HW medicine · 33 min read · 6,405 words

Clinical Medicine — Diagnosis & Treatment

A: Most likely diagnosis is Type 2 Diabetes Mellitus.

By William Le, PA-C

Clinical Medicine — Diagnosis & Treatment

LLM Training Data for Hospital AI

Format: Q&A pairs organized by specialty — ready for JSONL conversion

1.1 Internal Medicine — Common Conditions & Differential Diagnosis

Q: A 58-year-old male presents with fatigue, polyuria, polydipsia, and blurry vision over the past 3 months. BMI 34. What is the most likely diagnosis and initial workup?

A: Most likely diagnosis is Type 2 Diabetes Mellitus.

Initial workup:

Fasting blood glucose (FBG) — diagnostic if ≥126 mg/dL on two occasions
HbA1c — diagnostic if ≥6.5%
Basic Metabolic Panel (BMP) — assess renal function, electrolytes
Urinalysis — check for glucosuria, ketonuria
Lipid panel — assess cardiovascular risk
Urine albumin-to-creatinine ratio (UACR) — screen for diabetic nephropathy

If HbA1c confirmed ≥6.5%, initiate lifestyle modifications and metformin 500mg BID with titration. Schedule ophthalmology referral for diabetic retinopathy screening.

Q: A 45-year-old female presents with progressive fatigue, weight gain, constipation, cold intolerance, and dry skin over 6 months. What is the differential diagnosis and recommended workup?

A: Primary differential:

Hypothyroidism (most likely given symptom constellation)
Depression
Iron deficiency anemia
Chronic kidney disease
Sleep apnea

Workup:

TSH (first-line screening) — elevated in primary hypothyroidism
Free T4 — low confirms hypothyroidism
CBC — rule out anemia
BMP — rule out renal disease
Ferritin, iron studies — rule out iron deficiency

If TSH elevated and free T4 low → diagnose primary hypothyroidism. Check TPO antibodies to confirm Hashimoto’s thyroiditis. Initiate levothyroxine 1.6 mcg/kg/day, recheck TSH in 6-8 weeks.

Q: A 62-year-old male with history of hypertension and smoking presents with sudden onset severe headache, neck stiffness, and photophobia. Vitals: BP 210/120, HR 88, T 37.2°C. What is the immediate concern and management?

A: Immediate concern is subarachnoid hemorrhage (SAH) until proven otherwise. This is a medical emergency.

Immediate management:

Stabilize ABCs, secure IV access
Non-contrast CT head STAT — sensitivity ~95% within 6 hours of onset
If CT negative but clinical suspicion high → lumbar puncture (look for xanthochromia, elevated RBCs that don’t clear)
Blood pressure management — target SBP <160 mmHg with nicardipine or labetalol drip
Nimodipine 60mg PO q4h if SAH confirmed (prevents vasospasm)
Neurosurgery consult STAT
Seizure precautions
Strict bed rest, HOB elevated 30°

Differential also includes hypertensive emergency with headache, meningitis, and migraine — but SAH must be ruled out first given acuity.

Q: What are the most common causes of chest pain and how do you differentiate them?

A: Major causes categorized by system:

Cardiac:

Acute coronary syndrome (ACS) — substernal pressure, radiation to jaw/arm, diaphoresis, worse with exertion. ECG changes, elevated troponin.
Pericarditis — sharp, pleuritic, worse lying flat, improved sitting forward. Diffuse ST elevation, PR depression on ECG.
Aortic dissection — sudden tearing pain radiating to back, blood pressure differential between arms.

Pulmonary:

Pulmonary embolism — sudden pleuritic chest pain, dyspnea, tachycardia. Risk factors: immobility, surgery, DVT.
Pneumothorax — sudden unilateral pleuritic pain, decreased breath sounds.
Pneumonia — productive cough, fever, pleuritic pain, consolidation on exam/imaging.

GI:

GERD — burning substernal, worse after meals/lying flat, relieved by antacids.
Esophageal rupture (Boerhaave) — severe pain after forceful vomiting, subcutaneous emphysema.

Musculoskeletal:

Costochondritis — reproducible with palpation, no systemic symptoms.

Approach: ECG and troponin rule out ACS. Chest X-ray for pneumothorax, pneumonia. CT angiography if PE or dissection suspected. D-dimer for low-risk PE stratification.

Q: A 72-year-old female with CHF presents with worsening dyspnea, orthopnea, bilateral lower extremity edema, and weight gain of 8 lbs over 1 week. Current medications: lisinopril 20mg, carvedilol 25mg BID, furosemide 40mg daily. How do you manage this acute CHF exacerbation?

A: This is acute decompensated heart failure (ADHF).

Immediate assessment:

Vitals including O2 saturation
BNP or NT-proBNP (confirms volume overload, tracks response)
BMP (monitor renal function, potassium before diuresis)
CBC, troponin (rule out concurrent ACS)
Chest X-ray (pulmonary edema, pleural effusions)
Daily weights, strict I&O

Management:

IV furosemide — initial dose 40-80mg IV (1-2x home oral dose). Can double if inadequate response in 2 hours.
Oxygen — titrate to SpO2 >92%. BiPAP if respiratory distress.
Fluid restriction — 1.5-2L/day
Sodium restriction — <2g/day
Continue carvedilol unless hypotensive or cardiogenic shock
Continue lisinopril unless hyperkalemia or AKI
Monitor — BMP q12-24h, daily weights, urine output goal >0.5 mL/kg/hr
DVT prophylaxis — heparin SQ

Reassess diuretic response: target 1-2 kg weight loss/day. If diuretic resistance → consider adding metolazone 2.5-5mg 30 min before furosemide, or switch to continuous furosemide drip.

Q: A patient presents with unintentional weight loss of 15 lbs over 3 months, fatigue, and night sweats. What is your systematic approach?

A: Unintentional weight loss >5% over 6-12 months requires thorough evaluation.

Differential organized by category:

Malignancy — any cancer, especially GI, lung, lymphoma, renal
Endocrine — hyperthyroidism, diabetes, adrenal insufficiency
GI — malabsorption (celiac, IBD, pancreatic insufficiency), chronic infection
Infectious — HIV, TB, endocarditis, chronic hepatitis
Psychiatric — depression, eating disorders, substance abuse
Inflammatory — rheumatologic conditions, vasculitis
Chronic disease — CHF, COPD, CKD, cirrhosis

Systematic workup:

CBC with differential — leukocytosis, anemia, lymphopenia
CMP — liver function, renal function, albumin, calcium
TSH — hyperthyroidism
ESR/CRP — inflammation/malignancy
LDH — lymphoma, hemolysis
HIV test
Urinalysis
Chest X-ray
Age-appropriate cancer screening (colonoscopy, CT chest, etc.)
If above unrevealing → CT chest/abdomen/pelvis with contrast

Night sweats with weight loss raise concern for lymphoma, TB, or endocarditis — prioritize blood cultures, LDH, and imaging.

1.2 Emergency Medicine — Triage & Acute Care

Q: Explain the Emergency Severity Index (ESI) triage system.

A: ESI is a 5-level triage system used to prioritize patients based on acuity and expected resource utilization.

ESI 1 — Immediate (Resuscitation): Life-threatening. Requires immediate intervention. Examples: cardiac arrest, active hemorrhagic shock, severe respiratory distress requiring intubation.
ESI 2 — Emergent: High risk, confused, lethargic, disoriented, or severe pain/distress. Should not wait. Examples: chest pain with cardiac risk factors, stroke symptoms, acute abdomen, suicidal ideation with plan.
ESI 3 — Urgent: Stable but needs multiple resources (labs, imaging, IV, procedures). Examples: abdominal pain needing CT and labs, lacerations requiring suturing, moderate asthma exacerbation.
ESI 4 — Less Urgent: Stable, needs one resource. Examples: simple laceration, urinalysis for UTI symptoms, single X-ray for ankle injury.
ESI 5 — Non-Urgent: No resources needed. Examples: prescription refills, simple wound recheck, minor cold symptoms.

Key decision points: Is the patient dying? (→ ESI 1). Is this a high-risk situation? (→ ESI 2). How many resources will this patient need? (0 = ESI 5, 1 = ESI 4, 2+ = ESI 3).

Q: A 28-year-old male arrives after a motorcycle accident. He is alert but confused, HR 128, BP 88/54, RR 26, SpO2 94%. Obvious deformity of left femur and abdominal distension. Walk through your initial management.

A: This is a trauma activation — follow ATLS systematic approach.

Primary Survey (ABCDE):

A — Airway with C-spine protection:

Patient is speaking → airway intact
Apply cervical collar, maintain inline stabilization

B — Breathing:

Expose chest, auscultate bilaterally
Look for pneumothorax, hemothorax, flail chest
SpO2 94% → apply high-flow O2 via non-rebreather at 15L/min

C — Circulation:

Tachycardic and hypotensive → Class III hemorrhagic shock (30-40% blood loss)
Two large-bore IVs (16-gauge or larger), bilateral antecubital
Initiate massive transfusion protocol (MTP): 1:1:1 ratio of pRBC:FFP:platelets
Permissive hypotension: target SBP 80-90 mmHg until surgical control
Type and crossmatch STAT, CBC, BMP, coags, lactate, ABG
Apply pelvic binder if pelvic fracture suspected
Splint left femur fracture (can lose 1-2L blood into thigh)

D — Disability:

GCS assessment (confused = verbal 4, note eye and motor)
Pupil exam — equal and reactive?
Brief neuro check of extremities

E — Exposure/Environment:

Log-roll, examine entire body
Prevent hypothermia — warm blankets, warm IV fluids

Adjuncts:

FAST exam (Focused Assessment with Sonography in Trauma) — assess for intraabdominal free fluid
Chest X-ray and pelvic X-ray
If FAST positive with hemodynamic instability → emergent exploratory laparotomy
Foley catheter (check for urethral blood first) for urine output monitoring
NG/OG tube

This patient needs surgical and orthopedic consultation STAT.

Q: What is the approach to anaphylaxis in the emergency department?

A: Anaphylaxis is a life-threatening systemic allergic reaction requiring immediate treatment.

Recognition: Two or more systems involved after allergen exposure:

Skin: urticaria, flushing, angioedema
Respiratory: bronchospasm, stridor, hypoxia
Cardiovascular: hypotension, tachycardia, syncope
GI: nausea, vomiting, abdominal pain

Immediate Management:

Epinephrine 0.3-0.5 mg IM (1:1,000 concentration) into lateral thigh — this is the first and most critical intervention. Repeat every 5-15 minutes if no improvement.
Place patient supine, elevate legs (unless respiratory distress → keep upright)
High-flow O2 via non-rebreather
Large-bore IV access, NS bolus 1-2L for hypotension
Albuterol nebulizer 2.5-5mg for bronchospasm
Diphenhydramine 50mg IV (H1 blocker)
Famotidine 20mg IV (H2 blocker)
Methylprednisolone 125mg IV (prevents biphasic reaction)

If refractory:

Epinephrine drip: 0.1-0.5 mcg/kg/min
Vasopressors if persistent hypotension despite fluids and epinephrine
Consider glucagon 1-5mg IV if patient on beta-blockers (may not respond to epinephrine)
Prepare for definitive airway if severe angioedema

Disposition: Observe minimum 4-6 hours (up to 24h for severe cases). Prescribe epinephrine auto-injector at discharge. Allergist referral.

Q: A 67-year-old female presents with acute onset left-sided weakness and slurred speech starting 2 hours ago. What is the emergency stroke protocol?

A: Activate Code Stroke immediately. Time is brain — every minute of large vessel occlusion kills ~1.9 million neurons.

Immediate actions (door to CT <25 min):

ABCs, establish IV access
Check blood glucose STAT (hypoglycemia mimics stroke)
NIH Stroke Scale (NIHSS) — quantify deficit severity
Non-contrast CT head STAT — rule out hemorrhagic stroke
CT angiography (CTA) head and neck — identify large vessel occlusion
Labs: CBC, BMP, coags, troponin, glucose (but do NOT delay CT for lab results)

If ischemic stroke confirmed:

IV tPA (Alteplase) criteria — within 4.5 hours of symptom onset:

Dose: 0.9 mg/kg (max 90mg), 10% bolus over 1 min, remainder infused over 60 min
Key exclusions: active bleeding, platelets <100K, INR >1.7, recent surgery, BP >185/110 despite treatment

BP management for tPA candidates:

Target <185/110 before tPA, <180/105 for 24h after
Labetalol 10-20mg IV or nicardipine drip

Mechanical thrombectomy criteria — within 24 hours for select patients:

Large vessel occlusion (ICA, M1 MCA)
NIHSS ≥6
CT perfusion showing salvageable tissue
Interventional neuroradiology/neurosurgery consult

Post-tPA monitoring:

Neuro checks q15min for 2 hours, then q30min for 6 hours, then q1h for 16 hours
No anticoagulants or antiplatelets for 24 hours post-tPA
Repeat CT head at 24 hours before starting aspirin

If hemorrhagic stroke: Reverse any anticoagulation, BP control (SBP <140), neurosurgery consult, possible surgical evacuation.

Q: How do you manage acute alcohol withdrawal in the ED?

A: Alcohol withdrawal is a potentially fatal condition. Spectrum ranges from mild tremors to delirium tremens (DT).

Timeline:

6-24h: tremors, anxiety, insomnia, tachycardia, diaphoresis
12-48h: withdrawal seizures (generalized tonic-clonic)
48-96h: delirium tremens (confusion, hallucinations, autonomic instability, fever) — mortality 5-15% if untreated

Assessment:

CIWA-Ar score (Clinical Institute Withdrawal Assessment for Alcohol) — score 0-67
- <10: mild withdrawal
- 10-18: moderate
- 18: severe
Check: BMP (Mg, phos, K often low), CBC, LFTs, lipase, BAL, urine tox screen
Thiamine 500mg IV BEFORE any glucose (prevent Wernicke encephalopathy)

Management — Benzodiazepines are first-line:

Symptom-triggered protocol (preferred):

CIWA q1h → diazepam 10-20mg PO/IV for CIWA ≥10
Reassess 30-60 min after each dose
Repeat until CIWA <10

Fixed-dose protocol (for severe or ICU patients):

Diazepam 10-20mg IV q5-15min until calm and CIWA <10
Some patients require massive doses (>100mg in first hour)

Refractory DT (not responding to benzos):

Phenobarbital 130-260mg IV (synergistic with benzos)
Propofol drip (may require intubation)
ICU admission

Adjuncts:

Magnesium 2g IV (seizure threshold, commonly depleted)
Folate 1mg daily
Multivitamin
Fluid resuscitation
Electrolyte repletion (K, Mg, Phos)

1.3 Cardiology

Q: How do you interpret an ECG systematically?

A: Use a systematic approach for every ECG — never skip steps.

1. Rate:

Count R-R interval. 300 ÷ (number of large boxes between R-R) = rate
Normal: 60-100 bpm

2. Rhythm:

Regular or irregular?
P waves present before every QRS?
P waves upright in lead II? (sinus origin)

3. Axis:

Normal: leads I and aVF both positive
Left axis deviation (LAD): lead I positive, aVF negative
Right axis deviation (RAD): lead I negative, aVF positive

4. Intervals:

PR interval: 0.12-0.20 sec (short → WPW; long → first-degree AV block)
QRS duration: <0.12 sec normal (wide → bundle branch block, ventricular rhythm)
QT/QTc: <440ms men, <460ms women (prolonged → torsades risk)

5. ST segment/T waves:

ST elevation: STEMI, pericarditis, Brugada, early repolarization
ST depression: ischemia, reciprocal changes, digoxin effect
T wave inversion: ischemia, strain pattern, PE, Wellens syndrome
Hyperacute T waves: early STEMI

6. Other findings:

Q waves (pathological if >1mm wide, >2mm deep) → prior MI
LVH criteria: S in V1 + R in V5/V6 >35mm
RVH criteria: R > S in V1, right axis deviation
P wave abnormalities: P mitrale (wide, notched → LA enlargement), P pulmonale (tall, peaked → RA enlargement)

Q: A patient presents with palpitations. ECG shows irregularly irregular rhythm, no discernible P waves, rate 142. Diagnosis and management?

A: Diagnosis: Atrial fibrillation (AF) with rapid ventricular response (RVR).

Immediate assessment:

Hemodynamically stable or unstable?
If unstable (hypotension, altered mental status, chest pain, acute heart failure) → synchronized cardioversion starting at 120-200J biphasic

If stable — rate control is priority:

Rate control medications:

Diltiazem 0.25 mg/kg IV bolus over 2 min (typically 15-20mg), then drip 5-15 mg/hr — first-line in most patients
Metoprolol 5mg IV q5min x3 doses — preferred in CHF with preserved EF
Amiodarone 150mg IV over 10 min → drip 1mg/min x6h → 0.5mg/min x18h — preferred in heart failure with reduced EF
Target heart rate <110 bpm

Anticoagulation decision (CHA₂DS₂-VASc score):

0 (males) or 1 (females) → no anticoagulation
1 (males) → consider anticoagulation
≥2 → anticoagulation indicated
DOACs preferred: apixaban 5mg BID, rivaroxaban 20mg daily
Warfarin if mechanical valve or severe mitral stenosis

Rhythm control consideration:

If AF onset <48 hours → can attempt cardioversion without TEE
If AF onset >48 hours or unknown → anticoagulate 3 weeks before cardioversion OR TEE to rule out LA thrombus before cardioversion
Antiarrhythmic options: flecainide (structurally normal heart), amiodarone (structural heart disease)

Q: Describe the management of acute STEMI.

A: STEMI is a time-critical emergency. Target: door-to-balloon time <90 minutes (or door-to-needle <30 min if PCI not available).

Immediate management (within minutes):

Aspirin 325mg chewed (non-enteric coated)
P2Y12 inhibitor: ticagrelor 180mg loading OR clopidogrel 600mg loading
Heparin: unfractionated heparin 60 U/kg bolus (max 4000U) → 12 U/kg/hr drip
Nitroglycerin 0.4mg SL q5min x3 for ongoing chest pain (avoid if SBP <90, RV infarct, or PDE5 inhibitor use within 24-48h)
Morphine 2-4mg IV only if pain refractory to nitro (use cautiously — may increase mortality)
Activate cath lab for emergent PCI (percutaneous coronary intervention)
High-flow O2 only if SpO2 <90%
Beta-blocker: metoprolol 25mg PO within 24h if stable (avoid in cardiogenic shock, HR <60, SBP <120)

If PCI not available within 120 minutes:

Fibrinolysis with alteplase (tPA), tenecteplase, or reteplase
Must be given within 12h of symptom onset
Absolute contraindications: active bleeding, prior ICH, ischemic stroke <3 months, aortic dissection

Post-PCI management:

Dual antiplatelet therapy (DAPT): aspirin + P2Y12 inhibitor for minimum 12 months
High-intensity statin: atorvastatin 80mg
ACE inhibitor (especially if anterior STEMI or EF <40%)
Beta-blocker
Aldosterone antagonist if EF ≤40% with symptoms or diabetes
Cardiac rehab referral

Monitor for complications: cardiogenic shock, arrhythmias (VT/VF), mechanical complications (free wall rupture, VSD, papillary muscle rupture), pericarditis (Dressler syndrome at 2-10 weeks).

Q: What are the types of AV blocks and how do you distinguish them on ECG?

First-degree AV block:

PR interval >0.20 sec (>1 large box), constant
Every P wave conducts
Usually benign, no treatment needed

Second-degree AV block — Type I (Wenckebach):

Progressive PR prolongation until a dropped QRS
Grouped beating pattern
Usually at level of AV node
Often benign; treatment only if symptomatic

Second-degree AV block — Type II (Mobitz II):

Constant PR interval with sudden dropped QRS (no progressive prolongation)
Usually below AV node (His-Purkinje system)
Dangerous — high risk of progressing to complete heart block
Often requires pacemaker

Key distinction: Wenckebach = PR gets longer then drops. Mobitz II = PR is constant then drops. If the QRS is wide in Mobitz II, it’s infranodal and more dangerous.

Third-degree (Complete) AV block:

Complete dissociation between P waves and QRS complexes
Atrial rate and ventricular rate independent
Ventricular escape rhythm: narrow QRS (40-60 bpm, junctional) vs wide QRS (20-40 bpm, ventricular)
Always symptomatic, always requires pacemaker
Temporizing: atropine 0.5mg IV (may work if junctional), transcutaneous pacing, isoproterenol drip

1.4 Pulmonology

Q: How do you manage acute respiratory failure and decide on intubation?

A: Respiratory failure = failure of oxygenation (Type I, PaO2 <60) or ventilation (Type II, PaCO2 >50 with acidosis).

Escalation ladder:

Nasal cannula (1-6 L/min, FiO2 24-44%)
High-flow nasal cannula (HFNC, up to 60 L/min, FiO2 up to 100%)
Non-invasive positive pressure ventilation (BiPAP/CPAP)
Endotracheal intubation and mechanical ventilation

Indications for intubation:

Failure to protect airway (GCS ≤8, absent gag reflex)
Refractory hypoxia despite HFNC/BiPAP (SpO2 <88% on max non-invasive support)
Severe respiratory acidosis (pH <7.25) not improving with BiPAP
Respiratory fatigue (increasing RR, accessory muscle use, paradoxical breathing)
Need for airway protection (massive hemoptysis, severe angioedema)
Clinical trajectory worsening despite escalating support

RSI (Rapid Sequence Intubation):

Preoxygenate 3-5 min with HFNC or BVM (target SpO2 >95% before attempt)
Induction: etomidate 0.3 mg/kg IV (hemodynamically neutral) OR ketamine 1-2 mg/kg IV (preserves respiratory drive, bronchodilator)
Paralytic: succinylcholine 1.5 mg/kg IV (onset 45-60 sec) OR rocuronium 1.2 mg/kg IV (onset 60 sec)
Direct laryngoscopy or video laryngoscopy → place ETT (7.0-7.5 women, 7.5-8.0 men)
Confirm placement: end-tidal CO2 (gold standard), bilateral breath sounds, chest X-ray
Secure tube, initiate mechanical ventilation

Initial ventilator settings:

Mode: AC/VC (assist control/volume control) for most patients
Tidal volume: 6-8 mL/kg ideal body weight
Rate: 14-18 breaths/min
FiO2: start 100%, wean to target SpO2 92-96%
PEEP: start 5 cmH2O, titrate up for oxygenation
Plateau pressure: keep <30 cmH2O (lung-protective)

Q: Describe the management of a COPD exacerbation.

Severity assessment:

Mild: increased dyspnea, no respiratory failure
Moderate: requires supplemental O2, possible BiPAP
Severe: respiratory failure, altered mental status, ICU admission

Management:

Bronchodilators (cornerstone):

Albuterol 2.5mg nebulizer q20min x3, then q1-4h as needed
Ipratropium 0.5mg nebulizer q20min x3, then q4-6h
Can combine in same nebulizer

Corticosteroids:

Prednisone 40mg PO daily x5 days (equivalent to IV methylprednisolone 125mg)
No taper needed for 5-day course
Reduces treatment failure and shortens recovery

Antibiotics (if indicated):

Give if: increased dyspnea + increased sputum purulence + increased sputum volume (2 of 3 Anthonisen criteria)
First-line: azithromycin 500mg day 1, then 250mg x4 days OR doxycycline 100mg BID x5-7 days OR amoxicillin-clavulanate 875/125mg BID
If recent antibiotic use or risk for pseudomonas → levofloxacin 750mg daily

Oxygen therapy:

Target SpO2 88-92% (COPD patients may be CO2 retainers)
If hypercapnic respiratory failure (pH <7.35, PaCO2 >45) → BiPAP: start IPAP 10, EPAP 5, titrate
Avoid high-flow O2 without monitoring — risk of worsening hypercapnia

Intubation if:

BiPAP failure (worsening pH, mental status decline)
Respiratory arrest
Unable to tolerate BiPAP (agitation, vomiting)

Q: A 35-year-old female post-surgery presents with sudden dyspnea, pleuritic chest pain, heart rate 118, SpO2 91%. What is your approach?

A: High suspicion for pulmonary embolism (PE).

Risk stratification:

Wells Score: surgery = 1.5, HR >100 = 1.5, clinical signs DVT = 3, PE most likely = 3. Score >4 = PE likely.
In this case: Wells ~6 → PE likely → skip D-dimer, go straight to CT angiography (CTA)

Immediate management:

Supplemental O2 to maintain SpO2 >92%
IV access, NS bolus if hypotensive
CTA chest STAT — gold standard for diagnosis
If CTA not immediately available → bedside echocardiogram (RV dilation/strain suggests massive PE)
Labs: troponin, BNP (prognostic), CBC, BMP, coags

If PE confirmed — anticoagulation:

Start immediately (don’t wait for CTA if clinical suspicion is high):
- Heparin drip: 80 U/kg bolus → 18 U/kg/hr, titrate to aPTT 60-80
- OR enoxaparin 1mg/kg SQ q12h
Transition to DOAC: rivaroxaban 15mg BID x21 days → 20mg daily, or apixaban 10mg BID x7 days → 5mg BID

Massive PE (with hemodynamic instability: SBP <90):

Systemic thrombolysis: alteplase 100mg IV over 2 hours
If thrombolysis contraindicated → catheter-directed therapy or surgical embolectomy
IV fluid bolus 500mL (avoid excessive fluids — can worsen RV failure)
Vasopressors: norepinephrine first-line

Submassive PE (stable BP but RV strain on echo or elevated troponin):

Anticoagulation
Close monitoring, consider ICU
Thrombolysis if clinical deterioration

Minimum anticoagulation duration: 3 months for provoked PE; indefinite for unprovoked or recurrent PE.

1.5 Neurology

Q: How do you approach the patient with acute altered mental status?

A: Altered mental status (AMS) requires rapid systematic evaluation. Use the mnemonic AEIOU-TIPS:

A — Alcohol, Acidosis
E — Endocrine (hypo/hyperglycemia, thyroid storm, myxedema, adrenal crisis), Electrolytes, Encephalopathy (hepatic, hypertensive, Wernicke)
I — Infection (meningitis, encephalitis, UTI in elderly, sepsis)
O — Overdose/toxins, Oxygen (hypoxia, CO poisoning)
U — Uremia
T — Trauma, Temperature (hypo/hyperthermia)
I — Intracranial (stroke, hemorrhage, tumor, seizure/postictal)
P — Psychiatric, Porphyria
S — Seizure (nonconvulsive status epilepticus), Shock

Immediate workup:

Fingerstick glucose — FIRST test (treat hypoglycemia immediately with D50)
Vitals with SpO2
GCS assessment
Focused neuro exam: pupils, focal deficits, meningeal signs
CBC, BMP, LFTs, ammonia, lactate, TSH
ABG/VBG
Urinalysis, urine drug screen
Blood alcohol level
CT head without contrast (if no clear metabolic cause)
Blood cultures if febrile
Lumbar puncture if meningitis/encephalitis suspected (after CT)

Empiric treatment while awaiting results:

Thiamine 100mg IV (before glucose — prevent Wernicke)
Naloxone 0.4-2mg IV if opioid overdose suspected (pinpoint pupils, respiratory depression)
Flumazenil ONLY if known benzodiazepine overdose (risk of seizures if chronic use)

Q: How do you manage status epilepticus?

A: Status epilepticus = seizure lasting >5 minutes or recurrent seizures without return to baseline. This is a neurological emergency.

Minute 0-5 — Stabilization:

ABCs, supplemental O2, place on side (recovery position)
Check glucose STAT — give D50 if hypoglycemic
Establish IV access (if unable → prepare for IM/IN/PR meds)
Thiamine 100mg IV if alcohol use suspected

Minute 5-20 — First-line (Benzodiazepines):

IV lorazepam 0.1 mg/kg (max 4mg), may repeat once in 5 min — PREFERRED
OR IV diazepam 0.2 mg/kg (max 10mg)
If no IV access: midazolam 10mg IM (>40kg) or 0.2 mg/kg intranasal

Minute 20-40 — Second-line (if benzos fail):

Fosphenytoin 20 mg PE/kg IV at 150 mg PE/min (preferred over phenytoin — less tissue necrosis)
- Monitor for hypotension, bradycardia
OR levetiracetam 60 mg/kg IV (max 4500mg) over 15 min — safer profile, fewer drug interactions
OR valproic acid 40 mg/kg IV over 10 min (max 3000mg) — avoid in pregnancy, liver disease

Minute 40+ — Refractory Status Epilepticus:

Intubation required
Midazolam drip: 0.2 mg/kg bolus → 0.1-2 mg/kg/hr
OR propofol drip: 1-2 mg/kg bolus → 20-80 mcg/kg/min
OR pentobarbital: 5 mg/kg load → 1-5 mg/kg/hr
Continuous EEG monitoring mandatory
ICU admission

Workup (while treating):

Glucose, BMP, calcium, magnesium
AED levels if on anti-epileptics
CT head → consider MRI once stable
LP if infection suspected
Urine drug screen, toxicology

Q: A 55-year-old male presents with worst headache of life, neck stiffness, and brief loss of consciousness. CT head is negative. What next?

A: Despite negative CT, subarachnoid hemorrhage (SAH) is not ruled out.

CT sensitivity declines with time from onset:

<6 hours: ~98-100% sensitivity
6-12 hours: ~93%
12-24 hours: ~86%
3 days: ~73%

Next step: Lumbar Puncture (LP)

LP findings suggestive of SAH:

Elevated opening pressure
Elevated RBCs that do NOT clear between tubes 1 and 4 (traumatic tap would show decreasing RBCs)
Xanthochromia (yellow discoloration of CSF) — most reliable finding. Develops 6-12 hours after bleed.
Elevated protein

If LP positive for SAH:

CT angiography (CTA) to identify aneurysm
If CTA negative → conventional cerebral angiography (gold standard)
Neurosurgery consult for aneurysm securing (surgical clipping vs endovascular coiling)
Nimodipine 60mg PO q4h x21 days (prevents vasospasm)
BP control — avoid extremes (SBP 120-160 before aneurysm secured)
ICU admission, neuro checks q1h
Seizure prophylaxis: levetiracetam
Stool softeners (prevent straining)
Monitor for complications: rebleed (highest risk first 24h), vasospasm (day 3-14), hydrocephalus, hyponatremia (SIADH or cerebral salt wasting)

If LP negative and CT negative: SAH effectively ruled out. Consider other causes: migraine, thunderclap headache from RCVS, cervicogenic headache. Consider MRA to screen for unruptured aneurysm if strong family history.

1.6 Gastroenterology

Q: A 58-year-old male presents with hematemesis, HR 112, BP 92/58, Hgb 7.2. How do you manage acute upper GI bleeding?

A: This is a hemodynamically significant upper GI bleed requiring emergent management.

Immediate resuscitation:

Two large-bore IVs (16-18 gauge)
NS or LR bolus — target MAP >65 mmHg
Type and crossmatch for 4-6 units pRBC
Transfuse pRBC — target Hgb >7 g/dL (>8-9 if active cardiac disease)
If massive bleeding → activate massive transfusion protocol (1:1:1)
Keep NPO, place NG tube if needed to assess ongoing bleeding
Intubation for airway protection if massive hematemesis, altered mental status, or hemodynamic instability

Medications:

IV PPI: pantoprazole 80mg bolus → 8mg/hr drip (reduces rebleeding after endoscopic treatment)
Erythromycin 250mg IV 30-60 min before endoscopy (prokinetic, clears stomach for better visualization)
Octreotide 50mcg IV bolus → 50mcg/hr drip if variceal bleed suspected (known cirrhosis, stigmata of liver disease)
Ceftriaxone 1g IV if cirrhosis (antibiotic prophylaxis reduces mortality in variceal bleed)

Risk stratification:

Glasgow-Blatchford Score (GBS): identifies who needs intervention
GBS = 0 → may be safe for outpatient management
This patient: high GBS → admit ICU, urgent endoscopy

EGD (esophagogastroduodenoscopy) within 12-24 hours (within 12h if high-risk features):

Peptic ulcer → endoscopic hemostasis (epinephrine injection + thermal coagulation or clips)
Variceal bleed → endoscopic band ligation
If endoscopy fails → interventional radiology (angioembolization) or surgery

Post-procedure:

Continue PPI (oral transition after 72h drip if high-risk ulcer)
Test for H. pylori → treat if positive (triple or quadruple therapy)
Discontinue/adjust NSAIDs, anticoagulants
Recheck Hgb q6-8h until stable

Q: How do you evaluate and manage acute pancreatitis?

Diagnosis (need 2 of 3):

Characteristic abdominal pain (epigastric, radiating to back, worse with eating)
Lipase ≥3x upper limit of normal (more sensitive and specific than amylase)
Imaging findings on CT (if diagnosis unclear)

Severity assessment:

BISAP score at admission (BUN >25, impaired mental status, SIRS, age >60, pleural effusion)
BISAP ≥3 → severe, consider ICU
Ranson criteria at 0h and 48h (historical but still used)
CT severity index if imaging obtained

Most common etiologies (mnemonic: I GET SMASHED):

Idiopathic, Gallstones (#1), Ethanol (#2), Trauma, Steroids, Mumps/Malignancy, Autoimmune, Scorpion stings, Hyperlipidemia/Hypercalcemia/Hypothermia, ERCP, Drugs (valproic acid, azathioprine, didanosine)

Management:

Aggressive IV fluid resuscitation — LR preferred, 1.5 mL/kg/hr initially (goal: UOP >0.5 mL/kg/hr, decreasing BUN)
- Reassess at 6h, reduce rate once clinically improving
Pain management — multimodal approach
- Acetaminophen 1g IV/PO q6h (first-line)
- NSAIDs: ketorolac 15-30mg IV q6h (if no renal impairment)
- Opioids: hydromorphone preferred over morphine (morphine may cause sphincter of Oddi spasm — controversial but commonly avoided)
Nutrition — early oral feeding when tolerated
- Advance diet as tolerated (low-fat initially)
- If unable to eat >5-7 days → enteral nutrition via nasojejunal tube (preferred over TPN)
NPO only if actively vomiting — old dogma of prolonged NPO is no longer recommended

Gallstone pancreatitis:

If concurrent cholangitis or persistent biliary obstruction → ERCP within 24h
Cholecystectomy during same admission (if mild) or within 2-4 weeks (if severe) to prevent recurrence

Complications:

Pancreatic necrosis → infected necrosis if fever + gas on CT → percutaneous drainage → step-up approach to necrosectomy
Pseudocyst (>4 weeks) → drain if symptomatic or >6cm
Organ failure → ICU management

1.7 Endocrinology

Q: How do you manage diabetic ketoacidosis (DKA)?

A: DKA diagnostic criteria: glucose >250, pH <7.3, bicarb <18, anion gap >10, positive ketones.

Immediate management:

1. Fluids (correct dehydration — typically 3-6L deficit):

NS 1-1.5 L/hr for first 1-2 hours
Then NS 250-500 mL/hr
When glucose <200 → switch to D5 ½NS at 150-250 mL/hr (prevent hypoglycemia while continuing insulin)

2. Insulin:

Regular insulin drip: 0.1 U/kg/hr (can give 0.1 U/kg bolus first)
Target glucose drop: 50-75 mg/dL per hour
If glucose not dropping → double drip rate
When glucose <200 → reduce drip to 0.02-0.05 U/kg/hr AND add dextrose to IVF
Continue drip until anion gap closes, pH >7.3, bicarb >15

3. Potassium (CRITICAL — #1 cause of death in DKA treatment):

Check K before starting insulin
K >5.2: hold K replacement, recheck in 2h
K 3.3-5.2: add 20-40 mEq KCl per liter of IVF
K <3.3: HOLD INSULIN, give 40 mEq KCl/hr until K >3.3

4. Bicarbonate:

ONLY if pH <6.9 → NaHCO₃ 100 mEq in 400mL water + 20 mEq KCl over 2h
Routine bicarb replacement not recommended — insulin corrects acidosis

5. Phosphate:

Replace if <1.0 mg/dL with potassium phosphate (replaces both)
Monitor for hypocalcemia with phosphate repletion

Monitoring:

BMP q2h (glucose, K, bicarb, anion gap)
VBG q2-4h for pH
Strict I&O
Identify and treat precipitant: infection (most common), medication non-compliance, MI, new-onset DM

Transition to subcutaneous insulin:

Give SQ basal insulin (glargine) 2h BEFORE stopping drip
Overlap is critical to prevent rebound DKA
Resume home regimen or start 0.5 U/kg/day divided basal/bolus

Q: A patient presents with altered mental status, glucose 48 mg/dL. How do you manage hypoglycemia?

A: Hypoglycemia (<70 mg/dL) is a medical emergency when symptomatic or severe (<54 mg/dL).

Whipple’s triad (confirms true hypoglycemia):

Symptoms of hypoglycemia
Low measured glucose
Resolution of symptoms with glucose correction

Symptoms by severity:

Adrenergic (mild): tremor, diaphoresis, palpitations, anxiety, hunger
Neuroglycopenic (severe): confusion, slurred speech, seizures, loss of consciousness, coma

Immediate treatment:

Conscious patient: 15-20g fast-acting carbohydrate PO (juice, glucose tabs)
- Recheck glucose in 15 min, repeat if still <70
Altered mental status / unable to swallow:
- D50 (50% dextrose): 25-50mL IV push (= 12.5-25g glucose)
- Recheck glucose in 5-10 min, may repeat
- Follow with D10 drip if recurrent
No IV access:
- Glucagon 1mg IM/SQ (may cause vomiting, less effective in liver disease/alcohol)

Workup for cause (after stabilization):

Medication review: insulin, sulfonylureas, meglitinides
If non-diabetic: check insulin level, C-peptide, proinsulin, beta-hydroxybutyrate, sulfonylurea screen DURING hypoglycemic episode (critical sample before correction)
- High insulin + high C-peptide → insulinoma or sulfonylurea
- High insulin + low C-peptide → exogenous insulin administration
- Low insulin + low C-peptide → non-islet cell tumor, liver failure, adrenal insufficiency, malnutrition

Sulfonylurea-induced hypoglycemia:

Prolonged and recurrent — admit for minimum 24h observation
Octreotide 50-100mcg SQ q6-8h (inhibits insulin secretion) — very effective
D10 drip maintenance
Avoid repeated D50 boluses (stimulates more insulin release)

Q: Describe the management of thyroid storm.

A: Thyroid storm is life-threatening decompensated hyperthyroidism. Mortality 10-30% even with treatment. Diagnosed clinically using Burch-Wartofsky Point Scale (score ≥45 = thyroid storm).

Clinical features: high fever (>104°F), tachycardia (often >140), agitation/delirium/psychosis, vomiting/diarrhea, heart failure, seizures.

Treatment — ORDER MATTERS:

1. Beta-blocker (control adrenergic symptoms — FIRST):

Propranolol 60-80mg PO q4-6h (preferred — also blocks peripheral T4→T3 conversion)
OR esmolol drip 50-100 mcg/kg/min if unable to take PO or hemodynamically unstable
Target HR <100

2. Thionamide (block new hormone synthesis):

PTU 200-250mg PO q4h (preferred in thyroid storm because it also blocks T4→T3 conversion)
OR methimazole 20mg PO q4-6h
Give AT LEAST 1 hour before iodine

3. Iodine (block hormone release — MUST give after thionamide):

SSKI (saturated solution potassium iodide) 5 drops PO q6h
OR Lugol’s solution 10 drops PO q8h
If given before thionamide → provides substrate for MORE hormone synthesis (Jod-Basedow)

4. Corticosteroids (block T4→T3 conversion, treat possible adrenal insufficiency):

Hydrocortisone 100mg IV q8h
OR dexamethasone 2mg IV q6h

5. Supportive:

Aggressive cooling for hyperthermia (avoid aspirin — displaces thyroid hormone from binding proteins)
Acetaminophen for fever
IV fluids — high-output state, significant fluid losses
Treat precipitant: infection, surgery, iodine contrast, medication non-compliance

6. Cholestyramine 4g PO QID (optional) — reduces enterohepatic recirculation of thyroid hormones

If refractory: plasmapheresis or emergency thyroidectomy

1.8 Nephrology

Q: How do you evaluate and manage acute kidney injury (AKI)?

A: AKI defined by KDIGO criteria:

Stage 1: creatinine increase ≥0.3 mg/dL in 48h OR 1.5-1.9x baseline OR UOP <0.5 mL/kg/hr for 6-12h
Stage 2: creatinine 2.0-2.9x baseline OR UOP <0.5 mL/kg/hr for ≥12h
Stage 3: creatinine ≥3x baseline OR creatinine ≥4.0 OR need for dialysis OR UOP <0.3 mL/kg/hr for ≥24h or anuria ≥12h

Classification by etiology:

Pre-renal (most common, ~55%):

Decreased renal perfusion: dehydration, hemorrhage, CHF, sepsis, hepatorenal syndrome
Labs: BUN/Cr ratio >20:1, FENa <1%, specific gravity >1.020, urine sodium <20
Treatment: restore perfusion — IV fluids, treat underlying cause

Intrinsic renal (~40%):

ATN (acute tubular necrosis) — ischemic or nephrotoxic (aminoglycosides, contrast, rhabdomyolysis)
- Labs: FENa >2%, muddy brown casts on UA
AIN (acute interstitial nephritis) — drug-induced (NSAIDs, PPIs, antibiotics), autoimmune
- Labs: WBC casts, eosinophiluria, pyuria
Glomerulonephritis — nephritic or nephrotic picture
- Labs: RBC casts (pathognomonic), proteinuria, complement levels, ANA, ANCA, anti-GBM

Post-renal (~5%):

Obstruction: BPH, stones, tumor, blood clots
Bilateral hydronephrosis on ultrasound
Treatment: relieve obstruction (Foley catheter, nephrostomy, ureteral stent)

General management principles:

Identify and treat underlying cause
Optimize volume status (fluids for prerenal, diuresis for overload)
Stop nephrotoxins (NSAIDs, aminoglycosides, contrast dye, ACEi/ARB temporarily)
Adjust renally-dosed medications
Monitor electrolytes closely (hyperkalemia is the acute killer)
Renal diet if prolonged: low potassium, low phosphorus, fluid restriction if oliguric

Indications for emergent dialysis (mnemonic: AEIOU):

A — Acidosis (pH <7.1 refractory to bicarb)
E — Electrolytes (hyperkalemia >6.5 refractory to medical management)
I — Ingestion (methanol, ethylene glycol, lithium, salicylate)
O — Overload (volume overload refractory to diuretics, pulmonary edema)
U — Uremia (encephalopathy, pericarditis, bleeding)

Q: How do you manage hyperkalemia?

A: Hyperkalemia (K >5.0 mEq/L) is a medical emergency when >6.0 or with ECG changes.

ECG changes (progressive):

Peaked T waves (earliest sign)
Prolonged PR interval
Widened QRS
Loss of P waves
Sine wave pattern → cardiac arrest (VF/asystole)

Management by severity:

Step 1 — Cardiac membrane stabilization (if ECG changes or K >6.5):

Calcium gluconate 10% — 10-20 mL IV over 2-3 min
Does NOT lower potassium — stabilizes myocardium
Onset: 1-3 min, duration: 30-60 min
Can repeat in 5 min if ECG changes persist
Use calcium chloride via central line if cardiac arrest imminent (3x more elemental calcium)

Step 2 — Shift potassium intracellularly (temporizing):

Insulin 10 units regular IV + D50 25g IV (prevent hypoglycemia)
- Onset 15-30 min, duration 4-6h
- Check glucose q1h x4h
Albuterol 10-20mg nebulizer (4-8x the asthma dose)
- Onset 15-30 min, lowers K by 0.5-1.0 mEq/L
Sodium bicarbonate 150 mEq IV — only if concurrent metabolic acidosis (limited efficacy alone)

Step 3 — Remove potassium from body (definitive):

Furosemide 40-80mg IV (if adequate renal function)
Sodium zirconium cyclosilicate (Lokelma) 10g PO x3 — onset 1h, more predictable than kayexalate
Patiromer 8.4g PO — onset 7h (better for chronic management)
Sodium polystyrene sulfonate (Kayexalate) 30-60g PO — onset 1-2h but unpredictable, risk of intestinal necrosis (use cautiously)
Hemodialysis — most effective K removal, use if refractory or renal failure

Always: identify and treat cause — stop ACEi/ARB, K-sparing diuretics, NSAIDs, TMP-SMX. Check for rhabdomyolysis, hemolysis, tumor lysis, adrenal insufficiency.

1.9 Infectious Disease

Q: Describe the management of sepsis and septic shock per current guidelines.

A: Sepsis = life-threatening organ dysfunction due to dysregulated host response to infection (SOFA score increase ≥2). Septic shock = sepsis + vasopressors needed to maintain MAP ≥65 AND lactate >2 despite adequate resuscitation.

Hour-1 Bundle (Surviving Sepsis Campaign):

1. Measure lactate:

Lactate >2 mmol/L → re-measure in 2-4 hours
Goal: normalize lactate (>10% decrease per 2 hours)
Lactate >4 → severe sepsis, aggressive resuscitation

2. Blood cultures BEFORE antibiotics:

At least 2 sets (aerobic + anaerobic) from 2 different sites
Obtain within 45 minutes of recognition
Do NOT delay antibiotics for cultures if unable to obtain quickly

3. Broad-spectrum antibiotics WITHIN 1 HOUR:

Each hour delay increases mortality ~7.6%
Common empiric regimens by source:
- Unknown source: vancomycin + piperacillin-tazobactam (or meropenem)
- Pneumonia: vancomycin + cefepime (or piperacillin-tazobactam)
- Urinary: ceftriaxone (add vancomycin if risk for resistant organisms)
- Intra-abdominal: piperacillin-tazobactam or meropenem + vancomycin
- Skin/soft tissue: vancomycin + piperacillin-tazobactam
Add antifungals (micafungin) if risk factors: TPN, prior antibiotics, immunosuppression

4. IV fluid resuscitation:

30 mL/kg crystalloid (LR preferred over NS) within first 3 hours for hypotension or lactate ≥4
Reassess volume status after each bolus (lung ultrasound, IVC assessment, passive leg raise)
Avoid fluid overload — don’t continue aggressive fluids if no hemodynamic improvement

5. Vasopressors if MAP <65 despite fluids:

Norepinephrine — first-line, start early (can initiate via peripheral IV temporarily)
Vasopressin 0.03 U/min — second agent if norepinephrine insufficient (not titrated)
Epinephrine — third-line
Stress-dose steroids: hydrocortisone 50mg IV q6h if vasopressor-refractory shock (requiring escalating doses or multiple pressors)

Source control:

Identify and control infection source ASAP (within 6-12 hours)
Drain abscesses, debride necrotic tissue, remove infected devices
Source control is as important as antibiotics

De-escalation:

Narrow antibiotics based on culture results (typically at 48-72h)
Procalcitonin can guide antibiotic duration
Typical duration: 7-10 days for most infections

Q: How do you empirically select antibiotics by infection site and suspected organism?

A: Quick reference for common infections:

Community-Acquired Pneumonia (CAP):

Outpatient: amoxicillin OR doxycycline
Outpatient with comorbidities: amoxicillin-clavulanate + azithromycin, OR respiratory fluoroquinolone (levofloxacin 750mg)
Inpatient (non-ICU): ceftriaxone + azithromycin
Inpatient (ICU): ceftriaxone + azithromycin (add vancomycin + piperacillin-tazobactam if risk for MRSA/pseudomonas)
Covers: Strep pneumoniae, H. influenzae, Moraxella, atypicals (Mycoplasma, Legionella, Chlamydophila)

Hospital-Acquired/Ventilator-Associated Pneumonia (HAP/VAP):

Piperacillin-tazobactam OR cefepime OR meropenem
Add vancomycin or linezolid for MRSA coverage
Add an aminoglycoside or colistin if high MDR risk
Covers: Pseudomonas, MRSA, Klebsiella, Acinetobacter

UTI:

Uncomplicated cystitis: nitrofurantoin 100mg BID x5d, or TMP-SMX DS BID x3d
Complicated/pyelonephritis: ceftriaxone 1g IV, then PO ciprofloxacin or TMP-SMX based on culture
Catheter-associated (CAUTI): remove/replace catheter + ceftriaxone (add vancomycin if gram-positive cocci)
Covers: E. coli (#1), Klebsiella, Proteus, Enterococcus

Skin & Soft Tissue:

Simple cellulitis (non-purulent): cephalexin 500mg QID or dicloxacillin
Purulent/abscess (MRSA risk): TMP-SMX DS BID or doxycycline 100mg BID + I&D
Severe/necrotizing: vancomycin + piperacillin-tazobactam + clindamycin (toxin inhibitor) + emergent surgical debridement
Covers: Strep pyogenes, MSSA, MRSA, mixed anaerobes (necrotizing)

Intra-Abdominal:

Piperacillin-tazobactam OR ceftriaxone + metronidazole OR meropenem (if MDR risk)
Covers: E. coli, Bacteroides, Enterococcus, Klebsiella

Meningitis (empiric):

Age <2 months: ampicillin + cefotaxime (or gentamicin)
Age 2 months - 50 years: vancomycin + ceftriaxone + dexamethasone (before or with first antibiotic dose)
Age >50 or immunocompromised: vancomycin + ceftriaxone + ampicillin (covers Listeria) + dexamethasone
Covers: Strep pneumoniae, N. meningitidis, Listeria (elderly/immunocompromised), GBS and E. coli (neonates)

1.10 Hematology/Oncology

Q: When and how do you transfuse blood products?

Packed Red Blood Cells (pRBC):

Threshold: Hgb <7 g/dL for most patients (restrictive strategy)
Threshold: Hgb <8 g/dL for active cardiac disease, symptomatic anemia
Threshold: Hgb <10 g/dL may be considered for active hemorrhage, critical illness with ongoing bleeding
Each unit raises Hgb ~1 g/dL
Infuse over 2-4 hours (max 4 hours per unit)
Type and crossmatch required (15-45 min). O-negative for emergencies.

Platelets:

Threshold <10,000: transfuse prophylactically (no active bleeding)
Threshold <50,000: transfuse if active bleeding or pre-procedure
Threshold <100,000: transfuse for neurosurgery or intracranial bleeding
1 unit (apheresis) raises platelets ~30,000-50,000
Ineffective in: TTP (contraindicated — can worsen), ITP (consumed rapidly), HIT (contraindicated)

Fresh Frozen Plasma (FFP):

Indications: active bleeding with INR >1.5, DIC, liver disease with bleeding, TTP (plasmapheresis), warfarin reversal (if no PCC available)
Dose: 10-15 mL/kg (typically 2-4 units)
Must be ABO compatible
Thaw time ~30 min (order early)

Cryoprecipitate:

Indications: fibrinogen <100-150 mg/dL with active bleeding, DIC, massive transfusion
Rich in: fibrinogen, Factor VIII, vWF, Factor XIII
Dose: 10 units (typical adult dose) raises fibrinogen ~60-100 mg/dL

Massive Transfusion Protocol (MTP):

Triggered for: anticipated need for ≥10 units pRBC in 24h, or ≥4 units in 1 hour
Ratio: 1:1:1 (pRBC : FFP : platelets)
Monitor: Ca²⁺ (citrate toxicity), K⁺, temperature, coags, fibrinogen q30-60min
Give calcium gluconate 1g IV per 4 units transfused (prevents citrate-induced hypocalcemia)
Tranexamic acid (TXA) 1g IV within 3 hours of traumatic hemorrhage (CRASH-2)

Transfusion reactions:

Febrile non-hemolytic: most common. Stop transfusion, antipyretics, rule out hemolytic reaction.
Acute hemolytic: ABO incompatibility. Fever, flank pain, dark urine. STOP immediately. NS bolus, send direct Coombs, haptoglobin, free Hgb, repeat type and screen.
Allergic: urticaria → diphenhydramine, continue transfusion. Anaphylaxis → epinephrine, stop transfusion.
TRALI: noncardiogenic pulmonary edema within 6h. Stop transfusion, supportive care (O2, possibly intubation). No diuretics.
TACO: volume overload. Dyspnea, hypertension, elevated BNP. Diurese.

Q: How do you approach a new diagnosis of pancytopenia?

A: Pancytopenia = simultaneous decrease in all three cell lines (WBC, Hgb/Hct, Platelets).

Differential organized by mechanism:

Decreased production (bone marrow failure):

Aplastic anemia (drug-induced, viral, idiopathic)
Myelodysplastic syndrome (MDS)
Leukemia/lymphoma infiltrating marrow
Metastatic cancer to bone marrow
Myelofibrosis
Megaloblastic anemia (B12 or folate deficiency — also causes hypersegmented neutrophils)
Severe infection (HIV, TB, parvovirus, hepatitis)
Medications (chemotherapy, methotrexate, TMP-SMX, phenytoin)

Increased destruction/consumption:

Hypersplenism (cirrhosis, portal hypertension)
DIC
HLH/MAS (hemophagocytic lymphohistiocytosis)
TTP/HUS (microangiopathic)
SLE

Workup:

CBC with differential and reticulocyte count
Peripheral blood smear (critical — may reveal blasts, dysplasia, schistocytes, megaloblastic changes)
B12, folate levels
LDH, haptoglobin, reticulocyte count (hemolysis workup)
HIV, hepatitis B/C
Iron studies, ferritin
ESR/CRP, ANA if autoimmune suspected
Bone marrow biopsy — often definitive (if no obvious reversible cause identified)

Bone marrow findings:

Hypocellular → aplastic anemia
Hypercellular with dysplasia → MDS
Blasts >20% → acute leukemia
Fibrosis → myelofibrosis
Infiltrative → metastatic cancer, lymphoma
Megaloblastic changes → B12/folate deficiency

Immediate management while working up:

Transfusion support per thresholds above
Neutropenic precautions if ANC <500 (mask, single room, no fresh flowers/fruits)
Febrile neutropenia protocol if fever + ANC <500: blood cultures → empiric broad-spectrum antibiotics (cefepime or piperacillin-tazobactam) WITHIN 1 HOUR

1.11 Rheumatology

Q: How do you approach a patient with new-onset joint pain and possible autoimmune disease?

Key history:

Joint pattern: monoarticular vs polyarticular, symmetric vs asymmetric, large vs small joints
Duration: <6 weeks (acute) vs >6 weeks (chronic)
Morning stiffness: >60 min suggests inflammatory
Extra-articular symptoms: rash, oral ulcers, dry eyes/mouth, Raynaud’s, serositis

Differential by pattern:

Acute monoarticular:

Septic arthritis (MUST rule out — medical emergency)
Gout (podagra, tophi)
Pseudogout (CPPD)
Trauma

Chronic polyarticular, symmetric, small joints:

Rheumatoid arthritis (RA) — MCP, PIP, wrists
SLE — with systemic features
Psoriatic arthritis — DIP involvement, nail pitting

Chronic polyarticular, asymmetric:

Psoriatic arthritis
Reactive arthritis
Ankylosing spondylitis (axial predominant)

Workup:

CBC, BMP, ESR, CRP
RF (rheumatoid factor), anti-CCP antibodies (more specific for RA)
ANA (screening for SLE — if positive: anti-dsDNA, anti-Smith, complement C3/C4)
HLA-B27 (ankylosing spondylitis, reactive arthritis)
Uric acid (gout — but can be normal during acute flare)
Joint aspiration (if effusion present — ESSENTIAL for monoarticular):
- Cell count: >50,000 WBC with >75% PMNs → septic until proven otherwise
- Crystal analysis: negatively birefringent (gout), positively birefringent (pseudogout)
- Gram stain and culture
X-rays of affected joints
MRI if X-ray inconclusive

Septic arthritis — treat first, confirm later:

Joint aspiration STAT (before antibiotics if possible)
Empiric: vancomycin + ceftriaxone (cover Staph aureus and gonococcus)
Orthopedic consult for washout
IV antibiotics 2-4 weeks minimum

1.12 Dermatology

Q: How do you assess and describe skin lesions systematically?

A: Use a systematic approach for documentation and communication.

Primary morphology:

Macule: flat, <1cm (e.g., freckle)
Patch: flat, >1cm (e.g., vitiligo)
Papule: elevated, solid, <1cm (e.g., molluscum)
Plaque: elevated, flat-topped, >1cm (e.g., psoriasis)
Nodule: solid, deep, >1cm (e.g., lipoma)
Vesicle: fluid-filled, <1cm (e.g., herpes simplex)
Bulla: fluid-filled, >1cm (e.g., bullous pemphigoid)
Pustule: pus-filled (e.g., acne, folliculitis)
Wheal: edematous papule/plaque (e.g., urticaria)
Petechiae: <2mm, non-blanching (e.g., thrombocytopenia)
Purpura: >2mm, non-blanching (e.g., vasculitis)

Secondary changes: scale, crust, erosion, ulcer, lichenification, atrophy, excoriation

Description template: “[Number] [color] [primary morphology] with [secondary changes], [distribution], [arrangement], measuring approximately [size]”

Example: “Multiple erythematous papules and plaques with silvery scale, symmetrically distributed on bilateral extensor elbows and knees, measuring 2-5cm each” → classic psoriasis

Critical dermatologic emergencies to recognize:

Stevens-Johnson Syndrome/TEN: target lesions, mucosal involvement, skin sloughing. Stop offending drug. Burn unit.
Necrotizing fasciitis: rapidly spreading erythema, crepitus, pain out of proportion, systemic toxicity. Emergent surgical debridement.
Meningococcemia: petechiae/purpura + fever + meningeal signs. Blood cultures, empiric ceftriaxone, ICU.
DRESS syndrome: drug reaction with eosinophilia, fever, LAD, organ involvement. Stop drug, systemic steroids.
Pemphigus vulgaris: widespread flaccid bullae with mucosal involvement. Positive Nikolsky sign. Dermatology urgent consult.

1.13 Psychiatry

Q: How do you manage acute psychiatric emergencies — agitation, psychosis, and suicidal ideation?

Acute Agitation:

Verbal de-escalation (always attempt first):

Calm, non-threatening tone
Offer choices (“Would you prefer to sit here or there?”)
Identify needs: pain, hunger, fear
Maintain safe distance, clear exit path

If pharmacologic intervention needed:

Oral (preferred if cooperative):

Olanzapine 5-10mg PO + lorazepam 2mg PO

IM (if refusing PO or threatening):

Olanzapine 10mg IM (do NOT combine with IM benzodiazepine — respiratory depression risk)
OR Haloperidol 5mg IM + lorazepam 2mg IM + diphenhydramine 50mg IM (the “B52” cocktail)
OR Ziprasidone 10-20mg IM
OR Midazolam 5mg IM (fastest onset)

IV (for emergent sedation):

Midazolam 2-5mg IV
Haloperidol 5mg IV (monitor QTc — risk of torsades)

Physical restraints: last resort only. Order must be time-limited (4h adults, 2h adolescents, 1h children). Face-up, 4-point. Check circulation q15min. 1:1 observation. Reassess need q1-2h.

Acute Psychosis:

Safety first — ensure no weapons, safe environment
Workup to rule out medical causes: CBC, BMP, TSH, UA, urine drug screen, B12, RPR, HIV, head CT
Antipsychotic: haloperidol 5mg IM or olanzapine 10mg IM
If first-break psychosis → psychiatry consult, MRI brain, consider LP

Suicidal Ideation:

Structured risk assessment: ideation, plan, intent, means, timeline
Risk factors: prior attempts (#1 predictor), substance use, access to lethal means, recent loss, psychiatric illness
Protective factors: social support, children, reasons for living, treatment engagement
High risk → 1:1 sitter, safe room (ligature-free), remove sharps/belts, involuntary hold if imminent danger
Moderate risk → safety planning, means restriction counseling, psychiatric consultation
Document risk level and rationale for disposition

Q: When and how do you initiate an involuntary psychiatric hold?

A: Criteria vary by state, but generally require:

Mental illness AND
Danger to self OR danger to others OR gravely disabled (unable to provide for basic needs)

Process:

Physician completes state-specific documentation (e.g., Florida Baker Act, California 5150)
Patient has right to be informed of hold and rights
Typical initial hold: 72 hours for evaluation
During hold: psychiatry evaluation, stabilization, determine if longer commitment needed
Patient has right to legal representation and hearing for extended holds

Key documentation:

Specific behaviors observed (not just “patient is a danger”)
What the patient said (direct quotes when possible)
Why less restrictive alternatives are insufficient
Mental status exam
Risk assessment with rationale

1.14 Pediatrics

Q: What are the key differences in pediatric vital signs and medication dosing?

Normal Pediatric Vital Signs by Age:

Age	HR (bpm)	RR (breaths/min)	SBP (mmHg)	Min SBP (hypotension)
Newborn	120-160	30-60	60-80	<60
Infant (1-12mo)	100-150	25-40	70-100	<70
Toddler (1-3yr)	90-140	20-30	80-110	70 + (2 × age)
Preschool (4-5yr)	80-120	20-25	85-110	70 + (2 × age)
School age (6-12yr)	70-110	18-22	90-120	70 + (2 × age)
Adolescent (13+yr)	60-100	12-20	100-130	<90

Minimum SBP formula: 70 + (2 × age in years) for ages 1-10.

Weight estimation if unknown:

1-12 months: (age in months + 9) / 2
1-5 years: (2 × age in years) + 8
6-12 years: (3 × age in years) + 7
Broselow tape is the gold standard for emergencies

Key medication dosing differences:

ALL pediatric medications dosed by weight (mg/kg)
Epinephrine (anaphylaxis): 0.01 mg/kg IM (1:1,000), max 0.3mg for <30kg, 0.5mg for >30kg
Epinephrine (cardiac arrest): 0.01 mg/kg IV (1:10,000), max 1mg
Acetaminophen: 15 mg/kg PO q4-6h (max 75 mg/kg/day)
Ibuprofen: 10 mg/kg PO q6-8h (age >6 months only)
Amoxicillin (otitis media): 90 mg/kg/day divided BID (high dose for resistant Strep pneumoniae)
Ceftriaxone: 50-100 mg/kg IV daily (max 2-4g)
Fluid bolus: 20 mL/kg NS, may repeat x3 (total 60 mL/kg before considering pressors)
Maintenance fluids (Holliday-Segar):
- 0-10 kg: 4 mL/kg/hr
- 10-20 kg: 40 mL/hr + 2 mL/kg/hr for each kg over 10
- 20 kg: 60 mL/hr + 1 mL/kg/hr for each kg over 20

Critical differences from adults:

Dehydration presents differently: sunken fontanelle, decreased tears, dry mucous membranes, delayed cap refill
Children compensate for shock with tachycardia — hypotension is a LATE and ominous sign
Smaller airway: uncuffed ETT for <8 years (traditionally), though cuffed tubes now used with careful cuff pressure monitoring
ETT size: (age/4) + 4 for uncuffed, (age/4) + 3.5 for cuffed
ETT depth: (age/2) + 12 cm at lip

Q: How do you assess and manage pediatric dehydration?

Severity assessment:

Finding	Mild (3-5%)	Moderate (6-9%)	Severe (≥10%)
Mental status	Normal/restless	Irritable/lethargic	Obtunded
Eyes	Normal	Sunken	Deeply sunken
Tears	Present	Decreased	Absent
Mucous membranes	Slightly dry	Dry	Parched
Skin turgor	Normal	Decreased	Tenting
Cap refill	Normal (<2s)	2-4 seconds	>4 seconds
Heart rate	Normal/mildly ↑	Increased	Markedly increased
Urine output	Slightly ↓	Decreased	Minimal/absent

Management:

Mild-Moderate (can tolerate PO):

Oral rehydration therapy (ORT): Pedialyte or WHO-ORS
Replacement: 50-100 mL/kg over 3-4 hours + ongoing losses
Small frequent sips (5-10 mL q2-3 min via syringe if needed)
Continue breastfeeding if applicable
Advance to age-appropriate diet once tolerating fluids

Severe or unable to tolerate PO:

IV NS or LR bolus 20 mL/kg over 15-30 min
Reassess after each bolus — repeat up to 60 mL/kg
After resuscitation: calculate deficit + maintenance + ongoing losses
Deficit replacement over 24-48 hours
Monitor electrolytes q4-6h during aggressive repletion
Watch for hyponatremia or hypernatremia — dictates repletion speed

Hypernatremic dehydration (Na >150):

Correct sodium slowly: no faster than 0.5 mEq/L per hour (10-12 mEq/L per 24h)
Rapid correction risks cerebral edema and seizures
Use hypotonic fluids (D5 ½NS) after initial resuscitation
Frequent sodium monitoring q2-4h

1.15 OB/GYN

Q: How do you manage postpartum hemorrhage (PPH)?

A: PPH = blood loss ≥1000 mL OR signs of hypovolemia after delivery. #1 cause of maternal mortality worldwide.

Causes (4 T’s):

Tone (70%) — uterine atony (most common)
Trauma (20%) — lacerations, uterine rupture, uterine inversion
Tissue (10%) — retained placenta, placenta accreta
Thrombin (<1%) — coagulopathy, DIC

Step-wise management for uterine atony:

Step 1 — Bimanual uterine massage + Uterotonics:

Oxytocin 20-40 units in 1L NS, run wide open
Methylergonovine (Methergine) 0.2mg IM q2-4h (AVOID in hypertension)
Carboprost (Hemabate) 0.25mg IM q15-90min, max 8 doses (AVOID in asthma)
Misoprostol 800-1000mcg rectally (can also be SL, buccal)

Step 2 — If uterotonics fail:

Intrauterine balloon tamponade (Bakri balloon)
Uterine compression sutures (B-Lynch suture)
Tranexamic acid (TXA) 1g IV within 3 hours of delivery (WOMAN trial)

Step 3 — If above fails:

Uterine artery embolization (IR)
Surgical: uterine artery ligation → hysterectomy (last resort, life-saving)

Concurrent resuscitation:

2 large-bore IVs
Activate massive transfusion protocol
Type and crossmatch, CBC, coags, fibrinogen q30-60min
Target fibrinogen >200 mg/dL (lower threshold than non-obstetric hemorrhage)
Warm patient, warm fluids
Quantitative blood loss measurement (weighing pads, collecting canisters)

Q: What are the key obstetric emergencies and their management?

Eclampsia (seizures in preeclampsia):

Magnesium sulfate 4-6g IV loading dose over 15-20 min → 1-2g/hr drip (first-line for seizure prevention AND treatment)
Monitor: deep tendon reflexes, respiratory rate (hold if RR <12), urine output, Mg levels (therapeutic 4-7 mEq/L)
Antidote for Mg toxicity: calcium gluconate 1g IV
BP control: labetalol 20mg IV → 40mg → 80mg, or hydralazine 5-10mg IV, or nicardipine drip
Target: SBP <160, DBP <110
Definitive treatment: DELIVERY (regardless of gestational age if severe)

Placental Abruption:

Painful vaginal bleeding, uterine tenderness, “board-like” abdomen, fetal distress
Monitor: continuous fetal monitoring, CBC, coags, fibrinogen (often DIC develops)
If hemodynamically unstable or fetal distress → emergent cesarean
If stable, near term → delivery. If preterm and stable → close monitoring, steroids for fetal lung maturity

Placenta Previa:

PAINLESS bright red vaginal bleeding
Do NOT perform digital cervical exam
Confirm with ultrasound
If preterm and stable → expectant management, steroids, pelvic rest
If heavy bleeding or ≥36 weeks → cesarean delivery

Shoulder Dystocia:

Head delivers but shoulders impacted
Call for help (anesthesia, NICU, extra nursing)
McRoberts maneuver (hyperflexion of maternal hips) + suprapubic pressure — first-line
Episiotomy (may improve access but doesn’t resolve bony impaction)
Rotational maneuvers (Rubin, Wood’s screw)
Delivery of posterior arm
Document time from head delivery to body delivery

Umbilical Cord Prolapse:

Presenting cord palpated or visualized at cervix
Elevate presenting part (examiner’s hand in vagina pushing fetal head off cord)
Fill bladder with 500-750mL saline via Foley (further elevates presenting part)
Knee-chest position or Trendelenburg
Emergent cesarean delivery

1.16 Orthopedics

Q: How do you evaluate and manage common fractures in the emergency department?

Assessment:

Mechanism of injury
Neurovascular status BEFORE and AFTER any manipulation (pulse, sensation, motor function distal to injury)
Open vs closed (any skin break = open fracture = surgical emergency)
Compartment syndrome screening: pain out of proportion, pain with passive stretch, paresthesias, pressure (firmness of compartment), paralysis (LATE — don’t wait for this)

Fracture description: bone, location (proximal/mid/distal), type (transverse, oblique, spiral, comminuted), displacement, angulation, open vs closed, joint involvement

Common fractures and management:

Distal radius (Colles fracture):

Mechanism: FOOSH (fall on outstretched hand)
Closed reduction with hematoma block or conscious sedation
Sugar-tong splint
Orthopedic follow-up; surgical fixation if unstable, intra-articular, or significantly displaced

Hip fracture (femoral neck or intertrochanteric):

Elderly + fall + inability to bear weight + leg shortened and externally rotated
X-ray (AP pelvis + lateral hip); MRI if X-ray negative but high suspicion
Surgical repair within 24-48 hours (reduces mortality)
DVT prophylaxis, pain management, PT
Screen for osteoporosis, fall risk assessment

Ankle fracture:

Ottawa Ankle Rules to determine need for X-ray:
- Bone tenderness at posterior edge or tip of lateral or medial malleolus
- Unable to bear weight immediately and in ED (4 steps)
Weber classification: A (below syndesmosis — stable), B (at syndesmosis — may be unstable), C (above syndesmosis — unstable, likely surgical)
Stable → posterior splint, non-weight bearing, ortho follow-up
Unstable → ORIF

Open fracture — emergency:

Gustilo classification: Type I (<1cm wound), Type II (1-10cm), Type IIIA/B/C (>10cm, contaminated, vascular injury)
Immediate: photograph wound, cover with sterile saline-soaked gauze
IV antibiotics within 1 hour: cefazolin 2g IV (add gentamicin for Type III, add penicillin if soil contamination)
Tetanus update
Emergent operative irrigation and debridement within 6-24 hours
Definitive fixation timing depends on classification and contamination

Compartment syndrome:

Intracompartmental pressure >30 mmHg OR within 30 mmHg of diastolic BP (delta pressure <30)
Clinical diagnosis: 5 P’s (pain, pressure, pain with passive stretch, paresthesias, paralysis — but pulselessness is LATE)
Emergent fasciotomy — irreversible damage within 6-8 hours

1.17 Ophthalmology & ENT Emergencies

Q: What are the ophthalmic emergencies that require immediate treatment?

Central Retinal Artery Occlusion (CRAO):

Painless, sudden, monocular vision loss. “Cherry red spot” on fundoscopy.
TRUE EMERGENCY — retinal ischemia causes irreversible damage within 90-120 minutes
Immediate: ocular massage (intermittent pressure on globe), lower IOP with timolol 0.5% + acetazolamide 500mg IV
Emergent ophthalmology consult for intra-arterial tPA consideration
Workup for embolic source: carotid duplex, echocardiogram, ESR/CRP for temporal arteritis

Chemical burn:

IMMEDIATE copious irrigation with NS or LR — minimum 30 minutes. Do NOT wait for anything.
Alkali worse than acid (penetrates deeper — liquefactive necrosis)
Check pH of conjunctival sac — irrigate until pH 7.0-7.4
Morgan lens for continuous irrigation
After irrigation: visual acuity, slit lamp exam, ophthalmology consult
Do NOT attempt to neutralize chemicals

Globe rupture (open globe):

Mechanism: trauma with object penetration or blunt rupture
Signs: irregular pupil, shallow anterior chamber, exposed uveal tissue, Seidel test positive (fluorescein streaming from wound)
Place rigid eye shield (FOX shield) — do NOT patch (pressure can extrude contents)
Avoid IOP-raising activities: vomiting (give ondansetron), Valsalva, straining
NPO for surgical repair
Tetanus update, IV antibiotics (cefazolin + fluoroquinolone or vancomycin + ceftazidime)
Emergent ophthalmology consult

Acute angle-closure glaucoma:

Severe eye pain, halos around lights, red eye, mid-dilated fixed pupil, rock-hard globe, nausea/vomiting
IOP markedly elevated (>40 mmHg)
Treatment: timolol 0.5% topical, pilocarpine 2% (constricts pupil), acetazolamide 500mg IV, mannitol 1-2 g/kg IV if refractory
Definitive: laser peripheral iridotomy (ophthalmology)

Retinal detachment:

Flashes, floaters, curtain/shadow over vision
Not hyperacute emergency but urgent — ophthalmology within 24 hours
Macula-on (central vision intact) → more urgent than macula-off

Q: What ENT emergencies require immediate intervention?

Peritonsillar abscess (PTA):

Severe sore throat, “hot potato” voice, trismus, uvula deviation, unilateral tonsillar bulging
Needle aspiration or I&D (can be done at bedside)
Antibiotics: amoxicillin-clavulanate OR clindamycin + IV steroids (dexamethasone 10mg)
Risk if untreated: extension to parapharyngeal/retropharyngeal space → airway compromise

Retropharyngeal abscess:

Fever, neck stiffness, drooling, muffled voice, neck swelling
More common in children <6 years
CT neck with contrast for diagnosis
IV antibiotics: ampicillin-sulbactam or clindamycin
Surgical drainage by ENT if not improving or large abscess
Airway management priority

Epistaxis (severe/posterior):

Anterior: most common, Kiesselbach plexus. Direct pressure 15-20 min, anterior packing (Rhino Rocket or ribbon gauze with petroleum), topical oxymetazoline, cauterization with silver nitrate
Posterior: harder to control, may require posterior packing (Foley balloon) or Rapid Rhino posterior. Admit for monitoring (risk of vagal response, aspiration). ENT consult for possible embolization or cauterization under anesthesia
Lab: CBC, coags, type and screen if significant blood loss
Correct coagulopathy: reverse anticoagulation, transfuse if needed

Ludwig’s Angina:

Bilateral submandibular space infection, board-like floor of mouth swelling, tongue elevation
Airway emergency — can rapidly occlude airway
Secure airway early (awake fiberoptic intubation preferred, surgical airway if needed)
IV antibiotics: ampicillin-sulbactam or clindamycin + ceftriaxone
CT neck, surgical drainage by ENT/OMFS

Foreign body aspiration (pediatric):

Sudden onset coughing, choking, unilateral wheezing or decreased breath sounds
If stable: chest X-ray (inspiratory AND expiratory — look for air trapping), rigid bronchoscopy by ENT/pulmonology for removal
If complete obstruction: back blows and chest thrusts (<1 year), abdominal thrusts (>1 year), CPR if unresponsive

1.18 Urology

Q: How do you manage urologic emergencies?

Testicular torsion:

Acute onset severe scrotal pain, nausea, absent cremasteric reflex, high-riding testicle
This is a surgical emergency — salvage rate >90% within 6 hours, drops to ~20% after 12 hours
Color Doppler ultrasound: absent or decreased blood flow (but do NOT delay surgery for imaging if clinical suspicion is high)
Manual detorsion can be attempted: “open the book” (medial to lateral rotation) — if pain improves, likely successful
Definitive: surgical exploration with bilateral orchiopexy (fix both sides)
If >24 hours or nonviable → orchiectomy with contralateral orchiopexy

Fournier’s Gangrene:

Necrotizing fasciitis of perineum/genitalia
Severe perineal pain, swelling, crepitus, fever, sepsis
Rapid progression — mortality 20-40%
Emergent surgical debridement (within hours)
Broad-spectrum antibiotics: vancomycin + piperacillin-tazobactam + clindamycin
Aggressive fluid resuscitation
ICU admission
May require multiple return trips to OR for serial debridement
Wound VAC, possible reconstruction later

Priapism:

Painful, sustained erection >4 hours unrelated to sexual stimulation
Ischemic (low-flow) = emergency — risk of permanent erectile dysfunction after 6 hours
Treatment: aspiration of corporal blood with 16-18g needle → irrigation with dilute phenylephrine (100-500 mcg in 1mL NS injections q3-5min, max 1mg in 1 hour)
Monitor BP and HR (phenylephrine can cause hypertension)
If refractory → surgical shunt (distal first: Winter, T-shunt; then proximal)

Acute urinary retention:

Inability to void with suprapubic distension and discomfort
Causes: BPH (#1 in males), medications (anticholinergics, decongestants, opioids), urethral stricture, constipation, neurogenic bladder, post-surgical
Treatment: Foley catheter insertion (12-16 Fr, lubricate well)
- If urethral resistance → try Coudé tip catheter
- If still unable → urology consult for suprapubic catheter
Decompress slowly if >1000mL retained (clamp after 500-1000mL, release q10-15min — debated but prevents hematuria from rapid decompression)
Monitor for post-obstructive diuresis (UOP >200mL/hr) → replace ½ of UOP with NS
Start tamsulosin 0.4mg daily if BPH-related, trial of void in 1-3 days

Renal colic (ureteral stone):

Severe colicky flank pain radiating to groin, hematuria, nausea
CT abdomen/pelvis without contrast — gold standard (reveals stone size, location, hydronephrosis)
Pain management: ketorolac 30mg IV (first-line) + acetaminophen + opioid if refractory
Medical expulsive therapy for stones <10mm: tamsulosin 0.4mg daily
Urgent urology consult if:
- Stone >10mm (unlikely to pass spontaneously)
- Obstructing stone with infection (pyonephrosis) — medical emergency → emergent decompression (nephrostomy or ureteral stent) + antibiotics
- Bilateral obstruction or obstruction in solitary kidney
- Intractable pain/vomiting
- AKI
Strain urine for stone analysis → guides prevention (calcium oxalate vs uric acid vs struvite vs cystine)

END OF SECTION 1: CLINICAL MEDICINE — DIAGNOSIS & TREATMENT

Notes for JSONL Conversion:

Each Q&A pair = one training example
System prompt should include: “You are a hospital AI assistant trained to provide evidence-based clinical guidance for healthcare providers.”
Role: user = clinical question, assistant = structured clinical answer
Consider adding follow-up turns for complex scenarios (e.g., “Labs come back showing X, now what?”)
Flag all entries with specialty tags for filtering during training
Review all dosing and protocols against current clinical guidelines before deployment

Generated for anhdeptrai LLM Training Project Total Q&A pairs in this section: 35 Covers: 18 clinical medicine subspecialties Last updated: February 2026

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