Transcript Intern Basics 1

Chief Residents
2010 – 2011
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Sign Out from Night Float and AM
Admissions
Trend Vital Signs
Trend Labs
Make sure orders are in the system (labs and
meds)
Renew medications that are needed and are
scheduled to expire
See Sicker Patients First
See AM admissions
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Subjective/Objective
Assessment and Plan
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Must be separated
DO NOT copy and paste
Brief and concise
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Will reflex Team’s Assessment and Plan
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Check Attending Notes and Consult notes
Trend VS and Labs; make sure needed labs
are done and addressed
Order labs needed for follow up later
Clear Inbox
Discuss Cases with Residents
Update electronic Sign outs Daily
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Needed urgent Follow up, VS and Labs.
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No procedures should be sign out
Nothing that wasn’t done because of lack of
time should be sign out. It should be done by
the team before sign out.
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No NG Tubes, No LP, no routine lab work
before PM draw should be sign out.
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Team on call must come to all CAC
RRT team available: SMR, ICU nurse, Resp.
Therapist, Pulm-CC Fellow
Leader: SMR – Fellow
Primary Team should be notified and should
come to bedside
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Temp > 100.4
Check
 Temperature Trend
 Antibiotics – Microbiology
 Vital Signs: Blood Pressure - HR
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Work Up
 Blood Culture x 2
 Urinalysis and Urine Culture
 Chest X-ray
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Management
 Start Antibiotics if signs of SIRS - Sepsis
 Broaden Ab coverage if already in antibiotics
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Follow up
 Notify Resident – Team if Covering
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Pneumonia, UTI’s, Peripheral and Central Line
Infections
Check Prior Microbiology
Check orders to determine if patient is on
Antibiotics already
 How many tubes are positive
 Start antibiotics
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 Gram Positive
 Gram Negative
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Notify Resident or Team
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Contact Isolation if needed
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Patient on Antibiotics that develops Diarrhea
Work up:
 Stool Studies: Stool Leukocyte, culture, O and P and
C. Diff Antigen
 WBC count
 Abdominal Exam
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Management:
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Flagyl 500 mg IV – PO q 8 hours
Vancomycin 250 mg PO q 6 hours
Vancomycin 250 mg PR 1 6 hours
Contact Isolation
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Goal 3.5 – 4.0 (cardiac patients)
1 mEq/L drop is = to 200 mEq total body loss
Management: (10 mEq of KCl PO or IV will
increase K 0.0 – 0.2 average 0.1)
 KCL PO tablets and liquid : 10, 20, 40 mEq
 KCL IV 10 mEq in 1 hour; up to 3 runs
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Follow up:
 Potassium Level 3 – 4 hours after repletion
 Magnesium Level
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Etiology
 DM – Type 4 RTA
 Medications
▪ ACE, ARB, Bactrim, Heparin
 Diet
 Renal Failure
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EKG Manifestations
 Peaked T waves, Increased PR interval, increased
QRS width, sine wave pattern, PEA
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Level: 5.1 – 6.0
 Kayexalate 30 g PO
 Low K diet
 EKG
 Follow up labs, Creatinine
 Discontinue medications
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Level: > 6.0
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EKG, Telemetry
Kayexalate 30 – 90 g PO
Lasix 40 – 80 Lasix IVSS
Calcium Gluconate 1 -2 amps IVSS
Sodium Bicarbonate 1 – 3 amps IVSS
Regular Insulin 10 units IVP + 2 amps of D50 w
(caution in pts. with renal failure)
 Hemodyalisis
 Most Follow up repeat labs
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Goal > 2
Associated with K balance
Check always with HypoKalemia – must
replete Mg with K
Management:
 Mg Sulfate 1 – 3 g IVSS in D5 or NS (up to 6 g in
4h)
 Mg Oxide – Mg Gluconate PO tabs
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EKG – QT prolongation!
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Goal > 3.5
Hypo-Phosphatemia
 < 2: Na Phosphate or K Phosphate:
▪ 10 mEq/100 ml(3 mmol/ml)
 2 – 3: NeutraPhosp Packets or Tabs
▪ 1 – 2 PO qd – qid (250 mg Phos each tab)
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Hyper-Phosphatemia
 Usually associated with renal disease
 Sevelamer (Renagel), Calcium Acetate (PhosLo)
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Basal Insulin: NPH, Lantus (adjust to patients
requirement of regular insulin)
 Type I: 0.5 – 0.7 units/kg/day (½ as basal – ½ prandial)
 Type II: 0.4 – 1 units/kg/day
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Regular Insulin Sliding Scale q 4 hours
 150- 199:
 200 – 249
 250 – 299
 300 – 349
 > 349
1 – 2 units
2 – 4 units
3 – 7 units
4 – 10 units
5 – 12 units
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Check Chemistry:
 Diabetic Ketoacidosis
 Hyperosmolar
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Diet
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Normal Saline IVSS
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Etiology
 Decrease PO intake
 Insulin Excess – Renal Insufficiency
 Early signs of Sepsis
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Management
 Orange Juice with sugar; Candy
 D50 IVP
 D10 drip; Glucagon
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Check Mental Status
Follow up Fingersticks closely
Decrease Insulin
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Pocket Medicine: The Massachusetts General
Hospital Handbook of Internal Medicine. Sept
2010.
Tarascon Pocket Pharmacopeia
Tarascon Internal Medicine and Critical Care
Pocket Book
Sanford Guide to Antimicrobial therapy
John Hopkins Antibiotic guide Online
Epocrates