2013-2014 Survival Guide

Transcription

WAYNE STATE UNIVERSITY
DETROIT MEDICAL CENTER
DEPARTMENT OF INTERNAL MEDICINE
2013-2014
RESIDENT SURVIVAL GUIDE
Revision Date: August 2013
Created by the Resident Council Intern Representatives of 2004
Reviewed and revised by subsequent representatives yearly.
Current Edition Edited by: M. Singh (Associate Program Director), B. Bangalore (CMR), V.
Taneja (CMR), F. El-Khider (CMR), C. Mandapakala (CMR), L. Nandagopal (CMR)
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.
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 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!
Internal Medicine Resident Survival Guide
-2-
TABLE OF CONTENTS
SECTION 1: CONTACT INFORMATION
General Telephone Numbers and Information…………………………………….. 5
Food & Lockers…………………………………………………………………………6
Paging System………………………………………………………………………… 7
Internal Medicine Administration Pager Numbers…………………………………. 8
Internal Medicine Resident Pager Numbers……………………………………….. 9
Subspecialty Fellow Pager Numbers……………………………………………….. 11
Commonly Called Numbers…………………………………………………………. 13
Information Systems Contacts & Tech Tips………………………….…………….. 14
Nursing Station & ICU Phone Numbers..…………………………….…………….. 16
Subspecialty Clinic Numbers…………………………………...…………………….16
VA phone numbers…………………………………….………………………………17
Outside Hospitals/Clinics & Medical Records……………..………………………..19
SECTION 2: ROTATION INFORMATION
Guide to Rotations………………….………………………………………………….21
Intern Etiquette………………………………………………………………………… 22
Tips from Interns and Seniors……………………………………………………….. 24
Admission Orders………………………………………………………………………24
Do Not Use Abbreviations…………………………………………………………… 25
Prisoner Protocol……………………………………………………………………… 25
Writing Orders……………………………………………………………….………… 26
Progress Notes……………………………………………………………………….. 27
Power Notes…………………………………………………………………………… 28
How to Present a Patient…………………………………………………………….. 29
Discharge Planning…………………………………………………………………… 31
Discharge from the ICU………………………………………………………………. 32
Dictating…………………………………………………………………………………33
Consults………………………………………………………………………………... 34
Death Notes…………………………………………………………………………….35
SECTION 3: DOCUMENTATION & BILLING
Medical Documentation – Charting…………………………………………………. 36
Billing in the Hospital and Ambulatory Setting…………………………………….. 37
New Innovations Responsibilities ……………………………………………………40
SECTION 4: TEACHING INFORMATION
Residents’ Role in Teaching…………………………………………………………..41
Medical Student Expectations……………………………………………………….. 42
Responsibilities to Our Medical Students………………………………….……….. 43
SECTION 5: MEDICAL INFORMATION & TIPS
Acute Emergencies…………………………………………………………………… 48
AMS…………………………………………………………………………48
Seizures…………………………………………………………………….49
-3-
Chest Pain…………………………………………………………………..50
Shortness of Breath………………………………………………………..51
Stroke………………………………………………………………………..53
Alcohol Withdrawal…………………………………………………………54
How to Read an EKG………………………………………………………………….55
ACLS …………………………………………………………………………………... 56
Electrolyte Replacement……………………………………………………………… 62
Common On Call Complaints & Subspecialty Tips………………………………...65
Ambulatory………………………………………………………………….65
General…………………………………………………………………….. 65
Pain………………………………………………………………………….67
Cardiology/Hypertension…………………………………………………. 69
Critical Care/Pulmonary………………………………………………….. 85
Endocrine…………………………………………………………………...94
ENT…………………………………………………………………………. 97
Geriatrics…………………………………………………………………… 98
Hematology/Oncology……………………………………………………. 98
Infectious Disease………………………………………………………… 107
Nephrology and Acid Base………………………………………………. 111
Neurology………………………………………………………………….. 114
Rheumatology………………………………………………………………118
Miscellaneous………………………………………………………………119
Useful Equations……………………………………………………………………….121
Core Measures…………………………………………………………………………124
SECTION 6: RESOURCES
Community Resources……………………………………………………………….. 125
OTHER
Acknowledgements…………………………………………………………………….134
Corrections & Notes………………………………
…………………………135
-4-
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 Medical School – 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:
Sat & Sun 12 p.m. – 8 p.m.
Mon - Fri 7:30 a.m.- 12 a.m.
(313) 577-1094
WSU ONE CARD
What is it?
An access card for the School of Medicine, University Medical Library and Fitness Center.
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 8:30am – 5 pm
-5-
CAFETERIA HOURS and protocol to get fed on call or to get fed at all…
Detroit Receiving
6:30am – 10am
11:00 am – 2:00pm
5:00pm – 7:00pm
Harper Hospital
Hot breakfast 6:30 – 9:15
Grab “n” go 9:15 – 10:30
Hot lunch 11:30am – 1:45pm
Hot dinner 4:00pm – 6:30pm
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
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
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 3rd floor, close
to MED services.
On consult months: Use the lockers in the 7-Brush on-call suite
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.
-6-
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.
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.
2.
3.
4.
5.
Go to the DMC Intraweb.
Locate person by name or pager.
It brings up a list.
Click on person’s pager number if it is green (active).
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 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.
Entering the whole number prevents confusion at these two hospitals.
•
Out of the hospital: call the VA operator at 1-313-576-1000 and ask them to
page
-7-
Department of IM
4201 St. Antoine Fax
2E UHC
Detroit, MI 48201
745-4832
745-4052
Housestaff Office
DRH
5S10
Harper 2 Hudson
VAMC
C3-100
Tammy Lee
Laura Goss
Shirley Kmetz
Elinda Joseph
Payroll
745-7999
745-4832
745-4901
577-0348
578-3704
DMC Medical Records (Inpatient)
DRH
745-3285
Harper
745-8022
Karmanos
576-9393
VAMC
576-3638
745-4525
745-4063
966-7340
745-3322
AIl Medical Records (Outpatient)
GMAP
745-2899
745-4141
Resident Clinics
GMAP
Phones in staffing area
4C UHC
745-3265
745-8334
576-3450
Medical Education
and Program Directors
Chief Medical Residents
B. Bangalore (DRH )
V. Taneja (HUH/AMB)
F. El-Khider (VA)
L. Nandagopal (Quality)
C. Mandapakala (Quality)
8639
7213
7126
7184
7161
On Call Department Pagers
Anesthesia Pain - DRH
Anesthesia Pain – Harper
Bone Marrow Fellow
Cards Resident (Harper)
Cards Fellow (Harper)
CCU Resident (DRH)
Chaplin
Dermatology 313-436-2848
Echo Tech
EEG Fellow
Endocrinology
ENT
Geriatrics
GI
GYN Onc
Hematology
Interventional Radiology
Medicine on-call Harper
Medicine A (DRH)
Medicine B (DRH)
6238
9996
9080
4444
6666
9009
5661
0111
5298
5424
8445
0978
06565
5456
5548
6955
07777
6789
0997
5755
Dr. D. Levine
Dr. T. Vettese
Dr. J. Weinberger
Dr. M. Singh
Dr. S. Wilson
11204
60230
2028
3011
280-0426
MICU
6428
6313
5573
5513
9429
08888
5859
9981
09999
5228
1619
1234
9997
3622
5161
Harper
DRH
Nephrology
Nephro, Transplant
Neurology
Neuro-radiology
Neurosurgery Harper
DRH
Radiology
Palliative Care
PM&R nights/weekends
Pulmonary
Stroke pager
Toxicology
Urology
-8-
COMMONLY CALLED NUMBERS
DRH
Harper Hutzel
ABG Lab
53482
58070
Admitting
54400
54400
Anesthesia
52607
58521
57315
Angio Lab
58325
Blood Bank
54206
58565
50872
Brochoscopy
58516
Cath Lab
52692
Central Supp. 53396
58171
57428
Chemistry
54598
58555
50877
Coagulation 30714
Core Lab
54588
CT scan
57979
58412
57600
Cytogenetics
52541
Cytology
52849
50834
50864
Dental
51977
Dietary
53252
50825
57041
Drug Info.
54556
52005
57025
Echo Lab
52666
52666
TEE lab/results
52523
Echo Results
52680
Echo Strest lab
52679
Echo Tech
#5298
Endoscopy
53188
58358
EP consults
52626
EP lab
52390, 50680
EEG
58328
58328
57305
ER
53374
51477
50681
ER South
59726
FISH Cytology
60680
General Info. 53603
58811
57555
Gyn On Call
#5741
GynOnc oncall
#5548
Hematology 54714
59292
Home O2 Eval
P#9140
IR
58899
Immunology
30374
KCI Hospice (248) 827-7722
Lab Results 54100
54598
57202
Life Stress
54811
54811
54811
DRH
Harper Hutzel
Microbiology 30700
30700
57202
Medical Rec. 53285
58022
Molecular Genetics
32631
MRI - inpatient
51367
MRI – outpatient
51376
Neuro – Radiology
62807
Nuclear Med.
58417
57191
Nuclear Stress test
52326
Nutrition
53254
Occ. Therapy 53523
58242
57020
OMFS
54696
OR boarding 53182
52600
57279
Ostomy nurse
95192
Pastoral Care 52905
#5066
57279
Pathology
58940
59592
Patient Info. 53603
56000
57700
Pharm-inpt
53514
58623
58623
Pharm-outpt
65148
Physical Tx. 53535
58058
57020
PICC line
97547
PM&R
51000(RIM)
Poison control 800-222-1222
Pulm. Funct. 54761
58516
57417
Radiology
54685
58402
57417
Rad. Onc.
59191
59191
57626
Recovery
53188
58525
57531
Resp. Ther.
P#9827 #9140
57417
Security
53325
58352
57031
Shuttle Bus
58353
“
“
Smoking Ces. 58516
58516
58516
STAT Lab
30288
58555
59288
Social Work 53575
58313
57051
Telepage
55151
55151
55151
TB/AFB lab
30994
Ultrasound
53465
59461
57558
US Tech
59513
Vascular Lab 53465
58828
57305
Virology
30710
VNA
P#6374
-9-
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.
USEFUL WEBSITES:
•
•
•
•
•
•
•
•
•
•
•
•
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/
Medline Plus: http://www.nlm.nih.gov/medlineplus/evaluatinghealthinformation.html
Emedicine: http://www.emedicine.com/
National Guidelines Clearinghouse: http://guidelines.gov/
The Cohchrane Library: http://www3.interscience.wiley.com/cgibin/mrwhome/106568753/HOME?CRETRY=1&SRETRY=0
Clinical Knowledge Summaries: http://www.prodigy.nhs.uk/home
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
- 10 -
GUIDELINES:
There are many!
A useful place to start is The National Guidelines Clearinghouse:
http://guidelines.gov/
EMAIL:
http://owa.med.wayne.edu
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)
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.
•
Click into the DMC web Portal
•
Click the “Clinical Tools” Tab
•
“Search” Policies in the lower left of the screen
- 11 -
Harper Hospital Nursing Units
10 Webber North 576-9229
10 Webber South 51509
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
4 Webber South
4 Brush North
3 Webber North
3 Webber South
3 Brush
2 Brush North
2 Brush South
2 Webber North
2 Webber South
52127
52287
52216
50645
50755
52147
52168
50613
50623
50513
DRH Nursing Units
3Q
53199
3R
53547
5U
53573
4M
53018
4N
53124
4Q
53031
4R
53447
4U
53034
4V
5L
5M
5N
5Q
5R-1
4L
53082
53087
53091
53508
53511
52990
53093
Harper Hospital Intensive Care Units
9 ICU
58792
Cardiothoracic
8 PCU
65203
6 ICU
58694
5 ICU
4 ICU
52297
58568
4T
5Q
5R
4Q-2
Burn Unit Step Down
Coronary ICU
Medical ICU
Surgical ICU
DRH Intensive Care Units
4P
Surgical ICU
4Q-1
Surgical ICU
5T
Neurotrauma
4S
Burn Unit
53148
53164
33841
53074
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
•
Pulmonary, 4C
745-4525
•
Geriatrics, 5B
745-1741
•
Neurology
745-4275
•
Infectious Diseases 966-7601
•
Vaginitis Clinic
966-7600
•
•
•
•
•
Medicine
Neurology
53078
53911
52990
53447
HIV clinic
745-8172
Nephrology, Ste 917 745-4525
Transplant Clinic
745-4195
Rheum, Suite 917
745-7227
General Surgery
PDI/Highland Park
852-7700
•
Urology
833-3320
Outpatient Dialysis Centers
•
CAPD Clinic-Gambro/
Motor City Dialysis
993-2958
•
Gambro/Kresge
745-1885
•
Harper Pro Building 745-4195
- 12 -
VA NUMBERS
Location
A2N-MICU
A2S- Surgery
Clinics
A3 North
A3 South
A4 North
(SICU)
A4 South
(Surgical)
A4N- Short
Stay
A5 North
A5 South
A6 South
A6N
ADMITTING
Angiography
Ann Arbor VA
B2S
Blood Bank
C2 South –
Dialysis
C2S
Hemodialysis
C4 Tele/
Stepdown
House staff
office
Phone
Ext.
6-3640/
6-3642
6-5716/
6-3424
6-4150/
6-4151
6-3786/
6-3787
6-3948/
6-3949
6-4180/
6-4181
6-4209/
6-4210
6-4085
6-4241/
6-4242
6-4297/
6-4299
6-4327/
6-4328
6-4351/
6-4352
6-4114/
6-5602
Location
C4-SW / SICU
Cardiac alert
(code blue)
Phone
Ext.
6-3948/
6-3949
6-3333
Location
ER
Cardiology
6-3635
Cardiology
Clinic
Chem Lab
6-4666
6-4025
Fax Unit
(Endo
office)
Fire Code
(code red)
FIRM A
Pharmacy
FIRM A
Chief of
Medicine
CLINICS
6-3318
FIRM B
Coumadin
Clinic
CT Scan
6-5710
FIRM C
Pharmacy
FIRM C
Cytology
6-3365 /
6-5603
6-3414
Diabetic
teaching
Dietician
6-4829
Dietician C4
6-4566
1-800
361-8387
6-4951/
6-4303
6-3419
6-3454
Disturbance
(code green)
Echo
6-3777
6-3713
EEG
EKG
6-3425
6-3368
6-3454/
6-3648
6-5824
6-3295
6-3450
Endocrinology
6-3125
ENT
6-3210/
6-4017
6-3233
Pharmacy
inpatient
6-4595
- 13 -
FIRM D
FIRM D
Pharmacy
FIRM E
Pharmacy
FIRM E
Phone
Ext.
6-4436
576-1122
6-3555
6-5709
6-4145/
6-5868
6-5767/
6-5710
6-3276
6-3634/
6-3282
6-5883/
6-4425
6-3343
6-3386
6-3732
FIRM F
ALLEN
PARK
Fluoroscopy
6-6002
6-6003/
6-6004
6-3255
Gastroenter
ology
GEC
General
Diagnostic
Radiology
Heme Lab
6-3389
Home O2
evaluations
6-3297
250-5146
6-4276
6-4283 /
6-3255
6-3423
Location
Location
IR
Phone
Ext.
6-5541/
6-3901
6-5698
Laboratory general
6-3411
Laboratory Chemistry
6-4025
PICC lines and IR
procedures
Tom Lamacchia
PODIATRY
Laboratory Heme
6-3423
Police & Security
Laboratory Cytology
Laboratory -Micro
Laboratory- UA
Library
Medical Records
Micro
6-3414
6-5041
6-3860
6-3380
6-3224
6-3691
Pre-cert
Prosthetics
Psych
Psych(Dr.Day)
Radiology
Respiratory
MICU
6-3640/
6-3642
6-4283 /
6-3601
6-3601
6-3648
6-3434
6-3434
SICU
Infectious Diseases
MRI
MRI
Nephrology
Nuclear Medicine
Nuclear Medicine
Nursing home/rehab
250-1632
280-0359
250-3032
6-4062/
6-4078
6-4425
Operating Room
Outpaitent appointment
Palliative care
Dr. McDonald
Palliative care -Sheila Vogel
Pharmacy outpatient
Physical Tx.
Social Work
Phone
Ext.
6-3762/
6-3457
6-3516
6-9530
250-0947
6-3999/
6-4000
6-3375/
6-3201
250-3039
6-4897
6-4303
250-0991
6-3256
6-3024
6-3338
6-3513
6-3295/
6-3954
6-3215
Social work (C4 SD)
Social work (Karen)
Social work (Nicole)
To hold an on call meal
tray
Wound care
6-1332
6-3460
6-5816
6-4567
UHCMED
6-4896
Ultrasound
6-3255 /
6-5820
6-4683
705-7808
6-3802
6-3197
Urology
250-1240
Vascular Lab
6-4112
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.
- 14 -
Phone Numbers of Outside Hospitals/Medical Examiner
BiCounty Hospital
Medical Records
Emergency Room
586-759-7370
586-759-7310
Bon Secours
Medical Records
MR Fax Number
Emergency Room
313-343-1000
313-343-1625
313-343-1186
313-343-1605
Karmanos
Medical Records
1-800-527-6266
313-576-9393
Botsford
Medical Records
Emergency Dept.
248-471-8000
248-471-8175
248-471-8556
Northville State
Hospital
248-349-1800
Beaumont
Medical Records
MR Fax Number
Emergency Dept.
248-551-5000
248-551-5050
248-597-2848
313-593-7440
Oakwood
Medical Records
Emergency Dept.
313-593-7000
313-593-7780
248-551-6000
Children’s ER
Administration
Pt. information
Medical Records
313-745-0113
313-745-5255
313-966-5110
313-745-5356
Providence
Medical Records
Emergency Dept.
248-424-3000
248-849-5580
248-849-3000
RIM
313-745-1203
Riverview
Medical Records
Emergency Dept.
313-499-4000
313-499-4589
313-499-3331
Sinai-Grace
Medical Records
Emergency Dept.
313-966-3300
313-966-1092
313-966-1010
St. John’s Main
Medical Records
313-343-3400
313-343-3780
DRH
Triage
Crisis
ER x-ray
Fax
Medical Records
313-745-2230
313-745-3374
313-745-3546
313-745-3423
313-745-4038
313-745-3285
Detroit Psych Insitute
313-874-7500
Garden City
Medical Records
Emergency Dept.
734-421-3300
734-458-4405
734-458-3426
Henry Ford
Medical Records
After Hours MR
Emergency Dept.
313-916-2600
313-916-4540
313-434-2337
313-916-1545
Herman Keifer
313-876-4826
Medical Examiner
313-833-2568
(Call if death is a result of trauma,
suicide, or within 24 hrs. of
admission)
St. John’s Macomb
Emergency Dept.
586-573-5051
Medical Records
586-573-5080
- 15 -
St. Mary’s
Mental Health
Social Health
TB
1-800-464-7492
313-876-4400
313-876-4180
313-876-0335
Holy Cross
Medical Records
Emergency Dept.
313-369-9100
313-369-5727
313-369-5689
Huron Valley
Emergency Dept.
284-360-3400
Hutzel
Medical Records
Emergency Dept.
313-745-7141
313-745-0680
U of M
Medical Records
Fax
734-764-1817
734-936-5490
734-647-6220
Medical Records
Emergency Dept.
734-655-9253
734-655-1200
St John’s Oakland
Medical Records
Emergency Dept.
248-967-7000
248-967-7080
248-967-7670
Veterans
313-576-1000
Poison Control
(HPB)
St. Joseph Pontiac
313-745-5711
248-858-3000
Wyandotte
734-284-2400
Hospice KCI
248-827-7722
Southeast MI
Hospice
313-578-6300
Detroit Area Methadone Clinics
MY FREQUENTLY CALLED NUMBERS:
LOCATION
Herman Keifer Hospital
Medical Resource Center
Methadone Clinic
Metro-East
Metro-East Gratiot
Metropolitan Rehab Clinics
Mich Counselling Services
Nardin Park Drug Abuse
New Light Recovery Center
Parkman Counselling
Rainbow Clinic
St. Joseph Mercy
Starr Clinic
VA Methadone Clinic
Phone
876-4045
852-4838
852-4476
758-6670
745-7411
571-3140
371-7770
248-967-4310
248-547-2223
834-5930
867-8015
532-8015
248-370-0010
865-1580
858-3177
493-4410
576-1000 ext
5252
- 16 -
SECTION 2: Rotation Information
GUIDE TO ROTATIONS:
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 very 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 for 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 they
don’t know that the sickest patient that will require the most time may be the
third, forth, or even last patient on the list.
8. Noon conference: 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 doctors 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.
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 typical for Typical chest pain: substernal
squeezing or pressure, aggravated by activity, lasts <30 mins, may have
associated NV/SOB/diaphoresis/palpitations, relieved by nitro.
- 17 -
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
5. Code status
6. List of labs and x-rays to be checked (keep to a minimum)
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 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.
- 18 -
Beeper Etiquette
1. Answer all pages as soon as possible and should be within a 20 minute time span.
2. SIGN OUT your pager to covering intern/resident when you 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.
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.
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.
- 19 -
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 expresses needed days off in advance. Most of the time requests are granted
if at all possible.
•
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.)
- 20 -
Do not use” Abbreviations
Use of abbreviations is discouraged.
accepted:
Abbreviation
Intended
meaning
U or IU
Units or
international
units
Micrograms
µg
Avoid abbreviating drugs. The following will not be
Misinterpretation
Recommendation
Mistaken as a zero or a four
when poorly written, resulting
in overdose (ex: 4U  40)
Mistaken for “mg” when
handwritten, resulting in
overdose
Decimal overlooked and
mistaken for 5mg (overdose
yet again)
“units”
Lack of leading
zero (.5mg)
0.5mg
Use of trailing
zero (5.0mg)
5mg
Decimal overlooked and
mistaken for 50mg (you got it,
another overdose)
TIW
Three times a
week
Hours
Misinterpreted as “three times
a day” or “twice a week”
Misinterpreted as zero (q3° 
every 30 minutes)
Mistaken for one another;
period after the Q mistaken
for an “i”
Mistaken for one another
° symbol
Q.D., Q.O.D.
MS, MSO4,
MgSO4
Every day,
every other
day
Morphine
sulfate,
magnesium
sulfate
“mcg” or
“micrograms”
Always use leading
zeros when the
dose is less than a
whole unit (0.5mg)
Never use trailing
zeros for doses
expressed in whole
numbers
“three times a
week”
“hour, hr. or hrs.”
“daily” and “every
other day”
“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.
- 21 -
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
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.
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.
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.)
- 22 -
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.
O- Objective. What you see, factual information. This section includes vital signs, I/O’s,
physical exam, labs, and other test results.
A- Assessment. What you think the pt’s main problems are, in order of importance. If
appropriate, give underlying causes for the problems and their current progress. Problems
are to be 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. GIdiarrhea 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).
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
- 23 -
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.)
- 24 -
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
*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 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.
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.
- 25 -
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. The positive as well as pertinent negative findings of the physical exam
Depending upon the setting or format, this will be followed by review of laboratory,
radiology and other studies and assessment.
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
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 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.
- 26 -
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.
Lab Studies
Results of appropriate studies will then be presented along with interpretation and
application to the presented patient.
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.
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. 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
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
- 27 -
7.
Problem
a.
b.
c.
list
List in order of importance
Include most recent impressions regarding each problem
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
situation, then get the Care Management Team involved (write an order—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.
- 28 -
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
Social Work
•
Help establish/coordinate home needs on D/C
•
Help with pt’s without insurance  Medicaid apps, free clinic lists, shelter lists, 5day supply of meds, antibiotics, etc.
•
Help finding transportation  cab vouchers, ambulance transfers, wheelchair
vans, etc.
•
Elder abuse/neglect
•
Domestic violence
•
At Karmanos only  Nursing home/subacute placement, counseling, and
evaluation of home situation.
Case Management Specialists
•
Help set up home needs on D/C
•
Home PT/OT/nursing care
•
Help with prior authorization of outpatient meds
•
Home IV antibiotics
•
At Harper/DRH/HutzelNursing home/subacute placement
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, codis, 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.
d. Are there restraints? Can they be removed? If not, document reason
why in transfer note.
- 29 -
4.
5.
6.
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.
The followup:
a. What labs, consults, radiology, etc… need to be followed up on?
b. Document in transfer note.
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
- 30 -
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.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Start with the date of service (ie, date of admission and discharge)
State your name and pager
State who (Attending) you are dictating for, and the doctor’s pager number
Patient name (spell this out), MRN, and FIN #
Admission Date, Discharge Date
Primary Diagnoses
Secondary Diagnoses
Procedures (invasive) and dates
Problem list (at the end, what did they have, what were we following)
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)
One by one, review the problem list and how each was addressed during the
stay
Give vitals and brief exam of patient at time of discharge
List discharge plan, with disposition to location (i.e. nursing home, home, etc)
List discharge meds, dosages, and frequency
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.).
- 31 -
•
•
•
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.
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!
- 32 -
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 "offservice" 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.
- 33 -
BILLING in the HOSPITAL & AMBULATORY SETTINGS
DOCUMENTATION GUIDE
*Key components (History, Physical Exam, Decision Making) 3 of 3 REQUIRED
LEVEL OF
LEVEL 1-LOW
LEVEL 2-MOD
LEVEL 3-HIGH
SERVICE
CC
Required for all levels
HISTORY
4 Elements of HPI required (Location, duration, quality, severity, timing,
context, signs and symptoms)
SYSTEM REVIEW
2-9 Systems
10 individual system review or list pertinent
system negative and positive findings with a
note “all other systems are negative”
PAST, FAMILY,
1 of 3 required
3 of 3 required
SOCIAL HISTORY
EXAM
Detailed
Comprehensive
5-7 Systems
8 or more systems
* REFER TO DEFINITIONS
DECISION MAKING
Low
Moderate
High
SUBSEQUENT AND CONCURRENT HOSPITAL CARE
DOCUMENTATION GUIDE
* Key Componants (History, Physical, Decision Making) 2 of 3 REQUIRED
LEVEL OF SERVICE
LEVEL 1-LOW
LEVEL 2-MOD
LEVEL 3-HIGH
CC
HISTORY
4 Elements of HPI required (Location,
4 Elements of HPI
duration, quality, severity, timing, context,
signs and symptoms)
SYSTEM REVIEW
None
1 System
2-9 Systems
PAST, FAMILY,
Not required for interval history
SOCIAL HISTORY
EXAM
Problem Focused
Expanded Problem
Detailed
1 System
Focused
5-7 Systems
2-7 Systems
MEDICAL DECISION
Low Complexity
Moderate Complexity
High Complexity
MAKING
Stable, improved
Not responding to
Unstable or
treatment or
development of a new
development of a
problem or
minor complication
significant
complication
COUNSELING &
When 50% or more of encounter is spent counseling or coordinating
COORDINATION OF
care, document time spent & description of services. Bill for level that
CARE
corresponds to time increment (See time guideline).
CRITICAL CARE
Document start/stop time with critical care notes
- 34 -
NEW OFFICE PATIENT AND CONSULTATIONS
*Key Components (History, Physical, Decision Making) 3 of 3 Required
LEVEL OF
LEVEL 1
LEVEL 2
LEVEL 3
LEVEL 4
LEVEL 5
SERVICE
CC
HISTORY
1-3 Elements
4 Elements of HPI required for all levels
(Location, duration, quality, severity, timing,
context, signs & symptoms etc.)
SYSTEM
N/A
1 System
2-9 Systems
10 Individual system review
REVIEW
or list pertinent negative and
positive findings with a note
“All other systems are
negative”
PAST, FAMILY,
N/A
N/A
1 of 3
3 of 3 Required
SOCIAL Hx
Required
EXAM
Problem
Expanded
Detailed
Comprehensive 8 or more
Focused
Problem
5-7 Systems
systems
1 System
Focused
2-7 Systems
MEDICAL
Straight
Straight
LOW
Moderate
High
DECISION
forward
forward
MAKING
ESTABLISHED OFFICE PATIENT
*Key Components (History, Physical, Decision Making) 2 of 3 Required
LEVEL OF
LEVEL 1
LEVEL 2
LEVEL 3
LEVEL 4
LEVEL 5
SERVICE
CC
HISTORY
1-3 Elements
4 Elements of HPI required for all levels
(Location, duration, quality, severity,
timing, context, signs & symptoms etc.)
SYSTEM
N/A
1 System
2-9 Systems
10 Individual system
REVIEW
review or list
pertinent negative and
positive findings with
a note “All other
systems are negative”
PAST, FAMILY,
Not Required for level 2, 3
1 of 3 past,
2 of 3 past & family
SOCIAL Hx
family or
& social
social
Expanded
EXAM
Problem
Detailed
Comprehensive 8 or
Problem
Focused
5-7 Systems
more systems
Focused
1 System
2-7 Systems
DECISION
Straight
Straight
LOW
Moderate
High
MAKING
forward
forward
- 35 -
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
NEW PATIENT
OFFICE
ESTABLISHED
OFFICE
CONSULT OFFICE
CONSULT
HOSPITAL
SUBSEQUENT
HOSPITAL CARE
LEVEL 5
10 MIN.
20 MIN.
30 MIN.
45 MIN.
60 MIN.
5 MIN.
10 MIN.
15 MIN.
25 MIN.
40 MIN.
15 MIN.
20 MIN.
30 MIN.
40 MIN.
40 MIN.
55 MIN.
60 MIN.
80 MIN.
80 MIN.
110 MIN.
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)
- 36 -
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.
6. Confirm curriculum for each rotation.
- 37 -
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 in
clinic or 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).
- 38 -
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). 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)
b)
c)
d)
e)
f)
Perform a complete, orderly and technically correct H&P on each assigned patient.
Accurately, legibly record H&P in clear, logical fashion on each assigned patient.
Make a complete problem list and do this on each assigned patient.
Identify common syndromes (e.g., congestive heart failure, stroke).
List common components of the differential diagnosis for patients with problems
presented in seminars.
Realize when they need help handling or advice regarding care of a patient and seek
such aid from appropriate supervisors.
- 39 -
g)
h)
i)
Concisely (within 5-10 minutes) present the H&P for any patient that they work up.
Demonstrate appropriate interpersonal skills in interactions with patients, peers,
supervisors and ancillary personnel.
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.
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.
- 40 -
Note: students are responsible for being familiar with common problems seen on an inpatient 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.
•
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.
- 41 -
•
Discuss how days off are handled at your hospital/institution.
- 42 -
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
- 43 -
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 followup. “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?
- 44 -
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).
- 45 -
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
3. Differential Diagnosis of AMS: “MOVE STUPID”
Metabolic:
B12, thiamine deficiency, hepatic encephalopathy
(rare: Wilson’s dz, niacin deficiency)
Oxygen:
hypoxemia, hypercarbia, anemia, decreased cerebral blood
flow (e.g., from low cardiac output), sepsis, carbon monoxide
Vascular:
stroke, hemorrhage, vasculitis, TTP, DIC
Endocrine:
hyper/hypoglycemia, hyper/hypothyroidism, high/low cortisol
Electrolyte:
low Na, hyper/hypocalcaemia, hypermag, hypophos, abnl
LFTs
Seizures:
post-ictal, status epilepticus (nonconvulsive), complex partial
Structural:
lesions with mass effect, hydrocephalus
Tumor, Trauma, Temperature: fever or hypothermia
Uremia:
also dialysis disequilibrium syndrome
Psychiatric:
dx of exclusion, ICU psychosis, “sundowning”
Infection:
CNS, sepsis
Drugs:
intoxication or withdrawal (opiates, benzos, ETOH,
anticholinergics)
Degenerative dz: Alzheimer’s, Parkinson’s, Huntington’s
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 if even remote possibility of opiate OD
Thiamine, 100 mg IV (before glucose)
- Physical exam especially Neuro
- Fever, tachycardia, O2 saturation, myoclonus (uremia, cerebral
hypoxia, HONC), tremor (withdrawal, autonomic sx,
hyperactive), asterixis (liver/renal failure, drug intoxication)
- 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
- 46 -
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
- Prevent patient from injuring himself/herself
- If seizures continue after 2-3 minutes, try to start an IV and abort the seizure
with Ativan 0.02-0.03 mg/kg. Alternatively, Ativan IM Q5 minutes to
max 8 mg or Valium PR 20 mg
- Give thiamine 100 mg IV first, then 1 amp D50 IV
- If seizure is >10 minutes or is not easily responsive to benzodiazepines, the pt
is likely in status epilepticus and the patient will need ICU management
- Only if an absolute certain diagnosis of severe hyponatremia is established
should treatments such as iso- or hypertonic saline be used to halt a
seizure
2. Once seizure has stopped:
- Place oral airway. Get ABG if patient appears cyanotic
- Establish IV access and send basic labs (CBC with differential, BMP, Mg/phos,
albumin, antiepileptic levels)
- Evaluate if this is status: continuing seizing for > 30 minutes, no consciousness
after 30 minutes, if patient seizes again without achieving normal
consciousness. If the patient is in status epilepticus, send the patient to
the ICU and consult neurology.
3. Load with phenytoin 20 mg/kg in 3 divided doses at 50 mg/min (usually 1 g total); use
fosphenytoin when available at the same dose as its load is better tolerated.
- Remember, phenytoin (but not fosphenytoin) is not compatible with glucosecontaining solutions or with Valium. If you have given these meds earlier, you
need a second IV
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).
5. Write for seizure precautions. Watch for metabolic acidosis and rhabdomyolysis
- 47 -
CHEST PAIN
Initial Evaluation:
1. Over telephone: Vital Signs, recent telemetry data, EKG.
2. History: prior h/o CAD, onset: exertional/nonexertional, character, quality, location,
associations, duration, relief
3. Examine the pt: vitals, evidence of heart failure
4. Check EKG and compare to old EKG
Workup:
You will need to rule out life-threatening diagnoses rather than diagnose definitively
MI: typically “pressure-like” pain associated with SOB, diaphoresis, radiation to left jaw/arm,
nausea/vomiting, cardiac risk factors present; remember, MI can present
atypically, and not only in women and diabetics
Aortic dissection: “tearing”, assoc w/ HTN, smoking, radiation to back, unequal pulses
- Widened mediastinum on chest imaging
- Transfer to ICU to reduce BP and inotropy with ß–blocker
- Emergent 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
- 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 or V/Q scan if available. Begin anticoagulation
(if there are no contraindications) while you are waiting for the results
Other etiologies: pericarditis, pneumonia/pleurisy, GERD, PUD, esophageal spasm (may
respond to nitroglycerin), esophageal rupture (Boerhaave’s) or tear (MalloryWeiss), candidiasis, herpes zoster, costochondritis, rib fracture, anxiety (a
diagnosis of exclusion)
Treatment: “MONAS”
- Morphine 2-4 mg IV (watch BP and for over-sedation)
- Oxygen via NC
- Nitroglycerin 0.4 mg SL Q5 min x 3, hold for SBP <100. Can proceed to Nitropaste 1”
(note: variable and poor absorption). Remember, just because the chest pain responds to
NTG does not automatically rule in angina
- If patient is not already on aspirin and has no contraindications, give ASA 325 mg
- Statin for plaque stabilization
- Transfer to monitored bed, heparin gtt if no contraindication, check troponins, serial
EKG’s
- ALWAYS ASK ABOUT ALLERGIES, THIS CAN COMPLICATE THE PICTURE!
- 48 -
SHORTNESS OF BREATH
Initial Evaluation:
1. History
- Acuity of onset
- 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)
Differential Diagnosis:
1. Pulmonary
- Pneumonia
- Pneumothorax: acute onset, pleuritic CP, consider in intubated patients,
especially if peak and plateau pressures elevated
- PE: often difficult to rule in/out by history/exam. Consider early
- Aspiration: common in pts with altered sensorium
- 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
- 49 -
5. Psychiatric:
- Anxiety: common, but a diagnosis of exclusion!
6. GI:
- Massive ascites, abdominal mass: compressive
Initial Management:
1. Oxygen:
- 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, pnemonia)
3. Diuretics:
- Consider Lasix 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. Be careful in renal disease!
4. Assess potential need for intubation. BiPAP trial may be helpful method of temporizing
while making this decision.
- 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
- 50 -
CVA/TIA
Work Up:
1. Time of onset of symptoms (important for use of t-PA)
2. Vitals, including pulse ox, and complete physical exam
3. Detailed Neuro Exam (find the lesion!)
6. EKG, CBC, BMP/Mg/PO4, PT/PTT, fibrinogen, ESR, LFTs, cholesterol
7. Non-contrast Head CT
Management:
1. BP control: 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 DBP >140
Start Nipride gtt
- SBP >230 and/or DBP 121Labetalol* 20 mg IV Q10 min (max 150 mg); consider gtt
140
at 2-8 mg/min
- SBP 180-230 and/or DBP
Labetalol* 10 mg IV Q10 min
105-120
* if labetalol contraindicated (e.g. CHF), consider Nitroglycerin gtt (esp. if coronary
ischemia), Enalaprilat IV (IV ACE-I, useful in LV dysfxn; avoid if acute MI), or Hydralazine
DO NOT LOWER BP MORE THAN 25%
2. Establish Risk Factors
- A-fib – Check EKG
- Carotid Dz – Check U/S bilateral carotids
- Endocarditis – Check TTE
- Cancer – eval risk factors and health maintenance hx (mammo? PSA? colo?)
- HTN – Check BP, eval hx and tx
- CAD – Check EKG, lipid panel, consider stress test
- DM – fasting blood sugar
- Peripheral Vasc Dz – u/s LE
- Autoimmune Dz – Check ANA, ds DNA, RF, etc
- 51 -
ALCOHOL WITHDRAWL:
1.
2.
3.
4.
5.
6.
Mechanism: multifactorial. Withdrawal symptoms are the opposite of depressant
effects of EtOH = increased adrenergic, serotonergic and cholinergic activity.
For all EtOH withdrawal hospitalizations, evaluated for comorbid medical
conditions (alcoholic hepatitis, pancreatitis, liver failure, GIB, infection, trauma,
hypoglycemia, co-ingestions, arrhythmias, dilated cardiomyopathy, altered
electrolytes). Treatment/orders:
a. Thiamine, multivitamins, folate (= “banana bag”)
b. Always give Thiamine before glucose to avoid precipitating Wernicke’s
c. Hydration
d. Correct electrolytes
e. Follow blood sugars and give dextrose as needed
f.
Restraints PRN for safety
g. Seizure precautions
Minor Withdrawal: 6-12 hours after last drink
a. S/Sx: Insomnia, tremulousness, mild anxiety, GI upset, headache,
diaphoresis, palpitations, anorexia
b. Treatment: Thiamine 100mg IV x 3d, MVI, folate. Ativan or valium per
CIWA guidelins. Consider beta blockers for uncontrolled HTN.
Alcoholic Hallucinosis: 12-24 hours
a. S/Sx: Visual, auditory or tactile hallucinations. Sensorium is clear.
b. Treatment: Same as above. Consider haldol 1-2mg Q1h PRN (but be
careful, this may lower seizure threshold!)
Withdrawal Seizures: typically 24-48 hours, but may occur as soon as 6 hours.
a. S/Sx: generalized tonic-clonic seizures; post-ictal state.
b. Treatment: same as for other seizures- Ativan.
Delirium Tremens: 48-72 hours after last drink; can occur up to 7 days after last
drink. This is A MEDICAL EMERGENCY!
a. S/Sx: Clouded counsciousness, delirium, diaphoresis, agitation,
hallucinations (visual > tactile > auditory), HTN, tachycardia, low grade
fever.
b. Treatment: Thiamine, folate, MVI, electrolyte replacement, r/o infection.
Admit to telemetry. Benzos per CIWA protocol. Ativan IV usually
preferred;l may need drip. Haldol 1-2mg Q1h PRN severe agitation or
hallucinations.
- 52 -
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)
3rd degree AV block
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.)
b. p-R (prolonged/Type 1, consistent/Type 2)
5.
- 53 -
VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA
****Determine if you see a SHOCKABLE RHYTHM****
1. SHOCKABLE RHYTHMS: PULSELESS VT/VF
Defib Biphasic 200 J
CPR (5 Cycles of 30:2 compressions to breaths = 2 minutes; IF AIRWAY ESTABLISHED,
THEN NO LONGER "CYCLES" of 30:2 CPR, CPR CONTINUOUSLY ONLY.)
Intubate and start IV lines
Defib 360 joules (Monophasic 360 J @ DRH, VAMC, RIM; Biphasic 200 J @ HUH)
**Do NOT STOP CPR to push meds**
*Epinephrine 1mg IVP q3-5 min until pulse re-established
OR Vasopressin 40 units IVP x1 only dose;
*Amiodarone 300 mg bolus, repeat 150 mg bolus x2 (total dose 2.2 g/day)
Drip infusion (if works) >1 mg/min x6 hrs, then 0.5 mg/min x18 hrs
*Lidocaine 1-1.5 mg/kg IVP, repeat dose q3-5 min. to max 3 mg/kg
*Magnesium sulfate 1-2 g in 1-2 min. IVPB or IVP slowly (1st line in Torsades)
*Procainamide 20-30 mg/min to 1 g infusion –17 mg/kg (1st line in WPW SVT)
- 54 -
- 55 -
2. UNSHOCKABLE RHYTHMS: Asystole/PEA
Intubate and start IV lines
*Epinephrine 1mg IVP q3-5 min until pulse re-established
OR Vasopressin 40 units IVP x1 only dose;
Do NOT STOP CPR to push meds.
*Atropine 1mgIV/IO for asystole or slow PEA rate; Repeat every 3 to 5 min for 3
CHECK RHYTHM:
IF SHOCKABLE (VT/VF), then go to #1 ABOVE
IF NOT SHOCKABLE (Asystole/PEA), go to #2 ABOVE
Consider causes that are quickly reversible:
6 H's:
* Hypovolemia
* Hypoxia,
* Hypo/Hyperkalemia,
* Hypothermia,
* Hydrogen ion—Acidosis
5 T’s:
* Tension Pneumothorax
* Tamponade
* coronary Thrombosis
* pulmonary Thrombosis
* Tablets
**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 compressions/minute.
**Do not pause CODE to push IV medications, CPR should be maintained, only pausing to
deliver a shock.
- 56 -
- 57 -
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 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
EKG 12 Lead Monitoring
Consider Sedation (morphine, versed, etc.) QUICKLY
SYNCRONIZED CARDIOVERSION @ 200 Joules
*Lidocaine 1-1.5 mg/kg repeat 0.5-0.75 mg/kg
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 @ 200 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
For medical codes (code blue) the numbers are:
DRH/UHC 114
Harper 117
VA 3333 from any phone
RIM 119
CHM 115
Hutzel 118
Sinai / Grace 116
- 58 -
BRADYCARDIA
Some Useful Websites:
http://satyampatel.files.wordpress.com/2008/03/acls-algorithms.pdf ACLS
http://www.americanheart.org/presenter.jhtml?identifier=2158 AHA Guidelines
How to call a code
As a doctor, your responsibility is in running and assisting in medical code situations. The
nurses, clerks and other members of the care giving team know how to call a code into the
system, but just in case you’re alone, wouldn’t you like to know who/how to call one???
First of all, note that code information (what color is assigned to each code called
overhead) is on the back of the DMC badges. Take a look at your badge.
The emergency numbers (like what number to call for which emergency) is on the back of
our badges too. Take another look.
- 59 -
ELECTROLYTE REPLACEMENT OPTIONS
Potassium
DMC Normal Range (3.5 to 5.3 mmol/L):
Signs/Symptoms of Low Potassium
Arrhythmia
Impaired pressor response
Weakness
Respiratory failure
Myalgias
Hyporeflexia
Confusion
Metabolic alkalosis
Constipation
**Suggested Replacement
Range
IVPB (NTE 20mEq/1 hr)
PO
2.0 to 2.8mmol/L
20 mEq q 1 hr x 3*
---2.9 to 3.2 mmol/L 20 mEq q 1 hr x 2*
KCl 40 mEq liquid (IR)
3.3 to 3.5 mmol/L 20 mEq q 1 hr x 1*
KCl 20 mEq po
> 3.5 mmol/L
--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
Products Available:
Route
Dosage Form
Liquid
Tablet
PO
Powder
IVPB (over 1 hr.)
Product
KCl 20 mEq
KCl 40 mEq
-
KCl 20 mEq (K-dur)

K/Na Phos (Neutra Phos)
K=7.1 mEq Na= 7.1 Phos+ 8 mmol or 250 mg
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)
- 60 -
Phosphorus
DMC Normal Range (2.5 to 4.5 mg/dL)
Signs/Symptoms of Low Phosphorus
Myopathy
Neurological dysfunction
Weakness
Respiratory muscle paralysis
Confusion
Red cell hemolysis
Suggested Replacement
Range
IV
PO
<1.0 mg/dL
15 mmol* x 2
---1.0 to 2.5 mg/dL
15 mmol*
---Maintanence
--8 mmol
Neutra-phos (1) po tid
*recheck Phosphorus and if still <1.0 repeat with Na or K phos
** If K <3.5 then use K Phos, if K > 3.5 then use Na Phos
Products Available
Route
PO
IVPB (over 1 hr.)
Dosage Form Product
Powder
Neutra-phos
K=7.1 mEq, Na=7.1mEq, Phos=8 mmol or 250 mg
Na Phos** write Phos in mmol (Na=4 mEq/ml,
K Phos** write Phos in mmol (K=4.4 mEq/ml,
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 2*
--1.0 to 1.5 mg /dL
2 Gmx1
--1.6 to 2.0 mg/dL
1 Gm x1
--Maintenance
--Mag-Oxide 400 mg po tid
* recheck magnesium after replacement and repeat as necessary
Products Available:
Route
Dosage Form
PO
Tablet
IVPB
Product
Magnesium Oxide 400 mg (10 mmol Mg or
241 mg Mg)
Magnesium Sulfate 50% (1 gm/2ml=4 mmol
or 8 mEq or 98 mg of Mg)
- 61 -
Calcium
DMC Normal Range (Total 8.2 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:**
Severe Symptomatic
PO
----
IV
Ca Gluconate 1 gm
over 10 min*
Ca Carbonate 1 gm
in D5 over 30 min*
Asymptomatic
Ca Carbonate 1-2g/day
Ca Gluconate 2 gm
Divided TID/QID
in D5 over 1 hr.
* Repeat if symptoms persist with 1-2 mg/kg/hr ** Correct K and Mg deficits
Products Available:
Route
Form
Product
PO
Tablet
Calcium Carbonate 1250 mg (Ca 500 mg or 25 mEq) $0.02
Calcium Gluconate 1% (1 gm=90 mg or 4.5 mEq Ca) $0.38
Calcium Chloride 1% (1 gm=270 mg or 13.5 mEq Ca) $1.21
IVPB
- 62 -
Cost
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.
- 63 -
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
Restoril 7.5-30 mg po qhs. Risk of respiratory depression.
Sonata 10-20 mg po qhs. Decrease to half this dose in liver disease and elderly
Ambien 5-10 mg po qhs. Do not 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.
- 64 -
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
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
- 65 -
Table 1 Opioid Equivalents
Name
Codeine
Hydromorphone (Dilaudid)
Levophanol (Levodromoran)
Meperidene (Demerol)
Methadone (Dolophine)
Morphine (Roxanol)
Morphine CR (MS Contin)
Oxycondone (Percocet)
Oxycodone CR (Oxycontin)
Propoxyphene
Onset
(min)
10-30
15-30
30-90
10-45
30-60
15-60
15-60
15-30
15-30
30-60
Dosing
(hr)
4
4
4
4
6
4
12
6
12
4
Oral Eq
(mg)
200
7.5
4
300
20
30
90
30
30
200
I.V. Eq
(mg)
120
1.5
2
75
10
10
NA
NA
NA
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.
- 66 -
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. Accelerated HTN
--severe retinopathy (NO papilledema)
--acute dysfunction of target organs
2. Malignant HTN
--accelerated HTN + papilledema
--1/3 underlying renal artery stenosis
--1/4  renovascular HTN
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
----look for 2° causes
*critical renal artery stenosis
*glomerulonephritis
*Cushings syndrome
*pheochromocytoma
--1/4  renovascular HTN (25%)
IV meds--IN ALPHABETICAL ORDER
1. Diazoxide
- relaxes arteriolar smooth muscle
- significant side effects (Na retention, hyperglycemia, hyperuricemia)
2. Enalaprilat
- no adverse side effects/symptomatic hypotension reported
- contraindicated in pregnancy
3. Esmolol
- cardioselective B-blocker
- independent of renal/hepatic function
4. Fenoldopam
- Dopamine-1 agonist
- increases renal blood flow, increases Na excretion
- 67 -
5.
6.
7.
8.
9.
- renal vasodilator
- no alpha or beta activation
- liver metabolized to inactive agents
- no rebound HTN when stopped
Labetalol
- alpha and beta blockade
- metabolized by liver to inactive agents
- decreased PVR without decreased peripheral blood flow
Nicardipine
- as effective as nitroprusside
- decreased cardiac/cerebral ischemia
Nitroprusside
- arterial/venous vasodilator (decreased preload and afterload)
- decreased cerebral blood flow and increased ICP
- *coronary steal phenomenon*
- increased mortality if used in early AMI
- cyanogens metabolized to thiocyanate which is excreted by the
kidneys!!!
Cyanide removal needs good liver/kidney function and
adequate thiosulfate
Hydrocobalamine=treatment of toxicity
Phentolamine
- alpha blockade (excellent for catecholamine induced --aka.
Pheochromocytoma)
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.
- 68 -
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
- 69 -
⇒
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
HISTORY
Age >/= 65
>/= 3 CAD risk factors (FHx, HTN, ↑chol., DM, active smoker)
Known CAD (stenosis >/= 50%)
ASA use in past 7 days
PRESENTATION
Recent (</= 24hrs) severe angina
↑ cardiac markers
ST deviation >/= 0.5mm
RISK SCORE = Total points (0-7)
POINTS
1
1
1
1
1
1
1
Risk of Cardiac events (%) by 14 days in TIMI 11B∗
RISK SCORE
DEATH or MI
0-1
2
3
4
5
6/7
3
3
5
7
12
19
DEATH, MI, or URGENT
REVASC.
5
8
13
20
26
41
∗entry criteria: UA or NSTEMI defined as ischemic pain at rest within past 24hrs, with
evidence of CAD (ST segment deviation or +marker)
- 70 -
Algorithm (reproduced from Harrsion’s)
So you are wondering if the pt had an MI.
High /
CP with low likely
Intermittent
hood of ischemia
Atypical CP
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
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
1. RVH
2. Lateral or anterolateral MI
3. WPW with left freewall pathway
4. LPFB
Left Axis
1. LAFB
2. Inferior MI
3. WPW with posteroseptal pathway
4. COPD or PE
- 71 -
·
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
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
·
·
LPFB (Left Posterior Fascicular Block; must exclude anterolateral MI, RVH,
RBBB)
Axis >100 and QIII, SI 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
- 72 -
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)
RP shorter than 70
msec
Long
(RP longer than PR)
RP longer than 70
msec
Atrial Tachycardia
PJRT
Atypical AVNRT
AVNRT
AVRT
AVNRT
Atrial Tachycardia
- 73 -
Valve Defect
Murmurs
Clicks
Change in
Heart Sounds
Aortic
Stenosis
S: SEM at RUSB,
mid to late peaking
diamond shaped
Mitral
Stenosis
D: Diastolic rumble
S: Ejection
click if
congenital or
bicuspid
D: Opening
snap (only
diastolic click)
Chronic
Aortic
Regurge
S: Occasional
early systole SEM.
D: 1.) High pitched,
decrescendo mid to
holodiastolic
(regurgitation
through the valve).
2.) Austin Flint: low,
rumbling diastolic
(regurg stream
striking the anterior
mitral leaflets).
D: Short diastolic
murmur
S: MVP. Late
SEM follows click.
CMR: pansystolic
constant murmur
Absent 2nd
(occas.) S4:
Paradoxically
split S2
S1 is
enhanced
sometimes
"snapping".
May be silent
if severly
calcified
S3 if severe.
Acute Aortic
Regurge
MVP with
murmus;
Chronic
Mitral
Regurge
(CMR)
Acute Mitral
Regurge
S3 if severe
S: MVPMidsystolic
click (Clickmurmur
syndrome)
S: Pansystolic
decrescendo at
apex
Pulmonic
Stenosis
Tricuspid
Stenosis
Tricuspid
Regurge
S: Midsystolic
click often
preceded by
SEM
S: Ejection
click
Pulse
waveforms:
a/v Waves
Slowed
carotid
upstroke
Large L "a"
waves and
attenuated "y"
descent
"Corrigan's
pulse"
"Waterhamme
r pulse"
Thready
S3 if severe;
S4
S3 if severe
Large left "v"
waves
Persistently/wi
dely split S2
Large right
(jugular) "a"
wave
Giant right "a"
waves
Large right "v"
waves
D: Diastolic at LSB
D: Systolic at
LLSB
- 74 -
VSD
ASD- ostium
secundum
ASDostiuim
primum
Coarctation
of the Aorta
HCM
PDA
S: Holosystolic at
LLSB
S: SEM at LSB
(increased flow
across pulmonic
valve)
S: SEM at LSB
(increased flow
across pulmonic
valve), also often
assoc. TR or MR
murmur
Midsystolic to
continuous murmur
(depending on
severity) in the
upper back
S: Harsh
midsystolic
S+D: Continuous
"machine gun"
murmur at LUSB
Fixed-split S2
Fixed-split S2
S4
Paradoxically
split S2
- 75 -
Brisk carotid
upstroke
which is BIFID
in 2/3
Murmur Louder With:
Squatting
Expiration
After PVCs
CXR
LVE
Squatting
Expiration
LAE
Squatting
Expiration
LVE
Squatting
Expiration
Normal
Standing or valsalva:
Longer- moves earlier
into systole;
sustained handgrip.
Expiration
Squatting
Expiration
LAE
Inspiration
RVH: enlarged
pulmonary artery
Squatting/Inspiration
RAE
Normal
Other:
Sustained apical
impulse; Etiology:
Bicuspid valve
Classic triad is LVH,
angina, and syncope
with exercise
Etio: virtually always
rheumatic fever.
SSx: Hemoptysis.
Secondary
pulmonary, HTN
Etio: congenital,
endocarditis, or
dilated aortic root
from :marfan, VSD,
arteritis,
polychondritis,
syphilis
Cardiogenic shock
and pulmonary
edema. Consider
aortic dissection
Etio of MVP:
congenital, ischemia
Valve Defect
Aortic Stenosis
Etio: Endocarditis, MI
with papillary muscle
ischemia or rupture,
chordae tendineae
rupture.
SSx: Pulmonary
edema
Etio: virtually always
congenital- rarely
caused by rheumatic
fever and carcinoid.
Congenital type
usually does not
progress
TS is rare; Etio:
usually rheumatic
fever but also
congenital and
Acute Mitral
Regurgitation
- 76 -
Mitral Stenosis.
Chronic Aortic
Regurgitation
Acute Aortic
Regurgitation
MVP with
murmur; chronic
mitral regurge
(CMR).
Pulmonic
stenosis
Tricuspid
Stenosis
Squatting/Inspiration
RVE
Handgrip
RVE + LVE
RVE; shunt
vascularity
RVE
Standing, Valsalva
Note: Sustained
handgrip decreases
murmur
Rib notching,
loss or aortic
notch
LVE
carcinoid syndrome.
With carcinoid, pt.
usually also has TR.
SSx: venous
congestion
Etio: usually dilation
from pulmonary HTN,
other: rheumatic
fever, endocarditis
(IVDA), carcinoid,
Liver pulsations, JVD
Consider in new MI
with new systolic
murmus
EKG: RAD, RBBB
EKG: LAD, RBBB
Apical impulse may
have double or triple
taps
Calcification of
ductus arteriosis
- 77 -
Tricuspid
Regurgitation
VSD
ASD- ostium
secundum
ASD- ostium
primum
Coarctation of
the Aorta
HCM
PDA
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://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.185700
(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 evaluationInitial 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.
- 78 -
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.
3.
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.
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
- 79 -
ii.
iii.
iv.
v.
c.
Head and neck surgery
Intraperitoneal and intrathoracic surgery
Orthopedic surgery
Prostate surgery
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
- 80 -
(Reported cardiac risk often greater than 5%)
High
•
•
•
•
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
(Reported cardiac risk generally less than 5%)
Intermediate
•
•
•
•
•
Carotid endarterectomy surgery
Head and neck surgery
Intraperitoneal and intrathoracic surgery
Orthopedic surgery
Prostate surgery
(Reported cardiac risk generally less than 1%)
Low†
•
•
•
•
Endoscopic procedures
Superficial procedure
Cataract surgery
Breast surgery
- 81 -
- 82 -
ACC.org Stepwise Approach to Preoperative Cardiac Assessment
1 MET
Can you take care of
4 METs
yourself?
Eat, dress, or use the toilet?
Walk indoors around the
house?
Walk a block or two on level
ground at 2 to 3 mph or 3.2 to
4.8 km per h?
Do light work around the
house like dusting or
washing dishes?
4 METs
Climb a flight of stairs or
walk up a hill?
Walk on level ground at
4 mph or 6.4 km per h?
Run a short distance?
Do heavy work around
the house like scrubbing
floors or lifting or
moving heavy furniture?
Participate in moderate
recreational activities
like golf, bowling,
dancing, doubles tennis,
or throwing a baseball
or football?
Greater than Participate in strenuous
10 METs
sports like swimming,
singles tennis, football,
basketball, or skiing?
From ACC.org, Estimated Energy Requirements for Various Activities
CRITICAL CARE/ PULMONARY
Transudate vs. Exudate for Pleural FluidIf at least one of the following three criteria is present, the fluid is virtually always an
exudate; if none is present, the fluid is virtually always a transudate.

Pleural fluid protein/serum protein ratio greater than 0.5

Pleural fluid LDH/serum LDH ratio greater than 0.6

Pleural fluid LDH greater than two thirds the upper limits of normal of
the serum LDH

pH<7.2

Glucose< 20

Protein>3
Dyspnea
1. Ask for respiratory rate, oxygen saturation, vital signs over the phone, and get
yourself out of bed to see the patient
2. Do a focused cardiovascular and pulmonary H&P. Why was the patient
admitted?
3. If you get to the point of thinking you may need to call the MICU you should have
your senior resident with you. When you send the ABG the MICU would
appreciate having a lactate as well and you can check the lytes on that blood
sample.
- 83 -
Cardiovascular? Think: CHF,New Onset Tachy/Brady arrhythmias, Ischemia, Dissecting
Aneurysm, Hypertensive crisis
Rx:
Sit the patient up
Lasix 20-80 mg IVP, increase based on response (this means at least 300-500 cc out
in the next couple of hours)
Oxygen to keep saturation > 60 mmHg
Morphine 2-5 mg IV. Repeat q10-25 minutes
Pulmonary? Think: Pulmonary embolism, Pulmonary edema, Asthma / COPD
exacerbation with severe bronchospasm, Pneumonia / Pneumonitis, Atelectasis
Rx:
Albuterol / Atrovent respiratory treatment for INH—asthma or COPD 2.5 / 0.5 mg per
3mL INH q3-4 hours
Oxygen by nasal cannula (tubes in the nose), venturi mask (bird beak looking thing),
or non rebreather (bird beak with a beard/bag hanging off of it) to keep oxygen
saturation > 60 mmHg
Nasal canula can deliver FiO2 up to 38%
Venturi can deliver 55% FiO2
Nonrebreather can deliver 100% FiO2
If atelectasis, chest pulmonary toilet and positional change
Work up:
1.
2.
3.
4.
Chest x-ray
ABG with lactate and you can check the lytes from the same sample
Oxygen saturation monitoring
EKG
Hypotension
Cardiac Output Reduced?
Yes, if…
Small pulse pressure
Cold extremities
Poor capillary refill
Heart too full?
Yes, if…
Increased system venous pressure
Crackles, S3
Ischemia
No, if….
Large pulse pressure
Low diastolic BP
Warm extremities
Good capillary refill
No, if…
Dehydration
Blood Loss
Give 2 liters of 0.9% Normal Saline and reassess.
First initiate this with a 500cc-1 liter bolus
Give 2-3 L of NaCl over 15-30 minutes in patients in shock
If pressors are needed, this requires a central line and the ICU
- 84 -
Hemodynamic Values
Heart Rate
Pressures
Systemic Arterial
Peak Systolic/End Diastolic
Mean (MAP)
(2xdiastolic+systolic)/3
Left Ventricle
Peak systolic/End diastolic
Left Atrium (PCWP)
Mean
a wave
v wave
Pulmonary Artery
Mean
Right Ventricle
Right Atrium
Central Venous Pressure (CVP)
Mean
a wave
v wave
Resistances
Systemic Vascular Resistance (SVR)
SVR= [(MAP-CVP)/CO] x 80
Pulmonary Vascular Resistance (PVR)
PVR=[(PAP-PCWP)/CO]x80
Flow
Cardiac Output (CO)
CO=HRxSV
Cardiac Index (CI)
CI=CO/BSA5
Ejection Fraction
(SV/End-Diastolic Volume)x100
60-100 beats/min
100-140/60-90 mm Hg
70-105 mm Hg
100-140/3-12 mm Hg
2-12 mm Hg
3-10 mm Hg
3-15 mm Hg
15-30/4-14 mm Hg
9-17 mm Hg
15-30/2-7 mm Hg
- 85 -
< 5 mm Hg
2-6 mm Hg
2-8 mm Hg
2-7 mm Hg
700-1600 dynes sec cm-5
100-300 dynes sec cm-5
3.5-5.5 L/min
2.4-3.8 L/min/m2
>50%
PNEUMONIA PORT SCORE
1. Is pt > 50 yo? If so then use classification.
2. Does the pt have a history of neoplasm, CHF, CVA, renal or hepatic dysfunction? If yes
use classification.
3. Does pt have altered mental status, pulse >125, RR > 30, SBP < 90, or temperature <35
or > 40? If so then use classification.
4. If no to all 3 then risk is 1 and tx as outpatient.
Men=age
Women=age -10
Nursing home=10
Neoplasm=30
Liver dx=20
CHF=10
Renal disease = 10
CVA=10
Altered ms=20
RR > 30=20
SBP < 90=20
Temp <35 or >40=15
Pulse >125=10
Arterial pH <7.35=30
BUN >30=20
Na <130=20
CHO>250=10
Hct<30=10
PaO2 < 60 or SpO2 < 90 = 10
Pleural effusion = 10
Risk
Class I = 0 --> out pt
Class II = < 70 --> out pt
Class III = 71-90 --> brief in pt
Class IV = 91-130 --> in pt
Class V = > 130 --> in pt (29% chance of death)
PNEUMONIA SEVERITY INDEX
“CURB-65”
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 comorbidities are absent and if there are no social factors or other illnesses requiring
hospitalization.
A score of 2 or more require admission
- 86 -
Differential Diagnosis of Asthma
Differential Diagnosis of Dyspnea:
•
Acute – Asthma, pneumonia,
pulmonary edema, pneumothorax,
pulmonary embolus, metabolic
acidosis, ARDS, panic attack
•
Pulmonary – Airflow obstruction
(asthma, COPD, upper airway
obstruction), restrictive lung disease
(interstitial lung disease, pleural
thickening or effusion, respiratory
muscle weakness, obesity),
pneumonia, pneumothorax, PE,
aspiration, ARDS
•
Cardiac – Myocardial ischemia, CHF,
valvular obstruction, arrhythmia,
cardiac tamponade
•
Metabolic – Acidosis, hypercapnia,
sepsis
•
Hematologic – Anemia,
methemoglobinemia
Psychiatric – Anxiety
Differential Diagnosis of Wheeze:
•
Asthma
•
COPD
•
CHF (cardiac asthma)
•
Acute bronchitis
•
Pneumonia
•
GERD
•
Airway obstruction (e.g., tumor, goiter)
•
Foreign-body aspiration
•
Aspiration pneumonia
•
Interstitial lung disease
•
Pulmonary embolism
•
Angioedema or anaphylaxis
•
Carcinoid syndrome
•
Vocal cord dysfunction
Notable physical findings during acute exacerbation:
•
Tachycardia – up to 120 beats per minute is reasonable; > 120 bpm found in 10-15%,
and is worrisome
•
Tachypnea – up to 30 respirations per minute 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, though some
shunt physiology may play a role if there is mucous plugging of airways.
•
Accessory muscle use – worrisome sign associated with increased mortality
•
Depressed neurologic status - worrisome sign associated with increased mortality
- 87 -
Characteristics of Sudden vs. Slow Evolution of Acute Asthma – typically, those with a
more prolonged course prior to presentation have a more difficult hospital course
TYPE1: Slow Progression
Type 2: Sudden Progression
Slow-onset
Sudden-onset, asphyxia, brittle, or hyperacute asthma
Progressive deterioration > 6 h (usually
Rapid deterioration < 6h
days or weeks)
80 to 90% patients presented to an ED
10 to 20% patients who presented to an ED
Female predominance
Male predominance
More likely to be triggered by URI
More likely to be triggered by respiratory
allergens, exercise and psychosocial stress
Less severe obstruction at presentation
Slow response to treatment and higher
Rapid response to treatment and lower
hospital admissions
hospital admissions
Airflow inflammation mechanism
Bronchospastic mechanism of deterioration
Poor prognostic factors on history:
•
Previous severe exacerbations/ICU/intubation – only ~5% of mortalities had prior
ICU/intubation
•
>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
- 88 -
- 89 -
- 90 -
Inpatient Pharmacological Management:
1.
2.
Oxygen supplementation – if needed, guidelines recommend 1-3 liters by nasal
cannula; if more oxygen is required to alleviate hypoxia, consider an alternative or
concomitant diagnosis
a. O2, if needed, 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.
c.
Bronchodilators:
a. Beta Agonists – Albuterol; MDI provides better delivery in less time than
nebulized, so use when able. If using NMT (nebulized mist treatment)
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 bromide can have an inpatient role; use is
associated with decreased length of stay. If using NMT, 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 at least
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)
- 91 -
Predicted Average Peak Expiratory Flow for Normal Males (L/min)
Age
Height (inches)
60"
65"
70"
75"
20
554
602
649
693
25
543
590
636
679
30
532
577
622
664
35
521
565
609
651
40
509
552
596
636
45
498
540
583
622
50
486
527
569
607
55
475
515
556
593
60
463
502
542
578
65
452
490
529
564
70
440
477
515
550
Predicted Average Peak Expiratory Flow for Normal Females (L/min)
Age
Height (Inches)
55"
60"
65"
70"
20
390
423
460
496
25
385
418
454
490
30
380
413
448
483
35
375
408
442
476
40
370
402
436
470
45
365
397
430
464
50
360
391
424
457
55
355
386
418
451
60
350
380
412
445
65
345
375
406
439
70
340
369
400
432
80"
740
725
710
695
680
665
649
634
618
603
587
75"
529
523
516
509
502
495
488
482
475
468
461
ENDOCRINE
Blood Glucose
Hypoglycemia
Go to the floor, and await the response to treatment in all cases
1. Recheck (peripheral blood draw)
2. Assess prior treatment response
Asymptomatic patient and cooperative
1. Given 15-30 g CBH, 8 oz of juice or soda = 30g CBH
2. 2 graham cracker squares = 10 g CBH
3. For every 15 g CBH given, blood sugar is supposed to increase 25-50 mg/dL
Symptomatic (tremors, diaphoresis, palpitations) or NPO patient
- 92 -
1.
2.
3.
1 bolus Ampule of D50% IV. If no IV give 1mg Glucagon IM (watch for nausea,
vomiting)
Do accuchecks q 5-10 minutes depending on response
Follow ampule with D5W or D10W to maintain CBG 100mg/dL and do
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
less than 60 or greater than 400, call house officer.
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.
DIAGNOSTIC CRITERIA FOR DIABETIC KETOACIDOSIS AND HYPEROSMOLAR
HYPERGLYCEMIC STATE
* UpToDate, Treatment of diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults
DKA
HHS
Mild
Moderate
Severe
Plasma glucose
Arterial pH
Serum bicarbonate
> 250
7.25-7.3
15 to 18
>250
7.0-7.24
10 to <15
>250
<7.0
<10
>600
>7.3
>15
Urine ketones
Serum ketones
Effective serum
osmolality
Anion gap
Mental alteration
Positive
Postive
Variable
Positive
Positive
Variable
Positive
Positive
Variable
Small
Small
>320
>10
Alert
>12
Alert/drowsy
>12
Stupor/coma
<12
Stupor/coma
- 93 -
TREATMENT OF DKA
* UpToDate, Treatment of diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults
- 94 -
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?
-Can you visualize source of bleeding?
If non emergent and anticoagulated get INR
If emergent 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.
- 95 -
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:
1. Gastroenterology.
2. Psychiatry
3. Physical Medicine & Rehabilitation
4. Cardiology
5. Neuropsychology
Specialty Clinics: Multidisciplinary team consisting of a physician, nurse practitioner,
PharmD and MSW
1.
2.
3.
Memory Evaluation Clinic: Evaluate and treat cognitive impairment-new
or established.
Balance Clinic: See persons who have a history of falls or who are at high
risk for falls
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 and it’s easily accessed. We
have appointment availability on Tuesdays and Fridays, so that patients
may be seen within 3 days of discharge.
Patients who qualify for care in our specialty clinics or by a specialist: 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 <1.5)
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
- 96 -
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.
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.
- 97 -
- 98 -
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
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!!!
- 99 -
Increased ICP
Patient presents with confusion, depressed mental status secondary to brain mets etc.
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 20 mg IV x 1 then maintenance
dose
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…………….
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
Hyperuricemia
Acidosis
That then can lead to…………..
Acute Renal Failure
Cardiac Arrhythmias
Muscle cramps, tetany
Prophylaxis/Treatment
1. Allopurinol 600-900 mg x 1 then 300-600 mg qDay or Rasburicase.
2. IVF
3. If acute renal failure, consider dialysis.
- 100 -
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.
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
1. Broad spectrum Antibiotics
2. Surgery consult
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!
1. Supportive
2. Treat underlying condition.
3. Consult Hematology.
Leukostasis
Signs: pulmonary hypoxemia, intracerebral hemorrhage
1. Hydroxyurea 3g po x1, then 1g qhr until blast count <50,000.
2. Leukapheresis most effective: call fellow/attending for initiation
- 101 -
HIT – HEPARIN INDUCED THROMBOCYTOPENIA
Suspect HIT when:
- acute thrombocytopenia
- 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
Treatment
- stop ALL heparin including heparin flushes by the nurses
- start patient on direct thrombin inhibitor like Lepirudin 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
- 102 -
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!
-Scistocytes 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 smere
- If spherocytes present, could be hereditary spherocytosis
- If Coombs test is positive, then autoimmune hemolytic anemia
- Consider G6PD deficiency
- 103 -
DIFFERENTIATING INTRAVASCULAR AND EXTRAVASCULAR HEMOLYSIS
Test
All types
Intravascular Extravascular
Reticulocyte Count
Increased
Increased
Increased
LDH
Increased
Increased
Increased
Indirect bilirubin
Increased
Increased
Increased
or normal
or normal
Haptoglobin
Decreased
Decreased
Decreased
Urinary hemosiderin
Present or
Present
Absent
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. Guiac, NG suction. Monitor patient closely
5. Give blood products if Hct<30%, Hgb<8
6. For each unit of PRBC Hct should climb 3% and Hgb 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
Marrow reticuloendothelial iron
Serum iron, µg/dL
Iron binding capacity
(transferrin), µg/dL
Saturation (SI/TIBC),
percent
Hemoglobin, g/dL
Normal Fe deficiency
without
anemia
2+ to 3+ None
Fe deficiency
with mild
anemia
None
Severe Fe
deficiency with
severe anemia
None
60 to
60 to 150
150
300 to 300 to 390
360
20 to 50 30
<60
<40
350 to 400
>410
<15
<10
Normal Normal
9 to 12
6 to 7
Red cell morphology
Normal Normal
Plasma or serum
ferritin, ng/mL
Erythrocyte protoporphyrin, ng/mL RBC
Other tissue changes
40 to
<40
200
30 to 70 30 to 70
Normal or slight
hypochromia
<20
Hypochromia and
microcytosis
<10
>100
100 to 200
None
Nail and epithelial
changes
None
None
- 104 -
INFECTIOUS DISEASES
IDENTIFICATION OF BACTERIA ALGORITHMS
GRAM POSITIVE COCCI
Clusters
Staph
Clusters
Staph
Pairs
Pneumo.
Coagulase
positive
Staph
aureus
Coagulase
negative
S. epidermidis
S. saprophyticus
S. hominis
S. hemolyticus
S. warneri
GRAM POSITIVE BACILLI
Small
Large
Listeria
Proprionbacterium
Corynebacterium
Gardnerella
Chains
Strep.
Chains
Strep.
Chains
Strep.
Beta
hemolytic
Strep.
Pyogenes
S.
agalactiae
Groups C,
F, G
Alpha
hemolytic
Viridans
Strep.
S.
pneumoniae
Gamma
hemolytic
E. faecium
E. fascalis
Group D
Strep.
Large
Spore forming
Nonspore forming
Clostridium
Bacillus
Lactobacillus
GRAM NEGATIVE BACILLI
Lactose
Lactose Fermenter
Fermenter
Oxidase positive
Oxidase negative
Aeromonas
E. coli
Pasteurella
Klebsiella sp.
Vibrio
Enterobacter sp.
Citrobacter sp.
Non Lactose
Fermenter
Oxidase positive
Pseudomonas sp.
Flavobacterium sp.
Alcaligenes sp.
Achromobacter sp.
Moraxella sp.
GRAM NEGATIVE COCCI
Neisseria meningitides
Neisseria gonorrhea
Veillonella
Branching or
Filamentous
Norcardia
Actinomyces
Erysipelothrix
Non Lactose Fermenter
Oxidase negative
Proteus sp.
Providencia sp.
Serratia sp.
Morganella sp.
Salmonella sp.
Shigella sp.
Stenotrophomonas
Acinetobacter sp.
GRAM NEGATIVE COCCOBACILLI
Haemophilus influenzae
Moraxella catarrhalis
Acinetobacter
- 105 -
- 106 -
(from the DMC Pharmacy Website)
- 107 -
4+
4+
0
0
0
0
0
Amp/Amox
+
0
4+
4+
2+
2+
2+
0
Nafcillin
4+
0
3+
0
0
0
0
0
Vanco
Linezolid
Quinupristin
3+
3+
3+
3+
3+
3+
3+
3+
3+
3+
3+
3+
0
0
0
0
0
1+
1+
1° ceph.
4+
0
4+
0
3+
2+
2° ceph.
2+
0
3+
0
3+
3+
3° ceph.
2+
0
3+
0
4+
4
4+
4+
4° ceph.
3+
0
3+
0
4+
4+
4+
4+
Aztreonam
0
0
0
0
4+
4+
4+
4+
Unasyn
4+
0
4+
4+
4+
3+
4+
+
Timentin
3+
0
3+
3+
4+
4+
4+
4+
Zosyn
Primaxin
Meropenem
3+
3+
0
0
3+
3+
3+
3+
4+
4+
4+
4+
4+
4+
4+
4+
Genta
+
+
+
+
3+
3+
3+
2+
Tobra/Amik.
0
0
0
0
4+
4+
4+
4+
Other
0
Others
0
DRUGS
Penicillin
Strep/
Entero
B. frag
Proteus
E. coli
ANAEROBES
GNR
GPC
Pseudo
monas
Gram Neg Rods
H.flu
M. cat.
AEROBES
Gram Positive Cocci
Staph
MS/MR
BUGS
0
3+
+
+
3+
0
0
+
0
0
0
1
+
0
2+
1+
2+
2+
1+
2+
0
+
+
4+
+
0
3
+
3+
3+
+
2
+
2+
2+
2+
3+
0
3
+
3
+
3
+
3
+
0
0
4+
4+
3+
3+
3+
3+
3+
4+
0
0
0
0
0
Clindamycin
4+
2+
4+
0
0
0
0
0
Metronidazo
0
0
0
0
0
0
0
0
3
+
4
+
Bactrim
3+
2+
3+
0
4+
3+
3+
0
0
0
0
Cipro
+
+
+
+
4+
3+
4+
4+
0
0
0
Norfloxacin
+
+
+
+
4+
3+
3+
3+
0
0
Levofloxacin
3+
+
3+
+
4+
3+
4+
+
1+
1+
Moxifloxacin
3+
+
3+
+
4+
3+
4+
2+
3+
3+
Gatifloxacin
3+
+
3+
+
4+
3+
4+
2+
0
1
+
3
+
2
+
3+
3+
Clarithro.
3+
1+
4+
0
+
+
4+
0
+
+
2+
Azithro.
3+
1+
4+
0
2+
+
4+
0
+
2+
2+
- 108 -
4+
4+
4+
4+
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
HyperkalemiaIs 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
• Oligoanuric 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. 1 amp of calcium gluconate or calcium chloride to stabilize the myocardium
2. 1 amp of D50 and 10 units of IV regular insulin
3. Kayexelate- Either oral or retention enema.
4. Dialysis- If the patient is refractory to all of these things then you NEED to call the
nephrologists for URGENT DIALYSIS
5. Place the patient on Telemetry if there are EKG changes
- 109 -
Acute Renal Failure
• Prerenal vs. Post-renal vs. Intrarenal
• Calculate FeNa by ordering urine electrolytes, serum electrolytes, urine creatinine 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.
• 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
Urine Sodium
Urine Osm
Urine Cr/ Plasma Cr
Renal Failure Index
Fractional excretion of Na
Urine sediment
Prerenal ARF
<20
>500
>40
<1
<1
Benign
ATN
>40
<350
<20
>2
>1
Abnormal casts,
Renal tubular epithelial cells
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
1
2
3
4
5
Criteria
EGFR >90 and evidence of CKD (see below for definition of CKD)
EGFR >60-89 and evidence of CKD (mild ↓ in kidney function)
EGFR >30-59 (moderate ↓ in kidney function)
EGFR >15-29 (severe ↓ in kidney function)
EGFR <15 (kidney failure or end stage renal disease (ESRD).
- 110 -
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
3. Phosphorous
4. HCO3
5. PTH
Target Ranges
CKD
GFR
Stage
(ml/min/1.73 m2)
Intact PTH
(pg/ml)
Phosphorous
(mg/dL)
Corrected Ca
(mg/dL)
3
30-59
35-70
2.7-4.6
8.4-10.2
4
15-29
70-110
2.7-4.6
8.4-10.2
5
<15
150-300
3.5-5.5
8.4-9.5
- 111 -
NEUROLOGY
Generalized Tonic-Clonic Status Epilepticus
Suggested Guidelines for Initial Treatment
Time Frame
0-5 minutes
Procedure
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
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 seizureinduced 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.
- 112 -
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
If New or Worsened:
Neurological (Delirium, delirium tremens, stroke)
Metabolic (lytes, blood sugar, hypoxia, hypercapnia)
Toxic (drugs, medications, alcohol withdrawal)
Infectious (UTI, pneumonia, etc.)
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
Mental Status Exam (Folstein)
- 113 -
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
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
- 114 -
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
known prior
3. Assess:
Respiratory compromise risks:
s/p intubation, airway compromise
Poor respiratory effort
Significant lung disease
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)
< 10
10-45
Protein
(mg/dL)
>250
50-250
WBC Count (cells/µL)
>1000
100-1000
Early
bacterial
Viral
More
Common
Bacterial
Bacterial
Bacterial
Lyme
5-100
Bacterial
Viral
Viral
Neuro
syphillis
Bacterial
Neurosyphilis
TB
Neurosyphilis
Less
Common
TB
Fungal
Other
viral
infections
(mumps
or LCM)
TB
Some
Cases of
Mumps
And LCM
LCM = lymphocytic choriomeningitis virus
- 115 -
Encephalitis
Encephalitis
RHEUMATOLOGY
- 116 -
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
MISCELLANEOUS
STEROID EQUIVILENCIES
- 117 -
PAIN MEDICINE EQUIVLENCIES
- 118 -
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
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
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.
- 119 -
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
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
- 120 -
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…
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.
- 121 -
CORE MEASURES
ACUTE MYOCARDIAL INFARCTION
Measures
•
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
HEART FAILURE
Measures
•
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%
•
advice/counseling.
Compliance/Documentation Tips
•
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
•
Use standing orders
•
•
•
Documented LVF assessment can
be performed prior to or during
current hospitalization
•
If ACEi or ARB not prescribed,
document contraindication to both
•
•
discharge medication list
- 122 -
PNEUMONIA
Measures
•
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
•
•
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 actual date and time
blood cultures are collected
•
•
•
discharge medication list.
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)
- 123 -
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
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
INTERIM HOUSE
VICTIMS OF DOMESTIC VIOLENCE
313-861-5300
SALVATION ARMY
3737 LAWTON
WOMEN/CHILDREN/MEALS-90 DAY
STAY
SINGLE MEN ONLY OVERNIGHT
1-800-A-SHELTER
[180027435837]
MARINER’S INN
455 WEDYARD
313-962-9446
FOR MEN ONLY
T.C. SIMMMONS
10501 ORANGELAWN
WOMEN/CHILDREN
313-934-3331
MISSION OF CHARITY
4835 LINCOLN
WOMEN/CHILDREN/MEALS
313-831-1028
WARMING CENTER
WINTER ONLY!!!!!!!
313-963-STAY
MY SISTERS PLACE
VICTIMS OF DOMESTIC VIOLENCE
- 124 -
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.)
MEDICAID INQUIRY PHONE NUMBERS
800-292-2550
Provider Inquiry Hotline
800-638-6414
Recipient Inquiry Hotline
800-642-3195
Medicaid managed care office-for
changing Primary Sponsors, HMO or
Clinic Plan sites or providers
800-292-7972
Medicaid Prior Authorization Hotline
MEDICATIONS
AGENCY
AARP Price Quote Center
800-456-2226
belong to AARP.
COMMENTS
Medication sent by US mail or
US. Allow one week to 10 days Must
Cross Roads
92 E. Forest
313-831-2000
Must schedule appointments.
Will fill prescriptions one time
only.
Tribune Fund
313-226-9404
Provider must contact on only
Wed. and Thurs.
- 125 -
World Medical Relief
11745 12th street
Detroit, MI
313-866-5333
Must be low income and 55 or
older. Services Wayne, Oakland,
and Macomb Counties.
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.
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
- 126 -
SUBSTANCE ABUSE
AGENCY
Alcoholics Anonymous Hotline
248-541-6565
COMMENTS
24 Hour Number with counseling
Central Diagnostic and Referral Service
313-876-4070
Located at Herman Keifer Intake
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
3535 Third
Detroit, MI 48201
313-993-6703
Provides inpatient treatment and
outpatient aftercare. Must be a
resident of Detroit. For men only.
Eleanor Hutzel Recovery Center
University Health Center 6B
4201 St. Antoine Detroit, MI 48201
313-745-7411
Available to women only; must be a
resident of Detroit.
Harbor Light/Salvation Army
3737 Lawson
Detroit, MI 48208
313-361-6136
Inpatient beds available for detox.
Must call for availability. Must be a
resident of Wayne County.
Mariner's Inn
445 Ledyard
Detroit, MI 48201
313-962-9446
For Men Only.
Must be a resident of Detroit unless
referred by central diagnostics at
Herman Keifer
Narcotics Anonymous Hotline
248-543-7200
Sacred Heart Rehabilitation Center
220 Bagley Street
Suite 326
Detroit, MI 48226
313-961-6190
Patient can self refer services
State of Michigan
SHAR House
(Self Help Addiction Rehab)
1852 W. Grand Blvd.
Detroit, Mi 48208
313-894-8444
For men and women 18 or older
- 127 -
Sobriety House
2081 W. Grand Blvd
P.O. Box 08160
313-895-0500
For men only; age 18-69 of age.
No detox residential care.
Opiate Dependence Treatment Program
UPC-Jefferson Research
2761 E. Jefferson
Detroit, MI 48207
888-362-7792
For children, adolescence, and
adults. Individual, group, and family
therapy and medication treatment
TRANSPORTATION
Detroit Metrolift
313-833-7692
Provides curb to curb service
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)
313-521-1900
Mon-Fri 10-4:30
Call 9:00a.m.-1:00p.m.
To schedule a ride.
Van with wheelchair lift. Curb to
curb service. Must be 65 or older
or physically handicapped with no
age limitation. Must schedule appt.
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.
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
211 W. Congress, 3rd floor
Detroit MI, 48226
313-962-6740
Mon-Thurs 8:30a.m.-5:00p.m.
Friday 8:30a.m.-4:30p.m.
Will provide bus tickets to and from
medical appointments and to and from
job interviews. Will call to verify appoint.
Must make application in person.
- 128 -
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
Jewish Vocational Services
Michigan rehabilitation services
4250 Woodward
800-605-6722 admin office in lancing
Detroit MI 48201
Detroit offices
313-833-8100
707 west Milwaukee 871-3800
(Provides classes for preparation for a
19251 Mack Ave.
job. Must be 18 or older and low
313-886-8275
income.)
(Job placement service for adults with
history of work and job skills.
Jewish Vocational Services
Provides counseling and vocational
29699 Southfield Rd
rehabilitation and independent living
Southfield MI 48076
services to handicapped individuals 16
248-559-5000
and over. Handicap can be physical,
(Job placement service for adults with
mental or educational.)
history of work and job skills.)
- 129 -
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,
but Sunday
6333 Medbury
313-925-0514
Fort Street Open Door
9a-11a
Thursday
631 W. Fort
Cass Park Baptist Center
9a-9:30a
11:15a
breakfast MW
lunch
2700 Second
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,
but Sun
4860 15th St.
Trinity Episcopal Church
Cass Community
12p-2 p
12 p
Saturday
Saturday
1519 MLK Blvd.
3901 Cass
Crossroads
12p-3p
Sunday
92 E. Forrest
Salvation Army-Bagley
12-3p
Everyday
601 Bagley
Detroit Rescue Mission
5:30p-6p
Everyday
3535 Third
Salvation ArmyHarbor Light
6p-8 p
Everyday
2643 Park
DINNER
- 130 -
REFERRAL SERVICES FOR THE POOR AND UNINSURED
Name/Location/Phone
St. Frances Cabrini Clinic (Holy Trinity
Catholic Church)
1435 Sixth St., Det., 48226
313961-7863 (P)
313965-9891 (F)
Hours of Operation
Services Offered
5 PM till 25 patients are seen - Tues Mental health, primary
Need to register by 4 PM.
care, prescription
1 PM Thurs, Regis. by Noon
assistance
6 PM Thurs, Evenings, Regis. By 4
Mental Health (adults only) Wed
evenings by appointment only
Fee/Free
No Fee
St. John Community Health Center
3000 Gratiot Ave., Det., 48207
313-567-7462
St. Vincit DePaul Health Center
16000 Pembroke, Det., 48235
313-837-5078
Thea Bowman Health Center
2058 Fenkell Ave., Det, MI 48223
313-255-3333
Thea Bowman Nurse Managed Center
211 Glendale, Ste. 412, HP, 48203
313-866-2415
9 AM - 5 PM - Mon Wed Thurs and Primary Care for Adults (18 No Fee
Fri
10 - 64)
Am- 6 PM - Tues
3:30 - 6:30 PM Mon & Thurs
Family Practice
Financial
Support
Program
9 AM - 5 PM Weekdays
General Medicine,
Free
OB/GYN, Pediatrics,
Dental, Mental Health
9 AM - 5 PM Weekdays
Primary Care
No Fee
Walk-In/Appt.
Clinic - Walk-In
Mental Health Appointment Only
Appointment Only
Appointment Only
Walk-In and
Appointment
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, No Fee
Sexually Transmitted
Disease, and AIDS testing
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
9 - 11 AM, Thrusday - 10 ten people
Nutrition, Obstetrics &
Gynecology, Pediatric,
Pregnancy Testing
No Fee
Walk-In and
Appointment
Primary Care, HIV testing,
prescriptions
No Fee
Walk-In
3:30 - 6:30 PM - Mon - Thrus
Basic Medical and
Prescription Services
No Fee
Appointments Only
8:30 AM - 5 PM - Mon - Fri
Adult residents of the City of Detroit with
income less than 300% of the Federal
Poverty Guidelines
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
811 AM Thurs
Office visits, prescriptions, Fee Varies
lab work, X-rays
Call clinic nearest you for hours.
Reproductive health care
including annual exams,
pregnancy testing, and
sterilization to women and
men.
Fort Street Presbyterian Chruch Clinic
631 Fort Street, Det., MI
313-961-4533
Immaculate Heart of Mary Catholic
Church
1600 Pembroke, Det., MI 48235
313-272-0990
Mercy Primary Care Center
5555 Connor Ave., Det., MI 48213
313-579-4000
Northeast Health Center for Homeless
5400 E. 7 Mile Rd. Det., 48234
313-852-4231
Planned Parnethood
800-230-PLAN for the clinic nearest you.
26 clinics throughout Michigan
Appointments
Preferred
Pediatrics, Obstetrics &
Total Health
Appointments Only
Gynecology, Adult Internal Care, straight
Medicine
Medicaid or BC,
no PPO's/or fee
based on
income
- 131 -
Fee Based on
Sliding Scale.
Call individual
clinics
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
Leandro Perez, Class of 2007
Jason Schairer, Class of 2007
Staci Valley, Class of 2007
Julie Wright, Class of 2007
Christian Bimenyey, Class of 2008
Ivan Hanson, Class of 2008
Carlos Franco, Class of 2008
Stephanie Czarnik, Class of 2010
Mark Brewster, Class of 2010
Ali, Omaima, Class of 2011
Patel, Manish, Class of 2012
Ali, Azzat, Class of 2012
Lee, Crystal, Class of 2012
Kosny, Kinga, Class of 2013
Taylor, Stephanie, Class of 2013
Tuliani, Tushar, Class of 2014
Gironda, Valerie, Class of 2014
Alhusseini, Maha, Class of 2014
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!
- 132 -
CORRECTIONS:
- 133 -
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:
- 134 -

2013-2014 Survival Guide

Transcription

Similar documents

FOL-1-FORMA 1 - Service Alberta

The RC Laundromutt is now open!!! 201 S. 18th Street Philadelphia

Sea View Celebrates NALW

DJ G Kidd - DJ James Vincent

Youth Adventure Quest Flyer

Coppertree - My

Medicommunicator - Iron County Medical Care Facility

Cub Run ReCenter! Young Rembrandts is coming to

the farter`s survival guide

February 2016 Newsletter