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WAYNE STATE UNIVERSITY DETROIT MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE 2013-2014 RESIDENT SURVIVAL GUIDE Revision Date: August 2013 Created by the Resident Council Intern Representatives of 2004 Reviewed and revised by subsequent representatives yearly. Current Edition Edited by: M. Singh (Associate Program Director), B. Bangalore (CMR), V. Taneja (CMR), F. El-Khider (CMR), C. Mandapakala (CMR), L. Nandagopal (CMR) Not to be copied, used, or distributed without the express consent of the Internal Medicine Department at DMC. This booklet is to serve as a helpful assistance guide, and not meant to cover all medical scenarios, be all-inclusive for treatment protocols, or serve as a substitute for the clinician’s own clinical expertise and judgment. Welcome to the resident survival guide! You are training at one of the places in the country with amazing pathology and will work with a great bunch of people. The purpose of this book is to serve as a reference for key information you need throughout residency. It is a composite from numerous resources, put together by your fellow residents. A lot of this book contains helpful information for clinical questions. It is to be used as a reference only, not a substitute for your clinical judgment. If something here (or anywhere) does not jive with your thinking, THEN RECHECK IT YOURSELF AND FOLLOW YOUR OWN BEST JUDGEMENT. The medical team including yourself, your Senior Resident and Attending Physician will be directing appropriate medical care and making patient decisions. At the back of the book are pages for your own personal notes. At the end of the year, please forward a copy of this page to your Resident Council representatives. Then we can incorporate any key information that we may have missed into next year’s guide. Thanks! We hope that you find this resource helpful! Internal Medicine Resident Survival Guide -2- TABLE OF CONTENTS SECTION 1: CONTACT INFORMATION General Telephone Numbers and Information…………………………………….. 5 Food & Lockers…………………………………………………………………………6 Paging System………………………………………………………………………… 7 Internal Medicine Administration Pager Numbers…………………………………. 8 Internal Medicine Resident Pager Numbers……………………………………….. 9 Subspecialty Fellow Pager Numbers……………………………………………….. 11 Commonly Called Numbers…………………………………………………………. 13 Information Systems Contacts & Tech Tips………………………….…………….. 14 Nursing Station & ICU Phone Numbers..…………………………….…………….. 16 Subspecialty Clinic Numbers…………………………………...…………………….16 VA phone numbers…………………………………….………………………………17 Outside Hospitals/Clinics & Medical Records……………..………………………..19 SECTION 2: ROTATION INFORMATION Guide to Rotations………………….………………………………………………….21 Intern Etiquette………………………………………………………………………… 22 Tips from Interns and Seniors……………………………………………………….. 24 Admission Orders………………………………………………………………………24 Do Not Use Abbreviations…………………………………………………………… 25 Prisoner Protocol……………………………………………………………………… 25 Writing Orders……………………………………………………………….………… 26 Progress Notes……………………………………………………………………….. 27 Power Notes…………………………………………………………………………… 28 How to Present a Patient…………………………………………………………….. 29 Discharge Planning…………………………………………………………………… 31 Discharge from the ICU………………………………………………………………. 32 Dictating…………………………………………………………………………………33 Consults………………………………………………………………………………... 34 Death Notes…………………………………………………………………………….35 SECTION 3: DOCUMENTATION & BILLING Medical Documentation – Charting…………………………………………………. 36 Billing in the Hospital and Ambulatory Setting…………………………………….. 37 New Innovations Responsibilities ……………………………………………………40 SECTION 4: TEACHING INFORMATION Residents’ Role in Teaching…………………………………………………………..41 Medical Student Expectations……………………………………………………….. 42 Responsibilities to Our Medical Students………………………………….……….. 43 SECTION 5: MEDICAL INFORMATION & TIPS Acute Emergencies…………………………………………………………………… 48 AMS…………………………………………………………………………48 Seizures…………………………………………………………………….49 Internal Medicine Resident Survival Guide -3- Chest Pain…………………………………………………………………..50 Shortness of Breath………………………………………………………..51 Stroke………………………………………………………………………..53 Alcohol Withdrawal…………………………………………………………54 How to Read an EKG………………………………………………………………….55 ACLS …………………………………………………………………………………... 56 Electrolyte Replacement……………………………………………………………… 62 Common On Call Complaints & Subspecialty Tips………………………………...65 Ambulatory………………………………………………………………….65 General…………………………………………………………………….. 65 Pain………………………………………………………………………….67 Cardiology/Hypertension…………………………………………………. 69 Critical Care/Pulmonary………………………………………………….. 85 Endocrine…………………………………………………………………...94 ENT…………………………………………………………………………. 97 Geriatrics…………………………………………………………………… 98 Hematology/Oncology……………………………………………………. 98 Infectious Disease………………………………………………………… 107 Nephrology and Acid Base………………………………………………. 111 Neurology………………………………………………………………….. 114 Rheumatology………………………………………………………………118 Miscellaneous………………………………………………………………119 Useful Equations……………………………………………………………………….121 Core Measures…………………………………………………………………………124 SECTION 6: RESOURCES Community Resources……………………………………………………………….. 125 OTHER Acknowledgements…………………………………………………………………….134 Corrections & Notes……………………………… …………………………135 Internal Medicine Resident Survival Guide -4- SECTION 1: Contact Information GENERAL TELEPHONE NUMBERS The Detroit Medical Center Internal Medicine Residency program includes training at the following hospitals: Detroit Receiving 313-745-3000 Harper University 313-745-8040 Veteran’s Hospital 313-576-1000 Karmanos Cancer Institute 1-800-KARMANOS Rehabilitation Institute of Michigan 313-745-1203 Children’s Hospital of Michigan 313-745-5437 Sinai/Grace 313-966-3300 Hutzel Women’s Hospital 313-745-7555 SHIFFMAN MEDICAL LIBRARY Wayne State University Medical School – Need a One Card for access. The library is located on 320 E. Canfield St., in the Mazurek Medical Education Commons building between the School of Medicine and the Harper parking structure. Hours of Operation: Sat & Sun 12 p.m. – 8 p.m. Mon - Fri 7:30 a.m.- 12 a.m. (313) 577-1094 WSU ONE CARD What is it? An access card for the School of Medicine, University Medical Library and Fitness Center. Where to get it? Wayne State University Main Campus Welcome Center 42 W. Warren Avenue, Suite 257 313-577-CARD http://onecard.wayne.edu/ Hours of Operation: M - F 8:30am – 5 pm Internal Medicine Resident Survival Guide -5- CAFETERIA HOURS and protocol to get fed on call or to get fed at all… Detroit Receiving 6:30am – 10am 11:00 am – 2:00pm 5:00pm – 7:00pm Harper Hospital Hot breakfast 6:30 – 9:15 Grab “n” go 9:15 – 10:30 Hot lunch 11:30am – 1:45pm Hot dinner 4:00pm – 6:30pm VA 7:00 am – 2 pm Monday – Friday On call night dinner: To hold an on call meal tray, call 6-4567 well before the dinner hours. To get your tasty meal, go down to basement, south side of building, enter into the taped off rectangle (no joke), sign your name on the clipboard. Your meal will be made at that time. Quizno’s - Harper Coffee Shop and Gift store – Hutzel lobby Subway (24h) – DRH, Children’s Midtown Café – Harper/Karmanos Biggby Coffee (24h) – DRH, Children’s Wendy’s - Harper Lockers • Harper: Lockers are available in the on-call suite on 7-Brush and the House officer locker-room. Contact the Chief Resident to check out a lock. • DRH: Lockers given to you for floor months. This info is included in packets at the beginning of the month. • VA: As far as lockers go, there are some for residents to use, but you have to bring your own lock, they're located in the call rooms and on the 3rd floor, close to MED services. On consult months: Use the lockers in the 7-Brush on-call suite Security Call 111 at DMC, also this information is on the back of our badge. Parking Parking for all residents is at the Harper Parking structure, across from the Professional Building. You can park in the DRH underground lot after 6pm on weekdays and ANY time on weekends. Can also park at the Children’s and Kresge Eye lots. Internal Medicine Resident Survival Guide -6- PAGING SYSTEM DETROIT RECEIVING, HARPER AND KARMANOS HOSPITALS Dialing instructions • In house access: dial 122 then enter the pager number. Follow prompts. Enter your callback number, press * and enter your pager number. • Out of the hospital: dial 1-313-745-0203 then enter the pager number. Follow prompts. Enter your callback number, press * and enter your pager number. DO NOT return pages from your personal cell phone. If you must, press *67 and then dial the callback number. This will remove your number from caller ID. You do not want patients to have your personal number! Text paging 1. 2. 3. 4. 5. Go to the DMC Intraweb. Locate person by name or pager. It brings up a list. Click on person’s pager number if it is green (active). Type in note and send. You may also text page someone from a cell phone if you know the 10 digit number assigned to the pager. This is located on the back of the pager or through the intraweb paging page of a specific person. Signing out the pager or changing your greeting • Dial 123 or 1-313-745-4050 and follow prompts. VETERENS HOSPITAL • In house access: dial 6-1135 and follow prompts. Enter the full number, not just the extension when calling from the VA. • Both Karmanos and the VA have numbers that start with 576 – XXXX. Entering the whole number prevents confusion at these two hospitals. • Out of the hospital: call the VA operator at 1-313-576-1000 and ask them to page Internal Medicine Resident Survival Guide -7- Department of IM 4201 St. Antoine Fax 2E UHC Detroit, MI 48201 745-4832 745-4052 Housestaff Office DRH 5S10 Harper 2 Hudson VAMC C3-100 Tammy Lee Laura Goss Shirley Kmetz Elinda Joseph Payroll 745-7999 745-4832 745-4901 577-0348 578-3704 DMC Medical Records (Inpatient) DRH 745-3285 Harper 745-8022 Karmanos 576-9393 VAMC 576-3638 745-4525 745-4063 966-7340 745-3322 AIl Medical Records (Outpatient) GMAP 745-2899 745-4141 Resident Clinics GMAP Phones in staffing area 4C UHC 745-3265 745-8334 576-3450 Medical Education and Program Directors Chief Medical Residents B. Bangalore (DRH ) V. Taneja (HUH/AMB) F. El-Khider (VA) L. Nandagopal (Quality) C. Mandapakala (Quality) 8639 7213 7126 7184 7161 On Call Department Pagers Anesthesia Pain - DRH Anesthesia Pain – Harper Bone Marrow Fellow Cards Resident (Harper) Cards Fellow (Harper) CCU Resident (DRH) Chaplin Dermatology 313-436-2848 Echo Tech EEG Fellow Endocrinology ENT Geriatrics GI GYN Onc Hematology Interventional Radiology Medicine on-call Harper Medicine A (DRH) Medicine B (DRH) 6238 9996 9080 4444 6666 9009 5661 0111 5298 5424 8445 0978 06565 5456 5548 6955 07777 6789 0997 5755 Dr. D. Levine Dr. T. Vettese Dr. J. Weinberger Dr. M. Singh Dr. S. Wilson 11204 60230 2028 3011 280-0426 MICU 6428 6313 5573 5513 9429 08888 5859 9981 09999 5228 1619 1234 9997 3622 5161 Harper DRH Nephrology Nephro, Transplant Neurology Neuro-radiology Neurosurgery Harper DRH Radiology Palliative Care PM&R nights/weekends Pulmonary Stroke pager Toxicology Urology Internal Medicine Resident Survival Guide -8- COMMONLY CALLED NUMBERS DRH Harper Hutzel ABG Lab 53482 58070 Admitting 54400 54400 Anesthesia 52607 58521 57315 Angio Lab 58325 Blood Bank 54206 58565 50872 Brochoscopy 58516 Cath Lab 52692 Central Supp. 53396 58171 57428 Chemistry 54598 58555 50877 Coagulation 30714 Core Lab 54588 CT scan 57979 58412 57600 Cytogenetics 52541 Cytology 52849 50834 50864 Dental 51977 Dietary 53252 50825 57041 Drug Info. 54556 52005 57025 Echo Lab 52666 52666 TEE lab/results 52523 Echo Results 52680 Echo Strest lab 52679 Echo Tech #5298 Endoscopy 53188 58358 EP consults 52626 EP lab 52390, 50680 EEG 58328 58328 57305 ER 53374 51477 50681 ER South 59726 FISH Cytology 60680 General Info. 53603 58811 57555 Gyn On Call #5741 GynOnc oncall #5548 Hematology 54714 59292 Home O2 Eval P#9140 IR 58899 Immunology 30374 KCI Hospice (248) 827-7722 Lab Results 54100 54598 57202 Life Stress 54811 54811 54811 DRH Harper Hutzel Microbiology 30700 30700 57202 Medical Rec. 53285 58022 Molecular Genetics 32631 MRI - inpatient 51367 MRI – outpatient 51376 Neuro – Radiology 62807 Nuclear Med. 58417 57191 Nuclear Stress test 52326 Nutrition 53254 Occ. Therapy 53523 58242 57020 OMFS 54696 OR boarding 53182 52600 57279 Ostomy nurse 95192 Pastoral Care 52905 #5066 57279 Pathology 58940 59592 Patient Info. 53603 56000 57700 Pharm-inpt 53514 58623 58623 Pharm-outpt 65148 Physical Tx. 53535 58058 57020 PICC line 97547 PM&R 51000(RIM) Poison control 800-222-1222 Pulm. Funct. 54761 58516 57417 Radiology 54685 58402 57417 Rad. Onc. 59191 59191 57626 Recovery 53188 58525 57531 Resp. Ther. P#9827 #9140 57417 Security 53325 58352 57031 Shuttle Bus 58353 “ “ Smoking Ces. 58516 58516 58516 STAT Lab 30288 58555 59288 Social Work 53575 58313 57051 Telepage 55151 55151 55151 TB/AFB lab 30994 Ultrasound 53465 59461 57558 US Tech 59513 Vascular Lab 53465 58828 57305 Virology 30710 VNA P#6374 Internal Medicine Resident Survival Guide -9- INFORMATION SYSTEMS CONTACT Citrix/CIS Helpdesk 966-2400 Chris Harwood (DRH physician support) Pager #97530 MSIS Helpdesk 577-1527 (for GMAP EMR/NextGen & WSU email) TECH TIPS *INSTALLATION INSTRUCTIONS for Citrix on iPad/iPhone 1. Go to the App Store and download the latest Citrix Receiver. 2. Once the Receiver is installed on your mobile device, click on the icon “CITRIX” on your mobile device. Then click “Get started.” 3. The following screens will be for configuration, please use the following information: a. Description: Can be any name; suggest DMC Citrix b. User Name: Your DMC Citrix UserID c. Password: Your DMC Citrix password d. Domain: DMCNT1 4. Click “save” when all information is entered. 5. Now the device is ready! 6. Once you click DMC Citrix and enter your credentials, the list of applications will show up. 7. Click the “+” sign at dazzle and “+” sign in the list to add to your favorites. 8. Click on the Citrix Desktop Icon to launch DMC’s Citrix Desktop on your device. Note: When you change your DMC Citrix Desktop password, you will need to go into your iPhone/iPad Citrix Receiver account and update it. USEFUL WEBSITES: • • • • • • • • • • • • The Hospital Physician Journal: http://www.turner-white.com/hp/contenthp.php The Cleveland Clinic Journal: http://www.ccjm.org/default.asp Mayo Clinic Proceedings: http://www.mayoclinicproceedings.com/ Evidence Based Medicine Resource: http://www.supersmarthealth.com/ Medline Plus: http://www.nlm.nih.gov/medlineplus/evaluatinghealthinformation.html Emedicine: http://www.emedicine.com/ National Guidelines Clearinghouse: http://guidelines.gov/ The Cohchrane Library: http://www3.interscience.wiley.com/cgibin/mrwhome/106568753/HOME?CRETRY=1&SRETRY=0 Clinical Knowledge Summaries: http://www.prodigy.nhs.uk/home Center for Reviews and Dissemination: http://www.crd.york.ac.uk/crdweb/ The Ectopic Brain: http://pbrain.hypermart.net/medapps.html Medical Calculator: www.medcalc.com Internal Medicine Resident Survival Guide - 10 - GUIDELINES: There are many! A useful place to start is The National Guidelines Clearinghouse: http://guidelines.gov/ EMAIL: http://owa.med.wayne.edu LOGGING PROCEDURES and DUTY HOURS: New Innovations http://www.new-innov.com/login.htm • Institution login: DMC (all capital letters) • Username • Password JOHN HOPKINS MODULES: http://www.hopkinsilc.org/ • Click on "click here to register" if you are a first time user. • When you log in you must select the ILC group you are interested in. (i.e. Internal Medicine Curriculum or Internal Medicine: Medicine Consultation Curriculum) CIS & CITRIX AT HOME: www.dmc.org/staff • Click on Remote Access to CIS • Type username and password PACS Web CONNECT: • Call 966-2400 to have your account added to the “Vital Clinical Users” • Log onto the DMC Citrix Desktop • Double-click the PAC Web CONNECT icon. (CXR picture) • You do not have to login on the next window, Click “OK” PHARMWEB: Fantastic medication guide for all specialties • Log into CIS • Enter the Internet and Web-Portal • Click on Intraweb tab (at the very top of the page) • Click on the “Pharmacy” tab • Use the drop down menu to click “Pharmacy Website” HOSPITAL POLICIES: Detailed explanations can be found on the DMC intraweb. • Click into the DMC web Portal • Click the “Clinical Tools” Tab • “Search” Policies in the lower left of the screen Internal Medicine Resident Survival Guide - 11 - Harper Hospital Nursing Units 10 Webber North 576-9229 10 Webber South 51509 9 Webber North 576-9250 9 Webber South 52277 8 Webber North 576-9126 8 Webber South 56057 6 Brush 52147 5 Webber North 576-9213 5 Webber South 51509 5 Brush North 52200 5 Brush South 52200 4 Webber North 4 Webber South 4 Brush North 3 Webber North 3 Webber South 3 Brush 2 Brush North 2 Brush South 2 Webber North 2 Webber South 52127 52287 52216 50645 50755 52147 52168 50613 50623 50513 DRH Nursing Units 3Q 53199 3R 53547 5U 53573 4M 53018 4N 53124 4Q 53031 4R 53447 4U 53034 4V 5L 5M 5N 5Q 5R-1 4L 53082 53087 53091 53508 53511 52990 53093 Harper Hospital Intensive Care Units 9 ICU 58792 Cardiothoracic 8 PCU 65203 6 ICU 58694 5 ICU 4 ICU 52297 58568 4T 5Q 5R 4Q-2 Burn Unit Step Down Coronary ICU Medical ICU Surgical ICU DRH Intensive Care Units 4P Surgical ICU 4Q-1 Surgical ICU 5T Neurotrauma 4S Burn Unit 53148 53164 33841 53074 Subspecialty Clinics • Cardiology, 4C 745-3322 • Endocrinology, 4C 745-4525 • GI Endoscopy Unit 745-8358 • Heart Failure 745-4525 • DRH Endoscopy 745-3090 On Call # after 5 p.m. #5456 • Hem-Onc Clinics 1-800-KARMANOS • Pulmonary, 4C 745-4525 • Geriatrics, 5B 745-1741 • Neurology 745-4275 • Infectious Diseases 966-7601 • Vaginitis Clinic 966-7600 • • • • • Medicine Neurology 53078 53911 52990 53447 HIV clinic 745-8172 Nephrology, Ste 917 745-4525 Transplant Clinic 745-4195 Rheum, Suite 917 745-7227 General Surgery PDI/Highland Park 852-7700 • Urology 833-3320 Outpatient Dialysis Centers • CAPD Clinic-Gambro/ Motor City Dialysis 993-2958 • Gambro/Kresge 745-1885 • Harper Pro Building 745-4195 Internal Medicine Resident Survival Guide - 12 - VA NUMBERS Location A2N-MICU A2S- Surgery Clinics A3 North A3 South A4 North (SICU) A4 South (Surgical) A4N- Short Stay A5 North A5 South A6 South A6N ADMITTING Angiography Ann Arbor VA B2S Blood Bank C2 South – Dialysis C2S Hemodialysis C4 Tele/ Stepdown House staff office Phone Ext. 6-3640/ 6-3642 6-5716/ 6-3424 6-4150/ 6-4151 6-3786/ 6-3787 6-3948/ 6-3949 6-4180/ 6-4181 6-4209/ 6-4210 6-4085 6-4241/ 6-4242 6-4297/ 6-4299 6-4327/ 6-4328 6-4351/ 6-4352 6-4114/ 6-5602 Location C4-SW / SICU Cardiac alert (code blue) Phone Ext. 6-3948/ 6-3949 6-3333 Location ER Cardiology 6-3635 Cardiology Clinic Chem Lab 6-4666 6-4025 Fax Unit (Endo office) Fire Code (code red) FIRM A Pharmacy FIRM A Chief of Medicine CLINICS 6-3318 FIRM B Coumadin Clinic CT Scan 6-5710 FIRM C Pharmacy FIRM C Cytology 6-3365 / 6-5603 6-3414 Diabetic teaching Dietician 6-4829 Dietician C4 6-4566 1-800 361-8387 6-4951/ 6-4303 6-3419 6-3454 Disturbance (code green) Echo 6-3777 6-3713 EEG EKG 6-3425 6-3368 6-3454/ 6-3648 6-5824 6-3295 6-3450 Endocrinology 6-3125 ENT 6-3210/ 6-4017 6-3233 Pharmacy inpatient 6-4595 Internal Medicine Resident Survival Guide - 13 - FIRM D FIRM D Pharmacy FIRM E Pharmacy FIRM E Phone Ext. 6-4436 576-1122 6-3555 6-5709 6-4145/ 6-5868 6-5767/ 6-5710 6-3276 6-3634/ 6-3282 6-5883/ 6-4425 6-3343 6-3386 6-3732 FIRM F ALLEN PARK Fluoroscopy 6-6002 6-6003/ 6-6004 6-3255 Gastroenter ology GEC General Diagnostic Radiology Heme Lab 6-3389 Home O2 evaluations 6-3297 250-5146 6-4276 6-4283 / 6-3255 6-3423 Location Location IR Phone Ext. 6-5541/ 6-3901 6-5698 Laboratory general 6-3411 Laboratory Chemistry 6-4025 PICC lines and IR procedures Tom Lamacchia PODIATRY Laboratory Heme 6-3423 Police & Security Laboratory Cytology Laboratory -Micro Laboratory- UA Library Medical Records Micro 6-3414 6-5041 6-3860 6-3380 6-3224 6-3691 Pre-cert Prosthetics Psych Psych(Dr.Day) Radiology Respiratory MICU 6-3640/ 6-3642 6-4283 / 6-3601 6-3601 6-3648 6-3434 6-3434 SICU Infectious Diseases MRI MRI Nephrology Nuclear Medicine Nuclear Medicine Nursing home/rehab 250-1632 280-0359 250-3032 6-4062/ 6-4078 6-4425 Operating Room Outpaitent appointment Palliative care Dr. McDonald Palliative care -Sheila Vogel Pharmacy outpatient Physical Tx. Social Work Phone Ext. 6-3762/ 6-3457 6-3516 6-9530 250-0947 6-3999/ 6-4000 6-3375/ 6-3201 250-3039 6-4897 6-4303 250-0991 6-3256 6-3024 6-3338 6-3513 6-3295/ 6-3954 6-3215 Social work (C4 SD) Social work (Karen) Social work (Nicole) To hold an on call meal tray Wound care 6-1332 6-3460 6-5816 6-4567 UHCMED 6-4896 Ultrasound 6-3255 / 6-5820 6-4683 705-7808 6-3802 6-3197 Urology 250-1240 Vascular Lab 6-4112 VA paging system: For 5 digit numbers dial 61135 followed by the 5 digit number followed by your call back number. For paging a 7 digit VA pager dial 9 followed by the number and leave a call back number. For paging a DMC pager (4 digit number) dial 7450203. Internal Medicine Resident Survival Guide - 14 - Phone Numbers of Outside Hospitals/Medical Examiner BiCounty Hospital Medical Records Emergency Room 586-759-7370 586-759-7310 Bon Secours Medical Records MR Fax Number Emergency Room 313-343-1000 313-343-1625 313-343-1186 313-343-1605 Karmanos Medical Records 1-800-527-6266 313-576-9393 Botsford Medical Records Emergency Dept. 248-471-8000 248-471-8175 248-471-8556 Northville State Hospital 248-349-1800 Beaumont Medical Records MR Fax Number Emergency Dept. 248-551-5000 248-551-5050 248-597-2848 313-593-7440 Oakwood Medical Records Emergency Dept. 313-593-7000 313-593-7780 248-551-6000 Children’s ER Administration Pt. information Medical Records 313-745-0113 313-745-5255 313-966-5110 313-745-5356 Providence Medical Records Emergency Dept. 248-424-3000 248-849-5580 248-849-3000 RIM 313-745-1203 Riverview Medical Records Emergency Dept. 313-499-4000 313-499-4589 313-499-3331 Sinai-Grace Medical Records Emergency Dept. 313-966-3300 313-966-1092 313-966-1010 St. John’s Main Medical Records 313-343-3400 313-343-3780 DRH Triage Crisis ER x-ray Fax Medical Records 313-745-2230 313-745-3374 313-745-3546 313-745-3423 313-745-4038 313-745-3285 Detroit Psych Insitute 313-874-7500 Garden City Medical Records Emergency Dept. 734-421-3300 734-458-4405 734-458-3426 Henry Ford Medical Records After Hours MR Emergency Dept. 313-916-2600 313-916-4540 313-434-2337 313-916-1545 Herman Keifer 313-876-4826 Medical Examiner 313-833-2568 (Call if death is a result of trauma, suicide, or within 24 hrs. of admission) St. John’s Macomb Emergency Dept. 586-573-5051 Medical Records 586-573-5080 Internal Medicine Resident Survival Guide - 15 - St. Mary’s Mental Health Social Health TB 1-800-464-7492 313-876-4400 313-876-4180 313-876-0335 Holy Cross Medical Records Emergency Dept. 313-369-9100 313-369-5727 313-369-5689 Huron Valley Emergency Dept. 284-360-3400 Hutzel Medical Records Emergency Dept. 313-745-7141 313-745-0680 U of M Medical Records Fax 734-764-1817 734-936-5490 734-647-6220 Medical Records Emergency Dept. 734-655-9253 734-655-1200 St John’s Oakland Medical Records Emergency Dept. 248-967-7000 248-967-7080 248-967-7670 Veterans 313-576-1000 Poison Control (HPB) St. Joseph Pontiac 313-745-5711 248-858-3000 Wyandotte 734-284-2400 Hospice KCI 248-827-7722 Southeast MI Hospice 313-578-6300 Detroit Area Methadone Clinics MY FREQUENTLY CALLED NUMBERS: LOCATION Herman Keifer Hospital Medical Resource Center Methadone Clinic Metro-East Metro-East Gratiot Metropolitan Rehab Clinics Mich Counselling Services Nardin Park Drug Abuse New Light Recovery Center Parkman Counselling Rainbow Clinic St. Joseph Mercy Starr Clinic VA Methadone Clinic Phone 876-4045 852-4838 852-4476 758-6670 745-7411 571-3140 371-7770 248-967-4310 248-547-2223 834-5930 867-8015 532-8015 248-370-0010 865-1580 858-3177 493-4410 576-1000 ext 5252 Internal Medicine Resident Survival Guide - 16 - SECTION 2: Rotation Information GUIDE TO ROTATIONS: MEDICINE FLOORS 1. Get to the hospital on time. 2. See new patients/sicker patients first 3. Existing patients: Check orders, read nurse’s notes from your shift and overnight, vital signs, progress notes, focused physical exam. If you are not able to write your notes on all patients prior to rounding, make sure you check the vitals, and do a very focused exam. Then, check labs just before rounds. 4. Pre-round on patients with your senior as directed by your senior 5. Be ready to round with your attending in order to get to morning report on time. 6. Morning report: Put your pagers on vibrate. Leave for morning report 5 minutes early. The morning reports are a golden opportunity to review patient cases, articles, and actually talk through it. This is your time, so it can only be as good as you make it. Ask questions. And as uncomfortable as it may be when some of the higher ups pimp you, know that you are learning something every time you are unsure of the answer—hey, you probably won’t forget it for next time around! 7. Rounds with attending. You have to keep the attending moving and on pace. Remind them that you need to be at morning report/noon conference and they don’t know that the sickest patient that will require the most time may be the third, forth, or even last patient on the list. 8. Noon conference: Again, try to make it. Put your pagers on vibrate. THIS IS SUPPOSED TO BE “PROTECTED TIME” for your education. Leave so that you can make it. Most attending doctors are supportive, but if they are not, politely explain this is mandatory and you must sign in daily. 9. Recheck any labs, procedures, write follow up orders, finish notes. 10. Be available to take sign-outs from your colleagues. ICU & CCU • Be organized. • Know your limits and call when you need help. • Get sleep and food when you can get it. You won’t always have time. • “Know thy lytes.” Replacement for Mg and K is not the same as on the floors. Keep Mg at 2.0 or higher, and K at 4.0 or higher. Use electrolyte protocols. • Bringing pocket food helps—if you can’t catch dinner at least you have something in your pocket to snack on. • Bringing a change of scrubs; a face towel, and soap are little luxuries that make you feel better if you really did have some time to snooze. Tip from the peers on rounds standing next to you: Bringing some deodorant to put on in the AM is appreciated by your peers rounding the next day—to keep yourself smelling daisy fresh. • Education may be self driven, so read. • Learn the algorithm for discerning typical for Typical chest pain: substernal squeezing or pressure, aggravated by activity, lasts <30 mins, may have associated NV/SOB/diaphoresis/palpitations, relieved by nitro. Internal Medicine Resident Survival Guide - 17 - INTERN ETIQUETTE Sign Out List The team on-call (or night float residents ) is responsible for the care of all patients on the general medicine ward teaching service. To assist them in this, careful directive information must be provided by all non-call services prior to leaving the hospital. Usually this is done "intern-to-intern" or "subintern-to-subintern” preferably face-to-face, rather than over the telephone. The sign out list must contain the following: 1. All of your patients, not just the sick ones 2. Patient name, room number 3. Social security number 4. Major problems and possible interventions 5. Code status 6. List of labs and x-rays to be checked (keep to a minimum) Cross Coverage It is difficult to develop a complete list of complaints or problems, which require a physician's presence. Simple problems, such as the need for sleeping pills or pain medication for mild pain can be handled over the telephone. If you have any doubt as to whether a patient's problem can be handled by telephone or if a physician's presence is necessary, GO TO SEE THE PATIENT. As you gain experience you will become more comfortable with such situations. A few examples of problems needing IMMEDIATE attention include chest pain, shortness of breath, unresponsiveness or mental status changes, new fever and hypotension. Inform your supervising resident of these critical problems and elicit their opinion on the appropriateness of your response. Often it is necessary to see the patient. When you do, be sure to: 1. Place a note in the chart describing why you were called 2. Write a careful description of the patient 3. Write a directed physical exam 4. Indicate pertinent labs/tests performed 5. Indicate your impressions and what treatment (if any) was rendered We would recommend that for the first few months, you go to see all patients with complaints or problems until you become more experienced. Verbal Orders Verbal orders can be given in emergency situations, but all orders need to be entered by you into the EMR at some point in time. Do not rely on the nurse to enter the orders. If orders are not entered into EMR, mistakes will be made and patients will be hurt. Internal Medicine Resident Survival Guide - 18 - Beeper Etiquette 1. Answer all pages as soon as possible and should be within a 20 minute time span. 2. SIGN OUT your pager to covering intern/resident when you leave. 3. DO NOT turn your pager OFF unless you change your status to "Not Available" 4. ALWAYS remember to change your pager status at the beginning of the day to "In Hospital, On Page." 5. STAT pages have a "11" at the end or a “00” at the beginning of the call back phone number 6. Do Not page someone to your pager; page them to a telephone 7. Place your pager on VIBRATE during ALL conferences and meetings 8. DO NOT turn your pager OFF during call rotations - you are expected to have the pager on even when you sleep when on-call 9. DO NOT turn off your pager when you are on back-up call (JEOPARDY list) 10. Be sure to include your pager number with your call back telephone number in the event that you are called away. 11. Try to keep the phone line open if you place a page to that line. TIPS FOR INTERNS FROM INTERNS • • • • • • • • • • • • • If a patient is a poor historian, looking back in CIS is helpful as well as talking to family members. Previous Discharge Summaries, procedures and labs give lots of useful information. Getting a number to an outpatient pharmacy can lead to the list of home medications. No matter what, maintain a positive attitude. It goes a long way in patient care and work relationships. Maintain your sense of the world outside of residency. There is one! Maintain your relationships with your friends, family, and loved ones. We all get overwhelmed. You are not alone if you feel this way. Just keep going, be calm, and try to remain positive. Sometimes the different disciplines within the medical specialties enjoy slamming each other. Will this change? Probably not, but don’t perpetuate it by doing it yourself. Assume the care givers you work with are all out for the same goal as you—to get the patient the best possible care. Try to rest the day before your call; you will need it. Never forget to eat or use the restroom. If you have any time during you call try to rest, the night can change dramatically. Be ready to be paged for any crazy question from the nurses, but always remember you are a doctor and need to behave like it. Be nice to everybody, no matter what is going on you are still part of a health care team and you need their help and cooperation. Make a small plan of your expectations each month so you will have an idea of what you got from it at the end. Don’t be shy--if you don’t know ask, there is nothing wrong with not knowing. Bond with your fellow interns—at least on a professional level. We are the only support one another have…look out for each other. Be constructive, helpful and supportive of one another. Internal Medicine Resident Survival Guide - 19 - TIPS FOR INTERNS FROM THE SENIORS • Senior residents were interns not too long ago, and in general they are aware of your situation. If you think that is not the case, verbalize it and they will recall!! • Seniors might have become a "super intern" but they are still new as a "senior" as you are new as "intern". They may not be comfortable themselves functioning as senior and might have their own issues and frustrations. • If you are in doubt, always talk to the senior, they never mind a call. It is much better than to face adverse outcomes later. • If you think you are not getting enough support/guidance/backup from your senior, you should talk to the senior directly about it and try to solve it. If that does not work the safest way is to get support/backup from attending. Never leave your self alone without backup or support. You will slowly develop confidence in almost every matter and eventually will not need to ask questions that often, but that is the process of training. • All seniors have their own limitations and good seniors will reveal them honestly and handle them maturely. Some seniors won't and it may become frustrating. It is a very tricky situation, where a smart intern has to handle it very tactfully, understanding the fact that senior is feeling embarrassed and needs support themselves. • Try to find something interesting in your work even if you are bored by a particular month. • If the senior resident asks you to do something that you cannot do, simply say so without any hesitation. • Always expresses needed days off in advance. Most of the time requests are granted if at all possible. • Never disappear without telling someone. • Be punctual. It is OK to be late on occasion but you should call/page if possible. • Always be honest and friendly! ADMISSION ORDERS Mnemonic ADC(x2) VANDALS A –Admit to: Attending/Resident/Interns (include names and pager #s) D- Diagnosis C- Condition (i.e. stable, fair, poor, guarded) C- Code Status V- Vitals (routine, q shift, q 4 hrs, q 2 hrs, etc. Include vitals call orders (i.e. call MD for T >100.5, SBP >180, or <90, pulse >120 or <60, RR >30 or <10). Adjust these to fit the individual patient. A- Allergies (List all known drug allergies and reactions) N- Nursing (i.e. SCDs in bed, Foley to dependent drainage, Strict I’s/O’s, Daily wts. Accuchecks q ac and q hs, O2 N/C to keep sats >94%, wound dressing orders, etc.) D- Diet (Regular, 2 gm Na, Diabetic ADA diet, etc.) A- Activity (as tolerated, out of bed tid, bedrest with bedside commode). Order activity based on pt’s fall risk, strength, need for activity. L- Labs (If writing for a.m. labs it is helpful to the unit clerks to include the date you want the labs to avoid confusion) S- Special Tests (i.e. CT scans, 2-D echo, Consults, etc.) Internal Medicine Resident Survival Guide - 20 - Do not use” Abbreviations Use of abbreviations is discouraged. accepted: Abbreviation Intended meaning U or IU Units or international units Micrograms µg Avoid abbreviating drugs. The following will not be Misinterpretation Recommendation Mistaken as a zero or a four when poorly written, resulting in overdose (ex: 4U 40) Mistaken for “mg” when handwritten, resulting in overdose Decimal overlooked and mistaken for 5mg (overdose yet again) “units” Lack of leading zero (.5mg) 0.5mg Use of trailing zero (5.0mg) 5mg Decimal overlooked and mistaken for 50mg (you got it, another overdose) TIW Three times a week Hours Misinterpreted as “three times a day” or “twice a week” Misinterpreted as zero (q3° every 30 minutes) Mistaken for one another; period after the Q mistaken for an “i” Mistaken for one another ° symbol Q.D., Q.O.D. MS, MSO4, MgSO4 Every day, every other day Morphine sulfate, magnesium sulfate “mcg” or “micrograms” Always use leading zeros when the dose is less than a whole unit (0.5mg) Never use trailing zeros for doses expressed in whole numbers “three times a week” “hour, hr. or hrs.” “daily” and “every other day” “morphine sulfate” or “magnesium sulfate” PRISONER PROTOCOL Incarcerated individuals are frequently admitted to our hospitals. Frequently they are cuffed to their beds and have 2 police officers watching them in the room. Never tell a prisoner patient when their follow up appointments will be. Any information that could assist incarcerated patients with knowing accessible moments is not to be given to them. Do not take or make phone calls on their behalf. You may not even be able to call their family. You will need to ask the appropriate Officers/Deputies before doing so. Internal Medicine Resident Survival Guide - 21 - WRITING ORDERS PRN orders PRN" orders must include your criteria for administration. For example, simply writing Tylenol, 300 mg PRN is unacceptable. “Acetaminophen 300 mg 1 tab po q 4 hours prn low back pain” is ok. Use generic names if possible. IV Orders The same rule applies as for non-IV orders. To avoid confusion, each time you write for a new IV or make changes in an existing IV, include the following: IV solution, Volume, Additives, Rate. Change IV medications and fluids to oral as soon as possible; this is cheaper, fraught with less complications and demands less nursing and pharmacy time. Stat or Urgent Orders After entering such orders, go to the patient's nurse and discuss them. This will minimize misunderstanding and expedite patient care. Always contact the consultant by phone if the problem is urgent. Lab Tests Some general rules to follow: 1. Be able to justify every order you write and to explain the reason for every test required. There are no “routine screening labs”. 2. Repeat any grossly abnormal lab results, especially if they don't fit the clinical situation or the result is unexpected. 3. It is your responsibility to check and follow-up on every order you write in both the inpatient and outpatient setting. This must be done in a timely fashion. Do not let your attending rounder discover an abnormal lab result before you do. 4. Find out when phlebotomists will draw labs. Radiographic Studies Always include pertinent details with each procedure request. This will allow the radiologist to read the film with some knowledge of the patient's clinical condition (and allow the hospital to get paid). Note that “rule out” notations are not permitted. Whenever possible, please check the “wet-read” on the study in question before paging the radiology resident on call. There will often be a preliminary interpretation entered by the on-call resident which may be sufficient until the official dictation becomes available on CIS (i.e. “no pulmonary embolus”, etc.) Internal Medicine Resident Survival Guide - 22 - The Formulary System The Detroit Medical Center operates under a “closed formulary" system. In other words, there are a group of drugs, which are approved for use at our hospitals. A pharmacist will notify you if you have ordered a drug that is not available or requires permission of a subspecialist to use. Remember that the pharmacist is just doing his/her job by calling you, and that there are usually very good reasons why particular drugs are "non-formulary" or restricted. The pharmacist usually will be able to suggest a similar formulary item or assist you in obtaining non-formulary items or restricted drugs, if necessary. PROGRESS NOTES You will be responsible for writing daily progress notes on each of your patients. A good progress note is brief and concise. What you write in the chart becomes a legal document – the chart is not an arena for opposing viewpoints on patient care to be discussed. The SOAP format is the most utilized for daily progress notes: S- Subjective. What the patient says or what the nursing staff reports. May be written as a direct quote or as a general statement. eg: “My stomach hurts” or “The pt. c/o stomach ache, denies other complaints” or “Nursing staff reports pt. fell out of bed last evening”. It is prudent to focus on main issues/problems during current hospitalization. O- Objective. What you see, factual information. This section includes vital signs, I/O’s, physical exam, labs, and other test results. A- Assessment. What you think the pt’s main problems are, in order of importance. If appropriate, give underlying causes for the problems and their current progress. Problems are to be described as an entity (i.e., 1. Diarrhea secondary to C. difficille colitis, improved on oral vancomycin. 2. Heme positive stools, possible secondary to colitis. 3. Hypertension currently under good control) or lumped into a “systems” format (i.e., 1. GIdiarrhea secondary to C. difficile improving on oral Vanco. Pt. continues to have occasional heme positive stools. 2. Cardiovascular- HTN under good control on current meds). Always postulate a cause and suggest an evaluation/treatment plan for any abnormalities. If you write that a patient has abdominal pain last night in the subjective section then you must put what you think is causing the pain, and what work-up or treatment is needed (if any) in the A/P section. Similarly if you note that the pt’s hematocrit fell 5 points, don’t just write this in the lab section and then forget about it. Why did it drop and what are you going to do about it???? P- Plan. What do you plan to do about the problems listed in the assessment. This may be separate from your assessment or, most commonly, integrated into your assessment. Including discharge planning here regardless of how far away in the future you think that Internal Medicine Resident Survival Guide - 23 - will happen is helpful. It helps to assure that at the time you are ready to discharge less emergent things don’t hold the discharge up (i.e. social issues, insurance, home PT, etc.) Internal Medicine Resident Survival Guide - 24 - POWER NOTES – TIPS Creating a Note *Double check that you have selected the correct note TYPE. Once you “save” a note, it cannot be deleted. If you do start a wrong report type, enter it “In Error” and copy to the correct note type; otherwise no one will be able to bill/find your note for that day/type. *Create a list of “favorite” note types from the Power Notes Catalog. Include H&P, Progress Note, Brief Incident Note, Consultation and Discharge Summary (at the least). *Try not to “Copy to New Note” because every day is different and your note should reflect this. Note Types *Each patient MUST have a Progress Note for EACH 24h period. i.e you must write a note on all of your patients daily. You can write a note in the evening and “back-date” it for earlier in the day if you need to. *Use a Brief Incident Note for any major events that happen either on your own patients or while you are covering (i.e on nightfloat). These notes DO NOT require any of the normal parts of a progress note (SOAP format) and it is acceptable to include only pertinent details of what happened. *Discharge Summaries need to be done within 24h of pt’s discharge. A D/C Summary which includes a physical exam can be used as the daily Progress Note If you are anticipating a D/C, save yourself from having to do 2 notes and just do your D/C summary right away. Completing your Note *You do NOT need to include daily labs or results of imaging. For billing purposes, you can simply put “reviewed” under these sections. *BE SELECTIVE about information you include. It is bad “power notes etiquette” to include long lists of vitals, labs (especially irrelevant ones) and old imaging results. No one wants to scroll through, or even worse- print, that many pages! *Do not simply copy/paste physical exam from day to day. If you did NOT do it, do NOT document it. For billing purposes there is NOT a minimum number of systems examined; but the more you do, the higher the billing level. Documenting that you examined something you didn’t is FRAUD. *Do not simply copy/paste the assessment & plan. The plan on a patient is different every day, even if only in minor ways… your documentation should reflect this. Signing you Notes *You can re-open and edit a “Saved” note later. But you MUST click “correct document” instead of “modify document.” If you click “modify”, an addendum will be added and the attending will NOT be able to sign or add their own addendum. *This is your last chance to change the date/time of the note, so if you haven’t done it yet and need to… don’t forget! *When you actually SIGN the note, make sure only the attending you want to send it to is on the “Endorser” list. The system will send the note to EVERYONE on that list, so make sure you remove every other attending you don’t want getting it. Internal Medicine Resident Survival Guide - 25 - HOW TO PRESENT A PATIENT INPATIENT, New Admission: Introduction The ultimate goal of the oral presentation of a medical case is to provide a basis for decision-making. Each presentation should include: 1. Chief complaint 2. History of present illness (beginning from the time the patient was in usual state of health). 3. Important facets of past medical history, family history, social history and systems review 4. The positive as well as pertinent negative findings of the physical exam Depending upon the setting or format, this will be followed by review of laboratory, radiology and other studies and assessment. Assessment includes generating a problem list, differential diagnosis and evaluation and treatment plan. Such discussion requires the presenter have detailed knowledge of then patient’s course and/or problems. Chief Complaint Be concise and clear. The goal is to convey the reason for which patient is seeking attention. History of Present Illness (HPI) The HPI must begin with the age & sex of the patient. The HPI is a succinct discussion of the chief complaint including mode of onset, acuity, intensity, progression, current severity, course of the illness, exacerbating factors, relieving factors, risk factors and the degree of disability caused by the illness. In addition, there should be a discussion of associated symptoms and their temporal relationship to the chief complaint. Any current or attempted therapy should also be described as well as the response or reaction. Pertinent aspects of other portions of the history including past medical history, medications, allergies, social history, family history and systems review should then be described. Physical Examination The physical examination should begin with a brief description of the patient’s general appearance and vital signs. In a quality presentation, emphasis is placed on those areas likely to be involved based upon your assessment of the patient’s history including both pertinent positives and negatives. Portions of the physical examination, which are normal, should be described as being normal" or "unremarkable". Convenient divisions of the physical examination include general appearance, vital signs, HEENT (head, eyes, ear, nose, throat), neck thorax (chest, back), lungs, heart, abdomen, rectal, pelvic/genital, and neurological. Internal Medicine Resident Survival Guide - 26 - Summary At this point many presenters elect to give a 2-3-sentence summary of the H&P leading into the assessment. If presenting a complicated patient, a brief summary may be an excellent addition. Lab Studies Results of appropriate studies will then be presented along with interpretation and application to the presented patient. Assessment Depending upon format and the individual case, the presenter will then give his assessment of the case. This is where diagnostic reasoning occurs (i.e., grouping of data), resulting in a provisional diagnosis or medical syndrome with a list of potential diagnoses ranked according to probability. Additional Advice Limit the length of the entire presentation to between 5 and 10 minutes. Simplify the presentation wherever possible because the longer or more complex the discourse, the greater the likelihood of a somnolent, confused audience. Omit irrelevant details. If members of the audience desire further details, be ready to satisfy their curiosity. Clarifying questions are a normal part of the case presentation. If your patient has multiple problems or illnesses, which are unrelated, recount each separately in chronological fashion. Do not try to simultaneously discuss the course of multiple problems as they evolve through different points in time. References Yurchak, PM: A guide to Medical Case Presentations. Resident and Staff Physician, September 1981; p 109. Kraenke, K: The Case Presentation: Stumbling Blocks and Stepping Stones. AM J Med 79:605, 1985. INPATIENT, Follow-up: Format of Presentation 1. Patient’s name, age, date of admission, and working diagnosis 2. Symptoms complained of by the patient over the last 24 hours. 3. Interval developments (subjective) 4. Pertinent physical findings a. Vital signs (blood pressure (range), pulse (range), respirations, Tmax) b. Other pertinent physical findings 5. Present new data from the past 24 hours a. New laboratory data over the last 24 hours b. New radiology, ultrasound, or MRI results c. New diagnoses or recommendations from consultants seeing the patient over the last 24 hours 6. List all medications that the patient is currently being given Internal Medicine Resident Survival Guide - 27 - 7. Problem a. b. c. list List in order of importance Include most recent impressions regarding each problem Assessment and plan for each problem* AMBULATORY, The problem-oriented patient presentation: The "problem-oriented technique" jumps from an opening sentence directly to the processed data (problem list, assessment and plan). Example Mr. Doe is a 62-year-old man, complains of increased shortness of breath for the last month. He has the following problems: 1.Hypertensive heart disease - past history of HTN, for the last 20 years. Cardiomegaly on previous CXR; EKG and physical exam (LVH, S4, S3+ and BP of 160/100) 2.Congestive heart failure - based on history of PND, orthopnea and presence of S3. Previous CXR (cardiomegaly and interstitial markings) 3.Peripheral vascular disease - based on history of intermittent claudication diminished peripheral pulses on both legs (2/4) Assessment Problem 1 and 2 are chronologically and etiologically related. Problem 2 seems to be aggravated by suboptimal blood pressure control and needs more aggressive treatment. Problem 3 probably caused by atherosclerosis and is mild. Plan Control hypertension by afterload reduction that will also better control the congestive heart failure. We may consider digitalis and diuretics. DISCHARGE PLANNING All of this information is electronic and needs to be filled out in order to properly discharge a patient. If you keep up the patient’s medication list/ reconciliation, and what has happened during the stay, it will make writing the discharge summary a lot easier. Our Care Management Team is a group of RN’s that assist us (along with Social Work) in getting the patient discharged in a way that ensures the patient has what they need when returning home. If a patient has any special social needs, equipment, a unique social situation, then get the Care Management Team involved (write an order—RE: Consult for D/C planning) at the onset. Also, you will have to fill out a paper form to support what they need when the patient gets D/C’d (like diagnosis, basic meds, why you feel they have special needs, etc.) This form is different at each facility. Find a nurse; ask them which form to fill out. Internal Medicine Resident Survival Guide - 28 - The Care Management pager number for after hours and weekends: DRH – Call the ER for Social Work on call. Phone at Detroit Receiving ER Dept: 53580 Harper – Pager 5900 VA—(0800-1630 on weekends) page 1135, pager #9667 See VA phone list for a zillion other contact numbers… Case Management v.s. Social Work Social Work • Help establish/coordinate home needs on D/C • Help with pt’s without insurance Medicaid apps, free clinic lists, shelter lists, 5day supply of meds, antibiotics, etc. • Help finding transportation cab vouchers, ambulance transfers, wheelchair vans, etc. • Elder abuse/neglect • Domestic violence • At Karmanos only Nursing home/subacute placement, counseling, and evaluation of home situation. Case Management Specialists • Help set up home needs on D/C • Home PT/OT/nursing care • Help with prior authorization of outpatient meds • Home IV antibiotics • At Harper/DRH/HutzelNursing home/subacute placement DISCHARGE FROM THE ICU 1. Patient being discharged to: Ward LTAC Home? 2. The bed: a. Telemetry needed? b. Daytime NPPV needed? If yes, stay in unit. c. Nocturnal NPPV needed? If Yes, is bed NPPV appropriate (DRH only) 3. The patient: a. Are there CVCs, a-lines, codis, introducer sheaths? i. Remove a-lines, cordis, sheaths ii. Can CVC be removed? iii. If not, place order for PICC/middling/alternative iv. Is Quinton being used? If not, can it be removed? b. Is there a foley? Can it be removed? If not, document reason in transfer note. c. Is there a tracheostomy? i. If yes, secretions <Q2h. ii. If it is new, which service is following? Document. d. Are there restraints? Can they be removed? If not, document reason why in transfer note. Internal Medicine Resident Survival Guide - 29 - 4. 5. 6. The chart: a. Remove all vasoactive drugs from the MAR/orders. b. Convert all antihypertensives to PO/PEG/NGT if possible. c. Are IV sedatives needed? d. Ensure all medications are appropriate for the floor. The followup: a. What labs, consults, radiology, etc… need to be followed up on? b. Document in transfer note. Loop closure: a. Complete transfer summary b. Medication reconciliation (see Step #d above). c. Notify family – give exact location of new bed. d. Call accepting physician. – document name/pager in transfer note. e. Notify pt’s RN when report is given. DICTATING NOTES All/most notes are now done electronically on the EMR, either CIS (at DRH & HUH) or VA system. However, sometimes when rotating at Karmanos certain attendings still want their notes dictated. Below is a re-typed version of the dictation cards that are used and may be found in Medical Records. Dial 6-6666 from any DMC/Karmanos phone, 313-966-6666 OR dial 1-800-442-1791 Enter beeper# Enter site code Site code Detroit Receiving Hospital- 04 Harper University Hopsital- 05 Karmanos- 10 Enter report type Report type History and physical = 31 Inpatient progress note = 37 Discharge summary = 50 Consult = 32 Echo = 45 HealthSource Clinic= 62 Admission note = 33 Exercise stress test = 46 Operative note = 34 Enter Patients account/FIN number followed by the # key. 5 to end 2 = dictate / pause 3 = jump back………then 2 4 = go to end……….then 2 5 = disconnect 77 = rewind to beginning ….then 2 8 = end report and begin new ## = replay header…………then 2 Problems? call (313) 745-5070 Internal Medicine Resident Survival Guide - 30 - OK, so now you know how to negotiate through the system…Here is a suggested format for dictating. The templates in CIS will get you through the typed summaries. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Start with the date of service (ie, date of admission and discharge) State your name and pager State who (Attending) you are dictating for, and the doctor’s pager number Patient name (spell this out), MRN, and FIN # Admission Date, Discharge Date Primary Diagnoses Secondary Diagnoses Procedures (invasive) and dates Problem list (at the end, what did they have, what were we following) HPI (don’t repeat the entire admit note, just summarize why the patient was admitted, what led up to it, initial triage vitals and initial plan, pertinent labs) One by one, review the problem list and how each was addressed during the stay Give vitals and brief exam of patient at time of discharge List discharge plan, with disposition to location (i.e. nursing home, home, etc) List discharge meds, dosages, and frequency Restate your name, pager, who you are dictating for and patient name. When you disconnect, get your pen ready to write down the job ID# in the patient’s chart. Keep it in case it gets missed somehow…. CONSULTS When you are calling a consult (GI, rheumatology, ID, etc.), there are a few points you should ALWAYS convey to the consult fellow: 1. Identify your name and context of the call (i.e., My name is Dorothy Lowe and I am the resident on the wards) 2. Identify the nature of the call (i.e., I am calling because we are admitting a patient that I would like you to consult on OR This is not a formal consult, but I would like to ask you a curbside question) 3. Identify the question you are asking—THERE MUST ALWAYS BE A QUESTION! (i.e., for colonoscopy on a rectal bleeder OR for bronchoscopy on a pt with suspected PCP pneumonia OR to help us in the evaluation/management of a patient with advanced AIDS and mental status change, etc.) 4. Give a brief outline of the patient’s history and presentation • • • • You should always assess the patient yourself prior to calling the consult! Do not ask the fellow to see the patient before you do! Formulate your own ideas of what is going on with the patient and convey this to the consult fellow so that you can have an educated and educational discussion! You should have as much pertinent information as possible prior to calling the consult (i.e., vital signs and Hemoglobin in a GI bleeder, CD4 count for an HIV patient, etc.). Internal Medicine Resident Survival Guide - 31 - • • • If you are not certain why you are calling a consult, figure it out before calling— “my attending wants a consult but I don’t know why” is not appropriate. Try to call consults as EARLY as possible (prior to rounds, or at least before noon conference)—otherwise you may not get input from the consult attending until the following day. Please be appropriate and professional in your interactions with fellows and attendings— remember that we are all working together in order to take care of patients in the best possible way, and this requires collaboration that requires effective communication. DEATH NOTE *Note: If called to pronounce, use this as a guide; obviously, your actual note should reflect the pt’s clinical situation. **Note: Make sure the pt is really dead prior to pronouncing. Date/Time I was called by nursing to see this No Code Blue patient who was pulseless and breathless. On my physical exam, the patient was found to be without carotid pulses, heart tones, or breath sounds. Pupils were fixed and dilated. Patient was pronounced dead at (time and date). Dr. PMD was notified. Family was present at bedside (if they were) or contacted. Joe/Joanna Intern, MD. NOTE: Do not use abbreviations or cross things out on death certificate. Medical records will track you down and make you RE-DO it… even if you’re on vacation! Internal Medicine Resident Survival Guide - 32 - SECTION 3: Documentation & Billing MEDICAL DOCUMENTATION - CHARTING Residents are responsible for writing a complete history and physical examination for each patient for whom they admit. It must be placed in the computer at the time of hospital admission. Daily progress notes addressing all active problems must be typed into CIS by at least one member of the team. Student’s progress notes are forwarded to a resident or attending physician to co-sign. In addition, the intern must write a complete note every day for any patients that are seen with a junior student. Senior students (Sub-I’s) do not have to be accompanied by a housestaff note but have to be cosigned by the resident or attending. Discharge summaries must be completed on the day of patient discharge. This is the responsibility of the PGY-1. If there is no PGY-1, the PGY-2 or PGY-3 must do it. Senior residents will be contacted to complete discharge summaries for sub-interns who do not complete their discharge summary. If a patient is transferred to another service, a detailed transfer note must be written. The transfer note is structured similar to an H+P and should include an HPI outlining the pertinent hospital course, a complete physical exam (with findings at the time the note is written, not on admission) and should conclude with a problem list which serves as an “assessment and plan”. The problems should be ordered by importance or urgency. The student-resident team, prior to rotating to a different service must write complete "offservice" notes. Such notes must be provided for all patients not discharged at the time of rotation. An "off-service" note is not required if the patient was admitted the day prior to service change. If this is the case then a complete History & Physical will be sufficient. Residents who are delinquent with discharge summaries may be given additional "back-up" (jeopardy) call responsibility and may lose moonlighting privileges. Record keeping also is an important component of monthly and semi-annual evaluations. In addition, satisfactory record keeping is an expectation of the ABIM for board eligibility and of hospitals to which physicians apply for staff privileges. Chronic incomplete charts will be dealt with directly by the program director or their delegate. Internal Medicine Resident Survival Guide - 33 - BILLING in the HOSPITAL & AMBULATORY SETTINGS DOCUMENTATION GUIDE *Key components (History, Physical Exam, Decision Making) 3 of 3 REQUIRED LEVEL OF LEVEL 1-LOW LEVEL 2-MOD LEVEL 3-HIGH SERVICE CC Required for all levels HISTORY 4 Elements of HPI required (Location, duration, quality, severity, timing, context, signs and symptoms) SYSTEM REVIEW 2-9 Systems 10 individual system review or list pertinent system negative and positive findings with a note “all other systems are negative” PAST, FAMILY, 1 of 3 required 3 of 3 required SOCIAL HISTORY EXAM Detailed Comprehensive 5-7 Systems 8 or more systems * REFER TO DEFINITIONS DECISION MAKING Low Moderate High SUBSEQUENT AND CONCURRENT HOSPITAL CARE DOCUMENTATION GUIDE * Key Componants (History, Physical, Decision Making) 2 of 3 REQUIRED LEVEL OF SERVICE LEVEL 1-LOW LEVEL 2-MOD LEVEL 3-HIGH CC Required for all levels HISTORY 4 Elements of HPI required (Location, 4 Elements of HPI duration, quality, severity, timing, context, signs and symptoms) SYSTEM REVIEW None 1 System 2-9 Systems PAST, FAMILY, Not required for interval history SOCIAL HISTORY EXAM Problem Focused Expanded Problem Detailed 1 System Focused 5-7 Systems * REFER TO DEFINITIONS 2-7 Systems MEDICAL DECISION Low Complexity Moderate Complexity High Complexity MAKING Stable, improved Not responding to Unstable or treatment or development of a new development of a problem or minor complication significant complication COUNSELING & When 50% or more of encounter is spent counseling or coordinating COORDINATION OF care, document time spent & description of services. Bill for level that CARE corresponds to time increment (See time guideline). CRITICAL CARE Document start/stop time with critical care notes Internal Medicine Resident Survival Guide - 34 - NEW OFFICE PATIENT AND CONSULTATIONS *Key Components (History, Physical, Decision Making) 3 of 3 Required LEVEL OF LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 SERVICE CC Required for all levels HISTORY 1-3 Elements 4 Elements of HPI required for all levels (Location, duration, quality, severity, timing, context, signs & symptoms etc.) SYSTEM N/A 1 System 2-9 Systems 10 Individual system review REVIEW or list pertinent negative and positive findings with a note “All other systems are negative” PAST, FAMILY, N/A N/A 1 of 3 3 of 3 Required SOCIAL Hx Required EXAM Problem Expanded Detailed Comprehensive 8 or more Focused Problem 5-7 Systems systems * REFER TO DEFINITIONS 1 System Focused 2-7 Systems MEDICAL Straight Straight LOW Moderate High DECISION forward forward MAKING ESTABLISHED OFFICE PATIENT *Key Components (History, Physical, Decision Making) 2 of 3 Required LEVEL OF LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 SERVICE CC Required for all levels HISTORY 1-3 Elements 4 Elements of HPI required for all levels (Location, duration, quality, severity, timing, context, signs & symptoms etc.) SYSTEM N/A 1 System 2-9 Systems 10 Individual system REVIEW review or list pertinent negative and positive findings with a note “All other systems are negative” PAST, FAMILY, Not Required for level 2, 3 1 of 3 past, 2 of 3 past & family SOCIAL Hx family or & social social Expanded EXAM Problem Detailed Comprehensive 8 or Problem Focused 5-7 Systems more systems * REFER TO DEFINITIONS Focused 1 System 2-7 Systems DECISION Straight Straight LOW Moderate High MAKING forward forward Internal Medicine Resident Survival Guide - 35 - INCLUDE COMPLEXITY COMPONANTS • • • • • • • • Established problems – stable, improved, worse New Problems – additional workup Review and/or ordering of labs, x-ray, medical tests Discussion of test results with performing physician Independent review of image, tracing or specimen Decision to obtain old records and/or obtain history from other than patient Review and summary of old records Obtaining history from someone other than patient TIME GUIDELINE LEVEL OF SERVICE LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 NEW PATIENT OFFICE ESTABLISHED OFFICE CONSULT OFFICE CONSULT HOSPITAL SUBSEQUENT HOSPITAL CARE LEVEL 5 10 MIN. 20 MIN. 30 MIN. 45 MIN. 60 MIN. 5 MIN. 10 MIN. 15 MIN. 25 MIN. 40 MIN. 15 MIN. 20 MIN. 30 MIN. 40 MIN. 40 MIN. 55 MIN. 60 MIN. 80 MIN. 80 MIN. 110 MIN. 15 MIN. 25 MIN. 35 MIN. N/A N/A DOCUMENT: • Total time (teaching physician time only) • Time spent counseling (must be at least 50% of visit) • Issues discussed GENERAL MULTI-SYSTEM EXAM Documentation Requirements CPT EXAMINATION DEFINITIONS Problem Focused: A limited examination of affected body area or single organ system Expanded Problem Focused: A limited examination of affected area or organ system & other symptomatic or related organ system (2-7 systems) Detailed: An extended exam of the affected body area(s) and other symptomatic or related organ system (5-7 detailed body systems) Internal Medicine Resident Survival Guide - 36 - Comprehensive: A general multi-system exam (8 or more systems) or a complete examination of a single organ system RECOGNIZED BODY AREAS FOR CPT EXAM DEFINITIONS • • • • • • Head, including face Neck Abdomen Genitalia, Groin, Buttock Back Each Extremity RECOGNIZED ORGAN SYSTEMS • • • • • • • • • • Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Musculoskeletal Skin Neurological Psychiatric Hematological, Lymphatic, Immunological NEW INNOVATIONS – Responsibilities and Documentation: You MUST: 1. Log your duty hours and log them truthfully. You don’t need to log every day, but if you get behind, it becomes a big chore. 2. Complete all of your evaluations. 3. Complete conference surveys – must be done for conference credit. 4. Log all of your procedures. 5. Log all of your mini-CEX. 6. Confirm curriculum for each rotation. Internal Medicine Resident Survival Guide - 37 - SECTION 4: Teaching Information ROLE OF RESIDENTS IN TEACHING SENIOR RESIDENTS PGY-2 and PGY-3 (senior) residents are responsible for daily teaching of medical students and PGY-1 residents. This includes the observation and evaluation of performance of histories and physicals as well as reading and critiquing their write-ups and daily progress notes. They serve as important role models in the development of the students' attitudes, interpersonal skills and clinical skills. They will conduct morning patient care rounds and supervise the student and PGY-1 in the evaluation and management of all patients on the service. They will assist the assigned faculty teaching rounder in conducting daily teaching rounds, encourage the students to attend the regularly scheduled conferences, and conduct daily check-out chart rounds. The PGY-2/3 resident also is responsible to have the initial contact with the admitting physician (ER, Outpatient Clinic, transferring physician, etc.). He/she must personally evaluate all patients admitted to his/her service, write an admit note, and oversee care provided by students and PGY-1s. The senior resident is both a supervisor and teacher. As such he or she is required to review appropriate medical literature, teach and assign topics for team members. In addition, he or she should provide meaningful and timely feedback to both students and PGY s. Please read and observe the addendum at the back of this manual for the current resident-intern-student team organization. INTERNS The PGY-1 resident is responsible for the delivery of health care to his/her assigned patients. The intern must be on the wards early enough to examine their patients prior to work rounds. Actual arrival time may vary depending the particular intern’s efficiency, patient load and acuity of illness. The intern will assume responsibility for his/her patients at 7:00 AM. The senior resident determines what time work-rounds begin. All member of the team are expected to be present for work rounds (with the exception of those members who are in clinic or are off). Work rounds are to be made at the bedside and not in a conference room. This allows the senior resident to review patients and the plan prior to attending rounds. The intern will be sure that full communication of patient status and care is maintained with the attending physician. S/he will know every aspect of the patient's condition and problems in detail and make sure these are documented in the medical record (in the initial history and physical examination and in the daily progress notes). Internal Medicine Resident Survival Guide - 38 - The intern will leave the hospital no earlier than 4:00 p.m. and only when patients are stable or when assured that patient care will be provided by a colleague (after sign-out rounds). Post-call (for overnight calls) residents are to leave the hospital by 11:00 a.m., as per ACGME regulations. These timing may change and would be reviewed by CMR in observation at beginning of each block in ‘orientation”. S/he is responsible for the education and evaluation of junior medical students. MEDICAL STUDENT EXPECTATIONS YEAR 3 STUDENTS are expected to: 1. Be on the wards early enough to examine their patients, review all new data and be prepared to present their patients to the senior resident and Faculty Attending at work/management/teaching rounds. The students must attend both patient care and teaching rounds Monday through Friday, and to be at the hospital if on call Saturday and/or Sunday. 2. Work-up a minimum of 12 patients during the Internal Medicine clerkship. This translates to approximately one patient per call with an occasional admission during the day. Histories and physicals will be reviewed by residents, or attending rounders. 3. Write daily progress notes, noting the course of illness with detailed assessment and the basic management plan for each assigned patient (reviewed and signed by resident). 4. Attend the Year-3 teaching activities. In addition, they are expected to attend medical grand rounds, morning report and as many of the other conferences as possible. 5. Participate in discharge and home care planning for their patients. Procedure Manual/New Innovations Each student is required to keep a procedure log documenting the required number of specified procedures. They need the help of residents and teaching rounder(s) to learn indications, contraindications and methods of performing the procedures. All procedures must be documented and recorded in New Innovations. Minimum Proficiency Standards Year-3 Students must be able to: a) b) c) d) e) f) Perform a complete, orderly and technically correct H&P on each assigned patient. Accurately, legibly record H&P in clear, logical fashion on each assigned patient. Make a complete problem list and do this on each assigned patient. Identify common syndromes (e.g., congestive heart failure, stroke). List common components of the differential diagnosis for patients with problems presented in seminars. Realize when they need help handling or advice regarding care of a patient and seek such aid from appropriate supervisors. Internal Medicine Resident Survival Guide - 39 - g) h) i) Concisely (within 5-10 minutes) present the H&P for any patient that they work up. Demonstrate appropriate interpersonal skills in interactions with patients, peers, supervisors and ancillary personnel. Demonstrate adequate medical knowledge of common problems, pathophysiology and syndromes. YEAR-4 STUDENTS Year-4 students are referred to as “sub interns.” As the title implies, these students function at or near the level of PGY-1 trainees. The two important areas of difference are in: 1) patient numbers, and 2) order writing. In general, Year-4 students may handle 4-6 patients at a time, and may accept 1-2 admissions during a call night. Year-4 students are expected to arrive at the hospital at the same time as other team members. They are responsible for writing H&Ps and daily progress notes (to be reviewed and signed daily by the resident), writing all orders on assigned patients (to be reviewed and signed daily by the resident), and for reading a standard internal medicine text and appropriate literature relating to the problems presented by their patients. In addition, they are to "sign out" their patients to the cross-covering team before leaving on a non-call night. They are responsible for writing ”off-service" notes and discharge summaries, and for typing/dictating discharge summaries for all patients under the supervision of the resident. Minimum Proficiency Standards a. Satisfy those objectives listed for Year-3 students outlined in this manual and in addition they must... b. Demonstrate less dependence on supervising residents in identifying abnormalities on physical exam in articulating patients probable diagnosis and his/her management plans. c. Demonstrate a broader knowledge base and willingness/ability to use the medical library, literature, and literature search as they relate to patients under their care. d. Demonstrate a maturing attitude of commitment and advocacy for each patient under his/her care. e. Demonstrate increasing proficiency in procedural skills listed in objectives. RESPONSIBILITIES TO OUR MEDICAL STUDENTS Words from Dr. Diane Levine Introduction: Supervising residents are integral to the education of the students on the Internal Medicine clerkship. You are no longer a medical student but are now part of the core “faculty,” one of the teaching physicians. This manual was developed to provide you with important information about the clerkship. It includes a description of the goals and objectives for student clerks, expectations for the rotation and outlines your role and responsibility as a supervising resident. We hope you find this material useful. When you have completed reviewing the manual, please sign the attestation your student will provide to you. Internal Medicine Resident Survival Guide - 40 - Note: students are responsible for being familiar with common problems seen on an inpatient Internal Medicine service. Review this list and try to discuss an approach to these common problems as they relate to your student’s patients. Assign specific topics from this list to assist students in preparation for the National Board of Medicine Subject Examination or “shelf exam.” The Junior Year The junior year of medical school is the first clinical year for WSU students. During the primary care block, students rotate through two months of Internal Medicine, two months or Pediatrics, and one month of Family Medicine. During the primary care block all students participate in a mandatory “Continuity Clerkship” and leave their respective rotation for one half day a week to participate in an ambulatory primary care experience. As a consequence of the scheduling, you will notice distinct differences in the way students perform at different times of the year and within each six month block. Clerkship Orientation: On the first day of the clerkship, students are required to report to the School of Medicine for a large group orientation. Goals and objectives for the Internal Medicine Clerkship are introduced. Student expectations are discussed. Policies regarding absences are reviewed. Students are provided with information detailed the processes by which their performance in the clerkship will be evaluated and how overall grades are awarded. Students are notified of important dates including dates for ACLS*, last day of the clinical rotation the final examination date Orientation to your service: Students generally report to their assigned teams on the second day of the clerkship. You will most likely meet your students first thing in the morning. Encourage students to keep an open mind and consider Internal Medicine as a career option. Let them know how and why you decided to go into Internal Medicine. Now it is time to orient you students to your service. Make sure to review how your team is organized and how your day/week/month is structured. • Assign students to the appropriate interns. • Discuss the daily schedule. • Inform students what time they need to arrive at the hospital. • Define what time you want your team prepared to round and where you wish to meet. • Discuss how attending rounds are organized • Discuss conferences • Determine when x-ray rounds, peripheral smear rounds etc occur • Discuss how sign out rounds are made • Discuss how topics are assigned. • Review the call schedule. Make sure students understand call at your hospital. • Review clinic schedules. Note: students are excused from hospital duties one half day a week to attend their mandatory Continuity Clerkship. Internal Medicine Resident Survival Guide - 41 - • Discuss how days off are handled at your hospital/institution. Internal Medicine Resident Survival Guide - 42 - Explicating reviewing expectations at the beginning of the month sets the tone for a successful month and provides the basis for end of the month evaluation. Resident role and responsibility The role of the supervising resident is to teach and evaluate students during their Internal Medicine clerkship. Remember, interns and residents spend more time with junior students than any other member of the healthcare team including the attending physician. The clinical supervision and teaching residents provide makes a difference in the kind of education students receive on the clerkship. Help your student to succeed! You can do this by • Helping students learn his or her way around the hospital • Reviewing hospital forms with your students • Reviewing H&Ps and SOAP notes • Reviewing how to write orders • Teaching students to interpret primary data including EKGs, chest radiographs, gram stains, and basic laboratories (CBCs, peripheral smears, electrolytes, renal function, and liver function tests) • Providing opportunities for your students to practice presenting new and follow up patients • Teaching students how to keep track of their patients and daily lab results • Helping students prepare for attending rounds • Helping students to organize their work day • Keeping track of patients assigned to ensure students are exposed to as many different problems and diagnoses as possible • Providing feedback for your students In summary, resident physicians are expected to teach and guide student to them achieve the goals and objectives of the clerkship and understand the principles of Internal Medicine. In addition, resident physicians are important in helping students adjust to their new role as a student doctor. Feedback and Evaluation: Students need to receive feedback. Furthermore, feedback should be well timed and specific so students can incorporate feedback and improve their performance. Students should receive feedback in all areas of evaluation including: • Application of knowledge in the clinical arena • History taking • Performance of a physical examination* • Communication and relationships with patients and families • Professional attributes and responsibilities • Overall knowledge base • Written and oral case presentations • Record keeping (write-ups, progress notes) • Facility with technical skills and procedures • Communication and relationships with health care team • Self improvement and adaptability Internal Medicine Resident Survival Guide - 43 - Residents will need to observe students performance in these areas in order to provide meaningful feedback. This can be challenging on a busy clinical service. Here are some suggestions: • Ask questions that probe the students’ knowledge base and the students’ ability to use that knowledge to answer clinical questions. Is the students’ knowledge appropriate for their level of training? Is it “satisfactory” or does it “exceed expectations?” • Provide opportunities for students to demonstrate physical examination skills. Physicians need not observe an entire physical exam, but should have the student demonstrate various components of the physical examination over the course of the month. Many resident use call or work rounds to access student skills in physical examination. • Provide regular opportunities for students to present their new patients and their established patients. What is the quality of the students’ presentations? Are the presentations organized? Does the student present pertinent positive and negative findings or is the student unable to filter important information? How does this student’s presentation compare with other junior students at the beginning, middle, or end of the year? • Provide feedback immediately following presentations using the sandwich technique (First comment on one positive aspect of the presentation, next note an area which can be improved—be specific, end on a positive note. For example, “you certainly had all the information on your HPI, now you need to work on the organization, start from when the patient was in their usual state of health and work forward. You already have the information, now all you have to do is rearrange it. I am confident you can do it.” Lastly make a plan for followup. “Why don’t you practice on this HPI and present it to me tomorrow after rounds, that way you will be prepared for the next H&P.” • Provide opportunities for student to discuss their assessment and their plan for patient evaluation and treatment. Can student identify the patient’s primary problem? Can students elaborate a well ranked differential diagnosis appropriate for a junior student? Try to have realistic expectations for your student. Remember this is their first experience on Internal Medicine and in July it is their first clinical experience ever. • Assign topics for your students to present that encourage students to demonstrate the ability to go to the texts and literature to answer clinical questions. • Review documentation (H&P and SOAP notes) noting detail, organization, and thoroughness. Note: Students will be required to turn in one H&P, progress note and discharge note to the site director for formal evaluation and feedback. • Observe interactions with patients, physicians and ancillary medical staff. Does the student act professionally? • Does the student take responsibility for his or her patients? Does he or she read about his or her patients’ problems, follow-up on laboratory abnormalities, complete notes in a timely fashion, and discuss significant changes with the supervising interns and resident? • How well does student accept feedback? Internal Medicine Resident Survival Guide - 44 - Midmonth Feedback: Midmonth feedback is required. Unfortunately, students often do not recognize feedback unless it is identified as such. Furthermore, telling students they are doing a “good job” is often misinterpreted to mean they will get an “outstanding” on the final evaluation. This can be circumvented by providing feedback which both specific and timely. The School of Medicine requires students to complete a self-reflective midmonth formative evaluation form. You will be asked to review the student’s impression of their own performance. Please provide comments in the space provided and sign the form. Students are required to submit the form at the end of the rotation. End of the month feedback and evaluation: At the end of the month, resident physicians should sit down with their students and provide formal summative evaluation and feedback with suggestions for improvement. In evaluating students’ performance please remember that performance tends to improve as the academic year progresses. One should be careful not to under evaluate performance in July and August and not over evaluate performance in May and June. Attending physicians needing guidance in completing the evaluation form should contact the site director at their institution. Grading: Both faculty and residents evaluate student performance on the clerkship. Resident physicians must provide comments on their evaluations form as these are used by the Dean of students for students’ MSPE (Dean’s Letter) used for residency application!!! Final Clinical Grade: The final clinical grade is a composite based on clinical evaluations from attending physicians and resident physicians (but not interns) from both months of the clerkship and is assigned by the Internal Medicine Clerkship Director at Wayne State University. As defined in the curriculum guide, students must receive a minimum of 50-% of “outstanding or “exceeds expectations” in each category to receive “exceeds expectations” in that category. Students receiving seven or more “exceeds expectations” on the composite grading form will receive a final clinical grade of “Outstanding.” Students achieving less than seven “exceeds expectations” will receive a final clinical grade of “Satisfactory.” Students with evaluations of “Does Not Meet Expectations” will be closely reviewed by the Clerkship Director to determine if that student fails the clinical portion of the rotation. Final Grade: All students must take and pass the national subject examination commonly known as the “shelf exam” to successfully complete the clerkship. The final grade is assigned by the Clerkship Director and is based on both the final clinical grade and the performance on the shelf exam. The Department follows the grading policies of the School of Medicine for Year III Clerkships. (Please consult curriculum guide). Internal Medicine Resident Survival Guide - 45 - SECTION 5: Medical Information & Tips ACUTE EMERGENCIES – You Must See the Pt Immediately! ALTERED MENTAL STATUS 1. Questions during initial phone call: - Vital Signs - What is the change in level of consciousness? - Is the patient diabetic? - How old is the patient? 2. Orders over telephone: - Accu-Chek, O2 saturation, new set of vitals (if not done already), ± EKG 3. Differential Diagnosis of AMS: “MOVE STUPID” Metabolic: B12, thiamine deficiency, hepatic encephalopathy (rare: Wilson’s dz, niacin deficiency) Oxygen: hypoxemia, hypercarbia, anemia, decreased cerebral blood flow (e.g., from low cardiac output), sepsis, carbon monoxide Vascular: stroke, hemorrhage, vasculitis, TTP, DIC Endocrine: hyper/hypoglycemia, hyper/hypothyroidism, high/low cortisol Electrolyte: low Na, hyper/hypocalcaemia, hypermag, hypophos, abnl LFTs Seizures: post-ictal, status epilepticus (nonconvulsive), complex partial Structural: lesions with mass effect, hydrocephalus Tumor, Trauma, Temperature: fever or hypothermia Uremia: also dialysis disequilibrium syndrome Psychiatric: dx of exclusion, ICU psychosis, “sundowning” Infection: CNS, sepsis Drugs: intoxication or withdrawal (opiates, benzos, ETOH, anticholinergics) Degenerative dz: Alzheimer’s, Parkinson’s, Huntington’s 4. Initial Evaluation: “DON’T” D50, 1 amp after thiamine if accu-check available Oxygen with oropharyngeal airway if necessary Naloxone, usually 0.4-1.2 mg IV if even remote possibility of opiate OD Thiamine, 100 mg IV (before glucose) - Physical exam especially Neuro - Fever, tachycardia, O2 saturation, myoclonus (uremia, cerebral hypoxia, HONC), tremor (withdrawal, autonomic sx, hyperactive), asterixis (liver/renal failure, drug intoxication) - Labs: CBC, BMP, Mg/phos, LFTs, Utox, U/A, ABG, EKG, blood/urine cx, CXR - Low threshold for non-contrast head CT if focal neurologic signs or risk for CVA - Consider LP especially if fever/meningeal signs/immunosuppressed Internal Medicine Resident Survival Guide - 46 - SEIZURES 1. If patient is still seizing—remember your ABC's: - O2 by face mask, position pt on side to prevent aspiration. Suction airway as needed. Do not try to insert airway - Prevent patient from injuring himself/herself - If seizures continue after 2-3 minutes, try to start an IV and abort the seizure with Ativan 0.02-0.03 mg/kg. Alternatively, Ativan IM Q5 minutes to max 8 mg or Valium PR 20 mg - Give thiamine 100 mg IV first, then 1 amp D50 IV - If seizure is >10 minutes or is not easily responsive to benzodiazepines, the pt is likely in status epilepticus and the patient will need ICU management - Only if an absolute certain diagnosis of severe hyponatremia is established should treatments such as iso- or hypertonic saline be used to halt a seizure 2. Once seizure has stopped: - Place oral airway. Get ABG if patient appears cyanotic - Establish IV access and send basic labs (CBC with differential, BMP, Mg/phos, albumin, antiepileptic levels) - Evaluate if this is status: continuing seizing for > 30 minutes, no consciousness after 30 minutes, if patient seizes again without achieving normal consciousness. If the patient is in status epilepticus, send the patient to the ICU and consult neurology. 3. Load with phenytoin 20 mg/kg in 3 divided doses at 50 mg/min (usually 1 g total); use fosphenytoin when available at the same dose as its load is better tolerated. - Remember, phenytoin (but not fosphenytoin) is not compatible with glucosecontaining solutions or with Valium. If you have given these meds earlier, you need a second IV 4. Consider common causes of seizures (i.e. basic labs and a head CT for new onset seizures): - Alcohol withdrawal (2 mg ativan IV post-seizure may help to prevent recurrence) - CNS lesion/infxns (tumor, CVA, head injury, meningitis/encephalitis, etc.) - Meds (Demerol, benzo withdrawal, penicillin [imipenem], lidocaine toxicity, INH [only stops after giving Vitamin B6], ASA, TCA, cocaine, Benadryl, amphotericin, theophylline, buproprion etc.) - Metabolic (low glucose, Na, Ca, or Mg) - Toxins (CO, heavy metals, many drugs of abuse or withdrawal from these drugs) - Other (HIV, malignant hypertension, hypoxia, uremia). 5. Write for seizure precautions. Watch for metabolic acidosis and rhabdomyolysis Internal Medicine Resident Survival Guide - 47 - CHEST PAIN Initial Evaluation: 1. Over telephone: Vital Signs, recent telemetry data, EKG. 2. History: prior h/o CAD, onset: exertional/nonexertional, character, quality, location, associations, duration, relief 3. Examine the pt: vitals, evidence of heart failure 4. Check EKG and compare to old EKG Workup: You will need to rule out life-threatening diagnoses rather than diagnose definitively MI: typically “pressure-like” pain associated with SOB, diaphoresis, radiation to left jaw/arm, nausea/vomiting, cardiac risk factors present; remember, MI can present atypically, and not only in women and diabetics Aortic dissection: “tearing”, assoc w/ HTN, smoking, radiation to back, unequal pulses - Widened mediastinum on chest imaging - Transfer to ICU to reduce BP and inotropy with ß–blocker - Emergent CT scan with contrast, or echo and call vascular surgery - EKG may show evidence of ischemia in RCA distribution if dissection is proximal Pneumothorax: COPD, trauma, decreased breath sounds, hyperresonance, deviation of trachea away from side with pneumothorax, and hypoxia - CXR and call surgery for chest tube placement - If tension pneumothorax (hemodynamic instability), don’t wait for the CXR! Insert a 14 gauge angiocath into the 2nd intercostal space at the midclavicular line on the side of the pneumothorax PE: dyspnea, tachypnea, tachycardia, pleuritic chest pain, hypoxia, A-a O2 gradient, hemoptysis - obtain chest CT with PE protocol or V/Q scan if available. Begin anticoagulation (if there are no contraindications) while you are waiting for the results Other etiologies: pericarditis, pneumonia/pleurisy, GERD, PUD, esophageal spasm (may respond to nitroglycerin), esophageal rupture (Boerhaave’s) or tear (MalloryWeiss), candidiasis, herpes zoster, costochondritis, rib fracture, anxiety (a diagnosis of exclusion) Treatment: “MONAS” - Morphine 2-4 mg IV (watch BP and for over-sedation) - Oxygen via NC - Nitroglycerin 0.4 mg SL Q5 min x 3, hold for SBP <100. Can proceed to Nitropaste 1” (note: variable and poor absorption). Remember, just because the chest pain responds to NTG does not automatically rule in angina - If patient is not already on aspirin and has no contraindications, give ASA 325 mg - Statin for plaque stabilization - Transfer to monitored bed, heparin gtt if no contraindication, check troponins, serial EKG’s - ALWAYS ASK ABOUT ALLERGIES, THIS CAN COMPLICATE THE PICTURE! Internal Medicine Resident Survival Guide - 48 - SHORTNESS OF BREATH Initial Evaluation: 1. History - Acuity of onset - Associated symptoms (cough, chest pain, palpitations, fever) - New events or medications given (including IV fluids!) around the onset - Relevant PMH and admitting diagnosis 2. Physical Exam - Vital signs (include O2 sat; measure the respiratory rate yourself!) - Lungs: respiratory distress (cyanotic, accessory muscle use), wheezes, rales, stridor, symmetry of breath sounds. Remember that adventitious lung sounds may be absent in someone with severe airflow limitation - Cardiac: JVP, carotids, rate/rhythm, and murmurs or rubs - Extremities: edema (unilateral vs. bilateral) and perfusion (cool vs. warm, capillary refill, cyanosis) - Mental status: gives an idea of cerebral oxygen delivery 3. Labs/ studies - CXR, EKG, ABG, CBC (better to order all of these if there are any questions) Differential Diagnosis: 1. Pulmonary - Pneumonia - Pneumothorax: acute onset, pleuritic CP, consider in intubated patients, especially if peak and plateau pressures elevated - PE: often difficult to rule in/out by history/exam. Consider early - Aspiration: common in pts with altered sensorium - Bronchospasm: can occur in CHF, pneumonia, and asthma/COPD - Upper airway obstruction: often acute onset, stridor/ focal wheezing - ARDS: usually in pts hospitalized with another dx (e.g. sepsis) - TRALI: Usually very rapid onset post-transfusion - Pleural effusion 2. Cardiac: - MI/ischemia: dyspnea can be an anginal equivalent - CHF: common in elderly pts on IVF, or due to ischemia - Arrhythmia: can cause SOB even without CHF/ischemia - Tamponade: consider when pt has signs of isolated right heart failure 3. Metabolic - Sepsis: dyspnea can be an early, non-specific sign - Metabolic Acidosis: pts become tachypneic to blow off CO2 4. Hematologic: - Anemia: easy to miss this by history/general exam - Methemoglobinemia: rare; consider in pts taking dapsone or certain other meds with cyanosis/low sat, normal PaO2 Internal Medicine Resident Survival Guide - 49 - 5. Psychiatric: - Anxiety: common, but a diagnosis of exclusion! 6. GI: - Massive ascites, abdominal mass: compressive Initial Management: 1. Oxygen: - Your goal is a PaO2 > 60, or O2 sat > 92%. If nasal cannula isn't enough (max FiO2 is ~35-40%), try mask (up to 50%), non–rebreather (70%), or high-flow setup (90%) - Call RT early if you’re having any trouble, and they will help with nebulizers, suction, masks, ABGs, oral/nasal airways 2. Beta agonists: - Patients with wheezing from any etiology can benefit from bronchodilators - All that wheezes is not asthma! (e.g., CHF, pnemonia) 3. Diuretics: - Consider Lasix in a pt w/history or exam c/w CHF; other processes associated with increase in lung fluid (pneumonia, ARDS) may also improve temporarily with diuresis, and a single IV dose of Lasix is unlikely to do any irreversible damage. Be careful in renal disease! 4. Assess potential need for intubation. BiPAP trial may be helpful method of temporizing while making this decision. - BiPAP is most helpful to correct ventilation deficits (i.e., helps reduce pCO2), and in pts with CHF or COPD, but can assist any patient to help move air . Use only in the conscious patient, never the obtunded!! - BiPAP can be started at “12/5” and rapidly titrated as needed. Top number refers to IPAP (Inspiratory Positive Airway Pressure) while bottom number refers to EPAP (Expiratory PAP, equivalent to PEEP). You will also need to set the respiratory rate and FiO2 - BiPAP is contraindicated in patients who are at risk of aspirating, on tube feeds, have excessive secretions, AMS, or respiratory arrest 5. Once you have the patient stabilized and the results of your initial studies, you can initiate therapy directed at the specific etiology of the patient’s dyspnea Internal Medicine Resident Survival Guide - 50 - CVA/TIA Work Up: 1. Time of onset of symptoms (important for use of t-PA) 2. Vitals, including pulse ox, and complete physical exam 3. Detailed Neuro Exam (find the lesion!) 6. EKG, CBC, BMP/Mg/PO4, PT/PTT, fibrinogen, ESR, LFTs, cholesterol 7. Non-contrast Head CT Management: 1. BP control: Permissive hypertension in acute stroke. Goal SBP recommendations vary depending upon the type of the stroke. Ask the neurologist for their current recommendations, but aim for SBP ~160-180 - If DBP >140 Start Nipride gtt - SBP >230 and/or DBP 121Labetalol* 20 mg IV Q10 min (max 150 mg); consider gtt 140 at 2-8 mg/min - SBP 180-230 and/or DBP Labetalol* 10 mg IV Q10 min 105-120 * if labetalol contraindicated (e.g. CHF), consider Nitroglycerin gtt (esp. if coronary ischemia), Enalaprilat IV (IV ACE-I, useful in LV dysfxn; avoid if acute MI), or Hydralazine DO NOT LOWER BP MORE THAN 25% 2. Establish Risk Factors - A-fib – Check EKG - Carotid Dz – Check U/S bilateral carotids - Endocarditis – Check TTE - Cancer – eval risk factors and health maintenance hx (mammo? PSA? colo?) - HTN – Check BP, eval hx and tx - CAD – Check EKG, lipid panel, consider stress test - DM – fasting blood sugar - Peripheral Vasc Dz – u/s LE - Autoimmune Dz – Check ANA, ds DNA, RF, etc Internal Medicine Resident Survival Guide - 51 - ALCOHOL WITHDRAWL: 1. 2. 3. 4. 5. 6. Mechanism: multifactorial. Withdrawal symptoms are the opposite of depressant effects of EtOH = increased adrenergic, serotonergic and cholinergic activity. For all EtOH withdrawal hospitalizations, evaluated for comorbid medical conditions (alcoholic hepatitis, pancreatitis, liver failure, GIB, infection, trauma, hypoglycemia, co-ingestions, arrhythmias, dilated cardiomyopathy, altered electrolytes). Treatment/orders: a. Thiamine, multivitamins, folate (= “banana bag”) b. Always give Thiamine before glucose to avoid precipitating Wernicke’s c. Hydration d. Correct electrolytes e. Follow blood sugars and give dextrose as needed f. Restraints PRN for safety g. Seizure precautions Minor Withdrawal: 6-12 hours after last drink a. S/Sx: Insomnia, tremulousness, mild anxiety, GI upset, headache, diaphoresis, palpitations, anorexia b. Treatment: Thiamine 100mg IV x 3d, MVI, folate. Ativan or valium per CIWA guidelins. Consider beta blockers for uncontrolled HTN. Alcoholic Hallucinosis: 12-24 hours a. S/Sx: Visual, auditory or tactile hallucinations. Sensorium is clear. b. Treatment: Same as above. Consider haldol 1-2mg Q1h PRN (but be careful, this may lower seizure threshold!) Withdrawal Seizures: typically 24-48 hours, but may occur as soon as 6 hours. a. S/Sx: generalized tonic-clonic seizures; post-ictal state. b. Treatment: same as for other seizures- Ativan. Delirium Tremens: 48-72 hours after last drink; can occur up to 7 days after last drink. This is A MEDICAL EMERGENCY! a. S/Sx: Clouded counsciousness, delirium, diaphoresis, agitation, hallucinations (visual > tactile > auditory), HTN, tachycardia, low grade fever. b. Treatment: Thiamine, folate, MVI, electrolyte replacement, r/o infection. Admit to telemetry. Benzos per CIWA protocol. Ativan IV usually preferred;l may need drip. Haldol 1-2mg Q1h PRN severe agitation or hallucinations. Internal Medicine Resident Survival Guide - 52 - HOW TO READ AN EKG R-R method (Rate – Rhythm) [ECG rhythm recognition using R-wave regularity as a primary step] Regular (think pacemaker) 1. sinus rhythm a. p-p (regular, no block seen) b. p-R (consistent, normal 0.12-0.20) 2. Junctional rhythm a. p-p (no P waves seen, or inverted ones) b. p-R (no P’s, no P-R) 3. 1st degree AV block a. p-p (regular, no block seen) b. p-R (consistent, prolonged >0.20) c. (AV node problem, not a true block) 4. 2nd degree AV block (2:1, 3:1, etc.) a. p-p (regular, AV block seen) b. p-R (consistent) 3rd degree AV block a. p-p (regular, AV block seen) b. p-R (inconsistent) Irregular (think intermittent AV block vs. added ectopic beats) 1. Atrial Fibrillation a. p-p (no P waves seen) b. p-R (no P’s, no p-R) c. (variable AV block) 2. Atrial Flutter a. p-p (sawtooth, ~300/min) b. p-R (appears inconsistent) c. (variable AV block) 3. PACs a. p-p (irregular, abnormal non-sinus Ps seen) b. p-R (consistent) c. (ectopic beats, QRS/same) 4. PVCs a. p-p (irregular) b. p-R (consistent) c. (PVC’s QRS /wide >0.12 and never has a P wave) 5. 2nd degree AV block (all others – 3:2, 4:3, 5:4, etc.) a. p-p (regular, AV block seen) b. p-R (prolonged/Type 1, consistent/Type 2) 5. Internal Medicine Resident Survival Guide - 53 - VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA ****Determine if you see a SHOCKABLE RHYTHM**** 1. SHOCKABLE RHYTHMS: PULSELESS VT/VF Defib Biphasic 200 J CPR (5 Cycles of 30:2 compressions to breaths = 2 minutes; IF AIRWAY ESTABLISHED, THEN NO LONGER "CYCLES" of 30:2 CPR, CPR CONTINUOUSLY ONLY.) Intubate and start IV lines Defib 360 joules (Monophasic 360 J @ DRH, VAMC, RIM; Biphasic 200 J @ HUH) **Do NOT STOP CPR to push meds** *Epinephrine 1mg IVP q3-5 min until pulse re-established OR Vasopressin 40 units IVP x1 only dose; CPR (5 Cycles of 30:2 compressions to breaths = 2 minutes; IF AIRWAY ESTABLISHED, THEN NO LONGER "CYCLES" of 30:2 CPR, CPR CONTINUOUSLY ONLY.) Defib 360 joules (Monophasic 360 J @ DRH, VAMC, RIM; Biphasic 200 J @ HUH) *Amiodarone 300 mg bolus, repeat 150 mg bolus x2 (total dose 2.2 g/day) Drip infusion (if works) >1 mg/min x6 hrs, then 0.5 mg/min x18 hrs CPR (5 Cycles of 30:2 compressions to breaths = 2 minutes; IF AIRWAY ESTABLISHED, THEN NO LONGER "CYCLES" of 30:2 CPR, CPR CONTINUOUSLY ONLY.) Defib 360 joules (Monophasic 360 J @ DRH, VAMC, RIM; Biphasic 200 J @ HUH) CPR (5 Cycles of 30:2 compressions to breaths = 2 minutes; IF AIRWAY ESTABLISHED, THEN NO LONGER "CYCLES" of 30:2 CPR, CPR CONTINUOUSLY ONLY.) *Lidocaine 1-1.5 mg/kg IVP, repeat dose q3-5 min. to max 3 mg/kg Defib 360 joules (Monophasic 360 J @ DRH, VAMC, RIM; Biphasic 200 J @ HUH) CPR (5 Cycles of 30:2 compressions to breaths = 2 minutes; IF AIRWAY ESTABLISHED, THEN NO LONGER "CYCLES" of 30:2 CPR, CPR CONTINUOUSLY ONLY.) *Magnesium sulfate 1-2 g in 1-2 min. IVPB or IVP slowly (1st line in Torsades) Defib 360 joules (Monophasic 360 J @ DRH, VAMC, RIM; Biphasic 200 J @ HUH) CPR (5 Cycles of 30:2 compressions to breaths = 2 minutes; IF AIRWAY ESTABLISHED, THEN NO LONGER "CYCLES" of 30:2 CPR, CPR CONTINUOUSLY ONLY.) *Procainamide 20-30 mg/min to 1 g infusion –17 mg/kg (1st line in WPW SVT) Defib 360 joules (Monophasic 360 J @ DRH, VAMC, RIM; Biphasic 200 J @ HUH) CPR (5 Cycles of 30:2 compressions to breaths = 2 minutes; IF AIRWAY ESTABLISHED, THEN NO LONGER "CYCLES" of 30:2 CPR, CPR CONTINUOUSLY ONLY.) Internal Medicine Resident Survival Guide - 54 - Internal Medicine Resident Survival Guide - 55 - 2. UNSHOCKABLE RHYTHMS: Asystole/PEA CPR (5 Cycles of 30:2 compressions to breaths = 2 minutes; IF AIRWAY ESTABLISHED, THEN NO LONGER "CYCLES" of 30:2 CPR, CPR CONTINUOUSLY ONLY.) Intubate and start IV lines CPR (5 Cycles of 30:2 compressions to breaths = 2 minutes; IF AIRWAY ESTABLISHED, THEN NO LONGER "CYCLES" of 30:2 CPR, CPR CONTINUOUSLY ONLY.) *Epinephrine 1mg IVP q3-5 min until pulse re-established OR Vasopressin 40 units IVP x1 only dose; Do NOT STOP CPR to push meds. CPR (5 Cycles of 30:2 compressions to breaths = 2 minutes; IF AIRWAY ESTABLISHED, THEN NO LONGER "CYCLES" of 30:2 CPR, CPR CONTINUOUSLY ONLY.) *Atropine 1mgIV/IO for asystole or slow PEA rate; Repeat every 3 to 5 min for 3 CHECK RHYTHM: IF SHOCKABLE (VT/VF), then go to #1 ABOVE IF NOT SHOCKABLE (Asystole/PEA), go to #2 ABOVE Consider causes that are quickly reversible: 6 H's: * Hypovolemia * Hypoxia, * Hypo/Hyperkalemia, * Hypothermia, * Hydrogen ion—Acidosis 5 T’s: * Tension Pneumothorax * Tamponade * coronary Thrombosis * pulmonary Thrombosis * Tablets **Proven benefit for patients when "high quality CPR" is started early and maintained throughout CODE. **Do not pause CPR for breathing patient once definite airway has been established, at this point your goal is 100 compressions/minute. **Do not pause CODE to push IV medications, CPR should be maintained, only pausing to deliver a shock. Internal Medicine Resident Survival Guide - 56 - Internal Medicine Resident Survival Guide - 57 - VENTRICULAR TACHYCARDIA (WITH A PULSE) Asymptomatic (stable) Oxygen Lidocaine (1-1.5 mg/kg) repeat 0.5-0.75 mg/kg q5-10 min. Max 3 mg/kg Procainamide 20 mg/min. max 17 mg/kg Amiodarone 150 mg over 10 min Sotalol (not available in US) Bretylium 5-10 mg/kg max dose 30 mg/kg (1st line in hypothermics) Symptomatic (unstable) Oxygen EKG 12 Lead Monitoring Consider Sedation (morphine, versed, etc.) QUICKLY SYNCRONIZED CARDIOVERSION @ 200 Joules *Lidocaine 1-1.5 mg/kg repeat 0.5-0.75 mg/kg If PULSELESS ARREST, GO TO VT/VF PULSELESS ARREST ABOVE PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA Symptomatic SVT: (pain, ↓BP, CHF) narrow QRS (unstable) Prepare for SYNCRONIZED CARDIOVERSION if HR > 150 Consider sedation Cardiovert @ 200 joules Asymptomatic SVT : Stable Vagal Maneuvers (carotid massage, Valsalva) Adenosine 6 mg IV 1-3 seconds flush with 20 cc NS to rapidly infuse Repeat Adenosine 12 mg IV 1-2 min 3rd dose of Adenosine 12 mg IV 1-3 seconds Total of 30 mg of Adenosine can be given Calcium Channel Blockers Diltiazem (Cardizem) 20 mg bolus over 1-2 min Infusion of 5 mg/hr if converts Verapamil 2.5-5 mg IVP slowly over 1-2 min Beta-blockers Digoxin 0.25-0.5 mg loading dose For medical codes (code blue) the numbers are: DRH/UHC 114 Harper 117 VA 3333 from any phone RIM 119 CHM 115 Hutzel 118 Sinai / Grace 116 Internal Medicine Resident Survival Guide - 58 - BRADYCARDIA Some Useful Websites: http://satyampatel.files.wordpress.com/2008/03/acls-algorithms.pdf ACLS http://www.americanheart.org/presenter.jhtml?identifier=2158 AHA Guidelines How to call a code As a doctor, your responsibility is in running and assisting in medical code situations. The nurses, clerks and other members of the care giving team know how to call a code into the system, but just in case you’re alone, wouldn’t you like to know who/how to call one??? First of all, note that code information (what color is assigned to each code called overhead) is on the back of the DMC badges. Take a look at your badge. The emergency numbers (like what number to call for which emergency) is on the back of our badges too. Take another look. Internal Medicine Resident Survival Guide - 59 - ELECTROLYTE REPLACEMENT OPTIONS Potassium DMC Normal Range (3.5 to 5.3 mmol/L): Signs/Symptoms of Low Potassium Arrhythmia Impaired pressor response Weakness Respiratory failure Myalgias Hyporeflexia Confusion Metabolic alkalosis Constipation **Suggested Replacement Range IVPB (NTE 20mEq/1 hr) PO 2.0 to 2.8mmol/L 20 mEq q 1 hr x 3* ---2.9 to 3.2 mmol/L 20 mEq q 1 hr x 2* KCl 40 mEq liquid (IR) 3.3 to 3.5 mmol/L 20 mEq q 1 hr x 1* KCl 20 mEq po > 3.5 mmol/L --KCl 20 mEq tabs (SR) Maintenance 20 mEq/Liter of IVF KCl 20 mEq po daily (SR) Notes: If Phosphate also low (<2.5 mg/dL) use IV KPhos or PO Neutra-phos Replace Mg if low, as hypomagnesemia can make replacing K difficult Consider K Acetate in academia or hyperchloremic patients *Determine serum potassium prior to ordering additional potassium IVPB’s Products Available: Route Dosage Form Liquid Tablet PO Powder IVPB (over 1 hr.) Product KCl 20 mEq KCl 40 mEq - KCl 20 mEq (K-dur) K/Na Phos (Neutra Phos) K=7.1 mEq Na= 7.1 Phos+ 8 mmol or 250 mg KCl 20 mEq/100 ml K Acetate (40 mEq/20 ml) K Phos** write Phos in mmol (K=4.4 mEq/ml, Phos=3 mmol/ml or 93 mg/ml) Internal Medicine Resident Survival Guide - 60 - Phosphorus DMC Normal Range (2.5 to 4.5 mg/dL) Signs/Symptoms of Low Phosphorus Myopathy Neurological dysfunction Weakness Respiratory muscle paralysis Confusion Red cell hemolysis Suggested Replacement Range IV PO <1.0 mg/dL 15 mmol* x 2 ---1.0 to 2.5 mg/dL 15 mmol* ---Maintanence --8 mmol Neutra-phos (1) po tid *recheck Phosphorus and if still <1.0 repeat with Na or K phos ** If K <3.5 then use K Phos, if K > 3.5 then use Na Phos Products Available Route PO IVPB (over 1 hr.) Dosage Form Product Powder Neutra-phos K=7.1 mEq, Na=7.1mEq, Phos=8 mmol or 250 mg Na Phos** write Phos in mmol (Na=4 mEq/ml, Phos=3 mmol/ml or 93 mg/ml) K Phos** write Phos in mmol (K=4.4 mEq/ml, Phos=3 mmol/ml or 93 mg/ml) Magnesium DMC Normal Range (1.6 to 3.0 mg/dL) Signs/Symptoms of low Magnesium Arrhythmias Angina Confusion Weakness Tremor Irritability Dysphagia Nausea Refractory hypo:K, Ca, and PO4 Suggested Replacement Range IVPB PO <1.0 mg/dL 2 Gm q 1 hr x 2* --1.0 to 1.5 mg /dL 2 Gmx1 --1.6 to 2.0 mg/dL 1 Gm x1 --Maintenance --Mag-Oxide 400 mg po tid * recheck magnesium after replacement and repeat as necessary Products Available: Route Dosage Form PO Tablet IVPB Product Magnesium Oxide 400 mg (10 mmol Mg or 241 mg Mg) Magnesium Sulfate 50% (1 gm/2ml=4 mmol or 8 mEq or 98 mg of Mg) Internal Medicine Resident Survival Guide - 61 - Calcium DMC Normal Range (Total 8.2 to 10.6 mg/dL or Ionized 1.13 to 1.32) Corrected Ca= observed Ca + 0.8 (4 gm/dL-observed albumin) Signs/Symptoms of Hypocalcemia -- (CV effects are more severe with a ionized <0.7 mmol/L) QT prolongation Bradycardia Muscle spasm Parasthesias Weakness Fatique Hypotension *Chovstek’s sign (tap the facial nerve, get facial muscle spasm) *Trousseau’s sign (inflate a BP cuff on a patient’s arm get carpal spasm) Suggested Replacement:** Severe Symptomatic PO ---- IV Ca Gluconate 1 gm over 10 min* Ca Carbonate 1 gm in D5 over 30 min* Asymptomatic Ca Carbonate 1-2g/day Ca Gluconate 2 gm Divided TID/QID in D5 over 1 hr. * Repeat if symptoms persist with 1-2 mg/kg/hr ** Correct K and Mg deficits Products Available: Route Form Product PO Tablet Calcium Carbonate 1250 mg (Ca 500 mg or 25 mEq) $0.02 Calcium Gluconate 1% (1 gm=90 mg or 4.5 mEq Ca) $0.38 Calcium Chloride 1% (1 gm=270 mg or 13.5 mEq Ca) $1.21 IVPB Internal Medicine Resident Survival Guide - 62 - Cost Common On-Call Complaints/ Quick Reference By Subspecialty These are some of the common on call complaints that you may face. This list is not all inclusive, nor should it be a substitute for your own clinical judgment. With any concerns or questions, call you Senior Resident!!! And after you check the patient out, and administer anything, call your Senior Resident anyway! First and foremost. When you are called re: a patient—go see the patient! Yes, of course, you are tired. You want to sleep. This is the 100th page you have received and life is not looking up. Go see the patient anyway… AMBULATORY Ordering Compression Stockings 15-20 mmHg-- Minor varicosities, minor varicosities during pregnancy, tired, aching legs, minor ankle, leg and foot swelling, and post sclerotherapy. 20-30 mmHg-- Moderate to severe varicosities, post surgical, moderate edema, post sclerotherapy, helps prevent recurrence of venous ulcers, moderate to severe varicosities during pregnancy and superficial thrombophlebitis. 30-40 mmHg-- Severe varicosities, severe edema, lymphatic edema, management of active ulcers and manifestations of PTS; chronic venous insufficiency, helps prevent PTS and recurrence of venous ulcers, orthostatic hypotension, post surgical and post sclerotherapy. 40+ mmHg-- Severe varicosities, severe edema, lymphatic edema, management of active ulcers and manifestations of PTS; chronic venous insufficiency, orthostatic hypotension, postphlebitic syndrome. GENERAL Body Fluid Routine Labs---These need procedure notes as well. Lumbar Puncture Tube 1: Cell count and differential Tube 2: Gram stain and cultures Tube 3: Protein and glucose Tube 4: Cytology, VRDL, oligoclonal bands, may want to repeat cell count and diff. if first tube was bloody, other special studies Thoracentesis Pleural Fluid: Send albumin, protein, LDH, glucose, pH, cell count and differential, gram stain and culture, AFB smear and culture, fungal smear and culture, cell cytology Serum: Send serum LDH, glucose, protein, and albumin. Paracentesis Ascites Fluid Labs: Protein, LDH, glucose, amylase/lipase, pH, cell count and differential, gram stain and culture, cytology Serum Labs: LDH, glucose, protein, and albumin. Arthrocentesis Fluid Labs: Viscosity, glucose, protein, gram stain and culture, cell count and differential, cytology, crystals. Internal Medicine Resident Survival Guide - 63 - Fever So broad a differential, but it’s 3am, limit your choices: Review the signout sheet /chart for previous CXR, cultures, CBC’s Symptomatic relief: ASA 325-650mg po or PR q4hour PRN Tylenol 500mg-1 gram po q4h PRN Cooling blankets: D/C when temperature is 39 degrees Celsius Do a work up for sepsis: 1. CXR, if there are respiratory symptoms 2. Blood cultures times two=15 minutes apart, from two different sites 3. UA with microanalysis, culture & sensitivity if urinary symptoms present. 4. Stool cultures if indicated 5. CBC with differential 6. With mental status changes or focal neurological deficits, perform an LP 7. Check for phlebitis, assess indwelling foleys, IVs, A lines and remove and replace if necessary. 8. Check for decubitus ulcers, skin breakdown, new murmurs, rashes, and the perianal area. Insomnia Restoril 7.5-30 mg po qhs. Risk of respiratory depression. Sonata 10-20 mg po qhs. Decrease to half this dose in liver disease and elderly Ambien 5-10 mg po qhs. Do not use in obstructive sleep apnea. “Pain” Patients are often admitted with pain medications. Ask the patient if the pain is from the same location as before to insure it is not of a new onset. Then ask: 1. Location 2. Intensity 3. Quality 4. Rating 1-10 5. Relieved with pain meds prior? What seemed to work? Try first increasing the dose of meds that the patient is on. New onset pain requires a more thorough history: When you start the patient on the medications, do so conservatively, and discuss what you did with your co-intern when they arrive. They can then adjust the medications and dosages for a longer period as appropriate. Internal Medicine Resident Survival Guide - 64 - Mild-Moderate Pain (1-5) Acetaminophen and NSAIDS will usually suffice. Assess for possible contraindications: Liver disease or Hx of EtOH Age Tylenol 500mg-1000mg po q4-6 hours. Maximum dose 4g / day. Hepatotoxicity is a concern in doses > 4g/day chronically Adjust dose by ½ in elderly patients If known liver disease, choose plan B Tylenol with codeine (Tylenol #2 15/300, Tylenol #3 30/300, Tylenol #4 60/300) Same warnings as above, plus CNS depression 1-2 tabs q 4 hours PRN Constipation if chronically using opiods, but not usually with PRN doses NSAIDS Better choice if inflammation accompanies the pain Assess GI bleed/GI Ulcers/Gastritis/Esophagitis (risk increases 1.5 times on NSAIDS) Renal function (may exacerbate ARF and should be used with caution in renal failure patients) H/O CHF (may exacerbate secondary to antiprostaglandin effect) Motrin 400mg po q4-6 hours PRN maximum = 3.2 g / day Toradol (potent) 30-60 mg IM Short term (less than 5 days) 15-30 mg IV Celebrex 400mg po x 1, then 200mg po bid (Contraindicated in sulfa allergies) Moderate to Severe Pain Opioids Patients may already be on opioids and need supplementation doses for breakthrough pain Assess for: Liver dysfunction CNS depressants Hypotension Use PO whenever possible Morphine Sulfate Immediate release tablets 15-30 mg po q4 hours Use liquid if there is difficulty swallowing MS Contin is controlled release so it takes longer to act. 30mg po q8-12 hours 1-5 mg IV q4-6 hours. IV can lead to vasodilation and hypotension so do not use in decreased blood pressure. Demerol / Meperidine 50-150 mg po q4h prnDo not use in renal failure patients are metabolites can lead to accumulation and seizures with impaired renal function. Restoril 25 mg to decrease nausea and improve analgesia Contraindicated in MAOI / SSRI users and renal failure Internal Medicine Resident Survival Guide - 65 - Table 1 Opioid Equivalents Name Codeine Hydromorphone (Dilaudid) Levophanol (Levodromoran) Meperidene (Demerol) Methadone (Dolophine) Morphine (Roxanol) Morphine CR (MS Contin) Oxycondone (Percocet) Oxycodone CR (Oxycontin) Propoxyphene Onset (min) 10-30 15-30 30-90 10-45 30-60 15-60 15-60 15-30 15-30 30-60 Dosing (hr) 4 4 4 4 6 4 12 6 12 4 Oral Eq (mg) 200 7.5 4 300 20 30 90 30 30 200 I.V. Eq (mg) 120 1.5 2 75 10 10 NA NA NA NA Bowel Regimen (Begins when the prescription for opioid is written) STEP 1: Prevent Constipation a. Dietary Intervention b. Stool softener and gentle laxative c. 1-2 Peri-Colace PO qday-tid STEP 2: If No BM in 48 Hours a. 1-2 Colace po bid-tid + 2 Senokot po qhs - May increase Senokot to maximum dose of 4 tabs tid OR b. 30-45 cc Lactulose qhs with 8 oz. of water (range 15-60 cc Lactulose qhs-bid) STEP 3: If No BM in 72 Hours Perform rectal exam to rule out impaction NOTE: Constipation may worsen with time because of disease process. All potential causes of constipation should be evaluated. Rectal examination SHOULD NOT be performed in patients with neutropenia or mucositis. IF NOT IMPACTED: a. Lactulose (if not already done) OR b. Dulcolax (Biscodyl) 10 mg supp OR c. 8 oz. of Magnesium Citrate po OR d. Fleet Phospho-Soda Enema (Use with caution in patients with renal insufficiency. Not for use in patients receiving dialysis). IF IMPACTED: a. Manually disimpact if stool is soft OR b. If stool is hard, use Fleet Oil Retention Enema OR c. Follow with Saline Enemas until impaction resolved OR d. Adjust intensity of preventative bowel regimen. Internal Medicine Resident Survival Guide - 66 - CARDIOLOGY/ HYPERTENSION Hypertension Hypertensive urgency (usually treatable with oral meds) -DBP usually > 130, SBP usually > 210 -Pt. without major BP related symptoms -No evidence of new or worsening BP-related target organ damage (↑Cr, CHF, neurological Sx) Hypertensive Emergencies (always treat with IV meds in the ICU) 1. Accelerated HTN --severe retinopathy (NO papilledema) --acute dysfunction of target organs 2. Malignant HTN --accelerated HTN + papilledema --1/3 underlying renal artery stenosis --1/4 renovascular HTN 3. Hypertensive encephalopathy --severe BP elevation or rapid rise in BP --headache --nausea/vomiting --transient neurological dysfunction (agitation, altered sensorium) --visual disturbances --+/- papilledema ----goal = 15-20% ↓ in MAP over 1st hr. *should not be <170/110 *may be lowered more in setting of unstable angina, CHF, pulmonary edema, aortic dissection ----look for 2° causes *critical renal artery stenosis *glomerulonephritis *Cushings syndrome *pheochromocytoma --1/4 renovascular HTN (25%) IV meds--IN ALPHABETICAL ORDER 1. Diazoxide - relaxes arteriolar smooth muscle - significant side effects (Na retention, hyperglycemia, hyperuricemia) 2. Enalaprilat - no adverse side effects/symptomatic hypotension reported - contraindicated in pregnancy 3. Esmolol - cardioselective B-blocker - independent of renal/hepatic function 4. Fenoldopam - Dopamine-1 agonist - increases renal blood flow, increases Na excretion Internal Medicine Resident Survival Guide - 67 - 5. 6. 7. 8. 9. - renal vasodilator - no alpha or beta activation - liver metabolized to inactive agents - no rebound HTN when stopped Labetalol - alpha and beta blockade - metabolized by liver to inactive agents - decreased PVR without decreased peripheral blood flow Nicardipine - as effective as nitroprusside - decreased cardiac/cerebral ischemia Nitroprusside - arterial/venous vasodilator (decreased preload and afterload) - decreased cerebral blood flow and increased ICP - *coronary steal phenomenon* - increased mortality if used in early AMI - cyanogens metabolized to thiocyanate which is excreted by the kidneys!!! Cyanide removal needs good liver/kidney function and adequate thiosulfate Hydrocobalamine=treatment of toxicity Phentolamine - alpha blockade (excellent for catecholamine induced --aka. Pheochromocytoma) Nitroglycerin -venodilator -decreased preload and cardiac output Non Emergent Blood Pressure Elevations in the Hospital -Assess patient status hemodynamically. -Do not try to make the patient’s blood pressure 140/90 in the next five minutes or lower it dramatically just to please the other staff—as a matter of fact, it can be dangerous to lower it too quickly. -Rule Out: Any evidence of new, ongoing, current end organ damage that may lead you down the management pathway to hypertensive emergency. Some examples, CHF, Neurological changes, Decrease in Urine Output, Headaches, Bleeds -Review patient’s chart. See if patient missed any BP meds. If so, replace. There is no need to treat a blood pressure just because it is HIGH and SCARY. Have a reason why you are going what you are doing. Possible Interventions: Some will tell you that Clonidine is an option but you will get rebound when it wears off and/or the patient stops it on their own. Most of our patients are not ideal candidates to take Clonidine on a scheduled basis. PO Captopril 12.5-25 mg will decrease BP in 15-30 minutes. Watch out for an excessive response. Internal Medicine Resident Survival Guide - 68 - YOU SUSPECT YOUR PATIENT IS HAVING AN ACUTE MI What do you do? ⇒ Minutes 0-5 Place patient on a bedside monitor, with a bedside defibrillator Nursing to supply a bedside drug box, or park drug cart nearby Confirm or start reliable IV—DO NOT PLACE IN A NONCOMPRESSIBLE SITE Obtain a STAT 12-Lead EKG, and request old EKG’s/chart to compare Give ASA 325 mg p.o., unless contraindicated During the above, obtain relevant history During the above, perform relevant exam, with differential diagnosis in mind Reassure the patient; stay calm; stay at the bedside ⇒ Minutes 5-10 Review EKG immediately as it comes off the machine; keep the tech there. If inferior injury pattern or suspect RVMI, perform “V R” leads EKG Compare to old tracings Give NTG 0.4 mg SL, unless contraindicated If 1st EKG was equivocal, repeat in 10 minutes, or for clinical changes If dx unclear and you are not an expert EKG reader, GET ONE NOW ⇒ Minutes 10-15 Come to a working diagnosis; get whatever help you need to do so NOW If your working diagnosis Is acute MI, then, Start 2nd reliable IV --- DO NOT USE NONCOMPRESSIBLE SITES Initiate treatment for ischemic pain: IV NTG, IV Beta-blockade, Morphine sulfate In “window period” for myocardial salvage? IF SO, decide between thrombolysis, primary PTCA, or conservative Rx Inform attending physician, discuss with cardiology fellow or staff If thrombolytics are to be given, call Pharmacy STAT, confirm ASA given Re-examine, consider if any invasions are mandatory before thrombolytics Continuous treatment adjustments as needed Ward clerk to secure a CCU bed Review labs; baseline coags, CBC and platelets, lytes, etc as needed Internal Medicine Resident Survival Guide - 69 - ⇒ Minutes 15-20 Thrombolytic is hung, or Interventional team is coming, or c conservative Rx. Complete initial loading of IV beta blocker if indicated Advance dose of IV NTG as tolerated TIMI SCALE TIMI Risk Score for Unstable angina/Non ST elevation MI HISTORY Age >/= 65 >/= 3 CAD risk factors (FHx, HTN, ↑chol., DM, active smoker) Known CAD (stenosis >/= 50%) ASA use in past 7 days PRESENTATION Recent (</= 24hrs) severe angina ↑ cardiac markers ST deviation >/= 0.5mm RISK SCORE = Total points (0-7) POINTS 1 1 1 1 1 1 1 Risk of Cardiac events (%) by 14 days in TIMI 11B∗ RISK SCORE DEATH or MI 0-1 2 3 4 5 6/7 3 3 5 7 12 19 DEATH, MI, or URGENT REVASC. 5 8 13 20 26 41 ∗entry criteria: UA or NSTEMI defined as ischemic pain at rest within past 24hrs, with evidence of CAD (ST segment deviation or +marker) Internal Medicine Resident Survival Guide - 70 - Algorithm (reproduced from Harrsion’s) So you are wondering if the pt had an MI. High / CP with low likely Intermittent hood of ischemia Atypical CP low prob probability Check markers at 0 and 6 h, and ECG if any CP (+) markers or ECG (-) markers and ECG Exercise stress test abnormal normal UA/NSTEM pathway D/C Home Reading EKGs Note: height: 0.1 mV = 1 mm, duration: 0.04 seconds = 1 mm · Rate: 60–100 bpm normal · QRS Axis: normal axis is –30° to +90°. < -30° is left axis, >90° is right axis. · Differential diagnosis of axis deviations (in order of likelihood): Right Axis 1. RVH 2. Lateral or anterolateral MI 3. WPW with left freewall pathway 4. LPFB Left Axis 1. LAFB 2. Inferior MI 3. WPW with posteroseptal pathway 4. COPD or PE Internal Medicine Resident Survival Guide - 71 - · Intervals PR: normal 120 – 200 msec QRS: normal < 90 msec, abnormal > 120 msec QTc: normal <0.45 (measured QT/square root of R–R interval) · Right atrial abnormality (only 1 criteria needed) lead II P > 0.25 mV or > 25% QRS amplitude lead V1 P > 0.15 Mv · Left atrial abnormality (only 1 criteria needed) lead II P > 120 msec with notches separated by at least 1 small box lead V1 P wave has a negative terminal deflection that is 40 msec by 0.1 mV · Left ventricular hypertrophy: There are numerous criteria; three useful ones are below. All are specific but all are insensitive, so fulfillment of one set is sufficient for LVH (applies to age > 55) RaVL >11 mm (men), >9 mm (women) RaVL + SV3 >20 mm (women) and >25 mm (men) SV1 + (RV5 or RV6)>35 mm · Right ventricular hypertrophy: the following findings suggest RVH; there are several others. Right axis deviation R in V1 + S in V6 > 11 mm R:S ratio > 1 in V1 (in absence of RBBB or posterior MI) · RBBB (Right Bundle Branch Block) QRS > 120 msec Wide S wave in I, V5, V6 Secondary R wave (R’) in right precordial leads with R’ greater than initial R (rsR’ or rSR’). · LBBB (Left Bundle Branch Block) QRS > 120 msec, broad R in I and V6, broad S in V1 and normal axis or QRS > 120 msec, broad R wave in I, broad S in V1, RS in V6, and left axis deviation. · LAFB (Left Anterior Fascicular Block): There are several sets of criteria for LAFB Axis is more negative than – 45 degrees Q in aVL, and time from onset of QRS to peak of R wave is > 0.05 seconds. Also helpful is QI, SIII pattern · · LPFB (Left Posterior Fascicular Block; must exclude anterolateral MI, RVH, RBBB) Axis >100 and QIII, SI pattern Q Waves: Use the following for screening V1, V2, V3: "any, any, any"; V4, V5, V6: "20, 30, 30"; I, II, aVL, aVF: "30, 30, 30, 30"; V1, V2: "R > 40, R > 50". Numbers refer to width of Q wave in milliseconds ** Borrowed from http://medicine.ucsf.edu/housestaff/handbook/HospH2002_C2.htm#EC Internal Medicine Resident Survival Guide - 72 - Pathway for Determining Differential Diagnosis of Narrow QRS Tachycardia Narrow complex QRS tachycardia <120 msec Regular? Visible P waves? Atrial fibrillation Atrial tachycardia/flutter with variable AV conduction MAT Atrial rate greater than ventricular rate? Atrial flutter or Atrial tachycardia Analyze RP interval Short (RP shorter than PR) RP shorter than 70 msec Long (RP longer than PR) RP longer than 70 msec Atrial Tachycardia PJRT Atypical AVNRT AVNRT AVRT AVNRT Atrial Tachycardia Internal Medicine Resident Survival Guide - 73 - Valve Defect Murmurs Clicks Change in Heart Sounds Aortic Stenosis S: SEM at RUSB, mid to late peaking diamond shaped Mitral Stenosis D: Diastolic rumble S: Ejection click if congenital or bicuspid D: Opening snap (only diastolic click) Chronic Aortic Regurge S: Occasional early systole SEM. D: 1.) High pitched, decrescendo mid to holodiastolic (regurgitation through the valve). 2.) Austin Flint: low, rumbling diastolic (regurg stream striking the anterior mitral leaflets). D: Short diastolic murmur S: MVP. Late SEM follows click. CMR: pansystolic constant murmur Absent 2nd (occas.) S4: Paradoxically split S2 S1 is enhanced sometimes "snapping". May be silent if severly calcified S3 if severe. Acute Aortic Regurge MVP with murmus; Chronic Mitral Regurge (CMR) Acute Mitral Regurge S3 if severe S: MVPMidsystolic click (Clickmurmur syndrome) S: Pansystolic decrescendo at apex Pulmonic Stenosis Tricuspid Stenosis Tricuspid Regurge S: Midsystolic click often preceded by SEM S: Ejection click Pulse waveforms: a/v Waves Slowed carotid upstroke Large L "a" waves and attenuated "y" descent "Corrigan's pulse" "Waterhamme r pulse" Thready S3 if severe; S4 S3 if severe Large left "v" waves Persistently/wi dely split S2 Large right (jugular) "a" wave Giant right "a" waves Large right "v" waves D: Diastolic at LSB D: Systolic at LLSB Internal Medicine Resident Survival Guide - 74 - VSD ASD- ostium secundum ASDostiuim primum Coarctation of the Aorta HCM PDA S: Holosystolic at LLSB S: SEM at LSB (increased flow across pulmonic valve) S: SEM at LSB (increased flow across pulmonic valve), also often assoc. TR or MR murmur Midsystolic to continuous murmur (depending on severity) in the upper back S: Harsh midsystolic S+D: Continuous "machine gun" murmur at LUSB Fixed-split S2 Fixed-split S2 S4 Paradoxically split S2 Internal Medicine Resident Survival Guide - 75 - Brisk carotid upstroke which is BIFID in 2/3 Murmur Louder With: Squatting Expiration After PVCs CXR LVE Squatting Expiration LAE Squatting Expiration LVE Squatting Expiration Normal Standing or valsalva: Longer- moves earlier into systole; sustained handgrip. Expiration Squatting Expiration LAE Inspiration RVH: enlarged pulmonary artery Squatting/Inspiration RAE Normal Other: Sustained apical impulse; Etiology: Bicuspid valve Classic triad is LVH, angina, and syncope with exercise Etio: virtually always rheumatic fever. SSx: Hemoptysis. Secondary pulmonary, HTN Etio: congenital, endocarditis, or dilated aortic root from :marfan, VSD, arteritis, polychondritis, syphilis Cardiogenic shock and pulmonary edema. Consider aortic dissection Etio of MVP: congenital, ischemia Valve Defect Aortic Stenosis Etio: Endocarditis, MI with papillary muscle ischemia or rupture, chordae tendineae rupture. SSx: Pulmonary edema Etio: virtually always congenital- rarely caused by rheumatic fever and carcinoid. Congenital type usually does not progress TS is rare; Etio: usually rheumatic fever but also congenital and Acute Mitral Regurgitation Internal Medicine Resident Survival Guide - 76 - Mitral Stenosis. Chronic Aortic Regurgitation Acute Aortic Regurgitation MVP with murmur; chronic mitral regurge (CMR). Pulmonic stenosis Tricuspid Stenosis Squatting/Inspiration RVE Handgrip RVE + LVE RVE; shunt vascularity RVE Standing, Valsalva Note: Sustained handgrip decreases murmur Rib notching, loss or aortic notch LVE carcinoid syndrome. With carcinoid, pt. usually also has TR. SSx: venous congestion Etio: usually dilation from pulmonary HTN, other: rheumatic fever, endocarditis (IVDA), carcinoid, Liver pulsations, JVD Consider in new MI with new systolic murmus EKG: RAD, RBBB EKG: LAD, RBBB Apical impulse may have double or triple taps Calcification of ductus arteriosis Internal Medicine Resident Survival Guide - 77 - Tricuspid Regurgitation VSD ASD- ostium secundum ASD- ostium primum Coarctation of the Aorta HCM PDA DOING A PRE-OP CONSULT **See web links below for original guideline statements This is when you check out the patient for clearing them for surgery. ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery Goto:http://www.americanheart.org/presenter.jhtml?identifier=3004542 (all ACC/AHA Guidelines) Goto: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.185700 (guidelines) Theme of the guidelines is that preoperative intervention is rarely necessary simply to lower the risk of surgery unless the intervention is indicated irrespective of the preoperative context. The purpose of the evaluation is not simply to give cardiac clearance but instead to evaluate the patients current medical status, make recommendations concerning the evaluation, management and risk of cardiac problems over the entire perioperative period and make a clinical risk profile that all involved in the care can use to make treatment decisions about the short and long term cardiac outcomes. A large proportion of the data used in formulating the guidelines is retrospective or observational based or the knowledge of management of CV disorders in the non-operative setting. However the number of prospective or randomized studies that have been performed to establish the value of different treatments on perioperative outcomes is small. In general, perioperative testing should be limited to circumstances in which the results will affect patient treatment and outcomes. Clinical evaluationInitial history, physical, and ECG should focus on identifying potentially serious cardiac disorders, including CAD (prior MI or angina), heart failure, symptomatic arrhythmias, presence of a pacemaker or ICD, or a history of orthostatic intolerance. Severity, stability, and prior treatment should also be addressed. Other factors that determine cardiac risk include the functional capacity, age, comorbid conditions, and the type of surgery. Associated with increased perioperative cardiac morbidity: -CAD and HF, hx. of cerebrovascular disease, preoperative elevated Cr>2 mg/dL, insulin treatment for diabetes, and high risk surgery. Internal Medicine Resident Survival Guide - 78 - 1. Division into 3 categories based on clinical predictors. a. Major i. Recent unstable coronary syndrome such as an acute MI (<7day history) or recent MI (>7 days but <1 month) ii. Unstable or severe angina iii. Evidence of a large ischemic burden by clinical symptoms or noninvasive testing iv. Decompensated HF v. Significant arrhythmias (high-grade AV block, symptomatic arrhythmias in the presence of underlying heart disease, or SV arrhythmias with an uncontrolled ventricular rate). vi. Severe valvular disease. b. Intermediate i. Mild angina ii. More remote MI iii. Compensated HF iv. Preoperative creatinine greater than or equal to 2 v. DM c. Minor i. Advanced age ii. Abnormal ECG iii. Rhythm other than sinus iv. Low functional capacity v. History of stroke vi. Uncontrolled systemic HTN ***If a recent stress test does not indicate residual myocardium at risk, the likelihood of reinfarction after noncardiac surgery is low. Although there is no clinical trial on which to base firm recommendations generally it apprears reasonable to wait 4-6 weeks after MI to perform elective surgery. 2. 3. Functional Capacity-expressed in metabolic equivalents a. 1-4 METS- Eating, dressing, walking around the house, and dishwashing. b. 4-10 METS- Climbing a flight of stairs, walking on level ground at 6.4 km/hr, running a short distance, scrubbing floors, or playing golf. c. >10 METS- Strenuous sports such as swimming, singles tennis, and football. Risk of surgery a. High- Reported cardiac risk is often greater than 5% i. Emergent major operations, particularly in the elderly ii. Aortic and other major vascular surgery iii. Peripheral vascular surgery iv. Anticipated prolonged surgical procedures assoc. with large fluid shifts and/or blood loss b. Intermediate i. Carotid endarterectomy Internal Medicine Resident Survival Guide - 79 - ii. iii. iv. v. c. Head and neck surgery Intraperitoneal and intrathoracic surgery Orthopedic surgery Prostate surgery Low i. Endoscopic procedures ii. Superficial procedures iii. Cataract surgery iv. Breast surgery Hypertension- Greater than 180/110 should be managed and reduced medically, over several days to weeks. If surgery is more urgently needed IV anti-hypertensives can be used. Valvular Heart Disease- Indication for eval. and treatment are the same as in the nonoperative setting. Stenotic valves are assoc. with a risk of perioperative HF or shock and often require percutaneous valvotomy or valve replacement before noncardiac surgery to lower the cardiac risk. Regurg is better tolerated. Myocardial Disease Arrhythmias and conduction abnormalities- Should provoke a search for the underlying cause (underlying cardiopulmonary disease, drug toxicity, or metabolic abnormality). Percutaneous coronary intervention- No controlled trials comparing perioperative cardiac outcome after noncardiac surgery for patients treated with preoperative PCI vs. medical therapy. Delaying surgery for a week after balloon angioplasty to allow for healing of the vessel injury has theoretical benefits. If a coronary stent is used, a delay of at least 2 weeks and ideally 4-6 weeks should occur before noncardiac surgery to allow 4 weeks of dual antiplatelet therapy and re-endothelialization of the sent to be complete or nearly so. Beta-blockers- Reduced perioperative cardiac events and improves 6 month survival. When possible they should be started days to weeks prior to surgery and the dose titrated to HR 50-60. Post op pain management- Reduces catecholamine surges and hypercoagulability. Intraoperative NTG- Should only be used when the hemodynamic effects of the other agents have been considered. Perioperative Maintaince of Body Temp- One randomized trial demonstrated a reduced incidence of perioperative cardiac events in patients who were maintained in a state of normothermia via forced air warming compared with routine care. **Although the occasion of surgery is often taken as a specific high-risk time, most of the patients who have known or newly detected CAD during their preoperative evaluations will not have any events during elective noncardiac surgery. After the preoperative cardiac risk has been determined by clinical or noninvasive testing, most patients will benefit from pharmacological agents to reduce their LDL and/or increase their HDL. From ACC. org Cardiac Risk* Stratification for Noncardiac Surgical Procedures Internal Medicine Resident Survival Guide - 80 - (Reported cardiac risk often greater than 5%) High • • • • Emergent major operations, particularly in the elderly Aortic and other major vascular surgery Peripheral vascular surgery Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss (Reported cardiac risk generally less than 5%) Intermediate • • • • • Carotid endarterectomy surgery Head and neck surgery Intraperitoneal and intrathoracic surgery Orthopedic surgery Prostate surgery (Reported cardiac risk generally less than 1%) Low† • • • • Endoscopic procedures Superficial procedure Cataract surgery Breast surgery Internal Medicine Resident Survival Guide - 81 - Internal Medicine Resident Survival Guide - 82 - ACC.org Stepwise Approach to Preoperative Cardiac Assessment 1 MET Can you take care of 4 METs yourself? Eat, dress, or use the toilet? Walk indoors around the house? Walk a block or two on level ground at 2 to 3 mph or 3.2 to 4.8 km per h? Do light work around the house like dusting or washing dishes? 4 METs Climb a flight of stairs or walk up a hill? Walk on level ground at 4 mph or 6.4 km per h? Run a short distance? Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture? Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football? Greater than Participate in strenuous 10 METs sports like swimming, singles tennis, football, basketball, or skiing? From ACC.org, Estimated Energy Requirements for Various Activities CRITICAL CARE/ PULMONARY Transudate vs. Exudate for Pleural FluidIf at least one of the following three criteria is present, the fluid is virtually always an exudate; if none is present, the fluid is virtually always a transudate. Pleural fluid protein/serum protein ratio greater than 0.5 Pleural fluid LDH/serum LDH ratio greater than 0.6 Pleural fluid LDH greater than two thirds the upper limits of normal of the serum LDH pH<7.2 Glucose< 20 Protein>3 Dyspnea 1. Ask for respiratory rate, oxygen saturation, vital signs over the phone, and get yourself out of bed to see the patient 2. Do a focused cardiovascular and pulmonary H&P. Why was the patient admitted? 3. If you get to the point of thinking you may need to call the MICU you should have your senior resident with you. When you send the ABG the MICU would appreciate having a lactate as well and you can check the lytes on that blood sample. Internal Medicine Resident Survival Guide - 83 - Cardiovascular? Think: CHF,New Onset Tachy/Brady arrhythmias, Ischemia, Dissecting Aneurysm, Hypertensive crisis Rx: Sit the patient up Lasix 20-80 mg IVP, increase based on response (this means at least 300-500 cc out in the next couple of hours) Oxygen to keep saturation > 60 mmHg Morphine 2-5 mg IV. Repeat q10-25 minutes Pulmonary? Think: Pulmonary embolism, Pulmonary edema, Asthma / COPD exacerbation with severe bronchospasm, Pneumonia / Pneumonitis, Atelectasis Rx: Albuterol / Atrovent respiratory treatment for INH—asthma or COPD 2.5 / 0.5 mg per 3mL INH q3-4 hours Oxygen by nasal cannula (tubes in the nose), venturi mask (bird beak looking thing), or non rebreather (bird beak with a beard/bag hanging off of it) to keep oxygen saturation > 60 mmHg Nasal canula can deliver FiO2 up to 38% Venturi can deliver 55% FiO2 Nonrebreather can deliver 100% FiO2 If atelectasis, chest pulmonary toilet and positional change Work up: 1. 2. 3. 4. Chest x-ray ABG with lactate and you can check the lytes from the same sample Oxygen saturation monitoring EKG Hypotension Cardiac Output Reduced? Yes, if… Small pulse pressure Cold extremities Poor capillary refill Heart too full? Yes, if… Increased system venous pressure Crackles, S3 Ischemia No, if…. Large pulse pressure Low diastolic BP Warm extremities Good capillary refill No, if… Dehydration Blood Loss Give 2 liters of 0.9% Normal Saline and reassess. First initiate this with a 500cc-1 liter bolus Give 2-3 L of NaCl over 15-30 minutes in patients in shock If pressors are needed, this requires a central line and the ICU Internal Medicine Resident Survival Guide - 84 - Hemodynamic Values Heart Rate Pressures Systemic Arterial Peak Systolic/End Diastolic Mean (MAP) (2xdiastolic+systolic)/3 Left Ventricle Peak systolic/End diastolic Left Atrium (PCWP) Mean a wave v wave Pulmonary Artery Peak systolic/End diastolic Mean Right Ventricle Peak systolic/End diastolic Right Atrium Central Venous Pressure (CVP) Mean a wave v wave Resistances Systemic Vascular Resistance (SVR) SVR= [(MAP-CVP)/CO] x 80 Pulmonary Vascular Resistance (PVR) PVR=[(PAP-PCWP)/CO]x80 Flow Cardiac Output (CO) CO=HRxSV Cardiac Index (CI) CI=CO/BSA5 Ejection Fraction (SV/End-Diastolic Volume)x100 60-100 beats/min 100-140/60-90 mm Hg 70-105 mm Hg 100-140/3-12 mm Hg 2-12 mm Hg 3-10 mm Hg 3-15 mm Hg 15-30/4-14 mm Hg 9-17 mm Hg 15-30/2-7 mm Hg Internal Medicine Resident Survival Guide - 85 - < 5 mm Hg 2-6 mm Hg 2-8 mm Hg 2-7 mm Hg 700-1600 dynes sec cm-5 100-300 dynes sec cm-5 3.5-5.5 L/min 2.4-3.8 L/min/m2 >50% PNEUMONIA PORT SCORE 1. Is pt > 50 yo? If so then use classification. 2. Does the pt have a history of neoplasm, CHF, CVA, renal or hepatic dysfunction? If yes use classification. 3. Does pt have altered mental status, pulse >125, RR > 30, SBP < 90, or temperature <35 or > 40? If so then use classification. 4. If no to all 3 then risk is 1 and tx as outpatient. Men=age Women=age -10 Nursing home=10 Neoplasm=30 Liver dx=20 CHF=10 Renal disease = 10 CVA=10 Altered ms=20 RR > 30=20 SBP < 90=20 Temp <35 or >40=15 Pulse >125=10 Arterial pH <7.35=30 BUN >30=20 Na <130=20 CHO>250=10 Hct<30=10 PaO2 < 60 or SpO2 < 90 = 10 Pleural effusion = 10 Risk Class I = 0 --> out pt Class II = < 70 --> out pt Class III = 71-90 --> brief in pt Class IV = 91-130 --> in pt Class V = > 130 --> in pt (29% chance of death) PNEUMONIA SEVERITY INDEX “CURB-65” C = confusion U = uremia, > 7 R = Respiratory rate, > 30 B = Blood pressure low 65 = Patients over age 65 A score of 0 or 1 may be managed at home if serious vital sign abnormalities or comorbidities are absent and if there are no social factors or other illnesses requiring hospitalization. A score of 2 or more require admission Internal Medicine Resident Survival Guide - 86 - Differential Diagnosis of Asthma Differential Diagnosis of Dyspnea: • Acute – Asthma, pneumonia, pulmonary edema, pneumothorax, pulmonary embolus, metabolic acidosis, ARDS, panic attack • Pulmonary – Airflow obstruction (asthma, COPD, upper airway obstruction), restrictive lung disease (interstitial lung disease, pleural thickening or effusion, respiratory muscle weakness, obesity), pneumonia, pneumothorax, PE, aspiration, ARDS • Cardiac – Myocardial ischemia, CHF, valvular obstruction, arrhythmia, cardiac tamponade • Metabolic – Acidosis, hypercapnia, sepsis • Hematologic – Anemia, methemoglobinemia Psychiatric – Anxiety Differential Diagnosis of Wheeze: • Asthma • COPD • CHF (cardiac asthma) • Acute bronchitis • Pneumonia • GERD • Airway obstruction (e.g., tumor, goiter) • Foreign-body aspiration • Aspiration pneumonia • Interstitial lung disease • Pulmonary embolism • Angioedema or anaphylaxis • Carcinoid syndrome • Vocal cord dysfunction Notable physical findings during acute exacerbation: • Tachycardia – up to 120 beats per minute is reasonable; > 120 bpm found in 10-15%, and is worrisome • Tachypnea – up to 30 respirations per minute is reasonable; > 30 found in 10-15%, and is worrisome • Pulsus paradoxus – a positive finding when the systolic blood pressure decreases greater than 10-12 mmHg on passive inspiration; is the result of the dynamic hyperinflation that occurs with exacerbation • Mild hypoxia – should not normally be lower that 88% unless there is severe exacerbation and/or other pathology also present o During exacerbation, there is primarily regional V/Q mismatch, though some shunt physiology may play a role if there is mucous plugging of airways. • Accessory muscle use – worrisome sign associated with increased mortality • Depressed neurologic status - worrisome sign associated with increased mortality Internal Medicine Resident Survival Guide - 87 - Characteristics of Sudden vs. Slow Evolution of Acute Asthma – typically, those with a more prolonged course prior to presentation have a more difficult hospital course TYPE1: Slow Progression Type 2: Sudden Progression Slow-onset Sudden-onset, asphyxia, brittle, or hyperacute asthma Progressive deterioration > 6 h (usually Rapid deterioration < 6h days or weeks) 80 to 90% patients presented to an ED 10 to 20% patients who presented to an ED Female predominance Male predominance More likely to be triggered by URI More likely to be triggered by respiratory allergens, exercise and psychosocial stress Less severe obstruction at presentation Slow response to treatment and higher Rapid response to treatment and lower hospital admissions hospital admissions Airflow inflammation mechanism Bronchospastic mechanism of deterioration Poor prognostic factors on history: • Previous severe exacerbations/ICU/intubation – only ~5% of mortalities had prior ICU/intubation • >2 hospitalizations or 3 ER visits in past year , 1/3 of mortalities had recurrent admits • Use of greater than canisters of B2-agonists MDI’s per month • Current or recent (within 1 month) use of corticosteroids • Difficulty in perceiving presence or severity of airway obstruction Psychiatric illness (including depression) – due to compliance issues and/or difficulty in perceiving severity of disease • Low socioeconomic status • Illicit drug use (heroin and cocaine increased likelihood for intubation) • Serious co-morbidities • LACK OF AN ASTHMA ACTION PLAN Internal Medicine Resident Survival Guide - 88 - Internal Medicine Resident Survival Guide - 89 - Internal Medicine Resident Survival Guide - 90 - Inpatient Pharmacological Management: 1. 2. Oxygen supplementation – if needed, guidelines recommend 1-3 liters by nasal cannula; if more oxygen is required to alleviate hypoxia, consider an alternative or concomitant diagnosis a. O2, if needed, should be tailored to achieve a pulse ox ~ 92% b. High flow O2 use for treatment of pure asthma exacerbation is associated with increased mortality. c. Bronchodilators: a. Beta Agonists – Albuterol; MDI provides better delivery in less time than nebulized, so use when able. If using NMT (nebulized mist treatment) initially, stacked doses of 2.5 mg x 3 q 20 minutes are just as efficacious as a single dose of 7.5 mg, but with less side effects b. Anticholinergics – Ipratroprium bromide can have an inpatient role; use is associated with decreased length of stay. If using NMT, initial order can be for 0.5 mg q 30 minutes 3. Steroids – prednisone PO is just as efficacious, and MUCH less costly, than IV methylprednisolone if dosed properly. Proper dosing should initially be prednisone 60 mg po q 8 hours, then decrease to discharge dose of 60 mg po daily as patient stabilizes. 4. Others: a. Magnesium – 2g magnesium sulfate may be used as adjunctive treatment to oxygen, bronchodilators, and steroids, but only has a benefit in severe exacerbations. Discharge considerations: • Discharge is appropriate at peak flows > 70% of predicted AND minimal/absent symptoms • Along with other appropriate outpatient medications, patients should be given at least 7-14 days of prednisone 60 mg po daily. o However, the patient needs to follow up with a physician within 7 days. The outpatient physician should ultimately make the decision on the dosing and duration needed. • Always send with an asthma action plan (http://intraweb.dotnetapps.chmallergy) Internal Medicine Resident Survival Guide - 91 - Predicted Average Peak Expiratory Flow for Normal Males (L/min) Age Height (inches) 60" 65" 70" 75" 20 554 602 649 693 25 543 590 636 679 30 532 577 622 664 35 521 565 609 651 40 509 552 596 636 45 498 540 583 622 50 486 527 569 607 55 475 515 556 593 60 463 502 542 578 65 452 490 529 564 70 440 477 515 550 Predicted Average Peak Expiratory Flow for Normal Females (L/min) Age Height (Inches) 55" 60" 65" 70" 20 390 423 460 496 25 385 418 454 490 30 380 413 448 483 35 375 408 442 476 40 370 402 436 470 45 365 397 430 464 50 360 391 424 457 55 355 386 418 451 60 350 380 412 445 65 345 375 406 439 70 340 369 400 432 80" 740 725 710 695 680 665 649 634 618 603 587 75" 529 523 516 509 502 495 488 482 475 468 461 ENDOCRINE Blood Glucose Hypoglycemia Go to the floor, and await the response to treatment in all cases 1. Recheck (peripheral blood draw) 2. Assess prior treatment response Asymptomatic patient and cooperative 1. Given 15-30 g CBH, 8 oz of juice or soda = 30g CBH 2. 2 graham cracker squares = 10 g CBH 3. For every 15 g CBH given, blood sugar is supposed to increase 25-50 mg/dL Symptomatic (tremors, diaphoresis, palpitations) or NPO patient Internal Medicine Resident Survival Guide - 92 - 1. 2. 3. 1 bolus Ampule of D50% IV. If no IV give 1mg Glucagon IM (watch for nausea, vomiting) Do accuchecks q 5-10 minutes depending on response Follow ampule with D5W or D10W to maintain CBG 100mg/dL and do Accucheck q 30 minutes Sulfonylurea overdose 1. Requires prolonged, continuous IV D5W and close observation Hyperglycemia 2. Recheck blood sugar with a peripheral blood draw 3. Assess repeat CBG’s, treatment previously ordered and response 4. Assess baseline dosages if the patient is already on any medications for diabetes Be conservative, knowing that hyperglycemia is less dangerous than hypoglycemia. An aspart insulin sliding scale may be implemented: CBG Regular Insulin 200-250 4 units 251-300 6 units 301-350 8 units 351-400 10 units less than 60 or greater than 400, call house officer. If there is an infection, we may tighten this scale (means starting with 150-200 use 2 units). In the ICU setting an IV insulin normogram is started. DIAGNOSTIC CRITERIA FOR DIABETIC KETOACIDOSIS AND HYPEROSMOLAR HYPERGLYCEMIC STATE * UpToDate, Treatment of diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults DKA HHS Mild Moderate Severe Plasma glucose Arterial pH Serum bicarbonate > 250 7.25-7.3 15 to 18 >250 7.0-7.24 10 to <15 >250 <7.0 <10 >600 >7.3 >15 Urine ketones Serum ketones Effective serum osmolality Anion gap Mental alteration Positive Postive Variable Positive Positive Variable Positive Positive Variable Small Small >320 >10 Alert >12 Alert/drowsy >12 Stupor/coma <12 Stupor/coma Internal Medicine Resident Survival Guide - 93 - TREATMENT OF DKA * UpToDate, Treatment of diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults Internal Medicine Resident Survival Guide - 94 - ENT Epistaxis Anterior Most common, caused by Kiesselbach’s Triad and usually self limited from Trauma or irritation (O2) Posterior Usually spontaneous but may be vascular disease related Work Up -Vitals: Emergency? -Can you visualize source of bleeding? If non emergent and anticoagulated get INR If emergent H/H, Type and Cross Treatment 1. Have pt lean forward to avoid swallowing blood 2. Hemostasis is applied to distal part of nose 3. Consider cold compress to bridge of nose 4. Identify the source of bleeding 5. Topical oxymetazoline (Afrin) spray alone often stops the hemorrhage. 6. LET solution (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.4%) applied to a cotton ball or gauze and allowed to remain in the nares for 10-15 minutes is very useful in providing vasoconstriction and analgesia. Lidocaine 4% spray may work as well. 7. Chemical cautery with silver nitrate is performed for mild active bleeding or after bleeding has stopped and prominent vessels identified. 8. Nasal packing has been the next step for persistent bleeding Oxidized regenerated cellulose (Surgicel or Oxycel) and absorbable gelatin foam (Gelfoam) don't need extraction & increase clot formation by encouraging platelet aggregation, 9. Anterior packing is often inadequate to control bleeding from the posterior nasal. Need ENT for post packing. Internal Medicine Resident Survival Guide - 95 - GERIATRICS DMC: WSU/Rosa Parks Geriatric Center Location: DRH/UHC/5B Primary care by Geriatricians and Nurse Practitioners with specialty in Geriatrics Geriatric Specialists available: 1. Gastroenterology. 2. Psychiatry 3. Physical Medicine & Rehabilitation 4. Cardiology 5. Neuropsychology Specialty Clinics: Multidisciplinary team consisting of a physician, nurse practitioner, PharmD and MSW 1. 2. 3. Memory Evaluation Clinic: Evaluate and treat cognitive impairment-new or established. Balance Clinic: See persons who have a history of falls or who are at high risk for falls Multidisciplinary Anticoagulation Clinic: In addition to INR & Coumadin monitoring, this clinic addresses fall risk, cognitive and social issues of the patient in relation to medication and appt. adherence, and safety. We must have a faxed anticoagulation referral form completely filled out and signed by the physician before we can set up an appt. These are also available online: On Intraweb, go to Pharmacy and it’s easily accessed. We have appointment availability on Tuesdays and Fridays, so that patients may be seen within 3 days of discharge. Patients who qualify for care in our specialty clinics or by a specialist: age 60 and/or with Medicare. We also accept referrals/consults from private physicians for these specialty services. In preparation for discharge page Ann Blarezo at the contact info. below. Prior to discharge she will introduce herself and set up an appointment for them before they actually leave. Ann Balarezo, CNP DMC Geriatric Center of Excellence Rosa Parks Geriatric Center Phone: 745-4402 Email: [email protected] Beeper: 6303 Fax: 745-8165 HEMATOLOGY/ONCOLOGY Neutropenic Fever (absolute neutrophil count <1.5) Patient needs to be in isolation. All Antibiotics are ordered and administered as STAT. These patients might not show typical signs of infection. Upon initial neutropenic fever the following studies are obtained: a. Blood cultures- Obtain one set of blood cultures from the central catheter and Internal Medicine Resident Survival Guide - 96 - one set of peripheral blood cultures. b. Sputum culture c. Skin lesion culture if clinically indicated d. U/A with micro, culture, and sensitivities e. CXR, PA and Lateral f. Stool for C. diff toxin g. Don't forget to examine the mouth, sinuses, IV sites, perianal area, and skin. f. Start broad spectrum antibiotics like Cefepime/gentamicin, if still febrile, add Vancomycin, if still febrile start antifungals. If no beta lactam allergy start CEFEPIME: • Estimated creatinine clearance >60 mL/min -2 grams of cefepime IV q 8 hours. • Estimated creatinine clearance 30-60 mL/min- 2 grams cefepime IV q 12 hours. • Estimated creatinine clearance 11-29 mL/min- 2 grams cefepime IV q 24 hours. • Estimated creatinine clearance <11 mL/min.- 1 gram cefepime IV q 12 hours. If beta-lactam allergic start the following: • Aztreonam 2 grams IVPB every 8 hours plus, either: • Vancomycin 1 gram intravenously every 12 hours, OR • Clindamycin 600 mg intravenously every 8 hours. Add VANCOMYCIN if one of the following is suspected or documented: a. Erythema at the catheter exit site b. Tenderness at the catheter exit site c. Exudates at the catheter exit site d. Central venous catheter tunnel infection e. Cellulitis f. Folliculitis In the presence of severe mucositis add clindamycin or if on vancomycin add metronidazole. Internal Medicine Resident Survival Guide - 97 - Internal Medicine Resident Survival Guide - 98 - Hypercalcemia Correct for albumin!!! Common Tumors: multiple myeloma, breast, kidney, esophageal, thyroid, head and neck, parathyroid and squamous cell lung cancer (PTH-rp) What To Do About It: 1. Normal saline as much as possible depending on cardiac function 2. If becoming fluid overloaded, give Lasix, which will decrease Ca as well 3. Continue the fluids, you don’t want to cause volume contraction. 4. Ultimately the patient will need something to bring the calcium down. a. Zoledronate (4 mg IV over 15 min, typically outpatient) b. Pamidronate (60-90 mg IV infused over 4 hours, typically inpatient) c. If you can't use bisphosphonates calcitonin (4 units/kg q12 x 4 doses) may be helpful. **Can lead to tachyphylaxis. d. If all else fails, dialysis is effective (particularly those with CHF or ESRD who can't handle the volume you need to give them). Spinal Cord Compression * Neurological Emergency Pain worse with recumbency and valsalva. Can present with numbness, weakness, urine/stool incontinence, and new or worsening back pain. ~20% of new diagnoses of malignancy are made by finding cord compression. LACK OF NEUROLOGICAL FINDINGS DOESN'T RULE IT OUT, IT JUST MEANS YOU MAY MAKE THE DIAGNOSIS EARLY ENOUGH TO MAKE A DIFFERENCE!!!!! On Exam: do entire exam, including rectal exam for rectal tone Common tumors: include epidural/medullary spinal cord tumors, lymphoma, metastatic tumor to vertebral bodies (especially lung, breast, prostate, and renal cell). What to Do About It: 1. Decadron IV (dexamethasone) (The loading dose is typically 20 mg x1 plus scheduled dosing 2. MRI with and without contrast of the suspected area STAT. 3. Neurosurgery consult STAT if there is evidence of compression/cord compromise on the MRI. You need to CALL!!! Neurosurgery!! 4. Rad/Onc consult STAT if there is evidence of compression/cord compromise on the MRI. You need to call Rad/Onc!!! Internal Medicine Resident Survival Guide - 99 - Increased ICP Patient presents with confusion, depressed mental status secondary to brain mets etc. What to Do About It: 1. Imaging study to evaluate. Probably a CT at least initially then will probably ultimately need an MRI. 2. Elevate the head of the bed 3. Decadron (dexamethasone)- loading dose usually 20 mg IV x 1 then maintenance dose 4. Stat Neurosurgery consult 5. Chemotherapy is usually not effective in CNS tumors because of the difficulty in getting drugs across the blood brain barrier Pericardial Tamponade Tachypnea, Tachycardia, Distant Heart Sounds, Pulsus Paradoxus (fall of SBP of 10 mm with inspiration), electrical alternans on EKG. Late signs are JVD/hypotension. Treatment: 1. Oxygen 2. Fluids because the Right ventricle is volume dependent and may help to minimize collapse while therapy is arranged. 3. Call the Cardiology Fellow for a STAT bedside Echo.. 4. Call CT surgery for drainage/window if evidence of tamponade or hemodynamically unstable. Tumor Lysis Syndrome Lysis of tumor cells, esp after initiating chemotherapy. Associated with high tumor burden with rapid turnover rate: ALL, CLL, CML, blast crisis Which then leads to……………. Hyperkalemia Hyperphosphatemia Hypocalcemia Hyperuricemia Acidosis That then can lead to………….. Acute Renal Failure Cardiac Arrhythmias Muscle cramps, tetany Prophylaxis/Treatment 1. Allopurinol 600-900 mg x 1 then 300-600 mg qDay or Rasburicase. 2. IVF 3. If acute renal failure, consider dialysis. Internal Medicine Resident Survival Guide - 100 - Superior Vena Caval Obstruction (SVC Syndrome): The patient may complain of dyspnea, headache or head fullness which are worse when they lay flat, arm edema, visual disturbance, confusion, or facial swelling. Common Causes: Lung cancer (in particular small cell), Non-Hodgkin lymphoma, or other mediastinal tumors, indwelling lines thrombosis, aortic aneurysms, thyroid enlargement, fibrosing mediastinitis, radiation therapy. On Exam: Facial plethora, Elevated JVD, Distention on chest veins, Upper extremity edema, or cyanosis. What to Do About It: 1. Elevate the head of the bed 2. Administer O2 3. If there is evidence of airway compromise CALL ENT STAT. 4. Therapy should be discussed with your team, if you have a diagnosis radiation +/chemo, if you need a diagnosis radiating the tumor before you get a chance to biopsy it may make that job more difficult. 5. Other measures: low salt diet, careful diuresis, oxygen, stent/angioplasty (if recurrent superior vena cava syndrome) Typhlitis By definition is necrotizing infection of cecum/colon Patient may complain of fever, diarrhea, RLQ pain (not appendicitis!) Common Tumor association: acute leukemia What to Do About It: 1. Broad spectrum Antibiotics 2. Surgery consult Disseminated Intravascular Coagulation (DIC) Signs! anemia, thrombocytopenia, elevated PT and PTT, low fibrinogen, elevated D dimmer and fibrin monomers. Initial phase is prothrombotic, bleeding can occur after that! What To Do About It: 1. Supportive 2. Treat underlying condition. 3. Consult Hematology. Leukostasis Signs: pulmonary hypoxemia, intracerebral hemorrhage What To Do About It: 1. Hydroxyurea 3g po x1, then 1g qhr until blast count <50,000. 2. Leukapheresis most effective: call fellow/attending for initiation Internal Medicine Resident Survival Guide - 101 - HIT – HEPARIN INDUCED THROMBOCYTOPENIA Suspect HIT when: - acute thrombocytopenia - platelet fallen by 50% or more - necrotic skin lesions at injection sites in a patient started on heparin within the preceding 5 to 10 days Testing - platelet factor 4 assay Treatment - stop ALL heparin including heparin flushes by the nurses - start patient on direct thrombin inhibitor like Lepirudin or Argatroban - Lepirudin contraindicated in renal failure - Argatroban contraindicated in hepatic disease - after a direct thrombin inhibitor is on for at least 48 hours, can start warfarin Internal Medicine Resident Survival Guide - 102 - Initial Anemia Workup: - Order CBC, ferritin, iron saturation, TIBC, MCV, retic count - If suspecting hemolytic anemia, order haptoglobin, billirubin, LDH - Always look at the peripheral smear yourself! -Scistocytes are indication of hemolysis In hemolytic anemia: LDH elevated, retic elevated, bilirubin elevated, haptoglobin decreased Workup for Cause of Hemolytic Anemia: - Intravascular vs extravascular - Evidence of schistocytes on peripheral smere - If spherocytes present, could be hereditary spherocytosis - If Coombs test is positive, then autoimmune hemolytic anemia - Consider G6PD deficiency Internal Medicine Resident Survival Guide - 103 - DIFFERENTIATING INTRAVASCULAR AND EXTRAVASCULAR HEMOLYSIS Test All types Intravascular Extravascular Reticulocyte Count Increased Increased Increased LDH Increased Increased Increased Indirect bilirubin Increased Increased Increased or normal or normal Haptoglobin Decreased Decreased Decreased Urinary hemosiderin Present or Present Absent absent Blood Loss, Symptomatic Anemia 1. Type and Cross 2 units of Packed Red Blood Cells. 2. Order coagulation profile on the patient. 3. Secure large bore IV access 4. Determine origin: a. Guiac, NG suction. Monitor patient closely 5. Give blood products if Hct<30%, Hgb<8 6. For each unit of PRBC Hct should climb 3% and Hgb 1. If platelets <10,000, if coags are abnormal, or if >6 units PRBC’s were transfused, give FFP and platelets. 7. Remember—giving blood products needs consent. Tranfusion Reactions If a patient develops fever, chills, itching or any other symptoms during a transfusion: a. Stop the transfusion; call your senior. b. Benadryl may be given if it is felt to be a reaction to the transfusion Laboratory tests in iron deficiency of increasing severity Marrow reticuloendothelial iron Serum iron, µg/dL Iron binding capacity (transferrin), µg/dL Saturation (SI/TIBC), percent Hemoglobin, g/dL Normal Fe deficiency without anemia 2+ to 3+ None Fe deficiency with mild anemia None Severe Fe deficiency with severe anemia None 60 to 60 to 150 150 300 to 300 to 390 360 20 to 50 30 <60 <40 350 to 400 >410 <15 <10 Normal Normal 9 to 12 6 to 7 Red cell morphology Normal Normal Plasma or serum ferritin, ng/mL Erythrocyte protoporphyrin, ng/mL RBC Other tissue changes 40 to <40 200 30 to 70 30 to 70 Normal or slight hypochromia <20 Hypochromia and microcytosis <10 >100 100 to 200 None Nail and epithelial changes None None Internal Medicine Resident Survival Guide - 104 - INFECTIOUS DISEASES IDENTIFICATION OF BACTERIA ALGORITHMS GRAM POSITIVE COCCI Clusters Staph Clusters Staph Pairs Pneumo. Coagulase positive Staph aureus Coagulase negative S. epidermidis S. saprophyticus S. hominis S. hemolyticus S. warneri GRAM POSITIVE BACILLI Small Large Listeria Proprionbacterium Corynebacterium Gardnerella Chains Strep. Chains Strep. Chains Strep. Beta hemolytic Strep. Pyogenes S. agalactiae Groups C, F, G Alpha hemolytic Viridans Strep. S. pneumoniae Gamma hemolytic E. faecium E. fascalis Group D Strep. Large Spore forming Nonspore forming Clostridium Bacillus Lactobacillus GRAM NEGATIVE BACILLI Lactose Lactose Fermenter Fermenter Oxidase positive Oxidase negative Aeromonas E. coli Pasteurella Klebsiella sp. Vibrio Enterobacter sp. Citrobacter sp. Non Lactose Fermenter Oxidase positive Pseudomonas sp. Flavobacterium sp. Alcaligenes sp. Achromobacter sp. Moraxella sp. GRAM NEGATIVE COCCI Neisseria meningitides Neisseria gonorrhea Veillonella Branching or Filamentous Norcardia Actinomyces Erysipelothrix Non Lactose Fermenter Oxidase negative Proteus sp. Providencia sp. Serratia sp. Morganella sp. Salmonella sp. Shigella sp. Stenotrophomonas Acinetobacter sp. GRAM NEGATIVE COCCOBACILLI Haemophilus influenzae Moraxella catarrhalis Acinetobacter Internal Medicine Resident Survival Guide - 105 - Internal Medicine Resident Survival Guide - 106 - (from the DMC Pharmacy Website) Internal Medicine Resident Survival Guide - 107 - 4+ 4+ 0 0 0 0 0 Amp/Amox + 0 4+ 4+ 2+ 2+ 2+ 0 Nafcillin 4+ 0 3+ 0 0 0 0 0 Vanco Linezolid Quinupristin 3+ 3+ 3+ 3+ 3+ 3+ 3+ 3+ 3+ 3+ 3+ 3+ 0 0 0 0 0 1+ 1+ 1° ceph. 4+ 0 4+ 0 3+ 2+ 2° ceph. 2+ 0 3+ 0 3+ 3+ 3° ceph. 2+ 0 3+ 0 4+ 4 4+ 4+ 4° ceph. 3+ 0 3+ 0 4+ 4+ 4+ 4+ Aztreonam 0 0 0 0 4+ 4+ 4+ 4+ Unasyn 4+ 0 4+ 4+ 4+ 3+ 4+ + Timentin 3+ 0 3+ 3+ 4+ 4+ 4+ 4+ Zosyn Primaxin Meropenem 3+ 3+ 0 0 3+ 3+ 3+ 3+ 4+ 4+ 4+ 4+ 4+ 4+ 4+ 4+ Genta + + + + 3+ 3+ 3+ 2+ Tobra/Amik. 0 0 0 0 4+ 4+ 4+ 4+ Other 0 Others 0 DRUGS Penicillin Strep/ Entero B. frag Proteus E. coli ANAEROBES GNR GPC Pseudo monas Gram Neg Rods H.flu M. cat. AEROBES Gram Positive Cocci Staph MS/MR BUGS 0 3+ + + 3+ 0 0 + 0 0 0 1 + 0 2+ 1+ 2+ 2+ 1+ 2+ 0 + + 4+ + 0 3 + 3+ 3+ + 2 + 2+ 2+ 2+ 3+ 0 3 + 3 + 3 + 3 + 0 0 4+ 4+ 3+ 3+ 3+ 3+ 3+ 4+ 0 0 0 0 0 Clindamycin 4+ 2+ 4+ 0 0 0 0 0 Metronidazo 0 0 0 0 0 0 0 0 3 + 4 + Bactrim 3+ 2+ 3+ 0 4+ 3+ 3+ 0 0 0 0 Cipro + + + + 4+ 3+ 4+ 4+ 0 0 0 Norfloxacin + + + + 4+ 3+ 3+ 3+ 0 0 Levofloxacin 3+ + 3+ + 4+ 3+ 4+ + 1+ 1+ Moxifloxacin 3+ + 3+ + 4+ 3+ 4+ 2+ 3+ 3+ Gatifloxacin 3+ + 3+ + 4+ 3+ 4+ 2+ 0 1 + 3 + 2 + 3+ 3+ Clarithro. 3+ 1+ 4+ 0 + + 4+ 0 + + 2+ Azithro. 3+ 1+ 4+ 0 2+ + 4+ 0 + 2+ 2+ Internal Medicine Resident Survival Guide - 108 - 4+ 4+ 4+ 4+ NEPHROLOGY AND ACID BASE Thinking about Acid Base Disturbances (See the formulas section for help with formulas for compensation) 1. Is the patient acidemic or alkalemic? • Determine blood pH 2. Is the overriding disturbance respiratory or metabolic? • Measure arterial pCO2 and serum bicarbonate 3. If a respiratory disturbance is present is it acute or chronic? • Compare measured pH with expected change in pH 4. If a metabolic disturbance is present is there an increased anion gap present? • Measure serum sodium, chloride, and bicarb. Calculate an anion gap. 5. If a metabolic disturbance present is the respiratory compensation appropriate? • Compare pCO2 measure with expected pCO2. Using Winter's formula 6. Are other metabolic disturbances present in the patient with an increased anion gap metabolic acidosis? • Determine corrected bicarb level using the delta gap and compare to the measured bicarb HyperkalemiaIs the blood hemolyzed? If not, what is the cause: acute kidney injury, increased intake, increased breakdown of tissue (like tumor lysis). • ACE-I, ARB, Bactrim, NSAIDs, K sparing diuretics…HOLD THE DRUGS, Find alternative agents that are K neutral • Potassium in the TPN- HOLD TPN BAG for the duration • Oligoanuric acute renal failure • Ongoing production of potassium i.e. hemolysis, hematomas, rhabdo, tumor lysis syndrome • End stage renal disease not following potassium restriction Second, get a 12 lead EKG and look for changes. 1. Peaked T waves which progress to……. 2. Prolonged PR intervals & decrease in P wave magnitude, progresses to….. 3. Widened QRS which progresses to…….. 4. A sine wave and asystole…any change in EKG means IMMEDIATE ACTION! Treatment 1. 1 amp of calcium gluconate or calcium chloride to stabilize the myocardium 2. 1 amp of D50 and 10 units of IV regular insulin 3. Kayexelate- Either oral or retention enema. 4. Dialysis- If the patient is refractory to all of these things then you NEED to call the nephrologists for URGENT DIALYSIS 5. Place the patient on Telemetry if there are EKG changes Internal Medicine Resident Survival Guide - 109 - Acute Renal Failure • Prerenal vs. Post-renal vs. Intrarenal • Calculate FeNa by ordering urine electrolytes, serum electrolytes, urine creatinine and serum creatinine. • FeNa will be <1 in pre renal and post renal cause. To differentiate the two, do a post-void residual to rule out retention and a renal ultrasound to rule out hydronephrosis. Suspect retention in older males who may have BPH. • Go to the lab, spin the urine and examine for casts. Drugs that cause pseudo-elevation of blood urea nitrogen and creatinine. Competitive tubular secretion of creatinine: • Trimethoprim • Triamterene • Cimetidine • Amiloride • Probenecid • Spironolactone Urine Sodium Urine Osm Urine Cr/ Plasma Cr Renal Failure Index Fractional excretion of Na Urine sediment Prerenal ARF <20 >500 >40 <1 <1 Benign ATN >40 <350 <20 >2 >1 Abnormal casts, Renal tubular epithelial cells Interference with laboratory determination of creatinine • Ascorbic acid • Levodopa • Flucytosine • Methyldopa • Cephalosporins (cefoxitin and cephalothin) Hypercatabolic Effects • Steroids • Tetracycline Chronic Renal Failure Kidney Disease Outcome Quality Initiative (K/DOQI) Classification Scheme Stage 1 2 3 4 5 Criteria EGFR >90 and evidence of CKD (see below for definition of CKD) EGFR >60-89 and evidence of CKD (mild ↓ in kidney function) EGFR >30-59 (moderate ↓ in kidney function) EGFR >15-29 (severe ↓ in kidney function) EGFR <15 (kidney failure or end stage renal disease (ESRD). Internal Medicine Resident Survival Guide - 110 - Definition of Chronic Kidney Disease National Kidney Foundation Kidney damage >3 months, as defined by structural or functional abnormalities of the kidney with or without decreased GFR, manifest by either: • Pathological abnormalities (eg. Small kidney), or • Abnormalities in the composition of blood or urine, or abnormalities in imaging tests •Abnormalities GFR <60 ml/min/1.73 m2 for >3 months, with or without kidney damage. What is a renal diet? • Protein restriction in patients with CKD of 0.8 g/kg based on Ideal Body Weight • 1.2 gm/kg of Ideal Body Weight for those with End Stage Renal Disease on Hemodialysis. • 2 gram sodium diet • 2 gram potassium diet • Total Free Water Restriction based on the clinical scenario. Tests to Consider with EGFR is Less than 60 1. Hemoglobin 2. Calcium 3. Phosphorous 4. HCO3 5. PTH Target Ranges CKD GFR Stage (ml/min/1.73 m2) Intact PTH (pg/ml) Phosphorous (mg/dL) Corrected Ca (mg/dL) 3 30-59 35-70 2.7-4.6 8.4-10.2 4 15-29 70-110 2.7-4.6 8.4-10.2 5 <15 150-300 3.5-5.5 8.4-9.5 Internal Medicine Resident Survival Guide - 111 - NEUROLOGY Generalized Tonic-Clonic Status Epilepticus Suggested Guidelines for Initial Treatment Time Frame 0-5 minutes Procedure Obtain vital signs, establish airway, administer oxygen if needed. Observe seizures briefly to ascertain that patient is really in status. Draw baseline blood work (CBC, chemistry panel, antiepileptic drug levels, --send STAT), draw ABGs (for pO2 and pH), draw toxicology screen. Quickly assess patient for signs of cardiorespiratory compromise, hyperpyrexia, focal neurologic signs, head trauma, CNS infection, etc. Always have CPR equipment at bedside of a patient in status. 6-9 minutes Start IV infusion with saline solution. Administer 100 mg thiamine, IV. Administer 50 mL of 50% glucose solution IV, if blood sugar is low or unobtainable. Do not give glucose if blood sugar is normal or high. 10-45 minutes Infuse lorazepam (Ativan), 0.1 mg/kg, at 2 mg/min. Begin IV loading dose of fosphenytoin (Cerebyx), 20 mg PE/kg, at 150 mg PE/min. Monitor patient’s B/P, pulse, EKG, and respirations while giving IV fosphenytoin and lorazepam. Most common side effects: hypotension, arrhythmia, paresthesias, and respiratory depression. 46-60 minutes If seizures persist, intubate and give phenobarbital, 20 mg/kg, at 100 mg/min. Never use Valium and Phenobarbital sequentially in the treatment of status, unless the patient is intubated and in an ICU. Their hypotensive and respiratory depressant actions synergize. Serious and abrupt side effects can occur with these two drugs with given together. 1 hour If seizures persist, the patient should be placed in a drug induced coma with phenobarbital, a benzodiazepine, or other anesthetic agent to prevent life threatening lactic acidosis, hypoxia, hyperthermia, and permanent seizureinduced neuronal damage. The patient must be in an ICU, and outcome should be monitored and treatment guided by EEG with the goal being suppression of seizure activity on EEG. Internal Medicine Resident Survival Guide - 112 - Acute Mental Status Changes 1. Assess if it has happened previously, with at least 3-4 people 2. Also check sign-out sheet and chart for any previous note of such episodes 3. Check chart for underlying psychiatric, neurological, toxic, or ethanol/drug causes If New or Worsened: Neurological (Delirium, delirium tremens, stroke) Metabolic (lytes, blood sugar, hypoxia, hypercapnia) Toxic (drugs, medications, alcohol withdrawal) Infectious (UTI, pneumonia, etc.) Work Up: 1. ABG 8. Thyroid Function Tests 2. Blood glucose 9. EEG 3. Lytes, BUN, Cr, Ca, Mg, Phos 10. Coags 4. EKG 11. Ammonia level 5. Urine drug screen 12. Page Neurology 6. Serum drug screen 7. Head CT Mental Status Exam (Folstein) Internal Medicine Resident Survival Guide - 113 - Anxiety / Agitation 1. Look for cause: Medications, delirium tremens 2. Try not to give benzos/ benadryl in elderly as it can make the situation worse. 3. Reorient patient to calm them down 4. Try Haldol 1 mg for acute event 5. Trazodone 25 mg is for insomnia, but works well too. Headache Danger signs: if you find them, think something ELSE is going on • • • • • • • • • Severe persistent HA reaching max in few sec to min First or worst HA Sinusitis and Lung infection Change in mental status, Personality changes and fluctuation in level of consciousness HA started with strenuous exercise or trauma Pain spreading to lower neck Age <5 yrs or > 50 yrs Recent change in pattern of HA, progressive worsening despite treatment Indication for imaging: • • • • • • • Recent significant change in the pattern, frequency, or severity of headache Progressive worsening of headache despite appropriate therapy Focal neurologic signs or symptoms Onset of headache with exertion, cough, or sexual activity Orbital bruit Onset of headache after age 40 years HA causing awakening from sleep. Order CT scan with and without contrast. MRI/MRA if AVM or aneurysm is suspected or posterior fossa lesion is suspected. Migraine Abortive treatment: • Acetaminophen, NSAIDS, Antiemetics for mild cases • Triptans: Pt with moderate to severe migraine • Use triptans early in pts with cutaneous allodynia • Pt with N/V may need intranasal or subcut. triptans • Ergotamines: More than or equal to 48 hrs duration of attack or frequent HA recurrence • Preventive: determine based on co-morbid conditions If HTN, give Calcium channel blockers or beta-blockers If depression: give TCA If resistant to other treatments give anticonvulsants: Valproate, gabapentin or topiramate • Cognitive and behavioral therapy Internal Medicine Resident Survival Guide - 114 - Cluster Headaches Abortive: • O2 with a nonrebreather at 6 L/min has been shown to provide relief • Sumatriptan either subcut or intranasal or zolmitriptan • Ergots - Cafergot and DHE 45 • Indomethacin Tension Headaches Abortive: • Tylenol, ASA, NSAID are first line • Avoid ergots, caffeine, butalbital and codeine as they may cause rebound headaches Anxiety / Agitation 1. Look for cause: Medications, delirium tremens 2. May be a feature of mental status changes—establish a previous baseline if it is known prior 3. Assess: Respiratory compromise risks: s/p intubation, airway compromise Poor respiratory effort Significant lung disease Hypotension Ativan 0.5 – 2 mg IV (maximum 4mg) can cause cardiovascular collapse and apnea. Decrease dose in elderly and in liver dysfunction. Precipitates agitation. ½ life 10-20 hours CSF Evaluation Glucose (mg/dL) < 10 10-45 Protein (mg/dL) >250 50-250 WBC Count (cells/µL) >1000 100-1000 Early bacterial Viral More Common Bacterial Bacterial Bacterial Lyme 5-100 Bacterial Viral Viral Neuro syphillis Bacterial Neurosyphilis TB Neurosyphilis Less Common TB Fungal Other viral infections (mumps or LCM) TB Some Cases of Mumps And LCM LCM = lymphocytic choriomeningitis virus Internal Medicine Resident Survival Guide - 115 - Encephalitis Encephalitis RHEUMATOLOGY Internal Medicine Resident Survival Guide - 116 - Hand Findings (RA vs. OA) *RA: Metacarpophalangeal (MCP), proximal interphalangeal (PIP), and thumb interphalangeal (IP) joints are most frequently involved. Usually spares DIP (distal interphalangeal) and 1st MCP. The DIP joints are involved only in the presence of a coexisting MCP or PIP disease. *OA: Bouchard and Herberden nodules on PIP and DIP respectively; spares the MCP joints. Common Rheum Drugs: -Adalimumab (Humira "Human Monoclonal Antibody in RA"): TNF a inhibitor -Infliximab (Remicade): chimeric monoclonal antibody against TNF -Rituximab (Rituxin): chimeric monoclonal Ab against CD20 on B cells -Etanercept (Enbrel): a fusion protein from recombinant DNA (soluble human TNF receptors linked to Fc portion of IgG1) that acts as a decoy receptor to decrease naturally occurring TNF, hence a TNF inhibitor MISCELLANEOUS STEROID EQUIVILENCIES Internal Medicine Resident Survival Guide - 117 - PAIN MEDICINE EQUIVLENCIES Internal Medicine Resident Survival Guide - 118 - USEFUL EQUATIONS: Critical Care/Pulmonary [(713 x FIO2) – (1.25 x PaCO2)] – PaO2 So, what does it mean??? Interpretation: Increased gradient > 2.5+(0.25 x age) Diffusion defect, right to left shunt, VQ mismatch Simplified on Room Air: AA Gradient= (150-1.25X PaCO2) – PaO2 Mean Arterial Pressure: Diastolic BP + [(systolic BP-diastolic BP)/3] Fluids and Electrolytes Maintenance Hourly Fluids: 4 mL for each kg 1-10 + 2 mL for each kg 11-30 + 1 mL for each kg >30 Corrected Na For each 100 mg/dL of glucose over 100 add 1.6 to the sodium Body Water Deficit (Liters) 0.6 x wt (kg) x (Pt. Na- Normal Na) Normal Na Or TBW corrected = TBW (initial) x Na (initial) Na corrected Then Water deficit = TBW corrected – TBW initial Total Body Water 0.6 x Weight Kg (men) 0.5 x Weight Kg (elderly men, women) 0.45 x Weight Kg (elderly women) Calcium Correction in Hypoalbuminemia For every 1 g/dL decrease in albumin –serum Ca decreases by 0.8 So, to correct for a low albumin: Real Calcium = Calcium measured + (Normal albumin-Patient’s) * 0.8 Other option is to ask for ionized calcium. Internal Medicine Resident Survival Guide - 119 - Correcting Sodium per Liter of Fluid Na in solution- Patient Na Total body water +1 Na content of each solution: 5% sodium chloride: 855 3% sodium chloride: 513 0.9 % sodium chloride: 154 Ringer Lactate: 130 0.45 sodium chloride: 77 D5W : 0 Gastroenterology Interpretation of Serum to Ascites Albumin Gap (SAAG) <1.1 No Portal Hypertension Present >1.1 Portal Hypertension Present Discriminant Function in Alcoholic Hepatitis (Maddrey score) (4.6 x (PT-control PT)) + (serum bilirubin) A value greater than 32 +/- hepatic encepthalopathy indicates candidate for steroid therapy (if viral etiology ruled out). Hematology Reticulocyte Production Index: RPI= Reticulocytes (percent) x (Hct/45) x (1/2) If <2, the reticulocyte count is inadequate for the degree of anemia Nephrology Cr Clearance : (140-age) x wt. (kg) x (0.85 for females) 72 x serum Cr FENa: Urine Na x Serum Cr Serum Na x Urine Cr Renal Failure Index: Urine Sodium x Plasma Creatinine Urine Creatinine OSMOLALITY : 2 x Na +(glucose/18) + BUN/2.8 ANION GAP: Na – (Cl + HCO3) Correction of Anion Gap for Albumin Add 2.5 to gap for every 1 ↓ in albumin Internal Medicine Resident Survival Guide - 120 - Acid-Base Compensation for Metabolic Acidosis Winter’s Equation: pCO2= 1.5 (HCO3) + 8 (+ 2) Compensation for Metabolic Alkalosis ▲↑ 1 HCO2 = ▲ ↑ 0.7 pCO2 = pH ↑ 0.015 Compensation for Acute Respiratory Acidosis—Simple disturbance—HCO3 not over 30 ▲ 10 pCO2 = ▲ 1 HCO3 = pH ↓ 0.08 Compensation for Chronic Respiratory Acidosis Simple disturbance ▲10 ↑ pCO2 = ▲ ↑ 3-3.5 HCO3 = pH ↓ 0.03 Compensation for Acute Respiratory Alkalosis Simple Disturbance ▲ HCO3 ↓ 2 mEq/L per 10 mm Hg ▲pCO2 = pH ↑ 0.08 Compensation for Chronic Respiratory Alkalosis Simple disturbance ▲ HCO3 ↓ 4 mEq/L per 10 mmHg ▲ pCO2 = pH ↑ 0.117 Delta Gap: Use it to see if the corrected Bicarbonate is actually where it should be— if not, then man, you’ve got yet another acid base disturbance… Delta Gap = Calculated Gap – Standard Gap (The legendary Dr. Pravit uses 10 as the standard gap) Look at the current bicarb and add the delta gap…Is it corrected to normal or not? If less than normal, maybe a metabolic acidosis too. If greater than normal, than maybe a metabolic alkalosis too. Internal Medicine Resident Survival Guide - 121 - CORE MEASURES ACUTE MYOCARDIAL INFARCTION Measures • ASA upon arrival • ASA prescribed at discharge • ACEi or ARB prescribed at discharge for LVEF < 40% (or LVSD) • BB prescribed at discharge • BB within 24 hours after arrival time • Adult smoking cessation advice/counseling • Thrombolysis within 30 minutes of arrival • PCI within 90 minutes of arrival • JCAHO only – inpatient mortality HEART FAILURE Measures • Written discharge instructions include all of the following: Activity, diet, follow up, medications, weight monitoring and symptoms worsening. • LV function assessment • ACEi or ARB prescribed at discharge for LVEF < 40% • Adult smoking cessation advice/counseling. Compliance/Documentation Tips • Use standing orders • If medications not prescribed, document reasons/rationale • If ACEi or ARB not prescribed, document contraindications to BOTH • Use discharge instruction record • Document all discharge meds • Document smoking cessation counseling • Give patient discharge instructions, including complete discharge medication list Compliance/Documentation Tips • Use standing orders • Use discharge instruction record • Document all discharge meds • Documented LVF assessment can be performed prior to or during current hospitalization • If ACEi or ARB not prescribed, document contraindication to both • Document smoking cessation • Give patient discharge instructions, including complete discharge medication list Internal Medicine Resident Survival Guide - 122 - PNEUMONIA Measures • Oxygen assessment within 24 hours of arrival (pulse ox, ABG) • Influenza and pneumococcal screening performed. Vaccinations given if indicated. • Blood culture drawn prior to antibiotics • Blood culture within 24 hours of arrival for patients transferred or admitted to ICU • Adult smoking cessation • Initial antibiotics received within 4 hours from arrival • Initial antibiotics administered within first 24 hours consistent with guidelines for ICU and non-ICU pneumonia patients Compliance/Documentation Tips • Use standing orders • Document smoking cessation • Document actual date and time blood cultures are collected • Use discharge instruction record • Document all discharge meds • Give patient discharge instructions, including complete discharge medication list. SECTION 6: Resources COMMUNITY RESOURCES AIDS SUPPORT GROUPS AIDS Consortium of Southeastern Michigan, Inc. 3750 Woodward, Suite 32 Detroit, MI 48201 313-496-0140 (provides information, referrals and counseling) AIDS Hotline 800-872-2437 or 313-547-9040 (information) Deaf AIDS Hotline (TTY-TDD) 800-322-0849 (information) HIV/AIDS Home Help 800-515-3434 (Housing information and referral hotline) University Health Center 7B 4201 St. Antoine Detroit, MI 48201 (anonymous HIV testing and counseling) Wellness Network, Inc. 845 Livernois Ferndale, MI 48220 313-547-3783 800-322-0849 (information, referrals and support) Internal Medicine Resident Survival Guide - 123 - SHELTERS FOR AVAILABILITY OF BEDS/TRANSPORTATION PLEASE CALL THE TOLL FREE SHELTER HOTLINE (24 HRS) # 1-800-274-3583 (1-800-A-SHELTER) OR 1-313-963-782 COTS 26 PETERSBORO MEN, WOMEN, FAMILIES 313-831-3777 DETROIT RESCUE MISSION 3535 THIRD MEN ONLY/MEALS/OPEN 5 PM 313-993-6703 DOORSTEP WEST 244 HIGHLAND (HP) WOMEN/CHILDREN/MEALS 313-867-0111 OFF THE STREET 680 VIRGINIA PARK DETROIT MI 48202 313-873-0678 FOR RUNAWAY OR HOMELESS YOUTH 12-17 EASTSIDE EMERGENCY 14320 KIRCHEVAL MEN/MEALS 313-824-3060 313-371-3900 NEWLIFE RESCUE MISSION 2600 18TH STREET MEN/NO BEDS/OPEN 5 PM 313-237-0390 NSO WALK-IN SHELTER 3430 THIRD 24 HOUR WALK IN – MEALS/NO BEDS 313-832-3100 OPERATION HELPING HAND 2230 14TH STREET MEN ONLY/MEALS/24 HRS 313-961-5401 RAVENDALE 12260 CAMDEN MEN/WOMEN/MEALS 313-371-9100 INTERIM HOUSE VICTIMS OF DOMESTIC VIOLENCE 313-861-5300 SALVATION ARMY 3737 LAWTON WOMEN/CHILDREN/MEALS-90 DAY STAY SINGLE MEN ONLY OVERNIGHT 1-800-A-SHELTER [180027435837] MARINER’S INN 455 WEDYARD 313-962-9446 FOR MEN ONLY T.C. SIMMMONS 10501 ORANGELAWN WOMEN/CHILDREN 313-934-3331 MISSION OF CHARITY 4835 LINCOLN WOMEN/CHILDREN/MEALS 313-831-1028 WARMING CENTER WINTER ONLY!!!!!!! 313-963-STAY MY SISTERS PLACE VICTIMS OF DOMESTIC VIOLENCE Internal Medicine Resident Survival Guide - 124 - Wayne-Metropolitan Community services agency 3751 W. Jefferson Ecorse, MI. 164 Woodward Ave. Highland Park MI 731-782-6632313-843-2550 ****Families are housed at local motels. 15 days-will assist in paying first months rent and security deposit for housing (can extend days if needed) MENTAL HEALTH AGENCY Community Mental Health 313-224-7000 (Call from provider is helpful Has long waiting lists) Life Stress Center 313-745-4811 University Health Center – 35-14 (Uninsured or low-income individuals may be eligible for discount.) University Psychiatric Center (Wayne State University) 2751 E. Jefferson 313-993-3434 (Must be Wayne county resident, Fees are on a sliding scale.) MEDICAID INQUIRY PHONE NUMBERS 800-292-2550 Provider Inquiry Hotline 800-638-6414 Recipient Inquiry Hotline 800-642-3195 Medicaid managed care office-for changing Primary Sponsors, HMO or Clinic Plan sites or providers 800-292-7972 Medicaid Prior Authorization Hotline MEDICATIONS AGENCY AARP Price Quote Center 800-456-2226 belong to AARP. COMMENTS Medication sent by US mail or US. Allow one week to 10 days Must Cross Roads 92 E. Forest 313-831-2000 Must schedule appointments. Will fill prescriptions one time only. Tribune Fund 313-226-9404 Provider must contact on only Wed. and Thurs. Internal Medicine Resident Survival Guide - 125 - World Medical Relief 11745 12th street Detroit, MI 313-866-5333 Must be low income and 55 or older. Services Wayne, Oakland, and Macomb Counties. Eligibility based on income and amount in checking and savings. Limits- $1550 single/individual $2100 couple plus additional $300 for each dependent. PATIENT ASSISTANCE PROGRAMS/RESOURCES NeedyMeds-- www.needymeds.com Provides information on pharmaceutical manufactures that have special programs to assist people who can't afford to by the drugs they need. HelpingPatients.org-- www.helpingpatients.org PhRMA and its member companies present an interactive web site that provides a comprehensive one stop link to thousands of medicines RxAssist-- www.rxassist.org RxAssist provides physicians, advocates, and patients with the tools they need to access the pharmaceutical company assistance programs. Accessing Free Medication-- The Patient's Advocate-- www.themedicineprogram.com Free prescription medicine is available to those who qualify RxHope.com-- www.rxhope.com Provides information on patient assistance programs from pharmaceutical companies for low income, indigent, and uninsured people in need of prescription TogetherRx: Prescription Savings Program-- www.togetherrx.com Together Rx is a prescription savings program that offers a free, easy way for Medicare enrollees to save on brand-name medicines. Medicare.gov- PDOAP: Eligibility Questions-www.medicare.gov/Prescriptions/Home.asp This section of Medicare.gov provides information on public and private programs that offer discounted or free medication. Lilly Answers-- www.lillyanswers.com Internal Medicine Resident Survival Guide - 126 - SUBSTANCE ABUSE AGENCY Alcoholics Anonymous Hotline 248-541-6565 COMMENTS 24 Hour Number with counseling Central Diagnostic and Referral Service 313-876-4070 Located at Herman Keifer Intake Mon-Fri. on a first come, first served basis. Should arrive at 7a.m., need 3 pieces of ID. Must be a resident of Detroit. Detroit Rescue Mission 3535 Third Detroit, MI 48201 313-993-6703 Provides inpatient treatment and outpatient aftercare. Must be a resident of Detroit. For men only. Eleanor Hutzel Recovery Center University Health Center 6B 4201 St. Antoine Detroit, MI 48201 313-745-7411 Available to women only; must be a resident of Detroit. Harbor Light/Salvation Army 3737 Lawson Detroit, MI 48208 313-361-6136 Inpatient beds available for detox. Must call for availability. Must be a resident of Wayne County. Mariner's Inn 445 Ledyard Detroit, MI 48201 313-962-9446 For Men Only. Must be a resident of Detroit unless referred by central diagnostics at Herman Keifer Narcotics Anonymous Hotline 248-543-7200 Sacred Heart Rehabilitation Center 220 Bagley Street Suite 326 Detroit, MI 48226 313-961-6190 Patient can self refer services State of Michigan SHAR House (Self Help Addiction Rehab) 1852 W. Grand Blvd. Detroit, Mi 48208 313-894-8444 For men and women 18 or older Internal Medicine Resident Survival Guide - 127 - Sobriety House 2081 W. Grand Blvd P.O. Box 08160 313-895-0500 For men only; age 18-69 of age. No detox residential care. Opiate Dependence Treatment Program UPC-Jefferson Research 2761 E. Jefferson Detroit, MI 48207 888-362-7792 For children, adolescence, and adults. Individual, group, and family therapy and medication treatment TRANSPORTATION Detroit Metrolift 313-833-7692 Provides curb to curb service anywhere within the city of Detroit and up to 3/4 mile outside of city. Cost $2.50 each way. Must make reservation 1-8 days in advance. SCAT (Special Citizens Area Transit) 313-521-1900 Mon-Fri 10-4:30 Call 9:00a.m.-1:00p.m. To schedule a ride. Van with wheelchair lift. Curb to curb service. Must be 65 or older or physically handicapped with no age limitation. Must schedule appt. One week in advance. Call Monday -Friday 10-2 Services the City of Detroit East of Woodward, Hamtramack and Highland Park Charge in $1.50 each way. SMART 866-962-5515 Van with wheelchair lift. Curb to Curb service. Must call 2 days in advance for general and 6 days in advance for medical transportation. Minimum charge is $1.00 each way. Does not service Detroit. Travelers Aid Society of Detroit 211 W. Congress, 3rd floor Detroit MI, 48226 313-962-6740 Mon-Thurs 8:30a.m.-5:00p.m. Friday 8:30a.m.-4:30p.m. Will provide bus tickets to and from medical appointments and to and from job interviews. Will call to verify appoint. Must make application in person. Internal Medicine Resident Survival Guide - 128 - SENIOR CITIZENS PROGRAMS Adult Protective Service 1-877-963-6006 (updated April,2007) (To evaluate suspected cases of neglect or abuse Part of the Department of Social Services.) Area Agency on Ageing 313-446-4444 (Provides information and referral for citizens 60 and older. Provides meals on wheels, home care assistance, home care. Serves Detroit, Hamtramck, the Grosse Point and Harper woods.) Detroit Health Department 313-876-4000 (Food and friendship at selected sites serves nutrition and social needs. Meals on wheels for homebound seniors 60 or older; serves city of Detroit.) Detroit Senior Citizens Department 313-224-5444 (For citizens of Detroit 55 and over. A referral service.) SUPPLEMENTAL SECURITY INCOME Social Security Administration 800-772-1213 (Must be determined to be blind or disabled to receive disability payments. If approved payment is retroactive to the first month of application.) VOCATIONAL REHABILITATION, COUNSELING AND TESTING Jewish Vocational Services Michigan rehabilitation services 4250 Woodward 800-605-6722 admin office in lancing Detroit MI 48201 Detroit offices 313-833-8100 707 west Milwaukee 871-3800 (Provides classes for preparation for a 19251 Mack Ave. job. Must be 18 or older and low 313-886-8275 income.) (Job placement service for adults with history of work and job skills. Jewish Vocational Services Provides counseling and vocational 29699 Southfield Rd rehabilitation and independent living Southfield MI 48076 services to handicapped individuals 16 248-559-5000 and over. Handicap can be physical, (Job placement service for adults with mental or educational.) history of work and job skills.) Internal Medicine Resident Survival Guide - 129 - PLACES TO FIND A MEAL DURING THE WEEK BRUNCH TIME DAY LOCATION Manna meals 9a-11 MTWF Sat 1950 Trumbell Capuchin soup kitchen 4390 Conner 313-822-8606 Capuchin Community Center 8:30a-1p Everyday, but Sunday 6333 Medbury 313-925-0514 Fort Street Open Door 9a-11a Thursday 631 W. Fort Cass Park Baptist Center 9a-9:30a 11:15a breakfast MW lunch 2700 Second St. Dominic's Church 10a-11a Everyday 1421 W. Warren but Thursday Just Love Ministries 10a-12p M Th F 481 W. Columbia Central United Methodist 10:30a-12p M Th 23 E. Adams First Presbyterian Church 11a-12:30p Wed 2930 Woodward St. Leo's Church 11:30a-1:30p Everyday, but Sun 4860 15th St. Trinity Episcopal Church Cass Community 12p-2 p 12 p Saturday Saturday 1519 MLK Blvd. 3901 Cass Crossroads 12p-3p Sunday 92 E. Forrest Salvation Army-Bagley 12-3p Everyday 601 Bagley Detroit Rescue Mission 5:30p-6p Everyday 3535 Third Salvation ArmyHarbor Light 6p-8 p Everyday 2643 Park DINNER Internal Medicine Resident Survival Guide - 130 - REFERRAL SERVICES FOR THE POOR AND UNINSURED Name/Location/Phone St. Frances Cabrini Clinic (Holy Trinity Catholic Church) 1435 Sixth St., Det., 48226 313961-7863 (P) 313965-9891 (F) Hours of Operation Services Offered 5 PM till 25 patients are seen - Tues Mental health, primary Need to register by 4 PM. care, prescription 1 PM Thurs, Regis. by Noon assistance 6 PM Thurs, Evenings, Regis. By 4 Mental Health (adults only) Wed evenings by appointment only Fee/Free No Fee St. John Community Health Center 3000 Gratiot Ave., Det., 48207 313-567-7462 St. Vincit DePaul Health Center 16000 Pembroke, Det., 48235 313-837-5078 Thea Bowman Health Center 2058 Fenkell Ave., Det, MI 48223 313-255-3333 Thea Bowman Nurse Managed Center 211 Glendale, Ste. 412, HP, 48203 313-866-2415 9 AM - 5 PM - Mon Wed Thurs and Primary Care for Adults (18 No Fee Fri 10 - 64) Am- 6 PM - Tues 3:30 - 6:30 PM Mon & Thurs Family Practice Financial Support Program 9 AM - 5 PM Weekdays General Medicine, Free OB/GYN, Pediatrics, Dental, Mental Health 9 AM - 5 PM Weekdays Primary Care No Fee Walk-In/Appt. Clinic - Walk-In Mental Health Appointment Only Appointment Only Appointment Only Walk-In and Appointment Appointment Only Detroit Health Department (DHD) 1151 Taylor, Det., 48202 313-876-4000 8:30 AM - 4:30 PM - Mon Tues Thurs Fri 10 AM - 6:30 PM - Wed Primary Care, pregnancy, No Fee Sexually Transmitted Disease, and AIDS testing Walk-In (DHD) Grace Ross Health Center 2395 W. Grand Blvd., Det., MI 48208 313-897-2061 8:30 AM - 4:30 PM - Mon Tues Thurs Fri 10 AM - 6:30 PM - Wed Pregnancy testing: Mon Tues Thrus Fri - 8 - 10 AM, 12:30 - 3 PM; Wed 10 AM - 1:30 PM and 3 - 5:30 PM Immunization - Tues 12:30 - 3:30 PM ; Wed 10:30 AM - 1 PM 9 - 11 AM, Thrusday - 10 ten people Nutrition, Obstetrics & Gynecology, Pediatric, Pregnancy Testing No Fee Walk-In and Appointment Primary Care, HIV testing, prescriptions No Fee Walk-In 3:30 - 6:30 PM - Mon - Thrus Basic Medical and Prescription Services No Fee Appointments Only 8:30 AM - 5 PM - Mon - Fri Adult residents of the City of Detroit with income less than 300% of the Federal Poverty Guidelines 8 AM - 4:30 PM - Mon Tues Thurs Fri 10 AM - 6:30 PM - Wed Free pregnency testing 8 AM - 2 PM daily, and 10 AM - 4 PM Wed Free Immunizations 12 - 3:30 - Wed 811 AM Thurs Office visits, prescriptions, Fee Varies lab work, X-rays Call clinic nearest you for hours. Reproductive health care including annual exams, pregnancy testing, and sterilization to women and men. Fort Street Presbyterian Chruch Clinic 631 Fort Street, Det., MI 313-961-4533 Immaculate Heart of Mary Catholic Church 1600 Pembroke, Det., MI 48235 313-272-0990 Mercy Primary Care Center 5555 Connor Ave., Det., MI 48213 313-579-4000 Northeast Health Center for Homeless 5400 E. 7 Mile Rd. Det., 48234 313-852-4231 Planned Parnethood 800-230-PLAN for the clinic nearest you. 26 clinics throughout Michigan Appointments Preferred Pediatrics, Obstetrics & Total Health Appointments Only Gynecology, Adult Internal Care, straight Medicine Medicaid or BC, no PPO's/or fee based on income Internal Medicine Resident Survival Guide - 131 - Fee Based on Sliding Scale. Call individual clinics Acknowledgements This guide was compiled with information from the following sources: Intern lecture notes from our Amazing Attendings: Dr. Flack, Dr. Guzman, Dr. Pravit, Dr. Stellini, Dr. Tabbey, Dr. Gellman, Dr. Wiese, Dr. Watson, Dr. Heath, Dr. Singh, Dr. Weise, Dr. Brown, Dr. Diane Levine and Dr. Donald Levine. Past Fellows: Dr. Atallah, Dr. Shanidze, Dr. Pitta Our Fearless Alumni contributors: Dr. Corsino Class of 2005 Dr. Mamdani Class of 2005 Dr. Harpreet Sagar Class of 2006 Assorted Fluid, Drug and Nutrition Pharmacy book—DMC Pharmacy The DMC Antimicrobial Guidebook Up to Date Harrison’s Maxwell’s ACC.org MKSAP Cedars-Sinai IM Handbook Compiled from the above sources, with hard work and perseverance by… Sarah Hartley, Class of 2007 Leandro Perez, Class of 2007 Jason Schairer, Class of 2007 Staci Valley, Class of 2007 Julie Wright, Class of 2007 Christian Bimenyey, Class of 2008 Ivan Hanson, Class of 2008 Carlos Franco, Class of 2008 Stephanie Czarnik, Class of 2010 Mark Brewster, Class of 2010 Ali, Omaima, Class of 2011 Patel, Manish, Class of 2012 Ali, Azzat, Class of 2012 Lee, Crystal, Class of 2012 Kosny, Kinga, Class of 2013 Taylor, Stephanie, Class of 2013 Tuliani, Tushar, Class of 2014 Gironda, Valerie, Class of 2014 Alhusseini, Maha, Class of 2014 For the interns, by some interns, we hope you have found this resource useful! Much appreciation and thank you to the above parties and anyone else who may have put time and effort forth to help us! Internal Medicine Resident Survival Guide - 132 - CORRECTIONS: Internal Medicine Resident Survival Guide - 133 - NOTES TO SELF…AND THE RC COMMITTEE! Please use the last blank pages to jot down ideas for things that need to be changed or updated for next year. It is only with your help that we can continue to make this resource a cutting-edge tool for interns and residents. Take care and have a great year! NOTES: Internal Medicine Resident Survival Guide - 134 -
