實戰課題Medical internship topic 8: General complaints and initial approaches

General complaints and initial approaches

( Please do not hesitate to check formal resources for recommended treatments before practical use!)

1.  Starting orders: "ADCV AAD" NURSE LAB MEDICINE= admission, diagnosis, condition, vitals, allergy, activity, diet
2. Prevent CIN , if Cr=1.2-2.0 

- 0.9% NaCl 1 mL/kg/hour for 6 to 12 hours preprocedure, intraprocedure, and for 6 to 12 hours postprocedure

- Acetylcysteine 1200 mg orally BID the day before and the day of the procedure

3. Lab for effusions
- Pleural: check TP, LDH, glucose, Gram stain, AFS+ TB culture, bacterial culture, fungus culture, cytology
- Ascites: check albumin, Gram stain, AFS+ TB culture, bacterial culture, fungus culture, cytology, cell count
- CSF: TP, glucose, Gram stain, Indian Ink, Cryptococcal Ag, AFS+ TB culture, bacterial culture, fungus culture, cytology, rapid test for bacterial antigen, virus isolation
* TB PCR, HSV PCR, CDC

4. IV supplement
- Do not mix Ca, Mg + NaHCO3--> crystal formation! :(
- In glucose: amiodarone, amphotericin B, Levophed, NTG, SMX-TMP
- Slow drip: KCl, MgSO4, Ca. Gluconate, Vancomycin, Teicoplanin, aminoglycoside, SMX-TMP, amphotericin B

5. Dyspnea
- O2
*Nasal-->1L FiO2 24%, 2L FiO2 28%, 3L FiO2 32%, 4L FiO2 36%, 5L FiO2 40%
*Mask-->28% 5L, 35% 8L, 40% 10L, 60% ?
*NRM-->10L, FiO2=90%
*BiPAP, O2 5-15L
*Intubation-->
1) oxygenation: PaO2<60 under NRM
2) CO2 retention: PCO2>50, PH<7.35, RR >30 under BiPAP

3) Muscle fatigue: paradoxical movement, accessory muscle use under BiPAP

- ABG, CXR
- Wheezing? : combivent inh * sol 2.5 ml 1~2VIAL IH ST, 1VIAL IH QID
                     Methylprednisolone "NK*inj 125mg  30~40mg IVA Q8H
                     aminophyllin 1# tid  Meptin 1# bid
- HF: lasix + NTG pump