templates

Afib (+RVR)
Asthma
CAD
CHF
COPD
Cirrhosis
DKA / HHS
Diarrhea / Colitis
Dispo Checklist
EtOH Withdrawal
Fever in Returning Traveller
GI Bleed
H&P Template
ICU Observation
Leukemia
Meningitis
NSTEMI
Neutropenic Fever
PDialysis Peritonitis
Pancreatitis
Pleural Effusion
Pre-Op Risk Assess
Sample Calculation - Insulin
Suicidal Ingestion
Syncope
TIA
VA (Veteran Affairs) Chronic Musculoskeletal Pain
VTE/PE/DVT
Vaginal Bleed, 1st Trimester
- Health Maintenance Checklist

^ Afib (+RVR)

= Atrial Fibrillation =
Potential Primary Causes
- Cardiac: Any structural abnormalities (atrial dilation, valvular disease, infiltrative, ischemia, etc.)
- Pulmonary: Any abnormalities, including PE, COPD
- Ingestions (stimulants, albuterol)
- Rheumatic disease valvular
- Atherosclerotic: MI, CAD
- Thyroid, hyper
- EtOH, Endocarditis
- Sick Sinus

# New Afib Workup
- EKG+Telemetry
- Troponins
- TSH, FT4
- EtOH, UTox
- CXR
- TTEcho
- Ziopatch monitor and Cardiology follow-up appointment on discharge for extended monitoring of episode frequency to plan further cardioversion plans

# Ventricular Rate Control 
(AFFIRM: Rate control as effective as rhythm control for CV risk management, though less exercise tolerance)   
(RACE II: Lenient rate control (HR<110) as effective as strict (HR<80))

Agent Selection 
(Avoid mixing AV nodal blocking classes due to risk of complete block, but can add digoxin as a secondary agent if poor control with primary agent)
- Diltiazem (Avoid in heart failure)
- Beta-blocker (Avoid in reactive airway disease, favor in hyper-thyroid)
- Digoxin (Not for acute control, 2 hour onset.  Favor in heart failure)
- None of the above if WPW / accessory pathway (consider cardioversion, ablation, or anti-arrhythmic instead)

Afib+RVR Acute Rate Control (beware hypotension and address primary causes)
- Diltiazem 0.25mg/kg (15mg) IV x1 then maintain 5-15mg/hr drip
- Metoprolol 2.5-5mg IV up to x3 then PO maintenance
- Esmolol 0.5mg/kg (30mg) IV x1 then 5-15mg/min
- Keep NPO for option of TEEcho + DCCardioversion

Afib Maintenance Rate Control
- Diltiazem 30-90mg PO qid while titrating dose, then transition to SA daily formulation (max 360mg/day)
- Metoprolol 25-100mg PO bid (start q6h while titrating dose)
- Digoxin 0.25mg PO q2h up to 1.5mg then 0.125-0.375mg PO daily
(Check steady-state trough levels within a week, not targeting therapeutic so much as avoiding toxic levels)

# Thromboembolism Risk Management
CHADS2 = *** (Annual stroke risk 2-8.5+%) (~60% RRReduction with anticoagulation)
(http://www.mdcalc.com/chads2-score-for-atrial-fibrillation-stroke-risk/)
CHADS2 = 1
- ASA 75-325mg PO daily
CHADS2 > 1 
- Warfarin per pharmacy protocol, goal INR 2-3.  Anti-coagulation clinic follow-up
(Heparin / enoxaparin bridge not strictly necessary (including 1 week breaks for surgeries), unless high risk)
(If non-valvular Afib, adequate renal function, acceptable cost and bleeding risk, consider rivaroxaban or dabigatran)

# AFib+RVR, Unstable (hypotensive, MI, angina, acute heart failure)
- Proceed immediately to (DC) Cardioversion...

# Rhythm Control / Cardioversion
- TEEcho to exclude LAA thombus and embolus risk first, 
(Unless confirmed arrhythmia <48 hours or already anti-coagulated >3 weeks)
(if LAA thrombus identified, high risk for thromboembolism, cardioversion should be deferred unless urgent/unstable)

- Anti-coagulation prior and subsequent to cardioversion
(Stroke / embolism risk 1-7% if not anti-coagulated, equivalent between DC and pharmacologic cardioversion.  1 month anticoagulation or TEEcho guided therpay reduces risk <1%)
(Even if convert to sinus rhythm, "stunned" myocardium still prone to thrombus and embolism especially in first 10 days, warranting ongoing anticoagulation)
(No clear end point for anticoagulation, due to potential recurrence and ongoing thromboembolism risk)
- If Afib>48hrs, warfarin x3 weeks before then 4 weeks after cardioversion
- If Afib>48hrs + negative TEEcho, heparin/warfarin for 5 days before then 4 weeks after
- If Afib<48hrs, start heparin/enoxaparin and proceed to cardiovert
- If emergent cardioversion, heparin drip immediately then warfarin 4 weeks after

- DC Cardioversion (100-200J biphasic) under sedation with anesthesia and NPO
(>80% successful conversion, but ~50% annual relapse, consider suppressing with anti-arrhythmics after 2nd cardioversion)

- Pharmacologic Cardioversion (e.g., amiodarone, sotalol) 
(Most effective within 7 days of onset.  Equivalent stroke risk between DC and pharmacologic cardioversion.)
- Amiodarone 
1.2-1.8g/day until 10g total
(e.g. 150mg IV bolus, then 1mg/min x6 hrs, then 0.5mg/min for 18 hours, overlap PO with drip due to > 1 week for PO onset, 400mg PO bid x1 week), then 200-400mg PO daily 
or
800mg / day x1 week, then 600mg / day x1 week, then 400mg / day x 4-6 weeks, then 200mg / day 
- Monitor TFTs, LFTs, K, Mg (q3-6months) and one baseline PFT + annual CXRs while on prolonged amiodarone

- Cardiology EP Consultation for other regimens, ablation, pacer strategies, etc.

ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation. Circulation (Vol. 104, pp. 2118â€“50). 
http://www.ncbi.nlm.nih.gov/pubmed/11673357

^ Asthma

= Inpatient / Acute Exacerbation =
- PEF assessment <40% predicted = severe (suggests need for hospitalization)
Check pre- and post- 3 doses of albuterol to assess for response and triage admission
- Peak Flow pre/post Treatment
(Relative to baseline is more important measure)
(Generally expect normal >300 for women, >400 for men)
- ABG/VBG to assess for acidemia/CO2 retention that may prompt ICU admission

- Albuterol +/- Ipratropium q20min x3 then q1-4h PRN or continuous if ongoing
Latter with additive benefit for emergency but not hospital setting
- Prednisone (1mg/kg) 40-60mg up to 10 days? Or until achieve 70% PEF
- Magnesium sulfate 1-2g

= Outpatient Asthma Diagnosis =
-  Spirometry to assess airflow obstruction vs. Other causes
Methacholine challenge PFT (should induce bronchospasm, then improve FEV1 by 10% with beta agonist)

= Outpatient / Discharge Management =
(If using rescue inhaler >2x per week, then escalate therapy)
- Inhaled steroid
Beclomethasone bid (80-480mcg / day)
Budesonide (180-1200mcg/day)
Flunisolide (500-2000mcg/day)
Fluticasone (88-440mcg/day)
Momeetasone (200mcg-400mcg/day)
Triamcinolone (300-1500mcg/day)
(Consider Ca+Vit D and rinsing to avoid oral thrush if long-term high dose)  
- Inhaled long-acting beta agonist (salmeterol DPI 50mcg/blister, formoterol DPI 12mcg/capsule) q12h
- Combo ICS/LABA
Fluticasone/Salmeterol  Bid (dose dependent on severity)
Budesonide/Formoterol
- Leukotriene modifier (motelukast 10mg PO qhs, zafirlukast 40mg PO daily, zileuton 600mg daily qid)

(Probably refer to Pulmonology once need to escalate to further options)
- Methylxanthine (theophylline) 10mg/kg/day up to 300mg to start, then up to 800mg/day
- Cromolyn, Nedocromil  MDI 2 puffs qid
- Omalizumab (anti-IgE) SubQ 150mg q2weeks based on serum IgE levels

- Beta agonist rescue inhaler with spacer
Albuterol 90mcg/puff 2 puffs q4h PRN
Levalbuterol 45mcg/puff 1-2 puffs q4h PRN

- Pneumonia + Annual Influenza Vaccine
- Identify and avoid allergens, smoke
- Inhaler technique training, follow-up care plans

http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf

^ CAD

= Coronary Artery Disease =
+ Last catheterization ***
+ CABG ***
Indications: Left main disease, Left main >75% stenosis with 2v disease, 3 vessel disease (particularly with LVEF<40%), disabling angina despite max medical therapy
+ PCI s/p Stent ***
Indications: (COURAGE trial largely indicating that PCI+Stent not much better than medical management for stable angina, unless FFR guided as per FAME trials), angina despite max medical therapy, high risk lesions (large areas of at risk myocardium)

- ASA 81mg PO daily
- Clopidogrel 75mg PO daily (indicated within 30 days of BMStent, 1 year of DEStent)
- HTN, HLD, DM control as below

= Angina =
- Beta blockers
- Calcium channel blockers
- Nitrates
- Ranolazine

= HLD =
+ Goal LDL<100
- Atorvastatin 80mg PO qhs***
- Simvastatin 40mg PO qhs***

= HTN =
+ Goal BP <130/80
***Particularly if hx MI to protect against remodeling
- Beta-blocker
- ACE-Inhibitor

= DM =
- Insulin NPH SubQ bid + Aspart QAC 
- Titrate up based on ongoing Sliding Scale needs to maintain
	Goal FS glucose <180 (110-150 in ICU setting)

^ CHF

= Congestive Heart Failure =
? Ischemic Cardiomyopathy.  Last Echo ? EF ?, (?MR, TR, AS)
? Volume Overload, Pressure Overload, Low-Output
? Dry weight

(Below with demonstrated mortality or functional benefit)
- Afterload, Goal MAP <70: Lisinopril / Losartan
(Isordil/Hydralazine 37.5/20 (Specifically in African Americans as per A-HeFT)) 
- Beta-Blockade: Carvedilol (Metoprolol if want rate control more than BP control)
- Spironolactone (if EF<35% and GFR>30 with good monitoring follow-up) 
- Mechanical: 
BiV Pacer for cardiac resynchronization if LBBB / wide QRS (>120-150ms)
ICD if EF<35% after 3-6 months optimal med therapy and non-terminal Class IV sx

(Symptomatic treatments without mortality benefit (may even worsen mortality))
- Diuretics:
Furosemide 40 PO : Furosemide 20 IV : Bumetanide 1 IV/PO
(Furosemide PO may absorb less reliably during volume overload due to gut edema)
(No difference in bolus vs. infusion as per DOSE)
HCTZ (synergistic with loop diuretic, but may worsen hyponatremia).   
IV diureses >1L negative per day until approach euvolemia / worsening renal function.
- Inotropic Support: 
Hold beta-blockers during decompensation
Digoxin (Beware if renal impairment.  Use minimal effective dose, levels only for toxicity)
Dobutamine or milrinone for acute cardiogenic shock / low-output failure

- Low salt diet 
(No trial to confirm efficacy.  Evidence does exist *against* the value of fluid restriction.)

- CHF Teaching, Home Telehealth, etc.
- Close follow-up in clinic with repeat BMP within a week

(Diastolic Heart Failure / HFpEF.  Few trials, with none showing any intervention with mortality benefit.  Intuitively, just try to manage with HTN and volume / diuretic control)

^ COPD

(See IP Med COPD Order Set)

= Acute COPD Exacerbation =
*** exacerbations per year, *** previously required intubation, typical course of exacerbation: ***. ABG ***, CXR ***
- Supplemental O2, goal sat 88-92%
- Bronchodilators (albuterol/ipratropium) standing and PRN
- Corticosteroids: Prednisone 30-60mg PO daily x5-14 days
(Alternatively methylprednisolone 1-2mg/kg q6-12h, but likely excessive)
(As per REDUCE 2013, 5 day course non-inferior to conventional 7-14 day course)
- (May continue home long-acting anticholinergic: i.e., tiotropium, if pharmacy allows. Unlikely to benefit from, so can hold, inhaled steroids while already receiving systemic steroids)
- Sputum culture need NOT be performed for most exacerbations as per guidelines, given unreliable results and interpretations. 
(Consider if risk factors for Pseudomonas (recent hospitalization within 90 days, frequent antibiotics >4 courses/year, severe COPD <50% FEV1, prior Pseudomonas) or persistent symptoms in spite of empiric antibiotics.)
- Antibiotics ~5 days
(If at least 2 of 3 cardinal symptoms of increased sputum purulence AND sputum volume or dyspnea. Mechanically ventilated patients should also receive antibiotics.)
(If antibiotics within past 3 months, use a different class this time)

(If suspect Pseudomonas)
- Levofloxacin 750mg PO/IV daily
- Cefepime 2g IV q12h
- Ceftazidime 1g IV q12h
- Piperacillin-Tazobactam 4.5g IV q6h

(If do not suspect Pseudomonas)
- Moxifloxacin 400mg PO/IV daily
- Ceftriaxone 1g IV daily

(PO options for uncomplicated exacerbation, outpatient treatment:
Age<65, FEV1>50%, <3 exacerbations/year, no cardiac disease)
- Azithromycin 500mg PO daily
- Cefpodoxime 200mg PO bid
- Doxycycline 100mg PO bid
- TMP/SMX 5-10mg/kg/day PO divided q6-8h (1 DS tab (160mg TMP) q8h)

= COPD =
Chronic cough, sputum, dyspnea, slowly progressive. FEV1/FVC<70%
GOLD severity 1 (FEV1>80%), 2 (FEV1>50%), 3 (FEV1>30%), 4 (FEV1<30%)
- Bronchodilators (albuterol/ipratropium) PRN
- Tiotropium 18mcg inhaled daily
(Long acting inhaled bronchodilator to reduce exacerbations - UPLIFT 2008)
- Budesonide 90-300mcg inhaled bid
(Long-term inhaled corticosteroids may reduce frequent exacerbations, but increases pneumonia risk - TORCH 2007.  Add for more severe disease)
- Counseled on smoking cessation, offered replacement therapies
Nicotine transdermal 21mg/day patch daily x6weeks then decrease by 7mg/day every 2 weeks (Start at 14mg/day if <10 cigarettes/day)
Nicotine gum 2mg Transmucosal q2h PRN cravings
- Vaccinations: Influenza (seasonally), PneumoVax (<65yo and FEV1<40% or >65yo)
- Pulmonary rehabilitation referral

http://www.goldcopd.org/guidelines-pocket-guide-to-copd-diagnosis.html

^ Cirrhosis

= Cirrhosis - ESLD (Childs-Pugh ***, MELD ***, Transplant Status***) =
? Childs-Pugh: (http://gihep.com/?page_id=43)
? MELD-Na: (http://gihep.com/?page_id=49)
? Cause: Alcoholic, Hepatitis C, NASH, Toxin, AIH, PBC, PSC
? Decompensated: Prior variceal bleed, SBP, medically refractory ascites

- Consult: Hepatology

# Hepatic Encephalopathy
? Hx TIPS will make difficult to control
- Lactulose titrated to 3-4BM/day, Rifaximin 550mg PO bid, Zinc SO4 200mg PO daily
- Screen for (infectious) trigger: UA, Blood Cx, paracentesis, r/o dehydration / overdiuresis

# Ascites
? Hx TIPS?  Stable renal function?
- Furosemide 40mg PO : Spironolactone 100mg PO
- Therapeutic paracentesis, replete 25g albumin per 4L removed

# SBPeritonitis
? Paracentesis with >250 PMN or positive culture
- Ceftriaxone 1g IV daily -> norfloxacin 400mg PO bid or TMP/SMX DS PO bid x1 week
- Albumin 1.5mg/kg day 1 then 1.0mg/kg day 3 may help short-term survival/renal function
(Use if high risk: Cr>1, BUN>30, or TBili >4) 
Gastroenterology 2006;131:1049

# SBP Prophylaxis
? Hx prior SBP or ascites albumin <1.5 with renal/liver impairment (Cr>1.2, BUN>25, Na<130, Childs-Pugh>9, Bili >3) or ascitic albumin <1.5 and currently hospitalized
- Norfloxacin 400mg PO daily vs. Ciprofloxacin 500mg PO daily vs. TMP/SMX DS 1 tab PO daily?  Ciprofloxacin 750mg PO weekly sometimes used (but may select for resistant organisms).  VA recommends cefpodoxime given high rates of Cipro resistance

# Varices (Bleed): Octreotide gtt acutely, transition to Propranolol 20mg PO bid or Nadolol 20mg PO daily after stabilization with goal HR <70 (see .JonCGIBleed)
Antibiotic prophylaxis for week after bleed (ceftriaxone 1g IV daily while inpatient, transition to norfloxacin 400mg or ciprofloxacin 500mg PO bid upon discharge)
Hepatology 2005;41:572

# Hepatorenal? (Type I: Rapidly progressive over days.  Type II: "Diuretic refractory ascites")
? 1g/kg/day albumin challenge to confirm not pre-renal  
- Midodrine (7.5-12.5mg PO tid) + Octreotide (100-200mcg SubQ tid) + 20-40g/d albumin, goal increase MAP 15mmHg, but really only liver transplant will help at this point
Hepatology 1999;29:1690

# Coagulopathy / "Chronic DIC"
Elevated INR is actually misleading, patient missing both pro- and anti-coagulant factors, and should receive VTE prophylaxis (heparin) if Plt>50
- For purposes of procedure (i.e., paracentesis), can administer FFP, platelets, cryoprecipitate respectively (goal INR<2, Plt>50, fibrinogen>100), but no data to support.  Can't really avoid bleed risks (though minimal for paracentesis anyway).
Hepatology 2004;40;484

http://www.thececonsultants.com/images/Burton_Cirrhotic.pdf

= Cirrhosis / Outpatient =
- q6-12month RUQ ultrasound for HCC monitoring if cirrhosis or Hepatitis B+
- EGD
- Check Hep C genotype + viral load to guide potential therapy
- Hep A/B vaccination series
- Counsel on EtOH cessation

^ DKA / HHS

= Diabetic Ketoacidosis / Hyperglycemic Hyperosmolar Syndrome =
# Diagnostics
- CBC, BMP+Phos
- UA, Beta-hydroxybutyrate (assess for presence of ketones)
- Serum Osmolality
- ABG/VBG to assess severity of acidemia
# Trigger Assessment
- CXR, UA, Blood Cultures for infection
- Troponin, EKG for ischemia
- Lipase for pancreatitis

# Initial Treatment
- Insulin (regular) 0.1u/kg (~10 units) IV x1
- Insulin drip, DKA protocol (requires NPO)
- Isotonic (NS,LR) bolus 1L / hr until euvolemic (expect extensive volume depletion, could require 5L+)
- Foley catheter for high urine output monitoring
- Consider arterial/central line for repeated labs
- Treat any underling causes

# Treatment Maintenance
- Glucose: q1h to titrate insulin
- Lab monitoring: q2-4h BMP+Phosphorus+pH (ABG/VBG)

- Continue Insulin drip, DKA protocol
- If pH<6.9, consider D5W + 100mEq NaHCO3 IVF for few hours
- Maintenance fluids 1/2NS ~200mL/hr
- Change to D5 1/2NS when glucose <250
- Change to D5 1/2NS + 20-40mEq KCl when demonstrated urine output and K <5.5
	- If K<3.5, aggressively replete and hold insulin for couple hours until K>4
- Replete phosphorus with KPhos 20-40mmol if Phos severely low <1 (less evidence)

- Goal to normalize anion gap (eliminate beta-hydroxy butyrate / ketones) due to insulin deficiency (glucose and potassium repletion expected)

# Resolution / Transition
When normalize anion gap and low stable insulin requirement for 4 hours
- Calculate/extrapolate 24hr insulin requirement (example below)
- Start long acting insulin (NPH) then stop drip 2-3 hours AFTER to bridge effect
- Stop fluids and start carb-controlled diet

Sample Calculation:  Coming Off Insulin drip, Starting Diet
- Stable ~2 units / hr while NPO on drip
- 24hr need estimate 2x24 = 48 units
- 75% reduced need as "less stressed" = 75%x48 = 36 units
Orders:
- Insulin NPH 9 units SubQ bid (18 units split in two)
- Insulin Aspart 6 units SubQ qac (matching prandial doses once start eating meals / bolus feeds)
- Insulin Aspart Sliding Scale

Example Algorithm from Up-to-Date

# Mild DKA / Non-Drip / Non-ICU Management (monitored floors may allow insulin drip)
- Can try rapid acting Insulin lispro or aspart SubQ ~0.1u/kg/hr (~10u/hr) until glucose<250 then 0.05 (~5u/hr) until ketoacidosis resolved
- Other SubQ possible though not consistently studied

^ Diarrhea / Colitis

= C. Difficile Colitis =
Discontinue other antibiotics if possible.  Initial regimen based on disease severity, though criteria are only based on expert opinion.  No anti-motility agents (may precipitate toxic megacolon).  Evidence equivocal for probiotics, and may even risk fungemia in critically ill, CVC catheter, immunocompromised.
- Metronidazole 500mg PO tid x10+ days until diarrhea resolves or
- Vancomycin 125mg PO qid x10+ days if severe disease (WBC>15K or Cr>1.5x prior) or
- Vancomycin 500mg PO or PR qid + Metronidazole 500mg IV tid if severe, complicated disease (hypotensive, ileus, megacolon)
- Consider colectomy in severely ill (monitor lab trends, intervene before bad peri-operative mortality once WBC>50K, lactate>5)

- 1st Recurrence: Same regimen for first recurrence of same severity
- Further Recurrences: Vancomycin taper 125mg PO qid x2 weeks, then bid x1 week, then daily x1 week, then qod x2-8 weeks

- Further escalation options (need ID approval): Fidaxomicin 200mg PO q12h x10 days, stool transplant (for outpatient prevention, not inpatient acute management)

http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/cdiff2010a.pdf

===========================================

(See IP Gen Vomiting/Diarrhea and Specimen Testing, Stool Order Sets)

? Exposures:  Travel hx, sick contacts, day care, dietary (undercooked, dairy, seafood), risky sexual exposures, recent antibiotics or chemotherapy
? Timing: Chronicity, frequency, hospitalized >3 days
? Symptoms:  Bloody, nausea, vomiting, tenesmus
? Host: Immunocompromised?

= Diarrhea (acute, chronic, traveller's, bloody, febrile) =
Diagnostics generally more for epidemiologic / public health purposes.  Most causes of acute diarrhea will be self-limited.

? Community Acquired or Traveler's Diarrhea, especially if fever or bloody stools
- Stool Culture (assessing for Salmonella, Shigella, Campylobacter, E. Coli O157:H7)
- C. Difficile Toxin (if on antibiotics or chemotherapy recently)
- Vibrio testing if seafood / seacoast exposure
- ESR, CRP if suspect inflammatory bowel disease
- Norovirus testing for isolation of contagion

? Nosocomial Diarrhea (occurs >3 days into hospitalization), no reason to suspect community-based organisms
- C. Difficile Toxin
- Discontinue other antibiotics, or consider adding metronidazole

? Persistent Diarrhea >7 days (especially if immunocompromised)
- Stool O&P (consider EIA for Giardia, Cryptosporidium, acid-fast stains for Cyclospora, Isospora, MAC)
- Stool WBC / Lactoferrin (inflammatory screen)
- Add Microsporidia + MAC testing if HIV+

Primary Therapy is Rehydration (PO preferred)
- PO and IV rehydration and electrolyte repletion

Consider Selective Antibiotic Therapy for Traveler's Diarrhea, Shigellosis
- Ciprofloxacin 500mg PO bid x3 days or
- TMP/SMX DS (160/800) bid x3 days
(Can help reduce illness duration from <5 to <2 days)
(Avoid empiric therapy even for bloody diarrhea in US, with risk of Hemolytic Uremic Syndrome <- EHEcoli and just prolonging carrier states.  Similarly, avoid anti-diarrheal / anti-motility agents.)

Campylobacter
- Erythromycin 500mg PO bid x5 days

Vibrio
- Doxycycline 300mg PO x1 or
- TMP/SMX DS (160/800) PO bid x3 days or
- Ciprofloxacin 500mg PO x1

Giardia.  If persistent diarrhea >10 days without other cause and history suggestive, consider empiric therapy
- Metronidazole 500mg PO tid x7 days
http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Diarrhea.pdf

^ Dispo Checklist

^ EtOH Withdrawal

= EtOH Withdrawal =
? Average Drinks Per Day ***
? Last Drink ***
? Hx Seizures / DTs ***
? Evidence of End-Organ Damage *** 
? Motivation to abstain ***

- Check Volatile Screen (EtOH, Osmol Gap), UTox
- Check CMP, INR, Daily BMP+Mg
- Banana Bag x1 (1L NS or D5W, 100mg thiamine, 1mg folate, 1amp/tab MVI, 3g magnesium sulfate) if not tolerating PO
- Daily Thiamine, Folate, MVI once tolerating PO
- Insomnia Options: Melatonin 3mg, Doxepin 10mg, Hydroxyzine 50mg, Zolpidem 10mg
- SW consult for cessation resources
- PT/OT evaluation for mobility

== CIWA +/- Standing Protocol ==
- CIWA symptom triggered PRNs
Progressively double dose if poor control despite multiple doses within an hour
(See IP Med EtOH Withdrawal Order Set)
- Diazepam 10mg tid with daily 5mg taper or
- Lorazepam 2mg tid with daily 1mg taper

vs.

== Non-BZD Withdrawal Protocol ==
(Adapted from Maldonado drafts)
(Use if expect symptom resolution <5 days)
- Clonidine 0.2mg PO tid x3
- Clonidine 0.1mg/day patch x2
- Valproate 250mg PO/IV bid + 500 qhs
- Lorazepam 2mg IV PRN seizures

(Escalation Options)
- Increase Valproate to 500mg bid + 1000mg qhs
(If low BP unable to tolerate clonidine, hepatic disease unable to tolerate VPA, or need additional symptom/anxiety control after above, then add...)
- Gabapentin 600mg PO tid, taper by 300mg per day

(Tapering off)
- Peel off 1 clonidine patch after 1-4 days, leave other on for full 7 days duration
- At same time, taper off daytime valproate doses over couple days until eventual removal of all VPA by ~day 7
- If started gabapentin, consider extended continuation as outpatient to supress recidivism

= EtOH Hepatitis =
Maddrey Discriminant Function ***, treat if >32
(http://www.mdcalc.com/maddreys-discriminant-function-for-alcoholic-hepatitis/)
- Pentoxifylline 400mg PO tid x3 months (less adverse effects than steroids, though requires PO route, PMID 19340904)
- Prednisolone 40mg PO daily x4 weeks followed by 2 month taper
- Hepatology / GI consult
- Re-eval Lille Model in 1 week to verify beneficial effect
(http://gihep.com/?page_id=711)

^ Fever in Returning Traveller

^ GI Bleed

= GI Bleed =
Acute/Chronic, X unit EBLoss, Upper/Lower, with/without evidence hemodynamic instability
Hematemesis, Hematochezia, Melena, Guaic ***, stool content/quality before and during.Suspected causes: 
Risk Score:  If 0, consider outpatient management 
http://www.mdcalc.com/glasgow-blatchford-bleeding-score-gbs/
Upper GI: Peptic Ulcer Disease (H. Pylori vs. NSAID), Gastritis, Variceal Bleed, MW Tear, AVM, less likely malignancy
Lower GI: Diverticulosis, AVM, malignancy, hemorrhoids

- At least 2x IV access, 18 gauge or larger
- IVF resuscitation to maintain MAP>65
- H&H monitoring q6h
- Blood Consent.  Transfuse PRN Hgb<8
(Threshold of 7 may actually be non-inferior and even superior according to PMID:23281973)
(Massive Transfusion Protocol option or empiric FFP+Platelets if needing more than 2-4 units PRBC)
- Pantoprazole 80mg IV x1 then gtt 8mg/hr
(Oral PPI should be adequate if no stigmata / active bleeding, but no direct IV vs. PO comparison.  Lower dose 40mg IV bid PPI also effective)
- NG lavage with 1L cold NS then continue to suction if ongoing N/V***
(Intubation / ICU Admission for Airway Protection if excessive Hematemesis)
- NPO for pending endoscopy
- GI Consult for EGD/Colonoscopy
- Bowel prep with 4L Golytely (if suspect lower GI source / BRedBloodPR)***
(If massive lower GI bleed, CT angio to isolate source and IR Consult for embolization)

- Helicobacter pylori Ab + stool Ag.  If either positive, treat
- Hold NSAIDs, steroids, ASA

***Additional Interventions for Variceal Bleeds / Portal Gastropathy / AVMs
- Octreotide 50mcg IV x1 then 50mcg/hr drip
- (SBPeritonitis) Antibiotic Prophylaxis with ceftriaxone 1g IV daily -> norfloxacin 400mg PO bid x 7 days total for variceal bleeds / cirrhotics

***Post-EGD Stabilization
Risk Score: http://gihep.com/calculators/bleeding/rockall-score/
- Complete 72hr PPI drip vs 40mg IV bid if high risk lesion on EGD (visible vessel or bleed vs. clean base / red spot)
High- versus low-dose proton pump inhibitors after endoscopic hemostasis in patients with peptic ulcer bleeding: a multicentre, randomized study.  Am J Gastroenterol. 2008;103(12):3011.
- Transition to oral PPI (daily dosing adequate)
- If variceal bleed / portal gastropathy, start propranolol 20mg PO bid to suppress (goal HR <70 while maintain SBP>90) ***
- Iron supplementation outpatient until replete anemia, with respective counseling on darkened stools, GI upset / constipation
(Alternatively consider IV iron sucrose 200mg / day inpatient if Hgb<10 to help quickly replete with response within 1-2 weeks and avoid confounding subsequent dark stool interpretation)
- Restart ASA within 3 days if known CAD

^ H&P Template

Stanford Hospital and Clinics
***Internal Medicine History and Physical
Date: @TD@         		Attending: @ATTPROV@	
Admit Date: @ADMITDT@	Primary Care Provider:@PCP@     Phone:@PCPPH@

ID: @NAME@ (MRN: @MRN@) is a @AGE@ @SEX@ patient born on @DOB@ in @ROOMBED@
CC: ***

HPI: 
***

ED: ***

Review of Systems
Otherwise negative except as per HPI, including:
General: Denies fever, chills, night sweats or unintended weight loss.
Resp: Denies cough, wheezing, shortness of breath.
Cardiac: Denies chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea.
GI: Denies abdominal pain, nausea, vomiting, diarrhea or constipation
GU: Denies dysuria, frequency, hesitancy or incontinence
MS: Denies muscle aches, joint pain or swelling
Neuro: Denies headache, neurologic deficits (focal weakness, numbness, tingling), abnormal gait
Psych: Denies anxiety, depression, SI/HI/AVH
Skin: Denies new rashes or lesions
ID: Denies sick contacts, exotic exposures, travel

@HXPMH@
@HXPSH@
Allergies: @ALLERGY@
@PTAMEDSLIST@***Repopulate above with dot-phrase PTAMEDSLIST, PTAMEDS, PTAMEDSED, or TAKMED, MEDLIST as needed***
Family Hx: @FAMHX@
Social Hx: Patient @SOCHXP@

Physical Exam
@VS@
General Appearance: No acute distress, lying in bed
HEENT: EOMI, PERRL, anicteric, oropharynx clear, mucous membranes moist
Neck: Supple, no lymphdenopathy, JVP ~6-8cm
Lungs: Clear to auscultation bilaterally.  No wheezes/rhonchi/rales.  No accessory muscle usage.
Cardiac:  Regular rate and rhythm.  No murmurs, rubs or gallops.
Abdomen: Soft, non-tender, non-distended.  Normo-active bowel sounds.  No organomegaly or masses noted
Extremities: No clubbing, cyanosis, edema.  2+ DP pulses.
Neuro: Alert and oriented.  Grossly non-focal.  Conversant, moving all extremities.  No overt cerebellar signs / incoordination.
Skin: No rashes or lesions noted.
Lines: PIV, central IJ, arterial, PICC, Foley, rectal tube

Labs/Diagnostics
@RRCBC@ (N% ***)
@RRPTINR@
@RRCKMBTROP@
@RRBMP@
@RRBMP2@
@RRCAMG@
@RRLFT@
EKG: ***
CXR: ***
UA: ***
ABG: ***
Lactate: ***
TTEcho: ***
Imaging / Other Labs ***

Overall Impression
@SUMMARYLINE@

Plan 
@HOSPPROBL@

= FEN / PPx / Lines =
- Diet: @RRDIET@
- NPO at midnight for pending procedure
- IVF maintenance + PRN boluses
- Bowel regimen

- Enoxaparin / Heparin SubQ if poor mobility and stay >24hrs
- Hold anti-coagulation for thrombocytopenia / pending procedure / active bleed / brain lesions
- Therapeutically anti-coagulated with warfarin / dabigatran / enoxaparin / heparin

- Pantoprazole prophylaxis if any of...
Coagulopathy: Plt<50, INR>1.5, Mechanical Ventilation>48 hrs, hx GI bleed/ulcer within past year, traumatic brain, spinal cord or burn injury.  Or at least 2 of sepsis, ICU stay >1 week, occult GI bleed >1 week, steroids (>250mg hydrocortisone).  Enteral feeding is also protective.

= Dispo Checklist =
- Necessary Lines, Catheters, Telemetry, IV Meds, O2, Sitter: ***
- Dispo pending resolution of ***
- Consults/PT/OT recs: ***
- Destination and Transport: ***
- Med Rec: *** (Verify meds covered?  Triplicates?  AVS reviewed?  Discontinued meds & changes in DC instructions?)
- Additional Needs: *** (O2?  DME?  SNF orders & DC summary done?)
- Discharge Docs: IP Medicine Discharge Summary. (Goals of Care, POLST?)
- Estimated Discharge: *** (Patient and Family aware?  Updated Whiteboard and Epic?)
- Follow-up: *** (DC Coordinator x5-6879?  DC Summary routed?  Pending labs?)

= Goals of Care =
Code Status Order: @CODE@ 
@RREMERCONTACT@
*** Wishes to pursue full aggressive treatment and intervention options, including CPR and intubation, but goals of care should be addressed on going with family if that should become necessary.
*** Patient wishes to pursue ongoing treatment with relatively conservative measures (e.g., IV fluids, antibiotics), but would not wish to escalate to ICU level of care or other invasive measures.
*** Patient wishes to pursue ongoing treatment, but concurred that if deteriorated to pulselessness, patient would prefer a natural death as opposed to invasive measures such as CPR and intubation.  Family should be immediately contacted in such situations.

Assessment and Plan to be discussed with attending @ATTPROV@***
Route H&P to PCP***

@ME@
@TD@ @NOW@

^ ICU Observation

= Post IV TPA for Ischemic Stroke =
- admit to ICU with neuro-critical care service following and MICU primary team
- neuro checks per tPA protocol 
- No lines, catheters, antiplatelet or anticoagulants x24 hr after IV tPA unless required 
- keep BP <185/100 with short-acting antihypertensives (Labetolol, Hydralazine or Nicardipine Gtt as needed). 
- order MRI brain stroke protocol
- order TTE to r/o cardioembolic source, assess EF 
- check fasting Lipid Panel with Direct LDL in AM. 
- check HgA1c, TSH 
- Goal euthermia, eunatremia, euglycemia, euvolemia 
- NPO for now until passes swallow screen 
- SLP eval
- Aspiration precautions, Bleeding precautions
- if significant change in neurologic exam or severe HA, order stat Head CT and call the Neuro-critical care resident or after hours the Neurology resident on call.
(Adapted from Lucas McCarthy's SmartPhrase)

= Intracranial Hemorrhage =
- Goal SBP < 160 using prn Labetolol or Nicardipine Gtt if needed
- HOB >= 30 degrees with aspiration precautions
- Q1 neuro checks -- get stat head CT and call Neurology if acute change
- Goal Na>145 w/ Q2 hr Na checks, PRN 3%NS (bolus via central line)
- INR goal <1.4, daily coags. 
- Pain control
- if sedation is necessary: would recommend dex for sedation and ease of exam 
- MRI ICH strotocol when stable
- No HepSQ, antiplatelet or anticoagulant agents at this time
- Maintain strict euglycemia, euthermia, and euvolemia 
(Adapted from Lucas McCarthy's SmartPhrase)

======================================
== Monitoring after OSA Surgery ==
= Neuro = 
- Morphine PRN post-op pain 
= CV = 
Stable post-op, continue to monitor 
- PRN Hydralazine to maintain MAP<80 
= Resp = 
- Dexamethasone on for peri-operative edema 
- Continue to monitor post-operative for airway obstruction (mouth secured with rubber bands / wire)
= Renal = 
- IVF maintenance while NPO 
- Foley in, but d/c POD #1 
= GI = 
- NPO post-operative 
- Ondansetron + Metoclopramide PRN nausea/vomiting 
Consider GI PPx if extended NPO duration 
= Heme = 
No significant post-op bleed noted 
VTE PPx: SCDs post-op, heparin if remains immobile >24 hrs 
= ID = 
- Cefazolin peri-operative 
= Endo = 
No DM history, otherwise Glucose goal 110-150, Insulin SS 
= Lines = 
PIV, Foley

^ Leukemia

Summary Line: PCP, Primary Onc Dx, HLA type status, sibling HLA Type, BMT reference, Flow/Cytogenetics, Chemo, Day #1 Date

See "SHC Acute Leukemia" Order Set

== Acute Leukemia Checklist ==
= Labs =
- CBC with diff
- CMP
- Tumor Lysis (BMP, Phosphorus, Uric Acid, LDH)
- DIC Screen (INR, PTT, Fibrinogen, D-Dimer)
- Pregnancy test
- Type & Screen (every third day)
- Consent patient for transfusions
- HLA Tissue Banking (see "CC BMT" Order Sets)
- Flow Cytometry (might wait for BM biopsy, instead of extra peripheral blood test)
- Specialized Studies for AML
- AML Prognosis Assay (FLT3, NPM1)
- (CEBPA, c-Kit) 
- t(15:17) if suspect APL (Chromosome and/or FISH Analysis order)
- Cancer Somatic Mutation Panel
- Specialized Studies for ALL
- BCR-ABL Qualitative

= Orders =
- PICC/CVC
- CXR
- TTEcho
- Allopurinol 300mg PO BID (or appropriate renal dosing) + IVF for TLS Prophylaxis
- Norethindrone 15mg PO daily or Leuprolide 3.75mg monthly (for women, block menstrual bleeding)
- Sperm Banking? (Social Work consult, paper Rx for "Cryopreservation of Sperm")
- Bone Marrow Biopsy plan with fellow
- Tissue Banking for Research
- Bleeding + Neutropenic precautions PRN
- No NSAIDs
- No Anti-Coagulation (as appropriate)

= Pre-Bone Marrow Transplant Panel =
- Pulmonary function test with spirometry and DLCO
- Cardiac echo with Doppler and LVEF
- EKG
- Hepatitis B Surface Ag
- Hepatitis B Core Total Ab
- Hepatitis C Ab EIA
- Hepatitis C RNA PCR Quantitative
- HIV Quantitative PCR
- HIV (Type 1 and Type 2) ABY
- HTLV-1 Ab Screen
- Syphilis Treponemal Screen
- HSV 1 & 2 IgG
- Varicella Zoster Virus Ab IgG
- CMV Ab Total
- CMV IgM

===============================================

Typical Acute Leukemia Timeline
= Admit =
â—¾Order diagnostic labs
â—¾Consent for blood transfusions
â—¾Get PICC line
â—¾Pre-chemo TTEcho
â—¾Fellow does BM biopsy for diagnostics
â—¾If clotting evidence or otherwise concern for APLeukemia, fellow will empirically start ATRA (tretinoin)

= Day 1-7 =
â—¾Induction chemotherapy (variable depending on regimen chosen)
â—¾Monitor Tumor Lysis labs (K, Cr, Ca, Phos, LDH, Uric Acid)  
Mostly just keep hydrated to flush these out, and standing allopurinol 300mg PO bid while at active risk.  Only other meaningful intervention is rasburicase if uric acid >10, but requires a call to fellow.  Only relevant if very high WBC and early during induction chemotherapy.
â—¾Monitor DIC screen first several days, though mostly only looking at fibrinogen for cryoprecipitate repletion

= Day 7-21 =
â—¾Most severe period of pancytopenia
â—¾Daily CBC to monitor for blood and platelet transfusion
â—¾Neutropenic fever almost inevitably develops, grapple with this daily, as it represents the major threat to your patients' survival

= Day 14 =
Depending on treatment protocol, fellow will often do a repeat bone marrow biopsy.  Purpose is to verify an empty "hypocellular" marrow, to verify the chemo was effective at suppressing the leukemia

= Day 21-28 =
â—¾Usually expect to see recovery of normal bone marrow (e.g., ANC>500 and Plt>100k) with reduced transfusion requirements
â—¾Once not neutropenic, can start peeling off all antibiotics
â—¾May recheck bone marrow biopsy (or defer to clinic follow-up) after count recovery: If no leukemia present (<5% blasts) = disease remission.  If leukemia still present = refractory disease, warranting re-induction with different chemo regimen
â—¾Arrange outpatient follow-up either with patient's local hematologist or with admitting attending from Hematology service
â—¾Make sure expensive discharge meds are approved well in advance (e.g., voriconazole, ATRA, Neupogen).  Work with the Case Manager early to ensure these are in order early.  The Case Manager matters more for approving discharge than the attending does.

Transfusions
- Keep patients Type & Screened every 3 days (can order standing this way) so will always be ready.
- In general
Transfuse 2 units PRBC if Hgb<7
Transfuse 1 unit Platelets if Plt<10
Transfuse 1 unit (10 pooled) Cryoprecipitate if fibrinogen<100

^ Meningitis

= Meningitis (suspected / fever + headache) =
(Physical exam findings, jolt, Kernig's, Brudzinksi all non-sensitive and non-specific)

- Blood Cultures + CSF Studies
- CT Head NOT necessary in most cases (unless focal neuro sx, altered mentation, known CNS lesions, seizures, immunocompromised)
(If need CT, blood cultures, then antibiotics before CT Head to avoid potentially lethal average delay of 2 hours)

Lumbar Puncture / CSF Analysis
- Opening Pressure (<20-25cm can consider normal)
- Cell Counts: WBC
(if excess RBC, check peripheral RBC/WBC ratio or default 1000:1 to 500:1 ratio)
- Glucose (normal 2/3 of serum)
- Protein (normal <38)
- Lactate>4 more suggestive of bacterial
- Gram Stain + Culture
- Additional Studies depending on context: 
HSV PCR, Entero / other viral PCR, fungal Cx, AFB Smear + Cx, TB PCR, Crypto Ag

Empiric Treatment
- Vancomycin 20mg/kg load x1, then 15mg/kg IV q12hr, goal trough 15-20
- Ceftriaxone 2g IV q12h

Optional Treatments
- Ampicillin 2g IV q4h if young child, old (>50), immunocompromised (Listeria coverage)
- Cefepime 2g IV q8h if surgical exposure (Pseudomonas coverage)
- Acyclovir 10mg/kg IV q8h if altered mental status, focal neurologic Sx (suspect HSV encephalitis)
- Dexamethasone 15mg x1 then 10mg IV q6h x4 days (but only counts if first dose prior to antibiotics) (marginal evidence that helps neurologic sequelae in Pneumococcal meningitis)

Practice Guidelines for the Management of Bacterial Meningitis
Clin Infect Dis. (2004) 39 (9): 1267-1284. doi: 10.1086/425368 
http://www.idsociety.org/IDSA/Site_Map/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_by_Organ_System/Central_Nervous_System_(CNS)/Bacterial_Meningitis.aspx

^ NSTEMI

= NSTEMI / Unstable Angina (dynamic EKG changes with normal cardiac enzymes) =
+ TIMI Risk Score (http://www.mdcalc.com/timi-risk-score-for-uanstemi/)
- Cardiology Consult / Interventional Assessment

- ASA 81mg PO daily (initial 162-324mg = 2-4x 81mg chewable tablets)
(Consider higher dose >30 days if get BMStent, >3 months if get DEStent, otherwise CURE trial suggests 81mg should be adequate, while higher doses just increase bleeding)
- Clopidogrel 75mg PO daily (initial load 300mg if no cath, 600mg if cath planned) 
(Hold 5 days if surgery / CABG planned, suggested by diabetes, cardiogenic shock or VA patient since likely multi-vessel disease that will need surgery, probably should ask Cards fellow or attending first)
(Continue >30 days if get BMStent, >1 year if DEStent or only planning medical management)
- Atorvastatin 80mg PO daily, check lipid panel 
(Start high-dose statin prior to discharge regardless as per MIRACL and PROV-IT)

- Consider Beta-blocker: Metoprolol 12.5mg PO bid (titrate to goal HR<70) 
(Hold if SBP<90 / cardiogenic shock) 
(Beware may actually worsen near-term mortality from shock, especially if use IV.  Start prior to discharge)
- NTG + morphine PRN chest pain or NTG drip if ongoing chest pain 
(Hold if hypotensive / cardiogenic shock / inferior MI / sildenafil within past 24 hours)

- Anti-coagulation (Heparin drip per ACS protocol)
(Enoxaparin if planning medical management only (no cath), slightly superior as per ESSENCE, more appropriate if Low Risk TIMI <=2, but ask Interventional first as they usually prefer reversible and monitorable heparin)
(Continue until catheterization or at least 48hrs if only medical management)

(High Risk TIMI >=3) (Favor GP IIb/IIIa and early angiography)
- Consider GP IIb/IIIa inhibitor (e.g., eptifibatide) if ongoing chest pain, elevated troponin on presentation, heart failure, diabetes or otherwise planning early angiography (within 24-48hrs), but only helps if actually getting catheterization and per ACUITY and EARLY, same effect if wait until just prior to PCI, so usually defer to interventional cardiology
(Continue until catheterization, then 6-12 hours)

Prior to Discharge (core measures)
- Assess LV Function (i.e., TTEcho)
- ACE-I / ARB if EF<40% (though GISSI-3 indicates can help regardless of EF)
- Eplerenone (or spironolactone) if new EF<40% (as per EPHESUS)
- Beta-blocker

^ Neutropenic Fever

= Neutropenic Fever =
Tmax ***, ANC ***, Last Chemotherapy ***, Expected Nadir***, prior Abx prophylaxis***, prior Neupogen/Neulasta ***
Systolic Heart Function ***
Localizing Sources: Mucositis, line infection, rectal lesions, vesicular lesions***
- Cefepime 2g IV q8h
(***Zosyn (pip/tazo) if suspect anaerobes, but collect galactomannan test first so won't contaminate future result.  Add metronidazole if suspect C. Diff)
- Neupogen (filgrastim) 5mcg/kg SubQ daily (until ANC>500) (hold if leukemia with peripheral blasts)
- Vancomycin *** (if mucositis, hypotension, line infection, prior fluoroquinolone prophylaxis, or apparent HCAPneumonia, cellulitis, etc.)
- Acyclovir *** (if vesicular lesions suggestive of HSV/VZV or mucositis and HSV+)
- Fluconazole *** (if oral or other lesions suggestive of candidiasis)
- IVF bolus PRN (Goal CVP 8-12 / JVP 10-15, MAP>65, UOP>0.5mL/kg/hr)
- Neutropenic precautions
- Follow-up blood+urine cultures
- Discharge after confirm negative blood cultures, afebrile >24 hours, ANC>500

If persistent or recurrent fever >4 days without clear source, consider
- CT Thorax to assess for pulmonary nodules (likely Aspergillus mold)
- CT Sinuses?
- Serum galactomannan (may get false positive if already received Zosyn)
- Empiric anti-fungal (Voriconazole or Caspofungin)

^ PDialysis Peritonitis

Most commonly presents with diffuse abdominal pain with cloudy abdominal fluid.  Only ~50% with systemic fever.

= Peritoneal Dialysis-Related Peritonitis =
Most likely skin flora contamination from touch / catheter-related.  Less likely secondary to enteric pathology or hematogenous spread, unless systemic signs (hypotension).
- Call Renal Fellow to order Dialysis Nurse to access catheter for fluid sample and arrange for intraperitoneal antibiotics
- Peritoneal Fluid 
Cell Count (often neutrophils>100)
Gram Stain+Culture
Amylase+Lipase may suggest pancreatitis source
Fungal, AFB if culture negative or no improvement after several days, and consider catheter removal
- Blood Cultures (though bacteremia uncommon unless systemic symptoms)
- Consider Abd CT if concern for enteric / visceral pathology.  
(Some free air expected from PD itself)
(Further Surgical Consult if polymicrobial infection suggesting bowel defect)

- Empiric Antimicrobial Coverage (peritoneal dialysis dosing)
- Gram+ Skin Flora: 
	Cefazolin IV 1g q24h (if do not suspect MRSA) otherwise
	Vancomycin IV 20mg/kg load then daily troughs for dosing
- Enteric: Ceftazadime IV 1g x1 then 500mg q24h (3rd gen covering Pseudomonas)
- Fungal: Prophylactic Nystatin Swish & Swallow 15mL PO qid while on antibiotics
(Conflicting data, dependent on local rate of antibiotic-related fungal peritonitis rates)
A prospective randomized control study of oral nystatin prophylaxis for Candida peritonitis complicating continuous ambulatory peritoneal dialysis. PMID 8840945
Nystatin prophylaxis: its inability to prevent fungal peritonitis in patients on continuous ambulatory peritoneal dialysis.  PMID 9932656
(If yeast on Gram Stain, start Caspofungin IV 70mg x1 then 50mg daily and remove catheter)
- Coordinate with Renal fellow for subsequent intra-peritoneal antibiotics

- Consider catheter removal if relapsing (<4 weeks recurrence), refractory (>5 days treatment), fungal, mycobacterial, fecal peritonitis or associated intraabdominal pathology
(Replace after 3-4 weeks of antibiotic therapy)

http://www.ispd.org/guidelines/articles/update/ispdperitonitis.pdf

^ Pancreatitis

^ Pleural Effusion

= Pleural Effusion =
? Indication to Tap
Any new pleural effusion large enough to tap (e.g., >1cm on lateral decubitus X-ray)
Unless simply CHF / volume overload with bilateral effusions, afebrile and effusion resolves within 3 days

? Transudate vs. Exudate
Lightâ€™s criteria (Exudate if any ONE criteria satisfied)
- Pleural LDH > 2/3 upper limit of normal serum LDH (340 at Stanford)
- Pleural / Serum LDH > 0.6
- Pleural / Serum Total Protein > 0.5

Transudate DDx
CHF (90%), cirrhosis (hepatic hydrothorax), pulmonary embolism, nephrotic syndrome, peritoneal dialysis, myxedema, constrictive pericarditis, SVC syndrome.

Exudate DDx
Infection, cancer, connective tissue disease, pancreatitis, uremia, chylothorax, drug reaction, post-MI/CABG, esophageal rupture.

? Diagnostic Labs / Exudative Fluid Analysis
(See Specimen Testing, Pleural Fluid Order Set)
- LDH, Protein + Serum LDH, Protein to assess Light's criteria (transudate / exudate)
- Cell Count, pH, glucose to suggest certain infectious / inflammatory sources
- Cultures (optional Gram stain, anaerobic, AFB, Fungal depending on suspicion)
- Cytology (Malignancy?)
- Adenosine Deaminase (TB effusion?)
- Amylase (Pancreatitis, esophageal rupture, adenocarcinoma)

- Cell Count with differential:
PMNs > 50%: Parapneumonic, PE, pancreatitis.
Lymphs >50%: Cancer, TB, fungus or post-surgery 
Eos >10%: PTX, hemothorax, drug reaction, asbestos, parasite infection, Churg-Strauss
- Culture: Yield is increased if fluid sent in blood culture bottles. Send for fungus and mycobacteria if pleural lymphs > 50 % or clinical picture is suspicious. Yield in Tb is <50%.
- Glucose: Level <60 mg/dL is seen in complicated parapneumonic effusion, malignancy, hemothorax, Tb, RA, SLE, Churg-Strauss, parasite infection.
- Cytology: A case series of 971 lung cancer patients reported 7% prevalence of pleural effusion on chest xray and 40% of these pleural effusions had positive cytology. If cytology is negative and cancer is suspected, pleural biopsy should be performed.
- Adenosine Deaminase(ADA) for Tb: At least 50% of tuberculous pleural effusions do not involve other organs and are therefore difficult to diagnose. ADA levels >40-60 U/L in the setting of a lymphocytic effusion are specific for Tb.
- Amylase: Elevated in patients with pancreatitis, esophageal rupture, and malignancies.

15% of exudative effusions have no determined cause. For both transudative and exudative effusions without a cause, pulmonary embolism should be considered. Further evaluation by pleural biopsy via thoracoscopy or open biopsy is indicated for undiagnosed, unresolved exudative effusion.  Therapeutic drainage and assessment for reaccumulation is also informative.

Light, RW. Pleural Effusion NEJM 2002; 346: 1971-1977. Up To Date.
Martin Diaz E et al. Thoracentesis for the assessment of lung cancer with pleural effusion. Arch Bronconeumol 2002; 38: 479-84.
Lee YCG, et al. ADA levels in nontuberculous lymphocytic okeural effusions. Chest 2001;120: 356-361.

^ Pre-Op Risk Assess

= Pre-Operative Evaluation =
***(If below true, no need for evaluation)
+ Non-emergent surgery AND
(Low-Risk Surgery OR 
Good Functional Capacity without symptoms OR 
No Clinical Risk Factors)
-> No contraindications, proceed to surgery without further workup

***(Select risk level of patient and surgery based on choices below)
+ Major-Risk / Active Patient (MI within 30 days, severe angina, decompensated CHF, poorly controlled arrhythmia, severe valvular disease)
+ Intermediate-Risk Patient (mild angina, hx MI, CHF, diabetes, creatinine >2)
+ Minor-Risk Patient (Age>70, EKG other than simple sinus, poor functional capacity <4 METS, hx CVA, uncontrolled HTN)

+ High-Risk Surgery (>5% event rate): Emergency, aortic / vascular, long surgery (fluid shifts / blood loss)
+ Intermediate-Risk Surgery (1-5% event rate): Carotid endarterectomy, ENT, Intra-Peritoneal / Thoracic, Orthopedic, Prostate
+ Low-Risk Surgery (<1% event rate): Endoscopy, Superficial, Cataract, Breast

***(Select from below to calculate RCRI score)
+ Revised Cardiac Risk Index (1 point each)
+ Ischemic Heart Disease (hx MI, Q-waves, +Stress test, Angina, NTG use)
+ Congestive Heart Failure (hx CHF, pulmonary edema, PND, rales/S3)
+ Hx CVA / TIA
+ Diabetes, Insulin Dependent
+ Creatinine >2
+ High-Risk Surgery (Intra-Peritoneal, Thoracic or Supra-Inguinal Vascular)

***(Based on score above, select one of the following lines and delete the rest)
+ RCRI = 0 (<1% peri-operative evnt risk) -> No beta-blockers or stress testing
+ RCRI = 1 (1% peri-operative event risk) -> Unclear benefit to starting beta-blockers and stress testing, only if poor functional capacity, high-risk surgery
+ RCRI = 2 (4-7% peri-operative event risk) -> Consider beta-blockers if baseline indication and consider stress testing if poor functional capacity, concerning cardiovascular symptoms.
+ RCRI >= 3 (9-11% peri-operative event risk) -> Consider beta-blockers if not already on and consider stress test

***(Complete the following to summarize your overall pre-op assessment and recommendations)
+ Patient Risk: ***
+ Surgery Risk + Urgency: ***
+ Functional Status: *** (>4 METS: climb stairs / hill, walk 4 mph, short run, heavy housework)

***(Include beta-blocker + stress testing lines below if relevant based on RCRI)
+ Beta-blockers goal HR 60s and continue 30 days post-op, unless SBP<100, heart block, significant bronchospasm, stroke concern.  
POISE trial and meta-analysis indicate reduced MI rate, but actually increased mortality related to hypotension and stroke.  If going to start, better to initiate days-weeks in advance to ensure tolerance rather than just hours pre-operatively.  More appropriate if already have baseline indication: Angina, MI, CHF

+ Stress testing should only be considered if it would actually change management.  
CARP trial and DECREASE-V Pilot Study found no improvement in outcomes with pre-operative revascularization compared to medical therapy if no inherent indication for CAD revascularization.
If positive stress test findings actually did warrant PCI+BMStent based on inherent CAD criteria (high risk lesions, poorly controlled angina), would delay surgery at least 7 days post angioplasty or 30 days for BMStent + clopidogrel.  If such delay would not be acceptable, stress testing or revascularization consideration would not be useful.

- High/Moderate/Low Risk Patient without specific contraindication for a High/Moderate/Low Risk surgery
- No additional diagnostics or interventions recommended prior to surgery

+ Additional General Recommendations
- DVT + antibiotic prophylaxis per surgical team
- Stress dose steroids if on chronic steroids (>5mg prednisone daily)
(Hydrocortisone 25, 50, or 100mg IV q8h for 1,2, or 3 days depending on surgical risk)
- No oral diabetes medications.  Cut long-acting insulin dose in half for surgery / NPO
- Start statins if not already on for major vascular surgery
- Hold ACE-I if large fluid shifts or bleeding expected

+ Peri-Operative Anticoagulation and Meds
- ASA stopped 7 days prior if surgeon requests and is medically reasonable
- Clopidogrel stopped 5 days prior. Delay surgery if recent stent requires uninterrupted clopidogrel.
- Bridging anticoagulation: Should be done in high risk Afib (high CHADS score or previous cardioembolic event), any mechanical mitral or tricuspid valve, and mechanical aortic valves when the patient has at least one risk factor for thrombosis (Afib, reduced LV function, hypercoagulable state etc). If AVR and no risk factors, then ok to not bridge given low daily risk of thrombosis (4% per year).
- Warfarin: Stop 5 days prior for normal INR at time of surgery. Bridge with lovenox/UFH starting 2 days after stopping warfarin. Stop lovenox 24 hours prior to surgery and stop UFH 4-5 hours prior to surgery.
- Dabigatran: Stop 1-2 days prior to surgery

^ Sample Calculation - Insulin

Sample Calculation:  Diabetic, Holding Oral Meds, High Glucose>200 While Inpatient 
- Weight = 80kg
- Estimated Daily Need = 1 unit/kg/day = 80 units
- Conservative Estimate = 0.2-0.4 unit/kg/day = 18-36 units
- Adminster half in long-acting form, half in prandial doses:

Orders:
- Insulin NPH 5 units SubQ bid
- Insulin Aspart 3 units SubQ qac
- Insulin Aspart Sliding Scale
- Goal FS Glucose <180

Sample Calculation:  Coming Off Insulin drip, Starting Diet
- Stable ~2 units / hr while NPO on drip
- 24hr need estimate 2x24 = 48 units
- 75% reduced need as "less stressed" = 75%x48 = 36 units

Orders:
- Insulin NPH 9 units SubQ bid (18 units split in two)
- Insulin Aspart 6 units SubQ qac (matching prandial doses once start eating meals / bolus feeds)
- Insulin Aspart Sliding Scale

Sample Calculation: Adjusting Standing Insulin based on Sliding Scale Usage
- 12 units of Sliding Scale Insulin used in past 24 hours
- Increase Standing 24hr Insulin Dosing by 12 units,
split 50:50 between long-acting and prandial doses

Orders:
- Increase Insulin NPH by 3 units SubQ bid
- Increase Insulin Aspart by 2 units SubQ tid-ac

Steroids
- Expect increase 30-50% requirement
- Or just add 1 unit NPH per 1-2 units prednisone given similar peak times

Sample Calculation: Single Insulin Dose for Hyperglycemia
(Consider using a standard sliding scale, otherwise derive from prior calculations)
Insulin Dose = (Current Glucose - Target Glucose) / (1800/Daily Insulin Req)

^ Suicidal Ingestion

^ Syncope

= Syncope =
San Francisco Syncope Rule to Predict Serious Outcomes
(http://www.mdcalc.com/san-francisco-syncope-rule-to-predict-serious-outcomes/)

General purpose of admission is to exclude dangerous causes of syncope, typically by overnight telemetry, serial cardiac enzymes, and TTEcho

? Cardiac Mechanical 
(Aortic Stenosis, Hypertrophic Cardiomyopathy, Pulmonary Embolism, HTN, Stenosis, Aortic Dissection, Myocardial Infarction)
- Echo
- CXR
- D-dimer / CT-PE if hypoxic
- Cardiac Enzymes; Consider Stress Test if negative

? Cardiac Electrical 
(AV Block, Sick Sinus Syndrome, Arrhythmia, Long QT syndrome, Bradycardia, Ischemia, Pre-Excitation) 
- EKG
- Telemetry + Pulse Ox monitoring
- Pacer Interrogation
- Discharge with rhythm monitor (e.g., Ziopatch or loop recorder)

? Vasovagal 
(Carotid sinus cardioinhibitory, vasodepressor central, Vasovagal cough, micturition defecation, post-prandial valsalva, sneeze)
- Carotid Massage
? Orthostatic 
(Dehydration, Diuretic drugs, Blood Loss, Autonomic insufficiency, Sympathetic nervous system blocker drugs, Adrenal Insufficiency, Vasodilator drugs, Idiopathic)
- Orthostatic Vital Signs
- Review Electrolytes

? Neurologic 
Transient Ischemic Attack (TIA), Seizure, Takayatsu (Giant Cell) Arteritis, Intermittent Pressure Hydrocephalus, Subclavian Steal Syndrome, Vertebrobasilar insufficiency 
- Head CT
- EEG
- MRI/MRA
- Cardiac Echo
- Carotid Dopplers

? Metabolic
Hypoglycemia, Hypoxia, Shock, Hyperventilation, Anemia, Alcoholic 
- Blood sugar QAC/HS
- Review CBC
- U Tox + EtOH level
- Review medications (hypoglycemic dosing; sulfonylureas and insulin)

? Psychiatric
(Psychogenic / Conversion (self-concern, no self-injury).  Panic disorders, depression, hysteria)

^ TIA

= TIA (transient focal symptoms <24 hours) =
Need for hospitalization?  Present within 72hrs of symptoms with ABCD2 score >2 or other evidence of focal ischemia or unable to complete outpatient workup within 2 days
(http://www.mdcalc.com/abcd2-score-for-tia/)
Additional factors favoring hospitalization: Crescendo TIAs, Sx>1hr, Carotid Stenosis>50%, cardiac embolus source / Afib, hypercoagulable state

Assess and manage high risk of secondary stroke (3.5-9% risk within 2-90 days).  
Assess for differential diagnosis for transient neurologic symptoms (heme/metabolic derangements, encephalopathy, seizures, migraines, syncope, peripheral neuropathy)
- Basic Labs (CBC, BMP, TSH+T4) to exclude hypoglycemia, hyponatremia, thrombocytosis or other heme/metabolic causes of neurologic symptoms
- INR, PTT (if going to consider anticoagulation)
- Fasting Lipid Panel + Glucose and Hgb A1c for risk modifiers

- Neuroimaging to identify ischemic areas
(MRI Brain Stroke Protocol with DWI preferred within 24hrs of symptom onset, CT Head alternative)
- Neurovascular Imaging to assess for large artery obstructions (opportunity for CEA or other intervention)
(MRA w/ + w/o gadolinium contrast, CTA, Carotid Duplex US, Transcranial Doppler)

- EKG + Telemetry (review for Afib or other suggestion of cardiac embolic source)
- TTEcho (if no other explanation and considering new anticoagulation or suspect endocarditis)
- Blood Cultures, ESR, ANA, RF (if suspect endocarditis)

Anti-Platelet Therapy
- ASA/Dipyrimadole 25/200mg PO bid or Clopidogrel 75mg PO daily 
(or ASA 81mg PO daily if unable to afford or tolerate above)
(Clopidogrel slightly superior to ASA as per CAPRIE 1996.  Combination only increases bleeding risk as per MATCH 2004.  ASA/Dipyridamole comparable to Clopidogrel as per PRoFESS 2008)
- Anti-Coagulation (Warfarin) instead if Afib / cardioembolic source

Risk Factor Management
- Smoking cessation, reduce alcohol consumption
- HTN control after 24hrs from symptom onset (permissive HTN initially up to 220/120 hold home anti-hypertensives)
- DM / glucose control
- HLD control (Atorvastatin 80mg PO daily, goal LDL<70 or 50% reduction as per SPARCL)

^ VA (Veteran Affairs) Chronic Musculoskeletal Pain

^ VTE/PE/DVT

= VTE / Pulmonary Embolism / DVT =

== Risk Factors == 
(Virchow's Triad)
+ Hypercoaguable: Malignancy, estrogen, cigarettes, autoimmune / thrombophilia dz
+ Venous Stasis: Immobilization, stroke, paresis, paralysis, chronic heart disease
+ Endothelial Injury: Surgery / central venous instrumentation (within 3 months)

== Diagnostic Approach ==
- Well's Score - 
(Risk Stratification)
http://www.mdcalc.com/wells-criteria-for-dvt/
http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/
- PERC Score - 
(If low Well's risk, PERC score rules out PE without further testing.  Lack of tachycardia and hypoxia in general suggests low-value in trying to diagnose subsegmental PE)
http://www.mdcalc.com/perc-rule-for-pulmonary-embolism/
- D-Dimer - 
(If not high-risk, - D-Dimer can rule out VTE with high NPValue, but often non-specifically +)

Confirmatory Testing 
(If high risk or D-Dimer non-negative (>age x10), need confirmatory testing)
- Extremity DVT US -
(If positive, stop testing as same treatment as PE.  If negative, but high suspicion, repeat US in 1 week.  If negative but still concern for PE, still need PE confirmatory study)
- CT Angiogram PE Protocol -
(Needs 20g or larger IV access in antecubital or more proximal site, and beware contrast-induced nephropathy.  Local radiology will accept IJ central line, but not EJ due to risk of blowout.) 
- V/Q Scan -
(Nuclear scan not as reliable, especially if baseline abnormal CXR findings, and only available on weekdays.  Benefit is no nephrotoxic contrast)

? Massive PE  = Hemodynamic Instability (SBP<90) -> Consider Thromobolysis vs. Embolectomy and support with IVF + vasopressors
? Respiratory Stability, O2 Desaturation -> Consider Intubation
- Check Troponin, BNP, EKG for S1Q3T3 as prognostic indicators (R heart strain)
(Abnormalities may indicate TTEcho to evaluate R heart strain (McConnell's sign), though debatable whether this will change management (usually wish to avoid risks of thrombolysis))

- Pulmonary Embolism Severity Index (PESI) -
Per "Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial," Lancet. 2011;378(9785):41, PMID: 21703676, patients PESI class I or II do just as well with outpatient as inpatient treatment
http://www.mdcalc.com/pulmonary-embolism-severity-index-pesi/
- ED to CDU observation admission protocol

== Treatment / Anticoagulation ==
- Warfarin start 5-10mg/day and titrate as per pharmacy protocol 
- Anti-coagulation clinic or PCP referral follow-up to maintain therapeutic INR 2-3
>3 months for provoked DVT (assuming provoking factor e.g., surgery/trauma relieved)
>3-6 months for idiopathic DVT (post-treatment D-Dimer can guide clot vs. bleed risk)
Indefinitely if persistent risk factor (e.g., malignancy) or recurrent episode

- Enoxaparin 1mg/kg SubQ q12h or 1.5mg/kg SubQ daily bridge 
At least 5 days and until therapeutic INR 2-3 for 24 hours 
(Not approved if on dialysis, use UFHeparin.)
(Dosing adjustment if renal impairment or obesity.  Check anti-Xa levels 4 hours after)
(If malignancy, favor LMWHeparin indefinitely over warfarin as per CLOT trial)
- Nursing teaching for patient self-administration

(Rivaroxaban or dabigatran may be appropriate for VTE treatment, but not yet standard of care)
- Rivaroxaban 15mg PO bid x3 weeks then 20mg PO daily as per EINSTEIN-PE (2013)

- Graduated compression stockings to DVT leg to reduce post-thrombotic syndrome

? Indications for IVC Filter placement ?
. Contraindication to or failure of anti-coagulation
. High bleed risk?: Age>65, prior bleeds, thrombocytopenia, anti-platelet therapy, poor anti-coag control, recent surgery, frequent falls, reduced functional capacity, prior stroke, DM, anemia, malignancy, renal failure, liver failure, EtOH abuse.
. IVC Filter only reduces near-term risk of further embolisms, doesn't help clots already in lungs or change mortality (actually increases DVT rate) (PREPIC 1998).
- Consult IR/Vascular for IVC Filter placement

? Upper Extremity DVT ?
(No data on upper extremity DVT, so just treat like lower extremity DVT.  Usually main intervention is remove IV line that instigated it.)

? Thrombophilia Workup ?
. Do not bother if have other obvious risk factor 
(Recent trauma, surgery, immobillzation, malignancy, lupus, IBD, myeloproliferative disorder, HIT, preeclampsia)
. Do not bother unless suspected family history or recurrent disease.  
. Testing often unreliable in setting of active clot and anticoagulation.  
. Major risk factor for recurrence is the DVT/PE itself, whether it was provoked or not  
. Screening for family members would not likely recommend primary prophylaxis, except to caution women to beware of higher risk oral contraceptives and pregnancy.
. Consider more if family history, weird locations (mesenteric, hepatic, portal, splenic, renal, cerebral veins), baseline prolonged PTT -> antiphospholipid?

Per "Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (2008)."
"Presence of hereditary thrombophilia has not been used as a major factor to guide duration of anticoagulation for VTE in these guidelines because evidence from prospective studies suggests that these factors are not major determinants of the risk of recurrence."

- Protein C or S deficiency (but also depleted by clot, warfarin)
- Antithrombin deficiency (but also depleted by clot, heparin) 
(If above checked at all, should be checked couple weeks AFTER completion of anticoagulation, though normal levels drawn at initial presentation will essentially exclude these abnormalities)
- Factor V Leiden
- Anti-phospholipid Ab (prolonged PTT, lupus anti-coagulant, anti-cardiolipin, beta-2 glycoprotein I Ab, DRVVT, must be verified twice at 12 week interval)
- Prothrombin 20210A gene mutation
- JAK2 screening (Polycythemia vera and essential thrombocythemia association)

^ Vaginal Bleed, 1st Trimester

^ Health Maintenance Checklist

= Health Care Maintenance =
Screenings:
- HIV, HCV screen
- Lipid Panel, Hgb A1c by 40s, or earlier if hypertensive
- Colon Cancer: Colonoscopy (Age 50-75, q10years, assuming normal results) or FecalIT annually
- AAA (If +smoking history, offer at 65yo)
- Lung Cancer: Low-dose CT Thorax (Age 55-80, >30 pack years, quit <15 years. Consider annually, but cost-effectiveness and deleterious effects of mostly false-positives still issues)
- Breast Cancer: Mammogram Age 50-70, q1-2years (option while in 40s, or if +family member, 10 years prior to diagnosis)
- Cervical Cancer: Age 21-30 q3year Pap Smear. Age 30-70 q5year Pap Smear + HPV testing (assuming all negative)
- Bone Mineral Density / DEXA (women >65yo, men >70yo or consider >50 if prior falls / fractures, steroids, smoking, EtOH, hypogonadism) -> Home Safety Eval, Vit D+Ca, Bisphosphonates, PTH, Testosterone

Vaccines:
- Pneumovax (any with comorbidities or age >65yo. Additional dose 5 years later if first was <65 yo)
- Tdap (once in adult life)
- Influenza (annually)
- Zoster (offer at 60yo)
- Hepatitis B (liver disease or diabetes)
- HPV (Females and MSM 9-26, Males 9-21)
- Meningococcus (depending on exposure risk)

Habits
- Depression / PTSD
- Obesity / Weight
- EtOH use / abuse
- Tobacco use

Return to clinic in 6-12 months for semi-annual visit to review XXX and labs.

Discussed with Dr. XXX who agrees with above

DM2
- Goal HgbA1c <7, LDL <100, BP <140/90, Microalb/Cr Ratio <30
- Annual eye exam, foot exam, labs

HLD
http://tools.acc.org/ASCVD-Risk-Estimator/