From 42373d2cad4e8a1d31a61da9d3b826b5835ca231 Mon Sep 17 00:00:00 2001 From: pavl-g Date: Sun, 5 Apr 2026 01:00:33 +0200 Subject: [PATCH] e-portfolio: added the clinical companion --- antora.yml | 1 + modules/COMPANION/nav.adoc | 2 + modules/COMPANION/pages/comp.adoc | 738 ++++++++++++++++++++++++++++++ 3 files changed, 741 insertions(+) create mode 100644 modules/COMPANION/nav.adoc create mode 100644 modules/COMPANION/pages/comp.adoc diff --git a/antora.yml b/antora.yml index aab571d..8ad98bc 100644 --- a/antora.yml +++ b/antora.yml @@ -4,3 +4,4 @@ title: e-portofolio nav: - modules/ROOT/nav.adoc - modules/CASES/nav.adoc +- modules/COMPANION/nav.adoc diff --git a/modules/COMPANION/nav.adoc b/modules/COMPANION/nav.adoc new file mode 100644 index 0000000..45c28bb --- /dev/null +++ b/modules/COMPANION/nav.adoc @@ -0,0 +1,2 @@ +* Clinical Companion +** xref:comp.adoc[The Clinical Companion Cheat Sheet] \ No newline at end of file diff --git a/modules/COMPANION/pages/comp.adoc b/modules/COMPANION/pages/comp.adoc new file mode 100644 index 0000000..6676360 --- /dev/null +++ b/modules/COMPANION/pages/comp.adoc @@ -0,0 +1,738 @@ += The Clinical Companion + +[.subtitle] +**** +The complete tool to ace the clinical ward service by by link:https://github.com/pavly-gerges[Pavly G.]. +**** + +:doctype: article +:toc: left +:toclevels: 3 +:icons: font +:source-highlighter: highlight.js +:imagesdir: images +:description: The complete tool to ace the clinical ward service. +:keywords: critical care, medical emergencies, clinical assessment, ECG, EEG, drug dosing +:revdate: 2023-2024 +:revremark: Updated according to the latest NICE, ESC, AHA, ADA, ATS, KDIGO, & SCCM guidelines. + +[.modules] +____ +[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] + +[Drug dosing supplement] +____ + +[NOTE] +==== +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 + +[cols="1,2", options="header"] +|=== +| 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) + +[cols="1,2,3,1", options="header"] +|=== +| 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) + +[cols="2,3,1", options="header"] +|=== +| 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) + +[cols="2,1", options="header"] +|=== +| 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 +|=== + +[NOTE] +AMT Score >= 8 is normal for an elderly patient. + +--- + +== Cardiopulmonary Assessment + +=== Well's Pretest Criteria (PE) + +[cols="2,1", options="header"] +|=== +| 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) + +[cols="2,1", options="header"] +|=== +| 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 + +[NOTE] +Positive scores require life-long anti-coagulants to maintain INR (2.0–3.0) to prevent strokes. + +=== HAS-BLED (Pretest for bleeding tendency) + +[cols="2,1", options="header"] +|=== +| 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* +|=== + +[NOTE] +==== +* *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) + +[cols="2,1", options="header"] +|=== +| 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 +|=== + +[cols="1,3", options="header"] +|=== +| 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) + +[cols="1,2,2", options="header"] +|=== +| 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 +|=== + +[NOTE] +Validated definition includes either one major criterion or three or more minor criteria. + +=== SOFA (Sepsis-related Organ Failure Assessment) + +_[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) + +[cols="2,1", options="header"] +|=== +| Feature | Score + +| Age > 55 years | 1.0 +| PaO2 < 8.0 kPa (60 mm.Hg) | 1.0 +| WCC > 15 * 10^9^/L | 1.0 +| Ca^2+^ < 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 +|=== + +[NOTE] +>= 3 predicts an episode of severe pancreatitis prompting ICU admission & preparation for *ERCP if gallstone etiology. + +[NOTE] +==== +* *ERCP*: Endoscopic Retrograde cholangiopancreatography. +* *kPa*: Kilo Pascal. +==== + +=== AKIN Criteria (KDIGO) + +[cols="2,2,1", options="header"] +|=== +| 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/1.73m^2^ +| < 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): + +[cols="1,2", options="header"] +|=== +| 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 m^2^ (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 + +[NOTE] +==== +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) + +[NOTE] +"Timeline valid only for 6 weeks only" + +[cols="1,1,1,1,1,1,1,1", options="header"] +|=== +| Timeline | | | | | | | + +| Drugs | | | | | | | +| Investigations | | | | | | | +| Hand-over notes | | | | | | | +|=== + +[cols="1,1,1,1,1,1,1,1", options="header"] +|=== +| Timeline | | | | | | | + +| Drugs | | | | | | | +| Investigations | | | | | | | +| Hand-over notes | | | | | | | +|=== + +[cols="1,1,1,1,1,1,1,1", options="header"] +|=== +| 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 \ No newline at end of file