Top 10 Workups

Question 1

Chest Pain

Answer 1

Don’t Miss the BIG 4 (MI, Dissection , PE, Pneumothorax)
Nurse Calls (while on phone): Get vitals, stat ECG O2 to keep sats over 92%, confirm IV access
Labs: ECG, serial troponins, CXR
consider: d-dimer, V/Q, Spiral CT, LE Doppler, (contrast CT/TEE-if dissetion)
Tips (meds to consider):
Cardiac-O2, ASA, Nitro, B-blocker, morphine, heparin, or G2b3a inhibitor
Still CP after Nitro SL-consider Nitro drip
Dissection-labetalol or nitrprusside, BP in both arms/legs
PE-Heparin
Pneumothorax-needle decompression/chest tube
GI-maalox, H2 blockers, PPI’s
Get help (seniors/consultants)

Question 2

Abdominal Pain

Answer 2

Don’t Miss: AAA, Bowel Ischemia/Perforation, Cholangitis, Appendicitis, Cholecystitis
W/U (consider): CBC, CMP, Amylase/Lipase, ABG, lactate, B-hcg, UA, abdominal x-rays (flat/upright), CXR, ECG, Abdominal CT or U/s
Tips: avoid analgesics prior to exam, look for rebound/guarding, keep npo, IV fluids

Question 3

Altered Mental Status

Answer 3

Don’t Miss: Meningitis, Sepsis, CVA, DT’s, or increased ICP
W/U: CBC, CMP, TSH, Ammonia, UA, Blood/Urine culture, ECG, and CXR
Consider: LP, CT-head (always before LP), EEG,
Tips: DT’s –> Librium 100 mg PO TID or Ativan 0.5-1mg PO/IM/IV q6-8 hrs PRN
-Thiamine > Glucose

Question 4

Acute Renal Failure

Answer 4

Don’t Miss: Hyperkalemia
W/U: UA (cells, casts, protein), BMP, urine electrolytes (Na, Cr, Urea)
Consider: EKG, Renal U/S, ABG
Tips: Volume status? (orthostatics, I’s/O’s), Consider bolus
Rectal-Check prostate
Put foley in/flush foley/change foley
Check meds: ACEI’s, diuretics, NSAID, ABX, Contrast Dye

Question 5

Headache

Answer 5

Don’t Miss: menigitis, Bleed (epidural/subdural/subarachnoid)
W/U (consider): CBC, ESR, possible CT head, LP (again CT before LP)
Tips: mild – > tylenol 650 mg PO q6/motrin 600mg PO q6
severe –> narcotics (Demerol/codeine)
migraine –> sumatriptan (no triptans with angina/uncontrolled HTN)

Question 6

Blood Pressure (Too low)

Answer 6

LOW-Don’t Miss: Shock (SBP epinephrine, hydrocortisone, benadryl

HIGH-Hypertensive emergency (encephalopathy, MI, eclampsia, RI, respiratory failure)
W/U (consider): CE, EKG, ABG, CBC, CMP, U/A, CXR
Tips: IV hydralazine, labetalol, or nitroprusside

Question 7

Arrhythmias

Answer 7

Don’t miss: V-Tach/V-Fib!
W/U (consider): CE, EKG, ABG, CBC, CMP, CXR
Tips: Use ACLS cards
In general, if unstable with rate over 150-shock em
(don’t forget about the sedation if necessary)
If SVT (narrow/rapid) and stable –> carotid massage/adenosine/CCB

Question 8

Fever

Answer 8

Don’t Miss: menigitis, Sepsis
W/U (consider): CBC, Blood CX (two different sites), CMP, UA, UCX, Sputum CX and G/S, CXR, LP (CT>LP)
Tips: Consider changing out lines/foleys, empiric ABX before LP if suspect meningitis

Question 9

Shortness of Breath

Answer 9

Don’t Miss: PE, MI, tamponade…Hypoxia!
W/U (consider): EKG, ABG, CXR, CE, D-dimer, CBC, LE dopplers, V/Q scan-CT chest
Tips: Classic S1Q3T3 for PE. If high suspicion –> go ahead and anticoagulate
Don’t forget rescue nebs/diuretics

Question 10

GI Bleed

Answer 10

Don’t Miss: Shock!
W/U: CBC, Coags, CMP
Tips: Needs at least two 18 gauge IV, Type and Screen/Cross, NG tube, consider Vitamin K/FFP if anti-coagulated
If variceal –> Octreotide 50 ug bolus and then 50 ug/hr
Consult GI!