Approach to Common Things on Call (or, how to not look stupid at post-call morning rounds)

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Approach to common things on call

Approach to Common Things on Call (or, how to not look stupid at post-call morning rounds)

In General,

1. Go examine the patient and check investigations if the nurse calls and is worried

2. Do #1 and come up with a differential diagnosis/management plan before calling your senior

3. Rule out anything that could kill / seriously worsen your patients condition

4. Ask for help if you arent sure***

1. Shortness of breath differential: ACS, PE, pulmonary edema, bronchospasm. aspiration/pneumonia, arrhythmia (brady or tachy), tamponade

Hx: Chest pain (pleuritic or exertional), infectious symptoms, onset (sudden or gradual), syncope/presyncope

Physical: JVP, heart, lungs and pedal edema

Tests: ECG, CK/TnI, CXR, cap gas

Initial Management: ASSESS VOLUME STATUS, decide if diuresis warranted, consider bronchodilators *** If on more than 40-50% FiO2, consider calling CCOT and your senior sooner!2. Hypotension differential: Hypovolemia (blood or water), ACS, PE, sepsis, tachyarrhythmia, tamponade, medications

Hx: Level of consciousness, infectious symptoms, chest pain, SOB, new meds

Physical: Urine output, heatr rate, BP (both arms), temp, JVP, heart, lungs. Check graphics is this new/worse? Tests: CBC, lytes, Cr, BUN, CONSIDER: CXR, cap gas, ECG/CK/TnI Initial Management: EVERYONE GETS A FLUID BOLUS (ex. 500 cc over 2h, dont be afraid of fluids!!!!!!!!!)3. Confusion / decreased loc Differential: Structural vs. metabolic causes, drugs (too much or too little), infection, metabolic, PE, ACS, electrolytes, seizures, end-organ encephalopathies (lungs CO2, liver ammonia, kidneys uremia) Hx: check the MAR for benzos, narcotics etc, infectious symptoms, chest pain/SOB, focal neuro deficits, refresh your memory on PMHx (i.e alcoholic, known ESRD etc.)

Physical: BP, heart, lungs, quick neuro exam (pupils, move 4 limbs, DTRs, tone, plantars) Tests: glucose (FP), CBC, extended lytes, Cr, BUN, liver enzymes, ECG, CK/Tn; CONSIDER: capgas, CT head, B12, folate Initial Management: depends on underlying cause. PLEASE, dont just give everyone ativan and haldol

***if NEW focal neuro deficit, SIGNIFICANT decreased LOC, or any vitals are unstable, consider calling your senior sooner!

4. Chest pain Differential: ACS, PE, GERD, pneumonia/pleuritis, pericarditis/myodarditis, chest wall, dissection

Hx: cardiac RF, onset and duration, SOB, cough, pleuritic, infectious symptoms

Physical: vitals, JVP, heart, lungs, BP both arms, examine the precordium

Tests: ECG, CK/Tn, CBC, lytes; CONSIDER: CXR, capgas

Initial Management: Try NTG spray if thinking ACS. If ACS is RULED OUT, try a white night (dioval + lidocaine)

*** If NSTEMI is the diagnosis: MONAH B

morphine 1-5 mg IV Q 10 min prn (max 10 mg/30min)

O2 to keep sat >94%; NTG 0.4mg sl q5min prn x 3

ASA 160 mg po x 1 now to chew (usually 1st thing you do) Enoxaparin 1mg/kg s.c bid (or IV heparin per protocol if renal failure) Metoprolol 12.5 or 25 mg po bid (consider giving 2.5-5mg IV metoprolol if tachycardic or hypertensive)

Consider Clopidogrel 300 mg loading dose, then 75mg po od

Common complications during ACS to watch for are arrhythmias and pulmonary edema

5. Hyperkalemia (normal K is 3.5 5.0)

If K is 5 5.51. Kayexalate 30 to 90 g po and/or p.r, add lactulose if no bowel movement2. Check lytes again in 4-6 hours

If K is >5.51. Stat ECG (check for peaked T waves, wide QRS)2. CARDIAC STABILIZATION: Ca gluconate 1 amp I.V push3. SHIFTING: Insulin R 10 units I.V, Consider HCO3 and Salbutamol4. Repeat K in 30 min 1 hour, if still elevated then repeat5. Look for and treat underlying cause of hyperkalemia (new meds, renal failure, lysis)