TOPNOTCH MEDICAL BOARD PREP USMLE HANDOUT BY MARK JARED N.
KHO, MD
For inquiries visit [Link] or [Link]
ACTUAL ROUNDS – NSTE-ACS
DAILY ROUNDS 1. Do chart rounds first (read the nurses entries, intake output,
AND PROGRESS NOTES medications, entries of other services)*
2. Perform hand hygiene and wear protective equipment as
Marc Denver A. Tiongson, MD, FPCP, FPCC needed
3. Perform your bedside assessment (interview the patient,
EXPECTATIONS FROM THIS LECTURE perfom PE)
1. Learn General Approach in doing Rounds and Progress Notes 4. Summarize your findings to the patient and family
2. Learn a Systematic way to write your progress notes
3. Be familiar with the do’s and don’ts in your rounds and notes POST-ROUNDS – NSTE-ACS
1. Organize your findings based on your assessment
§ No chest pain for 24 hours (last chest pain was ___)
WHAT ARE ROUNDS? § No significant complaints / unremarkable ROS
• Actual patient encounter (Assessment) § Your PE
• Can be teaching (Digesting cases) 2. Write your progress notes and chart orders (will be discussed
• Can be purely academic (conference discussing one topic) later
• Can be an audit (discussion of a patient’s case, management and 3. Facilitate and follow up labs and referrals
course) 4. Update your consultant/senior and/or prepare for your
• Bedside / sit down / virtual rounds with the team
ACTUAL ASSESSMENT OF THE PATIENT SUPPLEMENT LECTURE
• Complete History (1st encounter)
• Focused history (events that happened since you last saw the
THE PATIENT’S MEDICAL CHART
patient) GENERAL PARTS
• Review of Systems (ROS) Chart Part Contents
• General Physical Examination and specific maneuvers needed to Demographics
assess the patient Address
• Assessment of patient’s surroundings – monitors, IV drips Patient Details
apparatus attached to the patient Information Attending Physician
Admitting Diagnosis
PRE-ROUNDS Discharge Diagnosis
Written consents for admission and
1. Read about the case Consent
management
2. Identify important points to monitor in day-to-day hospital
course of the patient Hospital
3. Make sure you have eaten something (you’ll never know when Agreement Policy
will be the next chance you grab something to eat) All labs segregated Into imaging, chem,
Labs
4. Make sure you have done your assignment (if something was micro, etc
assigned to you) Doctors’ Notes Progress notes and Orders
Nurses Notes Narrative of events per shift
Therapeutic Sheet All medications classified as IV, PO, SQ
ACTUAL ROUNDS
Vital Sign Graph of Blood Pressure, Temperature,
1. Check the chart of the patient for events / new labs / entries /
Monitoring Sheet RR, PR
orders / inputs after the last chart entry you saw
Intake: Total fluid and food intake,
2. Always perform hand hygiene before and after patient
Intake Output fluids given
encounter
Monitoring Sheet Output: Bowel movement, urination,
3. Do your patient assessment (History / Focused History / ROS
other tube output
/ Physical Examination)
CBG monitoring For patients requiring sugar
4. Check the surrounding of your patient
Sheet monitoring
5. Provide focused and accurate update on your findings to the
patient* Parenteral Sheet All parenteral fluids given to patient
POST-ROUNDS PROGRESS NOTES
1. Organize your findings based on your assessment GENERAL APPROACH - SOAP
2. Write your progress notes and chart orders • S: Subjective
3. Facilitate and follow up labs and referrals • O: Objective
4. Update the attending physician/senior and/or prepare for • A: Assessment
your rounds with the team • P: Plan
SAMPLE CASE ACUTE CORONARY SYNDROME
SUBJECTIVE
A 58-year-old male admitted for NSTE-ACS on his 2nd hospital
day. • Patient’s status from the patient’s and his or her keen’s
perspective
PRE-ROUNDS – NSTE-ACS • How is the patient clinically
1. Read about NSTE-ACS • Symptoms experienced
2. Identify Important points to monitor: • How is the patient compared to yesterday
§ Clinical Status
- Presence of chest pain and other anginal equivalent, OBJECTIVE
frequency, last episode • Physical Examination
- Vital Signs, Intake and Output of the patient • Compare your findings from previous encounter and present
- Medications being given and taken encounter
- Labs: ECG, Cardiac Enzyme Trends, Blood chemisty, • Special maneuvers to access if there are new findings
Echocardiogram
- Level of Activity ASSESSMENT
• Write your clinical assessment based on S and O
• REMEMBER: your assessment should be supported by S and O
• Identify your problem list, active, resolve
• Update regularly
TOPNOTCH MEDICAL BOARD PREP USMLE HANDOUT BY MARK JARED N. KHO, MD Page 1 of 3
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TOPNOTCH MEDICAL BOARD PREP USMLE HANDOUT BY MARK JARED N. KHO, MD
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PLAN PROGRESS NOTES
• Pharmacologic and Non-Pharmacologic • In writing your progress notes, remember the:
• Diet S, O and A are written in the “Doctors notes” or “Progress notes”
• Labs part of the ORDER SHEET/DOCTORS ORDER SHEET
• Medications • The P, is written in the Orders
• Monitoring • The P is the one read by nurses for carry out
• Referrals
• Special Instructions / Orders SAMPLE CASE ACUTE CORONARY SYNDROME
A 58-year-old male admitted for NSTE-ACS on his 2nd hospital
day.
TOPNOTCH MEDICAL CENTER
Name of Patient: Juan Dela Cruz
Age/Sex: 58/M
DOCTORS’ NOTES
DATE/TIME DOCTORS NOTES DOCTORS ORDERS
April 7, 2021 Resident on Duty P>
6:30am > Patient seen and examined, new labs noted Diet: low salt low fat diet
> Hospital Day 2 IVF: Heplock
I: 1800 > Inputs of co-managing services appreciated Diagnostics
O: 1900 S> 〇 2D echocardiogram with doppler studies
- 100 Patient claims to be much better today 〇 Ffup lipid profile
No episode of chest pain since yesterday 〇 Ffup HbA1c
No dyspnea, no palpitations, no near syncope 〇 12L ECG
No bleeding episodes Therapeutics
ROS 1. Aspirin 80mg/tab 1 tab once a day after lunch
(-) fever, weakness 2. Clopidogrel 75mg/tab 1 tab once a day
(-) headache, blurring of vision, dizziness 3. Enoxaparin 0.6cc SQ q12
(-) cough, difficulty of breathing 4. Atorvastatin 80mg once a day at night
(-) chest pain, palpitations 5. Isosorbide dinitrate 5mg/tab 1 tab SL as needed for
(-) abdominal pain, melena, hematochezia chest pain
(-) changes in urination 6. Isosorbide dinitrate 10mg/tab 1 tab 3x a day at
O> 7am-11am-4pm
GS: Patient seen awake, conscious, coherent 7. Captorpil 25mg/tab ½ tab once a day
Not in cardiorespiratory distress 8. Carvedolol 6.25mg ½ tab 2x a day
Speaks in full complete senteces 9. Omeprazole 20mg/cap 1 cap once a day 30 mins before
VS: BP 110/70-120/80 HR 55-65 RR 14-16 Breakfast
Temp: 36-36.5 Sats: 95-98% 10. Lactulose 30cc once a day at night
HEENT: Advised patient to walk around the bed, sit up more often
Anicteric sclerae, Pink conjunctivae Refer to dietary
No jugular venous distention noted, JVP 3cm Refer to Cardiac Rehab
Chest Monitoring: vital signs Q4
Symmetric chest expansion, bronchovesicular WOF: Chest pain, palpitation, dizziness, syncope
Breath sounds, no rales/wheezing Goals of care:
Heart Short term goals:
Adynamic precordium, distinct heart sounds 1. Risk stratify patient to identify need for invasive
Normal rate regular rhythm, no murmurs Strategy or conservative strategy
Abdomen 2. Optimize medications
Flat, normoactive bowel sounds 3. Improve functional capacity
Extremities Long term goals
Pink Nailbeds, Full equal pulses, warm extremities 1. Risk factor modification
Labs 2. Control of co-morbidites
12/12/20: Trop 3 from 2 3. Return to baseline functional capacity
12/12/20: Na 145 from 143
12/12/20: 12L ECG: Regular sinus rhythm, normal axis
Lateral wall ischemia Juan Dela Cruz, MD
12/12/20: chest x ray, cardiomegaly with pulmonary PRC License No. 0123456
congestive changes April 7, 2021 6:45am
A>
12/11/20: NSTE-ACS
12/11/20: Heart Failure secondary to Ischemic Heart
Disease Functional Class II
00/00/10: Hypertension Stage 2, controlled
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TOPNOTCH MEDICAL BOARD PREP USMLE HANDOUT BY MARK JARED N. KHO, MD
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OTHER EXMPLES OF MEDICAL CHARTING
RELATIVELY BENIGN CHARTING
TOPNOTCH MEDICAL CENTER
Name of Patient: Juan Dela Cruz
Age/Sex: 58/M
DOCTORS’ NOTES
DATE/TIME DOCTORS NOTES DOCTORS ORDERS
April 7, 2021 Resident on Duty P> continue present management
6:30am S > patient seen and examined
> no new subjective complaints Jun Santos, MD
I: 1800 > denies chest pain difficulty of breathing PRC License No. 0123456
O: 1900 O > Vital signs: BP 110-120/70-80 HR 68 RR 18 April 7, 2021 6:45am
- 100 > Bronchovesicular breath sounds
> Distinct heart sounds
> Noted new labs:
Troponin 1.18
A> Maintained
SUPER BENIGN CHARTING
TOPNOTCH MEDICAL CENTER
Name of Patient: Juan Dela Cruz
Age/Sex: 58/M
DOCTORS’ NOTES
DATE/TIME DOCTORS NOTES DOCTORS ORDERS
April 7, 2021 Resident on Duty P> continue present management
6:30am > no new complaints
> VS BP 110-120/70-80 HR 60-70 RR 18 Jun Santos, MD
> essentially normal physical findings PRC License No. 0123456
April 7, 2021 6:45am
DO’S AND DON’TS
DO’S
• Maintain integrity
• Be respectful of others
• Be cordial
• Bring lots of patience
• Keep the fire burning
DON’TS
• Neglect your duty as a physician
• Scold your patient or relative
• Do something MAJOR without the knowledge of your senior
consultant
• Bluff, say something that is not true
• Others
END OF PROGRESS NOTES AND ROUNDS
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