ICU Decoded › Library › Ward PathwaysWard Pathways
87 worked internal-medicine cases across 13 specialties. Each one is a decision sequence — ABCDE, order set, escalation criteria, treatment doses and a discharge package — not a textbook chapter. Cardiology free in full — the rest open with a referral.
Cardiology 12 cases · free
Acute Pulmonary Oedema Casualty: breathless, orthopnoea, rales, JVD, S3 gallop, bilateral pitting oedema; prior MI/HTN Congestive Heart Failure (chronic, systolic) Ambulatory: exertional dyspnoea, orthopnoea, PND, S4, apical murmur→axilla, oedema; long-standing HTN Acute Coronary Syndrome Casualty: crushing substernal chest pain; risk factors (HTN, smoking, dyslipidaemia) Aortic Stenosis Elderly: exertional dyspnoea, syncope, angina; crescendo-decrescendo systolic murmur 2nd R ICS → carotids; louder on… Mitral Stenosis Rheumatic fever in childhood (common in India): dyspnoea, haemoptysis, AF; diastolic rumble + opening snap, loud S1 at… Atrial Fibrillation Irregularly irregular pulse, no P waves, rapid rate SVT / VT / WPW SVT: narrow, regular, fast. VT: wide. WPW: delta wave, short PR Pericardial Tamponade Hypotension + ↑JVP + muffled sounds (Beck); pulsus paradoxus >10 mmHg; electrical alternans; effusion/post-MI Complete Heart Block AV dissociation, bradycardia, syncope, cannon a-waves Mitral Regurgitation Holosystolic murmur at apex → axilla, soft S1 Peripheral Arterial Disease Claudication, ↓ pulses, shiny hairless skin; smoker Syncope Transient LOC with spontaneous recovery
Hematology 8 cases · locked
Sickle Cell Crisis Casualty: known sickle cell disease (HbSS); severe bone, back or chest pain for 1 day, fever 38.6 °C; stopped… Autoimmune Hemolysis Fatigue, jaundice, dark urine; Hb 62 g/L falling; ↑reticulocytes, ↑LDH, ↑indirect bilirubin, ↓haptoglobin; spherocytes… G6PD Deficiency Young man with cola-coloured urine, jaundice, pallor and back pain 2 days after starting primaquine (or dapsone… Paroxysmal Nocturnal Hemoglobinuria Young adult with dark morning urine, fatigue and abdominal pain; DAT-negative haemolysis, low counts; new hepatic vein… HUS / TTP Fever, confusion and headache; purpura; platelets 12×10⁹/L, Hb 72 g/L; schistocytes; normal PT/aPTT. Bloody diarrhoea… Immune Thrombocytopenic Purpura Petechiae, bruising, gum bleeding; platelets 8×10⁹/L with normal Hb and WBC; otherwise well Clotting Factor Deficiency (Hemophilia) Known severe haemophilia A; painful swollen right knee after minor trauma (or groin pain with the hip held flexed, or a… Thrombophilia / DVT / HIT Swollen, painful left leg for 3 days after surgery; or platelets fallen >50% on day 5–10 of heparin with a new clot
Endocrinology 4 cases · locked
Diabetic Ketoacidosis Type 1 diabetes, stopped insulin 2 days ago; vomiting, abdominal pain, Kussmaul breathing; glucose 420 mg/dL, pH 7.12… Hyperosmolar Hyperglycaemic State (HHS) Elderly type 2 diabetes, 1 week of polyuria then confusion; very dry; glucose 980 mg/dL, Na⁺ 148, effective osmolality… Hypoglycaemia (Severe, Inpatient) Type 2 diabetes on gliclazide and insulin, eGFR 35; found sweaty and confused at 4 am; capillary glucose 42 mg/dL Adrenal Crisis On prednisolone 10 mg for 2 years, stopped it 1 week ago; vomiting, abdominal pain, confusion; BP 78/46, Na⁺ 126, K⁺…
Neurology 6 cases · locked
Stroke (Ischaemic) Sudden right weakness and slurred speech 90 min ago; BP 196/104; glucose 132 mg/dL; NIHSS 12 Myasthenia Gravis Known myasthenia gravis, chest infection; worsening ptosis, nasal speech, choking on liquids, breathless lying flat… Subarachnoid Haemorrhage Sudden "worst headache of my life" at peak intensity within a minute, vomiting, neck stiffness; GCS 14; BP 180/100 Guillain-Barré Syndrome Ascending leg weakness over 5 days after diarrhoea; now cannot walk; areflexia; tingling hands; FVC 22 mL/kg Meningitis (Bacterial) Fever, severe headache, neck stiffness, confusion (GCS 13) for 1 day; petechial rash on the legs Head Trauma — Subdural Hematoma 78-year-old on apixaban for AF; fall 3 weeks ago; now increasing confusion, headache and right-hand clumsiness; CT…
Gastroenterology 4 cases · locked
Gastrointestinal Bleeding Two episodes of haematemesis and melaena since morning; HR 118, BP 92/60; on aspirin and ibuprofen (or known cirrhosis) Inflammatory Bowel Disease Known ulcerative colitis; 9 bloody stools a day, cramps, fever 38.1 °C, HR 104; Hb 98 g/L, CRP 68 — acute severe UC… Acute Pancreatitis Severe epigastric pain radiating to the back, vomiting; gallstones on USS; lipase 12× ULN; HR 112, RR 24 Decompensated Cirrhosis (Ascites, SBP, Encephalopathy) Alcohol-related cirrhosis; tense ascites, fever 38.2 °C, drowsy with asterixis; creatinine 1.9 mg/dL (baseline 0.9)…
Nephrology 7 cases · locked
Acute Kidney Injury — Prerenal Three days of diarrhoea and vomiting on ramipril, furosemide and diclofenac; dizzy on standing; creatinine 2.8 mg/dL… Acute Tubular Necrosis (incl. Rhabdomyolysis) Found on the floor for 18 hours; tea-coloured urine; CK 48,000 U/L; creatinine 3.4 mg/dL; K⁺ 6.2; muddy-brown casts (or… Nephrotic Syndrome (Membranous) 45-year-old with 3 weeks of swelling from face to legs, frothy urine; albumin 1.8 g/dL, urine PCR 9 g/g, cholesterol… End-Stage Renal Failure / Dialysis CKD stage 5 (eGFR 8), not yet on dialysis; 1 week of vomiting, itching and breathlessness; K⁺ 6.8, HCO₃ 12, urea 260… SIADH 68-year-old on sertraline with pneumonia; confusion, vomiting, one seizure; Na⁺ 116, serum osmolality 245, urine… Central Diabetes Insipidus 3 days after pituitary surgery: urine 300 mL/h, thirsty; Na⁺ 154, serum osmolality 318, urine osmolality 120 (or an… Hyperkalaemia / Tumour Lysis CKD 4 on ramipril and spironolactone; weak and nauseated; K⁺ 7.1; ECG: peaked T waves, wide QRS
Pulmonary 6 cases · locked
Asthma Known asthma, 2 days of worsening wheeze; can speak only in phrases; RR 30, HR 120, SpO₂ 91%, PEF 35% of best COPD Ex-smoker with COPD, 3 days of more breathlessness and purulent sputum; SpO₂ 84% on air; ABG pH 7.30, PaCO₂ 62 mmHg… Pneumonia (CAP) Diabetic 60-year-old, 3 days of fever, cough with rusty sputum, right pleuritic pain; RR 28, BP 100/60, urea 50 mg/dL… Pneumocystis (PCP) Pneumonia Newly diagnosed HIV (CD4 60), 3 weeks of dry cough, fever, breathless on walking; SpO₂ 90% on air falling to 82% on… Tuberculosis 32-year-old, 2 months of cough, evening fever, 8 kg weight loss, streaky haemoptysis; right upper lobe cavity; sputum… Pulmonary Embolus Day 6 after knee replacement: sudden pleuritic chest pain and breathlessness; HR 118, BP 104/70, SpO₂ 90%; right calf…
Rheumatology 2 cases · locked
Oncology 4 cases · locked
Infectious Disease 7 cases · locked
Osteomyelitis Diabetic with a foul plantar ulcer over the 1st metatarsal head for 6 weeks; probe touches bone; swollen red forefoot… Endocarditis Rheumatic heart disease with mitral regurgitation; 3 weeks of fever, weight loss, new breathlessness; splinter… Pyelonephritis Diabetic woman, 2 days of fever with rigors, right flank pain, vomiting; renal angle tender; BP 96/60; urine nitrite +… Cellulitis Diabetic with filarial lymphoedema; 2 days of a hot, red, swollen, painful left leg with fever 38.8 °C; tinea between… Infectious Diarrhea 45-year-old, 1 day of profuse watery diarrhoea ("rice-water"), vomiting, leg cramps; very dry, BP 86/50, not passing… Malaria Fever with rigors for 5 days, now drowsy and jaundiced; creatinine 3.4, Hb 68 g/L, glucose 52 mg/dL; P. falciparum 8%… Dengue with Warning Signs Day 5 of fever (now settling); abdominal pain, repeated vomiting, gum bleeding, restless; liver 3 cm; haematocrit 48%…
Emergency / Toxicology 10 cases · locked
Tricyclic Antidepressant Overdose Took 30 tablets of amitriptyline 2 h ago; drowsy, dry, flushed, pupils dilated; HR 128, BP 88/50; QRS 128 ms Paracetamol Overdose Took 40 tablets of paracetamol 500 mg (20 g) 5 h ago; 60 kg; nausea only; 4-hour level pending Aspirin / Salicylate Overdose Took 60 tablets of aspirin 325 mg; tinnitus, vomiting, RR 32; VBG pH 7.36, PaCO₂ 22, HCO₃ 12 (mixed respiratory… Carbon Monoxide Poisoning Family found drowsy in a closed room with a coal brazier (angithi) overnight; headache, vomiting; GCS 13; SpO₂ reads… Ethylene Glycol / Methanol Several labourers after drinking illicit liquor 24 h ago; one has blurred "snowfield" vision, vomiting, RR 30; pH 7.08… Organophosphate Poisoning Farmer drank an organophosphate insecticide 1 h ago; vomiting, drooling, pinpoint pupils, fasciculations, wheeze with… Snakebite Envenomation Farmer bitten on the foot while harvesting at night 3 h ago; swelling to the knee, bleeding gums; 20-minute whole-blood… Digoxin Toxicity Elderly on digoxin for AF with CKD; 3 days of nausea, vomiting, yellow-tinged vision, confusion; HR 38 with regularised… Drowning / Hypothermia Pulled from a river after 5 minutes; now breathing, GCS 12, SpO₂ 86%, crackles; core temperature 32 °C (or found cold… Neuroleptic Malignant Syndrome Started haloperidol injections 5 days ago; now T 40.2 °C, lead-pipe rigidity, confusion, sweating, labile BP; CK 18,000…
Critical Care / ICU 10 cases · locked
Sepsis & Septic Shock Fever + confusion + lactate 4.2; BP 84/50 after 2 L — suspected pneumonia. Move fast: every hour of antibiotic delay… Undifferentiated Shock & Vasopressor Guide MAP 58 with cold mottled legs and a lactate of 5 — cold & wet, warm & dry, or obstructed? Pick the right pressor for… Anaphylaxis Urticaria + stridor + BP 78/40 minutes after IV antibiotic — this is adrenaline IM now, not antihistamines first. Acute Respiratory Failure — Initial Ventilator Setup Exhausted, SpO₂ 82% on 15 L, PaCO₂ 68 mmHg and climbing — type I vs type II failure, NIV or tube, and the first safe… ARDS Bilateral infiltrates, PaO₂/FiO₂ 110 on PEEP 5, 3 days into pneumonia — this is ARDS; the ventilator itself can injure… Status Epilepticus Generalised tonic-clonic seizure ongoing at 7 minutes — treat the clock: benzodiazepine at 5 min, second-line loaded by… Aortic Dissection Tearing interscapular pain, BP 210/120, right arm pulse weaker than left — kill the shear forces: β-block FIRST, then… Hypertensive Emergency BP 240/130 with blurred vision, pulmonary oedema and creatinine climbing — the DAMAGE defines the emergency, not the… Cardiac Arrest & Post-ROSC Care Collapse, pulseless — start the clockwork: quality CPR, adrenaline every 3–5 min, shock the shockable, hunt Hs & Ts… Acute Liver Failure Paracetamol overdose 2 days ago, now INR 3.8, confused, glucose 2.1 — INR ≥1.5 + encephalopathy = acute liver failure.…
Miscellaneous 7 cases · locked
Invasive Fungal Infection in the ICU ICU day 8, persistent fever on broad-spectrum antibiotics; central line, TPN, recent abdominal surgery Clostridioides difficile and ICU Diarrhoea Day 6 of piperacillin-tazobactam; 8 loose stools/day, cramping, WCC 22 × 10⁹/L, albumin falling Coagulopathy in the Bleeding Patient Post-operative patient oozing from every puncture site; INR 2.1, platelets 68 × 10⁹/L, fibrinogen 1.1 g/L, temperature… Rheumatological Emergencies Known vasculitis, now breathless with haemoptysis, creatinine risen from 1.0 to 3.6 mg/dL, urine dipstick blood +++ and… The Transplant Patient with Fever Renal transplant 4 months ago on tacrolimus, mycophenolate and prednisolone; fever 38.8 °C, dry cough, creatinine up 40% Thyroid Storm and Myxoedema Coma Agitated, temperature 40 °C, AF at 160/min, vomiting, jaundice — two weeks after stopping carbimazole Device-Associated Infection Prevention Bundles Daily ward round on a ventilated patient with a central line, an arterial line and a urinary catheter on day 5