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Orthopedic Resident Internal Medicine Consultation Rotation ExpectationsThis rotation covers Internal Medicine consults at the University Hospital and Huntsman Cancer Hospital. The expectation is that you will see all new consults and follow up consults at these hospitals as well as appropriate anticoagulation consults. You are expected to be available for new consults from 8 am- 5 pm M-F.Monday morning at 8 am you will page the Internal Medicine Consult Attending in SmartWeb to touch base for the week.You can find the consult list in Epic under Patient Lists: Available lists -> System Lists -> Provider group list -> IM Consults. This list can be moved into your “All My Patients” list. To add a new patient to the IM consult list, once you have found them on a unit or other system list, right-click and choose “Assign Teams”, then type “IM Consult” (this will add IM consult to the patient’s “Treatment Team” as well as add the patient to the consult list). Patients located at UNI do not need to be seen on this rotation. These patients will be seen by the consult attending.When preforming a consult the following steps should be taken:Clearly specify the consult question being askedIdentify the requesting attendingIdentify who is placing the consult and who to call back after consult is completeClarify if it is okay to write orders or if the primary service would like to do soComplete consultation and staff with consult attendingCall consulting service to verbally discuss recommendationsDocument written consultation note (ensure that family history and social history are documented as well at least 8 organ systems on physical exam and at least a 10 system ROS)Please review attached rotation curriculum. It is the expectation that this document and all references be read during your month rotation. In the course of the month, each item should be reviewed with an Internal Medicine attending. There is a separate sheet at the end of this document that you are responsible for keeping where you will document when these items were reviewed. If you do not see a patient with one of the items on the list, the expectation is that you will review this topic with the Internal Medicine attending. You are required to return this completed checklist to the Internal Medicine office at the end of your rotation.Part of your rotation will include a clinic day in the Faint and Fall Clinic supervised by Dr. Natalie Sanders. Please contact Dr. Sanders to arrange an opportunity to attend this clinic.Orthopedic Internal Medicine Consult Rotation CurriculumPreoperative Evaluation – Preoperative evaluation often focuses on cardiovascular risk of myocardial infarction and stroke. For all surgeries, there is a 1% post-operative risk of MI. This risk is able to be quantified using the Revised Cardiac Risk Index. During a preoperative evaluation, this risk is calculated, shared with the patient, and documented in the consultation note. Depending on the risk and urgency of surgery, other steps may be needed prior to the operation. Please review the ACC/AHA guidelines algorithm seen in Figure 1 in the Circulation article. In general, for urgent surgeries (hip fracture), the only cardiovascular conditions that will prevent immediate operative are unstable angina, active MI, decompensated heart failure, significant arrhythmia, or severe valvular disease. For elective surgeries, the guideline algorithm can be used to determine further evaluation. Pulmonary evaluation does not have as much research as CV evaluation and for urgent surgery, the only pulmonary determination is whether the patient has such severe lung disease that they would not tolerate the surgery. This determination is usually made by anesthesia. For elective surgeries, smoking cessation 6-8 weeks prior to operation can improve outcomes.Readings/References:Gregoratos, Gabriel. Current Guideline-Based Preoperative Evaluation Provides the Best Management of Patients Undergoing Noncardiac Surgery. Circulation 2008;117:3134.Bapoje, SR et al. Preoperative Evaluation of the Patient with Pulmonary Disease. Chest 2007;132:1637-1645.Admission Medication Reconciliation and Adverse Drug Events – Adverse drug events are common in hospitals and any transition of care (admission, SNF transfer, discharge to home) is an area that can cause confusion and lead to medication errors. Inpatient pharmacists can assist in reducing the number of errors and providing accuracy to the patient’s home medication through verification with patients, families, and filling pharmacies. Anticoagulants, diabetic medications, opiates, and antibiotics (all common medications) are leading classes of drugs that result in adverse drug events. Determining the patient’s home medications and reviewing the clinical condition for the appropriateness of those medications (e.g. ACEI should be stopped in acute kidney injury or hyperkalemia) is essential to help reducing adverse drug events. Specific medications that should be continued to reduce CV events are beta-blockers and statins. Frequent clinical conditions that require adjustment in medications are acute kidney injury, altered mental status, and hypotension.Postoperative ComplicationsHypoxia Evaluation – Hypoxia is a common complication for hospitalized patients. It may be due to a previously undiagnosed chronic problem such as COPD, obesity hypoventilation syndrome, or interstitial lung disease; or due to an acute change that has occurred in the hospital. There are several common causes of acute hypoxia including aspiration, volume overload, hypoventilation, COPD exacerbation, pneumonia, atelectasis, pulmonary embolism, and less commonly cardiac arrhythmia, mucus plugging, or acute coronary syndrome (ACS). The initial evaluation of hypoxia begins with a physical exam to assess a patient’s work of breathing (are they in respiratory distress?), auscultation to assess for adventitial breath sounds (crackles, wheezing, rhonchi), and volume assessment (JVP, lower extremity or dependent edema, review of daily weights and Is and Os of hospitalization, including the OR). Obtaining a chest x-ray (CXR) is the next step to look for new opacities (aspiration, fluid overload, pneumonia), atelectasis, or pneumothorax. If there are signs of respiratory distress, an arterial blood gas (ABG) is essential to determine appropriate oxygenation, ventilation, and need for ventilatory support. In patients with a likely pretest probability (simplified Wells score) and normal renal function a CT pulmonary angiogram is the gold standard to assess for pulmonary embolism. Opiate-induced hypoventilation is an exceedingly common problem in post-operative patients and should be assessed with an ABG, which will demonstrate an elevated PaCO2. Hypoxia with associated chest pain and/or tachycardia warrants an EKG look for ACS, an arrhythmia, or right heart strain seen with pulmonary embolism.Reading/ReferenceRotation curriculum: “Hypoxia Evaluation” – Sashidhar ReddyIleus Evaluation and Treatment – Post-operative ileus refers to non-mechanical obstipation and intolerance of oral intake. Symptoms include abdominal distention, nausea, vomiting, diffuse abdominal pain, inability to pass flatus, and inability to tolerate an oral diet. Symptoms typically begin immediately after surgery and may last for several days. Evaluation begins with a review of the patient’s history to determine possible causes and to exclude more serious complications (mechanical obstruction or perforation). Causes of ileus include electrolyte derangements, medications with hypomotility side effects (opiates, anticholinergics), predisposing medical illnesses (diabetic gastroparesis, hypothyroidism), sepsis, and intra-abdominal infection/inflammation (cholecystitis, appendicitis, pancreatitis.) Laboratory assessment should include a complete blood count (CBC) to assess for infection; comprehensive metabolic panel (CMP) for electrolytes, renal, and liver function; amylase and lipase; and possibly a magnesium level. Imaging begins with supine and upright abdominal xrays to assess for dilated loops of small bowel, air-fluid levels, free air, or evidence of small bowel obstruction (SBO). Abdominal xrays may not be able to distinguish an ileus from a SBO, in which case a CT of the abdomen/pelvis with oral contrast is necessary. Treatment should focus on correction of electrolyte derangements (hypokalemia), discontinuing or minimizing offending medications (substitution of NSAIDs for opiates), ambulation, methylnaltrexone if determined to be opiate-induced and there is no evidence of obstruction, NPO status (small sips are generally OK), IV fluid resuscitation, and nasogastric suction if frequent emesis. Once the abdomen is decompressed and bowel sounds return, remove the nasogastric tube, and advance diet to liquids. Reading/ReferencePostoperative Ileus- Lancet Oncol 2003;4:365-72Delirium – Delirium is a serious medical condition that is diagnosed by a fluctuating change in mental status. It is the most common post-operative complication in older adults. Patients at highest risk of delirium are those age >65, any cognitive impairment or dementia, current hip fracture, or severe illness. More than half of cases of delirium are unrecognized. It is serious with inpatient mortality around 20% (similar to MI or sepsis) and a one year mortality of roughly 40%. It should be treated as organ failure of the brain and evaluated promptly. Measures to prevent delirium (reduce medications, good sleep hygiene, appropriate pain control, glasses, hearing aids, early mobilization, prevention of constipation) should be instilled as nearly one-half of cases are preventable. The most common causes of delirium are medications (including anesthesia and pain medications), infection, and metabolic derangements. Should avoid or minimize benzos, anticholinergics (flexeril, oxybutynin, phenergan, compazine), benadryl, and narcotic pain meds. Treatment with antipsychotics should be reserved for agitated patients posing a harm to themselves or others, since pharmacologic treatment has not consistently been shown to modify duration or severity of delirium. Please see reference handout for specific information related to delirium and treatment.Readings/References:Delirium ACE Card.Clinical Practice Guideline for Postoperative Delirium in Older Adults – American Geriatrics Society Oct 2014 (summary of recommendations listed in Table 2 at end of document)Inouye, Sharon. Delirium in Older Persons. NEJM 2006;354:1157-65.Pain – Pain management can range from fairly easy (prn Lortab) to very complex (chronic opiate abuse with acute fracture). Consideration should be given to history of opiate use, mental status, age, liver or kidney failure, and route of administration. Opiates are the mainstay of treatment for severe pain in the hospital, although other non-pharmacological choices can be used. Acute Pain Service can assist with PCA management in more difficult to control patients. Common pitfalls are under dosing (patient on MS Contin 100 mg bid at home receiving Lortab 5 mg prn pain), over dosing (89 yo hip fracture opiate-na?ve female receiving Dilaudid 1 mg IV as initial opiate dose), no reassessment (like any intervention, follow up should occur to see if intervention was successful), and frequency not short enough (IV opiates frequently last 1-2 hours and oral opiates 3-4 hours). A common starting dose for a patient on chronic opiates would be a breakthrough dose 10% of their total daily doses. When prescribing opiates, there should be understanding of opiate:opiate and IV:PO equivalent doses. The link to the pocket card below is a good reference for dosing and conversions of frequently used opiates. There is also a review paper on opiate side effects as these are very common.Readings/ReferencesPain Management ACE Card.University Health Care Pain Management Pocket Guide: , JM and Logemann, C. Management of Common Opioid-Induced Adverse Effects. Am Fam Physician 2006;74:1347-54.Chest Pain Evaluation – Chest pain is challenging in post-operative patients as it may represent life-threatening situations such as acute coronary syndrome, pneumothorax, aortic dissection, pulmonary embolism, or esophageal rupture. Fortunately, the symptoms are usually of benign etiology. A detailed history will guide initial diagnostic and therapeutic interventions. Characterization of the pain is useful but certainly not diagnostic. Cardiac ischemia may present as crushing sub-sternal pressure, mild indigestion, dyspnea, shoulder/jaw/neck aching, nausea/vomiting or even no symptoms at all. Pneumothorax or pulmonary embolism typically is pleuritic in nature; sharp, stabbing, and worse with inspiration. Aortic dissection may be tearing or ripping and radiates into the back. Knowledge of the patient’s past medical history (coronary disease, hypertension, diabetes mellitus, or prior PE) and recent hospital course should be taken into account when considering a differential diagnosis. Less concerning etiologies such as musculoskeletal pain are typically localized and reproducible with palpation or movement. Diagnostic evaluation should be guided by the history and physical exam. Initial testing involves an EKG and CXR. Lab tests including troponin-I for myocardial injury. An ABG (elevated lactate or A-a gradient) can provide rapid and accurate differentiation of cardiac versus pulmonary processes. CT angiography of the aorta or pulmonary arteries may be warranted to detect aortic dissection or PE if initial tests are non-revealing. Some diagnoses are aided by therapeutic interventions such as a GI cocktail for GERD; sublingual nitroglycerin for angina; NSAIDs for musculoskeletal pain. Fever Evaluation – Fever, defined as a temperature >38.0C, is a common finding in the post-operative period. Identification of infection as the underlying cause is important, however studies show <10% of post-operative fevers are related to infection. Timing of fever onset is an important consideration in the differential diagnosis. Fever onset in the immediate post-op period may be related to perioperative medications (antibiotics, inhaled anesthetics), transfused blood products, or the inflammatory response triggered by surgery and usually abates within 48-72 hours. During the first week after surgery both community-acquired and nosocomial infections should be considered. Urinary tract infections are very common and their risk increases with prolonged urinary catheter use. Pneumonia related to either aspiration or prolonged mechanical ventilation should be a consideration. Surgical site infection (SSI) typically occurs more than one week after surgery but may occur sooner. Additionally, prolonged use of central venous catheters increases the risk of catheter-associated blood stream infections. Noninfectious causes of fever including drug fever, deep vein thrombosis, gout (both gout and pseudogout can flare post-operatively), and pancreatitis. Evaluation begins with obtaining a thorough history for localizing signs/symptoms of infection, physical examination (pulmonary exam, extremities, skin, central venous catheter sites, and surgical wounds), review of medications, and diagnostic testing. Labs including blood cultures, urinalysis, urine culture, and CBC may identify an infectious source. Imaging with a CXR and if high pretest probability for PE or intra-abdominal infection, CT of the chest or abdomen.Reading/Reference: Cleve Clin J Med 2006;73 Suppl 1:S62-6Common Inpatient Medical Problems:Anemia/Bleeding and Transfusion Thresholds – Anemia is very common in the hospital setting, especially in the post-operative setting. In general the cause is discernible by history. The most common causes of anemia are acute blood loss, chronic inflammation/chronic disease, chronic kidney disease, nutritional deficiencies, and bone marrow dysfunction in older patients. The evaluation of chronic anemia can include iron studies (ferritin, serum iron, TIBC), B12/Folate levels, reticulocyte count, peripheral smear, and in some cases bone marrow biopsy. There has been a longstanding debate about the benefit of transfusion and whether we should be more restrictive or liberal in transfusing blood. There have been multiple trials now evaluating this in different patient populations. These include a trial evaluating patients in critical care settings, patients with acute GI bleed, and patients with hip fractures undergoing surgery. In all of these studies the group that received more transfusions either had worse outcomes or there was no evidence of improvement in any significant outcome. The general approach to transfusion of PRBC given this data should be a restrictive one in which transfusion is avoided until absolutely necessary. Most patients can tolerate a hemoglobin of 7 and this is a standard transfusion threshold. There are exceptions to this rule: people who are markedly symptomatic, people who are exsanguinating or have massive bleeding, and possibly people with active cardiac ischemia (not a history of CAD).Readings/References:Hebert, P. C. A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care. NEJM 1999; 340:409-417Cooper, H.A. Conservative Versus Liberal Red Cell Transfusion in Acute Myocardial Infarction (the CRIT Randomized Pilot Study). Am J Cardiol 2011; 108:1108-1111.Carson, J. L. Liberal or Restrictive Transfusion in High-Risk Patients after Hip Surgery. NEJM 2011; 365:2453-2462Tefferi, A. How to Interpret and Pursue an Abnormal Complete Blood Cell Count in Adults. Mayo Clinic Proceedings 2005; 80:923-936.Diabetes Management – Diabetes is a very common inpatient medical problem. There has been a significant amount of literature in critically ill patients focused on aggressive glucose control. Initially this literature was exciting for improved mortality in cardiothoracic ICUs. However, more study indicated possible harm with aggressive control and the hypothesis is that multiple lows are immediately dangerous for the hospitalized patient. For hospitalized floor patients (non-ICU) there is less literature. Uncontrolled diabetes is a risk factor for poor outcomes and should be addressed in the hospital. Given potential harm though of overly aggressive glucose goals, for a floor patient, reasonable goals are in the 140-180 range. Oral agents are typically stopped during admission to the hospital. Metformin is contraindicated in renal failure and renal failure is common for hospitalized patients. Sulfonylureas can result in hypoglycemia and patients are frequently NPO in the hospital or have inconsistent PO intake. Insulin therefore is the major method for managing diabetes in the hospital. For a type 2 diabetic patient who is not on insulin at home, oral medications are typically stopped and sugars are managed with sliding scale insulin initially. For a type 1 diabetic patient, it is important to continue long-acting insulin as there is no endogenous insulin. However, as patients are frequently NPO or have reduced PO intake, cutting the long-acting insulin in half is recommended initially. If patients are stable post-operatively without evidence of organ failure and have good PO intake, then PO diabetic medications can be resumed.Readings/References:Inzucchi, Silvio. Management of Hyperglycemia in the Hospital Setting. NEJM 2006;355:1903-11.Vinik, R. Management of the Hyperglycemic inpatient: Tips, Tools, and Protocols for the Clinician. Hosp Practice 2011;39. Hyponatremia – Hyponatremia is common in hospitalized patients. Patients with hyponatremia, even mild (130-134) have an increased risk of death in the hospital (OR 1.47) compared to normonatremic patients. It is unclear if this is causal, but more likely thought to be a marker of other severe disease. Currently we only treat hyponatremia if there is an underlying reversible cause or patients are symptomatic. It is typically categorized into hypovolemic, normovolemic, and hypervolemic patients. Hypovolemia can be present from continuation of diuretics with poor PO intake. Hypervolemia is typically present in patients with heart failure or cirrhosis. The most common etiology for post-operative hyponatremia is SIADH. Surgery, likely via pain sensation, increases ADH secretion. This results in increased free water retention in the kidneys and resultant hyponatremia. The initial evaluation for patients with symptomatic hyponatremia includes urine sodium and urine osms. The mainstay of treatment for SIADH is fluid restriction. If this is unsuccessful, oral salt tabs can be started. For significantly lower sodium (<125) or symptoms or no improvement, Internal Medicine should be consulted for assistance in management.Readings/References:Ellison, David and Berl, Tomas. The Syndrome of Inappropriate Antidiuresis. NEJM 2007;356:2064-72.Adrogue, HJ. Hyponatremia. NEJM 2000;342:1581-89.VTE Prophylaxis – Venous thromboembolism (VTE) is a common, preventable, problem in both medical and surgical patients. Hospitalization for an acute medical illness is associated with an 8-fold increased risk for VTE and contributes to 25% of all VTE events. Additionally, one-third of the 150,000-200,000 VTE-related deaths/year occur in the post-operative period. Multiple risk factors for VTE exist such as active cancer, prior VTE, immobility, recent trauma/surgery, obesity, hormonal therapy, inflammatory illnesses (rheumatoid arthritis, IBD, pancreatitis), heart/respiratory failure, and thrombophilic conditions. Balancing VTE risk with bleeding risk is important when considering prophylactic strategies. Pharmacologic prophylaxis with low molecular-weight heparin (LMWH), unfractionated heparin (UFH), or fonadarinux is more efficacious than mechanical prophylaxis with intermittent pneumatic compression (ICP) or graduated compression stockings (GCS). Pharmacologic methods are associated with increased bleeding risk when compared to mechanical methods. In general, patients at increased risk of VTE with low bleeding risk should receive pharmacologic VTE prophylaxis. Conversely, patients at increased bleeding risk (active peptic ulcer, recent bleeding event, platelets < 50k) and/or low VTE risk may be treated with mechanical prophylaxis. Several risk prediction tools (Padua Score, Caprini Score) and clinical practice guidelines exist for different patient populations. These are excellent resources to guide intensity and duration of VTE prophylaxis.Readings/References:Prevention of VTE in Nonsurgical Patients- Chest 2012;141;e195S-e226SPrevention of VTE in Nonorthopedic Surgical Patients- Chest 2012;141;e227S-e277SPrevention of VTE in Orthopedic Surgery Patients- Chest 2012;141;e278S-e325SSepsis recognition - Sepsis is important to recognize early as appropriate early decisions can vastly improve the outcomes. Sepsis is an inflammatory process and often causes systemic evidence of inflammation. The SIRS (systemic inflammatory response syndrome) is the hallmark of sepsis. There are 4 criteria for SIRS and you must have 2/4 to be considered to have SIRS. The criteria are: 1. Tachycardia (HR >90) 2. Tachypnea (RR >20; or PCO2 <32) 3. Leukocytosis or leukopenia (WBC >12 or <4; or bands >10%) 4. Fever or hypothermia (T >38 <36). If you have 2/4 of these criteria a search for cause must be undertaken. Sepsis by definition is SIRS with a known or highly suspected source of infection. Not all people will present with SIRS when they have an underlying infection. The very young and very old often do not mount an inflammatory response as robust as the general population so more care must be taken in this population to make sure sepsis is not missed. Once you have found that a patient has SIRS, a complete history and physical must be performed to evaluate for likely sources. Common causes in patients who develop sepsis in the hospital include catheter associated UTI, aspiration PNA, bacteremia from indwelling lines, and C. diff colitis. Please see the fever evaluation for further discussion of how to work these up. Once sepsis is suspected early treatment is paramount. This includes IV fluid resuscitation, evaluating perfusion (i.e. monitoring BP, considering checking a lactate), and empirically treating with antibiotics to cover the presumed source. IV fluid resuscitation should be done in bolus fashion initially (i.e. 1 liter run in as fast as possible, not at 100ml/hr) and once adequate perfusion is present, frequent re-evaluation is necessary to see if further resuscitation is necessary. Readings/References:Dellinger, RP. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580–637)O’Brien, JM. Sepsis. American Journal of Medicine. 2007; 120: 1012-1022.Angus, DC. Severe sepsis and septic shock. NEJM 2013;369:840-51.Pneumonia - Pneumonia is an acute infection involving the lungs. We will focus here on bacterial pneumonia. Clinical signs include productive cough, fever, dyspnea, and pleuritic chest pain. These findings in conjunction with an infiltrate on chest imaging give the diagnosis of pneumonia. There are different types of pneumonia based on where the causative pathogen was acquired and how it was acquired. These include community acquired pneumonia (CAP), health-care associated pneumonia (HCAP), hospital acquired pneumonia (HAP), and aspiration pneumonia. CAP is a pneumonia acquired by someone with no exposures to hospitals or other healthcare settings (nursing homes, dialysis centers, etc) where potential for resistant pathogens is greater. HCAP and HAP are infections are acquired either in the hospital or with exposure to health care settings. Admission to the hospital for >48 hours in the last 90 days is one criteria for HCAP.In the initial approach to assessing pneumonia a severity of illness assessment is necessary. There are multiple tools for this, but the easiest to use clinically is the CURB-65 score. This gives 1 points for each aspect: Confusion, Uremia (BUN >20), RR >30, Blood pressure (systolic <90), and age >65. A score of 2 or greater generally indicates someone who needs to be closely monitored during their initial treatment and should be considered for admission. The ATS/IDSA guidelines recommend treatment with a respiratory fluoroquinolone or a beta-lactam + a macrolide for initial therapy of inpatients. These options include Levofloxacin (University Hospital formulary), Moxifloxacin, Cefotaxime + Azithro, Ceftriaxone + Azithro, or Unasyn + Azithro. If resistant gram negatives such as Pseudomonas are a potential cause, an anti-pseudomonal beta-lactam (Zosyn, Cefepime, Meropenem) + Ciprofloxacin/Levofloxacin should be considered. Aspiration pneumonia can result in patients with dysphagia, esophageal obstructions, severe ileus, altered mentation, and post-stroke patients. If this is suspected, coverage for oral anaerobes should be added. This can be done with most penicillin drugs (Augmentin, Unasyn, Zosyn), Clindamycin, or carbapenems).Readings/References:Mandell, L. ATS/IDSA Guidelines for the Management of Community Acquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44:S27-72Wunderink R. Community acquired pneumonia. N Engl J Med 2014;370:543-51.Marik, P. Pulmonary Aspiration Syndromes. Current Opinion in Pulmonary Medicine 2011; 17:148-154Abnormal UA - Urinalysis is a very useful tool for diagnosing UTI, evaluating acute kidney injury, and evaluating for stones and malignant processes. Ideally the collection should be mid-stream clean catch, but straight cath can also be used. The components of a UA include specific gravity, pH, protein, glucose, ketones, leukocyte esterase, nitrite, blood, RBC count, WBC count, and urobilinogen. pH is normally acidic. Specific gravity can be useful in evaluating the hydration status of a patient (>1.020 may be consistent with volume depletion). Glucose is spilled into the urine if the serum glucose is elevated and overwhelms the re-absorptive capacity of the kidney. This is generally occurs with serum glucoses of >200. Ketones in the urine indicate a state of abnormal metabolism either due to starvation, alcohol use, or DKA. Protein in the urine reflects underlying renal disease. Urinalysis picks up albumin generally, but may also pick up gamma-globulins or Bence-Jones proteins. 1+ protein is usually equivalent to 30mg/dl which is positive. Proteinuria can be further quantitated with a random protein/creatinine ratio or microalbumin/creatinine ratio. Hematuria can result from glomerular injury, tubular injury, or urologic causes. Dipstick for blood picks up hemoglobin and myoglobin so will occasionally be falsely positive in rhabdomyolysis. Hematuria can be further evaluated with microscopy to evaluate for dysmorphic RBCs which indicates a glomerular cause. If the red cells are normal, this likely indicates a urologic cause or from foley trauma and follow up is necessary to determine resolution or the need for cystoscopy. Leukocyte esterase is produced by neutrophils and can indicate infection. Nitrites are produced when bacteria reduce urinary nitrates. Many different bacteria are capable of this conversion. This is a specific, but not sensitive test. When positive it indicates the presence of bacteria and is associated with UTI. Leukocytes are generally not present in significant numbers and >5 indicates the possibility of infection or inflammation. If squamous cells are present this indicates likely contamination. Patients who have indwelling urinary catheters must have specimens interpreted with caution as pyuria and hematuria are common and may not indicate underlying UTI. Urobilinogen is detected generally when hemolysis or liver dysfunction elevates the conjugated bilirubin in the blood. Reading/Reference:Simerville, JA. Urinalysis: A Comprehensive Review. American Family Physician 2005; 71:1153-62.Acute Kidney Injury - This is defined as an increase in serum creatinine by 0.3mg/dl or an increase in Cr by 1.5x in 48 hours. It may also be recognized by a decrease in urine output. If suspected a BMP should be obtained to evaluate the BUN and creatinine. Once recognized, the goal is to define why the injury happened and take steps to reverse it. A basic approach is to consider the causes in 3 broad categories: 1. Pre-renal 2. Intrinsic renal 3. Post-renal. History and vitals can be helpful (i.e. Abdominal pain and no UOP in 12 hrs would make you think about possible obstruction) to help you think about these initial broad categories. Pre-renal physiology can be present in patients with true volume depletion, decreased effective arterial blood volume (EABV), and decreased renal perfusion due to drugs (NSAIDs, ACE/ARBs). Classically these people will have a bland UA, an elevated BUN/Cr ratio, and a low urine sodium. Intrinsic renal injury can occur from a multitude of causes including glomerular injury, tubular injury, vascular injury, and interstitial disease. One of the most common causes in the post-operative setting is acute tubular necrosis (ATN) due to intra-operative hypotension or toxins that cause tubular injury. Other commonly seen causes of intrinsic injury include contrast induced nephropathy from iodinated CT contrast, allergic interstitial nephritis from drug reactions, and post-infectious glomerulonephritis related to infections in the hospital. Classically you will see a UA with RBCs, WBCs, and often casts. Urine sodium is generally elevated. Post-renal is caused by obstruction of both kidneys. This is can be seen from urinary catheters that are not working, prostate issues in men, bilateral ureteral stones/compression. Renal ultrasound and bladder scan are the easiest ways to identify this. A general approach to evaluating AKI from a laboratory standpoint is to obtain the following: 1. Complete urinalysis 2. Bladder scan or renal ultrasound 3. Urine electrolytes (Na, Cr, Urea). These should be obtained in addition to basic labs including CBC and CMP. If the history and physical likely point to prerenal as the etiology, fluid challenge and repeat BMP is an acceptable intervention prior to further laboratory testing.Readings/References:Hilton, R. Acute Renal Failure. British Medical Journal 2006; 333:786-790.Bellomo R. Acute kidney injury. Lancet 2012; 380: 756–66Transitions of Care/Communication at Discharge – Transitions of care should be considered a dangerous time in patient care. Patients are frequently discharged from the hospital and remain with very serious medical and surgical issues that need continued care in skilled nursing facilities (SNF), long term acute-care hospitals (LTACH), or home with home health. Most of the providers outside of the hospital do not have access to our electronic medical record system and rely on clear orders with specific instructions for medications, wound care, follow up appointments, and laboratory tests (both needed in the future and pending at discharge). A patient discharged to a SNF will be seen within 3-days by a physician so the nursing staff is relying on clear discharge instructions and orders from the hospital. Readmission to the hospital is common with nearly 20% of Medicare patients being readmitted within 30-days of hospitalization. The following are common issues at discharge:Medication Reconciliation – As with admission, this process is essential to appropriate continuity of care and reduction of ADEs. A VA study of high-risk patients discharged home found that there were medication discrepancies in nearly 50% of patients discharged home when a follow up phone call was made 2-3 days after discharge. An accurate medication reconciliation process can help address some of these issues. Care should be taken to look at admission medications and compare that to current inpatient medications. A discharge medication list can then be generated that clearly states what medications to stop, what to continue, and what medications are new.Discharge Orders – should specifically identify medications, activity, diet, follow up laboratory tests, and follow up visits.Discharge VenuesAcute Inpatient Rehab – patient must be able to participate in 3 hours/day of intense therapy. Intended for patients with significant functional impairments who have potential to participate and improve with intense rehab.Long-Term Acute Care Hospital (LTACH) – intended for critically ill or unstable patients with serious chronic or long-term illness. Examples are IV antibiotics and specialized wound care requiring extended recovery time.Skilled Nursing Facility (SNF) – rehab less than 3 hours/day. Appropriate for patient recovering who is not able to participate in intensive therapy in acute rehab.Home Health – patient can get therapy and nursing care in the home.Readings/references: Discharge ACE cardGeriatric-Specific Considerations:Older adults warrant special consideration in several areas discussed above. Medical comorbidities are more prevalent in the aged including atrial fibrillation, hypertension, chronic kidney disease, dementia, osteoporosis, and cardiopulmonary diseases. Medical treatment for these comorbidities often translates into older adults being prescribed multiple medications, also known as polypharmacy. In addition, age-associated decline in organ function leads to impaired clearance of medications and/or increased susceptibility to physiologic derangements (e.g. dehydration, hyponatremia, infection, etc.), placing elderly patients at higher risk for adverse events (e.g. acute kidney injury, delirium, stroke, etc.). Special attention must be given to medication selection and dose adjustments. For example, when addressing pain management in an older adult selection of a non-sedating agent (e.g. acetaminophen), when appropriate, would be preferable to a sedating agent to decrease the risk of delirium. Dose adjustment for renal function should not be overlooked, as the typical dose used in a healthy adult may be excessive in an older adult leading to drug accumulation and/or adverse side effects (e.g antibiotics, anticoagulants, digoxin, etc.). Aging is also associated with impairments of the immune system. In the setting of an acute infection some older adults may not have the ability to elevate their WBC count or body temperature, masking typical signs of infection, therefore clinicians must maintain a high index of suspicion for an unusual presentation of common illnesses (e.g. pneumonia or urinary tract infection presenting as delirium). Reading/ReferencesRosenthal, RA. Chapter 29. Common Perioperative Complications in Older Patients. Principles and Practice of Geriatric Surgery. DOI 10.1007/978-1-4419-6999-6_29Oresanya, LB. Preoperative Assessment of the Older Patient. JAMA 2014;311:2111-2120.Teramoto S. Update on the pathogenesis and management of pneumonia in the elderly-roles of aspiration pneumonia. Respiratory Investigation 2015;53:178-184.Orthopedic Internal Medicine Consult Rotation Topic ListTopicAttendingDate ReviewedPreoperative Evaluation – OutpatientPreoperative Evaluation – Inpatient CVPreoperative Evaluation – PulmonaryMedication ReconciliationHypoxia EvaluationIleus Evaluation and TreatmentDeliriumPainChest Pain EvaluationFever EvaluationAnemia/Bleeding and TransfusionsDiabetes ManagementHyponatremiaVTE ProphylaxisSepsisPneumoniaAbnormal UAAcute Kidney InjuryTransitions of Care - DischargeFaint and Fall Clinic ................
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