The Washington Manual Internship Survival Guide Read Online Free Page B

admission, and your plan should be communicated to the private physician. Many private physicians or their covering partners like to be notified as soon as possible , regardless of the time of night.
5.   In summary, remember the three pearls of an admission:
•  Assess the stability of the patient immediately.
•  Obtain a good H&P, even if this has already been done by another medical team.
•  Write orders as soon as possible. This makes the nurses and unit clerks happy and allows you to get the lab data you need to finish your evaluation.
    ADMISSION ORDERS
    •   Many admission diagnoses have preset clinical pathways and associated order sets (i.e., CHF, asthma), which are often helpful. Also, consider the patient’s eligibility for appropriate research studies.
    •   The mnemonic ADC VAANDISML may be useful:
•   A dmit to ward/attending/house officers
•   D iagnosis
•   C ondition
•   V itals: e.g., routine, every shift, every 2 hours. Always include call orders (i.e., call HO for SBP >180 or <90, pulse >130 or <60, RR >30 or <10, T >38.0°C, O 2 saturation <92%)
•   A llergies and reactions
•   A ctivity (ad lib, bed rest with bedside commode, up to chair, etc.)
•   N ursing (strict I/O, daily weights, guaiac stools, blood sugars, Foleys, etc.)
•   D iet (NPO, prudent diabetic, low fat/low cholesterol, renal, low salt, etc.)
•   I V (IV fluids, heplock)
•   S pecial (wound care, consults with social work, dietitian, and PT/OT)
•   M eds: All medications should include dosage, timing, route, and indications. Don’t forget prn meds or you will be called often; if no contraindications, consider including acetaminophen, bisacodyl, docusate, and aluminum and magnesium hydroxide (Maalox).
•   L aboratory (including a.m. labs).
    •   Don’t forget DVT prophylaxis for every patient who is not ambulating and GI prophylaxis for critically ill patients (see below for guidelines)!
    DVT PROPHYLAXIS
    •   Indications: patients with one or more risk factors for DVT and confined to bed; critical care patients.
    •   Risk factors for DVT: cardiac dysfunction (heart failure, arrhythmia, MI), malignancy, surgery, trauma (especially orthopedic), previous DVT/PE, obesity, smoking, age >40 years, inflammatory disease (e.g., inflammatory bowel disease, lupus), nephrotic syndrome, pregnancy or postpartum within 6 weeks, immobility, acquired/genetic thrombophilia, chronic lung disease, ischemic stroke, serious infections, or indwelling central venous catheter.
    •   Contraindications to pharmacologic prophylaxis: heparin-induced thrombocytopenia; active bleeding; preoperative within 12 hours or postoperative within 24 hours; LP or epidural within 24 hours; recent intraocular or intracranial surgery; coagulopathy.
    •   Recommended regimens (for medical patients):
•  Low-molecular-weight heparin (LMWH): enoxaparin 40 mg subcutaneous qday (adjust dosage for CrCl <30 mg/dL, contraindicated in ESRD) or dalteparin 5,000 units subcutaneous qday.
•  Factor Xa Inhibitor: fondaparinux 2.5 mg subcutaneous qday.
•  Unfractionated heparin (UFH): for patients <100 kg: 5,000 units subcutaneous q8h, for patients >100 kg: 7,500 units subcutaneous q8h.
•  For patients at high risk for bleeding, consider intermittent pneumatic compression or graduated compression stockings.
    •   For planned invasive procedures (e.g., pacemaker placement, catheterization, surgery), hold UFH 8 hours prior to procedure and LMWH 12 hours prior to procedure!
    GI PROPHYLAXIS
    •   Gastric erosions and stress-induced ulcers can form in critically ill patients. However, not every patient needs GI prophylaxis—if patients do not have any of the risk factors listed below, prophylaxis is not necessary, even in the ICU setting! Most patients will not need GI prophylaxis.
    •   Risk factors for stress-induced ulcers: mechanical ventilation >48 hours, coagulopathy, shock, sepsis,