When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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CoreWards

Discharge Planning Checklist

A safe discharge prevents readmission. Medication reconciliation, follow-up, patient education, and safety-net instructions are the four pillars. Readmission within 30 days is often a failure of discharge, not disease.

✅ Discharge Checklist

Before Writing the Discharge Order

Medication reconciliation -compare admission meds vs discharge meds. What was added? Changed? Stopped? Does the patient understand each change and why?
Labs pending? -do NOT discharge with critical pending results (blood cultures, pathology). If minor labs pending → ensure follow-up plan for results.
Follow-up appointments -PCP within 7–14 days for all discharges. Specialist follow-up as needed (cardiology post-ACS, surgery post-op, oncology). High-risk patients: follow-up within 48–72h.
Discharge medications prescribed + sent to pharmacy. Verify the patient can afford them. Prior authorizations done? Assistance programs if needed.
Patient education -diagnosis explained in plain language. Red flags to return to ED. Medication side effects. Activity restrictions. Diet changes (low-sodium for HF, renal diet for CKD).
Durable medical equipment -O₂ arranged? CPAP? Walker/wheelchair? Home health nursing?
Social work / care coordination -safe living situation? Capable of ADLs? Need rehab (SNF, acute rehab, LTAC)? Substance use resources? Mental health follow-up?
VTE prophylaxis post-discharge -does the patient need extended prophylaxis (post-major orthopedic surgery × 35 days, post-cancer surgery)?
Discharge summary completed -timely, sent to PCP. Include: admission diagnosis, hospital course, key results, discharge meds (with changes highlighted), pending results, follow-up plan, and code status discussion if applicable.

High-Risk Discharges (30-Day Readmission Risk)

Condition	Key Discharge Interventions
Heart Failure	Daily weights at home. Fluid restrict 1.5–2 L/day. Low-sodium diet. Follow-up within 7 days. Action plan: "If weight ↑ 3 lbs in 2 days → call clinic / double Lasix."
COPD	Inhaler technique reviewed (observed return demonstration). Action plan. Smoking cessation. Pulmonary rehab referral. Prednisone taper if applicable.
Pneumonia	Complete antibiotic course. CXR follow-up in 6–8 weeks (to ensure resolution, rule out underlying mass). Smoking cessation.
ACS	DAPT education (do NOT stop without cardiology approval). Cardiac rehab referral. Statin, BB, ACEi. Nitroglycerin SL PRN prescription + instruction. Follow-up within 2 weeks.

🧪 Workup

Pre-Discharge Checklist

Domain	Before Discharge
Clinical stability	Afebrile ≥ 24h, improving trajectory, tolerating PO, ambulatory (or at baseline), stable vitals off telemetry
Pending results	Blood cultures, biopsy, imaging reads, consult recs -assign follow-up responsibility for each. Document who will call patient.
Medication reconciliation	Compare admission meds → current → discharge. Mark: NEW / CHANGED / STOPPED. Verify patient can access + afford meds.
Follow-up arranged	PCP within 7 days (48–72h if high-risk). Specialist follow-up with date. Labs with specific date and location.
Transitions of care	Discharge summary sent to PCP SAME DAY. Include: diagnosis, hospital course, pending results, medication changes, follow-up plan.

⚡ Management

High-Risk Discharge Situations

Situation	Risk	Mitigation
New anticoagulation	Bleeding, missed doses, drug interactions	Teach signs of bleeding, drug-food interactions (warfarin), ensure INR follow-up if warfarin
New insulin	Hypoglycemia, dosing errors	Teach-back injection technique, glucose monitoring, hypo treatment. Diabetes educator consult.
Heart failure	30-day readmission (25%)	Daily weights, sodium restriction, diuretic adjustment plan, 48–72h follow-up, call if gain > 3 lbs/2 days
COPD exacerbation	Readmission, ongoing steroid needs	Ensure inhaler technique (observed), prednisone taper written, pulmonary rehab referral, quit smoking
AMA discharge	Poor outcomes, medicolegal risk	Document capacity assessment, risks explained, medications offered, follow-up arranged despite AMA. Patients retain right to receive discharge meds and instructions.

I-PASS Sign-Out Format

Letter	Meaning	Example
I	Illness severity	"Stable" / "Watcher" / "Unstable"
P	Patient summary	"72M with COPD exacerbation, day 3 of prednisone, on 2L NC"
A	Action list	"Repeat BMP at 6 AM for K⁺ recheck. Call if below 3.5."
S	Situation awareness	"May need BiPAP if RR > 30 or SpO₂ < 88%. Has been borderline."
S	Synthesis by receiver	Receiving team reads back key action items and contingency plans.

I-PASS reduced medical errors by 23% and preventable adverse events by 30% in a multicenter study I-PASS Study, 2014.

💊 Medications

Medication Reconciliation -The #1 Safety Issue

~50% of patients have ≥ 1 medication discrepancy at discharge. The three most dangerous: (1) restarting a med that was intentionally held, (2) not starting a new med that was added, (3) duplicate therapy.

Step	Action
1. Compare lists	Home meds → inpatient meds → discharge meds. Use pharmacy reconciliation if available.
2. Mark changes	Flag: * = NEW, Δ = CHANGED dose/frequency, ✕ = STOPPED. Explain WHY for each change.
3. Teach-back	Review each changed med with patient. "Tell me how you'll take this at home." Low health literacy = use plain language.
4. Access check	Can patient afford meds? Has pharmacy? Need prior auth? Provide 30-day bridge if insurance gap.

⚡ Summary

Summary

I-PASS Handoff

Illness severity → Patient summary → Action list → Situation awareness → Synthesis by receiver. Reduces errors by 30% I-PASS Study, 2014.

Med Reconciliation

At bedside: review every med (new, changed, stopped). Teach-back: patient explains each med. Ensure meds in hand, not just prescriptions.

Follow-Up

PCP within 7 days for most. Within 48-72h for HF. Specialists as needed. Ensure patient has appointment BEFORE discharge.

Red Flags

Written instructions with specific return precautions: fever, worsening symptoms, new symptoms, unable to take meds, unable to eat/drink.

Readmission Prevention

Phone call within 48h post-discharge. Medication adherence check. Confirm follow-up appointments. Address social barriers (transport, cost).

Transitions of Care

Discharge summary to PCP same day. Include: diagnosis, hospital course, pending results, follow-up needs, medication changes with rationale.

📄 One Pager

SAFE DISCHARGE -AT A GLANCE

💊 Med rec: Compare lists → mark NEW/CHANGED/STOPPED → teach-back → access check
📋 Pending: Assign owner for every pending result
📅 Follow-up: PCP 7d (48–72h if high-risk). Specialist with date. Labs with date + location.
📄 Summary: To PCP same day -diagnosis, course, meds, pending, plan
🚨 Red flags: Specific symptoms to return for (not generic)
📞 Phone call: 24–48h post-discharge to verify meds filled + understanding

🔍 Overview

Overview

~20% of patients have adverse events within 3 weeks of discharge. ~40% involve medication errors. I-PASS handoff, bedside med reconciliation, teach-back, and 48h phone calls reduce readmissions.

📋 On Rounds

Pimp Questions

What is the single most commonly missed item on a discharge that leads to readmission?

Medication reconciliation -specifically, not communicating medication changes to the patient and PCP. Studies show that ~50% of patients have at least one medication discrepancy at discharge. The most dangerous errors: (1) restarting a medication that was intentionally stopped (e.g., metformin held for AKI, ACEi held for hyperkalemia), (2) not starting a new medication that was added (e.g., DAPT after stent, anticoagulation after new AFib)

When should follow-up be within 48–72 hours vs 7–14 days after discharge?

48–72 hour follow-up is indicated for high-risk discharges: heart failure (weight monitoring, diuretic adjustment), COPD exacerbation (inhaler reassessment), AKI (Cr recheck), medication changes requiring monitoring (new anticoagulation, new insulin), patients with limited health literacy or social support, and any patient you're worried about.

What is the I-PASS framework and why does it reduce medical errors?

I-PASS is a standardized handoff mnemonic that reduced medical errors by 30% in a multicenter study I-PASS Study, 2014. I = Illness severity (stable, watcher, unstable). P = Patient summary (one-liner: age, sex, diagnosis, key hospital course). A = Action list (what needs to be done overnight -labs to check, meds to give, pending results). S = Situation awareness ("if X happens, then do Y" -anticipatory guidance).

What are the most common causes of 30-day readmission and how do you prevent them?

The top 3: (1) Heart failure (highest readmission rate ~25%) -prevent with: weight monitoring daily at home, clear diuretic instructions ("if weight up 3 lbs in 1 day, take extra Lasix"), follow-up within 48-72h, dietary counseling (2g Na restriction). (2) COPD -prevent with: proper inhaler technique verified at discharge, action plan for exacerbations, pulm rehab referral, 5-7 day follow-up.

Clinical Examples

📋 Case 1, Heart Failure Discharge with High Readmission Risk

Patient: 72M with HFrEF (EF 25%), admitted for acute decompensation (fluid overload). Now euvolemic on furosemide 80 mg PO BID. Lives alone, limited health literacy. Eats canned soups daily.

Key findings: HF is the #1 readmission diagnosis (~25% 30-day readmission rate). High-risk features: lives alone, limited literacy, dietary non-adherence. Most HF readmissions are from volume overload due to dietary indiscretion or medication non-compliance.

Management:

Teach-back method: "Tell me in your own words when you should call your doctor" (verifies comprehension)
Daily weight instructions: "Weigh yourself every morning after using the bathroom. If you gain 3 lbs in 1 day or 5 lbs in 1 week, take an extra Lasix AND call us"
Dietary counseling: 2g sodium restriction, avoid canned foods, read labels (involve family/caregiver)
Follow-up within 48-72h (HF clinic or PCP). Transitional care nurse phone call within 48h
Medication reconciliation at bedside with patient: review each med, what it's for, when to take it

Teaching point: The discharge summary is a medical document, the discharge CONVERSATION is what prevents readmissions. Teach-back is more valuable than any written instruction. If a patient can't explain their weight monitoring plan back to you, they're not ready for discharge.

📋 Case 2, Complex Med Reconciliation After ACS

Patient: 58M admitted for NSTEMI, underwent PCI with DES to LAD. Started on DAPT (ASA + ticagrelor), high-intensity statin, beta-blocker, ACEi. Home meds included clopidogrel (prior stroke), PPI, metformin. Multiple medication changes.

Key findings: High-complexity medication reconciliation: new DAPT (replacing prior clopidogrel monotherapy), new statin dose, new BB and ACEi. Risk: patient may continue old clopidogrel + new ticagrelor (double P2Y12), or stop ASA thinking it's redundant.

Management:

Create a clean medication list with "STOP" and "NEW" clearly marked
STOP: clopidogrel (replaced by ticagrelor). CONTINUE: ASA 81 mg (part of DAPT)
NEW: ticagrelor 90 mg BID (must take twice daily, missed doses increase stent thrombosis risk)
PPI: continue (GI prophylaxis on DAPT). Note: omeprazole interacts with clopidogrel but NOT ticagrelor
Cardiology follow-up within 1-2 weeks. Emphasize: do NOT stop ticagrelor or ASA without calling cardiologist

Teaching point: Post-PCI patients who stop DAPT prematurely have a 5-10% risk of stent thrombosis (often fatal STEMI). The discharge conversation must include: "Do not stop these two blood thinners for ANY reason without calling your cardiologist first, not even for a dental cleaning."

📋 Case 3, Safe Opioid Tapering at Discharge

Patient: 45F admitted for pancreatitis × 7 days, received IV hydromorphone for pain control. Now tolerating PO, pain 3/10. Team wants to transition to oral and prepare for discharge. Patient has no prior opioid use.

Key findings: Opioid-naive patient on IV opioids × 7 days, at risk for physical dependence and outpatient opioid misuse. Must taper appropriately and set clear expectations for discharge prescribing.

Management:

Convert IV hydromorphone to oral equivalent (2 mg IV hydromorphone ≈ 8 mg PO hydromorphone)
Reduce by 25-50% when converting IV → PO (incomplete cross-tolerance)
Discharge with 3-5 day supply of oral opioid MAXIMUM with no refills (short-course prescribing)
Co-prescribe: acetaminophen 1g TID + ibuprofen 400 mg TID (multimodal, reduces opioid need by 30-40%)
Set expectations: "Pain should improve daily. If it's getting worse rather than better, call us, that's not normal"

Teaching point: The #1 risk factor for chronic opioid use is the initial prescription length. Prescribing > 7 days of opioids for acute pain doubles the risk of chronic use at 1 year. Always prescribe the minimum effective course with a clear taper plan.

📣 Sample Presentation

One-Liner

"Mrs. Baker is a 74-year-old admitted 4 days ago for COPD exacerbation, now back to baseline on home O₂ (2L), tolerating PO steroids, and able to ambulate. Ready for discharge."

Key Points to Cover on Rounds

Discharge medications reviewed at bedside: * NEW: prednisone 40 mg PO daily × 3 more days (5-day course total), * NEW: azithromycin 250 mg daily × 2 more days, * CHANGED: added Breo Ellipta 200/25 daily (was not on ICS/LABA before). Home meds continued: tiotropium, albuterol PRN, lisinopril, atorvastatin. Follow-up: PCP in 5 days, pulmonology in 2 weeks. Smoking cessation: quit 2 years ago -reinforced. Pulm rehab referral sent. Patient taught proper inhaler technique (observed return demo). Red flags reviewed: return if worsening dyspnea, fever, or unable to complete steroid taper.

Pre-Discharge Checklist -Discharge Planning

Domain	Checklist Item	Action / Details
Medication reconciliation	Complete and reviewed at bedside	Compare admission → discharge meds. Mark NEW / CHANGED / STOPPED. Ensure patient understands each change and why. Verify meds are affordable and filled.
Follow-up appointments	Scheduled before discharge	PCP within 7–14 days (48–72h if high-risk: HF, ACS, COPD). Specialist follow-up as needed with date and location confirmed. Patient has written appointment details.
Patient education	Red flags and return precautions	Disease-specific return precautions explained in plain language. Teach-back method: patient explains warning signs in their own words. Written instructions provided.
Discharge summary	Completed and sent to PCP	Sent same day. Include: admission diagnosis, hospital course, key results, medication changes with rationale, pending results, follow-up plan, code status.
Pending labs/results	Responsible provider assigned	Every pending result (blood cultures, pathology, imaging reads) must have a named provider responsible for follow-up. Document who will contact the patient.
VTE prophylaxis	Post-discharge plan if applicable	Extended prophylaxis for: post-major orthopedic surgery (35 days), post-cancer surgery (28 days). Ensure prescription and patient education on injection technique if applicable.
Code status	Confirmed and documented	Especially for patients with serious illness, recurrent admissions, or goals-of-care discussions during hospitalization. Ensure advance directive is in the chart.

Post-Discharge Monitoring Plan

Timeframe	Action
24–48 hours	Post-discharge phone call (nursing or pharmacy). Confirm: meds filled, understanding discharge instructions, no new symptoms.
48–72 hours	High-risk follow-up: HF (weight, diuretic response), AKI (Cr recheck), new anticoag (INR if warfarin), new insulin (glucose log).
7 days	PCP follow-up for most patients. Review hospital course, pending results, medication changes.
30 days	Specialist follow-up. Labs (Cr, CBC, LFTs as indicated). Functional status assessment.

Readmission within 30 days is often a failure of discharge, not disease. The most impactful interventions: medication reconciliation at bedside (not just on paper), confirmed follow-up appointment (not just "follow up with PCP"), and post-discharge phone call within 48h.