How to admit a patient Kun Huang, R3 July 9, 2015 Outline On call - - PowerPoint PPT Presentation

How to admit a patient

Kun Huang, R3 July 9, 2015

Outline

• On‐call team structure
• Expectations of a Jr level consult
• Approach to an effective consult
• Two case practice for Imp/plan and admission
• rders

On call team structure

• One Senior

– Most often fly‐in senior

• 2‐3 Jr residents (including 1‐2 IM R1)
• Variable number of med students (0‐3)

You are the work force on call! Be efficient and be ready to do lots of consults

What is expected from a Jr level Consult?

• Thoroughness is the first step!
• Details, details and details

– CHADS2, FEV1, LVEF, cath results etc. – Look up care connect for their previous results/dictated letters/treatments not available

• n your computer system

What is expected from a Jr level Consult?

• Clear history/sequence of events

– If the sequences of events don’t make sense to you, they wont make sense to your staff when you present.

What is expected from a Jr level Consult?

• Story‐telling

– You can’t possibly list everything a patient tells you in the orders he/she tells you. – Synthesize your own version of the patient’s history – To the point

What is expected from a Jr level Consult?

• Problem list reflects your synthesis skill

– It is not a laundry list – It goes from the most relevant/crucial medical problem to the more stable chronic issues. – Sometimes the first issue is a symptom. For example, acute confusion. – Sometimes it is a diagnosis, e.g. NSTEMI, pyelonephritis etc.

Before talking to the patient

• Gather the basic info and RFR from your Sr.
• Look up the patient labs, previous consult note,

care connect info if PCIS/SCM/Meditech info are limited.

• Write down PMHx and labs on the consult sheet

as you look through previous records.

• Generate an impression of what’s wrong based
• n labs and PMHx.
• Think about what relevant questions to ask.
• This takes 10min

Walking to patient bedside

• Review the vitals chart, ER physician’s note,

EMS note/yellow sheet.

• Review drugs already given by ER or your Sr

who has triaged the patient.

• Say hi to the RN who is there. Introduce

yourself to them. Hear what they say if they have any concern. They are your friends!

• This takes 5min.

Interviewing the patient

• Bring the med rec with you.
• Take a brief moment to look at the cardiac

monitor.

• Thorough history.
• Clarify any questions on their PMHx and meds
• Thorough yet focused physical exam
• Pay attention to the drugs on the IV pole.
• Do code status discussion before exiting
• Time varies. Aim for <30min.

Write your consult

• Re‐organize the information patient has told you

in the order that is “story‐telling”.

• Focus on diagnosis and generating problem list

and management plan. Always consider differential Dx.

• Read your handbook or UPTODATE
• Be specific with your management. Drug, dose.

Have the admission package and orders written, ready for review.

• This may take 30min.

• Total 60min‐75min.
• Aim for under 1.5 hours!
• Manage your time effectively.

How to present the case

• When you are presenting a case, you should be

LEADING the listener through the story

• They should have a clear picture of:

– WHO the patient is – WHY they are here – Pertinent positives and negatives

• There should be NO surprises

– i.e. all important information should be given up front – Should not be adding new information about the patient

You are not done yet!

• Follow up with the lab result if you order it timed
• If you need any new imaging study to be done
• vernight, or review an image, walk to the radiology

room and ask politely. You will learn tons there.

• If your patient is completely stable, see the patient at

least one more time before the next morning review.

• If your patient is stably unstable, check on the patient

frequently throughout the night. Consider exception to transfer.

• If your patient is unstable, let your Sr know right away.

Let’s have a virtual admission!

Case 1

History

• Mr. S is 80M with history of MI and CABG X3 in

2005, presents with a 2 week history of worsening shortness of breath on exertion, and leg edema.

• The patient used to be able to walk 3 blocks but

now can only walk across the room. The patient also reports using two pillows to sleep and difficulty breathing at night time.

• The patient denies any chest pain, palpitation,

cough, or fever. He has been compliant with his medications and diet.

History

Past medical history 1. CABG 2005 2. MI 2005 3. Query CHF – no prior Echo available 4. Type 2 DM 5. BPH 6. Prior bilateral knee arthroplasty MEDICATION: Separate bottles, not blister packed.

• 1. ASA 81 mg PO daily
• 2. Metformin 500mg PO BID
• 3. Lasix 40mg PO daily
• 4. Ramipril 7.5 mg PO daily
• 5. Bisoprolol 5mg PO daily.
• 6. Tamsulosin 0.4mg PO daily
• 7. Tylenol#3 2 tab PO Q6H PRN

• Social Hx
• The patient lives alone in an apartment, one step‐

daughter in Burnaby. Patient is independent with IADLs and ADLs. The patient has 30 pack year smoking, quit 20 years ago. Denies alcohol or illicit drug use.

Physical examination

• BP: 100/70 HR: 95 Temp 37.1 RR 23 Sats:92%
• n 4L NP
• Alert, Oriented X3. Increased work of breathing
• Cardiovascular exam: JVP at the angle of the jaw,

S3 present, no murmurs

• Respiratory exam: Diffuse crackles more in bases.
• Abdominal exam: Soft, non‐tender, negative for

ascites or hepatosplenomegaly.

• The patient has +2 pitting edema.

Investigation

• Blood work: CBC normal
• Na 130, K 5, Cr 170 (baseline 75 in 2014).
• Urea 10. BNP pending. Troponin 0.06. Lactate

1.4

ECG

CXR

Write down your impression, problem list, and plan

My Imp

• 80M with hx of MI, CABG 2005 presented with

2 week hx of progressive SOB, orthopnea, peripheral edema, NYHA IV, and CXR evidence

• f pulmonary edema. Provisional Dx is CHF

exacerbation.

1. CHF –

• POND. Consider BiPAP. O2 titrate >92%.small dose Nitro patch

0.2mg. IV lasix at 40mg BID and daily reassess. Daily weight. Goal is to decrease 1kg per day. Transition to po lasix. Monitor UOP. Salt and water restriction. Echo. CHF clinic referral – Exacerbating factor: Acronym FAILURE. Likely not enough lasix and life style. Will r/o sichemia, infection, hyperthyroidism

2. AKI

– Pre‐renal, renal, post‐renal. Most likely pre‐renal from decrease ECV. U/A, microscope, PVR, renal U/S 3. Trop – Likely from decreased renal excretion+/‐demand. Repeat in 8 hours to trend. 4. Diabetes – Insulin sliding scale 5. House keeping – Hold metformin, ramipril. Hold bisoprolol. – DVT prophylaxis: heparin 5000 units sc BID. – DNR‐3 6. Disposition – Likely a week. PT/OT to see. Home with family when stable.

The Paper work

Practice with VGH admission package

Allergy Status

Mrn: 2346273 PHN: 90387438 Smith, John Birthday: 08/11/23

Medication reconciliation

Tylenol#3 2 tab PO Q6H PRN Bisoprolol 5mg PO Daily Ramipril 7.5 mg PO daily Lasix 40mg PO daily Metformin 500mg PO BID Tamsulosin 0.4mg PO daily

Mrn: 2346273 PHN: 90387438 Smith, John Birthday: 08/11/23

Write admission orders

• Admit under CTU pink under Dr. ____
• Diagnosis: CHF exacerbation
• Diet ‐ Na restriction, < 2L, diabetic diet
• AAT
• VS q4H X12 h then VSR
• Inv. CBC, lytes, Cr, BUN X 3 days
• Echocardiogram
• Daily weight
• INs and Outs – Foley catheter
• Drug: Lasix 40 mg IV BID, Ramipril hold, metformin hold. Continue

Bisoprolol 5 mg daily.

• See Med rec
• Insulin Sliding scale
• PT/OT/SW

Insulin Sliding Scale

Mrn: 2346273 PHN: 90387438 Smith, John Birthday: 08/11/23

DVT prophylaxis

Mrn: 2346273 PHN: 90387438 Smith, John Birthday: 08/11/23

Code status

Case #2

History

• Ms. H is 60 F with polysubstance abuse

presenting with 3 months of increasing abdominal distention and leg edema.

• The patient drinks 6 beers per day for the past 4

years and smokes 1 pack per day X 20 years.

• Patient denies orthopnea, PND or SOB. History is

negative for nausea, vomiting or hematemesis or melena stool.

• Patient followed by addiction service in the

community but has not contacted family doctor for 15 years.

History

Past medical history

• 1. Methadone use
• 2. Chronic alcohol use. Previous hospitalization for

withdrawal

• 3. Chronic left knee pain after trauma

Medication

• 1. Methadone 80mg daily dispense
• 2. Ibuprofen 400mg PO QID

Physical examination

• BP 110/70, HR 80 Temp: 37.2 RR 20, 96% on room air.
• Oriented to place and time.
• H&N: Scleral icterus
• Cardiac exam: normal heart sound, JVP 1 cm
• Respiratory exam: Good air entry bilaterally
• Abdominal exam: Tense abdomen, Bulging flanks with

positive shifting dullness and fluid wave. Castell sign is

• negative. Liver edge not palpable.
• MSK: +1 pitting edema in bilateral legs, noted to have

clubbing

• No asterixis
• Skin: Palmar erythema, spider angioma

Investigation

• WBC 5.4 Hgb 103 MCV 102 Plt: 120
• Na 130, K 4.3, Cr 70 Urea 2. Albumin 33.
• AST 80 ALT 40 GGT 150 ALP 90 Bilirubin 40.

INR 1.6 PTT normal.

• CXR: normal

Write down your impression, problem list, and plan

My impression

• 60M polysubstance use, ETOH abuse,

presented with 3 month hx of increasing abdo girth, physical exam finding of tense ascites as well as stigmata of chronic liver disease. Provisional Dx is decompensated cirrhosis. DDx includes right side heart failure.

1. Tense Ascites – Likely 2ndary from decompensated cirrhosis. Parancentesis to confirm SAAG, cytology and infectious w/u. – Therapeutic tap 5L to relieve discomfort. 50cc of 25% Albumin. – Abdo U/S + doppler to r/o Budd‐Chiari, PVT, HCC. Echo to r/o RHF. – If etiology is cirrhosis, start lasix 40mg and spironolactone 50mg daily for diuresis. Titrate to effect. 2. Chronic liver disease, likely cirrhosis – Etiology maybe ETOH. Check Hepatitis serologies. autoimmune hepatitis, PBC, Hemachromatosis, wilson’s, alpha anti‐trypsin deficiency are unlikely but need to r/o. – Abdo U/S with doppler – Need Q6 months U/S for HCC surveillance. 3. ETOH w/d – CIWA protocol. Thiamine, B12, multivitamin, Mg. Addiction to see for both ETOH and polysubstance use.

• 4. Macrocytic anemia

– Multifatorial: liver disease, ETOH, nutritional deficiency. 5. HypoNa – Likely from decreased ECV. Urine Osm, serum Osm. Stable and watch. 6. House keeping – OK to continue ibuprofen for pain. Needs to watch Cr careful as pt is already intravascularly dry. – DVT prophylaxis: dalteparin sc – Code status: full 7. Disposition – SW to see. Likely short stay but safe discharge and followup needed.

The Paper work

Practice with RCH admission package

Allergy Status

Mrn: 2346273 PHN: 90387438 Smith, John Birthday: 08/11/23

Medication reconciliation

Ibuprofen 400mg po QID Methadone 80mg daily

Mrn: 2346273 PHN: 90387438 Smith, John Birthday: 08/11/23

Addictions consult requested

Write admission order

• Admit under CTU pink under Dr. ____
• Diagnosis: Ascites
• Diet ‐ Na restriction, < 2L fluid restriction
• AAT
• VS q4H X12 h then VSR
• IV S/L
• Inv. CBC, lytes, cr, bUN, LFTs, INR/PTT daily
• Viral hepatitis serology, Iron study with ferritin, Immunoquantative, ANA/AMA/ anti‐sm

antibody, ceruloplasmin etc

• Send Ascitic fluid for: CBC with diff, Albumin, LDH, protein, gram stain, culture etc etc.
• Urinalysis R &M, Urine ACR
• Echocardiogram: history of CHF.
• Ultrasound abdo ‐ liver
• Daily weight and monitor In and Out
• Drug: Morphine 5‐10 mg po q4h prn overnight. Vit K 2mg SL. Lasix 40 mg IV BID, Tylenol 325‐620

mg po QID prn, Ibuprofen as per med rec.

• CIWA protocol
• Nicotine replacement therapy
• Consult Addiction service
• PT/OT/SW

CIWA protocol

Mrn: 2346273 PHN: 90387438 Smith, John Birthday: 08/11/23

DVT prophylaxis

Mrn: 2346273 PHN: 90387438 Smith, John Birthday: 08/11/23

Code status