Obstetrics and Gynecology. Intern Handbook

Transcription

1 Obstetrics and Gynecology Intern Handbook

2 SIGNOUT TIMES & IMPORTANT NUMBERS Mon 0630 and 1830 Tues 0630 and 1730 Gyn Pager Wed 0630 and 1730 GynOnc Pager Thurs 0630 and 1830 R1 OB , Postpartum Pager Fri 0630 and 1730 R2/R3 OB Sat 0800 and 1930 Chief Sun 0800 and 1930 TABLE OF CONTENTS Day OB and Nightfloat.... pg 3 Conferences. pg 3 Postpartum. pg 5 OB Floor Calls... pg 6 Gyn Onc. pg 8 US/REI. pg 10 GYN.. pg 10 Continuity Clinic. pg 11 Medical Spanish. pg 13 Dictation 101 pg 17 An important note: Much of the information in the following pages can and will vary depending on your senior residents and attending. Communication with your team is key. 2

3 Day OB and Night Float Daily Schedule and Events Lectures/ Grand Rounds: Mon 7:30 11:30 am Fetal Strip Rounds: 1 st, 2 nd, and 5 th Wed of each month 7:30 am (7:15 if Dr Druzin) MFM Journal Club: 3 rd Wednesday of each month 7:30 (US or Gyn Clinic presents) GynOnc Journal Club 4 th Wednesday of each month 7:30 (Onc R2 presents) Perinatal conference: Fridays at noon (off-service intern covers this, expect Wed or Thurs with which cases are being presented) Intern Conferences: Wed AM Teaching 0730 in OB conference room (3 rd floor) All Wednesdays (except 3 rd and 4 th ): Fetal Strip Rounds. Day OB intern prepares and presents an interesting fetal strip. Another intern and students read the strip. Stockpile interesting strips for the future. 3 rd Wednesday: MFM Journal Club. An intern and MFM fellow present an article. Coordinate with fellow interns to make a calendar for the year. Communicate with MFM fellow about which article on your month. 4 th Wednesday: Onc Journal Club: R2 on Onc presents you re off the hook! Perinatal Conference Fridays at noon (1 st floor Packard by elevators) Attended by MFM and NICU faculty and residents. No strips, just prenatal course including interesting maternal diseases or complications. Be brief. Include US findings, +/- betamethasone, APGARs, cord gases (BE SURE TO HAVE THESE!), and weight. Peds resident will present the baby s hospital course. 3

4 ***You are not responsible for presenting babies transferred to LPCH after birth (outborn babies)*** The R1 on US/REI should present at Perinatal Conference and read the strip at Strip Rounds. If there is no R1 on US/REI, the intern on Gyn Clinics is responsible. If there is no resident on Gyn Clinics (on vacation) then perinatal conference becomes the L&D R1 s responsibility and the R1 on Onc will read the strip on Wednesdays, if you are the resident on Gyn clinic and have vacation, be sure to let the other R1 know! Admit Orders Pre-checked order sets available in Powerchart, with these items already checked off - Admit to L&D ADD the attending (SWC vs SMC) - Vitals (per routine) Cycle BPs at least q1hr for pts with ghtn/ PreEclampsia - Activities: bedrest (in active labor) - Nursing: CEFM x 2, strict I/O s if on magnesium - Diet: sips and chips in active labor - IVF: NS or LR See diabetic protocol for IVF Pre-eclampsia and receiving Mg fluid restrict <2400/24 hrs (100cc/hr) this is part of PIH/mag order set - Meds: Fentanyl 100 mcg IV Q1hr PRN x maximum of 3 doses Induction/augmentation agents (cervidil, miso, or pitocin) For Pre-E - Mg 4g loading dose, then 2gm/hr IAL (If Cr 1.0 check with upper level about dose/hr) For DM See protocol for insulin regimen For GBS+ Ampicillin 2g IV loading dose, then 1g q4h until delivery. See section on GBS+ for alternatives 4

5 Labs: CBC on everyone, T&S per protocol; for Pre-E (CBC, uric acid, AST/ALT, creatinine, UA (straight cath), Urine protein:creatinine ratio this is ordered as urine protein w/creatinine in Powerchart. Laboring Patients Complete OB MD Worksheet Care Form on PowerChart then generate H&P, print discharge prescriptions. Confirm fetal presentation with U/S on ALL new admits. Write progress notes every 2 hours while on Pit, Mag or IAL, every 4 hours if Cervidil or miso and healthy. If doing an exam, tell the nurse before or after. Have someone follow your cervical exams for the first 2 months. 5

6 Review the fetal central monitors frequently, if there is any concern, SEE the patient and ask another resident or the attending to review the strip with you. For AROM/FSE/IUPC you will always need the nurse present in the room. Update the sign-out on the computer regularly Consent patients for vacuum, forceps, C/S, BTL translators are always available if necessary. Patient signs the pre-printed consent and also write computerized progress note documenting consent Call upper resident and attending for all deliveries. For vacuum, forceps, preterm, twin deliveries upper years get first dibs. Triage/OB Checks 4 key questions: Contractions? Vaginal bleeding? Leakage of fluid/rom? Fetal movement? Confirm dates Date by LMP c/w US? When was US? Review pt s chart! Antepartum issues? Look at BPs. Has the patient had Pre-E labs? Present the case to upper resident. If a continuity patient is to be admitted, notify that resident Common OB check issues and management: LOF/VB: sterile speculum first with water/minimal gel (NO digital exam for previas!) Look for pool, nitrazine swab (or paper), make slide to check for ferning. Decreased FM: Reactive NST, nml AFI, and review kick counts. Arrange for NST/AFI in 3-4 days in PDC. Fax PDC form and give to patient. r/o PreE: cycle BPs, send serum labs and urine. If discharging with 24 hr urine, make sure to add patient to out there, follow up portion of sign out with phone number and MRN. UTI: Remember to send urine for culture and f/u result (put on out there, follow up list). Macrobid 100 mg po bid x 7 days prior to 37 wks Keflex 500 BID x 7 days any GA 6

7 **what # UTI in preg? Do they need daily suppressive abx after treatment? BV: Clue cells on wet mount, grey discharge with + whiff test. Metronidazole 500mg PO bid for 7 days Yeast: Budding hyphae on KOH. Fluconazole x 1 or Monistat 3 or 7 day course Perinatal Diagnostic Center: Formal ultrasounds, NST/AFI, amniocentesis, CVS, and FLM To schedule: Fill out requisition and FAX to the PDC; include EDC on form. If STAT, call PDC ext to let them know about the patient. Give a copy of the requisition to the patient and circle phone #. The patient must call to make the appt. PEARLS 1. GBS + or GBS bacteruria: Ampicillin 2g IV then 1g q4hr until delivery; ideally 2 doses (4 hr) of antibiotics prior to delivery. If PCN allergic: Ask about reaction. If not anaphylactoid, give Kefzol. If anaphylactiod (inc hives), check for sensitivities. Clinda 900mg IV q8h if sensitive, or Vanco 1gm q12h if not clinda sensitive or no sensitivies available. For labor checks, collect a GBS swab if not done already 2. Intrapartum fever VS Chorioamnionitis: Maternal temp >38 WITHOUT fetal or maternal tachycardia. Talk to chief/attg. - One time temp >38ºC in labor without second chorio diagnostic criteria (maternal tachycardia, fetal tachycardia, uterine tenderness, foul smelling AF, or maternal leukocytosis) management options: 1. Treat with Amp and Gent A. May diagnose as either Intrapartum Fever or CHORIO, based on risk factors (ROM status/duration, GBS status, misoprostol, epidural), trajectory of clinical 7

8 minutes! scenario (maternal temp curve, FHR trend, etc.) B. Inform NICU of final impression at delivery 1. CHORIO- full diagnostic evaluation and empiric antibiotics 2. IP Fever- evaluated clinically: no labs, monitored for infxn signs -- OR Repeat the temp in 30 minutes A. NO Tylenol, NO fluid boluses, NO ice packs/cooling blankets!!! B. If still >38ºC, then diagnose CHORIO or IP Fever ; tx w/ Amp & Gent C. If <38.0, may proceed without dx of/tx for chorio CONTINUE to monitor maternal temperature every Chorioamnionitis treatment: NSVD - Amp 2g IV q6h + Gent daily dosing 5mg/kg x 24h afebrile PP (error msg will pop up in Cerner stating calculated dose too high click OK; pharmacy is used to this dosing in labor) if C/S ADD Clinda 900mg IV q8h to Amp/Gent, x 48h afebrile PP Course begins from first afebrile, not last fever 4. Induction of Labor: Is cervix favorable? Is the patient contracting? If cervical ripening is indicated and contractions LESS than 3 per 10min Cervidil Placed in vagina, left in place x 12h Misoprostol Oral: 50mcg PO, then 100mcg in 4h if still necessary and few contractions If cervix unfavorable and contractions MORE than 3 per 10 min 8

9 Consider foley bulb filled with cc NS. +/- Low-dose Pitocin (max of 10) 5. Augmentation of labor (Induction with favorable cervix and/or frequent contractions) Pitocin Order as Pitocin per protocol, starting dose is 1 milliunit. Low-dose (not to exceed 10 milliunits) is sometimes used for unfavorable cervix with too frequent contractions 6. VBAC: Always consent for C/S and VBAC on admission Review operative note from previous surgery to confirm low transverse uterine incision NO prostaglandins (e.g. NO miso or cervidil). Low-dose pit (generally max of 10 mu) is okay different attgs have different max Pit for VBACs. Most attendings want an FSE placed as soon as feasible. Some will also want an IUPC, so ask. 7. Patients on Magnesium Sulfate: Review BPs, check reflexes, I/O, listen to lungs, follow labs. Ask patient about headaches, blurry vision, scotoma, SOB, RUQ pain. If a Stanford patient, Foley should remain in place x24 hrs PP, even if NSVD (for documentation of I/O). 8. Diabetes: (See Diabetic management protocol in Powerchart) A1GDM: Stanford: FS q4hr in latent labor, q1hr IAL, SMC: Admit FS. No postpartum FS necessary. 2hr GTT at 6wk PP A2GDM: FS q4hr in latent labor, q1hr IAL. Insulin drip if FS > 110. Fasting FS PPD1. Consider FS fasting and AC is suspicion for DM2. 2hr GTT at 6wk PP visit. Type 2 DM: FS q4hr in latent labor, q1hr IAL. Insulin drip if FS > 110. Fasting and AC FS postpartum with sliding scale for FS > 200. Consider 9

10 restarting pre-pregnancy hypoglycemics, preferable metformin (less risk of hypoglycemia). Type 1 DM: FS q1hr during labor. Insulin drip in labor if FS >70. Postpartum, start insulin at 1/2-1/3 pregnancy dose (ask chief/attg guidance) and check fasting, AC, PC and qhs FS. If pt has insulin pump, usually restart PPD1 or POD1 (when tol reg diet) ***ANY TIME PT IS ON AN INSULIN DRIP, THERE MUST BE D5 RUNNING AS WELL*** 9. Medical Students: Try to get them involved! Easiest to give them specific tasks at first. All notes need to be cosigned. Have them follow and write notes on laboring patients. Multips with epidurals are best for them to deliver. They can see OB checks and write notes. Also remove staples on post-op patients who are going home. L&D progress notes: (use.sigdatetime to date and time all notes) OB R1 Labor PN S: Comfortable/desires pain meds. If pre-eclamptic, any sxs? O: VS (.vitals), If on Mg, also note I/Os, MS, lung exam and DTRs (.io) FHT: baseline, variability, accels/decels Toco: q X minutes; x SVE: dil / eff / station, position of head if known, +/- caput Labs: If applicable A/P: X yo x weeks by LMP c/w x week US, in active labor/induction for. (.obmaternalid) MWB: AFVSS; if diabetic, fingersticks; if Pre-E, symptoms, etc. Other important maternal issues FWB: Cat X tracing. Other relevant info e.g. fetal anomalies, NICU presence for delivery? Labor: Adequate progress? Meds? Next intervention? Pain: comfortable; epidural/fentanyl 10

11 GBS: always verify for yourself that they are receiving antibiotics if indicated (.obgbsstatus) Delivery Note: ( make a dotphrase for yourself, amend as necessary!) Pt arrived in active labor/induced/ augmented for. (may include meds used). She progressed to complete rapidly /over x hours, and pushed x hours to deliver. (Note presence of increased BPs, infection, deviations from labor curve, meconium). Infant s head delivered in a controlled fashion/precipitously over IP/MLE, under local/epidural/no anesthesia. Nuchal cord x X (or no nuchal). Anterior shoulder delivered with/without difficulty (if dystocia, note maneuvers used). Posterior shoulder and body followed easily. Cord was clamped and cut, infant to mom/rn/peds. Placenta with 3VC delivered spontaneously and intact/ manually extracted. Describe placental/cord abnormalities, if present. X degree laceration repaired with x-vicryl/monocryl in usual fashion. Describe repair if complicated. If 3 rd or 4 th degree lac, document rectal exam. (If cord gas or placenta sent, document why). Baby to WBN/NICU for Mom to postpartum floor stable. The attending physician, Dr. X, was present and participated directly in the entire procedure. POSTPARTUM OB intern covers the postpartum pages (pager 12225) Transfer this to your pager at start of shift (call page operator at x34000) Ob Intern on Nights: - After midnight print 5 lists for rounding: 1.Yourself, 2. Day intern, 3. SWC attending, 4. SMC attending 5. Kathleen (NP) o Include service, PPD/POD, pertinent complications (chorio/endometritis/gdm/pree). 11

12 o Assign Kathleen 3-4 Stanford patients who are uncomplicated (A1GDM OK, chorio AFTER abx if have remained afebrile, etc). o CROSS OFF Kathleen s patients from everyone else s lists (attendings do NOT need to see her patients) o Highlight patients to be seen by each recipient of above list (see below who to round on ) - Prep all postpartum notes EXCEPT for those patients to be seen by Kathleen. o Basic note example: 25 yo G2P2002 POD2 s/p PLTCS for arrest of descent 1. RPPC (routine postpartum care) 2. POD1 Hct 28, appropriate given starting Hct and EBL. FeSO4 on discharge. 3. A2GDM: PPD1 FS 96. Pt to have 2h OGTT at 6 wk pp visit. 4. Vaccines: RI, s/p TDap and flu. VNI (varicella nonimmune) varivax ordered postpartum. Postpartum contraception: Mirena at 6 wk visit o o Make sure to advance dates (POD2 POD3). Can start prepping notes before midnight just make sure to advance to the next day s date at You cannot change the date after submitting the note! o If you make a note with the wrong date, right-click on the body of the note, select Forward click Review in yellow box, To: HIMS, Comment: Created in error, please delete. - Talk to your chief about when to go to PP (F1/F2) to round Who to round on: WEEKDAYS 1. All San Mateo County patients. 12

13 2. All SWC (Stanford) patients: NP Kathleen will round on uncomplicated NSVD and CS Complicated patient needs to be seen by the intern (In general if patient is on signout they are complicated) 3. Private CS with resident assist (look at CareForm delivery summary in Powerchart). We generally don t write orders on private patients (ask chief or private attending) Simple orders including Tylenol, Motrin, Benadryl, heating pads (KPads) are ok When called about issues (fever, BP, labs): evaluate the patient, run it by upper resident, and usually call the private to discuss plan WEEKENDS: ALL SMC, SWC and private CS - No NP or off-service intern Wound Care Horizontal staples remove on POD4 and place steris o POD3 OK if going home early o Use caution if pt obese, diabetic Vertical staples stay in for 7-10 days post op (i.e. leave in on discharge) o Instruct patient to return to her OB clinic to get staples removed. Include this CLEARLY on discharge summary o Call Deb at clinic (number on signout) to request appointment for patient Prolene (blue permanent suture) remove day of discharge o Make sure long end is free then pull by loop to remove Opsite (placed over subcutaneous sutures) remove prior to discharge 13

14 o No need to put anything on top POSTPARTUM ISSUES Anemia Anyone with Hct < 30 gets FeSO4 on discharge If Hct<25 consider starting as inpatient once tolerating PO If Hct <20 discuss transfusion with patient Rh Negative RhoGAM PRN pre-selected as part of postpartum orders If indicated (i.e. baby Rh pos) confirm on MAR that RhoGAM given and include on discharge summary Postpartum Contraception safe in breast feeding Micronor ( mini-pill ): Progesterone-only. 1 tab PO QD, start 2 nd Sunday after delivery. 11 refills. Can switch to regular OCPs when no longer breast feeding. No placebo week. Very important to take at same time every day Depo-Provera: 150 mg IM injection Q 3 months. Remind patient that they need to repeat every 3 months. Mirena or Paragard IUD: post-placental or at 6 weeks PP visit Implanon/Nexplanon: PP or at 6 week PP visit Condoms: if patient breastfeeding and refuses all of above encourage at least condoms Vaccinations 1. Rubella non-immune (RNI): MMR prior to d/c. Patients should not become pregnant 1 month after receiving vaccine. 2. Tdap: If no tetanus within 2 years recommended 3. Varicella non-immune: Varivax prior to d/c with booster at 6 week PP visit 14

15 Document all vaccinations in discharge summary, especially important for SMC patients Postpartum tubal ligations For MediCal must have tubal consent signed 30 days prior to due date If less than 40wks only 3 days prior is okay Consent patient with general surgical consent and document in electronic medical record Postpartum Floor Calls GO see the patient and TALK to your team! 1. Temperature Most everyone treats >38.5 regardless of mode of delivery, for temps it varies Questions: Mode and time of delivery, was temp repeated, do they have chorio, or did they get miso (this frequently causes a temp)? Patient Evaluation: Does pt look sick? Breast tenderness? Lungs clear? CVAT or suprapubic tenderness? Uterine tenderness? Wound cellulitis? Calf tenderness/swelling (DVTs)? Possibe studies: CBC, Cath UA and C&S, CXR, Tylenol mg PO q6 prn fever For presumed endomyometritis (temp with fundal tenderness >24h PP): Gentamicin 5 mg/kg q24h Clindamycin 900mg IV q8 +/- Ampicillin 2 g IV q6hours *** Treat with antibiotics until afebrile (T<38) >48 hours from first time afebrile (not last fever). 2. Low HCT: 15

16 If <20 need to go see patient to evaluate for transfusion Patient Evaluation: Vitals, orthostatics, urine output, symptoms, ongoing bleeding. Treatment: Consider transfusion (usually if Hct <20 or symptomatic), rechecking Hct, and FeSo4 3. Bleeding Questions: How much blood, mode of delivery, EBL/QBL, vitals, orthostatics, urine output Patient Evaluation: Look at quantity of blood yourself, and if concerning call upper level to do pelvic and remove clots, membranes, and/or administer meds. Treatment: Pitocin, methergine (if normal BPs), hemabate (if not asthmatic), or miso buccal. Consider Keflex 1 g if you perform manual extraction on the floor. 4. UTI Symptoms Cath UA, urine culture (follow up final culture) If positive treat with Keflex 500mg PO QID x 5-7 days 5. Anuria or low UOP Bolus LR or NS mL. (Do not bolus pts on Magnesium or with cardiopulm disease), strict I/Os, if low (<30cc/h) may straight cath with Foley to check for urinary retention. 6. Urinary rentention If pt has not voided for 4-6hrs s/p Foley removal: straight cath with Foley if > 250cc urine leave Foley in place for 24 hours of bladder rest. Voiding trial the next day: if pt fails, may need d/c with Foley plus leg bag with teaching and outpatient f/u for removal 6. Magnesium 16

17 Ask about scotoma, RUQ pain, headache. Check I/Os, DTRs, Lungs Common Mag Calls: Can we decrease frequency of vitals? Question: What have UOP and vitals been like? May go from vitals q1 to q2, etc. Is the patient Mag toxic? The patient is very groggy should we decrease the Mag? Go evaluate patient, do PE and check vitals. What are her UOP and Cr (if > 1.0 need to decrease)? Check Mag level and consider decreasing to 1.5g/hr or 1g/hr 7. Elevated BPs Questions: Any severe range (>160/105)? Trend BPs? New onset or ongoing problem? Does patient have preeclampsia, ghtn, chtn? Treatment: We treat BPs SBP>160 DBP>105. Please note these numbers vary according to attending. If the BP is new we may want to get labs to evaluate for Pre-E. Severe range blood pressure Ask RN to repeat reading in 10 minutes and to prepare to give IV meds at that time. If still > 160/> 105, IV push is necessary: Labetalol OR Hydralazine. We usually start with Labetalol. o Labetalol 20 mg IV 40 mg 80 mg 80 mg. Labetalol should be pushed slowly (over 2 min ideally). o Hydralazine 5 10 mg doses q 15 min After first IVP, ask RN to check vitals q 15 min x 1 hr, then q 30 min for the following 2 hrs. If persistently elevated BPs, continue along algorithm as above. Wait minutes after Hydral to allow for BP change before giving another dose. If NO IV access and severe range BPs, can give PO Labetalol 200 mg OR PO Nifedipine 30 mg (short-acting) while RNs get IV access. 17

18 Discharging NSVDs 1. Discharge home on PPD2, encourage multips to go home PPD1 (at least 24 hours since infant s birth) 2. Discharge prescriptions: Colace 100 mg po bid prn (#60, 3 refills) Motrin 600 mg po q6h prn (#30, no refills) Cont PNV if breastfeeding FeSO4 BID if Hct <30 Micronor if desired PO antihypertensives if on a regimen in-house Discharging C-sections 1. POD3 or 4 after passing flatus and tolerating reg diet. Remove staples (unless vertical or pt obese, diabetic), prolene or opsite. 2. Discharge Rx: As above plus Norco or Percocet 5/325 or Vicodin 5/ tabs po q4-6 hours pm pain (#30, no refills) Percocet MUST go on hand written Rx (get from upper level resident) Discharge Summaries 1. Create discharge summary for patients who receive a transfusion, are hospitalized longer than PPD2 or POD4, or received IV BP meds. Use your judgement if a patient has a complex course, it is helpful to outside and future providers to have a clear hospital course. 2. All patients previously on AP who then deliver that admission: copy and paste AP course from signout into CareForm (ask your 2 nd year to edit if needed). You add the postpartum course. 3. If a patient was transferred from OSH be sure to send discharge summary to outside provider. 18

19 Signing Out Post-Partum Sign out complex patients or those that need follow-up by the oncoming team. No need to go over FYIs. -DO sign out: pree, DM1, DM2, chorio/endometritis, PPH, wound complications -NOT necessary to sign out: FS for A2GDM, SW, or vaccinations; just confirm that the order is in *********************************************** CONSENTING BLOOD TRANSFUSION RISK HIV less than 1/2,000,000 Hepatitis C less than 1/2,000,000 Hepatitis B 1/500,000 SAMPLE C-SECTION CONSENT I discussed with the patient the risks, benefits, and alternatives of a Cesarean section. I explained to the patient there is a risk of infection and damage to internal organs including bladder, bowel, ureters, blood vessels, and nerves. I also explained to the patient there is a risk of bleeding which may require a blood transfusion or in rare cases a hysterectomy. I explained that the risks of a blood transfusion include the risks of the transmission of HIV (<1/2,000,000), Hepatitis C (<1/2,000,000), or Hepatitis B (1/500,000). The patient demonstrated understanding and all questions were answered. Consent signed. SAMPLE BILATERAL TUBAL LIGATION CONSENT 19

20 I discussed with the patient the risks, benefits, and alternatives of a bilateral tubal ligation. I explained to the patient that this is a method of permanent sterilization but does have a failure rate of 3-5/1000. I explained to the patient that if she does become pregnant after a tubal ligation she is at increased risk of an ectopic pregnancy and should be evaluated by a physician immediately. I explained to the patient there is a risk of infection and damage to internal organs including bladder, bowel, ureters, blood vessels, and nerves. I also explained to the patient there is a risk of bleeding which may require a blood transfusion. I explained that the risks of a blood transfusion include the risks of the transmission of HIV (<1/2,000,000), Hepatitis C (<1/2,000,000), or Hepatitis B (1/500,000). The patient demonstrated understanding and all questions were answered. Consents signed. Gyn-Onc AM To Do: 1. Call R2 NF for sign out , always by 6:15am or earlier 2. Call 288 (operator) to transfer pager #12825 to your pager # 3. Print sign-out off secure workspace: obgynresidents.stanford.edu 4. Print Rounding Report from epic 5. Circle abnormal vitals, note pain meds used, note Is and Os by shift 6. Copy Rounding Report for each member of team 7. Prep inpatient progress notes (if time and depending on team) Admissions and D/Cs 1. Admissions must have H&Ps. Use gyn-onc order sets and templates in EPIC for admission 2. For discharges: Use discharge tab in Epic. 20

21 First do general discharge order set. Include day and night contact numbers for the patient. Day # , Night and ask for gynonc doctor on call (.oncfu) Next do discharge summary. You can cut and paste course from sign out into Hospital course but change wording to make it understandable (e.g. spell out abbreviations). (.gyndischarge) All new meds or refills needed. Narcotics will require secure (paper) Rx from upper resident Clinics (M,W,F) 1. Clinic notes can be done in EPIC or dictated. Ask you chief which attendings want new patients dictated. Send note to referring MD. 2. Do as much floor work as possible from clinic. This is the interns 1 st priority. Orders, lab f/u, updates from nurses, etc. 3. For clinic patients: See the patient, get history and brief PE, then present to the attending (they will do pelvic/breast exams with you). 4. Try to finish clinic notes that evening (for Berek this is a must, for other attendings by the end of week is ok) Tumor Board (Fridays at 7:30) 1. Patients are most OR patients from the previous week and some new patients from clinic. Ask your chief or fellow. 2. Each patient is presented with their identifying info (age, type of cancer, stage) and a summary of their tumor history: a. Key events radiology and pathology b. Surgeries c. Chemo/Radiation d. Brief: PMHx, PSHx, ObGHx, Meds, FH, SH **look at previous TBs and the team will help you too** 4. Pathology slides have accession numbers which are listed in the computer. 21

22 5. For recent pathology, call Surgical Pathology (across from 2 nd floor escalators) and request new accession numbers. If you call the hot seat pathologist for a prelim read, just indicate that the pathology is pending and for review in the Tumor Board document 6.Outside radiology studies need to be submitted to radiology and scanned in. Ultimately your job but frequently clinic RNs Joanne and Cherie will help. 7. Send a copy of tumor board to Helen Wong hswong@stanford.edu by Wed at 4:30pm to distribute Weekly Schedule: Wear scrubs on OR days, clinic attire (business casual) on clinic days. All clinic is on the first floor of Blake Wilbur The intern must go to Multi-Disciplinary Rounds (MDRs) at 11:30 in the am conference room daily (except Monday fellow goes during chairman rounds) and sign-in. This is a meeting with case management, charge RN, SW- keep discharge needs/planning in mind. Monday (Dorigo/MacLaughlan clinic) 1. Grand rounds and lecture 7:30 11:30 am, transfer pager to fellow during this time 2. Chair Rounds 11:30 am 3. Sign-out at 1830 Tuesday (OR Day) 1. Facilitate patients going to the OR 2. Floor work: update discharge summaries, check labs, etc. 3. For urgent patient questions, go to or call into the OR, or ask upper residents 22

23 4. Post-op checks: Approx. 4h after procedure. Include vitals, fluids (I/Os), meds (esp. pain) 5. Work on Tumor Board. Just do it. Prep new patients for Wed clinic. 6. Signout at 1730 Wednesday (Teng/Berek Clinic) 1. Strip rounds or journal club 7:30 8:30AM 2. Clinic with Dr. Teng/ Berek (1 st floor Blake Wilbur), this clinic often goes late 3. Finalize Tumor Board Tumor Board to by 4:30pm 4. Signout at 1730 Thursday (OR Day) Just like Tuesdays. Prep new patients for Friday clinic. Sign-out at Friday (TBD) 1. Tumor Board 7:30AM 1. Clinic in Blake Wilbur 1 st floor 2. Signout at 1730 Helpful Hints: 1. Gyn Onc Pager: Chemo patients admitted to FGr or EGr 3. All other patients preferably go to F3 4. Replacing electrolytes Phosphorus: Phos NAK packets Magnesium: Mag Sulfate IV 8 meq is 1g, so order 8 or 16 Potassium: 10 meq IV will raise K by 0.1 replaced K <4.0 (order IV 2% lidocaine too! Potassium repletion stings) Calcium: Calcium gluconate 1g IV 6. Hct <30, consider transfusion discuss with chief (1 units PRBCs should increase Hb by 1 and Hct by 3) 23

24 7. IVF: D5 1/2NS + 20 meq K@ 125 cc/h (routine fluid orders postop or NPO) Sample Gyn Onc Note EPIC ** Click Notes tab on left, New Note. (.gyn) and chose gyn progress note. This will bring up a template and import all vitals, labs, and meds. Review imports and add interval history and plan. R1 Gyn Onc PN POD#1, HD#2 Interval History: Pain, flatus, nausea, vomiting, diet, SOB, etc. O: Filled in by EPIC. Review, especially I/O and drain output PE: Gen: does the patient look uncomfortable, is she alert, awake, and oriented? Neck: look at the line sites: is there erythema, warmth, bruising? Heart: rate, rhythm, murmurs.. Lungs: listen sitting up or patient rolled to side; crackles? Decreased breath sounds? Abdomen: look for distention, ascites; listen for bowel sounds; check ostomy sites, color of output Wound: check site for erythema, warmth, bruising, etc. if would is being packed remove packing and note granulation tissue, pus, fluid, bleeding, foul smell, etc. (allow extra time for packing wounds!) Extremities: check to see that TEDs/SCDs are placed, look for tenderness, edema Labs: imported by Epic (.rrcbc,.rrbmp, etc) Radiographic Studies: imported by Epic Pathology: Look up any pending pathology 24

25 A/P: ##yo with [diagnosis] s/p [surgery] etc. Onc: Brief dx, course, intraop findings pathology Pain: note PCA or oral meds Heme: note pt s last Hct, if any transfusions needed, epogen; note if pt has thrombocytopenia ID: note if pt has temperature spike, work-up involved, day of antibiotics; pending micro CV: Treatment of HTN, arrhythmias, chest pain, etc Resp: note saturations and oxygen requirements, and interventions needed for SOB, effusions, etc GI: note the patient s diet, if she is on GI prophylaxis (pepcid), stool softeners, if has NGT, tx for nausea/vomiting FEN: note plan for chem., labs, TPN, IVF, etc Endo: note if diabetic, has thyroid disease, meds PPx: note if pt has TEDs/SCDs, heparin, lovenox Dispo: discharge plan, SW or case manager consult if needed Dr. MacLaughlan has specific laproscopic post-op orders as follows: Post-op orders for minimally invasive hysterectomies +/- staging: (includes robotic and straight stick laparoscopy) Activity: Night of surgery - out of bed to chair OR sit up in bed with legs dangling. Ambulate in am POD1. SCDs while in bed. Nursing: at 6am on POD1 (assuming adequate urine output), backfill bladder and d/c foley. If no void in 30 minutes, notify housestaff. Resist replacing foley. Diet: regular IVF: maintenance fluid as indicated. Heplock patient when tolerating po. If patient is drinking at time of post-op check, has adequate UOP and labs are OK, make sure fluids are stopped. Patients often get a lot of fluid during a 25