內科值班01

和信醫院內科值班手冊

  • 要編輯文件的話按一下左上角的筆

Fever

值班發燒≠FUOs(survey過一輪還查不到原因才叫FUO), treat as infection ; Sepsis 需廣效抗生素 Lethal etiology Sepsis(CRBSI, CDI), Febrile neutropenia, CNS infection Hx, PE and Labs Vital signs+ from head to toe; SOFA score + lactate, B/C x2, U/A, CXR, ±CD toxin; r/o CNS infect; Cirrhosis → SBP Management Broad Abx in hour 1 if sepsis; L/R if septic shock Where is the focus? Do source control Curam or Fortum→Tazocin→Mero ± Teico ± Fluconazle Febrile neutropenia cover pseudomonas

Shock

Tissue hypoperfusion;秘訣BP ＝ CO x SVR ; Echo(FALLS) Lethal etiology Allergic, Septic, bleeding, PE, tamponade, ACS, arrhythmia Hx, PE and Labs Drug? HR? Cold or warm? Dry or wet? Basal rales? CBC + BCS + lactate/TnI ± Blood ; IVC, effusion, LVEF, RV Management Keep vital signs + IV/O2/monitor ; N/S 500 ml Hemorrhagic : 18 IC x 2, whole blood, monitor HR Anaphylactic : Epi 0.5 mg IM Septic : considering vasopressor

Altered mental status Vitals Sugar, Meta, 切CT ; Stroke: Time is brain! Lethal etiology Hypoglycemia,O2↓,CO2↑, stroke,Ca/K↑; CNS INF, Sepsis Hx, PE and Labs Trauma?Drugs? Progression +s/s? CNS INF? NE! (dolleye) F/S, ABG, BUN, ammonia, BCS(e-), INF(UTI could cause) Management ABC + vital signs ± protect airway? Treat accordingly. GCS + Pupils + muscle strength follow-up CT + Consult Neuro ± EEG; Seizure → Ativan+Keppra MRI + dexamethasone if malignancy + brain mets

Altered mental status

Dyspnea

Keep vitals ; 注意failure signs, Altered MS ; Echo(BLUE) Lethal etiology Pneumonia, tamponade, pneumothorax, atypical ACS, PE, CO2↑, O2↓(CHF,COPD…etc), Hx, PE and Labs Sputum? Chest pain? Jugular vein, rales, edema; EKG,TnI CXR, ABG, CBC/BCS ± f/u EKG; Echo: BLUE protocol Management ABC+ IV/O2/monitor; Treat accordingly Oxygen supplement; BIPAP for CHF/COPD 當你想到要插管，就是插管的時機。(除了PE)

Chest pain

一定要做心電圖!(STEMI equivalent) Echo can help! Lethal etiology ACS, PE, aortic dissection ± effusion, pneumothorax Hx, PE and Labs LQQOPERA, Jugular vein, rales, pulse pressure(SBP-DBP) EKG + TnI + CXR ; Echo: thoracic/Abd aorta Management Treat accordingly ; Suspect ACS consult CV 不確定可以追蹤EKG/TnI, 看risk 驗D-dimer或切CT Echo可幫忙診斷 大絕招: Triple CT angiography r/o PE+AMI+AoD

Abdominal pain

Abdominal pain 排除acute abdomen跟ischemic bowel ; Echo Lethal etiology PPU, ischemic bowel, AAA, dissection, obstruct, DKA Hx, PE and Labs LQQOPERA(sudden? Acute?), vitals, abd PE; lactate, CBC/BCS/blood/SBG, lipase, pregnancy? ; Echo: Abd Ao Management 確定病因最為重要，但還是可以給止痛+NPO。 If infection suspected → Broad antibiotics(App can mask) 40歲以上上腹痛記得做心電圖。 Acute abd→ 外科。不確定就切CTA + arterial phase。

Select a repo