A Medical Intern's Christmas

As we close this week on Work & Life Balance here at Scrub Notes, we are thankful for our guest authors who shed light on some of the issues affecting doctors and patients today that are not "pathophysiologic" in origin. We have heard about how to maintain balance as a medical student, for as any provider can tell you, if you are not in balance, how can you help restore order to your patient's life, especially one that has just been thrown a curveball with a new diagnosis? At times, we fail to maintain that balance, either because we are unable to manage the stress of our profession, or we fail to live up to the high academic standards we have set for ourselves. How medical students manage stress is a key skill that is not often directly addressed within medical schools. These skills often end up being more important to a successful patient interaction than all the pathology and physiology trivia one learns, whether dealing with patients with alternative backgrounds, or just learning how to handle the stress of the first night on-call.

As we end the week, many medical students, interns, and residents will not be celebrating the holidays with their families. Instead, they will be on call, or night shifts, or just long schedules, taking care of patients. For life and death, sickness and health, do not take holidays, and nor should our compassion for taking care of those who are in trying times. I recall working last year on Christmas Eve at the VA on an inpatient medicine rotation. Trust me, the VA hospital is probably close to the last place you want to be almost any time of the year, let alone Christmas. It is strange to say that in some ways. For the most part, the patients, staff, and doctors are all nice and well-intentioned. However, the VA simply is not home, and everyone should be home for the holidays, patients and providers alike.

But, as said above, illness does not care for such sentimental notions, so we must make do. The staff had put up a Christmas tree, and many patients' families came by with gifts or just to spend time with their loved ones. For that's what we as human beings do: we adapt. We make the best of what we have. We pull together and create a sense of family and home in even the most trying of situations. A diagnosis of cancer or heart failure or AIDS is not tantamount to a diagnosis of ill spirit. Although the patient may not see the promise that their life still holds, it is up to the caregiver to gently nudge them towards making the most of their time, whether they have days, months, or decades left. To do so, we must put aside our selves and our desires and truly empathize with the patient.

To be honest, going into the hospital that day, I had no intention of empathizing with anyone. It was a pity party: who was empathizing with me, the woeful intern stuck in the hospital when everyone else was at home relaxing or making merry? Yes, the cynicism of intern year had set in. But as the day progressed, I realized some of the ideas described above. If anything, it was one of the better days of the month - there truly was a festive spirit in the air. Like Scrooge, my cold heart mellowed. What would I really have done with the day off? Likely not much, nor did I have any grand plans. Instead, I ended up spending the day casually rounding (no conferences or discharges to worry / stress me), meeting the often-mentioned-but-never-seen almost mythical family members. The patients were happier around loved ones, sharing stories and laughs, letting me peak into their actual lives. We could all put aside worrying about lab results and planned procedures, and simply enjoy the presence of being together.

And ultimately, that is what medicine should be about. It should be about providing a sense of support for those in a time of weakness, whether that be mental or physical. Being the surrogate family when one's own family is not around. Throughout that day, as the clock slowly moved forward to my own departure from the hospital, I was reminded of the transient nature of my presence there. Sure, I could bemoan my lot, stuck there, but hey, at least I got to go home at some point. None of the patients were leaving that day, and many would not leave for many more days. Whether Christmas Eve or any other day, our role should be the same: providing a supportive environment to help the patient heal themselves,  both physically and mentally/spiritually, for a true physician should care for the totality of the patient, not merely their lab values or functional status. During the holidays, our goal as providers should be to provide a holiday worth remembering for our patients, which coincidentally should become a holiday we cherish ourselves.

Happy Holidays from Scrub Notes! See you next year!

What Is The First Night On-Call Like?

This common question is answered by an internal medicine intern's experiences on her first night. The text below is a repost of the entry "First Night On-Call", first published on the blog Life In A Q4 World.

October 7, 2010 - In our residency program, like in most others in internal medicine around the country, life revolves around a “q4” call schedule; that is, overnight 30-hour “on call” shifts every 4th night. As an intern, a first-year resident, our “on call” day starts at 8 AM, and we stay overnight in the hospital admitting patients and cross-covering for the other teams who aren’t in the hospital overnight until 2 PM the next day (i.e. 30 hours.) If we’re lucky, we can sleep for an hour or two, but usually cross-covering for 30-40 patients means getting paged constantly about every fever, request for sleeping pill or pain medication, or anything else that goes wrong in the middle of the night, and the little sleep you do get is interrupted and unsatisfying (not to mention the fact that we share a call room with the other intern on call who’s concurrently getting paged about her own separate patients.)

Anyways, the first night on call is sort of a rite of passage for interns, i.e. it will suck, but we survive it, and once that’s over with, the next 6 calls until the end of our one-month rotation (for a total of 7 calls per month) are usually not as bad, or at least not as shocking to the system. My first night on call as an intern was actually in the intensive care unit (ICU), which is generally a bit more stressful than the internal medicine wards, because the patients who are admitted to the ICU (the “unit”) are sicker than those admitted to the wards (the “floor”.) So while I was expecting that first night on call to be overwhelming, stressful, and exhausting, I was not expecting the very first patient I would admit that night to be one of the strangest and saddest cases in our residency program’s history.

She was a 23-year-old girl who came to the ER for shortness of breath, not an uncommon complaint. Her symptoms were way out of proportion to her physical exam or chest X-ray, which looked not quite normal but not like a horrible pneumonia or collapsed lung either. No matter how much oxygen we gave her through a mask, she continued to have more and more trouble breathing, and the oxygen saturation level in her blood continued to get lower and lower—not a good sign. By the time the ER doctors called us, the ICU team, about her, they already had the intubation tray set up and were planning to intubate her (put a tube down her airway so that she could be mechanically ventilated) in the ER. Given the rapid progression of her symptoms, they were able to get very little history from her, but it seemed that she had been completely healthy previously, and had not recently had any cough, fevers, or sick contacts. We gave her everything we could think of—a slew of antibiotics, antifungals, and antivirals to treat her for possible pneumonia or an early-in-the-season H1N1-type flu, all to no avail. We got a CT of her chest, thinking she may have had a massive pulmonary embolism, but that was not the case either, although like the chest X-ray, the CT wasn’t completely normal—it showed some collections of junk in her lungs, sort of like a pneumonia but not quite consistent with the classic pneumonia picture. In the ICU, she continued to deteriorate right before our eyes, her heart and kidneys started failing so that her blood pressure continued to be dangerously low even with maximum vasopressor medications and her kidneys had stopped making urine. Her husband and family members who were there with her could not give any more information about what had happened—she had been completely fine earlier that morning. The only other finding we got from examining her was that she had two cotton balls on her buttocks, covering what looked like recent injection sites. Neither her husband nor her family members could tell us what those were from—she had a couple tattoos on her legs but not recently and not on her butt.

Finally, after tracking down several of her friends on the phone, it was confirmed that she had gotten silicone injections in both her buttocks earlier that afternoon. At that point, we realized what had happened, or at least had a working theory—the injections had gone into her blood vessels and migrated into her lungs, basically turning her lungs into a solid chunk of rubber. This phenomenon apparently had been reported before, though extremely rarely of course, and was known in the literature as “silicone embolism syndrome”, which we spent the next 2 hours on Google trying to find case reports for. We looked for reports on how other hospitals had treated cases of suspected silicone embolism, only to find that basically nothing worked—it was just supportive care and waiting to see if the lungs would recover on their own, which they usually didn’t. One case report said steroids seemed to help, so we gave her a huge dose, but to no avail. She continued to worsen, and finally as the renal team was starting emergent hemodialysis on her to try to save her failing kidneys, her heart stopped beating and could not be restarted despite over an hour of CPR. She was 23 years old, had a husband and two small children, and had been completely healthy 12 hours ago before she decided to have cosmetic silicone injections in her butt.

The other wrinkle in the story was that the injections were performed illegally by an unlicensed doctor from Mexico who had been traveling around the LA area with his two Mexican assistants advertising these cosmetic butt injections. They had just been released from jail a few weeks prior, and had been posting flyers in the area, surreptitiously advertising these services for a mere $800 per injection. We were informed of this around 3 AM when a team of at least five members of the LAPD came in and started questioning us, informing us they were searching for this doctor and his two assistants, who were being charged with fraud and what it seemed like would soon be involuntary manslaughter as well. At that time we were all too stressed and exhausted to fully take in the horrible irony and moral injustice of it all—paying over $800 to die of complications from a cosmetic procedure, something that seemed almost too typical to witness in Los Angeles, especially within my first two months of moving here from Chicago. As I was writing the death summary for the patient the next day, thinking about how it would probably show up in court someday, the sadness and unfairness of it all did start to sink in some more, but I wasn’t as devastated or fraught with nightmares as I had feared I’d be. My first reaction was actually to email the story to all of my friends so that they would never get butt injections. Maybe medical school had prepared me better than I thought for psychological and emotional strains of residency.

Check out the blog Life In A Q4 World for more insights from a resident in a categorical internal medicine program in Southern California. Share your passion by publishing your writing on Scrub Notes today!

Gender Identity and Medicine, Or Why I Love Queer

This submission is from guest author Amanda Davis, an MS2 at Thomas Jefferson University, Philadelphia, PA

I almost took it for granted. “Do you have genderqueer patients?” I asked the physician. There
were murmurs around the room, not everyone knew what I meant, but the physician did. He
was talking about transhealth to a room full of healthcare professional students who had elected
to be there.

I didn’t take it for granted though. I asked the question because I already knew the answer was
probably yes. I asked because I knew many people would not know what “genderqueer” meant,
or had even thought about the spectrum of gender. I asked because I wanted to expose them. I
also asked because I wanted to know what the evidence shows on the safety of going on and off
hormones.

“I suspect not everyone here knows what genderqueer means,” the physician said. Some shook
their heads. It was only about two years ago that I was really introduced to the term myself.
For those who have not been exposed to this lovely idea, here is a definition from wikipedia1:

Genderqueer: catch-all term for gender identity other than man and woman. People
who identify as genderqueer may think of themselves as being both man and woman, as being
neither man nor woman, or as falling completely outside the gender binary. They may express a
combination of masculinity and femininity, one or the other, or neither.

For kicks, here is the wiki definition of queer2:
Queer is an umbrella term for minority sexual orientations and gender identities that are
not heterosexual, heteronormative or gender-binary.

I get all warm and fuzzy reading both these definitions. How lucky am I to be a part of a
community that has exposed me to these ideas, spectrums, and wonderful people?

I reflected on the evolution of my understanding of gender. I came out as bi when I was 15.
I knew one transperson in high school. I understood gender as a binary, but for a white kid
growing up in a republican suburb, I was progressive. You could identify as a man or a woman
and be attracted to men or women or both. Gender identity and sexual orientation were
separate. I was not sexually interested in transpeople, although I had thought about it. I liked
girls or I liked boys. I supported people whose bodies did not match their minds, but I did not
want to make out with them.

Fast forward to college – why do we have words like lesbian and gay for those who might
otherwise be called “homosexual,” but only bisexual for people who are attracted to more than
one gender? That emphasizes the sexual, and let’s not even talk about all the biphobia (actually
yes, let’s talk about it). I prefer to be “unidentified.” It’s about the person, not the genitals
(although, let’s be honest, genitals are fun).

Post-college: Oh yes, finally a word that makes sense to me: queer. My queer is different
from your queer. If I have to identify myself, and our culture loves labels, queer is what I am.

Sexuality is fluid. There are no absolutes. Dykes, queers, lezzies, butches, femmes, androgynous
bois or grrls, in betweenie weenies. What’s your type of girl? I just like girls, and sometimes
boys, and definitely bois, and boys who used to be girls (yeah, I got over that idea I had in high
school of not wanting to make out with transpeople).

The idea of anything more than the gender binary makes some people’s heads explode with fear
and rage. I find that so sad. Sad for all the trannies, queers and homos that cross their paths
and encounter hate. But also sad for those haters who will never know the joys of a whole range
of genders.

I only see beauty in the gender and sexuality spectrums. Beauty, sensuality, art, intrigue,
satisfaction, love. Anything else would just be… boring.


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How To Deal With Failure In Medicine

Failure is a common occurrence in medicine, but one that is far too rarely addressed. In her blog Wellness Rounds, pediatric surgeon and professor Mary Brandt, M.D., addresses the topic in response to a younger colleague's question. This is a repost of the entry "Failure".

It is part of our profession that we will never stop trying to be perfect and – just as true – that we will always fall short. As a student, it tends to be about the tests you are taking and the feeling that you will never study enough. As a resident, it’s the feeling that you don’t know enough to make the decisions you are being asked to make. As a practicing physician, you will at times stay awake at night worrying about your decisions, even when you know you did the best you could. All of this sounds like a huge downside to the profession we’ve chosen, but it’s actually a blessing. One of the core personality traits of physicians is that they care. In a way, all of the stress about not doing well enough happens only because you have empathy and compassion for your patients.

Although it’s hard to believe at the beginning, with time you will realize that the feeling of having “failed” is actually a gift. You’ll discover that “mistakes” and, more importantly, “near misses” become your most valuable teachers. What’s important is that you grasp the opportunity to learn from falling short, rather than beating yourself up. “Failing” at a task (or test) is different than being a “failure.” When you have moments you feel you could have done better, use it as motivation to study a little more, go back to the textbook, look up one more article, or review all the facts again. William Osler, in his famous book to medical students (Osler’s Aequanimitas) talked about keeping a journal of mistakes: “Begin early to make a threefold category – clear cases, doubtful cases, mistakes. And learn to play the game fair, no self-deception, no shrinking from the truth… It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way can you gain wisdom with experience. “

So, to answer your question about how to deal with the downfalls along the way - Start by revisiting your motivation. Remember why you started down this path in the first place. If you are trying your best to do the right thing, and are humble about the fact that you are human (and will therefore fall short) you can end every day with satisfaction and a sense of accomplishment. That being said, make sure that you work with focus – that when you study or work it is with dedication to the patients and families who are trusting you with some of the most precious decisions of their life. When you fall short, use it as motivation to learn. But, in this process, make sure you are taking care of yourself by taking time for good nutrition, exercise, social interactions and spiritual growth. The worst thing you can do when you feel inadequate is to just work more and more. This leads inevitably to compassion fatigue, which makes you less effective (and will make you suffer). Compassion fatigue is a common diagnosis for care-givers; it happens to every medical student, resident or physician at some point in time. Just like any other diagnosis, the next step is treatment. In a nutshell, the treatment is self-care.


Dr. Mary Brandt is a Professor of Surgery, Pediatrics and Medical Ethics at Baylor College of Medicine and Texas Children's Hospital. For more information and links to resources about self-care for physicians, visit Dr. Brandt's site Wellness Rounds.


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How Med Students Can Maintain Balance

This post kicks off "Work-Life Balance Week" here on Scrub Notes. For the next five days starting today, we will be publishing posts relating to maintaining balance in medical school as well as staying true to yourself. Alvina Lopez starts the series by describing tips to remain grounded as a medical student. 

Med students might as well kiss their sanity goodbye at the beginning of each term before they plunge into the work load that lies ahead. With all of the rigorous day-to-day studies that go on, the anxiety of trying to balance internship schedules and jobs alongside those studies, and the extra stress of examinations being thrown into the mix, med students can easily feel overwhelmed and pushed to the brink of mental exhaustion. Luckily, there are some relatively simple ways that med students can take time during each term to relax and stay sane.

Laugh on a regular basis.
It may sound strange, but laughing on a regular basis can do wonders for your stress. Try to find humor in your everyday situations, or even in a daily dose of humorous television shows or movies. Laughing often can cause you to have a brighter outlook on life instead of one filled with anxiety and a sense of doom and gloom. This is because laughter has been proven to dull pain, even pains caused by tension and mental pressure, according to WebMD. This positive attitude can also have the added benefit of drawing your loved ones closer, as people tend to like being around those who are happy rather than those who are frazzled or constantly upset. This tightened social network will help you to get through some of the tougher periods of your time in med school.

Bond with your fellow med school peers.
Feeling alone in your struggles can exacerbate stress. Med school can be an utterly isolating time because you are typically buried in your work. However, it is important to bond with some of your fellow med school peers because this will help to remind you that you are not the only person going through the stress of seemingly endless research projects, reading assignments, and tough in-class problems. While your friends who are not in med school will certainly be open to listening to your rants about examinations and clinicals, having someone who truly understands what you are enduring can be immensely more beneficial. Bonding with those who are also in med school will allow you to openly vent and even exchange advice on how to deal with specific issues, as well as allow you and your med school peers to feel a sense of camaraderie that will strengthen your will to get through the term.

Take breaks from studying to recharge.
Though you may feel like you have no time to do anything other than go to class and study, you still need to make some time during your busy week to take a break. Breaks are essential in preventing you from burning out before the term ends. In fact, your brain needs regularly breaks from studying in order to retain information efficiently. Take some time during the weekend to go shopping, watch a movie, see some friends, or even to just take a long stroll around the park. During the week days, you can make dinner time a time to relax, so instead of plowing through a bowl of macaroni and cheese with your textbook plopped in your lap, make something more nutritious and rewarding and enjoy your meal without any distractions. You will return to your studies afterwards feeling refreshed and ready to take on more. If you feel low in energy in the long run, perhaps your program of study is not the right one for you. If you looking to balance work and school, consider online bsn programs as an alternative to a traditional education. You might find yourself better suited to distance learning instead of a traditional classroom.

Finally, consider doing something to help you physically relax.
The condition of your body can greatly influence the state of your mind, so consider relaxing your body in order to relax your mind and de-stress. Something as simple as regular exercise can help to lift your spirits. The increased blood flow and heart rate, coupled with the endorphins that are released during sustained activity, will help to melt the stress away. Whatever your exercise activity of choice is, remember to stick to it throughout your term to help yourself reduce stress during some challenging moments in your academic career. For those who need even more relaxation, consider taking a few yoga classes or meditating. These activities are known to reduce stress, which would help any med student to stay sane and focused.

This guest post is contributed by Alvina Lopez, who writes on the topics of accredited online schools. She welcomes your comments at alvina.lopez@gmail.com. Share your passion by publishing your writing on Scrub Notes today!

SOAP Notes For The Pediatric Patient: A How-To Guide

The original post on how to write a SOAP note for a patient was intended to be a definitive post on how to write this daily note that every med student / intern / resident and even attending comes to know and love (haha, or hate). However, after receiving feedback on the initial post and going through more rotations myself, the need for specialty-specific SOAP note templates became apparent. Following the recent on post on how to write a SOAP note for a surgical patient, this post describes the basic format and outline of the note and what some basic options are for what exactly to describe in the note. For example, the mnemonic OLD CHARTS helps remind you of what to put for the history of a particular symptom, such as "cough."

Once again, the basic format for a note is the SOAP note. SOAP stands for:

Subjective: any information you receive from the patient (history of present illness, past medical history, etc)

Objective: any data, whether in the form of a physical finding during your exam, or lab results

Assessment: diagnoses derived from the history and objective data

Plan: what you intend to do about the diagnoses from your assessment

For pediatricians though, many other concerns come into play, especially depending on the precise age of the patient. The younger they are, the more this matters. Think about it: a 17 day old's note clearly will contain different pertinent information as compared to the SOAP note for an adolescent 17 year old! A medical student should share in this contextual-based note in order to excel on the service. The ideal student on pediatrics should be able to document the patient's complaints and exam findings succinctly, assess them, make a plan for treatment of any issues found, and anticipate and prevent other common problems. 

The pediatric note starts like any other note. Date and time the note, then write down your position and title of the document, such as "MS3 Purple Pediatrics Progress Note".  Next, note the day of admission. If the patient was previously started on antibiotics, it is also helpful to denote what day of antibiotics they are on. 

For the SUBJECTIVE portion of the note, you want to include any complaints the patient might have. If the patient is recovering normally, be sure to ask about regular body functions, such as voiding, passing flatus (gas), tolerating PO (oral food), and ambulation (walking) and mention these briefly in your note. For any symptom like a cough or rash, use the OLDCHARTS mnemonic from "How To Write a SOAP Note" to further describe the complaint.


A few age-specific notes: for pre-verbal patients (neonates up to two year olds), do not overlook the subjective! Even though the patient cannot express themselves like an older child or adult, you can still glean information from the parents and nursing staff as to whether the child has been fussy or sleepier than expected or any other change in their behavior. For adolescents, keep the HEADSS assessment in the back of your mind. HEADSS stands for:

Home - Inquire about the patient's support system at his place of residence and actual living environment. 

Education (or Employment) / Eating - Ask about the child's educational performance. If employed, assess how they find their job and their job performance. E can also cover eating; specifically ask about how many meals the child ingests and where their calories come from. Also consider any weight changes.

Activities - Discuss what the patient enjoys doing and who they share these pursuits with.

Drugs (including alcohol and tobacco) - Ask directly about drug use, both licit (caffeine) and illicit (alcohol, marijuana, cocaine, etc). If using, ask about frequency, amount, and other characteristics.

Sex - Inquire if patient is sexually active. If so, discuss protection, STD prevention, and who they feel comfortable discussing sexual issues with.

Suicidality (including general mood assessment) - Assess the patient's mood and whether they are a risk to themselves or others.

You may consider an additional S, Strengths, to end the discussion on a positive note.

For the OBJECTIVE portion, the note should include the vital signs, I/Os including from drains, and physical exam findings. The vital signs should note the maximum temperature and at what time it occurred. If above 38 deg C or 100.4 deg F, note what was done to remedy the fever (if anything). This number is very specific in pediatric medicine as opposed to adult medicine. A temperature of 100.5 F is a fever, period. 


For the I/Os, note the rate of IVF administration and the fluid being administered. For neonates, this is very very important. Make sure to note not only the total ins and outs, but also the caloric intake in kcal/kg/day, the fluid intake rate at cc/kg/day, and the urine output in cc/kg/hr. Because of the rapid changes right after birth as the baby adjusts to life outside the womb, sudden changes in these values can suggest very severe problems, so it is essential to pay close attention to these values. 

The physical exam should include the head-ears-eyes-nose-throat (HEENT), pulmonary, cardiovascular, abdominal, wound, and extremity exams. A normal exam may read:

GEN - A&O x 3 (alert and oriented to person, place, time), activity level  

HEAD - NC/AT (normocephalic / atraumatic)  

EYES - RR+, EOMI (red reflex present, extraocular movements intact)  

EARS - TMs intact (tympanic membranes intact) 

NOSE - nares clear 

THROAT - OP clear (oropharynx clear) 

NECK - supple, no LAD (no lymphadenopathy) 

PULM - CTAB, no C/W/R (clear to auscultation bilaterally, no crackles, wheezes, or rhonchi) 

CV - RRR, no M/R/G, 2+ pulses (regular rate and rhythm, no murmurs, rubs, or gallops, good pulses) 

ABD - +BS, S/NT/ND (positive bowel sounds, soft, nontender, nondistended)

EXT - no c/c/e (no clubbing, cyanosis, or edema) 

SKIN - no bruising, no rash 

Always have a concern for child abuse in the back of your mind, especially if you encounter physical findings that do not match the mechanism of injury given in the history. Any pediatric review book can go over typical physical and radiographic findings in cases of abuse. However, also be aware of physical exam differences in pediatrics, especially between the ages of zero to two, as certain body parts are still developing / regressing (ex. closure of fontanelles, changing reflexes, ossification of cartilage)

For the ASSESSMENT portion, the note should give a one sentence summary of the patient and why they are in the hospital. For newborns, include details about their birth, especially if they had a complicated pregnancy or delivery. For patients with complications, consider adding a clause or another sentence describing the reason for an extended hospital stay. 

For the PLAN portion, the note should address any issues raised in the subjective, objective, or assessment sections. Address each issue specifically. If unsure, refer to a book like Nelson Essentials of Pediatrics for management. Another good resource would be First Aid for the Pediatrics Clerkship. For every patient, include a plan for their fluids/diet and disposition (how are they getting home). 

If you follow this basic structure, you should do just fine as far as SOAP note writing on pediatrics goes. If you are in a general pediatrics ward, this should be sufficient. However, if you are on a team that addresses one particular age group, especially neonates and adolescents, take the time to look up more detailed SOAP note structures in your textbooks and review books (such as First Aid or Case Files For Pediatrics). These and other books for the pediatrics shelf exam will help guide you in developing clinical acumen when it comes to treating neonates, children, and adolescents. The more questions you ask, the more your star will shine, and more importantly, the better care you will take of *your* patient!

Updated 2015-12-20

How To Write A SOAP Note For A Surgical Patient

One of the most popular posts on this site regards how to write a SOAP note for a patient. The post describes the basic format and outline of the note and what some basic options are for what exactly to describe in the note. For example, the mnemonic OLD CHARTS helps remind you of what to put for the history of a particular symptom, such as "cough."

However, as you rotate through the wards, you realize that each service has its own way of writing a patient note. Knowing the particular format of a note by service is helpful. For example, for inputs/outputs on neonatology, you want to mention the volume per gram weight of the baby, but this measurement is nonsensical on a general surgery service. Therefore, this post aims to describe how to write a SOAP note for a surgical patient. Future posts will cover notes for patients on core services, such as medicine, pediatrics, and OB/GYN. 


As before, the basic format for a note is the SOAP note. SOAP stands for:

Subjective: any information you receive from the patient (history of present illness, past medical history, etc)

Objective: any data, whether in the form of a physical finding during your exam, or lab results

Assessment: diagnoses derived from the history and objective data

Plan: what you intend to do about the diagnoses from your assessment

For surgeons though, rounding is brief and sometimes treated as a loss of time from the OR. An attending surgeon can function just fine with that attitude, but a medical student should not share it in order to excel on the service. The ideal student on surgery should be able to document the patient's complaints and exam findings succinctly, assess them, make a plan for treatment of any issues found, and anticipate and prevent other common problems.

The surgery note starts like any other note. Date and time the note, then write down your position and title of the document, such as "MS3 Purple Surgery Progress Note". Next, note the postoperative day, or POD. If the patient just returned from surgery, denote that day as "POD #0". If the patient was previously started on antibiotics, it is also helpful to denote what day of antibiotics they are on.

For the SUBJECTIVE portion of the note, you want to include any complaints the patient might have. If the patient is recovering normally, be sure to ask about return of regular body functions, such as voiding, passing flatus (gas), tolerating PO (oral food), and ambulation (walking) and mention these briefly in your note.

For any symptom like a cough or rash, use the OLDCHARTS mnemonic from "How To Write a SOAP Note" to further describe the complaint.  Using a book like Surgical Recall, make yourself aware of the major problems in a post-operative patient (typically, the patients you would be writing notes on). In particular, be aware of fevers in the post-op patient, a very common and potentially very dangerous finding. A simple mnemonic to keep in mind is the 5 Ws for causes of postoperative fever:

WIND - stands for atelectasis, the most common cause of fever on POD #1

WATER - stands for UTI, the most common cause of fever on POD #3

WOUND - stands for wound infection, the most common cause of fever on POD #5

WALK - stands for DVT, the most common cause of fever on POD #7

WEIRD - stands for drug-induced fever or abscess, the most common cause of fever on POD #9 and beyond

For the OBJECTIVE portion, the note should include the vital signs, I/Os including from drains, and physical exam findings. The vital signs should note the maximum temperature and at what time it occurred. If above 38 deg C or 101 deg F, note what was done to remedy the fever (if anything). For the I/Os, note the rate of IVF administration and the fluid being administered. Also note the location, amount drained, and quality (serosanguinous, bloody, purulent, etc) of any Jackson-Pratt or JP drains here. The physical exam can be brief, but should include the pulmonary, cardiovascular, abdominal, wound, and extremity exams. A normal exam may read:

GEN - A&O x 3 (alert and oriented to person, place, time)

PULM - CTAB, no C/W/R (clear to auscultation bilaterally, no crackles, wheezes, or rhonchi) 

CV - RRR, no M/R/G, 2+ pulses (regular rate and rhythm, no murmurs, rubs, or gallops, good pulses) 

ABD - +BS, S/NT/ND (positive bowel sounds, soft, nontender, nondistended)

WOUND - c/d/i (clean, dry, intact) 

 EXT - no c/c/e (no clubbing, cyanosis, or edema)

  

For the ASSESSMENT portion, the note should give a one sentence summary of the patient and why they are in the hospital. For example, "35yo female s/p lap chole stable on POD#2." For patients with complications, consider adding a clause or another sentence describing the reason for an extended postoperative stay. For a patient with fever, you might say, "Patient developed fever on POD#5, subsequently found to have bilat DVT by duplex US." 


For the PLAN portion, the note should address any issues raised in the subjective, objective, or assessment sections. Address each issue specifically. If unsure, refer to a book like Lawrence's Essentials of General Surgery for management. For every patient, include a plan for their fluids/diet, pain control, prophylaxis, and disposition (how are they getting home). For prophylaxis, the major issues to consider are DVT prevention and peptic ulcer prevention. For deep vein thrombosis, thromboembolic deterrent (TED) hose and/or sequential compression devices (SCDs) should suffice. For ulcers, try any proton pump inhibitor (PPI) such as pantoprazole (aka Protonix). 


If you follow this basic structure, you should do just fine as far as SOAP note writing on surgery goes. The key to a surgery SOAP note is simply this: be concise but precise. Or, another way to remember it, is: Just the facts, med student. Just the facts. Good luck!

Updated 2015-12-20

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