Hospitalist Medicine-GL Van Bockern Flashcards
ADC Vandalism
Admit to Diagnosis Condition Vitals Allergies Nursing Orders Diet Activity Labs IV Fluids Special Studies Medications
Nursing: Pt ratio
Floor?
1:4+
Nursing: Pt ratio
IMC?
1:3+
Nursing: Pt ratio
ICU?
1:1 or 1:2
Dispo: Floor vs ICU
Floor–> hyperglycemic Pt?
Hyperglycemia (>400) without anion gap
Dispo: Floor vs ICU
IMC–>
DKA but pH > 7.2 and resolving anion gap
Dispo floor vs ICU:
DKA with multi-organ dysfunction, pH < 7.2
Lab draws: (how often)
floor?
daily, BID
Lab draws:
IMC? (step down unit)
ICU?
q2h
Ex’s of ICU Pts:
ventilator, BiPAP
Central lines/pressors/drips
Nursing needs (ie insulin)
Pt at risk of decompensation
Renal failures Pts:
floor vs ICU criteria
floor= Chronic hemodialysis/ non-emergent
ICU: Emergent dialysis, CRRT, K > 6.0with EKG changes, any K > 7.0
Hemodynamics: floor vs ICU criteria
floor: Stable hemodynamics (HR 50-130, SBP 85-200, RR 10-30)
ICU: Hemodynamically unstable; hypertensive emergency; IV antihypertensives
Respiratory status: floor vs ICU
Floor: Chronic stable NPPV overnight (CPAP for OSA)
ICU: NIPPV (BiPAP, CPAP); intubated;impending respiratory failure; threatened airway
Inpatient vs. Observation
list rules
- **Two-midnight rule= in patient
- “Complex medical judgment”
- “Generally, a patient is considered an inpatient … with the expectation that he or she will require hospital care that is expected to span at least two midnights”
-“However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors …”
Ex case:
66 year old female with past medical history of HTN, DM, and tobacco use disorder who presented with chest pain that was associated with shortness of breath. She has tried taking ASA with some relief. She denies any sick contacts. Negative ROS except chest pain and shortness of breath. Takes Lisinopril and Metformin at home. FH significant for Dad having MI. Social history significant for Tobacco use
Vitals: BP 130/80, pulse 110, RR 19, afebrile
Exam: No acute distress, CV: mild tachycardia with normal rhythm, Mild tachypneic with clear lungs, mild peripheral edema
Labs: Elevated cr (1.8), nml LFTs, trop elevated, BNP elevated,
D-dimer elevated, ECG with sinus tach and right axis deviation, CXR clear no PNA
DONT FORGET TO ASK CODE STATUS.
DDx?
Differential Diagnosis: MI, cardiac arrhythmia, pulmonary emboli
Outcome: Chest pain with elevated trop -> provider order stress test
Assessment and Plan from ED: Diagnosis NSTEMI, ordered stress and admitted to medicine
Ex 66yo Pt with CP:
2 hours later, pt developed worsening chest pain and went into PEA arrest resulting in death
WHY???
Don’t ignore the other differentials! Pt with elevated dimer, right axis deviation, and tachycardic.
**Ultimately, pt had a pulmonary emboli
Code status NOT discussed prior to PEA arrest
Code Status Discussion prior to Admit
Normalizing statements
Education/explanation
Further steps if patient interested
MOST form
During the hospital Stay: (steps)
- Daily (at least) re-evaluation of patients
- Adjustment of treatment plan
- Communication with consultants
- Discharge planning / longer-term plan
Case Manager (describe their role)
Arranging logistics/finances of: Home health Outpatient IV antibiotics Wound vacs, durable medical equipment Transfer to outside hospital SNF or LTAC referrals/placement
Social worker (describe their role)
Homelessness Uninsured Undocumented Substance abuse Adjustment to illness counseling Complex social issues Legal issues/guardianship
Role Of OT
Assess/improve ADLs, mobility
Cognitive screens, MOCA
-“Just because you’re walking around doesn’t mean you’re safe to go home”
Respiratory therapist: role
Ventilator and NIPPV management
Home oxygen evaluations
Nebulizers, chest PT
OSA screens
Sometimes intubate (hospital-dependent)
Pharmacy: role
- Confirmation of all inpatient med orders
- clarification of orders w providers
- prep meds
- RRT/MET/code involvement
Team base care: consultants
- How do you call a consult?
- “This is a consult for [main concern]. Ms. Jones is a 35 year old woman with h/o SIADH, who came in with….
-What will the consultant contribute?:
Procedures
Advice on workup
Advice on treatment
