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 FIRST AID I
FOR
THE i ( )

MEDICINE
i

Clerkship
FOURTH EDITION

Thoroughly revised to be THE MUST HAVE

RESOURCE for your internal medicine
clerkship

Covers the KNOWLEDGE and SKILLS

you need to SUCCEED in your clerkship
and on the shelf exam

ALL NEW FULL COLOR DESIGN

Includes new special boxes, tables, and

sections with HIGH-YIELD INFORMATION
to help you conquerthe wards

Graw
Matthew S. Kaufman Latha Ganti
Dennis Chang Alfredo J. Mena Lora
FIRST AID FOR THE ®

MEDICINE CLERKSHIP
FIRST AID FORTHE ®

MEDICINE
CLERKSHIP
4th Edition

Matthew S. Kaufman, MD, FACEP Dennis Chang, MD, FHM

Department of Emergency Medicine
Jersey City Medical Center
Jersey City, New Jersey
Latha Ganti, MD, MS, MBA, FACEP, FAHA
Vice Chair for Research and Academic Affairs
UCF HCA Emergency Medicine Residency Program
of Greater Orlando
Associate Medical Director, Polk County Fire Rescue
Professor of Emergency Medicine and Neurology
University of Central Florida College of Medicine
Editor -in -Chief, International Journal of Emergency
Medicine
Orlando, Florida
Associate Professor
Interprofessional Education Thread Director (MD
Curriculum)
Hospital Medicine, Department of Medicine
Washington University School of Medicine
St. Louis, Missouri
Alfredo J. Mena Lora, MD, FACP
Assistant Professor ofClinical Medicine
Program Director, Infectious Diseases Fellowship
Associate Program Director, Internal Medicine
Residency
Assistant Director, M3 Medicine Clerkship
Division of Infectious Diseases \ Department of
Medicine
University of Illinois at Chicago
Chicago, Illinois

Mc
NewYork Chicago San Francisco Athens London Madrid MexicoCity
Gra w
New Delhi Milan Singapore Sydney Toronto
Hill
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CONTENTS

apter 5 Evidence- Based Medicin

n II KnowledgefortheMedicineCIerkship
Chapter 6 Cardiology .
Chapter 7 Endocrinology .
Chapter 8 Hematology/Oncology ,

Chapter 9 Infectious Diseases .

Chapter 10 Pulmonology
Chapter 11 Dermatology .
Chapter 12 Psychiatry
Chapter 13 Gastroenterology and Hepatology
Chapter 14 Nephrology/Acid- Base Disorders.
Chapter 15 Rheumatology
Chapter 16 Neurology
Chapter 17 Ambulatory Medicine
Chapter 18 ln- patient Floor Emergencies
Chapter 19 PalliativeCare
CONTRIBUTORS
Eric Barna, MD, MPH New York , New York
Associate Professor 17 Ambulatory Medicine
Department of Internat Medicine
Mount Sinai Medical Center
John Cummins, MD
New York , New York Pyschiatry Fellow
18 Inpatient Emergencies University of Illinois at Chicago
Chicago, Illinois
Stephen Berns, MD, FAAHPM 12 Psychiatry
Associate Professor
Division ofPalliative Medicine
Department of Family Medicine Lindsay A. Dow, MD, MS
The Larner College of Medicine Assistant Professor
University ofVermont Associate Director ofNon- Fellowship Education
Burlington , Vermont Brookdale Department ofGeriatrics and Palliative Medicine
19 Palliative Care Icahn School of Medicine at Mount Sinai
New York , New York
Scott Borgetti, MD 19 Palliative Care
Assistant Professor of Clinical Medicine
Department oflnternal Medicine Richard J. Doyle, MD, PhD
Division oflnfectious Diseases Attending Physician
University oflllinois-Chicago College of Medicine Department ofEmergency Medicine
Chicago, Illinois Jesse Brown VA Hospital
9 Infectious Diseases Chicago, Illinois
11 Dermatology
Daniel Bunker, MD
Assistant Professor of Medicine Yuval Eisenberg, MD
Georgetown University School of Medicine Assistant Professor of Clinical Medicine
Washington , DC Department of Medicine
15 Rheumatology
Division of Endocrinology
Diabetes and Metabolism
Miriam Chung, MD
University of Illinois at Chicago
Associate Professor
Chicago, Illinois
Department oflnternal Medicine 7 Endocrinology
Division ofNephrology
Icahn School of Medicine at Mount Sinai
New York , New York Michelle T. Fabian, MD
14 Nephrology Assistant Professor
Corinne Goldsmith Dickinson Center for Multiple Sclerosis
Andrew Coyle, MD Director
Assistant Professor of Medicine and Medical Education Neurology Residency Program
Associate Program Director for Ambulatory Care Icahn School of Medicine at Mount Sinai
Internal Medicine Residency Program New York , New York
Icahn School of Medicine at Mount Sinai 16 Neurology
VIII
Samira S. Farouk, MD, MS, FASN
R Assistant Professor
QC Department ofMedicine
§ Division ofNephrology
U Assistant Professor Medical Education
Icahn School ofMedicine atMount Sinai
New York , New York
14 Nephrology / Acid - Base Disorders
Christopher P. Gans, MD, FACC, FASE
Assistant Professor ofClinical Medicine
Division ofCardiology
University of Illinois at Chicago
Chicago, Illinois
6 Cardiology
Michael Herscher, MD, MA
Assistant Professor
Division of Hospital Medicine
Icahn School ofMedicine at Mount Sinai
New York , New York
2 Physical Examination Pearls
Horatio (Teddy) Holzer, MD
Assistant Professor
Inpatient Medicine Clerkship Director
Department ofMedicine
Icahn School ofMedicine at Mount Sinai
New York , New York
4 Electrocardiogram
Peter H . Jin, MD
Assistant Professor
Department ofNeurology
University ofMaryland School ofMedicine
Baltimore, Maryland
16 Neurology
Tonia Kim, MD
Associate Professor
Department oflnternal Medicine
Division ofNephrology
Icahn School ofMedicine at Mount Sinai
New York , New York
14 Nephrology
Katie Mena, MD
Assistant Professor
Internal Medicine & Pediatrics
University of Illinois at Chicago
Chicago, Illinois
11 Dermatology
12 Psychiatry
Vinh-Tung Nguyen, MD
Assistant Professor
Department oflnternal Medicine
Icahn School ofMedicine at Mount Sinai
New York , New York
Chapter 3 Chest X -ray
Mahesh C. Patel, MD
Associate Professor
Internal Medicine - Infectious Diseases
University of Illinois at Chicago College ofMedicine
Chicago, Illinois
9 Infectious Diseases
Kamron Pourmand, MD
Assistant Professor, Division of Liver Diseases
Recanati/ Miller Transplantation Institute
Icahn School of Medicine at Mount Sinai
New York , New York
13 Gastroenterology and Hepatology
Ardaman Shergill, MD, MSPH
Assistant Professor ofMedicine in Oncology
The University of Chicago
Chicago, Illinois
8 Hematology/ Oncology
Melissa Wagner, MD, PhD
Clinical Assistant Professor of Psychiatry and Pediatrics
Medical Director of Inpatient Psychiatry
Associate Medical Director
Womens Mental Health
Department of Psychiatry
University of Illinois College ofMedicine
Chicago, Illinois
12 Psychiatry
Travis Yamanaka, MD
Physician
Section ofPulmonary and Critical Care
Mercy Hospital and Medical Center
Chicago, Illinois
10 Pulmonology
Maryam Zia, MD
John H . Stroger Hospital of Cook County
Chicago, Illinois
8 Hematology/ Oncology
STUDENT CONTRIBUTORS
Deepa Chellappa, MD
Internal Medicine Resident
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania
Jamilur Reja, MD
Internal Medicine Resident
Mount Sinai Beth Israel Hospital
New York , New York

Claire Eden, MD Emily Tixier, MD

General Surgery Resident Internal Medicine Resident
New York Presbyterian Queens Hospital Massachusetts General Hospital
Queens, New York Boston , Massachusetts

Sean Llewellyn, MD, PhD

Family Medicine Resident
University of Colorado
Anschutz Medical Campus
Aurora, Colorado
PREFACE
As current and former medicine clerkship directors, we know
firsthand how difficult and stressful the Internal Medicine
Clerkship is for medical students. But it doesht have to be that
way. The skills and knowledge to succeed in IM clerkships can
be mastered. And in the process, you can enjoy yourself and
grow to become the best physician you can be.
This 2020 updated First Aid for the * Medicine Clerkship is a
complete and thorough revision. In this revision we have made
major changes in response to in -depth reviews and feedback
from current and former medical students and internal med -
icine residents. We give deep thanks to these outstanding stu -
dents and residents for their thoughtful and brilliant sugges-
tions.
We have gone away from hullet points to a more narrative
format with more tables, figures, pictures, and color. We have
also added three new boxes to each chapter to emphasize im -
portant points:
1. Conquer the Boards
These boxes highlight facts and knowledge that will be
tested on your IM shelf exam.
2. Conquer the Wards
These boxes highlight facts and knowledge important to
take great care of patients and that your team will ask
about.
3. High- Yield Literature
These boxes will give you the high -yield literature that
every physician should know about on a given topic.
We have also added a new section entitled Skills for the Med -
icine Clerkship. In this section we cover the basic skills needed
to enjoy and succeed on the IM clerkship:
1. Basics Tips from former and current clerkship
- direc-
tors on how to succeed on the IM clerkship and basic
tips on what to do on pre - rounds, rounds, and after
rounds. We also give pointers on how to present your
patients and write a SOAP note.
2. Physical Examination Pearls - High -yield physical exam
facts and explanations to impress your teams. ECG -
Electrocardiogram ( ECG ) reading basics and example
ECGs with thorough explanations.
3. ECG - Electrocardiogram ( ECG ) reading basics and
example ECGs with thorough explanations.
4. Chest Radiograph - Chest x- ray reading basics and ex-
ample chest X- rays with detailed readings.
5. Inpatient Floor Emergencies - Learn how experienced
physicians approach common inpatient floor emergen -
cies like chest pain, dyspnea, and so much more.
6. Evidence- Based Medicine - This is a succinct review of
how you approach a medical question and appraise the
literature, as well as basic medical statistics
7. Palliative Care and Pain Management - In addition to
diagnosing and treating our patients, critical tasks of IM
doctors are communicating with and helping patients
through times of pain and severe illness. As Hippocrates
once said, “Cure sometimes, treat often , and comfort al-
ways.” This section reviews basic concepts and commu-
nication tools in end -of -life care and pain management
from palliative care experts.
We hope this book helps you enjoy and learn during the IM
clerkship. And as Sir William Osler once said, “Live neither in
the past nor in the future, but let each days work absorb your
entire energies and satisfy your widest ambition. Good luck!
Dennis Chang, MD, FHM
Alfredo J. Mena Lora, MD, FACP
SECTION
SKILLS FOR THE

MEDICINE CLERKSHIP
CHAPTER 1 BASICS
OVERVIEW OF HIGH- YIELD TOPICS IN BASICS OF

THE MEDICINE CLERKSHIP

Introduction .4
Tips for Success .4
1. Do Everything forYour Patients .4
2. Talk to Your Patients 5
3. Read and Ask Questions 5
4. State Your Assessment and Plan 6
5. Goals, Expectations, and Feedback 6
Whatto Do Each Day 6
Pre-rounds 6
Rounds 7
After Rounds 8
Admissions 8
Discharges 8
What to Do at Night 8
SOAP Notes and Presentations 9
S - Subjective 9
0 — Objective 9
A /P - Assessment and Plan 10
Conclusion 10
U
< INTRODUCTION
During the Internal Medicine ( IM ) clerkship, you will learn and be tested on
both knowledge and skills. This chapter will give you tips for success on the IM
clerkship.

TIPS FOR SUCCESS

At the beginning of the IM clerkship, you will be given a list of objectives that
you need to meet. No matter how long this list is for your clerkship, these 5 tips
will help you meet and hopefully exceed that list of objectives.

1. DO EVERYTHING FOR YOUR PATIENTS

During the IM clerkship, you will be asked to help take care of patients along
with an intern. Successful students do 3 things for all their patients:

1. Perform daily tasks

2. Contribute to creating the medical plan of care (see number 4 later )
3. Teach about what they have learned from their patient

Daily Tasks
After rounds there will be a “ To Do List” of things that need to get done for
the patient. Your role as a student is to proactively volunteer to do these things
for your patient and go above and beyond to accomplish these daily tasks. You
should also constantly communicate with your team the status of those tasks,
and once you have completed your tasks, ask your team if there is anything else
you can do to help.
Common tasks are:
Calling consults to other Services ( surgery, pulmonology, cardiology, etc.)
Reaching out to consult Services to clarify plans of care
Ensuring radiology tests and procedures are done in a timely manner
Getting medical records from outside hospitals
Calling primary care providers and other doctors who take care of the
patient as an outpatient
Speaking to and educating patients and families
Helping perform procedures (lumbar punctures, paracentesis, thoracentesis )

This is just to name a few. At first, it may not be possible to accomplish these
tasks on your own , so proactively ask your team if they can help or teach you
how to do them. Your goal by the end of the clerkship is to be able to accom -
plish these tasks on your own.
Teaching and Extra Tasks
It will impress your team if you do more than what is asked. Here are some
examples of extra tasks that impress IM teams:

Visiting your patients several times a day to get to know them hetter and
educate them about their disease and medical plan
Calling patients to see how they are doing after discharge
Looking up journal articles that help the team make decisions (see Chapter 5
on evidence-based medicine)
 Creating short (less than 5 minutes ) topic presentations on diseases your >
patient is being treated for Q

2. TALKT0 Y0UR PATIENTS

At the center of your IM clerkship will always be the patients. They will be your
greatest teachers and will be the reason you want to come to work. As a med-
ical student, you are in a unique and amazing position. You have access to all
the patient care information, are present for every physician discussion about
your teams’ patients, and have time to spend with your patients. Make sure you
are the best ambassador between your patient and the medical team.

The information you gather from your patients is the most comprehensive and
accurate history in the hospital, and medical students often have the closest
and most meaningful relationships with patients and their families. These rela-
tionships and information truly make a positive difference in the care patients
receive. Every year, I have a medical student who uncovers a key piece of his-
tory that completely alters our plan of care.

Talk to your patients as much as possible, advocate for them to your medical
team, and make sure they understand their plan of care. It will help them
receive better care and help you become a better doctor.

3. READ AND ASK QUESTIONS

All students go home and read about the diseases their patients have. However,
many students do not show that they are reading on rounds. Unfortunately
with clinical clerkships, unless you show what you know, people will assume
you dont know it. For many students, speaking out on rounds is challenging
and intimidating. Here are 2 tips:

1. Practice patient presentations: This is your time to shine, so own it and

practice your presentations so they have a smooth flow without ums or
pauses. And this only comes with practicing your presentations at night and
in the morning. Make sure, when you practice, you do the following (see
Soap Notes and Presentations later ):
• Build in questions you had and/ or journal articles or facts you looked up
the night before.
• Work on efficiency: Teams expect a great, efhcient presentation and ex-
pect you to bring in your knowledge. When students stumble during their
presentation, teams assume you are unprepared and will quickly jump in
before you get to your questions and reading.
• Make time to discuss the assessment and plan with your team: When
it comes to your assessment and plan, build in time in the morning to
discuss this with your intern and resident so you can confidently tell the
plan to your attending. Your residents success is tied to yours, and when
you present, you are representing the team - so make them proud.
2. Pay attention: Even though you may not be primarily following all the
patients on the team, pay attention to every discussion. Take notes. There is
nothing more impressive than when students ask questions about patients
they are not following or suggest a possible diagnosis. Obviously, this will not
be possible for every patient, but a few questions here and there show you are
engaged and interested. Make it a goal to ask 1 to 2 questions about patients
that are not yours each day. Teachers love questions, and your questions help
U them know what to teach you. Each question shows how you are applying
< your knowledge to clinical care, and this is an objective of every clerkship.

4. STATE YOUR ASSESSMENT AND PLAN

For every patient presentation you give, you must have an assessment and plan.
And do not worry if it is right or wrong. This is not what your team is looking
for. They just want you to try, and it shows how much you are applying your
knowledge to clinical care (see SOAP Notes and Presentations later ). It is also
important to always prioritize your differential diagnoses and to have a reason
why you think that is or is not the diagnosis. The same thing goes for your
plan - have a reason or logic behind why you are suggesting that plan.

5. GOALS, EXPECTATIONS, AND FEEDBACK

As a student on clerkships, you will be evaluated by your interns, residents, and
attendings. And as much as medical schools try to standardize their faculty
and house staff expectations, each individual person and team may have very
different expectations. So the only way to know is to ask.

Before you ask, it is important to think about what your goals are for the rota -
tion . Do you want to work on your patient presentations, physical exam , assess-
ment and plan, procedures, etc.? “Everything” is too broad of an answer, as we
are all trying to improve, but pinpoint a spedfic area that you want to improve.

On day 1 or 2, you must sit down with your intern and resident and attending
and get their expectations. And dont be satisfied with just “ work hard and take
good care of patients.” Ask them spedfically about the following:

1. Presentations: How should patients be presented in the morning ? Do they

want a classic subjective, objective, and assessment plan ( SOAP ) format or
just pertinent events overnight ? Do they want you to state your assessment
and plan by problem ?
2. Write- ups: What are the expectations on writing your own history and phys -
ical and daily progress notes in the chart ? What format is preferred: problem
list or by organ system ?
3. Presenting topic presentations: What format is preferred ? How long should
they be?
4. Feedback: Let them know that you would like feedback at the midpoint of
your rotation , as well as at the end.
5. Communication: Ask your residents and interns how they like to communi-
cate: text message, paging, phone, etc.

Lastly, enjoy your time on the IM clerkship - it is a transformative year that

you will look back on fondly for the rest of your career.

WHAT TO DO EACH DAY

Here is a blueprint of what you will be doing each day.

PRE- ROUNDS
Table 1-1 provides a to do list for you when you pre- round. When you first
start, pre- rounds may take you more time than you think so leave plenty of
time. When you start out I would give yourself at least 30 minutes per patient.
TABLE 1- 1 . Pre- Rounds >
Ln

un
Tips and Tricks
1 Get signout The intern covering your patients will meet with the
day intern every morning. Make sure you are there to
also hear what happened to your patient overnight.
(This is called signout.)
2 Read all notes for the last 24 A multitude of people will be seeing your patients
hours (physical therapist, social worker, case manager,
nurses). Read their notes. Look out for any event notes,
which are notes from the covering intern describing
significant events that happened overnight such as
hypotension or chest pain.
3 Vital signs • Write a range of vital signs that your patient had,
1 . Temperature including the lowest and highest and most recent
2. Blood pressure (BP) vitals. For example, BP: 111-150/55-85 (122 /75).
3. Pulse (P)
4. Respiratory rate (RR) • Look for overnight fevers.
5. 02 sat
6. Pain score • Don't forget to look at oxygen saturation (02), pain
7. Input and output score, weight, and input (IVfluids, oral intake) and
8. Weight output (urine output, stool, drains, etc.).
4 Medications • As- needed medications: Did the patient take any
pain medications or antinausea medications, for
example? These are also known as PRN ( pro re nata,
Latin for "as needed").

• How many days has a patient been on an antibiotic

(e.g., ceftriaxone day 5) ?
5 Labs Don't forget to look at:
• culture results (blood, urine, drains)
• pending lab tests

Know how labs have changed, especially white count,

hemoglobin, platelets, and creatinine.
6 Radiology Remember to look at all actual images even if you
don't know what you are looking at. It is good practice.
7 See and examine patient
8 Discuss with intern or resi- Set this up with your intern the day before.
dent assessment and plan
*** Leave time to practice your presentation before rounds.***

ROUNDS
TABLE 1 - 2. Rounds
1 Present This is your show. Take it and own it. Bring in what you've read
or literature that supports your ideas.
2 Stay involved Askquestions about other people's patients. Not on all of them,
but a few questions that come up.
3 Take notes on all You will likely get asked to do something for other patients, and
patients it helps if you know something about them.

4 Write questions Write down questions you have to look up later or ask later.
8

u
<
AFTER ROUNDS
1. Accomplish your “to do list” from rounds. (see Table 1- 2 )
2. Communicate constantly your progress on the “to do list” with your resi-
dents.
3. See your patients several times a day to update them.
4. Help: After you are done with your tasks, ask the interns and resident if
there is anything else you can do to help. If they say no, there is no need to
continue to ask them. Remember to be proactive. If you know there is a task
to do, tell them that you will take care of it. Interns will often default to just
taking care of it themselves.
5. Read: As with many rotations, there is definitely downtime; make sure you
have reading material or questions you can study.
6. When should I go home? Try to stay until the team does, but if they insist
on you leaving that is OK.

ADMISSIONS
A couple of tips on admissions include the following:

1. Try to see patients on your own: This is the best way to learn and start to
build independent history taking, as well as assessment and plan creation.
However, due to time constraints you will often see patients with your resi-
dent and / or intern. As you become more comfortable with your teams, ask if
you can lead the interview.
2. Time: Remember to give yourself time after interviewing the patient to read
and think about the assessment and plan. Your team may ask you questions
right after interviewing the patient or tell you what the plan is. Ask them if
you could have 30 minutes or an hour to collect your thoughts and notes
and then discuss the plan with them. This time for solo thinking is invalu-
able in your progress toward independently creating assessments and plans.
3. Return visit: Its OK to come back and speak to your patient to get more
information. Residents and attending physicians do this all the time.

DISCHARGES
Approximately 1 in 5 patients is readmitted to the hospital within 30 days after
discharge. Your role in their discharge can help prevent this.

1. Teach: The discharge process is a complex and challenging time for your
patients. The time you spend with your patients communicating to them the
plan and explaining medications can make all the difference.
2. Coordinate discharge: Make sure patients have follow- up appointments
with their primary care provider within 2 weeks of discharge, and make sure
they have all their other follow- ups with surgeons or other medicine special-
ties prior to discharge.
3. Follow up: Give your patients a call after discharge to see how they are doing.
Your team will love hearing any updates on patients they have sent home.

WHAT TO DOATNIGHT
Many times you will come back after a day on the wards feeling physically
exhausted and emotionally spent. As one of the most important clerkships, the
IM clerkship is one where you must use your time efficiently and wisely. One
of the challenges as a medical student on clerkships is finding a way to moti- >
vate yourself to continue to study when you get home while maintaining your Q
well - being. First, find something to do that you like or that helps you clear your
head, even if it s for only 10 or 20 minutes. You need to give yourself time to
unwind. Second, set realistic goals that you can accomplish each night.

WeVe all been there where you are excited to read an entire chapter at night
and because its unrealistic to read 20 pages in 1 hour, you just end up watching
videos and streaming your favorite show. Instead, set up realistic and attainable
goals, like doing 10 practice questions and looking up one literature review or
one clinical trial about the patient you are taking care of. If you do this every day,
in the course of a 2- or 3-month clerkship, you will have done 600 to 1000 ques-
tions and read on 60 or 80 different topics. Question banks prepare you for the
medicine shelf exam, and reading on topics helps you build habits to continue
to learn and improve throughout your career. As far as which question banks to
use, ask higher-level classmates what they used - they are the best resource.

SOAP NOTES AND PRESENTATIONS

From the beginning of medical school, you have practiced writing and present-
ing a full history and physical. One of the new skills on the clerkship is present-
ing and writing follow- up notes on patients for each day they are in the hospi-
tal. These are called SOAP notes, and following is an explanation of how you
should write one. Presentations are a simplified and more succinct version of
your SOAP note. For example, in your SOAP note you will write a full physical,
but during your presentation you would only include the pertinent negative
and positive findings.

S - SUBJECTIVE
This is any history you get from the patient that day. When you present this
information , you want it to be pertinent to the patients main diagnosis. If they
are here for asthma, then do not go into a long discussion about their issue
with the breakfast they were served.

0 — 0BJECTIVE
This is for data. And during your presentation , do not interpret that informa-
tion. This is for irrefutable facts. The data you need to include in this order is:

1. Vital Signs - Temperature ( and mention any fevers), pulse, blood pressure,
respiratory rate, oxygen saturation
2. Input and Output
3. Physical Exam - When you present, only include pertinent negative and
positive physical exam findings ( e.g., if the patient is here for asthma, the
normal abdominal exam is not pertinent )
4. Labs and Radiology
• If a lab is abnormal, it is always good to mention what it was the day
before and/ or what their baseline lab value is ( e.g., creatinine is 2 , but
yesterday it was 2.6 and their baseline is 1.5)
5. Current Medications ( if this is what your team wants - some teams do not
want the list of medications, as it is on their patient lists )
U
<
A /P - ASSESSMENT AND PLAN
The beginning of this section should always have a summary statement. A
summary statement, or “one-liner,” is a succinct sentence that summarizes the
patients past medical history and the reason for their admission. Each word in
this statement must be pertinent to their diagnoses. Example: 55 -year-old male
with a history of diabetes mellitus, hypertension , former smoker who presented
with chest pain and now found to a have non -ST-elevation ML

Then list their problems by acuity, meaning list the main reason they are still
in the hospital or their chief complaint first and then each subsequent problem
in order of importance. For each problem, there should be an assessment and
plan. Following is a formula for discussing assessments and plans:
Known Diagnosis
Assessment: Status with supporting evidence ( e.g., for a patient with pneumo-
nia - Assessment: Overall improving. Cough improved and white count down )

Plan: Discuss the plan and why you are deciding on that plan ( e.g., change to
CONQUER THE oral antibiotics, as now tolerating PO and anticipate discharge in 1 day)

>H1
The most likely diagnosis is often
the most common diagnosis.
Unknown Diagnosis
Assessment: List your differential diagnosis from what you think is most likely
to least likely. Explain why you think this is the diagnosis or why it isn’t the
diagnosis. A simple format to provide supporting evidence is anything in the
history, physical, labs, or radiology that supports or disproves that diagnosis.
However, it is OK to include zebras
in your differential, just not as the
Plan: Discuss the plan and why you decided on it.
most likely. If you don't go looking
for zebras, then you will never
find one. CONCLUSION
We hope this will help jump -start your experience and maximize your learning
on the IM clerkship. We leave you with one last thought:

“Observe, record, tabulate, communicate. Use your five senses. Learn to see,
learn to hear, learn to feel, learn to smell, and know that by practice alone you
can become [an ] expert.” - William Osler
 CHAPTER 2 PHYSICAL
EXAM PEARLS
O V E R V I E W O F H I G H - Y I E L D TOPICS IN PHYSICAL

EXAMINATION PEARLS
Lung Exam 12
Breath Sounds 12
Physical Findings of Common Pulmonary Diagnoses 12
Cardiac Exam 14
Stethoscope Basics 14
Heart Sounds 14
Systolic Murmurs 16
DiastolicMurmurs 17
NeckVeins 18
Abdominal Exam 19
Dermatologic Physical Exam Pearls . 22
a
LUNG EXAM
1 BREATH SOUNDS
2 There are 2 main types of breath sounds that you should know: vesicular and
<
u bronchial breath sounds.
£
E
Vesicular breath sounds: These are the soft breath sounds that are best
heard at the periphery in normal, healthy lungs, most prominently during
inspiration. This is what you hear when you describe the lungs as “clear to
auscultation .”
Bronchial breath sounds: Also known as tubular breath sounds or tracheal
breath sounds, these are more coarse -sounding breath sounds. These can
normally be appreciated by auscultating with the stethoscope placed directly
over the trachea; however, they are abnormal when heard over other parts
of the lung. Bronchial breath sounds are heard when a consolidation or
collapsed lung tissue transmits sound from the trachea or central airway
to the periphery ( thus “tracheal” breath sounds ). They are 96% specific for
pneumonia but only 14% sensitive.

Adventitious sounds: The main three extra, or “adventitious,” sounds are

crackles, wheezing, and rhonchi.

Crackles: Also known as “ rales,” these discontinuous sounds represent

CONQUER THE alveoli snapping open and therefore are predominantly inspiratory. Crackles

ivitmii
lt is often said that "all that
can be further subdivided into course and fine crackles.
• Coarse crackles: These sound coarser because of a lower frequency ( i.e.,
fewer crackles per second). Most commonly caused by pulmonary edema,
pneumonia, or atelectasis.
wheezes is not asthma." Also
considerCHF.
. Fine crackles: Often heard in interstitial lung disease. “Velcro” rales are
characteristic of interstitial pulmonary fibrosis.
Wheezing: High pitched and continuous, can be only expiratory or both
inspiratory and expiratory. Wheezing represents airway obstruction - the
sound is made by the vibrations of the walls of the narrowed airway. Classic
for asthma and chronic obstructive pulmonary disease ( COPD ) , it can also
be heard in other diseases such as congestive heart failure ( CHF ), sometimes
referred to as “cardiac asthma.”
Rhonchi: Tow pitched and continuous. The pathophysiology is thought to
be similar to wheezing; however, secretions may also play a role. Often heard
in COPD, can also be present in asthma.

Stridor: One other extra sound to know is stridor, which is caused by upper
airway obstruction. This sound is similar to wheezing in that it is high pitched
and continuous. However, stridor is inspiratory, whereas wheezing is either ex-
piratory or both inspiratory and expiratory, and stridor is louder over the neck
than over the lungs.

PHYSICAL FINDINGS OF COMMON PULMONARY DIAGNOSES

Pneumonia: The physical exam for pneumonia should include evaluation
for egophony, pectoriloquy, and tactile fremitus. Also, asymmetric chest
expansion, while insensitive, has a positive likelihood ratio ( LR ) of 44 for
pneumonia when present.
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 CHAPTER VI
MAGNETS AND MAGNETISM

In many parts of the world there is to be found a kind of iron ore,

some specimens of which have the peculiar power of attracting iron,
and of turning to the north if suspended freely. This is called the
lodestone, and it has been known from very remote times. The name
Magnetism has been given to this strange property of the lodestone,
but the origin of the name is not definitely known. There is an old
story about a shepherd named Magnes, who lived in Phrygia in Asia
Minor. One day, while tending his sheep on Mount Ida, he happened
to touch a dark coloured rock with the iron end of his crook, and he
was astonished and alarmed to find that the rock was apparently
alive, for it gripped his crook so firmly that he could not pull it away.
This rock is said to have been a mass of lodestone, and some
people believe that the name magnet comes from the shepherd
Magnes. Others think that the name is derived from Magnesia, in
Asia Minor, where the lodestone was found in large quantities; while
a third theory finds the origin in the Latin word magnus, heavy, on
account of the heavy nature of the lodestone. The word lodestone
itself comes from the Saxon laeden, meaning to lead.
It is fairly certain that the Chinese knew of the lodestone long
before Greek and Roman times, and according to ancient Chinese
records this knowledge extends as far back as 2600 b.c. Humboldt,
in his Cosmos, states that a miniature figure of a man which always
turned to the south was used by the Chinese to guide their caravans
across the plains of Tartary as early as 1000 b.c. The ancient Greek
and Roman writers frequently refer to the lodestone. Thales, of
whom we spoke in Chapter I., believed that its mysterious power
was due to the possession of a soul, and the Roman poet Claudian
imagined that iron was a food for which the lodestone was hungry.
Our limited space will not allow of an account of the many curious
speculations to which the lodestone has given rise, but the following
suggestion of one Famianus Strada, quoted from Houston’s
Electricity in Every-Day Life, is really too good to be omitted.
“Let there be two needles provided of an equal Length and
Bigness, being both of them touched by the same lodestone; let the
Letters of the Alphabet be placed on the Circles on which they are
moved, as the Points of the Compass under the needle of the
Mariner’s Chart. Let the Friend that is to travel take one of these with
him, first agreeing upon the Days and Hours wherein they should
confer together; at which times, if one of them move the Needle, the
other Needle, by Sympathy, will move unto the same letter in the
other instantly, though they are never so far distant; and thus, by
several Motions of the Needle to the Letters, they may easily make
up any Words or Sense which they have a mind to express.” This is
wireless telegraphy in good earnest!
The lodestone is a natural magnet. If we rub a piece of steel with
a lodestone we find that it acquires the same properties as the latter,
and in this way we are able to make any number of magnets, for the
lodestone does not lose any of its own magnetism in the process.
Such magnets are called artificial magnets. Iron is easier to
magnetize than steel, but it soon loses its magnetism, whereas steel
retains it; and the harder the steel the better it keeps its magnetism.
Artificial magnets, therefore, are made of specially hardened steel. In
this chapter we shall refer only to steel magnets, as they are much
more convenient to use than the lodestone, but it should be
remembered that both act in exactly the same way. We will suppose
that we have a pair of bar magnets, and a horse-shoe magnet, as
shown in Fig. 13.
If we roll a bar magnet amongst iron filings we find that the filings
remain clinging to it in two tufts, one at each end, and that few or
none adhere to the middle. These two points towards which the
filings are attracted are called the poles of the magnet. Each pole
attracts filings or ordinary needles, and one or two experiments will
show that the attraction becomes evident while the magnet is still
 some little distance away. If,
however, we test our magnet
with other substances, such
as wood, glass, paper, brass,
etc., we see that there is no
attraction whatever.
If one of our bar magnets
is suspended in a sort of
stirrup of copper wire attached
to a thread, it comes to rest in
a north and south direction,
and it will be noticed that the
end which points to the north
Fig. 13.—Horse-shoe and Bar Magnets, is marked, either with a letter
with Keepers. N or in some other way. This
is the north pole of the
magnet, and of course the other is the south pole. If now we take our
other magnet and bring its north pole near each pole of the
suspended magnet in turn, we find that it repels the other north pole,
but attracts the south pole. Similarly, if we present the south pole, it
repels the other south pole, but attracts the north pole. From these
experiments we learn that both poles of a magnet attract filings or
needles, and that in the case of two magnets unlike poles attract, but
similar poles repel one another. It will be noticed that this
corresponds closely with the results of our experiments in Chapter I.,
which showed that an electrified body attracts unelectrified bodies,
such as bits of paper or pith balls, and that unlike charges attract,
and similar charges repel each other. So far as we have seen,
however, a magnet attracts only iron or steel, whereas an electrified
body attracts any light substance. As a matter of fact, certain other
substances, such as nickel and cobalt, are attracted by a magnet,
but not so readily as iron and steel; while bismuth, antimony,
phosphorus, and a few other substances are feebly repelled.
The simplest method of magnetizing a piece of steel by means
of one of our bar magnets is the following: Lay the steel on the table,
and draw one pole of the magnet along it from end to end; lift the
magnet clear of the steel, and repeat the process several times,
always starting at the same end and treating each surface of the
steel in turn. A thin, flat bar of steel is the best for the purpose, but
steel knitting needles may be made in this way into useful
experimental magnets.
We have seen that a magnet has two poles or points where the
magnetism is strongest. It might be thought that by breaking a bar
magnet in the middle we should get two small bars each with a
single pole, but this is not the case, for the two poles are
inseparable. However many pieces we break a magnet into, each
piece is a perfect magnet having a north and south pole. Thus while
we can isolate a positive or a negative charge of electricity, we
cannot isolate north or south magnetism.
If we place the north pole of a bar magnet near to, but not
touching, a bar of soft iron, as in Plate II.a, we find that the latter
becomes a magnet, as shown by its ability to support filings; and that
as soon as the magnet is removed the filings drop off, showing that
the iron has lost its magnetism. If the iron is tested while the magnet
is in position it is found to have a south pole at the end nearer the
magnet, and a north pole at the end farther away; and if the magnet
is reversed, so as to bring its south pole nearer the iron, the poles of
the latter are found to reverse also. The iron has gained its new
properties by magnetic induction, and we cannot fail to notice the
similarity between this experiment and that in Fig. 2, Chapter II.,
which showed electro-static induction. A positively or a negatively
electrified body induces an opposite charge at the nearer end, and a
similar charge at the further end of a conductor, and a north or a
south pole of a magnet induces opposite polarity at the nearer end,
and a similar polarity at the further end of a bar of iron. In Chapter II.
we showed that the attraction of a pith ball by an electrified body was
due to induction, and from what we have just learnt about magnetic
induction the reader will have no difficulty in understanding why a
magnet attracts filings or needles.
 PLATE II.

(a) EXPERIMENT TO SHOW MAGNETIC INDUCTION.

(b) EXPERIMENT TO SHOW THE PRODUCTION OF MAGNETISM

BY AN ELECTRIC CURRENT.

Any one who experiments with magnets must be struck with the
distance at which one magnet can influence filings or another
magnet. If a layer of iron filings is spread on a sheet of paper, and a
magnet brought gradually nearer from above, the filings soon begin
to move about restlessly, and when the magnet comes close enough
they fly up to it as if pulled by invisible strings. A still more striking
experiment consists in spreading filings thinly over a sheet of
cardboard and moving a magnet to and fro underneath the sheet.
The result is most amusing. The filings seem to stand up on their
hind legs, and they march about like regiments of soldiers. Here
again invisible strings are suggested, and we might wonder whether
there really is anything of the kind. Yes, there is. To put the matter in
the simplest way, the magnet acts by means of strings or lines of
force, which emerge from it in definite directions, and in a most
interesting way we can see some of these lines of force actually at
work.
Place a magnet, or any arrangement of magnets, underneath a
sheet of glass, and sprinkle iron filings from a muslin bag thinly and
evenly all over the glass. Then tap the glass gently with a pencil, and
the filings at once arrange themselves in a most remarkable manner.
All the filings become magnetized by induction, and when the tap
sets them free for an instant from the friction of the glass they take
up definite positions under the influence of the force acting upon
them. In this way we get a map of the general direction of the
magnetic lines of force, which are our invisible strings.
Many different maps may be made in this way, but we have
space for only two. Plate III.a shows the lines of two opposite poles.
Notice how they appear to stream across from one pole to the other.
It is believed that there is a tension along the lines of force not unlike
that in stretched elastic bands, and if this is so it is easy to see from
the figure why opposite poles attract each other.
Plate III.b shows the lines of force of two similar poles. In this
case they do not stream from pole to pole, but turn aside as if
repelling one another, and from this figure we see why there is
repulsion between two similar poles. It can be shown, although in a
much less simple manner, that lines of electric force proceed from
electrified bodies, and in electric attraction and repulsion between
two charged bodies the lines of force take paths which closely
resemble those in our two figures. A space filled with lines of
magnetic force is called a magnetic field, and one filled with lines of
electric force is called an electric field.
A horse-shoe magnet, which is simply a bar of steel bent into the
shape of a horse-shoe before being magnetized, gradually loses its
magnetism if left with its poles unprotected, but this loss is prevented
if the poles are connected by a piece of soft iron. The same loss
occurs with a bar magnet, but as the two poles cannot be connected
in this way it is customary to keep two bar magnets side by side,
separated by a strip of wood; with opposite poles together and a
piece of soft iron across the ends. Such pieces of iron are called
keepers, and Fig. 13 shows a horse-shoe magnet and a pair of bar
magnets with their keepers. It may be remarked that a magnet never
should be knocked or allowed to fall, as rough usage of this kind
causes it to lose a considerable amount of its magnetism. A magnet
is injured also by allowing the keeper to slam on to it; but pulling the
keeper off vigorously does good instead of harm.
If a magnetized needle is suspended so that it is free to swing
either horizontally or vertically, it not only comes to rest in a north
and south direction, but also it tilts with its north-pointing end
downwards. If the needle were taken to a place south of the equator
it would still tilt, but the south-pointing end would be downwards. In
both cases the angle the needle makes with the horizontal is called
the magnetic dip.
 PLATE III.
(a) LINES OF MAGNETIC FORCE OF TWO OPPOSITE POLES.
 (b) LINES OF MAGNETIC FORCE OF TWO SIMILAR POLES.

It is evident that a suspended magnetized needle would not

invariably come to rest pointing north and south unless it were
compelled to do so, and a little consideration shows that the needle
acts as if it were under the influence of a magnet. Dr. Gilbert of
Colchester, of whom we spoke in Chapter I., gave a great deal of
time to the study of magnetic phenomena, and in 1600 he
announced what may be regarded as his greatest discovery: The
terrestrial globe itself is a great magnet. Here, then, is the
explanation of the behaviour of the magnetized needle. The Earth
itself is a great magnet, having its poles near to the geographical
north and south poles. But a question at once suggests itself: “Since
similar poles repel one another, how is it that the north pole of a
magnet turns towards the north magnetic pole of the earth?” This
apparent difficulty is caused by a confusion in terms. If the Earth’s
north magnetic pole really has north magnetism, then the north-
pointing end of a magnet must be a south pole; and on the other
hand, if the north-pointing end of a magnet has north magnetism,
then the Earth’s north magnetic pole must be really a south pole. It is
a troublesome matter to settle, but it is now customary to regard the
Earth’s north magnetic pole as possessing south magnetism, and
the south magnetic pole as possessing north magnetism. In this way
the north-pointing pole of a magnet may be looked upon as a true
north pole, and the south-pointing pole as a true south pole.
Magnetic dip also is seen to be a natural result of the Earth’s
magnetic influence. Here in England, for instance, the north
magnetic pole is much nearer than the south magnetic pole, and
consequently its influence is the stronger. Therefore a magnetized
needle, if free to do so, dips downwards towards the north. At any
place where the south magnetic pole is the nearer the direction of
the dip of course is reversed. If placed immediately over either
magnetic pole the needle would take up a vertical position, and at
the magnetic equator it would not dip at all, for the influence of the
two magnetic poles would be equal. A little study of Fig. 14, which
represents a dipping needle at different parts of the earth, will make
this matter clearer. N and S represent the Earth’s north and south
magnetic poles, and the arrow heads are the north poles of the
needles.
Since the Earth is a
magnet, we should expect it to
be able to induce magnetism
in a bar of iron, just as our
artificial magnets do, and we
can show that this is actually
the case. If a steel poker is
held pointing to and dipping
down towards the north, and
struck sharply with a piece of
wood while in this position, it
Fig. 14.—Diagram to illustrate Magnetic acquires magnetic properties
Dip. which can be tested by means
of a small compass needle. It
is an interesting fact that iron pillars and railings which have been
standing for a long time in one position are found to be magnetized.
In the northern hemisphere the bases of upright iron pillars are north
poles, and their upper ends south poles, and in the southern
hemisphere the polarity is reversed.
The most valuable application of the magnetic needle is in the
compass. An ordinary pocket compass for inland use consists simply
of a single magnetized needle pivoted so as to swing freely over a
card on which are marked the thirty-two points of the compass.
Ships’ compasses are much more elaborate. As a rule a compound
needle is used, consisting of eight slender strips of steel, magnetized
separately, and suspended side by side. A compound needle of this
kind is very much more reliable than a single needle. The material of
which the card is made depends upon whether the illumination for
night work is to come from above or below. If the latter, the card must
be transparent, and it is often made of thin sheet mica; but if the light
comes from above, the card is made of some opaque material, such
as very stout paper. The needle and card are contained in a sort of
bowl made of copper. In order to keep this bowl in a horizontal
position, however the ship may be pitching and rolling, it is supported
on gimbals, which are two concentric rings attached to horizontal
pivots, and moving in axes at right angles to one another. Further
stability may be obtained by weighting the bottom of the bowl with
lead. There are also liquid compasses, in which the card is floated
on the surface of dilute alcohol, and many modern ships’ compasses
have their movements regulated by a gyrostat.
The large amount of iron and steel used in the construction of
modern vessels has a considerable effect upon the compass needle,
and unless the compass is protected from this influence its readings
are liable to serious errors. The most satisfactory way of giving this
protection is by placing on each side of the compass a large globe of
soft iron, twelve or more inches in diameter.
On account of the fact that the magnetic poles of the Earth do
not coincide with the geographical north and south poles, a compass
needle seldom points exactly north and south, and the angle
between the magnetic meridian and the geographical meridian is
called the declination. The discovery that the declination varies in
different parts of the world was made by Columbus in 1492. For
purposes of navigation it is obviously very important that the
declination at all points of the Earth’s surface should be known, and
special magnetic maps are prepared in which all places having the
same declination are joined by a line.
It is an interesting fact that the Earth’s magnetism is subject to
variation. The declination and the dip slowly change through long
periods of years, and there are also slight annual and even daily
variations.
At one time magnets were credited with extraordinary effects
upon the human body. Small doses of lodestone, ground to powder
and mixed with water, were supposed to prolong life, and
Paracelsus, a famous alchemist and physician, born in Switzerland
in 1493, believed in the potency of lodestone ointment for wounds
made with steel weapons. Baron Reichenbach, 1788–1860, believed
that he had discovered the existence of a peculiar physical force
closely connected with magnetism, and he gave this force the name
Od. It was supposed to exist everywhere, and, like magnetism, to
have two poles, positive and negative; the left side of the body being
od-positive, and the right side od-negative. Certain individuals,
known as “sensitives,” were said to be specially open to its influence.
These people stated that they saw strange flickering lights at the
poles of magnets, and that they experienced peculiar sensations
when a magnet was passed over them. Some of them indeed were
unable to sleep on the left side, because the north pole of the Earth,
being od-negative, had a bad effect on the od-negative left side. The
pretended revelations of these “sensitives” created a great stir at the
time, but now nobody believes in the existence of Od.
Professor Tyndall was once invited to a seance, with the object
of convincing him of the genuineness of spiritualism. He sat beside a
young lady who claimed to have spiritualistic powers, and his record
of his conversation with her is amusing. The Reichenbach craze was
in full swing at the time, and Tyndall asked if the lady could see any
of the weird lights supposed to be visible to “sensitives.”

“Medium.—Oh yes; but I see the light around all bodies.

I.—Even in perfect darkness?
Medium.—Yes; I see luminous atmospheres round all
people. The atmosphere which surrounds Mr. R. C. would fill this
room with light.
I.—You are aware of the effects ascribed by Baron
Reichenbach to magnets?
Medium.—Yes; but a magnet makes me terribly ill.
I.—Am I to understand that, if this room were perfectly dark,
you could tell whether it contained a magnet, without being
informed of the fact?
Medium.—I should know of its presence on entering the
room.
I.—How?
Medium.—I should be rendered instantly ill.
 I.—How do you feel to-day?
Medium.—Particularly well; I have not been so well for
months.
I.—Then, may I ask you whether there is, at the present
moment, a magnet in my possession?
The young lady looked at me, blushed, and stammered, ‘No;
I am not en rapport with you.’
I sat at her right hand, and a left-hand pocket, within six
inches of her person, contained a magnet.”

Tyndall adds, “Our host here deprecated discussion as it

‘exhausted the medium.’”
 CHAPTER VII
THE PRODUCTION OF MAGNETISM BY
ELECTRICITY

Fig. 15.—Diagram to illustrate Magnetic effect of

an Electric Current.

In the previous chapter attention was drawn to the fact that there are
many close parallels between electric and magnetic phenomena,
and in this chapter it will be shown that magnetism can be produced
by electricity. In the year 1819 Professor Oersted, of the University of
Copenhagen, discovered that a freely swinging magnetized needle,
such as a compass needle, was deflected by a current of electricity
flowing through a wire. In Fig. 15, A, a magnetic needle is shown at
rest in its usual north and south direction, and over it is held a copper
wire, also pointing north and south. A current of electricity is now
sent through the wire, and the needle is at once deflected, Fig. 15, B.
The direction of the current is indicated by an arrow, and the
direction in which the needle has moved is shown by the two small
arrows. If the direction of the current is reversed, the needle will be
deflected in the opposite direction. From this experiment we see that
the current has brought magnetic influences into play, or in other
words has produced magnetism. If iron filings are brought near the
wire while the current is flowing, they are at once attracted and cling
to the wire, but as soon as the current is stopped they drop off. This
shows us that the wire itself becomes a magnet during the passage
of the current, and that it loses its magnetism when the current
ceases to flow.
Further, it can be shown that
two freely moving parallel wires
conveying currents attract or
repel one another according to
the direction of the currents. If
both currents are flowing in the
same direction the wires attract
one another, but if the currents
flow in opposite directions the
wires repel each other. Fig. 16
shows the direction of the lines
of force of a wire conveying a
current and passed through a
horizontal piece of cardboard
covered with a thin layer of iron Fig. 16.—Magnetic Field round wire
conveying a Current.
filings; and from this figure it is
evident that the passage of the
current produces what we may call magnetic whirls round the wire.
A spiral of insulated wire through which a current is flowing
shows all the properties of a magnet, and if free to move it comes to
rest pointing north and south. It is attracted or repelled by an
ordinary magnet according to the pole presented to it and the
direction of the current, and two such spirals show mutual attraction
and repulsion. A spiral of this kind is called a solenoid, and in
addition to the properties already mentioned it has the peculiar
power of drawing or sucking into its interior a rod of iron. Solenoids
have various practical applications, and in later chapters we shall
refer to them again.
If several turns of cotton-covered wire are wound round an iron
rod, the passing of a current through the wire makes the rod into a
magnet (Plate II.b), but the magnetism disappears as soon as the
current ceases to flow. A magnet made by the passage of an electric
current is called an electro-magnet, and it has all the properties of
the magnets mentioned in the previous chapter. A bar of steel may
be magnetized in the same way, but unlike the iron rod it retains its
magnetism after the current is interrupted. This provides us with a
means of magnetizing a piece of steel much more strongly than is
possible by rubbing with another magnet. Steel magnets, which
retain their magnetism, are called permanent magnets, as
distinguished from electro-magnets in which soft iron is used, so that
their magnetism lasts only as long as the current flows.
Electro-magnets play an extremely important part in the
harnessing of electricity; in fact they are used in one form or another
in almost every kind of electrical mechanism. In later chapters many
of these uses will be described, and here we will mention only the
use of electro-magnets for lifting purposes. In large engineering
works powerful electro-magnets, suspended from some sort of
travelling crane, are most useful for picking up and carrying about
heavy masses of metal, such as large castings. No time is lost in
attaching the casting to the crane; the magnet picks it up directly the
current is switched on, and lets it go the instant the current is
stopped. In any large steel works the amount of scrap material
produced is astonishingly great, hundreds of tons of turnings and
similar scrap accumulating in a very short time. A huge mound of
turnings is awkward to deal with by ordinary manual labour, but a
combination of electro-magnet and crane solves the difficulty
completely, lifting and loading the scrap into carts or trucks at
considerable speed, and without requiring much attention.
Some time ago a disastrous fire occurred at an engineering
works in the Midlands, the place being almost entirely burnt out.
Amongst the débris was, of course, a large amount of metal, and as
this was too valuable to be wasted, an electro-magnet was set to
work on the wreckage. The larger pieces of metal were picked up in
the ordinary way, and then the remaining rubbish was shovelled
against the face of the magnet, which held on to the metal but
dropped everything else, and in this way some tons of metal were
recovered.
The effect produced upon a magnetized needle by a current of
electricity affords a simple means of detecting the existence of such
a current. An ordinary pocket compass can be made to show the
presence of a moderate current, but for the detection of extremely
small currents a much more sensitive apparatus is employed. This is
called a galvanometer, and in its simplest form it consists essentially
of a delicately poised magnetic needle placed in the middle of a coil
of several turns of wire. The current thus passes many times round
the needle, and this has the effect of greatly increasing the deflection
of the needle, and hence the sensitiveness of the instrument.
Although such an arrangement is generally called a galvanometer, it
is really a galvanoscope, for it does not measure the current but only
shows its presence.
We have seen that electro-motive force is measured in volts, and
that the definition of a volt is that electro-motive force which will
cause a current of one ampere to flow through a conductor having a
resistance of one ohm. If we make a galvanometer with a long coil of
very thin wire having a high resistance, the amount of current that
will flow through it will be proportionate to the electro-motive force.
Such a galvanometer, fitted with a carefully graduated scale, in this
way will indicate the number of volts, and it is called a voltmeter. If
we have a galvanometer with a short coil of very thick wire, the
resistance put in the way of the current is so small that it may be left
out of account, and by means of a graduated scale the number of
amperes may be shown; such an instrument being called an
amperemeter, or ammeter.
For making exact measurements of electric currents the
instruments just described are not suitable, as they are not
sufficiently accurate; but their working shows the principle upon
which currents are measured. The actual instruments used in
electrical engineering and in scientific work are unfortunately too
complicated to be described here.
 CHAPTER VIII
THE INDUCTION COIL

The voltaic cell and the accumulator provide us with currents of

electricity of considerable volume, but at low pressure or voltage. For
many purposes, however, we require a comparatively small amount
of current at very high pressure, and in such cases we use an
apparatus called the induction coil. Just as an electrified body and a
magnet will induce electrification and magnetism respectively, so a
current of electricity will induce another current; and an induction coil
is simply an arrangement by which a current in one coil of wire is
made to induce a current in another coil.
Suppose we have two coils of wire placed close together, one
connected to a battery of voltaic cells, with some arrangement for
starting and stopping the current suddenly, and the other to a
galvanometer. As soon as we send the current through the first coil,
the needle of the galvanometer moves, showing that there is a
current flowing through the second coil; but the needle quickly
comes back to its original position, showing that this current was only
momentary. So long as we keep the current flowing through the first
coil the galvanometer shows no further movement, but as soon as
we stop the current the needle again shows by its movements that
another momentary current has been produced in the second coil.
This experiment shows us that a current induces another current
only at the instant it is started or stopped, or, as we say, at the
instant of making or breaking the circuit.
The coil through which we send the battery current is called the
“primary coil,” and the one in which a current is induced is called the
“secondary coil.” The two momentary currents in the secondary coil
do not both flow in the same direction. The current induced on
making the circuit flows in a direction opposite to that of the current
in the primary coil; and the current induced on breaking the circuit
flows in the same direction as that in the primary coil. If the two coils
are exactly alike, the induced current will have the same voltage as
the primary current; but if the secondary coil has twice as many turns
of wire as the primary coil, the induced current will have twice the
voltage of the primary current. In this way, by multiplying the turns of
wire in the secondary coil, we can go on increasing the voltage of the
induced current, and this is the principle upon which the induction
coil works.
We may now describe the construction of such a coil. The
primary coil is made of a few turns of thick copper wire carefully
insulated, and inside it is placed a core consisting of a bundle of
separate wires of soft iron. Upon this coil, but carefully insulated from
it, is wound the secondary coil, consisting of a great number of turns
of very fine wire. In large induction coils the secondary coil has
thousands of times as many turns as the primary, and the wire
forming it may be more than a hundred miles in length. The ends of
the secondary coil are brought to terminals so that they can be
connected up to any apparatus as desired.
In order that the induced currents
shall follow each other in quick
succession, some means of rapidly
making and breaking the circuit is
required, and this is provided by an
automatic contact breaker. It consists
of a small piece of soft iron, A, Fig.
17, fixed to a spring, B, having a
platinum tip at C. The adjustable
screw, D, also has a platinum tip, E.
Normally the two platinum tips are
just touching one another, and Fig. 17.—Diagram showing
matters are arranged so that their working of Contact-Breaker for
contact completes the circuit. When Induction Coil.
the apparatus is connected to a
suitable battery a current flows through the primary coil, and the iron