Clinical Guide The Nerd's Guide to Pre-Rounding Table of Contents Part 5. Pre-Rounding and Scut Basics What is "Pre-Rounding"? For inpatient services, most of the planning and work on patients gets done before 10 a.m. "Rounds" refers to visiting, literally or figuratively, each patient on your team’s service. A presentation at rounds involves summarizing the patient’s findings, analyzing their problems, and describing an action plan for the rest of the day. To be ready for rounds, there most be a "pre-rounds." This is when you, the medical student, gather your data, plan your presentation, and begin to write your note (a more detailed text version of what you present). By the way: Your note should be done as soon as possible, ideally by noon. The time to begin pre-rounding depends on the service, and when rounds will start. For a medical student, I advise giving yourself at least 30 minutes for each patient you’re covering (usually one or two at the beginning of the year.) Now, what to do? The tasks of pre-rounding are listed below. They are in rough chronological order. They are also, arguably, in order of priority: Get the vitals. Examine the patient. Get the labs. Check the medications record. Talk to the nurse. The Progress Note I recommend using cards to record the data from the above steps. Attached is a printable template of a progress note. It's easiest for me to review the methods of pre-rounding by explaining the progress note. Next to the note, you can see what a student would actually say at rounds, versus what's written on their note. Data How you would present it on rounds HD/POD: Hospital day/Post-op day. Example: "3/2" Mr. Jones is our abscess patient.[6] He's hospital day 3, post-op day 2. Abx: Antibiotics. Keep track of total days patient has received antibiotic treatment, as well as the number of days of each of the specific drugs they're on. (Patients sometimes start one drug, then switch.) Example: "day 2 cefazolin, 1 g IV q 8 hrs" Cefazolin, day 2. Diet: Patients waiting for a procedure or with certain disorders like pancreatitis will be "NPO"-nothing by mouth. Other possibilities would be: "regular," "ADA" (American Diabetes Assn.), "clears," "soft," etc. He's on clears but still feeling nauseated post-surgery, so he's on D5 ½ NS, plus 20 mEqs KCl, 100 cc's per hour. IVF: See Appendix 1, Fluid basics   Events: Basically, anything significant that's happened to the patient since the last report. usually, "no events." Other events could be, "Patient spiked a temp overnight," or "had fits of vomiting," "complained of dizziness," etc. Depends on the case No events overnight. Subjective: What the patient has to say about their condition. I usually record exactly what they say, in quotes. Usually things like, "I feel okay," or "My pain is worse and 8/10," or "Couldn't sleep last night." If you want a specific question for this, ask about pain. Says he slept okay but is still nauseated. Objective: Vitals: It's best to record the last set of vitals, usually found a clipboard on the bed or outside the room. You should also record the range of values over the past 24 hrs. Tm = max temp in 24 hrs Tc=current temp. BP=Blood pressure. P=pulse. RR=Respiratory rate. SaO2= oxygen saturation, which should be expressed as percent and under what conditions, e.g. "99% RA" or 99% on room air, "94%-2L NC" or 94% on oxygen by nasal canula, rate 2 liters/min. He's afebrile, vital signs stable.[7] I/O's: In's and Out's. A record of fluids and substances in, and out, over 24 hours. Po= per mouth, ng/gt =nasogastric/gastric tube. Uop = urinary output. CT=chest tube. You should note the fluid balance per day and since admission. He's had 2.6 liters in, 2.4 IV and 0.2 by mouth. He's had 2.4 liters urinary output, and had 2 bowel movements. He's down 0.2 L for yesterday but up 0.3 since admission. Meds: I think it's a good habit to note when patients received which meds, and at what doses. Some wards have a "med book" that you can check to see what your patient got, and when. This is esp. important for pain meds and antibiotics. He received 1 gram of Kefzol at 10, 18, and 02:00 hours. He's had 2 mgs of morphine at 15 and 23:00 hours, and he just got 2 more 20 minutes ago in preparation for wound packing, which we'll do shortly.[8] PE: Physical exam. The basic pre-round exam should be very quick, and has 5 parts. Tradition- ally, most people check the chest, heart, and abdomen. If the patient has a wound, you should check to see if it's "C/D/I"-"clean, dry, intact." I suggest also inspecting the IV-make sure it's not inflitrated or shows signs of infection.[9] Also check other tubes or drains to make sure they're open and don't show signs of infection. The normal chest exam is recorded as "CTAB"- Clear to auscultation bilaterally. The heart is "RRR-no MRG"-regular rate and rhythm, no murmurs, rubs, or gallops. Abd: "BS+, S, ND/NT"-bowel sounds were present,[10] abdomen was soft, non-distended, non- tender." I would then report on the wound condition, if appropriate. You can record the IV's or tubes in the note, but don't present them unless there's a problem. On exam, the chest was clear to auscultation bilaterally, the heart had regular rate and rhythm, no murmurs noted, and on the abdominal exam, bowel sounds were present, abdomen was soft, non-distended, and non-tender. Wound dressing on right axilla was clean, dry, and intact, with packing wick evident under the bandage. Labs: Recording these is pretty straightforward. Traditionally, they're recorded in the following order: CBC (WBC, Hgb, HCT, platelets); "Lytes" (Na, K, Cl, HCO3, BUN, Cr, gluc); note the gap, if any; "LFTs" or liver panel (AST, ALT, T bili, alk phos); "Coags" (PT, INR, PTT); Ca/Mg/Phos; other labs (amylase, lipase, albumin, etc.) You don't have to announce the test and then its value for CBC or lytes, just announce the panel- they know what numbers are what if you go in correct order. Also, you don't have to indicate if values are high or low-teams usually know what's normal or not. Record whether numbers are trending up or down on the progress note. You may indicate this in rounds, depending on the case. CBC was 9.8, 14, 42, and 220. That white count's down from 11 yesterday. Lytes were 140, 4, 100, 25, 15, and 1, with a glucose of 72. Studies: For urinalysis, give pH, spec grav, then the pertinent + and -'s.   A/P: Assessment and plan. This is the most important section of the presentation, and the point at which most students choke. See below for suggestions on how to In short, Mr. Jones is a 54-year-old man with suppurative hidradenitis, 2 days status-post incision and drainage of a right axillary abscess. Overall, doing very well. His issues include: 1. Wound. So far, healing well, no pus. We'll continue daily packing changes. 2. Infection. He's afebrile 24 hours, with white count down. We'll check the CBC today, but it looks like the Kefzol's working, so we'll continue it. 3. Pain. Adequately controlled with morphine. We'll need to wean him to TyCo3's for discharge And will start today. 4. Nausea. Could be post-general anaesthesia, or due to the morphine. We'll try starting him on Compazine today and see if it helps. 5. FEN. As I said, I'd like to get his nausea under control so he can increase his po's. Then we can dc the IV, maybe this evening if he's better. 6. Dispo. To home when clear. Probably tomorrow, if he remains afebrile another 24 hours.[11] 7. Code status: Full code. Tips on Rounds Presenting: "Think like Dickens, speak like Hemingway." In other words, know all the details, but don’t say them all. Knowing how to edit yourself is an acquired skill you will pick up over time, so don’t worry if you’re a tad confused about what to include/exclude in your rounds presentation. The rule of thumb is, short is better. In fact, the longer the list of patients on your service, the less commentary and analysis you should give—in the above, for example, we might not break down the ins and outs into the various types of fluid, just "2.6 in, 2.4 out, up 0.3 since admission." And in our A&P, we might eschew the assessment for the problems, and simply give the plan, e.g. "Nausea. Will start Compazine." If the attending or resident wants more from you, they will ask for it. (Which means you should have it ready.) To Create an Assessment and Plan Global Assessment: First of all, you should give a global assessment. The example above repeated his name, age, diagnosis, and hospital course. It also gave a global assessment: "Doing very well." Other descriptors could have been "stable," "recovering slowly," or "seems worse," etc. Problem List: Then you give the problem list, with an assessment and a plan for each item. To create a problem list, it’s helpful to think in terms of all the issues that have arisen on the patient. Some services, especially intensive care units, like to organize problem items by organ system, i.e. "1. Repiratory, blah blah. 2. Cardiac function, blah blah," etc. On most services, however, problem items should be specific problems, not organ systems. Notice in the list above, some items were diseases, like a wound or infection, and others were symptoms, like pain and nausea. What constitutes a unique problem item is a subjective call. In a patient with ESRD (end stage renal disease) and hyperkalemia, docs who are "splitters" might number each of those as separate issues (one chronic, the other acute), while "lumpers" would put them as one problem, since the K problem is due to the ESRD. "Splitting" tends to be more thorough and is a better approach for students at the beginning. Almost always, the first problem is the one that brought the patient into the hospital. The remainder should be presented in order of urgency—what poses the greatest danger to the patient’s health, will keep her in the hospital, or is her greatest concern. The following are more routine problem items that should be considered for your patient’s problem list. FEN (fluids, electrolytes, nutrition): You should always review what’s going on in this category, if only because you should show you’re following it. In the case of our patient above, Mr. Jones is not really getting much nutrition by mouth, due to his nausea (problem #4). Fortunately, he hasn’t developed any electrolyte problems. If he had, we might comment on them here, or make them a separate problem item. Prophylaxis: There are several forms of "prophylaxis" on inpatient care. Stress ulcers prevention: Common issue, esp. in surgery patients, many of whom receive cimetidine or other H2 blockers for this purpose. Technically, indications for anti-stress ulcer prophylaxis include having a coagulopathy, being on a vent for >48 hrs, having a previous history of a GI bleed, or having certain special problems (burns, liver failure) while in the ICU.[12] Supposedly, sucralfate is a better choice for gastritis prevention than is cimetidine for patients on ventilators, because the former is less associated with pneumonia. This is controversial, however.[13] DVT prevention: Risk factors for DVT in hospitalized patients include obesity, immobility, malignancy, previous DVT, age >40, recent MI, having lupus anticoagulant, having varicose veins, and being heterozygous for Factor V Leiden, a mutant clotting factor.[14] There are several preventive measures. One is getting up and walking. There are also "Teds and SCDs" (Teds are Ted stockings, which fit snugly around the legs; SCDs, pronounced "Scuds," are "sequential compression devices"—balloon-like trousers that squeeze alternate locations around the leg throughout the day). Finally, there are anti-coagulant drugs, like heparin or enoxaparin. Psychosocial: This could be higher on the list in a patient who is, for example, expressing extreme anxiety or depression, or has been disruptive with staff, etc. I think you should always have an idea of what the patient’s psychosocial condition is, but you do not need to necessarily comment on it or report on it unless you feel the team needs to intervene. Dispo (disposition): In other words, the plan for discharge. Typically, "To home when clear." If the patient doesn’t have a home, or may not be safe at home (frail elderly), then a social worker needs to be consulted to sort out a plan with you, the patient, and/or his family. See Appendix 2, "Dispo Dancing." CODE: This means the patient’s code status. Should always be your last problem item, and should be present on every note. If your patient has an event overnight, the team on call will check your note to confirm the current code status. Code options include "full code," "DNR," ("Do not resuscitate"), and statuses in-between, i.e. "wants CPR but no ventilator," etc. Diagnostic Issues and Treatment Issues: Once you have a sense of what your problem items are, break each item out according to diagnostic issues and treatment issues. (On outpatient services you also add patient education.) For each issue, think in terms of "assessment—how this has evolved since admission," and "plan—where we’re going." For example, in the case of Mr. Jones’ infection, it was noted that he’d been afebrile for 24 hours and WBC was down (diagnosis—assessment), and that the team was getting another CBC today, presumably to follow his white count (diagnosis—plan). It was noted that the Kefzol seemed to be working (treatment—assessment), and would be continued (treatment—plan). For new problems or symptoms, it’s appropriate for the "diagnosis—assessment" to briefly describe the possible causes of the problem, i.e. a differential. Your assessment should ideally indicate which is the likely cause, since it might affect the choice of proper treatment. In the example above, while morphine was mentioned as a cause of nausea, there was no plan made to stop or switch the drug—which implies that the presenter didn’t think this a likely explanation. In truth, there are almost as many ways to create an assessment and plan as there are doctors. Hopefully the above gives you a framework for making a problem list and presentation. Your residents can give you more instruction when you hit the wards. A Final Note on Pre-Rounding The last of the five tasks I mentioned was "talk to the nurse." If the patient is groggy, she will be able to discuss any overnight events you should be aware of. Also, if any questions have come up while reviewing the other documents—e.g. apparently missing doses of pain meds or antibiotics, vitals not recorded, IV removed and no note in the chart about it, etc.—she can probably answer them. Always reserve 10 minutes of pre-round time at the end to figure out your assessment and plan for each problem. It’s also a good idea to practice your presentation, at least mentally. Once you present, listen carefully to the team discussion about each problem, and note down any "to-do" items you hear. After rounds, talk to your intern about the "scut list" for your patient, and ask her which ones she wants you to do. I find it helpful to create a "to-do" checklist next to each problem item, on my card or in my progress note. [6] If this were a patient the team had not heard about before, or it was the student's first time presenting him, they might want a "bullet" or summary on who he is. For example: "Mr. Jones is a 54-year-old postal worker with suppurative hidradenitis. He presented with an abscess of the right axilla that required incision and drainage." Medicine teams might want more PMH in the bullet, but in general, short is good. [Back] [7] You can also report "T max 37.5" vs. "afebrile," since a Tm below 38.5 indicates patient has no fever. Teams will usually appreciate the brevity of "vital signs stable," but, early on, your resident may want you to report the vitals. If so, it's best to give a range over the past 24 hours, rather than just the most recent set. Example: "Blood pressure was 115-135 over 70-85, pulse was 60-82, respiratory rate was 22, sat was 99% on room air." [Back] [8] Pearl: Changing wound packing in I&D (incision and drainage) surgical wounds HURTS. Call the nurse when you start rounds and have her give a morphine dose about 15 minutes before you change the packing. [Back] [9] By the way, peripheral IV's should be changed after 4 days, 3 if placed in the ER; usually the nurses take care of this. See Appendix 1, "Admitting a patient/Meg's List," for more info. [Back] [10] Bowel sounds "present" never "positive". [Back] [11] Traditionally, patients must be afebrile (T<38.5 C) for 48 hours before discharge. [Back] [12] Am J Health Sys Pharm, Feb 15, 1999; 56:373. [Back] [13] Kappstein et al. Am J Med 1991;91 (Supp 2A): 125-S. See also Driks et al. NEJM 1987;317:1376. [Back] [14] Kimmerly WS et al. Graduate surgical trainee attitudes toward postoperative thromboprophylaxis. South Med J 1999;92:790-4. [Back]