Internal Medicine

Case Author: Mitchell Mammel, Class of 2021

Content Expert: Michael Klonarakis, Class of 2020

Case Objectives

Review the elements of an internal medicine consult.
Review the initial steps of an internal consult.
Understand how to find pertinent patient history on electronic medical records.
Practice creating a differential diagnosis to guide and organize an internal consult.
Practice delivering a structured presentation to an IM preceptor.
Practice writing admission orders for internal medicine.
Practice writing a rounding note for internal medicine patients.

Objective 1: Review the elements of an internal medicine consult.

When you do a consult, you are figuring out:

Why are they here? (CC)
Why are we seeing them?
And then completing the usual elements of a consult: CC, HPI, PMHx, Allergies, Social Hx, Medications, Physical exam, Investigations, Impression and Plan (Issues list)
Internal Medicine uses an “Issues List” for the various problems a patient will have: this sort of replaces the “Impression and Plan” portion, where you list the problems a patient has, give a one sentence summary of HPI, lab/physical findings, then talk about your plan for the patient.

Consults in Internal Medicine can happen throughout the day, or into the afternoon/evening if you are on call. If you are on call, you will take consults starting at around 3:30pm, and should NOT take consults after 9pm, because call shifts end at 11pm. The entire process of receiving a consult, finding the patient, reviewing history, completing history/physical, presenting to attending, completing orders and admitting patients takes up to 3hrs.

Start of Case: Receiving a Consult

You are on your first call shift of your Internal rotation, and it is 3:30, meaning you’ll now be taking consults up until 9pm (with call ending at 11pm). You have texted the preceptor you’ll be working with earlier so they have your number, and you receive a text from them: “Hey, we have a patient in the ER to see; they’re in Bay 6. Let me know when you’re ready to discuss the patient”.

Objective 2: Review the initial steps of an internal consult.

Finding your patients in the ER

Patients for Internal Medicine are generally found in the numbered bays in the diagram below, however they can also be in the other rooms shown. Charts are generally found in the following locations:

In the wall-mounted slots behind triage: these are typically patients in the Acute Emergency Room Waiting Area. In Internal Medicine you will not see these patients as they need to be assessed by the ER team before you are consulted.
In the rack above the Nursing Unit Clerk (NUC) station.
In the rack between the two NUC desks: these are charts with pending lab work and imaging orders.
In the slots at each of the nursing stations surrounding the ER core: the slot numbers correspond to bed numbers in the ER. This is where you will most commonly find your patient's chart.

2. Introducing yourself to the Patient's Nurse

You see the patient's nurse sitting at the staff table near Bay 6 and introduce yourself as the CTUstudent who will be reviewing the patient. They say "Oh yeah, that guy came in with chest pain, but he's settled a bit and looks OK".

Nursing staff are very important in giving important information about a patient's condition and course in the ER, but it is your job to assess the patient and come up with your own opinion of their condition and diagnosis.

3. Checking the Patient's ER Chart

You quickly scan the patient's ER chart for the Chief Complaint, vitals, and other information.

The ER chart is usually fairly brief, and is useful to scan to see if there is any extra information in the chief complaint or anything unusual in the vitals. You can do this, but must confirm the chief complaint and the patient's stability yourself.

Note: The ER chart's vitals can be up to a couple hours old, so you need to lay eyes on the patient and assess their current stability (while you get the CC).

4. Gathering the Chief Complaint

You introduce yourself to the patient, and they confirm their chief complaint with you. They also look stable (AKA they don’t look like they’re rapidly deteriorating/imminently dying). You explain you’ll then be reviewing some of their information on their electronic record and you’ll be back to do an examination.

Chief Complaint: “I just had this pain show up all of the sudden in my chest. It’s some of the worst pain I’ve ever felt.”

When you check their vitals, you see the following:

HR: 99 RR: 14 BP: 135/75 SaO2: 98% on RA T: 37.4

The patient looks uncomfortable, but not pale/cyanotic and does not appear to be in acute distress.

The Chief Complaint for this patient is Chest Pain, and you have determined the patient is stable. You can now review the patient's past medical history and create your differential diagnosis, which will guide your consult.

Objective 3: Understand how to find pertinent patient history on electronic medical records.

Gathering Past Medical History

Past Medical History is important for all areas of medicine, and is given particular focus in Internal Medicine. This does not mean you should spend 3 hours looking at their powerchart, but you should find:

A list of their comorbidities
The current status of their comorbidities (Ex. most recent A1C for diabetes...)
How these comorbidities are being managed

Find a computer that looks free. They are all around the staff area.

Log onto Powerchart (hospital’s EMR) where you can look at previous consults they may have had (most IM patients have previous consults). From that, you can pull the most recent PMHx list for that patient, and the basic additional info on the most-current status for each medical issue.
Review and list the Past/Current comorbidities and most-current information.
Medications
- Check to see if there’s a pharmanet (list of patient’s meds) printed out. If not, put in an order to get a pharmanet while you’re checking the PMHx. Patients often don’t know what meds they’re on, but if you can list them off and confirm they’re taking them (you can do this or if you’re lucky, a nurse already has).
- Write the information down onto your consult note. You won't remember it all and it needs to be in the consult note anyway.

Objective 4: Practice creating a differential diagnosis to guide and organize an internal consult.

Creating a DDx.

You’ve now reviewed the Past Medical History, and are preparing your Differential/History/physical for your patient

When preparing yourself to collect the history and physical on the patient, it is important to have a differential prepared so that this guides the questions and physical exams that you do. If you don't have a differential in mind, your history and physical, and later your patient presentation will be unorganized.
A useful trick is to have a spare piece of paper with your differential written out on it, with space below each for history, physical, and associated findings. You can use this to keep your questions to the patient organized and make sure you don't forget anything.
Below is an example of a partial differential for chest pain, with associated notes.

Practice: Create your own DDx.

Take 10 minutes to come up with a Differential for the CC, have one history question for each, and something you’d look for on Physical. Don’t really know a differential for this presentation? PERFECT: look one up (UptoDate/Dynamed/DxSaurus app).

Creating your Consult Note

With your prepared differential list, you enter the bay and interview the patient. Upon completion, you place your notes into the official patient notes that will go into the patient’s binder.

How you write your notes and if you copy them or not is your choice. The DDx. sheet above will organize you, and will allow you to put more succinct notes into the official Physician Notes sheet which will be part of the patient’s binder. Here is a scheme for what an Internal Consult note looks like.

Tip: Internal notes are generally fairly long (Approx. 2 pages). If the patient gets admitted, the notes you write on the admission consult will be the primary notes that people will often read. Having them organized and succinct is very helpful for your fellow students, preceptors, and other Health Care Professionals.

The "Issues List" in Internal Medicine

The "Issues List" is a unique aspect to Internal Medicine. It is the final portion of the consult note and lists the medical issues the patient has. These are given in order by most to least important, and include medical issues that aren't part of the presentation ("inactive" issues). This is meant to give an organized way of approaching the problems a patient has. See the consult note above for the pertinent aspects and an example of an issues list.

Objective 5: Practice delivering a structured presentation to an IM preceptor.

Tips for Presenting to your Preceptor

You’ve prepared your notes and think you’re ready to present to your attending. So, you call/text them saying “I’ve seen the patient and am ready to present”.

They respond “Great, I’ll be there in 20”.

When presenting to a preceptor in medicine, you are telling a story by going through the main sections of the chart and giving pertinent positives and negatives that point towards what you think is going on (aka for the example chart, we think it’s ACS). Think of your presentation as a "sales pitch" for your diagnosis, based on the info you've gathered. Here are some tips for your presentation.

Before you start your presentation, think about your DDx and commit to what you think is going on (IT'S OK TO BE WRONG). Also, think about what you will say and keep the DDx in mind; this will keep things organized.
When you give the CC, the preceptor is already starting to think of what it could be (they have a differential forming in their mind): what you are doing through your presentation is guiding them to why you think it’s X vs. Y and Z.
For a new consult on internal medicine, you are essentially just going step-by-step through ID/CC→ PmHx→ HPI→ other histories (social/family) → physical →investigations → Issues List/Plan.

The below figures will show a "Presentation Script", which will give an example of how to present the above Consult Note to a preceptor.

Patient Presentation in Summary

You have a DDx. in mind, and in each major section of your presentation (History, Physical, Investigations), you are describing the pertinent positives and negatives for each of your options on the DDx to rule them as more or less likely.
You’re not going to do these perfectly. You’ll get interrupted by questions from your attending, and you’ll say “I don’t know” to a lot of them, most likely. That’s normal.

You complete your presentation to your attending with the decision to admit the patient for further investigation and treatment.

Objective 6: Practice writing admission orders for internal medicine.

Practice Writing Admission Orders

Admission orders for this patient are written below. Try writing out some yourself using the above template before referencing the admission orders below.

Admission Orders For This Patient

Admission Orders

Admit To CTU under Dr. X

Diagnosis: NSTEMI

Diet: Cardiac and diabetic diet

Activity: activity as tolerated (AAT), bathroom privileges, bed rest

Vitals: Q4hrs

Investigations

CBC, E7 Daily
ECG daily, QAM
Troponin, CK-MB in 8hrs (put specific time in 24 hour time)
Insulin Sliding Scale, Medium Dose
CBGM TID
Cholesterol, Triglycerides, HDL,LDL, Fasting BG
Telemetry

IV start.

Medications:

ASA 81mg PO daily
Ramipril 5mg PO daily
Clopidogrel 75mg PO daily
Nitroglycerin patch 4mg. Apply Qam, remove QpM.
Metoprolol 12.5mg PO BID (want to reduce HR: depending on pt’s status, may start this once they’ve stabilized more)
Atorvastatin 80mg PO daily
Enoxaparin 1mg/kg SC Q12hrs (you’ll have to do the math on how many mg’s for your patient)
Metformin 1.5g PO daily
Ondansetron 4-8mg PO/IV Q8hrs PRN

You go home for some much needed rest. The next day, you are assigned this patient as you were the student who completed the consult. You are tasked with “rounding” on them and writing a progress note.

Objective 7: Practice writing a rounding note for internal medicine patients.

Rounding and Rounding Notes Template

“Rounding” is literally “going around” and checking in on how patients have done over the last day. Any changes in their clinical picture? Any tests returned that we ordered? By the look of them, do they need any additional tests?
Things to look at: Vitals, ins/outs (if they’re being recorded), lab measurements, imaging. Ask nurses how the patient is doing (are they eating? Are they able to ambulate? If they’re on oxygen, have they been needing more or less?)
Internal rounding notes usually take up about 1-1.5 pages of space, depending on how long their issues list is.

Rounding Note for this Case

ID: Pt. is a 64 YOM w/hx, CAD, HTN & T2D admitted for NSTEMI

Vitals: HR 88, BP 138/78, RR 16, SaO2 97% on RA, T 37.2.

CBGM: 7.8 yesterday PM, 13.4 Today AM.

Recent lab/ investigations:

ECG: No abnormal wavelengths noted.

Telemetry: No abnormal activity noted.

Issues (Active/Inactive)

NSTEMI: 64 YOM w/hx, CAD, HTN & T2D admitted for NSTEMI
- Chest pain decreased since last night. Previously 9/10, how 3-4/10. No lightheadedness/pre-syncope/syncope. Vitals stable. No abnormal wavelengths noted on ECG.
- Plan: Patient currently on ACS protocol, appears stable, initiating transfer to St. Paul’s Hospital for angiography.
Hyperglycemia
- Pt. w/T2D and last A1C of 8.3% on Metoprolol 1.5mg BID. BG this AM 13.1. Pt. states they infrequently get A1C. No peripheral neuropathy, blurring of vision, incontinence of urine at this time.
- Plan: Continue to monitor CBGM’s: If levels remain high, move patient to medium dose Sliding Scale
Housekeeping
- Code status: Full intervention

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