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					A Day in the Life
   of an MS3

  Capstone I - May 27, 2008
First, some basics…
  The Team
  The Call Cycle
  The Key
   Players
  Round and
   Round we go
  Wards vs.
   Clinic
The first day . . .
  You are a superstar
   MS3 on your first day
   of your Medicine
   rotation
  Your team is “on-call”
  Your senior turns to
   you and your intern
   and says…
  There’s a new admit
  You’re off to the ER!
A Case-
Your New Patient

  5:52 pm

  ID: 63 yo woman 2 wks s/p thoracic
   laminectomy, presenting with 1 hour of
   pleuritic chest pain.
Hot Tip # 1
  Be prepared
    Clothes
    White Coat
    Tools
    References-Maxwell’s
    Clipboard like device-
     H&P form
    Consider your
     differential diagnosis
        MI, PE, PNA, GERD,
         Costochondritis,
         Trauma, Esophageal
         Spasm . . .
Taking a History


  6:05 pm

  HPI: Pt was in her USOH, complicated by mild COPD
   until 1 hour prior to presentation when while watching
   tv she developed acute dyspnea and sharp L sided
   chest pain radiating to her L arm and jaw, worse with
   inspiration and exertion. Pain is 8/10. Pt denies
   nausea, diaphoresis, palpitations, leg pain or edema.
Still taking a history
  ROS: Per HPI, pt denies nausea, diaphoresis, palpitations, leg pain or
    edema. Don’t forget all systems!

  PMH/PSH: COPD, OA, Depression, Allergic rhinitis, GERD, Recent
    laminectomy

  Medications: Ipratropium, Citalopram, Lansoprazole,
    Salmeterol/Fluticasone Inhaled , Fluticasone nasal spray

  Allergies: NKDA

  FH: Father died from MI, age 72. Mother with CVA in her early 70’s.
    Strong family history of hypertension.

  Social: Patient has been a cigarette smoker since age 19. Reports that
    she has quit, but also admits that she had a cigarette this morning. She
    denies any alcohol or other drug use.
Quick Quiz
    O:   One hour PTA
    P:   Left-Sided
    Q:   Sharp pain
    R:   Radiates to left arm and jaw
    S:   8/10
    T:   Constant
    A:   Aggravated by inspiration and exertion
    A:   Not alleviated by anything
    A:   Patient attributes the pain to “her
          heart”
Physical Exam
    6:20 pm
    VITALS: P:110, R:20, BP:119/85, O2 sat 96% on 2L.
     GENERAL: Patient is sitting up, appearing dyspneic and in pain.
     HEENT: The head is atraumatic. PERRLA. EOMI. There is no nasal discharge. Oropharynx is clear without
     visible lesions. Moist mucous membranes.
     NECK: Supple.
     CHEST: CTAB without any crackles, wheezes or rhonchi. Pain not reproducible with palpation.
     CV: Tachycardia, regular rhythm, Normal S1 and S2. No murmurs, rubs or gallops.
     ABDOMEN: Soft, NT/ND without palpable HSM.
     BACK: There is a healing midline scar in the mid to lower thoracic region without overlying erythema,
     swelling or exudate.
     EXT: Warm and well perfused with brisk capillary refill. No clubbing, cyanosis or edema. There is no
     tenderness to palpation of the calves bilaterally.
     NEURO: Patient is alert and oriented. Cranial nerves are intact and strength is symmetric upper and lower
     extremities.
Differential Diagnosis

     Trauma
     GERD
     Costochondritis
     Esophageal Spasm
     Pneumonia
     MI
     PE
Hot Tip #2
  Admitting the patient

    Look up records, labs, studies

    References to help with diagnosis and
     treatment

    Admit orders
Reviewing the medical
record . . .

  Look up your patient in the electronic medical
   record
     Orca-Harborview, UW, Children’s
     CIS-Children’s
     VA-CPRS
  www.uwresidents.com
  If applicable, call primary care provider to notify
   that patient is being admitted and to gather
   additional information
References

  Healthlinks http://healthlinks.washington.edu
        UpToDate ?
        MD Consult
        Pubmed
        Micromedex
        Patient Handouts
  Pocket References
Studies/Labs

 Na | Cl | BUN / Glucose          WBC\Hg /PLT
 K | Bicarb | Cr \                   /HCT\


 141 | 102 | 13 / 90    5.4\11.3/544
 4.1 | 25 | 0.6 \           /34\

 Ca++ 9.7, Mg 2.1
 D-dimer 1.07
 Cardiac Enzymes Negative x1
 INR 1.0

  ECG: Tachycardia, rate 110, no specific ST or T-wave
   changes
Revisiting our Differential

     MI

     PE

     Confirm suspicion of PE with CT-PA- Computed
      Tomography with Pulmonary Angiogram

    But we can’t get the CT-PA right away so let’s
     admit her to the hospital in the meantime . . .
    Admit Orders

   6:45 pm
   Admit to Medicine
   Diagnosis: Pulmonary Embolism
   Condition: Stable
   Vitals: per routine
   Allergies: NKDA
   Activity: OOB TID with assistance
   Nursing: Call HO if HR>110, <50, T>38.5, BP>180/110, <100/40, RR>20, <6
   Diet: Regular
   IV fluids: None
   Medications:
        Ipratropium MDI 2-3 puffs inhaled TID
        Salmeterol/Fluticasone MDI 1 dose inhaled BID
        Citalopram 20mg PO q day
        Lansoprazole 20mg PO q day
   Labs: Troponin I, CK, CKMB x2 @ 2400 and 0600
   Special: TEDs and SCDs, Consult PT
   Code Status: Full Code (be sure to discuss with patient)
Hot tip #3
  Now that your patient is admitted, how do
   you keep track of her information?
    Notecards, patient tracking templates

    Copies of H&P write-up and daily notes

    Make a “To-Do” list with boxes to be
     checked off, consult this list frequently!
“To-Do” List

 □ Check CT results
 □ Follow-up cardiac enzymes
 □ Consult PT
 □ Call SNF for discharge planning
 □ Call PCP
And 2 hours later . . .
  9:45 pm
  CT Pulmonary
   angiogram showed
   right segmental and
   subsegmental
   pulmonary embolus
   in RUL.
Initiate Treatment
  Diagnosis of PE is confirmed by CT-PA

  Try suggesting a treatment plan to your
   resident, consult references for help

  Start patient on heparin drip per protocol,
   transition to warfarin once therapeutic
Heparin
IV Infusion
Orders
Example
Hot tip #4
Be an active learner and
educator
  Read as much as possible about your
   patient’s diagnosis and treatment options

  Come up with questions about your
   patient’s disease and bring in primary
   literature addressing those questions to
   share with the team
Before going to sleep
  Check in on patient

  Follow up additional labs/studies

  Write up the H&P

  Practice presentation! Don’t be afraid to
   practice with your residents . . .
The Next Morning
 Set your alarm so that
  you wake up with time to:
   Freshen up (bring your
    toothbrush!)
   Pre-round
   Start progress notes for
    previously admitted
    patients (if possible)
   Eat and hydrate (critical)
   Help your team with any
    misc. chores
Hot tip # 5 - Prerounding
  Goal is to check in on patient and gather the
   following information
      Overnight events
      Current symptoms
      Recent vitals and trend for relevant vitals
      Focused physical exam
      Current labs and study results from overnight
  Come up with a one line assessment and
   preliminary plan
  Leave plenty of time in your morning schedule
   for these tasks!
Rounds
  VIDEO
Tips to be a stellar student
  Attitude is everything
  Be on time
  Embrace new experiences
  Be okay with not knowing and not being
   perfect
  Don’t make excuses; Don’t complain
  Laugh at yourself
  Take care of yourself
That’s all folks . . .
  Have fun!

  Enjoy patient care!

  Don’t be afraid to ask for help!



                  Questions?

				
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