l********y
发帖数: 2295 | 1 【 以下文字转载自 Pre_Resident_Club 俱乐部 】
发信人: lovelypony (pony), 信区: Pre_Resident_Club
标 题: Tips for IM interns
发信站: BBS 未名空间站 (Sun May 27 09:34:24 2012, 美东)
INTERNS: daily management (orders, consults, pages, calls); replete lytes
daily before rounds (check for renal failure first; if Cr up, run by
resident before ordering repletion); the groundwork to get stuff done and
care for patients
--> BEFORE ROUNDS: arrive by 6am (weekdays), get signout, review all labs
and test results, see all your patients, get vitals (including i/o, BMs, etc
), f/u consultant recs, come up with a plan; run list with resident
**Tell resident of any SICK patients ASAP** - if you get signout that
someone is sick, that is 1st priority
--> DURING ROUNDS: enter orders, order consults and communicate with
consultants; goal = get as much stuff done as possible
--> AFTER ROUNDS: 1) finish entering orders 2) finish entering consults and
contacting consultants 3) work on notes 4) update daily sign out notes 5) f/
u on patients, do procedures, etc
RESIDENTS: manage the "big picture" for each patient, always be thinking
about discharge and disposition, consider all int med related problems,
manage the team; help other team members, teach
--> We will work with you and along side of you to help with procedures,
notes, DIs, discharging patients, etc, to help things flow smoothly
--> We will do our best to teach
--> We are also in charge of discharge summaries
____________________________________________________________________________
______
General advice and tips (for this month and the entire year):
1) Service can be *busy* and at any time we could have up to 20 total pts
and some can be quite sick. For us to be able to get out at 6pm every night,
you need to get signout at 6am.
2) Morning conference 7-8am; we will have to get there early, be efficient,
and take care of acute issues in time to go to class regularly.
3) Daily flow:
- orders in during rounds including consults (have computers on rounds; if
we sit round, sit at a computer)
- call consultants or page to notify of new c/s; arrange tests/procedures;
ex: for stat xray, call tech.
- notes, keep short/succinct
- update signouts/DIs (have med students help)
- procedures
4) GM specific tips:
- if someone needs marked for a para/thoracentesis, order the abdominal
fluid survey (ultrasound) ASAP
- Prior to procedures, check coags; does pt need reversed with FFP? do they
need platelets? may need to time it to start at 4am or 6am for morning
procedures (colonoscopy, EGD, etc)
- keep a close eye on Na levels and K levels in cirrhotic, heart, and renal
patients
CHADS2 score for Afib stroke risk - h/o CHF, h/o HTN, Age >= 75yo, DM,
stroke sx previously or TIA --> calculate for pts with Afib not currently
treated; if fall risk, may not be candidate
Well's criteria for PE risk (pretest probability) - si/sx of DVT, PE most
likely dx?, HR > 100? Immobilization for 3d or surgery in last 4wks? H/o PE
or DVT? Hemoptysis? h/o malignancy with tx in last 6mo?
Acute Pancreatitis & Ranson's criteria - most important thing is AGGRESSIVE
HYDRATION; if no CHF or ESRD, 300-500cc/hr. If CHF/ESRD, go lower and slower
(150-200cc/hr); also, Hct on admission. Look for 10% reduction with
hydration over first 34-48hrs.
TIMI risk score - risk scores for mortality 2/2 recurrent ischemia (UA/
NSTEMI TIMI score) or risk of all-cause mortality @ 30days in STEMI pts (
basically assess need for urgent catheterization); TIMI > 3 is high risk for
UA/NSTEMI pts and any score > 0 in a STEMI is high risk and goes straight
to the cath lab
DVT mgmt - doppler u/s of the LE(s); if +, IV heparin if no
contraindications (bleeding); si/sx: unilateral swelling, calf tenderness,
warmth, etc
PE - tachypnea, pleuritic chest pain, hypoxia, desaturations; w/u with stat
CTPE study (call resident!)
SIRS + sepsis + EGDT: *extremely important* --> review and know these! An
two of the following meets criteria for SIRS
- leukocytosis > 12 or < 4 or > 10% bands
- temperature < 36 C or > 38 C
- tachypnea > 20
- pulse > 90
EGDT: fluids, fluids, fluids!!! rev early goal directed therapy...
Acute desat: increase nasal cannula, if not improving --> venti mask --> non
-rebreather --> NIPPV (bipap / cpap) --> intubation
- once a pt's mental status changes and there are signs of respiratory
distress, get an ABG ASAP to check on oxygenation and acid/base status
All these and many more can be found at:
www.mdcalc.com
5) Notes:
- keep notes succinct; no need for long and detailed notes; include key
pertinent info
- if your note takes longer than 15min to write, you're spending too much
time on it
- can copy from eResults from previous day and edit in Word; or save them as
Drafts in your email and edit daily
6) DI's:
- similar to notes, keep succinct; refer to H&P, review initial problem list
, then review your most recent progress note and then fill in the blanks
succinctly
- have med students keep procedure list up to date so you don't get stuck
doing it all at the end; they should also update DIs on their people
- print a copy for the pt and a copy for the chart
- don't forget the d/c order or nurses will hunt you down
7) Know the PCRM's # and pharmacist's #
- very important people for you to work with and know; they can save your
sanity!
- be in constant touch with PCRM to ensure smooth discharges and follow-up
- DIs and discharges are priority #3 in the mornings after orders and
consults during/right after rounds | l********y
发帖数: 2295 | 2 GI specific tips:
- if someone needs marked for a para/thoracentesis, order the abdominal
fluid survey (ultrasound) ASAP or do yourself with a senior with you
- Prior to procedures, check coags; does pt need reversed with FFP? do they
need platelets? may need to time it to start at 4am or 6am for morning
procedures (colonoscopy, EGD, etc)
- keep a close eye on Na levels and K levels given diuresis and fluid
overload in these patients
- lactulose and rifaximin key for hepatic encephalopathy (help reduce
ammonia levels); keep in mind, ammonia levels themselves do not correlate
with si/sx of encephalopathy; do not order serial ammonia levels
- acetaminophen toxicity, treat with NAC (n-acetylcysteine). pharmacy can
help... usually run 3 rounds of NAC. and f/u q6 LFTs... AST/ALT should
downtrend. be sure to r/o other potential causes.
- quantitative immunoglobulins, if IgG > 2000, think autoimmune, keep in
mind age of pt...
- wilsons: ceruloplasmin will be low; keep in mind age. can also see lower
levels 2/2 dec protein prod / synthetic fxn, in ESLD
- hemochromatosis: will see high iron levels; bronze colored skin, DM
- PHYSICAL EXAM: look for asterixis daily; altered mental status? consider
SBP if has ascites; low threshold to tap (especially diagnostic)
- try to review hepatorenal syndrome and hepatopulmonary syndrome early in
the month; as well as ascites, SAAG scores, MELD scores, and hepatitis
serologies (damn those HepB Ags and Abs!)
- we use MELD, UNOS modification to calculate daily MELDs (just google it
and use calculator) | l********y
发帖数: 2295 | 3 NEPH: ESRD pts
- watch lytes closely; careful with things like laxatives (fleets enemas),
etc. Hi phos load, Na load; same with kayexalate
- if hyperkalemic: check EKG and see pt; if no peaked T's, likely can wait
to get HD; but give insulin, Ca gluconate, etc. If worried, give kayexalate
- if septic and oliguric: carefulw ith IVF; small boluses, ~500cc at a time
(like CHF pts); avoid fluid overload and causing pulm edema
- Phos: danger is elevated Ca x Phos product (serum Ca x serum Phos); > 55
increases risk of precipitation in renal tubules and extra-osseously;
Abnormalities in mineral metabolism were thought to be a passive
precipitation that predispose ESRD patients to vascular and soft tissue
calcification. Among dialysis patients, serum levels of phosphate should be
maintained between 3.5 and 5.5 mg/dL (1.13 to 1.78 mmol/L). Can give
sevelamir or lanthanum carbonate (avoid phoslo as it is calcium containing).
- Watch for increased risk of INFXN 2/2 frequent IV access for HD, chronic
inflammation, and chronic anemia | l********y
发帖数: 2295 | 4 LIVER:
- Volume: be careful not to fluid overload these pts; hypoalbuminemic
already, 3rd spacing. If unstable, hypotensive, consider IV albumin rather
than NS. Can do salt-poor 12.5gm BID for a few days (not much data supports
use past albumin levels of 3.0); useful in renal failure to reperfuse
kidneys. Esp if concern for hepatorenal syndrome, can start albumin. If
bolus fluids, do so gently.
- Variceal bleeding: immediately place 2 LBIVs; reverse coagulopathy with
FFP (contains ALL coagulation factors; best when deficiency unknown), cryo (
check fibrinogen, esp if concerned for DIC; < 100, give cryo; cryo has
fibrinogen, FFP does not). Bolus fluids, gently. Replete platelets. Start IV
octreotide (splanchnic vasoconstrictor to reduce portal pressures) and IV
nexium; Watch hemodynamics; if unstable at all, move to step down or MICU;
call GI fellow. Start SBP prophylaxis with ceftriaxone VS fluoroquinolone (
cipro). In an emergency, consider Sengstaken-Blakemore tube for balloon
tamponade (call for help) or call IR for emergent TIPS procedure.
- SBP: anyone with cirrhosis, consider SBP if febrile, abd pain, AMS/
confusion, leukocytosis. Low threshold to do dx tap. Order U/S to mark for
abd fluid ASAP. Send fluid for cell count & diff, LD, protein, and pH; also
for culture (2 blood cx bottles; directly innoculate at the bedside = higher
yield). Need dx para kit, gown, mask, gloves; 2 blacktops, and cx bottle
set. Empiric tx = ceftriaxone VS cipro/flagyl. If + for SBP, add IV albumin
(1.5g/kg) x 1. Tx = IV ceftriaxone x 5d; 10 PO cipro or norfloxacin. Then
ongoing prophylactic norfloxacin after 1st episode SBP.
- Acute liver failure: if 2/2 tylenol, start NAC (n-acetylcysteine). If
fulminant, look up fulminant liver failure protocol and follow
admit orders; staff ASAP and ask whether to trigger full protocol with
consults and everything. Check acetaminophen levels, tox screen. Depends on
underlying co-morbidities (ie, chronic hepB + C with acute tylenol toxicity
VS just tylenol). Calculate MELD, Unos (if low Na, calc MELD-Na). Assess for
AMS, asterixis, encephalopathy; coagulopathy; hemodynamics, renal dysfxn,
hypoglycemia; r/o infxn. | l********y
发帖数: 2295 | 5 ID:
- PNA: determine type (CAP, HCAP, or HAP) and start appropriate abx regimen;
r/o COPD exac
- DM with chronic infections: r/o bone infection, check for osteo (imaging,
XR); start vanco; inherently immunosuppressed; think of fungal infxn's too
- Back pain + fever: r/o epidural abscess with MRI; call neurosurgery
- Low threshold to do LP in anyone with AMS, h/a, nuchal rigidity, concern
for meningitis; consider septic emboli and checking TTE; image head
- TB: if suspect, admit to neg airflow isolation room; check quantiferon,
CXR; AFB culture of sputum
- HIV/AIDs: look up last CD4 count; pt on HAART tx? if not, why? if CD4 <
200, should be on bactrim prophylaxis. if no recent labs, check CD4, PCR
viral load; check BCx, CXR, sputum Cx, stool cx and studies, UA/UCx. if new
dx, check ELISA w/ reflex western blot; also check for opportunistic
infections (TB, syphilis, CMV, hepatitis); CD4 < 500: candidiasis; recurrent
bact infxns; TB, HSV, VZV // CD4 < 200: PCP; toxoplasma, crypto, histo,
coccidio // CD4 < 50-100: CMV, MAC; invasive aspergillosis; lymphomas; // if
CD4 < 50-100: start azithro for MAC prophylaxis; check for AFB cx and send
serum cx for fungal infxn. If CXR abnl, consider PCP and tx; check ABG.
start bactrim; look up most recent guidelines | l********y
发帖数: 2295 | 6 Thanks everyone, any advice/comment is appreciated. | m****a
发帖数: 287 | | s*********a
发帖数: 336 | | D********r
发帖数: 119 | 9 Thanks, Pony!
★ Sent from iPhone App: iReader Mitbbs Lite 7.56 | d********1
发帖数: 12 | 10 hi，谢谢！
什么是signout?具体怎么做？
DI`s 是discharge note的意思吗？ | | | c****r
发帖数: 494 | 11 啥时候整了个这么强的贴子啊。看来ready上岗了吗。
daily life在我们这里最重要的，除了order stat的，就是D／C，小朋友等着回家，bed出来了，好收新pt。弄晚了，是要挨骂的。 | D*********t
发帖数: 140 | 12 signout就是交班
DI不知是啥。 discharge一般写做D/C | l**e
发帖数: 70 | 13 appreication on nu tie!! | b******a
发帖数: 704 | | N**M
发帖数: 27 | 15 ALL Good ones! Thanks for sharing! |
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