CCS FILE 1

[Anonymous]

APPROACH TO CCS CASES

History of present illness:
Note vital signs: BP, Pulse, Resp. Rate, Temp.
Check vitals to make sure patient is hemodynamically stable.
Pay attention to quality of pain, dull, sharp, pleuritic, constant, etc. this can give you clues to the possible cause. For example pleuritic pain make you think of pericarditis, pulmonary embolism, pneumothorax, pneumonia, and infectious pleuritis.

You should formulate a differential diagnosis after you have read presentation and vital signs. Determine if the patient needs immediate care, if so do step I.

Step I: Emergent management: A, B, C, D, then O2, IV fluid . . .

Step II: Physical Examination
Complete vs focus- depending on situation. I think if someone is in your office for annual check or routine visit you should do a complete exam.

Step III: Diagnostic Investigations:
Think which one of the labs or imaging you need to do to give you more clues to make your diagnosis.

Imagining:
1. CXR: First imaging if patient has chest pain, tightness or after trauma (plus C-spine & pelvis X rays).
2. EKG: for any patient with chest pain, trauma, SOB and presurgery
3. Echocardiogram: Valve dx, cardiac effusion, cardiomyopathy.
4. CT: Head trauma, stroke, brain tumor, Aorta aneurysm/dissection, Abd. trauma/abscess/diverticulitis, chest mass.
5. USG: Pregnancy, cholecystitis/ choledocholithiasis, ovarian cysts, pelvic mass/fibroid uterus, pyloric stenosis
6. Colonscopy - sigmoidoscopy
7. Barium enama - Barium swallow
8. Broncoscopy - rigid vs flexible
9. VQ Scan - Venogram: pulmonary Embolism, DVT
10. Doppler Sonogram: Carotid stenosis
11. ERCP: to confirm choledocholithiasis or to check for pancreatic duct obstruction
12. MRI: MS, adrenal or pituitary tumors

13. IVP: Persistent hematuria, hydronephrosis


Labs:
1. CBC
2. Chem7/12
3. Lipid profile
4. LFT, Amylase/Lipase
5. Urinalysis
6. Cardiac enzymes
7. Blood or Urine C&S
8. CPK or cardiac enzymes
9. TSH, free T4 or TFT
10. Drug levels or toxicology screen, blood Alcohol level
11. Coagulation profile
12. D-dimer
13. Stool guiac (Hemoccult test)
14. Folate, B12, peipheral smear, iron, feritin level, reticulocyte count
15. Blood typing & cross

Treatment:
Treat as needed: if patient has pain give pain killer, if has PE start IV heparin.
Patients who needs consult for surgery etc.. get consult.

If patient needs surgery start presurgical orders. Including: CBC, Chem-12, Coagulation profile, EKG, CXR, LFT, NPO, blood T & C (at least 6 hours prior to surgery), and start Antibiotics. Most common antibiotics used are Ancef , Mefoxin, and Cefatetan. Especially for GI surgery. All given IV.

Step IV: Decision about changing patients location
After you have stabilized the patient you need to move patient to appropriate location:
If patient is stable and doesn’t require further workup or workup can be done outpatient then discharge patient home.
If patient came with chest pain/ cardiac problem transfer to CCU.
If patient is stable but need further evaluation move to ward.
When patient is stabilize discharge home with office follow up.

STEP V: Educate patient/family
counsel patient on exercise, smoking, drug use, safe sex; etc..

STEP VI: Final Diagnosis.

Standard Admit Orders


Name: ______________________ Age: ____ DOB: ____/____/____ Date: ____/____/____ Time: _______

M/F_________ Address _______________________________ Attending Physician's Name ________________





1. Admit to (Service), Medical floor, Telemetry, CCU or ICU

2. Diagnosis: Asthma or Chest Pain – R/O MI

Contributing Dx: DM, Dementia ....


3. Condition: (Stable, Fair, Serious, Critical)
4. Vitals: (Routine/Q shift/Q4 hours) or Q 1 hr until stable for 4 hr, then Q 4 hr.
5. Allergies: (NKDA)


6. Nurses instructions:

Spot pulse ox on arrival to floor and with nebulizer treatments.
PEFR pre and post nebulizer treatments; record on chart.
Call MD if: P < 50 or > 110; BP < 90/60 or > 160/100; RR > 30; pulse ox < 90%; decreased LOC; respiratory distress.
STAT EKG for significant chest pain



ASA Overdose:

Suicide precautions.

Gastric lavage in ER with activated charcoal.

Consider dialysis if serum salicylate level greater than 70 mg/dl

Replace NG output cc per cc with 1/2 normal saline Q shift



7. Diet: (Regular, 1800 ADA, 2gm or 4gm Na+) or Clear liquids x 12 hr.
8. Activity: Bed rest with/without bathroom privileges with assistance.


9. Lab: (CBC c d & p, A-8, SMA, PT/PTT, CXR, U/A, EKG, DXT's, Ca-Mg-PO4). ABG if pulse ox < 90%, respiratory distress or altered consciousness.
Total CK, monoclonal CK-MB, troponin I on admission (if not done in ER) for MI

CXR (portable) if not done in ER for Angina/MI.

CT of head without contrast if not previously done in ER for CVA

EEG: New onset seizures.



10. Meds: (Drug, dose, frequency): O2 @ 2, 4, 6 Liters/min via NC or FM.
Albuterol nebulizer (2.5 mg in 3 cc NaCl) Q 8 hr.
Methylprednisolone 125 mg IV bolus followed by 80 mg IVPS Q 6 hr.
MSO4 2-10 mg SIVP Q 30 min prn severe chest pain.

Heparin 5000 U SQ Q 12 hr.

Coumadin 10 mg PO Q day x 3 days, then 5 mg PO Q 5 pm starting day four.

If both magnesium and PO4 are low, supplement magnesium first.

Lactulose 30 mL/ PO TID for Hepatic encephalopathy.


Acetaminophen level:

If toxic range: begin N-acetylcysteine (mucomyst) 140 mg/kg PO followed by 70 mg/kg PO Q 4 hr for 68 hr.



11. PRN Meds:

Tylenol 500 mg 1-2 PO Q 4-6 hr prn pain/T > 101°F.
MOM 30 cc PO Q 12 hr prn constipation.

Maalox 30 cc PO Q 2-4 hr prn indigestion.
Benadryl 50 mg PO @ bedtime prn insomnia.

Ambien 10 mg PO QHS prn insomnia.
Haldol 1-2 mg PO Q hr prn agitation.

Ativan 1 mg 1/2 - 1 PO Q 8 hr prn anxiety.

Phenergan suppl 25 mg pr Q 4 hr prn n/v.

Demerol 25-50 mg slow IVP Q 3-4 hr prn pain



12. IV:

#1 – 1000 mL normal saline at 1000mL/hr.

#2 – 1000 mL normal saline with 20 mEq KCl at 500mL/hr.

#3 – 1000 mL normal saline with 20 mEq KCl at 500mL/hr.

#4 – 1000 mL 1/2 normal saline with 20 mEq KCl at 250mL/hr.

#5 – 1000 mL D5-1/2 NS with 20 mEq KCl at 250mL/hr when glucose < 250 mg per dL.


ASA Overdose: D5 1/2 normal saline with 44 mEq bicarbonate/L @ 300 cc/hr (forced alkaline diuresis).

D5 1/2 normal saline @ 125cc/hr.



If esophageal variceal bleeding is suspected, consider Sandostatin 50ug IV bolus, then 50 ug/lhr continuous infusion.



For Hyperkalemia: Calcium gluconate: 10% 5-10 cc IV over 2-5 min; second dose may be given in 5 min; may repeat Q 1 hr prn Sx. If dig toxicity suspected, give over 30 min or omit.

Furosemide: 40-80 mg IV Q day.

Hypovolemic: normal saline IV @ 500 cc/hr until orthostasis resolves, then D5W (if hyperosmolar) or D5 1/2 normal saline (if not hyperosmolar) IV @ _____ cc/hr.

13. Additional Orders:
IV orders: (Type at cc/hr or hr rate)
DXT (AC and HS, Q4 hours, Q6 hours) Consider DVT prophylaxis with Lovenox 40 mg SQ Qd or Heparin 5000 u SQ bid.



14. Alcohol (DT) Precautions:
B12 1000ug IM now & in Month
Vit. K 10mg IM now & qAM x3
Folate 1mg PO qday x4
MVI 1 PO qday
Thiamine 100mg IM qday x3
Librium 25mg Po q6hrs PRN agitation
Lab: Mg, ETOH level, PTT/PT



15. Sliding Scale Regular Humulin:
** <200 do nothing
** 200-300 5u SQ
** 300-400 10u SQ
** > 400 call MD



16. Hypoglycemia

1. First Line Investigations: Serum glucose, electrolytes, gas, uric acid, amino acids, bilirubin, transaminases, urinalysis.

2. Second Line Investigations: Plasma insulin, growth hormone, cortisol, glucagon, catecholamines, beta-hydroxybutyrate, acetoacetate, lactate, pyruvate

Treatment: (Severe Hypoglycemia)

Dextrose: start IV of D10-25W and run to give 5-10 mg glucose/kg/min and increase to keep glucose within the normal range (above 3 mmol/L).

Prednisone: impairs responsiveness to insulin. Start at 2 mg/kg/day po bid

Diazoxide (Proglycem): suppresses insulin secretion. Start at 5-10 mg/kg/day po tid and may increase to 20-25 mg/ kg/day

Glucagon Infusion: 1 mg IM/IV.




1. A 29 y/o female pt. with a panic attack. comes to the office or ER with chest pain, sob, an imminent sensation of death.
Admit the pt to the ER, if came to office.

Order EKG, ABG, CBC with Diff, Chem 7, TFT. UA with Urine tox.

Every thing was normal. Mild tachycardia.

Start Pt on O2 & Xanax 0.5 mg 1 tb TID prn. for 3 days.

Educate Pt about her dx. and Relaxation.

D/C home, Rx for Paxil to prevent these attack.

F/U appt in the office

Dx: Panic Attacks.


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2. Sickle cell crisis. An African American boy presenting with lower back pain, colicky abdominal pain and Sickle cell dx - ER

There are three main types of sickle cell disorders:
1. Sickle cell anemia
2. Hemoglobin SC disease (for sickle SC disease, remember that hematuria is more commonly found in it)
3. Sickle beta-thalassemia

Patients can develop many types of problems due to sickle cell disease. Anemia leads to fatigue.
Aplastic crisis: Pallor is an important sign. One should also be alert after a non-specific fever that may be due to Parvovirus B19. Parvovirus infection can precipitate Aplastic crisis.
Hand-and-foot syndrome: This is usually one of the earliest signs due to infarction in the digital bones and blood vessels..
Painful episodes called "sickling crisis" usually requires opiates to abort the pain.
Severe infections: Due to sickling in the splenic vessels, the spleen slowly dies due to multiple infarcts. These patients have reduced immunity (because spleen introduces antigens to the lymphocytes to evoke good antibody response). Encapsulated organisms including Streptococcus pneumoniae and Hemophilus influenzae are particularly left unchecked.
Splenic sequestration crisis: Spleen goes crazy and suddenly pools in and holds on to a large number of blood cells. Characterized by LUQ pain and abdominal pain.
Stroke: This again is due to sickling and clogging up of capillaries.
Acute chest syndrome: Fast or difficult breathing, chest pain, high fever, and coughing are symptoms of Acute Chest Syndrome.15% to 43% of sickle cell population will contract ACS.
One can find hypoxia (paO2<60 and sats <90%). One would also find infiltrates in the lungs. Usually bilateral.



Lab test: CBC with diff, Reticulocyte count, LDH. In Aplastic Crisis: low Hct & Reticulocte count.
Hb electrophoresis reveals Hb S. If diagnosis not known.

Blood Culture to exclude infection

Blood T&C

UA: Mic. Hematuria. & culture
Xray: if there is back or feet, hands pain- bone necrosis



Once diagnosed with the acute chest syndrome, patients should be given:

OXYGEN

Hydration: I.V. NS

Strong analgesics (iv), Morphine or Hydrocodone then switch to Ibuprofen.

Broad spectrum antibiotics, including a macrolide

Bronchodilators.

Packed RBCs transfusion if the hemolysis is severe

Folic acid

Ophthalmology consult for retinopathy - Laser photocoagulation.

Sequestration Crisis (low Hgb & pancytopenia): consider splenectomy

If they are at high risk for complications (adults and those who have a history of cardiac disease and severe pain in the arms and legs), patients should be given early transfusions.
One drug that has improved the quality of life for sickle cell patients is Hydroxyurea. It is known to increase the level of fetal hemoglobin in the patient and prevents excessive deoxygenation. It also decreases the level of sickle hemoglobin.
Peculiar problems of sickle cell disease also include Salmonella osteomyelitis, proliferative retinopathy and avascular necrosis. It is important though to remember that the commonest type of osteomyelitis in a sickle cell patient still remains Staphylococcal (like general population).
Preventive strategies useful to a sickle patient include Vaccinations against H. influenzae and Pneumovax. Hepatitis B vaccine also may be useful because of the frequent transfusions they receive


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3. Typical case of Cholecystitis. Patient mostly comes with fever, chills and RUQ tenderness, muscle guarding worse with inspiration.
Lab: CBC, UA, serum amylase & lipase, LFT, B-HCG if female pt. PT/PTT, blood type & screen.

First choice for evaluation is U/S. if it is biliary colic, sonogram will make the diagnosis.
If sonogram is doubtful, then HIDA can make a diagnosis.
Recognize appropriate treatment of asymptomatic gallstone disease.

Management

If pt has pain and fever start on :

Cipro 500 mg Bid for 10 days or Metronidazole 500 mg TID for 10 days.

Bentyl 20 mg Tid, AC for 10 days.

If pt has acute severe pain, nausea & vomiting: Hospitalize, NG tube, IV antibiotics, IV fluids, narcotics (Meperidine)
Good response: Plan surgery after acute attack is over
Poor response: Immediate surgery
Except under very unusual circumstances the gall bladder should be left alone. Exceptions include a concomitant porcelain gallbladder (risk of cancer), patients unable to clear Salmonella typhi infection, and possibly sickle cell patients.
If chronic small stones: Trial of ursodiol is beneficial.


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4. Cocaine-related myocardial infarction:

HPI: A 22 y/o man comes to ER with chest pain, tachycardia, High BP ...

Lab: CBC, chem 7, UA with tox screen. EKG, Cardiac Enzymes.
The accurate identification of patients with cocaine-related myocardial infarction can be difficult as the EKG may be abnormal in many patients with chest pain after cocaine use, even in the absence of acute MI.

Tx:

* Airway, O2, IV fluid, Monitor.

* If BP still high consider Nitroprusside (B-Blockers are contraindicated)

* Diazepam to reduce agitation & help resolve chest pain.
The routine use of thrombolysis in patients who may have cocaine-related infarction is not advised. Thrombolytic therapy should be considered only after treatment with oxygen, aspirin, nitrates, and benzodiazepines has failed, and when immediate coronary angiography and angioplasty are not available.

* Admit to ICU if not stable (cardiology consult)

* Psychiatric consult.


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5. Colo-rectal cancer. Anemia in an elderly male. Colorectal cancer is the second leading cause of cancer death in the United States.



True primary prevention includes:
1. Stressing a low fat, high fiber diet, adequate calcium intake, and identification of any risk factors such as a strong family history of colon cancer, which might increase an individual's risk.
2. Dietary supplementation with D-Glucarate is an exciting new approach.
Most colon cancers develop from benign polyps.


Screening for Colorectal Cancer:
1. An annual fecal occult blood test.
2. Flexible sigmoidoscopy once every 3-5 years to detect colorectal cancer at its earliest and most treatable stage. Begin at age 50.
3. An annual colonoscopy is recommended for high risk patients of any age with prior history of cancer, a strong family history of the disease, or a predisposing chronic digestive condition such as inflammatory bowel disease.


Colon cancer screening
age 40: DRE/every yr
age 50: DRE + fecal blood test/every yr, flexible sigmoidoscopy every 3 yrs
High risk:
1) FH/O colon cancer in 1st degree relative-age 40: DRE + fecal blood test/every yr; flexible sigmoidoscopy and Barium enema or colonoscopy every 3-5 yrs after 2 normal exams 1 yr apart
2) IBD of 8 yr duration: colonoscopy every yr



What are the Symptoms of Colon Cancer?
Right sided, ascending colon tumors often present with fatigue, weakness, and anemia of iron deficiency of unknown origin.
Left Sided, changes in bowel habits ( constipation and/or diarrhea ), crampy left lower quadrant pain and even perforation.

HPI: A 60 year old male presenting to office for regular checkup. Or patient has mild anemia and tiredness.

PE: Complete

LAB & Diagnostic Investigations:
1. CBC with Diff.
2. UA
3. Chem-12
4. Lipid profile
5. Because of his age he needs fecal blood test, If positive followed by colonoscopy. result will show evidence of colon cancer.
6. Liver function tests, Chest x-*** to look for metastatic disease.
7. CT scan: to evaluate the extent of CA or metastases.


Management:

1. Evaluate the Colonoscopy result.

2. After initial workup admit patient for elective surgery.
3. Surgery consult. Get type and cross, CBC, Chem 12, EKG, CXR, PT, PTT, LFT, inform consent, NPO, and CEA level prior to surgery.
4. Start patient on Iron if hgb is very low.
5. After surgery patient should be evaluated every 3-6 months for 3-5 yrs with history, physical examination, fecal occult blood testing, liver function tests, and CEA determinations.

6. Colonoscopy is performed within 6-12 months after operation to look for evidence of recurrence and then every 3-5 years.

* CEA: used as a marker for colorectal tumor growth postoperative (recurrence).



Educate patient and family: Advice patient about High Fiber Diet

Final Diagnosis: Colon Cancer


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6. Barbiturate overdose
In small doses, the person who abuses barbiturates feels drowsy, disinhibited, and intoxicated.
In higher doses, the user staggers as if drunk, develops slurred speech, and is confused.
At even higher doses, the person is unable to be aroused (coma) and may stop breathing. Death is possible. It has a narrow therapeutic-to-toxic range. This is the reason why barbiturates are dangerous. It is also why barbiturates are not prescribed often today. In addition to having a narrow therapeutic range, barbiturates are also addictive.
Symptoms of withdrawal or abstinence include tremors, difficulty sleeping, and agitation. These symptoms can become worse, resulting in life-threatening symptoms including hallucinations, high temperature, and seizures.
Pregnant women taking barbiturates can cause their baby to become addicted, and the newborn may have withdrawal symptoms.

Lab:

CBC, chem 7, urine tox screen, ABG

EKG, C xray


The treatment of barbiturate abuse or overdose is generally supportive. The amount of support required depends on the person’s symptoms.
If the patient is drowsy but awake and can swallow and breathe without difficulty, the treatment just monitor the patient closely.
If the patient is not breathing, mechanical ventilation until the drug have worn off.
* Activated charcoal may given via nasogastric tube.

* Start on Naloxone, Thiamine, Glucose, & IV fluid.

* NaHCO3 to alkalize the urine

* Admitted to the hospital or observe in the Emergency Department for a number of hours.

Advice the patient about drug abuse or Psychiatric consult.


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7. Ectopic Pregnancy. Pregnant woman in shock, Amenorrhea, abd. pain, & vaginal bleed. The most common place is in the fallopian tube.


What causes the ectopic pregnancy?
1. Advancing age
2. Pelvic inflammatory disease (# 1 risk factor)
3. Previous ectopic: about 10-20% of those attempting pregnancy after one ectopic will have another.
4. Tubal surgery or defects
5. Previous termination of pregnancy
6. DES exposure

7. IUD
Most patient report missed period, positive pregnancy test, some abdominal pain, and some irregular vaginal bleeding. Some women report fainting or suddenly, without warning a woman is very unwell, collapses and is taken to hospital.


Lab: CBC, UA, HCG, blood T&C



What tests are used to diagnose ectopics?
1. Obviously first of all a pregnancy test. If the test is negative then ectopic pregnancy is virtually excluded.
2. Transvaginal ultrasound can reliably demonstrate a pregnancy in the uterus from about 5 weeks onward. If TVUS is negative and HCG is < 2000 mIU/ml repeat HCG in 48 hrs, subnormal increases Ectopic probable.


What are the treatments?

* Start IV fluid, O2, blood transfusion if required
* Medical treatment: with a drug called methotrexate, which is given by injection. This makes the ectopic pregnancy shrink away by stopping the cells dividing, tube pregnacy must be small (less tan 4 cm) and low B-HCG.
* Laparoscopic surgery: open the tube and remove the pregnancy (salpingotomy), or remove the tube (salpingectomy).
* Laparotomy: either salpingotomy or salpingectomy performed.


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8. TENSION PNEUMOTHORAX: This is a 45 year Patient, smoker. He has a positive family history of cardiac disease, hypertension, obesity, and stroke. The patient is obese (he has a body mass index of 29) . He does not engage in regular exercise (dyspneic after 1 minute of brisk walk) .

Patients typically present with mild shortness of breath, pleuritic chest pain and cough.

TENSION PNEUMOTHORAX is an EMERGENCY. IT IS a CLINICAL DIAGNOSIS.


No need to examine everything: PE (HEENT, chest, CVS, extremities)

Heent: distended neck veins.
Exam: Lungs: no breath sounds, a hypertympanic percussion sounds on the affected side.
Heart: tachycardia


History and Physical: Essential Facts

· Patient is cyanotic and in marked respiratory distress

· There is chest asymmetry, with hyper-resonance on right side. Breath sounds are also absent on that side

· Cardiac examination essentially normal

· Peripheral pulses present but weak

· No pulsus paradoxus (a fall in pulse amplitude with quiet inspiration)

Then:
* Always start with ABC on Unstable Patient.

Next, click Order button at the bottom of the screen, and enter the following orders (one on each line):


· Chest x-***: Chest x-***, portable, click on Confirm Order button. Click OK. Stat.

· Oxygen, pulse oximeter: choose Inhalation for route and Continuous for frequency.

· Morphine: (Give The patient some Pain killer) choose Intravenous for route and Continuous for frequency.

· ECG: choose ECG 12-lead; Urgency: stat.



Obtain Results: Chest X-*** findings: Right tension pneumothorax

New Order:

* Needle insertion (Needle thoracostomy) FOLLOWED BY TUBE Thoracotomy (insertion of a chest tube) if needed.

* IV Access
* Pulse Oximetry (seconds to get result), ABG?
* Portable CXR immediately after tube insertion (you will get Collapsed lung and the impression is Tension pneumothorax, If done after 20 minutes the Lung is completely expanded)

* Click the Change Location button, and select Intensive Care Unit (ICU). Confirm move. Recorded vital signs are displayed Click OK.



Now we should add more treatment for the patient. Order the following orders:

1. Albuterol (inhalation, continuous)

2. Atrovent (inhalation, continuous)

* Order CXR after 6 hours (most probably the case will close because the patient already thanks you for pain relief).

* Transfer patient to ward (If the patient is stable)

Order the following orders:

1. Advise patient, smoking cessation (routine, start now)

2. Advise patient (Breathing) exercise program (routine, start later)

3. Advise patient, weight reduction (routine, start later)

D/C patient home.

Final diagnosis: Tension pneumothorax


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9. Dementia & Depression in an elderly.
PSEUDODEMENTIA: Term applied to apparent cognitive impairment associated with psychiatric disorders, most often depression (50-100%). Four criteria proposed by Caine for diagnosis:
1) intellectual impairment in a patient with a primary psychiatric disorder
2) features of impairment are similar to those seen in CNS disorders
3) the cognitive deficits are reversible
4) there is no known neurological condition to account for the presentation

Major characteristics of the dementia syndrome of depression (all characteristics need not be present):
Mental status changes Motor manifestations:
dysphoria, apathy
decreased motivation
anxiety, depressed affect
persecutory delusions
psychomotor retardation
impaired memory retrieval
poor word list generation
variable performance
awareness of cognitive deficit

Neurovegetative signs
sleep disturbance
loss of appetite and weight
constipation
impotence

Motor manifestations
bradykinesia, masked facies, stooped posture, slow, hypophonic speech

History
subacute onset and rapid progression of intellectual decline
past history of mood disorder
family history of mood disorder


Lab: CBC, TST, UA with Tox screen, B12, folic acid level, RPR,
1. positive Dexamethasone test 2. If new onset order CT scan of the head enlarged lateral ventricles



Tx: Start patient on Paxil or Trezadone if has insomnia

Psychiatric consult

Home support


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10. Iron deficiency anemia: A 27 y/o woman with bleeding .
Lab: CBC with diff.: Low Hgb & Hct, MCV: <80 Microcytic, 80-100 Normocytic, >100 Macrocytic.
Peripheral smear & Reticulocyte Index: should be <2% with anemia, if the idex high consider hemolysis.
Iron Def. Anemia: Look for low iron or ferritin, high TIBC.
This anemia is common in woman of reproductive age because of menstrual irregularities.
Manaegment:

Treat the underlying cause and Iron supplementation. FeSO4 325 mg PO BID.

Recheck CBC in 2-3 months

If severe Anemia admit to hospital for blood transfusion.


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11. STROKE:
Pt with risk factors htn/chol/dm/tob with C/O sudden weakness, physical exam consistant with umn lesion.
Management:
1. Head CT scan w/o contrast: shows Ischemia
2. Use Heparin only if: A FIB or crescendo stroke
3. Use Thrombolysis only if stroke within 3 hours of onset. Remember for MI it with in 6-8 hours
4. TPA is the thrombolysis of choice. It is the only FDA aproved.
5. When you give Heparin give it with Warfarin.

TIA - Transient Ischemic Attacks
Transient ischemic attacks (TIAs) are focal neurologic deficits caused by retinal or cerebral vascular disease. They last less than 24 hours. Crescendo TIAs are defined as two TIAs within 24 hours, three within 3 days, or four within 2 weeks. Acute TIA is defined here as a TIA that occurs within 2 weeks of presentation to a physician.

Diagnostic Tests
There is no routine, standard laboratory evaluation of patients with TIA because the individual medical history and specific characteristics of the TIA influence the optimal sequence and extent of diagnostic testing.
1. Duplex Ultrasound of the carotids may be helpful for those patients:
whose symptoms are attributable to ischemia in a distribution of the anterior (carotid) circulation.
who are candidates for endarterectomy of the carotids, where benefits of the surgery are likely to outweigh the burdens. If ordered, duplex ultrasound should be obtained within 3 days of presentation of an acute TIA (Grade C).


2. Echocardiography should be considered for those patients whose TIA is thought to be cardiogenic. This study usually does not need to be performed on an emergency basis. If a cardiac origin of an embolus is suspected, the patient can be treated with heparin anticoagulation without an echocardiogram. The diagnostic yield of echocardiography in a patient over the age of 40 without cardiac murmur or evidence from the history/physical examination to suggest cardiac disease is so low as to make the test usually unnecessary.
When cardiac disease is strongly suspected and external 2-D echocardiography is not diagnostic, additional yield may be obtained by transesophageal echocardiography.


3. CBC, Creat, ESR , glucose, PT/PTT, RPR/MAHTP, ECG - the studies could be obtained within 24 hours.
4. Imaging Studies - Brain CT scan
5. Additional Tests / In selected cases the following additional tests may be appropriate:
Anticardiolipin Antibody, Antithrombin III, Protein S, FBS, Lipid profile,
Telemetry/Holter Monitor
Selective, Digital, or Magnetic Resonance Angiography
Magnetic Resonance Image of Brain

6. Initial Medical Management of TIA
1.Blood Pressure Control. We encourage the use of antihypertensive agents that work by peripheral action, are short acting, and are unlikely to drop the blood pressure precipitouslly.
2.Anti-platelet agents. The antiplatelet agents aspirin and ticlopidine are both beneficial in the prevention of stroke following a TIA .
Aspirin dose of 325 mg/day
Patients who do not respond to or tolerate aspirin are candidates for ticlopidine 250 mg bid . Patients offered ticlopidine must be willing to accept the supervision associated with the use of this agent.
Plavix / Clopidogrel 75 mg/day is safer than Ticlopidine.
The combination of aspirin 325 mg and the antiplatelet agent dipyridamole 200 mg (Aggrenox)

7. Major Contraindication to TPA:

-ICH
-(significant) head trauma in the last 3 mo
-SBP > 190 or DBP > 110
-rapidly improving symptoms
-h/o GI or GU hemorrhage in the last 3 wks
-arterial puncture at non compressible site in the last 7 days
-pt on anticoagulants
-seizure at onset of CVA
-SAH (worst h/a of my life...more or less like step 3)
-major surgery during last 2 weeks or recent CPR
-another CVA in the last 3 mo.
-blood glucose >400 or < 50

8. Most common cause of sudden stroke: emboli
9. Most common source of Emboli is the heart.


10. Location of stroke:
ACA = legs
MCA = face
ICA = vision
Lentico Striate Artery = Pure Motor
Pons = MLF (Ipsilateral Adduct failure) = Lateral (7 TH nerve Bells Palsy).
Vertebral artery = Tongue = Medial = Horner = Lateral.



HEMORRHAGIC STROKE
Evaluate GCS (if <9 intubation is very likely) (if >9 check ABC and manage accordingly)
CT scan (unless already done) W/O contrast; if atypical ICH site (subarachnoid or lobar blood i.e.) check for secondary causes (AVM, Aneurysm, clotting abnormalities); if typical site (basal ganglia, esp. putamen +++) very likely primary (hypertensive ICH).
If pt. has intraventricular blood with or without hydrocephalus, call neurosurgeon; this situation is very ominous. NS can place intraventricular catheter for drain at bedside
BP control is OK (keep MAP < 130 mmHg but >70 mmHg) don't lower too much-> risk of poor cerebral perfusion.
Medication to start:

Nimodipine: to decrease cerebral vasospasm.

Labetalol: act slowly enough to prevent sudden BP pressure drops.
Zantac: there is high incidece of sress gastritis.

Phenytoin: to prevent seizures

Ventriculostomy: in case of ICP elevation to rapidly decompress the pressure.

Order Angiogram in case of aneurysm amd positive cerebral bleeding on CT scan.

If pt has impending herniation (i.e. with cerebellar clot or large parenchymal clot) manage w. intubation, osmotics (mannitol +++) hyperventilation, place in ICU and call Neurosurgeons for (possible) evacuation.
Cerebellar clots are evacuated most of the times.
If pt. fairly OK place her/him in ICU anyway, since 50% of ICH enlarge within 24 hrs with subsequent pt deterioration.
STEROIDS HAVE NO PLACE AT ALL.


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12. Alzheimer's Dementia.
Affects 15% of people over age 65. Occurs in Down's syndrome pts at younger ages (30-40).

Gradually progressive, neurofibrillary tangles.
Alzheimer's Disease: senile degenerative dementia (50%-90 of dementia pts) - Loss of cortical tissue (cerebral atrophy) with increased senile plaques.


Criteria for the clinical diagnosis of probable Alzheimer's disease
* Dementia established by clinical examination and documented by the Mini-Mental State Examination, include: Blessed Dementia Scale, or some similar examination and confirmed by neuropsychologic tests. Deficits in two or more areas of cognition.
* Progressive worsening of memory and other cognitive functions
* No disturbance of consciousness
* Onset between ages 40 and 90, most often after age 65
* Absence of systemic disorders or other brain diseases that could account for the progressive deficits in memory cognition
Lab. Orders:

CBC, Lytes, TFTs, PRP all normal. UA toxicology -ve.

CT: Evidence of cerebral atrophy with progression documented by serial observation
MRI shows changes highly suggestive of Alzheimers - tangled spaghetti patches.
Certain dx: not till autopsy - on PM see structural changes, abnormal proteins in brain biopsy. See shrinkage < neurons in cognitive areas of brain.
Early Signs: subtle loss of memory. Person neglect, ADL. Gradual loss continues. Loss of communication skills.
Later: ultimate loss of short and long term memory. Normal life span. May have good physical health.
Med Intervention: No real medical therapy. Nursing support primary.
Med Rx:

Donepezil (Aricept) 5-10 mg tablet /day
Tacrine (Cognex) Not a cure. Does not appear to stop progression as was hoped. Acts to increase amount of acetylcholine in brain to improve memory. Helps to improve in a minority of patients.
Side effects: Hepatic failure, GI, abd. Pain, skin rash.
Rivastigmine tartrate (Exelon) 6-12 mg cap/day
Premarin for ladies

Multivitamins 1 tb qd po

Aspirin For vascular dementia
Other supportive med Rx therapy for agitation: antidepressants, antipsychotic, sleeping aids.
Nursing focus: Safety, Help maintain function as long as possible, Care for caregiver.
Continuing Care: Medicare doesn't cover custodial long term. Must become impoverished to go on medicaid. Few families able to cope with entire trajectory of the illness. Nursing home care essential for some.

As for Alzheimer: Remember, on the exam, when ever you counsel it takes 5 minutes for it.

- Social services consult
- counsel, no driving
- counsel, advance living will
- reassure patient/family
- counsel medical alert bracelet


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13. Secondary Amenorrhea:
Any secondary amenorrhea in a lady of reproductive age is pregnancy related unless proven otherwise. The sensitivity of urine HCG is excellent therefore the test is reliable. After pregnancy has been excluded one may proceed to checking prolactin, LH, FSH.
Women with regular menses now with no menses for 7 months : Management of metroragia and menoragia in a woman who is on oral contraceptives is a favorite USMLE question. OC + complain of bleeding = break through bleeding
If bleed Ist few months of oc = add Progesterone
If bleed later in the cycle = add Progesterone
If bleed after years of use = add Estrogen
If bleed early in the cycle = add Estrogen
If problem occurs after above correction: add stronger dose in all the above cases.

Make Ob-gyn consult if persist.


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14. COPD. A 58 y/0 man comes to ER with SOB, copious, purulent sputum and cough. Patient has been on Albuterol without relieve.
Cxray: flattening of diaphragms, increased lung volume, small heart.
Lab: CBC, Sputum culture, ABG, Alpha 1 antitrypsin level, PFT


Management
1. O2 Goal to keep PaO2 60-80 mm Hg,
2. Bronchodilators:
A. Atrovent: Ipratropium Bromide 2 puffs qid - Should be 1st choice in COPD.
B. Albuterol Inh 2 puffs qid.
C. Combination: Combivent Inhaler 2 puff qid. Or DuoNeb Sol. Inh 1 vial by neb. Q6hrs
3. Prednisone 40 mg q d for 7-14 days then taper to lowest dose and switch to inhaler: Azmacort: Triamcinolone 1 puffs tid.
4. Cough meds, expectorant: Atuss EX 1 tsp tid
5. Erythromycin PO qid for 2 wks.

6. Vaccinations: Influenza annually, Pneumococcal q 5-10 yrs if age > 65 yrs.

* Advice to Stop smoking

* D/C home with office visit in 3 days.


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15. TCA Overdose.
Amitriptyline: Elavil, Nortriptyline: Pamelor, Imipramine: Tofranil.
The morbidity and mortality caused by tricyclic antidepressant (TCA) overdose are well recognized. Among newer antidepressants, the selective serotonin reuptake inhibitors (SSRIs) are thought to be safer in overdose.
At therapeutic doses tricyclic antidepressants block the reuptake of norepinephrine, serotonin, and dopamine

Their mechanisms of toxicity include:
A. Neuromuscular reuptake inhibition
B. Membrane depressant effects on sodium channels of the myocardium
C. Alpha blockade
D. Central sympathetic reflex inhibition

CLINICAL SYMPTOMS:
ANTICHOLINERGIC: tachycardia, mydriasis, hyperthermia, agitation, hypertension, flushed skin, decreased GI motility, urinary retention
CARDIOVASCULAR:
Dysrhythmias- sinus tachycardia, AV block, Torsades, V-tach, Vfib
Conduction abnormalities- QRS widening, prolonged PR interval, QT prolongation
Hypertension- usually short-lived and minimal
Hypotension- may be prolonged and severe
CNS- agitation, disorientation, ataxia, confusion, lethargy, seizures, coma

HEENT- mydriasis, blurred vision, dry mouth, nystagmus
PULMONARY-pulmonary edema, ARDS, aspiration pneumonitis

LEVELS/RANGE OF TOXICITY:
In adults, 10-20 mg/kg is considered a moderate to serious exposure where coma and cardiovascular symptoms are expected. Approximately 35 mg/kg is thought to be a lethal dose without medical intervention.
CV toxicity:

Sinus tachycardia- supportive measures only
Wide complex dysrhythmias
Sodium bicarbonate 1-2 mEq/kg IV bolus followed by maintenance infusion to maintain pH 7.4-7.5
Hyperventilation-reserved for conditions where administration of large quantities of sodium bicarb would be contraindicated (pulmonary edema, cerebral edema, head trauma, poorly controlled CHF)

Ventricular Arrhythmias
Sodium bicarbonate- same dosing as above
Lidocaine 1-1.5 mg/kg bolus over 1 minute then 2-4 mg/min infusion

Hypotension: Fluids and Norepinephrine 8-12 ug/min (generally high dose is necessary)

CNS toxicity
Seizures: Diazepam: Adults: 5-10 mg over 2-3 minutes, may repeat every 10-15 minutes (maximum of 30 mg total).
Peds: 0.25-0.4 mg/kg to maximum 10 mg- maximum 5mg if child less than 5 y.o.
Lorazepam: Adults: 1-2mg over several minutes Peds: 0.04 mg/kg
May try barbiturate if patient fails to respond to benzodiazepines

Enhanced Elimination
Reduce absorption: AC/C for all patients- recent studies suggest that activated charcoal is as effective as AC/lavage and AC/lavage/AC. Lavage may be indicated within 1 hour of ingestion or in patient who arrives with decreased level of consciousness and unknown time of ingestion.
Increase elimination: MDAC has been shown to enhance the rate of elimination- 25 grams q 4hr following the 50g initial load (sorbitol with every 2-3 doses)

Disposition
Admit any patient with a QRS> 100msec.
Admit any patient with a seizure.
Admit any patient in need of psychiatric or medical support.
Patients who have been decontaminated, who never seize or develop abnormal EKG's (other than sinus tachycardia) can be safely discharged after 6 hours of observation if otherwise stable.
Patients with significant symptoms or any EKG changes, or persistent mild symptoms should be admitted and monitored until CNS returns to baseline and normal EKG for 24 hours.



Nortryptiline toxicity in suicide attempt
ensure ABC
labs: ECG, ABG
Rx: Gastric lavage
Activated charcoal with intermittent gastric suctioning
Induce alkalinisation with NaHCo3 to maintain pH of 7.45 to7.55
If he is intubated hyperventilate to a PCo2 not< 25mmHg
If ECG normal and patient is asymptomatic, observe for 6 hrs in ER otherwise admit into icu.
After Admission ECG should be normal for 24hrs to discharge for psychiatric disposition.


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16. Viral Hepatitis A (RNA Virus). A young man with fatigue and jaundice.
Transmission: Hepatitis A virus (HAV), the most common cause of viral hepatitis worldwide, is an RNA virus transmitted exclusively by the fecal-oral route.
Its prevalence is as high as 95% in underdeveloped countries with poor sanitary conditions. The prevalence is >50% in persons older than 50 years in the United States, Canada, and Europe but falls to less than 10% in persons younger than 20 years. Therefore, many persons traveling to endemic regions do not have natural immunity and should receive passive immunization with immunoglobulin before travel.
Diagnosis: The presence of active HAV infection is detected by a positive IgM anti-HAV antibody; the presence of the IgG antibody indicates previous infection and immunity.


Signs and Symptoms:
Fever (60%); unusual with HBV and HCV
Malaise (67%), Fatigue (major complaint in HCV)
Nausea (80%) ,Vomiting, Anorexia (54%)
Jaundice (in adults, 62%); 66% of HCV anicteric
Dark urine (84%)
Abdominal pain (56%)
Headache
Meningismus (occasional)

Management:
(Supportive measures are the only treatment necessary in most cases of acute HAV infection.)
Rest and balanced diet
Symptomatic relief medications
Family members: hepatitis evaluation & passive immunization with immunoglobulin 0.02 mL/kg IM
Serial follow up of liver function tests
In patients with severe cholestasis, a short course of prednisolone (30 mg/day with a taper) may reduce the severity of symptoms such as pruritus and malaise and reduce the serum bilirubin level.

Immunization:
Active Immunization: Hepatitis A Vaccine x 2 doses about 6-12 months apart.
A single dose of a highly purified, formalin-inactivated hepatitis A vaccine is highly protective against HAV. A booster dose is required 6-18 months later for full immunity.
Passive Immunication (prophylaxis or post-exposure prophylaxis to Hepatitis A:
Pooled human Immune Serum Immuno Globulin (ISIG) 0.02 mL/kg single IM dose is recommended for travelers to endemic areas or for household & sexual contacts with serologically confirmed hepatitis A person, to be administered as soon as possible within 2 weeks of exposure. The duration of protection appears to be dose related, with the 0.02 mL/kg dose providing protection for approximately 3 months and a 0.05 mL/kg dose providing protection for 4 to 6 months.


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17. Cystic Fibrosis:

HPI: A 7 month old child with fool smelling stools and recurrent episodes of bronchiolitis.


PE:General appearance, Heent/Neck, skin, chest/lung, heart/CV , Abdomen

Labs: CBC, Chem-13, sweating test (CL 60 mEq/dl dgn). Sputum culture & sensitivities of cultured organisms.
CXR, Pulmonary function test, ABG's

Tx:

O2 mask
Antibiotics if signs of infection -iv ceftriaxone+gentamycin for pulm.infections (I/V Semi-synthetic Penicillin or Cephalosporin with Anti pseudomona activity-Ceftazidime)
Albuterol inh-Bronchodilators
Chest physiotherapy: postural drainage + percussion
Breathing exercise
Vigorous coughing
Exercise program
pain medication if needed

Nutritional support: high calorie diet, oral pancreatic enzymes, vitamin A,D,E and K supplement.
Educate Patient about the Dx.

Required Vaccination


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18. Cervical Dysplasia - Found on 25 yo for well women's exam. Also, A 26 yo healthy woman came in for examination (cin III in pap smear).
Cervical dysplasia is a condition in which the cervical tissue does not grow normally, causing precancerous changes which can range from mild to moderate to severe. In the most severe cases it can lead to cervical cancer.

Risk factors are thought to include:
Human papilloma virus (HPV) which is spread sexually is known to greaten the risk of developing cervical dysplasia and cancer. cigarette smoking & substance abuse;
TB;
DES exposure;
Sex & pregnancy at an early age.
Multiple lifetime sexual partners

Screening for cervical cancer
Regular Pap smears are recommended for all women who are or have been sexually active and who have a cervix.
Testing should begin when the woman first engages in sexual intercourse. Adolescents whose sexual history is thought to be unreliable should be presumed to be sexually active at age 18.
Pap smears should be performed at least every 1 to 3 years. Testing is usually discontinued after age 65 in women who have had regular normal screening tests. Women who have had a hysterectomy including removal of the cervix for reasons other than cervical cancer or its precursors do not require Pap testing.

Management of minor Pap smear abnormalities
Satisfactory, but limited by few (or absent) endocervical cells
Endocervical cells are absent in up to 10% of Pap smears before menopause and up to 50% postmenopausally.
Management. The Pap smear should either be repeated annually or only recall women with previously abnormal Pap smears.

Unsatisfactory for evaluation
Repeat Pap smear midcycle in 6-12 weeks. If atrophic smear, treat with estrogen cream for 6-8 weeks, then repeat Pap smear.

Benign cellular changes
Infection--Candida. Most cases represent asymptomatic colonization. Treatment is offered for symptomatic cases. The Pap should be repeated at usual interval.
Infection--Trichomonas. If wet preparation is positive, treat with metronidazole (Flagyl), then continue annual Pap smears.
Infection--predominance of coccobacilli consistent with shift in vaginal flora. This finding implies bacterial vaginosis, but it is a non-specific finding. Diagnosis should be confirmed by findings of a homogeneous vaginal discharge, positive amine test, and clue cells on saline suspension.
Infection-herpes simplex virus. Pap smear has poor sensitivity but good specificity for HSV; positive smears usually are caused by asymptomatic infection. The patient should be informed of pregnancy risks and the possibility of transmission. No treatment is necessary, and the Pap should be repeated as for a benign result.

Inflammation on Pap smear
Mild inflammation on an otherwise normal smear does not need further evaluation.
Moderate or severe inflammation should be evaluated with a saline preparation, KOH preparation, and gonorrhea and Chlamydia tests. If the source of infection is found, treatment should be provided, and a repeat Pap smear should be done every 6 to 12 months. If no etiology is found, the Pap smear should be repeated in 6 months.

Persistent inflammation may be infrequently the only manifestation of high-grade squamous intraepithelial lesions (HGSIL) or invasive cancer; therefore, persistent inflammation is an indication for colposcopy.

Atrophy with inflammation is common in post-menopausal women or in those with estrogen-deficiency states. Atrophy should be treated with vaginal estrogen for 4-6 weeks, then repeat Pap smear.

Hyperkeratosis and parakeratosis. Parakeratosis is defined as dense nuclei within a keratin layer. When no nuclei are present, the cells are designated hyperkeratotic. Parakeratosis and hyperkeratosis occur as a reaction to physical, chemical, or inflammatory trauma, and it may clinically appear as leukoplakia. Benign-appearing parakeratosis or hyperkeratosis requires only a repeat Pap test in 6 months. When this finding persists, colposcopy is indicated.

Management of squamous cell abnormalities
Atypical squamous cells of undetermined significance ( ASCUS)
ASCUS indicates cells with nuclear atypia, but not atypia caused by human papilloma virus (HPV).
The patient is asked to return every 6 months for a repeat Pap smear. The American College of Obstetricians and Gynecologists (ACOG) advises a colposcopic examination if a patient receives two or more ASCUS reports (repeat Pap smears being obtained every 6 months) or if the patient's compliance is uncertain with the original report.

Low-grade squamous intraepithelial lesions ( LGSIL)
LSIL includes human papilloma virus (HPV) and CIN 1 (or mild dysplasia). Koilocytotic atypia is indicative of HPV.
Repeat Pap smears every 4 to 6 months is recommended, with colposcopy being indicated if there is persistence or progression. However, because some women will progress and because of the high rate of false-negative Pap smears, clinicians may perform colposcopy after the initial LGSIL report.

High-grade squamous intraepithelial lesion ( HSIL).
If the Pap smear is consistent with HSIL (or persistent or high-risk LSIL), colposcopy and biopsy should be performed.
If biopsy results are consistent with CIN I, provide careful observation and follow-up.
If biopsy results are consistent with CIN II or III, cryotherapy, laser vaporization, LEEP or cone biopsy should be completed. If biopsy results are consistent with invasive disease, further staging procedures are indicated.

Management of glandular cell abnormalities
Endometrial cells on Pap smear. When a Pap smear is performed during menstruation, endometrial cells may be present. However, endometrial cells on a Pap smear performed during the second half of the menstrual cycle or in a post-menopausal patient may indicate the presence of polyps, hyperplasia, or endometrial adenocarcinoma. An endometrial biopsy should be considered in these women.


Atypical glandular cells of undetermined significance ( AGUS). Colposcopically directed biopsy and endocervical curettage is recommended in all women with AGUS smears, and abnormal endometrial cells should be investigated by endometrial biopsy, fractional curettage, or hysteroscopy.

Adenocarcinoma. This diagnosis requires endocervical curettage, cone biopsy, and/or endometrial biopsy.
Colposcopically directed biopsy

Liberally apply a solution of 3-5% acetic acid to cervix, and inspect cervix for abnormal areas (white epithelium, punctation, mosaic cells, atypical vessels). Biopsies of any abnormal areas should be obtained under colposcopic visualization. Record location of each biopsy. Monsel solution may be applied to stop bleeding.
Endocervical curettage is done routinely during colposcopy, except during pregnancy.

Treatment based on cervical biopsy findings
Benign cellular changes (infection, reactive inflammation). Treat the infection, and repeat the smear every 4-6 months; after 2 negatives, repeat yearly.
Squamous intraepithelial lesions
Treat on the basis of the histological biopsy diagnosis. Patients with CIN I require no further treatment because the majority of these lesions resolve spontaneously. Patients with CIN II or CIN III require treatment to prevent development of invasive disease.
These lesions are treated with cryotherapy, laser vaporization, or loop electric excision procedure (LEEP).


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19 Pulmonary nodule on CX ***:
A solitary pulmonary nodule consists of a solid nodule 1-6 cm in diameter that is surrounded by normal aerated lung tissue.
Once this picture is found, one works it up according to the probability of it being malignant. Some clinical features and some radiological features are useful pointers.
The best is to compare it with another X-*** of the chest that is more than 2 years old (if available). If no change has occurred, it is most likely benign.

Features that point towards a malignant potential are:
Age > 35 yrs
Smoker
Weight loss
Spiculated edges of lesion
<20 % of lesion calcified
In all the above 5 scenarios, a histologic diagnosis is important. if none of the above exist then one should re X-*** it in 6 months
If the lesion is in the medial 2/3 of the lung fields then a bronchoscopic biopsy is best. If in the peripheral 1/3 then a CT guided biopsy is appropriate.
Once a malignancy is established then one has to work - up a non small cell carcinoma. A small cell Ca is considered non-operable and is treated with chemotherapy.



Real Case:

HPI: 67 y/o female with 30 years history of smoking come to office c/o cough.



PE: Complete



Labs: Pluse ox, O2, CBC, Chem 7
CXR- mass on left upper lobe
Lung Biopsy- sq. cell carcinoma



Management:

surgical and oncology consult

Educate patient about the lung CA

Prepare pt for surgery

Smoking cessation if still smoking

Advance directive

Diagnosis: sq. cell carcinoma


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20. A 17 yo with DKA. and NIDDM pt with acute exacerbation, Dx: Ketoacidosis. Also TYPE II DM - 70 yr black male, resistant DM.
Screening appropriate for patients with:
a) family history of DM (remember DM type I has a stronger correlation with genetic transmission, but DM II is the frequent encounter-90%)
b) significant obesity
c) recurrent or hard healing skin wounds,
d) recurrent genital or UTI infections (especially yeast) pay special attention to nonSTD's UTI's in young man
e) pregnancy related problems-gestational diabetes, infant larger than 9 lb (over 4kg)
f) symptomatic patients with 3P symptoms (polyuria, polydipsia,weight loss-some include polyphagia too) may be dgn without further testing when random PG is greater than 200mg/dl

Screening methods:
-fasting plasma glucose140mg/dl -DM (only one measurement is considered dgn. now!)
-positive oral glucose tolerance test 200mg/dl

Different criteria for pregnancy:
-screening at 24-28wks for all pregnant women!
-glycosuria anytime in pregnancy
-fasting PG105 mg/dl
-OGT 150 mg/dl
Diffuse abdominal tenderness and rigidity in young person -check glucose level& serum/urinary ketones

Management:
ALL DM patients should have:
1. Diet control-ask for dietetician consult in CCS.
caloric intake for normoponderals ~35kcal/day, obese ~5-15kcal/day , food composition:carbohydrate 55-60%-complex glucocide preferred, protein 10-20%, fat 25-30% limit alcohol use recomand cessation of smoking
2. physical exercise-moderate effort proved to reduce insulin needs
This should control type II DM for a good period of time
Monitoring of therapy: self assessment of patient require intensive education-self-monitoring blood glucose devices (SMBG) 3 times/day-weekly blood glucose measurement at office-evaluation of therapy with Hb A1c at after 2 months ketone urinary assay


Pharmacologic therapy should be implied if:
-patient is unable of self assessment
-noncompliance with prescribed tx
-failure to achieve a normoglycemic status after a reasonable period of time
-patients presenting with diabetic coma,
-inability to mantain dietary intake
-infection(any fever)
-Type I DM
3. Preventive care:
a) vaccinations-consider pneumoccocal and influenza vaccine for all diabetics + normal vaccinations related to age
b) yearly measurement of lipidic profile
c) monthly measurement of blood pressure
d) foot care education
4. Pharmacologic measures:

Type II DM
a) oral antidiabetic drugs:
-sulfonylureas:
use rather short drugs as glipizide/glyburide
ContraIndication: DM I, pregnancy, children-caution in hepatic or renal disease toxic reactions: skin rash, blood dyscrasias, cholestatic jaundice, Disulfuram-like effects with alcohol
Drug interactions: Salicilates,Warfarin, Sulfonamides, Cloramphenicol, Methyldopa, Miconazole, MAOI-may potentiate the hypoglycemic effect of sulfonylureas


-biguanide: metformin-good choice for patients displaying hyperlipidemia associated with DM (increase HDL); when used alone metformin does not produce hypoglycemia.
ContraIndication: liver, renal,heart failure, pulmonary isf., pregnancy, alcoholism
b) Insulin therapy learn at least 1 type of insulin from each class i.e. short-acting insulin: Regular-onset 0.25-1h/semilente 0.5-1 h medium acting:lente onset 1-4 h long acting:ultralente onset 3-8h
Complications of insulin tx:
-Hypoglycemia-could be life threating-educate the patient regarding the signs, instruct to have permanent access to sugar/chocolate
-insulin allergy-erythema, induration, pruritus at inj. site-treat with purified human insulin
-lipoatrophy/lipodistrophy change the site of injections

Chronic complications of DM
1) Ophtalmic complications
recommandations: obtain an ophtalmo consulation at the time of dgn for DM II,and at 5 years after onset in type I-yearly consultation after that
a. FO exam may reveal diabetic retinopathy: nonproliferative-limited to retina-microaneurysms, hemorhages, exudates-cotton wool aspect; proliferative- neovascularisation
b. visual disturbances: acute monocular loss-retinal detachment, retinal embolic infarction;bilateral loss usually stroke
blurred vision-diabetic cataract
2) diabetic neuropathy:
pain-amytriptiline/application of capsaicin
sensory defficit/motor defficit-no tx
autonomic neuropathy-a) postural hypotension-treat spmtm
neurogenic bladder-recurent UTI's-intermitent catherisation
3) Diabetic nephropathy-the principal cause of morbidity and mortality in diabetics, give ACE I, treat aggresivelu UTI's
Hyperlipidemia-hypercholesterolemia & hypertrygliceridemia frequent accompany diabetes-increase in plasma tryglycerides &VLDL-give gemfibrosil along with diet.



IN DKA WHERE DO YOU MANAGE THE PATIENT, ER, ICU, INPATIENT?

ICU till the patient has been stable on his old method of insulin administration , ie sub q


DO YOU GIVE K & WHEN?

Along with insulin, some give a bolus of insulin and then start infusion.



DO YOU ORDER ABG's & WHEN?

STAT and q 2 hours

[Anonymous]

21. A 3 years old african american child presents with jaundice after a few days of respiratory infection treated with septrin, which is due to G6PD deficiency, so that you may need to stop septrin at first and should order G6PD TEST.

The pt present with pallor, jaundice and splenomegaly. Recent h/o URI treated with Bactrim (sulfa).

Order:
O2

IV hydration to prevent renal co from hemoglobinuria
CBC with Diff.: hgb and hct 8.0/34, MCV 89
CMP: bun/cr 20/1.2

Haptoglobin: Low
LDH, PT, PTT

Reticulocyte count: High
UA: urine hemosiderin and Hb.

Peripheral smear showed: Heinz bodies, spherocytes and fragmented RBC's

Normocytic normochromic and Heinz bodies on peripheral smears, think G6PD
Order quantitative G6P assay: positive


Treatment:

If still on bactrim, stop it.
Mild anemia can watch for now without transfusion.

Counsel to avoid bactrim, fava beans and napthalene.

Remember to repeat G6pd level in 6 mo, as can be normal initially since older cells with lower G6PD levels are already destroyed in acute phase.


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22. Rheumatoid arthritis. A 26 year old female patient comes to your office with joints pains. She has swelling in hands and knees, unable to get up in the morning because of the stiffness and tiredness the pain over the last 2 months.
Pt's chief complaint is generalized fatigue, morning stiffness 1-2 hours multiple joints, knee swelling (patient limping) and pain.

PE: HEENT, heart, lung, extremity.
Lab: CBC, chem 7 and order rheumatoid factor, x *** right knee,

Perform arthrocentesis if there is joint effusion



Management:

Motrin or Naproxen, follow up in two weeks to go over lab results with patient. change location to home.
Patient returns for a follow up visit at a office setting. I would order follow-up/interval history and repeat PE including HEENT, cardiac, lung, extremity.

Pt improved overall. RF is positive, confirming the diagnosis.

Now you can start patient on prednisone after confirming the diagnosis.

Continue Naproxen and order physical therapy and patient education (since this is her new diagnosis for her to live with). Then follow up in one month next then three months.

Patient's symptom was mild requiring no methotrexate agents in this case.


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23. Cardiac Tamponade: A 33 y/o male patient presents with multiple injuries after explosion. He is grasping for air and has lightheadedness. A piece of wood pierced his left sternal border.

PE: Heent, lung, heart, hypotension, distant heart sounds, pulsus paradoxus.

Lab: ECG, dminished QRS voltage.

Cxray: Mild cardiomegaly. Echo: accumulation of fluid in the pericardial sac.

Managemant:

IV fluid, Pericardiocentesis. Surgical Thoracotomy.


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24. Lead Poisoning: Child living in an old house coming to regular checkup
CBC, UA, Blood lead level (25 micro/dl), Free erythrocyte protoporphyrin (35micro/dl)
knee & wrist Xray: increased density in metaphyseal plate long bones = lead lines
Tx
1. Report to local health board
2. EDTA + dimercaprol for 5 days
3. Penicilamine for 3-6 months

Educate the patient: remove from the environment.


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25. ITP (Hx: A 5-year-old with nose bleeding and SBP of 90)

PE: including Heent, heart, lung, skin
Lab: Bleeding time, CBC, PT, PTT

Tx:

Nose packing

IV access, normal saline iv fluid
Admit to ward Start on: IVIG and IV Prednisone

Hematology consult - Bone marrow aspiration

Repeat CBC with Diff. daily

Remove nose packing
D/C home, when PLT > 50000-60000

appt in office


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26. ATN: Acute Tubular Necrosis

ATN is the most common cause of acute renal failure in hospital.
Oliguria or anuria - present in about 30% of patients with ATN (<400mL/day urine output)

Pay attention to Myoglobinuria (Rhabdomyolysis) and possibly Hemoglobinuria (hemolysis)



HPI: A patient after MVA had developed decreased urine out put.
Labs: CBC, Chem7, UA, CPK.



Treatment:

O2 if needed

Pulse Ox
1. IVF with NS
2. Diuresis with Lasix
3. Sodium bicarb.


Admit patient to medical floor for observation.

Patient patient should improve by now.


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27. Pneumocystis Carni Pneumonia
PCP is the most common life-threatening opportunistic infection occurring in patients with HIV disease. In the era of PCP prophylaxis and highly-active antiretroviral therapy, the incidence of PCP is decreasing.

Clinical presentation
PCP usually presents with fever, dry cough, and shortness of breath or dyspnea on exertion with a gradual onset over several weeks. Physical findings are often minimal; however, tachypnea may be pronounced, and patients may be so dyspneic that they are unable to speak without stopping to rest. Circumoral, acral, and mucous membrane cyanosis may be evident.

Laboratory findings
* Complete blood counts and sedimentation rates show no characteristic pattern in patients with PCP. Serum LDH concentration is frequently increased.
* Arterial blood gas measurements generally show increases in PaO2. Up to 25% of patients may have a PaO2 of 80 mm Hg or above while breathing room air.
* Pulmonary function tests. Patients with PCP usually have a decrease in diffusing capacity for carbon monoxide (DLCO).
* Radiographic presentation: PCP in AIDS patients usually causes a diffuse interstitial infiltrate. High resolution computerized tomography (HRCT) may be helpful for those patients who have normal chest radiographic findings.
Pneumatoceles (cavities, cysts, blebs, or bullae) and spontaneous pneumothoraces in patients with PCP are common.

Laboratory diagnosis
* Sputum induction. The least invasive means of establishing a specific diagnosis is the examination of sputum induced by inhalation of a 3 to 5% saline mist. If the sputum tests negative, an invasive diagnostic procedure is required to confirm the diagnosis of PCP.
* Transbronchial biopsy and bronchoalveolar lavage. The sensitivity of transbronchial biopsy for PCP is 98%. The sensitivity of bronchoalveolar is 90%.
* Open lung biopsy should be reserved for patients with progressive pulmonary disease in whom the less invasive procedures are nondiagnostic.

Therapy and prophylaxis
Trimethoprim-sulfamethoxazole ( Bactrim, Septra) is the recommended initial therapy for PCP.
Adverse effects include rash (33%), elevation of liver enzymes (44%), nausea and vomiting (50%), anemia (40%), creatinine elevation (33%), and hyponatremia (94%). The most common adverse reactions that necessitated a change in therapy were neutropenia (15%) and severe rash (15%).

Pentamidine is an alternative in patients who have adverse reactions or fail to respond to TMP-SMX.
Adverse effects include anemia (33%), creatinine elevation (60%), LFT elevation (63%), and hyponatremia (56%). The most common adverse effect requiring a change in therapy is neutropenia (32%). Pancreatitis, hypoglycemia, and hyperglycemia are common side effects of pentamidine.

Corticosteroids. Adjunctive corticosteroid treatment is beneficial with anti-PCP therapy in patients with a partial pressure of oxygen (PaO2) less than 70 mm Hg, or oxygen saturation less than 90% on room air. Contraindications include suspected tuberculosis or disseminated fungal infection. Treatment with prednisone (40 mg twice daily for 5 days, then 40 mg daily for 5 days, and then 20 mg daily until day 21 of therapy) should begin at the same time as anti-PCP therapy.

Prophylaxis
PCP is the most common life-threatening opportunistic infection in HIV-infected patients. HIV-infected patients who have CD4 counts less than 200 cells per microliter or who have survived an episode of PCP should receive prophylaxis against PCP.
Trimethoprim -sulfamethoxazole (once daily to thrice weekly) is the preferred regimen for PCP prophylaxis because of efficacy and simultaneous efficacy in prophylaxis against toxoplasmosis.
Dapsone (100 mg daily or twice weekly) is a prophylactic regimen for patients who can not tolerate TMP-SMX. Adverse reactions included anemia, LDH elevation, methemoglobinemia, nausea, and skin rash.


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28. Pericarditis
DX: chest pain especially with inspiration & lying down; pericardial friction rub
EKG: with diffuse elevation of ST segment
Echocardiagram: may show pericardial effusion if present.
* May cause CARDIAC TAMPONADE!

PERICARDIAL EFFUSION
DX (esp. of cardiac tamponade):
Low cardiac output Sx: dyspnea, tachycardia, hypotension, jugular vein distension, decreased heart sounds, paradoxical pulse >10 mmHg, Kussmaul's sign (rise in venous pulse with inspiration)
EKG may show electrical alternans, & decreased QRS voltage
Chest x *** may show cardiomegaly
Echocardiogram & CT scan will show pericardial effusion & thickening
Cardiac catheterization may show equalization of pulmonary wedge pressure with the RA, RV, & pulmonary artery diastolic pressure, & also the "square root" sign in the ventricular pressure pulses.
RX: Immediate pericardiocentesis may be lifesaving in cardiac tamponade !


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29. CHF - MI Classic : Myocardial Infarction
After obtaining history, 12 lead ECG to confirm, CXR, Pulse oximetry, establish IV and collect blood for CBC, cardiac enzymes: ck-mb, troponin-T, serum electrolytes, lipids.
Patient must be monitored for cardiac activity
Oxygen intranasal
Morphine sulphate iv
Sublingual Nitrogly ( check HR)
Metoprolol iv bolus ( if HR and BP are ok, generally avoided in inf. wall MI's)
Aspirin chewed
Iv bolus Heparin
IV streptokinase after ruling out contraindications.


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30. Neonatal hyperbilirubinemia or Neonatal jaundice in 2 day well and active neonate.
Labs: CBC
bilirubin total-normal 10-12mg with <5mg/day increase
bilirubin direct <1mg/dl anytime
Tx: observation alone
Dx: :normal physiologic jaundice.


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31. Acute Abdomen-ER.
For differential diagnosis purposes let us see the abdomen in 4 anterior quadrants and the left and right flanks.
RUQ: perihepatic structures
Liver- hepatitis, Budd chiari (esp if pt. has Nephrotic/paroxysmal nocturnal hemoglobinuria), ruptured hepatic adenoma (young female on oral contraceptives), hepatic trauma, Perihepatitis (e.g. Fitz-Hugh-Curtis syndrome-chlamydia or gonococcus).
Gall bladder- calculous or non calculous (esp in pt in ICU or on cephalosporins) cholecystitis, Gallstone colic
Duodenum-ulcer (on exams- think of Zolinger Ellison)
Lung base- Lower lobe pneumonia, pleuritis
Diaphragm-irritation due to blood in peritoneum (also pain in Right shoulder when patient is in head low position-esp seen in splenic rupture-inspite of spleen being left sided)

RLQ: Structures around cecum and those on right side of uterus.
Appendix-Appendicitis-acute or chronic
Cecum-Typhilitis esp in post chemotherapy patient - occurs with Pseudomonas and Clostridium septicum with approximately equal frequency.
Ovary- cyst rupture or torsion, fibroid- red degeneration, ECTOPIC pregnancy, Tubo-ovarian abscess (PID)
GI-rarely diverticulitis (usually occurs on left side).

LUQ: Spleen and structures around it.
Stomach, Spleen, pancreas, colon-splenic flexure

LLQ: Sigmoid colon- especially diverticulitis that is seen in elderly population and is treated with antibiotics: Cipro 500 mg Bid for 10 days + Metronidazole 500 my Tid for 10 days, hydration-PO or IV and stool softening. Encourage fiber in diet. Uterine structures-as in LLQ area.

Lab: CBC, UA, Chem 7, Amylase/Lipase, LFT, PT/PTT, B-HCG, Lactic acid.


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32. Retinal detachment: refers to the separation of the outer retinal pigment epithelial layer from the inner neurosensory retinal layer, often a result of a tear in the neuronal layer, causing fluid to leak between and separate the two.
The classic triad of symptoms in an acute RD consists of floaters, flashes of light, and a visual field defect. However, the triad is not always present. The visual field deficit is peripheral if the RD involves only the peripheral retina. Should the RD involve the macula, patients will complain of a loss of central vision. Loss of visual field is an important sign of RD, particularly when it occurs unilaterally and no other neurologic signs or symptoms are present. The flashing lights can last for only a few seconds and may occur over a period of days to weeks.
Although in emergency medicine retinal detachment is commonly associated with the sequellae of trauma, many factors can place the patient at risk for RD, including myopia, glaucoma, and cataract surgery.
The presence of symptoms or signs suggestive of RD should prompt urgent referral to an ophthalmologist. Treatment depends upon the type of RD, the location, and whether the macula is involved.


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33. Hyperkalemia : Order an EKG Look for sx.

If no sx and no EKG changes give Kayxelate, po/ngt/enema.
If there is changes then: Stop Potassium, give IV Calcium gluconate, give IV glucose & insulin.
Do not give Kayxelate for emergencies.
RX:
1. To control cardio toxicity: Ca gluconate 10% 10 cc amp over 2-5 min.
* Be extra careful if pt on Digoxin; use EKG monitor.
2. Kayexalate (Na Polystyrene Sulfonate) 30 gm in 100 cc 20% sorbitol PO q4h. (decreased 0.5-1 meqK).
3. Na HCO3 7.5% 50 cc amp 1-2 amp + 10-15 unit regular insulin in 500 cc D10W over a couple h.
4. Lasix 40 mg IV
5. Dialysis !


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34. Foreign body aspiration. A 1 year old baby in respiratory distress with history of asthma in the family.
The peak incidence of foreign body aspiration is six months to four years, and clinical manifestation is sudden onset. Sudden onset of coughing, gagging, choking, dyspnea, afebrile. And also an object that was previously visible is no longer visible. It’s very suggestive. If it is extrathoracic you are likely to hear stridor and a croupy cough. If it has gone down intrathoracic you are going to see more cough and wheezing.
Diagnosis: extrathoracic, x-rays are helpful if it is radiopaque and one key link that I think is relatively likely to show up on exams is what happens if you see a coin? And what you will see is that coins in the sagittal plane are in the larynx or trachea. The way you can remember that is the tracheal rings have an opening in front so that if a coin is going to slide down into the trachea it’s going to be pointed in this direction. So when you do an x-*** you are going to see it on end, whereas if it’s in the esophagus it’s going to be in the coronal plane. So nice little tip there if you see an x-*** with a coin in it.
Management of these: extrathoracic; if you have partial obstruction don’t try to dislodge it because it may lead to complete obstruction and you want to arrange for emergency bronchoscopy. Intrathoracic, you just need to arrange for bronchoscopy.


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35. Acute Adrenal Insufficiency or Adrenal Crisis (Addison's Disease)
SX: Weakness (99%), Pigmentation of skin (98%), Weight loss (97%), Abdominal pain (34%), Nausea & Vomiting, Salt craving (22%), Diarrhea (20%), Constipation (19%), Syncope (16%), Vitiligo (9%), fever, lethargy.
Hypovolemia, orthostatic hypotension, tachycardia, hyponatremia, hyperkalemia.

DX:
* Low serum cortisol level, & inadequate serum cortisol response 30 or 60 min after IV or IM Cortrosyn (synthetic ACTH) 0.25 mg (normal is >18-20 ug/dl with increment of 7 ug/dl or greater)
* Obtain baseline serum cortisol and ACTH levels. Normal response is indicated when the cortisol level at least doubles in response to ACTH stimulation.
* Plasma ACTH levels are typically elevated in patients with primary adrenal failure and are normal or unmeasurable in patients with primary ACTH deficiency.

RX:
Volume Replacement: IV D5NS >2 -3 liters
Glucocorticoid Replacement: IV hydrocortisone 100 mg q8h.
During ACTH stimulation testing, dexamethasone (4 mg IV) can be used instead of hydrocortisone, to avoid interference with testing of cortisol levels.
Fluorocortisol (mineralocorticoid) 0.1 mg qd
Supportive Rx for glucose, electrolytes, calcium imbalance, temp. abnormalities, etc.
Correct precipitating causes.


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36. Chest pain on exertion. A 32 yo woman with sob and chest pain on exertion. Involves stress test and precripton for a anti-anginal along with anti-hypertensive agent .
Chest pain has 4 dangerous causes:
1. Ischemic heart disease
2. Pneumothorax
3. Aortic dissection
4. Pulmonary embolism:

The best stress test in general is exercise stress testing but patients with intermittent claudication cannot exercise adequately. In such patients a chemical stress test needs to be performed.
Dipyridamole stress is preferred over Dobutamine but in a case with obstructive lung disease Dipyridamole may produce bronchospasm whereas Dobutamine would not- therefore Dobutamine stress test would be the test of choice in a patient like this.
Angina is defined as unstable if it fulfils any of the following criteria:
Angina at rest, or angina for the first time, angina after an MI, angina of increasing severity or duration.
It is said to be stable if it occurs on exertion and disappears shortly after rest (within 5-10 minutes)
Myocardial infarction is defined as muscle damage to the heart.
The most important mechanism of unstable angina is plaque rupture. Risk of plaque rupture increases if there is a thin coat of fibrous tissue over it, or thee is a lot of inflammatory reaction around the plaque or if the core is large and filled with fat.
The single most important intervention in a patient with USA or MI is administration of Aspirin and it is advised to be given right at the onset of the symptoms. Nitrates do not save lives.

HTN increases the risk of stroke, MI, heart failure, renal failure, diabetic nephropathy and aortic dissection.
The first line agents that should be used in patients should be Thiazide diuretics or beta blockers. Diuretics have proven to be the best. One can use other agents too but only if the above two give an inadequate response or if there is a reason not to use them.


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37. Thalassemia Anemia (Alpha-thalassemia & Beta-thalassemia)
The thalassemia syndromes are a heterogeneous group of inherited anemias characterized by de