Afib tx algorithm

Afib. Hemodynam unstable? Shock it. Hemodynam stable? Use rate control (like BB or CCB) If shorter than 48h, cardiovert (chem or electrically) If longer than 48 h, enough time has passed we're seriously worried about a clot or thromboembolus in the left atrial appendage. So either get a TEE or anticoagulate for 3 weeks, then cardiovert patient.

Post lithotomy

After a lithotomy it's common for pts to have visible blood in the urine, and patients may be sent home if they have hematuria, but clotting blood in urine or anuria is concerning since they indicate a stricture or clot preventing flow.

Hyperbilirubinemia

Evaluation of hyperbilirubinemia:
feeding history (squash, carrots, sweet potatoes can all make eyes yellow/orange), blood type, Direct Coombs, CBC, retic count, Total and Direct bilirubinemia, head to toe progression, transcutaneous bilirubin meter, yellow gums.

No reported cases of kernicterus in healthy term infants.
Nevertheless, ALWAYS order a bilirubin for newborns. There is no reason kernicterus should happen. It is completely preventable.

Jaundice Risk Factors without Hemolysis:
Jaundice in first 24 Hours
Previous Jaundice in a sibling
Gestational 35-38 weeks (That's 38, even though limit of prematurity is 37 weeks.)
Exclusively breastfed
East Asian race
Easy Bruising
Maternal Age > 25 years old
Male Sex

Always check the level because scleral icterus is not 100%.

Possible causes of hyperbilirubinemia:
Loss of blood
Increased shunt
Overproduction
Hemolysis
Polycythemia
Increased Enterohepatic Circulation
Bowel Obstruction
Intestinal Hypomotility
Undersecretion
-decreased conjugation
liver disease

CT Screening for Smokers and X-Smokers

Aortic Valve Replacement Areas

LEAD POISONING MANAGEMENT

EARLY MANAGEMENT OF PANCREATITIS

OSTEOPOROSIS AND OSTEOPENIA

COMAT Insight

Ranson's Criteria

Admission Criteria:

Glu > 200
Age > 55
LDH > 350
AST > 250
WBC > 16

First 48 hr after admit criteria

Calcium < 8
Decr Hct > 10%
PaO2 < 60
base def > 4
BUN incr > 8
Fluid sequestration > 6 L

Duke's Criteria

Causes of Hypokalemia

GI Losses
Kidney Urinary Loss
Poor oral intake
Insulin
Hyperthyroidism
Iatrogenic Cushings
Hypocalcemia
Bartter Genetic Syndrome = recessive derangement of renal tubule resulting in sodium, potassium, chloride loss.
Metabolic Alkalosis
Hypomagnesemia
Hyperaldosteronism = Conn's Syndrome,

Tx: K-sparing diuretics, antiemetics, KCl infusion.

COPD vs. Asthma

Asthma	COPD
	O2 sat, stationary/ambulatory
symptomatic albuterol	symptomatic per questionaire
Med adjust ICS 1st	med adjust LAMA/LABA 1st
Influenza vax annually	Influenza and PNA vax annually
3-6 month followup if stable	2-3 month followup if stable

Nova Core Rotation Forms

Student Rotation Eval

Case Presentation Eval

M4 OMM Log

Elective Rotation Application

Derm Office Phone: (407) 359-2100

J: Cayman

F: Pl Surg Choi

M: OBGYN Johnson Kenneth DO.

A: Peds/Hospital Palmetto

M: EM at FL Hospital East

1: evals
2: reading: www.cdemcurriculum.org
3: blackboard module
4: online tests: www.saemtests.org 
At least 10
Need to do these 6 within the 10:
Chest Pain and Cardiac Arrest

‣ Pulmonary

‣ Abdominal Pain and GI Bleed

‣ Neuro / Headache and AMS

‣ Trauma and Procedure


‣ Environmental and Endocrine

Jn: Surg II Memorial

Jl:

A:

S:

O:

PE2hday

CE: 3tday6twrday

Correcting Hyperkalemia Mnemonic: C BIG K

C: Calcium gluconate (fast)

B: sodium bicarb
I: Insulin
G: Glucose

K: K exelate (slow)


If it's a bit high: 5-6: just K

If it's 6-7: Use C

If  >7: Use it all.

Insulin Timing Table

The Significance of HASBLED and CHADS2 and CHADS2VASC2

C: CHF
H: HT
A2: Age 75+
D: DM
S2: Stroke/TIA/PE/DVT
V: Vascular issues
A: Age 65-74
S: Sex  Female

Interpretation:
Stroke Risk per year for the pt
0-0%
1-1.3%
2-2.2%
3-3.2%
4-4.0%
5-6.7%
6-9.8%
7-9.6%
8-6.7%
9-15.2%

Application to Afib: 2+ gets anticoagulation tx. 1, either way. 0 gets rate control. Tx: Oral anticoagulant, with well controlled Vitamin K Antagonist (VKA, e.g. warfarin with time in therapeutic range >70%), or a Non-VKA Oral Anticoagulant (NOAC, e.g. dabigatran, rivaroxaban, edoxaban or apixaban)


H: HT >160 sys
A: Abn Liver, Kidney Fxn (1 ea)
S: Stroke Hx
B: Bleed Hx
L: Labile INRs
E: Elderly >65yo
D: Drugs, EtOH (1 ea)

Interpretation:
Absolute Serious Bleed Risk
0-1.13%
1-1.02%
2-1.88%
3-3.74%
4-8.7%
5-12.5%

Causes of Hyperkalemia

Intake: Too much K either oral or IV.

Kidney-related:
Adrenals:
Adrenal Insufficiency
Chronic = Addison's
Adrenal Hyperplasia --> 22 hydroxylase def. (recall that 11 hydroxylase def causes High BP)
AKI
Acute Tubular Necrosis
Renal Tubular Acidosis Type IV
Hypoaldosteronism

Cellular Damage:
Trauma
Burns
Radiation
Rhabdomyolysis
Tumor Lysis Syndrome

Somatic Cell Pump Problems
Digitalis Toxicity: inhibits the sodium potassium pump.
Metabolic Acidosis: inhibits the sodium potassium pump via electrolytic dysregulation

Pseudohyperkalemia: Tying the touniquet too tight on the arm can cause cells to lyze spilling their potassium into the sample and causing a false elevation.

Viral Meningitis

Diagnose Meningitis on PE with tests:
Kernig: flex thigh and knee to 90 degrees. Wont be able to fully extend knee.
Bruzinski (1) Neck: curling neck painful and elicits thigh flexion. (2) cheek: pressing cheek elicits elbow flexion. (3) Symphyseal: pubic pressure elicits thigh flexion and abduction.

Diagnose Meningitis gold with Brain MRI

Diagnose Viral vs. Bacterial vs. Fungal with Lumbar Puncture.

Viral: elevated protein (norm: 15-45)
Bacterial: reduced glucose (norm: 50-75)
Fungal: elevated lymphocytes

Causes: Often fecal-oral spread, usually hematogenous. (sometimes resp)

85% caused by enteroviruses: Echovirus, Coxsackie A, B, assoc: rash, pharyngitis, pericrditis, pleurodynia

Also, Echoviruses 70, 71. May cause GBS = Guillain Barre

5% Arboviruses: St. Louis Encephalitis, West Nile, although encephalitis more common.

Also, Mumps causes 10-20% of VM cases in unvaccinated populations.

4% of cases are Herpes viruses. Acyclovir early tx can help. Most often HSV-2

5-10% of HIV+ pts get viral meningitis.

Tx of viral meningitis: analgesics w Acyclovir 750 IV q8 x 14 d just in case it's a Herpes virus. Otherwise self limiting.

Other causes of "aseptic" meningitis include TB-, Mycoplasma-, Fungal- and Lyme Dz-caused.

Core meds of CHF

beta blockers
ACEIs

Hypertensive Urgency and Hypertensive Emergency

Hypertensive Emergency defined by BP > 180/120 w evidence of impending or present organ dysfunction (e.g. cerebral dysfxn, renal failure, coronary ischemia, pulmonary edema

Hypertensive Urgency: no organ damage.

Pressor Talk

In order of preference for treating SHOCK, also in order of stack unless in parentheses

1. Norepinephrine if SBP < 70, alpha1 with very little beta1 activity. 0.013 ug/kilogram/min, or neo synephrine if you need to infuse via IV instead of central line.
2. Epinephrine alternative or stack, less active, 50 ug/kg/min
3. Vasopressin for combination w Norepi to decrease side effects. Not wt dependent.
(4.) Dopamine, but not recommended for first line. d/t greater beta1 activity, for renal perfusion. 20 ug/kg/min.

Revised Cardiac Risk Index ( RCRI )

Risk Factors:

1. High risk surgical procedure (including intraperitoneal, intrathoracic, supralingual vascular)
2. History of MI or positive exercise test, or chest pain 2/2 cardiac ischemia, current nitrate therapy, or ECG with pathologic Q waves.
3. Hx of CHF, pulmonary edema, paroxysmal nocturnal dyspnea, current b/l rales, S3 gallop, Chest radiography showing pulm vasc redistribution
4. Hx of cerebrovascular dz (includes TIA, stroke)
5. Preoperative tx with insulin
6. Preoperative serum Cr > 2.0 mg/dL

Risk MACE based on RCRI: (give 'em a point for every risk factor above that applies.)

Score/Risk Index Class/Risk of major cardiac complication (%)

0/I/0.4%
1/II/0.9%
2/III/6.6%
3+/IV/11.0%

ABx

Anaerobes above diaphragm: below diaphragm

cipro: flagyl

MRSA and PSA drugs IV and PO. and Dosage Ratios

PSA: Zosyn (IV), Levaquin (PO), Cipro (PO), Cefepime (IV), Aztreonam (IV), Ceftazidime (IV), Merrem (IV)

MRSA: Vanc (IV), Clinda (PO), Doxy (PO), Ceftaroline (IV), Daptomycin (IV), Linezolid (PO)

CAP: Rocephin (IV) virtually the same as Cefdinir (Omnicef) (PO)

Anaerobes: Unasyn = Ampicillin Sulbactim (PO) (Augmentin)

Atypical: Azithro (PO), Flagyl (PO)


Most POs available IV.



PO Choices

PSA Fluoroquinolones
MRSA-CLinda, Doxy, Zyvox

CAP- Omnicef


Anaerobes (Aspiration PNA, GI)-Augmentin, Flagyl


Atypical- Z-pack

Skin (G pos) Bactrim



Fluoroquinolones cover G+, G-, Atypical

IV to oral dosage ratios

Azithro 1:1 250-500mg
Cipro 400 BID :500 BID
Levaquin 1:1 750
Moxifloxacin 1:1 400
Doxycycline 1:1 100 BID
Rocephin 1 g qDay: 300  BID
Clinda 1:1 300 TID
Flagyl 1:1  500 QID
Zyvox 1:1 600

Diuretics

Bumex 1:1 0.5 OR 1 OR 2
Pepcid 1:1
Fluconazole 1:1 150-200
Lasix 1:2 10-80 QID
1 Bumex IV = 40 Lasix IV
Synthroid 1 : 2
Lorazepam 1:1
Metoprolol 1:2.5
Morphine 1:3-4
1 Morphine IV = 0.75 Dilaudid IV
Fentanyl 10 mcg IV = 1mg Morphine IV

Heart Block

1st Degree

PQ interval bigger than 5 little boxes = .1 s. One little box = 0.02 s

2nd Degree

Type 1 = Winkebach: PR interval gets longer and longer until a QRS drops, then restarts the cycle.

Type 2: QRS randomly drops, otherwie constant PR intervals.

3rd Degree

Totally dissociated Ps and QRSs

The Four and a Half Classes of PNA, Bugs, and Usual Drugs

WAP (Walking PNA)
Atypical

Azithromycin (N/V/D, rash, ringing)
Tetracycline (no kids allowed, vag candida, N/V/D, skin photosens)

CAP (Community Acquired PNA)
Atypical, G pos, G neg

outpatient young: Azithro, or else doxycycline
outpatient old (>60): Omnicef (

HAP (Hospital Acquired PNA) and VAP (Ventilator assoc. PNA)
> 48 hrs post hospital admit
PSA, MRSA, Atypical

Use all three: Zosyn (Kidneys, Salt) or Cefepime + Vanc (kidneys), or else Linezolid (thrombocytopenia) + Azithro

HCAP
2+ hosp days <90 days ago OR nurse txed you < 30 days ago OR family had MDR  (Multidrug resistant) infx.
PSA, MRSA, Atypical

see HAP

Light's Criteria OR transudate vs exudate

Light's Criteria

Determination of transudate versus exudate source of pleural effusion

Fluid is exudate if one or more of the following Light’s criteria is present:^{[1, 2, 3, 4]}

Mnemonic: 5,6,7 PLR. (Like "pleura"):

• Effusion protein/serum protein ratio greater than 0.5
• Effusion lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6
• Effusion LDH level greater than two-thirds (0.67) the upper limit of the laboratory's Reference range of serum LDH

Exudative effusions

See the list below:

• Abdominal abscess fluid near lung or PNA, Meigs syndrome (ovarian tumor, ascites, pleural effusion), pancreatitis
• Connective-tissue disease: Churg-Strauss disease, lupus, rheumatoid arthritis, Wegener granulomatosis
• Endocrine: Hypothyroidism, ovarian hyperstimulation
• Iatrogenic: Drug-induced, esophageal perforation, feeding tube in lung
• Infectious: bacterial pneumonia, fungal disease, parasites, tuberculosis
• Inflammatory: Acute respiratory distress syndrome (ARDS), asbestosis, pancreatitis, radiation, sarcoidosis, uremia
• Lymphatic abnormalities: Chylothorax, malignancy, lymphangiectasia
• Malignancy: Carcinoma, lymphoma, leukemia, mesothelioma, paraproteinemia

Transudative effusions

See the list below:

• Atelectasis: Due to increased negative intrapleural pressure
• Cerebrospinal fluid (CSF) leak into pleural space: Thoracic spine injury, ventriculoperitoneal (VP) shunt dysfunction
• Heart failure
• Hepatic hydrothorax
• Hypoalbuminemia
• Iatrogenic: Misplaced catheter into lung
• Nephrotic syndrome
• Peritoneal dialysis
• Urinothorax: Due to obstructive uropathy

Exceptions

These are processes that typically cause exudative effusions, but may cause transudative effusions.

• Amyloidosis
• Chylothorax
• Constrictive pericarditis
• Hypothyroid pleural effusion
• Malignancy
• Pulmonary embolism
• Sarcoidosis
• Superior vena cava obstruction
• Trapped lung

Admissions Mnemonic: ADCA VANDIMLS

A-Admit to you, attending physician to 1) Med Surg 2) Med Tele 3) PCU 4) ICU
D-Diagnosis
C-Condition Code Status
A-Allergies
V-Vitals
A-Activity Bed rest? Can get up?
N-Nursing Orders: eg skin care, glasses, hearing aids, lighting, toileting
D-Diet Liquids, Low salt, Low carb, Renal?
I- IV fluids NS 0.9%, Ringer's Lactate, for CHF < 2L a day
Meds
Labs
Special

What's a Hutchinson Sign?

herpetic lesion on the tip of the nose, which is on the same dermatome as the eye

merits a STAT ophthalmologic consult as can be a heralding sign of Zoster Ophthalmicus

Dx: Brain MRI
TX: Steroids, Valcyclovir OR Famcyclovir

For Chest Pain with SOB, always order these 10 Tests...

EKG
Chest X ray =CXR
CE x 3 = cardiac enzymes
CMP
CBC
D-dimer
BNP
Mg Phos
Procal
Respiratory PCR

For PNA always order these 6 Tests...

Resp PCR
Procal
Sputum Culture
UA = Urinalysis
Strep Ag
Legionella Ag

Common Meds, formulations and what they (basically) cover

Rocephin (IV): G neg, G poss
Omnicef (PO): G negs, G poss
Cipro (PO): G negs
Flagyl: G poss, Anaerobes
Zosyn (IV): G poss, G negs, PSA
Levo (PO): G negs, G poss, Atypicals, PSA
Azithro: Atypicals
Vancomycin: MRSA
Doxycycline: G poss, MRSA

Infections:
UTIs: G poss, G negs: Rocephin
Skin: G pos, MRSA: Doxycycline

11 Common Complaints of Pregnancy

1. Nausea

due to estrogen, twins (more estrogen), if nauseous w birth control

Hyperemesis gravidarum
-persistent vomiting w
>5% weight loss
Tx: grazing (snacking instead of big meals)
bland food, avoid problem foods.
mints
fluids
avoid odors
stay rested
Accupressure
Ginger 250 QID
Continue Folic Acid.
Vit B6 25 q6-8
 max 200/day

Complication: Ketoacidosis. Be sure to check Ketones in urine. Zofran if necessary.

2. Blurring of vision
r/o stroke, gestational DM, preeclampsia, but
often normal effect of pregnancy, will go away after pregnancy
do NOT get eyeglass Rx at this time.
Tx: OMT for orbital restriction

3. Intense B/L lower pelvic pain
Tylenol helps
Dx: round ligament pain
Usually 2nd trimester
Txs: heat pads, hot baths, downward-facing dog yoga position, pregnancy support belt.
OMT: hold up belly, release the pelvic floor.

4. Dark patches of skin over forehead
Dx: Cloasma, the melisma of pregnancy
Tx: hydroquinone cream

5. Acid Reflux
Tx: lifestyle modifications, smaller meals, NPO 3h QHS, elevate bed, sucralfate, Ca Carbonate, H2 blockers, proton pump inhibitors, OMT to ease fascial restrictions

6. Highly Pruritic Lesions all over body
Dx: PUPPP
Hives, primigravidas, 3rd trimester, pruritis/skin lesions.
Tx: Pine Tor Soap, Topical steroid, if not then oral steroid, if not then oral antihistamines (Benadryl, or famotidine)
Not a dangerous condition, just uncomfortable.

7. Numbness and Tingling in fingers, especially in the morning
35-40% of pregnant women get it. Resolves post-partum
Tx: Open the thoracic inlet, cross-thumb technique, long axis traction, lymphatic drainage, carpal tunnel pump

8. Intrahepatic cholestasis of pregnancy (IHC)
Very itchy, no rash
Tx: ursodeoxycholic acid or cholestyramine
Bilirubin normal, Coags, U/S normal.
Increased risk of NRDS, fetal demise, prematurity, consider sending to hospital with NICU for birth.

9. Lower Extremity Edema (d/t progesterone)
Tx: elevate legs, salt restriction, compression socks
OMT: open the pelvic diaphragm!, pedal pump, effleurage
r/o DVT, Pre-eclampsia,.

10. Meralgia Paresthetica
Tingling numbness in thigh, entraps lateral femoral cutaneous nerve.
Tx: release tight fascia, prolotherapy?

11. Low Back Pain (LBP)
d/t relaxin, estrogen, progesterone
Tx: stretch, Tylenol, swimming, yoga, Do NOT give motrin as will inhibit the closing of the Ductus arteriosus.

Hyponatremia

Hyponatremia

 Hyponatremia is clinically defined as serum sodium &lt; 135 mmol/L.

 Hyponatremia is the most common electrolyte abnormality.

 Symptoms of hyponatremia include nausea, vomiting, , muscle

weakness/cramps, headache, encephalopathy, and coma.

 Risk factors include advanced age, intensive athletic activity, and drugs

including thiazide diuretics, antidepressants, opioids, NSAIDs and Ecstacy.

 Treatment of asymptomatic patients consists of correction of the underlying

disorder, whereas IV saline should be used to correct symptomatic patients.

Hypovolemic Hyponatremia (thirst, dry mucus membranes, dry mouth) due to

total body sodium loss, with relatively smaller loss in body water.

 If Urine Sodium &gt; 20 mEq/L, renal solute loss may be cause.

o Increased diuresis, leading to increased ADH secretion

-loop diuretics (bumetanide, furosemide, torsemide, etc.)

-osmotic diuretics (mannitol, isosorbide, etc.)

-glucosuria (DM1, DM2): treat underlying DM.

o Post-obstructive diuresis (POD) (sudden release of bladder

obstruction, with decrease in hydrostatic bladder pressure, causes

sudden increase in diuresis)

 Urine Sodium ≤ 20 meq/L indicates extrarenal solute loss from different

causes of dehydration. Common etiologies include:

o GI loss

o Hyperhidrosis (eg Exercise Associated Hyponatremia (EAH))

o Diarrhea

o Vomiting

Hypervolemic Hyponatremia (peripheral edema, ascites, SOB)

 Urine Sodium &gt; 20 mEq/L

 Urine Sodium ≤ 20 meq/L Extrarenal solute loss

o Renal Failure

-Pre- renal (poor renal perfusion, HF, cirrhosis)

-Intrinsic

-Post- renal (obstruction)

o Post-obstruction (sudden release of bladder obstruction)

o Edematous Disorders

-HF

-Cirrhosis

-Nephrotic Syndrome

Euvolemic Hyponatremia (no edema, but with volume expansion in the body with

hyponatremia)

 Urine Sodium is usually &gt; 20 mEq/L

o Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

-Causes: Pneumonia, Tumor, Guillaine Barre Syndrome, Encephalitis,

Head Trauma

o Endocrinopathies

-Glucocorticoid deficiency: Addison’s disease, congenital adrenal

hyperplasia, secondary, or tertiary adrenal insufficiency

-Hypothyroidism: decreased kidney function

o Potassium Depletion, can lead to dysfunction of potassium-sodium

pump in collecting duct and loss of sodium.

o Overhydration from polydipsia: although ADH is appropriately

suppressed in these patients, excessive drinking of water overwhelms

kidneys’ ability to excrete.

Also: Pseudohyponatremia or Isotonic Hyponatremia (laboratory artifact from

blood abnormalities, serum tonicity will be 280 – 295 mOsm/L)

-Hyperlipidemia (HLD)

-Hyperproteinemia (after strenuous exercise, in MM, etc)

CAP PNA (community acquired pneumonia) regimen

Rocephin or Aztreonam
Azithromycin
Sputum Cx
Resp PCR
Strep Ag
Legionella Ag
Lactic Acid
IVF
O2

CHF regimen

IV lasix 20-40
Strict I/O, fluid restriction
Daily Weights

Longterm: ACE inhibitor, beta blocker

How to Think About Abx

Abx Categories:

Think in terms of 6 categories you need to cover, rather than all the organisms (except PSA and MRSA):

Gram (+)
Gram (-)
Atypicals
Anaerobes
PSA
MRSA

So for different regimens:

Zosyn (IV): G(+), G(-), PSA, Anaerobes
Vanc (IV): MRSA/MSSA
Azithro (PO): Atypical


OR


Levaquin (PO)(s/e: tendon rupture): PSA, G(-), G(+), Atypicals, Anaerobes
Doxy (PO): Atypical, MRSA (esp community acquired)


Complicated UTI:

Rocephin (IV)(s/e: transaminitis): G(+),G(-)

Pseudomonas and MRSA Abx Options

Pseudomonas aeruginosa: the PSA City Zoo Loves its Mischievous Animal Friends: , its Camel named C-dime and its Gorilla named C-pime.
Ciprofloxacin
Zosyn
Levoquin
Moxifloxacin
Amikacin
Fosfomycin
Carbapenems, eg. Merrem. Aztreonam
3rd Gen. Ceftazidime (big one it covers is Vibrio)
Gentamycin
4th Gen. Cefepime

MRSA: Mrs. Very-Cute-Bear doesn't mind looting delicious camp rations
Vancomycin
Clindamycin: o
TMP-SMX (Bactrim): o
Doxycycline: o
Minocycline
Linezolid
Daptomycin
Ceftaroline
Rifampin

PE Findings of Meningitis

Headache

Pos. Kernig's Sign: Pt supine with hip flexed to 90 deg. Extending lower leg painful.

Pos. Brudzinski Cheek: Pressure to cheek causes UExtremity flexion

Pos. Brudzinski Symphyseal Sign: Pubic Symph. pressure causes Hip flexion, abduction

Pos. Brudzinski Neck Sign: Flexion of Neck causes Flexion of Hips.

5 Types of MI

1. Spontaneous MI from burst Atherosclerotic Plaque
2. MI 2* Ischemia (increased )2 demand or decreased supply, eg Prinzmetal angina)
3. Sudden Cardiac Death - Hypertrophic Cardiomyopathy
4. a) MI Post-PCI   b) MI post-stent d/t thrombosis
5. MI post-CABG

Procalcitonin

Procal > 0.1 tells us probably bacterial

SIRS definition

HR > 90
RR > 20 or PaCO2 < 32mm Hg
Temp > 100.4 or <96.8
WBC > 12thousand

2 of these makes SIRS

SEPSIS = SIRS + SOURCE IDed

SEVERE SEPSIS = SEPSIS + Lactic Acid > 3 (ORGAN FAILURE)

SEPTIC SHOCK = SEVERE SEPSIS + BP profound drop MAP < 60 Hg

Complicated vs Uncomplicated UTI Management

Complicated: Male or Female w Flank Pain, Stone or WBC Casts/Clumps

treating G pos and neg:

FluoroQs
Zosyn
Penems
4th Gen Cephalosporins: Cefepime
Fosfomycin

For 7-14 days

Uncomplicated: Female otherwise w dysuria, bladder fullness

Nitro
Bactrim
FQ

3-5 days

Get the following

Renal US
ABx
Bio-K
Urine Cx
Blood Cx
Procal
Lactic Acid
CRP

With AMS?  Ammonia, RPR, TSH, Vit B12, Folate, UDS= urine drug screen (cocaine)

Weekend assignments

6,7: Paul, Pavan
13,14: A, M
20, 21: F, K
27, 28: A, K

Switching between NPH/Reg insulin and Long-acting+Ultra-short Acting Insulins

Let's say we have a patient on 20 units of Humulin BID normally who is admitted to the hospital.

To convert to long-acting and ultra-short acting units for her hospital stay, know the split, which is 70/30 between NPH/Reg. Making 40 x .7 = 28 units of Long-acting Glargine and 40 x 0.3 = 12 units of Lispro.

Since Glargine is slightly more "effective" than NPH, only use 80% of the 70%, which is about 22 units of Glargine.

Fecal Occult Positive procedure

Without iron def anemia, do a colonoscopy.
With iron deficiency anemia, do colonoscopy and upper endoscopy.

Muscle Strength Scale

5/5-full strength against resist.
4/5-some strength against resist
3/5-able to move against gravity, but not resistance.
2/5-able to move side to side, but not against gravity
1/5-muscle flicker
0/5-no muscle reaction.

Causes of Hyperkalemia

Kidney Failure: No GFR, no potassium loss.

RTA Type 4- urine pH usually below 5.3

Acute Tubular Necrosis- MCC of acute kidney injury, often from lack of Oxygen.

Adrenal Hyperplasia d/t deficiency of 22 beta hydroxylaseà no aldosteroneà potassium buildup.

Lupus Nephritis

Transplant Rejection

Glomerulonephritis

Cellular Damage

Rhabdomyolysis- Muscle overuse/overexertion causes rupture

Trauma-Electrical/Thermal Burns/Head Trauma, etc.

Tumor Lysis Syndrome- inappropriate cellular growth results in lysis.

Metabolic Acidosis

Ion Imbalance

Digitalis toxicity- mechanism is to inhibit Na-K ATPase.

Hypocalcemia-don’t discuss

Also Beware of Pseudohyperkalemia

Tying tourniquet too tight causes lysis of RBCs and falsely high serum potassium reading.

Principles of Sliding Scale Insulin in the Hospital Setting

In the Hospital, Everyone goes on Insulin, because we don't like the side effects of the oral meds on top of the stresses on the patient from hospital procedures. But how much of what kind to give?

Step 1: Figuring out the base insulin you will give to Patient:

For Pts on Orals outside the hospital (e.g. metformin), multiply their weight (kg) times 0.3 to get total insulin.
For Pts on Insulin with controlled glucose outside the hospital, mult. weight times 0.5 to get total insulin.
For pts on insulin with uncontrolled glucose outside the hospital, multiply wt times 0.7 to get total insulin.

Step 2: What insulin to give as a baseline

First divide total by 2. Half will be Glargine, long-acting that will cover baseline metabolic activity. Half will be untra-short-acting Lispro, which will further be divided in three for each of the three meals of the day.

Step 3: Sliding Scale

Everybody is different, and some people won't react as well as you want. Ideally you want your patient to be between 120 and 179 Serum Glucose at ALL times. You'll try using the amount of Glucose we derived from Step 2, but if their post-prandial glucose levels are out of range (measure for each of their meals), use the sliding scale.

Start with a low sliding scale, and if they are way  out of range, use a medium scale, which basically amounts to more units to be added the next day to the total insulin.

Typical scales look like this:

100-149: 0 addt'l units
150-199: 1 add'l unit
200-249: 2 add'l units
250-299: 3 add'l units
300+: 4 add'l units.

You will take each of the meals' glucose levels and add together add'l units of insulin from each meal. You will take the total add'l insulin and divide this in the same proportions as baseline insulin we calculated in Step 2, adding it to whatever we used the previous day.

Repeat as necessary, until patient is back in the normal range of 120-179 after meals.

For Example:

Let's say you have a 100 lb patient who takes oral metformin to control their diabetes who you are admitting.

Step 1: They will get a baseline of 30 units of insulin a day.

Step 2: 15 will be insulin glargine, and 15 insulin lispro divided among their 3 meals, making 5 units of lispro before every meal.

Step 3: After the first day, you note their post-prandial glucose levels are as follows:

Breakfast: 200
Lunch: 270
Dinner: 170

Using the scale above, You would then have to add 2 add'l units for breakfast, 3 for lunch and 1 for dinner, making a total of 6 units. So your insulin the next day will be 15 + 3 = 18 units of Glargine for the day, and 5 + 1 = 6 units of Lispro insulin for each meal.

DKA vs HHS Diagnosis and Management

Diagnosis: How to Tell the Difference

DKA vs HHS
Type 1 DM                                                 vs. Type 2 DM
Glucose > 250                                             vs. > 600
pH < 7.3                                                       vs. > 7.3
Bicarb < 15                                                  vs. > 15
Moderate Ketonuria                                     vs. Non-Ketotic
(Anion Gap = Na- (Cl + Bicarb)) > 12mEq vs. Osmolality > 320 mOsm/L
Abs Insulin Def.                                            vs. Profound Hyperglycemia, no significant ketones

3 Things needed to Dx DKA
Hyperglycemia
Ketosis
Systemic Acidosis

Food Poisoning Differential

Vomiting Predominant: 

Staph aureus (esp. mayo)
Bacillus cereus (esp. rice)
Noroviruses, eg Norwalk

Watery diarrhea predom:

C. perfringens
Enterotoxic E. coli
Enteric viruses
Cryptosporidium
Cyclospora
Intestinal tapeworms

Inflammatory diarrhea predominant

Salmonella (typhi and non-typhi)
Campylobacter
Shiga-toxin producing E. coli
Shigella
Enterobacter
Vibrio (usually parahaemolyticus)
Yersinia

Non-GI Symptoms

Botulism (descending paralysis)
Ciguatera toxin (paresthesia)
Scombroid (flushing, itching)
Listeria (meningitis)
V. vulnificus (cellulitis, sepsis)
Hep A (jaundice)
Brucellosis (fever, arthralgia)

Acute Cervical Adenitis in Children

Unilateral:

Staph aureus OR Strep pyogenes: erythema, tenderness

Anaerobic bacteria, eg Prevotella: Dental caries

Bartonella henselae: Papular nodularity at site of cat scratch

Mycobacterium avium: gradual onset, nontender

Bilateral:

Adenovirus: Pharyngoconjunctivitis

EBV: Mononucleosis

Seven Wise Words from Doctor Somji

1. Medicine is gray.
2. D/C patients by 9-9:30AM
3. D/C Summaries done by end of shift.
4. "I don't know" doesn't exist.
5. If it doesn't make dollars, it doesn't make sense (unless it is good medicine/good for the patient).
6. Don't regurgitate; understand.
7. Always call ED back IMMEDIATELY.
8. CHF patients get Cefepime instead of Zosyn because Zosyn has a lot of salt.

Converting A1c reading into average Glucose from last 3 months

For every point of A1c over 6, add 30 to a baseline Glucose of 120, to get the average glucose over the past 3 months.

For example, An A1c of 9, indicates an average glucose over the past 3 months of 210.

Correcting Sodium for High Glucose Values

When you've got a high glucose, sometimes it's necessary to correct sodium.

You do this by taking the recorded glucose and, if it's higher than 199, add 1 to the recorded Sodium for every additional hundred glucose, to get the actual, corrected Sodium.

So for example, your patient's Glucose is 359, and recorded Sodium is 139. You add 2, since you're in the 300s. So your corrected Sodium is 141.