Assessment v1

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# Atrial Fibrillation

- Rate control (*** bpm): ***
- Anticoagulation ***lovenox, heparin, coumadin
- Need for cardioversion ***
- CHADS2 score = 
	CHF 1
	Hypertension 1
	Age> 75 y.o 1
	Diabetes 1
	Stroke/TIA 2
	Score 0 associated with 1.9% stroke risk.
	Score 1 associated with 2.8% stroke risk.
	Score 2 associated with 4.0% stroke risk.
	Score 3 associated with 5.9% stroke risk.
	Score 4 associated with 8.5% stroke risk.
	Score 5 associated with 12.5% stroke risk.
	Score 6 associated with 18.2% stroke risk

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# TIA

Description: The ABCD2 scoring system for assessing stroke risk after a TIA (transient ischemic attack); formatted as an Epic Smart Phrase.

Stroke risk after transient ischemic attack.

	A. Age > 60 years = +1
	B. Blood pressure > 140/90 mmHg: +1 for hypertension at presentation
	C. Clinical features including unilateral weakness (+2), speech disturbance without weakness (+1)
	D. Duration of TIA between10–59 minutes (+1), >60 minutes (+2).
	D. Diabetes (+1).
Stroke risk at 2, 7 and 90 days
	0-3: low risk
	4-5: moderate risk
	6-7: high risk
Not that stroke risk is independent of mechanism whether cardioembolic, a watershed infarct, lacunar infarct, or other mechanism.

References
1. Rothwell PM, Giles MF, Flossmann E, Lovelock CE, Redgrave JN, Warlow CP, Mehta Z. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet. 2005 Jul 2-8;366(9479):29-36.
2. Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, Sidney S. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007 Jan 27;369(9558):283-92.

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# Altered Mental Status

Hypoxia vs. Infection vs. TIA/stroke vs. Metabolic/Toxic. Dementia an unlikely cause given rapidity of onset.

Hypoxia:
ED O2 sat showed ***
Continuous O2 NC and pulse ox - maintain O2 sat > 95%
CXR shows: ***PNA, effusion, COPD, edema

PE risk, Wells score:
***clinically suspected DVT - 3 points
***alternative diagnosis is less likely than PE - 3.0 points
***tachycardia - 1.5 points
***immobilization/surgery in previous four weeks - 1.5 points
***history of DVT or PE - 1.5 points
***hemoptysis - 1.0 points
***malignancy (treatment for within 6 months, palliative) - 1.0 points
Interpretation (Stein et al. 2007 Radiology 242:15-21)
Score >6.0 - High (probability 59% based on pooled data)
Score 2.0 to 6.0 - Moderate (probability 29% based on pooled data)
Score <2.0 - Low (probability 15% based on pooled data)

Infection: *** of 4 SIRS criteria: @BRIEFLAB(WBC)@, *** left shift, *** HR, *** RR, @TMAX(24)@
UA w/ reflex culture ***
Blood cultures x2 ***
CXR shows***
Physical exam findings ***not suggestive of meningitis: ***
***Season ***not appropriate to West Nile

TIA/stroke
History of TIA/CVA ***

*** focal findings on physical exam
***No early signs of stroke on Head CT, ***no hemorrhage or acute findings.
AMS started ***; in***out of TPA window.
***Permissive HTN
***Carotid dopplers ***MRA
Brain MRI***
***EEG

Metabolic
Electrolytes ***
TSH ***
New medicines ***
Recently stopped medicines ***
Tox screen ***

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# Acetaminophen ingestion treatment (Prescott Protocol)

GI decontamination
Activated charcoal
Antidote: N-acetylcysteine (NAC; Acetadote) for prophylaxis/prevention of acetaminophen-induced hepatic injury.
NAC Loading Dose: 150 mg/kg in 200 mL of 5% dextrose, infuse intravenously over 60 minutes.
NAC Maintenance Dose:
	First 4 hours: 50 mg/kg in 500 mL of 5% dextrose, infuse intravenously over 4 hours
	Followed by 100 mg/kg in 1000 mL of 5% dextrose, infuse intravenously over 16 hours
	Refs: Daly et al, 2008; Prod Info ACETADOTE(R) IV injection, 2006; Prescott et al, 1979.
Monitor Acetaminophen levels Q12hr.
Initial Acetaminophen level ***.
Monitor LFTs Q12hr.
Initial hepatic enzymes: ALT ***, AST ***
Continue NAC therapy until serum acetaminophen concentration is undetectable and liver function improves (Smith et al, 2008).

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# Dyspnea

Differential diagnosis include CHF, PE, pneumothorax, pneumonia, obstructive airway disease (COPD, asthma), restrictive airway disease, neuromuscular disorder, anemia

Evaluation
- O2 sat @FLO(2078:last)@ on *** O2
- exam significant for RR=***, accessory muscles used/not used***, pulmuonary exam shows ***
- CHF history ***neg/pos with BNP of ***, S3***, 
- DVT/PE risk factors (pregnancy, cancer, hormone therapy, previous DVT, immobility, recent surgery/injury, family history of DVT, inherited hypercoagulability, obesity, age>60, very tall, smoking, calf pain) - COPD history: PFTs***, smoking history***, physical exam (barrel chested, wheezes)***
- Anemia: exam findings: pallor, tachycardia, flow murmur***
- Neuromuscular disease: neuro exam shows ***
 
Plan
- CXR: PA/Lateral ***
- ECG ***
- BNP ***
- echocardiogram ***
- CT PE protocol ***
- Lower extremity dopplers ***
- ABG ***
- Pulmonary function tests ***
- tele ***
- DVT prophylaxis ***
- DuoNebs ***
- Daily CBC/BMG 
- Strict I&O, dailyl weights

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# # # [ Dizziness / Presyncope] # # #

DDx includes orthostatic hypotension, cardiac source, vestibular disorders, , anxiety/depression, medication induced. Evaluation plan:

Orthostatic hypotension
- Check orthostatic vital signs; IVF if orthostatic
- CBC/BMG
- Daily weights
Cardiac source: History of ***arrythmia ***aortic stenosis, and physical exam shows ***irregularly irregular rhythm, ***bradycardia, ***tachycardia, ***murmur suggesting cardiac source to pre-syncope
- ECG
- Telemetry
- Echocardiogram
Migraine: History of ***headache, photophobia, visual aura or changes, and previous migraines suggest migraine possible source.
CNS disorder: History of ***atrial fibrillation (CHADS2 score) on***not on coumadin, ***previous CVA, ***seizure disorder, with neuro exam findings of ***, suggest a neuro origin to dizziness.
- EEG
- Head CT
- If Head CT negative for bleed, permissive hypertension, daily aspirin
- Frequent neuro checks
Vestibular disorders: Vertigo (sensation of movement while sationary) suggests of vestibular source. History of ***brief (less than 30 s) dizziness with head movement in one direction and no tinnitus consistent with BPPV ***prolonged (longer than 30 s) dizziness, tinnitus, and nausea that has been happening for more than 2 weeks consistent with Meniere's disease ***prolonged (longer than 30 s) dizziness for less than 2 weeks and a recent URI consistent with viral vestibulitis or labyrinthitis ***worsening dizziness, hearing loss, tinitus, papilledema, other cranial nerve deficits (esp CN 7, 9/10) concerning for vestibular schwannoma (AKA acoustic neuroma).
- Otoscopic exam shows ***
- Ophthalmoscopic exam shows ***yes/no papilledema
- ***Dix-Hallpike test for BPV
- ***If hearing loss or tinnitus: Audiology testing
- ***If concern for schwannoma or Meniere's disease: Brain MRI with thin slices through posterior fossa
Anxiety/depression: History of *** suggests anxiety/depression as a contributing factor.
Medication: Recent medication addition/change of ***

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# # # [ Syncope ] # # #

Evaluating cardiac, neurological, and metabolic syncope

Cardiovascular syncope: Differential diagnosis includes mechanical, electrical, vasovagal, orthostatic
 
Cardiac mechanical (Aortic Stenosis, Hypertrophic cardiomyopathy, Pulmonary Embolism, HTN, Stenosis, Aortic Dissection, Myocardial Infarction)
Plan:
- Echo
- CXR
- D-dimer / CT-PE if hypoxic
- EKG
- CMx2; stress test if negative
- EKG PRN with pain
- Continuous pulse-ox
- tele
 
Cardiac electrical (AV Block, Sick Sinus Syndrome, Arrhythmia, Long QT syndrome) 
- EKG
- tele
 
Vasovagal Syncope (Carotid sinus cardioinhibitory, vasodepressor central, Vasovagal cough, micturition defecation, post-prandial valsalva, sneeze)
Orthostatic (Dehydration, Diuretic drugs, Blood Loss, Autonomic insufficiency, Sympathetic nervous system blocker drugs, Adrenal Insufficiency, Vasodilator drugs, Idiopathic)
Plan: 
- Measure orthostatic VS
- Daily CBC/BMG 
- Review drugs
 
Neurologic syncope: cerebral hypoperfusion due to Transient Ischemic Attack (TIA), Seizure, Takayatsu Arteritis, Intermittent Pressure Hydrocephalus, Subclavian Steel Syndrome, Vertebrobasilar insufficiency.
Plan
- Head CT
- EEG
- MRI/MRA
- Cardiac echo
- Carotid dopplers
 
Metabolic syncope: Hypoglycemia syncope, Hypoxia syncope, Shock, Hyperventilation, Anemia, Alcoholic 
Plan
- Blood sugar QAC/HS
- Continuous pulse-ox
- Frequent vitals
- CBC (iron studies if indicated)
- Blood alcohol level; tox screen
- Review medications (hypoglycemic dosing; sulfonylureas and insulin)
 
Psychiatric: panic disorders, depression , hysteria 

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# [C Difficle Diarrhea]

Diagnosis of C difficile diarrhea:

3 or more unformed stools in 24 or fewer consecutive hours
Positive test C. difficile and its toxins (conducted on unformed, diarrheal stool sample - only exception is suspected ileus).
Treatment:

Stop inciting antimicrobial therapy (all agents in the same class) ***.
Avoid probiotic (lack of clinical data and the potential risk of blood stream infection) and antiperistaltic agents (might interfere with symptoms of infection; might increase the risk of toxic megacolon).
@BRIEFLAB(WBC)@ ***> or <*** 15
@BRIEFLAB(creat)@ ***> or <*** 1.5xbaseline Cr of ***
Treat with:
If first episode, WBC<15 and Cr<1.5x baseline (mild-moderate disease) then Metronidazole 500 mg PO TID 10-14 days
If first episode, WBC>15 or Cr>1.5x baseline (sever disease) then vancomycin 125mg QID PO 10-14 days
If first episode with hypotension, shock, ileus or megacolon then vancomycin 500mg QID PO/NGT plus metronidazole 500 mg IV Q8h. Consider vancomycin per rectum with ileus or ostomy.
First recurrence, treat same as first episode
Second recurrence, use vancomycin PO in a tapered or pulsed regimen
References:

1.	Cohen SH et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31(5):000-000.

2.	Gerding, DN et al. Treatment of Clostridium difficile Infection. Clin Infect Dis 2008; 46:S-32-42.