M Modal Phrases

 

Insert appendicitis

 

  • RLQ pain and appendicitis on CT

  • Leukocytosis

  • Surgery

  • Will keep NPO

  • Will start ceftriaxone/metronidazole

  • Will follow up surgery reccs

  •  Will give IVF

 

Insert arterial

 

ARTERIAL LINE (A-Line) PLACEMENT
Date: <____>
Time: <____>
Indication: Hemodynamic monitoring
Attending: Pranay Parikh

 

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. Allen’s test was performed to ensure adequate perfusion. The patient’s <right/left> wrist was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the area. A 18G Arrow arterial line was introduced into the <radial/femoral> artery under ultrasound guidance. The catheter was threaded over the guide wire and the needle was removed with appropriate pulsatile blood return. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate

 

Estimated Blood Loss: 5 cc
The patient tolerated the procedure well and there were no complications.

 

Insert asthma

  • Will start Solumedrol

  •  Will start salmeterol, beclomethasone, montelukast

  • Will give albuterol nebs

Insert bleed (ICH admissions)

  • Dr. neurosurgery consulted

  •  Dr. neuro consulted

  •  Last known well

  • NIH

  •  Will keep SBP 100-140

  •  Will repeat CT in 6 hours

  •  Will follow up neuro/neruosurg reccs

  • Will admit to ICU

  • Will do q1 hour neurochecks

Insert central

Central Venous Catheter (CVC, Central Line) Placement
Date: <____>
Time: <____>
Indication: Hemodynamic monitoring/Intravenous access

 

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a dependent position appropriate for central line placement based on the vein to be cannulated. The patient’s <right/left> < neck/shoulder/groin> was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A triple lumen Cordis catheter was introduced into the the <subclavian/internal jugular/common femoral vein> using the Seldinger technique and under ultrasound guidance. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained. Each lumen of the catheter was evacuated of air and flushed with sterile saline. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate.

 

Estimated Blood Loss: 5 cc
The patient tolerated the procedure well and there were no complications.

 

Insert chest (chest pain admissions)

  • Saturating well on RA low concern for PE

  •  No signs of pneumothorax, pericardial effusion, or esophageal rupture on CXR

  • Given ASA

  • Troponin so far negative

  •  Heart score

  • EKG

  •  Will trend troponins

  • Will get echo

  • Will check a1c and lipid panel

Insert Chole

  •  RUQ pain and leukocytosis

  •  Imaging consistent with cholecystitis

  •  Will start ceftriaxone and flagyl

  • Will consult surgery

  • Will give IVF and pain meds

  •  Will keep NPO

Insert cirrhosis

  •  MELD Chigh Pugh

  • Secondary to alcohol

  •  EV: History of hematemesis

  • SBP: No history of ascites or SBP

  • HCC: No lesion on CT

  •  HE: No history of hepatic encephalopathy

  • Transplant: Not a candidate due to current drinking

  •  Will give ativan for possible withdrawal

  •  Will give banana bag

Insert coag

  • Most likely nutritional

  •  No signs of bleeding

  •  Will monitor, no need for acute intervention

Insert COPD

  • Continues to smoke

  •  Worsening dyspnea

  • No PNA on CXR

  •  Will start prednisone 40 mg PO x5 days

  •  Will do duonebs

  • Will council to stop smoking

  •  Will start azithromycin for anti-inflammatory effect

Insert critical care

 

DVT PPx: SCDs
GI PPx: Not needed, consider pepcid after 72 hours intubated
Diet: NPO
Activity: Bedrest
Code Status: FULL CODE
Disposition: Will admit to critical care

 

Insert diabetes

  • A1c pending

  • Will start SSI

  • Will start diabetic diet

Insert dialysissets (catheter)

Dialysis Catheter Placement
Date: <____>
Time: <____>
Indication: Hemodialysis
Attending: Pranay Parikh

 

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a dependent position appropriate for dialysis catheter placement based on the vein to be cannulated. The patients <right/left> < neck/shoulder/groin> was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A triple lumen diaylsys catheter was introduced into the the <subclavian/internal jugular/common femoral vein> using the Seldinger technique and under ultrasound guidance. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained. Each lumen of the catheter was evacuated of air and flushed with sterile saline. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate.

 

Estimated Blood Loss:
The patient tolerated the procedure well and there were no complications.

 

Insert DKA

  • Anion gap

  •  Secondary to medication non-adherence

  • Complicated by AKI

  •  Will stat insulin drip

  • Will start LR + KCL at 150 ml HR

  •  Will check BMP q4h

  •  Will switch to d5 1/2 NS once sugars <250

     

    Insert heart (CHF systolic)

  • Acute on chronic

  • EF

  •  Most likely secondary to

  • NO prolonged QRS on EKG

  • Will get echo

  • Will start BB

  • Will hold ACEi given AKI

  •  Will give lasix

  •  Will give nitro ointment to reduce afterload

Insert home (for home meds)

  • Will get list of home meds and continue

  • Insert hypokelamia (in alcoholics)

  • Acute

  • Most likely related to diuresis from excessive alcohol intake

  • Will replete

Insert ICU (for admissions)

 

DVT PPx: SCDs
GI PPx: Not needed
Diet: NPO
Activity: Bedrest
Code Status:
Disposition: Will admit to ICU

 

Insert intrinsic (for AKI)

  • Unknown baseline

  • BUN:Creatinine <20:1

  •  Concern for intrinsic kidney injury

  •  Will get renal US

  • Will give IVF

  • Will recheck in the AM

    Insert intubation

Endotracheal Intubation
Date: <____>
Time: <____>
Indication: Respiratory Distress
Attending: Pranay Parikh

 

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a flat position. Sedation was obtained using Ketamine 60 mg, and additionally with Rocuronium 20 mg. The patient was easily ventilated using an ambu bag. The <GLIDESCOPE TECHNOLOGY/ MAC 3.5 BLADE> was used and inserted into the oropharynx at which time there was a Grade 1 view of the vocal cords. A 7.5-french endotracheal tube was inserted and visualized going through the vocal cords. The stylette was removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were heard in both lung fields equally. The endotracheal tube was placed at 23 cm, measured at the teeth.

 

A chest x-ray was ordered to assess for pneumothorax and verify endotracheal tube placement.

 

Estimated Blood Loss: 0 cc
The patient tolerated the procedure well and there were no complications

 

Insert macrocytic

  •  Most likely nutritional deficiency

  • No signs of bleeding

  •  No need for acute intervention

  • Will check b12/folate

Insert normocytic (anemia)

  • At baseline

  • Most likely anemia of chronic disease

  •  No signs of bleeding

  •  No need for acute intervention

Insert prerenal

  • Most likely prerenal

  •  BUN:creatinine 20:1

  •  Will give IVF

  •  Will recheck in the AM

 

Insert pseudo

  • Pseudohyponatremia secondary to hyperglycemia

  •  Should improve with better glycemic control

Insert SAH

  •  Will keep SBP <140

  • Will do q1 hour neurochecks

  •  Will give keppra

  •  Will give nimodipine

  •  Will trend troponing and lactate q6hrs

  •  Will give platelets

  •  Will get transcranial doppler

  •  Will get echo

Insert sepsis

  •  SIRS /4 (tachycardia, tachypnea, leukocytosis, fever)

  •  Probable source

  • Most likely organism

  •  Unlikely meningitis due to

  •  Lactate

  • Shock index

  •  Complicated by

  •  Blood cultures drawn in the ER prior to abx

  •  Will give

  • Will give IVF

  • Will follow up blood cultures

Insert shock (cardioversion)
PROCEDURE: Direct current cardioversion.

REASON FOR PROCEDURE: Atrial fibrillation.

 

PROCEDURE IN DETAIL: The procedure was done emergently due to patient’s clinical status. Patient was intubated and sedated and additional sedation was not needed. The pads applied in the anterior and posterior approach. With synchronized biphasic waveform at 150 J, one shock was successful in restoring sinus rhythm. The patient had some occasional PACs noticed with occasional sinus tachycardia. The patient had no immediate post-procedure complications. The rhythm was maintained and 12-lead EKG was requested.

 

IMPRESSION: Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.

 

One shock was unsuccessful in restoring sinus rhythm. The patient was briefly in sinus tachycardia and then reverted to atrial fibrillation with rapid ventricular response.

 

Insert TPA

  • Aborted ischemic stroke due to thrombolysis

  • Duration; Acute, old

  •  Last known well

  • NHISS on admission

  • Caused by Thrombosis (atherosclerosis, vasculitis), Thromboembolus (atrial fibrillation), Infected embolus (endocarditis), Type A Aortic dissection, Aneurysm

  •  Causing: Hemiparesis/ hemiplegia/ weakness, Seizure, Hemorrhage, Cerebral edema, Cerebral herniation, Encephalopathy, Acute respiratory failure, Aphasia, Dysphagia, SIADH, Neglect

  • Status: Improved, worsened, stable, resolved

  • Neruology Dr. consulted

  •  Given TPA

  • Will admit to ICU for q1 hour neuro checks

  •  Will keep SBP <180

  • Will check a1c and lipid panel

  •  Will get echo in the AM

  •  Will get MRI in the AM

 

 

 

Why My Barber Being Closed was a Blessing in Disguise

Why My Barber Being Closed was a Blessing in Disguise

There’s a barbershop right under my apartment. It’s pretty convenient to call down and head over there. No driving. No looking for parking. walk downstairs. It saves me about 30 minutes or so. The catch is that it’s almost double as expensive as other places. It’s so convenient that I never looked elsewhere. Why would I? The haircut was good enough and it was convenient.

Well, one day I wanted to get a haircut and it was closed. What did I want at that time? Just for my normal haircut place to be open. So I can get the same convenient haircut that I always got.

I reluctantly looked for another haircut place. I was pretty surprised to find one a block away. It was half the price and a much better haircut. Now I always go to this new haircut place and would have never known about it if the first one wasn’t closed.

It made me wonder where else in my life was I willing to take good enough since it was convenient? It’s so easy to go with the flow. Stick to something that works. I did the same with a laptop that was showing signs of aging. Getting a new laptop improved my workflow. But I was stubborn and keeping to my old, slow laptop.

I decided to do an audit of some of my normal activities. Have I looked at this recently? Is there any way I could improve it? Could it be cheaper? Better quality? Or take less time? Do I even need to do it at all?

This last one is the most important. I used to spend an hour or two grocery shopping every week. This was would also lead me to buy a bunch of unhealthy food because I happened to run into it at the grocery store. Instead, I discovered I could order from pretty much anywhere and have it delivered. Get exactly what I need, and not end up buying a bunch of junk food. I was able to save time and money instead of the grocery shopping myself.

When was the last time you took a look at your normal activities? Could you find a cheaper, higher quality, or more efficient alternative?

Start at the Very First Step

Start at the Very First Step

During college, I started a club for people interested in working for a pharmaceutical company. It was my first time starting anything. I had a pretty decent job working at Pfizer and was still deciding if I wanted to go into medicine. The club sounded fun and something good to put on my resume.

 

I asked a couple of my smartest friends to join. And somehow got the courage to ask my favorite professor to be part of it and he even said yes. I was ecstatic. I already had visions of the club being on the biggest at school. Unfortunately, it never got anywhere close to that. It only lasted a few meetings before it fizzled out.

 

What did we talk about for those meetings? The name of the club. That’s it. We couldn’t come up with a name. And each person wanted it to be something different. It was my first venture as a leader. Looking back, I’m thankful that it was something with such low stakes.

 

I was with my smartest friends. I didn’t feel I had the right to change the subject. I wanted everyone to have their say. Everyone was so excited to start the club. We lost all our momentum. The club never even got started.

 

Thinking back, we lost the forest for the trees. A name? It didn’t matter. Just look at some of the biggest names out there now: Google, Uber, Facebook. Their names don’t mean anything. Nothing profound. If instead, we would have gotten a few easy wins the club may have survived to do something meaningful.

It did lead me to learn some lessons:

 

 

1. True leadership means looking at the bigger picture and choosing priorities

2.Don’t waste the momentum and excitement you have when starting something new. Do something.

3. Remember that not everything needs to be right in the beginning, you can always change or pivot.