INTERN APP INTERN =TO-INTERN CUIDE FOR MEDICINE VERSION 4.0 Pat DELI a VeaPREFACE ‘The Intern App is a compilation of my notes, lectures and references that | used during my internship. | originaly wrote them in a small notebook but due fo the requests from my colleagues, | have compiled them here. My internship was a challenge. | was expected to know what to write on the papers and case discussions and how to refer to residents or consultants. | did not have any summarized reference that could help me, so | decided to create a notebook that contained most of the information that every intern ought to know. The computations, laboratory values, acronyms and important points are in bold or underlined. Please take note that the values and treatment given may differ from each institution and that all patients are treated individually, The information placed here are from different references so if you would like to comment on any of its contents, do feel free to message me on the site mentioned below. Please also include your reference by writing the name of the book, author, citation, edition, and page numbers so that | could verily Version 4.0 includes notes encountered during my clerkship, internship, medical board review and prior to my residency. Corrections and revisions from Version 9 (Third edition 2017) have been made on dermatology, psychiatry, surgery, urology, orthopedics and much morel | would tke to thank my family for all their unending support and guidance especially to my beloved mother, Mitay Sayo, for managing the Intern App. And finally, | would like to thank you for your interest in my book that Ihave worked so hard for! Good luck and God bless you ‘on your medical career, NoTICE The Medical Field, surprisingly enough is quite dynamic, with the wealth of knowledge available, one would still be amazed at the speed with which new research come ‘nto fore. With this in mind, | have compiled this set of notes, mindful that we have to still be deep rooted in the basic wealth of knowledge that our professors, tutors, mentors have shared with us. | am simply putting their wealth of knowledge into a "book" that my fiends and I can find solace in The compiler and any other party who has been involved in the preparation of this book make ‘70 warranties, expressed, written or implied, and assume no responsibliias or labiltes for the results or effects from its implementation with respect to it being complete, accurale and up-to-date, PLEASE DO NOT PHOTOCOPY. THIS IS NOT FOR RE-SALE For your own Intern App, you may contact us here: http:/iwww facobook.convtheintermapp For comments, suggestions, additional references, corrections or other concems, kindly ‘message me at htlp:/uww facebook.comMheinternapp, INTERN APP: Intern-to-Intern Gulde for Medicine Copyright © 2018 by Intern App, Inc. All rights reserved Tintern App Version 4.0 a a a aTABLE OF CONTENTS RECORDING THE MEDICAL HISTORY. INTERNAL MEDICINE. ANESTHESIOLOGY. CARDIOVASCULAR SYSTEM... DERMATOLOGY svn ENDOCRINOLOGY. GASTROINTESTINAL SYSTEM su HEMATOLOGY AND ONCOLOGY sono INFECTIOUS enn RENAL SYSTEM. RESPIRATORY SYSTEM RHEUMATOLOGY... NEUROLOGICAL SYSTEM... OBSTETRICS & GYNECOLOGY. OBSTETRICS ann GYNECOLOGY... OPHTHALMOLOGY... “ OTORHINOLARYNGOLOGY (HEENT) PEDIATRICS wesonnenn 102 PSYCHIATRY. : a a 137 RADIOLOGY. 182 SURGERY. — — a tet 18 GENERAL SURGERY, 158 ORTHOPEDICS. 175 UROLOGY... svn —- 177 IV FLUIDS AND ELECTROLYTES ns se TD BLOOD SPECIMEN COLLECTION. COMMONLY USED PEDIATRIC MEDICATIONS. COMMONLY USED IM & SURGERY MEDICATIONS. sd BL 186 COMPUTATIONS vn 189 DOCTORS ORDERS... 190 NORMAL LABORATORY VALUES. 90 193 se 94 REFERENCES su 7 : LABORATORY VALUES FOR LAMINATION OR TO PUT IN YOUR ID. Tintern App Version 4.0RECORDING THE MEDICAL HISTORY S.0.A,P, FORMAT SUBJECTIVE > "Patient is a y/o female/male admitad/consulting for the _ndith ime inthis institution vith chief complaint of..." (quote the patient's own words) > History of Present liiness: (4 phases) © Restatement of the chief complaint with elaboration in greater detail © History of present problem from the time of onset with detailed description of the symptoms ‘Characteristics: (CLITA) * Character quantily, quality, consistency, appearance + Location and radiation ; + Intensity and severit * Timing: continuous or intermittent, duration, temporal relationship to other events * Associating symptoms + Aggravating/ alleviating factors + (Others: medications taken) © Full description of the current stalus of the patient © Summary of pertinent poslves and negatives (presence or absence of symptoms relevant to the diferental diagnosis) Bast Medical History: ‘Unremarkable" i there are no findings) Childhood diseases, allergies, major ilnesses Previous hospitalizations, surgeries Pregnancies and deliveries, any abnormally Accidents Immunizations, maintenance medication Childhood ilnesses: measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever, polio © Adultilinesses + Medical: Diabetes Melitus, hypertension, hepatitis, asthma, HIV: ‘ hospitalizations; number and gender of sentel partners, risky Sexual practices * Surgical: Dales, indications, lypes of operations + Obstetric! Gynecologic: Obstetic history, menstrual history, methods of contraception, sexual function + Psychiatric: liness and time frame, diagnoses, hospital Social History: smoker (pack years), aleoholic drinker + Review of Systems (uncover symptoms/ problems that the patient has overlooked) ‘© General : Recent weight change, weakness, fatigue, or fever © Skin Color, texture, itching, rashes, changes in hait/nalls © HEENT : Head (headache, head injury, dizziness, lightheadedness). Eyes (vision problems, pain, rednessiinflammation, excessive tearing). Ears (hearing loss, tinnitus, infection, fuid discharge); Nose and sinuses (cough, colds, nasal stuffiness, nasal discharge, itching, epistaxis); Throat (bleeding gums, dentures, dry mouth, frequent sore throat, voice hoarseness, dysphonia) Neck: Swollen glands, paipable lymph nodes, neck pain, neck stiffness Breasts : Lumps, pain or discomfort, nipple discharge Respiratory: Cough, hemoplysis, wheezing, rales, crackles, pleurisy Cardiovascular : Chest pain or discomfor, palpitations, heart murmurs, dyspnea, orthopnea, results of past ECG © Gastrointestinal : Dysphagia, loss of appetite, nausea, vomiting, color and consistency of stool, pain with defecation, constipation, diarthea, abdominal pain, {food intolerance, excessive belching/ flatulence, jaundice © Peripheral Vascular: intermittent claudication, leg cramps, varicose veins, past clots inveins © Urinary : Pain during urination, urinary tract infection, hematuria, kidney or flank pain, suprapubic pain, incontinence © Genital : + Female: Menarche age, regularly, frequency, duration of periods, amount of bleeding, bleeding between periods or after intercourse, last menstrual period, dysmenorthea, premenstrual tension, age at menopause, symptoms, bleeding, if born before 1971, exposure to diethylstibestral (DES) from maternal use during tions, treatments o intern App Version 4.0 3pregnancy, vaginal discharge, itching, sores, lumps, STD, treatments, number of pregnancies, number and type of deliveries, number of abortions (spontaneous ‘and induced), complications of pregnancy. ish control methods, sexual preference, inlerest, function, salisfaction, problems (dyspareunia), exposure to HIV infection Male : Discharge from sores on the penis, testicular pain or masses, history of STD and treatments, sexual habits, inlerest, function, salisfaction, problems, birth control methods, condom use Musculoskeletal : Generalized muscle weakness, muscle orjoint pain Psychiatric “History of trauma, dealh of a family member, hallucinations, delusions Neurologic: Seizures, headache, dizziness, numbness, tingling, tremors Hematologic : History of transfusion reactions, anemia, bleeding tendencies Endocrine: Coldiheat intolerance, excessive sweating, polydipsia, polyuria, polyphagia OBJECTIVE > General survey: “Awake, alert, coherent, not in cardiorespiratory distress (NICRD), ambulatory! wheelchair- boundi stretcher with bound’ ‘© Consciousness : Awake/asleep, ale! lethargic! oblunded! stuporous/ comatose © Coherence —_- Coherent/ incoherent © Ambulatory / carried! wheeled-in © Notin cardiorespiratory distress > Vial signs: BP>HR/ PR> RR> Temp via___> Pulse Ox ‘> Weight, height, Body mass index (BM) ‘BMI CHART (Informational WHO) Interpretation WHO ‘ASIANS | Ideal Body weight International (kgim?)__| «Females: 100 pds + (5 pds Severely undenweight | < 16.0 <76.0 per inch over 5 feet) Underweight 185 <185 les: 106 pds + (6 pds NORMAL 165-243 | 185-229 | perinch over S feel) ‘Overweight 25 23_- 24.9 | «Note: Divide 2.2 to convert (obese amaeeed 230 25.299 | lokg ‘Obese I 235 230. (Obese Ii 240 7 Skin: Smooth, warm, wilh good turgor, no rashes, no hematoma > HEN ‘0 Head: normocephalilatraumatic Eyes : aniteric/ Ieteric Sclerae (ASIIS), pink palpebral conjunctivae (PPC) Ears : normoset ears. (lesions, discharges, tenderness Nose: septum midline, (-) lesions, discharges, tendemess. Mouth: gums pink, (-) bleeding, (+) uleer Neck & Throat: ()tonsillopharyngeal congestion (TPC), (-) Cervical lymphadenopathies CLADS), thyroid not enlarged, trachea midline, not palpable lymph nades Thorax & Spine: Symmetrical with no masses or rib retraction noted Chest & Lungs: Equal! symmetric chest expansion (ECE), clear breath sounds (CBS) Heart & CVS: Adynamic precordium (AP), normal rate and regular rhythm (NRRR), distinct 51/82 heart sounds. () heaves or thrill. (-) murmurs > GIT & Abdomen: Flabby! flat abdomen, (-) scars, lesions or masses. Normoactive bowel sounds (NABS). (-) tendemess, Digital Recial Examination (DRE) (go fo Surgery section) > Extremities: Full equal pulses (FEP),(-) cyanosis, (-) edema, CRT <2 sec ASSESSMENT > Include category, location, laterality PLAN 7 Diagnostic plans > Therapeutic plans: Medical, surgical, supportive INTERNAL MEDICINE MRA- SUBSPECIALTY REFERRAL (UERM format) PATIENT DATA 7 History and Physical Examination ‘0 Name, age/sex, date of admission, present hospital day, background (co-marbidites), chief complaint, present working impression, reason for referral, intern App Version 4.0 4‘© Pasthealth and social history, medications with dose and frequency (generic name) © Physical Exemination (done by referring clerk) y — Procedute (for MRA) © Date and time > Conlemplated procedure and length of operation © Conlemplated anesthesia © Others: ie, anticipated blood lass, etc > NYHA classification (See Anesthesiology notes) Risk stratification (Patient and procedure's specific risks) > For patienls seen al the OPO please take nole of the (Medicine Resident on duly) MROD- in-charge DIAGNosTiCS % (Bring the complete and updaled lab flow sheet) © Interpret laboratory results Familiarize yourself and compute for the following as necessary (© eGFR by CKD-EPI, BCR, electrolyte deficits, water deficit © ABGs: interpretation, bicarbonate deficit, PIF ratio, desired FiO2 > Bring a copy of the ECG and interpret (See ECG notes) Radiology: bring the plates or pictures as necessary (See Radiology notes) > — Accomplish the MRA form TAKE NOTE OF THE FOLLOWING: ‘> Refer the patient to the Medicine Chief Resident fist. not availabe, 9 year)-on-duty (CCU) > The referring clerk must review the learning points prior to referring to the designated 2 year or 3 year resident fo handle the case Please refrain from approaching the MRODs while they're having raunds with consultants or itthey'e af the OPD (for in-patient referrals) or during AMBU duties a the ER, Ft the senior + Cutoff time for rferra is 3pm for elective cases > Please refrain from caling the residents on their cell phones BLOOD TRANSFUSION > pRBC: 10-15co/kg to run 2-3hrs o (desired Het-Actual Hol} x We > FEB: 10-tScc/kg in 3-4hrs ‘0 Note: make sure IVF rate is almost equal to running rate > Cryoprecipitate: 1 univ7kg Weight * 7=__units as fast crip + Blood transfusion orders: (© Prepare and transfuse cc of __properly yped and cross-matched to run for 3-4 hrs © Secure consent (© Monitor VSq15 mins while on BT © WOF (Waich out for) for the folowing + Hemolytic transfusion reactions: Inereased anwiely, low back pain, hypotension, tachycardia, fever and chills, chest pain, tachypnea, hemoglobinuria, may have immediate onset + Febrile reactions: Chills, fever, headache, fushing, tachycardia increased anxiety * Allergic reactions: Mid (hives, pruritus, facial fushing), severe ( shortness of breath, bronchospasm, anxiety) © Stop transfusion and refer accordingly * Change IV tubing at hub and begin NS + Treat symptoms if present: 02, fuids, meds ‘+ Give Diphenhydramine (Benadryl) tmkdose 30 mins prior to BT + Give Furosemide imkdose post BT after each aliquot + Recheck crossmatch record with unit * Obtain blood sample + Obtain urine sample for possible hemoglobinuria, * Monitor fui! electrolyte balance + Evaluate serum calcium levels DERMATOME LEVEL (Ginical Significance: Each ofthe spinal nerves provides sensation to a predictable area of skin Ex, Pain raating down the leg to the smalltoe in the general pattam of S1 decmatome suggests ‘hat @ hernieted sk may be pinching the S1 nerve root in the spine.) TAintorn App version 4.0 5We va tiga Thoracie Tene 1276 T10 ANTERIOR Nore: Levels of principal dermatomes: C5 Clavicle, C6 thumb, C7 middle finger, C8 ‘ing and itl finger, T4 nipple, T10 “belly buITEN’, L1 “is IL" (Inguinal Ligament), L4 knee “down on all 4's" and medial side of great foe, LS bottom of foot and loes 1-3, S1 lateral side of ite toe (loes 4-8), S2-4 perineum *S2,3,4, Keep the penis off the Moor’). Spinal Nerve Topography: 31 pairs of spinal nerves (8 cervical, 12 thoracic, § lumbar, 6 sacrococcygeal) ‘ANESTHESIOLOGY ANESTHESIA REFERRAL PREOPERATIVE EVALUATION FORM: (history taking and p.e.) 7 History and PE. in SOAP format © Review of systems © Include neurological exam as a baseline for Bromage score REVIEW OF SYSTEMS (Important in Anesthesiology) REVIEW OF SYSTEMS + Constitutional: recent fevers or infections, weight loss/gain Cardiovascular : exercise tolerance (‘how many stairs”), angina or chest pain, Palpitations, collapse/ syncope, ankle swelling, activily evel + “Patients who cannot meet the demands of 4-METS (Melabolic Equivalents) are high risk — climbing a fight of stars or doing light housework is 4-METS. Ife 4 METS without symptoms, proceed to OR * Pulmonary: shoriness of breath, cough, dyspnea on exertion, use of inhalers, baseline of Oxygen if applicable + Gastriointestinal: reflux symptoms, NPO status + Hematologic: easy bruising or bleeding Musculoskeletal : any cervical motion instabilly, myalgias, range of motion of extremities intern App Version 4.0BROMAGE SCORE BROMAGE SCORE Criteria Degree of Block | Score | Free movement of legs and feel None 0 Just able to flex knees with free movement of feet Partial 1 Unable to flex knees, but with free movement of feet_| Almost complete 2 Unable to move legs or feet Complete, 3 HOW LONG SHOULD YOUR PATIENT FAST? FOOD STARVATION TIME BEFORE SURGERY [HOURS] Clear Hide water, black Tea, cofea) Breast mike Boiler cows milk igh meal Heay meal 7 ASA Classification (below) + Mallampati Score, presence of dentures % Weight Height, sit > Past Medical History (AMPLE) 9 Allergies: Latex and antibiotics. Reactions to each allecgen known, © Medications: Curent medications including over-the-counter and herbal meds. © Past diseases 2 Past surgeries : Previous exposure to anesthesia and adverse reactions if any. © Last oral Intake Food and drinks and quant'y ©. Extraordinary events prior (ex. Car accident, etc.) > Altach la flow sheet ASK CLASSIFICATION ASA (American Society of Anesthesiologists) Cassification on Physical Status end ‘Anesthetic Risk or tortality Rate (‘pep primary care physician) Class | Patient's Medical Status Mortality Comments (ASA) | Rate (%) 1” TNO KNOWN systemic disease 0.06 -0.08 | Can have conscious (Healthy patient) ~o1 | sedation NO PCP CONSULT needed 1 | SINGLET MICDT WELL” 27-04 | Can have CONSCIOUS CONTROLLED systemic disease (eg. | 02 | SEDATION Consul PCP for HTN) disease assessment No functional imitations T[ MULTIPLEMODERATELY- 18-43 | Gelmedeal CONSULT | CONTROLLED systemic disease ~18 | FROM PCP With some funciona limitation Review Lab tests and meds TV] POORLY-CONTROLLEO systemic | 78-23 | Reterto disease ~78 | ANESTHESIOLOGIST for Functionally incapacitating sedation V_ | MORIBUND PATIENT not expeciedto | 84-51 [== survive 24 hours with or without surgery |_ = 9.4 VI_| BRAIN-DEAD palient whose organs are being harvested E | emergency procedure MALLAMPATI SCORE (PUSH): Indicators of Difficulty of Intubation (The patient maximally opens his mouth and protrudes his tongue while in sitting position. The more structures visible, the greater ease of intubation.) Sensitivity: 49%, specificity: 86% Class 4 Class 2 Class 3 Class 4 Faucial PILLARS, UWULA, Soft ‘SOFT palate, TARD palate only uuvula, soft palate, palate, Hard palate Hard palate hard palate ‘No difficulty No dificuty Moderate Severe dificully intubation aifficul Tintern App Version 4.0A wala Soft palate Hard palate Pillars NYHA (New York Heart Association Functional Classification) NYHA CLASSIFICATION. Class, Definition. \"] Patient has a cardiac disease but WITHOUT the resuling LIMITATIONS of physical activity. Ordinary chysical activity does not cause _symploms such as undue faligue, palpitation, dyspnea, or | with ease ‘anginal pain Patient has @ cardiac disease resulling in SLIGHT LIMITATION of | Glmbs 2 fights physical activity. They are comfortable at rest. Ordinary physical | of stairs but with aclivity results in symptoms such as fatigue, palpitation, dyspnea, of | difficulty anginal pain, Patient has a cardiac disease resuliing in MARKED LIMITATION of | Climb 1 fight oF Physical activity. They are comfortable at rest. Less than ordinary | stairs physical activity causes fatigue, palpitation, dyspnea, or anginal pain W_ | Patient has a cardiac disease resulling in INABILITY lo carry on any physical activity without discomfort. Symptoms of eardiac insufficiency ‘fof the anginal syndrome may be present even alrest ifany physical activity is undertaken, discomfort is increased i Dyspnea atrest APACHE Il Score for predicted ICU Mortality “Acute Physiology and Chronic Health Evaluation 1!7 is a severly of disease classification system applied within 24 hours admission of a patient fo an ICU using the following physiologic ‘measurements (Note: This can simply be computed using Medscape or any Med App) + Does the patient have a history of chronic organ insufficiency or immunocompromised? YIN © Yes, and is sip emergency surgery; Yes, and is sip elective surgery; Yes, bul is not SIP OR > Does the patient have acute renal failure? Yes/ No > Age (years), temperature (rectal, celsius), mean Arterial Pressure, pH (arterial), heart rate, respiratory rate (either ventilated or spontaneous) ~ Sodium (serum; mEq/L), potassium (serum; mEq/L), creatinine (serum: mg/dL), hematocrit x 10° celisimm?), white blood cell count > Glasgow Coma Scale (paints) > Oxygenation. Ether: A-a Gradient (i FiO2is = 0.6; mmHg) or Pa02 (i Fi02 <0.5; mmblg) ‘ALDRETE CRITERIA FOR DISCHARGE Variable Evaluated ‘Seore Activity Able fo move FOUR exiremilies on command 2 Able to move TWO exiremilies on command 1 UNABLE to move extremities on command o ‘Breathing ‘Able to breathe deeply and cough freely 2 Dyspnea, 1 ‘Apnea a Circulation ‘SBP +/- 20% of preanesihalic level z ‘SBP +/- 20-50% of preanasthelic level 1 ‘SBP ¥/- 50% of preanesthelic level o Consciousness | Fully awake 2 ‘Arousable 1 Not responding 0 Oxygen > 92% while breaihing room air 2 Saturation ‘Needs supplemental oxygen to maintain saturation >0% 1 (Pulso Oximetry) |< 30% even with supplemental oxygen 0 ‘Minimum score of 9's necessary to consider discharge from the recovery room. TAintern App Version 4.0