QUICK WARD REFERENCE: DIAGNOSIS & MANAGEMENT

CHECKLISTS
For Doctors on Daily Ward Rounds - Print & Keep in Pocket
TABLE OF CONTENTS

ACUTE CHEST PAIN

ACUTE DYSPNEA

ACUTE ABDOMINAL PAIN

ACUTE ALTERED MENTAL STATUS

ACUTE FEVERS

EMERGENCY DRUG DOSAGES

SHOCK MANAGEMENT

RAPID ASSESSMENT PROTOCOLS

ACUTE CHEST PAIN: DIAGNOSTIC ALGORITHM
IMMEDIATE ACTIONS:

Place on monitor, O2, IV access, 12-lead ECG within 10 minutes

Troponin, CK-MB, BNP, CBC, BMP, coagulation studies

Chest X-ray

Aspirin 325 mg (unless CI)

DIFFERENTIAL & KEY FEATURES:

ACUTE MI (STEMI): ST elevation on ECG, severe substernal pain, positive troponin → PCI/thrombolysis

NSTEMI/ACS: ST depression/T inversion, positive troponin, intermediate/high risk → Antiplatelet, anticoagulation,

PCI

UNSTABLE ANGINA: Severe/new angina, NO troponin elevation → Conservative management, rule out MI

AORTIC DISSECTION: Severe tearing pain, BP differential arms, CXR abnormal, echo shows dissection → Urgent
cardiothoracic consult

PULMONARY EMBOLISM: Pleuritic chest pain, dyspnea, CTPA positive → Anticoagulation, monitor

PNEUMONIA: Fever, cough, infiltrate on CXR → Antibiotics, oxygen

PERICARDITIS: Pleuritic pain relieved by sitting forward, ECG diffuse ST elevation, pericardial rub → NSAIDs,
colchicine, treat cause

GERD/MSK: Reproducible pain, heartburn symptoms, normal ECG/troponin → PPI, reassurance

RED FLAGS (ADMIT, MONITOR):Positive troponin, ST changes, hemodynamic instability, severe pain, high-risk
features (age, DM, prior CAD)
ACUTE DYSPNEA: DIAGNOSTIC ALGORITHM
IMMEDIATE ACTIONS:

O2, monitor, IV access

ABG/VBG (assess oxygenation, CO2)

Chest X-ray

ECG, troponin, BNP

D-dimer/CT if PE suspected

DIFFERENTIAL:

HEART FAILURE: Orthopnea, PND, edema, elevated JVP, rales, low EF on echo → Diuretics, O2, upright position
PNEUMONIA: Fever, cough, infiltrate CXR, elevated WBC → Antibiotics, O2
ASTHMA EXACERBATION: Wheezing, unable to speak, peak flow <50%, bronchospasm → Albuterol, steroids,
magnesium
COPD EXACERBATION: Increased dyspnea from baseline, hypercapnia, barrel chest → Low-flow O2, bronchodilators,
steroids
PULMONARY EMBOLISM: Pleuritic chest pain, tachycardia, D-dimer positive, CTPA shows clot → Anticoagulation,
thrombolysis if massive
PNEUMOTHORAX: Sudden dyspnea, unilateral decrease breath sounds, hyperresonance, CXR shows lung collapse →
O2, chest tube if tension/large
ANEMIA: Pallor, tachycardia, low Hgb → Transfuse if severe, find source
SEPSIS: Fever, hypotension, tachycardia, elevated lactate, source identified → Antibiotics, fluids, vasopressor
ACUTE ABDOMINAL PAIN: DIAGNOSTIC ALGORITHM
IMMEDIATE ASSESSMENT:

NPO, IV access, fluids

Labs: CBC, BMP, LFTs, lipase, lactate, ABG, coagulation

Abdominal exam: rigidity/rebound = peritonitis = URGENT

Imaging: Abdominal X-ray, CT abdomen/pelvis with contrast

LOCATION-BASED DIFFERENTIAL:

RUQ: Cholecystitis, cholangitis, hepatitis, pneumonia → Ultrasound, HIDA, ERCP if needed

Epigastrium: GERD, PUD, MI, pancreatitis, AAA → Troponin, lipase, CT

Periumbilical: Early appendicitis, gastroenteritis, AAA → CT, serial exams

LLQ: Diverticulitis, IBD, UTI, ovarian pathology → CT, urinalysis, pelvic ultrasound

RLQ: Appendicitis, ectopic, ovarian, mesenteric adenitis → CT, pregnancy test, ultrasound

Central/Diffuse: Peritonitis, perforation, pancreatitis, gastroenteritis, bowel obstruction → CT, upright CXR

RED FLAGS (URGENT SURGERY):Peritonitis (rebound/rigidity), shock, fever >39, severe pain, rapid deterioration,
free air on X-ray, AAA
ALTERED MENTAL STATUS: DIAGNOSTIC ALGORITHM
IMMEDIATE ACTIONS:

ABCs (airway, breathing, circulation)

Stat glucose (hypoglycemia = treatable emergency)

Place on monitor, O2, IV access

Labs: CBC, BMP, LFTs, coagulation, toxicology, lactate, ammonia, troponin

ECG (prolonged QT in drug toxicity)

CT head (rule out bleed, mass)

Lumbar puncture if fever + AMS (meningitis)

DIFFERENTIAL:

HYPOGLYCEMIA: <70 mg/dL glucose → D50 IV immediately

STROKE: Focal neuro deficit, CT head positive → tPA if within window

SEPSIS: Fever, elevated lactate, infection source → Antibiotics, fluids, vasopressor

MENINGITIS: Fever, neck stiffness, headache, CSF pleocytosis → Ceftriaxone IV, vancomycin, acyclovir

HEPATIC ENCEPHALOPATHY: Liver disease, elevated ammonia, asterixis → Lactulose, rifaxomicin, treat cause

UREMIA: High creatinine, BUN → Dialysis

HYPERAMMONEMIA: Elevated ammonia, liver disease or urea cycle → Lactulose, protein restriction

INTOXICATION: Drug/alcohol history, toxicology positive → Supportive care, reversal agents if available

HYPERTHERMIA: High temperature >39°C, altered mental status → Cooling measures, ICU support
FEVER IN HOSPITALIZED PATIENT: WORKUP
CLASSIC SOURCES (FUO Rule):

F = Fever from source (typical 3-5 days)

U = Unknown source (defined as FUO after 3 weeks workup)

O = Occult (source yet to be found)

INITIAL WORKUP:

Blood cultures ×2 (before antibiotics)

Urinalysis + urine culture

Sputum culture + CXR

Stool culture if diarrhea (C. diff toxin)

CBC (elevated WBC suggests bacterial)

Procalcitonin (elevated = bacterial, low = viral)

Lactate (elevated = sepsis)

COMMON HOSPITAL SOURCES:

1. UTI/Pyelonephritis (most common)

2. Pneumonia (CAP, HAP, VAP)

3. Bloodstream infection (line-related)

4. Surgical site infection

5. C. difficile colitis

6. Drug fever

7. PE (sometimes causes fever)

8. Transfusion reaction

EMPIRIC ANTIBIOTICS (if septic):

Broad-spectrum: Ceftriaxone + vancomycin

Nosocomial (VAP): Piperacillin-tazobactam or meropenem

Add coverage based on culture results

EMERGENCY DRUG DOSAGES (ACLS/CRITICAL CARE)

DRUG DOSE INDICATION

Epinephrine (1:10000) 0.3-0.5 mg IV push q3-5min Cardiac arrest, anaphylaxis,
hypotension
Amiodarone 300 mg IV push, then 150 mg VF/pulseless VT, SVT
Atropine 0.5-1 mg IV push Symptomatic bradycardia, asystole
Sodium Bicarbonate 1 mEq/kg IV push TCA overdose, hyperkalemia, severe
acidosis
D50 (dextrose 50%) 25-50 mL IV (1-2 amps) Hypoglycemia
Naloxone (Narcan) 0.4-2 mg IV/IM q2-3min Opioid overdose
Nitroglycerin 0.3-0.6 mg SL, 0.4 mg IV q3-5min Acute MI, angina, pulmonary edema
Metoprolol 5-10 mg IV q5min (max 15 mg) Acute MI, SVT, AFib RVR
Labetalol 10-20 mg IV q10min (max 300 mg) Hypertensive emergency
Sodium Nitroprusside 0.5-10 mcg/kg/min IV infusion Hypertensive crisis, cardiogenic
shock
Dobutamine 2-20 mcg/kg/min IV infusion Cardiogenic shock, low cardiac
output
Norepinephrine 0.05-2 mcg/kg/min IV infusion Shock (septic, cardiogenic)
Furosemide (Lasix) 40-100 mg IV push Pulmonary edema, heart failure,
fluid overload
Methylprednisolone 125 mg IV q6h Asthma, COPD, anaphylaxis
SHOCK MANAGEMENT PROTOCOL
SHOCK DEFINITION: SBP <90, cold extremities, altered mentation, oliguria, elevated lactate

IMMEDIATE (FIRST 30 MIN):

Position: Supine, elevate legs

Oxygen to SpO2 >90%

2 large-bore IVs, wide-open normal saline (500 mL bolus)

Catheterize bladder (assess urine output)

Labs: CBC, BMP, troponin, lactate, coagulation, procalcitonin

Imaging: CXR, ECG, ultrasound (assess filling), CT if needed

IDENTIFY TYPE OF SHOCK:

HYPOVOLEMIC: ↓ Filling (hemorrhage, dehydration) → IV FLUIDS (aggressive, transfuse if bleeding)

DISTRIBUTIVE (SEPTIC): Infection, ↓ SVR → Antibiotics, fluids, VASOPRESSOR (norepinephrine)

CARDIOGENIC: ↓ CO (MI, cardiomyopathy) → IABP, inotropes, revascularization

OBSTRUCTIVE (PE/Tamponade): Obstruction to flow → Thrombolysis/PE, pericardiocentesis

REFRACTORY SHOCK (if no improvement after fluids):

Vasopressor: Norepinephrine 0.05-2 mcg/kg/min

Inotrope if cardiogenic: Dobutamine 2-20 mcg/kg/min

ICU transfer, mechanical support (IABP, ECMO), consider transfer to higher level of care
RAPID ASSESSMENT PROTOCOLS
SEPSIS 6-HOUR BUNDLE:

1. Blood cultures ×2 (before antibiotics)

2. Lactate measurement

3. IV antibiotics (within 1 hour)

4. IV fluids (30 mL/kg for hypotension)

5. Vasopressor if refractory hypotension (norepinephrine)

6. Re-assess, source control (drain, remove source)

ACUTE MI: DOOR-TO-BALLOON <90 MIN

Symptom onset → EMS call/hospital arrival

12-lead ECG (interpret within 10 min)

STEMI → Catheterization lab (activate)

Aspirin + P2Y12 inhibitor

Anticoagulation (UFH or LMWH)

Primary PCI (balloon/stent deployment)

STROKE: TIME IS BRAIN (door-to-needle <60 min)

Last known well time crucial (determines thrombolysis window)

CT head (rule out hemorrhage)

NIHSS score (assess severity)

Labs: CBC, PT/INR, glucose, renal function

tPA IV if ischemic stroke <4.5 hours

Mechanical thrombectomy if LVO within 24 hours (select patients)