LONG OVERDUE!!

Yesterday was my last day of cardiology. I cannot believe how fast 4 weeks went by. I was hoping to write at least once a week and that clearly did not happen. I have every intent of doing that for ER, my next rotation, but maybe I'm being optimistic. This rotation went incredibly well and I received very good feedback, especially considering it was my first rotation! I saw a lot of interesting cases, worked with great preceptors and the hours were very forgiving. I left around 7:15-7:30 in the morning and was usually home by 4pm, some days even earlier. After one of my last posts, several of my "readers" wanted to hear more about the presentating process.

My days in the hospital would go about like this. Arrive at 7:45-8:00am (Adam only beat me there on 1 day) and get a list of patients to see that day. Adam would pick 3 or 4 and send me to see them on my own. I would review their chart, see what other services had seen them in the past day, what orders had been given, etc and then I would see the patient and write my note. The hardest part of the note for me is the management plan - especially since as I student I don't want to write it in ink for everyone else to read if I'm totally off. Then the fun begins...I would meet up with Adam and "present." An ideal presentation should be concise but thorough enough so that the preceptor knows what is going on and they are always done in the same order (the notes we write are called SOAP notes - S = subjective findings, O = objectives findings, A = assessment and P = plan). Here's an example......

"Mrs. J is a 45yo female who presented to the ER complaining of chest pain. The pain started 1 hour ago while she was shoveling snow and is still present. She tried taking some ibuprofen and resting but this did not relieve the pain. She also admits to nausea, diaphoresis (sweating) and radiation to her left arm. (does anyone know where I going with this?). She rates her pain as a 7/10 and has never experienced this before. She has no past medical history and no previous surgeries. She smokes 1/2 pack per day and doesn't drink alcohol."
From there you give the physical exam, usually just presenting abnormal findings. At this point Adam would interrupt me and ask "SO what's your differential diagnosis?" This is all the possible things both common and rare that could be causing this (this is the part that always makes me nervous!!!). If any labs have been done or ordered you should also mention these in your presentation. Then comes my favorite question, "So Michelle, what do you want to do with this patient?" This is challenging, especially as a cardiology student. There's a fine line between saying a patient with a cardiac complaint is okay and can go home and saying they need a heart cath. Of course, the questions don't stop there...after Adam sees the patient and either agrees or disagrees with my note, he always had more questions. In this case, it might be "so why would be give this patient drug A vs. drug B?" or "why did I order this particular test vs. this one?" Usually these questions would come as we were walking down the hall or up the stairs to my next patient and my overloaded brain is trying to answer the question and remember everything about the upcoming patient at the same time. I can't believe how much I learned in 4 weeks and hope that I retain even 50% of it. It's encouraging to work with Adam, who has only been out of school a little over a year and to see the knowledge base he has built already. It's way to early to say, but cardiology might be near the top of my list!