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Intern Survival Guide



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Author 27 Posts
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/10/07 - 03:11 PM   quote post  
#1
My resident colleague Dr.Mary Yang started this Intern Survival Guide at Kaiser Santa Clara and she was very kind to let me post the guide here.

Thank you!




Edited by admin on 06/10/07 - 07:09 PM
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/10/07 - 03:17 PM   quote post  
#2
Tips on surviving floor rotations

1) Be organized AND always write things down! You need to develop a good system to keep track of your patients’ information/daily labs/ ‘to do’ list. Some suggestions:

a. Copy your dictated H/P, fold it in half and write your daily vitals, labs, studies and ‘to do’ list on the back. You can also have a separate ‘to do’ list (examples on page 31.32).
b. There are pre-printed H/P and daily sheets you can use but many find them too time consuming. (http://www.medfools.com/downloads/medicine)
c. Copy every pt’s H&P, daily progress note and put it in a folder. Just don’t lose your folder. You may want to put your contact information so that they can page you if it is found.
d. Use your daily sign-out sheet and put whatever important information on the sign-out sheet during the day.


2) Pre-round: 6:30-9:00AM (You have to pick up your sign-out sheet by 7:00AM)

a. Get to work early and get your notes started or finished before rounds. It really helps to have your notes done before rounds so you can work on other things after rounds.

b. Many people pre-write or pre-type their progress notes. This makes a lot of sense particularly for chronic patients where the plan does not change very much. If you do this, leave some room under the active issues so that you can hand-write additional thoughts based on that morning’s labs. You don’t have to have the perfect plan or have all the labs in the morning. You can add addendum to your notes later if the plan changes during rounds.

c. Correct abnormal electrolytes early. At the beginning of the year you may feel a little uncomfortable so call your resident. Below are some recommendations.

i. Potassium: Each 10 mEq is equivalent to 0.1 increase on the lab level.
1. Supplement all potassium below 3.8-4.0 unless pt has renal failure (3.0-3.4 may be acceptable, check with resident)
2. KCl 10mEq IV (run over one hour)
a. If pt has a central line you can run IV per protocol
b. Can give 1ml of 1% lidocaine with each 10mEq bag if it’s painful: be careful with pts with cardiac conditions
3. K-Dur 10mEq PO (tablet)
4. K-Lyte 25mEq PO (liquid)
a. Has a lot of bicarb so if pt is alkolotic give KCl
5. K-Phos 2 tabs PO
6. K-Phos 10mmol IV (run over one hour)
7. Give 10mEq for every 0.1 below 4.0
8. Watch potassium closely in pts on lasix.
9. You can also add 20mEq KCl to each 1L bag of IV fluid
10. Remember K+ will not correct unless you replace Mg
11. Make sure to correct potassium cautiously in patients with renal disease, particularly those with end-stage renal disease.

ii. Magnesium
1. Supplement all Mg below 2.0 unless pt has renal failure (around 1.6 is fine, check with resident)
2. For every 0.5 deficit, give 1 g of Mg
3. Magnesium Sulfate 1 g IV (run over 1 hour) or 400mEq MgOxide po BID or TID

iii. Phosphorous
1. Consider supplement if less than 2.0
2. Particularly important for patients in respiratory distress (ATP).
3. K-Phos 2 tabs PO q daily
4. Neutra-Phos 2 packs PO q daily
a. only helps pts taking po
b. give it with meals
c. K-phos 10mmol IV
5. Na-phos 10mmol IV
iv. Calcium
1. check albumin to correct level
2. calcium carbonate
a. Tums: 500mg tab = 25 mEq cal
b. Os-Cal: 650mg = 13 mEq cal


3) Progress Notes: (sample on page 31)

a. SOAP note
i. S: what happened overnight (start with telemetry events or acute events)
ii. O: vital signs (include finger stick glucose checks, I/O, weight if applicable)
iii. A/P: Assessment of pt and your plan for the day
iv. Code status
v. Social (update family), disposition plan


4) Rounds: Time for rounding is usually between 9:30-11:30 but can vary. Rounding is a time to present your pts and also for learning and teaching.
a. Presentation: Concise and relevant information only. Always get the most recent lab data and look at all micro, radiology studies (listen to all reports before rounds)
b. Teaching: Interns are not expected to read all the time but you should read on topics related to your patients. It’s always good to bring in articles. You can access KP on-line library (http://cl.kp.org ) or use Up-to-date for information.


5) After Rounds: You need to prioritize your “to do” list. Call consults, put in e-consults for studies and replace electrolytes early. Always take care of your sickest patients first.


6) Always ask for help when you need it. Your team should work together. If you are overwhelmed tell your resident. There are usually two interns on a team, so help each other. Sometimes the patient load is very uneven, and it is the resident’s responsibility to redistribute.


7) Take care of your patients as you would your family members. Remember to keep your patients and their family members updated. You may not always see family around so ask the nurse to call you when they are there. Trust me, it will save you a lot of time at discharge and will also help avoid angry family members and patients.


8) Dealing with patient’s family:
a. Large family: You don’t have time to explain everything to everyone. The best thing to do is ask family members to designate a spokesperson to contact for updates.
b. Angry patient or family: Don’t try to handle the situation yourself. Tell the pt/family member you see that they are upset/angry and that you need to call your resident/attending to be present.


9) Be nice to nurses, clerks, PT, OT, RT and all other medical staff because they can make your life a lot easier. Interns are sleep-deprived and stressed, but remember to keep your cool. If you run into problems with a staff member call your resident/attending.


10) Verbal Orders: It is a privilege and can be taken away if we abuse it. All verbal orders must be signed within 24 hours. You can sign someone else’s verbal order. If you disagree with the order you can write on the order that you are signing for “Dr.X”, but you should still sign it. For all verbal orders remember to have the nurse read it back to you and double-check the name of the patient.

Edited by dr on 09/03/08 - 06:54 PM
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/10/07 - 03:21 PM   quote post  
#3
Tips on Admissions


1) Most of the information for H/P can be found in CIPS. But, before you start looking things up check on your pt. Introduce yourself and tell the pt you will be back after reviewing their information. (Look under CIPS section in this booklet for helpful tips.)
Note: Sometimes patients will have seen their primary care physician a few days before coming to the hospital, so check under “Visits” for category and read notes.

2) Forms you need to fill out:
1) General Adult Medicine Admission Orders
i. Suggestions for general admissions (remember every pt is different so go over pt’s baseline vitals before filling this part out)
1. HR less 60 or greater than 100
2. RR less than 10 or greater than 24
3. SBP less than 90 or greater than 145
a. For stroke pts: call for SBP greater than 180
4. Temperature greater than 100.6-101
5. Activity
a. Bedrest for AMS, stroke, seizure, ACS pts
b. Anyone bedbound: decubitus precautions/care
c. Head of bed elevated 30o for anyone at risk of aspiration
6. Diet:
a. You should always write: “bedside swallow eval” before diet for anyone you think may have trouble swallowing (ex. pts with CVA). Always include: “if fails bedside swallow eval please consult OT for swallow evaluation.”
b. For anyone who may be malnourished you can add instant carnation breakfast drinks. Usually 1 can q daily to TID
7. IV fluids: Most commonly used is NS or D51/2 NS.
a. For anyone on NPO you should consider D51/2 NS and don’t forget to D/C fluid when pt can eat. 75-100cc/hr
b. Ringer’s lactate is usually used in the ICU.
c. Put a limit on your IV fluids.
i. Ex: NS at 100cc/hr x 2 L. This way you don’t forget to d/c fluid and put someone in CHF.
d.
Fluid Na Cl HCO3 Sugar
NS (0.9%) 154 154
D5W 50g /L
LR 130 109 28

8. Pain Meds: Find something you are comfortable with.
a. Example 1: (pt can take po)
i. Tylenol 650mg po q 6h prn mild pain (make sure pt LFT is not extremely high): no greater than 4 g per day (2 g per day in patients with liver disease.
ii. Vicodin 1 tab po q 6 hours prn mod. pain
iii. Vicodin 2 tab po q 6 hours prn severe pain
b. Example 2: (pt can’t take po)
i. Tylenol 650 mg pr (per rectum) q 6hr. prn mild pain
ii. 1mg morphine q 3h IV prn mod. pain
iii. 2mg morphine q 3h IV prn severe pain
iv. Hold morphine (any narcotics) for RR <10 or sedation
c. Other pain meds to use:
i. Percocet: 1-2 tab q 4-6 hours po
ii. Elixir (liquid): 15ml po q 4-6 hours prn
iii. Toradol (NSAID: be careful with renal patients): po or IV
iv. Demerol: can start at 0.5mg IV q 2-3 hours. 5x stronger than morphine and can lower seizure threshold
v. Dialudid: start at 0.5-1mg IV. 5-6x stronger than morphine
9. Sleep: Give something prn for sleep so NF doesn’t get called. Find a drug you are comfortable with but be careful. Avoid ativan in respiratory distress pt. Ask your pt what they usually use for sleep.
a. Ambien 5-10mg po
b. Benadryl 25-50mg po
c. Restoril 7.5-15mg po
d. Klonopin 0.5mg po
10. Constipation
a. colace 100mg po BID (hold for loose stools)
b. senna 17.2mg po BID (hold for loose stools)
c. bisacodyl 10mg po BID
d. tap water enema
e. lactulose 20mg po q6hrs until BM
f. fleets enema (do not use in renal failure or CHF patients)
11. N/V
a. phenergan: be careful in elderly pts: can cause extrapyramidal sxs/hallucinations: 12.5-25mg po or IV q 4-6 hours
b. compazine: be careful in elderly pts: can cause extrapyramidal sxs: 5-10 mg po q 6-8 hours, 5-25 mg PR q12 (may cause SIADH)
c. zofran: 4-8mg po or IV q 8 hours
d. reglan 5-10 mg po or IV q6 hours
12. Order inpatient and outpatient charts early. Many reports (e.g. previous colonoscopy and cardiac cath reports) are not on the computer.
13. If pt has wounds write order for wound care consult early.
a. Decubitus ulcers/pressure ulcers:
i. Clean with NS. Apply petrolatum or petrolatum gauze to ulcer and dry 4x4 gauze on top.
ii. Tegaderm: cover for non-infected erosions and superficial ulcers



2) Admission room request form:

- Patients with positive troponins need to be on Stepdown
- Neuro/Stroke patients usually go to Stroke/TCU
- Syncope or R/O MI patients go to telemetry (if no positive troponin)


3) Cardiac form: complete if pt is r/o MI or being admitted to tele, SDU, ICU

4) CHF form: complete if pt coming in with heart failure

5) COPD form: for COPD exacerbation

6) GI Bleeding: for upper and lower GI bleeding.

7) CIWA/COWA: for alcohol/benzo (CIWA) and opiate (COWA) detoxification.

8) Community acquired pneumonia care pack: any pt coming in with community acquired pneumonia.

9) Code Status form: Always go over code status with patients and explain in detail what his or her options are. ID DPA if there is one and document it in your H/P. You need an attending to sign all code status forms other than full code.

10) Transfusion form:
i. PRBC
1. 1 unit will increase the Hct by 1 and hemoglobin by 3
2. type and screen expires in 72 hours
3. can pre-medicate with 650mg of Tylenol and 25mg benadryl half hour before transfusion
4. some may need lasix: usually 10-20mg IV lasix after 1-2 units
5. consider 1 gram of calcium gluconate for every 3 bags of transfusion
ii. Fresh frozen plasma
1. give each unit over 30 minutes or wide open
iii. Platelets
1. each unit increase platelet by 5,000-10,000.



3) Extra Tips for admission:

1) Get a social services consult for any elderly patient, which will expedite your disposition.
2) PT evaluation for nearly all elderly patients, or deconditioned patients. Mobilize them early on your admission form – OOB to chair BID, ambulate daily, etc.
3) Nutrition evaluation for anyone elderly or who looks malnourished. Nutrition teaching for diabetics, obese patients. Most patients with renal disease (CKD III or worse) will need a 40-70 gram protein restricted diet. Neutropenic patients need neutropenic diet.
4) Document in your H&P patient’s baseline mobility status (cane/walker; how far they walk)
5) Document last Hgb A1c, last lipid panel, last echo result or functional study (myocardial perfusion), EF if they have CHF.
6) For oxygen, check the boxes to record room air O2 sats and WEAN patients daily.
7) For DNR/DNI patients, document whether pressors or BIPAP are allowed.

Edited by dr on 09/03/08 - 06:55 PM
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/10/07 - 03:25 PM   quote post  
#4
Tips on Discharge


You will find out very quickly that discharge planning is a very important part of taking care of your patient. You want to make sure your patients have good follow-up care. Good discharge will also prevent patients from coming back to the hospital and to you as kickbacks.

1) Things to do after pt is admitted:
a. Touch base with PCC (Patient Care Coordinator) if pt is from a SNF. Write order for SW consult if there are social issues that will need to be addressed (e.g. long-term placement planning).
b. Always write in your progress note what the discharge plan is. It will allow PCC/SW to start things early.
c. Remember that the SNF office is closed on weekends so try to place your patients during the week.


2) Things to do 1-2 days before discharge:
a. D/C foley: if pt has had a foley for > 4-5 days consider bladder training.
b. Check pt’s diet and make sure pt’s diet is up-dated.
c. Always call family the day before discharge. If you anticipate discharge before 11 AM make sure the night before that the pt has a ride.
d. Talk with PCC/SW early. It takes a day to deliver oxygen and nebulizer equipments.
e. Ask PT to evaluate pt early (24 hours prior to SNF placement) if you are planning for discharge. You can leave a message on the PT line and state “anticipated discharge today or tomorrow” to expedite their coming to see your patient. It will often take an additional 24 hours to actually place the patient.
f. Fill out the three green SNF forms and dictate your patient under “21” for a transfer dictation.


3) On discharge day:
a. Go over medications with your patient and family. Don’t forget to complete Medication Reconciliation.
b. Check on CIPS to make sure patient has the appropriate follow-up appointment set up. (type pt MR number and type in CAT: app to check)
c. Give your patient your card, especially if you want to add them to your panel.
d. Remember to give lab slips for follow-up labs.
e. If you want, you can call PCP yourself to leave a message. Just let your resident know.


4) Discharge options:
a. Home: make sure a ride home is arranged. Pt can also go home with home care for lab draws, IV antibiotics, and PT/OT f/u. Even if PT doesn’t skill them for home PT (say, if the patient is uncooperative with PT in the hospital), you can have a home health nurse go to the home later to evaluate for the PT needs.
b. SNF/nursing homes: Arrange with PCC/SW. If pt is going to SNF, have all discharge summary (stat line [2][1]) and all orders written as soon as a placement may be available. Pt may get a bed anytime and you want to be ready for transfer.
c. Hospice: Usually hospice is arranged through palliative care. You have to consult them by calling palliative care M.D. on call and send e-consult. There will be a packet for you to fill out. PCC and SW also need to be aware of the situation.

Edited by dr on 09/03/08 - 06:56 PM
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/10/07 - 03:29 PM   quote post  
#5
Tips on Radiological Studies


CT scans:

- give mucomyst alone or with bicarb drip to decrease risk of nephropathy.
- 3ml/kg 1 hour before procedure and 1ml/kg for 6 hours after

1) CT abd: obstruction or most other abdominal processes can be well visualized with PO contrast only
-if concern for an abscess PO and IV contrast is necessary
-IV contrast for vascular structures and lymphadenopathy
-retroperitoneal bleed is well visualized without any contrast
-NPO for 4 hours prior to procedure if contrast is ordered.

2) CT chest: high resolution CT chest for evaluation of the lung parenchymal

3) CT head: contrast is needed for r/o brain mets or masses


MRI:
- contraindications: pacemaker, caranial aneurysm clips before 1992, recent stent (4-6 wks), some IVC filters, indwelling insulin pump

1) T1: fluid is dark, good for anatomy, most similar to CT: good for gray-white differentiation, hypodensity can be ischemia or edema
2) T2: fluid is bright, good for pathology. Bone is dark because not much water and fat
3) Flare: ischemia and edema both look white so can’t distinguish them
4) Diffusion weighted image: best for strokes edema does not light up, ischemia turns white within 15-20min and stays white for 7-10 days so can distinguish between acute and subacute strokes
5) Gadolinium: metastasis light up


Edited by dr on 09/03/08 - 06:57 PM
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/10/07 - 03:34 PM   quote post  
#6
ICU Tips
(Jessica Murphy)


The first thing to keep in mind is that while you are in the ICU, the overall concept is that it is a team approach to patient care. Get to know everyone, because everyone has a crucial role in taking care of these patients. It is crucial that you communicate clearly and effectively to all people involved in patient care to ensure that no loose ends are missed.
Besides the attending and your resident, the team includes: Pharmacists, Nurses, Respiratory Therapists, Social Workers, Patient Care Coordinators, nutritionists. You will learn the most in the ICU if you take the opportunity to learn from these experienced individuals. Also know that part of their job is to protect the patient from us new, but eager Physicians!
As the intern, you are responsible for knowing your patients well, and following up on important issues. You are the first person who sees the patient in the morning, and therefore, important issues will be brought to your attention before anyone else.
Make sure you communicate with your senior resident any issues that came up overnight, or anything you are unsure of. It is better to iron out issues before attending rounds if possible.

Ventilators/Intubation

Indications for Intubation:
- tachypnea (in general RR >35)
- apnea
- hypercarbia (Pco2 >50)
- hypoxia (Po2 <50)
- unable to protect airway (ALOC)


In General Anesthesiology performs most intubations, however if you are aggressive and prepared, they will allow you to perform the intubation.
If you can’t hold the Tongue Blade Correctly…your out!
Have suction ready, have a ETT tube available (a size 8 tube is preferred if possible)


Three Main Modes of Invasive Ventilation

Assist-Control = Where assisted breaths are given when the ventilator senses the patient’s inspiratory effort. Each breath has a set tidal volume or a set Pressure. If there is no initiated breaths, the machine will deliver breaths at a set rate.

Spontaneous Intermittent Mandatory Ventilation (SIMV) = Which mixes controlled breaths and spontaneous breaths. Breaths can be synchronized to prevent "stacking".

Pressure Support = Where the patient has control over all aspects of his/her breath except the pressure limit

In your note write down the following information: Mode/Volume or pressure Control seting/Pressure Support (if applicable)/PEEP/FiO2 and Check ABGs Q AM to ensure you are properly ventilating the patient.


Edited by dr on 09/03/08 - 06:57 PM
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/10/07 - 03:35 PM   quote post  
#7
Things to Consider for Your Patients


1) Ambulate patients or at least write orders for OOB to chair/cardiac chair ASAP
2) Advance diet whenever possible
3) Air mattress for elderly pts/bedbound pts
4) Order heal protectors to prevent heel drop/ulcers
5) Order incentive spirometry to prevent atelectasis for all pts in bed>1-2 days.
6) When putting in an NG tube consider using exactacaine spray or 2% lidocaine gel.
7) Tell pt your plan for the day. You can also write it on the board in pt room.


Tips on Preventing Nurses From Calling You

1) Write orders clearly
2) Hold IV fluid when pt is getting transfusions esp. for CHF patients
3) Resume previous diet after a procedure/study
4) Don’t forget to NPO pts for next-day procedures or surgeries
5) Always use your stamp so nurses know who to call
6) Write orders for any studies in the chart and not just e-consult so nurses are aware of the plan
7) NG tube: check if pt can have meds crushed (ask pharm D for help)
8) Corpak placement: general rule is below diaphragm and cross the midline

Edited by dr on 09/03/08 - 06:58 PM
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/10/07 - 03:36 PM   quote post  
#8
Deaths


In the room:

1) introduce yourself and explain why you are there
2) check pt ID bracelet
3) check overall appearance of body
4) check verbal and tactile stimuli
5) listen for heart sound and feel for carotid pulse
6) look and listen for respiration
7) check size, position of pupils, check light reflex
8) write down the time you completed your assessment
9) ask family if they would like an autopsy



Death Summary: cause of death should be listed in chart or on the sign-out sheet

1) Exam: pupils fixed and dilated, no chest rising observed, no resp or heart sounds by auscultation, no pulses felt, pt not responding to verbal or tactile stimulation, etc.
2) Pt officially pronounced expired at H:M
3) Pt’s family at bedside or family was notified (name of the person contacted)
4) Pt is/is not coroner’s case (if it is a coroner’s case you’ll have to call the coroner’s office and write down the case number). Criteria for coroner’s case can be found in the death packet.
5) Autopsy pending or pt’s family declined autopsy.
6) Primary care physician Dr. X was notified. (don’t forget to call the PCP)



Death Packet:

1) ask for the death packet
2) you have to let an attending know about the death and document the attending’s name
3) if pt needs an autopsy remember to fill out the appropriate form and call the pathologist.


Edited by dr on 09/03/08 - 06:58 PM
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/10/07 - 03:37 PM   quote post  
#9
Procedures


Don’t forget to log in your procedures and have them signed the same day. You need to fill out a consent form and complex procedure form for each pt. with exception of ABG. Let the nursing staff know you are going to do a procedure as soon as possible.


Procedure requirements
1) Arterial Puncture 5
2) Central Venous Line 5
3) Knee Arthrocentesis 3
4) Lumbar uncture 5
5) Nasogastric Intubation 3
6) Paracentesis 3
7) Rectal Exam 5
8) Thoracentesis 5


Tips on common procedures:


ABG

i. ABG kite, a cup of ice, fill out the ABG form
ii. Procedure:
i. go in at 45 degree angle
ii. ask someone to hold pt hand for you or tape pt wrist and hand down over a rolled up towel
iii. You can go to ABG lab (5th floor) and get the result sooner.


LP

i. Always check coags before doing an LP: platelet should be at least >50K and PT/PTT should be close to normal.
ii. Get a non-contrast CT of head before doing an LP to rule out mass effect: Age>65, immunocompomised sate, focal neurologic symptoms, increased ICP/papilledema.
iii. Warn your pts about post LP HA- can last up to one week after LP. Hydrate pt well and have pt flat for at least 2 hours post LP.
iv. If you are going to get opening pressure, you need to LP with the pt laying on their side. Otherwise you can have them sit up and lean over a table.
v. Get things ready before calling your resident/attending
vi. LP tray (2), sterile gloves, face shield, sterile gowns, 1 bottle of lidocain, betadine swab or 2-3 chloraprep, 5 name labels with initials/time/date
vii. special labs form and microlab form
viii. help pt get into position (side or sitting up: use a table with a pillow over it to rest pt head)
ix. Tube 1 cell count. diff / Tube 2: gram stain, Cx / Tube 3: Chemistry (total protein, glucose, crypto Ag, RPR, anything else special/ Tube 4: cell count, diff, hold for further studies: PCR for EBV, VZV, HSV, CMV, VDRL, IgG albumin index If suspicion for MS simultaneous sample of serum should be sent together.
x. if you want to get a pressure reading the pt has to be on his/her side


Paracentesis

1) Get things ready before calling resident/attending
i. Yueh catheter (2) and blood transfusion tubing (in ICU storage room or order them before-hand)
ii. sterile gloves, 2-3 vacutane bottles, 1% lidocaine bottle, 18 gauge needles (2), one 40 cc syringe and 2 x 20cc syringes, culture bottles (aerobic and anaerobic), 1 jungle top, 2 red tops, and 1 green top, 1 bandaid, 2-3 chloraprep
iii. procedure forms, consent forms
iv. special labs form, micro form, path forms, 5 labels and sign with initials, date and time.
v. labs to order: gram stain, bacterial culture aerobic/anerobic, fungus, LDH, total protein, albumin, cell count and diff.
vi. Don’t forget to add LDH and glucose to earlier serum study
vii. if it’s pt’s first tap do not remove more than 1-1.5 L. If removing more than 1.5 L consider giving albumin (comes in 25g bottles)


Thorocentesis

1) Thorocentesis kite
2) order stat chest X-ray after procedure to r/o pneumothorax
3) Labs: LDH, Glucose, cell count with differential, gram stain+ culture, pH (send on ice), TP, AFB, adenosine deaminase, cytology, amylase, triglycerides, rheumatoid factors.


Edited by dr on 09/03/08 - 06:58 PM
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/10/07 - 03:45 PM   quote post  
#10
Tips - Cardiology studies:

- light breakfast is okay for most cardiac studies
- hold isordil/nitro for p-thal studies, but no need to hold b-blockers
- hold beta blockers, Ca channel blockers and isordil/nitro for exercise treadmill studies


Tips - Renal:

- spin the urine and look at it under the microscope whenever you have an acute renal failure pt:
1. get a sample of 10-20 cc of urine.
2. spin the urine for 5 min then place a drop of the concentrated urine on a slide with cover slip
3. lab staff are usually very helpful. You can also call the nephrologists on call to look at it with you. Call them early.


Tips - Hematology:

- call lab to have them perform a blood smear and save it for you to look at with the hematologist. It’s especially important to do before you give any transfusion product.


Tips: - DM team:
Learn to manage DM pts. Do not depend on DM team. They are there to help with difficult cases and discharge medications/teaching. Also, let them know if you need recommendation for discharge meds. Get HA1C on admission if there isn’t one in past 3-4 months. Also write in your H/P pt’s insulin regimen prior to admission.



Tips - GI:
Be prepared to report last EGD or colonoscopy information, whether the last bowel movement is still bloody, NG lavage results, COLOR of stool as well as guiac status, baseline Hct
If pt is anemic have results of iron panel including ferritin available. Make sure you know the H/H trend, coag. Have most recent vital signs ready


Tips on avoiding calls from a Pharm:

1. Check Vanco trough 30 minutes before 4th dose. Target is 5-15mcg/mL
2. For pts with renal disease always renal dose all medications. If pt is receiving Vanco you can check Vanco random levels with AM labs.
3. Each medication ordered must have a documented diagnosis, condition or indication for use especially for “prn” orders.
4. Write clearly, sign/date, and use stamp.
5. Always use a “leading” zero (write 0.1 and not .1)
6. Always check to make sure you are writing orders in the right chart!
7. Abbreviations you are not allowed to use and what you should write:
a. qd = qdaily
b. QOD= every other day
c. MgSo4= Magnesium Sulfate
d. U or u= Units
e. MS=Morphine Sulfate
8. Hold spiriva if you put pt on atrovent
9. Xopenox can be used in pts with tachycardia it’s 0.63mg or 1.25mg q 8h nebs
10. Don’t forget to fill out IV antibiotic forms EVERY time you order IV antibiotics


Edited by dr on 09/03/08 - 06:59 PM
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/10/07 - 03:47 PM   quote post  
#11
Check Lists


End of the day check list:
2) Make sure all AM labs are ordered!
3) Make sure your sign-out sheet is updated
4) Always check on the board in the resident lounge to make sure you are not presenting at the intern report.
5) Check voicemail
6) Check lotus note
7) Document work hours
8) Check CIPS for any outpatient and inpatient follow up labs and dictations


Weekly check list:
1) Mailbox with your name on it is located at the back of the hospital near the loading dock.


Rotation check list:
1) Log procedures
2)_Sign off on Attestation sheet (only time you don’t need to is during inpatient rotations)


Edited by dr on 09/03/08 - 06:59 PM
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/10/07 - 04:02 PM   quote post  
#12
On-line Resources:

http://www4.umdnj.edu/rwjcweb/docs/handbook/imrev...
http://medicine.ucsf.edu/housestaff/handbook (This is a great handbook to have in your pocket. The handbook include section on ICU, NF and Floor)
http://info.med.yale.edu/intmed/cardio/imaging/co...



Palm Resources:
1) Epocrates: http://www.epocrates.com
2) Antibiotic guide: http://www.hopkins-abxguide.org
3) ABG Calc: http://www.stacworks.com
4) MedCal: http://medcalc.med-ia.net
5) PalmEKG: http://www.eMedic.com
6) GFR Est.: http://www.nephron.com



Recommended pocketbooks:

Pocket Medicine (The Massachusetts General Hospital Handbook of Internal Medicine) by Marc S. Sabatine

Maxwell Quick Medical Reference
smal
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Posted 04/02/08 - 03:05 PM   quote post  
#13
wow thanks!
dranagarcia
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Posted 05/30/08 - 08:59 AM   quote post  
#14
great tips... I can't wait to practice!
imnow
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Posted 06/08/08 - 04:21 AM   quote post  
#15
thank you so much!! a little overwhelmed though! hope i can get the hang of things soon!
justme
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Posted 06/18/08 - 10:24 PM   quote post  
#16
thanks a lot!
btw,what exactly constitutes an e-consult? who is supposed to carry it out?
thanks.
dr
admin

Total Topics: 6
Total Posts: 43
Posted 06/19/08 - 05:43 AM   quote post  
#17
justme wrote:
thanks a lot!
btw,what exactly constitutes an e-consult? who is supposed to carry it out?
thanks.

It is the name of the program used in our hospital to book patients for a consult with a specialist or for investigations.


smiling face
arlete
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Posted 08/28/08 - 02:53 PM   quote post  
#18
Awesome, thanks!
fua
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Posted 03/24/09 - 07:07 PM   quote post  
#19
thnx a bunch......!!!!!
ganesha123
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Posted 04/03/09 - 05:45 AM   quote post  
#20
thanks so much..awesome stuff..smiling face
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