Hospital Medicine 1 (Bockern) (Midterm)

Question 1

Common procedures done by Hospitalists

Answer 1

• Central lines
• Intubation
• Paracentesis
• Thoracentesis
• Lumbar puncture
• Ultrasonography
• Arthrocentesis

Question 2

Basic components of hospital medicine

Answer 2

• Admitting Pts
  
  • Admission orders: ADC VANDALISM
  • H&P note
  • Hand Off
• Rounding on Pts
  
  • Daily VS, labs, imaging, and consultants
  • Progress note
  • Hand off
• Discharging Pts
  
  • Discharge summary
  • Discharge order
  • Discharge instructions

Question 3

ADC VANDALISM stands for?

Answer 3

Admission orders

• Admit to
• Diagnosis
• Condition
• Vitals
• Allergies
• Nursing orders
• Diet
• Activity
• Labs
• IV fluids
• Special orders
• Medications

Question 4

What dictates which Pts can go to the floor vs ICU who have Hyper/hypoglycemia?

Answer 4

• Floor: Hyperglycemia (>400) without anion gap
• IMC (Step down): DKA but pH >7.2 and resolving anion gap
• ICU: DKA with multi-organ dysfunction, pH < 7.2

Question 5

Generally, which rate of lab draws requires ICU admission vs Floor?

Answer 5

• Floor: QD, BID
• IMC: Q2h
• ICU: < Q2h

Question 6

Which renal failure Pts can go to the floor and which need to go to the ICU?

Answer 6

• Floor: Chronic/non-emergent hemodialysis
• ICU: Emergent dialysis, CRRT, K > 6.0 with ECG changes, any K > 7.0

Question 7

When looking at hemodynamics which Pts are floor appropriate vs need ICU?

Answer 7

• Floor: Stable hemodynamics (HR 50-130, SBP 85-200, RR 10-30)
• ICU: Hemodynamically unstable; hypertensive emergency, IV antihypertensives

Question 8

Which respiratory statuses are okay for the floor vs need ICU?

Answer 8

• Floor: Chronic stable NPPV overnight (CPAP for OSA)
• ICU: NIPPV (BiPAP, CPAP); intubated; impending respiratory failure, threatened airway

Question 9

When is a Pt considered inpatient vs observation?

Answer 9

“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”

Question 10

66-year-old female with a 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 for 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 a 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

Name 3 DDX?

Answer 10

1. MI
2. Cardiac arrythmia
3. PE

Question 11

When admitting a Pt from the ED how many DDX should you have?

Answer 11

At least 3

Question 12

Regardless of suspected Dx what is something you need to ask all Pts who will be admitted?

Answer 12

What their code status is

Question 13

What are some good practices to follow when discussing code status with a Pt?

Answer 13

• Normalizing statements
• Education/explanation
• Further steps if Pt interested
• MOST form

Question 14

General work flow for a hospitalist?

Answer 14

• Daily (at least) re-evaluation of Pts
• Adjustment of treatment plans
• Communication with consultants
• Discharge planning/longer-term plan

Question 15

Within the Social work team, what does the case manager do?

Answer 15

• Arrange logistics/finances of
  
  • Home health
  • Outpatient IV Abx
  • Wound vacs, durable medical equipmemt
  • Transfer to an outside hospital
  • SNF or LTAC referrals/placement

Question 16

Within the Social work team, what issues does the Social Worker adress?

Answer 16

• Homelessness
• Uninsured
• Substance abuse
• Adjustment to illness counseling
• Complex social issues
  
  • Legal issues
  • Guardianship

Question 17

Within the Social work team, what does the Utilization manager determine?

Answer 17

• Medical necessity review
• Inpatient vs. OBS

Question 18

Occupational therapists do?

Answer 18

• Asses/improve ADLs and mobility
• Cognitive screens
  
  • MOCA
• Help determine if a Pt is safe to go home
  
  • “Just because you’re walking around doesn’t mean you’re safe to go home”

Question 19

What does the Respiratory Therapist do?

Answer 19

• Ventilator and NIPPV management
• Home O2 evaluations
• Nebulizers
• Chest PT
• OSA screens
• Intubate (Hospital dependent)

Question 20

The general job of a hospital RN?

Answer 20

• Patient assessment
• Medication administration
• Care coordination
• Front line for patient/family interaction
• Discharge logistics and education

Question 21

The general job for hospital pharmacy?

Answer 21

• Confirmation of all inpatient med orders
• Clarification of orders with providers
• Preparation of medications
• RRT/MET/code involvment

Question 22

What is a good format to use when calling as consult?

Answer 22

“This is a consult for [main concern]. Ms. Jones is a 35-year-old woman with h/o SIADH, who came in with…”

Question 23

What are some things a consultant will contribute?

Answer 23

• Procedures
• Advice on workup
• Advice on treatment

Question 24

You are working as X-cover on signout with the day team you are told the following:

• 78-year-old female with h/o of HTN, DM, admitted for altered mental status found to have new ICH
• Vitals: BP 155/70, RR 16, HR 85, Pulse Ox 92%
• Exam: No change in Neuro Exam from the day
• Recent Imaging: Stable Head CT from the day
• Follow up: CT-H for serial imaging

What questions should you ask?

Answer 24

• Code status?
• What do I do if there’s something on the CT Scan that is abnormal?
• What does her neuro exam consist of?

Question 25

• 78-year-old female with h/o of HTN, DM, admitted for altered mental status found to have new ICH
• Vitals: BP 155/70, RR 16, HR 85, Pulse Ox 92%
• Exam: No change in Neuro Exam from the day
• Recent Imaging: Stable Head CT from the day
• Follow up: CT-H for serial imaging

CT-H Shows small increased ICH no change from prior

What should you do next?

a. ) Do nothing because the attending from the day said not to worry about it
b. ) Call radiology to confirm bleed
c. ) Go see the patient and do a neuro exam
d. ) See the patient, do a neuro exam, and call your consultant (NSGY)

Answer 25

d.) See the patient, do a neuro exam, and call your consultant (NSGY)

Question 26

If there are any NEW findings on a head CT what should be done?

Answer 26

Physical exam and neurosurg consult

Question 27

You are working as X-cover on signout with the day team you are told the following:

• 38 year old male with no PMH admitted for UE cellulitis in the setting of IV drug use
• Vitals: BP: 90/60 Resp: 18 HR: 113 Pulse Ox: 97%
• Exam: NAD. CV: tachy with regular rhythm msk: LUE wrapped with surround erythema
• No u/s completed today
• Follow up: u/s results

What are some concerns you have?

Answer 27

Not exhaustive list:

• Shock?
• ABx?
• Blood cultures?
• Fluids?
• Baseline ECG?

Question 28

You are working as X-cover on signout with the day team you are told the following:

• 38 year old male with no PMH admitted for UE cellulitis in the setting of IV drug use
• Vitals: BP: 90/60 Resp: 18 HR: 113 Pulse Ox: 97%, he is febrile
• Exam: NAD. CV: tachy with regular rhythm msk: LUE wrapped with surround erythema
• No u/s completed today
• Follow up: u/s results

What questions should you ask?

Answer 28

• Why is he hypotensive and tachy?
• What abx is he on?
• What should I do with the u/s results?

Question 29

You are working as X-cover on signout with the day team you are told the following:

• 38 year old male with no PMH admitted for UE cellulitis in the setting of IV drug use
• Vitals: BP: 90/60 Resp: 18 HR: 113 Pulse Ox: 97%
• Exam: NAD. CV: tachy with regular rhythm msk: LUE wrapped with surround erythema
• No u/s completed today
• Follow up: u/s results

Later that night U/S results show a small fluid pocket. The Pt becomes more hypotensive, tachy, and the RN calls saying he “looks bad”

What should you do?

a. ) Order blood cultures and see the patient
b. ) Order blood cultures, switch pt from cefazolin to vancomycin, IVF, call gen surg, and go see patient
c. ) Order blood cultures, switch pts from cefazoline to zosyn, IVF, call gen surg, and go see patient
d. ) Order blood cultures, call gen surg, IVF, and day team can assess in am

Answer 29

b.) Order blood cultures, switch pt from cefazolin to vancomycin, IVF, call gen surg, and go see patient

This patient developed sepsis on the cross cover sign out. Given the patients history (IV drug use) blood cultures are important to eval for bacteremia and possible endocarditis. Switch abx to cover to MRSA given abscess on U/S, Call gen surg to I&D, and give IVF to keep hemodynamically stable

Question 30

You are working as X-cover on signout with the day team you are told the following:

• Pt is 68 year old male with history of obesity and HTN who presented with shortness of breath found to have COVID PNA.
• Vital Signs: BP: 130/70, RR: 24 HR: 105 Pulse Ox: 92% on 6L
• Exam: Tachypneic with bilateral rales
• Follow up: Just an FYI he isn’t looking great

What questions should you ask?

Answer 30

• What’s his Code status? Does he want to be moved to ICU?
• What was his O2 requirement all day?
• Is he getting RDV/Dex?

Question 31

You are working as X-cover on signout with the day team you are told the following:

• Pt is 68 year old male with history of obesity and HTN who presented with shortness of breath found to have COVID PNA.
• Vital Signs: BP: 130/70, RR: 24 HR: 105 Pulse Ox: 92% on 6L
• Exam: Tachypneic with bilateral rales
• Follow up: Just an FYI he isn’t looking great

Rapid response is called for this Pt due to him becoming more tachypneic and not being able to maintain his O2 saturation above 90% on 6L. A chest X-ray is ordered and shows diffuse ground-glass opacities.

What are your next steps?

a. ) Transfer to the ICU
b. ) Get patient to prone, increase O2 to heated high flow, call ICU
c. ) Tell the nurse that you are busy and just increase his O2
d. ) Call pulmonary for chest tube

Answer 31

b.) Get patient to prone, increase O2 to heated high flow, call ICU

When a rapid response is called: first stabilize the patient, then get the patient to the ICU

Question 32

What are the details of discharging a Pt?

Answer 32

• Discharge summary
• Follow up scheduled
• Discharge Order
• Coordinating DC meds