1    

Introduction

Personal Message from Dr. Unger:

“I would like to welcome you and say that I am very appreciative of your interest

in this office.”

Medical Practice: This office is the private practice of Dr. Christopher Unger

who practices internal medicine, pediatrics, and has a special interest in

dermatology.

Background: Christopher Unger, M.D. was born on October 15, 1944 in

Lancaster, Pennsylvania. Dr. Unger obtained his Bachelor of Science from Ursinus

College with a major in chemistry. He received his M.D. from the University of

Pennsylvania School of Medicine, Philadelphia, Pennsylvania. He completed

several residencies in New England, including New England Deaconess Hospital

and Children’s Hospital Medical Center in Boston, MA. He was appointed Clinical

Fellow in Medicine at Harvard Medical School. He then became chief of outpatient

medicine at the U.S. Naval Hospital in Annapolis, Maryland, where he held the

rank of Lieutenant Commander. Dr. Unger was certified by the American Board of

Family Practice in 1974. He was also certified by the American Board of Internal

Medicine in 1984. His special interests are diagnostics, skin preservation, and

2    

teaching. He has completed the required criteria for certification in

echocardiography by the American College of Cardiology. Dr. Unger was given

the Laughlin Award by the Medical and Chirurgical Faculty of Maryland in 2001.

Program: Dr. Unger enjoys teaching students and training future medical

professionals. The program offers opportunities for hands-on experience and

prepares you to become a competitive candidate for graduate school.

Expectations for Interns

• Maintain internet access and email communication

• Acquire the Hepatitis B vaccine

• Present a good appearance and dress professionally

• Exude enthusiasm

• Portray intellectual curiosity

Students are required to keep a dependable and reliable schedule. The attendance

policy requires a two week notification of any schedule changes as well as finding

someone to cover your shift in the case of any emergencies. Always call the night

before your scheduled shift to review pertinent information regarding patients

scheduled during your shift. Dr. Unger’s vision for all students is to see them set

realistic career goals, acquire compassion, and stay focused.

3    

The Internship Experience

Arcieri and Green, authors of “Majoring in Success: Building your career while

still in college” in quoting Adele Scheele, states: “The most profound question next

to ‘who am I’ is ‘what do I want to do’. And interestingly enough, both of these

questions become clear only by experimentation. There is no way to know

beforehand” (p. 7).

• The internship experience helps students make better career decisions by

either confirming their choice or by causing the student to pursue another

path.

• It provides students an opportunity to see which areas of industry they enjoy

the most.

• It helps students develop important skills needed in the field, builds their

practical experience, enhances their resume and makes students more

employable.

• It also allows students to develop professional contacts with whom to

network.

• It teaches students how to perform in a professional environment and to

work well with others.

4    

Outline of Administrative Duties

• Managing the telephone – The expected way to answer the telephone is:

“Good morning/afternoon, Dr. Unger’s office, Name speaking, It’s a pleasure to

help you.”

Connect the caller to the correct person they need to speak to by telling that

individual what extension the call is parked at indicated by the last digit of

the number that is illuminated. When unsure of how to handle the call, place

caller on hold and ask for help. Always get the caller’s name and contact

number.

• Scheduling appointments – Patients call to schedule or cancel

appointments. The appointment book is on Alison, the medical receptionist’s

desk. When scheduling an appointment, always record it in pencil. Record the

patient’s name and best contact telephone number. If it is a new patient, connect

them with Alison. When cancelling an appointment, try to reschedule that

patient or make a note to follow-up with that patient.

• Retrieving and organizing records – Patient charts are alphabetized.

Know the layout of the chart in terms of order and the format of the ‘problem

5    

oriented medical record’. Patient charts are updated with every visit and when

calls are placed to that patient. Documentation such as prescription refill

requests and lab reports are filed once processed/ discussed with patient. It is

important not to leave messages or patient medical information with anyone

other than the patient. The only exception is if that patient is a minor.

Remember to document your conversation and date and sign your name. Older

records are housed in the archive which is the last room on the right going

toward the back of the office. The office sees many transient patients and

patients who need medical clearance for surgery or flight licensing. The

paperwork differs in these situations, so always check with Alison or Dr. Unger.

All charts are written and updated using a black ink pen

• Writing skills – All writing in any medical document needs to be clear

and accurate. Please do not scratch through mistakes; if errors are made, please

rewrite.

• Miscellaneous – Other intern responsibilities include sending out office

emails or responding to emails on behalf of Dr. Unger. Students also research

medical information with regards to patient’s condition or medication

information.

6    

The most important message to remember is that when working with patient charts,

we are working with legal documents. When unsure, always ask someone who

knows. When making a mistake, ask for help in making corrections immediately.

Outline of Clinical Skills

• Obtaining accurate vital signs – A patient’s vital signs include four

measures: their pulse, temperature, blood pressure, and respirations.

- The pulse indicates the patient’s heart rate with the normal range being

60 – 80 beats per minute.

- The temperature reflects the patients internal body temperature with

normal being 98.7 degrees Fahrenheit. This office uses an under-the-

tongue digital thermometer.

- The blood pressure measures the pressure in the arteries when the heart

contracts (systole) and when the heart is at rest (diastole). Please see

appendix 1 for instructions on how to take an accurate manual BP

reading. The normal range for the systole is 100 – 140 mmHg and for the

diastole is 60 – 80 mmHg.

7    

- The respiration indicates the number of breathes per minute. Normal

range is 10 – 16.

Report all vital sign deviations to Dr. Unger and examine connections to the

patient’s medical history/condition.

• Obtaining complete medical history (yellow form in chart) – how, what,

why, who, where, and when. Obtain a complete medical history on all new

patients, patients having their annual physical exam, and patients who have not

been seen by Dr. Unger in a while. No amount of information is unnecessary or

insignificant. Ask patients open-ended questions that allow them to elaborate.

Chatting with patients allows them to relax while divulging pertinent

information. This information includes past and present medical conditions with

regards to patients, parents, siblings, and children if any. Part of the medical

report is also based on your observation of the patient. Record what you see in

addition to what the patient tells you. Observations include: general appearance,

color of skin such as pale and clammy to touch, any markings or growths, and

patients psychological disposition such as mood. The white form in chart is

used to update the patient’s medical information on all subsequent visits such as

follow-ups and any new conditions within the year. Remember to sign all

8    

forms where necessary. The skill of obtaining a good medical history is

perfected over time.

• Assisting with procedures – Please see Appendix 2 for supplies needed for

surgical preparation. If possible, discuss this with Dr. Unger during your night

before telephone contact time so you are prepared and know the specifics. Make

sure that the surgical room is set-up with necessary supplies. Keep a mental

note of all questions to ask during post-surgery discussion time. It’s an

awesome experience!! Ask if Dr. Unger needs you to write the operative notes.

If yes, follow the example listed as Appendix 4.

• Preparing labs – All lab supplies are kept in the lab (last room on

the left going towards the back of the office). All lab forms are kept in the

cupboard above the fax machine. Make sure that all specimen jars are clearly

marked with the patient’s name and the date. Alison will take care of the

paperwork. Place specimen and completed paperwork in a lab bag and place in

appropriate lab company’s drop box in hallway outside backdoor. Blood

samples are centrifuged in the lab. Make sure that you balance the patient’s

sample vials with the vials kept to the left of the centrifuge, lock centrifuge and

hit the start button. Please ask Alison if you need assistance.

• Sterilizing instruments – See Appendix 3 for step-by-step instructions.

9    

• EKG Testing – See Appendix 5 for guidelines on the placement of leads.

• Stocking supplies – All supplies are kept in the cupboard next to the

copy machine and the brown cabinet on the right across from the copier. Keep

examination rooms well stocked.

The most important message to remember when medically serving a patient is that

we cannot make mistakes. We have in our hands people’s lives, their health, their

privacy, and trust. We are not afforded opportunities to practice our skills at their

expense.

Intern’s Personal Growth and Development

Here are some ‘tips’ from Students helping Students in their “Scoring a great

Internship” article (p 3):

• Take initiative

• Be flexible

• Set realistic expectations

• Make the most of menial tasks

10    

• Ask for help and advice

• Don’t burn your bridges, build networks

• Acquire tacit knowledge through observing how the experts do it

• Build your portfolio and update your resume

Dr Unger’s Recommendation Requirements

• Minimum of 125 hours required for a written recommendation

• Ability to grow professionally

• Ability to work under stress

• Strong organizational skills

• Ability to understand highly stressed patients

We are located at 8218 Wisconsin Avenue Suite 208

Bethesda, MD 20814

11    

How to take an accurate manual blood pressure reading

Figure 1 – electronic blood pressure monitor and cuff.1 figure 2 – stethoscope.2

Introduction

Electronic blood pressure equipment is used at most medical facilities. It is,

however, very important that all health-care professionals are able to acquire the

                                                                                                                         1  30  November  2010.  http://www.health-­‐mobility.com/cgi-­‐bin/category/Blood_Pressure_Monitor?gclid=CNW48IiryaUCFRZy5QodRF7VYw  230  November  2010.  http://www.google.com/images?rlz=1T4RNTN_enUS366US366&q=picture+of+stethoscope&um=1&ie=UTF-­‐8&source=univ&ei=Xln1TLzfEcWblgfLocDVBQ&sa=X&oi=image_result_group&ct=title&resnum=1&ved=0CDkQsAQwAA&biw=1259&bih=531  

12    

skill of being able to take and record an accurate blood pressure reading. The

instruments needed are a stethoscope and blood pressure monitor and cuff.

Step-by-step Instructions

1. Check the stethoscope to see if the sound is amplified by placing the earpiece in your ear and tapping the flat end of the stethoscope lightly. If the sound is dull, turn the stethoscope around (switch ears).

2. Have patients extend either their right or left arm forward, with palm of hand facing upwards, and attach the cuff comfortably around the middle of their upper arm (just above the elbow area).

3. Explain to the patient that he/she will experience slight pressure when the cuff is inflated.

4. Place the flat round part of the stethoscope under the cuff just above the elbow crease of forearm and place the earpiece in your ears prior to inflating.

5. Tighten the bulb on the blood pressure cuff and begin to pump the bulb while watching the monitor. The monitor will indicate the pressure increasing in the cuff. Inflate until the pressure reaches 180.

6. Slowly release the bulb to deflate the cuff while watching the monitor and listening to the sound in your ear.

7. Record the first reading as the number reflected on the monitor at the first sound which will sound like a thump/beat. The reading on the monitor will also very briefly pause at this number so you have to be watching very closely as not to miss it. This first number is the systolic reading and is the top number of the blood pressure reading; it indicates the contracting of the heart.

8. Record the second number when the beating sound stops. This too will be indicated on the monitor by a brief pause. This number is the diastolic number and is the lower number of the blood pressure reading; it indicates the heart at rest.

13    

9. Once you have the second number, completely deflate the cuffs and remove

it and the stethoscope from patient’s arm and your ears respectively.

10. Record the blood pressure as the systolic (first number) over the diastolic (second number).

Blood pressure readings are measured in units of millimeters mercury (mmHg).

The normal range for the systolic is 100 – 140. The normal range for the diastolic is 60 – 80. The blood pressure is therefore recorded as: eg. 100/60.

Report any reading outside normal range to the attending physician. It is good practice to know the patient’s medical history that might be reflected in their blood pressure reading (eg. they have hypertension and might be taking blood pressure medication). Mention this to the physician when reporting the reading.

Notice

1. An  accurate  blood  pressure  reading  is  of  vital  importance.  When  you  are  unsure  of  the  reading,  tell  the  physician  so  he  /she  can  re-­‐take  it  or  you  should  re-­‐take  it  using  the  opposite  arm.    

2. Faulty  equipment  can  also  cause  inaccuracies,  so  check  cuff  for  air  leaks  and  be  sure  that  your  stethoscope  is  in  good  working  condition.  

14    

Surgical Preparation

Alcohol

Betadine

Cotton balls

Surgical drapes

Gauze pads

Razor

Specimen jars

Topical anesthetic

Xylocaine 2% with epinephrine

15    

Figure 1 - Iris Scissors – Iris scissors are used in ophthalmic surgery to remove necrotic tissue and follow the contours of the tissue in small areas.3

Figure 2 – Ethilon Suture Material – This material is non-absorbable, sterile, and is used as surgical sutures.4

                                                                                                                         330  November  2010.  http://www.surgicalsindia.com/iris-­‐scissors.html  4  30  November  2010.  http://www.surgicalsindia.com/iris-­‐scissors.html  

16    

Figure 3 – Mosquito Hemostats – Hemostats are used to grasp and clamp blood vessels.5

Figure 4 – Scalpel Blades and Holders – Blades used in surgical procedures.6

Figure 5 – Disposable Syringes - Syringes are used to administer injections, insert intravenous drugs into the bloodstream. 7

                                                                                                                         5  30  November  2010.  http://www.pjtool.com/hemostats.aspx?gclid=CLTzi7KnyaUCFZlN5QodsEdjFQ  630  November  2010.    http://www.swann-­‐morton.com/  7  30  November  2010.  http://www.amazon.com/Monoject-­‐3cc-­‐Syringes-­‐Syringe-­‐SWD513330Z/dp/B000VSXH5Q  

Any  potentially  sharp  item  should  always  be  disposed  of  in  the  SHARPS  CONTAINERS  

17    

18    

How to sterilize surgical instruments

1. Clean instruments thoroughly by soaking them in hot antibacterial soapy water immediately after each use.

2. Make sure that instruments are free from all residues such as blood and tissue.

3. Allow instruments to dry.

4. Place instruments in sterilization pouches.

5. Label, date, and initial pouches prior to sealing properly.

6. Place in autoclave for 1 hour.

7. Make sure instruments stay apart from one another and do not stack pouches on top of each other.

8. Check water level and replace with distilled water.

9. Canisters should be placed upside down in autoclave so as not to accumulate the water.

10. Allow a distance of approximately 1” between trays to allow the steam to circulate.

11. Lock and start autoclave.

19    

20    

Operative Notes

An Example

Date:

Time:

Patient: DOB:

Pre operative: Mosaic warts (on right foot): Patient has had two complex, deep, painful warts of the anterior plantar foot. There is one, one cm bulky lesion approximately five mm depth, there is a second lesion 1.5cm, approximately 5mm depth.

Procedure: The surgical field was carefully cleansed with isopropyl alcohol times three.

1. Anesthesia – none required

2. Excision of mosaic warts of right foot. Re-excision was performed three times. Liquid nitrogen was applied and reapplied times four.

3. Thermal ablation was applied at 6 watts.

4. Estimated blood loss of 14cc. 5. Wound care: Betadine applied three times. Sponge count 7 in / 7 out.

Following the cleansing of the operative site the wound was dressed with a dry-sterile non-adhesive dressing.

The patient tolerated all procedures well. She was advised to use ibuprofen 400mg as needed for pain.

Pathology sent to respective lab for histopathology.

Christopher Unger, M.D.

21    

The Placement of EKG Leads

An EKG test measures the electrical activity of the heart which causes the heart to pump blood through the heart chambers to the lungs and the rest of the body. The electrical activity is shown on the EKG machine as waves. The EKG machine connects to the patient through ten leads (some EKG machines have 12 leads) which are strategically placed on the patient’s body in the following positions indicated on the diagram of the anatomical body:

Figure 1 - Anatomical male8

                                                                                                                         8  5  December  2010.  http://www.google.com/search?sourceid=navclient&aq=1h&oq=ana&ie=UTF-­‐8&rlz=1T4RNTN_enUS366US366&q=anatomical+position+diagram  

22    

Limb Leads

1 – Right arm – RA

2 – Left arm – LA

3 – Right leg – RL

4 – Left leg - LL

Precordial Leads

5 – V1

6 - V2

7 – V3

8 – V4

9 – V5

10 – V6

   

EKG Graph

Figure 29 - graph

                                                                                                                         9  5  December  2010.  http://www.google.com/imgres?imgurl=http://images.picotech.com/ecg_graph_1.gif&imgrefurl=http://www.picotech.com/applications/ecg.html&h=531&w=635&sz=11&tbnid=tNQRjp2ZmeCgIM:&tbnh=115&tbnw=137&prev=/images%3Fq%3Dekg%2Bgraphs&zoom=1&q=ekg+graphs&usg=__hQd73i5KgXY1j8fcxjL9WWjnL5k=&sa=X&ei=di38TN-­‐-­‐J8SBlAemy4WaBQ&ved=0CCwQ9QEwBA  

24    

 

Abbreviations

NKDA – no known drug allergies

ROS – review of systems

ENT – ear, nose, throat

C/RESP – cardio-respiratory

GI – gastro-intestinal

GU – gastro-urinary

N/M – neuro-muscular

PFSH – past family social history