intern survival series lecture #2 - the wright center...intern survival series lecture #2...

Shaping the Future of Healthcare | www.thewrightcenter.org

Intern Survival Series Lecture #2 Introduction to

Medicine Part 2


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

orders, 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


A Brief Note • This lecture series is not meant to be all inclusive

or 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


Hospital Admission

• Orders are now done almost exclusively through EMR. – EPIC GCMC – Sorian Regional and Moses Taylor Hospitals – VA CPS VAMC WB


Admitting Orders • ADCA VAN DIMLS • mnemonic device for recalling hospital admission

orders. • The letters stand for

– Admission – Diagnosis – Condition – Allergies – Vitals – Activity

– Nursing Communication – Diet – IV Fluids – Medications – Labs – Special (consults, imaging, etc)


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


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


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


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


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


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


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


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!)


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


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


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


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


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


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


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


Office Phone Numbers

• Scranton Clinic – (570) 941-0630

• MVP – (570) 383-9934

• Clarke’s Summit – (570) 585-1300

• Student Health – (570) 955-1474


QUESTION????

intern survival series lecture #2 - the wright center...intern survival series lecture #2...

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