On Call
Medication Mayhem
Medication Mayhem
Patient requests an early refill of lisinopril; last fill was 25 days ago
Refill and educate; verify medication adherence; no misuse concern
Mom calls and states her 2-month old has a fever of 99.7 but otherwise is acting normal.
Monitor at home -- this is not a fever, and there are no symptoms -- give education.
BP on asymptomatic patient in clinic is 155/97.
Re-check BP
A1c of 6.8 in a previously healthy patient.
Lifestyle modification; recheck in 3 months
Patient fainted after blood draw, now alert.
Observe and document; monitor vital signs
You receive a message at 11pm stating the patient is out of lorazepam and they "need it to sleep before a big presentation". Last refill was 2 weeks ago.
Reassess -- this is a controlled substance, need to evaluate for dependence or misuse; need in-person visit before refill
3-year old bumped head on side of coffee table while sitting next to it playing calmly. Is acting normal.
Patient states smartwatch heart rate reading has been in the 40s for the past few days. Patient feels fine.
EKG
65 year old with history of diabetes (on metformin only) has a new BP reading of 167/94 and is asymptomatic.
Repeat BP. If still high, start on ACE
MA gave wrong vaccine (gave a Tdap instead of an HPV to a 14 year old patient).
Incident report; inform patient; reassurance
Patient calls asking for Adderall refill after 6 months with no visits.
Decline the refill and get scheduled follow-up appointment; Addreall is a controlled medication and this patient has a long lapse in care.
5yo won't stop coughing and mom wants refill of albuterol.
Need to be evaluated for wheezing or respiratory distress.
18-month old patient with a cough and vital signs showing: Temp 98.7, HR 105, RR 52, oxygen saturation 98%
Evaluate and likely send to ER
45 yo male with back pain after shoveling. Normal exam and no red flag symptoms.
Rest, Ice, anti-inflammatory pain medication
You have three patients waiting to be seen, one with a sore throat and a fever, one for a thyroid follow up, and one for a rash.
Ask team to start a rapid strep (and possible Covid/flu) test on the sore throat patient; proceed to see whoever has been waiting longer next; have team let other patient know of the delay and keep them informed.
Patient wants narcotic cough syrup for lingering cold.
Decline and recommend an OTC cough suppressant; no clinical indication for opioids in URI
Mother calls saying she noticed 4 day old female has a small some pink discharge noted in the diaper area. There is no overt signs of bleeding and having normal UOP, BM, and feeding without signs of illness.
Give reassurance -- without overt signs of bleeding or infection, this is a normal finding related to drop in maternal estrogen after birth causing bloody vaginal discharge -- will typically resolve in the first couple weeks of life.
Adult patient comes in for flu shot and has temperature of 101.5.
Evaluate for illness
Hold vaccines until afebrile
21yo female with sharp lower abdominal pain on the right side. No medical history. Medications include continuous birth control pills.
You are running behind in your clinic day and have been in with one patient for 30 minutes and are ready to finish that visit when they say 'Oh, by the way I also have this pain in my foot' when you are trying to leave the room.
Acknowledge the issue and let them know to fully evaluate and give it the time it deserves they should schedule another appointment.
Look in chart and review provider notes -- likely there was a transcription error from the call-in to pharmacy and instead of cetirizine, sertraline was entered into the system. STOP the sertraline, call in a change in script to cetirizine.
9 month old rolled off changing table but there was no loss of consciousness
Needs urgent evaluation -- any fall greater than 3 feet in a child less than 2 years of age needs immediate evaluation
Patient with history of heavy periods comes in with fatigue and dizziness. Orthostatic vitals are
Laying: BP 106/70, HR 72; Standing: BP 104/73, HR 103
Send to ER -- despite no significant change in BP, pulse increased 20 points and this is a more sensitive measure of hypovolemia
5 day old breastfed infant with slow weight gain and jaundice not requiring phototherapy.
Supplement with formula after every feeding
You just got called with lab results in the middle of a busy clinic day. Patient 1 -- elevated triglycerides of 657mg/dL; Patient 2 -- potassium 2.4mEq/L; Patient 3 -- hemoglobin 9.8g/dL.
Call the patient with the low potassium immediately -- needs to go to the ER
hemoglobin -- look at chart later in the day to see why test was ordered and decide
TRG -- can wait until the next day