Inpatient Medicine Flashcards
elements of the differential diagnosis
- top problem oriented diagnosis first
- prioritize most likely then most harmful
- remove dx easily removed
- keep broad differential until dx confirmed
3 parts to clinical reasoning
- reasoning
- skill
- knowledge
continually use clinical reasoning to verify dx
admission order mnemonic
ADCAVANDIMLS
admit order components
- A - admit to
- D - diagnosis
- C - condition
- A - allergies
- V - vitals
- A - activity
- N - nursing
- D - diet
- I - IV
- M - meds
- L - labs
- S - studies
when errors commonly occur
admission & discharge
(after med errors, discharge MC)
types of discharge errors
- medication continuity
- test follow-up errors
- workup error
discharge order criteria
- date admitted / discharged
- Dx- make sure pt. understands!
- procedures
- where they went when discharged
- vitals at discharge
- PE at discharge
- labs
- hospital course (summary of what done in hosp)
- names of drs./problem addressed/contact info
- date and time for follow-up
- discharge medications
- discharge course (how they were upon discharge)
- education
- appointments and recommendations - bullets
- give pt. copy
3 steps if faced with a clinical conundrum
- define the problem
- gather key information
- summarize the case
what is an order set
check list to reduce possibility of
missing important orders
what is the systems theory of error
small errors line up to produce an accident
(most hc workers doing right thing -
accidents d/t defects in system)
low risk for VTE
- surgery <30 min
- no comorbities
- immediately mobile
surgical risks for DVT
- surgery >1 h
- central venous catheter
- post-op infection
- extensive venous compression during surg.
- lithotomy position
- open surgical approach
- general anesthesia
non-surgical risks for DVT
- age
- pregnancy
- comorbidities
- recent stroke
- previous VTE
- obesity
- drugs
2 main risk of surgical VTE
- surgery type
- anesthesia type
DVT prophylaxis drugs
- Enoxaparin (Lovenox) 40mg SC once daily -OR- 30mg SC q12h
- Heparin 5000 units SC every 8 or 12h
risk factors for stress ulcer
(when to tx prophylactically)
- respiratory failure- vent > 48h
- coagulopathy- INR > 1.5, PTT >2x normal, platelets < 50,000
- 2+ other
- ICU > 1 week (burns, major trauma, head)
- sepsis, hypotension
- occult GI bleeding 6+ days
- glucocorticoids (>250mg daily)
stress ulcer prophylaxis meds
- H2 blockers (-tidine)
- Cimetidine continuous 50mg/h IV or bolus up to 300mg IV q6h
- Ranitidine 50mg IV bolus q8h
- Famotidine 20mg IV bolus bid
- PPIs (-prazole)
- Omeprazole (Prilosec) 40mg PO daily
- Pantoprazole (Protonix) PO/NG/IV
- Esomeprazole (Nexium)
- Lansoprazole (Prevacid) 30mg PO/NG
- Rabeprazole (Asefex) 20mg PO daily
when to d/c warfarin (Coumadin) pre-surg
3-5 days (consider heparin bridge)
when to d/c Clopidogrel (Plavix) pre-surg
3-7 days
(maintain and reschedule surg.
if drug-eluding stent placed in past year)
when to d/c insulin pre-surg
d/c short acting
admin. 1/3-2/3 usual morning long acting
when to d/c oral hypoglycemics pre-surg
morning of surgery
when to d/c ACE/ARB pre-surg
morning of surg if large fluid shift/blood loss anticipated
when to d/c diuretics pre-surg
morning of surg if large fluid shift/blood loss anticipated
when to d/c corticosteroids pre-surg
continue at current dose
(consider stress dosing med/high risk surg.)
