Introduction of the New Internee Aim: To have clear conception of Medical emergency To have an idea...
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Approach to the Patients on Admission in Wards
Introduction of the New Internee Aim: To have clear conception of Medical emergency To have an idea of the referral system of the patients To be rational
Aim: To have clear conception of Medical emergency To have an
idea of the referral system of the patients To be rational in the
use of drugs To be rational in sending investigations To ensure
better follow up of the patients
Slide 4
Thus, To provide better service to the patients
Slide 5
Through M.O.P.DThrough Emergency Alive With NOD Without NOD
Brought dead Psychiatric/ Functional Non psychiatric Admission
During Office Hour Beyond Office Hour Transferred/Referred NOD= No
Official Delay MOPD= Medicine out patient department
Slide 6
During Office Hour: Patients come through MOPD, Outdoor and
sometimes they are transferred from different wards. Patients
coming through emergency may have NOD note or may have admission
ticket
Slide 7
In Case of NOD 1. Rush to the patient without any delay 2.
Examine the patient, specially, vital signs (Pulse, Heart sound,
Pupil, Planter reflex) to see whether the patient is alive or Dead
3. If you find the patient dead, show your sincerity to the
attendants during examination though you are clinically certain
that the patient is dead. 4. If found dead clinically, talk to the
attendant/relative (specially with the 1 st degree), start
counseling. Tell them that your are almost sure about the death of
the patient, and Now going to do an ECG just to confirm it!
Slide 8
5. Then do the ECG (This time, the Long Leads only) 6. If
straight line is found, then address the EMO and declare the
patient dead as Brought dead
Slide 9
If the patient is found gasping on the trolley, dont waste time
for the bed-head ticket to be available! Rather, immediately start
the treatment with whatever resources you have. Never forget to
measure CBG of the Patients!
Slide 10
If CBG is found within normal range, you should be very much
cautious regarding examination and diagnosis.
Slide 11
Because, Unconsciousness matters!!!!!
Slide 12
SIMULATED COMA Psychologically disturbed patients sometimes
feign coma. The eyes are actually closed and the patient is usually
lying in a resting position, or supine with the arms and legs
extended. The eyelids resist attempts to open them On forced eye
opening, the eyes point upwards exposing the white conjunctiva
(Bell's phenomenon) as part of the patient's attempt to maintain
eyelid closure. The eyelids close rapidly when released. The slow
roving eye movements of organic coma cannot be simulated. Painful
stimuli to the limbs may be ignored, but pinprick to the nasal
mucosa or to the lips usually elicits volitional grimacing. The
pupillary light reflex is normal, as are plantar responses.
Slide 13
Cold caloric testing induces nystagmus with the fast phase away
from the stimulated side, rather than deviation of the eyes toward
the stimulus as would occur in true coma. Examination, especially
invasive tests as above, may induce a return of cooperation and
consciousness, or uncover a disturbed mental. (This is not
practised in the ward)
Slide 14
Psychogenic Hyperventilation, Respiratory distress Features:
1.May complaints of Light headedness 2.When excessive, tingling and
numbness of limbs with carpopedal spasm may occur due hypocalcaemia
resulting from Respiratory alkalosis 3.X-Ray and ECG is normal
Features: 1.May complaints of Light headedness 2.When excessive,
tingling and numbness of limbs with carpopedal spasm may occur due
hypocalcaemia resulting from Respiratory alkalosis 3.X-Ray and ECG
is normal Features: 1.Typically can locate exactly with his/her own
hand, particularly one finger! 2.On pressing over the point,
shout/cry out due to pain! 3.X-ray and ECG (Tachycardia only) is
normal Features: 1.Typically can locate exactly with his/her own
hand, particularly one finger! 2.On pressing over the point,
shout/cry out due to pain! 3.X-ray and ECG (Tachycardia only) is
normal Severe Chest Pain Acute Mutism/ Unconsciousness Acute
Mutism/ Unconsciousness Features: 1.Typical eyeball movement with
closure of eyelids! 2.Few maneuver (NG tube insertion etc) may not
be needed to treat them! Features: 1.Typical eyeball movement with
closure of eyelids! 2.Few maneuver (NG tube insertion etc) may not
be needed to treat them! In case of Functional disorder/Anxiety
disorder/Acute stress disorder coming with NOD, Pseudo emergency
may occur, like:
Slide 15
Just feel the pulse, hear the Heart sounds and look for
pupillary reflex to make the attendants think that your are taking
the case seriously Then, address the EMO to admit the patient in
the word Meanwhile, send one of the attendants to bring some drugs
(Just to make the attendants busy, other wise, they will make you
Busy!) Start counseling the attendants Dont talk/make any comment
in front of the patient regarding your diagnosis (as it may cause
exacerbation of symptoms)!
Slide 16
Management of the Patient: In case of Functional disorder, I.V.
drugs are given (or, sometimes need to be given) to make him/her
think that treatment is started appropriately. Drug list should
include: I.V. canula 20G JMS infusion set 1 inch Micropore Inj. 5%
DNS (If non diabetic) Inj. Omeprazole Inj. Dormicum/Inj.
Haloperidol (suspecting that the patient may be restless or
violent!)
Slide 17
Contd.. Sometimes, only oral medication is enough to treat the
patient specially at night, when Staff nurses are few in number
Intravenous management is troublesome. So, there is no reason to
engage the sisters in treating those patient, rather we should
think for really critically ill patients. In that case, the
medication will be: Tab. Clonazepam (0.5mg ) /Tab. Midazolam 7.5 mg
1 Tab. stat and then 0+0+1 Cap. Omeprazole (20mg) 1+0+1 [ hr A/C]
Actually, it is the clinical condition and patients surrounding,
which will lead you to the treatment.
Slide 18
Consciousness is a state of normal cerebral activity in which
the patient is aware of both self and environment and is able to
respond to internal changes, for example hunger, and to changes in
the external environment. Altered consciousness resulting from
brain disease may take the form of a confusional state, in which
the patient's alertness is clouded; this is associated with
\agitation, fright and confusion, i.e. disorientation. Such
patients usually show evidence of misperception of their
environment, and hallucinations and delusions may occur.
Slide 19
Confusional states must be carefully distinguished from
aphasia, in which a specific disorder of language is the
characteristic feature, and from continuous temporal lobe epilepsy,
a form of focal status epilepticus in which the behavioural
disorder is often accompanied by aphasia if the epileptic focus is
left- sided. Usually this can be recognized by the occurrence of
frequent but slight myoclonic jerks of facial and especially
perioral muscles, and by variability in the patient's confusion
from moment to moment during the examination. Always pause and
observe an unconscious or drowsy patient for a few moments before
disturbing them.
Slide 20
Abnormal drowsiness is often found in patients with
space-occupying intracranial lesions or metabolic disorders before
stupor or coma supervenes. The patient appears to be in normal
sleep but cannot easily be wakened and, once awake, tends to fall
asleep despite verbal stimulation or clinical examination. Further,
while awake such patients can usually be shown to be disorientated.
Higher intellectual function, such as the ability to perform
abstract tasks or to make judgements, is disturbed. Stupor means a
state of disturbed consciousness from which only vigorous external
stimuli can produce arousal. Arousal from stupor is invariably both
brief and incomplete.
Slide 21
Pupil: Pupillary size and responsiveness to a very bright
unfocused light beam (not the light of an ophthalmoscope) should be
noted. If the pupils are unequal, a decision as to which is
abnormal must be made. Usually the larger pupil indicates the
presence of an oculomotor (third) nerve palsy, whether from damage
to the oculomotor nerve by pressure and displacement or from a
lesion in the mesencephalon itself. Occasionally the smaller pupil
may be the abnormal one, as in Horner's syndrome. If the larger
pupil does not react to light it is likely that there is a partial
oculomotor nerve palsy on that side. If the smaller pupil also
fails to react to light this may be the midposition pupil of
complete sympathetic and parasympathetic lesions, indicating
extensive brainstem damage
Slide 22
In drug-induced coma and in most patients with metabolic coma
the pupillary responses to light are normal. Exceptions to this
rule are glutethimide poisoning and very deep metabolic coma, in
which the pupils may become dilated but only rarely become
unreactive to light. In pontine and in thalamic haemorrhage the
pupils may be very small (pinpoint pupils) and unreactive to
light.
Slide 23
Bilateral pinpoint pupils occur with brainstem lesions, opiate
and other drug intoxications, and with pontine infarction There is
ptosis, dilatation of the pupil with absence of the light reaction,
and slight lateral deviation of the eye.
Slide 24
There is ptosis and a small reactive pupil The eyes tend to
'look towards the tip of the nose' and the pupils are small; later
they become large and unreactive as upper brainstem involvement
follows
Slide 25
And, last but not the least..
Slide 26
When brainstem death occurs the midbrain disturbance is
manifest by midposition, fixed (unreactive) pupils with eye
closure
Slide 27
PATTERN OF BREATHING Alterations in the rhythm and pattern of
breathing are an important aspect of the assessment of the
unconscious patient.
Slide 28
CHEYNE-STOKES (PERIODIC) RESPIRATION In Cheyne-Stokes
respiration, breathing varies in regular cycles. A phase of
gradually deepening respiration is followed, after a period of very
deep rapid breaths, by a phase of slowly decreasing respiratory
excursion and rate. Respiration gradually becomes quieter and may
cease for several seconds before the cycle is repeated. Depressed
but regular breathing at a normal rate occurs in most drug-induced
comas, but Cheyne-Stokes respiration can occur in coma of any
cause, especially if there is coincidental chronic pulmonary
disease. Cheyne-Stokes breathing in a comatose patient is a sign of
a large unilateral space-occupying lesion with brainstem
distortion, for example subdural haematoma, or of bilateral lesions
from other causes, for example cerebral infarction or
meningitis.
Slide 29
KUSSMAUL RESPIRATION Deep, rapid sighing breathing at a regular
rate should immediately suggest metabolic acidosis. Metabolic or
uraemia is the commonest cause of this acidotic (Kussmaul)
breathing pattern, but a similar pattern may occur in some patients
with respiratory failure, and in deep metabolic coma, especially
hepatic coma.
Slide 30
CENTRAL PONTINE HYPERVENTILATION Deep, regular breathing may
also occur with rostral brainstem damage, whether due to reticular
pontine infarction or to central brainstem dysfunction secondary to
transtentorial herniation associated with an intra- or
extracerebral space-occupying lesion. This breathing pattern is
called central neurogenic (pontine) hyperventilation. Interspersed
deep sighs or yawns may precede the development of this respiratory
pattern.
Slide 31
Rapid shallow breathing occurs if central brainstem dysfunction
extends more caudally to the lower pons. When medullary respiratory
neurons are damaged, for example by progressive transtentorial
herniation, irregular, slow, deep gasping respirations, sometimes
associated with hiccups (ataxic respiration), may develop. In
patients with raised intracranial pressure, this sequence of
abnormal breathing patterns is often associated with other evidence
of brainstem dysfunction, including a rising blood pressure, a slow
pulse, flaccid limbs, absence of reflex ocular movements and
dilatation of the pupils.
Slide 32
Changing patterns of respiration in an unconscious patient,
particularly the development of central neurogenic
hyperventilation, provide important and relatively objective
evidence of deterioration. These changes in respiratory pattern may
occur in structural lesions with raised intracranial pressure, in
brainstem infarction, and less commonly in some varieties of
metabolic coma, especially hepatic coma. They are indicative of
progressive and potentially fatal brainstem dysfunction, but not of
its causation.
Slide 33
Now, let us come back to the patient that has just entered into
the ward!
Slide 34
Meanwhile, counseling should be done simultaneously regarding
the prognosis of the patient. Try to show pessimistic attitude to
the attendant (Specially when you can understand that the patient
is going to expire very soon) After initial resuscitation, try to
refer the case to the respective discipline (When indicated), e.g.
CCU/ICU/Nephrology/Neuromedicine etc. (in the office hour
only).
Slide 35
Medically unexplained somatic symptoms Patients commonly
present to doctors with somatic symptoms. Whilst these are often
clearly associated with a medical condition, in other cases they
are not. Symptoms may be disproportionate to, or occur in the
absence of, a medical condition and are then often referred to as
'medically unexplained symptoms' (MUS). MUS are very common and
occur in a quarter to a half of patients attending general medical
outpatient clinics. Almost any symptom can be medically unexplained
and common examples include: pain (including back, chest, abdominal
and headache) fatigue dizziness fits, 'funny turns' and feelings of
weakness.
Slide 36
Patients with MUS may receive a medical diagnosis of a
so-called functional somatic syndrome, such as irritable bowel
syndrome and may also merit a psychiatric diagnosis on the basis of
the same symptoms. The most frequent psychiatric diagnoses
associated with MUS are anxiety or depressive disorders. When these
are absent, a diagnosis of somatoform disorder may be applied
Slide 37
Slide 38
Cardiac Emergency (Non functional ) Gastro May involve various
systems of the body alone, or simultaneously RespiratoryEndocrine
InfectionHaematologicalCNSPoisoning Venomous snake bite OPC
poisoning Renal Others Through Outdoor Transferred /Referred
Slide 39
Cardiac Respiratory Gastro Endocrine Infection Haematological
CNS Shock, LVF, MI, CHB, Hypertensive Crisis Severe CAP, Acute
severe asthma/COPD, Tension pneumothoraxResp. failure, Ex. of COPD,
Cor-pulmonale Severe acute Pancreatitis, EV rupture, Severe
hemoptysis, Hypo. Shock, Perforation, Acute abdomen DKA,
Hypoglycemic attack, HONK, Addisons crisis, Septicaemia, shock,
Severe malaria Septicaemia, shock, anemic heart failure
Encephalopathy, Stroke, Meningitis, Encehalitis, GBS with resp.
distress/failure, Status Epilepticus etc. Emergency patients
commonly admitted in wards (Except poisoning) are: Renal ARF,
Ureamic encephalopathy, LVF, Metabolic acidosis etc
Slide 40
When patient comes through M.O.P.D Usually these patients are
admitted with some chronic disease, e.g. PUO and sometimes may be
presented with acute exacerbation, e.g. Huge ascites in case of
CLD, Constipation/vomiting in Ca-stomach etc. Take proper history
and fine out the causes of their admission this time, i.e.
presenting complaints Start thorough physical examination. Share
your findings to your colleagues
Slide 41
Fill up the Bed head ticket
Slide 42
On Bed head Ticket Fill up the front page with- (Necessary for
disease profile and some Medico-legal condition) Name of the
patient: Age: Sex: Address: Provisional Diagnosis Date and Time:
Doctors Signature (Preferably name)
Slide 43
On next page: Presenting complaints: (Try to avoid mentioning
more and irrelevant/non specific complaints) 1. 2. 3. History of
present Illness: (Here, the modified salient feature should be
written to save time) Which should include: Elaboration of positive
findings Mentioning of Important negative findings Mentioning risk
factors/co-morbid conditions
Slide 44
On physical examination: Try to mention the findings concisely,
such as: Appearance Build Anaemia Jaundice Cyanosis Clubbing Edema
Ascites Dehydration Pulse BP Temp Heart Lungs GCS Pupil Planter
reflex: Deep jerks Neck rigidity Kernigs sign Engorged vein
Lymphadenopathy * Sometimes, additional findings should be noted in
some particular diseases
Slide 45
Provisional diagnosis: Try to be specific Broad term can be
used otherwise, e.g. Anaemia under evaluation, Acute febrile
Illness, Acute Confusional State etc. Never write the abbreviated
form, like ACS, DVT, RA etc. As soon as you are confirmed, try to
mention the latest Diagnosis and omit the previous one. Try to
avoid confusing terms, e.g. Shock, Chest pain, Respiratory
distress, Abdominal pain etc.
Slide 46
Before sending Investigations, seek their previous reports.
Always ask your senior colleague regarding investigations, because,
it will reduce unnecessary wastage of time and money Always ask the
reason of sending the particular investigations to your respective
senior colleague Try to learn, in short, the basic pathogenesis of
the disease, and go through the text later on. Try to know the next
plan of investigation Treat the patient according to the
diagnosis
Slide 47
Adv: CBC Urine R/M/E CXR P/A view Blood Urea Serum Creatinine
Serum Electrolytes USG of Whole Abdomen Next Plan: CT scan of Brain
CT guided FNAC USG guided FNAC Endoscopy of UGIT etc. Adv: CBC
Urine R/M/E CXR P/A view Blood Urea Serum Creatinine Serum
Electrolytes USG of Whole Abdomen Next Plan: CT scan of Brain CT
guided FNAC USG guided FNAC Endoscopy of UGIT etc. O/A on Date at
Time:(Sample) Diet: NBM/Liquid/Soft/Normal/Diabetic/Salt and fluid
restricted/Protein restricted etc. Bed rest in Propped
up/Lateral/Semiprone position O 2 Inhalation 2L/min SOS Inj. N/S
1ooo cc I.V. @ 1o d/min (If I.V. antibiotic to be given) Inj. 5%
DNS I.V. @10 d/min ( If not known to be diabetic and CBG is normal)
Oral/ Inj. Antibiotic.. Oral / Inj. Omeprazole (40mg) + 9cc D/W
I.V. 12 hourly Oral Anti pyretic [If febrile] Oral anxiolytic (less
potent) Suppository antipyretic SOS [If fever > 102 For more]
Condom/Foleys catheter [ In case of bed ridden patients] Please
monitor Daily I/O Please monitor all vital signs regularly O/A on
Date at Time:(Sample) Diet: NBM/Liquid/Soft/Normal/Diabetic/Salt
and fluid restricted/Protein restricted etc. Bed rest in Propped
up/Lateral/Semiprone position O 2 Inhalation 2L/min SOS Inj. N/S
1ooo cc I.V. @ 1o d/min (If I.V. antibiotic to be given) Inj. 5%
DNS I.V. @10 d/min ( If not known to be diabetic and CBG is normal)
Oral/ Inj. Antibiotic.. Oral / Inj. Omeprazole (40mg) + 9cc D/W
I.V. 12 hourly Oral Anti pyretic [If febrile] Oral anxiolytic (less
potent) Suppository antipyretic SOS [If fever > 102 For more]
Condom/Foleys catheter [ In case of bed ridden patients] Please
monitor Daily I/O Please monitor all vital signs regularly Name of
Doctor Date: .. Name of Doctor Date: .. N N
Slide 48
Diet:
Slide 49
If the patient is to be kept NBM If Non diabetic If Parenteral
Nutrition is to be given Total 2500-3000 ml of fluid to be given
Inj. 5% DNS 1000 cc+ Inj. Regular Insulin (U-100) or Other soluble
Insulin 10 units I.V @ 25-30 drops/min If Diabetic Inj. 5% DNS 1000
cc I.V @ 25- 30drops/min Fluids Others Vitamins and Electrolytes
1.Inj. Vit B complex 2.Inj. Vit C 3.Extra electrolytes according to
severity and deficiency 1.Inj. Vit B complex 2.Inj. Vit C 3.Extra
electrolytes according to severity and deficiency Special condition
deserves special fluids therapy If NG tube feeding is to be given
[150 ml2 hourly10 feedings] Special Milk; Dal; Soup; F. Juice; Dub
water; etc [150 ml2 hourly10 feedings] Special Milk; Dal; Soup; F.
Juice; Dub water; etc The rest of the fluid should be replaced by
I.V
Slide 50
Half Neuralization in Diabetic patients : InJ. 5% DA/ Inj. 5 %
DNS contains 5 gm of Glucose per 100 ml, so 1000 ml of those fluids
contain 50 gm of glucose. 1 U of soluble insulin can neutralize 2.5
gm of glucose Therefore, full neutralization of 5% DNS 1000 ml
requires (502.5)= 20 U of insulin. So, half neutralizaton requires
10 U of Insulin
Slide 51
If patient is to be kept NBM for prolonged period,
Intracellular fluid requirement should be met with 5% DA 500 or
1000 cc. Sometimes, IV amino acids and fatty acid solutions are
given in selected patients along with vitamins.
Slide 52
Points to be remembered: Patients having any kind of
respiratory distress = No normal diet, rather liquid to soft diet
should be given Acute abdomen due to any cause = NBM+ No NG feeding
First few hours in Acute stroke = NBM+ No NG feeding If aspiration
is suspected = NBM+ No NG feeding for at least 48 hours Any kind of
shock = NBM+ No NG feeding Unconsciousness patient= No NG in first
few hours Any kind of Poisoning = NBM+ No NG feeding
Slide 53
O 2 Supply
Slide 54
Oxygen should be prescribed to achieve a target saturation of
9498% for most acutely ill patients or 8892% for those at risk of
hypercapnic respiratory failure. Sometimes, Low dose O 2 and High
Dose O 2 supply is needed Low dose means 24-28% O 2 Higher dose is
required in LVF, Shock, Severe bronchial asthma etc. Sometimes 100%
O 2 is required, prior to intubation
Slide 55
O 2 % Way of O 2 supply O 2 in L/min 24 Venturi mask 2-4Nasal
cannulae 1 28 Venturi mask 4-6Nasal cannulae 2 36 Venturi mask
8-10Nasal cannulae 4 40 Venturi mask 10-12Simple face mask 5-6 60
Venturi mask 12-15Simple face mask 7-10
Slide 56
Venturi Mask
Slide 57
Nasal Cannulae
Slide 58
Simple face mask
Slide 59
Posture of the Patient:
Slide 60
Normal but chronically ill patient Lateral/Rescue position
Semi- prone Propped up Supine Posture In acute LVF COPD Bronchial
asthma In acute LVF COPD Bronchial asthma Any unconscious patient,
e.g. transport poisoning, stroke, Patients with GCTS/Status
Epilepticus etc. Patients with aspiration pneumonia Foot end raised
In hypo- volaemic shock In hypo- volaemic shock
Slide 61
Lateral Position Supine Position Semi prone Position Prone
Position
Slide 62
Semi-Fowlers Position Fowlers Position
Slide 63
I.V. fluids:
Slide 64
All unconscious patient(Except hypoglycaemia)= Normal saline
All AWD patients with/Without shock = Cholera saline until renal
failure. If pre-renal ARF is suspected (clinically), switch over to
Normal saline In any hyperglycameic patients = Normal saline
Vomiting leading to hypovolaemia = Hartsol/ Hartsmann There is also
pre-surgical/post-surgical indication of various fluid (But,
unusual in our ward) Again, clinical condition and further
investigation will lead us to the selection of fluids
Slide 65
Anti Ulcerant:
Slide 66
No scope of H 2 blocker except allergic reaction PPI is
preferred Avoid Omeprazole in Pregnancy, Multi organ failure, renal
impairment etc. Esmoprazole is better in GERD Pantoprazole is
preferred in patients having multiple drugs chronically Last, but
not the least, we have to consider the socio- economic condition
before choosing the correct drugs
Slide 67
Antibiotics:
Slide 68
Things to be considered: Irrational use should be avoided Avoid
I.V. route where oral one is sufficient Choose I.V. in case of
septicaemia, shock, aspiration pneumonia, Acute abdomen (Intestinal
obstruction, along with other suspected GI infection) Usual site of
Colonization of micro-organism should be taken in consideration,
e.g. No Metronidazole in UTI etc. Proper duration should be
maintained Consider low but effective dose initially Again, we have
to consider the socio-economic condition before choosing the
correct drugs Always ask your seniors prior to selection
Slide 69
Catheterization
Slide 70
Consider in any bed ridden patient In any patient with shock
Any unconscious patient Any patient with acute retention Clinical
condition will lead us to the selection of catheter (Foleys
/Condom) Patient with restlessness with condom cathether in situ
with oliguria should have Foleys catheter In patient with BEP with
unconsciousness = Foleys catheter Patients of OPC poisoning =
Foleys catheter etc.
Slide 71
Referred or Transferred Patients: They are usually diagnosed
Due to newly developped complication related with medicine, they
are transferred. Dont be fixed on the previous diagnosis written in
the file, rather, Take proper History and do physical examination
to re- evaluate the case and to find out exactly what happened
during hospital stay Discuss with the senior colleague and, if
needed with the consultant regarding further management of the
patient. Advise investigations, depending on the complication after
discussing with the senior
Slide 72
Investigation Profile:
Slide 73
Investigation Profile*: When maximum investigations are
available, formulate them into an Investigation Profile in the
following way: 1. CBC: Hb ESR TC DC N: %; L: %; E: %; B: % Atypical
cells: 2. Urine RE: Pus cell: Epi cell RBC RBC Casts Albumin: Sugar
3. CXR P/A view: 4. USG of W/A: 5. Endoscopy of UGIT: 6. S.
Creatinine: 7. S. Electrolytes: 8. S. Bilirubin 9. Liver function
tests: S. Bilirubon: SGPT: SGOT PT: Alk. Phosphatase: S. Albmin 10.
Viral Markers: HBsAg: Anti HBcAg IgM antibody: Anti HCV antibody
Anti HEV antibody: Anti HAV antibody CT scan of Brain: MRI of
Brain/Cervical spine X-Ray of DLS (A/P, Lateral view) X-ray
cervical spine all views( Including Oblique) * Printed form for
Investigation Profile is available
Slide 74
Follow-Up and Treatment
Slide 75
Sometimes this type of treatment sheet is found!!
Slide 76
Please add: Inj. Oradexon 1amp I.V. b.d Plz add: Inj. Anadol
stat and 8 hrly O/A on Date at Time: Diet: NBM (how long?) Bed rest
in Propped up position O 2 Inhalation (How much?) Inj. N/S 1ooo cc
I.V. @ 1o d/min Inj. 5% DNS 1500 I.V. @10 d/min Inj. Antibiotic..
Inj. Omeprazole (40mg) + 9cc D/W I.V. 12 hourly Oral Anti pyretic
[If febrile] Oral anxiolytic (less potent) Suppository antipyretic
SOS [If fever > 102 For more] Catheter [ Which type?] Please
monitor Daily I/O Please monitor all vital signs regularly O/A on
Date at Time: Diet: NBM (how long?) Bed rest in Propped up position
O 2 Inhalation (How much?) Inj. N/S 1ooo cc I.V. @ 1o d/min Inj. 5%
DNS 1500 I.V. @10 d/min Inj. Antibiotic.. Inj. Omeprazole (40mg) +
9cc D/W I.V. 12 hourly Oral Anti pyretic [If febrile] Oral
anxiolytic (less potent) Suppository antipyretic SOS [If fever >
102 For more] Catheter [ Which type?] Please monitor Daily I/O
Please monitor all vital signs regularly Omit Signature (Greek to
All!) Diet: Normal
Slide 77
So, Fresh order is a must!
Slide 78
And, this type of Follow up note is not so Rare!
Slide 79
F/U at 10 am on Date: P:66/min BP:90/60 mmHg T: H: L: NAD F/U :
P:110/min BP: T: H:NAD L: Rhonchi + F/U at 11 am: P:78/min
BP:100/70 mmHg T:101 F H: NAD L:Creps F/U at 10 am: P: 110/min
BP:85/40 T: H: NAD L: creps N N (On the back side of Treatment
sheet) At 10 am On date
Slide 80
Follow up should be of this type:
Slide 81
Follow up On Date at Time : S S P P A A O O New drugs to be
added Old drugs be omitted/Altered New Investigations to be given
New drugs to be added Old drugs be omitted/Altered New
Investigations to be given Compare the condition with the previous
day Improvement/Static/Deterioration Compare the condition with the
previous day Improvement/Static/Deterioration Pulse BP Temp Heart
Lungs Pulse BP Temp Heart Lungs Complaints on that particular time
: Fever Abdominal pain Vomiting Generalised weakness etc.
Complaints on that particular time : Fever Abdominal pain Vomiting
Generalised weakness etc. GCS (In particular patients) Bowl Bladder
Intake Output GCS (In particular patients) Bowl Bladder Intake
Output
Slide 82
Some special conditions demand more detail follow- up, e.g.
Grading of Hepatic Encephalopathy (on that day), Appearance,
Measurement of Body weight and abdominal girth etc.
Slide 83
You should ensure the drugs (by the nurse, or, sometimes,
yourself!) written in the Treatment sheet on the very
beginning!!!!!
Slide 84
Slide 85
Everyone should present during round Gather all the necessary
investigation reports before the round starts Evacuate the
attendants from respective beds prior to round and allow only the
concerned one to stay in case of Terminal/
unconscoious/Disoriented/Bed ridden patient Do not rely completely
( and, thus formulate your plan of investigations or treatment) on
the diagnosis made earlier, e.g., during night. Try to listen what
the consultant discuss about the respective beds Later, discuss
with the senior colleague regarding further plan, Fresh order
etc.