Floor Book

��

�� 0��

Trusted by over 1 million members

Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.













��

Adult Medicine ............................................................................................................................................ 3

Everything you need to know about billing for an admission H & P ............................................... 3 Admission & H.O. Orders TTU ............................................................................................................. 5 Helpful Tips and Orders ........................................................................................................................ 9 Diabetic Ketoacidosis .......................................................................................................................... 12 Diabetic Ketoacidosis .......................................................................................................................... 13 Hypertensive Emergency .................................................................................................................... 15 Sepsis .................................................................................................................................................... 16 Adult Pneumonia .................................................................................................................................. 18 STEMI .................................................................................................................................................... 20 Ischemic Stroke Management ............................................................................................................ 22 Fever of Unknown Origin .................................................................................................................... 24 OB/GYN ..................................................................................................................................................... 25

OB/GYN Tips and Orders ................................................................................................................... 25 ............................................................................................................................................ 28 PEDIATRICS ..............................................................................................................................................

Pediatric Tips and Orders ................................................................................................................... 28 Pediatric Pneumonia Orders .............................................................................................................. 32 Criteria for admission of the child with Pneumonia ......................................................................... 33 Asthma in Pediatrics ............................................................................................................................ 34 Recommended Influenza Treatment Dosage .................................................................................. 37 Recommended Influenza Prophylaxis Dosage ................................................................................ 38 Inpatient Treatment of Bronchiolitis ................................................................................................... 39















Adult Medicine Everything you need to know about billing for an admission H & P You will make Allison, Dr. Young and Dr. Benton very happy if you will do these simple things:

Make sure you include something in family history and social history. For example: “Patient’s mother died of myocardial infarction at age 62. Patient’s father is alive and has COPD. Pt smokes 1 pack per day, perfect family and social history. history. denies use of alcohol and illegal drugs.” For billing purposes, that’s a perfect Include 10 systems on review of systems. For example: “Review of systems positive for cough, fever, hemoptysis, and leg swelling. All other review of systems negative including constitutional, eyes, ears nose and throat, respiratory, cardiovascular, gastrointestinal, gastrointestinal, genitourinary, musculoskeletal, skin, neurological, psychiatric and lymphatic except as already mentioned.” If you dictate that way, Allison will never bug you about missing $$ on billing because you messed up ROS. Include 18 things in 10 systems in your dictation for physical exam. Constitutional: Patient lying on bed in no apparent distress Eyes: Pupils equally round and reactive to light, no sclera icterus Ears nose and throat: Oral mucosa moist, tympanic membranes normal Respiratory: Lungs clear to auscultation bilaterally, no crackles or wheezes present Cardiovascular: Regular rate and rhythm with no rubs, gallops or murmurs. Peripheral pulses 2+ throughout. Gastrointestinal: Bowel sounds present in all 4 quadrants, patient has exquisite tenderness in right upper quadrant but no guarding or rebound tenderness. Murphy’s sign positive Genitourinary: No CVA tenderness (this is always a good one, unless of course it’s positive) Musculoskeletal: ROM intact all 4 extremities Skin: No rashes, ecchymoses or petechiae Neurological: Patient alert and oriented times 3, cranial nerves 2-12 grossly intact. DTR’s 2+ throughout Psychiatric: Mood and affect normal Lymphatic: 2+ pitting edema bilateral lower extremities

That’s about 30 items in 11 systems, and is able to be coded at a much higher rate. On assessment and plan, list each problem and talk about what you are doing for them. Billing is based on complexity. 1. 2. 3.

4. 5. 6. 7.

Hip fracture. The patient has suffered suffered an intertrochanteric intertrochanteric fracture fracture of the right femur. femur. Dr. Parker has already seen the patient and is planning on performing surgery tomorrow. Will maintain patient NPO and provide maintenance IV fluids. Pain control. In the ER, ER, the patient patient has been given Dilaudid and it seems to be working well. We will continue her on this medication and make adjustments if necessary. Cardiac risk assessment. assessment. The patient patient is 78 years old and does not have have a history of coronary artery disease. disease. We do not not have a current echocardiogram. Based on the Goldman criteria, the patient only scores 5 points for age and 7 points for atrial fibrillation, although the patient is adequately rate controlled on metoprolol. This gives the patient 12 points, making her risk category 2 with a 3% risk for myocardial infarction, ventricular tachycardia or congestive heart failure, and a 1% risk of cardiac death. Even if the patient had severe aortic stenosis on echo, which is unlikely given her normal pulse pressure and the absence of a murmur, her risk would only change to class 3, giving her an 11% risk for cardiac complication and a 2% risk of cardiac death. Will maintain patient on metoprolol to help reduce the risk of cardiac complications, but switch to IV for now. Diabetes. Patient takes metformin metformin at home, home, but will have surgery surgery so we will transition her to regular regular insulin q 6 hours with correction dose scale for now. We wi ll obtain a hemoglobin A1c to evaluate the effectiveness of her current outpatient therapy. UTI. Patient has positive leukocyte esterase esterase and nitrites nitrites on urinalysis, as well as 11 WBCs. Patient Patient had one dose of Levaquin in the ER, but given the extremely high resistance rates of our most common UTI bacteria to that particular antibiotic, I will give her Rocephin 1 gram IV daily. Dementia. Patient Patient appears stable in this this regard, and we will monitor monitor her during during her stay and continue her her Aricept. Hypothyroidism. Will obtain nt TSH and continue her home home dose of Synthroid fo















Talk about each problem, say a few sentences for the big issues and a short sentence for the small ones. You will make your fellow residents very happy if you will do these simple things:

1.

List all the patient’s patient’s doctors in the dictation. It’s embarrassing when we call Dr. Cox to see a patient that already sees sees Dr. Soya, and it hacks Dr. Cox off when he comes out here and learns this from the patient. We just wasted his time, and he knows it.

2.

Dictate quickly. The hospital and residency policy is to dictate dictate within 24 hours. hours. In reality, you you will never regret regret it if you just just get in the habit of dictating before you give the chart to the HUC for admission.

3.

Address code status when it’s appropriate. There’s no point point in asking a 35 year-old year-old who only has pneumonia, but anyone with an irreversible condition should be asked. “We don’t expect this to happen, but if your heart stopped beating or you needed to have a tube down your throat and be on a machine to help you breathe, what would you want us to do? Would you want us to provide chest compressions, shocks and intubate you? Again, we don’t expect that to happen, but what would you want i f it did?”















Admission & H.O. Orders TTU ADMIT to (attending’s name) as (23H Obs or Inpatient) to (Tele/Med-Surg/ICU/SICU) DIAGNOSIS: CONDITION: VITALS: (Q shift, per protocol, Q15 min, Q 4 hours, neuro neuro checks Q H x 24 H, then Q 4 if stable) Notify if temp temp >101 or SBP<90 SBP<90 ALLERGIES: (NKDA) NURSING: (accurate I/O Q shift; daily weights; O2 NC @ 2L/M titrate to SpO2>92%; foley to gravity; Accuchecks AC & HS/Q 6 H; seizure/aspiration/fall seizure/aspiration/fall precautions; IS Q H while awake; SCD’s to B/L LE; Neuro check Q H x 2, Q 2H x 2, Q 4 H x 2, then Q shift) DIET: (regular, carb-consistent, low salt, low fat, coumadin diet, clear/full liquid, NPO, meds with sips, 1500cc fluid restriction) ACTIVITY: (BR w/ BRP, Ad lib, BSC, up with assistance, ambulate TID) LABS: (CBC, CMP, BMP, PT/PTT, CXR (portable vs. PA & Lat), UA, EKG, ABG, amylase/lipase, Troponin/CE Q 8 x 3, Ca- MagPO4; STAT vs. in AM; GGT for biliary) IV: (type @ cc/hr; reseal; none) ex. D5 ½ NS @83cc/hr (?need bolus or K+ added) SPECIAL: old charts to floor, obtain other facility records MEDS: (drug, dose, route, frequency); Remember home meds PRN MEDS: Colace 100mg PO BID; Tylenol 325 (2) PO Q4-6 H PRN (if liver ok) CONSULTS: C&P Dr. (Name) for (service) re: (reason) (NOW vs. in AM) Maintenance hourly IV fluid (4/2/1 rule) st 4ml/kg for 1 10kg; 2ml/kg for next 20kg 1ml/kg for each kg>30 Kids: Bolus 20:20:10cc/kg, Maintenance is D51/2 NS if over 10 kg D5 ¼ NS if under 10kg PAIN: source? Need X-ray? Meds already ordered? PRN in place?  ALLERGIES & LABS (check LFTs) Tylenol 325 (2) PO/PR Q4-6H PRN Pain Lortab 5-10mg PO Q4H PRN Pain Darvocet N100 1-2 q 4-6 prn pain Percocet 5-10/325mg PO Q4H PRN Pain Morphine 1-4mg IV Q 2-4H PRN Pain Demerol 25-50mg IV Q6H PRN Pain (NOT IN RENAL PATIENTS) Phenergan 12.5-25mg IV Q 6H Toradol 15-30mg IV/IM Q 6H (watch SCr) ABX: Rocephin 1-2g IV QD/ Fortaz 1g q8∗∗ ∗∗ / Ancef 1g IV q6hr ∗ Levaquin 500-750mg IV QD ∗ CC 20-49 750mg q48 Unasyn 1.5-3g IV q6∗ CC 15-29 q 12 CC 5-14 qd Zosyn 3.375 g IV q 6 ∗ CC 20-40 2.25 g IV q6 rd Vanco 1g IV q12∗(trough 30 min before 4 ) ∗15mg/kg follow levels AFIB with RVR: Cardizem 20mg bolus over 2 minutes, wait 10-15 minutes, rebolus with 25mg (if needed), then start drip per protocol Agitation: ALWAYS EVAL PT FIRST! Look for cause… vitals, Accucheck, pulse ox, drug reaction, etc. Ativan 0.5-2mg IM/IV/PO Q6-8H max 10mg/qd (may cause resp ↓) Haldol 2-5mg IM/PO Q4-8H (may cause BP drop) If dystonic rxn occurs, Diphenhydramine 20-50mg IM/IV. Geodon 20mg IM x 1 (esp if Haldol allergic; watch in long QT) Seroquel 12.5 mg Alcohol (DT) precautions: (see also Banana Bag) Use Ativan taper AND Ativan, Librium or Valium PRN Ativan Taper Ativan 1-2mg IM/IV/PO Q6H PRN 1mg Q4H x 24H Librium 25mg PO Q6H PRN 1mg Q6H x 24H 0.5mg Q4H x 24H Labs: Mg, EtOH level, CMP, GGT, alk phos, CBC, PT/PTT, UDS, albumin, AST/ALT 0.5mg Q6H x 24H B12 1000mcg IM NOW & in AM 0.5mg Q24H then DC Use the following OR banana bag: Thiamine 100mg IM QD x 3, MVI PO daily, Folate 1mg PO qd x4 Allergic RXN: Solumedrol 125mg IV, Benadryl 25-50mg















BP Change: If  and symptomatic: check if pt got BP med today, if on NSAIDs, or any increase in pain Consider clonidine 0.1mg PO, recheck in 1H; repeat if SBP >180 For IV meds, pt must be on tele: Enalapril 0.6 mg Iv q6 ° over 5 min Labetalol 20mg IV over 2 minutes x 1, or 100mg PO BID Lopressor 5mg IV; hydralazine 10-20mg IV If  and symptomatic: do orthostatics, consider fluids, hold BP meds; if thinking sepsis get BCx and possibly m ove to ICU Chest Pain: ask for vitals (incl pulse ox), other signs/symptoms, order EKG and compare to old one, cardiac enzymes x 3 Q8H, PCXR If suspect cardiac, OH BATMAN & call resident/attending NTG SL 0.4mg Q5min x 3; ASA 325mg chewed Lovenox 1mg/kg Q12H or heparin protocol Metoprolol 100mg PO BID (keep HR<90, SBP<150) or Lopressor 5mg IV Q5min x 3 (must be on tele), then switch to PO NTG paste 1” to ACW Tridil drip & titrate to pain relief start: 5 mcg per min (if needed & must be in ICU) Morphine 2mg IV (hold for SBP<90) Repeat EKG in AM; consider ECHO, ABG Constipation: watch for SBO; consider rectal if warranted Dulcolax 10mg PO/PR PRN; Colace 100mg PO BID PRN Dulcolax PR, followed by Fleet’s enema in 45min MOM 30cc PO QHS PRN (NOT for renal patients) Lactulose 15-30cc PO; Miralax 17gm PO QD PRN Soap suds enemas Q1H x 3 or until clear Reglan 10mg PO/IV 30min AC (as prokinetic) Magnesium Citrate 150 cc po *1 COPD: HHN ABG PCXR (see also SOB) Albuterol 2.5mg HHNq4H PRN w/wo Atrovent 500mcg nebulized Q4H AND PRN (will save lots of calls!); Avelox 400mg IV daily If severe: Solumedrol 125mg IV Q24H or 60mg IV Q12H Decreased urine output: check fluids/intake, vitals (“No BP, No PeePee”), palpate bladder, get bladder scan, strait/foley cath/coude, check/flush foley if already in place. Chart initial urine output. If no output – Prerenal vs renal: listen to lungs, look for edema, oral cavity for moisture. If CHF, try Lasix. If dry – fluids (start slow; “easy in, hard out”) If renal – check labs (BUN, Cr, K) and look at meds (ACEI, nephrotoxic drugs [aminoglycosides, etc]) Diarrhea: ?infectious: recent Abx – c. diff screen; check occult blood, C&S, O&P; check lytes and replace fluids; no Immodium until cause identified. DVT prophylaxis: Legs elevated, bed rest, measure calves Venous doppler B/L LE, then apply SCD’s/Venodyne boots Heparin 5000u SQ Q8-12H, per wt base protocol 80:18 (Tx = 80 U per kg bolus then 18 U kg per hr) Lovenox 40mg SQ QD x 12D (Tx = 1mg/kg SQ BID or 1.5mg/kg qd), if CrCl<30 do q24H; for ST elev bolus 30mg then 1mg/kg q12H Contraindications: peptic ulcer, subarachnoid hemorrhage, tumor, recent CVA, recent surgery, bleeding disorder Electrolytes: Hyperglycemia  Accucheck AC/QHS (+0200) or Q6H and cover with sliding scale regular or Humalog SQ as follows: 0-60  call HO (see  glucose below) 60-150  0 units Alt: NPO for sx  give ½ insulin dose and start D5 ½ NS IVF 151-200  2 units 3, 5 201-250  4 units 6, 10 May need to  sliding scale for 251-300  6 units 9, 15 larger patients 301-350  8 units 12, 20 351-400  10 units 15, 25 >400  call HO (give 15, 20 or 30 units) If still uncontrolled, may need to go to unit for insulin drip. symptomatic? last dose meds/insulin? Hypoglycemia  is pt symptomatic? If A&O, give oral glucose (crackers or OJ) If obtunded, give 1 amp D50 Recheck in 15 minutes; may repeat if needed 8oz juice = 30g carbs; 2 graham crackers = 10g carbs 15g carbs   BS 25-50mg/dL

















Hyperkalemia  hemolyzed specimen? How ? EKG changes? If rapid tx needed (symptomatic) & pt not going for dialysis: Calcium gluconate 10% 5ml IV (esp. if EKG changes) 10units regular insulin & 50ml D50 IV bolus Sodium bicarb 1 amp (44mEq = 50mEq Na+) Kayexalate with sorbitol 15-30g PO or NGT (60cc=15g) Recheck K+ 2-4H after the above is completed Alternatives (if needed): Lasix 40-80mg IV Albuterol nebs Bicarb drip (3vials in 1 L D5W) if needed Hypokalemia  Check for EKG ∆s  u wave, flat T, ST ∆s 0.1 in pH  0.4-0.6 K+ (how bicarb works!) Total body deficit: 150-400 mEq per 1.0 mEq change in serum K+ Correct underlying d/o:  Mg, alkalosis, vol c ontraction, hyperald) PO (easier & quicker)  KCL / Kdur 20-40mEq PO up to TID IV (limited rate)  40mEq in 250cc NS over 3 hr Use 10mEq for every 0.1 of K+ to increase Recheck K level 2 hours after last dose of replacement K+ Hypomagnesemia  2g MagSulfate in 100cc NS over 2H 1g MagSulfate in 50cc D5W over 1 hour Slo Mag 2 tabs PO QD or BID (MgCl is 64mg/tab) Mag Oxide 400mg PO bid X 2 days Hypophosphatemia  Neutra-phos 2 packets tid x 1 day If ↓ 2 Kphos 20mmol in 500 cc NS over 4° or Sodium Phosphate 40 mmol in 1 L NS over 8 ° Fall: check vitals, pulse ox, accucheck, review meds, examine pt. Check for LOC, obvious injuries (lacs & fx), do neuro exam, additional symptoms (chest pain, SOB) *If tachypneic or tachycardic, think PE Order appropriate studies, make fall precautions, ?night light, note in chart and complete incident report (does not go in chart) Fever: NO TYLENOL IN SURGERY PTs! Refer to surgery resident. Otherwise, Tylenol OK. OK. Look for cause: UA, PCXR, BC x 2, etc. Safest Rx even in liver dz: 650mg PO/PR Q 4-6H PRN temp >101 If considering Motrin, check renal function and BP GI Cocktail: Donnatol 10cc, Maalox 10cc, viscous lidocaine 10cc Headache: R/O bad things first: subarachnoid bleed, temporal arteritis, migraine, acute angle glaucoma. Ibuprofen 400-800mg PO Q6H x 2 (watch renal func and BP) Tylenol 650-1000mg PO Q4-6H PRN Pain st Indigestion: 1 R/O cardiac origin Maalox Plus 30cc PO Q6H PRN (caution in renal pts) May need ulcer prophylaxis with PPI or H2 blocker daily Insomnia: Caution in COPD pts; no sleepers in carotid pts Ambien 5mg PO QHS PRN, may repeat x 1 (best choice) Restoril 15-30mg PO QHS PRN (7.5mg in elderly) Benadryl 25-50mg PO QHS PRN (not in BPH pts) Vistaril 50-100mg PO QHS PRN Elderly: Lunesta 1mg PO qhs Delirium: Seroquel 25 mg po bid / Risperdal 0.5 mg bid*Any of above may be source of altered M status* Infiltrated IV: D/C IV and ∆ site May use warm compresses PRN and elevate extremity

















PEG tube: if >2wks, should slide easily in/out and can irrigate if < 2wks, needs surgery Pronouncing DNR patient: wear gloves, check for verbal and noxious stimuli response, check pupils (should be non-responsive and dilated), check for HS/BS/carotid and apical pulses, may use tissue paper to check corneal reflex. reflex. HO is responsible to document all physical findings, time and date of death, notification of attending and consultants (document in note) and to document who notified family. Time of death is when you examine pt, not when nursing calls and tells you they’ve expired. Template for pronouncement below: (this will generally be the last note in the chart, and should be relatively formal in nature, so PRINT clearly and use a new progress note, and don’t forget to sign and print your name) “Called by nursing to pronounce the death of Mr/Mrs _______. The patient was examined and did not respond to verbal or physical stimuli. The skin was cool and dry, the pupils were were fixed and dilated. There was no heartbeat, respirations,blood respirations,blood pressure, or reflexes present. Mr/Mrs_______ Mr/Mrs_______ is pronounced dead at _____AM/PM on MM/DD/YYYY MM/DD/YYYY at the age of ___. Family was/was not present. Primary physician and attendings were notified by the House Officer at ____AM/PM.” ____AM/PM.” st PT elevation: 1 hold Coumadin if bleeding, give FFP x 2 units or vitamin K 10mg PO/IV/SC/IM if stable, give vitamin K 10mg PO/IV/SC/IM PTT elevation: hold heparin for 4H (½life is 1.5H), recheck PTT and follow protocol. Rectal pain: Americaine ointment QID Pericolace 2 PO now and QHS (softener and laxative) SOB: check vitals, pulse ox, ABG, EKG, PCXR, review H/H Consider HHN, increasing O2, hold fluids and give Lasix if suspect CHF. RT will help guide you! May need resident/att. Tele changes: GET EKG! Compare, look at pt, read chart. Symptoms? What type of change? Consider ACLS and call resident/attending Thrush: Nystatin oral susp 5cc swish & swallow QID Diflucan 100mg PO/IV QD Transfusion: T&C vs T&S Need 18-20 gauge needle Use leukocyte filter H&H 3 hours after last unit Hold maintenance fluids during transfusion Consider Lasix 20mg IV between units or after last unit Transfusion fever: check for transfusion rxn (IV site red, vitals, etc); may need to D/C transfusion; if fever only, consider Tylenol. Ulcer prophylaxis: prophylaxis: Protonix 40mg PO/IV Daily Zantac 150mg PO BID Pepcid 20mg PO BID Vents: AC – want 8-10cc/kg for tidal volume SIMV with pressure support and PEEP for weaning Want your I:E = 1:2-3 With increased RR want increased Q rate ↑ Co2 = ↓ rate ↓ TV ↓ Co2 = ↑ rate ↑ TV or ↑ Fio2 ↑ PEEP

Use good clinical judgment and evaluate all patients before starting any treatment. Review all dosages, side effects, and contraindications before prescribing any medications. Treat your patients, not your numbers. Take a deep breath, rel ax. Don’t be afraid to ask for help. Trust the nurses.

















Helpful Tips and Orders Use good clinical judgment and evaluate all patients before starting any treatment. Review all dosages, side effects, and contraindications before prescribing any any medications. Treat your patients, not not your numbers. Take a deep breath, breath, relax. Don’t be afraid to ask for help. Trust the nurses.

ADMIT to (Ped’s, floor, ICU) per CMP (case mgmt protocol) for TTFM, under (attending’s name) DIAGNOSIS: (Start with acute, then add chronic) CONDITION: (Stable, guarded, critical) floor/ICU,( or Q shift, shift, Q15 min, Q 4 hours, neuro checks Q Hr x 24 H, then Q 4 if stable) Notify if temp >101 or VITALS: As per floor/ICU,( SBP<90 ALLERGIES: (NKDA) NURSING: (I/O Q shift or strict I/Os; daily weights; O2 prn to keep SpO2>90%; foley to gravity; Accuchecks AC & HS/Q 6 H; seizure/aspiration/fall seizure/aspiration/fall precautions; SCD’s to B/L LE; Neuro check Q H x 2, Q 2H x 2, Q 4 H x 2, then Q shift) DIET: (regular, 1800 cal ADA or Diabetic, low salt, low fat, Renal, coumadin diet, clear/full liquid, NPO, meds with sips, 1500cc fluid restriction) ACTIVITY: (BR w/ BRP, Ad lib, BSC, up with assistance, ambulate TID) LABS: (CBC, CMP, BMP, PT/PTT, CXR (portable vs. PA & Lat), UA, EKG, ABG, amylase/lipase, Troponin/CE Q 8 x 3, Ca- MagPO4; STAT vs. in AM; GGT for biliary) IV: (type @ cc/hr; reseal; none) ex. D5 ½ NS @83cc/hr (?need bolus or K+ added) SPECIAL: old charts to floor, obtain other facility records, Add to Dr Consult’s list, PT/OT MEDS: (drug, dose, route, frequency); Remember home meds- See Med Rec Sheet AFIB with RVR: Cardizem 20mg bolus over 2 min, wait 10-15 minutes, rebolus with 25mg (if needed), then start drip per protocol (ex- titrate to SBP <120) Agitation: ALWAYS EVAL PT FIRST! Look for cause; vitals, Accucheck, pulse ox, drug rxn Ativan 0.5-2mg IM/IV/PO Q6-8H max 10mg/qd (may cause resp ↓) Haldol 0.5-5mg IM/PO Q4-8H (may cause BP drop) If dystonic rxn occurs, Diphenhydramine 20-50mg IM/IV. Geodon 20mg IM x 1 (esp if Haldol allergic; watch in long QT) Seroquel 12.5 mg Alcohol (DT) precautions: (see also Banana Bag) Use Ativan taper AND Ativan, Librium or Valium PRN Ativan Taper Ativan 1-2mg IM/IV/PO Q6H PRN 1mg Q4H x 24H Librium 25mg PO Q6H PRN 1mg Q6H x 24H Labs: Mg, EtOH level, CMP, GGT, alk phos, CBC, PT/PTT, UDS, albumin, AST/ALT 0.5mg Q4H x 24H 0.5mg Q6H x 24H B12 1000mcg IM NOW & in AM 0.5mg Q24H then DC Use the following OR banana bag: Thiamine 100mg IM QD x 3, MVI PO daily, Folate 1mg PO qd x4 Allergic RXN: Solumedrol 125mg IV, Benadryl 25-50mg Pepcid 20mg IV, EPI (if needed) Banana Bag (must order specifics below per L NS QD) 1mg folate, 2g MgSO4 (if Mg low), 100mg thiamine, 1 amp MVI BP Change: If  and symptomatic: check if pt got BP med today, if on NSAIDs, or has pain Consider clonidine 0.1mg PO, recheck in 1H; repeat if SBP >180 For IV meds, pt must be on tele: Enalapril 0.6 mg Iv q6 ° over 5 min ; Hydralazine 10-20mg IV

















Decreased urine output: Check fluids/intake, Vitals (“No BP, No PeePee”), Palpate bladder, Consider bladder scan, Strait/foley cath, Check/flush foley if in place. Chart initial urine output. If no output – Prerenal vs renal: listen to lungs, look for edema. If CHF, try Lasix. If dry – fluids (start slow; “easy in, hard out”) If renal – check labs (BUN, Cr, K), check meds (ACEI, nephrotoxic drugs [aminoglycosides, etc]) Diarrhea: ?infectious: recent Abx – c. diff screen x3; Check occult blood (x3), W BS’s, C&S, O&P; Check lytes and replace fluids; no Immodium until cause identified. DVT prophylaxis: Legs elevated, bed rest, measure calves Venous doppler B/L LE, then apply SCD’s/Venodyne boots Lovenox 40mg SQ QD x 12D (Tx = 1mg/kg SQ BID or 1.5mg/kg qd), if CrCl<30 do q24H; for ST elev bolus 30mg then 1mg/kg q12H Heparin 5000u SQ Q8-12H, per wt base protocol 80:18 (Tx = 80 U/kg bolus then 18 U kg/hr) Contraindications: peptic ulcer, subarachnoid hemorrhage, tumor, recent CVA, recent surgery, bleeding disorder Electrolytes: Hyperglycemia  Accucheck AC/QHS (+0200) or Q6H, and cover with sliding scale regular or Humalog SQ as follows: 0-60  call HO (see  glucose below) 60-150  0 units Alt: NPO for sx  give ½ insulin dose 151-200  2 units 3, 5 and start D5 ½ NS IVF 201-250  4 units 6, 10 251-300  6 units 9, 15 May need to  sliding scale for larger patients 301-350  8 units 12, 20 351-400  10 units 15, 25 >400  call HO (give 15, 20 or 30 units) If still uncontrolled, may need to go to unit for insulin drip. Hypoglycemia  is pt symptomatic? symptomatic? last dose meds/insulin? If A&O, give oral glucose (crackers or OJ) If obtunded, give 1 amp D50 Recheck in 15 minutes; may repeat if needed 8oz juice = 30g carbs; 2 graham crackers = 10g carbs (15g carbs   BS 25-50mg/dL) Hyperkalemia  hemolyzed specimen?(-in kids), How ? EKG changes? If rapid tx needed (symptomatic) & pt not going for dialysis: Ca gluconate 10% 5ml IV (esp. if EKG changes), 10 units reg insulin & 50ml D50 IV bolus Kayexalate 15-30g PO/NGT (60cc=15g), Na bicarb 1 amp (44mEq = 50mEq Na+) Recheck K+ 2-4H after the above is completed Alternatives (if needed): Lasix 40-80mg IV, Albuterol nebs, Bicarb drip (3vials i n 1 L D5W) Hypokalemia  Check for EKG ∆s  u wave, flat T, ST ∆s; 0.1 in pH  0.4-0.6 K+ Correct underlying d/o:  Mg, alkalosis, vol c ontraction, hyperald) PO (easier & quicker)  KCL / Kdur 40mEq PO up to TID elixir or tabs (ck K in AM) IV (limited rate)  40mEq in 250cc NS over 4 hr (can give 10 mEq per hr) Total body deficit: 150-400 mEq per 1.0 mEq change in serum K+ Use 10mEq for every 0.1 of K+ to increase Recheck K level 2 hours after last dose of replacement K+ Hypomagnesemia  2g MagSulf in 100cc NS over 2H, 1g MagSulf in 50cc D5W over 1 hr Slo Mag 2 tabs PO QD or BID (MgCl is 64mg/tab), Mag Oxide 400mg PO bid X 2 days Hypophosphatemia  Neutra-phos 2 packets tid x 1 day If ↓ 2 Kphos 20mmol in 500 cc NS over 4° or , Sodium Phosphate Phosphate 40 mmol in 1 L NS over 8 ° IV fluid Maintenance (4/2/1 rule) st nd 4ml/kg for 1 10kg; 2ml/kg for 2 10kg; 1ml/kg for each kg>20 Kids: Bolus 20cc/kg, Maintenance is D51/2 NS if over 10 kg; D5 ¼ NS if under 10kg Fall: check vitals, pulse ox, accucheck, review meds, examine pt.

















Mental status change: Check vitals, pulse ox, accucheck, med list Examine patient! If suspect CVA, CT brain without contrast. ABG, CBC, CMP. Call res/att Nausea: Ck NGT function; Phenergan 12.5-25mg PO/IV/IM/PR PO/IV/IM/PR Q4-6H PRN N/V (caution elderly) Zofran 4mg IV/IM x 1 (can use Q 8H PRN N/V) (can cause possible bronchospasm) Reglan 10mg 10mg IV Q6H PRN N/V (not for use in Parkinson’s pts, GI obstruction or seizure d/o) Compazine 5mg PO/PR Tigan 200mg IM/PR Q4H PRN N/V NG tube placement: Use 16-18 french; confirm with PCXR Neuro checks: Q1H x 2, Q2H x 2, Q4H x 2, then Q shift PAIN: source?, need X-ray?, meds already ordered?, PRN in place?  ALLERGIES & LABS (check LFTs) Tylenol 325 (2) PO/PR Q4-6H PRN Pain Percocet 5-10/325mg PO Q4H PRN Pain Morphine 1-4mg IV Q 2-4H PRN Pain Demerol 25-50mg IV Q6H PRN Pain

Lortab 5-10/500mg PO Q4H PRN Pain Darvocet N100 1-2 q 4-6 prn pain Phenergan 12.5-25mg IV Q 6H Toradol 15-30mg IV/IM Q 6H (watch SCr)

(NOT IN RENAL PATIENTS) st PCA’s: if NPO and/or significant pain; 1 check allergies; PCA’s need at least a maintenance IV rate of KVO (40ml/hr), PCA protocol sheet available at most nursing stations, or order as below: Morphine PCA: 1mg basal rate, 1 mg unit dose, 6min lockout, 20mg 4H max (may drop BP; caution in pancreatitis or choleycystitis) Demerol PCA: 5mg unit dose, 6min lockout, 100mg 4H max (not in renal or seizure pts) Pronouncing DNR patient: Wear gloves, check for verbal and noxious stimuli response, check pupils (should be non-responsive and dilated), check for HS/BS/carotid and apical pulses, use tissue paper to check corneal reflex. HO to document all physical findings, time and date of death, notification of attending and consultants (document in note) and to document who notified family. Time of death is when you examine pt, not when nursing calls and tells you they’ve expired. Template for pronouncement below: (this will generally be the last note in the chart, and should be relatively formal, so PRINT clearly and use a new progress note, and sign and print your name) “Called by nursing to pronounce the death of Mr/Mrs _____. The patient was examined and did not respond to verbal or physical stimuli. The skin was cool and dry, the pupils were fixed and dilated. There was no heartbeat, respirations, blood pressure, or reflexes present. Mr/Mrs_____ is pronounced dead at _____AM/PM on MM/DD/YYYY at the age of ___. Cause of death is ______ secondary to _______. Family was/was was/was not present. present. Primary physician physician and attendings attendings were notified by the House Officer at ____AM/PM.” ____AM/PM.” st PT elevation: 1 hold Coumadin if bleeding, give FFP x 2 units or vitamin K 10mg PO/IV/SC/IM if stable, give vitamin K 10mg PO/IV/SC/IM PTT elevation: hold heparin for 4H (½life is 1.5H), recheck PTT and follow protocol. Rectal pain: Americaine ointment QID Pericolace 2 PO now and QHS (softener and laxative) SOB: check vitals, pulse ox, ABG, EKG, PCXR, review H/H Consider HHN, increasing O2, hold fluids and give Lasix if suspect CHF. RT will help guide you! May need resident/att. Tele changes: GET EKG! Compare, look at pt, read chart. Symptoms? What type of change? Consider ACLS and call resident/attending Thrush: Nystatin oral susp 5cc swish & swallow QID Diflucan 100mg PO/IV QD Transfusion: T&C vs T&S; Need 18-20 gauge needle; Use leukocyte filter H&H 3 hours after last unit If CHF, hold fluids during transfusion; consider Lasix 20mg IV between units or after last unit Transfusion fever: check for transfusion rxn (IV site red, vitals, etc); may need to D/C transfusion; if fever only, consider Tylenol. Ulcer prophylaxis: prophylaxis: If in ICU, or if has GERD Protonix 40mg PO/IV q24 (hosp contract); Zantac 150mg PO BID; Pepcid 20mg PO BID



















Diabetic Ketoacidosis Diagnosis: Glucose > 250 mg/dl, pH < 7.30, HC03
2.)

Insulin a. b. c. d. e.

3.)

Bolus 10-20 U then 0.1 0.1 U/kg/hr → till Anion gap closed then convert to SQ 2° resistance 50-100 U/h IV Improvement should be 70-100 mg/dl per hr 600 → 500 → 400 When converting to SC, give 10 U Regular SQ, sto[p drip 1 hour later NEVER use the intensive insulin drip form (the one with the multiplier) to lower glucose – that form is only to MAINTAIN glucose that is already low. You CAN use the less intensive Insulin Drip form to lower insulin, but start patients on column 1 or 2 so the glucose does not fall too rapidly.

Volume a. NS 2 L over 1° needs 3-4 L b. NS 250 cc/hr

4.)

Glucose a. Hypoglycemia = cerebral Edema b. When glucose < 250 - 300 start D5W or D5NS @ 50-100cc/hr

5.)

Give Bicarb if pH < 7 or HCO3
6.)

Free Water (Tonicity)

a. 2 amps HCO3 in 1L ½ NS @ 200cc/hr a. Na will ↑ 1.6 for every ↓ 100 in glucose b. Glucose pulls water out of cells cells diluting Na c. Treat hyperglycemia

7.)

Phos a. If initial Phos is Low can replace ½ of K deficit with K-Phos. Monitor Ca2+



















Diabetic Ketoacidosis From Harrison's 18th Ed, TABLE 338-6. MANAGEMENT OF DIABETIC KETOACIDOSIS

1. 2. 3.

Confirm diagnosis (plasma glucose, positive serum ketones, metabolic acidosis). Admit to hospital; intensive-care intensive-care setting may be necessary necessary for frequent monitoring monitoring or if pH < 7.00 7.00 or unconscious. unconscious. Assess: • Serum electrolytes electrolytes (K+, Na+, Mg2+, Cl-, bicarbonate, phosphate) phosphate) (pH, HCO3-, PCO2, b-hydroxybutyrate) b-hydroxybutyrate) • Acid-base status (pH, (creatinine, urine output) • Renal function (creatinine,

4.

Replace fluids: 2-3 L of 0.9% saline over first 1-3 h (10-15 (10-15 mL/kg per per hour); subsequently, 0.45% saline at 150-300 mL/h; change to 5% glucose and 0.45% saline at 100-200 mL/h when plasma glucose reaches 250 mg/dL (14 mmol/L). 5. Administer short-acting short-acting insulin: IV IV (0.1 units/kg) or IM (0.3 units/kg), units/kg), then then 0.1 units/kg per per hour by continuous continuous IV infusion; increase 2- to 3-fold if no response by 2-4 h. If initial serum potassium is < 3.3 mmol/L (3.3 meq/L), do not administer insulin until the potassium is corrected to > 3.3 mmol/L (3.3.meq/L). 6. Assess patient: patient: What precipitated precipitated the episode (noncompliance, (noncompliance, infection, trauma, infarction, infarction, cocaine)? cocaine)? Initiate appropriate appropriate workup for precipitating event (cultures, CXR, ECG). 7. Measure capillary glucose every every 1-2 h; measure electrolytes electrolytes (especially (especially K+, bicarbonate, bicarbonate, phosphate) phosphate) and anion gap every 4 h for first 24 h. 8. Monitor blood blood pressure, pulse, resp., resp., mental status, fluid intake and output every 1-4 1-4 h. 9. Replace K+: 10 mEq/h when K+ K+ < 5.5 mEq/L, mEq/L, ECG normal, normal urine flow and creatinine; administer administer 40-80 mEq/h mEq/h when K+ < 3.5 mEq/L or if bicarb is given. 10. Continue above until patient is stable, stable, glucose goal is 150-250 mg/dL, mg/dL, and acidosis is resolved. Insulin infusion infusion may be decreased to 0.05-0.1 units/kg per hour. 11. Administer intermediate intermediate or long-acting insulin as soon as patient patient is eating. Allow for overlap in insulin infusion infusion and subcutaneous insulin injection. Dr. Brantley's DKA drip orders: Glucose Over 300 251-300 201-250 151-200

Insulin 5 units/hr 3 2 1.5

D10 0 mL/Hr 0 30 40



















DKA Glucose > 250 mg/dl PH < 7.30 HC03


















Hypertensive Emergency • • •

Definition : marked increase in BP, generally SBP >180 or DBP 120, associated with end organ damage Labs: CBC, UA, CMP, EKG, Cardiac enzymes, Imaging, Echo Management : Admit to ICU. Continuous cardiac monitoring, assess volume and neurological status, urine output. Lower mean arterial BP by 20-25% in 1 hour, DBP 10-15% (or ~110 mm Hg) over 30-60 min. After stabilization reduce BP to 160/110 over 2-6 hrs. Assess volume status. Gentle hydration hydration with NS to restore fluid/Na.

DRUG

Nitroprusside

Nitroglycerin

Labetalol

IV DOSE and ONSET Initial: 0.3-0.5 mcg/kg/min; increase in increments of 0.5 mcg/kg/min, titrating to the desired hemodynamic effect or the appearance of headache or nausea; usual dose: 3 mcg/kg/min; rarely need >4 mcg/kg/min; ma x: 10 mcg/kg/min. Onset 1-2 min. Initial: 5 mcg/min. Doses of 5-100 mcg/min typically used.Onset 2-5 min 20 mg bolus, followed by boluses of 20-80 mg or an infusion of 0.5 to 2 mg/min titrated until effect. Avoid boluses of 1-2 mg/kg due to precipitous fall in BP. Max cumulative 24-h dose 300 mg. Onset 2-5 min

Enalaprilat

1.25 mg IV over 5 min Q 6 h, titrated by increments of 1.25 mg at 12- to 24-h intervals to a max of 5 mg Q 6 h. Onset 15-30 min

Esmolol

250 to 500 mcg/kg/min by infusion; may repeat bolus after 5 min or increase infusion to 300 mcg/min. Onset 12 min.

Fenoldapam

Initial: 0.1 mcg/kg/min, titrated by increments of 0.05–0.1 mcgg/kg/min to max of 1.6 mcgg/kg/min. Onset 2-5 min.

5 mg bolus then 5–10 mg IV every 20–30 min PRN.

SPECIAL INDICATIONS/ CONSIDERATIONS Arterial and venous vasodilator. Acute pulmonary edema (may u se with NTG). Can be used in most HTN emergencies except MI and renal impairment. Venous >>arteriolar vasodilator. Not generally first line. Often used as adjunct, esp. in coronary ischemia or acute pulmonary edema Non-selective β and α1 blocker. DOC in hyperadrenergic activity, aortic dissection, acute myocardial ischemia (with NTG), aneurysm, acute ischemic stroke/intercerebral bleed, eclampsia/pre-eclampsia, hypertensive encephalopathy, post op HTN. Contraindicated in COPD, HF, or heart block ACEI. DOC for HF. Reduce dose in azotemia. Contraindicated in MI, eclampsia, bilateral RAS Ultra-short acting β1 blocker. DOC in acute myocardial ischemia (with NTG), aortic dissection, and peri/post operative HTN. Do not use in patients already on a β-blocker, bradycardic, or decompensated HF. Dopamine agonist. May use in myocardial ischemia, acute pulmonary edema/diastolic dysfunction, acute ischemic stroke/intracerebral bleed, acute renal failure/microangiopathic anemia, HTN encephalopathy, sympathetic crisis. Caution in angina, glaucoma, and increased intracranial pressure. Contains sulfite. Vasodilation of arterioles (preload and afterload reducer). DOC in eclampsia. Contraindicated in HF, MI, aortic dissection. Generally



















Sepsis Bacteremia – Bacteria i n blood no symptoms SIRS – systemic inflammatory response syndrome Fever, tachycardia, Tachypnea SIRS: Any 2 of these + suspected or known infection = Sepsis 1. WBC > 12 cells/ml, < 4000 cells/ml or > 10% bands 2. Temp > 100.4 or < 95 3. HR > 90 4. RR > 20 PaCo2 < 32 mm Hg Septicemia- Source of infection With Bacteremia Septic Shock – hypotension with septicemia Elderly may not have fever or white count Fluids 2 large bore IV’s – can give up to 4-5 liters if fluid deficit Central Line – I J, Femoral, Subclavian Art Line Pressers Dopamine – 5 mcg/kg/min MAP >50 • Not if Tachy Levophed – 0.5-1 mcg/min Ok if Tachy • NeoSynephrine – 100-180 mcg/min Won’t raise HR as much • • Periferal OK w/ [10mg/250ML] D5W Vasopressin – 0.04 unit/min ABX –Broad Spectrum Rocephin 1g IV q 12 ° Unasyn Zosyn 3.375 q IV q 6 ° Zithromax 500 mg IV qd Levaquin 750 mg IV qd Vancomycin with Sepsis– 1gm IV q 12 °





















Random Cortisol 15-34 ug/dl --> HDCST Random Cortisom < 15 ug/dl glucocorticoid replacement therapy 15-34 > 34

HDCST NO treatment

Hydrocortisone 75 mg IV q 6 ° If < 9 --> GRT

High-dose corticotropin stimulation test Mortality Base Cortisol 26% Good < 34 ug/dl 67% Intermediate > 34 ug/dl 82% Bad > 34 ug/dl Peds sepsis: WBC > 15 / CRP > 3 / HCO3< 24 Sedatives: Versed 0.02-0.10 mg/kg/hr (titrate to effect) Versed 2mg * 4 --> Breakthrough (Haldol, Ativan) Ativan gtts – MINDS Score

ChangeTest ChangeTest

>/= 9 >/= 9


















Adult Pneumonia Where to Treat the Patient • CURB-65: Confusion, Uremia, RR>30, BP <90/60, Age >=65 Score of <= 1: low risk, outpatient Rx • Score = 2: Short inpatient Rx or closely monitored outpatient • • Score > 2: Severe pneumonia: hospitalize and consider ICU admission Classify the Pneumonia 1. Hospital Acquired Pneumonia • Within 48 hours hours of hospital hospital admission 2. Healthcare Associated Pneumonia • Resident of NH within last 30 days • Wound care, IV therapy, or chemotherapy within • Hospitalization in acute care facility facility for at least 48 hours within within the last 90 days hemodialysis center within 30 days • Attendance of a hospital or hemodialysis 3. Ventilator Associated Pneumonia hours after after intubation • 48-72 hours



















Hospital Acquired Pneumonia / HCAP / VAP:

Risk Factors Hospital or Vent Vent > 3 days, days, Nursing home, Hemodialysis, Hemodialysis, LTAC, SNU, Wound Care, Abx > 5 days, HAP - Antibiotic

Dosage - IV

IV chemo, IV therapy

Renal Dose Adjustments

Anti-Pseudomonal Cephalosporin Cefepi Cefepime me

1-2 gm q 8-12° 8-12°

Ceft Ceftaz azid idim ime e

2 gm q 8°

CrCl CrCl 30-60 30-60 give give 1 gm q 12°*1 then then 1 qm q 24° CrCl 11-29 give 1 gm q 12°*1 then 0.5 gm q 24° CrCl CrCl 31-5 31-50 0 give give 1 gm IV load load then then 1 gm q 12° 12° CrCl 16-30 give 1 gm IV load then 1 gm q 24°

Carbepenems= 10% cross reactive PCN Imipenem (Primaxin)

500 mg q 6°or 1 gm q 8°

Meropenem

1 gm q 8°

• •

CrCl 30-70 decrease dose by 50% CrCl 20-30 decrease dose by 63% CrCl 6-20 decrease dose by 75% then divide q 12° L racemi c epinephri ne ne CrCl 10-25 decrease dose by 50% q 12° CrCl < 10 decrease dose by 50% q 24°

MRSA = Vanc / Linezolid Pseudomonas = B-Lactam + (FQ or Aminoglycoside) 1. B-Lactams = Cefepime, Cefepime, Ceftazidime Ceftazidime / Doripenem, Doripenem, Imipenem, Meropenem / Zosyn, Timentin, Aztreonam



















STEMI Diagnostic Criteria: • 2 mm of ST segment segment elevation the precordial leads for men and 1.5 mm for women women (who tend to have less ST elevation) and greater than 1mm in other leads. • Over time, the ST segment gradually returns to baseline, the R wave amplitude amplitude becomes reduced, and and the Q wave deepen deepens. s. In addition, the T wave becomes inverted. These changes generally occur within the first two weeks after the event, but may progress more rapidly, within several hours of presentation. bundle branch block or true posterior MI is STEMI. • New left bundle • Widened QRS QRS (>3 small boxes) boxes) in Lead 1 is likely a bundle branch branch block. Drugs/Doses: • 162-325 mg chewable nonenteric nonenteric coated ASA CrCl<30, no • Lovenox: if pt <75, 30mg IV bolus plus 1 mg/kg SC (no initial renal adjustment). Over 75, no bolus, give 0.75 mg/kg. Over 75 and CrCl<30, bolus and 1 mg/kg. bolus (max 4000 4000 U) followed by 12 U/kg/hr (max 1000 U/hr). • Or heparin 60 U/kg bolus • Metoprolol tartrate 25-50mg PO, can give 5 mg IV q5min X 3 if hypertensive hypertensive or A-Fib with RVR • Clopidogrel 300-600mg PO



















Thrombolytics : • Alteplase appears superior to streptokinase – Patients >67 kg: Total Total dose: 100 mg over 1.5 hours; infuse 15 mg over 1-2 minutes. Infuse 50 mg over 30 minutes. Infuse remaining 35 mg of alteplase over the next hour. Patients ≤67 kg: Infuse Infuse 15 mg I.V. bolus over 1-2 minutes, then infuse 0.75 mg/kg (not to exceed 50 mg) over next 30 minutes, followed by 0.5 mg/kg over next 60 min (not to exceed 35 mg). • Streptokinase, Tenectaplase, or Reteplase





















Ischemic Stroke Management Transient Ischemic Attack (TIA):



















Prevention of Recurrent Stroke/TIA: Stroke/TIA: • Control hypertension. Only 10/5 mmHg reduction has been shown to ↓ stroke risk. Close monitoring after discharge. Lifestyle changes and medications should be used. T he guideline states that no optimal medication regimen is known, but lists ACE inhibitors and diuretics as good options . • Control lipids and and BP more more rigorously in diabetics. ACEI and ARB are 1st line agents. control has fewer microvascular complications. complications. • Goal HbA1c is < 7%; good control atherosclerotic disease, target LDL is <100; with severe disease and/or DM, target target is <70. • Pt’s with symptomatic atherosclerotic



















Fever of Unknown Origin Most common Infectious causes: o Extrapulmonary TB o Intra-abdominal abscess



















OB/GYN OB/GYN Tips and Orders



















Dehydration- IVF replacement supplement w/ multivitamin Dimenhydrinate 50 mg (in 50 ml saline/20 min) q 4-6h IV ADD Metoclopramide 5-10 mg q8h IV or Prochlorperazine 2.5 -10 mg q3-4h IV or Promethazine 12.5 - 25 mg q 4 IV Thiamine 100 mg daily for 2-3 days (If vomited >3 wks) ADD Methylprednisolone 16 mg q8h IV/PO for 3 days, taper over 2 wks, wks, If beneficial limit total duration of use to 6 wks, OR









































































































































































































Floor Book

Recommend Documents