Best Clinical Guide for Your Family and Your Doctor

AuthorHouse

Contents

Introduction...................................................................................viiClinical Scenario One..........................................................................1Alcohol and Drugs: Family Health Guide.........................................................3Healthy Habits: Regular Exercise and a Healthy Diet............................................4Common Critical Hospital Situations for Medical Personnel......................................5Family Health Guide: Why Are All These Wires and Machines Connected To Me?.....................7Healthy Diet: Family Health Guide..............................................................11Chest Pain: Is He Having a Heart Attack? How Can I Help?.......................................12Warning Signs of a Serious Medical Problem.....................................................17Why Your Doctor Says to Stop Using Tobacco.....................................................21Warning Signs of Serious Medical Problems......................................................24Why Do I Need an Annual Physical?..............................................................28Secrets of Doctors Who Write Good History and Physical Reports.................................31Family Health Hints............................................................................36When It Is Time to Return Home.................................................................37Prepare Your Family for Major Disaster.........................................................38Medical References.............................................................................41Disclaimer.....................................................................................43About the Author...............................................................................45

Chapter One

Mr. A. is a forty-five-year-old male. He was brought to the emergency department of the community hospital after his wife called 911. His hands and legs had been shaking, and he was not responding to verbal commands.

When the emergency team arrived, they confirmed he was having seizure. He was given intravenous Ativan by the team. He has a history of heavy alcohol use. He drinks beer and vodka. He has been abusing alcohol most of his life.

His wife said that he had not had alcohol for two days because he was trying to stop drinking. He had lost his job recently due to alcohol use. He had been reporting late to work.

On physical examination in the emergency department, he has tachycardia (irregular heartbeat) and diaphoresis (excessive sweating). His face was flushed. He was awake but confused. He was hallucinating, seeing spiders and objects. He had tremors of both upper extremities.

What should you do?

A. He is withdrawing from alcohol. He needs to be admitted to the hospital for intravenous Ativan, thiamine, and alcohol withdrawal protocol. He is sick.

B. He is malingering (intentional deceptive behavior). It is not a medical problem.

C. He has alcohol withdrawal. He needs to resume alcohol use immediately.

The correct answer is A. He has alcohol withdrawal signs. This is a serious medical condition. He should be admitted to the hospital for treatment.

Options A and C are wrong. He tried to quit, but he needs help to do it safely because his body is addicted and dependent on alcohol. It is safe to get treatment in the hospital. Resuming his alcohol use will result in more harm. It is unsafe to leave the hospital in his current medical condition.

Chapter Two

Drugs and alcohol are very addictive and difficult to quit. The safest approach is not to start using then. If they already have their grip on you, your best option is to make every effort to quit. Drugs and alcohol damage your brain.

They also cause injuries to the liver, which is an organ needed to remove waste products from your body. Toxins will accumulate and make you sick and confused.

People who become confused due to alcohol use or drug dependence cannot function well at work or at home. The consequences include job losses and broken homes.

Drug and alcohol use are serious financial burdens to you, your family, and society in general. The financial implications are exorbitant; they come from the direct cost of obtaining drugs. People who abuse alcohol are more likely to be jobless and homeless. Society pays a big price to treat dependence-related issues that sometimes require multiple admissions to hospitals.

Chapter Three

Exercise regularly—outside in the fresh air if the weather permits. A simple way is to park your car at home and walk to the grocery store instead of driving. Consider getting off the bus one stop ahead and walking home.

Dancing is great exercise for your body. Switch on your favorite music and dance. It is even better when you dance with your spouse. This is not only exercise; it helps build a common interest.

Running, bicycle riding, and jogging are wonderful for healthier, younger people. Participating in gym programs with treadmills and weights can be great for those who can afford it. Alternatives include simple home exercises: pushups, stretching, or walking for thirty minutes each day. Do whatever works for your family and job schedule.

Always observe safety precautions during exercise to prevent injuries and falls. Examples of safety measures include wearing helmets when riding and avoiding wet floors. Frail people and the elderly need extra support to prevent falls and injuries.

Chapter Four

You are a physician on call for a local hospital in the open intensive care unit. You are on call for the entire hospital, including the ICU.

The nurse calls your direct phone because of a critical situation. She is up to date with her ACLS certifications. She has great clinical skills and more than twenty-five years of experience in the intensive care unit.

She tells you that the patient in ICU is not doing well. He is not responding to any stimuli—not even a sternal rub. There is no palpable pulse. His blood pressure cannot be recorded because it is too low. The patient is a fifty- five year old male with diabetes mellitus. He had been admitted the night before with acute renal failure and hyperkalemia (high potassium levels in the blood). He is awaiting hemodialysis. His renal has been consulted.

The nurse and her ICU colleagues have initiated ACLS protocol with good CPR. The monitor shows normal sinus rhythm. You confirm that the patient has no pulse.

The printed 12-lead electrocardiogram is normal, but the patient is unresponsive and has no pulse.

What do you call this condition?

A: A: Sleeping Syndrome

B. Ventricular Tachycardia

C. Pulseless Electrical Activity

The correct answer is C. Pulseless Electrical Activity is a serious medical condition managed as per ACLS protocol. This is a life-threatening condition. When in doubt, call senior doctors.

Option A is wrong because he is not sleeping. He is dying. Act immediately.

Option B is wrong. Ventricular Tachycardia is different because the electrocardiogram will appear ugly—not normal.

Chapter Five

Many patients admitted to the hospital with serious conditions are connected to wires called cardiac monitors. They are used to continuously monitor the heart for abnormal rhythms, which is when the heart starts working in abnormal state. It kills people if it is not identified in time.

You are a first-year medical intern excited about your first overnight call after all the effort to get into medical residency. The nurse calls and says, "Doctor, please help.

The patient is not responding. I cannot feel a pulse." You hear panic, commotion and crying in the background.

What should you do?

A. Wait until you consult your senior doctors. Present the case to them and review your ACLS manual before calling the nurse back.

B. Tell the nurse to do ABCs (airways, breathing, circulation). Initiate CPR if there is no pulse as you rush to help the patient.

C. Tell the nurse to allow the patient to sleep. He must be very tired.

The correct answer is B.

Option A and B are wrong because they will delay care for a patient in critical condition.

Remember that hospital nurse is ACLS trained. Tell her to do ABCs as you rush toward the patient to his save life. This is serious.

Remember that most hospitals have rapid response teams. Bring the crash cart and initiate ABC. Check for a pulse and start CPR immediately.

As you rush toward the patient, think of possible causes (see examples below).

Differential diagnoses include:

• Intracranial Hemorrhage. Do not forget to look for dilated pupils. The head CT will tell you when the patient is stable.

• Ventricular Tachycardia. Is the patient on a monitor? VT is a shockable rhythm.

• Myocardiac Infarction. Was the patient having chest pain or dyspnea before?

• Complete Heart Block (EKG needs to be done)

• Other Arrhythmia

• Pulmonary Emboli (any history of DVT)

• Aortic Dissection. This kills patients if missed.

• Pneumothorax. Is the breathing equal and tympanic?

• Drug Overdose. Was the patient given too much opioid because of severe pain?

• Electrolyte Abnormality. The arterial blood gas and chemistry panel will help you.

Action Plan

Remember to consult experienced doctors and nurses, but do not to delay patient care. See the doctor's menu and select which is applicable based on the specific case scenario:

• Investigations: Use updated ACLS guidelines. Focused exam, ABCD, intubation, shocks, vitals, physical examination monitors, electrocardiogram, laboratory investigations, arterial blood gas, complete blood count, chemistry panel, cardiac enzymes imaging, X-rays, and head CT.

• Medications: Ask yourself when to give any life-saving medication: aspirin, betablock, and anticoagulation during myocardial infarction. If the patient is bleeding, is there contraindication (aspirin and heparin, for example).

• Quick chart review of documentation will tell you about allergies.

• Level of care: Remember that most medical floors do not have enough staff to manage very sick patients that require too much attention. Transfer to step down or intensive care for high care after a near-death situation.

• Advanced care may be necessary in special situations: chest decompression for pneumothorax, cardiac pacing for heart block, TPA for acute stroke, or urgent cardiac catherization for ST-elevated myocardiac infarction.

Chapter Six

The idea of a healthy diet varies due to cultural, religious, and individual preferences. The simple rule is that a diet rich in fruit and vegetables is always great choice because it provides fiber, vitamins, and less fat. It also has high water and nutritional contents.

A high-calorie diet and fried food soaked in oil are is more likely to result in weight gain and obesity

CH7[ Chest Pain: Is He Having a Heart Attack? How Can I Help?

The causes of chest pain include heart attacks, blood clots on the lungs or blood system, blood vessel rupture, chest infection, heartburn, chest trauma, and many more. Physicians are in a better position to diagnose it with modern equipment.

Mr. H. is a sixty-two-year-old male with a history of hypertension, hyperlipidemia, and coronary artery disease. He had cardiac bypass operation two years earlier after a stress test result showed three-vessel disease.

He says the chest pressure feels like an elephant is sitting on his chest. He appears sweaty and anxious. He has been holding his chest for more than forty-five minutes, but it is not resolving. He took baby aspirin without any benefit.

What should he do?

A. Take his anti-anxiety medication and relax because he looks anxious.

B. Call 911 and get to the emergency department right away because he might be having a heart attack.

C. Take his wife's stronger pain medication (Percocet), which her doctor prescribed for pain after her knee replacement.

The correct answer is B. Call 911 and get to the emergency department. He may be having a heart attack because chest pressure is a typical symptom for a heart attack. He has risk factors for heart attack: age, history of coronary artery disease, and a cardiac bypass operation.

Tell the nurse get an electrocardiogram on the patient. See the patient immediately and review the electrocardiogram.

If it is not myocardial infarction, what can it be? Make a mental list of possible causes:

• Myocardial Infarction. If there is STEMI on the EKG, the patient needs urgent cardiac catheterization or thrombolysis if cath lab is very far.

• Pulmonary Emboli. Patients with DVT, low INR, and limited mobility are prone to PE.

• Pericarditis. EKG of pericarditis may appear like STEMI—watch out!

• Pneumothorax. A large pneumothorax causes cardiac arrest. Check lung for equal breathing sounds. Do a portable chest X-ray.

• Aortic Dissection. A leaking large blood vessel is deadly. If this is suspected, get CT angiogram.

• Pneumonia.

• GERD

• Anxiety

• Musculoskeletal

Action Plan

Perform a focused physical examination. Perform and review an electrocardiogram and compare with an old one if available. If there is an elevated ST, this is STEMI until proven otherwise. Timely intervention is crucial during myocardial infarction. Call the on-call cardiologist. Fax the electrocardiogram to him. Some hospitals have a myocardial infarction code. Get the help of more experienced doctors.

Place the patient on a cardiac monitor because arrhythmia is more likely to occur during a heart attack. Obtain a laboratory test, including cardiac enzymes to identify an enzyme leak. Use the chemistry panel. The chest X-ray may show pneumothorax as the cause of chest pain.

Think of any medication you need to give right away. Consider the patient's contraindications for any medications you need to give, such as allergies, bradycardia, or hypotension.

For MI, always review the most recent management guidelines as they change often. Recommended medications include betablocker, aspirin, plavix, nitrate, anticoagulation, ACEI, and statins. BP control to reduce demand ischemia.

If you suspect gastritis as the cause, try proton pump inhibitors such as omeprazole.

When you suspect pulmonary emboli or aortic, have a CT angiogram to rule them out.

Diffuse crackle on a physical lung physical examination may be a clue to pulmonary edema. A portable chest X-ray will you a quick answer. Intravenous furosemide will provide immediate relief for most patients. Antibiotics will be the proper treatment for pneumonia on a chest X-ray. Do not be a medical hero; when in doubt, call the senior doctors for help.

Ms D is a fifty-year-old female. She went to her primary care physician and complained of severe shortness of acute onset a day earlier. It woke her up after she returned from vacation. The flight was thirteen hours with a two-hour stopover.

Her medical problem is diet-controlled hypertension and rheumatoid arthritis controlled on prednisone, which she takes regularly. She had a normal stress test, electrocardiogram, and echocardiogram two months earlier. She has no allergies.

The system review was unremarkable except that she noticed that her left leg had been getting bigger since yesterday. She thinks it is due to her leg position on the plane.

During the physical examination, her vitals, temperature, and blood pressure are normal. Her respiratory rate is twenty-eight per minute. Oxygen saturation on room air is 86 percent.

She appears to be in moderate respiratory distress, but she is able to complete sentences.

The lung examination is normal—no crackles. The cardiac examination is remarkable for only mild tachycardia. There is no jugular vein distension on her neck. Her left leg is obviously swollen compared to right, but it is not warm to the touch.

The chest radiograph is normal. The chemistry panel and complete blood count are normal. Her D-dimer is above 2000.

(Continues...) ]CH7

Excerpted from Best Clinical Guide for Your Family and Your Doctorby Onyechela Ogbonna Copyright © 2012 by Onyechela Ogbonna. Excerpted by permission of AuthorHouse. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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