BUMC Basics.pdf - Anesthesia Home

BUMC BASICS

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TABLE OF CONTENTS 

Welcome and General Information 5 

Authors: Jenny Duewall, MD and Sara Lindsey, MD 

• BUMC Basics 

• Intern Cross Cover Cheat Sheet 

• Contact List 

• Obtaining a Consult at Baylor 

• Dictation Guide for Discharge/Death Summaries 

• Sample Orders/Order Sets 

• Prn’s/Prophylaxis Meds 

• Social Work vs. Care Coordinators 

• DISPO 

CLINICAL SECTIONS 

Cardiology 29 

Authors: Adam Falcone, MD and Alexi Mantas, MD 

• CCU in General 

• Acute Coronary Syndrome 

• Atrial fibrillation 

• Calcium Channel Blockers 

• Chest Pain 

• EKG 

• Heart Failure 

• Hypertensive Crisis 

• Pulmonary Edema 

• Syncope 

• Tachycardia 

Gastroenterology/Hepatology 47 

Authors: Tom Van Dinter, MD and Alexi Mantas, MD 

• GI Consults and Groups 

• General GI/Liver Topics 

• General Gastroenterology 

• General Hepatology 

• GI Studies 

Infectious Diseases 58 

Author: Jenny Duewall, MD 

• Bugs and Drugs 

• Fever in the ICU 

• Fever of Unknown Origin 

• Pneumonia 

• Sepsis 

• Tests to Consider Ordering 

Neurology 66 


• Altered Mental Status 

• Brain death exam 

• Neuromuscular Emergencies 

• Seizures

• Status Epilepticus 

• Stroke management 

Oncology 73 

Author: Troy Neal, MD 

• The Acute Leukemic 

Palliative Care and Clinical Ethics 77 

Author: Troy Neal, MD 

Pressor Chart 82 

Author: Natalie Norman, MD 

Pulmonary 83 

Authors: Jenny Duewall, MD and Alexi Mantas, MD 

• ARDS 

• Asthma/COPD 

• Mechanical Ventilation 

• Pleural effusion 

• Pulmonary embolus 

Radiology 97 

Author: Sara Lindsey, MD 

• Radiology Hints 

Renal 101 


• Acid/Base Disturbances 

• Acute Kidney Injury 

• Basic Electrolyte Repletion 

• Chronic Kidney Disease 

• Hyponatremia 

• Oliguia 

• Renal Replacement Therapy 

OUTPATIENT CLINIC GUIDE 112 

Authors: Sophie Esmail, MD and Ryan Jones, MD 

• $4 Walmart Rx list 

OTHER INFORMATION 120 

• Top Ten Intern Tips 

• Duewall’s Mnemonics (Author: Jenny Duewall, MD) 

• Sustenance/Comfort Food (Author: Sara Lindsey, MD) 

• Map 

3

Special thanks to the following Attendings who dedicated their 

time to edit each section in his or her respective specialties: 

4 

Manish Assar, MD (cardiology/EP) 

Robert Black, MD (pulmonary) 

Erin Bowman, MD (radiology) 

Micheal Emmett, MD (renal) 

Robert Fine, MD (palliative care) 

Dion Graybeal, MD (neurology) 

Chris Haden, MD (pulmonology) 

Houston Holmes, III, MD (oncology) 

Louis Sloan, MD (ID) 

William Sutker, MD (ID) 

Ravi Vallabahn, MD (cardiology) 

Special thanks to Kim Miller, editorial assistant, UpToDate, Inc. 

EDITOR: Jenny Duewall, MD 

CONTRIBUTING AUTHORS: 

Jenny Duewall, MD, Internal Medicine Resident, BUMC Dallas 

Sophie Esmail, MD, Internal Medicine Resident, BUMC Dallas 

Adam Falcone, MD, Internal Medicine Resident, BUMC Dallas 

Ryan Jones, MD, Internal Medicine Resident, BUMC Dallas 

Sara Lindsey, MD, Radiology Resident, BUMC Dallas 

Alexi Mantas, MD, Internal Medicine Resident, BUMC Dallas 

Troy Neal, MD, Internal Medicine Resident, BUMC Dallas 

Natalie Norman, MD, Internal Medicine Resident, BUMC Dallas 

Tom Van Dinter, MD, Gastroenterology Fellow, BUMC Dallas

5 

Welcome to Baylor University Medical 

Center (BUMC) 

Welcome to BUMC! This book has been assembled by Baylor 

residents to make the transition from being a medical student 

to an intern as smooth as possible. Although this book has 

several helpful hints and is a good reference, please remember 

to use your clinical judgment and practice evidence based 

medicine using the multiple references and resources you 

have available to you. 

We look forward to working with you and we know it will be a 

great year! 

Sincerely, 

The BUMC Internal Medicine Residents, 2008-2009

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GENERAL INFORMATION 

BUMC BASICS 

Scheduled rounds: 

• Attending rounds: Usually 5 times per week, schedule 

determined usually at the beginning of the month 

• Morning Report: For R2’s and R3’s, every M,W,F from 

7-8 a.m. 

Conferences: 

• Noon conference daily: Roberts Medical Education 

Classroom 

• Grand Rounds: Tuesday at 8 a.m. in Beasley Auditorium 

• Chief’s Conference: Every Friday at noon in the Truett 

Conference Room 8ABC (get lunch from the Truett 

Cafeteria or Doctor’s lounge and charge it to the room); 

during interview season, chief’s conference is on 

Thursdays (interview day) on 17 Roberts and buffet is 

served 

• Potpourri: During Chief’s conference once monthly: 

Cases presented by interns and residents 

• Intern/Resident Evaluations/Med Student: Last Friday of 

each ward month. Residents and Attendings meet at 7:00 

and interns meet at 7:30. It is in a conference room 

outside of the Truett cafeteria. Get breakfast and charge it 

to the room. 

Call schedule: 

• On general medicine wards: Call every fifth night. 

• On CCU, call every fourth night. 

• On electives, no call and no weekends except for select 

electives when you may work on Saturday (ie ID). 

• On ER, no clinic and no call. You work 12-hour shifts, 

7 a.m. to 7 p.m. or 7 p.m. to 7 a.m. in the following format: 

3 day shifts, 3 night shifts, 3 days off. 

• Float month: No call and no weekends. The Float 

resident also usually does not work on holidays, so be 

considerate and try not to ask them to cover you on those 

days.

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Rounding on your patients: 

• See ICU patients first, then floor patients. 

• Update your attending as they request; if not specified 

otherwise, update them daily. 

• See patients you plan on discharging as early as 

possible and notify attending of possible discharge so they 

can plan on seeing the patient and evaluate readiness for 

discharge. 

The following need to be done to complete a 

discharge: 

• Medical Reconciliation Form updated and signed 

• Prescriptions filled out and signed 

• You can obtain a 2 week supply (no refills) of 

medications for your indigent patients if needed. Fill out 

the Rx form for a 2 week supply and write social work 

across the top and place with discharge information. 

• Discharge instructions with follow-up appointments 

(separate form) 

• Transfer orders are needed if going to a SNF or long 

term care facility 

• BIR/BSH have special packets that need to be done 

• Write discharge order (to home, SNF, BSH, BIR, etc) 

• Dictate patient and keep track of job # (write in the chart 

if dictated at time of discharge; keep track separately if 

dictated later) 

Cross cover and check-out: 

• Cross Cover starts after 5 p.m. on weekdays and at 

noon on weekends 

• Check out on-line: please write down user name and 

password at orientation 

• Call the cross cover intern and check out any seriously 

ill patients 

• Try to anticipate what may happen to your patient and 

instruct cross cover on how you would like that managed. 

Codes: 

• While on wards you are on the code team two days prior 

to your call day. Wear scrubs when you are on codes, oncall, 

and post-call

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• M-F, Code team runs codes starting at 7 a.m. until your 

resident lets you know you are off codes, at which time the 

on-call team takes over codes. On Saturday, the on-call 

team takes codes from 8 a.m. until 8 a.m. Sunday. 

Sunday, the on-call team takes codes from 8 am Sunday 

to 7 a.m. Monday. 

• The supervising resident runs the code. Medical 

students often do chest compressions. Interns will 

intubate if needed, run lines, and review the chart and 

other responsibilities as needed. 

• Simultaneous codes or codes within 30 minutes of one 

another: Response to the first code is by the code team. 

The on-call ward team should go to the second code. If 

there is a third code, one intern from each code team and 

on-call team should go to that code. If the code team is 

gone and the on-call team is called to a code, a second 

code within 30 minutes will be run by the CCU 

intern/resident on call. 

Procedures: 

• The ABIM requires that graduates be proficient in the 

procedures listed below. There is no specified number, but 

a minimum of 3-5 directly supervised procedures is 

considered appropriate. 

1. Paracentesis 

2. Arterial puncture 

3. Arthrocentesis 

4. Central line placement 

5. Lumbar puncture 

6. NG tube 

7. Pap smear and endocervical culture 

8. Thoracentesis 

• All other procedures are not required, but residents often 

have the opportunity to do intubation, punch biopsies, 

bone marrow biopsies. 

• Each time you perform a procedure, take a sticker so 

you can record it in new innovations (www.newinnov.com) 

in your procedure log. 

• You will be supervised by a resident until the resident 

feels you are proficient, and then you can perform 

procedures unsupervised. As a general rule, you are 

supervised for the first 6 months of internship. 

• Hints for procedures: 

1. Use aseptic technique (cap, mask, gown, gloves, 

large sterile drape) for central lines and arterial 

lines. Other procedures can be done with sterile

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2. gloves only. During codes, if emergent central 

access is needed, lines are typically placed with 

gloves only. These emergent lines should be 

replaced using aseptic technique as soon as 

possible. 

3. DO A TIME OUT AND FILL OUT TIME OUT 

FORMS 

4. Write a procedure note when you are done. 

5. Bone Marrow Biopsy: Call hematology lab and 

ask for bone marrow technician about 15 minutes 

prior to your planned starting time. 

6. IJ and Subclavian TLC: Order a stat pCXR and 

review it when it returns to ensure placement and 

rule out a pneumothorax 

7. Arterial line: Check a-line wave form after a-line 

placement 

New Innovations (www.new-innov.com): 

• On-line system for logging hours, procedures, 

evaluations, and reviewing curriculum. 

• Hours need to be logged and approved by the last day 

of the month. 

• If you log more than 80 hours a week or violate any work 

rules, this will appear in red and you need to change it to 

meet rules. 

• Curriculum needs to be reviewed prior to each rotation. 

The curriculum assigned to you for you to review will 

appear on your front log-in page. 

• When you log in at the end of the month, the front log-on 

page will have who you will be giving patients to or picking 

patients up from if you are coming on and going off 

general medicine wards. 

• Evaluations of your intern/resident/attending will be 

assigned to you at the end of the month and you will 

receive an e-mail reminder to sign-on and evaluate the 

other members of your team. 

Electives: The following electives are required. You need 3 

out of 4 or 4 out of 5 weeks of these (ie, no 2 weeks of 

vacation in a 4 week block): 

• Cardiology: If you are interested in a primarily 

outpatient experience, consider Drs. Thomas Andrews, 

Stephen Johnston, Charles Gottlich, or Karen Klatte. If you 

are interested in inpatient experience, consider Drs. 

Jeffrey Schussler, Rafic Berbarie, Ravi Vallabhan, Robert 

Stoller, James Choi, Jerold Grodin, or Carlos Velasco.

10 

• Dermatology: The office of Drs. Alan Menter and Dan 

McCoy, or the office of Dr. Farhad Niroomand. 

• Endocrinology: The office of Drs. Zaven Chakmakjian, 

Howard Heller, Brian Welch, Raphaelle Vallera, and Neil 

Breslau, or for diabetes intensive rotation, Dr. Priscilla 

Hollander. 

• Gastroenterology: For primarily outpatient experience, 

Drs. Angela Carollo, Catherine Yaussy, Christopher Vesy, 

Lawrence Schiller, or Charles Richardon. For more 

inpatient experience, Drs. Robert Anderson, Daniel 

DeMarco, Esmail Elwazir. 

• Geriatrics: (only need a minimum of 2 weeks) 

• Hematology: Drs. Barry Cooper, Houston Holmes, and 

Christopher Maisel 

• ID: Drs. Mezegbe Behre, Louis Sloan and Cedrik Spak. 

For outpatient/HIV experience, consider Dr. Mark Tribble. 

On ID, you work on Saturdays. 

• Nephrology: Drs. Fenves, Wiederkehr, Hayes, Tran, or 

Hebert. 

• Neurology: Coordinated by Dr. Dion Graybeal. 

• Oncology: Drs. Claude Denham, Thomas Hutson 

(primarily GU), David McCullum (primarily GI), Robert 

Mennel, Eric Nadler, John Pippin (primarily breast 

malignancy) 

• Pulmonary/Critical Care: For outpatient experience, 

Drs. Millard or Luterman. For inpatient, Drs. Black, 

Haden/Woolley, or Ausloos. You can also do one week 

with Black, one with Haden/Woolley, one with Millard, etc. 

and customize your experience. 

• Rheumatology: Coordinated through Alex Limanni. 

• Outpatient: Drs. Dean Dimmitt, William Chritensen, 

Aggarwal, Armstrong, Neubach, Sibley. 

**The remainder of your electives (2) are your choice. 

CCU: 

• Call every fourth night. 

• Each team member is on call by themselves. 

• All patients admitted by the intern are then picked up by 

the supervising resident in the morning and they will see 

the patients behind you. 

• All patients admitted by the resident are distributed to 

the interns the next day (the resident does not carry their 

own patients, but covers the entire service behind the 

interns).

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• There is one resident and 3 interns until the Spring, 

when the team becomes 4 interns. 

• Teaching rounds are with a separate CCU attending and 

are often daily M-F based on the attending’s preference. 

Clinic: 

• ½ Day per week on your assigned day 

• No clinic during ER month 

• No clinic when you are post-call 

• If clinic patients are admitted to the hospital, they will be 

admitted by teaching, and stay on that team unless the 

primary clinic intern/resident is on wards, and then they 

will transfer to that service in the am. 

• See Clinic guide section. 

Vacation: 

• 3 weeks total per year. Can be taken as 2 weeks and 1 

week or 1 week at a time. 

• Cannot be taken during ward, CCU, or float months 

(thus you can use it during electives or ER) 

• Turn in a form ahead of time (6 weeks if possible). Pick 

up a request from Suzanne. She will fax it to the clinic so 

they block out your clinic schedule for that time. See 

vacation policy/request. 

• Maternity leave is 6 weeks. You can combine it with your 

vacation for that year for a total of 9 weeks. The caveat is 

that you cannot exceed 12 weeks total off during your 

residency per the ABIM. 

• Paternity leave is 2 weeks. 

• Vacation does not roll over from year to year. What you 

don’t take is lost.

12 

INTERN CROSS-COVER CHEAT SHEET 

The following are general suggestions. Indicated medications 

are recommended but this sheet does not replace the need to 

refer to your own prescribing reference (Epocrates, etc). Not all 

medications or suggestions are useful for all patients. Please 

use your own clinical judgment. 

Patients that you should definitely go see are indicated with 

a *. Again, please use your clinical judgment when evaluating 

whether or not to see a patient. When in doubt, just go lay eyes 

on them. 

Altered Mental Status 

MOVE STUPID 

• Metabolic (hypothyroid, hepatic encephalopathy) 

• Oxygen (Hypoxia from PNA, pulm edema, etc) 

• Vascular (TIA, CVA, Subdural hematoma) 

• Electrolytes (Specifically Na, Ca) 

• Seizure 

• Trauma 

• Uremia 

• Porphyria 

• Infection (sepsis/meningitis) 

• Drugs 

Things to do 

• Chart to see hospital course 

• History to narrow differential 

• Physical, esp. neuro exam and vital signs 

• If fever, do BCx, UCx, CXR 

• Pulse ox with ABG for hypoxia. If CXR shows edema, 

give IV Lasix. 

• IVF if hypotensive 

• CT head to r/o bleed or CVA 

• Electrolytes & CBC 

• LP if you suspect meningitis 

• Lactulose therapy if hepatic encephalopathy: Lactulose 

30 g packet PO Q8 hours; titrate to 3-4 BM’s per day 

• Start ABX if patient appears ill 

• Stabilize seizure with drug therapy (Valium, dilantin, 

etc.)

Chest pain 

13 

DDx to consider 

• MI 

• Angina 

• PE 

• Pericarditis 

• Musculoskeletal 

• Pneumonia 

• PTX 

• Anxiety (very common) 

• Aortic Dissection 

• Pleurisy 

• Boerhave’s syndrome (ruptured esophagus) 

Things to do 

• Obtain history to try to elucidate etiology of CP 

• Focused Physical 

• Evaluate chart to see past history (CAD, etc.) 

• EKG after you take history. This will help limit the DDx 

above. 

• Cardiac enzymes if cardiac cause is considered. 

• CXR to look for pneumonia and aortic aneurysm 

• ABG for PE and pneumonia 

• Pain meds if musculoskeletal 

• Mild anxiolytic if anxiety 

• 100% O2 by facemask if small PTX, Chest tube if large 

PTX (>15%) 

If it’s angina, do following: 

• EKG first! Make sure it’s not a STEMI. Trend out 

CKMB/Troponins. 

• Check BP and then give NTG q 5 min until CP relieved. 

Make sure nurse checks BP in between each Nitro to 

avoid hypotension 

• If pt requires more than 3 nitro, give IV morphine 2 mg-4 

mg for pain relief. If you are unsuccessful after 20-30 min, 

pt will need IV NTG in ICU. Think MONA BASH for 

UA/NSTEMI/STEMI: Morphine/Oxygen/Nitro/Aspirin/B- 

Blocker/ACE Inhibitor/Statin/Heparin

Fever 

14 

DDx to consider 

• Infection (pneumonia, UTI, etc.) 

• PE 

• Drug fever 

• DVT 

• Fungal infection 

Things to do 

• Take history to try to find source (cough, dysuria, etc.) 

• Look through chart to see what has been done (previous 

blood cultures, etc.) 

• Perform focused physical exam, esp. vital signs 

• Do CXR, Blood cultures, Urine culture, sputum culture (if 

indicated) 

• Start abx only if patient looks ill with broad spectrum 

• Refer to cross cover sheet or progress notes for 

preference of what to advance antibiotics to if already on 

abx (esp neutropenic fever) 

Hypotension 

DDx 

• Sepsis 

• Cardiogenic shock 

• Adrenal insufficiency 

• Hemorrhagic shock 

• Volume depletion (overdiuresed) 

• Medication 

Things to do: 

• Try fluid bolus of 1 L NS (less if CHF/3 rd spacing) 

• Assess cause 

• If septic: volume resuscitate; check cultures; broad abx; 

start pressors (levophed) if needed to keep MAP>65 

• If Cardiogenic shock: Assess why. Start dopamine or 

dobutamine if needed 

• If concern for adrenal insufficiency, start stress dose 

steroids: Solumedrol 50 mg IV Q6 is a good start 

• If hemorrhagic shock: Volume resuscitate with NS and 

Blood. Check Hemostasis profile and give platelets/FFP 

as needed. If in DIC, give cryo. Determine source of 

bleeding and then stat consult for 

GI/Surgery/Neurosurgery/etc. 

• Hold BP meds, diuretics or reduce if needed

SOB 

DDx 

• Pneumonia 

• PE 

• Anxiety 

• Pulm edema 

• MI 

• PTX 

15 

Check CXR/ABG; O2 protocol; A/A nebs if bronchospasm, IV 

Lasix if volume overloaded 

Work-up and treat as indicated. 

Quick reference guide to targeted therapies 

to answer calls: 

1. Agitation: Ativan 2 mg IV x one, Haldol 2-4 mg IV/IM 

Q6hours prn, or seroquel 12.5-25 mg PO/NG q8hours prn 

agitation 

2. Anxiety: Ativan 2 mg IV x one 

3. Atrial fibrillation with RVR: Assess patient. If necessary, 

start on diltiazem gtt for rate control. Primary team can 

determine need for anticoagulation in the a.m. 

4. Bradycardia: Evaluate the patient and why they are 

bradycardic. If no symptoms, rarely need to treat. If 

symptoms, try atropine 0.4 mg IVP as needed x 3 doses. 

5. Constipation: Colace 100 mg PO Q12, sennakot one tab 

PO BID, Miralax 17g in 4-8 oz water QDay to BID until 

BM, MOM 30 ml PO Qday or Dulcolax 10 mg PR 

suppository Qday; If severe can try Fleet enema if 

needed-usually avoid enemas in neutropenic patients 

6. Cough: Tessalon perles 100 mg 3 times/day or every 4 

hours up to 600 mg/day, Guaifenesin 200-400 mg PO Q4 

hours to maximum of 2.3 g/day 

7. Diarrhea: First assess cause; If infectious causes are a 

concern, do not treat with anti-motility drugs. Do stool 

studies and treat underlying condition. Otherwise, can give 

Immodium 4 mg, followed by 2 mg after each loose stool, 

up to 16 mg/day; if ICU patient, and non-infectious, can try 

adding Banana Flakes to Tube Feeds as a bulking agent 

8. Electrolyte disturbances (low): See Electrolyte repletion 

9. Fever: Tylenol 325-650 mg PO Q4 hours; Abx if needed 

10. Gas: Mylicon

16 

11. Heart Burn: AOC. Maalox 320 mg PO Q6 hoursor TUMS 

1000 mg PO Q6 hours and/or Pepcid 20 mg PO BID or 

Protonix 40 mg PO Qday 

12. Hyperkalemia: Check EKG; if peaked T waves or 

prolonged QRS, give 1-2 amps Ca gluconate IV; then 

consider one or more of the following: 10 Units IV insulin 

with 1-2 amps D50, 1-2 amps HCO3; 10-20 mg inhaled 

albuterol, 40 mg IV Lasix, or hemodialysis if decreased 

GFR. If K is trending up and acute tx is not needed, give 

kayexalate 30-90 g PO 

13. Hypertension: Clonidine 0.1-0.2 mg PO or SL followed by 

0.1 mg Q1hour up to a max dose of 0.6 mg; can also try 

increasing the oral medication they are on or giving an 

extra dose. If IV needed, try labetalol 5 mg IVP every 5 

minutes if HR ok with max dose of 20 mg or Hydralazine 5 

mg IVP every 15 minutes, max dose 20 mg 

14. Insomnia: Ambien 5-10 mg PO Qhs 

15. Nausea/Vomiting: Phenergan 12.5-25 mg IV Q4 hours or 

Zofran 4-8 mg IV Q8 hours 

16. Nasal congestion: Ocean spray nasal one spray in each 

nostril Q8 hours, Oxymetazoline 0.05% 2 sprays in each 

nostril Q12 hours 

17. Pain: Norco 5/325 one to two tabs PO Q6 hours PRN pain 

or Morphine 1-2 mg IV Q4 hours; Careful when Rx 

Dilaudid. 1.5 mg Dilaudid is equal to 10 mg of IV 

Morphine. We tend to under dose morphine and overdose 

dilaudid. If adding narcotics, add a bowel regimen. If pain 

persists, can also try 25-50 micrograms Fentanyl every 5- 

10 minutes prn not to exceed 100 mcg. 

18. Positive Blood Culture: If not on antibiotics, start the 

following: 

Gram positive: Vanc 1 gram IV, then Rx to dose 

Gram negative: Zosyn or Merrem 

19. Pruritis: Benadryl 25 mg PO Q4 hours 

Drips that can be used on the floor 

(telemetry) as of 4/2009: 

• Diltiazem 

• Amiodarone 

• Dobutamine 

• Dopamine 

• Flolan (Epoprostenol) 

• Aggrastat (Tirofiban) 

• Integrillin (Eptifibatide) 

• Reopro (Abciximab)

17 

• Heparin 

• Lidocaine 

• Nitroglycerin for chest pain 

• Milrinone 

• Procainamide 

• Nicardipine

TPC 

972-545-4872 

Abrar Ahmad 972-451- 

3454 

Ali Bagheri 972-356- 

2754 

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2756 

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2702 

Stephanie Houck 972-356- 

2777 

Shalita Jones 972-451- 

0648 

Susan Kohl 972-356- 

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Aysha Kunju 972-451- 

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0291 

Brad Lembcke 972-356- 

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Carolyn Quan 972-356- 

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Suman Reddy 972-451- 

6192 

18 

CONTACT LIST 

Pager Cell Phone 

214-557- 

5568 

972-380- 

4994 

469-878- 

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713-530- 

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Med 

Provider 

214-820- 

3000 

After hours 

214-346- 

1494 

Cell 

Phone 

Robert Beard 214-912- 

6178 

Steven Bray 214-263- 

2016 

Laura De 469-939- 

Moya 5330 

Sharmila 214-282- 

Dias 6601 

Grady 214-564- 

Goodwin 2510 

Tara 214-418- 

Goodwin 4384 

Amy Haller 817-879- 

8131 

Emily Hebert 972-322- 

1997 

Nichole 469-688- 

Johnson 3797 

Anita Khetan 214-244- 

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Khetan 1413 

Roger 214-213- 

Khetan 3544 

Lisa Luke 214-912- 

7852 

Andrew 469-878- 

Masica 2715 

Catherine 972-352- 

Raver 1722

19 

TPC 

(cont’d) 

Pager Cell Phone Cardiologists (cont’d) 

Samir Sahai 

Brett Stauffer 

Bach Tran 

972-356- 

7218 

972-356- 

2706 

972-356- 

2703 

214-448- 

7264 

214-282- 

6220 

214-735- 

0039 

Heart Place 

(cont’d) 

Assar (EP) 

Berbarie 

Pager 

214-595- 

0131 

214-595- 

0118 

Sue Williams 972-356- 214-906- Donsky, M 214-595- 

0292 2578 

0105 

Radha Yalamachili 972-356- 214-929- Gottlich 214-595- 

2704 0653 

1607 

Cardiologists 

Hall 214-595- 

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CCT 

214-824-8721 

Pager 

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North TX 

0945 

Card 

214-826- 

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Heart Place 

214-842-2000 

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Velasco 972-602- 

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6313

20 

Cardiothoracic 

Surgeons 

Office Pager Gastroenterologists 

Cheung 214-821- 

3603 

214-897- 

0014 

DHAT 

(cont’d) 

Office 

Hammon 214-841- 214-595- John 214-821- 

2000 0108 Hamilton* 5266 

Hebeler 214-821- 214-897- D. Mallat** 214-821- 

3603 9342 

5266 

Henry 214-821- 214-897- Yaussy 214-821- 

3603 9343 

5266 

Hoang 214-942- 214-595- Wash Ave Grp 

8300 0109 

Kourlis 214-821- 214-822- Angela 214-545- 

3603 7867 Carollo 3390 

Matter 214-841- 214-595- Dan 

214-545- 

2000 0107 Demarco 3390 

Wood 214-827- 214-920- Katherine 214-545- 

3890 3030 Little 3390 

Colorectal 

Surgeons 

Office 

Daniel Polter 214-545- 

3390 

Franko, Edward 214-824- 

Schiller 214-545- 

1730 

3390 

Jacobson 214-824- 

Anderson** 214-821- 

1730 

5266 

Lichliter 214-824- 

1730 

Liver Consultants of TX 

Rodriguez-Ruesga 214-824- 

Linsheng 214-820- 

1730 

Guo 

8500 

Tulanon 214-824- 

Lepe- 214-820- 

1730 

Suastegui 8500 

Dermatologists Office 

Jacqueline 

O’Leary 

214-820- 

8500 

McCoy 972-386- 

Texas Digestive Disease 

7546 

Consultants 

Mentor 972-386- 

Esmail 214-818- 

7546 

Elwazir* 0948 

Endocrinologists Office 

Greg 

Hodges* 

214-818- 

0948 

Welch 214-823- 

Bhavani 214-818- 

6435 

Moparty** 0948 

Hollander 214-820- 

Charles 214-818- 

3466 

Richardon 0948 

Gastroenterologists 

C. Vesy 214-818- 

*does ERCP 

**ERCP and EUS 

0948 

DHAT Office 

Texas Digestive Health 

Consultants 

Landry Center Group James 

Burdick 

214-820- 

8899 

Blair Connor* 214-821- 

5266

21 

Gen Surgery Neurologists 

Urgent Surgical 

Associates 

Office 

Texas Neurology 

214-827-3610 

ASV 214-346-1317 

El-Feky 

Matthew Lovitt 214-821- 

1599 

Laura Petry 214-821- 

1599 

Greenfield 

Surgical Institute Office Heitzman 

Howard Derrick 214-826- 

6276 

Herzog 

Zelig Lieberman 214-826- 

6276 

Jenevein 

John Preskitt 214-826- 

6276 

Martin 

Jill Stephenson 214-826- 

6276 

Phillips 

Chad Tate 214-826- 

6276 

Shamim 

Health TX 

Provider Network 

Office 

Tunnell 

G. McKenna 214-820- 

Addt’l Office 

2050 

Neurologists 

Henry Randall 214-820- 

Romero 214-827- 

2050 

5525 

ID Office 

Graybeal 214-820- 

4561 

Behre 214-823- 

2533 

Psychiatrists Office 

Columbus 214-823- 

John 214-824- 

2533 

Brennan 2273 

Sloan 214-823- 

Robert 214-522- 

2533 

Moore 1960 

Spak 214-823- 

Antonio 214-363- 

2533 

Roman 2953 

Sutker 214-823- 

Vladislav 214-824- 

2533 

Yeganov 9100 

Neurosurgeons Office 

Pulmonologists (Critical Care 

designated with *) 

Bidiwala 214-823- 

2052 

TX Lung Center (214-824-8521) 

Doughty 214-820- 

8585 

Office Pager 

Finn 214-823- *Ausloos 214-246- 214-824- 

2161 

7767 8521 

Gray 214-820- *Black 214-246- 214-824- 

8585 

7765 8521 

Michael 214-823- *Brancaccio 214-246- 214-824- 

2052 

7774 8521 

Naftalis 214-820- *Jordan 214-246- 214-824- 

8585 

7763 8521

22 

Pulmonologists Rheum (214-823-6503) 

TX Lung Center (cont’d) Chubick 

Luterman 214-246- 214-824- Limani 

7770 8521 

Millard 214-246- 214-820- Himanshu 

7775 3500 Patel 

TX Pulm Assoc Pager Cell Phone Petrone 

*Haden 972-356- 214-370- Sackler 

2725 5555 

*Woolley 972-356- 214-673- Tehlirian 

2776 6298 

Addt’l Pulm John Willis 

Baird 214-820- 214-798- 

1000 8154 

Shotwell 214-824- 214-886- Texas Oncology 

4412 1119 

214-370-1000 

Renal Mobile 

Hebert 214-587- 

7290 

Dallas Nephrology Associates 

214-820-2350 

Urologists Office 

Barri Josh Fine 214-826- 

6235 

Carino Myron Fine 214-826- 

6235 

Chandrakantan Steven Frost 214-826- 

6021 

Fazal Goldstein 214-826- 

6021 

Fenves Schnitzer 214-824- 

0171 

Fischbach Schoenvogel 214-827- 

1602 

Gieser Shuford 214-826- 

6021 

Hays 214-497- 

Eric Smith 214-826- 

3755 

6235 

McDonald 

Larry Melton 

Webster 214-826- 

6021 

Arthi Rajagopal 

Palliative Care (214- 

820-7227) 

Kim Rice Minn 214-497- 

2612 

Joris Schuller Pain mgt 214-512- 

John Schwartz 

nurse 1106 

Long Tran Addt’l IM staff 

Wiederkehr Ricardo 214-557- 

Murillo 5410

23 

OBTAINING A CONSULT AT BAYLOR 

Obtaining a consult at BUMC is different than at a county 

system. Rather than consulting a service, you consult a 

specific physician within a service, or whoever is taking call for 

that physician if it is after hours. Call consults as early in the 

day as possible. If you call a consult after 5pm, this implies that 

it is emergent. 

If you need a consult, first ensure the attending physician 

agrees and ask if they have anyone specifically they would like 

you to call. Also, review old records and if a physician has 

seen the patient previously from a service, re-consult the same 

physician or group if that person is not available. Then, refer to 

the above list for whom you would like to consult (May not be 

all inclusive, but is a start for who to call). When you call, be 

sure to have the patient’s name, room number, date of birth, 

and pertinent history, exam, and labs. 

There are a few ways to consult. The best is to call the 

physician’s office or answering service and ask who is taking 

new consults for that day/night. Then ask them to be paged 

with the information. You can also call the ER, who has a list 

for who is on call. If you do not hear back, and you feel it is 

appropriate, then page the physician directly. Some physicians 

prefer text messages with name and room number, and they 

will let you know that when you work with them. 

Here are a few specifics regarding particular 

consults: 

• GI: The hepatologists rotate call every 3 rd night listed 

above. Also, if you need an ERCP or EUS, physicians that 

do one or both are noted with an asterisk under the GI 

contacts. GI Bleeders often require an emergent GI 

consult. For more information, see GI section for obtaining 

a consult. 

• Neurology: There is someone on call M-F now for 

neurology. Call page operator to find out who is on call. 

• Psychiatry: To obtain a psych consult, you may either 

write an order for psych consult, or call the ER and ask 

who is on call for Psych and call the office or answering 

service to have them paged. 

• Pulmonary Critical Care: This consult is required if 

your patient is on the ventilator more than 48 hours.

24 

• Rheumatology: The patient typically will need to have 

insurance to be seen. You can always call for advice over 

the telephone. 

• Palliative Care: You can write an order for a palliative 

care consult or call 2-7227 to speak with someone directly 

(always the best option). 

• Pain management: If you need assistance with pain 

management, palliative care is available. 

• Hospice consult: You can write an order for hospice 

consult. The hospice nurse will then evaluate the patient 

and if appropriate, write orders to convert the patient to 

inpatient hospice care and/or begin to work on referrals 

with social work to hospice facilities or home hospice. She 

will write orders and call you to review them with you for 

any orders you may have missed for comfort care. 

• Other: Nutrition/Social Work/Care Coordination/Home 

Health/PT/OT/ST/Pastoral care/Recreational Therapy 

consults can all be written for in the order section of the 

chart. For vanc/gent, there is an automatic pharmacy 

consult. If you need pharmacy to renally dose, you can 

write for the medication and then write pharmacy to dose. 

DICTATION GUIDE 

Dial 26008 in-house; 972-980-8955 outside the hospital 

Problems/?: 6171 

Keypad Commands (same for BUMC/BHVH): 

1-play 7-fast forward 

2-record 8-rewind to beginning 

3-short rewind 9- disconnect/job confirmation 

4-pause (write down the confirmation 

5-next report number) 

6-go to end of job 

For BUMC dictations: 

Site ID: 43310 

Work type: 20 H&P, 25 D/C summary, 30 consult, 98 

outpatient clinic note 

• Enter 11 digit MRN 

• Press 2, begin dictating after the tone 

For BHVH dictations: 

Site ID: 43310 

Work type: 52 H&P, 53 D/C summary, 55 consult, 56 

Radiology

25 

• Enter 2 initial zeros and then 9 digit BHVH account 

number (begins with V) 

• Press 2, begin dictating after the tone 

DISCHARE SUMMARY OUTLINE 

Attending: 

Date of Admission: 

Date of Discharge: Tell what facility they were 

transferred to if applicable. 

Admission Diagnoses: 

Discharge Diagnoses: 

Procedures/Tests: 

Consultants: 

Discharge Medications: 

Follow-up: 

Brief History & Physical: 

Summarize the HPI and admission physical exam; it’s helpful 

to the next provider if you also briefly review the MHx, 

SurgHx, FamHx, Social Hx 

Hospital Course: Most people organize this as a numbered 

problem list. Mention the suspected etiology (CHF from 

medication noncompliance, hypokalemia secondary to 

diuretics, etc.) and explain what work-up, testing and 

treatment was performed for each issue. Mention any studies 

that are pending at the time of discharge. For simple admits 

or for death notes, you can summarize the hospital course in 

paragraph format. 

MEDICAL RECORDS 

Located in the basement of Jonsson. Access WebESA to 

edit/review your dictations & electronically sign your charts 

either in Medical Records or via the EMR (link on the left). 

You have to keep up-to-date with your dictations/charts or you 

lose your $50 monthly meal money and get yourself (and 

possibly your attending) put on the “B list.” It’s painful … 

made better by the giant cookies and snacks waiting for you 

in Medical Records. 

ADMISSION ORDERS 

1. Admit to floor/ICU/telemetry 

2. Attending: Dr. 

3. R1—Dr. xxx—call 1st 

R2/3—Dr. xxx 

4. Service: Medicine teaching/CCU teaching

26 

5. Diagnosis: 

6. Condition: Stable/fair/critical 

7. Vitals: per floor/ICU protocol 

8. Allergy: 

9. Diet: regular/ADA/Heart Healthy/clear liquids/full 

liquids/NPO 

10. Ins/Outs: 

11. Meds: 

12. IVF: 

13. Labs for AM: 

14. Labs for now: 

15. Activity: 

16. Code Status: Full, DNR/DNI 

17. Call HO (house officer) for T>100.4, SBP >170 or 120 or

27 

• Albuterol/Atrovent nebulizer Q6 hours prn 

• Benadryl 25 mg PO Q4 hours prn pruritus 

• Potassium Protocol (cannot use protocol if Cr>1.5, 

wt80) 

• Oxygen Protocol 

PROPHYLAXIS MEDS 

• Pepcid 20 mg po BID OR Protonix 40 mg po qday 

• Lovenox 40 mg SC qday (if renal function okay) OR 

Heparin 5000 units SC TID 

SOCIAL WORK VS CARE COORDINATORS 

Social Work: 

• SNF, LTAC, extended care outside of Baylor, hospice 

(in or outpatient) 

• Ambulance transport 

• Protective Services 

• Family Locating 

• Transportation 

• Crisis Intervention 

• Physical Needs (places to stay, vouchers, parking, etc) 

• PCP referrals 

Care Coordinators: 

• Home Health Care Referrals 

• Dallas Medical Examiner 

• BIR Referrals 

• VA/Parkland Referrals 

• Liason to payer/utilization management 

DISPO 

(ie, where the pt goes when they get off your service) 

• Home 

Can arrange home health care, home PT/OT if 

needed 

• SNF (skilled nursing facility, pronounced “sniff”) 

Must require the skills of a qualified technician or 

professional (RN, PT, OT, ST, etc) 

• LTAC (long term acute care, pronounced “L-tach”) 

Must have 2+ complex needs to qualify 

• Acute Rehab 

Must be medically stable & able to participate in 3 

hours of therapy/day; must require 24 hr nursing 

supervision and physician care which demonstrates

28 

“necessity” for inpatient care; must have viable 

disposition to return to community upon discharge 

• BIR (Baylor Institute for Rehab) 

BUMC long term acute care; write “transfer to BIR 

when bed available” (no separate orders) 

• BSH (Baylor Specialty Hospital) 

BUMC physical rehabilitation hospital; just complete 

the BSH order set prior to transfer 

• NH (nursing home) 

• Hospice (end of life care) 

Must be terminally ill with life expectancy < 6months; 

hospice can be at home, NH, hospital or freestanding 

hospice facility; note: inpatient hospice is for an 

actively dying patient 

The patient’s funding (Medicaire/Medicaid/private) affects their 

options; the social workers and care coordinators can help you 

figure out each patient’s options. “Charity beds” are available 

at BIR and BSH on a case-by-case basis. You can write an 

order for a “BIR [or BSH] consult” and the liaison will review the 

pt’s case.

29 

CARDIOLOGY 

CCU IN GENERAL 

You are typically called for the following patients: 

• Patient in the cath lab having a stent placed 2/2 STEMI: 

You can go to the cath lab and watch the cath, or you may not 

meet them until recovery or when they get to the CCU. These 

patients typically come out with post-cath orders filled out by 

the cardiologist or fellow, but you sometimes also fill these out 

if you are there early in the process. You are then responsible 

for getting the HPI and adding additional orders/meds. 

• Patient transferring from OSH 2/2 MI s/p lytics: These 

patients will need orders as below for ACS, but no GpIIb/IIIa 

inhibitors. You will likely do H&P and initial orders and then talk 

with the cardiologist then or in the A.M. (if the patient comes in 

the night) whether they need to go to cath. 

• Patients in the ER with UA/NSTEMI: See management 

below 

• Decompensated CHF patients with pulmonary edema in 

the ER: Follow CHF order set and treat pulmonary edema as 

below in pulmonary edema section. 

ACUTE CORONARY SYNDROME 

Stable Angina: Chest pain resulting from imbalance of 

oxygen supply and demand to cardiac 

tissue. Usually happens at the same 

frequency, intensity, and duration. Most 

common cause is CAD; other causes include 

aortic valvular disease, HCM, and coronary 

artery spasm. This is due to a stable plaque. 

UA/NSTEMI: New onset of severe angina, angina at rest 

or with minimal activity, or recent increase in 

frequency and or intensity of stable angina. If 

patient has positive cardiac markers 

(necrosis) without ST elevation, then this is 

defined as NSTEMI. This is due to a partially 

occluding thrombus.

30 

STEMI: Complete occlusion of coronary artery by 

thrombus resulting in ST elevation on EKG. 

Progression — Stable plaque-unstable plaque-plaque 

rupture-UA/NSTEMI (partial occlusion)-microemboli-STEMI 

(complete occlusion) 

Orders — For ACS: Think MONA BASH (Morphine, Oxygen, 

Nitroglycerin, Aspirin, B-blocker, Statin, Heparin) 

Meds: 

1. Morphine 2 to 4 mg IV Q4 hours prn chest pain 

2. Oxygen per protocol to keep SpO2>92% 

3. Nitroglycerin 0.4 mg SL Q3-5 minutes x 3 doses prn 

chest pain 

4. ASA 325 mg PO Qday 

5. BBlocker: Can use coreg 3.125 mg to 6.25 mg PO 

BID and increase as needed: write parameters on BP 

meds (hold for SBP

31 

Unstable Angina/NSTEMI 

• Can use history, physical exam, and TIMI risk score to 

stratify. 

• TIMI risk score will help dictate conservative versus invasive 

strategy. 

**Get Cardiology on case soon if not admitted by a 

cardiologist! 

Tests — Chest X ray, EKG, Echo (non emergent) and cardiac 

enzymes (Troponin and CKMB) 

EKG: Will show ST depression, T wave inversion, or 

nonspecific changes. 

Treatment — Revolves around three keys: (1) anti-ischemic 

therapy, (2) antiplatelet therapy, and (3) anticoagulation. 

• Anti-Ischemic Therapy: Nitrates, Beta blockers (don’t 

use if hypotensive, wheezing, bradycardia), Calcium 

channel blockers (nondihydropyridines, if can’t use beta 

blockers), morphine, and oxygen. 

• Antiplatelet Therapy: ASA, Plavix (load with 300 or 

600mg, don’t use if suspect going to CABG), GP IIB/IIIa 

inhibitors (pts with >3 TIMI risk score and positive cardiac 

enzymes) 

• Anticoagulation: UFH (bolus and wt. based titrate for 

aPTT of 50-70). Use bivalirudin if patient has heparin 

induced thrombocytopenia. 

Low Risk: Negative cardiac enzymes, no ST depression, 

TIMI score 3. Use GPIIb/IIIa and will need angiography 

with in 24-48 hours. 

STEMI 

• Immediately call cardiologist on call and activate cath lab. 

• Will have ST elevation in >2 leads with reciprocal changes or 

new onset of LBBB.

32 

EKG Artery Areas of Complications 

Leads 

Damage 

V1-V2 LAD septal Septum, Nodal block and 

branch bundles of his BBB 

V3-V4 LAD diag. Ant. Wall LV LV dysfunc, 

branch 

CHF, BBB, AVB 

V5-V6, + I & Circumflex High lateral LV dysfunc, AVB 

AVL 

wall LV 

II, III, AVF RCA Post. Inf. Wall, post. Hypotension 

Descending Wall LV sensitivity to 

branch 

NTG and 

Morphine 

V4R (II, III, RCA proximal RV, inferior Hypotension, A 

AVF) 

branch and posterior 

wall 

fib/flutter, 

V1-V4 Circumflex or Posterior wall LV dysfunction 

Depression RCA 

• Need emergent fibrinolysis versus PCI. At Baylor, PCI is 

done, so you need to activate cath lab. **TIME IS TISSUE. 

• We have STEMI protocol at BUMC. Door to balloon time 60), free wall rupture (surgery), VSD 

(surgery), papillary muscle rupture (new onset of holosystolic 

murmur, get stat Echo and use diurectics, vasodilators, IABP, 

& surgery), A fib, VT/VF (in first 48 hours, often due to 

myocardial healing and can consider no treatment even in 

sustained; need to treat if symptomatic; more likely to treat if 

monomorphic, fast rate->200-, or low EF; if occurs after more 

than 48 hours from the MI, needs an ICD as mortality is >20% 

in next year from an arrhythmia), LV thrombus (anticoagulate), 

ventricular aneurysm (persistent ST elev.), ventricular 

pseudoaneurysm (surgery), pericarditis (1-4 days post MI, tx. 

NSAIDS), and Dressler’s syndrome (2-10 wks post MI, tx. 

NSAIDS)

33 

Post PCI Complications — In your note following PCI, be 

sure to comment on the following: 

1. Vascular access site (check for hematoma) 

2. Distal pulses 

3. Any signs of cholesterol emboli syndrome (any livedo 

pattern or toe necrosis) 

4. H&H, Tele monitoring, Creatinine 

5. Watch for the following complications: 

• Hematoma/Bleeding: Manual compression, 

reverse/stop anticoagulation 

• Retroperitoneal bleed (hypotension, 

abdominal/flank pain, dropping H&H): Stat CT 

abd/pelvis if concern for retroperitoneal bleed and 

stable enough to go. Blood, fluid, and pressors, 

and call cardiologist immediately. May need 

vascular consult. 

• Pseudoanerysm: triad of pain, expansile mass, 

systolic bruit; Dx with U/S; treat with compression 

or surgical repair 

• Contrast induced Acute Kidney Injury: 

Manifests within 24 hours; peaks at 3-5 days; 

Pre-hydrate patients to prevent kidney injury with 

IV fluids. Continue IVF’s after cath to protect 

kidneys 

• Cholesterol emboli syndrome: Renal failure, 

eos in urine, mesenteric ischemia, toe necrosis, 

Hollenhorst plaques in retinal arteries 

• Stent thrombosis: Urgent return to cath lab 

• In-stent restenosis (months after PCI) 

Prognosis 

Killip Class (on admission): 

Class Signs Mortality 

I No CHF 5% 

II S3, and/or crackles of lung 

exam 

17% 

III Pulmonary edema 30-40% 

IV Cardiogenic shock 60-80%

34 

Post MI and Discharge Medications: 

1. Post MI ECHO 

2. Meds: ASA, Plavix, Beta Blockers, statins, 

ACEI/ARB’s, NTG (PRN), aldosterone (if LVF

35 

function, elevated troponin T is still a predictor of cardiac 

events across all creatinine clearance levels) 

ATRIAL FIBRILLATION 

Classification — Paroxysmal (self terminating < 7 days, 

usually 7 days), and permanent (typically 

greater than a year or cardioversion failed/not attempted) 

Causes: 

• “I SMART CHAP” 

• Infection/Sepsis 

• Surgery (post CABG, post valve surgery) 

• Medication (theophylline, caffeine, etc) 

• Atherosclerotic Heart Disease 

• Rheumatic Heart Disease (MS, MR) 

• Thyrotoxicosis 

• Congenital Heart Disease (ASD) 

• Hypertension 

• Alcohol (dilated cardiomyopathy, holiday heart 

syndrome) 

• Pulmonary (PE, PNA, Hypoxia, COPD) 

Evaluation — H&P, EKG, CBC, CMP, TSH, Drug screen (if 

indicated), chest X-ray, TTE, cardiac enzymes. 

Treatment — Treatment revolves around rate control, 

rhythm control, and deciding on needed anticoagulation. 

**IF PT IS UNSTABLE, THEY NEED EMERGENT 

CARDIOVERSION** 

Rate Control: Goal HR 60-80’s 

• B blockers (metoprolol, coreg) 

• Digoxin (good for people with borderline BP's as 

does not lower BP; watch dig levels) 

• CaCh Blockers (diltiazem drip vs PO verapamil). If 

maintained on a diltiazem drip, can add up total mg in 

24 hour period, and then give them this amount in 

Diltiazem ER P.O. Give first oral dose then overlap 

with drip for 3 hours. 

Anticoagulation: CHADS2 Score: C (CHF), H (HTN), A 

(age ≥75), D (DM), S (stroke, TIA, and most add systemic 

embolic event).

36 

Get 1 point for each and 2 points for stroke or TIA. 

0 Points: ASA 325mg q day alone 

1 point: ASA 325mg q day or Coumadin (INR 2-3) 

2 or greater points: Coumadin (INR 2-3) 

Rhythm Control: Electrical or Pharmacologic cardioversion 

• Electrical: 

- 48 hours, and has been with INR 2.0 to 3.0 for 

3 weeks, no need for TEE. If INR not therapeutic, 

need IV heparin or SQ lovenox before TEE & 

then DC CV 

- If LA thrombus, anticoagulate >8 weeks, then 

cardiovert 

- If pt. is cardioverted and they were in AFIB 

greater than 48 hours they will need to be anticoagulated 

with Coumadin for at least 4 weeks. 

(High likelihood of reoccurrence). 

• Pharmacologic choices: Procainamide, ibutilide, 

flecainide, propafenone, amiodarone (watch PFT’s, 

TFT’s, LFT’s), sotalol (watch QTc), Dofetilide (watch 

QTc, no Bblocker effect so good for patients who 

can’t tolerate amiodarone or sotalol, but need special 

prescribing privileges.) 

CALCIUM CHANNEL BLOCKERS 

Class/Drug AV 

Blockade 

Vasodilation BP 

Control 

Dihydropyridine None +++ +++ 

Verapamil +++ + + 

Diltiazem ++ ++ + 

CHEST PAIN 

Can be typical, atypical, or non-cardiogenic chest pain. 

Assess chest pain — If has chest pain (1 point), if occurs 

with exertion (1 point), and relieved with rest or NTG (1 point)

37 

**0-1 point non-cardiogenic, 2 points atypical chest pain, 3 

points typical chest pain. 

Cardiogenic causes: Angina, MI, pericarditis, 

myocarditis, aortic dissection 

Pulmonary Causes: PNA, pleuritis, pneumothorax, 

PE, Pulmonary HTN 

GI Causes: Reflux, esophageal spasm, 

Mallory-Weiss Tear, Boerhaves, 

PUD, pancreatitis, biliary 

Muscle/other causes: Costochondritis, osteoarthritis, 

shingles, and anxiety 

Initial work up: History and PE going to dictate your workup, 

but good places to start are EKG, chest x-ray, and 

troponin/CKMB 

Ongoing chest pain 2/2 ACS: Can start on Nitroglycerin gtt at 

10 mcg/min and then titrate up (side effect=HA) 

EKG 

Ventricular Rate 

• Count large boxes between R waves: 

300,150,100,75,60,50. Can also count # of beats on 6 sec 

strip and multiply x 10 

• Conduction rates of specialized tissue: 

20-40 Ventricular rhythm 

40-60 Junctional rhythm 

60-100 Normal sinus rhythm 

100-150 Sinus tachycardia 

150-250 Supraventricular/Ventricular 

tachycardias 

Rhythm 

• Sinus (upright P in I and aVF and negative in aVR 

suggesting that the direction of atrial depolarization is from 

SA to AV node, there is a P wave before each QRS, the P 

wave marches out w/ calipers, the P wave has the same 

morphology) 

• Junctional (no P wave but still narrow QRS; rate 40-60) 

• Idioventricular (no P wave and QRS is wide; rate 20-40)

38 

Axis 

• Normal (-30 to +90): upright QRS in I and aVF 

• RAD (+90 to +180): negative in I and positive in aVF 

• LAD (-30 to -120): positive in I and negative in aVF 

• Extreme RAD (-120 to +180): if negative in I and II, then 

you have either extreme LAD or RAD 

Intervals 

• PR interval: Normal 120 to 200 msec 

- Shortened: Think WPW or Lown-Ganong-Levine 

syndrome 

- Prolonged (>200 msec), think: 

• 1° AV Block: Prolonged PR interval >200 msec; 

QRS follows all p waves 

• 2° AV Mobitz Type I (Wenckebach): prolonged 

PR interval that gets progressively longer 

followed by a dropped QRS; Mobitz Type II: PR 

interval that are constant with intermittently 

dropped QRS complexes 

• 3° AV Block: Atria and ventricles acting 

independently; atrial rate>ventricular rate 

• QRS interval: normal is 120msec Deep S RSR’ 

(L Heart if < then 

Dz) “incomplete” 

RBBB >120msec RSR’ Large S Slurring 

(R Heart if < then 

of S 

Dz) “incomplete” 

L Anterior Fascicular Block (LAFB) aka Hemiblock 

LAD + QRS

39 

• Erythromycin 

• Phenothiazines 

- Short QTc is caused by hyperkalemia, 

hypermagnesemia, and hypercalcemia. 

Hypertrophy and Enlargement 

• P (atrial depolarization) 

II (nl: 3mm 

more Negative (>1mm) 

RAE Tall >2.5mm More Positive Peak 

>1.5mm 

• Ventricular hypertrophy 

- LVH: kissing waves, S in V1 + R in V5/6 >35mm, R 

in aVL >11mm, or R in V4-V6 >25mm 

- RVH: tall R wave in V1 with an amplitude > 7 mm or 

R wave in lead V1 + the amplitude of the S wave in 

lead V6 > 10 mm. 

Signs of ischemia/infarction 

• ST Depression: Indicates ischemia; significant if the ST 

segment is depressed by 1 mm or more 

• T-Wave Inversion (TWI): Can also indicate ischemia but 

can be due to LVH with strain, abdominal pain, 

medications (digitalis), and CNS hemorrhage. 

• ST elevation (STE): indicates transmural infarction 

(injury); significant elevation is 1 mm in the limb leads and 

2 mm in the precordial leads. 

• Q wave: indicates muscle death from a lack of blood 

supply. A Q wave is considered pathologic if it is 1 small 

box wide and deeper than 25% of the R wave. “Q’s in III 

are free”. 

Other 

• Early repolarization: Concave “Happy” STE (early repol 

which is seen in young pts and those w/ LVH, pericarditis, 

myocarditis, head contusion, PTX) 

• Low Voltage (

40 

sleeping, EKG: ST elevation and TWI in V1-3 in setting of 

RBBB) 

• Hypothermia (Osborn Wave = small wave at J point) 

• Pulmonary Embolism (R heart strain signified by 

RBBB/RAD/RVH/RAE, sinus tachycardia, S1Q3T3:broad 

S in I, Q wave in III, inverted T in III) 

• Pericarditis (PR depression in II, diffuse STE) 

• COPD (R heart strain like above + Low Voltage of 

Precordial Leads only, Prominent P Waves) 

• Digitalis (therapeutic: sloping downward ST, T 

depressed or inverted, short QT) vs (Excess: SA Block, 

PAT w/ Block, AV Block, AV Dissociation) vs (Toxicity: 

Afib, JT, VT, multiple PVC, VFib) 

HEART FAILURE 

The heart cannot produce output to match the metabolic 

demands of the body. 

Systolic Dysfunction: Decreased EF, pump failure 

Diastolic Dysfunction: Preserved EF, but impaired 

relaxation of the ventricle. 

Causes: 

• CAD/MI 

• HTN 

• Valvular Disease: AS, AR, and MR 

• Arrhythmias: Long standing tachycardias 

• Metabolic/Toxic/Drugs: Beriberi, Pagets disease, 

chemo drugs, alcohol, thyroid 

• Infectious: Sepsis, coxsackie virus, chagas disease, etc 

• Pericardial Disease 

• Infiltrative Disease of Myocardium: Amyloid, sarcoid, 

and hemochromatosis 

Initial work up — H&P, CBC, CMP, EKG, chest X-ray, 

cardiac enzymes, TSH, TTE, if new onset +/- inpatient 

coronary angiography 

Functional classification: 

NYHA Class I: Symptomatic only with greater than 

ordinary activity. 

NYHA Class II: Symptomatic with ordinary activity. 

NYHA Class III: Symptomatic with minimal activity. 

NYHA Class IV: Symptomatic at rest.

41 

Therapy — Therapy is guided by stage of heart failure. For 

acute HF relief refer to pulmonary edema section. 

Stage Characteristics Therapy 

A No symptoms, no 

structural 

disease, just risk 

factors. (CAD, 

DM, HTN, 

cardiotoxic 

exposures) 

B Abnl. LVF, 

structural heart 

disease, previous 

MI, but 

asymptomatic. 

C Structural heart 

disease and 

symptomatic HF. 

Life style 

modifications, treat 

HTN, treat HLD, and 

control DM. 

ACEI: if HTN, DM, & 

PVD are present. 

All of stage A therapy, 

plus ACEI and beta 

blocker 

All stage’s A&B, plus 

diuretics, Na+ restrict, 

aldactone, AICD, BiV 

pacing, 

nitrates/hydralazine, 

and digoxin 

D Refractory HF All stages A,B, & C, 

plus LVAD, heart 

transplant, IV 

ionotropes, and 

hospice 

In the chart if you state that a person has heart failure you 

need to record EF, state if it’s diastolic or systolic dysfunction, 

and if it is acute or chronic. 

HYPERTENSIVE CRISIS 

Hypertensive Urgency: SBP >180 or DBP> 120 with 

minimal or no target end organ 

damage. 

Hypertensive Emergency: Acute rise in BP with end organ 

damage noted. Neurologic 

(hemorrhages, encephalopathy, 

papilledema), cardiac (ACS, HF, 

aortic dissection), or renal 

(proteinuria, hematuria, renal 

failure).

42 

Causes: 

• Progression of HTN 

• Medical noncompliance on BP meds 

• Progression of renal disease 

• Glomerulonephritis 

• Preeclampsia 

• Scleroderma 

• Pheochromocytoma 

• Cocaine/Amphetamines 

• MAO inhibitors + tyramine rich foods 

Treatment: 

• Hypertensive Urgency: Decrease MAP by 25% over 

hours using oral agents. Beta blockers, calcium channel 

blockers, hydralazine and ACEI. Then start BP regimen to 

get WNL. 

• Hypertensive Emergency: Decrease MAP by

43 

Nitroglycerine (Onset in 2-5 min) 5-100 mcg/hr 

(Tridyl): IV and titrate to keep desired MAP 

**Specific Conditions and Agents to Use: 

• In HTN Encephalopathy, use Nitroprusside and if that 

fails then Beta-Blocker or Nicardipine 

• In Subarachnoid Hemorrhage, use Nimodipine and if 

that fails then Beta-Blocker or Nicardipine 

• In CVA or aortic dissection, use Beta-Blocker and if that 

fails then Nitroprusside 

• In ARF, use Nicardipine and if that fails then Fenoldopan 

• In Cardiac Ischemia use Nitroglycerine + Beta-Blocker 

and if that fails then Nitroprusside 

• In post surgical patient, use Fenoldopam. 

PULMONARY EDEMA 

Causes — Revolves around three major organ systems 

Cardiogenic: Valvular abnormalities (acute MR, acute 

AR), MI/CAD, new onset arrhythmias, 

severe HTN, diastolic/systolic 

dysfunction w/ volume overloaded state, 

and pericardial dz. Usually must have 

some underlying cardiac disease 

(systolic/diastolic dysfunction) and 

another one of the other causes 

compounded to put pt. into cardiogenic 

pulmonary edema. Will have elevated 

PCWP >18mmHg. 

Pulmonary: Disruption of alveolocapillary barrier 

dysfunction (ARDS, trauma, aspiration, 

PE, and goodpastures); PCWP 

44 

Start out with aggressive diuretic therapy over first 24 hours, 

and reevaluate diuretic therapy every 24 hours. Oxygenation: 

start with nasal canula; then may need to advance to BIPAP, 

or even intubation if can’t keep adequate oxygenation (PaO2 

>60mmHg). 

SYNCOPE 

Sudden and brief loss of consciousness due to cerebral 

hypoperfusion 

Causes: 

• Neurocardiogenic: “Vasovagal syncope” 2/2 increased 

vagal tone 

• Orthostatic Hypotension: Hypovolemia, diuretic therapy, 

vasodilators, autonomic neuropathy. 

• Cardiovascular: Usually has a sudden onset and 

recovery 

1) Arrhythmias: Bradycardia (AVB, SSS), 

Tachycardia (VT, SVT) 

2) Mechanical: Endocardial, Myocardial, 

Pericardial, or Vascular 

• Neurological:Seizure, TIA/CVA (rare), vertebrobasilar 

insufficiency, and migraines. 

• Misc: Hypoxia, anemia, hypoglycemia. 

Work up: 

• In this Case H&P are the most important part of work up. 

• What was pt. doing prior to episode, how did they feel 

(palpitations, flushed, light headed, etc.), was it witnessed, 

did they lose consciousness, how long did they lose 

consciousness, was there seizure activity, previous 

episodes, PMHx important, Meds pt. taking, etc. 

• H&P will guide causes, work up and therapy. 

• Labs/Studies: EKG, CBC, CMP, check orthostatic vitals, 

u/s Doppler lower ext (usually not indicated), u/s carotids, 

TTE, CT scan head (usually not indicated but usually done 

in ER when pt. first comes in), EEG (if seizure is highly 

suspected). 

• Admit pt to telemetry bed, hold meds that could cause 

syncope. 

• A lot of times specific cause will not be found; try to 

optimize meds to avoid recurrence.

45 

Treatment: 

• Vasovagal: Recognize prodrome and take supine 

position when prodrome comes on. Increase salt/ fluid 

intake. Medications include beta-blocker, prozac, 

midodrine, fluorinef. 

• Bradycardia: Hold AVB agents, may need pacemaker. If 

SSS with tachy-brady, may need additional of AVN 

ablation. 

• Tachycardia: If VT/VF, may need AICD. 

• Valvular Disease: Surgery to correct. 

• Hypovolemia: Correct volume status, d/c diuretics, d/c 

vasodilator drugs. 

1) SinusTachy. 

(P – in AVR 

and + I&AVF) 

2) Atrial Flutter 

w/ 2:1 Block 

3) Atrial Tach. 

4) AVRT 

5)AVNRT 

TACHYCARDIA 

QRS< 

0.12ms 

Narrow Complex 

Regular Irregular 

1) Atrial 

Fib. 

2) Aflutter 

with 

variable 

block 

3) Multi 

focal atrial 

tach. 

Tachycardia 

QRS 

>0.12 

Regular 

1) V-Tach 

2) SVT 

with 

aberrant 

pathway 

(WPW). 

Wide Complex 

Irregular 

1) A-fib with 

aberrant 

pathway. 

2) A-fib with 

WPW 

3) Torsades 

Regular Narrow tachycardia — Can use adenosine to 

help differentiate. Ventricular response with Aflutter & Atrial 

tachycardia will transiently slow down with adenosine. AVRT & 

AVNRT will typically convert to SR with adenosine.

46 

Multi Focal atrial tachycardia — RR interval variable 

making rhythm irregular looking. There will be at least 3 

morphologically different p waves with rate greater than 100. 

Favors V-tachycardia on EKG — 1) AV dissociation. 2) if 

QRS >0.16. 3) Fusion/capture beats 4) Concordance (all R 

waves positive or negative). 5) Hx of structural heart dz. 6) 

RBBB in V1 7) look for negative in V6 8) NW axis-extreme right 

axis deviation (neg in I and aVF)

47 

GI/HEPATOLOGY 

GI CONSULTS AND GROUPS 

Digestive Health Associates of Texas (DHAT) 

(Ten gastroenterologists in two different call group 

arrangements) 

Washington Avenue Group (214) 545-3990 

Daniel Polter, MD 

Daniel DeMarco, MD 

Cathy Little, MD 

Angela Carollo, MD 

Lawrence Schiller, MD 

Landry center group (214) 821-5266 

J. Kent Hamilton, MD* 

Blair Conner, MD* 

Robert Anderson, MD** 

Damian Mallat, MD** 

Catherine Yaussy, MD 

Texas Digestive Disease Consultants (TDDC) 

(214) 820-4490 

Charles Richardson, MD 

Esmail Elwazir, MD* 

Greg Hodges, MD* 

Bhavani Moparty, MD** 

Chris Vesy, MD 

Texas Digestive Health Consultants (Health 

Texas/Baylor affiliate) (214) 820-8899 

Steve Burdick, MD** 

**Star designations: * ERCP **ERCP and EUS 

GI lab phone: (214) 820-3463 

(214) 820-4627 

Liver Consultants of Texas 

Inpatient Hepatologists (214) 820-8500 

Jacqueline O’Leary, MD 

Rita Lepe, MD 

Linsheng Guo, MD

James Trotter, MD 

Liverresources.com 

48 

GENERAL GI/LIVER TOPICS 

How do I get a GI consult? 

In general, you can call whomever you want. There are a 

few things to keep in mind- there is no consult schedule or 

GI service. Some gastroenterologists predominantly focus 

on outpatient Gastroenterology, and some have special 

areas of interest. Of course if a patient has a established 

relationship with a Gastroenterologist, then you should call 

that particular Gastroenterologist. You can usually find this 

information on EMR but it can be tricky. 

What do I tell the Gastroenterologist? 

Basic patient information; GI issue; Does the patient need 

to be seen today? Active bleeding? What/where do you 

think they are bleeding from? NSAIDs? Prior endoscopy 

(when, where whom) Is the patient NPO, Is a procedure 

needed? 

When do I call for an urgent GI consult? 

Active upper GI bleeding, specifically variceal bleeding. 

Most lower GI bleeding (diverticular) stops and is only 

occasionally brisk and persistent. 

How do I get a Hepatology/Liver consult? 

There is an inpatient “liver service.” All consults go to the 

general number. The inpatient hepatologist is on service 

for a week at a time (usually Monday to Monday). All 

established hepatology patients (ie, those previously seen 

in the Hepatology clinic or who are on the transplant list) 

are admitted by the TPC hospitalist group, so in general 

hepatology is already seeing these patients. 

What do I tell the Hepatologist? 

Basic patient information. Newly diagnosed cirrhosis? If 

calling for hepatitis — results of viral serologies, 

autoimmune studies, suspected medications. 

When do I call for an urgent Hepatology consult? 

Acute liver failure — in general, defined as new onset of 

encephalopathy, jaundice and coagulopathy. Remember, 

if they have risk factors for cirrhosis (EtOH, Chronic viral

49 

hepatitis, obesity), then they probably don’t have acute 

liver failure; they have decompensated cirrhosis. 

GENERAL GASTROENTEROLOGY 

C. difficile 

• Only one test is indicated: C diff toxin in stool 

• The test may sometimes take > 24 hours to return, so 

consider empiric treatment with oral Flagyl or Vancomycin 

• If a patient is really sick, it is best to start directly with 

Oral Vancomycin (pill or suspension): 125 mg po QID; 

Otherwise, can use oral flagyl. DO NOT use IV 

Vancomycin for C. difficile. 

• Always consider C. difficile if unexplained leukocytosis 

and diarrhea. Diarrhea is not always present, in fact in 

severe C. difficile they may get a dilated colon with ileus, 

so consider checking a KUB. If colon is dilated then make 

sure GI is following and consider surgical consultation 

(Colorectal or general) 

Cholangitis 

If you suspect a patient has cholangitis, then it is best to call a 

gastroenterologist who does ERCP. Cholangitis is an indication 

for urgent ERCP. Cholangitis should be suspected if a patient 

has symptoms of Charcot’s triad: 

1. Fever 

2. RUQ pain 

3. Jaundice 

The patient may also have hypotension and altered mental 

status which gives them all five of Reynold’s pentad. Patients 

can sometimes just present with vague upper abdominal pain 

and elevated transaminases. Always check a right upper 

quadrant ultrasound. 

Colonoscopy Prep 

Nulytely 4 liters- 8 oz PO Q 10-15 minutes until gone. We 

usually start this at about 5 p.m. on the day before a planned 

colonoscopy. NPO except meds after midnight. Write generous 

PRN orders for anti-emetics such as Zofran, Phenergan,

50 

Reglan. DO NOT prep a patient unless GI says that they were 

able to get the patient on the schedule for the next day. 

GI Prophylaxis 

Generally not indicated unless patient is at high risk of GI 

bleeding: high dose steroids, previous peptic ulcer disease, 

heavy NSAID use, neurotrauma, etc. GI prophylaxis may put 

patients at increased risk for C. difficile infection. 

Nutrition 

• TPN- there is a standard order sheet/order set. You 

should become familiar with this order set and in general 

write your own TPN. The dieticians are very good at 

writing and are a very valuable resource. 

• Tube feeds- enteral nutrition is always preferable to 

TPN. There are a variety of formulas available at Baylor 

(the Baylor EMR website has a list). Remember, Dobhoff 

tubes are more comfortable for patients due to their small 

size, but crushed meds don’t go down them very well, so 

order your meds as suspensions. 

Pancreatic Masses 

If a patient has a pancreatic mass, and an FNA is indicated, 

than it is best to call a gastroenterologist that does EUS/FNA 

Pancreatitis 

• Always assess severity — mild, moderate, severe — via 

Ranson’s criteria or other criteria, and watch closely for 

complications. 

• If severe, then ICU treatment is needed. 

• Treatment- IVF. If necrosis on CT, consider antibiotics 

(controversial). Pancreatic necrosis can only be 

determined on a CT with IV contrast (which may be 

problematic as many patients with pancreatitis develop 

AKI) 

• Early tube feeds (gastric or duodenal) are controversial 

• Always check a sonogram for stones. Consult surgery if 

you suspect biliary pancreatitis because they usually need 

a cholecystectomy before they leave the hospital. The

51 

timing and necessity of ERCP for biliary pancreatitis is 

variable. 

PEG tubes 

Preferences 

> 6 months life expectancy 

• Indications: Dysphagia- aspiration or penetration 

documented by speech therapy or dysphagiagram 

• Prefer for patients to be off anticoagulation and no 

coagulopathy. ASA is okay. If they have cirrhosis and 

ascites, then no PEG tube. 

When they “fall out” or are pulled out (this only happens at 

night)- replace with a 15-20 French foley catheter and inflate 

the balloon ASAP, but do not use the tube until position is 

verified or GI has seen patient. 

Upper Gastrointestinal Bleeding (UGIB) 

Treatment — Use Baylor GI bleeding order set. 

• First priority: Volume resuscitation. Ensure two large 

bore peripheral IV’s or central line. Give IVF and blood 

products as appropriate to keep HR 100. 

• Check hemostasis profile and give FFP and platelets as 

needed to correct any coagulopathy. General goal: INR 

50 

• Discontinue anti-platelet agents and anticoagulants. 

• Peptic ulcer disease is a common etiology, so give a 

Protonix 80 mg IVP, the 8 mg/hr 

• If cirrhosis and variceal bleeding suspected, give 

Octreotide 50 mcg IVP, then 50 mcg/hr (Octreotide drip 

per protocol). Also start cirrhotics with suspected variceal 

bleeding on prophylactic antibiotic coverage (usually start 

with 3 rd /4 th generation Cephalosporin (such as Ceftriaxone 

or Cefepime) or levaquin 500 mg IV qday, then change to 

PO

52 

• Vasopressin — pressor of choice if not able to maintain 

adequate blood pressure with blood product and fluid 

resuscitation. 

• NGT aspirate: If red blood then may indicate active GI 

bleeding. If coffee ground, than probably UGIB within 1 to 

2 days. 

**A negative NGT lavage does not rule out an UGIB. 

Large post-pyloric bleeds such as duodenal ulcers 

commonly have negative aspirates. It is usually okay 

to remove the NGT after the aspirate (unless you are 

going to use it for medications or something else). 

• Consult GI: Important things to tell them are 

1. Patient name and location 

2. Presentation 

3. Co morbidities and medications (including any 

NSAIDS) 

4. Actively bleeding or not (results of lavage) 

5. Significant labs: H&H, PT/INR 

6. Resuscitation efforts (how much blood/FFP has 

been given) 

7. Hemodynamics 

8. If a procedure is needed 

9. Remember the definition of urgent endoscopy is 

an endoscopy within 24 hours. 

• Follow serial H&H Q6 hours for 1-2 days, then change to 

Q 8-12 hrs 

• Make sure to repeat INR 1-2 hours after FFP 

• Vitamin K: Most cirrhotics who have significant jaundice 

are also Vitamin K deficient so give Vitamin K 10 mg SC 

daily x 3 days. 

• Keep NPO 

GENERAL HEPATOLOGY 

Acute liver failure 

▪ Basic definition: Jaundice, coagulopathy, and AMS 

▪ Very complex, sick ICU patients. Acute liver failure can 

progress very rapidly. Best managed on 4 west ICU (aka

53 

the liver transplant ICU) where the nurses are very 

comfortable taking care of liver patients. 

▪ Transplant candidacy vs evaluation. 

▪ If intubated in the ICU, propofol is usually your sedative 

of choice. 

▪ Levophed is in general your pressor of choice. 

▪ If Tylenol is on your differential, always give at least one 

dose of Acetadote- (acetylcysteine) which can be given 

orally or IV until the Tylenol level comes back. 

Alcoholic hepatitis 

▪ Always calculate the discriminant function and consider 

steroids or Trental if >32 

▪ No steroids if any sign of infection 

▪ Give folate 2 mg daily and thiamine 100 mg daily 

▪ Nutrition is very important. Always consider tube feeds 

(at least for a couple of days) if the patient does not have 

good PO intake. 

▪ Withdrawal precautions: Oxazepam preferred over other 

benzodiazepines for withdrawal. Librium is very longacting 

and can be problematic. Consider non-selective 

beta-blockers as well, if the patient is hyperadrenergic 

(hypertensive, tachycardic) 

▪ Vitamin repletion: Always give thiamine before any 

dextrose containing IV fluids. Because of malnourishment, 

alcoholics often have thiamine, folate, and magnesium 

deficiencies. Suggested orders: Add to first bag of IV 

fluids daily (aka the “banana bag”) Thiamine 100 mg, 

Folate 2 mg, one vial of multivitamins. Okay to follow Mg 

levels or give 1-2 grams of Magnesium sulfate IV daily for 

the first day or two. Watch Phosphate levels for refeeding 

syndrome. 

▪ High mortality 

Decompensated Cirrhosis 

When managing cirrhotics, mention patients Child’s Class or 

MELD score (MELD score if preferable if pt is a transplant 

candidate or is on the transplant list). Also mention underlying 

cause if known (Laennec's cirrhosis, etc) 

Hepatic encephalopathy 

Stages of encephalopathy: The simplest assessment system 

(most commonly used) grades HE as stages 1 to 4. The 

grading is based upon changes in consciousness.

54 

Stage 1: Mild confusion, decreased attention, 

irritability, reversed sleep pattern 

Stage 2: Drowsiness, personality changes, 

intermittent disorientation, asterixis 

Stage 3: Gross disorientation, marked confusion, 

slurred speech 

Stage 4: Frank coma 

The grading/staging of HE can be difficult. The presence of 

asterixis is a fairly reliable indicator of at least stage II HE. 

** Always look for what precipitated the HE. Common 

etiologies: Infection, bleeding, electrolyte abnormality, 

dehydration. 

• Kristalose (same as Lactulose but tastes better and 

comes as packets of crystals): a good starting does is 20- 

30 g po TID, then titrate to 3-4 BM/day 

• Rifaxamin: 400 mg PO TID- this is very expensive, and 

so it can be difficult to continue as an outpatient 

• For your patients with Stage III/IV HE or refractory HE: 

Kristalose 30-60 grams every hour until BM. Lactulose 

enema: 200 g of lactulose in 800-1000 mL water 

Ascites-volume overload 

Large volume paracentesis is greater than >2L 

If the patient’s serum albumin is less than 3 g/dL, then give 8 to 

10 g of albumin per liter of ascites removed. All albumin at 

Baylor is “sodium poor” so no need to specify “sodium poor 

albumin- SPA”. Albumin comes in 25 g vials, so it is best to 

round to the next highest 25 g interval. Usually best to hang 

the albumin as you are about to do the tap. 

• Diagnostic paracentesis - SBP, etc. 

- Send for: cell count/diff, albumin, total protein 

- Inoculate culture bottles at bedside with 10 mL of 

ascitic fluid in each bottle (increases yield) 

- SBP if >250 PMNs 

• Coagulopathy is not a contraindication to paracentesis. 

In general, we do not give FFP or platelets prior to a 

paracentesis unless the patient has a severe 

coagulopathy

55 

GI bleeding 

(**See above under GI Bleeding; in addition, think about the 

following) 

• All cirrhotics with GI bleeding should get prophylactic 

antibiotics to prevent SBP. Good options include a 3rd or 

4th generation cephalosporin or quinolone. Antibiotics 

should be continued for 5 days. 

• Fluid resuscitate- central line preferred. If not, then 

ensure a 18-20G IV in each arm 

If INR>2, then give at least 4Units FFP 

• Give platelets if

Liver transplant 

56 

Liver transplant evaluation (LTE) 

▪ Can only be initiated by a hepatologist. 

▪ Standardized 3 page order set which includes an 

extensive battery of imaging studies, labs, and consults. 

The evaluation usually takes 2-3 days minimum to 

complete. The liver transplant coordinator calls the 

consults (Psychiatry, etc.) as the transplant service often 

has consultants that they prefer to use. 

▪ Be careful what you tell families and patients about their 

candidacy for transplant. Remember that the decision to 

transplant a patient is a committee decision. In general 

always defer this to the hepatologist. Patients and families 

are sometimes under the impression that they are being 

sent to Baylor for a liver transplant. It is important to tell 

the patient and family that a liver transplant evaluation is 

required first. 

▪ Once a patient is transplanted, it is usually okay to sign 

off as the transplant surgery team will completely manage 

the patient. 

General liver patient guidelines 

• Avoid benzodiazepines and narcotics as they can 

precipitate encephalopathy 

• Tramadol is a good choice for pain management: 50 mg 

PO q12 hours prn pain 

• Insomnia is very prevalent. It is best to use Trazodone 

for insomnia. Do not use Ambien, Lunesta, etc. if possible. 

• If agitation is a significant problem, then low dose IM 

Zyprexa or Haldol is a possible treatment that can be 

used. 

• Always notify the liver transplant service if a patient that 

is on the liver transplant list is hospitalized. 

GI STUDIES 

Study Orders 

• Abdominal US (NPO 6hrs prior) 

• Barium Swallow (NPO 1hr prior) 

• Upper GI (NPO after MN) 

• SBFT (NPO after MN and one glass of water qhr from 

noon to 1900)

57 

• Barium Enema (clear liquids 1d prior, NPO after MN, 

one glass of water qhr from noon to 1900, MgCitrate at 

8pm, Dulcolax at 11pm, Dulcolax at 7am) 

• HIDA (NPO after MN) 

• Other notes: 

- CT abdomen/pelvis- always use oral contract 

(Gastrografin). Use IV contrast if possible. 

- Plain X-rays: KUBs and acute obstructive series are 

always best done in radiology rather than as 

portables. 

Endoscopy Orders 

• Colonoscopy, etc: Clear Liquid Diet day before then 

NPO except meds (except antiplatelets and iron) after MN 

and Nulytely 250cc PO Q10min until all 4L consumed 

starting at 1800 

• EGD, etc: just NPO except meds for 6hrs prioir or after 

MN 

• Permits on chart for colonoscopy, endoscopy, and 

anesthesia 

• To GI lab on call 

• If pt is still passing stool in am the give fleet enema x1 

• Have functioning IV (not heplock). The best way to do 

this is just to order IV fluids to start 4-6 hours before the 

procedure. 

• Patient to resume diet when alert ~1hr (for capsule can 

resume liquid/diet 2/4hrs after swallow 

• Benefits: 1/20 r/o cancer vs Risks: 1/500 r/o significant 

bleed, 1/2000 r/o perforation

58 

INFECTIOUS DISEASES 

BUGS AND DRUGS 

(This is not a comprehensive list, but think of these drugs when 

you are dealing with the listed bugs; refer to Sanford Guide 

and your prescribing references for treatment doses and 

specific clinical scenarios) 

Atypical PNA (Chlamydia, Mycoplasma, Legionella) 

• Azithromycin (Zithromax) 

• Levofloxacin (Levaquin) 

Candidemia 

• Micafungin (Mycamine) 

• Fluconazole (Diflucan) 

• Voriconazole (Vfend) 

• Amphotericin B 

• Liposomal Amphotericin B (AmBisome) 

Candiduria 

• C. albicans (No chronic foley, has symptoms, +pyuria): 

Fluconazole 

• C. glabrata (With symptoms): Fluconazole, Amphotericin 

B 

Chronic foley: Change out foley and monitor (unless 

neutropenic) 

Good anaerobic coverage: 

• Zosyn (and anti-pseudomonal penicillins) 

• Merrem (and other carbepenems) 

• Clindamycin (anaerobes above the diaphragm) (Cleocin) 

• Metronidazole (anaerobes below the diaphragm) 

(Flagyl) 

MRSA 

• Vancomycin 

• Linezolid (Zyvox) 

• Trimethoprim/Sulfamethoxazole (Bactrim) 

• Daptomycin (Cubicin)-not indicated for tx of PNA 

• Tigecycline (Tygacil) 

• Minocycline (for CA-MRSA) 

• Doxycycline (for CA-MRSA)

59 

Pseudomonas: 

• Piperacillin/Tazobactam (Zosyn) 

• Meropenem (Merrem) 

• Imipenem/Cilastatin (Primaxin) 

• Doripenem(Doribax) 

• Ceftazidime (Fortaz) 

• Cefepime (Maxipime) 

• Gentamicin (Garamycin) 

• Tobramycin (Nebcin) 

• Amikacin (Amikin) 

• Ciprofloxacin (Cipro) 

• Levafloxacin (Levaquin) 

• Colistin (for multiresistant strains) 

VRE 

• Linezolid (Zyvox) 

• Daptomycin (Cubicin) 

• Tigecycline (Tygacil) 

• Quinupristin and dalfopristin (Synercid) 

Etiologies 

FEVER IN THE ICU 

• VAP (PNA developing after 48 hours intubation) 

- Risk highest in the first week 

- Higher risk in patients with comorbidities, ARDS, 

paralyzed, H2B, NGT; mortality 20 to 60 percent. 

- Infection control/prevention: NIV; if possible, 

carafate over other anti-ulcer, tight cuff seal (>20cm); 

semi-recumbent position. 

• Central line infection 

- Infection rate: Fem>PICC>IJ>SCL 

- No evidence to support prophylactic scheduled 

changes, but should be changed if new infection 

arises. Consider changing anyway if in >3 weeks. 

• Other catheter related infections (foley catheter, 

arterial line, peripheral IV) 

• CMV infection after blood transfusion 

• Surgical site infections

60 

• Resistant pathogens: MRSA, VRE, Pseudomonas 

• Other infections: Cellulitis, cholangitis, cholecystitis, 

diverticulitis, endocarditis, intra-abdominal abscess, 

meningitis, sinusitis, thrombophlebitis 

• Non-infectious causes: Transfusion reactions, drug 

fever, intra-abdominal source (pancreatitis, acute 

mesenteric ischemia), thyroid disease, or thromboembolic 

disease (DVT/PE) 

Work-up and treatment — Consider the following: 

• CBC with diff, CMP 

• Repeat blood cultures x2 

• CMV PCR 

• UA/urine culture 

• Sputum gram stain/culture 

• Change out central lines if >48 hours (venous lines first) 

and culture tips 

• pCXR 

• Stool studies if indicated 

• Abdominal ultrasound if indicated 

• CT chest, abdomen, or pelvis if indicated 

• Bilateral lower extremity Doppler if indicated 

• CT sinuses if chronic NG tube 

• Empiric antibiotics 

Definition 

FEVER OF UNKNOWN ORIGIN 

• Fever >101°F (38.5°C) on one or more occasion 

• Duration >3 weeks 

• No diagnosis despite 1 week of intensive evaluation 

Etiologies 

• Infection: 

Tuberculosis, endocarditis, intra-abdominal abscess, 

osteomyelitis, fungal infection, meningitis, hepatitis, CMV, 

EBV, Lyme disease, HIV, etc. 

• Connective tissue disease: 

Temporal arteritis, Polyarteritis nodosa, RA, SLE, etc.

61 

• Neoplasm: 

Lymphoma, leukemia, carcinoma, etc. 

• Others: Drugs, DVT, PE, adrenal insufficiency, etc. 

Work-up — Consider if appropriate: 

• Reassess medications 

• Thorough history and physical exam 

• Lab — CBC with diff, CMP, Blood cultures x2, UA, urine 

culture, sputum gram stain and culture, Quantiferon Gold, 

ESR/CRP, ANA, RF, LDH, CMV PCR, EBV PCR, HSV 

PCR, Lyme titers, Hepatitis panel, HBV or HCV PCR, HIV 

antibody or PCR, fungal complement panel, D-dimer 

• Imaging — TTE followed by TEE if indicated, CXR, CT 

of targeted area, LE Doppler, CT chest with PE protocol, 

bone/gallium scan 

• Procedures — Lumbar puncture, bone marrow biopsy, 

temporal artery biopsy 

PNEUMONIA 

Use pneumonia admission protocol 

SEPSIS 

Define the condition of your patient in your notes 

using the following: 

• SIRS — 2 out of the 4 following criteria: 

- T>38 or 90 

- RR>20 or PaCO212,000 or >10 percent Bands 

• Sepsis — SIRS in response to a documented or 

suspected infection (does not have to have proven 

infection to call it sepsis) 

• Severe sepsis — Sepsis PLUS signs of organ 

hypoperfusion or damage, such as: 

- Capillary refill >3 sec 

- Mottled skin 

- Uop 4 mmol/liter

62 

- Altered mental status 

- Platelets 15 

mcg/kg/min or NE/Epi >0.25 mcg/kg/min for MAP>60 

Goals in sepsis: 

• MAP 65 to 90 (MAP = [SBP+(DBPx2)]/3) 

• CVP 10 to 12 (>12 if intubated) 

• SvO2>70 (can draw random ScvO2: early goal directed 

therapy suggests to transfuse to Hct>30 percent, then 

redraw; if 65 or SBP>90 OR 

• CVP≥8 or ≥12mmHg if intubated OR 

• Total fluid bolus of 45 ml/kg have been given including 

all fluid boluses in ER and on floor within 6 hours of 

arriving in the ICU. 

• If still hypotensive, then initiate pressors. 

• Establish central access 

Pressors: 

• Start with Levophed gtt: titrate to keep MAP>65 

• Can then escalate based on specific patient 

• Vasopressin can be added at 0.01-0.04 Units/min, 

neosynephrine starting at 100-180 mcg/min, or dopamine 

starting at 5 mcg/kg/min. Addition of vasopressin to high 

doses of levophed have shown to cause increases in

63 

mortality. It lowers mortality if added to moderate doses of 

levophed. 

Antibiotics — First dose stat in ER 

Blood cultures — x2 drawn in ER prior to first dose 

antibiotics 

• Order labs and antibiotics based on suspected etiology 

• Consider pharmacy evaluation for Xigris if >2 organ 

system failure 2/2 sepsis or APACHE II score ≥25 

Other factors in shock — If still refractory hypotenstion, 

check Ca, TSH, possible hemorrhage into any organ, GIB, 

TTE, acidosis. HCO3 drip if ph

Histoplasmosis 

HIV 

64 

Urine histo antigen, LDH. 

HIV (Multidrug-resistant) HIV genotype 

Acute retroviral syndrome: Order 

HIV PCR for viral load and CD4 

count. 

Chronic illness or AIDS: HIV 

antibody/CD4 count. 

Meningitis Blood cultures x2, CT head without 

contrast to r/o mass effect before 

LP (if indicated), LP: opening 

pressure, CSF gram stain and 

culture, Cell count with diff, 

Glucose, Protein. 

Osteomyelitis 

Pneumonia (Communityacquired) 

Pneumonia 

(immunocompromised) 

Also consider if indicated: CSF for 

acid fast stain/culture, fungal 

stain/culture, cryptococcal antigen, 

HSV/VZV/Enteroviral/CMV/West 

Nile PCR, Lyme IgG/IgM 

antibodies, VDRL, cytology, Serum 

Toxo IgG/IgM HIV test, RPR, ANA, 

RF 

Blood cultures x2, surgical 

sampling/needle biopsy (not swab 

of sinus tract or fistula), MRI (most 

Se and Sp) 

CXR, blood cultures x2, Sputum 

gram stain and culture, Urine 

Legionella antigen, Urine Strep 

Pneumo antigen, Rapid influenza 

nasal swab; consider HIV test 

All under CAP plus Blood fungal 

culture, Induced sputum for silver 

stain (PCP), sputum fungal 

stain/culture, sputum for acid fast 

bacilli stain/culture (TB),

Pneumonia 

(immunocompromised) 

(continued) 

Prion disease: Creutzfeldt- 

Jakob disease 

65 

Quantiferon Gold (TB), CMV PCR, 

HSV PCR, fungal compliment 

panel, aspergillus galactogamman 

(aspergillus), urine histo antigen; 

also consider bronchoscopy with 

fungal, bacterial, mycobacterial, 

viral cultures, with appropriate viral 

PCR’s, silver stain (PCP), 

Legionella DFA, Legionella culture, 

MTB Direct probe, and nocardia 

culture 

Send CSF for 14-3-3 Protein; If 

concern for prion disease, notify 

epidemiology as special 

precautions need to be taken. 

SBP Send ascitic fluid for: albumin, total 

protein, gram stain and culture 

(bedside inoculation of culture 

bottles increases Se), cell count 

with diff; can also send amylase, 

triglycerides, AFB stain/culture, 

adenosine deaminase (if TB 

suspected), or cytology 

Tuberculosis AFB sputum stain and culture x3 

(order induced sputum if needed); 

PPD or Quantiferon Gold

66 

NEUROLOGY 

ALTERED MENTAL STATUS 

Patient states: 

• Confused: disoriented but calm 

• Delerium:disoriented but agitated 

• Lethargic: Drifts off to sleep 

• Coma:Unarousable and unresponsive 

Etiology: MOVE STUPID 

• Metabolic (hypothyroid, hyperthyroid, hepatic 

encephalopathy) 

• Oxygen (Hypoxia from PNA, pulm edema, etc) 

• Vascular (TIA, CVA, Subdural hematoma, TTP) 

• Electrolytes (Specifically Na, Ca) 

• Seizure 

• Trauma 

• Uremia 

• Porphyria 

• Infection (sepsis/meningitis) 

• Drugs/Toxins 

Immediate ER cocktail (if history unobtainable): Thiamine 

IV (always give before glucose), D50, Narcan. Flumazenil only 

if BZD OD certain. 

Immediate assessment — Intubate if indicated. Vitals, 

Exam, ABG, DFS, O2 sat, EKG, utox 

Initial labs — CBC, CMP, serum osmolar gap, 

Acetaminophen level, Salicylate level, appropriate med levels if 

suspected, serum ETOH, TSH, Blood cultures x 2, UA and 

urine cx 

Consider additional diagnostic studies — CT Head 

(non-contrast), CXR, LP, EEG, additional infectious work-up if 

indicated

67 

BRAIN DEATH EXAM 

• Can order brain death exam order set and it guides you 

through the following: 

• Brain death is a clinical diagnosis 

• Need to exclude the presence of 

exogenous/endogenous toxins 

• Patient can’t be hypothermic: Need to warm them up to 

declare them brain dead 

• Exam has 3 components (need to have all of the 

following): 1) Coma 2) Absent brain stem reflexes 3) 

Apnea test 

1. Coma: Needs to be at least 6 hours if patient has a 

structural lesion and 24 hours if patient has anoxic 

brain injury 

2. Brain stem reflexes: 

- Absent motor response 

- Pupils are midposition or dilated (4-9 mm), absent 

light reflex, doll’s eye maneuver 

- Absent corneal reflex 

- Absent oculovestibular reflexes (30-60 cc ice water 

in ear canal results in no movement; in normal 

person, fast beat is described by COWS: cold 

opposite, warm same, in coma, a response would be 

seen if eye slowly moves toward ear irrigated with 

cold water) 

- Absent jaw jerk 

- Absent gag reflex 

- Absent cough with tracheal suctioning 

- Absent sucking or rooting reflex 

If all brain stem reflexes are absent, proceed to 

3. Apnea test: Pre-oxygenate at 100% FiO2 x 5-10 

minutes. Would like pCO2 to be around 40 to begin 

with if possible. Then, disconnect from ventilator 

support for 8-10 minutes (deliver O2 at 8-10L/min, a 

small canula is placed down the ET tube) and watch 

for respirations. A positive test is absence of any 

respiratory response and a post test ABG with PaCO2 

>60 or 20 mmHg greater than baseline. 

4. Confirmatory testing (Not mandatory): 

- Brain flow study: nuclear scan to evaluate for 

cerebral blood flow (no flow when ICP exceeds SBP)bedside 

(pitfall – does not evaluate posterior 

circulation)

68 

- EEG silence x2 12 hours apart (pitfall – can be 

confounded with medications on board, also at high 

sensitivities, much artifact comes through) 

- Cerebral angiography-Gold standard (no flow-no 

brain. pitfall – costly, invasive, requires transporting 

patient out of ICU setting to radiology, not readily 

available) 

5. Southwest Organ Transplant can come and talk to the 

family about organ donation, but keep that separate 

from the talking you do with the family. 

NEUROMUSCULAR EMERGENCIES 

Some patients will present with generalized weakness with 

certain neurological conditions. This may result in bulbar 

(facial) or respiratory weakness, and require close monitoring. 

Patients with severe bulbar weakness are more likely to 

require mechanical ventilation. 

• The following conditions in particular should prompt 

special attention: Guillain-Barre, Myasthenia Gravis 

Exacerbation, Polymyositis 

• Watch FVC and Negative Inspiratory Force (NIF) 

frequently (approximately Q6 hours). NIF=Maximum 

Inspiratory Pressure (MIP). You can write an order in the 

chart to monitor NIF as above and this will be performed 

by respiratory therapy. 

• If FVC drops below 15 cc/kg, the patient will require 

intubation and ventilation. 

• NIF should be at least -25 cm H20. If NIF begins to 

become more positive, this may indicate worsening 

diaphragmatic weakness and require intubation. 

• Also severe facial/bulbar weakness may make 

performance of bedside spirometry difficult if not 

impossible. Patients should be able to take a deep breath 

and count out loud to at least 1 to 20 in a single breath. If 

the time period is shorter, the patient may need to be 

intubated. 

• Follow ABG and if PaCO2 if creeping up, then have a 

low threshold for intubation.

69 

SEIZURES 

Can use BZD ativan IV or valium rectally if no access (0.1 

mg/kg max IV if needed) to stop seizure, most seizures will be 

self limiting and brief not requiring treatment. If patient having 

frequent convulsive seizures and not returning to baseline 

between events or if two or more events last longer than 30 

minutes and patient not awakening between, see status 

epilepticus below. 

Etiology: ABCDE 

• Alcohol withdrawal, illicit drugs 

• Brain tumor or trauma 

• CVA 

• Degenerative disorders of the CNS (Alzheimers) 

• Electrolytes (Na) and other metabolic (uremia, liver 

failure, hypoglycemic), Epilepsy 

Diagnostic studies — CBC, CMP, Utox, med levels, 

ETOH level, EEG, MRI or CT head, LP 

Treatment: 

1. Treat underlying condition 

2. Anti-epileptic drugs (AED) for patients with underlying 

structural disorder or idiopathic seizure plus: a) status 

on presentation, b) focal neuro exam, c) Todd’s 

paralysis, or d) abnormal EEG 

3. Introduce slowly and monitor closely 

4. Check levels on medication until therapeutic 

5. May consider withdrawing tx if seizure free for a 

defined interval (ex: 1 year) and normal EEG in select 

patients 

6. In TX: Need to be seizure free x 6 months to drive 

STATUS EPILEPTICUS 

Definition — One continuous seizure lasting >5-10min or 

two or more discrete seizures between which there is 

incomplete recovery back to baseline 

Stat labs — DFS, Na, Ca, serum and urine tox screen, AED 

levels

70 

Additional studies — MRI brain with and without contrast 

with seizure protocol, need LP 

Treatment: 

1. Intubate if indicated 

2. Ativan 0.1mg/kg IV at 2mg/min; if no response, then 

3. Dilantin 20mg/kg IV at 50 mg/min (or Cerebyx 20mg 

p.e./kgIV at 150mg p.e./min); if no response, then 

4. Additional IV dilantin or cerebyx (5-10mg/kg) bolus; if 

still no response, and continued sz>one hr, or 

hyperthermic, then definitely needs intubation if not 

already done, EEG monitoring, and ICU admission; 

then, 

5. Phenobarbital 20mg/kg IV at 50-75 mg/min initially, 

then additional 5-10 mg/kg bolus if still seizing; if no 

response then 

6. Sedate (versed 0.1mg/kg, then run at 10mcg/kg/min 

or propofol 2mg/kg, then run at 5mg/kg/hr) 

7. Additional phenobarb prn 

8. Pentobarb coma as last line of treatment with 

continuous EEG monitoring in place. Titrate 

pentobarb to burst suppression with 1 to 3 bursts per 

minute. 

Neuro consult, EEG monitoring (if sedated/unclear status) 

CVA: Hemorrhagic 

STROKE MANAGEMENT 

• Intracranial or SAH 

• Usually intubated either 2/2 AMS, elective 

hyperventilation, or post-craniotomy/repair/ventric 

placement. 

Diagnostic studies — Labs including CBC, CMP, PT/INR 

and urine drug screen, non-contrast CT head, LP to check for 

xanthochromia if no evidence of SAH on CT, but suspicion still 

high 

Treatment: 

1. Stat neurosurgery consult to review films/patient 

2. Admit using Hemorrhagic stroke protocol

71 

3. Stop anticoagulants and reverse coagulopathies, 

vitamin K, FFP 

4. Insulin for hyperglycemia 

5. Usually hypertensive: treat to MAP 100-120; maintain 

CPP (MAP-ICP) >60-70. 

6. HTN is usually labile use gtt: nicardipine, nipride or 

labetalol based on other comorbidities. 

7. Load with Dilantin or cerebyx to levels of 

approximately 20. Most indicated in lobar ICH, SAH, 

or subcortical ICH with diameter >4cm and shift. 

8. Treat ICP (goal < 20): elevate HOB to 30 degrees, 

sedate using propofol, mannitol IV at 1 g/kg bolus 

followed by 0.5 to 0.25g/kg q6hours(follow Na, Posmkeep 

300 to 320), hyperventilate (goal pC02 25-30) 

9. Bilateral SCD’s for DVT prophylaxis 

CVA: Ischemic 

• Admit using ischemic stroke protocol 

• If indicated, admit to stroke unit (3 Truett) 

Labs — CBC, CMP, Fasting Lipid level, DFS, HgbA1C, PT, 

PTT, utox, hypercoagulable work-up and blood cultures on 

young patients 

Imaging — Stat CT head without contrast to evaluate for 

hemorrhage, MRI/MRA head and neck or CTA head and neck, 

Carotid Doppler if you do not obtain other imaging of the 

neck(carotids), EKG, TEE in patients who are suspected to 

have embolic stroke without known source (Afib), TTE with 

Bubble study is acceptable as screen in others if low suspicion 

of central embolic process (cross out TEE on protocol as you 

want to order TTE with bubble study instead) 

Treatment: 

1. If

72 

4. Tx of HTN not of proven benefit unless >220/120 or 

comorbidities present: aortic dissection, MI, CHF, IC 

mass, etc. 

5. If giving lytics, treat if sbp>185, dbp>110. 

6. Statin: Consider Zocor 40 mg HS. 

7. DVT prophylaxis: Lovenox 40 mg SC daily vs heparin 

sc BID/TID, with renal insufficiency/failure, lovenox 30 

mg sc daily 

8. If cerebral edema (peaks 3-4 days post-stroke) with 

shift/impending herniation, then treat as elevated ICP 

(below). 

9. Carotid endarterectomy if indicated (see NASCET 

and ACST trials)

73 

ONCOLOGY 

THE ACUTE LEUKEMIC 

“The greatest ‘crumpability’ of any hospital patient you will care 

for.” 

-Troy Neal M.D. 

The acute leukemic patient, AKA the acute leuk, is a common 

admission during a typical ward month at BUMC. As house 

staff, we are involved generally in the care of patients with a 

NEW diagnosis. 

Nuts and bolts — Acute leukemia results from the clonal 

expansion of a hematopoietic precursor that has lost the ability 

to differentiate while maintaining the ability to proliferate. AML 

represents >80 percent of adult cases with a median age of 65 

years. ALL represents

74 

7. Serum and urine lysozyme (may be useful in cases with 

monocytic features) 

8. HLA Class I & II DNA-SBT— if patient candidate for 

allogeneic HSCT 

9. HSV IgM/IgG serologies 

10. Coagulation studies to rule out DIC including PT, PTT, 

fibrinogen, and D-dimer 

11. Lumbar puncture to assess cytology and administer 

chemotherapy for all ALL patients (sanctuary sites) and for 

AML patients with symptoms of CNS dysfunction 

Make sure your patient has the following: 

1. Central access via TLC (subclavian preferable for 

patient comfort but a non-compressible site) or PICC line 

by IV services (may refuse if platelets below their 

threshold-usually 50K, but can transfuse platelets in 

preparation of PICC) 

2. Preserved left ventricular systolic function as confirmed 

by TTE or MUGA scan before use of anthracyclines. 

3. Aggressive bicarbonate-containing IVFs to alkalinize the 

urine and prevent uric acid nephropathy from tumor lysis 

(Generally D5W in 1/2NS with 2 amps HCO3 @ 150 

cc/hour) 

4. Allopurinol 300 mg PO BID +/- rasburicase also for TLS 

prophylaxis 

5. Prophylactic antimicrobials, typically in the form of 

Levaquin 500 mg PO daily, Posaconazole 200 mg PO 

TID, and Famvir 250 mg PO BID (If HSV IgG/IgM+) once 

ANC approximately 500-1000 

6. Orders for daily weights and strict I/O’s (many chemo 

regimens have a large volume and need to watch for signs 

of volume overload) 

7. Orders for daily CMP and CBC 

8. Orders for daily TLS labs initially including potassium, 

uric acid, LDH, phosphorous, and calcium

Timeline*: 

75 

Day 0 (admit) — Bone marrow biopsy and other 

evaluations 

Day 1 — Induction chemotherapy with “7+3” (cytarabine & 

idarubicin/daunorubicin) written by Heme-Onc attending 

Day 10 to 14 — Bone marrow biopsy #2 to evaluate for 

aplasia; G-CSF if no blasts to recover neutrophils 

Day 30 (as outpatient) — CBC and Bone marrow biopsy 

#3 to assess for complete remission (CR); CR = clean 

bone marrow in the setting of no peripheral cytopenias; 

CR does NOT equal cure, therefore, induction 

chemotherapy if successful, must always be followed by 

consolidation therapy (occurs at later admission) 

*The above timeline roughly represents a routine 

admission for an acute leukemic patient. Obviously, there 

will be variation and numerous exceptions depending 

upon whether or not remission was achieved, tolerance of 

chemotherapy, infectious issues, etc. Intended for 

simplified overview only. Day to day supportive care 

issues omitted. 

Fever in the acute leukemic: 

In general, you want to be sure to do the following: 

• Examine the patient 

• Blood cultures x2 

• Fungal culture 

• UA and Urine culture 

• Sputum culture if cough 

• CXR 

• Advance antibiotics: typically with first fever, we advance 

from levaquin to vancomycin and merrem. The second 

time the patient fevers, we advance from posaconazole to 

voriconazole. If they continue to fever, you can consider 

adding micafungin but will likely need ID involvement. 

Most attendings have a preference that they will specify 

for antibiotic advancement. Also, if there is a defined 

etiology, obviously treat appropriately with antibiotics.

76 

Shortness of breath in the acute leukemic: 

Worry about typical causes of shortness of breath in addition to 

severe anemia and opportunistic infections. Also, consider 

leukostasis leading to hypoxemia if blast counts are greater 

than 50,000 to 100,000. If the patient just started 

chemotherapy, they could be having an acute inflammatory 

reaction secondary to treatment or they could have pulmonary 

edema secondary to volume overload. In these instances, 

consider the following possible treatments based on suspected 

etiology and diagnostic work-up: advance airway/oxygen 

support as needed, transfer to the ICU if needed, appropriate 

antibiotics, leukapheresis, and/or IV Lasix.

77 

PALLIATIVE CARE AND CLINICAL 

ETHICS 

The Palliative Care Consultation Service (PCCS) and the 

Clinical Ethics Committee are a vital element of patient care at 

BUMC. The services are closely linked, but not identical. 

The Clinical Ethics Committee is a multidisciplinary committee 

of the medical staff responsible for developing and maintaining 

clinical ethics policies/guidelines, ethics education, and clinical 

ethics consultation. Baylor house staff typically interact with the 

ethics committee when an ethics consult is requested. Ethics 

consultation may be requested for moral guidance in 

circumstances of ethical uncertainty. A consult may be as brief 

as a several minute conversation with one of the ethics 

committee consultants or may involve the consultant seeing 

the patient, reviewing the chart, and actively engaging the 

treatment team, patient, and or family to bring resolution to 

ethical dilemmas. Ethics consultants are advisers only and do 

not write orders nor tell any party what they must do (unless it 

is a matter of hospital policy). Any member of a treatment team 

may request a consult, though it is customary to seek 

involvement from the attending physician prior to this as a 

courtesy. An ethics consult may be obtained by contacting the 

Medical Staff Office (2-2139) or by calling the office of Dr. Fine 

and Dr. Casanova (214-828-5090). 

The Palliative Care Consultation Service is a multidisciplinary 

team composed of staff physicians, nurses, pharmacists, 

speech therapists, nutritionists, social workers, physical and 

occupational therapists, and chaplains, all with extra skills and 

competencies to help manage patients with advanced lifelimiting 

illnesses. It is important to realize that palliative care, 

although often serving as a bridge to hospice, is not the same 

as hospice. Patients seen by the PCCS may continue to 

receive all treatments while receiving expert symptom 

management and the additional psycho-social-spiritual support 

often needed by patients and families facing the most serious 

illness. Unlike clinical ethics consults, members of the palliative 

care team help actively manage patients and write orders. The 

physicians, nurses, and pharmacist team members all have 

special expertise in pain and other symptom management. 

Circumstances in which to consider asking for a palliative care

78 

consult include assistance with controlling a patient’s symptom 

burden, guidance with the often difficult planning and 

conversations associated with decisions near the end of life, 

spiritual support for patients and their families, and 

complimentary therapies. Consults for the Palliative Care 

Consult Service (PCCS) are easily obtained by calling 214- 

820-PCCS (7227). Routine consults are handled 7 days a 

week primarily between 8:30 and 4:30. True palliative care 

emergencies may be called in after hours but must be called in 

directly by the physician requesting emergency assistance. 

Physician team members 

• Dr. Robert Fine 

• Dr. Mark Casanova 

• Dr. Shawnta Pittman-Hobbs 

• Dr. Roberto De La Cruz 

• Dr. Susan Kohl 

Palliative Care nurses 

• Min Patel — weekdays (available at 214-497-2612) 

• Grace Youseff — weekends (available at 214-724- 

5623) 

Palliative Care Pharmacist 

Jennifer Craft — weekdays 

Pain control tidbits 

• There is ample evidence that pain is under treated in 

American hospitals. Among the barriers to effective pain 

management are failure to adequately assess the pain 

and failures to prescribe opioids and other pain 

medications appropriately. 

• Basic pain assessment should always include a pain 

severity score. Remember that pain is subjective and a 

patient’s pain is what they say it is. Baylor uses a 0 – 10 

scale where 0 is no pain at all and 10 is the worst pain 

ever or the worst imaginable to the patient. Some patients 

may not be able to put a number on their pain. If not, they 

should be encouraged to rate the pain as mild, moderate, 

or severe. 

• Acute and/or intermittent pain requires rapid onset short 

acting opioids. The onset of action for these drugs is 5-10 

minutes when given IV and 30- 60 minutes when given 

orally. Typical duration of action is 3 to 4 hours. Some 

commonly used short acting oral opioids include 

hydrocodone, immediate release morphine, immediate

79 

release oxycodone, and hydromorphone. Commonly used 

parenteral opioids are morphine and hydromorphone. 

• Chronic or persistent pain requires long acting 

(inevitably slower onset) opioids such as sustained 

release morphine or sustained release oxycodone – both 

typically dosed at 8 to 12 hour intervals, or Transdermal 

fentanyl. 

• CALCULATION OF ORAL OR PARENTERAL 

MORPHINE EQUIVALENTS — This is the standard way 

to assess a patient’s opioid analgesic requirements, 

generally over a 24 hr period; this allows for summation 

and/or rotation to a simpler and more effective regimen of 

pain control; the John Hopkin’s opioid calculator is a good 

tool for this task. 

• When a patient is thought to be refractory to a particular 

opioid, consider opioid rotation. When rotating patients 

from one opioid to another, begin with 50-75% of the 

equianalgesic dose as the maintenance dose and provide 

the rest as breakthrough. Then adjust the maintenance 

dose as needed to achieve adequate pain relief based on 

the breakthrough usage documented. Allow for 10-15% of 

the total daily dose as a PRN given every 2-4 hours. 

• The preferred route of administration for opioids is oral. 

• “The hand that writes the opioids should also write the 

bowel regimen.” 

• Some useful opiod conversions (see front of chart for full 

equianalgesic dosing chart): 

- PO Morphine : IV Morphine = 3 : 1 

- IV Morphine : IV Hydromorphone = 10 : 2 

- PO Morphine : PO Hydromorphone = 30 : 7.5 

- PO Morphine : PO Hydrocodone = 1 : 1 

• When a patient is in a pain crisis, you may redose if pain 

uncontrolled at the opiod’s peak. 

• Do not exceed 12 tabs of Norco (325 mg Tylenol) or 8 

tabs of Lortab (500 mg Tylenol) in a 24 hr period due to 

the risk of acetaminophen toxicity. For this reason, avoid 

Percocet and Tylox (oxycodone plus Tylenol) for 

chronic/severe pain. 

• Dose Fentanyl transdermal patch (Duragesic) based on 

50% of the total oral morphine equivalent dose over 24 hr 

period. Rapid metabolizers of Fentanyl may require 

changing the patch every 48 hrs vs. every 72 hrs. Also, 

febrile patients will liberate the medication faster. Patch 

may be less effective in thin/cachectic patients due to 

unpredictable absorption. Patch reaches peak effect in

80 

17-20 hrs and takes the same to be eliminated once 

removed. Titrate doses every 48 hrs but no sooner. 

• Methadone is often an effective opioid when other 

opioids are not working. However, it is easily mis-dosed 

and carries some increased risks. Involve a physician, 

nurse, or pharmacist member of the palliative care team 

when starting and titrating methadone. 

• There is no “ceiling” for the amount of opioids that a 

patient can have, but side effects may eventually become 

limiting and alternatives (like Ketamine, for opiod-sparing 

effect) may have to be explored. Undesirable effects to 

monitor for are 1.) respiratory depression 2.) over-sedation 

3.) delirium 4.) hyperalgesia 5.) myoclonus 

• Stimulants such as Ritalin (10 mg upon arising then 10 

mg 4-6 hrs later), Dexedrene, and Provigil can offer 

periods of improved alertness by combating the sedation 

of opioids during the day or more specifically for planned 

family time or visits. Avoid doses late in the day to avoid 

insomnia. 

• For dyspnea/air hunger, consider morphine 1-2 mg IV 

every 1-2 hours PRN in an opioid naieve patient. Patients 

tolerant of opioids may need higher doses for air hunger 

managment. 

• Saturate the opioid receptors to achieve sedation before 

adding benzodiazepines because you want patients to be 

comfortable, not just look comfortable. Benzodiazepines 

can mask pain despite a patient’s appearance. 

• Always be open to adjuvant therapies such as TENs 

unit, heat, trigger point maneuvers (injections, ball in 

sock), myorelaxants, neuropathic agents (TCAs, 

Neurontin, Lyrica), relaxation/complimentary therapy, 

nerve blockade, NSAIDs, palliative radiation, 

bisphosphonates, glucocorticoids, anti-emetics, and 

scopolamine for control of secretions 

• Don’t forget other potentiators of pain such as 

emotional, spiritual, or relational distress. 

Useful resources 

• Hopkins opioid calculator for PDA or on the web at 

http://www.hopweb.org/hop/login.cfm; you then create a 

user name and password for free to gain access. 

• Palliative Care “Fast Facts” available at 

http://www.eperc.mcw.edu/ff_index.htm 

• CPR Outcomes and Counseling Guidelines tri-fold 

brochure

81 

• Institutional Ethics and Palliative Care link on the Baylor 

home page 

Hospice/comfort care measures 

Helpful medications/orders if you are transitioning to in-patient 

hospice and comfort care: 

• The hospice nurse will write orders as she evaluates the 

needs of the patient and call you to make 

recommendations and get your verbal approval if the 

patient is going on in-patient hospice. 

• Excess Secretions: Scopolamine patch behind ear 

once every 72 hours; if still struggling, can add atropine 

1% ophthalmic solution, 2 gtts under tongue Q3 hours prn 

• Fever: Tylenol 650 mg PO or per rectum Q4-6 hours prn 

pain/fever 

• Nausea/Vomiting: Phenergan 12.5 to 25 mg PO or per 

rectum Q6 hours prn nausea or vomiting 

• Pain regimens: Consult above; can try morphine gtt, 

titrate to comfort if patient is nearing end of life and pain 

not able to be controlled with orals or patch. 

• Air hunger: Morphine 1-2 mg per hour prn; add Oxygen 

by NC at 4-6 L, but write for nurse to not check O2 sats as 

this is for comfort only. 

• Constipation: Milk of magnesia, Miralax, Senna, or 

Dulcolax on a daily basis. Constipation is better prevented 

than treated. Do not use fiber supplements to treat 

constipation due to opioids or at the end of life. 

• Wheezing: A/A nebs q4 hours prn. 

• If patient aspirates and is under aspiration precautions, 

including ordered to be NPO status, consider changing 

this to comfort feedings. 

• Other symptomatic treatment as needed. Pastoral 

services are always available.

NeoSynephrine(phenylephrine) 

10-300 

mcg/min 

Dobutamine 

2-20 

mcg/kg/ 

min 

Levophed 

(norepine 

-phrine) 

1-40 

mcg/min 

Dopamine 

Epinephrine 

2-20 

mcg/min 

Primacor 

(milrinone) 

Vasopressin(antidiuretic 

hormone) 

0.04 

units/hr 

82 

PRESSOR CHART 

Alpha Beta Dopa 

(renal 

recept 

or) 

Heart 

Rate 

SVR 

Cardiac 

output 

++ 0 0 0 ↑↑↑ 0 

0 +++ 0 ↑↑ ↓ ↑↑ 

+++ + 0 ↑↑ ↑↑↑ ↑ 

>10 

mcg/ 

kg/min 

2-10 

mcg/ 

kg/min 

0.5-2 

mcg/ 

kg/min 

↑↑ ↑↑ ↑ 

+ +++ 0 ↑↑ ↑ ↑ 

0 ++ 0 ↑↑ ↓ ↑↑ 

Primarily used in conjunction with levophed or 

neosynephrine in septic patients to aid with 

peripheral vasoconstriction (direct stimulation of 

smooth muscle V1 receptors).

83 

PULMONARY 

ARDS 

Definition: Need all 4 criteria 

1. Acute onset 

2. PCWP

84 

Higher PEEP/lower FiO2 

FiO 2 0.3 0.3 0.3 0.3 0.3 0.4 0.4 0.5 

PEEP 5 8 10 12 14 14 16 16 

FiO 

2 

0.5 0.5- 

0.8 

0.8 0.9 1.0 1.0 

PEEP 18 20 22 22 22 24 

ASTHMA/COPD 

Treatment of Asthma exacerbation: 

1. Albuterol nebs at least 3 times in first hour, then 

scheduled Q2-4 hours, plus prn nebs 

2. Steroids: Either IV or PO based on severity (IV not 

superior to PO). 60 mg prednisone PO qday or 1 

mg/kg prednisone equivalent Q6-12 hours (at Baylor 

for severe asthma exac, typically 60 mg IV solumedrol 

Q6 hours) until PEFR reaches 70% predicted; then 

begin taper. 

3. Continue home dose of inhaled steroid if on one 

4. O2 per protocol to keep SaO2 above 90%; use NPPV 

if patient’s paCO2 begins to normalize or rise; also in 

status asthmaticus 

5. Determine severity of exacerbation and ward level 

versus ICU level of care 

6. Check CXR and signs of infection 

Treatment of COPD exacerbation: 

1. Ipratropium/Albuterol nebs Q1-2 hours to begin 

2. O2 per protocol to keep SaO2 >90% 

3. Steroids: IV solumedrol at 60 -125 mg IV Q6 

hours (usually 60), or oral at 60 mg prednisone PO 

Qday 

4. Antibiotics: amoxicillin, Bactrim, doxy, 

clarithromycin, levoquin (no single abx proven 

superior but we typically use levaquin) 

5. NPPV: Initiate early if mod/severe dyspnea, 

decreased pH/high pCO2, RR>25 

6. CXR 

7. Smoking cessation counseling

85 

MECHANICAL VENITALTION 

Oxygen support 

Nasal Cannula (NC) 

• Each L adds about 3% FiO2 therefore 1L is 24% FiO2 

w/ max of 6L and thus Max FiO2 of about 40% 

Venturi Mask (VM): Can set an FiO2 

• Max FiO2 of 50% 

Partial ReBreather (PRB) Mask w/ Reservoir Bag (exhaled 

gas mixes with bag oxygen) 


Non-ReBreather (NRB) Mask w/ Reservoir Bag (exhaled gas 

does not mix with bag oxygen) 


Types of ventilatory support 

Noninvasive Positive Pressure Ventilation (NPPV) 

Face/Nasal Mask Continuous Positive Airway Pressure 

(CPAP): One continuous pressure during inspiration and 

expiration 

Uses: Patients whose primary problem is hypoxemia; 

typically used with CHF patients as well as OSA 

Face/Nasal Mask Bilevel Positive Airway Pressure (BiPAP): 

Set different inspiratory/expiratory pressures 

Uses: Patients whose primary problem is hypoventilation 

or hypoxemia such as COPD, immunocompromised, postextubation 

especially if patient is high risk, DNI patients, 

PNA, etc. 

Inspiratory Pressure (IP): Start at 8 to 10 cm of H2O and 

increase as tolerated to improve Tidal Volume (TV) and 

decrease work of breathing, which will result in decreased 

pCO2. 

Expiratory Pressure (EP) ~ PEEP start at 4 to 5 cm of H2O and 

increase as tolerated to increase PO2.

86 

Invasive Mechanical Ventilation (MV) Modes 

Pressure Support Ventilation (PSV): *NOTE: This mode is 

only for patients with an intact respiratory drive* 

• Patient initiates a breath, which is supported by vent at a 

preset pressure 

• Flow cycled NOT volume cycled like in SIMV/AC 

• “Pressure Support” = inspiratory pressure selected to 

achieve adequate TV and ventilatory support 

• Can be combined w/ SIMV to partially assist 

spontaneous breaths 

• Could be considered to make patient more “comfortable” 

on vent; also used for SBT at the appropriate level. 

Synchronized Intermittent Mechanical Ventilation (SIMV): 

• Patient receives vent support at a given tidal volume and 

respiratory rate. If patient initiates additional breaths, the 

vent provides no support to these breaths unless pressure 

support is added. 

• This mode has been proposed to prevent respiratory 

alkalosis; however, it requires more respiratory muscle 

work than AC. 

• Used primarily in SICU 

Assist-Controlled Mechanical Ventilation (AC): Can set volume 

targeted or pressure targeted. 

• When using volume targeted: Patient receives vent 

support at a given tidal volume and respiratory rate. If 

patient initiates additional breaths, the vent delivers the 

pre-set tidal volume with each additional breath. 

• If the patient is tachypnic, then hyperventilation can 

occur 

Other modes to minimize lung injury: 

• High Frequency Jet Ventilation/Oscillation: Alveoli are 

kept fully open as if the patient is kept at full inspiration 

while gases are exchanged by oscillating the air at high 

frequency 

Indications for intubation 

• Refractory hypoxemia 

• Hypercapnea with respiratory acidosis (note that 

patients w/ COPD often live w/ pCO2 b/t 50-70)

87 

• Ineffective respiratory effort, ie, Agonal Breathing or 

Respiratory Muscle Weakness (Max Inspiratory Force 1d) 

I:E Ratio = 1:2 to 1:4 which is determined by your Inspiratory 

Flow Rate. TV and respiratory rate in Volume Controlled 

Ventilation 

Positive End Expiratory Pressure (PEEP) = 0-10 cm of H20 

(may have to increase more if clinically indicated) 

• Higher levels of PEEP in asthmatics and COPD patients 

may worsen auto-peeping 

• In ARDS, may have to use higher level of PEEP for any 

given FiO2 (see ARDS)

88 

Any time a patient is on MV, the minute volume, plateau, 

and peak pressures should be monitored and reported it 

in your daily note. 

VT (VTE) x RR (fTOT) = minute volume (VETOT) L/min 

Specific disease states and mechanical ventilation 

suggestions: 

• Acute Brain Injury: Volume cycled, Avoid PEEP, Limit 

suctioning, Hyperventilate with pCO2 of 34-37 

• Neuromuscular disease: Volume cycled, Larger VT 

(12-15 ml/kg), Higher flow rate 

• COPD: Volume cycled, VT (5-7 ml/kg), higher peak flow 

rate, lower mandatory rate, low level PEEP(3), Limit 

plateau airway pressures, Reduce autopeep/hyperinflation 

• ARDS: Volume cycled, VT (4-6 ml/kg), plateau airway 

pressures 5 days as the drug 

accumulates in adipose tissue.

89 

- Daily sedation vacations at 0700 (“Sedation 

Vacation”) if the following is NOT present 

• FiO2 >60% 

• PEEP >10cm 

• Neurosurgical Pt 

• Increased ICP 

• Hemodynamically Unstable 

• Neuromuscular Blockade 

Consider a pulmonary critical care consult for every 

patient on a ventilator. After 48 hours of MV, it is hospital 

policy that you must get a pulmonary critical care consult. 

Simplistic approach to adjusting the vent 

• Low pO2: increase FiO2 or increase PEEP (to recruit 

more alveoli) 

• High pCO2: increase TV or increase rate (to increase 

minute volume) 

• Use ratios: pCO2 current x RR current=pCO2 desired x 

RR desired 

• For every 10 change in pCO2, the pH changes 

approximately 0.8 (acutely) 

Troubleshooting the vent 

Decreased Peak Inspiratory Pressure (PIP) 

• Disconnect problem: Consider disconnected tubing, lost 

airway 

Increased Peak Inspiratory Pressure (PIP) 

• First, check plateau pressure 

• Do this by pressing Inspiratory Pause Button 

• Check PPlat 

- Normal (Plateau Pressure10): This means there is increased airway 

resistance. Examples of what could be causing this 

include: Patient biting tube (increase sedation or add 

bite block), Airway Obstruction from bronchospasm 

(BD), secretions/aspiration (suction), plugging 

(mucolytics), etc. When the alarm goes off, increase 

parameter for peak pressure alarm while 

troubleshooting the vent: otherwise ventilator stops 

giving a breath with each breath when peak pressures 

are high and patient is not ventilated.

90 

- Increased (Plateau Pressure>30 and gradient of 

Peak to plateau

91 

• After 1 wk of intubation determine likelihood of 

extubation at 2wks. If unlikely proceed with 

bedside/surgical tracheostomy with a GS 

• Tracheostomy may be beneficial because it is more 

comfortable, more ease in clearing secretions, decreased 

airway resistance, decreased laryngeal injury, can eat 

orally, can partially vocalize, etc. 

- Complications: Infection (mediastinitis), bleeding, 

accidental removal with closure of stoma and then 

blind reinsertion potentially creating a false tract, 

injury to surrounding structures 

- Consider a Passy-Muir valve when a patient has a 

trach after weaning off ventilator to help with talking. 

The Passy-Muir valve acts as a one-way valve 

allowing air to go in through the trach and be exhaled 

through the native airway. 

- You can put a red cap over trach and see if pt can 

breath/talk fine, and, if so, you can decanulate the 

patient (the hole closes on its own in 2-3d) 

Oxygen Toxicity — Remember oxygen toxicity (FiO2 >60% 

for >48hrs) from the production of oxidizing radicals which 

damage membranes, denature proteins, and break DNA 

Cardiac Output Changes — Can reduce cardiac output 

because of decreased venous return and increase right 

ventricle afterload 

Respiratory Muscle Atrophy 

Trauma to Airway, Dentition, etc 

ETT Migration (normally the tip of the ETT should be 2cm 

above carina) 

Critical Illness Polyneuropathy/Myopaythy 

• Consider when patients continually need MV despite 

resolution of primary problem 

After Extubation 

• Sore throat, Hoarseness, Cough, etc: Can be normal 

and should resolve. 

• Laryngeal Edema 

- Usually occurs when patient is extubated from 2- 

7days post-extubation. After extubation, an average 

of 40% of patients have laryngeal edema but only 5% 

having severe obstruction

92 

-If you extubate and hear stridor with poor respiration 

then consider edema and acutely give racemic Epi 

nebs prn stridor, keep HOB elevated to 90°, and give 

solumedrol 60 mg IV Q6 hours x 48 hours 

• Vocal Cord Dysfunction (VCD) 

- This is a long term complication: Need ENT 

evaluation 

Weaning MV 

When pts are clinically improved, assess the following criteria 

for extubation: 

• Original condition requiring intubation has been reversed 

or improved 

• During sedation vacation, patients are awake and alert 

• Hemodynamically Stable (HR60mm, no 

evidence of myocardial ischemia) while on minimum to no 

vasopressor support and no sedation 

• Stable Oxygenation (PaO2>60mm and O2Sat>92%) 

while on minimum non-toxic oxygenation settings 

(PEEP

93 

- Sustained changes in the heart rate of 20 percent in 

either direction 

- A systolic blood pressure greater than 180 mm Hg 

or less than 90 mm Hg 

- Increased anxiety 

- Diaphoresis 

If pts pass SBT then write orders: 

• Check Cuff Leak Test prior to extubation (Patients 

without a cuff leak are at increased risk for post-extubation 

stridor) 

• Respiratory to Extubate (How is it done? HOB elevated 

to 90°, pull ETT, suction, listen for stridor, suction, then 

Face Mask/NC) 

• Place pt on 6L NC and then proceed w/ O2 Protocol 

• Incentive Spirometry (IS) Q2hrs while awake 

• Med Nebs: IPPB A/A nebs Q4 hours x 48 hours 

(Intermittent Positive Pressure Breathing (IPPB)) which is 

mainly used to treat atelectasis after surgery or postextubation 

to improve inspiratory capacity 

• Consider BiPAP if patient is high risk for re-intubation as 

post-extubation BiPAP has been shown to decrease reintubation 

• Swallow Study and Advance Diet as tolerated if passes 

• PT/OT 

If pts fail SBT then assess cause (see below) and retry SBT 

Qday if you feel patient is still clinically prepared. 

F Fluid overload: Diurese as able 

A Airway resistance: Check if ET tube is too small or 

obstructed 

I Infection: Treat as indicated 

L Lying down, bad V/Q mismatch: Elevate head of bed 

T Thyroid, toxicity of drugs: check TFT’s, check med list 

O Oxygen: Increase FiO2 as patient is taken off 

ventilator 

W Wheezing: treat with nebs/steroids as needed 

E Electrolyte disturbances: Correct K, Mg, Phos, 

Calcium 

A Anti-inflammatory needed?: Consider steroids in 

asthma/COPD 

N Neuromuscular disease, neuro status compromised

94 

PLEURAL EFFUSION 

Thoracentesis needed if effusion >1 cm in decubitus view; also 

patient with fever, chest pain, unilateral effusion, or new 

effusion. Parapneumonic effusions should be tapped ASAP. 

Transudate versus Exudate: 

1. Light’s criteria:TP eff/TP serum=>0.5, LDH eff/LDH 

serum >0.6, or LDH eff > 2/3 upper limit of normal of 

LDH serum (Best sensitivity but will misidentify 25% 

of transudates as exudates). Light’s criteria is most 

used and clinically applicable. 

2. Exudative criteria with better specificity: two test rule 

(pleural fluid cholesterol >45 and pleural fluid LDH 

>0.45 times upper limit of normal serum LDH), or 

three test rule (pleural fluid protein >2.9, pleural fluid 

cholesterol >45, and pleural fluid LDH >0.45 times 

upper limit of normal serum LDH) 

Complicated versus Uncomplicated Parapneumonic 

effusion: 

1. Complicated=positive gram stain or culture or pH

95 

PULMONARY EMBOLUS (PE) 

Evaluating using Dichotomized Wells clinical PE 

Probability for Algorithm using CT angiography 

(CTA) 

Variable Point Score 

Symptoms and signs of DVT 3 

PE more likely than alternative 

diagnosis 

3 

HR >100 beats/ minute 1.5 

Recent immobilization or surgery 

(

96 

• All other combinations with V/Q scan requires further 

testing (ie, serial venous ultrasonography and pulmonary 

angiography) 

Treatment 

• Reserve TPA for patients with hemodynamic 

compromise (cardiogenic shock, persistent arterial 

hypotension, or both). If hemodynamically unstable, start 

on heparin drip immediately and prepare for thrombolytics. 

• Start patients with intermediate-risk or high risk PE on 

unfractionated heparin drip per protocol or enoxaparin at 1 

mg/kg SC BID (can use fondaparinux in HIT patients). 

Patient needs to be on enoxaparin or fondaparinux 

eventually for outpatient bridge to long term 

anticoagulation therapy. These agents are generally 

preferred because they are easier to administer and are 

associated with lower rates of heparin-induced 

thrombocytopenia 

• If patient has HIT, can use argatroban or lepirudin drip 

instead of heparin drip (there are protocols for both). 

• Start patient on warfarin when heparin assay therapeutic 

or after 1 st does of LMWH; goal INR 2-3. Need to overlap 

treatment-usually 2-3 days after INR is therapeutic, and 

then can discontinue heparin. 

• Send patient to IR for IVC filter placement if 

contraindication to anticoagulation, treatment failure, or 

bleeding. 

References: 

1. Fauci, AS, Martin, JB Braunwald, E. et al (Eds). Harrison’s 

Principles of Internal Medicine. 14 th Edition. McGraw Hill, New York, 

1998. 

2. Konstantinides, S. Acute Pulmonary Embolism. N Engl J Med 2008; 

359:2804-2813. 

3. Esteban, A, Frutos, F, Tobin, MJ, et al. A Comparison of Four 

Methods of Weaning Patients from Mechanical Ventilation. N Engl J 

Med 1995; 332:345-350. 

4. Manthous, C, Schmidt, G, Hall, J. Liberation from Mechanical 

Ventilation: A Decade of Progress. Chest 1998; 114:886-901. 

5. Schmidt, SL, Hyzy, RC. Overview of Mechanical Ventilation. In: 

UpToDate, Basow, D (Ed), UpToDate, Waltham, MA, 2009. 

6. Tobin, MJ. Advances in Mechanical Ventilation. N Engl J Med 2001; 

344:1986-96. 

7. Ventilation with lower tidal volumes as compared with traditional 

tidal volumes for acute lung injury and acute respiratory distress 

syndrome. The Acute Respiratory Distress Syndrome Network. N Engl 

J Med 2000; 342:1301-8.

97 

RADIOLOGY 

RADIOLOGY HINTS 

IF YOU’RE THINKING THIS: ORDER THIS 

FIRST 

Shortness of breath CXR* 

Chest pain CXR* 

Volume overload CXR* 

Obstruction Supine/upright 

KUB 

Acute abdomen, bowel 

perforation 

Abdomen 

obstructive series 

After subclavian line placement pCXR to r/o PTX 

DVT (pain, swelling) Lower extremity 

Doppler 

ultrasound 

PE (Consider 

checking ddimer 

+/- doing LE 

Doppler first) -- 

CTA chest (CT 

chest PE protocol) 

AMS CT head 

Carotid stenosis Carotid Doppler 

ultrasound 

Stroke CT head 

WITHOUT 

contrast, then MRI 

brain

98 

F/U pulmonary nodules CT without IV 

contrast 

Abdominal pain CT abdomen with 

oral and IV 

contrast 

Cirrhosis, elevated LFT’s, 

jaundice 

RUQ ultrasound 

Hepatomegaly, 

Abdominal 

splenomegaly 

ultrasound 

Hepatocellular carcinoma MRI liver 

Confirm hemangiomas MRI 

GB- Chronic 

cholecystitis/gallstones/b 

iliary colic 

Ultrasound 

GB- Acute cholecystitis Ultrasound; 

consider HIDA if 

U/S equivocal 

Kidney stones Renal stone 

protocol CT 

Renal disease, elevated 

Renal Ultrasound 

creatinine 

Pancreas (complications 

of pancreatitis, 

pancreatic cancer) 

CT Abdomen with 

contrast 

Adrenal mass Adrenal mass 

protocol CT or 

MRI 

Acute GI bleed < .5-1.0 

Tagged RBC 

ml/min 

Acute GI bleed < 2 ml/min Endoscopy 

Acute GI bleed 2 ml/min Mesenteric 

Angiography 

Mesenteric Ischemia CT Angiogram 

Abdomen/Pelvis 

Appendicitis Ultrasound (if 

thin), CT 

Abdomen/Pelvis 

with oral and IV 

contrast

Superficial Abscess/Mass 

Abscess/Mass/ 

Infection 

99 

Ultrasound 

CT chest, 

abdomen or pelvis 

with oral and IV 

contrast 

Trauma CT 

Tumor Staging CT with IV 

contrast 

Testicular Mass/Torsion Testicular 

Ultrasound 

Myositis MRI 

Osteomyelitis MRI/ Indium / 

Gallium 

Breast Mass Mammogram 

Dysphagia, non-cardiac 

chest pain, GERD 

GI ulcer, hiatal hernia, 

abdominal pain 

IBD, small bowel 

obstruction, small bowel 

mass, malabsorption 

Large bowel obstruction, 

LLQ pain, constipation, 

diarrhea 

Biopsy (peripheral lung 

mass, liver, renal, lymph 

node, etc) 

Gastrostomy tube, IVC 

Filter 

Esophagogram 

UGI 

Small bowel follow 

through 

Barium enema 

Consult biopsy 

service 

Consult IR 

Ovarian Torsion Ultrasound 

Endocarditis TEE 

Pulm HTN/CHF TTE

100 

*With CXR: PA/lateral if pt able to stand; portable if unable to 

go to radiology or if STAT 

If you have any questions about what test to order, feel free to 

call and ask. Also, when you write the order for an exam, write 

an indication including what you are worried about and why. It 

will help make sure your test gets done correctly and that your 

specific concern is addressed in the report. This will save you 

from having to track someone down later if the report doesn’t 

address your main concern. 

To hear dictations of radiology reports: call “2 X-RAY” (29729). 

You will be prompted to enter your “logon ID” (your 4-digit 

dictation number), followed by #. Then you will be prompted for 

your password (1 st time is your 4-digit dictation number, but it 

will prompt you to change it), followed by #. Then you put in the 

pt’s date of birth, followed by #. The most recent dictation plays 

first.

101 

RENAL 

ACID/BASE DISTURBANCES 

Quick guide to acid/base disturbances: 

1. Look at the Ph: 

7.40 = normal 

7.45 = alkalemia 

Decide primary disorder (this is if compensated): 

Primary disorder pH HCO3 paCO2 

Metabolic 

acidosis 

↓ ↓ ↓ 

Metabolic 

alkalosis 

↑ ↑ ↑ 

Resp acidosis ↓ ↑ ↑ 

Resp alkalosis ↑ ↓ ↓ 

2. Determine if degree of compensation is appropriate: 

Metabolic acidosis: PCO2 = HCO3 + 15 (or the Winter’s 

Equation — pCO2 = 1.5(HCO3) + 8 +/- 2) 

Also, with metabolic acidosis the last decimal digits of 

the pH should equal pCO2 +/-2. 

Metabolic alkalosis: Increase in PaCO2 = 0.75 x change 

in HCO3 (HCO3 + 15 works fairly well) 

Respiratory acidosis: 

Acute: for every increase in 10 in pCO2, there is an 

increase in HCO3 by 1 

Chronic: for every increase in 10 in pCO2, there is an 

increase in HCO3 by 4 

Respiratory alkalosis: 

Acute: for every decrease in 10 in pCO2, there is a 

decrease in HCO3 by 2 

Chronic: for every decrease in 10 pCO2, there is a 

decrease in HCO3 by 5 

If not what expected, consider a mixed disorder.

102 

3. Calculate anion gap by Na- Cl- HCO3 (nl 8-12; if albumin 

is low reduce normal range by 2-3 for each 1 gm reduction 

of albumin below normal): 

Causes of AGMA: KUSMALE (ketones, uremia, 

salicylates, methanol, paraldehyde, lactic acidosis, or 

ethylene glycol) or GOLDMARK-paper submitted by 

Mehta et al (glycols, oxyproline, L-lactate, D-lactate, 

Methanol, Aspirin, Renal, Ketoacidosis) 

If anion gap, consider the following: urine and serum 

ketones, renal function, lactate, Utox, plasma osmolal gap. 

Osmolal gap: “Delta Osmoles” =measured plasma 

osmolality - calculated osmolality 

Calculated osmolality = (2xNa)+(glucose/18)+(BUN/2.8) 

Osmolal gap >15 suggests methanol or ethylene glycol 

If anion gap is decreased, you should suspect a 

decreased albumin or disorders that increase 

“unmeasured” cations such as multiple myeloma, extreme 

hypercalcemia, hypermagnesemia, lithium. 

4. If there is a high anion gap, then calculate how much it is 

increased above the normal range (ie, Anion Gap Increase 

= observed anion gap-expected anion gap (8 - 12 if 

albumin is normal) 

Increase in Gap + measured HCO3 should = about 24 

(The gap should go up about the same amount the HCO3 

goes down) 

• If this is >24 consider concomitant metabolic 

alkalosis or severe chronic respiratory acidosis 

• If this is

103 

ACUTE KIDNEY INJURY 

Acute Kidney Injury Network (AKIN) definition of 

AKI: (Have offered a modification/update of RIFLE) 

The proposed diagnostic criteria are an abrupt (within 48 

hours): 

• Absolute increase in the serum creatinine concentration 

of ≥0.3 mg/dL from baseline, or 

• A percentage increase in the serum creatinine 

concentration of ≥50 percent, 

• Or oliguria of less than 0.5 mL/kg per hour for more than 

six hours. 

The diagnostic criteria should be applied only after volume 

status has been optimized and urinary tract obstruction has 

been ruled out if oliguria was used as the sole diagnostic 

criterion. 

The Acute Kidney Injury Network also includes a staging 

system that correlates to the RIFLE criteria. Stage 1 (risk), 

stage 2 (injury), and stage 3 (failure) are included and loss and 

ESRD are considered outcomes. 

RIFLE criteria proposed by the Acute Dialysis 

Quality Initiative (ADQI): 

• Risk — 1.5-fold increase in the serum creatinine or GFR 

decrease by 25 percent or urine output

104 

Consider obtaining the following history or ordering 

the following labs/studies: 

• History: Any history of contrast, NSAIDS, nephrotoxins, 

intravascular volume depletion (vomiting, diarrhea, 

hemorrhage, diuretics, third spacing, burns), sepsis, 

recent procedure or surgery (angiography, if CABG-check 

aorta cross clamp time, check anesthesia log for any 

episodes of hypotension), medication history, history of 

renal disease, history of vasculitis 

• UA with microscopy (simple test to perform and can 

give you very valuable information) 

• Consider bladder outlet obstruction. If Foley is in place, 

is it blocked? 

• Renal ultrasound to evaluate for hydronephrosis 

• Urine spot Na, Cr at same time as BMP to calculate 

FENa if oliguric 

• Urine eosinophils if thinking about interstitial 

nephritis/cholesterol emboli/ATN 

Treatment: 

• Treat underlying cause 

• IV Fluids if needed 

• Avoid nephrotoxins/contrast 

• Renally dose medications 

• See indications for renal replacement therapy below 

BASIC ELECTROLYE REPLACEMENT 

Can replete as below and then look for underlying cause of 

deficiency. 

Calcium: Check ionized calcium, then give one to two 

amps of Calcium gluconate IVPB if low 

Magnesium: Each 1 gram given increases the serum level 

by about 0.1 

MgSO4 comes as a 50% solution in 2cc amps 

(2cc = 1 gm MgSO4 = 98 mg Mg = 4 mM Mg = 8 mEq 

Mg) 

Send blood and urine for Mg and Cr before replacing to 

check FEx Mg

105 

Mg

106 

Remember to adjust this is they have an elevated creatinine, 

low weight, etc. 

If patient taking a diet: 

K 3.6 to 3.8 50 meq K PO x1 

K 3.3 to 3.5 50 meq K PO q 2 hours x 2 doses 

K 2.8 to 3.2 50 meq K PO q 2 hours x 3 doses 

K

107 

CHRONIC KIDNEY DISEASE 

Stage GFR 

I >90 

II 60-89 

III 30-59 

IV 15-29 

V

108 

disease (GFR of 30 to 59 mL/min per 1.73 m2), 70 to 110 

pg/mL for those with stage 4 disease (GFR of 15 to 29 

mL/min per 1.73 m2), 150 to 300 pg/mL for stage 5 

disease (dialysis or GFR of less than 15 mL/min per 1.73 

m2) 

• Hypertension: Goal blood pressure is at least

Hypovolemic 

Hyponatremia 

EABV low 

Renal losses 

Diuretics/Salt 

Wasting 

GI losses 

Diarrhea/ 

Vomiting 

Bleeding 

Other 

Pancreatitis 

3 rd Spacing 

(Burns,etc.) 

Treatment: 

Volume replete 

with 

• NS 

• Blood 

• Colloid 

Uosm100 

• SIADH (also see Una high, 

Plasma BUN and uric acid low 

• Hypothyroidism 

• Glucocorticoid deficiency 

Treatments: 

• Fluid restriction 

• Hypertonic saline 

• Demeclocycline

Anuria: UOP

111 

fluid pulled off and into the peritoneum. Access is through a 

temporary or permanent catheter. 

Choice of therapy: 

• Continuous Renal Replacement Therapy (CRRT): 

-Continuous venovenous hemodialysis (CVVHD) 

-Continuous arteriovenous hemodialysis (CAVHD) 

-Continuous venovenous hemodialysis with filtration 

(CVVHDF) 

-Continuous arteriovenous hemodialysis with filtration 

(CAVHDF) 

-Continuous venovenous hemofiltration (CVVHF) 

-Continuous arteriovenous hemofiltration (CAVHF) 

• Intermittent Hemodialysis (IDH) 

• Peritoneal Dialysis (PD) 

Timing of therapy: Optimal timing of RRT in patients with 

AKI remains to be clearly elucidated. Some retrospective and 

uncontrolled studies suggest that prophylactic dialysis prior to 

the development of overt uremia among patients with 

progressive AKI may be associated with reduced mortality. 

Some show no difference in mortality. Only one prospective 

randomized trial has been done to evaluate the timing of 

CRRT and it showed no survival benefit in early versus late 

CVVHF. Timing is therefore very much practitioner based. 

Choice of modality: 

• Hemofiltration versus hemodialysis: HF can more quickly 

clear larger molecular weight molecules. However, no trials 

have shown improved clinical outcomes with either modality 

over the other. 

• CRRT versus IHD: Current data suggests that survival and 

renal recovery are equal in patients who undergo CRRT versus 

IHD. Data do not support the superiority of any particular 

mode of RRT in patients with AKI.

112 

OUTPATIENT CLINIC GUIDE 

THE PATIENT ENCOUNTER 

• Check-in and vitals are completed by the medical 

assistant (MA). 

• All charts are viewed via Baylor EMR. Go to “Clinic Visit 

History.” 

• Once you have completed your clinic visit, complete the 

following checklist: 

- Clinic Visit form, only middle and right column is 

required. 

- Universal Medication List at each visit with resident 

signature. 

- Lab Request form for same day, one week prior to 

next visit, or both. 

- Fill out any consult or imaging forms as needed. 

- Retrieve, record on log, and place med samples in 

bag with “Instructions” form placed inside and patient 

label placed on outside of bag. 

- Write all prescriptions with DPS and DEA # on each 

Rx 

- Return appointment/referral form. 

- Dictate Clinic Visit. Dictation “type” = ‘98’. 

- Find a nurse to “check-out” by reviewing each 

above item with RN. The nurse will then dispense 

meds, prescriptions, and papers to the patient. 

RESOURCES 

• The clinic chiefs (two residents) accept clinic patients bimonthly. 

BUMC then assigns them to category 1 through 

8, category 1 being least funded. There are various 

resources that can be offered to the patients based on 

these categories. 

• The patient’s category and insurance information are 

located on the face sheet. 

Referrals 

Specialties offered via Resident Clinic and open to all clinic 

patients: 

• Renal, Cards, Oncology, GI, OB-Gyn, General Surgery,

113 

Colorectal Surgery, and Plastic Surgery � Fill out consult 

form. 

• Dermatology: Dr. Menter sees un-funded patients in the 

resident clinic weekly, and gets booked in advance. � Fill 

out consult form. 

• PM&R, Physical Therapy � Fill out consult form. 

Specialties not offered via Resident Clinic: 

• Psychiatry: 

- Funded patients � BUMC Psychiatry. Make 

referral. 

- Un-funded � Northstar. Consult Social Work to 

arrange. 

• Others (eg Ophtho, Urology): 

- Funded � BUMC referral. 

- Un-funded and in-county � Parkland. Consult 

Social Work. 

• BUMC also offers Podiatry and COPD clinic, but 

requires insurance. 

Dentistry 

• The Dental School Clinic provides dental services at a 

reduced cost. 

• The patient will initially need to call the dental clinic at 

(214) 823-1376, Wednesdays from 9-10:30 am. There is a 

non-refundable screening fee of $54.00. To refer, let the 

RN know during check-out. 

Coumadin Clinic 

• Run by our Clinical Pharmacist Jennifer. 

Medications 

• Formulary medications (list posted on wall) for Category 

I, II, and III patients. 

• Samples available for all clinic patients. 

• Insulin (70/30 and Levemir). Write Rx and consult clinic 

pharmacist. 

• $4 Walmart List (see next section in book for full listing) 

Insulin-dependent diabetes mellitus 

When starting insulin, the clinic offers these resources: 

• Insulin at no cost for un-funded patients. Write Rx and 

pharmacy consult. Pharmacist dispenses and provides 

patient education. 

• Glucometers and strips for un-funded patients. Write Rx 

and social work consult.

114 

• Diabetes Clinic 

- Requires referral by resident. Form is available on 

wall. 

- Can titrate insulin without resident's signature or 

resident can opt to titrate insulin him/herself. 

Social Work - Vendetta (mostly for un-funded patients) 

• Off-campus specialist referrals (eg, Parkland Clinics) 

• Meds not offered on formulary or Walmart $4 List 

• Medical supplies (eg glucometers/strips) 

• Patient Transportation 

• Counseling 

• Home care needs 

• Short-term psycho-social intervention for patients, (eg 

emergency shelter, severe financial need, etc.) 

Interpreter Service: 

A phone service is available. The phone is in the nurse’s 

station. Take the phone to your exam room, press redial, give 

the code “BUMC” and state the language requested. 

Emergency psychiatric evaluation and observation (eg 

acutely suicidal patient) 

• Inform the charge nurse who will contact the ED Psych 

services. 

• If the patient is on the phone with you, inform them that 

you or they need to call 911, and stay on the phone until 

an EMT arrives. 

HOW TO ORDER 

• IVFs or PO/IV meds in clinic = order using physician 

order sheet. Give to RN. 

• Screening tests: All order sheets are on wall in 

resident’s area. 

- Mammogram = mammo order sheet 

- Bone density scan = on Radiology form, write in 

"Bone density scan" for type of study. 

- Colonoscopy = GI referral on Consult form. 

- Eye exam = if patient is un-funded and in-county, 

write social work order to refer to Parkland 

Opthalmology Resident clinic (long wait to get 

appointment, patients will be called.) 

• MRI/CT scans = Fill out Radiology form. 

• Flu/Pneumovax = write on Encounter form (under 

medication administration).

115 

• Social work: Circle Social Work on "Return Visit" sheet, 

and write a summary of what you need. 

HOW TO ADMIT A PATIENT DIRECTLY 

FROM CLINIC 

1. Discuss with attending before admitting. 

2. Call admitting resident and present the patient. If you are 

on wards, you will assume care of the patient the following 

morning. 

3. Inform charge RN and request bed type. 

4. Send patient to admitting desk. 

5. Fill out H&P and write brief admit orders for team. 

6. Dictate clinic note. 

URGENT CARE VISIT 

• If you need to see your patient on a non-clinic day for an 

urgent problem, contact the clinic to obtain an 

appointment. 

• For any patient emergency, advise them to go to the ER 

or call EMS immediately. 

WELL-WOMAN EXAM 

Once patient is gowned, have RN/MA bring tray for Pap smear 

and stay for breast exam. 

SIGNING DOCUMENTS 

• Labs/Imaging/Pathology results = Initial/Date each page 

and place folder in “Medical Records” pile at RN’s station. 

• No-shows = select action to be taken (eg re-schedule, 

call patient, discharge from clinic with attending’s consent) 

and place chart on counter across from Carolyn’s 

(scheduler) desk. 

• Phone messages and social work documents = After 

returning call and documenting your encounter, place 

chart in black tray behind resident’s area.

116 

$4 Rx LIST 

(Most have 90 day supply for $10) 

Please refer to your own prescribing reference when writing your 

Rx’s 

Allergies & Cold and Flu 

Benzonatate 100mg cap 

Ceron DM syrup 

C-Phen drops* (ml bottle) 

Dex PC syrup 

Loratadine 10mg tab 

Promethazine DM syrup 

Antibiotic Treatments 

Amoxicillin 125mg/5ml susp 

(80ml bottle)(100ml bottle) 

(150ml bottle) 


(50ml bottle) (75ml bottle)* 

(100ml bottle)* 





(50ml bottle)(75ml bottle)* 

(100ml bottle)* 

Amoxicillin 250mg cap/500mg 

cap 

Amoxil 50mg/ml drops* (ml 

bottle) 

Cephalexin 250mg cap/500mg 

cap 

Ciprofloxacin 250mg tab/500mg 

tab 

Doxycycline Hyclate 50mg 

cap/100mg cap/100mg tab 

Erythromycin EC 250mg cap 

Metronidazole 250mg tab/500mg 

tab 

Penicillin VK 250mg tab 

Penicillin VK 125mg/5ml susp 


Penicillin VK 250mg/5ml susp 


SMZ-TMP 200mg-40mg/5ml 

susp 

SMZ-TMP 400mg-80mg tab 

SMZ-TMP DS 800mg-160mg tab 

Tetracycline 250mg cap/500mg 

cap 

Arthritis & Pain 

Allopurinol 100mg tab 

Baclofen 10mg tab 

Colchicine 06mg tab 

Cyclobenzaprine 5mg tab/10mg 

tab 

Dexamethasone 0.5mg 

tab/0.75mg tab/4mg tab 

Diclofenac DR 75mg tab 

Ibuprofen 100mg/5ml susp 

Ibuprofen 400mg tab/600mg 

tab/800mg tab 

Indomethacin 25mg cap 

Meloxicam 7.5mg tab/15mg tab 

Naproxen 375mg tab/500mg tab 

Piroxicam 20mg cap 

Salsalate 500mg tab 

Asthma 

Albuterol 2mg tab/4mg tab 

Albuterol 2mg/5ml syrup 

Albuterol 0.5% nebulizer soln 

(20ml bottle) 

Albuterol 0.083% nebulizer soln* 

(25x3ml vials) 

Ipratropium 0.02% nebulizer 

soln* (25x25ml vials) 

Cholesterol 

Lovastatin 10mg tab/20mg tab 

Pravastatin 10mg tab/20mg 

tab/40mg tab 

Diabetes 

Chlorpropamide 100mg tab 

Glimepiride 1mg tab/2mg 

tab/4mg tab 

Glipizide 5mg tab/10mg tab 

Glyburide 2.5mg tab 

Glyburide 5mg tab (blue)/(green) 

Glyburide, micronized 3mg 

tab/6mg tab 

Metformin 500mg tab/1000mg 

tab 

Metformin 500mg ER tab

Ear Health 

Antipyrine/Benzocaine otic (10ml 

bottle) 

Fungal Infections 

Fluconazole 150mg tab 

Nystatin/Triamcin cream (15gm 

tube) 

Nystatin/Triamcin ointment 

(15gm tube) 

Nystatin cream (15gm tube) 

Nystatin ointment (15gm tube) 

Terbinafine 250mg tab 

Gastrointestinal Health 

Belladonna Alkaloid/PB tab 

Cimetidine 800mg tab 

Cytra2 solution 

Dicyclomine 10mg cap/20mg tab 

Famotidine 20mg tab 

Lactulose syrup 

Metoclopramide 10mg tab 

Metoclopramide syrup 

Promethazine 25mg tab 

Promethazine plain syrup 

Ranitidine 150mg tab/300mg tab 

Glaucoma & Eye Care 

Atropine Sulfate 1% op soln (5ml 

bottle) 

Bacitracin op ointment (35gm 

tube) 

Erythromycin op ointment (35gm 

tube) 

Gentamicin 0.3% op soln (5ml 

bottle) 

Levobunolol 0.5% op soln (5ml 

bottle) 

Neomycin/Polymyxin/Dexameth 

asone 0.1% op ointment (35gm 

tube) 

Neomycin/Polymyxin/Dexameth 

asone 01% op susp (5ml bottle) 

Pilocarpine 1% op soln (15ml 

bottle) 

Pilocarpine 2% op soln (15ml 

bottle) 

Polymyxin Sulfate/TMP op soln* 

(10ml bottle) 

Sulfacet Sodium 10% op soln 

(15ml bottle) 

Timolol Maleate 0.25% op soln 

(5ml bottle) 

117 

Timolol Maleate 0.5% op soln 

(5ml bottle) 

Tobramycin 0.3% op soln (5ml 

bottle) 

Heart Health & Blood Pressure 

Amiloride-HCTZ 5mg-50mg tab 

Atenolol-Chlorthalidone 50mg- 

25mg tab/100mg-25mg tab 

Atenolol 25mg tab/50mg 

tab/100mg tab 

Benazepril 5mg tab/10mg 

tab/20mg tab/40mg tab 

Bisoprolol-HCTZ 25mg-625mg 

tab/5mg-625mg tab/10mg- 

625mg tab 

Bumetanide 0.5mg tab/1mg tab 

Captopril 125mg tab/25mg 


Carvedilol 3.125mg tab/6.25mg 

tab/12.5mg tab/25mg tab* 

Chlorthalidone 25mg tab/50mg 

tab 

Clonidine 0.1mg tab/0.2mg tab 

Digoxin 0.125mg tab/0.25mg tab 

Diltiazem 30mg tab/60mg 

tab/90mg tab*/120mg tab 

Doxazosin 1mg tab/2mg 


Enalapril-HCTZ 5mg-12.5mg tab 

Enalapril 25mg tab/5mg 


Furosemide 20mg tab/40mg 

tab/80mg tab 

Guanfacine 1mg tab 

Hydralazine 10mg tab/25mg tab 

Hydrochlorothiazide (HCTZ) 

12.5mg cap*/25mg tab/50mg tab 

Indapamide 1.25mg tab/2.5mg 

tab 

Isosorbide Mononitrate 30mg ER 

tab/60mg ER tab 

Lisinopril-HCTZ 10mg-12.5mg 

tab/20mg-12.5mg tab*/20mg- 

25mg tab* 

Lisinopril 2.5mg tab/5mg 


Methyldopa 250mg tab*/500mg 

tab* 

Metoprolol Tartrate 25mg 

tab/50mg tab/100mg tab* 

Nadolol 20mg tab/40mg tab

Nitroquick 0.3mg sub tab* (100 

count bottle)† 


count)† 


count bottle) 

Pindolol 5mg tab/10mg tab 

Prazosin HCL 1mg cap/2mg 

cap/5mg cap 

Propranolol 10mg tab/20mg 


Sotalol HCL 80mg tab 

Spironolactone 25mg tab 

Terazosin 1mg cap/2mg 

cap/5mg cap/10mg cap 

Triamterene-HCTZ 37.5mg- 

25mg cap/37.5mg-25mg 

tab/75mg-50mg tab 

Verapamil 80mg tab/120mg tab 

Warfarin 1mg tab/2mg tab/2.5mg 

tab/3mg tab/4mg tab/5mg 

tab*/6mg tab/7.5mg tab/10mg 

tab 

Mental Health 

Amitriptyline 10mg tab/25 mg 

tab/50mg tab/75mg tab/100mg 

tab 

Benztropine 2mg tab 

Buspirone 5mg tab/10mg tab* 

Carbamazepine 200mg tab 

Citalopram 20mg tab/40mg tab 

Doxepin HCL 10mg cap/25mg 

cap/50mg cap/75mg cap/100mg 

cap 

Fluoxetine 10mg tab*/10mg 

cap/20mg cap/40mg cap 

Fluphenazine 1mg tab 

Haloperidol 0.5mg tab/1mg 


Lithium Carbonate 300mg cap 

Nortriptyline 10mg cap/25mg 

cap 

Paroxetine 10mg tab*/20mg tab* 

Prochlorperazine 10mg tab 

Thioridazine 25mg tab/50mg tab 

Thiothixene 2mg cap 

Trazodone 50mg tab/100mg 

tab/150mg tab 

Trihexyphenidyl 2mg tab 

118 

Skin Conditions 

Benzoyl Peroxide 4% creamy 

wash (1701ml bottle) 

Betamethasone Dipropionate 

0.05% cream (45gm tube) 

Betamethasone Valerate 0.1% 

cream (15gm tube) 

Betamethasone Val 0.1% cream 

(45gm tube) 

Fluocinolone Acet 0.01% soln 

(60ml bottle)† 

Fluocinonide 0.05% cream 

(15gm tube)† 

Fluocinonide 0.05% cream (gm 

tube)† 

Gentamicin 0.1% cream (15gm 

tube) 

Gentamicin 0.1% ointment 


Hydrocortisone 1% cream 

(2835-g tube)† 

Hydrocortisone 25% cream (gm 

tube)† 

Selenium Sulfide 25% lotion* 


Silver Sulfadiazine 1% cream* 

(50gm tube) 

Triamcinolone 0.025% cream 

(15gm tube)†(80gm tube)† 


(15gm tube)† (80gm tube)† 

Triamcinolone 0.1% ointment 

(15gm tube)† (80gm tube)† 



Thyroid Conditions 

Levothyroxine 25mcg tab/50mcg 

tab/75mcg tab/88mcg 




tab*/200mcg tab* 

Viruses 

Acyclovir 200mg cap 

Vitamins & Nutritional Health 

Folic Acid 1mg tab 

Klorcon 8 8mEq ER tab 

Klorcon 10 10mEq ER tab 

Klorcon M10 10mEq tab 

Mag 64 64mg tab

Magnesium Oxide 400mg tab 

Prenatal Plus qty 30 

Potassium Chloride 10% liquid 

Sodium Fluoride .5mg chewable 

(120ct bottle) 

Women’s Health 

Estradiol 0.5mg tab/1mg 

tab/2mg tab 

Estropipate 0.75mg tab/1.5mg 

tab* 

Medroxyprogesterone Acetate 

25mg tab/5mg tab/10mg tab 

Alendronate SOD 35mg 

tab/70mg tab 

Clomiphene 50mg tab 

EST Estrogen/Methyl Testost 

HS tab/ DS tab 

Sprintec 28-day tab* 

Tri-Sprintec 28-day tab* 

Tamoxifen 10mg tab/20mg tab 

Other Medical Conditions 

Chlorhexidine Gluconate 0.12% 

soln 

Hydrocortisone AC 25mg 

suppositories 

Isoniazid 300mg tab 

Lidocaine 2% viscous solution 


Megestrol 20mg tab* 

Methylpred 4mg tab 

Methylpred 4mg dose pak (21 

tablets)† 

Oxybutynin 5mg tab 

Phenazopyridine 100mg 

tab/200mg tab 

Prednisone 2.5mg tab/5mg 


Prednisone 5mg dose pak (21 

tablets)† (48 tablets)*† 

Prednisone 10mg dose pak (21 

tablets)† (48 tablets)*† 

119

120 

OTHER INFORMATION 

TOP TEN INTERN TIPS 

1. Be sure when you admit a patient, you ask the admitting 

attending how often they want to be contacted, and update 

them as they request. 

2. If you plan on discharging a patient, call the attending first 

thing in the am (esp TPC) so they can plan on seeing the 

patient early prior to discharge. If you can’t reach anyone from 

TPC and the patient has been set for discharge based on prior 

days’ attending, make sure to leave a message on the main 

line letting them know you plan on discharging the patient at X 

time unless you hear otherwise. ALWAYS CALL BEFORE 

YOU DISCHARGE. 

3. Dictate in a timely manner and review dictations/electronic 

signatures often so your attending does not end up on the B 

list and lose their admitting privileges. Go to medical records 

and have cookies and juice and review your dictations if you 

need to find a happy place! 

4. When you order an echo, write who needs to read it: Heart 

Place, CCT, or NTC. Look back at old echos and have the 

same group read it as did before. 

5. If you are waiting for a read on a radiologic study, look on 

centricity and see if it is dictated. If so, dial 2-XRAY and enter 

your user name/password to hear the dictation. 

6. Review the nurses notes from the previous night as well as 

PT/OT/Respiratory notes (located under a separate tab). 

Nutrition leaves notes at the back of the physician progress 

note section. 

7. Help out your other interns: Write prns on your admission 

orders and then sign cross-cover verbal orders when you 

round in the am so they don’t have to have them appear on 

their ESA’s and sign them electronically. 

8. If you need to call a patient from your cell phone or home 

phone, dial *67 and then the number. 

9. If you need to obtain medical records from an outside 

facility, write an order and the clerk will fax the request with the 

help of the nurse. Follow-up if the records do not come in a 

few days. 

10. Live, laugh, and learn … take the best care of your 

patients that you can and you will make it with flying colors!

121 

DUEWALL’S FAVORITE MNEMONICS 

• Pancreatitis: 

GET SMASHED 

Gallstones 

Ethanol 

Trauma 

Steroids 

Mumps 

Autoimmune 

Scorpion bites 

Hypercalcemia/triglyc 

eridemia 

ERCP (post-ERCP) 

Drugs (azathioprine, 

thiazides) 

• ACS treatment 

MONA BASH 

Morphine, Oxygen, 

Nitroglycerin, Aspirin, 

B-blocker, ACE- 

Inhibitor, Statin, 

Heparin 

• Alt. Mental Status 

MOVE STUPID 

Metabolic 

(Hypothyroid, Hepatic 

encephalopathy) 

Oxygen (hypoxia) 

Vascular (stroke) 

Electrolytes 

(Hypercalcemia, 

Hyponatremia) 

Seizure 

Trauma (subdural 

hematoma, epidural 

hematoma) 

Uremia 

Porphyria 

Infection (Meningitis, 

Encephalitis, Sepsis, 

specifically urosepsis 

in elderly) 

Drugs 

• Ranson’s Criteria: 

At admiss.: GALAW 

Glucose >200 

Age >55 

LDH >350 

AST>250 

WBC >16,000 

• At 48 hours-C 

HOBBS 

Calcium 10% 

Oxygen: PaO2 5 

mg/dL 

Base deficit >4 mEq/L 

Sequestration of fluid 

>6L 

• TTP (FAT RN) 

Fever 

Anemia 

(Microangiopathic 

hemolytic anemia) 

Thrombocytopenia 

Renal Failure 

Neuro changes (AMS) 

+if suspect TTP, it is 

an emergency to get 

patient to plasma 

exchange 

• Acute Dialysis 

Indications-AEIOU 

Acidemia, Electrolyte 

disturbances, 

Intoxication, Overload 

(volume), Uremia 

• Fractional 

excretion of Sodium 

(FENa) 

“UNaP over UCraP” 

(Urine Na x Plasma 

Cr)/(Urine Cr x 

Plasma Na) 

• Kinds Of Tumors 

Leaping Primarily To 

Bone 

Kidney 

Ovarian 

Thyroid 

Lung 

Prostate 

Testicular 

Breast 

• Drug Induced 

Lupus Agents- 

SHIPS drugs 

Sulfasalazine, 

Hydralazine, 

Isoniazid, 

Procainamide, Statins 

• Causes of Atrial 

Fibrillation 

I SMART CHAP 

Infectious 

(endocarditis, 

myocarditis, sepsis) 

Surgery (Post-CABG) 

Medications (caffeine, 

theophylline) 

Artheroclerotic CAD 

Rheumatic Heart 

Disease (MS or MR) 

Thyrotoxicosis 

Congential 

malformation (ASD) 

Hypertensive heart 

disease 

Alcohol (Alcoholic 

CM, Holiday Heart 

Syn) 

PE 

• Anion Gap 

Metabolic Acidosis 

GOLD MARK or 

KUSMALE 

Glycols 

Oxyproline 

L-lactate 

D-lactate 

Methanol 

Aspirin 

Aspirin 

Renal 

Ketoacidosis 

Ketones 

Uremia 

Salicylates 

Methanol 

Acetaldehyde 

Lactic Acidosis 

Ehtylene Glycol

122 

SUSTENANCE AND COMFORT FOOD 

Will deliver… 

www.diningin.com 

Bangkok City (Thai) 214-824-6200 

www.bangkokcityrestaurant.com 

You can send your students… 

Angry Dog (salads/sandwiches) 214-741-4406 

2726 Commerce, www.angrydog.com 

Jimmy’s Italian Deli/Food Store 214-823-6180 

4901 Bryan, www.jimmysfoodstore.com 

Lenny’s Sub Shop 214-826-1500 

4201 Gaston, www.lennys.com 

Matt’s Rancho Martinez 214-823-5517 

6332 La Vista, www.thetexmexchef.com 

Pei Wei (Asian diner) 214-219-0000 

3001 Knox St, www.peiwei.com 

Fadi’s (Mediterranean) 214-528-1800 

3001 Know St, www.fadiscuisine.com 

Chuy’s (Mexican) 214-559-2489 

4544 McKinney Ave, www.chuys.com 

Pot Belly (sandwiches) 

www.potbelly.com 

5715 Lemmon 214-353-0581 

4447 N Central Expressway 214-520-3251 

Or you can eat at BUMC… 

Cafeteria (Truett basement) 

Daily 6:30 AM-7:30 PM 

Bake Shop/Starbucks (next to cafeteria) 

M-F 6:30 AM – 2 PM 

Atrium (Roberts lobby) 

M-F 6:30 AM–1:30 AM, S/S 7:30 PM-1:30 AM 

Frulatti (Barnett lobby) 

M-F 6 AM-8 PM, Sat 8 AM-4 PM

123

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