HOW DO U ADMIT PATIENTS??!!

[sozme]

How do you admit patients? In our clerkship manual it says "med students are responsible for admitting all patients, blah blah etc." but doesn't have any info HOW you gots to do it.

Internal medicine rotation begins tomorrow.


Help plz

I so scared

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[justin1390]

WHOA! Slow down there. I am guessing you are going into 3rd year? I am positive there will be residents or someone there to teach you the ropes. It would be highly improbably for them to throw you onto an EMR and tell you to do an admit. Medicine it fun if you like details. 🙂 Here are some things to keep in mind.

You'll need to interview the patient, obviously. Things to cover will be chief complaint, HPI including the 7 dimensions, PMH (specifically ask about diabetes, heart disease, strokes, etc), past surgical history, past family history, social history (alcohol, tobacco, drugs, travel, living situation, etc), review of systems, review any medications/supplements they are taking, and cover allergies and DNR status.

Do a full physical, including a brief neuro exam. As a student, GU may or may not be done.

I have no idea what kind of stuff they want you to do regarding actually admitting documentation and orders. This is typically left to the resident. You can start and pend it using the limited access med students sometimes have. Things to keep in mind:

-Admitting location (ICU, Med-surg, etc)
-Diagnosis
-Condition
-Vitals
-Diet (regular, diabetic, cardiac, etc)
-Pain control (tylenol, dilaudid, norco)
-Ambulation
-Allergies
-Fluid resuscitation (you can usually give 1L bolus, unless it's a cardiac patient)
-Fluid maintenance
-Consults (surgery, neurology, nephrology, etc)
-Tests (CBC, BMP, morning lytes, UA, CXR, mg, phos, etc)

You'll do fine. We admit patients like crazy here, too. That meant that the first few days we'd give it our best shot and the residents would tell us what we did wrong and how to improve. Work hard and it'll pay off!

 

[J ROD]

i would start with orders.

 

[Jeffrety]

Admitting patients as a third year is great training. Like the other posters said get the H&P first. Practice your bedside manner! You probably cant do orders but write them down anyway in case you get asked. But really this is great training to actually practice medicine instead of following a neglectful resident all day.

 

[sozme]

WHOA! Slow down there. I am guessing you are going into 3rd year? I am positive there will be residents or someone there to teach you the ropes. It would be highly improbably for them to throw you onto an EMR and tell you to do an admit. Medicine it fun if you like details. 🙂 Here are some things to keep in mind.

You'll need to interview the patient, obviously. Things to cover will be chief complaint, HPI including the 7 dimensions, PMH (specifically ask about diabetes, heart disease, strokes, etc), past surgical history, past family history, social history (alcohol, tobacco, drugs, travel, living situation, etc), review of systems, review any medications/supplements they are taking, and cover allergies and DNR status.

Do a full physical, including a brief neuro exam. As a student, GU may or may not be done.

I have no idea what kind of stuff they want you to do regarding actually admitting documentation and orders. This is typically left to the resident. You can start and pend it using the limited access med students sometimes have. Things to keep in mind:

-Admitting location (ICU, Med-surg, etc)
-Diagnosis
-Condition
-Vitals
-Diet (regular, diabetic, cardiac, etc)
-Pain control (tylenol, dilaudid, norco)
-Ambulation
-Allergies
-Fluid resuscitation (you can usually give 1L bolus, unless it's a cardiac patient)
-Fluid maintenance
-Consults (surgery, neurology, nephrology, etc)
-Tests (CBC, BMP, morning lytes, UA, CXR, mg, phos, etc)

You'll do fine. We admit patients like crazy here, too. That meant that the first few days we'd give it our best shot and the residents would tell us what we did wrong and how to improve. Work hard and it'll pay off!

We don't have any residents where I am at. And we are expected to write the orders which go to pending.

Thank you for your reply though it was very helpful.

As far as admissions go, I just have some Qs
- do pretty much everyone get a standing order for docusate sodium or bisacodyl? How much/frequent do you typically give? (I've seen varying suggestions)
- For maintenance fluids on most (obv not all) what is the typical fluid? D5 1/4 40 mEq K? How is this typically written?
- VTE prophylaxis... what is the default here? Obviously everyone will be different (renal function and whatnot), but assuming no contraindications to anything

• Unfrac. heparin 5,000U SQ Q8H-Q12H
• enoxaparin 40mg SQ Q24H
• dalteparin) 5,000U SQ Q24H
• Fondaparinux 2.5mg SQ Q24H

Our admissions go as follows... we perform PE, do all paperwork, write out all the orders, etc. everything THEN call the attending on-call and go over everything. We do not have any residency programs at this hospital (level 1 trauma center), and the M4s have warned us that we will be expected to do a lot. And it is a pretty big hospital, so there are admits every night.

Any tips for how to NOT piss off the attending/make these admits as smooth as possible? Obviously there will be problems due to our inexperience/cluelessness, and they will probably have to rewrite/redo most everything at first, but anything tips on extra things to do/resources to lower the learning curve or look good early on would help.

 

[J ROD]

It sounds scary as hell. But, great learning instead of having to watch the resident. Not sure if I would have been ready at the beginning of 3rd year.

 

[justin1390]

As far as admissions go, I just have some Qs
- do pretty much everyone get a standing order for docusate sodium or bisacodyl? How much/frequent do you typically give? (I've seen varying suggestions)
- For maintenance fluids on most (obv not all) what is the typical fluid? D5 1/4 40 mEq K? How is this typically written?
- VTE prophylaxis... what is the default here? Obviously everyone will be different (renal function and whatnot), but assuming no contraindications to anything

• Unfrac. heparin 5,000U SQ Q8H-Q12H
• enoxaparin 40mg SQ Q24H
• dalteparin) 5,000U SQ Q24H
• Fondaparinux 2.5mg SQ Q24H

Any tips for how to NOT piss off the attending/make these admits as smooth as possible? Obviously there will be problems due to our inexperience/cluelessness, and they will probably have to rewrite/redo most everything at first, but anything tips on extra things to do/resources to lower the learning curve or look good early on would help.

Wow you guys are very busy indeed! Best of luck to you. You will actually have a huge advantage over many medical students by functioning as interns. In answer to your questions (I know it's late and I have to be into the hospital in 7.5 hrs, so this will be brief. Keep in mind I'm a new MS4, so this is only what I would do. Doesn't mean it's right. Hopefully a resident can chime in:

1. Give everyone a docusate sodium order. It would be something like 50mg or 100mg BID or QID.
2. Typical fluid would be D5 1/2NS. If the patient is getting hypo or hypernatremic, you could switch over to a D5 1/4 or up to NS. You would write it as a rate/hr. A good rule is the 4-2-1 rule.

• 100 ml/kg/24-hours = 4 ml/kg/hr for the 1st 10 kg
• 50 ml/kg/24-hours = 2 ml/kg/hr for the 2nd 10 kg
• 20 ml/kg/24-hours = 1 ml/kg/hr for the remainder
  • (credit: http://www.utmb.edu/pedi_ed/CORE/Fluids&Electyrolytes/page_04.htm)

3. As a general rule, 10meq raises K by 0.1. Thus, if the patient is 2.8 and need to --> 3.5 you must give 70meq to get them there. Don't write potassium in unless they are hypokalemic. Unless it's an alcohol, then give them a banana bag.
4. Best option is give every one 5000 U of unfractionated heparin BID.
5. For more, go here: http://medicine.mikearef.com/home/practical/admission-orders
6. To not piss off attending, be pertinent. When calling, tell them:

• Patient names, MRN, PMH, presenting problem, very brief HPI, only pertinent social/family hx (COPDer with 50 pack year smoking hx), meds, and physical exam plus tests. Then you can give them A/P. They may want EVERYTHING initially (color of sputum, how much per day), but as your get experienced, they'll want the quick and dirty.
• Example: Hi Dr. Awesome, we've got a new admit, do you want the long or quick version? Ok great! Let me know when you are ready for patient information. Mr. John Smith, MRN 1234567, 58yo male with PMH of COPD, HTN, significant smoking hx, and CAD presenting with shortness of breath. Symptoms started 4 days ago and have progressively worsened. Used to be able to walk 500ft, now can't make it to the bathroom. Patient denies any other symptoms besides SOB. Has been using albuterol around the clock with no improvement. Admits to 1 prior episode 6 months ago similar in onset. Denies fever/chills/purulent sputum. Current smoker with 50yr pack history. IV drug use 2 weeks ago. Takes albuterol only, ran out of his ipratropium 2 weeks ago. On exam, bilateral upper/lower expiratory wheezes and fine crackles. Initial chest xray showed flattened diaphragms, increased vascularity. No signs of infection. EKG normal. For A/P, number 1 is likely COPD exacerbation, recommend starting blah blah blah, number 2, hypertension, recommend starting blah blah blah.

You get the picture. You are literally framing the patient context. Don't include irrelevant information (patient had chlamydia infection 4 years ago and appendectomy at age 6), if the attending doesn't want it.

Wow, that was longer than I expected. Good luck and happy 3rd year. 🙂

 

[Winged Scapula]

^

Strong work. OP bear in mind that every attending will have certain quirks or preferences and that the above is not necessarily translatable to other specialties (eg, your post op patient may not need anticoagulation due to bleeding concerns; your patient with ulcerative colitis may not appreciate the Dulcolax).

 

[Psai]

damn bro that's a sweet rotation
it's going to suck at the beginning but not having residents is amazing because what happens a lot is that you end up shadowing a lot unless you have an awesome resident that makes you do stuff and teaches you things. this is not very common

 

[sozme]

Ty @justin1390

^

Strong work. OP bear in mind that every attending will have certain quirks or preferences and that the above is not necessarily translatable to other specialties (eg, your post op patient may not need anticoagulation due to bleeding concerns; your patient with ulcerative colitis may not appreciate the Dulcolax).

Ofc ofc, I am just really looking for a good starting point. I hear our surgery rotation is very similar in terms of how much we actually get to do as students though (also no surgery residents).

damn bro that's a sweet rotation
it's going to suck at the beginning but not having residents is amazing because what happens a lot is that you end up shadowing a lot unless you have an awesome resident that makes you do stuff and teaches you things. this is not very common

It is a very unique situation where I am at. We have 3 teaching hospitals all within 20 minutes or less (at most) driving distance from each other. Two of them are level 1 trauma centers, and the level 2 is a 357 bed facility that is home to the only residency program at our campus (Family medicine). This is an MD school too.

Of course today was just my first day so we will see if the lack of residents really does mean we get to do as much, but that is what the 4th years have told us (except OB which apparently everyone hates - I'm told that is not unusual though).

 

[justin1390]

Glad I could help. 🙂 You'll learn fast! As others have mentioned, you really do have a very unique opportunity. I'd make the most of it!

 

[Bacchus]

i would start with orders.

Sometimes our EM RNs think its 1) Orders 2) See the patient. I have to remind them there's a logical order to all this, although I do agree sometimes orders could be put in and the patient could be seen the next day 😉

 

[VisionaryTics]

Sometimes our EM RNs think its 1) Orders 2) See the patient. I have to remind them there's a logical order to all this, although I do agree sometimes orders could be put in and the patient could be seen the next day 😉

I did that on EM. Seeing the patient changed management a minority of the time. Just shotgun labs and imaging for any given chief complaint.

I had a horrible experience though.

 

[cbrons]

Just shotgun labs and imaging for any given chief complaint.

I had a horrible experience though.

I feel like this is an unfinished story...

 

[Jlaw]

How do you admit patients? In our clerkship manual it says "med students are responsible for admitting all patients, blah blah etc." but doesn't have any info HOW you gots to do it.

Internal medicine rotation begins tomorrow.


Help plz

I so scared

Relax, no hospital is going to just toss a 3rd year med student into the mix and put them in charge of doing anything without instruction and supervision. That is a recipe for disaster. The attending and the hospital have way too much to lose if we F something up. I had a couple of rotation sites that didn't even let us write notes in the EMR system for fear that something a student said or didn't document could come back to haunt them.

 

[cabinbuilder]

Be sure you get a Maxwell's pocket helper: it has basic orders, labs, chart notes for every rotation. It has a full physical exam template. You can get one for about $10. It will save you.

 

[redpanda]

The complete H&P is pretty much your job now, but it's good to learn, if you can, how to do admission orders. Unfortunately, given the time constraints and inability of med students to write orders in any efficient way in our EMR, I barely got experience dealing with that as a student. Our EMR just added a new-ish feature for the giant-admission-order-set-of-everything and I just had to use it last week. The good: it covers all the common areas of orders to admit a patient. The bad: it's a massive order set (like a bunch of nested Russian dolls) and difficult to navigate (an intelligent function to scan the chart and maybe bring up some more prioritized orders based on the patient's problem would help). This is really an intern job to navigate though. For now, just focus on getting a good H&P so that you can make some intelligent plan.

 

[Bacchus]

I did that on EM. Seeing the patient changed management a minority of the time. Just shotgun labs and imaging for any given chief complaint.

I had a horrible experience though.

I admit, I don't work in the ED.

 

[FutureInternist]

I'll put in my plug for the 2 books by Paul Chan (History & Physical; and Medicine)

The first ones helps with Qs to ask given a particular complaint - SOB

Then once you have dx'ed it as CHF exacerbation then you can look into the 2nd book for order sets for that particular dz process

Helped a lot in med school (and to some extent in internship)

The way to learn is to do all the Qs you can think of, then look to see what you missed

Good Luck

 

[cbrons]

The first ones helps with Qs to ask given a particular complaint - SOB

Any other resource like this? (matching good questions to ask with complaints)

 

[JustPlainBill]

Sometimes our EM RNs think its 1) Orders 2) See the patient. I have to remind them there's a logical order to all this, although I do agree sometimes orders could be put in and the patient could be seen the next day 😉

And as we all know, at least at a certain county hospital in the Southwest, you WILL get hammer paged no matter what time of day or night, if your patient arrives to the floor WITHOUT a diet order -- they will forget to do BP checks or give HTN meds for SBP > 160 or hold if DBP < 60, but for the love of St. Barnabas and all that is holy, WRITE THE *()*&^& DIET ORDER!

Get the Maxwells -- learn your attending -- follow the lead of the residents -- as a resident, I had one attending that wanted the PMH,PFHx, SocHx in a specific order and actually gigged me on that in my evals -- this is the same numbnuts who pimped me on a patient's baseline WBC differential and waited until the Sunday night before I was about to go off service to tell me that I was getting a bad eval...I had been there 2 weeks and never said a word to me -- no other residents on the service -- the douche was later moved from resident faculty into research where he couldn't hurt anybody... but the damage was done.

The attending immediately after him (like the Monday after that little Sunday night soiree) actually stopped me and said,"Look, let's be reasonable in the amount of detail -- just tell me what's going on with this guy and let's go see the patient".... taught a lot, took me to lunch quite a few times on rotation, encouraged outside reading -- wound up with 4's and 5's (5 being the highest) on that eval with good comments ---

Be thorough, you may want to consider grabbing a copy of the Washinton Manual for internal medicine -- they do a pretty good short synopsis of a lot of the stuff you're asking -- VTE PPx, fluids, feeding, etc. --

Good luck -- I did well on my medicine rotations in school only to step into the living hell of a Family Medicine residency that couldn't teach a bunch of horny Boy Scouts what to do inside a Vegas cathouse trying to run an inpatient medicine service to maintain the "Family Medicine" perspective when we had a world class IM shop sitting right there in the freakin' hospital.....