ICU Decoded › Library › Ward PathwaysWard Pathways
113 worked internal-medicine cases across 12 specialties. Each one is a decision sequence — ABCDE, order set, escalation criteria, treatment doses and a discharge package — not a textbook chapter. Free in full
Cardiology 12 cases
Acute Pulmonary Edema ED: SOB, orthopnea, rales, JVD, S3 gallop, bilateral pitting edema; prior MI/HTN Congestive Heart Failure (chronic, systolic) Ambulatory: exertional dyspnea, orthopnea, PND, S4, apical murmur→axilla, edema; long-standing HTN Acute Coronary Syndrome ED: crushing substernal chest pain; risk factors (HTN, smoking, hyperlipidemia) Aortic Stenosis Elderly: exertional dyspnea, syncope, angina; crescendo-decrescendo systolic murmur 2nd R ICS → carotids; louder w/… Mitral Stenosis Rheumatic fever hx (often immigrant): dyspnea, hemoptysis, AF; diastolic rumble + opening snap, loud S1 at apex 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 12 cases
Iron Deficiency Anemia Microcytic hypochromic; fatigue, pica, koilonychia Thalassemia Microcytic, target cells, NORMAL iron studies; ethnicity Vitamin B12 Deficiency Macrocytic; peripheral neuropathy, ↓proprioception, glossitis, hypersegmented neutrophils; alcoholism Sickle Cell Crisis Severe bone/chest/back pain; fever; noncompliant with hydroxyurea Autoimmune Hemolysis Anemia, ↑retic, ↑LDH, ↑indirect bili, ↓haptoglobin G6PD Deficiency Episodic hemolysis after oxidant (primaquine, dapsone, sulfa, fava, infection) Paroxysmal Nocturnal Hemoglobinuria Hemolysis + thrombosis (DVT) + pancytopenia; dark morning urine HUS / TTP MAHA + thrombocytopenia; schistocytes, ↑LDH, ↑indirect bili. TTP adds fever/renal/neuro (↓ADAMTS13); HUS = E. coli… Immune Thrombocytopenic Purpura Isolated ↓platelets, mucocutaneous bleeding; diagnosis of exclusion Von Willebrand Disease Mucosal bleeding, ↑aPTT, ↑bleeding time, normal platelets Clotting Factor Deficiency (Hemophilia) ↑aPTT, normal PT; hemarthrosis / deep bleeds; X-linked male Thrombophilia / DVT / HIT Unilateral leg swelling/pain
Endocrinology 9 cases
Diabetes — Initial Diagnosis & Treatment Polyuria, polydipsia; obesity/insulin resistance Diabetes — Prevent Complications Established diabetic on metformin Diabetic Ketoacidosis Stopped insulin; hyperglycemia, anion-gap acidosis, ketones, Kussmaul Hypothyroidism Fatigue, cold, weight gain, constipation, hyponatremia Hyperparathyroidism ↑Ca; stones, bones, groans, psychiatric moans Hypercortisolism (Cushing) Central obesity, striae, HTN, hyperglycemia, vertebral fracture Acromegaly Enlarging hands/jaw, sleep apnea, sweating Hyperaldosteronism (Conn) HTN + hypokalemia + muscle weakness Prolactinoma Galactorrhea, amenorrhea, ↓libido, bitemporal hemianopia
Neurology 8 cases
Stroke (Ischemic) Sudden focal deficit; ↑BP Parkinson Disease Resting tremor, rigidity, bradykinesia, postural instability Myasthenia Gravis Fatigable weakness, ptosis, diplopia worse in evening Subarachnoid Hemorrhage Thunderclap 'worst headache of life', meningismus Guillain-Barré Syndrome Ascending symmetric weakness + areflexia; post-infection (Campylobacter) Dementia Progressive memory loss, functional decline Meningitis (Bacterial) Fever, stiff neck, headache, photophobia, ΔMS Head Trauma — Subdural Hematoma Elderly/alcoholic, gradual decline; crescent (concave) on CT, crosses sutures
Gastroenterology 9 cases
Gastrointestinal Bleeding Melena / hematemesis / hematochezia; tachycardia, orthostatic ↓BP Achalasia Dysphagia to solids AND liquids, regurgitation GERD Heartburn, regurgitation, dental enamel loss, pharyngitis (no exam finding) Peptic Ulcer Disease Epigastric pain; duodenal better with food, gastric worse Zollinger-Ellison Syndrome Multiple / refractory ulcers, diarrhea Inflammatory Bowel Disease UC: bloody diarrhea, continuous from rectum. Crohn: skip lesions, transmural, fistula, granulomas Celiac Disease Diarrhea, weight loss, iron deficiency (no GI bleed), dermatitis herpetiformis Hemochromatosis Bronze skin, diabetes, cirrhosis, arthropathy, cardiomyopathy Acute Pancreatitis Epigastric pain → back, N/V; gallstones / alcohol
Nephrology 10 cases
Pulmonary 8 cases
Asthma Wheeze, dyspnea; acute attack with respiratory alkalosis COPD Smoker, chronic dyspnea, barrel chest Pneumonia (CAP) Fever, productive cough, pleuritic pain, infiltrate on CXR Pneumocystis (PCP) Pneumonia HIV CD4 <200, dry cough, exertional hypoxia, ↑LDH, bilateral interstitial Tuberculosis Immigrant: fever, cough, hemoptysis, weight loss; upper-lobe cavitary Pulmonary Embolus Pleuritic pain, dyspnea, tachycardia, hypoxia Sarcoidosis Bilateral hilar adenopathy, erythema nodosum, ↑ACE, ↑Ca; young Pulmonary Hypertension Progressive dyspnea, ↑RV pressure on echo
Rheumatology 8 cases
Rheumatoid Arthritis Symmetric small-joint (MCP/PIP) pain, morning stiffness >1 h Ankylosing Spondylitis Young man, inflammatory back pain, ↓chest expansion Sjögren Syndrome Dry eyes + dry mouth Gout Acute monoarthritis (1st MTP), after NSAID failure Osteoarthritis Weight-bearing joints worse with use; Heberden/Bouchard nodes Scleroderma Skin tightening, Raynaud, telangiectasia Poly/Dermatomyositis Proximal muscle weakness; Gottron papules, heliotrope, shawl sign Systemic Lupus Erythematosus Malar rash, arthritis, serositis, cytopenia, nephritis
Oncology 7 cases
Breast Cancer Palpable mass / abnormal mammogram Prostate Cancer ↑PSA / abnormal DRE Multiple Myeloma CRAB: ↑Ca, Renal, Anemia, Bone lytic lesions; older adult, high total protein Polycythemia Vera ↑Hct, pruritus after shower, thrombosis, splenomegaly Tumour Lysis Syndrome Day 2 after first chemo for Burkitt lymphoma — K⁺ 6.4, phosphate 2.8, creatinine doubling. Cell death is flooding the… Febrile Neutropenia Chemo 8 days ago, now T 38.6 °C, ANC 0.2 — treat as sepsis with an hour on the clock: cultures then… Hypercalcaemia of Malignancy Known myeloma, now confused and constipated — corrected Ca²⁺ 3.6. Volume first, calcitonin for speed, zoledronate for…
Infectious Disease 10 cases
Osteomyelitis Localized bone pain/tenderness, ± overlying ulcer Endocarditis Fever, new murmur, emboli, splinters; IVDU / prosthetic valve Pyelonephritis Fever, flank pain, CVA tenderness, dysuria Cellulitis Warm, erythematous, tender spreading skin Urethritis Dysuria, discharge Syphilis Painless chancre / rash palms & soles / gumma Herpes Zoster Painful vesicular rash in a dermatome Infectious Diarrhea Acute diarrhea ± blood/fever Malaria Cyclic fever, travel to endemic area HIV / AIDS Opportunistic infection / new diagnosis
Emergency / Toxicology 10 cases
Tricyclic Antidepressant Overdose Anticholinergic + wide QRS + seizures + hypotension Acetaminophen Overdose Nausea early → hepatic failure late Aspirin / Salicylate Overdose Tinnitus, tachypnea, mixed respiratory alkalosis + anion-gap acidosis Carbon Monoxide Poisoning Fire/smoke, headache, confusion; normal PaO₂, ↑COHb Ethylene Glycol / Methanol ↑osmolar gap + anion-gap acidosis; EG → oxalate crystals/renal; MeOH → visual loss Organophosphate Poisoning Cholinergic (DUMBELS): salivation, lacrimation, bronchorrhea, miosis Spider Bite Black widow: muscle rigidity/cramps. Brown recluse: necrotic ulcer Digoxin Toxicity N/V, yellow-green vision, arrhythmia; ↑K in acute Drowning / Hypothermia Cold exposure; bradycardia, Osborn J waves Neuroleptic Malignant Syndrome Antipsychotic + hyperthermia + lead-pipe rigidity + ↑CK + ΔMS
Critical Care / ICU 10 cases
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 9.1 kPa 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.…