HM Exam 1 Cards Flashcards
(156 cards)
1
Q
Traditional approach to hospital medicine
A
Primary care doctor follows care while in hospital - inefficient leading to delay of care
2
Q
Patient centered hospital model
A
Integrated, shared decision making, open communication, full disclosure, individualized treatments, evidence based medicine
3
Q
2 components of patient centered care
A
Patient experiencePatient engagement
4
Q
HCAHPS components (7)
A
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
5
Q
Patient engagement - 4 aspects
A
Enables patient to get the most out of healthcare - Includes literacy, Family dynamics, Learning style, Readiness to learn and change
6
Q
Consultant
A
Gives recommendations for pt but does not become primary provider
7
Q
4 principles of ethical consultation
A
Only when indicatedProvide case summary1 person retains responsibilityPunctuality
8
Q
How fast does a stat consult need to happen
A
Within 1 Hour
9
Q
Two models of co-management
A
Hospitalist as primary attending with subspecialist as consultantSubspecialist as attending with hospitalist as consultant
10
Q
ED Boarding
A
Patient waiting for an ED bed after being seen
11
Q
Direct admit
A
Admit directly from PCPCan save ED visit but don’t do it if they may decompensate rapidly
12
Q
Selection recommendations for direct admission
A
Fairly certain admitting diagnosisStableArrives at hospital before 4pm
13
Q
Risks of interhospital transfer
A
Delay of care initiationDecompensation during transitArrive to long levelDuplicate testingMedical errors
14
Q
Transfer from a SNF
A
More complex and less likely to have a caregiver with themMay be missing basic testingMUST have a CODE form!!
15
Q
Who is responsible once a patient begins a transfer
A
The place they are going to
16
Q
Inpatient or outpatient hospital stay
A
2 midnight ruleIf they are there 2+ midnights, they are INPATIENT
17
Q
4 types of units in a hospital
A
ICUIntermediate careTelemetryMed/Surg
18
Q
Intermediate care units
A
Monitoring like ICU but w/o critical care drugs
19
Q
Med/Surg units
A
Fewer patients, checked on every 8 hours for vitals
20
Q
Shift Change
A
Transfer of content from one professional to another - no documentation
21
Q
Service change
A
A permanent transfer of information to a new team - End of week before you get offRequires documentation
22
Q
Service transfer
A
Transfer of care to an entirely new group of clinicians - ie. a new specialty/ward
23
Q
Core components of handoff
A
Verbal communication -phoneWritten - supplements verbalTransfer responsibility - Acknowledgement of transfer
24
Q
IPASS
A
Handoff method
Intorduction
Patient
Assessment
Situation
Safetey concerns
25
SBAR
Situation
Background
Assessment
Recommendations
26
4 key elements of discharge
Appropriate destinationFollow up scheduledMed reconcilliationEngagement of patient and caregivers
27
SNF Care
Physician every 30 days2-4 hours nursingRehab 1 hr per day
28
Inpatient rehab care
5-6 hours nursingPhysician 3x per week3hrs rehab per day
29
LTACH care
5-6 hours nursingNear daily physician presenceRehab varies
30
Extended care facility care
Less than 2 nursing hours per dayPhysician every 30 daysRehab available
31
Reasonable average follow up after hospital stay
7-14 days - may need to be sooner!!
32
Five elements of a discharge summary
Primary and secondary diagnosis
Test results
Pending results
Additional workup recommendations and treatment plan
Condition at discharge
33
Components of evaluation and management level
HistoryPhysical examMedical Decision Making (Labs, etc.)
34
Eight elements of an HPI
Location, Quality, Severity, Duration, Time, COntext, Associated factors, Associated SYmptoms
35
PFSH
Past, Family, and Social History2 or 3 needed for comprehensive
36
Comprehensive PE
More than 8 organ systems represented
37
3 Types of data we can use for MDM
Medical data - EKG, Echo, etc.RadiologyLabs or Specimens
38
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
39
Problem focused Hx
Brief HPI with 3 or less elements, No ROS, No PFSH
40
Expanded problem focused HPI
Brief HPI with 3 or less elements, 1 ROS, No PFSH
41
Detailed Hx
Expanded HPI with 4+elements, Extedned ROS with 2-9 systems, 1 PFSH
42
Comprehensive Hx
Extended HPI with 4+ elements, Complete ROS with 10+ elements, 2 or 3 PFSH
43
PFSH for Comprehensive Hx
All three for new patients, 2 or 3 for subsequent encounters
44
Problem focused PE
1 organ system with 1 comment
45
Expanded problem focused PE
2-7 Organ systems with 1 comment
46
Detailed PE
2-7 organ systems with more than one comment
47
Comprehensive PE
8+ systems with 1 comment
48
3 elements of medical decision making
Number of diagnoses, Amount and complexity of data, the risk to the patient
49
Points for self limited/minor problems in MDM
1 point each with 2 max
50
Points for established problems stable or improving in MDM
1
51
Points for worsening established problem in MDM
2
52
Points for new problem with additional workup in MDM
3, max 1 problem
53
Points for new problem with additional workup planned
4
54
Qualifications for a diagnosis to be included in MDM
Must do workup related to that problem during the encounter
55
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
56
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
57
Minimal risk presenting problems
One self limited minor problem - cold, bite, tinea corporis
58
Minimal risk dx procedures
Lab tests requireing venipuncture, CXR, EKG/EEG, Urinalysis, US, KOH prep
59
Minimal risk management options
Rest, gargles, elastic bandages, superficial dressings
60
Low risk presenting problems
Two or more self limited/minor problems; One stable chronic illness; Acute uncomplicated illness
61
Moderate risk presenting problems
1+ chronic illnesses with mild exacerbation; 2+ stable chronic illnesses, Acute illness with systemic symptoms, Acute complicated injury
62
Low risk dx procedures
PFT, Non cardiac imaging, arterial puncture lab tests, skin biopsy
63
Low risk management options
OTC drugs, Minor surgery, PT, OT, Simple IV fluids
64
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
65
Moderate risk tx
Minor surgery with risk factors, elective major surgery, Prescription drug management, Nuclear medicine, Closed fracture tx without manipulation
66
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
67
High risk dx procedures
Cardio studies with contrast AND risk factors, Cardiac EP tests, endoscopy with risk factors, Discography
68
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
69
Criteria to select an MDM level
2 categories must meet or exceed the requirements for that level
70
Problem focused MDM level
1 dx/tx or less, 1 data point or less, Minimal risk level
71
Low complexity MDM
2dx/tx points, 2 data points, Low risk level
72
Moderate complexity MDM
3dx/tx points, 3 data points, Moderate risk level
73
High complexity MDM level
4dx/tx points, 4 data points, High risk level
74
What determines visit level of service
The LOWEST component of the 3 required things: Hx, PE, MDM
75
Determining MDM lavel from 3 data points
Exclude the lowest category and then shoose the lower of the remaining ones
76
Initial hospital care codes
99221
99222
99223
77
99221
Hx: Detailed or comprehensive
Pe: Detailed or comprehensive
MDM: Straightforward or low
30 minutes
78
99222
Hx: Comprehensive
PE: Comprehehnsive
MDM: Moderate
50 minutes
79
99223
Hx: Comprehensive
PE: Comprehensive
MDM: High
80
Subsequent hospital care codes
99231
99232
99233
For follow up notes
81
99231
Hx: Problem focused
PE: Problem focused
MDM: Straightforward or Low
15 minutes
82
99232
Hx: Expanded
PE: Expanded
MDM: Moderate
25 minutes
83
99233
Hx: Detailed
PE: Detailed
MDM: High
35 minutes
84
When can you replace 3 components with time spent counseling the patient
When the counseling takes 50+% of the time spent
85
To types of time that must be reported
Time spent counseling
Time spent coordinating care
86
Role of ethics committee
Purely advisory - does not review labs, etc.
87
2 most common ethics consulting indications
Advance directive and Brain death
88
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
89
Capacity
Determined by psych
90
Authority of an advanced directive
Must always be followed except in rare exceptions
Include living will, code status, and surrogates/MPOA
91
Order of surrogacy in healthcare
Spouse
Adult children
Own parents
Adult siblings
Adult grandchildren
Close friend
DHHR appointee
92
When two surrogates of equal standing disagree
Go with the one who is more involved in the patient's care
93
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)
94
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
95
Physiological futility
When it is absolutely or reasonable impossible to acheive a certain physiologic effect
96
Qualitative futility
When physiology may improve but there is no patient centered benefit
97
Quantatative futility
When an intervention has not worked in similar patients within an accepted confidence interval
98
4 things associated with malnutrition
Increased infection
Longer stay
Increased cost
Mortality
99
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
100
Injuries the cause the highest change in metabolic rate (4)
Sepsis, Trauma, Respiratory failure, Burns
101
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
102
Preferred feeding route
Oral
May boost with shakes
103
Nutrition in ensure shake
240 cals and 10g of protein
104
Indication of enteral or parenteral nutrition
Initiate 7-10 days after no eating
105
J-tube
In the jejunum, may have absorption problems
106
Situations in which not to use a PEG tube
Peritonitis
Major GI bleed
Ileus
Bowel obstruction
Fistual
Copious diarrhea
Reflux - consider J-tube
107
Common complication of tube feeding
DIarrhea, may need free water supplementation
108
Induction of tube feeding
Give at a low rate and watch for intolerance symptoms - nausea, vomiting, diarrhea
109
Refeeding syndrome
K+, Mag and phosphorus drop
110
Route of TPN administtation
Through a CENTRAL line
111
Reasons for IV fluids
NPO
Volume deficit
Ongoing losses
Hydration
Contrast dye use - so they will pee it out
112
Estimation of Total body water
wt x .6 for males OR .5 for females
113
Total body water usual dist.
2/3 ICF
1/3 ECF
114
ECF distribution
1/4 intravascular
3/4 interstitial - hardest to get out
115
Minimal water intake of water for most adults
Total - 1600 mL
Ingested - 500mL
Water in food = 800mL
From oxidation = 300mL
116
Temperature and water need increase
Increase by 100-150 mL per day for each degree of body temp above 37
117
Sources of water output in adults
Urine - 500mL
Skin - 500 mL
Respiratory tract - 400 mL
Stool - 200 mL
118
Usual daily fluid requirement
35mL/kg/day
119
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
120
Normal sodium requirement
1-3meq/kg/day
121
Sodium in .45NS
77 meq/L
122
Normal K+ requirement
1meq/kg/day
20meq/L is most common additive
123
Preferred method of K+ supplementation
Oral!!
124
Max rate for K+ infusion
10meq/hour max - burns
125
Potassium required for hypokalemia
200-400 mmol for drop of 1 mmol/L
400-800 mmol for frop of 2 mmol/L
126
Equation for K+ deficit
(K Lower limit - K measured) x body weight x 0.4
1mmol=1meq
127
Serum K+ raise per 10mEq perfused
Raises level by 0.13mEq/L
128
Initial oral K+ dose
40-100 mEq per day - check levels after 1st dose
129
Normal glucose requirements
100-200 g/day
At least 100g/day decreases protein loss by 1/2
130
Colloids
Contain large molecules that stay in the bloodstream only - Albumin
131
Crystalloids
Most common - NS, Dextrose, etc.
132
Use of 3% saline
Only for severe hyponatremia
133
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
134
Isotonic fluid types - 4
NS
Lactated ringers
D5W
Ringer's acetate
135
Hypertonic solutions - 4
D10, D20, D50, 3% saline
136
RIngers lactate solution comp
Na - 130 meq
K - 4 meq
Ca - 3 meq
Cl - 109 meq
HCO3 - 28 meq
137
D5W use
50g/L sugar content
170 calories
Provides free water
Not enough for nutrition replacement no elevtrolytes
138
Fluids for hypovolemia
Volume expansion is the goal
NS or LR is best
139
Fluids for dehydration
Goal is free water in hyperosmolar states
1/2NS or D5W (becomes hypotonic) are preferred
140
Fluids for post-op patients
NS is safer than hypotonic fluids (can cause hyponatremia) but will give free water in setting of SIADH
141
Volume expansion with fluid given
Free water is distributed evenly throughout compartments
Sodium stays in ECF - NS has no free water
142
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
143
IVF rate for adults
weight in Kg plus 40
144
How long to transfuse a bag at 10cc/hr
Takes 10 hours - bag is 1000 cc
145
Percent of patients developing a joint contracture
39% of those spending 2+ weeks in the ICU
146
OT v. PT
OT - Waist up
PT - Waist down
147
5 indications for a bedside swallow study by ST
Observed or reported dysphagia
Suspected aspiration
Decreased feeding
Intubation or vent weaning
Vocal cord paralysis
148
Swallow test
Fluoroscopic with XR
Thin liquid
Thick liquid
Thin solid
Thick solid
149
Where should stuff go in a swallow test
Go down the back of the throat where the esophagus is
150
Aspiration
Food down trachea -often silent
151
Penetration
Food enters throat without being swallowed - warning for aspiration
152
Valecular stasis
FLuid/Food gets stuck in the area anterior to the epiglottis
153
Osteoporosis prevention for hospitalized patients
Early mobilization and strength training
154
Condition for which we MUST involved PT/OT
Stroke
155
Cardiac rehab
Post MI, CHF, CABG, Heart transplant OT and PT involved
156
Main focus of pulm rehab
Exercise with increased use of resp muscles
