Embedded Files
CPRS Auotexts
CPRS Auotexts
Walk-up Flex Sig
We can perform an unsedated flexible sigmoidoscopy to evaluate for source of rectal bleeding on a walk-in basis Mon-Fri 8AM-2PM. The endoscopy unit is located on 5th floor of VAMC. Please inform the patient that exam would be performed unsedated and following an enema administration. Patient should present to endoscopy unit on a day when having rectal bleeding for improved diagnostic yield. If hemodynamically unstable, patient should present to ED for evaluation.
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Normal Cirrhosis A&P
1) HCC screen: Last US ***
-Repeat US ordered and continue every 6 months
2) EV screen: Last EGD ***
3) Fluid/Ascites: None present
-Encourage 2 g Na limitation, monitor for symptoms
4) HE: No overt symptoms
-Continue to monitor
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GERD A&P
-Ensure that patient takes PPI dose 30-60 minutes prior to breakfast and dinner
-Instruct patient to avoid late night meals (no food 3 hours prior to bedtime)
-Instruct patient to elevate head of bed 30 degrees (place pillows underneath
mattress or buy cinder block to elevate bed) if symptoms are worse at night
-Patient should be counseled to loose weight. May benefit from referral to MOVE
program
-Please ensure patient is not taking any OTC NSAIDs which can exacerbate
symptoms
-If patient still has symptoms in about 6 weeks after above recommendations have
been in place, repeat e-consult to GI for clinic evaluation
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Diarrhea: DDx includes infection (bacterial, viral, other), medication-induced, toxins, bile acid malabsorption, IBS, endocrine disorders, antibiotic use, SIBO, osmotic diarrhea 2/2 intake of particular osmoles, IBD
- Check celiac serology (i.e. TTG IgA & TTG IgG), HIV
- Avoid sorbitol based elixirs & limit fructose/sucrose based food/liquid intake
- Avoid: magnesium, phosphate, sulfate based dietary additions & supplements
- Check stool cultures, stool O&P, c. diff, fecal leukocytes, fecal calprotectin, stool osmolality
Treatment:
- psyllium
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Colonoscopy:
- maintain two large bore IVs. volume resuscitate as needed to maintain adequate perfusion.
- Transfuse PRBC to keep Hgb > 7
- clear liquids for now
- keep NPO after MN
- please give 4L of golytely in a split prep fashion, (i.e. 2L from 6-8L tonight & 2L from 5AM-7AM early tomorrow morning)
- will plan for colonoscopy tomorrow
- please page the on-call fellow with any changes in hemodynamic status or any signs of clinical deterioration that might warrant earlier intervention
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Constipation: DDx includes medication-induced, metabolic (i.e. DM2, elytes), obstructive lesions (i.e. strictures, tumors, diverticulitis), endocrine (i.e. hypothyroidism), neuropathy
- limit narcotics if feasible
- avoid anti-cholinergic drugs, anti-histamines, nsaids
- check TSH, order KUB
- therapeutic trial w/ psyllium
- bulk laxatives (i.e. psyllium, metamucil, etc)
- emolient --> docusate
- osmotic agents --> milk of magnesia, lactulose, miralax
- stimulant laxatives--> senna, bisacodyl
- chloride secretagogues --> lubiprostone
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UGIB:
- maintain two large bore IVs. volume resuscitate as needed to maintain adequate perfusion.
- Transfuse PRBC to keep Hgb > 7
- keep NPO after MN
- start on IV PPI Q12H
- start on octreotide gtt
- start on Abx (i.e. ceftriaxone)
- will plan for EGD in AM
- please page the on-call fellow with any changes in hemodynamic status or any signs of clinical deterioration that might warrant earlier intervention
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ERCP:
- maintain two large bore IVs. volume resuscitate as needed to maintain adequate perfusion.
- Transfuse PRBC to keep Hgb > 7
- keep NPO after MN
- consider Abx if elevated WBC or fever spike
- hold anti-coagulation, check AM coags (i.e. INR, PTT, etc)
- prefer INR <1.5 for procedure, would recommend FFP/vit K to optimize this (though particulars are left to discretion of the primary team)
- will plan for ERCP tentatively
- please page the on-call fellow with any changes in hemodynamic status or any signs of clinical deterioration that might warrant earlier intervention
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Cirrhosis, _compensated.
- MELD _
- Etiology: _
- Complicated by: _
- Portal HTN: _
- Volume Status: _
- Hepatic enceph:
- Variceal Screening on: _
- HCC Screening: _
- Vaccination Status:
-Hep A & B:
-Influenza:
-Pneumococcal:
- Transplant evaluation:
Templates courtesy of Dr. Bilal Siddiqui
Cirrhosis 2/2 _, _compensated. MELD _. Complicated by _
1. Volume Status: _
2. Hepatic enceph:_
3. Variceal Screening on: _
4. HCC Screening: _
5. Vaccination Status:
-Hep A & B:
-Influenza:
-Pneumococcal:
6. Transplant evaluation: _
Constipation: DDx includes medication-induced, metabolic (i.e. DM2, elytes), obstructive lesions (i.e. strictures, tumors, diverticulitis), endocrine (i.e. hypothyroidism), neuropathy
- limit narcotics if feasible
- avoid anti-cholinergic drugs, anti-histamines, nsaids
- check TSH, order KUB
- therapeutic trial w/ psyllium
- bulk laxatives (i.e. psyllium, metamucil, etc)
- emolient --> docusate
- osmotic agents --> milk of magnesia, lactulose, miralax
- stimulant laxatives--> senna, bisacodyl
- chloride secretagogues --> lubiprostone
Diarrhea: DDx includes infection (bacterial, viral, other), medication-induced, toxins, bile acid malabsorption, IBS, endocrine disorders, antibiotic use, SIBO, osmotic diarrhea 2/2 intake of particular osmoles, IBD
- Check celiac serology (i.e. TTG IgA & TTG IgG), HIV
- Avoid sorbitol based elixirs & limit fructose/sucrose based food/liquid intake
- Avoid: magnesium, phosphate, sulfate based dietary additions & supplements
- - Check stool cultures, stool O&P, c. diff, fecal leukocytes, fecal calprotectin, stool osmolality
-
Treatment:
- psyllium
GERD:
- PPI BID
- add ranitidine 150mg QHS
- Weight loss
- elevated head of bed at night
- Avoid eating meals 2-3h prior to sleeping.
- Avoid fatty foods, caffeine, chocolate, spicy foods, etc. which may precipitate symptoms
Inflammatory Bowel Disease, type_, location _, disease activity _
-date of diagnosis: _
Steroid hx: _
- DEXA:
- Colonoscopy status: _
- Treatment: _
IBD-related Healthcare Maintenance:
- TPMT level: _
- TB status: _
- Vitamin levels:_
- Smoking status:_
Vaccination status:
- Hep A/B:
- Influenza:
- Pneumococcal:
Inflammatory Bowel Disease, type_, location _, disease activity _ (INPATIENT CONSULT)
-date of diagnosis: _
- steroids: _exposed, _dexa
- please order stool studies/cultures, stool O&P, c. diff, fecal calprotectin
- please order KUB
- pregnancy test
- IV methylpred 60mg Q24h
- daily CBC w/ diff, BMP, ESR, CRP
- avoid narcotics
- volume resuscitate w/ IVF as needed
- subQ heparin for DVT PPx
- will need f/u in 2w after discharge
- consider nutritional consult
IBD-related Healthcare Maintenance:
- please check TPMT, T-spot, vitamin D, iron panel & ferritin, Hep A IgG, HBcAb, HBsAb, HBsAg
- smoking cessation counselng
- consider vaccination w/ pneumococcal & influenza if feasible
Transplant Evaluation:
- Echo:
- LHC:
- PFTs:
-psych
-social work
-dental
Age related screening:
- DEXA
-pap
-colon
-mammogram
UGIB template (i.e. Melena/Hematemesis):
- maintain two large bore IVs. volume resuscitate as needed
- Transfuse PRBC to keep Hgb > 7
- keep NPO after MN
- start on IV PPI Q12H
- start on octreotide gtt
- start on Abx (i.e. ceftriaxone) for 7d for SBP prophylaxis
- will plan for EGD in AM
- please page the on-call fellow with any changes in hemodynamic status or any signs of clinical deterioration that might warrant earlier intervention
LGIB/Colon Template:
- maintain two large bore IVs. volume resuscitate as needed
- Transfuse PRBC to keep Hgb > 7
- clear liquids for now
- keep NPO after MN
- please give golytely & bisacodyl per inpatient colonoscopy order set (listed as Endoscopy: Colonoscopy Prep)
- will plan for colonoscopy tomorrow
- please page the on-call fellow with any changes in hemodynamic status or any signs of clinical deterioration that might warrant earlier intervention
Anemia workup (double EGD/colon:
- maintain two large bore IVs. volume resuscitate as needed
- Transfuse PRBC to keep Hgb > 7
- clear liquids tomorrow
- keep NPO after MN
- please give golytely & bisacodyl per inpatient colonoscopy order set (listed as Endoscopy: Colonoscopy Prep)
- start IV PPI BID
- will plan for colonoscopy & EGD tomorrow
- please page the on-call fellow with any changes in hemodynamic status or any signs of clinical deterioration that might warrant earlier intervention
Cirrhosis: _compensated, c/b _, MELD _ (INPATIENT CONSULT)
- liver U/S w/ vascular/doppler
- diagnostic/therapeutic para
- start ceftriaxone for 7d (UGIB in cirrhotic patient)
- check viral hepatitis panel
- please check daily CBC, BMP, LFTs & INR
- maintain 2 large bore IVs, supportive care & volume resuscitation as needed
- transfuse to maintain Hgb >7
- c/w lactulose, titrate to 3-4 BM/day, give lactulose enema if patient gets overtly encephalopathic. avoid BM >3 as dehydration can precipitate overt HE. add rifaximin 550mg BID if not tolerating/responding to lactulose.
- counseled on complete alcohol abstinence
ALF:
Workup:
- Please order: ABG, lactate, type and screen, tylenol level, UDS/tox screen, ammonia (arterial preferred),
- check for viral hepatitis: HAV IgM, HBsAg, HBcAb IgM, HEV Ab, HCV Ab, HCV RNA, HSV1 IgM, VZV,
- check ceruloplasmin level, ANA, ASMA, immunoglobulin levels, HIV, amylase & lipase
- pregnancy test
- start NAC
- serum urinary & copper levels
Therapy:
- brain CT to r/o other causes
-avoid stimulation/sedation if possible
-panculture & empirically treat if concerned for infection w/ broad spectrum Abx
hypertonic saline to raise sodium to 145-155
give 1 dose of vitamin K
give FFP, plt for invasive procedures or active bleeding
give PPI or H2 blocker for stress ulcer prophylaxis
volume replacement as tolerated, pressor support (i.e. epinephrine, norepinephrine, dopamine) to maintain adequate MAP. add vasopressin for refractory hypotension
CRRT if needed
give lactulose, target serum ammonia <75 (level >200 associated w/ cerebral herniation)
Chronic Liver Disease panel:
please rule out other forms of chronic liver disease by checking: iron panel. ceruloplasmin, antinuclear antibody, anti-LKM ab, anti mitochondrial antibody, anti smooth muscle antibody, serum levels of IgG IgM and IgE, HIV, EBV viral load, CMV viral load, HSV serology and viral load, alpha 1 antitrypsin level
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