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FADevisM_FM.qxp 9/12/08 7:46 PM Page 3
Medical
Notes Clinical Medicine Pocket Guide
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
As new scientific information becomes available through basic and clinical research,
recommended treatments and drug therapies undergo changes. The author(s) and
publisher have done everything possible to make this book accurate, up to date, and
in accord with accepted standards at the time of publication. The author(s), editors,
and publisher are not responsible for errors or omissions or for consequences from
application of the book, and make no warranty, expressed or implied, in regard to
the contents of the book. Any practice described in this book should be applied by
the reader in accordance with professional standards of care used in regard to the
unique circumstances that may apply in each situation. The reader is advised always
to check product information (package inserts) for changes and new information
regarding dose and contraindications before administering any drug. Caution is
especially urged when using new or infrequently ordered drugs.
Authorization to photocopy items for internal or personal use, or the internal or per-
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vided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Dan-
vers, MA 01923. For those organizations that have been granted a photocopy license
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the Transactional Reporting Service is: 8036-1746/09 $.25.
FADevisM_FM.qxp 9/12/08 7:46 PM Page 5
✓ HIPAA Compliant
✓ OSHA Compliant
For a complete list of Davis’s Notes and other titles for health
care providers, visit www.fadavis.com
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 1
1
Diseases and Disorders
American Cancer Society Guidelines:
Cancer (CA) Detection
Breast CA (Women)
■ ⱖ40 y.o.: Mammogram every year
■ Clinical breast exam: 20-39 y.o. ~q3yr and ⱖ40 y.o. every year
■ Breast self-exam option for ⱖ20 y.o
■ ⬎20% lifetime risk: MRI and mammogram every year
■ 15%-20% lifetime risk: discuss w/physician about MRI
Colon and Rectal CA
■ ⱖ50 y.o. male or female: Do one of following five:
■ Fecal occult blood test (FOBT) or fecal immunochemical
test (FIT) every year
■ Flexible sigmoidoscopy q5yr
■ Yearly FOBT or FIT and flexible sigmoidoscopy q5yr
(preferred)
■ Double-contrast barium enema q5yr
■ Colonoscopy q10yr
■ Start earlier (e.g., ⱖ40 y.o.) if:
■ Pt history of colorectal CA, adenomatous polyps, or
chronic inflammatory bowel disease
■ Strong family history of colorectal CA or polyps (CA or
polyps first-degree relative ⬍60 y.o. or two first-degree
relatives any age)
■ Family history of hereditary colorectal CA syndrome
Cervical CA (for Women)
■ ~3 yr after begin vaginal intercourse or ⱖ21 y.o., whichever
comes first: Regular Papanicolaou (Pap) test every year or
newer liquid-based Pap test q2yr
■ When ⱖ30 y.o.:
■ May continue every year or change to q3yr HPV DNA test
and either conventional or liquid-based Pap test
■ If 3 normal Pap tests in a row, may change to q2-3yr
■ If risk factors*: Continue every year
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 2
BASICS
2
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 3
3
PR Interval (Normal: 0.12–0.20 sec)
■ Short PR (⬍0.12 sec) Could be normal variant or:
■ Wolff-Parkinson-White (WPW): Accessory path RA†RV or
LA†LV so early ventricle activation leads to Δ-wave (initial
slurring of QRS), ⁄QRS duration (usu. ⬎0.10 sec), second-
degree ST-T Δs from altered ventricular activation
■ Lown-Ganong-Levine: AV nodal bypass track into bundle
of His † early ventricle activation w/o Δ-wave
■ AV junctional rhythms w/retrograde atrial activation
(inverted P in II, III, aVF)
■ Ectopic atrial rhythms w/origin near AV node
■ Prolonged PR (:0.20 sec):
■ First-degree AV block (PR interval usu. constant); øconduc-
tion in atria, AV node, bundle of His, or bundle branch
(when contralateral bundle blocked)
■ Second-degree AV block (PR interval normal or ⁄; some P
waves do not conduct): Type I (Wenckebach): increasingly
⁄PR until a P not conducted; type II (Mobitz): fixed PR
intervals and nonconducted Ps
■ AV dissociation (Ps and QRS dissociated): Incomplete
(slow SA node so subsidiary escape pacemaker takes over
or subsidiary pacemaker faster than sinus rhythm) or
complete (third-degree AV block: atria and ventricles each
have separate pacemakers)
QRS Complex
■ Poor R wave progression (PRWP): Rⱕ3 mm in V1–3, normal
variant, LVH, LBBB, LAFB, anterior or anteroseptal MI, COPD
(R/S ratio in V5–6 ⬍1) ), diffuse infiltrative/myopathic
processes, WPW pre-excitation, heart rotates clockwise,
misplaced leads
■ Prominent anterior forces: R/S ratio ⬎1 in V1 or V2; normal
variant, posterior MI, RBBB, WPW pre-excite
QRS Interval (Normal: 0.6–0.10 sec)
■ QRS duration 0.10–0.12 sec: Incomplete RBBB or LBBB
(same as complete RBBB and LBBB except QRS duration),
nonspecific IVCD, LAFB, or LPFB (some)
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 4
BASICS
4
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 5
5
ST Segment
■ ST elevation
■ Normal variant “early repolarization” (usu. concave up,
ending w/symmetrical, large, upright T waves)
■ Ischemic heart disease: Acute transmural injury (usu.
convex up or straightened); persistent in post-acute MI
suggests ventricular aneurysm
■ Prinzmetal’s (variant) angina (coronary vasospasm)
■ During exercise testing † ⁄⁄⁄tight coronary artery stenosis
or spasm (transmural ischemia)
■ Acute pericarditis: Concave up ⁄ST (not aVR); no reciprocal
øST (except in aVR); unlike “early repolarization”, usu. T
low amplitude and ⁄HR; may see øPR (atrial injury)
■ Other causes: LVH (in right precordial leads w/large S);
LBBB; ⁄K+; hypothermia
■ ST Depression
■ Normal variants/artifacts: Pseudo ST depression (poor
skin-electrode contact); physiologic J-junctional depression
w/sinus tachycardia; hyperventilation
■ Ischemic heart disease: Subendocardial ischemia, non
Q-wave MI, reciprocal Δs in acute Q-wave MI (e.g., ST
depression in leads I and aVL with acute inferior MI)
■ Nonischemic causes: RVH (right precordial leads) or LVH
(left precordial leads, I, aVL), digoxin, øK+, MVP (some),
CNS dz, second-degree to IVCD (e.g., WPW, BBB)
T Wave
■ Normal: T same direction as QRS except in V2; asymmetric
w/first half moving more slowly than second half; T always
upright in I, II, V3–6, and always inverted in aVR
■ T-wave inversions: Normal variant, myocardial ischemia or
infarction or contusion, pericarditis (subacute or old),
myocarditis, CNS dz † ⁄QT (esp. SAH), idiopathic apical
hypertrophy, MVP, abnormal electrolytes, O2, CO2, pH, or
temperature, digoxin, post-tachycardia or -pacing, RVH and
LVH w/”strain”
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 6
BASICS
Evolution of Q-Wave MI
Q* T ST
Pre-MI
Hyperacute ⁄Amplitude/width May ⁄
Transmural Injury ⁄⁄⁄
Necrosis ⫹ Terminal inversion Less
Necrosis/Fibrosis ⫹ Inversion
Fibrosis ⫹ Upright
7
Atrial Arrythmias
■ Premature atrial complexes: Single or repetitive, unifocal or
multifocal, ectopic P (P’) may hide in preceding ST-T; P’R
interval nl/⁄; P’ may be nonconducted, conducted w/aberration
(e.g., wide QRS), or conducted normal
■ Premature junctional complexes: Retrograde P appears
before (PR usu. ⬍0.12 sec), during, or after QRS
■ Atrial fibrillation: Poorly defined atrial activity; appearance
may ~old saw; ventricular response = irregularly irregular
unless AV block
■ Atrial flutter: Regular atrial activity w/”clean” sawtooth appear-
ance in II, III, aVF, and usu. discrete ‘P’ in V1; atrial rate = 150-
450/min; AV conduction ratio may vary 2:1, 3:1, etc
■ Ectopic atrial tachycardia and rhythm: Ectopic, discrete,
unifocal P’ w/atrial rate ⬍250/min (⬍100 † rhythm); ectopic
P' waves usu. precede QRS w/P'R interval ⬍RP' interval;
ventricular response: 1:1 or varying AV block
■ Multifocal atrial tachycardia and rhythm: ⱖThree different P
morphologies in given lead; rate = 100-250/min (⬍100 †
rhythm), varying P'R intervals; ventricles: irregularly irregular
(i.e., often confused with atrial fibrillation); may be intermittent
■ Paroxysmal supraventricular tachycardia: Different re-entry
cicuits; sudden onset and stop; usu. narrow QRS (unless BBB
or rate-related aberrant ventricular conduction); types: AV
nodal re-entrant tachycardia, AV reciprocating tachycardia,
sinoatrial re-entrant tachycardia
■ Junctional rhythms and tachycardias:
■ Junctional escape beats: Origin AV jxn; rate: 40-60 bpm
■ Junctional escape rhythm: ⱖ3 Junctional escapes; rate
40-60 bpm; may be AV dissociation or retrograde † atria
■ Accelerated junctional rhythm: Rate = 60-100 bpm
■ Nonparoxysmal junctional tachycardia: HR ⬎100 bpm
Ventricular Arrythmias
■ Premature ventricular complexes (PVCs): May be unifocal,
multifocal, or multiformed; may be isolated single events or
couplets, triplets, or salvos (4-6 in row); may occur early in cycle
(R-on-T), after T, or late in cycle (fuse w/next QRS = fusion beat)
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 8
BASICS
Lumbar Puncture
Indications
■ Dx CNS disease, administer CNS treatment or treat
hydrocephalus
Contraindications
■ ⁄Intracranial pressure (ICP); intracranial mass effect (r/o mass
lesion: head CT when signs of ⁄ICP)
■ Bleeding dysfunction
■ Infection near site
■ Elderly: avoid fast and large volume withdrawals.
Equipment
■ Skin preparation: sterile sponges, povidone-iodine swabs,
and EtOH swabs
■ Mask, sterile field (towels and drapes), and gloves
■ Local anesthetic, usu. lidocaine 1% plain
■ Syringe (3 mL) and needles (22-G ⫻ 1.5”, 25-G ⫻ 5/8”)
■ Spinal needles (both 18- and 20-G, 3” length)
■ Three-way stopcock, sterile collection tubes, and manometer
■ Gauze dressings and adhesive bandage
Preparation
■ Sterile technique; skin preparation
■ Find L4-5 space (L4 at iliac crest level)
8
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 9
9
■ Local anesthesia: infiltrate skin (25-G needle), then Δ to 22-G
needle and advance † infiltrate deeper tissue
Patient Positioning
■ Lateral decubitus: (preferred): Lateral decubitus position at
edge of bed, while maximally flexing knees (near chest),
hips, and back (opens L3/L4 space) pt. shoulders and hips
perpendicular to bed
■ Sitting: (easier for obese or spinal dz/deformity): Pt. sits at
bed edge, leans over two pillows, flexes head
Technique
■ Insert spinal needle into skin and slowly advance (keep per-
pendicular to skin, hold w/two hands, keep stylet in place);
feel “pop”; perforate ligamentum flavum; withdraw stylet,
and look for CSF drainage
■ If no CSF and needle advanced ⬍4 cm (in adult), advance 2 mm,
remove stylet, and check for CSF drainage; repeat until get CSF
or needle advanced ⬎4 cm (then withdraw and redirect needle)
■ Connect three-way stopcock, and attach manometer;
measure opening pressure (normal 70-180 mm CSF)
■ Send fluid for studies; remove needle and dress wound;
pt. remains supine ⱖ12 h (minimize headaches)
Complications
Brain herniation (⁄ ICP and mass), infection (meningitis or empyema),
subdural hematoma (rapid withdrawal of large volume CSF), bloody
tap, spinal epidural hematoma, headache, dry tap † needle may be
too lateral or deep
■ For CSF interpretation see Labs Tab
Cricothyroidotomy
Indications
■ Emergent need for airway; airway obstruction above cricoid
cartilage level, failed intubation, or laryngeal trauma, mass,
or hematoma
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 10
BASICS
Contraindications
■ Subglottic airway obstruction
■ Intubation possible
■ Uncorrectable coagulopathy
Equipment
■ Suction
■ Local anesthesia (e.g., 1% lidocaine and 1:100,000 epinephrine)
■ Scalpel (ideally, No. 15 blade)
■ Retractors (Army-Navy or large vein refractors)
■ Kelly clamps
■ Suture (2-0 or 3-0 silk, 4-0 vicryl)
■ Cuffed tracheostomy tubes (preferable) or No. 4 or 5 small,
flexible endotracheal (ET) tubes.
Preparation
■ Palpate and locate cricothyroid ligament: between cricoid
and thyroid cartilages (~1.5 cm inferior to thyroid cartilage);
neck strap muscles lateral to ligament
Patient Positioning
■ Neck extended (unless cervical injury)
Technique
■ Sterilely prepare and drape skin
■ If enough time, infiltrate entry site with lidocaine
■ Scalpel † 3 cm horizontal (ørisk of thyroid or cricothyroid
cartilage damage) or vertical (better in obese when cannot
palpate cricothyroid membrane) incision over center of
cricothyroid membrane
■ Gently spread subcutaneous tissue w/clamp † expose
cricothyroid membrane; may need retractors to spread neck
strap muscles laterally
■ Avoid blood vessels, use scalpel to cut horizontally through
membrane; may widen incision with clamp
■ Insert tracheostomy tube or endotracheal tube
■ Inflate tube cuff; suture or tie down tube
■ Ventilate w/Ambu bag
■ Δ to formal tracheostomy ⱕ1 week (or risk stenosis)
Complications
■ Bleeding, subglottic/glottic stenosis, chondritis
10
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 11
11
Endotracheal Intubation
Indications
■ Significant ⁄ CO2 or ø O2 from respiration
■ Protect airway or pulmonary toilet
Contraindications
■ Only intubate if necessary
■ Inaccessible/damaged oral cavity/larynx † nasal intubation
(if no coagulopathy, severe intranasal problems, basilar skull
fracture, or CSF leak)
■ Cervical spine instability
Equipment
■ Lubricant: Water-soluble 2% lidocaine jelly
■ Tape and skin adhesive
■ O2 and bag-valve-mask ventilation device (Ambu bag)
■ If available: O2 saturation monitor,in-line CO2 monitor
■ Suction apparatus, suction tubing, tips, catheters
■ Laryngoscope w/straight and/or curved blade
■ Endotracheal tubes; syringe (10 mL) † inflate cuff
■ Flexible metal stylet and Magill forceps
■ Anesthesia
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 12
BASICS
Preparation
Patient Positioning
■ Extend head and flex neck; if possible (i.e., no cervical spine
problem), place foam material, “doughnut”, or folded towel
under occiput
Technique
■ Ventilate pt. w/bag-valve-mask; assess airway
■ Remove foreign bodies (e.g., dentures)
■ Assistant: Continuously push back anterolateral cricoid carti-
lage rim with first and second fingers until tube is placed
■ Open laryngoscope; use dominant hand to open mouth and
nondominant hand to insert laryngoscope blade into right
(left if left-handed) side of mouth
■ Sweep blade to midline tongue base (sweep tongue to other
side); blade tip should be in valleculae (curved blade) or
below epiglottis (straight blade)
12
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 13
13
■ Lift laryngoscope handle straight upward and forward †
expose vocal cord; avoid lips, teeth, and trap tongue; using
dominant hand pass lubricated ET tube through right (left if
left-handed) corner of mouth and advance tip through vocal
cords (while looking)
■ Remove stylet when proximal cuff ends at cord level
■ Advance tube into trachea; inflate cuff (~15 mm Hg); check
placement: symmetric chest expansion, breath sounds both
lungs (no breath in stomach)
■ Attach in-line CO2 monitor: Check for ⁄O2 saturation and CO2
in exhaled air
■ Secure tube w/tape (upper lip and cheek or neck)
■ Check chest x-ray (tip should be 4 cm above carina)
■ Once tube in place, longer-term sedation (aerosol benzocaine
[20%] † tongue and posterior pharynx, midazolam or
thiopental, fentanyl or morphine)
Complications
■ Tube in esophagus or right mainstem bronchus
■ Aspiration (may ørisk w/antacids, H2-blockers,
metoclopramide, head-up positioning)
■ Damage to lips, teeth, tongue, airway
Pericardiocentesis
Indications
■ Cardiac tamponade
■ ⁄ pericardial effusion † ø hemodynamics
Contraindications
■ Coagulopathy/bleeding dysfunction
■ Skin infection over needle insertion site
Equipment
■ Skin preparation supplies, sterile gloves, towels/drapes
■ Local anesthetic (1% or 2% lidocaine, 25-G needle, 3-mL syringe)
■ Pulse oximeter, ECG monitoring (V lead)
■ 16- to 18-G spinal needle and No. 11 blade
■ 20-mL syringe and sample tubes
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 14
BASICS
Preparation
■ Continuous ECG monitoring (30° semi-Fowler position pre-
ferred); if V lead attached to pericardiocentesis needle † ⁄
sensitivity; an insulated wire with alligator clips at each end
works well
■ Prepare skin; sterile technique; wear sterile gloves, mask,
and gown; drape over xiphoid area
■ Local anesthesia (infiltrate skin 1%-2% lidocaine)
Patient Positioning
■ Supine with thorax (i.e., head of bed) elevated 30-45 degrees
Technique
■ Needle: Insert (2 cm below costal margin to left adjacent to
xiphoid with blade) and direct (upward and posterior) at
45-degree angle for 4-5 cm; aim toward right (preferable) or
left (⁄risk penetrate RV) scapular tip
■ Advance (aspirate continuously) needle until encounter fluid,
check for cardiac pulsations, or ⁄ST on ECG. May feel needle
enter cavity
■ Remove blood: (usu. 5-10 mL because most is clotted); if
ⱖ20 mL, then probably in RV
■ If hemodynamics do not improve, then may need
thoracotomy or local pericardial window excision
■ Send fluid for appropriate studies
Complications
Myocardial wall injury/penetration, myocardial infarction, pneu-
mothorax, bowel perforation
Arterial Line
Indications
■ Hemodynamic monitoring
■ Arterial blood sampling
■ Frequent blood draws
Contraindications
■ Infection or lesion at insertion point
■ Occlusion or thrombosis of artery
14
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 15
15
■ Uncorrectable coagulopathy
■ Systemic infection (use peripheral site)
Equipment
■ Peripheral arterial line (with angiocatheter): Angiocatheter
(20- or 22-G, 2” length) or arterial line kit, sterile scalpel
■ Femoral arterial line (Seldinger technique): Seldinger kit:
needle (16-18 G), 10-mL syringe, guide wire, sterile scalpel,
dilator, catheter
■ Skin preparation supplies
■ Local anesthetic (1%-2% lidocaine, 25-G needle, 3-mL syringe)
■ Sterile gloves, towels or drapes, dressing supplies
■ Heparinized saline (pressurized delivery system)
■ Blood gas syringe (for arterial blood sampling)
■ Another 5-mL syringe w/heparinized saline
■ Sutures
■ Arterial pressure monitoring equipment
■ Arm board w/terrycloth roll
Preparation
■ Peripheral (radial): Nondominant hand: perform Allen test
(compress radial and ulnar arteries † palm blanches; release
ulnar artery and check reperfusion of palm; delay ⬎5 sec =
abnl † choose another site) to confirm collateral circulation
■ Use sterile technique; prepare and drape skin
■ Use lidocaine to infiltrate entry and suture points
Patient Positioning
■ Peripheral: Usu. radial artery but can do dorsalis pedis; pt.
seated and supine; immobilize wrist on arm board w/roll
under wrist in slight dorsiflexion
■ Femoral: Supine
Technique
Peripheral Arterial Line (Angiocatheter)
■ Locate pulse w/index finger of nondominant hand; small
incision w/scalpel over entry site
■ Insert angiocatheter at 30°–45° to artery † bright pulsatile
red blood freely † catheter; slowly advance catheter until
flow stops; withdraw slightly until blood pumps again;
advance catheter over needle into vessel
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 16
BASICS
16
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 17
17
Central Line
Locations
■ Femoral vein: Easy access; far from airways and lungs, but
area can be dirty and prevent pt. from walking
■ Internal jugular (IJ) vein: øBleed risk, but poor landmarks and
can puncture carotid artery
■ Subclavian vein: Comfortable; clear landmarks; but risk of
pneumothorax or bleeding
Indications
■ Hyperalimentation or long-term IV therapy
■ Give medications (e.g., vasoactive/inotropes, phlebitic)
■ Hemodialysis or rapid fluid administration
■ Intracardiac pacing
■ Central venous pressure monitoring
Contraindications
■ Subclavian: øPulmonary function (COPD, asthma), high levels
of PEEP, coagulopathy, superior vena cava thrombosis, upper
thoracic trauma
■ IJ: Tracheostomy, ⁄⁄⁄pulmonary secretions
■ Femoral: Vena caval compromise (clot, extrinsic
compression, IVC filter), local infection, cardiac arrest or low
flow states, requirements for pt. mobility.
Equipment
■ Central line kits are available
■ Skin preparation supplies (iodine, chlorhexidine, or EtOH)
■ Local anesthetic (1%-2% lidocaine, 25-G needle, 3-mL syringe)
■ Sterile gloves, dressings, towels or drapes
■ Supplies for Seldinger technique (or specific intravascular
access kit)
■ Needle (16- to 18-G): For IJ lines, only insert needle 0.5-1.0”
(⬎1.5” may † pneumothorax); 10-mL syringe
■ Guidewire, scalpel, dilator, catheter
■ If the Seldinger technique is not used, a catheter-over-needle
system may be used
■ Heparinized saline
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 18
BASICS
■ Suture
■ Central venous pressure monitoring device
■ May need ultrasound if difficulty inserting
Preparation
■ For both insertion and removal: Use sterile technique; sterile
gown, hair cover, face mask/shield
■ Skin preparation; sterile drapes
■ Flush catheter w/saline
■ Liberally infuse area w/local anesthetic
Patient Positioning
■ Femoral: Supine; stand on side of your dominant hand (right
side of pt. if you are right-handed)
■ IJ: Supine; turn pt. head 45° away from insertion side;
remove pillow from under pt. head and place pt. in
Trendelenburg position
■ Subclavian: Trendelenburg position, remove pillow, towel
roll between scapulae
Insertion Points
■ Femoral vein: One finger breadth medial to artery and two fin-
ger breadths inferior to inguinal ligament; with bevel up and
at 45°–60° above skin, insert needle parallel to vessel (steeper
angle †ørisk of entering peritoneum; more medial insertion
angle † less chance of needle entering femoral artery)
■ IJ: Lateral to carotid; Landmark: Apex of triangle (clavicle and
two heads of sternocleidomastoid) OR between sternal notch
and mastoid process; insert needle at 70° to skin, and aim for
ipsilateral nipple
■ Subclavian: 2 cm inferior to junction of lateral third and
medial two thirds of clavicle and 2 cm above suprasternal
notch; finder needle may be too short to reach vein
Needle Approach
■ Femoral vein: With bevel up and at 45°-60° above skin, insert
needle parallel to vessel (steeper angle †ørisk of entering
peritoneum; more medial insertion angle †øchance of enter-
ing femoral artery)
■ IJ: Insert needle at 70° to skin and aim for ipsilateral nipple;
aim lateral; if unsuccessful, withdraw and carefully go
18
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 19
19
slightly medial; reassess landmarks; can use long (~3”)
angiocatheter instead of regular needle
■ Subclavian: Insert needle bevel up; guide placement w/
nondominant hand: place index finger at sternal notch and
thumb at clavicle; keep needle parallel to floor and first aim
for clavicle; when hit clavicle, walk needle down (push on
needle tip; do not push on syringe) until just below clavicle;
then advance needle 4-5 cm; once find vein, rotate needle
90° so that bevel faces caudally; if no blood, withdraw and
redirect more cephalad
Technique
■ Make sure you continuously aspirate while advancing or
withdrawing needle
■ Using appropriate insertion point and approach, locate vein
w/finder needle (optional w/femoral vein)
■ Aspirate venous blood w/finder needle, then insert large-bore
needle at same site and at same angle; use nondominant
hand to grab needle hub and lower needle to parallel vein
and aspirate again to reconfirm flow (may use transducer to
confirm venous blood); hold needle in place, remove syringe,
and thread guidewire into needle; check for ectopy
■ Remove needle over guidewire and continue to hold wire
w/gauze; do not let go of guidewire until removed
■ Make incision 3–4 mm (w/scalpel) through skin and fascia; push
dilator 3–4 cm over guidewire to expand subcutaneous tissue
■ Thread catheter over guidewire
■ Advance catheter and remove guidewire
■ Aspirate blood and flush each port
■ Suture line in place and consider spacer in small pt
■ STAT chest x-ray to r/o PTX and check line placement
Removing Central Lines
■ If line tunneled/trapped, may have to remove under
fluoroscopy
■ Place pt. in Trendelenburg position (reverse Trendenlenburg
for femoral lines) and remove any pillows
■ Remove all bandages, gauze, and all suture material
■ Pt. should hum or Valsalva maneuver during line removal
■ Apply sterile dressing (gauze and occlusive dressing)
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 20
BASICS
Complications
Nonplacement/misplacement/nonfunction of line, dislodged line,
infection, suppurative thrombophlebitis, catheter-related sepsis,
pneumothorax, catheter/guidewire embolism, air embolism, vessel
thrombosis, central vein thrombosis, hemorrhage, arrhythmias,
myocardial or central vein perforation, pericardial tamponade,
infection, hematoma, subcutaneous emphysema or fluid infiltra-
tion, arterial puncture/laceration, hemorrhage
Indications
■ Acute heart failure or severe hypovolemia
■ Hemodynamic instability
■ Severe pulmonary disease
■ Sample blood and determine cardiac output
Contraindications
■ Infection or lesion at entry point
■ Occlusion or thrombosis of desired vessel
■ Uncorrectable coagulopathy
■ Caution: systemic infection
Equipment
■ Skin preparation (iodine, chlorhexidine, or EtOH)
■ Local anesthetic (1%–2% lidocaine, 25-G needle, 3-mL syringe)
■ Sterile gloves, towels or drapes, dressings
■ Seldinger supplies: Needle (16–18-G), syringe (10 mL), guide
wire, scalpel, dilator, catheter
■ Catheter supplies: SG catheter, monitor, protective sheath,
syringe (3 mL),heparinized saline
■ Sutures
Preparation
■ Prepare and drape skin; sites: subclavian (preferred), internal
jugular (preferred), or femoral veins
■ Local anesthesia: Infiltrate skin entry site
■ SG catheter: Flush each lumen w/heparinized saline; check
balloon (inflate w/1–1.5 mL air); attach pressure monitor and
infusion ports
20
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 21
21
■ Keep catheter in protective plastic container until zeroing pro-
cedure complete; remove catheter from plastic container and
move tip w/wrist flick † appropriate waveform (monitor screen)
Patient Positioning
■ Subclavian or IJ: Supine and 15° Trendelenburg’s position;
turn pt.’s head away from entry site; place roll under spine
between shoulder blades
■ Femoral: Supine and flat
Technique
■ Use sterile technique
■ Connect 10-mL syringe to needle; small incision w/scalpel;
Seldinger technique: cannulate vessel w/needle, pass wire
through needle into vessel (no resistance) and widen passage-
way w/dilator; thread introducer over wire into incision
■ Remove wire and aspirate blood to confirm placement
■ Flush w/normal saline or heparin solution
■ Tightly cap introducer; suture introducer to skin
■ Insert flushed and zeroed SG catheter; another person
needed to inflate/deflate balloon during placement
■ Thread catheter through sheath protector; move protector
out of way to end of catheter
■ Watch pressure monitor while advancing catheter; when
catheter tip clears introducer, inflate balloon † 1-1.5 mL;
balloon floats catheter w/blood flow † RA and through
heart; check for distinctive pressures
■ Further advance catheter † “wedge” balloon in PA
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 22
BASICS
Thoracentesis
Indications
■ Diagnostic: Most new effusions, unless clear clinical dx with
no e/o pleural space infection
■ Therapeutic: Dyspnea from large pleural effusion; also may
aid work-up of large effusion
Contraindications
■ No absolute contraindications
■ May need platelets/factor replacement: e.g., platelets
⬍50,000, PT/PTT ⬎ 2 ⫻ normal
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FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 23
23
■ Relative contraindication: Cellulitis or herpes zoster at needle
puncture site
■ Caution: mechanical or manual ventilation
Equipment
■ Sterile towel, gauze pads, dressing, drape w/fenestration
■ Basin for preparation solution
■ Syringe(s) (10-20 mL)
■ Needles (22- and 25-G) for infiltration
■ Povidone iodine
■ Local anesthetic (e.g., 1% lidocaine): 10 mL
■ Heparin: 1 mL
■ Atropine: Available at bedside (for vasovagal reaction)
■ Syringe (50- to 60-mL) for aspiration
■ Sterile drainage tubing
■ Three-way stopcock
■ Needle or needle catheter (depends on technique): Hypodermic
needle (18–22-G, 1.5”–2”), over-the-needle catheter (16–20-G
needle) or through-the-needle catheter (14–18-G needle)
■ Scalpel (needle catheter technique only)
■ Sterile specimen bowl or Vacutainer bottle
■ Analysis containers: Iced blood gas syringe, specimen tubes
(red-top and purple-top), sterile transport media for culture
y or 10-mL sterile container, 5 red-top specimen tubes for
cytology or 10- to 50-mL plain bottle
Preparation
■ Start IV; draw serum protein and LDH
■ Pulse-oximetry monitoring; O2 as needed
■ Diagnostic: Premoisten 50– to 60-mL collection syringe with
1 mL heparin (100 U/mL) to prevent clotting
■ Sterile technique, prepare skin with antiseptic; place sterile
towels/drape around site
■ Effusion height: Percussion and tactile fremitus
Patient Positioning
■ Upright (preferred): Pt. sits erect on bed edge and extended
arms rest on bedside table; large effusion † pt. leans
forward slightly; insert needle posterior rib at least one
interspace below top of effusion; midscapular or posterior
axillary line
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 24
BASICS
24
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 25
25
Complications
Pneumothorax, cough, infection, hemothorax, splenic rupture,
abdominal hemorrhage, unilateral pulmonary edema, air
embolism, retained catheter fragment
Light’s Criteria (Pleural Fluid = Exudate)
1) Pleural fluid:serum protein ratio ⬎0.5; 2) Pleural fluid LDH
⬎2/3 upper limit of normal serum LDH; 3) Pleural fluid:serum
LDH ratio ⬎0.6
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 26
BASICS
*Optional
26
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27
Patient Positioning
■ Upright or decubitus, neck flexed
Technique
■ Turn on suction apparatus (w/tonsil tip attached)
■ Pt. should hold emesis basin and cup of water
■ Insert tube in nostril toward occiput
■ Apply firm, constant pressure to tube while pt. takes small
sips of water and swallows
■ Advance until two black lines on tube visible out of nares
and nose between second and third black lines
■ Hold tube firmly in place close to nostril
■ Check placement in stomach: Attach catheter tip syringe to
tube and inject 30-60 mL air; use stethoscope to hear air
“whoosh” over epigastrium; use syringe to aspirate gastric
fluid (normal pH ⬍5)
■ Secure tube in two places (nose and second site like
forehead or shoulder) w/benzoin and tape
■ Abdominal x-ray to confirm placement (not necessary if
suction applied)
■ Mark tube near nose to track proper placement
■ Record suction output volume and character
Tube Removal
■ Disconnect tube from suction; remove tape
■ Pull steadily to remove tube; discard tube
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 28
BASICS
Complications
■ ⁄⁄⁄ Gagging during placement: spray more topical anesthetic
to back of throat
■ Difficulty passing tube † tube stuck in nose (try other nos-
tril), coils in mouth or esophagus (use ice to chill/stiffen tube)
■ Placement in lung (coughing): Remove immediately
■ Hypovolemia from ⁄⁄⁄ nasogastric tube output: IV fluids
0.5–1 mL LR or NS and 30 mEq KCI/L for every mL of output
■ If tube blockage, try any or all of following:
■ Check tube: Inject air into vent port and listen for hissing
(which is normal)
■ Disconnect/reconnect apparatus or reposition tube
■ Irrigate tube w/30–40 mL NS
■ Throat discomfort: Throat lozenges prn
■ Aspiration pneumonia
■ Trauma to nasal mucosa, nares, sinus orifices († sinusitis),
lung, esophagus, gastric mucosa
■ Tube too low (NGT drains drain bile)
■ Tube too high (⁄aspiration risk)
Paracentesis
Indications
■ Therapeutic: Massive ascites †ø respiration, pain
■ Diagnostic: distinguish transudative vs exudative ascites
■ Dx spontaneous bacterial peritonitis, malignant, chylous
Contraindications
■ Coagulopathy
■ Abdominal adhesions
■ Agitation
■ Significantly distended bowel
■ Pregnancy
■ Infection (e.g., cellulitis at insertion site)
Equipment
■ Paracentesis kits available
■ Skin preparation supplies
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29
■ Local anesthetic (1%–2% lidocaine, 25-G needle, 3-mL
syringe)
■ Sterile gloves, towels or drapes, and dressing
■ Spinal needle (20-G)
■ Syringe or vacuum bottle
■ Scalpel, #11 blade
■ Butterfly needle (ⱖ20-G with sterile tubing)
Preparation
■ Decompress bladder (void or urinary catheterization)
■ ID flank region (gas-filled bowel will float to top); avoid
previous incisions
■ Prepare skin; sterile technique; prepare and drape skin
■ Local anesthesia: Infiltrate skin entry site, lower fascial levels
and peritoneum
■ Ultrasound guidance: If previous abdominal surgery or
infection
Patient Positioning
■ Supine or sitting (leaning forward: better w/small amount of
fluid); raise bed so pt. is comfortable
Technique
■ Sterile technique
■ Insert and advance 20-G spinal needle w/stylet until feel
peritoneum “give”
■ Remove stylet; attach syringe and advance needle (5-mm
increments) while aspirate until get fluid
■ If remove large volume: Connect tubing btween spinal needle
and (butterfly needle) vacuum bottle; placing soft catheter
(Seldinger technique) into peritoneal cavity may help
■ Remove needle and sterile dry dressing over site
■ Send fluid for appropriate tests
Complications
■ Perforate organ or blood vesel, bleed/hematoma,
persistent site leakage, infection, leaving catheter in
abdominal cavity, hypotension, dilutional øNa⫹,
hepatorenal syndrome
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 30
BASICS
31
Equipment
■ Skin preparation supplies (povidone-iodine solution)
■ Mask, sterile sponges, towels and drapes, gown, gloves
■ Local anesthetic, preferably 1% lidocaine w/1:100,000
epinephrine
■ Syringe (5- or 10-mL)
■ Needles (21-G ⫻ 1.5” and 25-G ⫻ 1/8”)
■ Sterile surgical tray, include scalpels (Nos. 11 and 15),
scissors, Kelly clamps, pickups, needle holders
■ Sutures (0 silk, 2-0 silk, #1 and 4-0 vicryl, and 4-0 nylon)
■ Peritoneal catheter and connection tubing
■ Normal saline
■ Dressing supplies
Preparation
■ Decompress stomach (nasogastric or orogastric tube)
■ Empty urinary bladder (void or Foley catheter)
■ Prepare and drape skin
■ Entry site: usu. just caudal to umbilicus; if pelvic fracture,
supraumbilical
■ If not unconscious/sedated, local anesthesia to skin entry
site, lower fascial levels, and peritoneum
Patient Positioning
■ Supine or (if therapeutic) sitting
Technique
■ Use sterile technique
■ Open technique described here. [Alternative: Seldinger
technique (insert needle † abdomen, pass wire over needle,
dilate, and pass catheter through tract)]
■ 5-mm vertical incision (No. 11 blade) down to linea alba
fascia; do not enter abdominal cavity
■ Expose linea alba and place stay suture on each side of
fascia (0 silk); hemostat † “tag” each suture
■ Make 1 cm vertical incision in linea alba; enter peritoneal
cavity using blunt dissection; retract abdominal wall w/blunt
end of Senn retractor
■ Insert and direct catheter (always keep perpendicular to
abdominal wall) † right or left iliac region
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 32
BASICS
Transurethral Catheterization
Indications
■ Urinary retention (e.g., neurogenic bladder)
■ Urinary sampling
■ Monitor urinary output
■ Bladder irrigation or tests (e.g., cystogram)
Contraindications
■ Ureteral stricture or disruption
■ Acute urethral or prostatic infection
■ Relative: Anticoagulated pt. (use ⁄⁄⁄lubricants and
nontraumatic technique)
Equipment
■ Skin preparation supplies (povidone-iodine solution)
■ Sterile gloves, gauze, sponges, towels
■ Water-soluble lubricant (may use lidocaine 2% jelly)
■ Syringe (10-mL); sterile water or saline (5 mL)
■ Adhesive tape
■ Urinary drainage system w/tubing and collection bag
■ Urinary catheter (usually 16- or 18-Fr Foley):
32
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33
■ Foley: Double-lumen (larger † urine, smaller † balloon
inflation): Usu. used to drain bladder
■ Straight (red Robinson): Straight catheterization
■ Coude: Difficult cases; narrow, curved, firmer tip
■ 3-way irrigation: Retrograde bladder irrigation
Preparation
Patient Positioning
■ Supine; male: penis straight upward; female: frog-leg position
Technique
■ Always use sterile technique; insert and slowly advance
catheter through urethral meatus (male: maintain continuous
upward penile traction; retract penis caudally may help pass
prostatic urethra)
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 34
BASICS
Suprapubic Catheterization
Indications
■ Pelvic trauma causing urethral tear or disruption
■ Need for bladder drainage in the presence of urethral or
prostate infection
■ Acute urinary retention when transurethral catheterization
not possible
Contraindications
■ Nonpalpable bladder
■ Uncorrectable bleeding diatheses
Equipment
■ Skin preparation supplies (povidone-iodine solution)
■ Local anesthetic (1% lidocaine ⫾ epinephrine; 22-G, 1.5”
needle, 10-mL syringe)
■ Razor
■ Sterile gloves, mask, gauze sponges, towels and sheets
■ No. 11 scalpel
■ Syringe (60-mL)
■ Suprapubic catheter (usu. 14-G, 12”); intracatheter needle;
needle holder, scissors, and pickups
■ Suture (2-0 silk or nylon)
■ Adhesive tape
■ Urinary drainage system w/bag and tubing
■ Sterile dressings
34
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35
Preparation
■ Local anesthetic agent ⫾ IV sedation
■ Bladder must be distended and palpable
■ Shave umbilicus to pubis
■ Locate puncture site (midline, 4 cm above pubis)
■ Prepare skin w/alcohol solution
■ Infiltrate skin, subcutaneous, abdominal wall, bladder wall
w/local anesthetic
■ Prepare skin w/providone-iodine; sterile towels/drapes
Patient Positioning
■ Supine w/roll under hips † extend abdomen and pelvis
Technique
■ Always use sterile technique
■ Avoid multiple needle passes
■ Catheter-through-needle or sterile Seldinger technique
■ Shallow skin incision (No. 11 blade)
■ While aspirating, advance needle w/syringe through incision
(at 60° to abdominal skin) until get urine flow † syringe;
remove syringe from needle
■ Thread intracath catheter through needle † bladder
■ Urine flow in catheter † remove needle over catheter
■ Free flow urine through catheter † suture catheter in place;
attach urine collection device to catheter
■ Sterile dressing
Complications
Difficulty passing the suprapubic catheter, infection, traumatic
placement, bowel perforation
Arthrocentesis
Indications
■ Dx septic joint or crystal-induced arthritis
■ Traumatic (blood in joint) vs inflammatory effusion
■ Dx intra-articular fracture (blood and fat globules)
■ Sx relief: Pain (hemarthrosis or tense effusion)
■ Give anti-inflammatory or local anesthetic medications
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 36
BASICS
Contraindications
■ Infection in tissue overlying puncture site
■ Bacteremia
■ Bleeding diatheses
■ Joint prosthesis
Equipment
■ Skin preparation supplies and sterile gloves, drapes, basin,
cup, test tubes, gauze, dressings, saline hemostat
■ Local anesthetic
■ Syringes (2, 10, and 20 mL); needles (18, 20, 22, and 25G)
■ Three-way stopcock
■ Green-top tube w/liquid anticoagulant, microscope slides
w/coverslips, culture media (for infection)
Preparation
■ Carefully identify landmarks and choose puncture site (avoid
nerves, tendons, major vessels)
■ Sterile technique; prepare skin (allow betadine solution to
dry btween applications); remove betadine w/EtOH to
prevent betadine † joint space
■ Δ gloves after skin preparation; apply sterile towels/drape
■ Infiltrate skin w/local anesthetic (22-/25-G needle)
Patient Positioning
■ For knee lateral approach: Supine on examination table, feet
at right angle, knee slightly flexed (15°–20°), rolled towel
under popliteal space
■ For knee patella tendon approach: Pt. sits upright with foot
perpendicular to floor
Technique
■ Attach (18- to 22-G) needle to syringe and insert through
skin, subcutaneous tissue, and into joint space
■ Knee lateral approach: Insert needle 1 cm superior/lateral to
superior lateral patella; may use hand to grasp and elevate
patella slightly; needle † under patella at 45° to midjoint
area; should be no resistance
■ Other approaches: Enter through patella tendon or medially
or laterally directly above joint line
36
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37
■ Aspiration of synovial fluid confirms joint space placement
■ If Δ syringe: Use hemostat to hold needle hub
■ Aspirate all joint space contents/fluid
■ Remove needle and dress wound; send fluid for tests
■ Larger effusions: Use larger syringe and consider using
three-way stopcock (do not have to Δ syringe)
Complications
Infection, bleeding, anesthetic hypersensitivity.
Fluid stops flowing (joint space drained, needle tip dislodged, or
debris/clot obstruct tip), needle dislodged (slightly advance/retract
needle, rotate bevel, or use ø pressure to aspirate), cartilage dam-
age (from bouncing needle off bone)
Indications
■ Palpable skin abscess (usu. ⬎5 mm) that does not resolve
with conservative measures (warm soaks)
BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 38
BASICS
Contraindications
■ Very large abscesses (may need operating room)
■ Deep abscesses in very sensitive areas (supralevator,
ischiorectal, perirectal)
■ Locations: Palmar space, deep plantar spaces, nasolabial
folds (may drain to sphenoid sinus)
Equipment
■ Universal precautions materials
■ Local anesthesia: 1% or 2% lidocaine with epinephrine, 10-cc
syringe and 25-G needle
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39
■ Skin preparation solution and sterile drapes
■ No. 11 scalpel blade with handle
■ Sterile gauze and tape
■ Hemostat, scissors
■ Packing strip (plain or iodoform, 1/2”)
■ Culture swab
Preparation
■ Universal precautions; prepare skin and sterile drapes
■ Infiltrate local anesthetic, allow 2–3 minutes for anesthetic to
take effect
Patient Positioning
■ Depends on abscess location
Technique
■ Cut through skin into abscess w/wide incision (No. 11 blade);
incision should follow skin fold lines
■ Allow pus to drain; soak up w/gauzes
■ Swab inside abscess cavity (culture swab)
■ Gently explore cavity w/hemostat, break up loculations
■ Pack abscess cavity; dress wound w/gauze and tape
■ May send pus for Gram stain and culture (commonly strepto-
coccus, staphylococcus, or enterics (perianal), or anaerobic
and gram-negatives.
Complications
Abscess actually sebaceous cyst or hematoma, no drainage,
bleeding
BASICS
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 40
H&P
40
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 41
41
Distinguishing Vestibular (peripheral VIII
nerve), Cerebellar, and Sensory (afferent
pathway: peripheral nerve to thalamus/
parietal lobe) Lesions
Finding Vestibular Cerebellar Sensory
Vertigo ⫹ ⫾ ⫺
Nystagmus ⫹ Often ⫹ ⫺
Dysarthria ⫺ ⫾ ⫺
Limb ataxia ⫺ Usual ⫹ ⫹
Stand feet together; ⫹ ⫺ ⫹
eyes open
Stand feet together; ø ⫺ ⫺
eyes closed
Vibratory and position sense ⫹ ⫹ ø
Ankle reflexes ⫹ ⫹ ø
Distinguishing
Causes Upper Lower
of Motor Motor Motor Extra-
Defects Neuron Neuron Muscle Cerebellar pyramidal
øStrength ⫹ ⫹ ⫹ ⫺ ⫺
Atrophy ⫺ ⁄⁄⁄ ⁄ ⫺ ⫺
Fasciculations ⫺ ⫹ ⫺ ⫺ ⫺
Babinski’s ⫹ ⫺ ⫺ ⫺ ⫺
⁄Tone ⫹ ⫺ ⫺ ⫺ ⫺
øTone ⫺ ⫹ ⫹/⫺ ⫺ ⫺
Hyperreflexia ⫹ ⫺ ⫺ ⫺ ⫺
Hyporeflexia ⫺ ⫹ ⫹/⫺ ⫺ ⫺
Clasp knife ⫹ ⫺ ⫺ ⫺ ⫺
Ataxia ⫺ ⫺ ⫺ ⫹ ⫺
(continued)
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 42
H&P
Distinguishing
Causes Upper Lower
of Motor Motor Motor Extra-
Defects Neuron Neuron Muscle Cerebellar pyramidal
Akinesia ⫺ ⫺ ⫺ ⫺ ⫹/⫺
Chorea or ⫺ ⫺ ⫺ ⫺ ⫹/⫺
athetosis
Intention ⫺ ⫺ ⫺ ⫹/⫺ ⫺
tremor
Resting tremor ⫺ ⫺ ⫺ ⫺ ⫹/⫺
Lower Extremities
Cannot toe walk when ⱖ50% loss S1 † gastrocnemius and anterior
tibialis; cannot heel walk when ⱖ50% loss L4, L5 † tibialis anterior
Intrathecal Pathology
■ Milgram’s test: Pt. lies supine and raises legs ~5 cm and
holds for 30 sec † stretches iliopsoas and anterior
42
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43
abdominal muscles and ⁄ intrathecal pressure; if no leg pain,
no intrathecal pathology
Reflexes
Nerve
Reflex Root Nerve Testing
Jaw Pons Mandibular Tap mandible at down-
branch, ward angle w/mouth
trigeminal slightly open
Biceps C5–6 Musculocu- Tap biceps tendon
taneous w/arm flexed partially
at elbow
Brachiora- C5–6 Radial Strike radius lower end
dialis just above wrist
Normal: Elbow flexion
Triceps C7–8 Radial Tap triceps tendon;
support upper arm; let
forearm hang
Finger C8, T1 Median Either tap palm or hold
pt.’s middle finger
loosely and flick
fingernail down †
normal: finger slightly
extends; abnormal:
Hoffman’s sign (thumb
flexes, adducts)
Upper T7–10 Use blunt object to
abdomen stroke abdomen lightly
in and down
Lower T11–L1
Normal: Umbilicus
abdomen
deviates toward
stimulus
(continued)
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 44
H&P
Reflexes
Nerve
Reflex Root Nerve Testing
Patellar L3–4 Femoral Strike patellar tendon
Ankle S1–2 Tibial Tap Achilles tendon
(Achilles) when pt. dorsiflexes
foot at ankle
Normal: Plantar flexion
Cremasteric T12 Genital Stroke inner thigh
reflex branch (gen- Normal: Ipsilateral
itofemoral) scrotal sac move ⁄
Anal wink S2–4 Touch perianal skin
Normal: Anus contracts
44
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45
Peripheral Nerves
Trigeminal
Anterior cutaneous
nerve neck
C2
Supraclavicular
C3
Axillary C4 C5
Anterior thoracic rami
T2 T1 C6
Lateral thoracic rami T3
Lateral cutaneous T4
nerve arm T5
Median cutaneous T6
nerve arm T7
T8
Lateral cutaneous T9
nerve forearm T10
Iliohypo- T11
Median gastric T12
Ilio-
cutaneous S2 L1
inguinal S3 C8
nerve
forearm C7
Ulnar L2
Radial
Median
Lateral femoral cutaneous
L3
Medial femoral cutaneous
Obturator
Anterior femoral cutaneous
Superficial peroneal
L4 L5
Sural Tibial
Saphenous Saphenous
Medial
Lateral
plantar Sural Deep
plantar
Sole of foot peroneal
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 46
H&P
Peripheral Nerves
Great occipital
Lesser occipital C2
Greater auricular
C3
Posterior rami of cervical nerves C4
C5
Supraclavicular
Lateral thoracic rami C6
Posterior thoracic rami C8 C7
Axillary
T10
Posterior cutaneous
nerve forearm
Median cutaneous
nerve arm T12
Lateral cutaneous L1
L2
nerve forearm L3
Median cutaneous L4
S3 S1
nerve forearm S4
S5 S2
Radial L5
Posterior
Median lumbar
Ulnar rami
L2
Posterior sacral rami
Lateral femoral cutaneous
L3
Medial femoral cutaneous
Lateral femoral nerve of calf Obturator
Superficial peroneal
L4 L5
Sural Tibial Sural
Saphenous
Saphenous
Medial
Lateral
plantar
plantar Calcaneal
Sole of foot
46
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47
Referred Pain
Periumbilical
Duodenum
Appendix
Epigastric Suprapubic
Duodenum Bladder
Appendix Uterus
Hiatal hernia
Gallbladder
and bile ducts Groin/
Pancreas Inner thigh
Ureters
Kidneys
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 48
H&P
Brain Circulation
Anterior
Anterior cerebral artery communicating
artery
Internal carotid
Communicating artery
Posterior cerebral
artery
Superior cerebellar
Basilar artery
Anterior inferior
cerebellar
Vertebral artery
Anterior spinal
Posterior inferior cerebellar
48
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49
Main Artery Region of Brain Sustained
Anterior cerebral Medial frontal and parietal
Anterior corpus callosum
Middle cerebral Lateral frontal, parietal, occipital,
temporal cortex
Lenticulostriate branches †
caudate nucleus, putamen,
upper internal capsule
Posterior cerebral Medial occipital and temporal cortex
Posterior corpus callosum
Upper midbrain
Thalamus
Superior cerebellar Upper cerebellum
Upper pons
Low midbrain
Anterior inferior Upper cerebellum
cerebellar Upper pons
Low midbrain
Posterior inferior Lower cerebellum
cerebellar Medulla
Anterior spinal (ASA) Anterior (ventral) spinal cord
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 50
H&P
Parietal lobe
contralateral sensation
Frontal lobe Dominant:
problem solving, reading, writing,
planning, apathy, or math ability
inattention, aphasia, Non-dominant:
contralateral weakness, neglect, difficulty dressing
labile affect,
Broca’s area Occipital lobe
vision problems
Temporal lobe
memory problems,
aggressive sexual behavior
Dominant:
Wernicke’s aphasia
Cerebellum
Midbrain, Pons,
ataxia, dysarthria,
Medulla
dysmetria, intention
CN 3–12
tremor, nystagmus,
scanning speech
50
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51
Eye Examination
Conjuctiva Zonule
Choroid Anterior
Sclera chamber
Retina
Cornea
Macula
Fovea Vitreous
humor
Pupil
Optic
nerve Iris
Optic Lens
disk
Ciliary body
Left eye Right eye
Optic nerve
Optic chiasm 1
Optic tract 2
3 4
Lateral
geniculate
nucleus
Optic
radiation
5
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 52
H&P
Optic nerve
Superior
rectus
CN3 Superior
oblique
Inferior CN4
rectus
CN3
Medial
rectus Lateral
CN3 rectus
CN6
Inferior oblique
CN3
Optic
disk
Blood
Optic vessels
cup
Fovea
Optic nerve
(“blind spot”) Macula
52
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53
Ear Examination
Vertigo
Dix-Hallpike test (Nylen-Barany test): Pt. sits on examination table
and extends legs; turn pt.’s head 30°–45° to one side, and pt. quickly
lies back so head hangs over table end; look for nystagmus; repeat
whole procedure with head turned in opposite direction
Positive: Nystagmus † benign paroxysmal positional vertigo
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 54
H&P
Cardiac Manuevers
Mitral
Right- Aortic Regurgi-
Sided Stenosis tation
Mechanism Maneuvers Murmurs (AS) (MR) IHSS*
Preload ⁄ Inspiration, ⁄ ⁄ ø ø
squatting,
raise ⁄legs
Venous ø Expiration, ø ø ø ⁄
return Valsalva’s,
standing,
nitrates,
diuretics
Afterload ⁄ Isometric ⁄ ø
hand grip
ø Valsalva’s, ø ø ø ⁄
vasodila-
tors
*IHSS ⫽ idiopathic hypertrophic subaortic stenosis
54
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 55
55
Systole Diastole
Comments
Early Mid Late Early Mid Late
Harsh
Heard best @ R base
AS
(radiate R carotid)
Blowing Heard best @ 3rd/4th L ICS
AI (if radiate R sternal border
aortic root dilate, e.g., Marfan)
Low
All MV murmurs heard best@ apex , S1.
Can be confused with Austin Flint
Opening snap
MS (AI: mid-diastolic murmur @ MV
Rumble
when blood enters from aorta &
L atrium simultaneously; No OS)
Opening snap
Radiate L axilla/back;
MI severe MR S3; with isometric
handgrip & stand squat
If LV volume (stand, Valsalva) earlier
clicks, duration, intensity; if LV volume
MVP
(squat, legs, hand grip) delay clicks,
Systolic click duration, intensity
Heard best @ L 2nd ICS (radiate to
PS L neck) + palpable thrill; wide split S2
Blowing
Heard best @ L 2nd/3rd ICS;
PI may during inspiration
Systolic click
Rumble Heard best @ 4th L sternal border;
TS wide split S1; may with inspiration
Opening snap (Carvallo’s sign); TS often occurs with MS
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 56
H&P
Inspiration Expiration
Type Causes
S1 S2 S1 S2
Hypertrophic
Paradoxical splitting
PA PA cardiomyopathy
56
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 57
57
a Small and usually
not visible
c
v
R atrial y
contraction
TV opening and
x
atrial emptying
RV contraction Maximal
and TV closure atrial filling
Sternum
45°
Right atrium
Jugular vein
JVP
• Fluid overload
• Blockage before heart (SVC obstruction)
• CO (e.g., HR, constrictive pericarditis,
R heart failure pericardial effusion, TS or TI,
cardial tamponade)
• Hyperdynamic circulation
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 58
H&P
Sign Causes
Kussmaul’s (during inspiration, Constrictive pericarditis
JVP ⁄distention; øin normal pt.) (negative in cardiac tamponade)
Severe right heart failure
Hepatojugular reflux (push Right ventricular failure if
liver † ⁄venous return to right JVP remains elevated
atrium) (transient only in normal pt.)
Absent A waves Atrial fibrillation
Sinus tachycardia
Dominant A waves Pulmonary HTN
Pulmonary stenosis
Tricuspid stenosis
Right atrial myxoma
Cannon A wave (very large Ventricular tachycardia
A waves) Complete heart block
Paroxysmal nodal tachycardia
Dominant V wave Tricuspid regurgitation
Absent X descent Atrial fibrillation
Exaggerated X descent Cardiac tamponade
Constrictive pericarditis
Large CV waves Tricuspid regurgitation
Constrictive percarditis
Sharp Y descent Constrictive pericarditis
Tricuspid regurgitation
Slow Y descent Right atrial myxoma
Tricuspid stenosis
Absent Y waves Cardiac tamponade
Abdominal Examination
58
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 59
59
RUQ LUQ
Biliary colic Gastritis
Cholecystitis LLL pneumonia
Duodenal ulcer Pancreatitis
Hepatitis Splenic problems
RLL pneumonia
Periumbilical
Flank Appendicitis
Abdominal aortic Gastroenteritis
aneurysm Mesenteric
Pylelonephritis lymphadenitis
Renal colic Myocardial
ischemia or
McBurney’s point
infarction
RLQ Pancreatitis
Appendicitis
Cecal diverticulitis Back
Ectopic pregnancy Acute pancreatitis
Ovarian cyst Posterior
Ovarian torsion duodenal ulcer
Tubo-ovarian Retrocecal
abscess appendicitis
Ruptured AAA
Suprapubic
LLQ
Ectopic pregnancy
Diverticulitis
Endometriosis
Ectopic pregnancy
Mittelschmerz
Ovarian cyst
PID
Ovarian torsion
Ovarian cyst
Tubo-ovarian
Uterine leiomyoma
abscess
UTI
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 60
H&P
Vaginitis
Candida Vulvovaginitis
■ Discharge: Dry cottage cheese–like
■ Symptoms: Vaginal/vulvar pruritus, irritation, burning, sore
■ Examination: Vulva: red, edema, and adherent white clumps
Bacterial Vaginosis
Amsel’s criteria (3 of 4 needed for diagnosis):
■ Discharge: Gray-white, thin, homogenous, adherent
■ Vaginal pH ⬎4.5 (normal pH: 3.8–4.5)
■ Clue cells: Bacteria-coated vaginal epithelial cells
■ ⫹ Whiff (amine) test: KOH ⫹ discharge † fishy odor
Trichomonas Vaginitis
■ Discharge: ⁄⁄⁄, grayish-green, frothy (CO2 bubbles)
■ Symptoms: Vulvar/vaginal pruritus, irritation, edema
60
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 61
61
■ Examination: strawberry cervix (punctate hemorrhage),
pH ⬎5.0, ⫹ whiff test, wet preparation (vaginal vault, not
endocervix): Motile, flagellated trichomonads
Atrophic Vaginitis
■ Discharge: Thin or clear
■ Symptoms: Vaginal irritation
■ Examination: Vagina/vulva: pale, dry, thin, øørugae, pH 5–7
Scrotal Complaints
Testicular
veins
Varicocele
Testicular Spermatocele
artery
Epididymitis
Vas deferens
Epididymis
Testicle
Hydrocele
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 62
H&P
62
I II III IV V
⬍10 y.o. 10–11 y.o. 12–14 y.o. 13–15 y.o. 16⫹ y.o.
H&P
None Small amount; Dark, coarse, Adult quality; Adult (extends
long, downy, starts to curl note distribution to medial
slightly and extend (spare medial thigh)
pigmented laterally thighs)
Pubic Hair
FADavis_Chapter 02.qxd
63
Tanner Stages
Male
9/12/08
(continued)
3:40 PM
Page 63
H&P
I II III IV V
⬍10 y.o. 10–11 y.o. 12–14 y.o. 13–15 y.o. 16⫹ y.o.
No Areola widens; ⁄Elevated, extends ⁄Size, ⁄elevation; Adult; areola
budding budding, small beyond areolar areola ⫹ papilla back to breast
glandular tissue borders; areola form secondary contour;
Breast
surrounds widens mound papilla projects
FADavis_Chapter 02.qxd
64
Female
Testicle 1.6–6 mL; skin 6–12 mL; 12–20 mL, ⬎20 mL,
volume thins, reddens, penis adult
9/12/08
⁄⁄Scrotum
⬍1.5 mL; enlarges; penis: lengthens (and darkens);
penis no change penis: ⁄length,
Testicles
small ⁄circumference
3:40 PM
Page 64
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 65
65
Stages of Labor
Cervical
Comments Duration Dilation
Contractions ⁄ frequency, Most 0–4 cm
Latent
effacement days
Most rapid cervical Average 4–10 cm
dilation nulliparous:
Active
5 hr;
multiparous:
2 hr
May blend into active 15 min–3 hr 7–10 cm;
(Deceleration)
Accelerated by
breastfeeding (release
oxytocin) or pitocin
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 66
H&P
Placenta abruptia
More common when mother has high
blood pressure or uses cocaine
Placenta
Uterus
Cervix
Umbilical
cord
Placenta previa
Usually in multiparous women or
uterine structural abnormalities (e.g., fibroids)
Placenta implants
over or near cervix
66
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 67
67
The cephalic or vertex
presentation (normal)
Usually normal vaginal delivery
• Vertical or • Vertical or
longitudinal lie longitudinal lie
• Legs pointed
straight
upward
Front Back
The transverse
x
position (rare)
Usually shoulder first to
present; usually cesarean
section required
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 68
H&P
Front Metopic
Anterior fontanelle
suture
(closes at age 18–24
months, may bulge
Frontal Frontal
with crying or ICP)
bone bone
Coronal
suture Parietal Parietal
bone bone
Sagittal
suture
Posterior fontanelle
(closes at 2 months)
Occipital bone
Lambdoidal
suture Back
68
0 10 20 30 40
Weeks 16 24 28 32 35 37
Every 4 weeks Q 2–4 wks Q 1–2 Q 0.5–1 wk
OB Visits Fetal heart tone Fetal Fundal height
with Doppler General Fetal movement heart & toxemia
tone signs
H&P
Initial Visit Labs
HgB/HCT, blood type, Rh antibody Gonorrhea, chlamydia,
screen, RPR/VDRL, rubella Ab, hep group B strep cx
Bs Ag, UA, urine C&S, Pap (thin
prep), wet prep, PPD, HIV, TSH,
gonorrhea, chlamydia
Sickle cell, Tay-Sachs, cystic fibrosis, VZV, genetic screen, and urine tox screens
Uterus size
Symphysis pubis Midpoint S pubis/umbilicus Umbilicus Size (cm) = Week of gestation
4 regular contractions in 20 minutes or 8 regular contractions in 60 minutes with PROM
FADavis_Chapter 02.qxd
Preterm labor with progressive effacement >80% and cervical dilation >1 cm
69
Biophysical
profile
Non-stress test
RhoGAM If Rh (–)
9/12/08
Pregnancy-
associated Optional
plasma protein
Triple Screen:
-HCG, AFP,
estradiol
One-hour If > 140 & 3 hr wnl, then repeat
glucola test @32 wks
3:40 PM
H&P
Skin Examination
Lesion Descriptions
■ Macule: Flat; different color; can be seen, not felt
■ Excoriation: Mechanical skin erosion or destruction
■ Lichenification: Chronic irritation † leathery skin thickening
with induration and hyperkeratosis
■ Onycholysis: Nail substance loosening or loss
■ Plaque: Flat, elevated, usu. ⬎5 mm
■ Solid raised, discrete: Papule (ⱕ5 mm), nodule (⬎5 mm),
pustule (pus-filled)
■ Blister: Fluid-filled vesicle (ⱕ5 mm), bulla (⬎5 mm)
Shoulder Examination
70
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 71
71
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 72
H&P
Hawkin’s (for more subtle impingement): Raise pt. arm to 90° for-
ward flexion; rotate it internally (i.e., thumb pointed down); puts
humerus greater tubercle position to further compromise space
beneath acromion; positive: pain
72
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 73
73
Biceps
Yergason’s test: Flex pt. elbow 90°; pt. resists while externally
rotate arm; if pain in biceps tendon † positive test † biceps
tendon injury
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 74
H&P
Knee Examination
Anterior Cruciate Ligament (ACL)
Anterior drawer: Flex knee ~80°; relax hamstrings; stabilize foot;
leg in neutral rotation; pull proximal tibia forward to see anterior
74
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 75
75
displacement; quantify displacement (mm), and grade end point:
hard (anterior cruciate ligament [ACL] halts forward motion) or
soft (no ACL)
Pivot shift: Slight distal traction on leg; apply valgus and internal
rotation force to extended knee; (no ACL † tibia anteriorly sub-
luxes on distal femur); flex knee ⬎30° (IT band † extendor †
flexor of knee and tibial anterolateral subluxation reduces)
Posterior Cruciate Ligament (PCL)
Tibial drop back test: Flex knee 80°; compare proximal tibial
prominence to femoral condyles; PCL-deficient knee † gravity
subluxes knee posteriorly; normal knee: tibial plateau located
approximately 1 cm anterior to femoral condyles
Quadriceps active test: Starting position: flex knee 80°, neutral
rotation; apply counterpressure against ankle while pt. fires
quadriceps muscle (i.e., tries to straighten leg); quadriceps pulls
anteriorly through the tibial tubercle to reduce any posterior
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 76
H&P
Squat test: During full squat, check joint line tenderness and
rotate each leg internally (test lateral meniscus) and externally
(test medial mensiscus)
76
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 77
77
Patella
Bulge test: Check for effusion; press down patella † empty
suprapatellar pouch; wipe hand along medial side to displace
fluid laterally; compress lateral side, and watch for bulge medially
Effusion: tap test: Push sharply on patella; if effusion, patella will
bounce off femur
Patellar tilt test: With knee flexed 20°, use thumb to flip up
lateral edge of patella; normally can tilt patella up above hori-
zontal; excessively tight lateral retinaculum † no upward
movement
Soloman’s test: Lift patella away from femur; synovial thickening
† patella hard to grasp
Patellar compression test: Attempts to correlate anterior knee
pain w/articular degeneration; compress patella down into
trochlear groove as pt. flexes and extends knee
Lateral patellar apprehension test: Flex knee 45°; keep knee
relaxed; use one hand to stabilize leg while using other hand to
apply lateral pressure to patella
Medial patellar apprehension test: Fully extend knee; apply
medial translation force; medial subluxation, which most often
occurs in a pt. after a lateral release, occurs in the initial flexion
arc of 0°–30°; after this point, the patella reduces into the bony
confines of the trochlear groove when the knee is flexed
H&P
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 78
H&P
78
FADavis_Chapter 02.qxd 9/12/08 3:40 PM Page 79
79
Part Action Muscle Root Nerve
Knee Extend Quadriceps femoris L3–4 Femoral
Flex Hamstrings L5–S1 Sciatic
Ankle Dorsi Tibialis anterior L4–5 Peroneal
(flex)
Plantar Gastrocnemius S1–2 Tibial
Soleus
Foot Evert Peronei L5–S1 Peroneal
Invert Tibialis posterior L4 Tibial
Toes Dorsiflex Extensor digitorum L5–S1 Peroneal
longus
Extensor digitorum S1
brevis
H&P
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 80
ALGOR
Algorithms
Hyperprolactinemia (⬍100 ng/mL)
■ Ectopic production
■ Breast stimulation (e.g., breastfeeding)
■ Δ metabolism (liver failure, renal failure)
■ Hypothyroidism
■ Medications (e.g., oral contraceptives, antipsychotics, antide-
pressants, antihypertensives, H2-receptor blockers, opiates)
Hypergonadotropic Hypogonadism
(Ovarian Failure)
■ Postmenopausal
■ Premature failure: e.g., autoimmune, chemotherapy,
galactosemia, genetic, 17-hydroxylase deficiency syndrome,
mumps, pelvic radiation
80
Primary Amenorrhea
ALGOR
Hyperandrogenism? Karyotype
Yes <5 >40
ng/mL ng/mL
46XX 46XY FSH
Polycystic ovary
syndrome
Adrenal or Karyotype
FADavis_Chapter 03 .qxd
81
ovarian tumor
No
46XX 46X0
No Yes
disease
Hyperprolactinemia Prolactin
Normal
Vaginal bleeding
FADavis_Chapter 03 .qxd
82
<7 days Progestin No bleeding
challenge
Hypogonadotropic Hypogonadism
■ ⁄⁄⁄ exercise (e.g., marathon running)
■ øøø weight or malnutrition (e.g., anorexia)
■ Chronic illness (e.g., liver, renal, diabetes, inflammatory
bowel disease, thyroid)
Nephrotoxic Agents
Mechanism Examples
Tubular toxicity Aminoglycosides, radiocontrast,
amphotericin B, cisplatinum, heavy metals,
cyclosporin
Tubular Acyclovir, sulfonamides, ethylene glycol,
obstruction methotrexate
Interstitial Penicillin, cephalosporin, sulfonamides,
nephritis rifampin, NSAIDs, furosemide, thiazides,
allopurinol
Renal ACE inhibitors, NSAIDs, cyclosporin,
hemodynamics radiocontrast, amphotericin
ALGOR
Workup of Acute Renal Failure
84
irradiation, Sheehan’s syndrome)
Renal azotemia
3:48 PM
Page 84
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 85
85
Macrocytic Anemia Workup
MCV
Macrocytic >97 fL
Megalocytes
Yes No
Megaloblastic Nonmegaloblastic
Aplastic
anemia
ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 86
ALGOR
MCV
Microcytic <82 fL
Ferritin
Fe deficiency Lead
Normal
High
Hgb Lead
electrophoresis toxicity
Thalassemia, other
86
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 87
87
Normocytic Anemia Workup
MCV
Normocytic 82–97 fL
Corrected abs
retic count
LDH, Suspect
haptoglobin marrow
failure
Normal High Yes No
No
Hemolytic Splenomegaly
anemia Yes
ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 88
ALGOR
Diabetic Ketoacidosis
1 Perform Steps 1, 2, 3, 4, 5, and 6 simultaneously.
Fluids (Step 1) should be started as soon as possible.
88
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 89
89
Diabetic Ketoacidosis (continued)
2 Insulin Therapy
<3.3 mEq/L (3.3 mmol/L)
>3.3 mEq/L Check serum K+
(3.3 mmol/L)
Hold insulin
IM/SC insulin
IV insulin
Monitor and give K+
3 Serum potassium
<3.3 mEq/L 3.3-5.0 mEq/L >5.0 mEq/L
(continued )
ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 90
ALGOR
5 Serum phosphate
<1.0 mg/dL or
cardiac dysfunction, Normal
respiration,
or anemia
6 Serum magnesium
<1.8 mg/dL Normal
(0.74 mmol/L)
No
Symptomatic? Monitor magnesium; Monitor as
consider oral needed
Yes magnesium replacement
90
GI Bleed
Yes
Airway endangered? Intubate
No
ALGOR
CBC, PT/PTT, type and cross
50 mL normal saline
boluses until mean
Low BP of 70
Blood pressure
FADavis_Chapter 03 .qxd
91
Normal or elevated
NG lavage
Negative
Positive for blood
Consider lower
GI source
9/12/08
Emergent Yes
Bright red blood fails to clear after 1 L lavage
endoscopy
Anoscopy,
No
sigmoidoscopy
Peptic ulcer Varices Start empiric H2-blocker
Tagged RBC scan,
H2-blocker Octreotide angiogram, or
3:48 PM
No RBCs
Myoglobin, Urinalysis
hemoglobin
ALGOR
RBCs
Macroscopic; isomorphic RBCs; Dysmorphic
Pyuria
no proteinuria RBCs/RBC casts
92
Workup for GN
Consider biopsy
Negative
+ –
9/12/08
Adapted from Li, T. Approach to Hematuria. In: Agha, IA, Green, G, eds.
The Washington Manual: Nephrology Subspecialty Consult. Phialdelphia: Lippincott, 2004,
3:48 PM
and htttp://www.acpmedicine.com/sample/ch10083-f3.htm
Page 92
Hypercalcemia Workup
Yes
IV fluids Correctable by hydration
Normal
Not true hypercalcemia Ionized calcium
Elevated
ALGOR
Stop meds Caused by medications: (e.g.; Excess Familial
Recheck Ca2+ thiazides, lithium, vitamin A or D) Ca2+/ hypocalciuric
in 48-72 hrs vitamin D hypercalcemia
No or
Acute Chronic aluminum
FADavis_Chapter 03 .qxd
93
ALGOR
Hyperkalemia Management
Rule Out Spurious Causes
■ Laboratory error
■ Blood-draw issues (from vessel with potassium infusion, fist
clenching, tourniquet, traumatic)
■ Pseudohyperkalemia
■ Hemolysis
■ Leukocytosis
■ Thrombocytosis
■ Genetic syndromes
■ Familial pseudohyperkalemia
■ Hereditary spherocytosis
94
Hyperkalemia (K+>5.0 meq/L) Management
ALGOR
Serum K+
Emergent Treatment
<6.0 meq/L P eaked or tented T
S T depres s ion
F irs t-degree AV block or los s of P
ECG QR S widening IV calcium gluconate
FADavis_Chapter 03 .qxd
95
Shift K+ intracellular
A bnormal
Renal function
Insulin + glucose +/-
Normal albuterol
9/12/08
P res ent
Metabolic acidosis
A bs ent
Increase K+ excretion R efrac tory
Hemodialysis
Sodium polystyrene sulfate (Kayexelate) & furosemide
3:48 PM
Volume status
96
Response to DDAVP?
Central Nephrogenic
Hypotonic fluid loss, Renal hypotonic diabetes diabetes
Insensible loss, fluid loss, insipidus insipidus
GI loss Diuretics,
Osmotic diuresis
3:48 PM
Page 96
Hypocalcemia Workup
Normal
Low albumin Ionized calcium
ALGOR
Low
Low Appropriately
Hypomagnesemia mg2+ PTH PO4 3 - Hyperphosphatemia
Normal Normal
FADavis_Chapter 03 .qxd
97
Vitamin D
9/12/08
98
Decreased RTA Type 1
Hyperaldosteronism Plasma HCO3
state RTA Type 2
Increased
hyperaldosteronism
state
Page 98
Hyponatremia (Na+<135 meq/L) Workup
ALGOR
Hyperlipidemia Urine osmolality Hyperglycemia
Mannitol therapy
<100 mOs m/kg >100 mOs m/kg
99
PaCO2
ALGOR
100
C lear F oc al infiltrates Diffus e infiltrates
ALGOR
>90% <90%
SpO2
FADavis_Chapter 03 .qxd
101
stable
No improvement
Intubation NIPPP (e.g., BIPAP)
3:48 PM
Page 101
Hypoxia Mechanical Ventilation (Initiation)
PaO2 <55 mm Hg, PaCO2 >50 mm Hg
Indications for intubation: respiratory distress, and pH <7.32
⌬ mental status, respiratory acidosis, Vital capacity <10 mL/kg
refractory hypoxemia, airway protection Negative inspiratory force <25 cm H2O
FEV1 <10 mL/kg
ALGOR
Intubate: start assist control, rate 12-14/min, TV 8-10 mL/kg, FiO2 100%, PEEP 5 cm H2O*
102
Respiratory Respiratory Adequate Inadequate
pH and PaCO2 PaCO2 PEEP
alkalosis acidosis
NI/baseline Correct anemia
FiO2 by 10% at a time:
9/12/08
**Sedate/paralyze/control pain
Page 102
Infertility
Male Female
High Low <5 ng/mL >40 ng/mL
Testosterone LH
Normal <5 ng/mL >20 ng/mL
FSH
LH LH LH
ALGOR
Abnormal Normal
High Prolactin
FSH FSH
FSH
Normal Normal
MRI r/o Ovarian
pituitary failure
FADavis_Chapter 03 .qxd
Androgen Testicular
103
adenoma
receptor ultrasound
insensitivity
Hysterosalpingogram
r/o retrograde and laparoscopy
ejaculation,
9/12/08
hypospadia
Low High
adenoma
Page 103
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 104
ALGOR
Hemodynamic stability
Vital capacity >10 mL/kg
Maximum inspiratory pressure <-25 cm H2O
Respiratory rate <20 breaths/min
Respiratory minute volume (VE) <10-20 L/min + normal PaCO2
Adequate arterial oxygenation (e.g., PaO2/FiO2 ratio >150-200)
with FiO2 <40%–50%, PEEP <5-8 cm H2O
Ratio of ventilatory frequency to tidal volume (f/Vt) <100 during
1-2-minute trial of spontaneous ventilation
104
Mechanical Ventilation: While on Ventilator
Peak pressure
Increased Decreased
ALGOR
No ⌬
No ⌬ agitation)
105
Increased
ascitic fluid, peritoneal dialysis), atelectasis or clenching teeth), obstruction from retained
(e.g., lobar collapse), large pleural effusions, airway secretions (e.g., mucous plugging)
pneumothorax, stiff lung (e.g. acute respiratory
distress syndrome, cardiogenic pulmonary
edema, fluid overload, pneumonia),
hyperinflation (e.g., auto-PEEP in COPD)
3:48 PM
Page 105
Mechanical Ventilation: Modes
Mode Ventilator Breath Initiated
Continuous mandatory ventilation (CMV) At preset intervals, regardless of patient effort
With patient’s respiratory effort; no spontaneous breathing allowed;
Assist-control ventilation mandatory minimum set rate; patient can easily minute ventilation,
but cannot wean rate, on PIP or Vt
ALGOR
Intermittent mandatory ventilation (IMV) At preset interval, spontaneous breathing allowed between breaths
Synchronous intermittent At preset and coordinated with patient’s respiratory effort;
mandatory ventilation (SIMV) spontaneous breathing allowed between breaths
Spontaneously by patient; set level of support pressure (not TV) to assist every
Pressure support spontaneous effort; airway pressure support maintained until patient's
FADavis_Chapter 03 .qxd
inspiratory flow falls below certain cutoff (e.g., 25% of peak flow)
106
No ventilator breath; deliver set pressure to airways maintain lung volume
Continuous positive
and improve oxygenation; FRC and work of breathing (exhale vs. pressure)
airway pressure (CPAP)
may impaired ventilation
ALGOR
Cold nodule
107
ALGOR
Scales
Brain and Central Nervous System
108
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 109
109
Yes No
Current oral anticoagulant use with PT over 15? ⫺5 1
Use of heparin within last 48 hours and elevated PTT? ⫺5 1
Platelet count ⬎100,000? ⫺5 1
Stroke symptom onset more than 3 hours ago? ⫺5 1
Severe neurologic deficit (e.g., NIHSS ⬍22)? 0 1
Major early infarct signs on CT (⁄⁄edema, mass 0 1
effect, or midline shift)?
Total score: 15 thrombolysis indicated; ⬍13
thrombolysis contraindicated
ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 110
ALGOR
110
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111
Cardiovascular
ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 112
ALGOR
Gastrointestinal
112
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113
Ranson’s Criteria for Pancreatitis
On admission Yes No
Age ⬎55? 1 0
WBC ⬎16K/cubic mm? 1 0
Blood glucose ⬎200 mg%? 1 0
Serum LDH ⬎350 IU/L? 1 0
Serum SGOT ⬎250 SF units? 1 0
Within 48 hr of admission
Hct fall ⬎10%? 1 0
BUN rise ⬎5 mg/dL? 1 0
Serum calcium ⬍8 mg%? 1 0
Arterial pO2 ⬍60 mm Hg? 1 0
Base deficit ⬍4 mEq/L? 1 0
Fluid sequestration ⬎6L? 1 0
Predicted mortality if total score: ⬍3 † 1%; 3–4 † 15%;
5–6 † 40%; ⬎6 † 100%
ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 114
ALGOR
Genitourinary
114
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115
Ectopic Pregnancy Risk
Questions Yes No
Peritoneal signs or definite cervical motion 2 0
tenderness?
Pain or tenderness, other than midline cramping, 1 0
plus no fetal heart tones and no tissue visible at the
cervical os?
Total score: ⬍1 low risk (⬍1% risk of ectopic pregnancy);
1 intermediate (7%); ⬎1 high (29%)
ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 116
ALGOR
116
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117
Additional criteria: 1. temperature ⬎38.3°C (101°F) 2. Abnormal
cervical or vaginal mucopurulent discharge 3. ⫹WBCs on vaginal
secretion saline microscopy 4. ⁄ESR 5. ⁄CRP 6. Laboratory
evidence of cervical infection with N. gonorrhoeae or C.
trachomatis
Definitive criteria: 1. Endometrial biopsy: Histopathologic e/o
endometritis 2. Transvaginal U/S or MRI † thick,
fluid-filled tubes with or without free pelvic fluid or tubo-ovarian
complex 3. PID laparoscopic abnormalities
ALGOR
Chapter 04 .qxd 9/12/08 3:51 PM Page 118
EQUAT
Toxicology Levels
Measure Equation
Half-life (T1/2) 0.693/kelim [0.693 (volume of
distribution)/(clearance)]
kelim [ln (Cpeak) – ln (Ctrough)]/tinterval
Blood EtOH (volume ingestedin mL beverage
concentration “proof” 1.463)/(pt. weightin lb)
Adjusted phenytoin measured/[(serum
phenytoin albumin renal function) 0.1] renal
level fx 0.1 if creatinine clear 10 mL/min;
otherwise 0.2
Phenytoin: (0.55 phenytoin measured/serum
free-drug level albumin) 0.14
118
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119
Cardiovacular Hemodynamics
Measure Equation/Interpetation
Stroke volume End diastolic volume end systolic
(SV) volume Normal: 69–87 mL/beat
SV index (SI) SV/BSA Normal: 40–50 mL/
contraction/m2
Ejection fraction (SV 100%)/(end diastolic volume)
(EF) Normal: 55%–78%
Cardiac output (CO) SV HR Normal: 3–7 L/min
Blood volume Plasma volume/(1-Hct) Normal: 2–5.1 L
O2 content in blood (Hgbin g/dL) (1.34mL O2/g Hgb)
(O2 saturationin %)
O2 consumption BSA * basal O2 consumption BSA *
125 mL O2/m2
CO (Fick’s method) (O2 consumption)/{[(O2 content arterial
bloodin vol%) (O2 content mixed venous
bloodin vol%)) 10)]}
CO (indicator- (60 amount indicator injectedin mg)/
dilution ) [(mean blood concentration
method of indicator)in mg/L) (time total curve
durationin seconds)]
Cardiac index SV HR/BSA Normal:
2.5–4.5 L/min/m2
Heart rate (HR) Normal: 60–100 bpm
Jose and Collison Males: (0.55 agein years) 118
predicted intrinsic Females: (0.61 agein years) 119
HR (IHR)
Rate pressure product (SBPin mm Hg* HRin BPM)/1000
Mean arterial ~ 1/3 * SBP 2/3 * DBP Normal:
pressure (MAP) 70–100 mm Hg
Cardiothoracic ratio (Transverse diameter of heart on PA
or AP view)/(transverse diameter of
bony thoracic cage) 50% † cardiac
enlargement
(continued )
EQUAT
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EQUAT
120
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121
CVP in mm Hg (CVPin cm H2O)/1.36
Mean vascular DBP ((SBP DBP)/3)
pressure
Left cardiac CI MAP 0.0144 Normal:
work index 3.4–4.2 kg-m/m2
Left cardiac CI MPAP 0.0144 Normal:
work index 540–660 g-m/m2
Left ventricular SI MAP 0.0144 Normal:
stroke work 50–62 g-m/m2
index (LVSWI)
RVSWI SI MPAP 0.0144 Normal:
7.9–9.7 g-m/m2
Cardiovascular Monitoring
Condition SAP CVP PAP PCWP CO C(a-v)O2 PVR SVR
Hypo- ø ø ø ø ø ⁄ ⁄ ⁄
volemic
Shock Cardio- ø ⁄ ⁄ ⁄ ø ⁄ ⁄ ⁄
genic
Septic ø ø ø ø ⁄ ø ø ø
Cardiac ø ⁄ ⁄ ⁄ ø ⁄ 0 ⁄
tamponade
RV infarct ø ⁄ 0 0 ø ⁄ 0 0⁄
Pulmonary ø ⁄ ⁄ 0⁄ ø ⁄ ⁄ ⁄
embolism
Airway 0⁄ 0⁄ ⁄ 0 0⁄ 0 ⁄ 0
obstruction
Pressure adjusted HR HR CVP/MAP
EQUAT
Heart Valves
Valve Gorlin (CO/(flow_time * HR))/(valve_factor * sqr (valve_gradient))
Chapter 04 .qxd
122
9/12/08
123
Hematology
Measures Equations
Absolute neutrophil 10 WBCin 1000s (%PMNs
count (ANC) %bands)
Neutropenia: 1500 cells/mm3
Transferrin saturation (Fe/TIBC) 100
(TFS)
Fe replacement Dose .3 wgt (100 (Hgb 100)
(parenteral dosing) /age_factor)
for Fe deficiency Adult 15 kg (14.8); child 15 kg
EQUAT
Chapter 04 .qxd 9/12/08 3:51 PM Page 124
EQUAT
Ventilation Equations
Measures Equations
Minute ventilation VT RR
Ventilation index [RR (PIP PEEP) CO2]/1000
CO2 production VExp (FECO2 FICO2) VExp
(VCO2) expired volume over 1 min.
FECO2 & FICO2 fraction expired
and inspired CO2
124
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125
Right-to-left ([pAO2 paO2] 0.003)/
shunt fraction [([pAO2 paO2] 0.003) 5]
(Qs/Qt) Where: pAO2 FIO2 (pAtm pH2O)
(paCO2/R) [paCO2 FIO2 (1 R)/R]
pAtm 760 mm Hg
e(-altitude in meters/7000)
pH2O 47 mm Hg
e([Temperature in Celsius-37]/18.4)
Closing capacity Closing volume residual volume
EQUAT
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EQUAT
126
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127
Predicted PFTs for Children
Measure Males Females
FEV1 e{[(1.2669 (.0174 * Age)] e{[(1.5016 (.0119 * Age)]
height) 1.2933 height) 1.5974)
FVC e{[(1.3731 (.0164 * Age)] e{[(1.48 (.0127 * Age)]
height) 1.2782) height) 1.4057)
FEV1/FVC 86.21 88.88
Lung Volumes
Maximum inspiration
Normal resting
inspiration IC IRV
IVC
VT VC
TLC
Normal resting
expiration ERV
FRC
EQUAT
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EQUAT
128
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129
Peak Females: (((height * 3.72) 2.24)
expiratory (age * .03)) * 60
flow (PEF) Males: (((height * 5.48) 1.58)
prediction (age * .041)) * 60
Peak 100 * (highest_PEF lowest_PEF)/
expiratory highest_PEF 15 asthma: (20–30: mild
flow persistence; 31–100: moderate to severe
variability persistence
in asthma
Ventilation (PaCO2)in mm Hg (RR) (peak inspiratory
index pressurein cm H2O)/1000 ⁄ † the poorer
the ventilation achieved
Arterial O2 saturation (SaO2) 96%–99%; mixed venous O2
tension (PvO2) 35–45 mm Hg; mixed venous O2 saturation
(SaO2) 60%–80%; FIO2 0.21 for room air; H2O partial pressure
(PH2O) 47 mm Hg; arterial CO2 tension (PaCO2) 35–45 mm Hg;
alveolar CO2 tension (PACO2) 35–45 mm Hg; mixed venous CO2
tension (Pv CO2) 40–50 mm Hg; expired CO2 tension (PECO2)
25–35 mm Hg
Gastrointestinal Equations
Measure Equation
Stool Stool osmolar (2 Na K) 100 †
osmolal osmotic diarrhea, 100 † secretory
gap
Fractional 100 (urine amylase plasma creatinine)/
excretion of (plasma amylase urine creatinine) 5%
amylase suggest acute pancreatitis; 1% may
mean macroamylasemia
(continued )
EQUAT
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EQUAT
130
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131
Diabetes Formulae
Measurement Equation
Hgb A1C Estimation (MPG 77.3)/35.6
Mean plasma glucose (MPG) (35.6 * HbA1C) 77.3
Creatinine Clearance
Normal: Males: 90–130 mL/min; females: 80–125 mL/min
Calculated (Urine creatininein mg/dL) (urine
volumein mL)/(creatininein mg/dL * timemin)
Per standard Calculated creatinine clearance *
surface area (1.73/BSAin m2)
Estimated Males (140 agein years) (body
(Cockcroft weightin kg)/(72 serum creatininein mg/dL)
& Gault) mL/min
Females 0.85 (estimated creatinine
clearance for males)
Estimated Males (LBWin kg (29.3 (0.203
(Mawer) agein years))) (1 (0.03 serum
creatininein mg/dL))/(14.4 serum
creatininein mg/dL)
Females (LBWin kg (25.3 (0.174 agein yr)
(1 –(0.03 serum creatininein mg/dL))/(14.4
serum creatininein mg/dL)
Pediatric GFR δ Htcm/PCr δ 0.33 (_birth wt δ infants),
0.45 (term infants 1 yr), 0.55 (males 2–12 yr
& females 13–21 yr), 0.70 (males 13–21 yr)
EQUAT
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EQUAT
132
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133
Correcting Ca2+ When
øAlbumin (Measured Ca2in mg/dL) (0.8 (4
albuminin g/dL)) ~(current total serum
Ca2 in mg/dL) 4 (albuminin g/dL)
⁄Globulin (Measured Ca2in mg/dL) (0.16 (normal
globulin globulinin g/dL))
⁄pH (Measured Ca2in mg/dL) (0.12 (pH 7.41))
Correcting K+ When
øpH [(Measured KmEq/L) [0.6 (7.41 pH)]
⁄Serum Osm (Measured KmEq/L) (0.6 (serum
osmolality 290)/10)
⁄Platelets (Measured KmEq/L) [0.15 (platelets
normal platelets)/100 109]
EQUAT
Chapter 04 .qxd 9/12/08 3:51 PM Page 134
EQUAT
Measure Equation
(Na) (Cl HCO3)
Normal: 8–16 mEq/L
Anion gap (AG)
(Na K) (Cl HCO3)
Normal: 10–20 mEq/L
AG 12 † RTA, diarrhea, CaCl2, other acids
AG 15 † MUDPALES: Methanol, Uremia, DKA, Paraldehyde,
Alcohol, Lactic Acid, Ethylene glycol, Salicyclates
Corrected anion (Observed AG) (0.25 [(normal
gap serum albumin)in g/L (observed serum
albumin)in g/L)]
(AGobserved) (0.25 (44 (albuminobserved)]
Delta gap AG normal AG AG–12
Delta/delta ΔAG/ΔHCO3 Normal: 1.0–2.0
134
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135
Acid deficit Weightin kg 0.5 (measured HCO3
desired HCO3)
Bicarbonate deficit 0.4 weightin kg (24 HCO3)
Chloride deficit 0.5 weightin kg (desired Cl measured Cl)
Henderson- 6.1 log (HCO3concentration/(0.03 *
Hasselbach (pH) PaCO2))
Winter’s formula (Expected pCO2) 1.5 HCO3 8
for meta-acid / 2
compensation
Urine anion gap Urine Na urine K urine Cl
(UAG) Normal: -10 to 10; extrarenal non-AG
metabolic acidosis: 10 renal non-AG
metabolic acidosis: 10
Acid-base (24 PaCO2)/HCO3
equation (H)
H/K exchange K (0.6 ((pH initial pH final) 0.1)
index
EQUAT
Chapter 04 .qxd 9/12/08 3:51 PM Page 136
EQUAT
Urology Calculations
Measure Equation
Total motile (Volumein mL) (sperm density) (%
functional sperm motile) (% normal morphology)
Normal: 40,000,000/mL
Testicular volume 0.71 length2in cm2 widthin cm
PSA density PSAin ng/mL/prostate volumein cc from
in ng/mL/cc transrectal ultrasound
Absolute PSAin ng/mL/weight of
prostatectomy specimenin g after removal
of seminal vesicles
øPSA density † benign diagnosis; ⁄ in
PSA density † further investigation
PSA velocity (PSA at time 2 in ng/mL PSA at time
1in ng/mL)/(period between time 1 &
time 2)in yr
0.75 ng/mL/year when 3 tests
performed † further w/u
Pregnancy Calculations
Measure Equation
Nagele’s rule for Estimated day of confinement
due date (1st day of LMP) (3 mo) 7 d
Fundal height Weeks gestation / 2 cm
(MacDonald’s rule) At 20 wk fundal height should
20 cm / 2 cm; rule holds 20–36
wk; if ø then suggests
oligohydramnios
Menstrual age (weeks) (Crown Rump Length)in cm
6.5
136
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137
Weight, Energy, and Fluid Calculations
Measurement Equation
Ideal body weight Sex sq (height); if male sex, 23;
(IBW) female sex, 21.5
Normal range for body Low normal 20 sq (height)
weight High normal 27 sq (height)
Body mass index (BMI) Weightin kg/Height in m2
Underweight: 18.5; ideal: 18.5–25;
overweight: 25–30; obese: 30–40;
morbidly obese: 40
Body surface area 0.20247 heightin in.0.725
(BSA) weightin lb0.425
Basal energy Male: 66.5 (13.75 wtin kg)
expenditure (5.003 htin cm) (age 6.775)
(BEE) Female: 655.1 (9.563 wtin kg)
(1.850 htin cm) (age 4.676)
Total daily energy Female: [655.1 (9.563 wt)
requirement (1.85 hgt) (4.676 age)]
(TDER) activity injury
Male: (66.5 (13.75 wt)
(5.003 hgt) (6.775 age))
activity injury
Activity 1.2 confined to bed; 1.3 out
of bed; injury 1.05 minor surgery;
1.15 major surgery; 1.1 mild infection;
1.3 moderate infection; 1.6 severe
infection; 1.275 skeletal trauma; 1.6
head injury with steroid therapy;
1.25 blunt trauma; 1.25 20% burn;
1.85 20%–40% burn; 1.95 40%
burn
(continued )
EQUAT
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EQUAT
138
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139
Fluid Loss (% body weight)
Sign 5% 10% 15%
Mucous membranes Dry Very dry Parched
Sensorium Normal Lethargic Obtunded
Orthostatic Δs in Mild Present Marked
pulse or BP
Urinary flow rate Mild ø ø øøø
Pulse rate Normal/⁄ ⁄ ⁄⁄⁄
Blood pressure Normal Mild ø ø
EQUAT
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MEDS
Angioedema
■ Epinephrine, diphenhydramine, methylprednisolone
■ Acute/recurrent Rx-resistant: prednisone
■ Chronic/recurrent: hydroxyzine, cetirizine, fexofenadine,
doxepin, desloratadine, loratadine
■ Hereditary angioedema: FFP transfusion, C1 esterase inhibitor
■ Prevention: danazol: 50–600 mg PO qd
Asthma
140
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141
Leukotriene 2 or 1* or
modifier
Theophylline 3 2*
Omalizumab 1
Rehabilitation
FEV1/ FEV1 (%
COPD Stage FVC Predicted) Symptoms
0 At risk Nl Nl Chronic
risk factor
exposure
I Mild 70% 80% / prn
IIA 50 /
80%
Moderate 70%
IIB 30% /
50%
III Severe 70% 30% Respiratory
or R heart
failure
(with any
spirometry)
MEDS
FADavis_C05.qxd 9/12/08 3:53 PM Page 142
MEDS
Community-Acquired Pneumonia
1. Outpatient: No Cardiopulmonary Disease
■ S. pneumoniae, Mycoplasma, C. pneumoniae, H. influenzae,
viruses, Legionella, TB, endemic fungi
■ Advanced generation macrolide (azithromycin or
clarithromycin) or doxycycline
3. Hospitalized
■ Same as 1.† mixed infection, viruses, PCP
■ IV azithromycin or [Doxycycline ⫹ -lactam] or IV antipneu-
mococcal fluoroquinolone
142
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143
4. Hospitalized (Non-ICU) ⫹ Cardiopulmonary
Disease*
■ Same as 3.† enteric gram-negatives, aspiration
■ [IV -lactam ⫹ (macrolide or doxycycline)] or IV antipneu-
mococcal fluoroquinolone
5. ICU Admission
■ Same as 4.† ⫹ S. aureus
■ IV -lactam ⴙ [IV macrolide or IV fluoroquinolone]
■ Risks for P. aeruginosa: IV antipseudomonal -lactam ⴙ
either [IV antipseudomonal fluoroquinolone (ciprofloxacin)]
or [IV aminoglycoside ⴙ (IV macrolide or fluoroquinolone]
Systolic Dysfunction
Receptor Blocker
■ Hydralazine
or Eplerenone
NYHA Class
Implantable
Defibrillator
-blocker†
■ Nitrates
Diuretic
Digoxin
■ Dobutamine
Sx ■ Dopamine
■ Revascularization
■ Transplant
I No
II Yes
*
IIIa Yes
*
IIIb Yes
*
IV Yes
*If EF ⬍35%
†Avoid in decompensated CHF
MEDS
FADavis_C05.qxd 9/12/08 3:53 PM Page 144
MEDS
Diastolic Dysfunction
First-line Mechanism Use Only as Alternative
-blocker Maximum diastolic Dihydropyrimidine
filling, øcardiac work CCBs (e.g., amlodipine)
Nondihydropyrimidine
CCBs (avoid in LV
dysfunction)
Angiotensin- ⁄Myocardial relaxation Vasodilators (nitrates,
converting and compliance, hydralazine): øpreload
enzyme øpre- and afterload and angina
inhibitor
or ARB
Diuretics øSx Spironolactone
(? efficacy)
144
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145
■ Milrinone (Load: 50 mcg/kg over 10 min; dose: 0.37–75
mcg/kg/min): Vasodilator (systemic, pulmonary, coronary);
øBP, ⁄HR; aggravates atrial, ventricular arrhythmias, headache
■ Amrinone (load: 0.75 mg/kg over 3 min; dose: 5–20 mcg/kg/min
[max 10 mg/kg/d]): Inotrope and vasodilator for CHF); øøBP,
thrombocytopenia, ⁄AV and ventricular conduction
■ Isoproterenol (initial: 1–4 mcg/min † titrate to HR max:
20 mcg/min):
■ Nonspecific -agonist; øBP; ⁄HR, myocardial infarction (MI)
contraindications: myocardial ischemia, tachycardia, digitalis-
induced bradycardia
Vasopressors
■ Dopamine (6–20 mcg/kg/min): Inotrope at lower doses
■ Norepinephrine (initial: 2 mcg/min; dose: 2–20 mg/min;
titrate to response Max: 40 mg/min): Moderate inotrope;
1/-agonist (low-dose: ) (high-dose: ); may
dampen peripheral A-lines; Rx extravasation with
phentolamine
■ Phenylephrine bolus: 0.1–0.5 mcg IV q15min; initial: 100
mcg/min; titrate to 40–200 mcg/min: Postsynaptic -agonist;
reflex bradycardia; coronary, cerebral, and pulmonary
vasoconstriction; ødose if MAO inhibitors
■ Epinephrine (200–600 mcg/kg/min): Typically used only for
inotropic effects
■ Vasopressin (0.04–0.1 units/min): Antidiuretic; procoagulant;
coronary vasoconstriction (may need to combine with
nitroglycerin); SIADH/H2O intoxication
MEDS
FADavis_C05.qxd 9/12/08 3:53 PM Page 146
MEDS
Duration of Anticoagulation
Type of DVT At Least
Isolated calf vein ⫹ symptoms 6–12 wk
Low risk (first episode or reversible cause) 3 mo
First episode idiopathic 6 mo
Recurrent 12 mo
Hypercoagulable (may need lifetime) 12⫹ mo
DVT Prophylaxis
Highest Risk
■ Major surgery in pt. 40 y.o. prior venous
thromboembolism, malignant disease, or hypercoagulable
■ Elective major lower extremity orthopedic surgery, hip
fracture, CVA, multiple trauma, or spinal cord injury
LMWH, Warfarin (Target INR 2–3), or IV Heparin
HIGH RISK
■ Major surgery in pt. 60 y.o. with no additional risk factors
or in pt. 40–60 y.o. additional risk factors
■ MI
■ Medical patients with risk factors
LMWH, Unfractionated Heparin 5000 U q8h, or
Compression Devices (CDs)
MODERATE
■ Any surgery in pt. 40–60 y.o. and no additional risk factors
■ Major surgery in pt. 40 y.o. with no additional risk factors;
general anesthesia 30 min
■ Minor surgery in pt. with risk factors
LMWH, Unfractionated Heparin 5000 U q12h, or CDs
LOW RISK
■ Uncomplicated minor surgery in pt. 40 y.o. with no clinical
risk factors; general anesthesia 30 min
146
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147
Early Mobilization
PREGNANCY
■ Indications: Mechanical heart valve, rheumatic heart
disease, atrial fibrillation, antithrombin III deficiency,
antiphospholipid syndrome, prior anticoagulation
treatment, factor V Leiden defect, prothrombin G20210A
mutation
Unfractionated Heparin or LMWH
Diabetes
Insulin Preparations
Onset Peak Duration Onset
Humalog 15–30 min 30 min–2.5 hr 3–5 hr
Novolog 10–20 min 1–3 hr 3–5 hr
Regular (R) 30 min–1 hr 2–5 hr 5–8 hr
NPH (N) 1–2 hr 4–12 hr 18–24 hr
Lente (L) 1–21⁄2 hr 3–10 hr 18–24 hr
Ultralente (U) 30 min–3 hr 10–20 hr 20–36 hr
Lantus 1–1.5 hr None (steady level) 20–24 hr
Humulin 70/30 30 min 2–4 hr 14–24 hr
Novolin 70/30 30 min 2–12 hr 24 hr
Novolog 70/30 10–20 min 1–4 hr 24 hr
Humulin 50/50 30 min 2–5 hr 18–24 hr
Humalog 75/25 15 min 30 min–2.5 hr 16–20 hr
MEDS
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MEDS
148
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149
Endocarditis
Indications for Prophylaxis
Patient Risk
■ High: History of subacute bacterial endocarditis, prosthetic
heart valve, complex congenital heart disease (e.g., transpo-
sition great vessel, tetralogy of Fallot), surgical systemic pul-
monary shunts or conduits
■ Moderate: Most other congenital heart disease, acquired valvu-
lar disease, idiopathic hypertrophic subaortic stenosis, mitral
valve prolapse (MVP insufficiency and/or leaflet thickening
■ Low: Isolated secundum atrial septal defect (ASD),
ASD/VSD/PDA 6 mo post-repair if no residual history of
coronary artery bypass graft, pacemaker, automatic internal
cardiac defibrillator, MVP, Kawasaki’s disease, or rheumatic
fever (no valvular dysfunction)
Procedures (Prophylaxis if Moderate or High Risk)
■ Dental: Bleeding anticipated
■ Respiratory: Tonsillectomy and adenoidectomy, rigid
bronchoscopy, mucosal surgery
■ GU: Prostate, cystoscopy, urethral dilation
■ GI: Esophageal varices sclerotherapy/dilation, endoscopic
retrograde cholangiopancreatography, mucosal/biliary tract
surgery
Prior to procedure:
*1 hr
†30 min
MEDS
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MEDS
Endocarditis Treatment
Native Valve
■ Presumptive treatment, no history of intravenous drug abuse
(IVDA): penicillin G OR ampicillin and [nafcillin or oxacillin]
and gentamicin
■ Presumptive treatment, IVDA: vancomycin
■ S. viridans or bovis: [penicillin G ⴞ gentamicin] OR,
ceftriaxone OR [ampicillin and gentamicin]
■ Aminoglycoside resistance: penicillin G or ampicillin
■ Enterococci, PCN-resistant: amoxicillin/sulbactam and
gentamicin
■ Enterococci ⫹ intrinsic penicillin G or ampicillin resistance:
vancomycin and gentamicin
■ S. aureus: [nafcillin or oxacillin] and gentamicin
■ MRSA: Vancomycin
■ Slow-growing gram-negative bacilli: ceftriaxone
■ Bartonella: gentamicin and doxycycline
Prosthetic Valve
■ Empiric: vancomycin, gentamicin, and rifampin
■ Candida/Aspergillus: amphotericin B ⴞ fluconazole
■ C. burnetii: doxycycline and hydroxychloroquine
■ S. epidermidis: vancomycin, rifampin, and gentamicin
150
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151
■ S. aureus: nafcillin, rifampin, and gentamicin
■ MRSA: vancomycin, rifampin, and gentamicin
Headaches
Cluster
Strictly unilateral, severe, duration: 15–90 min, associated auto-
nomic symptoms males more than females
Abortive Treatment
■ First-line: acetaminophen, NSAIDs, aspirin
■ Other: indomethacin, intranasdeal (lidocaine,
dihydroergotamine, or capsaicin)
Preventive
■ First-line: PO corticosteroids, verapamil
■ Others: Anticonvulsants (valproic acid, topiramate,
gabapentin), indomethacin
■ Verapamil, lithium (for chronic cluster)
Tension
Bilateral, mild/moderate pressing/tightening, duration: 30 min–7 d,
no associated Sx, females more than males
Abortive Treatment
■ First-line: sumatriptan, O2 inhalation
■ Other: Trigger-point injections
Preventive
■ Trichloroacetic acid (TCA) (e.g., amitriptyline), SSRIs
Migraine
Unilateral, moderate/severe throbbing, duration: 4–72 hr, associ-
ated Sx, females more than males
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MEDS
Abortive Treatment
■ Aura or mild-to-moderate early ( 2 hr): First-line analgesics
(ASA ⴙ acetaminophen ⴙ caffeine, ASA ⴙ metoclopramide);
other NSAIDs: anaprox DS, indomethacin, acetaminophen,
COX2 inhibitor, ultram
■ Moderate (⬍4 hr) refractory: Antiemetics (first-line: Reglan,
prochlorperazine; others: Dramamine, Atarax, Phenergan) ⴙ
abortive medications (triptans, indomethacin PR, or
isometheptene)
■ (Severe refractory(2–6 hr): Antiemetics serotonin agonist
(dihydroergotamine, triptans)
■ Severe refractory(6–72 hr)
■ Antiemetics (IV/IM): prochlorperazine, metoclopramide,
droperidol, diphenhydramine (for dyskinesia)
■ Serotonin agonist: dihydroergotamine (DHE), triptans
■ Anticonvulsant: valproic acid
■ Antipsychotics with analgesic and antiemetic properties
(IV): chlorpromazine, haloperidol
■ Analgesics/anti-inflammatories (IV/IM): toradol,
dexamethasone, hydrocortisone, methylprednisolone
Preventive
■ -blockers: propranolol*†, timolol†, metoprolol
■ Ca2⫹ channel blockers (?efficacy): verapamil
■ NSAIDs: Aspirin, naproxen sodium, indomethacin
■ Antidepressants: amitriptyline†, doxepin, phenelzine, SSRIs
(fluoxetine)
■ Anticonvulsants: valproic acid and derivatives†, topiramate†,
phenytoin
■ Serotonin agonist: cyproheptadine, methysergide
■ Vitamin supplementation: Petasites hybridus (butterbur):
petadolex, feverfew, vitamin B2, magnesium oxide,
coenzyme Q10
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Helicobacter pylori
■ Clarithromycin 500 mg, amoxicillin 1 g, and proton pump
inhibitor (PPI) PO bid 7 d (rabeprazole) to 10 d (other PPI)
■ Clarithromycin 500 mg, metronidazole 500 mg, and PPI PO
bid 7 d (rabeprazole) to 10 d (other PPIs)
■ Prevpac kit: clarithromycin 500 mg, lansoprazole 30 mg, and
amoxicillin 2 capsules 500 mg PO bid 10 d
Hyperlipidemia
Statin or HMG-CoA Reductase Inhibitor
■ Atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin
■ øLDL 20%–50%, ⁄HDL 5%–15% øTG 10%–25%
■ Adverse effects: GI upset, hepatitis, myopathy, lupus-like
syndrome, rash, peripheral neuropathy, ⁄bleeding risk with
Coumadin
■ Contraindications: Liver disease, myopathy
■ Avoid: Grapefruit and alcohol
MEDS
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MEDS
Bile-Binding Resin
■ Cholestyramine, colestipol, colesevelam
■ øLDL: 15%–30%, ⁄HDL 3%–5%, ⁄TG ?%
■ Adverse effects: GI effects (constipation, flatulence, dyspepsia)
■ Contraindications: TG 500 mg/dL
Hypertension
Monotherapy
■ Diuretics (e.g., hydrochlorothiazide), -blocker, ACE inhibitor
(ACEi), ARB
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Agents for Specific Conditions
Thiazide Diuretics
Spironolactone
Key:
Central Active
␣-Antagonists
Preferred: Y, 1, 2,
Agonists
-Blockers
ACEi/ARB
*, **
Nitrates
Alternative: A
CCB
Caution: ?
Avoid: N
Diabetes 1 N A 2
Renal disease Y Y
Dyslipidemia Y
BPH Y N
COPD/asthma N
Osteoporosis Y
Gout N
Obesity Y
Peptic ulcer N
Edema N
CAD/MI Y Y
Angina Y *
Atrial tachycardia Y **
and fibrillation
Perioperative Y
PVD ? Y
Essential tremor Y
Migraine Y **
Major depression N
Substance abuse † Y Y
Systolic dysfunction Y ? Y
Diastolic dysfunction Y ?
LVH Y Y Y
MEDS
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Hypertensive Emergencies
■ Quiet room, reduce pain, treat underlying cause
■ Screen target organ damage (e.g., renal, CV, CNS)
■ Rapidly øBP may øperfusion † ischemia and infarction
■ Lower MAP 20%–25% in first hour of treatment; if stable,
lower BP to 160/100–110 in next 2–6 hr
■ IV agents: nitroprusside*, nitroglycerin†, esmolol, labetolol,
hydralazine, phentolamine, fenoldopam, nicardipine‡, enalapril
■ Oral agents: captopril, labetalol, clonidine, hydralazine
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CVA: øøøSBP † øcerebral If SBP 220 mm Hg or DBP
perfusion; SBP ⬎185 or DBP 120–140 mm Hg, cautiously ø
⬎110 mm Hg; BP by ~10%–15%: IV
contraindications to tPA use nitroprusside or IV labetalol
Intracranial hemorrhage Careful with IV nitroprusside or
labetalol when SBP 200 or
DBP 110 mm Hg
Oral
■ [Ceftriaxone 250 mg IM 1 or cefoxitin 2 g IM and
probenecid 1 g PO 1 or other parenteral third-generation
cephalosporin (e.g., ceftizoxime or cefotaxime)] doxycycline
100 mg PO bid 14 d
metronidazole 500 mg PO bid 14 d
■ Fluoroquinolones (e.g., levofloxacin 500 mg PO qd or ofloxacin
400 mg bid 14 d)
metronidazole 500 mg PO bid 14 d
MEDS
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MEDS
Nausea/Vomiting/Hyperemesis Gravidum
■ Phosphorated carbohydrates (Emetrol)
■ Antiemetics: metoclopramide (Reglan), not recommended
due to lack of safety data: ondansetron (Zofran), droperidol
(Inapsine)
■ Phenothiazines/antipsychotics: promethazine (Phenergan),
prochlorperazine (Compazine), chlorpromazine (Thorazine)
■ Antihistamines: doxylamine succinate (Unisom), doxylamine ⫹
pyridoxine (Bendectin), meclizine (Antivert),
chlorpheniramine (Chlor-Trimeton), diphenhydramine
(Benadryl), trimethobenzamide (Tigan)
■ Others: pyridoxine (B6), multivitamin (MV1–12), Metamucil,
thiamine
■ Corticosteroids for refractory hyperemesis
Premature Labor
Tocolytic Agents
■ Magnesium sulfate: Contraindications: myasthenia gravis,
ørenal function, recent MI
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■ Terbutaline: Contraindications: antepartum hemorrhage, CV
disease, ⁄thyroid, uncontrolled diabetes
■ Ritodrine: Absolute contraindications: uncontrolled DM,
maternal cardiac disease, pregnancy-induced HTN, ⁄thyroid,
hypovolemia, multiple gestation; relative contraindications:
chronic HTN, DM, migraine, resting tachycardia
■ Nifedipine: PO not effective; contraindications: CHF, AS,
concomitant MgSO4 use
Delayed Labor
Labor Induction
■ Common indications: Pregnancy-induced HTN, premature
rupture of membranes, chorioamnionitis, suspected fetal
jeopardy (e.g., severe fetal growth restriction, isoimmuniza-
tion), maternal medical problems (e.g., diabetes mellitus,
renal disease), fetal demise, post-term pregnancy
■ Contraindications: Placenta previa or vasa previa, transverse
fetal lie, prolapsed umbilical cord, prior classical uterine incision
■ Membrane sweep
■ Artificial rupture of membranes
■ Cervically applied prostaglandins: e.g., dinoprostone
(Cervidil) or misoprostol
■ IV synthetic oxytocin preparations: e.g., Pitocin
■ Other holistic, CAM, or “natural” methods
Seizures
Partial (limited on one brain hemisphere)
■ Simple: Usually no consciousness change; focal motor,
sensory, autonomic, and/or psychology symptoms (may
spread)
■ Prophylaxis: First stage: phenytoin, carbamazepine, valproic
acid adjunctive: phenobarbital, primidone, zonisamide
■ Complex: Usually øconsciousness; often aura precedes; begin
with motionless stare or activity arrest then † complicated
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161
If persistent at 30 min: Intubate/ventilate, Foley catheter, EEG,
follow temperature closely, phenobarbital IV
If persistent at 60 min: pentobarbital IV, midazolam IV, or
propofol IV (titrate per EEG), blood pressure support if necessary
Chlamydia
■ Azithromycin* PO 1 g 1 or doxycycline 100 mg bid 7 d
■ Amoxicillin* 500 mg PO tid 10 d
■ Ofloxacin 300 mg PO bid 7 d
■ Erythromycin* 500 mg PO qid 7 d
Granuloma Inguinale
■ Tetracycline, doxycycline, sulfamethoxazole, gentamicin,
streptomycin, ciprofloxacin, erythromycin 3 wk
e
*Infection in pregnancy
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MEDS
Human Papillomavirus
■ Topical treatment: imiquimod cream, 20% podophyllin
antimitotic solution, 0.5% podofilox solution, 5%
5-fluorouracil cream, trichloroacetic acid (TCA)
■ Procedures: Freezing (cryosurgery), burning (electrocautery),
laser treatment
■ Prevention: vaccine (Gardasil): For 9 y.o. and 26 y.o.: IM
3 separate does: second dose 2 mo and third dose 6 mo
Nongonococcal Urethritis/Cervicitis
■ First line: azithromycin 1 g 1 or doxycycline 100 mg PO bid
7d
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■ Persistent/recurrent: PO [metronidazole or tinidazole 2 g 1]
and [erythromycin 500 mg qid 7 d or azithromycin 1 g 1]
Pediculosis Pubis
■ Permethrin, lindane, pyrethrins with piperonyl butoxide,
malathion
Scabies
■ Permethrin: 5% cream, lindane: 1% lotion, crotamiton: 10%
cream, ivermectin: PO
Syphilis
■ Early (first stage, second stage, early latent): Penicillin G
benzathine: 2.4 mU IM 1; alternative: doxycycline: 100 mg
PO bid 14 d
■ Late (late latent, third stage): Penicillin G 2.4 mU IM qwk
3 wk or doxycycline: 100 mg PO bid 28 d
■ Neurosyphilis: Aqueous crystalline penicillin G 3–4 mU IV
q4h 10–14 d; alternative: procaine penicillin G 2.4 mU IM
qd probenecid 500 mg qid 10–14 d; ceftriaxone 2 mg qd
IV/IM 10–14 d
MEDS
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MEDS
Vaginal Disorders
Atrophic Vaginitis
■ Vaginal creams or tablets: dienestrol, estradiol, conjugated
estrogens
Bacterial Vaginosis
■ Metronidazole: 500 mg PO bid or 250 mg PO tid 7 d or 5 g
0.75% gel intravaginal qd for 5 d
■ Clindamycin: 5 g 2% cream intravaginal qhs 7 d or 300 mg
PO bid 7 d or 100 mg ovules intravaginally qhs 3 d
Vaginal Trichomoniasis
■ Metronidazole: 2 g PO 1 or 500 mg PO bid 7 d
■ Tinidazole: 2 g PO 1
Vulvovaginal Candidiasis
Uncomplicated
■ Vaginal applications: butoconazole, clotrimazole,
miconazole, terconazole, tioconazole, nystatin
■ Fluconazole: 150 mg PO 1
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Head Computed Tomography (CT)
Indications
Craniofacial trauma, acute neurologic dysfunction (⬍72 hr),
intracranial masses, sinus disease, temporal bone disease
Patient Preparation
Keep pt. hydrated; sedate if agitated; when IV contrast: check
serum creatinine and history of allergic reaction
Procedure Description
Pt. supine on CT table; slice thickness varies but usually between
5–10 mm; IV contrast not routine, but may be used to evaluate
for tumors, cerebral infections, and sometimes cerebrovascular
accident
Normal Study
Water ⫽ 0 Hounsfield units (HU); sense bone ⫽ 1000 HU; air⫽
⫺1000 HU; blood ⫽ 50–100 HU
Abnormal Studies
Skull Fractures
■ Classified: Linear (more common) vs. depressed (inward
displacement of fracture fragments)
■ Most clinically significant: Involve paranasal sinus or skull base
■ Distinguish sagittal, coronal, or lambdoidal sutures
(undulating, sclerotic margins) and venous channels
(sclerotic margins and undulating sides)
Subarachnoid Hemorrhage (SAH)
■ Superficial small arteries/veins injury bleeds into space
between pia and arachnoid matter
■ Causes: Trauma, cerebral aneurysm rupture
■ Focal high density in sulci and fissures or linear hyperdensity
in cerebral sulci
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Neurodegenerative Diseases
■ Parkinson’s disease: Nonspecific atrophy with enlarged
lateral ventricles and widened sulci
■ Huntington’s disease: Caudate atrophy † bilateral øconvexity
of caudate heads or ⁄ relative lateral ventricle volume
■ Pick’s disease: Atrophy temporal/frontal lobes
Masses
■ Tumors: Usually hypodense; poorly defined without IV
contrast ⫾ calcification, hemorrhage (hyperdense), and
edema (hypodense); IV contrast † contrast-enhancing ring
around tumor
■ Abscess: Ill-defined, hypodense without IV contrast; variable
edema; often ring-enhanced with IV contrast
Pitfalls
■ Metal foreign bodies can cause scatter artifact and obscure
small areas of hemorrhage or ischemia
■ Motion † difficult to visualize acute ischemic changes and
isodense structures
Cervical Spine
Indications
Neurologic deficits compared with cord lesion, differentiate
MS from head injury or intoxication, neck pain/tenderness, or
significant distracting injuries; can use 1 of 2 clinical criteria to
rule out cervical spine injury (i.e., no cervical spine imaging
necessary):
1. Canadian C-Spine Rules
■ Alert (GCS 15) and not intoxicated
■ No distracting injury (e.g., long bone fracture, large laceration)
■ Not high risk (High risk means age ⬎65 y.o. or dangerous
mechanism or paresthesias in extremities) ⫹ low risk
factor allowing safe ROM assessment (e.g., simple rear
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Patient Preparation
None
Procedure Description
Standard five-view trauma series: Cross-table lateral, swimmer’s,
oblique, odontoid, and anteroposterior
Normal Study
From Graber MA, Kathol M. Cervical spine radiographs in the trauma patient.
Am Fam Physician 1999 Jan 15;59(2):331–42
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169
Check A(lignment), B(ones), C(artilage,) D(isk Space), S(oft Tissue)
Cross-table lateral: Must see all 7 vertebral bodies and cervi-
cothoracic junction; each of 4 imaginary contour lines must form
smooth lordotic curve: 1. anterior vertebral: vertebral anterior
margins; 2. posterior vertebral: vertebral posterior margins;
3. sinolaminar: sinal canal posterior margin; 4. posterior spinous:
sinous process tips
Abnormal Studies
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Pitfalls
■ Relative contraindication: pregnancy
Chest X-Ray
Indications
Evaluate pulmonary disease, pleural disease, cardiac disease,
mediastinal disease, pulmonary edema; initial screen for aortic
rupture
Patient Preparation
None
Procedure Description
Usual (inspiratory PA and lateral); portable (AP); expiratory upright
film (suspected pneumothorax); decubitus (free-flowing fluid)
Normal Study
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Trachea
Aortic
arch
Superior Pulmonary
vena cava artery
Left
Right
ventricle
ventricle
Gastric
Diaphragm air bubble
Abnormal Studies
Lung Cancer
■ Adenocarcinoma (most common): Typically peripheral
nodule, can be associated with fibrosis or bullous disease;
can be Pancoast’s, clubbing, hypertrophic pulmonary
osteoarthropathy, Trousseau’s syndrome of hypercoagulability
■ Bronchioloalveolar carcinoma (subset of adenocarcinoma):
Nodule, multiple nodules, alveolar infiltrate; clubbing,
hypertrophic pulmonary osteoarthropathy, Trousseau’s
syndrome
■ Squamous cell carcinoma (strongly associated with tobacco):
Cavitate, most common Pancoast’s (lung apex; superior
pulmonary sulcus † destroy adjacent rib or vertebra,
Horner’s syndrome, arm pain, hand atrophy), centrally
located, endobronchial, atelectasis, postobstruct pneumonia;
secrete PTH † hypercalcemia
■ Large cell carcinoma: Classically, large (⬎3 cm) peripheral
mass; gynecomastia/galactorrhea
■ Small cell carcinoma (strongly associated with tobacco):
Usually located centrally, ⁄⁄aggressive, early distant spread
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Pleural Effusion: “Blunting” of costophrenic angles
■ Lateral: ⱕ75 mL subpulmonic fluid can be unseen
■ PA: ⱕ175 mL fluid can be unseen
■ Decubitus: ⱖ10 mL can be seen
■ Quantifying: R-sided difficult because large one can invert
diaphragm, L-sided if stomach bubble
■ Loculated: Can appear mass-like
■ Subpulmonic: Appearance of ⁄hemidiaphragm
■ “Psuedotumor”: Collect in major or minor fissures
CHF
■ Left atrial (i.e., mean pulm wedge) pressure 12–19 mm Hg:
Pulmonary vessel cephalization
■ 20–25 mm Hg: Interstitial edema, bronchial wall thickening,
interlobular septa fluid (Kerley’s lines)
■ ⬎25 mm Hg: Alveolar edema: bilateral symmetric perihilar,
coalescent opacities, air bronchograms.
Pneumonia: Infiltrate (= ⁄lung density)
■ Interstitial (frequently viral): Lines (reticular opacities) or nodules
■ Alveolar (frequently bacterial): Hazy coalescent opacity;
obliterate mediastinal/diaphragmatic borders
Sarcoid: Stages:
■ 0: Normal CXR
■ I: Bilateral hilar, paratracheal and mediastinal lymphadenopathy
■ II: Bilateral hilar/mediastinal adenopathy ⫹ interstitial infiltrates
■ III: Interstitial infiltrates
■ IV: Fibrosis
Endotracheal Tube
■ Ideal position: 5 cm from carina (~T4–T5 interspace) when
head neither flexed nor extended; minimal safe distance:
2 cm
■ Dee method to approximate carina position: Define aortic
arch; draw line inferomedially through middle of arch at
45° angle to midline; intersection of midline and diagonal
line ~carina position
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Thoracostomy Tube
■ Placed into pleural space to evacuate air/fluid; in supine pt.,
air collects anteriorly and fluid collects posteriorly; insert
within fissures † may not function; incorrect placement for
empyemas may † ødrainage and loculation
■ Gap in radiopaque line (last tube fenestration) must be
within thoracic cavity; if subcutaneous air, then tube may not
be completely inserted
Nasogastric (NGT) and Feeding Tubes
■ Generally chest x-ray not necessary post-NGT placement
unless s/p esophagectomy
■ Feeding tubes: Usually placed into proximal small bowel
(check abdominal film); for small-bore feeding tube: rule out
placement in lung
Central Venous Pressure Monitors
■ Tip should lie between most proximal venous valves of
subclavian or jugular veins and right atrium; placement in
heart † arrhythmias or cardiac perforations
Swan-Ganz Catheters
■ Tip no more distal than proximal interlobar pulmonary
arteries (i.e., within mediastinal shadow)
Intra-aortic Counterpulsation Devices
■ øAfterload and ⁄cardiac perfusion in cardiogenic shock;
synchronized with either aortic pressures or EKG † diastole:
inflate and systole: deflate
■ Catheter should be near aortic isthmus or left main bronchus
and above celiac trunk and superior mesenteric artery origins
Transvenous Pacing Devices
■ Frontal view: Pacer tip at apex with no sharp angulations
throughout its length
■ Lateral view: Tip embedded in cardiac trabeculae † 3–4 mm
beneath epicardial fat stripe; if beyond epicardial fat stripe
may have perforated myocardium; check pacer wire integrity
Pitfalls
■ Relative contraindication: pregnancy
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Chest Computed Tomography
Indications
Evaluate thoracic trauma, pulmonary nodules, aortic dissection/
aneurysm, lung neoplasm and interstitial lung disease, mediasti-
nal and hilar lymphadenopathy vs. vascular strictures, parenchy-
mal vs. pleural processes
Patient Preparation
Preferably NPO 2 hr prior; normal hydration; sedate agitated pt.;
if IV contrast, check serum creatinine
Procedure Description
High resolution chest CT (HRCT): For interstitial lung disease;
thinner slices and less tissue scanned but more detail than con-
ventional chest CT
Normal Study
■ HRCT “lung windows”: air ⫽ black, aerated lung ⫽ dark gray,
other structures ⫽ white
■ Central, branching paired pulmonary arteries ⫹ bronchi ⫹
connective tissue (bronchovascular bundles)
■ Bronchus: X-section ⫽ thin-wall, white circle with central air
(black); adjacent artery ⫽ solid, white circle
■ Peripherally, arteries and veins: Numerous small “dots” and
a few branching lines; arteries branch at acute angles; veins
branch at 90° angles
■ Major interlobar fissure pleura ⫽ thin, horizontal line
traversing lung
■ Normal interstitium invisible on HRCT; interstitial compartments:
bronchovascular (surrounds bronchovascular bundle);
centrilobular (surrounds distal bronchiolovascular bundle);
interlobular septal (often lines perpendicular to pleura); pleural
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Abnormal Studies
Air Trapping
■ Abnormal gas retention postexpiration (lung parenchyma
remain lucent and normal lung areas † ⁄attenuation); can
appear normal on inspiration, must check on expiration
Bronchiectasis
■ Traction bronchiectasis ⫽ bronchial dilation in lung fibrosis
or distorted lung architecture † irregular bronchial dilation;
usually segmental and subsegmental bronchi, but may affect
small peripheral bronchi or bronchioles; commonly
associated with honeycombing
Pulmonary Nodules
■ HCRT can detect nodules ⱖ1–2 mm diameter; appearance:
well-defined (likely interstitial) vs. ill-defined (likely air space);
distribution: perilymphatic, random vs. centrilobular;
differential diagnoses (DDx): tumor, granulomas,
pneumoconioses, mucous plugs, endobronchial disease,
hypersensitivity pneumonia.
Ground Glass Opacity
■ Nonspecific term ⁄hazy opacity within lungs not obscuring
underlying vessels (if obscure underlying vessels †
consolidation); reflects minimal septal, alveolar interstitium,
or alveolar wall thickening or ⫹cells or fluid filling alveolar
spaces
■ DDx: pulmonary edema; ARDS; pneumonia (viral,
mycoplasmal, PCP); hypersensitivity pneumonia; pulmonary
hemorrhage; other diffuse interstitial lung disease
Cysts
■ Round, thin walls filled with air (darker than normal aerated
lung)
■ Cystic bronchiectasis (multiple dilated bronchi): often
clustered together and focal
■ Honeycombing: ⁄⁄lung fibrosis ⫹ alveolar destruction; thick-
walled, air-filled cysts (3 mm – 1 cm)
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177
■ DDx of multiple cysts: chronic interstitial fibrosis,
Langerhans’ cell histiocytosis, lymphangioleiomyomatosis
Mosaic Attenuation/Perfusion
■ Areas of often patchy øattenuation from regional lung
perfusion differences secondary to airway disease or
pulmonary vascular disease; often pulmonary arteries øin
size in lucent lung fields
Interlobular Septal Thickening
■ Many clearly visible septal lines (smooth, nodular, or
irregular); common with interstitial lung disease
“Tree-in-bud” Appearance
■ Dilated and fluid-filled (i.e., pus, mucus, or inflammatory
exudate) centrilobular bronchioles; irregular, no tapering,
knobby/bulbous at branch tips
Consolidation
■ Opacity completely obscuring vessels; if bronchi aerated †
branching lucencies (“air-bronchograms”)
■ DDx: Any process filling air spaces with blood, fluid, or
inflammatory cells, atelectasis
Pitfalls
■ Requires breath holding
■ Contraindications: See Head Computed Tomography above
Patient Preparation
None
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Procedure Description
Usually PA supine, erect (free air), or lateral decubitus (free fluid);
show lower anterior ribs
Normal Study
■ Solid organs
■ Liver: RUQ soft-tissue density
■ Spleen: LUQ soft-tissue mass; may not be seen
■ Kidneys: Left higher than right; upper poles tilt medially;
should be ~three vertebrae in size
■ Psoas muscle: Line (lumbar spine † lesser trochanter)
■ Bladder: If full, pelvic soft-tissue density
■ Uterus: May indent bladder; usually not seen
■ Prostate: Usually only seen if calcified
■ Hollow organs
■ Stomach: Supine; air † anterior and fluid † posterior
■ Small bowel: Normal 2.5–3.0 cm diameter; valvulae cross
entire lumen; often little seen on plain film
■ Colon: Abdominal periphery
■ Normal calcification: Costal cartilage, mesenteric lymph
nodes, pelvic vein phleboliths, prostate gland
Abnormal Studies
Intestinal Obstruction
■ Dilated loops proximal to obstruction (⬎3 cm small bowel,
⬎6 cm large bowel)
■ Stepladder or hairpin pattern: Air-fluid levels at different
heights within same loop
■ “String of pearls”: Small gas bubbles trapped between folds
in dilated, fluid-filled loops
Ischemic Colitis
■ Thumbprinting of mucosa, bowel wall thickening
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Volvulus
■ May be normal; ahaustral distention, air-fluid levels, liver/left
flank/pelvic overlap
Intussusception
■ Usually in ileocolic region; may be anywhere
■ Soft-tissue mass and small bowel obstruction
Toxic Megacolon
■ Colonic distention with absent haustra; edematous and
ulcerated mucosa may † pseudopolyps
Diverticulosis
■ Gas-filled sacs parallel to colon lumen
Pseudomembranous Colitis
■ Dilated colon, ascites, and nodular thickened haustra
Ascites
■ Detect ⬎500 mL fluid; accumulate in most dependent areas;
supine: hepatorenal recess (Morrison’s pouch); upright:
pouch of Douglas
■ Diffusely ⁄density or “ground glass sign” (hazy appearance);
indistinct liver, spleen, and psoas muscle margins; colon,
liver, and spleen medial displaced away from flank stripe;
bulging of flanks
■ “Dog ears”: Fluid accumulates in peritoneal recesses
superolateral to bladder
Free Air (Pneumoperitoneum)
■ Best seen on upright film (below diaphragm domes)
■ Double wall sign (Rigler’s): Air outline both inside and
outside bowel walls
■ Falciform ligament sign: (Supine) outline ligament
■ Football sign: Gas outline peritoneal cavity
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Pneumoretroperitoneum
■ Air outline right kidney and liver undersurface
■ Unlike pneumoperitoneum, does not move with position
change
■ Can extend into mediastinum or neck
Pneumobilia
■ Biliary gas outline bile ducts
■ Pseudopneumobilia: Normal periductal fat that surrounds
and parallels bile duct course
Calcification
■ Appendicoliths, costal cartilages, mesenteric lymph nodes,
phleboliths, aging prostate, prostate carcinoma, pancreatitis
(T9–T12), nephrocalcinosis (T12–L2), blood vessels,
abdominal aortic aneurysm (AAA), uterine fibroids,
gallstones, porcelain gallbladder, renal calculi, bladder
calculi, bladder tumor, schistosomiasis (Ca2⫹ bladder wall),
ovarian teratoma (tooth)
Pitfalls
■ If spine visible, most structures will be visible
■ View overexposed (dark) areas with bright light
■ Artifacts from piercings and metallic objects
Abdominal-Pelvic CT
Indications
Assess abdominal pathology
Patient Preparation
Keep pt. hydrated; sedate agitated pt.; if IV contrast used, check
serum creatinine and history of allergic reaction
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181
Procedure Description
IV contrast: Ionic: ⁄osmolar and Nonionic: øosmolar
■ GI contrast media
■ Esophacat (thick barium): Opacify esophagus
■ Gastrograffiin (H2O-soluble): Opacify entire GI tract
■ Readicat (barium): Outpatient examinations opacify all GI tract
■ Outpatient: Readicat first half bottle at qhs before and
second half ~ 1 hr before examination; third dose:
immediately before scan
■ Urgent: Gastrograffin 3 doses at 1 hr, 30 min, and
immediately prior to examination
■ Emergent trauma: First dose in ED and second dose at table
■ Delayed images: 5–10 min post-IV contrast † visualize
urinary system
■ Liver Imaging
■ Three-phase scan (especially hypervascular lesions such as
hepatoma, metastatic disease, or hemangioma): 1. arterial
(contrast in aorta and main hepatic arteries); 2. portal
venous (contrast † liver parenchyma and mix with portal
blood); 3. equilibrium (contrast in parenchyma † hepatic
veins † kidneys)
■ First-stage and second-stage liver malignancies usually
have hepatic arterial supply (arterial phase)
■ Benign entities and normal liver: Portal venous supply
(portal-venous phase)
Normal Study
■ Liver parenchyma: Homogeneous 54–60 HU, usually 8–10 HU
⬎ than spleen
Abnormal Studies
k
Liver
Hepatic Abscess
■ Bacterial: Heterogeneous with irregular margin and possible
peripheral enhancement, internal septations or papillary
projections; may contain gas
RADIOL
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183
Budd-Chiari Syndrome
■ Hepatosplenomegaly and patchy enhancement; caudate lobe
may be enlarged after ⬎several weeks; may see collateral
circulation
Passive Hepatic Congestion
■ Chronic ⁄hepatic venous pressure † low attenuation areas
Gallbladder and Biliary System
Porcelain Gallbladder
■ Calcification of the gallbladder wall (arrows), often
accompanied by stones
Choledocholithiasis
■ May have target and crescent signs
Acute Cholecystitis
■ Cholelithiasis, GB wall thickens, pericholecystic fluid,
perforation or hepatic abscess
Pancreas
Pancreatitis
■ Enlarged pancreas ⫹ infiltration of surrounding fat
■ Peripancreatic fluid collections
■ Pseudocysts: Encapsulated fluid collections
■ Pancreatic necrosis: No enhancement with IV contrast
■ Pseudoaneurysm: Saccular dilation of artery (most
commonly splenic and gastroduodenal)
Pancreatic Injuries
■ May appear normal, especially during first 12 hr; may need
to rescan in 12–24 hr
■ Linear hypodensity around pancreatic parenchyma
■ Diffuse, thickened Gerota’s fascia
■ Retropancreatic fluid anterior to splenic vein
■ Delayed formation of pancreatic pseudocyst
Intestines
Acute Appendicitis
■ Dilated appendix ⬎6 mm OR appendicolith
■ Periappendiceal fat stranding
RADIOL
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RADIOL
Crohn’s Disease
■ See Barium and Gastrograffin Enema above
Ulcerative Colitis
■ See Barium and Gastrograffin Enema above
■ Extraintestinal: Sacroiliitis, cholangitis, and thromboembolic
disease
Ischemic Colitis
■ Mucosal “thumbprinting” or thickening of bowel wall
Intussusception
■ Characteristic doughnut/target-shaped intestinal mass
Intestinal Obstruction
■ See Abdominal Plain Film Findings above
Toxic Megacolon
■ Thin bowel wall with irregular nodular configuration
Pseudomembranous Colitis
■ Wall thickening (~15 cm) with target-like appearance,
pericolic fat inflammation, ascites
■ “Accordion sign”: Intraluminal contrast stripes trapped
between nodular, hypertrophied wall
Diverticulitis
■ Pericolonic fat inflammation/stranding, pericolonic abscess,
focal bowel wall thickening, diverticula near inflammation
site
Polyps
■ Benign: Small diameter, stable growth, spherical-shaped,
normal mucosa, long stalks, and smooth surface
■ Malignant: Large diameter, sessile, irregular shape, sudden
growth, broader base, and puckered mucosa
Kidneys
Renal or Ureteral Stones
■ Initial protocol without IV or oral contrast
■ If equivocal: IV contrast † 5–10 min. delayed images
■ Pelvic Ca2⫹ (?distinguish vs. phlebolith)
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185
■ Second-stage signs: Hydronephrosis, perinephric stranding,
and “rim sign” ⫽ edematous ureter ⫽ soft-tissue rim around
pelvic calcification
Peritoneum
Ascites
■ Fluid densities in recesses of peritoneal cavity
■ Serous fluid ~ H2O density; exudative: slightly ⬎ H2O dense;
acute bleed ⫽ most dense
■ Fluid posterior to diaphragm ⫽ pleural fluid; Fluid within
diaphragm ⫽ ascites
Free Air (Pneumoperitoneum)
■ Use lung windows to help distinguish vs. bowel gas
■ Falciform ligament and double-wall (see plain film).
Peritonitis
■ Ascites ⫹ peritoneal and mesenteric thickening
■ Abscess: Early † ~soft-tissue attenuation; as ages †
liquefactive necrosis; mature † definable wall and low
attenuation center
■ Thicken/obliterate adjacent fat and displacement of adjacent
structures
■ ~Hematomas, urinomas, necrotic tumors, pseudocyst
Pitfalls
■ Bone artifacts
■ Contraindications: Pregnant, allergy to IV contrast, iodine,
shellfish
■ Warnings: Renal insufficiency/failure, metformin
Obstetric Ultrasound
Indications
See below
RADIOL
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RADIOL
Patient Preparation
None
Procedure Description
■ Abdominal and transvaginal scans, Doppler ultrasound
■ 3D and 4D ultrasound
Normal Study
Confirm Pregnancy
■ Gestational sac ~41⁄2 wk gestation; yolk sac ~5 wk; embryo
~51⁄2 wk
Gestational Age and Fetal Size
■ Crown-rump length (CRL): Measure at 7–13 wk; estimate
gestational age
■ Biparietal diameter: Measure ⬎13 wk; diameter between two
sides of head ~2.4 cm at 13 wk to 9.5 cm at term; dating later
pregnancy unreliable
■ Femur length: Measure longest bone in body (longitudinal
fetal growth) ~1.5 cm at 14 wk to 7.8 cm at term; dating later
pregnancy unreliable
■ Abdominal circumference: Important to judge fetal
size/weight in late pregnancy; not for dating
Timing of Scans
■ Scan at ~7 wk: Confirm pregnancy, exclude ectopic or molar
pregnancies, confirm cardiac pulsation and measure CRL for
dating
■ 11–14 wk: Evaluate fetal nuchal translucency, nasal bone, and
tricuspid regurgitation (?Down’s syndrome)
■ 18–20 wk: Look for congenital malformations, multiple
pregnancies, placental position
■ ⱖ32 wk: Evaluate fetal size, weight, and fetal growth; verify
placental position
■ Level II (“targeted”) scan: Suspected abnormality
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187
Abnormal Studies
Pitfalls
■ Accuracy highly operator-dependent
Bone Films
Indications
Suspected fractures, dislocations, joint effusions, arthritis, bone
cancer, or bone disease; before and after orthopedic operations
Patient Preparation
None
Procedure Description
Must see at least two views
For long bones, must see joints at both ends
Normal Study
Check: A (anatomic appearance, alignment, asymmetry);
B (bone density/mineralizations); C (cartilage, contours); D (distri-
bution, deformity); E (erosions, extent); S (soft tissue, swelling)
RADIOL
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RADIOL
Abnormal Studies
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189
Psoriatic Arthritis
■ Involves DIP joints, hands ⬎ feet; cup-in-pencil deformity;
resorption terminal phalanges; no osteoporosis
Ankylosing Spondylitis
■ Bilateral sacroiliac arthritis; squaring of vertebral bodies;
bamboo-spine from continuous syndesmophytes; peripheral
large joint erosive arthritis
Reiter’s Syndrome
■ Urethritis, arthritis, conjunctivitis
■ Periostitis at tendinous insertion sites; whiskering; like DISH,
ankylosing spondylitis affects feet ⬎ hands; also SI joint ~to
RA; also, ⫹osteoporosis
Lucent Bone Lesions (mnemonic: FOGMACHINES)
Fibrous dysplasia, Osteoblastoma, Giant cell tumor, Metastasis/
Myeloma, Aneurysmal bone cyst, Chondroblastoma/
chondromyxoid fibroma, Hyperparathyroidism (brown
tumors)/hemangioma, Infection, Nonossifying fibroma,
Eosinophilic granuloma/enchondroma, Solitary bone cyst
Sclerotic Bone Lesions (mnemonic: VINDICATE)
■ Vascular: Hemangiomas, infarct
■ Infection: Chronic osteomyelitis
■ Neoplasm: First stage (osteoma, osteosarcoma), metastatic
(prostate, breast)
■ Drugs: Vitamin D, fluoride
■ Inflammatory/Idiopathic
■ Congenital: Bone islands, osteopoikilosis, osteopetrosis,
pyknodysostosis
■ Autoimmune
■ Trauma: Fracture (stress)
■ Endocrine/metabolic: ⁄Parathyroid, Paget’s disease
Osteonecrosis
■ Early: Appears normal
■ After weeks to months: Ill-defined mottling trabecular
■ Late: (Medullary space well away from joint) dense,
serpiginous calcification (subchondral bone) microfractures
RADIOL
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190
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191
■ Impacted: End of bone driven into contiguous metaphyseal
region without displacement, resulting from axial or
compressive force
■ Depressed: Type of impacted fracture; involves articular
surface of bone † joint incongruity
■ Avulsion: Tendon/ligament pulled away from bone, carrying
bone fragment with it
Pitfalls
■ Relative contraindication: pregnancy
RADIOL
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LABS
Toxicology Screen
Amphetamine/ Remains ⫹ 24–48 hr after use
methamphetamine
Barbiturates Remains ⫹ 2–6 wk after use
Benzodiazepines Moderate use: ⫹ for 3–5 d; heavy: ⫹ for
3–6 wk
Carbon monoxide Suggested by ⬎9% carboxyhemoglobin
Cocaine Direct: ⫹5 hr; metabolite
(benzoylecgonine): ⫹ 2–4 d
Heavy use: ⫹ up to 10–22 d
Codeine ⫹1–2 d
⫹3–10 hr, peak blood levels (on empty
stomach: ⬍40–70 min
Ethanol Metabolism rate: (for 70-kg man) 15⫾5
mg/dL/hr
Urine:blood: 1.35:1 (variable);
saliva:blood: 1:20
Heroin ⫹ 1–2 d (detected as morphine)
Hydromorphone ⫹ 1–2 d
Methadone ⫹ 2–3 d
Methaqualone ⫹ 2 wk
Morphine ⫹ 1–2 d
Phencyclidine ⫹ 1–8 d
Propoxyphene Direct: 6 hr; metabolites: 6–48 hr
Tetrahydrocannabinol 2 d/joint; daily use: 3–6 wk; heavy use:
or marijuana 6–11 wk
metabolite
192
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193
Other Toxicity Tests
Test ⁄ Cause
Lead (Pb) Children For children with ⁄Pb
(⬍16 y.o.): levels, if screening result is:
⬎10 mcg/dL 10–19 mcg/dL perform
Adults: ⬎20 diagnostic test within 3 mo
mcg/dL 20–44 mcg/dL within 1 mo
45–59 mcg/dL within 48 hr
60–69 mcg/dL within 24 hr
ⱖ70 mcg/dL immediately
Free erythrocyte ⬍35 mcg/dL In adults, lead toxicity or
protoporphyrin chronic exposure
Fe–deficiency (can catch
before manifests in
anemia)
Other anemias: e.g.,
hemolytic anemia, chronic
disease
Acetaminophen Rumack–Matthew
nomogram
LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 194
LABS
200
150 Probable
100 hepatic
toxicity
50
Possible
hepatic
toxicity
10
Hepatic
5 toxicity
unlikely
1
4 8 12 16 20 24
Hours after ingestion
194
Cerebrospinal Fluid (CSF) Findings in
Different Conditions
Hemor- Neo- Neurosy- Guillain–
Test Bacterial Viral Fungal TB rhage plasm philis Barré
Color Cloudy Clear to Clear to Cloudy Xan- Clear to Clear to Clear to
cloudy cloudy thochro- xan- cloudy cloudy
mia thochro-
mia
Opening ⁄ Normal Normal Variable ⁄ ⁄ Normal
pressure or ⁄ or ⁄ or ⁄
WBC ⬎=1000 ⬍100 Variable Variable Normal Normal ⁄ Normal
FADavis_Chapter 07.qxd
LABS
CSF-to- Normal Normal ø ø ø Normal Normal Normal
serum to ø to ø
glucose
4:00 PM
ratio
Page 195
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LABS
CSF Tests
Test Result Cause
Leukocyte ⁄ ⬎5 WBCs/ Blood (⁄⁄ one WBC for every
mm3 500–1000 RBCs): Subarachnoid
hemorrhage
Predominantly neutrophils
(bacterial meningitis); lymphocytes
(viral meningitis, chronic intracranial
inflammation); eosinophils
(intracranial parasites, aseptic
meningitis, malignancy, VP shunt)
Blood ⫹ Subarachnoid or intracranial
bleeding; traumatic tap
⁄ ⬎80 mg/mL Hyperglycemia
ø ⬍50 mg/mL Hypoglycemia; granulomatous
disease (e.g., TB, sarcoid);
Glucose Newborn: meningitis (e.g., bacterial,
⬍60% Infant: chemical, fungal); subarachnoid
⬍50% serum hemorrhage; neoplasm; certain
glucose CNS viral infections (e.g., HSV,
mumps, lymphocytic
choriomeningitis)
196
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197
Polycystic ovarian Normal or ⁄ ⬎1.5
syndrome (PCO)
Obesity Can be normal Can be ⁄
or ø
⁄ Thyroid Can be normal Can be ⁄
or ø
Liver disease Can be normal Can be ⁄
or ø
Distinguishing Gonadal Failure
First stage ⁄⁄ ⁄⁄
Second stage Normal or ø Normal or ø
(hypothalamus or
pituitary)
Prolactin (PRL)
⁄ Males and Breast, chest wall, skin, or spinal
nonpregnant cord stimulation: e.g., Manipulation/
females: 20 physical stimulation, surgery, masses,
ng/mL infection
Pregnant: Physiologic: Pregnancy, sleep, exercise,
300 ng/mL eating, stress
Endocrine: e.g., Hypoglycemia,
øthyroid, adrenal adenoma/tumor,
ovarian tumor, PCO
PRL–secreting tumors: e.g., Pituitary
tumors, breast CA, hypernephroma
øPRL inhibiting factor (PIF) synthesis:
Hypothalamic or pineal disorders
øPIF transport: Pituitary stalk
compression (e.g., cerebral aneurysm,
pseudotumor cerebri)
Rheumatism/musculoskeletal: SLE
Various drugs: e.g., Estrogens, TCAs
LABS
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LABS
198
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199
Thyroid Function Tests
Test ⁄ Causes of ⁄ ø Causes of ø
Thyroid– ⬎4.0 mc øThyroid ⬍0.4 mc ⁄Thyroid
stimulating U/mL TSH anti- U/mL Pituitary
hormone bodies disorder Acute
(TSH) Pituitary illness or
resistance malnutrition
Acute Hyponatremia
illness
recovery
Total ⬎11.2 ⁄Thyroid ⬍5.0 øThyroid
thyroxine mcg/dL secretion mcg/dL secretion:
(T4) ⁄Thyroid– øPituitary/
binding øhypothalamus
globulin øTBG: e.g.,
(TBG): e.g., Congenitalø,
Pregnancy chronic
⁄Thyroxine illness
intake
Free ⬎1.9 Same as ⁄T4 ⬍0.7 Same as øT4
thyroxine ng/dL but not ng/dL but not affected
(FT4) affected by by ⁄TBG
TBG
Free ⬎13 Same as ⁄T4 ⬍4.2 Same as ⁄T4
thyroxine but corrects but corrects
index for ⁄TBG for ⁄TBG
Total ⬎200 Same as ⁄T4 ⬍80 Same as
triiodothy- ng/dL ng/dL øT4; when
ronine (T3) T4 normal
or ⁄, ø T4 † T3
conversion : e.g.,
Fasting, surgical
stress
(continued )
LABS
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LABS
Coagulation Studies
Test ⁄ Causes of ⁄ ø Causes of ø
Prothrom- ⬎35 øFactor I, II, V, 25 Vitamin K
bin time sec VII, or X sec Throm-
(PT) øSynthesis: e.g., bophlebitis
Liver disease Drugs: e.g.,
øConsumption: Estrogens,
e.g., DIC griseofulvin
øVitamin K
Drugs: e.g.,
Warfarin
200
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201
Partial ⬎35 øFactor I, II, V, 25 Hypercoagulable
thrombo- sec VIII (hemophilia sec states: DIC
plastin A), IX (hemo-
time philia B),
(PTT) X, XI, or XII
øSynthesis/
⁄consumption/
inhibitors:
e.g., Lupus anti-
coagulant
Drugs: Heparin,
warfarin
Anti- ⬎120 Acute hepatitis/ ⬍80% Hereditary
thrombin % or cholestasis or øAT III
(AT) III ⬎30 Kidney ⬍17 Thrombosis:
mg/ transplant mg/ e.g., DIC
dL øVitamin K dL øSynthesis/
Post–MI ⁄loss
Drugs: Coumadin Drugs: e.g.,
Thrombolytics
Factor ⬎ Inflammation 50% Hemophilia A,
VIII assay 200% (acute phase nor- von Willebrand
nL reactant) mal disease
Pregnancy ⁄Consumption:
(last trimester) DIC
Drugs: OCPs Factor VIII
inhibitor
Fibrinogen ⬎433 Inflammation, 175 øSynthesis: e.g.,
(functional) mg/ infection, mg/ Afibrinogenemia
dL pregnancy, MI dL Consumption:
Drugs: OCPs e.g., DIC
Drugs: e.g.,
Androgens
Bleeding ⬎9 øPlatelet number or function: e.g., Bernard–
time min Soulier syndrome, thrombasthenia, von
Willebrand (some forms)
Vascular wall defects
Drugs: Dextran, indomethacin, salicylates
(continued )
LABS
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LABS
Coagulation Studies
(Continued )
Test ⁄ Causes of ⁄
Activated ⬎180 øClotting factor (except factors VII and III)
clotting sec Platelet function disorder (but normal in
time pure thrombocytopenia and von
(ACT) Willebrand)
Afibrinogenemia
Circulating anticoagulants
Drugs: Heparin
Fibrin ⬎10 When plasmin dissolves fibrin blood clots †
degrada- mcg FDPs (which inhibit clotting); ⁄⁄⁄ indicates ⁄
tion /mL fibrinolysis or clot breakdown: e.g., DIC,
products primary fibrinolytic disorders, PE
(FDP) Severe liver disease
False-positive: Rheumatoid factor
Thrombin ⬎20 Consumption: e.g., DIC
time sec Hereditary disorders: Hypofibrinogenemia,
dysfibrinogenemia
Drugs: Heparin, fibrinolytic agents (e.g.,
streptokinase, TPA)
D–Dimer ⫹ Venous or arterial thrombosis: e.g., PE/DVT,
MI, recent surgery, infection, sepsis, cancer,
DIC
Drugs: Anticoagulants
Direct Detect RBCs coated with antibodies including, the
Coombs’ following types of hemolysis:
test Autoimmune: Warm autoimmune hemolytic anemia
(e.g., idiopathic, SLE, Evans’ syndrome), cold
autoimmune hemolytic anemia (e.g., mononucleosis)
Alloimmune: Various newborn hemolytic disease
(e.g., erythroblastosis fetalis, Rh disease, Rhesus C,
ABO, anti–Kell), other blood group incompatibility
(e.g., RhC, Rhe, RhE, Kid, Duffy, MN, P)
Drug–induced: e.g., Methyldopa, various antibiotics,
L–dopa, quinidine
202
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203
Indirect Detect anti–RBC antibodies in serum (specifically
Coombs’ IgG, but may detect IgM):
test Acquired hemolytic anemia, incompatible blood
transfusion, and anti–Rh antibodies (maternal Rh
sensitization)
Ham Used to diagnose paroxysmal nocturnal
test hemoglobinuria
False-positive: Myeloproliferative disorders,
spherocytosis, transfusion with old RBCs,
hereditary dyserythropoietic anemia type II
Test ø Causes of ø
Vitamin ⬍200 ⁄Requirements (e.g., pregnancy),øintake
B12 pg/mL (e.g., vegan diet)
øIntestinal absorption: Inflammation
(e.g., Crohn’s), disruption (e.g., blind
loop), infection (e.g., D. latum)
øIntrinsic factor: e.g., Pernicious anemia,
⁄metabolism (e.g., ⁄thyroid), gastric CA,
atrophic gastritis, gastrectomy
Note: May be ⁄⁄ in liver or myeloprolifer-
ative disease (e.g., myelocytic leukemia)
B12 In 24 h, øIntrinsic factor
absorption excrete øIleal absorption
(Schilling ⬍8%
test)
Folic acid ⬍2.7 øIntake (e.g., chronic EtOH)/øabsorption
ng/mL (e.g., celiac disease)
øVitamin B12
Various drugs: e.g., Antimalarials,
estrogens, methotrexate
LABS
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LABS
Iron Studies
Test ⁄ Causes of ⁄ ø Causes of ø
Iron (Fe2+) ⬎170 Hemolysis, ⬍60 øIntake/
mcg/dL Non–iron- mcg/dL absorption: e.g.,
deficiency Malnutrition,
anemias celiac disease
and lead Chronic blood
poisoning loss: e.g., GI,
Iron menstrual,
overload: postoperative
e.g., ⁄Iron demand:
Multiple e.g., Pregnancy
blood Drugs: e.g.,
transfusions Allopurinol,
Ineffective cholestyramine,
erythro- colchicine,
poiesis: e.g., methicillin,
Liver disease testosterone
øVitamin B6
or B12
Drugs: e.g.,
Estrogens
Total iron– ⬎450 Fe– ⬍240 Non–iron-
binding mcg/dL deficiency mcg/dL deficiency
capacity anemia anemias
⁄Fe demand: Iron overload:
pregnancy e.g., Hemochro-
(3rd matosis
trimester), øIntake/
infancy øsynthesis/
Poly- ⁄loss protein
cythemia ⁄Thyroid
vera Chronic
Acute liver inflammation:
disease e.g., RA
Drugs: Fluo- Drugs: e.g.,
rides, OCPs Chloramphenicol
204
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205
Ferritin Males: Inflamma- Males: Iron
⬎300 tion (acute ⬍12 deficiency
ng/mL phase ng/mL anemia
Females: reactant): Females:
⬎150 e.g., RA, ⬍12
ng/mL adult Still’s ng/mL
(⬎500)
Iron
overload
Other: Liver
necrosis,
⁄thyroid,
neoplasms
Transferrin ⬎370 Iron ⬍200 øIntake/
mg/dL deficiency mg/dL øsynthesis/
Drugs: Oral ⁄loss protein
contracep- Chronic
tives inflammation
and neoplasms
Hereditaryø:
Atransfer-
rinemia
RBCs
Test ⁄© ⁄ª Causes of ⁄ ø© øª Causes of ø
RBC ⬎6.1 ⬎5.4 ⁄Production: ⬍4.7 ⬍4.2 øProduction:
count ⫻ ⫻ e.g., ⫻ ⫻ e.g., Liver
106/ 106/ Polycythemia 106/ 106/ disease, øFe,
mcL mcL vera, ⁄EPO mcL mcL øbone
production, marrow, renal
Hema- ⬎ ⬎ øblood O2 ⬍ ⬍ failure (øEPO
tocrit 50% 45% 40% 36% production)
Fluid loss †
hemoconcen- Loss:
Hemo- ⬎ ⬎ ⬍ ⬍ Hemorrhage
globin trate: e.g.,
17.4 16.0 13.6 12.0 Destruction
(Hgb) Burns, diuresis
g/dL g/dL g/dL
(continued )
LABS
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LABS
RBCs
(Continued)
Test ⁄© ⁄ª Causes of ⁄ ø© øª Causes of ø
Eryth- ⬎19 mIU/ øO2 ⬍0–5 Inflammation/
ropoi- mL (secondary mIU/mL chronic
etin polycythemia)/ disease/renal
(EPO) ⁄O2 demand: disease
e.g., Primary
Pregnancy polycythemia
Anemia (polycythemia
EPO– vera)
producing
masses
RBC Indices
Test ⁄ Causes of ⁄ ø Causes of ø
Mean 95 Abnormal RBC 80 Abnormal Hgb
corpuscular maturation synthesis: e.g.,
volume Spurious causes: øFe, CRF,
(MCV) (fL) Autoagglutination, thalassemia, Pb
⁄WBC poisoning,
chronic disease
Some drugs: e.g.,
Phenytoin
Mean 36 = (HCT/Hct) ⫻ 100 31
corpuscular Spurious causes:
Hgb concen- Lipemia, sample
tration turbidity, hemoly-
(g/dL) sis (in vitro/vivo)
Mean 34 = Hemoglobin/ 26
corpuscular RBC count
hemoglobin See causes of
(pg/cell) ⁄MCV
206
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207
Red cell 14. = (Standard deviation of RBC volume/
distribution 5% MCV) ⫻ 100
width ⁄Variation in RBC size: e.g., øFe, øB12, øfolate,
immune hemolytic anemia, liver disease,
RBC fragmentation
LABS
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LABS
Platelets (Plt)
Test ⁄ Causes of ⁄ ø Causes of ø
Plt count 4.5 ⫻ Essential 1.5 øProduction:
105/ (primary) throm- ⫻ 105/ øBone marrow,
3 3
mm bocytosis: Myelo- mm ømegakaryocyte
proliferative (e.g., aplastic
disorders anemia, EtOH,
Reactive radiation), hered-
(secondary) itary (e.g., TAR
thrombocytosis: syndrome,
e.g., Inflamma- Fanconi’s,
tion (e.g., inflam- May–Hegglin)
matory bowel Sequestration:
disease [IBD]), e.g.,
surgery, øspleen Splenomegaly
208
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 209
209
(øbreakdown), ⁄Destruction:
hemorrhage, Immune (e.g.,
malignancy, ITP), mechanical
postinfection (e.g., prosthetic
Drugs: Epineph- valves)
rine, vincristine Various drugs
Mean Plt 11 fL ⁄Platelet 6 fL øProduction
volume turnover: e.g., Myeloprolifera-
ITP tive disorders:
Sudden ø ø gesta- Polycythemia
tional proteinuria rubra vera,
and hypertension essential throm-
Stored EDTA bocythemia,
blood artifact myelofibrosis
Other: Hereditary: Stor-
Bernard–Soulier, age pool disease,
May–Hegglin, Wiskott–Aldrich,
Epstein, Fechtner, TAR syndrome
Sebastian, Alport
øPlatelet Congenital: e.g., Glanzmann’s, Bernard–Soulier, stor-
aggrega- age pool disease, von Willebrand’s
tion Acquired: e.g., Antiplatelet Abs, myeloproliferative
disease, uremia, FDPs, acquired storage pool
disease, medications
Lipids
Test Targets Comments
Total ⬍200 mg/dL
cholesterol
High-density Females: ≥50 mg/dL Highest amount
lipoprotein Males: ⱖ40 mg/dL of protein
(HDL)
(continued)
LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 210
LABS
Lipids
(Continued)
Test Targets Comments
⬍2 cardiac risk ⬍160 mg/dL = Total choles-
factors: Medication if: terol – HDL –
⬎190 mg/dL (TG/5)
ⱖ2 cardiac risk ⬍130 mg/dL or
factors: Medication if: = Total choles-
Low-density ⬎160 mg/dL terol – HDL –
Lipoprotein VLDL
CAD or equiva- ⬍100 mg/dL Contains high-
(LDL)
lent (diabetes): Medication if est amount of
⬎130 mg/dL cholesterol
CAD ⫹ multiple ⬍70 mg/dL
uncontrolled Medication if
risks: ⬎100 mg/dL
Very low– ⬍31 mg/dL = (TG/5)
density Contains high-
lipoprotein est amount of
(VLDL) TG
Triglycerides ⬍150 mg/dL
(TG)
Cardiac Markers
Begins to Returns
Test ⁄ Rise Peaks to Normal
Myoglobin ⬎50.0 ng/mL 2 hr 6–8 hr 20–36 hr
Creatine ⬎161 U/L or ⬎4% 3–4 hr 12–24 hr 2d
kinase–MB of total CK
(CK–MB)
Total CK ⬎267 IU/L 4–6 hr 24 hr 3–4 d
Troponin–I ⬎1.0 ng/mL 2–6 hr 12–16 hr 5–10 d
Troponin–T Less specific than I 2–6 hr 12–16 hr 5–14 d
210
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 211
211
Brain (B–Type) Natriuretic Peptide
Level
(pg/mL) Interpretation
Normal ⬍10 Look for other causes of dyspnea
⬍99 Heart failure unlikely
100–300 CHF present Myocardial
stress/injury:
300–600 Mild CHF øexcretion: Renal
Abnormal
600–900 Moderate failure
CHF Primary hyperaldos-
teronism or
900 Severe CHF Cushing’s
⁄Age
Drugs: Cardiac
glycosides, diuretics
Sweat Chloride
⁄ 60 mmol/L Diagnose cystic fibrosis (false-positive:
øAdrenal, øG6PD, glycogen storage disease,
øthyroid, malnutrition, renal failure)
ø Dehydration, heavy perspiration, øaldosterone
Drugs: Corticosteroids
LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 212
LABS
Liver Tests
Test ⁄ Liver Injury Also ⁄ in
Alanine ⬎35 U/L Most specific Heart, pancreas,
aminotrans- for liver injury kidneys, muscle
ferase (ALT) injury
Aspartate ⬎35 U/L øSpecific than Heart, lung, RBCs,
aminotrans- ALT muscle, bone, pan-
ferase (AST) creas, kidney
injury; vitamin A
Gamma(γ) – 51 U/L Biliary tract CHF, SLE (mild ⁄
glutamyl (more respon- from disease and
transpeptidase sive to obstruc- NSAIDs)
tion than AST or
ALT)
Lactic dehy- ⬎333 IU/L Liver isoenzyme LDH–1: Heart mus-
drogenase LDH–5 so LDH5 cle and RBCs
(LDH) LDH4 † liver LDH–2: WBCs
disease LDH–3: Lungs
If LDH1/LDH2: LDH–4: Kidney,
0.85: MI, placenta, pancreas
hemolysis, renal LDH–5: Skeletal
infarct muscle, liver
Alkaline phos- ⬎147 IU/L Liver and bile Kidney, bone, pla-
phatase ducts centa, lung, heart,
stomach, bowel,
benign familial
hyperphos-
phatasemia,
ectopic tumor pro-
duction (e.g.,
hypernephroma)
212
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 213
213
Test ⁄ Causes
Conjug- ⬎0.4 In adults:
ated mg/dL øBilirubin excretion: Liver disease (e.g., EtOH,
bilirubin cancer, primary biliary cirrhosis), cholestasis
(direct) (e.g., drugs, ⁄TPN, pregnancy), biliary tract
obstruction (e.g., cholelithiasis, pancreatic
mass)
In neonates:
Hemolysis: e.g., Hemolytic disease of
newborn
øBilirubin excretion: Liver disease, biliary
obstruction
Pancreatic problems: e.g., Cystic fibrosis,
øøøα–antitrypsin
Intrauterine infections: e.g., Sepsis
Congenital disorders: Dubin–Johnson
syndrome, Rotor’s syndrome, trisomy 18,
galactosemia, tyrosinemia, hereditary
hypermethioninemia
Unconj- ⬎0.7 RBC hemolysis: e.g., Sickle–cell, PNH, G6PD
ugated mg/dL deficiency
bilirubin Liver disease: e.g., Hepatitis, tumor, hepatic
(indirect) congestion from CHF
Biliary tract disease: e.g., Cholangitis, biliary
tract obstruction
Hereditary disorder: Gilbert’s, Crigler–Najjar
Total ⬎8.0 Abnormal protein ⬍6.0 øIntake/
protein g/dL production: e.g., g/dL øabsorption/
Gammopathies øsynthesis
øIntravascular protein: e.g.,
volume: e.g., Malabsorption,
Dehydration liver disease
Drugs: e.g., ⁄Protein loss: e.g.,
Androgens Nephrotic
syndrome, burns,
(continued)
LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 214
LABS
Liver Tests
(Continued )
hemorrhage,
enteropathy,
fistulae
⁄Intravascular
volume: e.g., CHF,
pregnancy
Albumin ⬎5.4 øintravascular ⬍3.4 Causes of øprotein
g/dL volume g/dL above
Drugs: Estrogen
Am- ⁄⬎60 Liver destruction (e.g., cirrhosis), urea cycle
monia mcg/ metabolic defect or urea–splitting UTI: (e.g.,
dL Proteus, Klebsiella), organic acidemias,
hemolysis
ø⬍10 Renal failure and drugs (e.g., lactulose,
mcg/ neomycin)
dL
Antimit- ⫹ Abs vs. liver mitochondria: Primary biliary
ochon- cirrhosis, hepatitis, viral hepatitis, cryptogenic
drial Ab cirrhosis, EBV
Anti- ⫹ ⬎1:80 titer: Autoimmune chronic active
smooth hepatitis
muscle ⬍1:80 titer: Primary biliary cirrhosis, viral
Abs hepatitis, cryptogenic cirrhosis, endometriosis,
Behçet’s, vitiligo, CMV, EBV, HIV
214
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 215
215
Glucose Tests
Test ⁄ Causes of ⁄ ø Causes of ø
Glucose ⬎100 ⁄Glucose ⬍60 ⁄Insulin: e.g.,
mg/dL intake mg/dL Insulinoma
(fast) øInsulin: Postprandial
⬎140 Pancreatic (i.e., glucose
mg/dL disorders, type absorption †
(non- I diabetes ⁄⁄⁄insulin
fast) Insulin resis- surge):
tance: Type II øGastric emp-
diabetes tying (e.g.,
⁄Metabolism: gastrectomy,
e.g., vagotomy)
Pregnancy, øGlucose
⁄thyroid, intake/
⁄adrenal, øproduction:
infection e.g., øAdrenal,
Various drugs: øpituitary,
e.g., TCAs, øglucagon,
corticosteroids liver disease,
øG6PD
Various drugs
Glycosylated ⬎6.5% Chronic hyper- ⬍4.0% ⁄Normal Hgb
hemoglobin glycemia or ⁄Hgb
(HbA1c) øHgb clearance: e.g.,
clearance: e.g., Hemolytic
øSpleen anemias,
False ⁄: e.g., spherocytosis,
Uremia, hemoglo-
⁄triglycerides, binopathies
⁄bilirubin, False ø:
EtOH, salicy- Vitamins C
lates, opiates and E
Fructosamine ⬎223 Measures diabetic control for 2–3 wk vs.
µmol/L HbA1c (4–8 wk); useful where HbA1c may
be inaccurate: e.g., abnormal hemoglobin
(continued)
LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 216
LABS
Glucose Tests
(Continued)
Test ⁄ Causes of ⁄ ø Causes of ø
Insulin ⬎16 yr: Proinsulin ⬎16 yr: ⁄Exogenous
C–peptide ⬎5.0 split † insulin ⬍1.1 insulin: e.g.,
⬍16 yr: and C–peptide; ⬍16 yr: Factitious
⬎3.3 evaluate øglu- ⬍0.4 hypoglycemia
ng/mL cose or resid- ng/mL ⁄⁄⁄EtOH
ual B–cell øøøInsulin
function production:
⁄⁄⁄ Insulin e.g., Type 1
production: diabetes,
e.g., pancreatec-
Insulinomas, tomy
pregnancy
øExcretion:
e.g., CRF
Drugs: Oral
hypoglycemics
Pancreatic Tests
Test Result Causes
Amylase ⁄⬎130 U/L Injury/inflammation of:
Pancreas
Salivary gland: e.g., Sialoadenitis
Stomach/intestinal tract, ovaries
(e.g., ruptured ectopic pregnancy),
skeletal muscle
Various drugs: e.g., Bethanechol,
cholinergic medications
⁄⬍20 U/L Pancreatic destruction: e.g.,
Advanced chronic pancreatitis
216
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 217
217
Lipase ⁄ ⬎160 U/L Injury/inflammation of:
Pancreas
Stomach/intestinal tract, tongue
Various drugs: e.g., Meperidine, mor-
phine, indomethacin
Glucose Screen for gestational diabetes (24 and 28 wk of
tolerance pregnancy)
test Diagnose diabetes when suspected but fasting
blood glucose normal
Fasting: 1 hr: 2 hr:
After
⫹ if ⬎110 drinking ⫹ if ⬎200 ⫹ if ⬎140
mg/dL glucose: mg/dL mg/dL
Tumor Markers
Benign
Tumor Marker ⁄ Cancers Conditions
α–fetoprotein ⬍5.4 ng/mL Primary: Hepa- Cirrhosis, viral
(AFP) (⬎500)* tocellular, non- hepatitis, preg-
seminomatous nancy
germ cell (other:
gastric, biliary,
pancreatic)
CA 19–9 ⬍37 U/mL Primary: Pan- Biliary disease,
(⬎1000)* creas, biliary cirrhosis, pan-
tract (other: creatitis
colon,
esophageal,
hepatic)
CA 27–29 ⬎38 U/mL Primary: Breast Breast, liver,
(⬎100)* (other: colon, kidney disease,
gastric, hepatic, ovarian cysts
lung, ovarian,
pancreatic,
prostate)
(continued)
LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 218
LABS
Tumor Markers
(Continued)
Benign
Tumor Marker ⁄ Cancers Conditions
CA 125 ⬎35 U/mL Primary: Ovar- Cirrhosis, effu-
(⬎200)* ian (other: sion (pleural
breast, endome- and pericardial),
trial, esophagus, endometriosis,
fallopian tube, fibroids, men-
gastric, hepatic, struation, ovar-
lung, pancreas) ian cysts, pelvic
inflammatory
disease (PID),
pregnancy
Calcitonin Males:⬎80 Primary: Thyroid ⁄Gastrin,
Females:⬎ medullary carci- pancreatitis,
70 pg/mL noma (other: thyroiditis, renal
lung, breast, failure,
carcinoids, islet pregnancy,
cell, apudomas) newborns
Carcinoembry- ⬎5 ng/mL Primary: Biliary
onic antigen (⬎10)* Colorectal (other: obstruction,
(CEA) bladder, breast, cirrhosis, IBD,
cervix, gastric, pancreatitis,
hepatic, ENT, peptic ulcer,
lung, lymphoma, tobacco,
medullary thy- øthyroid
roid, melanoma,
pancreas)
Human ⬎5 mIU/mL Primary: øGonads,
chorionic (⬎30)* Nonseminoma- marijuana use
gonadotropin tous germ cell,
gestational tro-
phoblastic dis-
ease (other: GI)
*Level at which cancer likely
218
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 219
219
Prostate Specific Antigen (PSA)
Test ⁄ Causes of ⁄ ø Causes of ø
PSA ⬎10 ng/ 10 ng/mL 0 ng/ Prostate
mL suspicious for mL removal
prostate CA Antiandrogen
Can be ⁄ 4 therapy
ng/mL with
prostate stimu-
lation: e.g.,
Inflammation,
procedures
(e.g., urinary
catheter)
Free PSA ⬎25% Free PSA ⬍11% Prostate
⁄⁄more in BPH CA–associated
PSA is more
protein-bound
LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 220
LABS
Electrolytes
Serum Urine
Test ⁄ (Critical⁄) ø (Criticalø) ⁄ ø
Sodium 150 (160) 135 (120) 280 30 meq/d
(Na+) meq/L meq/L meq/d
Potassium 5.0 (6.5) 3.5 (2.5) 80 meq/d 40 meq/d
(K) meq/L meq/L
Chloride 106 (115) 96 (90) 250 110
(Cl–) meq/L meq/L meq/d meq/d
CO2 29 meq/L 20 meq/L
220
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 221
221
Magnesium 3.0 (5.0) 1.8 (1.0) 150 mg/d
(Mg2) mg/dL mg/dL
Phospho- ⬎4.1 ⬍2.4 (1.0) 1.3 g/d 0.9 g/d
rus (HPO4–2, mg/dL mg/dL
–3
PO4 )
Test ⁄ Causes of ⁄ ø Causes of ø
Creatinine ⬎1.4 Renal ⬍0.8 øMuscle mass:
mg/dL insufficiency/fail mg/dL e.g., Muscular
ure: Prerenal dystrophy
(ørenal blood ⁄Cardiac output:
flow), renal e.g., Pregnancy
impairment,
postrenal
obstruction
Muscle break-
down or crea-
tine ingestion
Blood urea ⬎20 Renal ⬍8 øIntake/
nitrogen mg/dL insufficiency/ mg/dL øsynthesis/⁄loss
failure protein
⁄⁄protein ⁄Intravascular
ingestion fluid: e.g.,
GI bleed Pregnancy,
overhydration
LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 222
LABS
Uric Acid
⁄ 750 Seen in gout
mg/24 h ⁄Cell destruction (e.g., hemolysis) or ⁄intake (e.g.,
high–purine diet)
øRenal excretion: e.g., Renal disease, CHF, acidosis,
øthyroid, ⁄parathyroid
Hereditary ⁄production: e.g., Kelley–Seegmiller
syndrome, Lesch–Nyhan
⁄Production and øexcretion: e.g., Alcohol consump-
tion, exercise, glucose-6-phosphate dehydrogenase
deficiency, øfructose–1–phosphate aldolase
ø 250 øøPurine and protein intake
mg/24 h øXanthine oxidase activity: e.g., Hereditary
xanthinuria, liver disease
⁄Renal excretion: e.g., Fanconi’s, intracranial
disease (e.g., SIADH), AIDS
222
Testosterone
⁄ Causes of ⁄ ø Causes of ø
Testosterone Male: Male: testicular Male: Congenital: Primary
⬎1000 tumors ⬍300 (testicular), (e.g.,
Female: Male 10 y.o.: Female:⬍ anorchism), secondary
⬎80 ng/dL precocious puberty 20 ng/dL (pituitary), or tertiary
⁄Adrenals: e.g., (hypothalamus)
Tumors, hyperplasia disruption
Drugs: Acquired (testicular,
Anticonvulsants, pituitary, or hypothal-
biturates, estrogens amic damage):
(through ⁄SHBG) Chemotherapy treat-
FADavis_Chapter 07.qxd
LABS
testosterone Male:⬎680 index (TFI) = (total Male:⬍100
Female: testosterone/SHBG) Female:
4:00 PM
224
Volume: ⬍1.5 mL
Progress.(37°): ⬍2 % Primary/secondary testicular failure
Live: ⬍50% ⁄Semen viscosity/⁄⁄pus (WBCs):
Defects: Head ⬎60%, e.g., Infection
midpiece⬎25%, tail ⬎25% Postvasectomy
9/12/08
Lecithin/Sphingomyelin (L/S)
LABS
⁄ 10 mIU/mL Developing placenta: Intrauterine pregnancies and ectopic pregnancies do not
produce hCG at same levels as IUP; identify threatened abortions/miscarriages
225
LABS
usal
mIU/mL 5–50 5–426 18– 1080– 7650– 25,700– 13,300– 4060– 3640– ⬍5.0 ⬍9.5
4:00 PM
LABS
Urine Tests
ⴙ: UTI, vaginal contaminant
Leukocyte False-negative: ⁄Urine specific gravity, glucose,
esterase ketones, or protein in urine, drugs (gentamicin,
Keflex, nitrofurantoin, tetracycline, vitamin C)
: UTI, gross hematuria
False-positive: Vaginal contaminant,
phenazopyridine, dipstick exposed to air
Nitrite False-negative: ⁄Urine specific gravity,
⁄urobilinogen, bacteria lacking nitrate reductase
enzyme, urine pH ⬍6.0, vitamin C
supplementation, ønitrate diet
: ⁄Blood glucose, renal causes (e.g., ⁄GFR,
Fanconi’s syndrome, toxic renal tubular disease,
acute glomerulonephritis, nephrosis)
Glucose False-positive: Ascorbic acid, cephalosporins,
ketones, levodopa, probenecid
False-negative: ⁄Urine specific gravity, ⁄uric acid,
vitamin C supplementation
Myoglobin : Muscle damage (e.g., trauma, hyperthermia,
dermatomyositis, polymyositis)
Hemosiderin : ⁄⁄Intravascular hemolysis † free hemoglobin
† filtered by kidneys
: Dehydration, starvation or øcarbohydrate diets,
DKA, EtOH ketoacidosis, isopropanol toxicity,
pregnancy
Ketones False-positive: ⁄Urine pH (acidic), ⁄urine specific
gravity, phenolphthalein, L–dopa
False-negative: Delayed urine examination
: Hematuria, pyelonephritis, hemolytic anemia
Hemoglobin
False-positive: Urine pus, iodides, bromides
226
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 227
227
Protein : Primary, secondary, and drug-induced
glomerulonephropathy, øtubular reabsorption,
protein overfllow (e.g., hemoglobinuria,
myoglobinuria, multiple myeloma, amyloid)
False-positive: Alkaline urine, concentrated urine,
contamination by chlorhexidine detergent or
body flluids, medications (e.g., penicillin,
sulfonamide)
LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 228
LABS
Complement
Test ⁄ Causes of ⁄ ø Causes of ø
Comple- Male: Nonspecific Female:
⁄ Consumption: e.g.,
ment C3 ⬎252 acute phase ⬍88 SLE (especially
mg/dL reactant in mg/dL lupus nephritis),
Female: inflammatory Male: ø complementemic
⬎206 conditions ⬍88 nephritis, subacute
mg/dL mg/dL bacterial
endocarditis, DIC
ø Protein intake/
absorption/
synthesis: e.g.,
Anorexia nervosa,
celiac disease, liver
disease
Comple- Male: Not clinically Female: C4 ø only when
ment C4 ⬎72 useful ⬍12 classical pathway
mg/dL mg/dL is activated
Female: Male: ⁄Consumption: e.g.,
⬎75 ⬍13 SLE, RA, hereditary
mg/dL mg/dL angioedema (from
unopposed lysis of
C4), glomeru-
lonephritis,
Henoch–Schönlein
ø Protein intake/
absorption/
synthesis
Total ⬎60 Inflammation ⬍22 ø Catabolism: e.g.,
comple- U/mL Infection U/mL ⴙImmune complex
ment (ølevels may predict
(CH5O) flares, such as
lupus nephritis)
Hereditary
deficiency
228
Hepatitis Tests
Hepatitis A Hepatitis B Hepatitis C
IgM IgM PCR
Anti– anti– Anti– Anti– anti– Anti– or Interpretation
HAV HAV HBsAg HBs HBc HBc HCV RIBA TMA
– – Susceptible to HAV
– Immune to HAV
FADavis_Chapter 07.qxd
ⴙ
229
ⴙ ⴙ Acute HAV
– – – – Susceptible to HBV
– ⴙ ⴙ HBV immunity from vaccine
– ⴙ ⴙ HBV immunity from infection
9/12/08
ⴙ – ⴙ ⴙ Acute HBV
ⴙ – ⴙ – Chronic HBV
(continued)
LABS
4:00 PM
Page 229
Hepatitis Tests
(Continued )
– – ⴙ Recovery from acute HBV OR
Distantly immune,
øanti–HBV OR
False-positive anti–HBc †
HBV-susceptible OR
Chronic with øHBsAg in serum
FADavis_Chapter 07.qxd
– No current infection
230
ⴙ ⁄S/Co Acute, chronic, or past HCV
ⴙ øS/Co Possible HCV infection
ⴙ ⴙ Past or current HCV
ⴙ – False-positive
9/12/08
ⴙ ⴙ Current infection
ⴙ – Past infection or false-positive
anti–HCV
LABS
4:00 PM
Page 230
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 231
231
Hepatitis A Infection
Clinical illness
Viremia
ALT
Total
anti-HAV
Titer
IgM
anti-HAV
Stool HAV
0 1 2 3 4 5 6
Weeks after exposure Adapted from CDC
Symptomatic
period Window
period
HBV DNA
Total anti-HBc
HBsAg
Titer
IgM
Anti-HBc Anti-HBs
HBeAg Anti-HBe
0 4 8 12 16 20 24 28 32 36 52 100
Weeks after exposure
Adapted from CDC
LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 232
LABS
Hepatitis C Infection
In acute HCV with resolution:
• Anti-HCV remains
• HCV RNA disappears
• ALT returns to normal
Symptons (20%)
Anti-HCV
ALT in acute
Titer
infection
0 4 2 3 4 5 6
Months after exposure
232
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 233
233
Inflammatory Markers
Test ⁄ Causes
Erythrocyte ⁄ ⴙ: ⁄ inflammation † ⁄ESR; can
sedimentation Male: monitor esponse to therapy; ⁄ in:
rate (ESR) ⬍50 y.o.: Inflammation: e.g., Various
⬎15 mm/hr rheumatolgic disorders, IBD
⬎50 y.o.: Infection: e.g., TB, osteomyelitis,
⬎20 mm/hr endocarditis, PID
Female: Metabolic changes:
⬍50 y.o.: e.g., Pregnancy, thyroid
⬎20 mm/hr diseases
⬎50 y.o.: Renal disease:
⬎30 mm/hr e.g., Glomerulonephritis,
hemolytic uremic syndrome
Heme/oncologic disease: e.g.,
Malignant neoplasms, ⁄⁄⁄ anemia
False-positive: Anything interfering
rouleaux formation:
Severe leukocytosis
⁄⁄⁄ or abnormal RBCs: e.g., Sphero-
cytosis, polycythemia
Abnormal protein:
e.g., Hypofibrinogenemia,
hypogammaglobulinemia
Drugs: High-dose corticosteroids
C–reactive ⁄ 0.6 Diagnose/monitor: Tissue
protein mg/dL inflammation/injury (e.g.,
(CRP) pancreatitis, IBD, rheumatologic
disorders), infections (e.g., bacterial
meningitis, sepsis, UTI, PID, TB),
malignancy (e.g., lymphoma)
If ⁄ 3 d postsurgery, suggests
infection
⁄ CAD risk (i.e., coronary artery
inflammation)
(continued)
LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 234
LABS
Inflammatory Markers
(Continued)
Test ⁄ Causes
Procalcitonin ⁄ 0.5 Severe infections: e.g., Acute
ng/mL malaria, meningitis, pneumonia,
sepsis (especially children)
Cardiopulmonary bypass
Rheumatologic Antibodies
Anti– CREST syndrome, systemic sclerosis,
centromere scleroderma, Raynaud’s disease
Anti–histone SLE, drug–induced lupus, but nonspecific
(seen in many disorders)
Anti–Jo 1 Polymyositis/dermatomyositis, interstitial
lung disease, Raynaud’s
Anti–Ku SLE, polymyositis/dermatomyositis
Anti–Mi–2 Dermatomyositis/polymyositis
Anti– Highly specific for SLE: Confirm diagnosis
ribosomal P of CNS lupus (psychosis)
Anti– Specific for mixed connective tissue
ribonucleoprotein disease SLE (correlates with SLE activity, if
antiribonucleoprotein is positive without
presence of anti–dsDNA Abs, it means
decreased risk of nephritis), drug–induced
lupus, Sjögren’s, systemic sclerosis, RA
Anti– Highly specific for and suggests poor
topoisomerase I prognosis scleroderma: Associated with renal
(AntiSc1–70) involvement
Anti– Antiphospholipid antibody syndrome:
phospholipid Anticardiolipin and lupus anticoagulant most
commonly measured antiphospholipid
antibodies
Drugs: e.g., Some antibiotics, Ca2ⴙ–channel
blocker
234
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 235
235
SS–A/Ro and Diagnose Sjögren’s syndrome and lupus with
SS–B/La Sjögren’s overlap
SLE: Useful to diagnose ANA-SLE (in ANAⴙ,
ⴙSS–A and ⴙSS–B suggests nephritis)
Antiphospholipid Ab syndrome (ⴙSS–A and
cardiolipin Abs, lupus anticoagulant, and
thromboses), neonatal lupus
Anti–double- Specificity for SLE anti–single-stranded
stranded DNA DNA (anti–single strand seen in healthy
(ds–DNA Ab) patients, SLE pt. relatives, and other
autoimmune disease; not useful for diagnosis):
Diagnose and monitor SLE activity (especially
lupus nephritis)
Other autoimmune disease (usually øtiters):
e.g., RA, Sjögren’s, Graves’, scleroderma,
MCTD, antiphospholipid syndrome,
autoimmune hepatitis
Some infectious diseases: EBV, CMV
Drugs: e.g., Minocycline, etanercept,
infliximab, penicillamine
Rheumatoid Present in normal patients and more common
factor as ⁄ age
⁄ 35 mg/dL RA: ⁄⁄ initial titer † øprognosis, ⁄likelihood of
being positive the longer pt. has disease
Also: Autoimmune disease (e.g., Sjögren’s,
poly/dermatomyositis, SLE, scleroderma,
cryoglobulinemia, MCTD), some infections
(e.g., bacterial endocarditis, osteomyelitis, TB,
syphilis, hepatitis, EBV) and other disease
(e.g., diffuse IPF, cirrhosis, primary biliary
cirrhosis, sarcoidosis)
Lupus Common in asymptomatic elderly and
anticoagulant postpartum
Various autoimmune and inflammatory disease:
e.g., SLE, drug–induced lupus, RA, ulcerative
colitis, HIV, hemophilia, multiple myeloma
Drugs: e.g., Procainamide, hydralazine,
dilantin, ACE inhibitors
LABS
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LABS
Anti–Neutrophil Cytoplasmic
Antibodies (ANCA)
Cytoplasmic Strong association: Wegener’s granulomatosis
(C–ANCA) Moderate association: Crescentic
glomerulonephritis
Weak association: Polyarteritis nodosa
Perinuclear Strong association: Crescentic glomerulonephritis
(p–ANCA) Moderate association: Polyarteritis nodosa,
Churg–Strauss vasculitis
Weak association: Wegener’s granulomatosis
Other possible: Henoch–Schönlein purpura,
temporal arteritis
Atypical Primary sclerosing cholangitis, primary biliary
(x–ANCA) cirrhosis, autoimmune hepatitis, SLE, RA
Calcium Studies
Test ⁄ Causes of ⁄ ø Causes of ø
Serum ⬎10.2 ⁄ Vitamin D or ⬍8.5 Vitamin D/Ca2ⴙ
Calcium mg/dL Ca2ⴙ intake mg/dL øintake/
(Ca2ⴙ) ⁄ PTH ø absorption
⁄ Bone ø PTH or
breakdown ⁄ calcitonin
Hereditary Ca2ⴙ sequestra-
disorders: e.g., tion: e.g.,
Familial Saponification
hypocalciuria ø albumin: e.g.,
Metabolic: e.g., Liver disease
⁄⁄ Thyroid, øˆMg2ⴙ or
acromegaly, ⁄ phosphorus
Addison’s (binds Ca2ⴙ)
Drugs: e.g., Osteoblastic
Thiazides, Liⴙ malignancy
Drugs: e.g.,
Aminoglycosides
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237
Test ⁄ Causes of ⁄ ø Causes of ø
Ionized ⬎5.3 Measures ⬍4.4 ø with ⁄ blood
Ca2ⴙ mg/dL physiologically mg/dL pH/⁄ protein/
@ pH active @ pH ⁄ albumin: e.g.,
7.4 nonbound 7.4 Multiple
Ca2ⴙ, ⁄ with myeloma,
ø blood pH or dehydration
ø protein or
ø albumin
Urine ⬎300 ⁄ serum Ca2ⴙ, ⬍100 ø Serum Ca2ⴙ,
Ca2ⴙ mg also specific mg also specific
(UCa) /24hr renal disease: /24hr renal disease
e.g., Idiopathic and drugs (e.g.,
hypercalciuria, thiazides)
RTA
Parathyroid Primary/ ⬍10 ø Parathyroid,
hormone ⬎55 secondary pg/mL ⁄ thyroid,
(PTH) pg/mL ⁄ parathyroid sarcoid, ø Mg,
ø Vitamin D nonparathyroid
⁄ Ca2ⴙ
Vitamin D3: ⬎50 ⬍10 ø Sun
25-hydroxy ng/mL ng/mL exposure
[25(OH)D3] ⁄Ca2ⴙ ø Vitamin D
⁄Vitamin D intake/
intake absorption
1,25-hydroxy ⬎76 ⁄Sunlight ⬍20 Pregnancy
[1,25 pg/mL exposure pg/mL Drugs:
(OH)2D3] phenobarbital,
phenytoin
LABS
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239
CDC Recommended Adult
Immunization Schedule
19–49 y.o. 50–64 y.o. ⱖ 65 y.o.
1 dose Td booster q10 yr
Diphtheria, tetanus,
pertussis (Td, DTaP) Substitute 1 dose DTaP for Td
Human papillomavirus 3 doses
(HPV) females
Measles, mumps, 1 or 2 doses 1 dose
rubella (MMR)
Varicella 2 doses (0, 4–8 wk) 2 doses
(0, 4–8 wk)
Inflluenza 1 dose annually 1 dose annually
Meningococcal ⱖ1 doses
Disease, Chronic
Disease, Chronic
Diabetes, Heart
Cancer, Cancer
Disease Given
Chronic Liver
Clot Factors
Treatment*
Health-care
Pulmonary
Pregnancy
Asplenia
Workers
ESRD
EtOH
HIV
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Diabetes, Heart
Cancer, Cancer
Disease Given
Chronic EtOH
Chronic Liver
Clot Factors
Treatment*
Health-care
Pulmonary
Pregnancy
Asplenia
Workers
Disease,
Disease,
Chronic
ESRD
HIV
MMR 1 or 2 doses
Varicella 2 doses (0, 4–8 wk) 2
doses
Flu 1 dose annually 1 1 dose annually
dose
Pneumonia 1–2 1–2 doses 1–2
doses doses
HAV 2 doses 2 2 doses
doses
HBV 3 doses 3 doses
Meningitis 1 dose 1 1 dose
dose
Genital øimmune, leukemia, lymphoma, generalized malignancy, CSF leaks, treat
with alkylating agents, antimetabolites, x-ray treatment, or ⁄ dose,
long-term steroids
HAV ⫽ hepatitis A; HBV ⫽ hepatitis B; Flu ⫽ influenza
240
Recommended 0–6 Yr
Immunization Schedule
Birth 1 2 4 6 12 15 18 19–23 2–3 4–6
mo mo mo mo mo mo mo mo yrs yrs
HBV HBV HBV HBV HBV series
Rota Rota Rota Rota
DTaP DTaP DTaP DTaP DTaP DTaP
Hfllu Hib Hib Hib Hib Hib
PCV PCV PCV PCV PCV PCV PPV
IPV IPV IPV IPV
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MPSV4 MPSV4
HBV ⫽ hepatitis B; Rota ⫽ rotavirus; DTaP ⫽ diphtheria, tetanus, pertussis; Hib ⫽ Haemophilus influenza type
B; PCV ⫽ pneumococcal conjugate vaccine; IPV ⫽ inactivated poliovirus; Flu ⫽ influenza; MMR ⫽ measles,
mumps, rubella; HAV ⫽ hepatitis A; MPSV4 ⫽ meningococcal
Range of
Catch-up High-Risk Groups
Recommended Ages
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ECG Interpretation
QRS T R
P P
Q S
P-R interval
Microbiology
Normal Flora
Skin
α-Hemolytic streptococci
Coagulase-negative staphylococci
Bacillus species
Respiratory
α-Hemolytic streptococci (not Enterococcus)
Nonhemolytic streptococci
Corynebacteria species
Neisseria species
Coagulase-negative staphylococci*
Haemophilus inflluenzae*
H. parainflluenzae*
(continued )
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Microbiology (Continued )
Moraxella catarrhalis*
N. meningitidis*
Streptococcus pneumoniae*
Genitourinary Tract
α-Hemolytic streptococci (not Enterococcus)
Nonhemolytic streptococci
Coagulase-negative staphylococci*
Corynebacteria species
Lactobacilli
*If not predominant in specimen
Patient List
Name Location Diagnosis/Notes
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Test Results
Patient Name:
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Notes
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Index
A C
Abdomen, 30, 59–60, 177–185 Calcium correction, 133
Abscess, 37–39, 167, 181 Calcium studies, 236–237
Acetaminophen toxicity, Cancer detection guidelines,
193–194 1–2
Acid/base disorders, 134–135 Cardiac arrhythmias, 2, 7–8
Acute renal failure, 84 Cardiac markers, 210
Amenorrhea, 81–82 Cardiovascular hemodynamics,
Anemia, 85–87, 203–205 119–121
Angina, 5 Catecholamine–secreting
Angioedema, 140 tumors, 219–220
Ankylosing spondylitis, 189 Catheters/catheterization, 15,
Anticoagulants, 145–147 20–22, 32–35, 174
Antidiabetes medications, 148 Central nervous system
Antineutrophil cytoplasmic assessment, 108–110
antibodies, 236 Central venous lines, 17–20, 174
Antinuclear antibody test, 227 Cerebellar disorders, 41–42, 50
APGAR score, 115–116 Cerebral spinal fluid analysis,
Appendicitis, 60, 183 118, 194–196
Arterial line placement, 14–16 Cervical cancer, 1–2
Arthritis, 35–38, 188–189 Cervical spine imaging, 167–170
Arthrocentesis, 35–38 Cervicitis, 162–163
Ascites, 28–30, 179, 185 Charcot’s arthropathy, 188
Asthma, 140–141 Chest imaging, 170–177
Azotemia, 83 Childbirth, 65–67, 158–159
Chorionic gonadotropin, 235
B Chronic obstructive pulmonary
Bile–binding resin, 154 disease, 141
Biophysical profile score, Cirrhosis, 112, 182
116 Coagulation, 200–202
Bone radiography, 187–191 Colitis, 178–179, 184
Brain, 40–41, 48–50 Colon cancer, 1
Brain natriuretic peptide, 211 Complement values and
Breast cancer, 1 disorders, 228
Budd–Chiari syndrome, 183 Cranial nerves, 40–41
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Hypernatremia, 96 Liver function tests, 212–214
Hyperprolactinemia, 80 Lumbar puncture, 8–9
Hypertension, 154, 156–158, 182 Lung cancer, 171
Hypocalcemia, 97 Lung volumes and values,
Hypogonadism, 80–83 125–129
Hypokalemia, 98
Hyponatremia, 99 M
Hypoprolactinemia, 80 Mechanical ventilation, 102,
Hypoxia, 100–102 104–106
Mediastinal masses, 172
I Ménière’s disease, 112
Immunization schedules, Migraine, 109–110, 151–152
239–242 Muscle/motor disorders, 41–42
Infertility algorithm, 103
Inflammatory markers, 233–235 N
Inotropes, 144–145 Nasogastric tube placement,
Insulin, 147 26–28, 174
Intestinal obstruction or Necrotic bowel, 157
perforation, 157, 178 Nephrotoxic agents, 83
Intra–aortic counterpulsation Neurodegenerative diseases,
devices, 174 167
Intussusception, 179, 184 Niacin, 153
Iron deficiency, 124, 204–205
O
J Obstetrics, 65–67, 69, 114–115,
Joint fluid analysis, 37–38 136, 185–187
Jugular venous pressure Optic nerve, 51–52
measurement, 57–58 Osteonecrosis and
osteoporosis, 189–190
K Ovarian failure, 80
Ketoacidosis, 88–90 Oxygen therapy indications, 142
Kidney stones, 184–185
Knee examination, 74–77 P
Pancreatic tests, 216–217
L Pancreatitis, 113, 183
Labor, 65, 114, 158–159 Paracentesis, 28–30
Lead testing, 193 Patient list template, 244
Lipid values, 209–210 Pelvic inflammatory disease,
Liver disease, 112–113, 181–183 116–117, 157
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Testosterone values, 223–225 Urine tests, 226–227
Thalassemia minor, 124 Urology equations, 136
Thoracentesis, 22–25 Uterine disorders, 2, 80
Thoracoscopy tube placement,
174 V
Thyroid function tests, 199–200 Vaginitis/vaginosis, 60–61, 117,
Thyroid nodule, 107 164
Tissue plasminogen activator, Varicocele, 62
108 Vasopressors, 145
Toxic megacolon, 179, 184 Ventilation equations, 124–
Toxicology testing, 118, 192–194 125
Transvenous pacing devices, Vertigo, 53
174 Vestibular disorders, 41
Trauma, 110, 139, 165–166, 183 Vitamin B12 deficiency, 203
Tumors, 167, 171–172, 182, Volvulus, 179
217–218
W
U Weight calculations, 137
Urethritis, 162–163 White blood cell values and
Uric acid values, 222 disorders, 207–208
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