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Chief Residents 2010 – 2011 . Internship Basics 1. Routine Work. AM Rounds 700 am. 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 - PowerPoint PPT Presentation
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Internship Basics 1
Chief Residents2010 – 2011
Routine Work
AM Rounds 700 amSign Out from Night Float and AM
AdmissionsTrend Vital SignsTrend LabsMake sure orders are in the system
(labs and meds)Renew medications that are needed
and are scheduled to expireSee Sicker Patients FirstSee AM admissions
Documenting House Staff NotesSubjective/ObjectiveAssessment and Plan
Must be separatedDO NOT copy and pasteBrief and concise
Will reflex Team’s Assessment and Plan
PM rounds – Sign-outs
Check Attending Notes and Consult notes
Trend VS and Labs; make sure needed labs are done and addressed
Order labs needed for follow up laterClear Inbox
Discuss Cases with ResidentsUpdate electronic Sign outs Daily
Sign Outs
Needed urgent Follow up, VS and Labs.
No procedures should be sign outNothing that wasn’t done because of
lack of time should be sign out. It should be done by the team before sign out.
No NG Tubes, No LP, no routine lab work before PM draw should be sign out.
CAC – RRT
Team on call must come to all CACRRT team available: SMR, ICU nurse,
Resp. Therapist, Pulm-CC FellowLeader: SMR – FellowPrimary Team should be notified and
should come to bedside
Infectious Diseases
Fever
Temp > 100.4 Check
Temperature Trend Antibiotics – Microbiology Vital Signs: Blood Pressure - HR
Work Up Blood Culture x 2 Urinalysis and Urine Culture Chest X-ray
Fever
Management Start Antibiotics if signs of SIRS - Sepsis Broaden Ab coverage if already in
antibioticsFollow up
Notify Resident – Team if Covering
Pneumonia, UTI’s, Peripheral and Central Line Infections
Positive Blood Cultures
Check Prior Microbiology Check orders to determine if patient is
on Antibiotics already How many tubes are positive Start antibiotics
Gram Positive Gram Negative
Notify Resident or Team Contact Isolation if needed
Clostridium Difficile Patient on Antibiotics that develops
Diarrhea Work up:
Stool Studies: Stool Leukocyte, culture, O and P and C. Diff Antigen
WBC count Abdominal Exam
Management: Flagyl 500 mg IV – PO q 8 hours Vancomycin 250 mg PO q 6 hours Vancomycin 250 mg PR 1 6 hours Contact Isolation
Electrolytes
Hypokalemia
Goal 3.5 – 4.0 (cardiac patients)1 mEq/L drop is = to 200 mEq total
body lossManagement: (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
Follow up: Potassium Level 3 – 4 hours after
repletion Magnesium Level
Hyperkalemia
Etiology DM – Type 4 RTA Medications▪ ACE, ARB, Bactrim, Heparin
Diet Renal Failure
EKG Manifestations Peaked T waves, Increased PR interval,
increased QRS width, sine wave pattern, PEA
Hyperkalemia
Level: 5.1 – 6.0 Kayexalate 30 g PO Low K diet EKG Follow up labs, Creatinine Discontinue medications
Hyperkalemia Level: > 6.0
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
Magnesium - HypomagnesemiaGoal > 2Associated with K balanceCheck always with HypoKalemia –
must replete Mg with KManagement:
Mg Sulfate 1 – 3 g IVSS in D5 or NS (up to 6 g in 4h)
Mg Oxide – Mg Gluconate PO tabsEKG – QT prolongation!
Phosphorus
Goal > 3.5Hypo-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)
Hyper-Phosphatemia Usually associated with renal disease Sevelamer (Renagel), Calcium Acetate
(PhosLo)
Glucose
Hyperglycemia 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
Regular Insulin Sliding Scale q 4 hours 150- 199: 1 – 2 units 200 – 249 2 – 4 units 250 – 299 3 – 7 units 300 – 349 4 – 10 units > 349 5 – 12 units
Hyperglycemia
Check Chemistry: Diabetic Ketoacidosis Hyperosmolar
Diet
Normal Saline IVSS
HypoglycemiaEtiology
Decrease PO intake Insulin Excess – Renal Insufficiency Early signs of Sepsis
Management Orange Juice with sugar; Candy D50 IVP D10 drip; Glucagon
Check Mental StatusFollow up Fingersticks closelyDecrease Insulin
Resources
Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine. Sept 2010.
Tarascon Pocket PharmacopeiaTarascon Internal Medicine and
Critical Care Pocket BookSanford Guide to Antimicrobial
therapy John Hopkins Antibiotic guide OnlineEpocrates
Thanks