#AKI
Likely 2/2
- trend BMP, ins and outs, daily weights
- obtain urine lytes, UA, and UPCr
- obtain RBUS to rule out obstruction and assess kidney size
- avoid nephrotoxins if able
- maintain K>4, phos > 3, mag >2
#ACS Rule Out
Patient presents with chest pain concerning for acute coronary syndrome. Initial troponin [elevated/normal], ECG shows [ST elevations/depressions, T-wave inversions, nonspecific changes]. Risk factors include [HTN, DM, tobacco use, family history, hyperlipidemia]. TIMI risk score: __ /7 (Age ≥65, ≥3 CAD risk factors, known CAD, ASA use in past 7 days, severe angina, ST deviation, elevated biomarkers). Currently [low/intermediate/high] risk for adverse cardiac events.
- antiplatelet therapy: asa 162-325mg chewed, then 81mg daily; if high suspicion add ADP receptor inhibitor - ticagrelor 180mg load then 90mg BID (preferred) or clopidogrel 300-600mg load then 75mg daily; hold prasugrel until anatomy known given significant bleeding risk
- anticoagulation if ACS confirmed: enoxaparin 1mg/kg q12h or UFH 60 units/kg bolus then 12 units/kg/hr (adjust per aPTT) or fondaparinux 2.5mg daily
- high-intensity statin: atorvastatin 80mg or rosuvastatin 40mg daily (target LDL <70 mg/dL)
- beta blockade: metoprolol 25mg BID if no contraindications (avoid if acute HF, hypotension, bradycardia, severe COPD)
- serial ECGs q6-8h x24h, troponins q6h x3 or high-sensitivity troponin per protocol
- telemetry monitoring for arrhythmias and ischemic changes
- CBC daily (monitor bleeding), BMP daily (renal function), lipid panel, HbA1c if diabetic
- echo if signs of heart failure or wall motion abnormalities suspected
- CXR to evaluate for pulmonary edema
- avoid NSAIDs, COX-2 inhibitors, nephrotoxic agents if able
- immediate cath (<2 hours): STEMI, cardiogenic shock, mechanical complications
- early invasive (<24 hours): recurrent ischemia, hemodynamic instability, sustained VT, elevated troponin with high TIMI score (≥3)
- conservative strategy: low-risk patients - stress testing before discharge, outpatient cardiology follow-up
- evaluate for ACS mimics: aortic dissection (CTA if suspicious), PE, takotsubo cardiomyopathy
- cardiology consulted – Dr. __, appreciate recommendations
Clinical Reflection: Follow ACC/AHA 2023 guidelines. TIMI risk score guides invasive strategy: low risk (0-2) managed conservatively with stress testing, intermediate-high risk (≥3) benefits from invasive approach. Use HAS-BLED score for bleeding risk assessment (≥3 indicates high risk). calculate GRACE score if NSTEMI confirmed for mortality prediction. Duration of dual antiplatelet therapy typically 12 months minimum for ACS. Early invasive strategy within 24 hours reduces recurrent ischemia in high-risk NSTEMI. Avoid routine beta blockers if signs of heart failure or shock. Consider atypical presentations in women, elderly, and diabetics. Ensure medication compliance education and lifestyle modifications before discharge.
HISTORY & PHYSICAL
@CC@
HPI:
@M@ @NAME@ is a @AGE@ @SEX@ with a history of
Patient denies *** chest pain, shortness of breath, abdominal pain, changes in bowel or urinary habits, frank blood loss, melena, recent illnesses or hospitalizations, fevers, chills, n/v/d.
In the ED,
Relevant diagnostic studies:
@ALLERGY@: nkda ***
PMH/PSH: as above
Social History:
Family History:
Home Medications:
@HMEDS@
Current Hospital Medications:
Scheduled Meds:@MEDSSCHEDULED@
PRN Meds:@MEDSPRN@
Review of Systems: as above but otherwise negative
Objective:
Vital Signs/Intake & Output
@VSRANGES@
@IOBRIEF@
@LASTLAB(pocglu:3,
@BMI@
Physical exam:
Gen: NAD ***
CV: nrnr, no mrg
Lungs: CTAB
Abd: ntnd
Ext: no LE edema
Neuro: Aox3, no obvious focal deficits
Labs:
@24HRLABS@
Assessment and Plan:
Plan:
***
@DIETHANDOFF@
@DGSDVTPROPHYLAXIS@
@DGSACTIVELDAS@
Code Status: @CODESTATUS@
@MECRED@
@TD@ @NOW@
#Atrial fibrillation with RVR
Patient presents with palpitations, shortness of breath, or fatigue. ecg confirms afib with rapid ventricular response, hr [x]. no evidence of stemi, chf decompensation, or underlying infection. likely new or recurrent episode. CHADVASc: CHF (1), HTN (1), age >/= 75 (2), DM (1), CVA/TIA/VTE (2), vascular disease (1), ages 65-74 (1), female (1).
- rate control with iv metoprolol, diltiazem, or digoxin
- assess need for rhythm control if unstable, persistent, or patient with advanced HF
- check tsh, cmp, troponin, magnesium
- assess for reversible causes (infection, thyrotoxicosis, alcohol)
- initiate oral anticoagulation (chadvasc ≥2 men or ≥3 women) unless contraindicated
- preferred AC: DOACs (apixaban, rivaroxaban, edoxaban) over warfarin for nonvalvular AF d/t lower bleeding risk
- warfarin if patient has either moderate or severe mitral stenosis or a mechanical heart valve
- telemetry monitoring
- evaluate chadsvasc score for stroke risk
- cardiology consult if refractory or unclear history
Clinical reflection: most stable patients require only rate control and anticoagulation. avoid rhythm agents unless unstable, young, or symptomatic. evaluate for secondary causes: infection, hyperthyroidism, hypoxia. avoid beta blockers in decompensated chf; use digoxin or amiodarone instead. - warfarin - , asa not recommended for stroke prevention in afib. for symptomatic paroxysmal AF and for patients with HFrEF, catheter ablation is first line Tx. Consider left atrial appendage occlusion in patient with contraindications to long term AC.
#Acute kidney injury
Assessment: Patient with baseline creatinine [x], now [y]. AKI Stage [1: 1.5-1.9x baseline / 2: 2-2.9x baseline / 3: ≥3x baseline]. Differential by category: Prerenal (volume depletion, diuretics, sepsis, HF, cirrhosis, NSAIDs, ACE-I/ARB, hepatorenal syndrome), Intrinsic renal (ATN from ischemia or nephrotoxins, AIN from medications, GN, vascular), Postrenal (obstruction from BPH, stones, malignancy). Current assessment suggests [prerenal/intrinsic/postrenal] based on volume status, UA findings [bland/muddy casts/RBC casts/WBC casts/eosinophils], and FENa. Calculate FENa: FENa <1% suggests prerenal, >2% suggests ATN (use FEUrea if on diuretics). Urinalysis with microscopy: bland (prerenal/postrenal), muddy brown casts (ATN), RBC casts (GN), WBC casts/eosinophils (AIN)
- if prerenal: IV fluid resuscitation with LR or balanced crystalloid
- if postrenal: bladder scan, foley if retention, urology consult if obstruction
- follow up urine lytes and UA if not already done
- RBUS to rule out obstruction and assess kidney size
- daily BMP, strict I/Os, daily weights
- goal urine output ≥0.5 mL/kg/hr
- avoid nephrotoxins in able, renally dose medications
- adjust or hold ACE-I/ARB in prerenal states
- treat underlying cause: sepsis, hypoperfusion, relieve obstruction
- manage hyperkalemia if K >5.5: insulin/glucose, calcium gluconate, kayexalate, diuretics
- consider nephrology consult if Stage 3 AKI, unclear etiology needing biopsy, suspected GN, dialysis indication (AEIOU: acidosis, electrolytes, intoxication, overload, uremia), or CKD G4-5
Clinical Reflection: AKI requires volume assessment first. Prerenal most common (60-70%) - responds to fluids within 24-48h. FENa <1% and bland UA suggest prerenal. Muddy brown casts indicate ATN. WBC casts/eosinophils suggest AIN (beta-lactams, PPIs, NSAIDs). RBC casts pathognomonic for GN. Rule out postrenal early with ultrasound. Contrast nephropathy occurs 24-72h post-exposure. Avoid triple whammy (ACE-I/ARB + diuretic + NSAID). Rhabdomyolysis causes ATN - check CK if suspected. Dialysis indications: AEIOU (acidosis refractory, electrolytes K >6.5 refractory, intoxication, overload refractory, uremia symptomatic). Recheck creatinine 1-2 weeks post-discharge to ensure return to baseline.
#Alcohol withdrawal
Patient with history of heavy alcohol use presents with tremor, tachycardia, agitation. last drink was approximately [x] hours ago. reports [x] drinks daily for [duration]. ciwa score [x]. risk factors include prior withdrawal seizures, DTs, concurrent medical illness. no evidence of seizures or dt at this time.
- ~highly institution dependent~
- start librium taper (100 > 75 > 50 > 25 mg q8 > q12 > qd) depending on Sx severity
- lorazepam/diazepam/ativan prn based on ciwa protocol
- monitor ciwa and vital signs every 2 hours
- in severe AW or benzo resistant, IV phenobarbital per institutional protocol (e.g., 10-12 mg/kg - 130–260 mg IV loading, then as needed) - max ICU pbarb dose ~2g in 24 hours, max medical floor dose ~1g in 24 hours
- consider critical care consult if concerned for severe AW (history +/- significant risk factors)
- IV thiamine 500mg daily for 3-5 days, then oral thiamine 100mg daily
- if patient at risk of Wernicke's, IV thiamine 500mg q8 for 2-5 days, can then taper to IV 500mg daily, then po 100mg daily
- administer thiamine before any glucose
- continue folate, multivitamin, magnesium, and fluids with d5 NS
- cardiac and respiratory monitoring
- monitor for signs of progression to seizures or delirium tremens
- consider psychiatry or addiction consult, SW referral
- consider naltrexone (IM depot + orals) if patient with high risk of relapse
Clinical reflection: withdrawal peaks at 48–72 hours. always give thiamine before glucose. consider phenobarbital if refractory to benzodiazepines. watch for electrolyte derangements. ensure safe disposition with follow-up plan.
#AMS
Patient with acute altered mental status. no known focal deficits. wide differential including metabolic, infectious, neurologic, toxicologic, or structural causes.
- checked fingerstick glucose and reviewed vitals
- rule out toxic-metabolic etiology, f/u bmp, cbc, ua, tox screen, lft, ammonia
- follow head ct without contrast
- review medications and recent changes
- consider lumbar puncture if concern for cns infection
- initiated neuro monitoring and supportive care
- neurology consult if unclear etiology or prolonged course
Clinical reflection: altered mental status requires broad workup. prioritize abc, glucose, infection, and medications first. use delirium vs dementia vs structural thinking. ammonia, eeg, or mri if initial tests unrevealing. monitor airway if gcs declines.
#Asthma
Patient with known asthma presents with wheezing, sob, tachypnea, increased wob / accessory muscle use, unable to speak in full sentences. recent trigger of [URI, allergen exposure, med changes peak flow [x]% of baseline (mild >70%, moderate 50-70%, severe <50%). no signs of impending respiratory failure.
- duonebs (q20mins (up to 3x) > then q2-q6 prn)
- consider continuous albuterol in severe exacerbations
- IV magnesium 2g if severe or poor response to bronchodilators (or just give because low risk of harm)
- start systemic corticosteroid: prednisone 40 mg po daily x 5 days
- consider IV methylprednisolone 1-2 mg/kg/day if c/f respiratory failure
- supplemental oxygen to maintain spo2 >92%
- monitor for improvement in peak flow and work of breathing
- hold beta-blockers as clinically indicated
- avoid sedatives; consider heliox or bipap before intubation
- consider pulmonology consult if frequent exacerbations
- discharge criteria: peak flow >70% personal best, sustained improvement at least 4 hours, minimal Sx at rest
Clinical reflection: per GINA guidelines, treat with short-acting beta agonists and systemic steroids. magnesium sulfate may be added in severe cases. assess for compliance, triggers, and controller med adequacy at discharge.
#Cellulitis
Patient presents with localized erythema, warmth, swelling, and tenderness of [site]. no fluctuance or drainable abscess appreciated. likely uncomplicated cellulitis. risk factors include chronic edema, skin break, or diabetes. concerning features: crepitus, bullae, skin necrosis, disproportionate pain, systemic symptoms. necrotizing fasciitis indicators: pain out of proportion, rapid spread, systemic toxicity.
- initiated empiric iv antibiotics: cefazolin 1-2g IV q6-8h; vancomycin 15-20mg/kg q12h if MRSA risk
- outlined margins to monitor spread
- elevate affected limb to reduce edema
- pain control as needed
- blood cultures if febrile or immunocompromised
- monitor for progression or necrotizing infection
- consider surgical consult if worsening or abscess suspected
- transition to PO when improving: cephalexin 500mg q6h or clindamycin 300mg q8h
Clinical reflection: most cases due to streptococcus or mssa. empiric mrsa coverage not always required unless risk factors which include prior MRSA, recent hospitalization, IVDU, chronic wounds, hemodialysis, recent abx. beware of mimics like stasis dermatitis or gout. assess for necrotizing fasciitis in rapidly progressing or very painful cases.
#Acute decompensated heart failure
patient with history of HFrEF presents with dyspnea, orthopnea, and le edema. exam reveals jvd, rales, and peripheral edema. bnp elevated; cxr shows pulmonary congestion. likely volume overload precipitated by [e.g., dietary indiscretion, med nonadherence, ischemia].
Classifications: HFpEF (EF >50%): HCM, DM, HTN, restrictive and infiltrative CM, HFmrEF (EF 40-50%): new entity, still being studied, HFrEF (EF <40%): ischemia, HTN, structural disease, genetic, viral, tachycardia, etc. NYHA – I: symptomatic with exercise, II: symptomatic with walking, III: symptomatic with minimal activity (ADL’s, out of chair), IV: symptomatic at rest. Warm/dry - normal, warm/wet - hypervolemic, cold/dry - admit to hospital for gentle IVF, inotropes, and/or afterload reducers, cold/wet - likely needs specialist mgmt.
- iv diuresis with loop diuretic: [e.g., furosemide iv] goal targets: net negative 1-3L daily, weight loss 1-2kg/day, uOP >100-150 mL/hr in first 6 hrs
- follow up TTE if indicated
- consider metolazone or thiazide adjunct if diuresis inadequate
- trend daily weights, i/o’s, renal function
- replete lytes prn while diuresing
- sodium and fluid restriction (na <2g/day, fluid <2L/day)
- continue or adjust guideline-directed medical therapy (bb, acei/arni, mra, sglt2i)
- hold beta blocker if recently initiated and patient is unstable or decompensated
- troponin and ekg to evaluate for ischemia
- initiate supplemental O2 to maintain SpO2 ≥ 92%; use upright positioning; nippv if hypoxemia or pulmonary edema
- avoid nsaids, thiazolidinediones, and other medications that exacerbate hf
- cardiology consult if poor response, arrhythmia, or gdmt intolerance
if hemodynamically unstable:
- initiate invasive bp monitoring (art line)
- serial ecgs and troponins to rule out ischemia
- obtain bedside echo for real-time cardiac function and volume assessment
- initiate inotropic support for low output:
–dobutamine 2.5–20 mcg/kg/min iv
–or milrinone 0.125–0.75 mcg/kg/min iv
–or dopamine 5–15 mcg/kg/min iv
- if hypotensive with organ dysfunction, initiate norepinephrine 0.05–0.4 mcg/kg/min iv
- small fluid bolus if hypovolemic
- diuretics or ultrafiltration if volume overloaded
- evaluate for cardiogenic shock: consider mechanical support (iabp, impella, ecmo)
- consult cardiology for acute coronary syndrome and revascularization
- urgent rhythm management for unstable arrhythmias
- initiate antihypertensives (e.g., nitroglycerin or nitroprusside) for hypertensive emergency
- initiate antibiotics for suspected infection or sepsis
- consider thoracentesis or paracentesis if effusions contribute to respiratory compromise
*** Clinical reflection: management follows ACC/AHA 2022 heart failure guidelines. early, aggressive iv diuresis is key—initial loop dose should match or exceed the patient's home dose. monitor for diuretic resistance (uop, urine sodium), and escalate promptly if inadequate response. reassess for precipitating causes using the champ mnemonic (cad, hypertensive crisis, arrhythmia, medication nonadherence, pulmonary embolism). hold beta blockers temporarily during acute decompensation and reintroduce only after euvolemia is achieved. same applies to acei/arb/arni (although evidence is mixed). assess volume and perfusion profiles frequently: in “cold and dry” states, trial a small fluid challenge to assess responsiveness; if refractory, initiate vasopressors and escalate to inotropes if needed. in “cold and wet” states, start with inotropes (e.g., dobutamine, milrinone), and add vasopressors if shock persists. avoid inotropes in patients with left ventricular outflow tract obstruction (e.g., hocm, aortic stenosis). consider nitro if HF 2/2 hypertensive crisis / flash pulmonary edema. reassess hemodynamics and end-organ perfusion serially. initiate pt/ot, dietary education, and discharge planning early—these reduce length of stay and readmission risk.
#Decompensated cirrhosis
Assessment: this is a @age@-year-old @sex@ with a history of cirrhosis secondary to [alcohol, hepatitis c, mash], now presenting with decompensation. current complications include [ascites, hepatic encephalopathy, variceal bleeding, or infection]. precipitating factors include [infection, gastrointestinal bleeding, alcohol use, medication nonadherence, or unknown].
- admit to inpatient service; consider icu if hemodynamically unstable or active variceal bleeding
- send cbc, cmp, inr, ammonia, blood cultures, and lactate
- obtain abdominal ultrasound with doppler to assess for portal vein thrombosis
- if ascites present, perform diagnostic paracentesis: cell count, differential, albumin, protein, culture
- monitor map ≥ 65 mm hg, daily bmp, and assess mental status and fluid balance
volume (ascites):
- initiate sodium restriction < 2 g/day
- start diuretics: spironolactone 100 mg and furosemide 40 mg daily, titrate in 100:40 ratio
- goal weight loss: 0.5–1 kg/day
- for tense ascites: large-volume paracentesis with albumin (6–8 g per liter removed)
- avoid nsaids and nephrotoxic agents
infection (sbp, sepsis):
- treat suspected sbp with cefotaxime 2 g iv every 8 hours or ceftriaxone 1 g iv daily
- if septic, broaden antibiotics based on source and provide fluid resuscitation
- send blood and ascitic fluid cultures before antibiotics if possible
bleeding (variceal):
- initiate octreotide 50 mcg bolus, then 50 mcg/hour infusion
- start IV ceftriaxone 1g daily for 7 days for sbp prophylaxis
- consult GI for egd within 12–24 hours
- hold beta blockers during acute bleed; resume carvedilol once stable
encephalopathy:
- lactulose 30–45 ml every 1–2 hours until 2–3 soft stools/day, then titrate to maintain
- add rifaximin 550 mg po twice daily for recurrent or refractory cases
- monitor for triggers including constipation, gi bleeding, and infection
screening and transplant evaluation:
- ruq ultrasound every 6 months for hcc screening
- egd every 1–2 years to assess for varices
- update immunizations: hepatitis a/b, pneumococcal, influenza, covid-19, tdap
- consult hepatology for liver transplant evaluation if meld ≥ 15 or multiple decompensation events
- discuss goals of care and long-term management planning
f/e/n:
- maintain protein intake 1.0–1.5 g/kg/day unless encephalopathy is refractory
- target 25–35 kcal/kg/day caloric intake
- restrict fluids if serum sodium < 120 mmol/l
- replete electrolytes as needed (especially potassium, magnesium, phosphate)
Clinical reflection: the management of decompensated cirrhosis hinges on early identification of precipitating factors, prevention of complications, and referral for transplant when appropriate. prompt treatment of sbp, tight volume management, and lactulose-based therapy for encephalopathy reduce mortality risk. early hepatology involvement improves transplant access and long-term outcomes.
#COPD exacerbation
Patient presenting with acute worsening of dyspnea, cough, and sputum production, consistent with an acute exacerbation of copd (aecopd). suspected triggers include [viral or bacterial infection, environmental exposure, or medication nonadherence]. differential diagnoses include acute heart failure, pulmonary embolism, pneumonia, and asthma exacerbation.
- admit to inpatient medicine for close monitoring due to symptom severity, failed outpatient therapy, or need for noninvasive ventilation
- albuterol 2.5 mg via nebulizer every 1–4 hours prn or 90 mcg via mdi 1–2 puffs every 1–4 hours prn
- ipratropium 0.5 mg nebulized every 6–8 hours prn or hfa 8 puffs every 20 minutes up to 3 hours prn
- initiate prednisone 40 mg po daily x5d for most AECOPD’s
- consider IV methylprednisolone 1-2 mg/kg/day for patients with concern for respiratory failure
- initiate antibiotics if increased sputum purulence, worsening dyspnea, or suspected bacterial infection: options include amoxicillin/clavulanate 875 mg po every 12 hours, doxycycline 200 mg po daily, or azithromycin 500 mg day 1 then 250 mg daily
- continuous pulse oximetry
- titrate supplemental oxygen to maintain spo2 88–92%
- initiate nippv if persistent hypercapnia, ph < 7.35, or increased work of breathing
- consider intubation and mechanical ventilation if nippv fails, or if respiratory arrest, encephalopathy, or hemodynamic instability occurs
- address underlying triggers such as infection or pulmonary embolism
- pulmonology consult if indicated
- consider pneumococcal and influenza vaccines on discharge
- provide smoking cessation counseling if current smoker
- transition to maintenance inhaler regimen once stable
- educate patient on proper inhaler technique, symptom monitoring, and exacerbation prevention
- arrange outpatient follow-up within 1–2 weeks
- refer to pulmonary rehabilitation if not previously enrolled
Clinical reflection: inpatient management of aecopd includes bronchodilation, corticosteroids, and antibiotics when clinically indicated. early use of nippv can reduce need for intubation and improve outcomes. avoid excessive oxygen which can worsen hypercapnia. evaluate for non-respiratory contributors including heart failure, pe, and infection. education, inhaler review, and timely follow-up are key to reducing readmission risk.
#DKA
Patient with history of diabetes presents with polyuria, vomiting, and abdominal pain. labs show ag metabolic acidosis, ketonemia +/- ketonuria, and glucose >250. ph <7.3, bicarb <15. likely triggered by infection, insulin omission, or infarction.
- initiated iv fluids with ns; switch to d5 ½ns when glucose <200
- start insulin gtt with hourly glucose and gap checks
- dosing protocol: loading dose (0.1 units/kg bolus), then 0.1 units/kg/hr drip
- avoid rapid glucose correction >75-100 mg/dL/hr to prevent cerebral edema
- potassium correction as follows: K>5.2 no replacement, K 3.3-5.2 add 20-30 mEq per L of IVF, K <3.3 hold insulin and give 40 mEq per hour until K >3.3
- replete bicarb if pH <6.9 (example: 100 mEq of bicarb in 400 mL over 2 hours)
- avoid excess bicarb as it can worsen hypokalemia
- monitor bmp, venous ph, and ketones every 4 hours
- evaluate for triggers: cxr, ua, ekg, lipase
- transition to subq basal insulin once gap closed and patient tolerating oral intake/diet
- continue insulin gtt for 1-2 hours after subq insulin dose
- consider two bag system: bag 1 – NS with insulin gtt, bag 2 - d10W with (+/- same insulin gtt)-> switch between bags or give both bags simultaneously at variable rates based on glucose levels (helps with ketone clearance iso hypo- or normoglycemia)
- endocrine consult and diabetes education before discharge
Clinical reflection: follow ada protocol. fluid first, then insulin. monitor k closely. resolution = closed gap, not just glucose <200. reintroduce basal insulin before stopping drip. always investigate cause. cerebral edema is rare but serious.
#Deep vein thrombosis
Assessment: Patient with unilateral leg swelling, pain, and/or erythema. Wells score: [x] (≥2 DVT likely, <2 unlikely). Doppler ultrasound confirms [proximal/distal] lower extremity DVT involving [femoral/popliteal/calf veins]. No current signs of PE. Risk factors: [recent surgery, immobility, malignancy, pregnancy, OCPs, prior VTE, thrombophilia]. Classification: Provoked (identifiable temporary risk factor within 3 months) vs Unprovoked (no clear precipitant) vs Cancer-associated. Current DVT is [provoked/unprovoked].
- start AC with apixaban 10mg BID x7 days then 5mg BID, or rivaroxaban 15mg BID x21 days then 20mg daily, or enoxaparin 1mg/kg q12h bridge to warfarin (INR 2-3), or UFH if CrCl <30
- duration: 3 months for provoked, 3-6 months or indefinite for unprovoked (based on bleeding risk), indefinite for recurrent or cancer-associated
- consider bleeding risk: recent surgery, GI bleed, falls, thrombocytopenia
- leg elevation and early mobilization (bed rest not recommended)
- compression stockings 30-40 mmHg for symptom relief
- evaluate for PE if respiratory symptoms develop
- monitor for complications: phlegmasia alba/cerulea dolens, compartment syndrome
- cancer screening if unprovoked and age-appropriate
- thrombophilia workup if age <50, recurrent VTE, strong family history, or unprovoked - defer until ≥3 months post-DVT off anticoagulation x2-4 weeks
- IVC filter only if absolute contraindication to anticoagulation
- hematology consulted - Dr. __, appreciate recommendations (consider if recurrent DVT, unprovoked requiring long-term decisions, or thrombophilia suspected)
Clinical Reflection: Proximal DVTs (popliteal and above) carry higher PE risk and always require anticoagulation. Isolated distal/calf DVT management controversial - treat if symptomatic or extensive. DOACs preferred over warfarin (no monitoring, similar efficacy). Three months minimum for provoked DVT; unprovoked may need indefinite therapy if low bleeding risk. Cancer-associated DVT: LMWH or rivaroxaban/edoxaban per guidelines. Thrombophilia testing rarely changes acute management - defer until after acute phase. Phlegmasia cerulea dolens (massive DVT with venous gangrene) is surgical emergency. Post-thrombotic syndrome occurs in 20-50%. Early mobilization safe. HIT suspected if platelet drop >50% on heparin - stop immediately, use alternative anticoagulant. May-Thurner syndrome and Paget-Schroetter require specialized management.
#Deep vein thrombosis
Assessment: Patient with unilateral leg swelling, pain, and/or erythema. Wells score: [x] (≥2 DVT likely, <2 unlikely). Doppler ultrasound confirms [proximal/distal] lower extremity DVT involving [femoral/popliteal/calf veins]. No current signs of PE. Risk factors: [recent surgery, immobility, malignancy, pregnancy, OCPs, prior VTE, thrombophilia]. Classification: Provoked (identifiable temporary risk factor within 3 months) vs Unprovoked (no clear precipitant) vs Cancer-associated. Current DVT is [provoked/unprovoked].
- start AC with apixaban 10mg BID x7 days then 5mg BID, or rivaroxaban 15mg BID x21 days then 20mg daily, or enoxaparin 1mg/kg q12h bridge to warfarin (INR 2-3), or UFH if CrCl <30
- duration: 3 months for provoked, 3-6 months or indefinite for unprovoked (based on bleeding risk), indefinite for recurrent or cancer-associated
- consider bleeding risk: recent surgery, GI bleed, falls, thrombocytopenia
- leg elevation and early mobilization (bed rest not recommended)
- compression stockings 30-40 mmHg for symptom relief
- evaluate for PE if respiratory symptoms develop
- monitor for complications: phlegmasia alba/cerulea dolens, compartment syndrome
- cancer screening if unprovoked and age-appropriate
- thrombophilia workup if age <50, recurrent VTE, strong family history, or unprovoked - defer until ≥3 months post-DVT off anticoagulation x2-4 weeks
- IVC filter only if absolute contraindication to anticoagulation
- hematology consulted - Dr. __, appreciate recommendations (consider if recurrent DVT, unprovoked requiring long-term decisions, or thrombophilia suspected)
Clinical Reflection: Proximal DVTs (popliteal and above) carry higher PE risk and always require anticoagulation. Isolated distal/calf DVT management controversial - treat if symptomatic or extensive. DOACs preferred over warfarin (no monitoring, similar efficacy). Three months minimum for provoked DVT; unprovoked may need indefinite therapy if low bleeding risk. Cancer-associated DVT: LMWH or rivaroxaban/edoxaban per guidelines. Thrombophilia testing rarely changes acute management - defer until after acute phase. Phlegmasia cerulea dolens (massive DVT with venous gangrene) is surgical emergency. Post-thrombotic syndrome occurs in 20-50%. Early mobilization safe. HIT suspected if platelet drop >50% on heparin - stop immediately, use alternative anticoagulant. May-Thurner syndrome and Paget-Schroetter require specialized management.
#Hypertensive emergency
Patient with severe hypertension >180/120 and signs of end-organ damage such as aki, chest pain, vision changes, acute stroke, encephalopathy, pulmonary edema, retinal hemorrhages. consistent with hypertensive emergency.
- continuous blood pressure monitoring
- initiated iv antihypertensive: nicardipine, labetalol, or clevidipine
- nicardipine: 5mg/hr IV, titrate by 2.5mg/hr q15min (max 15mg/hr)
- clevidipine: 1-2mg/hr IV, double q2-3min (max 21mg/hr)
- labetalol: 20mg IV bolus, then 20-80mg q10min or 0.5-2mg/min infusion (avoid in cocaine use, severe asthma, decompensated HF)
- avoid CCB and hydralazine in severe aortic stenosis
- goal is to reduce MAP by 10–20% in first hour, max 25% in 24 hours
- if aortic dissection, SBP goal 100-120 in first 20 minutes (esmolol preferred agent)
- monitor renal function, neuro status, and cardiac enzymes
- assess for secondary causes: pheochromocytoma, drug use, renal artery stenosis
- if urgency (no end-organ damage) can manage with oral agents
Clinical reflection: treat based on the target organ involved. don't lower bp too quickly unless dissection or stroke. nicardipine preferred in neuro cases, nitroglycerin for acs. reassess need for po agents once stable.
#Pancreatitis
Patient with a [x]-day history of constant, severe epigastric pain radiating to the back, lipase [or amylase] ≥ 3x upper limit of normal, and imaging findings consistent with acute pancreatitis on ultrasound or ct. most likely diagnosis is acute pancreatitis. severity is classified as [mild (no organ failure or complications) or moderate-to-severe (organ failure and/or systemic or local complications)]. differential diagnosis includes peptic ulcer disease, gastritis, acute peritonitis, cholecystitis, cholangitis, biliary colic, or myocardial infarction.
- admit to inpatient ward or icu based on severity: icu if organ dysfunction, sirs, persistent hypotension, high-risk comorbidities, or electrolyte instability
- initiate lactated ringers iv fluids at 1.5 ml/kg/hr for 24–48 hours if normovolemic; if hypovolemic, give 10 ml/kg bolus followed by same maintenance rate
- monitor vitals, oxygen saturation, and urine output every 1–2 hours during fluid resuscitation
- check bmp and cbc every 6–12 hours to guide resuscitation and perfusion
- serial abdominal exams (r/o compartment syndrome or worsening tenderness)
- provide pain control with nsaids such as ketorolac 15–30 mg iv/im q6h prn or diclofenac or ibuprofen alternatives; use opioids (e.g., hydromorphone 0.2–1 mg iv q2–3h or pca) if pain is severe or contraindications to nsaids (morphine a/w sphincter of Oddi spasm)
- treat nausea with ondansetron 4–8 mg po/iv q8h prn or metoclopramide 10 mg po/iv q4–8h prn
- replete electrolytes and monitor for hypo/hyperkalemia, hypocalcemia, and hypomagnesemia
- advance to low-fat solid diet as tolerated; consider enteral feeding if npo >48–72 hours or unable to tolerate oral intake; consider tpn only if enteral not feasible
- hold oral intake initially if active vomiting, ileus, or severe pain with eating
- evaluate for gallstone pancreatitis with ruq ultrasound; order mrcp if cbd dilation or cholestatic LFT's
- consult gi or surgery for ercp in cases of suspected cbd obstruction, ascending cholangitis, or persistent biliary pancreatitis
- monitor for complications: necrosis, pseudocyst, fluid collections, infection, or organ failure
- discharge criteria: tolerating po intake, pain controlled with po meds, improving labs
Clinical reflection: early fluid resuscitation is the cornerstone of management in acute pancreatitis, ideally with lactated ringers to minimize risk of acidosis. pain control is essential but should avoid over-sedation or ileus. most cases are mild and self-limited, but close monitoring helps identify evolving organ dysfunction or complications. nutrition should be reintroduced as soon as tolerated, with enteral feeding preferred over tpn. consider etiology workup including triglycerides, alcohol use, gallstones, and medications. ercp is reserved for biliary obstruction or cholangitis. repeat imaging is not routinely required unless worsening clinically.
#Pulmonary embolism
Patient presenting with dyspnea, hypoxemia, tachycardia, and/or pleuritic chest pain, found to have pulmonary embolism on CTPA. Risk stratification: Low-risk (hemodynamically stable, no RV dysfunction, normal biomarkers, sPESI 0 or PESI I-II, mortality <1%), Intermediate-risk (stable but RV dysfunction OR elevated troponin/BNP - subdivide as intermediate-low if one positive, intermediate-high if both positive, mortality 3-15%), High-risk/Massive (sustained hypotension SBP <90 or pressors, shock, or arrest, mortality >15%). Current assessment: [Low/Intermediate-low/
- admit to [medicine with telemetry / icu] based on presence or absence of hypotension or shock
- initiate continuous cardiac monitoring and pulse ox
- provide supplemental oxygen as needed to maintain saturation >92%
- administer cautious IV fluids if hypotensive (e.g., 250–500 ml lr), avoid volume overload
- initiate vasopressors if signs of hypoperfusion or persistent hypotension
- anticoagulation:
- start enoxaparin 1 mg/kg sc every 12 hours or 1.5 mg/kg sc once daily
- or fondaparinux based on weight: 5 mg (<50 kg), 7.5 mg (50–100 kg), 10 mg (>100 kg) sc daily
- or ufh bolus 80 units/kg, then infusion 18 units/kg/hr with aptt or anti-xa monitoring
- transition to doac after 48–72 hours if stable: dabigatran 150 mg po bid or edoxaban 30–60 mg po daily (weight-based)
- if high risk (hemodynamic instability, shock): consider alteplase 100 mg iv over 2 hours
- consult IR or vascular surgery for catheter-directed thrombolysis if thrombolytics contraindicated or failed
- consult PERT team if available to coordinate multidisciplinary care
- evaluate for DVT and possible need for IVC filter only if AC contraindicated
- reassess for decompensation and escalating support needs during first 24–48 hours
Clinical reflection: PE risk stratification guides management - low-risk can be considered for outpatient treatment with close follow-up, intermediate-risk requires hospitalization, high-risk needs ICU and consideration of thrombolysis. RV dysfunction and elevated biomarkers indicate higher mortality risk. Systemic thrombolysis reserved for hemodynamically unstable patients due to bleeding risk. Catheter-directed therapy emerging as option for intermediate-high risk. Avoid aggressive fluids in RV strain - can cause paradoxical worsening. DOACs preferred over warfarin for most patients (faster onset, no monitoring). Provoked PE (surgery, trauma, temporary risk factor) typically treated 3 months; unprovoked PE may require extended anticoagulation. Consider thrombophilia workup if unprovoked PE in young patient, strong family history, or recurrent events. Post-PE syndrome and CTEPH are rare long-term complications - refer to pulmonary hypertension specialist if persistent dyspnea at 3-6 months.
Physical exam:
Gen: NAD
CV: nrnr, no mrg
Lungs: CTAB
Abd: ntnd
Ext: no LE edema
Neuro: Aox3, no obvious focal deficits
#Pneumonia
Patient with cough, fever, and sob. lung exam reveals focal crackles; cxr shows new infiltrate in [location]. leukocytosis and elevated inflammatory markers present. no mdr risk factors or recent hospitalization. most consistent with community-acquired pneumonia (cap).
- empiric antibiotics (CTX / azithro vs doxy)
- [ceftriaxone 1–2 g iv once daily] or [ampicillin/sulbactam 3 g iv every 6 hours]
- or if pseudomonas risk factors: [piperacillin/tazobactam 4.5 g iv every 6 hours] or [cefepime 2 g iv every 8 hours]
- plus [azithromycin 500 mg iv daily] or [doxycycline 100 mg iv every 12 hours] or [moxifloxacin 400 mg po/iv once daily] or [levofloxacin 750 mg po once daily]
- plus if risk factors for mrsa: [vancomycin 15 mg/kg iv every 12 hours; adjust based on serum trough levels] or [linezolid 600 mg iv/po every 12 hours]
- supplemental oxygen to maintain SpO2 >92%
- f/u blood and sputum cultures, strep/legionella urinary antigen
- cater antibiotics to speciation
- trend wbc, fever curve
- if no improvement by 48–72 hours, consider ct chest or alternative dx
- consider glucocorticoids (hydrocort, methylpred) in severe CAP without viral component (i.e. sepsis 2/2 CAP, significant O2 requirement, ICU requirement)
- encourage incentive spirometry, mobilization
- consider id consult if treatment failure or atypical features
*** Clinical reflection: according to idsa/ats 2019 cap guidelines, empiric coverage should include both typical and atypical pathogens unless risk factors for mdr or pseudomonas exist. dual therapy (beta-lactam + macrolide) is preferred in hospitalized, non-icu patients. use the curb-65 or psi score to guide disposition. avoid fluoroquinolones in patients with qtc prolongation or tendinopathy risk. reassess the need for repeat imaging. consider aspiration or viral causes in elderly and altered patients. considering HIV+? -> consider diagnostic workup for opportunistic infections (PCP, TB, fungi).
Pre-operative Cardiac Evaluation for Non-Cardiac Surgery
Urgency of the Procedure
-Emergent
-Urgent
-Elective
Active Cardiac Condition Present?
-Acute Coronary Syndrome
-Decompensated Heart Failure
-Severe Valvular Disease
-Malignant Arrhythmia
Procedure Risk for MACE?
-Low < 1% (e.g. endoscopic, breast, plastic surgery, cataract surgery)
Revised Cardiac Risk Index?
-Intermediate-risk surgery(intraperitoneal, intrathoracic, suprainguinal)
-History of CAD
-History of CHF
-History of CVA
-Pre-op treatment with insulin
-Pre-op creatinine >2
The patient’s Revised Cardiac Index is:
-Low (0-1) (Perioperative MACE <1%)
-High (2-6) (Perioperative MACE >1%)
Patient’s Functional Capacity?
<4 METs
4 -10 METs- Patient can walk at least 4 blocks, up one flights of stairs, or walk up hill without stopping
Other important factors to consider?
None
Pre-operative Cardiac Evaluation:
The patient is at elevated/low risk for a low/intermediate/high risk procedure
Assessment:
There are no cardiac contraindications for the planned procedure.
No further cardiac pre-operative testing is indicated.
Low procedrual risk suggest that further testing is not inidicated
#Sepsis
Patient presents with fever, tachycardia, and hypotension concerning for sepsis, likely secondary to [suspected source: e.g., pneumonia, uti]. initial labs notable for leukocytosis, elevated lactate, and [organ dysfunction, e.g., aki, altered mentation]. cxr/ua/imaging supportive of infection. meets qsofa/sirs criteria and demonstrates end-organ compromise, consistent with sepsis.
- empiric broad spectrum antibiotics: [e.g., vancomycin and zosyn]; blood cultures prior to antibiotics if no delay >45 min;
- iv fluid resuscitation: 30 ml/kg ns bolus administered; reassess response hourly; target MAP ≥65
- follow up blood cultures x2, urine culture, +/- source-directed cultures
- adjust abx per speciation
- monitor map, uop, lactate clearance; target lactate <2 mmol/L or 50% reduction from baseline; repeat lactate in 6 hrs if >2
- imaging (cxr, ct) as clinically indicated to identify infection source
- if hypotension persists after fluids, initiate vasopressors; consult critical care
- consider id consult for unclear source or resistant organisms
- monitor for progression to septic shock and secondary complications
*** Clinical reflection: the Surviving Sepsis Campaign Hour-1 Bundle (2021) recommends: (1) measure lactate level, (2) obtain blood cultures prior to antibiotics, (3) administer broad-spectrum antibiotics, (4) begin rapid administration of 30 ml/kg crystalloid for hypotension or lactate ≥4 mmol/L, and (5) apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥65 mmHg. Always reassess volume status (JVP, IVC, UOP) after initial bolus. Target lactate <2 mmol/L or 50% reduction from baseline as resuscitation goal. Consider procalcitonin to de-escalate antibiotics in 48–72 hours. Ensure source control (e.g., abscess drainage, line removal). Don't miss atypical sources: spinal epidural abscess, endocarditis, abdominal sepsis. In elderly patients, consider early discussion of goals of care.
#Sepsis
Patient presents with fever, tachycardia, and hypotension concerning for sepsis, likely secondary to [suspected source: e.g., pneumonia, uti]. initial labs notable for leukocytosis, elevated lactate, and [organ dysfunction, e.g., aki, altered mentation]. cxr/ua/imaging supportive of infection. meets qsofa/sirs criteria and demonstrates end-organ compromise, consistent with sepsis.
- empiric broad spectrum antibiotics: [e.g., vancomycin and zosyn]; blood cultures prior to antibiotics if no delay >45 min;
- iv fluid resuscitation: 30 ml/kg ns bolus administered; reassess response hourly; target MAP ≥65
- follow up blood cultures x2, urine culture, +/- source-directed cultures
- adjust abx per speciation
- monitor map, uop, lactate clearance; target lactate <2 mmol/L or 50% reduction from baseline; repeat lactate in 6 hrs if >2
- imaging (cxr, ct) as clinically indicated to identify infection source
- if hypotension persists after fluids, initiate vasopressors; consult critical care
- consider id consult for unclear source or resistant organisms
- monitor for progression to septic shock and secondary complications
*** Clinical reflection: the Surviving Sepsis Campaign Hour-1 Bundle (2021) recommends: (1) measure lactate level, (2) obtain blood cultures prior to antibiotics, (3) administer broad-spectrum antibiotics, (4) begin rapid administration of 30 ml/kg crystalloid for hypotension or lactate ≥4 mmol/L, and (5) apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥65 mmHg. Always reassess volume status (JVP, IVC, UOP) after initial bolus. Target lactate <2 mmol/L or 50% reduction from baseline as resuscitation goal. Consider procalcitonin to de-escalate antibiotics in 48–72 hours. Ensure source control (e.g., abscess drainage, line removal). Don't miss atypical sources: spinal epidural abscess, endocarditis, abdominal sepsis. In elderly patients, consider early discussion of goals of care.
#STEMI
Patient presents with chest pain and ECG showing ST elevations in [leads/territory] consistent with acute STEMI. Symptom onset [time], door-to-balloon goal <90 minutes. Culprit vessel likely [LAD/RCA/LCX] based on ECG findings. Risk factors include [HTN, DM, tobacco use]. Currently hemodynamically [stable/unstable].
- immediate dual antiplatelet therapy: aspirin 325mg chewed, ticagrelor 180mg load or clopidogrel 600mg load (if ticagrelor contraindicated)
- anticoagulation: UFH 60 units/kg bolus then 12 units/kg/hr or bivalirudin for primary PCI
- high-intensity statin: atorvastatin 80mg immediately
- beta blocker: metoprolol 25mg BID only if no signs of heart failure, cardiogenic shock, or hemodynamic instability
- activate cath lab for primary PCI - door-to-balloon <90 minutes
- if PCI not available: consider fibrinolytic therapy if <12 hours from onset and no contraindications (tPA, tenecteplase, or reteplase)
- continuous telemetry monitoring for arrhythmias (VF/VT risk highest in first 24-48 hours)
- serial troponins q6h x3, daily ECGs to assess for extension or reinfarction
- echo to assess wall motion, EF, and mechanical complications
- CBC daily, BMP daily (renal function pre/post contrast)
- avoid NSAIDs, hold ACE inhibitors initially if hypotensive
- monitor for complications: cardiogenic shock, mechanical complications (papillary muscle rupture, VSD, free wall rupture), pericarditis
- if cardiogenic shock: consider mechanical support (IABP, Impella), pressors, urgent revascularization
- ACE inhibitor within 24 hours if hemodynamically stable and no contraindications
- cardiology managing primary PCI and post-procedure care
Clinical Reflection: Time is muscle - door-to-balloon <90 minutes for primary PCI or door-to-needle <30 minutes for fibrinolytics if PCI unavailable. Primary PCI preferred over fibrinolytics when available. Posterior STEMI often missed - look for ST depressions in V1-V3 with tall R waves. RV infarction with inferior STEMI requires preload maintenance (avoid nitrates/diuretics). Post-PCI, continue dual antiplatelets for minimum 12 months. Start ACE inhibitor and beta blocker before discharge if tolerated. Early complications include arrhythmias, mechanical complications, and cardiogenic shock. Pericarditis common 2-5 days post-MI. Ensure cardiac rehab referral and aggressive secondary prevention.
#Stroke
Patient with sudden focal neuro deficit. last known normal [x]. nihss [x]. no overt toxic/metabolic disturbances displayed through history or labs. head ct negative for hemorrhage. imaging shows ischemic stroke affecting [region]. no contraindications to tpa if within 4.5 hours.
- ?s/p aspirin 325 mg and plavix load of 300mg if not giving tpa
- continue daily asa 81mg and plavix 75mg
- high intensity statin
- follow up remaining imaging studies (MRI brain, CTA carotids, neuroperfusion, carotid dopplers, echo w/ bubble)
- monitor vitals, neuro checks per unit protocols
- consider tpa if within window
- permissive hypertension (< 220/120) unless tpa administered
- if BP ≥ 220/120 then careful BP reduction by 15% within first 24 hours with IV nicardipine/clevidipine/
- if tpa administered, reduce BP to <185/110 beforehand and keep <180/105 for the first 24 hours after treatment
- f/u A1c, lipid panel
- keep npo until swallow evaluation/dysphagia screen
- PT / OT / SLP evals
- dvt prophylaxis with chemical ppx (if no tpa) and scds
- neurology consulted
Clinical reflection: tpa eligibility requires time window and blood pressure management. thrombectomy may be considered up to 24 hours for large vessel occlusion. avoid unnecessary lowering of bp. start stroke prevention measures early: antiplatelet, statin, blood pressure control.
#Syncope
Patient with transient loss of consciousness with spontaneous recovery. no postictal confusion or focal neuro signs. likely vasovagal or orthostatic etiology. no evidence of seizure or arrhythmia. High risk cardiac features: exertional syncope, family history of SCD, structural heart disease, abnormal ECG, age >60. ECG abnormalities: prolonged QT, Brugada pattern, heart block, LVH with strain. Canadian Syncope Risk Score: [-3 – 11].
- obtain orthostatic vitals
- treat with IVF if positive
- if suspected vasovagal: consider tilt-table testing (outpatient) and carotid sinus massage
- review medications and hold if concerned for polypharmacy
- obtain ekg, monitor on telemetry
- obtain TTE if murmur or structural heart disease suspected
- obtain CTH if focal neurologic signs or head trauma
- avoid carotid doppler studies unless indicated (CVA, carotid bruit, known carotid stenosis, preop for carotid revasc, retinal artery embolization)
- consider Holter and/or stress test (if exertional) on discharge
- neurology or cardiology consult if recurrent or atypical features
Clinical reflection: syncope requires evaluating cardiac, neuro, and reflex causes. red flags include exertional onset, family history of sudden death, or abnormal ekg. consider tilt testing or loop monitoring for unclear cases. assess fall risk in elderly. Vasovagal – a/w trigger/prodrome -> vagus nerve/parasympathetic activation resulting in decreased CO, BP and increased vasodilation. Carotid sinus hypersensitivity – recurrent reflex syncope after pressure applied to carotid sinus – diagnosed with pause in HR ≥ 3 seconds or fall in SBP by ≥ 50 mmHg after carotid massage.
_____________________________
By buckets
General purpose of admission is to exclude dangerous causes of syncope, typically by overnight telemetry, serial cardiac enzymes, and TTE
? Cardiac Mechanical
(Aortic Stenosis, Hypertrophic Cardiomyopathy, Pulmonary Embolism, HTN, Stenosis, Aortic Dissection, Myocardial Infarction)
- Echo
- CXR
- D-dimer / CT-PE if hypoxic
- Cardiac Enzymes; Consider Stress Test if negative
? Cardiac Electrical
(AV Block, Sick Sinus Syndrome, Arrhythmia, Long QT syndrome, Bradycardia, Ischemia, Pre-Excitation)
- EKG
- Telemetry + Pulse Ox monitoring
- Pacer Interrogation
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