Typical Day in the Hospital


Chris Leba, Class of 2017

I am writing this in regards to internal medicine. Other specialties will differ in certain regards.

Pre-rounding:

This is what you do when you first get into the hospital in the morning. Depending on how many patients you have and how quick you are, you can decide to show up earlier or later. I think a good rule of thumb is 2-2.5 hours before you round with your attending at first. As you get faster, you can decide how much earlier you need to show up. So if your attending wants to do rounds at 10, you would show up in the hospital around 7:30 AM. You will get onto Epic and looks up your patients. This means writing down anything important that happened over night (by reading notes written or hearing from nurses, etc.), writing down vital signs, noting any important PRN medications given, writing down Input/output values, writing down labs, etc. You will determine what things are important as you become familiar with your patients’ problems. Once you’ve got all the objective information you need for the patients you are following, you will go see them. You may end up waking them up – it’s something you’ll just get used to. At that point you will ask them how the night went and inquire upon any symptoms and if they are getting better/worse. This is the time to ask any further questions you need answered. After that, you’ll do a quick physical exam focusing on their condition. After you have done this for your patients, you will write each a SOAP note and look up anything you need to on UpToDate to sound smart. You can also bring up anything important to the residents or ask them any questions about the plan.

Rounding:

Now that you have pre-rounding done, it is time to present to the attending. They each have their own styles. Sometimes you will discuss patients in the rounding room, other times you will walk around and talk about patients outside each of their rooms, other times you will present inside the room doing “bedside rounds.” Each attending is also different based on how in-depth a presentation they want. If you are doing an H&P, usually this is the most detailed. You will start with your one-liner that gives a little bit of background about the patient (pertinent medical conditions) and why they are in the hospital.

“Chris Leba is a 25 year old male with a pertinent history of CHF, chronic alcoholism, and food addiction who presents to the hospital with 4 days of worsening dyspnea.”

As you can see, my history of CHF is pertinent to the current problem of  dyspnea and demonstrates this may be an acute on chronic event. After the one-liner, you will give the history of present illness (HPI) – what happened, how did it progress, associated symptoms, pertinent negatives, etc. For pain, I use OPQRST.

Onset: When did it start? Was is sudden? Gradual? Where is the pain?
Provocation/Palliation: What makes it better or worse?
Quality: Burning, stabbing, dull, etc. Feel like something you’ve had before?
Radiation: Does it move anywhere else? Is it localized?
Severity: 1-10. Does it impair your life to a certain extent?
Timing: Constant, intermittent?

After HPI, you can cover the review of systems – just a list of symptoms that you may or may not have already covered in your HPI. Then you will report the past medical history, family history, medications they are taking, and allergies. Then the social history – tobacco hx, alcohol hx, illicit drugs, living situation, job, etc.

With the subjective done, you will give the physical exam. This starts with vital signs, then general presentation, then head to toe. Don’t forget lines, drains, ostomy, wounds, etc.

Next are the labs – some attendings want you to list all the components of the cell blood count, the comprehensive metabolic panel, etc. Others just want any abnormal labs.

Next I include microbiology – blood cultures, urine cultures, urinalysis, acid-fast stains, etc.

After this is imaging – any ECG’s, CT’s, X-rays.

Assessment and plan is the real meat of the presentation. Here is your chance to show your attending that you know stuff and are actually smart. Start again with your one-liner to set the stage. After that, you list problems that are being addressed and what you’re doing for it.

Assessment
“Chris Leba is a 25 year old male with a pertinent history of CHF, chronic alcoholism, and food addiction who presents to the hospital with 4 days of worsening dyspnea.”

Plan
#Acute on chronic CHF exacerbation: Differentials for his dyspnea and volume overload could include his CHF, nephrotic syndrome, and cirrhosis. Because he has signs of pulmonary edema, elevated JVD, and hepatojugular reflux along with an elevated BNP and echo demonstrating decreased ejection fraction, this is most likely exacerbation of his underlying CHF. He also reports increased fast food consumption recently, which could have led to a salt load and volume retention. Nephrotic syndrome is less likely as he has no proteinuria on his urinalysis. Despite his chronic alcoholism and fatty food intake, there are no signs of liver injury as he does not have elevated LFT’s and his abdominal exam is normal.
– Lasix 20 mg IV BID
– Fluid restriction to 1.5 L daily
– Sodium restricted diet
– Etc

#Problem 2, etc.

During or after your presentation your attending may “pimp” you. This has now commonly come into the vernacular to mean “ask you questions.” A good way to prepare for this is to read up on your patients’ conditions, be ready to cite any diagnostic criteria, interesting physical exam findings, etc. Be able to explain abnormal exam findings, lab values, imaging, etc.

This will occur for each new patient on call days or post-call days. After an H&P has been given for a patient and you are now following them, you will do an abbreviated presentation. This includes the above with shorter subjectives that comment on overnight events. There is no more need to repeat the past medical history, family, social, etc. You will mention physical exam again, commonly reporting any changes. You will report any new labs, micro, imaging. Then you will do the assessment and plan again, indicating any new changes.

Call Days:
You’ll be on call at Parkland every 4 days. Your call day starts at 7 AM, meaning your team can start getting patients at that time. If you are seeing previous patients, you may decide to show up early than 7 AM in order to pre-round. Throughout the day your team will be paged to see new patients which may come from the emergency department or be transferred from the MICU. You will see the patient and obtain a history of physical, commonly doing at least 2 each call day. Your attending will let your team know when they want to round, sometimes rounding once in the morning to cover old patients and maybe some new ones, then rounding in the afternoon to hear about more new ones. Depending on how nice your residents are, you may be released sometime early evening. Call days can be hit or miss on how busy they are, so you may want to bring a book or UWorld questions to do during down time.

Post-Call Days:
You will usually round around 7 AM so that the night intern can present any new admissions from over night then leave. That means you will likely need to come in rather early to pre-round on your patients. These days are usually shorter and hopefully you can leave after conference.

Non-Call Days:
These days you pre-round and round on your patients as usual and follow-up on things being done. New imaging, consults for specialists, etc. If your resident needs something done, you can offer to help. Send some fax requests to obtain hospital records, call the imaging department to ask when a CT or echo is going to be done. Again, these depend on how nice your residents are for when you can leave. Hopefully early afternoon.

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