Intern-On-Call Primer
AM rounds start at
progress notes before rounds and write addendums
throughout the day.
Suggested
General Medicine Handbooks
-Tarascon’s
Pharmacopiea
-
-The
-If you have a PDA, I recommend
"epocrates" and "5 minute
consult"
-See the sinai-grace
residency website (www.sgintmed.com) for more
palm links.
Components
of the “Assessment and Plan”
# Problem
-etiology or
differential diagnosis
-current status
-physical findings,
laboratory data, radiological data to support current status
-what you will do next
Initial Patient
Work-up
-complete
History and Physical (don’t forget fundus, rectal,
pelvic exams and sputum gram stains, urine microscopy and peripheral smear when
appropriate).
-obtain old medical record (call
6-3156)
-look back in CIS to 1997
-contact patient’s family if
patient cannot make his/her own medical decisions or give their own history
-discuss the case with attending physician and ask for their choice
of consultants if needed
-contact any
specialist/consultant
-determine code status
-please make sure there is a
Yellow cross-coverage sheet and Blue Problem List card in every patient's chart
(both are available in the department of medicine)
Follow-up Patient Work-up (prior to AM rounds)
-see and examine your
patient. Ask for any problems
overnight. Check vitals. Manually confirm any abnormal vitals.
-if patient is crashing, CALL YOUR RESIDENT IMMEDIATELY.
-review the chart. Read consultants notes, cross-coverage notes,
nurses notes.
-review the order sheet for any
new orders written by others.
-review
the MAR every 2-3 days to ensure its accuracy
-I encourage you to finish your
progress notes (SOAP format) before AM rounds.
This isn't always possible, but it does make the rest of your day go
smoother.
-All pages of your notes MUST have a time and date and
heading at the top (e.g…A Medicine Intern). Please ensure that there is a patient ID
sticker at the top right hand corner.
-If you are discharging the
patient that day, YOU MUST inform
the attending physician prior to doing so.
-It is always a good idea to call
your consultants before discharging your patient for any final recommendations
and follow-up.
***For all patients that you see on cross-coverage, you must write a note in the chart
(entitled “A-Medicine Cross Coverage”) to prove that you saw the patient. Document why you were called to see the
patient and write a brief SOAP note.***
As always, please call your resident at anytime for questions about
your patients or cross-coverage.
Electrolyte Replacement
*Potassium 3.5-5.3 mmol/L Oral: K-dur (tab) or K-lyte
(liquid) 20-40 mEq
IV: KCl
20-40 mEq or
Kphos 15-30 mmol
IVPB
*Always
know the patients current BUN/Cr before prescribing supplemental
potassium (avoid in renal failure).
For every 0.1 mmol/L
deficit below 3.5, replace with 10mEq of Potassium
Magnesium 1.6-3.0 mg/dL Oral: MgOxide 400mg
IV: MgSulfate 2g IVPB
Phosphorus 2.3-5.0 m/dL Oral: NeutraPhos
1-2 packets TID
with meals
IV: NaPhos or *KPhos
15-30 mmol IVPB
**Calcium 8-10.6 mg/dL Oral: OsCal 1 Tab
IV: Do not replace by IV on the floor unless in
overt tetany.
Call your resident.
**Always
calculate the corrected calcium (with the help of albumin) before
supplementing.
Hyperglycemia and
Hypoglycemia
- elevated
levels, follow regular insulin sliding scale
Glucose Regular
insulin
0-200 no insulin
201-250 2U
251-300 4U
301-350 6U
351-400 8U
<60
- >400 call house
officer
-
<60mg/dL and if patient AAO X 3, feed the patient and
recheck accucheck
in 20 minutes
-
<60 mg/dL and if patient not AAO X 3, then give 1
ampule of D50 IVP. If no IV access, give Glucagon
1mg SC/IM STAT (If not on the
floor, call Pharmacy 6-3270)
->400 enquire about
clinical scenario prior to deciding insulin dose( eg…patient
may be in DKA
so check the anion
gap…..etc….).
Principle: Maintenance therapy (longacting insulin or oral hypoglycemics +
Rescue therapy (aspart insulin sliding scale)
Hyperkalemia
-
for K > 5.4, ask for current heart rate and ask for
a STAT 12-lead EKG. Review the EKG. If bradycardic
and/or EKG changes are present, give:
1-ampule CalciumGluconate or Calcium Chloride
1-ampule of D50
(50%Dextrose)
10 units of Regular Insulin subcutaneously
30
grams of Kayexalate orally or rectally
-if
no EKG changes or no bradycardia, do not give IV
Calcium
-stop
all Potassium supplements (oral, IVPB, in IV fluids)
-may
add Inhaled Albuterol via nebulizer
(2.5mg ampule X 2) to regimen.
-bicarbonate
should be used only in Code Blue situations
Dosing IV Heparin and
-Follow
nomogram
-ensure
no bleeding (nose, mouth, IV sites, urine, stool, vagina…etc….)
-recheck
PTT in 6 hours (for Heparin dose adjustment) or check PT/INR in AM (for
Coumadin dose adjustment)
Chest Pain
-over
the phone, ask for vitals, ask for STAT 12-lead EKG,
ASA to chew, one
SL-NTG,
oxygen and then see the patient immediately
-distinguish
between cardiac and noncardiac chest pain by history
and physical exam
-get
12-lead EKG and compare to old one
-if
cardiac pain or EKG changes present, sublingual NTG (0.4mg) q5minutes X 2 if
pain persists, also add morphine 2-4mg IVP, draw
blood for CPK (red top tube),
CPK-MB (red top tube), Troponin
I (thin green top tube “Lithium Heparin”).
-call
your resident
Positive Blood Cultures
-any
blood cultures with Gm Negative and Fungi needs immediate appropriate
antibiotics.
Fungi typically need change in any central lines (seeding).
-for
Gm Positive cultures, decide use of appropriate antibiotics based on the
clinical situation (fever, bp,
WBC count, diagnosis, mental status).
-if
unclear, evaluate the patient and the chart.
Death Pronouncement
ensure death by doing ALL the following……..
-ensure
no response to vocal and pain stimuli
-ensure
that pupils are fixed and dilated
-ensure
that conjunctival and corneal reflexes are absent
-ensure
that gag reflex is absent
-ensure
there are no spontaneous movements
-ensure
there are no breathing movements
-ensure
there are no heart and breath sounds
-ensure
there are no pulses palpable
-note
the time
-DOCUMENT
ALL OF THE ABOVE in the chart
-inform
the attending and document that you informed the attending
-call
the family and ask them to come to the hospital ASAP. Please don’t tell
them of the death over the telephone. Say something to the effect of, “your
family member’s condition has taken a turn. Please come to the hospital as soon
as possible.”
-document that you called the family.
-once
the family arrives, tactfully inform them of the death. Ask them if they
would like a Pastor present. Ask them if they would be interested in an
autopsy.
Ask them if they would be interested in organ donation (if so, double
witnessed signatures are required and fill out the
autopsy clinical information
form for the pathologist).
-document
that you asked the family about autopsy and organ procurement
.
-if
patient died within 24 hours of admission or if foul play is suspected, call
the medical examiner (313-833-2569) right away
(open 24 hrs a day) after
pronouncement. Once you present the case to the examiner,
document with whom
you spoke, the case ID number, what the examiner
decided to do with the body
(e.g…..release it to the family,
accepted for autopsy…etc….)
Blood Transfusion
Reactions
-stop
the transfusion
-increase
IV fluids (caution in ESRD or CHF patient) and ensure 200cc/hr urine
output
-check
urine hemoglobin, if positive, add 2-amps of
bicarbonate to IV fluids
-send
labs for hemolysis profile (LDH, Haptoglobin,
Total and Direct Bilirubin, Hb)
-for
symptoms, give Benadryl 50mg IVP X 1 and Tylenol 650 mg PO, if ineffective,
give Hydrocortisone 100 mg IVP X 1
-sign
transfusion reaction incident form
-call
your resident and the patient’s attending
Fever and Blood Product
Transfusions
-For
fever >100.5 deg F, first give Tylenol (assuming liver function normal)
-have
the temp checked again 30 minutes. If
fever subsides, then begin transfusion and have vitals checked qProtocol.
-If
fever does not subside, then evaluate the patient.
Pain Management
-For
those patients with known Liver Disease, NO ACETAMINOPHEN (Tylenol, Tylenol
#3, Tylenol #4, Vicodin, Vicodin ES, Percocet)
-For
those patents with known PUD, severe anemia, low platelets NO NSAIDS (ASA,
Ibupofen, Naproxen, Cox-II inhibitors)
-For
those patents with seizures or ESRD, NO MEPERIDINE (Demerol)
-For
ESRD, NO HYDROMORPHONE OR MEPERIDINE because of impaired excretion
Sleep Aid
-Choices:
Benadryl 25-50 mg IVP or
-use
small doses and avoid Benadryl in the elderly
Hypoxia
-Call
your resident and evaluate the patient immediately
-Oxygen
-nasal cannula
up to 4 L
-40-60% Venturi
Mask
-100% nonrebreather
mask
-Keep SpO2 >90%
-Albuterol/Atrovent breathing treatment if wheezes present
-STAT
Portable Chest Xray
-Consider
getting an Arterial Blood Gas
-Think V/Q mismatch
Ethanol Withdrawal/Delerium Tremens
-Ativan 2-4 mg IVP q4 hours
-Seizure
and Fall Precautions
-Thiamine
100 mg
-Folate 1 mg
-Multivitamin
1 Tab
-IV
fluids (Use D5-0.45NS if not Diabetic).
Give thiamine first!
-Look
for hallucinations, tachycardia, seizure, hyperthermia, and hypertension
-If
present, call your resident!
Status Epilepticus
-Ativan 2mg IVP
-Seizure
and Fall Precautions
-Dilantin 1000mg IV bolus
-Call
your resident
Status Asthmaticus
-Oxygen
-Stat
Albuterol (2.5 mg in 3cc 0.9 NS) breathing treatment
-Solumedrol 125 mg IVP X 1 then 60mg IVP q 6hours
-Call
your resident
Hypertensive Urgency
-control
BP with extra dose of current medication
-use
Clonidine only if patient is already on Clonidine
-if
no renal failure, can use Vasotec 1.25 mg IV X 1
-if
renal failure, can use Hydralazine 10 mg IV q4hrs X 2
-if
target organ damage present (e.g…brain, retina,
heart, kidneys), call your
resident
***For
all patients that you see on cross-coverage, you must write a note in the
chart (entitled “A-Medicine Cross Coverage”) to prove
that you saw the patient.
Document
why you were called to see the patient and write a brief SOAP note.***
As
always, please call your resident at anytime for questions about your
patients or cross-coverage.