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Temperature >38°C (100.4°F) or <36°C (96.8°F)

Heart rate >90 bpm

Respiratory rate >20 or PaCO₂ <32 mmHg

WBC >12,000 or <4,000 or >10% bands

Suspected or confirmed source of infection

Lactic acidosis (lactate >2 mmol/L)

SBP <90 or drop ≥40 mmHg from baseline

Hypotension despite adequate fluid resuscitation

Evidence of ≥2 organ failures

Congestive heart failureHistory of CHF or LVEF <40%

HypertensionBP >140/90 or on antihypertensives

Age ≥75 years

Diabetes mellitus

Stroke / TIA / thromboembolism history

Vascular diseasePrior MI, PAD, or aortic plaque

Age 65–74 years

Sex category — Female

C — ConfusionNew disorientation to person, place, or time

U — Urea >19 mg/dL (BUN >7 mmol/L)

R — Respiratory rate ≥30 breaths/min

B — Blood pressure <90 systolic or ≤60 diastolic

65 — Age ≥65 years

Clinical signs of DVTLeg swelling, pain with palpation of deep veins

PE is #1 diagnosis or equally likely

Heart rate >100 bpm

Immobilization ≥3 days or surgery in past 4 weeks

Prior DVT or PE

Hemoptysis

Malignancy (active or treated within 6 months)

Blood glucose (mg/dL)

Arterial pH

Serum bicarbonate (mEq/L)

Serum potassium (mEq/L)

Altered mental status / stupor

Current serum sodium (mEq/L)

Target sodium (mEq/L)Usually 125 for symptomatic, 130–135 for goal

Patient weight (kg)

Sex

Symptomatic hyponatremia?Seizures, severe confusion, coma

Systolic BP (mmHg)

Diastolic BP (mmHg)

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Best eye response

Best verbal response

Best motor response

How often do you have a drink containing alcohol?

How many drinks do you have on a typical day?

How often do you have 6 or more drinks on one occasion?

C — Have you ever felt you should Cut down on your drinking?

A — Have people Annoyed you by criticizing your drinking?

G — Have you ever felt Guilty about drinking?

E — Have you ever had a drink first thing in the morning (Eye-opener)?

H — History

E — EKG

A — Age

R — Risk Factors

T — Troponin

Urine sodium (mEq/L)

Serum sodium (mEq/L)

Urine creatinine (mg/dL)

Serum creatinine (mg/dL)

On diuretics?

H — Hypertension (uncontrolled, SBP >160)

A — Abnormal renal or liver functionEach scores +1 (max +2)

S — Stroke history

B — Bleeding history or predisposition

L — Labile INR (if on warfarin)

E — Elderly (age >65)

D — Drugs (antiplatelets/NSAIDs) or alcoholEach scores +1 (max +2)

Age (years)

Weight (kg)

Serum creatinine (mg/dL)

Sex

Height (inches) e.g. 5'6" = 66 inches

Weight (lbs)

QT interval (ms)

Heart rate (bpm)

Sex

Sodium (mEq/L)

Chloride (mEq/L)

Bicarbonate (mEq/L)

Albumin (g/dL) For corrected AG

Age ≥50 years

Heart rate ≥100 bpm

SpO₂ <95% on room air

Unilateral leg swelling

Hemoptysis

Recent surgery or trauma (<4 weeks)

Prior DVT or PE

Estrogen use (OCP, HRT, pregnancy)

Current serum sodium (mEq/L)

Weight (kg)

Sex

Weight (kg)

S — Do you Snore loudly?

T — Do you often feel Tired, fatigued, or sleepy during the daytime?

O — Has anyone Observed you stop breathing during sleep?

P — Do you have or are you being treated for high blood Pressure?

B — BMI >35?

A — Age >50?

N — Neck circumference >40 cm (15.7 in)?

G — Gender male?

Serum Calcium (mg/dL)

Serum Albumin (g/dL)

Height (cm)

Actual Body Weight (kg)

Sex

MCV (fL)Normal 80-100 fL

Hemoglobin (g/dL)Normal: M >13.5, F >12.0

Reticulocyte count (%)Optional — helps classify if normocytic

Opioid

Daily dose (mg/day)For fentanyl patch enter mcg/hr

Weight (kg)

Total Body Surface Area Burned (%)Do not include superficial (1st degree) burns

Hours since burn injury

High-risk surgeryIntraperitoneal, intrathoracic, or suprainguinal vascular

History of ischemic heart diseaseMI, positive stress test, angina, nitrate use, EKG Q waves

History of congestive heart failure

History of cerebrovascular diseasePrior stroke or TIA

Diabetes on insulin

Preoperative creatinine >2.0 mg/dL

PaO₂/FiO₂ ratio (or SpO₂/FiO₂)0=≥400, 1=300-399, 2=200-299, 3=100-199 on vent, 4=<100 on vent

Platelets (×10³/μL)0=≥150, 1=100-149, 2=50-99, 3=20-49, 4=<20

Bilirubin (mg/dL)0=<1.2, 1=1.2-1.9, 2=2.0-5.9, 3=6.0-11.9, 4=≥12.0

Cardiovascular0=No hypotension, 1=MAP<70, 2=Dopa≤5 or Dobu, 3=Dopa>5 or Epi/NE≤0.1, 4=Dopa>15 or Epi/NE>0.1

GCS0=15, 1=13-14, 2=10-12, 3=6-9, 4=<6

Creatinine (mg/dL) or Urine Output0=<1.2, 1=1.2-1.9, 2=2.0-3.4, 3=3.5-4.9 or UO<500mL/d, 4=≥5.0 or UO<200mL/d

MSSA (Methicillin-sensitive Staph aureus)
First line: Nafcillin, Oxacillin, Dicloxacillin (oral)
Alternatives: Cefazolin IV, Cephalexin PO
Avoid: Vancomycin if MSSA confirmed — inferior outcomes

MRSA (Methicillin-resistant Staph aureus)
IV: Vancomycin (target AUC/MIC 400-600) or Daptomycin
Oral: TMP-SMX DS BID, Doxycycline 100mg BID, Linezolid 600mg BID
Note: Daptomycin NOT for pneumonia — inactivated by surfactant

Streptococcus pneumoniae
Penicillin-sensitive: Amoxicillin, Penicillin G IV
PCN-resistant: Ceftriaxone, Levofloxacin, Moxifloxacin
Meningitis: High-dose Ceftriaxone + Vancomycin until sensitivities known

Streptococcus pyogenes (Group A Strep)
First line: Penicillin VK PO or Penicillin G IV
PCN allergy: Azithromycin, Clindamycin
Necrotizing fasciitis: Pip-tazo + Clindamycin (toxin suppression)

Enterococcus faecalis
First line: Ampicillin ± Gentamicin (synergy for endocarditis)
Alternatives: Vancomycin
Note: Intrinsically resistant to cephalosporins

VRE (Vancomycin-resistant Enterococcus)
Linezolid 600mg BID or Daptomycin
ID consult strongly recommended

E. coli / Klebsiella (non-ESBL)
Ceftriaxone, Cefazolin, TMP-SMX (if sensitive), Ciprofloxacin
IV severe: Ceftriaxone 1-2g IV daily

ESBL-producing organisms
Carbapenems (Meropenem, Ertapenem) — first line
Avoid: Cephalosporins, fluoroquinolones even if sensitive in vitro
Oral step-down: Fosfomycin for ESBL UTI, Ertapenem IM in some cases

Pseudomonas aeruginosa
Anti-pseudomonal beta-lactams: Pip-tazo, Cefepime, Ceftazidime
Carbapenems: Meropenem, Imipenem (not Ertapenem — no Pseudomonas coverage)
Combination therapy for severe/bacteremic: add Ciprofloxacin or Tobramycin
MDR Pseudomonas: Ceftolozane-tazobactam, Ceftazidime-avibactam — ID consult

Acinetobacter baumannii
Carbapenem-sensitive: Meropenem or Imipenem
Carbapenem-resistant (CRAB): Sulbactam-based regimens, Polymyxins — ID consult essential
Often hospital-acquired, ICU patients, ventilator-associated

Haemophilus influenzae
Beta-lactamase negative: Amoxicillin PO or Ampicillin IV
Beta-lactamase positive: Amox-clav, Cefuroxime, Ceftriaxone
Common in COPD exacerbations and otitis media

Neisseria gonorrhoeae
Ceftriaxone 500mg IM single dose (1g if >150kg)
Plus Doxycycline 100mg BID × 7 days if chlamydia not excluded
Avoid fluoroquinolones — high resistance rates

Bacteroides / Anaerobes
Metronidazole — first line for most anaerobic coverage
Pip-tazo, Amox-clav, Carbapenems — broad anaerobic + aerobic coverage
Clindamycin — good for oral/pulmonary anaerobes, Group A Strep toxin suppression

Mycoplasma pneumoniae / Chlamydophila pneumoniae / Legionella
Azithromycin 500mg day 1, then 250mg × 4 days
Doxycycline 100mg BID × 5-7 days
Fluoroquinolones (Levofloxacin, Moxifloxacin) — all cover atypicals
Note: Beta-lactams have NO activity against atypicals

Chlamydia trachomatis
Doxycycline 100mg BID × 7 days — preferred
Azithromycin 1g single dose — alternative (less effective)
Treat partners. Test for gonorrhea concurrently.

Gram-positive only: Vancomycin, Daptomycin, Linezolid, Nafcillin, PCN
Gram-negative only: Aztreonam (PCN-allergic option)
Broad gram-pos + gram-neg: Ceftriaxone, Pip-tazo, Carbapenems, Fluoroquinolones
Adds MRSA: Vancomycin, Linezolid, Daptomycin, TMP-SMX
Adds Pseudomonas: Pip-tazo, Cefepime, Ceftazidime, Meropenem, Ciprofloxacin
Adds anaerobes: Metronidazole, Pip-tazo, Amox-clav, Carbapenems, Clindamycin
Adds atypicals: Azithromycin, Doxycycline, Fluoroquinolones

CAP outpatient (no comorbidities): Amoxicillin 1g TID × 5d or Doxycycline 100mg BID × 5d
CAP outpatient (comorbidities): Amox-clav + Azithromycin or Levofloxacin 750mg × 5d
CAP inpatient non-ICU: Ceftriaxone + Azithromycin × 5d
CAP ICU: Ceftriaxone + Azithromycin or anti-pseudomonal if risk factors
UTI uncomplicated: Nitrofurantoin 100mg BID × 5d or TMP-SMX DS BID × 3d
Pyelonephritis outpatient: Ciprofloxacin 500mg BID × 7d
Pyelonephritis inpatient: Ceftriaxone IV — de-escalate per culture
Cellulitis non-purulent: Cephalexin 500mg QID × 5-7d
Cellulitis MRSA concern: TMP-SMX DS BID × 5-7d or Doxycycline 100mg BID
Intra-abdominal (mild-mod): Ceftriaxone + Metronidazole or Amox-clav
Intra-abdominal (severe): Pip-tazo or Carbapenem

Always narrow based on culture results. Use shortest effective duration. Reassess necessity at 48-72 hours. Document indication, agent, dose, and planned duration in every note.

Nausea/vomiting0=none, 4=intermittent nausea, 7=constant nausea with retching

Tremor0=none, 4=moderate with arms extended, 7=severe

Paroxysmal sweats0=none, 4=beads of sweat, 7=drenching sweats

Anxiety0=none, 4=moderately anxious, 7=equivalent to acute panic

Agitation0=normal, 4=moderately fidgety, 7=thrashes about

Tactile disturbances0=none, 7=continuous hallucinations

Auditory disturbances0=none, 7=continuous hallucinations

Visual disturbances0=none, 7=continuous hallucinations

Headache0=none, 7=extremely severe

Orientation0=oriented, 2=date uncertain, 4=disoriented

Feature 1 — Acute onset and fluctuating courseIs there an acute change from baseline? Does it fluctuate during the day?

Feature 2 — InattentionDoes the patient have difficulty focusing attention? Easily distracted?

Feature 3 — Disorganized thinkingRambling speech, illogical flow of ideas, unpredictable topic changes

Feature 4 — Altered level of consciousnessAnything other than alert: vigilant, lethargic, stuporous, or comatose

Reorientation — clock, calendar, familiar faces. Reduce sensory deprivation — glasses and hearing aids in. Mobility — get patient up and moving. Sleep hygiene — minimize nighttime interruptions. Hydration and nutrition. Remove unnecessary lines, catheters, restraints. Consistent caregivers when possible.

Haloperidol: 0.5-1mg PO/IV q4-6h PRN — lowest effective dose, shortest duration. Monitor QTc. Avoid in Parkinson's/Lewy body dementia.
Quetiapine: 12.5-25mg BID — preferred if Parkinson's or Lewy body. Monitor for sedation.
Avoid: Benzodiazepines (worsen delirium except alcohol/benzo withdrawal)

Blood glucose >250 mg/dL
Anion gap acidosis (AG >12, pH <7.3, HCO₃ <18)
Positive serum or urine ketones

Mild: pH 7.25-7.30 · HCO₃ 15-18 · AG >10 · Alert
Moderate: pH 7.00-7.24 · HCO₃ 10-14 · AG >12 · Drowsy
Severe: pH <7.00 · HCO₃ <10 · AG >12 · Stupor/coma → ICU

Hour 1: 1L NS IV bolus (15-20 mL/kg)
Hours 2-4: NS 500 mL/hr
Then: Check corrected sodium
— If corrected Na normal or high → switch to 0.45% NS at 250-500 mL/hr
— If corrected Na low → continue NS at 250-500 mL/hr
When glucose reaches 200 mg/dL: Switch to D5-0.45% NS at 150-250 mL/hr

K+ <3.3: HOLD insulin. Replace 20-40 mEq/hr IV until K+ ≥3.3
K+ 3.3-5.3: Add 20-30 mEq K+ per liter of IV fluid. Start insulin.
K+ >5.3: Start insulin. Check K+ q2h. Hold K+ replacement.

Recheck potassium every 2 hours. Insulin drives K+ intracellularly — levels will fall.

Starting dose: Regular insulin 0.1 units/kg/hr IV drip (no bolus needed)
Alternative if no IV pump: Regular insulin 0.1 units/kg SQ q1h
Target glucose drop: 50-75 mg/dL per hour
— If <50 drop in first hour: bolus 0.14 units/kg, continue drip
— If >100 drop/hr: reduce drip rate by 50%
When glucose reaches 200 mg/dL: Reduce to 0.02-0.05 units/kg/hr. Add dextrose to fluids. Continue until AG closes.

Generally NOT recommended — may worsen hypokalemia and paradoxical CNS acidosis.
Consider ONLY if: pH <6.9 with hemodynamic instability
If used: 100 mEq NaHCO₃ in 400 mL sterile water + 20 mEq KCl over 2 hours. Recheck pH.

Blood glucose <200 mg/dL
Serum bicarbonate ≥15 mEq/L
Venous pH >7.3
Anion gap ≤12
Patient tolerating oral intake

Give first dose of SQ long-acting insulin 2-4 hours BEFORE stopping IV drip.
Never stop drip without overlap — rebound DKA can occur within 1-2 hours.
Calculate total 24h insulin drip used to guide SQ dosing. Typically start at 80% of 24h drip dose split as 50% basal / 50% prandial.

Glucose: q1h until stable, then q2h
BMP: q2-4h (K+ critical)
Venous blood gas: q2-4h until AG closed
Urine output: hourly (target ≥0.5 mL/kg/hr)
Mental status: continuous
Phosphate and magnesium: q4-6h

Infection (most common) — cultures, CXR, UA
Insulin omission — assess adherence, cost barriers
New diabetes diagnosis — A1C, educate before discharge
MI, stroke, pancreatitis — consider if no obvious trigger
Medications — steroids, SGLT2 inhibitors (euglycemic DKA)

Weight (kg)

Indication

<35 sec: Bolus 80 units/kg, ↑ rate 4 units/kg/hr
35-45 sec: Bolus 40 units/kg, ↑ rate 2 units/kg/hr
46-70 sec: No change (therapeutic)
71-90 sec: ↓ rate 2 units/kg/hr
>90 sec: Hold 1 hour, ↓ rate 3 units/kg/hr

Check aPTT 6 hours after bolus and any rate change. Once therapeutic × 2 checks, check daily.

1a. Level of consciousness0=Alert, 1=Drowsy, 2=Obtunded, 3=Unresponsive

1b. LOC Questions (month/age)0=Both correct, 1=One correct, 2=Neither

1c. LOC Commands (open/close eyes, grip)0=Both, 1=One, 2=Neither

2. Best gaze0=Normal, 1=Partial palsy, 2=Forced deviation

3. Visual fields0=Normal, 1=Partial hemianopia, 2=Complete, 3=Bilateral blindness

4. Facial palsy0=Normal, 1=Minor, 2=Partial, 3=Complete

5a. Motor arm — Left0=Normal, 1=Drift, 2=Can't resist gravity, 3=No effort against gravity, 4=No movement

5b. Motor arm — Right

6a. Motor leg — Left0=Normal, 1=Drift, 2=Can't resist gravity, 3=No effort, 4=No movement

6b. Motor leg — Right

7. Limb ataxia0=Absent, 1=One limb, 2=Two limbs

8. Sensory0=Normal, 1=Mild loss, 2=Severe loss

9. Best language0=Normal, 1=Mild aphasia, 2=Severe aphasia, 3=Mute/global

10. Dysarthria0=Normal, 1=Mild, 2=Severe/mute

11. Extinction/inattention0=Normal, 1=Mild, 2=Severe

Verbal de-escalation: calm voice, non-threatening posture, offer choices, reduce stimulation. Remove potential weapons. Ensure staff safety. Offer oral medication before IM.

Olanzapine 5-10mg PO/ODT — first line for psychosis-related agitation
Lorazepam 1-2mg PO — anxiety/agitation without psychosis
Haloperidol 5mg PO + Lorazepam 2mg PO — combination for severe agitation
Quetiapine 25-50mg PO — elderly or Parkinson's patients

Droperidol 5mg IM — fast onset, monitor QTc
Haloperidol 5mg IM ± Lorazepam 2mg IM
Olanzapine 10mg IM — do NOT combine with IM benzodiazepine (respiratory risk)
Ziprasidone 20mg IM — alternative if QTc concern with droperidol
Ketamine 4-5mg/kg IM — for extreme agitation when other options fail

C-SSRS for SI/HI. Medical workup to rule out organic causes — glucose, electrolytes, UDS, EtOH level, TSH, head CT if new neuro findings. Document capacity assessment. 1:1 observation if SI/HI present.

Physical restraints only when patient is danger to self or others and less restrictive measures failed. Document necessity, type, q15 min checks, neurovascular checks. Face-to-face within 1 hour. Order renewal per facility policy.

HR <40 or >130 bpm
RR <8 or >28 breaths/min
SBP <90 or >200 mmHg
SpO₂ <90% on any O₂
Acute change in mental status
Urine output <50mL over 4 hours
Concern something is seriously wrong — trust your instincts

A — Airway: patent? Positioning, suction if needed
B — Breathing: RR, SpO₂, work of breathing — apply O₂, consider BVM
C — Circulation: HR, BP, cap refill, IV access, bolus if hypotensive
D — Disability: GCS, glucose, pupils
E — Exposure: full assessment, temperature, skin changes

ICU transfer criteria: Hemodynamic instability, respiratory failure requiring intubation, altered mental status with airway concern, lactate >4, refractory to initial treatment

Step-down criteria: Responding to treatment, stable vital signs, no immediate ICU-level needs but requires closer monitoring than floor

Situation: "I'm calling about [patient name], [room], admitted for [diagnosis]."
Background: "They are [X] days post-admission. Relevant history: [PMH, recent events]."
Assessment: "I am concerned because [specific change/finding]."
Recommendation: "I think we need [specific action]. What would you like to do?"

Vancomycin + Piperacillin-tazobactam (Zosyn)
High-risk combination. Associated with significantly increased rates of acute kidney injury — AKI risk up to 3-4× higher than either agent alone. Avoid when possible. If required, monitor SCr q24-48h, ensure adequate hydration, use shortest necessary duration. Consider alternative broad-spectrum coverage (Cefepime + Metronidazole) to avoid this combination.

Vancomycin + Aminoglycosides (Gentamicin, Tobramycin)
Additive nephrotoxicity and ototoxicity. Avoid combination unless no alternative (eg. enterococcal endocarditis with synergy required). If used, monitor levels, SCr daily, urine output.

Vancomycin + Loop Diuretics (Furosemide)
Increased ototoxicity risk. Monitor hearing and vancomycin levels closely. Avoid high-dose furosemide concurrently when possible.

TMP-SMX (Bactrim) + ACE Inhibitors or ARBs
Risk of life-threatening hyperkalemia. TMP-SMX blocks tubular secretion of potassium. In patients on lisinopril, losartan, etc. — monitor K+ closely or choose alternative antibiotic.

NSAIDs + Any Nephrotoxic Antibiotic
NSAIDs reduce renal perfusion and dramatically worsen nephrotoxicity of aminoglycosides, vancomycin, and contrast. Hold NSAIDs during courses of nephrotoxic antibiotics.

Aminoglycosides (Gentamicin, Tobramycin, Amikacin)
Nephrotoxic and ototoxic. Use extended-interval dosing (once daily) to reduce nephrotoxicity. Monitor SCr and drug levels. Avoid in CKD if alternatives exist. Duration should be as short as possible.

Amphotericin B (antifungal)
Highly nephrotoxic. Use lipid formulation (AmBisome) when possible — significantly lower nephrotoxicity. Hydrate aggressively before each dose. Monitor SCr daily.

Nitrofurantoin — AVOID if eGFR <30
Does not achieve adequate urinary concentrations at low eGFR. Risk of peripheral neuropathy with accumulation. Commonly used for UTI — do NOT use in elderly patients with CKD. Use Fosfomycin or Cephalexin instead.
⚠ High-risk in elderly — frequently prescribed inappropriately

TMP-SMX (Bactrim) — Use with Caution in Elderly, AVOID if eGFR <15
Raises serum creatinine by blocking tubular secretion — does not reflect true GFR decline but can be misleading. In elderly patients: increased risk of hyperkalemia, bone marrow suppression, and nephrotoxicity. Not preferred for UTI in elderly or those with CKD — use Nitrofurantoin (if eGFR ≥30), Fosfomycin, or Cephalexin instead.
⚠ Bactrim for UTI in the elderly — frequently flagged by pharmacists

Tetracyclines (except Doxycycline) — AVOID in renal impairment
Can worsen azotemia. Doxycycline is the exception — it is safe in renal impairment and does not require dose adjustment.

Methenamine — AVOID if eGFR <30
Requires acidic urine and adequate flow to work. Ineffective in significant renal impairment.

Vancomycin
Dose based on AUC/MIC monitoring (target 400-600). Initial: 25-30 mg/kg IV. Interval extends with decreasing renal function.
eGFR >50: q8-12h · eGFR 20-50: q24h · eGFR <20: q48-96h · Dialysis: dose after each session

Piperacillin-Tazobactam (Zosyn)
eGFR >40: 3.375g q6h or 4.5g q8h (standard)
eGFR 20-40: 2.25g q6h
eGFR <20: 2.25g q8h
Hemodialysis: 2.25g q8h + supplemental dose after each session

Ciprofloxacin
eGFR >50: 400mg IV q12h or 500mg PO q12h (standard)
eGFR 30-50: 200-400mg IV q12h or 250-500mg PO q12h
eGFR <30: 200mg IV q18-24h or 250-500mg PO q18-24h

Levofloxacin
eGFR >50: 500-750mg q24h (standard)
eGFR 20-50: 500mg loading, then 250mg q24h
eGFR <20: 500mg loading, then 250mg q48h

TMP-SMX (Bactrim)
eGFR >30: Standard dosing
eGFR 15-30: 50% dose reduction, use with caution
eGFR <15: Avoid

Nitrofurantoin
eGFR ≥30: 100mg BID × 5 days (standard for UTI)
eGFR <30: CONTRAINDICATED

Ceftriaxone
No dose adjustment needed in renal impairment. Safe across all eGFR levels. One of the most renal-friendly antibiotics available.

Azithromycin
No dose adjustment needed. Primarily hepatic elimination. Safe in CKD.

Doxycycline
No dose adjustment needed. Safe across all eGFR levels. Exception among tetracyclines.

Metronidazole
Minimal adjustment needed for renal impairment. Use with caution in severe CKD — metabolites may accumulate. Standard dosing generally acceptable.

Meropenem
eGFR >50: 1g q8h (standard)
eGFR 25-50: 1g q12h
eGFR 10-25: 500mg q12h
eGFR <10: 500mg q24h

Gentamicin / Tobramycin (extended-interval dosing)
eGFR >60: 5-7 mg/kg q24h
eGFR 40-60: 5-7 mg/kg q36h
eGFR 20-40: 5-7 mg/kg q48h
eGFR <20: Avoid if possible. If required, dose based on levels — pharmacy guidance essential.

Preferred agents in elderly with CKD:
Fosfomycin 3g PO single dose — effective for uncomplicated UTI, minimal systemic absorption, safe in mild-moderate CKD
Cephalexin 500mg QID × 3-7 days — safe across renal function ranges
Amoxicillin-clavulanate — if organism sensitive

Avoid in elderly:
Nitrofurantoin if eGFR <30
Bactrim if eGFR <30 or on ACE/ARB/K-sparing diuretics
Fluoroquinolones — reserve for complicated UTI, pyelonephritis, or when alternatives fail. High resistance rates. Risk of tendinopathy, aortic aneurysm, CNS effects in elderly.

Remember: Asymptomatic bacteriuria in elderly does NOT require treatment. Treat only if symptomatic.

Hold metformin 48h before and after IV contrast. Hold NSAIDs before procedures. Pre-hydrate with NS 1mL/kg/hr for 3-12h before contrast in high-risk patients (eGFR <45). Avoid concurrent nephrotoxins when giving contrast.

Ischemic stroke with measurable neurologic deficit
Symptom onset within 4.5 hours (or last known well)
Age ≥18
CT head negative for hemorrhage
BP ≤185/110 (treat if above, then reassess)

Intracranial hemorrhage on CT
Significant head trauma or stroke in past 3 months
Intracranial/intraspinal surgery in past 3 months
History of intracranial hemorrhage
Active internal bleeding (not menses)
Platelet <100,000
Heparin within 48h with elevated aPTT
Current anticoagulant use with INR >1.7, PT >15, or therapeutic DOAC levels
Blood glucose <50 or >400 mg/dL

Improving symptoms or minor deficit
Major surgery/trauma in past 14 days
GI/urinary tract hemorrhage in past 21 days
MI in past 3 months
Seizure at onset (if residual deficit is from stroke)
Age >80 + severe stroke (NIHSS >25) + prior stroke + diabetes (3-hour window still reasonable)

Patient weight (kg)

Neuro checks q15min × 2h, q30min × 6h, q1h × 16h. BP <180/105 for 24h. No antiplatelets or anticoagulants × 24h. CT head at 24h. Hold NG tube, urinary catheter, arterial line if possible × 30min after infusion.

Peritoneal signs — guarding, rigidity, rebound tenderness
Hemodynamic instability — hypotension, tachycardia, diaphoresis
Signs of bowel obstruction — distension, high-pitched or absent bowel sounds
Pulsatile abdominal mass — consider AAA
Fever with focal tenderness — perforation, abscess, appendicitis
Elderly or immunocompromised — pain may be masked, threshold for imaging lower
Pain out of proportion to exam — mesenteric ischemia until proven otherwise
Pregnancy with acute abdominal pain — ectopic must be excluded

RUQ: Cholecystitis, choledocholithiasis, hepatitis, Fitz-Hugh-Curtis, RLL pneumonia
Epigastric: PUD, GERD, pancreatitis, MI (atypical), gastritis, esophageal spasm
LUQ: Splenic pathology, gastric ulcer, pancreatitis (tail), LLL pneumonia
RLQ: Appendicitis, ovarian cyst/torsion, ectopic pregnancy, IBD (Crohn's), psoas abscess, mesenteric adenitis
LLQ: Diverticulitis, ovarian cyst/torsion, ectopic, sigmoid volvulus, IBD
Periumbilical: Early appendicitis, small bowel obstruction, mesenteric ischemia, gastroenteritis
Diffuse: Peritonitis, mesenteric ischemia, DKA, IBD flare, bowel obstruction, constipation

Labs: CBC, CMP, lipase, LFTs, UA, beta-hCG (all women of childbearing age), lactate if ischemia concern
Imaging: Abdominal X-ray (obstruction, free air), CT abdomen/pelvis with contrast (most sensitive), RUQ ultrasound (biliary), pelvic ultrasound (gynecologic)
EKG: Rule out MI in epigastric/atypical presentations especially in elderly

Appendicitis: Alvarado score, CT abdomen, surgical consult. Antibiotics if perforated or abscess.
Acute cholecystitis: RUQ ultrasound, NPO, IV fluids, antibiotics (Ceftriaxone + Metronidazole), surgery consult.
Pancreatitis: Aggressive IV fluids (LR preferred), pain control, NPO initially, lipase trending, CT if severe.
Diverticulitis: CT confirms, uncomplicated can be outpatient with oral antibiotics (Amox-clav or Cipro + Flagyl), complicated needs admission.
Bowel obstruction: NPO, NGT decompression, surgery consult, CT to assess for strangulation.
Mesenteric ischemia: Lactate, CT angiography, emergent vascular surgery — high mortality if delayed.

Step 1 — Nasal cannula: 1-6 L/min → SpO₂ target ≥92% (≥88% in COPD)
Step 2 — Simple face mask: 6-10 L/min
Step 3 — Non-rebreather mask: 10-15 L/min → FiO₂ ~60-90%
Step 4 — High-flow nasal cannula (HFNC): Up to 60 L/min, FiO₂ up to 100% — first choice for moderate-severe hypoxia before BiPAP in most patients
Step 5 — BiPAP/CPAP
Step 6 — Intubation

COPD exacerbation with hypercapnia (pH <7.35, pCO₂ >45) — strongest evidence
Acute cardiogenic pulmonary edema — reduces preload, improves oxygenation rapidly
Hypoxemic respiratory failure failing HFNC (SpO₂ <92% on 40+ L/min)
Immunocompromised patients — avoid intubation if possible
Obesity hypoventilation syndrome

Avoid BiPAP if: Vomiting, unable to protect airway, hemodynamic instability, facial trauma, decreased consciousness (GCS <10), pneumothorax

Failure to maintain SpO₂ >90% despite max non-invasive support
Increasing work of breathing — accessory muscle use, paradoxical breathing
Altered mental status — cannot protect airway
Respiratory acidosis worsening despite BiPAP (pH <7.25)
Hemodynamic collapse
Impending respiratory arrest — do not wait for arrest

RSI medications: Ketamine 1.5 mg/kg IV (preferred — maintains BP) or Etomidate 0.3 mg/kg IV, then Succinylcholine 1.5 mg/kg IV or Rocuronium 1.2 mg/kg IV

CURB-65 to guide admission. Supplemental O₂ to target SpO₂ ≥92%.
Non-ICU: Ceftriaxone + Azithromycin × 5 days
ICU: Ceftriaxone + Azithromycin or Levofloxacin. Add Vancomycin/Linezolid if MRSA risk.
Consider Legionella and pneumococcal urinary antigens. Blood cultures × 2 before antibiotics if admitted.

Prone positioning — awake proning improves oxygenation even before intubation
Dexamethasone 6mg IV/PO daily × 10 days if requiring supplemental O₂
Remdesivir if hospitalized and <10 days symptoms (check current guidelines)
Anticoagulation — prophylactic dose for most hospitalized; therapeutic only if VTE confirmed
Baricitinib or Tocilizumab in rapidly progressing disease on dexamethasone
Avoid steroids if not on supplemental O₂ — may worsen outcomes

Oseltamivir (Tamiflu) 75mg BID × 5 days — start within 48h of symptoms for best effect, but still beneficial in hospitalized patients regardless of timing
Severe/ICU: Oseltamivir 75mg BID × 10 days
Renal adjustment: CrCl 10-30: 75mg daily. CrCl <10: 30mg daily.
Secondary bacterial pneumonia common — add antibiotics if clinical concern (S. aureus, Strep pneumo)
MRSA pneumonia post-influenza: Add Vancomycin or Linezolid

Primarily supportive — no specific antiviral approved for most adult RSV
High-risk adults (elderly, immunocompromised, cardiopulmonary disease): monitor closely
Nirsevimab (Beyfortus) — prevention in high-risk infants; newer RSV vaccines for adults ≥60
Supplemental O₂, hydration, bronchodilators for bronchospasm
Secondary bacterial pneumonia — treat if suspected
ICU admission criteria same as other respiratory failure — do not underestimate in elderly

Resting pulse rate0=≤80, 1=81-100, 2=101-120, 4=>120

Sweating0=none, 1=subjective, 2=flushed/diaphoretic, 3=beads of sweat, 4=drenching

Restlessness0=able to sit still, 1=reports difficulty, 3=frequent shifting, 5=unable to sit still

Pupil size0=pinned/normal, 1=possibly larger, 2=moderately dilated, 5=maximally dilated

Bone/joint aches0=none, 1=mild, 2=moderate, 4=severe

Runny nose/tearing0=none, 1=nasal stuffiness, 2=rhinorrhea, 4=streaming

GI upset0=none, 1=stomach cramps, 2=nausea, 3=vomiting, 5=diarrhea+vomiting

Tremor0=none, 1=slight, 2=moderate, 4=gross tremor

Yawning0=none, 1=once or twice, 2=three or more, 4=constant

Anxiety/irritability0=none, 1=mild, 2=moderate, 4=severe

Gooseflesh0=none, 3=piloerection, 5=prominent gooseflesh

Begin induction when COWS ≥8-12 (mild-moderate withdrawal) — patient must be in withdrawal to avoid precipitated withdrawal
Day 1: Buprenorphine/naloxone (Suboxone) 2-4mg SL. Observe 1 hour. If COWS persists give additional 2-4mg. Max 8-12mg day 1.
Day 2: Previous day total dose given as single morning dose. Titrate by 2-4mg/day.
Maintenance: Typical range 16-24mg/day. Max 32mg/day.
Contraindications to immediate induction: Recent methadone use, long-acting opioids, uncertain last use — risk of precipitated withdrawal

Clonidine 0.1mg TID-QID — autonomic symptoms (sweating, tachycardia, hypertension)
Ondansetron 4mg q6h PRN — nausea
Loperamide 4mg then 2mg after each loose stool — diarrhea
Ibuprofen 400-600mg q6h — muscle aches
Hydroxyzine 25-50mg q6h PRN — anxiety, insomnia
Dicyclomine 20mg q6h PRN — GI cramping

EKG within 10 minutes of arrival — look for ST elevation, depression, new LBBB, T-wave changes
Troponin (high-sensitivity preferred) — at presentation and 1-3 hours later
IV access × 2, continuous telemetry, supplemental O₂ only if SpO₂ <90%
Aspirin 325mg PO immediately (chewed) unless true allergy
Nitrates — SL NTG 0.4mg q5min × 3 for ongoing pain (hold if SBP <90, RV infarct suspected, PDE5 inhibitor use within 24-48h)

Criteria: ST elevation ≥1mm in ≥2 contiguous leads, or new LBBB with symptoms
Goal door-to-balloon time: <90 minutes
Activate cath lab immediately — this is the single most important action
P2Y12 inhibitor: Ticagrelor 180mg PO loading dose (preferred) or Clopidogrel 600mg PO
Anticoagulation: Heparin 60 units/kg IV bolus (max 4,000 units) + 12 units/kg/hr infusion
If PCI not available within 120 min: Fibrinolysis (tPA) if no contraindications

Inferior STEMI (II, III, aVF): Obtain right-sided EKG leads (V4R) to rule out RV infarction
RV infarction: Avoid nitrates and diuretics — these patients need volume. Treat hypotension with IV fluids first.

High-risk features requiring urgent cath (<2 hours):
Hemodynamic instability, refractory chest pain, acute HF, mechanical complications, recurrent ST changes, sustained VT/VF

Early invasive strategy (<24 hours) — most NSTEMI:
Troponin positive, new ST depression, GRACE score >140, diabetes, renal impairment

Medical management:
Aspirin + P2Y12 inhibitor (Ticagrelor 90mg BID or Clopidogrel 75mg daily)
Anticoagulation: Enoxaparin 1mg/kg SQ q12h (reduce if eGFR <30) or Heparin infusion
Beta-blocker: Metoprolol 25-50mg PO BID if no contraindications (HR >50, SBP >90, no acute HF, no high-degree block)
High-intensity statin: Atorvastatin 80mg PO daily
ACE inhibitor: Start within 24h if EF reduced, HF, HTN, or diabetes

Aspirin 81mg daily — lifelong
P2Y12 inhibitor (Ticagrelor or Clopidogrel) × 12 months minimum after stent
High-intensity statin (Atorvastatin 80mg)
Beta-blocker if reduced EF or HF
ACE inhibitor/ARB if reduced EF, HF, HTN, DM
Sublingual NTG PRN — educate patient on use
Cardiac rehabilitation referral

First-line medications:
SSRIs: Sertraline 50mg daily (titrate to 200mg), Escitalopram 10mg daily (titrate to 20mg), Fluoxetine 20mg daily
SNRIs: Duloxetine 30mg daily (titrate to 60-120mg), Venlafaxine XR 37.5mg daily
Other: Bupropion XL 150mg daily (titrate to 300-450mg) — good if fatigue/weight gain concern, avoid in seizure disorder

Augmentation if partial response: Aripiprazole 2-5mg, Quetiapine 25-50mg QHS, Lithium, Buspirone
Always combine with therapy: CBT most evidence-based
Onset of action: 2-6 weeks. Adequate trial = 6-8 weeks at therapeutic dose.
Duration: First episode: 6-12 months after remission. Recurrent: 2+ years or indefinite.

First-line: SSRIs (Escitalopram, Sertraline) or SNRIs (Duloxetine, Venlafaxine XR)
Second-line: Buspirone 7.5mg BID (titrate to 15-30mg BID) — non-addictive, takes 2-4 weeks
Adjunct: Hydroxyzine 25-50mg TID-QID PRN — non-addictive for acute anxiety
Avoid long-term benzodiazepines — risk of dependence, tolerance, cognitive effects. Short-term bridge only while SSRI/SNRI takes effect.
CBT is equally effective as medication — recommend both

Mood stabilizers (first-line):
Lithium 300mg TID — target level 0.8-1.2 mEq/L (acute mania), 0.6-1.0 (maintenance). Monitor renal/thyroid/levels q3-6 months.
Valproate (Depakote) — target level 50-125 mcg/mL. Teratogenic — avoid in women of childbearing age without reliable contraception.
Lamotrigine — better for depressive phase. Slow titration required to reduce Stevens-Johnson risk. Start 25mg daily.

Atypical antipsychotics (acute mania and maintenance):
Quetiapine, Olanzapine, Aripiprazole, Risperidone

Critical rule: Antidepressants alone can precipitate mania or rapid cycling. Never use antidepressant monotherapy in Bipolar I. If used at all, always with mood stabilizer.
Acute mania: Mood stabilizer + antipsychotic. Benzodiazepine for agitation/sleep.

First-line — second generation antipsychotics (SGAs):
Risperidone 2-4mg daily (titrate to 4-8mg) — good for positive symptoms
Quetiapine 150-750mg/day — also treats depression and anxiety components
Aripiprazole 10-30mg daily — lower metabolic side effects
Olanzapine 10-20mg daily — weight gain risk
Lurasidone 40-80mg daily — best metabolic profile, must take with food ≥350 calories

Long-acting injectables (LAIs) — for adherence issues:
Paliperidone palmitate (Invega Sustenna) monthly injection
Aripiprazole lauroxil (Aristada) monthly/bimonthly

Clozapine — for treatment-resistant schizophrenia (failed 2+ antipsychotics). Requires REMS enrollment, weekly to monthly ANC monitoring due to agranulocytosis risk.
Monitor all SGAs: weight, lipids, glucose, EKG (QTc), EPS symptoms.

C-SSRS assessment: Passive ideation vs active ideation vs plan vs intent vs means access

High risk — requires immediate intervention:
Active plan with means and intent
Recent attempt (within 90 days — highest re-attempt risk)
Male gender, older age, substance use, access to firearms
Severe hopelessness, command hallucinations, recent loss

Immediate actions:
1:1 monitoring, remove access to means, medical clearance
Psychiatric emergency evaluation, voluntary vs involuntary hospitalization
Safety planning — identify warning signs, coping strategies, support contacts, means restriction

Medications with anti-suicidal evidence:
Lithium — strongest evidence for reducing suicide in mood disorders
Clozapine — reduces suicidality in schizophrenia
Ketamine/Esketamine — rapid effect (hours) for acute suicidal crisis in MDD

Document: SI content, C-SSRS score, risk factors, protective factors, clinical reasoning for disposition

Assess: Specific target, plan, means, intent, history of violence
High risk: Specific named victim + plan + means + history of violence

Tarasoff duty to protect — varies by state:
Warn identified potential victim
Notify law enforcement
Consider involuntary hospitalization

Document clearly: nature of ideation, risk factors, clinical reasoning, actions taken
Consult psychiatry immediately for any credible homicidal threat with specific target

Mild: Na 130-134 mEq/L — often asymptomatic
Moderate: Na 125-129 mEq/L — nausea, headache, confusion possible
Severe: Na <125 mEq/L — high risk for cerebral edema, seizures, respiratory arrest
Critical: Na <120 mEq/L — ICU-level monitoring required

Hypovolemic hyponatremia (low volume)
Causes: GI losses (vomiting, diarrhea), diuretics, adrenal insufficiency, third spacing
Exam: Dry mucous membranes, tachycardia, orthostasis, decreased skin turgor
Urine Na: <20 mEq/L (renal Na conservation)
Treatment: Isotonic saline (NS) to restore volume — sodium will correct as volume restores

Euvolemic hyponatremia (normal volume)
Causes: SIADH (most common), hypothyroidism, adrenal insufficiency, psychogenic polydipsia, beer potomania
Exam: No edema, no signs of dehydration
Urine Na: >40 mEq/L, Urine Osm >100
Treatment: Free water restriction 500-1000 mL/day. Treat underlying cause. Vaptans for refractory SIADH.

Hypervolemic hyponatremia (excess volume)
Causes: Heart failure, cirrhosis, nephrotic syndrome
Exam: Edema, ascites, JVD, pulmonary crackles
Urine Na: <20 mEq/L
Treatment: Free water restriction. Treat underlying cause. Diuresis with careful monitoring.

Serum sodium <135 mEq/L
Serum osmolality <275 mOsm/kg
Urine osmolality >100 mOsm/kg (inappropriately concentrated)
Urine sodium >40 mEq/L
Clinically euvolemic
Normal thyroid and adrenal function
No diuretic use

CNS: Stroke, SAH, meningitis, head trauma, brain tumor
Pulmonary: Pneumonia, COPD, PE, mechanical ventilation
Malignancy: Small cell lung cancer (most common), pancreatic, duodenal
Medications: SSRIs, SNRIs, carbamazepine, oxcarbazepine, cyclophosphamide, NSAIDs, PPIs, antipsychotics, opioids, MDMA
Pain and stress: Postoperative state, nausea, severe pain — all stimulate ADH
Other: HIV, hypothyroidism, adrenal insufficiency

Free water restriction 500-1000 mL/day (all fluids counted)
Treat underlying cause
Discontinue offending medications if possible
Oral salt tablets if persistent SIADH
Target correction: no more than 8-10 mEq/L per 24 hours
Check sodium q6-12h initially

ICU or step-down admission for monitoring
3% Hypertonic Saline:
— Symptomatic (seizures, coma): 100-150 mL IV bolus over 10-20 min. Repeat if symptoms persist. Target: raise Na 4-6 mEq/L acutely to stop symptoms.
— Maintenance: 0.5-1 mL/kg/hr, titrate to correction rate
Check sodium q2h during active correction
Target correction rate: 1-2 mEq/L per hour for first 2-3 hours if symptomatic, then slow to <0.5 mEq/L/hr
24-hour limit: Never exceed 10-12 mEq/L — risk of osmotic demyelination syndrome (ODS)

Use when sodium is rising faster than 0.5 mEq/L/hr or approaches 24-hour limit
DDAVP 1-2 mcg IV or SQ q6-8h — locks in ADH effect, prevents free water diuresis
Combine with D5W infusion if sodium still rising after DDAVP
Monitor sodium q2h
Once 24-hour correction goal reached — hold hypertonic saline, continue DDAVP
Risk if not used: Aquaresis (sudden free water diuresis) after treating underlying cause can cause rapid sodium rise → ODS

Occurs 2-6 days after overcorrection. Irreversible demyelination of pons and other brain areas.
High-risk patients: Alcoholism, malnutrition, liver disease, hypokalemia, chronic hyponatremia (>48h)
Symptoms: Dysarthria, dysphagia, behavioral changes, quadriplegia, locked-in syndrome
Prevention: Never exceed 10-12 mEq/L in 24h. Use DDAVP clamp proactively in high-risk patients. If overcorrection occurs — give D5W + DDAVP to lower sodium back down.

Serum osmolality · Urine osmolality · Urine sodium · BMP · TSH · AM cortisol · LFTs · Urine creatinine
Consider: CXR (pulmonary cause of SIADH) · Head CT/MRI if neurologic symptoms · Review all medications

Stage 1: SCr increase ≥0.3 mg/dL in 48h OR ≥1.5-1.9× baseline in 7 days · UO <0.5 mL/kg/hr × 6-12h
Stage 2: SCr 2.0-2.9× baseline · UO <0.5 mL/kg/hr × 12h
Stage 3: SCr ≥3× baseline OR SCr ≥4 mg/dL OR RRT initiated · UO <0.3 mL/kg/hr × 24h or anuria × 12h

Pre-renal (most common — ~60-70%)
Causes: Volume depletion, heart failure, sepsis, hepatorenal syndrome, NSAIDs, ACE inhibitors, contrast
BUN:Cr ratio >20:1 · FENa <1% · Urine Na <20 · Urine Osm >500
Treatment: Fluid resuscitation, treat underlying cause, hold nephrotoxins

Intrinsic Renal (~25-30%)
ATN (most common intrinsic): Ischemia (prolonged pre-renal), nephrotoxins (aminoglycosides, contrast, myoglobin)
Urine: Muddy brown granular casts, FENa >2%, Urine Na >40
AIN (interstitial nephritis): Drug reaction (NSAIDs, PPIs, penicillins, sulfonamides), infection, autoimmune
Urine: WBC casts, eosinophils, sterile pyuria
Glomerulonephritis: RBC casts, proteinuria, dysmorphic RBCs
Treatment: Remove nephrotoxin, supportive care. AIN may respond to steroids. Nephrology consult.

Post-renal (~5-10%)
Causes: BPH, kidney stones, bladder outlet obstruction, malignancy, retroperitoneal fibrosis
Bilateral obstruction required to cause AKI (or unilateral in solitary kidney)
Ultrasound: Hydronephrosis
Treatment: Relieve obstruction urgently — Foley catheter, ureteral stent, or nephrostomy tube

BMP (trend creatinine, BUN, electrolytes) · Urinalysis with microscopy · Urine Na and Cr (for FENa) · Urine osmolality · CBC · LFTs · Urine protein:creatinine ratio · Renal ultrasound (rule out obstruction) · Review medication list for nephrotoxins · Volume status assessment

1. Remove nephrotoxins: Hold NSAIDs, ACE inhibitors/ARBs (temporarily), aminoglycosides, metformin, contrast agents. Hold Vancomycin + Zosyn combination if possible.
2. Optimize volume: Isotonic saline if hypovolemic. Avoid over-resuscitation — can worsen outcomes. No benefit to "renal dose" dopamine.
3. Treat underlying cause: Sepsis bundle, relieve obstruction, treat infection
4. Monitor electrolytes: Hyperkalemia and metabolic acidosis are life-threatening complications
5. Adjust medications: Renally-cleared drugs require dose adjustment or hold

K+ 5.5-6.0: Dietary restriction, hold K+-sparing drugs, Kayexalate or Patiromer
K+ 6.0-6.5 or EKG changes: Calcium gluconate 1-2g IV (membrane stabilization) + Insulin 10 units IV + D50 one amp + Albuterol nebulizer + Kayexalate/Patiromer
K+ >6.5 or severe EKG changes: All of above + Nephrology/ICU — emergent dialysis consideration
EKG changes of hyperkalemia: Peaked T waves → PR prolongation → wide QRS → sine wave → VFib

Acidosis — pH <7.1 refractory to treatment
Electrolytes — Hyperkalemia refractory to medical management
Ingestion — Certain toxic ingestions (lithium, methanol, ethylene glycol, salicylates)
Overload — Fluid overload refractory to diuretics with pulmonary edema
Uremia — Uremic encephalopathy, pericarditis, or BUN >100 with symptoms

High risk if: eGFR <45, diabetes + CKD, heart failure, volume depletion, concurrent nephrotoxins
Pre-hydration: NS 1 mL/kg/hr for 3-12h before and 6-12h after
Use lowest effective contrast volume · Use iso-osmolar or low-osmolar contrast · Hold metformin 48h · Hold NSAIDs · Avoid concurrent aminoglycosides

AKI Stage 2 or 3 · Unclear etiology · Suspected GN or AIN · Refractory hyperkalemia or acidosis · Oliguria/anuria >12h · Rapidly rising creatinine · Consideration for dialysis · AKI in setting of liver disease (hepatorenal syndrome) · AKI with significant proteinuria or hematuria

SIRS: ≥2 of: Temp >38°C or <36°C · HR >90 · RR >20 or PaCO₂ <32 · WBC >12k or <4k or >10% bands
Sepsis: SIRS + suspected/confirmed infection source
Severe Sepsis: Sepsis + organ dysfunction or hypoperfusion (lactate >2, oliguria, AMS, AKI)
Septic Shock: Sepsis + persistent hypotension (SBP <90 or MAP <65) despite adequate fluid resuscitation OR lactate >4 mmol/L

1. Measure lactate — if >2 mmol/L, remeasure in 2 hours. If >4, ICU.
2. Blood cultures × 2 — before antibiotics. Do NOT delay antibiotics waiting for cultures.
3. Broad-spectrum antibiotics within 1 hour — see empiric choices below
4. 30 mL/kg IV crystalloid — for hypotension (SBP <90) or lactate ≥4 mmol/L. Give over 3 hours. Reassess after each 500 mL.
5. Vasopressors if MAP <65 after fluids — Norepinephrine first line

Initial: 30 mL/kg isotonic crystalloid (NS or LR) — give over 3 hours
Reassess after each 500 mL bolus: Check lung exam, HR, BP, urine output, JVD
Fluid responsiveness markers: Pulse pressure variation, passive leg raise (↑CO >10% = responsive)
Stop or slow fluids if: Worsening hypoxia, new crackles, worsening edema, CVP >12, non-responsive
Balanced crystalloids preferred (LR over NS) — reduces hyperchloremic acidosis and AKI risk
Avoid: Hetastarch (HES) — increases AKI and mortality

Unknown source / sepsis NOS: Pip-tazo 4.5g q6h IV + Vancomycin (if MRSA risk)
Pulmonary source: Ceftriaxone 2g IV + Azithromycin 500mg IV (non-ICU) · Pip-tazo + Azithromycin (ICU or Pseudomonas risk)
Urinary source: Ceftriaxone 2g IV (if no ESBL risk) · Pip-tazo or Carbapenem (if ESBL risk, recent hospitalization, resistant organism history)
Intra-abdominal: Pip-tazo 4.5g q6h OR Meropenem 1g q8h (severe)
Skin/soft tissue: Pip-tazo + Vancomycin (necrotizing) · Cefazolin (non-purulent cellulitis)
CNS source: Ceftriaxone 2g q12h + Vancomycin + Dexamethasone 0.15 mg/kg q6h × 4 days
De-escalate at 48-72h based on culture results. Shortest effective duration.

First line — Norepinephrine: Start 0.01-0.03 mcg/kg/min. Titrate to MAP ≥65. Max 0.5-1 mcg/kg/min.
Add Vasopressin 0.03-0.04 units/min if NE >0.25 mcg/kg/min (NE-sparing, reduces NE dose)
Add Epinephrine if MAP not achieved on NE + vasopressin
Dopamine — alternative only if low HR or bradycardia. Higher arrhythmia risk.
Phenylephrine — avoid in septic shock (pure vasoconstriction reduces CO)
Target: MAP ≥65 mmHg (higher target 70-80 if chronic HTN or CAD)

Hydrocortisone 200mg/day IV (50mg q6h or 200mg continuous infusion)
Indicated when: Septic shock refractory to adequate fluids AND vasopressors (NE ≥0.25 mcg/kg/min)
Duration: Until vasopressors are no longer required — then taper
Do NOT use if infection source is fungal without antifungal coverage

Initial lactate — then remeasure at 2 hours if initial >2
Lactate <2: Low risk — monitor closely
Lactate 2-4: Resuscitate, treat source, goal normalize within 6 hours
Lactate >4: Septic shock — ICU, aggressive resuscitation, vasopressors
Lactate clearance ≥10% at 2h is associated with improved survival
Persistent elevation despite treatment suggests ongoing hypoperfusion or mitochondrial dysfunction

Identify and control infectious source as early as possible — ideally within 6-12 hours.
Remove infected lines and devices. Drain abscesses. Decompress obstructed systems (biliary, urinary). Débride infected tissue. Surgical consultation for necrotizing infections, bowel perforation, empyema.

Lactate >4 mmol/L · Persistent hypotension requiring vasopressors · Respiratory failure · AMS · Oliguria refractory to fluids · Progressive organ dysfunction · SOFA score ≥2 · Any patient in septic shock

Seizure: Abnormal electrical brain activity causing transient neurologic symptoms
Status Epilepticus (SE): Seizure lasting >5 minutes OR ≥2 seizures without full recovery between them
Refractory SE: SE not responding to 2 adequate doses of benzodiazepines + 1 second-line agent
Super-refractory SE: SE continuing >24h despite anesthesia — neurology/ICU

Position patient on side (recovery position) — prevent aspiration
Protect airway — suction if needed, do NOT force anything in mouth
Time the seizure — document start time
IV/IO access — obtain immediately
Monitor: SpO₂, cardiac monitor, BP
Fingerstick glucose — treat hypoglycemia immediately (D50 one amp IV)
Thiamine 100mg IV before glucose if alcoholism or malnutrition suspected
Call for help — prepare emergency medications

IV access available:
Lorazepam (Ativan) 0.1 mg/kg IV (max 4mg) — push slowly over 2 min. Repeat once in 5 min if seizure continues.

No IV access:
Midazolam 10mg IM (adult >40kg) — fastest onset, preferred if no IV
Diazepam rectal gel 0.2 mg/kg PR — if IM not available
Midazolam intranasal 5mg per nostril (10mg total) — emerging option

If seizure stops: Monitor closely, proceed to workup. Do NOT give second-line agent unless seizure recurs.

Levetiracetam (Keppra) 60 mg/kg IV (max 4,500mg) over 10 min — preferred, fewer drug interactions, safe in liver disease
Valproic acid 40 mg/kg IV (max 3,000mg) over 10 min — avoid in pregnancy, liver disease, mitochondrial disorders
Fosphenytoin 20 PE/kg IV at max 150 PE/min — monitor BP and cardiac rhythm during infusion
Choose ONE second-line agent. If seizure continues after 20 min → refractory SE.

ICU transfer and intubation required
Continuous EEG monitoring
Anesthetic agents — choose one:
Propofol 1-2 mg/kg IV bolus, then 20-200 mcg/kg/min infusion
Midazolam 0.2 mg/kg IV bolus, then 0.05-2 mg/kg/hr infusion
Ketamine 1.5-4.5 mg/kg IV — increasingly used, NMDA antagonist, less hypotension
Phenobarbital 15-20 mg/kg IV at 50-100 mg/min — older but effective
Neurology consult emergent

AEIOU TIPS mnemonic:
Alcohol withdrawal or toxin · Epilepsy (breakthrough — missed medication) · Infection (meningitis, encephalitis, sepsis) · Overdose (cocaine, TCAs, INH, bupropion, tramadol) · Uremia / metabolic
Trauma · Infarct/ischemia or intracranial hemorrhage · Pseudoseizure (non-epileptic) · Structure (tumor, AVM)

Key metabolic causes: Hypoglycemia · Hyponatremia · Hypomagnesemia · Hypocalcemia · Hypoxia · Hypertensive encephalopathy

Glucose (stat) · BMP · Calcium · Magnesium · CBC · LFTs · Toxicology screen · Antiepileptic drug levels (if on AEDs) · Pregnancy test (women of childbearing age)
CT head — new seizure, trauma, focal deficit, immunocompromised, age >40, fever, headache
LP — if meningitis/encephalitis suspected (after CT)
EEG — if diagnosis uncertain, post-ictal prolonged, or non-convulsive SE suspected

Expected post-ictal period: 15-30 minutes of confusion, lethargy, headache
If not returning to baseline within 30-60 min — consider non-convulsive SE, structural cause, or prolonged effect of medications
Seizure precautions: Fall precautions, bed in lowest position, call light in reach, nothing by mouth until fully awake
Driving restrictions — varies by state, typically 3-12 months seizure-free
Neurology follow-up for new-onset seizure

Verify scene safety · Check responsiveness (tap shoulders, shout)
Call for help — activate code team / call 911
Check pulse AND breathing simultaneously — no more than 10 seconds
Get AED/defibrillator
If no pulse → start CPR immediately

Rate: 100-120 compressions/min
Depth: At least 2 inches (5cm) in adults — do not exceed 2.4 inches
Recoil: Full chest recoil between compressions — do not lean
Interruptions: Minimize — pause <10 seconds for rhythm check or shock
Ratio: 30:2 compressions to ventilations (without advanced airway) · Continuous compressions with advanced airway at 10 breaths/min
Rotate compressors every 2 minutes to maintain quality
Avoid: Hyperventilation — causes air trapping and reduces venous return

Step 1: CPR while charging defibrillator
Step 2: Shock — Biphasic: 120-200J (manufacturer recommended) · Monophasic: 360J
Step 3: Resume CPR immediately × 2 minutes — do not check rhythm right after shock
Step 4: Rhythm check — if VF/VT persists → shock again
Step 5: Epinephrine 1mg IV/IO q3-5 min — give during CPR, not when stopped
Step 6: After 3rd shock → Amiodarone 300mg IV/IO push. Repeat 150mg once if needed.
OR Lidocaine 1-1.5 mg/kg IV/IO if amiodarone unavailable
Continue: Shock q2 min → Epi q3-5 min → Amiodarone cycle until ROSC or termination

CPR immediately — do not shock PEA or asystole
Epinephrine 1mg IV/IO q3-5 min — give as soon as access obtained
Rhythm check every 2 minutes
Search for and treat reversible causes (H's and T's)
If rhythm changes to VF/VT → follow shockable algorithm
Atropine is NOT recommended for PEA or asystole in current ACLS guidelines

H's:
Hypovolemia — IV fluid bolus
Hypoxia — ensure adequate ventilation, 100% O₂
Hydrogen ion (acidosis) — sodium bicarb, treat underlying cause
Hypo/Hyperkalemia — check BMP, treat accordingly
Hypothermia — warm the patient

T's:
Tension pneumothorax — needle decompression 2nd ICS MCL, then chest tube
Tamponade (cardiac) — pericardiocentesis
Toxins — antidote if known (Narcan for opioids, lipid emulsion for LA toxicity)
Thrombosis pulmonary (PE) — consider thrombolytics during CPR
Thrombosis coronary (MI) — emergent cath if ROSC achieved

Signs of ROSC: Palpable pulse, BP on monitor, spontaneous breathing, patient movement
Immediately after ROSC:
Avoid hyperoxia — titrate O₂ to SpO₂ 92-98%
Avoid hypotension — target SBP ≥90, MAP ≥65. Start vasopressors if needed.
12-lead EKG — look for STEMI → emergent cath lab activation
Check glucose — treat hypoglycemia. Avoid hyperglycemia (>180).
Temperature management — target 32-36°C × 24h if comatose after cardiac arrest
Ventilator: Target PaCO₂ 35-45 mmHg. Avoid hyperventilation.
ICU admission — all post-cardiac arrest patients

Symptomatic = HR <50 with hypotension, AMS, ischemia, or pulmonary edema
Atropine 0.5mg IV — repeat q3-5 min, max 3mg total. First line for sinus brady and AV nodal block.
If atropine fails or high-degree block (Mobitz II, 3rd degree):
Transcutaneous pacing — set rate 60-80, increase mA until capture. Sedate patient.
Dopamine 2-20 mcg/kg/min OR Epinephrine 2-10 mcg/min as bridge to pacing
Transvenous pacing for persistent high-degree block — cardiology consult
Do NOT use atropine for infranodal blocks (Mobitz II, 3rd degree) — may worsen

Unstable = hypotension, AMS, ischemia, or pulmonary edema due to tachycardia
Synchronized cardioversion — immediately
Narrow regular (SVT): 50-100J
Narrow irregular (AFib): 120-200J
Wide regular (VT with pulse): 100J
Wide irregular (polymorphic VT): Treat as VF — unsynchronized shock 200J
Sedate if time allows. Do not delay if truly unstable.

Vagal maneuvers first: Valsalva (modified — legs elevated), carotid sinus massage
Adenosine 6mg IV rapid push — flush immediately with 20mL NS. If no conversion in 1-2 min → 12mg. Repeat 12mg once.
Warn patient — transient chest pressure, flushing, sense of doom (seconds only)
If adenosine fails or AFib/Flutter:
Rate control: Diltiazem 15-20mg IV over 2 min OR Metoprolol 5mg IV q5 min × 3
Do NOT use adenosine or CCB in pre-excitation (WPW) — may cause VF

Assume VT until proven otherwise — especially in patients with known heart disease
Amiodarone 150mg IV over 10 min — then 1mg/min × 6h, then 0.5mg/min × 18h
Procainamide 20-50 mg/min IV until arrhythmia suppressed, hypotension, QRS widens 50%, or max 17mg/kg — avoid in prolonged QT or HF
Avoid: Verapamil, diltiazem, adenosine in wide complex tachycardia of unknown origin
Cardiology consult for all stable wide complex tachycardia

Epinephrine: 1mg IV/IO q3-5 min (cardiac arrest) · 2-10 mcg/min infusion (bradycardia/hypotension)
Amiodarone: 300mg push (VF/VT arrest) · 150mg over 10 min (stable VT)
Lidocaine: 1-1.5 mg/kg IV (VF/VT if amio unavailable) · Max 3mg/kg
Atropine: 0.5mg IV q3-5 min (bradycardia) · Max 3mg
Adenosine: 6mg rapid IV push → 12mg → 12mg (SVT)
Dopamine: 2-20 mcg/kg/min (bradycardia, hypotension)
Sodium Bicarb: 1 mEq/kg IV (hyperkalemia, TCA OD, prolonged arrest, acidosis)
Calcium Chloride: 1g IV (hyperkalemia, CCB toxicity, hypocalcemia)
Magnesium: 1-2g IV over 5-20 min (Torsades de Pointes, refractory VF)

Opening
"How has your mood been lately?"
"How long have you been feeling this way?"
"Has anything happened that may have triggered this?"

Core Symptoms
"Would you say you feel depressed, down, or hopeless most of the day?"
"Have you lost interest in things you used to enjoy?"
"How is your energy? Do you feel tired even when you haven't done much?"
"How is your sleep — are you sleeping too much or too little?"
"Has your appetite changed? Have you noticed any weight changes?"
"Are you having trouble concentrating or making decisions?"
"Do you feel worthless or find yourself blaming yourself for things?"
"Have you noticed yourself moving or speaking more slowly than usual?"

Safety
"Have you had any thoughts of death or of not wanting to be here?"
"Have you had any thoughts of hurting yourself or ending your life?"
"Have you made any plans? Do you have access to means?"
"What has stopped you from acting on those thoughts?"

Rule Out Bipolar Before Prescribing
"Have you ever had a period when you felt the opposite — unusually high, energetic, or needed very little sleep?"
"Have you ever done things during those times you later regretted?"

General Anxiety
"Do you find yourself worrying a lot — even about things that may not be that serious?"
"Is it hard to control the worrying once it starts?"
"How long has anxiety been a problem for you?"
"Does anxiety interfere with your work, relationships, or daily life?"

Physical Symptoms
"Do you notice physical symptoms when anxious — racing heart, shortness of breath, chest tightness, sweating, trembling?"
"Do you have muscle tension, headaches, or GI symptoms related to anxiety?"
"How is your sleep — does anxiety keep you awake or wake you up?"

Panic
"Have you ever had a sudden episode of intense fear or physical symptoms that came out of nowhere?"
"During these episodes did you feel like something terrible was about to happen — like you were dying or losing control?"
"Do you avoid places or situations because you are afraid of having one of these episodes?"

Social Anxiety
"Do you feel very anxious in social situations or when you might be observed or judged?"
"Do you avoid social situations because of anxiety?"

OCD Screen
"Do you have recurring thoughts that feel intrusive or hard to control?"
"Do you feel compelled to do certain things repeatedly to reduce anxiety?"

Trauma Screen
"Have you experienced a traumatic event? Do you have flashbacks, nightmares, or feel on edge as a result?"

Criteria: Excessive anxiety and worry about multiple domains × ≥6 months, difficult to control. ≥3 of: restlessness, fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance.

First Line: SSRIs (Sertraline, Escitalopram) or SNRIs (Venlafaxine XR, Duloxetine)
Buspirone: 7.5mg BID, titrate to 15-30mg BID — non-habit forming, takes 2-4 weeks, good for long-term
Adjunct short-term: Hydroxyzine 25-50mg TID/QID PRN — non-addictive, good for acute anxiety
Avoid benzodiazepines as first line — reserve for short-term bridging only
Therapy: CBT is gold standard — equal to medication, superior long-term

Criteria: Recurrent unexpected panic attacks + ≥1 month of anticipatory anxiety or avoidance behavior. Rule out medical causes (cardiac, thyroid, pheochromocytoma, hypoglycemia).

First Line: SSRIs (Sertraline, Fluoxetine, Paroxetine) or SNRIs (Venlafaxine XR)
Start at very low doses — panic patients are sensitive. Sertraline 12.5-25mg, Fluoxetine 5-10mg.
Clonazepam 0.25-0.5mg BID — for bridging while SSRI takes effect. Taper once SSRI therapeutic.
Therapy: CBT with interoceptive exposure — most effective long-term treatment

First Line: SSRIs (Sertraline, Paroxetine, Fluvoxamine) or Venlafaxine XR
Performance anxiety (situational): Propranolol 10-40mg 1 hour before event — for discrete situations (presentations, procedures)
Therapy: CBT with exposure — essential component of treatment

Criteria: Exposure to trauma + intrusion symptoms + avoidance + negative cognitions/mood + hyperarousal × >1 month with functional impairment.

First Line medications: Sertraline or Paroxetine (only FDA-approved for PTSD)
Venlafaxine XR — strong evidence despite not FDA-approved for PTSD
Nightmares/hyperarousal: Prazosin 1-15mg QHS — good evidence for trauma nightmares
Avoid benzodiazepines — worsens PTSD outcomes, high addiction risk in trauma survivors
Therapy: Trauma-focused CBT, EMDR — first line. Medications are adjunctive.

Use only when: Short-term bridging, acute severe anxiety, procedure anxiety, alcohol withdrawal
Avoid in: PTSD, substance use disorder history, elderly (fall/cognitive risk), pregnancy, sleep apnea
Lorazepam: 0.5-2mg TID PRN — intermediate acting, no active metabolites (preferred in elderly/liver disease)
Clonazepam: 0.25-1mg BID — longer acting, less breakthrough anxiety
Diazepam: 2-10mg BID-QID — very long acting, active metabolites
Always use lowest effective dose. Taper slowly — never abrupt discontinuation. Document rationale.

≥5 inattentive symptoms AND/OR ≥5 hyperactive-impulsive symptoms (≥6 for children)
Present × ≥6 months, inconsistent with developmental level
Several symptoms present before age 12
Symptoms present in ≥2 settings
Significant functional impairment
Not better explained by another mental disorder

Presentations: Predominantly Inattentive · Predominantly Hyperactive-Impulsive · Combined

Amphetamine-based (Schedule II)
Adderall XR: Start 10mg daily, titrate by 5-10mg weekly, max 40mg (adults)
Vyvanse (Lisdexamfetamine): Start 30mg daily, titrate by 10-20mg weekly, max 70mg — prodrug, lower abuse potential, smoother onset/offset
Adderall IR: 5-10mg BID-TID — flexible dosing, shorter duration (4-6h)

Methylphenidate-based (Schedule II)
Concerta (OROS-MPH): Start 18mg daily, titrate by 18mg weekly, max 72mg
Ritalin LA: Start 10-20mg daily, max 60mg
Ritalin IR: 5-10mg BID-TID — short acting (3-5h)
Focalin XR (Dexmethylphenidate): Start 10mg, max 40mg — active isomer only

Monitoring: BP and HR at baseline and each titration. Height/weight (children). Assess for cardiac symptoms. Risk of abuse/diversion.

Atomoxetine (Strattera): Start 40mg daily × 3 days, then 80mg. Target 80-100mg. Full effect at 4-8 weeks. Good for anxiety/tic comorbidity, substance use disorder, cardiac concerns. Black box for suicidality in children.

Viloxazine (Qelbree): Start 100mg daily, max 400mg — newer SNRI-like, non-stimulant, FDA approved 2021. Less studied in adults.

Guanfacine ER (Intuniv): 1-4mg daily — alpha-2 agonist, good for hyperactivity/impulsivity, emotional dysregulation. Sedating. Monitor BP.

Clonidine ER (Kapvay): 0.1-0.4mg daily — similar to guanfacine, more sedating

Bupropion (off-label): 150-300mg XL — modest evidence, useful when ADHD + depression comorbid

Controlled substance documentation — PDMP check before prescribing
Diagnose before prescribing — comprehensive evaluation, rating scales (Adult ADHD Self-Report Scale)
Start with longest-acting formulation — better adherence, less abuse potential
Drug holidays for children — not typically recommended for adults
Comorbidities affect choice: Anxiety → atomoxetine or non-stimulant. Substance use → atomoxetine, Vyvanse. Tics → guanfacine. Insomnia → avoid afternoon doses, earlier cutoff time.
Screen for bipolar disorder before stimulants — can precipitate mania

Mania / Hypomania Screen
"Have you ever had a period when you felt unusually high, euphoric, or on top of the world?"
"Have you had times when you felt more irritable or easily angered than usual for several days?"
"During those times did you need much less sleep than usual and still feel full of energy?"
"Did your thoughts race or did you feel you couldn't slow your mind down?"
"Were you more talkative or speaking faster than usual?"
"Did you take on many projects at once or feel like you could accomplish anything?"
"Did you do things that were out of character — spending a lot of money, risky sexual behavior, reckless decisions?"
"Did others notice a significant change in your behavior during these times?"
"How long did these episodes last? Did you need to be hospitalized?"

Cycling Pattern
"How often do your mood episodes occur?"
"Do you have periods of relatively normal mood between episodes?"
"Have antidepressants ever made you feel worse, more agitated, or caused a high episode?"

Safety During Mania
"When you are in those high states do you have thoughts of hurting yourself or others?"
"Have you ever been hospitalized for your mood?"

Bipolar I: ≥1 manic episode (≥7 days or any duration if hospitalized or psychotic). Depressive episodes common but not required for diagnosis.
Bipolar II: ≥1 hypomanic episode (≥4 days, less severe than mania, no psychosis, no hospitalization required) + ≥1 major depressive episode. Never had full mania — if mania occurs, reclassify as Bipolar I.

Mania criteria: Elevated/expansive/irritable mood + increased goal-directed activity × ≥1 week + ≥3 of: grandiosity, decreased sleep need, pressured speech, racing thoughts, distractibility, psychomotor agitation, risky behavior

Common misdiagnosis: Bipolar frequently misdiagnosed as MDD. Red flags for bipolar in apparent depression: early onset, multiple depressive episodes, treatment-resistant depression, hypersomnia, family history of bipolar, antidepressant-induced hypomania.

Lithium: Most evidence for mania and suicide prevention. Start 150-300mg BID, titrate to level 0.6-1.2 mEq/L (acute mania 0.8-1.2). Monitor: levels, renal function, TSH q6 months. Narrow therapeutic window — toxicity risk. Excellent for classic euphoric mania, fewer relapses.

Valproate/Divalproex (Depakote): Start 250mg BID-TID, titrate to level 50-125 mcg/mL. Better for mixed states, rapid cycling, dysphoric mania. Monitor: LFTs, CBC, levels. Teratogenic (neural tube defects) — contraindicated in pregnancy. Weight gain, hair loss.

Lamotrigine (Lamictal): Best for bipolar depression maintenance — poor for acute mania. Start 25mg daily, titrate very slowly over 6 weeks (risk of Stevens-Johnson syndrome). Target 100-400mg. No weight gain, well tolerated. No monitoring required.

Quetiapine (Seroquel): FDA approved for mania, depression, and maintenance. Most versatile. 50-800mg. Sedating — useful for insomnia. Metabolic monitoring required.
Aripiprazole (Abilify): FDA approved for mania and maintenance. Weight neutral, activating. 10-30mg.
Olanzapine (Zyprexa): FDA approved for mania. Highly effective but significant metabolic risk — weight gain, diabetes. Reserve for refractory cases.
Risperidone: FDA approved for acute mania. 2-6mg. EPS risk, prolactin elevation.
Cariprazine (Vraylar): FDA approved for mania AND bipolar depression. 1.5-6mg. Activating, weight neutral — emerging evidence.
Lumateperone (Caplyta): FDA approved for bipolar depression as monotherapy and adjunct. 42mg. Well tolerated.

Antidepressant monotherapy is contraindicated in bipolar disorder — can precipitate mania, mixed states, rapid cycling
If used at all — only with concurrent mood stabilizer or antipsychotic
Avoid in: Bipolar I with recent mania, mixed features, rapid cycling
Bupropion — lowest risk of switch to mania if antidepressant needed
SSRIs — some evidence for bipolar II depression with mood stabilizer
Always document informed consent discussion about risks

Lithium: Level q3-6 months (stable) · SCr and eGFR q6 months · TSH annually · Calcium annually
Valproate: Level q6 months · LFTs · CBC · Weight
Atypical antipsychotics: Weight/BMI · Fasting glucose · Lipids · BP — baseline then q3 months × 1 year then annually
Lamotrigine: No routine blood monitoring — educate on rash

Hallucinations
"Have you been hearing voices or sounds that others around you don't seem to hear?"
"What do the voices say? Are they commenting on what you are doing or telling you to do things?"
"Have you seen things that others don't seem to see?"
"Have you felt things on your body that have no physical explanation?"

Delusions
"Do you feel like someone is out to get you or that people are watching or following you?"
"Do you feel like the TV, radio, or strangers are sending you special messages?"
"Do you believe you have special powers or a special mission?"
"Do you feel like your thoughts are being controlled by someone else, or that others can hear your thoughts?"
"Do you feel like your thoughts are being taken out of your head or that thoughts are being inserted?"

Disorganization
"Have people told you that your thinking or speech is hard to follow?"
"Do you find it hard to organize your thoughts?"

Negative Symptoms
"Have you lost motivation to do things — even things you used to care about?"
"Have you been withdrawing from people or activities?"
"Has your ability to feel emotions changed?"

Safety — Always Assess
"Are the voices telling you to hurt yourself or someone else?"
"Do you feel you need to act on what the voices tell you?"
"Do you have thoughts of hurting yourself or anyone else?"

≥2 of the following × ≥1 month (at least one must be #1, #2, or #3):
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (avolition, alogia, anhedonia, asociality, blunted affect)

Continuous disturbance × ≥6 months · Significant functional decline · Not attributable to substances or medical conditions

Spectrum disorders: Schizophrenia · Schizoaffective disorder · Schizophreniform · Brief psychotic disorder · Delusional disorder

Positive symptoms: Hallucinations, delusions, disorganized thinking — respond best to antipsychotics
Negative symptoms: Flat affect, avolition, alogia, anhedonia, social withdrawal — harder to treat, predict long-term functioning
Cognitive symptoms: Working memory, processing speed, executive function deficits — often most disabling
Mood symptoms: Depression and anxiety common — assess carefully, treat appropriately

Risperidone: 2-8mg daily — most studied SGA. EPS risk at higher doses. Prolactin elevation. Good evidence for positive symptoms.
Olanzapine: 10-20mg daily — highly effective for positive and negative symptoms. Significant metabolic risk — weight gain, diabetes, dyslipidemia. Reserve when metabolic risks acceptable.
Quetiapine: 400-800mg daily — lower EPS, sedating, metabolic risk. Good for mood symptoms.
Aripiprazole: 10-30mg daily — partial dopamine agonist, weight neutral, activating. Can worsen agitation in acute psychosis.
Ziprasidone: 120-200mg daily (with food) — weight neutral, QTc prolongation risk. Take with 500 calorie meal.
Lurasidone: 40-160mg daily (with food) — weight neutral, good cognitive profile, FDA approved for schizophrenia and bipolar depression.
Paliperidone: 3-12mg daily — active metabolite of risperidone. Available as monthly injectable (Invega Sustenna) and 3-month injectable (Invega Trinza).

Strongly preferred for patients with adherence issues — which is most patients with schizophrenia
Consider early — not just for non-adherence after multiple relapses

Monthly injectables:
Risperdal Consta (biweekly) · Invega Sustenna (monthly) · Abilify Maintena (monthly) · Aristada (monthly or q6 weeks)

Longer-acting:
Invega Trinza — every 3 months · Invega Hafyera — every 6 months · Abilify Asimtufii — every 2 months

Benefits: Eliminates adherence uncertainty, detects relapse earlier, reduces hospitalization rates

Most effective antipsychotic — reduces suicidality, reduces violence, improves treatment-resistant cases
Indicated after failure of ≥2 adequate antipsychotic trials
REMS program required — mandatory ANC monitoring
Risk of agranulocytosis: ANC weekly × 6 months, then biweekly × 6 months, then monthly
Start 12.5-25mg daily, titrate slowly to 300-450mg (max 900mg)
Other risks: Seizures (dose-dependent), myocarditis (first month — monitor CRP and troponin), metabolic syndrome, sialorrhea, sedation, orthostasis
Should be managed by psychiatry — refer

Baseline: Weight/BMI · Waist circumference · BP · Fasting glucose · HbA1c · Fasting lipids · EKG (if QTc concern)
4 weeks: Weight
8 weeks: Weight
12 weeks: Weight · BP · Fasting glucose · Fasting lipids
Annually: All of above + HbA1c
Prolactin: If symptomatic (amenorrhea, galactorrhea, sexual dysfunction) — risperidone/paliperidone highest risk

Acute dystonia: Sudden painful muscle spasm — Benztropine 1-2mg IM/IV or Diphenhydramine 25-50mg IM/IV. Immediate relief.
Akathisia: Inner restlessness, inability to sit still — reduce dose, propranolol 10-40mg BID, benzodiazepine, mirtazapine
Parkinsonism: Tremor, rigidity, bradykinesia — reduce dose, switch to lower EPS agent, add Benztropine 0.5-2mg BID
Tardive dyskinesia: Late-onset involuntary movements — reduce/discontinue if possible. Valbenazine (Ingrezza) or Deutetrabenazine (Austedo) FDA approved. AIMS scale to monitor.

Normal: <120/80
Elevated: 120-129/<80
Stage 1 HTN: 130-139/80-89
Stage 2 HTN: ≥140/90
Hypertensive Urgency: SBP >180 or DBP >120 — no acute target organ damage
Hypertensive Emergency: Severely elevated BP + acute target organ damage (AKI, encephalopathy, MI, aortic dissection, eclampsia)

General adults: <130/80 (ACC/AHA 2017)
Elderly ≥65: <130/80 if tolerated (SPRINT trial)
CKD with proteinuria: <130/80
Diabetes: <130/80
High CVD risk: <130/80
Bilateral renal artery stenosis: More cautious — avoid ACE/ARB

DASH diet — reduces SBP 8-14 mmHg
Sodium restriction <2.3g/day — reduces 5-6 mmHg
Weight loss — 1 mmHg per kg lost
Aerobic exercise 30 min × 5 days/week — reduces 5-8 mmHg
Alcohol reduction — <2 drinks/day men, <1 women
Smoking cessation — cardiovascular risk reduction
Stress reduction — mindfulness, sleep hygiene

Thiazide diuretics: Chlorthalidone 12.5-25mg daily (preferred over HCTZ — longer acting) · HCTZ 25-50mg daily. Monitor K+, uric acid, glucose.

ACE Inhibitors: Lisinopril 5-40mg · Enalapril 5-40mg BID · Ramipril 2.5-20mg. Monitor K+, Cr. Avoid in pregnancy. Cough in 10-15% — switch to ARB.

ARBs: Losartan 25-100mg · Valsartan 80-320mg · Olmesartan 20-40mg. Fewer side effects than ACEi. Avoid in pregnancy.

Calcium Channel Blockers:
Dihydropyridines (vasodilatory): Amlodipine 2.5-10mg daily — excellent, well tolerated, no HR effect. Pedal edema.
Non-dihydropyridines (rate slowing): Diltiazem, Verapamil — avoid in HFrEF

Combination preferred for Stage 2 or BP >20/10 above goal. ACEi/ARB + CCB or Thiazide most evidence.

HFrEF: ACEi/ARB + Beta-blocker + Aldosterone antagonist + SGLT2i
Post-MI: Beta-blocker + ACEi/ARB
Diabetes: ACEi or ARB (renal protection) — first line
CKD with proteinuria: ACEi or ARB — first line regardless of BP
Afib (rate control): Beta-blocker or non-DHP CCB
Angina: Beta-blocker or CCB
Black patients: Thiazide or CCB preferred (ACEi less effective as monotherapy)
Pregnancy: Labetalol, Nifedipine, Methyldopa — safe. AVOID ACEi/ARB/direct renin inhibitors.

ICU admission · Arterial line for continuous monitoring
Reduce MAP by no more than 25% in first hour — then to 160/100 over next 2-6h — then to goal over 24-48h
Exception: Aortic dissection — reduce SBP to <120 within minutes

IV Agents:
Nicardipine 5-15 mg/hr — titratable, preferred for most emergencies
Labetalol 20-80mg IV boluses or 0.5-2 mg/min infusion — good for dissection, pregnancy
Clevidipine 1-32 mg/hr — ultra-short acting, excellent for titration
Hydralazine 10-20mg IV — commonly used in pregnancy/eclampsia
Nitroprusside — powerful but cyanide toxicity risk, avoid prolonged use

HFrEF (EF <40%): Reduced ejection fraction — systolic dysfunction. Disease-modifying therapy available.
HFmrEF (EF 40-49%): Mildly reduced — emerging evidence for similar treatment to HFrEF
HFpEF (EF ≥50%): Preserved ejection fraction — diastolic dysfunction. Fewer proven therapies. Most common in elderly, women, hypertensives, diabetics.

NYHA Classification:
Class I: No symptoms with ordinary activity
Class II: Symptoms with moderate exertion
Class III: Symptoms with minimal exertion
Class IV: Symptoms at rest

All four pillars reduce mortality — maximize doses as tolerated:

1. ACEi/ARB or ARNI:
Lisinopril 2.5-40mg · Enalapril 2.5-20mg BID
Sacubitril/Valsartan (Entresto) — superior to ACEi, preferred if tolerated. Start 24/26mg BID, target 97/103mg BID. 36h washout from ACEi before starting.

2. Beta-blockers (evidence-based only):
Carvedilol 3.125-25mg BID · Metoprolol succinate XL 12.5-200mg · Bisoprolol 1.25-10mg
Start low, titrate slowly. Do NOT start during acute decompensation.

3. Mineralocorticoid Receptor Antagonists (MRA):
Spironolactone 12.5-50mg daily · Eplerenone 25-50mg daily
Avoid if K+ >5.0 or eGFR <30. Monitor K+ closely with ACEi/ARB.

4. SGLT2 Inhibitors:
Dapagliflozin (Farxiga) 10mg daily · Empagliflozin (Jardiance) 10mg daily
Reduces HF hospitalization and CV death independent of diabetes status. Now standard of care.

Treat underlying causes: HTN, AFib, obesity, sleep apnea, diabetes
SGLT2 inhibitors: Empagliflozin and Dapagliflozin now have evidence for HFpEF — use
Diuretics: For volume overload symptom relief — furosemide, torsemide
Spironolactone: Modest benefit in HFpEF
Blood pressure control — target <130/80
Exercise training — improves functional capacity
No mortality benefit shown for ACEi/ARB/beta-blockers in HFpEF alone

Furosemide (Lasix): 20-600mg daily PO or IV. Torsemide has better bioavailability (preferred).
Torsemide: 10-200mg daily — better oral absorption than furosemide
Bumetanide: 0.5-10mg daily
Metolazone: 2.5-10mg — add to loop diuretic for diuretic resistance. Synergistic. Monitor electrolytes closely.

Target: Urine output 1-2L/day above intake during decongestion · Daily weights · Monitor K+, Mg, Cr · Goal dry weight without orthostasis

IV diuresis: Furosemide IV at 1-2.5× home oral dose or continuous infusion
Restrict fluids 1.5-2L/day · Low sodium diet <2g
Daily weights — target 0.5-1kg/day diuresis
Monitor BMP q24-48h during active diuresis
Continue GDMT if possible — do not routinely hold beta-blockers unless cardiogenic shock
Avoid: NSAIDs, thiazolidinediones, most CCBs (except amlodipine), dronedarone
Discharge criteria: On oral diuretics ≥24h before discharge · Stable weight · BMP acceptable · GDMT optimized · Follow-up within 7 days

Paroxysmal: Terminates spontaneously within 7 days
Persistent: Lasts >7 days, requires cardioversion
Long-standing persistent: Continuous >12 months
Permanent: Rhythm control no longer pursued — rate control and anticoagulation only

Score 0 (male) or 1 (female): No anticoagulation
Score 1 (male): Consider anticoagulation
Score ≥2 (male) or ≥3 (female): Anticoagulate

Preferred agents — DOACs over warfarin:
Apixaban (Eliquis) 5mg BID — preferred, lowest bleeding risk. Reduce to 2.5mg BID if 2 of 3: age ≥80, weight ≤60kg, Cr ≥1.5
Rivaroxaban (Xarelto) 20mg daily with evening meal
Dabigatran (Pradaxa) 150mg BID (75mg BID if CrCl 15-30)
Edoxaban 60mg daily (30mg if CrCl 15-50 or weight ≤60kg)
Warfarin — use if mechanical valve, mitral stenosis, CrCl <15. Target INR 2-3.

Target resting HR <110 bpm (lenient) — adequate for most stable patients
Target <80 bpm (strict) — for symptomatic patients or HF

Beta-blockers (first line):
Metoprolol succinate 25-200mg daily · Carvedilol 3.125-25mg BID
Esmolol IV for acute rate control

Non-DHP Calcium Channel Blockers:
Diltiazem 120-360mg daily (CD) · Verapamil 120-480mg daily
AVOID in HFrEF — negative inotropy worsens function

Digoxin: 0.125-0.25mg daily — adjunct only, not first line. Monitor levels (target 0.5-0.9). Reduced in renal impairment.

Cardioversion: If AFib <48h — can cardiovert without TEE. If >48h or unknown — anticoagulate ≥3 weeks before OR TEE to rule out LAA thrombus.
Continue anticoagulation ≥4 weeks after cardioversion regardless of CHA₂DS₂-VASc score.

Antiarrhythmics for rhythm control:
Flecainide/Propafenone — only in structurally normal hearts (no CAD, HF, LVH)
Amiodarone — most effective, usable in structural heart disease, but significant toxicity (thyroid, pulmonary, hepatic, ocular) — monitor TFTs, LFTs, CXR annually
Sotalol — requires inpatient QTc monitoring for initiation
Dronedarone — fewer side effects than amiodarone, less effective. Avoid in permanent AFib, HFrEF.

Catheter ablation: Pulmonary vein isolation — refer to EP for symptomatic paroxysmal AFib or rhythm control failure

Unstable (hypotension, AMS, acute HF, ischemia) → Synchronized cardioversion immediately
Stable → Rate control first · Anticoagulate · Identify and treat triggers
Common triggers: Infection/sepsis · Hyperthyroidism · PE · Alcohol (holiday heart) · Electrolyte disturbance · Post-cardiac surgery · Sleep apnea

Immediately life-threatening — rule out first:
ACS (STEMI/NSTEMI/UA) · Aortic dissection · Pulmonary embolism · Tension pneumothorax · Cardiac tamponade

Initial workup: EKG within 10 minutes · Troponin (high-sensitivity) × 2 (0h and 3h) · CXR · BMP · CBC
History features suggesting ACS: Pressure/squeezing quality, radiation to arm/jaw/back, diaphoresis, nausea, exertional, relieved by nitro, known CAD risk factors

Time is muscle — door to balloon <90 min
Activate cath lab immediately
Aspirin 325mg chewed · P2Y12 inhibitor (Ticagrelor 180mg or Clopidogrel 600mg)
Heparin bolus per ACS weight-based protocol
Nitroglycerin SL (if SBP >90, no RV infarct, no PDE5 inhibitor use)
Oxygen if SpO₂ <90%
IV access × 2 · Continuous monitoring · NPO

Aspirin 325mg then 81mg daily
P2Y12: Ticagrelor 180mg load then 90mg BID (preferred) or Clopidogrel 300-600mg load then 75mg daily
Anticoagulation: Enoxaparin 1mg/kg SQ q12h (adjust for renal function) or Heparin IV
Beta-blocker: Metoprolol 25-50mg — if no contraindications (no bradycardia, HF, bronchospasm)
High-intensity statin: Atorvastatin 80mg or Rosuvastatin 40mg — start immediately
Risk stratification: TIMI or GRACE score → early invasive (cath within 24h) vs conservative strategy
High risk features requiring early cath: Elevated troponin, new ST changes, recurrent ischemia, hemodynamic instability, EF <40%, prior PCI/CABG

Antiplatelet: Aspirin 81mg daily lifelong · Clopidogrel if aspirin intolerant
Statin: High-intensity — Atorvastatin 40-80mg or Rosuvastatin 20-40mg. Target LDL <70 (very high risk: <55)
Beta-blocker: If prior MI or HFrEF
ACEi/ARB: If prior MI, HFrEF, HTN, or diabetes
Anti-anginal therapy: Beta-blocker first line · Long-acting nitrates · CCB
Risk factor modification: BP <130/80 · LDL at goal · Diabetes control · Smoking cessation · Exercise · Weight loss

Bare metal stent: DAPT minimum 1 month
Drug-eluting stent (stable CAD): DAPT minimum 6 months
ACS with DES: DAPT minimum 12 months — consider extended if low bleeding risk
Post-CABG: Aspirin 81mg lifelong · Clopidogrel may be added for 12 months after ACS
Do NOT stop DAPT without cardiology consultation — stent thrombosis risk

Very High Risk (established ASCVD, DM + ASCVD, LDL >190): LDL <55 mg/dL
High Risk (DM age 40-75, 10-yr ASCVD risk ≥20%): LDL <70 mg/dL
Intermediate Risk (10-yr ASCVD risk 7.5-20%): LDL <100 mg/dL
Low Risk (10-yr ASCVD risk <7.5%): LDL <130 mg/dL

Use AHA/ACC Pooled Cohort Equations to calculate 10-year ASCVD risk

High-Intensity (reduces LDL ≥50%):
Atorvastatin 40-80mg daily · Rosuvastatin 20-40mg daily

Moderate-Intensity (reduces LDL 30-49%):
Atorvastatin 10-20mg · Rosuvastatin 5-10mg · Simvastatin 20-40mg · Pravastatin 40-80mg · Lovastatin 40mg

Low-Intensity (reduces LDL <30%):
Simvastatin 10mg · Pravastatin 10-20mg — use if high-intensity not tolerated

Always high-intensity for: ASCVD · DM age 40-75 · LDL >190 · High ASCVD risk

Ezetimibe (Zetia) 10mg daily: Add when LDL not at goal on max statin. Reduces LDL additional 15-25%. Well tolerated. First non-statin add-on.

PCSK9 Inhibitors: Evolocumab (Repatha) 140mg SQ q2 weeks or 420mg monthly · Alirocumab (Praluent) 75-150mg SQ q2 weeks. Reduces LDL 50-60% on top of statin+ezetimibe. Very high cost — prior auth required. Use for very high risk not at goal or statin intolerance.

Inclisiran (Leqvio): 284mg SQ — given at baseline, 3 months, then every 6 months. PCSK9 siRNA — office-administered, adherence advantage.

Bempedoic acid (Nexletol): 180mg daily — non-statin, useful for statin intolerance. Reduces LDL ~18%.

Fenofibrate / Gemfibrozil: For severe hypertriglyceridemia (TG >500) — pancreatitis prevention. Avoid gemfibrozil with statins (myopathy risk).

Icosapent ethyl (Vascepa) 4g daily: For TG 150-499 + ASCVD or diabetes on statin — reduces CV events (REDUCE-IT trial)

Statin-associated muscle symptoms (SAMS): Myalgia without CK elevation (most common) → try lower dose, different statin, alternate-day dosing
Myositis: Muscle symptoms + elevated CK → hold statin, recheck, consider rechallenge
Rhabdomyolysis: Severe muscle pain + CK >10× ULN + myoglobinuria → STOP statin, IV fluids, nephrology
Hydrophilic statins (pravastatin, rosuvastatin) — lower myopathy risk
True statin intolerance (>2 statins failed) → Ezetimibe + PCSK9 inhibitor
Check CK and CMP at baseline. Repeat if symptoms develop. Routine CK monitoring not recommended.

Reduce saturated fat <7% of calories · Eliminate trans fats · Increase soluble fiber (oats, beans, psyllium) · Plant stanols/sterols · Mediterranean diet · Weight loss · Exercise · Reduce refined carbohydrates (for high TG) · Reduce alcohol (for high TG)

HFrEF (EF <40%): Reduced ejection fraction — most evidence-based treatment options
HFmrEF (EF 40-49%): Mildly reduced — emerging evidence, treat like HFrEF
HFpEF (EF ≥50%): Preserved ejection fraction — limited proven mortality benefit from most medications. Focus on symptom control and comorbidities.

NYHA Functional Classification:
Class I: No symptoms with ordinary activity
Class II: Symptoms with moderate exertion
Class III: Symptoms with minimal exertion
Class IV: Symptoms at rest

The "Fantastic Four" — all four classes reduce mortality. Start all as tolerated.

1. ACE Inhibitor or ARB or ARNI
Lisinopril: Start 2.5-5mg daily, target 40mg daily
Enalapril: Start 2.5mg BID, target 10-20mg BID
Sacubitril/Valsartan (Entresto): Start 24/26mg BID, target 97/103mg BID — superior to ACEi for mortality. Cannot combine with ACEi (washout 36h). First line when tolerated.

2. Beta-Blockers
Carvedilol: Start 3.125mg BID, target 25mg BID (50mg if >85kg)
Metoprolol Succinate XL: Start 12.5-25mg daily, target 200mg daily
Bisoprolol: Start 1.25mg daily, target 10mg daily
Only these three proven to reduce mortality in HFrEF. Do NOT start during acute decompensation.

3. MRA (Mineralocorticoid Receptor Antagonist)
Spironolactone: Start 12.5-25mg daily, target 25-50mg — monitor K+ and renal function. Avoid if K+ >5.0 or eGFR <30.
Eplerenone: Start 25mg daily, target 50mg — fewer hormonal side effects

4. SGLT2 Inhibitor
Dapagliflozin (Farxiga): 10mg daily — FDA approved for HFrEF regardless of diabetes
Empagliflozin (Jardiance): 10mg daily — FDA approved for HFrEF and HFpEF
Monitor for UTI, genital mycotic infections, DKA (rare). Hold before surgery.

Furosemide (Lasix): Start 20-40mg daily or BID. Titrate to euvolemia. IV bioavailability 2× oral — double oral dose for IV equivalent.
Torsemide: Better oral bioavailability than furosemide (80-90% vs 50%). 10-20mg = furosemide 40mg. Consider switching if inadequate response to furosemide.
Metolazone: Add 2.5-5mg 30 min before loop diuretic for diuretic resistance — powerful combination. Monitor electrolytes closely.
Target: Euvolemia. Daily weights — call if +2-3 lbs in 24h or +5 lbs in week. Restrict sodium <2g/day. Fluid restriction 1.5-2L/day if severe.

LMNOP mnemonic:
Lasix IV — furosemide 1-2.5× oral daily dose IV
Morphine — use cautiously, may worsen outcomes (consider avoiding)
Nitrates — sublingual or IV nitroglycerin for hypertensive HF, pulmonary edema
Oxygen — titrate to SpO₂ >92%. CPAP/BiPAP for respiratory distress before intubation.
Positioning — sit upright, legs dependent

Continue GDMT if tolerated. Do NOT stop beta-blocker unless cardiogenic shock. Avoid NSAIDs, CCBs (verapamil/diltiazem), thiazolidinediones.

Treat underlying causes: HTN (most important), AFib, obesity, diabetes, sleep apnea
Diuretics for volume overload — same as HFrEF
SGLT2 inhibitors — Empagliflozin reduces HF hospitalization in HFpEF
Spironolactone — some evidence for reducing hospitalization
Manage comorbidities aggressively — HTN target <130/80, treat AFib, weight loss
Exercise training — significant symptom benefit

BMP within 1-2 weeks of any medication change (ACEi/ARB/MRA — K+ and Cr)
BNP or NT-proBNP — guides therapy, assess volume status
Echo q1-2 years if stable, sooner after medication changes or clinical change
Daily weights — patient education essential
Cardiology referral: EF <35% (ICD/CRT evaluation), refractory symptoms, consideration of advanced therapies

Paroxysmal: Terminates spontaneously or with intervention within 7 days
Persistent: Lasts >7 days, requires intervention to terminate
Long-standing persistent: Continuous >12 months
Permanent: Accepted by patient and provider — rate control only strategy

Score 0 (male) or 1 (female): No anticoagulation recommended
Score 1 (male): Consider anticoagulation
Score ≥2 (male) or ≥3 (female): Anticoagulation recommended

Use HAS-BLED to assess bleeding risk — high bleeding risk does not automatically preclude anticoagulation. Treat modifiable bleeding risk factors.

Apixaban (Eliquis): 5mg BID (2.5mg BID if ≥2 of: age ≥80, weight ≤60kg, Cr ≥1.5) — lowest bleeding risk, preferred in most patients
Rivaroxaban (Xarelto): 20mg daily with evening meal — once daily (adherence advantage)
Dabigatran (Pradaxa): 150mg BID (75mg BID if CrCl 15-30) — only DOAC with reversal agent (idarucizumab). Avoid if CrCl <15.
Edoxaban (Savaysa): 60mg daily (30mg if CrCl 15-50 or weight ≤60kg)
Warfarin: Target INR 2-3 — use when DOAC contraindicated (mechanical valves, severe mitral stenosis, CrCl <15). Requires frequent monitoring.

DOAC reversal: Apixaban/Rivaroxaban → Andexanet alfa · Dabigatran → Idarucizumab · All → 4-factor PCC

Target resting HR <110 bpm (lenient) or <80 bpm (strict — if symptomatic)

Beta-Blockers (first line):
Metoprolol tartrate: 25-100mg BID · Metoprolol succinate XL: 25-200mg daily · Carvedilol: 3.125-25mg BID

Non-dihydropyridine CCBs (avoid in HFrEF):
Diltiazem: 120-360mg XR daily · Verapamil: 120-480mg XR daily

Digoxin: 0.125-0.25mg daily — adjunct for rate control, especially HFrEF. Target level 0.5-0.9 ng/mL. Narrow TI — toxicity risk. Not first line.

Amiodarone: For rate control when other agents fail — last resort due to toxicity profile

Preferred over rate control for symptomatic patients, younger patients, HF with EF improvement expected

Cardioversion: If AFib <48h or adequately anticoagulated ≥3 weeks — DC cardioversion
If >48h without anticoagulation — TEE to rule out LAA thrombus before cardioversion
Anticoagulate ≥4 weeks after cardioversion regardless of CHA₂DS₂-VASc

Antiarrhythmic Drugs:
Flecainide/Propafenone: Only if no structural heart disease — pill-in-pocket or daily
Sotalol: Requires QTc monitoring — hospitalization for initiation
Dofetilide: Hospital initiation required — QTc monitoring
Amiodarone: Most effective but most toxic — thyroid, pulmonary, hepatic, ocular toxicity. Last resort for long-term use.

Catheter Ablation: Pulmonary vein isolation — refer to EP. First-line for symptomatic paroxysmal AFib in many patients.

AFib <48h: Can cardiovert without prolonged anticoagulation — anticoagulate post-cardioversion ≥4 weeks
AFib >48h or unknown duration: Anticoagulate ≥3 weeks before cardioversion OR TEE to exclude LAA thrombus → then cardiovert → then anticoagulate ≥4 weeks
Continue long-term anticoagulation based on CHA₂DS₂-VASc — not on whether in sinus rhythm

Normal: <120/<80
Elevated: 120-129/<80 — lifestyle modification
Stage 1: 130-139/80-89 — lifestyle ± medication based on CVD risk
Stage 2: ≥140/≥90 — lifestyle + medication
Hypertensive Urgency: >180/>120 without end-organ damage — oral agents, reduce over 24-48h
Hypertensive Emergency: >180/>120 WITH end-organ damage (encephalopathy, AKI, ACS, aortic dissection, eclampsia) — IV agents, ICU, reduce MAP by 25% in first hour

Thiazide Diuretics:
Chlorthalidone 12.5-25mg daily — preferred over HCTZ (longer acting, more CV evidence)
HCTZ 12.5-25mg daily — widely used, less CV outcome data
Indapamide 1.25-2.5mg daily

ACE Inhibitors:
Lisinopril 5-40mg daily · Enalapril 5-40mg daily · Ramipril 2.5-20mg daily
Preferred: DM with proteinuria, CKD, HFrEF, post-MI. Avoid in pregnancy. Monitor K+ and Cr. Cough 10-15% — switch to ARB.

ARBs (if ACEi not tolerated):
Losartan 25-100mg daily · Valsartan 80-320mg daily · Olmesartan 20-40mg daily · Irbesartan 150-300mg daily
Same indications as ACEi, no cough. Avoid in pregnancy.

Dihydropyridine CCBs:
Amlodipine 2.5-10mg daily — excellent tolerability, no monitoring needed. Good for elderly, African American patients, angina.
Nifedipine XL 30-90mg daily · Felodipine 2.5-10mg daily

Heart failure (HFrEF): ACEi/ARB/ARNI + beta-blocker + MRA + SGLT2i
Post-MI: Beta-blocker + ACEi/ARB + MRA
Diabetes + CKD/proteinuria: ACEi or ARB — slow CKD progression
Stable angina/CAD: Beta-blocker + CCB (amlodipine)
African American patients: Thiazide + CCB (ACEi less effective as monotherapy)
Elderly (isolated systolic HTN): Thiazide or CCB — amlodipine excellent choice
Pregnancy: Labetalol, Nifedipine XL, Methyldopa — avoid ACEi/ARB/direct renin inhibitors

Defined as BP above goal despite ≥3 medications at optimal doses (including diuretic)
First: Confirm adherence, rule out white coat, check 24h ABPM
Rule out secondary causes: Sleep apnea, renal artery stenosis, primary aldosteronism, pheochromocytoma, Cushing's
Add-on agents:
Spironolactone 25-50mg — most effective add-on for resistant HTN (especially primary aldosteronism)
Eplerenone 25-50mg — if spironolactone not tolerated
Hydralazine 10-50mg BID-TID — direct vasodilator, add with beta-blocker to prevent reflex tachycardia
Minoxidil — powerful, last resort, causes fluid retention and hirsutism
Clonidine 0.1-0.3mg BID — central alpha-2 agonist, discontinuation syndrome risk

Identify end-organ damage: Neuro exam, BMP, UA, troponin, EKG, CXR, fundoscopy
Target: Reduce MAP by no more than 25% in first hour, then to 160/100 over next 2-6h
Exception: Aortic dissection — target SBP <120 within 20 min (labetalol + nitroprusside)

IV agents by indication:
Labetalol — most indications, safe in pregnancy, avoid in severe asthma/bradycardia
Nicardipine — most indications, excellent titrability, preferred for stroke
Clevidipine — ultrashort acting CCB, very precise
Nitroprusside — most conditions, monitor for cyanide toxicity >72h
Hydralazine — pregnancy/eclampsia
Phentolamine — pheochromocytoma crisis

Life-threatening causes first (RSVP):
Rule out: ACS · Aortic dissection · PE · Tension pneumothorax · Esophageal rupture

Immediate: 12-lead EKG within 10 min · Troponin (high-sensitivity) · CXR · IV access · O₂ if SpO₂ <94% · ASA 325mg if ACS suspected

High-risk features: Radiation to arm/jaw, diaphoresis, N/V, ST changes, new LBBB, hemodynamic instability, known CAD

Immediate management (MONA-B):
Morphine — 2-4mg IV PRN for refractory pain (use cautiously)
Oxygen — if SpO₂ <90%
Nitrates — sublingual NTG q5 min × 3, then IV if persistent pain. Avoid if SBP <90, recent PDE5 inhibitor use, RV infarct.
Aspirin — 325mg PO stat, then 81mg daily indefinitely
Beta-blocker — oral within 24h if no contraindications (HR <60, SBP <90, AV block, decompensated HF, reactive airway)

Anticoagulation: Heparin UFH (see heparin protocol) or Enoxaparin 1mg/kg SQ q12h (adjust for renal function)

P2Y12 inhibitor: Ticagrelor 180mg load then 90mg BID (preferred) or Clopidogrel 600mg load then 75mg daily

Cardiology consult immediately — risk stratification, timing of cath

Goal: Door-to-balloon time <90 min
Activate cath lab immediately on EKG diagnosis
Criteria: ST elevation ≥1mm in ≥2 contiguous limb leads OR ≥2mm in ≥2 contiguous precordial leads OR new LBBB

Pre-cath medications:
ASA 325mg · Ticagrelor 180mg (preferred) or Clopidogrel 600mg · Heparin UFH bolus · Statin high-intensity

If PCI not available within 120 min: Fibrinolysis within 30 min of arrival — alteplase, reteplase, or tenecteplase
Fibrinolysis contraindications: Prior ICH, ischemic stroke <3 months, active bleeding, aortic dissection, BP >180/110 uncontrolled

Antiplatelet: ASA 81mg daily indefinitely. Dual antiplatelet (DAPT) after stent — duration depends on stent type and bleeding risk (typically 6-12 months).
Statin — high intensity: Atorvastatin 40-80mg or Rosuvastatin 20-40mg. Target LDL <70 mg/dL (very high risk: <55).
Beta-blocker: Post-MI × ≥3 years (indefinitely if HFrEF). For angina symptom control.
ACE inhibitor/ARB: Post-MI with EF <40%, DM, HTN, CKD.
Nitrates: SL NTG PRN for angina. Long-acting nitrate for chronic angina — nitrate-free interval required to prevent tolerance.
Ranolazine: Add-on for refractory angina — does not affect HR or BP.

BP: <130/80 mmHg
LDL: <70 mg/dL (established CAD) · <55 mg/dL (very high risk, recurrent events)
HbA1c: <7% (individualized — <8% if elderly/comorbid)
Smoking: Complete cessation — single most impactful intervention
Weight: BMI <25, waist <40" men / <35" women
Exercise: 150 min/week moderate intensity
Cardiac rehab: After MI, revascularization, or HF — significantly reduces mortality

High intensity (↓LDL ≥50%): Atorvastatin 40-80mg · Rosuvastatin 20-40mg
Moderate intensity (↓LDL 30-50%): Atorvastatin 10-20mg · Rosuvastatin 5-10mg · Simvastatin 20-40mg · Pravastatin 40-80mg · Lovastatin 40mg
Low intensity: Simvastatin 10mg · Pravastatin 10-20mg · Lovastatin 20mg

Monitor: LFTs at baseline (not routinely after). CK if myalgias. Avoid high-dose simvastatin with many drugs (CYP3A4 interactions). Avoid in pregnancy.

Cardioselective (β1): Metoprolol, Atenolol, Bisoprolol, Nebivolol — safer in mild asthma/COPD
Non-selective: Carvedilol (α+β), Propranolol, Labetalol (α+β IV)

Uses: HTN · Angina · HFrEF (carvedilol, metoprolol succinate, bisoprolol) · Post-MI · Rate control AFib · Anxiety/tremor (propranolol)

Contraindications: Severe bradycardia · High-degree AV block · Decompensated HF · Cardiogenic shock · Severe reactive airway disease
Do NOT abruptly discontinue — rebound angina/MI risk

ACEi: Cough in 10-15%, angioedema rare but serious. Monitor K+ and Cr within 1-2 weeks of start/change. Avoid in pregnancy, bilateral renal artery stenosis.
ARBs: No cough, lower angioedema risk. Same monitoring and contraindications as ACEi. Do NOT combine ACEi + ARB.
ARNI (Entresto): Superior to ACEi in HFrEF. 36h washout from ACEi before starting. Hypotension common — start low. Monitor K+ and Cr.

Hyperkalemia management with RAASi:
K+ 5.0-5.5: Reduce dose, dietary counseling
K+ >5.5: Hold drug, treat hyperkalemia, reassess
Patiromer (Veltassa) or Sodium zirconium cyclosilicate (Lokelma) — potassium binders enabling continuation of RAASi

Loop diuretics: Furosemide · Torsemide (better bioavailability) · Bumetanide
Monitor: K+, Na+, Cr, Mg. Replace K+ and Mg proactively.

Thiazides: Chlorthalidone · HCTZ — less potent than loops, good for HTN
Potassium-sparing: Spironolactone · Eplerenone — MRAs, add-on in HFrEF and resistant HTN
Carbonic anhydrase inhibitors: Acetazolamide — used in acute decompensated HF with metabolic alkalosis (diuretic resistance)

Diuretic resistance: Check adherence · IV rather than PO · Switch furosemide to torsemide · Add metolazone 30 min before loop · Continuous infusion

Aspirin: 81mg daily — irreversible COX inhibitor. Standard secondary prevention.
Clopidogrel (Plavix): 75mg daily — prodrug, CYP2C19 metabolism (poor metabolizers have reduced effect). Use if ASA intolerant or with ASA for DAPT.
Ticagrelor (Brilinta): 90mg BID — more potent, faster onset, reversible. Preferred over clopidogrel for ACS. Causes dyspnea in ~15%.
Prasugrel (Effient): 10mg daily — most potent P2Y12 inhibitor. Avoid if age ≥75, weight <60kg, prior stroke/TIA. PCI only.

DAPT duration: Bare metal stent ≥1 month · Drug eluting stent 6-12 months · ACS 12 months minimum

High risk: Amiodarone · Sotalol · Dofetilide · Dronedarone · Quinidine · Procainamide
Monitor QTc at baseline and with dose changes. Avoid combinations. Correct electrolytes (K+, Mg).
Threshold for concern: QTc >500ms or increase >60ms from baseline → consider dose reduction or discontinuation
Check crediblemeds.org for complete drug interaction database

Personality disorders are enduring patterns of inner experience and behavior that deviate markedly from cultural expectations, are pervasive and inflexible, cause significant distress or impairment, and are stable since adolescence or early adulthood.

DSM-5 Clusters:
Cluster A (Odd/Eccentric): Paranoid · Schizoid · Schizotypal
Cluster B (Dramatic/Emotional): Antisocial · Borderline · Histrionic · Narcissistic
Cluster C (Anxious/Fearful): Avoidant · Dependent · Obsessive-Compulsive

Personality disorders are frequently comorbid with Axis I disorders (depression, anxiety, substance use) and significantly affect treatment response and prognosis.

Core features: Fear of abandonment · Unstable relationships (idealization/devaluation) · Unstable self-image · Impulsivity · Self-harm or suicidal behavior · Emotional dysregulation · Chronic emptiness · Inappropriate anger · Transient paranoia or dissociation
Diagnosis requires ≥5 of 9 criteria, present across contexts

Treatment — Psychotherapy is First Line:
DBT (Dialectical Behavior Therapy) — gold standard. Skills training: mindfulness, distress tolerance, emotional regulation, interpersonal effectiveness.
MBT (Mentalization-Based Treatment) — strong evidence
Schema Therapy — effective for longer-term restructuring

Pharmacotherapy (adjunctive only — no FDA-approved medication for BPD):
Emotional dysregulation/mood instability: Lamotrigine 50-200mg · Valproate 500-1500mg · Topiramate
Impulsivity/aggression: Mood stabilizers as above · Low-dose atypical antipsychotics (Quetiapine 25-100mg, Olanzapine 2.5-10mg)
Depression/anxiety: SSRIs (modest benefit) — Fluoxetine, Sertraline
Psychosis/severe dissociation: Low-dose antipsychotics
Avoid: Benzodiazepines (behavioral disinhibition, dependence risk) · High-dose antipsychotics without clear indication · Polypharmacy

Clinical pearls: Suicidal behavior in BPD is often communicative — assess carefully but avoid reinforcing behavior with disproportionate hospitalization. Consistency, limit-setting, and therapeutic relationship are critical. Avoid splitting between providers.

Core features: Grandiosity · Need for admiration · Lack of empathy · Entitlement · Exploitative relationships · Envy · Arrogance · Fantasy of unlimited success/power
Diagnosis requires ≥5 of 9 criteria

Underlying fragile self-esteem beneath grandiose presentation — narcissistic injury triggers rage or shame

Treatment:
Psychotherapy is primary — long-term psychodynamic or schema therapy
No FDA-approved medication. Treat comorbid depression, anxiety, substance use.
SSRIs for comorbid depression/anxiety
Mood stabilizers if significant irritability or rage episodes

Clinical pearls: Patients rarely present for NPD itself — come for depression, relationship problems, or "everyone else is the problem." Avoid confrontation — use collaborative, curious approach. Flattery and appeals to their expertise can improve engagement.

Core features: Disregard for rights of others · Deceitfulness · Impulsivity · Irritability/aggression · Reckless disregard for safety · Irresponsibility · Lack of remorse
Requires age ≥18 + evidence of conduct disorder before age 15

Treatment:
Most difficult personality disorder to treat — limited evidence base
Contingency management — behavioral approaches
Treat comorbid substance use disorder aggressively (high prevalence)
Mood stabilizers for impulsivity/aggression: Valproate, Lithium
Avoid controlled substances — high abuse potential

Clinical pearls: Document carefully. Maintain firm professional boundaries. Do not be manipulated into prescribing controlled substances. Safety assessment is critical — assess for violence risk, not just suicide.

Avoidant PD: Social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation. Distinguished from social anxiety by pervasiveness and ego-syntonic nature.
Treatment: SSRIs · CBT with exposure · Social skills training

Dependent PD: Excessive need to be taken care of, submissive behavior, clinging, fear of separation.
Treatment: Psychotherapy (CBT, psychodynamic) — build autonomy. SSRIs for comorbid anxiety/depression.

Obsessive-Compulsive PD (OCPD — NOT OCD): Preoccupation with orderliness, perfectionism, mental and interpersonal control at expense of flexibility. Ego-syntonic (unlike OCD which is ego-dystonic).
Treatment: Psychotherapy. SSRIs for comorbid anxiety or depression. Distinguish from OCD — treatment differs.

Paranoid PD: Pervasive distrust and suspiciousness. Interprets motives as malevolent. Not delusional — distinguishes from paranoid schizophrenia.
Treatment: Individual therapy (supportive, CBT). Low-dose antipsychotics for severe suspiciousness. Therapeutic alliance very difficult to establish.

Schizoid PD: Detachment from social relationships, restricted emotional expression. Prefers solitary activities. No psychosis.
Treatment: Psychotherapy if patient willing (rare). No medication indicated unless comorbid condition.

Schizotypal PD: Social/interpersonal deficits + cognitive/perceptual distortions + eccentric behavior. Considered on schizophrenia spectrum — increased genetic risk.
Treatment: Low-dose antipsychotics for perceptual distortions/odd thinking. SSRIs for anxiety/depression. Supportive therapy.

Psychotherapy is the primary treatment for all personality disorders — medications treat symptoms and comorbidities, not the disorder itself
Long-term treatment required — personality change is slow
Treat comorbid Axis I disorders — depression, anxiety, substance use are common and affect prognosis
Consistency and therapeutic alliance are the most powerful treatment tools
Avoid polypharmacy — resist pressure to add medications for every symptom
Document risk assessments carefully — personality disorders carry elevated suicide and violence risk
Coordinate care — communicate with therapists and other providers
Know your limits — refer to psychiatry for complex or high-risk cases

Criterion A — Traumatic Event Exposure (1 required)
Direct experience of death, threatened death, serious injury, or sexual violence
Witnessing such events in person
Learning that a close family member or friend experienced such events
Indirect exposure to traumatic details (first responders, clinicians)

Criterion B — Intrusion Symptoms (1+ required)
1. Recurrent, involuntary, intrusive distressing memories
2. Recurrent distressing dreams related to the trauma
3. Dissociative reactions (flashbacks) — feeling the trauma is recurring
4. Intense psychological distress at trauma cues
5. Marked physiological reactions to trauma cues

Criterion C — Avoidance (1+ required)
1. Avoidance of distressing trauma-related thoughts or feelings
2. Avoidance of external reminders (people, places, activities, situations)

Criterion D — Negative Cognitions and Mood (2+ required)
1. Inability to remember important aspects of the traumatic event
2. Persistent negative beliefs about self, others, or the world
3. Persistent distorted blame of self or others
4. Persistent negative emotional state (fear, horror, anger, guilt, shame)
5. Markedly diminished interest or participation in activities
6. Feelings of detachment or estrangement from others
7. Persistent inability to experience positive emotions

Criterion E — Alterations in Arousal and Reactivity (2+ required)
1. Irritable behavior or angry outbursts
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle response
5. Difficulty concentrating
6. Sleep disturbance

Criterion F: Duration >1 month
Criterion G: Clinically significant distress or functional impairment
Criterion H: Not attributable to substances or medical condition

Specifiers: With dissociative symptoms (depersonalization/derealization) · With delayed expression (full criteria not met until ≥6 months after event)

First-Line Psychotherapy: Prolonged Exposure (PE) · Cognitive Processing Therapy (CPT) · EMDR
First-Line Medications (FDA approved): Sertraline · Paroxetine
Also used: Venlafaxine · Prazosin (nightmares) · Mirtazapine
Avoid: Benzodiazepines — may impair trauma processing and increase dependence
PCL-5 cutoff ≥33 suggests probable PTSD · Use for monitoring treatment response

Criterion A — Obsessions, Compulsions, or Both

Obsessions defined by both:
1. Recurrent, persistent thoughts, urges, or images that are experienced as intrusive and unwanted and cause anxiety or distress
2. The person attempts to ignore, suppress, or neutralize them with another thought or action (compulsion)

Compulsions defined by both:
1. Repetitive behaviors (handwashing, ordering, checking) or mental acts (praying, counting, repeating words) the person feels driven to perform in response to an obsession or rigid rules
2. The behaviors are aimed at preventing distress or a feared event but are not realistically connected or are clearly excessive

Criterion B: Time consuming (>1 hour/day) OR cause significant distress or functional impairment
Criterion C: Not attributable to substances or medical condition
Criterion D: Not better explained by another mental disorder

Specifiers:
Good/fair insight — recognizes beliefs are probably not true
Poor insight — thinks beliefs are probably true
Absent insight/delusional — completely convinced beliefs are true
Tic-related — current or past tic disorder

Common Obsession Themes: Contamination · Harm · Symmetry/order · Forbidden/taboo thoughts · Religious/moral (scrupulosity)
Common Compulsions: Cleaning/washing · Checking · Ordering/arranging · Counting · Mental rituals · Seeking reassurance

First-Line: ERP (Exposure and Response Prevention) — most effective
First-Line Medications: SSRIs at higher doses than depression — Fluvoxamine, Fluoxetine, Sertraline, Paroxetine, Escitalopram
Note: OCD requires higher SSRI doses and longer trials (10-12 weeks) than depression
Second-Line: Clomipramine (TCA) — effective but more side effects
Augmentation: Antipsychotics (aripiprazole, risperidone) for partial SSRI response
Y-BOCS for severity rating and treatment monitoring

Criterion A: Recurrent unexpected panic attacks — abrupt surge of intense fear or discomfort peaking within minutes with ≥4 of:

1. Palpitations, pounding heart, or rapid heart rate
2. Sweating
3. Trembling or shaking
4. Shortness of breath or smothering sensation
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Dizziness, unsteadiness, lightheadedness, or faintness
9. Chills or hot flashes
10. Paresthesias (numbness or tingling)
11. Derealization or depersonalization
12. Fear of losing control or "going crazy"
13. Fear of dying

Criterion B: ≥1 month of either or both:
Persistent concern or worry about additional attacks or their consequences
Significant maladaptive behavioral change related to attacks (avoidance)

Criterion C: Not attributable to substances or medical condition
Criterion D: Not better explained by another mental disorder

Rule Out Medical Causes First:
Cardiac arrhythmia · Hyperthyroidism · Hypoglycemia · Pheochromocytoma · Seizure disorder · Vestibular disorders · Pulmonary embolism · Stimulant/caffeine use

Specifier: With agoraphobia (fear/avoidance of situations where escape might be difficult)

First-Line: CBT with interoceptive exposure · SSRIs (Sertraline, Escitalopram, Paroxetine) · SNRIs (Venlafaxine XR)
Adjunct short-term: Benzodiazepines for bridging only — avoid long-term
Avoid: Caffeine, stimulants, decongestants
Psychoeducation: Explain the physiology of panic — fight-or-flight response, not dangerous

Criterion A: Depressed mood most of the day, more days than not, for ≥2 years (≥1 year in children/adolescents)

Criterion B: ≥2 of the following while depressed:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness

Criterion C: During the 2-year period, never without symptoms for more than 2 months at a time
Criterion D: Criteria for MDD may be continuously present for 2 years
Criterion E: No manic or hypomanic episodes, no cyclothymia
Criterion F: Not better explained by schizoaffective disorder, schizophrenia, or psychotic disorder
Criterion G: Not attributable to substances or medical condition
Criterion H: Clinically significant distress or functional impairment

Specifiers:
With pure dysthymic syndrome — MDD criteria not met in last 2 years
With persistent MDD — full MDD criteria met throughout the 2-year period
With intermittent MDD episodes — currently in episode
With intermittent MDD episodes — currently not in episode
Early onset (<21 years) vs late onset (≥21 years)

Double Depression: MDD superimposed on PDD — common, associated with worse prognosis and more chronic course

Medications: SSRIs · SNRIs · Bupropion — same agents as MDD, may require longer treatment
Psychotherapy: CBT · Interpersonal therapy (IPT) · CBASP (Cognitive Behavioral Analysis System — designed specifically for chronic depression)
Combined treatment superior to either alone for chronic depression
Note: PDD is often underdiagnosed — patients may consider chronic low mood their "baseline personality" rather than a treatable condition. Psychoeducation is essential.

Criterion A: Emotional or behavioral symptoms in response to an identifiable stressor developing within 3 months of onset of stressor

Criterion B: Either or both:
1. Marked distress out of proportion to the severity of the stressor (considering cultural and contextual factors)
2. Significant impairment in social, occupational, or other functioning

Criterion C: Not better explained by another mental disorder and not exacerbation of a preexisting disorder
Criterion D: Does not represent normal bereavement
Criterion E: Once stressor or its consequences end, symptoms do not persist more than 6 additional months

Specifiers (subtypes):
309.0 — With depressed mood
309.24 — With anxiety
309.28 — With mixed anxiety and depressed mood
309.3 — With disturbance of conduct
309.4 — With mixed disturbance of emotions and conduct
309.9 — Unspecified

Acute: Symptoms <6 months
Persistent/Chronic: Symptoms ≥6 months (stressor has prolonged consequences)

Common Stressors: Medical diagnosis · Relationship loss · Job loss · Financial stress · Natural disaster · Major life transition · Bereavement (when exceeds normal grief)

First-Line: Psychotherapy — supportive therapy, CBT, problem-solving therapy
Medications: Consider short-term SSRI or SNRI if significant distress or impairment · Short-term anxiolytic if severe anxiety
Prognosis: Generally favorable — most resolve when stressor resolves
Reassess: If symptoms persist beyond expected timeframe or worsen — reconsider diagnosis (MDD, PTSD, anxiety disorder)
Clinical Pearl: Adjustment disorder with depressed mood is frequently misdiagnosed as MDD — verify that symptoms are clearly linked to an identifiable stressor and would not meet full MDD criteria independently

Criterion A: One or more somatic symptoms that are distressing or result in significant disruption of daily life

Criterion B: Excessive thoughts, feelings, or behaviors related to somatic symptoms or associated health concerns as manifested by ≥1 of:
1. Disproportionate and persistent thoughts about the seriousness of symptoms
2. Persistently high level of anxiety about health or symptoms
3. Excessive time and energy devoted to these symptoms or health concerns

Criterion C: Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically >6 months)

Specifiers:
With predominant pain (previously pain disorder)
Persistent — severe symptoms, marked impairment, long duration (>6 months)
Mild / Moderate / Severe based on number of Criterion B symptoms

Related Disorders:
Illness Anxiety Disorder (300.7): High illness anxiety with minimal or no somatic symptoms · Preoccupied with having or acquiring a serious illness · Medical care seeking or avoidance
Functional Neurological Symptom Disorder (300.11): Neurological symptoms (weakness, paralysis, seizures, sensory loss) inconsistent with neurological disease
Psychological Factors Affecting Medical Condition: Medical symptom influenced by psychological or behavioral factors

Clinical Pearls:
Never dismiss symptoms — they are real to the patient and cause real distress
Avoid excessive testing — reinforces illness behavior and catastrophizing
Validate experience: "I believe you are suffering. Let's work together on what helps you function."
Shift focus from symptoms to functioning
Consistent care with single provider reduces unnecessary testing

Treatment:
CBT — most evidence-based treatment
Mindfulness-based therapy
SSRIs or SNRIs — may help if comorbid depression or anxiety
Avoid opioids and benzodiazepines
Scheduled visits — not PRN, reduces symptom-driven care seeking
Coordinate with primary care and specialists

Addiction is a chronic brain disorder — not a moral failing or lack of willpower.
Treatment works and recovery is possible at any stage.
Relapse is part of the disease — not treatment failure.
The goal is long-term remission and improved functioning, not just abstinence.
Co-occurring psychiatric disorders are the rule, not the exception — treat both simultaneously.

Precontemplation — not considering change. Does not see use as a problem. Plant a seed. "I am worried about how this is affecting your health."

Contemplation — ambivalent. Use motivational interviewing. "What would be different in your life if you cut back or stopped?"

Preparation — ready to change soon. Make a concrete plan. Discuss treatment options and medications.

Action — actively making changes. Support, encourage, connect to resources. Start medications if appropriate.

Maintenance — sustaining change. Focus on relapse prevention, coping skills, support systems.

Relapse — return to use. Normalize. Assess triggers. Re-engage treatment. Never punish or shame.

The spirit: collaboration, evocation, and autonomy. The goal is to elicit change talk from the patient — not convince them.

Open-ended questions — "What concerns do you have about your use?"
Affirmations — "It took courage to talk about this today."
Reflective listening — "It sounds like you feel stuck between wanting to change and not being ready."
Summaries — "Let me make sure I understand what you have shared with me."

People are more likely to act on their own reasons for change than on yours.

MAT is the gold standard — reduces mortality, overdose, and disease transmission. Withholding MAT is undertreated illness.

Buprenorphine/Naloxone (Suboxone) — First-line outpatient. Partial opioid agonist. Any DEA-registered provider can now prescribe (X-waiver eliminated 2023). Start 8-16mg SL daily. Ceiling effect reduces overdose risk.

Methadone — Full agonist. Highly effective for severe OUD. Dispensed only through certified OTPs daily. Best for high tolerance or failed buprenorphine.

Naltrexone (Vivitrol) — Opioid antagonist. Monthly IM injection. No abuse potential. Requires full detox first — precipitates withdrawal if opioids present. Best for highly motivated patients.

Naltrexone — First-line. Reduces craving and reward. 50mg PO daily or 380mg IM monthly. Avoid if active opioid use or liver failure.

Acamprosate — First-line. Reduces protracted withdrawal symptoms. 666mg TID. Renally cleared — safe in liver disease.

Disulfiram — Aversive therapy. Causes severe reaction with alcohol. Requires motivation and supervised administration. Not first-line.

Gabapentin — Off-label, evidence-based. 300-600mg TID for withdrawal and craving reduction.

Topiramate — Off-label. Evidence for reducing heavy drinking days.

Alcohol — Can be fatal. Seizures 24-48 hours. DTs 48-96 hours. Use CIWA-Ar. Benzodiazepines standard of care. Thiamine 100mg IV/IM before any glucose — prevent Wernicke encephalopathy.

Opioids — Rarely fatal but drives continued use. Buprenorphine initiated during withdrawal dramatically improves retention. Clonidine for autonomic symptoms.

Benzodiazepines — Potentially fatal. Never abruptly stop. Taper slowly using long-acting agent (diazepam, clonazepam).

Stimulants — Not medically dangerous. Intense dysphoria, fatigue, depression. Monitor for suicidal ideation during crash.

Cannabis — Irritability, insomnia, anxiety. Uncomfortable but not dangerous. Supportive care.

CBT — Identifies triggers, builds coping skills. Strong evidence across all SUDs.
Motivational Enhancement Therapy — Structured MI-based. 2-4 sessions. Evidence for alcohol, cannabis, stimulants.
Contingency Management — Tangible rewards for negative drug screens. Strongest evidence for stimulants. Highly effective and underutilized.
12-Step Facilitation — AA/NA/CA. Free, widely available, peer support. Most effective combined with professional treatment.
SMART Recovery — Science-based, secular alternative to 12-step.
DBT — Especially useful for co-occurring BPD and SUD.

Level 0.5 — Early intervention. Brief counseling in primary care.
Level 1 — Outpatient. <9 hours/week. Therapy plus medication management.
Level 2.1 — Intensive Outpatient (IOP). 9+ hours/week. Patient lives at home.
Level 2.5 — Partial Hospitalization (PHP). 20+ hours/week. More intensive structure.
Level 3.1-3.5 — Residential. 24-hour structured living. Varying intensity.
Level 4 — Medically Managed Inpatient. Hospital-based. Severe withdrawal, medical or psychiatric instability.

Harm reduction meets patients where they are. Not everyone is ready for abstinence — reducing harm is a legitimate and life-saving goal.

Naloxone — Prescribe to every patient with OUD or high-dose opioid use. Train patient and family. Available OTC in most states.
Fentanyl test strips — Help patients test supply. Evidence shows they reduce overdose deaths.
Needle exchange — Reduces HIV and hepatitis C transmission. Refer to local programs.
Never use alone — Fentanyl has made even experienced users vulnerable to fatal overdose from a single dose.

Recovery capital — the resources that support sustained recovery.
Internal: Coping skills · Self-efficacy · Hope · Meaning framework
External: Safe housing · Employment · Supportive relationships · Sober social network · Healthcare access

Language matters — use person-first non-stigmatizing terms:
✓ "Person with opioid use disorder" — not "addict" or "junkie"
✓ "Positive drug screen" — not "dirty urine"
✓ "Substance use disorder" — not "substance abuse"
✓ "Died of overdose" — not "overdosed"
✓ "Medication for opioid use disorder" — not "medication-assisted treatment"

Language shapes how patients feel about themselves and how likely they are to seek help.

Step 1 — Open the door
"Sometimes when people are going through a hard time they have thoughts of not wanting to be here anymore. Have you had any thoughts like that?"
"Have you had any thoughts of death or dying recently?"

Step 2 — Clarify ideation type
"Are these passive thoughts — like wishing you wouldn't wake up — or active thoughts of ending your life?"
"How often are you having these thoughts?"
"How intense are they on a scale of 1 to 10?"

Step 3 — Assess plan
"Have you thought about how you would do it?"
"Do you have a specific plan?"

Step 4 — Assess intent and timeline
"Do you have any intention of acting on these thoughts?"
"Have you set a time or date?"

Step 5 — Assess means
"Do you have access to weapons, medications, or other means?"
"Is there anyone in your home with firearms?"

Step 6 — Assess history
"Have you ever attempted suicide before?"
"Has anyone in your family died by suicide?"

Step 7 — Protective factors
"What has stopped you from acting on these thoughts?"
"What gives you a reason to stay alive — family, children, faith, future plans?"
"Who can you call if the thoughts get worse?"

Columbia Suicide Severity Rating (C-SSRS) Categories
1 — Wish to be dead
2 — Suicidal ideation without plan or intent
3 — Active SI with some plan
4 — Active SI with specific plan and intent
5 — Active SI with intent and timeline — highest acuity

"Have you had any thoughts of hurting or harming someone else?"
"Is there a specific person you have been thinking about harming?"
"Have you made any plans to act on these thoughts?"
"Do you have access to weapons or means to carry this out?"
"What has stopped you from acting on these thoughts?"

Tarasoff Duty to Warn
If patient has identified target, specific plan, and means — duty to warn applies in most states. Document thoroughly. Notify supervisor. Contact intended victim and law enforcement as appropriate. Consider involuntary hold.

High Risk: Active SI with plan, intent, means, or timeline · Prior attempt · Recent major loss · Command hallucinations · Active psychosis · Substance intoxication · Limited protective factors → Emergency evaluation / hospitalization

Moderate Risk: Active SI without clear plan · Some intent · Chronic ideation with recent worsening · Limited support → Urgent psychiatric evaluation · Safety plan · Means restriction · Close follow-up

Lower Risk: Passive ideation · No plan or intent · Strong protective factors · Good therapeutic alliance → Outpatient management · Safety plan · Crisis resources · Documented assessment

"I ask all of my patients about substance use because it can affect your health and any medications I prescribe. Is it okay if I ask you a few questions?"
"Do you drink alcohol? How much and how often?"
"Do you use any recreational drugs or substances — marijuana, cocaine, opioids, stimulants, or anything else?"
"Do you use any prescription medications in a way other than prescribed?"

CAGE Questions
"Have you ever felt you should Cut down on your drinking?"
"Have people Annoyed you by criticizing your drinking?"
"Have you ever felt bad or Guilty about your drinking?"
"Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?"

Quantity/Frequency
"How many days per week do you drink?"
"On a typical day when you drink, how many drinks do you have?"
"What is the most you have had in a single day?"

Dependence Screen
"Have you ever experienced withdrawal — sweating, tremors, seizures, or DTs when you stop drinking?"
"Do you need to drink more than you used to to feel the same effect?"
"Do you drink to avoid feeling sick or shaky?"

"Do you use any opioids — prescription pain medications, heroin, or fentanyl?"
"How are you using them — oral, intranasal, injecting?"
"How often and how much?"
"Have you ever overdosed or been given Narcan?"
"Have you ever tried to cut down or stop and couldn't?"
"Have you experienced withdrawal — muscle cramps, sweating, nausea, diarrhea, restlessness?"
"Would you be interested in medication-assisted treatment like buprenorphine?"

Stimulants (cocaine, methamphetamine, Adderall misuse)
"Do you use cocaine, methamphetamine, or stimulants?"
"How often? How do you use them?"
"Have you noticed heart palpitations, chest pain, or paranoia when using?"

Cannabis
"Do you use marijuana or cannabis products?"
"How often — daily, weekly?"
"Has it affected your motivation, memory, or functioning?"
"Have you experienced anxiety, paranoia, or psychotic symptoms from cannabis?"

Benzodiazepines / Sedatives
"Do you take benzodiazepines or sleeping pills? Are they prescribed?"
"Have you ever taken more than prescribed or run out early?"
"Have you tried to stop and had difficulty?"

Impact and Readiness
"How has your substance use affected your life — relationships, work, health, legal issues?"
"Have you ever wanted to cut down or stop?"
"On a scale of 1-10 how ready are you to make a change?"

Always explain why you are asking. Never require disclosure. Follow the patient's lead.

"As part of your mental health assessment I ask everyone about difficult or traumatic experiences. This helps me understand what you have been through and provide better care. You do not have to share anything you are not comfortable with. Is it okay if I ask you a few questions?"

"Have you ever experienced or witnessed something that was very frightening, overwhelming, or life-threatening?"
"Have you ever been in a serious accident, natural disaster, or war?"
"Have you ever been physically harmed or threatened with harm?"
"Have you ever experienced unwanted sexual contact or assault?"
"Have you ever witnessed violence — including in your home growing up?"
"Have you experienced the sudden unexpected death of someone close to you?"
"Is there anything else that has happened to you that still bothers you when you think about it?"

Intrusion
"Do you have unwanted memories, flashbacks, or nightmares about what happened?"
"Do you ever feel as if the traumatic event is happening again?"
"Do certain things trigger intense distress or physical reactions — sounds, smells, places?"

Avoidance
"Do you avoid thinking or talking about what happened?"
"Do you avoid people, places, or situations that remind you of it?"

Negative Cognitions and Mood
"Since the trauma have you had negative beliefs about yourself — like it was your fault, or that you are damaged or worthless?"
"Have you lost interest in things you used to enjoy?"
"Do you feel distant or cut off from people you care about?"
"Do you have difficulty experiencing positive emotions?"

Hyperarousal
"Are you easily startled or always on guard — like waiting for something bad to happen?"
"Do you have trouble sleeping or concentrating?"
"Do you find yourself becoming irritable or having angry outbursts?"

Duration and Impact
"How long have you been experiencing these symptoms?"
"How much are these symptoms affecting your daily life, relationships, or work?"

Safety: Create a physically and emotionally safe environment. Explain what you are doing before doing it. Ask permission.
Trustworthiness: Be transparent. Follow through on what you say. Maintain confidentiality.
Choice: Offer options. Respect patient decisions. Never force disclosure.
Collaboration: Work with the patient, not on the patient.
Empowerment: Recognize strengths. Validate experiences. Build on resilience.

Evidence-Based Treatments for PTSD:
Prolonged Exposure (PE) · Cognitive Processing Therapy (CPT) · EMDR
Medications: Sertraline or Paroxetine (FDA approved) · Venlafaxine · Prazosin for nightmares
Avoid benzodiazepines — may interfere with trauma processing

Eating disorders have the highest mortality of any psychiatric illness. Ask directly. Use neutral, non-shaming language. Avoid commenting on weight or appearance.

"I would like to ask you a few questions about your eating and relationship with food. This is something I ask all patients as part of a complete assessment."

"Do you make yourself Sick because you feel uncomfortably full?"
"Do you worry that you have lost Control over how much you eat?"
"Have you recently lost more than One stone (14 lbs) in a 3-month period?"
"Do you believe yourself to be Fat when others say you are too thin?"
"Would you say that Food dominates your life?"

≥2 yes answers = positive screen → further evaluation needed

Restriction / Anorexia
"Can you walk me through what you typically eat in a day?"
"Do you avoid certain foods or entire food groups?"
"How much time do you spend thinking about food, calories, or your weight?"
"How do you feel about your body and weight right now?"
"Have others expressed concern about how little you are eating?"

Bingeing / Bulimia
"Have you had episodes of eating a very large amount of food in a short period of time — more than most people would eat?"
"During those episodes did you feel like you couldn't stop or control what or how much you were eating?"
"After eating have you ever made yourself vomit, used laxatives, exercised excessively, or fasted to compensate?"

Medical Complications Screen
"Have you noticed any physical symptoms — weakness, dizziness, irregular heartbeat, hair loss, cold intolerance, dental problems, swollen glands in your jaw?"
"Have your periods become irregular or stopped?"

Psychological
"How much does your weight or shape affect how you feel about yourself?"
"Do you ever feel disgusted, ashamed, or guilty after eating?"
"Have you avoided social situations because of food?"

Labs: BMP (electrolytes — hypokalemia in purging), CBC, LFTs, TSH, glucose, phosphorus, magnesium, prealbumin
EKG: QTc prolongation, bradycardia — especially in anorexia
Vital signs: Bradycardia, hypotension, hypothermia — signs of medical instability
BMI <15: Consider inpatient medical stabilization
Refeeding syndrome risk: Hypophosphatemia, cardiac arrhythmia — monitor closely when reintroducing nutrition

Treatment Resources:
National Alliance for Eating Disorders Helpline: 1-866-662-1235
Higher levels of care: Residential, PHP, IOP programs — refer early
Team approach: NP + therapist + dietitian + psychiatrist

Before Starting:
BMP — baseline renal function (lithium is renally cleared)
TSH — baseline thyroid (lithium causes hypothyroidism)
CBC — baseline
Urinalysis — baseline renal
Pregnancy test if applicable — lithium is teratogenic (Ebstein anomaly risk)
EKG — if cardiac history or age >50
Weight/BMI — baseline

After Starting — Frequency:
Lithium level: 5-7 days after initiation or dose change · Draw 12 hours after last dose (trough)
BMP + lithium level: Every 1-2 weeks during titration
Once stable: Lithium level + BMP + TSH every 3-6 months
Long-term (>5 years): Renal function every 6 months — lithium nephropathy risk

Target Levels:
Acute mania: 0.8-1.2 mEq/L
Maintenance: 0.6-0.8 mEq/L (lower in elderly)
Toxicity risk: >1.5 mEq/L (mild) · >2.0 mEq/L (severe)

Toxicity Signs: Tremor · Nausea/vomiting · Diarrhea · Confusion · Ataxia · Slurred speech · Seizure · Coma

Drug Interactions That Raise Lithium Levels:
NSAIDs · Thiazide diuretics · ACE inhibitors/ARBs · Low-sodium diet · Dehydration

Hypothyroidism: Occurs in up to 40% on long-term lithium — monitor TSH every 6 months · Treat with levothyroxine if develops — lithium does not need to be stopped

When to Order in Psychiatry:
Baseline before starting lithium, quetiapine, or any mood stabilizer
New onset depression — hypothyroidism mimics depression perfectly
Treatment-resistant depression — hypothyroidism is a common reversible cause
New onset anxiety or panic — hyperthyroidism can cause anxiety, tachycardia, panic
New onset psychosis — thyroid storm can cause psychotic symptoms
Cognitive decline — hypothyroidism commonly overlooked cause
Rapid cycling bipolar — thyroid dysfunction accelerates cycling
Postpartum mood disorders — postpartum thyroiditis common

Labs:
TSH — first-line screen (most sensitive)
Free T4 — order if TSH abnormal
Free T3 — order if hyperthyroidism suspected with normal T4
TPO antibodies — if Hashimoto's suspected (elevated TSH + positive antibodies)
TRAb/TSI — if Graves' disease suspected

Reference Ranges:
TSH: 0.4-4.0 mIU/L (some labs 0.5-4.5)
Subclinical hypothyroidism: TSH 4.0-10.0 with normal Free T4
Overt hypothyroidism: TSH >10 OR elevated TSH + low Free T4

Monitoring on Lithium: TSH at baseline, 3 months, then every 6 months
Monitoring on Amiodarone: TSH every 3-6 months — causes both hyper and hypothyroidism

Renal Function — Key Drugs Requiring Monitoring:
Lithium: CrCl or eGFR at baseline and every 6 months · Reduce dose or avoid if eGFR <30
Gabapentin/Pregabalin: Dose-adjust for eGFR <60 · Can accumulate and cause sedation/toxicity
Topiramate: Renal stones risk — urinalysis, hydration counseling
Memantine: Reduce dose if CrCl <30

Hepatic Function — Key Drugs Requiring LFT Monitoring:
Valproate/Divalproex: LFTs at baseline, 1 month, then every 6-12 months · AST/ALT elevation common but usually benign · Rare severe hepatotoxicity — stop if >3x ULN with symptoms
Carbamazepine: LFTs + CBC at baseline and regularly · Also CBC for agranulocytosis risk · Check HLA-B*1502 before starting in Asian patients (Stevens-Johnson risk)
MAOIs: LFTs at baseline and periodically
Duloxetine: Avoid in hepatic impairment · LFTs if clinical concern
Nefazodone: Black box warning for liver failure — LFTs required

Metabolic Monitoring — Antipsychotics:
Fasting glucose + HbA1c · Fasting lipids · Weight/BMI · Waist circumference
Frequency: Baseline → 1 month → 3 months → then annually
Highest metabolic risk: Clozapine · Olanzapine · Quetiapine
Lower metabolic risk: Aripiprazole · Ziprasidone · Lurasidone

Clozapine Specific:
ANC required before every prescription — REMS program mandatory
ANC >1500 to initiate · Weekly for 6 months → biweekly × 6 months → monthly

Clinical Rationale:
Emerging evidence supports an inflammatory subtype of depression. Patients with elevated hsCRP (>1 mg/L) may have a different biological pathway underlying their depression — neuroinflammation — that responds poorly to standard SSRIs and may respond better to anti-inflammatory strategies.

When to Order hsCRP:
SSRI or SNRI non-response after adequate trial (6-8 weeks at therapeutic dose)
Treatment-resistant depression (failed ≥2 adequate trials)
Depression with prominent fatigue, cognitive slowing, or somatic symptoms
Depression with comorbid metabolic syndrome, obesity, autoimmune disease, or chronic pain
Atypical depression features (hypersomnia, leaden paralysis, rejection sensitivity)

Interpretation:
hsCRP <1 mg/L — low inflammation · standard antidepressant approach appropriate
hsCRP 1-3 mg/L — intermediate · consider metabolic and lifestyle factors
hsCRP >3 mg/L — elevated inflammation · may predict SSRI non-response
hsCRP >10 mg/L — rule out acute infection or inflammatory condition first

Clinical Implications of Elevated hsCRP in Depression:
Consider anti-inflammatory adjuncts: Omega-3 fatty acids (EPA >1g/day) · Exercise prescription · Mediterranean diet counseling
NSAIDs not routinely recommended — insufficient evidence and GI/renal risk
Celecoxib has some evidence as augmentation — use cautiously
Address underlying inflammatory drivers: Metabolic syndrome · Sleep apnea · Chronic stress · Sedentary lifestyle · Obesity
Consider TNF-alpha antagonists for treatment-resistant depression in research context
Bupropion may have mild anti-inflammatory properties

Also Order in Treatment-Resistant Depression:
TSH · B12 · 25-OH Vitamin D · CBC · BMP · Fasting glucose · HbA1c · Sleep study if OSA suspected

Clinical Rationale:
Vitamin D receptors are expressed throughout the brain. Deficiency is associated with depression, cognitive decline, fatigue, and increased risk of dementia. Highly prevalent — up to 40% of Americans are deficient. Often missed as a reversible contributor to psychiatric symptoms.

When to Order:
New onset depression or anxiety
Treatment-resistant or partially-responsive depression
Seasonal depression / SAD (seasonal affective disorder)
Fatigue, cognitive slowing, or low motivation
Baseline in all new psychiatric patients — especially in northern latitudes, limited sun exposure, darker skin pigmentation, older adults, obese patients
Patients on antiepileptics (phenytoin, carbamazepine, phenobarbital) — accelerate Vitamin D breakdown

Lab: 25-hydroxyvitamin D (25-OH-D) — this is the correct test (not 1,25-dihydroxy)

Interpretation:
<12 ng/mL — Severe deficiency · Immediate treatment required
12-20 ng/mL — Deficiency · Supplement and recheck in 3 months
20-30 ng/mL — Insufficiency · Supplement and optimize
30-50 ng/mL — Optimal range for most adults
50-100 ng/mL — Acceptable · No toxicity concern
>100 ng/mL — Potential toxicity · Hold supplementation

Supplementation:
Deficiency (<20): Vitamin D3 50,000 IU weekly × 8-12 weeks (prescription) OR 2000-4000 IU daily OTC
Insufficiency (20-30): 1000-2000 IU daily
Maintenance: 600-2000 IU daily depending on baseline
Recheck 25-OH-D in 3 months after initiating supplementation
Give with fatty meal for best absorption · D3 (cholecalciferol) preferred over D2

Note: While evidence for Vitamin D supplementation improving depression outcomes is mixed, correcting deficiency removes a potentially reversible contributor and supports overall neurological health

Clinical Rationale:
B12 deficiency is one of the most commonly missed reversible causes of depression, cognitive decline, fatigue, and peripheral neuropathy. Essential for myelin synthesis and neurotransmitter production including serotonin and dopamine. Can present as psychiatric symptoms before neurological symptoms appear.

When to Order:
New onset depression — especially in elderly
Cognitive decline or memory complaints at any age
Treatment-resistant depression
Fatigue, weakness, or paresthesias
Macrocytic anemia (MCV >100)
Patients on long-term Metformin — depletes B12
Patients on long-term PPIs or H2 blockers — impair B12 absorption
Strict vegetarians or vegans
History of gastric bypass or GI malabsorption
Elderly patients — decreased intrinsic factor production
Patients with autoimmune disease — pernicious anemia risk

Labs:
Serum B12 — first-line screen
Methylmalonic acid (MMA) — more sensitive marker of functional B12 deficiency · Order if B12 borderline (200-350)
Homocysteine — elevated in B12 and folate deficiency · cardiovascular risk marker
Intrinsic factor antibodies — if pernicious anemia suspected
Folate level — order with B12

Interpretation:
<200 pg/mL — Deficiency · Treat
200-350 pg/mL — Borderline · Check MMA · Treat if symptomatic
>350 pg/mL — Normal

Treatment:
Dietary deficiency / malabsorption: Oral cyanocobalamin 1000-2000 mcg daily OR IM cyanocobalamin 1000 mcg monthly
Pernicious anemia: IM B12 required — cannot absorb oral
Metformin-induced: Oral supplementation 1000 mcg daily · Consider monitoring every 6-12 months on metformin
Recheck B12 in 3 months after initiating treatment

Neuropsychiatric Presentations of B12 Deficiency:
Depression · Psychosis · Cognitive impairment · Delirium · Personality change · Irritability · Paranoia · Peripheral neuropathy (paresthesias, weakness) · Subacute combined degeneration of the spinal cord (severe, late)

All New Psychiatric Patients: TSH · B12 · 25-OH-D · CBC · BMP · Fasting glucose · UA

Lithium: + Renal function · Pregnancy test · EKG if indicated
Valproate: + LFTs · CBC · Pregnancy test (teratogenic)
Carbamazepine: + LFTs · CBC · HLA-B*1502 (Asian patients)
Atypical Antipsychotics: + Fasting lipids · HbA1c · Weight/BMI
Clozapine: + ANC (mandatory REMS) · Fasting lipids · HbA1c
SSRIs/SNRIs: BMP · Consider hsCRP if treatment-resistant · QTc if citalopram/escitalopram
Stimulants (ADHD): BP · HR · Weight · EKG if cardiac history
Bupropion: No specific labs — lower seizure threshold consideration
MAOIs: LFTs · BP (hypertensive crisis risk with tyramine)

1. Did a parent or adult in your home often swear at, insult, put down, or humiliate you? Or act in a way that made you afraid you might be physically hurt?

2. Did a parent or adult in your home often push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured?

3. Did an adult or person at least 5 years older than you ever touch or fondle you in a sexual way, or have you touch their body in a sexual way, or attempt to or actually have oral, anal, or vaginal intercourse with you?

4. Did you often feel that no one in your family loved you or thought you were important or special? Or that your family didn't look out for each other, feel close to each other, or support each other?

5. Did you often feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? Or that your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

6. Were your parents ever separated or divorced?

7. Was your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? Or sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

10. Did a household member go to prison?

1. Fail to give close attention or make careless mistakes

2. Difficulty sustaining attention in tasks

3. Does not seem to listen when spoken to directly

4. Does not follow through on instructions or finish tasks

5. Difficulty organizing tasks and activities

6. Avoids tasks requiring sustained mental effort

7. Loses things necessary for tasks

8. Easily distracted by extraneous stimuli

9. Forgetful in daily activities

10. Fidgets with hands/feet or squirms in seat

11. Leaves seat in situations where remaining seated is expected

12. Feels restless

13. Difficulty engaging in activities quietly

14. Feels "on the go" or acts as if "driven by a motor"

15. Talks excessively

16. Blurts out answers before questions completed

17. Difficulty waiting turn

18. Interrupts or intrudes on others

1. You felt so good or so hyper that other people thought you were not your normal self, or you were so hyper that you got into trouble?

2. You were so irritable that you shouted at people or started fights or arguments?

3. You felt much more self-confident than usual?

4. You got much less sleep than usual and found you didn't really miss it?

5. You were much more talkative or spoke much faster than usual?

6. Thoughts raced through your head or you couldn't slow your mind down?

7. You were so easily distracted by things around you that you had trouble concentrating or staying on track?

8. You had much more energy than usual?

9. You were much more active or did many more things than usual?

10. You were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

11. You were much more interested in sex than usual?

12. You did things that were unusual for you or that other people might have thought were foolish or risky?

13. Spending money got you or your family into trouble?

14. If you checked YES to more than one above: have several of these ever happened during the same period of time?

15. How much of a problem did any of these cause — like being unable to work, family/money troubles, getting into arguments or fights?
0=No problem, 1=Minor, 2=Moderate, 3=Serious

Visuospatial/ExecutiveTrail making, cube copy, clock drawing (0-5)

NamingLion, rhino, camel (0-3)

Memory / Delayed Recall5-word recall after delay (0-5)

AttentionDigit span, serial 7s, tap on A (0-6)

LanguageSentence repetition, verbal fluency (0-3)

AbstractionSimilarity pairs (0-2)

OrientationDate, month, year, day, place, city (0-6)

Education ≤12 years?Add 1 point if yes

1. Repeated, disturbing, and unwanted memories of the stressful experience

2. Repeated, disturbing dreams of the stressful experience

3. Suddenly feeling or acting as if the stressful experience were actually happening again

4. Feeling very upset when something reminded you of the stressful experience

5. Having strong physical reactions when something reminded you of the stressful experience

6. Avoiding memories, thoughts, or feelings related to the stressful experience

7. Avoiding external reminders of the stressful experience

8. Trouble remembering important parts of the stressful experience

9. Having strong negative beliefs about yourself, other people, or the world

10. Blaming yourself or someone else for the stressful experience or what happened after it

11. Having strong negative feelings such as fear, horror, anger, guilt, or shame

12. Loss of interest in activities that you used to enjoy

13. Feeling distant or cut off from other people

14. Trouble experiencing positive feelings

15. Irritable behavior, angry outbursts, or acting aggressively

16. Taking too many risks or doing things that could cause you harm

17. Being "superalert" or watchful or on guard

18. Feeling jumpy or easily startled

19. Having difficulty concentrating

20. Trouble falling or staying asleep

1. Have you ever had a period of time when you felt so good, "high," or hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?

2. Have you ever had a period when you were so irritable that you shouted at people or started fights or arguments?

3. Have you ever experienced a period of time when you needed much less sleep than usual and still felt rested and full of energy?

4. Have you ever had a period of time when you were much more talkative or spoke much faster than usual?

5. Have you ever had a period of time when thoughts raced through your head or you couldn't slow your mind down?

6. Have you ever had a period of time when you were much more interested in sex than usual?

7. Have you ever had a period of time when you did things that were unusual for you or that other people might have thought were foolish or risky?

1. Time occupied by obsessions0=None, 1=<1hr/day, 2=1-3hr, 3=3-8hr, 4=>8hr

2. Interference from obsessions

3. Distress from obsessions

4. Resistance to obsessions0=Always resists, 4=Completely yields

5. Control over obsessions0=Complete control, 4=No control

6. Time spent on compulsions

7. Interference from compulsions

8. Distress if compulsions prevented

9. Resistance to compulsions

10. Control over compulsions

Grooming & hygiene

Apparent age

Eye contact

Psychomotor activity

Attitude toward examiner

Rate

Volume & tone

"How would you describe your mood today?"

Mood rating (patient self-report 1-10)

Range

Congruence with mood

Organization

Suicidal ideation

Homicidal ideation

Delusions

Obsessions / compulsions

Hallucinations

Orientation

Memory

Concentration

Insight into illness

Judgment

Access to means (weapons, medications)

Protective factors