(PGY、R)住院醫師生存守則-1 @ ~Teachingcenter的醫學筆記~

Survival tips
= Vital signs, vital signs, vital signs: T, P, R, BP, SpO2, Consciousness
= 病人大於學習，義務大於權利，如果病人是你媽媽你會怎麼做？
= R1一定會被罵，也一定會犯錯，也一定會有病人mortality，R1要越多critical case, complaint很多的家屬，值班很累接很多病人，才會進步的快，不要怕，每個人都被罵過，盡力了就好
= 一定要到bedside看病人(緩解症狀→進行診斷→決定最終處置)
= 換course交班要交: 兩個人一起把
1) order單看一遍
2) 最近lab看一遍
3) 最近CXR看一遍
4) 主治醫師何時查房
5) 病房有哪些活動
6) 哪些data要追
= 開藥先算estimated Ccr然後查如何調劑量

飲食醫囑Diet
= 一般：約每公斤30kcal，例如：60kg → 1750-1800kcal/day
= 因疾病而調整
- COPD: high fat diet
- Dialysis: dialysis diet
- CRF not under dialysis: low protein diet
- Persistent diarrhea: elemental diet
- Gout: low purine diet
- DM: DM diet
- CHF: low sodium diet，限水<1000ml/day例如：NG: 1750kcal/1133ml/day，限鹽: 2g salt起跳

點滴醫囑IVF
= 無糖：
- N/S, H/S <500ml>
- Lactate ringer <500ml>：有K 4meq，Na約為N/S的85%，有Ca
= 有糖
- D10W, D5W, D2.5W <500ml>
- Taita No.5 <500ml>：有K 10meq，Na約為N/S的1/4，糖濃度同D10W，有Mg！
※含Ca、Mg的點滴或藥品不可以跟Jusonin (NaHCO3, 現稱Rolikan)混在一起，會結晶
※只能泡glucose water的藥物：amiodarone, amphoB, levophed, septrin
= 要慢慢滴的藥品：KCl, MgSO4, CaGluconate, vancomycin, teicoplanin, aminoglycoside, septrin, amphotericin B
= 要用CVC給予的藥品：levophed, dopamine, amphoB, TPN, KCl>20meq/500ml

胸水、腹水、CSF
= 胸水六管
- key routine, TP, LDH, glucose, gram stain, bacterial culture, (Gram stain 和bacterial culture共一管), AFS+ TB culture, fungus culture, cytology
- 其他：cryptococcus antigen, TB PCR (自費), amylase (chylothorax), cell block(病理單)
= 腹水六管
- key routine, albumin, gram stain, bacterial culture, (Gram stain 和bacterial culture共一管), AFS+ TB culture, fungus culture, cytology
- 其他：Cryptococcus antigen, TB PCR (自費), cell block(病理單)
※自發性腹膜炎(spontaneous bacterial peritonitis, SBP)定義：PMN>=250 or WBC>=500 and PMN>=50%
= CSF 9管
- key routine, Indian ink (routine和Indian ink共一管), TP, glucose, gram stain, bacterial culture, (Gram stain 和bacterial culture共一管), AFS+ TB culture, fungus culture, cryptococcus antigen(fungus culture和cryptococcus antigen起來), cytology, virus isolation, 兩管冰冰箱
- 其他：HSV antigen, TB PCR, 急性神經症候群, rapid test for bacterial antigen(緊急)

救命常用藥物Common drugs

NTG: 1amp in D5W 250ml run 3ml/hr = 10mcg/min, max 60ml/hr
Dopamine premix = dopamine 2amp in N/S 250ml run 10ml/hr ~5mcg/kg/min, max 40ml/hr
Dopamine double dose: dopamine 4amp in N/S 250ml run 10ml/hr ~10mcg/kg/min, max 20ml/hr
Dobutamine 2amp in N/S 250ml run 10ml/hr ~5mcg/kg/min, max 40ml/hr
Dobutamine double dose: dobutamine 4amp in N/S 250ml run 10ml/hr ~10mcg/kg/min, max 20ml/hr
Levophed 2amp in D5W 250ml run 4ml/hr = 2mcg/min, max 60ml/hr <on CVC>
Pitressin 3amp in N/S 100ml run 1-4 ml/hr ~0.01-0.04U/min
Amiodarone 1amp in D5W 100ml ivd >10min st then 6amp in D5W 500ml run 34ml/hr x 6hr then 17ml/hr
Amiodarone double dose: 1amp in D5W 100ml ivd>10min st, then 6amp in D5W 250ml run 17ml/hr x 8 hr, then 8.5ml/hr
Heparin 3000U-5000U iv bolus, then 15000U in N/S 500ml run 21ml/hr with titration *Check PTT q8h

* In a 60kg man,
If PTT< 40, heparin bolus 3000U iv, then increase 6ml/hr
If PTT 40-50, heparin bolus 2000U iv, then increase 4ml/hr
If PTT >50-70, heparin no change
If PTT >70-80, decrease heparin 2ml/hr
If PTT >80-90, hold heparin x 30min, then decrease 4ml/hr
If PTT >90, hold heparin x 1hr, then decrease 6ml/hr