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overall Strategy: write down the following so you find it quickly
Differential Diagnosis:
Allergies:
Counseling:
Then, follow this order for each case:
1) ABC's: stable or not?
2) PE: focused unless pt has a general complaint
3) Labs/ Rad
4) Triage/Meds
5) Counsel/Follow-up appt
General Orders:everyone
CBC/CMP/TSH
General Orders: Females:
β-HCG
General Orders: Infection:
CXR/UA/ Cultures/Tylenol
General Orders: Cardiac:
EKG / CXR/Echo /Cardiac enzymes
General Orders: Pulmonary:
ABG/EKG/CXR
General Orders: GI:
Guaiac
General Orders:
Renal
UA
General Orders:Heme:
Guaiac/PT / PTT /Type and match
general orders Ob-Gyn:
β-HCG / Pap/ Prolactin/ ABO, Rh
Cellulitis
Clindamycin + Ciprofloxacin
Prostatitis
Ciprofloxacin + Ampicillin + Gentamycin
Urosepsis:
Ciprofloxacin + Ceftriaxone
Diverticulitis
Metronidazol + Ciprofloxacin
Appendicitis
Metronidazole + Cefazolin
Septic Arthritis:
Azithromycin + Ceftriaxone
perforated ulcer
Metronidazole + Ampicillin + Gentamycin
Cholecystitis:
Cefuroxime
Sickle Cell:
Azithtomycin + Cefuroxime
Community-Aquired Pneumonia
Azithromycin + Ceftriaxone
Bacterial Meningitis
Vancomycin + Ceftriaxone
Bacterial Endocarditis
Vancomycin+ Gentamycin
Pelvic Inflammatory Disease
Doxycyclin + Cefoxitin
Febrile Neutropenia
Ceftazidime
Emergency Room:
1) Pulse ox/ Oxygen
2) IV access/NSS (0.9%NaCl)
3) Vitals/Continuous (BP /Cardiac)
Ward Admission:
''NAD HIC"
1) NPO/Foley/Urine outputs
2) Activity
3) Discomfort Meds: Mepiridine/ Phenergan
4) Home meds
5) Interval PE/Hx
6) Consults
ICU Admission:
1) Prophylaxis: Pantoprazole/ Pneumatic compression stockings
2) Interval PE/Hx
3) Send to ward -> then home
Discharge:
1) D/C IV access, D/C all tubes
2) D/C IVF
3) Change all meds to PO
4) Diet: disease-specific
5) Follow-up appt: 2wk unless specified
Counseling (at the 5min warning):
'X-RATED SEX"
X: safe seX
Rx: medication compliance/side effects
Alcohol: limit intake
Tobacco: cessation
Exercise: program
Directives: advance
Seat belt: when driving
Eat: diet
X: no illegal drugs
Preventative Medicine:
21 y / o:
Cholesterol/Pap smear
Preventative Medicine: 40 y/o:
Glucose/Mammogram/Prostate exam
Preventative Medicine: 50 y/ o:
Colonoscopy
Preventative Medicine: 65 y/o:
TSH/Female Pelvic exam
ALZHEIMER'S:
Labs: (4)
Tests:
Labs: TSH, Vit B12, Folate, UA
Tests: Head CT
ALZHEIMER'S:
(tx Alzheimer's)
(tx delusions
(tx anxiety)
(tx depression)
(tx insomnia)
Donepezil (tx Alzheimer's)
• Olanzapine (tx delusions)
• Buspirone (tx anxiety)
• Fluoxetine (tx depression)
• Triazolam (tx insomnia)
ALZHEIMER'S:
Location:
Counsel:
Follow-up:
Location: Office
Counsel: No driving, Advance directives
Follow-up: 2mo
BACTERIAL MENINGITIS:
Labs:
CSF:
Tests:
BACTERIAL MENINGITIS:
Labs: Blood C&S, UA/C&S, PT / PTT
CSF: Cells/Glucose/Protein/C&S + fungal/Gram/Meningococcal Ag
Tests: EKG, LP
BACTERIAL MENINGITIS:
Rx
Contact Prophylaxis
Consult:
Location:
Rx Acetaminophen (rectal), Dexamethasone -> Vancomycin/Ceftriaxone
Contact Prophylaxis: Rifampin or Ciprofloxacin
Consult: ID
Location: Ward (isolation)
SUBARACHNOID HEMORRHAGE
Labs:
Tests:
"worst HA of my life"
Labs: ESR, PT / PTT
Tests: EKG, Head CT (no contrast), Angiography (cerebral arteries)
SUBARACHNOID HEMORRHAGE Rx: tx pain, prevent vasospasm, prevent seizures, if HTN
Ketorolac (tx pain), Nimodipine (prevent vasospasm), Phenytoin (prevent seizures), Labetalol (if HTN)
SUBARACHNOID HEMORRHAGE: Consult, Location and management
Consult: Neurosurgery, Location: ICU (Neurochecks q1hr)
TRANSIENT ISCHEMIC ATTACK: Labs and Tests
Labs: PT / PTT, Lipid profile, Tests: EKG /Echo, CXR, Head CT (no contrast), Carotid Doppler
TRANSIENT ISCHEMIC ATTACK: Rx, Consult and when is an endarterectomy done?, Location
Rx: ASA, Pneumatic compression stockings, Consult: Vascular Surgery (for carotid endarterectomy if 70-99% stenosis), Location: Ward
ALCOHOL WITHDRAWAL: Labs and Tests:
Labs: ABG, EtOH/Urine tox, Blood C&S/UA, Mg/Phos /Glucometer, PT / PTT, Tests: EKG, CXR, Head CT
ALCOHOL WITHDRAWAL:
Rx:
Location:
Rx: NG tube suction, Thiamine -> Dextrose 50%, Folate, Lorazepam
Location: ICU
DEPRESSION: Labs, Tests, Rx
Labs: TSH, Vit B12, Folate, Tests: EKG, Rx: Fluoxetine, Suicide contract
DEPRESSION:
Consult
Location:
Follow-up:
Consult Psychiatry
Location: Office
Follow-up: 6wk
NARCOTIC OVERDOSE: Labs, Tests:
Labs: ABG, Cardiac enzymes, EtOH/Urine tox/ Acetaminophen, Blood C&S/UA, Mg/Phos/Glucometer, PT/PTT, Tests: EKG, CXR, Head CT
NARCOTIC OVERDOSE: Rx, Location
Rx: NG tube suction, Naloxone, Thiamine -> Dextrose 50%, Charcoal (Gastric lavage if needed), Location: ICU
PANIC ATTACK:
Sx
Labs:
Tests:
palpitations, chest pain, dyspnea
Labs: TSH, β-HCG, UA/ Urine tox, Glucometer
Tests: EKG, CXR
PANIC ATTACK:
Rx:
Location:
Rx: Alprazolam + Fluoxetine
Location: Office
AORTIC DISSECTION:
Sx:
#1
Tests:
Sx: sudden severe abdominal/pain radiating to back
#1IVF
Tests: US (abdomen) if stable
AORTIC DISSECTION:
Rx:
Labs:
Rx: Vascular Surgery Consult (stat, for AAA repair)
Labs: Type x cross, PT /PIT
AORTIC DISSECTION:
Pre-op:
Location:
Pre-op: Analgesia, Consent, NPO?Foley, UA/ CXR (portable), CBC/CMP, EKG
Location: ER -> OR
ATRIAL FIBRILLATION:
Labs:
Tests:
Labs: Cardiac enzymes, TSH/Free T4, UA, PT /PTT
Tests: EKG, CXR (FA/Lateral), Echo
ATRIAL FIBRILLATION:
Rx:
Location:
Rx: Cardizem, Metoprolol (if HR >120), Heparin/Plt/Guaiac
Location: ward
CHF EXACERBATION:
Labs
Tests
Labs: cardiac enzymes
Tests: EKG,-CXR, Echo, Daily weights
CHF EXACERBATION:
Rx:
Location:
Rx: ASA,β-blocker, Cholesterol drug, Digoxin, Enalapril, Furosemide/K.Cl ''ABCDEF"
Location: ward
COMPLETE HEART BLOCK:
Sx:
Labs:
Tests:
Sx: can occur secondary to trauma
Labs: cardiac enzymes, PT /PTT
Tests: EKG, portable CXR, Echo
COMPLETE HEART BLOCK:
Rx:
Consult:
Location:
Rx: Atropine. (stat),Pacemaker (temp transcutaneous)
Consult: Cardiology
Location: ER -> Cardiac Cath lab
HYPERTENSION:
Labs:
test:
Labs: TSH, UA, Lipid profile
Tests: EKG
HYPERTENSION:
Rx:
Location:
Rx: ⇧Fiber/ ⇩Na Diet, Exercise, Meds as appropriate.
Location: Office
HYPERTENSIVE EMERGENCY:
Sx:
#1:
Labs: T
Sx: diastole > 120
#1: Head CT (⇧ICP or Stroke)
Labs: UA, PT /PTT
HYPERTENSIVE EMERGENCY:
Tests:
Rx:
Tests: EKG, CXR
Rx: Arterial line, Nitroprusside -> Metoprolol
HYPERTENSIVE EMERGENCY:
Follow-up (1 wk):
Location:
Follow-up (1 wk): Lipid profile
Location: ICU
INFECTIVE ENDOCARDITIS:
Sx:
Labs:
Tests:
Sx: splinter hemorrhages, painfulfinger nodes
Labs: Blood C&S, UA/C&S/Urine tox, PT /PTT
Tests: EKG, CXR, Echo
INFECTIVE ENDOCARDITIS:
Rx:
Location:
Follow-up (1 wk):
Rx: IVF /Central line, Vancomycin+ Gentamycin, Acetaminophen
Location: Ward
Follow-up (1 wk): Hepatitis panel, HIV
MYOCARDIAL INFARCTION:
ST
Labs:
Tests:
ST elevation
Labs: Cardiac enzymes q8hr x 3, Lipid profile, LFT
Tests: EKG, CXR
MYOCARDIAL INFARCTION:
Rx:
Discharge meds:
Rx: 02, ASA, Metoprolol, Nitroglycerin, Heparin/Plt/Guaiac,"Morphine
Discharge meds: ASA + Metoprolol + Atorvastatin
MYOCARDIAL INFARCTION:
Follow-up:
Location:
Follow-up: cardiac Cath (if not improving), Cardiology Consult, Stress test
Location: ward
CROHN'S:
Labs:
Tests:
Labs: Stool: culture/O&P
Tests: Guaiac
CROHN'S:
Rx:
Location:
Rx: Colonoscopy, Biopsy (small intestine), GI consult, Mesalamine
Location: Office
DIVERTICULITIS:
Sx:
Labs:
Sx: RUQ pain
Labs: Amylase/Lipase, Blood culture, UA/C&S
Stool: WBC/Cultute/O&P
DIVERTICULITIS:
Tests:
Rx:
Tests: EKG, Guaiac, X-ray (abdomen), CT (abdomen)
Rx: Acetaminophen (rectal), Ciprofloxacin/Metronidazole, GI consult
DIVERTICULITIS:
Location:
Follow-up (4wk):
Location: Ward
Follow-up (4wk): Colonoscopy
DIVERTICULOSIS:
Sx:
Labs:
Sx: bloody stool
Labs: Type x cross, PT/ PTT, H/H q6h
DIVERTICULOSIS:
Tests:
Rx:
Tests: Postural vitals (stat), Guaiac, EKG, Anoscopy
Rx: NG, NPO, Polyethylene Glycol, Colonoscopy (GI consult)
DIVERTICULOSIS:
Location:
Follow-up (1 wk):
Location: Ward
Follow-up (1 wk): high fiber diet, check H/H
DUODENAL ULCER (acute)
Sx:
Labs:
Sx: vomit blood. black stool
Labs: PT /PTT, Type x match, H/H q6h
DUODENAL ULCER (acute)
Tests:
Rx:
Tests: EKG, EGD, Biopsy (gastric), GI consult
Rx: NG, Gastric Lavage, Pantoprazole
DUODENAL ULCER (acute)
Location:
Follow-up (2wk):
Location: ICU
Follow-up (2wk): check H/H
DUODENAL ULCER (chronic)
Sx:
Labs:
Sx: weakness, SOB
Labs: β-HCG, Fe/Ferritin/TIBC, UA, Type x cross, PT /PTT, H. pylori Ab, Amylase /Lipase
DUODENAL ULCER (chronic)
Tests:
Rx:
Tests: Guaiac, CXR, EGD, Biopsy (gastric), GI consult
Rx: Fe/Vit C, Omeprazole + Clarithromycin + Amoxicillin (if H. pylori+)
DUODENAL ULCER (chronic)
Location: Ward
Follow-up (2wk):
Location: Ward
Follow-up (2wk): Urea breath test
DUODENAL ULCER
Sx: (perforated):
Labs:
Sx: (perforated): free air under diaphragm
Labs: Amylase/Lipase, Type x cross, PT /PTT
DUODENAL ULCER
Tests:
Rx:
Tests: EKG, X-ray (abdomen)
Rx: NG, Ranitidine, Ampicillin+ Gentamycin + Metronidazole
DUODENAL ULCER
Pre-op:
Location:
Pre-op: Surgery consult (stat), Analgesia, Consent, NPO, CXR/UA
Location: ICU
GASTROENTERITIS:
Rx:
Location:
Rx: 02, ASA, Heparin/Ph/Guaiac, warfarin/INR/β-HCG
Location: ICU
SINUSITIS:
Rx:
Location:
Rx: Humidified air, Acetaminophen, Pseudoephedrine, Amoxicillin
Location: Office
TENSION PNEUMOTHORAX:
Sx:
Rx:
Sx: decreased breath sounds, hypotension
Rx: Needle thoracostomy (stat) ~>chest tube~>CXR
Labs: ABG
Tests: EKG, repeat CXR qam
Location: Ward
TENSION PNEUMOTHORAX:
Labs:
Tests:
Location:
Labs: ABG
Tests: EKG, repeat CXR qam
Location: Ward
APPENDICITIS:
Labs:
Tests:
Labs: ABG, β-HCG, Amylase/Lipase, PT/PIT
Tests: Guaiac, X-ray (abd), CT (abd) for adults, or US (abd) for kids
APPENDICITIS:
Rx:
Pre-op:
Location:
Rx: morphine, Cefazolin + Metronidazole, Appendectomy (Surgery consult)
Pre-op: Analgesia,Consent, NPO, Type x cross, CXR/UA
Location: Ward
CHOLECYSTITIS:
Labs:
Tests:
Rx:
Labs: β-HCG, Amylase/Lipase. PT /PIT
Tests: X-ray (abdomen), US (abdomen)
Rx: NG tube, Demerol, Cefuroxime (Surgery consult)
CHOLECYSTITIS:
Rx:
Pre-op:
Location:
Rx: NG tube, Demerol, Cefuroxime (Surgery consult)
Pre-op: Analgesia, Consent, NPO, IVF, Type x cross, CXR/UA
Location: Ward
COLON CANCER:
Labs:
Tests:
Labs: TSH, CEA
Tests: Guaiac, X-ray (abdomen), CT (abdomen)
COLON CANCER:
Rx:
Location:
Follow-up (2wk):
Rx: Fe sulfate, Docusate, Surgery consult/Oncology consult
Location: Office
Follow-up (2wk): Colonoscopy (GI consult
CONSTIPATION:
Labs:
Tests:
Labs: TSH, Mg/Phos
Tests: EKG, Guaiac, X-ray (abd)
CONSTIPATION:
Rx:
Location:
Rx: High fiber diet, Docusate, Metamucil
Location: Office
CONSTIPATION:
Follow-up:
Follow-up: NPO, Polyethylene Glycol Colonoscopy w/ consent (if symptomatic)
CROUP:
Sx:
Labs:
Tests:
Sx: barking cough
Labs: CBC
Tests: Neck x-ray
CROUP:
Rx:
Location:
Rx: Cool mist ~> Dexamethasone (IM) ~> Epinephrine (inhaled)
Location: ER (observe for 4hr)
CYSTIC FIBROSIS:
Labs:
Tests:
Labs: Sweat Cl> 60, Fecal fat, Blood C&S, Sputum: Gram/C&S
Tests: CXR, Sinus x-ray
CYSTIC FIBROSIS:
Rx:
Location:
Rx: D5N5, Albuterol, N-acetylcysteine, Tobramycin + Piperacillin, Chest PT
Discharge: Pancreatic enzymes, Influenza/Pneumococcal vaccinations
Location: Ward
LUNG CANCER:
Labs:
Tests:
Mets:
Labs: ABG/PFT, Blood C&S, Sputum: Gram/C&S/Cytology
Tests: EKG, CXR (FA/Lateral), spiral CT (chest)
Mets: Ca/ AlkPhos, CT (A/P), Brain MRI, Bone Scan
LUNG CANCER:
Rx: (2)
Rx: Bronchoscopy/Biopsy lung, Branch: Cytology/Gram/C&S+Fungal/AFB
Rx: Albuterol/Iprattopium, Levofloxacin ·
LUNG CANCER:
Consults: Pulmonary, Oncology
Location: Ward
Consults: Pulmonary, Oncology
Location: Ward
PLEURAL EFFUSION:
Sx:
Labs:
Sx: x-ray blunting of costophrenic angles
Labs: Cr/LDH/Protein, PT /PTT
PLEURAL EFFUSION:
Pleural Fluid:
Tests:
Pleural Fluid: pH/LDH/Protein/Glucose/Grarn/Cells/Cytology/C&S/ AFB
Tests: EKG, CXR (FA/Lateral/Decubitus)
PLEURAL EFFUSION:
Rx:
Location:
Rx: Thoracentesis (Pulmonary consult)
Location: Ward
PNEUMONIA:
Sx:
Labs:
Sputum:
Sx: may present with RUQ pain
Labs: ABG, Blood ex, Urine ex, Sputum: Gram/C&S
PNEUMONIA:
Rx:
Rx:
• Community Acquired: Azithromycin ( + Ceftriaxone if dyspnea)
• Nosocomial: Piperacillin + Tazobactim
• Aspiration: Clindamycin
• Group B Strep: Ampicillin + Cefotaxime
• Atypicals (Chlamydia/Mycoplasma/Legionella): Erythromycin
PNEUMONIA:
Tests:
Location:
Tests: EKG, CXR (FA/Lateral)
Location: Ward
PULMONARY EMBOLUS:
Labs:
Tests:
Labs: ABG, D-dimer, Cardiac enzymes, PT /PTT
Tests: EKG, CXR (PA), V /Q scan
PERICARDIAL TAMPONADE:
Sx:
Rx:
Sx: hypotention, muffled heart, ⇧ JVD
Rx: Pericarcliocentesis (stat), CT Surgery consult, Swan-Ganz catheter
PERICARDIAL TAMPONADE
Labs:
Tests:
Location:
Labs: ABG, Pericardial fluid: cell count
Tests: EKG, CXR, Echo
Location: ICU
PERICARDITIS:
Sx:
Labs:
Tests:
Sx: worse w/ inspiration and leaning forward
Labs: Cardiac enzymes, Blood C&S, ESR
Tests: EKG, CXR, Echo, Pulse ox, ABC
PERICARDITIS:
Rx:
Location:
Rx: 02, ASA, Pericardiocentesis (if febrile)
Location: Ward
UNSTABLE ANGINA:
Sx:
Labs:
Sx: chest pain at rest, ST depression
Labs: Cardiac enzymes, Lipid profile, PT /PTT
UNSTABLE ANGINA:
Rx:
Tests:
Rx: ASA, NGN, Metoprolol,02, Heparin/Pit/Guaiac, Morphine
Tests: EKG, CXR, Echo
UNSTABLE ANGINA:
Location:
Follow-up
Location: ICU
Follow-up (4wk): Stress test, Angiography (coronary)
ASTHMA EXACERBATION:
Labs:
Tests:
Labs: ABG, FEV/PEFR (peak expiratory flow rate)
Tests: EKG, CXR
ASTHMA EXACERBATION:
Rx:
Location:
Discharge:
Rx: Albuterol, methyprednisolone ~> Ipratropium
Location: Ward
Discharge: Beclomethasone (inhaled)
BRONCHIOLITIS:
Labs:
Tests:
Rx:
Labs: ABG, RSV Antigen
Tests: CXR
Rx: Albuterol, Humidified air, Suction airway, Chest PT, Ribavirin (if resp failure)
BRONCHIOLITIS:
Location:
Follow-up:
Location: Ward (isolation)
Follow-up: 24hr
COPD EXACERBATION:
Labs:
Tests:
Rx:
Labs: ABG, PEFR/FEV1
Tests: EKG, CXR
Rx: 02, Albuterol, Ipratropium, Prednisone, Levofloxacin
COPD EXACERBATION:
Location:
Follow-up:
Location: Ward
Follow-up: Influenza/Pneumococcal vaccinations, Home 02
(if p02<55)