Always physically see the patient before you talk to your senior about them.
Dangerous red flag clinical signs that should prompt consideration for condition / ICU transfer / expedient notification of your senior/chief or direct calling of a condition - you will have to use your judgement, err on the side of calling for help.
- Not protecting airway
- not swallowing their own secretions
- totally obtunded
- hematemesis / hemoptysis (any degree)
- Seizures
- Hypotension (systolic < 80 unresponsive to fluid bolus or if systolic < 80/90 and displaying e/o perfusion e.g. drowsy, CP, etc.)
- Obtunded
- Symptomatic hyponatremia
- Clear stroke symptoms (see above for calling condition stroke)
Page | Ask / Tell Nurse | Ask Patient | Examine | Management |
Neuro exam change | turn off sedation and paralysis now and please have a train of four and pupillometer ready. | ㅤ | everything | NOTE: this is exception to rule of ordering things before talking to senior. Talk to a senior before ordering a CTH unless it is a profoundly obvious exam change. |
Not protecting airway | Call respiratory ASAP for suctioning and go see immediately. | ㅤ | ㅤ | Condition and ICU transfer |
"I think they just aspirated" | Ok I will order a stat CXR | ㅤ | ㅤ | CXR |
Intractable vomiting | When was the last time? How many times? was it after eating? Did they aspirate the vomitus or clear it? | ㅤ | ㅤ | Add more anti-emetics (see HY pharm chart) Make sure not aspirating |
HYPO-tension | What is the MAP? If > 65, that is ok Did you repeat check on other arm? Is BP cuff size appropriate? What meds on? | Symptomatic? HA, drowsy, etc. | ㅤ | try giving 500 BOLUS (careful CKD or CHR)ask what NA+ is, if high give plasmalyte if low give NSOrthostatics + / - medicine consult if orthostatic |
HYPER-tension | Do they take any home anti-HTN? Were they in pain when you measured? Did you give labetalol / hydralazine | Is your pain well-controlled? Red flag signs for hypertensive emergency - AMS - Headache - Blurry vision - Vision loss - Chest pain - Palpitations - Sweating - SOB - Nausea / vomiting - Back pain? | ㅤ | Restart home anti-HTN meds Give PRNs for CAP 180 (unless this is a stroke, in which case ICU should be managing this) Consider medicine consult |
Febrile | can you recheck a core temp (rectal) What is the actual temperature? A true fever is 38.5 / 101.3 | ㅤ | ㅤ | basic fever workup: ESR, CRP, CXR, UA, BCx if you want them and LEDs |
Chest pain | Are they anxious? Are they in pain? | Is it crushing? | Is it reproducible? | EKG, Trop, BMP w/ Mg/Phos |
Diarrhea | Is it truly watery? How many times in past 24h? Does it smell like C Diff? | ㅤ | ㅤ | C diff test if 3 liquid BM in < 24 hrs |
Arm swelling | Was there an IV there? Is it infiltrated? Is it painful? | swelling/erythema | ㅤ | Monitor +/- UED |
Abdominal pain | ㅤ | ㅤ | distended? Hard? rebound tenderness? | Abdominal Xray if ALIF patient, very low threshold for ACS consult or STAT page to general surgery team that operated with us. |
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