Stepping in the Middle

January 13, 2019
by Mark David Siegel

Hi everyone,  

Some of you have asked me how to present patients who are already hospitalized but new to your team, for example coming as a transfer. The short answer is you should describe highlights from the hospitalization in your Chief Concern and HPI. Let’s consider a patient transferred to the MICU:

Chief Concern (or “Critical Care Chief Concern” in MICU parlance): Include the standard name/age/gender/key medical history part, but also explain why the patient was initially admitted and why he came to you:  

“Mr. Smith is a 74-year-old man with severe emphysema, admitted to the floor 5 days ago for a COPD flare, now transferred to the MICU with respiratory failure requiring intubation and mechanical ventilation.”  

HPI: Like all good HPIs, your transfer HPI should follow a narrative arc. Don’t heap on unnecessary detail from earlier in the hospitalization. Instead, create a coherent story by synthesizing and highlighting key facts. Don’t include the three days of rhinorrhea before admission, exposure to grandchildren with colds, refusal to come to the hospital right away, etc. Leave out useless detail like his wheezing in all lung fields on the first day, wheezing more on the right than left on the second day, etc., etc., etc... Just highlight the facts that explain the transfer, including the change in his condition and key findings from the floor team’s evaluation. For example:   

“The patient was initially admitted to the floor for a COPD flare, attributed to a rhinovirus URI. He was treated with prednisone, Duo-Nebs, doxycycline, and oxygen and said his cough and shortness of breath were gradually improving. However, he reported intermittent difficulty bringing up sputum, which got no better with guaifenesin. On the day of transfer, an RRT was called at 9AM when his nurse was unable to wake him and found he had an SpO2 of 76% on 2LPM oxygen. The patient was afebrile with otherwise stable vital signs. On physical exam, he was unresponsive to sternal rub and air movement was poor; there were no wheezes. The JVD was flat and there was no peripheral edema or leg asymmetry. A stat portable chest x-ray showed a new opacity in the RLL and an ABG showed an acute respiratory acidosis and hypoxemia with a pH 7.10, PCO2 84, PO2 44. The patient was intubated and transferred to the MICU for further management.”

PMH: List the same PMH included in a standard admission note. New diagnoses found during the hospitalization go in the HPI (for example a new DVT).

Meds: Give the current medications. You should know the patient’s home meds and can cite them in your note, but only recite them during your presentation if relevant (e.g., if a patient’s home diazepam was stopped and now he’s withdrawing).

FHx/SHx: As with the meds, cite these in your note and recite them in your presentation if relevant. Include information about family and significant others. If the patient has a substance use disorder, say so.

ROS: Use your discretion about obtaining a new ROS if done before. Don’t confuse the ROS with pertinent positives and negatives; they go in the HPI.

Physical Exam: Describe your physical exam, including the vital signs taken when you saw the patient.

Diagnostic Studies: Describe your work up, including blood work, urinalysis, EKG, and imaging. Don’t belabor tests already discussed in the HPI (like the ABG and CXR above). Use discretion about tests done earlier but not discussed in the HPI (e.g., a negative sputum culture or an unremarkable echocardiogram).

Summary: Provide a synthesized summary:  

“In summary, this is an elderly man with COPD, admitted five days ago with a flare, who initially improved with prednisone, bronchodilators, and antibiotics but suddenly developed depressed mental status, an acute respiratory acidosis, hypoxemia, and a new RLL opacity and is now transferred to the MICU with respiratory failure requiring intubation and mechanical ventilation.”

Assessment: Provide a differential diagnosis, focusing on the issues leading to the transfer. In this case, you might consider mucus plugging with atelectasis, hospital acquired pneumonia, and an aspiration, since he has a new RLL opacity. Tell the team which diagnoses you favor and which you consider less likely, and explain your rationale.

Plan: Same as always (usually problem-based on the floor and system-based in the ICU).   

So in short, when you take over care in the middle of a hospitalization, your writes ups and presentations should still follow the “Yale Way,” but you need to describe the hospital course in your history and make key decisions about what to include and what to leave out.  

As some of you may have guessed, subspecialty fellows have to master this skill too, for example when they’re called to evaluate a hospitalized patient with a rising creatinine or a persistent fever. But we can discuss consult presentations another day...  

And with that, I’m off to the MICU where my team just got an influx of holdovers,

Mark

Submitted by Mark David Siegel on January 13, 2019