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Internship Basics 1

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

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Internship Basics 1

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  1. Chief Residents 2010 – 2011 Internship Basics 1

  2. Routine Work

  3. 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 See Sicker Patients First See AM admissions

  4. Documenting House Staff Notes Subjective/Objective Assessment and Plan Must be separated DO NOT copy and paste Brief and concise Will reflex Team’s Assessment and Plan

  5. 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 later Clear Inbox Discuss Cases with Residents Update electronic Sign outs Daily

  6. Sign Outs Needed urgent Follow up, VS and Labs. 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. No NG Tubes, No LP, no routine lab work before PM draw should be sign out.

  7. CAC – RRT 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

  8. Infectious Diseases

  9. 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

  10. Fever • Management • Start Antibiotics if signs of SIRS - Sepsis • Broaden Ab coverage if already in antibiotics • Follow up • Notify Resident – Team if Covering • Pneumonia, UTI’s, Peripheral and Central Line Infections

  11. 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

  12. 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

  13. Electrolytes

  14. Hypokalemia • 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 • Follow up: • Potassium Level 3 – 4 hours after repletion • Magnesium Level

  15. 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

  16. Hyperkalemia • Level: 5.1 – 6.0 • Kayexalate 30 g PO • Low K diet • EKG • Follow up labs, Creatinine • Discontinue medications

  17. 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

  18. Magnesium - Hypomagnesemia • 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 • EKG – QT prolongation!

  19. Phosphorus • 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) • Hyper-Phosphatemia • Usually associated with renal disease • Sevelamer (Renagel), Calcium Acetate (PhosLo)

  20. Glucose

  21. 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

  22. Hyperglycemia • Check Chemistry: • Diabetic Ketoacidosis • Hyperosmolar • Diet • Normal Saline IVSS

  23. 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 Status • Follow up Fingersticks closely • Decrease Insulin

  24. Resources • 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

  25. Thanks

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