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A Practical Guide to Clinical Medicine

A comprehensive physical examination and clinical education site for medical students and other health care professionals

Web Site Design by Jan Thompson, Program Representative, UCSD School of Medicine.
Content and Photographs by Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California 92093-0611.
Send Comments to: Charlie Goldberg, M.D.

Introduction Breast Exam Write Ups
History of Present Illness Male Genital/Rectal Exam The Oral Presentation
The Rest of the History The Upper Extremities Outpatient Clinics
Review of Systems The Lower Extremities Inpatient Medicine
Vital Signs Musculo-Skeletal Exam Clinical Decision Making
The Eye Exam The Mental Status Exam Physical Exam Lecture Series
Head and Neck Exam The Neurological Exam A Few Thoughts
The Lung Exam Physical Exam Check Lists Commonly Used Abbreviations
Cardiovascular Exam Medical Links References
Exam of the Abdomen    

The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures. DaVinci's Anatomy Symbol

Inpatient Medicine

General Comments: You will spend a significant portion of your clinical training caring for hospitalized patients. This environment presents different demands and opportunities then other areas of the healthcare system. Within the hospital, each branch of medicine has its own structure and approach. Several elements, however, are common to all:
  1. Organization: Health care in teaching hospitals is very hierarchical. At the top of the pyramid is the attending physician, a staff doctor who has ultimate responsibility for the patient. Beneath them is the supervising resident, a physician in the advanced stages of their training. They supervise the interns, doctors in their first year out of medical school who are generally the worker bees of the service. Fourth year students (referred to as Sub or Acting Interns) may also be members of the team. This is their opportunity to work with an increased degree of autonomy in order to prepare them for their future role as doctors. Some teams have additional layers of residents or fellows (physicians participating in advanced post-residency training), depending on the complexity and volume of work to be done.
  2. Team Approach: Those at the higher levels function as managers while those in the trenches tend to focus on getting things done. However, this is also a system of graduated responsibility, allowing less experienced providers the chance to become increasingly involved in the decision making process over time.
  3. Role of the Student: The third year student occupies a variably placed position on the team. Clinical education is based on the concept that students learn through a process of observation and controlled participation in patient care. Their ability to function and contribute will depend on the scope of their general experience as well as specific knowledge in any one field. During the beginning of the year and/or early in a particular rotation, students will be less functional then towards the end. Furthermore, the very nature of some rotations (e.g. surgery) will pose obvious limits on the degree to which the student may actually participate. In addition, the student has a somewhat distinct position from the other team members in that their purpose is not merely to get work done. Nor, for obvious reasons, do they function with speed or efficiency, traits which frequently define the work of the other team members.
Why is it important that you understand this structure? The quality of your educational experience will be heavily influenced by your ability to identify, and then make the most of, your role within this system. You will receive educational input, to some degree, from all members of the team. Realize that their experience and abilities as teachers will vary widely. Some will be naturally gifted, most will be adequate and a few will be horrific. However, almost all value this exchange and want to do a good job. Be patient. Recognize that you're functioning in a world of competing priorities. The primary focus of the team is to provide good care for the patient. Within this context, these physicians are also expected to supervise and train others, increase their own knowledge base, and provide for your educational needs. That's quite a daunting task, particularly for someone who may have had little formal experience in either management or teaching. In order to get the most out of each rotation, try to make use of the following questions and behaviors:
  1. Ask the head of your team (both resident and attending physician) for a precise description of your responsibilities. How many patients will you follow? Will you be writing admission H&Ps, daily notes, presenting at attending or work rounds, etc? Who will be reviewing your work?
  2. What are your expectations for the rotation? What are the most important things that you want to learn or experience? Even if these are no different then the other students (e.g. observe operations on a surgical service, practice putting in I.V.s, etc.), keep a mental list for yourself that you can refer to periodically. If you have unusual expectations that you feel can be reasonably met within the scope of the rotation, discuss them with your supervising physicians.
  3. With whom will you be working? One or several of the interns or with the resident directly? Make sure that you know how to contact them and that they know how to find you. It helps to confirm even the most obvious details as non-communication of what others feel is implicitly understood information can become the substrate for conflict.
  4. Offer feedback to your teachers. Let them know what works and what does not. Similarly, solicit input on your own performance. Don't leave this for the end of the rotation as by then you'll have lost the opportunity to incorporate suggestions and experiment with new approaches.
  5. Determine the weekly schedule of events. Are there student conferences or other commitments that will make you unavailable to the team? When and where are work rounds, radiology rounds, attending rounds, etc.? If you're on a surgical rotation, when will you be expected to be in the operating room?
  6. Identify when you are expected to be on call and what your exact responsibilities will be on those days. Will you be sleeping in the hospital? Who is responsible for informing you about new admissions? Should you see these patients with the rest of the team or interview them separately? If there are specific days that you need off, let your team members know at the start of the rotation.
  7. Realize that education is a two-way street. Students can and should contribute to the learning process. This is of particular value on fast paced rotations, when time constraints prevent other team members from being able to pursue this information on their own.
  8. Address conflicts or areas of dissatisfaction early in the rotation. Frequently, these are simply the result of miscommunication and can be easily remedied. More complex issues should be taken up either directly with the person(s) involved or, if you are uncomfortable with this approach, via the attending physician or course director. Don't let problems fester!
  9. Take each rotation seriously and try to learn as much as possible while you're there. A casual or cavalier attitude is rapidly transmitted to those with whom you work. Any lack of interest on your part will almost certainly lead to less enthusiasm and effort from your teachers. The resulting clinical experience is destined to be less fulfilling and interesting. Try to adopt the attitude that you are truly a practitioner in the field of medicine to which you've been assigned. The resulting experience will be more enjoyable, the teaching superior, and you may occasionally identify a previously undiscovered area of interest or aptitude.
Ultimately, you are responsible for your own education. As such, you really need to stop and consider the unique opportunities and challenges provided by the hospital environment. This is likely to be an experience which differs from any that you've encountered in your previous careers as students. The elements described above can either make or break a particular rotation. By becoming more aware of how and why things happen, you will hopefully be able to maximize the quantity and quality of each educational encounter.

Specific Suggestions for Making the Most of Inpatient Rotations

Pre-Rounding: Work rounds occur each morning and are the time when the team sees each patient, discusses their course, and decides on the diagnostic and therapeutic plan of the day. In order to be maximally efficient, it falls to the students and interns to gather relevant clinical data. This process is referred to as pre-rounding and should incorporate the following:

  1. Review the flow chart that is kept for each patient. This sheet is a record of their vital signs as well as fluids taken in or excreted (referred to as Is and Os, for Ins and Outs) over a twenty-four hour period.
  2. Be aware of major events that have occurred over the past day. Were any studies performed? Were there major changes in clinical status? Of course, access to this information is predicated on your having been actively involved in the patient's care (i.e. you need to make it a priority to stay informed about the patient's clinical activity). If things are happening that you are not made aware of, mention this to the interns and residents so that they can help you become an active participant in the patient care process.
  3. Tracking down events that occurred overnight can be challenging. These can range from evaluation of a fever to initiation of new medications. A few places to check:
    1. If your team was not on call, try to speak with the person who was responsible for caring for the patient overnight. Alternatively, it may be easier to check with your intern as they have, in all likelihood, obtained some sort of sign out from the covering person.
    2. Check the chart to see if any notes were written about specific overnight events (or by consulting physicians who may have stopped by late on the previous day). Also, take a look in the order section for things initiated over night. You may then be able to piece together what happened during your absence. If, for example, new antibiotics were given, then someone must have discovered a previously unrecognized infection.
    3. Speak with the nurse who was covering the patients overnight and/or the one who has taken over in the AM.
    4. Query the patient about any overnight events. You will need to perform a focused exam each morning, which is a prime opportunity to ask if anything has happened.
  4. Leave yourself plenty of time to pre-round. Early in the year, this can require up to 30 minutes per patient. You may need to arrive quite early, depending on your experience, as well as patient volume and complexity. However, providing yourself with a realistic time cushion will generate much less anxiety and allow you to be as complete and accurate as possible.
Record Keeping: It is important to develop a system for keeping tract of all your hospitalized patients. Whichever mechanism you choose should allow you to:
  1. Have instant access to each patient's relevant past history, medications and baseline labs.
  2. Be aware of in-house medications and daily lab results.
  3. Maintain a list of things that need to be done for each patient.
Why is this necessary? You will frequently be required to recount specific information (when talking with consultants, arranging for studies, reviewing lab tests, etc.) at times when you don't have access to the patient's paper chart. It is therefore critical that you maintain a portable record keeping system. Furthermore, caring for patients can get quite complicated, particularly early in your careers when everything seems confusing. This tends to get worse with time as your responsibilities (and fatigue) grow. It's quite easy to either mistake one patient for another or simply forget to follow through on a previously determined plan. As a wise resident once told me: "There are two types of house officers; those that write things down and those that forget!".

The following system allows you to keep all relevant information on 5x8 index cards. This method has several advantages:

  1. It's readily portable. The cards fit nicely into standard lab coat pockets and are available on most hospital floors.
  2. As opposed to clip-boards (which are frequently misplaced), these cards leave your hands free to perform tasks (e.g. physical examinations, compressions during CPR, etc.).
  3. It makes relevant data readily available and allows you to keep an organized list of things that need to be done.
  4. It's easily standardized and understandable by others.
  5. This system can be learned and used by students and then carried over and applied during later careers as house officers and attending physicians.

Front of Card
Front of Card

Back of Card
Back of Card

A few things to remember:

  1. Over time you will develop a short-hand that allows you to make best use of the card space available. You can also adjust the format any way you wish.
  2. The information included on the back (PMH, PSH, HPI, PE, etc.) is in very brief form. It should only include the critical highlights. More detailed points can be found in the chart.
  3. If a patient is hospitalized for a very long period of time, additional cards can be stapled on top of the original.
Note Writing: The format for the complete H&P is discussed elsewhere. Daily notes should be organized so that they are brief, yet highlight important data and clearly express clinical impressions. This must, of course, be done within the context of your knowledge base. As with many of the other tasks in which students participate, notes serve two purposes: They are an actual descriptive document that chronicles the patient's course. And, they are a learning tool that allows you to think about what's going on and express organized thoughts. A few things to remember:
  1. The data presented should be factual. Old events that were described in earlier notes should not be repeated. The daily note is not meant to be a recapitulation of the H&P.
  2. The impression and plan generally reflects the thoughts of the entire team. That is, don't use the note as a format for expressing ideas that differ wildly from everyone else. If you don't understand, or even disagree with, the dominant view, talk to your team members and try to gain insight into their thought process. Independent reasoning is certainly encouraged. However, avoid using the note as a means of battling with (or inflaming) your colleagues. This is, unfortunately, a common problem for many "higher level" providers, leading to energy and time wasting "chart wars."
  3. Don't take hours (or more then 10 minutes, for that matter) to write a note. The length of the note will depend to a large extent on your experience, understanding of the case and the complexity of the patient's illness. However, there is generally WAY TOO MUCH attention paid to this process. Many, many other endeavors are of greater value, to both the patient and yourself. Remember, compared with all of the other aspects of patient care, the note is a minor end unto itself. After all, those most interested in the note are you and your team members. Thus, the exquisite detail found in many of these masterpieces is for the benefit of physicians who are already well aware of the patient and their course! In the event that some point is unclear, the reader can always find you to discuss the matter further.
  4. Make sure that you get feedback from team members about your written work.
  5. Certain services have very particular styles, emphasizing aspects that are important to the care that they provide. General Surgery teams, for example, tend to highlight fluid status, wound care, and IV access issues, areas that are critical to their patient population. Furthermore, these notes are very brief. The surgeon's time is spent elsewhere (e.g. the Operating Room) and by necessity they cannot spend exorbitant amounts of time charting. Realize that being succinct is not equivalent to being incomplete nor does it imply sub-optimal care. To my knowledge, no one has shown that the length of the note correlates with the quality of care delivered. In fact, it occasionally seems that more time and energy is put into notes then actual patient care!
The basic format is referred to as a SOAP note. This stands for the major categories included within the note: Subjective information, Objective data, Assessment, and Plan. A sample note for a patient receiving treatment for pneumonia is as follows:

Hospital Day # 3