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1. If a patient has a fever, give acetaminophen (unless it is contraindicated)
2. If a patient is on a statin or you order a statin, get baseline LFTs and check frequently
3. If a patient is found to have abnormal LFTs, get a TSH
4. If a patient is going to surgery (including cardiac catheterization), make them NPO
5. All NPO patients must also have their urine output measured (type "urine output")
6. If a woman is between 12 and 52 years old and there is no mention of a very recent menses (that is, < 2 weeks ago), order a beta-hCG
7. Don't forget to discontinue anything that is no longer required (especially if you are sending the patient home)
8. When a patient is stable, decide whether or not you should change locations (if you anticipate that the patient could crash in the very near future, send the patient to the ICU; if the patient just needs overnight monitoring, send to the ward; if the patient is back to baseline, send home with follow-up)
9. In any diabetic (new or long-standing), order an HbA1c as well as continuous Accuchecks.
10. If this is a long-standing diabetic, also order an ophthalmology consult (to evaluate for diabetic retinopathy)
11. In any patient with respiratory distress (especially with low oxygen saturations), order an ABG
12. In any overdose, do a gastric lavage and activated charcoal (no harm in doing so, unless the patient is unconscious or has risk for aspiration)
13. In any suicidal patient, admit to ward and get "suicide contract" and "suicide precautions"
14. Patients who cannot tolerate Aspirin get Clopidogrel or Ticlopidine
15. Post-PTCA patients get Abciximab
16. In any bleeding patient, order PT, PTT, and Blood Type and Crossmatch (just in case they have to go to the O.R.)
17. In any pregnant patient, get "Blood Type and Rh" as well as "Atypical Antibody Screen"
18. In any patient with excess bleeding (especially GI bleeding), type "no aspirin" upon D/C of patient
19. If the patient is having any upper GI distress or is at risk for aspiration, order "head elevation" and "aspiration precautions"
20. In any asthmatic, order bedside FEV1 and PEFR (and use this to follow treatment progress)
21. Before you D/C a patient, change all IV meds to PO and all nebulizers to MDI
22. In any patient who has GI distress, make them NPO
23. All diabetic in-patients get Accuchecks, D/C oral hypoglycemic agents, start insulin, HbA1c, advise strict glycemic control, recommend diabetic foot care
24. All patients with altered mental status of unknown etiology get a "fingerstick glucose" check (for hypoglycemia), IV thiamine, IV dextrose, IV naloxone, urine toxicology, blood alcohol level, NPO
25. If hemolysis is in the differential, order a reticulocyte count
26. If you administer heparin, check platelets on Day 3 and Day 5 (for heparin-induced thrombocytopenia), as well as frequent H&H
27. If you administer coumadin, check daily PT/INR until it is within therapeutic range for two consecutive days
28. Before giving a woman coumadin, isotretinoin, doxycycline, OCPs or other teratogens, get a beta-hCG
29. If you give furosemide (Lasix), also give KCl (it depletes K+)
30. All children who are given gentamycin, should have a hearing test (audiometry) and check BUN/Cr before and after treatment
31. Don't forget about patient comfort! Treat pain with IV morphine, nausea with IV phenergan, constipation with PO docusate, diarrhea with PO loperamide, insomnia with PO temazepam
32. All ICU patients get stress ulcer prophylaxis with IV omeprazole or ranitidine
33. If you put a patient on complete bed rest (such as those who are pre-op), get "pneumatic compression stockings"
34. If fluid status is vital to a patient's prognosis (such as those with dehydration, hypovolemia, or fluid overload), place a Foley catheter and order "urine output"
35. If a CXR shows an effusion, get a decubitus CXR next
36. If you intubate a patient you also have to order "mechanical ventilation" (otherwise the patient will just sit there with a tube in his mouth!)
37. With any major procedure (including surgery, biopsy, centesis), you MUST type "consent for procedure" (typing consent will not reveal any results)
38. With any fluid aspiration (such as paracentesis or pericardiocentesis), get fluid analysis separately (it is not automatic). If you don't order anything on the fluid, it will just be discarded.
39. With high-dose steroids (such as in temporal arteritis), give IV ranitidine, calcium, vitamin D, alendronate, and get a baseline DEXA scan.
40. In all suspected DKA or HHNC, check osmolality and ketone levels in the serum.
41. In alcoholic ketoacidosis, just give dextrose (no need for insulin), in addition to IV normal saline and thiamine
42. All patients over 50 with no history of FOBT or colonoscopy should get a rectal exam, a FOBT, and have a sigmoidoscopy or colonoscopy scheduled.
43. All women > 40 years old should get a yearly clinical breast exam and mammogram (if risk factors are present, start at 35)
44. All men > 50 years old should get a prostate exam and a PSA (if risk factors are present, start at 45)
45. If a patient has a terminal disease, advise "advanced directives"
46. In any patient with a chronic disease that can cause future altered mental status, type "medical alert bracelet" upon D/C
47. Any patient with diarrhea should have their stool checked for "ova and parasites", "white cells", "culture", and C.diff antigen (if warranted)
48. Any patient on lithium or theophylline should have their levels checked
49. All patients with suspected MI should be given a statin (and check baseline LFTs)
50. All suspected hemolysis patients should get a direct Coombs test
51. Schedule all women older than 18 for a Pap smear (unless she has had a normal Pap within one year)
52. Pre-op patients should have the following done: â€œNPOâ€, â€œIV accessâ€, â€œIV normal salineâ€, â€œblood type and crossmatchâ€, â€œanalgesiaâ€, â€œPTâ€, â€œPTTâ€, â€œpneumatic compression stockingsâ€, â€œFoleyâ€, â€œurine outputâ€, â€œCBCâ€, and any appropriate antibiotics
53. If a patient requires epinephrine (such as in anaphylaxis), and he/she is on a beta-blocker, give glucagon first
54. If lipid profile is abnormal, order a TSH
55. All dementia and alcoholic patients should be advised â€œno drivingâ€
56. To diagnose Alzheimerâ€™s, first rule out other causes. Order a CT head, vitamin B12 levels, folate levels, TSH, and routine labs like CBC, BMP, LFT, UA. Also, if the history suggests it, order a VDRL and HIV ELISA as well
57. Also rule out depression in suspected dementia patients
58. For all women who are sexually active and of reproductive age, give folate. In fact, you should give ALL your patients a multivitamin upon D/C home
59. All pancreatitis patients should be made NPO and have NG suction so that no food can stimulate the pancreas
60. Send patients home on a disease-specific diet: diabetics get a â€œdiabetic dietâ€, hypertensives get a â€œlow salt dietâ€, irritable bowel patients get a â€œhigh fiber dietâ€, hepatic failure patients get â€œlow protein dietâ€, etc
61. Do not give a thrombolytic (tPA or streptokinase) in a patient with unstable angina
62. Patients who are having a large amount of secretions, order â€œpulmonary toiletâ€ to reduce the risk of aspiration
63. Every patient should be advised to wear a â€œseatbeltâ€, to â€œexerciseâ€, and advised about â€œcomplianceâ€
64. In any patient who presents with an unprotected airway (as in overdoses, comatoses), get a CXR to rule out aspiration
65. In any patient with one sexually transmitted disease (such as Trichomonas), check for other STDs as well (Gonorrhea, Chlamydia, HIV, syphilis, etc.) and do a Pap smear in all women with an STD
66. Remember to treat children with croup with a â€œmist tentâ€ and racemic epinephrine
67. Any acute abdomen patient with a suspected or proven perforation, give a TRIPLE antibiotic: Gentamycin, Ampicillin, Metronidazole
68. Get iron studies in patients with microcytic anemia if the cause is unknown. Order â€œironâ€, â€œferritinâ€, â€œTIBCâ€
69. Women with vaginal discharge should get a KOH prep, saline (wet) prep, vaginal pH, cervical gonococcal, chlamydia culture
70. If a woman is found to have vaginal candida, check her fasting glucose
71. All suspected child abuse patients should be admitted and you should order THREE consults: consult â€œchild protection servicesâ€, consult â€œophthalmologyâ€ (to look for retinal hemorrhages), consult â€œpsychiatristâ€ (to examine the family dynamics)
72. When a woman reaches her menopause, she should have a â€œfasting lipid profileâ€ checked (because without estrogen, LDL will rise and the HDL will drop), a DEXA scan (for baseline bone density), FOBT and colonoscopy (if she is over 50
73. When the 5 minute warning screen is displayed, go through the following mnemonic
Recreational drugs & Reassurance
Diet of high protein, no lactose, low fat
Seat belt, Safety plan & Suicide precautions
X for safe sex
74. If colon cancer is suspected, order a CEA; if pancreatic cancer, order CA 19-9; if ovarian cancer, order CA 125.
75. Remember to give â€œphototherapyâ€ to a newborn with pathologic unconjugated bilirubinemia (it is not helpful if it is predominantly conjugated). Also, with phototherapy, keep the neonate on IV fluids (the heat can dehydrate them), and give erythromycin ointment in their eyes
76. Before giving a child prednisone, get a PPD
77. If a patient is found to have high triglycerides, check â€œamylaseâ€ and â€œlipaseâ€ (high triglycerides can cause pancreatitis)
78. Remember that any newborn under 3 weeks of age who develops a fever is SEPSIS until proven otherwise. Admit to the ward and culture EVERYTHING: â€œblood cultureâ€, â€œurine cultureâ€, â€œsputum cultureâ€, and even â€œCSF cultureâ€. And give antibiotics to cover EVERYTHING.
79. If you get a high lead level in a child, you have to check a â€œvenous blood lead levelâ€ to confirm. If the value is > 70, admit immediately and begin IV â€œdimercaprolâ€ and â€œEDTAâ€. Order â€œlead abatement agencyâ€ and â€œlead pain assayâ€ upon discharge.
80. If you perform arthrocentesis, send the synovial fluid for â€œgram stainâ€ and the 3 Cs: â€œcrystalsâ€, â€œcultureâ€, and â€œcell countâ€
81. If a patient has exophthalmos with hyperthyroidism, it is not enough to just treat the hyperthyroidism (as the eye findings may worsen). You should give prednisone.
82. If any patient has cancer, get an â€œoncology consultâ€.
83. In a patient with rapid atrial fibrillation, decrease heart rate first. Then use a CCB (diltiazem) or a beta-blocker (metoprolol) for rate control.
84. In any patient with new-onset atrial fibrillation, make sure you check a TSH
85. In any patient with suspected fluid volume depletion, order â€œpostural vitalsâ€ to detect orthostasis
86. Before a colonoscopy or a sigmoidoscopy, you should prepare the bowel: make the patient NPO, give IV fluids (if necessary) and order â€œpolyethylene glycolâ€.
87. Any patient with Mobitz II or complete heart block gets an immediate â€œtranscutaneous pacemakerâ€. Then order a cardiology consult to implant a â€œtransvenous pacemakerâ€
88. If calcium level is abnormal, order a â€œserum magnesiumâ€, â€œserum phosphorusâ€, and â€œPTHâ€
89. Treat both malignant hyperthermia and neuroleptic malignant syndrome with â€œdantroleneâ€
90. All splenectomy patients get a â€œpneumovaxâ€, an â€œinfluenzaâ€ vaccine, and a â€œhemophilusâ€ vaccine if not previously given.
91. If you give INH (for Tb), also give â€œpyridoxineâ€ (this is vitamin B6)
92. If you give pyrazinamide, get baseline â€œserum uric acidâ€ levels
93. If you give ethambutol, order an ophthalmology consult (follow optic neuritis)
94. If you perform a thoracocentesis (lung aspirate), send the EFFUSION as well as a peripheral blood sample for: LDH and protein (to help differentiate a transudate versus an exudates) and pH of the effusion
95. Give sickle cell disease children prophylactic penicillin continuously until they turn 5 years old
96. Any patient with a recent anaphylactic reaction (for any reason), should get â€œskin testâ€ for allergens (to help prevent future disasters) and consult an allergist
97. Do not give cephalosporins to any patient with anaphylactic penicillin allergies (there is a 5% cross-reactivity)
98. Order Holter monitor on patients who have had symptomatic palpitations.
99. Any patient with a first-time panic attack gets a â€œurine toxicologyâ€ screen, a TSH, and â€œfinger stick glucoseâ€
100. All renal failure patients get: â€œnephrology consultâ€, â€œcalcium acetateâ€ (to decrease the phosphorus levels), â€œcalciumâ€ supplement, and erythropoietin
Thanks robin its really helpful
Thanks robin its a great effort, i really appreciate it.
THANK YOU robin.
that is invaluable info.
Robin your post is very helpfull.Thanks for sharing with us.
In CCS No.26 -what is frequent H&H in HIT
class of 2012
thanks a lot for this post... Very helpful...
thanks, this list is god sent more power to you Robin!!!!!
Very helpful post.
Wow! Im going to go through this. Thanks for making a list.
thanks for this list.
To dr.shailu: H&H means hemoglobin and hematocrit.
i tried to type in several of these options and many of them were not available. how did you come up with your list and test it's validity?
transfer:step 3 prison
awesome! Good stuff
Thanks! that's extremely helpful!
its wonderful work u did....looking forward for more!!!
wow ! thanks a bunch. God bless you
thanx... its great info...
53. If a patient requires epinephrine (such as in anaphylaxis), and he/she is on a beta-blocker, give glucagon first
Please can somone explain why we need to give glucagon here. thanks
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