# 內科值班01
[和信醫院內科值班手冊](/B9JKdRsFRBmv56ZcOMaP-g)
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## Fever
值班發燒≠FUOs(survey過一輪還查不到原因才叫FUO), treat as infection ; Sepsis 需廣效抗生素
Lethal etiology
Sepsis(CRBSI, CDI), Febrile neutropenia, CNS infection
Hx, PE and Labs
Vital signs+ from head to toe; SOFA score + lactate, B/C
x2, U/A, CXR, ±CD toxin; r/o CNS infect; Cirrhosis → SBP
Management
Broad Abx in hour 1 if sepsis; L/R if septic shock
Where is the focus? Do source control
Curam or Fortum→Tazocin→Mero ± Teico ± Fluconazle
Febrile neutropenia cover pseudomonas

## Shock
Tissue hypoperfusion;秘訣BP ＝ CO x SVR ; Echo(FALLS)
Lethal etiology
Allergic, Septic, bleeding, PE, tamponade, ACS, arrhythmia
Hx, PE and Labs
Drug? HR? Cold or warm? Dry or wet? Basal rales?
CBC + BCS + lactate/TnI ± Blood ; IVC, effusion, LVEF, RV
Management
Keep vital signs + IV/O2/monitor ; N/S 500 ml
Hemorrhagic : 18 IC x 2, whole blood, monitor HR
Anaphylactic : Epi 0.5 mg IM
Septic : considering vasopressor

Altered mental status
Vitals Sugar, Meta, 切CT ; Stroke: Time is brain!
Lethal etiology
Hypoglycemia,O2↓,CO2↑, stroke,Ca/K↑; CNS INF, Sepsis
Hx, PE and Labs
Trauma?Drugs? Progression +s/s? CNS INF? NE! (dolleye)
F/S, ABG, BUN, ammonia, BCS(e-), INF(UTI could cause)
Management
ABC + vital signs ± protect airway? Treat accordingly.
GCS + Pupils + muscle strength follow-up
CT + Consult Neuro ± EEG; Seizure → Ativan+Keppra
MRI + dexamethasone if malignancy + brain mets

## Altered mental status

## Dyspnea
Keep vitals ; 注意failure signs, Altered MS ; Echo(BLUE)
Lethal etiology
Pneumonia, tamponade, pneumothorax, atypical ACS,
PE, CO2↑, O2↓(CHF,COPD…etc),
Hx, PE and Labs
Sputum? Chest pain? Jugular vein, rales, edema; EKG,TnI
CXR, ABG, CBC/BCS ± f/u EKG; Echo: BLUE protocol
Management
ABC+ IV/O2/monitor; Treat accordingly
Oxygen supplement; BIPAP for CHF/COPD
當你想到要插管，就是插管的時機。(除了PE)

## Chest pain
一定要做心電圖!(STEMI equivalent) Echo can help!
Lethal etiology
ACS, PE, aortic dissection ± effusion, pneumothorax
Hx, PE and Labs
LQQOPERA, Jugular vein, rales, pulse pressure(SBP-DBP)
EKG + TnI + CXR ; Echo: thoracic/Abd aorta
Management
Treat accordingly ; Suspect ACS consult CV
不確定可以追蹤EKG/TnI, 看risk 驗D-dimer或切CT
Echo可幫忙診斷
大絕招: Triple CT angiography r/o PE+AMI+AoD

## Abdominal pain
Abdominal pain
排除acute abdomen跟ischemic bowel ; Echo
Lethal etiology
PPU, ischemic bowel, AAA, dissection, obstruct, DKA
Hx, PE and Labs
LQQOPERA(sudden? Acute?), vitals, abd PE; lactate,
CBC/BCS/blood/SBG, lipase, pregnancy? ; Echo: Abd Ao
Management
確定病因最為重要，但還是可以給止痛+NPO。
If infection suspected → Broad antibiotics(App can mask)
40歲以上上腹痛記得做心電圖。
Acute abd→ 外科。不確定就切CTA + arterial phase。