Transcript Introduction to Medical Consultation 2012

Jacobi
Ambulatory Care Service
Medical Consultation:
An Overview
Lori A. Lemberg, MD
Fall 2012
Yes, this is Medical
Consult, How can I
help you?
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Learning Objectives
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Function of the Medical Consultant
Goldman’s “Ten Commandments”
Surgical Considerations
Anesthesia Considerations
Appropriate History and Evaluation of Patient
ACC-AHA Guidelines
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Jacobi
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Function of the Medical Consultant
to offer an opinion on diagnosis
or management
Goldman’s Ten Commandments for
Effective Consultation
1. Determine the
Question
2. Establish Urgency
3. Look for Yourself
4. Be as Brief as
Appropriate
5. Be Specific
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6.
Provide
Contingency Plans
7. Honor Thy Turf
8. Teach …With Tact
9. Talk is Cheap…and
Effective
10. Follow Up
Goldman et al, Arch Int Med 1983; 143: 1753
1. Determine the Question
Ask the requesting
service to be as specific
as possible
Clarify verbally if the
question(s) are unclear
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Jacobi
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2. Establish Urgency
• Emergency, Urgent, Elective
• See the patient within 24 hours
3.
Look for Yourself
• Review pertinent history and
physical exam
• Make an independent judgment
4.
Be as Brief as Appropriate
• Do not recopy the history and physical
• Highlight important points
5.
Be Specific
• The more detailed the suggestions the better
• Spell out dosing, timing of meds
• Less is more
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6. Provide Contingency
Plans
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Anticipate problems
7.
Honor Thy Turf
• Do not step on other’s toes
• Remember your position as consultant
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8.
Teach with Tact
• Encourage collegial relations
9.
Talk is Cheap and Effective
• Talk with the primary physician or service about your
findings and recommendations
• Discuss disagreements
• Bring the attendings to the table if necessary
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10. Follow-Up
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Interval as appropriate to the case
Improves compliance with recommendations
Tell services you are signing off
Provide specific outpatient follow-up plan
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Factors Improving Compliance with
Recommendations
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Consult within 24 hours
More than two follow-up notes
Verbal contact with referring MD
Limited number of recommendations (<5)
Recommendations related to “central reason”
of consult
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Kammerer, Gross, Medical Consultation
Factors Improving Compliance with
Recommendations
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Definitiveness of recommendation
“Crucial” recommendation
Details spelled out
Medication/treatment vs. diagnostic
Severely ill patient
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Pre Operative Consultation
Pre Operative Consultation
Why?
• Elucidate patient’s risks and benefits of
surgery
• Improve risk by optimizing medical condition
• Anticipate perioperative and postoperative
complications
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Risk of Surgery
INHERENT RISKS OF PROCEDURE
High: Emergency procedures, Major Vascular,
Craniotomy
Medium: Orthopedic, Prostate, Abdominal, Thoracic
Low: Breast, Plastic
Very Low: Cataract, Dental, Endoscopic
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Jacobi
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Surgeon Specific Risk
Hospital Specific Risk
Anesthesia
GENERAL
• depresses cardiac function
• airway control, but reduced lung volumes
SPINAL or EPIDURAL
• vasodilates
• avoid with aortic stenosis
No difference in CV events!
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When do things go wrong?
• Mortality Related to Surgery
10-15% during induction
30-40% during surgery
45-60% post-operative
• Peak for Myocardial Infarction
Day 0, 1, 2 days postoperatively
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Induction
Catecholamine surge
Blood pressure lability
Post Operative State
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Metabolic demands
Pain
Fluid Shifts
Catecholamine surges
CHF, Coronary ischemia
Atelectasis, VQ mismatch, Pneumonia
DVT
Immobilization
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Jacobi
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If the inherent risk of surgery is low,
can I make an impact?
Medical Considerations
for Surgery
• Cardiovascular: CAD, CHF, HTN, Arrhythmias,
Valvular heart disease
• Hematologic: Bleeding, DVT risk
• Pulmonary: COPD, Asthma, Smoking
• Renal: Renal insufficiency
• Endocrine: Diabetes, Thyroid, Adrenal
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Medical Considerations
for Surgery
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Hepatic: Cirrhosis, Hepatitis
Habits: Alcohol, Drugs
Medications
Endocarditis prophylaxis
Pregnancy
Geriatric patients
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History
Include:
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Previous surgery or complications
Bleeding
Functional capacity / Exercise tolerance
Medications
Allergies
Substance Use
Family History (bleeding, malignant hyperthermia)
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Exam
• Vitals
• General Exam
• Mental Status
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Laboratories
Controversial, Low predictive value
CBC Anemia? Baseline?
Chemistries K+? BUN/Cr?
PT, PTT, Bleeding Time not predictive
EKG for higher risk or older patients?
CXR doubtful
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Jacobi
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Cardiovascular Risk Assessment
Higher Risk Features
Goldman et al
• Age > 70
• MI < 6 months
• S3 or JVD
• Important valvular AS
• Rhythm other than sinus
• > 5 PVCs per minute
5 pts
10 pts
11 pts
3 pts
5 pts
5 pts
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NEJM 1977; 297:845
Goldman continued
• Poor general medical status
3 pts
• Intraperitoneal,
3 pts
intrathoracic or aortic surgery
• Emergency surgery
4 pts
Total
53 pts
Medium
High Risk
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13-25 pts
>25 pts
12% complications
56% complications
Lee et al
Risk Factors in Multivariate Analysis of 4315
Patients
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High Risk Surgery
Ischemic Heart Disease
Congestive Heart Failure
History of TIA or Stroke
Insulin Therapy for Diabetes
Pre Op Creatinine > 2.0
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Circulation 1999:100: 1043
Lee et al
12
10
11
8
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O factors
1 factor
2 factors
3 factors
6.6
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2
0.4
0.9
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Rate of Cardiac Complications (MI, Pulm
Edema, VFib, Cardiac Arrest, Complete Heart
Block)
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Circulation 1999:100: 1043
Table 1. Applying classification of recommendations and level of evidence.
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Copyright © American Heart Association
Fleisher L A et al. Circulation 2007;116:e418-e500
American College of Cardiology American Heart
Association
Revised 2002/2007 Guidelines
MAJOR CLINICAL PREDICTORS
• Unstable angina, Recent MI
• Decompensated CHF
• Significant Arrhythmias (high grade AV block,
symptomatic ventricular arrhythmias, SVT uncontrolled
• Severe valvular disease
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ACC-AHA 2002/2007 Guidelines
INTERMEDIATE CLINICAL
PREDICTORS
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Mild angina
Past history of CHF
Prior MI
Diabetes
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ACC-AHA 2002/2007 Guidelines
MINOR CLINICAL PREDICTORS
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Age
ECG (LVH, LBBB, ST-T changes)
Low functional capacity (< 4 mets)
Rhythm other than sinus
Uncontrolled hypertension
Past history of stroke
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