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Comment patient progress report

hey guys I'm Eddie and in this particular video I'm going to be teaching you how to present your patients on Realms when you're in the ICU now this information will pertain to all types of ICU since I think that on testing this at the end of the day we think alike we're all detail oriented people the reason why I decided to do this video is because I teach medical students medical residents and interns nurse practitioners as well as physician's assistants who are both in training as well as practicing and there's not a variation a lot of confusion as to how a patient should be presented and ultimately everybody has a different style the way that I particularly like to work is in a low-stress kind of environment because there's a lot of stress inside the patient's room so if you keep your team nice and happy then your work day is going to be better and more productive but at the end of the day outside things are different and expectations are different and so while this might seem a lot what I'm teaching you I think that at the end of the day it's more important that you understand why we do it as opposed to just speaking out numbers which is what a lot of people who do not have experience actually do during rounds they just read their piece of paper and read out vital signs to me ultimately I know what the vital signs you should be are at the beginning of rounds and I just want you to understand it and try to make the patient better take that information to make the patient better I went through all this myself I mean I hit a number of brick walls when I was presenting patients there was a lot of hand-holding that certain attendings I'm very grateful for did with me in order to get me to the point where I am now and hopefully you will be at this point - okay going through the things this as I said before this may seem overwhelming to you and like going to the gym you need to get a lot of repetitions in in order to get good at this and once you start getting better at this your comfort level will improve and as you keep on working with the same team of folks you will become more comfortable with your team with your environment and you will do a lot of this subconsciously this particular information that I'm going to be teaching you is tailored for United States I see use I practice at a number of places I've also practiced in other countries and every country is different so for those viewers who are abroad and are looking to come to the United States I wish you a lot of luck in getting over here and putting your skills to to great use and taking care of people and ultimately this is how we do it here when we start presenting with patients well when you all start presenting patients to the ICU attending such as myself you need to keep in the back of your mind that most of us by the time that we start rounds at 8:30 or 9:00 o'clock in the morning or whatever time is designated we've already seen all the patients quickly and we've already gone through all the patients information I know that I could see 16 patients in the course of an hour and a half as well as go through all their data and all that stuff it's just quick boom boom boom boom boom take care of everybody take care of what needs to be done immediately and move on so most of the stuff that you're going to be telling us during rounds we're already aware of it but this is for teaching purposes and in academic institutions we want to teach so we want to make you better so um that's just something that keep in the back of your mind when I dissect people's charts to see what their labs aren't all that remember everything that we do is to try to help the patient out okay so that's the reason why we go through every little piece of data to try to improve the care of the patient um I am a details kind of guy and I like all the little nuances one of the things that I'm not going to do in this video is break down how to do the assessment and plan because I think that that's something that you need to work on yourself and it's something that's kind of lengthy to go through and for the sake of time I'm going to avoid going over how to do an assessment and plan because some some places like a problem-based assessment plan and some people like an assist excuse me systems based assessment plan so I'm not going to go through all that maybe in a later video if you think I should do it okay so this is what I'm going to teach you and I apologize for the glare behind me but I won't go through this in detail so couple steps that I'm going to go through to present a patient well some people say how long should be presenting the patient for well you should get through all this data and once you become comfortable with it it will occur fairly quickly I know it seems like a lot but once you get the hang of it it's really not that bad trust me so we'll start off with a one-liner the one-liner is not an official term but it's something that I think is important because it Orient's the whole group as to what's going on and I'll go over that in a second then we're going to talk about the overnight events vital signs eyes and nose the ventilator if your patient is on ventilator the lab data the imaging basically all those tests that we ordered for our patient we need to talk about it the patient's - how many days the lines how many days catheters etc the medications because at the end of the day we're doctors we practice medicine so we need to know our patient's medications inside out in addition to that we're going to talk a little bit about the physical exam as well as what I really meant that I'm not going to teach about which is the assessment plan okay so the one liner what is it well when you come and present a patient I want you ah just smack me in the face and tell me what's why I want the patient so you can see here in bed 6 we have Jane Doe she's a 68 year old female hospital day X number and the reason why I want you to tell me what hospital day the patient is in is because if the patient's on the vent and they've been on for a prolonged hospitalization I'm already thinking about treating the patient I'm thinking about goals of care which I'm already thinking about from day one but nevertheless it just triggers me to take into consideration how long the patient has been there and what progress should we have made by now okay so once again Jane Doe that's a made-up name by the way Jane Doe 68 year old female hospital day six here for a COPD exacerbation boom I know what's going on with the patient okay so right there my mind is channeled into knowing that I'm going to be treating Jane Doe for a COPD exacerbation and she's on the bed good okay now the next step is the overnight events I want you to be able to tell me what happened during the 12 hours or so that I was not in the hospital and this information could be obtained pretty darn well from either the person who was checking out from the overnight shift or from speaking to the nurses because the nurses are a fantastic fantastic resource for two fantastic resource to get information with regards to what happened to your patient and the patient's self extubated if the patient drop your blood pressure if the patient's stopped making urine overnight these are things that your nurse will be able to tell you right away so these overnight events are things that you should definitely bring up during rounds immediately after you give me the one-liner you go ahead and give me a job and then you give me an uppercut okay you let me know boom boom what's going on with the patient so the next step is the vital signs and so don't be that person who write these down the vital signs with regards to arrange all of the temperature was between 98.2 and 100.1 that really doesn't that shows me that you can read off of a piece of paper off of a computer screen but it does show me you're thinking about it so if the patient for example had a fever or if they received any time in arm and says there any that fan-type I'm ready to combat fever I didn't know the person was normal thermic but they did receive tylenol during the course of a night or the patient was febrile and they received time well for that fever okay so the other thing is that comes up in the vital signs is the temperature their oxygenation so you might say oh there's ask for between 95 and 100 percent the whole night that's great but were they getting oxygen with it where the guy needs a cannula weren't they on the vent was the leaders of oxygen turned up sometime during the night or was the were the settings on the vent change a certain had a certain type of the night these are things that I want to hear that you thought about okay so you could say oh they're their sets were great during the whole night they're on two liters nasal cannula boom that showed me that you were smart enough to identify that the patient was okay with regards to oxygen but it did require some some some assistance from two liters nasal cannula okay so then you should tell me about their respiratory rate that could be you know a range as well with regards to respiratory rate you could tell me if there are reading sixteen times a minute but are they reading sixteen times a minute because they're on a vent that's set at 16 or they spontaneously breathing 16 times a minute or is the vent set at 16 times a minute and they're breathing 34 times a minute over the bed these are things that you should be able to interpret and give me that information so the next thing in the vital sign and once again all these different parameters respiratory rate temperature etc could be in different orders it's all you know basically what you want to do as long as you get that information out of there the next piece of information is the blood pressure and in patients who are critically ill those who have an arterial line and those patients who are oppressors I would rather prefer for to hear the mean arterial pressures as opposed to systolic and diastolic because we know about the problems with the blood pressure cuffs that are computerized and sent up to the monitor that they're not really that accurate okay so I prefer to know the mean arterial pressure so if you can tell me all the patient with normal tests in the whole night that's fantastic there are normal tensive but were they on pressors or the unhappy or the out phenylephrine where they are basal press with Levophed these are things that I need to know and if they were on pressors I need a know if it was titrated upward or downward during the course of the night so you could say yeah this person was normal tested the whole night but there you go says there Levophed requirements went up from two mics to 30 mics well then they were really stable they were actually getting safer so you kind of see what I mean by that I hope that I hope that I'm elaborating all this perfectly and if for example somebody has a an intracranial hemorrhage you really should keep their systolic blood pressure less than 140 per the guidelines now you can say oh this person was under 140 the whole night yes but did they get any PRN blood pressure medications they get a need to bathe a lot to get any hydralazine these are things that you should people tell me during course rounds okay what they got to treat their blood pressure so part of that might seem like a lot so far well we have a lot more to go and I understand how this might be overwhelming but trust me trust me trust me and once you get the hang of doing this it'll be pretty pretty darn easy okay so I went over the one-liner overnight events we cooked the vital signs next thing is eyes and nose and when you start seeing the eyes and nose you should say oh this person and this is usually obtained through the EMR somewhere in the software or you could obtain this by printouts you know basically everything that the nurses chart you should tell me how much the patient's net negative or net positive over the last 24 hours as well as how much they are negative or net positive during the course of the hospitalization and of course insensible losses are something that you should keep in the back of your mind and you know use that in your supplement plan the other thing that's extremely important in critically ill patients is measuring the urinary output on an hour to hour basis okay and sometimes you can find that on your EMR because I need to know whether the patient's urine output dropped off and then they got a 500cc bolus at some point or the urine picked up spontaneously because I could lead us into clues as to things that could be going wrong with the king so the the other thing with regards to the eyes and nose on the eyes component of it we need to know what the patient's getting with regards to IV fluids like is are they net positive because they received X amount of bonuses do they get normal shaving maintenance fluid at 125 we need to keep that in the back of our minds because these are things that we could potentially cut back on if the patient is net negative we need to know is it because they're having a post ATM diuresis or is it because we're actually trying to diary something using furiosa light or some other agent are they having a lot of drainage from their JDP drains in the case of people who are in the cases of people who have had abdominal surgery did they put out a lot from their chest tube while they're having a lot of very obama ting we need to know all these things and we also need to know the patient's having Bob it's because that's important one of the things about eyes and nose as I said you have to take accessible losses into a cow so they're not 100% accurate and we're aware of this so you know that's just some more information from the presentation that we should go over the next thing I'm going to talk about now is the ventilator now I don't expect you to know absolutely everything about the ventilator because there's a reason why there's a fellowship for critical care and pulmonary and critical care it's to be the expert on the ventilator also there's a reason why there's respiratory therapists because the ventilator ultimately belongs to them but I do need you to understand basic principles with regards to the ventilator because I need you to give me that information during during rounds so it's just going to be the basics I want you to be able to tell me what the mode of ventilation is and usually the motor ventilation which I plan on making an independent video talking about ventilators but you got to tell me if they're on pressure support if there are pressure control if there are volume control they're on simv if they're on prvc are they on aprv these particular components are important okay I need you to tell me if what they're what they're driving pressure is if there are or pressure support moment excuse me some sort of pressure control mode yeah or pressure control mode I would like for you to tell me what the fio2 and peep is and the respiratory rate and the tidal volume now when you tell me the respiratory rate you might go ahead and take a look and see that the rate is set to for example 16 as I used earlier during this talk but the patient might actually be breathing spontaneously over over this particular range so you might actually go over look at the patient might see that they're breathing faster than 16 times per minute and if you look on the vendor is usually an F somewhere in there depending on the under brand name and that will be able to indicate what the actual respiratory rate is for the patient okay so that's basically it for the for the ventilator also talk to your arteries they might be helpful in telling you if there are any issues overnight with regards to a ventilator so now we get to lab data a lot of data tends to bog down people because they just go to the piece of paper and they say Oh CBC hemoglobin let's go with normal order how does in the United States Oh WBC 15.3 hemoglobin 9.6 how matter do you think you really think that anybody's listening to you when you're saying that I might be throwing over a bunch of I might be like kicking myself under the tape on a bunch of intensivist but that's just mundane data that most of us who are hyperactive people don't have the attention span to listen to and like I said we already went through that data so when you actually go through your CBC I want to know about trends I want to know about her what killed trans or hemoglobin trends platelet counts and things of that nature okay and the differential is always important okay so don't forget when you're saying the white count on trends keep in mind I'll also and you know somewhere in there whether there biotics or not or whether they are on some medication is going to push their white count up for example steroids they kick up your white cell count so keep that in mind with regards to the hemoglobin trends you know this is also important in patients who you suspect with bleeding patients who are anti quiet it is things like that so you might say oh the hemoglobin is 7.1 and you know it's different if it's 7.1 and it was 9.6 yesterday versus 7.1 and no 7.3 yesterday so the trends are very important because clinically they tell us what to do and we need to know what to do that's the whole point of getting all this information um platelet count trends are also important in the site with regards to pig as being something reactive so it could be something else extremely elevated in patients who have some sort of intra-abdominal abscess or you think of thrombocytopenia because of critical illness sepsis or the big scary three-letter acronym that we are not supposed to say during rounds which is hit okay always keep that in mind and don't forget that he will die Lucien and hemo concentration please into your white count and nuts your white number to your CBC so that's why I kind of want you to know what your eyes and o's are when you present the patients to me because you can say oh the patient's net negative over the last 24 hours 2 liters right and then you could correlate that into your CBC and say oh but the white count went up and the haemoglobin went up and the platelet count went up well that's because you got rid of two liters somewhere so there is some component of human concentration in that particular patient so keep that in mind remember you're here to analyze data not just to regurgitate it to me and now with regards to the basic metabolic panel or the comprehensive metabolic panel once again knowing the trends is sometimes better than knowing the absolute number so if you read to me sodium 137 potassium 3.8 now that's something that's that's just not going to work for me and yeah here's how you should do it the sodium is 145 yesterday today it's 152 and you might think to yourself oh man this patient is getting a bunch of sodium chloride which is 154 million quipment per liter hmm maybe I should change the IV fluids to something like plasma light or LR so that this patient doesn't become hypernatremia and hyperkalemic because of some mistake that were overlooking okay so you can I hope that I'm hooked on portraying you know the common-sense approach to presenting a patient rather than just getting through presenting a patient and going to go eat lunch okay so other things like that affect the sodium always remember the medications the the IV fluids diuretics whether they be thighs eyes making hyponatremic or buros alive which could make you hyper natrium I guess you excrete more for your water these are things that you should keep in the back your mind because you could go ahead and show off in your assessment and plan and say oh this patients hyper main treatment because amongst other things they're getting a bunch of normal saline which has 150 formal equivalence and when you present that to me during rounds I'm going to be impressed by you because that shows me you're thinking about things more so than you saying numbers over to me so when it comes down to their electrolytes that we could replace whether they be potassium magnesium phosphorus remember phosphorus is very important for the respiratory muscles so you got to keep that within normal limits especially for ventilated patients and critically ill patients you should be able to tell me whether those numbers are higher during your presentation you say oh the K is 3.2 which is low or old magnesium 0.8 that's pretty darn old we need to fix these and you go ahead and you show off in your assessment of class a hypomagnesemia which will replete hypo cane etc okay excuse me as I clear my throat also on your on your CMP and BMP you also going to get the glucose my camera hunches so getting back to what I was saying about glucose the glucose trend is very important that's usually charted by your nursing staff and so you should report during your report during your presentation about the patient has a glucose range between let's say 120 and 350 and then in your assessment and plan you have to come up with a reason or way to bring that blood glucose down from 350 to a level that's more acceptable another thing that's very important to look at with regards to trends is to be UN in Korean okay because there are certain parameters which you should know differential diagnosis for elevated B ones and it's not only the patient is dry but something like a GI bleed caused an elevated B be un so take that into account and the creatinine is also super important even though it's ultimately not the best test for renal function it is the best that we have right now and basically it's an international test that you don't need to be at a fancy institution to be able to use and so you might say that the creatinine is 1.1 and it doesn't show up on red on the computer or on the printout and so therefore it's normal well that's not true you have a person without a creatinine 0.5 the day before and the next day is 1.1 and this patient's creatinine has doubled in the last 24 hours sir they're basically in renal failure right now okay so that's why trends are important to just analyze the days before and what the numbers have been in which general direction that their their renal function is going so it's not only seeing the numbers but interpreting it okay fft is also important think about what drugs and which medications you're giving the patient in order to alter those numbers okay so as we move along the next step is the culture data which is here in the labs my camera has overheated twice now so we're going to continue on talking about the culture data and this is the part where you have to say what the results blood cultures are and keep in mind when they were drawn okay because that helps me decide whether I need to be draw blood cultures that they're still sick if they're still fevering if they're still requiring escalating pressors or if I'm thinking I'm not getting the right blood with the right antibiotics so the culture is if they're negative one were they drawn respiratory Quandt you're in culture things that I made sure should come up here um cultures many other thing you might have cultured that was redundant anyway let's move on um so after we go over the lab data which includes the culture data next up is the imaging and the one thing I recommend for trainees as well as nurse practitioners on pas is to review the images yourself don't just look at what the radiologist said and you know present that on rounds take a look at the picture yourself and interpreting during medical school and I'm sure that this also applies to nurse practitioner school and physician assistant school they don't dedicate that much time to radiology it's very important and so if you look at a lot of pictures you're able to pick up uh some trends and kind of be able to identify things that you weren't able to identify one so look at the picture look at the read from the radiologist then look at the picture again and use all that information to present your chest x-rays kayuu B's CT scans of the chest head whatever you need learn to basically read it yourself you also should keep in mind the nuances of echocardiograms because that's also part of the imaging in critical care medicine the left heart is very important but the right heart is as well so keep that in mind your patients take on the venom that they're not right heart failure that's a conversation for another day but look at the look at the whole entire report for an echocardiogram and don't just focus on the ejection fraction okay and next step is to look to slice and cap is that the patients been to for three weeks now well you should have been thinking about a tracheostomy a while ago if the patient has central lines you should always be thinking about alternatives to central lines at the central net central line doesn't need it anymore you should definitely talk to your nursing staff but obtaining peripherals yeah the thing is that um you should always take a look at the folding not look at the for yourself well you should look at for forming yourself but could before we come out okay and these these things you need to try to get them out and talk about that during your assessment and plan now we're all medicine doctors even if you might be a surgeon you're still a medicine doctor so you shouldn't know every medication that the patient is on and whether something needs be escalated or de-escalated and you should tell me when you say all this patient's been on vancomycin as an example you should tell me how long the patient's been on mango mice and for you already told me what they're being treated for in the in the culture data if something grew out but you should tell me how long the patient has been on peg Meissen as well as any antibiotic for here you should also tell me what fluids are on what's the rate of the fluids you should also be really analyzing how much inside the patient got in case at their hyperglycemic and how much legs give a patient God because that sliding scale could be converted to a long-acting insulin if that's available in your country now here's the time for the physical exam and please pleaseplease on this particular part talk to your attending and find out what they prefer for you to present during the physical exam in my particular case we already talked about the vital signs so you raise your not tell me the vital signs again and when you go into the patient to examine the patient you should always take a look at all the drips that the patient is on the reason for that is because your physical exam could be altered based on the patient's sedation so if the patient's on fentanyl and propofol your Mental Status is the Status exam it's not going to be kind of where where you want it to be they're not going to be as brisk and as happy and as wake as as a you would think okay so first when presentation on the physical examination you just say whether the patient's sedated and intubated if they're if they're awake following commands a neurologic exam is extremely important on a critically ill patient because a lot of times it's stroke and if you don't turn off the sedation and try to get an exam on them you're not going to be able to find out whether they have a stroke or not and then you're going to miss it and then they're going to be sicker because you miss something and that that's pretty bad so when you dig in our logic exam of a patient I don't really expect you to be doing reflexes and things of that nature but make sure you turn off sedation and try to get the patient awake up open your eyes follow commands follow two-step commands see what they can do if they're not by doing that pinch um try to elicit painful reflexes see if they localize to pain other components like that which I'm not going to go over on this video which are important for a neurologic exam okay make sure that the tubes and the lines look good make sure that their heart sounds are good that they're that the breath sounds are okay that the patient does not have a distended belly rubs and bowel sounds make sure that they don't have anything going on with your skin other components of the physical exam which not going into it too much in depth because your physical exam should be pretty concise and critical care but at the same time pretty thorough to what you're looking for in a particular patient you don't you want you don't want to miss anything okay so that's what not least is the assessment plan like I said I'm not going to discuss this during this talk because the assessment pens depends on the institution and the assessment plan is basically your opportunity to shine and your opportunity to say what the problem is with the patient and how you're going to fix it okay whether you go by systems or by problem based that's up to you but rows up to your institution excuse me but ultimately that's your time to shine the whole point of doing all this is to be able to talk about your assessment plan so this video is I guess it will be like 20 something minutes long now and I basically went through the whole entire the whole entire presentation of a patient so your should be less than that because I ran my mouth quite a bit so lastly thank you very much for watching this video I've met on growing my channel substantially now in 2017 it's been one of my new year's resolutions and I want to get 10,000 subscribers before the years up right now and we have about 47 subscribers but hey please give me a thumbs up I like if you think about giving me a thumbs down please tell me why the comments below thank you so much for watching and I hope you have a great 2017 as well thank you guys