[PPT] - Intern Survival Series Lecture #2 Introduction to Medicine Part 2 PowerPoint Presentation

SLIDE 1

Shaping the Future of Healthcare | www.thewrightcenter.org

Intern Survival Series Lecture #2

Introduction to Medicine Part 2

SLIDE 2

Shaping the Future of Healthcare | www.thewrightcenter.org

Objectives

After participating in this lecture, you should

be able to:

– Identify the roles of the Service Team – Complete a comprehensive H&P exam – Have an understanding of the flow of admitting

rders, and be able to write as needed with

appropriate supervision – Identify and complete all parts of a SOAP note – Identify and complete an appropriate discharge summary

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A Brief Note

This lecture series is not meant to be all inclusive
r totally comprehensive to all of medicine
It is not meant to supersede clinical judgment
It is not meant to replace daily reading or bedside

teaching

It is meant to act as a starting point for which to

grow from as new primary care physicians

It is a tool to help you survive the your new job

SLIDE 4

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Hospital Admission

Orders are now done almost exclusively

through EMR.

– EPIC  GCMC – Sorian Regional and Moses Taylor Hospitals – VA CPS  VAMC WB

SLIDE 5

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Admitting Orders

ADCA VAN DIMLS
mnemonic device for recalling hospital admission
rders.
The letters stand for

– Admission – Diagnosis – Condition – Allergies – Vitals – Activity – Nursing Communication – Diet – IV Fluids – Medications – Labs – Special (consults, imaging, etc)

SLIDE 6

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Sample Admission Orders

Observation: Remote Tele
Dx: New onset Afib
Condition: Guarded
NKDA
Vitals q shift
Activity: OOB to chair
Nursing: Call for HR>120
Diet: Heart Health 2000cal

diet

IV: Heplock
M: Metoprolol Tartrate 25mg PO BID

– Rivaroxaban 20mg PO HS

Labs:

– Cardiac enzymes x3, 8 hrs apart – RFP w/ Mg in am

Special:

– EKG in am – CXR- PA/Lateral views – 2D echo, reason: abnormal EKG

SLIDE 7

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Progress Notes

Daily notes

– descriptive document that chronicles a patient’s hospital course – Brief, not meant to be a repeated H&P – Highlight important data – Express clear clinical impression

SLIDE 8

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Progress Notes

Basic Format is a S.O.A.P. note

– Subjective Information – Objective Data – Assessment of Clinical Picture – Plan of Care

Data Collected/Reported

– not meant to be a recapitulation of the H&P – Old events described in earlier notes should not be repeated

SLIDE 9

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Sample Soap Note

S: 65 yo male hospital day #2, patient reports one episode of acute onset, 2-3 second chest pain

while at rest, associated with movement, remitting spontaneously without reoccurrence, similar to presenting symptoms. No other complaints or problems, tolerating diet, ambulating on own w/o complaints or problems.

O:

– Vitals: 97.8, 55, 18, 120/86, 98%RA, accucheck 96 – G: NAD – CV: RRR, +s1/s2, no m/c/g/r – R: CTA – A: +BS, s/nt/nd, no pain with deep palpation – Ex: -edema, clubbing or cyanosis, +strong peripheral pulses B/L – N: no focal deficits, A&Ox3 – Labs: Trop 0.00 x3, Sodium 140, K+ 4, Cl- 106, CO2 26, BUN 20, Cr 1, Glucose 100 – EKG: NSR @ 76bpm, normal axis, RsR’ in V1

A/P

– 1)Chest Pain: Acute Coronary Syndrome vs GERD vs costochondritis – 2)Hypertension: Controlled with Lisinopril – 3)DM II: stable with metformin – 4)DVT prophylaxis: enoxaparin

SLIDE 10

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Common Daily Orders

Electrolyte Replacement

Potassium

– (goal 4-4.5)-do not replete if pt is on HD – Example Order – KDUR 20meq PO Q.I.D. x 1 day (MAKE SURE YOU PUT AN END TIME ON ORDER) – 10mEq of K raises serum K by 0.1mmol.

For mild renal failure, cut the dose in half.
For severe renal failure (CrCl<30) ask senior resident for help.
Administration Consideration

– PO tabs are huge – Liquid tastes gross, fast-acting – IV can be painful through a peripheral line. Go Slow

KCL 20mEq in 100ml sterile H20 IV, run at rate of 10mEq/hr

– Ideally run through a Central line – Can be added to maintenance IVF

SLIDE 11

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Common Daily Orders

Electrolyte Replacement

Magnesium (goal>2)-do not replete in HD

– 1 g of Mg will raise Mg level by 0.1. – PO: Mag Oxide.

Causes diarrhea, consider not replacing if K+ is WNL
Mag oxide 400mg PO BID (x4 doses if Mg 1.5-1.7, x6 if

<1.4) – IV: Mag Sulfate

8mEq if Mg 1.6-1.9
16mEq if 1.3-1.5
32mEq if 1-1.2

In 100 ml D5W In 250ml D5W

SLIDE 12

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Common Daily Orders

Electrolyte Replacement

Phosphate (goal 3-4.5, usually replace if <2.5)
Replacement options

– Neutraphos 1 packet PO TID x 1 day – Kphos 1-2 Tabs PO QID x 1 day – Kphos 15mmol in 100ml NS IV, infuse over 6 hrs, x 2 doses

SLIDE 13

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Common Daily Orders

Electrolyte Replacement

Calcium (goal 8.5-10) –don’t replete in HD unless dangerously low and nephrologist aware
Remember to correct for albumin.

– Corr. Calcium=Ca + 0.8 x(4-Alb)

Be very cautious when giving Calcium- Can precipitate MI, HypoTN, arrythmia etc
Indicated when decreased level causing increased QTC, seizure, arrhythmia
PO:

– Tums – Calcium Carbonate 500mg PO BID/QID for 1-2 grams total

IV:

– Calcium Gluconate 1-2g IV runs (1st choice for peripheral IV) – Calcium Chloride 1-2g IV runs (through central IV’s only ~4-5x as potent!)

SLIDE 14

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Discharge Summary

A vital tool for transferring information

between the hospitalist and primary care physician

Extremely important for continuity of

care

Discharge planning should start at the

time of admission

SLIDE 16

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Discharge Summary

The Joint Commission mandates that discharge

summaries contain certain components:

– reason for hospitalization – significant findings – procedures – treatment provided – patient’s discharge condition – patient and family instructions – attending physician’s signature

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Discharge Summary

Research suggests summaries contain

insufficient or unnecessary information and fail to reach the primary care physician in time for the patient’s follow-up visit, if they arrive at all.

Delay can cause

– patient harm/frustration – repeated and unnecessary tests – medical error

SLIDE 18

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Discharge Summary

A structured, standard discharge summary

form ensures that all the important information is included

Allows the receiving physician to more quickly

identify how to respond to the patient’s hospitalization

Should be completed within 24 hours of

discharge

SLIDE 19

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Discharge Summary

Standard Format in a Local Hospital System
1.Patient Name
2.Medical Record Number
3.Date Admitted
4.Date Discharged
5.Encounter Number
6.Diagnosis

– Principle – Secondary

7.Operations/Procedures
8. Complications
9. Allergies
10. Disposition
a. Medications
b. Follow up
c. Special Instructions
d. Activity
e. Diet
f. Condition
11.History
12. Physical Exam
13.Hospital Course
14.Laboratory
15. Consults
16. Referring Physician

SLIDE 20

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Important Notes for DC

As residents we often take patients who do

not have a PCP

These patients are frequently asked to follow

up at a WCGME clinic

If that is the case YOU MUST

– call the clinic – make an appointment for the patient – Relay any FU instructions/tests patient is scheduled for to the proper care coordinator

SLIDE 21

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Important Notes for DC

Patients on COUMADIN or INSULIN

– NEED to have inr, coumadin dose or insulin regiment communicated verbally to the clinic via telephone – Very important for patient safety

SLIDE 22

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Office Phone Numbers

Scranton Clinic

– (570) 941-0630

MVP

– (570) 383-9934

Clarke’s Summit

– (570) 585-1300

Student Health

– (570) 955-1474

SLIDE 23

Shaping the Future of Healthcare | www.thewrightcenter.org

Intern Survival Series Lecture #2

Introduction to Medicine Part 2

Objectives

be able to:

– Identify the roles of the Service Team – Complete a comprehensive H&P exam – Have an understanding of the flow of admitting

appropriate supervision – Identify and complete all parts of a SOAP note – Identify and complete an appropriate discharge summary

A Brief Note

teaching

grow from as new primary care physicians

Hospital Admission

through EMR.

– EPIC  GCMC – Sorian Regional and Moses Taylor Hospitals – VA CPS  VAMC WB

Admitting Orders

– Admission – Diagnosis – Condition – Allergies – Vitals – Activity – Nursing Communication – Diet – IV Fluids – Medications – Labs – Special (consults, imaging, etc)

Sample Admission Orders

diet

– Rivaroxaban 20mg PO HS

– EKG in am – CXR- PA/Lateral views – 2D echo, reason: abnormal EKG

Progress Notes

– descriptive document that chronicles a patient’s hospital course – Brief, not meant to be a repeated H&P – Highlight important data – Express clear clinical impression

Progress Notes

– Subjective Information – Objective Data – Assessment of Clinical Picture – Plan of Care

– not meant to be a recapitulation of the H&P – Old events described in earlier notes should not be repeated

Sample Soap Note

Common Daily Orders

Electrolyte Replacement

Common Daily Orders

Electrolyte Replacement

– 1 g of Mg will raise Mg level by 0.1. – PO: Mag Oxide.

<1.4) – IV: Mag Sulfate

Common Daily Orders

Electrolyte Replacement

– Neutraphos 1 packet PO TID x 1 day – Kphos 1-2 Tabs PO QID x 1 day – Kphos 15mmol in 100ml NS IV, infuse over 6 hrs, x 2 doses

Common Daily Orders

Electrolyte Replacement

Discharge Summary

between the hospitalist and primary care physician

care

time of admission

Discharge Summary

summaries contain certain components:

– reason for hospitalization – significant findings – procedures – treatment provided – patient’s discharge condition – patient and family instructions – attending physician’s signature

Discharge Summary

insufficient or unnecessary information and fail to reach the primary care physician in time for the patient’s follow-up visit, if they arrive at all.

– patient harm/frustration – repeated and unnecessary tests – medical error

Discharge Summary

form ensures that all the important information is included

identify how to respond to the patient’s hospitalization

discharge

Discharge Summary

Important Notes for DC

not have a PCP

up at a WCGME clinic

– call the clinic – make an appointment for the patient – Relay any FU instructions/tests patient is scheduled for to the proper care coordinator

Important Notes for DC

– NEED to have inr, coumadin dose or insulin regiment communicated verbally to the clinic via telephone – Very important for patient safety

Office Phone Numbers

– (570) 941-0630

– (570) 383-9934

– (570) 585-1300

– (570) 955-1474

QUESTION????