ABPS Hospital Medicine cheat sheet

Revised Cardiac Risk Index (RCRI) predictors: ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, creatinine >2.0 mg/dL, and high-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular); each scores 1 point.

Perioperative risk strata by RCRI: 0 predictors ≈ 0.4% major cardiac events, 1 ≈ 0.9%, 2 ≈ 7%, ≥3 ≈ 11%.

ACC/AHA stepwise approach: emergency surgery proceeds directly; otherwise estimate surgical risk, then assess functional capacity (≥4 METs generally permits surgery without further testing), then clinical risk factors.

Active cardiac conditions deferring elective surgery: unstable angina or recent MI, decompensated heart failure, significant arrhythmia, severe valvular disease.

Perioperative beta-blockade should not be acutely initiated on the day of surgery; continue established therapy in patients already taking a beta-blocker.

Dual antiplatelet therapy after coronary stenting: elective surgery generally deferred 6 months after drug-eluting stent and 1 month after bare-metal stent when possible.

Surgery is a hypercoagulable state; VTE prophylaxis with low-molecular-weight heparin or unfractionated heparin plus mechanical prophylaxis is indicated for most moderate- to high-risk inpatients unless contraindicated.

Perioperative hyperglycemia (>180 mg/dL) is associated with increased surgical site infection and mortality; insulin-based control is preferred over sliding-scale-only regimens.

ARDS Berlin definition: acute onset within 1 week, bilateral opacities not fully explained by effusion/collapse/nodule, not primarily cardiogenic, PaO2/FiO2 ≤300 with PEEP ≥5; severity mild 201–300, moderate 101–200, severe ≤100.

Lung-protective ventilation for ARDS: tidal volume 6 mL/kg predicted body weight (range 4–8), plateau pressure ≤30 cm H2O, permissive hypercapnia.

Septic shock: sepsis with vasopressor requirement to maintain MAP ≥65 mmHg and lactate >2 mmol/L despite adequate fluid resuscitation; initial crystalloid 30 mL/kg is recommended by Surviving Sepsis.

Norepinephrine is the first-line vasopressor for septic shock; vasopressin or epinephrine is added to reach MAP target rather than escalating norepinephrine alone.

Vasopressor initiation via peripheral line is acceptable short-term while central access is obtained; extravasation risk increases with high doses and distal sites.

Sedation strategy: light sedation with daily interruption reduces ventilator days; dexmedetomidine is an option when extubation is planned and delirium is present.

ICU delirium prevention bundles target orientation, sleep, early mobility, pain control, and minimizing deliriogenic drugs such as benzodiazepines and anticholinergics.

Prone positioning for ≥16 hours/day reduces mortality in moderate-severe ARDS (PaO2/FiO2 <150) when used with lung-protective ventilation.

STEMI reperfusion: primary PCI within 90 minutes of first medical contact at a PCI-capable center; fibrinolysis within 30 minutes when PCI cannot be achieved within 120 minutes and no contraindication exists.

Acute decompensated heart failure initial therapy: IV loop diuretic for congestion; nitroglycerin for hypertensive pulmonary edema; avoid negative inotropes in low-output states.

Atrial fibrillation with rapid ventricular response and hemodynamic instability requires emergent synchronized cardioversion; rate control with beta-blocker or calcium channel blocker in stable patients.

Aortic dissection: type A involves ascending aorta and is a surgical emergency; type B is managed medically with heart rate control (target 60 bpm) and blood pressure control.

Hypertensive emergency: BP >180/120 with end-organ damage (encephalopathy, aortic dissection, pulmonary edema, AKI, ACS); use titratable IV agents and reduce MAP by ≤25% in the first hour.

Pulmonary embolism risk stratification: massive (hemodynamic instability) warrants systemic thrombolysis or embolectomy; submassive with RV dysfunction and elevated troponin warrants close monitoring and consideration of reperfusion.

Ventricular tachycardia with a pulse and instability is treated with synchronized cardioversion; pulseless VT or VF requires immediate defibrillation and CPR.

Wellens syndrome (biphasic or deeply inverted T waves in V2–V3) and new left bundle branch block suggest critical LAD stenosis and warrant urgent cardiology evaluation.

Type 1 respiratory failure: hypoxemia with normal or low PaCO2; type 2: hypoxemia with PaCO2 >45 mmHg, often from alveolar hypoventilation.

A-a gradient = PAO2 − PaO2, where PAO2 = FiO2 × (Patm − 47) − (PaCO2 / 0.8); a normal gradient in hypoxemia suggests hypoventilation or low inspired oxygen.

COPD exacerbation: controlled oxygen to target SpO2 88–92%, short-acting bronchodilators, systemic corticosteroids, and antibiotics when increased sputum purulence or ventilatory support is present.

Noninvasive ventilation is preferred for COPD exacerbation with acute hypercapnic respiratory failure and for acute cardiogenic pulmonary edema; contraindicated with altered mental status, vomiting, or hemodynamic instability.

Asthma severe exacerbation: continuous inhaled beta-agonist, ipratropium, systemic corticosteroids, and magnesium sulfate for refractory cases; avoid routine antibiotics.

High-flow nasal cannula delivers heated humidified oxygen at up to 60 L/min with FiO2 up to 1.0 and provides low-level PEEP; it is not a substitute for invasive ventilation in exhaustion.

Lung-protective ventilation principles apply to all mechanically ventilated patients to reduce ventilator-induced lung injury and barotrauma.

Pleural effusion evaluation: Light criteria classify exudate when pleural protein/serum protein >0.5, pleural LDH/serum LDH >0.6, or pleural LDH >2/3 upper limit of normal serum LDH.

Sepsis bundle timing: obtain blood cultures before antibiotics, administer broad-spectrum antibiotics within 1 hour for septic shock or high likelihood of sepsis, and measure lactate.

Community-acquired pneumonia: CAP severity tools (CURB-65, PSI) guide site of care; empiric therapy typically includes a beta-lactam plus macrolide or a respiratory fluoroquinolone for inpatients.

Asymptomatic bacteriuria should not be treated except in pregnancy or before urologic procedures with mucosal trauma; treatment drives resistance and C. difficile risk.

Clostridioides difficile: oral vancomycin or fidaxomicin for initial episodes; stop unnecessary antibiotics; avoid antiperistaltic agents.

MRSA nasal PCR has high negative predictive value; a negative result supports de-escalation of empiric anti-MRSA therapy in pneumonia.

Antimicrobial de-escalation: narrow therapy based on culture and susceptibility data, and set a stop date or prospective audit at 48–72 hours.

Blood culture contamination is reduced by aseptic technique and appropriate skin antisepsis; a single positive coagulase-negative staphylococcal bottle often reflects contamination.

Endocarditis: obtain three sets of blood cultures from separate sites before antibiotics; add echocardiography; surgery is indicated for heart failure, uncontrolled infection, or high embolic risk.

Acute ischemic stroke: IV thrombolysis (alteplase or tenecteplase) within 4.5 hours of last known well in eligible patients; mechanical thrombectomy up to 24 hours in selected large-vessel occlusion with favorable imaging.

NIHSS quantifies stroke severity; a score ≥6 often prompts consideration of large-vessel imaging and thrombectomy evaluation.

Status epilepticus: benzodiazepine first-line (lorazepam or midazolam), followed by a second-line antiseizure drug (levetiracetam, fosphenytoin, or valproate); refractory cases require continuous infusion.

Delirium is acute, fluctuating inattention; the Confusion Assessment Method (CAM) requires acute onset/fluctuation plus inattention and either disorganized thinking or altered consciousness.

Nonconvulsive status epilepticus should be considered in unexplained persistent altered mental status; continuous EEG is the diagnostic standard.

Subarachnoid hemorrhage: sudden severe headache warrants noncontrast head CT; if CT is negative and suspicion is high beyond 6 hours, lumbar puncture for xanthochromia.

Bacterial meningitis: dexamethasone before or with the first antibiotic dose reduces hearing loss and neurologic sequelae in pneumococcal meningitis.

Alcohol withdrawal: symptom-triggered benzodiazepine therapy guided by CIWA-Ar reduces total drug exposure compared with fixed-dose regimens.

AKI KDIGO staging: stage 1 = creatinine rise ≥0.3 mg/dL in 48 h or 1.5–1.9× baseline; stage 2 = 2.0–2.9×; stage 3 = ≥3× or creatinine ≥4.0 mg/dL or initiation of renal replacement therapy.

Fractional excretion of urea (FEUrea) <35% suggests prerenal azotemia, particularly useful when diuretics are in use; FENa <1% suggests prerenal state without diuretics.

Urine sodium <20 mEq/L suggests prerenal; >40 mEq/L suggests intrinsic renal injury such as ATN.

Hyperkalemia with ECG changes (peaked T waves, widened QRS, sine wave) requires IV calcium for membrane stabilization, then insulin/glucose and beta-agonist for intracellular shift, then elimination.

Dialysis indications (AEIOU): acidosis, electrolyte disturbance (refractory hyperkalemia), intoxication, overload (refractory volume), uremia (encephalopathy, pericarditis).

Nephrotoxic exposures (NSAIDs, aminoglycosides, contrast, vancomycin plus piperacillin-tazobactam) should be reviewed and minimized in patients with rising creatinine.

Hemodialysis catheter-related bacteremia usually requires catheter removal and systemic antibiotics; catheter salvage is associated with higher failure rates.

Contrast-associated AKI risk is reduced by volume expansion with isotonic crystalloid; routine use of N-acetylcysteine is not supported by strong evidence.

Hyponatremia: assess volume status and urine osmolality; symptomatic or severe cases require hypertonic saline with correction not exceeding 8–10 mEq/L in 24 hours to avoid osmotic demyelination.

SIADH: euvolemic hyponatremia with urine osmolality >100 mOsm/kg and urine sodium >30 mEq/L; first-line therapy is fluid restriction.

Hyperkalemia treatment sequence: stabilize membrane (calcium), shift potassium intracellularly (insulin/glucose, albuterol), remove potassium (diuretics, binders, dialysis).

Metabolic acidosis: calculate anion gap = Na − (Cl + HCO3); high-gap causes include ketoacidosis, lactic acidosis, renal failure, and toxins (MUDPILES).

Winter's formula predicts expected PaCO2 in metabolic acidosis: 1.5 × HCO3 + 8 ± 2; deviation indicates a mixed disorder.

Metabolic alkalosis: assess urine chloride; low urine chloride (<20 mEq/L) suggests chloride-responsive alkalosis treated with normal saline.

Hypokalemia: ECG changes include flattened T waves and U waves; severe cases require IV potassium with cardiac monitoring and correction of concurrent hypomagnesemia.

Hypercalcemia of malignancy: IV isotonic saline plus calcitonin for rapid effect and a bisphosphonate for sustained control; loop diuretics only after volume repletion.

Diabetic ketoacidosis: IV fluids, insulin infusion, and potassium replacement; total body potassium is depleted, so withhold insulin until K >3.3 mEq/L and replace as needed.

DKA resolution criteria: glucose <200 mg/dL plus two of pH >7.3, bicarbonate >15 mEq/L, or anion gap ≤12; transition to subcutaneous insulin with overlap.

Hyperosmolar hyperglycemic state: profound hyperglycemia and hyperosmolality with minimal ketosis; fluid deficit is often 8–12 L and should be replaced gradually with isotonic crystalloid.

Thyroid storm: high clinical suspicion with Burch-Wartofsky score; treat with beta-blocker, thionamide (PTU or methimazole), iodine after thionamide, and glucocorticoid.

Myxedema coma: IV levothyroxine with or without liothyronine, stress-dose hydrocortisone until adrenal insufficiency is excluded, and passive rewarming with supportive care.

Adrenal crisis: IV hydrocortisone immediately after or with a draw for cortisol; do not delay steroids for confirmatory testing when shock is present.

Hypoglycemia in hospitalized patients is defined as glucose <70 mg/dL; severe hypoglycemia (<40 mg/dL or requiring assistance) warrants immediate dextrose or glucagon.

Inpatient glycemic targets are generally 140–180 mg/dL for most critically ill and noncritically ill patients, balancing hypoglycemia risk.

Upper GI bleeding: IV proton pump inhibitor after endoscopic hemostasis for high-risk stigmata; transfuse to a restrictive hemoglobin threshold (≈7 g/dL) in most patients.

Lower GI bleeding: most cases are self-limited; urgent colonoscopy after adequate preparation is preferred, and CT angiography is used for brisk bleeding.

Acute pancreatitis: aggressive isotonic fluid resuscitation, analgesia, early enteral nutrition when tolerated, and treat the cause; antibiotics are not indicated without infection.

Spontaneous bacterial peritonitis: diagnostic paracentesis with ascitic PMN ≥250 cells/mm³; treat with a third-generation cephalosporin and give albumin for creatinine >1 mg/dL or bilirubin >4 mg/dL.

Hepatic encephalopathy: lactulose titrated to 2–3 bowel movements daily; rifaximin is added for secondary prophylaxis; identify and treat precipitants (GI bleed, infection, constipation).

Decompensated cirrhosis: avoid NSAIDs and nephrotoxins; large-volume paracentesis requires albumin (6–8 g per liter removed) to reduce post-paracentesis circulatory dysfunction.

C. difficile testing should be limited to patients with ≥3 unformed stools in 24 hours; testing formed stool leads to false-positive results.

GI prophylaxis with PPI is indicated for high-risk ICU patients (mechanical ventilation, coagulopathy); indiscriminate use increases pneumonia and C. difficile risk.

Root cause analysis targets system factors rather than individual blame; it is used for serious safety events and near misses to identify latent failures.

Plan-Do-Study-Act (PDSA) cycles drive iterative improvement; measure with balancing measures to detect unintended consequences.

Central line-associated bloodstream infection (CLABSI) prevention bundle: hand hygiene, maximal sterile barrier, chlorhexidine skin antisepsis, optimal site selection, and daily line necessity review.

Catheter-associated urinary tract infection (CAUTI) prevention: avoid unnecessary catheters, use aseptic insertion, maintain closed drainage, and remove promptly with daily review.

Delirium and falls prevention: multicomponent interventions including orientation, mobility, medication review, and vision/hearing optimization; benzodiazepines and anticholinergics increase risk.

Medication reconciliation at transitions of care reduces adverse drug events; high-risk medications include anticoagulants, insulin, opioids, and diuretics.

Hospital-acquired pressure injury prevention: risk assessment (Braden), repositioning, moisture management, and nutrition support.

Handoff standardization (e.g., I-PASS: illness severity, patient summary, action list, situation awareness, synthesis) reduces communication-related adverse events.