Resident Guide04

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RESIDENT SURVIVAL GUIDE 2004-2005 Introduction Welcome to residency. You are about to start one of the busiest, most fulfilling times of your life. Your fear is probably appropriate a lot is going to be expected of you. But, try to keep it in check. You are here for a reason. You have passed all the tests, clerkships, and other hurdles you needed to graduate from medical school. This is another part of your learning experience. Many have gone before you and many will go after youyou can do this! Remember, you are not a superhero. Exercise, eat well, and take time to enjoy the things that help you relax. Residency is a marathon and not a short sprint. We have written this guide because many of our residents thought it would be helpful to have a quick reference for those inevitable questions and pimping sessions. This is based on the Resident Survival Guide produced by EVMS for its residents as well as the University of California at San Franciscos Housestaff Handbook. This is not meant to be an exhaustive explanation for everything that goes on at each site or how to deal with every nurses call at night but it will hopefully help make your transition into residency easier. We have gone to great lengths to ensure the accuracy but it is not guaranteed. If you see something that is incorrect, please make a note of it so when we collect suggestions and changes for next year, we can update it correctly. Have a great year! General Team Lists: Each team has a list of its patients. Generally, updating the list is the responsibility of the students but students need clear instructions on what your expectations are for the list. Try to find out what your senior residents preferences are for the list and convey that to the students. Ultimately, the list usually needs to be further updated by the intern during the wee hours of the morning on call nights. Students should always have a copy of the list for the attending at the beginning of rounds. Sample Progress Note: This is a pretty thorough format and may not pertain to every patient but if you cover this on most patients, you should satisfy all of the attendings in the department. Time/Date PGY-1 Progress Note S: Events over last 24 hours. Complaints. N/V/CP/SOB/po intake? Address the reason why they were admitted. (For example, no chest List pain since admission.) current O: Tm Tc RR HR BP O2 sat (on RA, etc.) meds in (Include ranges of any abnormal vital signs but also include the current value for all vitals.) the margin I/O: Time/ Accuchecks listed Gen: CV: Resp: Abd:

Extrem: (Also include any system that is pertinent to the diagnosis.) Labs: Micro: list dates and results--check daily X-ray/PVL/ECHO, etc. results A/P: (or you can separate them into two categories) 1. chest pain - . . . 2. HTN, controlled - . . . 3. hypokalemia - replete 4. DM type II, moderate control - increase AM regular Your signature Pager Number/Stamp ICU Note Format: Please note-some attendings prefer the note be by system. Other attendings prefer this format. Admit Date:_____ ICU Day: _____ ABX and Day #:_______ IV Lines & Day #:____ Meds:_____________ Problem List:___________________________ _____________ ____________________________ _____________ ____________________________ _____________ ____________________________ 24 Hour Events: PE: Vitals: (include current values and ranges) I/O Total:_________ Gen: Lungs: FiO2:_____ CVP:_____ CV: AC/IMV:_____ PA:_____ Abd.: Vt:_____ PAWP:_____ Extrem.: PSV:_____ CO/CI:_____ Neuro: SpVt:_____ SVR:_____ PEEP:_____ SvO2:_____ Labs: CBC/Chem/ABG/etc. Micro: CXR: Assessment & Plan: Pulm.: CV: include volume status Heme: GI: Renal: acid-base status Neuro: ID: F/E/N: (fluids, electrolytes, and nutrition) Misc: stress ulcer & DVT prophylaxis; appearance of lines Sample Admit Orders: Of course, you will develop your own style but this may be helpful in the beginning when things seem overwhelming. (ADC VANDALISM)

Admit to Medicine (stepdown or telemetry, if needed) Attending - name Resident - name Intern - name and pager number Diagnosis: 1. main reason why they are being admitted 2. list all other diagnoses in order of importance Condition: stable/fair/guarded/critical, etc. Vitals: routine with pulse ox q12 hours Allergies: medication-reaction Nursing: Call MD for T >100.5 or 180 or 95 or 120 or 24 or 220/120, no endorgan damage)? Remember that in a patient who has "lived at this level" of hypertension for a while, a large acute reduction in BP may change an asymptomatic patient into a symptomatic one (precipitate cerebral/myocardial ischemia). If you decide to intervene, suggestions include: nitropaste is easy and can be easily removed (but can cause HA) captopril 6.25-25 mg po tid (check K, Cr, allergies before) nifedipine 10 mg po tid clonidine 0.1 mg po bid 6. Special situation: In patients with an acute CNS process (i.e. during/post-CVA), HTN is usually compensatory and should be permitted as long as the BP is < 220/110. FEVER (also check ID section for fever workup) I. Your differential diagnosis is fairly broad. Infection (lung, heart, brain, urine, sinuses, prostate, abdomen, skin, lines) Inflammation (collagen vascular disease, neoplastic disease) Mucositis Atelectasis Blood product reaction Drug fever (beta lactam antibiotics and amphotericin are frequent offenders) PE or DVT II. Determine whether the patient is stable or unstable (i.e. look at other vital signs and examine the patient). If unstable, you may want to call the resident and/or the ICU resident to arrange an ICU transfer. III. Take a focused H&P. Remember drug allergies! Determine whether additional studies to rule out the above diagnoses are indicated (e.g. CXR, U/A). IV. Determine whether blood cultures have been drawn within 48 hours. If so, there is generally no need to draw additional cultures. Also, anticipate this problem with your patient leave explicit instructions in case of fever in your patients. V. If your suspicion of infection is high, determine if antibiotics should be started. However, it is tricky starting new drugs on patients unless you are specifically told to do so at checkout. Think long and hard; there may be a good reason why the primary team didnt

use antibiotics on this patient. HYPOTHERMIA 1. "Theyre not dead until theyre warm and dead." Significant depression of vital signs and mental status occur, so do not delay resuscitation if pt appears dead. 2. Risk factors for hypothermia: Extremes of age: infants have greater body surface area relative to mass; elderly have lower metabolic rate and poor temperature sensation Submersion in cold water: rapid thermal conduction in water Alcohol ingestion: vasodilation, impaired shivering and awareness, hypothalamic dysfunction Sepsis, especially in geriatric and immune compromised population. Endocrine disorders: hypothyroidism, hypopituitarism, hypoadrenalism, diabetes, hypoglycemia Head injury: central core temperature dysregulation Drug ingestions (especially phenothiazines and barbiturates) 3. Classification: Mild (temp 3436) Initial increase in metabolic rate and shivering Increased HR, BP, CO, RR Impaired judgment, mild lethargy, confusion, loss of fine motor coordination Moderate (temp 3033.9) Pupillary dilation, severe lethargy and confusion Decrease in BP and HR, cessation of cardiovascular activity Atrial fibrillation and other arrhythmias common Severe (temp 50% of patients; many with J point elevation or LVH with repolarization abnormality; may be normal in many patients with MI. 4. Most patients should be admitted; 6% of pts. with cocaine-associated chest pain have MI. 5. Management: (NO randomized controlled trials) benzodiazepines, aspirin, oxygen, NTG for persistent pain, calcium channel blocker vs B-blocker plus phentolamine, thrombolysis vs angioplasty. The conventional wisdom is that beta-blockers should be avoided in cocaine chest pain, since they can lead to unopposed alpha-stimulation and thus, theoretically, worsening of the underlying pathophysiology. CONGESTIVE HEART FAILURE 1. Admit to floor if pressor support not needed (i.e. patient not in shock). 2. Determine whether patient is in leftsided or rightsided failure or both. Leftsided CHF Rales Tachypnea Leftsided S3 Rightsided CHF Elevated JVP Hepatojugular reflux Ascites Peripheral edema Congestive hepatopathy 3. Look in the old records for a prior echo or cath describing prior ejection fraction and presence of systolic versus diastolic dysfunction. 4. If CHF exacerbation, determine possible reason(s) based on H&P. Medical noncompliance

Dietary indiscretion Ischemia Arrhythmia Cardiovascular stress (infection, anemia, pregnancy, hyperthyroidism) PE Worsening valvular disease (e.g. aortic stenosis) 5. For systolic dysfunction, treatment may include: A. ACE inhibitorthe mainstay of CHF treatment. Start with captopril 6.25 mg po tid and increase dose as BP allows. If one dose is well-tolerated, you can go ahead and increase the next dose; it's not necessary to wait 24h. Once stable, switch to equivalent dose of oncedaily ACE inhibitor. Consult your local friendly pharmacist for hints, or use a rough conversion based on the following table: Captopril Benazepril/ Enalapril Fosinopril/ Lisinopril 6.25 mg po tid 12.5 mg po tid 25 mg po tid 50 mg po tid 5 mg po qd 10 mg po qd 20 mg po qd 40 mg po qd Hydralazine plus nitrates can be used in pts that cannot tolerate ACE-Is. B. Diureticused to reduce symptoms of pulmonary edema. The workhorse is furosemide; doses can vary from 20400 mg IV q6hr. When giving furosemide, watch BP carefully. To convert IV to po, double the dose (i.e. 20 IV is equivalent to 40 po). If furosemide is ineffective, try adding metolazone 520 mg po qd (must give 30 min before Lasix dose). Watch serum electrolytes (especially K) and replace as necessary. C. Other important considerations:

All patients should be on a low salt