The Sick Patient
Identify unstable vital signs (bonus: what is the indicator of sepsis i.e. how many unstable vital signs indicate sepsis?)
RR>20bpm
HR>90bpm
SpO2<90% or new need for supplemental O2
Temp>38(100.4) or <36
WBC>12k or <4k
Bonus: 2 unstable vital signs is enough to suspect sepsis
What is the difference between an admission note and a SOAP note?
Admission note: HPI, ROS, PMH, PE, diagnostic tests that have already been run, patient assessment, plan
SOAP: usually a much shorter follow up note to document any changes in the patients condition or plan -> subjective, objective, assessment, plan
What is the differential for a red eye?
Conjunctivitis, corneal abrasion/FB, keratitis, uveitis, scleritis, acute angle closure glaucoma, subconjunctival hemorrhage, trauma w/ or w/out hyphema, peri-orbital/orbital cellulitis, optic neuritis
What are the four core bioethical principles of being a PA?
Autonomy - respect the patient's right to make decisions
Beneficence - act in the patient's best interest
Nonmaleficence - avoid unnecessary harm or burden
Justice - treat similar patients similarly & distribute resources fairly
What documents/licensure are required for a PA to prescribe medications in Massachusetts?
- PA license
- prescriptive authority
- MCSR (to prescribe ANY meds)
- DEA (to prescribe schedule 2-5)
- required practice/prescribing guidelines (resigned annually)
- scope consistent with PA practice
What labs should be run when sepsis is suspected?
Bonus: When should you obtain blood cultures?
CBC, CMP/BMP, lactate, blood culture, possible ABG
You should obtain 2 blood cultures (first aerobic, second anaerobic)
Lactate>2mmol/L should be redrawn q3 hours until it returns to normal
Bonus: As soon as you suspect sepsis but BEFORE starting broad spectrum IV abx
What is the difference between a regular admission and an admission for observation?
Admission for observation usually means the patient is expected to stay less than 24 hours in the hospital and they are not receiving active treatment during that time period. It has different billing and documentation protocols.
Regular admission can be from the ED, from PCP or outpatient clinic, and for a planned surgical procedure. These admissions are expected to stay longer and receive active treatment/care throughout their stay.
What are basic diagnostic eye and derm exams?
Eye: inspection, palpation, fundoscopy, snellen test of visual acuity, cover/uncover, fluorescein staining
Derm: inspection, palpation, KOH microscopy, biopsy
What is the primary responsibility of the PA?
Bonus: What 3 questions should PAs consider when considering legal and ethical principles?
Patient health, wellness, welfare, dignity
Bonus: What does the patient want? What does the law say? What are my ethical obligations?
What are the components of a prescription? (Hint there are 7 major categories)
- patient information (name, DOB, address, issue date)
- med (name, strength, form)
- route of administration
- dose (plus total quantity)
- instructions (how frequently do they take the med)
- refills (how long should they use it for and how many refills should they get)
- prescriber information (name, credentials, practice, NPI, MCSR, DEA, signature)
Differentiate SIRS, sepsis, and septic shock.
SIRS: systemic inflammation
Sepsis: SIRS + infection (bacteremia or localized infection) +/- end organ damage
Septic shock: Sepsis + hemodynamic instability (SBP<90mmHg or drop>40mmHg from baseline)
What types of activities fall under nursing orders in a hospital admission order?
Bonus: Can you name all the parts of ADCVANDIMALS?
Nursing orders: wound/skin care, precautions, DVT prophylaxis, incentive spirometry, restraints, splint/brace care, toileting, glasses/hearing aids
Bonus: admission, diagnoses, condition/code status, vitals, activity, nursing, diet, IV fluids, medications, allergies, labs, special
What is the initial management for corneal ulcer keratitis, acute angle closure glaucoma, rosacea, and psoriasis?
CUK: culture, abx, cycloplegics, NO CONTACTS
AACG: TAP + acetazolamide, recheck IOP every 30 minutes, supportive care, gonioscopy or emergency iridotomy
Rosacea: avoid triggers, metronidazole, azelaic acid, PO tetracycline for severe cases
Psoriasis: assess for psoriatic arthritis, topical corticosteroid, topical calcipotriene, moisturize
What is the minimum level of information that you need to give a patient to have decision making capacity?
- nature of medical decision
- objectives of proposal treatment
- treatment options
- possible outcomes and risks
What do the abbreviations AC, PC, and HS stand for in a healthcare setting?
AC = before meals
PC = after meals
HS = at bedtime
What are the signs of end organ damage?
Neurologic (LOC, decreased GCS)
Cardiovascular (BP drop or MAP<65)
Renal (anuria, dysuria, Cr>2, decreased GFR)
Hematologic (platelets<100,000 or INR>1.5)
Others (mottled skin, decreased cap refill, hyperglycemia, arterial hypoxia, absent bowel sounds, elevated biliruben)
What are the proper handoff and sign-out practices during transition of care?
You must present the case to the provider that is taking over care so they are aware of the status of the patient and can ask any clarifying questions
What is in the differential for dry patches on the skin?
Atopic dermatitis, seborrheic dermatitis, tinea corporis, contact dermatitis, pityriasis roasea, lichen planus, plaque psoriasis, psoriatic arthritis
What types of communication are protected under patient confidentiality?
Bonus: What are exceptions to patient confidentiality in Massachusetts?
- electronic
- verbal
- written
- medical records
Bonus: suspected child or elder abuse/neglect, abuse of persons with disabilities, reportable infectious diseases (HIV, syphilis, gonorrhea, hepatitis), certain sexual assault, firearm related injury, burns >5% surface area, criminal knife/sharp instrument wounds, serious/imminent threat to safety, court order
How many refills does each schedule class of drugs get in Massachusetts?
Bonus: examples of drugs in each class
Schedule 1: not prescribed (illicit drugs)
Schedule 2: NO REFILLS (ex. oxy, fentanyl, amphetamine, methadone)
Schedule 3: No more than 5 refills in 6 months (ex. buprenorphine, ketamine, testosterone, anabolic steroids, codeine)
Schedule 4: No more than 5 refills in 6 months (ex. benzos and tramadol)
Schedule 5: Unlimited refills (ex. pregabalin, lomotil, low codeine cough preparations)
Schedule 6 (MA only): Unlimited refills (all other prescription drugs - ex. abx)
What is the management plan for a patient presenting with sepsis?
1. Pt presents with si/sx of sepsis or septic shock
2. Give 3, take 3 (give O2, abx, IVF, take blood culture, urinalysis, lactate)
3. Broad spectrum IV abx should be started within an hour and fluid resuscitation should be started within 3 hours (sooner if severe septic shock)
4. Monitor closely, run any outstanding labs (CBC, CMP), reasses/redraw as needed until patient is more stable
5. When blood cultures come back you can decrease abx to something less broad spectrum based on the results
What are the steps to admitting a patient?
Bonus: What considerations do you have to make when deciding where to admit a patient?
1. Get asked to consult/review for admission
2. Review the patients' chart and CC/HPI
3. See the patient (actually chat with them and do your own PE)
4. Give admission orders (if busy or requires quick admit you can write ghost orders and then finish them later)
Bonus: What is the condition of the patient and what level of care do they need (general med/surg, step down, ICU)?
Do they require specialty services? Can you admit directly to that service or do they have to be admitted to a general services with specialty consult?
What is the differential for red/flushing face?
Rosacea, acne, SLE, seborrheic dermatitis, contact dermatitis, photosensitivity reaction, seborrheic dermatitis, cellulitis, impetigo
What is the difference between laws and ethics?
Laws establish minimally acceptable standards.
Ethics describe higher moral standards.
What is Mass-PAT and when are you required to check it before writing a prescription?
Mass-PAT is the Massachusetts prescription monitoring program that monitors all scheduled medications. It includes information on medication, prescriber, pharmacy, quantity, and fill date for every prescription written.
YOU ARE REQUIRED TO CHECK IT BEFORE PRESCRIBING ANY BENZOS OR SCHEDULE 2-3 NARCOTICS!!