WORK-UP/TX CONSIDERATIONS

Sepsis: sputum/urine GS and culture, blood cx x 2

from 2 different sites (consider stool, CSF, other fluids),
A-line, central line, O2 con!t pulse ox, "#G, A$%s,
C&', A(G, lactate, )**m+ ,S bolus -.*min /ith 0oal
1A% 23) and 4O% 2*5)ml/60/hr ," if refractor7
inotropes, transfusions, 0lucocorticoids8 (G9:;*,
<=>/ulcer proph8 abx x ?-:*d

CAP@ blood cx, C&', C(C, C1%, A(G, sputum GS/cx,
le0ionella/strep urine a0, %C' for m7co/chlam7dia/Airal,
C> chest5 >x@ .
rd
0en ceph macrolide O' resp5 FB8
aspiration use ertapenem solel7 or add clinda8 tx for
)-?d
Cellulitis: GAS/1SSA/1'SA, blood cx 9)C sens
(obtain if s7stemic, special circ)8 >x@ eleAate infx, eAal
underl7in0 cause8 mild D %O dicloxacillin or cephalexin8
mod D $= nafcillin, cefaEolin8 /- clinda8 1'SA D
Amox/(actrim, Amox/<ox7, Clinda, +ineEolid
Osteomyelitis r/o: <1 D pol7microbial8 sur05
Sample/needle bx, blood cx, "S'/C'%, 1'$8 >x@ 1SSA
(naf, oxac, cefaEolin), 1'SA (=anc), G- (cipro, leAa-uin,
ceftaE, cefepime)8 empiric D =anc G- coAera0e8 at
least 3/6s tx, can follo/ /ith "S'/C'%
UTI: 4A // cx (2:*
)
, :*
2
in s7mp/cath pt), blood cx if
febrile/complicated8 >x F 4ncomplicated
nitrofurantoin :** ($< x )d, (actrim :3*/;** ($< x .d
or leAa-uin/cipro ($< for ?d (complicated)8 remoAe
catheter8 Complicated cipro/leAa-uin %O for :*-:Gd
or dail7 $= ceftriaxone :0, ertapenem :0 improAin0
s/itch to %O
Neutropeni !e"er: mech is intestinal translocation 8
often coa0 ne0 staph or S5 aureus 2 G- bacilli 2
fun0al8 dx oral temp2:*: (.;5.) O' 2:**5G (.;5*) x
:hr and A,C 9)**8 labs, blood/urine/sputum cx,
septicH, O2, ,S, C&' (C> if hi0h-ris6)8 abx if lo/-ris6
(solid tumor, lo/ A,C for 9?d) cipro ?)*m0 %O ($<
or leAa-uin ?)*m0 %O dail7 and amox-claA )**m0/:2)
%O >$<8 abx if hi0h ris6 cefepime, meropenem,
imipenem, pip-taEo %+4S Aanc onl7 if suspected line
infx, cellulitis, pneumonia, hemod7namicall7 unstable,
seAere mucositis, A,C9:**, or on -uinolone
proph7laxis8 add antifun0al if still febrile after Gd
COPD E#$: C&', "#G, A(G, C(C, C1%8 ipratropium
)**mc0 neb -Gh albuterol 25)m0 neb -:-Ghr
meth7lprednisolone 3*m0 $= -d--id O' .*-)*m0
prednisone dail7 (tr7 %O first) and consider taper to
assess maintenance (actrim/<ox7/FB/'ocephin
(onl7 if inpt) for .-?d SaO2 2 I*C /- ,%%=
Dyspne$@ thin6 obstruction, parench7mal, Aasc, chest
/all/musc, O2, ps7ch8 C&', "#G, A(G, (,%, A$%, <-
dimer, C> chest, echo, %F>s, C(C, C1%, >SJ8 >x@
mucol7tics, bronchodilators, abx, diuretics
Ast%m$ E#$@ A(G, C&', %"F8 albuterol 25)-)m0 neb
-2*min or cont5, prednisone G*-3*m0 %O -d-bid or
meth7lpred 3*-;*m0 $= bid--id (tr7 %O first),
ipratropium )**mc0 neb -.*min x . 10 20 $= (if
refractor7), SaO2 2 I*C
PE: Kell!s Criteria, %"'C rule-out8 C&', "#G, A(G,
%>/%>>, <-dimer, echo, =/B, C>A, +" 4/S (no chan0e in
outcome // C>A), A$%, (,%8 consider thrombophilia,
mali0nanc78 >x@ +oAenox :m0/60 SC -:2 O'
fondaparinux )-:*m0 (/ei0ht based) SC O' 4FJ
;*4/60 bolus, then :;4/60/hr infusion // %>> L 3hrs
(0oal 3*-;)s) especiall7 if renal failure8 earl7
ambulation, O2, $=F (9 :+)8 start /arfarin at same
time, oAerlap for min )d and therapeutic $,' for
22Ghrs
A-!i& R'R: cardiac, pulm, metabolic, dru0s, C=A8 "#G,
C&', echo, A$%, <-dimer, C(C, C1%, >SJ, 10, FO(8
Stable rate control // $= Aerapamil/dilt (caution (%,
CJF) O' metoprolol/propranolol/esmolol (/atch (%,
CJF, lun0 dE), then add <i0 ((% neutral, 0ood for CJF
pt), then amio8 (( <i0 D 0ood combo8 0oal
J' 3*-::*8 9G; hrs, s7mptomatic cardioAert /-
anticoa08 2G;hrs >"" anticoa0 then cardioAert8
Anticoa0@ CJA2<S2-=ASc (CJF, Jtn, ?) (2), <1,
Stro6e (2), Aasc dE, 3)-?G, female) *Dnone, 2 D
anticoa0 /ith either <>$ - dabi0atran (%radaxa), &a
inhibitors riAaroxaban (&arelto) or apixiban ("li-uis) or
/arfarin (least preferred)8 ASA is a last resort
C() E#$: Class $ F no sx // normal actiAit78 Class $$@
sx // normal actiAit78 Class $$$@ sx // minimal actiAit78
Class $=@ sx at rest8 thin6 1$, renal failure, Jtn crisis,
non compliance, ((/CC(s/,SA$<s, "tOJ8 consider
C&', (,%, C1%, C(C, A$%, echo, %A Cath, "#G,
an0io0raph7, strict $/O and /ei0ht8 >x@ +asix $=( (:-
25)x %O dose), 1 (no morphineM) ,($=)O% /- thiaEide8
if poor perfusion consider ,>G, dobutamine, <A, and
,%%=
C%est P$in: thin6 1$, 4A, -itis, dissection, %,A, %>&,
%", G$, 1s68 chec6 (/+ (%, "#G (repeat -:*min if
needed), A$%s -3-;, C&', echo, <-dimer, C(C, C1%,
10, %OG, exercise stress (CA< pt /- chan0e in sx, s/p
ACS, localiEe ischemia), >$1$ score8 ,S>"1$ tx@
nitrates, (( 2 CC(, AC"/A'(, atorAastatin ;*m0,
morphine, ox70en, ASA :32-.2)m0 tica0relor :;*0 x
: or "ffient 3*m0 (if <1, 9?), no hx of bleed/stro6e)
4FJ :24/60/hr (%>> :5)-2x) or +oAenox :m0/60 ($<
x 2-;d, <C all ,SA$<s8 cocaine induced use benEos,
not ((M
Synope@ 4n6no/n 2 AasoAa0al D C= 2 orthostatic 2
neurolo0ic8 orthostatic =S, (% in both arms, C(C, C1%,
"#G, >SJ, 10, %OG, echo (="'N lo/ 7ield), tilt-test,
holter/loop5 "mer0ent //u if "#G, concernin0 cardiac
hx (includin0 exertional, palps), anemia, -l7te
abnormalities5
AKI: Cr increase of *5. in G;hrs or :5)x baseline, 4O%
9*5)ml/60/hr8 4A eos/K(Cs/,a/Cr microscop7,
renal 4/S, C1%, uric acid, 10, %OG, "#G, consider
A,CA, anti-G(1, C., CG, A,A, AS+O, cr7o0lob,
hepatitis, C(C peripheral smear, S%"%/4%"% (/-
immunofixation and serum free li0ht chain assa7)8 >x@
<C ,SA$<s, AC"/A'(, nephrotoxic a0ents, 0iAe :+ ,S,
short-term loops, J<, %OG 2 3 use binders, /atch #,
monitor acid-base, consider bicarb
(yper*$lemi$: thin6 acidosis, insulin, ((, di0, cellular
necrosis, succ, renal failure, CJF, cirrhosis, lo/ renin
(<1, ,SA$<s), normal renin (lo/ aldo, AC"/A'(,
heparin), (actrim8 Get "#G, eAal pseudo (fluids, l7sis,
K(C/plats)8 >x ("#G chan0es, 35))@ CaGluc :-2amps
$=, 'e0ular $nsulin :*4 :-2amps <)*K, (icarb if
acidotic, +asix G*m0 $=, #a7exalate :)-.*m0 in
multiple doses
(yper$lemi$: thin6 h7perparath7roidism, familial,
mali0nanc7 (SCC, renal, breast, bladder, heme,
m7eloma), =it5 <, h7perth7roid, immobile, thiaEides,
lithium8 consider Ca, $Ca, %>J, albumin, %OG, %>Jr%,
=it5 <, al6 phos, urinar7 Ca, S%"%/4%"%, AC", C&',
mammo8 >x (:2-:G in most cases)@ ,S G-?+/d (0oal
4O% :**-:)*ml/hr) +asix (onl7 if Aolume
oAerloaded) calcitonin
Si*le Cell Crisis: C(C // retic, C1%, +<J,
hapto0lobin, bili8 >x@ Aaccinations, folic acid :m0 dail7,
1= //o iron (concerns of oAerload, oxidation), =it5 <,
calcium replacement, h7poAolemic ,S, euAolemic
O or P ,S // 0lucose or <)K L :2)-:)*cc/hr,
leu6oreduced and matched %'(Cs8 %ain control@ $= 1S
*5:*-*5:)m0/60 -2h or h7dromorphone *5*:)-
*5*2m0/60 -.h8 use %CA if refractor78 use fentan7l if
renal/hepatic dE8 Acute Chest S7ndrome@ C&' densit7
feAer and/or resp5 sx fluids, pain control,
bronchodilator therap7, CA% abx coAera0e, %'(C
transfusion /ith 0oal J0b9:*, h7drox7urea initiation
A+S: A"$O4 >$%S8 C(C, C1%, 10, %OG, %>/%>>, >SJ,
Ammonia, 4A, C&', blood cx, 4<S, C> head, +%, ""G8
>x@ A(Cs, thiamine :**m0 $= then <)* $=%, naloxone
*5*:m0/60, decrease $C% if suspected
EtO( Wit%,r$-l@ 3-G;hrs anxiet7, tremor8 9G;hrs
sE8 :2-G;hrs hallucinations8 2-.d <ts8 Chec6
C(C, all -l7tes, 4<S, C> head, +F>s, FO(8 >x@ $=
diaEepam )-:*m0 -)-:*min (=alium, lon0 t:/2),
loraEepam 2-Gm0 -:)-2*min (AtiAan, short t:/2),
chlordiaEepoxide (for proph7laxis), oxaEepam (for liAer
dE)8 C$KA 0oal 9 ;8 phenobarb or propofol if
refractor78 thiamine :**-)**m0 %O B<->$< before
0lucose, 1=, folate :m0 dail7, <),S // 2*m"- #Cl
Un*no-n +ets@ Adeno Abd C> //, %">, %SA,
mammo0ram/1'$, endoscop7/colonoscop78 SCC C>
Chest, Jead, ,ec6, %">, endoscop7, G4 exam, s6in
exam
DKA: $nsulin, $atro0enic, $nfx, $nflammation, $schemia,
$ntoxication8 C(C, C1%, 10, %OG, JbA:C, A(G, 4A //
cx, serum 6etones, am7lase, lipase, 4<S, A$%, C&',
blood cx, (G hourl7, Aenous pJ -2-Gh8 >x@ ,SL:)-
2*ml/60/hr (can chan0e to P ,S G-:Gml/60/hr if
normo/h7pernatremic) $nsulin :*4 $=% then
*5:4/60/hr drip until normal AG then add )C dextrose
/hen (G 9 2)*5 Add 2*m"- #Cl if #9G5) (/atch 4O%)5
Acidosis resolAed SC insulin5 (icarb for pJ9?5 %hos if
9: or cardiac/resp failure5
(ypo.lyemi$: <1 thin6 insulin, meds, renal failure8
,on-<1 thin6 eleAated insulin, lo/ 0lucose (h7popit,
adrenal insuff, 0luca0on def5, hepatic/renal failure, CJF,
"tOJ, sepsis)8 post-prandial, 0astrectom78 <x@ C1%,
>F>s, $GF, C-peptide, (-OJ but7rate, sulfon7lurea
leAels durin0 h7po0l7cemia8 >x@ <)* 2)-)*0 $= or
0luca0on *5)-:m0 $1/SC
(tn Ur.eny/Emer.eny: 4r0 2:;*/:2* // no
end-or0an dama0e8 "mer0 encephalopath7,
hemorrha0e, stro6e, ACS, JF, pulm edema, dissection,
A#$, 1AJA8 4r0enc7 >x lo/er oAer hrs to da7s
(9.*C reduction) /ith oral furosemide, clonidine,
captopril, labetolol, h7dralaEine5 "mer0enc7 >x
labetolol 2*m0 load 2*-;*m0 $=( -:*min or
h7dralaEine :*-2*m0 -2*-.*min (-uic6 drop in (%M)
/0 1in +RSA2 Pseu,omon$s unli*ely Pseu,omon$s li*ely
=anc Ceftriaxone/cefotaxime CeftaEidime/cefepime
<aptom7cin %ip/taEo or ticarcillin/claA %ip/taEo or ticarcillin/claA
+ineEolid 1eropenem/imipenem 1eropenem/imipenem
Ceftaroline Cipro
AEtreonam
Gentam7cin
O," %+4S O," O' ------222 %+4S >KO
U/I 3lee,: thin6 %4<, Aarices, A=1, tumor, 1allor7-
Keiss8 t7pe Q screen, C(C, C1%, coa0s, ,G laAa0e,
C&' if pain (perf), troponins if seAere blood loss8 ma6e
,%O, 2 lar0e-bore $=s, O2, esomepraEole/pantopraEole
;*m0 $=( then ;m0/hr x ?2hrs, ,S boluses
transfuse, transfuse if h0b9I (elderl7, CA<), 9? for
lo/-ris68 /- FF%, platelets (9)*6)8 Aarices/cirrhotic
octreotide )*u0 $=( then )*u0/hr x )d and rocephin
:0 $= (do ,O> oAertransfuse these ptsM), consult G$
ASA%8 4/I &lee,: thin6 tics, neoplasm, colitis,
an0iod7splasia8 r/o 4G$ bleed first, then colonoscop7 if
stable8 no source artio0raph7, '(C scan
P$nre$titis@ am7lase (2.x), lipase, K(C, C1%, C&',
Abd C> // (not re- if sx labs are pos5), Abd 4/S,
>Gs, lactate, A%ACJ"-$$ score5 >x@ ,S/+' )-:*ml/60/hr
(up to 2* if unstable), $= h7dromoprhone/fentan7l
(0ood for renal pt) %CA, soft, lo/-fat diet if mild and
improAin0, mod-seAere needs ReRunal or ,G tube //i
G;hrs, carbepenem if 2.*C necrosis
(ep$ti enep%$lop$t%y: sleep disturbance
depression/asterixis disoriented/slurred speech
neuro si0ns/somnolence and confusion coma8 do
brief 11S", eleAated ammonia not dia0nostic (clinical
dxM), also eleA in@ G$ bleed, renal dE, shoc6, muscle
brea6do/n, parenteral nutriton, ci0s, chemo, dru0s
(Aalproate, narcotics, diuretics, salic7lates)8 consider
C(C, C1%, blood/urine cx, A(G, paracentesis8 tx@
h7dration, lactulose 2*-.*0 ($<-B$<, and if needed
add rifaximin ))*m0 ($<, fall precautions
Aute 4i"er )$ilure: thin6 Airal (plus C1=, "(=, JS=,
=S=), dru0s (t7lenol, $,J, phen7toin, rifampin, amio,
%>4), Aascular, A$, Kilson!s, J"++%, 'e7e!s, idiopathic5
<ef!n D enceph %> 2:5)8 Chec6 JA= $01, J(sA0,
Jep C $01, Jep C ',A, Jep " Ab (in pt /ith
international traAel), JS= and =S= Ab, A,A, anti-
liAer/6idne7 microsomal A( t7pe :, anti-smooth muscle,
ceruloplasmin, urine copper, acetaminophen leAels,
lactate, ammonia, lipase/am7lase, 4A, '4B 4/S8 tx@ all
pt 0et ,-acet7lc7steine, -2hr neuro chec6s (eleA $C%
eleAated JO(, .C ,S, mannitol), C(C/C1%/Coa0s/A(G
>$<-B$<, /- =anc 'ocephin