Can you provide a complete management plan for the common inpatient internal medicine cases that a resident will encounter?

Complete Management of Common Inpatient Internal Medicine Cases

Community-Acquired Pneumonia

Initial Assessment and Risk Stratification

Calculate CURB-65 score immediately upon admission to guide management intensity. 1 Score one point for each: Confusion (mental test score <8 or new disorientation), Urea >7 mmol/L, Respiratory rate ≥30/min, Blood pressure (SBP <90 or DBP ≤60 mmHg), Age ≥65 years. 1

• CURB-65 score 0-1: Low risk, consider outpatient management 1
• CURB-65 score 2: Moderate risk, short-stay inpatient observation recommended 1, 2
• CURB-65 score 3-5: High risk of death, manage as severe pneumonia with ICU consideration 1, 2
• Bilateral infiltrates on chest X-ray: Treat as severe pneumonia regardless of CURB-65 score 1, 2

Immediate Diagnostic Workup

• Full blood count, urea/electrolytes, liver function tests 1, 2
• Chest radiograph on all admitted patients 1
• Pulse oximetry; if SpO2 <92% on room air, obtain arterial blood gases 1, 2
• ECG when cardiac or respiratory complications suspected 1
• C-reactive protein when pneumonia suspected 1

Microbiological Investigations

For severe pneumonia (CURB-65 ≥3 or bilateral changes):

• Blood cultures before antibiotics 1, 2
• Pneumococcal urine antigen (20 mL urine) 1
• Legionella urine antigen 1
• Sputum Gram stain, culture, and susceptibility if purulent sample available and no prior antibiotics 1

For non-severe pneumonia (CURB-65 0-2):

• No routine testing initially 1
• Send sputum only if patient fails empirical therapy 1

Oxygen Therapy Protocol

Maintain PaO2 ≥8 kPa and SpO2 ≥92% with appropriate oxygen delivery. 1, 2 High concentrations of oxygen can safely be given in uncomplicated pneumonia. 1

• For COPD patients with ventilatory failure: Start with 24-28% oxygen, titrate using repeated arterial blood gases to keep SpO2 >90% without pH falling below 7.35 1
• Consider non-invasive ventilation in COPD patients with acute hypercapnic respiratory failure 1

Antibiotic Therapy

Non-severe pneumonia (CURB-65 0-2):

• Oral co-amoxiclav or tetracycline preferred 1
• Alternative: Macrolide (clarithromycin/erythromycin) or fluoroquinolone active against S. pneumoniae and S. aureus 1

Severe pneumonia (CURB-65 ≥3 or bilateral infiltrates):

• IV co-amoxiclav or second/third-generation cephalosporin PLUS macrolide 2
• Administer within 4 hours of recognition 3

Acute bronchitis without pneumonia:

• Previously well adults do not routinely require antibiotics 1
• Consider antibiotics if worsening symptoms (recrudescent fever, increasing dyspnea) 1
• High-risk patients (see below) should receive antibiotics with lower respiratory features 1

ICU/HDU Transfer Criteria

Transfer immediately if any of the following present:

• Persistent hypoxia with PaO2 <8 kPa despite FiO2 >60% 1, 2
• Progressive hypercapnia 1
• Severe acidosis (pH <7.26) 1
• Septic shock 1
• CURB-65 score 4 or 5 1, 2

Supportive Care

• Assess for volume depletion and cardiac complications; provide IV fluids as indicated 1
• Nutritional support in severe or prolonged illness 1
• Monitor temperature, respiratory rate, pulse, blood pressure, mental status, SpO2, and FiO2 at least twice daily 1, 2
• Use Early Warning Score system for systematic monitoring 1

Discharge Criteria

Do NOT discharge if ≥2 of the following unstable factors present:

• Temperature >37.8°C 1
• Heart rate >100/min 1
• Respiratory rate >24/min 1
• Systolic blood pressure <90 mmHg 1
• Oxygen saturation <90% 1
• Inability to maintain oral intake 1
• Abnormal mental status 1

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Influenza with Pneumonia

Antiviral Therapy

Initiate oseltamivir immediately on clinical suspicion—do not wait for laboratory confirmation. 2, 4

• Adults: 75 mg orally twice daily for 5 days 1, 2, 4
• Reduce to 75 mg once daily if creatinine clearance <30 mL/min 1, 2, 4
• Start even if >48 hours from symptom onset in hospitalized or severely ill patients 1, 2
• Immunocompromised or very elderly patients may receive treatment despite lack of documented fever 1

Combined Antibiotic Coverage

Always add antibiotics to oseltamivir for influenza-related pneumonia. 1

• Non-severe: Oral co-amoxiclav or tetracycline 1
• Severe: IV co-amoxiclav or cephalosporin PLUS macrolide 1, 3

Management Otherwise Identical to CAP

Follow CURB-65 stratification, oxygen therapy, monitoring, and discharge criteria as outlined above for community-acquired pneumonia. 2

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Acute Heart Failure

Immediate Assessment

Measure blood pressure and oxygen saturation immediately—these two parameters provide rapid risk stratification. 5

• SBP <120 mmHg: Associated with significantly increased mortality at 1 and 6 months 5
• SpO2 <90%: Associated with higher rates of worsening heart failure and mortality 5
• Combined low SpO2 and low SBP: Particularly strong adverse prognostic implication 5

Initial Diagnostic Workup

• ECG to assess for ischemia, arrhythmias, conduction abnormalities 4
• Chest radiograph 1
• Full blood count, urea/electrolytes, liver function tests 4
• Troponin and BNP/NT-proBNP 4
• Arterial blood gases if SpO2 <92% 5

Oxygen Therapy

• Target SpO2 ≥92% 5
• High-flow oxygen as needed to maintain adequate oxygenation 5

Hemodynamic Support

• Assess for volume status carefully 1, 4
• IV diuretics for volume overload 4
• Vasopressors/inotropes if hypotension with evidence of shock (altered consciousness, decreased urine output, end-organ failure) 1

ICU Transfer Criteria

• Requirement for invasive ventilatory support: Refractory hypoxemia (SpO2 <90% on non-rebreather mask), respiratory acidosis pH <7.2, clinical evidence of impending respiratory failure, inability to protect airway 1
• Hypotension (SBP <90 mmHg) with clinical shock refractory to volume resuscitation requiring vasopressor/inotrope support 1
• Patients requiring ventilatory support: 81% recurrent heart failure rate, 41% mortality at 1 month 5
• Patients requiring IV pressors without mechanical ventilation: 72% recurrent heart failure rate, 28% mortality at 1 month 5

Monitoring

• Vital signs at least twice daily 4
• Continuous cardiac monitoring 6, 7, 8
• Strict intake/output 6

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Acute Appendicitis

Clinical Pathway

Establish standardized clinical pathways involving surgery, emergency medicine, radiology, and pharmacy. 1

Diagnostic Approach

• Constellation of characteristic abdominal pain, localized tenderness, and laboratory evidence of acute inflammation identifies most patients 1
• Helical CT abdomen/pelvis with IV contrast (no oral or rectal contrast) is the recommended imaging 1
• All female patients should undergo diagnostic imaging 1
• Pregnancy testing for women of childbearing potential; if first trimester, use ultrasound or MRI instead of CT 1
• Imaging recommended for all children, particularly age <3 years, when diagnosis uncertain 1

Antibiotic Therapy

Uncomplicated appendicitis (no perforation, abscess, or local peritonitis):

• Narrow-spectrum regimen active against aerobic/facultative and obligate anaerobes 1
• Discontinue within 24 hours 1

Complicated intra-abdominal infection:

• Broad-spectrum coverage until source control achieved 1

Bowel injuries repaired within 12 hours:

• Antibiotics for 24 hours only 1

Surgical Management

• Proceed to appendectomy based on clinical and imaging findings 1
• Source control is definitive treatment 1

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Suspected Treatment Failure in Intra-Abdominal Infection

Diagnostic Investigation

If persistent or recurrent clinical evidence of infection after 4-7 days of therapy, obtain CT or ultrasound imaging. 1

• Continue antimicrobial therapy effective against initially identified organisms 1
• Investigate extra-abdominal sources and noninfectious inflammatory conditions if inadequate response 1

Repeat Cultures

• Obtain both aerobic and anaerobic cultures from ≥1 mL fluid or tissue in anaerobic transport system 1
• Inoculate 1-10 mL fluid directly into anaerobic blood culture bottle to improve yield 1

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ICU Triage During Mass Casualty Events

Inclusion Criteria for ICU Admission

Patient must have requirement for invasive ventilatory support OR hypotension with shock:

Category A (Ventilatory support needed):

• Refractory hypoxemia (SpO2 <90% on non-rebreather mask/FiO2 0.85) 1
• Respiratory acidosis with pH <7.2 1
• Clinical evidence of impending respiratory failure 1
• Inability to protect or maintain airway 1

Category B (Circulatory support needed):

• Hypotension (SBP <90 mmHg or relative hypotension) with clinical shock (altered consciousness, decreased urine output, end-organ failure) refractory to volume resuscitation requiring vasopressor/inotrope support 1

Exclusion Criteria from ICU Admission

Exclude if ANY of the following present:

• Severe trauma with TRISS predicted mortality >80% 1
• Severe burns with age >60 years AND >40% TBSA AND inhalation injury (any two) 1
• Unwitnessed cardiac arrest, or witnessed arrest not responsive to electrical therapy, or recurrent arrest 1
• Severe baseline cognitive impairment (unable to perform ADLs independently or institutionalized due to cognitive impairment) 1
• Metastatic malignant disease 1
• Advanced irreversible immunocompromised state (AIDS with no antiviral options) 1
• End-stage organ failure: NYHA class III/IV heart failure, COPD with FEV1 <25% predicted, Child-Pugh score ≥7 liver disease 1

Triggering Triage Protocols

• ICU triage protocols should only be triggered when ICU resources across a broad geographic area are or will be overwhelmed despite all reasonable efforts 1

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General ICU Monitoring Principles

Hemodynamic Monitoring

• Continuous assessment of oxygen delivery to tissues according to metabolic needs 6
• Sequential optimization of heart function followed by assessment of perfusion/oxygenation adequacy ("goal-directed therapy") 6
• Invasive hemodynamic monitoring enables pressure, flow, and saturation measurements in systemic and pulmonary circulation 8

Respiratory Monitoring

• Serial assessment of gas exchange 6
• Respiratory system mechanics 6
• Readiness for liberation from mechanical ventilation 6

Temperature Monitoring

• Maintenance of normal temperature is critical and should be regularly monitored 6

Nutritional and Metabolic Monitoring

• Control nutrient delivery 6
• Ensure adequation between energy needs and delivery 6
• Blood glucose monitoring 6

Critical Principle

Advanced monitoring devices must supplement and not supplant clinical assessment. 7 Pitfalls in data acquisition and interpretation must be recognized before therapeutic decisions are made. 7