A and P



CARDIOLOGY 

  • Problem / Diagnosis: New onset A fib; Paroxsymal 
  • Assessment of Etiology: likely due to HTN cardiomyopathy and / or OSA ; PE, Valvular Heart Disease, Hyperthyroidism ruled out
  • Assessment of Severity: CHADSVaSC: 2; HASBLED score: 1; Associated with RVR; With evidence of LA dilatation 
  • Other aspects of assessment: Time of onset : 6 hrs earlier
  • Plan based on Etiology: Control HTN, STOPBANG for OSA screen along with outpatient  sleep study
  • Plan based on Severity: Diltiazem drip for rate control, Start NOAC, continue for 4 weeks after cardioversion, Admit to floor; Add PPI or not
  • How should note be written:
  • New onset A fib of 6 hr duration; Paroxsymal with RVR likely due to HTN cardiomyopathy and / or OSA ; PE, Valvular Heart Disease, Hyperthyroidism ruled out; CHADSVaSC: 2; HASBLED score: 1; With evidence of LA dilatation ; Control HTN, STOPBANG for OSA screen along with outpatient  sleep study; Diltiazem drip for rate control, Start NOAC, continue for 4 weeks after cardioversion, Admit to floor; Add PPI or not

HEME/ONC
  • Problem: Microcytic Anemia 
  • Assessment of Etiology: likely due to Iron Deficiency likely due to chronic GI blood loss likely due to Portal HTN gastropathy, DDx. GI Malignancy. 
  • Assessment of Severity: Severe with significant SOB, no evidence of Heart Failure
  • Other aspects of Assessment: Hemodynamically stable; Decreased BM response with Retic Count of 1.9
  • Plan based on Etiology: EGD and Colonoscopy, 
  • Plan based on Severity: Transfuse if Hgb < 7, Start PO Iron, Increased to TID as tolerated by patient; Follow up Retic Count in 1 week, Hgb in 1 month, and Iron studies in 3 months to assess the effectiveness
  • How should note be written: 
  • Microcytic Anemia likely due to Iron Deficiency likely due to chronic GI blood loss likely due to Portal HTN gastropathy, DDx. GI Malignancy. Severe with significant SOB, no evidence of Heart Failure. Hemodynamically stable; Decreased BM response with Retic Count of 1.9. EGD and Colonoscopy, Transfuse if Hgb < 7, Start PO Iron, Increased to TID as tolerated by patient; Follow up Retic Count in 1 week, Hgb in 1 month, and Iron studies in 3 months to assess the effectiveness


PULMONOLOGY
  • Problem: Rt Upper Lobe 2 cm cavitatory lesion 
  • Assessment of Etiology: likely due to Non- MDR Primary Pulmonary Tuberculosis; DDx: Malignancy; With concern for superimposed anaerobic infection 
  • Assessment of Severity:  no hemoptysis, no evidence of sepsis, HIV negative 
  • Plan based on Etiology: Bronchoscopy for AFB,Cell count,Cytology, Culture; PCR for rifampicin resistance; If unable to confirm the diagnosis, CT chest; Start on RIPE; Airborne Precaution until three AFB negative sputum; Zosyn for now- reassess in 48 hr;
  • Plan based on Severity: Admit to floor; 
  • How should note be written:
  • Rt Upper Lobe 2 cm cavitatory lesion likely due to Non- MDR Pulmonary Tuberculosis; DDx: Malignancy; With concern for superimposed anaerobic infection; Patient continues to cough, no hemoptysis; bronchoscopy for AFB,Cell count,Cytology, Culture; PCR for rifampicin resistance; If unable to confirm the diagnosis, CT chest; Start on RIPE; Airborne Precaution until three AFB negative sputum; Zosyn for now- reassess in 48 hr;

  • Problem: Acute Hypercapnic,  Hypoxemic Respiratory Failure 
  • Assessment of Etiology: likely due to COPD (likely emphysema with baseline hypoxemia) exacerbation and Pneumothorax
  • Assessment of Severity:  Severe with respiratory distress but awake and alert
  • Plan based on Etiology: Treat COPD as below; Treat Pneumothorax as below
  • Plan based on Severity: MSI, BiPAP with 50 % oxygen, Monitor respiratory status, if there is worsening then may need intubation; Gradually decrease the oxygen flow 

  • Problem: COPD exacerbation
  • Assessment of Etiology: likely due to bacterial infection, Concern for Pseudomonas colonization and influenza infection at this time of year 
  • Assessment of Severity:  Severe; Complicated
  • Plan based on Etiology: Flu test, Sputum culture, IV steroids, IV abx to cover Pseudomonas, Tamiful, Breathing treatment Q4H, Treat COPD as below; Treat Pneumothorax as below
  • Plan based on Severity: MSI, BiPAP with 50 % oxygen, Monitor respiratory status, if there is worsening then may need intubation; Gradually decrease the oxygen flow 

  • Problem: Pneumothorax
  • Assessment of Etiology: Secondary spontaneous (in a patient with likely underlying significant emphysema); possibly in the setting of COPD exacerbation 
  • Assessment of Severity:  > 2 cm in Xray
  • Plan based on Etiology: CT in place, monitor for air leak, will eventually will need VATS assisted Pleuredesis vs surgical excison of blebs
  • Plan based on Severity: MSI, NC oxygen, Monitor respiratory status, if there is worsening then may need intubation; Gradually decrease the oxygen flow


NEUROLOGY
  • Problem: Rt MCA ischemic stroke 
  • Assessment of Etiology: likely due to Cardioembolic process likely due to Atrial Fibrillation
  • Assessment of Severity: With some residual Left sided weakness and dysarthria; Significant area of stroke with concern for hemorrhage
  • Other aspects of Assessment: Time of stroke: > 10 hrs of arrival
  • Plan based on Etiology: Start Anti-coagulation in 1-2 week given significant size stroke due to concern for hemorrhage; ASA to continue
  • Plan based on Severity: Admit to floor; OT/PT/ST; Rehab
  • How should note be written:
  • Rt MCA ischemic stroke likely of > 10 hrs duration likely due to Cardioembolic process likely due to Atrial Fibrillation; with some residual Left sided weakness and dysarthria; ASA for now, Anti-coagulation in 1-2 weeks to delay risk of hemorragic transformation ; Admit to floor; OT/PT/ST; Rehab eval; Fall risk; Permissive HTN for first 48 hr


ENDO

  • Problem: DKA
  • Assessment of Etiology: likely due to Infection, likely DFI with Severe Rt LE Cellulitis with abscess. 
  • Assessment of Severity: severe (pH < 7.0 ) 
  • Plan based on Etiology:DKA protocol, start abx (Vancomycin). 
  • Plan based on Severity: Given Severe presentation also add Zosyn to cover for anaerobic and gram negative infection. I and D, Wound Care. Blood Culture, 
ID
  • Problem: Febrile Illness with Peripherally distributed maculo-papualar rash
  • Assessment of Etiology: likely Hand Foot and Mouth Disease; Tick born illness and other atypical bacterial infection remains a possibility; Chronic Meningococcal ischemic is a possibility, Syphilis and HIV less likely as RPR and HIV test negative in a patient with no risk factors for sexually transmitted disease. SLE, Still's diseae less likely based on clinical presentation and work up; less likely typical bacterial infection given chronicity, no evidence of VTE or malignancy based on clinical presentation and initial evaluation 
  • Assessment of Severity: Subacute presentation; SIRS present, but without Sepsis syndrome, 
  • Plan based on Etiology: Blood culture, Isolation, Start emperic abx to cover for tick born illness, if fever persists will need HIV PCR, and other trepanomal specific Syphilis tests; if patient condition improves will complete 7  days of abx, and eventually needs repeat HIV and Syphlis test as outpatient,
  • Plan based on Severity: Admit to floor; No need of Vancomycin, IV fluid, encourage PO, continue to monitor clinically, 
  • Problem: DFI 
  • Assessment of Etiology: likely due to Infection, likely DFI with Severe Rt LE Cellulitis with abscess. 
  • Assessment of Severity: Severe 
  • Other aspects of assessment
  • Plan based on Etiology:DKA protocol, start abx (Vancomycin). 
  • Plan based on Severity: Given Severe presentation also add Zosyn to cover for anaerobic and gram negative infection. I and D, Wound Care. Blood Culture, 
  • C. DIFF COLITIS - NAP1/BI/027 or not - Initial episode / 1st or 2nd recurrence -  Mild / Moderate / Severe / Severe Complicated - Improving / Worsening - Treatment plan
  • SSTI: 
  • Purulent- Mild / Moderate / Severe - If Moderate and Severe, will need I and D
  • Non-Purulent -  Mild / Mod / Severe - If Severe, will need emergent surgical exploration
  • Diabetic Foot Infection (DFI): Classification (see below Table 2) of DFI (Mild / Mod / Severe or Imminent Limb - Threatening (see below Table 12) ) - 2/2 - Evaluate at 3 level - Patient as a whole, affected limb (Vascularity, Venous Congestion, Peripheral Neuropathy etc), and then the wound - Obtain Culture or tissue biopsy (see below Table 5, 9) - Antibiotic  based on Clinical Severity  (see below Table 6, 8, 7, 11)-  Wound Debridement and wound care - consider Imaging Study (Xray, MRI if clinically indicated for evaluation of DFO) - Vascular and ID consultation if necessary
  • STAPH. AUREUS BACTEREMIA, MSSA or MRSA: Source-      ; MIC-      ; Clinical Improvement / Stable / Worsening - Search for source if unclear, 2D ECHO; Treatment plan -     ; Remove source of Infection; Repeat cultures in 3-4 days; Need of PICC line. 

  • HIV / AIDS: duration, last CD4 Counts, on ART or not, who is treating this, if not why is patient not taking medication

  • Chest Pain
  • Typical / Atypical / Non-anginal 
  • Risk stratification  
    • Pretest probability of CAD  (based on Age and Sex OR Age, Sex, and Risk Factors)
  • Consider other possible DDx especially life threading ones


  • CHRONIC STABLE ANGINA : symptoms controlled or not - if not controlled, short term risk of death or MI not consistent with Intermediate to High Risk for UA (see below) - Antianginal Medications (PCI does not improve survival) - Cardioprotective Medications - Tobacco use and other lifestyle counseling

  • UA / NSTEMI: 
    • Typical Chest Pain: see Chest Pain for detailsPretest Probability of CAD or established CAD : see Chest Pain for detailsRisk Stratification for short term / long term risk of death or MI: see Chest Pain for details
    • TIMI or GRACE Score or Based on Clinical Characters in a patient with established CAD 
    TIMI Score Note: Predicts 14 day All cause Mortality Risk, new or recurrent MI, severe recurrent ischemia requiring fluctuation. 

    ELEVATED TROPONIN: 
    • 2/2 due to 
      • MI (Type 1, 2, 3, 4, 5) or 
      • Non-MI (i.e Direct Myocardial Damage ;
        •  Cardiac vs 
        • Systemic - 
    • Pretest probability of CAD 
    • Pretest probability of ACS (Figure 4 and Table 1) 
      • Low (ACS unlikely - look for other cause) or 
      • High (Early Invasive vs. Initial Conservative Strategy) 
    Heart Failure: Address Following 4 points in Assessment of Heart Failure 

    Type 
    • HFrEF / HFpEF / HFpEF, borderline / HFpEF, improved; 
    • Ischemic vs Non-Ischemic
    • Lowest EF …Last EF
    Volume Status
    • Compensated / Decompensated 
    • Acute / Acute on Chronic / Chronic 
      • Classification of Acute Decompensation
    Functional Status (NYHA I/II/III/IV) 
    Worsening 2/2 – ACS/Uncontrolled HTN / Noncompliant to Salt or Med (with reasons for non-compliant) – Rx
     
    Treatment:
    • Goal of Acute HF management: No benefit seen on long term survival 
    • Diuretics (2-3 X their home dose, initially IV)
    •  
       
    • ACEI or BB (if already on it, and reasonably good BP) or Aldo ants (see reference)
    • No need to put in Foley cath in floor; daily in/out and weight MUST
    HYPERLIPIDEMIA: LDL / ASCVD / or ASCVD Risk score - Moderate / High dose statin or no treatment


    HYPERTENSION: 
    • Stage 1 /2 / 3 - Goal - Controlled / Uncontrolled - cause, if uncontrolled - treatment plan if uncontrolled
    SYNCOPE: Cardiogenic / Orthostatics / Neurocardiogenic / Psychogenic / rule out Seizure - Perform and document orthostatics BP your self

    ENDOCRINOLOGY

    HYPOCALCEMIA: Correct for Sodium for Albumin à 2/2 (see reference) à if in doubt check ionized calcium à iPTH, Magnesium, Vitamin D (25-OH), check 1,25-OH Vitamin D only if suspecting vitamin D deficiency or CKD à Rx:

    a.     If symptomatic, and severe: IV SLOW infusion of Calcium Gluconate (0.5-1.5 mg elemental calcium/kg/h); switch to oral once symptoms have resolved

    b.     If asymptomatic, and mild: Oral is okay (see reference)



    DKA: in a Type 1 or Type 2. mild/moderate/severe; 2/2 : Treatment Plan 

    HYPERCALCEMIA: rule out factitious hypercalcemia (check iCa++ under anaerobic conditions, and in ice) - Once True Hypercalcemia confirmed - check iPTH and iCa++ simultaneously - check PO43- and Vitamin D - DDx. 2/2 (MKSAP Table)  based on if PTH is high or low 
    • Asymptomatic or Symptomatic due to prolonged or severe disease (Nephrolithiasis, CKD, fragility fractures,  bony pain)
    DM (in Hospitalized Patients) – Type 2/Type 1 – 4 questions will help you in deciding the DM treatment in Hospital: 
    • 1) Controlled/uncontrolled - last A1C –– Current glucose level 
    • 2) Fasting / Non-Fasting State at hospital
    • 3) On Insulin / or oral medications at home
    • 4) Risk of hypoglycemia or sensitivity to Insulin (CKD, low basal home insulin requirement, chronic pancreatitis or brittle DM) 
    GI

    DYSPHAGIA: 3 questions needs to be defined: 
    • Location of Dysphagia
      • Orophyrangeal or 
      • Esophageal; 
    • If Esophageal mechanism of dysphagia- 
      • Mechnical (only solid) or 
      • Motor (Both Solid and/or Liquid) - 
    • Then characteristics of dysphagia
      • progressive or 
      • intermittent or non-progressive
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