Common misconceptions and mistakes
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Giving three complete, separate physical examinations when presenting a single new admission (emegency department [ED] examination, intensive care unit (ICU) admit examination, and the current examination)
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Derailing the presentation by saying things that are very unusual, without specific preface (eg, saying the patient was treated for small-cell lung cancer 10 years ago, instead of just adding “ incredibly ” at the front)
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Reporting a history of the present illness that defies normal human logic, without specifically explaining that follow-up questions were asked and that, yes, this is really the way it occurred (eg, the patient had crushing chest pain, felt like he was going to die, and then returned to bed)
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Not knowing important home medication doses (like prednisone)
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Failing to assess volume status and plan volume goals for every patient, every day (erroneously presuming autoregulation of volume)
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Failing to identify the surrogate decision maker
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Editorializing while giving the labs (ie, “his Cr. is 3.4 up from 1, probably ATN”)
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Skipping or glossing over the final overall assessment (instead, launching straight into the plan)
Goal of the bedside presentation
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The goal of the bedside presentation is to accurately convey all the necessary facts such that by the end of the presentation, all who are listening have a clear idea of what you think happened to the patient and what you believe needs to be done
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The presentation must never cause the listeners to become confused or distracted, as occurs when the presenter:
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Violates the anticipated order of the presentation
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Provides several complete physical examinations (“Wait, was this when you saw him in the ED or this morning?”)
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Says something extremely unusual without special preface (this makes those who are listening concerned that the presenter does not know it is usual)
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Reads instead of presents—or worse, reads someone else’s note
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New admission
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History of the present illness (HPI):
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The goal is for the HPI to elegantly summarize all the events from presentation up to that morning at the bedside
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Should contain:
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Age and demographics
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67-year-old white male
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Relevant comorbidities
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With a past medical history significant for hypertension (HTN), heart failure with preserved ejection fraction (HFpEF), and chronic obstructive pulmonary disease (COPD) (FEV 1 78% predicted)
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Relevant recent medical history
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Recently hospitalized for an non-ST segment elevation myocardial infarction (NSTEMI) (discharged 2 months prior on acetylsalicylic acid [ASA])
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Presenting scenario
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ED or floor hospital course before ICU admission
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A brief summary of the assessment made by the first doctors to see the patient including pertinent data only (eg, important vitals, examination findings, test results, ED impression, plan) in a narrative form
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Presented to the ED complaining of a 5-day productive cough and fever. The ED thought he was septic from pneumonia because of a 102 ° F temperature, a white blood cell (WBC) count of 17,000, a lactate of 5 mmol/L, and a new right lower lobe (RLL) opacity seen by chest x-ray (CXR); he was given vanc zosyn and 4 L of IVF before we were called
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ICU course (narrative form) detailing major events and interventions from arrival right up to the present time (ie, morning rounds)
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Including important vitals, changes to examination, and new test results in a narrative form
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When we saw him in the ED we noticed his left leg was swollen and had an ultrasound done, which showed a nonocclusive deep vein thrombosis (DVT). His partial thromboplastin time (PTT) was 36 seconds, his platelets (plts) were 180,000 cells/μL, and his hemoglobin and hematocrit (H&H) were at baseline (11 g/dL/33%), so he was given IV heparin after putting in a right internal jugular (IJ) in preparation for pressors. Overnight his blood pressure remained low and his repeat lactate trended up to 7 mmol/L, so we started him on Levophed and then added vasopressin. We also ordered an ECHO for the morning to look for isolated right-sided heart failure because he had DVT and may have had a pulmonary embolism (PE).
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Past medical history (PMHx):
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Disease/relevant details
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COPD—report pertinent pulmonary function test (PFT) data (FEV 1 /FVC ration [absolute] and FEV 1 %, TLC %, and DLCO %)
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Heart failure (HF)—report pertinent ECHO data (eg, left ventricular ejection fraction [LVEF], left atrium [LA]-size, pulmonary artery systolic pressure [PAS], right ventricular ejection fraction [RVEF])
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Social history (SHx):
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Include surrogate decision maker/ durable power of attorney (DPOA) information/advanced directive status
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Family history (FMHx):
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Only present relevant information
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More important in younger patients
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Allergies
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Medications
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Outpatient , without dose and interval (unless asked or clearly relevant; based on the medication [eg, prednisone or Lasix])
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Inpatient (emphasizing)
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Pressors/inotropes (dose and trend)
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Sedation/pain medication (dose and trend)
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Antibiotics
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What day, which antibiotics, and for what reason (eg, “Cipro, day 5 out of 10, for E. coli UTI”)
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Steroids (dose and indication)
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Anticoagulation/DVT prophylaxis
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Vitals signs and Fluid Balance (ie I/O)
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Ventilator data— must have:
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For pressure control mode:
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Inspiratory pressure (a.k.a. driving pressure)— set
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Tidal volume (both absolute number in mL and approximate mg/kg value)— observed (variable)
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Example: “tidal volumes are 450–510 mL and ~ 6–7 mg/kg ideal body weight”
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Rate (set/observed)
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Minute ventilation (MV): observed (variable)
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Positive end-expiratory pressure (PEEP)
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Peak airway pressure: set (driving pressure + PEEP)
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Plateau pressure: observed (variable)
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Fi o 2
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Low exhaled tidal volume alarm limit ( critical in pressure control mode; set as the lowest tidal volume you are willing to accept)
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This is the alarm that detects a decrease in compliance or an increase in airway resistance in patients placed on a pressure control mode (ie, decreased volumes for the same driving pressure)
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For volume control mode:
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Tidal volume (both absolute number in mL and approximate mg/kg value)— set (fixed)
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Example: “tidal volume is 450 mL and ~ 6 mg/kg ideal body weight”
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Rate (set/observed)
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MV: observed (variable)
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PEEP
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Fi o 2
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Peak airway pressure: observed (variable)
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Plateau pressure: observed (variable)
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Arterial blood gas (ABG) for the previously mentioned settings (pH/P co 2 /P o 2 /Fi o 2 )
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Physical examination (first and ONLY complete examination):
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Always look hard for , and comment on, the presence or absence of dependent or generalized edema
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The presence of edema has huge clinical significance (by defining volume overload)
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Labs with trends on abnormal values (creatinine, Hgb)
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Do not editorialize
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Do not trend labs in the normal range (ie, “WBC 9000, up from 6000”)
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Know all the microbiology data, including sensitivities, but only report new results
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Imaging findings, studies, or other clinical data
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The overall assessment is very important
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The quality of the overall assessment equals your understanding of the case
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Age and demographics
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67-year-old white male
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Relevant comorbidities (clearly related to, or relevant to, the presentation)
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With a PMHx significant for HFpEF and COPD with a recent NSTEMI
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“Presented complaining of…” (clearly related to the presentation)
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Presented complaining of fever and cough
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“Found to have… ” relevant abnormal findings in an organized fashion (clearly related to the presentation)
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Found to have pneumonia, DVT, and shock
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“Concerning for…” (differential diagnosis; most likely entities first)
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Concerning for septic shock with a possible isolated right-sided heart failure component, given venous thromboembolic disease (VTE)
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Trajectory (stable, worse, or better)
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Stable and improving with a down-trending lactate and Levophed requirement
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Impression and plan by problem in descending order of importance (ie, respiratory failure and shock near or at the top)
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Problem-based organization is superior to systems-based organization for three reasons:
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It requires a better understanding of the patient
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Patients should be thought of as having a series of problems, interacting in a descending order of importance
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It is not possible to make a sensible plan going from head to toe, because you inevitably discuss feeds before getting to the concern for necrotizing fasciitis of the foot
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Systems-based organization argues that in order not to miss anything, one must go head to toe, system by system, in an orderly and systematic fashion
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Instead, a checklist, like the FAST HUG SSL below, can be used to systematically ensure that nothing is missed
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Volume status should always be addressed as a problem, with a daily assessment of both:
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Total body volume (ie, a survey for any edema, effusions, and ascites) and
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Intravascular volume assessment (using blood pressure [BP] and urine output, pressor requirement, and possibly central venous pressure [CVP] and/or pulmonary capillary wedge pressure [PCWP] if available)
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The above volume assessment should lead to both :
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The 24-hour I/O goal:
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Example: total body volume up and intravascular euvolemic = negative 1-2 L fluid balance over the next 24 hours
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A simple algorithm regarding the initial management of hypotension , poor urine output , worsening respiratory mechanics , and/or gas exchange
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Example 1: total body volume up and intravascular volume up :
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Poor urine output = loop diuretic
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Worsening respiratory mechanics and/or gas exchange = loop diuretic
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Worsening hypotension = pressors and/or inotropes (ie, no more intravenous fluid (IVF))
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Example 2: total body euvolemic and intravascular euvolemic:
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Poor urine output = IVF bolus
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Hypotension = IVF bolus
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Worsening respiratory mechanics concerning for a noncardiogenic edema process necessitating an urgent workup
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FAST HUGSSLR (checklist/mnemonic)
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F eeding: discuss
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A nalgesia: ensure analgesia is adequate
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S edation: ensure sedation level is appropriate
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T hromboembolic prophylaxis: verify/discuss
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H ead-of-bed elevation to > 30 degrees: verify
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Peptic U lcer prevention: verify/discuss
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G lucose control: ensure no hypoglycemic episodes and reasonable control (blood glucose [BG] < 180 mg/dL)
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S kin breakdown: survey for skin breakdown, listing any pressure ulcers, incisions, or wounds
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S tool: verify no constipation/no diarrhea
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L ines: list every indwelling catheter, ensure no sign of obvious infection, and verify need for continued use
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R eadiness to wean: discuss weaning attempts or reasons it is not being attempted (when applicable)
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The mnemonic serves as both a bedside checklist and an excellent way to document (in the daily note) compliance with good practice measures (personalize and add what you like)
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It allows you to focus on the significant problems, assured that everything else will be covered at the end
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