Transcript Intern Orientation - University of California, Irvine

Pearls for Interns
UCI Internal Medicine Residency
Things to Do in AM











As you drive in to work, think about pending issues from yesterday and
potential discharges
Pick up your sign-out from the overnight night float/team.
Let senior know of anything urgent/major changes
check vitals, I/O
check labs, REPLETE LYTES AS YOU CHECK LABS so you don't forget
check telemetry – think about D/C telemetry if no longer indicated
See your patients.
While seeing them, see how much of prn meds were used (i.e. pain meds,
insulin sliding scale) etc. For ICU, determine doses of all pressors currently
running.
check if your patient has the following:
1) Foley. Does it need to be in?
2) Central line. Does it need to be in?
3) IV Fluids. Does the rate need adjustment? *** Are the fluids appropriate?
Run through the list with senior resident for assessment/plan for your patients
At UCI - have blue progress notes filled out at UCI (see next slide)
Rounds – keep checklist of stuff to do on scut sheet, with checkboxes
Progress Notes - UCI

Check with your Attending on preference for billing (Attending charts entire note vs
Attending writes Attestation statement for combined Resident/Attending note.)



SOAP Format
S: Includes Chief Complaint, HPI, and ROS




Do NOT chart PE (except vitals) if the Attending does not want to write Attestation
Chart static data (relevant medications, vitals, pertinent lab or radiology results, pulse ox, test
results)
A/P: Includes Dx or symptom, type or Stage, acuity or severity, & etiology if applicable
(example: Chronic microcytic anemia due to menorrhagia; DM II, uncontrolled, etc.)




Do NOT chart S: if the Attending does not want to write Attestation
If charting, include as many of the 7 dimensions of chief complaint as appropriate and
overnight events. If pt unable to give history, mention why (i.e. intubated/sedated).
O: Includes Medications, PE, Lab or Radiology results, Pulse Ox, Telemetry, EKG, Dx
test results


Students (including sub-I’s) should only chart static data (see below) or write a separate blank
Blue Note progress note (not the Hospitalist PN) and have Resident or Attending co-signature
Do NOT chart A/P if the Attending does not want to write Attestation
NEVER chart “FEN,” instead “dehydration” or “hypokalemia,” or “malnutrition.” Use a Dx.
NEVER chart “PPx,” instead “risk for DVT due to cancer” or “risk for GI bleed due to steroid”
All notes with Attending Attestation also require a Resident signature, printed name,
date, and time
After Rounds
1.
2.
3.
4.
5.
6.
7.
Run the list with senior resident to confirm things to do
Put in the most important orders from rounds first (i.e. antibiotics,
imaging, time-critical IR procedures)
Call consults: know your question is & what you want answered
Work on discharges and sick patients first. For discharges, set up
discharge meds/prescriptions for the patients, ensure patient has ride
home, discuss dispo issues (i.e. transportation) with case management
EARLY.
Noon Conference
Afternoon: continue work, F/U Consults. Run the list. Update
signout. Can start on discharge summaries for future discharges. Do
not enter anything in the DC summary which has not yet
occurred (i.e., condition at discharge, discharge date, etc).
Anticipate care path requirements for CHF, pneumonia and MI. i.e.
for CHF pts, are they on all the correct medications?
Sign-Outs

Before sign-out:




Highlight key parts of patient’s hospitalization and active issues




Renew all orders that need renewal (IV fluids, restraints, Abx, etc.)
Order AM labs if indicated
Review sign-out with senior Resident or your Attending
Anticipate what on-call Resident may get called about
Try to avoid signing out things to do that aren’t absolutely necessary (i.e. will
not change management overnight).
Common things to sign out (to get an idea):
- check H/H if pt bleeding
- check lytes, I/O if pt being diuresed
- checking cardiac enzymes/EKGs
- F/U on critical imaging studies management
Carefully sign out what to do with if-then scenarios, especially for sick/dying
patients. Include things like OK for ICU transfer, DNR/DNI, calling
consultants if this happens etc.
- common overnight calls: pain control, fever
Admissions








First eyeball the patient and vitals to make sure they’re stable
If patient appears unstable or has critical labs (especially ICU patients),
address those first.
Then quickly read through the patient’s chart (prior H&Ps and discharge
summaries are key) before doing the full interview (this may make the
interview more efficient).
Don’t forget to get the name and number of pt’s PCP.
Don’t forget Code Status
HPI should be structured in three parts:
1) Introductory statement with patient’s age and pertinent presenting info
relating to chief complaint
2) The HPI consisting of 7 dimensions of the chief complaint
3) List of what was done in ED
For physical exam:
- don’t forget rectal exam in any patient with GI bleed or anemia
- don’t forget orthostatic vitals in patients with GI bleed, syncope etc
For abnormal labs, look back to see what the pt’s baseline is
Admissions Cont



Print/make copy of EKG to keep with you
After interviewing/examining the patient:
- present the pt to your senior resident and formulate a plan. Make
list of orders.
- put in patient’s orders first, starting with the most critical
Don’t forget AM labs. Review the routine (AM) labs; you
probably don’t need to order most of them.
- call consultants (check with your senior first)
- after all of the above is done, THEN write the H&P
When presenting new patients: have all the details, but make your
presentation pertinent. H&P should be presented within 5-10 min.
First present the H&P, then summarize 24 hr events and progress
note from today (i.e. today’s subjective, vitals, labs, imaging).
Discharges







Anticipate discharge needs and speak with case managers ahead of time.
Examples:
- equipment: walkers, bedside commodes, etc
- meds: IV abx, coumadin clinic, glucometers, Lovenox etc
- follow-up appointments (done by case managers at UCI)
- placement: SNF, board & care, hospice, referral to drug rehab
transportation home
Think of things holding pt in hospital: alimentation (nutrition), elimination
(Foley, bowel obstruction), ambulation (independence), and oxygenation
Convert IV meds to po; wean off oxygen if possible
When discharge is planned, notify pt/family for transportation
Reconcile patient’s medications and write new Rx
Notify nurse of discharge
Write D/C Instructions, Summary, enter d/c order
At End of Day

Don’t forget to ask yourself:
1) Did you place am lab orders? Do you really need those
labs?
2) NPO past midnight for procedure in am? Did I adjust
the diabetes meds and IV fluids when I made the
patient NPO?
3) Held antiplatelet drugs or anticoagulants for future
procedure?
4) Checked charts for recs from consultants, and entered
those orders?
5) Restarted diet after patient has returned from procedure?
Tips on medication orders:





For all anti-hypertensive meds, always write hold parameters for the
RNs. i.e. hold for systolic blood pressure <100. For beta blockers,
include heart rate parameter i.e. HR <55
For septic/hypotensive patient, consider discontinuing all BP meds
rather than relying on hold parameters
For all topical meds, write what part of the body to apply it to, and in
what amount (i.e. left arm thin film)
For all prn meds, must specify the prn indication (i.e. prn constipation,
nausea, anxiety etc)
For prn narcotic pain meds, must specify severity of pain (i.e. prn
severe pain).
- consider using dilaudid in patients with impaired renal function
(other narcotics have more renal excreted metabolites and therefore
their narcotic effect may be more pronounced or linger)
Tips on Meds cont









For all meds, always ask yourself if the pt has any contraindications
to it before you click the "submit" button. This is a good way to learn
contraindications. Some common ones to watch for:
heparin: bleeding/peptic ulcer, history of heparin induced
thrombocytopenia. Consider holding before any procedures/surgery
H2 blocker – thrombocytopenia
Statin + plavix (statin may decrease plavix concentration; don’t
change a stable dose unless cardiology approves)
lovenox – renal failure
ACE inhibitor – hyperkalemia with acute renal failure
NSAIDs – risk of GI bleed, renal failure
Acute liver injury – statin
Coumadin – bleeding/peptic ulcer, risk of falls (elderly). Consider
holding before any procedures/surgery
Tips on Meds Cont









A few meds to watch out for that have extensive renal clearance or
can make AKI worse, so dose must be adjusted or stopped if the
patient is admitted with AKI or develops it in the hospital:
ACE inhibitors/ARBs – monitor for hyperkalemia
atenolol
lovenox
***insulin – watch out for this one!!!
vancomycin
NSAIDs
aminoglycosides
narcotic pain meds, except dilaudid and fentanyl
Common Meds that Need
Levels Checked






Vancomycin
Digoxin
Aminoglycosides
Valproic acid
Carbamazepine
FK506 (Tacrolimus)
Tips on IV Maintenance Fluids:


Be careful giving IV fluids to pts with: CHF, renal failure,
ascites. Can cause pulmonary edema or increased ascites.
Selecting what IV fluids to use:





Dehydrated: Use NS for bolus or maintenance until euvolemic
Metabolic acidosis or hyperchloremia: Use LR
Maintenance or volume overload: Use ½ NS or D5W (preferred
for CHF, renal failure, hepatic failure)
Lack of nutrition source: add dextrose (D5 or D10 if volume
overload)
Dextrose should be added to IVF for diabetics who are
NPO and treated with long-acting insulin, even if
hyperglycemic.
Calling Consults



When calling a consultant, have the patient’s H&P and
labs handy to answer any questions.
Have a specific question in mind and ask it early on in the
conversation. i.e. “We are requesting a GI consult on Mr.
Doe to determine if he needs an inpatient colo with his
degree of iron deficiency anemia. He is a 68 y/o man
with…”
Specify how urgent the consult request is.
Calling consults cont

Anticipate information that the consultant will require over
the phone and make sure you have it ready. Common
consults:



GI bleed: vitals, rectal exam, hemoglobin, whether the patient is
iron deficient, coags, last EGD/Colo + results, hx of liver
disease/PUD, any anticoagulants
ID consult: vitals/fever curve, WBC, results of all cultures, how
many bottles positive (i.e. 1 of 2), any central lines, what
antibiotics/when started
AKI: baseline creatinine, prerenal risks (CHF, n/v/d), ins/outs,
urinary obstruction, post-void residual, BPH, recent antibiotics
(especially aminoglycosides), recent iodine contrast for CT scans
GI Prophylaxis






Overt GI bleed incidence 1.5-8.5% in all ICU patients, up to 15% with no ppx
Up to Date, after review of the literature, suggests GI ppx for all ICU pts at high risk
for bleeding, including patients with any of the following:

Coagulopathy (platelets <50K, INR >1.5, or PTT >2 times control) - odds ratio 4.3

Mechanical ventilation for >48 hours - odds ratio 15.6

History of GI ulceration or bleeding within the past year

Traumatic brain injury, traumatic spinal cord injury, or burn injury

Two or more of the following: sepsis, ICU >1 week, occult GI bleeding for ≥6
days, or steroid therapy (> 250 mg hydrocortisone or the equivalent).
H2 blocker vs PPI probably equal, some studies show oral PPI most cost effective
Recommend to use PPI instead of H2 blocker if pt has thrombocytopenia
Consider GI prophylaxis for patients on steroid therapy
Remember to D/C prophylaxis when no longer indicated (not in ICU, off steroids, etc)
DVT Prophylaxis


Strong risk factors (odds ratio >10)
- Fracture (hip or leg)
- Hip or knee replacement
- Major general surgery
- Major trauma or spinal cord injury
Moderate risk factors (odds ratio 2–9)
- Arthroscopic knee surgery
- Central venous lines
- Malignancy or chemotherapy
- Congestive heart or respiratory failure
- HRT or OCPs
- Paralytic stroke
- Postpartum
- Previous DVT
- Thrombophilia
Circulation. 2003;107:I-9


Weak risk factors (odds ratio <2)
- Bed rest >3 days
- Immobility due to sitting (e.g. prolonged car or air travel)
- Age >40
- Laparoscopic surgery
- Obesity
- Antepartum
- Varicose veins
Use the Admission VTE order set in Quest (click to fully expand) to
guide appropriate prophylaxis
Miscellaneous Pearls






HTN patient running chronically high --> don't drop BP too fast
Usually hold oral anti-glycemics on admission and prior to
surgery, especially metformin
Obtain blood/urine cultures before giving antibiotics
Patient admitted for any reason: if they have significant EtOH
history, consider withdrawal risk and doing seizure/DT
precautions or order CIWA protocol in Quest
Patient admitted for any reason: if they have significant history
of steroid use, be careful for adrenal insufficiency if stopping
steroids after more than 3 week course, or if patient has
increased need for steroids (i.e infection)
Avoid beta blockers with no alpha blockade in a cocaine user.
Use alpha blockers instead.
Miscellaneous Pearls Cont






Transfusion time for packed RBCs should be no faster than 2
hours per unit (unless acutely bleeding) as it increases risk of
transfusion reaction
Consider obtaining head CT prior to LP to assess for increased
ICH
Watch insulin dosing if patient is NPO  risk hypoglycemia
In ICU, be careful with using propofol continuously for >72
hours (risk of pancreatitis)
Patients who have small bowel obstruction: remember to
convert PO meds to IV when possible
Every patient on narcotic pain meds should have bowel
prophylaxis for constipation. Senna works well. Can order it as
standing dose instead of prn and write “hold for diarrhea”