The Clinical Companion

The complete tool to ace the clinical ward service by by Pavly G.

[Critical-care sheet]
[Medical emergencies guidance]
[Critical-care emergencies guidance]
[Surgical Emergencies guidance]
[Target-based Clinical Examination]
[Emergency maneuvers guidance]
[ECG Quick Guide]
[EEG Quick Guide]

The final bulletin copyright 2023-2024. Updated according to the latest NICE, ESC, AHA, ADA, ATS, KDIGO, & SCCM guidelines. Works best with Emergency & Critical Care.

General Assessment

Vitals

Parameter Value

SaO2

HR

BP (reading, artery, position)

RR

Temp.

Random-Blood-Sugar

General Systems-Review (or Notes)

[Free text field]

Neurological Assessment

NIHSS (National Institute of Health Stroke Scale)

Item Title Description Score

1A

Level of Consciousness

0 = Alert
1 = Drowsy
2 = Obtunded
3 = Coma/unresponsiveness

1B

Orientation Questions (2)

0 = Answers both correctly
1 = Answers one correctly
2 = Answers neither correctly

1C

Response to commands (2)

0 = Performs both tasks correctly
1 = Performs 1 task correctly
2 = Performs neither

2

Gaze

0 = Normal horizontal movements
1 = Partial gaze palsy
2 = Complete gaze palsy

3

Visual Fields

0 = No visual field defect
1 = Partial hemianopia
2 = Complete hemianopia
3 = Bilateral hemianopia

4

Facial movement

0 = Normal
1 = Minor Facial Weakness
2 = Partial Facial Weakness
3 = Complete unilateral palsy

5a

Motor function (arm) – Left

0 = No drift
1 = Drift before 10s
2 = Falls before 10s
3 = No effort against gravity
4 = No movement

5b

Motor function (arm) – Right

0 = No drift
1 = Drift before 10s
2 = Falls before 10s
3 = No effort against gravity
4 = No movement

6a

Motor function (leg) – Left

0 = No drift
1 = Drift before 10s
2 = Falls before 10s
3 = No effort against gravity
4 = No movement

6b

Motor function (leg) – Right

0 = No drift
1 = Drift before 10s
2 = Falls before 10s
3 = No effort against gravity
4 = No movement

7

Limb ataxia

0 = No Ataxia
1 = Ataxia in 1 limb
2 = Ataxia in 2 limbs

8

Sensory

0 = No sensory loss
1 = Mild sensory loss
2 = Severe sensory loss

9

Language

0 = Normal
1 = Mild aphasia
2 = Severe aphasia
3 = Mute or global aphasia

10

Articulation

0 = Normal
1 = Mild dysarthria
2 = Severe dysarthria

11

Extinction or Inattention

0 = Absent
1 = Mild loss (1 sensory modality lost)
2 = Severe loss (2 sensory modality lost)

GCS (Glasgow Coma Scale)

Component Description Score

Eye

Spontaneous = 4
To sound = 3
To pressure = 2
None = 1
Not Testable = NT

Verbal

Orientated = 5
Confused = 4
Words = 3
Sounds = 2
None = 1
Not Testable = NT

Motor

Obeys commands = 6
Localizing = 5
Normal Flexion = 4
Abnormal Flexion = 3
Extension = 2
None = 1
Not Testable = NT

Pupils Light Reactivity

Both non-reactive = 2.0
Only-one non-reactive = 1.0
Both are reactive = 0.0

GCS = ( )/15, E( )V( )M( ). GCS-P = ( )/15.

Abbreviated Mental Test (AMT Score)

Feature Score

Age

1.0

Date of birth

1.0

Current Year

1.0

Time (nearest hour)

1.0

Name of hospital

1.0

Recognize 2 people (e.g: Dr & Nurse)

1.0

Qualifications

1.0

President Name

1.0

Recall address: "42 west street" or any other words.

1.0

Count backwards from 20 to 1

1.0
AMT Score >= 8 is normal for an elderly patient.

Cardiopulmonary Assessment

Well’s Pretest Criteria (PE)

Feature Score

Signs of DVT (swelling + tenderness)

3.0

IV drug use

3.0

HR > 100 Bpm

1.5

Prior PE or DVT

1.5

Bedridden > 3 days or surgery within the past 4 weeks

1.5

Cancer (treated actively or with palliation within 6 months)

1.0

Hemoptysis (signs of pulmonary infarction)

1.0

PE is most likely "HIGH D-dimer?? – Abnormal V/Q – Abnormal CTPA"

3.0

  • Total Score ⇐ 4.0 → PE unlikely

  • >= 4.5 → PE likely – PA imaging is needed to exclude PE.

CHA2DS2-VASc (AFib)

Feature Score

C.H.F

1

HTN

1

Age >= 75

2

DM

1

Stroke/TIA/TE

2

Vascular disease (prior MI, PAD or aortic plaque)

1

Age 65–74

1

Sex Category (ie, female sex)

1

  • Total Score: Males >= 2, Females >= 3

Positive scores require life-long anti-coagulants to maintain INR (2.0–3.0) to prevent strokes.

HAS-BLED (Pretest for bleeding tendency)

Feature Score

Hypertension (SP > 160 mm.Hg)

1.0

*Abnormal renal function and/or *Abnormal hepatic function

1.0 for each

Stroke (previous ischemic or hemorrhagic)

1.0

^Bleeding history or predisposition

1.0

#Labile INRs

1.0

Elderly (age > 65)

1.0

>Drugs or excessive alcohol drinking

1.0 for each

Maximum Score

9.0

  • Abnormal renal function = dialysis – transplant – serum creatinine > 200 micromol/L.

  • Abnormal hepatic function = cirrhosis – bilirubin > x2 upper limit of normal – AST/ALT/ALP > 3x upper limit of normal.

  • ^Bleeding history = previous major hemorrhage (hemorrhagic stroke) – anemia – severe thrombocytopenia.

  • #Labile INRs = Time therapeutic range (TTR) < 60% in patient receiving VKA.

  • >Drugs = concomitant use of antiplatelet or NSAIDs; and/or excessive alcohol per week.

CURB-65 (CAP Severity Assessment)

Feature Score

Confusion (AMT 8 or less)

1.0

Urea > 7 mmol/L

1.0

Respiratory Rate >= 30 Bpm

1.0

Blood pressure (SP < 90 or DP ⇐ 60 mm.Hg)

1.0

Age >= 65 years

1.0
Total Score Management

0–1 (Low severity)

Home treatment, amoxicillin 500mg/8h PO.

2 (Moderate severity)

Ward treatment, send pan-cultures, amoxicillin 500mg–1g/8h PO + clarithromycin 500mg/12h.

3–5 (High Severity)

Critical Care, send pan-cultures, co-amoxiclav 1.2g/8h IV + Clarithromycin 500mg/12h.

IDSA/ATS Criteria (for defining severe CAP)

Criterion Type Feature Value

Minor

Respiratory Rate

>= 30 Bpm

Minor

PaO2/FiO2

⇐ 250

Minor

Multilobar infilterates

Yes

Minor

Confusion/disorientation

Yes

Minor

Uremia

BUN >= 20 mg/dL

Minor

Leukopenia

WBC < 4000 cells/micro-liter

Minor

Thrombocytopenia

Platelets < 100,000 cells/micro-liter

Minor

Hypothermia

core temperature < 36 deg.C

Minor

Hypotension

requiring aggressive fluid resuscitation

Major

Septic shock

with need for vasopressors

Major

Respiratory failure

requiring mechanical ventilation
Validated definition includes either one major criterion or three or more minor criteria.

[See Appendix-B: Critical-care emergencies guidance]

Diagnostic Criteria for ARDS

[See Appendix-B: Critical-care emergencies guidance]

Diagnostic Criteria for Sepsis & Septic Shock (2016 SSC)

[See Appendix-B: Critical-care emergencies guidance]

Gastroenterology, Hepatology & Renal Assessment

Modified Glasgow-Ranson’s Criteria (Acute Pancreatitis Severity)

Feature Score

Age > 55 years

1.0

PaO2 < 8.0 kPa (60 mm.Hg)

1.0

WCC > 15 * 109/L

1.0

Ca2+ < 2 mmol/L (36 mg/dL)

1.0

Glucose > 10 mmol/L (180 mg/dL)

1.0

ALT > 100u/L

1.0

LDH > 600u/L

1.0

Urea > 16 mmol/L (288 mg/dL)

1.0

Albumin < 32 g/L

1.0
>= 3 predicts an episode of severe pancreatitis prompting ICU admission & preparation for *ERCP if gallstone etiology.

  • ERCP: Endoscopic Retrograde cholangiopancreatography.

  • kPa: Kilo Pascal.

AKIN Criteria (KDIGO)

Serum Creatinine Urine Output Stage

(1.5–1.9) x baseline within the prior 7 days
--OR-- an increase of >= 0.3 mg/dl within 48 hours

< 0.5 ml/kg/hr for 6–12 hrs

1

(2.0–2.9) x baseline

< 0.5 ml/kg/hr for >= 12 hrs

2

(3.0) x baseline
--OR-- an increase in SCr to >= (4.0) mg/dl
--OR-- initiation of RRT
--OR-- In patients < 18 yrs, decrease in eGFR to less than 35 ml/min/1.73m2

< 0.3 ml/kg/hr for >= 24 hrs
--OR-- Anuria for >= 12 hrs

3

CKD Criteria (KDIGO)

Criteria for CKD (either one or more present for > 3 months):

Criterion Definition

Markers of kidney damage (Albuminuria – Cause criteria)

Albuminuria (AER >= 30 mg/24 hrs; ACR >= 30 mg/gm)
Urine sediment abnormalities
Electrolyte & other abnormalities due to tubular disorders
Abnormalities detected by histology
Structural abnormalities detected by imaging
History of renal transplantation

Decreased GFR (GFR criteria)

GFR < 60 ml/min/1.73 m2 (GFR categories G3a–G5)

Personal Data

Pick up relevant items only.

  • Name:

  • Age:

  • Gender:

  • Ethnicity:

  • Occupation:

  • Residency:

  • Special habits (smoking – drinking):

  • Known Chronic diseases:

  • Presentation time:

Chief Complaint

[Follow the is?–what?–List]

  • Acute Onset:

  • Chronic Onset:

  • Recurring Condition & Frequency:

  • Estimated Duration:

  • Progressiveness (progress/regress) over:

  • Characteristics of symptoms (pain class – sputum/vomitus/urine/stool/discharge class/color/odor/quantity):

  • Radiation of pain:

  • Associations:

  • Premonitory symptoms:

  • Exacerbating Factors:

  • Relieving Factors:

Menstrual & Obstetric History

  • Age of menarche:

  • Age of Menopause:

  • Period frequency:

  • Is pregnant?

  • First day of the last menstrual period (LMP) aka. first day of menstruation:

  • Estimated Gestation Age (EGA = Current Date – LMP Date):

  • Estimated due date (EDD = LMP + 9m + length-of-previous-cycle – 21d):

  • HCG (+ve) date:

  • Gravidity, term, preterm, abortuses, and living (GxP-TPAL): G…​…​, P…​…​…​

  • Contraception methods, duration, and side effects:

  • Sexually transmitted diseases:

Past Medical History

Major Illnesses

  • HTN

  • DM

  • Reactive Airway Disease

  • CHF

  • Angina

  • CVS

  • Others:

Minor Illnesses

  • Infections:

  • Others:

Hospitalizations

  • Indications:

  • Estimated Date:

  • Estimated Discharge time:

Past Surgical History

  • Procedures:

  • Date:

  • Approach:

  • Hospital name:

  • Complications:

Allergies (Drugs & Substances)

  • Medications:

  • Dosages:

  • Route of administration:

  • Indications:

  • Frequency:

  • Duration:

  • Significant Adverse Effects:

Social History

  • Occupation:

  • Marital Status:

  • Children:

  • Drug abuse/smoking:

Family History

Summary of Systems-Review

Focused on life threatening conditions – see clinical pretest scores.

  • Cardiovascular:

  • Head & Neck:

  • Respiratory:

  • Neurological:

  • Gastroenterology:

  • Musculoskeletal:

  • Genitourinary:

Examination Findings

  • Head & Neck:

  • Neurological:

  • Cardiovascular:

  • Gastroenterology:

  • Respiratory:

  • Musculoskeletal:

  • Genitourinary:

Requested Investigations

  • EKG (HR – Rhythm – PR – QRS morph – QRS Axis – ST – T – QT):

  • Ultrasonography:

  • Doppler:

  • X-ray:

  • CT:

  • MRI:

  • C&S:

Laboratory Studies

  • FBC:

  • ABG:

  • U&E:

  • SCr:

  • Urinalysis & Sediments:

  • LFT:

  • Blood glucose (HbA1c – 2hrsGTT):

  • Lipid profile:

  • Pancreatic Enzymes:

  • Cardiac Enzymes:

  • Coagulation Profile (PT, PTT, INR):

  • Serum Cultures:

  • Urine Cultures:

  • Urine AER (Albumin excretion rate):

  • Urine ACR (Albumin:Creatinine ratio):

Analysis

[Free text field]

Case Analysis

Adapted from Dr. J. Reason’s Swiss Cheese Model for complex analysis. Subsequent active failures alignment with latent organ failure, leading to an inevitable catastrophic failure (denoted as a "Lightning Spark"). To analyze the case properly, insert the sequential active failures, and the catastrophic events at the lightning spark polygon.
Latent failure 1 Latent failure 2 Latent failure 3 Active failure 1 Active failure 2 Hazard Catastrophic failure Reason’s Swiss Cheese Model

Approach to Therapy

[Free text field]

Five-Week Timeline (Drugs & Diagnostics)

"Timeline valid only for 6 weeks only"
Timeline

Drugs

Investigations

Hand-over notes
Timeline

Drugs

Investigations

Hand-over notes
Timeline

Drugs

Investigations

Hand-over notes

Appendices

  • Appendix-A: Medical emergencies guidance

  • Appendix-B: Critical-care emergencies guidance

  • Appendix-C: Surgical emergencies guidance

  • Appendix-D: Target-based examination

  • Appendix-E: Emergency maneuvers guidance

  • Appendix-F: ECG Quick guide

  • Appendix-G: EEG Quick guide

  • Appendix-H: Drug dosing guidance