A/P elements final
A # Abdominal Pain (unspecified) Patient reports new abdominal pain characterized by ***. Although with benign abdominal exam, ddx for acute abdominal pain include inflammatory (gastritis, PUD, cholecystitis, appendicitis, peritonitis, diverticulitis), vascular (AAA, mesenteric ischemia), obstruction (bowel, ureter, bladder), luminal perforation, and obstetric. Image negative abdominal pain include DKA, IBS/functional pain, withdrawal, angioedema, lead toxicity, vaso-occlusive events and porphyria. - CBC, CMP, lipase, INR - UA, UTox - Consider imaging PRN # Acute Adrenal Insufficiency (Adrenal Crisis) Patient with*** history of adrenal insufficiency who presents with lethargy, fever, nausea, nonspecific abdominal pain, and hypotension concerning for adrenal crisis. Common etiologies include autoimmune, infectious, infarction, and medication inadherence. Dx - CBC, CMP, cortisol, ACTH, aldosterone, renin, TSH, lactate - CXR, BCx x2, UA, Utox - Evaluate fever, abdominal pain, hypotension per clinical scenario Tx - Hydrocortisone 100mg IV x1, then 50mg IV q6h (following lab draws) - Consider empiric antibiotics and fluids if concerned for sepsis # Acute Chest Syndrome / Vaso-occlusive Pain Episode Patient with known history of sickle cell disease who present with concern for acute chest syndrome given segmental pulmonary infiltrate and symptoms of ***. Most likely due to ***. Common triggers include dehydrations, drugs/ETOH, stress, infection, and hypoxia. Patient with*** hx of acute chest syndrome, with *** hospitalizations over the past year for vaso-occlusive pain episodes. Dx - CBC, retic count - CXR, BCx x2, Sputum Cx, Procalcitonin. Consider influenza, viral panel per clinical scenario - EKG, Troponin. Consider PE eval per clinical scenario Tx - Aggressive pain control - Aggressive fluid resuscitation with maintenance (assuming no heart failure) - Antibiotics per clinical scenario - Supplemental O2, Bronchodilator, incentive spirometry - DVT ppx - If concern for moderate/severe/very severe acute chest syndrome, consult hematology for exchange transfusion # Acute Kidney Injury Patient noted to have AKI with Cr *** over baseline ***. Suspect due to relative hypovolemia and systemic illness. Currently producing urine and with normal bladder scan; will defer additional lab/imaging diagnostics pending fluid resuscitation. - BMP - s/p *** L IVF - Consider UA with microscopy, Renal/bladder US, UNa, UCr if refractory or significant AKI # Acute Liver Failure Patient without history of liver dysfunction who presents with INR >1.5 and encephalopathy concerning for ALF. Should this be ALF, etiologies include viral, tox, autoimmune, vascular, shock, and iatrogenic med effect. Will proceed with broad diagnostics and evaluation for altered mental status. If this is not acute liver failure, may be acute liver injury from similar reasons listed above, with INR elevation from poor nutrition, DIC, MAHAs, or anticoagulation. Dx - RUQ with Doppler - APAP level, arterial ammonia - Hepatitis A IgM, anti-HBC IgM, anti-HCV IgG, HCV RNA, - HBsAg, HBsAb, HBcAb, HBV DNA, - ANA, ASMA, IgG, ceruloplasmin, and Utox - INR, LFTs BID - Q2hr POC Glucose Tx - Appreciate Liver Transplant Unit assistance - NAC - Elevate Head of bed - 2g APAP limit # Acute Respiratory Distress Syndrome (ARDS) Patient presents with acute onset of bilateral alveolar infiltrates (noncardiogenic) and hypoxemia concerning for ARDS. Likely due to ***, with common etiologies including sepsis, pneumonia/pneumonitis, meds, toxins/inhalation injury, trauma/surgery, burns, and pancreatitis. P/F ratio: *** Dx - CBC, CMP, INR, Lactate - CXR, BNP, SputumCx, BCx x2 - CPO, Telemetry Tx - ARDSnet protocol, VC 6cc/kg of ideal body weight - Goal CVP <4 - Proning, paralysis per ICU # Alcoholic Hepatitis Patient presents with right upper quadrant abdominal pain, fever, and leukocytosis in the setting of significant alochol use, concerning for alcoholic hepatitis. Ddx also includes ***. On presentation, MELD is *** and Maddrey's Discriminant Function is ***. Empiric treatment for alcoholic hepatitis with steroids is generally indicated in patients with MDF >32. - CBC, CMP, INR, Lactate, BCx x2 - Thiamine, Folate, multivitamin - Dx Para if ascites present - Consider Prednisolone 40 mg QD if no contraindications - If receiving steroids, measure Lille score at one week, If >0.45, consider stopping steroid treatment. - Alcohol abstinence counselling and SW assistance. # Altered Mental Status (AMS) Most likely due to ***. Ddx also includes infectious encephalopathy, substance/tox, metabolic derangement, and endocrinopathy. - NCHCT - CXR, UA/UCx, BCx x2 - BMP, VBG, CBC - UTox # Anaphylaxis Patient with*** history of anaphylaxis, who presents with acute onset respiratory compromise or hypotension, with skin or mucosal involvement concerning for anaphylaxis. Suspect triggered by ***. Ddx includes but is not limited to acute generalized urticaria, angioedema, asthma exacerbation, panic attack, and shock. Dx - CBC w/ diff, CMP, INR, Lactate, Tryptase Tx - Airway – Albuterol, racemic epinephrine nebulizer - Epinephrine initial management: 0.3 – 0.5 mg IM, repeat q5-15min for hypotension - Epinephrine gtt: 0.1 mcg/kg/minute, with increase every 2 min by 0.05 mcg/kg/min to MAP >65 - IVF: ***L bolus - H1: Benadryl 50 IV - H2: Ranitidine 50 IV (for urticarial relief) - Methylprednisolone 125 IV - Telemetry, CPO, Airway management per ICU # Anion Gap Metabolic Acidosis Pt presents with elevated anion gap of *** and acidosis. Renal insufficiency is ***present. Suspicion of toxic ingestion is ***. Most likely etiology is ***, with a differential including lactic acidosis, uremia/ESRD, ketosis (starvation, alcoholic, diabetic), toxic alcohols (ethylene glycol, methanol, ASA). Dx: - osm, EtOH, ASA, APAP, osm gap calculation per clinical scenario - BHB - VBG/lactate Tx: - per etiology # Anxiety Disorder, New GAD-7: ***. The patient meets criteria for generalized anxiety disorder, given functional impairment from excessive unconrollable worry about a number of concerns. No psychotic features, personal history of PTSD or manic episodes, or significant fam hx of bipolar disorders. No SI HI AVH. Given new onset, consider secondary causes including hypoglycemia, hyperthyroid, anemia, withdrawal (EtOH, opioids, BZD, antidepressants), and excess caffeine. - TSH, CBC, BMP, consider Utox - psychotherapy referral for CBT and/or exposure therapy - Biofeedback, yoga, meditation - Pharm Tx: - f/u 4 weeks # Anxiety Disorder, New The patient meets criteria for anxiety disorder, specifically... ***generalized anxiety disorder given functional impairment from excessive unconrollable worry about a number of concerns, with*** agoraphobia. Screen with GAD-7: ***. ***panic disorder given recurrent out of the blue panic attacks with concern about recurrences. Screen with panic disorder severity scale: ***. ***social anxiety disorder given excessive anxiety related to social situations and potential scrutiny of others. Screen with Mini-SPIN: ***. ***specific phobia given excessive fear about *** with avoidance and/or enduring distress. No personal history of PTSD or manic episodes, significant famhx of bipolar, and no psychotic features. Given new onset, consider secondary causes including hypoglycemia, hyperthyroid, anemia, withdrawal (EtOH, opioids, BZD, antidepressants), SUD, excess caffeine. Dx: - TSH, CBC, BMP, consider Utox - psychiatry referral for suicidality, thought d/o, unclear dx, psychotic features, bipolar, refractory to multiple therapiest Tx: Non-Pharm Tx: - psychotherapy referral for CBT and/or exposure therapy - biofeedback, yoga, meditation Pharm Tx: (uptitrate qweekly to qmonthly as tolerated; anxiolytic effect may require higher doses than for depression; trial slow taper off 6-9 months post-remission) - start SSRI [escitalopram 5mg qd, then increase to 20-30 mg qd as tolerated] [sertraline (more stimulating, more diarrhea) start 50mg qd, uptitrate by 25-50mg qweekly as tolerated to 200mg qd max] -- if comorbid panic attacks or inability to tolerate low dose SSRIs, can start with liquid formulation of eg escitalopram 1mg qd and increase by 1mg weekly - consider starting other classes of meds instead in special circumstances: -- consider SNRI (esp duloxetine start 30mg qd -> 60-120mg qd max) if chronic pain -- consider TCA eg nortryptyline (25mg->50-150mg qd) if chronic pain/migraine or amitriptyline (25mg->100-300mg qd) if significant insomnia (caution: TCA lethal in OD) -- avoid buproprion - can augment with buspirone 10-60mg in 2-3 divided doses - can augment with gabapentin/pregabalin (slow uptitration to max 3600mg total daily / 300mg total daily) - consider propranolol 20-40mg BID PRN especially for social or performance anxiety; occasional PRN BZD reasonable for specific phobias - reasonable for SHORT bridge of eg clonazepam 0.25-0.5mg BID PRN during SSRI uptitration but long term BZD should be reserved for patients who have failed first line treatments; - f/u 4 weeks # Asthma Exacerbation Increased frequency of SABA, using MDI [＞2x per week], increased dyspnea, night awakenings, limited normal activity. Most recent spirometry was [date]. Number of ED visits in the past year that required oral steroids [#]. DDx: laryngeal / tracheal dysfunction, narrow supraglottic airway, foreign body aspiration, airway edema, chronic bronchitis or emphysema, bronchiectasis, allergic bronchopulmonary mycosis, cystic fibrosis, eosinophilic pneumonia, hypersensitivity pneumonitis, sarcoidosis, and bronchiolitis obliterans, eosinophilic granulomatosis with polyangitis, heart failure and pulmonary hypertension, conversion disorder. - SpO2 ＞95% on 5L nasal cannula - peak expiratory flow (PEF), normally 450-650 L/min in men and 350-500 L/min in women. Mild severity, PEF ＞300L/min, HR＜100, SaO2＞95, speaks in sentences, can lie down, not using accessory muscles Moderate, 100-300L/min, RR＞20, HR＞100, SaO2＞90, FEV1 40-69%, speaks in phrases, Pulsus paradoxus ＞10mmgHg drop in BP blood pressure during inspiration Severe: PEF ＜100L/min, RR＞30, HR＞120, SaO2＜90, speaks in words, sits upright, Pulsus paradoxus ＞20mmgHg drop in BP blood pressure during inspiration - CXR Tx: if mild: -SABA by MDI, q20min in first hour or Neb 0.15 mg/kg with a max dose of 5 mg. - predisone PO 0.5-1.0 mg/kg/day), prednisolone 40-50mg, children 1-2mg/kg -consider ipratropium (IB), 17 mcg/puff, 2-3 puffs q6h -if good response SABA q4h 7 days, oral steroid 7 days, continue controller meds, consider ICS if moderate: - continuous SABA and ipratropium bromide (IB) by neb, oral corticosteroids, then SABA q40min if severe: - continuous SABA, IB, consider heliox, epinephrine IM, 2g Mg sulfate IV over 20min Admit if... ARDS, Decreased level of consciousness, Hypoxia: ＜93%, Hypercapnea: CO2 ＞42, Dehydration, Peak flow ＜50% predicted, pulsus paradoxus ＞15mmHg, need for IV SABA, mechanical vent Underlying high risk factors: heart disease, neuromuscular disease, cystic fibrosis, bronchopulmonary dysplasia, history of ICU admission, unreliable parents or care givers, long distance from the ER. ER visit within the preceding 24 hours. D/c Provide written action plan Train for self-monitoring (peak flows), Educate and reinforce correct inhaler techniques, Refer to an asthma education program Schedule follow-up Consider home environment (tobacco exposure, allergen avoidance, social support) Step down therapy is considered after at least 3 months of being well-controlled # Atrial Fibrillation (new) Patient with new atrial fibrillation, with symptoms/onset notable for ***. Suspect due to ***, with common etiologies including infection, cardiac disease (ischemic, heart failure, structural), HTN, PE, ETOH/tox, sleep disorder and endocrinopathy. CHA2DS2-VASc: *** - Rate Control: - Anticoagulation: - CBC, BMP, TSH #Afib with RVR (stable) Acute management of stable Afib with RVR with IV Metoprolol tartrate 5mg IV q15min x3 or Diltiazem 10-20mg IV q15min x3 may be warranted. Amiodarone can be used if the patient's blood pressure may not support IV metop/dilt, althought it carries the thromboembolic risk of chemical cardioversion. If the patient is hemodynamically unstable, synchronized cardioversion is warranted, with subsequent anticoagulation depending on Afib chronicity and onset. # Atypical Chest Pain Pt presents with atypical chest pain without troponinemia, ischemic EKG changes, or hemodynamics compromise, with low suspicion for acute coronary syndrome. Highest suspicion for ***. DDx also includes dissection, pericarditis, tamponade, PE, PTX, PNA, esophageal rupture, food impaction, and MSK strain/injury. - HEART score *** - Trop, EKG - CBC, BMP, VBG - CXR - Consider 6hr repeat Trop, EKG per clinical scenario - Consider DDimer, BP in 4 extremities per clinical scenario #CAD s/p PCI/Cardiac Catheterization Admitted for observation post-LHC that was significant for ***. S/p PCI with stents placed to ***. Pt recovering adequately from procedure with no evidence of swelling, hemorrhage, loss of perfusion, strength or sensation at arterial entry site. -Admit for observation on telemetry -Patient will need at least 6 months of uninterrupted DAPT. -Aspirin 81 mg 1 tablet by mouth daily for heart attack prevention -Clopidogrel (Plavix) 75 mg 1 tablet by mouth daily for heart attack prevention -Optimization of guideline directed medical therapy for coronary atherosclerosis: beta blocker, ARB, and statin (high intensity preferred) as indicated. -Optimize antianginal therapy. -Aggressive risk factor modification. -Consider referral to cardiac rehab outpatient -Outpatient follow up with cardiology B C # Cardiogenic Shock Patient presents in shock with history, physical exam, lab, and imaging findings of hypervolemia concerning for cardiogenic shock. Past clinical hx and TTE notable for ***. Alternative causes of shock less likely (see # Shock). Dx - Bedside TTE showing *** - Bedside IVC showing *** - EKG, Troponin, CBC, CMP, BNP - Q6h CBC, ABG with COOX, Central Venous O2 saturation with COOX, CVP, Lactate - BMP, Mg BID to TID - CXR, UA with microscopy, consider BCx - Strict I/O, daily standing weights - Formal TTE, telemetry Tx - Goal net negative: *** - Bumex 4 IV, Diuril 250 IV x1 with 1 hour UOP re-assessment - Replete K>4, Mg>2 - Na-restricted diet (<3 grams per day), 2L fluid restriction - ICU admission, central line placement - Goal MAP 65, pressors (norepinephrine first line) and afterload reduction PRN - Avoid initial BB, CCB # Cavitary Nodule Imaging notable for cavitary nodule, generally defined by thick walls greater than 4mm (cystic lesions < 4mm). Ddx includes infectious (bacterial, fungal, septic emboli, TB), malignancy, GPA, and foreign body. # Cellulitis Patient presents with skin and soft tissue infection of *** with *** evidence of purulence. No evidence of abscess at this time. - Abx: - CBC, CMP, Lactate - Consider HIV, A1c, BCx per clinical scenario # Chronic Kidney Disease Defined by CKD <60 (Stage II) for 3 months or proteinuria (or evidence) for 3 months A. Progression/proteinuria: Slowly progressive. Cr **. Proteinuria increased to ** compared to ***, remains < 1g/g. Continue RAAS blockade. P/Cr: <150 mg/g (<15mg/mmol), severe >500 Alb/Cr: <30 mg/g (<3mg/mmol), severe >300 Cr >2.5: hold RAAS B. Hypertension: SBP goal <140 w/o proteinuria, SBP<130/80 + proteinuria use ACEi, ARB, Dilt/Verapamil, thiazide if GFR>30, if <30 need Lasix, (Spironolactone, Aliskiren). S/E: hyperkalemia, angioedema, and teratogenicity C. Bone/mineral metabolism: Ca, Phos, PTH, 25-OH-VitD (longer half-life). Calcium repletion if……Phosphate binders if >4.5 in CKD3b-5. When 25OH vitamin D levels are <10ng/ml, start with ergocalciferol 50,000IU weekly for 6-8 weeks, then switch to cholecalciferol 800-1000IU daily. Calcitriol if ………. D. Acid/base and electrolytes: derangements. E. Erythropoiesis: screening begins with Stage 3a. Erythropoiesis-stimulating agents (ESA) for Hb <10. Anemia 2/2 is dx of exclusion F. Volume: Euvolemic. G. Cardioprotection: Continue aspirin and statin. # Code Blue Note (ROSC) Code blue called at approximately ***. On my arrival, patient was without a pulse with rhythm showing ***. ACLS performed with *** rounds prior to ROSC. Patient's neurologic status was notable for ***, with GCS***. Family/contact was notified. - EKG, Trop, CBC, CMP, Lactate, CXR - CPO, Tele, ICU admission - Cooling Protocol per Neuro PRN // Code Blue Overview (Not for Note Documentation) // ** Your main job is to coordinate/run the room! You are not alone!** [ ] Walk into the roomHi my name is _____ and I am the code leader. Does the patient have a pulse? Is he/she full code? [ ] Quiet the room – ask directly for people to quiet down if needed and ask extra people to step out if too crowded [ ] Stand at the foot of the bed, stay calm but make sure your voice is loud enough [ ] Used close loop communication [ ] Identify your team: announce rolesCode whisperer: ____________ [ ] Place back board/pads: Ask that someone places backboard and leads/pads if not already done [ ] CPR: 100-120/min- beat of “Staying alive”. Make a line and get LUCAS if available. [ ] Time-keeper: _____________ consider using Code Blue App [ ] Airway: Identify anesthesia and intubate asap if needed. If trach patient, make sure pt hooked up to oxygen. Ask for end tidal CO2- ideally >20 if good compressions, if <10 then improve chest compressions or think about reasons for poor ventilation and V/Q mismatch (e.g. PE!). [ ] Pharmacist: __________ Ask for 1mg epi right away, then see algorithm below. Ask for closed loop communication to confirm when meds are given. [ ] Labs: Ask for rainbow to be sent (iSTAT; ABG with lytes/lactate, CBC, CMP, coags, type and cross, POC glucose, troponin). Ask to confirm when sent or let you know in two minutes if can’t get them. If at SFGH can run ABG with lytes faster in ED so another resident to run it down [ ] Access: Get IV access. If no PIVs, get IO access. Occasionally get central line / Aline during code if long code, needed for access, etc but not an immediate priority. [ ] Other tasks:Ask another resident to look up recent labs, review tele, etc [ ] Ask primary team for basic info and that they call family asap [ ] Ask another resident to grab an ultrasound- look for e/o tamponade, right heart strain ACLS algorithm and Medications [ ] Immediately: 1mg epinephrine if PEA/asystole, 1L NS wide open (unless cardiogenic shock) [ ] Then per ACLS algorithm epi every 3-5min (I do every 4min) and amio if shock! See next page [ ] Next: Consider 1 gram calcium chloride, 1 gram mag sulfate, 2-3 amps bicarb, 1amp D50 I often give all of these within the first few rounds, but not part of ACLS. Caution with multiple rounds of bicarb if not intubated yet. [ ] If you want TPA (PEA/asystole only), ask early! Takes 10-15min to make it, then after given it takes 20min to take effect so need to continue the code for at least 25 more minutes [ ] Ask for levophed to be hung so ready when ROSC achieved SUMMARIZE and TALK OUT LOUD [ ] Review pt one liner and where we are in the algorithm every few minutesExample “This is a 75M admitted with PNA who was hypoxic and then lost a pulse, we are in the PEA algorithm. This is our second round of check compressions, we have given 1mg epi and 1amp bicarb, he was just intubated and end tidal being set up, labs are being drawn, etc etc)” Then go through the H’s and Ts out loud [ ] Hs: 1. Hypovolemia 2. Hypoxia 3. Hydrogen (acidosis) 4. Hypo/hyperK 5. Hypothermia [ ] Ts: 1. Tension pneumo 2. Tamponade 3. Toxins 4. Thrombosis (PE) 5. Thrombosis (ACS) [ ] Invite thoughts from the room [ ] End of code If you get ROSC, see post-ROSC instructions on page 2 CALL CODE IF... [ ] 20 minus with end tidal <10 = call code; [ ] 30 mins without clear etiology = call code If the code has gone on >10 rounds, check with the ICU triage fellow/attending quietly first whether you should consider calling it then also ask the room. It is a group decision, you definitely don’t decide alone! Once decided, continue the round of chest compressions and tell the room that we will continue chest compressions until the next rhythm check and if no pulse at that time we will call it – gives chance for everyone to anticipate ending mentally/emotionally and to make sure no final ideas Can invite family into room during code or after- if during, ask primary team to stay with them It’s just an algorithm! The harder part is the leadership/organization piece above… the meds are pretty easy once you’ve done it a few times. This is a brief summary, see Code Cards for complete version. I typically didn’t look at Code Cards during the code since distracting, but can hand them to the Code Whisperer or have them in your pocket in case. // ACLS Algorithms // # PEA Arrest 0 Min: [ ] Begin chest compressions. As soon as leads/pads set up [ ] stop compressions to do a rhythm check - (don’t wait for 2min the first time around!). - No need to shock for PEA algorithm [ ] Give 1mg epinephrine right off the bat 2 Min: [ ] Pulse/rhythm check. 4 Min: [ ] Pulse/rhythm check. [ ] Give 1mg epinephrine (Give every 3-5minues) // Vfib/Vtach Arrest // 0 Min: [ ] Begin chest compressions. [ ] leads/pads set up [ ] stop compressions [ ] do a rhythm check ? If shockable rhythm (Vfib/Vtach) [ ] charge to 200J [ ] shock. [ ] continue chest compressions 2 Min: [ ] Pulse/rhythm check. ? If shockable rhythm, charge to 200J and shock. [ ] Give 1mg epinephrine at 2-4 mins (consider 1mg epi + vaso 20 + methylpred 40mg) 4 Min: [ ] Pulse/rhythm check. ? If shockable rhythm = charge to 200J and shock. [ ] Give 300mg amiodarone (for refractory Vfib/Vtach) 6 Min: [ ] Pulse/rhythm check. ?If shockable rhythm [ ] charge to 200J [ ] shock. [ ] Give 1mg epinephrine (consider + vaso 20mg) 8 Min: [ ] Pulse/rhythm check. ? If shockable rhythm [ ] charge to 200J [ ] shock. [ ] Give 150mg amiodarone ROSC: Post-Arrest Care [ ] Make sure pressors ready [ ] ask for levophed to be hung during code if possible. [ ] Can consider asking for 1mg epi with you for transport. [ ] Consider sedation if intubated, esp if paralytics used to intubate (often forgotten) // Where is patient is going? // ? ICU, cath lab, scanner etc. [ ] Ask charge when bed ready and you help transport [ ] Make pt stable for a couple min [ ] transport monitors ready, etc before transport // pt arrives in ICU // [ ] Get EKG [ ] repeat labs [ ] CXR [ ] additional imaging [ ] lines [ ] Ask primary team to call neuro to get their recommendation about cooling [ ] primary team calls family [ ] notifies attending (remind/offer to help the early Foxes if medicine pts) [ ] Always write code note (even if code is a false alarm!). “Significant Event Note” or “Code Documentation” // Post-code debrief // [ ] ask all parties to meet 20min after to debrief. - If floor code, try to do this on the floor so floor RNs there [ ] Ask for feedback – from ICU triage fellow, attending, co-residents, charge nurse, etc… ask specific questions! // Peri-Code Situations // These situations can sometimes be more challenging than codes, since less algorithmic. Ask for help! [ ] Ask somebody in the room to stat call cardiology or other relevant consultants if needed. // Bradycardia with a Pulse // [ ] Atropine 0.5mg IV bolus [ ] set up transcutaneous pacing at the same time. 3-5min (3-5m) [ ] Atropine 0.5mg IV bolus 3-5min (6-10m) [ ] Atropine 0.5mg IV bolus 3-5min (9-15m) [ ] Atropine 0.5mg IV bolus 3-5min (12-20m) [ ] Atropine 0.5mg IV bolus 3-5min (15-25) [ ] Atropine 0.5mg IV bolus max 3mg Reached – but note won’t work if third degree block so ALSO [ ] set up transcutaneous pacing at the same time. Transcutaneous pacing [ ] look for capture. [ ] Start 60 beats/min and go up Dopamine infusion (2-20mcg/kg/min) or Epinephrine infusion (2-10 mcg/min) [ ] Call cardiology! DATE: Dopamine, Atropine, Transcutaneous pace, Epi // Tachycardia with a Pulse // (Narrow regular) [ ] Attempt vagal maneuvers [ ] Give adenosine (only if regular!) - 6mg, then 12mg (but 3mg if via central line) [ ] Call cardiology. [ ] Consider beta blocker, calcium channel blocker // Unstable // [ ] synchronized cardioversion. [ ] 50 J [ ] 100 J. cardiovert! ? Awake [ ] Provide sedation (50mcg fentanyl) // Irregular + Narrow // Afib with RVR: [ ] Give metop 2.5 or 5mg IV if BPs can tolerate. [ ] Consider amio loading // Unstable // [ ] synchronized cardioversion. [ ] 120-200J biphasic / 200J monophasic. // Regular + Wide // [ ] Call cardiology. // Regular + Monomorphic// [ ] Consider adenosine [ ] check with cardiology - Consider anti-arrythmic infusion (Amio) // unstable // [ ] synchronized cardioversion: 100J // Wide Irregular // [ ] Call cardiology – specifically EP if possible. [ ] Defibrillation dose (200J). // Other non-pulseless situations // AMS: [ ] empirically given 1amp D50. [ ] Check glucose [ ] VBG to r/o hypercarbia. [ ] Review MAR- consider narcan. [ ] Consider stroke, seizure. [ ] Intubate if not protecting airway Hypotension: [ ] Ask pharmacy to get levo or epi gtt ready; [ ] give smaller pushes of epi in meantime (eg 0.2mg epi). [ ] Ask for IVF wide open unless cardiogenic shock Seizure: [ ] Give Ativan, [ ] call neuro CVA: [ ] Check pupils, [ ] call code stroke Dissection: [ ] Check bilateral cuff pressures and pulses. [ ] Get imaging if stable enough. [ ] Call vascular stat if concern Anaphylaxis: [ ] Steroids [ ] benadryl [ ] famotidine [ ] fluids [ ] airway Tamponade: [ ] Call cards stat. [ ] Avoid intubation if possible (drops preloadà HD collapse) Chest tubes: [ ] If had air leak and now doesn’t, think about tension pneumo. [ ] Ask nurses to strip chest tubes. [ ] Call CT surgery stat for trouble shooting Massive transfusion protocol: [ ] Ask co-resident to help count blood products – write on board or wall. [ ] Call GI/IR. [ ] Ask to get Belmont from the OR. Trach issues: [ ] Cuff up/down? [ ] Call ENT stat for help. [ ] Get oral airway if issues and no contraindication Torsades: [ ] Give magnesium // Massive transfusion protocol // Definition: 4U in 4 hours, 3U in 1 hour, anticipated ongoing bleeding Setup: [ ] Identify point person to blood bank to activate MTP [ ] Ask co-resident to help count blood products – write on board or wall. Identify cause: [ ] FAST exam [ ] start compression/tourniquet [ ] Call surgery/GI/IR. [ ] Ask to get Belmont from the OR. [ ] Start active warming of patient Access? [ ] 2 16-18g PIVs at least, [ ] consider upsizing with RIC. Anticoagulation? [ ] Consider K-centra/vitK; [ ] TXA in trauma patients Plyte/LR [ ] Initial 1:1:1 pRBC/FFP/platelets [ ] labs q30m - damage control approach then guided by labs q30m Labs: [ ] iSTAT [ ] CBC [ ] coags [ ] fibrinogen [ ] iCal [ ] Type and cross [ ] thromboelastography Goals -MAP>65 (>85 if CNS) -Temperature >35 °C - Acid-base status -- pH >7.2 -- base excess <–6 -- lactate <4 mmol/L - Ionised calcium (Ca) >1.1 mmol/L - Haemoglobin (Hb) >10. - Platelet (Plt) ≥ 50 (>100 if CNS) - PT/APTT ≤ 1.5x of normal (FFP) - Fibrinogen ≥ 100 (cryo) //Complications// - volume overload (careful monitoring of filling pressures, response to volume, diuresis etc) - over-transfusion (monitor Hb regularly, titrate according to needs) - hypothermia (monitor temp, use fluid warmers and other measures to reduce heat loss) - dilutional coagulopathy of clotting factors and platelets (regular and early monitoring of coagulation, involvement of haematology for replacement therapy ) - Transfusion related acute lung injury (consider use of filters, leukodepletion) - excessive citrate causing metabolic alkalosis and hypocalcaemia (monitor pH and ionised calcium, replace calcium as necessary) - hyperkalaemia (use of younger blood, monitor regularly, may require specific therapy) - disease transmission (use of products only on a needed basis only, standard blood banking precautions etc) # COPD exacerbation (Acute on Chronic) Patient with history of COPD who presents with wheezing, worsening cough and dyspnea, concerning for COPD exacerbation without concomitant pneumonia. - Influenza, viral panel per clinical scenario - CBC, BMP, ABG/VBG - CPO, SpO2 goal>88% - Albuterol/Ipratroprium nebulizer q4hr, reassessment - Prednisone 40mg QD x 5 days - Consider CRP, Azithro or Doxy x 5 days #Acute Hypoxic Respiratory Failure secondary to COVID-19, confirmed Onset of symptoms on 8/18, including fever, cough, SOB, GI sx. Admitted to *med floor *ICU* on 8/25 with hypoexmic/hypercarbic respiratory failure. CXR notable for ***. COVID test positive on ****. Received therapies include *** proning, convalescent plasma, remdesivir, flolan, and/or ECMO. Goal SpO2 92-96, PaO2＞75 Labs/dx - Admission: CBC w diff, CMP, CRP, procal, CPK, PTT, INR, BNP, ferritin, EKG, CXR - Daily: CBC w diff, BMP, Mag, CPK, BNP - Strict isolation = Contact (gown+ gloves) + Droplet (N95) - AVOID aerosolizing procedures when possible (Non-invasive, high flow, nebs, bronchoscopy) Tx: - Duoneb q6h - Budesonide 0.5mg bid - Remdesivir - Baricitinib - Methyprednisolone (Solumedrol) - Zinc 220mg qd, Vitamin D 4,000u qd, Vitamin C 500mg q6h, Thiamine 100mg, Famotidine 20mg bid, Melatonin 9mg qhs - Lovenox 55mg q12 # Cystic Lung Disease Imaging notable for cystic lung disease, generally defined by thin walls less than 4mm (cavitary lesions > 4mm). Parencyhmal mimickers of cystic lung disease include emphysema, bronchiectasis, blebs, bullae and pneumatocele. Cystic lung disease ddx includes lymphoid interstitial pneumonia (LIP), lymphangioleiomyomatosis (LAM), Birt-Hogg-Dubé syndrome (BHD), and pulmonary Langerhans cell histiocytosis. # Decompensated Cirrhosis Pt with known history of cirrhosis secondary to ***, with decompensation as evidenced by varices, ascites, and/or hepatic encephalopathy. MELD-Na: ***. ## Hepatic Encephalopathy - Lactulose titrate to 4 BM/day, Rifaximin 550 mg BID ## Variceal Bleeding - Last EGD *** - Octreotide gtt, PPI, CTX x 5 days ## Ascites - Lasix 20mg, spironolactone 50 mg - Dx/Tx paracentesis - SBP ppx PRN ## HCC Screening - AFP + US/CT/MRI every 6 months; last *** # Decompensated Cirrhosis Pt with known history of cirrhosis secondary to ***, with decompensation as evidenced by varices, ascites, and/or hepatic encephalopathy. Child Pugh Class: ***. MELD-Na: ***. Potential precipitants of decompensation: ***. ## Hepatic Encephalopathy - Lactulose 25mL q2-3h until BM, then titrate to 3-4 BM/d. (Lactulose + Rifaximin 550 mg BID better than lactulose alone for HE reversal and all-cause mortality) ## Variceal bleeding - Baseline EGD performed? - Management: IV access, transfusions PRN, octreotide gtt, PPI, CTX x 5 days, and EGD; in refractory cases consider TIPS - Secondary prophylaxis: Propranolol with goal HR 50-60s AND Serial EVL until obliteration & then re-assessment every 6-12 months ## Ascites/volume overload - Management: 2g Na restriction, Start with 100mg/day spironolactone + 40mg/day furosemide (titrate every 3-5 days as tolerated, max doses: 400mg spironolactone, 160mg furosemide) - Therapeutic Paracentesis PRN, If >4L ascites removed, then transfuse 6-8g albumin for every 1L ascites removed - D/C Beta-Blocker as no longer beneficial once in decompensated state ## Spontaneous bacterial peritonitis (SBP) Must rule out SBP in ALL inpatients with cirrhotic ascites - Workup: Diagnostic Paracentesis with fluid sent for Cell count with Diff, Gram Stain, Culture, Glucose, Protein, - Diagnosis: >250 PMNs, regardless of GS/Cx - Treatment: Ceftriaxone x 5 days; 25% Albumin (1.5 g/kg day 1 & 1.0 g/kg day 3, max 100 g); d/c Beta-Blocker - Prophylaxis: Cipro 500mg qday ## HCC Screening: AFP + US/CT/MRI every 6 months; last *** ## Transplant candidacy: *** ## Healthcare maintenance: - Vaccinations: Pneumovax, Influenza, HAV, HBV - Alcohol abstinence - Avoid NSAIDs, limit APAP <2g/daily, avoid raw oysters/shellfish # Demand Ischemia / Type 2 MI Positive troponin without clinical history or EKG suggestive of acute coronary syndrome. Demand ischemia most likely secondary to ***. Common alternative etiologies include LVH, pericarditis, myocarditis, drug toxicity, trauma, and PE. - Trend to peak PRN - EKG # Major Depressive Episode, new The patient meets criteria for a depressive episode based on PHQ9 of ***. Denies SI, HI, AVH. No personal history of panic attacks, PTSD or manic episodes, significant famhx of bipolar, and no psychotic features. Dx: - TSH, CBC, BMP, HIV, HCV. Consider Utox, LFTs, HgbA1C, RPR - Psychotherapy referral for CBT and/or supportive therapy - Aerobic exercise 30m qd x 5 days/week - Biofeedback, yoga, meditation Tx: - Meds: - f/u 4 weeks # Depression; Major Depressive Episode, new The patient meets criteria for a depressive episode based on PHQ9 of ***. ***Denies suicidal or homicidal ideation. Functional impairment manifested by ***. No personal history of panic attacks, PTSD or manic episodes, significant famhx of bipolar, and no psychotic features. Given new onset, consider secondary causes including cardiac disease, neoplasm (especially oropharyngeal and pancreatic), neurologic disease (including stroke and movement disorders), anemia, diabetes, hypothyroidism, chronic infection (including HIV and HCV), medications (eg, AEDs, steroids, BZDs, BBs, others), and substance use (eg, alcohol, any illicits). Dx: - TSH, CBC, BMP, HIV, HCV - consider Utox, LFTs, HgbA1C, RPR - defer addn’l cardiac and neoplastic testing for now - psychiatry referral for suicidality, thought d/o, unclear dx, psychotic features, bipolar, refractory to multiple antidepressants Non-Pharm Tx: - psychotherapy referral for CBT and/or supportive therapy - light therapy (light box vs glasses on Amazon), gradually incresase to 30-45m qd - aerobic exercise 30m qd x 5 days/week - biofeedback, yoga, meditation Pharm Tx: (uptitrate qweekly to qmonthly as tolerated; slow taper off 6-9 months post-remission) - Medication shared decision making aid: https://depressiondecisionaid.mayoclinic.org/ - start SSRI [escitalopram 5mg qd, then increase to 10-20 mg qd as tolerated] [sertraline (more stimulating, more diarrhea) start 50mg qd, uptitrate by 25-50mg qweekly as tolerated to 200mg qd max] -- if comorbid panic attacks or inability to tolerate low dose SSRIs, can start with liquid formulation of eg escitalopram 1mg qd and increase by 1mg weekly - consider starting other classes of meds instead in special circumstances: -- consider SNRI (esp duloxetine start 30mg qd -> 60-120mg qd max) if chronic pain -- consider TCA eg nortryptyline (25mg->50-150mg qd) if chronic pain/migraine or amitriptyline (25mg->100-300mg qd) if significant insomnia (caution: TCA lethal in OD) -- consider buproprion (start 150mg qd -> max 450mg) if desire to avoid weight gain or sexual side effects, or for smoking cessation; (CI: h/o seizures or anxiety) -- especially if pt naturally inclined, consider adding trial EPA 2g/day and/or SAMe up to 800mg BID (for SAMe, theoretical risk of serotonin syndrome if also taking serotonergic meds) Resistant/refractory Tx: (unresponsive to 2 therapeutic doses of antidepressant meds) - trial AD from another class and augment with CBT - refer to psychiatry - reassess organic causes, treat SUD/personality disorder/hx trauma - augment with buproprion/mirtaz or atypical antipsychotic (eg aripiprazole) - augment with T3, transcranial magnetic stimulation - consider referral for psychadelic assisted psychotherapy (ketamine is legal, MDMA/psilocybin as part of clinical trials) - consider electroconvulsive therapy - f/u 4 weeks # Depression; Major depressive disorder, recurrent Diagnosed ***year. Has comorbid ***anxiety but no prior manic episodes, suicide attempts or psychosis. Workup for secondary causes unrevealing and denies ongoing substance use. Previous medication trials have included: (med, max dose, duration, response, limiting side effects). Max PHQ9 of *** on ***. Most recent PHQ9 of *** on ***. Plan for today: ***. - follows with ***therapist, ***psychiatrist (refer if suicidality, thought d/o, unclear dx, psychotic features, bipolar, refractory to multiple antidepressants) Non-Pharm Tx: - psychotherapy referral for CBT and/or supportive therapy - light therapy (light box vs glasses on Amazon), gradually incresase to 30-45m qd - aerobic exercise 30m qd x 5 days/week - biofeedback, yoga, meditation Pharm Tx: (uptitrate qweekly to qmonthly as tolerated; slow taper off 6-9 months post-remission or continue lifelong if >2 episodes of depression) - start previously effective medication or if none, review medication shared decision making aid: https://depressiondecisionaid.mayoclinic.org/ - start SSRI [escitalopram 5mg qd, then increase to 10-20 mg qd as tolerated] [sertraline (more stimulating, more diarrhea) start 50mg qd, uptitrate by 25-50mg qweekly as tolerated to 200mg qd max] -- if comorbid panic attacks or inability to tolerate low dose SSRIs, can start with liquid formulation of eg escitalopram 1mg qd and increase by 1mg weekly - consider starting other classes of meds instead in special circumstances: -- consider SNRI (esp duloxetine start 30mg qd -> 60-120mg qd max) if chronic pain -- consider TCA eg nortryptyline (25mg->50-150mg qd) if chronic pain/migraine or amitriptyline (25mg->100-300mg qd) if significant insomnia (caution: TCA lethal in OD) -- consider buproprion (start 150mg qd -> max 450mg) if desire to avoid weight gain or sexual side effects, or for smoking cessation; (CI: h/o seizures or anxiety) -- especially if pt naturally inclined, consider adding trial EPA 2g/day and/or SAMe up to 800mg BID (for SAMe, theoretical risk of serotonin syndrome if also taking serotonergic meds) Resistant/refractory Tx: (unresponsive to 2 therapeutic doses of antidepressant meds) - trial AD from another class and augment with CBT - refer to psychiatry - reassess organic causes, treat SUD/personality disorder/hx trauma - augment with buproprion/mirtaz or atypical antipsychotic (eg aripiprazole) - augment with T3, transcranial magnetic stimulation - consider referral for psychadelic assisted psychotherapy (ketamine is legal, MDMA/psilocybin as part of clinical trials) - consider electroconvulsive therapy - f/u 4 weeks # Diabetic Ketoacidosis Patient presents with malaise, polydipsea and polyuria, found to have significant hyperglycemia. pH ***, AG ***, BHB ***, UA with Ketones. Last A1c ***. Suspect trigger is ***. No history of heart failure or evidence of volume overload. Dx - tele/CPO - CBC, CMP, VBG, BHB, UA, Utox - CXR, BCx x2 - q1-2hr Na, K, glucose checks per DKA protocol - Troponin if chest discomfort - A1c Tx - DKA protocol, s/p 10u IV regular (0.1U/kg), then insulin gtt - IVF: *** (LR preferred; 1L/hr x 4h; 250-500cc/hr x 4h; 100-250cc/hr) - Hold insulin for K<3.3 # Diabetic Ketoacidosis Patient presents with malaise, polydipsea and polyuria, found to have significant hyperglycemia. pH ***, AG ***, BHB ***, UA with Ketones. Last A1c ***. Suspect trigger ***med inadherence, as pt without infectious symptoms and low concern for stroke or MI. No history of heart failure or evidence of volume overload. Dx - tele/CPO - ICU for pH<7.1, access issues, hypotension, oliguria, AMS - CBC, CMP, VBG, BHB, UA, Utox - CXR, BCx x2 - q1-2hr Na, K, glucose checks per DKA protocol - Troponin if chest discomfort - A1c Tx - Access: *** - hold insulin for K<3.3; supplement 20-30mEq/1L IVF for K 3.3-5.3) - DKA protocol, s/p 10u IV regular (0.1U/kg), then insulin 5u/hr gtt - NaHCO3 for pH<7 - IVF: *** (LR preferred; 1L/hr x 4h; 250-500cc/hr x 4h; 100-250cc/hr) - Holding Home insulin regimen: *** # Disseminated Intravascular Coagulation (DIC) Concern for DIC given ***, most likely due to ***. Common etiologies include sepsis, malignancy (APML, mucinous adenocarcinoma (GI), prostate), tumor lysis, liver dysfunction, drugs, trauma, pancreatitis, and obstetric. - Trend CBC, INR, LDH, Fibrinogen, Ddimer - Tbili/Dbili, Smear, iron panel # Dysphagia Patient reports progressive dysphagia characterized by ***. Oropharyngeal ddx includes neuromuscular (CVA, dementia, ALS, myelopathy), mass (malignancy, Zenker, web), and other (infection, xerostomia, medications, radiation). Esophageal ddx includes dysmotility (achalasia, DES, scleroderma, Chagas, neuromuscular disease), internal obstruction (malignancy, stricture, web, rings) and external compression. - NPO - Endoscopic evaluation/imaging per clinical scenario # End Stage Renal Disease (ESRD) Hemodialysis vs. Peritoneal dialysis, Treatment location and schedule, Date of last dialysis: *** Access HD: (fistula, graft, catheter) or ...PD: catheter fistula - native vein or artery graft - artificial conduit connecting native vein and artery catheter - temporary (vascath) or tunneled/permanent (permacath) - consult IR if weak thrill or pulsatility (stenosis) - patient making urine? - assess volume status, oxygen, BP - potassium - pH Routine Management: - No BP or labs in access arm (No PICC or IVs or subclavian lines in the nondominant arm of CKD 4-5 pt's) - renal diet (low K and phos) - dose meds appropriately - No maintenance IVF -be very cautious repleting electrolytes - HTN - goal Hb 9.5-11, check iron stores, consider ESA as out pt - Bone mineral disease (phos binder with meals, hold if NPO. calcium binders (Ca carbonate vs sevelamer or lanthanum) // Contrast Considerations: // - if pt still makes urine avoid iodinated contrast. If used, maintain dialysis schedule. - Avoid gadolinium if GFR＜30 (risk of nephrogenic systemic fibrosis), if needed in life-threatening situtaion, dialyze immediately after GAD. // Contrast Nephropathy: // - High risk: diabetics, proteinuria, AKI, CKD4-5, heart / liver failure, dehydration. Pretreatement: - hold diuretics, - hold RAAS inhibitor if new med (ok if chronic med and renal fxn at baseline) - hydrate, NS or NaB (sodium bicarb 150mEq in 1L). infuse 3cc/kg for 1 hour prior to contrast, 1cc/kg for 6 hours after contrast - consider Mucomyst 1300mg bid, two doses before and after contrast - supportive care and avoidance of additional injury if contrast injury manifests 12-48 hrs after administration of contrast # Epidural Hematoma Pt presents with ***, found to have epidural hematoma (likely traumatic arterial injury). GCS on admission ***. Clinically stable, small volume EDH (<15 mm clot thickness and <5 mm midline shift) may be monitored with serial imaging, while patients with focal neurologic deficits or EDH >30 mL should be managed surgically. - NCHCT with q6hr repeat - Neuro monitoring - AC Reversal if safe to do so - LP, steroids contraindicated # Extubation Criteria [ ] FIO2 <= 0.5, PEEP <=10 [ ] RSBI <=105 [ ] Treatment of underlying disease [ ] Spontaneous breathing, cough, gag, minimal sputum [ ] Following commands # Extubation checklist [ ] Is the patient ready for an SBT? Required criteria [ ] Cause of respiratory failure/intubation is treated and improving [ ] Adequate oxygenationPO2>=60 on FiO2 <=0.5 [ ] PEEP <=10 [ ] P/F >=150 (>=120 for patients with chronic hypoxemia) [ ] Adequate ventilationNo significant respiratory acidosis [ ] Patient-initiated inspiratory effort [ ] Hemodynamic stability without active cardiac ischemia [ ] HR <=140 [ ] Stable BP and at most moderate dose of 1 pressor [ ] pH>=7.25 Optional Additional criteria [ ] Adequate mentation: arousable, GCS>=8-13 [ ] Afebrile T<=38-38.5 [ ] Hb>8-10 g/dL [ ] No general anesthesia planned in next 24 hours [ ] Should not be on paralytics, have an open abdomen or undergoing therapeutic hypothermia // Did the patient PASS their SBT? // - Best validated measurement of predicting successful extubation: - Rapid shallow breathing index (RSBI) = RR/TV in mlPS 10-12cm, PEEP<=8, FiO2<=0.6 for 30-120 mins - 80% of patients with RSBI<=105 are successfully extubated // Other predictors of successful extubation // Ventilator numbers [ ] RR<=30 [ ] TV>=5 ml/kg [ ] MV<=15 L/min [ ] Negative maximal inspiratory force (MIF or NIF) <=-20 to -30cm H20 Patient characteristics [ ] Strong cough [ ] Scant secretions [ ] Adequate mentation: Opens eyes, tracks (aware and alert) [ ] Sticks out tongue (higher cortical function) [ ] Lifts head off of bed (sufficient strength) // Did the patient FAIL their SBT? // Objective criteria [ ] RR>=30 or RR changes >=50% [ ] Inadequate gas exchange: PaO2 <=60 or O2 sat <=85-90% [ ] Increase in PaCO2 >=10 mmhg [ ] Hemodynamic instability: HR change >20% [ ] SBP >=180, DBP>90 or BP change >=20% Subjective criteria [ ] Change in mentation (ex: anxiety, agitation, somnolence) [ ] Increased work of breathing (ex: diaphoresis, accessory muscles, paradoxical abdominal movement) // Post extubation care // Before extubation, consider the most likely causes of post-extubation failure and develop a post-extubation care plan: [ ] Volume (diuresis) [ ] Mucous (suctioning, pneumonia treatment, acapella, meta-nebs, cough assist) [ ] Atelectasis/collapse (positive pressure [NIVV, EZPAP], IS, meta-nebs, early ambulation) [ ] Bronchospasm (bronchodilators) [ ] Monitor for upper airway obstruction aka post-extubation stridor [ ] Avoid sedation and medication that can cause respiratory depression [ ] Good patient positioning [ ] Non-invasive ventilation (NIVV) -- in patients with high risk of failure, extubate directly to NIVV, don't want for post-extubation respiratory failure [ ] SOAR to RSBI # Fever and Rash Patient presents with new fever and rash, concerning for ***. Common etiologies include infectious (bacterial SSTI, necrotizing fasciitis, endocarditis, viral, disseminated gonorrhea, rickettsia), autoimmune, drug reaction, malignancy, and dermatologic emergencies (toxic shock, SJS/TEN, DRESS, staph scalded). - CBC, CMP, BCx2 - See alternative problem for more specific dx/tx # Fever in a Returning Traveler Patient presents with fever and *** symptoms following travel to *** that began *** days after returning. History notable for ***. First, must determine if this travel is related to travel. If so, consider exposures, timecourse, route of entry, and endemic pathogens. Common atypical organisms include typhoid/paratyphoid fever, EBV, CMV, Rickettsia, Dengue, and malaria. - CBC w/ diff, CMP, Lactate, INR - CXR, UA/UCx, BCx x2, consider HIV - Additional labs and imaging per clinical scenario # Fever of Unknown Origin (FUO) Patient presents with FUO, as defined by 3 weeks of intermittent fevers without diagnosis after inpatient stay or 3 outpatient visits. History notable for ***. FUO ddx includes infectious, autoimmune, malignancy, and other. Dx - Past workup: - CBC w/ diff, CMP, Lactate, INR - HIV, ESR, CRP, ANA, RF, SPEP, EBV, LDH, CK, appropriate TB evaluation - Hep A, B, C, serologies if LFT abnormalities - CXR, UA/UCx, BCx x2 - CT Chest, A/P # GERD Reflux or retrosternal burning sensation worse with eating or when lying flat. DDx: dyspepsia (epigastric discomfort, gas, nausea), esophagitis, stricture, adenocarcinoma Complicatons: barret esophagus, stricutres, esophagitis, adenocarcinoma. Worrisome: bleeding, odynophagia, dysphagia, anorexia, weight loss, and signs of systemic illness, unexplained IDA, should prompt referral. Tx - PPI, lowest effective dose, - long term PPI for barrett's, bleeding ulcer - consider H. pylori testing - consider esophageal pH/impedance monitoring, GERD vs functional syndrome. - Get endoscopy if uncontrolled on BID PPI or if male with > 5y GERD and any two of: age>50; Caucasian; central obesity (waist >102cm); current/former smoker; +FH of Barrett's esophagus or esophageal adenocarcinoma. - long term control: limit soda, chocolate, coffee, citrus, onions, tomatos, high-fat, spicy, overeating, EtOH, smoking, medications (antiACh, SSRIs, TCAs, benzo, BB, CCB, NSAIDs, nitrates, sildenafil, bisphosphonates, prostaglandins) # Gross Hematuria Patient presents with gross hematuria without clots. No UTI symptoms and UA not suggestive of infection. Ddx includes inflammation/infection of prostate or bladder, menstruation, kidney stones, malignancy, and glomerular bleeding. - UA with microscopy/Cx, CBC, BMP, Albumin - Consider Upreg to guide imaging - Consider CT Urogram per clinical situation # Headache Most likely ***. Primary headaches include tension, migraine, and cluster. Secondary headache etiologies include but are not limited to tumor, cyst, meningitis, AVM, GCA, cerebral vein thrombosis, and carotic/vertebral artery dissection. If the headache onset after 50, sudden/severe, focal neuro findings, or patients with cancer or HIV, consider imaging. # Heart Failure (HFpEF), Acute on Chronic Diastolic Heart Failure Exacerbation Patient presents with symptoms and evidence of volume overload. Trigger likely ***. Last TTE ***. - Admission weight ***, dry weight ***. - Goal net negative: *** - CBC, CMP, BNP, Lactate - BMP, Mg BID - Strict I/O, daily standing weights, 2L fluid restriction, Na-resticted diet - Inpt med regimen: *** - Home med regimen: *** # Heart Failure (HFrEF), Acute on Chronic Systolic Heart Failure Exacerbation Patient presents with symptoms and evidence of volume overload. Trigger likely ***. Last TTE ***. - Admission weight ***, dry weight ***. - Goal net negative: *** - CBC, CMP, BNP, Lactate - BMP, Mg BID - Strict I/O, daily standing weights, 2L fluid restriction, Na-resticted diet - Inpt med regimen: *** - Home med regimen: *** # Heart Failure, New (unspecified) Patient presents with new symptoms of heart failure and evidence of volume overload. Suspect secondary to ***. Common etiologies include ischemic, infiltrative, structural, endocrine, viral, toxin-mediated, tachycardia, and idiopathic. Admission weight ***, dry weight ***. Dx - Bedside TTE showing *** - Bedside IVC showing *** - BMP, Mg, CBC, troponin, BNP - CXR, EKG - HgbA1C, Lipid panel - TSH, HIV, Ferritin, Utox, UA - Formal TTE, telemetry - Consider left heart cath - Strict I/O, daily standing weights Tx - Goal net negative: *** - Preload: *** - Afterload: *** - Neurohormonal blockade: *** - Na-restricted diet (<3 grams per day), 2L fluid restriction - Replete K>4, Mg>2 # Systolic Heart Failure: Etiology: - Coronary evaluation. - Non-ischemic evaluation. First pass: EtOH/drug hx, TSH, HIV, +/- SPEP/UPEP. 2nd Pass V/Q scan, Cardiac MRI, PET. Volume: -Estimated Dry Weight = -Goal net neg ***L/day -Spot dose Lasix *** IV q6 hours to meet above goal. -Keep K>4, Mg>2 -Daily Standing weights -Strict I/O Inotropic Support: -Indicated for cardiogenic shock or failure to make urine with very high dose diuretic. Hormonal Blockade: -ACE/ARB: -BB: -Aldo: (EF < 30%, NYHF III). -Further Afterload: -Advanced meds: -Valsartan/sacubitril (Entrusto) instead of ACE/ARB, no ACE/ARB x 48 hours, eGFR >30, ?dementia? -Ivabradine (Corlanor): If on goal dose bblocker, NSR only, & HR > 70. DM: -Consider empagliflozin (Jardiance) if eGFR > 45 and A1C > 7 despite metformin Devices: -AICD: Secondary prevention, Primary prevention (Ischemic EF<40%, non-ischemic EF<35%, both s/p optimal medical Rx x 3 months) -CRT: EF < 30% and QRS > 120. Follow up: -Ensure f/u with PCP or cardiology within 10 days of DC -Ensure pt has scale at home and can weigh self daily. If pt gains > 3lbs in 24 hours or >5lbs in 7 days, pt is to double diuretic dose x1 and call MD. -Torsemide (and bumex) PO preferred over lasix for reduction in HF hospitalizations and CV mortality (https://pubmed.ncbi.nlm.nih.gov/30846351/) # Hemoptysis Patient with history of *** presents with hemoptysis, most likely due to ***. Common etiologies include infection (bronchiectasis, PNA, TB, abscess, fungal), malignancy, vascular (PE, AVM), autoimmune (GPA, SLE, Goodpastures), medications and contusion. - Massive hemoptysis is generally defined as ~100-150ml (~half a cup) in 24 hours. - If massive, consider urgent bronchoscopy vs CTA Chest/IR - CBC w/ diff, CMP, ABG, type and cross, INR - CXR, UA with micro - Consider sputum cultures (AFB, isolation per clinical scenario), BNP - CPO # Hypercalcemia Patient with new significant hypercalcemia, likely due to ***. If PTH elevated, ddx includes primary/tertiary hyperparathyroid, FHH, and lithium. If PTH low (consider ordering PTHrP, 25D and 1,25D), ddx includes malignancy, Vitamin D toxicity, granulomatous disease, Drugs, Milk alkali, Thyrotoxicosis, and Immobilization. - Corrected Calcium = Measured + (4-albumin) - CBC, CMP, Albumin - s/p *** L IVF. If refractory, consider furosemide, calcitonin, and bisphosphonates # Hypercarbic Respiratory Failure Elevated PaCO2 with acidosis concerning for hypercarbic respiratory failure. Most likely secondary to ***. Common etiologies include obstructive lung physiology, pulmonary edema, effusions, and central or mechanical hypoventilation. Bilevel ventilation indications include COPD with pH <7.3, cardiogenic pulmonary edema, neuromuscular disease, and pneumonia in an immunocompromised host. - CPO, Telemetry, RT assessment - CBC, CMP, Lactate, ABG/VBG - CXR # Hyperferritinemia Nonspecific measure of inflammation, with common etiologies including infection, autoimmune, malignancy, renal failure, and liver failure. Extreme hyperferritinemia (greater than 5x upper limit of normal) still nonspecific, but warrants considering Stills, HLH, infection in immunocompromised host (e.g., crypto, histo), and hemochromatosis. # Hyperkalemia Hyperkalemia likely due to ***. Etiology related to decreased K excretion include CKD, adrenal insufficiency, RTA T4 and meds (e.g., K sparing diuretics, ACEi/ARB, NSAIDS, Bactrim, Heparin). Etiology related to increased K production include tumor lysis syndrome, hemolysis and rhabdomyolysis. - Albuterol, furosemide, insulin with glucose, kayexalate PRN - EKG, Calcium/Bicarb PRN per severity # HLD Likely primarily secondary to diet, lifestyle, weight, and/or genetics. No known secondary etiologies including hypothyroid, DM, nephrotic syndrome, CKD, EtOH, liver disease, meds (OCPs, steroids, antipsychotics, thiazides, BB). ASCVD 10 year risk *** # HLD Mainly hyperLDL, hyperTG. Likely primary 2/2 diet, lifestyle, weight, genetics. No known secondary etiologies including hypothyroid, DM, nephrotic syndrome, CKD, EtOH, liver disease, meds (OCPs, steroids, antipsychotics, thiazides, BB). No known prior ASCVD. ASCVD 10 year risk *** (https://statindecisionaid.mayoclinic.org/). Likely underestimate given risk enhancers including family history early CAD, CKD, metabolic syndrome, inflammatory disease, south Asian ancestry, TG>175. - consider TSH, BUN/Cr, UA, A1c, Crp; consider baseline LFTs/CK if starting statin (no need for routine monitoring subsequently) - if famhx early CAD, borderline/intermediate risk (5-20%), or equivocation about statin consider coronary calcium CT ($150 out of pocket, may be covered by insurance; CAC of 0 = no benefit from statin) - consider statin if risk>7.5%; strongly encourage if >20% -- moderate vs high dose per: https://tools.acc.org/ASCVD-Risk-Estimator-Plus/assets/graphics/new-primary-prevention.svg -- rosuvastatin 10-20mg; atorva 20-80mg (both now generic; QHS may be best) -- note myalgias are equally common in placebo vs statin groups; statin intolerance extremely rare -- associated with 10% increased risk of new DM (NNH 100); memory loss may be rare side effect of lipophilic (eg atorva) but not hydrophilic (eg rosuva) - consider EPA fish oil (OTC vs vascepa) 2g BID for 20-50% TG reduction and 25% MACE reduction - consider aspirin 80-100mg if ASCVD risk >10% and no increased bleeding risk -- https://aspirinbenefitharmcalculator.shinyapps.io/calculator/ - note: niacin, fibrates no ASCVD reduction; ezetimibe has clinically insignificant effect - start fenofibrate for TG persistently >885; for <885 maximize statin and EPA; if fasting TG>500, reduce dietary fat to <20g/day - avoid NSAIDs (a/w 42% increase in CV death) - encourage concomitant lifestyle interventions -- aerobic exercise 30mins 3-4x/wk; wt loss 2%->6% decrease LDL -- more whole foods including veg/fruits, complex carbs -- less saturated and trans fats but no restriction on dietary cholesterol -- quit smoking (up to 40% risk reduction) -- avoid EtOH (esp if high TG) - recheck lipids 3 months after regimen changes then q1-3 years when on stable regimen (or more often for adherence) Risk scores using CAC: - https://www.mesa-nhlbi.org/MESACHDRisk/MesaRiskScore/RiskScore.aspx - http://astrocharm.org/calculator-working/ Statin decision aid: - https://statindecisionaid.mayoclinic.org/ # Hypernatremia Likely due to decreased PO intake. Ddx also includes excessive sweating, diarrhea, diuretics, diabetes insipidus, hyperaldosteronism, and Lithium. #Hypertension, new, uncontrolled Confirmed based on two appropriately measured readings >2 weeks apart. Goal BP ***. ASCVD risk ***. - Initial workup: CBC, BMP, LFTs, lipids, TSH, UA, A1c, EKG - Diet and lifestyle modifications: - Meds: # Hypertension, new, uncontrolled Confirmed based on two appropriately measured readings >2 weeks apart. Stage 1 (130-139/80-89) vs Stage 2 (140+/90+). Goal (ACC, 2017) <130/80 especially if ASCVD (or risk>10%), CKD, DM [goal <140/80 if labile HTN, side effects, age >75 with many cormorbidities or DBP<55] [goal individualized if frail or limited life expectancy]. ASCVD risk ***. - initial workup: CBC, BMP, LFTs, lipids, TSH, UA, A1c, EKG; if DM/CKD, add urine albumin/creatinine. - low threshold for ambulatory 24h monitor for episodic, resistant or white coat HTN - reviewed consequences of untreated HTN (eg, 10mm decrease--> decrease of 20% MACE, 28% HF, 13% mortality) - encouraged lifestyle modifications: -- weight loss: 1mmHg/kg -- decrease EtOH 1(F) or 2(M)/day: 4mm -- reduce sodium to <2.4g: 2-8mm -- DASH diet: 6mm alone; 14mm if combined with low sodium -- aerobic exercise 30mins/day: 4-9mm - given Stage 2 HTN and/or patient preference, will also start first line pharmacologic therapy: -- amlodipine 2.5mg qd -- chlorthalidone 12.5mg qd (mortality benefit vs HCTZ; thiazides effective even in CKD4) -- ACE/ARB -- note: metaanalyses show decreased side effect profile with multiple low dose (eg 1/4 of max dose) antihypertensives compared to single agents at full doses; thiazide and ACE/ARB can balance K -- consider spironolactone/eplereonone as 4th line or if hypoK -- no BBs indicated unless symptomatic CAD or HRrEF (then choose metoprolol succinate or carvedilol) - pt advised to buy home upper arm-cuff BP monitor to bring to next visit for calibration and teaching - defer workup for secondary hypertension - decision aids: -- https://www.healthwise.net/ohridecisionaid/Content/StdDocument.aspx?DOCHWID=zx1768 -- https://www.healthdecision.org/tool#/tool/hypertension -- https://statindecisionaid.mayoclinic.org/index.php/statin/index # Hypertension; suspected secondary Will pursue workup for secondary HTN, with most common etiologies being OSA, renal artery stenosis, hyperaldo, CKD, illicits, and endocrinopathies - 24 hr ambulatory BP monitor for baseline - TSH, UTox, BMP, Renin/Aldo - Second pass workup: consider sleep study, 24hr urine free cortisol, 24hr catecholeamines and metanephrins, Renal artery doppler - Med review for OCPs, NSAIDs, SNRIs, stimulants, VEGFi/TKIs # Hypertension (Resistant); Concern for secondary hypertension This patient has indication for a secondary hypertension work-up (age < 30 in a non-obese, non-black patient with no family Hx; resistant hypertension defined as persistent HTN on >= 3 hypertensives at adequate doses or 4 at 50% doses, at least one of which is a diuretic; malignant hypertension w/ end-organ damage; or proven age of onset before puberty). Most common etiologies are OSA (60-70%), hyperaldo (7-20%), RAS (2-24%), meds/illicits (2-24%), CKD (1-2%), endocrine (1%). - TSH, UTox, Scr for CKD - medication review for OCPs, NSAIDs, SNRIs, stimulants, VEGFi/TKIs - 24 hr ambulatory BP monitor for baseline - sleep study (if obese, snoring, daytime somnolence, headaches, fatigue) - renin/aldosterone (consider oral sodium suppression test if negative) - 24 hr urine free cortisol (only if facies, obesity, bruising, muscle weakness, or adrenal incidentaloma) - renal artery dopplers (only if patient might be a surgical candidate: flash pulmonary edema, refractory heart failure with unexplained impaired kidney function, short duration of BP elevation, intolerance to optimal medical therapy) and something to suggest RAS (> 50% Cr bump after RAAS inhibition, unexplained kidney asymmetry, abdominal bruit) - consider 24 hr urine catecholeamines and metanephrins (prefer over plasma fractionated metanephrines given high false positive rate if not measured supine via indwelling cannula after 30 minutes of supine rest) - consider referral to cardiology/renal # Hypocalcemia Likely due to ***. Ddx also includes hypoparathyroidism, hyperphosphatemia, massive transfusions (citrate toxicity), secondary hyperparathyroidism, Vitamin D deficiency, pseudohypoparathyroidism. # Hypoxemic Respiratory Failure Patient with persistently low O2 saturation or PaO2<60 on room air. Most likely secondary to ***. Common etiologies include aspiration, PE, PTX, PNA. Lower suspicion for ARDS, shunting, hypoventilation, TACO/TRALI, pulmonary edema, ILD, alveolar hemorrhage or pulmonary contusion. - CPO, Telemetry, RT assessment PRN - CXR, Cross-sectional chest imaging PRN - CBC, CMP, ABG #ICU Bundle - Code Status: - ICU indication: - GI ppx: - DVT ppx: - Lines: - Tubes, Drains, Foley: - Last contact update: # ICU Bundle Ventilator ? Spontaneous Awakening Trial (SAT) = turn off sedation ? Spontaneous Breathing Trial (SBT) = Place patient on Pressure Support 5/5 - Perform SAT & SBT concurrently if able - Contraindications to SAT/SBT include FiO2 > 50%, PEEP > 8, O2 sat < 90%, pH < 7.30, SBP < 90 or MAP < 60, paralysis, intracranial pressure >15, concern for significant bleeding ? If ARDS: goal Vt 4-6 cc/kg of ideal body weight (calculated by height), plateau pressure < 30 ? Head of bed at >30 degrees ? Oral care is ordered Sedation / Delirium ? Ask: Is patient delirious (CAM+)? ? Review med list for any deliriogenic medications and discontinue/change where possible ? Define RASS goal ? Record QTc daily, consider changing medications if QTc > 500 Restraints ? Ask: Are restraints needed? ? Sign necessary restraint orders ? Discuss barriers to removing restraint orders Mobility ? Consult PT for early mobility - Contraindications include: deep sedation, paralysis Pressure Ulcers ? Ask: Are pressure ulcers present? Is a wound care consult needed? ? Discuss whether any changes are needed to ulcer management plan DVT prophylaxis ? Review patient’s current DVT prophylaxis orders and adjust if needed - Contraindications to LMWH DVT ppx include AKI (switch to UFH TID), clinically significant bleeding (hold pharmacologic), platelet count < 30K (hold pharmacologic) - Add sequential compression boots if holding pharmacologic prophylaxis GI / Nutrition ? Famotidine 20mg IV BID in intubated patients; Pantoprazole 20-40mg IV daily if history of GERD or GI bleed ? Review nutrition, consult nutrition if not already done. While awaiting nutrition input, start enteral nutrition: - In most patients, Osmolite 1.5 @10mL/hr, advance by 20mL Q6h to goal 50mL/hr - If renal failure and high K or phos: Nepro @ 10mL/hr, advance by 10mL Q6h to goal 40mL/hr - MVI with minerals daily - thiamine 100mg daily x3 days - folate 1mg daily x 3 days ? Ask: Is bowel regimen adequate? Make changes if necessary. ? Review glucose range over past 48h and insulin regimen, adjust regimen if needed. - Goal glucose range is 70-180 Tubes / Lines / Drains ? List all tubes / lines / drains and discuss if any can be removed or should be changed Patient / Family Communication ? Discuss if patient has healthcare making capacity - if not, activate healthcare proxy ? Update families by phone - Suggest RN update at least daily - MD update Q3 days, with any significant clinical change, or per family request Disposition ? Discuss anticipated dispo, barriers to dispo Code Status ? Review current code status, discuss if goals of care are realistic with prognosis - if not, discuss with patient / family Abbreviations: SAT = Spontaneous Awakening Trial SBT = Spontaneous Breathing Trial CAM = Confusion Assessment Method RASS = Richmond Agitation and Sedation Scale # Inflammatory Arthritis (generic) Patient presents with inflammatory arthritis (warm, swollen joints that are worse in morning, improve with use), with additive***migratory pattern. Common etiologies based on distribution include: - Monoarticular arthritis - Bacterial, Crystalline - Oligoarticular arthritis - Spondyloarthropathies, gonococcal, Lyme - Polyarticular arthritis - Viral, RA, SLE, Psoriatic # Inflammatory Bowel Disease, Acute on Chronic Flare Patient with known history of inflammatory bowel disease, who presents with likely acute flare characterized by worsening pain and increasing bloody stool frequency. Will rule out infectious etiology prior to proceeding with IV steroids. Dx - Serum: CBC, CMP, Lactate, ESR, CRP, INR, Full Iron panel, Prealbumin, Vitamin D level - Stool: Cdiff, Bacterial assay/culture, fecal calprotectin. Consider O&P per clinical scenario - Consider CT A/P if concern for extraluminal complications or acute abdominal findings - Appreciate RN staff recording timing and quality (?bloody) of stools to assess response to therapy Tx - s/p *** L IVF - IV steroids per GI pending stool studies - DVT ppx - NPO midnight on day of admission - Minimize opioid use as possible, tramadol preferred # Interstitial Lung Disease (ILD) Patient presents with progressive dyspnea concerning for new diagnosis of interstitial lung disease. ILD can have known etiologies (exposures, drugs, connective tissue disease, eosinophilic PNA, amyloid, sarcoid) or unknown etiologies known as idiopathic interstitial pneumonia (IPF and non-IPF (NSIP, COP, AIP, LIP)). # Involuntary Weight Loss Involuntary weight loss (IWL) is typically defined as a loss of weight >10 lbs or >5% of one’s body weight over a period of 6-12 months. The differential diagnosis for IWL is wide, and includes neoplastic and psychiatric causes, as well as diseases in nearly every organ system. Notably, exhaustive investigation will not yield a definitive diagnosis in up to a quarter of patients. -- History, physical, MMSE, nutritional assessment, ADL/IADL assessment, medication review -- Age appropriate cancer screening -- CBC with diff, CMP, TFT, ESR, CRP, Ferritin, HIV testing -- Nutrition referral # Leukocytosis Likely due to ***. Common etiologies include infection/sepsis, stress demargination, and steroids, with less common etiologies including systemic inflammation, medications, smoking, malignancy, asplenia, and congenital/genetic disorders. - Trend CBC with diff # Low Back Pain, Non-Radicular, Acute Likely lumbar muscle strain (70% of cases) vs DJD (10%), no hx/exam features of radiculopathy. Conservative management given no red flags (specifically no trauma, steroid use, malignancy, IVDU, constitutional sx, GI/GU sx) and normal neuro exam - Consider NSAIDs, APAP for 7-14 days per clinical scenario - Activity as tolerated, Avoid bedrest - Complementary therapies: heat/cold x 10-20 mins QID, yoga, acupuncture, chiropractic, aquatherapy, massage - PT if not improving in 4-6 weeks or now if severe pain/disability - RTC for any increased pain or new symptoms. # Lumbar Radiculopathy, Acute Most likely lumbar radiculopathy in the setting of ***. Will pursue conservative management given no red flags (specifically no trauma, steroid use, malignancy, IVDU, constitutional sx, GI/GU sx) and otherwise normal neuro exam. - Consider NSAIDs, APAP for 7-14 days per clinical scenario - Activity as tolerated, Avoid bedrest - Complementary therapies: heat/cold x 10-20 mins QID, yoga, acupuncture, chiropractic, aquatherapy, massage - PT if not improving in 4-6 weeks or now if severe pain/disability - RTC for any increased pain or new symptoms. # Lumbar Radiculopathy, Acute Most likely given radiation below knee in dermatomal distribution, positive SLR, worse with coughing/straining. Likely [L4 given weak ankle dorsiflexion/inversion, decreased patellar reflex, pain/numbness of medial ankle/foot] [L5 given weakness of EHL/1st toe extension, decreased medial hamstring reflex, pain/numbness dorsal surface of foot] [S1 given weakness ankle plantarflexion/eversion, decreased achilles reflex, pain/numbness lateral foot/leg]. Note: L4/L5 compresses L5 root. Conservative management given no red flags (specifically no h/o trauma, steroid use, malignancy, IVDU, constitutional sx, GI/GU sx) and otherwise normal neuro exam (no saddle anesthesia, midline spinal TTP or weakness). Dx: - consider MRI if muscle weakness (not 2/2 pain, with maximal effort) or no improvement in 4-6 weeks - for subacute, consider EMG/NCS if MRI unrevealing Non-pharmacologic: - activity as tolerated, avoid bedrest - complementary therapies: heat/cold x 10-20 mins QID, yoga, acupuncture, chiropractic, aquatherapy, massage, "The Back Book" - good lifting technique, sleep flat w/ pillow under knees, tempurpedic mattress - PT if not improving in 4-6 weeks or now if severe pain/disability Pharmacologic: - NSAIDs x 7-14 days: Naproxen 500 mg BID (add PPI if prior GI sx; consider replacing with nabumetone if CKD1-2; no NSAIDs if CKD3-4) -- discussed GI symptoms to be watchful for - APAP up to 3g/day if helpful (Cochrane: same as placebo https://www.cochrane.org/CD012230/BACK_paracetamol-low-back-pain) - cyclobenzaprine/baclofen PO PRN, voltaren gel PRN (lidocaine not usually helpful) - RTC for any increased pain or new symptoms. # Low Back Pain, Non-Radicular, Acute Likely lumbar muscle strain (70% of cases) vs DJD (10%), no hx/exam features of radiculopathy. Conservative management given no red flags (specifically no h/o trauma, steroid use, malignancy, IVDU, constitutional sx, GI/GU sx) and normal neuro exam (no saddle anesthesia, midline spinal TTP or weakness). Non-pharmacologic: - activity as tolerated, avoid bedrest - complementary therapies: heat/cold x 10-20 mins QID, yoga, acupuncture, chiropractic, aquatherapy, massage, "The Back Book" - good lifting technique, sleep flat w/ pillow under knees, tempurpedic mattress - PT if not improving in 4-6 weeks or now if severe pain/disability Pharmacologic: - NSAIDs x 7-14 days: Naproxen 500 mg BID (add PPI if prior GI sx; consider replacing with nabumetone if CKD1-2; no NSAIDs if CKD3-4) -- discussed GI symptoms to be watchful for - APAP up to 3g/day if helpful (Cochrane: same as placebo https://www.cochrane.org/CD012230/BACK_paracetamol-low-back-pain) - cyclobenzaprine/baclofen PO PRN, voltaren gel PRN (lidocaine not usually helpful) - RTC for any increased pain or new symptoms. # Low Back Pain, Chronic Etiology likely DDD/OA (10%), disk herniation/radiculopathy (4%), spinal stenosis (3%), ankylosing spondylitis (<1%). Therapies tried include ***. Given significant functional impairment, will emphasize a multimodal approach to manage pain, increase function, and maximize coping skills. Dx: - if not done previously, lumbar MRI w/o contrast - if c/f AS (inflammatory pattern, <45yo), get lumbar/SI XR and/or MRI Non-pharm tx: - PT for supervised exercise therapy - weight loss, smoking cessation - Movement-based therapy with mind-body component such as Tai-chi or Yoga - if available, pain psychology referral for cognitive behavioral therapy and mind-body interventions (mindfulness-based stress reduction, biofeedback, and progressive relaxation) Pharm tx: - NSAIDs PRN (not RTC) - start duloxetine 30mg qd x 1 week then increase to 60mg qd; consider TCA instead if comorbid insomnia - cyclobenzaprine/baclofen PO PRN, voltaren gel PRN (lidocaine not usually helpful) - if above ineffective and still severe functional impairment, reasonable to do a short trial of tramadol (but avoid full opioid agonists) - referral to pain clinic for consideration of epidural steroid injections; if ineffective, can trial RF ablation or surgical referral # Low Back Pain With Red Flags Concern for spinal process +/- cord compression 2/2 *** * recent trauma (major vs minor in elderly/known CA); *malignancy given night pain, supine pain, new urinary symptoms, saddle anesthesia, new weakness, constitutional sx; * infection given fever, neurological deficits, recent instrumentation, h/o HIV or TB, IVDU, recent infection (UTI, SSTI, bacteremia, osteomyelitis, line-associated); * compression fracture given h/o osteporosisis/steroid use/malignancy/elderly and sudden onset after coughing/bending/lifting/minor trauma with point TTP - lumbar XR if concern for compression fracture - MRI L-spine w/o contrast (plus contrast if immunosuppressed or suspicion for cancer or infection) - CBC/diff, ESR/CRP, BCx, AlkPhos, PSA - urgent ortho/neurosurg eval if cauda equina/motor weakness # Lower GI Bleed Patient presents with bright red blood per rectum concerning for lower GI bleed. History and rectal exam notable for ***. DDx includes anatomic (diverticulosis), vascular (angiodysplasia, hemorrhoids, ischemic, post-polypectomy), inflammatory (infectious, IBD, radiation) or neoplastic (polyp, carcinoma), as well as brisk upper GI bleed. Dx - CBC, CMP, INR, Type and screen - Telemetry - GI consult/Endoscopic evaluation per clinical scenario Tx - NPO - 2 large bore IVs - Transfuse to keep hgb >7 - If concern for brisk upper, Protonix 80mg bolus x1, followed by Protonix 40 mg IV BID - Hold antiplatelet agent, anticoagulation, anti-hypertensives - Correct coagulopathy (Goal plt > 50k, INR < 2.0) # Meningitis (Suspected) Patients presents with altered mental status, nuchal rigidity, and fever, concerning for meningitis. Ddx also includes alternative infectious encephalopathy, substance/tox, respiratory/metabolic derangement, endocrinopathy or intracranial mass effect. NCHCT and antibiotics prior to Lumbar Puncture if abnormal consciousness, focal neuro deficits, over 60 y.o., immunocompromised host, history of CNS disease, new onset seizures within 1 week, or papilledema. Dx - CXR, UA/UCx - Serum: CBC, CMP, VBG, Lactate, BCx x2, INR, Utox, TSH, HIV, RPR, - CSF: Protein, Glucose, Bacterial Gram Stain+Cx, Cell count + diff, HSV DNA. Consider VZV IgM+IgG, CrAg, Cocci, Histo, VDRL - Opening pressure: *** - CPO/Tele - NCHCT as above PRN Tx - Droplet precautions if concerned for Neisseria meningitidis - Vanc Ceftriaxone (meningeal dosing) - Add Acyclovir if concern for HSV or encephalitis - Add Ampicillin if >50 y.o. - Dexamethasone 10q4 if suspected Streptococcus pneumoniae # Metabolic Acidosis (Gap) Most likely due to ***. Ddx includes lactate, ketones, ingestions (glycols, oxoproline, methanol, ASA), and renal failure. - Lactate, UA - Consider Tox screen PRN # Metabolic Acidosis (Non-gap) Most likely due to ***. Ddx includes GI losses, normal saline, and renal losses (RTA, acetazolamide, CKD, ureteral diversion). Positive urine anion gap (NA+K-Cl) suggests RTA, whereas negative urine anion gap suggests GI losses. - Consider urine lytes per clinical scenario # Metabolic Alkalosis Most likely due to contraction alkalosis, with ddx of saline responsive metabolic alkalosis (UCl <10) including hypovolemia, GI losses, and diuretics. Ddx of saline resistant metabolic alkalosis (UCl>10) including hyperaldosteronism, Cushings, and severe hypokalemia. - Consder UCl prior to fluid challenge # Inflammatory Arthritis (Monoarticular, Concern for Septic) New monoarticular arthritis of *** joint. With*** limited range of motion and severe pain concerning for septic vs crystalline joint. No history of recent infection, RA, prosthetic joint, or IVDU. Sexual history notable for ***. Appreciate orthopedics consult and joint tap. - Serum: CBC, CMP, INR, BCx x2. Consider Uric acid, A1c, HIV, ESR, CRP per clinical scenario - Synovial fluid: CBC diff, Bacterial GS/Cx, crystalline analysis - XR of joint, additional imaging per orthopedics - Empiric abx: Consider Vancomycin Ceftriaxone - Pain control: - NPO # Myocardial Infarction - NSTEMI Patient presents with chest discomfort with concern for NSTE-ACS given troponin elevation and EKG with ***. Dx - GRACE score *** - Trop, EKG, with 4-6hr repeat - CBC, BMP, VBG - CXR - CPO, Telemetry - Consider DDimer, BP in 4 extremities - Consider urgent to emergent cath if with refractory chest pain, new heart failure, new MR murmur, shock, or sustained VT. Tx - s/p ASA 325 mg, Atorvastatin 80 mg - P2Y12 inhibitor per institutional preference - Metoprolol tartrate 12.5 q8h if not in heart failure/shock - ACEi within 24hrs. - Heparin gtt (ACS orderset) - Nitroglycerin 0.4 mg SL q5m x 3 PRN -> Nitroglycerin gtt if refractory - Avoid morphine # Myocardial Infarction - STEMI Patient presented with chest discomfort with concern for STEMI given troponinemia and EKG with ***; now s/p cath lab with ***. - s/p ASA 325, P2Y12, heparin gtt, SL Nitro PRN - CBC, BMP, Lactate, Trop, EKG - CPO, Telemetry - Continue ASA 81 QD, P2Y12 - Atorvastatin 80mg QD - BB and ACEi/ARB within 24 hours # STEMI, Type I NSTEMI, or Unstable Angina Coronary evaluation: -EKG, trop, TTE WMA, Stress, LHC. Antithrombotic: - ASA: Cont. ASA 81mg PO QD x life. - P2Y12:-Clopidogrel (Plavix) load 600mg PO x 1 then 75mg qD (some resistance particular in East Asian and Pacific Islander). - Ticagrelor (Brilinta) load 180mg PO x 1 then 90mg BID (may cause bradycardia and/or SOB). - Prasugrel (Efient, Effient) load 60mg PO x 1 then 10mg PO qD (contraindicated if h/o CVA). - IIb/IIIa: -- Eptifibatide (Integrilin): Can be given “up front” prior to cath. -- Abciximab (ReoPro): Okay in ESRD, can be given only after cath Anticoagulation: - Heparin bolus and gtt. Demand reduction: - Nitrates: (SLNTG, nitro paste, nitro gtt). - BB: (within 24 hours of MI). - ACE/ARB: (within 24 hours of MI). - CCB: (if intolerant to BB). - Pain medication: (Morphine a/w increased mortality in retrospective studies, if possible maximize above and use fentanyl). - Advanced meds: Ranolazine (Renexa) for intractable UA, avoid in renal/liver failure and with long QTC. Antiinflammatory/Antilipid: - Start Atorva 80mg QHS. -If admitted for ACS on high intensity statin and LDL > 50, consider adding Zetia 10mg PO QHS. -If familial hyperlipidemia or cannot tolerate statin, consider PCSK9. -In acute MI, avoid NSAIDs & steroids if at all possible. -Defer screening and management of DM2 and inflammatory dz to PCP. # Myositis Concern for myositis (inflammation) over isolated myopathy (weakness) given ***. Common etiologies include dermatomyositis, polymyositis, rheumatologic overlap syndromes, drug associated, immune mediated, and inclusion body myositis. - CBC, CMP, ESR, CRP, CK - Location specific imaging per clinical scenario - Med list review # Myxedema Crisis Patient with*** history of hypothyroidism who presents with altered mental status, hypothermia, and bradycardia, concerning for myxedema crisis. DDx includes ***. Dx - CBC, CMP, Free T4, TSH, cortisol, lactate - CXR, BCx x2, UA, Utox - Na, Glucose q2-4h PRN - EKG Tx - Following endo consultation, consider T4 200-400mcg IV, T3 5-20mcg IV, and hydrocortisone 100mg q8h IV - Consider empiric antibiotics and fluids if concerned for sepsis - Passive warming, mechanical ventilation, pressors PRN # Necrotizing Fasciitis Patient with fever, severe pain, edema, and erythema of ***, concerning for necrotizing fasciitis. LRINEC *** - Urgent Gen Surg consultation, site-specific imaging - Abx: Vanc Erta Clinda - s/p *** L IVF - CBC, CMP, Lactate, CRP, ESR, BCx x2 - INR, Type and screen - Consider HIV, A1c # Neutropenic Fever Patient who has received cytotoxic antineoplastic therapy presents with neutropenic fever likely due to ***. Dx - CBC with diff, BCx x2 - UA/UCx, CXR - Influenza, viral panel, additional imaging per clinical scenario Tx - Cefepime 2g IV q8h (per renal function) - Consider Vancomycin if suspected catheter-associated infection, SSTI, PNA, or HD unstable. # New Intracranial Lesions (Suspected Metastasis) Patients presents with symptoms of ***, with imaging concern for new metastatic intracranial lesions. Following consultation with NSGY, no current surgical intervention, and future intervention dependent on patient prognosis. Will coordinate care with NSGY, Rad Onc, and Med Onc. Dx - Appreciate NSGY, Rad Onc, and Med Onc consults - MRI w w/o contrast - CT C/A/P for staging - EKG for baseline QTC Tx - Dexamethasone 4mg q6h IV - Q2 hr neuro checks - Zofran PRN - Elevate HOB # Organizing Pneumonia Imaging notable for patchy consolidation concerning for organizing pneumonia. Organizing pneumonias can be unilateral or bilateral, are often peripherally located, and may have small nodules or associated atoll sign (low sensitivity, high specificity). Cryptogenic (primary) organizing pneumonia is characterized by excessive granulation tissue proliferation, and is often treated with steroids. Secondary organizing pneumonia may be associated with meds/drugs, infections, autoimmune conditions, malignancy,mixed cryoglobulinemia, hypersensitivity pneumonitis, CVID, IBD, radiation and transplantation. # Orthostatic Hypotension Most likely secondary to ***. DDx also includes decreased PO intake, age-related baroreceptor dysfunction, primary or secondary autonomic insufficiency, neurodegenerative disease, med effect, and cardiac etiology. - Fluid resuscitation challenge, IVC US - Eval for dysautonomia - A1c, HIV, TSH, RPR, B12 - EKG # Pancytopenia Patient with new pancytopenia likely due to ***. Ddx includes aplastic anemia (meds, tox, viral), infiltrative (malignancy, TB, MAC, Histo), myelodysplastic, nutritional, chronic inflammation, and HLH. - CBC with diff, retic count, smear # Pericardial Effusion w/o Tamponade *** sized pericardial effusion noted on ***, without hypotension, muffled heart sounds, or jugular venous distention. EKG without electrical alternans. Etiologies include idiopathic, acute infectious pericarditis, drug associated, malignancy-related, autoimmune, post-MI, trauma, aortic dissection with extension, and uremia. - Telemetry - Troponin, CBC with differential, CMP, INR - CXR - Cardiology consult PRN # Community Acquired Pneumonia (CAP) Patient reports fever and cough, with CXR showing ***, concerning for CAP. No recent hospitalization or abx exposure. Dx - CBC, BMP, Lactate - Influenza, viral panel, procalcitonin, sputum Cx per clinical scenario - Defer BCx if clinically stable - CPO Tx - CTX Doxy - s/p *** L IVF # Hospital Acquired Pneumonia (HAP) Patient with symptoms of *** and CXR showing ***, ≥48 hours after hospitalization, in the absence of intubation. Past cultures notable for ***. Dx - CBC, BMP, Lactate, sputum Cx, BCx x2, CXR - CPO - Abx: # Ventilator Associated Pneumonia (VAP) Patient with fever, leukocytosis, and increased secretions ≥48 hours after intubations, concerning for VAP. Past cultures notable for ***. Dx - CBC, BMP, Lactate, BAL Cx, BCx x2, CXR - CPO - Abx: MRSA and Pseudomonal coverage # Post-Cardiac Arrest Out of hospital cardiac arrest with PEA***VT/VF noted in field. ROSC achieved after *** rounds of compression. EKG notable for ***. Post-ROSC neuro exam notable for ***. - CBC, CMP, Troponin, Lactate, INR - EKG, CXR, TTE if concern for ACS - CPO, Telemetry, ICU admission - Cath Lab PRN per EKG, Troponin, and/or clinical scenario - Cooling per Neuro PRN # Prepartum ROS Contractions: *** Nausea vomiting: *** Vaginal bleeding: *** Vaginal discharge: *** RUQ or epigastric pain: *** Headaches: *** Swollen legs: *** Breast tenderness: *** # Pulmonary Embolism, Acute (Sub-Segmental) sPESI ***. Pt presents with symptomatic but hemodynamically stable PE without biomarker or imaging findings of right ventricular strain. In these patients, thrombolytics (local or systemic) are not indicated. Unclear trigger, as pt is without past hx suggestive of hypercoagulable state or recent travel. - Anticoagulation: *** - CPO, Tele - Trop, BNP, CBC, BMP, INR - EKG, CT PE - Ensure outpatient age appropriate cancer screening - Consider outpatient hypercoagulability studies, TTE # Pulmonary Embolism, Acute (Sub-Massive) sPESI *** BOVA ***. Pt presents with symptomatic but hemodynamically stable PE with biomarker or imaging findings of right ventricular strain. In these patients, anticoagulation is the mainstay of treatment, although local thrombolytics are rarely indicated. Unclear trigger, as pt is without past hx suggestive of hypercoagulable state or recent travel. - Anticoagulation: *** - CPO, Tele - Trop, BNP, CBC, BMP, INR - EKG, CT PE. Consider TTE - Ensure outpatient age appropriate cancer screening - Consider outpatient hypercoagulability studies - If clinical deterioration, contact IR/PE team regarding thrombolytics vs thrombectomy # Pulmonary Embolism, Acute (Massive) Patient presents with symptomatic and hemodynamically unstable PE (SBP <90 for greater than 15 minutes) with biomarker or imaging findings of right ventricular strain. Contact IR/PE team regarding local vs systemic thrombolytics. Unclear trigger, as pt is without past hx suggestive of hypercoagulable state or recent travel. - Start Heparin gtt vs Enoxaparin while awaiting IR decision - CPO, Tele, ICU - Trop, BNP, CBC, BMP, INR, ABG - EKG, CT PE, TTE - Ensure outpatient age appropriate cancer screening - Consider outpatient hypercoagulability studies # Pulmonary Hypertension (pHTN) Patient with history of pulmonary hypertension. Pre-capillary pHTN is defined as PVR Wood unit>3 or Transpulmonary Pressure gradient (meanPA - PCWP) > 12. Post-capillary pHTN is defined as PCWP >15. T1 - Vascular (idiopathic, HIV, CTD, drugs/toxins, portopulmHTN). Consider Utox, ANA, RF, HIV, Hep serologies T2 - LH Disease. Consider RHC T3 - Chronic Lung Disease/Hypoxemia. Consider High Res CT, sleep study, PFTs, nocturnal and exercise pulse ox T4 - CTEPH. Consider V/Q scan T5 - Misc - Sarcoid, Hematologic disease, congenital/metabolid, thyroid disease. # Pulmonary Nodules Patient noted to have ***new pulmonary nodules. Pulmonary nodules can be random, centrilobular (TB, NTM, aspergillus, hypersensitivity pneumonitis, GPA, sarcoid), perilymphatic (malignancy, sarcoid, amyloidosis), or miliary (TB, Cocci, Histo), with overlap in etiologies between categories. # Rheumatoid Factor Positive RF is a nonspecific biomarker, with ~10% of population >65 y.o being RF+. Other than true rheumatoid arthritis as a cause of RF+, common etiologies include infection (Hep C, osteomyelitis, SBE, HIV, Syphilis), Cryoglobulinemia (~100%), autoimmune/inflammatory (Sjogrens (20-30%), SLE (15-25%), Scleroderma (10-20%), Polymyositis/Dermatomyositis (5-10%), sarcoidosis), IPF and cirrhosis. - CCP if concerned for RA, additiona dx per clinical scenario Copied! # Sepsis Concern for sepsis with suspected *** source. - qSOFA *** (high-risk mortality prediction; positive if ≥2 points for GCS <15, RR ≥22, or SBP ≤100) - Abx: - s/p *** L IVF - CBC, CMP, Lactate, INR - CXR, UA/UCx, BCx x2 - Consider site specific labs and imaging PRN # Septic Shock Concern for septic shock with suspected *** source. History, exam, and data notable for ***. Alternative shock etiologies includes cardiogenic, distributive (non-septic), obstructive, hypovolemic, and neurogenic. Dx - Bedside TTE showing *** - Bedside IVC showing *** - CBC, CMP, Lactate - CXR, UA/UCx, BCx 2 - Telemetry, Strict I/O, Goal MAP >65 - Consider EKG, Troponin, BNP, DDimer/CTPE per clinical scenario Tx - s/p *** L IVF - Empiric abx: *** # Intracerebral Hemorrhage (ICH) Patient with new neuro deficits characterized by ***. Last seen normal at ***. NCHCT noted to have ***. Surgical indications based on site of bleed (e.g., cerebellar w/ diameter >3cm). Dx - NIHSS score ***, GCS *** - INR, CBC, Glucose FS - EKG, Tele, consider TTE Tx - SBP Goal <140 (Nicardipine preferred), outpt SBP goal <130 - Head of the bed to 30 degrees - ICU for q1h neuro checks - SCD # Seronegative Spondyloarthropathy Seronegative (RF neg) spondyloarthropathies include reactive arthritis (GI, GU infections), psoriatic arthritis, IBD associated arthritis, and ankylosing spondylitits. # Shock Patient presents in undifferentiated shock with history, physical exam, lab, and imaging findings concerning for ***. Common shock etiologies includes cardiogenic, distributive, obstructive, hypovolemic, and neurogenic. Dx - Bedside TTE showing *** - Bedside IVC showing *** - CXR, UA/UCx, BCx 2 - EKG, Troponin, BNP - CBC, CMP, Lactate, Random cortisol - CPO, Telemetry - Strict I/O - Consider DDimer vs CTPE - Goal MAP >65 Tx - s/p *** L IVF - Empiric abx: *** # Staph Aureus Bacteremia Patient noted to have ***/2 cultures positive for staph aureus, with suspected source being ***. Best practices for staph aureus bacteremia include identification and control of source, appropriate abx choice and duration, evaluation for endocarditis and other foci of infection, and repeat cultures to demonstrate clearance. - Vancomycin, goal trough 15-20, pending susceptibilities - Last BCx positive date: *** - q48h Bcx until cleared - TTE, additional imaging per clinical scenario # Stroke ; Intracerebral Hemorrhage (ICH) Patient with new neuro deficits characterized by ***. Last seen normal at ***. NCHCT noted to have ***. Surgical indications based on site of bleed (e.g., cerebellar w/ diameter >3cm). Dx - NIHSS score ***, GCS *** - INR, CBC, Glucose FS - EKG, Tele, consider TTE Tx - SBP Goal <140 (Nicardipine preferred), outpt SBP goal <130 - Head of the bed to 30 degrees - ICU for q1h neuro checks - SCD # Stroke (Ischemic) Patient with focal neuro deficits characterized by ***. Last seen normal at ***. On imaging noted to have ***. Contraindications to TPA reviewed, with decision to ***. Dx - NIHSS score *** - Stat NCHCT/CTA, Neuro consult - Glucose FS, INR, CBC, Cholesterol, A1c - EKG, Tele, consider TTE with bubble if <60 y.o Tx - If TPA given, ICU admission, Q1hr neuro checks x 24 until repeat NCHCT. BP goal <185/110 (Nicardipine preferred). - If TPA not given, BP goal <220/120 - Antiplatelet agent # Stroke; (Ischemic) Patient with focal neuro deficits characterized by ***. Last seen normal at ***. On imaging noted to have ***. Contraindications to TPA reviewed, with decision to ***. If given TPA, symptomatic ICH occurs in ~6% with 50% mortality. If large vessel occlusion in anterior circulation and <16h or even <24h LSN, consider mechanical thrombectomy. If cardioembolic etiology, give antiplatelet, with transition to AC in 4d to 2 weeks. Dx - NIHSS score *** - Stat NCHCT/CTA, Neuro consult - Glucose FS, INR, CBC, Cholesterol, A1c - EKG, Tele, consider TTE with bubble if <60 y.o Tx - If TPA given, ICU admission, Q1hr neuro checks x 24 until repeat NCHCT. BP goal <185/110 (Nicardipine preferred). - If TPA not given, BP goal <220/120 - Antiplatelet agent # Syncope Acute loss of consciousness (***witnessed) concerning for syncope. Clinical history most suggestive of ***. Cardiogenic ddx includes structural, arrhythmic, and ischemic etiology. Noncardiogenic ddx includes orthostatic, vasovagal, PE, dissection, seizure, and basilar stroke. - Orthostatic VS - EKG, Telemetry - CBC, BMP, Troponin, Lactate - TTE if with concerning murmur or history - Consider outpatient rhythm monitor per clinical scenario # Systemic Lupus Erythematosus (SLE) Flare Patient with known history of SLE who presents with *** concerning for lupus flare, given change in symptomatology and lab findings. - CBC with diff, smear, BCx x2, CMP, ESR, CRP, Anti-dsDNA, C3, C4 - No indication to repeat ANA if positive - CXR, UA with microscopy, Urine P/Cr, - Additional organ specific labs/imaging per clinical scenario - Appreciate rheumatology consult # T2DM, Established, ***Controlled Diagnosed (year). Last A1c: *** (q3-6 months), goal: <7 (FBG 70-130, postprandial <180) [<8 in elderly/low life expectancy, high risk of hypoglycemia]. Complicated by ***. Aim for aggressive early control to prevent micro/macrovascular complications--leading cause of death is ASCVD. Changes today: *** - Medications -- non insulin therapies: --- uptitrate metformin to 1g BIDAC by 500mg qweek to minimize GI side effects (caution GFR 30-45); consider B12 supplementation --- GLP/SGLT if ASCVD --- SGLT2 if HF/CKD --- DPP4/GLP/SGLT if c/f hypoglycemia --- GLP/SGLT if weight loss --- SU/TZD if cost concern -- insulin: (consider if initial A1c>10 or not at goal on 3 agents) -- statin/ASA/ACEi: (consider ASA if ASCVD risk >10%) -- FSBS frequency: (regular checks not necessary unless on insulin) - Non-medication therapies -- Diet/Nutritionist: low-carb or mediteranean -- Exercise: -- Weight loss: (goal 5-10% for obese; consider bariatic surgery if BMI>35) -- DM Education date: - Monitoring/prevention -- Microalbuminuria (annual): -- Blood Pressure < 130/80: -- Statin: moderate/high intensity, ? LDL goal <100 -- Foot Exam (annual): -- Podiatry (y/n): -- Ophthalmology (annual): -- Flu shot (annual): -- Pneumovax (before age 65, boost after): -- Hypoglycemia risk: - Workup if young, thin, fam/personal hx autoimmune dz, hyperglycemia despite PO agents, h/o DKA -- send GAD, ICA, IA2, insulin autoab -- consider hemochromatosis, CF-related, pancreatic CA, cushings, chronic pancreatitis https://care.diabetesjournals.org/content/diacare/42/Supplement_1/S90/F1.large.jpg # Testosterone Deficiency Patient complains of fatigue, depressed mood, loss of muscle mass, weight gain, low libido and poor sexual function. Physical exam is *absent of* gynecomastia and testicular atrophy (less than 20-30 cc and soft consistency) -Order AM total testosterone x1. If less than 300 then repeat total T with prolactin, FSH, LH, SHBG and bioavailable testosterone. Consider a brain MRI in young men. (free T, bioT and SHBG are more accurate in the morning) -Treat modifiable risk factors: opiate abuse, heavy alcohol use, sleep apnea, obesity -Recommend a trial of topical therapy at 40 mg daily. Goal total T is 400-700. -Monitor PSA and CBC yearly. # Testosterone Deficiency - Candidate for treatment Mixed primary and secondary hypogonadism. Low testosterone x2, Low free/total and low LH in am. Discussed risks and benefits of hormone replacement therapy at length and patient opts for testosterone therapy with the monitoring requirements listed below. -continue to treat modifiable risk factors: alcohol use, sleep apnea, obesity -retest total testosterone, PSA and CBC after 6 weeks of therapy -Monitor PSA and CBC every 6 months, consider DRE and Lipid panel as well --refer to a urologist if PSA level greater than 4.0 ng/mL or more than 0.75 ng/ml increase in a year --hematocrit (testosterone stimulates bone marrow production of erythrocytes) -100mg testosterone cypionate weekly, Goal total T is 400-700. -150-200mg twice daily estrogen blocker - DIM Supplement (Diindolylmethane) or Indole-3-Carbinol (I3C) -Call us when your prescription arrives and we can set up a nursing visit to demonstrate proper injection techniques // Education // - Step 1) Check total testosterone (total T) between 7am and 10am. Testosterone is 60% bound to sex hormone binding globulin (SHBG), 39% albumin bound and 1% free testosterone. - Step 2) If total T is less than 300, then repeat total T but add FSH, LH, prolactin, SHBG and bioavailable testosterone. and PSA to establish baseline. - Step 3) Consider MRI if prolactin high or if low testosterone in a young male - Note: Obese males have low sex hormone binding globulin. This creates an artifact of low Total T (since 60% is bound to SHBG). Therefore, do not treat these patients unless they have low bioavailable testosterone. THERAPY: - Trial of topical therapy recommended. Apply in AM to mimic physiologic levels. Start at 40 mg. Consider repeat level in 2-4 weeks. Goal is Total T 400 to 700 and monitor for improved mood, energy and libido. If no improvement then stop therapy. - Note: Some patients may ask but use is not recommended in women. # 1 Dealing with Male Hypogonadism and Low Testosterone - Primary if testes unable to produce testosterone. - Secondary if pituitary is under producing gonadotropins. - Age related hypogonadism is controversial since men have a 1% per year loss of testosterone after age 30 years old. - Mixed 1y and 2y: sickle-cell disease, thalassemia, alcoholism, glucocorticoid treatment, and in older men # Thrombocytopenia Physical exam and history e/o thrombocytopenia may include: petechiae, purpura, oral petechiae, ecchymoses, lymphadenopathy, hypersplenism, bloody diarrhea, fever, s/sx of blood clots if hypercoaguable as in HIT. New thrombocytopenia likely due to ***. Common mechanisms include destruction (TTP, HUS, DIC, HIT, ITP), decreased production (leukemia, myelodysplastic, viral, drugs, ETOH, Vit B12, folate, copper deficiencies), and sequestration/hypersplenism (cirrhosis, heart failure, malignancy, infections). Also considered is pseudothrombocytopenia from clumping, smear can exclude. - CBC w/diff - HIV, HCV - HIT Ab with reflex SRA if c/f HIT, stop all heparin products - Smear, coags, fibrinogen, LDH, retics (if c/f BM suppression) - Retics, immature platelet fraction (if c/f production problem) - Platelet goal > *** (often 10 unless active bleeding then 50, 100 if c/f CNS bleed) - Patient consented for blood products - Hold DVT prophylaxis for plts < *** (typically 50), otherwise continue as appropriate # Thrombocytosis The differential diagnosis for thrombocytosis can be broadly separated into primary/autonomous thrombocytosis (15%; myeloproliferative neoplasms eg ET, PV, MDS; familial thrombocytosis) and secondary/reactive thrombocytosis (85%). Causes of secondary thrombocytosis can be divided into transient and sustained processes. Amongst transient processes are acute blood loss, recovery from prior thrombocytopenia, acute infection/inflammation, and response to vigorous exercise. Sustained processes include Fe-deficiency, hemolytic anemia, asplenia, cancer, chronic inflammatory or infectious diseases (e.g., connective tissue disease, temporal arteritis, IBD, TB, chronic pneumonitis), and drug reactions (e.g., vincristine, ATRA, cytokines, growth factors). In this patient with ***, the most likely etiology is ***. - assess for HA, CP, bleeding/clotting, visual disturbances - assess for vasomotor symptoms (eg, erythromelalgia, flushing, pruritus), and constitutional symptoms - CBC/diff, smear, ferritin, ESR/CRP - heme referral for primary (urgent if symptomatic or >1M/uL) or reactive if worsening despite tx, thrombosis/hemorrhage, or symptomatic # Upper GI Bleed Patient presents with new melena/coffee ground emesis concerning for upper GI Bleed. History notable for ***. DDx includes gastric and/or duodenal ulcers, esophagitis, gastritis/duodenitis, Mallory-Weiss syndrome, angiodysplasia, malignancy, and Dieulafoy's lesion. Disposition per Glasgow Blatchford score ***. Dx - CBC, CMP, INR, Type and screen, H pylori Ag - Telemetry - GI consult/Endoscopic evaluation per clinical scenario Tx - Protonix 80mg bolus x1, followed by Protonix 40 mg IV BID - If concerned for variceal bleed in cirrhotic, consider Octreotide and Ceftriaxone - NPO - 2 large bore IVs - Transfuse to keep hgb >7 - Hold antiplatelet agent, anticoagulation, anti-hypertensives - Correct coagulopathy (Goal plt > 50k, INR < 2.0) # VT (Electrical) Storm Admitted with electrical storm as defined by >= 3x *** [ symptoms or shocks ] within 24 hours with confirmed VT on *** [tele, device interrogation ]. Considered triggers include QT-prolonging drugs or substances, electrolyte disturbance, heart failure, ACS, thyrotoxicosis. ## Dx: - [ ] BMP/Mg, UDS, BNP, TFTs - [ ] EKG/trop - [ ] CXR - [ ] TTE (if c/f CHF) - [ ] Med review (for QT prolonging medications) - [ ] Device interrogation (if s/p PPM, CRT) ## Initial tx - HDUS —> ACLS (electrical cardioversion!); if successful, initiate antiarrhythmic therapy with amio as below - HDS —> IV amio (150 mg x 10 min f/b 1 mg/min x 6h f/b 0.5 mg/min x 18 h) + propranolol (PO 40 mg Q6H x 48 h); Amio preferred over lido, procainamide given superior efficacy for VT termination; Beta blockade reduces adrenergic surge associated with VT and defibrillator shocks (which contributes to VT via increased sympathetic output); Propranolol, a non-selective beta-blocker, is more efficacious than B1-selective agents (eg metop) - If component of ischemia, urgent revascularization indicated ## Long-term arrhythmia control: - Catheter ablation: recommended for patients with persistence of electrical storm or incessant VT despite medical rx with amio and beta blocker - Maintenance oral antiarrhythmic therapy indicated for recurrence of VT after catheter ablation - If component of heart failure, initiate or uptitrate GDMT - Initiate appropriate GDMT # Vasculitis (small vessel) Patients presents with concern for new small vessel vasculitis given ***. Pauci Immune/ANCA mediated etiologies include GPA, EGPA, MPA, Paraneoplastic, and medications (e.g., sulfa, penicillin, thiazide). Immune complex mediated etiologies (generally decreased C3/C4) include infection (Post-Strep, SBE, Hep C, HIV, Osteomyleitis), connective tissue disease (SLE, RA, Sjogrens, IgG4), Cryoglobulinemia, and IgA/HSP (immune complex with normal complement levels). - CBC w/ diff, ESR, CRP - Consider ANA, ANCA (PR3/MPO), C3, C4, UA w/ micro, BCx, HIV, HBV, HCV, ASO - Imaging per symptomatology and organ involvement - Rheumatology and Dermatology consult per clinical scenario # Vasculitis (large and medium vessel) Patient presents with concern for new large/medium vessel vasculitis given ***. Large vessel vasculitis includes GCA/temporal arteritis and Takayasu. Medium vessel vasculitis includes PAN, Kawasaki, and Buergers (mimic). If concern for GCA/temporal arteritis, following evaluation for infection, consider prompt rheumatology consult and high dose steroids - CBC w/ diff, ESR, CRP, BCx x2, ANA, UA w/ micro - Imaging per symptomatology and organ involvement # Weakness (Diffuse) ***Acute/Subacute/Chronic diffuse weakness, most likely due to ***. No evidence of localizing weakness and neuro exam is unremarkable. Dx includes weakness secondary to infection, electrolyte/metabolic disturbance, neuromuscular insult, inflammatory disorders, endocrinopathy, drugs and toxins. - If true muscle weakness, pain, or localized, consider imaging, ESR, CRP, CK - TSH, B12, A1c, RPR - CXR, UA/UCx, BCx x 2 - BMP, CBC
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