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 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

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

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

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.

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

 Temp >  Check  Temperature Trend  Antibiotics – Microbiology  Vital Signs: Blood Pressure - HR  Work Up  Blood Culture x 2  Urinalysis and Urine Culture  Chest X-ray

 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

 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

 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

 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

 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

 Level: 5.1 – 6.0  Kayexalate 30 g PO  Low K diet  EKG  Follow up labs, Creatinine  Discontinue medications

 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

 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!

 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)

 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  :1 – 2 units  200 – 2492 – 4 units  250 – 2993 – 7 units  300 – 3494 – 10 units  > 3495 – 12 units

 Check Chemistry:  Diabetic Ketoacidosis  Hyperosmolar  Diet  Normal Saline IVSS

 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

 Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine. Sept  Tarascon Pocket Pharmacopeia  Tarascon Internal Medicine and Critical Care Pocket Book  Sanford Guide to Antimicrobial therapy  John Hopkins Antibiotic guide Online  Epocrates