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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.
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.
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
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.
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.
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.
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.
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.
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.
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.
CT scans:
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
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
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.
Pressure Support = Where the patient has control over all aspects of his/her
breath except the pressure limit
Deaths
In the room:
Death Packet:
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
ABG
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
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.
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
Check Lists
On-line Resources:
http://www4.umdnj.edu/rwjcweb/docs/handbook/imreview.html
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/contents.html
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:
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SOB
Is pt tachypneic? Desaturating (<90)? Wheezing? Having crackles on exam?
Always need to go evaluate a patient who is SOB!! Always check to see if a
patient is on fluids and evaluate if you need to stop these fluids! Obtain
1) O2 Sat >90% 2) ABG 3) CXR (portable) 4) possibly an EKG 5) possible CBG
Different modes of O2
1. O2 by nasal cannula up to 5 L/min
2. O2 by face mask up to 50%
3. O2 by venture mask 50%-80%
4. O2 by non-rebreeding face mask (100%)- need to be contacting both your
resident and the ICU fellow on call by this time (unless pt is DNR/DNI)
SEIZURE
Ativan 2mg IV x1 and may repeat q1min if patient still seizing; if no IV
access, may use diazepam 5mg-10mg PR
Phenytoin = load dose Fosphenytoin IV then Phenytoin PO maintenance dose (
100 mg PO TID) Ask for levels next morning (always need to adjust level for
patient’s albumin)
FEVER >38.3
If known cause = Tylenol + cold compresses
If unknown cause = Pan-culture pt (not necessarilly in all pt’s though-
therefore need to ask when the pt was last cultured) + Tylenol (give after
pt is cultured)
Pan-culture:
Blood culture x2 sets
UA & Urine culture
Sputum gram stain & culture (if cough or URI symptoms)
Stool gram stain & culture (if Diarrhea) + think about C. diff toxin
(esp if pt has been on Abx)and fecal WBCs
CROSSCOVERING INTERN NOTE
Notes for: Chest pain, tachycardia, SOB, Bleeding, falls
i.e.: called by nurse staff because pt was c/o ________, pt seen and
evaluated at bedside, reported…..
Assessment:
*Chest Pain: DDx includes…… After obtaining history, physical exam,
lab data, and imaging studies, patient most likely having………………….
Plan:
* ____, _______, _____, Fellow was called and decided to …..(if this is
applicable).
* Reevaluation in 2 hours
DNR NOTE / ORDERS (VA)
When the pt is admitted, the resident writes a DNR note which will expire in
24 h. Make sure to communicate to the team that their attending needs to
write a DNR order and note in the chart, otherwise the nurses will be
calling you every night because those notes usually expires at midnight.
• If the pt has a note signed by the attending or if there is a Non
-attending note written within 24 hours, but done on a different service-
you could write a text order saying “Pt’s DNR order signed by Dr XXXX on
xx/xx/xx at xx:xx am” and make sure to communicate the situation to the
team the next morning.
• If you have to renew a DNR because it has expired during the
night, the first question is: Does the pt have decision making capacity? If
not, who is the next of kin? You have to talk to the pt or his family about
the DNR, resuscitation, electric shocks, endotracheal intubation, and
mechanical ventilation issues. Once you have this information covered you
can write a Non-attending DNR order that will expire in 24 hours (be sure to
communicate to the team). If the pt or his family changes their mind (try
to avoid this situation) write an explicit note explaining the situation and
why the pt decided to change his code status.
PRONOUNCING DEATH ON CALL
1. First you must examine the pt for:
a. Response to verbal or tactile stimuli (none)
b. Spontaneous respiration (none)
c. Heart sounds and pulses (absent)
d. Pupillary response (pupils fixed and dilated)
2. Document the time the pt was pronounced death
3. Notify the family immediately and inquire whether they request an
autopsy and if they have thought in organ donation: (at VA concersation with
family needs to be recorded by AOD ext2044)
a. Familiarized yourself with the pt medical history and mode of death.
b. Identify yourself to the family in a humble and caring manner and
inform that their next of kin has expired. Inform them when the pt was
pronounced death and try to comfort them that their relative died peacefully.
c. If it is not clear from the pt's records, inquire whether the family
requests an autopsy. Autopsy’s DO NOT delay funeral services and are NO
COST to the family!
d. Ask the next of kin if the family wishes to come to the hospital to
view the body before it is transported to the hospital morgue. Notify the
charge nurse of their decision immediately.
4. Document the findings on pt's chart in a brief progress note format: i
.e.: ''called by charge nurse to pronounce Mr. XXXX dead. Pt examined,
unresponsive to verbal or tactile stimuli, no spontaneous respirations noted
, absent heart sounds, no palpable pulses, pupils fixed and dilated. Pt
pronounced dead at XX:XX am/pm. Family was notified and requested/denied
autopsy. Patients’ organs will/will not be donated. Funeral home will be
…...''
5. There will be many forms to fill out:
a. Brief history
b. Hospital course
c. Medical problems
d. Death Certificates = Reason of death (code 99 or CPR is not acceptable)
6. Do I need to call the Coroner?
a. Coroner’s case = if the death is unexpected (any other cause than a
chronic medical condition) and if the patient expires within 24 hours of
admission
7. As the NF intern, you are not responsible for doing the death
dictation; this is the responsibility of the primary team