HM Exam 1 Cards Flashcards
Traditional approach to hospital medicine
Primary care doctor follows care while in hospital - inefficient leading to delay of care
Patient centered hospital model
Integrated, shared decision making, open communication, full disclosure, individualized treatments, evidence based medicine
2 components of patient centered care
Patient experiencePatient engagement
HCAHPS components (7)
Common metric for measuring patient experience
Discharge information
Responsiveness of staff
Cleanliness and Quietness
Communication with nurses
Communication about medicine
Communication with Doctors
Pain management
Patient engagement - 4 aspects
Enables patient to get the most out of healthcare - Includes literacy, Family dynamics, Learning style, Readiness to learn and change
Consultant
Gives recommendations for pt but does not become primary provider
4 principles of ethical consultation
Only when indicatedProvide case summary1 person retains responsibilityPunctuality
How fast does a stat consult need to happen
Within 1 Hour
Two models of co-management
Hospitalist as primary attending with subspecialist as consultantSubspecialist as attending with hospitalist as consultant
ED Boarding
Patient waiting for an ED bed after being seen
Direct admit
Admit directly from PCPCan save ED visit but don’t do it if they may decompensate rapidly
Selection recommendations for direct admission
Fairly certain admitting diagnosisStableArrives at hospital before 4pm
Risks of interhospital transfer
Delay of care initiationDecompensation during transitArrive to long levelDuplicate testingMedical errors
Transfer from a SNF
More complex and less likely to have a caregiver with themMay be missing basic testingMUST have a CODE form!!
Who is responsible once a patient begins a transfer
The place they are going to
Inpatient or outpatient hospital stay
2 midnight ruleIf they are there 2+ midnights, they are INPATIENT
4 types of units in a hospital
ICUIntermediate careTelemetryMed/Surg
Intermediate care units
Monitoring like ICU but w/o critical care drugs
Med/Surg units
Fewer patients, checked on every 8 hours for vitals
Shift Change
Transfer of content from one professional to another - no documentation
Service change
A permanent transfer of information to a new team - End of week before you get offRequires documentation
Service transfer
Transfer of care to an entirely new group of clinicians - ie. a new specialty/ward
Core components of handoff
Verbal communication -phoneWritten - supplements verbalTransfer responsibility - Acknowledgement of transfer
IPASS
Handoff method
Intorduction
Patient
Assessment
Situation
Safetey concerns
SBAR
Situation
Background
Assessment
Recommendations
4 key elements of discharge
Appropriate destinationFollow up scheduledMed reconcilliationEngagement of patient and caregivers
SNF Care
Physician every 30 days2-4 hours nursingRehab 1 hr per day
Inpatient rehab care
5-6 hours nursingPhysician 3x per week3hrs rehab per day
LTACH care
5-6 hours nursingNear daily physician presenceRehab varies
Extended care facility care
Less than 2 nursing hours per dayPhysician every 30 daysRehab available
Reasonable average follow up after hospital stay
7-14 days - may need to be sooner!!
Five elements of a discharge summary
Primary and secondary diagnosis
Test results
Pending results
Additional workup recommendations and treatment plan
Condition at discharge
Components of evaluation and management level
HistoryPhysical examMedical Decision Making (Labs, etc.)
Eight elements of an HPI
Location, Quality, Severity, Duration, Time, COntext, Associated factors, Associated SYmptoms
PFSH
Past, Family, and Social History2 or 3 needed for comprehensive
Comprehensive PE
More than 8 organ systems represented
3 Types of data we can use for MDM
Medical data - EKG, Echo, etc.RadiologyLabs or Specimens
Documentation of time spent on care
Document total time spent and how much of that was spent coordinating the careMust document what you DID with that time
Problem focused Hx
Brief HPI with 3 or less elements, No ROS, No PFSH
Expanded problem focused HPI
Brief HPI with 3 or less elements, 1 ROS, No PFSH
Detailed Hx
Expanded HPI with 4+elements, Extedned ROS with 2-9 systems, 1 PFSH
Comprehensive Hx
Extended HPI with 4+ elements, Complete ROS with 10+ elements, 2 or 3 PFSH
PFSH for Comprehensive Hx
All three for new patients, 2 or 3 for subsequent encounters
Problem focused PE
1 organ system with 1 comment
Expanded problem focused PE
2-7 Organ systems with 1 comment
Detailed PE
2-7 organ systems with more than one comment
Comprehensive PE
8+ systems with 1 comment
3 elements of medical decision making
Number of diagnoses, Amount and complexity of data, the risk to the patient
Points for self limited/minor problems in MDM
1 point each with 2 max
Points for established problems stable or improving in MDM
1
Points for worsening established problem in MDM
2
Points for new problem with additional workup in MDM
3, max 1 problem
Points for new problem with additional workup planned
4
Qualifications for a diagnosis to be included in MDM
Must do workup related to that problem during the encounter
5 data reviews that get 1 pont in MDM
Reveiw and/or order of: Clinical tests, pathology/lab tests, radiology tests, medicine tests, obtain old records or get info from someone else
2 data review ponts that get 2 points in MDM
Review and summarize old records obtain additional hx or consult with another provider, Indipendant visualization of image, tracing or specimen
Minimal risk presenting problems
One self limited minor problem - cold, bite, tinea corporis
Minimal risk dx procedures
Lab tests requireing venipuncture, CXR, EKG/EEG, Urinalysis, US, KOH prep
Minimal risk management options
Rest, gargles, elastic bandages, superficial dressings
Low risk presenting problems
Two or more self limited/minor problems; One stable chronic illness; Acute uncomplicated illness
Moderate risk presenting problems
1+ chronic illnesses with mild exacerbation; 2+ stable chronic illnesses, Acute illness with systemic symptoms, Acute complicated injury
Low risk dx procedures
PFT, Non cardiac imaging, arterial puncture lab tests, skin biopsy
Low risk management options
OTC drugs, Minor surgery, PT, OT, Simple IV fluids
Moderate risk dx procedures
Cardiac or fetal stress test, Endoscopy, Deep inscisional biopsy, Cardio imaging w/ imaging but w/o identified risk factors, any -centesis
Moderate risk tx
Minor surgery with risk factors, elective major surgery, Prescription drug management, Nuclear medicine, Closed fracture tx without manipulation
High risk presenting problems
1+ chronic illnesses with severe exacerbation, progression or side effects of tx; Injuries that pose a threat to life or bodily function; Abrupt change in neurologic status
High risk dx procedures
Cardio studies with contrast AND risk factors, Cardiac EP tests, endoscopy with risk factors, Discography
High risk management options
Elective major surgery with risk factors, Emergency surgery, Parenteral controlled substances, Drug therapy requiring toxicity monitoring, Decision not to resuscitate or deescalate care d/t poor prognosis
Criteria to select an MDM level
2 categories must meet or exceed the requirements for that level
Problem focused MDM level
1 dx/tx or less, 1 data point or less, Minimal risk level
Low complexity MDM
2dx/tx points, 2 data points, Low risk level
Moderate complexity MDM
3dx/tx points, 3 data points, Moderate risk level
High complexity MDM level
4dx/tx points, 4 data points, High risk level
What determines visit level of service
The LOWEST component of the 3 required things: Hx, PE, MDM
Determining MDM lavel from 3 data points
Exclude the lowest category and then shoose the lower of the remaining ones
Initial hospital care codes
99221
99222
99223
99221
Hx: Detailed or comprehensive
Pe: Detailed or comprehensive
MDM: Straightforward or low
30 minutes
99222
Hx: Comprehensive
PE: Comprehehnsive
MDM: Moderate
50 minutes
99223
Hx: Comprehensive
PE: Comprehensive
MDM: High
Subsequent hospital care codes
99231
99232
99233
For follow up notes
99231
Hx: Problem focused
PE: Problem focused
MDM: Straightforward or Low
15 minutes
99232
Hx: Expanded
PE: Expanded
MDM: Moderate
25 minutes
99233
Hx: Detailed
PE: Detailed
MDM: High
35 minutes
When can you replace 3 components with time spent counseling the patient
When the counseling takes 50+% of the time spent
To types of time that must be reported
Time spent counseling
Time spent coordinating care
Role of ethics committee
Purely advisory - does not review labs, etc.
2 most common ethics consulting indications
Advance directive and Brain death
Elements of informed consent decision making capacity
Ability to communicate choice
Understand nature and consequences of the choice
Manipulate rationally the information necessary to make a choice
Reason consistenly with previously expressed values and goals
Capacity
Determined by psych
Authority of an advanced directive
Must always be followed except in rare exceptions
Include living will, code status, and surrogates/MPOA
Order of surrogacy in healthcare
Spouse
Adult children
Own parents
Adult siblings
Adult grandchildren
Close friend
DHHR appointee
When two surrogates of equal standing disagree
Go with the one who is more involved in the patient’s care
ICU care for DNR patients
Still can be admitted or go to the OR (not recommended to go to surgery - change status if patient willing)
Medical devices and end of life
Patient or surrogate has the right to turn off or remove device as a part of life-sustaining therapy withdrawal
Physiological futility
When it is absolutely or reasonable impossible to acheive a certain physiologic effect
Qualitative futility
When physiology may improve but there is no patient centered benefit
Quantatative futility
When an intervention has not worked in similar patients within an accepted confidence interval
4 things associated with malnutrition
Increased infection
Longer stay
Increased cost
Mortality
Diagnostic criteria for malnutrition
Must meet 2 to qualify
Insufficient caloric intake via dietary recall
Weight loss
Loss of muscle mass
Loss of SQ fat
Local or general fluid accumulation
Diminished functional status - hand grip to measure
Injuries the cause the highest change in metabolic rate (4)
Sepsis, Trauma, Respiratory failure, Burns
Protein rule of thumb
Need 1.2-1.5 g/kg/day
2g/kg/day for burns
2.5 for obese or severely ill patients
Preferred feeding route
Oral
May boost with shakes
Nutrition in ensure shake
240 cals and 10g of protein
Indication of enteral or parenteral nutrition
Initiate 7-10 days after no eating
J-tube
In the jejunum, may have absorption problems
Situations in which not to use a PEG tube
Peritonitis
Major GI bleed
Ileus
Bowel obstruction
Fistual
Copious diarrhea
Reflux - consider J-tube
Common complication of tube feeding
DIarrhea, may need free water supplementation
Induction of tube feeding
Give at a low rate and watch for intolerance symptoms - nausea, vomiting, diarrhea
Refeeding syndrome
K+, Mag and phosphorus drop
Route of TPN administtation
Through a CENTRAL line
Reasons for IV fluids
NPO
Volume deficit
Ongoing losses
Hydration
Contrast dye use - so they will pee it out
Estimation of Total body water
wt x .6 for males OR .5 for females
Total body water usual dist.
2/3 ICF
1/3 ECF
ECF distribution
1/4 intravascular
3/4 interstitial - hardest to get out
Minimal water intake of water for most adults
Total - 1600 mL
Ingested - 500mL
Water in food = 800mL
From oxidation = 300mL
Temperature and water need increase
Increase by 100-150 mL per day for each degree of body temp above 37
Sources of water output in adults
Urine - 500mL
Skin - 500 mL
Respiratory tract - 400 mL
Stool - 200 mL
Usual daily fluid requirement
35mL/kg/day
Usual daily fluid req based on weight
100mL/kg/day at 0-10
1000mL + 50mL/kg/day at 10-20kg
1500 mL + 20mL for each kg above 20 for 20-70kg
2,500mL for over 70kg
Normal sodium requirement
1-3meq/kg/day
Sodium in .45NS
77 meq/L
Normal K+ requirement
1meq/kg/day
20meq/L is most common additive
Preferred method of K+ supplementation
Oral!!
Max rate for K+ infusion
10meq/hour max - burns
Potassium required for hypokalemia
200-400 mmol for drop of 1 mmol/L
400-800 mmol for frop of 2 mmol/L
Equation for K+ deficit
(K Lower limit - K measured) x body weight x 0.4
1mmol=1meq
Serum K+ raise per 10mEq perfused
Raises level by 0.13mEq/L
Initial oral K+ dose
40-100 mEq per day - check levels after 1st dose
Normal glucose requirements
100-200 g/day
At least 100g/day decreases protein loss by 1/2
Colloids
Contain large molecules that stay in the bloodstream only - Albumin
Crystalloids
Most common - NS, Dextrose, etc.
Use of 3% saline
Only for severe hyponatremia
Use for lactated ringers
Surgeons love it
GI tract issues and third spacing
Can be hard on the liver and kidneys
Not for pH over 7.5
Increase in lactic acid
Isotonic fluid types - 4
NS
Lactated ringers
D5W
Ringer’s acetate
Hypertonic solutions - 4
D10, D20, D50, 3% saline
RIngers lactate solution comp
Na - 130 meq
K - 4 meq
Ca - 3 meq
Cl - 109 meq
HCO3 - 28 meq
D5W use
50g/L sugar content
170 calories
Provides free water
Not enough for nutrition replacement no elevtrolytes
Fluids for hypovolemia
Volume expansion is the goal
NS or LR is best
Fluids for dehydration
Goal is free water in hyperosmolar states
1/2NS or D5W (becomes hypotonic) are preferred
Fluids for post-op patients
NS is safer than hypotonic fluids (can cause hyponatremia) but will give free water in setting of SIADH
Volume expansion with fluid given
Free water is distributed evenly throughout compartments
Sodium stays in ECF - NS has no free water
4,2,1 rule for pediatrics
4cc/kg/hr for first 10kg
2cc/kg/hr for second 10kg
1cc/kg/hr for remaining weight
Adjust for fluid loss
IVF rate for adults
weight in Kg plus 40
How long to transfuse a bag at 10cc/hr
Takes 10 hours - bag is 1000 cc
Percent of patients developing a joint contracture
39% of those spending 2+ weeks in the ICU
OT v. PT
OT - Waist up
PT - Waist down
5 indications for a bedside swallow study by ST
Observed or reported dysphagia
Suspected aspiration
Decreased feeding
Intubation or vent weaning
Vocal cord paralysis
Swallow test
Fluoroscopic with XR
Thin liquid
Thick liquid
Thin solid
Thick solid
Where should stuff go in a swallow test
Go down the back of the throat where the esophagus is
Aspiration
Food down trachea -often silent
Penetration
Food enters throat without being swallowed - warning for aspiration
Valecular stasis
FLuid/Food gets stuck in the area anterior to the epiglottis
Osteoporosis prevention for hospitalized patients
Early mobilization and strength training
Condition for which we MUST involved PT/OT
Stroke
Cardiac rehab
Post MI, CHF, CABG, Heart transplant OT and PT involved
Main focus of pulm rehab
Exercise with increased use of resp muscles
