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2015-2016 ATLANTA VAMC HOUSESTAFF ORIENTATION
Shahed Brown, MD
Associate Program Director
J. Willis Hurst Internal Medicine Residency, Emory University School of Medicine
Andrew Ip, MD
Chief Medical Resident
215-901-7383
Department of Veterans’ AffairsMission Statement
Who is a “Veteran”?
Chuck Norris Hammer-TimeIce-T Pat Tillman
Drew Carey
VA Healthcare
• 22 millions veterans in the US– Approximately 9 million receive care within the VA
healthcare system
• Comprehensive care– Primary care– Specialty care– Mental health– Substance abuse treatment – Home care – Respite care – Palliative care
Veterans are a Unique, Complex, Widely Variable Population
Veterans & Mental Health
Veterans & Mental Health
• From 2008:– Prevalence of 36.9% for mental health
diagnoses– 21.8% diagnosed with PTSD– 17.4% diagnosed with depression
• Active duty veterans < 25 y/o have higher rates of PTSD and alcohol/drug use disorders compared with active duty veterans > 40
J Gen Intern Med. 2012 Sep; 27(9): 1200–1209Am J Public Health. 2009;99:1651–8.
THE BASICS
Where do I park?
– There are 2 large parking garages in the front & back of the hospital
• PLEASE PARK IN THE BACK
– Don’t need a special sticker or pass – Obey all traffic & parking rules… this is a
federal property, you will have to go to the Richard Russell Federal Building if you want to challenge your parking ticket!!!
Where am I??GROUND FLOOR Dialysis, Radiation Oncology, Police/Badge & ID area
(Ken Ratcliffe GA-243)
1ST FLOOR Entrance from parking lot, cafeteria, Starbucks, store, radiology, most clinics, ER
2ND FLOOR MICU/SICU, Cath lab, PFTs, OR, laboratory, pathology, call rooms
3RD FLOOR Administrative offices
4TH FLOOR Psychiatry inpatient/PICU
5TH FLOOR Mental Health offices, outpatient clinics
6TH FLOOR Conference room, Chief Resident’s Office, Library
7TH FLOOR General Medicine (non-telemetry) & oncology inpatients, Team # 1 and Team #2 office
8TH FLOOR “Surgical” patient floor, Palliative Care Ward, Team #3 office
9TH FLOOR Patient floor, Sleep Lab
10th FLOOR Telemetry, Team #4, Team #5, Team #6 office
Telephone Numbers
• Outside of hospital, calling into VA:– (404) 321-6111, then you press 1 + 4 digit extension
• Inside the VA, dial the 4-digit extension• VA-pager, dial 1590, enter the pager number
then your call back number • To call local numbers (Grady, Emory) – need to
dial 9 + 404- then the number• Long Distance - Dial 9 then 1 and the long
distance # - use 339960 as PIN
On-Line Training
• MUST BE COMPLETED IN ORDER TO RECEIVE COMPUTER ACCESS CODES
MUST do the on-line training for privacy & information security EVERY year
Computer Access
• Cannot “share” your computer log-on information with anyone.
• Using someone else’s computer log-on will be considered a serious professionalism breach
• Codes will expire (deleted from the system) after 3 months of inactivity
• After 1 month of inactivity, you can call “HELP” (4357) on a VA-phone & your codes can be reactivated
• HOME CPRS Access – see atlvainfo.wikidot.com under general info
Computer Access
VA BADGES• Once you have computer access,
you can get a VA-Badge• *Must be fingerprinted as well • See Mr. Ken Ratcliffe in Education
– Office is located on Ground Floor– Will give you a document to take over
to badge office – Should have your badge within a few
days
• Ok to use your Grady badge until VA badge is ready
How to get your VA ID Badge• First get fingerprinted!
– Go to the ID-badge office on the Ground floor (bottom floor) of the Atlanta VA Medical Center before 2 pm
• Approximately 3 days after fingerprinting, contact Mr. Ken Ratcliffe in Education office, also on Ground Floor in Room GA243 – (404) 321 – 6111, extension 2720– [email protected]
• Mr. Ratcliffe will sponsor your badge • Return to the ID office to get your picture taken and ID
badge made • Ok to wear Grady badge until VA badge is ready!
This is helpful! Can access this website from any computer!
http://atlvainfo.wikidot.com/
• We have an electronic on-call schedule for medicine and medicine subspecialties and surgery subspecialties that is accessible via VA-intranet. It is a great way to find out who is covering weekends, or who is on call for urology, etc
• The link is on the Emory VA info page under “Rosters” and is also accessible from the VISN7 homepage
http://atlvainfo.wikidot.com/ http://vaww.visn7.med.va.gov/intranet/facilities/182247/
Noon Conference - Daily, 12:00 pm
- Tuesday Core conference- INTERNS at noon; residents at 1 pm
- Room 6C-130
EDUCATION & CONFERENCES
• Noon conference everyday, unless otherwise noted (12pm-1pm) in 6C-130 Conference Room– Emory Grand Rounds, “Core” Conference Tuesdays
• Chief residents work VERY hard on creating and organizing these conferences
• Schedule: http://atlvainfo.wikidot.com/ • Attendance is mandatory, unless:
– Day off– Clinic– Crashing patient
• Bring your lunch & enjoy!
EDUCATION & CONFERENCES
• INTERN REPORT– THURSDAYS 2:30 pm to 3:15 pm on 6C 130– COFFEE AND PASTRIES/SNACKS provided!!– Mandatory for all wards interns, optional for
subspecialty interns– Goal is to go over intern specific issues such as
cross-cover, interesting cases, bread & butter questions
EDUCATION & CONFERENCES
• Dr. Jurado Rounds– Occur M-F, 9:00 am – Usually on pre-call day– Informal discussion of interesting cases– He will come to your team room– Great opportunity to discuss something that
you’re stumped on, need advice, or his opinion
CALL ROOMS
• Call room in MICU• Call room for Night Float Resident on 8th floor
164– Both call rooms are locked, with a bed, computer,
TV, telephone and bathroom
• Small Conference room on the 6th floor has a “Snack Fridge” – food for residents who are on call
Code for this door: 3-1-5;
Fridge Code 0-9-1-4
ROOM CODES Room Location Door Code
Night Float Resident 8C164 8273#
ICU Call Room *located within MICU
5-1-4 (*5 then 1 then 4)
Snack Fridge Room (*aka small conference room)
6C-129 3-1-5 (*3 then 1 then 5)
Conference Room 6C-130 3-1-5 (*3 then 1 then 5)
Endo/Rheum Fellow & Podiatry Work Room 7C-169 1-3-5-2-4 (*1 then 3 then 5 then 2 then 4)
Team 1 Room 7C-157 2+4, then 3
Team 2 Room 7C-109 2+4, then 3
Team 3 Room 8C-109 2 then 5 then 3
Team 4 Room 10C-109 2+4, then 3
Team 5 Room 10C-157 2+4, then 3
Team 6 Room 10C-108 1-3-5-7-9-# (*1 then 3 then 5 then 7 then 9 then #)
FOOD
• You will receive “meal tickets” from your chief resident for each call day– @ 10 tickets/month, $5.50 per ticket– There is an expiration date!!– Can be redeemed in cafeteria, Starbucks
• Team rooms have a mini-fridge if you bring food from home
• Several restaurants nearby that deliver
SUMMARY
• Use our website!! – atlvainfo.wikidot.com• NOON CONFERENCE – mandatory, bring
lunch or use your food vouchers• INTERN REPORT EVERY THURSDAY
2:30 – free coffee/snacks!
Schedules , your multidisciplinary team
Inpatient Medicine
• Each team has a team room– Keypad for entry– Lockers to keep your things secure– Mini-fridge– Computers, printer in each team room
• Each team has a mobile computer to facilitate rounds
WORK HOURS
• Start time: 7 am– Receive sign out– If you have AM clinic, discuss with resident
if you need to come in before clinic (you should not need to unless your resident requests you to). Same with PM clinic – you should not need to return unless on call
• On-Call days:– 7 AM to 7 PM
•WE TAKE THE RRC RULES VERY SERIOUSLY
– 4 days off per month– <80 hours per week averaged over a
4 week period– LOG DUTY HOURS!!
Schedules• Work with your team to set up the
schedule early in the month, including days off
• Let your resident and attending know as soon as possible if there are certain days that you need off (no guarantees)
• Discuss with your resident expectations for clinic days
Medicine Wards at the VA• 6 Resident Teams
– 4 Emory Teams (1- 4)– 2 Morehouse Teams (5, 6)
• 2 Hospitalist (“Direct Care”) Teams– Hospitalist A– Hospitalist B
• MICU, CCU rotations – “Closed Unit”
• Subspecialists are consultants– Do not have their own inpatient services
Medicine Wards Call Schedule
• Every 3rd day 2 teams are “on-call”– Team 1, 2– Team 3, 4– Team 5, 6– *Hospitalists admit daily
• Care for patients admitted from overnight & admitted during the day– Until 7 PM (7-days a week)– Total of 10 new patients– Cap of 20 patients total for your team
• Night Float resident admits and crosscovers already admitted patients overnight (7pm-7am)
Medicine Wards Call Schedule
• On your call day, every team member will go to the 6th floor conference room at 7 am sharp– Night float resident will hand-over their overnight admissions – Hear about your new admissions briefly, discuss what has been
done already & what else needs to happen– Admissions are alternated between the 2 “on-call” teams &
hospitalists
• After morning sign-out, your resident will be contacted by the ER, clinics, etc with admissions until 7 PM
Medicine Wards Call Schedule
• On your non-call day, AT LEAST one team member will go to the 6th floor conference room at 7 am sharp– Night float resident will discuss any crosscover issues that
occurred overnight – Good teaching opportunity to hear about the other new patients
that were admitted
• Be on-time.
Medicine Wards Call: Crosscover • Check the on-call schedule carefully• Every 6th or so day, you will be on “Crosscover
Call”, unless you have PM clinic on a call day– Crosscover already admitted patients for 3 other teams
• Teams 1, 3, 5 cover each other• Teams 2, 4, 6 cover each other
• When you are not on call & your work is done, you sign-out your patients to the crosscover intern after 5 pm– You are responsible for your patients until 5 pm.
• Crosscover intern will cover 3 teams until 9 pm, then sign-out those patients to night float (see schedule on who to page at 9 pm)
Typical Day
• 7am-9 am – pre-round and work-round• 9-9:30 – make discharges ready, can call consult• 9:30 or 10:00 to 11:30 – attending rounds• 11:30 – 12:00 – finish up discharges or consults,
get lunch• 12:00 – 1:00 – Noon conference• Afternoon – pre-call/post-call – finish work/place
morning labs and finish signout ; on call admits until 7 pm, cross cover intern stays until 9
“The Book”
• Admission log• Hospitalists keep track of admissions • Hospitalist team A/B admit every day,
so they typically only take patients from their nocturnist, and then if teaching teams cap they will admit in afternoon
Admissions
• MICU/CCU transfers occur from 7 am- 2pm (ICU resident needs to page the book before 2 pm)
• Transfers count as “1” to team• Transferring service must write “Transfer
Summary” note• When ward team accepts the patient:
– Write an accept note– Reconcile orders– Change the “Admit To” order to your respective
team with the attending, intern and intern pager
Night Float Who is cross-covering my patients?• Before the team leaves the hospital:
• Use the “Shift Hand-Off Tool” as your sign-out sheet
• Print it out from CPRS, meet with the cross-cover intern and go over your sign-out, from sickest patient to least sick
• Must have your cell phone, your resident’s cell phone, and your attending’s cell phone printed on the sheet.
Nurse Practitioners• Each team has a NP
– In process of hiring NP for Team #2– All teams are covered
• Integral part of the team– Know the VA system very well & how to get
things done– Help you orient to and learn the VA system– Direct patient care – Input and recommendations for patient care– Assistance with care coordination, follow-
up
Nurse PractitionersRoles:• Discharge coordination• Liaison between housestaff and nursing• Direct patient care:
– Working on system for NP to admit 1 pt each call (will vary team by team)
– continued care of acute inpatients
– Nurse practitioners can write admission orders, H&P, progress notes, daily orders, discharge instructions, etc
– Write orders, place consults, participate in family meetings
Nurse PractitionersExpectations:• Must involve your NP in daily work rounds• NPs must be aware of the care plan & changes in
care plan at all times• Beneficial to participate in afternoon “huddle”
with your NP, other team members– Discuss potential discharges for next day– Discuss tests, consults, etc that are pending – Make sure everyone is on the same page
Social Workers • Inpatient social workers cover 3 teams each• Office is located on Ground Floor• Communicate daily with your social worker
– Keep them updated with new admissions that may have difficult social circumstances
– All patients that may need nursing home placement– All patients that may need transportation – Patients that may be in vulnerable situations, potential
for abuse– Assist with advanced directives, VA-benefits
questions, eligibility
• Beneficial to participate in afternoon “huddle” with your SW as well
Pharmacists • Each team has their own dedicated PharmD• Medication selection (indications, drug-drug
interactions)• Pharmacokinetics• Formulary vs non-formulary medications• Discharge medication counseling• See monthly roster schedule for PharmD contact
information
Notes, Sign out
History & Physical
• Complete H&P, on the day the patient is admitted!!!
• HPI: extensive description including location, duration, severity, quality, timing, context, modifying factors and associated signs and symptoms
• Include 10 organ systems in ROS• Always document PMHx, Fam Hx and Social Hx• In physical, complete all organ systems; always
document “4 extremities” in your note
History & Physical
Words you should never use in your H&P or progress notes:– “Rule out” : no one pays for ruling out!– “Non-contributory” : use “No heart dz,” “no
DM,” – “Urosepsis”
• Billed as UTI (pays nothing)• Better to use “bacteremia,” “sepsis of urinary tract
origin,” or just “sepsis”
Sign-Out
• Process of talking to the “on-call” intern who
will cover your patients from the time you leave
until the time you return
• Generally a print-out that you update EVERY SINGLE DAYPrint Your name, your resident’s name,
Attending’s name , with the pager for everyone and your cell #
Include in signoutIV Access & Do they need it?Code statusFamily/Next of kin contact information SHORT synopsis of plan for patient
Sign-Out
• APPROPRIATE:– “Please check Chem-8 at 10 pm. If K <3.0, give 40 mEq of
KCl po x1”– “Check 10 pm troponin. If > 1.0, start heparin drip, no
bolus”– “Check CBC at 10 pm. If Hgb less than 7.0, give 2 units
PRBCs” Must consent your patients for blood if you are signing this out!!!
• INAPPROPRIATE:– “Check CBC”– “Check Chem-8”
Discuss the items for follow-up with the on-call intern, as well as any patients that are critically ill
Sign Out Do’s and Don’ts
• Must have face to face sign-out• Students cannot do sign-out• Do not sign-out unstable patients• Update EVERY SINGLE DAY• Make sure your resident has access to
your sign out • Use “If… then” statements for all
follow-up items
• When to write a cross-cover note:– Any change in vitals, mental status, or any
other pertinent factor that will influence patient’s plan of care
– Your follow-up on things signed out to you- what the value was & what you did with that result:
• Repeat Potassium • Troponins
– You do not have to write a cross-cover note for writing for prn colace or prn mylanta!
Crosscover Call
Progress Notes – good exampleS: No events overnight. Pt reports feeling "okay" this morning. No SOB, CP. No abdominal pain.O: 104/56 (09/27/2008 00:47)70 (09/27/2008 00:47)20 (09/27/2008 00:47)98.2 F [36.8 C] (09/27/2008 00:47)Gen: NAD, resting comfortably, AAOx2 (person/place)Pulm: Few bibasilar crackles CV: IRRR, s1 s2, 2/6 HSM at apex, JVP at 12cm.Abd: soft, +BS, non-tender, +distension, increased, +shifting dullness. Ext: Warm ext, 2+pitting edema BLE, decub ulcer with dressing in place, no oozing noted.Labs:WBC - 29.5, 8% bands, 78% segs, PO4 - 1.7, K - 3.6, Mg - 1.9, BUN – 29, Cr - 0.7MEDICATIONS=========================================================================1) ACETAMINOPHEN TAB 650MG PO Q6H PRN PAIN OR HEADACHE ACTIVE2) ALOH/MGOH/SIMTH REG STRENGTH LIQUID 30 ML PO Q6H PRN ACTIVE3) ASPIRIN (325) TAB 325MG PO DAILY ACTIVE4) CHLOROPHYLL/PAPAIN/UREA OINT,TOP SMALL AMOUNT TOP ACTIVE DAILY Apply to coccyx decub. daily. cleanse skin5) FERROUS SULFATE TAB 325MG PO DAILY ACTIVE6) FINASTERIDE (PROSCAR - PROSTATE) TAB 5MG PO DAILY ACTIVE7) HEPARIN INJ,SOLN 5000UNT/0.5ML SQ Q12H ACTIVE8) LACTINEX (EQUIV) GRANULES 1GM/1PKT PO TID ACTIVE9) MILK OF MAGNESIA SUSP,ORAL 30 CC PO Q12H PRN CONSTIPATION10) RANITIDINE TAB 150MG PO DAILY ACTIVE11) VANCOMYCIN INJ 250MG PO QID Dilute with 20cc S.W. 125mg/2.5cc12) VENLAFAXINE (DOSED DAILY) CAP,SA 75MG PO DAILY ACTIVE
A/P: 90 y/o man c h/o CHF, peritoneal carcinomatosis admitted with SBP, now with severe C-diff colitis.1. C-diff colitis: - Pt continues to have high stool output. - WBC trending down now, continue with PO vanc with increased dose and dc flagyl per ID recs. Appears
stable currently, no signs of tox megacolon. Monitor closely.2. Acutely decompensated systolic heart failure:- Pt initially diuresed aggresively however diuretics dc'd 2ndary to concern for volume depletion as pt became
hypotensive. - Now appears to be volume overloaded, very delicate balance given CHF and on-going GI losses 2ndary to c-diff. - Will resume low-dose hydralazine for afterload reduction and schedule lasix IV q 24hours. - Afib - Heart rate improved - monitor. - Monitor vitals q4. Strict I/O's.
3. F/E/N- Very poor Po intake currently, likely 2ndary to multiple acute issues. - Pt started on supplements per nutrition recs. Will likely need to discuss enteral feeding options with family given severity of malnutrition. - Continue to aggresively replete K. Will replete Phos IV.
4. Recent SBP- S/p course of Abx, repeat paracentesis w/o evid of infection.- Monitor. No further Abx at this time, will discuss need for prophylaxis with ID.5. Peritoneal carcinomatosis: - Unknown etiology at this time. - Urine cytology negative. - Previous peritoneal cytology suspicious for CA, will likely repeat diagnostic
paracentesis once more stable. May need U/S marking if ascites improves with diuretics.
A not so good example…S: Patient appears confused today, but states that he's doing well.O: BP 120/64 (09/20/2008 03:22), HR 94 (09/20/2008 03:22), RR 18 (09/20/2008 03:22), T 97.6 F [36.4 C] (09/20/2008 03:22)Gen: AAOX1 TO PERSON ONLYPULM: AUDIBLE WHEEZING, DIFFUSE CRACKLES THROUGHOUT LUNG FIELDSCV: IRREGULARLY IRREGULAR, +JVD ~ 6CM ABOVE CLAVICLE, ENGORGED EJGI: HYPOACTIVE BS, FIRM, + DISTENSION, + TTP, NO REBOUNDEXTR: + COOL DRY SKIN B.LE, 2-3+ PITTING EDEMA, MULTIPLE ULCERATIONS ALONG B. LE W/DRESSING TO RLE (SHIN), STAGE 11 DECUBITUS ULCER
Labs:---- CBC PROFILE ---- 09/20 09/19 09/18 09/17 Reference 2008 2008 2008 2008 03:37 03:05 19:06 12:45 Units Ranges-------------------------------------------------------------------------------WBC 9.0 10.7 14.6 H 14.3 H K/cmm 4 to 11RBC 2.9 L 3.0 L 3.1 L 3.2 L M/cmm 4.7 to 6.1HGB 7.7 L 7.8 L 8.1 L 8.5 L g/dL 14 to 18HCT 25.1 L 25.1 L 25.6 L 26.7 L % 40 to 52MCV 85.7 84.2 83.4 82.4 fL 80 to 100MCH 26.3 L 26.2 L 26.4 L 26.2 L pg 31 to 34MCHC 30.7 L 31.1 L 31.6 L 31.8 L g/dL 32 to 37RDW 17.4 H 17.4 H 17.4 H 17.5 H % 11.6 to 16.5PLT 300 288 300 322 K/cmm 150 to 400MPV 9.1 L 9 L 9.1 L 9.2 L fL 9.4 to 12.4SEGS % 69.9 76.2 H 83.4 H % 37.5 to 75.5LYMPH % 10.5 L 11 L 6.7 L % 20 to 55.5MONO % 15.1 H 9.9 8.9 % 2.5 to 12EOSIN % 4.2 2.6 0.9 % 0 to 6BASO % 0.3 0.3 0.1 % 0 to 2.5
CHEMISTRY PROFILE ----PLASMA 09/20 09/19 09/18 09/18 09/17 Reference 2008 2008 2008 2008 2008 03:37 03:05 13:20 03:16 15:53 Units Ranges-------------------------------------------------------------------------------NA 132 L 133 L 133 L 148 H mmol/L 136 to 145K 4.4 4.3 4.6 3.4 L mmol/L 3.5 to 5.3CL 101 102 102 111 H mmol/L 96 to 106CO2 21.0 L 24.0 L 21.0 L 30.0 mmol/L 25 to 3GLUCOSE 95 116 H 119 H 147 H mg/dL 70 to 110CA 8.9 8.6 8.3 L 9.1 mg/dL 8.5 to 10.9BUN 34 H 34 H 33 H 38 H mg/dL 11 to 24CREAT 0.7 0.8 0.7 2.1 H mg/dL .5 to 1.2BUN/CR 48.6 H 42.5 H 47.1 18.1 Ratio 12 to 20
There’s
More….
ANCILLARY GLUCOSE ----BLOOD ANC.GL Ref range low 70 Ref range high 110 ------------------------------------------------------------------------------- 09/20/2008 06:54 98 09/19/2008 21:19 109 09/19/2008 11:26 116 H 09/19/2008 06:45 109 09/18/2008 20:37 151 H 09/18/2008 16:36 136 H 09/18/2008 11:53 127 H 09/18/2008 05:53 126 HDATE TIME SPECIMEN TEST VALUE Ref ranges-------------------------------------------------------------------------------09/19/2008 03:05 PLASMA PRO-BNP: 13430 pg/mL Test(s) ordered: CULTURE & SUSCEPTIBILITY (ANAEROBES) completed: Sep 20, 2008 GRAM STAIN completed: Sep 17, 2008 17:12* BACTERIOLOGY FINAL REPORT => Sep 20, 2008 TECH CODE: 24298 GRAM STAIN: FEW WBC'S SEEN FEW GRAM POSITIVE COCCI IN PAIRS
SEEN FEW GRAM NEGATIVE RODS SEEN FEW GRAM POSITIVE RODS SEEN DR. NOTIFIED AT 1711 ON 09/17/08. TK Repeated Back and Verified CULTURE RESULTS: 1. HEAVY GROWTH ESCHERICHIA COLI 2. HEAVY GROWTH KLEBSIELLA PNEUMONIAE 3. SCANT
GROWTH ENTEROCOCCUS FAECALIS (GROUP D) Comment: Synergy is expected between gentamicin and either ampicillin or vancomycin if the enterococcus is susceptible to one of these latter agents. Synergy with STREPTOMYCIN-PENICILLINS expected.
ANTIBIOTIC SUSCEPTIBILITY TEST RESULTS: 1. ESCHERICHIA COLI• : 2. KLEBSIELLA PNEUMONIAE• : : 3. ENTEROCOCCUS FAECALIS (GROUP D)• : : :• SUSC INTP SUSC INTP SUSC INTP• AMIKACN <=2 S • AMOXICILLIN/CA <=8 S • AMPICLN 4 S >=32 R 0.5 S • AMPICILLIN/SUL<=4 S • CEFEPIME 8 S • CEFAZOLIN <=8 S <=8 S • CEFOTETAN <=16 S • PIPERACILLIN/T<=8 S <=8 S • CEFTAZIDIME <=8 S <=8 S • CEFTRIX <=8 S <=8 S • CIPROFLOXACIN <=0.5 S <=0.5 S • GENTMCN <=0.5 S <=0.5 S • GENTAMICIN 500 SYN-S SYN-S • IMIPENEM <=4 S <=4 S • STREPTOMYCIN 2 SYN-S SYN-S • TETRCLN >=16 R • TOBRMCN <=0.5 S <=0.5 S • TRMSULF <=10 S <=10 S • VANCMCN 2 S • LEVOFLOXACIN <=1 S <=1 S • ESBL NEG NEG NEG NEG
ASSESSMENT & PLAN: 90 Y.O. CAUCASIAN MALE WITH SUSPECTED MALIGNANT ASCITES ADMITTED TO THE SERVICE FOR SEPSIS 2/2 SPONTANEOUS BACTERIAL PERITONITIS.
1. SEPSIS: 2/2 SBP E.COLI & E.FAECALIS- Continue Vancomycin 1G IV Q12 HRS, Imipenem 500MG IV Q6 HRS for now- Hold albumin given elevated BNP levels.
2. PERITONEAL CARCINOMATOSIS (?): UNKNOWN ETIOLOGY- Diagnostic tap to be done yesterday, patient provided consent; patient's son notified by phone- left a voicemail. However, when we attempted to perform the procedure, the patient appeared confused about our intent and declined the procedure. We did not feel comfortable proceeding with the paracentesis as the patient was insistent upon us not withdrawing fluid from his abdomen and was actively guarding his abdomen with his hands.- Per the cross-cover resident, after we left for the
day, the patient's son arrived at the bedside and was very upset about us having not performed the procedure. Dr. has spoken in depth (~1 hour over the phone) with one of the patient's daughters this morning to explain the rationale behind not proceeding with the diagnostic paracentesis at that time.- Will re-attempt diagnostic paracentesis tomorrow with patient's daughter present.
3. ELEVATED BNP: >13,000- CXR, diuresis today with Lasix 40MG IV x 1 now: will monitor Is & Os, reassess and diurese again as needed - All anti-HTN/CHF meds currently being held given HOTN: will re-start once BP normalizes
4. ALTERED MENTAL STATUS: ONGOING SBP VS. DELIRIUM5. ACUTE RENAL FAILURE: - Cr stable at 0.7-0.86. HYPOTENSION: 2/2 SEPSIS- D/C all anti-HTN meds7. AFIB: STABLE- Not on anticoagulation 2/2 fall risk8. DEPRESSION:- Continue Effexor 75MG PO QD9. ANEMIA: - Continue FeSO410. CONSTIPATION:- Continue Colace 100MG PO BID- Dulcolax 10MG PRNActive Inpatient Medications (including Supplies):=========================================================================• 1) ACETAMINOPHEN TAB 650MG PO Q6H PRN PAIN OR HEADACHE ACTIVE• 2) ALBUTEROL 0.083% SOLN,INHL 2.5MG (3ML) INH Q4H ACTIVE• NEBULIZER• 3) ALOH/MGOH/SIMTH REG STRENGTH LIQUID 30 ML PO Q6H PRN ACTIVE• FOR DYSPEPSIA• 4) ASPIRIN (325) TAB 325MG PO DAILY ACTIVE• 5) DOCUSATE CAP,ORAL 100MG PO BID FOR STOOL SOFTENER. ACTIVE• 6) FERROUS SULFATE TAB 325MG PO DAILY ACTIVE• 7) FINASTERIDE (PROSCAR - PROSTATE) TAB 5MG PO DAILY ACTIVE• 8) FUROSEMIDE INJ,SOLN 40MG/4ML IV ONCE ACTIVE• 9) HEPARIN INJ,SOLN 5000UNT/0.5ML SQ Q12H ACTIVE• 10) IPRATROPIUM (ATROVENT) 0.02% SOLN,INHL 0.5MG ACTIVE• (2.5ML) INH Q4H NEBULIZER• 11) MEROPENEM INJ,PWDR MEROPENEM 1000 MG in SOLUTION 100 ACTIVE• ML INFUSE OVER 30-60 MIN. ASSEMBLED ________• ACTIVATED __________ IVPB Q12H• 12) MILK OF MAGNESIA SUSP,ORAL 30 CC PO Q12H PRN ACTIVE• CONSTIPATION• 13) MORPHINE (mORPhine)-(MS CONTIN EQUIV) 15MG PO Q8H ACTIVE• 14) VANCOMYCIN INJ VANCOMYCIN 1250 MG in NORMAL ACTIVE• SALINE 500 ML INFUSE OVER 2 HOURS• ASSEMBLED__________ACTIVATED__________ IV DAILY• 15) VENLAFAXINE (DOSED DAILY) CAP,SA 75MG PO DAILY ACTIVE
A/P:
Keeping Track of Patient Data
• Have a system for tracking Labs, Radiology, Medications, etc– Cards– Templates
• Have a system for a daily checklist – Signout sheets– To-Do list
Helpful Tips for Inpatient Wards• Orders:
– Everything is done through CPRS– Enter the orders, and they print where the
patient is located (9th floor, ER)– PAIN MEDS PRN (Tylenol, tramadol, etc), sliding
scale insulin, DVT ppx– NEVER assume the nurse will realize you put in
orders as soon as you enter them– Best to communicate with nurses what you
need done• AM labs:
• Don’t forget to order them the day before• “Lab Collect = 3 am”
• Medications:– Pay close attention to when the first dose
will be given
Basic Rules to Remember…
The patient always comes FIRST Your education and that of others
is important, take time to learn and to teach
Take care of yourself and your team
If you have concerns or problems, bring them up, we are here to help you!
Shahed Brown, MDAssistant Chief of Medicine for Education, Atlanta VA Medical Center; Associate Program Director, Emory University Internal
Medicine Residency Program
(404) 321-6111, Ext. 2083 (office)
(404) 593-9923, (cell phone)
Any questions?
The rest of these slides will go into detail about using our charting system. Best way to go about this is to have this powerpoint open while you’re here at the VA getting used to CPRS.
Desktop View
• CPRS• VISN7 Telephone
Directory: For VA numbers
• Emory Simonweb paging & phonebook
• “Clinical Call Back Roster”: Non-medicine services contact info
• My computer: takes you to your I:Drive
Computers at the VA
• You will receive 2 codes:– Network log-on (to get on a computer)– CPRS log-on (for the charting system)
• Cannot log onto a computer unless you have a log-on
• Desktop icon for CPRS
CPRS= Computerized Patient Record System
Patient Identifiers
• No medical record numbers• Patients are identified by the first letter of
last name + last 4 of social security number– Mr. John Doe, SSN: 999-99-9999 = D9999
• This is what you would enter in the first screen once you have logged onto CPRS to pull up a chart
If you click on this box, it will bring up the “Face Sheet” – has address, phone number, next of kin, etc.
Patient Location Primary Care Provider & Clinic
Medications
Active Problems
Vital Signs
Past & Future Appointments
Allergies, Reminders, Remote Data
Clinical Reminders
“The Cover Sheet”
Bottom of the page menu
These menu options are always on the screen,
allowing you to move back & forth between sections easily.
Problems….
MEDICATIONS
MEDICATIONS
When you double click on any medication, it brings up a “History”:- Who prescribed it & when,
dosage, frequency, etc.
For inpatient:- Tells you the time each dose was given, how it was given, etc
ORDERS
LABS
• Must enter lab orders everyday• Phlebotomy (“Lab collect”)
– Scheduled daily collections early morning (order for “3 am”)
– “Immediate Collect” – if you need labs any other time, up until 11 pm
– “Ward Collect” - either YOU or the NURSE will obtain specimen (used for Stat/after-hours)
Admit Orders
• Delayed vs. Active orders• Easy to use “Admit to Medicine” orders• Telemetry orders• Medication Reconciliation • Hypoglycemia order set• Diabetes order bundle• Document DVT prophylaxis• Text orders
NOTES
NOTES
CONSULTSIt is customary to also CALL physician consultants.Asking for a consult takes practice. Be clear, specific, and concise in your request.
For Non-physician consultants (PT, OT, speech) I usually don’t call unless it is an urgent consult or something very specific that needs to be conveyed.
SURGERY
• Lists dictated surgery notes• Detailed description of everything that
occurred, from anesthesia, positioning, surgical approach/technique, nursing documentation
DISCHARGE SUMMARIESOne of the most valuable places to get information
Team Resident is responsible for
discharge summaries
LABS
LABS – CUMULATIVE
LOOKING FOR SPECIFIC LAB
LAB WORKSHEET
LAB GRAPHS
MICROBIOLOGY
ANATOMIC PATHOLOGY
REPORTS TAB
• HEALTH SUMMARY:– Immunization history
• IMAGING – Dictated/Transcribed “reads” of imaging
• MEDICATION– Charting from nurses
RADIOLOGY REPORTS
RADIOLOGY
• Can view most images in “Vista Imaging”
VISTA IMAGING
VISTA IMAGING
VISTA IMAGING
CARDIOLOGY PROCEDURES
• Transthoracic & Transesophageal Echocardiograms are located in “Vista Imaging” as PDF files
• Cardiac catheterization reports are found in the “Notes” tabs
• Nuclear stress test reports are found in the “Reports” tab under imaging
TOOLS TAB
EKGs
Helpful Tools
• Atlanta Clinical Resources– UP TO DATE– NEW ENGLAND JOURNAL OF MEDICINE– MICROMEDEX– VISUAL DIAGNOSIS – THERADOC (Log-in: antibiotic, Password:
resident)
TOOLS tab at top of screen, select “ATLANTA CLINICAL RESOURCES”
ATLANTA CLINICAL RESOURCES
REMOTE DATA
