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Stewart H. Lecker
Bliss J. Chang
Editors
The Ultimate Medical

School Rotation Guide
123
The Ultimate Medical School Rotation Guide
Stewart H. Lecker • Bliss J. Chang
Editors
The Ultimate
Medical School
Rotation Guide
Editors
Stewart H. Lecker Bliss J. Chang
Beth Israel Deaconness Medical Center Harvard Medical School
Boston, MA, USA Boston, MA, USA
ISBN 978-3-030-63559-6 ISBN 978-3-030-63560-2 (eBook)

https://doi.org/10.1007/978-3-030-63560-2
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2021
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specifically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are exempt
from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material con-
tained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
V
To:
Ahn Hyee, Moon, and Bright
Preface
I remember the frustration of asking upperclassmen what resources they used

to prepare for a rotation and being given a mélange of answers that all came
back to one theme—existing board preparation resources such as First Aid,
Step Up to Medicine, and Case Files. While these are great for standardized
exams, they do not contain the depth or practical details necessary to be suc-
cessful on a rotation. You cannot, for instance, merely know that the solution
to heart failure exacerbation is “diuresis”; there is much more depth to provid-
ing great clinical care. What does it mean to “be helpful” when in the OR?
What separates the superstars from the average student is all in the details.
This work was born to finally put to rest the age-old question of “How do I
prepare for this rotation?” It is meant to be a concise, one-stop resource for you
to use for your rotations. This work brings together twenty of the most tal-
ented medical students I know, utilizing their experience and expertise to distill
down everything you need to know and do to ace your rotations. Without fluff,
it covers the most common cases you will encounter as a medical student. We
provide you with everything we knew at the end of a rotation that we wish we
had known at the beginning. There is a true power and benefit to a work like
this, written by medical students, for medical students.
With the upcoming Pass/Fail changes to USMLE Step 1 in 2022, clerkship
performance will likely be by far the most important criteria for residency
applications. In fact, the letter of recommendation from attendings you’ve
worked with is already one of the most important factors—it is the best insight
into your clinical skills and potential to be a stellar resident. Given the subjec-
tive nature of student evaluations, obtaining great evaluations is a daunting
and uncertain prospect. However, our hope is that this book can help you con-
vince even the most subjective of evaluators to provide you with the stellar
evaluations you deserve so you can pursue your dream residency and career.
All the best in your studies. May medicine benefit from your successes on
the wards.
Bliss J. Chang
Harvard Medical School
Class of 2020

VII
Acknowledgments
Lead Editor
Bliss J. Chang
Class of 2020
Co-Editor
Stewart H. Lecker, MD, PhD
Assistant Professor of Medicine, Harvard Medical School
Director, Nephrology Fellowship Training Program
Beth Israel Deaconess Medical Center
Boston, MA
Radiology Image Team

Sukjin Koh, MD
Department of Interventional Radiology
Brigham and Women’s Hospital
Boston, MA
Colette M. Glaser, MD
Department of Radiology
Boston, MA
Erika M. Chow, M.D., M.B.A.
Department of Radiology
Boston, MA
Interpersonal Skills
Authored by:
Jeffrey Herrala
Class of 2020
Faculty Reviewers:
Erik Alexander, MD
Professor of Medicine, Harvard Medical School
Director of Undergraduate Medical Education and the Principal Clerkship
Experience
Executive Director of the Brigham Education Institute
Boston, MA
William C. Taylor, MD
Associate Professor of Population Medicine, Harvard Medical School
Department of Population Medicine, Brigham and Women’s Hospital
Director of Medical Education, Harvard Vanguard Medical Associates
Boston, MA
Student Reviewers:
Allison A. Merz
Class of 2020
VIII Acknowledgments
Pranayraj Kondapally
University of South Alabama Medical School
Class of 2022
Adam Beckman
Class of 2022
Priya Shah
Class of 2022
Lin Mu
Yale School of Medicine
Class of 2020
Wellness
Authored by:
Amira Song
Harvard College
Class of 2020
Student Reviewers:
Bliss J. Chang
Class of 2020
What Attendings/Residents Look For

Authored by:
Bliss J. Chang
Class of 2020
Boston, MA
Faculty/Fellow/Resident Contributors:
Krishna Agarwal, MD
Melanie Hoenig, MD
Larissa Kruger, MD
Rahul Maheshwari, MD
Wilfredo R. Matias, MD
Edison K Miyawaki, MD
Subha Perni, MD
Celeste Royce, MD
Stephen Sozio, MD
Anonymous x3
Student Reviewers:
Curtis Bashore
University of Minnesota Medical School
Class of 2021
Jenna Fleming
Class of 2021
IX
Acknowledgments
Amanda Zhou
Class of 2022
Clinical Tips and Pearls

Authored by:
Bliss J. Chang
Class of 2020
Student Reviewers:
Cara Lachtrupp
Class of 2021
Lin Mu
Class of 2020
EMR Tips and Tricks

Authored by:
Bliss J. Chang
Class of 2020
Screenshots Courtesy of:

Epic Systems Corporation
1979 Milky Way
Verona, WI 53593
Reviewed by:
Epic Systems Corporation
1979 Milky Way
Verona, WI 53593
Student Reviewers:
Daniel Michelson
Class of 2021
Amrita Singh
Class of 2023
Internal Medicine
Authored by:
Bliss J. Chang
Class of 2020
Faculty Reviewers:
Yamini Saravanan, MD
Internal Medicine Clerkship Director, Cambridge Health Alliance Hospital
Instructor in Medicine, Harvard Medical School
Boston, MA
X Acknowledgments
Student Reviewers:
Simon Yang
Class of 2021
Lucas Zellmer
Class of 2021
Baraa Hijaz
Class of 2024
General Surgery
Authored by:
Selena Li
Class of 2020
Faculty Reviewers:
Roy Phitayakorn, MD MHPE (Med) FACS
Associate Professor of Surgery, Harvard Medical School
Director of Medical Student Education and Surgery Education
Massachusetts General Hospital
Boston, MA
Elan Witkowski, MD
Instructor in Surgery, Harvard Medical School
Department of Surgery, Massachusetts General Hospital
Boston, MA
Student Reviewers:
Ameen Barghi
Class of 2020
Danny Wang
WashU St. Louis School of Medicine
Class of 2020
Lena Trager
Class of 2022
Huma Baig
Class of 2021
OB-GYN
Authored by:
Allison A. Merz
Class of 2020
Faculty Reviewers:
Celeste Royce, M.D.
Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology
Boston, MA
XI
Acknowledgments
Student Reviewers:
Jeffrey Herrala
Class of 2020
Meagan Brockman
Class of 2021
Neurology
Authored by:
Iyas Daghlas
Class of 2021
Faculty Reviewers:
Edison Miyawaki, MD
Assistant Professor of Neurology, Harvard Medical School
Department of Neurology, Brigham and Women’s Hospital
Boston, MA
Student Reviewers:
Ellen Zhang
Class of 2023
Apurv H. Shekhar
Class of 2023
Charlie W. Zhao
Class of 2021
Pediatrics
Authored by:
Aditya Achanta
Class of 2021
Kelly Hallowell
Class of 2021
Faculty Reviewers:
Joanne Cox, MD
Associate Professor of Pediatrics, Harvard Medical School
Associate Chief, Division of General Pediatrics
Boston Children’s Hospital
Boston, MA
Student Reviewers:
Margaret Irwin
Class of 2021
Logan Beyer
Class of 2023
XII Acknowledgments
Radiology
Authored by:
Bliss J. Chang
Class of 2020
Psychiatry
Authored by:
Michael Dinh
Class of 2020
Faculty Reviewers:
Stuart Beck, MD
Assistant Professor of Psychiatry, Harvard Medical School
Department of Psychiatry, Massachusetts General Hospital
Boston, MA
Student Reviewers:
Catherine Bledsoe
Class of 2021
David Johnson
Class of 2023
Itamar Shapira
UAB School of Medicine
Class of 2023
Primary Care
Authored by:
Bliss J. Chang
Class of 2020
Faculty Reviewers:
Yamini Saravanan, MD
Internal Medicine Clerkship Director, Cambridge Health Alliance Hospital
Boston, MA
Student Reviewers:
Azan Virji
Class of 2023
Jack Inglis
Class of 2021
Emergency Medicine
Authored by:
Alex Bonilla
Class of 2020
XIII
Acknowledgments
Faculty Reviewers:
Susan E. Farrell, MD, EdM
Director, OSCE Program
Associate Professor, Emergency Medicine
Boston, MA
Andy Jagoda, MD, FACEP
Professor and Chair Emeritus
Department of Emergency Medicine
Icahn School of Medicine at Mount Sinai
New York City, New York
Student Reviewers:
Lake Crawford
Class of 2023
John McGrory
Class of 2021
Critical Care
Authored by:
Balakrishnan Pillai
Medical University of South Carolina
Class of 2020
Ultrasound Images by:

J. Terrill Huggins, MD
Designated Education Officer
Ralph H. Johnson VA Medical Center
Professor of Medicine, Medical University of South Carolina
Division of Pulmonary, Critical Care, Allergy and Sleep Medicine
Charleston, SC
Faculty Reviewers:
Alice M. Boylan, MD
Professor of Medicine, Medical University of South Carolina
Chief, Acute, Critical, and Trauma Integrated Center of Clinical Excellence
Charleston, SC
Student Reviewers:
Amrita Singh
Class of 2023
Cardiology
Authored by:
Bliss J. Chang
Class of 2020
XIV Acknowledgments
Faculty Reviewer:
Leonard S. Lilly, M.D.
Professor of Medicine, Harvard Medical School
Chief, Brigham/Faulkner Cardiology
Boston, MA
Fellow Reviewer:
Timothy J. Fernandez, M.D.
Emory University
Cardiology Fellow, Class of 2022
Student Reviewers:
Ethan Katznelson
Class of 2020
Lena Trager
Class of 2022
Gastroenterology
Authored by:
Emily Gutowski
Class of 2020
Faculty Reviewers:
Navin Kumar, MD
Department of Gastroenterology, Brigham and Women’s Hospital
Boston, MA
Student Reviewers:
Itamar Shapira
UAB School of Medicine
Class of 2023
Hema Pingali
Class of 2021
Gaurav Suryawanshi
Class of 2020
Nephrology
Authored by:
Bliss J. Chang
Class of 2020
Faculty Reviewers:
Boston, MA
XV
Acknowledgments
Infectious Diseases
Authored by:
Bliss J. Chang
Class of 2020
Faculty Reviewers:
Simi Padival, MD
Division of Infectious Diseases, Beth Israel Deaconess Medical Center
Boston, MA
Student Reviewers:
Azan Virji
Class of 2023
Bina Kassamali
Class of 2022
Anesthesia
Authored by:
Sarah Osmulski
Class of 2020
Faculty Reviewers:
Richard M. Pino, MD, PhD
Division Chief, Critical Care
Department of Anesthesia, Critical Care and Pain Medicine
Boston, MA
Student Reviewers:
Michael Koller
Class of 2021
Lovemore Peter Makusha
Class of 2020
Radiation Oncology
Authored by:
Parsa Erfani
Class of 2021
Faculty Reviewers:
Matthew Abrams, MD
Instructor in Radiation Oncology, Harvard Medical School
Boston, MA
XVI Acknowledgments
Resident Reviewers:
Subha Perni, MD
Resident, Harvard Radiation Oncology Program
Boston, MA
Sharareh Koufigar, MS
Medical Physics Resident
Piedmont Cancer Institute
Atlanta, GA
Student Reviewers:
Grace Lee
Class of 2020
Kerrie Greene
Class of 2023
Dermatology
Authored by:
Connie Zhong
Class of 2020
Faculty Reviewers:
Jennifer Huang, MD
Dermatology Clerkship Director, Harvard Medical School
Boston Children’s Hospital
Boston, MA
Vinod Nambudiri, MD
Assistant Professor of Dermatology, Harvard Medical School
Department of Dermatology, Brigham and Women’s Hospital
Boston, MA
Susan Burgin, MD
Associate Professor of Dermatology, Harvard Medical School
Department of Dermatology, Brigham and Women’s Hospital
Boston, MA
Student Reviewers:
Amy Blum
Class of 2021
Bina Kassamali
Class of 2022
James Pathoulas
Class of 2021
XVII
Acknowledgments
Orthopedic Surgery
Authored by:
Ameen Barghi
Class of 2020
Faculty Reviewers:
James Herndon, MD MBA
Chair Emeritus, Department of Orthopedics
Boston, MA
James D. Kang, MD
Chair, Department of Orthopedics
Boston, MA
Edward K. Rodriguez, MD
Clerkship Director, Orthopedics
Associate Professor of Orthopedic Surgery
Boston, MA
Collin May, MD, MPH
Clerkship Director, Pediatric Orthopedics
Instructor in Orthopedic Surgery, Boston Children’s Hospital
Boston, MA
Student Reviewers:
Lily Wood
Class of 2020
Neurosurgery
Authored by:
Malia McAvoy
Class of 2020
Zack Abecaissis
Northwestern Feinberg School of Medicine
Class of 2020
Faculty Reviewers:
Richard Ellenbogen, MD
Chair, Department of Neurosurgery
University of Washington
Seattle, WA
G. Rees Cosgrove, MD
Lecturer on Neurosurgery, Harvard Medical School
Neurosurgery Program Director, Brigham and Women’s Hospital
Boston, MA
XVIII Acknowledgments
Student Reviewers:
Tony Larson
Class of 2022
Julia Song
Class of 2022
Charlie W. Zhao
Class of 2021
Ophthalmology
Authored by:
Theodore Bowe
Class of 2020
Faculty Reviewers:
Yoshihiro Yonekawa, MD
Assistant Professor of Ophthalmology, Sidney Kimmel Medical College
Thomas Jefferson University
Wills Eye Hospital
Philadelphia, PA
Zeba A. Syed, MD
Assistant Professor of Ophthalmology, Sidney Kimmel Medical College
Thomas Jefferson University
Wills Eye Hospital
Philadelphia, PA
Student Reviewers:
Sameen Meshkin
Class of 2022
Osama M. Ahmed
Class of 2021
XIX
Introduction
Welcome to The Ultimate Medical School Rotation Guide. We are thrilled to

embark on a journey with you through the clinical years of medical school.
Our mission is simple: to help you learn the most medicine while earning the
best evaluations and maximizing your physical and mental well-being.
Clinical rotations are the highlight of medical school for many, if not most,
medical students. It is a daunting period where you transition from the class-
room onto the hospital wards and begin interacting with patients. Your actions
take on consequences for your patient and your team. Despite all this, it is one
of the most fun and rewarding periods of your life as you spend long days with
your teams and hold intimate conversations with the ill. By the end of your
rotations, you will be in awe at how much medicine you have learned and how
you have matured as a clinician and person.
We encourage you to start by familiarizing yourself with the soft skills of
medicine and general tips for success on the wards. These fundamental skills
will form the foundation for any rotation, and are arguably as important if not
more important than the content of a specific rotation. As you near the start
of a rotation, you will ideally read through the respective chapter and then
revisit it throughout your rotation.
We wish you all the best with your clinical endeavors and look forward to
working with you in the future as our dear colleagues.
XXI
Contents
1 Interpersonal Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Jeffrey Herrala
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

1.2 Sections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2.1 The Medical Learning Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2.2 The AMIGAS Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2.3 Suggestion Tables for Various Relationships and Scenarios . . . . . . . . . . . . . . . . . . . . . 5
1.3 Special Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2 Wellness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Amira Song
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3 What Attendings and Residents Look For . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Bliss J. Chang and Stewart H. Lecker
3.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

3.2 The Unaltered Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3.3 Dissecting the Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.3.1 Interpersonal Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.3.2 Knowledge Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.3.3 Clinical Reasoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.3.4 Curiosity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.3.5 Reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.3.6 Honesty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.3.7 Enthusiasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.3.8 Proactivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.3.9 Teamwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.3.10 Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.4 Example Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.5 Dealing with Negative Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.6 Mid-Rotation Feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.7 Concluding Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
4 Clinical Tips and Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Bliss J. Chang
4.1 General Rotation Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

4.2 Feedback and Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.3 Pre-rounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.4 History-Taking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.5 Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.6 Objective Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.7 Oral Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.7.1 General Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.7.2 One-Liner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4.7.3 History of Present Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4.7.4 All Other History (Medical, Surgical, Medications, Social, etc.) . . . . . . . . . . . . . . . . . . . 39
4.7.5 Vitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4.7.6 Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4.7.7 Objective Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.7.8 Assessment/Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
XXII Contents
4.8 Note-Writing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

4.9 Calling a Consult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.10 Logistical Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
5 EMR Tips and Tricks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

Bliss J. Chang
5.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

5.2 Prior to the Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.2.1 Create Patient Lists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.2.2 Smart Phrases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.2.3 Dot Phrases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.3 Daily Workflow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.3.1 Creating Notifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.3.2 Chart Search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.3.3 Chart Review Filters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.3.4 Time Mark Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.3.5 Summary Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.3.6 Copy Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
6 Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Bliss J. Chang
6.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

6.1.1 Setting Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
6.1.2 Rotation Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
6.1.3 Team Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
6.2 Practical Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
6.2.1 External Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
6.2.2 Shelf Prep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
6.2.3 Pre-rounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
6.2.4 Oral Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
6.2.5 Rounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
6.2.6 EMR Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
6.2.7 Calling Consults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
6.2.8 Road to Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
6.3 Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.3.1 Basic Metabolic Panel (BMP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.3.2 Complete Blood Count (CBC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.3.3 Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.3.4 Bowel Regimen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.3.5 IV Fluids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
6.3.6 DVT Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
6.3.7 Insulin Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
6.3.8 Approach to Supplemental Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.3.9 When to Provide Supplemental Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.4 Common Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
6.4.1 Pneumonia (Question-Based Approach) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
6.4.2 Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.3 COPD Exacerbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
6.4.4 Urinary Tract Infection (UTI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
6.4.5 Acute Kidney Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
6.4.6 Chest Pain Rule-Out Myocardial Infarction (CPROMI) . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
6.4.7 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
6.4.8 Other Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
XXIII
Contents
7 General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Selena Li
7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98

7.1.1 The Surgeon’s Mindset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
7.1.2 Establishing Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
7.1.3 Learning in the OR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
7.2 Clinical Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
7.2.1 Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
7.2.2 Content Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
7.2.3 Studying for Shelf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
7.2.4 Studying for the Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
7.3 What to Expect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
7.3.1 Before the Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
7.3.2 Team Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
7.3.3 Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
7.3.4 Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
7.4 A Practical Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
7.4.1 The Floor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
7.4.2 The Operating Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
7.4.3 In the OR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
7.4.4 Post-op . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
7.5 The Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
7.5.1 New Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
7.5.2 Follow-Up Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
7.6 The Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
7.6.1 Admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
7.6.2 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
7.7 Technical Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
7.7.1 References/Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
7.7.2 Bedside Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
7.7.3 Operating Room Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
7.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
7.9 Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
8 Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Allison A. Merz
8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154

8.1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
8.1.2 An Introduction to the Specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
8.1.3 Before Your Rotation: Resources to Download or Subscribe to . . . . . . . . . . . . . . . . . . 155
8.1.4 OB-GYN Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
8.2 Obstetrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
8.2.1 OB Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
8.2.2 Prenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
8.2.3 Labor and Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
8.2.4 MFM (High-Risk Pregnancy): Select Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
8.2.5 Postpartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
8.3 Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
8.3.1 GYN Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .200
8.3.2 Outpatient GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
8.3.3 Inpatient GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
8.3.4 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
8.3.5 Select Subspecialty Topics in Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Appendix (. Table 8.6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
OB Triage Note Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
XXIV Contents
9 Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Iyas Daghlas
9.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232

9.2 The Neurological Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
9.2.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
9.2.2 The Mental Status Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
9.2.3 The Cranial Nerve Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
9.2.4 The Motor Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
9.2.5 Sensory Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
9.2.6 Reflexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
9.2.7 Cerebellar (Coordination) Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
9.2.8 Gait Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
9.2.9 Non-neurological Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
9.3 The Oral Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
9.3.1 One-Liner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
9.3.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
9.3.3 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
9.3.4 Objective Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
9.3.5 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
9.3.6 Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
9.4 Common Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
9.4.1 Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
9.4.2 Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
9.4.3 First Seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
9.4.4 Bacterial Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
9.5 Evidence-Based Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
9.5.1 POINT [5] Trial: Dual Antiplatelet Therapy for Secondary Prevention of Ischemic
Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
9.5.2 SPARCL Trial [6]: Statin Therapy for Secondary Prevention of Ischemic Stroke . . . . 264
9.5.3 NINDS Trial [7]: Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
9.5.4 FIRST Trial [8]: Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
9.5.5 The Optic Neuritis Treatment Trial (ONTT) [9]: Multiple Sclerosis . . . . . . . . . . . . . . . . .265
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
10 Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .267
Aditya Achanta and Kelly Hallowell
10.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .269

10.1.1 History Taking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
10.1.2 Past Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .270
10.1.3 Medication Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
10.1.4 Medications to Avoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
10.1.5 Labs and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
10.1.6 Family-Centered Rounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
10.1.7 How to Really Shine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
10.1.8 Well-Child Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
10.2 6-Month-Old Well-Child Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
10.2.1 Subjective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
10.2.2 Previous Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
10.2.3 Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
10.2.4 Assessment/Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
10.3 Sick vs Not Sick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
10.4 Approach to Acute Fever from Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
10.5 Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
10.6 Infectious Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
XXV
Contents
10.6.1 Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282

10.6.2 Urinary Tract Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
10.6.3 Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
10.6.4 Acute Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
10.6.5 Conjunctivitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
10.6.6 Bronchiolitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
10.6.7 Croup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
10.6.8 Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
10.6.9 Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
10.7 Atopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
10.7.1 Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
10.7.2 Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
10.8 Food Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
10.8.1 Food Protein-Induced Colitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
10.9 Strep Throat and Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
10.9.1 Strep Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
10.9.2 Rheumatic Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
10.9.3 Post-Streptococcal/Infectious Glomerulonephritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
10.10 Skin Rashes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
10.10.1 Tinea Corporis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
10.10.2 Tinea Versicolor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
10.10.3 Pityriasis Alba . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
10.10.4 Impetigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
10.10.5 Erythema Toxicum Neonatorum and Neonatal Cephalic Pustulosis . . . . . . . . . . . . . . 301
10.11 Gastrointestinal Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .302
10.11.1 Physiologic Reflux . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
10.11.2 Pyloric Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
10.11.3 Lead Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
10.11.4 Foreign Bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
10.11.5 Viral Gastroenteritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
10.11.6 Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
10.12 Acute and Chronic Knee Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
10.12.1 Acute Knee Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
10.12.2 Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
10.12.3 Knee Strains and Sprains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
10.12.4 Transient Synovitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
10.12.5 Septic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
10.12.6 Chronic Knee Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
10.13 Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
10.13.1 Diabetic Ketoacidosis (DKA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
10.14 Example Day in Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
10.15 Example Day on a General Inpatient Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
10.16 Review Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
10.16.1 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
11 Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Bliss J. Chang
11.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .318

11.2 Recommended Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
11.3 The Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
11.4 Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
11.4.1 The Black and White Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
11.4.2 Systematic Reading of CXRs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
11.4.3 Image Quality (Mainly Applicable to X-rays) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
11.5 Common Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
XXVI Contents
12 Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Michael Dinh
12.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .334

12.2 The Interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
12.2.1 The Biopsychosocial Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
12.2.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
12.2.3 History Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
12.2.4 Sensitive Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
12.2.5 Handling Displays of Emotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
12.2.6 Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
12.3 Verbal Aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
12.3.1 Mental Status Examination (MSE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
12.3.2 Other Sources of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
12.4 Clinical Vignette and Note Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
12.5 Inpatient Psychiatry Initial Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
12.6 Differentiating the Differential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
12.7 A Day in the Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
12.7.1 Daily Task List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
12.8 The Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
12.9 Common Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
12.10 How to Stand Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
13 Primary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

Bliss J. Chang
13.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .354

13.2 Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
13.2.1 Checkup Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
13.2.2 Follow-Up Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
13.2.3 New Complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
13.3 Common Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360
13.3.1 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360
13.3.2 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
13.3.3 Chronic Obstructive Pulmonary Disease (COPD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
13.3.4 Congestive Heart Failure (CHF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
13.3.5 CAD Primary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
13.3.6 Musculoskeletal Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
13.4 Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
13.5 Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .373
14 Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375

Alex Bonilla
14.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .377

14.1.1 Emergency Medicine Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
14.1.2 First Day of Your Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
14.2 Before the Shift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
14.3 During the Shift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
14.3.1 Preparing for the Patient Encounter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
14.3.2 The Patient Encounter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
14.3.3 History of Present Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
14.3.4 Review of Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
14.3.5 Past Medical/Surgical History, Family History, Medications, Allergies and Social
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
14.3.6 Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
14.3.7 Managing Patient Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
XXVII
Contents
14.3.8 After the Patient Encounter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386

14.3.9 The Oral Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
14.3.10 Assessment and Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
14.3.11 After the Oral Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
14.3.12 The Patient Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
14.3.13 Follow-Up and Reassessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
14.4 End and Beyond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
14.4.1 Calling Consults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
14.4.2 The Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
14.4.3 Signing Out Your Patient to Another Team Member/Pass-off . . . . . . . . . . . . . . . . . . . . 400
14.4.4 Final Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
14.5 Most Common Emergency Department Chief Complaints . . . . . . . . . . . . . . . . . . . 402
14.5.1 Chief Complaint: Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402
14.5.2 Chief Complaint: Dyspnea/Shortness of Breath . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
14.5.3 CC: Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
14.6 Additional Skills/Procedures to Learn About . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
14.6.1 Trauma/Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
14.6.2 Important Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
14.6.3 Laceration Repairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
14.6.4 Incision and Drainage (I&D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
14.6.5 Splinting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
14.6.6 Ultrasound-Guided IV Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
15 Critical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427

Balakrishnan Pillai
15.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .429

15.2 ICU Design and Cast of Characters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
15.2.1 Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
15.2.2 Respiratory Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430
15.2.3 Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430
15.2.4 Primary Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430
15.2.5 Medical Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
15.2.6 Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
15.2.7 Medical Student Routines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
15.3 The ICU Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
15.4 Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
15.4.1 A Review of the Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
15.4.2 ICU Assessment of Fluid Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436
15.4.3 Oxygen Delivery Systems and Noninvasive Positive Pressure Ventilation . . . . . . . . 437
15.4.4 Basics of Mechanical Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440
15.4.5 Pressors and Inotropes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
15.4.6 ICU Sedation and Analgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
15.4.7 ICU Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
15.5 Common ICU Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
15.5.1 Central Venous Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
15.5.2 Arterial Access/Invasive Hemodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450
15.5.3 Intubation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
15.5.4 Bronchoscopy with Bronchoalveolar Lavage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
15.5.5 Extracorporeal Membrane Oxygenation (ECMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
15.5.6 Lumbar Puncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
15.5.7 Thoracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
15.5.8 Paracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
15.5.9 Thoracic Ultrasound in the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
15.6 Common Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
15.7 Acute Respiratory Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
XXVIII Contents
15.7.1 Hypoxemic Respiratory Failure and Acute Respiratory Distress Syndrome (ARDS) 459
15.7.2 Hypercapnic Respiratory Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
15.8 Septic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
15.9 Helpful Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
15.10 Common ICU Equations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
15.10.1 Alveolar Gas Equation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
15.10.2 Alveolar–Arterial Gradient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
15.10.3 Dead Space Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
15.10.4 Alveolar Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
15.10.5 Ideal Body Weight Equation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
15.10.6 Mean Arterial Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
15.10.7 Acid/Base Compensations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
16 Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
Bliss J. Chang
16.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .475

16.2 Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
16.2.1 Heart Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
16.2.2 Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476
16.2.3 Oxygen Saturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
16.2.4 Chest Pain and/or Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
16.2.5 Shortness of Breath (SOB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478
16.2.6 Volume Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478
16.2.7 Heart Auscultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479
16.2.8 Normal Heart Sounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
16.2.9 Extra Heart Sounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
16.2.10 Cardiac Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486
16.2.11 EKGs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
16.2.12 PQRSTU Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
16.2.13 Common EKG Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
16.2.14 Telemetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506
16.2.15 Pacemakers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
16.2.16 Echo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
16.3 Practical Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 510
16.3.1 Pre-Rounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 510
16.3.2 Rounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
16.3.3 Cardiology-Specific Oral Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
16.3.4 Tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
16.3.5 Admissions/Consults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
16.3.6 Sign-Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
16.3.7 Discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
16.4 Approach to Cardiac Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
16.4.1 Mechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
16.4.2 Electrical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518
16.4.3 Reacting to Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
16.5 Acute Coronary Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520
16.5.1 Differentiating the Differential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
16.5.2 Chart Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
16.5.3 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522
16.5.4 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522
16.5.5 Initial Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
16.5.6 Goals of Admission (Management) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
16.5.7 When to Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 526
16.6 Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 526
16.6.1 Heart Failure Exacerbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
16.6.2 Causes of Heart Failure Exacerbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
XXIX
Contents
16.6.3 Differentiating the Differential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528

16.6.4 Chart Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
16.6.5 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
16.6.6 Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
16.6.7 Objective Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
16.6.8 Goals of Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
16.6.9 Optimizing Guideline-Directed Medical Therapy (GDMT) . . . . . . . . . . . . . . . . . . . . . . . 533
16.7 Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
16.7.1 Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
16.7.2 Chart Review Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
16.7.3 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
16.7.4 Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
16.7.6 Determining the Afib Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
16.7.7 Controlling the Afib . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
16.7.8 Anticoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
16.7.9 Atrial Flutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 538
16.7.10 Monomorphic Ventricular Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 538
16.7.12 EP Recs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540
16.7.13 Ventricular Fibrillation (VFib) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540
16.7.14 Atrioventricular (AV) Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541
16.8 Valvular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541
16.8.1 Replacement Valve Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541
16.9 Note Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
17 Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Emily Gutowski
17.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .546

17.2 Gastroenterology-Focused History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546
17.3 Gastroenterology-Focused Abdominal Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
17.3.1 Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
17.3.2 Auscultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548
17.3.3 Percussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
17.3.4 Palpation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 550
17.3.5 Additions for Liver Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551
17.4 Unique Vocabulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
17.4.1 Scoring Systems and Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
17.4.2 Endoscopy Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554
17.5 Lab Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
17.5.1 Liver Function Test (LFT) Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
17.5.2 Viral Hepatitis Antibody Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
17.6 GI-Specific Diagnostic Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558
17.7 Chief Complaints and Diagnoses: Approach To … . . . . . . . . . . . . . . . . . . . . . . . . . . . 562
17.7.1 Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562
17.7.2 Biliary Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
17.7.3 Diagnosis and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
17.7.4 Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569
17.7.5 Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572
17.7.6 Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 574
17.7.7 Upper GI Bleeding (UGIB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 574
17.7.8 Lower GI Bleeding (LGIB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578
17.7.9 Liver Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580
17.8 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591
17.8.1 Digital Rectal Exam (DRE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591
XXX Contents
17.8.2 Diagnostic Paracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592

17.8.3 Therapeutic (Large Volume) Paracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593
18 Nephrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595
Bliss J. Chang
18.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .596

18.2 Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596
18.2.1 Big Picture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596
18.2.2 Urine Output (UOP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596
18.2.3 Glomerular Filtration Rate (GFR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596
18.2.4 Creatinine (Cr) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597
18.2.5 Blood Urea Nitrogen (BUN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 598
18.2.6 Sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 598
18.2.7 Urine Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 598
18.2.8 Volume Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
18.2.9 Fluid Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
18.2.10 Renal Replacement Therapy (Dialysis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601
18.3 Practical Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
18.3.1 Foley Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
18.3.2 Urine Sediment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
18.4 Common Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603
18.4.1 Acute Kidney Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603
18.4.2 Electrolyte Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606
18.4.3 Sodium Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606
18.4.4 Potassium Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 608
18.4.5 Calcium Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
18.4.6 Diuresis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
18.4.7 Cardiorenal Syndrome (CRS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
18.4.8 Hepatorenal Syndrome (HRS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
18.4.9 Acid–Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
18.4.10 Glomerular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618
19 Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621

Bliss J. Chang
19.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .622

19.2 Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622
19.2.1 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622
19.2.2 Other Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622
19.2.3 White Blood Cell (WBC) Count . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
19.2.4 CBC with Differential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
19.2.5 ESR/CRP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
19.2.6 Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
19.2.7 Antibiotics Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
19.2.8 Sensitivities (Sensis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624
19.2.9 ID-Specific History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624
19.2.10 Chart Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625
19.3 Microbes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625
19.3.1 Gram Positives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626
19.3.2 Gram Negatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
19.4 Antimicrobials Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
19.4.1 Spectrum of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 628
19.4.2 Beta-Lactams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 628
19.5 Top Infectious Disease Consults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642
19.5.1 Bacteremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642
XXXI
Contents
19.5.2 Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644

19.5.3 Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644
19.5.4 Skin and Soft-Tissue Infections (SSTIs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
19.5.5 Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 649
19.5.6 HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 650
19.5.7 Recap Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651
19.5.8 Answers for Common Empiric Antibiotic Regimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652
20 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653
Sarah Osmulski
20.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .655

20.1.1 Anesthesiologists’ Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655
20.1.2 Anesthesia Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655
20.1.3 Exceling on the Anesthesia Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 656
20.2 Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 656
20.2.1 Machine (. Table 20.2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657
20.2.2 Suction (. Table 20.3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 658
20.3 NG and OG Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 658
20.3.1 Noninvasive and Invasive Monitoring (. Table 20.4) . . . . . . . . . . . . . . . . . . . . . . . . . . . 658
20.4 Pulse Oximetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 658
20.5 Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660
20.6 EKG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660
20.7 Anesthetic Depth Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660
20.8 Temperature Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660
20.9 Train of Four (TOF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 662
20.10 Urinary Catheters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 662
20.10.1 Airway Management (. Table 20.5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
20.11 Bag-Mask Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 664
20.12 Laryngeal Mask Airways (LMAs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665
20.13 Intubation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 668
20.13.1 IV Access (. Table 20.7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 675
20.13.2 Regional Blockade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 678
20.14 Drugs, Drugs, Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679
20.14.1 Preinduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 680
20.14.2 Induction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 680
20.14.3 Maintenance of Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683
20.14.4 Emergence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 686
20.14.5 Summary (. Table 20.14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 688
20.15 A Day in the Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 689
20.15.1 The Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 689
20.15.2 The Night Before . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690
20.15.3 The Day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .690
20.15.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 696
20.16 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 696
21 Radiation Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701

Parsa Erfani
21.1 Introduction to Radiation Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 702

21.1.1 What Is Radiation Oncology? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 702
21.1.2 What Is Radiation Therapy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 702
21.1.3 How Do RT and Fractionation Work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703
21.1.4 How Is the RT Dose Measured? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703
21.1.5 What Are the Various Types of Ionizing Radiation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 704
21.1.6 What Are the Various Delivery Techniques for EBRT? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 706
XXXII Contents
21.1.7 What Are the Side Effects of RT? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707

21.2 Steps of Radiation Therapy: Role of Medical Students . . . . . . . . . . . . . . . . . . . . . . . 708
21.2.1 What Is the Workflow for Receiving RT? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 708
21.3 Disease Site Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 718
21.3.1 Central Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 718
21.3.2 Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
21.3.3 Thoracic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721
21.3.4 Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 722
21.3.5 Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 723
21.3.6 Genitourinary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724
21.3.7 Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 725
21.3.8 Palliative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
22 Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729
Connie Zhong
22.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .731

22.1.1 Skin Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 731
22.2 Fundamentals of Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734
22.2.1 How to Approach a Skin Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734
22.2.2 Fitzpatrick Skin Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737
22.2.3 Basics of Dermatologic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
22.2.4 Basics of Dermoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741
22.2.5 Other Clinical Exam Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742
22.2.6 Diagnostic Tests by Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 744
22.2.7 Skin Biopsies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 746
22.3 Patient Clinical Encounter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 746
22.3.1 Oral Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 749
22.3.2 Note-Writing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 749
22.4 Differentiating the Differential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 751
22.4.1 Pigmented Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 751
22.4.2 Scaly Patch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 756
22.4.3 Non-melanoma Skin Cancer and Other Discrete Scaly or Smooth Papules . . . . . . . 767
22.4.4 Follicular-Based Papules/Pustules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 770
22.4.5 Erythematous Cheeks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775
22.4.6 Lighter Skin Patches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776
22.4.7 Leg Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 780
22.4.8 Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 782
22.4.9 Urticaria and Angioedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 784
22.4.10 Blistering Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 786
22.4.11 Target and Targetoid Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 792
22.4.12 Red/Violaceous Papules and Plaques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 793
22.4.13 Viral Exanthems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 797
22.4.14 Drug Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 799
22.4.15 Erythroderma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 804
22.4.16 Nail Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 805
22.4.17 Hair Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 807
23 Orthopaedic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 813

Ameen Barghi
23.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .814

23.2 What Is the Role of an Orthopaedic Surgeon? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 814
23.2.1 Clinic Days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 814
23.2.2 OR Days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 815
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Contents
23.2.3 Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816

23.2.4 Practice Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816
23.3 Useful Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 817
23.3.1 Web-Based Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 817
23.3.2 Textbooks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818
23.3.3 Surgical Technique Guides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
23.3.4 Zuckerman and Koval’s (Handbook of Fractures) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 821
23.3.5 Rockwood and Green’s Fractures in Adults, Rockwood and Wilkin’s
Fractures in Children (Three Volume Set) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 821
23.3.6 Miller’s Review of Orthopaedics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 822
23.3.7 VuMedi and the Orthopaedic Video Theater (OVT) from AAOS . . . . . . . . . . . . . . . . . . 822
23.4 A Typical Day: OR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 823
23.4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 823
23.4.2 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 823
23.5 A Typical Day: Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 836
23.5.1 The Night Before . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 836
23.5.2 During Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 837
23.6 A Typical Night: Call Nights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 838
23.7 Procedure Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839
23.7.1 Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839
23.7.2 Splint Rolling and Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839
23.8 Compartment Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 840
23.8.1 Splint Takedown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 840
23.8.2 Cast Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 842
23.8.3 Fracture Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 843
24 Neurosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 845
Malia McAvoy and Zack Abecaissis
24.1 Neurosurgery Mentality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847

24.2 The Neurosurgical Neuro Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847
24.3 How to Look at Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 854
24.3.1 Tips for Being Pimped . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 854
24.3.2 How to Read a Head CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 854
24.3.3 How to Read a Head MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 858
24.3.4 How to Present Images on Rounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 859
24.4 Rounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 859
24.4.1 Pre-Rounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 859
24.4.2 On Rounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 862
24.4.3 Patient Presentations (. Table 24.15) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 862
24.5 OR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 862
24.5.1 Night Before the Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 862
24.5.2 Before Rounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 865
24.5.3 Before the Patient Rolls In . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 865
24.5.4 When the Patient Rolls In . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 867
24.5.5 During the Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 872
24.5.6 Technical Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 873
24.5.7 Instruments and Proper Handling (. Table 24.22) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 873
24.5.8 Pterional Cranial Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 877
24.5.9 Open Posterior Lumbar Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 878
24.5.10 Minimally Invasive (MIS) Posterior Lumbar Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . 879
24.5.11 Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 880
24.5.12 After the Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 881
24.6 Neuro ICU Essentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 881
24.6.1 Management of Post-Op Neurosurgical Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882
24.6.2 Postoperative DVT Prophylaxis (. Table 24.34) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888
XXXIV Contents
24.6.3 Paroxysmal Sympathetic Hyperactivity (Storming) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888

24.6.4 ICP Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888
24.6.5 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 895
24.7 Consults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899
24.7.1 Consult 1: Malignant Cerebral Edema ISO MCA Infarction (. Table 24.38) . . . . . . 899
24.7.2 Consult 2: Intracerebral Hemorrhage (ICH) (. Table 24.40) . . . . . . . . . . . . . . . . . . . . . 901
24.7.3 Consult 3: Traumatic Brain Injury (TBI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 902
24.7.4 Consult 4: Spontaneous SAH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905
24.7.5 Consult 5: New Brain Tumor (. Table 24.46) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 908
24.7.6 Consult 6: Pituitary Tumor (. Table 24.47) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 909
24.7.7 Consult 7: Shunt Evaluation (. Table 24.48) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 909
24.7.8 Consult 8: Cauda Equina (. Table 24.49) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911
24.7.9 Consult 9: Spinal Cord Injury (SCI) (. Table 24.51) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 912
24.8 Essential Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 916
24.8.1 Case 1: Decompressive Hemicrani (“Crash Case”) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 916
24.8.2 Case 2: MCA Aneurysm Clipping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 918
24.8.3 Case 3: ACDF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 921
24.8.4 Case 4: Open Posterior Lumbar Laminectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 922
24.8.5 Case 5: Ventriculoperitoneal Shunt Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 923
24.9 Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 925
25 Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 929
Theodore Bowe
25.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .931

25.2 High-Yield Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 931
25.3 High-Yield Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 932
25.3.1 Eyelids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 932
25.3.2 EOMs and Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 933
25.3.3 Globe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934
25.3.4 Conjunctiva/Sclera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934
25.3.5 Cornea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934
25.3.6 Uvea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935
25.3.7 Lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935
25.3.8 Vitreous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 936
25.3.9 Retina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 937
25.3.10 Optic Nerve/Disc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 937
25.3.11 Orbit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 937
25.4 History, Exam, and Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 938
25.4.1 External Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939
25.4.2 Lids and Lacrimation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939
25.4.3 Conjunctiva and Sclera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939
25.4.4 Cornea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 940
25.4.5 Anterior Chamber . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 940
25.4.6 Iris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 941
25.4.7 Lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 941
25.4.8 Vitreous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 941
25.4.9 Retina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 942
25.5 High-Yield Investigative Tools and Resources for In-Depth Orientation . . . . . . . 943
25.5.1 Conditions by Subspecialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 945
25.6 Cornea and Refractive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 946
25.6.1 DtDx: Corneal Abrasion vs Corneal Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 950
25.6.2 High-Yield Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 951
25.6.3 Procedures for Further Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 952
25.7 Cataract and Lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 952
25.7.1 Grading of Nuclear Sclerotic Cataracts in Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 954
XXXV
Contents
25.7.2 Topics for Further Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955

25.8 Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955
25.8.1 Options for Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 958
25.8.3 Visual Field Findings in Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .959
25.9 Pediatric Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 959
25.9.1 Differentiating the Differential: Leukocoria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 961
25.10 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .962
25.11 Neuro-ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 965
25.11.1 Differentiating the Differential: Cause of a Third Nerve Palsy . . . . . . . . . . . . . . . . . . . . 965
25.11.2 DtDx: NAION vs AAION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 967
25.12 Retina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 968
25.12.1 DtDx: Floaters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 971
25.12.3 Surgical Techniques and Topics for Further Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 974
25.13 Infection and Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 974
25.13.1 DtDx: Preseptal vs Orbital Cellulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 978
25.13.2 Options for Management of Uveitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 978
25.14 Oculoplastics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 979
25.14.1 Surgical Techniques for Further Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 981
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 985
Contributors
Zack Abecaissis Northwestern Feinberg School of Medicine, Class of 2020, Chicago,

IL, USA
Aditya Achanta Harvard Medical School, Class of 2021, Boston, MA, USA
Ameen Barghi Harvard Medical School, Class of 2020, Boston, MA, USA
Alex Bonilla Harvard Medical School, Class of 2020, Boston, MA, USA
Theodore Bowe Harvard Medical School, Class of 2020, Boston, MA, USA
Bliss J. Chang Harvard Medical School, Class of 2020, Boston, MA, USA
Iyas Daghlas Harvard Medical School, Class of 2021, Boston, MA, USA
Michael Dinh Harvard Medical School, Class of 2020, Boston, MA, USA
Parsa Erfani Harvard Medical School, Class of 2021, Boston, MA, USA
Emily Gutowski Harvard Medical School, Class of 2020, Boston, MA, USA
Kelly Hallowell University of Minnesota Medical School, Class of 2021, Minneapo-

lis, MN, USA
Jeffrey Herrala Harvard Medical School, Class of 2020, Boston, MA, USA
Stewart H. Lecker Assistant Professor of Medicine, Harvard Medical School, Bos-

ton, MA, USA
Director, Nephrology Fellowship Training Program, Beth Israel Deaconess Medical
Center, Boston, MA, USA
Selena Li Harvard Medical School, Class of 2020, Boston, MA, USA
Malia McAvoy Harvard Medical School, Class of 2020, Boston, MA, USA
Allison A. Merz Harvard Medical School, Class of 2020, Boston, MA, USA
Sarah Osmulski Harvard Medical School, Class of 2020, Boston, MA, USA
Balakrishnan Pillai Medical University of South Carolina, Class of 2020, Charleston,

SC, USA
Amira Song Harvard College, Class of 2022, Cambridge, MA, USA
Connie Zhong Harvard Medical School, Class of 2020, Boston, MA, USA
Faculty Reviewers
Matthew Abrams, MD Instructor in Radiation Oncology, Harvard Medical School,

Boston, MA, USA
Beth Israel Deaconess Medical Center, Boston, MA, USA
XXXVII
Contributors
Erik Alexander, MD Professor of Medicine, Harvard Medical School, Boston,

MA, USA
Director of Undergraduate Medical Education and the Principal Clerkship Experience,
Boston, MA, USA
Executive Director of the Brigham Education Institute, Boston, MA, USA
Stuart Beck Assistant Professor of Psychiatry, Harvard Medical School, Boston,

MA, USA
Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
Alice M. Boylan, MD Professor of Medicine, Medical University of South Carolina,

Charleston, SC, USA
Chief, Acute, Critical, and Trauma Integrated Center of Clinical Excellence, Charles-
ton, SC, USA
Susan Burgin Associate Professor of Dermatology, Harvard Medical School, Bos-

ton, MA, USA
Department of Dermatology, Brigham and Women’s Hospital, Boston, MA, USA
Joanne Cox, MD Associate Professor of Pediatrics, Harvard Medical School, Boston,

MA, USA
Associate Chief, Division of General Pediatrics, Boston Children’s Hospital, Boston,
MA, USA
Susan E. Farrell, MD, EdM Director, OSCE Program, Boston, MA, USA
Associate Professor, Emergency Medicine, Harvard Medical School, Boston, MA,
USA
James Herndon, MD MBA Chair Emeritus, Department of Orthopedics, Massachu-

setts General Hospital, Boston, MA, USA
Jennifer Huang Dermatology Clerkship Director, Harvard Medical School, Boston,

MA, USA
Boston Children’s Hospital, Boston, MA, USA
Brigham and Women’s Hospital, Boston, MA, USA
Andy Jagoda, MD, FACEP Professor and Chair Emeritus, Department of Emergency
Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
James D. Kang, MD Chair, Department of Orthopedics, Brigham and Women’s Hos-

pital, Boston, MA, USA
Navin Kumar Instructor in Medicine, Harvard Medical School, Boston, MA, USA
Department of Gastroenterology, Brigham and Women’s Hospital, Boston, MA, USA
Stewart H. Lecker, MD, PhD Assistant Professor of Medicine, Harvard Medical

School, Boston, MA, USA
Director, Nephrology Fellowship Training Program, Beth Israel Deaconess Medical
Center, Boston, MA, USA
Leonard S. Lilly, M.D. Professor of Medicine, Harvard Medical School, Boston, MA,
USA
Chief, Brigham/Faulkner Cardiology, Brigham and Women’s Hospital, Boston, MA,
USA
XXXVIII Contributors
Edison Miyawaki Assistant Professor of Neurology, Harvard Medical School, Bos-

ton, MA, USA
Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
Vinod Nambudiri Assistant Professor of Dermatology, Harvard Medical School,

Boston, MA, USA
Department of Dermatology, Brigham and Women’s Hospital, Boston, MA, USA
Simi Padival Instructor in Medicine, Harvard Medical School, Boston, MA, USA
Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
Roy Phitayakorn, MD MHPE (Med) FACS Associate Professor of Surgery, Harvard

Medical School, Boston, MA, USA
Director of Medical Student Education and Surgery Education, Massachusetts Gen-
eral Hospital, Boston, MA, USA
Richard M. Pino, MD, PhD Division Chief, Critical Care, Department of Anesthesia,
Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
Harvard Medical School, Boston, MA, USA
Edward K. Rodriguez, MD Clerkship Director, Pediatric Orthopedics, Boston, MA,

USA
Associate Professor of Orthopedic Surgery, Beth Israel Deaconess Medical Center,
Boston, MA, USA
Yamini Saravanan Internal Medicine Clerkship Director, Cambridge Health Alliance

Hospital, Cambridge, MA, USA
Instructor in Medicine, Harvard Medical School, Boston, MA, USA
Zeba A. Syed, MD Assistant Professor of Ophthalmology, Sidney Kimmel Medical

College, Thomas Jefferson University,Wills Eye Hospital, Philadelphia, PA, USA
William C. Taylor, MD Associate Professor of Population Medicine, Harvard Medical

School, Boston, MA, USA
Department of Population Medicine, Brigham and Women’s Hospital, Boston,
MA, USA
Director of Medical Education, Harvard Vanguard Medical Associates, Boston, MA,
USA
Elan Witkowski, MD Instructor in Surgery, Harvard Medical School, Boston, MA,

USA
Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
Yoshihiro Yonekawa, MD Assistant Professor of Ophthalmology, Sidney Kimmel

Medical College, Philadelphia, PA, USA
Thomas Jefferson University, Wills Eye Hospital, Philadelphia, PA, USA
Student Reviewers
Osama M. Ahmed Yale School of Medicine, New Haven, CT, USA
Huma Baig Harvard Medical School, Boston, MA, USA

XXXIX
Contributors
Ameen Barghi Harvard Medical School, Boston, MA, USA
Curtis Bashore University of Minnesota Medical School, Minneapolis, MN, USA
Adam Beckman Harvard Medical School, Boston, MA, USA
Logan Beyer Harvard Medical School, Boston, MA, USA
Catherine Bledsoe University of Minnesota Medical School, Minneapolis,

MN, USA
Amy Blum Harvard Medical School, Boston, MA, USA
Meagan Brockman University of Minnesota Medical School, Minneapolis,

MN, USA
Bliss J. Chang Harvard Medical School, Boston, MA, USA
Lake Crawford Yale School of Medicine, New Haven, CT, USA
Jenna Fleming University of Minnesota Medical School, Minneapolis, MN, USA
Kerrie Greene Yale School of Medicine, New Haven, CT, USA
Jeffrey Herrala Harvard Medical School, Boston, MA, USA
Baraa Hijaz Harvard Medical School, Boston, MA, USA
Jack Inglis University of Minnesota Medical School, Minneapolis, MN, USA
Margaret Irwin Harvard Medical School, Boston, MA, USA
David Johnson University of Minnesota Medical School, Minneapolis, MN, USA
Ethan Katznelson Harvard Medical School, Boston, MA, USA
Bina Kassamali Harvard Medical School, Boston, MA, USA
Michael Koller University of Minnesota Medical School, Minneapolis, MN, USA
Pranayraj Kondapally University of South Alabama Medical School, Mobile,

AL, USA
Cara Lachtrupp Harvard Medical School, Boston, MA, USA
Tony Larson University of Minnesota School of Medicine, Minneapolis, MN, USA
Grace Lee Harvard Medical School, Boston, MA, USA
Lovemore Peter Makusha Yale School of Medicine, New Haven, CT, USA
John McGrory University of Minnesota Medical School, Minneapolis, MN, USA
Daniel Michelson University of Minnesota Medical School, Minneapolis, MN, USA
Allison A. Merz Harvard Medical School, Boston, MA, USA

XL Contributors
Sameen Meshkin Harvard Medical School, Boston, MA, USA
Lin Mu Yale School of Medicine, New Haven, CT, USA
James Pathoulas University of Minnesota Medical School, Minneapolis, MN, USA
Hema Pingali Harvard Medical School, Boston, MA, USA
Priya Shah Harvard Medical School, Boston, MA, USA
Itamar Shapira UAB School of Medicine, Birmingham, AL, USA

UAB School of Medicine, Boston, MA, USA
Apurv H. Shekhar Yale School of Medicine, New Haven, CT, USA
Amrita Singh Yale School of Medicine, New Haven, CT, USA
Julia Song Harvard Medical School, Boston, MA, USA
Gaurav Suryawanshi University of Minnesota Medical School, Minneapolis,

MN, USA
Lena Trager University of Minnesota Medical School, Minneapolis, MN, USA
Azan Virji Harvard Medical School, Boston, MA, USA
Danny Wang WashU St. Louis School of Medicine, St. Louis, MO, USA
Lily Wood University of Minnesota Medical School, Minneapolis, MN, USA
Simon Yang University of Minnesota Medical School, Minneapolis, MN, USA
Lucas Zellmer University of Minnesota Medical School, Minneapolis, MN, USA
Ellen Zhang Harvard Medical School, Boston, MA, USA
Charlie W. Zhao Yale School of Medicine, New Haven, CT, USA
Amanda Zhou Yale School of Medicine, New Haven, CT, USA
Fellow Reviewer
Timothy J. Fernandez, M.D. Emory University, Atlanta, GA, USA
Resident Reviewers
Sharareh Koufigar, MS Piedmont Cancer Institute, Atlanta, GA, USA
Subha Perni, MD Harvard Radiation Oncology Program, Harvard Medical School,

Boston, MA, USA
1 1
Jeffrey Herrala
Contents
1.1 Introduction – 2
1.2 Sections – 2
1.2.1 T he Medical Learning Environment – 2
1.2.2 The AMIGAS Framework – 3
1.2.3 Suggestion Tables for Various Relationships and Scenarios – 5
1.3 Special Topics – 13
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

S. H. Lecker, B. J. Chang (eds.), The Ultimate Medical School Rotation Guide,
https://doi.org/10.1007/978-3-030-63560-2_1
2 J. Herrala
»» The end of all knowledge should surely be service to others (César Chávez)
1
1.1 Introduction
From the start of a student’s first clinical rotation, a shift in expectations

occurs. In this new role, the value placed on an individual’s performance (e.g.,
fund of knowledge, test scores) diminishes, and in its place rises the impor-
tance of a trainee’s sincere motivation to serve their patients, families, and the
medical team. The significance of a patient-centered and service-oriented med-
ical student cannot be overemphasized. With this mindset, the student becomes
a tremendous advocate, ally, and an irreplaceable teammate, vastly improving
team interactions and patient care.
However, even with such intentions, the medical learning environment can
be disorienting for trainees. In the absence of formal skills development, inter-
personal habits (both desired and undesired) are left to be inherited from peers,
from supervisors, or through trial and error. This process, commonly referred
to as the “hidden curriculum,” is a common source of stress for learners. Thus,
this chapter seeks to accomplish the following: (1) describe the function of the
medical learning environment, (2) provide an approach to forge interpersonal
connections within the medical setting, and (3) improve patient care and allevi-
ate student stress by outlining expectations and advice for common scenarios
and relationships.
1.2 Sections
1. The Medical Learning Environment

2. The AMIGAS Framework
3. Suggestion Tables for Various Relationships and Scenarios Patients and
Families
(a) Attending and Fellows
(b) Residents and Interns
(c) Nurses and Staff
(d) Peer Medical Students
(e) Pre-rounds and Rounds
4. Special Topics Making Mistakes and Apologies
(a) High-Stakes Conversations
(b) The End of the Day
(c) Feedback and Challenging Team Dynamics
1.2.1 The Medical Learning Environment
To be interpersonal experts, students must honor and equally value the con-
tributions of each member of the medical learning environment, no matter
their role: janitorial staff, clerks, attendings, and co-students alike. Each mem-
ber of the team is uniquely skilled and mission essential for patient care and
should be regarded as such. Outstanding medical students (as well as attend-
ings, nurses, and residents for that matter) are patient-centered and ambi-
tiously invest in interpersonal connection in all areas of the medical learning
environment.
3 1
1.2.2 The AMIGAS Framework
Pearl: It is important to
While forging interpersonal relationships in the medical environment may mention that “overasking” exists. By
come naturally for some, others may benefit from a formulaic approach for this asking many questions, you may
skill. To this end, we offer the “AMIGAS” framework, one possible framework exhaust or distract others from
for relationship building. Each step—absorb, mirror, imagine, goal, ask, and patient care. If your teammate
serve—is described below. Once learned, these steps can be adapted to various seems overwhelmed and distracted
situations and relationships. or meets your question with a brisk
reply, allow them space to refocus
kAbsorb and complete their immediate task
This is the information gathering stage. As medical students, we are frequently before asking another question
placed in unfamiliar and complex situations before fully understanding their (unless your request is urgent or
context. Asked to join a new team or meet a patient, we might speak or act in concerning important patient
ways we regret once further information about the situation or individual matters, in which case asking your
becomes apparent. Classic examples of this are using technical jargon with attending/resident immediately is
someone who prefers another language or speaking in overly simplified terms encouraged).
to a patient we later learn is a physician. A student might joke only to realize
that the tone was previously somber or speak too loudly when a team is using
soft voices. We might walk slowly on rounds when others expect us to rush or
move too quickly when a process demands meticulousness.
Pearl: Don’t be limited by
To avoid these situations, during the absorb stage, teach yourself to be max-
what you see in one patient’s room,
imally observant so you can keep learning and growing based on what you see.
the whole hospital is your pantry!
This is a habit of thought to be developed continually. Absorb everything
This is a great example of going the
about the scenario or an individual: what is the overall mood of the setting?
extra mile for your patient.
What volume and cadence of speech is used in conversation? What is a patient’s
level of medical literacy? Where are ice chips and patient food located on the
hospital floor? How long are patient presentations on this service? Interpersonal
connections should be formed at a slow and steady rate, while each party learns Pearl: You can learn a lot
from the other’s cues. Remember the importance of this first step, even when about the patient in indirect ways.
pressured for time. Do they furrow their eyebrows when
you use certain words, indicating
kMirror
confusion? Or, are they using highly
Mirror is a reflection stage and occurs simultaneously with the absorb stage. As medicalized terms which suggest
we absorb information about an individual or a situation, we should subtly prior healthcare experience?
reflect the positive things we observe: a person’s posture, head tilt, tone, voice,
cadence, etc. People feel more comfortable and safe when they notice that oth-
ers are willing to meet them where they are. We do this to communicate our
desire to make others comfortable and show them that we are reliably there to
take care of them. If an individual appears sad or overjoyed, adjust your mood
and nonverbal communication to mirror them. Pay attention to how individu-
als respond to each of your gestures and adjust accordingly. When speaking,
be sure to save space for others, especially patients, by pausing occasionally.
Absorbing allows you to obtain as much information as possible about your
surroundings before action is required, and mirroring appropriate gestures and
affect sets others at ease while you identify next steps.*
*Only mirror appropriate and professional behaviors of patients and the
medical team. As a human institution, the medical establishment is far from Pearl: When asking a
immune to the unacceptable behaviors and attitudes held by society at large patient if they need an interpreter,
(systematic discrimination, implicit bias, racism, sexism, classism, xenophobia) consider normalizing with some-
which significantly affect the health of the patients and communities we seek to thing like, “We’re taught it’s always
uplift. As medical students, we are charged with the responsibility of intervening better to ask, as some people with
on any unjust practices within medicine which propagate disparity. If we rec- excellent English language skills
ognize inappropriate behavior expressed by peers, senior clinicians, patients, or prefer to have an interpreter
other team members (such as unequal treatment of a patient due to a given present.”
4 J. Herrala
demographic factor or a microaggression or racist slur used against ourselves

1 Pearl: Setting realistic or a peer), we must intervene. For a framework on intervening in situations of
expectations early avoids feelings of this kind, reference the work Disarming Racial Microaggressions:
surprise or disappointment sur- Microintervention Strategies for Targets, White Allies, and Bystanders by Derald
rounding common issues within the Wing Sue et al.
clinic or hospital. If the issue does
occur, the patient and family will kImagine
react more acceptingly, as they In the imagine step, try synthesizing what you observed in the absorb and mir-
anticipated that it may happen ror stages and empathize with the person with whom you are interacting.
beforehand. Empathy is defined as the “ability to understand and share the feelings of
another.” Practice this skill by exploring the possible priorities, concerns,
desires, and plans of the other person. From what their actions and verbal and
nonverbal communication suggest, how might they feel about this visit, proce-
dure, or hospitalization? If you were them, how would you feel about a medical
Pearl: Important caveats to
student overseeing your care? What is it like to go without food or fluids for a
taking ownership include sharing
day? What words might you want to hear? These are only hypotheses, subject
significant decisions or pieces of
to continuous testing and reframing.
information without your team’s
Practice the same with your medical teammates. Imagine you are the intern:
permission. Examples include:
how do you feel about your level of expertise? What might make your job eas-
1. Informing patient of new cancer
ier? Imagine you are the chief resident: what is it like to orient multiple stu-
diagnosis
dents? Imagine you are an attending: what matters to you while leading the
2. Informing patient of HIV result
team? After you absorb information and mirror, use empathy to imagine what
3. Speaking with family about the
an individual might be feeling about a situation and about you.
death of a loved one under your
care
kGoal
4. Promising medications, discharge
Now that you have imagined the thoughts, priorities, and desires of your
dates/times, or procedure timing
patient or teammate, anticipate what their immediate goal might be. How
5. Telling a patient they can eat
could you as a medical student bring them closer to achieving this goal? Does
when they are NPO
your patient need water? A tissue? Might their tired family member benefit
from a cup of coffee or tea? Are they preoccupied by a question that is above
your level of expertise? What does your attending need for the next step in a
procedure? Does the intern have a long list of to-dos keeping them in the hos-
Pearl: Anyone who has been pital? No task is too menial and often small actions have a large impact on
hospitalized knows how difficult it patients. Furthermore, if you help out with small tasks, your team is more
can be to get privacy and sleep. likely to have extra time to teach you. Go the extra mile and do what others will
Doors and curtains are often left not do. Identify your patient or colleague’s most important goal and make it
open, and providers may speak your own.
audibly in the hallways and
workstations, leading patients to kAsk
spend days and night restless. At this point, you have ideas on how to help your patient, classmate, resident,
Further, patients are often con- or attending achieve their goal. However, each step has been built upon
nected to I.V.s and monitors and assumptions regarding the person’s goals and preferences. What if you are
cannot ambulate to the door or wrong? What if your plan to assist would offend a teammate or make a task
light switch themselves. Rest and more difficult? Thus, it is always best to ask for permission before helping out.
privacy are crucial for healing. For example: “Dr. [Attending], is now an appropriate time for a question about
Always ask for patient preferences the surgical anatomy in our patient?” “[Patient], would you like to discuss your
with lights, doors, and curtains results right now with family, or at another time?” “[Intern], would it be helpful
before you depart for me to work on obtaining your patient’s medical records from an outside
hospital?” Find their goal, plan a solution, and ask permission before
proceeding.
kServe
Now it is time to serve! Ask your timely and thoughtful question, assist with a
step in the procedure, or complete a favor for a teammate. Do it carefully, effi-
ciently, and when it’s appropriate, use closed-loop feedback to inform the indi-
5 1
vidual of their goal’s completion. For example: “I received the records by fax,
reviewed them, and placed them in our patient’s binder.” Closed-loop feedback Pearl: This is something you
ensures the other person is aware of the task’s completion and, further, reminds can ask for specific feedback on
them that your efforts helped move the team closer to its goal(s). It is crucial from your team and will demon-
that you do not dwell on this success, though. Announcing loudly or repeatedly strate your thoughtfulness and
that a task is complete may cause patients, peers, staff, or superiors to question dedication to patient-centered care.
your intentions or find your actions self-serving. Solve the problem, use closed-
loop feedback once, and then repeat the AMIGAS process from the beginning.
Use of the AMIGAS method works best when applied within a situation or
relationship repeatedly.
To ensure that you are communicating authentically and how you intend, Pearl: When a question is
try practicing with a friend or family member. Have them act as a clinic or above your level, resist the tempta-
preoperative patient, an attending, a nurse, or a clerk. If you have not done so tion to provide inaccurate or
before, film yourself in this practice environment to ensure that your body lan- incomplete answers. Elevate these to
guage, posture, and style matches what you hope to communicate. the team at the beginning or
Finally, though the AMIGAS framework might be helpful, making hypoth- conclusion of your oral
eses about the feelings and needs of everyone around you can be exhausting! presentation.
This style of interaction requires intense attention to detail, emotional energy,
and persistence.
Pearl: Unfortunately, this is

1.2.3 uggestion Tables for Various Relationships
S surprisingly common by medical
and Scenarios professionals. “I’ll be back later”
means that you will indeed visit
Using the AMIGAS method, it is possible to infer many ways to forge positive them prior to leaving that day.
relationships on your medical team. However, specific examples may be useful,
especially if you have never tried or seen them practiced before. In the tables
below, we will provide recommendations as they apply to various relationships.
Pearl: Keep in mind that
kPatients and Families patients often nod “yes” to ques-
By default, the needs of the patient and their family must come first. If as a tions, even if they do not under-
medical student you recognize a factor impeding a patient’s care, you should stand you, to be respectful.
bring it to the team’s attention in a tactful and timely fashion. If done well,
they should appreciate this intervention. See the table below for ideas for incor-
porating excellence into interactions with patients and families (. Table 1.1).
Pearl: Attendings and
kAttendings, Fellows, and Advanced Practitioners residents cannot enter orders until
Leading the medical team, attendings (and in many clinical contexts, fellows you present to them, and this can be
and advanced practitioners) are tasked with crucial decisions for a large panel a significant source of delay for
of patients: end-of-life discussions, surgical planning, ICU transfers, coordina- patient care. Aim for 30 minutes
tion with consulting services, etc. Similarly, though nuances exist between between being assigned a patient
advanced practitioners (physician’s assistants, nurse practitioners) and attend- and presenting them to the team
ings, they should be treated similarly to attendings in most situations. Avoid (though context dependent, e.g.,
the term “mid-level provider,” as this can be seen as disrespectful. While shorter for ED patients, longer for
attendings, fellows, and advanced practitioners may verify documentation, his- new patient visits at PCP office).
tory and exam findings, and decisions, it is often difficult to be comprehensive
due to competing demands. Therefore, closed-loop feedback and self-suffi-
ciency in problem-solving while never appropriating decision-making beyond
your level of responsibility are essential to earn their trust. Interactions with
attendings should remain succinct, positive, triaged by your interns/residents/
nurses, and reflect your decision-making ability and dedication to patients.
Before asking a question, attempt to answer it yourself: if a patient’s labs return
abnormal, form your own differential, diagnostic plan, and initial treatment. If
6 J. Herrala
.. Table 1.1 Patients and families

1 Encouraged Avoid
• Knock and wait for a positive response prior to entering any room. • Repeatedly mispronounce names,
• Awaken sleeping patients gracefully if you must interact with them. misgender a patient, or refer to them only
• Ask if now is a good time and if they would like family members in or out of the by age and diagnosis—especially during
room. patient-centered rounds, keep it personal.
• Whenever possible, sit at the patient’s bedside (if there is no chair, bring one in). • Stand above a patient while talking.
• Speak slowly and gently. Pause often to allow for processing and questions. • Use overly technical or overly simplified
• Follow your patient’s lead (smile if they are smiling, be serious if they are serious). language (too difficult = risk of
• Introduce your role early and repeat your name several times (the hospital is a misunderstanding; too simple = patron-
disorienting place—they will appreciate the reminder). izing).
• Ask how they prefer to be addressed and the proper pronunciation of their • Examine a patient without their
name. permission.
• Remember names for key family members. Jot them down if helpful. • Leave a room without providing the
• Learn about them: what are they missing out on while in the hospital? Do they patient time to ask questions.
have any specific fears? What is their level of medical literacy? Do they have • Answer questions that are above your
language preferences? abilities or level of decision-making
• It’s always okay to inquire respectfully with something like, “I wondered from (regarding NPO status, admission, or
your expression/pause/reaction if my comment might have upset/concerned/ discharge plan).
confused you.” If appropriate, maybe add, “That certainly wasn’t my intention” • Break promises, such as forgetting to
or some such clarifier. forward a request onto the team, fetch
• Use layperson terms; avoid medical jargon. water, etc. This forces your patients to
• Obtain an in-person or phone interpreter when needed. repeat requests to you or someone else
• To prepare for this, ask staff how to use the interpreter services on day #1, write (which can be embarrassing and difficult
down the phone number, and schedule this for the team whenever needed. given vulnerable status of patients) and is
• If an in-person interpreter is available, inform teammates of their scheduled deleterious to trust-building.
arrival time before rounds. If using phone interpretation, call while walking to • Rely on a suboptimal second language
the patient’s room to provide details they routinely request before entering the skill (on your part or a patient’s part) to
patient’s room. This vastly improves patient care and team efficiency. communicate information. Be humble;
• When using an interpreter, speak in 1–2 sentences at a time; this is better for arrange a professional interpreter
patient comprehension and interpreter memory. whenever necessary.
• Ask permission before performing physical examinations, and inform patients of • A history gathered without aid from a
exactly what you are doing. professional interpreter may yield
• Set expectations early, for example: “Today will be a long day, Ms. G. Many inaccurate and potentially dangerous
patients in the Emergency Department find the wait exhausting. We will do our information.
best to keep things moving quickly” or “Your procedure is scheduled for 2 PM, but • Delay care by spending excessive time
changes and delays often occur. We will keep you up to date with any changes.” between gathering a patient’s H&P and
• Communicate that your primary goal as medical student is to advocate for them, reporting your plan to the team.
move care forward, answer questions, keep them comfortable, and ensure they • Begin speaking to a patient or family
are up to date with the plan. member about clinical matters without
• Advocate: you often have more time for each patient than your teammates. Use first asking how they are doing.
this time to advocate for your patients. Was a medication dosage miscalculated? • Share medical matters in front of family
Has the patient been repeatedly awoken by labs or vitals that are now unneces- members without gaining the patient’s
sary for care? Your oral presentation on daily rounds provides you with a permission. Ideally, seek such permission
platform to advocate for any of these changes. before a family member is present
• Take ownership: as permitted by the team, be the first to inform your patient of
lab findings, changes in procedure timing, discharge plan, etc. As able, update
family members at the patient’s request.
• In all of these situations, allow your attending/resident to determine who is the
best person to inform the patient of particular information.
• Provide patients (as allowed by the treatment plan) water, coffee, snacks, ice chips,
and warm blankets. Whenever the opportunity presents itself, say the following:
“My goal is to make you as comfortable as possible, what else can I do?”
• If you find yourself without anything to do, check-in again with each of your
patients. Do they have any new symptoms, questions, concerns, or requests?
• Does the patient or family have any social concerns they are afraid to discuss
(finances, legal issues, etc.)? Gently probe, and if present, offer a social work
consultation.
• When leaving any room, ask the patient if they prefer their door and curtain
open or closed and if their lights should be on or off.
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apparently, in the case of solemn vows of perpetual chastity. It will be
observed that this heaven is moved by the Angels, who are severally
assigned to individuals as guardians, and who are the bearers of
tidings of God’s bounty to men; and, corresponding to this, the
questions solved relate to the salvation and guidance of individual
souls, and to the great gift of liberty, whereby God’s bounty is
specially shown.
The Heaven of Mercury.—In the second sphere, the heaven of
Mercury, appear the souls of those who did great things for humanity
or for special nations, but who were actuated by mixed motives;
personal ambition, desire of fame and honour, made “the rays of true
love mount upwards less vividly” (Par. vi. 117); and they have thus
the next lowest mansion of beatitude to the spirits that appeared in
the inconstant Moon. The Emperor Justinian recites the proud
history of the Roman Eagle, and shows how Divine Providence
established the sway of the Roman people over all the earth, made
the Eagle the instrument of the Atonement offered by Christ for all
mankind, the avenger of His death, the protector of His Church. As
the monarch who reformed and codified Roman Law, of which he is
for Dante the personification, and who restored Italy to the Empire
(the work which the Veltro is to renew under altered conditions of
Christendom), Justinian lifts the imperial ideal far above the factious
politics of the Middle Ages, condemning Guelfs and Ghibellines alike
as traitors and sowers of discord. Here, too, is Romeo of Villanova,
who did in a lesser degree for Provence what Justinian did for the
Empire, thus appearing with him in the sphere that is moved by the
Archangels, whose function is to guide and protect particular nations.
The figure of Romeo—unjustly accused of corrupt practices in office,
supporting with magnanimous heart the poverty and humiliations of
voluntary exile—is perhaps an unconscious portrait of Dante himself.
Even as the Archangels announce messages of special import and
sacredness, as Gabriel did to Mary, so Beatrice explains to Dante
the mystery of man’s redemption by the Incarnation and Crucifixion,
the supremest work at once of Divine Justice and Divine Mercy (Par.
vii.), and touches somewhat upon the immortality of the soul and the
resurrection of the body.
The Heaven of Venus.—The third heaven, the sphere of Venus,
is moved by the celestial Principalities, whose office is to influence
earthly rulers to imitate the principality of God, by uniting love with
their lordship. They are those, according to St. Bernard, “by whose
management and wisdom all principality on earth is set up, ruled,
limited, transferred, diminished, and changed.” Into this sphere
descend the souls of purified lovers, brilliant lights moving circle-wise
and hidden in the rays of their own joy. Carlo Martello, son of
Charles II. of Naples, and son-in-law of Rudolph of Hapsburg, who,
by reason of his marriage with Clemenza, might have healed the
feuds of Guelfs and Ghibellines, pictures the realms over which he
should have ruled, denounces the misgovernment of his own house,
and explains the influence of the celestial bodies for the constitution
of society and the government of states (Par. viii.). Cunizza da
Romano, the famous sister of Ezzelino, rebukes the anarchy of the
March of Treviso; a “modern child of Venus,” she here appears as
the type of a perfect penitent (Par. ix.). Like her, Folco of Marseilles,
poet then prelate, but here recorded only as troubadour, remembers
the love sins of his youth, not with sorrow, but with gratitude to the
Divine Mercy and wonder at the mysteries of Providence. Rahab of
Jericho, the highest spirit of this sphere, is a type of the Church,
saved by Christ’s blood from the ruin of the world; and, with a fine
thrust at the loveless avarice of the Pope and his cardinals, Dante
passes with Beatrice beyond the shadow of the earth.
The Heaven of the Sun.—To mark this higher grade of bliss and
knowledge, Dante pauses on his entrance into the fourth sphere, the
heaven of the Sun, to sing again of the Creation, the work of the
Blessed Trinity, and the order of the Universe, the visible expression
of the perfection of Divine art (Par. x. 1-21). The Sun is ruled by the
celestial Powers, the angelic order that represents the Divine
majesty and power, combats the powers of darkness, and stays
diseases. Here, in two garlands of celestial lights surrounding Dante
and Beatrice, appear the glorious souls of twenty-four teachers and
doctors, who illuminated the world by example and doctrine; the
twofold work of co-operation with the celestial Powers, which is seen
in its supereminent degree in the lives of St. Francis and St.
Dominic, the champions who led the armies of Christ against the
powers of darkness and healed the spiritual diseases of the Christian
world. St. Thomas Aquinas, the great light of the Dominicans, after
naming the other eleven spirits of his circle (Albertus Magnus,
Gratian, Peter Lombard, Solomon, Dionysius, Orosius, Boëthius,
Isidore, Bede, Richard of St. Victor, and Siger), sings the glorious
panegyric of St. Francis, the seraphic bridegroom of Poverty,
laments the backsliding of the Dominicans (Par. xi.). St.
Bonaventura, once minister-general of the Franciscans, extols the
marvellous life of St. Dominic, the cherubical lover of Faith, the great
paladin in Holy Church’s victorious battle where St. Francis bore the
standard of the Crucified (Par. xii.). Lamenting the degenerate state
of the Franciscans, he names the eleven spirits that accompany him;
two of the followers of St. Francis, Illuminato and Agostino; Hugh of
St. Victor; Peter Comestor, Peter of Spain (the logician whose
elevation to the papacy as John XXI. may be ignored in Paradise),
Nathan, Chrysostom, St. Anselm, Aelius Donatus (the Latin
grammarian), Rabanus Maurus, and the Calabrian abbot Joachim.
Lovers of poverty, rebukers of corruption, historians, mystics,
theologians, writers of humble text-books are here associated in the
same glory, as servants of truth in the same warfare against the
powers of darkness. They illustrate what St. Bonaventura calls the
broadness of the illuminative way. Each group closes with a spirit
whose orthodoxy had been at least questioned. Siger of Brabant, the
champion of Averroism at the university of Paris, had “syllogised
invidious truths,” and met with a violent death at the Papal Court at
Orvieto about 1284. Joachim of Flora, “endowed with prophetic
spirit,” had foretold the advent of the epoch of the Holy Ghost, in
which the Everlasting Gospel, the spiritual interpretation of the
Gospel of Christ, would leave no place for disciplinary institutions;
his later followers among the Franciscans had been condemned at
the Council of Anagni in 1256.
St. Thomas further explains to Dante the grades of perfection in
God’s creatures, from the Angels downwards; whereby His Divine
light is more or less imperfectly reflected, and the likeness of the
Divine ideas more or less imperfectly expressed—perfectly only
when the Trinity creates immediately, as in the case of Adam and the
humanity of Christ (Par. xiii.). Solomon, whose peerless wisdom St.
Thomas had explained as “royal prudence,” instructs Dante
concerning the splendour of the body after the resurrection, when
human personality will be completed and the perfection of beatitude
fulfilled (Par. xiv.). In a mysteriously beautiful apparition of what
seems to be another garland of spirits in the Sun, this vision of the
fourth heaven closes; and Beatrice and her lover are “translated to
more lofty salvation” in the glowing red of Mars.
The Heaven of Mars.—The fifth heaven, the sphere of Mars, is
ruled by the angelic Virtues. This is the order which images the
Divine strength and fortitude; their name, according to Dionysius,
signifies “a certain valiant and unconquerable virility.” According to
St. Bernard, they are those “by whose command or work signs and
prodigies are wrought among the elements, for the admonition of
mortals,” and it is through them that the sign of the Son of Man shall
appear in heaven as foretold in the Gospel.[39] Therefore, in Mars,
Dante beholds a great image of the Crucified, blood-red, formed by
stars which are the souls of the warrior saints, whom the Virtues
impressed at their birth with the influence of the planet (Par. xvii. 76-
78), to be strongly and manfully valiant, and to do notable things on
earth (ibid. 92, 93), even as the Virtues, according to St. Bernard,
work signs and prodigies among the elements.
Cacciaguida passes from the right arm of the Cross to greet his
descendant, like Anchises to Aeneas in Elysium. In his long
discourse with the poet (Par. xv. and xvi.) we dimly discern a
splendidly ideal picture of a free Italian commune of the twelfth
century, before what Dante regards as the corrupting influence of
wealth and illegitimate extension of its boundaries had fallen upon it,
and before the hostility of the Church to the Empire, with the
resulting confusion of persons in the city, had involved the
Florentines in the feuds of Guelfs and Ghibellines. Then, having
bitterly lamented the decay of the old Florentine families and the
corruption of their successors, Cacciaguida co-operates with the
Virtues by inspiring Dante with endurance and fortitude to suffer
unjust exile and perform his life’s work (Par. xvii.). In the famous and
most noble lines, to which reference has already been made in
touching upon this epoch of Dante’s life, Cacciaguida foretells the
poet’s banishment, the calumnies of his enemies, his sufferings in
exile, his forming a party to himself, the future greatness of Can
Grande, Dante’s own certainty of eternal fame. And let him be no
timid friend to truth, but make manifest his whole vision, and
especially assail corruption in highest places (cf. Mon. iii. 1). It is
Dante’s apologia for his own life, first as citizen, then as poet. The
keynote of the closing years of his life is struck at the opening of
Canto xviii.: “And that Lady who was leading me to God said:
‘Change thy thought; think that I am near to Him who unburdens
every wrong.’” Gazing upon her, his affection “was free from every
other desire.” Then, with a charge of celestial chivalry across the sky,
this vision of warriors closes; Joshua and Judas Maccabaeus,
Charlemagne and Orlando, William of Orange still with Renoardo,
Godfrey de Bouillon and Robert Guiscard, flash through the Cross,
and are rejoined by Cacciaguida in their motion and their song.
The Heaven of Jupiter.—The silvery white sphere of Jupiter, the
sixth heaven, is ruled by the Dominations, the angelic order which
images the archetypal dominion in God as the source of true
dominion. “We must consider in the Dominations,” writes St.
Bernard, “how great is the majesty of the Lord, at whose bidding
empire is established, and of whose empire universality and eternity
are the bounds.” This, then, is the sphere of ideal government, the
heaven of the planet that effectuates justice upon earth (Par. xviii.
115-117). The souls of faithful and just rulers appear as golden
lights, singing and flying like celestial birds. They first form the text,
Diligite iustitiam que iudicatis terram, “Love justice, you that are the
judges of the earth” (Wisdom, i. 1, Vulgate), tracing successively the
letters until they rest in the final golden M, the initial letter of
Monarchy or Empire, under which alone can justice be paramount on
earth, and then, with further transformations, become the celestial
Eagle (Par. xviii. 100-114). This is the “sign which made the Romans
reverend in the world” (xix. 101); no emblem of material conquest,
but the image of the sempiternal justice of the Primal Will, the type of
dominion on earth ordained by God. It is the allegorical
representation of the doctrines of the Monarchia. And, since justice
is obscured and good government rendered abortive by the simony
of the pastors of the Church, which leads them to oppose the
Empire, Dante has a bitter word in season for the reigning pontiff,
John XXII (Par. xviii. 130-136).
In the perfect concord of its component spirits the Eagle, speaking
with one voice, discourses upon the immutability and absolute justice
of the Divine Will, which is inscrutable and incomprehensible to
mortals (Par. xix.). Having rebuked the wickedness of all the kings
and princes then reigning, from the Emperor-elect (Albert of Austria
in 1300) to the King of Cyprus, it sets forth in contrast to them the
example of just and righteous monarchs and rulers of olden time, the
six noblest of whom now form its eye—David, Trajan, Hezekiah,
Constantine, the Norman William II. of Sicily, and Rhipeus the Trojan
(Par. xx.). Three exquisite lines (73-75)—introduced as a mere
image—render the flight and song of the skylark with a beauty and
fidelity to nature which even Shelley was not to surpass. The
salvation of Trajan, through the prayers of St. Gregory, and Rhipeus,
by internal inspiration concerning the Redeemer to come, unveils yet
more wondrous mysteries in the treasury of Divine Justice, which
suffers itself to be overcome by hope and love. Rhipeus, the justest
among the Trojans and the strictest observer of right (Virgil, Aen. ii.
426, 427; cf. Acts x. 35), by his presence solves Dante’s doubt
concerning the fate of the just heathen who die without baptism, and
indicates that the race which gave the ancestors to the Roman
people was not without Divine light.
Heaven of Saturn.—The last of the seven heavens of the
planets is the sphere of Saturn, over which the Thrones preside.
According to Dionysius, the Thrones are associated with
steadfastness, supermundane tendency towards and reception of
the Divine. They represent, according to St. Bernard, supreme
tranquillity, most calm serenity, peace which surpasses all
understanding; and upon them God sits as judge (cf. Par. ix. 61, 62).
In Saturn appear the contemplative saints, and the monks who kept
firm and steadfast in the cloister. They pass up and down the
celestial Ladder of Contemplation (Par. xxi. and xxii.), the stairway by
which the soul mystically ascends to the consideration of the
impenetrable mysteries of God which transcend all reason. In this
high stage of progress towards the suprasensible Beatrice does not
smile, for Dante’s human intellect could not yet sustain it, and the
sweet symphonies of Paradise are silent. St. Peter Damian
discourses upon the impenetrable mysteries of Divine
predestination, and rebukes the vicious and luxurious lives of the
great prelate and cardinals. St. Benedict describes the foundation of
his own great order, and laments the shameless corruption of
contemporary Benedictines. Thus in this, and, above all, in the cry
like thunder which bursts from the contemplatives at the conclusion
of Peter Damian’s words, threatening the Divine vengeance which is
to fall upon the corrupt pastors of the Church, the saints of the
seventh sphere unite themselves with the celestial Thrones, whose
office is purification, and who are the mirrors of the terrible
judgments of God.
The Gemini.—At Beatrice’s bidding, Dante follows the
contemplatives up the celestial ladder, entering the Firmament at the
sign of the Gemini or Twins, beneath which he was born (Par. xxii.
112-123). To his natal stars, and thus to the Cherubim with whose
virtue they are animated, he appeals for power to complete the work
for which they have inspired him. In a momentary vision, with the
capacity of his inward soul enlarged, he looks down upon the whole
Universe, and estimates aright the relative value of all things in
heaven and earth, now that he is prepared to witness the true glories
of Paradise.
The Stellar Heaven.—The Firmament or stellar heaven, the
eighth sphere, is ruled by the Cherubim, who represent the Divine
Wisdom; it is the celestial counterpart of the Garden of Eden. Here
the fruit of man’s redemption is mystically shown in a vision of the
triumph of Christ, the new Adam, surrounded by myriads of shining
lights which draw their light from Him and represent the souls of the
blessed whom He has sanctified (Par. xxiii.). After Christ has
ascended from this celestial garden, where Mary is the rose and the
Apostles the lilies, the Archangel Gabriel descends with ineffable
melody and attends upon the new Eve, “the living garden of delight,
wherein the condemnation was annulled and the tree of life
planted,”[40] in her Assumption.
The four spheres of the higher planets had set forth a celestial
realisation of the four cardinal virtues, Prudence, Fortitude, Justice,
and Temperance, with perfect man according to the capacity of
human nature; now, in this sphere of the Cherubim whose name
indicates plenitude of the knowledge of God, Dante is examined
upon the three theological virtues, which have God for their object as
He transcends the knowledge of our reason, and which put man on
the way to supernatural happiness. “If we would enter Paradise and
the fruition of Truth,” writes St. Bonaventura, “the image of our mind
must be clothed with the three theological virtues, whereby the mind
is purified, illumined, and rendered perfect, and thus the image is
reformed and made fit for the Jerusalem which is above.” Dante’s
answers to St. Peter upon Faith (Par. xxiv.), to St. James upon Hope
(Par. xxv.), to St. John upon Charity (Par. xxvi.), contain the essence
of the devout wisdom of the schoolmen upon those three divine gifts,
whereby man participates in the Deity, and “we ascend to
philosophise in that celestial Athens, where Stoics and Peripatetics
and Epicureans, by the art of the eternal Truth, harmoniously concur
in one will” (Conv. iii. 14). For the object of Faith and Love alike
Dante, even in Paradise, can appeal to the Metaphysics of Aristotle
(Par. xxiv. 130-132, xxvi. 37-39); and all the celestial music cannot
quite drown the poet’s sigh for that fair Florentine sheepfold, from
which he is still barred out, though Hell and Heaven have opened for
him their eternal gates (Par. xxv. 1-12). Within a fourth light the soul
of Adam appears, to instruct Dante upon the proper cause of his fall
and upon his life in the Earthly Paradise, now that the poet has seen
the triumph and ascent of the new Adam. Adam, in whom was
directly infused all the light lawful to human nature to have (Par. xiii.
43), is the last soul that appears to Dante until the consummation of
the vision in the Empyrean. On the close of his discourse, a hymn of
glory to the Blessed Trinity resounds through Paradise, a laugh of
the Universe in joy of the mystery of Redemption (Par. xxvii. 1-9).
Then, while all Heaven blushes and there is a celestial eclipse as at
the Crucifixion, St. Peter utters a terrible denunciation of the
scandals and corruption in the Papacy and the Church, wherein
Dante, as in the Epistle to the Italian Cardinals, takes his stand as
the Jeremiah of Roman Catholicity.
The Ninth Heaven.—When the saints have returned to their
places in the Empyrean, Dante, after a last look to earth, passes up
with his lady into the ninth sphere, the Crystalline heaven. Beatrice
discourses upon the order of the heavens and the want of
government upon earth, prophesying that, before very long,
deliverance and reformation will come, even as St. Peter had
announced in the sphere below. Here, where nature begins, Dante
has a preparatory manifestation of the nine angelic orders, the
ministers of Divine Providence, who ordain and dispose all things by
moving the spheres. They appear as nine circles of flame, revolving
round an atomic Point of surpassing brilliancy, which symbolises the
supreme unity of God, the poet again having recourse to the
Metaphysics of Aristotle: “From that Point depends heaven and all
nature” (Par. xxviii. 41, 42). Each angelic circle is swifter and more
brilliant as it is nearer to the centre, each hierarchy striving after the
utmost possible assimilation to God and union with Him. Swiftest and
brightest of all are the Seraphim, who move this ninth sphere; the
angelic order that, representing the Divine Love, loves most and
knows most. “In the Angels,” says Colet on Dionysius, “an intensity
of knowledge is love; a less intense love is knowledge.” The relation
of the Seraphim to the Cherubim is that of fire to light; their special
office is perfecting, as that of the Cherubim is illumination. All the
orders contemplate God, and manifest Him to creatures to draw
them to Him. Receiving from God the Divine light and love that
makes them like to Him, the higher orders reflect this to the lower,
like mirrors reflecting the Divine rays; and these lower orders reflect
it to men, so rendering all things, as far as possible to each nature,
like to God and in union with Him. After distinguishing between the
different orders according to Dionysius, Beatrice speaks of their
creation as especially illustrating the Divine Love, which the
Seraphim represent (Par. xxix.), and their place in the order of the
Universe, the fall of the rebellious, the reward of the faithful, and their
immeasurable number. Each Angel belongs to a different species,
and each differs from every other in its reception of Divine light and
love.
The Empyrean.—Dante and Beatrice now issue forth of the last
material sphere into the Empyrean, the true Paradise of vision,
comprehension, and fruition, where man’s will is set at rest in union
with universal Good, and his intellect in the possession of universal
Truth. In preparation for this Divine union, Dante is momentarily
blinded by the Divine light which overpowers him with its radiance—
a blindness followed by a new celestial sight and new faculties for
comprehending the essence of spiritual things. The first empyreal
vision is still a foreshadowing preface: a river of light, the stream
which makes the city of God joyful, the wondrous flowers of celestial
spring, the living sparks of angelic fire. This river of Divine grace is
the fountain of wisdom from which, according to Bernard, the
Cherubim drink, to pour out the streams of knowledge upon all God’s
citizens; and of this fountain Dante, too, drinks with his eyes, that he
may more fully see the vision of God which he has to relate, to
diffuse His knowledge upon earth as the Cherubim do from Heaven.
By the light of glory his mind is rendered capable of seeing those
spiritual things which the blessed behold with immediate intuition,
and of ultimate union with the Divine Essence (Par. xxx. 100-102).
The river seems to change to a circular ocean of light; the saints and
Angels appear in their true forms, all united in the sempiternal Rose
of Paradise. Even at this height of ecstatic alienation from terrestrial
things, Dante can turn in thought to Pope and Emperor who should
be leading men to beatitude; a throne is prepared for Henry in this
convent of white stoles, while the hell of the simoniacs is gaping for
Boniface and Clement.
Eternity, as defined by Boëthius, is “the complete and perfect
simultaneous possession of unlimited life”; and Dante is one who
has come from time to the eternal: a l’etterno dal tempo era venuto
(Par. xxxi. 38).[41] Beatrice has returned to her throne, her allegorical
mission ended; and for this supreme revelation of the Divine beauty
in the mystical Rose, where there is no medium to impede the poet’s
sight of the Divine light (for his is now that of a separated spirit), but
blessed souls and flying Angels are absorbed in love and vision, St.
Bernard completes her work, even as that of Virgil had been
completed by Matelda in the Earthly Paradise. St. Bernard may
represent the glorified contemplative life in our heavenly country, as
Matelda may symbolise the glorified active life in the state of
restored Eden; or, perhaps better, if Matelda is taken as the love
rightly ordered to which the Purgatorio leads, Bernard represents the
loving contemplation or contemplative love, attained by the mystic in
brief moments here and now, in which the eternal and unchanging
life of the soul in the hereafter consists. In an exquisite lyrical inter-
breathing Dante addresses Beatrice for the last time, thanking her
for having led him from servitude to liberty, praying to her for final
perseverance (Par. xxxi. 79-90). Under the guidance of Bernard, he
prepares himself for the vision of the Divine Essence, by disciplining
his spiritual sight in contemplation of the glory of the saints and of
the ineffable beauty of Mary, surrounded by her Angels, and clothed,
as Bernard himself puts it elsewhere, in the Sun by whose fire the
prophet’s lips were cleansed and the Cherubim kindled with love.
Throughout the Rose two descending lines divide the redeemed of
the old law from the redeemed under the new. The one line passes
down from Mary’s throne, composed of holy women, ancestresses of
Christ or types of His Church: Eve, Rachel, Sarah, Rebecca, Judith,
Ruth (Par. xxxii.). With Rachel, in the third row, Beatrice is seated.
The opposite line passes down from the seat of the Baptist, Christ’s
precursor; and begins with St. Francis, His closest and most perfect
imitator, St. Benedict (in the third row opposite to Rachel and
Beatrice), St. Augustine. The lower sections of each half of the Rose
are occupied by the little children who died before attaining use of
reason; and who yet have different degrees of bliss, according to the
inscrutable mysteries of predestination and Divine Justice, which
willed to give grace differently to each. Another vision of Mary, the
supreme of created things, “the face that is most like to Christ,
whose beauty alone can dispose thee to see Christ” (Par. xxxii. 85-
87), is the prelude to the vision of the Deity. Before her hovers her
chosen knight, Gabriel, the “strength of God,” the pattern of celestial
chivalry, leggiadria. Round her are Adam and St. Peter, Moses and
St. John the Divine; opposite the two latter are St. Anne and St.
Lucy. Thus the three Ladies who took pity upon Dante in the dark
wood, when the mystical journey opened, have been seen in their
glory at its close.
Mary and the Divine Essence.—And the poet turns finally to the
Primal Love, by Mary’s grace and Bernard’s intercession, in the
lyrical prayer that opens the wonderful closing canto of the
Commedia:
Vergine madre, figlia del tuo figlio,
“Virgin Mother, daughter of thy Son.” Setting forth her predestination

from eternity to bring the Redeemer into the world, her office of love
and hope to Heaven and earth, her infinite excellence and dignity,
her power and never-failing love, St. Bernard implores of her grace
for Dante to rise to the vision of the Divine Essence now, in ecstatic
contemplation, and then for his final perseverance that, on his return
to earth, her loving protection may strengthen him against the
assaults of passion, until he rejoice once more in the Beatific Vision
for all eternity. Human love becomes one with the divine where
Beatrice—joined with him now in the union of fruition—is named for
the last time in the poem as he draws near to his mystical goal.
In answer to Mary’s intercession, an anticipation is granted to
Dante of the vision wherein the last and perfect beatitude of man
consists. The supreme experience of the soul, recognised by the
great mystics from Plotinus and Augustine to Richard of St. Victor
and Bonaventura, is rendered into unsurpassable poetry with the
impassioned conviction that it has been the writer’s own. All ardour
of desire dies away. Entering into the Divine light, uniting his
intellectual gaze with the Divine Essence, he actualises all
potentialities of spiritual vision therein. In the Divine light, he beholds
all nature, all Being scattered in leaves throughout the Universe here
united by love into one volume; the vision of the First Cause which
satisfies the understanding becomes that of the Supreme Goodness
which fulfils the will; and this First Cause, this Supreme Goodness,
itself remaining unchanged, becomes revealed to the poet’s ever
strengthening intuition as the mystery of the Blessed Trinity, in which
the Person of the Word took Human Nature.
A l’alta fantasia qui mancò possa;
“Here power failed the lofty phantasy”—the inspired imagination of

the prophet; but it left the desire and will assimilated in perfect
harmony with the will of God—the Divine will revealed as universal,
all-pervading, and all-moving love, “the love that moves the sun and
the other stars”:
L’amor che move il sole e l’altre stelle.
FOOTNOTES:
[28] “Della insufficienza del titolo è prova ed effetto il pronto e
universale accoglimento, che, messo una volta sul frontespizio,
trovò l’epiteto divina, che al generico Commedia diede
determinatezza e colore” (P. Rajna, Il titolo del poema dantesco,
in Studi danteschi diretti da M. Barbi, vol. iv.).
[29] For details of structure and scansion, the reader should
consult P. E. Guarnerio, Manuale di versificazione italiana; G.
Federzoni, Dei versi e dei metri italiani; F. D’Ovidio, Versificaizone
italiana e arte poetica medioevale.
[30] Cf. G. Livi, op. cit., pp. 26, 27.
[31] Traces of an earlier design have been tentatively found in
various places of the first seven cantos, and associated with
Boccaccio’s story of Dante having begun the poem before his
exile and resumed it after the recovery of his manuscript when the
guest of Moroello Malaspina. In Boccaccio’s commentary upon
the opening of Inf. viii., Andrea Poggi and Dino Perini are
represented as rival claimants for the honor of having recovered
the manuscript for Dante.
[32] Cf. Conv. ii. 5.
[33] Cf. Inf. xxxiii. 79-84 with Phars. viii. 827-830.
[34] See Moore’s Time-References.
[35] Cf. Sonnets lx. and lxi. of The House of Life.
[36] See in particular Parodi, “L’Albero dell’Impero,” in his
Poesia e storia nella Divina Commedia.
[37] In Purg. xxx. 109-117, Dante thus distinguishes between
the ovra de le rote magne and the larghezza di grazie divine in his
own case. St. Gregory the Great, speaking of the correspondence
of men with the angelic orders, uses the phrase: divinae largitatis
munere refecti (Hom. in Evangelia, ii. 34).
[38] I venture to retain this reading, although the testo critico
now gives: E’n la sua volontade.
[39] The Vulgate has virtutes caelorum, in Matt. xxiv. and Luke
xxi., where the English Bible reads “the powers of the heavens.”
[40] St. John of Damascus.
[41] Note the scansion of the previous line (37): Io che al divino
da l’umano. There is no syneresis in ïo, no elision of the e in che;
thus emphasising Dante’s personal experience, his wonder that it
should be vouchsafed to him, and producing the slow movement,
the solemn intonation of the line.
BIBLIOGRAPHICAL APPENDIX
The following notes do not attempt to give a full bibliography, but
merely a selection of works that will be found useful by the readers
of this Primer.
A. Text of Complete Works of Dante,

Dictionaries and Concordances
Le Opere di Dante, testo critico della Società Dantesca Italiana, a
cura di M. Barbi, E. G. Parodi, F. Pellegrini, E. Pistelli, P. Rajna, E.
Rostagno, G. Vandelli. Con indice analitico dei nomi e delle cose di
Mario Casella. Florence, 1921. The “Sexcentenary Dante.”
Le Opere di Dante Alighieri, a cura del Dr. E. Moore, nuovamente
rivedute nel testo dal Dr. Paget Toynbee. Fourth edition. Oxford,
1923.
A Dictionary of Proper Names and Notable Matters in the Works of
Dante, by Paget Toynbee. Oxford, 1898.
A Concise Dictionary of Proper Names and Notable Matters in the
Works of Dante, by Paget Toynbee, Oxford, 1914.
Concordance of the “Divina Commedia.” By E. A. Fay. Boston,
1888.
Concordanza delle opere italiane in prosa e del Canzoniere di
Dante Alighieri. By E. S. Sheldon and A. C. White. Oxford, 1905.
Dantis Alagherii Operum Latinorum Concordantiae. By E. K. Rand
and E. H. Wilkins, Oxford, 1912.
B. History and Literature of Dante’s Times

Caggese, R., Firenze dalla decadenza di Roma al Risorgimento
d’Italia. Vols. i. and ii. Florence, 1912-1913.
Casini, T., Letteratura italiana: storia ed esempi. Vols. i. and ii.
Rome, 1909.
Dino Compagni, La Cronica con introduzione e commento di G.
Luzzatto. Milan, 1906. (English translation of the Chronicle by E.
Benecke and A. G. F. Howell in the “Temple Classics,” London.)
D’Ancona, A., and Bacci, O., Manuale della letteratura italiana, vol.
i. Florence.
Gaspary, A., History of Early Italian Literature to the Death of
Dante, translated by H. Oelsner. London, 1901.
Del Lungo, I., Dino Compagni e la sua Cronica (Florence, 1879-
1887); I Bianchi e i Neri (second edition. Milan, 1921).
Piccioni, L., Da Prudenzio a Dante. Turin, 1916.
Rossi, V., Storia della Letteratura Italiana per uso dei Licei. Voi. i.
(Il Medio Evo). Milan, sixth edition, 1914.
Salvemini, G., Magnati e Popolani in Firenze dal 1280 al 1295.
Florence, 1899.
Villani, Giovanni, Croniche (Istorie) fiorentine. (Best edition at
present, Florence, 1823.)
Villani, Giovanni, Selections from the first Nine Books, translated
by Rose Selfe and edited by P. H. Wicksteed. London. 1906.
Villari, P., I primi due secoli della storia di Firenze, new edition,
Florence, 1905. (English translation by Linda Villari from the first
edition.)
For the expedition of Henry of Luxemburg, the reader should study
Caggese, Roberto d’Angiò e i suoi tempi, vol. i. chap. ii. (Florence,
1922).
C. Biography, Etc.
Codice Diplomatico Dantesco: i documenti della vita e della
famiglia di Dante, ed. G. Biagi and G. L. Passerini. Florence (in
course of publication).
Barbadoro, B., La condanna di Dante e le fazioni politiche del suo
tempo. In Studi danteschi, ed. M. Barbi, vol. ii. Florence, 1920.
Boccaccio, Il comento alla Divina Commedia e gli altri scritti
intorno a Dante, a cura di D. Guerri. Three vols. Bari, 1918. Vol. i.
contains the Vita di Dante and the Compendio.
Bruni, Leonardo, Vita di Dante (in Le vite di Dante, Petrarca e
Boccaccio scritte fino al secolo decimosesto, ed. A. Solerti. Milan,
1904).
Foligno, C., Dante. Bergamo, 1921.
Howell, A. G. F., Dante (in “The People’s Books,” London).
Del Lungo, I., Dell’esilio di Dante. Florence, 1881.
Ricci, C., L’ultimo rifugio di Dante. Second edition. Milan, 1921.
Scherillo, M., Alcuni capitoli della biografia di Dante. Turin, 1896.
Toynbee, P., Dante Alighieri, his Life and Works. Fourth edition.
London, 1910.
Wicksteed, P. H., The Early Lives of Dante (translated). London,
1904.
Zingarelli, N., Dante (Milan, 1903); Vita di Dante in compendio
(Milan, 1905).
D. The Minor Works

The Convivio or Convito was first printed at Florence in 1490.
Eighteen canzoni (erroneously numbered as fourteen) were
published at the end of a Venetian edition of the Commedia in
November, 1491. Fifteen genuine Dantesque canzoni, with others
wrongly ascribed to him, are contained in a collection printed at
Milan and at Venice in 1518. The first partially complete edition of
Dante’s lyrical poetry is contained in the first four books of Sonetti e
canzoni di diversi antichi autori toscani in dieci libri raccolte, edited
by Bernardo di Giunta at Florence in 1527. The Vita Nuova was first
printed at Florence in 1576; but its lyrics had been given in the first
book of the 1527 Sonetti e canzoni. The De Vulgari Eloquentia was
published in Trissino’s Italian translation at Vicenza in 1529, and in
the original Latin at Paris in 1577; the Monarchia in 1559 at Basle.
The latter work had been translated into Italian by Marsilio Ficino in
the latter half of the fifteenth century. The Letter to Henry VII. was
first published in an old Italian version in 1547; in its original Latin by
Witte in 1827.
The Epistle to Can Grande was first published in 1700, the
Eclogues in 1719. The Letters as a whole were edited by Witte in
1827 and by Torri in 1842.
Special editions and studies. (a) Vita Nuova. Critical edition by M.
Barbi (Florence, 1907); with notes and commentary by M. Scherillo
(Milan, 1911, reprinted with the Canzoniere); G. Salvadori, Sulla vita
giovanile di Dante (Rome, 1906); Vita Nuova and Canzoniere, text,
translation, and notes by P. H. Wicksteed and T. Okey (“Temple
Classics”). For the “dolce stil nuovo,” V. Rossi, in Lectura Dantis, Le
Opere Minori (Florence, 1906), and Parodi, Poesia e storia nella
D.C. A new edition of the Vita Nuova is published by K. McKenzie
(London, 1923). (b) Rime or Canzoniere. M. Barbi, Studi sul
Canzoniere di Dante (Florence, 1915); G. Zonta, La lirica di Dante
(in Miscellanea dantesca, supplement 18-21 of Giornale storico della
letteratura italiana, Turin, 1922); E. G. Gardner, The Lyrical Poetry of
Dante (in preparation). For the tenzone with Forese F. Torraca, Nuovi
studi danteschi (Naples, 1921), and A. F. Massèra, Sonetti burleschi
e realistici dei primi due secoli (Bari, 1920); for the tenzone with
Dante da Maiano, S. Santangelo, Dante Alighieri e Dante da Maiano
(in Bullettino della Società Dantesca Italiana, N. S., XXVII., 1920); for
the canzone of the Tre donne, Torraca, op. cit., and Carducci, Opere
xvi (“Poesia e Storia”). The majority of the Rime are translated by
Wicksteed in the “Temple Classics” volume cited above. (c)
Convivio. Translation by W. W. Jackson (Oxford, 1909); translation
and commentary by Wicksteed in the “Temple Classics”; Wicksteed,
From Vita Nuova to Paradiso (Manchester University Press, 1922).
(d) De Vulgari Eloquentia. Critical edition by P. Rajna (Florence,
1896); facsimile reproduction of Berlin MS., L. Bertalot, Il Codice B
del “De Vulgari Eloquentia” (Florence, 1923); studies by F. D’Ovidio,
Versificazione italiana e arte poetica medioevale (Milan, 1910);
translation and commentary by A. G. F. Howell in “Temple Classics
Latin Works of Dante”; C. Foligno, Dante, the Poet (Brit. Acad.
Annual Italian Lecture, 1921). (e) Monarchia. C. Cipolla, Il trattato
“De Monarchia” di D. A. e l’opuscolo “De potestate regia et papali” di
Giovanni da Parigi (reprinted in Gli studi danteschi di Carlo Cipolla,
Verona, 1921); F. Ercole, L’unità politica della nazione italiana e
l’Impero nel pensiero di Dante (in Archivio storico italiano, LXXV.,
Florence, 1917), and Per la genesi del pensiero politico di Dante (in
Giornale storico della letteratura italiana, LXXII., Turin, 1918); E. G.
Parodi, Del concetto dell’Impero in Dante e del suo averroismo (in
Bull. d. Soc. Dantesca Italiana, N.S., XXVI., Florence, 1919); A.
Solmi, Il pensiero politico di Dante (Florence, 1922); C. Foligno, The
Date of the Monarchia (in Dante, Essays in Commemoration,
University of London Press, 1921); translation and commentary by P.
H. Wicksteed in “Temple Classics Latin Works of Dante.” (f)
Epistolae. P. Toynbee, Dantis Alagherii Epistolae (The Letters of
Dante, emended text, with introduction, translation, notes, etc.,
Oxford, 1920); F. Torraca, Le lettere di Dante (in Nuovi studi
danteschi); E. Moore, The Genuineness of the Dedicatory Epistle to
Can Grande (in Studies in Dante, Series III.). (g) Eclogae. P. H.
Wicksteed, Dante and Giovanni del Virgilio (London, 1902); G.
Albini, Dantis Eclogae, etc. (Florence, 1903). (h) Quaesto de Aqua
et Terra. Edited and translated by C. L. Shadwell (Oxford, 1909);
ed. V. Biagi, with critical dissertation (Modena, 1907); E. Moore,
Studies in Dante, Series II. (Oxford, 1899); Wicksteed, translation
and commentary in “Temple Classics Latin Works of Dante.”
E. The “Divina Commedia”

Editions with Notes and Commentaries
[The first three editions of the Divina Commedia were printed in
1472, at Foligno, Mantua, and Jesi. They were reprinted, together
with the Neapolitan edition of 1477, by Lord Vernon and Panizzi: Le
Prime Quattro Edizioni della Divina Commedia letteralmente
ristampate (London, 1858). The first Venetian edition is dated 1477,
the first Florentine 1481. There were about fifteen editions of the
Divina Commedia published before the end of the fifteenth century.
The first Aldine was printed in 1502. The two earliest dated
manuscripts, the Landiano (1336) and the Trivulziano (1337), have
been published in facsimile: Il Codice Trivulziano 1080 della D.C.,
with introduction by L. Rocca (Milan, 1921); Il Codice Landiano with
preface by A. Balsamo and introduction by G. Bertoni (Florence,
1921).]
La Divina Commedia nuovamente commentata da F. Torraca.
Milan and Rome, third edition 1915.
La Divina Commedia commentata da G. A. Scartazzini. Seventh
edition revised by G. Vandelli, Milan, 1914.
La Divina Commedia con il commento di Tommaso Casini. Sixth
edition renovated and augmented by S. A. Barbi. Florence, 1923.
Inferno, Purgatorio, and Paradiso, Italian text with English prose
translation on opposite pages, maps and notes, three vols., “Temple
Classics” (London). Inferno, Carlyle’s translation with notes by H.
Oelsner; Purgatorio, translation and notes by T. Okey; Paradiso,
translation and notes by P. H. Wicksteed.
Vernon, W. W., Readings on the Inferno, Purgatorio, and Paradiso,
chiefly based upon the Commentary of Benvenuto da Imola. Six
vols. (two on each part). London, new edition, 1906-1909.
La Divina Commedia, edited and annotated by C. H. Grandgent.
London, 1914.
La Divina Commedia nella figurazione artistica e nel secolare
commento, a cura di Guido Biagi. Turin, 1921, et seq.
F. Subsidiary to the “Commedia” and General.

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1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

3 What Attendings and Residents Look For . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

3.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

4 Clinical Tips and Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

4.1 General Rotation Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

4.8 Note-Writing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

5 EMR Tips and Tricks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

5.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

6 Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

6.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

7 General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98

8 Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154

9.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232

10.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .269

10.6.1 Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282

11.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .318

12.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .334

13 Primary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

13.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .354

14 Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375

14.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .377

14.3.8 After the Patient Encounter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386

15 Critical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427

15.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .429

16.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .475

16.6.3 Differentiating the Differential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528

17.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .546

17.8.2 Diagnostic Paracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592

18.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .596

19 Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621

19.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .622

19.5.2 Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644

20.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .655

21 Radiation Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701

21.1 Introduction to Radiation Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 702

21.1.7 What Are the Side Effects of RT? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707

22.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .731

23 Orthopaedic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 813

23.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .814

23.2.3 Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816

24.1 Neurosurgery Mentality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847

1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

3 What Attendings and Residents Look For . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

3.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

4 Clinical Tips and Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

4.1 General Rotation Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

4.8 Note-Writing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

5 EMR Tips and Tricks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

5.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

6 Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

6.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

7 General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98

8 Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154

9.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232

10.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .269

10.6.1 Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282

11.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .318

12.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .334

13 Primary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

13.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .354

14 Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375

14.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .377

14.3.8 After the Patient Encounter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386

15 Critical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427

15.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .429

16.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .475

16.6.3 Differentiating the Differential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528

17.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .546

17.8.2 Diagnostic Paracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592

18.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .596

19 Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621

19.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .622

19.5.2 Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644

20.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .655

21 Radiation Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701

21.1 Introduction to Radiation Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 702

21.1.7 What Are the Side Effects of RT? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707

22.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .731

23 Orthopaedic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 813

23.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .814

23.2.3 Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816

24.1 Neurosurgery Mentality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847

24.6.3 Paroxysmal Sympathetic Hyperactivity (Storming) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888

25.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .931

25.7.2 Topics for Further Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955