cheatsheet

# goose ca staging

Cancer of the Esophagus and Esophagogastric Junction: An Eighth Edition Staging Primer - Journal of Thoracic OncologyEsophagus: Structure

# goose layers

startpage

mucosa consists of the:
– epithelium,
– underlying lamina propria (lymphatic capillaries, blood capilaries, and loose connective tissue)
– underlying muscularis mucosa. (The muscularis mucosa is a thin, double layer of smooth muscle, more substantial in the lower part of the oesophagus.)

The submucosa is highly vascular, and contains loose connective tissue. It contains oesophageal glands, that secrete mucus to help ease the passage of swallowed food.

The muscularis externa layer in the top third of the oesophagus contains skeletal muscle, in the middle, it is a mixture of smooth and skeletal muscle, and in the bottom third it is entirely smooth. This photograph shows an example of the muscle layers from the upper oesophagus.

#growth hormone

http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/hypopit/gh.html

# GI anatomy

http://www.vivo.colostate.edu/hbooks/pathphys/digestion/basics/peritoneum.html#:~:text=The%20glistening%20membrane%20inside%20the,of%20fat%20are%20clearly%20visible.&text=The%20greater%20omentum%20is%20given,then%20converges%20into%20parietal%20peritoneum.

Module - Peritoneal Cavity Development

Surgical Anatomy of the Esophageal Hiatus | Abdominal Key

 

Anatomy and physiology of the stomach - Canadian Cancer Society

Structure Stomach Clipart Stomach Anatomy Human Digestive ...

Omental bursa: Anatomy, contents and clinical aspects | Kenhub

 

Greater sac - Wikipedia

Cardiovascular and Ventilatory Consequences of Laparoscopic Surgery |  Circulation

Hernia Laparoscopic Surgery & Repair - Procedure, Benefits and Recovery |  University Hospitals Cleveland Medical Center | University Hospitals

# To do for lists:

(early morning) Review plans/signout for each patient

Print the list

List: Circle-Vitals/labs

Documentation: Events

RR: Imaging

RR: Micro

RR, recent: Any special labs

 

Mar-PRNs

MAR – Standing Meds

MAR – Drips/fluids

 

Flowsheet: IO breakdowns

 

 

Secondary survey = head to toe xm:

Head eye mouth

Push on face

Spine

Neuro xm

Turn patient and look at back

CT non-con of head

Thorax + contrast, (look for aneurysms, ligamentous aterteriosum )

# Panscan

CT Abd Pelivs

CT neck – contrast (+ if seatbelt sign, neuro signs, jumpted facets, lefot 3 (face fracture)

If negative, CT head

 

# neck anatomy

Lymph nodes potentially amenable to sampling by EBUS, TBNA, or ...

Brachial plexus

Hernias (anatomy)

Abd arteries

Lower leg arteries

 

# layers of tissue abdomen

image

#GCS

  • Eyes: 4eyes
  • Motor think Engine (V6)

#ABX

 

 

Antibiotic Sensitivity Overview

# Spinal cord

# DERMATOMES Myotomes

 

# Really good advice

(from reddit)

I got H in all clerkships, and can share some keys to success that worked for me. Apologies for the incoming wall of text. This is something I wrote months ago in a word doc like halfway through 3rd year, and now I guess is the time to drop it. To answer your question, I would have done things pretty much the same, I’d just worry a little bit less.

 

I guess this is about rotations in general. The way I have been navigating the hospital is by treating it like a game, where the ultimate goal is getting honors. You can use skills in your toolbox like medical knowledge and social engineering/EQ to score points with your evaluators. If you keep your radar on, you can find so many ways to not only get the most out of your learning, but also to be always on point.

Any time you first start working with a new intern/resident/attending (preferably one you’ll be sticking with for a while), be attentive to what scut work they do. Be proactive in taking some of it over for them! But tread carefully because you want to avoid creating extra work for them. So for example, my first day with a certain intern I saw that she had to copy and paste a bunch of stuff into a discharge summary, and call the PCP. Easy stuff, but tedious, therefore it is practically made for an M3 on a silver platter. So the next day, I came in a few minutes early and started on that for a patient who I knew would be leaving that day. For the things that aren’t so easy to just do on your own after watching it done once, ask them if you can do that task for them. Worst case they say no, but are appreciative of you asking.

 

Also, any time you are working with someone new, pay attention to their habits, no matter how small. I pay attention to the glove sizes people use so that I can pull them if I’m closer to the glove boxes than they are. I also pay attention to where a person moves when they are in a patient room, and it helps me predict where the doc will go next. This way I can smoothly move out of the way before I am actually in the way. Also if a doc does the same procedure often, figure out in what order they do it, so that you can hand them things or get out of the way when needed.

Read all the time. Specifically, read directly about your patients. This may be controversial, but don’t study for the shelf during downtime. I only study for the shelf when I go home. During the day, whenever there is a lull in patient care, I’m always on UpToDate about whatever is going on on the floor that particular day. This is the best way to nail pimp questions, and also interns/residents/attendings do notice that you are reading about patients. I’m of the strong opinion that attendings couldn’t care less about whether you are studying for your shelf or not – that’s why the shelf grade exists in the first place, to take care of that aspect. Reading about relevant things shows that you care about what you are leaning in the hospital. (Maybe I’m wrong and overthinking it, but studying for the shelf in plain view has always felt like a no-no to me. Somehow it feels to me like I am not present and in-the-moment).

 

Every time you have a patient, look up some research on their condition. Even if it is bread-and-butter, most cases have something unique about them, or have research that is very recent that the team might not be aware of. Then take the article, summarize the pertinent facts in a little paragraph in an email, and attach the paper. Send to everyone on the team. I’ve been given advice by upperclassmen/interns to do presentations to the team on this kind of research, but I’ve found that in reality there may be no time to do that, and sending out an email with your commentary accomplishes that much easier. And it can be done from home.

 

Find out what unique things you can do to help out the team. Most recently, I was at a community hospital where the interns and residents rotate through as well, so they are not caught up on all the protocols that the hospital has. We had a patient once who was on a protocol that spanned a whole packet, like 15+ pages. I overheard the intern and resident talking about how they should go through that protocol once they wrap up things for other patients. So while they did that, I went through the protocol myself and created a 1-page Word document where I essentially summarized the most important points in the protocol that the medical team was responsible for (there was a bunch of other stuff for other teams too, so I didn’t include any of that). Then printed out copies for everyone on the team. They kept referring to my document the whole week. I’m not saying do exactly that, just saying that it’s helpful to always be on the lookout for ways to make things easier for people – medical students have more time than anyone else in the hospital, so we can do this kind of stuff no problem. Many times I have done something and it ended up being totally useless. But this one time I hit a jackpot. You miss 100% of the shots you don’t take. As long as what you’re doing isn’t going to create more work for someone else, go for it full force.

 

If you’re at an outpatient setting, figure out how to get a hold of the EMR and the patient records. If I am ever at an off-campus site with a different EMR than the one I have access to, I talk to a nurse or MA – 100% of the time if you are polite and approachable, they will help you out and may even let you hop on to their account. Then I print out the most recent note for every single patient I might see that day, and read them ahead of time to learn about the patients. This is not a HIPAA violation. You are a medical student whose job it is to learn from every single patient, such that you can then provide the best level care. This way, when an attending says “would you like to see the next patient?” you can go into that interview armed with a lot of knowledge about everything pertinent to their follow-up. This scores major points imo.

 

Also another thing about outpatient settings – I’ve heard lots of people complain about how working one-on-one with an outpatient doc is too much like glorified shadowing. Obviously that’s the way it is – PCPs and specialists are very pressed for time, so they don’t have the time to let you ask questions or do the interview. Two things help with transforming your glorified shadowing into actual clerkship material. First, is being informed as I said above. Once the doc realizes that you are caught up about their patients, they may let you actually lead part of the interview because you won’t be slow. Second, nothing is stopping you from examining the patient while there is a lull in the visit. If the doctor is charting in their computer, or if it is a pediatric patient and the doc is talking to the parent, you can start listening to the heart and lungs, and do whatever else is pertinent to the visit. Feel this out, but most of the time the docs that I have been with have been very welcoming to that, and have commented to me that it shows that I care about learning while respecting the busy nature of the visit.

 

In the OR, be cool, stay quiet, and don’t ask too many questions. Keep your back straight. If you are retracting for a long time, use the weight of your body to retract rather than your arm muscles – this helps prevent strain. Always be aware of your body positioning. Walk around the OR slower than you think you need. Move your hands a little slower than you think you need. Doing these things will allow for greater precision, and you will appear much more composed and relaxed in the OR, which is a good thing in terms of showing clinical competence.

Never say no to anything. Any time you are offered to go down to talk to radiology/go in with a consult to the pt/offered to see a new procedure/asked to do an errand/asked to get food for a patient/literally anything, always say yes and do it.

Along the same lines, volunteer for everything. If you are rotating with a group of students, gauge the situation – if people are being hesitant when the attending asks “Which one of you wants to be the first to do ____,” jump in and raise your hand! But always gauge the situation first. Which brings me to my next point.

 

Don’t step on anyone’s toes and don’t make anyone look bad. While this includes interns/residents/attendings, there usually isn’t much of an opportunity to mess that up because their responsibilities don’t often overlap with yours. So this rule mainly applies to peers – medical students, PA students, nursing students, etc. Don’t do stuff for their patients. Don’t answer their pimp questions. Also, my modus operandi is to talk everyone up who deserves it. If I enjoyed rotating with someone, I’ll always make sure the team knows why I thought they were a great person to work with. If another medical student or PA student teaches me something, or if they did something that I really liked for their own patient, and it somehow comes up, I’ll absolutely make sure that they get the credit they deserve. Especially if the student isn’t particularly outgoing or assertive.

Treat everyone as your work colleague. Keep the relationship very professional, but part of a professional and cooperative work environment involves the interpersonal stuff like work-appropriate small-talk. This is the same across any industry. Your interns/residents/attendings/nurses aren’t your friends, but I’ll absolutely remember if one of them goes away for the weekend, and I’ll absolutely ask them how it was/did they enjoy it/etc. Being liked doesn’t mean you are everyone’s friend, it just means you navigate the relationships just like you would in any other professional team.

 

 

 

# County phone numbers

 

Wards

Jail 94568

2E 96355

3C 93354

4AL 93929            4AH 93933

4BL 97490            4BH 94005

4C 7405/7376

5A 97391                 5F 97393

5BL 98050

B5E 97882

6A 97730            6B 97812

6C 97225            6D 97227

7A 92592            7B 94021

7C 97312              7D 97304

8A 97651             8B

 

CCU 97111, 97113

Ob.Gyn 90504

NICU 93264

PICU 93883

Recovery 95530

ED NORTH 96707

CCU 97111

PCU 91727

 

Chief google: 213 375 4455

Chief Office: 323 226 7644

Office Ed Affairs: 226 7556

Galaxy 323 226 2206

Long-distance code: 2112039280

Dictation Line: 888 201 8590

 

Cards:

Cards c/s: 226-4238

C/s VOIPs: A 93982, B 93983

Stress Lab Marci: 97468

Cath lab 95284, 95783

Cath Recovery: 95284

Echo scheduling: 97444

Echo tech 97445

Echo Read x97520

EKG tech office: 97466

 

Pacer maker’s:

Biotronik 800-547-0394

Medtronic (800) 328-2518

St. Jude’s 800.681.9293

Boston Sci 508-650-8000

 

GI:

GI & Liver c/s: 97974

GI Lab/Sched: 95530

GI recovery: 95530

GI Fellow work rm: 92679

ERCP room: 97275

GI VOIPs: A 93988, B 93989

Liver VOIPs: 93990, 97974

 

Heme/Onc:

Heme c/s 226-6969

Heme fellow: 888-218-6789

Onc: c/s &appts: 226-6395

Onc 226-4981

RadOnc:95019,outpt appt 95023

 

ID:

ID c/s: 226 3851, 93851

Rand Schrader 323-343-8255

 

Pulm:

Pulm c/s: 226 7923, 97184

Bronch Suite: 94730

PFT lab: 91266

Sleep Lab 92859

RT: 97928, 226 7492

 

Renal:

Renal consult: 226 7307

VOIP: A 93996, B 93997

HD nurse VOIP: 93243

 

Neuro:

Neuro inpt svc VOIP: 94537

Neuro c/s: 94536 (secretary: 97405)

EEG: 97388

Stroke hotline: 7-7455

 

Other:

Derm consult: 213-717-2626

Derm pgr: 717-2626, 919-9578

Endo 442-2807, c/s voip: 93987

Geriatrics: 226-3638

Palliative Care: 98532

Pain mgt 213 919 8545, 97483

Psych ED: 97085

Psych c/s: 226-7976—97976

Psych VoIP 96353

Rheum 226-7889, c/s voip: 93998

Gyn-Onc c/s: 919-0468, 94198

OB: 94170 Gyn 94198

 

SURG CONSULTS

Anesthesia 97748

ACS consults: 97728

ACS non-trauma VOIP 97769

Trauma VoIP 97767

ACS A 919 8751

ACS B 919 8752

ACS C 919 8755

ACS D 919 4529

Burns 97996

CRS: 97363, 919-7363

CTS: 97819

ENT: 97309, 919-7000

HBS: 226-7791, 919-8749

NeuroSurg 97376

OMFS: 213-217-0215, 95051,97309

Ophtho 919-9254

Ortho 81-213-919-3487

Ortho intern 2132081193

Ortho ID x97227

Plastics: 919-7299, 97730

Podiatry – outpt 226-4172

SICU 91817 – c/s PEG/Trachs

Surg Onc 226-4981

TMIS: 213-919-8581, 96417

Tumor/Breast: 990-8574

Urology 919-2156, 95787

Urology lab 92821

Vasc 95816, 98750, 919-8750

Vasc Lab 94618

 

RADS

CT scheduling: inpt: 97202

CT outpt: 97278, 97268, 92805

CT approvals: 91583. After 9PM weekdays / 5PM weekends: 92798

 

CT reading room: 92798, 91583 radread.usc.edu

FNA biopsy: 94615

IR consult: 94100

Angio suite room: 94099

Neuro reading room: 94149

Nuc Med: 97855

Mammo: 92531

MRI: 91289, 90, 91, 92, 93

MRI msk 91293

MRI MSK reading: 96104

Xray: 97234e

Xray Read: 98063, 96081/2

U/S: scheduling: 97207

US Reading room: 94386

 

PHARMACY

Inpt: 97641, clinic tower: 96763

DC pharmacy: 97165

TPN: 97438, MICU: 93936

Anticoag 97606

Chemo 97551, DEA 9271

ID approval 213-717-0039

 

LABORATORY

Core: 97039

Micro: 97012

Blood Bank 97134

Cytology 94615

Path 94606

Immunology 97141

Virology 97012

Heme Path 91804

Manual CBC 97177

TB 91366

 

ANCILLARY

Bed Control: 95321

Dietary 9690

Epi. 96645

Jail liaison 98685

Nursing sup: 92965

Nutrition 96906/96901

PT/OT: 97437, 93772. Wkds: 95096

Speech: 226-5081, 95082

Page operator 94906

PICC scheduling – 226 7516

PICC nurse: 94186, 90779

Sched Admit (Grace, UR 96412)

Skin Care 213-919-0407

SW ER – 96883

SW office: 95253

SW wkds/nts: 91 7063

SW sup 93761, 97447

TB control:226 7962

TB liaison: 226 28 66

Pierre induced sputum: 91825

Translation Svc: 800-643-2255 (201173)

In-house Translation: 3232263600 (201609)

Surgical Wound Care 95269

Wound care

UR ER: 95001

UR InPt: 92962

VNA RN: 95090, 919-6216

Rancho liaison office: 91674/5

Rancho – Shirley pgr 562 446 2347

Deputy room 4563

Sleep study 91266

 

Vein mapping appt 94618 ( order: cv vas arterial duplex UE, CV vas vein mapping, order for future, location:usc)

 

 

VOIPS:

Med consult 91644

RA-94145            RB-94146

RC-94147            RD-94148

GA-94013            GB-93987

GC-94150            GD-94151

WA-94109            WB-94153

WC-94154            WD-94155

Res room on 8A – 91385

CCU A C 93980

CCU B D 93981

Heme on call 93991

MICU I – 93984

MICU II – 93986

Faculty in house 93999

 

Gold c

Ada 92164

Melissa (sW) 2132081687

 

ED

Observation 91683

Ed pharmacist 91604

Nursing management

And

My health LA

◦    8447446452

 

# PEs

 

Breast Exam

  1. Inspect breasts with patient in sitting position.
  2. Ask patient to perform maneuver to accentuate skin dimpling (must do 2 of 3 maneuvers: lean forward, pectoralis contraction, raise arms above head).
  3. Perform axillary exam with patient in the sitting position (holds elbow and encourages arm relaxation).
  4. Examine for supraclavicular nodes.
  5. Perform quadrant sweep maneuver to localize and elicit discharge only if spontaneous nipple discharge is present.
  6. Palpate breasts in a systemic fashion using the strip or circle method. Must be done with patient in supine position with arm raised over head. Must cover all breast tissue including tail.
  7. Cover breast not being examined.
  8. Male breast should be examined and palpated as well.

 

Chest Exam

  1. Ask patient to sit up for exam (or roll on side if seriously ill).
  2. Ask patient to breathe with mouth open.
  3. Inspection performed (respiratory pattern, increased AP diameter, barrel chest, asymmetry, masses, lips and nails).
  4. Palpate chest wall for tenderness, crepitus, respiratory excursion.
  5. Percuss anterior and posterior chest wall.
  6. Rotate back and forth from right to left chest for comparison in percussion.
  7. Check bilaterally for diaphragm excursion.
  8. Auscultate anterior and posterior chest wall.
  9. Rotate back and forth from right to left chest for comparison on auscultation.
  10. Auscultate apices in supraclavicular areas.

 

Abdomen XM.

 

  1. Place patient supine with head on pillow. Remove all clothing from abdomen.
  2. Inspect abdomen (shape, scars, distension, color) before auscultation or percussion.
  3. Auscultate in at least two quadrants. Listen for bruits – aorta, renal arteries.
  4. Auscultate before percussion or palpation.
  5. Percuss abdomen in four quadrants.
  6. Percuss liver and spleen.
  7. Assess for peritoneal signs before palpation.
  8. Palpate all four quadrants (painful quadrant last).
  9. Palpate superficially first, then more deeply.
  10. Attempt to define liver edge beginning inferiorly and progressing superiorly on the right side.
  11. Palpate liver edge during inspiration.
  12. Measure liver span.
  13. Palpate for spleen tip.
  14. Assess for CVA and Suprapubic tenderness.
  15. Palpate inguinal lymph nodes.
  16. If indicated test for ascites, abdominal wall defect, costovertebral angle tenderness, and palpate suprapubic area.

 

SPECAIAL MANEUVERS ABD

Psosas (top) is an active test: they need to flex at the hip against pressure

Obturator is passive: doctor flexes them at hip and externally rotates leg

 

 

 

GU/Hernia Exam

  1. Perform exam seated in front of patient with patient standing.
  2. Ask patient to strain (cough, Valsalva, etc.) for exam of inguinal floor.
  3. Place fingers over inguinal floor during straining maneuver.
  4. Palpate inguinal floor without having patient strain.
  5. Place finger at external ring.
  6. Examine right external ring with right index finger.
  7. Examine left external ring with left index finger.
  8. Inspect penis.
  9. Inspect both testes.
  10. Inspect cord bilaterally.
  11. Examine medial thigh below inguinal ligament for femoral hernia with straining maneuvers.

 

Vascular Exam

  1. Palpate carotids superficially and separately.
  2. Auscultate both carotids with bell of stethoscope.
  3. Auscultate the heart in all four valve areas for S1, S2, S3, S4, murmurs, clicks and rubs with the diaphragm and bell of stethoscope.
  4. Palpate brachial arteries simultaneously for rhythm, grade and amplitude 0-4.
  5. Palpate radial arteries simultaneously.
  6. Palpate femoral arteries simultaneously and listen to both with bell of stethoscope.
  7. Palpate popliteal arteries with thumbs anterior, fingers in fossa and with knee flexion.
  8. Palpate posterior tibialis arteries simultaneously.
  9. Palpate dorsalispedis arteries simultaneously.
  10. Palpate aorta.
  11. Auscultate aorta for bruits.
  12. Auscultate renal arteries with bell of stethoscope.

 

Rectal Exam

  1. Inspect perianal area.
  2. Perform digital examination.
  3. Inspect stool, checks for occult blood.
  4. Palpate prostate.

 

 

 

# Opiates Chart / pain killers

 

Dr Phung’s 10 rules

 

Notes from Dr. Phung’s lecture: how to succeed in residency

  1. Trust but verify, aka trust no one, expect sabotage (you can always say: “Thanks… but I like to verify physical xm findings myself.” story: the night resident who kept giving lasix based on a nurse’s impression of crackles. Story 2: when the chief resident trusted somebody who said the baby was cephalic (but the baby was actually breech)
  2. Be proud of your documentation (be proud of your work, so they know what you did and what you were thinking (story: waking up the night resident at home and having them come in to correct the documentation)
  3. Take the complement. Story: 6 good deliveries, 1 bad delivery. Related: each time you remember one bad thing, force yourself to remember one good thing
  4. Learn from everyone and don’t burn bridges, even if they have personality disorders (story: the gyn/onc attending who was wrong about some medications. Dr. Phung corrected them, in a nice way. several years later, that attending helped Dr. Phong pass his Gyn/onc rotation)
  5. Take the high road and give kindness. The staff here are “petty” be extra nice to people who don’t like you (bc it annoys them). Story: the day he forgot his name tag and the nurse yelled at him and told him he was in the wrong OR even though he was in the right one.
  6. Remember names: if you know their names, you can hold them accountable. Story: waiting for a whole day to get the paracentesis stuff set up vs. almost immediately
  7. Pick your battles. Better to bring up issues as a group/as a class bc of solidarity. Story: the powerful surgeon who was kicked out of UCLA bc she pushed a resident while everyone in the OR watched. All the OR ppl subsequently refused to work with her
  8. Communicate to prep the team for success beforehand: story: tell the curb tech in advance who could be a crash c-section
  9. Utilize mentors – talk to ppl who just matched to your specialty of interest to get advice about what to do
  10. be good to your class and juniors – watch out for each other
  11. Teach: keep and use the powerpoint you make and teach your juniors when you have a spare 5-10 min
  12. Ask for expectations when you start a new rotation. Ask how to succeed and how to help
  13. Enjoy the journey. If each year = shit, then you’re in the wrong profession
  14. Perspective: remember how many ppl would kill to be here
  15. Get back on the horse. You will inevitably get knocked down, what matters is how your respond.