Intern Survival Series Lecture #3 Overview of Common Problems, - PowerPoint PPT Presentation

Intern Survival Series Lecture #3 Overview of Common Problems, Calls and Medications Shaping the Future of Healthcare | www.thewrightcenter.org

Objectives • After participating in this lecture, you should be able to: – Appreciate that physically seeing the patient is superior to doctoring by phone – Have a basic understanding of the types of calls common to internal medicine – Be aware of the common treatment options available to physicians on call and on the floors Shaping the Future of Healthcare | www.thewrightcenter.org

A Brief Note • This lecture series is not meant to be all inclusive or totally comprehensive to all of medicine • It is not meant to supersede clinical judgment • It is not meant to replace daily reading or bedside teaching • It is meant to act as a starting point for which to grow from as new primary care physicians • It is a tool to help you survive the your new job Shaping the Future of Healthcare | www.thewrightcenter.org

Situation • July 1 st , 11pm • You receive the following call from the floor nurse………… Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Medications • Patient is complaining of back pain and increased temperature of 100.2 F • Remember Fever Definition=>100.4 • You should always go and see a patient when possible before prescribing any medication – Once assessed, what are your options? • NSAIDs? • Opioids? • Ice? Heat? • Do Nothing? Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Medications • Tylenol: – frequently given as a prn order for pain and fever – Potent analgesic and antipyretic with weak anti-inflammatory activity – Can be given PO, IV, PR • Ordered as followed – Tylenol 650mg PO q6 hours prn fever, pain – Tylenol 650mg IV q6 hours prn fever, pain – Tylenol 650mg PR q 6 hours prn fever, pain Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Medications • Tylenol – Administration/Dosing considerations – Allergies? – GFR? » CrCl 10-50, administer q 6hr » CrCl <10 administer q 8hr – Hepatic Function? » Ok to give up to 2grams/24hrs – Level of pain? – Degree of fever? – Clinical Picture? – Hospital Course? Shaping the Future of Healthcare | www.thewrightcenter.org

Remember • Anytime you order a medication you are potentially – Providing relief – Preventing harm – Causing harm – Changing a patient’s hospitalization course • Increasing or decreasing – Contributing to medical error – Contributing to patients well being Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Example Medications • Nausea/Vomiting – Zofran 4mg PO/IV/SL Q 6hrs prn N/V – Promethazine • 25 mg PO/PR q 6 hrs prn • 12.5-25 mg IV/IM q 6 hrs prn • Diarrhea – Imodium 4mg PO QID – Bismuth subsalicylate 30ml Q 1 hr prn, max 8doses in 24 hr period – Lomotil 5 mg PO q 6hrs for persistent diarrhea Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Example Medications • Constipation – Milk of Magnesia 30ml PO x 1 • #1 choice for initial treatment – Metamucil 7.5mg in 8oz H20 PO TID – Dulcolax 5-15 mg PO q day – Colace 100mg PO BID for chronic constipation – Miralax 17 grams in 8oz H20 – Lactulose 15-30 ml PO q day – Enema • Mineral oil, tap water, fleet – Disimpaction Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Example Medications • Cough – Robitussin 10ml PO q 4-6 hr prn – Tessalon Perles 100mg PO TID (max 600mg/day) Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Example Medications • Insomnia – Evaluate prior to medication administration • History-> Clarify sleep pattern, patients can often pinpoint why they cannot sleep • Check to see if any new meds are contributing – Ambien • ER=6.25mg PO HS x1 • IR=5-10mg PO HS x1 – Lorazepam 0.5-2mg PO HS x1 • Should be prescribed with caution Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Example Medications • Delirium – Haldol 0.5-1 mg PO/IM – Lorazepam 0.5-1mg PO/IV • Delirium treatment is complicated by – critical nature of the illness – Pt’s impaired capacity to make decisions – Meds given under implied consent to stabilize a life-threatening process – should be used with caution and typically should be administered by senior resident Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Example Medications • Alcohol Withdrawal Prophylaxis – Lorazepam • Dose and frequency per clinical situation • Prn? • ATC? – Banana bag • Multivitamin In 500ml of NS daily, • Thiamine 100mg In 250ml if LVEF<20% • Folic Acid 1mg Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Example Medications • Warfarin Nomagram Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Example Medications Notes on Warfarin Nomagram Helpful in hospitalized patients in whom INR can be checked on a daily • basis. Typically, 5mg initiation achieves therapeutic anticoagulation as rapidly as • 10mg initiation but with a lower frequency of supra-therapeutic INRs, but this is debated frequently amongst providers and should be addressed with your attending The 10mg initiation nomogram should only be used in relatively young and • healthy patients who are likely to be insensitive to warfarin, or in patients taking concurrent medications known to induce warfarin metabolism Please note that loading doses of warfarin are NOT RECOMMENDED • Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Example Medications DVT Prophylaxis • – Questions: • Bleeding? • Procedures Scheduled? • GFR • DVT risk-low, med, high? Heparin 5000Units subcutaneously q 8 hr* • Enoxaparin 40mg sq daily* • – If GFR> 30 – If BMI >40 may need to adjust *Not valid doses for active DVT Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Example Medications • Elevated INR – INR>5 & no signs of bleed • Hold Coumadin • Vit K 1-2.5 mg PO if increased risk of bleed – INR>9 • Vit K 2.5-5mg PO – A word about Vit K: • May take 24-48 hrs to decrease inr, too much can cause warfarin resistance for up to 1 week Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Example Medications Elevated INR *In patients with • Serious Bleed-regardless of inr* mechanical valves get cardio ok first – IV Vitamin K • Use should be deemed appropriate by an attending – FFP ~3-5 Units • Hemostasis can be achieved when coag factors are 25- 30% normal • An average adult plasma volume is 40ml/kg, so you need 10-15ml/kg FFP to achieve hemostasis • Roughly 3-5 Units Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Workups • Shortness of Breath -DDx – Questions Volume Overload/CHF • • Vitals Afib • • O2 Sats MI • • Time of onset PE • PND • Last ABG • Bronchospasm/COPD • • Current meds Pneumonia • Pain • Pain med overdose • Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Workups • Shortness of Breath – Workup • History and Physical  Go see the patient • ABG, EKG, CXR? CTA? LE Doppler? » Should be decided by senior with attending guidance – Treatment • Diuretics, anticoagulation, Heart Cath, Rate controlling medications, BiPAP, Intubation, Narcan, nebulizers etc…… Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Workups • HYPOtension DDx • – Questions – Shock? • What is pt’s normal BP? • Hypovolemic • What BP meds is pt on? – Bleeding, N/V/D, HD etc. • What are pt’s other • Cardiogenic vitals – Tension pneumo, tamponade, MI, arrhythmia, etc. • Associated Symptoms • Disruptive -sepsis, anaphylaxis, etc. – Medication overdose/error – Normal variant Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Workups • HYPOtension – Workup • History and Physical  Go see the patient – Make sure patient has good IV access • Blood work-review earlier set or order appropriately – CBC?, RFP?, Lactic Acid?, Blood Cultures? Cardiac Enzymes? • Rhythm Analysis • If signs of hypoperfusion consider ICU – Treatment options vary depending on etiology, senior and attending input necessary Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Workups • HYPERtension • DDx – Questions – Medication held? • Known history of HTN? • NPO? • Did pt take BP meds today? • Delirious? • When are meds scheduled • New admission? to be given? – New med? • BP checked manually? • NSAIDs? • Rechecked? • MAOI? • Last BP WNL? – Pain? • Renal function? – Stroke? – Acute Renal Failure? – New onset? Shaping the Future of Healthcare | www.thewrightcenter.org

Common Calls and Workups • HYPERtension – Workup • History and Physical  Go see the patient – R/O HTN Emergency • Review recent blood work • Review medication list • Per clinical scenario – Treatment • Consider treatment for SBP>160 or DBP>100mmHG • Should treat SBP>180, DBP>120 mmHG Shaping the Future of Healthcare | www.thewrightcenter.org