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


origin GI



ileus, interssusception
ascites toxic
PE shifting 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: ->
anti IVF hydration

Appendicitis: Mcburney point PE
tenderness rebound pain ->
Abdominal CT finding
protocol
GI Abdominal pain

1. WBC, Seg, CRP , fever
Gastritis:
NSAID H.
pylori -> ulcer
PPI ( Esomeprazole, Lansoprazole, Pantoprazole)
Misoprostol sucralfate
H. 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 -> NPO
anti ( 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) ->
NSAID 5-
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)
ileum colon
-> abdominal
CT NSAID
steriod Anti-TNF

GI Abdominal pain

1. WBC, Seg, CRP , fever
Peritonitis:
trauma, appendicitis,
perforation bowel
sinus tachycardia PE
rebounding pain muscle guarding ->
NPO
Augmentin, Tazocin, Timentin
GI Abdominal pain

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

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

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


->
Ursodeoxycholic acid
cholecystectomy
GI Abdominal pain

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

-> Abdominal CT
lab amylase, lipase
IVF hydration ( pancreatitis 10
L/D) Demerol Morphine Foy
(Gabexate,
)
pancreatitis ERCP
GI Abdominal pain

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

Volvulus: interssusception

GI Abdominal pain

2.
Constipation: KUB
history constipation
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 CT GS

GI Abdominal pain

3.
AAA: PE palpable
mass bruit -> abdominal CT
consult CVS
Aortic dissection: consult CVS

Ovarian torsion: ->
GYN
Ectopic pregnancy: -> -hCG
GYN
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 routine stool
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

DM uremia

Multiple sclerosis (MS) Guillain-
Barre spinal cord injury CNS injury
GI Constipation

MgO: 1# QID
NSAIDs
2# TID - QID ESRD
Mg Mg
Sennoside: 1 - 2# HS
diarrhea
Duclolax (Bisacodyl): supp.
STAT
regular
GI Constipation

Lactulose: NH3
ammonia
hepatoencephalopathy
Glycerin:

Fleet enema:


GI Constipation



->
GI Nausea/Vomiting

underlying disease

1. GI
colon N/V

GERD
B Lamivudine ( ) 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:

-> underlying disease!!
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: EPS
primperan
GI Nausea/Vomiting


-
->
GI GI bleeding
GI bleeding
(hematemesis) coffee
ground UGIB bloody stool
UGIB LGIB
(melana) UGIB
UGIB LGIB ( )
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 bleeding check vital sign
conscious level O2
supplement aspiration
on endo vital sign IVF
challenge N/S L/R 500cc run
Hct 30 Plt 50000
PES ligation Terlipressin
GI GI bleeding

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

1. UGIB
Varices: UGIB
cirrhosis underlying
IVF hydration
Terlipressin ( FFP Vit.
K, Plt 50000 ) endoscopic therapy
Bosmin ligation
PPI Transamin
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:
NSAIDs proctosedyl

GI GERD


(heartburn)
(regurgitation)

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


GI GERD


GERD


->
Neuro headache


scanol
NSAIDs

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 sign Bruzinskis sign ->
lumbar puncture antibiotics
c. hematoma or tumor:
SAH ->
brain CT
Neuro headache

2. Secondary headache
d. closed-angle glaucoma:
nausea and vomiting
Timolol, Pilocarpine
*e. sinnusitis headache
Neuro headache


->
Neuro migraine
30

throbbing
pulsatile
Classic
migraine (18%) aura common
migraine (64%)
Sumatriptan (5-HT1 agonists)
NSAIDs migraine
TCA, -blocker, CCB, topiramate

Neuro insomnia


intern





Neuro insomnia

1. BZD
Ativan (Lorazepam):

seizure
Fludiazepam:

Xanax (Alprazolam):

Estazolam:

Neuro insomnia

1. BZD
*Valium (Diazepam): dilirium
seizure
seizure (IV )
*Midazolam:
2. non-BZD
Stilnox (Zolpidem):
(
)
3. Antihistamine: ( )
Vena (Diphenhydramine): IV STAT
Neuro insomnia



->
Neuro seizure

seizure alcohol
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

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


sedation
->



Neuro conscious
change

tra
order CBC, DC, PT,
APTT, glucose, electrolyte, BUN, Cr, AST, ALT,
ammonia bedside / vital sign
apnea on endo pun Gas
set IV line
review underlying 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
CV
dopamine, dobutamine, pulse Bosmin
CPR
2. liver failure: hepatic encephalopathy
lactulose, antibiotics, , supportive treatment
3. uremia: consult Nephro
4. hypo/hypernatremia: nephro
5. blood sugar: DM underly
hypoglycemia HHS
Neuro conscious
change
b.

6. hyperthyroidism: meta
7. hypothyroidism myxedema coma:
hypothermia, hypotension, hypoventilation,
cons change IV Thyroxine
Levothyroxine corticosteroids
(hydrocortisone)
8. Pneumonia: infection
9. Septic shock: (IV resuscitation)
Levophed (norepinephrine)
10.
Neuro stroke
70%
30%
brain
CT hemorrhage
gyrus ischemic stroke
IV thrombolysis agent ( t-PA
) antiplatelet therapy ( aspirin,
dipyridamole, clopidogrel) BP
( 220/120mmHg)
IVF hydration
Neuro stroke
*TIA (Transient ischemia attack)
24

brain
CT hemorrhage
putamen hold
( SBP
140mmHg ) IVF
Neuro stroke




Neuro dizziness/vertigo


1. dizziness :
a. anemia underlying disease
active bleeding anemia
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 (Cephadol peripheral
vertigo/ Menieres vertigo);
.Anemia Hb < 8 ;
.Hypoglycemia glucose 50% 4PC STAT;
.Orthostatic hypotension

hypotension midodrine

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 test
swab
pneumonia, bronchopneumonia, TB ->
CXR
acute bronchiolitis ( RSV ) ->
O2 hood supply, bronchodilator steroid
( )
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 spray

!!
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 chart history lab data

3. bedside / PE
toxic dyspnea gas


Chest shortness of
breath
DD

1. pneumothorax PE & CXR (acute
dyspnea, pleuritic chest pain, hypotension)
CXR pleural line & tracheal deviation
PE 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 use pleural
effusion pleural friction rub) ABG
showed PaO2 & PaCO2 CXR (Kerley B lines,
pleural effusion -> butterfly sign) pulmonary
edema heart disease CXR

Chest shortness of
breath
DD

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

3. restricted airway
choking (conscious clear
)
GS thyroidectomy ENT
tongue base
hematoma airway
on endo
thyroid mass compression
Chest shortness of
breath
DD

4. cardiac tamponade
PE distant heart sound,
tachycardia, jugular venous distention, and pulsus
paradoxus ( 10mmHg ) EKG
low limb lead voltage CXR
O2 IVF hydration CVS
pericardiocentesis
dobutamine lasix!!
Chest shortness of
breath
DD

5. heart failure pattern orthopnea PND
(
pul. edema )
decreased heart sound jugular venous
distention PE lab
BNP cardiac 2D Dopplar echo
EF<50% , ACEi/ARB,
digoxin, -blocker, diuretics preload,
Hydralazine + nitrate afterload CCB!!
Chest shortness of
breath
DD

6. acute myocardial infaction CV
chest pain
Chest shortness of
breath
DD

7. pulmonary hypertension
dyspnea, chest pain, syncope
peripheral edema, RUQ fullness, abd.
Distention PE jugular vein distention,
P2(pulmonary valve ) , R-sided S4
CXR pulmoary arteries dilatation, RA & RV
, EKG RVH, right axis deviation

Chest shortness of
breath
DD

7. pulmonary hypertension O2 supplement
SaO2 > 90-92%, diuretics preload
RV , digoxin dobutamine , anticoagulant
thrombosis 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, hemoptysis
PE tachypnea, crackles, tachycardia,
cyanosis, pleural friction rub, jugular venous
distention, loud P2 EKG PE RV
failure sign CTA&CTV
D-dimer ( 500
PE)
Chest shortness of
breath
DD

8. pulmonary embolism
heparin IV 80U/kg initial bolus
18U/kg/hr 7-10 warfarin

*PE DVT lab D-dimer FDP

DVT Enoxeparin
warfarin PT, INR prolong
Chest shortness of
breath
DD

9. severe acidosis
Respiratory acidosis hypoventilation
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

consciousness ABG


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

9. severe acidosis
Metabolic acidosis
a. DKA (Diabetes ketoacidosis) type 1 DM
insulin ( )
Kussmaul repiration(
) (N/S) Insulin
( +
) pH<7.0 Jusomin
Chest shortness of
breath
DD

9. severe acidosis
Metabolic acidosis
b. hyperchloremic acidosis Na+ HCO3-
anion gap
bicarbonate severe diarrhea GI loss
renal tubule acidosis kidney loss(RTA type I distal
H+ , ; RTA type II proximal
HCO3- , ; RTA type IV hypoaldo.
, )
Chest shortness of
breath
DD

9. severe acidosis
Metabolic acidosis
b. hyperchloremic acidosis acidosis
Sodium bicarbonate
(pH < 7.20) IV Jusomin
=(24-X)/2 STAT
serum HCO3- > 8 pH > 7.2
renal correct
Chest shortness of
breath
DD

9. severe acidosis
Metabolic acidosis
c. Lactic acidosis hyperventilation
lab data lactate levels >5 mmol/L
serum pH <7.35
hypoperfusion sepsis shock
DKA
Jusomin
Chest shortness of
breath
DD

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

DC STAT :
Vena (Diphenhydramine) IV ->
Dexamethasone IV ->
Bosmin (Epinephrine) IV anaphylactic
shock
Chest shortness of
breath
DD

11. Ascites related fatty liver, OHSS
PE shifting dullness diaphragm
albumin
Lasix ascites
tapping ~
fluid loss hypotension
carcinomatosis related ascites tapping
ascites
Chest shortness of
breath
DD

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

2. COPD
CXR hyperinflation, 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
PE crackles CXR infiltration
leukocytosis with left shift, CRP
fever
Chest shortness of
breath
DD

4. Anemia anemia
Chest shortness of
breath
DD

5. Neuromuscular disease underlying
disease
autoimmune steroid
Chest shortness of
breath
DD

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






saturation
Chest saturation down
saturation down dyspnea
dyspnea differential diagnosis


( bedside
) obstructive sleep
apnea (OSA) 30
OSA ENT

STAT suction
Chest saturation down
(1) Nasal cannula

FIO2 = 20% + 4
FIO2

(2) O2 simple mask
100 300 6 10
35% 55%
5
FIO2


Chest saturation down
(3)Venturi

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

bag 8 10
90% FIO2 COPD
hypercapnia high flow
CO2 retention respiratory acidosis
Nephro Urinary
retention
complain
I/O
imbalance

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

ICP STAT
ICP Foley
Foley
ICP training remove Foley RU
(residual urine) ICP
( bladder scan RU)
RU 200cc
RU ( )
Foley training failure

Nephro Urinary
retention

anticholinergic urinary retention

Bethanechol cholinergic
agent
BPH urinary retention
Tamsulosin (Harnalidge D) - blocker
Finasteride 5mg 5-
reductase inhibitor

*PS. Finasteride 1mg(Proscar)

Nephro Urinary
retention



->
Nephro Edema



1. Unilateral / localized edema:
a. Cellulitis -> anti infection
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 afterload CCB!!
b. Cirrhosis ascites, bilirubin, PT,
albumin, anemia, neutropenia,
thrombocytopenia ->
diuretics

Nephro Edema

2. Bilateral edema:
c. Nephrotic syndrome, proteinuria,
albumin, cholesterol ->
protein diuretics statin
ACEi/ARB proteinuria
*ACEi/ARB resistance
GFR protein tubule
proteinuria RAAS
hyperkalemia

Nephro Edema

2. Bilateral edema:
d. Acute or chronic renal failure:
NSAID
diuretics contrast
N-acetylcysteine contrast

AKI dialysis
CKD uremia ->
( ACEi/ARB)
metabolic acidosis anemia ESRD

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/L central pontine
myelinolysis
dysarthria
dysphagia
Nephro Electrolyte
imbalance
Hyponatremia
*
40 85kg 105
1. = (125-105)x85x0.6 = 1020mEq
* Na 125mEq/L
2. Liter:
3% saline 1020/513 = 2L
N/S 1020/153 = 6.7L
3. 0.5mEq/L
: 0.5x85x0.6 = 13mEq
4. CC :
3% saline 13 / 513 = 0.025L
N/S 13 / 153 = 0.085L
Nephro Electrolyte
imbalance
Hyponatremia
UNa osm Cl Posm Na K record I/O

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

-> N/S
Nephro Electrolyte
imbalance
Hyponatremia
UNa osm Cl Posm Na K cortisol, thyroid fn.
record I/O

2. Euvolemic hyponatremia:
a. SIADH Uosm > 100 UNa
b. Endocrinopathies glucocorticoid
hypothyroidism ADH
-> SIADH underlying disease
hypertonic 3% saline loop diuretics
Nephro Electrolyte
imbalance
Hyponatremia
UNa osm Cl Posm Na K record I/O

3. Hypervolemic hyponatremia:
a. CHF UNa < 10 mEq/L FENa > 1%
b. Cirrhosis ascites UNa < 10 mEq/L
c. Nephrotic syndrome
hypoalbuminemia edema UNa < 10 mEq/L
d. Advanced renal failure UNa > 20 mEq/L FENa
> 1%
-> underlying disease
Nephro Electrolyte
imbalance
Hypernatremia
UNa osm record I/O

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

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

-> Diuretics DI
desmopressin (dDAVP)
Nephro Electrolyte
imbalance
Hypokalemia
Weakness

1. Slow K
KCl N/S
run hypokalemia

2. QD follow lab data
Nephro Electrolyte
imbalance
Hypokalemia
UK osm PK osm 24

1. GI loss: UK < 25 mEq/d TTKG < 3
diarrhea ->
2. Renal loss: UK > 30 mEq/d TTKG > 7
a. hypo- or normotensive
acidosis: DKA, RTA
alkalosis: diuretics, vomiting
Mg depletion distal K secretion
-> underlying disease.
Nephro Electrolyte
imbalance
Hypokalemia
UK osm PK osm 24

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

Kalimate
palpitation, arrhythmia, A-V
block, VF, cardiac arrest
RI 10U + Glucose 50% 4PC IV push
Fleet enema
Lasix H/D QD
follow up lab data
EKG: peaked T waves, PR interval, QRS
widening, P , slow sinusoidal pattern
Nephro Electrolyte
imbalance
Hyperkalemia
UNa osm record I/O

1. : AKI or ESRD
-> underlying disease
2. :
a. aldosterone
CHF cirrhosis
-> underlying disease
Nephro Electrolyte
imbalance
Hyperkalemia
UNa osm record 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 IV calcium
carbonate PO
Nephro Electrolyte
imbalance
Hypercalcemia
cons change, constipation

hyperparathyroidism, malignancy, Vit. D

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

TTKG
TTKG > 7
U K / U osm osm
TTKG < 3
PK / Posm
FENa FENa < 1
U Na / U Cl Cl ->
PNa / PCl FENa > 1
->

CV chest
tightness/pain
STAT
EKG AMI
acute coronary syndrome CK-
MB Troponin I
x Unstable NSTEMI STEMI
angina (UA)
Coronary Subtotal Subtotal Total
thromb.
History Angina that is new-onset, Angina at rest
crescendo, or at rest; usually < 30 usually > 30 min
min
EKG ST depression and/or T wave ST elevations
inversion
Troponin/CK-MB - + ++
CV chest
tightness/pain
*AMI EKG :
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) CXR pleural line &
tracheal deviation PE tympanic and breathing
sound O2 on chest tube
3. pulmonary embolism (dyspnea, hemoptysis,
pleurutic chest pain) CXR D-dimer
CT angiography warfarin
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 disorder Anxiety
Alprazolam (Xanax)
->
3. Anemia -> B/T
4. Cardiac -> Arrhythmia
5. Endocrine -> , Meta
6. Drug ->


CV - palpitation
Arrhythmia:
EKG
arrhythmia
1. PSVT: regular, normal QRS complex, HR 150-
250 bpm, P P , history
sudden onset palpitation
-> : Adenosine, Vagal maneuver:
carotid massage, Non-DHP CCB (eg. Verapamil,
Diltiazem), -blockers (eg. propranolol)
Conscious change, , hypotension
sedation(Valium) defibrillator
50-100J ( 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: VF VT
120-200J CPR VT
100J( ) -> ACLS
CV - palpitation
Arrhythmia:
*Bradycardia: HR < 50bpm
vital sign OBS vital sign
conciousness Atropine 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 ( preeclampsia HTN)

call
Captopril, Labetalol ACEi/ARB
-blockers
CCB heart failure
diuretics Lasix Spirolactone
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, 10mg 30mg
, 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 system CHF
mortality 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 hyperthyroidism retro-
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
*GS thyroid
(ENT tongue base )
thyroid blood supply system
hematoma trachea dyspnea
inhalation therapy on endo airway!
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)
300 RI 6U 400
RI 8U show high RI 10U
300 OBS
RI 1U
20mg/dl 10U sulfonylurea
Meta
hyper/hypoglycemia
hyperglycemia
OAD (oral anti-hyperglycemic agent)
meta OAD Biguanides
Metformin TID Sulphonylureas
Glipizide, Glimepiride renal toxicity
insulin resistance s/e Amaryl
M: Glimepiride + Metformin -
glucosidase inhibitor: acarbose (
) TZDs Rosiglitazone(Avandia):
Thiazolidinediones
PPAR

Meta
hyper/hypoglycemia
hyperglycemia
DM steroid induced infection
induced
Meta
hyper/hypoglycemia
*HHS (hyperosmolar hyperglycemic
state): Hyperglycemia > 600 mg/dL. Serum
osmolality > 320 mosm/kg.
8-12L
focal sign motor impairment
seizure
24 1L/hr N/S

*Gestational DM diet control
insulin (RI & NPH)
Meta
hyper/hypoglycemia




peripheral
circulation
intact (dorsalis pedis
& posterior tibial
artery)
-> +

Infection - fever
Fever
fever
infection infection
infectious source vital sign
consciousness (r/o meningitis) survey
lab data CBC, DC, CRP culture
empiric antibiotics antipyretics
TPR sheet ( ) anti
culture
acetaminophen 1# STAT intermittent
fever high fever toxic anti
Infection - fever
Fever routine:
BT > 38C, ice packing ( )
BT > 38.5C, Scanol (Acetaminophen) 1PC PO
BT > 39C, Inteban (Indomethacin) 1PC SUPP
*BT > 42C CNS
Fever routine:
BT > 38C, acetaminophen syrup
BT > 38.5C, ibuprofen syrup
BT > 39C, diclofenac/indomethacin supp
BT > 40C, hot water bath
* syrup 4=cc Q6H
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
chest empiric antibiotics
Augmentin community-acquired
pneumonia, pharyngitis, AOM
hospital acquired pneumonia
pseudomonas infection 3rd
Fortum (ceftazidime) + vancomycin
aspiration pneumonia 3rd
Rocephin (ceftriaxone) clindamycin
TB TB
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 ( 1st cefazolin
gentamicin toxic Rocephin
prostatitis ciprofloxacin
perirenal/cortical abscess Tazocin
UTI Baktar )

Infection - fever

7. local inflammation (reddish, local selling, local
heat, tenderness)
#Suspect cellulitis -> PE ( ) -> B/C ->
anti ( Strptococcus
penicillin Rocephin
S. aureus oxacillin 1st
cefazolin cover G(+)
G(+) G(+) MRSA
vancomycin)
Infection - fever

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

9. Suspect infective endocarditis -> Duke criteria
-> anti ( S. aureus
vancomycin + gentamicin
S. viridans
ampicillin + gentamicin )
Modified Duke Criteria
Major minor
1. Sustained bacteremia 2. Endocardial 1. Predisposing factors (abn. valve or
involvement (cardiac echo: vegetation, abn. bacteremia) 2. fever 3. vascular
abscess..) or new valvular regurgitation disease 4. 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 fever r/o infection
naproxen
*12. allergic response to drug
high fever, chills,
anti DC Vena IV STAT
allergy
*13. IVF antipyretics
*14. Fever of Unknown Origin (FUO)
Infection - fever


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

DC STAT
Vena (Diphenhydramine) IV ->
Dexamethasone IV ->
Bosmin (Epinephrine) IV
anaphylactic 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
Urticaria Allegra
(fexofenadine,
) Xyzal (levocetirizine, )
Vena IV
prednisolone
Other - pruritis
* spinal epidural




Vena


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

pressure sore DM foot
Proctodyl: steroid + local anesthetic
Dexamethasone 0.1%:
Antiscar:
*Other
Heparinoid:
Urea cream:
Other - myalgia
underlying underlying

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

1.


Other - myalgia

2.



Other - myalgia

3.


Other - myalgia

4.

Rheuma - arthralgia


survey
arthralgia OA, 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, MTP, feet,

typically spine, 1st CMC, wrists, feet, ankles, knees
involved DIP, PIP ankles
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,
features pulmonary, olecranon
cardiac, bursitis, renal
splenomegaly stone
Rheuma - arthralgia
Feature Osteoarthritis RA Gouty arthritis

Lab data normal RF +, anti-CCP Uric acid

Treatment Acetaminophen NSAIDs or Acute:

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

suprapubic cramping pain
N/V, diarrhea

1. Primary dysmenorrhea:
pelvic pathology onset

2. Secondary dysmenorrhea:
underlying pathology endometriosis,
MUC

Other - dysmenorrhea

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








PE


Other Pain control
Pain control
acetaminophen
PRN Q6H NSAIDs
(Mefenamic acid & Sulindac NSAID
) NPO IV /
IM NSAID - Ketorolac NSAIDs failed
weak opiod Tramadol PO
Ultracet (Acetaminophen + Tramadol) PO
Codeine IV / IM moderate
opiod Nubain (Nalbuphine) strong
opiod morphine IV
Other Pain control
under regular
PRN
Other Pain control
Demerol post-op


PCA (Patient control analgesics)
complaint
STAT Demerol

under Demerol regular Q6H
Demerol C (Vitamin C) 1cc
IM Normal saline 1cc IM

Other Pain control
post-op


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

COX inhibitor
Acemetacin (
lower back pain )
QD~BID
Celecoxib Acemetacin NSAID

* MST
(Morphine sulfate continus)
Other anemia
data Hb
PE
conjunctiva pale tachycardia
(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,
splenomegaly Lab Hct < 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:
Lab MCV < 70, Fe level,
MCV/RBC < 13 iron
overload oral 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
folate folic acid
b. Vitamin B12 deficiency:
motor, sensory
Lab B12 Vit. B12
Vitamin B-complex (Hi-Beston)
Other anemia
*
pRBC 2U Hb 1
Hb 8-9 2U Hb 7-8 4U Hb 6-
7 6U



Vena Scanol PRN if BT > 38C
primary care
Other anemia

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





* intern
1.
2. chest tube complication
: subcutaneous emphysema
3. decorticate seizure
*
OR
HIS -> ->
-> => ->






*
-
Harrisons

2009 Intern Note
First Choice 2012
(online)
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