Thursday, June 25, 2020

Nine Steps to The Best Medical Notebook You'll Ever Use

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Author: Philip A Castrovinci MD
Undersea Medical Officer
US Navy

While a medical student, I remember a fourth-year emergency medicine resident with a notebook of his own creation. We did not see a single patient over a dozen shifts that he didn't pull out the notebook to extract some high-yield crucial information about the variety of conditions we came across. It was like a clown car of medical knowledge. He let me look at it. It was glorious. What I found was, and subsequently copied, was the best medical notebook I have ever seen. I forget what I learned during those dozen shifts, but the organization of the medical notebook will stay with me for the rest of my career.

Brief outline:
  1. Administrative pieces (front and back covers)
  2. Index
  3. Landing pages for common complaints and diseases
  4. Question Repository
  5. Patient Log
Full Instructions:
  1. You need an approximately 6x9 inch notebook, preferably soft cover. This is small enough to fit in your white coat, but large enough you so that you are not strapped for space, or have one topic over multiple pages. Additionally, a hardcover notebook is liable to deform over the course of the year, affecting its longevity. The more pages the better.
  2. The front inside pages- name, email, start date, and dates of any milestones that this book will encompass (tests, rotations, graduations, major patient scenarios, awards given, etc.).

    "Jane Doe., JUNE 2018"
    Jun 2018-Aug 2018 - Surgery Rotation
    10 Aug 2018- STEP 2
    Sep 2018 -Oct 2018 -Emergency Medicine Rotation
    Nov 2018- My first intubation.
  3.  The back inside cover should have the Advanced Cardiac Life Support (ACLS) protocol algorithm so it is always available.
  4. The first front page can personalize the notebook with an inspirational quote, dedication or doodle. This should be something that will keep you motivated and grounded. (I copied down the rules from The House of God.)
  5. The back of the last page should have a list of topics written on it like an index by specialty. I recommend the following from an emergency medicine quick reference guide index:
Anesthesia/Airway/Dental/Otolaryngology (ENT)
Gastrointestinal (GI)
Infectious Disease (ID)

Additionally, starting from the bottom, put the activities you participate in through your training where you draw information from. For example:

Reading Notes (learning on your own)
Rounds/Clinic Notes (learning in the hospital and clinic)
Grand Rounds Notes (lectures, seminars, grand rounds, etc.)

6. Starting from the front, the first fifty pages should be common ailments you see in the outpatient and inpatient setting. This start will act as the nidus and landing pages to collect more information about specific topics. This will help you as an intern to master these ailments. All doctors in training should have a good grasp on these topics, at least academically:

Chief Complaints Specific Disease States
Confusion/Memory Loss
Loss of Vision
Depressed Mood
Cough/Shortness of Breath
Chest Pain
Weight Loss/Gain
Dysphagia/Acid Reflux
Neck Mass
Abdominal Pain
Blood in Stool
Erectile Dysfunction
Vaginal Bleeding
Vaginal Discharge
Limb Pain
Low Back Pain
Pediatrics- Fever
Pediatrics- GI symptoms
Pediatrics- Red Eye
Alcohol Dependence
Mental Status Change
Thromboembolic Disease
Ischemic Stroke
Chronic Obstructive Pulmonary Disease (COPD)/Asthma
Upper GI Bleed
Lower GI Bleed
Acute Renal Failure
Transfusion Medicine
Diabetes/Diabetic Ketoacidosis
Acute Leukemia

Each symptom or disease should take up two pages (one page and the opposing page). The page should have the topic name at the top, with the date you are writing about it.
You may include the following sections:

  • Specific questions to ask in the History and Physical
  • Specific findings on exam to comment on 
  • Differential diagnosis, especially those you need rule out (what is it, what should be ruled out, catastrophes you should consider)
  • Any appropriate scoring systems
  • Initial labs and radiology (The more sensitivity and specificity numbers or likelihood ratios you can include, the better.)
  • Initial treatments
  • Complications to monitor for
  • Any high-yield evidence-based medicine pearls
  • Brief narrative to give a three-sentence presentation that is appreciated on an emergency medicine rotation

Make notes high yield and try to save as much space as you can. You should be coming back to these landing pages for patients you see as you go across the hospital.

7. Index: When you write a topic, aligned on the same line as the index topic, make a small dark mark on the left page. This way, when you need to find a page you've written, you can curve the pages and find all the topics related to a given specialty. The Index eliminates the need for a page order, and you can find information quickly without adding tabs to the notebook which will threaten the paper's longevity. Additionally, you can put several topics to one subject—i.e. inhalation injuries can be included in “airway,” “exposure,” and “pulmonology.” The index will keep the notebook organized for life.

8. Starting from the back page (the next page in after the index), start writing all the questions you are ever asked on rounds. Any question asked on rounds is likely high yield and will be asked again. Also, you can add question that you get wrong or learned something new on while studying for Step, shelf exams, or boards.

9. The rest of the book is to fill up with specific topics you learn. However, the idea is, when you go to a lecture on abdominal pain, or pancreatitis, you will have that landing page available and you can fill in the notes. If it's a specific disease or a new topic, start a new page. Additionally, every so often make a page for special patients you see, and collect their deidentified patient identification number for your future reference to check up on them, or even a case report. (Do not include Personal Health Information.)

If you do it correctly, this notebook can stay with you for the rest of your life. When you specialize, you can create a new notebook with new topics and complaints/conditions in the same format.

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