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cybermd: Intern calls (No.1-4/discussions)
作者:USMedEdu
发表时间:2008-06-18
更新时间:2008-06-18
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发信人: cybermd (yo), 信区: MedicalCareer
标 题: intern calls 1
发信站: BBS 未名空间站 (Thu Jun 12 15:38:01 2008)


As many of us here are going to intern year in internal medicine soon, you

will have to deal with a LOT of night calls. As promised, I will give you

guys a few tips on most common calls. Rather than "lecturing" , I 'd like
to
ask you guys to solve the common hypothetical calls as intern. So, please

jump in and give your answers and this will reflect your clinical reasoning.
You guys can learn from each other. In the end, I will tell you what I will
do in these situations. It is not going to be evidence-based but rather
"
survival based" as an intern to keep the patients alive and do not kill
them
. Hopefully, by the end of these series, you will be comfortable with most

calls.

Cut the crap let's do some drilling,


1. 65 yo female chronic a fib tipped over and had a fall. RN called you
as
an intern to see the patient. What you do?

2. 66 yo COPD on home O2 can not sleep, RN called to give him some Ambien,

what you do?

3. One patient on Oncology floor expired, RN called you, what you do?

4. 72 yo male admitted for pneumonia three days ago, now desat (O2 sat)

dropped to 85%, what you do?

That is for today, please join the fun. I will be back with my way.



--


发信人: scrub2008 (jobsmac), 信区: MedicalCareer
标 题: Re: intern calls 1
发信站: BBS 未名空间站 (Thu Jun 12 17:24:30 2008)

Thank you for your kindness.
I have no experience of night calls at all. These answers maybe pretty silly.

1. Check the patient including neuro check. Ask her fall history. If she
is
on coumadin, she has increase risk of intracranial bleeding like SAH. Ask
RN
watch her closly. Also rule out hip fracture.

2.Ask the detail about insomnia and other symptom. Make sure his symptom
not
due to COPD exacerbation. Ambien should be given to COPD patient with
precaution. I am not sure I should prescribe him ambien at this time.

3.Make sure he was dead. Should I ask the resident come with me and document
the death. To be honest, I don't know the answer.

4.See the patient first and try to find some clue of hypoxia. Order EKG
and
Give some oxygen, after 20 min check the O2 sat again. If is not improved,
I
'll get the resident's opinion.
--

发信人: usatravel (usatravel), 信区: MedicalCareer
标 题: Re: intern calls 1
发信站: BBS 未名空间站 (Thu Jun 12 18:35:00 2008)

1. 65 yo female chronic a fib tipped over and had a fall. RN called you
as
an intern to see the patient. What you do?
Check vital signs 1st. if unstable, ( confusion, SOB, chest pain,
Hypotension) shock her; if stable,check ventricular rate, if not rate
control, give medication to control ventricular rate below 100. Get a head

CT, to exclude bleeding or hematoma.
I will not anticoagulate her based on the potential brain bleeding.

2. 66 yo COPD on home O2 can not sleep, RN called to give him some Ambien,

what you do?
check SaO2 to maintain >90%. but not too high, low O2 level is imporatnt
to
drive breath in COPD. Ask pt the exact reason why he cannot fall a sleep

before giving Ambien

3. One patient on Oncology floor expired, RN called you, what you do?
Call PGY-2. see pt, check vitals, declare death

4. 72 yo male admitted for pneumonia three days ago, now desat (O2 sat)

dropped to 85%, what you do?

get a CXR to document any change in the lung would explain desat.

--

发信人: cybermd (yo), 信区: MedicalCareer
标 题: Re: intern calls 1
发信站: BBS 未名空间站 (Fri Jun 13 23:23:28 2008)

Thanks for the guys who participated. Good job.

For intern calls, a few general rules, which you can not learn from any
book.

First, when you peeper goes off, answer it right away if you can, otherwise

you might skip and that one may haunt you later. One intern missed a fall

call (RN did not think was bad and did not page again )and pt died the next

day.

When you pick up the phone and talk to the RN, write down where is the 
patient, name and who is paging you. ALWAYS ASK FOR VITALS ON THE PHONE,
so
you will know if you should rush the bedside or not.

First and most, always remeber you are only an intern, you always have 
residents. fellows, and attenings behind you. Ask them if ANY doubt.

Document EVERYTHING in chart about your call. Time to see the pt, what 
happened, your exam and assessment and discussion with residents attending

ect.

When you return the pager, always assess the urgency of the call. You are

going to have multiple pages at the same time. PRIORITIZE them. Go see the

most urgent patients and this requires some clinical judgements. ABC applies
here too. Anything to do with desat, tachycardia, chest pain, see them 
right away and call your residents ASAP (esp for the first few months.

When see the patient, always check vitals YOURSELF. This is very important

cause' I have seen so many sick patients with "good vitals" by RN.

Always notify attendings of any major changes to the patient,no matter how

late it is. It is not only important for attendings to help you out also

protects attendings. One attending came in one morning and met the patient

family in the elevator and the attending did not know the patient already

died the previuos evening. Imagine how he will be pissed off when he sees

the intern on call.

Now back to the above calls.

1.. 65 yo female chronic a fib tipped over and had a fall. RN called you
as
an intern to see the patient. What you do?

Fall is very common. Most important thing, do not miss things could kill
the
patient. First, what caused the fall, anybody witnessed the fall. Any
cardio patient, please check the telemetry. You do not want to miss any

significant arrthymia. Talk to RN and patient, do a phyical, review med
list
. ANYONE ON COUMADIN WITH A FALL, CT HEAD W/O CONTRAST PLEASE. The yield

will be low, but you miss one, you are done. Any patient for pain and pain

control. Neuro checks. Document. You do not have to call resident for simple
fall.BUT YOU ORDER A CT HEARD, MAKE SURE YOU FOLLOW UP AND DOCUMENT IN 
CHART.

2.2. 66 yo COPD on home O2 can not sleep, RN called to give him some Ambien,
what you do?

Point here is no benzo for COPDer. I have seen so many ICU transfers due
to
benzo for COPDer. You guys are right on the money, make sure vitals stable.

3. One patient on Oncology floor expired, RN called you, what you do?


When called to pronunce death, check the patient. Point here is to call

attending and family member (no matter how late) and document.You do not
need to call your resident.

4. 72 yo male admitted for pneumonia three days ago, now desat (O2 sat)

dropped to 85%, what you do?

The point here is for any unstable patient, call your resident right away
(
esp for the first few months). When you heard the 85 sat, you do not fool

around with RN on the phone, rush to the bedside to see the patient stat.
If patient is not responsive, do not fool around, intubate the patient.
If
patient still talking, put O2 first. There are a few ways to give O2. nasal,
face mask, nonrebreather, CPAP, BIPAP. you should know this now by reading.
If you do not know, ask RN and resident whoever is in the room. Hypoxia

work-up is beyond the scope of discussion here. However, when you do not

know what is going on, you throw everything you have to stabilize the
patient first before a final diagnosis (O2, nebs, possibly lasix, intubation
as needed), broaden antibiotics. R/O spesis shock, remeber, always check

vitals yourself. Do not leave the patient unless either patient is better
or somebody else like ICU team take over.

That is it for now. I will post second of the series.
--

发信人: cybermd (yo), 信区: MedicalCareer
标 题: Intern calls #2
发信站: BBS 未名空间站 (Sat Jun 14 00:02:50 2008)

1. RN called that a patient accidentally put out his PEG tube, what you
do

2. RN called about a patient with a fever of 100.8 and ask for tylenol

3. RN called you that a patient's urine in the foley bag is only 100 for
the
last 6 hours.

4. RN called a patient had a large bowel movement of "black stool"

Please share your thoughts and I will be back with my approch.
--

scrub2008 (jobsmac), 信区: MedicalCareer
标 题: Re: Intern calls #2
发信站: BBS 未名空间站 (Sat Jun 14 08:22:13 2008)

1, consult GI surgeon and see whether he can place a new one later.
2, Check the patient first and then make the final decision.
3, Go to the bedside and If the tube is kinky, reinsert it. If oliguia is

due to other reason, talk with the resident.
4, Check patient's vital, If he is not stable, do fulid resuscitation. Then

work on the reason of GI bleeding.
--

发信人: MADMD (麦地PANGPANG), 信区: MedicalCareer
标 题: Re: Intern calls #2
发信站: BBS 未名空间站 (Sat Jun 14 13:06:06 2008)


1. RN called that a patient accidentally put out his PEG tube, what you
do?
Call GI consult stat. A new tube must be replaced within 24 hours or the

incision may close.

2. RN called about a patient with a fever of 100.8 and asked for Tylenol.
See the pt and read the chart, make sure do not screw up by giving Tylenol

to a patient who has liver failure.

3. RN called you that a patient's urine in the foley bag is only 100 for
the
last 6 hours.
Check the foley, nurse chart of fluid in/out, VS.

4. RN called a patient had a large bowel movement of "black stool".
Check VS, stabilize the pt (IV fluid or even order blood type cross match

and transfusion), may also need to do a digital rectal exam and stool
hemoccult stat.

--

发信人: knockingdown (麦地撂E倒), 信区: MedicalCareer
标 题: Re: Intern calls #2
发信站: BBS 未名空间站 (Sat Jun 14 22:54:52 2008)

Thanks for the first one, it was great! Let me try this one.

1. RN called that a patient accidentally put out his PEG tube, what you
do

If PEG tube has been there for a while, there should be a fistula formed

around it, all we need to do is keeping it open by temporarily putting in
a
Foley catheter through the channel. An endoscopy can be done later to insert
another PEG.

2. RN called about a patient with a fever of 100.8 and ask for tylenol.

Go check th patient, figure our what caused fever, treat underlying disease(
atelectasis/urethral catheter/thrombosis...). 100.8 doesn't need tylenol,

warm water can do that.

3. RN called you that a patient's urine in the foley bag is only 100 for
the
last 6 hours.

Check pt's chart, is he hemodynamically stable, check if the catheter is

open, if open, do urine analysis/electrolyte/CBC

4. RN called a patient had a large bowel movement of "black stool"

Make sure patient is stable, check the "black stool" to see if it is tarry,

do FOB/ask diet/similiar problem before. If patient is not stable, ste up

IVE, NS, CBC/blood type...

--

发信人: cybermd (yo), 信区: MedicalCareer
标 题: Re: Intern calls #2
发信站: BBS 未名空间站 (Sun Jun 15 00:31:20 2008)

You guys are pretty good.

1.RN called that a patient accidentally put out his PEG tube, what you do.

Point here is put a Foley catheter in to keep the PEG site open. Call GI
in
AM for replacement (u wont learn this from any book).


2. RN called about a patient with a fever of 100.8 and ask for tylenol.

Point here is your response to any call depends on who is the patient.

Depending on the patient, you will respond differently. For any
immunocompromised patient,such as AIDS, cirrhotic pt, transplant pt, BMT
pt
,neutropenic pt, any degree of fever warrants a full work-up (pan culture,
c
diff and stool, crx, U/A (always have a U/A when you order a urine culture

to tell u colonization or infection) and treatment with broad spectrum abx

while cultures pending. check vitals in these patients esp heart rate and
BP
. Do not miss early sepsis.

For otherwise uncomplicated patient, you can usually give tylenol over the

phone. Fever work up or not is your clinical judgement. Yes, pay attention

to liver function with tylenol.

Also, do not forget non-infectious etiology of fever, such as post
transfusion, drug fever, or atelectasis.

3. RN called you that a patient's urine in the foley bag is only 100ml for

the last 6 hours.

Point here is you do not sit around till next AM and pray sth good happens.

Yes, first r/o foley catheter problem (ask RN to flush it when you are at

bedside). if foley is fine, you can not leave there. From here, it is not

going to be easy. Call your resident to guide you.Most importantly, do not

think I am busy now and maybe in AM, pt will make more urine. You gotta
have
some action either with fluid challenge with 250 to 500 ml boluses, U/S

kidney stat, depending your assessment (fluid status by CVP, orthostasis,

meds review). Many times, interns leave the scene, so to speak, because
they
do not know what is going on and hope things will be ok till AM.
Understandable but wrong. Call resident and fellow if you have to.


4. RN called a patient had a large bowel movement of "black stool".

Point here is any hospitalized patient with possible GI bleed needs to be

dealt with carefully.

Again see the patient, check vitals yourself, have at least 2-3 large bore

iv access (GI bleeding can kill pt fast if u are not prepared).
If unstable (meaning altered mental status, low BP, tachy, ongoing bleeding)
call ICU right away. EARLY surgery consult.

If pt stable, NG tube down and lavage. check cbc, coagulation, renal
function, cross and type blood. call resident and GI. Put patient on PPI
iv.
Stop any NSAIDS or anticoagulant.
Know your stuff for difference between lower and upper GI bleed. The Rx
is a
little different. Upper GI ongoing bleed usually is dealth with by GI and

scope; lower GI ongoing bleeding usually is better dealt with by
interventional radiology. First and most though is resuscitation. Read now

if you do not know them cold.


--




发信人: cybermd (yo), 信区: MedicalCareer
标 题: Intern calls #3
发信站: BBS 未名空间站 (Sun Jun 15 00:53:55 2008)

1. 72 yo admitted for UTI 3 days ago, RN called you" he had 4 bowel
movements tonight, please give this poor guy some immodium and let him sleep'


2. 66 yo IV drug user admitted for new A fib and was started on IV heparin

by admitting team. RN called you : his only iv just came out, I cant get
a
line in him he is such a hard stick"

3. "tele just showed a run of tachy of 200 for 15 sec on patient Z or heart

rate was just 48/min.

4. RN called you patient A, who is a 76 yo admitted for CHF, is very
confused and tries to get out of bed" please order some restrain order,
he
is out of control and I am too busy to keep an eye on him"
--


发信人: cybermd (yo), 信区: MedicalCareer
标 题: Intern calls #4
发信站: BBS 未名空间站 (Wed Jun 18 00:14:25 2008)

1. RN called you that lab called blood culture drawn earlier one out of
two
samples grew candida from patient PICC line, or grew staph epidermis from

his PICC or MRSA from his PICC. Patient is afebrile and is a on ceftriaxone

for his UTI.

2. gross blood in foley bag.

3. patient wants to go out to have a smoke break, otherwise she will leave

voluntarily.

4. Patient just admitted 5pm, he claims "doc, i am on methadone program
70 a
day for years, i forgot to mention to another doc at ER. please give me

that so i won't go crazy".
--

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