Rotation Recap: Inpatient Medicine
Before starting this rotation 30 days ago, I had no idea what to expect for inpatient medicine. The unit I rotated in was technically an inpatient rehabilitation floor but my preceptor also saw patients on the regular floor and in the ICU (so I was lucky enough to get experience in rehab medicine as well as critical care!) I also gained a huge appreciation for physical, occupational, & speech therapists and the incredible work they do alongside providers. A typical day for me included rounding on the patients by myself before my preceptor arrived, writing progress notes (more on that later), and then presenting the patients with my assessment and plan. I also performed detailed H&Ps on new admits and dictated discharge summaries. Perhaps the most difficult aspect of the rotation was the pharmacology.. Medication is basically the cornerstone of inpatient life. Many of the patients are on a long list of medications that require fine-tuning day by day (and sometimes even hour by hour) as their vital signs, I&Os, and overall stability changes. Sometimes I struggled with the drug interactions, contraindications, different renal and hepatic dosages, etc. but overall I gained a lot of confidence in choosing the most appropriate drug, particularly when it came to antibiotics! With that being said, let’s dive in to how to prepare!
How To Prepare
Lab Values: If you never committed the fishbone diagrams to memory, go ahead and do that. BMPs and CBCs are taken almost every single day on patients to check basic electrolytes, kidney function at a glance, and for trending things like hemoglobin and hematocrit. Just like with the emergency medicine rotation, it’s in your best interest to memorize the normal values for each component of the BMP/CBC as well as the signs and symptoms of an imbalance, remember stones, bones, abdominal groans, psychic overtones? (Yes I knooow Ca+ is not included on a BMP, gimme a break! You catch my drift!)
Pharmacology: As I said before, medication regimens rule the world of inpatient medicine. It’s not uncommon for a patient to be on 15 (or more) medications at a time. One skill that will serve you incredibly well is to be able to review a patient’s med list and create a picture in your mind of their diagnoses and chronic conditions. For example, if you see a patient is currently on clarithromycin, amoxicillin, and pantoprazole, you can pretty much guess they’re H. Pylori positive. If a patient is on furosemide and digoxin you might be thinking about CHF. You get the idea.
Shock Syndromes: A leading cause of death in hospitals is sepsis leading to MODS. It’s important to remember the criteria for each stage of sepsis (SIRS → sepsis → severe sepsis → septic shock → MODS). This is something my preceptor continuously drilled me on and even had me fill out a worksheet on it. It’s also important to know when pressors are indicated and which ones to use. (More meds, yay!)
Resources: A big part of inpatient medicine is completing very detailed H&Ps on new admissions as well as dictating discharge summaries when the patients go home. Many times, patients are admitted from the ED where the exams are very focused and important details like family and social history gets left out. It’s easy to forget all of the many, many portions of a comprehensive H&P so I relied on my Maxwell pocket guide to help me out. I also used it to guide my discharge summaries, which is something I never learned about in school. The Maxwell guide has been my most-used pocket guide thus far and if you don’t have one yet, I suggest snagging one. Super cheap, super useful! For in depth reading, I like Marino’s Little ICU Book.
What To Expect
Round and round and round you go – One of my main responsibilities over the month was to round on all my preceptor’s patients before he got there. If (like me) you’re not exactly sure what rounding is, you basically go into each patient’s room and find out how they’re doing. I liked to sign on to the computer and check labs, imaging, and consults that may have happened while I was away before going to see the patient. You want to do a quick once over on each patient, listen to their heart and lungs, check extremities for edema or skin breakdown, if they had surgery check the incision site, look for urine output if they have a foley, check the fluid if there’s a wound vac. Just get an overall idea of what’s going on that day. Take careful notes (preferably next to where you noted their labs) so you’re ready to answer any question you get. I also wrote down any antibiotics, cardiac drips, or pressors they were on (and the dose).
Trends, trends, trends – For the most part, a single lab value is not very helpful, particularly on patients who have been in the hospital awhile. For example, if you check a CBC on a patient and see that their H&H is 10/32, you might report to your preceptor that your patient is anemic. This is true but if you trend the H&H you may see that it has been around that range for weeks and is essentially baseline. However, if you see that just 2 days ago, their H&H was normal, you should become concerned for active bleeding. The same concept applies to BUN and creatinine. The point is, don’t get tricked by a single POC lab value. Always check the trend and report the direction (up or down) when you present.
Progress notes – Every single time you see a patient, you will be expected to write a progress note in the SOAP note format (subjective, objective, assessment, and plan). Do it exactly as it reads. Subjective – What the patient tells you. Did they sleep well? Are they in pain? Objective – I broke this part down into a quick review of vitals (T, HR, BP, O2) and a VERY brief review of systems: General, Pulm, CV, Ext, and Abd. Assessment and plan can go together (if your preceptor doesn’t mind). List your patient’s diagnoses starting with what brought them to the hospital and ending in any chronic comorbidities and then what you plan to do about it. Here’s an example of a SOAP note on a patient who was in rehab after undergoing an amputation.
Be a team player – Inpatient care consists of many, many people working together to take care of a patient. This includes PCTs, nurses, hospitalists, surgeons, specialists, physical therapists, students, family members, lab techs, and more! In order to be successful, every member of the team must be informed about any changes to a patient’s condition. Talk with the PCTs and nurses who spend the most time w/ the patient. The information they have is invaluable to you as a clinician, especially since patients can clam up when the white coat comes in! Be prepared to answer questions from EVERYONE, especially patient’s family members. If you don’t know the answer simply say, “I don’t remember that off the top of my head, let me go find out for you.”
Tackling the EOR – Much like emergency medicine, the EOR for inpatient medicine is considered one of the most difficult because of the amount of material it covers. To study, I used the PAEA blueprint and PANCE Prep Pearls to go down the list one by one and review the topic. If you’re most concerned about preparing for the EOR, check out my best study tips.
Thanks for taking the time to hang out in my little corner of the web. If you have any more questions about the inpatient rotation that I didn’t answer, or any helpful hints of your own, drop a comment or shoot me an email! I love to hear from y’all!