. It should be in the SOAP note format and should include the following: Heading: Post-op Note - Service (i.e. HH Silver Service) - your rank (i.e., MS-3) Subjective: Comment on the patient s activity and symptoms: pain control, ambulation, flatus, bowel movement, urination, diet, breathing. Objective: -Vitals: current temp (Tc), BP range, HR, RR, +/- O 2 sats -I/Os (ins and outs): Record total input and total output since surgery -Physical exam: Be brief. All patients need resp, cardiac, abdominal, extremities (i.e. edema, rash), neuro (global mental status, i.e. awake, alert, and cooperative ), condition of wound (i.e. dressed and dry, erythematous, drainage, tenderness), and other info. pertinent to this surgery. A/P: Post-op check S/P Briefly comment on how the patient is doing. The plan should be brief and should be reflective of post-op orders. Pre-Rounds, Rounds, and the Progress Note One of the main tasks of the medical student is to pre-round on one s assigned patients and chart the daily progress note. If rounds begin at 6:00 AM, you may have to begin pre-rounds by 5:00. This is not the patient s favorite time of day, and the night nurses are usually trying to finish charting for the shift. This means that gathering information may be all the more difficult. Your task is to understand what has happened to the patient since the last note and to document this. Use the medication record, dictations/notes from consults, and the nursing flow sheet for this. Always ask the patient s nurse how your patient is doing and what issues there are but do this only after reading the chart and flow sheet so the nurse does not have to duplicate information. Remember that the chart is a legal document do not write inflammatory notes (e.g. no chart wars ). Do not write down findings if you are unsure of them, etc. Your note should consist of the following: Heading: Progress Note - Service (i.e. LBJ purple) - your rank (i.e., MS-3) Hospital day #, Post op day #, S/P (procedure) Subjective: Comment on the patient s activity and symptoms: Pain control, ambulation, flatus, bowel movement, appetite, diet, breathing. Objective: -Vitals: Maximum temp (Tmax), current temp (Tc), BP range, HR, RR, O 2 sats, weight -I/Os (ins and outs): Record total input and total output for 24h and for last shift. Include po, IV fluids rate and type, urine output, stool output, emesis, drains, and NG output. -Meds: List all meds. Include dosage for pain meds, antibiotics, and meds that

24 24 SURGERY NOTES (continued) -Physical exam: Be brief. All patients need resp, cardiac, abdominal, extremities (i.e. edema, rash), neuro (global mental status, i.e. awake, alert, and cooperative ), condition of wound (i.e. dressed and dry, erythematous, drainage, tenderness) and other info pertinent to this surgery. -Labs: results, labs pending Assessment/Plan: Be brief. Begin your assessment with patient s age, post op day #, S/P (procedure). State general condition, any significant improvements or concerns since last note. Devise a plan for the day to include the following: -patient activity -change in pain control -antibiotics -diet -foley -drains. *Always write consider when making a significant change in plan or any change in meds (i.e. consider D/C morphine and change to Percocet po ). Post-op Fever Etiology The 5 W s Wind: Atelectasis (most common POD #1-2), pneumonia Water: UTI (POD #3-5) Wound: Infection (POD #4-7) Walking: DVT, pulmonary embolus Wonder drugs: drug reaction Fluids and electrolytes Blood loss and 3rd spacing: 3rd spacing is fluid accumulation in tissue interstitium and in the bowel lumen, typically occurring for h following surgery. Replace with isotonic solution (NS or LR). Typically resolves on day 3 when this fluid shifts back into the intravascular space, at which time overhydration can be a problem (particularly in heart failure pts). Diuresis typically occurs with this fluid shift on post-op day 3. Maintenance fluid and electrolytes: Daily fluid Daily LR NS ½ losses: Electrolytes: NS Urine= ml K+ = 1-2 meq/kg Sweat= ml Na+ = 2-3 meq/kg Resp=500ml Cl- = 1-2 meq/kg Feces=100ml

25 SURGERY NOTES (continued) 25 Daily Fluid/Electrolyte Replacement Hourly fluid replacement 1 st 10 kg: 100cc/kg/day 4cc/kg/hr 2 nd 10 kg: 50cc/kg/day 2cc/kg/hr Each kg >20: 20cc/kg/day 1cc/kg/hr e.g. 70 kg man: 2500cc/day* 110cc/hr* * Given as D5W ½ NS + 20 meq KCl/L = 193 meq Na and 50 meq K. Never add K+ to a patient whose renal function is questionable. PROCEDURE NOTE Procedure: type, date, time, indications, who performed Consent form: explained, signed, and on chart Description: Pt draped and prepped in a sterile manner. Local anesthesia achieved w/ Findings: Describe fluid withdrawn, specimens sent to lab or pathology, how pt tolerated. Complications: (if there are complications, best to have resident or attending write the procedure note) DISCHARGE SUMMARY Dictated by, medical student, for, MD on (date) Patient name, medical record number Admit date, admit diagnosis Discharge date, discharge diagnosis Date and type of surgery, procedure(s) this admission Brief summary of pt s history & physical Summary of hospital course Pathology reports (if any) Disposition: discharge medications, follow-up instructions, discharged to home/nursing home/etc., discharge diet and activity Copies to: Repeat dictated by for on (date) Pt name and medical record number

26 26 LABOR AND DELIVERY H&P CC: age, race, female, gravida, parity (TPAL=Term, Preterm, Abortive, Living) Dates: LMP, EGA and EDD by dates, with ultrasound on date, and EGA by scan. Current labor: +/- contractions (regularity, interval, duration), +/- vaginal bleeding, +/- leakage of fluid, +/- SROM, +/- fetal movement. Prenatal history: Prenatal care: where, since date, # of visits, EGA at first visit Prenatal screening labs should include following and dates: PAP smear; CBC; UA; urine cx; ABO; Rh; antibody screen; GTT/glucose screen, RPR;Triple screen; GBS rubella titer; HBsAg; HIV; chlamydia/gonorrhea. Medications: prenatal vitamins (PNV), Fe, other prescription meds Complications: substance abuse (alcohol, tobacco, IVDA); UTI s; HTN; DM/GDM; PIH; large babies; h/o multiple births (eg. twins); h/o congenital anomalies. Past OB history: for each pregnancy, note date of birth, location, type of delivery (C-section/NSVD/forceps); gestational age; anesthesia; sex; weight; complications; or if pregnancy aborted, specify elective vs. spontaneous and gestational age. Past GYN history: age at menarche, interval, duration, flow, regularity, contraceptive history; h/o STD s and STD treatment, history of pap smear if abnormal Past Med Hx: highlight DM, HTN, asthma, renal disease, hepatitis. Past Surg Hx: procedure, age, location, surgeon, complications; any trauma. Social Hx: tobacco, alcohol; IVDA, animal exposure (Toxo). Family Hx: medical hx; birth complications; birth defects. Allergies PE: vital signs, head to toe, and including Extremities: reflexes, edema are important Abdomen: gravid, fundal height, fetal heart tones (type of monitor, baseline rate, BTBV, reactivity, decels, uterine contraction pattern) Pelvic exam: dilation = closed to 10 cm effacement = 0 to 100% present = vertex, breech (footling or frank), LOA, ROA, etc. station = +3 to 3 membranes = intact, SROM/AROM, time of rupture, +/- meconium A/P:1) Term IUP in active labor 2) Routine labor room care and admitting lab work 3) Expectant management LABOR & DELIVERY NOTE (example) Diagnosis: Term IUP s/p NSVD over a 2 midline episiotomy (with extension to 3 ) Anesthesia: epidural/local with 3-5 cc anesthetic agent Physician: Attending/Resident/MS Episiotomy/Lacerations: 2 midline episiotomy was cut with extension to 3. Repaired with (suture types/sizes) in layers. EBL (Estimated blood loss): Findings: Term male/female infant, APGAR s 8 1 /9 5, weight 3450g born at 08:12 with nuchal cord x 1, easily freed at perineum. Placenta delivered at 08:21, Schultze/Duncan, intact with 3 vessel cord. Cord blood sent to lab. Complications: none Dispo: Mother to recovery room in good condition; baby to TCN/NICU in condition.

27 LABOR AND DELIVERY H&P (CONT.) AND PEDI NOTES Glucose Screening in OB glucose screening between 24 and 28 weeks gest. Fasting < 100 mg/dl 1 hour after 50-gm glucose load < hour after 100-gm glucose load < 140 (if abnormal fasting OR 1 hr OR 2 hr glucose, order 2 or 3 hr Glucose Tolerance Test) 27 APGARS Heart rate none <100 >100 Respiration none slow, irreg good cry Tone none floppy active Color blue acrocyanotic all pink Reflex irritability none grimace cry A appearance Blue acrocyanotic all pink P pulse None <100 >100 G grimace None grimace cry A activity None floppy active R respiration None slow, irregular good cry NEONATAL/BIRTH H&P DOB DOL# Gestational age (WBD=wks by dates/wbe=wks by exam), birth wt, SGA/AGA/LGA male/female: BTA (born to a): mom s age, Gravidity and Parity (G x P TPAL ), labs (ABO/HepB/ RPR/Rub/HIV), complications of pregnancy (maternal DM, PIH, PTL, chorio, smoking, ETOH/drug abuse, HIV, etc), maternal temp at delivery /fever during labor Delivered via: SVD/C-sect with nuchal cord x 1, ROM (spontaneous or artificial) at 05:20 with meconium Perinatal course: Infant to NICU warmer, suctioned with ETT x 1 with NBTC (no meconium below the cords), suctioned by NGT x 1 with cc of meconium-stained fluid removed, dried & stimulated, APGARS 8 1 /9 5. Infant transferred to TCN for transitioning PE:Vitals, weight, length, FOC (%tiles) HEENT: fontanelles, red reflex Heart/Lungs/Abd/GU Extremities: hip click Neuro: reflexes of infancy Labs: Infant s ABO, pre- and post-natal labs (RPR, HIV, HepB, Blood type, GBS, GC/ chlamydia) Temperature: F = (1.8) C + 32 C = (F-32) / 1.8 Liquid: 1 tsp = 5 ml 1 tbsp = 15 ml 1 fl oz = 30 ml Weight: 1 kg = 2.2 lb 1 oz = 30 g CONVERSIONS

28 28 PEDIATRIC H&P PRIMITIVE REFLEXES OF INFANCY Reflex Age of Appearance Age of Disappearance Moro birth 4-6 months Grasp birth 4-6 months Rooting birth 4-6 months Placing birth 4-6 months Crossed extension birth 4-6 months Tonic neck birth 4-6 months Trunk incurvation (Gallant) birth 8-9 months Landau 6-8 months 15 mo-2 yrs PEDIATRIC H&P Chief complaint Informant (parent, guardian, etc.) HPI PMH: Hosp/surgeries Allergies Medications Complete birth hx for child, sibs Dietary history (how much, how often, water source) Immunizations Developmental milestones Travel Pets FamHx: Include TB exposure, congenital disease, SIDS Psych/SocHx: who cares for, day care, sleep position in infants, consanguinity ROS: PE: Vitals Growth: wt, ht, FOC (and %tiles) HEENT: fontanelles, red reflex Neck: stiffness, adenopathy Lungs/Heart/Abd GU: Tanner staging Mental Status Neuro and developmental ESTIMATING BODY SURFACE AREA IN CHILDREN Weight (lb) Body Surface Area (m2) >60 add 0.1 for each additional 10 lb

29 1 m GM Head up inprone FM Track horizontally 2 m L Social smile GM Chest up in prone FM Track vertically 3 m L Coo GM Support weight on forearms in prone FM Track 360 ; hands unfisted 4 m L Laugh aloud; orient to voice GM Support weight in prone w/ arms straight; roll prone to supine 5 m L Razz; alert to sound in 1 plane GM Roll supine to prone FM Reach and pull down in supine 6 m L Babble GM Sits w/ anterior propping FM Intentional grasp; transfer object; rake 7 m L Alert to sound in 2 planes 8 m L Non-specific Mama, Dada GM Lateral protective response in sitting; reach to side when sitting 9 m L Alert to sound directly; wave bye; pat-a-cake; gestured communication GM Crawl; pull to stand 10 m L No. Specific Mama, Dada FM Pincer grasp 12 m L One step gestured command; one word PEDIATRIC H&P Denver Chart (abridged) GM=Gross motor FM=Fine motor L=Language other than Mama, Dada, or name of person GM Independent steps; posterior protective response in sitting FM Intentional release 16 m L One step ungestured command FM Scribble in Imitation 18 m L Body parts; 7-10 word vocabulary. GM Run FM Scribble spontaneously 24 m L 2 word sentences; 2 step commands; 50 word vocabulary GM Up and down stairs 30 m L Concept of one, on, and under GM Up stairs alternating FM Circular motion 36 m L Are you a boy or a girl? What do you do when you re hungry/ tired? Big and little. 3 items from a greater number; 250 word vocabulary. Behind and next to. GM pedal tricycle FM unbutton 4 y L What do you do when you re cold? What s a house made of? ; Long and short ; complex syntax; 4 items from greater number 4.5 y L What does mommy cook on? GM Stand either foot for 5 seconds 5 y L 3 step command; phone number, address, identify coins; vocabulary too numerous to count GM Skip FM tie shoes 7 y GM Two-wheeled bicycle 29

30 30 PSYCHIATRIC HISTORY Organizational components: identifying data, referral source, chief complaint, history of present problem, medical history, drug and alcohol history, mental status exam, formulation, diagnostic impression, treatment plan. HPI: Onset of problems (time, setting) Duration and course (chronic vs. episodic) Psychological symptoms Symptoms of psychoses Cognitive Problems Mood Changes (irritability, depression, elation) Somatic symptoms Medical conditions Vegetative signs (anorexia, weight loss, insomnia, anergy, agitation or retardation, decreased sexual energy and interest, diurnal mood variation) Neurological symptoms Somatic complaints without organic basis detected with our present systems Severity of problems-degree of impairment in functioning Possible precipitants. Psychiatric History: Previous hospitalizations; duration of stay; involuntary commitment Types of treatments: medications, ECT, etc. Efficacy of past treatments; compliance with treatment; side effects Prior diagnosis/diagnoses given; h/o harm to self or others Medical History: Presence, course and severity of medical conditions Use of prescription and non-prescription meds EtOH use, recreational drug use, head injuries, pregnancies Neurologic conditions, environmental exposure, unexplained symptoms Personal History: Family relations (father, mother, siblings, others at home, important family relationships, major losses and separations) Infancy (birth complications, birth order, birth history, developmental milestones) Childhood (health/hospitalizations, preschool years, friendships, h/o of abuse) Adolescence (onset of puberty, early sexual experiences, peer relationships, experimentation with drugs, smoking, EtOH) Adulthood (education, military experience, employment, social life & friendships, romantic relationships, sexual history, marriage, children, legal involvement) Family History: Presence of psychiatric and medical conditions in first-degree relatives Types of treatment used and effectiveness H/o suicides and attempts, neurologic conditions, intellectual developmental disabilities

31 PSYCHIATRIC HISTORY (continued) 31 Mental Status Exam: Appearance and behavior (dress and grooming, posture and gait, physical characteristics, facial expressions, eye contact, motor activity, specific mannerisms) Speech (rate, pitch, volume, clarity, abnormalities) Emotions (mood, affect-variability, intensity, lability, appropriateness) Thought Process (flow of ideas, quality of associations) Content (Distortions -delusions, ideas of reference, depersonalization) (Preoccupations-obsession, phobias, somatic concerns) (Suicidal or homicidal ideation) Perception (Illusions or hallucinations) Sensorium and Intellect Consciousness Orientation Time ( What is today s date? ) Place ( What is the name of this place? ) Person ( What is your full name? ) Concentration Serial 7 s (or 3 s)-ask patient to subtract 7 s (or 3 s) in succession, starting from 100. Memory Immediate (Digit span-ask patient to repeat a series of random numbers, first forward, then backward) Recent (Ask patient to remember 3 unrelated objects then recall them after 15 minutes.) Remote (Ask about names and dates in patients earlier life; ask patient to name U.S. Presidents beginning with the current one and going backwards.) Fund of Knowledge ( Who is the Vice-President of the U.S.? What are the colors of the American flag? How far is it from Houston to Austin? What is a thermometer? ) Abstraction Proverbs- Ask patient to interpret a Proverb (a stitch in time saves nine, the grass is always greener on the other side of the fence, a rolling stone gathers no moss, etc.) Similarities- Ask the patient what two things have in common (a table and chair, an orange and a baseball) Judgement - Ask what the patient would do in a social situation that requires judgement (smelling smoke in a crowded theater; finding a stamped, addressed, sealed letter on the street) describe as impaired vs intact Insight - Ask patient if he knows why he is in hospital or if he thinks that he currently has any problems. (poor, fair, good, excellent) Attitude toward interviewer DSM-IV: Axis I: Major Psychiatric Syndromes or Clinical Disorders Axis II: Personality Disorders and Intellectual Developmental Disabilities Axis III: General Medical Conditions Axis IV: Psychosocial and Environmental Problems Axis V: Global Assessment of Functioning (GAF score 0-100)

32 32 ABBREVIATED NEUROLOGICAL EXAM MINI MENTAL STATUS EXAMINATION/MMSE Serial exams will reveal progress, no change, or deterioration. Orientation What is the year, season, month, day, date? {1 point each} Where are we (state, county, city, hospital, floor)? {1 point each} Registration Name 3 objects taking one second to say each. Ask pt. to repeat all 3 immediately after you say them. Repeat until he/she learns all three. {1 point each} Attention & Calculation Serial 7 s (stop after 5 correct), or spell world backwards {1 point each up to 5} Recall Ask pt. to name the three objects named above. {1 point each} Language Name 2 objects that you show (i.e. pencil, pen,cup). {1 point each} Repeat no ifs, ands, or buts. {1 point} Have pt read sentence Close your eyes and have them do what it says. {1 point} Follow a three step command (i.e. take the piece of paper, fold it in half, and toss it on the floor). {1point each step} Write a sentence. {1 point} Copy a complex polygon. {1 point} Total 30 points <27 considered abnl GLASGOW COMA SCALE 1. Eye opening: Spontaneous 4 To voice 3 To pain 2 None 1 2. Verbal response: Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 3. Motor response: Obeys commands 6 Purposeful movement 5 Withdrawn 4 Abnormal flexion 3 Abnormal extension 2 None 1 PEDIATRIC COMA SCALE 2-5 yrs <2 yrs Same Same Appropriate Coos or looks Inappropriate Inappropriate Cries at pain Cries at pain Moves at pain Mooves at pain Moves Moves Same Same

33 ABBREVIATED NEUROLOGICAL EXAM (continued) CRANIAL NERVES I test sense of smell II visual acuity III, IV, VI extraocular movements (LR6,SO4,all others3) V facial pinprick/touch (optional corneal reflex) VII upper/lower facial muscles (optional taste test for Bell s Palsy) VIII hearing (check for nystagmus) IX, X midline palate elevation XI turn head in both directions XII tongue protrudes in midline 33 MOTOR Tone: degree of stiffness or toughness Strength: selected distal and proximal muscle groups C5 = elbow flexors L2 = hip flexors C6 = wrist extensors L3 = knee extensors C7 = elbow extensors L4 = anterior foot dorsiflexors C8 = finger flexors L5 = long toe extensor T1 = small finger abductors S1 = anterior foot plantarflexors Muscle Strength: 0 = No muscular contraction detected 1 = Trace contraction 2 = Active movement of body point with gravity eliminated 3 = Active movement against gravity 4 = Active movement against gravity & some resistance 5 = Active movement against full resistance without evidence of fatigue Reflexes: biceps = C5 knee = L2-4 brachioradialis = C6 ankle = S1 triceps = C7-8 Pathological reflexes: i.e. Glabellar, snout, palmornental, Babinski, clonus Deep tendon reflexes 4+ Very brisk hyperactive with clonus 3+ More brisk than average 2+ Average 1+ Somewhat diminished 0 No response1 CEREBELLAR Finger-to-nose Heel-to-shin Rapid alternating movements SENSORY compare side vs. side, upper vs. lower in ability to discern pinprick (use broken tongue depressor or broken wooden handled cotton swab), light touch (brush package that help tongue depressor or cotton swab), vibration, and proprioception. GAIT heel walking, toe walking, walk heel to toe regularly.

34 34 { Ophthalmic branch TrigeminalMaxillary branch Mandibular branch Cervical cutaneous Supraclavicular Axillary Intercostobrachial cutaneous Medial brachial cutaneous Posterior brachial cutaneous (radial) Medial antebrachial cutaneous Lateral antebrachial cutaneous (musculocutaneous) Radial Median Ulnar Post Lateral thoracic rami Ant Mid Anterior thoracic rami DERMATOMES Hypogastric Posterior lumbar rami Posterior sacral rami Posterior thoracic rami Iliohypogastric Ilioinguinal Lumboinguinal Great occipital Small occipital Great auricular Cervical cutaneous Posterior cervical rami Posterior supracalvicu Lateral thoracic rami Axillary Intercostobrachial cutaneous Posterior brachial cutaneous (radial) Medial brachial cutane Medial antebrachial cutaneous Lateral antebrachia cutaneous (musculocutaneous) Radial Ulnar Lateral femoral cutaneous Obturator Anterior femoral cutaneous (femoral) Common peroneal Saphenous Obturator Median Lateral femoral cutaneou Anterior femoral cutaneous Posterior femoral cutaneous Common peroneal Superficial peroneal Saphenous Superficial peroneal Sural Deep peroneal Tibial Lateral plantar Medial plantar For dermatomes by segmental distribution, refer to the Pharmacopeia.

35 PROCEDURES BLOOD TUBE TYPE: CBC: purple top ABGs: heparinized syringe w/ air bled out & on ice PT/PTT: blue top TFT s: red top Chem 7: small red top Ammonia: green top on ice Chem 20: large red top Lipid profile fasting: red top Others: call lab but usually red top 35 BODY FLUID ROUTINE LABS Lumbar Puncture Tube 1: Gram stain & cultures Tube 3: cell count with differential Tube 2: prot, glc, spec. grav Tube 4: special studies Thoracentesis specific gravity, protein, LDH, ph, cell count with differential, glucose, Gram stain, cultures, AFB smear & cultures, fungal smear, culture, & cytology. Paracentesis cell count with differential, Gram stain & cultures, lactic acid, ph, protein, glucose, LDH, specific gravity, amylase, cytology Arthrocentesis unheparinized tube: viscosity, mucin clots heparinized tube: glucose, Gram stain, culture, cytology, cell count & differential glass slide for polarized light examination GRAM STAIN 1. Air dry specimen after smearing thinly on slide. 2. Heat fix by quickly passing the slide through a flame 2-3 times. 3. Cover the entire slide with Crystal Violet for 30 seconds. 4. Rinse with water.* 5. Cover slide with Iodine for 1 minute. 6. Rinse with water. 7. Hold slide at 45 and decolorize with acetone/ethanol for 5-10 seconds or until no more blue runs off. 8. Rinse with water. 9. Cover slide with Safranine for 30 seconds. 10. Rinse with water and blot dry with bibulous paper. *NOTE: use distilled water for rinsing when available URINALYSIS 1. Dipstick urine and record values. 2. Pour sample of urine off into test tube for dipstick. Do not contaminate sterile specimen cup with dipstick. 3. Spin urine in cetrifuge for 3-5 minutes. 4. Pour most of the supernatant off, leaving a few drops in the bottom of the test tube. 5. Put a few drops of the remaining mixture on each of 2 slides, put a cover slip on one (wet prep) and examine under the microscope while the other dries. 6. If >5 WBC s/hpf in spun urine, then it is considered infected. If you see WBC s then you will probably want to gram stain the slide you left to dry to see if you can see any bacteria. If the wet prep is clear, there is no reason to gram stain the other slide. 7. Other things to look for: RBC s, yeast, Trich, sperm, epithelial cells, etc. If specimen contains many epithelial cells, considered a dirty catch; should get another specimen from patient. *Quick and dirty test for UTI, gram stain a slide of unspun urine.

36 36 EKG INTERPRETATION Each large square = 0.2 sec; each small square = 0.04 sec. RHYTHM: regular? NSR = Regular; positive P wave in II, III, avf; bpm RATE: 300/(# of large boxes between R-R intervals, ie. 300,150,100,75,60,50,43,38) Nl = Sinus Tach >100 Sinus Bardy <60 INTERVALS: PR Interval: [ sec] (3-5 little boxes) Prolonged: AV block, hyperthyroidism, rare nl variant Shortened: AV nodal/low atrial rhythm, WPW, LGL, HTN, nl variant QRS Interval: [ sec] (1-3 little boxes) Prolonged (>3 little boxes) abnl intraventricular conduction (LBBB, RBBB) Low amplitude(<5 mm in limb leads): diffuse coronary disease, CHF, obesity, pericardial effusion, myxedema, amyloidosis, emphysema, anasarca High amplitude: look at criteria for LVH QT Interval: [ sec] QTc= QT/ RR; if nl rate, QT = 1/2 R-R interval. Lengthened: (increased risk of V-Tach) CHF, MI, ik, ica, img, Type 1 antiarrhythmics, RF, myocarditis Shortened: digitalis, hypercalcemia, hyperkalemia, phenothiazines QRS AXIS: Nl (between 30 and +90) LAD (between 30 and 90): mechanical shifts, LAH, LBBB, WPW, emphysema, hyperkalemia, RV ectopic rhythms RAD (between 90 and 180): emphysema, RVH, BBBB, L posterior hemiblock, WPW, LV ectopic rhythms QRS in LEAD I LEAD avf Extreme RAD - - RAD - + NI range + + LAD + - P-WAVE: Nl: upright (I,II, avf, V4-6); inverted (avr); variable (III, avl, V1-3) Inversion: ectopic atrial, AV nodal rhythm Inc. amplitude: atrial hypertrophy/dilation, HTN, cor pulmonale, congenital heart dz Biphasic: LAE if 2nd 1/2 is neg (III, V1) Notching: (>0.04 s between peaks; I, II, or avl) = P-mitrale/LAE Peaking: (>2.5mm tall, narrow in lead II, III, and avf) = P-pulmonale/RAE Absence: SA block, AV nodal rhythms

37 EKG INTERPRETATION (continued) VENTRICULAR HYPERTROPHY: Axis deviation + Voltage criteria (see below) LVH: R in lead I + S in lead III > 25mm R in avl >11mm R in II, III, or avf >20mm S in avr >14 S in V1 or V2 + R in V5 or V6 >35mm (in pts e 35 yrs old) R in V5 or V6 >27mm R + S in any V lead >45mm RVH: Reversal or precordial pattern (tall R in V1-2; deep S in V5-6) Normal QRS duration ST seg depression with upward convexity & inverted T waves in V ST CHANGES: Elevation: AMI, acute coronary spasm, pericarditis, early repol changes Depression: digitalis, strain, ischemia, non-transmural MI Tall peaked T: hyperkalemia, AMI Inverted T: Non Q-wave MI, ventricular strain, hypokalemia, hypocalcemia T-WAVE: Nl: upright (I, II, V3-6); inverted (avr) Shape (NI smooth): notched = pericarditis; pointed = MI Height (NI <5mm standard leads and > 10mm in precordial leads): Tall = hyperkalemia, MI, ischemia, CVA INDICATORS OF INFARCT: 1) ST elevation indicates injury 2) T wave inversion indicates ischemia 3) Pathologic Q waves (Q waves >.04 s or > 25% total QRS height) Anterior Wall Q waves in V1-4 (LAD) Anteroseptal Q waves in V1-2 (Proximal LAD) Anteroapical Q waves in V2-3 (LAD or branches of LAD) Anterolateral Q waves in V4-6; I, avl (mid-lad or CFX) Lateral Wall Q waves in I and avl, or in V5-6 (CFX) Inferior Wall Q waves in II, III, avf (RCA) Posterior Wall Q wave in V6; R>S in V1-2 (PDA) 4) Reciprocal ST depression BBB: QRS duration >0.12 sec Lead LBBB RBBB I monophasic R wide S V1 QS,rS M-shaped QRS, occ.wide R or qr V6 monophasic R wide S

38 38 EKG INTERPRETATION (continued) U WAVE: Nl same polarity as T wave, seen best in V3 prominence: hypokalemia amplitude: digitalis, quinidine, hypercalcemia, epinephrine, thyrotoxicosis Lead I Lead AVF Axis + + normal + - LAD - + RAD

39 NORMAL LAB VALUES (different from hospital to hospital and different in children--check age-based norms) TEST CONVENTIONAL UNITS SI UNITS HEMATOLOGIC VALUES Coagulation tests: Bleeding time 2. 7 minutes 2. 7 minutes Fibrin degradation products <10µg/ml Fibrinogen mg/dl 2. 4 g/l sec (or <2 sec Prothrombin time (PT) sec deviation from control) Partial thromboplastin time, seconds seconds activated (aptt) Thrombin time Control ± 5 sec Control ± 5 sec Whole-blood clot lysis No clot lysis in 24 hr 0/day 39 Complete Blood Count Hematocrit Male % Female % Hemoglobin Male g/dl mmol/l Female g/dl mmol/l Carboxyhemoglobin <2% of total (<9% in smokers) Methemoglobin <3% of total Erythrocyte count (RBC) Male X 10 6 /mm X /L Female o X 10 6 /mm X /L MCH pg/rbc fmol/cell MCHC % Hb/cell mmol Hb/L MCV µm3/cell fl Leukocyte count (WBC) 4, ,000/mm X 109/L Segs 54 62% Bands 3 5% Lymphocytes 25 40% Monocytes 2 8% Eosinophils 1 3% Basophils 0 1% Platelet count 150, ,000/mm X 10 9 /L RDW Erythrocyte sedimentation rate (ESR) Male 0 13 mm/hr 0 13 mm/hr Female 20 mm/hr 0 20 mm/hr Reticulocyte count % red cells SERUM, BLOOD, PLASMA Alanine aminotransferase (ALT, SGPT) 8 20 U/L 8 20 U/L Albumin g/dl g/l Alkaline Phosphatase U/L U/L Ammonia µmol/l µmol/l

40 40 NORMAL LAB VALUES (continued) TEST CONVENTIONAL UNITS SI UNITS SERUM, BLOOD, PLASMA Amylase U/L U/L Aspartate aminotransferase 8 20 U/L 8 20 U/L (AST, SGOT) Bicarbonate meq/l mmol/l Bilirubin, Direct mg/dl 0 5 µmol/l Bilirubin, Total mg/dl 2 17 µmol/l Blood gases (arterial) [room air]: po mm Hg kpa pco mm Hg kpa ph [H+] nmol/l O2 sat % HCO meq/l mmol/l Calcium mg/dl mmol/l Ceruloplasmin mg/dl mg/l Chloride meq/l mmol/l Cholesterol <200 mg/dl <5.2 mmol/l Copper µg/dl µmol/l Cortisol, serum 0800h: 5 23 µg/dl nmol/l 1600 h: 3 15 µg/dl nmol/l 2000h: <50% of 0800h fraction of 0800 h: <50% Creatine kinase (CK): Male U/L U/L Female U/L U/L Creatinine mg/dl µmol/l Cyanocobalamin pg/ml Erythropoietin 4 26 mu/ml Ferritin (serum): Male ng/ml µg/l Female ng/ml µg/l Folate: Serum 0 20 ng/ml Red cell ng/ml packed cells Glucose (fasting) mg/dl mmol/l Hemoglobin A1c 4 7% Iron (total): Male µg/dl µmol/l Female µg/dl µmol/l Hemoglobin A1c 4 6% Lactate meq/l mmol/l Lactate dehydrogenase (LDH) U/L U/L Lead 0 40 µg/100 ml Magnesium meq/dl mmol/l Myoglobin (serum) ng/ml Osmolality (serum) mosmol/kg mosmol/kg Phosphatase, Acid: Male (total) sigma U/mL nmol/sec-l

41 NORMAL LAB VALUES (continued) TEST CONVENTIONAL UNITS SI UNITS SERUM, BLOOD, PLASMA Potassium meq/l mmol/l Protein: Total g/dl g/l Albumin g/dl g/l Globulin g/dl g/l Electrophoresis (% of total protein) Albumin 60 75% Alpha % Alpha % Beta % Gamma % Sodium meq/l mmol/l Transferrin mg/dl g/l TIBC µg/dl µmol/l Triglycerides <160 mg/dl <1.8 mmol/l Urea nitrogen (BUN) 7 18 mg/dl mmol urea/l Uric acid mg/dl mmol/l Vitamin B pg/ml 41 URINE VALUES Amylase Somogyi units/24h U/hr Calcium mg/24h mmol/day Catecholamines: Epinephrine <10 µg/day <55 nmol/day Norepinephrine <100 µg/day <590 nmol/day Chloride mEq/L mmol/day Creatine (non-pregnant) <100 mg/d Creatinine (Cr) mg/kg body wt/day 13 22mmol/kg-day Creatinine Clearance: Male ml/min Female ml/min 5-Hydroxyindoleacetic acid 2 9 mg/d (women < men) µmol/day (5-HIAA) Glucose 0 Ketones 0 Microscopic exam <1 2 RBC,WBC, epithelial cells/hpf; occasional hyaline Myoglobin, urine cast/hpf; 0 2 Mb/ml Osmolality mosmol/kg ph Phosphorus gm/24h (depends on diet) Porphobilinogen 0 2mg/24h Potassium meq/24h mmol/day Protein, Quantitative <165 mg/24 hr <0.16 g/day Sodium meq/24h mmol/day Specific gravity Urobiligen <4mg/24h Vanillymandelic acid (VMA) <6.8 mg/24 hr <35 µmol/day

42 42 NORMAL LAB VALUES (continued) TEST CONVENTIONAL UNITS SI UNITS CEREBROSPINAL FLUID Appearance clear Cell count 0 5 monos; no polys Chloride meq/l mmol/l Gamma globulin 3 12% total proteins Glucose mg/dl mmol/l LDH approx. 10% of serum level ph Pressure, opening mm H2O mm H2O Protein, total mg/dl g/l

43 43 DIAGNOSTIC PARAMETERS CHOLESTEROL VALUES Initial Classification Based on Total Cholesterol and HDL Cholesterol Levels Cholesterol Level Initial Classification Total Cholesterol <200 mg/dl (5.2 mmol/l) Desirable blood cholesterol mg/dl ( mmol/l) Borderline high blood cholesterol 240 mg/dl (6.2 mmol/l) High blood cholesterol HDL Cholesterol <35 mg/dl (0.9 mmol/l) Low HDL cholesterol Treatment Decisions Based on LDL Cholesterol Level 100 mg/dl (2.6 mmol/l) Patient Category Initiation Level LDL Goal Dietary Therapy Without CHD and <2 RF Without CHD and e 2 RF With CHD 160 mg/dl (4.1 mmol/l) 130 mg/dl (3.4 mmol/l) >100 mg/dl (2.6 mmol/l) <160 mg/dl (4.1 mmol/l) <130 mg/dl (3.4 mmo/l) Drug Treatment Without CHD and <2 RF 190 mg/dl (4.9 mmol/l) <160 mg/dl (4.1 mmol/l) Without CHD and e 2 RF 160 mg/dl (4.1 mmol/l) <130 mg/dl (3.4 mmol/l) With CHD 130 mg/dl (3.4 mmol/l) 100 mg.dl (2.6 mmol/l) DIAGNOSIS OF DIABETES Fasting blood glucose >126 Any glucose >200 GTT: 2hrs >200 EFFUSIONS (PLEURAL/PERITONEAL) Exudate (IU/dl) Transudate (IU/dl) Fluid LDH >200 <200 Fluid protein >3 g <3 g Fluid/serum LDH ratio >0.6 <0.6 Fluid/serum protein ratio <0.5 >0.5 Specific gravity >1.016 <1.016 HYPERTENSION (JNC VII for Adults 18 yrs old) Normal <120 <80 Pre-hypertension HTN Stage Stage 2 >160 >100

44 DIAGNOSTIC PARAMETERS 44 ACID-BASE DISORDERS Acid-base Initial Compensatory ph Expected value range disorder change change change Metabolic HCO3 PCO2 ph PCO2=1.5(HCO3) + 8 Acidosis (PCO2=last 2 digits of ph) Metabolic HCO3 PCO2 ph PCO2=0.9(HCO3) + 9 Alkalosis Respiratory PCO2 HCO3 ph acute:10(hpco2 )=0.08(ipH) Acidosis chronic:10(hpco2)= 0.03(ipH) Respiratory PCO2 HCO3 ph acute: 10(iPCO2)=0.08(hpH) Alkalosis chronic:10(ipco2)=0.03(hph)