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Resource Manual for non-GIM staff
attending on the inpatient medical
service and caring for potential
COVID19 patients
March 2020 University of Calgary
Cumming School of Medicine, Marcy Mintz, FRCPC
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Much of this information was initially compiled by core IM trainees at the University of Calgary and we are grateful for their dedication {Aliza Moledina (GIM Fellow, Ottawa), Amro Qaddoura (PGY2, Calgary), Marya Hussain,PGY2, Calgary}. Special thanks to:
• Chief Medical Residents (Welcome, Logistics)
• Michael Bosch, (Contributions to “How to Survive on MTU”, Approach to Internal Medicine Worthy Consult Note/Discharge Summary)
• Matthew Church, (Rotation specific advice); Umair Iftikhar, PGY3 (Remote access to Netcare/SCM); Rabia Kashur, (Approach to the Tachycardic patient); Nazia Sharfuddin Contributions to “How to Survive on MTU”)
• William Stokes, (Contributions to “How to Survive on MTU”)
• Senior Medicine Workbook (Jeffrey Shaw, Kim Cheema, Omar Khan, Qahir Ramji, Lauren Clark, Irene Ma) and How to do an effective goals of care discussion, Allied Health Care roles on MTU
Disclaimer: The contents of this resource manual should not substitute
clinical decision making/clinical reasoning. Please double check dosages of medications before using
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Table of Contents
Welcome! .............................................................................................. Error! Bookmark not defined. Useful Phone Numbers: ............................................................................................................................ 5 Paging System: ......................................................................................................................................... 6 On Call Lists: .............................................................................................................................................. 6 Call Rooms: ............................................................................................................................................... 6 Scrubs: ....................................................................................................................................................... 7
How to use this resource manual .......................................................................................................... 7
Approach to Common and Critical Overnight Calls ............................................................................ 8 RESPIRATORY ................................................................................................................................................ 8
Acute shortness of breath: ........................................................................................................................ 8 Hypoxemia: ............................................................................................................................................. 13 Non-Invasive Mechanical Ventilation (BiPAP) ........................................................................................ 14 Anaphylaxis: ............................................................................................................................................ 15
CARDIOLOGY: .............................................................................................................................................. 16 Approach to Acute Hypotension and Shock: ........................................................................................... 16 Chest Pain ............................................................................................................................................... 20 Hypertensive Urgency/Emergency: ........................................................................................................ 23 Anti-hypertensive Medications: .............................................................................................................. 24 Approach to the Tachycardic Patient: .................................................................................................... 26 ACLS Algorithms ...................................................................................................................................... 29
GI: ................................................................................................................................................................ 33 Approach to Abdominal Pain: ................................................................................................................. 33 Management of a GI Bleed ..................................................................................................................... 34
NEUROLOGY ................................................................................................................................................ 35 Seizures ................................................................................................................................................... 35 Agitated/Combative Patient: .................................................................................................................. 38 Altered level of consciousness: ............................................................................................................... 39
NEPHROLOGY: ............................................................................................................................................. 42 Hyperkalemia Management ................................................................................................................... 42
ENDOCRINE: ................................................................................................................................................ 44 Inpatient Diabetes Management: .......................................................................................................... 44
Miscellaneous ............................................................................................................................................. 47 Inpatient Pain Management:.................................................................................................................. 47 Fall from Bed: .......................................................................................................................................... 49 Pronouncing Death: ................................................................................................................................ 51
Interpreting Tests: ................................................................................................................................. 52 ECG ABNORMALITIES: COMMON AND CAN’T MISS ................................................................................... 52 CXR REVIEW: ............................................................................................................................................... 60 APPROACH TO BLOOD GASES: .................................................................................................................... 62
The “How To’s” of Internal Medicine MTU ...................................................................................... 65 HOW TO THRIVE ON MTU: .......................................................................................................................... 65
Patient safety while rounding: ................................................................................................................ 67 Allied healthcare roles on MTU: ............................................................................................................. 68
HOW TO DO AN INTERNAL MEDICINE WORTHY CONSULT NOTE: ............................................................. 70
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HOW TO WRITE AN INTERNAL MEDICINE WORTHY DISCHARGE SUMMARY: ............................................ 75 ADMISSION ORDERS: .................................................................................................................................. 78 PROGRESS NOTES: ...................................................................................................................................... 79 HANDY APPS AND IM RESOURCES: ............................................................................................................. 79
6. General Skills ....................................................................................................................................... 80 HOW TO DO AN EFFECTIVE GOALS OF CARE DISCUSSION: ........................................................................ 80
Serious illness conversation guide .......................................................................................................... 84 CONSENTING A PATIENT FOR A BLOOD TRANSFUSION: ............................................................................ 86 PROCEDURAL SKILLS: .................................................................................................................................. 87
7. For the Out-of-Calgary Incoming Resident: ................................................................................... 88 HOW DO GOALS OF CARE WORK IN CALGARY: .......................................................................................... 88 TIPS ON NAVIGATING SUNRISE CLINICAL MANAGER: ................................................................................ 89
Admission Order Set ............................................................................................................................... 91 TIPS ON NAVIGATING ALBERTA NETCARE: ................................................................................................. 92 REMOTE ACCESS SCM AND NETCARE: ........................................................................................................ 93
9. References ........................................................................................................................................... 96
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Useful Phone Numbers: For FMC, RGH, PLC, and SHC phone calls use 5-digit dialing. For FMC, RGH and PLC add a 94X-XXXX to the 5 digits; for SHC add a 95X-XXXX to get the full number if you are calling from an outside phone. **If the 5-digit number starts with a “7”, this number works in hospital only. If you are calling staff in the middle of the night, choose another phone if possible (or they have to call switchboard and get linked to you). Every unit should have a phone linked to a 944, 943 or 956 number that your staff can call you at.
**At FMC, RGH, and PLC the 2-digit unit number completes the phone number. For example, to call Unit 61 at FMC, dial 41361. FMC: xx indicates unit number
Main building: 413xx SSB (Special Services Building): 411xx
ER: 41315 ICU: 41464
Pharmacy: 41920 Health Records: 41356
Radiology: 48252 (protocol CT or MRI) Radiology resident pager: 00889
PLC:
Old building/west wing: 357xx New building/east wing: 366xx
ER: 34999 ICU (Unit 28): 36628
CCU (Unit 48): 36648 Pharmacy: 34977
Health Records: 34875 Radiology main number: 34570
RGH:
All units except floors 9 & 10: 335xx Floors 9 & 10: 338xx
ER: 33449 ICU: 33446
CCU: 33444 Pharmacy: 33593
Health Records: 33580 Radiology main number: 33415
SHC:
All units: 611xx ER: 63000
ICU: 62100 Pharmacy: 61557
Health records: 62950 Radiology main number: 62700
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Laboratory:
• Calgary lab services: 403-770-3602 (can add tests)
• Provincial lab: 403-944-1200 (for special tests like AFB, HSV PCR and others)
• Microbiologist on Call: 403-770-3757 (to discuss antimicrobial susceptibilities, testing, etc)
Paging System:
Our pagers in Calgary are wonderful and can read text messages up to 15 or so words. On the internal website (AHS Insite), choose Paging System (3rd item under in the top right hand corner). Search for a pager number using first or last name or page their number directly. To access the paging system by phone, dial 403-212-8223 from outside the hospital or 671 from within the hospital.
**Make sure to leave a contact number (like the phone you are sitting by and/or pager number) with your name in the message. For example, “please call Cam Griffiths re: pt X @ 41315/07923(pager)”
Remember to give people an opportunity to call back (traditionally 5-10 minutes) – so if you need something ASAP, say it in the message.
On Call Lists: On the internal website (AHS Insite), click on Employee Tools, then click Medical Staff, open the Contact Information and Scheduling column. Then click on Regional On Call Application (ROCA). This menu will allow you to choose the service and date that you are looking for. This can also be accessed through SCM. Call Rooms: Call Rooms are available for all rotations with in-house call. FMC: Call rooms for neurology and MTU are found in the basement near the med school. From the main elevators, go to the ground level. Then swing a left and follow the hallway past the radiology area Eventually, you will reach a mandatory left turn. Follow the hallway and the call rooms will be on your right side (swipe card entry). Code for MTU rooms 1500*. CCU and ICU call rooms are in the units.
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PLC: MTU call rooms are in the basement of the old building/west wing. From Second Cup: With your back to Second Cup, go left. Elevators will be on right (these elevators access psych wings) Go to level OR and the access will be right in front of you. Alternatively go to level O -> Turn right and go up the short staircase. Swipe card entry to call rooms on right. CCU and ICU call rooms are near the units. Ask when you start the rotations. RGH: MTU, CCU, and ICU call rooms are in the portables. This area also has the Residents’ Lounge. Follow the signs for Conference Room 4577. Go up the stairs and through the door. Will need to enter the code 1234* (the code for everything in trailer park). SHC:
MTU call rooms are on the 6th floor right beside unit 66. Currently residents do not do call for CCU or ICU at SHC. Scrubs:
We have been asked to not use the hospital scrubs as these are reserved for surgery and anesthesia staff.
How to use this resource manual This manual is intended as a resource only. Hopefully, it will be something you can pull out on your electronic devices on call, to help guide your clinical management and reduce some anxiety in on overnight MTU call. The manual also contains some advice in how to succeed on MTU, daily responsibilities/expectations. The manual is meant to bridge the gap between medical school and residency. There was a lack of a single consolidated resource for this purpose, and we hope that this manual can help to fill in some of those gaps.
Here are some tips (especially for overnight call):
• Patient safety comes first.
o If you are unsure, do not hesitate to contact the buddy GIM staff or senior.
Disclaimer:
The contents of this resource manual should not substitute clinical decision making/clinical reasoning. Please double check dosages of medications before using.
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Approach to Common and Critical Overnight Calls RESPIRATORY Acute shortness of breath:
Major threat to life
• Hypoxia: inadequate organ perfusion
o Clinical clues: mentation, warmth of peripheries/strength of peripheral pulses, renal perfusion (low urine output)
• Respiratory failure
o See section on respiratory failure
Targeted Clinical Assessment:
• General appearance: sick or not?
o ABC
o Vitals
▪ Temperature? Hypotension? Tachycardia?
o Cyanosis
o Cardiac
o Respiratory
o Check for crackles, wheezes, pleural effusion
o Mental status – alert vs drowsy/unresponsive
Differential (most common and critical causes overnight):
• Cardiac:
o CHF (especially if worse supine)
o ACS (angina equivalent)
o Cardiac tamponade
o Arrhythmia
• Respiratory
o Pneumonia
▪ Aspiration
▪ Hospital Acquired Pneumonia
▪ Community Acquired Pneumonia – wrong bug, wrong drug
o Bronchospasm – asthma or COPD
o Anaphylaxis
o Pleural effusion
o Upper airway obstruction
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o Pneumothorax
• Vascular:
o Pulmonary Embolism
o Anemia
• Miscellaneous causes
o Anxiety
o Massive ascites
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Initial Management:
• Stabilize:
o Oxygen
▪ Beware not to over-target SpO2 in a patient with COPD (CO2 retainer), as they are dependent on mild hypoxia to stimulate the respiratory center; target SpO2 88-92%
• Check vitals/general appearance to see how worried you are
o If worried, order investigations right away as they will take some time to come back (+/- call senior)
▪ Usually ECG, CXR (portable), +/- ABG (done by RT), troponin
▪ Can also add NT-proBNP, CBC, Cr, lytes in appropriate clinical context
▪ If you want them STAT, ask charge RN to page the technicians/RT.
• What was the duration?
o Sudden onset SOB: think PE, pneumothorax, flash pulmonary edema
• When was the patient admitted?
o Hospital acquired vs community cause
Clues to Etiology:
• Does the patient have a history of CHF or cardiac disorders?
o Check previous echos/admissions for CHF
▪ Home meds (eg Lasix is a good clue)
o CHF risk factors, previous angios on Netcare
o Examine the patient for CHF/volume overload
▪ Orthopnea? PND?
▪ Elevated JVP, peripheral edema/ascites, bibasilar crackles/wheezes, S3, daily weights, urine output
o Order EKG, troponin, CXR. If suspect new CHF, NT-proBNP as well.
• Infectious
o Are they admitted for pneumonia?
o Fever, sputum production, URT/LRT symptoms
▪ Pleuritic chest pain, productive cough, auscultation suggestive of consolidative changes
o Immunocompromised vs Immunocompetent Host
▪ Different bugs
o Risk of aspiration (example: low RR secondary to narcotics, history of stroke, note previous barium swallows/SLP assessments)
▪ Consider aspiration pneumonia vs pneumonitis
o Consider: what are current antibiotics covering and what bugs are they not covering? Do you need to broaden antibiotics?
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o Consider: possible lack of source control (eg: in complicated parapneumonic effusion/empyema)
• Bronchospasm
o History of smoking, COPD, asthma
o Wheezes
o Response to bronchodilators
• Pulmonary Embolism – Should always be on the differential **
o Assess risk factors: Wells score – https://www.mdcalc.com/wells-criteria-pulmonary-embolism
o Are they on anticoagulation?
▪ DVT prophylaxis
▪ Therapeutic anticoagulation (if on warfarin, check INR to ensure at therapeutic target: goal INR 2-3 in most circumstances)
▪ Contraindications to anticoagulation? (ie GI bleed)
• Signs of anaphylaxis – look for history of allergies (found on SCM)
o Skin – hives, rash, itch, warm extremities, flushing
o Vascular – hypotension, warm extremities
o Swelling – tongue, lips, throat, fingers, toes
o Respiratory – dyspnea, wheeze, difficulty with breathing
o GI – stomach upset/pain, nausea, vomiting, diarrhea
o Mental status changes
Interpreting your investigations:
• ECG
o Look for signs of ischemia/infarction, arrhythmia, electrical alternans
o Compare to baseline ECG (could be found on Netcare or SCM
• CXR
o Look for causes of dyspnea (see differential above); in particular:
▪ New infiltrate/worsening infiltrate
▪ Signs of CHF: cardiomegaly, perihilar congestion, pulmonary vascular redistribution, kerley B lines, pleural effusions bilateral interstitial infiltrates (early) or alveolar infiltrates (late)
▪ Pneumothorax
▪ Large pleural effusion
▪ Widened mediastinum (may suggest aortic dissection)
▪ Globular heart (suggests possible large pericardial effusion)
▪ Lung hyperinflation
• Troponin
o Compare to baseline
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o Repeat in a 4-6 hours if elevated to see if stable or increasing (demand ischemia vs ACS)
o Call Buddy staff, senior +/- Cardiology if concerned
• ABG or VBG – please see “interpreting tests” section on ABG
o Very useful if someone is sick!
o Look for signs of respiratory failure (see section on hypoxemia)
• CBC
o Elevated / left-shifted neutrophils or low neutrophils suggest infection
o Hgb trend
• NT-proBNP – useful especially if suspecting new CHF
• Cr – look for worsening renal failure
Note: other investigations may be ordered as guided by history and exam
Management:
• As guided by history/exam
• ABG is very useful in helping to determine whether they are compensated, and giving you a clue as to how worried you should be
o Look for hypercapnic/hypoxemic respiratory failure; another possible etiology is metabolic acidosis. See the section on ABG interpretation for details
Management of common causes of acute shortness of breath:
• CHF
o Lasix IV
▪ Note that IV is 2x PO dose (2:1 ratio)- standard IV dose is ~ 30-40 mg IVPB or IV push if not in CRF. Patients with CRF may require 2-3 times higher dose
o Other agents for afterload reduction (if blood pressure is amenable):
▪ Nitro patch (0.4 mg/hr and above -8 am-8 pm or 8 pm-8 am)
▪ Hydralazine (25-50mg QID)
▪ ACE-I (ramipril 5-10 mg/day)
o BiPaP if medical treatment ineffective (see non-invasive ventilation section)
▪ Need ICU or Respiratory to initiate BiPAP
▪ If considering this, respiratory staff or fellow on call
o If hypotensive and decompensating, and appropriate goals of care, call code 66
• New/worsening pneumonia
o Signs of infectious etiology and new/worsening infiltrate on CXR. CBC suggestive of infection
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o IV fluids and antibiotics. The Spectrum app is a great resource!
▪ www.spectrum.md
o Consider what bugs are not being covered
▪ Consider broadening antibiotics –ie coverage of atypical organisms, anaerobes, hospital acquired organisms
▪ Immunocompetent vs immunocompromised host – may have different bugs
▪ Consider Tamiflu if flu season and nasopharyngeal viral swab
• Anaphylaxis – see section on Anaphylaxis
• PE – consider CTPE or empiric anticoagulation
• Bronchospasm
o Add bronchodilators:
▪ Salbutamol nebs or MDI (2-4 puffs QID or Q1h if acute)
▪ Ipratropium nebs or MDI (2-4 puffs QID)
o Consider adding prednisone 50 mg po daily for 5 days
o Consider adding antibiotics if concerned about COPD exacerbation
• Calling for help – always the right thing to do if worried!
o Code 66 – ICU outreach if patient is acutely unstable. Can ask nurses to help you activate.
Hypoxemia:
• Hypoxemia: decrease in O2 in blood
o O2 Sat (bound to HGB)
o Partial Pressure (dissolved in plasma - PaO2, from ABG)
• Hypoxia: decrease in O2 at tissue (perfusion of tissue)
Respiratory Failure:
• Hypoxemic Respiratory Failure (not able to oxygenate)
o PaO2 < 60 mm Hg despite FiO2 >60%
o Not oxygenating despite high amounts of oxygen
• Hypercapnic Respiratory Failure: (not able to ventilate)
o PaCO2 > baseline with acidosis
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o Of note, can give BiPaP to help blow CO2 off (eg: in COPD)
Eventually hypercapnic respiratory failure progresses to hypoxemic respiratory failure if not treated promptly.
Note that a normal PaCO2 in an acute situation may be sign of impending failure
Non-Invasive Mechanical Ventilation (NIMV-BiPAP)
• Improves acute respiratory acidosis
• Decreases work of breathing (WOB) dyspnea
• Decreases mortality and requirement for intubation
• When to BiPAP – call the buddy staff or respiratory! You will need a Respiratory tech or ICU to help you
o pH <7.35
o PaCO2 >45
o Severe dyspnea with signs of respiratory muscle fatigue, increased WOB
o "sweet spot" – pH 7.25-7.35, PaCO2 >45
• When NOT to BiPAP
o Patient wishes (GoC discussion- if M1 or lower this may not be an appropriate choice as warrants a discussion)
o Hypotensive (SBP <90)
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o Hemodynamically unstable
o Unable to control secretions/+++ secretions
o Decreased LOC (can't remove mask), GCS<9, uncooperative/agitated
o Poor mask fit (facial trauma)
o If they need intubation
o Pneumothorax (positive pressure will enlarge)
Note: Patients with an acute exacerbation of COPD and a baseline arterial blood gas pH >7.35 are not likely to benefit from NIMV
Repeat ABG 1-2h after starting BiPAP to monitor progress Anaphylaxis:
Is patient having an anaphylactic reaction:
• Look for evidence of systemic autacoid (eg: histamine) release:
o Skin – hives, rash, itch, warm extremities, flushing
o Vascular – hypotension, warm extremities
o Swelling – tongue, lips, throat, fingers, toes
o Respiratory – dyspnea, wheeze, difficulty with breathing
o GI – stomach upset/pain, nausea, vomiting, diarrhea
o Mental status changes
• Common agents: IV dye, blood transfusion, PCN, ASA, food
o If related to blood transfusion, must alert the lab
• Danger signs: rapid progression of symptoms, respiratory distress (stridor, wheezing, dyspnea, increased WOB), vomiting, abdominal pain, hypotension, dysrhythmias, CV collapse
Acute Management:
• First and most important treatment is epinephrine
o No contraindications in acute anaphylaxis
• Airway – immediate intubation if impending respiratory failure from angioedema
o Code 66
• Simultaneously:
o IM epinephrine (1 mg/mL preparation: give 0.3-0.5 mg IM preferably in mid-outer thigh; can repeat q5-15 mins prn – usually patients respond to 1-2 doses (at most 3). If not responding, may need IV epinephrine in monitored setting (ICU)
o Oxygen
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o Normal saline or Ringer’s lacate rapid bolus as needed for hypotension 1-2 L
o Consider H1 antihistamine: diphenhydramine 25-50 mg IV (for relief of uriticaria/itching only)
o Consider H2 antihistamine: ranitidine 50 mg IV
o Glucocorticoid: consider methylprednisone 125 mg IV
o Salbutamol 2.5 mg by nebs if bronchospasm
o If any concerns, call code 66
• Close monitoring
o Especially for biphasic anaphylaxis (rebound after initial treatment) CARDIOLOGY: Approach to Acute Hypotension and Shock:
Initial Questions Overnight in the Hypotensive Patient:
• Vitals: What is their BP, HR, temperature?
o What is the trend?
o Is this new?
• Symptoms: LOC/mentation, chest pain, evidence of bleeding?
• Any recent IV contrast/antibiotic in last 6 hours?
• Concern for anaphylaxis?
• Admitting diagnosis
*Note: some patients (ie younger patients, athletic patients) will have SBP normally in the range of 80-100 mm Hg – if they are asymptomatic, they do NOT need aggressive management.
Bedside Test:
• General appearance: sick or not?
• ABC
o Assess for signs of shock: inadequate tissue perfusion (mentation, cold/clammy skin, cyanosis, low urine output)
• Vitals
o Temperature – clue for possible septic shock
o If they have a normal HR, check if they are on a beta blocker or a condition that may blunt their compensatory tachycardic response
• Check extremities – hot versus cold
• Active bleeding?
Consider investigations based on possible causes of shock.
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Shock:
• Patients are not necessarily hypotensive; for example, in hypovolemic shock, patients may initially be tachycardic while maintaining their blood pressure
• Must have a high index of suspicion if the patient is unwell
• If there is refractory hypotension (absolute or relative), it results in:
o Hypoperfusion
▪ Hypoxemia
▪ Lactic acidosis
o Organ Failure:
▪ Urine output <0.5cc/kg/hour
▪ Mental status
▪ Chest pain / dyspnea
▪ Liver failure
Items to remember in shock
• Blood pressure is a function of cardiac output and peripheral vascular resistance (BP = CO x PVR)
• Cardiac output is a function of heart rate and stroke volume (CO = HR x SV)
Overnight Approach to Shock:
• Distributive (warm)
o Septic
o Anaphylaxis
o Neurogenic
• Obstructive (cold)
o Cardiogenic: Pump Failure
o Obstructive (PE, Tension Pneumothorax, Tamponade)
• Hypovolemic (cold)
• Endocrine (usually cold) – adrenal insufficiency, myxedema coma
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• Assessment of shock:
WARM SHOCK: (low SVR)
Sepsis
• Sepsis
o IV fluids
o Pan culture (CXR, UCx, BCx; other cultures based on Hx and physical, including potential lumbar puncture)
o Early antibiotics
o Consider ICU for possible pressors, especially if not maintaining MAP > 65. We do not use pressors on the ward
• Defining sepsis and septic shock: despite new criteria (SOFA and qSOFA), we still rely on SIRS often to help us have a high index of suspicion for shock
o SIRS Criteria: 2 or more of the following:
▪ Heart rate >90
▪ T >38 or <36
▪ RR >20 or PaCO2 <32
▪ WBC>12 or <4 or >10% bands
o Sepsis = SIRS + confirmed or presumed infection
o Severe sepsis = end organ dysfunction + sepsis
o Septic Shock = severe sepsis with refractory hypotension despite at least 40 ml/kg of crystalloid resuscitation. For a 70 kg patient, that’s ~3L crystalloid
• qSOFA score – sepsis is likely and has worse outcome if 2/3 of below with presumed or confirmed infection
o RR >22
o SBP <100
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o Altered LOC (usually GCS <15)
• SOFA score – predicts ICU mortality o https://www.mdcalc.com/sequential-organ-failure-assessment-sofa-score
Anaphylactic shock
• Please see section on anaphylaxis
Neurogenic shock
• IV fluids
• Consider pressors if refractory to fluids. Seek expert consultation.
COLD SHOCK (high SVR)
JVP high: (DDx – Obstructive, Cardiogenic)
• Obstructive:
o Tension Pneumothorax: Deviated trachea, unequal BS, subcutaneous emphysema
o Tamponade: muffled heart sounds, hypotension, Pulsus Paradoxus, Kussmaul's
o Treatment
▪ Relieve the obstruction (ie needle decompression, chest tube, needle pericardiocentesis, crash thoracotomy)
• Cardiogenic
o Clinically fits in with history and physical
o S3, new arrhythmia, ACS
o Murmurs – acute MR and acute AR
o “Wet lungs”
o CXR shows signs of heart failure
o Treatment
▪ Help from CCU – may need inotropes/mechanical assist devices
▪ Rate/rhythm control
▪ Diuresis
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JVP low: (DDx – decompensated septic shock, hypovolemia, possibly adrenal insufficiency)
• Give IVF
• Order CBC and type & screen
• Pan culture and empiric antibiotics
Chest Pain Differential (critical conditions bolded):
• Cardiovascular:
o Acute coronary syndrome
o Aortic dissection
o Pulmonary embolism
o Pericarditis
• Respiratory:
o Pneumothorax
o Pleuritis (+/- pneumonia)
• GI:
o Esophageal spasm, dysmotility, esophagitis (GERD, other)
o Peptic ulcer disease
• MSK:
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o Costochondritis
o Arthropathies
o Rib fracture
• Skin:
o Herpes zoster
• Psych:
o Anxiety/panic attack
Clinical examination:
• General appearance: sick or not?
• Vitals
o Especially HR and blood pressure
▪ Hypotension: MI, massive PE, aortic dissection resulting in tamponade, tension pneumothorax
▪ Hypertension: MI or aortic dissection
▪ Tachycardia:
• Sinus versus arrhythmia
▪ Bradycardia
• Note symptomatic bradyarrythmia (see ACLS protocol)
• May be a sign of ischemia
Initial Investigations:
• ECG, troponin, CBC, CXR +/- ABG
• Additional investigations as guided by history and physical exam
• For acute PE, most common ECG sign is sinus tachycardia, but also look for signs of right heart strain and RV ischemia
o Don’t forget to compare to old EKGs
Targeted History/Physical:
• Describe pain – quality, location, duration, severity, aggravating/alleviating factors
• Risk factors
o Check cardiac RF, previous MI/CAD, previous angios/echo
o Wells score for PE; HTN and connective tissue disorder for dissection
o Reason for admission?
o Same quality of pain as angina/previous MI?
• Pleuritic?
• Radiation?
• Associated symptoms: SOB, nausea/vomiting, presyncope, palpitations
• Targeted physical exam directed towards above differential
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o Don’t forget bilateral BP and to auscultate for a pericardial rub
Acute Coronary Syndrome:
Pathophysiology:
• Most commonly plaque rupture (75%)
• Plaque erosion (25%)
STEMI: complete occlusion of coronary artery by thrombus
• Ischemic chest pain (or equivalent) and > 1 mm ST elevation in 2 or more consecutive leads or new LBBB on ECG
NSTEMI: incomplete occlusion of coronary artery by thrombus
• Ischemic chest pain (or equivalent) + increased markers (eg: troponin) +/- ischemic ECG changes (usually ST depression or T wave inversion) but without ST elevation or new LBBB
Unstable angina: same as NSTEMI, but no elevation in markers. Defined clinically as any of:
• Accelerating pattern of pain (crescendo): increased frequency, increased duration, decreased response to treatment
• Angina at rest
• New onset angina (CCS 3)
• Angina post MI or post-procedure
Note: 30% are unrecognized or silent due to “atypical symptoms” - more often in women, elderly, patients with diabetes mellitus, and post-heart transplant
Management:
• Alert Senior.
• Cardiology consult. If STEMI, call Cardiology / Cath lab immediately
• Oxygen in hypoxic patients
• ASA 160 mg po chewed x 1 STAT, then 81 mg PO daily
• Second anti-platelet agent
o Ticagrelor loading dose: 180 mg PO once then 90 mg PO BID
o Clopidogrel loading dose: 300 or 600 mg PO once, then 75 mg PO daily
• Nitro patch
o Avoid if hypotensive or signs of RV infarction on ECG
o Alternatively, can use IV nitro infusion if ongoing chest pain and monitored setting (emergency, ICU/CCU) – talk to senior first
• Anti-coagulant
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o Can use fondaparinux 2.5 mg SC daily; avoid in renal failure
o Can use IV heparin
• High-dose statin
• +/- Beta blocker
• +/- ACE inhibitor
Aortic Dissection:
• Diagnosis
o Consider the diagnosis in any patient with chest or back pain, especially with high BP or pulse differentials and CXR showing widened mediastinum
o Three major clinical predictors of aortic dissection (from JAMA ):
▪ Sudden and tearing chest pain
▪ Asymmetric pulses or BPs (>20 mm Hg difference between arms) or focal neurologic deficits
▪ Abnormal aortic or mediastinal contour on CXR.
▪ If all 3 present, positive LR=66 (but this triad only present in 27% of patients). If all three absent, LR=0.07.
*If thinking ACS or dissection or worried about patient, call buddy staff or senior for help. Hypertensive Urgency/Emergency:
Precipitants:
• Medication non-compliance
• Diet indiscretion /EtOH
• Drugs
• Stimulants, NSAIDs, OCP, HRT
• Progression renal disease
• Endo - Pheo, Cushing’s, Conn’s
Physical exam:
• Vitals including GCS
• Neuro - ?stroke (any focal deficits)
• ?Aortic dissection - unequal pulses, chest pain radiating to back
• Cardiac/lungs
• Renal: bruit
• Pulses
•
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Investigations:
• CBC
o Look for microangiopathic hemolytic anemia in pregnant pts (can add smear)
• Cr/Urine output; electrolytes; +/- extended electrolytes
• Cardiac enzymes, ECG
• CXR
• bHCG
• +/- CT head
• +/- tox screen
• +/- TSH
Hypertensive Urgency:
• Increased BP without symptoms or end organ damage; usually SBP >180 or DBP > 110, but depends on patient and their baseline
• Can use PO anti-hypertensive agents:
o Target to decrease MAP by 25% over 48-72h (cerebral auto-regulation)
o May start by resuming home BP meds or increasing dose
o Add new medications based on comorbidities
▪ Common options include hydralazine, labetalol, clonidine, captopril
▪ Ideally use medications with quicker onset of action and quicker elimination (i.e. avoid medications with long half-life)
Hypertensive Emergency:
• Same as hypertensive urgency but with symptoms or end organ damage
• Target: decrease MAP 10-15% in first hour
o No more than 25% in next 6h
o Do not lower BP too quickly - can precipitate ischemic infarction
• CCU/ICU/ED for invasive monitoring: IV meds in monitored setting
o Monitor: mental status, urine output, creatinine, symptoms
• Options:
o IV hydralazine
o IV labetalol - prevention of reflex tachycardia
o Nitro infusion
o Nicardipine Anti-hypertensive Medications:
In the hypertensive patient, consider:
• New or existing HTN?
• How severe?
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• Etiology?
o Usually primary, but consider work-up for secondary if resistant hypertension
• Symptoms/Complications? (see section on hypertensive urgency/emergency)
Considerations for individualizing antihypertensive therapy:
• Start low and go slow
• If asymptomatic, then can up-titrate existing medications first
• Consider underlying medical conditions and contraindications (below) in starting new anti-hypertensives
• Common PRN medications overnight
o Hydralazine
o Captopril
o Clonidine
o Labetalol
Indication Antihypertensive drugs
Compelling indications
Systolic heart failure ACE inhibitor or ARB, beta blocker, diuretic, aldosterone antagonist*
Postmyocardial infarction ACE inhibitor, beta blocker, ARB, aldosterone antagonist
Proteinuric chronic kidney disease ACE inhibitor or ARB
Angina pectoris Beta blocker, calcium channel blocker
Atrial fibrillation rate control Beta blocker, nondihydropyridine calcium channel blocker
Atrial flutter rate control Beta blocker, nondihydropyridine calcium channel blocker
Likely to have a favorable effect on symptoms in comorbid conditions
Benign prostatic hyperplasia Alpha blocker
Essential tremor Beta blocker (noncardioselective)
Hyperthyroidism Beta blocker
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Migraine Beta blocker, calcium channel blocker
Osteoporosis Thiazide diuretic
Raynaud's syndrome Dihydropyridine calcium channel blocker
Contraindications Angioedema ACE inhibitor
Bronchospastic disease Beta blocker
Depression Reserpine
Liver disease Methyldopa
Pregnancy (or at risk for) ACE inhibitor, ARB, renin inhibitor
Second- or third-degree heart block Beta blocker, nondihydropyridine calcium channel blocker
May have adverse effect on comorbid conditions
Depression Beta blocker, central alpha-2 agonist
Gout Diuretic
Hyperkalemia Aldosterone antagonist, ACE inhibitor, ARB, renin inhibitor
Hyponatremia Thiazide diuretic
Renovascular disease ACE inhibitor, ARB, or renin inhibitor
*A benefit from an aldosterone antagonist has been demonstrated in patients with NYHA class III-IV heart failure or decreased left ventricular ejection fraction after a myocardial infarction.
Adapted from: The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. JAMA 2003; 289:2560. Approach to the Tachycardic Patient:
Pre-bedside stage:
Initial questions:
• What is the patient’s heart rate? Is it regular vs irregular?
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• What are the vitals: Stable vs unstable?
• Is the patient symptomatic: Chest pain, dizziness, shortness of breath, palpitations?
• What was the last set of vitals for the patient and what is the trend?
• Has this been an issue previously during this admission and what happened if yes?
• Quick look at the latest labs for the patient and if any critical results have been noticed. Review any previous ECGs (Available on SCM/Muse) for any known arrhythmias.
• Quick look on medication profile (? Cardiac meds: B. Blockers, digoxin, others might affect QTc)
• Quick history of PMHx, main reason of admission and current active issues
• What are the goals of care?
Initial orders and next steps to take:
• Inform the nurse about when you will be there: immediately or later
• Ask to have a stat ECG ordered
• If you are concerned about metabolic abnormalities that might drive the arrhythmia, consider ordering a stat VBG/ABG (Takes 10-15 minutes to get the results). You may ask for cardiac enzymes/extended lytes if needed (It may take longer)
• If concerned about resuscitation, make sure you have two large IV lines inserted
• If worried, inform your immediate senior or buddy staff
Bedside stage:
• Have a quick look at the patient general condition: comfortable(stable) vs in distress (sick) vs critical: usually gives you an idea of how fasts you may need help (code team)
• Check the vitals and assess the ABCs
• Review the patients’ 12 lead ECG/Monitor
• Assess if the patient is stable vs unstable and use your ACLS algorithms and act accordingly
• Meanwhile assessing the patient, try to recognize any reversible or life threating causes:
o History: Admission diagnosis, active issues in the hospital, PMHx including CAD, CHF, HTN, PE, Thyroid, Hypoxia, COPD, Toxic ingestions including EtOH
o Physical exam: Mentation, Volume status, Hypoxia (COPDE, PE, PNA), Cardiac exam (JVP; murmurs; S3 and S4; signs of CHF; heaves: strain on ECG), Abdomen (ascites, sepsis), Extremities (peripheral perfusion; shock; DVT; edema)
Formulate a quick potential differential diagnoses:
• Serious life threatening: Ischemia, HF, PE, drugs including intoxication, electrolyte imbalance: K+, Mg++, Ca++, sepsis
• Reversible causes: dehydration, Hypoxia (eg: COPD, PNA)
o Correct reversible causes and initiate treatment for possible underlying etiologies
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• Review with the buddy staff or senior and reassess if ICU/CCU needs to be involved if not done yet
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ACLS Algorithms
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Reversible Causes: (Hs and Ts):
• Hypoxia
• Hypovolemia
• Hypothermia
• Hypo/Hyperkalemia
• H+ - Acidosis
• Tension Pneumothorax
• Tamponade
• Thrombosis – PE, ACS
• Toxins
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GI: Approach to Abdominal Pain:
Red Flags Overnight:
• Severe (unbearable) pain
• Associated with chest pain, which suggest myocardial infarction or pneumonia or pulmonary embolism
• Systemically unwell (tachycardia, hypotension, diaphoresis, confusion)
• Hypotensive shock can suggest intra-abdominal hemorrhage
• Fever – sepsis
• Guarding or rebound tenderness, which suggest peritonitis
• Abdominal distention, which suggest bowel obstruction
• Unexplained weight loss, which suggest malignancy
Ask the RN:
• Vitals
o Fever – abdominal infection?
o Hypotension/Tachycardia → patient is sick!
• Pain localized/generalized?
• How severe?
• Is the pain new? Reason for admission?
• Taking steroids/anti-inflammatories? Otherwise immunosuppressed?
o Could mask severity/fever Assess the Patient (sooner if the patient’s vitals show they are sick or the patient has new or worsening pain)
• It’s important to not just give pain medications if you don’t know the cause of the pain – you could be masking something more sinister
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Management of a GI Bleed Key overnight questions
• HR and BP • HGB with trend
• Medications especially anticoagulants
• Cirrhosis Differential:
• Upper GI bleed o Esophagitis o Esophageal varices o Mallory-Weiss syndrome (tear) o Gastric ulcer, gastritis o Duodenal ulcer, duodenitis o Neoplasm (esophageal cancer, gastric cancer) o Aorto-duodenal fistula
• Lower GI bleed o Angiodysplasia o Diverticulosis o Neoplasm o Colitis (ulcerative, ischemic, infectious) o Mesenteric thrombosis o Meckel’s diverticulum o Hemorrhoids
Management:
• ABC:
o Determine unstable versus stable
▪ For unstable: resuscitate, call for help
▪ Tachycardic, hypotensive
• Large bore IV – two if unstable
• Fluid resuscitate or transfuse as necessary
o Transfuse below HGB <70, or <80 if CAD
o Transfuse platelets if <10 or <50 if active bleeding
o If unstable – activate massive transfusion protocol
• Order CBC, type and screen stat +/- INR and PTT
• Hold anticoagulation (including ASA, NSAIDs, DVT prophylaxis), steroids
• Reverse anticoagulation if necessary (ie vitamin K, Octaplex or FFP)
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• Hold anti-hypertensives
• For UGIB, pantoprazole 80 mg IV bolus then 8 mg/hour infusion (or 40 IV BID)
o +/- Octreotide if suspected cirrhosis by history, exam, lab or imaging/suspicion of variceal bleed
▪ 50 mcg bolus then 50 mcg/hour infusion
o Add ceftriaxone 1 g IV q daily x maximum 7 days for SBP prophylaxis
▪ Decreases mortality from infections, decreases re-bleeding
• GI consult for endoscopy/colonoscopy
o If stable, can usually wait until morning
• Keep patient NPO for possible endoscopy/surgery (especially if they suddenly become unstable and need emergent scope)
• Early / immediate consultation for:
o Exsanguinating hemorrhage
o Lots of bleeding with high transfusion requirements
o Consider in patient refusing blood transfusion
Major threat to life: Hypovolemic shock
• Clinical diagnosis: hypotension sBP <90, with signs of tissue hypoperfusion (cold/clammy skin, change in LOC, low urine output, high lactate)
Note: • Pepto-bismol and iron supplements can turn stools black • Aorto-duodenal fistula can present with minor bleeding then rapid exsanguination –
consider if they have had abdominal vascular surgery or in any patient with midline abdominal scar who can’t give history.
• For LGIB, don’t automatically dismiss bleeding as caused by hemorrhoids before ruling out other causes
NEUROLOGY Seizures
Seizures Differential Diagnosis:
• Unprovoked epileptic seizures
• Provoked Seizures
o Drugs
▪ Withdrawal - BZD, alcohol
▪ Overdoses - methanol, ethylene glycol, TCAs
▪ Illicit drug use - cocaine, amphetamines, LSD
▪ Note drugs that lower seizure threshold – eg: buproprion
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o Metabolic: hypoglycemia, hyponatremia, hypocalcemia, uremia, hypoxia, hyperthyroidism
o Infections
▪ Any infection, but especially meningitis. Febrile seizures in children
o Structural - brain mass/bleed/trauma, hypertensive encephalopathy, congenital
o Other – egs: arrythmia, idiopathic
• Psychogenic: Non epileptic
• Seizure mimics
o Syncope, TIA, migraine, BPV, hypoglycemia, sleep disorders, periodic paralysis, breath holding spells
Complications of seizures:
• Aspiration pneumonia- CXR if suspected
• Neurogenic pulmonary edema- CXR
• Hypoxic brain injury
• Cardiac injury – Troponin, ECG
• Rhabdomyolysis (ARF, hyperkalemia)- electrolytes, Creatinine
• Lactic acidosis – VBG (look for lactate)
Management:
• Seizure may be a sign of cardiac arrest - check pulse
• ABC, O2, IV, POCT glucose
• Stat investigations - ABG, CBC, lytes, Cr, glucose, extended lytes +/- toxic screen, antiepileptic drug level, LFTs
• Finger-stick glucose Acute Seizure Control:
• Immediate management focuses on stabilization of patient (especially airway and vital signs) and rapid identification of any reversible causes
• Glucose if hypoglycemia (thiamine 100 mg IV if suspicion of alcohol withdrawal, 50% glucose 50 mL IV)
• BZD (lorazepam 2 mg IV/SL prn q1-3 mins prn, up to total dose of 0.1 mg/kg)
o If no IV access, can do Midazolam 10 mg IM once if weight > 40 kg
• Can use diazepam 10 mg po q6h and 5 mg po q2h prn
• Brain imaging (CT then eventually MRI) and EEG for any patient with unprovoked seizure
o Urgent non-contrast head CT to exclude hemorrhage in patients with focal neurological deficits, impaired mental status or head trauma.
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• May not need anti-epileptic if provoked - instead treat underlying cause.
• May not need neuroimaging/EEG if clear reversible cause and normal neuro exam.
Status Epilepticus: Code 66
• Cardiac monitoring with pulse oximetry
• First line: lorazepam - 2 -4 mg q1-3 mins IV push (max 2 mg/minute); max 0.1 mg/kg
o May also do Diazepam 0.2 mg/kg IV or midazolam 0.02 mg/kg IV
o If no IV access, can do Midazolam 10 mg IM if weight > 40 kg
• Second line: Phenytoin 20 mg/kg IV, at 25-50 mg/minute - no faster than 50 mg/min, need continuous monitor (SE: hypotension, respiratory depression)
• Consider calling ICU at this point if seizure not terminated
• Note: Need separate lines for phenytoin and BZD as it will precipitate if infused in same line
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Agitated/Combative Patient: Initial Questions to ask overnight:
• Why was the patient admitted? o Change from previous?
• Sick or not? o Cyanosis, difficulty breathing o Signs of meningitis/encephalitis
• Medications/drugs o Including EtOH
• What has been done so far? • Reasons for agitation
o Are they in pain? o Is there a language barrier? o Are they delirious? If yes, then why? o EtOH/drug withdrawal o Drug-seeking behavior o CNS pathology
• Do you need hospital security? o Don’t forget to think about your own safety before entering the room!**
**Before pursuing medications, consider: ‘Delirium Management for Older patients’- order set in SCM. Gives non-pharmacologic options. If must use medications for a combative patient:
• Haloperidol 0.5-5 mg po/IM/IV o Elderly patients should be given smaller initial dose of 0.25-0.5 mg o Additional dose if still agitated 30 minutes after initial dose then can give another
(q4h prn) o Elderly patients rarely need total dose higher than 5 mg o Avoid in Parkinson Patients o Watch QT o Other potential agents: olanzapine, risperidone, quetiapine
• Benzodiazepines – try to avoid as may worsen confusion o Lorazepam 0.5 – 2.0 mg po/SL/IM/IV o First line for alcohol withdrawal or sedative drug withdrawal
• If physical restraints needed for patient/staff safety, call patient’s family to reassure them that the restraints are probably needed only temporarily
o Note that physical restraints should not be commonly used and are an absolute LAST resort. They can worsen patient outcomes, and can lead to mistrust with the healthcare system
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Altered level of consciousness: History
• Recent febrile illness or symptomatic complaint • History of organ failure
• EtOH or drug abuse • Medication List • Targeted at identifying underlying cause on examination:
Physical Exam • Vitals • General
o GCS o Oriented - person, place, time o Poor attention (serial 7s, spelling WORLD backward). o Memory - ie mini cog: 3 world recall and clock drawing o Speech - tangential, disorganized or incoherent
• System based
• Volume status, potential infectious foci, neurological deficits, toxidromes Differential Diagnosis: DIMS (bolded are the most common) Drugs: Intoxication OR withdrawal
• Alcohol • Anticholinergics (atropine, benztropine, scopalamine, dimenhydrinate) • Antidepressants (SSRIs, TCAs) • Anticonvulsants (carbamazepine, phenytoin, valproate, phenobarbital)
• Analgesics: (opiods, NSAIDs, steroids)
• Anti-histamines (cimetidine, famotidine, ranitidine)
• BZD (lorazepam, diazepam)
• Cardiac (Amiodarone, Bblockers, Digoxin, diuretics) • Dopamine agents (Levodopa) • Review Med list carefully • +/- serum EtOH, urine tox screen, blood gas, AG, osmolar gap
Infection: • Respiratory: pneumonia, URTI • Urinary: UTI, syphilis • Skin/soft tissue, abscesses, MSK • Bacteremia • CNS: Meningitis/encephalitis/abscess • Workup as guided by history and exam: do they have a fever, or WBC count?
o CXR, U/A or urine Cx, BCx, LP, skin/wound Cx, arthrocentesis
Metabolic
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• Organ Failure o Hepatic o Renal (azotemia) o Hypothyroidism o Hypoxia, hypercapnia o Hypothermia o Hypertension o Adrenal insufficiency
• Serum ammonia level, Cr, BUN, TSH/free T4/T3, Blood Gas/pulse ox, temperature, BP, lactate
• Electrolyte / nutrient abnormalities
o Hyponatremia, hypernatremia
o Hypercalcemia
o Hypoglycemia – check POCT blood glucose*
o Acidosis
o Hypomagensemia
• Serum electrolytes, extended lytes, POCT glucose, blood gas
Structural/Seizure
• Seizure • Cerebral ischemia or hemorrhage • SAH, epidural, subdural, intracerebral • Tumour
• Abscess • Management: CT head +/- EEG
Who is at Risk of Delirium: • Elderly • Underlying neurocognitive disease (dementia, stroke, PD) • Polypharmacy especially psychoactive drugs • Infection • Dehydration, malnutrition
• Immobility - restraint use
• Urinary catheter Approach:
• Recognize disorder is present • Identify cause • Treat cause
• Manage symptoms
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Management of delirium:
• Modify risk factors • Treat underlying condition • Manage agitation
o Non pharm interventions: ‘Delirium Management for Older patients’- order set in SCM
▪ Interpersonal/environmental manipulations ▪ Frequent reassurance, verbal orientation ▪ Family or professional sitters ▪ Physical restraints should be last resort
o Neuroleptic medications ▪ Haldol - standard Rx
• Start with 0.5-1 mg PO, IM or IV
• Caution in arrythmias, increased QTc, hypotension, ANY hemodynamic instability, any pre-existing dementia if used with other sedatives
• Avoid in Parkinsonism/LBD (worsens) ▪ Seroquel, Risperidone, Olanzapine also effective ▪ Always check QTc prior to use
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NEPHROLOGY: Hyperkalemia Management
EKG Changes: • Tall/Peaked T waves • P wave flattening • Lengthening of PR interval • QRS widening***
• Sine wave*** Other: RBBB/LBBB, AV block, sinus bradycardia, VT, VFib
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Management of acute hyperkalemia:
• Monitored bed (ie K > 6.5)
• If wide QRS, stabilize cardiac membrane with: o Calcium gluconate 1A - IV push (2-3 minute infusion) o Of note, calcium chloride, can cause sclerosis in peripheral line (do not push) o Don't need to give if only peaked T waves o May only last 15 minutes - repeat ECG q30 mins once significant ECG changes
• Beware of patients on Digoxin - "stone heart" with calcium - sudden onset asystole as digoxin blocks Na/K ATPASe of cardiac myocytes which will cause downstream accumulation of calcium intracellularly
• Shift o Insulin: 1A (or 50 ml) D50W + 10 units R insulin
▪ Ensure blood glucose check before, and 30mins, 1h,2h, 3h post treatment.
▪ Give D50W first, then Insulin ▪ Consider giving 5 units of insulin R in patients with renal failure ▪ Duration 4-6h
o 2.5 - 5.0 cc salbutamol nebs ▪ Monitor for sympathetic SE (tachycardia, angina) ▪ Effect: 30 minutes, duration: 90 minutes
o +/- Bicarb if very acidotic - * ▪ 1-3 amps (50-150 mmol) or 150 mmol/L in D5W infusion ▪ Effect: 15-30 mins, duration: 60 mins (unless infusion) ▪ Raises pH and results in H+ release from cell (K+ moves intracellularly)
o Dialysis for excretion if K+ very high and/or refractory to initial shift measures
• Excretion o Diuretic: lasix (ie 40 mg IV Lasix, repeat as necessary) o Resins (6-12h): resonium, lactulose (always give resin with lactulose), kayexelate
▪ Kayexelate: Highly selective cation exchange that entraps potassium in the intestine tract in exchange for sodium and hydrogen
▪ Resonium - in exchange for calcium ▪ Heart Failure - do not use kayexelate; use resonium instead to minimize
sodium load o Dialysis (see above)
Ensure to excrete as well, because shift is a temporizing measure
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ENDOCRINE:
Inpatient Diabetes Management:
Stepwise approach to Inpatient Diabetes:
• Order HbA1C, urine ACR, serum creatinine • If on diet/oral agents on admission and eating
o Diabetic diet, POCT ac meals, hs and prn ▪ If HbA1C <8% and CBG <10 - continue pre-admission treatment if no
contraindication ▪ If HbA1C >8% or CBG > 10 – Maximize dose of oral agents and/or add
(another) oral agent and/or start insulin To start insulin:
• Discontinue oral agents except metformin if starting basal and mealtime insulin • Continue oral agents if starting only basal insulin • Total daily insulin: 0.3-0.5 units/kg/day for Type I and 0.5 - 1 units/kg/day for Type II DM
o 50% long acting o 50% short acting (divide by 3: AC with meals tid) o Sliding scale insulin based on TDD and insulin sensitivity factor
• Basal insulin: (If only starting basal) o 0.2-0.3 units/kg NPH split ac breakfast and qhs OR o 0.2-0.3 units/kg Glargine (Lantus) or Levemir qhs
• Meal time insulin: o 0.1-0.2 units/kg rapid insulin split with breakfast and supper if patient receiving
NPH as basal or 0.1-0.2 units/kg rapid insulin split between breakfast, lunch and supper if patient receiving glargine or detemir as basal insulin.
o Can use corrective insulin sliding scale in addition to above o Adjust based on glucose pattern - change insulin by 10-20% for increases
• There is an order set on SCM on basal bolus insulin (BBIT) – this is a great template and will help you work through the above. Just type “Basal Bolus Insulin” or “BBIT” into the Order Tab of SCM.
If patient not eating/NPO:
• Hold oral agents
• POCT Glucose q6h
• If previously on oral agents or diet controlled (and DM2): o BG <10: may not need basal insulin
▪ Can use insulin R or rapid acting sliding scale q6h if available o If BG >10, start basal insulin: If previously on insulin:, basal 1/2 - 2/3 usual basal
insulin dose, no mealtime insulin, use corrective scale. Consider IV protocol if perioperative or expect NPO >48h
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Continuous feeds/TPN:
• POCT Glucose q6h
• basal 0.3-0.4 units/kg Management of Hyperglycemia Overnight: General principles:
• Avoid lows o Err on the side of avoiding too tight control while in hospital o When giving insulin, consider half-life of insulin to ensure that you are not going
to accumulate insulin o If you give any extra insulin at bedtime ->check a 3am sugar to prevent lows
• If persistently high, consider DKA/HHS: o Do they have ketones in urine? o What is their anion gap? o Consider ordering ABG to determine whether they have metabolic acidosis
• What is their general trend? When do they get high/low? • Remember that T1DM need some basal insulin as they are not producing any – can half
their long-acting dose if NPO, but do not hold insulin entirely. If needed, give them D5W IV maintenance to prevent them from getting hypoglycaemic.
Clinical Pearl for management of hyperglycemia on insulin: • Calculate insulin correction dose
o 100 divided by the Total Daily Dose (TDD) = correction dose For example: If the TDD = 25u then100/ 25 = 4. Therefore, the blood sugar should drop by 4 with each unit of NovoRapid or Humalog.(Correction Dose). Keep in mind that this is not always perfect, and best to check the glucose 1h and 2h after administration if concerned for a low sugar.
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Hypoglycemia:
Symptoms: • Sweating, palpitations, tachycardia, dizziness, blurred vision +/- mental deficits, altered
LOC • Whipple's triad:
o Hypoglycemia, symptoms of hypoglycemia, reversal of symptoms with glucose Management:
• Glucose tabs: 15 g carbohydrates is 4 glucose tabs o Need to also give snack to sustain long term otherwise will return to low blood
glucose
• If ineffective: 25-50 mL D50W IV push
• POCT BG q15 minutes until improved • Is there a clear cause?
o Consider decrease previous meal insulin, or basal if AM glucose low
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Miscellaneous Inpatient Pain Management:
Important: ensure that you have a reason for the etiology of the pain and are not just offering a “blanket solution” for something more sinister
• What are the patient’s vitals?
• Is this pain new? • Is this pain increased from baseline? • Are there any associated features?
Regimen:
• Acetaminophen 1g PO Q6H PRN (max 4 g/day or 2g/day in cirrhosis) • NSAID such as Ibuprofen 200-400mg PO Q6H PRN if patient is young and there are no
contraindications • Opioid: Hydromorphone (Dilaudid) starting dose if opioid naive: 0.5-1mg po/IV Q4H prn.
Remember that this is ~5 times stronger than morphine so a much smaller dose must be given. Safer than morphine in renal failure
o Ensure bowel routine ordered o Avoid morphine in renal failure o If hypotension, consider fentanyl 0.5mcg/kg IV Q30-60 minutes instead of
Hydromorphone or Morphine, because Fentanyl has least effect on blood pressure
o Start with immediate release (not long acting) formulations for opioid naïve patients
o Regularly reassess: taper if harms exceed benefits • If inadequate pain control, consider etiology of their pain (would they benefit from a
neuropathic agent?) • More advanced acute pain – call Acute Pain Service
Two components of dosing regimen for opioid:
• Start regular dosing (fixed number of times a day) for sustained pain control • Add breakthrough dose (dose taken as needed PRN) for acute episode of pain
superimposed on constant pain o Breakthrough opioid dose should be 10% of the total daily straight regular dosing o Sometimes 10% is impractical, so breakthrough dose can be 5- 20% of total daily
opioid dose o Breakthrough opioid dose is Q2H PO PRN or Q1H SC/ IV PRN o Patient should only be allowed no more than 5 breakthrough doses in a day,
where need for >3 breakthrough doses should prompt reassessment and readjustment of treatment
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Conversion of Opioids (general principles):
• Hydromorphone is 4-5 times more potent than Morphine. o To calculate from Hydromorphone to Morphine multiply by 5.
• IV/SC is ~2x as potent as PO • Cross Tolerance: Decrease dose of rotated opioid by 25%. • When you are completing opioid calculations, you must first calculate the morphine
equivalent and then calculate based on what the dose is in morphine. Everything is calculated through PO morphine.
o For example, when rotating from Oxycodone to Hydromorphone you must first calculate the equivalency of Oxycodone to Morphine then to Hydromorphone.
If respiratory depression:
• Narcan 0.4 – 2 mg initial dose IV/IM/subQ
o May need to repeat doses every 2-3 minutes
o Lower initial dose (0.1-0.2 mg) should be considered in patients with opioid dependence to avoid acute withdrawal or precipitant of pain crisis
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Fall from Bed: Questions to ask RN on the phone:
• Witnessed? • Vital signs?
• Obvious injury? Did they hit their head? Change in vital signs? • On anticoagulant? • Reason for admission
Why did the patient fall?
• Cardiac o Postural hypotension
▪ Dehydration, drug effects, autonomic o Arrythmia o MI o Vasovagal
• Neurologic o Confusion/cognitive impairment o TIA/Stroke o Seizure o Dementia o Gait/balance disorder o Visual impairment
• Drugs o Narcotics, sedatives, o Anti-depressants o Anti-hypertensives, anti-arrhythmic o Antiseizure medications o Diuretics – volume depletion o Insulin/oral hypoglycemic hypoglycemia
• Metabolic – electrolyte abnormalities, renal failure, hepatic failure • Environmental/accidental
o Disorientation at night o Couldn’t access call beds o Restraints o Improper bed height o Wet clothes o Unsafe clothing o Obstacles including clutter, IV poles, oxygen
Major threat to life:
• Epidural/subdural hemorrhage
o Must do neurologic exam – if no deficits, ask for frequent neuro-vitals o Use Canadian CT Head Rules to guide need for CT head
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Assessment:
• Sick or not sick? • HR and rhythm? • Postural changes in BP? • What drugs is the patient on? • What were they doing before the fall?
o (cough, straining, etc) – vasovagal syncope o (sudden change in position) – postural o Warning symptoms pre-fall? o Aura o Palpitations o Chest pain
• History of falls • Diabetic? • Hypo/hyperglycemia –order POCT glucose • Injuries?
Physical Exam:
• Vitals
• Signs of injury o General injury – fractures especially hip fracture in elderly, check passive ROM of
all limbs o Palpate skull and face o Basal skull fracture signs (hemotympanum, CSF fluid leakage from ear/nose,
Battle’s sign or “panda eyes”)
• Volume status
• Neurologic exam
• Cardiovascular exam
• Canadian CT Head Rule: https://www.mdcalc.com/canadian-ct-head-injury-trauma-rule
Investigations/Management:
• Check glucose level, electrolytes, extended electrolytes, urea/creatinine (uremia), anti- seizure drug levels
• CT scan as per Canadian CT Head Rule or if high suspicion for finding on CT that will change management: https://www.mdcalc.com/canadian-ct-head-injury-trauma-rule
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Pronouncing Death:
Before you go in, consider:
• Circumstances of death (expected or not)
• Is the family present? (grieving? angry? ) • Familiarize yourself with the background history and in-hospital events • Note: If you think you need help, ask for it. Calm yourself before you enter the room.
Declaring death:
• Identify the patient by their wrist bracelet
• Demonstrate they are : o Unresponsive to verbal and tactile stimuli o Absent of heart sounds and central pulse
▪ Absent of spontaneous respirations o Absent pupillary responses o No response to noxious stimuli (e.g. bright light for pupils, sternal rub for tactile
stimulus)
If Family is present:
• Identify yourself and your role • Gauge initial reaction (grieving, anxious?) • Proceed with exam as above (can ask them if they would like to stay or leave)
• Clearly state the patient has died, offer condolences • Pause for grief reaction, remain quiet yet available • Console as appropriate • Give permission to pause before addressing autopsy, doing notifications
• Document in the chart and notify senior/attending/family MD
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Interpreting Tests:
ECG ABNORMALITIES: COMMON AND CAN’T MISS
Normal EKG:
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ST Segment Abnormalities:
ST segment depression - always abnormal, although often non specific
ST segment elevation
Normal ST elevation - in leads with large S waves (eg V1-V3) and normal configuration is concave upward
May also be seen in other leads - early repolarization
Convex or straight upward ST segment elevation is abnormal and indicates transmural injury/infarction
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ST elevation in AVR:
• ST elevation in AVR with ST depression in other leads AND concerning symptoms: concerning for ACS: left main coronary artery disease, triple vessel disease, proximal LAD
• Any other causes of global cardiac ischemia o Thoracic aortic dissection, massive PE, severe anemia, early post arrest (with 15
minutes of epi or shocks) • LVH with strain, especially severe HTN • LBBB, pacers, SVT (esp AVRT, rapid atrial fibrillation) • Severe hypokalemia • Sodium channel blockade (TCAs, hyperkalemia, Brugada etc)
Possible ECG findings in PE:
• Sinus tachycardia (note: >50% of non-massive pulmonary embolism will not have sinus tachycardia)
• Atrial/ventricular dysrhythmias
• Right heart strain
o Rightward axis o S1 (ie S as big as R, or bigger) Q3T3 o Incomplete RBBB (rSr' or qR) o New TWI especially anteroseptal +/- inferior leads o ST changes including STE in rightward leads
▪ Can mimic STEMI - if this in conjunction with rightward axis, think PE!
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Wellen’s Sign:
• Pattern of deeply inverted or biphasic T waves in V2-3, which is highly specific for a critical stenosis of the left anterior descending artery (LAD).
• Patients may be pain free by the time the ECG is taken and have normally or minimally elevated cardiac enzymes; however, they are at extremely high risk for extensive anterior wall MI within the next few days to weeks.
• Due to the critical LAD stenosis, these patients usually require invasive therapy, do poorly with medical management and may suffer MI or cardiac arrest if inappropriately stress tested.
Diagnostic Criteria
• Deeply inverted or biphasic T waves in V2-V3 (may extend to V1-V6) • Isoelectric or minimally elevated ST Segment (<1 mm) • No precordial Q waves • Preserved precordial R wave progression • Recent history of angina • ECG pattern in pain-free state • Normal or slightly elevated serum cardiac markers
TWO patterns of T wave abnormality in Wellens' syndrome:
• Type A: biphasic with initial positivity and terminal negativity (25% of cases) • Type B: deeply and symmetrically inverted (75% of cases) • T waves evolve over time from Type A to Type B pattern
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Biphasic T Waves (Type A)
Deeply Inverted T Waves (Type B)
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LBBB:
• Reversal of normal direction of septal depolarization (becomes right --> left)
• QRS duration > 120 ms
• Eliminates normal septal Q waves in lateral leads
• Tall R waves in lateral leads (I, V5, V6) and deep S waves in right precordial leads (V1-V3), usually also left axis deviation
• M shaped notched R wave in lateral leads as ventricles activated sequentially
Diagnostic Criteria: • QRS duration >120 ms
• Dominant S wave in V1
• Broad monophasic R wave in lateral leads (I, AVL, V5-6)
• Absence of Q waves in lateral leads
• Prolonged R wave peak time
Modified Sgarbossa Criteria: diagnosing STEMI in the context of LBBB (images below)
• Infarct diagnosis in patients with LBBB or ventricular paced rhythm can be difficult • Baseline ST segments and T waves tend to be shifted in a discordant direction
("appropriate discordance") which can mask or mimic acute MI
• Serial EKGs can show dynamic ST segment changes during ischemia
Note that NEW LBBB is ALWAYS pathological and can be sign of MI
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≥ 1 lead with ≥1 mm of concordant ST elevation
≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression
≥ 1 lead anywhere with ≥ 1 mm STE and proportionally excessive discordant STE, as defined by ≥ 25% of the depth of the preceding S-wave.
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RBBB:
• Activation of the RV is delayed as depolarization has to spread across the septum from the LV
• LV activated normally - early part of QRS unchanged
• Delayed RV activation produces a second R wave (R') in right precordial leads (V1-V3) and a wide slurred S wave in lateral leads
• Also leads to secondary repolarization abnormalities, with ST depression and T wave inversion in right precordial leads
• In isolated RBBB, axis unchanged as LV activates normally via left branch • Diagnostic Criteria:
o Broad QRS >120 ms o RSR' pattern in V1-3 (M shaped pattern) o Wide slurred S wave in lateral leads (I, aVL, V5-V6)
• Associated features: St depression and TWI in right precordial leads (V1-V3)
• Variations
o Sometimes rather than RSR' in V1, there might be a broad monophasic R wave or a qR complex
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CXR REVIEW:
APPROACH TO CHEST RADIOGRAPHS
• Identification
• View type o PA (posteroanterior) and lateral o Portable AP (anteroposterior) o Lateral decubitus: o Expiratory view: detect pneumothorax & air trapping o Apical lordotic view: visualize lung apex o Oblique views
• Adequate inspiration: 8-10 posterior ribs
• Adequate quality: see intervertebral disc spaces
(1) ABNORMAL LUNG:
• TOO WHITE: o Consolidation:
▪ Air bronchogram, silhouette sign o Atelectasis:
▪ NO air bronchograms ▪ Silhouette sign ▪ Signs of volume loss:
• Tracheal/mediastinal shift TOWARD too white area • Less space between ribs on affected side • Higher hemidiaphragm (note: diaphragm still same shape but just
higher vs. emphysema loose curvature) o Pleural Fluid:
▪ Too white with shift of mediastinal structures AWAY from effusion ▪ Meniscus Sign (upright view)
o Masses/Nodules: ▪ Focal opacity < 3 cm (nodule) or > 3 cm (mass)
• TOO BLACK: (increased air: hyperlucent) o Pneumothorax:
▪ Increased air (hyperlucent) OUTSIDE the lung ▪ Lung is sharply demarkated from the homogeneous hyperlucency of
extra-pulmonary air o Emphysema
▪ Increased air (hyperlucent) INSIDE the lung = emphysema or bullae
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• TOO MANY LINES – reticulonodular = interstitial
o Pulmonary Edema
▪ Kerley B lines (septal lines)
▪ Peribronchial wall thickening (bronchial cuffing) leakage of fluid in interstitum surrounding bronchus - appears as cuffing
▪ Vascular indistinctness (haziness) of the hila leakage of fluid around vessels = loose sharp border = vessels hazy
▪ Vascular redistribution Early sign of pulmonary edema. Lower lobes normally have more blood supply so normally diameter of vessels in lower lobes is larger. If diameter of upper lobes is greater, this is caused vascular distribution because trying to conserve oxygen. Get constriction of lower vessels.
▪ Ancillary findings of edema secondary to CHF: Cardiomegaly, Pleural effusions (bilateral or right sided)
o Interstitial Diseases Eg. Pulmonary fibrosis
▪ Loss of volume and reticulation
▪ No Kerley B
▪ On CT may see dilated spaces = honeycombing Key Point: Interstitial Diseases = INTERSTITIUM filled with cells, fluid, blood reticular/reticulonodular pattern Airspace Diseases = AIRSPACES filled with cells, fluid, blood
(2) ABNORMAL MEDIASTINUM
• Wide mediastinum - Acute aortic dissection (with dissection, don’t get the normal concave shape of hila toward outside)
• Mediastinal mass - Eg. Lymphoma • Hilar enlargement (Normally the hila should have a concave outer margin when the hila are
enlarged by lymphadenopathy the margin is convex) o Adenopathy in lymphoma, metastasis o Adenopathy in sarcoidosis (Bilateral symmetrical loss of concavity = Sarcoid) o Lung cancer o Enlargement pulmonary arteries (pulmonary hypertension)
• Enlargement cardiopericardium silhouette o Cardiomegaly (cardiac disease) - Diameter of heart should be <50% of diameter of
thorax o Pericardial effusion
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(3) ABNORMAL SURROUNDING SOFT TISSUES AND BONES
• Fractures / dislocations, Bony destruction (metastasis), Foreign bodies (metallic), Soft tissue mass, Missing parts (mastectomy etc), Air in the wrong place (eg. Subcutaneous emphysema; eg. Pneumoperitoneum = air below diaphragm - may be normal is have hx of surgery but if not, can be from perforation)
• Don’t forget the subdiaphragmatic region! • Check type of line/tube and correct/incorrect position - ie. NG in esophagus or stomach
APPROACH TO BLOOD GASES:
1. VENOUS BLOOD GAS: - Usually used to get a quick check on:
pH: In cases of acidosis to monitor treatment response Electrolytes/Bicarb: for management of DKA (calculating gap), hyperkalemia Lactate: in cases of sepsis where you are worried about ischemia/hypoperfusion Hemoglobin: Helpful in GI bleeds for a quick check when a CBC may take time
2. ARTERIAL BLOOD GAS: More painful for the patient! - More helpful in cases of hypoxia, to get the PaO2 - Helpful to look for hypercapnic respiratory failure - Also helpful in looking for pH, electrolytes, lactate, Hemoglobin as VBGs above.
Approach to ABGs:
• Step 1: Identify primary acid/base disturbance: • pH < 7.35: Acidosis • pH > 7.45: Alkalosis
• Step 2: Metabolic vs. Respiratory • Metabolic: initiated by change in HCO3- • Respiratory: initiated by change in pCO2
• Step 3: Check for compensation:
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• Step 4: Calculate anion gap: Na – (Cl + HCO3): Normal is 8-12
• Step 5: IF high anion gap metabolic acidosis, calculate osmolar gap: Osmolar gap: measured osmolality – calculated osmolality *Calculated osmolality: Remember: 2 salts and a sticky BUN: 2x Na + glucose + BUN (all the units here are in mmol/L, if you change the units the formula will not apply - Normal osmolar gap: -2 to +6, if elevated, think of toxic alcohols (eg: polyethylene glycol, methanol), alcohol ketoacidosis, DKA, and severe lactic acidosis. Can correct for ethanol if there is a high ethanol level.
• Step 6: Check for delta ratio for superimposed metabolic disorders: • Delta ratio: Change in anion gap (AG- 10)/(24- HCO3), interpret the results as
follows:
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DDx for HAGMA: remember your * MUD PILE CATS* (Methanol, uremia, DKA/Starvation ketosis, Paraldehyde, INH/Iron, Lactic acidosis, Ethylene glycol, Cyanide, Arsenic, Toluene, Salicylates) Other Important things to look for on ABGs: - If you have a patient with respiratory failure with increasing O2 requirements, an ABG will be helpful to see their PaO2 to assess how hypoxic they are and if you need more invasive methods of ventilation. - If you have a patient with known COPD/Opioid toxicity/respiratory depression and a change in mental status, delirium, asterixis: a PaCO2 will be helpful to know if hypercapnia is the cause! - If you need a Hgb level quickly (eg: brisk UGIB), then a gas is the fastest way to get it - Lastly, on the Wards, you should request for a room air ABG on day of discharge if you would like to arrange for home O2 to see if they qualify.
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The “How To’s” of Internal Medicine MTU
HOW TO THRIVE ON MTU:
Typical Day:
• 8:00 – Start Time
• 8:00-handover from the overnight staff (ward issues and new patients)
• 8:20 to 10:00 – review of new patients, write notes, check orders
• 10:00 onward – See patients
• ~11:00-12:00 – allied health care rounds (confirm timing with charge nurse on Unit 36)
• lunch
• post lunch-5 pm see patients, update handovers and discharge summaries
• 5:00 – Finish outstanding tasks and handover to covering team member with paper handover update
Morning:
• Show up early (at least 10 min before 8) and print your lists
Rounding: • See sick patients followed by patients being discharged first • Always consult services early in AM if possible. This is particularly true for hospitalists. • For outline on proper IM rounding note see below • Try not to be late for 8 am patient review.
Daily checklist:
• Each medication ordered on SCM should have a good reason to be there. If you notice any medications ordered that you are unsure about, talk to your Seniors and/or buddy Staff
• PRN Meds: Many times, bowel routines or analgesias are ordered as PRN medications. That doesn’t mean that each patient needs it. Critically appraise your PRN list and decide if the patient really needs it. If they don’t, then scrap it!
• Investigations – Ensure labwork is ordered for your patient for the next day: only labwork that is needed!
• Allied Health – Don’t forget to check SCM for documents relating to PT/OT/TS, dietitian and other services. These are often missed but can include pertinent data (e.g. patient can’t go home because PT is concerned about mobility)
• Disposition - What needs to be done before your patient can go home? Most issues occur with PT/OT/TS therefore always consult them in advance if needed
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Discharge Summaries:
• Think of these as ongoing summaries. Please try to update all your patients’ discharge summaries by the end of the day
• If any of your patients are going home on the weekend, ensure the discharges are done (or up to date) prior to leaving that Friday.
• See below for discharge summary outline
On call/handing over:
• Patients on ward take priority as patients in ER are closely watched and can be managed by ER physicians for anything acute. On the ward you are the main doctor overnight
EXPECTATIONS ON MTU
a) Examine your patients daily. Basic exam includes review:
1. Vitals (including overnight) – all vitals are recorded in SCM 2. Physical exam: CV/Resp/Abdo and any additional pertinent exams 3. Drains, foley, lines, chest tubes etc.
b) Communicate with bedside nurse daily
c) Review lab work – address critical values immediately. Order tomorrow’s labs rationally. Note: patients with
central lines or PICC lines are ordered as “unit to collect”.
d) Review medications 1. Know what is ordered and why. 2. Cancel old PRNs that aren’t needed. 3. Ensure medications such as antibiotics have appropriate stop dates. 4. Mark medications as “reviewed” and renew appropriately. 5. Consider DVT and constipation Prophylaxis when appropriate.
e) Discharge Planning 1. Preventative Health - vaccinations: Influenza, pneumococcal 2. Patient Education 3. Follow-up Appointments - whenever possible, ask the Unit Clerk to book
BEFORE the patient is discharged. Record appointment dates, locations, and contact numbers in the chart AND in the written discharge summary provided to the patient.
f) Write a note – date and time always! Every patient gets a daily note. Use SOAP format. g) Handover
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1. Each day, update the “Health Issues” section of SCM so that they may be integrated into the Handover Document. This will also automatically populate the discharge summary at the FMC.
2. Take ownership of your patients at 1700h Handover. Present your patients succinctly, giving an Identification, relevant Past Medical Issues, Present Active Issues, and Anticipated Overnight Problems.
Patient safety while rounding:
Major causes of patient harm in hospitals:
• Falls • Medications • Nosocomial infections - lines, foley, aspiration • VTE
• Delirium • Procedural Harm • Ulcers
Daily Problem List should include consideration of the following safety issues:
• Stopping drugs that are unnecessary or where potential harm outweighs potential benefit
o Discontinue unnecessary sedatives (especially in the elderly) o Discontinue IV Fluids if unnecessary – can develop pulmonary edema, volume
overload – reassess daily
• DVT prophylaxis o If contraindication to anticoagulation, ensure patient is on SCD’s or ambulating
• Rollover – ulcers
• Encourage ambulation if possible (ie meals in chair, etc)
• Discontinue attachments that increase risk for falling o Oxygen if unnecessary o Foley catheters (also increase risk of infection)
• Head of bed up to prevent aspiration especially when eating
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Allied healthcare roles on MTU:
MTU Care Coordinator RN: (only at FMC and PLC) Acts as an advocate for patients, families,
and care providers on MTU. Supports learning needs of trainees and acts as a resource for
facilitating appropriate patient care in hospital and in the community. Helps coordinate with
allied health care providers and identify resources available for outpatient follow up.
Charge Nurse and Unit Clinicians: They will help facilitate bullet rounds and coordinate care for
patients, establish patient flow and direction of care needs. Touch base throughout the day to
provide updates and info re: patient discharges. If you would like a patient on your team to be
transferred to U36 from a more remote location (ie: U62), discuss this with the Charge RN.
Pharmacy: Drug monitoring, dose adjustment, patient and trainee teaching. It is not a part of
their job description to complete discharge medication prescriptions although if they have time
available they may offer to help with this. Please notify the pharmacist well in advance if you
think your patient will require medication scheduling, blister packing, outpatient pharmacy
arrangements.
Transition Services: Co-coordinator between hospital and community health care initiatives
including Home Care, Supportive Living and Long-Term Care. Should automatically be involved
for patients who have these services as an outpatient. Initiate the process 48 hours in advance
to have home care (re)initiated. Remember that certain dressing, drains, indwelling catheters,
etc. require home care services and outpatient physician contact. (GP needs to be aware)
Social Work: Assists patients and their families with navigating systems that provide community
resources and services specific to housing resources (homeless patient, shelters), finances, out-
of-province/country coverage, medication coverage etc.
Physiotherapy: Provides treatment and teaching to help increase strength and flexibility,
decrease pain and manage daily activities. Able to assess candidacy for Community
Rehabilitation Program (CRP) and other long-term PT options. Always perform an initial mobility
assessment prior to consulting physiotherapy to avoid unnecessary consultations.
Occupational Therapy: Provides assessment of current skills, physical and emotional abilities
and safety of patient environment. Able to teach patients how to
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use adaptive equipment to overcome barriers to everyday activities (e.g. power wheelchair,
specialized utensils, etc.). Also able to assess cognition and decision- making and incorporate
this into patient safety assessments.
Registered Dietitian: Able to address concerns regarding current or anticipated inadequate
nutrition. Should be involved for patients requiring tube feeding or parenteral nutrition. Also
consult for re-feeding syndrome, metabolic disorders, and patients new to dialysis.
Spiritual Services: Spiritual and emotional support for patients, family and staff. Able to
collaborate with religious leaders at patient and families request. Able to facilitate certain rituals
and sacraments.
Aboriginal Hospital Liaison: Provides service to Aboriginal clients and their families to help
make them feel comfortable within the culture of the hospital. Able to identify spiritual, cultural
and social issues and ensure these issues are addressed.
Addiction & Substance Abuse: Provides assessment, treatment and referral for clients with
alcohol, other drug or gambling concerns.
Heart Failure Liaison Nurse: For patients with a new diagnosis of CHF requiring outpatient
follow at the Heart Failure Clinic.
Diabetic Nurse Educator: For patients with diabetes mellitus who present with DKA, require new insulin start, or have a new diagnosis of diabetes and require teaching. Provides excellent education, resources, and tips for patients. Advanced Venous Access Services (PICC): Do not work on weekends. Try to arrange placement
early in the week if possible because by Friday they have usually filled all appointments for that
week. Remember that patients need to have negative blood cultures prior to having a PICC line
placed.
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HOW TO DO AN INTERNAL MEDICINE WORTHY CONSULT NOTE:
Impression/Plan:
• Most important part of note • Need to integrate all the information from the history, physical and investigations
o Show medical reasoning • Suggest making diagnosis list/problem list and discussing plan for each
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• Start with most important diagnosis/problem first • Some problems may need a differential diagnosis • Some will already have a diagnosis and will just need a plan
Example: IDENTIFICATION 77-year-old male with 5-day history progressive orthopnea, PND, and SOBOE
REASON FOR CONSULT Write ED diagnosis (heart failure). For admission
MEDICAL PROFILE
1. Atrial fibrillation (CHADS2 = 4; on warfarin)
• New diagnosis (approx 2 months ago)
• INR therapeutic/undertherapeutic/supratherapeutic (INR 2.4)
• Rate controlled on metoprolol
• Managed by (usually GP but sometimes a cardiologist)
2. HFrEF
• Secondary to ischemia (etiology)
• Followed by Dr. Smith (Cardiology); last saw 6 months ago. No concerns.
• Multiple admissions for same, last 1 year ago
• June 2015 echo: EF 30%. RVSP ____. LV size ____. RV size and function ____. Left atrial enlargement. No valvular disease. No WMAs.
3. CAD with MI in 2005
• DES to LAD in 2005. Last angiogram 2014 shows 40% RCA, 50% LCx, DES in LAD patent
• Last MPI 2 months ago: normal
• Followed by Dr. Smith
4. Type 2 diabetes poorly controlled on metformin monotherapy (A1c 11.4 in June 2019)
• Diagnosed in 1999
• Neuropathy and Nephropathy; no retinopathy. Sees Optometrist regularly.
• Followed by Dr. Doe (GP)
5. CKD – baseline Cr 230, GFR 20
• Secondary to #4 – biopsy proven
• Followed by Dr. Jones; last seen 3 months ago and concerned that patient may need dialysis in next 5 years
6. Dyslipidemia – on atorvastatin. Last LDL 2.67 in September 2018
7. HTN – well controlled x10 years. On Ramipril monotherapy. Followed by Dr. Doe (GP)
8. GERD – on pantoprazole
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HOME MEDS
Feel free to just write these on the med req and write “refer to med req”, writing any majorly important ones on consult sheet. Make sure the meds correspond to the patients comorbidities. You will find that there are a lot of meds that suggest other medical conditions not already listed by emerg, NetCare, and the patient All PO meds:
1. Warfarin 5mg OD 2. ASA 81mg OD 3. Metoprolol 25mg BID 4. Ramipril 5mg OD 5. Spironolactone 25mg OD 6. Lasix 20mg OD 7. Atorvastatin 40mg OD 8. Pantoprazole 40mg OD 9. Metformin 1000mg BID
ALLERGIES What are they allergic to and what happens if they are exposed to that allergen - Drugs first then environmental factors - Put intolerances at the end
FAMILY HISTORY People in the family with similar conditions is the most important thing
SOCIAL HISTORY Do they smoke/drink/use cannabis/illicit drugs? If so, how much for each? Where do they live? Who do they live with? Social Supports? Coping at home? Where do they work? Where did they used to work? Environmental exposures as relevant for the history.
HISTORY PRESENTING ILLNESS This section does not have to be long. I try to keep mine to no more than three sentences of "story" then no more than three sentences or points where I review and screen for other symptoms. 5 days ago, reports progressive orthopnea, PND and SOBOE. One week ago could walk 5 blocks without SOBOE but now can’t even go to bathroom without SOB. Previously slept with one pillow but now has to sleep in chair secondary to SOB when lying flat. Denies chest pain, URTI or flu like symptoms. No sick contacts. No cough. Reports taking medications appropriately. Does report + palpitations and a “racing heart beat” that he has had for over 1 week. Did not measure HR at time but said it was “going fast.”
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REVIEW OF SYSTEMS No weight loss, no night sweats. Bowel movements normal, no melena or BRBPR. No dysuria, no abdominal pain. No fevers/chills. COURSE IN ER --> Major interventions and improvements/deteriorations Ex: Given lasix 40mg IV and metoprolol 5mg IV at 1730 - Less Short of breath PHYSICAL EXAM --> Break things down by system Vitals at triage (or EMS): T 36.4, P 140, BP 100/60, RR 30, O2 80% RA Vitals now: Tmax 36.6, P 120, BP 120/50, RR 16, O2 90% on 3L O2 H&N: No pharyngeal erythema. No cervical lymphadenopathy. CVS: JVP 7cm. +2 pitting edema to knees. S1/S2 normal. +S3. No murmur. RESP: Diffuse crackles, worse at bases. No evidence effusion. No wheeze GI: +BS. Soft abdomen, non-tender. No organomegaly. GU: No CVA tenderness. Skin: No rash. No ulcers. MSK: ROM full in all joints. No evidence of joint inflammation or tenderness on exam. Neuro: Grossly intact.
PERTINENT LABS + IMAGING
Labs + EKG + CXR, etc
Also include previous pertinent labs/imaging IMPRESSION – Major issue and cause 77-year-old male with multiple comorbidities including left-sided HFrEF and Afib presenting with a 5-day history of progressive orthopnea, PND and SOBOE in background of symptomatically worsening Afib over last 7 days. Physical exam and CXR/EKG confirms heart failure and poorly controlled A. fib. The cause of his worsening A. fib causing heart failure exacerbation is likely due to inadequate rate control as his A fib is a recent diagnosis.
PLAN
1. Left-sided, HFrEF exacerbation secondary to poorly controlled A. fib - Currently stable but requires further diuresis - Lasix 40mg IV BID with daily weights, ins/outs, salt restriction - Should resolve with better A. fib control (see #2)
2. Poorly controlled A. fib - Increase home dose metoprolol to 50mg PO BID and titrate as needed to achieve HR <
110 - If tachycardia persists consider other causes such as PE
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- Request Dr. Smith’s clinic notes for further information re: A. fib - Continue warfarin at home dose
3. Chronic kidney disease - Stable at present. Avoid nephrotoxic agents and adjust medications based on GFR.
Monitor renal function, volume status, ins/outs 4. DM2, poorly controlled on metformin
- Start insulin (patient agreeable) to achieve better control - Insulin glargine 10 units QHS, insulin lispro 3 units TID with meals, BBIT to adjust as
needed - Consult diabetic educator
5. Miscellaneous - Admit to PLC gold under Dr. Scott. Diagnosis = Heart failure - AAT, vitals q4hr, R1 GoC - No DVT prophylaxis necessary (pt therapeutic on warfarin) - PT/OT/TS consults in for disposition planning
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HOW TO WRITE AN INTERNAL MEDICINE WORTHY DISCHARGE SUMMARY:
* When you write this, think of that person you saw unconscious at FMC that was hospitalized at the PLC 2 weeks prior and you had no idea what in the world was going on with them. * Think of what the family physician who takes care of them may want to know! -------------------------------------------------
IDENTIFICATION 77-year-old male with 5 day history progressive orthopnea, PND and SOBOE
MOST RESPONSIBLE DIAGNOSIS Congestive heart failure exacerbation SECONDARY DIAGNO(SIS/SES): Other medical issues diagnosed in hospital, for example: c.diff diarrhea
MEDICAL PROFILE
1. Atrial fibrillation (CHADS2 = 4; on warfarin)
• New diagnosis (approx 2 months ago)
• INR therapeutic/undertherapeutic/supratherapeutic (INR 2.4)
• Rate controlled on metoprolol
• Managed by (usually GP but sometimes a cardiologist)
2. HFrEF
• Secondary to ischemia (etiology)
• Followed by Dr. Smith (Cardiology); last saw 6 months ago. No concerns.
• Multiple admissions for same, last 1 year ago
• June 2015 echo: EF 30%. RVSP ____. LV size ____. RV size and function ____. Left atrial enlargement. No valvular disease. No WMAs.
3. CAD with MI in 2005
• DES to LAD in 2005. Last angiogram 2014 shows 40% RCA, 50% LCx, DES in LAD patent
• Last MPI 2 months ago: normal
• Followed by Dr. Smith
4. Type 2 diabetes poorly controlled on metformin monotherapy (A1c 11.4 in June 2019)
• Diagnosed in 1999
• Neuropathy and Nephropathy; no retinopathy. Sees Optometerist regularly.
• Followed by Dr. Doe (GP)
5. CKD – baseline Cr 230, GFR 20
• Secondary to #4 – biopsy proven
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• Followed by Dr. Jones; last seen 3 months ago and concerned that patient may need dialysis in next 5 years
6. Dyslipidemia – on atorvastatin. Last LDL 2.67 in September 2018
7. HTN – well controlled x10 years. On Ramipril monotherapy. Followed by Dr. Doe (GP)
8. GERD – on pantoprazole
HOME MEDS PRIOR TO ADMISSION: All PO meds:
1. Warfarin 5mg OD 2. ASA 81mg OD 3. Metoprolol 25mg BID 4. Ramipril 5mg OD 5. Spironolactone 25mg OD 6. Lasix 20mg OD 7. Atorvastatin 40mg OD 8. Pantoprazole 40mg OD 9. Metformin 1000mg BID
ALLERGIES – NKDA. No environmental or food allergies.
FAMILY HISTORY – Nil contributory – Becomes less relevant for elderly patients, can omit in discharge summary if not contributory
SOCIAL HISTORY: Do they smoke/drink/use cannabis/illicit drugs? If so, how much for each? Where do they live? Who do they live with? Social Supports? Coping at home? Where do they work? Where did they used to work? Environmental exposures as relevant for the history.
HISTORY PRESENTING ILLNESS Brief. Write as a small paragraph and include admission physical exam, pertinent labs and imaging, as below: Mr. X presented with a 5-day history of dyspnea on minimal exertion, worsening orthopnea, and PND in the context of >1 week history of rapid heart rate and palpitations. His exam was significant for volume overload and irregularly irregular pulse with high heart rate. His CXR was consistent with CHF, ECG consistent with atrial fibrillation with rapid ventricular response, and his BNP was elevated at 20,000. Troponin was minimally elevated at 22 (close to his baseline).
COURSE IN HOSPITAL
1. Left sided HFrEF exacerbation
• Exacerbated by poorly controlled, recently diagnosed A. fib (HR 130s)
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• Resolved with diuresis and better rate control of A. fib
• Repeat ECHO demonstrated no change from previous ECHO in June 2015
• Patient’s dry weight determined to be roughly 83Kg
• No changes were made to his home medications for CHF; he received education about daily weights, salt/water restriction, and when to seek medical attention
• He will follow-up with his GP and Dr. Smith (Cardiologist) for his heart failure.
2. Atrial fibrillation
• Increased metoprolol dose to 50 mg PO BID (compared to 25 mg PO BID at home). Achieved good rate control.
• Mr. X continues to be on warfarin with a therapeutic INR of 2.6 at the time of discharge. He will follow-up with his GP and Dr. Smith (Cardiologist) for his atrial fibrillation.
3. T2DM
• Due to poorly controlled DM2 we started the patient on insulin
• The diabetic educator was involved who taught Mr. X self-injections. His sugars were well controlled (7-10) at the time of discharge
• He will follow-up with Dr. Doe (GP) for his diabetes
4. Chronic conditions – hypertension and CKD remained stable. We did not make changes to his medications.
5. Miscellaneous – PT, OT and transition services were involved with his care. They recommended that the patient would benefit from increased home supports and home care equipment to help with mobility. These items were arranged prior to hospital discharge. At time of discharge, PT/OT had no further concerns.
DISCHARGE PLAN: This is a plain language summary for the patient. Minimize medical jargon and advise them of the plan in concise sentences. Inform them of when to seek medical attention / ER.
DISCHARGE MEDS:
• Ensure you have clicked all medications you need the patient to continue on discharge summary, and
• You must complete the discharge medication reconciliation – with mention to new medications and why, medications stopped and why, medication dose/schedule change and why.
COPIES TO RELEVANT SUB SPECIALIST:
• Ensure a copy of your discharge summary has been copied to all the relevant subspecialists. You can look for details of subspecialists on CPSA website.
• If including a new specialist, ensure to fax a referral as well and to leave the phone number of the specialist’s office in the discharge summary so that the patient can call if they do not hear anything
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ADMISSION ORDERS:
Mnemonic: ADD DAVID A = Admit to (service, attending physician); Eg: “Admit to MTU Gold, Staff: Dr Wilson D= Diagnosis; Eg: “Diagnosis: COPD exacerbation ” D=“DNR status”; (Goals of care) D = Diet (regular, diabetic, low Na, NPO, etc) A = Activity (AAT, bedrest, fall risk, etc) V = vitals (q4h while awake, TID, etc) I = Instructions to nurse, Investigations, IV fluids, ? Isolation Eg: POCT glucose QID, IV RL at 125 mL/h until drinking well, CBC/lytes/Cr, etc D = Drugs
• Pain, “poop” (PRN constipation), PRN nausea, Prophylaxis (DVT), Previous (home meds); place the held drugs on SCM too so others know they were held
• Any new medications you want to prescribe
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PROGRESS NOTES:
• Clear progress notes improve communication and reduce error
• Standardized format helps! • Always start note with ID (who is patient, pertinent medical profile, and reason for
admission)
Assessment/Plan:
• Can combine into one heading
• Problem-based list (Modify daily, based on most important to least important issue): EXAMPLE: #1 Hypoxia: Secondary to Pneumonia.
• Improving- Afebrile, 1LO2, WBC trending down. • Continue Levofloxacin (Day 2/5)
#2 Diabetes/ Hypertension is always on the issues list if they have these conditions #3 Do not forget housekeeping: Goals of Care, DVT prophylaxis, Foley, IV fluids, diet orders, antibiotic stop dates #4 Last issue in note should always be discharge plan/disposition HANDY APPS AND IM RESOURCES:
Apps:
• UptoDate o Pricey but worth it! Order through the CMA website for member discount o Other choices: DynaMed – Free through U of C
• Medscape o Free!
• Antibiotics
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o Spectrum – made by AHS o Other choices but more $$: Bugs and Drugs, Sanford Guide to antibiotics
• MedCalc/ Qx calculate • MD on Call • Journal Club – Paid app, but well worth it! • Thrombosis Canada • iCCS • DC CPG (Diabetes Canada guidelines)
IM resources:
• Approach to Internal Medicine by David Hui • Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine
• MKSAP Series by American College of Physicians (one textbook per specialty)- copies available through the IMRP office- contac Marcy Mintz if interested in borring these [email protected]
• JAMA Physical Exam • Calgary Black Book
Standard approaches/flow charts (available free on line https://blackbook.ucalgary.ca/)
• ECGs: lifeinthefastlane.com
• ICU: Marino’s the ICU Book
6. General Skills
HOW TO DO AN EFFECTIVE GOALS OF CARE DISCUSSION:
Pre-conversation considerations:
• Before you begin this conversation with the patient, you may want to check with them to see if
they want family or other people to be a part of these discussions.
• If applicable, consult with other members of the health care team involved in the patient’s care, to get a consensus of capacity of the patient to provide informed consent; the patient’s prognosis, planned treatments, and other related issues
• Clarify if the patient has appointed a substitute decision maker and encourage that person/those persons to attend especially if there are concerns about capacity.
• Review the hospital chart and talk to staff to see if there is an advance care plan or if wishes are previously documented or verbalized. Triaging the conversation (see next page):
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#1: Low Risk of Death
Conduct a check in: Proposed language: “There is no medical reason why we would not offer you the full extent and types of treatment at our disposal. However, given your own values, should we be aware of limits that you would provide on the types or extent of care that you would like to receive?” #2: Intermediate Risk of Death
I. Broaching/introduction : Explanation, permission and exploration of prior conversations
"When people with serious illnesses get worse, they face decisions about their care. It is a lot less
stressful on the patient and their family if conversations about their wishes happen before they
get really sick. Is it OK if we talk now about what we might do if you were to get worse?”
II. Knowledge of illness exploration: Diagnosis, natural hx/prognosis and current functional state.
Example: “Some people like to know a lot of information about their illness, what their quality of life will be like in the future, and how long they have to live. Other people prefer not to be told a lot of information, and ask us to speak to their family members about these things. I’m OK with either approach, but I would like to know which one you prefer.”
III. Assessment of values: conditional quality of life factors (ie: I wouldn’t want to lose my
cognition), medical care & dying values
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Example: “We want to make treatment decisions that honor what’s important to you. What sort of quality of life would you find acceptable, and what would you find unacceptable?” Offer graphic values tool to further conversation as an inpatient if values not clear. (This tool will become available shortly)
IV. GOC guidance/confirmation: based on II &III determine appropriate GOC for patient and
confirm with patient if this is right
Example: “Given what you have told me about your values and what I know of your medical condition, I do not think that resuscitative measures would fit with your goals of care.”
V. Documentation: SDM, GOC and who was there, follow up plan if incomplete (Note: There is
now a ACP/GCD tracking document in SCM- Please fill this out!)
#3: High risk of imminent death For category #3, the focus is on assessing illness understanding, communicating prognosis, and assessing patient/family supportive needs.
I. Broaching/introduction : Explanation, permission (determine SDM if necessary)
II. Knowledge of illness exploration: Knowledge of prognosis, fill in gaps
“What have the previous doctors told you about what has been going on?” III. Assessment of values: Dying values
IV. GOC guidance/confirmation: based on II &III determine appropriate GOC for patient and
confirm with patient if his is right. Is home or hospice based care appropriate?
V. Documentation: SDM, GOC and who was there, follow up plan if incomplete.
Approach to Disclosing Prognosis Normalize the uncertainty of prognosis*; that we will never know with certainty what will happen to given individuals.
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Example: “I understand that you want more accurate information about the future. The reality is we can never be certain about the future. I wish I could be more certain but I will give you the best information I have.”
Use evidence-based tools/studies to estimate future quality and quantity of life.
For example, if you are being asked to provide statements about ‘how long do I have to live”, consider going to ePrognosis (http://eprognosis.ucsf.edu/ ) or some other evidence-based source to determine best estimates given the patient’s disease or underlying condition. If asked about the chance of different outcomes associated with certain treatments, such as the probability of full recovery for in hospital cardiac arrest with CPR, use robust outcome data or validated clinical prediction rules. If there are no good data to support your prognostic declaration and you are relying on your clinical judgment, say so. In any case, consider providing estimates of outcomes in ways that continue to express ‘uncertainty.’ Some patients may prefer precision that comes from a quantitative representation of data such as: “If there were 100 people with an illness just like yours, 50 of them or half would not be alive in 6 months.”
For illnesses with higher levels of uncertainty, like COPD or CHF, consider something like:
“Some may live for years, some may only live for weeks but half will have died by 6 months. Of those who are alive, many would not as healthy as you are now. It is hard to say for sure what will happen to you. We like to hope for the best and plan for the worst.”
For illness where there is more certainty of prognosis but less time for the patient, like with many advanced Stage IV cancers, consider saying:
“I am sorry. Given your situation, you likely have only {weeks to months} or {months to a year or so} to live OR I expect a {low, moderate, or high} chance of success with the [proposed treatment]
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Serious illness conversation guide
• Advanced Care planning is an exploration of the patient’s values and wishes, in order to define goals and preferences for future medical treatment and care.
• Previous research has shown that earlier conversations about patient values and goals, helps lead to better care including:
o Increased goal concordant care o Improved quality of life/patient well being o Fewer hospitalizations o More and earlier hospice care o Better patient and family coping
• The Serious Illness Conversation Program is a quality improvement project that started on unit 36 at FMC in March 2018. It is a 3-year initiative funded out of a larger program within the Canadian Frailty Network called “Improved Advance Care Planning for Frail Elderly Canadians”. Other sites include Hamilton General, and Montreal General Hospital.
• The program is a system-based intervention originally designed for outpatient cancer care which has been shown in a randomized controlled trial to result in more, better, and earlier conversations about goals of care and sustained reductions in patient anxiety and depression.
• The target population includes patients admitted to MTU at FMC who are identified as frail, with an estimated prognosis of < 1 year.
• The aim is to have meaningful conversations with frail individuals on MTU, using the serious illness conversation tool (next page). If you’re interested in learning more about the guide, there is a 2.5 hour course through AHS on how to use it, which gives you a chance to role-play situations using the guide, to increase your comfort level.
• The Serious Illness conversation guide contains patient tested language on how to approach difficult conversations.
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CONSENTING A PATIENT FOR A BLOOD TRANSFUSION:
Indications for blood transfusion: • HGB <70 or HGB <80 with CAD • Massive bleeding/Hemorrhagic shock
o Massive transfusion protocol • Informed Consent Process:
o Discuss condition, proposed treatment, risks & benefits, possible alternatives o If patient is competent and understands risks and benefits of action or non-
action, they have a right to refuse treatment o Allow patient opportunity to ask questions o Complete the informed consent form, requires patient signature and signature
from a Witness (can be nurse, family member, another resident)
• If not competent to make decision maker o Substitute decision maker (SDM) o If no SDM, then 2 physician consent
• In special cases of Jehovah’s Witnesses, helpful advice can be obtained from Hospital Information Services at 1-800-265- 0327
Note: CMV irradiated blood decreases risk of CMV
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PROCEDURAL SKILLS: Canadian Internal Medicine Point of Care Ultrasound Website (CIMUS): https://sites.google.com/site/calgaryimus/ NEJM Videos in Clinical Medicine Series (has many procedures): https://www.nejm.org/multimedia/medical-videos Commonly performed procedures include paracentesis, arthrocentesis, thoracentesis, and lumbar puncture. Can search for these in websites above.
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For the Out-of-Calgary Incoming faculty:
HOW DO GOALS OF CARE WORK IN CALGARY:
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TIPS ON NAVIGATING SUNRISE CLINICAL MANAGER:
You will get formal SCM training which will help you maneuver SCM. However, here are some tips about common functions used by residents:
1) Insert order (more about this later) 2) Create document
a. Doing a History/Physical (ie a consult in ED) b. Starting Discharge Summaries
3) Print Function for printing lists 4) Create new list (ie when you’re starting a rotation)
a. If unsure how to create a list, ask your senior 5) Orders/Results
a. Orders: currently ordered (Active/Pending/Hold filter) b. To see all orders, click No status/Priority filter on left hand side c. Results: lab tests/imaging results
6) Documents – see documents a. Doing a History/Physical (ie a consult in ED) b. Accessing some Inpatient Consults by Specialties c. Reading ED handover notes, accessing triage vitals (super useful when you’re on call
and seeing a patient for the first time) d. Starting/editing Discharge Summaries e. Accessing Nursing progress notes
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7) Flowsheets a. Vitals b. Ins and outs c. Daily weights (useful for CHF patients)
8) Medication Record (MAR) a. See what medications were actually given (see what was signed off by RN) and what
time it was given exactly. b. Including how many prn’s the patient is using
Entering Orders:
• SCM has AWESOME order sets which save time and make sure you don’t miss
anything!
• Here are some common ones: (you will find more awesome ones as you move through
residency – ie chronic liver disease work up, smoking cessation, etc)
• For entering daily labs (if necessary), click “Insert Order” button (#1 on diagram above) and then type “Common Labs” – you can click either “one time” or repeating and click what investigations you want to order
• Don’t forget to change the date if you want the lab for a different day (ie next AM)
• You can also do this for Common Radiology
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Admission Order Set Type “Admission – Medical” for MTU admission, then go through and select orders as needed
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TIPS ON NAVIGATING ALBERTA NETCARE:
• When you click Netcare from SCM, you will see this at the bottom
Click “Refresh” to access patient records
• When you get into Netcare, make sure you click this button (circled in red below) otherwise you will only see things within the last 1-2 years instead of everything
Useful Things on Netcare:
• Medications o Check what medications they are on and when they were last filled (also helps
determine compliance) o Be sure to always correlate with the patient to ensure it is up to date
• Review Labs o When you click the lab work, you can click “View Cumulative Results” in the top right
to view trend
• Review Consults/Discharge Summaries
• Review previous ED visits
• Review key imaging including: recent imaging, past echos/angiograms
• Review previous procedures
• Review Microbiology – what have they grown in the past and what resistant organisms
• Review pathology
• Review other areas as guided by history/physical/investigations
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REMOTE ACCESS SCM AND NETCARE:
Remote Netcare access:
1) Download the citrix receiver. Instructions: http://www.albertanetcare.ca/learningcentre/documents/Access_QR_Install CitrixOnMac.pdf
2) YOU DON’T NEED TO ENTER YOUR CREDENTIALS/LOGINS IN CITRIX. 3) Open the following link and enter the login information here
https://myapps.albertahealthservices.ca/vpn/index-ahs.html **You must have your 4 digit personal PIN. If you need help with the PIN, call the help desk at 1-877-931-1638 and they can assist you with that.
Remote SCM access
1) Call the help desk at 403-310-3111 and pick option 1. Then just ask the operator to have SCM remote access added to your Citrix apps.
2) Open the following link and enter your credentials https://myapps.albertahealthservices.ca/vpn/index-ahs.html
3) Once you logon, click the first icon on the left (Green arrow below)
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4) A citrix file will be downloaded automatically (Red arrow above). Click to open. The SCM window will then open, asking for your login info.
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Good luck with your with this new adventure- you will all do great!
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References
• Academic half day lectures, Calgary Internal Medicine Residency Program
• ACLS Course Resources and Guidelines
• Callum J, Pinkerton P, Lima A, Lin Y, Karbouti K, Lieberman L et al. Bloody easy 4. 2016. ISBN: 978-0-9869176-2-2.
• Canadian Researchers at the End of Life Network, Just Ask Conversation Guide. Retrieved from www.advancedcareplanning.ca.
• Garcia-Tsao, G., Abraldes, J., Berzigotti, A. and Bosch, J. (2016). Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology, 65(1), pp.310-335.
• Hui, D., Leung, A., & Padwal, R. (2011). Approach to internal medicine: A resource • book for clinical practice (3rd ed). New York: Springer.
• Joint Center for Health Systems Innovaton Dana-Farber Cancer Institute (2015). Serious Illness Conversation Guide. Retrieved from: https://www.talkaboutwhatmatters.org/documents/Providers/PSJH-Serious-Illness-Conversation-Guide.pdf
• Life in the Fast Lane (2018). Retrieved from lifeinthefastlane.com.
• Marshall, S., & Ruedy, J. (2011). On Call: principles and protocols. Philadelphia: Elsevier Saunders.
• Uptodate.com
• Serious Illness Conversation Guide – Alberta Health Services
• Shaw, J., Cheema, K., Khan, O., Ramji, Q., Clark, L, & Ma, I. (2015). Senior Medicine Workbook Calgary: Internal Medicine