Basics of Inpatient Medicine for the SubI

8/12/2019 Basics of Inpatient Medicine for the SubI

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Basics of Inpatient Medicine

for the SubInternSusan Merel, MD

2012-2013 Academic Year


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Overview

Goals of the subinternship Practical guide to admitting a patient

Fluid management, pain management Communication Efficiency tips


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Goals of Subinternship

Transition from student to intern Learn to manage your patients

Build confidence Work on efficiency Develop good habits As always, continue to learn medicine!


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Your goals?


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Case

It is your first day at Harborview as asubintern. Your senior resident gets a

call from the ER about your first patient,a 75 year old woman with heart failure,diabetes and chronic kidney diseasepresenting with bright red blood perrectum.


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Case

What do you do next?


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Case

Your senior resident goes to grab a cupof coffee and tells you to go down to theER and get started. What do you do now? What do you want to know from the ER

records? How are you recording this data?


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Available on medfools.com


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Case

You gather the following data: PCP is not in our system

Last d/c summary from 1 year ago Was admitted for pneumonia Hematocrit was 30 and Cr was 1.3

Last echo in our system was 2 years ago, EFwas normal, mild diastolic dysfunction


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In the ER

Current vitals: T 37.5, BP 120/80, HR90, RR 14, 97 %/RA

Pertinent ER course: Hematocrit was 28 on admission and SBP

was 100 with a HR of 110.

2 large bore IV

s placed 2 L LR bolus One stool with some bright red blood


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Interviewing the patient

HPI: Spend the most time here! But keep it problem-focused

Past medical history: OK to use past notes as a starting point

Family history: focus on first-degree relatives

Social history: More than just ETOH/tob/drugs! Meds: Accurate list is very important

May reveal more about PMH


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Interviewing the patient

Physical exam: Can do ROS while you are examining pt

Who

s their PCP/other important specialists? Code status: will need a longer discussion in sicker patients

Before you leave the room: Present tentative plan Explain again who you are and team structure Ask if they have any questions


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Admit Orders

Admit to: Tele?

Diagnosis: Condition: Call MD for:

T: > SBP: > < DBP: > < HR: > < RR: > < UO: < O2 sat:


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Admit Orders

Vitals: Allergies: Activity: Nursing:

Diet: IVF:


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IV Fluids

Is the patient volume depleted orbleeding? Needs volume resuscitation

Is the patient euvolemic but NPO? Needs

maintenance.

Continuing reevaluation of fluid needs Think of fluids like a medication.


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Maintenance IV fluids

Daily fluid needs: 2-3L/day for adults = 100-125 cc

s/hour

Sample: D5 NS with 20 meq KCL at100 cc

s/hour while NPO.

Monitor Chem 7; change to NS if

hyponatremic; replete potassium or addto fluid.


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Volume resuscitation

500 1000 cc

bolus

of isotonic fluidsinitially; revaluate frequently

Replete rapidly in shock/sepsis; morecautiously in renal disease, ESLD orCHF but still with boluses.


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Electrolyte Replacement

Potassium: nl about 3.7 to 5.2 Replete orally when possible up to 60 meq at a time; 10 meq

per 0.1 mm/l decrease

Replete cautiously in renal insufficiency and do not give todialysis patient

Magnesium: nl about 1.3-2.2 Oral Magnesium oxide up to 400 mg TID Magnesium sulfate 1 gm IV per 0.1 mml/l decrease

Calcium: nl about 8.4-10.3 Correct for albumin: add 0.8 to measured Ca for every 1 mg

their albumin is below 4 1-2 amps IV Ca gluconate or oral calcium carbonate 500 tid


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Anticipating Electrolyte Needs

Patients with diarrhea (e.g. lactulose) oron diuretics will need additional

potassium Remember to check Magnesium in

patients with hypokalemia (chem 10 or

chem 7 + Mag)!


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Admit Orders

Meds: Labs:


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PRN

s: Constipation

Sample bowel regimen Docusate 250 bid and senna 2 tabs qhs

scheduled, hold for loose stool Target different aspects of bowel

function

Motility: senna, bisacodyl Lubrication: docusate, mineral oil enema Water content: lactulose, PEG (Miralax),

sorbitol, magnesium salts


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PRNs: Nausea Consider etiology of nausea

Bowel dysmotility: prokinetics e.g.metoclopramide

Opioid-induced nausea: prochlorperazine,ondansetron

Vestibular causes: scopolamine patch,

promethazine Best-tolerated agents are ondansetron

and metoclopramidehttp://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_005.htm


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Pain Management

What are some considerations inchoosing a pain medication for our

patient?


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Pain Management

Acetaminophen is first line; safe under3-4 gm/day for most

Be cautious with NSAIDS in inpatients GI bleeding, renal failure, surgical bleeding Avoid in the elderly

Become familiar with opioid conversiontables


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Narcotic Equianalgesic Doses

Drug PO IVMorphine 30 mg 10 mg

Oxycodone 20 mg ---Hydromorphone 7.5 mg 1.5 mg

Hydrocodone 30 mg ---

1 mg morphine IV 0.15 mg hydromorphone IV1.5 mg hydromorphone IV = X

10mg MS IV 1mg MS IV


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Hopweb.orgRequires free registration and log-in


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DVT Prophylaxis

Recent ACP metaanalysis showed heparin prophyreduced risk for PE but not mortality; increased riskfor bleeding, but not major bleeding

Generally all pts over 75 and all ICU pts w/out majorbleeding risk should receive pharmacologicprophylaxis

No evidence for TEDs or SCDs Heparin 5000 U SQ q 8 or q 12 or daily LMWH;

LMWH may have lower bleeding risk and is preferredin critically ill patients

CHEST ACCP Clinical Practice Guidelines 2012; ACP Clinical Practice Guideline 2011


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Ragni MV hematology.org Jan 2012


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Glycemic Control

Our patient is on metformin andglipizide. HbA1C is 8.7 and admission

glucose is 190. How should we manage her diabetes

while she is in the hospital?


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Glycemic Control

Generally hold oral agents on admission Use basal-bolus insulin when possible

Avoid prolonged use of sliding scale alone

Follow hospital protocols (CPOE) Make sure discharge instructions are

clear regarding DM management


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Managementof diabetesand

hyperglycemiain the hospital:A practicalguide tosubcutaneousinsulin use inthe non-critically ill,adult patient.

Wesorick D etal J Hosp Med2008

Hyperglycemia guidelines in


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Hyperglycemia guidelines inhospitalized patients J Clin Endocrinol Metab 97 (1) 16-38


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Code Status


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Code Status

Use clear language When you are dying . . .

Would you want heroic measures . . . Avoid the term do everything Make a recommendation when

appropriate


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Code Status

Basic structure of conversation inseriously ill patient:

What is your understanding of your illness? What are you hoping for? What are you afraid of?

Then make a recommendation based ontheir wishes and the medical facts.


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Order writing (typing?) tips

Never give a verbal order by yourself! Let nurse know about most orders.

Anything time-sensitive Anything unusual


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Call a consult!

Your resident asks you to call the GIconsult for this patient.

What do you say?


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Call a consult!

Always know your question Present your case very concisely

Include only the PMH relevant to theconsult question

Identify who you are and know who you

are speaking to Consider practicing first


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Presentations

Practice and ask for feedback Be prepared for bedside presentations

Remember you are telling a story Should lead towards the diagnosis you chose Most common pitfalls :

Too long (especially the HPI)

Reading from H and P Not focusing enough on differential and

management


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What to read?

Again, focus on management Uptodate a good start NEJM review articles

Pocket Medicine green book by Marc Sabatine 52 articles in 52 weeks:

https://depts.washington.edu/uwmedres/resources/52articles/index.htm
https://depts.washington.edu/uwmedres/resources/52articles/index.htmhttps://depts.washington.edu/uwmedres/resources/52articles/index.htmhttps://depts.washington.edu/uwmedres/resources/52articles/index.htmhttps://depts.washington.edu/uwmedres/resources/52articles/index.htm


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Manage your patient

Come up with a plan of care every day topresent to your team They will appreciate your efforts even if the plan

changes! Be able to justify your decision.

Communicate frequently with the patient,nurse and family

Be the face of your team with consultants


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Examples of management

Dr Merel, I just read that one of themedications my patient is taking can causetheir presenting problem. I thought I

d call the

consultant and ask them if we should stop itnow. Is that ok?

Sr. resident, labs just came back and my

patient s potassium is 3.3. He s still vomiting,so I would like to replace it IV with 40 meq ofKCL. Can you cosign this order?


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Take care of your patient!

Spend some time getting to know them Call PCP on admit and discharge when

possible Be the face of your team with

consultants

Become comfortable using teach -backfor patient communication


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Teachback

Asking patients to repeat in their ownwords what they need to know or do.

Not a test of the patient, but of how wellyou explained a concept.

A chance to check for understanding

and, if necessary, re-teach theinformation.


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Teachback

Examples: I want to be sure that I explained your medication

correctly. Can you tell me how you are going totake this medicine at home?

We covered a lot today about your diabetes, and Iwant to make sure that I explained things clearly.SO lets review what we discussed. What arethree strategies that will help you control yourdiabetes?

What are you going to do when you get home?

https://hmc.uwmedicine.org/PatientEducation/Pages/TeachBack.aspx


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Parting Words

Focus on taking excellent care of yourpatients and learning as much as

possible and the rest should follow. Feel free to contact your site director or

myself with questions/concerns:

[email protected]

Basics of Inpatient Medicine for the SubI

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