TSH

● If LFT abnormal, get TSH

● If lipid profile abnormal, get TSH

Discharge:
● Discontinue if something is not needed
● Change all IV meds to PO and all nebulizers to MDI.
● For all women who are sexually active and of reproductive age, give folate.
● Multivitamin upon D/C home.
● Disease-specific diet:
○ Diabetics get a diabetic diet
○ Hypertensives get a low salt diet
○ Irritable bowel patients get a high fiber diet
○ Hepatic failure patients get low protein diet

Location
● Decide whether to change location if the patient is stable:
○ If pt. Could crash: ICU
○ Overnight monitoring: ward
○ Back to baseline: send home with follow up
Diabetic
● Accu check
● HbAIc
● Long standing: optha consult
● Inpatient:
○ Accuchecks
○ D/C oral hypoglycemic agents
○ Start insulin
○ HbAlc
○ Advise strict glycemic control
○ Recommend diabetic foot care.
● In all suspected DKA or HHNC, check osmolality and ketone levels in theserum

Resp. Distress:
● ABG

Overdose:
● Gastric lavage
● Activate charcoal (unless unconsciousness, risk of aspiration)

Suicide:
● Admit
● “Suicide contract”
● “Suicide precautions”

Post-PTCA
● Abciximab
Pregnant
● “Blood Type and Rh”
● “Atypical Antibody Screen”
● Before giving a woman coumadin, isotretinoin, doxycycline, OCPs or other teratogens, get a beta-hCG.

Bleed
● “No aspirin” upon D/C

Upper GI bleed
● “Head elevation “
● “Aspiration precautions”

Asthma
● Order beside FEV1 And PEFR (follow treatment progress)

GI distress:
● NPO

AMS:
● "fingerstick glucose" check (for hypoglycemia)
● IV thiamine
● IV dextrose
● IV naloxone
● Urine toxicology
● Blood alcohol level
● NPO.
● In any patient with a chronic disease that can cause future altered mental status, type "medical alert
bracelet" upon D/C.

Hemolysis
● Reticulocyte Count
● All suspected hemolysis patients should get a direct Coombs test

Patient comfort:
● Treat pain with IV morphine
● Nausea with IV phenergan
● Constipation with PO docusate
● Diarrhea with PO loperamide
● Insomnia with PO temazepam.
● Secretions, order pulmonary toilet

ICU

● All ICU patients get stress ulcer prophylaxis with IV omeprazole or ranitidine.
Bed rest:
● "Pneumatic compression stockings"

Fluids:

● If fluid status is vital to a patient's prognosis (such as those with dehydration, hypovolemia, or fluid
overload), place a Foley catheter and order "urine output".

Pleural Effusion

● If a CXR shows an effusion, get a decubitus CXR next

● If you perform a thoracocentesis (lung aspirate), send the EFFUSION as well as a peripheral blood
sample for: LDH and protein (to help differentiate a transudate versus an exudates) and pH of the
effusion.

Intubation

● .If you intubate a patient you also have to order "mechanical ventilation" (otherwise the patient will just
sit there with a tube in his mouth!).

Procedure:

● With any major procedure (including surgery, biopsy, centesis), you MUST type "consent for procedure"
(typing consent will not reveal any results).

Fluid Aspiration:

● With any fluid aspiration (such as paracentesis or pericardiocentesis), get fluid analysis separately (it
is not automatic). If you don't order anything on the fluid, it will just be discarded.

Steroids:

● With high-dose steroids (such as in temporal arteritis), give

a. IV ranitidine
b. Calcium
c. Vitamin D
d. Alendronate
e. Baseline DEXA scan.
● Before giving a child prednisone, get a PPD.

Alcohol:

● Ketoacidosis, give
a. Dextrose (no need for insulin)
b. IV normal saline
c. Thiamine.
● “no driving”

Dementia:

● “no driving”
Anaphylaxis:

● If a patient requires epinephrine (such as in anaphylaxis), and he/she is on a beta-blocker, give
glucagon first.
● Skin test•for allergens (to help prevent future disasters)
● Consult an allergist
● Do not give cephalosporins to any patient with anaphylactic penicillin allergies (there is a 5%
cross-reactivity)

Surgery:

● NPO
● IV access
● IV normal saline
● Blood type and crossmatch
● Analgesia
● PT, PTT
● Pneumatic compression stockings
● Foley
● Urine output
● CBC,
● Any appropriate antibiotics.

MI

● Suspected MI should be given a statin (and check baseline LFTs).

●

Drugs:

● Lithium and Theophylline:

○ Levels Checked
● Heparin
○ Check platelets on Day 3 and Day 5 (for heparin-induced thrombocytopenia), as well as
frequent H&H.
● Coumadin:
○ Check daily PT/INR until it is within therapeutic range for two consecutive days
● Lasix:
○ Also, give KC (it depletes K+).
● Gentamycin:
○ All children given gentamycin should have a hearing test (audiometry) and check BUN/Cr
before and after treatment.
● Statin
○ Baseline LFT and check frequently
○ If myalgia: Check CK
● TB
○ INH: pyridoxine (this is vitamin B6)
○ Pyrazinamide: Baseline serum uric acid levels.
○ Ethambutol: Ophthalmology consult (follow optic neuritis)
Screening

● All patients over 50 with no history of FOBT or colonoscopy should get a rectal exam, a FOBT, and
have a sigmoidoscopy or colonoscopy scheduled.
● All women > 40 years old should get a yearly clinical breast exam and mammogram (if risk factors are
present, start at 35).
● All men > 50 years old should get a prostate exam and a PSA (if risk factors are present, start at 45).

Diarrhea

● "ova and parasites"

● "white cells"
● "Culture"
● [Link] antigen (if warranted).

Terminal Disease

● Advise "advanced directives".

Alzheimers:

● Rule out other causes:

○ CT head
○ Vitamin B12 levels
○ Folate levels
○ TSH
○ VDRL
○ HIV ELISA
○ Routine labs:
■ CBC
■ BMP
■ LFT
■ UA
● Rule out depression

Pancreatitis

● NPO
● NG suction so that no food can stimulate the pancreas

Vaginal Discharge:

● KOH prep
● Saline (wet) prep
● Vaginal pH
● Cervical gonococcal, chlamydia culture
● HIV in some cases
● If vaginal candiasis:
○ Check fasting glucose

Microcytic Anemia:
 ● Iron
● Ferritin,
● TIBC

Acute abdomen patient with a suspected or proven perforation

● Give a TRIPLE antibiotic: Gentamycin, Ampicillin, Metronidazole

Croup:

● Mist tent and racemic epinephrine

STDs:

● In any patient with one sexually transmitted disease (such as Trichomonas), check for other STDs as
well (Gonorrhea, Chlamydia, HIV, syphilis, etc.) and do a Pap smear in all women with an STD

Unstable Angina

● Do not give a thrombolytic (PA or streptokinase)

Unprotected airway (as in overdoses, comatose)

● Get a CXR to rule out aspiration

Child Abuse

● Admitted and you should order THREE consults:

○ Consult child protection services
○ Consult ophthalmology (to look for retinal hemorrhages)
○ Consult psychiatrist•(to examine the family dynamics)

Menopause

● Fasting lipid profile checked (because without estrogen, LDL will rise and the HDL will drop)
● DEXA scan (for baseline bone density)
● FOBT and colonoscopy (if she is over 50)

Newborn

● Jaundice
○ Phototherapy (unconjugated bilirubinemia)
○ Also, with phototherapy, keep the neonate on IV fluids (the heat can dehydrate them)
● Erythromycin ointment in their eyes.
● Under three weeks, develops fever:
○ SEPSIS until proven otherwise.
○ Admit to the ward and culture
○ EVERYTHING: blood culture, urine culture, sputum culture, and even CSF culture; Give
antibiotics to cover EVERYTHING.

High triglycerides
 ● Check amylase and lipase (high triglycerides can cause pancreatitis).

High lead level:

● Check a venous blood lead level-to confirm.

● If the value is >70, admit immediately and begin IV dimercaprol and EDTA.
● Order lead abatement agency and lead pain assay• upon discharge

Arthrocentesis

● Send the synovial fluid for Gram stain• and the 3 Cs:
○ Crystals
○ Culture
○ Cell count.

Hyperthyroidism:

● Exophthalmos: Give prednisone.

Arrhythmia:

● Afib
○ Heart rate should be decreased first. Then use a CCB (diltiazem) or a beta-blocker (metoprolol)
for rate control.
○ New-onset: TSH.
● Mobitz II or complete heart block
○ Immediate transcutaneous pacemaker.
○ Then order a cardiology consult to implant a transvenous pacemaker
● Symptomatic Palpitations
○ Holter Monitor

Colonoscopy or a sigmoidoscopy

● Make the patient NPO, give IV fluids (if necessary) and order polyethylene glycol.

Calcium

● If abnormal: order
○ Serum magnesium
○ Serum phosphorus
○ PTH

Renal Failure:

● Nephrology consult
● Calcium acetate (to decrease the phosphorus levels)
● Calcium-supplement
● Erythropoietin.

Panic Attack:

● First time:
 ○ Urine toxicology• screen
○ TSH
○ Finger stick glucose.

Splenectomy

● Pneumovax, an influenza vaccine, and a hemophilus vaccine if not previously given.