Patient Care

Evaluate and manage p atients hospitalized with acute illness.

History Taking

Objective

Obtain and record a patient’s history in a logical, organized, and thorough manner.

Learning Activity

Interview, examine, and write an H&P for each new patient assigned to you (even if there is already a note).

Evaluation

H&Ps are submitted to the attending is primarily who is primarily responsible for evaluating these. The resident will give ongoing feedback as well. The four best H&Ps are included in the final portfolio for additional evaluation by the Clerkship Director.

Physical Exam

Objective

Perform and record a complete physical examination in a logical, organized, and thorough manner for new patients and an appropriately focused physical examination for follow up patients. Specific physical examination skill we expect students to master by the end of the third year medicine clerkship includes:

  1. Abnormal lung sounds. Be able to identify pulmonary crackles and wheezes
  2. Abnormal heart sounds. Be able to identify extra heart sounds (S3, S4, pericardial friction rubs), systolic vs. diastolic murmurs, and specifically aortic stenosis and mitral regurgitation
  3. Abnormalities related to liver disease. Be able to recognize and describe stigmata of liver disease including findings consistent with ascites, spider angiomata, palmar erythema, jaundice/scleral icterus

Learning Activity

Each student should be observed performing a complete physical examination and/or targeted portions to the exam. Physical finding rounds will be offered to supplement students’ skills.

Evaluation

House staff and faculty will observe students perform physical examinations in the course of patient care and these observations will inform the summative evaluation. Evaluation forms to use for a formal, observed complete physical examination as well as mini-CEX forms for focused exams are available here. The completed mini-CEX form will be part of the student portfolio.

Lab Interpretation

Objective

Obtain and understand important supplemental information, including CBC, serum chemistries, ABG, coagulation studies, ECG, chest x-ray, and urinalysis.

Learning Activity

  1. Lab Studies. Students will have a two-hour session the first Monday of each block (4 hours total) in the Laboratory Medicine Section. These sessions consist of rotations through 6 different areas of the clinical lab where students are presented with illustrative cases and guided through the appropriate use and interpretation of laboratory tests with an emphasis on how to use the lab and Laboratory Medicine staff as resources.
  2. ECG Studies. Students will also participate in an 8-week (8 hours total) ECG conference run entirely by experienced attending-level Cardiologists. The course covers a systematic approach to reading ECGs (beginning with rate, rhythm, axis, intervals progressing through heart block and ventricular and atrial arrhythmias) supplemented by small group discussion.
  3. Radiologic Studies. Students will participate in an 8- week (8 hours total) progressive radiology course that instructs students on the basics of reading plain radiographs (chest, abdomen) beginning with normal studies and progressing through abnormal studies (pulmonary infiltrates, edema, pneumothorax, effusion, etc) and introduces students to CT scanning, ultrasonography, and magnetic resonance imaging. Images are presented both in a disease-specific orientation as well as in a problem-based setting (i.e. how to choose and interpret radiographic studies for the patient with hematuria; headache; abdominal pain, etc).

Evaluation

Students’ understanding of these tests will be assessed in small group discussions on rounds and on the Exam Master knowledge assessment.

Clinical Reasoning

Objective

Formulate and document an assessment that includes the relevant differential diagnoses based on data gathered to guide initial diagnostic evaluation and disease management.

Learning Activity

This will be discussed on daily rounds with the teams and the clinical reasoning process is explicitly taught in weekly Student Report led by a core faculty member.

Evaluation

This is assessed by the teams on daily round interactions and review of progress notes. This is also assessed formally in the portfolio with the H&Ps. Full development of this skill is a crucial component and goal of this clerkship.

Presentation Skills: Initial

Objective

Orally present a new patient’s history and physical examination clearly and with appropriate detail.

Learning Activity

This is typically performed with the attending or resident one-on-one and feedback is given at that time, though this can occur as part of rounds.

Evaluation

Attending and residents who directly observe this will provide formative and summative feedback. A mini-CEX form is available online to enhance this feedback and that may be included in the portfolio.

Presentation Skills: Follow-up

Objective

Orally present a follow-up patient’s case (including those with more than one problem) in a focused manner, including diagnostic and therapeutic plans.

Learning Activity

This is practiced on daily rounds with the whole team present.

Evaluation

Attending and residents who directly observe this will provide formative and summative feedback. A mini-CEX form is available online to enhance this feedback and that may be included in the portfolio.

Written Skills

Objective

Write cogent, clear progress notes documenting working diagnosis and status of diagnostic evaluation and therapeutic plans.

Learning Activity

Students practice this by writing daily progress notes on all their patients. These should be on the chart in a timely manner (ideally before noon conference) if feedback is to be given.

Evaluation

The house staff and attending primarily evaluate Progress notes. However, students also have the option of submitting them in the portfolio for additional feedback by the Clerkship director.

Requirements

Students are strongly encouraged to complete 8 full H and Ps in Med 1 and 14 in Med 2. Students are required to submit 4 of the best H and Ps per block to their Portfolio. The Portfolio is submitted to the Clerkship coordinator at the end of each 4 week block (i.e. treat each block as an independent unit) and should consist of the above mentioned 4 H and Ps, patient log (without identifier), examples of presentations /patient-based clinical learning, and Mini-CEX.