Cerner/Powerchart

• Click on the link to view the recorded EHR tutorial sessionfrom 06-30-2020 to access on  Microsoft Stream. Click on the gear icon on the video to adjust the playback speed.
  • DO NOT share this link with any non-Wayne State/DMC resident or anyone else as there is HIPAA-protected information in the training video.
• I’m also including a PDF of some online Cerner modules from DMC. Note, some of these are a bit outdated, but can be used as a reference point in the future (please click link for a list of suggested changes/corrections/missing info). The PDF is fairly comprehensive with the exception of Ambulatory Cerner workflow as well as Dragon text to speech integration.
• You will receive Dragon on-site training by the 2nd week of July of the academic year.
• Saving Favorites on Citrix – Instructs you on how to save favorites on Citrix, and includes a list of frequent orders which should be saved.

NextGen

• Please click the link for the online NextGen Tutorials (@wayne.edu login required)
  • Refer to ~Lecture List Nextgen Tutorials(located in the shared folder) for a list of topics
  • Also, take a look at this Ambulatory EHR Manualcreated by Ambulatory CMR 2019-2020 Leslie Kao, MD for tips/tricks
• NextGen has a steep learning curve, but once you have used it a few times, you will no doubt get the hang of it. These tutorials are by no means comprehensive. You guys will learn a lot more tips/tricks along the way, but these resources should help you get through the clinic day without issues.

Welcome to Ambulatory Clinic for the 2020-2021 Academic Year!

Please click the link for the folder containing the Ambulatory Orientation Presentation

Please email me with any questions,

Thank you,

Nabil

Nabil Al-Kourainy, MD
———————————————————
Chief Resident of Ambulatory Medicine
Department of Internal Medicine
Wayne State University/Detroit Medical Center

Email: [email protected]
Pager: 313-745-0203 ext 7305

Please see the attached link for the folder containing the Jeopardy Schedule for the academic year.

Please click the link to access the folder with the Clinic Schedule (2020-2021)

Clinic schedule PDF is searchable and contains the following contents:

1. Clinic cohorts – Navigate to your cohort color and locate your name.
2. Cohort Clinic Calendar –  to determine which weeks of the academic year your cohort is in clinic
3. Intercohort CCR Groups – to determine the residents tasks that you will be covering during your clinic week
4. CCR weekly assignments – your assigned CCR week(s) for the academic year

Specialty Clinics: PGY1s and PGY2s the following policies apply to specialty clinics

1. Resident will send a reminder email to their specialty attending prior to the start of each clinic week of the clinic date/shift where they will be joining the attending’s clinic
2. In the event of an absence from the specialty clinic due to medical/family emergency, post-call, exam, conference etc. the resident will notify their specialty attending via phone, email or text prior to the start of clinic, preferably 24 hours ahead of time.
3. Failure to complete either #1 or #2 will be considered a professionalism violation with consequences.

Clinic exchanges/switches: The following rules apply to clinic exchanges/switches

1. All clinic exchange/switch requests, regardless of the reason, even if payback is not required must be submitted formally online (see link below). Requests submitted via text/WhatsApp/email/phone call will not be considered.
2. Please submit requests at least 8 weeks if not sooner. Requests submitted with less than 8 weeks will be considered on an individual case basis.
3. Residents are required to find coverage and determine payback date, clinic name and clinic shift prior to submitting a request. Requests that require payback without this information will not be considered.
4. All requests will be reviewed by Dr. Thati. No clinic request is granted prior to receiving written approval (via email) from either CMR or Dr. Thati. Please email CMR if you do not hear back about your requested switch.

https://bit.ly/WSUClinicSwitch

If you have questions, please review my email “[Clinic] Resident Clinic Schedule 2020-2021 AY” sent on 06/23/2020. If your question is not answered, please feel free to email me at [email protected]

Ambulatory EMR Manual

Inside:

How to log onto NextGen remotely

How to check your GMAP/6A schedule the day before

And how to write notes and order labs, meds and referrals via NextGen.

Being an avid horror movie fan, you can instantly deduce how October 31st is special to me… I always wanted to throw a Halloween party with crazy decorations… This year I made my dream come true by throwing the party during Morning Report!

So let me tell you about my curious case of bun cellulitis:

Once upon a time, on a quiet call day, the intern me admitted a 68 year-old patient with a history of uncontrolled HTN and cocaine/alcohol dependence… The patient apparently had two fifths of Vodka two days prior to admission (a fifth is a whole bottle, FYI…) and passed out on his back for at least six hours with his wallet in the back pocket. His reason for coming into the hospital was paresthesia of the right foot. He was started on Vancomycin/Cefepime for what we were told a right buttock cellulitis…

The thought sounded outlandish at the time, however I went down to see the patient, I was trying to link the cellulitis and the numbness of the foot, I didn’t have a logical connection then…

Examining the “cellulitis”, the right bun was mildly erythematous and not warm to touch, however there was an induration that you wouldn’t expect in such a circumstance. The labs looked funny: Acute kidney injury (from a previous CKD stage 2), hyperkalemia of 5.8 and hypocalcemia (corrected calcium was 7)… Now Hercule Poirot’s voice was in my brain “Use your little gray cells, mon amie!”, I could see his satisfied smile when the UA showed the tell-tale positive blood with absent RBCs

You know what I am talking about, right? I could see the soft smile on your face!

So a patient who passed out from alcohol for long time, combined with a sprinkle of cocaine who is coming in with AKI, hyperkalemia, hyperphosphatemia and hypocalcemia, with a UA that is showing blood and no RBCs would be having rhabdomyolytis. We ordered a CPK that was > 50,ooo confirming our suspicions!

Now, let’s talk treatment! You would flush them with fluids (aiming for 200 mL/hr of urinary output, you can give anything between 400 to 1000 mL per hour), however after many liters, progressively rising CPK, minimal to absent urine output, rising potassium and signs of pulmonary edema nephrology started the patient on hemodialysis. Keep in mind that dialysis in rahbdo is indicated when you have severe or progressing hyperkalemia, fluid overload and decreased urinary output. The patient recovered his baseline kidney functions and didn’t require continuous dialysis!

It doesn’t have to be a “super interesting” or a “Zebra” case. If you have COPD exacerbations and HF exacerbations that is OK, we can always learn something from a bread and butter case. You might want to focus on differential, or workup, or treatment. All cases are welcome

Identify your case early on. Work with your senior on choosing a patient. You have a week head-start so use it.

2-Content:

It simply follows your H&P: You should have a chief complaint, an HPI (that includes active complaint and review of systems pertaining to it), a ROS, Histories, Illness script, Physical exam (including the vitals), your differential diagnosis, then the workup that was done. It is good to have a hospital course slide telling how you came to the active diagnosis and what was done, then your teaching slides about the subject of the case. Your teaching slides should not exceed 5 or 6 slides, quick take away points

I have attached a template that can aid you in doing your presentation

3-HPI rules 

Please make sure your HPI is clear. It is not a copy paste from admission note, make sure the chief complaint is explored properly along with the pertinent review of systems

4-Senior/Intern roles

• work with your intern on choosing an appropriate case.
• Send the CMR the FIN number of that patient and what do you want to discuss.
• Oversee the intern’s presentation and correct mistakes.
• Teaching slides are your responsibility (5 maximum)
• As you see fit, you can add a MKSAP question

-Intern responsibilities:

• arrange your case on a power point file
• send it to your senior for feedback as soon as you are done
• on day of MR, present your case as prompted by CMR

-Presentations should be sent to CMR 48 hrs in advance. Cases that are sent late will be run by the team senior

-Presenting team should be in the board room 10-15 minutes in advance to set up

Morning Report Template

The patient, a 52 year old man and a smoker went to his PCP for complaints of right shoulder pain that has been going on for the past three months, he has been consuming Ibuprofen without significant improvement. He was found to have severe hypokalemia (K of 1.9) and subsequently sent to the hospital. His shoulder pain was not associated with muscular weakness, however he did complain of some numbness and tingling in the right arm.

His work up included 1-Hypokalemia and 2-Shoulder pain. The fact that he was a smoker for the past twenty years, and the absence of a significant trauma or overuse history to explain the shoulder pain lead to the idea of having a common culprit that would explain his hypokalemia and shoulder pain putting together all the pieces of his history, the though process was to rule out a lung cancer that can cause hypokalemia via paraneoplastic syndrome and shoulder pain via tumor invasion of the surrounding structures.

A chest X-Ray showed a left upper lobe mass, and a subsequent CT chest showed a 7 cm left upper lobe mass, a 2 cm right upper lobe mass and a 7 cm paraspinal mass extending into the thoracic spinal canal prompting neurosugery to start him on dexamethasone and eventually he received laminectomy and resection of part of the paraspinal mass. The biopsy eventually showed poorly differentiated carcinoma with clear cell features.

Now going back to the hypokalemia, and starting workup to see whether this could be caused by this patient tumor, a basic metabolic panel was ordered and it showed a potassium level of 2.3, a normal sodium level (140) as well as metabolic acidosis with HCO3 of 17 and hyperchloremia (111)

Back to the tumor, usually small cell lung cancer can produce ectopic ACTH. SCLC usually shows densly packed small tumor cells with scant cytoplasm (picture on the right). Our patient had clear cells on pathology which points towards other types (SCC, AC, NSCLC).

The fact that the patient had metabolic acidosis with hypokalemia rather than alkalosis which would be expected in an ACTH secreting tumor prompted further search: A urine anion gap was calculated and was found to be negative (-16) and urine pH was 7. This translates into a possibility of a type 2 RTA versus a GI cause of NAGMA (which is less likely as the patient denied any diarrhea)

Further workup for underlying causes of type 2 RTA in this patient included SPEP to evaluate for light chains, which didn’t show spikes, and exclusion of other medications that can cause this disorder (Ifosfamide, Tenofovir, tacrolimus, cyclosporine) as well as vitamin D deficiency and further auto-immune syndromes.

So who could the culprit be? Some digging up in the literature yielded some case reports by Ng et al. and Dang et al. describing cases of type 2 RTA associated with Ibuprofen excessive ingestion, keep in mind that Ibuprofen usually gives a picture of type 1 RTA (hypokalemia and positive UAG) or type 4 RTA (hyperkalemia) .

Fun facts we learned today: GOLD MARK is the new MUD PILES for anion gap metabolic acidosis. GOLD MARK stands for Glycols (ethylene and propylene), Oxoproline, L-lactate, D-lactate, Methanol, Aspirin, Renal failure, and Ketoacidosis. 

1-Suspect endocarditis in a patient with high fevers (>38C) and risk factors either cardiac (prior IE, prosthetic valve, cardiac device, congenital or valvular heart disease) or non-cardiac risk factors (indwelling vascular catheter, IVDU, immunosuppression…)

2-Signs and symptoms can include:

A- Fever (90% of patients) 

B- New cardiac murmur (85% of patients) 

C-Relatively uncommon clinical manifestations that are highly suggestive of IE include:

Janeway lesions – Nontender erythematous macules on the palms and soles

Osler nodes – Tender subcutaneous violaceous nodules mostly on the pads of the fingers and toes, which may also occur on the thenar and hypothenar eminences

Roth spots – Exudative, edematous hemorrhagic lesions of the retina with pale centers

D-Endocarditis can manifest by its complications, namely cardiac (valvular insufficiency, conduction abnormality, heart failure) or neurologic (embolic strokes, brain abscess, mycotic aneurysms)

3-To diagnose: Remember Duke’s Criteria 

Major

–Typical bacteria associated with IE from two separate blood cultures, or persistently positive blood cultures (two > 12 hrs apart)

–Echocardiogram positive for IE

Minor 

–Predisposition: Intravenous drug use or presence of a predisposing heart condition

–Fever: Temperature ≥38.0°C (100.4°F)

–Vascular phenomena: Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, or Janeway lesions

–Immunologic phenomena: Glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor

–Microbiologic evidence: Positive blood cultures that do not meet major criteria OR serologic evidence of active infection with organism consistent with IE

Definitive endocarditis: two major criteria/One major and three minor criteria/five minor criteria

4-Your workup: You are looking for

• Blood cultures: At least three should be obtained prior to antibiotic initiation. Staphylococcus aureus, viridans streptococci, Streptococcus gallolyticus (formerly S. bovis), HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella) organisms

• TTE, if negative then choose TEE to check out for vegitation
• Of note, endocardiatis complications (septic emboli, to the brain in our patient case) will require separate workup (MRI brain….)

5-Treatment:

• Duration: 4-6 weeks in left sided endocarditis, 2 weeks in uncomplicated right sided endocarditis 
• Choice of agents: Cover initially with vancomycin and narrow spectrum based on pathogen grown from blood cultures 
• Indication for surgery: Persistent vegetation (Anterior mitral leaflet vegetation, particularly with size >10 mm as in our patient case), Valvular dysfunction (acute AR or MR with signs of ventricular failure, heart failure unresponsive to medical therapy), valve perforation or rupture 

Images were taken intra-op of our patient’s valvular lesion

6-Notes 

• Our patient received antibiotic prophylaxis with penicillin (as she had a rheumatic fever as a kid, she knew she had a “heart murmur” but unsure of cardiac disease), that should clue us in that she already had valvular complications of her rheumatic fever

This content is password protected. To view it please enter your password below:

Password: