This is a starting place when you are confronted with a page that you are not quite sure how to answer. It is by no means an exhaustive list or meant to guide care. Please discuss with your senior resident prior to doing anything on your own if you are not sure what to do.

+ Abdominal Pain

This is a broad topic that should be approached with guidance from your senior resident. In this space, we will be discussing urgent etiologies that must be considered during nightfloat / cross-cover.

General elements:

  • obtain full set of vitals
  • perform thorough abdominal exam
  • perform serial abdominal exams

Urgent diagnoses requiring surgical consultation and co-management:

  • Peritonitis: severe pain with +rebound, +guarding, absent bowel sounds. Abdominal imaging with +free air.
  • Ischemic bowel: pain out of proportion to exam, +bloody stool.
  • Abdominal Aortic Aneurysm: severe pain, large pulsatile mass, hypotension
  • Obstruction: nausea, vomiting (feculent), bloat/distention. XR with air-fluid levels.
  • Cholangititis: Fever, RUQ pain, jaundice (+/- hypotension and AMS). LFTs in cholestatic pattern.

Work up: lactate, lipase, LFTs, UA, Abdominal XR, CT versus ultrasound.

Consider: NPO, IVF, IV antibiotics (if appropriate), IV narcotics*

*If surgical evaluation warranted, consider holding narcotic administration until surgical team has performed bedside exam.

Differential by location

  • Diffuse: Peritonitis; Mimics: Diabetic Ketoacidosis, Adrenal Insufficiency
  • Epigastric: PUD, pancreatitis, gastritis, AAA; Mimics: Myocardial Infarction
  • RUQ: cholecystitis, biliary colic, cholangitis, hepatitis; Mimics: pulmonary infarction, pneumonia, rib fracture
  • LUQ: gastritis, pancreatitis, ovarian torsion, ectopic pregnancy; Mimics: splenic infarction, rib fracture
  • RLQ: appendicitis, ureteral kidney stone, hernia, ovarian torsion, ectopic pregnancy, constipation
  • LLQ: diverticulitis, ureteral kidney stone, hernia
  • Suprapubic: cystitis, bladder outlet obstruction

+ Agitation/Delirium

+ AMA

Discharge Against Medical Advice (AMA) is when a patient chooses to leave the hospital before the medical team recommends discharge.

1.) Confirm patient has medical capacity. Cannot have medical conditions that would impair decision making (delirium, encephalopathy, intoxication). Must be able to express understanding of the risks of leaving.

2.) Attempt to identify motivation for leaving and address if possible.

3.) Obtain AMA form from HUC or bedside RN. Explain to patient potential consequences of leaving prior to completion of treatment. Obtain teach-back from patient. Have patient sign form. Remove all lines.

4.) Notify your senior. Discuss if any scripts should be sent with patient. No controlled substances should be prescribed.

5.) Documentation. Document your conversation. If capacity exam was necessary, use .capacity template.

+ Arrhythmias

+ Chest Pain

+ Constipation

+ Electrolyte Replacement

+ Fever

+ Pain Control

+ Hyperglycemia

Assess symptoms (mental status is most important!).

Review medications (including IVFs) and diet. Adjust if necessary.

Give additional insulin if more than 3 hours since last dose. If severe hyperglycemia, may consider additional dose of insulin given IV.

Consider giving additional IV hydration if appropriate.

Do not miss DKA! (typically T1DM)

  • Diagnosis: hyperglycemia, serum ketones (specific), urine ketones (sensitive), pH < 7.3 or HCO2 < 22, elevated anion gap
  • Treatment: Aggressive hydration, insulin IV and consider drip, call senior!

Do not miss HHS! (typically T2DM)

  • Diagnosis: hyperglycemia, not acidotic, no ketones, elevated osmolality = 2(Na+K) + BUN/2.8 + glucose/18
  • Treatment: Aggressive hydration, insulin IV and consider drip, call senior!

Identify precipitants: doses of insulin held, inadequate insulin dosing, sepsis, nonadherence to consistent carbohydrate diet.

+ Hypoglycemia

Assess symptoms (mental status is most important!)

Treat quickly!

  • If able to take PO, give 4 ounces of juice
  • If unable to take PO, give 1 amp of D50 IV
  • If symptomatic and no IV access, give glucagon 1.0 mg SQ or IM

Recheck glucose 15 minutes after intervention.

Review medications and diet. Adjust if necessary. (If NPO for a procedure, their insulin should be decreased by 25-50%).

Identify causes: Sepsis, decreased PO intake, renal insufficiency, reactive post-prandial, EtOH, liver disease, adrenal insufficiency, hypopituitarism, adrenal insufficiency, severe malnutrition, insulinoma

+ Hyperkalemia

Evaluation:

Check if the specimen was hemolyzed. If the result seems suspicious, repeat the lab ASAP.

Obtain STAT EKG. Progression of changes as follows:

  • Peaked T-waves with shortened QT interval
  • Lengthening of the PR interval and QRS duration
  • P wave disappear
  • QRS widens further
  • Sine wave pattern
  • Flat line… uh oh!

Check I/Os to see if patient is urinating.

Management "C BIG K Di"

  • Calcium gluconate: 1 amp over 2-3 minutes for cardiac protection.
  • Beta-agonist: Albuterol nebulization
  • Insulin: 10 units IV regular insulin with D50 1 amp (consider dose decrease if AKI)
  • Diuretics: furosemide 40 mg IV if renal function adequate
  • Kayexalate: 15-45 grams PO or as enema
  • Sodium bicarbonate: 1 amp IV if severe metabolic acidosis (avoid in ESRD for large osmotic load)
  • Dialysis

Identify causes: renal insufficiency, medications, acidosis, type 4 RTA, tissue destruction (i.e. rhabdo, tissue infarction, hemolysis)

+ Hypertenion

Definitions:

  • HTN Urgency: SBP >180 or DBP >120 without symptoms or end-organ damage
  • HTN Emergency: Elevated BP with signs of acute end-organ damage

    End-organ damage: headache, vision change, papilledema, mental status change, chest pain, EKG changes, shortness of breath, pulmonary edema on CXR, and acute elevation of Cr on BM

What to consider:

  • Is the patient symptomatic?
  • Is this acute or chronic?
  • Consider: reactive elevation in BP due to pain, anxiety or agitation; cerebral injury; pheochromocytoma, Cushing’s or progression of essential HTN, progression of renal disease, or autonomic dysfunction

Initial steps:

  • Review BP trend in chart
  • Review I/O in chart
  • Review Med-Rec and MAR to see if anti-HTN therapy was missed
  • Go see the patient and perform cardiac, pulm, and neuro exam
  • Ask MA or RN to check bilateral manual BP with appropriately sized cuff
  • Check EKG, BMP, CXR, and CT head as indicated based on clinical context, symptoms, and exam

Treatment Goals:

  • HTN Urgency: decrease BP in hours with PO agents
  • HTN Emergency: decrease MAP by 25% within min to 2 hours with IV agents

Treatment Options for Uncontrolled HTN:

  • If pre-existing HTN, then consider restarting home anti-HTN meds +/- intensify dose
  • If new diagnosis of HTN, then initiate therapy based on pt demographics and co-existing conditions (DM, CKD, HF, ischemic heart disease, etc). In general, thiazide, CCB, or ACEi
  • If due to pain, nausea, anxiety, or agitation, then address accordingly

Treatment Options for HTNsive Emergency (IV agents):

  • Nicardipine: Drug of choice (DOC) for AKI; Contraindicated (CI) in advanced aortic stenosis
  • Nitroprusside: DOC HTN Encephalopathy; Tachyphylaxis and cyanide poisoning with extended use
  • Nitroglycerin: DOC cardiac ischemia and pulmonary edema; Do NOT use if pt is taking PDE-5 inhibitor
  • Labetalol and esmolol: DOC in CVA, aortic dissection, and ACS; Do NOT use if bradycardia or 2nd or 3rd degree block; May worsen HF. Do NOT use if HTNsive emergency with pulmonary edema as this is acute decompensated CHF. Labetalol is CI in asthma and COPD
  • Hydralazine: NOT first line due to unpredictable response and prolonged duration (2-4 h) and causes rebound tachycardia

+ Hypotension

Always notify your senior resident when you are called for any hypotensive event.

Definitions:

  • Relative Hypotension: drop in SBP > 40 mmHg
  • Absolute Hypotension: SBP < 90 or MAP < 65
  • Shock: state of insufficient perfusion and oxygen delivery to tissues

What to consider:

  • This is urgent and takes top priority
  • Is hypotension associated with signs of decreased tissue perfusion?
  • Is this sepsis (qSOFA (+) or SIRS (+) with suspected source)?
  • Other etiologies of shock: distributive, hypovolemic, cardiogenic, obstructive

SIRS Criteria (2 of 4)

  • Temp > 38 or < 36 C
  • HR > 90
  • RR > 20 or PaCO2 < 32
  • WBC >12, <4, data-preserve-html-node="true" or >10% bands)

qSOFA Criteria (2 of 3)

  • SBP ≤ 100 mmHg
  • RR < 22
  • AMS (GCS < 15)

What to do:

  • Tell the senior immediately
  • Go see the patient

If concerned for shock and etiology is undifferentiated, then check the following:

  • Lactate, CMP, troponin, BNP, CBC with diff, PT/INR, VBG, cortisol
  • EKG
  • CXR

Treatment:

  • Volume resuscitation. Be cautious if there is cardiac dysfunction. Check last known LVEF. If EF <50% data-preserve-html-node="true" and patient appears in compensated CHF, consider 250 - 500 mL bolus.
  • Consider vasopressors or inotropic support if refractory to IVF or cardiogenic shock etiology

+ Insomnia

Sleep disturbances are common during hospitalizations and are typically due to acute illness and sleep environment

What to consider:

  • Is this acute (new during the hospitalization) or chronic?
  • If chronic, then see if the patient was on therapy for insomnia prior to the admission? If so, consider if there was a reason the therapy was held during the admission?

What to do:

  • Go see the patient
  • Review PMHx, medications, and allergies

Treatment:

If chronic and on therapy at home, then restart if appropriate and no contraindications.

If new during hospitalization, then attempt non-pharmacologic interventions: Sleep Care Bundle Orderset

  • Reduce noise at night
  • Limit interactions during sleeping hours
  • Establish day/night light exposure
  • Consider melatonin to augment sleep/wake cycle

If above therapies do not work, then ask primary team to discuss on rounds with patient and attending

+ Medical / Psych Holds

+ Shortness of Breath

Always notify your senior resident when you are called for any acute respiratory event. If you need additional support (RN, respiratory, AOD), do not hesitate to call a rapid response.

Determine urgency

  • Vitals are vital. Get a full set.
  • Triage seeing a hypoxic patient as a #1 above other tasks.

Information Gathering

  • Review signout and most recent progress note
  • Review meds – can give clues to what is going on (COPD inhalers? Fluids? CHF meds?)
  • Review most recent labs (history of hypercapnia? troponin elevation? elevated NT-proBNP?)

Perform focused cardiopulmonary examination

  • General: Awake or drowsy? Rash suspicious for anaphylaxis?
  • HEENT: Evidence of angioedema?
  • Pulmonary: Working of breathing? Speaking in full sentences? Crackles? Wheezing?
  • Cardiac: Regular rhythm? Edema? JVD?
  • Review continuous pulse oximetry to confirm good wave form (good “pleth”)

Differential and diagnostic testing

  • Cardiovascular: acute coronary syndrome, heart failure, tamponade, hypertensive emergency
  • Pulmonary: Pulmonary embolism, pneumothorax, pneumonia, asthma/COPD, airway - obstruction (foreign body? angioedema? anaphylaxis?)
  • Other: acute blood loss, acute chest syndrome, diabetic ketoacidosis

Diagnostic tests to consider: ECG, CBC (other labs: troponin, BMP, NT-proBNP, ABG/VBG), CXR, beside echo, CTPA

Determine disposition and implement interventions

  • If patient is remaining on the floor, strongly consider telemetry monitoring and continuous pulse oximetry if not already implemented

+ Phone Numbers