complaint

-Primary care note

2013/5/23

The Most Important: For Patients Sakes!!
 Topic
GI: abdominal fullness, abdominal pain, diarrhea, constipation,
nausea/vomiting, UGIB, GERD
Neuro: headache, migraine, insomnia, conscious change, seizure,
stroke, dizziness/vertigo
Chest: cough, nasal congestion/rhinorrhea, SOB, asthma,
saturation down
Nephro: urinary retention, edema, electrolyte imbalance
CV: chest tightness/pain, palpitation, hypertension
Meta: hyperthyroidism, hyperglycemia, hypoglycemia
Other: fever, allergy, myalgia, arthralgia, pruritis, dysmenorrhea,
postmenopausal syndrome,
pain control, anemia
 GI Abdominal fullness


originGI



ileus, interssusception
ascitestoxic
PEshifting dullness
 GI Abdominal fullness

1. Anti-dopaminergic
Primperan (Metoclopramide):
anorexia
EPS
Mosapride: primperan
specific
EPS
 GI Abdominal fullness

2.
Domperidone: EPS
primperan
Dimethicone (Gascon):
(
)
Megesterol (Megace): cachexia

*Menthol packing:

 GI Abdominal fullness

3.
AGE

Lactobacillus casei:

Bio-Three: Clostrisdium butyricum +
Streptococcus faecalis + Bacillus mesentericus

 GI Abdominal fullness


specific
-
 GI Abdominal pain

r/o

1. WBC, Seg, CRP , fever
Gastroenteritis:
-> antiIVF hydration

Appendicitis: Mcburney point
PEtendernessrebound
pain -> Abdominal CTfinding
 GI Abdominal pain

1. WBC, Seg, CRP , fever
Gastritis:
NSAIDH.
pylori -> ulcerPPI
(Esomeprazole, Lansoprazole, Pantoprazole)
MisoprostolsucralfateH.
pylori
ps. ulcer
H2-blocker (Cimetidine, Famotidine)PPI

 GI Abdominal pain

1. WBC, Seg, CRP , fever
Enterocolitis:
PE (BS:
hyperreactive, rebounding pain) -> B/C, Stool
routine, stool culture, KUB -> NPOanti
(Rocephin + metronidazole)
 GI Abdominal pain

1. WBC, Seg, CRP , fever
Diverticulitis: (classic
triad: left lower quadrant pain, fever, and
leukocytosis) ->
Abdominal CT
NPO

 GI Abdominal pain

1. WBC, Seg, CRP , fever
Ulcerative colitis (UC): inflammatory bowel
disease (IBD)bloody
diarrhea (tenesmus) ->
NSAID5-
ASA (Mesalamine, Sulfasalazine)steroids
5-ASA
anti-TNF (infliximab, adalimumab)
azathioprine
 GI Abdominal pain

1. WBC, Seg, CRP , fever
Crohns disease(CD): inflammatory bowel
disease (IBD)
ileumcolon
-> abdominal CT
NSAID
steriodAnti-TNF

 GI Abdominal pain

1. WBC, Seg, CRP , fever
Peritonitis:
trauma, appendicitis,
perforation bowel
sinus tachycardiaPE
rebounding painmuscle guarding ->
NPOAugmentin,
Tazocin, Timentin
 GI Abdominal pain

1. WBC, Seg, CRP , fever
Cholecystitis: PE
(Murphys sign) ->
AST, ALTNPO

Cholangitis: Charcots triad:
fever/chills ->
AST, ALT, bilirubin, Alk-P, -GT
NPOERCP(ERCP failure
 GI Abdominal pain

1. WBC, Seg, CRP , fever
Cholelithiasis (Gallstones):


->
Ursodeoxycholic acid
cholecystectomy
 GI Abdominal pain

1. WBC, Seg, CRP , fever
Pancreatitis: (
)

-> Abdominal CT
labamylase, lipase
IVF hydration (pancreatitis10
L/D)DemerolMorphineFoy
(Gabexate,
)
pancreatitisERCP
 GI Abdominal pain

2.
Hernia: inguinal hernia, ventral hernia,
umbilical hernia, diaphragmatic hernia->
herniaCT
bowel incarceration
Interssusception:
-> abdominal CT
KUBair reduction

Volvulus: interssusception

 GI Abdominal pain

2.
Constipation: KUB
historyconstipation
Hemorrhoid:
(
) ->
NSAIDs
proctosedyl (
)
 GI Abdominal pain

2.
Bowel spasm:
gastric ulcer, duodenal ulcer,
hernia, post-op, carcinomatosis ->
Buscopan (Scopolamine)
 GI Abdominal pain

3.
Ischemic bowel:
-> CT angiogram
angiography
Bowel perforation:

peritonitis -> abdominal CTGS

 GI Abdominal pain

3.
AAA: PEpalpable
massbruit -> abdominal CT
consult CVS
Aortic dissection: consult CVS

Ovarian torsion: ->
GYN
Ectopic pregnancy: -> -
 GI Abdominal pain

3.
pelvic inflammatory disease (PID),
dysmenorrhea, endometriosis, cancer, liver
abscess, pyelonephritis, kidney stones,
urolithiasis, urinary retention
 GI Abdominal pain



GI


 GI Diarrhea

metabolic acidosis

stool routinestool
culture




Irritable bowel syndrome
Delibs
 GI Diarrhea

Kaopectin
Smecta (Dioctahedral Smectite)

Imodium (Loperamide)opioid
PRN
ileus

Delibs (Pinaverium)
IBS
 GI Diarrhea





->
 GI Constipation



opioids, anticholinergics (
), CCB, Fe

DMuremia

Multiple sclerosis (MS)
Guillain-Barrespinal cord injuryCNS injury
 GI Constipation

MgO: 1# QID
NSAIDs
2# TID - QIDESRD
MgMg

Sennoside: 1 - 2# HS
diarrhea
Duclolax (Bisacodyl): supp.
STAT
 GI Constipation

Lactulose: NH3
ammonia
hepatoencephalopathy
Glycerin:

Fleet enema:


 GI Constipation



->
 GI Nausea/Vomiting

underlying disease

1. GI
colonN/V

GERD
BLamivudine ()
Adefovir ()Entecavir ()
Silymarin () Vit.
B complex
 GI Nausea/Vomiting

2. GI
Brain: malignancy, hemorrhage
Labyrinth: motion sickness, malignancy
Psychiatric: depression, anxiety
Endocrine: pregnancy, uremia, DKA
Drug: post-op analgesics, chemotherapy, anti,
OAD, OCP
Toxins:

 GI Nausea/Vomiting

1. Anti-dopaminergic
Primperan (Metoclopramide):
anorexia
EPS
Mosapride: primperan
specific
EPS
 GI Nausea/Vomiting

2.
Novamin (Prochlorperazine): post-op PRN
for N/V
Wintermin (Chlorpromazine):
3. 5-HT3 receptor antagonists
Ondansetron (Zofran):
post-op N/V
4.
Domperidone:
EPSprimperan
 GI Nausea/Vomiting


-
->
 GI GI bleeding
GI bleeding
(hematemesis)coffee
groundUGIBbloody stool
UGIBLGIB
(melana)UGIB
UGIBLGIB ()
UGIB > LGIB: N/V, hematemesis, coffee-ground
emesis, epigastric pain, melana
LGIB > UGIB: diarrhea, tenesmus, hematochezia
(bloody stools)
 GI GI bleeding

Blood loss 500-1000cc; 1000-1500cc (10%)
tachycardia; 1500-2000cc (20%)hypotension;
>2000cc (>30%)shock

massive active bleedingcheck vital sign
conscious levelO2
supplementaspiration
on endovital signIVF
challengeN/SL/R 500ccrun
Hct30Plt50000
PES ligationTerlipressin
 GI GI bleeding

1. UGIB
Peptic ulcer disease: UGIBH. pylori,
NSAIDscoffee-ground
NG irrigation (: 1.
, 2.checkactive bleeding)
active bleeding
PPI(Esomeprazole,
Lansoprazole, Pantoprazole)peptic ulcer
H2-blocker (Cimetidine, Famotidine)
H. pylori (clarithromycin +
amoxicillin)
 GI GI bleeding

1. UGIB
Varices: UGIB
cirrhosisunderlying
IVF hydration
Terlipressin (FFP
Vit. K, Plt50000)endoscopic therapy
Bosminligation
PPITransamin
Gastritis/duodenitis: PPI or H2-blocker
Erosive esophagitis/ulcer: PPI or H2-blocker
 GI GI bleeding

1. UGIB
Mallory-Weiss syndrome: tear
24-48
(PPI or H2-blocker,
Transamin)
 GI GI bleeding

2. LGIB
Diverticular hemorrhage:

: occlut blood
Colitis: infection, IBD (UC, CD), radiation related

Hemorrhoid:
NSAIDsproctosedyl

 GI GERD


(heartburn)
(regurgitation)

()
dental erosion
mucosal damage
(esophagitis)PPI or H2-blocker

 GI GERD


GERD


->
 Neuro headache



scanolNSAIDs


1. Primary headache
2. Secondary headache
underlying disease

 Neuro headache

2. Secondary headache
a. IICP: Cushings triad (
)blurred vision
cons change -> Mannitol
b. Meningitis: neck stiffness
Kernigs signBruzinskis sign -> lumbar puncture
antibiotics
c. hematoma or tumor:
SAH -> brain
CT
 Neuro headache

2. Secondary headache
d. closed-angle glaucoma:
nausea and vomitingTimolol,
Pilocarpine
*e. sinnusitisheadache
 Neuro headache


->
 Neuro migraine

30
throbbing
pulsatile

Classic migraine (18%)auracommon
migraine (64%)
Sumatriptan (5-HT1 agonists)
NSAIDsmigraine
TCA, -blocker, CCB, topiramate
 Neuro insomnia


intern





 Neuro insomnia

1. BZD
Ativan (Lorazepam):
seizure

Fludiazepam:

Xanax (Alprazolam):

Estazolam:

 Neuro insomnia

1. BZD
*Valium (Diazepam): diliriumseizure
seizure
(IV)
*Midazolam:
2. non-BZD
Stilnox (Zolpidem):
()

3. Antihistamine: ()
Vena (Diphenhydramine): IV STAT
 Neuro insomnia



->
 Neuro seizure

seizurealcohol
withdrawal, medication s/e, brain tumor,
, Alzheimers,
ellectrolyte imbalance, ,
AED (anti-epileptic
drug)underlying disease
aura (
), convulsion, post-ictal state, tongue
biting, incontinence ()
 Neuro seizure

seizureCBC, DC, Na, K, Ca,
Mg, Cl, BUN, Cr, AST, ALT, glucose, ammonia, dilantin
level, depakin level ()
Partial or focal seizureOBS
status epilepsy (tonic-clonic seizure
30neural death, rhabdomyolysis,
lactic acidosis)GTC
N/C 2L/min
AtivanValium
 Neuro seizure


sedation
->



 Neuro conscious change

tra
orderCBC, DC, PT, APTT,
glucose, electrolyte, BUN, Cr, AST, ALT,
ammoniabedside/vital sign
apneaon endopun Gasset
IV line
reviewunderlying disease


 Neuro conscious change
a. vital sign
brain CT

1. stroke:
2. seizure:
3. CNS infection: infection
4. EDH: spinal shape, -> consult NS
5. SDH: crescent shape, sulcus, mid-line
shift -> consult NS
6. concussion, hydrocephalus: -> consult NS
7. IICP: Cushings triad -> Mannitol
8. brain tumor: -> consult NS
 Neuro conscious change
b.

1. Congestive heart failure: heart failure
CVdopamine,
dobutamine, pulseBosminCPR
2. liver failure: hepatic encephalopathy
lactulose, antibiotics, , supportive treatment
3. uremia: consult Nephro
4. hypo/hypernatremia: nephro
5. blood sugar: DM underly
hypoglycemiaHHS
 Neuro conscious change
b.

6. hyperthyroidism: meta
7. hypothyroidismmyxedema coma:
hypothermia, hypotension, hypoventilation, cons
changeIVThyroxineLevothyroxine
corticosteroids (hydrocortisone)
8. Pneumonia: infection
9. Septic shock: (IV resuscitation)
Levophed (norepinephrine)
10.
 Neuro stroke
70%
30%

brain CThemorrhage
gyrusischemic stroke
IV thrombolysis agent (t-PA
)antiplatelet therapy (aspirin,
dipyridamole, clopidogrel)BP
(220/120mmHg)
IVF hydration
 Neuro stroke
*TIA (Transient ischemia attack)
24


brain CThemorrhage
putamenhold
(SBP
140mmHg)IVF
 Neuro stroke




 Neuro dizziness/vertigo


1. dizziness:
a. anemia underlying disease
active bleedinganemia
b. hypoglycemia DM
dizziness
c. saturation down chest
d. orthostatic hypotension hypertension
baroreceptor

 Neuro dizziness/vertigo

2. peripheral vertigo: nausea/ vomiting, tinnitus,
hearing loss, jerk nystagmus
3. central vertigo: (abnormal brainstem or
cerebellar sign) dysarthria, diplopia,
paresthesia, weakness, limb ataxia
4. BPPV (benign paroxysmal positional vertigo):

 Neuro dizziness/vertigo

Meclizine (
antihistamine & anti-muscarinic receptor)
Diphenidol (Cephadolperipheral
vertigo/ Menieres vertigo);
.AnemiaHb < 8;
.Hypoglycemiaglucose 50% 4PC STAT;
.Orthostatic hypotension

hypotensionmidodrine
 Neuro dizziness/vertigo

1. :


->

2. :

 Chest - cough

onset &
duration

1.
viral URI, pneumonia, bronchopneumonia,
pulmonary TB
2.
, asthma, GERD, post-nasal drip
 Chest - cough

1.
viral URI -> influenza rapid testswab

pneumonia, bronchopneumonia, TB -> CXR

acute bronchiolitis (RSV) -> O2
hood supply, bronchodilatorsteroid
()
 Chest - cough

2.
asthma ()-> steroid
bronchodilator
GERD (
) -> PPI
cimetidine
post-nasal drip (PE
cobble stone) ->
levocetirizine (Xyzal)
 Chest - cough

CMA (Cough mixture A) :
Brown mixture :

Ambroxol :

Acetylcysteine :

Jusomin (Sodium bicarbonate) inhalation:

 Chest - cough

Secorine :

Guanifenesin (Robitussin) :

Medicon-A :

Codeine:

*Benzydamine HCl
 Chest - cough



->


 Chest nasal congestion/rhinorrhea

-
1. Suspect URI
2. Suspect allergic rhinitis
-
3. CSF leakage, r/o basal skull
fracture
-
4. Suspect sinusitis -> Waters view
 Chest nasal congestion/rhinorrhea

Clarinase (pseudoephedrine +
loratadine)Peace/Spiz

Allegra
Xyzal
Chest nasal congestion/rhinorrhea


 Chest shortness of breath
call
chest pain

1. vital sign
underlying diseases
2. review charthistory
lab data
3. bedside/PE
toxic dyspneagas


 Chest shortness of breath
DD

1. pneumothorax PE & CXR(acute dyspnea,
pleuritic chest pain, hypotension)CXR
pleural line & tracheal deviationPE tympanic
and breathing sound on chest tube
O2 supplement
 Chest shortness of breath
DD

2. acute pulmonary edema pattern
orthopnea, PND(paroxysmal noctural dyspnea)
PE (crackles, accessory muscle
usepleural effusion
pleural friction rub) ABG showed PaO2 &
PaCO2CXR (Kerley B lines, pleural effusion -
> butterfly sign)pulmonary edema
heart diseaseCXR
 Chest shortness of breath
DD

2. acute pulmonary edema
: (LMNOP)
P.
O. O2 mask supply
ventilatorCPAP, PEEP
M. Morphine IV
L & N. preload (Lasix
Bumetanide IV)afterload (NTG)
 Chest shortness of breath
DD

3. restricted airway
choking(conscious clear
)
GS
thyroidectomyENTtongue base
hematoma
airwayon
endo
 Chest shortness of breath
DD

4. cardiac tamponade
PEdistant heart sound,
tachycardia, jugular venous distention, and
pulsus paradoxus (10mmHg
)EKGlow limb lead voltageCXR
O2IVF
hydrationCVSpericardiocentesis

 Chest shortness of breath
DD

5. heart failure patternorthopneaPND
(
pul. edema)
decreased heart soundjugular venous distention
PElab BNPcardiac 2D
Dopplar echoEF<50%
, ACEi/ARB, digoxin, -blocker, diuretics
preload, Hydralazine + nitrate
afterloadCCB!!
 Chest shortness of breath
DD

6. acute myocardial infaction CVchest
pain
 Chest shortness of breath
DD

7. pulmonary hypertension
dyspnea, chest pain, syncope
peripheral edema, RUQ
fullness, abd. DistentionPEjugular
vein distention, P2(pulmonary valve
), R-sided S4CXRpulmoary
arteries dilatation, RA & RV, EKG
RVH, right axis deviation
 Chest shortness of breath
DD

7. pulmonary hypertension O2
supplementSaO2 > 90-92%, diuretics
preloadRV, digoxindobutamine
, anticoagulantthrombosis
vasodilators: oral CCB (nifedipine, diltiazem),
prostacyclin (epoprostenol), endothelin-1
antagonist (bosentan), PDE-5 inhibitor (
sildenafil)
 Chest shortness of breath
DD

8. pulmonary embolism sudden
onset of dyspnea, pleuritic chest pain, cough,
hemoptysisPEtachypnea, crackles,
tachycardia, cyanosis, pleural friction rub,
jugular venous distention, loud P2EKGPE
RV failure sign
CTA&CTVD-
dimer(500PE)
 Chest shortness of breath
DD

8. pulmonary embolism
heparin IV 80U/kginitial bolus
18U/kg/hr7-10warfarin

*PEDVTlabD-dimerFDP
DVTEnoxeparin
warfarinPT, INR prolong
 Chest shortness of breath
DD

9. severe acidosis
Respiratory acidosishypoventilation
CNS
depression(, trauma...), Neuromuscular
disorders (MG, Guillain-Barre...), Upper airway
(, OSA...), Lower airway (asthma, COPD),
diaphragm...on endo
Jusomin (NaHCO3)
 Chest shortness of breath
DD

9. severe acidosis
Metabolic acidosis


consciousnessABG

a. DKA (Diabetes ketoacidosis)
b. Hyperchloremic acidosis
 Chest shortness of breath
DD

9. severe acidosis
Metabolic acidosis
a. DKA (Diabetes ketoacidosis)type 1
DMinsulin
()
Kussmaul repiration()
(N/S)Insulin(
+
 Chest shortness of breath
DD

9. severe acidosis
Metabolic acidosis
b. hyperchloremic acidosisNa+HCO3-
anion gap
bicarbonatesevere diarrheaGI loss
renal tubule acidosiskidney loss(RTA type I
distalH+, ; RTA type II
proximalHCO3-, ; RTA
type IVhypoaldo.,
)
 Chest shortness of breath
DD

9. severe acidosis
Metabolic acidosis
b. hyperchloremic acidosisacidosis
Sodium bicarbonate
(pH < 7.20)IV Jusomin
=(24-X)/2STAT
serumHCO3- > 8pH > 7.2
renalcorrect
 Chest shortness of breath
DD

9. severe acidosis
Metabolic acidosis
c. Lactic acidosishyperventilation
lab datalactate levels >5 mmol/L
serum pH <7.35
hypoperfusionsepsisshock
DKA
Jusomin
 Chest shortness of breath
DD

10. Analphylaxis systemic skin rash,
skin itchy, fever, chills, dyspnea,
wheezing or stridor

DCSTAT:
Vena (Diphenhydramine) IV ->
Dexamethasone IV ->
Bosmin (Epinephrine) IV
 Chest shortness of breath
DD

11. Ascites related fatty liver, OHSS
PEshifting dullness
diaphragm
albuminLasix
ascites tapping~
fluid loss
hypotensioncarcinomatosis related
ascitestapping ascites
 Chest shortness of breath
DD

1. asthma wheezing
(classic triad),
asthma AE
oral steroid(prednisolone)
Salbutamol
ipratropium(Combivent)
Berotec (fenoterol)
/LABA
 Chest shortness of breath
DD

2. COPD
CXRhyperinflation, flattened
diaphragm, interstitial lung marking
Combivent (Ipratropium +
Salbutamol)A+B
(Atrovent/Ipratropium + Butanyl/Terbutaline)
SABA, steroid,
anti, O2 supply
 Chest shortness of breath
DD

3. pneumonia
PEcracklesCXRinfiltration
leukocytosis with left shift, CRP
fever
 Chest shortness of breath
DD

4. Anemia anemia
 Chest shortness of breath
DD

5. Neuromuscular disease underlying
disease
autoimmunesteroid
 Chest shortness of breath
DD

6. Psychological Alprazolam (Xanax)
mental support (!!)
 Chest shortness of breath






saturation
 Chest saturation down
saturation downdyspnea
dyspneadifferential diagnosis


(bedside
)obstructive
sleep apnea (OSA)30
OSAENT

STAT suction
 Chest saturation down
(1) Nasal cannula

FIO2 = 20% + 4
FIO2

(2) O2 simple mask
100300610
35%55%
5
FIO2


 Chest saturation down
(3)Venturi

FIO2 ()
24%28%31%35%40%
COPD(CO2 retention)
(4) (non-rebreathing mask)

bag810
90%FIO2COPD hypercapnia
high flowCO2
retentionrespiratory acidosis
 Nephro Urinary retention
complain
I/O
imbalance

Neurogenic bladder, BPH, constipation,
(anticholinergic, ipratropium,
atropine, scopolamine/Buscopan), pelvic

 Nephro Urinary retention

ICP STAT
ICPFoley
Foley
ICP trainingremove Foley
RU (residual urine)
ICP (bladder scan
RU)RU200cc
RU (
)Foleytraining
failure
 Nephro Urinary retention

anticholinergicurinary retention

Bethanecholcholinergic
agent
BPHurinary retention
Tamsulosin (Harnalidge D) - blocker
Finasteride 5mg5-
reductase inhibitor
 Nephro Urinary retention



->
 Nephro Edema



1. Unilateral / localized edema:
a. Cellulitis -> antiinfection
b. Allergy -> allergy
c. DVT -> enoxaparin
d. PAOD -> aspirin, clopidogrel and statins

 Nephro Edema

2. Bilateral edema:
a. Congestive heart failure (CHF) ->
, ACEi/ARB, digoxin, -blocker, diuretics
preload, Hydralazine + nitrate
afterloadCCB!!
b. Cirrhosisascites, bilirubin, PT,
albumin, anemia, neutropenia,
thrombocytopenia ->
diuretics
 Nephro Edema

2. Bilateral edema:
c. Nephrotic syndrome, proteinuria,
albumin, cholesterol ->
proteindiureticsstatin
ACEi/ARBproteinuria
*ACEi/ARBresistance
GFRproteintubule
proteinuriaRAAS
hyperkalemia
 Nephro Edema

2. Bilateral edema:
d. Acute or chronic renal failure:
NSAID
diureticscontrast
N-acetylcysteinecontrast

AKIdialysisCKD
uremia ->
(ACEi/ARB)metabolic acidosis
anemiaESRD
 Nephro Edema


diuretics

()
 Nephro Edema


/

->

*


!!!
 Nephro Electrolyte imbalance
data
cons change, seizure,
weakness, arrhythmia
Hormones: ()
1. ADH:
Na+
effective arterial volume

2. Aldosterone:
Na+

 Nephro Electrolyte imbalance
Hyponatremia

QD follow up lab data
N/S(153mEq)3% saline
(513mEq)
: 0.5mEq/L
12mEq/Lcentral
pontine myelinolysis
dysarthria
dysphagia
 Nephro Electrolyte imbalance
Hyponatremia
*
4085kg105
1. = (125-105)x85x0.6 = 1020mEq
*Na125mEq/L
2. Liter:
3% saline1020/513 = 2L
N/S1020/153 = 6.7L
3. 0.5mEq/L
: 0.5x85x0.6 = 13mEq
4. CC:
3% saline13 / 513 = 0.025L
N/S13 / 153 = 0.085L
 Nephro Electrolyte imbalance
Hyponatremia
UNaosmClPosmNaKrecord I/O

1. Hypovolemic hyponatremia:
a. UNa > 20mEq/LFENa > 1%
(esp. thiazide)
b. UNa < 10mEq/LFENa < 1%

-> N/S
 Nephro Electrolyte imbalance
Hyponatremia
UNaosmClPosmNaKcortisol, thyroid fn.
record I/O

2. Euvolemic hyponatremia:
a. SIADHUosm > 100 UNa
b. Endocrinopathiesglucocorticoid
hypothyroidismADH
-> SIADHunderlying disease
hypertonic 3% salineloop
 Nephro Electrolyte imbalance
Hyponatremia
UNaosmClPosmNaKrecord I/O

3. Hypervolemic hyponatremia:
a. CHFUNa < 10 mEq/LFENa > 1%
b. CirrhosisascitesUNa < 10 mEq/L
c. Nephrotic syndrome
hypoalbuminemiaedemaUNa < 10 mEq/L
d. Advanced renal failureUNa > 20
mEq/LFENa > 1%
 Nephro Electrolyte imbalance
Hypernatremia
UNaosmrecord I/O

1. Uosm > 700-800
a. UNa < 25 mEq/LGI
insensible loss
b. UNa > 100 mEq/LNa overload
mineralocorticoids
-> Na overload
D5W + Lasix
 Nephro Electrolyte imbalance
Hypernatremia
UNaosmrecord I/O

2. Uosm < 700-800
a. UOsm < 300complete DI
b. UOsm > 300-600partial DI, diuretics

-> DiureticsDI
desmopressin (dDAVP)
 Nephro Electrolyte imbalance
Hypokalemia
Weakness

1. Slow K
KClN/S
runhypokalemia
2. QD follow lab data
 Nephro Electrolyte imbalance
Hypokalemia
UKosmPKosm24

1. GI loss: UK < 25 mEq/dTTKG < 3
diarrhea ->
2. Renal loss: UK > 30 mEq/dTTKG > 7
a. hypo- or normotensive
acidosis: DKA, RTA
alkalosis: diuretics, vomiting
Mg depletiondistal K secretion
 Nephro Electrolyte imbalance
Hypokalemia
UKosmPKosm24

2. Renal loss: UK > 30 mEq/dTTKG > 7
b. Hypertensive: mineralocorticoid excess
Hyperaldosteronism, non-aldosterone
mineralocorticoid
-> underlying disease.
 Nephro Electrolyte imbalance
Hyperkalemia

Kalimate
palpitation, arrhythmia, A-V block,
VF, cardiac arrestRI 10U
+ Glucose 50% 4PCIV push
Fleet enema
LasixH/DQD follow up lab data
EKG: peaked T waves, PR interval, QRS widening,
P, slow sinusoidal pattern
 Nephro Electrolyte imbalance
Hyperkalemia
UNaosmrecord I/O

1. : AKI or ESRD
-> underlying disease
2. :
a. aldosteroneCHF
cirrhosis
-> underlying disease
 Nephro Electrolyte imbalance
Hyperkalemia
UNaosmrecord I/O

2. :
b. aldosterone
renin: DM nephropathy, NSAIDs, ACEi,
ARB
aldosterone: spirolactone
-> underlying disease
 Nephro Electrolyte imbalance
Hypocalcemia
cons change

hypoparathyroidism, renal failure, Vit. D, Mg
.. Ca, P, Mg, Cr, PTH
PE
Chvosteks sign, Trousseaus sign

calcium gluconate IVcalcium
carbonate PO
 Nephro Electrolyte imbalance
Hypercalcemia
cons change, constipation

hyperparathyroidism, malignancy, Vit. D

(Ca > 12)N/S challenge
3 4Lcalcitoninlasix
 Nephro Electrolyte imbalance
*First Choice 2012P.29

TTKG U K / U osm
TTKG > 7
PK / Posm osm TTKG < 3
FENa FENa < 1
U Na / U Cl ->
Cl FENa > 1-
PNa / PCl
>
 CV chest tightness/pain
STAT
EKGAMI
acute coronary syndromeCK-MB
Troponin I
x Unstable angina NSTEMI STEMI
(UA)
Coronary thromb. Subtotal Subtotal Total

History Angina that is new-onset, crescendo, or Angina at rest

at rest; usually < 30 min usually > 30 min
EKG ST depression and/or T wave inversion ST elevations

Troponin/CK-MB - + ++
 CV chest tightness/pain
*AMIEKG:
Hyperacute T waves -> T wave inversion -> ST
elevation -> pathologic Q waves
MONA
M: morphine IV
O: O2 ()
N: NTG (nitroglycerin)
A: Aspirin (STAT and QD)
*consult CV
 CV chest tightness/pain

acute coronary syndrome (EKG
referred pain):
1. aortic dissection (radiated
pain)consult CVS
2. pneumothorax (acute dyspnea, pleuritic chest pain,
hypotension)CXRpleural line & tracheal
deviationPE tympanic and breathing sound
O2on chest tube
3. pulmonary embolism (dyspnea, hemoptysis,
pleurutic chest pain)CXRD-dimer
CT angiographywarfarin
 CV chest tightness/pain

highly suspected ACS
order MONA
RT
bedside




(psychi)
 CV - palpitation

(E-Paced)
E: Electrolytes
P: Psychiatric ,
A: Anemia
C: Cardiac , ,
E: Endocrine ,
D: Drug , , ,
 CV - palpitation

1. Electrolytes -> correct electrolyte
2. Psychiatric -> Panic disorderAnxiety
Alprazolam (Xanax)
->

3. Anemia -> B/T
4. Cardiac -> Arrhythmia
5. Endocrine -> , Meta
6. Drug ->
 CV - palpitation
Arrhythmia:
EKGarrhythmia

1. PSVT: regular, normal QRS complex, HR 150-250
bpm, PP, historysudden onset
palpitation
-> : Adenosine, Vagal maneuver: carotid
massage, Non-DHP CCB (eg. Verapamil, Diltiazem), -
blockers (eg. propranolol)Conscious change,
, hypotensionsedation(Valium)
defibrillator50-100J (ACLS)
 CV - palpitation
Arrhythmia:
2. Atrial fibrillation: P, QRS, irregularly
irregular, ,
-> : 120-200
200 Joules:
Non-DHP CCB -blockers
digoxin
3. Atrial flutter: P
->: 50-100J
4. VT, VF: VFVT
120-200JCPRVT
100J() -> ACLS
 CV - palpitation
Arrhythmia:
*Bradycardia: HR < 50bpm
vital signOBSvital sign
conciousnessAtropine 0.5mg IV (3-5min
3mg)Bosmin
Dopamine line
 CV - palpitation
Arrhythmia

 CV - hypertension

SBP/DBP level:
Normal: <120/80
Pre-HTN: 120-139/80-89
Stage 1 HTN: 140-159/90-99
Stage 2 HTN: 160-179/100-119
Hypertensive urgency: >180/120
Hypertensive emergency: acute target
organ damage
 CV - hypertension

1. Essential hypertension
2. : coarctation of aorta, renal artery
stenosis
3. : renal parenchymal disease, DM
nephropathy, polycystic kidney, glomerulonephritis,
ACEi/ARB induced acute kidney injury
4. : pheochromocytoma, hyperaldosterone,
Cushings, hypercalemia
5. : preeclampsia, OCP, steriods use, fluid
overload, pain induced, anxiety
 CV - hypertension

1. ACEi/ARB 2. -blockers
3. CCB 4. Diuretics
5. Vasodilators hydralazine
6. Methyldopa (preeclampsiaHTN)

call
Captopril, LabetalolACEi/ARB
-blockers
CCBheart failure
 CV - hypertension
*
1. ACEi: DM
Captopril (), Enalapril, Fosinopril (,
)
2. ARB:
Losartan (), Irbesartan(),
Valsartan ()
3. -blocker:
Propranolol (Inderal), Bisoprolol (Concor), Labetalol (
), Carvedilol (Dilatrend, CAD, CHF)
 CV - hypertension
*
4. CCB (DHP):
Amlodipine (Norvasc, ),
Nifedipine (Adalat, 10mg30mg,
HF, arrhythmia,
preeclampsia),
Lercanidipine
5. CCB (non-DHP):

Diltiazem (Herbesser, ), Diltelan (); Verapamil
(), Verelan ()
 CV - hypertension
*
6. Diuretics:
Furosemide (Lasix, loop diuretics, ,
, , );
Spironolactone (Aldactone, K-sparing, Lasix
, renal failure, ,
anti-RAA systemCHFmortality rate);
Hydrochlorothiazide (thiazide, ,
, )
 CV - hypertension

1. :

->

2. :

 Meta - hyperthyroidism
meta
DM foot



(especially proximal extremities
!!)

 Meta - hyperthyroidism
*Thyroid storm: life threatening
(40C)
(seizure)
(delirium)
*(exophthalmos)Graves disease
hyperthyroidismretro-orbital fat
(eye socket)immuno-mediated
inflammation
 Meta - hyperthyroidism

1. Antithyroid drug: carbimazole (CMZ), methimazole
(MMZ), prophlthiouracil (PTU);
2. -blockers: propranolol
IV form;
3. Radioiodine: I-131
4. Surgery
*GSthyroid
(ENTtongue base)
thyroidblood supply system
hematomatracheadyspnea
inhalation therapyon endoairway!
 Meta - hyperthyroidism

(sedation
seizure)
->



 Meta hyper/hypoglycemia



(DM retinopathy)
(DM vasculopathy)
erectile dysfunction
(DM vasculopathy)
 Meta hyper/hypoglycemia

OBS

HbA1c (glycohemoglobulin)
(AC, PC, 3PM, 9PM)
300RI 6U400
RI 8Ushow highRI 10U
300OBS
RI 1U20mg/dl10U
sulfonylurea
 Meta hyper/hypoglycemia
hyperglycemia
OAD (oral anti-hyperglycemic agent)
metaOADBiguanidesMetformin TID
SulphonylureasGlipizide, Glimepiride
renal toxicityinsulin resistances/e
Amaryl M: Glimepiride + Metformin
-glucosidase inhibitor: acarbose (
)TZDsRosiglitazone(Avandia):
Thiazolidinediones
PPAR

 Meta hyper/hypoglycemia
hyperglycemia
DMsteroid inducedinfection
induced
 Meta hyper/hypoglycemia
*HHS (hyperosmolar hyperglycemic
state): Hyperglycemia > 600 mg/dL. Serum
osmolality > 320 mosm/kg.
8-
12Lfocal signmotor
impairmentseizure
24
1L/hrN/S
*Gestational DMdiet control
insulin (RI & NPH)
 Meta hyper/hypoglycemia





peripheral circulation
intact (dorsalis
pedis & posterior
tibial artery)
-> +
 Infection - fever
Fever
fever
infectioninfection
infectious sourcevital signconsciousness
(r/o meningitis)survey lab data CBC, DC,
CRPcultureempiric antibiotics
antipyretics
TPR sheet()anti
culture
acetaminophen 1# STATintermittent
feverhigh fevertoxicanti
 Infection - fever
Fever routine:
BT > 38C, ice packing ()
BT > 38.5C, Scanol (Acetaminophen) 1PC PO
BT > 39C, Inteban (Indomethacin) 1PC SUPP
*BT > 42CCNS
Fever routine:
BT > 38C, acetaminophen syrup
BT > 38.5C, ibuprofen syrup
BT > 39C, diclofenac/indomethacin supp
BT > 40C, hot water bath
*syrup4=ccQ6H
 Infection - fever
*SIRS (Systemic inflammatory response syndrome):
!
1. BT > 38C or < 36C
2. HR > 90 bpm
3. RR > 20/min or PaCO2 < 32 mmHg
4. WBC < 4000/mm or > 12000/mm or Band form >
10%
*Sepsis = SIRS + evidence of infection (B/C)
*Severe sepsis = sepsis + end organ damage
*Septic shock = severe sepsis + hypotension
 Infection - fever

1. cough, high fever, chills, myalgia, headache
# suspect influenza -> rapid influenza test -> Tamiflu
(oseltamivir)
2. cough with much yellowish sputum
# suspect penumonia -> PE (crackles) w/ dyspnea ->
CXR (infiltration), Sp/C -> anti
# suspect pharyngitis/tonsillitis -> PE (tonsil
engorged, pharynx injected) -> swab or Sp/C ->
anti
 Infection - fever

2. cough with much yellowish sputum
chestempiric antibiotics
Augmentincommunity-acquired
pneumonia, pharyngitis, AOM
hospital acquired pneumonia
pseudomonas infection3rd
Fortum (ceftazidime) + vancomycin
aspiration pneumonia3rdRocephin
(ceftriaxone)clindamycinTBTB

 Infection - fever

3. headache, neck stiffness, photosensitivity, conscious
change
# suspect meningitis -> PE (nuchal regidity, Kernigs sign,
Bruzinskis sign) -> B/C + Lumbar puncture -> anti
(Rocephin 2g IV Q12H + vancomycin 1g IV Q12H) &
Dexamethasone IV Q6H
 Infection - fever

4. RUQ abdominal pain, malaise, juandice
#Suspect biliary tract infection/acute cholangitis ->
PE (Murphys sign) -> AST, ALT, Alk-P, -GT, bilirubin,
B/C, abdominal echo -> NPO +anti (
cefazolin + gentamicin + metronidazole
Rocephin + metronidazole) & ursodeoxycholic
acid -> arrange ERCP
*Cefa+Anegyn
Clindamycin (cover G+)Genta
Ciprofloxacin (cover G-G+)Amikacin (
)Tazocin
 Infection - fever

5. abdominal pain, diarrhea
#Suspect acute enterocolitis peritonitis -> PE (BS:
hyperreactive, rebounding pain) -> B/C, Stool routine,
stool culture, KUB -> NPO +anti (Rocephin +
metronidazole)
 Infection - fever

6. dysuria, urgency, frequency, hematuria
#Suspect urinary tract infection -> PE (flank knocking
pain) -> U/A (pyuria, WBC > 30), U/C, B/C -> anti (
1stcefazolin gentamicin
toxicRocephinprostatitis
ciprofloxacinperirenal/cortical abscess
TazocinUTIBaktar
)
 Infection - fever

7. local inflammation (reddish, local selling, local heat,
tenderness)
#Suspect cellulitis -> PE () -> B/C -> anti (
Strptococcuspenicillin
Rocephin
S. aureusoxacillin1st
cefazolincover G(+)
G(+)G(+)MRSA
vancomycin)
 Infection - fever

8. arthralgia, single joint inflammation
#Suspect septic arthritis -> PE (monoarthritis) ->
synovial fluid analysis & culture G(+), G(-) -> anti (
VancomycinpathogenS. aureus
MRSAStrptococcus
G(-)Rocephin)
 Infection - fever

9. Suspect infective endocarditis -> Duke criteria
-> anti (S. aureus
vancomycin + gentamicin
S. viridansampicillin
+ gentamicin)
Modified Duke Criteria
Major minor
1. Sustained bacteremia 2. Endocardial 1. Predisposing factors (abn. valve or abn.
involvement (cardiac echo: vegetation, bacteremia) 2. fever 3. vascular disease 4.
abscess..) or new valvular regurgitation immune 5. + blood culture
Definite: 2 Major / 1 Major + 3 minor / 5 minor
Possible: 1 Major + 1 minor / 3 minor
 Infection - fever

10. Suspect CVP, double lumen related infection
-> PE (local inflammation sign) ->line, B/C,
Wd/C -> Vancomycin
 Infection - fever

*11. tumor feverr/o infection
naproxen
*12. allergic response to drug
high fever, chills, anti
DCVena IV STATallergy

*13. IVFantipyretics
*14. Fever of Unknown Origin (FUO)
 Infection - fever


 Other - allergy
systemic skin rash, skin itchy,
fever, chills, dyspnea, wheezing or stridor

DCSTAT
Vena (Diphenhydramine) IV ->
Dexamethasone IV ->
Bosmin (Epinephrine) IVanaphylactic
shock
 Other - pruritis
differential diagnosis
1. infection related:
Herpes Acyclovir, + Gabapentin if
Scabies Ulex, Crotamiton
Athletes foot Ketaconazole

2. allergy related (food, medication, allergen)
3. underlying diseases:
Cholestasis Urso, ERCP
Uremic syndrome supportive care and H/D
Diabetes mellitus control blood sugar

 Other - pruritis
differential diagnosis
4. eczematous dermatitis and urticaria wheals ->
Neo-cortisone ointment
calamine lotion
Doxepin
UrticariaAllegra
(fexofenadine,
)Xyzal (levocetirizine, )
Vena IV
prednisolone
 Other - pruritis
*spinalepidural




Vena


 *Other
Bacitracin-Neomycin ointment:
Sodium fusidate:
ZnO:
()
Sulfacil (silver sulfadiazine):

pressure soreDM foot
Proctodyl: steroid + local anesthetic
Dexamethasone 0.1%:
Antiscar:
 *Other
Heparinoid:
Urea cream:
 Other - myalgia
underlyingunderlying

1. NSAID: Mefenamic acid (Ponstan)Sulindac
Flurbiprofen patch Rheumon gel (Etofenamate)
Fentanyl patch(opiod)
2. Muscle relaxants: methocarbamolmephenoxalone
fludiazepam (Erispan)baclofen
3. Local steroid injection
 Other - myalgia

1.


 Other - myalgia

2.



 Other - myalgia

3.


 Other - myalgia

4.

 Rheuma - arthralgia


survey
arthralgiaOA, RA, Gout
Feature Osteoarthritis RA Gouty arthritis

Onset Gradual Gradual Acute

Inflammation - + +

Pathology degeneration pannus () microtophi

# of joints poly poly mono to poly

 Rheuma - arthralgia
Feature Osteoarthritis RA Gouty arthritis

Type of joints Small or large small Small or large

Locations Hips, knees, MCP. PIP, wrists, MTP, feet, ankles,

typically involved spine, 1st CMC, feet, ankles knees
DIP, PIP
Special articular Bouchards Ulnar deviation, Urate, crystals
findings nodes, swan neck,
Herverdens boutonniere
nodes
Bone changes osteophytes Osteopenia, Erosions
erosions
Extra-articular SC nodules, Tophi, olecranon
features pulmonary, bursitis, renal
cardiac, stone
splenomegaly
 Rheuma - arthralgia
Feature Osteoarthritis RA Gouty arthritis

Lab data normal RF +, anti-CCP Uric acid

Treatment Acetaminophen, NSAIDs or Acute: colchicine,

NSAID or celecoxib, NSAIDs,
celecoxib PRN if glucocorticoids corticosteriods;
severe pain; (joint injection or Chronic:
Glucosamine as low-dose oral), allopurinol,
cartilage DMARD probenecid
protection
 Other - dysmenorrhea

suprapubic cramping pain
N/V, diarrhea

1. Primary dysmenorrhea:
pelvic pathologyonset

2. Secondary dysmenorrhea:
underlying pathologyendometriosis, MUC


 Other - dysmenorrhea

NSAIDs: Mefenamic acid, diclofenac
ibuprofen, naproxen
COX-2 inhibitor (Celecoxib, )
OCP
 Other - dysmenorrhea








PE


 Other Pain control
Pain control
acetaminophen
PRN Q6HNSAIDs
(Mefenamic acid & SulindacNSAID
)NPOIV / IM
NSAID - KetorolacNSAIDs failed
weak opiodTramadol PO
Ultracet (Acetaminophen + Tramadol) POCodeine
IV / IMmoderate opiod
Nubain (Nalbuphine)strong opiod
morphine IV
 Other Pain control
underregular
PRN
 Other Pain control
Demerolpost-op


PCA (Patient control analgesics)
complaint
STAT
Demerol
under Demerol regular Q6H
Demerol C (Vitamin C) 1cc
IMNormal saline 1cc IM

 Other Pain control
post-op

Dynastat
(Parecoxib 40mg/vial)
400
ps. PCADynastat
 Other Pain control
COX-2 inhibitor: Celecoxib
rheuma

Etoricoxib
COX inhibitor
Acemetacin
(lower back pain)
QD~BID
CelecoxibAcemetacinNSAID

*MST
(Morphine sulfate continus)
 Other anemia
dataHb
PE
conjunctiva paletachycardia
(from )
Juandice -> hemolysis
Splenomegaly -> thalassemia, neoplasm, chronic
hemolysis induced iron deficiency anemia
Petechiae/purpura -> bleeding disorder
Glossitis (: ) -> iron, folate,
vit. B12 deficiency
Spoon nail -> iron deficiency
Neurologic abnormalities -> B12 deficiency
 Other anemia
anemia
1. Microcytic anemia (Hb, HCV):
a. Iron deficiency anemia:
PE
spoon nail, splenomegalyLabHct <
30%, Fe, ferritin, TIBC, Fe/TIBC < 18%,
MCV/RBC > 13(MCV)
Ferral, Ferrous gluco-B
IV form
 Other anemia
anemia
1. Microcytic anemia (Hb, HCV):
b. Thalassemia:
LabMCV < 70, Fe level, MCV/RBC <
13iron overloadoral
iron chelator deferoxamine, deferasirox
 Other anemia
anemia
2. Normocytic anemia (Hb, HCV):
a. Pancytopenia:
acute
leukemia, HIV infection induced
immunocompromised
Rhg-CSF (bone marrow)EPO
b. Chronic disorder or inflammation:
underlying disease
transamin
 Other anemia
anemia
2. Normocytic anemia (Hb, HCV):
c. Acute blood loss:

d. Chronic renal insufficiency:
EPO

*EPO indication:
1. anemia associated with chronic renal failure
2. anemia induced by chemotherapy in patients with
non-myeloid malignancies
 Other anemia
anemia
3. Macrocytic anemia (Hb, HCV):
a. Folate deficiency:
Lab
folatefolic acid
b. Vitamin B12 deficiency:
motor, sensory
LabB12Vit. B12
Vitamin B-complex (Hi-Beston)
 Other anemia
*
pRBC 2UHb1Hb
8-92UHb 7-84UHb 6-7
6U


VenaScanol PRN if BT > 38C
primary care
 Other anemia

*Dr. :
3g+
3g+
6PC
TID
 *






 *intern
1.
2. chest tubecomplication:
subcutaneous emphysema
3. decorticateseizure
 *
OR
HIS->->->
=>->






 *
-
Harrisons

2009 Intern Note
First Choice 2012
(online)
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