WAYNE STATE UNIVERSITY DETROIT MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE 2015-2016 RESIDENT SURVIVAL GUIDE Revision Date: July 2016 Created by the Resident Council Intern Representatives of 2004 Reviewed and revised by subsequent representatives yearly. Current Edition Edited by: Harold Obiakor (PGY1), Monica Peravali (PGY 1), Abdelaziz Mohamed (PGY1). Not to be copied, used, or distributed without the express consent of the Internal Medicine Department at DMC. This booklet is to serve as a helpful assistance guide, and not meant to cover all medical scenarios, be all-inclusive for treatment protocols, or serve as a substitute for the clinician’s own clinical expertise and judgment.
Transcript
WAYNE STATE UNIVERSITY DETROIT MEDICAL CENTER
DEPARTMENT OF INTERNAL MEDICINE 2015-2016
RESIDENT SURVIVAL GUIDE
Revision Date: July 2016
Created by the Resident Council Intern Representatives of 2004
Reviewed and revised by subsequent representatives yearly. Current Edition Edited by: Harold Obiakor (PGY1), Monica Peravali (PGY 1), Abdelaziz
Mohamed (PGY1).
Not to be copied, used, or distributed without the express consent of the Internal Medicine Department at DMC. This booklet is to serve as a helpful assistance guide, and not meant to cover all medical scenarios, be all-inclusive for
treatment protocols, or serve as a substitute for the clinician’s own clinical expertise and judgment.
Internal Medicine Resident Survival Guide - 2 -
Welcome to the resident survival guide! You are training at one of the places in the country with amazing pathology and will work with a great bunch of people.
The purpose of this book is to serve as a reference for key information you will need throughout residency. It is a composite from numerous resources, put together by
your fellow residents. A lot of this book contains helpful information for clinical questions. It is to be used as a reference only, not a substitute for your clinical
judgment. If something here (or anywhere) does not jive with your thinking, THEN RECHECK IT YOURSELF AND FOLLOW YOUR OWN BEST JUDGEMENT.
The medical team including yourself, your Senior Resident and Attending Physician will be directing appropriate medical care and making patient decisions.
At the back of the book are pages for your own personal notes. At the end of the year, please forward a copy of this page to your Resident Council representatives. Then we can
incorporate any key information that we may have missed into next year’s guide.
Thanks! We hope that you find this resource helpful!
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TABLE OF CONTENTS SECTION 1: CONTACT INFORMATION General Telephone Numbers and Information...……………………………………..5 Food & Lockers…………………………………………………………………………..6 Paging System….………………………………………………………………………..8 Internal Medicine Administration Pager Numbers……………………………………9 Subspecialty on call Fellow Pager Numbers………………………………………….9 Commonly Called Numbers…………………………………………………………. 10 Information Systems Contacts & Tech Tips………………………….…………….. 11 Nursing Station & ICU Phone Numbers..…………………………….…………….. 15 Subspecialty Clinic Numbers…………………………………...……………………. 15 VA phone numbers…………………………………….……………………………… 16 Outside Hospitals/Clinics & Medical Records……………..……………………….. 17 SECTION 2: ROTATION INFORMATION Guide to Rotations and Medical Floors ………………………………………. 19 Intern Etiquette………………………………………………………………………… 21 Tips from Interns and Seniors……………………………………………………….. 23 Admission Orders…………………………………………………………………… 25 Do Not Use Abbreviations…………………………………………………………… 26 Prisoner Protocol……………………………………………………………………… 26 Writing Orders……………………………………………………………….………… 27 Progress Notes……………………………………………………………………….. 28 Power Notes…………………………………………………………………………… 29 How to Present a Patient…………………………………………………………….. 31 Discharge Planning…………………………………………………………………… 33 Discharge from the ICU……………………………………………………………… 35 Dictating……………………………………………………………………………… 36 Consults………………………………………………………………………………... 37 Death Notes……………………………………………………………………………. 38 SECTION 3: DOCUMENTATION & BILLING Medical Documentation – Charting…………………………………………………. 39 Billing in the Hospital and Ambulatory Setting…………………………………….. 40 New Innovations Responsibilities ………………………………………………… 43 SECTION 4: TEACHING INFORMATION Residents’ Role in Teaching………………………………………………………….44 Medical Student Expectations……………………………………………………….. 45 Responsibilities to Our Medical Students………………………………….……….. 47 SECTION 5: MEDICAL INFORMATION & TIPS Acute Emergencies……………………………………………………………………52
How to Read an EKG…………………………………………………………………. 59 ACLS …………………………………………………………………………………... 63 Electrolyte Replacement……………………………………………………………… 68 Common On Call Complaints & Subspecialty Tips ………………………………..71 Ambulatory …………………………………………………………………71 General…………………………………………………………………….. 71 Pain …………………………………………………………………………72 Cardiology/Hypertension…………………………………………………. 76 Critical Care/Pulmonary………………………………………………….. 89 Endocrine…………………………………………………………………... 98 ENT ………………………………………………………………………101 Geriatrics …………………………………………………………………102 Hematology/Oncology……………………………………………………103 Infectious Disease ………………………………………………………112 Nephrology and Acid Base………………………………………………117 Neurology………………………………………………………………….120 Rheumatology…………………………………………………………… 124 Miscellaneous…………………………………………………………… 125 Useful Equations…………………………………………………………………… 127 Core Measures……………………………………………………………………… 130 SECTION 6: RESOURCES Community Resources………………………………………………………………132 OTHER Acknowledgements …………………………………………………………………140 Corrections & Notes…………………………………………………………………141
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SECTION 1: Contact Information
GENERAL TELEPHONE NUMBERS The Detroit Medical Center Internal Medicine Residency program includes training at the following hospitals: Detroit Receiving 313-745-3000 Harper University 313-745-8040 Veteran’s Hospital 313-576-1000 Karmanos Cancer Institute 1-800-KARMANOS Rehabilitation Institute of Michigan 313-745-1203 Children’s Hospital of Michigan 313-745-5437 Sinai/Grace 313-966-3300 Hutzel Women’s Hospital 313-745-7555 SHIFFMAN MEDICAL LIBRARY Wayne State University School of Medicine – Need a One Card for access. The library is located on 320 E. Canfield St., in the Mazurek Medical Education Commons building between the School of Medicine and the Harper parking structure. Hours of Operation: Sun 12 p.m. – 12:00 a.m. Sat 12 p.m. – 8:00 p.m. Fri 8:00 a.m. – 8:00 p.m. Mon - Thu 8:00 a.m. – 12:00 a.m. (313) 577-1088 WSU ONE CARD What is it? An access card for the School of Medicine, University Medical Library and Fitness Center. - it can also get you discounts at restaurants and stores Where to get it? Wayne State University Main Campus Welcome Center 42 W. Warren Avenue, Suite 257 313-577-CARD http://onecard.wayne.edu/ Hours of Operation: M - F 8:30 am – 5:00 pm
CAFETERIA HOURS and protocol to get fed on call or to get fed at all… Detroit Receiving Harper Hospital 6:30am – 10am Hot breakfast 6:30 – 9:15 11:00 am – 2:00pm Grab “n” go 9:15 – 10:30 5:00pm – 7:00pm Hot lunch 11:30am – 1:45pm
Hot dinner 4:00pm – 6:30pm Free coffee for residents in DRH cafeteria 7am – 8am and 5pm – 6pm (first and last hours of opening) VA 7:00 am – 2 pm Monday – Friday On call night dinner: To hold an on call meal tray, call 6-4567 well before the dinner hours. To get your tasty meal, go down to basement, south side of building, enter into the taped off rectangle (no joke), sign your name on the clipboard. Your meal will be made at that time. Quizno’s - Harper DMC Midtown Market Place – Brush mall Coffee Shop and Gift store – Hutzel lobby Subway (24h) – DRH, Children’s
Midtown Café – Harper/Karmanos Biggby Coffee (24h) – DRH, Children’s Wendy’s - Harper Security Call 111 at DMC, also this information is on the back of our badge. Parking Parking for all residents is at the Harper Parking structure, across from the Professional Building. You can park in the DRH underground lot after 6pm on weekdays and ANY time on weekends. Can also park at the Children’s and Kresge Eye lots.
Lockers
Harper: Lockers are available in the on-call suite on 7-Brush and the House officer locker-room. Contact the Chief Resident to check out a lock.
DRH: Lockers given to you for floor months. This info is included in packets at the beginning of the month.
VA: As far as lockers go, there are some for residents to use, but you have to bring your own lock, they're located in the call rooms and on the 6th floor, close to CLC services.
On consult months: Use the lockers in the 7-Brush on-call suite
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Resident Lounges DRH - 5N, 4S Harper – 7th floor of Brush building White coat cleaning Level 1 of DRH – in main hallway connecting DRH and Harper there is a room with a window next to the door to drop off white coats and have them dry cleaned for free. Hours: usually 12-4:30pm Resident Perks Look for a copy of the DMC Discount Directory on the wsumed website or ask your Resident Steering Committee about this. It is a list of discounts at various places of interest which are available to you courtesy DMC Employees Activities Committee. I also advise each of you to sign up at https://tenet.corporateperks.com/ and avail the wide range of corporate discounts available to you across the US. Once you sign up, you can share the corporate perks with 5 family & friends! The EAC office is across the cafeteria in Harper Hospital, it is open Tuesdays & Thursdays from 8AM-3PM only. You can purchase sports tickets etc. directly from them.
PAGING SYSTEM DETROIT RECEIVING, HARPER AND KARMANOS HOSPITALS
Dialing instructions
In house access: dial 122 then enter the pager number. Follow prompts. Enter your callback number, press * and enter your pager number.
Out of the hospital: dial 1-313-745-0203 then enter the pager number. Follow prompts. Enter your callback number, press * and enter your pager number.
If page says return call to *53499, call 313-745-3499 on an outside phone
If page says return call to *62254, call 313-966-2254 on an outside phone DO NOT return pages from your personal cell phone. If you must, press *67 and then dial the callback number. This will remove your number from caller ID. You do not want patients to have your personal number! Text paging
1. Go to the DMC Intraweb. 2. Locate person by name or pager. 3. It brings up a list. 4. Click on person’s pager number if it is green (active). 5. Type in note and send.
You may also text page someone from a cell phone if you know the 10 digit number assigned to the pager. This is located on the back of the pager or through the intraweb paging page of a specific person.
Signing out the pager or changing your greeting
Dial 123 or 1-313-745-4050 and follow prompts. VETERENS HOSPITAL
In house access: dial 6-1135 –xxxx and follow prompts. Enter the full number, not just the extension when calling from the VA.
Both Karmanos and the VA have numbers that start with 576 – XXXX or 6xxxx. Entering the whole number (with 576) prevents confusion at these two hospitals. Or you can dial 313-576-1000 ext. 6xxxx
You can look up pagers at the VA using VISTA Pagers: 9- 250 or 9-280 then pager
Out of the hospital: call the VA operator at 1-313-576-1000 and ask them to page
Internal Medicine Resident Survival Guide - 9 -
Department of IM 745-4832 Housestaff Office 4201 St. Antoine Fax 745-4052 DRH 5S10 745-3265 2E UHC Harper 2 Hudson 745-8334 Detroit, MI 48201 VAMC C3-100 576-3450 DMC Medical Records (Inpatient) Michelle Balan 745-4832 DRH 745-3285 Shirley Kmetz 745-4901 Harper 745-8022 Elinda Joseph 577-0348 Karmanos 576-9393 VAMC 576-3638 Resident Clinics GMAP 745-4525 AIl Medical Records (Outpatient) Phones in staffing area 745-4063 GMAP 745-2899 966-7340 745-4141 4C UHC 745-3322 Medical Education Chief Medical Residents and Program Directors R. Bloomingdale (DRH) 7939 M. Diab (HUH) 7947 Dr. D. Levine Med Ed Chair 11204 R. Alhasan (AMB) 7906 Dr. J. Weinberger PD 2028 S. Goyal (VA) 7956 Dr. N. Thati APD 2989 A. Zhang (VA Quality) 8073 Dr. M. Singh APD 3011 On Call Department Pagers Anesthesia Pain - DRH 6238 MICU Harper 6428 Anesthesia Pain – Harper 9996 DRH 6313 Bone Marrow Fellow 9080 Nephrology 5573 Cards Resident (Harper) 4444 Nephro, Transplant 5513 Cards Fellow (Harper) 6666 Neurology 9429
INFORMATION SYSTEMS CONTACT Citrix/CIS Helpdesk 966-2400 Chris Harwood (DRH physician support) Pager #97530 MSIS Helpdesk 577-1527 (for GMAP EMR/NextGen & WSU email) TECH TIPS *INSTALLATION INSTRUCTIONS for Citrix on iPad/iPhone
1. Go to the App Store and download the latest Citrix Receiver. 2. Once the Receiver is installed on your mobile device, click on the icon “CITRIX”
on your mobile device. Then click “Get started.” 3. The following screens will be for configuration, please use the following
information: a. Description: Can be any name; suggest DMC Citrix b. User Name: Your DMC Citrix UserID c. Password: Your DMC Citrix password d. Domain: DMCNT1
4. Click “save” when all information is entered. 5. Now the device is ready! 6. Once you click DMC Citrix and enter your credentials, the list of applications will
show up. 7. Click the “+” sign at dazzle and “+” sign in the list to add to your favorites. 8. Click on the Citrix Desktop Icon to launch DMC’s Citrix Desktop on your device.
Note: When you change your DMC Citrix Desktop password, you will need to go into your iPhone/iPad Citrix Receiver account and update it. NextGen access from Mac: Two options: #1. Remote Desktop that is pre-existing on your Mac (disadvantage is that you may notice it doesn’t permit FULL screen - like you get when you are in GMAP. It limits how much you expand the window). If there is some way to make it FULL screen, I haven’t looked into it, but my computer refuses to do it. But luckily in the meantime, I discovered this upgraded version, which is Option 2. #2. Remote Desktop app that you can download from App Store. This new app allows FULL screen, just like you see in the clinic itself, and is much nicer to have. Only problem is it often disconnects or becomes static if you let it idle for more than a couple minutes. I have a big screen monitor at home, so I started using this. OPTION 1: 1. Using the magnifying glass icon on top right corner (the Macbook search icon), search for “Remote Desktop Connection” 2. In the window that opens, type: emr.med.wayne.edu, then hit Connect 3. In the login window that pops up: - User Name: same as your med.wayne.edu email username
- Password: same as your email password - Domain: type in “MED” 4. Now you’re in the Remote Desktop, then you can go through the second login that takes you inside NextGen, just like in clinic. OPTION 2: (better if you want the full screen) 1. Go to the Macbook App Store (you can find it on the bar of icons on your desktop, or by using the Search icon) 2. Type in Microsoft Remote Desktop 3. Install the app with the red-colored icon (it’s free) 4. Open the app (if you can’t find where it installed, use the Search icon to locate it). Go through whatever installation questions that remain. 5. Once it opens, Click “New” (the plus-sign icon on the top bar of the app). This allows you to add NextGen as a favorite Remote Desktop 6. In the window that opens, fill in the boxes as follows: - Connection name: (name it anything you want, like - “Tania’s NextGen Connection”) - PC name: “emr.med.wayne.edu" - Gateway: No gateway configured - Username: "med\(your med.wayne email username)” - Password: your med.wayne email password - Resolution: Native - Colors: True Color (24 bit) - Full screen mode: OS X Native - Start session in full screen to be checked If you want to use Citrix at the same time, or do other things on the computer while on NextGen Full-screen, you can always do it on a duplicate desktop - if you press the F3 button on your keyboard, on the top you may see Desktop 1, Desktop 2, Desktop 3, and so on…clicking on any of those opens a fresh new desktop and allows other things to be opened in parallel. Press F3 again to go back to the other desktops as you need. Assigning another provider to your NextGen Inbox and PAQ while you are away: In the inbox: 1. click on the button next to Tasks 2. Select Out of Office Schedule from the list 3. Select the delegate name 4. Click ADD under the appropriate sections 5. click OK 6. Don’t forget to switch back For more NextGen tips, refer to wsumed website** Nathaniel Lewis can help with technical issues for NextGen: 248-581-5733
www.wsumed.com -> password wsumed. This website has tech tips, schedules, voluntary opportunities, guides, updates from Resident Steering Committee, Board Review, Clinical Question of the Month, Patient Safety info, Research Corner, Procedures, Morning Report Blog
The Hospital Physician Journal: http://www.turner-white.com/hp/contenthp.php
The Cleveland Clinic Journal: http://www.ccjm.org/default.asp
Mayo Clinic Proceedings: http://www.mayoclinicproceedings.com/
Evidence Based Medicine Resource: http://www.supersmarthealth.com/
Center for Reviews and Dissemination: http://www.crd.york.ac.uk/crdweb/
The Ectopic Brain: http://pbrain.hypermart.net/medapps.html
Medical Calculator: www.medcalc.com
DMC Pharmacy guidelines (great for antibiotic use at DMC!!): http://intraweb/default.aspx?ifscc=/pharmweb/http://intraweb/default.aspx?ifscc=/pharmweb/
For resident perks: https://tenet.corporateperks.com/
DMC Perfect Care: dmcperfectcare.org Micromedex – access through citrix for free access
To make notes that you can access on any electronic equipment, consider programs like: evernote.com Apps: NI GME – to document hours DMC perfect care Epcorates for meds ASCVD Risk Estimator AHRQ ePSS – for screening Uptodate Library website from intraweb has some info: http://intrawebcns/Mobile GUIDELINES: There are many! A useful place to start is The National Guidelines Clearinghouse: http://guidelines.gov/ EMAIL: https://outlook.office.com/owa/
LOGGING PROCEDURES and DUTY HOURS: New Innovations http://www.new-innov.com/login.htm
Institution login: DMC (all capital letters)
Username
Password JOHN HOPKINS MODULES: http://www.hopkinsilc.org/
Click on "click here to register" if you are a first time user.
When you log in you must select the ILC group you are interested in. (i.e. Internal Medicine Curriculum or Internal Medicine: Medicine Consultation Curriculum)
**residents are responsible for completing the John Hopkins Modules assigned every 5 weeks. These will be assigned each academic year. CIS & CITRIX AT HOME: www.dmc.org/staff
Click on Remote Access to CIS
Type username and password PACS Web CONNECT:
Call 966-2400 to have your account added to the “Vital Clinical Users”
Log onto the DMC Citrix Desktop
Double-click the PAC Web CONNECT icon. (CXR picture)
You do not have to login on the next window, Click “OK” PHARMWEB: Fantastic medication guide for all specialties
Log into CIS
Enter the Internet and Web-Portal
Click on Intraweb tab (at the very top of the page)
Click on the “Pharmacy” tab
Use the drop down menu to click “Pharmacy Website” HOSPITAL POLICIES: Detailed explanations can be found on the DMC intraweb.
Harper Hospital Nursing Units10 Webber North 576-9229 10 Webber South 51509 58849 Hemodialysis 9 Webber North 576-9250 9 Webber South 52277 8 Webber North 576-9126 8 Webber South 56057
6 Brush 52147 5 Webber North 576-9213 5 Webber South 51509 5 Brush North 52200 5 Brush South 52200 4 Webber North 52127 4 Webber South 52287 4 Brush North 52216 3 Webber North 50645 3 Webber South 50755 3 Brush 52147 2 Brush North 52168 2 Brush South 50613 2 Webber North 50623 2 Webber South 50513
DRH Nursing Units
3Q 53199
3R 53547 5U 53573
4M 53018
4N 53124 4Q 53031 4R 53447 4U 53034
4V 53082
5L 53087 5M 53091
5N 53508
5Q 53511 5R-1 52990
4L 53093
Harper Hospital Intensive Care Units 9 ICU 58792 Cardiothoracic 8 PCU 65203 6 ICU 58694
5 ICU 52297 Medicine 4 ICU 58568 Neurology
DRH Intensive Care Units 4P Surgical ICU 53148 4Q-1 Surgical ICU 53164 5T Neurotrauma 33841 4S Burn Unit 53074
4T Burn Unit Step Down 53078 5Q Coronary ICU 53911 5R Medical ICU 52990 4Q-2 Surgical ICU 53447
Subspecialty Clinics
Cardiology, 4C 745-3322
Endocrinology, 4C 745-4525
GI Endoscopy Unit 745-8358
Heart Failure 745-4525
DRH Endoscopy 745-3090
On Call # after 5 p.m. #5456 Hem-Onc Clinics 1-800-KARMANOS
VA paging system: For 5 digit numbers dial 61135 followed by the 5 digit number followed by your call back number. For paging a 7 digit VA pager dial 9 followed by the number and leave a call back number. For paging a DMC pager (4 digit number) dial 7450203.
Phone Numbers of Outside Hospitals/Medical Examiner
BiCounty Hospital Medical Examiner 313-833-2568 Medical Records 586-759-7370 (Call if death is a result of trauma, Emergency Room 586-759-7310 suicide, or within 24 hrs. of
admission) Bon Secours 313-343-1000 Karmanos 1-800-527-6266 Medical Records 313-343-1625 Medical Records 313-576-9393 MR Fax Number 313-343-1186 Emergency Room 313-343-1605 Botsford 248-471-8000 Northville State 248-349-1800 Medical Records 248-471-8175 Hospital Emergency Dept. 248-471-8556 Beaumont 248-551-5000 Oakwood 313-593-7000 Medical Records 248-551-5050 Medical Records 313-593-7780 MR Fax Number 248-597-2848 Emergency Dept. 248-551-6000 Emergency Dept. 313-593-7440 Children’s ER 313-745-0113 Providence 248-424-3000 Administration 313-745-5255 Medical Records 248-849-5580 Pt. information 313-966-5110 Emergency Dept. 248-849-3000 Medical Records 313-745-5356 RIM 313-745-1203 DRH 313-745-2230 Triage 313-745-3374 Crisis 313-745-3546 Riverview 313-499-4000 ER x-ray 313-745-3423 Medical Records 313-499-4589 Fax 313-745-4038 Emergency Dept. 313-499-3331 Medical Records 313-745-3285 Detroit Psych Insitute 313-874-7500 Sinai-Grace 313-966-3300 Garden City 734-421-3300 Medical Records 313-966-1092 Medical Records 734-458-4405 Emergency Dept. 313-966-1010 Emergency Dept. 734-458-3426 St. John’s Main 313-343-3400 Henry Ford 313-916-2600 Medical Records 313-343-3780 Medical Records 313-916-4540 After Hours MR 313-434-2337 St. John’s Macomb Emergency Dept. 313-916-1545 Emergency Dept. 586-573-5051 Medical Records 586-573-5080 Herman Keifer 313-876-4826
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St. Mary’s 1-800-464-7492 Mental Health 313-876-4400 Medical Records 734-655-9253 Social Health 313-876-4180 Emergency Dept. 734-655-1200 TB 313-876-0335 St John’s Oakland 248-967-7000 Holy Cross 313-369-9100 Medical Records 248-967-7080 Medical Records 313-369-5727 Emergency Dept. 248-967-7670 Emergency Dept. 313-369-5689 Veterans 313-576-1000 Huron Valley Emergency Dept. 284-360-3400 Poison Control 313-745-5711 (HPB) Hutzel St. Joseph Pontiac 248-858-3000 Medical Records 313-745-7141 Emergency Dept. 313-745-0680 Wyandotte 734-284-2400 U of M 734-764-1817 Hospice KCI 248-827-7722 Medical Records 734-936-5490 Fax 734-647-6220 Southeast MI Hospice 313-578-6300
Detroit Area Methadone Clinics
MY FREQUENTLY CALLED NUMBERS:
LOCATION Phone
Herman Keifer Hospital 876-4045 852-4838 852-4476
Medical Resource Center 758-6670
Methadone Clinic 745-7411
Metro-East 571-3140
Metro-East Gratiot 371-7770
Metropolitan Rehab Clinics 248-967-4310
Mich Counselling Services 248-547-2223
Nardin Park Drug Abuse 834-5930
New Light Recovery Center 867-8015
Parkman Counselling 532-8015 248-370-0010
Rainbow Clinic 865-1580
St. Joseph Mercy 858-3177
Starr Clinic 493-4410
VA Methadone Clinic 576-1000 ext 5252
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SECTION 2: Rotation Information GUIDE TO ROTATIONS: 4+1 Scheduling
Residents are divided into 5 cohorts (Blue, Green, Purple, Red, and Yellow) Residents will be assigned to general medicine floors or subspecialties rotations for a 4-week block which is then followed by 1 week of clinic (hence 4+1)
The clinic week overlaps a full weekend, so each resident is guaranteed a “golden
weekend” with two days off in a row every 5 weeks
MEDICINE FLOORS
1. Get to the hospital on time. 2. See new patients/sicker patients first 3. Existing patients: Check orders, read nurse’s notes from your shift and
overnight, vital signs, progress notes, focused physical exam. If you are not able to write your notes on all patients prior to rounding, make sure you check the vitals, and do a focused exam. Then, check labs just before rounds.
4. Pre-round on patients with your senior as directed by your senior 5. Be ready to round with your attending in order to get to morning report on time. 6. Morning report: Put your pagers on vibrate. Leave for morning report 5 minutes
early. The morning reports are a golden opportunity to review patient cases, articles, and actually talk through it. This is your time, so it can only be as good as you make it. Ask questions. And as uncomfortable as it may be when some of the higher ups pimp you, know that you are learning something every time you are unsure of the answer - hey, you probably won’t forget it the next time around!
7. Rounds with attending. You have to keep the attending moving and on pace. Remind them that you need to be at morning report/noon conference and indicate the sickest patient that will require the most time on the list.
8. Grand Rounds and other resident year specific lectures: Again, try to make it. Put your pagers on vibrate. THIS IS SUPPOSED TO BE “PROTECTED TIME” for your education. Leave so that you can make it. Most attending are supportive, but if they are not, politely explain this is mandatory and you must sign in daily.
9. Recheck any labs, procedures, write follow up orders, finish notes. 10. Be available to take sign-outs from your colleagues.
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DRH:
o There are 4 teams, each with 1 senior, 2 interns. One team will be on call every
4th day until 8pm when night float arrives.
o Call teams will begin admitting at 3pm and stop at 6pm and can admit a
maximum of 7 patients for the call period.
o Patients admitted after 6pm can be triaged with orders by the senior and held for
night float. Night float at DRH will cap at a total of 5 patients, or a total call team
cap of 7 new patients for the call period. Note that the night float is an extension
of the call team
Harper:
o Interns will be reinstated at Harper. Team structure and call details are yet to be
determined.
VA:
o There are 4 teams, each with 1 senior, 2 interns. One team will be on call every 4th day until 8pm when night float arrives.
o On call team will start admitting at 2pm and stop at 6pm to allow for adequate time
to work up all the patients and leave on time
o Total number of patients for the on call team will be 9 patients
o On call team will admit 5 patients till 6pm (will be at senior resident discretion how
the patients get distributed between the interns)
o On call team will stop admitting new patients at 6pm to prevent violating
mandatory short break
o From 6pm MOD for the day will start admitting till night float team comes in at 8pm
o Night float will admit total of 5 patients, should have zero patients waiting on arrival
at 8pm
o Once the night float team reaches the cap of 5 patients, MOD will again admit rest
of the night
o As the total team cap is 9 patients, the on call team will receive 4 patients from
night float the following day to meet the total number of 9 patients
o The other patient admitted by night float and any patients admitted by MOD will
become overflow to be distributed to the non-call teams.
o In the event the on call team gets total of 9 patients before 5pm, the senior resident
is expected to have admissions orders entered for all 9 patients and call the MOD
at 5pm to hand off the other 4 patients to be admitted by MOD.
Bounceback
Internal Medicine Resident Survival Guide - 21 -
o Bouncebacks to the call team do not count to the team’s total cap for the day. A
bounceback admitted by the call team for another team will count as a hit for the
call team. The call team will staff patient the next morning, and then transferred
to the original team after the daily work is completed.
o Bouncebacks to another team admitted by night float will be staffed by the night
float senior over the phone with the bounceback attending, and then immediately
handed off to the bounceback team in the morning prior to rounds.
o Post-call teams will accept the admissions from night float and are responsible
for admitting any bouncebacks to their team until 3pm.
o The post-post-call and pre-call teams (non-call teams) can each admit a
maximum of 3 patients not including bouncebacks.
ICU & CCU
Be organized.
Know your limits and call when you need help.
Get sleep and food when you can get it. You won’t always have time.
“Know thy lytes.” Replacement for Mg and K is not the same as on the floors. Keep Mg at 2.0 or higher, and K at 4.0 or higher. Use electrolyte protocols.
Bringing pocket food helps—if you can’t catch dinner at least you have something in your pocket to snack on.
Bringing a change of scrubs; a face towel, and soap are little luxuries that make you feel better if you really did have some time to snooze. Tip from the peers on rounds standing next to you: Bringing some deodorant to put on in the AM is appreciated by your peers rounding the next day—to keep yourself smelling daisy fresh.
Education may be self driven, so read.
Learn the algorithm for discerning atypical from Typical chest pain: substernal squeezing or pressure, aggravated by activity, may have associated NV/SOB/diaphoresis/palpitations, relieved by nitro.
INTERN ETIQUETTE Sign Out List The team on-call (or night float residents) is responsible for the care of all patients on the general medicine ward teaching service. To assist them in this, careful directive information must be provided by all non-call services prior to leaving the hospital. Usually this is done "intern-to-intern" or "subintern-to-subintern” preferably face-to-face, rather than over the telephone. The sign out list must contain the following: 1. All of your patients, not just the sick ones 2. Patient name, room number 3. Social security number 4. Major problems and possible interventions
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5. Code status 6. List of labs and x-rays to be checked (keep to a minimum). Things to do should be kept to actions that need to be done overnight or will make a difference in patient care overnight. Cross Coverage It is difficult to develop a complete list of complaints or problems, which require a physician's presence. Simple problems, such as the need for sleeping pills or pain medication for mild pain can be handled over the telephone. If you have any doubt as to whether a patient's problem can be handled by telephone or if a physician's presence is necessary, GO TO SEE THE PATIENT. As you gain experience you will become more comfortable with such situations. A few examples of problems needing IMMEDIATE attention include chest pain, shortness of breath, unresponsiveness or mental status changes, new fever and hypotension. Inform your supervising resident of these critical problems and elicit their opinion on the appropriateness of your response. Often it is necessary to see the patient. When you do, be sure to: 1. Place a brief incident note in the chart describing why you were called 2. Write a careful description of the patient 3. Write a directed physical exam 4. Indicate pertinent labs/tests performed 5. Indicate your impressions and what treatment (if any) was rendered We would recommend that for the first few months, you go to see all patients with complaints or problems until you become more experienced. Verbal Orders Verbal orders can be given in emergency situations, but all orders need to be entered by you into the EMR at some point in time. Do not rely on the nurse to enter the orders. If orders are not entered into EMR, mistakes will be made and patients will be hurt.
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Beeper Etiquette 1. Answer all pages as soon as possible and should be within a 10 minute time span. 2. FORWARD your pager to covering intern/resident when you leave. This includes night
float forwarding their pager to the morning senior resident when they leave. 3. DO NOT turn your pager OFF unless you change your status to "Not Available" 4. ALWAYS remember to change your pager status at the beginning of the day to "In
Hospital, On Page." 5. STAT pages have a "11" at the end or a “00” at the beginning of the call back phone
number 6. Do Not page someone to your pager; page them to a telephone 7. Place your pager on VIBRATE during ALL conferences and meetings 8. DO NOT turn your pager OFF during call rotations - you are expected to have the pager
on even when you sleep when on-call 9. DO NOT turn off your pager when you are on back-up call (JEOPARDY list) 10. Be sure to include your pager number with your call back telephone number in the event
that you are called away. 11. Try to keep the phone line open if you place a page to that line. 12. When placing a consult, leave a call back number (should also be physician to physician
communication for paging. 13. Include your pager at the bottom of your notes. Can be hard to contact people through
webextend sometimes. TIPS FOR INTERNS FROM INTERNS
If a patient is a poor historian, looking back in CIS is helpful as well as talking to family members. Previous Discharge Summaries, procedures and labs give lots of useful information. Getting a number to an outpatient pharmacy can lead to the list of home medications.
No matter what, maintain a positive attitude. It goes a long way in patient care and work relationships.
Maintain your sense of the world outside of residency. There is one! Maintain your relationships with your friends, family, and loved ones.
We all get overwhelmed. You are not alone if you feel this way. Just keep going, be calm, and try to remain positive.
Sometimes the different disciplines within the medical specialties enjoy slamming each other. Will this change? Probably not, but don’t perpetuate it by doing it yourself. Assume the care givers you work with are all out for the same goal as you—to get the patient the best possible care.
Try to rest the day before your call; you will need it.
Never forget to eat or use the restroom.
If you have any time during you call try to rest, the night can change dramatically.
Be ready to be paged for any crazy question from the nurses, but always remember you are a doctor and need to behave like it.
Be nice to everybody, no matter what is going on you are still part of a health care team and you need their help and cooperation.
Make a small plan of your expectations each month so you will have an idea of what you got from it at the end.
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Don’t be shy--if you don’t know ask, there is nothing wrong with not knowing.
Bond with your fellow interns—at least on a professional level. We are the only support one another have…look out for each other. Be constructive, helpful and supportive of one another.
Look to your seniors for answers. They may not have all the answers but they may be able to share some insight or guide you in the right direction. They have likely felt the same stresses or face the same questions before.
You may have an ongoing list of things to look up or to know. Feel good about looking up one or two things a day even if you don’t finish that entire list. You are in residency to learn and you will progress day by day. Be patient and stay positive.
Clinical work can be stressful. Take care of yourself so that you can give your best efforts to patient care. This includes sleeping, eating well, going to your own medical appointments, and exercising.
Always report exposures in patient care. Don’t be afraid to mention it to your senior or attending and go to Occupational Health in the UHC. Report the incident on MIDAS- Perfect Care website. These are more common than you think and it’s ok to be unsure of the next steps.
Keep track of potential case reports and participate in research. Speak to senior residents or fellows if have questions on how to get started.
TIPS FOR INTERNS FROM THE SENIORS
Senior residents were interns not too long ago, and in general they are aware of your
situation. If you think that is not the case, verbalize it and they will recall!!
Seniors might have become a "super intern" but they are still new as a "senior" as you are new as "intern". They may not be comfortable themselves functioning as senior and might have their own issues and frustrations.
If you are in doubt, always talk to the senior, they never mind a call. It is much better than to face adverse outcomes later.
If you think you are not getting enough support/guidance/backup from your senior, you should talk to the senior directly about it and try to solve it. If that does not work the safest way is to get support/backup from attending. Never leave your self alone without backup or support. You will slowly develop confidence in almost every matter and eventually will not need to ask questions that often, but that is the process of training.
All seniors have their own limitations and good seniors will reveal them honestly and handle them maturely. Some seniors won't and it may become frustrating. It is a very tricky situation, where a smart intern has to handle it very tactfully, understanding the fact that senior is feeling embarrassed and needs support themselves.
Try to find something interesting in your work even if you are bored by a particular month.
If the senior resident asks you to do something that you cannot do, simply say so without any hesitation.
Always express needed days off in advance. Most of the time requests are granted if at all possible.
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Never disappear without telling someone.
Be punctual. It is OK to be late on occasion but you should call/page if possible.
Always be honest and friendly! ADMISSION ORDERS Mnemonic ADC(x2) VANDALS A –Admit to: Attending/Resident/Interns (include names and pager #s) D- Diagnosis C- Condition (i.e. stable, fair, poor, guarded) C- Code Status V- Vitals (routine, q shift, q 4 hrs, q 2 hrs, etc. Include vitals call orders (i.e. call MD for T >100.5, SBP >180, or <90, pulse >120 or <60, RR >30 or <10). Adjust these to fit the individual patient. A- Allergies (List all known drug allergies and reactions) N- Nursing (i.e. SCDs in bed, Foley to dependent drainage, Strict I’s/O’s, Daily wts. Accuchecks q ac and q hs, O2 N/C to keep sats >94%, wound dressing orders, etc.) D- Diet (Regular, 2 gm Na, Diabetic ADA diet, etc.) A- Activity (as tolerated, out of bed tid, bedrest with bedside commode). Order activity based on pt’s fall risk, strength, need for activity. L- Labs (If writing for a.m. labs it is helpful to the unit clerks to include the date you want the labs to avoid confusion) S- Special Tests (i.e. CT scans, 2-D echo, Consults, etc.)
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Do not use” Abbreviations Use of abbreviations is discouraged. Avoid abbreviating drugs. The following will not be accepted:
Abbreviation Intended meaning
Misinterpretation Recommendation
U or IU Units or international units
Mistaken as a zero or a four when poorly written, resulting in overdose (ex: 4U 40)
“units”
g Micrograms Mistaken for “mg” when handwritten, resulting in overdose
“mcg” or “micrograms”
Lack of leading zero (.5mg)
0.5mg Decimal overlooked and mistaken for 5mg (overdose yet again)
Always use leading zeros when the dose is less than a whole unit (0.5mg)
Use of trailing zero (5.0mg)
5mg Decimal overlooked and mistaken for 50mg (you got it, another overdose)
Never use trailing zeros for doses expressed in whole numbers
TIW Three times a week
Misinterpreted as “three times a day” or “twice a week”
“three times a week”
symbol Hours Misinterpreted as zero (q3 every 30 minutes)
“hour, hr. or hrs.”
Q.D., Q.O.D. Every day, every other day
Mistaken for one another; period after the Q mistaken for an “i”
“daily” and “every other day”
MS, MSO4, MgSO4
Morphine sulfate, magnesium sulfate
Mistaken for one another “morphine sulfate” or “magnesium sulfate”
PRISONER PROTOCOL Incarcerated individuals are frequently admitted to our hospitals. Frequently they are cuffed to their beds and have 2 police officers watching them in the room. Never tell a prisoner patient when their follow up appointments will be. Any information that could assist incarcerated patients with knowing accessible moments is not to be given to them. Do not take or make phone calls on their behalf. You may not even be able to call their family. You will need to ask the appropriate Officers/Deputies before doing so.
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WRITING ORDERS PRN orders PRN" orders must include your criteria for administration. For example, simply writing Tylenol, 300 mg PRN is unacceptable. “Acetaminophen 300 mg 1 tab po q 4 hours prn low back pain” is ok. Use generic names if possible. IV Orders The same rule applies as for non-IV orders. To avoid confusion, each time you write for a new IV or make changes in an existing IV, include the following: IV solution, Volume, Additives, Rate. Change IV medications and fluids to oral as soon as possible; this is cheaper, fraught with less complications and demands less nursing and pharmacy time. Stat or Urgent Orders STAT= 20 min. Now = 60 min. Routine = 4 hours. After entering such orders, go to the patient's nurse and discuss them. This will minimize misunderstanding and expedite patient care. Always contact the consultant by phone if the problem is urgent. Stat orders should only be ordered if you will be making a medical decision based on that immediate result and if it is considered a life-threatening situation. ‘Now’ orders should result in immediate action or for pending discharge. Hours of medication administration Daily = given at 9 am every day, Q24 hr can specify time BID = given at 9 am and 9 pm TID = given at 5am, 1 pm, and 9 pm QHS= given at 9 pm TIDAC= 8am, noon, 5 pm Consulting pharmacy - Dosing of anticoagulation, certain antibiotics like: Vancomycin, Renal dosing, TPN management, Lab Tests Some general rules to follow: 1. Be able to justify every order you write and to explain the reason for every test required. There are no “routine screening labs”. 2. Repeat any grossly abnormal lab results, especially if they don't fit the clinical situation or the result is unexpected. 3. It is your responsibility to check and follow-up on every order you write in both the inpatient and outpatient setting. This must be done in a timely fashion. Do not let your attending rounder discover an abnormal lab result before you do. 4. Find out when phlebotomists will draw labs. Differs between hospitals.
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Radiographic Studies Always include pertinent details with each procedure request. This will allow the radiologist to read the film with some knowledge of the patient's clinical condition (and allow the hospital to get paid). Note that “rule out” notations are not permitted. Whenever possible, please check the “wet-read” on the study in question before paging the radiology resident on call. There will often be a preliminary interpretation entered by the on-call resident which may be sufficient until the official dictation becomes available on CIS (i.e. “no pulmonary embolus”, etc.) The Formulary System The Detroit Medical Center operates under a “closed formulary" system. In other words, there are a group of drugs, which are approved for use at our hospitals. A pharmacist will notify you if you have ordered a drug that is not available or requires permission of a subspecialist to use. Remember that the pharmacist is just doing his/her job
by calling you, and that there are usually very good reasons why particular drugs are "non-
formulary" or restricted. The pharmacist usually will be able to suggest a similar formulary item or assist you in obtaining non-formulary items or restricted drugs, if necessary. PROGRESS NOTES
You will be responsible for writing daily progress notes on each of your patients. A good progress note is brief and concise. What you write in the chart becomes a legal document – the chart is not an arena for opposing viewpoints on patient care to be discussed. The SOAP format is the most utilized for daily progress notes: S- Subjective. What the patient says or what the nursing staff reports. May be written as a direct quote or as a general statement. eg: “My stomach hurts” or “The pt. c/o stomach ache, denies other complaints” or “Nursing staff reports pt. fell out of bed last evening”. It is prudent to focus on main issues/problems during current hospitalization. Some attendings like to include: “Pre-hospital history”, “Hospital course”, and “Interval history” especially for complicated patients who have had long hospitalizations O- Objective. What you see, factual information. This section includes vital signs, I/O’s, physical exam, labs, and other test results. Lines, Tubes, and culture results can be included in this section A-Assessment. List pt’s main problems, in order of importance. If appropriate, give underlying causes for the problems and their current progress. Problems are to be
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described as an entity (i.e., 1. Diarrhea secondary to C. difficille colitis, improved on oral vancomycin. 2. Heme positive stools, possible secondary to colitis. 3. Hypertension currently under good control) or lumped into a “systems” format (i.e., 1. GI- diarrhea secondary to C. difficile improving on oral Vanco. Pt. continues to have occasional heme positive stools. 2. Cardiovascular- HTN under good control on current meds). Refer to ICD-10 guidelines. Always postulate a cause and suggest an evaluation/treatment plan for any abnormalities. If you write that a patient has abdominal pain last night in the subjective section then you must put what you think is causing the pain, and what work-up or treatment is needed (if any) in the A/P section. Similarly if you note that the pt’s hematocrit fell 5 points, don’t just write this in the lab section and then forget about it. Why did it drop and what are you going to do about it???? P- Plan. What do you plan to do about the problems listed in the assessment? This may be separate from your assessment or, most commonly, integrated into your assessment. Including discharge planning here regardless of how far away in the future you think that will happen is helpful. It helps to assure that at the time you are ready to discharge less emergent things don’t hold the discharge up (i.e. social issues, insurance, home PT, etc.) POWER NOTES – TIPS Creating a Note *Double check that you have selected the correct note TYPE. Once you “save” a note, it
cannot be deleted. If you do start a wrong report type, enter it “In Error” and copy to the correct note type; otherwise no one will be able to bill/find your note for that day/type.
*Create a list of “favorite” note types from the Power Notes Catalog. Include H&P, Progress Note, Brief Incident Note, Consultation and Discharge Summary (at the least).
*Try not to “Copy to New Note” because every day is different and your note should reflect this.
Note Types – specify title to the specialty if on consult service *Each patient MUST have a Progress Note for EACH 24h period. i.e you must write a note
on all of your patients daily. You can write a note in the evening and “back-date” it for earlier in the day if you need to.
*Use a Brief Incident Note for any major events that happen either on your own patients or while you are covering (i.e on nightfloat). These notes DO NOT require any of the normal parts of a progress note (SOAP format) and it is acceptable to include only pertinent details of what happened.
*Discharge Summaries need to be done within 24h of pt’s discharge. A D/C Summary which includes a physical exam and Subjective can be used as the daily Progress Note. If you are anticipating a D/C, save yourself from having to do 2 notes and just do your D/C summary right away. This may not apply if the patient is discharged on day of admission. The VA has it’s own rules about notes. Discharged patients require a
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Discharge Note and Discharge Summary (Discharge Summary can be withheld if patient was an observation patient).
Completing your Note *You do NOT need to include daily labs or results of imaging. For billing purposes, you can
simply put “reviewed” under these sections. *BE SELECTIVE about information you include. It is bad “power notes etiquette” to include
long lists of vitals, labs (especially irrelevant ones) and old imaging results. No one wants to scroll through, or even worse- print, that many pages!
*Do not simply copy/paste physical exam from day to day. If you did NOT do it, do NOT document it. For billing purposes there is NOT a minimum number of systems examined; but the more you do, the higher the billing level. Documenting that you examined something you didn’t is FRAUD.
*Do not simply copy/paste the assessment & plan. The plan on a patient is different every day, even if only in minor ways… your documentation should reflect this.
Signing you Notes *You can re-open and edit a “Saved” note later. But you MUST click “correct document”
instead of “modify document.” If you click “modify”, an addendum will be added and the attending will NOT be able to sign or add their own addendum.
*This is your last chance to change the date/time of the note, so if you haven’t done it yet and need to… don’t forget!
*When you actually SIGN the note, make sure only the attending you want to send it to is on the “Endorser” list. The system will send the note to EVERYONE on that list, so make sure you remove every other attending you don’t want getting it.
Clinic Notes For new patients you must document the PMH, FH, and SH in the Histories section of the EMR. For old and new patients click review>“detailed” under the history section (even for the first visit) for this information to appear on the final note. - Please provide a social history that includes more than risk taking behavior. Document marital status, sexual preference, HIV status, occupation, etc. Reconcile your meds! Look at the med list and STOP meds that the patient is not taking. It is unfortunate but our EMR does not automatically stop meds that run out. A course of antibiotics from 2011 still shows up on the med list unless you stop it. We share a medical record with everyone in UPG. The med list must be accurate Coding: screening should be listed last in the A/P - don’t use “Routine exam” for patients who have medical problems. Many insurance companies will not cover more routing exam or cover more than one exam per year. If it is listed first or in the first four diagnoses your patient may incur costs.
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You must complete the “My Plan” for every patient before they leave so that it can be printed and given to them before they leave. When you complete ask the patient to schedule the appointment specifically with YOU. Also, ask your patients to take a picture with their phone of all the medications they take. Having a photo of each bottle with the name of the med and pharmacy will help with med reconciliation.
HOW TO PRESENT A PATIENT INPATIENT, New Admission: Introduction The ultimate goal of the oral presentation of a medical case is to provide a basis for decision-making. Each presentation should include: 1. Chief complaint 2. History of present illness (beginning from the time the patient was in usual state of
health). 3. Important facets of past medical history, family history, social history and systems
review 4. Vitals. Then positive as well as pertinent negative findings of the physical exam 5. Medication list and allergies 6. Labs and imaging – your interpretation Assessment includes generating a problem list, differential diagnosis and evaluation and treatment plan. Such discussion requires the presenter have detailed knowledge of then patient’s course and/or problems. Chief Complaint Be concise and clear. The goal is to convey the reason for which patient is seeking attention. History of Present Illness (HPI) The HPI must begin with the age & sex of the patient. The HPI is a succinct discussion of the chief complaint including mode of onset, acuity, intensity, progression, current severity, course of the illness, exacerbating factors, relieving factors, risk factors and the degree of disability caused by the illness. In addition, there should be a discussion of associated symptoms and their temporal relationship to the chief complaint. Any current or attempted therapy should also be described as well as the response or reaction. Pertinent aspects of other portions of the history including past medical history, medications, allergies, social history, family history and systems review should then be described. Physical Examination Start with vitals. This is where you would present vitals from the ED and initial physical exam findings. The physical examination should begin with a brief description of the
patient’s general appearance and vital signs. In a quality presentation, emphasis is placed
on those areas likely to be involved based upon your assessment of the patient’s history
including both pertinent positives and negatives. Portions of the physical examination, which are normal, should be described as being normal" or "unremarkable". Convenient
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divisions of the physical examination include general appearance, vital signs, HEENT (head, eyes, ear, nose, throat), neck thorax (chest, back), lungs, heart, abdomen, rectal, pelvic/genital, and neurological. Lab Studies and Imaging Results of appropriate studies will then be presented along with interpretation and application to the presented patient. Summary At this point many presenters elect to give a 2-3-sentence summary of the H&P leading into the assessment. If presenting a complicated patient, a brief summary may be an excellent addition. Assessment Depending upon format and the individual case, the presenter will then give his assessment of the case. This is where diagnostic reasoning occurs (i.e., grouping of data), resulting in a provisional diagnosis or medical syndrome with a list of potential diagnoses ranked according to probability. Start with the most important issue first. Give your reasoning for the plan. Additional Advice Limit the length of the entire presentation to between 5 and 10 minutes. Simplify the presentation wherever possible because the longer or more complex the discourse, the greater the likelihood of a somnolent, confused audience. Omit irrelevant details. If members of the audience desire further details, be ready to satisfy their curiosity. Clarifying questions are a normal part of the case presentation. If your patient has multiple problems or illnesses, which are unrelated, recount each separately in chronological fashion. Do not try to simultaneously discuss the course of multiple problems as they evolve through different points in time. References Yurchak, PM: A guide to Medical Case Presentations. Resident and Staff Physician, September 1981; p 109. Kraenke, K: The Case Presentation: Stumbling Blocks and Stepping Stones. AM J Med 79:605, 1985.
INPATIENT, Follow-up:
Format of Presentation
1. Brief introduction sentence: Patient’s name, age, date of admission, and working diagnosis
2. Symptoms complained of by the patient over the last 24 hours. 3. Interval developments (subjective) 4. Pertinent physical findings
a. Vital signs (blood pressure (range), pulse (range), respirations, Tmax) b. Other pertinent physical findings
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5. Present new data from the past 24 hours a. New laboratory data over the last 24 hours b. New radiology, ultrasound, or MRI results c. New diagnoses or recommendations from consultants seeing the
patient over the last 24 hours 6. List all medications that the patient is currently being given (including drips and
prn meds) 7. Problem list
a. List in order of importance b. Include most recent impressions regarding each problem c. Assessment and plan for each problem*
AMBULATORY, The problem-oriented patient presentation: The "problem-oriented technique" jumps from an opening sentence directly to the processed data (problem list, assessment and plan). Example Mr. Doe is a 62-year-old man, complains of increased shortness of breath for the last month. He has the following problems: 1.Hypertensive heart disease - past history of HTN, for the last 20 years. Cardiomegaly on previous CXR; EKG and physical exam (LVH, S4, S3+ and BP of 160/100) 2.Congestive heart failure - based on history of PND, orthopnea and presence of S3. Previous CXR (cardiomegaly and interstitial markings) 3.Peripheral vascular disease - based on history of intermittent claudication diminished peripheral pulses on both legs (2/4) Assessment Problem 1 and 2 are chronologically and etiologically related. Problem 2 seems to be aggravated by suboptimal blood pressure control and needs more aggressive treatment. Problem 3 probably caused by atherosclerosis and is mild. Plan Control hypertension by afterload reduction that will also better control the congestive heart failure. We may consider digitalis and diuretics. DISCHARGE PLANNING All of this information is electronic and needs to be filled out in order to properly discharge a patient. If you keep up the patient’s medication list/ reconciliation, and what has happened during the stay, it will make writing the discharge summary a lot easier. Our Care Management Team is a group of RN’s that assist us (along with Social Work) in getting the patient discharged in a way that ensures the patient has what they need when returning home. If a patient has any special social needs, equipment, a unique social
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situation, then get the Care Management Team involved (write an order/consult—RE: Consult for D/C planning) at the onset. Also, you will have to fill out a paper form to support what they need when the patient gets D/C’d (like diagnosis, basic meds, why you feel they have special needs, etc.) This form is different at each facility. Find a nurse; ask them which form to fill out. Home oxygen – evals (by respiratory therapy) need to be done the same day or day before (within 24 hrs) discharge - need Durable medical equipment order for oxygen including delivery method (nasal cannula), rate (at rest and exercise), and if oxygen conserver is needed. Print and put in chart. Patient cannot leave until o2 cannister is at bedside or if ambulance is transporting patient. Appointments:- Recommend that patient follow up with their PCP in a few days or find them a PCP if they do not have one. -To make appointment for patients with consultants in WSUPG call: 313-745-4525. Medical students can help with this. Prescriptions: -Need to write DEA #, pager and NPI # on narcotic prescriptions. Make sure that insurance will cover anticoagulants or antibiotics before you discharge the patient. SAR: If discharging to acute inpatient rehab, you need to place a consult to PM&R (Lawrence Horn) and have PT/OT see the patient? Nursing homes: - Prior to being discharged to a nursing home, patient will need a recent chest xray, every prescription printed and signed, ambulance form PT/OT consults as well as respiratory therapy notes are found under ‘Forms’ Social Work and Case Manager notes are found under Clin Doc – Patient Care Support Services. Over the weekends cannot organize: LTAC placement, ECF for vent, new nursing home, SAR placement, transfer to EQ, home infusion (unless receiving prior to admission), home oxygen, complicated or custom durable medical equipment, medications or other items that require insurance prior authorization The Care Management pager number for after hours and weekends: DRH – Call the ER for Social Work on call. Phone at Detroit Receiving ER Dept: 53580 Harper – Pager 5900 VA—(0800-1630 on weekends) page 1135, pager #9667 See VA phone list for a zillion other contact numbers… Case Management v.s. Social Work *Below is a guide to assist in selecting the correct discipline for the task that needs to be performed.*
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Consult CMS for: Consult SW for:
Homecare – Visiting Nurse/Physician Return to or New Nursing Home
placements
DME (Durable Medical Equipment) –
Walker, wheelchair, cane, etc.
Hospice Nursing Home placement
IV Antibiotics – consult needed 24hrs
prior to discharge
Adult Foster Care (AFC) placements
Home Oxygen – Needs Respiratory
Therapy home O2 eval. same day as
discharge
Substance Abuse Programs
Home Situation Evaluation Psychiatric Placements
Home Hospice Community Resources
D/C Medications – including med. assist
program.
Identify Mary & John Doe
VA or other Hospital transfers Locate Family Homeless - shelter/room & board (low
cost/free Clinics, free meds)
Prisoner discharge – only if significant
change in function
Domestic Violence & Abuse situation/
programs
Subacute Rehab Placement ( short term)
Long Term Acute Care (LTAC) and vent
placements
DISCHARGE FROM THE ICU
1. Patient being discharged to: Ward LTAC Home? 2. The bed:
a. Telemetry needed? b. Daytime NPPV needed? If yes, stay in unit. c. Nocturnal NPPV needed? If Yes, is bed NPPV appropriate (DRH only)
3. The patient: a. Are there CVCs, a-lines, cordis, introducer sheaths?
i. Remove a-lines, cordis, sheaths ii. Can CVC be removed? iii. If not, place order for PICC/middling/alternative iv. Is Quinton being used? If not, can it be removed?
b. Is there a foley? Can it be removed? If not, document reason in transfer note.
c. Is there a tracheostomy? i. If yes, secretions <Q2h. ii. If it is new, which service is following? Document.
4. Are there restraints? Can they be removed? If not, document reason why in transfer note.
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4. The chart: a. Remove all vasoactive drugs from the MAR/orders. b. Convert all antihypertensives to PO/PEG/NGT if possible. c. Are IV sedatives needed? d. Ensure all medications are appropriate for the floor.
5. The followup: a. What labs, consults, radiology, etc… need to be followed up on? b. Document in transfer note.
6. Loop closure: a. Complete transfer summary b. Medication reconciliation (see Step #d above). c. Notify family – give exact location of new bed. d. Call accepting physician. – document name/pager in transfer note. e. Notify pt’s RN when report is given.
DICTATING NOTES All/most notes are now done electronically on the EMR, either CIS (at DRH & HUH) or VA system. However, sometimes when rotating at Karmanos certain attendings still want their notes dictated. Below is a re-typed version of the dictation cards that are used and may be found in Medical Records. Dial 6-6666 from any DMC/Karmanos phone, 313-966-6666 OR dial 1-800-442-1791 Enter beeper# Enter site code
Site code Detroit Receiving Hospital- 04 Harper University Hopsital- 05 Karmanos- 10
Enter report type Report type History and physical = 31 Inpatient progress note = 37 Discharge summary = 50 Consult = 32 Echo = 45 HealthSource Clinic= 62 Admission note = 33 Exercise stress test = 46 Operative note = 34
Enter Patients account/FIN number followed by the # key. 5 to end 2 = dictate / pause 3 = jump back………then 2 4 = go to end……….then 2 5 = disconnect 77 = rewind to beginning ….then 2 8 = end report and begin new ## = replay header…………then 2 Problems? call (313) 745-5070 OK, so now you know how to negotiate through the system…Here is a suggested format for dictating. The templates in CIS will get you through the typed summaries.
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1. Start with the date of service (ie, date of admission and discharge) 2. State your name and pager 3. State who (Attending) you are dictating for, and the doctor’s pager number 4. Patient name (spell this out), MRN, and FIN # 5. Admission Date, Discharge Date 6. Primary Diagnoses 7. Secondary Diagnoses 8. Procedures (invasive) and dates 9. Problem list (at the end, what did they have, what were we following) 10. HPI (don’t repeat the entire admit note, just summarize why the patient was
admitted, what led up to it, initial triage vitals and initial plan, pertinent labs) 11. One by one, review the problem list and how each was addressed during the
stay 12. Give vitals and brief exam of patient at time of discharge 13. List discharge plan, with disposition to location (i.e. nursing home, home, etc) 14. List discharge meds, dosages, and frequency 15. Restate your name, pager, who you are dictating for and patient name.
When you disconnect, get your pen ready to write down the job ID# in the patient’s chart. Keep it in case it gets missed somehow…. CONSULTS When you are calling a consult (GI, rheumatology, ID, etc.), there are a few points you should ALWAYS convey to the consult fellow:
1. Identify your name and context of the call (i.e., My name is Dorothy Lowe and I am the resident on the wards)
2. Identify the nature of the call (i.e., I am calling because we are admitting a patient that I would like you to consult on OR This is not a formal consult, but I would like to ask you a curbside question)
3. Identify the question you are asking—THERE MUST ALWAYS BE A QUESTION! (i.e., for colonoscopy on a rectal bleeder OR for bronchoscopy on a pt with suspected PCP pneumonia OR to help us in the evaluation/management of a patient with advanced AIDS and mental status change, etc.)
4. Give a brief outline of the patient’s history and presentation
You should always assess the patient yourself prior to calling the consult!
Do not ask the fellow to see the patient before you do!
Formulate your own ideas of what is going on with the patient and convey this to the consult fellow so that you can have an educated and educational discussion!
You should have as much pertinent information as possible prior to calling the consult (i.e., vital signs and Hemoglobin in a GI bleeder, CD4 count for an HIV patient, etc.).
If you are not certain why you are calling a consult, figure it out before calling—“my attending wants a consult but I don’t know why” is not appropriate.
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Try to call consults as EARLY as possible (prior to rounds, or at least before noon conference)—otherwise you may not get input from the consult attending until the following day.
Please be appropriate and professional in your interactions with fellows and attendings— remember that we are all working together in order to take care of patients in the best possible way, and this requires collaboration that requires effective communication.
DEATH NOTE *Note: If called to pronounce, use this as a guide; obviously, your actual note should reflect the pt’s clinical situation. **Note: Make sure the pt is really dead prior to pronouncing. Date/Time I was called by nursing to see this No Code Blue patient who was pulseless and breathless. On my physical exam, the patient was found to be without carotid pulses, heart tones, or breath sounds. Pupils were fixed and dilated. Patient was pronounced dead at (time and date). Dr. PMD was notified. Family was present at bedside (if they were) or contacted. Joe/Joanna Intern, MD. NOTE: Do not use abbreviations or cross things out on death certificate. Medical records will track you down and make you RE-DO it… even if you’re on vacation!
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SECTION 3: Documentation & Billing
MEDICAL DOCUMENTATION - CHARTING Residents are responsible for writing a complete history and physical examination for each patient for whom they admit. It must be placed in the computer at the time of hospital admission. Daily progress notes addressing all active problems must be typed into CIS by at least one member of the team. Student’s progress notes are forwarded to a resident or attending physician to co-sign. In addition, the intern must write a complete note every day for any patients that are seen with a junior student. Senior students (Sub-I’s) do not have to be accompanied by a housestaff note but have to be cosigned by the resident or attending. Discharge summaries must be completed on the day of patient discharge. This is the responsibility of the PGY-1. If there is no PGY-1, the PGY-2 or PGY-3 must do it. Senior residents will be contacted to complete discharge summaries for sub-interns who do not complete their discharge summary. If a patient is transferred to another service, a detailed transfer note must be written. The transfer note is structured similar to an H+P and should include an HPI outlining the pertinent hospital course, a complete physical exam (with findings at the time the note is written, not on admission) and should conclude with a problem list which serves as an “assessment and plan”. The problems should be ordered by importance or urgency. The student-resident team, prior to rotating to a different service must write complete "off-service" notes. Such notes must be provided for all patients not discharged at the time of rotation. An "off-service" note is not required if the patient was admitted the day prior to service change. If this is the case then a complete History & Physical will be sufficient. Residents who are delinquent with discharge summaries may be given additional "back-up" (jeopardy) call responsibility and may lose moonlighting privileges. Record keeping also is an important component of monthly and semi-annual evaluations. In addition, satisfactory record keeping is an expectation of the ABIM for board eligibility and of hospitals to which physicians apply for staff privileges. Chronic incomplete charts will be dealt with directly by the program director or their delegate.
LEVEL OF SERVICE LEVEL 1-LOW LEVEL 2-MOD LEVEL 3-HIGH
CC Required for all levels
HISTORY 4 Elements of HPI required (Location,
duration, quality, severity, timing, context,
signs and symptoms)
4 Elements of HPI
SYSTEM REVIEW None 1 System 2-9 Systems
PAST, FAMILY,
SOCIAL HISTORY
Not required for interval history
EXAM
* REFER TO DEFINITIONS
Problem Focused
1 System
Expanded Problem
Focused 2-7 Systems
Detailed
5-7 Systems
MEDICAL DECISION
MAKING
Low Complexity
Stable, improved
Moderate
Complexity
Not responding to
treatment or
development of a minor complication
High Complexity
Unstable or
development of a
new problem or
significant complication
COUNSELING &
COORDINATION OF CARE
When 50% or more of encounter is spent counseling or coordinating
care, document time spent & description of services. Bill for level that corresponds to time increment (See time guideline).
CRITICAL CARE Document start/stop time with critical care notes
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NEW OFFICE PATIENT AND CONSULTATIONS *Key Components (History, Physical, Decision Making) 3 of 3 Required
LEVEL OF
SERVICE
LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5
CC Required for all levels
HISTORY 1-3 Elements 4 Elements of HPI required for all levels
(Location, duration, quality, severity,
timing, context, signs & symptoms etc.)
SYSTEM REVIEW
N/A 1 System 2-9 Systems 10 Individual system review or list pertinent
negative and positive
findings with a note “All other systems are negative”
PAST, FAMILY,
SOCIAL Hx
N/A N/A 1 of 3
Required
3 of 3 Required
EXAM * REFER TO
DEFINITIONS
Problem Focused
1 System
Expanded Problem
Focused
2-7 Systems
Detailed 5-7 Systems
Comprehensive 8 or more systems
MEDICAL
DECISION
MAKING
Straight
forward
Straight
forward
LOW Moderate High
ESTABLISHED OFFICE PATIENT
*Key Components (History, Physical, Decision Making) 2 of 3 Required LEVEL OF
SERVICE
LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5
CC Required for all levels
HISTORY 1-3 Elements 4 Elements of HPI required for all levels (Location, duration, quality,
severity, timing, context, signs &
symptoms etc.)
SYSTEM
REVIEW
N/A 1 System 2-9 Systems 10 Individual system
review or list pertinent
negative and positive
findings with a note
“All other systems are
negative”
PAST, FAMILY,
SOCIAL Hx
Not Required for level 2, 3 1 of 3 past, family or
social
2 of 3 past & family & social
EXAM * REFER TO
DEFINITIONS
Problem Focused
1 System
Expanded Problem
Focused
2-7 Systems
Detailed 5-7 Systems
Comprehensive 8 or more systems
DECISION MAKING
Straight forward
Straight forward
LOW Moderate High
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INCLUDE COMPLEXITY COMPONANTS
Established problems – stable, improved, worse
New Problems – additional workup
Review and/or ordering of labs, x-ray, medical tests
Discussion of test results with performing physician
Independent review of image, tracing or specimen
Decision to obtain old records and/or obtain history from other than patient
Review and summary of old records
Obtaining history from someone other than patient TIME GUIDELINE
LEVEL OF SERVICE
LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5
NEW PATIENT OFFICE
10 MIN. 20 MIN. 30 MIN. 45 MIN. 60 MIN.
ESTABLISHED OFFICE
5 MIN. 10 MIN. 15 MIN. 25 MIN. 40 MIN.
CONSULT OFFICE
15 MIN. 30 MIN. 40 MIN. 60 MIN. 80 MIN.
CONSULT HOSPITAL
20 MIN. 40 MIN. 55 MIN. 80 MIN. 110 MIN.
SUBSEQUENT HOSPITAL CARE
15 MIN. 25 MIN. 35 MIN. N/A N/A
DOCUMENT:
Total time (teaching physician time only)
Time spent counseling (must be at least 50% of visit)
Issues discussed
GENERAL MULTI-SYSTEM EXAM Documentation Requirements
CPT EXAMINATION DEFINITIONS Problem Focused: A limited examination of affected body area or single organ system Expanded Problem Focused: A limited examination of affected area or organ system & other symptomatic or related organ system (2-7 systems) Detailed: An extended exam of the affected body area(s) and other symptomatic or related organ system (5-7 detailed body systems)
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Comprehensive: A general multi-system exam (8 or more systems) or a complete examination of a single organ system RECOGNIZED BODY AREAS FOR CPT EXAM DEFINITIONS
Head, including face
Neck
Abdomen
Genitalia, Groin, Buttock
Back
Each Extremity RECOGNIZED ORGAN SYSTEMS
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Musculoskeletal
Skin
Neurological
Psychiatric
Hematological, Lymphatic, Immunological NEW INNOVATIONS – Responsibilities and Documentation: You MUST:
1. Log your duty hours and log them truthfully. You don’t need to log every day, but if you get behind, it becomes a big chore.
2. Complete all of your evaluations. 3. Complete conference surveys – must be done for conference credit. 4. Log all of your procedures. 5. Log all of your mini-CEX -> can be completed by senior residents, fellows,
attending’s. Require 5 in PGY-1, 3 in PGY-2, 2 in PGY-3. 6. Confirm curriculum for each rotation.
Required procedures before graduation: 5 arterial blood draws, 5 venous blood draws, 5 ACLS participation, 5 pap smears, 5 IV placements, 50 EKG interpretations. Document these as you go so they are not all left to the last minute. E-mail the attendings that you need to sign off on the procedures. If they still do not sign off on the procedures. Ask the program director what he recommends.
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SECTION 4: Teaching Information ROLE OF RESIDENTS IN TEACHING SENIOR RESIDENTS PGY-2 and PGY-3 (senior) residents are responsible for daily teaching of medical students and PGY-1 residents. This includes the observation and evaluation of performance of histories and physicals as well as reading and critiquing their write-ups and daily progress notes. They serve as important role models in the development of the students' attitudes, interpersonal skills and clinical skills. They will conduct morning patient care rounds and supervise the student and PGY-1 in the evaluation and management of all patients on the service. They will assist the assigned faculty teaching rounder in conducting daily teaching rounds, encourage the students to attend the regularly scheduled conferences, and conduct daily check-out chart rounds. The PGY-2/3 resident also is responsible to have the initial contact with the admitting physician (ER, Outpatient Clinic, transferring physician, etc.). He/she must personally evaluate all patients admitted to his/her service, write an admit note, and oversee care provided by students and PGY-1s. The senior resident is both a supervisor and teacher. As such he or she is required to review appropriate medical literature, teach and assign topics for team members. In addition, he or she should provide meaningful and timely feedback to both students and PGY s. Please read and observe the addendum at the back of this manual for the current resident-intern-student team organization. INTERNS The PGY-1 resident is responsible for the delivery of health care to his/her assigned patients. The intern must be on the wards early enough to examine their patients prior to work rounds. Actual arrival time may vary depending the particular intern’s efficiency, patient load and acuity of illness. The intern will assume responsibility for his/her patients at 7:00 AM. The senior resident determines what time work-rounds begin. All member of the team are expected to be present for work rounds (with the exception of those members who are off). Work rounds are to be made at the bedside and not in a conference room. This allows the senior resident to review patients and the plan prior to attending rounds. The intern will be sure that full communication of patient status and care is maintained with the attending physician. S/he will know every aspect of the patient's condition and problems in detail and make sure these are documented in the medical record (in the initial history and physical examination and in the daily progress notes). The intern will leave the hospital no earlier than 4:00 p.m. and only when patients are stable or when assured that patient care will be provided by a colleague (after sign-out rounds).
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Post-call (for overnight calls) residents are to leave the hospital by 11:00 a.m., as per ACGME regulations. These timing may change and would be reviewed by CMR in observation at beginning of each block in ‘orientation”. S/he is responsible for the education and evaluation of junior medical students. MEDICAL STUDENT EXPECTATIONS YEAR 3 STUDENTS are expected to: 1. Be on the wards early enough to examine their patients, review all new data and be
prepared to present their patients to the senior resident and Faculty Attending at work/management/teaching rounds. The students must attend both patient care and teaching rounds Monday through Friday, and to be at the hospital if on call Saturday and/or Sunday.
2. Work-up a minimum of 12 patients during the Internal Medicine clerkship. This
translates to approximately one patient per call with an occasional admission during the day. Histories and physicals will be reviewed by residents, or attending rounders.
3. Write daily progress notes, noting the course of illness with detailed assessment and
the basic management plan for each assigned patient (reviewed and signed by resident).
4. Attend the Year-3 teaching activities. In addition, they are expected to attend medical
grand rounds, morning report and as many of the other conferences as possible. 5. Participate in discharge and home care planning for their patients. Procedure Manual/New Innovations Each student is required to keep a procedure log documenting the required number of specified procedures. They need the help of residents and teaching rounder(s) to learn indications, contraindications and methods of performing the procedures. All procedures must be documented and recorded in New Innovations. Minimum Proficiency Standards Year-3 Students must be able to: a) Perform a complete, orderly and technically correct H&P on each assigned patient. b) Accurately, legibly record H&P in clear, logical fashion on each assigned patient. c) Make a complete problem list and do this on each assigned patient. d) Identify common syndromes (e.g., congestive heart failure, stroke). e) List common components of the differential diagnosis for patients with problems
presented in seminars. f) Realize when they need help handling or advice regarding care of a patient and seek
such aid from appropriate supervisors. g) Concisely (within 5-10 minutes) present the H&P for any patient that they work up. h) Demonstrate appropriate interpersonal skills in interactions with patients, peers,
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supervisors and ancillary personnel. i) Demonstrate adequate medical knowledge of common problems, pathophysiology and
syndromes. YEAR-4 STUDENTS Year-4 students are referred to as “sub interns.” As the title implies, these students function at or near the level of PGY-1 trainees. The two important areas of difference are in: 1) patient numbers, and 2) order writing. In general, Year-4 students may handle 4-6 patients at a time, and may accept 1-2 admissions during a call night. Year-4 students are expected to arrive at the hospital at the same time as other team members. They are responsible for writing H&Ps and daily progress notes (to be reviewed and signed daily by the resident), writing all orders on assigned patients (to be reviewed and signed daily by the resident), and for reading a standard internal medicine text and appropriate literature relating to the problems presented by their patients. In addition, they are to "sign out" their patients to the cross-covering team before leaving on a non-call night. They are responsible for writing ”off-service" notes and discharge summaries, and for typing/dictating discharge summaries for all patients under the supervision of the resident. Minimum Proficiency Standards a. Satisfy those objectives listed for Year-3 students outlined in this manual and in addition
they must... b. Demonstrate less dependence on supervising residents in identifying abnormalities on
physical exam in articulating patients probable diagnosis and his/her management plans.
c. Demonstrate a broader knowledge base and willingness/ability to use the medical library, literature, and literature search as they relate to patients under their care.
d. Demonstrate a maturing attitude of commitment and advocacy for each patient under his/her care.
e. Demonstrate increasing proficiency in procedural skills listed in objectives.
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RESPONSIBILITIES TO OUR MEDICAL STUDENTS
Words from Dr. Diane Levine
Introduction: Supervising residents are integral to the education of the students on the Internal Medicine clerkship. You are no longer a medical student but are now part of the core “faculty,” one of the teaching physicians. This manual was developed to provide you with important information about the clerkship. It includes a description of the goals and objectives for student clerks, expectations for the rotation and outlines your role and responsibility as a supervising resident. We hope you find this material useful. When you have completed reviewing the manual, please sign the attestation your student will provide to you. Note: students are responsible for being familiar with common problems seen on an in-patient Internal Medicine service. Review this list and try to discuss an approach to these common problems as they relate to your student’s patients. Assign specific topics from this list to assist students in preparation for the National Board of Medicine Subject Examination or “shelf exam.” The Junior Year The junior year of medical school is the first clinical year for WSU students. During the primary care block, students rotate through two months of Internal Medicine, two months or Pediatrics, and one month of Family Medicine. During the primary care block all students participate in a mandatory “Continuity Clerkship” and leave their respective rotation for one half day a week to participate in an ambulatory primary care experience. As a consequence of the scheduling, you will notice distinct differences in the way students perform at different times of the year and within each six month block. Clerkship Orientation: On the first day of the clerkship, students are required to report to the School of Medicine for a large group orientation. Goals and objectives for the Internal Medicine Clerkship are introduced. Student expectations are discussed. Policies regarding absences are reviewed. Students are provided with information detailed the processes by which their performance in the clerkship will be evaluated and how overall grades are awarded. Students are notified of important dates including dates for ACLS*, last day of the clinical rotation the final examination date Orientation to your service: Students generally report to their assigned teams on the second day of the clerkship. You will most likely meet your students first thing in the morning. Encourage students to keep an open mind and consider Internal Medicine as a career option. Let them know how and why you decided to go into Internal Medicine. Now it is time to orient you students to your service. Make sure to review how your team is organized and how your day/week/month is structured.
Assign students to the appropriate interns.
Discuss the daily schedule.
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Inform students what time they need to arrive at the hospital.
Define what time you want your team prepared to round and where you wish to meet.
Discuss how attending rounds are organized
Discuss conferences
Determine when x-ray rounds, peripheral smear rounds etc occur
Discuss how sign out rounds are made
Discuss how topics are assigned.
Review the call schedule. Make sure students understand call at your hospital.
Review clinic schedules. Note: students are excused from hospital duties one half day a week to attend their mandatory Continuity Clerkship.
Discuss how days off are handled at your hospital/institution.
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Explicating reviewing expectations at the beginning of the month sets the tone for a successful month and provides the basis for end of the month evaluation. Resident role and responsibility The role of the supervising resident is to teach and evaluate students during their Internal Medicine clerkship. Remember, interns and residents spend more time with junior students than any other member of the healthcare team including the attending physician. The clinical supervision and teaching residents provide makes a difference in the kind of education students receive on the clerkship. Help your student to succeed! You can do this by
Helping students learn his or her way around the hospital
Reviewing hospital forms with your students
Reviewing H&Ps and SOAP notes
Reviewing how to write orders
Teaching students to interpret primary data including EKGs, chest radiographs, gram stains, and basic laboratories (CBCs, peripheral smears, electrolytes, renal function, and liver function tests)
Providing opportunities for your students to practice presenting new and follow up patients
Teaching students how to keep track of their patients and daily lab results
Helping students prepare for attending rounds
Helping students to organize their work day
Keeping track of patients assigned to ensure students are exposed to as many different problems and diagnoses as possible
Providing feedback for your students In summary, resident physicians are expected to teach and guide student to them achieve the goals and objectives of the clerkship and understand the principles of Internal Medicine. In addition, resident physicians are important in helping students adjust to their new role as a student doctor. Feedback and Evaluation: Students need to receive feedback. Furthermore, feedback should be well timed and specific so students can incorporate feedback and improve their performance. Students should receive feedback in all areas of evaluation including:
Application of knowledge in the clinical arena
History taking
Performance of a physical examination*
Communication and relationships with patients and families
Professional attributes and responsibilities
Overall knowledge base
Written and oral case presentations
Record keeping (write-ups, progress notes)
Facility with technical skills and procedures
Communication and relationships with health care team
Self improvement and adaptability
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Residents will need to observe students performance in these areas in order to provide meaningful feedback. This can be challenging on a busy clinical service. Here are some suggestions:
Ask questions that probe the students’ knowledge base and the students’ ability to use that knowledge to answer clinical questions. Is the students’ knowledge appropriate for their level of training? Is it “satisfactory” or does it “exceed expectations?”
Provide opportunities for students to demonstrate physical examination skills. Physicians need not observe an entire physical exam, but should have the student demonstrate various components of the physical examination over the course of the month. Many resident use call or work rounds to access student skills in physical examination.
Provide regular opportunities for students to present their new patients and their established patients. What is the quality of the students’ presentations? Are the presentations organized? Does the student present pertinent positive and negative findings or is the student unable to filter important information? How does this student’s presentation compare with other junior students at the beginning, middle, or end of the year?
Provide feedback immediately following presentations using the sandwich technique (First comment on one positive aspect of the presentation, next note an area which can be improved—be specific, end on a positive note. For example, “you certainly had all the information on your HPI, now you need to work on the organization, start from when the patient was in their usual state of health and work forward. You already have the information, now all you have to do is rearrange it. I am confident you can do it.” Lastly make a plan for follow-up. “Why don’t you practice on this HPI and present it to me tomorrow after rounds, that way you will be prepared for the next H&P.”
Provide opportunities for student to discuss their assessment and their plan for patient evaluation and treatment. Can student identify the patient’s primary problem? Can students elaborate a well ranked differential diagnosis appropriate for a junior student? Try to have realistic expectations for your student. Remember this is their first experience on Internal Medicine and in July it is their first clinical experience ever.
Assign topics for your students to present that encourage students to demonstrate the ability to go to the texts and literature to answer clinical questions.
Review documentation (H&P and SOAP notes) noting detail, organization, and thoroughness. Note: Students will be required to turn in one H&P, progress note and discharge note to the site director for formal evaluation and feedback.
Observe interactions with patients, physicians and ancillary medical staff. Does the student act professionally?
Does the student take responsibility for his or her patients? Does he or she read about his or her patients’ problems, follow-up on laboratory abnormalities, complete notes in a timely fashion, and discuss significant changes with the supervising interns and resident?
How well does student accept feedback?
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Midmonth Feedback: Midmonth feedback is required. Unfortunately, students often do not recognize feedback unless it is identified as such. Furthermore, telling students they are doing a “good job” is often misinterpreted to mean they will get an “outstanding” on the final evaluation. This can be circumvented by providing feedback which both specific and timely. The School of Medicine requires students to complete a self-reflective midmonth formative evaluation form. You will be asked to review the student’s impression of their own performance. Please provide comments in the space provided and sign the form. Students are required to submit the form at the end of the rotation. End of the month feedback and evaluation: At the end of the month, resident physicians should sit down with their students and provide formal summative evaluation and feedback with suggestions for improvement. In evaluating students’ performance please remember that performance tends to improve as the academic year progresses. One should be careful not to under evaluate performance in July and August and not over evaluate performance in May and June. Attending physicians needing guidance in completing the evaluation form should contact the site director at their institution. Grading: Both faculty and residents evaluate student performance on the clerkship. Resident physicians must provide comments on their evaluations form as these are used by the Dean of students for students’ MSPE (Dean’s Letter) used for residency application!!! Final Clinical Grade: The final clinical grade is a composite based on clinical evaluations from attending physicians and resident physicians (but not interns) from both months of the clerkship and is assigned by the Internal Medicine Clerkship Director at Wayne State University. As defined in the curriculum guide, students must receive a minimum of 50-% of “outstanding or “exceeds expectations” in each category to receive “exceeds expectations” in that category. Students receiving seven or more “exceeds expectations” on the composite grading form will receive a final clinical grade of “Outstanding.” Students achieving less than seven “exceeds expectations” will receive a final clinical grade of “Satisfactory.” Students with evaluations of “Does Not Meet Expectations” will be closely reviewed by the Clerkship Director to determine if that student fails the clinical portion of the rotation. Final Grade: All students must take and pass the national subject examination commonly known as the “shelf exam” to successfully complete the clerkship. The final grade is assigned by the Clerkship Director and is based on both the final clinical grade and the performance on the shelf exam. The Department follows the grading policies of the School of Medicine for Year III Clerkships. (Please consult curriculum guide).
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SECTION 5: Medical Information & Tips
ACUTE EMERGENCIES – You Must See the Pt Immediately! ALTERED MENTAL STATUS 1. Questions during initial phone call:
- Vital Signs - What is the change in level of consciousness? - Is the patient diabetic? - How old is the patient?
2. Orders over telephone: - Accu-Chek, O2 saturation, new set of vitals (if not done already), ± EKG
4. Initial Evaluation: “DON’T” D50, 1 amp after thiamine if accu-check available Oxygen with oropharyngeal airway if necessary Naloxone, usually 0.4-1.2 mg IV q2-3 min if even remote possibility of opiate OD Thiamine, 100 mg IV (before glucose) - Physical exam especially Neuro
- Labs: CBC, BMP, Mg/phos, LFTs, Utox, U/A, ABG, EKG, blood/urine cx, CXR - Low threshold for non-contrast head CT if focal neurologic signs or risk for CVA - Consider LP especially if fever/meningeal signs/immunosuppressed
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SEIZURES 1. If patient is still seizing—remember your ABC's:
- O2 by face mask, position pt on side to prevent aspiration. Suction airway as needed. Do not try to insert airway -Start an IV with normal saline infusion - Prevent patient from injuring himself/herself - If seizures continue after 2-3 minutes, try to start an IV and abort the seizure with Ativan 2-4 mg IV pushes per minute - Give thiamine 100 mg IV first, then 1 amp D50 IV - If seizure is >5 minutes or is not easily responsive to benzodiazepines, the pt is likely in status epilepticus and the patient will need ICU management and STAT neurology consult
2. Status epilepticus: -Ativan 2-4 mg IV pushes every minute for 10 minutes -Load with phenytoin 20 mg/kg in 3 divided doses at 50 mg/min (usually 1-1.5 g total over 20 min); use fosphenytoin when available at the same dose as its load is better tolerated. - Remember, phenytoin (but not fosphenytoin) is not compatible with glucose-containing solutions or with Valium. If you have given these meds earlier, you need a second IV -STAT labs BMP, Mg, Phos, fingerstick glucose, LFTs, CBC, toxicology, antiepileptic levels -If continuing to seize after phenytoin, next step is administration of phenobarbital, intubation, EEG monitoring. Should have MICU and/or neurology at bedside by this time.
3. Once seizure has stopped:
- Place oral airway. Get ABG if patient appears cyanotic - Monitor closely for repeat seizure activity. Complete neuro exam. Neurology consult -Write for seizure precautions. Watch for metabolic acidosis and rhabdomyolysis
4. Consider common causes of seizures (i.e. basic labs and a head CT for new onset seizures):
- Alcohol withdrawal (2 mg ativan IV post-seizure may help to prevent recurrence) - CNS lesion/infxns (tumor, CVA, head injury, meningitis/encephalitis, etc.) - Meds (Demerol, benzo withdrawal, penicillin [imipenem], lidocaine toxicity, INH [only stops after giving Vitamin B6], ASA, TCA, cocaine, Benadryl, amphotericin, theophylline, buproprion etc.) - Metabolic (low glucose, Na, Ca, or Mg) - Toxins (CO, heavy metals, many drugs of abuse or withdrawal from these drugs) - Other (HIV, malignant hypertension, hypoxia, uremia).
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CHEST PAIN Initial Evaluation: 1. Over telephone: vital signs, recent telemetry data, EKG 2. History: risk factors for CAD and PE; onset, exertional/nonexertional, character, quality,
location, associations, duration, relief 3. Examine : vitals (blood pressure in both arms), concentrate on heart, lungs, abdomen, evidence of heart failure, always palpate chest for reproduciblity 4. Initial w/u based on clinical suspicion: ABG if hypoxic, EKG, chest xray, troponin x3 (6-8 hours apart) if suspicion for MI D/d: **You will need to rule out life-threatening diagnoses rather than diagnose definitively! MI: typical sx: “pressure-like” midsternal pain associated with SOB, diaphoresis, radiation
to left jaw/arm or bilateral shoulders, nausea/vomiting, cardiac risk factors **Atypical symptoms in diabetics and women but can occur in others. Should w/u if high clinical suspicion
Treatment: 1) ASA 325 mg if no C/I 2) O2 via nasal canula 3) Morphine 1-2 mg IV and/or Nitroglycerin 0.4 mg SL Q5 min x 3 (hold both for
SBP <100) 4) Stat ICU or CCU consult 5) High intensity statin (Lipitor 80 mg) for plaque stabilization and IV heparin per
pharmacy protocol can be started for NSTEMI 6) Beta blockers such as metoprolol or coreg should be started
Aortic dissection: “tearing”, assoc w/ HTN, smoking, radiation to back, unequal pulses 1) Obtain stat CXR: widened mediastinum 2)Transfer to ICU to reduce BP and inotropy with ß–blocker 3)Order stat CT scan with contrast or echo and call vascular surgery
**EKG may show evidence of ischemia in RCA distribution if dissection is proximal Pneumothorax: COPD, trauma, decreased breath sounds, hyperresonance, deviation of
trachea away from side with pneumothorax, and hypoxia - Stat CXR and call surgery for chest tube placement - If tension pneumothorax (hemodynamic instability), don’t wait for the CXR! Insert a 14 gauge angiocath into the 2nd intercostal space at the midclavicular line on the side of the pneumothorax
PE: dyspnea, tachypnea, tachycardia, pleuritic chest pain, hypoxia, A-a O2 gradient, hemoptysis - Obtain chest CT with PE protocol (preferred) or V/Q scan. Begin anticoagulation with IV heparin (order heparin per pharmacy protocol) if there are no contraindications while you are waiting for the results
Other common etiologies: pericarditis (NSAIDS), pneumonia (start antibiotics), GERD or PUD (order protonix or maalox), esophageal spasm (may respond to nitroglycerin), esophageal rupture (Boerhaave’s) or tear (Mallory-Weiss), candidiasis, herpes zoster, costochondritis (NSAIDS or Tylenol), rib fracture, anxiety (a diagnosis of exclusion)
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SHORTNESS OF BREATH Initial Evaluation: 1. History - Acuity of onset – sudden versus slow - Associated symptoms (cough, chest pain, palpitations, fever) - New events or medications given (including IV fluids!) around the onset - Relevant PMH and admitting diagnosis 2. Physical Exam - Vital signs (include O2 sat; measure the respiratory rate yourself!) - Lungs: respiratory distress (cyanotic, accessory muscle use), wheezes, rales, stridor, symmetry of breath sounds. Remember that adventitious lung sounds may be absent in someone with severe airflow limitation - Cardiac: JVP, carotids, rate/rhythm, and murmurs or rubs, extremities: edema (unilateral vs. bilateral) and perfusion (cool vs. warm, capillary refill, cyanosis) - Mental status: gives an idea of cerebral oxygen delivery 3. Labs/ studies - CXR, EKG, ABG, CBC (better to order all of these if there are any questions) D/d: 1. Pulmonary
especially if peak and plateau pressures elevated - PE: often difficult to rule in/out by history/exam. Consider early - Aspiration: common in pts with AMS, alcoholics, post seizure/intubation - Bronchospasm: can occur in CHF, pneumonia, and asthma/COPD - Upper airway obstruction: often acute onset, stridor/ focal wheezing - ARDS: usually in pts hospitalized with another dx (e.g. sepsis) - TRALI: Usually very rapid onset post-transfusion - Pleural effusion
2. Cardiac: - MI/ischemia: dyspnea can be an anginal equivalent - CHF: common in elderly pts on IVF or due to ischemia - Arrhythmia: can cause SOB even without CHF/ischemia - Tamponade: consider when pt has signs of isolated right heart failure
3. Metabolic - Sepsis: dyspnea can be an early, non-specific sign - Metabolic Acidosis: pts become tachypneic to blow off CO2
4. Hematologic:
- Anemia: easy to miss this by history/general exam - Methemoglobinemia: rare; consider in pts taking dapsone or certain other meds with cyanosis/low sat, normal PaO2
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5. Psychiatric: - Anxiety: common, but a diagnosis of exclusion!
- Your goal is a PaO2 > 60, or O2 sat > 92%. If nasal cannula isn't enough (max FiO2 is ~35-40%), try mask (up to 50%), non–rebreather (70%), or high-flow setup (90%)
- Call RT early if you’re having any trouble, and they will help with nebulizers, suction, masks, ABGs, oral/nasal airways
2. Beta agonists:
- Patients with wheezing from any etiology can benefit from bronchodilators - All that wheezes is not asthma! (e.g., CHF, pneumonia)
3. Diuretics: - Consider Lasix (20 or 40 mg based on fluid status) in a pt w/history or exam c/w CHF; other processes associated with increase in lung fluid (pneumonia, ARDS) may also improve temporarily with diuresis, and a single IV dose of Lasix is unlikely to do any irreversible damage - Patient’s should respond to IV Lasix within the hour with a target urine output of 200 cc/hr
4. Assess potential need for intubation. BiPAP trial may be helpful method of temporizing while making this decision. RT will help with the settings! - BiPAP is most helpful to correct ventilation deficits (i.e., helps reduce pCO2), and in pts with CHF or COPD, but can assist any patient to help move air. Use only in the conscious patient, never the obtunded!! - BiPAP can be started at “12/5” and rapidly titrated as needed. Top number refers to IPAP (Inspiratory Positive Airway Pressure) while bottom number refers to EPAP (Expiratory PAP, equivalent to PEEP). You will also need to set the respiratory rate and FiO2 - BiPAP is contraindicated in patients who are at risk of aspirating, on tube feeds, have excessive secretions, AMS, or respiratory arrest
5. Once you have the patient stabilized and the results of your initial studies, you can initiate therapy directed at the specific etiology of the patient’s dyspnea
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CVA/TIA Initial work up and management: 1. Time of onset of symptoms, Cincinnati Prehospital Stroke Scale (CPSS) 2. Assess ABCs, vital signs -> provide oxygen if hypoxic, goal O2 sat of >94% 3. Complete physical exam with emphasis on neuro exam (NIH stroke scale) 4. Obtain IV access and get CBC, coag panel, glucose (treat hypoglycemia promptly) 5. Non-contrast head CT (completed within 25 min of ED arrival): Ischemic vs hemorrhagic 6. Normal CT-> checklist for rtPA -> if eligible administer within 3 hours of symptom onset; if not eligible administer ASA 7. Obtain EKG and continuous cardiac monitoring (telemetry order) **Activate stroke pager and obtain help from Neurology team as soon as possible but should not delay care in following the above steps** CPSS: 1/3 signs abnormal-> probability of stroke 72%, 3/3-> 85% probability
1) Facial droop (show teeth or smile) 2) Arm drift (extend both arms with palms facing up, eyes closed, for 10 secs) 3) Abnormal speech (you can’t teach an old dog new tricks)
NIHSS: more comprehensive neurological exam for stroke assessment Post CVA management:
1) Continuously monitor vitals, scheduled neuro checks 2) Perform dysphagia screening 3) Maintain blood glucose <185 to prevent worse clinical outcome 4) Daily ASA 81 mg and high intensity statin therapy 5) Further work up based on risk factors to establish etiology as detailed below
Check EKG, telemetry monitoring, U/S bilateral carotids or MRA of neck, TTE, UDS, lipid panel, HBa1c, concerns for autoimmune disease -> ANA, ds DNA, RF, etc, **MRI of head after 24-48 hours **Allow for permissive hypertension in acute stroke. Goal SBP recommendations vary depending upon the type of the stroke. Ask the neurologist for their current recommendations, but aim for SBP ~160-180. If bp >220/120, consider treatment as detailed below. Goal should be to lower by 15%. DO NOT LOWER BP MORE THAN 25%.
- If DBP >140 Consider sodium nitroprusside
- SBP >220 and/or DBP 121-140
Labetalol* 10 mg IV followed by IV infusion at 2-8 mg/min or Nicardipine IV 5 mg/hand titrate up with max 15 mg/h
* if labetalol contraindicated (e.g. CHF), consider Nitroglycerin gtt (esp. if coronary ischemia), Enalapril at IV (IV ACE-I, useful in LV dysfxn; avoid if acute MI), or Hydralazine
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ALCOHOL WITHDRAWL: Obtain initial CIWA score to assess for severity of withdrawl symptoms:
1. Minor Withdrawal: 6-48 hours after last drink Insomina, tremulousness, mild anxiety, GI upset, headache, diaphoresis, palpitations, anorexia
2. Alcoholic Hallucinosis: 12-48 hours Visual (typical), auditory or tactile hallucinations. Sensorium is clear.
3. Withdrawal Seizures: typically 24-48 hours, but may occur as soon as 6 hours 4. Delirium Tremens: 48-96 hours after last drink; can occur up to 7 days after last
drink. This is A MEDICAL EMERGENCY! Requires MICU care. Clouded counsciousness, delirium, diaphoresis, agitation, hallucinations (visual > tactile > auditory), HTN, tachycardia, low grade fever. Treatment/orders:
a. Ativan 2-4 mg IV q15-20 min until appropriate sedation achieved or abortion of seizure
b. Prophylaxis: Librium 10-25 mg q6h based on severity of alcohol use or initial CIWA score. Ativan 2-4 mg q4h PRN
c. Thiamine 100 mg IV x 3 days, multivitamins, folate (= “banana bag”) d. Always give Thiamine before glucose to avoid precipitating Wernicke’s e. IV hydration f. Correct electrolytes: Mg, K, PO4 g. Follow blood sugars and give dextrose as needed h. Restraints PRN for safety. AVOID Haldol as it lowers seizure
threshold. i. Seizure precautions
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HOW TO READ AN EKG R-R method (Rate – Rhythm) [ECG rhythm recognition using R-wave regularity as a primary step] Regular (think pacemaker)
1. sinus rhythm a. p-p (regular, no block seen) b. p-R (consistent, normal 0.12-0.20)
2. Junctional rhythm a. p-p (no P waves seen, or inverted ones) b. p-R (no P’s, no P-R)
3. 1st degree AV block a. p-p (regular, no block seen) b. p-R (consistent, prolonged >0.20) c. (AV node problem, not a true block)
4. 2nd degree AV block (2:1, 3:1, etc.) a. p-p (regular, AV block seen) b. p-R (consistent)
5. 3rd degree AV block a. p-p (regular, AV block seen) b. p-R (inconsistent)
Irregular (think intermittent AV block vs. added ectopic beats) 1. Atrial Fibrillation
a. p-p (no P waves seen) b. p-R (no P’s, no p-R) c. (variable AV block)
2. Atrial Flutter a. p-p (sawtooth, ~300/min) b. p-R (appears inconsistent) c. (variable AV block)
3. PACs a. p-p (irregular, abnormal non-sinus Ps seen) b. p-R (consistent) c. (ectopic beats, QRS/same)
4. PVCs a. p-p (irregular) b. p-R (consistent) c. (PVC’s QRS /wide >0.12 and never has a P wave)
5. 2nd degree AV block (all others – 3:2, 4:3, 5:4, etc.) a. p-p (regular, AV block seen) b. p-R (prolonged/Type 1, consistent/Type 2)
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Reading EKGs Note: height: 0.1 mV = 1 mm, duration: 0.04 seconds = 1 mm · Rate: 60–100 bpm normal · QRS Axis: normal axis is –30° to +90°. < -30° is left axis, >90° is right axis. · Differential diagnosis of axis deviations (in order of likelihood):
Right Axis Left Axis
1. RVH 1. LAFB
2. Lateral or anterolateral MI 2. Inferior MI
3. WPW with left freewall pathway 3. WPW with posteroseptal pathway
4. LPFB 4. COPD or PE
· Intervals
PR: normal 120 – 200 msec QRS: normal < 90 msec, abnormal > 120 msec QTc: normal <0.45 (measured QT/square root of R–R interval)
· Right atrial abnormality (only 1 criteria needed) lead II P > 0.25 mV or > 25% QRS amplitude lead V1 P > 0.15 Mv
· Left atrial abnormality (only 1 criteria needed) lead II P > 120 msec with notches separated by at least 1 small box lead V1 P wave has a negative terminal deflection that is 40 msec by 0.1 mV
· Left ventricular hypertrophy: There are numerous criteria; three useful ones are below. All are specific but all are insensitive, so fulfillment of one set is sufficient for LVH (applies to age > 55) RaVL >11 mm (men), >9 mm (women) RaVL + SV3 >20 mm (women) and >25 mm (men) SV1 + (RV5 or RV6)>35 mm
· Right ventricular hypertrophy: the following findings suggest RVH; there are several others. Right axis deviation R in V1 + S in V6 > 11 mm R:S ratio > 1 in V1 (in absence of RBBB or posterior MI)
· RBBB (Right Bundle Branch Block) QRS > 120 msec Wide S wave in I, V5, V6 Secondary R wave (R’) in right precordial leads with R’ greater than initial R (rsR’ or rSR’).
· LBBB (Left Bundle Branch Block) QRS > 120 msec, broad R in I and V6, broad S in V1 and normal axis or QRS > 120 msec, broad R wave in I, broad S in V1, RS in V6, and left axis deviation.
· LAFB (Left Anterior Fascicular Block): There are several sets of criteria for LAFB
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Axis is more negative than – 45 degrees Q in aVL, and time from onset of QRS to peak of R wave is > 0.05 seconds. Also helpful is QI, SIII pattern
· Q Waves: Use the following for screening V1, V2, V3: "any, any, any"; V4, V5, V6: "20, 30, 30"; I, II, aVL, aVF: "30, 30, 30, 30"; V1, V2: "R > 40, R > 50". Numbers refer to width of Q wave in milliseconds
** Borrowed from http://medicine.ucsf.edu/housestaff/handbook/HospH2002_C2.htm#EC
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Pathway for Determining Differential Diagnosis of Narrow QRS Tachycardia
Narrow complex QRS tachycardia
<120 msec
Regular?
Visible P waves? Atrial fibrillation Atrial tachycardia/flutter
with variable AV conduction
MAT Atrial rate greater than ventricular
rate?
Atrial flutter or Atrial tachycardia
Analyze RP interval
Short (RP shorter than PR)
Long (RP longer than PR)
RP shorter than 70 msec
RP longer than 70 msec
Atrial Tachycardia PJRT
Atypical AVNRT
AVNRT AVRT AVNRT
Atrial Tachycardia
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ADULT CARDIAC ARREST:
1. Check for pulse. If no palpable pulse… 2. Start compressions immediately at a rate of 100-120 compressions per
minute with a depth of 2 inches 3. Give oxygen with 2 breaths every 30 compressions. IF airway is
established (patient intubated), continuous compressions 4. Obtain vital signs, IV access and attach monitor 5. Shockable rhythm? VF/pVT shock immediately (all the defibrillators in
DRH are biphasic 120-200 J) Non-shockable rhythm? Asystole/PEAProceed to step 6
6. Resume compressions after the shock is delivered 7. In the next 2 minutes as high quality CPR is going on:
a. Administer 1 mg epinephrine (can be given q3 min until pulse re-established)
b. Review possible reversible causes of cardiac arrest and treat accordingly:
c. Reassess rhythm q2min and deliver shock accordingly
**Proven benefit for patients when "high quality CPR" is started early and maintained throughout CODE. **Do not pause CPR for breathing patient once definite airway has been established, at this point your goal is 100-120 compressions/minute. **Do not pause CODE to push IV medications, CPR should be maintained, only pausing to deliver a shock.
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VENTRICULAR TACHYCARDIA (WITH A PULSE) Asymptomatic (stable) Oxygen Lidocaine (1-1.5 mg/kg) repeat 0.5-0.75 mg/kg q5-10 min. Max 3 mg/kg Procainamide 20-50 mg/min. Max 17 mg/kg Amiodarone 150 mg over 10 min Sotalol (not available in US) Bretylium 5-10 mg/kg max dose 30 mg/kg (1st line in hypothermics) Symptomatic (unstable) Oxygen
If PULSELESS ARREST, GO TO VT/VF PULSELESS ARREST ABOVE PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
Symptomatic SVT: (pain, BP, CHF) narrow QRS (unstable) Prepare for SYNCRONIZED CARDIOVERSION if HR > 150 Consider sedation Cardiovert @ 100 joules Asymptomatic SVT : Stable Vagal Maneuvers (carotid massage, Valsalva) Adenosine 6 mg IV 1-3 seconds flush with 20 cc NS to rapidly infuse Repeat Adenosine 12 mg IV 1-2 min 3rd dose of Adenosine 12 mg IV 1-3 seconds Total of 30 mg of Adenosine can be given Calcium Channel Blockers Diltiazem (Cardizem) 20 mg bolus over 1-2 min Infusion of 5 mg/hr if converts Verapamil 2.5-5 mg IVP slowly over 1-2 min Beta-blockers Digoxin 0.25-0.5 mg loading dose
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BRADYCARDIA
Some Useful Websites: https://eccguidelines.heart.org/wp-content/themes/eccstaging/dompdf-master/pdffiles/part-7-adult-advanced-cardiovascular-life-support.pdf ACLS
**Suggested Replacement Range IVPB (NTE 20mEq/1 hr) PO <3 mmol/L 20 mEq q 1 hr x 4* ---- 3.0 to 3.2 mmol/L 20 mEq q 1 hr x 3* KCl 40 mEq liquid (IR) 3.3 to 3.6 mmol/L 20 mEq q 1 hr x 2* KCl 20 mEq po 3.7 to 3.9 mmol/L 20 mEq q 1 hr x 1* KCl 20 mEq tabs (SR) Maintenance 20 mEq/Liter of IVF KCl 20 mEq po daily (SR) Notes: If Phosphate also low (<2.5 mg/dL) use IV KPhos or PO Neutra-phos Replace Mg if low, as hypomagnesemia can make replacing K difficult
Consider K Acetate in academia or hyperchloremic patients *Determine serum potassium prior to ordering additional potassium IVPB’s
KCl 20 mEq/100 ml K Acetate (40 mEq/20 ml) K Phos** write Phos in mmol (K=4.4 mEq/ml, Phos=3 mmol/ml or 93 mg/ml)
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Phosphorus DMC Normal Range (2.3 to 5 mg/dL) Signs/Symptoms of Low Phosphorus Myopathy Neurological dysfunction Weakness Respiratory muscle paralysis Confusion Red cell hemolysis Suggested Replacement Range IV PO <1.5 mg/dL 15 mmol* x 3 ---- 1.6 to 2.3 mg/dL 15 mmol* x 2 ---- 2.3 to 3 15 mmol x 1 ---- ** If K <3.5 then use K Phos, if K > 3.5 then use Na Phos Products Available
Magnesium DMC Normal Range (1.6 to 3.0 mg/dL) Signs/Symptoms of low Magnesium Arrhythmias Angina Confusion Weakness Tremor Irritability Dysphagia Nausea Refractory hypo:K, Ca, and PO4 Suggested Replacement Range IVPB PO <1.0 mg/dL 2 Gm q 1 hr x 4* --- 1.0 to 1.5 mg /dL 2 Gmx 2 --- 1.6 to 2.0 mg/dL 2 Gm x1 --- Maintenance --- Mag-Oxide 400 mg po tid * recheck magnesium after replacement and repeat as necessary Products Available:
Route Dosage Form Product
PO Tablet Magnesium Oxide 400 mg (10 mmol Mg or 241 mg Mg)
IVPB Magnesium Sulfate 50% (1 gm/2ml=4 mmol or 8 mEq or 98 mg of Mg)
Route Dosage Form Product
PO
Powder
Neutra-phos K=7.1 mEq, Na=7.1mEq, Phos=8 mmol or 250 mg
IVPB (over 1 hr.)
Na Phos** write Phos in mmol (Na=4 mEq/ml, Phos=3 mmol/ml or 93 mg/ml) K Phos** write Phos in mmol (K=4.4 mEq/ml, Phos=3 mmol/ml or 93 mg/ml)
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Calcium DMC Normal Range (Total 8.0 to 10.6 mg/dL or Ionized 1.13 to 1.32) Corrected Ca= observed Ca + 0.8 (4 gm/dL-observed albumin) Signs/Symptoms of Hypocalcemia -- (CV effects are more severe with a ionized <0.7 mmol/L) QT prolongation Bradycardia Muscle spasm Parasthesias Weakness Fatique Hypotension *Chovstek’s sign (tap the facial nerve, get facial muscle spasm) *Trousseau’s sign (inflate a BP cuff on a patient’s arm get carpal spasm) Suggested Replacement:**
PO IV
Severe Symptomatic ---- Ca Gluconate 3 gm IVPB Asymptomatic Ca Carbonate 1-2g/day Divided TID/QID ** Correct K and Mg deficits Products Available:
Route Form Product Cost
PO Tablet Calcium Carbonate 1250 mg (Ca 500 mg or 25 mEq) $0.02
DMC intraweb electrolyte replacement guide: http://intrawebcns/upload/docs/Pharmacy%20Services/Electrolytes-Nutrition/DMC%20Electrolyte%20Replacement%20guidelines%2005.16.2016%20KCl%20edit.doc 1. Go to internet explorer on citrix 2. Click on intraweb 3. Go to pharmacy tab 4. Electrolyte replacement protocol
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Common On-Call Complaints/ Quick Reference By Subspecialty These are some of the common on call complaints that you may face. This list is not all inclusive, nor should it be a substitute for your own clinical judgment. With any concerns or questions, call you Senior Resident!!! And after you check the patient out, and administer anything, call your Senior Resident anyway! First and foremost. When you are called re: a patient—go see the patient! Yes, of course, you are tired. You want to sleep. This is the 100th page you have received and life is not looking up. Go see the patient anyway… AMBULATORY Ordering Compression Stockings 15-20 mmHg-- Minor varicosities, minor varicosities during pregnancy, tired, aching legs, minor ankle, leg and foot swelling, and post sclerotherapy. 20-30 mmHg-- Moderate to severe varicosities, post surgical, moderate edema, post sclerotherapy, helps prevent recurrence of venous ulcers, moderate to severe varicosities during pregnancy and superficial thrombophlebitis. 30-40 mmHg-- Severe varicosities, severe edema, lymphatic edema, management of active ulcers and manifestations of PTS; chronic venous insufficiency, helps prevent PTS and recurrence of venous ulcers, orthostatic hypotension, post surgical and post sclerotherapy. 40+ mmHg-- Severe varicosities, severe edema, lymphatic edema, management of active ulcers and manifestations of PTS; chronic venous insufficiency, orthostatic hypotension, postphlebitic syndrome. GENERAL Body Fluid Routine Labs---These need procedure notes as well. Lumbar Puncture Tube 1: Cell count and differential Tube 2: Gram stain and cultures Tube 3: Protein and glucose
Tube 4: Cytology, VRDL, oligoclonal bands, may want to repeat cell count and diff. if first tube was bloody, other special studies
Thoracentesis Pleural Fluid: Send albumin, protein, LDH, glucose, pH, cell count and differential, gram stain and culture, AFB smear and culture, fungal smear and culture, cell cytology
Serum: Send serum LDH, glucose, protein, and albumin. Paracentesis
Ascites Fluid Labs: Protein, LDH, glucose, amylase/lipase, pH, cell count and differential, gram stain and culture, cytology
Serum Labs: LDH, glucose, protein, and albumin. Arthrocentesis
Fluid Labs: Viscosity, glucose, protein, gram stain and culture, cell count and differential, cytology, crystals.
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Fever So broad a differential, but it’s 3am, limit your choices: Review the signout sheet /chart for previous CXR, cultures, CBC’s
Symptomatic relief: ASA 325-650mg po or PR q4hour PRN Tylenol 500mg-1 gram po q4h PRN Cooling blankets: D/C when temperature is 39 degrees Celsius
Do a work up for sepsis: 1. CXR, if there are respiratory symptoms 2. Blood cultures times two=15 minutes apart, from two different sites 3. UA with microanalysis, culture & sensitivity if urinary symptoms present. 4. Stool cultures if indicated 5. CBC with differential 6. With mental status changes or focal neurological deficits, perform an LP 7. Check for phlebitis, assess indwelling foleys, IVs, A lines and remove and
replace if necessary. 8. Check for decubitus ulcers, skin breakdown, new murmurs, rashes, and the
perianal area. Insomnia Avoid sedatives especially in elderly. Try to give Benadryl first. If continuing to complain of insomnia use the smallest dose of ambien 5 mg qhs (do no use in obstructive sleep apnea) “Pain” Patients are often admitted with pain medications. Ask the patient if the pain is from the same location as before to insure it is not of a new onset. Then ask:
1. Location 2. Intensity 3. Quality 4. Rating 1-10 5. Relieved with pain meds prior? What seemed to work?
Try first increasing the dose of meds that the patient is on. New onset pain requires a more thorough history: When you start the patient on the medications, do so conservatively, and discuss what you did with your co-intern when they arrive. They can then adjust the medications and dosages for a longer period as appropriate.
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Mild-Moderate Pain (1-5) Acetaminophen and NSAIDS will usually suffice. Assess for possible contraindications:
Liver disease or Hx of EtOH Age
Tylenol 500mg-1000mg po q4-6 hours. Maximum dose 4g / day. Hepatotoxicity is a concern in doses > 4g/day chronically Adjust dose by ½ in elderly patients If known liver disease, choose plan B
Tylenol with codeine (Tylenol #2 15/300, Tylenol #3 30/300, Tylenol #4 60/300) Same warnings as above, plus CNS depression 1-2 tabs q 4 hours PRN Constipation if chronically using opiods, but not usually with PRN doses
NSAIDS Better choice if inflammation accompanies the pain Assess
GI bleed/GI Ulcers/Gastritis/Esophagitis (risk increases 1.5 times on NSAIDS) Renal function (may exacerbate ARF and should be used with caution in renal failure patients) H/O CHF (may exacerbate secondary to antiprostaglandin effect)
Motrin 400mg po q4-6 hours PRN maximum = 3.2 g / day Naproxen 250-500 mg PO q12h PRN maximum = 1000 mg/day Toradol (potent) 30-60 mg IM
Short term (less than 5 days) 15-30 mg IV Celebrex 400mg po x 1, then 200mg po bid
(Contraindicated in sulfa allergies)
Moderate to Severe Pain Opioids Patients may already be on opioids and need supplementation doses for breakthrough pain Assess for:
Liver dysfunction CNS depressants Hypotension Use PO whenever possible
Morphine Sulfate Immediate release tablets 15-30 mg po q4 hours Use liquid if there is difficulty swallowing
MS Contin is controlled release so it takes longer to act. 30mg po q8-12 hours 1-5 mg IV q4-6 hours. IV can lead to vasodilation and hypotension so do not use in decreased blood pressure.
Demerol / Meperidine 50-150 mg po q4h prnDo not use in renal failure patients are metabolites can lead to accumulation and seizures with impaired renal function.
Restoril 25 mg to decrease nausea and improve analgesia Contraindicated in MAOI / SSRI users and renal failure
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Table 1 Opioid Equivalents
Name
Onset (min)
Dosing (hr)
Oral Eq (mg)
I.V. Eq (mg)
Codeine 10-30 4 200 120
Hydromorphone (Dilaudid) 15-30 4 7.5 1.5
Levophanol (Levodromoran) 30-90 4 4 2
Meperidene (Demerol) 10-45 4 300 75
Methadone (Dolophine) 30-60 6 20 10
Morphine (Roxanol) 15-60 4 30 10
Morphine CR (MS Contin) 15-60 12 90 NA
Oxycondone (Percocet) 15-30 6 30 NA
Oxycodone CR (Oxycontin) 15-30 12 30 NA
Propoxyphene 30-60 4 200 NA
Bowel Regimen (Begins when the prescription for opioid is written) STEP 1: Prevent Constipation a. Dietary Intervention b. Stool softener and gentle laxative c. 1-2 Peri-Colace PO qday-tid STEP 2: If No BM in 48 Hours a. 1-2 Colace po bid-tid + 2 Senokot po qhs - May increase Senokot to maximum dose of 4 tabs tid OR
b. 30-45 cc Lactulose qhs with 8 oz. of water (range 15-60 cc Lactulose qhs-bid)
STEP 3: If No BM in 72 Hours Perform rectal exam to rule out impaction NOTE: Constipation may worsen with time because of disease process. All potential causes of constipation should be evaluated. Rectal examination SHOULD NOT be performed in patients with neutropenia or mucositis. IF NOT IMPACTED: a. Lactulose (if not already done) OR b. Dulcolax (Biscodyl) 10 mg supp OR c. 8 oz. of Magnesium Citrate po OR
d. Fleet Phospho-Soda Enema (Use with caution in patients with renal insufficiency. Not for use in patients receiving dialysis).
IF IMPACTED: a. Manually disimpact if stool is soft OR b. If stool is hard, use Fleet Oil Retention Enema OR c. Follow with Saline Enemas until impaction resolved OR d. Adjust intensity of preventative bowel regimen.
Simple and easy way to convert opioids for clinical use :
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-Use the following scheme to convert from different form of Oral and IV opioids (Dilaudi(hydromorphone)), Morphine and hydrocodone
-Multiply by the number beside the arrow if you are converting in the direction of the arrow. -Divide by the number beside the arrow if you are converting in the direction against the arrow. For example : To convert 5 mg of IV dilaudid to PO Morphine . -IV Dilaudid to Po Dilaudid (converting in the direction of the arrow multiply by 5 (5 *5=25 mg of PO dilaudid ). -25 mg of PO Dilaudid to PO Morphine, converting in the direction of arrow, multiply by 4 (25*4= 100 mg of oral Morphine). -So 5 mg IV Dilaudid =100 mg of oral Morphine . Heroin to Morphine Equivalents Detroit has one of the highest grade heroin in the country. But it’s usually cut with Benadryl, fentanyl, and other adulterants like talc. Based on what is seized, and my most educated opinion - heroin is around 60-80% pure in Detroit. A 1 gram bag of heroin is about $200 (this is weight, not 1000 mg of heroin). $30 is the going rate for a "bag" or "book" of heroin. Usually 1/10 of a gram (again weight, not dose). A bag of heroin is about 15-30 mg IV morphine equiv. Interestingly, you can prescribe heroin in Canada for opiate withdrawal - diacetylmorphine or diamorphine. But remember!! Heroin and morphine are the same drug except heroin has 2 acetyl groups....thus its 100% lipophilic and it crosses the blood brain barrier100% vs morphine where you only get 10-25% crossing the blood brain barrier. Thus, it’s easy to overdose on heroin. Info from Joshua N. Raub, Pharm.D., BCPS
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CARDIOLOGY/ HYPERTENSION Hypertension Hypertensive urgency (usually treatable with oral meds)
-DBP usually > 130, SBP usually > 210 -Pt. without major BP related symptoms
-No evidence of new or worsening BP-related target organ damage (Cr, CHF, neurological Sx)
Hypertensive Emergencies (always treat with IV meds in the ICU) 1. Moderate hypertensive retinopathy (Formerly Accelerated HTN)
--severe retinopathy (NO papilledema) --acute dysfunction of target organs
3. Hypertensive encephalopathy --severe BP elevation or rapid rise in BP --headache --nausea/vomiting --transient neurological dysfunction (agitation, altered sensorium) --visual disturbances --+/- papilledema
----goal = 15-20% in MAP over 1st hr. *should not be <170/110 *may be lowered more in setting of unstable angina, CHF, pulmonary edema, aortic dissection
- vasodilator is a potassium channel activator. - relaxes arteriolar smooth muscle - significant side effects (Na retention, hyperglycemia, hyperuricemia)
2. Enalaprilat - is the active metabolite of enalapril - no adverse side effects/symptomatic hypotension reported - contraindicated in pregnancy
3. Esmolol - cardioselective B-blocker - independent of renal/hepatic function
9. Nitroglycerin -venodilator -decreased preload and cardiac output Non Emergent Blood Pressure Elevations in the Hospital -Assess patient status hemodynamically. -Do not try to make the patient’s blood pressure 140/90 in the next five minutes or lower it
dramatically just to please the other staff—as a matter of fact, it can be dangerous to lower it too quickly.
-Rule Out: Any evidence of new, ongoing, current end organ damage that may lead you down the management pathway to hypertensive emergency. Some examples, CHF, Neurological changes, Decrease in Urine Output, Headaches, Bleeds
-Review patient’s chart. See if patient missed any BP meds. If so, replace. There is no need to treat a blood pressure just because it is HIGH and SCARY. Have a reason why you are going what you are doing.
Possible Interventions: Some will tell you that Clonidine is an option but you will get rebound when it wears off and/or the patient stops it on their own. Most of our patients are not ideal candidates to take Clonidine on a scheduled basis. PO Captopril 12.5-25 mg will decrease BP in 15-30 minutes. Watch out for an excessive response.
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YOU SUSPECT YOUR PATIENT IS HAVING AN ACUTE MI What do you do?
Minutes 0-5 Place patient on a bedside monitor, with a bedside defibrillator
Nursing to supply a bedside drug box, or park drug cart nearby Confirm or start reliable IV—DO NOT PLACE IN A NONCOMPRESSIBLE SITE Obtain a STAT 12-Lead EKG, and request old EKG’s/chart to compare
Give ASA 325 mg p.o., unless contraindicated During the above, obtain relevant history During the above, perform relevant exam, with differential diagnosis in mind
Reassure the patient; stay calm; stay at the bedside
Minutes 5-10 Review EKG immediately as it comes off the machine; keep the tech there. If inferior injury pattern or suspect RVMI, perform “V R” leads EKG Compare to old tracings Give NTG 0.4 mg SL, unless contraindicated If 1st EKG was equivocal, repeat in 10 minutes, or for clinical changes If dx unclear and you are not an expert EKG reader, GET ONE NOW
Minutes 10-15 Come to a working diagnosis; get whatever help you need to do so NOW
If your working diagnosis Is acute MI, then, Start 2nd reliable IV --- DO NOT USE NONCOMPRESSIBLE SITES Initiate treatment for ischemic pain: IV NTG, IV Beta-blockade, Morphine sulfate
In “window period” for myocardial salvage? IF SO, decide between thrombolysis, primary PTCA, or conservative Rx Inform attending physician, discuss with cardiology fellow or staff If thrombolytics are to be given, call Pharmacy STAT, confirm ASA given Re-examine, consider if any invasions are mandatory before thrombolytics
Continuous treatment adjustments as needed Ward clerk to secure a CCU bed
Review labs; baseline coags, CBC and platelets, lytes, etc as needed
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Minutes 15-20 Thrombolytic is hung, or Interventional team is coming, or c
conservative Rx. Complete initial loading of IV beta blocker if indicated Advance dose of IV NTG as tolerated
TIMI SCALE TIMI Risk Score for Unstable angina/Non ST elevation MI
RISK SCORE DEATH or MI DEATH, MI, or URGENT REVASC.
0-1 3 5
2 3 8
3 5 13
4 7 20
5 12 26
6/7 19 41
entry criteria: UA or NSTEMI defined as ischemic pain at rest within past 24hrs, with evidence of CAD (ST segment deviation or +marker)
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Algorithm (reproduced from Harrsion’s)
So you are wondering if the pt had an MI.
High / CP with low likely Atypical CP
Intermittent hood of ischemia low prob
probability
Check markers at 0
and 6 h, and ECG if
any CP
(+) markers
or ECG
(-) markers and ECG
Exercise stress test
abnormal normal UA/NSTEM pathway D/C Home
DOING A PRE-OP CONSULT **See web links below for original guideline statements This is when you check out the patient for clearing them for surgery. ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery Goto:http://www.americanheart.org/presenter.jhtml?identifier=3004542 (all ACC/AHA Guidelines) Goto:http://content.onlinejacc.org/article.aspx?articleid=1893784&_ga=1.175625574.575809076.1465851509 (guidelines)
Theme of the guidelines is that preoperative intervention is rarely necessary simply to lower the risk of surgery unless the intervention is indicated irrespective of the preoperative context. The purpose of the evaluation is not simply to give cardiac clearance but instead to evaluate the patients current medical status, make recommendations concerning the evaluation, management and risk of cardiac problems over the entire perioperative period and make a clinical risk profile that all involved in the care can use to make treatment decisions about the short and long term cardiac outcomes. A large proportion of the data used in formulating the guidelines is retrospective or observational based or the knowledge of management of CV disorders in the non-operative setting. However the number of prospective or randomized studies that have been performed to establish the value of different treatments on perioperative outcomes is small. In general, perioperative testing should be limited to circumstances in which the results will affect patient treatment and outcomes. Clinical evaluation- Initial history, physical, and ECG should focus on identifying potentially serious cardiac disorders, including CAD (prior MI or angina), heart failure, symptomatic arrhythmias, presence of a pacemaker or ICD, or a history of orthostatic intolerance. Severity, stability, and prior treatment should also be addressed. Other factors that determine cardiac risk include the functional capacity, age, comorbid conditions, and the type of surgery. Associated with increased perioperative cardiac morbidity:
-CAD and HF, hx. of cerebrovascular disease, preoperative elevated Cr>2 mg/dL, insulin treatment for diabetes, and high risk surgery.
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1. Division into 3 categories based on clinical predictors. a. Major
i. Recent unstable coronary syndrome such as an acute MI (<7day history) or recent MI (>7 days but <1 month)
ii. Unstable or severe angina iii. Evidence of a large ischemic burden by clinical symptoms or
noninvasive testing iv. Decompensated HF v. Significant arrhythmias (high-grade AV block, symptomatic
arrhythmias in the presence of underlying heart disease, or SV arrhythmias with an uncontrolled ventricular rate).
vi. Severe valvular disease. b. Intermediate
i. Mild angina ii. More remote MI iii. Compensated HF iv. Preoperative creatinine greater than or equal to 2 v. DM
c. Minor i. Advanced age ii. Abnormal ECG iii. Rhythm other than sinus iv. Low functional capacity v. History of stroke vi. Uncontrolled systemic HTN
***If a recent stress test does not indicate residual myocardium at risk, the likelihood of reinfarction after noncardiac surgery is low. Although there is no clinical trial on which to base firm recommendations generally it apprears reasonable to wait 4-6 weeks after MI to perform elective surgery.
2. Functional Capacity-expressed in metabolic equivalents a. 1-4 METS- Eating, dressing, walking around the house, and
dishwashing. b. 4-10 METS- Climbing a flight of stairs, walking on level ground at 6.4
km/hr, running a short distance, scrubbing floors, or playing golf. c. >10 METS- Strenuous sports such as swimming, singles tennis, and
football. 3. Risk of surgery
a. High- Reported cardiac risk is often greater than 5% i. Emergent major operations, particularly in the elderly ii. Aortic and other major vascular surgery iii. Peripheral vascular surgery iv. Anticipated prolonged surgical procedures assoc. with large
fluid shifts and/or blood loss b. Intermediate
i. Carotid endarterectomy
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ii. Head and neck surgery iii. Intraperitoneal and intrathoracic surgery iv. Orthopedic surgery v. Prostate surgery
c. Low i. Endoscopic procedures ii. Superficial procedures iii. Cataract surgery iv. Breast surgery
Hypertension- Greater than 180/110 should be managed and reduced medically, over several days to weeks. If surgery is more urgently needed IV anti-hypertensives can be used. Valvular Heart Disease- Indication for eval. and treatment are the same as in the nonoperative setting. Stenotic valves are assoc. with a risk of perioperative HF or shock and often require percutaneous valvotomy or valve replacement before noncardiac surgery to lower the cardiac risk. Regurg is better tolerated. Myocardial Disease Arrhythmias and conduction abnormalities- Should provoke a search for the underlying cause (underlying cardiopulmonary disease, drug toxicity, or metabolic abnormality). Percutaneous coronary intervention- No controlled trials comparing perioperative cardiac outcome after noncardiac surgery for patients treated with preoperative PCI vs. medical therapy. Delaying surgery for a week after balloon angioplasty to allow for healing of the vessel injury has theoretical benefits. If a coronary stent is used, a delay of at least 2 weeks and ideally 4-6 weeks should occur before noncardiac surgery to allow 4 weeks of dual antiplatelet therapy and re-endothelialization of the sent to be complete or nearly so. Beta-blockers- Reduced perioperative cardiac events and improves 6 month survival. When possible they should be started days to weeks prior to surgery and the dose titrated to HR 50-60. Post op pain management- Reduces catecholamine surges and hypercoagulability. Intraoperative NTG- Should only be used when the hemodynamic effects of the other agents have been considered. Perioperative Maintaince of Body Temp- One randomized trial demonstrated a reduced incidence of perioperative cardiac events in patients who were maintained in a state of normothermia via forced air warming compared with routine care. **Although the occasion of surgery is often taken as a specific high-risk time, most of the patients who have known or newly detected CAD during their preoperative evaluations will not have any events during elective noncardiac surgery. After the preoperative cardiac risk has been determined by clinical or noninvasive testing, most patients will benefit from pharmacological agents to reduce their LDL and/or increase their HDL.
From ACC. org Cardiac Risk* Stratification for Noncardiac Surgical Procedures
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High
(Reported cardiac risk often greater than 5%)
Emergent major operations, particularly in the elderly
Aortic and other major vascular surgery
Peripheral vascular surgery
Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss
Intermediate
(Reported cardiac risk generally less than 5%)
Carotid endarterectomy surgery
Head and neck surgery
Intraperitoneal and intrathoracic surgery
Orthopedic surgery
Prostate surgery
Low†
(Reported cardiac risk generally less than 1%)
Endoscopic procedures
Superficial procedure
Cataract surgery
Breast surgery
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Step 1: In patients scheduled for surgery with risk factors for or known CAD, determine the urgency of surgery. If an emergency, then determine the clinical risk factors that may influence perioperative management and proceed to surgery with appropriate monitoring and management strategies based on the clinical assessment. Step 2: If the surgery is urgent or elective, determine if the patient has an ACS. If yes, then refer patient for cardiology evaluation and management according to GDMT according to the UA/NSTEMI and STEMI CPGs. Step 3: If the patient has risk factors for stable CAD, then estimate the perioperative risk of MACE on the basis of the combined clinical/surgical risk. This estimate can use the American College of Surgeons NSQIP risk calculator (http://www.surgicalriskcalculator.com) or incorporate the RCRI with an estimation of surgical risk. For example, a patient undergoing very low-risk surgery (e.g., ophthalmologic surgery), even with multiple risk factors, would have a low risk of MACE, whereas a patient undergoing major vascular surgery with few risk factors would have an elevated risk of MACE. Step 4: If the patient has a low risk of MACE (<1%), then no further testing is needed, and the patient may proceed to surgery. Step 5: If the patient is at elevated risk of MACE, then determine functional capacity with an objective measure or scale such as the DASI. If the patient has moderate, good, or excellent functional capacity (>4 METs), then proceed to surgery without further evaluation. Step 6: If the patient has poor (<4 METs) or unknown functional capacity, then the clinician should consult with the patient and perioperative team to determine whether further testing will impact patient decision making (e.g., decision to perform original surgery or willingness to undergo CABG or PCI, depending on the results of the test) or perioperative care. If yes, then pharmacological stress testing is appropriate. In those patients with unknown functional capacity, exercise stress testing may be reasonable to perform. If the stress test is abnormal, consider coronary angiography and revascularization depending on the extent of the abnormal test. The patient can then proceed to surgery with GDMT or consider alternative strategies, such as noninvasive treatment of the indication for surgery (e.g., radiation therapy for cancer) or palliation. If the test is normal, proceed to surgery according to GDMT. Step 7: If testing will not impact decision making or care, then proceed to surgery according to GDMT or consider alternative strategies, such as noninvasive treatment of the indication for surgery (e.g., radiation therapy for cancer) or palliation. ACS indicates acute coronary syndrome; CABG, coronary artery bypass graft; CAD, coronary artery disease; CPG, clinical practice guideline; DASI, Duke Activity Status Index; GDMT, guideline-directed medical therapy; HF, heart failure; MACE, major adverse cardiac event; MET, metabolic equivalent; NB, No Benefit; NSQIP, National Surgical Quality Improvement Program; PCI, percutaneous coronary intervention; RCRI, Revised Cardiac Risk Index; STEMI, ST-elevation myocardial infarction; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; and VHD, valvular heart disease. ACC.org Stepwise Approach to Preoperative Cardiac Assessment
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Metabolic Equivalents
Take care of self, eat, dress, use toilet 1 MET
Walk up a flight of steps or a hill, walk on level ground at 3-4mph 4 METs
Heavy work around the house, such as scubbing floors or lifting/moving heavy furniture
4-10 METs
Strenuous sports >10 METs
Calculate major adverse cardiac event with multiple calculators: American College of Surgeons’ National Surgical Quality Improvement Program risk (ACS-NSQIP) – see online calculator Gupta MI Revised Goldman Cardiac Risk Index Six independent predictors of major cardiac complications:
- high risk surgery (vascular surgery, open intraperitoneal or intrathoracic) - history of ischemic heart disease - history of HF - history of cerebrovascular disease - diabetes mellitus requiring treatment with insulin - preoperative serum creatinine > 2.0 mg/dL
Rate of cardiac death, nonfatal MI, nonfatal cardiac arrest:
- No risk factors – 0.4% - One risk factor – 1.0% - Two risk factors – 2.4% - Three or more risk factors – 5.4%
Rate of MI, pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete heart block
- No risk factors – 0.5% - One risk factor – 1.3% - Two risk factors – 3.6% - Three or more risk factors – 9.1%
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Respiratory system Acute Respiratory Failure
1. Assess ABCs first before thinking about the cause: Give oxygen, check BP and make sure you have a peripheral IV, determine need for intubation or NIV
2. Get ABG and calculate A-a gradient to see if hypoxia, hypercapnia, or both Hypoxic Respiratory Failure Elevated A-a gradient and normal or near normal PaCO2
Give 100% FiO2 by nonrebreather. If the hypoxia corrects, the problem is a V/Q mismatch, usually increased dead space. If it does not, it is a true shunt.
Hypercapnic Respiratory Failure And hypoxic-hypercapnic failure Can’t Breathe or Won’t Breathe Can’t Breathe Lung/Airways Low tidal volume or increased dead space
Supplemental Oxygen – Delivery Methods Nasal Cannula: Each liter adds 4% to the FiO2, so 3LNC = FiO2 ~32%. Actual oxygen delivery varies with tidal volume and rate. 6 liters is maximum, above this the flow sucks in more room air Simple Face Mask: Delivers FiO2 40-60% at 5-10L/min. Actual dose varies with tidal volume, rate, and disease Venturi Mask: Can select the exact FiO2 desired by changing the plastic inserts – 24, 28, 31, 35, 40%. Use this if you’re worried about CO2 retention. (Don’t look at the wall to see how much O2 they’re on, it will always say 12L) Nonrebreather: Provides ~90% FiO2, requires good mask seal to be effective High Flow Nasal Cannula: Provides 10-40L of humidified, warmed air at a selectable FiO2. Also provides a small amount of PEEP (~3cmH2O.) Generally used for hypoxic resp. failure. Usually must be started in the ICU BIPAP (NIV): Used when ventilation is severely impaired but the patient can still protect their airway. FiO2 of 20-100%, provides inspiratory and lower expiratory pressure. ICU/stepdown required to start BIPAP
“CURB-65” Stratifies disease severity – predicts 30 day mortality risk from CAP C = confusion U = uremia, > 7 R = Respiratory rate, > 30 B = Blood pressure low 65 = Patients over age 65 A score of 0 or 1 may be managed at home if serious vital sign abnormalities or co-morbidities are absent and if there are no social factors or other illnesses requiring hospitalization. A score of 2 or more require admission. For scores 3-5, consider MICU admission PNEUMONIA SEVERITY INDEX An alternate scoring system, may be useful to compare to CURB-65 Acute Asthma Exacerbation Notable physical findings during acute exacerbation:
Tachycardia – up to 120bpm is reasonable; > 120 bpm found in 10-15% and is worrisome
Tachypnea – up to 30 resp/min is reasonable; > 30 found in 10-15%, and is worrisome
Pulsus paradoxus – a positive finding when the systolic blood pressure decreases greater than 10-12 mmHg on passive inspiration; is the result of the dynamic hyperinflation that occurs with exacerbation
Mild hypoxia – should not normally be lower that 88% unless there is severe exacerbation and/or other pathology also present
o During exacerbation, there is primarily regional V/Q mismatch, but some shunt physiology may play a role if there is mucous plugging of airways.
Accessory muscle use, AMS –associated with increased mortality Poor prognostic factors on history:
Previous severe exacerbations/ICU/intubation – only ~5% of mortalities had prior ICU/intubation
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>2 hospitalizations or 3 ER visits in past year , 1/3 of mortalities had recurrent admits
Use of greater than canisters of B2-agonists MDI’s per month
Current or recent (within 1 month) use of corticosteroids
Difficulty in perceiving presence or severity of airway obstruction Psychiatric illness (including depression) – due to compliance issues and/or difficulty in perceiving severity of disease
Low socioeconomic status
Illicit drug use (heroin and cocaine increased likelihood for intubation)
Serious co-morbidities
LACK OF AN ASTHMA ACTION PLAN
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Inpatient Pharmacological Management: 1. Oxygen supplementation – if needed,1-3 liters by nasal cannula; if more oxygen is
required to alleviate hypoxia, consider an alternative or concomitant diagnosis a. O2 should be tailored to achieve a pulse ox ~ 92% b. High flow O2 use for treatment of pure asthma exacerbation is associated
with increased mortality. 2. Bronchodilators:
a. Beta Agonists – Albuterol; MDI provides better delivery in less time than nebulized, so use when able. If using nebulizer initially, stacked doses of 2.5 mg x 3 q 20 minutes are just as efficacious as a single dose of 7.5 mg, but with less side effects
b. Anticholinergics – Ipratroprium can have an inpatient role; use is associated with decreased length of stay. If using nebs, initial order can be for 0.5 mg q 30 minutes
3. Steroids – prednisone PO is just as efficacious, and MUCH less costly, than IV
methylprednisolone if dosed properly. Proper dosing should initially be prednisone 60 mg po q 8 hours, then decrease to discharge dose of 60 mg po daily as patient stabilizes.
4. Others:
a. Magnesium – 2g magnesium sulfate may be used as adjunctive treatment to oxygen, bronchodilators, and steroids, but only has a benefit in severe exacerbations.
Discharge considerations:
Discharge is appropriate at peak flows > 70% of predicted AND minimal/absent symptoms
Along with other appropriate outpatient medications, patients should be given 7-14 days of prednisone 60 mg po daily.
o However, the patient needs to follow up with a physician within 7 days. The outpatient physician should ultimately make the decision on the dosing and duration needed.
Always send with an asthma action plan (http://intraweb.dotnetapps.chmallergy)
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COPD Classification
Outpatient management of exacerbations of COPD
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ENDOCRINE Blood Glucose Hypoglycemia Go to the floor, and await the response to treatment in all cases
1. Given 15-30 g CBH, 8 oz of juice or soda = 30g 2. 2 graham cracker squares = 10 g 3. For every 15 g CBH given, blood sugar should increase 25-50 mg/dL
Symptomatic (tremors, diaphoresis, palpitations) or NPO patient
1. 1 Ampule of D50% IV. If no IV give 1mg Glucagon IM (watch for nausea, vomiting)
2. Accuchecks q 5-10 minutes depending on response 3. Follow ampule with D5W or D10W to maintain CBG 100mg/dL and Accucheck q
30 minutes Sulfonylurea overdose
1. Requires prolonged, continuous IV D5W and close observation Hyperglycemia
2. Recheck blood sugar with a peripheral blood draw 3. Assess repeat CBG’s, treatment previously ordered and response 4. Assess baseline dosages if the patient is already on any medications for diabetes
Be conservative, knowing that hyperglycemia is less dangerous than hypoglycemia. An aspart insulin sliding scale may be implemented: CBG Regular Insulin 200-250 4 units 251-300 6 units 301-350 8 units 351-400 10 units If there is an infection, we may tighten this scale (means starting with 150-200 use 2 units). In the ICU setting an IV insulin normogram is started.
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DIAGNOSTIC CRITERIA FOR DIABETIC KETOACIDOSIS AND HYPEROSMOLAR HYPERGLYCEMIC STATE * UpToDate, Treatment of diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults
* UpToDate, Treatment of diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults
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ENT Epistaxis Anterior
Most common, caused by Kiesselbach’s Triad and usually self limited from Trauma or irritation (O2)
Posterior Usually spontaneous but may be vascular disease related
Work Up -Vitals: Emergency, is the airway safe? -Can you visualize source of bleeding?
If non emergent and anticoagulated get INR If emergent get an H/H, Type and Cross
Treatment 1. Have pt lean forward to avoid swallowing blood 2. Hemostasis is applied to distal part of nose 3. Consider cold compress to bridge of nose 4. Identify the source of bleeding 5. Topical oxymetazoline (Afrin) spray alone often stops the hemorrhage. 6. LET solution (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.4%) applied to
a cotton ball or gauze and allowed to remain in the nares for 10-15 minutes is very useful in providing vasoconstriction and analgesia. Lidocaine 4% spray may work as well.
7. Chemical cautery with silver nitrate is performed for mild active bleeding or after bleeding has stopped and prominent vessels identified.
8. Nasal packing has been the next step for persistent bleeding Oxidized regenerated cellulose (Surgicel or Oxycel) and absorbable gelatin foam (Gelfoam) don't need extraction & increase clot formation by encouraging platelet aggregation,
9. Anterior packing is often inadequate to control bleeding from the posterior nasal. Need ENT for post packing.
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GERIATRICS DMC: WSU/Rosa Parks Geriatric Center Location: DRH/UHC/5B Primary care by Geriatricians and Nurse Practitioners with specialty in Geriatrics Geriatric Specialists available:
Specialty Clinics: Multidisciplinary team consisting of a physician, nurse practitioner, PharmD and MSW
1. Memory Evaluation Clinic: Evaluate and treat cognitive impairment-new or established.
2. Balance Clinic: See persons who have a history of falls or who are at high risk for falls
3. Multidisciplinary Anticoagulation Clinic: In addition to INR & Coumadin monitoring, this clinic addresses fall risk, cognitive and social issues of the patient in relation to medication and appt. adherence, and safety. We must have a faxed anticoagulation referral form completely filled out and signed by the physician before we can set up an appt. These are also available online: On Intraweb, go to Pharmacy. Appointments are on Tuesdays and Fridays, so that patients may be seen within 3 days of discharge.
Patients who qualify for: age 60 and/or with Medicare. We also accept referrals/consults from private physicians for these specialty services. In preparation for discharge page Ann Blarezo at the contact info. below. Prior to discharge she will introduce herself and set up an appointment for them before they actually leave. Ann Balarezo, CNP DMC Geriatric Center of Excellence Rosa Parks Geriatric Center Phone: 745-4402 Email: [email protected] Beeper: 6303 Fax: 745-8165
HEMATOLOGY/ONCOLOGY Neutropenic Fever (absolute neutrophil count <500, T- 100.4 sustained or 101.0 single reading) Patient needs to be in isolation. All Antibiotics are ordered and administered as STAT.
These patients might not show typical signs of infection. Upon initial neutropenic fever the following studies are obtained:
a. Blood cultures- Obtain one set of blood cultures from the central catheter and one set of peripheral blood cultures. b. Sputum culture c. Skin lesion culture if clinically indicated d. U/A with micro, culture, and sensitivities e. CXR, PA and Lateral f. Stool for C. diff toxin g. Don't forget to examine the mouth, sinuses, IV sites, perianal area, and skin. f. Start broad spectrum antibiotics like Cefepime/gentamicin, if still febrile, add
Vancomycin, if still febrile start antifungals.
If no beta lactam allergy start CEFEPIME: • Estimated creatinine clearance >60 mL/min -2 grams of cefepime IV q 8 hours. • Estimated creatinine clearance 30-60 mL/min- 2 grams cefepime IV q 12 hours. • Estimated creatinine clearance 11-29 mL/min- 2 grams cefepime IV q 24 hours. • Estimated creatinine clearance <11 mL/min.- 1 gram cefepime IV q 12 hours. . Hemodialysis patients: 1 gram q24h, give after dialysis **Usually can do “cefepime pharmacy dosing” where they care of the above details If beta-lactam allergic start the following: • Aztreonam 2 grams IVPB every 8 hours plus, either: • Vancomycin 1 gram intravenously every 12 hours, OR • Clindamycin 600 mg intravenously every 8 hours. Add VANCOMYCIN if one of the following is suspected or documented:
a. Erythema at the catheter exit site b. Tenderness at the catheter exit site c. Exudates at the catheter exit site d. Central venous catheter tunnel infection e. Cellulitis f. Folliculitis
In the presence of severe mucositis add clindamycin or if on vancomycin add metronidazole. Sepsis:
1. Start empiric abx with cefepime and escalate to vancomycin if needed 2. Obtain cultures as mentioned above and lactate
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3. Start aggressive IVF with normal saline (give boluses if blood pressure is low) 4. Low threshold for MICU evaluation especially if lactic acid >2, blood pressure not
responding to fluid boluses (sign of septic shock)
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Hypercalcemia Correct for albumin!!! Common Tumors: multiple myeloma, breast, kidney, esophageal, thyroid, head and neck, parathyroid and squamous cell lung cancer (PTH-rp) What To Do About It:
1. Normal saline as much as possible depending on cardiac function 2. If becoming fluid overloaded, give Lasix, which will decrease Ca as well 3. Continue the fluids, you don’t want to cause volume contraction. 4. Ultimately the patient will need something to bring the calcium down.
a. Zoledronate (4 mg IV over 15 min, typically outpatient) b. Pamidronate (60-90 mg IV infused over 4 hours, typically inpatient) c. If you can't use bisphosphonates calcitonin (4 units/kg q12 x 4 doses) may be
helpful. **Can lead to tachyphylaxis. d. If all else fails, dialysis is effective (particularly those with CHF or ESRD who
can't handle the volume you need to give them). Spinal Cord Compression * Neurological Emergency Pain worse with recumbency and valsalva. Can present with numbness, weakness, urine/stool incontinence, and new or worsening
back pain. ~20% of new diagnoses of malignancy are made by finding cord compression. LACK OF NEUROLOGICAL FINDINGS DOESN'T RULE IT OUT, IT JUST MEANS YOU MAY MAKE THE DIAGNOSIS EARLY ENOUGH TO MAKE A DIFFERENCE!!!!! On Exam: do entire exam, including rectal exam for rectal tone
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Common tumors: include epidural/medullary spinal cord tumors, lymphoma, metastatic tumor to vertebral bodies (especially lung, breast, prostate, and renal cell). What to Do About It:
1. Decadron IV (dexamethasone) (The loading dose is typically 20 mg x1 plus scheduled dosing
2. MRI with and without contrast of the suspected area STAT. 3. Neurosurgery consult STAT if there is evidence of compression/cord compromise on
the MRI. You need to CALL!!! Neurosurgery!! 4. Rad/Onc consult STAT if there is evidence of compression/cord compromise on the
MRI. You need to call Rad/Onc!!!
Increased ICP Patient presents with confusion, depressed mental status secondary to brain mets etc. What to Do About It:
1. Imaging study to evaluate. Probably a CT at least initially then will probably ultimately need an MRI.
2. Elevate the head of the bed 3. Decadron (dexamethasone)- loading dose usually 10 mg IV x 1 then maintenance
dose (4 mg q6h) 4. Stat Neurosurgery consult 5. Chemotherapy is usually not effective in CNS tumors because of the difficulty in
getting drugs across the blood brain barrier
Pericardial Tamponade Tachypnea, Tachycardia, Distant Heart Sounds, Pulsus Paradoxus (fall of SBP of 10 mm with inspiration), electrical alternans on EKG. Late signs are JVD/hypotension. Treatment:
1. Oxygen 2. Fluids because the Right ventricle is volume dependent and may help to minimize
collapse while therapy is arranged. 3. Call the Cardiology Fellow for a STAT bedside Echo.. 4. Call CT surgery for drainage/window if evidence of tamponade or hemodynamically
unstable. Tumor Lysis Syndrome Lysis of tumor cells, esp after initiating chemotherapy. Associated with high tumor burden with rapid turnover rate: ALL, CLL, CML, blast crisis Which then leads to…………….
That then can lead to………….. Acute Renal Failure Cardiac Arrhythmias Muscle cramps, tetany
Prophylaxis/Treatment 1. Allopurinol 600-800 mg x 1 then 300-600 mg qDay or Rasburicase 0.2 mg/kg qdaily (preferred) 2. Aggressive IVF 3. If acute renal failure, consider dialysis. 4. Continuous monitoring of electrolytes, cardiac, and creatinine (q6h-q8h) 5. Phosphate binder, eg. Ca acetate 6. Normal hyperkalemia treatment, but avoid unnecessary Ca gluconate
Superior Vena Caval Obstruction (SVC Syndrome): The patient may complain of dyspnea, headache or head fullness which are worse when they lay flat, arm edema, visual disturbance, confusion, or facial swelling. Common Causes: Lung cancer (in particular small cell), Non-Hodgkin lymphoma, or other mediastinal tumors, indwelling lines thrombosis, aortic aneurysms, thyroid enlargement, fibrosing mediastinitis, radiation therapy. On Exam: Facial plethora, Elevated JVD, Distention on chest veins, Upper extremity edema, or cyanosis. What to Do About It:
1. Elevate the head of the bed 2. Administer O2 3. If there is evidence of airway compromise CALL ENT STAT. 4. Therapy should be discussed with your team, if you have a diagnosis radiation +/-
chemo, if you need a diagnosis radiating the tumor before you get a chance to biopsy it may make that job more difficult.
5. Other measures: low salt diet, careful diuresis, oxygen, stent/angioplasty (if recurrent superior vena cava syndrome)
Typhlitis By definition is necrotizing infection of cecum/colon Patient may complain of fever, diarrhea, RLQ pain (not appendicitis!) Common Tumor association: acute leukemia What to Do About It:
1. Broad spectrum Antibiotics 2. Surgery consult
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Disseminated Intravascular Coagulation (DIC) Signs! anemia, thrombocytopenia, elevated PT and PTT, low fibrinogen, elevated D dimmer and fibrin monomers. Initial phase is prothrombotic, bleeding can occur after that! What To Do About It:
Leukostasis Signs: pulmonary hypoxemia, intracerebral hemorrhage What To Do About It:
1. Hydroxyurea 50-100mg/kg/day qhr until WBC <100,000. 2. Leukapheresis most effective: call fellow/attending for initiation
HIT – HEPARIN INDUCED THROMBOCYTOPENIA Suspect HIT when:
- Acute thrombocytopenia within 5-10 days of initiation of heparin - Platelet fallen by 50% or more - Necrotic skin lesions at injection sites in a patient started on heparin within the
preceding 5 to 10 days
Testing - Platelet factor 4 assay, SRA
Treatment - stop ALL heparin including heparin flushes by the nurses - start patient on direct thrombin inhibitor like Fondaparinux or Argatroban - Lepirudin contraindicated in renal failure - Argatroban contraindicated in hepatic disease - After a direct thrombin inhibitor is on for at least 48 hours, can start warfarin
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Initial Anemia Workup: - Order CBC, ferritin, iron saturation, TIBC, MCV, retic count - If suspecting hemolytic anemia, order haptoglobin, billirubin, LDH - Always look at the peripheral smear yourself! -Schistocytes are indication of hemolysis
In hemolytic anemia: LDH elevated, retic elevated, bilirubin elevated, haptoglobin decreased Workup for Cause of Hemolytic Anemia: - Intravascular vs extravascular - Evidence of schistocytes on peripheral smear - If spherocytes present, could be hereditary spherocytosis - If Coombs test is positive, then autoimmune hemolytic anemia - Consider G6PD deficiency
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DIFFERENTIATING INTRAVASCULAR AND EXTRAVASCULAR HEMOLYSIS
Test All types Intravascular Extravascular
Reticulocyte Count Increased Increased Increased
LDH Increased Increased Increased
Indirect bilirubin Increased or normal
Increased Increased or normal
Haptoglobin Decreased Decreased Decreased
Urinary hemosiderin Present or absent
Present Absent
Blood Loss, Symptomatic Anemia
1. Type and Cross 2 units of Packed Red Blood Cells. 2. Order coagulation profile on the patient. 3. Secure large bore IV access 4. Determine origin:
a. Guaic, NG suction. Monitor patient closely 5. Give blood products if Hgb<7 or symptomatic 6. For each unit of PRBC hb should 1. If platelets <10,000, if coags are abnormal, or if
>6 units PRBC’s were transfused, give FFP and platelets. 7. Remember—giving blood products needs consent.
Tranfusion Reactions If a patient develops fever, chills, itching or any other symptoms during a transfusion:
a. Stop the transfusion; call your senior. b. Benadryl may be given if it is felt to be a reaction to the transfusion
Laboratory tests in iron deficiency of increasing severity
Normal Fe deficiency without anemia
Fe deficiency with mild anemia
Severe Fe deficiency with severe anemia
Marrow reticulo- endothelial iron
2+ to 3+ None None None
Serum iron, µg/dL 60 to 150
60 to 150 <60 <40
Iron binding capacity (transferrin), µg/dL
300 to 360
300 to 390 350 to 400 >410
Saturation (SI/TIBC), percent
20 to 50 30 <15 <10
Hemoglobin, g/dL Normal Normal 9 to 12 6 to 7
Red cell morphology Normal Normal Normal or slight hypochromia
Hypochromia and microcytosis
Plasma or serum ferritin, ng/mL
40 to 200
<40 <20 <10
Erythrocyte proto- porphyrin, ng/mL RBC
30 to 70 30 to 70 >100 100 to 200
Other tissue changes None None None Nail and epithelial changes
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INFECTIOUS DISEASES IDENTIFICATION OF BACTERIA ALGORITHMS
NEPHROLOGY AND ACID BASE Thinking about Acid Base Disturbances (See the formulas section for help with formulas for compensation) 1. Is the patient acidemic or alkalemic?
• Determine blood pH 2. Is the overriding disturbance respiratory or metabolic?
• Measure arterial pCO2 and serum bicarbonate 3. If a respiratory disturbance is present is it acute or chronic?
• Compare measured pH with expected change in pH 4. If a metabolic disturbance is present is there an increased anion gap present?
• Measure serum sodium, chloride, and bicarb. Calculate an anion gap. 5. If a metabolic disturbance present is the respiratory compensation appropriate?
• Compare pCO2 measure with expected pCO2. Using Winter's formula 6. Are other metabolic disturbances present in the patient with an increased anion gap
metabolic acidosis? • Determine corrected bicarb level using the delta gap and compare to the measured bicarb
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Hyperkalemia- Is the blood hemolyzed? If not, what is the cause: acute kidney injury, increased intake, increased breakdown of
tissue (like tumor lysis). • ACE-I, ARB, Bactrim, NSAIDs, K sparing diuretics…HOLD THE DRUGS, Find alternative agents that are K neutral • Potassium in the TPN- HOLD TPN BAG for the duration • Oligo/anuric acute renal failure • Ongoing production of potassium i.e. hemolysis, hematomas, rhabdo, tumor lysis syndrome • End stage renal disease not following potassium restriction
Second, get a 12 lead EKG and look for changes. 1. Peaked T waves which progress to……. 2. Prolonged PR intervals & decrease in P wave magnitude, progresses to….. 3. Widened QRS which progresses to…….. 4. A sine wave and asystole…any change in EKG means IMMEDIATE ACTION!
Treatment 1. Calcium gluconate IVPB or 1 amp CaCl (codes) to stabilize the myocardium 2. 1 amp of D50 and 10 units of IV regular insulin 3. Albuterol 10-20mg nebulized 4. Kayexelate- Either oral or retention enema 5. Dialysis- If the patient is refractory to all of these things then you NEED to call the
nephrologists for URGENT DIALYSIS 6. Place the patient on Telemetry if there are EKG changes Acute Renal Failure • Prerenal vs. Post-renal vs. Intrarenal • Calculate FeNa or FeUrea by ordering urine electrolytes, serum electrolytes, urine
creatinine, urine urea, and serum creatinine. • FeNa will be <1 in pre renal and post renal cause. To differentiate the two, do a post-void
residual to rule out retention and a renal ultrasound to rule out hydronephrosis. Suspect retention in older males who may have BPH. If diuretics have been used, FeUrea <35% is prerenal
• Go to the lab, spin the urine and examine for casts. Drugs that cause pseudo-elevation of blood urea nitrogen and creatinine. Competitive tubular secretion of creatinine: • Trimethoprim • Triamterene • Cimetidine • Amiloride • Probenecid • Spironolactone
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Interference with laboratory determination of creatinine • Ascorbic acid • Levodopa • Flucytosine • Methyldopa • Cephalosporins (cefoxitin and cephalothin) Hypercatabolic Effects • Steroids • Tetracycline Chronic Renal Failure Kidney Disease Outcome Quality Initiative (K/DOQI) Classification Scheme Stage Criteria 1 EGFR >90 and evidence of CKD (see below for definition of CKD) 2 EGFR >60-89 and evidence of CKD (mild ↓ in kidney function) 3 EGFR >30-59 (moderate ↓ in kidney function) 4 EGFR >15-29 (severe ↓ in kidney function) 5 EGFR <15 (kidney failure or end stage renal disease (ESRD). Definition of Chronic Kidney Disease National Kidney Foundation Kidney damage >3 months, as defined by structural or functional abnormalities of the
kidney with or without decreased GFR, manifest by either: • Pathological abnormalities (eg. Small kidney), or • Abnormalities in the composition of blood or urine, or abnormalities in imaging tests •Abnormalities GFR <60 ml/min/1.73 m2 for >3 months, with or without kidney damage. What is a renal diet? • Protein restriction in patients with CKD of 0.8 g/kg based on Ideal Body Weight • 1.2 gm/kg of Ideal Body Weight for those with End Stage Renal Disease on Hemodialysis. • 2 gram sodium diet • 2 gram potassium diet • Total Free Water Restriction based on the clinical scenario.
Tests to Consider with EGFR is Less than 60 1. Hemoglobin 2. Calcium
Generalized Tonic-Clonic Status Epilepticus Suggested Guidelines for Initial Treatment
Time Frame Procedure 0-5 minutes Obtain vital signs, establish airway, administer oxygen if
needed. Observe seizures briefly to ascertain that patient is really in status. Draw baseline blood work (CBC, chemistry panel, antiepileptic drug levels, --send STAT), draw ABGs (for pO2 and pH), draw toxicology screen. Quickly assess patient for signs of cardiorespiratory compromise, hyperpyrexia, focal neurologic signs, head trauma, CNS infection, etc. Always have CPR equipment at bedside of a patient in status.
6-9 minutes Start IV infusion with saline solution.
Administer 100 mg thiamine, IV. Administer 50 mL of 50% glucose solution IV, if blood sugar is low or unobtainable. Do not give glucose if blood sugar is normal or high.
10-45 minutes Infuse lorazepam (Ativan), 0.1 mg/kg, at 2 mg/min. Begin IV loading dose of fosphenytoin (Cerebyx), 20 mg PE/kg, at 150 mg PE/min. Monitor patient’s B/P, pulse, EKG, and respirations while giving IV fosphenytoin and lorazepam. Most common side effects: hypotension, arrhythmia, paresthesias, and respiratory depression.
46-60 minutes If seizures persist, intubate and give phenobarbital, 20
mg/kg, at 100 mg/min. Never use Valium and Phenobarbital sequentially in the treatment of status, unless the patient is intubated and in an ICU. Their hypotensive and respiratory
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depressant actions synergize. Serious and abrupt side effects can occur with these two drugs with given together.
1 hour If seizures persist, the patient should be placed in a drug
induced coma with phenobarbital, a benzodiazepine, or other anesthetic agent to prevent life threatening lactic acidosis, hypoxia, hyperthermia, and permanent seizure-induced neuronal damage. The patient must be in an ICU, and outcome should be monitored and treatment guided by EEG with the goal being suppression of seizure activity on EEG.
Acute Mental Status Changes
1. Assess if it has happened previously, with at least 3-4 people 2. Also check sign-out sheet and chart for any previous note of such episodes 3. Check chart for underlying psychiatric, neurological, toxic, or ethanol/drug causes
Work Up: 1. ABG 8. Thyroid Function Tests 2. Blood glucose 9. EEG 3. Lytes, BUN, Cr, Ca, Mg, Phos 10. Coags 4. EKG 11. Ammonia level 5. Urine drug screen 12. Page Neurology 6. Serum drug screen 7. Head CT
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Mental Status Exam (Folstein)
Anxiety / Agitation
1. Look for cause: Medications, delirium tremens 2. Try not to give benzos/ benadryl in elderly as it can make the situation worse. 3. Reorient patient to calm them down 4. Try Haldol 1 mg for acute event 5. Trazodone 25 mg is for insomnia, but works well too.
Headache Danger signs: if you find them, think something ELSE is going on
Severe persistent HA reaching max in few sec to min
First or worst HA
Sinusitis and Lung infection
Change in mental status,
Personality changes and fluctuation in level of consciousness
HA started with strenuous exercise or trauma
Pain spreading to lower neck
Age <5 yrs or > 50 yrs
Recent change in pattern of HA, progressive worsening despite treatment
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Indication for imaging:
Recent significant change in the pattern, frequency, or severity of headache
Progressive worsening of headache despite appropriate therapy
Focal neurologic signs or symptoms
Onset of headache with exertion, cough, or sexual activity
Orbital bruit
Onset of headache after age 40 years
HA causing awakening from sleep. Order CT scan with and without contrast. MRI/MRA if AVM or aneurysm is suspected or posterior fossa lesion is suspected. Migraine Abortive treatment: • Acetaminophen, NSAIDS, Antiemetics for mild cases • Triptans: Pt with moderate to severe migraine • Use triptans early in pts with cutaneous allodynia • Pt with N/V may need intranasal or subcut. triptans • Ergotamines: More than or equal to 48 hrs duration of attack or frequent HA recurrence • Preventive: determine based on co-morbid conditions If HTN, give Calcium channel blockers or beta-blockers If depression: give TCA
If resistant to other treatments give anticonvulsants: Valproate, gabapentin or topiramate
• Cognitive and behavioral therapy Cluster Headaches Abortive: • O2 with a nonrebreather at 6 L/min has been shown to provide relief • Sumatriptan either subcut or intranasal or zolmitriptan • Ergots - Cafergot and DHE 45 • Indomethacin Tension Headaches Abortive: • Tylenol, ASA, NSAID are first line • Avoid ergots, caffeine, butalbital and codeine as they may cause rebound headaches Anxiety / Agitation
1. Look for cause: Medications, delirium tremens 2. May be a feature of mental status changes—establish a previous baseline if it is
Hypotension Ativan 0.5 – 2 mg IV (maximum 4mg) can cause cardiovascular collapse and apnea. Decrease dose in elderly and in liver dysfunction. Precipitates agitation. ½ life 10-20 hours
CSF Evaluation
Glucose (mg/dL)
Protein (mg/dL)
WBC Count (cells/L)
< 10 10-45 >250 50-250
>1000 100-1000
5-100
More Common
Bacterial
Bacterial
Bacterial
Viral
Lyme
Neuro-syphili
s
Bacterial Bacterial
Viral
Early bacterial
Viral
Neuro
syphillis
TB
Less Common
TB
Fungal
Neuro-syphilis
Other viral
infections
(mumps or LCM)
TB
Some Cases of Mumps
And LCM
Enceph-alitis
Enceph-alitis
LCM = lymphocytic choriomeningitis virus
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RHEUMATOLOGY
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Hand Findings (RA vs. OA) *RA: Metacarpophalangeal (MCP), proximal interphalangeal (PIP), and thumb interphalangeal (IP) joints are most frequently involved. Usually spares DIP (distal interphalangeal) and 1st MCP. The DIP joints are involved only in the presence of a coexisting MCP or PIP disease. *OA: Bouchard and Herberden nodules on PIP and DIP respectively; spares the MCP joints. Common Rheum Drugs: -Adalimumab (Humira "Human Monoclonal Antibody in RA"): TNF a inhibitor -Infliximab (Remicade): chimeric monoclonal antibody against TNF -Rituximab (Rituxin): chimeric monoclonal Ab against CD20 on B cells -Etanercept (Enbrel): a fusion protein from recombinant DNA (soluble human TNF
receptors linked to Fc portion of IgG1) that acts as a decoy receptor to decrease naturally occurring TNF, hence a TNF inhibitor
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MISCELLANEOUS STEROID EQUIVILENCIES
PAIN MEDICINE EQUIVLENCIES
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USEFUL EQUATIONS: Critical Care/Pulmonary [(713 x FIO2) – (1.25 x PaCO2)] – PaO2 So, what does it mean??? Interpretation: Increased gradient > 2.5+(0.25 x age) Diffusion defect, right to left shunt, VQ mismatch Simplified on Room Air: AA Gradient= (150-1.25X PaCO2) – PaO2 Mean Arterial Pressure: Diastolic BP + [(systolic BP-diastolic BP)/3] Fluids and Electrolytes A Note About IV Crystalloid
Fluid Na Cl K Ca Mg Buffers pH Osmolality
Plasma 140 103 4 4 2 HCO3- (25)
7.4 290
NS (0.9%NaCl)
154 154 - - - - 5.7 308
Lactated Ringer’s
130 109 4 3 - Lactate (28)
6.5 275
Dextrose 5%/H20
- - - - - - 4.3 278
Normal Saline – not really normal. An acidic, hyperosmotic, hyperchloremic solution. Due to the strong ion difference, large infusions cause NAGMA. Each liter of NS will add 275ml to plasma volume and 825ml to the interstitium Lactated Ringer’s – More physiologic solution than NS, closer to the electrolytes in plasma. Will not alter acid/base balance (Use for DKA/HHS!) Slightly hypotonic, so large infusions can cause cerebral edema Dextrose 5% in Water – Isoosmotic in the bag, but as cells take up glucose it becomes effectively hypoosmotic, leads to RBC swelling and interstitial edema. 50g dextrose/liter = 170 kilocalories Maintenance Hourly Fluids: 4 mL for each kg 1-10 + 2 mL for each kg 11-30 + 1 mL for each kg >30 Corrected Na For each 100 mg/dL of glucose over 100 add 1.6 to the sodium
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Body Water Deficit (Liters) 0.6 x wt (kg) x (Pt. Na- Normal Na) Normal Na Or TBW corrected = TBW (initial) x Na (initial) Na corrected Then Water deficit = TBW corrected – TBW initial Total Body Water 0.6 x Weight Kg (men) 0.5 x Weight Kg (elderly men, women) 0.45 x Weight Kg (elderly women) Calcium Correction in Hypoalbuminemia For every 1 g/dL decrease in albumin –serum Ca decreases by 0.8 So, to correct for a low albumin: Real Calcium = Calcium measured + (Normal albumin-Patient’s) * 0.8 Other option is to ask for ionized calcium. Correcting Sodium per Liter of Fluid Na in solution- Patient Na Total body water +1 Na content of each solution: 5% sodium chloride: 855 3% sodium chloride: 513 0.9 % sodium chloride: 154 Ringer Lactate: 130 0.45 sodium chloride: 77 D5W : 0 Gastroenterology Interpretation of Serum to Ascites Albumin Gap (SAAG) <1.1 No Portal Hypertension Present >1.1 Portal Hypertension Present Discriminant Function in Alcoholic Hepatitis (Maddrey score) (4.6 x (PT-control PT)) + (serum bilirubin) A value greater than 32 +/- hepatic encepthalopathy indicates candidate for steroid therapy (if viral etiology ruled out). Hematology
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Reticulocyte Production Index: RPI= Reticulocytes (percent) x (Hct/45) x (1/2) If <2, the reticulocyte count is inadequate for the degree of anemia Nephrology Cr Clearance : (140-age) x wt. (kg) x (0.85 for females) 72 x serum Cr FENa: Urine Na x Serum Cr Serum Na x Urine Cr Renal Failure Index: Urine Sodium x Plasma Creatinine Urine Creatinine OSMOLALITY : 2 x Na +(glucose/18) + BUN/2.8 ANION GAP: Na – (Cl + HCO3) Correction of Anion Gap for Albumin Add 2.5 to gap for every 1 ↓ in albumin Acid-Base Compensation for Metabolic Acidosis Winter’s Equation: pCO2= 1.5 (HCO3) + 8 (+ 2) Compensation for Metabolic Alkalosis ▲↑ 1 HCO2 = ▲ ↑ 0.7 pCO2 = pH ↑ 0.015 Compensation for Acute Respiratory Acidosis—Simple disturbance—HCO3 not over 30 ▲ 10 pCO2 = ▲ 1 HCO3 = pH ↓ 0.08 Compensation for Chronic Respiratory Acidosis Simple disturbance ▲10 ↑ pCO2 = ▲ ↑ 3-3.5 HCO3 = pH ↓ 0.03 Compensation for Acute Respiratory Alkalosis Simple Disturbance ▲ HCO3 ↓ 2 mEq/L per 10 mm Hg ▲pCO2 = pH ↑ 0.08 Compensation for Chronic Respiratory Alkalosis Simple disturbance ▲ HCO3 ↓ 4 mEq/L per 10 mmHg ▲ pCO2 = pH ↑ 0.117 Delta Gap: Use it to see if the corrected Bicarbonate is actually where it should be—if not, then man, you’ve got yet another acid base disturbance…
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Delta Gap = Calculated Gap – Standard Gap (The legendary Dr. Pravit uses 10 as the standard gap) Look at the current bicarb and add the delta gap…Is it corrected to normal or not? If less than normal, maybe a metabolic acidosis too. If greater than normal, than maybe a metabolic alkalosis too. CORE MEASURES ACUTE MYOCARDIAL INFARCTION
Measures Compliance/Documentation Tips
ASA upon arrival
ASA prescribed at discharge
ACEi or ARB prescribed at discharge for LVEF < 40% (or LVSD)
BB prescribed at discharge
BB within 24 hours after arrival time
Adult smoking cessation advice/counseling
Thrombolysis within 30 minutes of arrival
PCI within 90 minutes of arrival
JCAHO only – inpatient mortality
Use standing orders
If medications not prescribed, document reasons/rationale
If ACEi or ARB not prescribed, document contraindications to BOTH
Use discharge instruction record
Document all discharge meds
Document smoking cessation counseling
Give patient discharge instructions, including complete discharge medication list
HEART FAILURE
Measures Compliance/Documentation Tips
Written discharge instructions include all of the following: Activity, diet, follow up, medications, weight monitoring and symptoms worsening.
LV function assessment
ACEi or ARB prescribed at discharge for LVEF < 40%
Adult smoking cessation advice/counseling.
Use standing orders
Use discharge instruction record
Document all discharge meds
Documented LVF assessment can be performed prior to or during current hospitalization
If ACEi or ARB not prescribed, document contraindication to both
Document smoking cessation
Give patient discharge instructions, including complete discharge medication list
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PNEUMONIA
Measures Compliance/Documentation Tips
Oxygen assessment within 24 hours of arrival (pulse ox, ABG)
Influenza and pneumococcal screening performed. Vaccinations given if indicated.
Blood culture drawn prior to antibiotics
Blood culture within 24 hours of arrival for patients transferred or admitted to ICU
Adult smoking cessation
Initial antibiotics received within 4 hours from arrival
Initial antibiotics administered within first 24 hours consistent with guidelines for ICU and non-ICU pneumonia patients
Use standing orders
Document smoking cessation
Document actual date and time blood cultures are collected
Use discharge instruction record
Document all discharge meds
Give patient discharge instructions, including complete discharge medication list.
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SECTION 6: Resources
COMMUNITY RESOURCES AIDS SUPPORT GROUPS AIDS Consortium of Southeastern Michigan, Inc. 3750 Woodward, Suite 32 Detroit, MI 48201 313-496-0140 (provides information, referrals and counseling) AIDS Hotline 800-872-2437 or 313-547-9040 (information) Deaf AIDS Hotline (TTY-TDD) 800-322-0849 (information)
HIV/AIDS Home Help 800-515-3434 (Housing information and referral hotline) University Health Center 7B 4201 St. Antoine Detroit, MI 48201 (anonymous HIV testing and counseling) Wellness Network, Inc. 845 Livernois Ferndale, MI 48220 313-547-3783 800-322-0849 (information, referrals and support)
SHELTERS FOR AVAILABILITY OF BEDS/TRANSPORTATION PLEASE CALL THE TOLL FREE SHELTER HOTLINE (24 HRS) # 1-800-274-3583 (1-800-A-SHELTER) OR 1-313-963-782 COTS 26 PETERSBORO MEN, WOMEN, FAMILIES 313-831-3777 DETROIT RESCUE MISSION 3535 THIRD MEN ONLY/MEALS/OPEN 5 PM 313-993-6703 DOORSTEP WEST 244 HIGHLAND (HP) WOMEN/CHILDREN/MEALS 313-867-0111 OFF THE STREET 680 VIRGINIA PARK DETROIT MI 48202 313-873-0678
FOR RUNAWAY OR HOMELESS YOUTH 12-17 EASTSIDE EMERGENCY 14320 KIRCHEVAL MEN/MEALS 313-824-3060 INTERIM HOUSE VICTIMS OF DOMESTIC VIOLENCE 313-861-5300 MARINER’S INN 455 WEDYARD 313-962-9446 FOR MEN ONLY MISSION OF CHARITY 4835 LINCOLN WOMEN/CHILDREN/MEALS
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313-831-1028 MY SISTERS PLACE VICTIMS OF DOMESTIC VIOLENCE 313-371-3900 NEWLIFE RESCUE MISSION 2600 18TH STREET MEN/NO BEDS/OPEN 5 PM 313-237-0390 NSO WALK-IN SHELTER 3430 THIRD 24 HOUR WALK IN – MEALS/NO BEDS 313-832-3100 OPERATION HELPING HAND 2230 14TH STREET MEN ONLY/MEALS/24 HRS 313-961-5401 RAVENDALE 12260 CAMDEN MEN/WOMEN/MEALS 313-371-9100 SALVATION ARMY 3737 LAWTON
WOMEN/CHILDREN/MEALS-90 DAY STAY SINGLE MEN ONLY OVERNIGHT 1-800-A-SHELTER [180027435837] T.C. SIMMMONS 10501 ORANGELAWN WOMEN/CHILDREN 313-934-3331 WARMING CENTER WINTER ONLY!!!!!!! 313-963-STAY Wayne-Metropolitan Community services agency 3751 W. Jefferson Ecorse, MI. 164 Woodward Ave. Highland Park MI 731-782-6632313-843-2550 ****Families are housed at local motels. 15 days-will assist in paying first months rent and security deposit for housing (can extend days if needed)
MENTAL HEALTH AGENCY Community Mental Health 313-224-7000 (Call from provider is helpful Has long waiting lists) Life Stress Center 313-745-4811 University Health Center – 35-14 (Uninsured or low-income individuals may be eligible for discount.)
University Psychiatric Center (Wayne State University) 2751 E. Jefferson 313-993-3434 (Must be Wayne county resident, Fees are on a sliding scale.)
changing Primary Sponsors, HMO or Clinic Plan sites or providers
MEDICATIONS
AGENCY COMMENTS AARP Price Quote Center Medication sent by US mail or 800-456-2226 US. Allow one week to 10 days Must belong to AARP. Cross Roads Must schedule appointments. 92 E. Forest Will fill prescriptions one time 313-831-2000 only. Tribune Fund Provider must contact on only 313-226-9404 Wed. and Thurs. World Medical Relief Must be low income and 55 or 11745 Rosa Parks Blvd older. Services Wayne, Oakland, Detroit, MI and Macomb Counties. 313-866-5333 Eligibility based on income and amount
in checking and savings. Limits- $1550 single/individual $2100 couple plus additional $300 for each dependent.
PATIENT ASSISTANCE PROGRAMS/RESOURCES NeedyMeds-- www.needymeds.com Provides information on pharmaceutical manufactures that have special programs to assist people who can't afford to by the drugs they need. HelpingPatients.org-- www.helpingpatients.org PhRMA and its member companies present an interactive web site that provides a comprehensive one stop link to thousands of medicines RxAssist-- www.rxassist.org
RxAssist provides physicians, advocates, and patients with the tools they need to access the pharmaceutical company assistance programs.
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Accessing Free Medication-- The Patient's Advocate-- www.themedicineprogram.com Free prescription medicine is available to those who qualify RxHope.com-- www.rxhope.com Provides information on patient assistance programs from pharmaceutical companies for low income, indigent, and uninsured people in need of prescription TogetherRx: Prescription Savings Program-- www.togetherrx.com Together Rx is a prescription savings program that offers a free, easy way for Medicare enrollees to save on brand-name medicines. Medicare.gov- PDOAP: Eligibility Questions-- www.medicare.gov/Prescriptions/Home.asp This section of Medicare.gov provides information on public and private programs that offer discounted or free medication. Lilly Answers-- www.lillyanswers.com SUBSTANCE ABUSE AGENCY COMMENTS Alcoholics Anonymous Hotline 24 Hour Number with counseling 248-541-6565 Central Diagnostic and Referral Service Located at Herman Keifer Intake 313-876-4070 Mon-Fri. on a first come, first served
basis. Should arrive at 7a.m., need 3 pieces of ID. Must be a resident of Detroit.
Detroit Rescue Mission Provides inpatient treatment and 3535 Third outpatient aftercare. Must be a Detroit, MI 48201 resident of Detroit. For men only. 313-993-6703 Eleanor Hutzel Recovery Center Available to women only; must be a University Health Center 6B resident of Detroit. 4201 St. Antoine Detroit, MI 48201 313-745-7411 Harbor Light/Salvation Army Inpatient beds available for detox. 3737 Lawson Must call for availability. Must be a Detroit, MI 48208 resident of Wayne County. 313-361-6136
Mariner's Inn For Men Only. 445 Ledyard Must be a resident of Detroit unless Detroit, MI 48201 referred by central diagnostics at 313-962-9446 Herman Keifer Narcotics Anonymous Hotline 248-543-7200 Sacred Heart Rehabilitation Center Patient can self refer services 220 Bagley Street State of Michigan Suite 326 Detroit, MI 48226 313-961-6190 SHAR House For men and women 18 or older (Self Help Addiction Rehab) 1852 W. Grand Blvd. Detroit, Mi 48208 313-894-8444 Sobriety House For men only; age 18-69 of age. 2081 W. Grand Blvd No detox residential care. P.O. Box 08160 313-895-0500 Opiate Dependence Treatment Program For children, adolescence, and UPC-Jefferson Research adults. Individual, group, and family 2761 E. Jefferson therapy and medication treatment Detroit, MI 48207 888-362-7792 TRANSPORTATION Detroit Metrolift Provides curb to curb service 313-833-7692 anywhere within the city of Detroit and up to 3/4 mile outside of city.
Cost $2.50 each way. Must make reservation 1-8 days in advance.
SCAT (Special Citizens Area Transit) Van with wheelchair lift. Curb to 313-521-1900 curb service. Must be 65 or older Mon-Fri 10-4:30 or physically handicapped with no Call 9:00a.m.-1:00p.m. age limitation. Must schedule appt. To schedule a ride. One week in advance. Call Monday -Friday 10-2 Services the City of Detroit East of Woodward, Hamtramack and Highland Park Charge in $1.50 each way.
Internal Medicine Resident Survival Guide - 138 -
SMART 866-962-5515 Van with wheelchair lift. Curb to Curb service. Must call 2 days in
advance for general and 6 days in advance for medical transportation.
Minimum charge is $1.00 each way. Does not service Detroit.
Travelers Aid Society of Detroit Will provide bus tickets to and from 211 W. Congress, 3rd floor medical appointments and to and from Detroit MI, 48226 job interviews. Will call to verify appoint. 313-962-6740 Must make application in person. Mon-Thurs 8:30a.m.-5:00p.m. Friday 8:30a.m.-4:30p.m. SENIOR CITIZENS PROGRAMS Adult Protective Service 1-877-963-6006 (updated April,2007) (To evaluate suspected cases of neglect or abuse Part of the Department of Social Services.) Area Agency on Ageing 313-446-4444 (Provides information and referral for citizens 60 and older. Provides meals on wheels, home care assistance, home care. Serves Detroit, Hamtramck, the Grosse Point and Harper woods.)
Detroit Health Department 313-876-4000 (Food and friendship at selected sites serves nutrition and social needs. Meals on wheels for homebound seniors 60 or older; serves city of Detroit.) Detroit Senior Citizens Department 313-224-5444 (For citizens of Detroit 55 and over. A referral service.)
SUPPLEMENTAL SECURITY INCOME Social Security Administration 800-772-1213 (Must be determined to be blind or disabled to receive disability payments. If approved payment is retroactive to the first month of application.) VOCATIONAL REHABILITATION, COUNSELING AND TESTING Michigan rehabilitation services 800-605-6722 admin office in lancing Detroit offices 707 west Milwaukee 871-3800 19251 Mack Ave. 313-886-8275
(Job placement service for adults with history of work and job skills. Provides counseling and vocational rehabilitation and independent living services to handicapped individuals 16 and over. Handicap can be physical, mental or educational.)
Internal Medicine Resident Survival Guide - 139 -
Jewish Vocational Services 4250 Woodward Detroit MI 48201 313-833-8100 (Provides classes for preparation for a job. Must be 18 or older and low income.)
Jewish Vocational Services 29699 Southfield Rd Southfield MI 48076 248-559-5000 (Job placement service for adults with history of work and job skills.)
PLACES TO FIND A MEAL DURING THE WEEK BRUNCH TIME DAY LOCATION Manna meals 9a-11 MTWF Sat 1950 Trumbell Capuchin soup kitchen 4390 Conner 313-822-8606 Capuchin Community Center 8:30a-1p Everyday, 6333 Medbury but Sunday 313-925-0514 Fort Street Open Door 9a-11a Thursday 631 W. Fort Cass Park Baptist Center 9a-9:30a breakfast MW 2700 Second 11:15a lunch St. Dominic's Church 10a-11a Everyday 1421 W. Warren but Thursday Just Love Ministries 10a-12p M Th F 481 W. Columbia Central United Methodist 10:30a-12p M Th 23 E. Adams First Presbyterian Church 11a-12:30p Wed 2930 Woodward St. Leo's Church 11:30a-1:30p Everyday, 4860 15th St. but Sun Trinity Episcopal Church 12p-2 p Saturday 1519 MLK Blvd. Cass Community 12 p Saturday 3901 Cass Crossroads 12p-3p Sunday 92 E. Forrest
Internal Medicine Resident Survival Guide - 140 -
DINNER Salvation Army-Bagley 12-3p Everyday 601 Bagley Detroit Rescue Mission 5:30p-6p Everyday 3535 Third Salvation Army- 6p-8 p Everyday 2643 Park Harbor Light REFERRAL SERVICES FOR THE POOR AND UNINSURED
Name/Location/Phone Hours of Operation Services Offered Fee/Free Walk-In/Appt.
St. Frances Cabrini Clinic (Holy Trinity
Catholic Church)
1435 Sixth St., Det., 48226 313-
961-7863 (P) 313-
965-9891 (F)
5 PM till 25 patients are seen - Tues
Need to register by 4 PM.
1 PM Thurs, Regis. by Noon
6 PM Thurs, Evenings, Regis. By 4
Mental Health (adults only) Wed
evenings by appointment only
Mental health, primary
care, prescription
assistance
No Fee Clinic - Walk-In
Mental Health -
Appointment Only
St. John Community Health Center
3000 Gratiot Ave., Det., 48207
313-567-7462
9 AM - 5 PM - Mon Wed Thurs and
Fri 10
Am- 6 PM - Tues
Primary Care for Adults (18
- 64)
No Fee Appointment Only
St. Vincit DePaul Health Center
16000 Pembroke, Det., 48235
313-837-5078
3:30 - 6:30 PM Mon & Thurs Family Practice Financial
Support
Program
Appointment Only
Thea Bowman Health Center
2058 Fenkell Ave., Det, MI 48223
313-255-3333
9 AM - 5 PM Weekdays General Medicine,
OB/GYN, Pediatrics,
Dental, Mental Health
Free Walk-In and
Appointment
Thea Bowman Nurse Managed Center
211 Glendale, Ste. 412, HP, 48203
313-866-2415
9 AM - 5 PM Weekdays Primary Care No Fee Appointment Only
Detroit Health Department (DHD)
1151 Taylor, Det., 48202
313-876-4000
8:30 AM - 4:30 PM - Mon Tues Thurs Fri
10 AM - 6:30 PM - Wed
Primary Care, pregnancy,
Sexually Transmitted
Disease, and AIDS testing
No Fee Walk-In
(DHD) Grace Ross Health Center
2395 W. Grand Blvd., Det., MI 48208
313-897-2061
8:30 AM - 4:30 PM - Mon Tues Thurs Fri
10 AM - 6:30 PM - Wed
Pregnancy testing: Mon Tues Thrus Fri - 8
- 10 AM, 12:30 - 3 PM; Wed
10 AM - 1:30 PM and 3 - 5:30 PM
Immunization - Tues 12:30 - 3:30 PM ;
Wed 10:30 AM - 1 PM
Nutrition, Obstetrics &
Gynecology, Pediatric,
Pregnancy Testing
No Fee Walk-In and
Appointment
Fort Street Presbyterian Chruch Clinic
631 Fort Street, Det., MI
313-961-4533
9 - 11 AM, Thrusday - 10 ten people Primary Care, HIV testing,
prescriptions
No Fee Walk-In
Immaculate Heart of Mary Catholic
Church
1600 Pembroke, Det., MI 48235
313-272-0990
3:30 - 6:30 PM - Mon - Thrus Basic Medical and
Prescription Services
No Fee Appointments Only
Mercy Primary Care Center
5555 Connor Ave., Det., MI 48213
313-579-4000
8:30 AM - 5 PM - Mon - Fri
Adult residents of the City of Detroit with
income less than 300% of the Federal
Poverty Guidelines
Office visits, prescriptions,
lab work, X-rays
Fee Varies Appointments
Preferred
Northeast Health Center for Homeless
5400 E. 7 Mile Rd. Det., 48234
313-852-4231
8 AM - 4:30 PM - Mon Tues Thurs Fri
10 AM - 6:30 PM - Wed
Free pregnency testing 8 AM - 2 PM daily,
and 10 AM - 4 PM Wed Free
Immunizations 12 - 3:30 - Wed 8 -
11 AM Thurs
Pediatrics, Obstetrics &
Gynecology, Adult Internal
Medicine
Total Health
Care, straight
Medicaid or BC,
no PPO's/or fee
based on
income
Appointments Only
Planned Parnethood
800-230-PLAN for the clinic nearest you.
26 clinics throughout Michigan
Call clinic nearest you for hours. Reproductive health care
including annual exams,
pregnancy testing, and
sterilization to women and
men.
Fee Based on
Sliding Scale.
Call individual
clinics
Internal Medicine Resident Survival Guide - 141 -
Acknowledgements
This guide was compiled with information from the following sources: Intern lecture notes from our Amazing Attendings: Dr. Flack, Dr. Guzman, Dr. Pravit, Dr. Stellini, Dr. Tabbey, Dr. Gellman, Dr. Wiese, Dr. Watson, Dr. Heath, Dr. Singh, Dr. Weise, Dr. Brown, Dr. Diane Levine and Dr. Donald Levine. Past Fellows: Dr. Atallah, Dr. Shanidze, Dr. Pitta Our Fearless Alumni contributors: Dr. Corsino Class of 2005 Dr. Mamdani Class of 2005 Dr. Harpreet Sagar Class of 2006 Assorted Fluid, Drug and Nutrition Pharmacy book—DMC Pharmacy The DMC Antimicrobial Guidebook Up to Date Harrison’s Maxwell’s ACC.org MKSAP Cedars-Sinai IM Handbook Compiled from the above sources, with hard work and perseverance by… Sarah Hartley, Class of 2007 Patel, Manish, Class of 2012 Leandro Perez, Class of 2007 Ali, Azzat, Class of 2012 Jason Schairer, Class of 2007 Lee, Crystal, Class of 2012 Staci Valley, Class of 2007 Kosny, Kinga, Class of 2013 Julie Wright, Class of 2007 Taylor, Stephanie, Class of 2013 Christian Bimenyey, Class of 2008 Tuliani, Tushar, Class of 2014 Ivan Hanson, Class of 2008 Gironda, Valerie, Class of 2014 Carlos Franco, Class of 2008 Alhusseini, Maha, Class of 2014 Stephanie Czarnik, Class of 2010 Abubaker Hassan, Class of 2018 Mark Brewster, Class of 2010 Walid Ibrahim, Class of 2018 Ali, Omaima, Class of 2011 Kalyna Jakibuchuk, Class of 2018 Ashley Ducharme Class of 2017 Michael Hill Class of 2018 For the interns, by some interns, we hope you have found this resource useful! Much appreciation and thank you to the above parties and anyone else who may have put time and effort forth to help us!
Internal Medicine Resident Survival Guide - 142 -
CORRECTIONS:
Internal Medicine Resident Survival Guide - 143 -
NOTES TO SELF…AND THE RC COMMITTEE! Please use the last blank pages to jot down ideas for things that need to be changed or updated for next year. It is only with your help that we can continue to make this resource a cutting-edge tool for interns and residents. Take care and have a great year! NOTES:
![2016 Annual Enrollment Survival [Guide]](https://static.documents.pub/doc/80x56/5870db6a1a28ab64768b7c99/2016-annual-enrollment-survival-guide.jpg)
