2016

Orthopedic Resident Internal Medicine Consultation Rotation Expectations

1.  This 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.

2.  Monday morning at 8 am you will page the Internal Medicine Consult Attending in SmartWeb to touch base for the week.

3.  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.

4.  When preforming a consult the following steps should be taken:

  1. Clearly specify the consult question being asked
  2. Identify the requesting attending
  3. Identify who is placing the consult and who to call back after consult is complete
  4. Clarify if it is okay to write orders or if the primary service would like to do so
  5. Complete consultation and staff with consult attending
  6. Call consulting service to verbally discuss recommendations
  7. Document 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)

5.  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.

6.  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 Curriculum

1.  Preoperative 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.

  1. Readings/References:
  2. Gregoratos, Gabriel. Current Guideline-Based Preoperative Evaluation Provides the Best Management of Patients Undergoing Noncardiac Surgery. Circulation 2008;117:3134.
  3. Bapoje, SR et al. Preoperative Evaluation of the Patient with Pulmonary Disease. Chest 2007;132:1637-1645.

2.  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.

3.  Postoperative Complications

  1. Hypoxia 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.
  2. Reading/Reference
  3. Rotation curriculum: “Hypoxia Evaluation” – Sashidhar Reddy
  1. Ileus 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.
  2. Reading/Reference
  3. Postoperative Ileus- Lancet Oncol 2003;4:365-72
  1. Delirium – 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.
  2. Readings/References:
  3. Delirium ACE Card.

2.  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)

  1. Inouye, Sharon. Delirium in Older Persons. NEJM 2006;354:1157-65.
  2. 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-naïve 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.
  3. Readings/References
  4. Pain Management ACE Card.
  5. University Health Care Pain Management Pocket Guide: https://hscintranet.utah.edu/document_center/Documents/DIS-Pocket-Card-Pain-Management.pdf
  6. Swegle, JM and Logemann, C. Management of Common Opioid-Induced Adverse Effects. Am Fam Physician 2006;74:1347-54.
  7. 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.
  8. 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.
  9. Reading/Reference:
  10. Cleve Clin J Med 2006;73 Suppl 1:S62-6

4.  Common Inpatient Medical Problems: