Today, we’re hitting the wards and tackling some of the scary clinical scenarios you will see as an intern.

Hosts: Shanaz Hossain, Nina Clark

Tips for new interns:
THINGS TO REMEMBER
·       BREATHE. In most cases, you have a little bit of time – at least enough to take a breath and calm down outside the room before heading into an emergency. Panic doesn’t help anybody.
·       See the patient. Getting a bunch of pages? Worried about someone? Confused as to what’s going on? Go see the patient and chat with the bedside team.
·       Know your toolbox. There are a ton of people around who can help you in the hospital, and knowing the basic labs/imaging studies and when to use them can help you to triage even the sickest patients.
·       Load the boat. You’ve heard this one from us all week! Loop senior level residents in early.

HYPOTENSION
·       Differential: measurement error, patient’s baseline, and don’t miss – SHOCK.
           – Etiologies of shock: hemorrhagic, hypovolemic,
·       On the phone: full set of vitals, accurate I/Os,
·       On the way: recent notes, PMH/PSH including from this hospital stay, and vitals/I&Os/studies from earlier in the day
·       In the room: ABCDs – rapidly gives you a sense of how high acuity the patient is
·       Get more info: labs, consider imaging, work up specific types of shock based on clinical concern.
·       Initial management: depends on etiology of hypotension; don’t forget to consider peripheral or central access, foley catheterization for close monitoring of urine output, and level of care

 HYPOXEMIA
·       Differential: atelectasis, baseline pulmonary disease, pneumonia, PE, hemo/pneumothorax, volume overload
·       On the phone: full set of vitals, amount of supplemental oxygen required and delivery device, rate of escalation in oxygen requirement
·       On the way: review PMH/PSH, known injuries (known hemothorax/pneumothorax? Rib fractures? Chest tubes in already?), risk factors for DVT/PE, review I/Os for evidence of volume status, vitals and labs for evidence of infection
·       In the room: ABCDs, pulmonary and cardiac exam, volume status exam
·       Get more info: basic labs, ABG if worried about oxygenation, CXR, consider bedside US of the lungs/heart, if high suspicion for PE consider CTA chest
·       Initial Management: supplemental O2, higher level of care, consider intubation or other supplemental oxygenation adjuncts, additional management dependent on suspected etiology
·       ABG Vs VBG (IBCC): https://emcrit.org/ibcc/vbg/ 

ALTERED MENTAL STATUS
·       Differential: stroke, medication effect, hypoxemia or hypercarbia, toxic or medication effect, endocrine/metabolic, stroke or MI, psychiatric illness, or infections, delirium
·       On the way: review PMH/PSH, recent notes for evidence of altered mentation or agitation, or signs hinting at above etiologies
·       In the room: ABCDs, focal neuro deficits?, alert/oriented? Be sure the patient’s mental status is adequate for airway protection!
·       Get more info: basic labs, blood gas/lactate, CT head noncontrast if concerned for stroke.
·       Initial management: rule out above; if concerned about delirium, optimize sleep/wake cycles, pain control, and lines/drains/tubes. 

OLIGURIA
·       Differential: prerenal due to hypovolemia or low effective circulating volume, intrinsic renal disease, post-renal obstruction
·       On the phone: clarify functional foley or bladder scan results, full set of vitals
·       On the way: review PMH/PSH, known injuries (known hemothorax/pneumothorax? Rib fractures? Chest tubes in already?), risk factors for DVT/PE, review I/Os for evidence of volume status, vitals and labs for evidence of infection
·       In the room: ABCDs, confirm functioning foley catheter
·       Get more info: basic labs, urine electrolytes, consider fluid challenge to evaluate responsiveness, consider adjuncts including renal US
·       Initial management: typically consider IVF bolus initially, but if patient not volume responsive, don’t overload them — look for other etiologies! 

TACHYCARDIA
·       Differential: sinus tachycardia (pain, hypovolemia, agitation, infection), cardiac arrhythmia, MI, PE
·       On the phone: full set of vitals, acuity of change in heart rate, updated I/Os
·       On the way: Review PMH/PSH, known cardiac history, cardiac and PE risk factors, volume resuscitation, signs concerning for infection, updated I/Os
·       In the room: ABCDs, cardiac/pulmonary exam, evaluate for any localizing signs for infection
·       Get more info: basic labs, EKG, consider CXR, troponins
·       Initial management: depends heavily on etiology

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