Subinternship Medicine · Year 4 · from Subinternship Medicine
Case 1: Effective Sign-Out and Overnight Symptom Management
Clinical Image
Source: Wikimedia Commons - Medical Handoff - CC BY-SA 4.0
Case Presentation
The medicine sub-intern receives sign-out at 6 PM for 18 patients. One patient is highlighted as a "watcher": Mr. Johnson, a 72-year-old with COPD admitted for pneumonia. The day team uses I-PASS format: Illness severity - "Watcher, he's improved but still on 3L O2"; Patient summary - "Day 3 of community-acquired pneumonia, on ceftriaxone and azithromycin, improving clinically"; Action list - "None tonight, continue antibiotics"; Situation awareness - "If his oxygen requirement increases, get a chest X-ray and page the senior. If he spikes a fever, get blood cultures and consider broadening antibiotics"; Synthesis - the sub-intern repeats back: "So he's improving but if O2 goes up or he fevers, I should get imaging and cultures and call you." At 2 AM, the nurse pages about Mr. Johnson: he is requesting something for sleep. The sub-intern reviews his sign-out and chart - no documented sleep aids, no contraindications. She goes to bedside (rather than ordering blindly) and finds him mildly anxious but vital signs stable. She tries non-pharmacologic measures first: ensures a quiet room, offers warm blanket. He still cannot sleep. She orders melatonin 3 mg PO (first-line, low risk). The nurse pages again at 4 AM - he is still awake. She assesses again; he is now more anxious, worried about his breathing. His O2 sat is 93% on 3L, unchanged. She provides reassurance and offers trazodone 25 mg PO for refractory insomnia. He falls asleep within an hour. She documents a brief cross-cover note describing the events and interventions.
Key Learning Points
- I-PASS sign-out structure: Illness severity, Patient summary, Action list, Situation awareness (if-then guidance), Synthesis (receiver reads back)
- "Watchers" are patients at higher risk for deterioration who warrant closer attention and lower threshold for escalation
- Insomnia management: start with non-pharmacologic measures; if pharmacologic needed, melatonin is first-line, trazodone for refractory; avoid benzodiazepines in elderly
- Always assess the patient when possible rather than ordering blindly; symptoms like insomnia may reflect underlying problems (anxiety, dyspnea, pain)