Donuts



FLINT WANGMARTIN STUDY GUIDE 2018***PRNs***GENERAL PAIN: acetaminophen (Tylenol), PO ibuprofen (Motrin) or naproxen (Naprosyn or Aleve), IV ketorolac (Toradol), PO Tramadol, PO Tylenol with codeine, PO oxycodone or oxycodone-acetaminophen (Percocet), PO Dilaudid or IV Dilaudid, IV Dilaudid PCA ICAL PAIN: capsaicin cream, lidocaine patch, fentanyl patch.MUSCLE SPASM: PO cyclobenzaprine (Flexeril).NERVE PAIN: PO gabapentin, PO amitriptyline, PO duloxetine (Cymbalta), PO pregabalin (Lyrica).HEADACHE: acetaminophen, Tylenol, ibuprofen (Motrin), aspirin-acetaminophen-caffeine (Excedrin), IV fluid bolus, IV ketorolac (Toradol), metoclopramide (Reglan), sumatriptan (Imitrex), oxycodone as last resort.SLEEP/INSOMNIA: temazepam (Restoril), trazodone, Benadryl.EAR FULLNESS: carbamide peroxide (Debrox) ear drops, pseudoephedrine tablet.NASAL CONGESTION: saline nasal spray, cetirizine (Zyrtec), fluticasone nasal spray (NOT inhaler) oxymetazoline (Afrin)NASAL BLEEDING: saline nasal spray, Afrin (bend neck back and give as a stream rather than a spray), packing with Afrin-soaked gauze.SORE THROAT: benzocaine (Cepacol) lozenge or spray, salt water gurgle, magic mouthwash (lidocaine) swish and swallow.SECRETIONS: glycopyrrolate.COUGH: guaifenesin (Mucinex), guaifenesin-dextromethorphan (Robitussin), guaifenesin-codeine.ORAL ULCERS: magic mouthwash (lidocaine) swish and spit/swallow, Ulcerease, oxycodone liquid.HICCUPS: baclofen, thorazine.HEARTBURN/REFLUX/BLOATING: ranitidine (Zantac) for quicker effect, lansoprazole (Prevacid) for slower effect, calcium carbonate (Tums), simethicone (Gas-X), magnesium-aluminum hydroxide (Maalox), bismuth subsalicylate (Pepto-Bismol).NAUSEA: ondansetron (Zofran), prochlorperazine (Compazine), promethazine (Phenergan), metoclopramide (Reglan), scopolamine patch, trimethobenzamide (Tigan), lorazepam (Ativan), dexamethasone.CONSTIPATION: Senna, docusate (Colace), polyethylene glycol (Miralax), bisacodyl PO (Dulcolax), lactulose, bisacodyl suppository, tap water enema, mineral oil enema, sodium phosphate (Fleet) enema, manual disimpaction, gastrograffin enema, colonoscopic disimpaction.DIARRHEA: loperamide (Imodium), atropine-diphenoxylate (Lomotil), bismuth subsalicylate (Pepto-Bismol), pancreatic enzymes (Creon), tincture of opium, octreotide (Sandostatin).ITCHING: hydroxyzine (Atarax), diphenhydramine (Benadryl), Eucerin lotion, camphor-menthol lotion, hydrocortisone cream, cholestyramine, ursodiol.***CONSTITUTIONAL***FAILURE TO THRIVEDIFFERENTIAL:-Psychosocial: dementia, depression, lack of social support or food)-Illness: cancer, lung/liver/kidney failure, infection, stroke, rheumatology, TB, hyperthyroidism-Malabsorption: celiac, gut surgeryLABS: CBC/BMP/LFTs, albumin, prealbumin, TSH, HIV, CXR, UA, FOBT, pan-CT, EGD/colonoscopy/mammo/PSA.***NEUROLOGIC***HEADACHERED FLAG: new/different in age >50, develops within minutes (thunderclap), confusion, unilateral weakness, wakes you up, worse with Valsalva, visual changes, neck stiffness, fever, HIV, cancer, prior clot disorder.DIFFERENTIAL: tension, cluster, migraine, dehydration, trigeminal neuralgia, stroke, venous sinus thrombosis, tumor, meningitis, medication or caffeine withdrawal, post-lumbar puncture, giant cell arteritis, hypertensive emergency, carbon monoxide, closed angle glaucoma. TREATMENT: acetaminophen, Tylenol, ibuprofen (Motrin), aspirin-acetaminophen-caffeine (Excedrin), IV fluid bolus, IV ketorolac (Toradol), metoclopramide (Reglan), sumatriptan (Imitrex), oxycodone as last resort.DIZZINESS/VERTIGO/PRESYNCOPEVESTIBULAR: BPPV, Eustachian tube dysfunction, otitis media, Meniere’s, vestibular neuronitis, labyrinthitis, chronic motion sickness, Ramsay Hunt syndromePRESYNCOPE: orthostatic, hypotension, vasovagalCNS: migraine, brain tumor, acoustic neuroma, multiple sclerosisPSYCHIATRIC: depression, anxietyPERIPHERAL: hypoglycemia, hypoxemia, MI, thyroid, anemia, pregnancy, postural orthostatic tachycardia syndrome (POTS), pure autonomic failure.SYNCOPEDIFFERENTIAL: neurologic (stroke ischemic or hemorrhagic, migraine, seizure, narcolepsy, hydrocephalus, amyloid or diabetic neuropathy), vasovagal, cardiac (arrhythmia, aortic stenosis, sinus pause/complete heart block, hypertrophic obstructive cardiomyopathy (HOCM), situational (post-tussive, micturition or urination), orthostatic or hypovolemic (dehydration, hemorrhage), or metabolic (hypoglycemia).LABS: CBC/BMP/LFT, fingerstick, ammonia, orthostatic BP, EKG, head CT/MRI, echo, A1c, SPEP/UPEPALTERED MENTAL STATUSDrugs: intox/withdrawal of opiates/benzos/alcohol/anticholinergics/sedation medsInfection: CNS, sepsisGI: hepatic encephalopathyCNS: seizure/post-ictal, status epilepticus, hydrocephalus/mass, stroke, hemorrhage, vasculitisRenal: dialysis disequilibirium syndromeEndocrine: glucose/thyroid/cortisolRespiratory: hypercarbia, hypoxiaMetabolic: hypoglycemia, Na, Ca, carbon monoxide, B12, thiaminePsych: sundowning, ICU deliriumLABS: CBC/BMP/LFTs, fingerstick, BCx/UA/CXR, urine/serum tox, ammonia, ABG, head CT/MRI, B12/folate, thiamine, TSH, cortisol.STROKEORDERS: head CT/MRI, Neurology consult, consider tPA, aspirin (if no bleed), statin, consider (clopidogrel) Plavix, head of bed flat x 24hrs, telemetry, permissive HTN, PT/OT, NPO, speech/swallow, neuro checks, echo with bubble study.LABS: CBC/BMP/LFTs/coags, ESR/CRP, TSH, lipid panel, A1c, RPR.SEIZUREDIFFERENTIAL (HIMMM):-Hemorrhagic (bleed, subarachnoid, stroke)-Infection (meningitis/encephalitis)-Metabolic (hypoNa/Ca/Mg/gluc, febrile, uremia, hyperthyroid, HONK, hypoxia, dialysis disequilibrium syndrome, porphyria), -Medication/toxin (missing AED, alcohol/benzo withdrawal, penicillin/bupropion/tacrolimus)-MassORDERS: fingerstick, CBC/BMP/LFT/coag, serum/urine tox, antiepileptic drug levels, head CT, MRI, EEG, LP.***PSYCHIATRY***ALCOHOL WITHDRAWALImportant to know when was last drink.CIWA score (Clinical Institute Withdrawal Assessment). Based on nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, orientation. If CIWA score <=8 then just watch.If CIWA score 9-15is mild withdrawal.If CIWA score 16-20 is moderate.If CIWA score > 20 then send to ICU or if needs quickly escalating doses of Ativan then send to ICU.Start with Ativan 1mg q4 PRN for CIWA > 8. Then double to Ativan 2mg, then 4mg, 8mg. Then phenobarbital. Consider intubation.***CARDIAC***CHEST PAINDIFFERENTIAL: cardiac (ACS/MI, pericarditis, aortic stenosis, aortic dissection, Takatsubo’s, prinzmetal, cocaine chest pain, crack lung, hypertensive emergency), pulmonary (pneumonia, pulmonary embolism, pneumothorax), GI (diffuse esophageal spasm, GERD, peptic ulcer, pancreatitis), psych (somatization, panic attack), MSK (costochondritis, Zoster).MYOCARDIAL ISCHEMIAINITIAL MEDICATIONS: aspirin 81x4 chewable, clopidogrel (Plavix) 300mg loading then 75mg daily thereafter (only give Plavix after talking to Cardiology), nitroglycerin sublingual, heparin bolus + drip, atorvastatin 80mg or rosuvastatin 40mg, metoprolol 6.25mg q6 (titrate to HR 60), enalapril 2.5mg q12 (titrate to BP 120).HYPERTENSIONCHRONIC HOME MEDS: ACEI/ARB (lisinopril, losartan, BB (carvedilol, labetalol), CCB (amlodipine, nifedipine, Diuretic (HCTZ, chlorthalidone, spironolactone). Other: isosorbide mononitrate, hydralazine, methyldopa, clonidine.ACUTE INPATIENT MEDS: hydralazine, labetalol.HYPERTENSIVE EMERGENCY: nicardipine drip, nitroprusside drip, labetalol drip.PERICARDITIS/PERICARDIAL EFFUSION-Idiopathic-Infectious: viral (Coxsackie, echovirus, adenovirus, enterovirus), bacterial (Strep pneumo, Staph, E.coli, Proteus, PsA, Klebsiella, Neisseria, Legionella), granulomatous (tuberculosis, histoplasma, coccidiomycosis)-Inflammatory: rheumatologic, systemic lupus erythematosus, scleroderma, rheumatic fever-Metabolic: uremia (uremic platelets can lead to hemorrhagic conversion), severe hypothyroidism, hypercholesterolemia crystals-Cardiovascular: acute MI (1-10d), Dressler syndrome (2-3wks), aortic dissection-Other: iatrogenic, malignancy, drugs (penicillin, procainamide/hydralazine lupus reaction), radiation induced inflammation, cardiac procedures (puncture right atrium with pacemaker) or post-open heart surgery, traumaSYSTOLIC CHF/EXACERBATIONCauses of New Systolic CHF or CHF Exacerbation:-Heart: ischemia, post-myocardial infarction complication (rupture, aneurysm), hypertension, valvular disease especially mitral regurgitation, atrial fibrillation, tachycardia or tachyarrhythmia, Takotsubo’s cardiomyopathy, noncompaction cardiomyopathy, structural heart disease (ex: hypertrophic obstructive cardiomyopathy), pulmonary embolism, amyloid, myocarditis, cardiac transplant rejection-Systemic: medication (NSAID, calcium channel blockers, anthracycline chemotherapy, thiazolidinediones), infection, iron deficiency anemia, diabetes, thyroid, electrolyte, pregnancy, obstructive sleep apnea, renal failure, systemic lupus erythematosus, sarcoid, HIV, hemochromatosis, thiamine deficiency-Lifestyle: med noncompliance, dietary indiscretion, alcohol, cocaineNYHA Classification: -Class 1 (CHF no symptoms)-Class 2 (slight limit)-Class 3 (marked limit)-Class 4 (significant limit)ACC/AHA Classification:-Stage A (at risk of CHF, no symptoms)-Stage B (structural disease but no signs of CHF)-Stage C (structural with prior/current symptoms)-Stage D (refractory needing advanced therapies)Diuretics:-Furosemide (Lasix) or bumetanide (Bumex) or torsemide (Demadex)-PO to IV: Furosemide (2:1), bumetanide (1:1), torsemide (no IV)-If on home furosemide then choose IV equivalent and double if trying to aggressively diurese. Ex: home furosemide 40mg PO BIDif keep net even then furosemide 20mg IV BIDif trying to diurese then furosemide 40mg IV BID. Diurese goal 1L neg/day. Diurese until start to see Cr rise or contraction alkalosis (bicarb rise).-High creatinine means need more diuretics to reach therapeutic threshold.LOWER EXTREMITY EDEMABilateral:-Cardiovascular: CHF, pericardial effusion, pulmonary HTN, venous stasis, immobilization, upstream clot-Hypoalbuminemia: cirrhosis, nephrotic, malnutrition/Kwashiorkor, protein-losing enteropathy-Skin: cellulitis-Medication: CCB, NSAIDs-Cancer: lymphatic obstruction -Endocrine: myxedemaUnilateral:-DVT, venous insufficiency, cellulitis, trauma, lymphatic obstruction, May-Thurner syndrome, lymphedema from lymph node dissectionATRIAL FIBRILLATIONNEW AFIB CAUSES: ACS/MI, CHF, mitral regurgitation, pericarditis, accessory pathway, pulmonary embolism, COPD, sepsis/infection, hyperthyroidism, alcohol, cocaine, caffeine.SCORING: CHA2DS2VASc (CHF, HTN, Age>65, Age >75, DM, Stroke, Vascular disease, sex category)LABS: CBC/BMP/Mg/Phos/LFT/coags, TSH, trop/CKMB, serum/urine tox, EKG, echo.IF STABLE Afib RVR: metoprolol 5mg IV, diltiazem 10-20mg IV, amiodarone 150mg IV bolus with amiodarone drip @ 1mg/min.IF UNSTABLE Afib RVR: synched cardioversion @100J then 150J.SVTIF STABLE SVT: try vagal maneuvers (carotid massage, Valsalva, ice to face), hook up continuous EKG, adenosine 6mg IV, then 12mg IV, then another 12mg, then synched cardioversion.IF UNSTABLE SVT: synched cardioversion.SINUS BRADYCARDIACAUSES: medications (BB, CCB, amiodarone, digoxin, lithium, methadone), heart block (1st, 2nd Type 1, 2nd Type 2, 3rd), elevated intracranial pressure, herniation.MEDICATIONS TO GIVE: place pacer pads, atropine 0.5mg IV bolus, dopamine or epinephrine drips.CODE BLUE6Hs and 6Ts of PEA arrest: hypovolemia, hypoxia, hypothermia, hypoglycemia, hypo/hyperK, hydrogen (acidosis), thrombosis, tachycardia, trauma, tension PTX, tamponade, toxins.***RESPIRATORY***SHORTNESS OF BREATHThink of 5 P’s and 5 A’s (like a CXR is an AP film or a PA film)5 P’s: 2 waters (pulmonary edema, pleural effusion), 3 acronyms: PNA (pneumonia), PE (pulmonary embolism), PTX (pneumothorax)5 A’s: aspiration, atelectasis, asthma/COPD, anaphylaxis, acidosisAnd MI.Others: URI, aortic stenosis, transfusion associated cardiac overload, transfusion related acute lung injury, leukemic infiltrate, radiation pneumonitis, compressive ascites, pregnancy hyperventilation.OXYGEN MODALITIESNasal cannula (up to 6L=40%), Ventimask (55%), Nonrebreather (NRB, 80-100%), High Flow Nasal Cannula (30-100% but with high flow rate), BiPAP, intubation (adjusting FiO2/PEEP).HEMOPTYSISInfection (bronchitis, PNA, abscess, TB, Aspergillus)Inflammation (bronchiectasis, CF)GI/ENT (nosebleed, varices, gastritis, Mallory Weiss tear)Cancer (lung cancer)Vascular (PE, pulmonary artery rupture, bronchial fistula, Wegeners, Goodpasture, pulmonary AVMs)COUGHURI, postnasal drip, PNA, bronchitis, bronchiectasis, asthma/COPD, aspiration, CHF/pulmonary edema, GERD or reflux laryngitis, foreign body, ACEI, TB, interstitial lung disease, cancer.ASTHMA-OUTPATIENTCLASSIFICATIONS: intermittent (<2d/wk, <2n/mo)albuterol, mild persistent (>2d/wk, 3-4n/mo)add low dose fluticasone, mod persistent (daily, >1n/wk but not nightly)add Advair (low dose flutic + salmeterol) or med dose flutic, severe (all day, all nights of wk)Advair (med dose flutic + salmeterol, then high dose flutic + salmeterol, then prednisone or omalizumab if allergies).ASTHMA EXACERBATIONDay 1:-Albuterol nebs q20min x 3-Prednisone 40mg or methylprednisolone (Solumedrol) 125mg x 1.-Magnesium sulfate 2gm x 1Day 2-5:-Albuterol nebs q4 and space to q6 PRN-Prednisone 40mg x 5 days then with taper (can be made up like down by 10mg every 2-3 days)-Advair/Symbicort/Dulera (LABA+steroid)COPD EXACERBATIONDay 1:-Albuterol/ipratropium nebs q20min x 3-Prednisone 40mg or methylprednisolone (Solumedrol) 125mg x 1.Day 2-5:-Albuterol/ipratropium nebs q4 and space to q6 PRN-Prednisone 40mg x 5 days as a burst. Only need taper if severe disease (can be made up like down by 10mg every 2-3 days)-Advair/Symbicort/Dulera (LABA+steroid)-Tiotropium (Spiriva)PNEUMONIA-Community acquired PNA (CAP): worry about Strep pneumo, H influenzae, Moraxella catarrhalis. Cover with ceftriaxone 1g q24 x5 days and azithromycin 500mg q24 x 3 days. Or can switch to PO levofloxacin (Levaquin) 750mg q24 x 5 days (if normal renal function) or PO cefpodoxime with azithromycin. Send MRSA swab and sputum culture.-Healthcare associated PNA (HCAP, if admitted x 48hrs in last 90 days, dialysis or nursing home patient) or hospital acquired PNA (HAP) if developed while in hospital. Worry about CAP + Pseudomonas + MRSA. Cover with cefepime (if normal renal function), vancomycin. Can also consider azithromycin 500mg q24 x 3 days. Send MRSA swab and sputum culture. If MRSA neg and low suspicion of Pseudomonas can narrow to CAP coverage. -Aspiration PNA (consider if dementia, lethargy, bedbound). Worry about anaerobes and HCAP bugs. Cover with cefepime/vancomycin or cefepime/metronidazole (Flagyl)/vancomycin, or piperacillin-tazobactam (Zosyn)/vancomycin. If low suspicion of Pseudomonas and MRSA swab is neg then can narrow to amoxicillin-clavulanate (Augmentin) or levofloxacin (Levaquin) with metronidazole (Flagyl) x 7 days.-Fungal PNA (consider in neutropenic patient or patient on steroids). Worry about Aspergillus or less likely Mucormycosis. Cover with voriconazole or if Mucor then amphotericin/pposaconazole.-PCP PNA (consider in HIV or chronic steroids): treat with high dose Bactrim and steroids.PULMONARY EMBOLISMCAUSES: idiopathic, DVT, immobilization (surgery, fracture), rheumatologic or vasculitic disorder, OCPs, hormonal replacement therapy, cancer.TREATMENT: If cancer then enoxaparin (Lovenox) ideally as 1mg/kg each dose BID moreso than 1.5mg/kg each dose once daily. If no cancer then start with heparin bolus/drip. Then start Coumadin or switch to rivaroxaban (Xarelto) or apixiban (Eliquis).Treatment duration: 3 months if provoked, 6 months if nonprovoked, lifelong if cancer or if this is a second unprovoked clot.PLEURAL EFFUSION-Thoracentesis labs: protein, LDH, albumin, amylase, pH, glucose, gram stain/culture, cell count and differential, cytopathology (cancer), fungal culture, lipids (chylothorax). Make sure to add on serum LDH/total protein.-Light’s criteria for exudative: Protein ratio>0.5, LDH ratio>0.6, pleural LDH>2/3 upper limit of normal-Transudative: CHF, hepatic cirrhosis, hypoproteinemia, nephrotic-Exudative: infection, cancer, rheumatoid/SLE pleuritis, pancreatitis, PE, Boerhaave’s, TB***GI/LIVER***GI BLEED-UPPEREpistaxis, peptic ulcer (Hpylori, NSAID, hypersecretory), varices (esophageal, gastric), gastritis (NSAID, aspirin, stress, alcohol, steroid), radiation esophagitis, vascular malformation (Dieulafoy’s lesion, AVM, angioectasia, aortoenteric fistula), cancer.GI BLEED-LOWERDiverticulosis, angiodysplasia, cancer, infectious colitis, inflammatory colitis, mesenteric ischemia, hemorrhoid, anal fissure, post-polypectomy.ABDOMINAL PAINUPPER ABDOMEN: gastroenteritis, GERD/ulcer/gastritis, biliary disease (cholelithiasis, biliary colic, cholangitis, gallstone pancreatitis), pancreatic (pancreatitis), incarcerated hernia, MI, splenic infarction/abscess (sickle cell)LOWER ABDOMEN: appendicitis, inflammatory bowel disease, Celiac disease, partial small bowel obstruction, mesenteric ischemia, diverticulitis, kidney stone, bladder obstruction, cervicitis, ovarian torsion or cyst, pregnancy (intrauterine or ectopic).NAUSEAMOST COMMON: food poisoning, gastroenteritis, medication/chemo, pregnancy/hyperemesis gravidarum, motion sickness/vertigoOTHER: MI, DKA, brain tumor, meningitis, migraine, pancreatitis, SBO, appendicitis, cholecystitis, Addisonian crisis, hepatitis, carbon monoxide.TREATMENTS: ondansetron (Zofran), prochlorperazine (Compazine), promethazine (Phenergan), metoclopramide (Reglan), scopolamine patch, trimethobenzamide (Tigan), lorazepam (Ativan), dexamethasone.DIARRHEAINFECTIOUS: bacteria/virus/parasite/HIV opportunistic/CMVMEDICATION: antibiotics, antacids, TEN, lactulose, kayexalate, sorbitolInflammatory: IBD/PTLDMOTILITY: IBS, scleroderma pseudo-obstruction, diabetic neuropathy, hyperthyroidMALABSORPTION: bile salt deficiency, pancreatic insufficiency, mucosal (celiac, tropical, Whipple, lactose)SECRETORY: hormonal (VIP/carcinoid/ZES), laxative, cancerTREATMENT: loperamide (Imodium), atropine-diphenoxylate (Lomotil), bismuth subsalicylate (Pepto-Bismol), pancreatic enzymes (Creon), tincture of opium, octreotide (Sandostatin).CONSTIPATIONFUNCTIONAL: slow transit/pelvic floor/IBS)OBSTRUCTION: cancer/strictureADYNAMIC: severe illness, Ogilvie’s, gallstone, post-surgery opiatesMETABOLIC: DM, hypothyroid, hypercalcemiaMEDS: opiate, anticholinergicNEUROGENIC: Parkinson’s, Hirschsprung, ChagasTREATMENT: Senna, docusate (Colace), polyethylene glycol (Miralax), bisacodyl PO (Dulcolax), lactulose, bisacodyl suppository, tap water enema, mineral oil enema, sodium phosphate (Fleet) enema, manual disimpaction, gastrograffin enema, colonoscopic disimpaction.DYSPHAGIASolids (mechanical): intermittent (esoph ring/eos esophagitis), progressive w/ GERD (peptic stricture), progressive (esoph CA).Both (motility): intermittent (DES), progressive w/ GERD (scleroderma), progressive (achalasia).SMALL BOWEL OBSTRUCTION-Etiology: cancer, adhesions from prior abdominal surgeries-Start with KUB, then CT A/P with oral contrast-Try anti-nausea meds and non-opiate pain meds-If intractable then place NG tube and put to continuous low intermittent suction. Call surgery.ADYNAMIC ILEUS-Etiology: recent opiate use, ICU illness, hypokalemia, hypocalcemia-Start with KUB, less likely to need CT-Treat with promotility agents.TRANSAMINITISALT/AST: viral hepatitis, vascular (ischemic, shock liver, Budd-Chiari), hereditary (hemochromatosis, Wilson, alpha1-AT), autoimmune hepatitis, non-alcoholic fatty liver disease, drugs/toxins (EtOH/Tylenol).Alk/Bili: dilated duct (biliary obstruction from choledocholithiasis, PSC, gallbladder/pancreas CA) or normal duct (hepatic)Alk: malignancy, granuloma, abscess, other (meds/idiopathic)Bili: conjugated (Dubin Johnson/Rotors) or unconjugated (overproduction/hemolysis or underconjugation/Gilberts/Crigler-Najjar)CIRRHOSISCAUSES: alcohol, Hepatitis B/C, non-alcoholic steatohepatitis (NASH), primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH), hemochromatosis, Wilson’s disease, a1AT deficiency, cardiac cirrhosis (from right sided CHF).DECOMPENSATIONS: ascites, spontaneous bacterial peritonitis (SBP), hepatic encephalopathy, esophageal varices, hepatocellular carcinoma.ASCITES: do paracentesis to confirm SAAG (serum-ascites albumin gradient). If > 1.1 then from portal hypertension aka cirrhosis. If < 1.1 then non-portal hypertension cause (cancer, TB, pancreatitis, nephrotic, cardiac ascites). SBP: do diagnostic (60cc) instead of therapeutic (several liters) paracentesis and check cell count and differential. If >250 PMNs (neutrophils, not total WBC) then consider spontaneous or secondary bacterial peritonitis, can be positive even with negative gram stain. Treat with piperacillin-tazobactam (Zosyn) then narrow based on sensitivities. Repeat diagnostic paracentesis on Day 3. Give albumin on Day 1 and Day 3.HEPATIC ENCEPHALOPATHY: treat with lactulose (titrate to 3-4BMs per day or 500cc/day of stool), rifaximin (needs prior auth), zinc sulfate.ESOPHAGEAL VARICES: do EGD, place on nonselective beta-blocker like nadolol.HEPATOCELLULAR CARCINOMA: needs q6 month ultrasound abdomen and AFP.***RENAL/VAGINAL***ACUTE KIDNEY INJURYPrerenal (volume depletion, overdiuresis, heart failure, hypotension, renal artery stenosis).Intrinsic renal injury (recent contrast, tumor lysis, acute interstitial nephritis from pain meds/antibiotics/statins-rhabdomyolysis, glomerulonephritis, transplant rejection, underdialysis, cholesterol embolism.Postrenal (BPH, kidney stones, neurogenic bladder, hydronephrosis).CKDGFR GRADES: G1 (>90), G2 (60-90), G3a (45-60), G3b (30-45), G4 (15-30), G5 <15 or on dialysis.DYSURIACystitis (UTI), pyelonephritis, vaginitis (Candida/bacterial/Trichomonas), urethritis/cervicitis (GC), prostatitis, urethritis, STD, renal abscess, kidney stone.URINARY TRACT INFECTIONFEMALE: If nonseptic uncomplicated and from community can start cephalexin (Keflex). If febrile but uncomplicated can start ceftriaxone. If complicated (includes Foley or in-hospital UTI) then start cefepime.MALE: start with cefepime or levofloxacin (Levaquin) to cover Pseudomonas.VAGINAL INFECTIONCANDIDA YEAST: fluconazole (Diflucan) 150mg oral x1 or miconazole (Monistat 1) 1200mg vaginal suppository x1 or Monistat 3 combo (200mg vaginal supp x3d + 2% miconazole cream)GARDNERELLA BV: metronidazole (Flagyl) 500 BID x7d or 750qd x 7dTRICHOMONAS: metronidazole (Flagyl) 250q8 x7d or 375 BID x7d or 2g single dose or 1g BID x 2 doses on same dayGC/CHLAMYDIA: ceftriaxone 250mg IM + azithro 1gm x 1 dose HEMATURIAEXTRARENAL: neoplasm (transitional cell/prostate), infection (cystitis, urethritis, prostatitis), Foley trauma.INTRARENAL: nephrolithiasis, crystalluria, neoplasm (RCC), trauma, vascular (renal infarct/renal vein thrombosis), glomerulonephritis.HYPOKALEMIAGI losses (diarrhea/laxative)Renal losses: hypertensive (hyperaldosteronism), hypo/normotensive (academic—DKA/RTA, variable—magnesium deficiency, alkalemic—diuretics/vomiting/Bartter’s/Gitelman’s, medication (diuretics)HYPERKALEMIAPseudohyperkalemia (phlebotomy, hemolyzed sample)Renal insufficiency (acute kidney injury, non-adherence to renal diet, underdialysis, overuse of potassium supplements, Type 4 RTA resistance to aldosterone).Medication (ACEI, spironolactone, trimethoprim, tacrolimus, succinylcholine with intubation, digoxin overdose/overrepletion of K).Cell lysis (rhabdomyolysis, tumor lysis syndrome, massive transfusion, hemolysis).Shift (acidosis-H/K transport, DKA)HYPONATREMIAHYPERVOLEMIC: UNa>20: renal failure, UNa<10: third-spacing from CHF/cirrhosis/nephrosis)EUVOLEMIC: Uosm>100 (SIADH, glucocorticoid deficiency), Uosm<100 (primary polydipsia, low solute (tea/toast), UOsm varies (rest osmostat due to starvation)HYPOVOLEMIC: UNa>20 (renal losses, mineralocorticoid deficiency), UNa<10 (extrarenal losses like diarrhea)HYPERNATREMIAHYPERVOLEMIC: exogenous (IV fluids and infusions, minealocorticoid excess).EUVOLEMIC: Uosm>600 (intracellular osmolar generation: seizure/exercise), UOsm 300-600 (partial DI), Uosm<300 (complete DI).HYPOVOLEMIC: Uosm>600 and UNa<20 (extrarenal losses (diarrhea), Uosm300-600 and UNa>20 (renal losses (diuretic, osmotic diuresis).METABOLIC ACIDOSISAnion gap: +ketones (DKA/AKA/starvation), -ketones (lactate from sepsis or ischemia or muscle or metformin, uremia from renal failure, tox screen with osmotic gap >10 (methanol/ethylene glycol) or osmotic gap<10 (ASA). Non-anion gap: +urine AG (GI: diarrhea, fistula, ingestion, dilutional), -urine AG (renal: hypokalemia Type I/II RTA, hyperkalemia Type IV RTA), also consider normal saline resuscitation.METABOLIC ALKALOSISUrine Cl<20 and saline responsive: GI loss, diuretics, post-hypercapnea.Urine Cl>20 and saline unresponsive: hypertensive (hyperaldosteronism), hypo/normotensive (current diuretics, Bartter’s, Gitelman’s).***DERMATOLOGY***ITCHINGDISEASED SKIN: dryness (xerosis), reactive (atopic, contact, urticaria, allergies, psoriasis), infective (dermatophytosis tinea, scabies, bed bugs, body/pubic lice), scratching (lichen simplex chronicus).NONDISEASED SKIN: renal (uremia), hepatic (cholestasis from PBC/PSC/hepatitis), heme/onc (polycythemia vera, lymphoma), endocrine (thyrotoxicosis/diabetes), rheum (dermatomyositis, systemic sclerosis), ID (HIV), neuro (brachioradial pruritis, nostalgia paresthetica in nerve distributions, postherpetic neuralgia, multiple sclerosis), psych (psychogenic itch), medications (opiates/IV drugs/adhesives).CELLULITISIf non-purulent (low likelihood of MRSA): cephalexin (Keflex).If purulent (high likelihood of MRSA): Bactrim, clindamycin, doxycycline.***MISCELLANEOUS***PRE-OPERATIVE RISK STRATIFICATIONHISTORY: cards/pulm testing, OSA, CVA/MI, detailed meds (OTC), prior surgeries/complications, family rxn to anesthesia, substance use.RISK OF CARDIAC EVENT: Low risk<1% (local anesthesia): endoscopic, superficial, fistula, cataract, breast). Med risk<5% (general anesthesia): carotid, head/neck, chest/abd, ortho, prostate. High risk>5%: emergent, major vascular, long surg with high volume loss.CRITERIA: 1) Emergent procedure? 2) Active cardiac condition? (cards consult). 3) Low risk procedure? 4) Adequate functional capacity? (>4 METS w/o sx—2 flights or 4 blocks). 5) Clinical risk factors?RCRI SCORE: revised cardiac risk index (if can’t do >4 METS or unknown): 1) major thoracic, abd, suprainguinal vascular surgery. 2) CHF. 3) CAD/MI/Qwaves. 4) CVA/TIA. 5) DM on insulin. 6) Creatinine>2.RCRI DECISION: 0 (risk 0.4%, proceed), 1-2 (risk 0.9%/6.6%, proceed with HR blocker), >3 (risk 11%, consider non-invasive tests).RULES: stop ASA/fish oil/glucosamine-chondroitin, stop oral DM meds, cut Lantus in half and stop prandial insulin, continue BB/statin.NOTE: 65M here for pre-op eval of non-emergent hip surgery. Active cards condition managed by cards. High risk procedure due to >5% risk. Cannot do >4METS so RCRI 2 with risk 6.6%. Ok to proceed with surgery if benefits outweigh risks.DIET OPTIONS-NPO, clear liquids, full liquids, GI soft, regular diet-Nectar thick, thin liquids-Cardiac, carbohydrate (diabetic), liver failure, renal failure.DVT PROPHYLAXIS-If bleeding: intermittent compression device.-If no bleeding and want short acting or if have renal failure: heparin subcutaneous 5000U q8hrs.-If no bleeding and want something easier with less injections: enoxaparin (Lovenox) subcutaneous 40mg qd.HEPARIN CHASEDone when you start heparin for treatment of DVT, PE, atrial fibrillation, NSTEMI/STEMI.Bolus heparin for MI and PE (not for DVT or Afib unless about to cardiovert for Afib).Order heparin drip at calculated rate (need PTT beforehand).Goal PTT 62-80.For each rate change check PTT 6 hours afterward. Then recheck PTT 6 hours afterward.Need to have 2 PTTs that are in range. Then becomes daily PTT chase with AM labs.COLONOSCOPY BOWEL PREPGolytely (polyethylene glycol): 4 liters with stool check and NPO at 10pm, if stool not clear then do repeat with 2-4 liters more of Golytely.If unable to tolerate much liquid, order Golytely but fill container to only 2L (same amount of polyethylene glycol but more concentrated) and then give bisacodyl (Dulcolax) total of 20mg at the start.NEW FEVERINFECTIOUS: respiratory (viral URI, flu, pneumonia, urinary (UTI, pyelonephritis), neurologic (meningitis, encephalitis), blood (bacteremia), osteomyelitis, gastroenteritis, mononucleosis, TB, endocarditis, sinusitis, sacral decubitus ulcer, intra-abdominal abscess, dental abscess, septic arthritis, HIV, CMV.NON-INFECTIOUS: DVT/PE, malignancy (solid or liquid), drug fever, Adult Still’s disease, temporal arteritisCOMMON ORDERS: CXR, UA/urine culture (if neutropenic then must send culture too), 2 peripheral blood cultures (not from PICC/Port), sputum culture, MRSA swab, respiratory viral panel (aka rapid respiratory panel RRP).LESS COMMON: wound culture (very likely to be contaminated), lumbar puncture, diagnostic paracentesis, diagnostic thoracentesis, echocardiogram (to look for vegetation), 4 extremity dopplers, HIV, CMV, pan-CT.ELECTROLYTE REPLETIONSPOTASSIUM: goal 4.0-Potassium chloride 10mEq will raise K by 0.1 (works for oral and IV)-PO: Can give as pills or liquid-IV: Can give as peripheral (500cc) or central line (100cc) but takes 1hr per 10mEq-Max repletion of one method (IV or oral): 60mEq-Max total repletion: 60+40-=100MAGNESIUM: goal 2.0-PO Magnesium oxide (comes as 400mg tablets): every 400mg raises by 0.2, max 800mg at a time.-IV Magnesium sulfate (comes as 1gm, 2gm, 4gm): each 1gm raises by 0.1. Takes 1hr per 1gm.PHOSPHATE: ideally 4.0 but needs to be at least 2.5-Can replete as sodium phosphate or potassium phosphate (potassium phosphate contains significant potassium if given IV but not if given orally)-PO potassium phosphate: 2 pills-IV sodium phosphate or potassium phosphate: give 15mmol if very low, 30mmol if mildly lowBLOOD REPLETIONS-Hemoglobin goal >7. 1gm hemoglobin rise/drop = 1 unit RBCs.-Platelet goal: if active bleeding or about to get procedure then > 50, otherwise > 10 (sometimes Onc or MICU will transfuse to 20 if septic). 1 unit platelet = 10-25 platelet rise. -INR goal: only transfuse FFP if INR > 2 and either bleeding. If isolated elevated INR rise without bleeding can give Vitamin K. ................
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