Altered Mental Status
Structural: brain mass, mets, SZRs, NCSE, postictal state, Hydrocephalus
Vascular: Ischemic/hemorrhagic stroke, SAH, TBI(EDH/SDH/DAI/diffuse cerebral swelling/Contusions/SAH/IVH), AVM, CVT, Aneurysym, TIA
Infectious: Meningitis, aseptic meningitis, encephalititis, sepsis, GBS
Metabollic: Delirium, electrolyte disturbance(glucose, sodium,calcium, magnesium, phosphate), Hypercarbia, Headache(cluster/migraine/tension), septic/hepatic/metabollic/hypoxemic/hypertensive/uremic/Wernicke encephalopathy, severe hypothyroidism (myexedema coma)
Toxins: Drugs(current meds too much or missed), illicit drug use, poly-pharmacy, withdrawal or overdose
Other: Re-accumulation of SDH/EDH, herniation from cerebral edema/hematoma, anoxic injury, dehydration, drug overdose/rxn, missed medication, slow metabolism of analgesics, etoh withdrawal, dementias, primary psychiatric illness. Vitamin deficiency, prion’s disease(CJD)
Delirium ddx: dementia, primary psychiatric illnesses, NCSE, focal syndromes(Wernicke's aphasia/RMCA stroke, brain tumor/trauma, anton syndrome), sundowning, metabolic encephalopathy
UNRESPONSIVE/COMA ddx: structural(neoplasm, mets)/vascular(stroke), CNS infection/autoimmune encephalitits, Acute disseminated encephalomyelitis, sepsis, metabollic, toxin/OD, vitamin deficiency/nutritional deficiency, SZR/NCSE, mechanical fall, MI, arrythmia, shock, aortic trauma, hypoxia, CO poisoning, PE, PNA, PTX, GI bleed, fx, suicide attempt, HIE(Hypoxic ischemic encephalopathy), PRES
Seizure ddx: alcohol withdrawal, lowered seizure threshold (meds), medication noncompliance, PNES, Medications (opioids [meperidine, tramadol], anticancer drugs, ABXs [carbapenems, Csporins 4th gen, Quinolones, Isoniazid, PCNs], hypoglycemic agents, immunosuppresants, antipsychotics/antidepressants, stimulants[adderall], sympathomimetics, decongestants), infection, syncope, TIA, Migraine, Panic attack and Anxiety, transient global amnesia, narcolepsy with cataplexy, paroxysmal movement disorder.
Headache ddx: migraine, hypoglycemia, hunger, tension headache, CVA, CV sinusT, CSF leak, idiopathic intracranial hypertension, giant cell arteritis.
Syncope ddx: Hemorrhage, PE, SAH, vasovagal syncope(MCC), orthostasis, medications (CCBs, BBs, alpha blockers, nitrates, diuretics, QTc prolongers antipsychs, antiemetics)
Cardiac (arrhythmia, ischemia, structural/valvular abnormalities (AS, particularly in older adults, HCM), cardiac tamponade, and pacemaker malfunction)
Shortness Of Breath/Dyspnea
Infectious: Pna(bacterial, fungal, atypical, viral, Tb, covid), bronchiolitis, bronchitis, Flu, Croup, epiglotittis, pneumonitis
Obstructive: COPDAE, AsthmaAE, mass/nodule, carcinoid tumors, foreign body
Restrictive: ILDs, autoimmune disease
Vascular: cor pulmonale/chf, PE, pHTN
Pleural: pEffusion, PTX
Other: sleep apnea, Obesity hypoventilation syndrome, ARDS, angioedema, anaphylaxis, pulmonary contusions, neurogenic pulmonary edema(from SAH)
Cardiac: ACS, CHF, arrhythmias, Valvular dz, Endocarditis
Parenchymal(COPD, pulmonary tumor, pneumonitis, bronchiectasis, pulmonary contusion, ILD, sarcoidosis),
Airway(asthma, bronchitis, laryngitis, pharyngitis, OSA, angioedema, foreign body aspiration, trachea bronchial tumor, vocal cord dysfunction),
Pulmonary vascular disease(PE,pHTN, pulmonary AV malformations, hepatopulmonary syndrome)
Pleural disease(pEffusion, PTX, pneumomediastinum, mesothelioma, pleuritis, HTX), Anemia, CO poisoning, methemoglobinemia, pulmonary leukostasis, GERD, ascites, thyroid disease, Cushing, pheochromocytoma, kyphoscoliosis, pectus excavatum, shock, and relaxes, stroke, botulism, ALS, tetanus, polio, PNS infection, GBS, MG, paraneoplastic my Stanek syndrome, respiratory muscle deficiency, anxiety, panic attack, aging, obesity.
Airspace disease ddx: blood(hemorrhage), water (edema), tumor, pus(pneumonia)
HEMOPTYSIS DDX
PE, coagulopathy, Acute or chronic bronchitis, airway trauma, bronchiectasis, bronchovascular fistula, dieulafoy lesion(superficial, sub epithelial bronchial artery), foreign body, neoplasm. TB, PNA, lung abscess, Wegener disease, Goodpasture syndrome, idiopathic pulmonary hemosideroosis, lupus pneumonitis.
Chest Pain
Pleuritic chest pain/non traumatic: PE, PTX, PNA, pleurisy, pericarditis
Traumatic: Tamponade, Contusion, PTX
Reproducible: muscle strain(from activity/coughing), costochondritis, Rib/sternal fx, infenction, Zoster
Substernal: MI/Angina, Sikcle cell crisis, Dissecting TAA/AAA, GI ulcer/perf, pneumomediastinum, mediastinitis
Cardiac: ACS, tachyarrhythmias, htn emergency, Takotsubo CM, uremic pericarditis, PE(post ortho surgery, malignacy)
GI: esophagitis, GERD, gastritis,
Other: panic attack, anxiety
Leg Swelling
Acute: HF exacerbation, Nephrotic syndrome, Venous thrombosis, Acute worsening of chronic causes, PAD, compartment syndrome
Chronic: Venous insufficiency, HF history, pHTN (including sleep apnea), Restrictive pericarditis, Restrictive cardiomyopathy, Liver disease (early cirrhosis), Premenstrual edema, Pregnancy,
Pelvic compression (including tumor or lymphoma), Dependent edema
Sodium or fluid overload (including parenteral fluids, antibiotics and other drugs with large amounts of sodium), Refeeding edema, Idiopathic edema, Inflammation (including sepsis), Medications
Lymph related: Primary lymphedema (presenting in childhood), Secondary lymphedema (including lymph node dissection), Thyroid disease (myxedema)
Abdominal Pain
Esophageal disorders(esophagitis, MW tear, GERD, motility disorder, stricture/varices)
Gastric disorders(gastritis, PUD, pyloric stenosis)
Hepatic(acute/chronic hepatitis, cirrhosis)
Biliary(acute/chronic cholecystitis, cholangitis, cholelithiasis)
Pancreatic disorder(acute/chronic pancreatitis, pancreatic cyst/necrosis/fistula, pancCA)
Small intestine disorders(appendicitis, celiac disea, intussusception, obstruction, polyps)
Colorectal disorders(Ischemic bowel disease, abscess/fistula, diverticulitis, Obstruction, TOXIC megacolon, fecal impaction, fissures/hemorrhoids, constipation, IBD/IBS)
Neoplasm
Food allergies, hernia, diarrhea, toxic ingestion
Metabollic disorder
Nutritional/vitamin disorders
RUQ/Epigastric: Cholecystitis, cholangitis, Hepatitis, Ulcer(gastric/duodenal), Renal (pyelonephritis/kidney stone), esophagitis, gerd,
LUQ/Epigastric: gastritis/PUD, pancreatitis, splenic rupture/infarct/sequestration, Mono, kidney dz
RLQ: Appendicitis, Ovarian (rupture, cyst, torsion, abscess, PID), Testicular (torsion/hernia/epididymitis)
LLQ: Diverticulitis, Proctitis, Prostatitis, Ischemic colitis, ulcerative colitis
Generalized: Mesenteric ischemia, AAA, Constipation, SBO, IBS, Colitis, Toxic megacolon, Cdiff, Gastroenteritis, perforation, DKA, volvulus, GI bleed, Hernias, cancers
Other: Lower lobe pneumonia, ACS, UTI, tumor, urinary retention/obstruction, thyrotoxicosis, hypercalcemia
Rash
Emergencies: SJS, TENs, DRESS syndrome (Drug reaction with eosinophilia and systemic symptoms), Acute generalized exanthematous pustulosis, Necrotizing fasciitis, staphylococcal scalded skin syndrome
Bacterial: cellulitis, impetigo
Fungal: candidiasis, esophagitis
Viral: HSV, Molluscum, Varicella-zoster
Other: contact dermatitis, drug eruption,
OLIGURIA/ANURIA
AKI
Pre-Renal: hypovolemic, hypervolemic states with low effective circulating volume (HF with reduced EF (cardiorenal), decompensated liver disease with portal HTN (HRS), alterations in renal vascular auto regulation (medications: NSAIDS - prevent prostaglandin release, ACEinhibitors - prevents renin release)
- Prerenal most often leads to Intrinsic. (Atn) if not corrected.
- may also be a combined effect of afferent arterial constriction, (I.e nsaids, IV contrast) + efferent arterial dilation, (I. eACEI, ARBS)
-Labs: Scr increase slower than 0.3/day, uNa <20, FENA <1%, UA normal, High specific gravity(elevated Uosm), rapid SCr improvement to IV fluids, BUN:CR ratio >20:1.
- TX is volume repletion. To restore volume and renal perfusion. Rapidly response to treatment.
Intrinsic(ATN, AIN, AGN, Vascular)- nephrotoxic, cytotoxic, prolonged ischemic, inflammatory insults to the kidney.
ATN
Causes:
-ischemic: from prolonged prerenal, hypotension., hypovolemia or post op.
- nephrotoxic: exogenous(drugs, contrast), endogenous(gout, myoglobinuria/rhabdo, lymphoma/leukemia,MM, What can be nephrotoxic? From drugs, dye, medications.
- muddy brown casts, epithelial casts, low specific gravity, hyperK,hyperPhos
-Labs: Scr increase >0.3/day, uNa>40, FENa>2%, low specific gravity, UA with epithelial cells/granular casts, SCr doesn’t improve with fluids, BUN:SCr ration 10-15:1.
- consider diuretics, Iv fluids, stop offending meds
- Most patients return to baseline in seven dash 21 days.
AIN- Inflammatory or allergic response in interstitium with sparing of Glomeruli and blood vessels.
- Causes: Drugs, infections, autoimmune. Idiopathic.
-sx: Fever, eosinophilia, Maculopapular rash, anthralgias, WBC casts, elevated serum IgE
- creat bumps 7-10 days after drug exposure
- pyuria with or without WBCs or hematuria (no red cell casts)
- Tx is withdraw offending medications. Recovery in 1 year
- can use corticosteroids - Prednisone 1mg/kg per day
Abx: cephalosporins, ampicillin, amoxicillin, penicillin G, sulfa, rifampin, tetracycline
Diuretics: Lasix, Thiazidees
NSAIDS
AGN
- Hematuria (RBC casts), Azotemia, proteinuria. Management is high dose corticosteroids, cytotoxic agents.
FENA
Urine Na should be < 20mEq/L in hypovolemia
Urine Na is high in ATN due to impaired tubular function
<1% in pre renal, >2% in ATN
Diuretics: Use FeUrea - Prerenal is <35%, ATN is >35%
Post renal: Obstruction from stone or BPH. Tx Is removal of obstruction.
FEVER
ICU related causes: Sinusitis, blood transfusions, drug fever, catheter infection, surgical site infection, pneumonia, PE, MI, endocarditis, Acalculous cholecystitis, Bowel translocation, bowel infarction, Cdiff, UTI, DVT
Bacterial: chlamydia, gonorrhea, MRSA, rheumatic fever, shigella, tetanus, atypical mycobacterial disease, Tuberculosis
Viral: CMV, EBV, HSV, HIV, Influenza, VZV
Other: Lyme disease, syphilis, toxoplasmosis, infective thrombophlebitis, fistula infection
VAP ddxs: staph aureus, PSA, aerobic GNBs(E.coli, Kleb pna, enterobacter), early vap mcc’s are***, PSA(MCC of VAP), mdro Acenitobactar baumanni