Approach to the Patients on Admission in Wards

Managemment of Paients on Admission in Wards

Approach to the Patients on Admission in WardsIntroduction of the New [email protected]:To have clear conception of Medical emergencyTo have an idea of the referral system of the patientsTo be rational in the use of drugsTo be rational in sending investigationsTo ensure better follow up of the patients

[email protected], To provide better service to the [email protected] M.O.P.DThrough EmergencyAliveWith NODWithout NODBrought deadPsychiatric/FunctionalNon psychiatricAdmission During Office HourBeyond Office HourTransferred/ReferredNOD= No Official DelayMOPD= Medicine out patient [email protected] Office Hour:Patients come through MOPD, Outdoor and sometimes they are transferred from different wards.Patients coming through emergency may have NOD note or may have admission ticket

[email protected]

In Case of NODRush to the patient without any delayExamine the patient, specially, vital signs (Pulse, Heart sound, Pupil, Planter reflex) to see whether the patient is alive or DeadIf you find the patient dead, show your sincerity to the attendants during examination though you are clinically certain that the patient is dead.If found dead clinically, talk to the attendant/relative (specially with the 1st degree), start counseling. Tell them that your are almost sure about the death of the patient, and Now going to do an ECG just to confirm [email protected]. Then do the ECG (This time, the Long Leads only)6. If straight line is found, then address the EMO and declare the patient dead as Brought dead

[email protected] the patient is found gasping on the trolley, dont waste time for the bed-head ticket to be available! Rather, immediately start the treatment with whatever resources you have.

Never forget to measure CBG of the [email protected] CBG is found within normal range, you should be very much cautious regarding examination and [email protected],Unconsciousness [email protected] COMAPsychologically disturbed patients sometimes feign coma. The eyes are actually closed and the patient is usually lying in a resting position, or supine with the arms and legs extended. The eyelids resist attempts to open them On forced eye opening, the eyes point upwards exposing the white conjunctiva (Bell's phenomenon) as part of the patient's attempt to maintain eyelid closure. The eyelids close rapidly when released. The slow roving eye movements of organic coma cannot be simulated. Painful stimuli to the limbs may be ignored, but pinprick to the nasal mucosa or to the lips usually elicits volitional grimacing. The pupillary light reflex is normal, as are plantar [email protected] caloric testing induces nystagmus with the fast phase away from the stimulated side, rather than deviation of the eyes toward the stimulus as would occur in true coma. Examination, especially invasive tests as above, may induce a return of cooperation and consciousness, or uncover a disturbed mental.

(This is not practised in the ward)[email protected] Hyperventilation, Respiratory distressFeatures:May complaints of Light headednessWhen excessive, tingling and numbness of limbs with carpopedal spasm may occur due hypocalcaemia resulting from Respiratory alkalosisX-Ray and ECG is normal

Features:Typically can locate exactly with his/her own hand, particularly one finger!On pressing over the point, shout/cry out due to pain!X-ray and ECG (Tachycardia only) is normal

Severe Chest PainAcute Mutism/UnconsciousnessFeatures:Typical eyeball movement with closure of eyelids!Few maneuver (NG tube insertion etc) may not be needed to treat them! In case of Functional disorder/Anxiety disorder/Acute stress disorder coming with NOD, Pseudo emergency may occur, like:[email protected] feel the pulse, hear the Heart sounds and look for pupillary reflex to make the attendants think that your are taking the case seriouslyThen, address the EMO to admit the patient in the wordMeanwhile, send one of the attendants to bring some drugs (Just to make the attendants busy, other wise, they will make you Busy!)Start counseling the attendantsDont talk/make any comment in front of the patient regarding your diagnosis (as it may cause exacerbation of symptoms)[email protected] of the Patient:In case of Functional disorder, I.V. drugs are given (or, sometimes need to be given) to make him/her think that treatment is started appropriately.Drug list should include:I.V. canula 20GJMS infusion set1 inch MicroporeInj. 5% DNS (If non diabetic)Inj. OmeprazoleInj. Dormicum/Inj. Haloperidol (suspecting that the patient may be restless or violent!)

[email protected], only oral medication is enough to treat the patient specially at night, when Staff nurses are few in numberIntravenous management is troublesome. So, there is no reason to engage the sisters in treating those patient, rather we should think for really critically ill patients.In that case, the medication will be:Tab. Clonazepam (0.5mg ) /Tab. Midazolam 7.5 mg 1 Tab. stat and then 0+0+1Cap. Omeprazole (20mg) 1+0+1 [ hr A/C]Actually, it is the clinical condition and patients surrounding, which will lead you to the treatment.

[email protected] is a state of normal cerebral activity in which the patient is aware of both self and environment and is able to respond to internal changes, for example hunger, and to changes in the external environment. Altered consciousness resulting from brain disease may take the form of a confusional state, in which the patient's alertness is clouded; this is associated with \agitation, fright and confusion, i.e. disorientation. Such patients usually show evidence of misperception of their environment, and hallucinations and delusions may occur. [email protected] states must be carefully distinguished from aphasia, in which a specific disorder of language is the characteristic feature, and from continuous temporal lobe epilepsy, a form of focal status epilepticus in which the behavioural disorder is often accompanied by aphasia if the epileptic focus is left-sided. Usually this can be recognized by the occurrence of frequent but slight myoclonic jerks of facial and especially perioral muscles, and by variability in the patient's confusion from moment to moment during the examination. Always pause and observe an unconscious or drowsy patient for a few moments before disturbing them.

[email protected] drowsiness is often found in patients with space-occupying intracranial lesions or metabolic disorders before stupor or coma supervenes. The patient appears to be in normal sleep but cannot easily be wakened and, once awake, tends to fall asleep despite verbal stimulation or clinical examination. Further, while awake such patients can usually be shown to be disorientated. Higher intellectual function, such as the ability to perform abstract tasks or to make judgements, is disturbed. Stupor means a state of disturbed consciousness from which only vigorous external stimuli can produce arousal. Arousal from stupor is invariably both brief and incomplete.

[email protected]:Pupillary size and responsiveness to a very bright unfocused light beam (not the light of an ophthalmoscope) should be noted. If the pupils are unequal, a decision as to which is abnormal must be made. Usually the larger pupil indicates the presence of an oculomotor (third) nerve palsy, whether from damage to the oculomotor nerve by pressure and displacement or from a lesion in the mesencephalon itself. Occasionally the smaller pupil may be the abnormal one, as in Horner's syndrome. If the larger pupil does not react to light it is likely that there is a partial oculomotor nerve palsy on that side. If the smaller pupil also fails to react to light this may be the midposition pupil of complete sympathetic and parasympathetic lesions, indicating extensive brainstem [email protected] drug-induced coma and in most patients with metabolic coma the pupillary responses to light are normal. Exceptions to this rule are glutethimide poisoning and very deep metabolic coma, in which the pupils may become dilated but only rarely become unreactive to light. In pontine and in thalamic haemorrhage the pupils may be very small (pinpoint pupils) and unreactive to [email protected]

Bilateral pinpoint pupils occur with brainstem lesions, opiate and other drug intoxications, and with pontine infarctionThere is ptosis, dilatation of the pupil with absence of the light reaction, and slight lateral deviation of the eye. [email protected]

There is ptosis and a small reactive pupilThe eyes tend to 'look towards the tip of the nose' and the pupils are small; later they become large and unreactive as upper brainstem involvement [email protected], last but not the [email protected]

When brainstem death occurs the midbrain disturbance is manifest by midposition, fixed (unreactive) pupils with eye [email protected] OF BREATHINGAlterations in the rhythm and pattern of breathing are an important aspect of the assessment of the unconscious [email protected] (PERIODIC) RESPIRATION

In Cheyne-Stokes respiration, breathing varies in regular cycles. A phase of gradually deepening respiration is followed, after a period of very deep rapid breaths, by a phase of slowly decreasing respiratory excursion and rate. Respiration gradually becomes quieter and may cease for several seconds before the cycle is repeated. Depressed but regular breathing at a normal rate occurs in most drug-induced comas, but Cheyne-Stokes respiration can occur in coma of any cause, especially if there is coincidental chronic pulmonary disease. Cheyne-Stokes breathing in a comatose patient is a sign of a large unilateral space-occupying lesion with brainstem distortion, for example subdural haematoma, or of bilateral lesions from other causes, for example cerebral infarction or meningitis.

[email protected] RESPIRATION

Deep, rapid sighing breathing at a regular rate should immediately suggest metabolic acidosis. Metabolic or uraemia is the commonest cause of this acidotic (Kussmaul) breathing pattern, but a similar pattern may occur in some patients with respiratory failure, and in deep metabolic coma, especially hepatic [email protected]

CENTRAL PONTINE HYPERVENTILATIONDeep, regular breathing may also occur with rostral brainstem damage, whether due to reticular pontine infarction or to central brainstem dysfunction secondary to transtentorial herniation associated with an intra- or extracerebral space-occupying lesion. This breathing pattern is called central neurogenic (pontine) hyperventilation. Interspersed deep sighs or yawns may precede the development of this respiratory [email protected] shallow breathing occurs if central brainstem dysfunction extends more caudally to the lower pons. When medullary respiratory neurons are damaged, for example by progressive transtentorial herniation, irregular, slow, deep gasping respirations, sometimes associated with hiccups (ataxic respiration), may develop. In patients with raised intracranial pressure, this sequence of abnormal breathing patterns is often associated with other evidence of brainstem dysfunction, including a rising blood pressure, a slow pulse, flaccid limbs, absence of reflex ocular movements and dilatation of the [email protected] patterns of respiration in an unconscious patient, particularly the development of central neurogenic hyperventilation, provide important and relatively objective evidence of deterioration. These changes in respiratory pattern may occur in structural lesions with raised intracranial pressure, in brainstem infarction, and less commonly in some varieties of metabolic coma, especially hepatic coma. They are indicative of progressive and potentially fatal brainstem dysfunction, but not of its causation.

[email protected], let us come back to the patient that has just entered into the [email protected], counseling should be done simultaneously regarding the prognosis of the patient.Try to show pessimistic attitude to the attendant (Specially when you can understand that the patient is going to expire very soon)After initial resuscitation, try to refer the case to the respective discipline (When indicated), e.g. CCU/ICU/Nephrology/Neuromedicine etc. (in the office hour only). [email protected] unexplained somatic symptomsPatients commonly present to doctors with somatic symptoms. Whilst these are often clearly associated with a medical condition, in other cases they are not. Symptoms may be disproportionate to, or occur in the absence of, a medical condition and are then often referred to as 'medically unexplained symptoms' (MUS). MUS are very common and occur in a quarter to a half of patients attending general medical outpatient clinics. Almost any symptom can be medically unexplained and common examples include: pain (including back, chest, abdominal and headache) fatigue dizziness fits, 'funny turns' and feelings of weakness. [email protected] with MUS may receive a medical diagnosis of a so-called functional somatic syndrome, such as irritable bowel syndrome and may also merit a psychiatric diagnosis on the basis of the same symptoms. The most frequent psychiatric diagnoses associated with MUS are anxiety or depressive disorders. When these are absent, a diagnosis of somatoform disorder may be [email protected]

[email protected] (Non functional)GastroMay involve various systems of the body alone, or simultaneouslyRespiratoryEndocrineInfectionHaematologicalCNSPoisoningVenomous snake biteOPC poisoningRenalOthersThrough OutdoorTransferred/Referreddrsuman_chowdhury@yahoo.comCardiacRespiratoryGastroEndocrineInfectionHaematologicalCNSShock, LVF, MI, CHB, Hypertensive Crisis Severe CAP, Acute severe asthma/COPD, Tension pneumothoraxResp. failure , Ex. of COPD, Cor-pulmonaleSevere acute Pancreatitis, EV rupture, Severe hemoptysis, Hypo. Shock, Perforation, Acute abdomenDKA, Hypoglycemic attack, HONK, Addisons crisis, Septicaemia, shock, Severe malariaSepticaemia, shock, anemic heart failureEncephalopathy, Stroke , Meningitis, Encehalitis, GBS with resp. distress/failure, Status Epilepticus etc.Emergency patients commonly admitted in wards (Except poisoning) are:RenalARF, Ureamic encephalopathy, LVF, Metabolic acidosis etc [email protected] patient comes through M.O.P.DUsually these patients are admitted with some chronic disease, e.g. PUO and sometimes may be presented with acute exacerbation, e.g. Huge ascites in case of CLD, Constipation/vomiting in Ca-stomach etc.Take proper history and fine out the causes of their admission this time, i.e. presenting complaintsStart thorough physical examination.Share your findings to your colleagues

[email protected] up the Bed head [email protected] Bed head TicketFill up the front page with- (Necessary for disease profile and some Medico-legal condition)Name of the patient:Age:Sex:Address: Provisional DiagnosisDate and Time:Doctors Signature (Preferably name)[email protected] next page:Presenting complaints: (Try to avoid mentioning more and irrelevant/non specific complaints)1.2.3.History of present Illness: (Here, the modified salient feature should be written to save time)Which should include:Elaboration of positive findingsMentioning of Important negative findingsMentioning risk factors/co-morbid conditions

[email protected] physical examination:Try to mention the findings concisely, such as:AppearanceBuildAnaemiaJaundice CyanosisClubbingEdemaAscitesDehydrationPulseBPTempHeartLungsGCSPupilPlanter reflex:Deep jerksNeck rigidityKernigs signEngorged veinLymphadenopathy

* Sometimes, additional findings should be noted in some particular diseases

Provisional diagnosis:Try to be specificBroad term can be used otherwise, e.g. Anaemia under evaluation, Acute febrile Illness, Acute Confusional State etc.Never write the abbreviated form, like ACS, DVT, RA etc.As soon as you are confirmed, try to mention the latest Diagnosis and omit the previous one.Try to avoid confusing terms, e.g. Shock, Chest pain, Respiratory distress, Abdominal pain etc.

[email protected] sending Investigations, seek their previous reports.Always ask your senior colleague regarding investigations, because, it will reduce unnecessary wastage of time and moneyAlways ask the reason of sending the particular investigations to your respective senior colleagueTry to learn, in short, the basic pathogenesis of the disease, and go through the text later on.Try to know the next plan of investigationTreat the patient according to the diagnosis

[email protected]:CBCUrine R/M/ECXR P/A viewBlood UreaSerum CreatinineSerum ElectrolytesUSG of Whole Abdomen

Next Plan:

CT scan of BrainCT guided FNACUSG guided FNACEndoscopy of UGIT etc.

O/A on Date at Time:(Sample)

Diet: NBM/Liquid/Soft/Normal/Diabetic/Salt and fluid restricted/Protein restricted etc.Bed rest in Propped up/Lateral/Semiprone positionO2 Inhalation 2L/min SOSInj. N/S 1ooo cc I.V. @ 1o d/min (If I.V. antibiotic to be given)Inj. 5% DNS I.V. @10 d/min ( If not known to be diabetic and CBG is normal)Oral/ Inj. Antibiotic..Oral / Inj. Omeprazole (40mg) + 9cc D/W I.V. 12 hourlyOral Anti pyretic [If febrile]Oral anxiolytic (less potent)Suppository antipyretic SOS [If fever > 102 For more] Condom/Foleys catheter [ In case of bed ridden patients]Please monitor Daily I/O Please monitor all vital signs regularly

Name of DoctorDate: [email protected]:[email protected] the patient is to be kept NBMIf Non diabeticIf Parenteral Nutrition is to be given Total 2500-3000 ml of fluid to be givenInj. 5% DNS 1000 cc+ Inj. Regular Insulin (U-100) or Other soluble Insulin 10 units I.V @ 25-30 drops/minIf DiabeticInj. 5% DNS 1000 cc I.V @ 25-30drops/minFluidsOthersVitamins and ElectrolytesInj. Vit B complexInj. Vit CExtra electrolytes according to severity and deficiencySpecial condition deserves special fluids therapy If NG tube feeding is to be given[150 ml2 hourly10 feedings]Special Milk; Dal; Soup; F. Juice; Dub water; etcThe rest of the fluid should be replaced by [email protected] Neuralization in Diabetic patients:

InJ. 5% DA/ Inj. 5 % DNS contains 5 gm of Glucose per 100 ml, so 1000 ml of those fluids contain 50 gm of glucose.1 U of soluble insulin can neutralize 2.5 gm of glucose Therefore, full neutralization of 5% DNS 1000 ml requires (502.5)= 20 U of insulin.So, half neutralizaton requires 10 U of [email protected] patient is to be kept NBM for prolonged period, Intracellular fluid requirement should be met with 5% DA 500 or 1000 cc. Sometimes, IV amino acids and fatty acid solutions are given in selected patients along with [email protected] to be remembered:Patients having any kind of respiratory distress = No normal diet, rather liquid to soft diet should be givenAcute abdomen due to any cause = NBM+ No NG feedingFirst few hours in Acute stroke = NBM+ No NG feedingIf aspiration is suspected = NBM+ No NG feeding for at least 48 hoursAny kind of shock = NBM+ No NG feedingUnconsciousness patient= No NG in first few hoursAny kind of Poisoning = NBM+ No NG feeding

[email protected] [email protected] should be prescribed to achieve a target saturation of 9498% for most acutely ill patients or 8892% for those at risk of hypercapnic respiratory failure.Sometimes, Low dose O2 and High Dose O2 supply is neededLow dose means 24-28% O2 Higher dose is required in LVF, Shock, Severe bronchial asthma etc.Sometimes 100% O2 is required, prior to [email protected] %Way of O2 supply O2 in L/min

O2 in L/min

O2 in L/min24Venturi mask2-4Nasal cannulae1 28Venturi mask4-6Nasal cannulae2 36Venturi mask8-10Nasal cannulae4 40Venturi mask10-12Simple face mask5-660Venturi mask12-15Simple face [email protected]

Venturi [email protected]

Nasal [email protected]

Simple face [email protected] of the Patient:[email protected] but chronically ill patient

Lateral/Rescue positionSemi-pronePropped upSupinePostureIn acute LVFCOPDBronchial asthma

Any unconscious patient, e.g. transport poisoning , stroke, Patients with GCTS/Status Epilepticus etc.

Patients with aspiration pneumoniaFoot end raisedIn hypo-volaemic [email protected]

Lateral PositionSupine PositionSemi prone PositionProne Position

[email protected]

Semi-Fowlers PositionFowlers [email protected]. fluids:[email protected] unconscious patient(Except hypoglycaemia)= Normal salineAll AWD patients with/Without shock = Cholera saline until renal failure. If pre-renal ARF is suspected (clinically), switch over to Normal salineIn any hyperglycameic patients = Normal salineVomiting leading to hypovolaemia = Hartsol/Hartsmann There is also pre-surgical/post-surgical indication of various fluid (But, unusual in our ward)Again, clinical condition and further investigation will lead us to the selection of fluids

[email protected] Ulcerant:[email protected] scope of H2 blocker except allergic reactionPPI is preferredAvoid Omeprazole in Pregnancy, Multi organ failure, renal impairment etc. Esmoprazole is better in GERDPantoprazole is preferred in patients having multiple drugs chronicallyLast, but not the least, we have to consider the socio-economic condition before choosing the correct [email protected]:[email protected] to be considered:Irrational use should be avoidedAvoid I.V. route where oral one is sufficientChoose I.V. in case of septicaemia, shock, aspiration pneumonia, Acute abdomen (Intestinal obstruction, along with other suspected GI infection)Usual site of Colonization of micro-organism should be taken in consideration, e.g. No Metronidazole in UTI etc.Proper duration should be maintainedConsider low but effective dose initiallyAgain , we have to consider the socio-economic condition before choosing the correct drugsAlways ask your seniors prior to [email protected][email protected] in any bed ridden patientIn any patient with shock Any unconscious patientAny patient with acute retentionClinical condition will lead us to the selection of catheter (Foleys /Condom) Patient with restlessness with condom cathether in situ with oliguria should have Foleys catheterIn patient with BEP with unconsciousness = Foleys catheterPatients of OPC poisoning = Foleys catheter etc.

[email protected] or Transferred Patients:They are usually diagnosed Due to newly developped complication related with medicine, they are transferred.Dont be fixed on the previous diagnosis written in the file, rather,Take proper History and do physical examination to re-evaluate the case and to find out exactly what happened during hospital stayDiscuss with the senior colleague and, if needed with the consultant regarding further management of the patient.Advise investigations, depending on the complication after discussing with the senior

[email protected] Profile:Investigation Profile*:When maximum investigations are available, formulate them into an Investigation Profile in the following way:1. CBC:HbESRTCDCN: %; L: %; E: %; B: % Atypical cells:2. Urine RE:Pus cell:Epi cellRBCRBC CastsAlbumin:Sugar3. CXR P/A view:4. USG of W/A:5. Endoscopy of UGIT:6. S. Creatinine:7. S. Electrolytes:8. S. Bilirubin

9. Liver function tests:S. Bilirubon:SGPT:SGOTPT:Alk. Phosphatase:S. Albmin10. Viral Markers:HBsAg:Anti HBcAg IgM antibody:Anti HCV antibodyAnti HEV antibody:Anti HAV antibodyCT scan of Brain:MRI of Brain/Cervical spineX-Ray of DLS (A/P, Lateral view)X-ray cervical spine all views( Including Oblique)

* Printed form for Investigation Profile is availableFollow-Up and TreatmentSometimes this type of treatment sheet is [email protected] add:Inj. Oradexon 1amp I.V. b.dPlz add:Inj. Anadol stat and 8 hrlyO/A on Date at Time:

Diet: NBM (how long?)Bed rest in Propped up positionO2 Inhalation (How much?)Inj. N/S 1ooo cc I.V. @ 1o d/min Inj. 5% DNS 1500 I.V. @10 d/min Inj. Antibiotic.. Inj. Omeprazole (40mg) + 9cc D/W I.V. 12 hourlyOral Anti pyretic [If febrile]Oral anxiolytic (less potent)Suppository antipyretic SOS [If fever > 102 For more] Catheter [ Which type?]Please monitor Daily I/O Please monitor all vital signs regularly

OmitSignature (Greek to All!)Diet: Normal

[email protected], Fresh order is a [email protected], this type of Follow up note is not so [email protected]/U at 10 am on Date:

P:66/minBP:90/60 mmHg

T: H:L:NADF/U :

P:110/minBP:T:H:NADL: Rhonchi +F/U at 11 am:

P:78/minBP:100/70 mmHgT:101 FH: NADL:CrepsF/U at 10 am:

P: 110/minBP:85/40T:H: NADL: crepsNN(On the back side of Treatment sheet)At 10 amOn [email protected] up should be of this type:[email protected] up On Date at Time:SPAONew drugs to be addedOld drugs be omitted/AlteredNew Investigations to be givenCompare the condition with the previous dayImprovement/Static/DeteriorationPulseBPTempHeartLungsComplaints on that particular time :FeverAbdominal pain VomitingGeneralised weakness etc.GCS (In particular patients)[email protected] special conditions demand more detail follow-up, e.g. Grading of Hepatic Encephalopathy (on that day), Appearance, Measurement of Body weight and abdominal girth [email protected] should ensure the drugs (by the nurse, or, sometimes, yourself!) written in the Treatment sheet on the very [email protected] Everyone should present during round Gather all the necessary investigation reports before the round starts Evacuate the attendants from respective beds prior to round and allow only the concerned one to stay in case of Terminal/ unconscoious/Disoriented/Bed ridden patientDo not rely completely ( and, thus formulate your plan of investigations or treatment) on the diagnosis made earlier, e.g., during night. Try to listen what the consultant discuss about the respective beds Later, discuss with the senior colleague regarding further plan, Fresh order etc.

[email protected] be [email protected]