CARDIOLOGY

Myocardial Infarction

1. Admission orders – follow the cardiology admit pathway in PIN

a. Labs

i. Cardiac profile: CK-MB, CK-Total, troponin x 3 (q8h apart).

ii. FBP with Mg²⁺, Ca²⁺, and PO₄ qd – maintain Mg at 2, K at 4.

iii. Fasting lipid profile – if not done in the last 6 months.

b. Other

i. EKG q am x 3.

ii. Telemetry – check this every morning via the red phones .

iii. Oxygen via nasal cannula.

c. Diet – cardiac prudent unless pt is likely to go to cath, then NPO.

2. Meds

a. ISDN and/or nitropaste

b. Aspirin

c. Lovenox or Heparin (lovenox is more commonly used)

d. Low dose beta-blocker (metoprolol)

3. In house plan

a. Mibi scan vs. catheterization.

b. Surgery if indicated.

c. Add an ACE inhibitor if possible.

d. Start on a lipid lowering agent if necessary.

e. Discharge on aspirin, ISDN, and the beta-blocker also.

f. Teach the patient about smoking cessation (good luck).

Congestive Heart Failure

1. Admission Orders

a. Labs/Studies

i. TTE – you can call the echo lab and have the results faxed to the floor.

ii. FBP q am.

iii. Digoxin level.

iv. CXR on admission to check for pulmonary edema.

b. Meds

i. Lasix – start IV at twice the recent home dose.

ii. Digoxin

iii. Consider dobutamine/dopamine drip if indicated.

c. Diet – cardiac prudent

d. Other

i. Telemetry

ii. Oxygen

iii. Check the “CDA” files for further info – may patients are bounce-backs. Also, previous echo and cath reports can be found here.

e. Nursing - strict ins and outs to monitor diuresis.

2. In house plan

a. Successful diuresis – monitor ins and outs; gauge this clinically by the patient’s dyspnea upon walking the hospital halls.

b. Start ACE inhibitor.

c. Continue digoxin and the diuretic upon discharge.

d. Ambulate the patient daily to clinically assess improvement.

e. Teach smoking cessation (good luck).

Other Pearls

Daily to-dos

² Look in CDA for previous admissions/caths/echo reports on all admitted patients.

² Call telemetry each morning using the red phones located at the nurses station.

² Most of the time, a CXR will be done in the ER before the pt is moved to the floor.

² Call the echo lab to have results faxed up to the floor.

² All cath reports are hand written in the chart under progress notes.

² OM = obtuse marginal, LD = long diagonal.

² Also look in PIN for a previous creatinine for comparison. They do not like to cath if Cr > 2.

² A lecture is given every morning at 8 am in the conference room by the CCU – these are good lectures. Rounds normally begin after this lecture, at 9 am.

History and Physicals

² ROS = orthopnea/PND/syncope/edema/diaphoresis/palpitations/DOE - # of blocks or stairs.

² Include any cath / echo / mibi information in the PMH of the patient (be specific!!).

² Exam: be sure to include pulses / JVP / possible peripheral bruits.

Other stuff

² Be familiar with aFib, syncope, and myocarditis – you may encounter these patients.

² Know the classifications of CHF.

² You are responsible for discharging your patients, but you may not enter discharge orders in the computer. Write the prescriptions and a discharge note, however.

² Check out to the AI on call by printing out your patient list with a brief summary of the vital important facts on your patients. Warn the AI of any potential calls from each patient.

Cross Cover

² Any weird telemetry call from the nurse: verbal order a 12-lead EKG and evaluate.

² Many times, constipation meds can be given as a verbal order.

² Call the upper level for any problem that you are uncomfortable with handling.

² Always write a brief note concerning the cross-cover situation.