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 expire

See Sicker Patients FirstSee AM admissions

Documenting House Staff Notes

Subjective/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 - Hypomagnesemia

Goal > 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

Hypoglycemia

Etiology 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