Intern Survival Series Lecture #3 Overview of Common Problems, - - PowerPoint PPT Presentation

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Intern Survival Series Lecture #3

Overview of Common Problems, Calls and Medications

Shaping the Future of Healthcare | www.thewrightcenter.org

Objectives

• After participating in this lecture, you should be able

to: – Appreciate that physically seeing the patient is superior to doctoring by phone – Have a basic understanding of the types of calls common to internal medicine – Be aware of the common treatment options available to physicians on call and on the floors

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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

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Situation

• July 1st, 11pm
• You receive the following call from

the floor nurse…………

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Common Calls and Medications

• Patient is complaining of back pain and

increased temperature of 100.2 F

• Remember Fever Definition=>100.4
• You should always go and see a patient when

possible before prescribing any medication

– Once assessed, what are your options?

• NSAIDs?
• Opioids?
• Ice? Heat?
• Do Nothing?

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Common Calls and Medications

• Tylenol:

– frequently given as a prn order for pain and fever – Potent analgesic and antipyretic with weak anti-inflammatory activity – Can be given PO, IV, PR

• Ordered as followed

– Tylenol 650mg PO q6 hours prn fever, pain – Tylenol 650mg IV q6 hours prn fever, pain – Tylenol 650mg PR q 6 hours prn fever, pain

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Common Calls and Medications

• Tylenol

– Administration/Dosing considerations

– Allergies? – GFR? » CrCl 10-50, administer q 6hr » CrCl <10 administer q 8hr – Hepatic Function? » Ok to give up to 2grams/24hrs – Level of pain? – Degree of fever? – Clinical Picture? – Hospital Course?

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Remember

• Anytime you order a medication you are

potentially

– Providing relief – Preventing harm – Causing harm – Changing a patient’s hospitalization course

• Increasing or decreasing

– Contributing to medical error – Contributing to patients well being

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Common Calls and Example Medications

• Nausea/Vomiting

– Zofran 4mg PO/IV/SL Q 6hrs prn N/V – Promethazine

• 25 mg PO/PR q 6 hrs prn
• 12.5-25 mg IV/IM q 6 hrs prn
• Diarrhea

– Imodium 4mg PO QID

– Bismuth subsalicylate 30ml Q 1 hr prn, max 8doses in 24 hr period – Lomotil 5 mg PO q 6hrs for persistent diarrhea

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Common Calls and Example Medications

• Constipation

– Milk of Magnesia 30ml PO x 1

• #1 choice for initial treatment

– Metamucil 7.5mg in 8oz H20 PO TID – Dulcolax 5-15 mg PO q day – Colace 100mg PO BID for chronic constipation – Miralax 17 grams in 8oz H20 – Lactulose 15-30 ml PO q day – Enema

• Mineral oil, tap water, fleet

– Disimpaction

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Common Calls and Example Medications

• Cough

– Robitussin 10ml PO q 4-6 hr prn – Tessalon Perles 100mg PO TID (max 600mg/day)

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Common Calls and Example Medications

• Insomnia

– Evaluate prior to medication administration

• History-> Clarify sleep pattern, patients can often

pinpoint why they cannot sleep

• Check to see if any new meds are contributing

– Ambien

• ER=6.25mg PO HS x1
• IR=5-10mg PO HS x1

– Lorazepam 0.5-2mg PO HS x1

• Should be prescribed with caution

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Common Calls and Example Medications

• Delirium

– Haldol 0.5-1 mg PO/IM – Lorazepam 0.5-1mg PO/IV

• Delirium treatment is complicated by

– critical nature of the illness – Pt’s impaired capacity to make decisions – Meds given under implied consent to stabilize a life-threatening process – should be used with caution and typically should be administered by senior resident

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Common Calls and Example Medications

• Alcohol Withdrawal Prophylaxis

– Lorazepam

• Dose and frequency per clinical situation
• Prn?
• ATC?

– Banana bag

• Multivitamin
• Thiamine 100mg
• Folic Acid 1mg

In 500ml of NS daily, In 250ml if LVEF<20%

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Common Calls and Example Medications

• Warfarin Nomagram

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Common Calls and Example Medications

Notes on Warfarin Nomagram

• Helpful in hospitalized patients in whom INR can be checked on a daily

basis.

• Typically, 5mg initiation achieves therapeutic anticoagulation as rapidly as

10mg initiation but with a lower frequency of supra-therapeutic INRs, but this is debated frequently amongst providers and should be addressed with your attending

• The 10mg initiation nomogram should only be used in relatively young and

healthy patients who are likely to be insensitive to warfarin, or in patients taking concurrent medications known to induce warfarin metabolism

• Please note that loading doses of warfarin are NOT RECOMMENDED

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Common Calls and Example Medications

• DVT Prophylaxis

– Questions:

• Bleeding?
• Procedures Scheduled?
• GFR
• DVT risk-low, med, high?
• Heparin 5000Units subcutaneously q 8 hr*
• Enoxaparin 40mg sq daily*

– If GFR> 30 – If BMI >40 may need to adjust *Not valid doses for active DVT

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Common Calls and Example Medications

• Elevated INR

– INR>5 & no signs of bleed

• Hold Coumadin
• Vit K 1-2.5 mg PO if increased risk of bleed

– INR>9

• Vit K 2.5-5mg PO

– A word about Vit K:

• May take 24-48 hrs to decrease inr, too much can cause

warfarin resistance for up to 1 week

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Common Calls and Example Medications

Elevated INR

• Serious Bleed-regardless of inr*

– IV Vitamin K

• Use should be deemed appropriate by an attending

– FFP ~3-5 Units

• Hemostasis can be achieved when coag factors are 25-

30% normal

• An average adult plasma volume is 40ml/kg, so you need

10-15ml/kg FFP to achieve hemostasis

• Roughly 3-5 Units

*In patients with mechanical valves get cardio ok first

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Common Calls and Workups

• Shortness of Breath

– Questions

• Vitals
• O2 Sats
• Time of onset
• Last ABG
• Current meds
• DDx
• Volume Overload/CHF
• Afib
• MI
• PE
• PND
• Bronchospasm/COPD
• Pneumonia
• Pain
• Pain med overdose

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Common Calls and Workups

• Shortness of Breath

– Workup

• History and Physical Go see the patient
• ABG, EKG, CXR? CTA? LE Doppler?

» Should be decided by senior with attending guidance

– Treatment

• Diuretics, anticoagulation, Heart Cath, Rate controlling

medications, BiPAP, Intubation, Narcan, nebulizers etc……

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Common Calls and Workups

• HYPOtension

– Questions

• What is pt’s normal BP?
• What BP meds is pt on?
• What are pt’s other

vitals

• Associated Symptoms
• DDx

– Shock?

• Hypovolemic

– Bleeding, N/V/D, HD etc.

• Cardiogenic

– Tension pneumo, tamponade, MI, arrhythmia, etc.

• Disruptive
• sepsis, anaphylaxis, etc.

– Medication overdose/error – Normal variant

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Common Calls and Workups

• HYPOtension

– Workup

• History and Physical Go see the patient

– Make sure patient has good IV access

• Blood work-review earlier set or order appropriately

– CBC?, RFP?, Lactic Acid?, Blood Cultures? Cardiac Enzymes?

• Rhythm Analysis
• If signs of hypoperfusion consider ICU

– Treatment options vary depending on etiology, senior and attending input necessary

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Common Calls and Workups

• HYPERtension

– Questions

• Known history of HTN?
• Did pt take BP meds today?
• When are meds scheduled

to be given?

• BP checked manually?
• Rechecked?
• Last BP WNL?
• Renal function?
• DDx

– Medication held?

• NPO?
• Delirious?
• New admission?

– New med?

• NSAIDs?
• MAOI?

– Pain? – Stroke? – Acute Renal Failure? – New onset?

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Common Calls and Workups

• HYPERtension

– Workup

• History and Physical Go see the patient

– R/O HTN Emergency

• Review recent blood work
• Review medication list
• Per clinical scenario

– Treatment

• Consider treatment for SBP>160 or DBP>100mmHG
• Should treat SBP>180, DBP>120 mmHG

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Common Calls and Workups

• Tachycardia

– Questions

• Onset?
• Symptomatic?

– Dyspnea, palpitations?

• Unstable?

– Acute AMS, chest pain? – CHF, Hypotension?

• Wide vs Narrow QRS?
• Regular vs Irregular?
• Known cardiomyopathy?
• Pacemaker/Defibrillator?
• H/O Afib?
• Did pt receive meds today?
• DDx
• Sinus Tachycardia
• Afib/flutter
• MAT
• Ectopic Atrial Tachycardia
• AVRT
• SVT
• SVT with aberrancy
• Accelerated idioventricular

rhythm

• Ventricular Tachycardia
• Ventricular Fibrillation

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Common Calls and Workups

• Tachycardia

– Workup

• History and Physical Go see the patient
• Tele strip, EKG, O2 sat
• Blood work-review earlier set or order appropriately

– CBC?, RFP?, TSH?, Cardiac Enzymes?

– Treatment

• Restart meds, O2, volume expansion, diuresis, rate

control, cardioversion, defibrillation,

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Common Calls and Workups

• Chest Pain

– Questions

• Vitals?
• Pain characteristics?
• Known CAD case?
• Anything been tried

already to relieve pain?

• On telemetry?
• EKG?
• DDx

– MI – Angina – Pericarditis – PE – Aortic Dissection – Pneumothorax – Pneumonia – Esophageal rupture – GERD – Biliary Colic – Costochondritis – Zoster – Panic Attack

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Common Calls and Workups

• Chest Pain

– Workup

• History and Physical Go see the patient
• Tele strip, EKG, O2 sat
• Recent blood work

– Treatment

• Nitroglycerine, O2, ASA, analgesics, PPI, Abxs,

PCI, Chest tube, surgical consult

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Common Calls and Workups

• Rapid Response

– When a group of healthcare clinicians are assembled quickly to deliver critical care

• Sudden deterioration of a patient outside the ICU

– Team members

• Critical care RN
• Respiratory Therapy
• EKG Tech
• Lab/Phlebotomist
• +/- Physician

– When do we go

• GCMC-Always
• MTH, Regional HOS, VA-When it is your patient

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Common Calls and Workups

• CODE BLUE

– A cardio-pulmonary arrest – When do we go

• Always…. at all

hospitals….no matter what – Who else goes

• Attending physicians
• Nurse Anesthetist
• Critical Care Nurse
• Respiratory Therapy
• EKG, Lab, Radiology, ER

staff

– Advise

• Take your own pulse, then

take the patient’s

• The more you go to, the

less crazy they seem

• Know your algorithms

cold

• After Code, follow patient

to ICU. Ensure proper transition

• Always review events of

code afterward with your attending/senior