SENIOR CLERK’S GUIDELINES

for

O P H T H A L M O L O G Y    R O T A T I O N

ATTENDANCE

You go on 24-hour duty every other day.

Time in:             

7am at CIM Bundy clock (be at your posts within 3 minutes)

7:15 means late

3 lates mean 1 day absence

Note: When you time in you should be ready for the day’s activity.

Punch card:

·         Sample entries in punch card:

Mondays to Saturdays

Sundays

There are no lunch breaks.  But you still have to punch out at 12 noon and punch in at 2pm when you are off duty.  Unable to punch in is automatically absent.  1 day absence means 2 day extension.

If you are assisting surgery, let the resident sign your punch card.  You are given only until the next day to have your punch card signed by the resident.

Ask permission from the OROD when you are out of the hospital premises.  You are given 20 minutes for meals before surgery or after OPD time only.  The boundaries are Dan Erie, Babsi’s, Pury’s and Velez Lab. Beyond this area is out of post. 

Answer paging, ward calls or texts within 3 minutes.  Failure to do so means out of post, thus a 7 day extension. (Paging for Dr. Detalla every Monday and Friday at 6:00am, you need not answer the page).

Always bring the tackle box. It should always be complete.  Every first day of the rotation all senior clerks will do an inventory of the things present inside the tackle box. No tackle box, failure to do inventory of the tackle box or an incomplete tackle box means you have one day unexcused absence equal to a 2 day extension.

Your post is at the OR if there are surgeries; at the OPD if none.  After office hours, be at the ward.  Answer ward calls within 3 minutes.  Out of post gives you a 7 day extension.

Leave the department phone number (0922-79-02-69-2) in every ward and ER.

RELAYING OF SCHEDULES AND UPDATES

Gather ALL scheduled surgeries from ACES OR and CVGH OR Reservation logbooks. Text allophtha residents, PGI and off-duty interns of ALL scheduled surgeries before 6:30pm. You don’t have to text at 10:00pm, except, if there are changes in the schedule.

Format: place (CVGH ACES, CVGH OR, PSH), time, surgeon, name of patient, complete procedure. Indicate if patients are for cardiac monitoring and other special instructions.

Use the ENTER sign to format the text message. And by the way BE POLITE when you text.

Sample:

Good evening doc, these are the OR sched for tomorrow, 04-06-09, Monday.

CVGH ACES

9AM  RA Dela Cruz, Juan for PHACO w/ PC IOL, OD

TFFCSanchez, Raul for Pterygium excision with autograft, OS

10AM VC Pamplona, Vicky for PHACO w/ PC IOL, OS

CVGH OR

10AMVC Tenebro, Janice for CV, MP, EL, OD

Text the CONSULTANTS of their OR schedule before 6:30PM.  In other words, your text to the consultant should include ONLY his surgery and not other consultants’ surgeries. 

Failure to relay* the complete schedule means a 7 day extension.

An incomplete schedule** means a 2 day extension.

*the clerk was not able to get the entire OR schedule

**meaning the clerk was able to get the OR schedule of only 1 area, or forgot to text 0ne specific surgeon of his surgery

WARD DUTIES

We have in-patients even if most of our patients are out-patients. 

Most patients in our department do not stay for long.  Thus, make sure when you make your charts, they are always completed before the patient is discharged so that your paperworks are up to date.

If you are the intern in charge, make it a point that you know what the doctor’s assessments are prior to and after the surgery.  You will need these data for you discharge summaries.

In-patient charts/ Co-management notes

Histories should be complete. The medical, social and personal histories of the patient including previous hospitalizations, medical conditions, and allergies should be included.  The social history should include family size, means of livelihood, basic income and the usual daily activities,

There should be a complete history of present illness which should include co-existing, non-related conditions, like DM type 2, HACVD, etc.

Do not forget to ask the patient of his/her PAST OCULAR history which includes surgery of the eye, wearing of spectacles, eye drops used, etc…

The physical examination should include the vital signs a complete PE and a complete VATEF (VA should include FAR, NEAR, and PINHOLE with and without correction lens; Fundus exam, write findings, not just +ROR). Failure to do so mean 1 day extension per offense..

The formulation should be concise.   Synthesize what you read from the book and correlate it with patient’s condition. Include your diagnostics and therapeutics. Let us know your thoughts.  Be brief and concise. Formulate as if you are the attending physician. Do not just say “it’s a diagnosed case of…”

The general format is:

§  Problem 1

§  Problem 2

§  PE

§  Formulation 1

§  Formulation 2

Progress notes/ Receiving notes

Indicate date and time of examination. A progress note is due at 7am every day. Text your progress notes to ALL Ophtha residents.

Problem: should include diagnosis, surgery or

                   intervention, days post-op

S:             current complaints of the patient;

          subjective improvement or  

subjective worsening; compliance to meds

O:            VATEF only

A:            Make your own assessment

P:             Make your plans and defend them

OUT-PATIENT DEPARTMENT (OPD) DUTIES

Performance in the OPD makes up more than half of your performance evaluation in the rotation. 

The way you treat and manage your patients in the OPD and the way you work with your fellow interns will give us a gauge as to what kind of doctors you will become. 

Be at OPD at 8am to 12noon and 2pm to 5pm if there are no scheduled surgeries.  

If there are scheduled surgeries, OPD will start at 2pm and end at 5pm.  No matter what time the surgery ends in the afternoon, the OPD should be opened at 2pm.

If you need to go out please ask permission from the resident.

Have your own ophthalmoscope & textbook (General Ophthalmology by Vaughan, et al) No ophthalmoscope or book, absent.

ALWAYS have dry/wet cotton, cotton pledgets at the OPD(ask from OPD nurse) & inside the TACKLE BOX.

CHARTS

Write all your history and PE like a hospital chart format. Ask patients if they have PHILHEALTH, if they have, then put a note on the first page of the chart – w/ PHIC or w/o PHIC. Get the contact numbers of ALL patients. Failure to do so mean 1 day extension per offense.

First consult, CIM patient

Fill up problem list & update (diagnosis, surgery). Failure to do so mean 1 day extension.

Medical, social & personal histories to include previous hospitalizations, medical conditions, allergies; family size; means of livelihood; basic income; usual daily activities.

Complete history of present illness. Include co-existing, non-related conditions, like DM type 2, HACVD, etc.

PE: V/S, complete PE; VATEF (VA should include FAR, NEAR, and PINHOLE with and without correction lens; Fundus exam, write findings, not just +ROR). Failure to do so mean 1 day extension per offense.

Formulation: Synthesize what you read from the book; correlate it with patient’s condition. If this were your patient, let us know your diagnosis, diagnostics and therapeutics. Let us know your thoughts. Be brief and concise.

The resident will have a separate entry after the intern’s formulation.

Data not included in the original history should be written as an addendum after the last entry in the history

The general format is:

Problem 1

PE

Formulation 1

Follow-up, CIM patients

The same OIIC should follow-up a patient for the duration of his/her rotation, for continuity. Failure to do so mean 1 day extension.

Indicate date of follow-up.

Format:

Problem: should include diagnosis, surgery or intervention, days post-op. Failure to do so mean 1 day extension.

S:            current complaints of the patient; subjective improvement or subjective worsening; compliance to meds

O:           VATEF only

A:           improved, not improved or the same

P:           filled up by RIC or OIIC with the instruction of the RIC

House patients

The entries should be short and contain the complaints, pertinent medical histories and PE (as you would an ER blotter).

Follow-up entries are the same as in CIM patients.

Emergency room follow-ups

Refer to ER blotter for your short history.  Include diagnosis, plans, and medications given.  Include also the drawings made by the resident who saw the patient in the ER.

Record the current complaints of the patient and other pertinent data.  Note if there is worsening or improvement of the condition.

A complete VATEF should include FAR, NEAR, and PINHOLE with and without correction lens; Fundus exam, write your findings, not just +ROR, we also need a legible drawings of the adnexae. Failure to do so mean 1 day extension per offense.

CARDIO-PULMONARY CLEARANCE

Internal Medicine

Schedule:  Monday and Thursday afternoon (2:00 to 5:00 pm)

OIIC should make consult notes before clearance day.

·         ECG 12 leads          

·         CXR-PA view

·         CBC    

·         FBS (8H NPO)

·         Serum creatinine                  

·         U/A-MSCC

*Give the necessary lab preparation instructions 

Gather all lab results, ECG strips and Xray plates, even if these don’t have official readings yet.

Complete them before lining up to IM. 

Pediatrics

Schedule:  everyday in the morning (8:00 to 12:00 noon)

OIIC should make consult notes before clearance day.

·         U/A-MSCC

·         CBC

·         CXR-AP view

·         SE-OPEH

*Give the necessary lab preparation instructions 

Gather all lab results, ECG strips and Xray plates, even if these don’t have official readings yet.

Complete them before lining up to Pedia. 

PRE-SURGERY PREPARATIONS

CIM Patients

Once cleared, CIM patients for surgery should be endorsed to the chief resident for scheduling. 

Once scheduled, patients with PHIC/PHILHEALTH should be identified.  For those with PHIC, accompany them to the Philhealth window at the information to facilitate the processing of their Philhealth requirements.

If they are not PHIC members, sponsors of the patient should be identified to facilitate the needed guarantee or authorization letters.

CIM patients should be asked to sign the consent form.  DO NOT write the date of surgery until the day of the surgery itself to avoid erasures.  Ask the resident in charge for the details to be written on the consent form.

Secure 1/8 sheet from the OPD desk and attach this to the consent form.

The following guarantee letters for CIM patients with sponsors should be photocopied (3 copies):

·         Mabuhay Deseret Foundation

All patients under MDF should be given the referral letter and asked to come back with the following:

1.       guarantee letter

2.      intraocular lens

3.       viscoelastic gel and/or nylon 10-0 sutures

·         Philippine Charity Sweepstakes Office

All patients under PCSO should be given the referral letter, expense breakdown and medical abstract made by the intern and asked to come back with the following:

1.       guarantee letter

2.      photocopy of the guarantee letter

·         Franciscan Sisters

·         Letters of Authorization

·         All other guarantee letters

HOUSE Patients

Once cleared, patients for surgery should be endorsed to the chief resident for scheduling. 

Once scheduled, patients with PHIC/PHILHEALTH should be identified.  For those with PHIC, accompany them to the Philhealth window at the information to facilitate the processing of their Philhealth requirements.

House patients should be asked to sign the consent form.

They don’t need the 1/8 sheet from the OPD Desk.

EMERGENCY ROOM DUTIES

Inform the PGIOD & OROD of ER call, thru text or call.

1^st text/call will include: General data and chief complaint. You wait for the OROD’s reply, OROD will decide if you have to fill in the ER blotter …

2^nd text/call will be: Brief history of current complaint. Include first aid measures, medications or physicians seen prior to ER visit, allergies, eye medications, and other diagnosed eye disorders, PE & impression.

Do VATEF after V/S are taken.  Use the Snellen’s chart and not any other chart.

For suspected penetrating injury, DO NOT DO DIGITAL PALPATION!   You will do more harm than good.  Always remember that as a physician, FIRST DO NO HARM.

All trauma patients should have the following in the ER blotter:

                Nature of injury (NOI):

                Time of injury (TOI):

                Date of injury (DOI):

                Place of injury (POI):

In chemical injury, inform ROD ASAP.

Ask NOD to prepare PNSS and thermometer. Irrigate 2 liters if acid burns; 8 liters if alkali burns. Do VATEF AFTER irrigation.

The OROD will need litmus paper, sterile cotton pledgets, dry & wet cotton, Alcaine with and without fluorescein during slit lamp examination. The OIIC should prepare prescriptions & final instructions.

The ER blotter should be filled up legibly and neatly. Make sure the ER blotter has complete diagnosis and signature of the OROD.

Inform the ER nurse of discharge for billing purposes.         

OPERATING ROOM DUTIES

RECEIVING PATIENTS FOR SURGERY

An intern should wait for the patient for surgery near the information desk or at the ACES benches at least 2 hours before.

When receiving patients for surgery, always ask for their CARRIED ORDERS. 

Carried orders do not necessarily mean that they are being admitted to the hospital, but that they are being admitted for surgery on an out-patient basis. 

Patients who are for admission in the hospital will have carried orders that will contain such orders.

Carried orders will usually state if the patient’s eye is to be dilated or constricted. 

If the patient does not have their carried orders, please ask the OROD or the nurse to check which eye will be undergoing a procedure.

Inform the resident in charge once the patient/s has arrived for surgery.  The resident will be the one to inform AP.

Get baseline vital signs & refer any problems to resident.  Note the medical history and maintenance meds of the patient.

If patient is for cardiac monitoring, inform MROD the night before & upon patient’s arrival (include vital signs & medical problem).

PRE-OPERATIVE DUTIES

CVGH-OR

Attend to patient’s needs (change patient to OR gown – make sure the knots of men’s shirt is in front, head cap, slippers) and inform the accompanying of patients to stay outside the OR.

Drop Alcaine to eye to be operated on. Wipe periorbital area with cotton soaked with alcohol.  Wipe dry

Put plaster on the head cap along the hairline.  This gives your surgeon the working space he needs for surgery.  A head cap too near the eye leaves no room for the surgeon to do the surgery under sterile conditions.

Remove all jewelry.

If the patient needs dilation or constriction, then do so.  Be careful of which eye you dilate, since dilating or constricting the wrong eye gives you a 3 day extension.

Since not all patients are for dilation or constriction, it is very important that you read all admitting orders before doing anything. 

It is also always good to remember the preferences of the different surgeons and be familiar with their routine.

When instilling drops, do not let the dropper touch the lashes; retract the lower lids.

Place a name tag using about 4 inches of transpore tape and place it on the left upper chest of the patient.  It must contain the patient’s family name, age, sex, and eye for surgery. Failure to do so mean 1 day extension.

Fill up PHIC forms and post-op instruction forms BEFORE the surgery.

Prescribe post-operative medications that are not part of the surgical package.  Refer to consultant’s preferences.

For in-patients, dilate in their room 2 hours prior to surgery or as ordered in the chart. 

An hour prior to surgery, bring the patient to the OR & maintain dilation of the eye for surgery.  Call for the CVGH-OR transport personnel at local 23 or 2536853.

Bring patient to the operating room 30 minutes prior to surgery but let patient urinate first before bringing them to the OR.  For incontinent patients, use adult diapers. 

In the OR, place BP cuff on the left arm, O2 nasal cannula, ether screen & rod. Failure to do so mean 1 day extension.

Never leave the patient alone. Unattended patients are unassisted patients and translates to poor intraoperative care giving you a 3 day extension. 

Wear blue OR scrubs, blue caps, blue masks & slippers.  Remove all your jewelry; set cellphones on silent mode. Failure to do so mean 1 day extension.

Always observe proper OR etiquette.

Leave tackle box outside.  Bring only dilating drops inside the operating room.  The department phone should be with the intern who is not scrubbing.

ACES-OR

Attend to patient’s needs (change patient to prepared OR gown, head cap, slippers) and inform the accompanying of patients to stay outside the OR.

Drop Alcaine to eye to be operated on. Wipe periorbital area with cotton soaked with alcohol.  Wipe dry.

Put plaster on the head cap along the hairline.  This gives your surgeon the working space he needs for surgery.  A head cap too near the eye leaves no room for the surgeon to do the surgery under sterile conditions.

Remove all jewelry.

If the patient needs dilation or constriction, then do so.  Be careful of which eye you dilate, since dilating or constricting the wrong eye gives you a 3 day extension.

Since not all patients are for dilation or constriction, it is very important that you read all admitting orders before doing anything. 

It is also always good to remember the preferences of the different surgeons and be familiar with their routine.

When instilling drops, do not let the dropper touch the lashes; retract the lower lids.

Fill up post-op instruction forms BEFORE the surgery.

Prescribe post-operative medications that are not part of the surgical package.  Refer to consultant’s preferences.

Let the patient urinate first before bringing them to the OR.  For incontinent patients, use adult diapers. 

In the OR, place BP cuff on the arm opposite to the eye to be operated on, O2 nasal cannula, O2 sat on the same side & rod.  Depends on the situation.

Never leave the patient alone. Unattended patients are unassisted patients and translates to poor intraoperative care giving you a 3 day extension. 

Wear blue OR scrubs, blue caps, blue masks & slippers.  Bring your own slippers.

Remove all your jewelry; set cellphones on silent mode. Failure to do so mean 1 day extension.

Always observe proper OR etiquette.

Leave tackle box outside.  Bring only dilating drops inside the operating room.  The department phone should be with the intern who is not scrubbing.

Addendum:

DR. AQUINO’s patients have prior prescription of pre-operative medication which include: Vigamox, Pred forte/Maxidex, Systane Ultra, and 5 tabs of OFLODIN, you get all these meds and bring it inside ACES OR, these will be used pre-op and post-op.

DR.MEDALLE and DR.TAN’s patients have either Vigamox or Gatifloxacin as pre-operative meds. You get these meds and bring it inside ACES OR, these will be used pre-op and post-op. Dr. Medalle’s px is also prescribed with 1 tab of Acetazolamide.

DR.ONG’s patient’s are prescribed with 3 tabs of Acetazolamide, you ask the patient or the accompanying if they were able to buy, if not, let them buy from ACES cashier. These meds are taken an hour after surgery, then every 8 hours thereafter, usual timing is 2pm, 10pm and 6 am the next day, just confirm these timing with the RIC.

INTRA-OPERATIVE DUTIES

cvgh-or

Read about the surgery you will be assisting. 

Failure to answer 3 random questions pre-op excludes the OIIC from assisting the surgery. Unassisted surgery means 7 days extension.

Do not move the operating microscope especially during surgery!

Observe proper aseptic technique and correct closed gloving. Improper technique means 2 days extension.

Observe proper handling of instruments so as not to cause any mishaps.  If you are unsure of what you are doing, it is always good to stay put and keep your hand close to your body to avoid becoming unsterile.  If you have questions, you better ask.

ACES-OR

Read about the surgery you will be assisting. 

Failure to answer 3 random questions pre-op excludes the OIIC from assisting the surgery. Unassisted surgery means 7 days extension.

Do not move the operating microscope especially during surgery!

Observe proper aseptic technique and correct closed gloving if you are asked to scrub in. Improper technique means 2 days extension.

Observe proper handling of instruments so as not to cause any mishaps.  If you are unsure of what you are doing, it is always good to stay put and keep your hand close to your body to avoid becoming unsterile.  If you have questions, you better ask.

POST-OPERATIVE DUTIES

CVGH-OR

Remove BP cuff and other attachments.

Assist the resident by getting the post-op drops and eye shield or goggles ready. 

Accompany the patient.  Lead the patient and do not be led by the patient.  You should always go first.

Give post-operative instructions correctly and check whether the medications are all in order and do not contain mistakes.  Bring the eye drops & give them to the patient or to the accompanying.  Failure to do so mean 3 day extension.

When instructing patients and their accompanying, make the instructions as simple as possible.  This is achieved by writing down for them the timing as to when the eye drops should be given and when the oral medications should be taken. 

Remind them of when they should follow-up. Ask the RIC about their follow up.

Remember that patients are highly emotional at the time of surgery and most are anxious.  Giving them the paper containing the post-op instructions is not enough.  Post-op care dictates that you verbally explain the instructions thoroughly but simply.  Make sure the patient understands what it is you want them to do so and why you want them to do it.

Your goal is to have a patient who is most comfortable with you instructions and not one who leaves with many questions left unanswered.

Thus, it is important that you understand the instructions and the principles behind the instructions.

For CIM or House post op patients under GA, the OIIC is required to monitor in the recovery room until the vital signs are stable.

ACES-OR

Remove BP cuff and other attachments.

Assist the resident by getting the post-op drops and eye shield or goggles ready. 

Accompany the patient.  Lead the patient and do not be led by the patient.  You should always go first.

Give post-operative instructions correctly and check whether the medications are all in order and do not contain mistakes.  Bring the eye drops & give them to the patient or to the accompanying.  Failure to do so mean 3 day extension.

When instructing patients and their accompanying, make the instructions as simple as possible.  This is achieved by writing down for them the timing as to when the eye drops should be given and when the oral medications should be taken. 

Remind them of when they should follow-up. Ask the RIC about their follow up.

Remember that patients are highly emotional at the time of surgery and most are anxious.  Giving them the paper containing the post-op instructions is not enough.  Post-op care dictates that you verbally explain the instructions thoroughly but simply.  Make sure the patient understands what it is you want them to do so and why you want them to do it.

Your goal is to have a patient who is most comfortable with you instructions and not one who leaves with many questions left unanswered.

Thus, it is important that you understand the instructions and the principles behind the instructions.

After the patient has left, make sure to fill up the PHILHEALTH forms.

LOGBOOKS, PAPERWORKS, PATIENT TRACKERS, AND NOTEBOOKS

LOGBOOKS

Logbooks should be updated DAILY. 

Logs should be made neatly and 2 or 3 spaces should be left between entries. 

Write legibly and if you make mistakes, please do not use white ink to erase the mistakes.  Draw a line over the mistake once to indicate that it is an erasure. 

Logbooks are not to be taken out of the OPD. 

Logbooks

1.       OPD Logbook

All OPD patients seen for the day should be logged at the end of the day.  Students, employees, and visa patients referred for routine physical examination should be included in the log.

2.      Surgical Logbook

All surgeries done in the CVGH operating room should be included whether they be inpatient or outpatient.  DO NOT INCLUDE surgeries done in ACES unless the patient is an OPD HOUSE or CIM patient. 

3.       Admissions Logbook

All admissions INCLUDING co-managements should be logged.

4.      ER Logbook

All patients seen in the ER with an ER blotter should be included in the log.

Loss of any logbook means REPEAT ROTATION!

Wrong entries that encompass more than one page means you have to redo the whole logbook.  Neat entries reflect how well you manage your paperworks.

PAPERWORKS

Decking

Decking of patients does not always turn out equally.  There are days when the intern on duty will receive more patients, assist more surgeries, or make more paperworks than the intern who is not on duty. 

Histories are always made by the intern on duty. 

Daily progress notes should be made by the intern in charge.

The surgical techniques of surgeries are always made by the intern who assisted. 

The rest of the paperworks are divided equally.  Paperworks include the logging-in of patients in the respective logbooks, filling up of PHILHEALTH forms, OPD charts, and all other papers that help keep the department running smoothly.

CIM patients that need to be presented to the medical director should be decked equally—meaning, those who have less work should be the one taking the deck.

Private outpatient cases should be decked first by those who are off duty unless there are no in-patient surgeries for the day.

In-patients

A responsible intern knows ALL patients even those whom he or she does not handle.

TEAMWORKshould be foremost in your mind in this rotation.  For your rotation to be as smooth and as easy as it can possibly be, you have to know how to work as a team.  Know how to endorse, share, and lend a hand.  Work becomes easier and faster if the team is efficient.

Your history & PE are due 2 hours after admission. 

Formulationis due 24 hours after admission.

 Insert your history in the chart and submit a duplicate copy to the admitting resident for checking.  The admitting resident should be the one checking the history.

Discharge summariesare due 8 days from discharge.  Checking should be done by the admitting resident.

Surgical techniques of all IN-PATIENTSshould be typewritten and made by the assisting intern.  If it happens that no intern assisted, the admitting intern will make the surgical technique.  Surgical techniques are due 2 days from surgery date and are checked by the assisting resident.  If 2 residents assisted, the more senior resident should check the technique.

Your in-service notes are due at 5 pm.  Thus, all patients you receive during the start of the rotation should have been seen by you by 5pm.  Your in-service notes serve as the benchmark of your patient’s progress the moment you receive them.  This does not mean, though, that you wait until 5 pm before you see your patients.  The first thing you should do when you receive ward patients is to see them and assess their well-being.

Progress notesare due at 7am.

Late progress notes and late in-service notes is NO progress notes! 

Each time you are caught with no progress notes you will be warned.  The third time you are caught, you will be given a 7 day extension.

Out-patients

All private out-patients do not need surgical techniques.

All Velez-HOUSE and Velez-CIM patients must have surgical techniques attached to their charts.  The surgical techniques must be handwritten.  The surgical techniques are due 2 days after the surgery date.  Surgical techniques are checked by the surgeon if the surgeon is a resident and by the first assist if the surgeon is a consultant.

PATIENT TRACKERS

Patient trackers should be made for ALL IN-PATIENTS including co-managements. 

Patient trackers should be made for ALL Velez-HOUSE and Velez-CIM patients undergoing surgery.  This includes those who had their surgery done in ACES.

A patient without a tracker is like a patient without an identification tag.  Thus, no tracker means no paperwork and merits a repeat rotation.

NOTEBOOKS

Like other departments, you are required to have a small notebook which will contain the list of your patients handled. It will also track your paperworks whether the draft or the final papers are already checked.

Format is:

Case#:

Name of Patient:                                 

Age/Sex:

DOA:                       TOA:

DOD:                       TOD:

AP:

Final Dx:

History:

                Draft:

                Final:

Surgical Technique:

                Draft:

                Final:

Discharge summary:

                Draft:

                Final:

Always let the resident sign the notebook every after your paperworks were checked.

If you are not the one making the history or the surgical technique, or the discharge summary put: c/o name of intern in charge, and let him sign.

Notebooks should be passed within 15 days after your rotation. It should be complete with signatures. You should also show your index card with complete signature – meaning all paperworks are inserted.

DILATING AND CONSTRICTING THE PUPIL

Generally, patients undergoing cataract extraction will need to have their pupils dilated.  The same goes for patients undergoing vitrectomy, intravitreal injections (Avastin, triamcinolone), and secondary IOLs.  In the OPD and in the ward, patients who will need to have their retinas checked (diabetics, hypertensives, possible retinal detachments) are dilated. 

Avastin patients will have a Vigamox or Gatifloxacin eyedrops to be given while on dilation. You give it 1 drop every 15 minutes x 4cycles.

Pupilloconstriction, on the other hand, is done for glaucoma procedures such as trabeculectomy and laser iridotomy.

Wrong eye dilated or constricted gives you a 3 day extension since it translates to poor pre-operative care.

Wrong task done (dilation instead of constriction or vice versa) gives you a 3 day extension since it translates to poor pre-operative care.

Eye Drops Used:

1. Proparacaine (Alcaine)
2. Phenylephrine (Mydfrin)
3. Tropicamide (Mydriacyl)
4. Phyenylephrine + Tropicamide (Sanmyd)
5. Diclofenac (Voltaren)
6. Pilocarpine

PUPILLODILATATION

Surgical Dilation:

1.   Drop Alcaine 1 gtt to OU.

2.   Drop Sanmyd 1 gtt after 1 minute to the eye for surgery.

3.   Drop Voltaren 1 gtt after 5 minutes to the eye fro surgery.

*Repeat Sanmyd & Voltaren until fully dilated (9mm pupils, nonreactive).

                *Maintain on Sanmyd Q30 min.

* DR. AQUINO’s patients, no Alcaine, just pure Sanmyd.

OR

1.       Alcaine 1 gtt to OU.

2.      Mydfrin 1 gtt after 1 minute.

3.       Mydriacyl 1 gtt after 5 minutes.

4.      Voltaren 1 gtt after 5 minutes.

*Repeat Mydfrin, Mydriacyl & Voltaren until fully dilated.

                *Maintain on Mydfrin Q30 min (Mydriacyl if hypertensive)

OPD Dilation:

1.      Mydfrin 1 gtt after 1 minute.

2.      Mydriacyl 1 gtt after 5 minutes.

*Repeat Mydfrin, Mydriacyl until fully dilated.

                *Maintain on Mydfrin Q30 min (Mydriacyl if hypertensive)

PUPILLOCONSTRICTION

CONSTRICTING an eye for surgery:

1.      Alcaine 1 gtt to OU.

2.      Pilocarpine 2% 1 gtt Q15min x 2 hours or until fully constricted (1mm, pinpoint pupils).

REMINDERS

It is always good to know your anatomy, physiology, and pathophysiology to have an idea of what you should do with the patients that are in your care. 

It is also good to know the different medications that are used so that you know why they are being used and what are the side effects of these medications. 

Not being familiar with the common medications shows that you are not studying for the rotation and will give you a 3 day extension.

Not knowing your basics and the clinical aspects of your duties in the rotation gives you a repeat rotation since it translates to inadequate knowledge.

The basics include anatomy, physiology, and pathophysiology.  The basic clinical aspects of your duties include good performance in doing VATEF including fundoscopy and  testing for visual fields.  You should also know the various charts used for visual acuity testing including test infants and children.

Making a mistake because of ignorance is not an excuse and should never be a reason as to why you failed to do your duty as an intern.

COMMON EYE DROPS USED

ANTIBIOTICS

1. Tobramycin (TOBREX) eye drops or eye ointment
2. Moxifloxacin (VIGAMOX) eye drops
3. Gatifloxacin (ZYMAR) eye drops
4. Levofloxacin (OFTAQUIX) eye drops
5. Fusidic acid (FUCITHALMIC) eye drops
6. Ofloxacin (INOFLOX) eye drops or eye ointment

STEROIDS

1. Dexamethasone (MAXIDEX)
2. Prednisolone acetate (PRED FORTE)
3. Fluorometholone (FML)
4. Fluorometholone (FLAREX)

MIXED ANTIBIOTICS + STEROIDS

1. Tobramycin + Dexamethasone (TOBRADEX)

NSAIDS

1. Diclofenac (Voltaren)
2. Ketorolac tromethamine (ACULAR)

GLAUCOMA MEDICATIONS

1. Pilocarpine
2. Timolol
3. Pilocarpine + Timolol (Fotil)
4. Dorzolamide (Azopt)
5. Dorzolamide + Timolol (Cosopt)
6. Brimonidine + Timolol (Combigan)
7. Brimonidine (Alphagan-P)
8. Travaprost (TRAVATAN)
9. Travaprost + Timolol (DUOTRAV)

OTHERS

1. Acetazolamide
2. Ibuprofen + Paracetamol (MUSKELAX)
3. Etoricoxib (ARCOXIA)
4. Oxymetazoline (DRIXINE)
5. Phenylpropanolamine (AP HISTALIN)
6. Co Amoxiclav (Clavoxin)

SURGEON’S PREFERENCES