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Crimson Book: A CLINICAL REFERENCE GUIDE 17TH EDITION, 2014-2015 Edited by The UASOM Class of 2015 Tuscaloosa Campus Representatives on the wards. It includes elements of many pocket manuals, reference books, journal articles and websites as well as personal experiences of those who came before you. All of the information was double checked to make sure that it is correct and as up to date as possible. You will find there are many facts in this book that can make your life easier if you read each clerkship section prior to and during that rotation. It is impossible to thank all the students, residents, and attendings who have been involved in the conception and continued efforts to produce this reference book each year. Thanks to the founding authors of the class of 2002 and all those who have put in effort since. Good luck on your rotations! Love, UASOM Class of 2015, Tuscaloosa Campus Page 3 Normal Lab Values Reading EKG Approach to Tachycardia Reading CXR Acid/Base disorders Evaluating LFTs Evaluating Anemia Managing Ventilator Notes and Orders History and Physical Internal Medicine Cardiology Endocrinology Fluids, Electrolytes, Nutrition Gastroenterology Hematology Infectious Disease Nephrology Oncology Pulmonary Rheumatology Neurology Psychiatry Pediatrics OB/GYN Prenatal Charts Surgery Family/Rural Abbreviations Page 4 14 15 17 18 19 20 22 23 24 25 26 32 35 37 41 44 47 51 53 54 55 56 62 68 74 80 82 89 91 medical school as though it is just that – school. But it is meant to be much more than that, particularly as you enter into the clinical years. At this campus, we have the opportunity to work very closely with the attendings, at times even one-on-one, almost as though it were an apprenticeship. Take advantage of this! We encourage you to approach this year with the same commitment, work ethic, and professional attitude that you would your residency or any other job. Often the hospital staff does not distinguish between the residents and the medical students. You may even be called “doctor” in passing – try to conduct yourself in a manner worthy of that title. It will not be long until you have it. You are here to both learn and to be involved in patient care – don’t underestimate your role in the latter. It is true that a resident or attending will almost always come behind you to talk to patients, examine them, and write a note. However, that does not mean that your work is superfluous. Perhaps, a patient tells you something that he didn’t tell anyone else, or you find something on exam that you can alert the rest of the team to. You can participate effectively in patient care if you make the effort to. And your role is important if for no other reason than for your own learning! There will come a day when you are the resident or the attending, both of which come with much more responsibility. Take advantage of the practice! 2. Medicine is both a team sport and a hierarchy – remember where you fit into both. As you know, the preclinical years require relatively little group collaboration, and it is easy to get into the mindset that it is all about you. You try to learn as much as possible to do as well as possible on the exams. It is important as you transition to the clerkships that you remember that it is NOT all about you. You are still here to learn as much as possible (and hopefully do well on the exams), but keep in mind that the purpose of your learning is much bigger than an exam grade. You are here to learn to become good doctors and to take good care of people. Page 5 patient receive better care, but you will learn much more if you interact well with the various members of the treatment team, whether they be attendings, residents, other medical students, nurses, PCAs, pharmacists, physical therapists, social workers, etc. Be polite to everyone – being a medical student does not make you better than anyone else in the hospital. The staff can easily help you or hurt you – try to stay on everyone’s good side. If you have a problem with a particular staff member, notify your resident or attending, and let them help you take care of the situation. Try to remember that you are not the only person who is here to learn. Don’t try to take all of the patients or answer questions directed at another student or resident. It may make you stand out to the attending, but probably not in the way that you want it to. Always fully check out your patients to the other members of your team. It is a good idea to find your resident before rounds each morning and make sure you got the same story from the patient and that you are on the same page about the treatment plan. This is to benefit both of you – often the resident will know more about what happened overnight than you do. It also gives you a chance to ask any questions about the plan and for them to help you prepare for any questions you might be asked by the attending. If you help your residents, they will help you! In general, they want you to do well. Do not withhold patient information from them, try to show them up, or throw them under the bus – it will not make you look good! The atmosphere on this campus is quite laidback, but a hierarchy does still exist. We are privileged here to work so closely with the attendings and residents, but do not take advantage of this relationship. Be respectful of the fact that they do still have authority and seniority, and be thankful that you are not constantly reminded of that as some medical students are during their clerkships. There are boundaries! You will often be invited into the doctor’s lounge to eat breakfast and lunch with your attendings. That does not mean that you are allowed to eat there whenever you want. Page 6 lounge on the 4th floor. Bottom line – being a medical student does not buy you any special treatment. Be respectful of those above you, of your fellow students, of the hospital staff, and finally of the patients and their families. Remember that you are part of team whose purpose is optimal patient care. If you function well in this role, your life will be easier, and you will draw positive attention to yourself. 3. Dress professionally and appropriately. You have most likely already been given this speech, complete with a laundry list of dos and don’ts. It may seem unnecessary to remind you what constitutes professional dress and what does not, but this continues to be a problem. Wardrobe restrictions are not arbitrary. Think about it – you will be directly involved in patient care, which means two things. First, you want your appearance to instill confidence in your patients and make them feel like they can trust you to take care of them. Although it may seem silly, your patient’s may make assumptions about your maturity, trustworthiness, and competence based on your appearance – don’t give them a reason to doubt you. Second, remember that patient care involves lots of moving around, whether you are examining patients or walking to make rounds. Make sure that your outfit is appropriate even when bending over or squatting as may be required during a patient exam. Comfortable shoes are a must! It is important to dress professionally but also appropriately for the clerkship you are on. The dress code will vary from rotation to rotation and should be addressed in orientation for each clerkship. When in doubt, ask someone! In general, you are required to wear dress clothes for Internal Medicine, Pediatrics (if working in clinic), Psychiatry, Neurology, and Family Medicine (may differ based on preceptor). Scrubs are appropriate (and encouraged) for Surgery and OB/GYN. This should go without saying, but make sure to wear appropriately sized scrubs – they are not meant to be fitted! Page 7 Chances are that of the six required clerkships, there will be a couple that you love, a couple that you hate, and a couple that you are indifferent to. Regardless of how much you like a particular clerkship, try to make the most of the experience and learn something. You have probably been told to approach each clerkship as though that is what you are going to do the rest of your life. Using this approach, you will likely take each clerkship more seriously and really get something out of it. Don’t fall into the trap of thinking that you won’t need to know at least something about each of the basic specialties in your future career – medicine is not that compartmentalized. Try to soak up as much as possible now because you likely won’t be exposed to many of these fields again in the same way. It will make you a better doctor in whatever specialty you choose. This approach will also help you discern what field you would like to pursue. Students are often surprised by which fields they like and which ones they don’t. If you spend some time each block thinking about what you do and don’t like about that specialty and why it would or wouldn’t be a good fit, it will hopefully provide some clarity about what you are looking for out of your career and guide you in the right direction. Try not to approach any of the clerkships with the preconceived notion that you will hate it – you might be surprised! 5. Don’t complain! Third year is hard – there will be times when you are tired, stressed, and overwhelmed. Try to take it all in stride, and remember that you can handle anything for a few weeks. Keep doing whatever you did in the first two years to relieve stress – exercise, go out with friends, read for pleasure, or whatever else you find helpful. You will have some free time this year, more on some rotations than on others. It is important for your own well-being that you make time for yourself and for the people in your life that are important to you. With that said, try to maintain a good attitude at work and be willing to help. Complaining will not solve any of your frustrations. It will just make you and the people around you miserable. Page 8 tation. In general, students may be excused from duties two days per 8week block without penalty. These are NOT meant to be vacation days!! These days should only be taken when necessary – illness, death in the family, etc. Clerkship directors are often understanding if you need time off for other events, such as weddings or medical conferences out of town. If there is such an event that you need to miss work for, discuss this with your clerkship director in advance, but do not take advantage of this privilege. If you do miss more than two days per block, you and the clerkship director will have to discuss a way for you to make up the time. 7. General study tips You will notice as you read through the information for each clerkship that we have provided some study tips and a list of resources that may be helpful. We purposefully made the information fairly general because there is no one way to study in each clerkship or to master each shelf. After surviving the first two years of medical school, you should have a fairly good idea of how you most effectively study – stick to that. You probably know if you like textbooks with more detailed explanations or more of an outline format, if cases improve your retention or not, and if practice questions are helpful or not. Guide your studying for clerkships based on what has worked for you in the past. Because the format is different and your independent study time is more limited in third year, it may take some trial and error in the first couple of blocks for you to get a good handle on what works for you. It can be helpful to talk to other students about what they found useful, but remember that you may study differently than they do. The following is a short description of each of the commonly recommended texts/resources used in the clerkships: Blueprints – essentially a “mini-textbook” and one of the lengthier review books (generally 250 – 300 pages varying with specialty). Written in sentence and not outline form. Probably best used as a resource to read throughout the clerkship but not good for quick review in the week or two leading up to the shelf. Often contains good pictures and tables. Page 9 each topic. Good tables for quick reference. Case Files – presents information in case format followed by a short explanation about the diagnosis, treatment, etc. Helpful because shelf exam questions are in the form of clinical vignettes, and the cases give the information context. Good for shelf exam review but not for reading about a particular condition. Pretest – typically contains about 500 questions, some in board-style format and some not. PDF versions are available on the UMC network for free. Particularly helpful if you learn well by doing practice questions. The questions are not always representative of what you will see on the shelf exam – sometimes easier, sometimes harder, sometimes more obscure – but it is still a useful resource. USMLE World Step 2 CK QBank – many of you probably used this QBank for Step 1, and it is equally as helpful for Step 2. The shelf exams, or mini-boards, or designed to be just that – specialty-specific versions of the Step 2 CK exam. This QBank includes questions that closely resemble what you will see on your shelf exams and actual boards. However, subscriptions are expensive, ranging from $99 for 1 month to $399 for 12 months. It is by no means necessary that you purchase a subscription. In fact, some students choose not to because they want to save that QBank for when they study for the actual Step 2 exam. However, it is an extremely useful resource if you do decide to purchase a subscription, particularly for internal medicine. The vast majority of the questions (about 75%) are classified as internal medicine questions, and therefore, it is probably most worthwhile to have during that clerkship. Most of these resources are available at the Health Sciences Library and can be checked out. It might be a good idea to at least review the library’s copies initially to get some sense of what format you might like before you purchase anything. Page 10 Maxwell Quick Medical Reference – you may have already purchased one of these for ICM but if you haven’t you NEED one! It contains a plethora of information – normal lab values, progress note formats, physical exam cheat sheets, and much more – and fits nicely into your coat pocket. Familiarize yourself with what information it contains – it can be your best friend! Pocket Medicine – very useful pocket guide, particularly on Internal Medicine, but not a bad thing to have in your white coat at all times. Great resource to quickly look up information while on rounds. Sanford Guide To Antimicrobial Therapy – annually updated handbook of the antimicrobial drugs, what they are used for, and how to prescribe them. Not the easiest format to navigate but considered by some to be a necessity. Boards and Wards – concise review of all of the third year clerkships, which can be helpful, both while you are on the rotation and as a quick review the week of the shelf exam. Not a must-have but useful. Clinician’s Pocket Reference: The Scut Monkey’s Handbook – diverse handbook that contains a lot of helpful information about life on the wards. It reviews the H&P, format for different types of chart notes, fluid management, bedside procedures, ECG reading, commonly used medications, and much more. Not a must-have but full of a ton of information that can make you look like an all-star. Page 11 method for that particular clerkship during orientation. It does differ slightly from one rotation to the next, but in general, about 70% of your grade will come from clinical evaluations from your attendings and about 30% will come from your scaled shelf exam score. A few of the clerkships have other components – oral exams, observed H&P, etc. – that might factor in, but this is the general grading format. We won’t go into specifics about how your grade is calculated, but we wanted to touch on a couple of major points. First, it IS possible to get Honors on a clerkship. That is not to say that it is easy to get, but it is possible. There will most likely be a time before this year is over that you get frustrated with the grading system because you don’t feel like your grade is representative of the work that you put in. It has happened to all of us, but try not to complain. If you have concerns, express them to the appropriate party in a reasonable fashion. No one can tell you that grades don’t matter, but as mentioned above, keep in mind why you are here – ultimately, it is to take care of people and to learn how to be a good doctor. You will probably have much more luck obtaining the Honors designation if you focus on your daily responsibilities, taking care of your patients, working well with your team, and reading and studying than if you focus on how to get Honors. Try not to get frustrated. Don’t fall into the trap of deciding that you won’t be able to get Honors and therefore are not going to even try – think about what that says to your attendings about your commitment to the ultimate goal of your education. Again, it is not all about you! Page 12 1 kg = 2.2 lb 1 oz = 30 g A/a gradient: (713 x FiO2 – PaCO2/0.8) – PaO2 Absolute neutrophil count: WBC x (Seg% + Band%)/100 39.4C = 103.0oF 40.0C = 104.0oF Fractional Na+ excretion: “U kNow the SeCret” is a good mnemonic for the numerator. (UNa x SCr) / (SNa x UCr) Ideal body weight (kg): ♂: 51.65 + 1.85 x [ht(in) – 60] ♀: 48.67 + 1.65 x [ht(in) – 60] Anion gap: Na+ – (HCO3 + Cl-) Basal energy expenditure (kcal/day): ♂: 66.5 + 13.75 x wt(kg) + 5.003 x ht(cm) – 6.775 x age ♀: 655.1 + 9.563 x wt(kg) + 1.85 x ht(cm) – 4.676 x age Body mass index (BMI): kg/m2 or #(703)/inches2 <19 underweight, > 30 obese, > 40 very obese Body surface area (m2): sqrt [ht (cm) x wt (kg) / 3600] Body water deficit (liters): [0.6 x wt(kg) x (Na+ - normal Na+)] / normal Na+ Ca2+ corrected for albumin: [0.8 x (normal albumin – patient albumin)] + Ca2+ Creatinine clearance: (estimate of GFR) [UCr x urine volume(mL)] / [SCr x time (min)] or [(140 – age) x wt(kg) (x 0.85 if ♀)] / [72 x SCr (mg/dL)] Page 13 Mean arterial pressure: DBP + (SBP – DBP)/3 Na+ corrected for - glucose: Na+ + [(glu-100)/100]x 1.6] Osmolality: 2 x Na+ + glc/18 + BUN/2.8 Reticulocyte production index: % retics x (hct/45) / retic maturation time (days) Urine Anion Gap (UAG) = (UNa + UK) – UCl Winter’s equation (expected PaCO2 in met. acidosis) (1.5 x HCO3-) + 8 (± 2) Water deficit (WD) hypovolemic hypernatremia (L): 0.6 x body wt (kg) x (P[Na]- Nl[Na})/Nl [Na] Expected PaO2 in a normal patient: 103 – 0.4 x age Chloride Bicarbonate BUN Creatinine Glucose Calcium Phosphate Magnesium Anion gap Osmolality 98 – 106 mEq/L 22 – 29 mEq/L 7 – 18 mg/dL 0.6 – 1.2 mg/dL 70 – 115 mg/dL 8.4 – 10.2 mg/dL 2.7 – 4.5 mg/dL 1.3 – 2.1 mg/dL 7 – 16 mEq/L 275 – 295 mOsm/kg Protein Albumin Total bilirubin Dir. bilirubin Lipase Amylase SGOT/AST SGPT/ALT GGT AlkPhos Uric Acid LDH Free T4 TSH 6.0 – 8.0 mg/dL 3.5 – 5.5 g/dL 0.2 – 1.0 mg/dL 0.0 – 0.2 mg/dL 10 – 140 U/dL 25 – 125 U/dL 7 – 40 U/L 7 – 40 U/L 9 – 50 U/L 38 – 126 U/L 2.0 – 6.9 mg/dL 120 – 240 U/L 0.71 – 1.85 ng/dL 0.32 – 5.00 IU/mL ARTERIAL BLOOD GASES pH 7.35 – 7.45 PaCO2 35 – 45 mmHg PaO2 80 – 100 mmHg HCO321 – 27 mEq/L O2 Saturation 95 – 98% Base Excess 2 mEq/L Page 14 Hemoglobin Hematocrit MCV MCH MCHC Platelets RDW Segs (Neuts) Lymphocytes Monocytes Eosinophils Basophils 13.5 – 17.0 g/dL 39 – 50% 80 – 96 fL 27 – 33 pg/cell 32 – 36% hgb / cell 150 – 400 x 103 / L 11.0 – 16.0% 35 – 73% 15 – 52% 4 – 13% 1 – 3% 0 – 1% URINALYSIS Color Turbidity Specific Gravity pH Ketones Protein Blood Glucose Nitrite Leukocyte Esterase Osmolality Sodium Potassium <yellow> <clear> 1.003 – 1.035 4.5 – 8.0 <negative> <negative> <negative> <negative> <negative> <negative> 50 – 1400 mOsm/kg 40 – 220 mEq/day 25 – 125 mEq/day COAGULATION PT extrinsic, Coumadin INR extrinsic, Coumadin PTT intrinsic, Heparin Bleeding Time Thrombin Time Fibrinogen 12.3 – 14.2 sec 2 -- 3 therapeutic 25 – 34 sec 2 – 7 min 6.3 – 11.1 sec 200 – 400 mg/dL PR interval: normally 0.12 to 0.20 seconds (will not exceed a large box) QRS interval: normally 0.04 to 0.10 seconds (no larger than half a large box) QT interval: should be less than half the R-R interval (if HR < 100) or [QT/(? RR)] 5. Axis deviation – net QRS deflection should be positive in both leads I and aVF Right axis deviation: QRS negative in I, positive in aVF Left axis deviation: QRS positive in I, negative in aVF, negative in II 6. INTERPRETATION A. Infarction Q waves: normal (<1 small box) Q waves can be seen in lateral leads (I, aVL, V5 to V6). Enlarged by ventricular myocardial enlargement, conduction abnormalities, and MI. To localize the infarction, look for groupings of Q waves in the following leads… Inferior II, III, aVF R or L Coronary Posterior, AV Node V1 and V2 RCA Septal V1 and V2 LAD Anterior V1 and V4 LAD Anterolateral V5 and V6, I, aVL Circumflex R wave progression: transition should occur between V2 and V4. ST segment elevation or depression: ischemia is associated with ST depression, while infarction is associated with ST elevation “convex, tombstone”. Look for changes in two adjacent leads. T wave inversion: may be normally inverted in III, aVF, aVL, and V1. T wave inversion indicates areas of ischemia in Q wave infarctions. Also see B. Metabolic. B. Metabolic Effects/Others Hypokalemia: ST depression, decreased or inverted T waves, U waves Hypocalcemia: prolonged QT, flat or inverted T waves Hypercalcemia: short or absent ST, decreased QTc interval Hypomagnesemia: prolonged QT, flat T waves, prolonged PR, aFib, torsade Hypermagnesemia: short PR, heart block, peaked T waves, widened QRS Digitalis toxicity: ST depression (scoop), flat T waves Quinidine: prolonged QT, widened QRS Pericarditis: diffuse ST elevation with PR interval depression Wolff-Parkinson-White Syndrome – ventricular preexcitation syndrome (extra tracts that need to be ablated), delta wave C. Arrhythmias Tachycardia – >100bpm, see next chart Bradycardia -- <60 bpm Sinus Bradycardia -- most often caused by ? Vagal or ? sympathetic tone or sometimes by intrinsic Dz of sinus with ? spontaneity and impulse generation rate. AV Block (2nd, 3rd Degree) -- see E. Conduction Delay Junctional and Escape Rhythms – impulse from AV junction, 40-60 bpm, no normal P waves seen (may be hidden in QRST or inverted) with narrow QRS. Junctional escape rhythm is the failure of the sinus node or atrial focus to assume pacing. Extra Beats Premature Atrial Contractions – ectopic focus in atrium, P wave usually has different morphology than NSR, and occurs early and followed by compensatory pause. Page 15 E. Conduction Block/Delay Heart Block (AV block) 1st Degree AV block: PR interval > 0.20 sec 2nd Degree AV block o Mobitz I: (Wenckebach) PR interval progressively widens until a beat is dropped o Mobitz II: PR interval is prolonged, randomly dropped beatNeeds pacemaker rd 3 Degree AV Block: No connection (dissociation) between atrial and ventricular ratesNeeds Pacer Prolonged QT – Drugs (antiarrythmics, tricyclics, phenothiazines), low electrolytes, acute stroke/bleed, BBB or conduction delay, and congenital Left Bundle Branch Block (LBBB) – “Bunny Ears;” wide QRS; lateral lead RSR’; ST depression and inverted T; more (-) than (+) in V1. Right Bundle Branch Block (RBBB) – “Bunny Ears,” wide QRS; V1 and V2; R’>R; wide S in I, V5, V6; and more (+) than (–) in V1. Page 16 Tachycardia (> 100 bpm) No relationship between P waves and QRS Constant relationship between P waves and QRS Wide QRS (> 0.12 s) Typically ventricular origin APPROACH TO THE PATIENT WITH TACHYCARDIA Irregular rhythm No distinct P waves WPW Supraventricular Tachycardia with Aberrant Conduction > 3 P wave shapes Atrial Fibrillation Ventricular Tachycardia Multifocal Atrial Tachycardia Short PR interval Delta wave (QRS) Wide QRS Shock 200, 300, 360J! Causes death rapidly if not treated. Chaotic, irregular appearance without discrete QRS forms Ventricular Fibrillation Irregularly irregular Atria @ 350-600 bpm Ventricles @ ~160 bpm Torsades De Pointes 100-200 bpm Wide QRS with variant AV dissociation amplitudes “twisting” QRS may be mono- or about baseline. polymorphic QT prolongation “Sustained” if > 30 sec or Quinidine, procainamide, requires termination due hypocalcemia, to severe symptoms. hypokalemia, hypomagnesemia Ventricular Tachycardia Seen in COPD’ers with pneumonia or respiratory distress; > 100 bpm Often asymptomatic Not related to P wave Common following acute MI Appearance of two or three in a row is a marker of increased mortality. Ventricular Premature Beats Atrial Flutter Atria @ 250-350 bpm Saw-toothed P waves 2:1 AV block most common Slows, but does not revert with carotid massage. Non-reentrant Atrial Tachycardia Narrow QRS pically supraventricular RT 250 bpm Atria @ 130-250 bpm III, aVF) or Peaked P waves re QRS or g QRS turns to AV block may increase carotid and does not revert with ge. carotid massage. Page 17 2. 3. 4. 5. 6. 7. 8. 9. B = Bones: are the clavicles, ribs, and sternum present and are there fractures? C = Cardiac silhouette: is the diameter of the heart > ½ thoracic diameter or R atrium >1 fingerwidth (enlarged)? Hypertrophy or Pericardial Effusion? D = Diaphragm: are the costophrenic and costocardiac margins sharp? is one hemidiaphragm enlarged over another? is free air present beneath the diaphragm? E = Effusion/empty space: is either present? F = Fields (lungs): are there infiltrates, increased interstitial markings, masses, air bronchograms, increased vascularity, or silhouette signs? G = Gastric bubble: is it present and on the correct (left) side? H = Hilar region: is there increased hilar lymphadenopathy? I = Inspiration: did the patient inspire well enough for 10 ribs to be counted, or was the patient rotated? Method 2: A random method adapted from Ferri. 1. Check for over or underpenetration – if underpenetrated, you will not be able to see the thoracic vertebrae, a very common problem. 2. Verify right and left by looking for the gastric bubble and at the heart shape. 3. Check for rotation – does the thoracic spine align in the center of the sternum between the clavicles? 4. Was the film taken under full inspiration – are 10 posterior or 6 anterior ribs visible? 5. Is the film a portable, an AP, or a PA film? Remember that the heart will be enlarged on an AP film; thus the cardiac silhouette cannot be accurately judged. PA looks sharper. 6. Check the soft tissues for foreign bodies or subcutaneous emphysema. 7. Check visible bones and joints for fractures, metastatic lesions, cervical ribs, etc. 8. Look at the diaphragm for tenting, free air, and abnormal elevation. 9. Check hilar and mediastinal areas for: size and shape of aorta, presence of hilar nodes, prominence of hilar blood vessels, elevation of vessels. 10. Check the heart for size, shape, calcified valves, and enlarged atria. 11. Check costophrenic angles for fluid or pleural scarring. 12. Check lung fields for infiltrates, increased interstitial markings, masses, absence of normal margins, air bronchograms, increased vascularity, and silhouette signs. Random Stuff 1. R middle lobe and lingular (LUL) area obscure the cardiac silhouette when opaque on AP. 2. Effusions “homogeneous opacity” have a meniscus and (-) bronchograms. 3. Pneumonia “heterogeneous opacity” obeys anatomic boundaries and has (+) bronchogram. 4. Atelectasias “heterogeneous opacity” have ? lung volume and (-) bronchograms. 5. Tb will be ULL and multinodular. 6. Malignancies cause mass effect and do not obey anatomical boundaries. Use the lateral film to confirm the position of questionable masses or infiltrates, AP diameter, and to check the posterior costophrenic angle for small effusions. If the lateral film is good, then you should see the vertebrae better. Also, for lateral films you should be able to follow the right hemidiaphragm all the way from the costovertebral angle to where the diaphragm meets the sternum; the left hemidiaphragm will be partially obscured by the heart. For great examples of chest films and other cardiothoracic imaging, check out this site: http://info.med.yale.edu/intmed/cardio/imaging Page 18 HCO3 PaCO2 Alkalemic 4. If the disorder is respiratory, determine whether it is acute or chronic. Acidosis Respiratory Disorder Alkalosis 5. 6. 7. Metabolic Alkalosis Respiratory Alkalosis Acute pH by 0.08(PaCO2 – 40)/10 Airway Obs., Pneumothorax, Opiods Chronic pH by 0.03(PaCO2 – 40)/10 Emphysema Acute pH by 0.08(40 – PaCO2)/10 Chronic pH by 0.03(40 – PaCO2)/10 Both = hypoxia, sepsis, ASA, PTE, Liver F, Hyperventilation/anxiety, pregnancy If the disorder is metabolic acidosis, determine whether it is an anion gap or a non-anion gap acidosis. Anion gap (AG) = Na+ – (HCO3 + Cl-) [nl 7-16]. If <7.0 consider adding NaHCO3. AG causes: a big anion gap might… KIL U Ketoacidosis Diabetic see Endocrine EtOH (when bld EtOH is 0, Tx with D5NS to stimulate insulin) Starvation Ingestion Salicylates (usually assoc. with respiratory alkalosis 20 to respiratory stimulation) Methanol Ethylen Glycol/EtOH Fe, INH Lactic Acidosis (Bowel ischemia) Uremia (as in Acute Renal Failure) Ren F also ? phosphates and sulfates If suspecting ingestion then Osmolar Gap = Measured Osmo – (2Na + Glu/18 + BUN/18) Causes of non-anion gap acidosis include Renal tubular acidosis (hyperchloremic metabolic acidosis) UAG (+) GI losses – diarrhea, ileostomy (stool is basic) UAG (--) drugs (acetazolamide, amiloride, triamterene, spironolactone, -blockers) If a metabolic disturbance is present, is the respiratory system compensating adequately? Metabolic acidosis – use Winter’s formula: expected compensatory PaCO2 in a patient in metabolic acidosis = [1.5 x HCO3] + 8 (2) If measured paCO2 from ABG < calculated PaCO2, then there is also a respiratory alkalosisthink Salicylates Metabolic alkalosis – PCO2 = 40 + {0.7 X (HCO3 – 24)} (+/-)5 If measured PCO2 higher then concomitant respiratory acidosis If measured PCO2 lower then concomitant respiratory alkalosis PaCO2 should be > 40 or <50 if appropriate compensation occurring If the patient has an anion-gap acidosis, is there secondary metabolic disturbance present? Determine the corrected bicarbonate (? gap) level = HCO3 + (anion gap – 12) Page 19 Remember: “POD” “Production” Tests of Hepatic Function 1. Albumin: t½ = 2-3 wk; levels fall with prolonged hepatic dysfunction. 2. PT: a daily marker of altered hepatic function; more sensitive than albumin in looking at liver dysfunction. The most common cause of a prolonged PT is dietary vitamin K deficiency. “Obstruction” Tests of Cholestatic Disease 1. Bilirubin: an indicator of hepatic uptake, metabolic and excretory function. See next page for an approach to the patient with jaundice. Total Bilirubin (Bil T) > 3.5 will be icteric. Indirect bilirubin (Bil I): Normally, 70% of the Bil T level is indirect. If Bil I > 80%, it is an unconjugated hyperbilirubinemia, and ? levels suggests overproduction of pigment, ?uptake, ?conjugation, hemolysis, or Gilbert’s syndrome Direct bilirubin (Bil D): Found in urine If > 50% of the Bil T is Bil D, it is a conjugated hyperbilirubinemia, and ? levels suggests hepatocellular dysfunction or cholestasis such as impaired excretion or biliary obstruction 2. Alkaline phosphatase (AlkP): indicator of intrahepatic cholestasis, biliary obstruction, and liver infiltration; may also be elevated in childhood, pregnancy, bone regeneration, hyperthyroidism, and neoplastic diseases. If AlkP is markedly elevated in conjunction with a normal/mildly elevated bilirubin, suspect an infiltrative or granulomatous hepatic disease (sarcoidosis, lymphoma, tuberculosis) or primary biliary sclerosis / primary sclerosing cholangitis. 3. Gamma glutamyltransferase (GGT): elevated levels are used to confirm that elevated AlkP levels are of hepatic or cholestatic origin. GGT bone, recent EtOH binge. “Destruction” Tests of Hepatocellular Damage (i.e. hepatitis) Aspartate and Alanine Aminotransferase 1. AST (SGOT), ALT (SGPT): enzymes released after hepatocellular death ? transaminase levels “transaminitis” ? drugs (APAP), non-alcoholic steatohepatitis (NASH), hepatitis C, and alcohol use ALT is more specific for liver damage since AST is found in cardiac and skeletal muscle, kidney, and brain tissue Hepatic steatosis / NASH: AST:ALT ratio ~ 1:1, mild elevations in levels (not > 4x normal). Alcoholic hepatitis: AST:ALT ratio > 2:1, AST usually not > 250. AST, ALT levels in the low thousands seen in viral and drug-induced (NSAIDs, ACE inhibitors, statins, phenytoin, carbamazepine, isoniazid, sulfonamides, erythromycin, griseofulvin, fluconazole) hepatitis. AST, ALT levels > 10,000 seen in ischemic and herpes hepatitis, acetaminophen overdose. Other causes of elevated AST/ALT levels include autoimmune hepatitis, hemochromatosis, Wilson’s disease, alpha-1-antitrypsin deficiency, acquired muscle diseases, and strenuous exercise. References: Kamath P. Clinical Approach to the Patient with Abnormal Liver Test Results. Mayo Clinic Proceedings 1996; 71(11) 1089-1095 Pratt DS, Kaplan MM. Evaluation of Abnormal Liver-Enzyme Results in Asymptomatic Patients. NEJM 2000; 342(17) 1266-1271 Page 20 itamin K) U/S? < 20% < 6 mg/dL Splenomegaly May be asymptomatic or with back ache, joint pain. > 5x normal > 50% Variable Tender hepatomegaly, splenomegaly Nausea, vomiting, fever, anorexia Hepatocellular jaundice < 3-5x normal Prolonged (variable) No Usually not necessary 2-5x normal Variable, may be > 30 mg/dL > 50% Tender hepatomegaly Deep jaundice, darkcolored urine, clay-colored stools, pruritus Intrahepatic cholestatic jaundice APPROACH TO THE PATIENT WITH JAUNDICE Normal < 2-3x normal Prolonged (no) No Not necessary Hemolytic jaundice Normal Normal No Not necessary Extrahepatic cholestatic jaundice Deep jaundice, darkcolored urine, clay-colored stools, pruritus, cholangitis, biliary colic Hepatomegaly, palpable gallbladder < 30 mg/dL > 50% < 2-3x normal; if with cholangitis > 3-5x normal > 3-5x normal Prolonged (yes) Yes Usually necessary Page 21 Low (< 1%) reased production MCV EVALUATING ANEMIA High (> 4%) Hemolysis / Bleeding Hemolysis? ( IBili, LDH, hemoglobinuria, haptoglobins) Yes = Hemolysis (Bld smear has schistocytes) Yes = Inherited intrinsic defect Family History No = Acquired extrinsic defect Membrane defects Hemoglobinopathies Enzyme deficiencies ( – ) = Non-immune Direct Coombs’ Test (+) = Immune Hypersplenism MAHA PNH Malaria No = Bleeding Reticulocyte count defective DNA synthesis Macrocytic (>94) demand or stem cell failure Liver disease B12 deficiency Folate deficiency ormocytic (80-94) Bleeding Dilution Hypothyroidism ronic renal failure Aplastic anemia rrow replacement Chronic disease Transfusion reaction Autoimmune hemolysis Drug induced eticulocyte count x (Pt Hct/expected Hct), if less than 2% suspect hypoproliferative BM Page 22 1. 2. 3. 4. 5. ACV (assist control): produces a ventilator-delivered breath for every patient-initiated breath. If the patient’s respiratory rate decreases past a preset rate, the ventilator delivers tidal breaths at a preset rate. Should be the initial mode of ventilation in most patients with respiratory failure. IMV (intermittent mandatory ventilation): allows the patient to breathe at a spontaneous rate and tidal volume without triggering a ventilator; the ventilator also adds additional mechanical breaths at a preset rate and tidal volume. Indicated in the majority of spontaneously breathing patients becaue it maintains respiratory muscle tone and results in less depression of cardiac output than assist control. SIMV (synchronized IMV): a hybrid of assist control and IMV – the ventilator becomes coordinated with the patient’s respiratory cycle, waiting for patient effort to deliver a positive pressure breath at the appropriate interval (every 6 seconds if the machine rate is 10/min). This prevents inadvertent stacking of a mechanical breath on top of a spontaneous breath. Advantages include less respiratory alkalosis, fewer adverse CV effects due to lower intrathoracic pressures, less requirement for sedation/paralysis, maintenance of respiratory muscle function, and facilitation of long-term weaning. CMV (controlled mechanical ventilation): a mode in which the patient does not breathe spontaneously – the respiratory rate and tidal volumes are determined by the physician. May be used with sedation or paralysis, but paralyzed patients need to be monitored closely, and the ventilator cannot respond to ventilatory needs. PSV (pressure support ventilation): the patient breathes at his own frequency, and the ventilator augments each patient-initiated breath with a set pressure; tidal volumes are determined by patient effort and the mechanical properties of the lung. Advantages include increased patient comfort and decreased work of breathing. Selection of settings 1. Tidal volume (VT): usually 10-15 ml/kg body weight, but should be lower in patients with decreased lung compliance/ARDS (6-8 ml/kg) 2. Rate: begin with 10-15 breaths per minute and adjust to achieve desired PaCO2 or pH. 3. Oxygen concentration (FIO2): initially set to 100%, then decrease to the lowest level that will maintain a PaO2 > 60 mmHg or SaO2 > 90%. O2 will be 0.21 to 1.0. 4. PEEP: used to prevent airway collapse at the end of expiration (especially in those with COPD, diffuse lung edema, or ARDS); use is indicated when SaO2 < 90% despite an FIO2 > 50%. Start with a PEEP of 5 cm H2O and increase in increments of 2-5 cm to maintain PaO2 > 60 mmHg. May result in pulmonary barotrauma and hemodynamic compromise (decreased RV filling). Get an ABG 15-30 minutes after initiating ventilation and a CXR to check for placement of the endotracheal tube. Other considerations include PTE prophylaxis (heparin, anti-embolic stockings, etc.), GI bleeding prophylaxis (IV ranitidine), pulmonary toilet to avoid accumulation of secretions, and placement in a semirecumbent position (45o angle) to decrease risk for nosocomial pneumonia. Other notes about oxygen management Room air is 21% oxygen. If a patient is on nasal cannula, for each L/min of O2 being given, add 4% to the FIO2. Nasal cannula is only effective up to about 6 L/min O2 (FIO2 ~ 45%). Open face masks can deliver 40-60% O2 effectively. Non-rebreather masks with O2 reservoir are as close as you can get to deliver FIO2 ~ 100% without intubation. Page 23 DIET IV FLUIDS MEDS ACTIVITY LABS SPECIAL CALL IF telemetry”, “elevate head of bed”, “change dressing bid”, “foley to gravity”, etc. NPO / regular / clear liquids / ADA / heart healthy, etc. Type of fluid at rate for # bags List all medications ad lib / bed rest / up to chair, etc. CBC, BMP, ABG, EKG, urinalysis, CXR – PA and lateral, etc. Physical therapy, diabetic educator, dietician consult, etc. Temp > 101 or < 96, HR > 120 or < 60, RR > 30, BP > 160/90 or < 85/60 DISCHARGE SUMMARY ADMISSION/DISCHARGE DATES ADMISISON/DISCHARGE DIAGNOSES SERVICE CONSULTS PROCEDURES HISTORY and PHYSICAL COURSE CONDITION DISPOSITION MEDICATIONS INSTRUCTIONS FOLLOW-UP List in order of importance Service, Attending, Resident, Intern/AI Service, Attending physician, Date Procedure name, Date, Results (this includes ABG, CT, MRI, Echo, biopsies and pathology results, etc.) “See Admission History and Physical” List problems in order of importance and a brief summary of hospital course, including status of problem at discharge. good / stable / fair / guarded / critical, etc. Discharged to home, nursing home, etc. Discharge medications with dosage, etc. Activity, diet, dressing care Follow-up appointments with doctor on date PROGRESS (“SOAP”) NOTES Subjective Objective Assessment/ Plan Patient’s status overnight, including complaints and interval change (“no chest pain past 24 hours,” etc.), as well as nursing comments. Vitals – Temp, Tmax, BP range, HR, RR, O2 sat, ventilator settings; Ins/Outs – IV/PO intake; urine/NG suction/drain volume, #BM/emesis; Physical exam; Labs, imaging, etc. Summarize the patient in one sentence – “63 yo wm with history of CHF, HTN, COPD presenting with chest pain and SOB.” Provide problem list and what is being done about problem in order of importance. How to write a prescription Disulfiram 500 mg Sig: T po qd x 7d for abstinence Disp: # 7 (seven) Refills: 0 Try to make sure your prescription is legible. Sig – how to take the medication; ideally, you should put what the medicine is for, i.e. Prilosec 20 mg T po qhs for acid reflux, Lortab 7.5 T po q4-6h prn pain. Disp – amount of medication to dispense Page 24 Social Hx: Review of Systems: Physical Exam: Labs: Assessment/Plan: stroke, cancer, bleeding disorders, asthma, arthritis, tuberculosis, seizures, mental illness, symptoms of presenting illness. Current residence, education, employment, persons at home, diet, exercise; tobacco, alcohol, or drug use (amount, frequency, duration of each); prostitutes, tattoos, males having sex with males (MSM), prison 1. General: weight change, fatigue, weakness, fever, chills, night sweats. 2. Skin: skin, hair, nail changes, itching, rashes, sores, lumps, moles. 3. HEENT: trauma, headache location/frequency, nausea, vomiting, visual changes, diplopia, hearing loss, tinnitus, vertigo, earache, rhinorrhea, stuffiness, sneezing, allergy, epistaxis, bleeding gums, hoarseness, sore throat, swollen neck. 4. Breasts: skin changes, masses/lumps, pain, discharge, self exams? 5. Lungs: shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, asthma, bronchitis, emphysema, tuberculosis, last CXR. 6. Heart: hypertension, murmurs, angina, palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, edema, last EKG. 7. GI: appetite, nausea, vomiting, indigestion, dysphagia, BM frequency/change, diarrhea, constipation, hematemesis, melena, hematochezia, hemorrhoids, abdominal pain, jaundice, hepatitis. 8. Urinary: frequency, hesitancy, urgency, polyuria, dysuria, hematuria, nocturia, incontinence, stones, infection. 9. Genital: STD history/treatment, contraception, sex interest and function; male = penile discharge/sores, testicular pain/masses, hernias; female = menarche, period regularity, frequency, duration, dysmenorrhea, last period, itching, discharge, sores, pregnancies and complications, miscarriages, abortions, birth control, menopause, hot flashes/sweats. 10. Vascular: edema, claudication, varicose veins, thromboses/emboli 11. Musculoskeletal: muscle weakness, pain, joint stiffness, range of motion, instability, redness, swelling, arthritis, gout. 12. Neurologic: loss of sensation, tingling, tremors, weakness, paralysis, fainting, blackouts, seizures. 13. Heme: anemia, easy bruising/bleeding, petechiae, purpura, transfusions 14. Endocrine: heat/cold intolerance, excessive sweating, polyuria, polydipsia, po lyphagia, thyroid, diabetes. 15. Psychiatric: mood, anxiety, depression, tension, memory 1. Vitals: temperature, BP, HR, respirations, SaO2, height, weight 2. General: sex, race, state of health, stature, development, dress, hygiene, affect 3. Skin: scars, rashes, bruises, hair consistency, nail pitting, stippling. 4. HEENT: size/shape of head, trauma?, pupil size, shape, and reactivity, conjunctival injection, scleral icterus, fundal papilledema/hemorrhage, extraocular movements, visual fields and acuity, gross auditory acuity, nasal discharge and mucosa color, tonsilar enlargement, moistness of mucous membranes, pharyngeal exudate. 5. Neck: masses, range of motion, tracheal deviation, thyroid size, lymphadenopathy? 6. Breasts: skin changes, symmetry, tenderness, masses, dimpling, discharge 7. Lungs: chest symmetry with respirations, wheezes, crackles, fremitus, whispered pectoriloquy, percussion, diaphragmatic excursion, egophony. 8. Heart: rate, rhythm, murmurs, rubs, gallops, clicks, precordial movements. 9. Abdomen: shape, scars, bowel sounds, consistency (soft vs. firm), tenderness, rebound, masses, guarding, spleen size, liver span, percussion (tympany, shifting dullness), CVA tenderness. 10. GU: male – rashes, ulcers, scars, nodules, induration, discharge, scrotal masses, hernias; female – external genitalia, vaginal mucosa and cervix: look for inflammation, discharge, bleeding, ulcers, nodules, masses, internal vaginal support, bimanual/rectovaginal palpation of cervix, uterus, ovaries 11. Rectal: sphincter tone, prostate consistency and size, masses, hemoccult. 12. Vascular: carotid, radial, femoral, popiliteal, posterior tibial, dorsalis pedis pulses, carotid bruits, jugular venous distension, edema, varicose veins. 13. Musculoskeletal: atrophy, weakness, joint range of motion, instability, redness, swelling, tenderness, spine deviation, gait. 14. Neurologic: see “Neurology” for full neurologic exam. Fluid balance, hematology, urinalysis, coagulation panel, cultures, EKG, any imaging results, etc. Differential diagnosis – state each possibility and reasons for inclusion or exclusion from history, physical, and lab results; medications to be started, procedures and additional labs to be done, consults to be obtained, etc. Page 25 both services, but the private attendings tend to round earlier and be more informal. Each block consists of 3 weeks of inpatient duties and 1 week of clinic – UMC clinic or Tuskaloosa Internal Medicine clinic depending on the block Morning report daily at 10 am in Room 401 for all students on inpatient services and all students on Thrusday. Lecture almost daily beginning between 11 am and 12 pm and lasting about an hour. A lecture schedule will be handed out at IM orientation but will frequently change, so make sure to check your email everyday for updates. Each student takes in-house call until 7 pm every 4th day except during his or her ambulatory (clinic) week. Weekend call is divided into Friday/Sunday or Saturday call. If you have Friday/Sunday call, you will work until 7 pm on Friday, come back to preround/round on Saturday morning, and then round and work until 7 pm on Sunday. If you have Saturday call, you will work until 7 pm and then come back to pre-round/round on Sunday morning. Expect to be on call at least 2 weekends during the clerkship. During the inpatient weeks, you will be dismissed after lecture (between noon and 1 pm) unless you are on call. You are asked to be available by pager until 5 pm, although you will probably never be paged. Clinic hours are generally 8 or 8:30 am until 5 pm. You do not attend morning report during that week (except Thursday), but you are expected to attend lecture. Page 26 num service, but it can make presenting the patient easier if your note is done. Present your patients on rounds. Presentations vary based on whether it is a new or existing patient, whether the attending has seen the patient before, and just by attending in general. You will learn to adjust as necessary with time. Use your intern or resident as a resource if you have questions about how to present a particular patient. Present at morning report. Each morning, a student or resident from the previous day’s admitting team will present a patient from their service. Led by the attending, the students and residents proceed through a differential diagnosis, work-up, and management. Participate in patient admissions by performing histories and physicals when on call. Attend lecture – they are mandatory. Attend clinic during the ambulatory week. At UMC, you will be assigned to a particular attending each morning and afternoon, and they will often tell you which of their patients they want you to see. Generally, they do not have you write notes in the EMR, but you may be asked to write a note on your own as though you were writing a clinic note in the chart. At Tuskaloosa Internal Medicine, you will work with whichever physician is attending in the hospital that month. Two patient write-ups will be due at the end of the first block. They should be written in the format of a standard H&P and include a short discussion of a relevant topic at the end. An example may be provided during orientation. 5 SIMPLE Internal Medicine Cases – online clinical cases, which take about 30 – 40 minutes each to complete. Login information will be provided during IM orientation. Several cases are available, and you choose which ones you want to complete. Page 27 Alabama. This includes one outpatient visit and one inpatient visit when you are on the Burnum service. Recommended Resources: (listed in order of “usefulness” according to surveys of past students) MKSAP (provided) – book/CD containing several board-style questions, organized by subspecialty. Several students find it helpful to go through these questions one or more times in preparation for the shelf. USMLE World Step 2 QBank – online question bank with almost 1500 board -style internal medicine questions. These questions provide excellent shelf exam preparation, but subscriptions are expensive, and some students prefer to save these questions for right before they take the Step 2 CK exam. Case Files Step Up to Medicine – similar outline format as First Aid. Considered by many students to be the a very good review book for this clerkship. First Aid for the Medicine Clerkship Blueprints UpToDate – online resource with good clinical information about a variety of topics. It is a good resource to use to look up information on your patient’s conditions or to prepare for a short topic review that you may be asked to give on rounds. It can be accessed for free from DCH and UMC computers but requires a subscription to be accessed from home. Washington Manual of Medical Therapeutics Page 28 presentation skills. Ask you resident to critique your presentations and give you suggestions for improvement. KNOW YOUR PATIENTS! Read up on their current medical problems – pathophysiology, common presenting symptoms, associated physical exam findings, helpful labs and imaging, and management options. Use the EMR to look for past records (admits, baseline labs, etc). Looking at the patient’s prior records can help you form a more complete picture of their medical problems and perhaps fill in gaps in the history. Plus, it will impress your attending that you took the initiative to find out as much as you could. It can also be helpful to use a scut sheet (found at www.medfools.com) to track patient info daily. Be attentive on rounds! It can be tempting to zone out when you are not the one presenting, but be respectful of the attending, residents, and other students on your team and listen. Rounds often provide useful information about patient management. If you are engaged and ask questions, you will get much more out of the experience. Attempt to develop your own differential diagnosis and plan for each patient! It can be tempting to rely on your resident, particularly for work-up and treatment options, but you will learn a lot by at least attempting to come up with something on your own. Don’t be afraid to be wrong – the attendings will not think less of you! They understand where you are in your training and often don’t expect that you will know the best management for a particular problem. But they will be impressed if you try because it shows that you are engaged and trying to learn. Even if your plan is wrong, you will learn a lot by discussing with them why it is wrong and how/why they would do something different. Organize your studying based on what you have seen. Internal medicine is the most demanding clerkship in terms of the amount of information that must be mastered. It can be overwhelming knowing how to tackle it all. One good way to start is to read a little bit each night, focusing on your patient’s problems and then those of the other patients on your service. Make sure to review their medications as well to help expand your pharmacology knowledge. Use the free time provided to read about your patients and study. There is a lot of information to cover in 8 weeks, and the shelf exam will sneak up on you! The clerkship schedule allows plenty of independent study time, so use it wisely. Most students recommend starting to study early in the rotation. Page 29 A = Atelectasis E = Effusion (small, unilateral) I = Infarct (wedge shaped) O = Oligemia (Westermark’s sign) U = Upriding diaphragm (Hampton’s hump) Klebsiella E. coli Enterobacter Proteus mirabilis Indications for Dialysis A = Acidosis E = Electrolytes (hyperkalemia) I = Ingestions (salicylates, alcohol, amphetamines, lithium, theophyline) O = Overload (volume) U = Uremia (chronic renal failure) Generic Differential Diagnosis Mnemonic… ‘Vitamins” Vascular, Infection, Trauma, Allergy/Autoimmune, Metabolic / Musculoskeletal, Iatrogenic/ Ingestions Neoplasm, Special (Degenerative/Congenital/ Special (Degenerative/Congenital/ Drugs) Drugs) Rx of Pulmonary Edema / Volume Overload U = Upright (sit) N = Nitropaste ( preload) L = Lasix O = Oxygen (nasal cannula, etc.) A = ACE inhibitor ( afterload) D = Diuretic M = Morphine ( smothering/dyspnea; vasodilator) E = Enalaprat (IV ACE inhibitor) Most common bugs causing UTIs Klebsiella E. coli Enterobacter Proteus mirabilis Thrombocytopenia Platelet D/O Leukemia Anemia Trauma Enlarged Spleen Liver Dz EtOH Toxins Sepsis Generic Differential Diagnosis Mnemonic… ‘Vitamins” Vascular, Infection, Trauma, Allergy/Autoimmune, Metabolic / Musculoskeletal, Iatrogenic/ Ingestions Neoplasm, Special (Degenerative/Congenital/ Drugs) Page 30 Inflammation Malnutrition GI / protein losing enteropathies Localized Edema Lymphatic obstruction Venous insufficiency / deep venous thrombosis Infection / inflammation Hemoptysis (rule out hematemesis and pulmonary edema) Lung cancer Infection (bacterial, fungal) Arteriovenous malformations PTE Vasculitis (Wegener’s, Goodpasture’s) Bronchiolitis/bronchiectasis Mitral valve stenosis Trauma Coagulopathies Drugs Nausea V = Vestibular causes O = Obstruction M = Motility problems (opiates), metabolic problems I = Infection / inflammation T = Toxins Fever of Unknown Origin (FUO) Infection Malignancy Collagen vascular Dz Drugs Page 31 Pneumothorax Idiopathic pulmonary fibrosis PTE Upper airway obstruction Pleural effusion Cardiovascular causes Ischemia CHF Valvular disease Cardiomyopathy Hypertension Arrhythmias Pericarditis Metabolic acidosis Anemia Anxiety Exudative pleural effusions Bacterial pneumonias Metastatic disease PTE Tuberculosis Mesotheliomas Transudative pleural effusions <Rx with diuretics> Congestive heart failure Cirrhosis Nephrotic syndrome PTE Syncope Non-Cardiac Seizure Vasovagal Shy-Drager Syndrome Autonomic Dysfunction Subclavian Steal Cardiac Aortic Stenosis Arrhythmia Muscle dysfunction HOCM PTE SVC obstruction Pulmonary Embolis AMI N Myocardial Infarction 1. Admission orders – follow the cardiology admit pathway in PIN a. Labs i. Cardiac profile: CK-MB, CK-Total, troponin x 3 (q8h apart). ii. FBP with Mg2+, Ca2+, and PO4 qd – maintain Mg at 2, K at 4. iii. Fasting lipid profile – if not done in the last 6 months. b. Other i. EKG q am x 3. ii. Telemetry – check this every morning via the red phones. iii. Oxygen via nasal cannula. c. Diet – cardiac prudent unless pt is likely to go to cath, then NPO. 2. Meds a. Sublingual NG and/or nitropaste b. Aspirin c. Consider low dose beta-blocker (metoprolol) if ? HR and HTN d. Lovenox or Heparin (lovenox is more commonly used) 3. In house plan a. Mibi scan vs. catheterization. b. Surgery if indicated. c. Add an ACE inhibitor if possible. d. Start on a lipid lowering agent if necessary. e. Discharge on aspirin, ISDN, and the beta-blocker also. f. Teach the patient about smoking cessation (good luck). Congestive Heart Failure -- Failure of heart to perfuse tissues 1. Risk Factors Valvular Dz Congenital HDz Restrictive Cardiomyopathy Constrictive Pericarditis Drugs – EtOH, cocaine 2. Signs/Symptoms LHF RHF Orthopenea Nocturia RUQ Hepatomegaly PND S3 Peripheral edema Hepatojugular distension Rales Diaphoresis JVD Ascitis DOE Tachycardia Cyanosis Cough 3. New York Heart Asso. Classification a. Class I – Usually asymptomatic b. Class II – Ordinary activity results in symptoms Page 32 MIBI, ASA, Plaxix, or Lovanox a. 6. Labs/Studies i. TTE –call echo lab and fax results to the floor. ii. FBP q am. iii. Digoxin level. iv. CXR to check for pulmonary edema. v. UA for oliguria, proteinuria, hyaline casts, increased specific gravity. b. Meds i. Lasix – start IV at twice the recent home dose. ii. Digoxin iii. Consider dobutamine/dopamine drip if indicated. c. Diet – cardiac prudent d. Other i. Telemetry ii. Oxygen iii. Check the “CDA” files for further info – may patients are bounce-backs. Also, previous echo and cath reports can be found here. e. Nursing - strict ins and outs to monitor diuresis. In house plan a. Successful diuresis – monitor ins and outs; gauge this clinically by the patient’s dyspnea upon walking the hospital halls. b. Start ACE inhibitor. c. Continue digoxin and the diuretic upon discharge. d. Ambulate the patient daily to clinically assess improvement. e. Teach smoking cessation (good luck). Other Pearls Daily to-dos Look in CDA for previous admissions/caths/echo reports on all admitted patients. Call telemetry each morning using the red phones located at the nurses station. Most of the time, a CXR will be done in the ER before the pt is moved to the floor. Call the echo lab to have results faxed up to the floor. All cath reports are hand written in the chart under progress notes. OM = obtuse marginal, LD = long diagonal. Also look in PIN for a previous creatinine for comparison. They do not like to cath if Cr > 2. A lecture is given every morning at 8 am in the conference room by the CCU – these are good lectures. Rounds normally begin after this lecture, at 9 am. History and Physicals ROS = orthopnea/PND/syncope/edema/diaphoresis/palpitations/DOE - # of blocks or stairs. Include any cath / echo / mibi information in the PMH of the patient (be specific!!). Exam: be sure to include pulses / JVP / possible peripheral bruits. Other stuff You are responsible for discharging your patients, but you may not enter discharge orders in the computer. Write the prescriptions and a discharge note, however. Any weird telemetry call from the nurse: verbal order a 12-lead EKG and evaluate. Page 33 MVP Systolic Mid-late “click” Apex MR Holosystolic blowing Apex to L axilla Holosystolic “high pitch”, > on inspire than MR Diastolic, rumbling Diastolic dec-cre rumbling “opening snap” LLSB and subxiphoid LLSB TR TS MS AI Apex RUSB Wide pulse pressure “pistol shot” pulse Bobbing head Diastolic, dec, ? pitch, blowing Systolic “harsh” cre-dec Apex ? when squatting Sys/Dia “machine” 2nd L Holosystolic “harsh” LSB No or very wide S2 Friction Rub Quality is I-VI based on loudness. S1 is mitral/tricuspid closing. Inspiration ?venous return and ? cardiac output. Inspiration ? rIght-sided murmurs. Expiration ? lEft-sided murmurs. HOCM IVDU, RHF IVDU, RHF Sx hemoptysis, emboli, hoarseness r/o Rheumatic fever Sx CHF r/o dissection or aortic root Dz Hypertrophic Cardiomyopathy PDA VSD ASD Cyanosis in adulthood when R? L Pericardiits Squatting ? venous return, stroke volume, SVR. Most murmurs ?; HOCM and MVP ? Standing and Valsalva ? venous return and stroke volume. Coronary Heart Dz Risk Factors Smoking FHx (Males <45 or Females <55) ? LDL PMP ? HDL HTN Obesity DM Hyperlipidemia Treatment Guidelines Tx Statins Screen males at 35 and females at 45. LDL < 160 factors LDL 130-159 factors LDL < 100 Sx CHF #1 cause MVP Classification of Blood Pressure Normal <120 / <80 PreHTN 120-139 / 80-89 HTN, Stage 1 140-159 / 90-99 HTN, Stage 2 >160 / >100 HTN Tx – Diuretics and β-Blockers DM or CHF – ACEI/ARB CHF – β-Blocker BPH – α-Blocker CHD, DM, or other equivalent <2 CHD risk 2 + CHD risk Page 34 Type 2 – (90%) insulin resistant with a relative secretory defect Gestational DM – see OB/GYN 3. Symptoms/Signs Polyuria Blurry vision Polydipsia Vaginitis, balanitis Polyphagia Aconthosis Nigricans Diabetic Foot 4. DM complications and prevention FLECK (macrovascular and microvascular) Feet – yearly MD, qd patient Lipids – q3 months Eyes (retinopathy) – q year Control -- HgbA1c <7% q3 months, smoking, HTN, weight, exercise ( insulin resistance) Kidneys (nephropathy) -- microalbumin(>30 mg) q6 months, ACEI & ARB 5. Drugs Insulin – usual is 70/30 (NPH/regular) given BID insulin secretion – sulfonureas (glyburide -- cause wt. gain, but cheap), meglitidines insulin action – Biguanides (metformin -- gluconeogenesis, resistance, action, improves lipids, no wt gain), thiazolidinediones change intestinal absorption – Alpha-glucosidase inhibitors, lipase inhibitors Hypoglycemia Brain does not store glucose. 1. Symptoms/signs Early (adrenergic) – seating, anxiety, palpitations, tremors Late (neurologic) – fatigue, lethargy, obtundation, seizure 2. Evaluation Whipple’s Triad – hypoglycemia, Sx of Hypoglycemia, and resolution of Sx when treated for hypoglycemia Check insulin and C-peptide before Tx 3. Tx Dextrose – IV, PO, NG Glucogon IM if unconscious and no IV Tx underlying disorder 4. Etiology DM with too much insulin or sulfonurea #1 Surreptitious insulin ( C-peptide), sulfonurea or insulinoma( C-peptide) Sepsis EtOH Liver Dz/Failure Non-Ketotic Hyperosmolar State (NKHOS) Type 2 DM Hyperglycemia (often >1000 mg/dL) Dehydation serum osmolarity AMS (--) ketones, acidosis Tx with hydration and insulin Page 35 Work-up 1. Serum glucose level (usually > 300 mg/dL). 2. ABGs (usually a pH < 7.3, and Pa CO2 < 40 mmHg). 3. Serum electrolytes (HCO3 < 15 mEq/L, decreased sodium (pseudohyponatremia secondary to hyperglycemia), increased anion gap, decreased total body K + (initial K+ may be low, normal, or high). 4. CBC & differential, U/A, urine and blood cultures, and CXR to rule out an infectious cause. 5. Calcium, magnesium, and phosphate (may be depressed, and will drop further with correction of DKA). 6. BUN and creatinine (typically show dehydration). 7. Amylase and LFTs (in a patient complaining of abdominal pain). Diagnosis: Hyperglycemia, metabolic acidosis with (+) anion gap, urinary (+) ketones Treatment (Tx the Gap and manage the sugar) 1. Patients in DKA should be admitted to the ICU for close monitoring. 2. Replace fluids with normal saline until the glucose level is below 300 mg/dL; then switch to D 5W to avoid hypoglycemia. Fluid replacement strategies vary; a common method is to replace 1/3 of the total deficit in the first 8 hours, 1/3 in the next 16 hours, and then the last 1/3 over the next 24 hours, in addition to maintenance fluids. 3. Give regular insulin as an initial IV bolus of 0.15-0.2 U/kg, followed by a constant infusion at 0.1 U/kg/hr. Monitor serum glucose hourly for the first few hours, and then q2 -4 hours. You would like to see the serum glucose decrease by about 80 mg/dL/hr. 4. When the serum glucose reaches 250 mg/dL, the insulin infusion rate should be slowed to around 2-3 U/hr until the HCO 3 level is close to normal and the urinalysis is free of ketones. Around an hour before stopping the infusion, administer an appropriate dose of subcutaneous insulin to cover the patient when the infusion stops. Restart the patient on sliding scale insulin when they are able to eat. 5. Serum potassium levels in patients with DKA may be low, normal or high. Do not replace the patient’s potassium until the patient’s DKA has resolved and you have rechecked the patient’s potassium. 6. Phosphate should only be replaced when the serum phosphate is less than 1.5 mEq/L. In this case, you should give 2.5 mg/kg of elemental phosphate intravenously over 6 hours. 7. Mg replacement is only needed in cases of significant hypomagnesemia or refractory hypokalemia. 8. Bicarbonate replacement is contraindicated because it can result in cerebral edema. 9. Remember to r/o cause (two methods) ID – BCx, UCx, Sputum, CXR Infection CV – ischemia/infarction Ischemia/Infarction GI -- pancreatitis (lip, amy) Initial presentation OB -- Pregnancy Infant (pregnancy) MS -- Trauma Injury FEN – HgbA1c I smoked crack “drugs” Page 36 LR 130 4 109 28 3 9 -- 5. Content of Body Fluids (mEq/L) Biliary Diarrheal Gastric Ileal Pancreas Salivary Na+ 145 60 60 130 140 10 K+ 5 35 10 5 5 26 Cl100 40 130 100 75 10 HCO335 30 0 50 115 30 6. Daily Volume and Electrolyte Requirements Daily maintenance fluids (assuming normal kidneys/heart) 100 cc/kg for the first 10 kg 50 cc/kg for the next 10 kg 20 cc/kg for the remainder or 4 cc/kg/hr for the first 10 kg 2 cc/kg/hr for the next 10 kg 1 cc/kg/hr for the remainder 7. Volume status Hypovolemic Signs Orthostatic Hypotension ? HR Dry mucosa Skin tenting Sodium requirement = 1 – 2 mEq/kg/day Potassium requirement = 0.5 – 1 mEq/kg/day Urine output = 0.5 cc/kg/hr Hypervolemic Signs Rales JVD Edematous Treatment of Hyperkalemia 1. Repeat potassium level to rule out lab error. 2. Obtain EKG to look for peaked T waves, flattened P waves, AV block, and ventricular arrhythmias. 3. Stop any IV or PO potassium intake. 4. Start continuous EKG monitoring. Page 37 6. 7. d. Lasix, 40-160 mg IV over 30 minutes. e. Dialysis. Check electrolytes and pH. Correct electrolyte abnormalities and acidosis if present. Identify and treat underlying cause of hyperkalemia (renal failure, potassium-sparing diuretics, exogenous potassium administration). Page 38 i. GI -- Sx of constipation, ileus 1. Diarrhea and Emesis volume contraction aldosterone K loss 2. Diarrhea is a direct loss ii. Renal 1. Loop diuretics 2. Incresded secretion a. Hyperaldosteronism – Na/K exchange in distal tube b. renin c. Cushings aldosterone receptor stimulation d. Renal Tubular Disease (types I & II RTA) 3. Diagnosis a. R/o decreased intake b. Non-renal loss < Urinary K 15 < Renal loss 4. Treatment a. Always treat Mg first. b. Give no more than 20 mEq per hour. c. 10 mEq KCl = 0.1 mEq/L serum K d. Heart failure patients should have K+ maintained > 4.0, as K+ is a good antiarrhythmic. Hypocalcemia 1. Etiology and w/u PTH Vit D def. Phosphate binds Ca Mg ENT surgury 2. Sypmtoms/signs Chvostek’s Sign – facial muscle spasm when tapped. Trousseau’s sign – Carpal tunnel spasm when occluding blood with BP cuff. Perioral tingling EKG changes 3. If Albumin is low (<4), then use correction formula. 4. Can treat with oral CaGluconate or Tums, treat underlying disorder Hypernatremia 1. Symptoms/Signs – fatigue, lethargy, AMS, edema 2. Etiology and treatment – Calculate Water Deficit; do not hydrate faster than 0.5 mEq/L/hr Volume Status Hypovolemic Renal Loss Osmotic Tx:diuretics Renal failure Obstruction Extrarenal loss Vomiting Diarrhea Skin losses Burns NS Isovolemic Hypervolemic Diabetes Insipidus (DI): Central DI -- U Osm > 50% Nephrogenic DI – no change in U Osm Mineralcorticoid excess (eg, Conn’s Syndrome) ½ NS Vasopressin for central DI ½ NS Loop diuretic ( Na excretion) Page 39 pontine myelinolysis (CPM); Tx underlying cause APPROACH TO THE PATIENT WITH HYPONATREMIA (Na+ < 135) Serum osmolality Normal 280-285 mOsm Low < 280 mOsm Isotonic Hyponatremia 1. Pseudohyponatremia hyperlipidemia hyperproteinemia 2. Isotonic infusions of glucose, mannitol, glycine Elevated > 285 mOsm Hypertonic Hyponatremia 1. Hyperglycemia 2. Hypertonic infusions of glucose, mannitol, glycine Clinical assessment of extracellular fluid volume Hypovolemic Hyposmotic Hyponatremia Isovolemic Hyposmotic Hyponatremia Hypervolemic Hyposmotic Hyponatremia UNa > 20 UNa < 10 UNa > 20 UNa < 10 UNa > 20 UNa < 10 Renal loss Extrarenal loss Renal failure SIADH Hypothyroidism Drugs (EtOH) Adrenal insuff Water intoxication (Polydipsia) Acute or chronic renal failure Nephrosis Cirrhosis CHF Diuretics Renal damage Obstruction Adrenal insuff RTA Salt wasting nephritis Vomiting Diarrhea Pancreatitis Skin losses Lung losses -bronchorrhea Isotonic saline replacement Water restriction Water restriction *Acute Renal Failure (ARF)- is generally defined as rapid increase in creatinine of 0.5 above baseline. -Workup should include Urinalysis, Urine electrolytes and osmolality (to calculate FENa, fractional excretion of sodium), foley cath placement, Renal Ultrasound (sometimes skipped), and most of the time aggressive IV fluid hydration. Often a BUN/Cr ratio of >20 can give you a quick and dirty way of determining the etiology is prerenal (i.e. severe dehydration or volume depletion). FENa= [(Urine sodium x Plasma Creatinine)/(Plasma Sodium x Urine Creatinine)] x100 Page 40 3. 4. 5. 6. 7. infection; Neoplasm Risk factors: previous GI bleed, ASA, NSAIDs, steroids, "blood thinners", EtOH, and smoking Physical exam a. Resting tachycardia b. Orthostatics – positive tilt if pulse increases > 20 and systolic BP decreases > 20 and/or diastolic BP decrease > 10 from lying to standing. c. Digital rectal exam – black stools may be seen if patient takes bismuth or Fe supplements. Tests a. Hgb/Hct – It takes 6hrs to 1 day for Hct to drop after bleeding or hydration. b. Type and cross – with significant bleed, otherwise type and screen. c. FBP – BUN increases with bleed, in the absence of renal disease. d. PT/INR/PTT – rule out any bleeding disorders. e. NG tube – if you suspect hematemesis, insert NG tube and aspirate. A negative result does not rule out a bleed (bleed could be from duodenal bulb without reflux into the stomach). f. Hemocult g. Abdominal flat and upright – air under the right diaphragm indicates a perforation and requires immediate surgical intervention. h. Consider consult for EGD, colonoscopy, arteriography, radionucleotide imaging. Treatment a. ABC’s b. Two large bore IV’s c. Volume expansion with NS, FFP, PRBC if needed. d. Consider pressors/statins e. Follow vitals Admission criteria to ICU with a GI bleed a. Mnemonic: VISA = Variceal bleeding (suspected or confirmed); Instability of vital signs; Serious cormorbid condition (e.g. CAD, COPD); Active GI bleeding Acute Pancreatitis 1. Etiology a. Most common causes: EtOH and gallstones. b. Other causes: drugs (list is extensive), iatrogenic (ERCP or surgery), hyperlipidemia, hypercalcemia, scorpion bite (extremely rare but sounds good when giving differential). c. Mnemonic: BAD HITS = Biliary Stones; Alcohol abuse; Drugs; Hyperlipidemia or hypercalcemia; Idiopathic or infectious; Trauma; Surgery (ERCP) or scorpion bite. 2. Signs of hemorrhagic pancreatitis a. Cullen's sign – around the umbilicus. b. Grey Turner's – around the flank (think Turn = sides). 3. Tests a. Amylase, lipase – elevated. b. LFTs – with EtOH hepatitis, AST/ALT > 2:1. c. Ultrasound – if gallstones are suspected. 4. Ranson's Criteria – provides prognosis during first 24 hrs a. At admission, use the mnemonic GA LAW = Glucose > 200 mg/dL; Age > 55 yo; LDH > 350; AST > 250; WBC > 16,000. b. During the initial 48 hours, criteria include: Page 41 d. Consider DT prophylaxis in EtOH-induced pancreatitis with Ativan – DT usually occurs during first 12- 48 hrs after withdrawl from EtOH, most prominent around 24-36 hrs. Signs include tremors, tachycardia, and agitation. Diarrhea Diarhea Most common chronic is Irritable Bowel Syndrome Inflammatory Bowel Disease 1. Crohn's Disease – can be anywhere in the GI tract. "Skip lesions." Transmural involvement with lymphoid aggregates. Non-caseating granulomas. Can lead to strictures and fistulas. 2. Ulcerative Colitis – extends continuously from the rectum in proximal fashion. Only mucosal inflammation. Increased risk of colon carcinoma. Associated with sclerosing cholangitis. 3. Extraintestinal manifestations – can be seen in both CD and UC, and includes migratory polyarthritis, sacroilitis, ankylosing spondylitis, uveitis, and erythema nodosum. 4. Treatment a. Sulfasalazine, Asacol, and Rowasa – effective in UC and in CD confined to colon. b. Steroids – retention enemas can be helpful in those patients with disease in the rectum accompanied by tenesmus. c. Immunosuppressants – azathioprine, cyclosporine, mercaptopurine are helpful in refractory cases. Liver Diseases 1. Hallmark of liver dieases - hepatomegaly, splenomegaly, gynecomastia, palmar erythema, spider angiomata (>3 in women, >1 in men), testicular atrophy, Dupuytren's contracture, caput medusae, jaundice, ecchymoses, ascites 2. Etiology of cirrhosis: EtOH and hepatitis C are most common causes in Western world a. EtOH abuse b. Hepatitis B or C – look for risk factors such as IVDA, transfusion, prostitutes, tattoos c. Primary biliary cirrhosis – pruritus, xanthomas, and hyperlipoproteinemia in middle-aged or elderly women and is associated with Sjogren's, CREST, and scleroderma. Patients have a high antimitochondrial antibody titer. d. Secondary biliary cirrhosis – obstruction of common bile duct (gallstones, pancreatic cancer, sclerosing cholangitis, stricture). e. Drugs – isoniazid, methotrexate, acetominophen. f. Hemochromatosis – "bronze diabetes" (hyperpigmentation, diabetes, arthritis, impotence). Patients have elevated ferritin and transferrin saturation levels. g. Wilson's Disease – Kayser-Fleischer rings in the cornea. Decreased ceruloplasmin. h. Alpha-1-antitrypsin deficiency – family history with lung and liver pathology. Decreased alpha-1globulin levels. i. Autoimmune hepatits – amenorrhea, rash, acne, vasculitis, Sjogren’s or thyroiditis in young women. Patients have high ANA titer (>1:150), anti-smooth muscle antibody, and liver and kidney microsomal (LKM) antibody. j. Cryptogenic 3. See above for discussion of liver function test evaluation. 4. Complications of cirrhosis a. Portal hypertension – collaterals between the portal and systemic circulations leading to esophageal varices, caput medusae, and hemorrhoids. Page 42 (2) c. d. e. f. Esophageal varices bleeding may be prevented through the use of non-selective beta-blockers. Propanolol is most commonly used. Nadolol can also be used, and it has less CNS side effects than propanolol. Beta-blockers should be titrated up to decrease the heart rate by 25%. (3) Vasopressin, octreotide, and somatostatin can be used to decrease portal flow and pressure in acute settings Hepatic encephalopathy – altered mental status due to impairment of liver function and subsequent accumulation of nitrogenous compounds and other toxins. Encephalopathy is classified in grades I through IV. Clinical signs include asterixis, myoclonus, and hyperreflexia. Blood level of ammonia correlates poorly with degree of encephalopathy. i. Treatment of hepatic encephalopathy (1) Decrease protein intake (2) Lactulose – converts ammonia (NH3) to ammonium (NH4) which can be excreted in the stool. Lactulose should be titrated until patient has 2 to 4 stools daily (3) Neomycin – decreases urease-containing bacteria in the colon which produces NH3. Ascites – caused by increased hydrostatic pressure in the splanchnic capillaries and decreased oncotic pressure secondary to hypoalbuminemia. i. Diagnostic paracentesis – send fluid for LDH, glucose, albumin, cell count, and differential. If malignancy is suspected, consider CEA level and cytologic evaluation ii. A transudate with protein < 3 and serum-ascites albumin gradient > 1.1 is likely to be secondary to cirrhosis. iii. Treatment of ascites (1) Restrict sodium and fluid intake. (2) Spironolactone and Lasix (3) In patients with large ascites, a pleural effusion may be present. Fluid accumulates in pleural space through small fenestrations in the diaphragm. Spontaneous bacterial peritonitis – patients present with fever, abdominal pain, and tenderness. Ascitic fluid PMN count > 250. Culture confirms diagnosis. Patients with cirrhosis should be on prophylaxis with Cipro or Bactrim. Hepatocellular carcinoma – elevated AFP levels. Page 43 Enlarged Spleen Liver Dz EtOH Toxins Sepsis 3. Random Stuff 30% sequestered in spleen platelets survive 7-10 days 1 unit = 10k platelets Thrombotic Thrombocytopenic Purpura (TTP) Microangiopathic hemolytic anemia Congenital deposition of abnormal Von Willebrand factor Acquired IgG against vWF protease 1. Risk Factors Infection – HIV, E. coli Malignancy Drugs Autoimmune D/O Pregnancy 2. Symptoms/Signs – FAT RN Fever Anemia Thrombocytopenia Renal Neural 3. Diagnosis Clinical Sx Nl PT, PTT Blood smear = Schistocytes LDH Possible BUN, Cr 4. Treatment NO platelets Plasmaphoresis Refractory steroids Vincristine Splenectomy Page 44 4. Petechia/mucosal bleeding < 20 k platelets Blood smear has large platelets BMBx has or Nl megakaryocytes Diagnosis Dx of exclusion Antiplatelets Abs not specific Treatment Children – resolves Steroids IV Ig Splenectomy for chronic Platelets for emergency Disseminated Intravascular Coagulation (DIC) Consumptive Coagulopathy 1. Risk Factors Sepsis Trauma Malignancy Transfusion Liver Dz 2. Symptoms/Signs Petechia, Purpura 3. Diagnosis PT, PTT D-Dimer Fibinogen Blood smear = Schistocytes 4. Treatment Treat underlying cause FFP, platelets 3. Destruction Immune ITP Drug HIV DLE Heparin – paroxysmal clotting b. Non-Immune DIC TTP Pre-eclampsia HELLP Anti-phospholipid a. Alport’s Syndrome Fanconi’s May-Hegglin TAR Syndrome Wiskott Aldrich Anemia SEE ALSO FLOW CHART AT BEGINNING Definition: decrease in red cells or hemoglobin concentration in peripheral venous blood. For women, hemoglobin < 12 g/dL or hematocrit < 36%; for men, hemoglobin < 14 g/dL or hematocrit <41%. Symptoms: fatigue, headache, lightheadedness, dyspnea. Signs: hypotension, tachycardia, blood loss, pallor, jaundice, petechiae, purpura, flow murmur, splenomegaly. RBC turnover is 90-120 days; Reticulocytes are produced within 1-2 days Evaluation of Anemia 1. Start with reticulocyte count. Reticulocytes are immature red blood cells seen on peripheral smear that indicate increased bone marrow activity. Correct for the degree of anemia using the reticulocyte production index (RPI). A low retic count (< 1%) or RPI < 3 in the face of anemia indicates that production of red blood cells or hemoglobin is deficient. A high retic count (> 4%) or RPI > 3 shows that the bone marrow is working to replace blood lost through hemolysis or bleeding. 2. If the reticulocyte count is low, there must be a defect in the production of red blood cells or hemoglobin. Check the MCV. a. MCV < 80 Microcytic Anemia – a problem making hemoglobin. i. Fe deficiency anemia: check ferritin. A ferritin < 20 indicates iron deficiency, and a ferritin > 100 rules it out. A ferritin between 20 and 100 is indeterminate – check the bone marrow. ii. Anemia of chronic inflammation: in cases of microcytic anemia with a ferritin > 100, check the TIBC. A low TIBC and a high ferritin is seen in states of chronic disease. A normal or high TIBC and a high ferritin warrants examination of the bone marrow. iii. Thalassemia: check the Hgb/MCV ratio (high in thalassemia and low in iron deficiency). iv. Sideroblastic anemia: check for sideroblasts in the bone marrow. b. MCV 80-94 Normocytic Anemia – often due to stem cell failure, as in aplastic anemia. c. MCV > 94 Macrocytic Anemia – a problem making DNA. i. Liver disease: check the peripheral smear. Target cells are indicative of liver disease. ii. B12/Folate deficiency: on the peripheral smear, hypersegmented neutrophils and macroovalocytes will be present. Check serum B12 and folate levels. Page 45 melena, etc. and check hemoccult and urinalysis. Many hemolytic anemias are hereditary, so find out if the patient has any family history of bleeding problems or anemia. Positive family history Check the peripheral smear. i. Sickle cell anemia: patients will have sickle cells on peripheral smear. Check hemoglobin electrophoresis, which will help identify sickle cell anemia and other hemoglobinopathies. ii. Hereditary spherocytosis: spherocytes will be seen. Test osmotic fragility. iii. Hereditary elliptocytosis: again, the peripheral smear will demonstrate elliptocytes. iv. Enzyme deficiencies (G6PD Deficiency, PK Deficiency): peripheral smear will be normal, but specific enzyme assays are available to test for these conditions. b. Negative family history These are acquired hemolytic anemias. The peripheral smear is still important, as is the Coombs test. i. Autoimmune hemolytic anemias: these can be due to autoantibodies, transfusion reactions, or drugs. Coombs test will be positive in these patients. It is important to work up possible causes for the autoimmune reactions (check ANA, evaluate medications, etc.) ii. Microangiopathic hemolytic anemia (MAHA): schistocytes will often be seen on peripheral smear. Coombs test will be negative. Check a coagulation profile to evaluate for potential causes, like DIC, TTP, and HUS. iii. Paroxysmal nocturnal hemoglobinuria (PNH): the peripheral smear will be normal, and Coombs test will be negative. These patients will have a history of having brown or red urine in the morning. Check a sucrose lysis test to diagnose this condition. a. Page 46 Evaluation of pneumonia 1. History a. Pre-disposing factors i. COPD: H. influenzae, S. pneumoniae, Legionella, Moraxella catarrhalis ii. Recent seizures: aspiration pneumonia (mixed anaerobes) iii. Compromized host: Pneumocystis carinii, CMV, Legionella, gram-negatives, fungi, MAC iv. Alcoholics: aspiration, S. pneumoniae, Klebsiella, gram-negatives, H. influenzae v. Diabetes mellitus: gram-negatives, M. tuberculosis vi. Sickle cell: S. pneumoniae, Mycoplasma b. Symptoms i. S. pneumoniae – abrupt onset with fever, shaking chills, rust-colored sputum. ii. Mycoplasma – insidious onset with gradual onset of fever, hacking cough, scant sputum. iii. Legionella – bradycardia, abd. pain, diarrhea, elderly, Dx urine Ag or IMF Ab smear iv. Viral pneumonias – generalized body aches, malaise, dry, non-productive cough. 2. Diagnosis a. Sputum for Gram stain and culture –many false positive results (oral flora contamination) and false negative results. Aerosol induction with hypertonic saline may increase diagnostic yield. b. PA and lateral CXR – also use to rule out empyema, pneumothorax, and abscess. i. S. pneumoniae – segmental or lobar infiltrate ii. Mycoplasma – patchy infiltrates; may suggest a more serious infection than the patient’s appearance or physical exam. iii. Viral – hazy infiltrates iv. Diffuse infiltrates – Legionella, Mycoplasma, viral pneumonia, P. carinii, aspiration pneumonia, hypersensitivity pneumonitis, aspergillosis c. CBC d. Blood cultures – positive in 20% of patients with pneumococcal pneumonia. e. ABG – PaO2 of 60 mmHg on room air is criteria for hospital admission. Initial antibiotic treatment of pneumonia (taken from Sanford Guide to Antimicrobial Therapy 2001 edition) Patient type Outpatient CAP, < 60 yo, otherwise healthy Outpatient CAP, > 60 yo or with comorbidity (COPD, CHF, DM, liver disease, renal failure, alcoholic) CAP requiring hospitalization Severe CAP requiring ICU care Nosocomial pneumonia – patient hospitalized > 48 hours Suspected pathogens S. pneumoniae, Mycoplasma, Chlamydia, H. influenzae, viral S. pneumoniae, H. influenzae, aerobic gram negative rods, S. aureus S. pneumoniae, H. influenzae, anaerobes, aerobic gram-negatives, Chlamydia S. pneumoniae, H. influenzae, aerobic gram-negatives, Mycoplasma, Legionella S. pneumoniae, Gram-negative rods (Pseudomonas, Legionella, Acinetobacter), S. aureus Page 47 Initial coverage Macrolide (azithromycin, clarithromycin) or a fluoroquinolone or doxycycline Fluoroquinolone or second generation cephalosporin (cefuroxime) plus macrolide if atypicals suspected Third generation cephalosporin (cefotaxime, ceftriaxone) plus a macrolide or a fluoroquinolone alone Third generation cephalosporin or lactam / -lactamase inhibitor (Zosyn, Unasyn, Augmentin) plus either a fluoroquinolone or a macrolide Imipenem or meropenem or aminoglycoside plus either an antipseudomonal penicillin (piperacillin, ticarcillin) or -lactam / -lactamase inhibitor clindamycin > 50 yo Impaired cellular immunity With head trauma, neuro-surgery, CSF shunt S. pneumoniae, Listeria, or gramnegative rods Listeria or gram-negative rods S. aureus, S. pneumoniae, coagnegative Staphylococcus, gram-negative rods, P. aeruginosa ampicillin vancomycin Ampicillin plus third generation cephalosporin vancomycin Ampicillin plus ceftazidime Vancomycin plus ceftazidime (table taken from Sanford Guide to Antimicrobial Therapy 2001 edition, Ferri, and NEJM 1997;336:708 -716 Evaluation of meningitis 1. History a. Predisposing factors i. S. pneumoniae – common in adults, elderly; predisposing factors include blunt head trauma, otitis media, pneumonia, sickle cell, CSF leaks; mortality is 30%. ii. N. meningitidis – complement deficiencies iii. H. influenzae – usually seen in preschool age children; predisposing factors in adults include head trauma, otitis media, and sinusitis. iv. S. aureus – diabetics, patients with S. aureus pneumonia, cancer. v. Enteroviruses (coxsackievirus, echovirus) are the most common cause of viral meningitis. vi. Suspect tuberculosis meningitis in a patient with unrelenting headache, malaise, low grade fever with lymphocytic pleocytosis, and mildly decreased CSF glucose. b. Symptoms and physical exam i. Classic presentation is fever, headache, lethargy, confusion, nuchal rigidity. A recent review (JAMA 1999;282:175-181) reported that 95% of patients will have at least two symptoms from the triad of fever, neck stiffness, and altered mental status/headache, 99-100% will have at least one of these three symptoms. However, these symptoms may not always be present in infants, immunocompromised, and the elderly. (1) Fever – 85% sensitive (2) Neck stiffness – 70% sensitive (3) Altered mental status – 67% sensitive; more commonly seen in bacterial meningitis ii. Meningeal signs (1) Kernig’s sign: pain in the lower back or posterior thigh when knee is extended while patient is lying in supine position and hip is flexed at a right angle. (2) Brudzinski’s sign: rapid neck flexion involuntary knee flexion in a supine position. (3) These signs are not very sensitive but are very specific for meningitis iii. Infants may have a bulging fontanelle, poor feeding, vomiting, and respiratory distress. iv. Petechial-purpuric rashes (trunk, lower extremities, mucous membranes, conjunctiva) are suggestive of meningococcal meningitis; also seen in viral and other bacterial meningitis. v. Seizures and papilledema are unusual. 2. Diagnosis a. CBC – elevated WBC with left shift. b. Blood cultures – if patient is very ill, start antibiotics before cultures are obtained. c. Coagulation panel and fibrin split products – rule out DIC in patients with petechiae, purpura, and hypotension. d. CSF studies i. Tube 1 = protein, glucose, cell count and differential ii. Tube 2 = Gram stain, cultures iii. Tube 3 = other tests (EV-PCR, etc.) iv. Tube 4 = cell count and differential, (AFB smear if suspected) Page 48 Fungal meningitis Neurosyphillis Guillain-Barre syndrome Neoplasm Hemorrhage 3. 4. Clear / cloudy Clear / cloudy Clear / cloudy Clear / xanthochromic Bloody / xanthochromic Treatment a. Normal Normal Nl / Nl / Nl / lymphs (late) monocytes monocytes Normal / , monocytes Normal / , lymphs RBCs Nl / Normal See table on previous page for antibiotics recommended for empiric therapy (taken from Sanford Guide to Antimicrobial Therapy 2001 edition, Ferri, and NEJM 1997;336:708-716). b. Dexamethasone i.Mechanism of action in meningitis 1. Inhibits synthesis of inflammatory cytokines (IL-1, TNF) that induce meningeal inflammation. 2. Stabilizes blood-brain barrier. 3. Decreases CSF outflow resistance. 4. Improves indices of inflammation in CSF when given before first dose of antibiotics. 5. Reduces sensorineural hearing loss and other neurologic sequelae in meningitis secondary to H. influenzae. 6. Reduces mortality and adverse neurologic sequelae in meningitis secondary to S. pneumoniae. ii.Recommendations for use 1. Treatment of H. influenzae meningitis in previously healthy infants and children > 2 mo. Give for the first 4 days of antimicrobial therapy. 2. Treatment of S. pneumoniae meningitis in children within the first 2 days of the illness. 3. Tuberculous meningitis. 4. Any adult with bacterial meningitis and significant change in sensorium. c. Repeat lumbar punctue after 24-36 hours of antibiotic therapy to verify eradication of the organism. d. Prophylaxis i.Indications include contact with patients who have N. meningitidis or H. influenzae meningitis, including members of the same household and those with close contact to the index case, including hospital personnel. Consider prophylaxis of contacts at day care, school, or chronic care facilities on an individual basis. ii.Rifampin is commonly used for prophylaxis of both N. meningitidis and H. influenzae meningitis. Aseptic Meningitis Viral – Enterovirus, HSVZ, HIV, Arborvirus Fungal Drugs – Ibuprofen/NSAIDS Malignancy – lymphoma, leukemia Autoimmune – SLE, sarcodosis Page 49 Evidence of endocardial involvement (TTE or TEE) b. Minor Predisposition: predisposing heart condition or intravenous drug use Fever: temperature >=38.0°C Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth spots, and rheumatoid factor Microbiological evidence (BCx) that does not meet criteria as above Evidence suggestive of IE 2. Etiology a. Native valve or Replacement Valve > 2 months old “community bugs” Strept viridans (from mouth), PCN G MSSA (from skin), Naficillin Rheumatic Fever Enterococcus (from gut), Amp + Gent Sequela of Gr. A Strep Pharyngitis J? NES b. Replacement Valve < 2 months old “hospital bugs” Joint (migrating arthritis) Staph aureus ? (carditis) Gram negative Rods Nodules (subcutaneous) Enterococcus Erythema marginatum Fungi Sydenham’s Chorea Blood Culture Negative Bugs #1 are Abx prior to culture HACEK Fungi Haemophilus sp. Coxiella burnetti Actinobacillus actinomycetemcomitans Bartonella sp. Cardiobacterium hominis Brucella sp. Eikenella corrodens Kingella sp Human immunodeficiency Virus AIDS CD4 < 200 Most common pneumonia is still Pneumococcus 1. Dx Acute Chronic RNA RNA p24 p24 ELISA W. Blot 2. Opportunistic Infections and CD4 Levels 200 100 50 Kaposi”s Toxoplasmosis MAC Oral Thrush Disseminated Candida CMV Oral Hairy Leukoplakia Cryptococcus PML PCP Lymphoma Atypical Tb PML = Progressive Multifocal Leukoencephalopathy (JC virus) Page 50 An abrupt decrease in renal function sufficient to result in the retention of nitrogenous waste in the body (BUN). Can be classified as pre-renal, renal, and post-renal. 1. 2. Pre-renal failure – 50% of ARF cases (hypoperfusion) a. Caused by i. Absolute effective blood volume (hemorrhage, skin/GI losses, diuretics, third spacing) ii. Relative effective blood volume (CHF, sepsis, liver failure) iii. Arterial occlusion (bilateral thromboembolism) b. Clinical presentation i. History of fluid losses, use of NSAIDs or ACE inhibitors, thirst. ii. Signs of weight loss, oliguria, orthostatic hypotension, tachycardia, dry mucous membranes. c. Laboratory tests i. Decreased UNa (< 20 mEq/L) ii. BUN/Cr > 20:1, and FENa < 1%. iii. Uosm > Sosm and Uosm > 500 mOsm/kg H2O iv. Urine specific gravity > 1.030 v. Minimal proteinuria and negative urine sediment findings d. Treatment i. Rapid volume replacement – fluid challenge of 300-500 mL NS over 30-60 min. ii. Then replace fluids to maintain urine output at 1-2 mL/min. iii. Correct underlying disorder (CHF, etc.) Intrinsic renal failure a. Caused by i. Vascular disorders (vasculitis, malignant hypertension) ii. Acute glomerulonephritis (post-streptococccal) iii. Acute interstitial nephriis (drug associated, e.g. methicillin) iv. Acute tubular necrosis (ATN) – makes up the majority of hospital associated ARF. (1) Perfusional defects (shock, hypovolemia, sepsis, etc.) (2) Nephrotoxic agents (a) Exogenous toxins (i) Aminoglycosides, i.e gentamicin – nonoliguric, related to duration of treatment (5-10 days), may be seen after cessation of treatment. (ii) Contrast – oliguric (iii) Mercury, cisplatin, solvents (b) Endogenous toxins (hemoglobinuria, myoglobinuria, myeloma, uric acid) b. Laboratory tests i. May or may not be oliguric ii. BUN by 20-40/day; Cr by 2-4/day, and FENa > 1%. iii. Uosm < 350 mOsm/kg, UNa elevated (> 30) iv. Modest proteinuria with ATN, nephrotic range proteinuria with acute glomerulopathies. v. Urine sediment – ATN = muddy brown; RPGN = RBC casts; interstitial nephritis = lymphocytes, eosinophils, and WBC casts. c. Treatment of ATN i. Find reversible sources of ATN and treat rapidly. ii. Convert oliguric ATN to nonoliguric ATN with Lasix (80-400 mg IV, repeat in 1 hr). Page 51 vii.Dialysis – keep predialysis BUN/Cr < 100 / 8. 3.Post-renal failure (obstruction) a. Caused by obstruction of the collecting system (bladder outlet obstruction, neoplasm, bilateral ureteral obstruction). b. Clinical presentation i. History of dysuria, nondysmorphic hematuria, clots. ii. Evidence of prostatic hypertrophy in men or pelvic pathology in women. c. Laboratory tests i. BUN by 20-40/day; Cr by 2-4/day ii. Ultra Sound -- Enlarged kidneys with dilated calyces iii. Absent proteinuria iv. Urinary sediment may be negative or may have hematuria with stones. d. Treatment includes catheter drainage, ureteral stents, percutaneous nephrostomy. Indications for Dialysis A = Acidosis E = Electrolytes (hyperkalemia) I = Ingestions (salicylates, alcohol, amphetamines, lithium, theophyline) O = Overload (volume) U = Uremia (chronic renal failure) Renin-Angiotensin Axis 1. JG Cells detect ? stretch and macula densa detects ? fluids/NaCl. JG secretes renin. 2. Angiotensinogen from liver is converted to Angiotensin I by renin in blood. 3. Angiotensin I is converted to Angiotensin II by ACE in lung. 4. Angiotensin II causes: a. Nephron efferent arterioles to constrict ? ? glomerular hydrostatic pressure. ? Afterload b. Adrenal cortex to release aldosterone ? ? Na resorption and ? blood volume. ? Preload c. Hypothalamus to ? thirst ? ? blood volume. ? Preload d. Posterior pituitary to release ADH ? ? kidney resorption of water. ? Preload e. Bradykinin Page 52 Late menopause Nulliparity or late Obesity 2. Screening/Evaluation Monthly pt. breast exams; Yearly by MD MMG – 40-49, q2y; 50+ annually (Young women dense breasts, common masses are fibroadenomas; Radiology – Spiculated masses and microcalcifications) Sonography – cystic vrs. Solid FNA Core/Excisional Bx – Dx 3. Types Ductile Carcinoma – most common, unilateral Lobular – often bilateral Paget’s – highly malignant, nipple with eczema Medullary – low grade, slow growing 4. Tx – based on size, type, lymph nodes, metastasis, receptor positive Lumpectomy/XRT Modified radical mastectomy Adjunctive chemotherapy, Hormonal therapy (Tamoxifen) Multiple Endocrine Neoplasia MEN I -- parathyroid glands, pancreatic islet cells, and pituitary gland MEN IIa -- medullary carcinoma of the thyroid, pheochromocytoma, and hyperparathyroidism MEN IIb -- medullary carcinoma of the thyroid, pheochromocytoma, and mucosal neuromas Inflammatory Bowel Dz High fat, low fiber Adenomatous polyps 3. Screening/Evaluation Age 50 – FOBT annually and flex-sig q5 years Bx of masses/polyps CT to r/o metastasis 4. Staging – Duke’s classification which involves depth, lymph nodes, and metastasis 5. Tx Rectal CA – 80% cured surgery; post-op 5FU Colon – 50% recurrence post surgery, chemotherapy for mets Prostate Leading malignancy in men Most men die with it, than from it. 1. Risk Factors > 40 years old AA > whites > Asians High fat, low fiber Family Hx 2. Screening/Evaluation Men 40-50 DRE Men > 50 DRE + PSA PSA > 4 30% with cancer PSA > 10 50% with cancer Transrectal US and Bx Bone Scan – commonly goes to vertebra 3. Tx – Prostectomy, XRT, and/or hormonal Tx Monitor with PSA Paraneoplastic Syndromes Syndrome Hypercoaguable State Erythrocytosis Hypercalcemia Page 53 Malignancy Pancreatic CA, GI CA Renal Cell CA Sq Lung (PTH-rP), Myeloma (OAF) 2. Hospital course a. These patients typically stay 2-4 days – you will generally notice a significant improvement in their physical exam (less wheezing/rhonchi, improved air movement and peak flows). b. Start to taper down their steroids as they improve – one way is to go from Solumedrol 80 q8h to 40 q8h to Prednisone 60 mg bid – each resident has a different way of tapering. c. A set of pulmonary function tests may be necessary to monitor long-term progress. d. Does the patient need home oxygen? Walk them around the hall on room air; if they desaturate below 88-90%, they qualify for home oxygen. Cystic Fibrosis Exacerbations Stuff to know University Hospital has seen increasing numbers of admissions for CF exacerbation. The Pulmonary department has a protocol for these patients and the nurse coordinator will generally give you a previous discharge summary an order set to put in, including antibiotics and dosages. Make sure that you wash up before and after examining a CF patient – this includes swabbing down your stethoscope with alcohol. This is especially necessary if a patient is known to have B. cepacia, a bug that is easy to spread between CF patients and hard to eliminate. It is important that you get a sputum culture on admission – order the “Cystic Fibrosis Culture” (found in the alphabetized lab orders section in PIN) – and get chest physical therapy on all patients (unless they have active hemoptysis). Get at least one set of PFTs during the admission (usually a day before discharge). Patients do not require daily labs, but they do need a fluid balance and a CBC drawn every 3-4 days. Many patients are on an aminoglycoside, so they must be monitored for nephrotoxicity. The average patient stay is 10-14 days. Pleural Effusions Laboratory Findings 1. Diagnostic criteria for an exudate (at least one of 3 must be present) a. Pleural fluid protein/serum protein ratio > 0.5 b. Pleural fluid LDH/serum LDH ratio > 0.6 c. Pleural fluid LDH > 2/3 upper limits of normal of the serum LDH 2. Transudates are usually due to altered hydrostatic and oncotic forces – they usually have WBCs < 1000/L, mononuclear predominance, glucose levels in pleural fluid equal to that of serum, normal pH). They suggest absence of local pleural disease and are usually due to CHF. 3. Exudates a. Normal pleural fluid pH ~ 7.6; pleural fluid pH < 7.3 suggests empyema, cancer, SLE/RA effusion, tuberculosis, esophageal rupture, or parapneumonic effusion. b. Low glucose levels (< 60 mg/dL or pleural fluid glucose/serum glucose ratio < 0.5) suggest cancer, empyema, tuberculosis, esophageal rupture, or connective tissue disease. c. Cell counts > 10000/L are seen in pneumonia, acute pancreatitis, and lupus pleuritis; chronic exudates (tuberculosis, malignancy) usually have cell counts < 5000/L. d. Amylase-rich pleural effusions suggest acute pancreatitis, chronic pancreatic pleural effusions, esophageal rupture, and malignancy. e. Lymphocyte predominance (85-95%) and absence of mesothelial cells suggest tuberculosis (include lymphoma, sarcoidosis, chylothorax, and chronic rheumatoid pleurisy in the differential). Page 54 Genetic or post-infectious PE -- Extensor SQ nodules PIP, radial of wrist, ulnar deviation of digits Labs – Rh factor, ? ESR, ? WBC synovium Dx Criteria (4/7 required) Morning stiffness > 1 hour Rheumatoid nodules Arthritis 3 or + joints Serum RF Symmetric XR showing erosive synovitis Hand joint arthritis Tx -- APAP Osteoarthritis – Loss of articular cartilage due to “wear and tear” – DIP most common Bouchard’s nodes – PIP osteophyte formation Heberden’s nodes – DIP osteophyte formation Morning stiffness < 30 minutes Labs – unremarkable Tx – APAP or surgery Gout MTP of Hallux ? podagra Needle shaped negative birefringment Tx Colchcine acute, Allopurinol preventative; CI ASA retards Uric acid excretion Pseudogout (CPPD) Aligned, Blue, Clcium Blunted, rhomboid, positive birefringence Seronegative Spondyloarthropathies – Rh Factor (--) Ankylosing spondylitis 90% HLA-B27 Schober test (bending) to measure fusion of spine. Asso. with uveitis Reiter’s Syndrome – autoimmune Asymmetric oligoarthritis Uveitis Urethritis Skin: Keratoderma blenorrhagica on palms and soles Etiology GU – Chlamydia, ureaplasma GI -- Shigella Psoriatric Arthritis -- Asymmetric oligoarthritis with active psoriasis Page 55 Mondays, Tuesdays, and Friday mornings are spent doing Neurology Divided into 4 weeks of inpatient and 4 weeks of outpatient. During the inpatient weeks, students spend Mondays and Tuesdays working with Drs. Slaughter and Lucy (neurology hospitalists at DCH). During the outpatient weeks, students spend Monday mornings working with the physicians at Alabama Neurology and Sleep Medicine. Monday afternoon is spent in lecture time with Dr. Mark Woods at Bryce Hospital while Tuesday mornings are currently independent study time. One Tuesday afternoon on outpatient Neuro week is spent volunteering at Caring Days, a day care program for elders with dementia. This is the TEAM requirement for the Neuro/Psych rotation. Friday mornings are reserved for Neurology PBLs (problem-based learning sessions) Hours worked may vary from week to week but you will receive a excessively detailed scheduled. Students are required to take call one weekend, that will be assigned, during the 8 week rotation. The hours are similar to regular weekdays – about 8 am until 3 or 4 pm, sometimes earlier if the service is not busy. Once you are dismissed, you will not be called back to the hospital unless something very rare comes in. Clerkship Duties/Requirements: During the inpatient weeks, arrive at the hospital by 8 am and contact the attending. He will give you several consults to see and examine (1 – 2 per student). Perform histories and physical exams, specifically a thorough neurological exam, on your patients. You do NOT have to write a note in the patient’s chart. Be sure to make your own notes for your patient presentation. Present your patients to the attending, complete with an impression & plan. Towards the end of the inpatient block, Dr. Slaughter will observe each student performing a complete neurological exam on a patient on the service. You will have plenty of practice as you see and exam patients during the preceding weeks. Page 56 experience and there is plenty of downtime for studying. Be sure bring something to study– you will not see patients on your own, but you will sometimes asked to give your impression and plan after observing the attending’s H&P. You will also have the opportunity to observe some procedures, including Botox injections, and testing, such as NCVs and EMGs. Overall, the atmosphere is very laidback. You will not be asked to do or say much, but the attendings are good teachers and always happy to answer questions. Friday morning PBLs – attended by all students on Neurology and Psychiatry. In these sessions, a case is presented, and the group proceeds through the work-up and formulation of a differential diagnosis, not entirely unlike morning report in IM. Learning issues will be identified from the case and assigned to the students. You are asked to research your learning issue and make a handout that you will present the following week. Presentations are very informal. Each week’s PBL will begin with presentations and discussions of the learning issues from the previous week, and then another case will be presented and new learning issues assigned. TEAM Service Learning Requirement: you will volunteer at Caring Days on one Tuesday afternoon (1:30-5:00pm) during your outpatient half of the block. This is very laid-back and fun, including helping the Caring Days clients with crafts, games, and other activities. At the end of the block you are required to turn in a half-page reflection about your volunteer experience in addition to the post-clerkship survey. Recommended Resources: (listed in order of “usefulness” according to surveys of past students) Blueprints Neurology Pretest Neurology Case Files Neurology Clinical Neurology (provided for a rental fee) – more thorough resource Page 57 Clinical Neuroanatomy Made Ridiculously Simple and other resources used during the Neuroscience module in second year – helpful for reviewing neuroanatomy and pathways for PBLs and for the shelf exam. Tips for Success: Use every opportunity to practice the neurologic exam! This part of the physical exam is probably the most detailed and the most daunting to students. Use your Maxwell to guide you as you are learning the exam. The inpatient block of this clerkship provides a lot of opportunities to see patients and practice performing the exam. If you have questions about why or how to perform an element of the exam, ask your attending for help! Develop an organized method for performing the neurologic exam and presenting your findings. Dr. Lucy in particular will critique your presentation and help with your organization – pay attention to what he has to say. Present an impression and plan, not just your findings on history and physical. The attendings will appreciate your attempt to apply your knowledge to a management plan. Ask questions and pay attention! This may be your only clinical exposure to neurology. Use this time to ask questions about the concepts that confuse you, the medications you are unfamiliar with, the reasoning behind certain management decisions, etc. Try to get comfortable with the basics – they will be helpful no matter what you choose to go into. Always have study materials with you! You will find that you have a decent amount of down time, particularly during your clinic days, so make use of that time. Remember – at the end of this 8-week clerkship, you have to take 2 shelf exams, so try to stay on top of your studying. Page 58 Motor exam Sensory Coordination DTRs Gait Discs sharp without papilledema (ou = bilateral, od = right eye, os = left eye) Normal bulk/tone, 5/5 strength throughout, no involuntary movements (Strength gradations: 0 = none, 1 = flicker of strength, 2 = movement not against gravity; 3 = movement against gravity, 4 = good strength, but breakable, 5 = normal strength) Normal pinprick, vibration, proprioception (remember to test 6 points on the face) Finger nose intact bilaterally without dysmetria, heel shin normal bilaterally 2+ symmetric, plantar response flexor (or toes ) (4+ Hyperactive with clonus, 3+ hyperactive, 2+ normal, 1+ hypoactive, 0 negative) Normal; good tandem, negative Romberg Stroke week tips Presenting ICU patients is a daunting task, but it’s not as bad as you think. Copy the following data from the huge flowsheets in the NICU: 1. Present how the patient did overnight and if there was any change in his/her neurologic status. If the patient is sedated, state that. 2. Temperature, Tmax and when it happened. Antibiotics and day #. 3. CV data (give a range): HR, BP, MAP, other CV data if present. 4. Pulmonary data: ventilator settings (mode, RR, FIO2, pressure support, PEEP), SaO2, most recent ABG, and yesterdays and today’s a/A ratio. a/A ratio = PaO2 / (713xFIO2 – PaCO2/0.8) 5. Fluids: total ins and outs for the previous day and that morning 6. Labs: start out with CBC (note any trends in WBC, Hct, plt), then fluid balance panel, coags, culture data, drug peak/trough levels, etc. 7. Plan: try to discuss this with the fellow prior to rounds, but usually you won’t have time. State the obvious – i.e., “K+ is low, so we went ahead and replenished it, Hct is dropping, so we are hemocculting stools,” etc. If the patient’s renal function or fever are improving or the patient is tolerating tube feeds well, note those things. Then defer to the fellow… Code stroke protocol 1. Initial assessment: include age and sex of patient, neurologic deficits, estimated time of onset, vital signs. 2. Place the patient flat in bed. 3. Administer O2. 4. Have the patient chew and swallow an Aspirin 325 mg 5. Give IV Bolus – NS bolus 500cc, then 125cc/hr. 6. Obtain stat EKG. 7. Obtain stat non-contrast head CT, if non-hemorrhagic give heparin and/or consider TPA. 8. Draw blood for labs. 9. Document the patient’s current medical problems. 10. DO NOT lower blood pressure (i.e. no anti-hypertensive meds) 11. DO NOT leave patient unattended. -Differential for delirium/coma: A(Apoplexy=stroke), E(Epilepsy), I(Infection), O (Opiates, O/D), U(Uremia, nutritional or metabolic abnormalities), Y (Ψ=psych) Page 59 2. 3. 4. mg IV and a 50 mL bolus of D50W. First drug (5-20 min): give Ativan 0.1 mg/kg IV at 2 mg/min, and monitor BP, RR, and pulse for respiratory depression and hypotension. Second drug (20-40 min): if seizures continue, give Dilantin 20 mg/kg IV at 50 mg/min (or fosphenytoin – dosing is same, but can be pushed). Seizures in 90% of patients in status epilepticus should be controlled by this stage. Intubation / anesthesia (40-60 min): intubate, begin EEG monitoring, and give entamicin al 20 mg/kg at 100 mg/min. If seizures persist, initiate general anesthesia with propofol 10 mg bolus followed by 0.5-1 mg/kg/hr. Upper motor neuron vs. Lower motor neuron lesions UMN Lesions No muscle wasting Increased tone (clasp knife) Weakness (antigravity muscles) Increased DTRs / clonus Extensor plantar response LMN Lesions Muscle atrophy, fasciculations Decreased tone (flaccid) Weakness (variable pattern) Decreased or absent reflexes Flexor / absent plantar response Stroke sites and resultant neurologic deficits Vessel Anterior circulation Middle cerebral artery division division Region supplied Lateral cerebral hemisphere, deep subcortical structures Superior Motor / sensory cortex of face, arm, hand; Broca’s area Inferior Parietal lobe (visual radiations, Wernicke’s area), macular visual cortex Anterior cerebral artery Ophthalmic artery Posterior circulation Posterior cerebral artery Parasagittal cerebral cortex Retina Neurologic deficit See superior / inferior division deficits, may also see coma or symptoms of increased intracranial pressure Contralateral hemiparesis of face, arm, and hand; expressive aphasia if dominant hemisphere Homonymous hemianopsia, receptive aphasia (if dominant hemisphere), impaired cortical sensory functions, gaze preference, apraxias, neglect Contralateral leg paresis and sensory loss Monocular blindness Basilar artery Occipital lobe, thalamus, rostral midbrain, medial temporal lobes Ventral midbrain, brainstem, posterior limb of the internal capsule, cerebellum, PCA distribution Contralateral homonymous heminanopsia, memory or sensory disturbances Coma, cranial nerve palsies (leading to double vision, facial numbness or weakness, dysphagia, etc…), apnea, cardiovascular instability Deep circulation Lenticulostriate, paramedian, thalamoperforate, circumferential arteries Basal ganglia, pons, thalamus, internal capsule, cerebellum Pure motor or sensory deficits, ataxic hemiparesis, “dysarthria-clumsy hand” syndrome Pts 1 2 3 4 5 6 Motor Response (M) No response Decerebrate (extend) to pain Decorticate (flex) to pain Withdrawal from pain Localizes to pain Obeys verbal command Glasgow Coma Scale Verbal Response (V) No response Unintelligible sounds Inappropriate responses Disoriented, conversing Oriented, conversing Page 60 Eye Response (E) No response Open to pain Open to command Open Spontaneously Root / Nerve Motor C4 C5 C6 C7 C8 T1 T1-T12 L1 L2 L3 L4 L5 S1 S2-S4 I Olfactory II Optic III Oculomotor IV Troclear VI Abducens V Trigeminal VII Facial VIII Vestibulocochlear IX Glossopharyngeal X Vagus XI Accessory XII Hypoglossal Axillary Musculocutaneous Median Radial Femoral Sciatic Peroneal Tibial Breathing Shoulder abduction Wrist extension Wrist flexion Finger flexion Finger abadduction Abs, ribs Hip flexion (T12-L3) Hip adduction (L2-L4) Knee extension (L2-L4) Foot dorsiflexion & inversion Toe extension Foot plantarflex & eversion Rectal Tone MR, SR, IR, IO, eyelid, iris, lens SO LR Mastecation Eyebrows, eyelid close, smile Swallowing Larynx, swallowing Shoulder shrug Tongue protrusion Shoulder Abduction Elbow flexion Thumb opposition Finger Extension Knee extension Knee flexion Toe extension Toe flexion Page 61 Sensation Reflex / Pathology Lateral arm Thumb, index Middle finger Ring, small finger Medial arm Biceps Brachioradialis Triceps Below inguinal lig Middle thigh Lower thigh Medial leg & foot Lat. leg, dorsal foot Lateral foot Smell Sight Face Taste ant. 2/3 Hearing, balance Taste post. 1/3 Lateral Shoulder Lateral forearm Lateral Palm Dorsolateral hand Anterior thigh Posterolateral calf Dorsal foot Plantar foot Patellar Achilles Anosmia Blind, nonreactive Dilated, “down and out”, ptosis Downward gaze weak Esotropia Corneal Doll’s Eye Gag reflex Students will work at Bryce Hospital, WOW and/or the VA. UMC Betty Shirley Clinic – Wednesday afternoon with Dr. Arnold, Thursday afternoon with Dr. Williamson, and Friday afternoon with Dr. Giggie Wednesday mornings are reserved for lectures and PBLs – attended by all students on Neurology and Psychiatry Expect to be at work from 8 am until about 5 pm Monday – Friday. You will have Friday afternoons off for half of the clerkship for psychiatry independent study There is no call for psychiatry!! In the place of call students will attend 2 half-days at the Tuscaloosa County Jail with Dr. Giggie. In general students feel that this is a very unique and educational experience, so make the most of it! Clerkship Duties/Requirements: You will be required to log patients on a designated form and you are required to get signatures for each of these patients. Attend all of your required activities. Depending on the number of students on the clerkship, you may or may not have another student with you for these various activities. Students function mostly in an observation role at the various offsite placements. At Bryce, you will participate in new patient admissions and treatment team meetings. You may be asked to interview a patient or document in the chart as you get more comfortable, but this is site and attending specific. At the VA, you will observe outpatient clinic visits. Attend all assigned UMC Clinics, where you will interview new and established patients while the attending observes via closed circuit TV. You will be asked to document all patient encounters in the EMR, so ask for help navigating the system if necessary. Page 62 will present your learning issue at the start of the next PBL. Two patient write-ups – the first is due prior to the end of the first 4 weeks and the second is due prior to the end of the second 4 weeks. These write-ups must be thorough! Unless you are writing up a new patient, you will most likely have to review their previous records in the EMR to obtain all of the information that you need. Ask the nurses in clinic to help you. Detailed instructions and a sample write-up are available on the clerkship website – use them to help you! Again, these are very detailed, thorough write-ups and can be time consuming! Do not wait until the last minute to complete them. Basic science paper on a topic of your choice – due at the end of the 4 weeks in which you have psychiatry independent study time. More details will be provided during clerkship orientation. This is another time-consuming activity, so plan accordingly, especially if yours is due around the time of the shelf exams. Oral exam – You will watch a 30-minute video of a patient interview and then present that patient to one of the attendings (usually either Dr. Ulzen or Dr. Williamson). The attending will ask pertinent questions throughout your presentation and discussion of the patient. Instructions on what to expect and how to prepare on provided on the clerkship website – use them! TEAM Service Learning Requirement: there is a single TEAM activity for the Neuro/Psych rotation. For more information, see page 57. Recommended Resources: (listed in order of “usefulness” according to surveys of past students) First Aid for the Psychiatry Clerkship – highly recommended text for shelf exam review and oral exam preparation. Pretest Psychiatry Case Files Psychiatry Page 63 Psychiatry for Medical Students (provided for a rental fee) – another excellent resource for the things mentioned above. High Yield Psychiatry (provided for a rental fee) – very concise text with helpful tables, useful for quick review USMLE Work Step 2 CK QBank – about 150 board-style questions. Again, not worth the subscription fees just for this clerkship but helpful if you already have a subscription. Tips for Success: Pay attention and actively engage in all activities to the best of your ability! Students will often write off this clerkship, falsely assuming that it will not be relevant to them in their future careers. But regardless of what you choose to go into, you will encounter patients with psychiatric diagnoses! Use this clerkship to familiarize yourself with the common conditions and their treatments. It is also important to be familiar with the medical illnesses and drugs that can mimic psychiatric conditions. Because you spend the majority of your time talking to patients, it is also a good opportunity to work on your interviewing and rapport-building skills. The attendings will appreciate your attention and willingness to learn. Attempt to participate as much as possible, even at your offsite assignments. As mentioned above, you will primarily function in a shadowing capacity outside of the UMC clinic. However, it does not hurt to ask if you can interview a patient or write a note. As you become more familiar with how your particular site works, the attending may allow you to become more involved. Put some effort into your basic sciences paper. It does not have to be a lengthy dissertation, but a 2 – 3 page paper is not going to cut it. Make the assignment easier on yourself and choose a topic that will be relatively easy to find basic science information for. If you need help choosing a relevant topic, ask one of your attendings. Page 64 social profile) that may be completely unfamiliar to you. Use the resources provided on the clerkship website and ask one of the attendings for help/clarification if necessary. Do your best on the first write-up and try to use Dr. Williamson’s feedback to make the second one better. Include a thorough differential diagnosis (for each of the patient’s psychiatric diagnoses) and treatment plan – feel free to continue writing as long as you have something useful to say. Know the components of the mental status exam and what they mean for the oral exam! You may have to defend your impression of the patient, so be familiar with what you are talking about. Also know how to organize your diagnoses into Axis I, II, III, IV, and V. Be able to justify your GAF (or global assessment of functioning) score in Axis V! First Aid for Psychiatry provides a good GAF table. You can also probably find this information online. You can do really well on this shelf with appropriate studying. Again, remember to manage your time well because you will have 2 shelf exams during the last week of this clerkship. Focus your studying on psychopharmacology, including mechanism of action and common side effects, and how to distinguish one psychiatric condition from another, as there are sometimes only subtle differences. The vignettes on this shelf are very long and many students have difficulty finishing on time. Page 65 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. HPI Past medical history Past surgical history Past psychiatric history (include previous hospitalizations, diagnoses, treatments, ECTs, etc.) Social and family histories ROS Mental Status Exam a. Appearance, Behavior, Attitude i. General Appearance (apparent age, peculiarity of dress, cleanliness, cosmetics) ii. Motor Status (posture, gait, gestures, tics, grimacing, tone, tremors, picking, mannerisms) iii. Activity (over or under active, purposeful or disorganized, stereotyped, graceful, echopraxia) iv. Facial Expression (alert, tense, worried, sad, happy, dreamy, frightened, in pain, angry, sneering, ecstatic, laughing, smiling, suspicious) v. Behavior (indifferent, frank, friendly, embarrassed, seeking help, evasive, afraid, resentful, sullen, angry, irritable, assaultive, erotic, negativistic, denudative, exhibitionistic, dramatic, impulsive) b. Mood and Affect i. Mood (subjective emotional state – how the patient feels) ii. Affect (observed emotional state – your evaluation of the patient’s emotional state) c. Stream of Thought and Speech i. Speech (soft or loud, stuttering, hesitant, accent, enunciation) ii. Speed and Quality (rate of speech, delay, variation with different topics) iii. Stream of Thought (coherent or incoherent, illogical, vague, loosely organized, neologisms) d. Content of Thought i. Delusions (delusions of reference, delusions of alien control, special messages, nihilistic delusions, delusions of self-depreciation, delusions of grandeur, somatic delusions) ii. Hallucinations (auditory, visual, olfactory, gustatory, tactile, feelings of depersonalization) iii. Obsessions and Compulsions iv. Fantasies and Daydreams v. Thoughts of Violence (suicide, homicide, specific plans) e. Insight (patient’s understanding of significance of symptoms and situation) f. Judgment (patient’s past decisions and plans for the future) g. Cognitive Exam (MMSE) Physical Exam Labs/Studies Assessment (All 5 Axes) a. Psych b. Personality disorders, MR c. Physical, organic disorders d. Life stressors and quality (mild, moderate, severe) e. Global Assessment of Functioning Page 66 Ask the patient to count backwards by 7 from 100 (93, 86, 79, 72, 65). Stop after five answers. Alternatively, ask the patient to spell “world” backwards. 1 point for each correct answer, total = 5 Ask for the three objects mentioned earlier. 1 point for each correct answer, total = 3 Ask the patient to name two items, like a watch and a pencil. 1 point each, total = 2 Have the patient repeat the following sentence: “No ifs, ands, or buts.” 1 point Ask the patient to follow a three-step command: “Take this piece of paper in your right hand, fold it in half, and put it on the floor.” 1 point for each command, total = 3 Write “Close your eyes” on a piece of paper, and ask the patient to read it and do what it says. 1 point Ask the patient to write a sentence. 1 point if it contains both a subject and a verb Draw a pair of intersecting pentagons and ask the patient to copy it. 1 point Record the score as a total out of 30 points, and note which parts the patient missed. Total = 30 Record level of consciousness as ALERT – DROWSY – STUPOR - COMA Symptoms of Depression S = Sleep (increased or decreased amount) I = Interest (decreased) G = Guilt E = Energy (decreased) C = Concentration (impaired) A = Appetite (increased or decreased) P = Psychomotor Retardation S = Suicidal Ideation Symptoms of Bipolar Disorder Distractability Insomnia (dec. need for sleep) Grandiosity Flight of ideas Activitiesinc. goal oriented activities, impulsive Speechpressured, rapid Thought processracing thoughts Page 67 Dementia – most common are Alzheimer’s, multi-infarct, depression (pseudo-dementia) Degenerative diseases - Parkinson’s, Huntington’s, Diffuse Lewy Body Disease Endocrine - Thyroid, parathyroid, pituitary, adrenal Metabolic - EtOH, electrolytes, B12, glucose, hepatic, renal, Wilson’s Exogenous- Heavy metals, CO, drugs Neoplasia Trauma - Subdural hematoma Infection - meningitis, encephalitis, abscess, endocarditis, HIV, syphilis, Lyme, Prions Affective disorders – depression Stroke/Structure - multi-infarct dementia, ischemia, vasculitis, NPH Divided into two inpatient weeks, two ambulatory clinic weeks, one week at Children’s in Birmingham on a specialty service, and one week on “specialty” clinics (ADHD, adolescent, high risk, autism, sickle cell). The first and last weeks of the clerkship will be a mix of the above. Inpatient weeks: Rounds daily beginning around 8 or 8:30 am depending on the attending. Meet in the Pediatrics conference room (Room 501). You will alternate call days with the other student(s) who are also assigned to inpatient. Call is until 5pm (M-F), until 7pm (Sat) or until 7pm (Sun). Clinic Weeks: Morning clinic is from 8:30 am until noon and afternoon clinic is from 1:30 pm until about 5 pm. During the ambulatory week, students will attend lecture from 8-9am on Tuesday, Wednesday, and Thursday before going to clinic. On Friday morning you will go to rounds prior to clinic. In addition to call on your inpatient weeks, each student will be on call 2 total weekends. In addition to working your call day, you will also come in the next day to pre-round/round. For example, if you are on call on Saturday, you will come in Sunday morning for pre-rounds/rounds and then you can leave. Clerkship Duties/Requirements: Pre-round on your patients and write a progress note only if on inpatient. If it is a floor patient, the note will be in SOAP format just like on IM. For patients in the newborn nursery (well babies), there is a specific format for the note that will be provided during clerkship orientation, and you basically just fill in the blanks. Page 68 Attend assigned clinics. There will be often be more than one student and a couple of residents in clinic, and you are not assigned to a particular attending. You will take turns seeing patients as they become available and can then present to any of the attendings present in clinic. You will be asked to document all patient encounters on a designated form that you will hand to one of the attendings for review. If you need help with the EMR, just ask. You will learn to use it efficiently with time. Two patient write-ups – one for each of your outpatient clinic weeks. These must be turned in to the attending that saw the patient with you within 72 hours. Write-ups must include a fairly detailed differential and formulation. This part of the write-up can be time-consuming, so plan appropriately. Examples will be provided at orientation. If you cannot complete the write-up within 72 hours and need an extension, discuss this with your attending ahead of time. 30 – 45 minute PowerPoint presentation on a topic of your choice in the format of case presentation. These presentations will be given on Friday mornings after rounds. Your topic must be approved by the physician attending that week, so make sure to discuss it with them before you start working on your presentation. Observed history and physical. You will be videotaped performing a history and physical on a patient in the clinic and critiqued by one of the attendings. Don’t worry – this is not like an OSCE! The patients are real, not standardized patients. These sessions are scheduled towards the end of your clinic weeks, so you will be used to seeing patients in the clinic. Try to forget that you are being taped and proceed as you would through any other clinic visit. 22 CLIPP cases – online clinical cases, each of which takes about 30 – 40 minutes to complete. Unlike the online cases in IM, you do not choose which cases you want to do. There is a guide detailing which cases coincide with ambulatory, inpatient, and specialty weeks along with some relevant reading material in the provided textbook. You do not have to complete the cases as they are assigned, but it is a good way to keep up with them. Otherwise, you will find that you are trying to complete them all at the end of the block when you are also trying to study for your shelf. Page 69 but will involve children! These activities will be scheduled for you. Recommended Resources: (Listed in order of “usefulness” according to surveys of past students) Case Files Pediatrics Pretest Pediatrics BRS Pediatrics– provides a great textbook/outline for all pediatric problems, diseases, etc. Worth the buy on Amazon.com. Pediatrics for Medical Students (provided) – will be helpful for weekly assigned reading and as a more in-depth resource for write-ups and presentations. USMLE World Step 2 QBank – almost 300 board-style pediatrics questions. Not worth the subscription cost just for this clerkship, but it is helpful to go through these questions if you have a subscription. Others with mixed reviews: Blueprints Pediatrics, First Aid for Pediatrics Tips for Success: Participate, participate, participate! The attendings on this rotation really like to hear from you. In general, they foster a very relaxed environment and want to make you feel comfortable to speak up. Because the service can often slow down and have very few patients, the attendings frequently use rounds as a time to teach in the form of interactive lectures or games. Try to contribute during these times. It gives them a chance to hear what you know and to identify any concepts or skills that the group might need further instruction on. It also gives you a chance to show that you are interested and eager to learn. Page 70 mg/kg/day! Put in the time and effort necessary to do a good job on your write-ups and PowerPoint presentation. Although your grades on these activities do not directly factor into your overall grade, they can make an impression (good or bad) on your attending, which may factor into your evaluation. Use these opportunities as a time to shine. Try to take good social and developmental histories, as these are particularly important in pediatrics. Gleaning an impression of a child’s home environment and social structure can lend a great deal to the pictures of his or her overall health. Your attending will be impressed if you are able to garner some of this information and determine how it might impact the patient’s current complaint or management possibilities. Show an interest in learning to take care of children and adolescents. When you are rounding in the Well Baby Nursery, you’ll often be examining a baby with a dirty diaper.... don’t think that changing a diaper is above you! The nurses are especially appreciative of students who are willing to help, and they will do their best to help you if you return the favor. Just be sure to let them know that you changed a diaper, as the nurses have to tally voids and bowel movements for all of their infants. Utilize your down-time on inpatient weeks. If things are slow during the day in the hospital, use your spare time to read up on patients and study for the shelf. You will have less down-time on clinic weeks in which to study. Know your bugs and drugs for the shelf! Page 71 Sepsis Workup (SWU) Viral Respiratory Panel (VRP) CXR, CBC with differential, blood cultures, lumbar puncture P = Parainfluenza Treatment A = Adenovirus Ampicillin 50 mg/kg q6h I = Influenza Cefotaxime 50 mg/kg q8h R = Respiratory Syncytial Virus (RSV) Treat for 48 hours or until cultures are negative. If patient looks good clinically, sometimes they can be managed at home on Rocephin after 24 hours on IV antibiotics and if cultures are negative. Immunization Schedule (as of 1/01) more recent Update always available Birth HepB Apparent Life Threatening Event (ALTE) 2 months DtaP, Hib, IPV, PCV, HepB Check for sepsis (SWU). 4 months DtaP, Hib, IPV, PCV Check for reflux (Upper GI). 6 months DtaP, IPV, PCV, HepB Check for seizure (EEG). 12-15 mo DtaP, Hib, PCV, MMR, VZV, HepA Check for cardiac disease (EKG). 4–6 years DtaP, IPV, MMR, HepA 11-12 years MCV4, Tdap (Td q10 years after) Formulas for Pediatrics Body Surface Area (m2): [(4 * weight in kg) + 7] / [wt. in kg + 90] Intake: neonates (1-28 days old) in cc/kg/day (note: 1 oz = 30 cc) All other children in cc/ m2 /day Output: cc/kg/hr (note: anything <1 cc/kg/hr is too little, report it to a resident) Maintenance IVF > 1500 cc/ m2 /d to prevent dehydration —use ¼ NS for pt. 6 mo —use ½ NS for 6 mo – 2 yrs Page 72 Fine motor: Follows objects past midline Personal/social: Recognizes parent Three months old Gross motor: Supports on forearms in prone, holds head up steadily Coos Holds hands open at rest, follows in circular fashion Personal/social: Reaches for familiar people or objects Language: Fine motor: Four to five months old Gross motor: Rolls front to back, back to front, sits well when propped, shifts weight Orients to voice Moves arms in unison to grasp, touches cube Personal/social: Enjoys looking around Language: Fine motor: Six to eight months old Gross motor: Language: Fine motor: Sits well unsupported, puts feet in mouth Babbles Reaches with either hand, transfers, uses raking grasp Personal/social: Recognizes strangers Nine months old Gross motor: Language: Creeps, crawls, cruises, pulls to stand Understands no, waves bye-bye, dada, mama Fine motor: Pincer grasp, holds bottle, finger feeds Personal/social: Explores environment, plays patty-cake Two years old Gross motor: Language: Walks up and down steps without help Uses pronouns inappropriately, understands two step commands; one-half of speech can be understood Fine motor: Removes shoes and pants Personal/social: Parallel play Three years old Gross motor: Pedals tricycle, can alternate feet when going up steps Three word sentences, uses plurals, past tense, 250 words, ¾th of speech can be understood Fine motor: Dresses and undresses partially, dries hands, draws a circle Personal/social: Group play, shares toys, plays well with others, knows name, age, and sex Language: Four years old Gross motor: Hops, skips, alternates feet going down stairs Knows colors, says song or poem from memory, asks questions Fine motor: Buttons clothing fully, catches ball Personal/social: Tells tales, plays cooperatively with a group Language: Five years old Gross motor: Twelve months old Gross motor: Language: Walks alone Two words other than dada and mama 13 months = 3 words 14 months = follows one step commands Fine motor: Throws objects, lets go of toys, mature pincer grasp Personal/social: Imitates actions, comes when called Fifteen months old Gross motor: Language: Fine motor: Personal/social: vocabulary Builds tower of five blocks, drinks well from cup Personal/social: Asks for food and to go to the toilet Fine motor: Creeps up stairs, walks backwards Uses 4 to 6 words Builds tower of two blocks Cooperates with dressing Page 73 Skips alternating feet, jumps over low obstacles Language: Prints first name Fine motor: Ties shoes, spreads with knive Personal/social: Plays competitive games, abides by rules, likes to help in household tasks morning rounds. You will be assigned an attending each week and will go to surgery when they do. Specifics about the schedule will be given during clerkship orientation. Morning rounds at 7:30 am, meet in the 3rd floor conference room Lectures, typically Monday – Thursday afternoons around 1 pm at UMC. These are subject to change per the attending’s schedule. Clerkship Duties/Requirements: Pre-round on your patients each morning and write a progress note. Typically, patients are divided up evenly amongst the students on the service. It is helpful to ask the resident on night float to contact your group around 5 am to let them know how many patients are on the service, so they can plan appropriately. These patients are generally less complicated than those on medicine, but you should probably still give yourself at least about 30 minutes in the beginning to see the patient and write your note. Use your Maxwell or the outlines on pg 78 as a guide for how to write a postpartum progress note. Your note on other inpatients will typically follow the standard SOAP format. Present your patients during morning report. You will have to formally present your patients each morning, but these presentations are far more concise than those on medicine. Again, there is some variation between attendings in terms of how they like patients presented. Ask your resident/ fellow for help! While on day call, participate in patient admissions and consults by performing histories and physicals. These histories are a bit different, focusing on a patient’s menstrual, sexual, and obstetrical histories. Get comfortable talking about these sensitive subjects with patients – this rotation is probably your best opportunity to do so. Page 74 Check on laboring and post-op patients and write progress notes when necessary. Patients on magnesium require checks every 2 hours – ask your resident to show you what is involved in these. Participate in all deliveries while on call and write the delivery and postpartum notes. If not on day float, attend clinic after morning report, arriving no later than 9:00 am. You will be assigned to a particular attending each week to work with in clinic. Although each attending is different, you will have the opportunity to be quite autonomous in clinic once your attending is comfortable with your exam skills. You may or may not be asked to document all patient encounters in the EMR. Attend lecture – these are mandatory. 30 minute PowerPoint presentation on a topic of your choice related to women’s health. These presentations will be given in front of the other students and Dr. Hooper on Thursday afternoons in lieu of lecture. Don’t wait until the last minute to prepare! Dr. Hooper likes these presentations to be a bit more formal than those required on other clerkships in an effort to help the students work on their oral presentation skills. You will be asked to give one another constructive criticism, so be prepared. Everyone has room for improvement, so be honest and try to give helpful feedback. Oral exam – discussion of 3 – 4 cases with one of the attendings, lasting about 30 minutes. This exam causes a lot of stress amongst the students, but trust those who have taken it before you when they say it is not that bad. Students generally perform very well, and the questions are relatively direct and straightforward. There is a study guide available on the UMC shared drive (ask prior students where to find it). It is a good resource along with the handouts from student presentations. Scrub in on surgeries when time allows. Details on when you can work in OR time will be given during clerkship orientation. Page 75 rics and Gynecology (ACOG). This is a free question bank that requires you to create a login for access. Great boards-style review questions on a variety of topics. First Aid for the OB/GYN Clerkship Case Files OB/GYN Others: Blueprints (particularly the test at the end), Pre-test OB/GYN Obstetrics and Gynecology (provided)– same textbook used for the Reproduction module in second year. Good resource for topic reviews, PowerPoint presentation, and in-depth review. USMLE World Step 2 CK QBank – about 200 board-style questions. Not worth the subscription fees just for this clerkship but helpful if you already have a subscription. Tips for Success: Be proactive! Ask to see as many patients as possible and perform as many exams and procedures as possible. However, be respectful of that fact that the attendings do have private patients that may not want to see a student, so always ask! Be confident but not cocky. The attendings will appreciate if you are eager to learn and participate in exams and procedures, so don’t be timid. The old adage of “see one, do one, teach one” applies here – be prepared to perform a delivery (with the close assistance of a resident and attending). Page 76 make you look good! Make friends with the L&D nurses! Introduce yourself and ask them to help you and teach you, and they will generally respond well. They are a great resource for certain procedures, especially cervical checks. Be respectful and stay out of their way. Practice your suturing and knot tying! There are great instructional videos on YouTube and equipment to practice with in clinic – ask where to find it. Use slow clinic days to practice. Attendings will often expect you to suture or tie during surgery and will impressed if they don’t have to stop to teach you then. Talk to your patients while you are examining them! The pelvic exam can be an uncomfortable experience for a patient, and distraction is an effective tool to help them relax. Try to strike up a conversation and build rapport during the less invasive parts of the exam, and continue talking as you proceed through the rest of the exam. It will also help you relax and feel less awkward. Read and study because the information in this clerkship is masterable. You can perform quite well on the oral exam and shelf if you put in the work. Be prepared to be pimped thoroughly by some attendings. Often, they will continue asking questions until no one, not even the fellow, knows the answer. You are not expected to know every answer, but the more you read and study and speak up, the more impressed they will be. Spend time preparing and practicing your presentation for Dr. Hooper. He likes for students to begin with a brief introduction addressing why their topic is relevant to the audience and to provide some conclusion to the presentation after questions from the audience have been fielded. He will be impressed if you can give your presentation without reading off of your slides and with minimal “ums” and “uhs.” Practice for the oral exam with the other students, particularly if you are someone who gets nervous or blanks when asked questions directly. Answering questions for an oral exam requires different skills than those required to do so on a multiple-choice exam. Practice asking one another questions from the study guide or handouts to get a feel for the format. Page 77 Family: Social: PN Labs: ROS: PE: Assessment: Plan: newborns), last period. fetal anomalies, deaths, etc. smoking, EtOH, drugs, work. H/H, glucose screen/GTT, Urine, U/S, rubella, Rh+/-, etc. HA, scotomas, diplopia, edema, epigastric pain, pruritus, dysuria, flank pain, fever… Important things here are the vitals, abdominal exam (fundal height), cervical exam (dilation/effacement/station), extremity exam (edema, pedal pulses), and monitoring (FHT, decelerations) __ yo f GP with IUP @ __ wk EGA by ___ Admit, observe, manage expectant vaginal delivery. Activity: bedrest with bathroom privileges <Anesthesia consult if epidural requested> Diet: NPO, ice chips Continuous toco and FHM Labs: CBC, U/A, etc. DELIVERY NOTE Pt is a __ yo f GP @ __ wks. At (time) pt delivered a __lb __oz baby (sex) with Apgars _, _. Baby was (position) and delivered (method), nuchal cord x __ over __ degree episiotomy. Bulb suction was performed on the perineum. (? Meconium present) Placenta was delivered intact with three vessel cord. (? Episiotomy – median or medial lateral performed with repair in __ layers with __ suture.) EBL = ___ ml. Mother to recovery room in stable condition. Infant to __ nursery in __ condition. Anesthesia __ per __. Attending/Resident/MS. POST-PARTUM PROGRESS NOTE S: O: A/P: PPD(POD)#__ s/p SVD (C/S 2o to indication)/Gest. Age, date & time of delivery/Sex of baby, Apgars/Med. Problems/Antibiotics/Rh status (RhoGAM)/Rubella status/Breast or Bottle Feeding /Contraception/Follow-up Clinic. Document the following, e.g. Pt ambulating without difficulty and passing flatus. Eating and voiding without difficulty. Vaginal d/c (lochia, rubra). +/- breast engorgement. Pain control. Vitals, I/O, PE including abdomen (fundal height, firm/soft, bowel sounds), extremities, incision status. Labs, including pre and post-partum H/H. __ yo f Para___ PPD/POD#__ s/p SVD/cesarean with pertinent findings. Continue routine care. Ambulate, DC Foley, Hep-lock IV, start PO pain meds, etc. Discharge on Iron (if Hct <25 then start FeSO4 325 mg PO tid; >25 but <30, give bid; >30, give qD). Info to get on a gynecologic history Age, G’s and P’s, LMP, contraceptive use?, last Pap smear and mammogram Menarche, cycle length, regularity, # days of menses, light vs. heavy flow, changes in flow Spotting or post-coital bleeding, vaginal discharge (color and smell) Pre-menstrual symptoms and medications History of STDs, vaginal discharge, abnormal pap smears, gynecologic surgeries If past menopause – use of hormone replacement therapy If with abnormal uterine bleeding - # pads used per day, passage of clots & size Page 78 Naegle’s rule: EDC = LMP – 3 mo + 7 days Pregnancy dating Use the LMP if: 1st trimester, and U/S and LMP differ < 7 d 2nd trimester, and U/S and LMP differ < 14 d 3rd trimester, and U/S and LMP differ < 21 d FHT should be heard with Doppler @ 10-12 wk FHT should be heard with stethoscope @ 18-20 wk Fetal movement first occurs around 18-20 wk From 15-36 wk, fundal height in cm = # wk gestation 18-20 wks 24-28 wks 34-38 wks 36 wks A1 GB B C Ante-natal labs 15-18 wks White Classification for Diabetes in Pregnancy A2 Clinic visits (goal > 10 visits) every 4 wk until 28 wk, then every 2 wk until 36 wk, then every week until 41 wk, then twice weekly post dates. Initial Visit values are elevated on the OGTT: Fasting < 105 mg/dL 1-hour < 190 mg/dL 2-hour < 165 mg/dL 3-hour < 145 mg/dL. Additionally, two fasting glucose levels > 120 mg/dL in one week are diagnostic of gestational diabetes (no OGTT necessary). CBC, type and screen, Rh, rubella, VRDL, GC/ entamici, HbsAg, Pap, PPD, U/A, HIV, 50 g glucose tolerance test (GTT) if with risk factors. mat serum FP, hCG, estriol, amniocentesis ultrasound for dates 50 g GTT; 3 hr GTT if needed; if Rh(-), give RhoGAM @ 28 wk; repeat CBC if anemic CBC check cervix q week Normal labor Engagement Flexion Descent Internal rotation Extension External rotation Causes of abnormal labor 1. Powers: ineffective uterine contractions, excess sedation, exhaustion, infection, severe polyhydramnios, neuromuscular disease 2. Passenger: abnormal fetal position, lie, or presentation (face, brow, compound), fetal macrosomia, hydrocephalus 3. Passage: cephalopelvic disproportion, uterine masses, unripe cervix, pelvic fractures, kyphosis, rickets, cervical pathology, overdistended bladder Page 79 D F H R Abnormal Glucose Tolerance Test (GTT), controlled by diet Abnormal GTT, fasting glucose between 105-120 with 20-25 U NPH qd Fasting glucose > 120 despite diet and split-mix insulin Age of onset > 20, or duration < 10 years Age of onset between 10-20, or duration 10-20 years Age of onset < 10, or duration > 20 years Presence of diabetic nephropathy Presence of ischemic cardiovascular disease Presence of prolific retinopathy Management during Pregnancy A1 A2 GB-R ADA diet (35 kcal/kg/day), check fasting blood sugars at routine prenatal visits. ADA diet and low-dose insulin (start with 20-25 U NPH before breakfast). ADA diet and split-mix insulin, prenatal visits every 2 weeks until 30 weeks, then every week. Baseline ophthalmology exam. Monitor urine protein/creatinine ratio. Ultrasound at 20-22 weeks, then every 4 weeks beginning at 28 weeks. Post-partum Management A1,2 GB B-R ADA or regular diet, no insulin needed. Follow pattern dextrosticks for 24 hours, consider SSI. ADA diet when tolerating PO. Decrease insulin to half pregnancy dose, or SSI. Dextrosticks q6h until taking PO, then pattern. Use NS instead of LR. Follow-up in one week. Triple Screen: Down syndrome = ↓aFP (20-25%),↓unconjugated estriol ↑hCG. Neural tube defects = ↑aFP. Abno and genetic amniocentesis. This screen ID’s 60% of Down syndrome and 60-75% of all trisomy 18. 2 Offered if birth defect has occurred in mother, father, or previous offspring. 3Quad Screen: ↓aFP &estriol + ↑ hCG & Inhibin A = Down Syndrome/Trisomy 18 (Edwards). ↑aFP in neural tube drome, TOF, anencephaly 1 Page 80 Page 81 Harris and Falgout; Glenn Wheeling, PA) and 4 weeks spent with University Surgical Associates (Drs. Matthews, Gross, and Bilton). If you are interested in a surgical subspecialty, it does not hurt to ask if you can work with one of the surgeons in that field for one block. There is a considerable amount of variation in your schedule during this rotation depending on who you work with. Each attending will differ in terms of required clinic time and if/when to pre-round on patients. Most of the surgeons operate at multiple sites (DCH, Northport, Tuscaloosa Surgical Center), so be prepared to travel between these locations. When you are with “the Group,” you will be assigned to a surgeon for two week intervals. Pre-rounding requirements will vary depending on the surgeon you are assigned to. You will sometimes round with the attending between cases or before going to clinic. The amount of clinic time required on this service is increasing. Specifics about when you are to attend clinic will be given during orientation for the clerkship. Generally, you will attend surgeries in the morning and clinic in the afternoon if there are no surgeries. When you are with “the Group,” you determine your own call schedule with the other students on the service, dividing it equally amongst yourselves. Whoever is on call needs to notify the attending on call in person and/or call their office so that they know which student to call/page. As you divide up call days, it might be helpful to know that trauma call is generally the busiest, and some attendings are more likely to call you than others. Prior students can provide you with more details and suggestions for how to divide up the schedule. When you are with one of the University Surgical Associates, you will take call when they take call. It usually works out to be every 4 th night and one weekend a month unless someone is on vacation. Again, trauma call is the busiest – expect to get a call on these nights. Page 82 you to pre-round on all patients before the first surgery of the day and attend clinic every day. Others have you pre-round after surgery while they are in clinic. Your attending will tell you what he expects. You are allowed to take surgical call from home if you live in the Tuscaloosa area (within 20 minutes of the hospital). Once dismissed by your attending, you may go home, but keep your cell phone and/or pager on you in case your attending needs you to come back to the hospital. If you are commuting from the Birmingham area, there are call rooms available on the 4 th floor for you to use. Remember – you are NOT allowed to consume alcohol, medications, or any other substance that may impair your abilities to participate in patient care while you are on call. If you do and your attending calls, notify him that you will be unable to return to the hospital. DO NOT return to work after drinking under any circumstances! Clerkship Duties/Requirements: Attend and participate in surgeries. Often, you will act as first assist and will help suture at the end of a case. Your attending may allow you to perform some of the more minor procedures, so don’t be shy! Take advantage of the one-onone teaching provided on this campus. Attend clinic as required by your surgeon. You will occasionally see patients on your own and present them to the attending, but often you will do more shadowing in clinic. You will often be allowed to remove staples and stitches and perform other minor procedural tasks. Clinic provides an opportunity to learn a lot of useful information – when surgery is indicated and when it is not, what work-up is necessary prior to surgery, who is a good surgical candidate and who is not, how to counsel a patient prior to surgery, etc. You will see this type of information on your shelf, probably more than what you are learning during the surgeries themselves. Attend all lectures. Lectures occur almost daily, usually in the afternoons, on the 4th floor of DCH. A lecture schedule will be posted on the door but changes frequently. Grace, the clerkship secretary, will text you reminders about lecture and about any changes to the schedule. Lecture is mandatory unless you are scrubbed in on a rare surgery. Page 83 round on some of their patients without being asked. Pre-rounding/ rounding gives you an opportunity to focus on post-operative management of patients, another important topic for your shelf. Surgical progress notes follow the SOAP format but are meant to be very concise, focusing on pain control, vital signs, urine output, relevant labs, and wound healing. Use your Maxwell for guidance on how to write surgical notes. Dictate H&Ps/consult notes as required by your attending. Some attendings, particularly with University Surgical Associates, will ask you to dictate H&Ps and consults for them. Information will be provided about how to use the dictation system. While this might seem like a daunting task at first, it is excellent practice. You will be required to dictate histories, consults, and discharge summaries as a resident, so doing it on this rotation gives you a head start. If he does not already do so, ask your attending to review your dictations with you and offer suggestions for improvement. Osler presentation – 15 – 20 minute PowerPoint presentation on a case that you have seen during the rotation. Keep at patient/procedure log using the E-Value system. You must log at least 60 procedures. Try to enter your procedures every day or two, so that you can keep up with them. You must turn in a print out of your log at the end of the rotation to Grace. TEAM Service Learning Requirement— One Tuesday morning during the clerkship from 8-12 will be spent at Northport Rehab. The first half of the morning will be spent rounding with the Dr. Barnett the physiatrist and the second half be spent with rehab team. Page 84 a great brief summary of a wide variety of surgical cases. Pestana has worked for Kaplan in the past, so his material is very similar to Kaplan reviews. This is a great high-yield resource. Print out a copy to stick in your white coat and review during down time between surgeries. Surgical Recall (provided) – provides a good overview of various surgical conditions, the relevant anatomy, and the surgical procedures used. You will typically know what surgeries are the on the schedule for the following day, so this is a great resource to use the night before (or even 10 minutes before) you go into the OR to brush up on the procedure you are doing. It typically has answers to lots of the questions the surgeons will ask you during a procedure. Case Files (provided) – easy to keep on you and study with when you have down time between cases. Essentials of General Surgery (provided), NMS Surgery (provided) – more detailed textbooks that can be used as a reference when preparing your Osler presentation or when you need an in-depth review. NMS includes various cases to address management issues. It has a good trauma section that is high-yield for the shelf exam. Pretest Surgery—mixed reviews. Some found it helpful while others found the questions much more difficult than the shelf exam. USMLE World Step 2 CK QBank – about 160 board-style surgery questions. Not worth the subscription fees just for this clerkship but helpful if you already have a subscription. Page 85 tired when you leave work, but try to make a little bit of time to read for the following day. It will pay off when you are able to answer your attending’s questions and generate questions of your own that show you are interested. KNOW THE ANATOMY! The OR is the best place to learn to ventilate, intubate, suture, start IVs, and place Foleys, central lines, and chest tubes – seek out these opportunities! You may not be directly asked to participate in these procedures, but if you ask to help, you will typically be allowed to do so. These are good skills for any medical specialty. The OR staff is helpful and willing to teach if you show interest. Get to know the OR staff and use them as a resource, particularly if you are unfamiliar with the OR setting. It can take some getting used to if you don’t know your way around, so the nurses and scrub techs are immensely helpful. Always introduce yourself to the staff working the case and ask if you can help. Learn what you can and cannot touch and how to maintain a sterile field – this will save you from getting yelled at. Always ask permission before taking an instrument off the Mayo table! The nurse and scrub tech are responsible for accounting for all of the instruments and sharps at the end of a case, so they need to be aware of where everything is. The surgical PAs are an amazing resource – use them! Glenn has more experience than most of the surgeons combined. He will teach you how to properly suture but also how to be an effective first assist who can anticipate the surgeon’s needs. Don’t complain about the hours you are required to work! You can do anything for 8 weeks. Also, invest in some comfortable shoes: new tennis shoes, Danskos, and Clarks have served past students well. If you are interested in surgery, look for opportunities to take on extra responsibilities without being asked – pre-round on your attending’s patients, check on them post-op, etc. The attendings will appreciate your initiative. Pay attention during your OR orientation, when safety and sterile technique are reviewed. Even the “cleanest” patients could have something you don’t want, so protect yourself with all of the necessary OR garb, including eyewear. Be mindful of sharps and speak up if you get stuck. It might seem like an inconvenience to go through the reporting process, but it is worth it! Page 86 Appendicitis Inguinal hernia Salpingitis Ectopic pregnancy Inflammatory bowel disease Mesenteric adenitis (Yersinia) Early appendicitis Bowel obstruction Ruptured aortic aneurysm Gastroenteritis Inflammatory bowel disease Salpingitis Ectopic pregnancy Irritable bowel disease Constipation Diffuse: Causes include gastroenteritis, peritonitis, mesenteric ischemia, bowel obstruction Differential Diagnosis of Surgical Fevers Intraoperative or immediately post-operative Malignant hyperthermia (halothane) Transfusion reaction Drug hypersensitivity Atelectasis Aspiration pneumonia Endocrine (Addisonian crisis, thyroid storm, pheochromocytoma) Post-operative fever (any time) Thrombophlebitis Deep venous thrombosis Drug hypersensitivity Transfusion reactions Central line sepsis Post-operative fever (> 24 hours) POD# 1-2 = “Wind” (atelectasis) POD# 3-4 = “Water” (urinary tract infections) Pneumonia IV complications (infection) Wound complications (leaking anastamosis, hematoma) POD# 4-6 = “Wound” (wound infections) POD# 6-10 = “Walking” (DVT) and “Wonder drugs” Abscess Drug fever Pneumonia Wound infections C. difficile colitis Anastamotic leak Post-operative fever (< 24 hours) C = Clostridial wound infections S = Streptococcal wound infections T = Thyroid problems A = Addisonian crisis T = Transfusion reaction Causes of Small Bowel Obstruction Adhesions from prior surgery Hernias Inflammatory Bowel DZ Malignancy-lymphoma, carcinoid, metast. Intussusception (mucous stools) PROCEDURE NOTE Recovery of Bowel Fx Post-Op: 1) Small Intest. Hours, 2) Stomach Day, 3) Colon ~3 days PROCEDURE PERMIT INDICATION PHYSICIAN(S) DESCRIPTION COMPLICATIONS EBL DISPOSITION Procedure, benefits, risks (including those of bleeding, infection, injury, anesthesia), and alternatives explained to patient who voiced understanding of the information and agreed to proceed. Permit signed and on the chart. Meningitis, pleural effusion, venous access, ascites, etc. Area prepped and draped in a sterile fashion. (Local, spinal, etc.) anesthetic administered using (cc medication). Describe technique including body location, instruments, etc. (Hopefully none) (estimated blood loss in cc) Patient resting comfortably, breathing non-labored, incision clean, dry, and intact, etc. Page 87 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Findings Procedure Surgeon Assistant(s) Anesthesia (type) Specimen(s) Estimated blood loss Fluids Tubes/drains Complications Miscellaneous/special Meds Post-operative Orders Disposition—where you want the patient to go Special Recovery Room Requests—labs, CXR, etc. Vitals—Q4h (or as per routine) Tubes/Drains—NG—>well suction, Foley to gravity... Bed position—elevated to ____ degrees Activity—where, frequency, etc. Diet—NPO except ice chips, liquid, regular, diabetic.. AM labs to be drawn Meds—the 6 A’s and home meds (analgesics, antibiotics, antiemetics, antacids, anticoagulants, and anti-inflammatories) Page 88 lectures, and presentations Each student will choose a family medicine preceptor in a rural location of his or her choice. A list of possible preceptors will be provided for you to choose from or you can make your own arrangements. Either way, try to choose someone early to ensure that you get the preceptor you want and all of the arrangements can be made. You will take the family medicine shelf at the end of the 4th week unless you are a rural medicine scholar. Clerkship Duties/Requirements; Assist your family medicine preceptor in his or her clinical and/or hospital duties. Specifics, including call requirements and schedule, will differ based on your preceptor. Attend all lectures and presentations in Tuscaloosa. These generally occur every couple of weeks and last a full day. One patient write-up/presentation to be presented at the end of week 2. Conduct interviews with several members of the community in which you are working. A list of who you should interview and suggested questions will be provided during clerkship orientation. Final paper and presentation describing what you learned about the community and its health needs based on your interviews. More information will be provided during clerkship orientation. Design and attempt to implement a project to address one identified health need in the community. Suggestions for projects based on what students have done in the past along with more information will be provided during clerkship orientation. Page 89 (Listed in order of “usefulness” according to surveys of past students) Note: Since this specialty contains elements from several of the other disciplines, any resources you used in past clerkships will be helpful to review for this one. AAFP Website questions (available with registration) Case Files Family Medicine USMLE World Step 2 CK QBank, Others with mixed reviews: First Aid, Blueprints, Kaplan Tips for Success: The family medicine shelf exam is difficult, particularly if you have this clerkship early in your third year. It includes info from internal medicine, pediatrics, OB/GYN, public health, community medicine, etc. If you have not had IM yet, spend a good amount of time reviewing that information. If you do not know of a preceptor you want to work with, ask for guidance from other students or the clerkship staff. Try to find someone who will let you actively participate and see patients on your own, and be proactive and participate in whatever ways your attending will allow you to. Practice developing your own impression and plan. Just like in IM, you learn a lot from doing this, even when you are wrong. Keep in touch with your mentor for rural medicine. Ask them to help you stay on top of your interviews and other requirements for your project. Page 90 AFVSS - afebrile vital signs stable ALI - acute lung injury AlkP - alkaline phosphatase ALT - alanine aminotransferase AMS - altered mental status APAP - tylenol APE - acute pulmonary edema ARA - advanced reproductive age ASA -- aspirin AST - aspartate aminotransferase AVNRT - atrioventricular nodal reentry AZT - zidovudine BLOC -- Brief Loss of Consciousness BNP - brain natrilretic peptide (measures CHF) BRBPR - bright red blood per rectum BRP – bathroom privileges BV – bacterial vaginosis Bx -- biopsy c (dash above) – with CA -- cancer CAP -- Community acquired pneumonia CCE - clubbing cyanosis edema CDI - clean dry intact CEE - conjugated equine estrogen CHIBLOC - closed head injury brief loss of consciousness COPD - chronic obstructive pulmonary disease CPPD - calcium pyrophosphate dz (pseudogout) C&S -- culture and sensitivity CST -- Contraction stimulation test CTA - clear to auscultation cTnI - cardiac specific troponin I CTS - carpal tunnel syndrome Cx -- culture DAU - drugs of abuse in urine ddI – didianosine DM -- diabetes DOE -- dyspnea on exertion DOS - day of surgery DRE - digital rectal examination DRG - diagnostic related group DTR - deep tendon reflexes EASI -- Extra-amniotic saline infusion ELISA - enzyme-linked immunosorbent assay EMC - endometrial curettage env - HIV structural gene envelope EOF -- Elective outlet forceps EOMI -- extraocular movements intact EPO - erythropoeitin EPS - extra pyramidal symptoms ERCP - endoscopic retrograde cholangiopancreatography ERT - estrogen replacement therapy ESWL - extracorporeal shock wave lithotripsy FBP - fluid balance panel f/c – fevers / chills FEF - forced expiratory flow FEN -- fluids, electrolytes, nutrition FENa - fractional exretion of Na FESS - functional endoscopic sinus surgery FEV1 - forced expiratory volume 1 second FH -- Fundal height FNA – fine needle aspiration FOBT - fecal occult blood testing f/u – follow up FUO - fever of unknown origen gag - HIV structural gene group antigen (core, capsid) GBS - group B strept GDM -- Gestational diabetes mellitus GGT - gamma glutamyltransferase GN - glomular nephritis GTT -- Glucose tolerance test GTTS - drops (opthalmic) HA - headache HAART - highly active antiretroviral therapy HD - hemodialysis Page 91 I&D -- Incise and Drain IADL - instramental activity of daily living IUD – intrauterine device IUP – intrauterine pregnancy IUFD -- Intrauterine fetal demise JP - jackson pratt drain JVD -- jugular venous distention KUB - kidney, urinary, bladder (Xray) LAD -- lymphadenopathy LMP – last menstrual period LOA - loss of appetite, looseness of associations LOC - loss of conciousness LTB - laryngotracheobronchitis LTCS -- low transverse cesarean section MAHA - microangiopathic hemolytic syndrome MAEW -- Moves All Extremeties Well MEN - multiple endocrine neoplasms M/G/S -- Moro, grasp, suck reflexes MMF - maxillary madibular fixation MMG -- mammogram MMM -- mucous membranes moist MMSE - mini mental status exam MOA - mechanism of action MRA - magnetic resonance angiogram M/R/G - murmurs, rubs, gallops MSM - male having sex c male MSO4 PCA - morphine pump(patient controlled analgesic) MVI - multivitamin MTR - microtubal reanastamosis NABS -- normal active bowel sounds NAD - no acute distress NGSF - no growth so far os - left od - right OCOP: oral cavity oral pharynx OCP -- Oral contraceptive pills OOB - out of bed OSH -- Outside hospital OTD – out the door p (dash above) – after, post p (circled) -- pending PBC - primary biliary cirrhosis PEA - pulseless electrical activity PEG - percutaneous endoscopic (esophageal) gastrostomy PERRL -- pupils equally round and reactive to light PIH - pregnancy induced hypertension PND -- paroxysmal nocturnal dyspnea PNH - paroxysmal nocturnal hemoglobinuria PNV - prenatal vitamin POC - products of conception; point of care POD - post Op Day pol - HIV structural gene polymerase PPD -- Post-partum day PROM - premature rupture of membranes (vrs. prolonged) PPROM -- Preterm PROM PSA – prostate specific antigen PSC - primary sclerosing cholangitis PTC -- Pre-term contractions PTCA - percutaneous transluminal coronary angioplasty RAIF - radioactive iodine uptake RF - renal/respiratory failure; rheumatic fever RH - rheumatoid arthritis r/o – rule out ROM -- Rupture of membranes RPOC -- Routine post-op care RPR - rapid plasmin reagin (syphillis) RRR - regular rate rythm elevation gt – drop SVD -- Spontaneous vaginal gtts – drops ID – intradermal delivery IM – intramuscular Sx -- symptom IV – intravenous Sz -- seizure IVPB – intravenous piggy back T&C -- type and cross T&S -- type and screen od – right eye TAB -- Therapeutic abortion os – left eye ou – both eyes TAH-BSO - total abdominal PO – by mouth hysterectomy bilateral PR – per rectum salpingoophrectomy PRN – as needed TBBX - transbnchial biopsy q – every TD - tardive dyskinesia TEE - trans esophageal echo qd – every day qam – every morning TEP - tracheal eeophageal puncture (for speech) qhs – at bedtime each night qid – four times a day TF - tubal factor TOA - tubo ovarian abscess q#h – every # hours qod – every other day TP - total protein TRALI - transfusion related acute SC – subcutaneous Sig – label lung injury TTE - trans thoracic echo Sol’n – solution Tx - treatment/therapy Supp – suppository UAG – urine anion gap Susp -- suspension UA/NSTEMI - unstable angina Tab – tablet non-STEMI Tid – three times a day UDS - urine drug screen Ung -- ointment UFH - unfractionated heparin US - ultrasound WDWN - well developed well nourished XRT - radiation Tx CRIMSON BOOK 2013-2014 Good Luck on your rotations! And remember, you can do anything for 8 weeks! Thanks, UASOM Class of 2014, Tuscaloosa Campus Page 92