Ask a Hospitalist

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Dear Hospitalist,

I’ve been having chest pain for the past three weeks.  I get it right in the middle of the chest, it’s worse when I move around, but goes away when I sit down and take a few deep breaths.  My Dad died of a heart attack when he was 48.  I just turned 45.  I’m scared!  What should I do?

Concerned in Chattanooga

Obviously the internist. Givaway: stethascope
You mean YOU can’t treat the DKA and want a Medicine consult?  I thought you were a doctor!

Dear Concerned,

Writing an organized SOAP note is the most important thing any hospitalist can do.  The subjective reflects the patient’s concerns; you can even quote the patient here.  The objective includes vital signs, exam findings, labs, and diagnostic tests, like interpretation of an ECG or CXR.  Do not confuse the sections and do not make assessments here.

In your assessment and plan, ask yourself how each problem is doing – better, worse, or the same? – and how you plan to address each.  Convey your thoughts well, I cannot stress this enough.  I recommend an “other” section for things like DVT prophylaxis, peripheral access, family contacts, and code status, so they’re always in the back of your mind.  Do not forget to date and time your note.  This is absolutely crucial. Did you get a D-Dimer? Argh. I hope you have another 30min so I can explain what that means.

Dear Hospitalist,

I just returned from a two-week trip to Uganda and yesterday noticed high-grade fevers and weakness.  Today the fever persists and I feel even worse.  My wife thinks I have malaria but I got vaccinated and took the medications given by the doctor I saw in travel clinic.  How would you approach this situation?  I feel like I should play it safe and head to the Emergency Room.

Sickly in Sacramento

Dear Sickly,

You never really “clear” a patient when doing a preoperative evaluation for noncardiac surgery.  The goal is to make an objective assessment of risk and make recommendations to best optimize a patient before surgery.  It’s up to the surgeon to use that information to properly inform the patient about risks, benefits, and alternatives.  Many hospitalists want to defer to cardiology, but it’s best to keep it simple.  If surgery is emergent, that trumps all.  If there are active cardiac issues, fix those first.  If there are no cardiac issues and the surgery is low risk, then proceed to surgery.  The Revised Cardiac Risk Index is a very useful tool if you need to quote risk as percentages.

Dear Hospitalist,

I’m currently hospitalized for blood in my stool.  I was found to have a diverticular bleed, but haven’t required any blood transfusions.  Yesterday, I developed swelling in my right leg and an ultrasound revealed a new DVT.  I feel like I’m stuck between a rock and a hard place.  If I start a blood thinner, I might bleed.  But if I don’t, I could develop a blood clot in my lungs!  Please help!

– Fearful in Fargo

Dear Fearful,

The trick to effective CPR is getting good depth with each compression and keeping a good rate, about 100 compressions per minute.  The Bee Gees’ “Stayin’ Alive” is a good reference point.  Before you start compressions, make sure you’ve verified code status.  There’s nothing more embarrassing than cracking an elderly lady’s sternum when she was DNR all along.  If they truly are full code, be sure to lower the bed and place a backboard to maximize your leverage.  Chest compressions done well are extremely tiring.  Never hesitate to tag out.  You can always help assess for pulse while you recover.  Make sure you know your ACLS algorithms.

Dr. Abby Johnson is a hospitalist at Boston University.  Her column, Ask a Hospitalist, appears in over 2 newspapers worldwide.  Stay tuned!

Need some more advice?  
Ask a 4th-Year Med Student (Who’s Checked Out for the Year)
Ask a July 1st Medicine Intern
Ask a Surgical Intern, Part 1
Ask a Surgical Intern, Part 2

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