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Intern Survival Guide 2012-2013
Intern Survival Guide 2012-2013
DISCLAIMER
Medicine is an ever-changing field. Standard safety precautions must be followed and allowances must be made for
new discoveries, drugs, and changes to standards of care. Though every effort has been made to ensure that the
information in this book is correct and up to date, readers are advised to verify for themselves, relying on their
experience and knowledge of their patient to determine if the recommendations made are actually the best for their
individual patient. Neither the author nor the Department of Internal Medicine assume any liability for any injury and/or
damage to persons or property arising from this handbook
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Studying
Random Tips
The Wards
Pain
Constipation
Using Affinity (charting)
What to do when you get a New Patient
Admission Orders
Diet Sheet
Presenting the H&P
Running a Code
Generating a Differential Diagnosis
Writing your Daily Note
Ordering Imaging Studies
Insulin and DM Management
Procedures
Interpreting ABGs
Useful Hematology
Useful Microbiology
EKGs
Formulas
Electrolyte Replacement
On Studying
Study what you can, when you can, ESPECIALLY on Medicine Wards, and ESPECIALLY as an Intern. Youre going to be
busy and probably pretty tired, so just read something and dont worry if youre not reading New England Journal of Medicine
from cover-to-cover every week. Push yourself, but be realistic.
You will find that as you focus your studying on your patients, you will have an easier time of retaining the information. As a
general rule get in the habit of reading SOMETHING every day, even if it is only a few pages. You are going to be busy but a
little daily reading can go a long way over 3 years.
MKSAP
Try to keep up with MKSAP reading and questions! It is a great way to stay current on your board studying throughout
residency while also reinforcing important concepts. It is generally a good idea to do about 5 questions a day (2 to 3 in
st
the morning before work while sipping that 1 cup of coffee at home and 2 to 3 in the evening). This will easily get you
through all of the questions that will be covered for the monthly exam.
Record the ones you miss and keep doing them until you get them right (the Breck Nichols Strategy). For example, out
of 50 questions, say I miss 25 of them. I then go back and redo the 25 I missed. This time, I miss 10. I go back and do
those 10. This time I miss 4. By the time you no longer miss any of the questions, youve repeated the ones you had
the most trouble with a few times, and hopefully, the reasoning behind the question will stick better.
MedStudy
The MedStudy people always offer deals to residents when they buy in bulk. Some initiative-taking person should
look into this, then send an email and talk with the other interns/residents about buying a bunch at once to save
rd
money; Also some of the graduating 3 years will want to sell theirs at a discount
MedStudy books are board-review style texts that are organized by system, and are great for ELECTIVES. Make it
a priority to get through the MedStudy section that corresponds with the elective youre on. Ambulatory would also
be a good time to crack open MedStudy. This will help you both on the elective and in preparing for the boards.
Ambulatory Core Curriculum
The Ambulatory Core Curriculum is compiled from a great collection of articles with corresponding cases and
questions to help you think critically about patient care in the outpatient setting. This will be available on the Chiefs
Website. Read these articles and think about the answers so youre prepared in clinic! It will help you be a better
physician! .
UpToDate is a great resource best used when you need information quickly, but its probably not the best tool to use when
studying for the boards. Pocket Medicine is another great resource for quick information
Review articles and primary research literature is best used when preparing a presentation. New England Journal of Medicine,
Annals of Internal Medicine, JAMA, and Lancet should be sought out in this regard.
The beach! We Recommend Malibu (Zuma beach) and Manhattan Beach. If going on a weekend, try to leave early
to beat the crowd and the traffic.
The mountains. The San Gabriels are the mountains you see north of Pasadena on a clear day. Lots of hikes and
nice views. Hit up the Sam Merrill Trail at the end of Lake Ave in Pasadena for a nice view of the LA Basin. Tons of
other trails are all over the city. And of course, Big Bear and Mammoth are both within reach during the winter if you
ski/snowboard.
Eat. Yelp.com is one of my favorite websites for restaurant reviews. You can find any type of food in this city that
you want.
Wine Tasting. There are great wineries within a couple of hours of L.A. Try the Santa Ynez Valley (think
Sideways) for nice Pinots and Syrahs. Other places to enjoy vino are Paso Robles and Temecula.
Farmers Markets. If youre into cooking, fresh produce, people watching, or being outside, then there are tons of
farmers markets across the city. The one in Hollywood is Sunday mornings and has a nice selection of stuff, but
there are probably local ones near where you live as well.
..
...
Moderate Pain
...
Toradol (Ketorolac) 15-30mg IV/IM or 10mg po q6 prn mod pain (max dose 40mg/day for 5 days), careful in renal failure
Ultram (Tramadol) 50-100mg po q4 (max 400mg/day
Naprosyn (Naproxen) 500mg po then 250mg q8 (max 1250mg/day) prn mod pain
Tylenol #3 (Acetominophen with Codeine) 2 tabs po q4prn mod pain
Severe Pain
Percocet (Oxycodone/Acetominophen) 2 tabs po q6prn
Percodan(Oxycodone/ASA) 2 tabs po q6 prn
Vicodin (Hydrocodone/Acetominophen)2 tabspo q4prn
Dilaudid(Hydromorphone)2-4mg po/PR/IM/SQ/IV q4prn severe pain
Morphine 0.1mg/kg (up to 15mg)IM/SQ/slow IVq4prn (good starting dose is 2mg IV q 4h PRN pain)
Demerol (Meperidine)1-1.8mg/kg (max150mg) IM/SQ/POq 4 prn severe pain
PO/PR
3
PO/PR
150
150
150
15
15
10
5
3
2
--
Intrathecal
0.01
IV/SC/IM
50
-50
-5
--1
1
0.050
Treating Constipation:
o
o
o
o
o
o
o
o
o
We put pretty much everyone on Colace 100mg PO BID but it is unlikely to have much effect
Minimize opiods if possible
Miralax (polyethelene glycol) works well (17grams in 8 oz H20 daily, can increase to BID)
Senna 8.6mg 2 tabs PO BID
Bisacodyl 5mg or 10mg PO works well, can also give PR which often time works even better
Avoid fiber or bulking agents if patient is on opiods. It just makes the problem worse
If not BM for several days, you must consider obstruction/ileus but not the case most of the time
Always check bowel sounds ask if patient is passing flatus as you dont want to miss obstruction/illeus
Check Abdominal Series to further evaluate before giving any further treatments if suspecting obstruction/illeus
Using Affinity
It is HIGHLY RECOMMENDED that you review the LAC+USC Medical Software Instructional Videos on the Chiefs Website
under FAQs. You will use Affinity to check labs, read dictated reports from imaging studies, find pathology reports, get
vitals, ins and outs, etc.
Review ER sheet to see what was done and include a brief ER course in your H&P
Go to the chart and write admit Orders (include your admit panel and prns).
Medications will need to be written on the Medication Reconciliation Form (PADI). If the PADI form is not signed
then pharmacy will not be able to dispense medications.
Do full H&P (Template available on Chiefs Website) dont be afraid to call the patients family, doctor, ER physician
etc. for more info. Modify orders as necessary
Start D/C Summary. If you are confident the patient will be discharged the next day, start prescriptions.
ADMIT ORDERS
D: Diagnosis
o Ex: CHF exacerbation, PNA, etc (this should be the admitting dx)
V: Vitals:
o Usually per routine is sufficient (this is q 4 hours on the floor and q 1h in ICU)
o If particularly concerned about a patient you can initially check more frequently (ex: q 1 hour x 2, then q 4h)
A: Allergies:
o Ex: PCN (anaphylaxis), Morphine (rash), etc.
N: Nursing:
o Usually per routine unless special concerns (i.e. strict Is/Os, daily weights, dressing changes, seizure precautions,
O2 to keep Sat > 92%, foley to gravity, etc.)
D: Diet:
o Regular, 1800 ADA/Consistent Carbohydrate, 2gm Na, Low Fat, Soft Mechanical, Clear liq, Full liq, Puree,
Dysphagia, Neutropenic, (see diet sheet on next page)
I: IV Fluids:
o You can just write SLIV for saline lock which means the nurse periodically flushes the line and no standing IVF
o If the patient is not eating, does not have Renal Failure, Cirrhosis or CHF you can consider given maintenance fluids
w/ NS
o consider D5 w/ NS if patient is not diabetic
o One trick is to add 40 to their weight in kg and use that is your rate in cc/hr (ex: 70kg person would get 110cc/hr of
IVF)
o If patient ETOH intoxication or withdrawl can give banana bag: 1mg Folate, 100mg Thiamine, 10cc MVI, 2gm
MgSO4 in 1L NS at ~100cc/
S: Studies:
o EKG, CXR, ,U/S, CT, MRI, etc.
M: Meds
o Make sure you fill out and sign the med reconciliation sheet (otherwise the patient will not get their meds)
o Check off PRNs on the admission orders (Benadryl, MOM, etc.) but make sure they dont have any
contraindications
o Make sure you address PRN pain medications. All opiods have to be written x 72 hours or they will fall off after 1
day. You can write x indeffinate (cancer) if the patient has a malignancy and it will stay on for the admission
A: Activity:
o as tolerated unless you dont want them getting out of bed in which case you and write bed rest,
o bed rest with BRP (bathroom privileges) if they are not a fall risk is also acceptable
o If you are worried they will not get out of bed and you want them to you can write out of bed to chair tid
L: Labs:
o order CBC w/ diff, BMP, Mg, Phos, LFTs, PT/INR and UA on nearly everyone then add any more specific labs
o if labs were drawn a few hours ago (in ER or Clinic) no need to repeat until AM unless you need something specific
o if no labs were drawn in last few hours, everything should be sent STAT
o Dont forget to fill out the separate Radiology Request form.
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Running a Code
Check Responsiveness
Airway (head tilt, chin lift)
Breathing (look listen feel, 2 slow breaths)
Circulation (start CPR 15compressions:2breaths)
Call A CODE and ask for all of the following as if it were one word:
O2 Oral Airway, bag valve mask, prepare to intubate
IV 2 large bore peripheral IVs or central line and obtain stat labs:
Glucose ABG with Lytes, and Tox screen
Monitor look at the rhythm and Vital Signs and Pulse Ox
Analyzing the Rhythm
Asystole:
PEA:
Bradycardia:
Epi 1mg
Epi 1mg or Atropine 1mg if brady
Atropine 1mg unless
2 Mobitz II or 3 Heart block (use transcutaneous pacing)
Tachycardia:
Afib/Flutter:
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1) Pathology: VINDICATE
Vasculitis
Infectious
Neoplasm
Degenerative (Aging)
Iatrogenic (Procedures/Drugs)
Congenital
Allergic/Autoimmune
Trauma
Environmental (Poisons/Chemicals)
2) Anatomy
This works well with pain: RUQ pain: think of what anatomical structures are in the area or nearby: liver, gallbladder, colon,
R kidney, stomach, pancreas, lower lobe of right lung . . .
3) Pathophysiology
This works well with things like acute anemia where based on pathophysiology it should be:
1. Decreased production due to problems in the bone marrow or erythrocyte precursors.
2. Increased destruction due to things like autoimmune destruction or MAHA.
3. Blood loss due to internal or external bleeds.
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IVF:
Hardware: (foley, NG, NC, leg squeezers
central line (when placed, Day #)
O:
VS: T, HR, RR, BP, O2 sat, Is/Os
GEN
HEENT
PULM
CVS
ABD
EXT
NEURO
Results:
(include important information, dont copy and paste every lab and study the patient has had from the beginning of time.
Only whats relevant!)
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Assessment:
(this is where you should put a good one liner that summarizes why the patient was admitted to the hospital and how the
patient is doing. Keep it simple enough to be one line but informative enough that anyone reading your note would
understand what is going on. Writing this is harder than you think and it takes time to get good at it. Very important skill to
have)
50 YO F w/ h/o DM admitted for PNA found to have strep bacteremia, now improving and afebrile x 24 hours.
Plan:
(go through each problem daily and update. This is the most important part of your note. If the rest of your note is 20 pages
and this part is 1 pageyou have a problem. Really make sure your plans are good. This is what consult services read and
more importantly your attending will read and is an easy way to tell if an intern has a good understanding of their patient)
#1 PNA-improving
-cont ceftriaxone and azithromycin, today day # .
-sputum culture negative
-bcx positive for strep, see below
#DM -controlled
-cont weight based insulin and ISS
-adjust as needed
#HTN-well controlled
-cont home doses of benazapril and HCTZ
Prophylaxis/FEN
-PPI (yes or no)
-DVT prophylaxis (leg squeezers, fragmin, etc. )
-Diet (ADA, 2 gram Na, etc.)
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For CT's:
Order CT head without contrast before any LP to rule out increased intracranial pressure OR if looking for
intracranial bleeding
Order with IV contrast when looking for tumor or any significant source of inflammation/infection (e.g., abscess).
Check renal function before hitting their kidneys with contrast! Hydrate and use Mucomyst if necessary
Order IV contrast AND po contrast (10 ccs Gastrograffin in 400 cc H2O) when checking the bowels (for tumor,
other cause of obstruction, diverticular disease, etc). Give the po contrast 1 hour before the procedure and a
second dose immediately before the patient goes to CT.
For MRI's
fill out the radiology request form INCLUDING the bottom questions stable, metal, claustrophobic, AMS/dementia, over
300 pounds
For Nuclear Med scans such as the Gallium, WBC Scan, or MUGA
fill out a Radiology form.
For myocardial perfusion scans (eg, stress thallium), make a copy of the patients EKG, fill out a radiology form, and go to
the Non-Interventional Cardiology area in the D&T Building to complete the stress test form and submit it all together.
Insulin Management
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Intervention
1 amp D50 and call MD
nothing to do
2U CZI (crystalline zinc insulin)
4U CZI
6U CZI
8U CZI
10U CZI
12U CZI and call MD
- To calculate an insulin regimen give 0.6 units/kg in DM2 and 0.3 mg/kg in DM1.
Take 2/3 of the total calculated to be admin in the am 2/3 NPH and 1/3 regular.
Take 1/3 of the total and give it in the pm reg before dinner and NPH at bedtime.
For example:
Nick is a 70kg diabetic & on
unknown insulin regimen at home
70X0.6= 42 U of
insulin/24 hours
42 X 2/3 =
28 U q AM
28 X 2/3 ~
19 U NPH q AM
28 X 1/3 ~
9 U R q AM
42 X 1/3 =
14 U q PM
14 X 1/2 =
7 U NPH q PM
14 X 1/2 =
7 U R q PM
qAC and HS, which means before meals and at bedtime (amounts to 4values per day)
When patient are eating, scheduled insulin is usually given prior to breakfast and dinner
Before Breakfast (affected by evening NPH from the night before
Before Lunch (affected by morning R insulin
Before Dinner (affected by morning NPH insulin)
Bedtime (affected by evening regular insulin dose)
The only tricky one is the am bs if it is high it is possibly due to the Somogyi phenomenon (more common in DM1)
which is a rebound high bs in response to a low 2am bs. T
To check for this you need them to check 2am bs prior to adjusting the eve NPH.
PROCEDURES:
Procedure Consents: Always obtain consent prior to procedures use iMedConsent for forms
Lumbar puncture: we will use a needle to take some spinal fluid for analysis
Risks: bleeding, infection, nerve damage, brain herniation, and very rarely death
Benefits: diagnosis for appropriate therapy
Alternatives: no LP, Benefits of alternative: none, Risks: incorrect diagnosis and therapy
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Thoracentesis: we will use a needle to take out some of the abnormal fluid from around the lung
Risks: bleeding, infection, perforation of a lung, and very rarely death
Benefits: diagnosis for appropriate therapy
Alternatives: no thoracentisis, Benefits of alternative: none, Risks: incorrect diagnosis and therapy
Paracentesis: we will use a needle to take out some of the abnormal fluid from abdomen
Risks: bleeding, infection, perforation of an internal organ, and very rarely death
Benefits: diagnosis for appropriate therapy
Alternatives: no paracentesis, Benefits of alternative: none, Risks: incorrect diagnosis and therapy
Alternatives: no contrast, Benefits of alternative: none, Risks: incorrect diagnosis and therapy
Central Line: we place a catheter in a vein for long term venous access
Risks: bleeding, infection, perforation of an internal organ, and very rarely death
Benefits: administration of special medicines easier venous access
Alternatives: no central line, Benefits of alternative: none, Risks: incorrect diagnosis and therapy
Procedure Tubes
LP: collect 4-5 red top tubes depending on what you suspect
#1 = 1 cc for cell count
#2 = 1 cc for prot/glucose
#3 = 3 cc for bact, fungal, and AFB Cx
#4 = 1cc for a second cell count (to help ddx between traumatic and Subarachnoid Hemorrhage)
#4 = 2 cc for cytology (use the brown non-gyn cytology form)
#4 = 3+ cc send for special tests (these often require a lot of CSF). If you suspect one of the following:
TB send for AFB Cx and AFB PCR
Neurosyphilis send for VDRL or FTA-ABS
HSV send for HSV PCR
HIV pt with CNS sxs send for CSF toxo titer, crypto latex agglutination, cocci titer
For Thoracentesis it is the same except for tubes 2 and 5
#2 = 2 cc for protein, glucose, and LDH
#5 = if fluid looks milky send it for triglycerides and cholesterol
For Paracentesis it is the same as Thoracentesis except for tube 2
#2 = 2 cc for protein, glucose, LDH, albumin, and amylase
Use albumin to caculate SAAG (Serum Ascites Albumin Gradient = Ser Alb - Asc Alb)
if > 1.1 (transudative) sugg portal HTN
if <1.1 (exudative) consider CA, Nephrotic syndrome, Pancreatitis, Tb peritionitis
If Asc amylase > Ser amylase = pancreatic dz
Procedure Note
Type of Procedure
Prepped and draped in sterile fashion ...
Indication
Site
Consent
Technique
Anesthesia: Lido, MSO4, etc Findings/Complications
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Operating MD
Supervising MD
Assisting RN
ABG's
They are useful but very painful and not without risk. Be sure to perform the Allen test prior to performance of an ABG to
make sure the radial and ulnar arteries are both functional in the wrist you will be sticking. Have patient make a fist clamp
down on ventral side of wrist on both sides have them open their hand it should be pale. Release one finger watch for
adequate perfusion then repeat same for other artery on same wrist. If both are perfusing fine it should be safe to attempt
ABG. Push plunger on syringe down to 1 or 1.5 cc. Locate artery with two fingers. Hold syringe like a pencil enter artery
(usually it is very superficial if you do not get it on the way in come out slowly and you may get it on the way out. The tube
should fill on its own without drawing back on the plunger. Take note of any supplemental O2 and pts position
Interpreting ABG's
Adapted from:
Interpretation of Arterial Blood Gases (ABGs). Kaufman, David A. MD
(http://www.thoracic.org/clinical/critical-care/clinical-education/abgs.php)
Step 1
o Is there alkalemia or acidemia present?
o pH < 7.35 acidemia
o pH > 7.45 alkalemia
Step 2
o Is the disturbance respiratory or metabolic?
o If PH and CO2 go in opposite directions = likely respiratory
o If PH and CO2 go in same direction = likely metabolic
Step 3
o Is there appropriate compensation for the primary disturbance? , compensation does not always return normal pH
(7.35 7.45).
o Metabolic Acidosis PaCO2 = (1.5 x [HCO3-]) +8 (correction factor 2)
o Acute respiratory acidosis Increase in [HCO3-]= PaCO2/10 (correction factor 3
o Chronic respiratory acidosis (3-5 days) Increase in [HCO3-]= 3.5( PaCO2/10)
o Metabolic alkalosis Increase in PaCO2 = 40 + 0.6(HCO3-)
o Acute respiratory alkalosis Decrease in [HCO3-]= 2( PaCO2/10)
o Chronic respiratory alkalosis Decrease in [HCO3-] = 5( PaCO2/10) to 7( PaCO2/10)
Step 4 :
o
o
o
o
Step 5
o
o
o
o
o
o
Calculate the anion gap (if a metabolic acidosis exists): AG= [Na+]-( [Cl-] + [HCO3-] )-12 2
A normal anion gap is approximately 12 meq/L.
In patients with hypoalbuminemia, the normal anion gap is lower.
About 2.5 meq/L lower for each 1 gm/dL decrease in the plasma albumin
If there is an anion gap, assess the relationship between the increase in the anion gap and the decrease in [HCO 3-]
Assess the ratio of the change in the anion gap (AG ) to the change in [HCO3-] ([HCO3-]): AG/[HCO3-]
This ratio should be between 1.0 and 2.0 if an uncomplicated anion gap metabolic acidosis is present.
If this ratio falls outside of this range, then another metabolic disorder is present:
If AG/[HCO3-] < 1.0, then a concurrent non-anion gap metabolic acidosis is likely to be present.
If AG/[HCO3-] > 2.0, then a concurrent metabolic alkalosis is likely to be present.
19
7
\
10, 5, 2, 1 (common to both pathways)
/
12, 11, 9, 8
8 is involved in Classic Hemophilia & is the only one not made in the liver
9 is involved in Christmas Disease
2,7,9,10 are Vit K dependent
Heparin increases the activity of Antithrombin III which binds 9,10,11, & 12 decreasing their effect
Anemia
|
|
|
|
|
Normal| Normal
MCV |
|
|
|
|
Low
|
MCV |
|
|
High
MCV
Disease
Aplastic anemia |
Myelodysplastic Sd
|
Folate/B12 defic
|
Immune Hemolysis
|
Cold agglutinins
|
CLL
|
Early Iron/Folate Defic
Chronic Disease
|
Hemoglobinopathy
Transfusion
|
Myelofibrosis
Chemo
|
Sideroblastic anemia
CLL, CML
|
Bleeding
|
Thallassemia trait
|
Iron Defic
Chronic Dz
|
Beta thal
|
MAHA
Normal RDW |
High RDW
20
Glucose
Protein
RBC
Other
clear colorless
Normal
<10
6080(2/3serGlu)
15-50
occas
Partially Txd
bact
>500
20-40
>100
occas
Bacterial
>500
0-20
>100
occas
Abcess
20-75
50-80
>50
occas
>10
60-80
50-150
(20-150 in HSV)
HSV PCR
TB
20-200
0-20
200-2000
20-150
AFB PCR
Fungal
20-200
50-80
>50
occas
India Ink
17
21
G stain,
purulent
or q-
22
Anion Gap:
Na - (Cl + HCO3) = Normal 10 14
Causes of Increased AG:
Managing Electrolytes:
Below are suggestions for electrolyte replacement but each clinical scenario may differ. When in doubt, you can always call
pharmacy (x97641) and they can talk you through it or you can check with your senior.
Very Important: ALL BETS ARE OFF if patient is in renal failure. If creatanine is abnormal or patient is not making urine,
make sure you are checking with your senior. Especially in the beginning of the year.
Potassium: before replacement check Cr and make sure they are making urine
Plasma K
Intervention
> 6.5
Call resident
Consider giving Insulin 10-20U IV with an amp of D50
> 5.2 with Sx
Give Ca Gluconate 10% 10cc IVP over 2-3min if QRS widening ( not just for peaked Ts)
or EKG changes
Give Insulin 10-20U IV with an amp of D50
> 5.2 with out Sxs
Give Kayexalate 25-50g PO q hour until patient has BM then re-check STAT K
or EKG changes
>4.0
Nothing to do
3.8-3.9
20 mEq PO x 1 or IV over 2
3.6-3.7
40 mEq PO x 1 or IV over 4
3.4-3.5
60 mEq PO x 1 or IV over 6
3.2-3.3
40 mEq PO q4 x 2 or 80 mEq IV over 8
3.0-3.1
40 mEq PO q4 x 3 or 80 mEq IV over 8
< 3.0
80 mEq IV over 8 then recheck K and continue
*general rule is that 10 meq of K should raise the serum K by 0.1 as long as their isnt any renal failure
**can only do 10 meq of K per hour on the floor
***PO options for K include KDUR (horse pill) or K elixir (both are dosed the same)
If your patient is not eating you need to replace the approximately 60 mEq of K they will lose each day
that is why if they are NOT in renal failure and are peeing you should be giving them K in their fluids. Be very careful
with patients in renal failure as they will not pee out the K you give them
At 120 cc/ you will be giving them about 3 liters of fluid a day so to achieve 60mEq of KCl
you should give them 20mEq/L
At 60 cc/ you will be giving the about 1.5 liters of fluid a day so to achieve 60mEq of KCl
you should give about 40mEq/L
Magnesium
Plasma Mg
Intervention
5.0-7.5
Ca Gluconate 1g IVP
1.9-4.9
Nothing to do
1.6-1.9
Mg Sulfate 2g IV over 8 or 7 - 400mg tabs MgOxide(causes diarrhea)
1.2-1.4
4g IV over 16 (or 16 on the floor) or fourteen 400mg tabs
Phosphorus
Plasma Phos
> 4.5
2.3-4.5
1.0-2.5
< 1.0
Intervention
if Phos x Ca > 65 give Amphojel 10cc PO TID with meals
if Phos x Ca < 65 give CaCO3 650mg PO TID with meals
Nothing to do
Kphos or Na Phos (depending on serum K and Na) can do 15 mmol of either over 8
K phos 500mg PO TID x 1 day, renew each day if phos low on subsequent checks
23