Intern Tips in Internal Medicine Sanja Kupesic Plavsic, Lorenzo Aragon
INDEX
×
Chapter Notes

Save Clear

General SectionCHAPTER 1

Lorenzo Aragon,
Sanja Kupesic Plavsic
CHAPTER OUTLINE
  • ❖ Rules of Call
  • ❖ Normal Lab Values
  • ❖ Admission Orders, Differential Mnemonics
  • ❖ Presenting Patients on Rounds
 
RULES OF CALL
  • Start with a good sign in of patients on the floor and fill comfortable with the medical information provided.
    PICC lines and Foley catheters are potential sites for infection. Remove Foleys on patients that do not truly need them and consider the risks before placing PICC lines (peripherally inserted central catheter).
  • Always write a concise and explicit note in the chart if something major has occurred while on call. If uncertain whether or not a note is required, write one so that the rounding team has a heads up about what happened.
    Always see admission patients and write admission orders as soon as possible, nursing staff needed to process and expedite the plans of diagnosis and treatment. If you receive several patients at one time, see each one quickly and set priorities: write quick admission orders, and go into more detail on the sick patients first.
  • When getting a page, always return it, and keep always in mind that all calls are important. If you do not know what the answer is to their question: ask for current vital signs. This can buy you time to think and remember there is always a senior ready to help you.
  • Always see the patients. You cannot see a patient's condition over the phone. Start your differential diagnosis in your head on the walk.
  • Always be nice to the nursing staff. Most of the time they know what you need and can provide the best information. Check in with them to see if they need any orders or have any questions 2about your patients. If you do this, you will provide better patient care and receive a lot less pages about simple matters.
  • Never hesitate to call for help or advice from an upper year resident or attending; in a teaching institution they know your needs.
  • Never leave the hospital at the end of the day without checking test results pending; make you own list of this important tests.
  • Only sign out items that you cannot finish, and always have plans in place for the results that would need interventions.
  • Always check the charts for allergies before starting new medications.
  • For every patient you admit, make sure to verify the allergies during the admission process and what their reaction to the medication was.
  • If the patient needs an increased or new medication at night, just order one-time doses and allow the rounding team to make the adjustment during the day.
  • Speak with family member is available; find legal status, power of attorney, and living will, know who you can call and inform of patient change of medical status.
 
NORMAL LAB VALUES
Table 1.1 shows lab values of normal hematologic, chemistry, hepatic, renal laboratory values and urine text.
Table 1.1   Normal hematologic, chemistry, hepatic, renal laboratory values and urine test
Hematologic
Men
Women
Hemoglobin
13.5–18 g/dL
12–16 g/dL
Hematocrit
40–54%
38–47%
Red blood cells (RBC)
4.6–6.2 million/mm3
4.2–5.4 million/mm3
Mean corpuscular volume (MCV)
76–100 (micrometer)3
76–100 (micrometer)3
Mean corpuscular hemoglobin (MCH)
27–33 picogram
27–33 picogram
Mean corpuscular hemoglobin concentration (MCHC)
33–37 g/dL
33–37 g/dL
3
Erythrocyte sedimentation rate (ESR)
≤20 mm/hr
≤30 mm/hr
Leukocytes (WBC)
5000–10,000/mm3
5000–10,000/mm3
Neutrophils
54–75% (3000–7500/mm3)
54–75% (3000–7500/mm3)
Bands
3–8% (150–700/mm3)
3–8% (150–700/mm3)
Eosinophils
1–4% (50–400/mm3)
1–4% (50–400/mm3)
Basophils
0–1% (25–100/mm3)
0–1% (25–100/mm3)
Monocytes
2–8% (100–500/mm3)
2–8% (100–500/mm3)
Lymphocytes
25–40% (1500–4500/mm3)
25–40% (1500–4500/mm3)
T-lymphocytes
60–80% of lymphocytes
60–80% of lymphocytes
B-lymphocytes
10–20% of lymphocytes
10–20% of lymphocytes
Platelets
150,000–450,000/mm3
150,000–450,000/mm3
Prothrombin time (PT)
9.6–11.8 sec
9.5–11.3 sec
Partial thromboplastin time (PTT)
30–45 sec
30–45 sec
Bleeding time
1–3 min
1–3 min
Chemistry
Men
Women
Sodium
135–145 mEq/L
135–145 mEq/L
Potassium
3.5–5.0 mEq/L
3.5–5.0 mEq/L
Chloride
95–105 mEq/L
95–105 mEq/L
Bicarbonate (HCO3)
19–25 mEq/L
19–25 mEq/L
Total calcium
9–11 mg/dL or 4.5–5.5 mEq/L
9–11 mg/dL or 4.5–5.5 mEq/L
Ionized calcium
4.2–5.4 mg/dL or 2.1–2.6 mEq/L
4.2–5.4 mg/dL or 2.1–2.6 mEq/L
Phosphorus/phosphate
2.4–4.7 mg/dL
2.4–4.7 mg/dL
Magnesium
1.8–3.0 mg/dL or 1.5–2.5 mEq/L
1.8–3.0 mg/dL or 1.5–2.5 mEq/L
4
Glucose
65–99 mg/dL
65–99 mg/dL
Osmolality
285–310 mOsm/kg
285–310 mOsm/kg
Ammonia (NH3)
10–80 μg/dL
10–80 μg/dL
Amylase
≤130 U/L
≤130 U/L
Creatine phosphokinase (CPK)
<150 U/L
<150 U/L
Creatine kinase isoenzymes, MB fraction
>5% in MI
>5% in MI
Lactic dehydrogenase (LDH)
50–150 U/L
50–150 U/L
Protein, total
6–8 g/d
6–8 g/d
Albumin
4–6 g/dL
4–6 g/dL
Hepatic
Men
Women
AST
8–46 U/L
7–34 U/L
ALT
10–30 IU/mL
10–30 IU/mL
Total bilirubin
0.3–1.2 mg/dL
0.3–1.2 mg/dL
Conjugated bilirubin
0.0–0.2 mg/dL
0.0–0.2 mg/dL
Unconjugated (indirect) bilirubin
0.2–0.8 mg/dL
0.2–0.8 mg/dL
Alkaline phosphatase
20–90 U/L
20–90 U/L
Renal
Men
Women
BUN
6–20 mg/dL
6–20 mg/dL
Creatinine
0.6–1.3 mg/dL
0.5–1.0 mg/dL
Uric acid
4.0–8.5 mg/dL
2.7–7.3 mg/dL
Arterial blood gases
Men
Women
pH
7.35–7.45
7.35–7.45
PO2
80–100 mm Hg
80–100 mm Hg
PCO2
35–45 mm Hg
35–45 mm Hg
O2 saturation
95–97%
95–97%
Base excess
+2–(‐2)
+2–(‐2)
Bicarbonate (HCO3−)
22–26 mEq/L
22–26 mEq/L
Urine tests
Men
Women
pH
4.5–8.0
4.5–8.0
Specific gravity
1.010–1.025
1.010–1.025
5
 
ADMISSION ORDERS, DIFFERENTIAL MNEMONICS
Use “ADC-VAN-DISMMAL” mnemonic to remember the orders needed to admit patients to the hospital:
  • Admission order
  • Diagnosis
  • Condition
  • Vitals
  • Activity
  • Nursing orders
  • Diet
  • IV Fluids
  • I's and O's
  • Studies
  • Monitor
  • Meds
  • Allergies
  • Labs
 
Differential Diagnosis Mnemonics
  • Use the mnemonics to start your differential diagnosis
  • Apply the thought process based on the location of the pain/problem
  • Focus your HPI questions and perform lab and testing workup based on the differential diagnosis.
 
PRESENTING PATIENTS ON ROUNDS
Present the patient in a well-organized manner with a plan. For new patients start the presentation with the admission HPI (history of present illness). Always perform full history and physical.
  • Use proper name, [age] year/old [gender] with a history of [major/pertinent history or otherwise healthy] who presented on [date] with [major symptoms, such as cough, fever, and chills], and was found in the [ED/clinic] to have [working diagnosis].
  • Physical examination (PE), vitals, [imaging/labs/tests done] showed [results].
  • Plan/interventions from admission.
  • For follow-up of admitted patients follow your SOAP note.
  • 6This morning the patient feels [state the patient's words], vital signs, intake and output (I/O), and the physical exam (state major findings).
  • Pending studies.
  • Assessment: It does not have to be final, just a reasonable working diagnosis.
  • Plan usually consists of diagnostic tests and treatments. Always consider the discharge needs of the patient.
  • Make sure to check vital signs, weight, labs, imaging and intake/output on your patient prior to rounds.
  • For diabetics, know what time their sugars were measured, what their level was, how much coverage of insulin they needed in 24 hours.
  • Check the medication report to make sure that abnormal vitals aren't due to medications not being administered as ordered, and that your orders are in the computer in the way that you intended.
  • See the patient and ask them how they are doing. Spending an extra 5 minutes with each patient can give them enough time to remember their questions. Ask for appetite, bowel movements, pain control, chest or abdominal pain.
  • Double check the dose of medications to avoid possible toxicity.
BIBLIOGRAPHY
Admission Orders, Differential Mnemonics
  1. Mosby's Medical Dictionary, 8th edn, Elsevier;  2009.
  1. Normal values of common laboratory tests. Unbound Medline: http://nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-Guide/109505/all/Normal_Values_of_Common_Laboratory_Tests
Presenting Patients on Rounds
  1. Culver BH. How should the lower limit of the normal range be defined? Respir Care. 2012;57(1):136-45.
  1. Pagana KD, Pagana TJ. Diagnostic and Laboratory Test Reference. Mosby,  2010.