The Intern Pocket Card Discharge Summary

Dictated by
Pre-op Note
Pre-op diagnosis
Electrolyte Replacement
Do not replace K or Ph in renal pts
Admit Orders Attending Procedure Potassium - 0.1 per 10 mEq
A dmit to Dr. Smith Tele 5th Floor Patient name Surgeon(s)
KCl 10-40 mEq po (10/ hr by gut)
D iagnosis CHF exacerbation Medical record number Labs: CBC/BMP/PT/INR
KCl 10-40 mEq IV in NSS (10/hr PIV)
C ondition Stable Admit date, discharge date CXR: WNL Phosphorous
C ode Full Admit dx, discharge dx EKG: NSR
Nutraphos 1 packet PO TID x 1 day
V itals Per protocol Consults Blood: not required o contains potassium
A llergies Procedures Consent: signed, in chart
NaPhos 10, 21 or 42 mmol in NSS
A ctivity ad lib Discharge medications Orders: 1 g Ancef OCTOR
KPhos 21 or 42 mmol in NSS
N ursing Accurate I/O's History of presentation CHA2DS2-VASc Magnesium
D iet Cardiac Pertinent lab/rads data Age
MagOxide 400-800 mg PO
I VF Hep lock Hospital course <65 +0
MagSulfate 1-2 g IV in NSS
S tudies 2D echo in AM re: eval LV Discharge instructions 65-74 +1 Calcium
M eds Lasix 40 mg IV daily etc. (diet, activity, f/u) >75 +2
Cal Gluconate 1-2 g IV in NSS
L abs BNP, CBC, BMP in AM Wells' Criteria for PE Hx of CHF? +1
Ca Chloride 1 amp (code)
Sepsis Clinical s/s of DVT? + 3 Hx of HTN? +1 Common Medication Orders
SIRS(2of below) PE is #1 diagnosis + 3 Hx of CVA/TIA/VTE? + 2 1 mg IV Dilaudid = 7 mg IV Morphine

Temp >38 or <36 HR> 100? + 1.5 Hx of vascular dz? + 1 Tylenol 650 mg PO q6 prn mild pain

HR > 90 Immobilized 3d + 1.5 Diabetes? +1 Zofran 4 mg IV q6 prn N/V

RR > 20 or PaCO2 <32 Previous PE or DVT? + 1.5 Female? +1 Reglan 10-20 mg IV q6 prn N/V

WBC >12k, <4k or >10% bands Hemoptysis? +3 Score 2 anticoagulate Protonix 40 mg IV daily
Sepsis Malignancy? +3 Take into consideration Heparin 5000 units SQ TID

Source of infection? 4 PE unlikely >4 PE likely history of falls, bleeds etc Docusate 100-200 mg PO BID
Severe Sepsis Declaring Death Miralax 17 g PO daily or prn const.

Organ dysfunction, hypotension Patient was noted to be in asystole, there was no Albuterol 2.5 mg Neb q4 prn SOB
Septic Shock response to noxious stimuli, pupils were fixed and Lasix 20-40 mg IV/PO

hypotension despite fluids dilated, no lung or heart sounds were present on Ambien 5 mg PO QHS prn insomnia
auscultation. The patient was pronounced dead at X Benadryl 25- 50 mg PO/IV

Common Calls Vitals? Symptomatic?
Atrial Fibrillation with RVR
Goal is rate in 110's
Stat EKG
Consider CBC, BMP, Troponins
Cardizem 0.25 mg/kg redose at 0.35 mg/kg prn Hydralazine 5-10 mg IV/PO
Lopressor 5-10 mg IV (avoid in asthma)
Verapamil 5-10 mg IV
If no response consider cardizem gtt
Consider anticoagulation if new-onset
Chest Pain
Goal CP free, rule out ACS
Stat EKG and CXR
Stat BMP, Mg, Ph, CBC, Troponin series
ASA 81-325 mg
Nitro 0.4 mg SL q 5 mins
Supplemental O2
STEMI if ST elevation in 2 contiguous leads
>1 mm limb leads, >2 mm precordial leads
Pain control with morphine, 1" nitropaste
Should be on ACE, Statin, -blocker
If + trop or STEMI call resident/attending
Agitation
Careful with elderly
Consider mechanical restraints
Risperdal 0.5-2 mg IV (if QTc<420 ms)
Haldol 1-5 mg IM (if QTc<420 ms)
Ativan 0.25-2 mg IV
The information above is a guide, please use your clinical judgement 2013 http://www.survivinggrays.com All rights reserved
Hypertension Shortness of Breath
Should be corrected acutely Consider BMP, CBC, ABG, pCXR, EKG
If BP >170/100 or symptomatic Recent narcotics ? Assess for Narcan
If symptomatic alert resident Wheeze? COPD vs Asthma - Neb tx
Give scheduled med early Consider solu-medrol
Lopressor 5-10 mg IV CO2? consider BiPAP
Edema on CXR? CHF- Lasix 40-80 mg IV
Clonidine 0.1-0.2 mg PO New infiltrate on CXR? PNA, Tx w/ Abx
Esmolol/Cardene gtt (ICU) Well's criteria >4? PE likely CTA
Hypotension Pneumothorax?
Review chart Unstable- Call rapid response team
Hemorrhage? Septic? Overdose? Stable - Call resident/surgical resident
Arrhythmia? MI? Tamponade? PTX? BiPAP vs CPAP
Usually safe with 500-1000 mL bolus CPAP- air splint, used for OSA
Hyperglycemia BiPAP- decreases work of breathing
Initiating insulin therapy Patient must be able to cooperate
weight in kg/2 = total #units /24 h Top # - Inspiratory pressure (10-14)
half of total given as AM Lantus Increase if CO2
remaining half dived by three Bot # - Expiratory pressure (4-8)
each 1/3 given as novolog w/ meals Increase If O2
If hyperglycemia give 2-10 units Regular Re-check ABG 1-2 hours after initiation
- may have to in more severe disease Urinary retention
Hypoglycemia If bladder scan >300 straight cath
Able to take PO: 1 cup of juice If still retains then foley
Unable to take PO: 0.5-1.0 amp D50 18 or 20 Fr Coude cath if nursing uable
Levsin 0.125-0.25 mg SL q4 prn spasm
NEVER HESITATE TO CALL B + O suppository BID prn spasm
YOUR RESDIDENT! Hematuria emergency if clots- setup CBI