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10 Clinical Calculators for Inpatient Providers

Nurse Practitioner | 0 comments

Working in a hospital as a provider can be unexpected and stressful. There are so many factors to consider when managing a patient’s acute and chronic diseases. Luckily, there has been a great amount of research involving management of patients within the hospital. There are many different systems and calculations which can help with risk stratification, prevention, diagnosis, and management. These inpatient clinical calculators are sure to be useful to you during your shift in the hospital!

1

Padua Predictive Score for Risk of VTE

Inpatient medicine constantly involves predicting, preventing, diagnosing, and treating blood clots. Venous Thromboembolism (VTE) is the general term used to describe blood clots (thrombi) in the body which may have moved (embolized) to the lungs (pulmonary embolism).

VTE are an important cause of morbidity and mortality – especially with patient’s who have many comorbidities. Approximately 900,000 patients in the US are affected by VTE each year, and 60,000-100,00 American’s die. The first symptom of a PE is sudden cardiac death in 25% of people! You can see why it is SO important to prevent this from occurring within the hospital. Those admitted to the hospital are at higher risk for developing health-care associated VTE due to decreased mobility and recent surgery and/or procedures.

The Padua Predictive Score is a useful tool which separates patients into high and low risk groups for developing VTE. Those who score < 4 points are considered low-risk, and those >/= 4 are considered high risk. This calculator takes into account 11 factors which increase risk for VTE including age, mobility, history of cancer, heart disease, or respiratory disease, obesity, among others. If scores less than 4, consider non-pharmacologic measures such as SCDs or early ambulation. With scores greater than 4, pharmacologic measures are indicated including unfractionated heparin (UFH) or Lovenox (Enoxaparin).

Check out the Calculator!

2

Wells’ Criteria for DVT

The Wells’ criteria score system is a method to quantify the diagnostic probability for a patient presenting with a DVT/PE, however the calculators are different depending on which you are assessing for.

The Wells’ score for DVT involves specific risk factors for developing a DVT including the presence of symptoms such as calf/leg edema, recent immobility or surgery, leg tenderness, etc. The modified Wells’ score factors in a previous history of DVT.

Low Probability

Scores of 0 or less have a low-probability of needing further workout to rule out a DVT.

Moderate Probability

Scores of 1-2 points have a moderate probability and should get a high-sensitive D-dimer result. If <500 ng/ml, this effectively rules out a DVT. However, since the D-dimer test is nonspecific, a score >500 ng/ml warrants further investigation (i.e. a venous duplex).

High Probability

Scores of 3-8 have a high probability of a DVT and should get a venous duplex to rule out a clot regardless.

https://www.mdcalc.com/wells-criteria-dvt

3

Wells’ Criteria for PE

Just like the Wells’ score for DVT, there is a calculator for the pretest probability of a PE. The calculator assesses for PE risk factors including s/s of DVT, clinical suspicion of PE, HR >100, immobility/recent surgery, previous VTE, the presence of hemoptysis, and malignancy.

Low Probability

Scores <2 indicate a low probability of a PE. However, if s/s of PE are present (pleuritic chest pain, SOB, tachycardia, etc) then clinicians are encourages to use the PERC rule. The PERC rule is a list of 8 criteria which effectively rule out a PE in those with low-probability of having a PE. The patient must meet all of the following criteria:

  • Age < 50 years
  • Heart rate < 100 bpm
  • Oxyhemoglobin saturation ≥ 95% on RA
  • No hymoptysis
  • No estrogen use
  • No prior DVT/PE
  • No unilateral leg swelling
  • No surgery/trauma requiring hospitalization within the prior 4 weeks

If the patient meets any of the above, a D-dimer should be performed. In those already admitted to the hospital or critically ill patients, a D-dimer should be obtained regardless. As above, levels < 500 ng/ml do not require further workup, but levels > 500 ng/ml need further workup (i.e. CT Pulmonary Angiography).

Moderate Probability

Scores 2-6 indicate moderate probability for having a PE. This is handled with a high-sensitivity D-dimer score as above – the PERC rule is not used. If less than the cut-off, PE is ruled out. Otherwise, further testing must be performed.

High Probability

Scores >6 indicate high probability for having a PE. Those with high-risk should NOT have a D-dimer level checked. Instead, they should have diagnostic imaging to rule out PE regardless. The preferred test is a CTPA, but if this cannot be obtained than a V/Q scan should be ordered.

https://www.mdcalc.com/wells-criteria-pulmonary-embolism

4

CHA₂DS₂-VASc Score for AFIB Stroke Risk

Some medical conditions predispose patients to blood clot formation. One of those conditions is Atrial fibrillation, which increases the chance of clot formation within the atria of the heart. Clots formed in the right atria may embolize to the lungs, and clots formed in the left atria may embolize to the brain and cause a embolic stroke.

The CHA₂DS₂-VASc Score is a scoring system which helps clinicians to determine the need for oral anticoagulation to prevent clot formation and subsequent embolization. The score includes their age, sex, and their medical history including CHF, HTN, CVA, VTE, Vascular dz, or Diabetes.

Low Risk

Scores of 0 indicate a low-risk for stroke in those with Afib. No oral anticoagulation is recommended. Sometimes these patients are placed on low-dose aspirin.

Low-Moderate Risk

Scores of 1 indicate a low-moderate risk of stroke in those with Afib. In this category, clinical judgement must be used. If you are a generalist, remember that cardiology will often be the one to make this decision. Many choose not to anticoagulate those who’s only score is that they are a woman.

Moderate-High Risk

Scores ≥ 2 points indicate a moderate-high risk of stroke in those with Afib. Anticoagulation in this group is highly recommended. All studies have shown the benefit of anticoagulation significantly exceeds the risk for almost all patients with afib and a score ≥ 2. Typically the cardiologists specialists will be determining which anticoagulation that will be used.

https://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism

5

HAS-BLED Score for Major Bleeding Risk

HAS-BLED is a system which scores the risk for major bleeding for those with Afib who are on oral anticoagulation. The system is scored by the following:

  • Hypertension – 1 point
  • Abnormal renal and/or hepatic function – 1 point each
  • Stroke – 1 point
  • Bleeding tendency/predisposition – 1 point
  • Labile INR on warfarin – 1 point
  • Elderly (age >65) – 1 point
  • Drugs (asa or NSAIDs) and/or alcohol – 1 point each

https://www.mdcalc.com/has-bled-score-major-bleeding-risk

Results are not separated into probability categories. Instead, clinical judgement must weight the benefits vs risks. However, the following risk can be estimated:

  • 0 points – 1.13 bleeds per 100 patient-years
  • 1 point – 1.02 bleeds per 100 patient-years
  • 2 points – 1.88 bleeds per 100 patient-years
  • 3 points – 3.74 bleeds per 100 patient-years
  • 4 points – 8.70 bleeds per 100 patient-years
  • 5-9 points – insufficient data (but high risk)

Remember this decision should be made with specialty consultation to cardiology.

6

Serum Osmolality

Other than blood clots and anticoagulation, inpatient providers often have to manage electrolyte abnormalities. One important electrolyte which often is low is sodium – called hyponatremia. The treatment of hyponatremia depends on the etiology. In order to determine the cause, an important calculation is the serum osmolality.

The calculator uses the serum sodium, BUN, Glucose, and ETOH to estimate the osmolality.

HypoOsmolar

Calculated osmolality <275 mOsm/kg is considered hypoosmolar (and usually hypotonic). This is the most common type of hyponatremia and fluid status must then be considered to determine etiology:

Euvolemic

Often caused by SIADH (from many causes) or thiazide diuretics.

Hypovolemic

Often caused by decreased PO intake, diuretics, GI losses, 3rd spacing, or adrenal insufficiency. This is treated with careful fluid resuscitation as replacing sodium too quickly can lead to deleterious effects such as osmotic demyelination syndrome (previously referred to as central pontine myelinosis).

Hypervolemic

Often caused by heart failure, liver cirrhosis, nephrotic syndrome, and severe AKI/CKD. Treatment in this case involves restricting water, loop diuretics (i.e. IV Lasix), and sometimes medications.

IsoOsmolar

Calculated osmolality 275-290 mOsm/kg is considered IsoOsmolar (and usually isotonic). This used to be caused by lab errors secondary to high lipid or protein levels.  However, Ion-specific electrodes are now used in the lab, so this error does not really happen anymore.

HyperOsmolar

Calculated osmolality >290 mOsm/kg is considered hyperOsmolary (and usually hypertonic). This is usually caused from solutes which cause osmotoic shifts of water out of cells into the extracellular fluid (i.e. glucose, mannitol, sorbitol, etc).

https://www.mdcalc.com/serum-osmolality-osmolarity

7

Sodium Correction for Hyperglycemia

Due to the osmotic shifts caused by hyperglycemia, hyponatremia should be corrected when glucose levels are elevated. The serum sodium concentration will fall by ~2. mEq/L for every 100 mg/dL of glucose elevation. For example, if the blood sugar is 400 and the sodium level is 124, the corrected sodium level is ~130 mEq/L. But you don’t have to do math, just use the calculator! It’s recommended to base your treatment plan on the calculated sodium level, as once the glucose is corrected the osmotic shifts will resolve.

https://www.mdcalc.com/sodium-correction-hyperglycemia

8

Fractional Excretion of Sodium (FENa)

The Fractional Excretion of Sodium (FENa) is calculated to determine the cause of acute kidney injury (AKI), and is a useful tool that many nephrologists utilize. This can help determine the difference between prerenal AKI from Acute tubular necrosis (ATN). This is calculated from the serum sodium creatinine, and the urine sodium and creatinine.

FENa levels < 1% generally indicate prerenal disease (i.e. decreased bloodflow to kidneys). Levels >2% usually indicates ATN. Levels between 1-2% can indicate both.

Remember that the FENa will not be accurate if the patient is on a diuretic. In general FENa is utilized by Nephrology, but can be useful to calculate if the etiology is unclear.

https://www.mdcalc.com/fractional-excretion-sodium-fena

9

Fractional Excretion of Urea (FEUrea)

The Fractional Excretion of Urea (FEUrea) can be used to differentiate between prerenal AKI and ATN in patients who are on diuretics as FENa will not be accurate. Levels 50-65% generally indicate ATN , and levels <35% indicate prerenal disease.

Again, many factors can determine these tests and they should be interpreted with the consultation of specialists (nephrologists).

https://www.mdcalc.com/fractional-excretion-urea-feurea

10

    Calcium Correction for Hypoalbuminemia

Unrelated to sodium and fluid status, calcium levels can be falsely altered in the presence of hypoalbuminemia. Calcium ions have two forms – ionized and protein-bound. About 40% of calcium in the blood is bound to protein (i.e. albumin), and about 50% circulates as free ionized calcium. The ionized calcium is what is truly clinically significant because this is what is physiologically active. If a patient is symptomatic from hypocalcemia – their ionized calcium will be low.

Since almost half of the calcium in the bloodstream attached to albumin, abnormal albumin levels will affect serum calcium levels. To correct this, you need to know the patients serum calcium and their albumin level. The calculator will give you a good idea of what their corrected calcium level actually is. So if you see a malnourished patient with an Albumin of 2.0 and a serum calcium of 7.0, the corrected calcium is 8.6 mg/dl.

This is not an exact science and many factors (i.e. acid-base disturbance) will alter calcium binding to protein and may cause ionized calcium levels to fluctuate. This is why most clinicians will order an ionized calcium level when serum calcium levels are significantly low (even in the presence of low albumin).

https://www.mdcalc.com/calcium-correction-hypoalbuminemia

1

Padua Predictive Score for Risk of VTE

Inpatient medicine constantly involves predicting, preventing, diagnosing, and treating blood clots. Venous Thromboembolism (VTE) is the general term used to describe blood clots (thrombi) in the body which may have moved (embolized) to the lungs (pulmonary embolism).

VTE are an important cause of morbidity and mortality – especially with patient’s who have many comorbidities. Approximately 900,000 patients in the US are affected by VTE each year, and of those 60,000-100,00 die. The first symptom of a PE is sudden cardiac death in 25% of people! You can see why it is SO important to prevent this from occurring within the hospital. Those admitted to the hospital are at higher risk for developing health-care associated VTE due to decreased mobility and recent surgery and/or procedures.

The Padua Predictive Score is a useful tool which separates patients into high and low risk groups for developing VTE. Those who score < 4 points are considered low-risk, and those ≥ 4 are considered high risk. This calculator takes into account 11 factors which increase risk for VTE including age, mobility, history of cancer, heart disease, or respiratory disease, obesity, among others. If scores less than 4, consider non-pharmacologic measures such as SCDs or early ambulation. With scores 4 or greater, pharmacologic measures are indicated including unfractionated heparin (UFH) or Lovenox (Enoxaparin).

2

Wells’ Criteria for DVT

The Wells’ criteria score system is a method to quantify the diagnostic probability for a patient presenting with a DVT/PE, however the calculators are different depending on which you are assessing for.

The Wells’ score for DVT involves specific risk factors for developing a DVT including the presence of symptoms such as calf/leg edema, recent immobility or surgery, leg tenderness, etc. The modified Wells’ score factors in a previous history of DVT, as these patients are more likely to develop another one.

Low Probability

Scores of 0 or less have a low-probability of DVT, and thus usually do not warrant further workup to rule out a DVT.

Moderate Probability

Scores of 1-2 points have a moderate probability and should get a high-sensitive D-dimer. If <500 ng/ml, this effectively rules out a DVT. However, since the D-dimer test is nonspecific, a score >500 ng/ml warrants further investigation (i.e. a venous duplex).

High Probability

Scores of 3-8 have a high probability of a DVT and should get a venous duplex to rule out a clot regardless. This means that a D-dimer test is not indicated since a Venous Duplex will be obtained regardless.

3

Wells’ Criteria for PE

Just like the Wells’ score for DVT, there is a calculator for the pretest probability of a PE. This calculator assesses for PE risk factors including s/s of DVT, clinical suspicion of PE, HR >100, immobility/recent surgery, previous VTE, the presence of hemoptysis, or malignancy.

Low Probability

Scores <2 indicate a low probability of a PE. However, if s/s of PE are present (pleuritic chest pain, SOB, tachycardia, etc) then clinicians are encourages to use the PERC rule. The PERC rule is a list of 8 criteria which effectively rules out a PE in those with low-probability of having a PE. The patient must meet all of the following criteria:

  • Age < 50 years
  • Heart rate < 100 bpm
  • Oxyhemoglobin saturation ≥ 95% on RA
  • No hymoptysis
  • No estrogen use
  • No prior DVT/PE
  • No unilateral leg swelling
  • No surgery/trauma requiring hospitalization within the prior 4 weeks

If the patient meets any of the above, a D-dimer should be performed. In those already admitted to the hospital or critically ill patients, a D-dimer should be obtained regardless. As above, levels < 500 ng/ml do not require further workup, but levels > 500 ng/ml do (i.e. CT Pulmonary Angiography).

Moderate Probability

Scores 2-6 indicate moderate probability for having a PE. This is handled with a high-sensitivity D-dimer score as above – the PERC rule is not used. If less than the cut-off, PE is ruled out. Otherwise, further testing must be performed.

High Probability

Scores >6 indicate high probability for having a PE. Those with high-risk should NOT have a D-dimer level checked. Instead, they should have diagnostic imaging to rule out PE regardless. The preferred test is a CT Pulmonary Angiography (CTPA) – but if this cannot be obtained, a V/Q scan should be ordered.

4

CHA₂DS₂-VASc Score for AFIB Stroke Risk

Some medical conditions predispose patients to blood clot formation. One of those conditions is Atrial fibrillation, which increases the chance of clot formation within the atria of the heart. Clots formed in the right atria may embolize to the lungs and cause a pulmonary embolism, and clots formed in the left atria may embolize to the brain and cause an embolic stroke.

The CHA₂DS₂-VASc Score is a scoring system which helps clinicians to determine the need for oral anticoagulation to prevent clot formation and subsequent embolization. The score includes their age, sex, and their medical history including CHF, HTN, CVA, VTE, Vascular dz, or Diabetes.

Low Risk

Scores of 0 indicate a low-risk for stroke in those with Afib. No oral anticoagulation is recommended. Sometimes these patients are placed on low-dose aspirin.

Low-Moderate Risk

Scores of 1 indicate a low-moderate risk of stroke in those with Afib. In this category, clinical judgement must be used. If you are a generalist, remember that cardiology will often be the one to make this decision. Many choose not to anticoagulate those who’s only score is that they are a woman.

Moderate-High Risk

Scores ≥ 2 points indicate a moderate-high risk of stroke in those with Afib. Anticoagulation in this group is highly recommended. All studies have shown the benefit of anticoagulation significantly exceeds the risk for almost all patients with afib and a score ≥ 2. Typically the cardiologists specialists will be determining which anticoagulation that will be used.

Remember to always take into account the patient’s risk of major bleeding (see below!)

 

5

HAS-BLED Score for Major Bleeding Risk

HAS-BLED is a system which quantifies the risk for major bleeding for those with Afib who are on oral anticoagulation. The system is scored by the following:

  • Hypertension – 1 point
  • Abnormal renal and/or hepatic function – 1 point each
  • Stroke – 1 point
  • Bleeding tendency/predisposition – 1 point
  • Labile INR on warfarin – 1 point
  • Elderly (age >65) – 1 point
  • Drugs (asa or NSAIDs) and/or alcohol – 1 point each

Results are not separated into probability categories. Instead, clinical judgement must weight the benefits vs risks. However, the following risk can be estimated:

  • 0 points – 1.13 bleeds per 100 patient-years
  • 1 point – 1.02 bleeds per 100 patient-years
  • 2 points – 1.88 bleeds per 100 patient-years
  • 3 points – 3.74 bleeds per 100 patient-years
  • 4 points – 8.70 bleeds per 100 patient-years
  • 5-9 points – insufficient data (but high risk)

Remember the decision for a patient with Afib to not be on oral anticoagulation should be made with specialty consultation.

6

Serum Osmolality

Other than blood clots and anticoagulation, inpatient providers often have to manage electrolyte abnormalities. One important electrolyte which often is low is sodium – called hyponatremia. The management of hyponatremia depends on the etiology. In order to determine the cause, an important calculation is the serum osmolality.

The calculator uses the serum sodium, BUN, Glucose, and ETOH to estimate the osmolality.

HypoOsmolar

Calculated osmolality <275 mOsm/kg is considered hypoosmolar (and usually hypotonic). This is the most common type of hyponatremia and fluid status must then be considered to determine etiology:

Euvolemic

Often caused by SIADH (from many causes) or thiazide diuretics.

Hypovolemic

Often caused by decreased PO intake, diuretics, GI losses, 3rd spacing, or adrenal insufficiency. This is treated with careful fluid resuscitation as replacing sodium too quickly can lead to deleterious effects such as osmotic demyelination syndrome (previously referred to as central pontine myelinosis).

Hypervolemic

Often caused by heart failure, liver cirrhosis, nephrotic syndrome, or severe AKI/CKD. Treatment in this case involves restricting water, administering loop diuretics (i.e. IV Lasix), and sometimes other medications.

IsoOsmolar

Calculated osmolality 275-290 mOsm/kg is considered IsoOsmolar (and usually isotonic). This used to be caused by lab errors secondary to high lipid or protein levels.  However, ion-specific electrodes are now used in the lab, so this error does not really happen anymore.

HyperOsmolar

Calculated osmolality >290 mOsm/kg is considered hyperOsmolary (and usually hypertonic). This is usually caused from solutes which cause osmotoic shifts of water out of cells into the extracellular fluid (i.e. glucose, mannitol, sorbitol, etc).

 

7

Sodium Correction for Hyperglycemia

Due to the osmotic shifts caused by hyperglycemia, hyponatremia should be corrected when glucose levels are elevated. The serum sodium concentration will fall by ~2. mEq/L for every 100 mg/dL of glucose elevation. For example, if the blood sugar is 400 and the sodium level is 124, the corrected sodium level is ~130 mEq/L. But you don’t have to do math, just use the calculator! It’s recommended to base your treatment plan on the corrected sodium level, as once the glucose is corrected the osmotic shifts will resolve.

8

Maintenance Fluid Rate

As inpatient providers, we have to order IV fluids on many patients. Maintenance fluids may need ordered if the patient is NPO, or if they have fluid losses/dehydration. In order to determine the best rate at which to run the IV fluids, there is a simple calculation. Take their weight in Kg, subtract 20 Kg and add 60mL. Then for every over Kg left, add 1mL. So a 60Kg patient gets 100ml/hr. If this is confusing – you can just use the calculator below!

Keep in mind this rate is a general estimation, and the patient’s own medical history should be taken into account. If they are fluid overloaded (i.e. CHF, Liver cirrhosis, etc), then a slower rate may be more appropriate. Always use your physical examination to guide your management. If the patient is elderly, consider slowing the rate as well. If the patient is having continuous fluid losses (i.e. diarrhea), then consider increasing the rate to 1.5x the maintenance rate – or using your best judgement.

(The calculator also lists the 20ml/kg bolus amount for sepsis patients)

9

Calcium Correction for Hypoalbuminemia

Unrelated to sodium and fluid status, calcium levels can be falsely altered in the presence of hypoalbuminemia. Calcium ions have two forms – ionized and protein-bound. About 40% of calcium in the blood is bound to protein (i.e. albumin), and about 50% circulates as free ionized calcium. The ionized calcium is what is truly clinically significant because this is what is physiologically active. If a patient is symptomatic from hypocalcemia – their ionized calcium will be low.

Since almost half of the calcium in the bloodstream attached to albumin, abnormal albumin levels will affect serum calcium levels. To correct this, you need to know the patients serum calcium and their albumin level. The calculator will give you a good idea of what their corrected calcium level actually is. So if you see a malnourished patient with an Albumin of 2.0 and a serum calcium of 7.0, the corrected calcium is 8.6 mg/dl.

This is not an exact science and many factors (i.e. acid-base disturbance) will alter calcium binding to protein and may cause ionized calcium levels to fluctuate. This is why most clinicians will order an ionized calcium level when serum calcium levels are significantly low (even in the presence of low albumin).

10

   Arterial Blood Gas (ABG) Analyzer

Arterial Blood Gases (ABGs) are commonly ordered in patients with respiratory failure in the hospital. This helps clinicians determine etiology and guides management of many respiratory conditions. If you struggle with analyzing ABGs, this calculator can help. Simply input the pH, PaCO2, Bicarb, Sodium, Chloride, and Albumin. This will help you determine whether the ABG abnormality is respiratory, metabolic, and which type with compensation (if any).

It is important for clinicians to be able to analyze blood gases on their own as well. You can read more about ABG interpretation in my ABG guide!

 

If you’re a practicing NP or NP student and need access to my free NP Resource library – sign up here! It has both inpatient and outpatient SOAP note templates, History and physical sheets, death pronouncement notes, and more to come!

References:

Barbar, S., Noventa, F., Rossetto, V., Ferrari, A., Brandolin, B., Perlati, M., … Prandoni, P. (2010). A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. Journal of Thrombosis and Haemostasis, 8(11), 2450-2457. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20738765

Bauer, K. A., & Lip, G. Y. (2019). Overview of the causes of venous thrombosis. In UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-causes-of-venous-thrombosis

Data and Statistics on Venous Thromboembolism. (2019, August 9). Retrieved August 11, 2019, from https://www.cdc.gov/ncbddd/dvt/data.html

Garcia, D. A., & Crowther, M. (2019). Risks and prevention of bleeding with oral anticoagulants. In UpToDate. Retrieved from https://www.uptodate.com/contents/risks-and-prevention-of-bleeding-with-oral-anticoagulants

Goltzman, D. (2019). Diagnostic approach to hypocalcemia. In UpToDate. Retrieved from https://www.uptodate.com/contents/diagnostic-approach-to-hypocalcemia

Higgins, C. (2007, July). Ionized calcium. Retrieved from https://acutecaretesting.org/en/articles/ionized-calcium

Hoorn, E. J., & Sterns, R. H. (2019). Causes of hyponatremia without hypotonicity (including pseudohyponatremia). In UpToDate. Retrieved from https://www.uptodate.com/contents/causes-of-hyponatremia-without-hypotonicity-including-pseudohyponatremia

Kearon, C., & Bauer, K. A. (2019). Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity. In UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-deep-vein-thrombosis-of-the-lower-extremity

Lip, G. Y. (2011). Implications of the CHA2DS2-VASc and HAS-BLED Scores for Thromboprophylaxis in Atrial Fibrillation. The American Journal of Medicine, 124(2), 111-114. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20887966

Manning, W. J., Singer, D. E., & Lip, G. Y. (2019). Atrial fibrillation: Anticoagulant therapy to prevent thromboembolism. In UpToDate. Retrieved from https://www.uptodate.com/contents/atrial-fibrillation-anticoagulant-therapy-to-prevent-thromboembolism

Sterns, R. H. (2019). Causes of hypotonic hyponatremia in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/causes-of-hypotonic-hyponatremia-in-adults

Sterns, R. H. (2019). Overview of the treatment of hyponatremia in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-treatment-of-hyponatremia-in-adults

Sterns, R. H. (2019). General principles of disorders of water balance (hyponatremia and hypernatremia) and sodium balance (hypovolemia and edema). In UpToDate. Retrieved from https://www.uptodate.com/contents/general-principles-of-disorders-of-water-balance-hyponatremia-and-hypernatremia-and-sodium-balance-hypovolemia-and-edema

Sterns, R. H. (n.d.). Diagnostic evaluation of adults with hyponatremia. In UpToDate. Retrieved from https://www.uptodate.com/contents/diagnostic-evaluation-of-adults-with-hyponatremia

Thompson, B. T., Kabrhel, C., & Pena, C. (2019). Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism. In UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism

Wells, P. S., Anderson, D. R., Bormanis, J., Guy, F., Mitchell, M., Gray, L., … Lewandowski, B. (1997). Value of assessment of pretest probability of deep-vein thrombosis in clinical management. The Lancet, 350(9094), 1795-1798. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed?term=9428249

Yu, A. S., & Stubbs, J. R. (2019). Relation between total and ionized serum calcium concentrations. In UpToDate. Retrieved from https://www.uptodate.com/contents/relation-between-total-and-ionized-serum-calcium-concentrations

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