chief residents 2010 – 2011. routine work am rounds 700 am sign out from night float and am...
TRANSCRIPT
![Page 1: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/1.jpg)
Internship Basics 1
Chief Residents2010 – 2011
![Page 2: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/2.jpg)
Routine Work
![Page 3: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/3.jpg)
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
![Page 4: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/4.jpg)
Documenting House Staff Notes
Subjective/ObjectiveAssessment and Plan
Must be separatedDO NOT copy and pasteBrief and concise
Will reflex Team’s Assessment and Plan
![Page 5: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/5.jpg)
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
![Page 6: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/6.jpg)
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.
![Page 7: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/7.jpg)
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
![Page 8: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/8.jpg)
Infectious Diseases
![Page 9: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/9.jpg)
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
![Page 10: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/10.jpg)
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
![Page 11: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/11.jpg)
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
![Page 12: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/12.jpg)
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
![Page 13: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/13.jpg)
Electrolytes
![Page 14: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/14.jpg)
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
![Page 15: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/15.jpg)
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
![Page 16: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/16.jpg)
Hyperkalemia
Level: 5.1 – 6.0 Kayexalate 30 g PO Low K diet EKG Follow up labs, Creatinine Discontinue medications
![Page 17: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/17.jpg)
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
![Page 18: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/18.jpg)
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!
![Page 19: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/19.jpg)
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)
![Page 20: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/20.jpg)
Glucose
![Page 21: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/21.jpg)
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
![Page 22: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/22.jpg)
Hyperglycemia
Check Chemistry: Diabetic Ketoacidosis Hyperosmolar
Diet
Normal Saline IVSS
![Page 23: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/23.jpg)
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
![Page 24: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/24.jpg)
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
![Page 25: Chief Residents 2010 – 2011. Routine Work AM Rounds 700 am Sign Out from Night Float and AM Admissions Trend Vital Signs Trend Labs Make sure](https://reader036.vdocuments.us/reader036/viewer/2022062407/56649c9b5503460f949592aa/html5/thumbnails/25.jpg)
Thanks