Internal Medicine

Eye Symptoms

Dry Eyes

• Management:
  • Natural tears 1-2 drops QID

GI symptoms

Acute Abdomen

• Signs:
  • 1. Sharp pain
    
  • 2. Board like rigidity
    
  • 3. Guarding
    
  • 4. Rebound tenderness
•  Diagnosis:
  • Order immediately:
    • 1. CBC
      
    • 2. BMP
      
    • 3. Coags
      
    • 4. VBG
• Management:
  • Organisms: B. Fragilis, E.coli, Klebsiella(gram negatives and anaerobes
    
    • 1. Ceftriaxone or Cefepime
      or
      
    • 2. Levofloxacin + Metronidazole
      or
      
    • 3. Zosyn
      or
      
    • 4. Iminipenem + Cilistatin

Bowel Ileus

• Presentation:
  • 90 y.o. recent eye surgery
• Labs:
  • BUN/Cr (may be HIGH if clogged due to Dehydration)
  • CBC, Mg, PO4
• Imaging:
  • KUB (can trend)
  • CT A/P if necessary
• Management:
  • NG Tube
  • Miralax, Senekot, Enemas, etc……
  • Clear Liquid Diet (or NPO)
  • Encourage AMBULATION
  • *No Narcotics……No Electrolyte Imbalances
  • Digitally disimpact / Rectal tube………Consult GI/Surgery

Constipation

• Management:
  • 1. Lactulose 30mL PO qDay
    
  • 2. Colace 50-100 mg qDay
    
  • 3. Milk of Magnesia 60 mL PO
    
  • 4.Dulcolax

Diarrhea

• Management:
  • 1. Lomotil 10 mL PO qDay
    
  • 2. Imodium 4 mg PO one time then 2mg after each episode of diarrhea up to a max of 16 mg/day

Hepatorenal syndrome

• Presentation:
  • *Happens acutely in a cirrhotic patient
  • Cr will be HIGH & looks like Pre-Renal AKI that is refractory to fluid Tx
    
• Management:
  • Albumin + Octreotide + Midodrine
    
  • if refractory……..Dialysis……..then……Transplant

Hernia

• Questions to ask:
  • Anything that increases Intra-abdominal pressure which will precipitate a hernia
    
  • Ask about constipation, urinary retention, straining while peeing or pooping, heavy lifting, chronic cough, ascites, weight gain
• Presentation:
  • Strangulated inguinal hernia:
    • SIRS, nausea, vomiting, bowel obstruction with high pitched bowel sounds
    • DO NOT reduce, if you reduce it back into the abdominal cavity it can cause a peritonitis and septic shock
• Management:
  • Asymptomatic Inguinal Hernia:
    • You can observe, however, most will become symptomatic in the future, so you can offer elective surgery
  • 3 inguinal hernias need immediate surgery:
    • 1. Femoral hernias
      
    • 2. Inguinal hernias in infants
      
    • 3. Strangulated inguinal hernias(direct, and indirect)
• Complications of Inguinal Surgery:
  • 1. Testicular ischemia
    
  • 2. Pain and loss of sensation due to nerve injury
    
  • 3. Recurrence of hernia

Jaundice

• Jaundiced individual with known Hep. C:
  • LABS:
    
    • *Viral serologies – Hepatitis
      
    • *Autoimmune workup: ASMA, AMA, IgG
      
    • *Consider Ceruloplasmin and Urine copper
      
    • *Ammonia….CBC….BMP……LFT (AST, ALT, Bili, Alk Phos)
      
  • IMAGING:
    
    • *CT A/P
      
    • *RUQ U/S……….U/S for ascites possibly

PEG Tube

• Def:
  • Percutaneous endoscopic gastronomy
  • Nothing in it first 4 hours
• Indications:
  • Usually, for people who can’t swallow (ALS, Stroke, etc) (((Not passing Speech/Swallow eval)))
• “PEG” preferred over “TPN”:
  • TPN is used when GI tract must be avoided…..
    
  • TPN is given IV thru either limb vein or centrally in vein
    
  • TPN usually for…….Severe Crohns/UC…..Short Gut syndrome…….malabsorption
• How to take out:
  • grab the tube and pull super hard and be careful not to spill the fluid
  • …….pull tube all the way out and place gauze and tape there…..will heal in 24-48hrs
    
  • ****Make SURE Pain meds are on board BEFORE pulling tube…..bc it is SO PAINFUL
• Notes:
  • PEG will form eventually a permanent fistula from the stomach to outside belly
  • People with Cancer or recent upper GI surgery may temporarily need PEG to maintain nutrition
  • ***Woody: “PEGs do NOT lengthen life or its quality”
  • ***You can remove PEGs and the site will heal to normal on its own 

Infection Symptoms

Bacterial Endocarditis

• Diagnosis:
  • === Duke Criteria (2 major…or…3 minor + 1 major)
  • Major Criteria
    • + Blood cultures
    • + TEE/TTE New vegetation
  • Minor Criteria: (FIVE PM)
    • 1) Fever
    • 2) Immunological phenomenon (Osler node, Roth spots)
    • 3) Vascular (infarcts, septic emboli, conjunctival hemorrhage, Janeway lesions)
    • 4) Echo (suggestive)
    • 5) Predisposition (+ Hx of IVDU; Heart condition)
    • 6) Micro (+ Blood culture, but not enough for Major count)
• Tx/Workup:
  • *Minimum of 3 blood cultures BEFORE starting Antibx (drawn from Peripheral veins)
  • *TTE (TEE if inconclusive)
  • *NO Anticoagulants (Mycotic aneurysm)
  • *Vancomycin + Gentamicin (Broad coverage 1st)

Metabolic Symptoms

HypOnatremia

• Determine volume status by:
  • H&P 
• Management:
  • Compare the Measured Serum Osmolarity to the Calculated Serum Osmolarity
  • calculate Serum Osmolarity: Serum Osm = 2(Na) + (Glucose/18) + (BUN/2.8)
  • Hypotonic hypOnatremia:
    • when measured serum osms are < calculated serum osms
    • order Urine Sodium and Urine Osmolarity
    • Types:
      • Hypotonic Hypervolemic Hyponatremia:
        • 4 MC causes:
          • 1. CHF
            
          • 2. Nephrotic Syndrome
            
          • 3. Cirrhosis
            
          • 4. Advanced kidney disease
        • Management:
          • Diuresis
      • Hypotonic Euvolemic Hyponatremia:
        • 4 MC causes: RATS
          
          • 1. RTA type 4 (due to aldosterone insufficiency/resistance, so they will be hyperkalemic as well)
            
          • 2. Addison’s or Addisonian crisis
            
          • 3. Thyroid conditions(hypothyroidism)
            
          • 4. SIADH
        • Tests:
          • 1. RTA type 4: Urinalysis
            2. Addison’s: ACTH test measuring serum cortisol
            3. Thyroid disorder: TSH
            4. SIADH: Volume Restriction
        • Management:
          • water restriction
      • Hypotonic Hypovolemic Hyponatremia:
        • Management:
          • IV fluids
  • Isotonic Hyponatremia:
    • when measured and calculated serum osms are isotonic
    • Fats and proteins are messing with the lab measurement of serum sodium. Hyperlipidemia or Hyperprotenemia
  • Hypertonic Hyponatremia:
    • when measured serum osms are > calculated serum osms
    • Something else in the plasma is contributing to the osmolarity, such as Glucose from hyperglycemia. It could also be alcohol.
• Notes:
  • ADH:
    • Volume or osmolality win when Blood pressure is low and osmolality is low in regards to ADH release:
      • Volume wins. Even though osmolality is low, ADH is still stimulated because body needs to conserve water to keep perfusion up.
    • 3 causes of hyponatremia with low ADH:
      • 1. Tea and Toast syndrome
        
      • 2. Beer Potomania
        
      • 3. Compulsive water drinking
    • Tea & toast syndrome and beer potomania cause hyponatremia:
      • No solutes in beer and carbs, so Carbohydrates and Alcohol are metabolized to water and CO2, so basically they are just adding water to their system.
    • Tests for ADH response:
      • Urine Specific gravity or Urine Osms will tell you if ADH is active or not

Hyperkalemia

• Diagnosis:
  • 2 EKG changes due to hyperkalemia:
    • 1. Tented T waves
      
    • 2. Widened QRS
• Management:
  • 1. Stabilize:
    
    • IV Calcium Gluconate or IV calcium chloride
  • 2. Temporize:
    
    • Insulin + D50 or Sodium Bicarbonate
  • 3. Eliminate:
    • 1. Kayexalate which eliminates K+ in the stool
      Or
      
    • 2. Furosemide which eliminates K+ in the urine…but cannot use in renal failure patients
• Notes:
  • Maximum rate of replacement of K+ through a central line: <20 mEq/L per hour
  • Serum K+ rise in response to 10 Meq of KCl: 10 Meq of KCl raises serum K+ 0.1 meq
  • K+ Ryder: KCl 40 Meq in 250 mL Normal saline given as a piggyback IV
  • Infusion rate for K+ Ryder: 
    • Never more than 10 Meq per hour.
      
    • In the K+ Ryder, there is 0.16 K+ Meq per mL(40 meq/250ml NS) thus works out to never be more than about 60 mL/hr. However, if it is a 100mL bag of K ryder then you don’t want to infuse greater than 25 mL/hr, so it depends how much saline volume the KCl is dissolved in
  • K+ Dur: KCl 40 Meq tablets PO
  • Replace potassium PO: KCl PO q4hrs

HypOkalemia

• Diagnosis:
  • EKG findings:
    • 1. Flattened T waves or T wave inversions
      
    • 2. Widened P waves
      
    • 3. ST depression
      
    • 4. U waves

Hypercalcemia

• Emergent situation:
  • Furosemide + IV Fluids
    
  • you need the furosemide to get rid of calcium in the urine, but the diuresis can cause hemoconcentration and cause serum calcium to increase, so you need to provide IV fluids simultaneously to prevent this dilution effect

Hypermagnesemia

• Signs:
  • 1. Hypotension
    
  • 2. Bradycardia
    
  • 3. Loss of DTRs
    
  • 4. Confusion
• Definitive Treatments:
  • 1. IV Calcium Gluconate
    
  • 2. Hemodialysis

Hypomagnesemia

• Causes:
  • 1. PPIs
    
  • 2. Loop diuretics
    
  • 3. Cisplatin
    
  • 4. Tacrolimus and Cyclosporine
    
  • 5. Foscarnet
    
  • 6. Amphotericin B

Notes:

• any electrolyte abnormality where the patient is at serious risk for death or injury:
  • Put in a Quinton catheter into the right IJ and start dialysis
• Recommended daily intake of Sodium according to WHO:
  • 87 mmol sodium. Thus, if you give too much IV fluids of normal saline, patients will get too much sodium and become edematous and hypertensive
     

Musculoskeletal Symptoms

Open Fractures

• Management:
  • cefazolin 2 mg IV q12hr
    
  • vancomycin 15mg/kg IV q8hr
    
  • give both within 1 hour of open fracture

Respiratory Symptoms

Anaphylaxis

• Etiology:
  • Basophils and Mast cells…….release IgE
    
• Presentation:
  • “Urticaria + Angioedema + Hypotension”
    
• Treatment:
  • 0.3-0.5 mg IM q5minutes

Toxicology

Alcoholic

• Banana Bags:
  • most often used for *alcoholics who need thiamine* to prevent Wernicke-Korsakoff syndrome.
  • used in the Intensive Care Unit to correct *acute magnesium deficiencies*
  • Contents:
    • The typical composition of a banana bag is 1 liter of normal saline (sodium chloride 0.9%) with:
    • Thiamine 100 mg
    • Folic acid 1 mg
    • Multivitamin for infusion (MVI), 1 ampule
    • Magnesium sulfate 3 g

Urinary Symptoms

Acute Kidney Injury (AKI)

• Diagnosis:
  • 1. Spot urine sodium or FeNa or FeUrea or Urine Osmolality
    
  • 2. Renal Ultrasound to check for hydronephrosis and rule out Postrenal cause
  • If a patient with prerenal/renal AKI is on diuretics, to determine cause order: FeUrea
• Management:
  • Initial:
    • 1. IV fluids
      
    • 2. Stop any nephrotoxic drugs
      
    • 3. treat conditions like sepsis that predispose the patient to AKI
    • Fluid challenge with crystalloid or colloid solutions should improve urine output

Dialysis

• Length and duration:
  • Hemodialysis is 3 days per week and last 4 hours each time
  • Peritoneal dialysis is done each night and last 8 hours

Free water

• 3 enteric ways:
  • Free Water Flushes through PO, NG-Tube or PEG/PEJ tube
• Management:
  • IV fluid do you use to replace Free water: D5W

Fluids

• Types:
  • D5W:
    • 1. D5W Osms: 278
      
    • 2. D5W = 50 g glucose in 1 Liter of water
  • Normal saline:
    • pH 5.5
    • Normal saline(0.9%):
      • Osms: 308
      • There are 154 mEq of Na+ and 154 mEq of Cl-
    • Normal saline(3%):
      • Osms: 1026
    • 1/2 NS = 500mL of NS + 500mL of free water
      
    • 1/4 NS = 250 mL of NS + 750 mL of free water
  • Lactated Ringers:
    • Osm = 272
      
    • mEq:
      • Na+ = 130
        
      • Cl- = 109
        
      • K+ = 4
        
      • Ca2+ = 3
        
      • Lactate = 28
  • Plasmalyte A:
    • Osm: 294
      
    • mEq:
      • Na+: 140
        
      • Cl- = 98
        
      • K+ = 5
        
      • Lactate: 8
        
      • Mg2+ = 3
        
      • Acetate: 27
        
      • Gluconate = 23
  • Colloids:
    • Osm: 308-310.
    • They are NS + proteins/starches that increase oncotic pressure
• Rate per hour each day:
  • 1 liter = 42 mL/hr
    
  • 2 liter = 84 mL/hr
    
  • 3 liter = 125 mL/hr
    
  • 4 liter = 166 mL/hr
    
  • 5 liter = 200 mL/hr
    
  • Increments of about 42 mL/hr
• Notes:
  • Maintenance fluid rate equation estimate the rate:
    • It overestimates. Thus you do not want to go above calculated maintenance fluid rate unless the patient is having severe diarrhea or vomiting.
  • 25% of a volume of saline solution stays intravascular space
  • 8.25% of a volume of free water (D5W) solution stays in the vascular space

Hematuria

• Management:
  • 1. Ask if the patient stuck anything up their urethra
    
  • 2. Get PT/PTT/INR
    
  • 3. Place 3-way foley catheter if not already present
    
  • 4. Irrigate with 2L of free H2O until urine is light pink

Notes:

• Acetazolamide:
  • Acetazolamide causes an Acidosis because you will lose sodium bicarbonate in the urine
    
  • It also causes HypOkalemia because the sodium in sodium bicarb will be presented to the collecting duct and cause potassium to be excreted there
• Loops and Thiazides:
  • cause metabolic alkalosis and HypOkalemia
  • Calculate Lasix dose: 20 x serum creatinine = Furosemide dose
  • Oral bioavailability of furosemide decrease in a CHF/CKD patient:
    • CKD/CHF patients get intestinal edema too. So they need a higher dose of oral furosemide to diurese. Giving IV furosemide will make them diurese a lot.
  • Best diuretic to give a patient with CHF to control their edema so that they are less likely to need future hospitalization:
    • Torsemide. Torsemide has a longer half-life than furosemide, so you only need to give it once throughout the day and it lasts a long time. Shown to reduce rehospitalizations of patients.
  • Bumetanide and Torsemide better than Furosemide:
    • Easier to convert IV to oral dose since bioavailability is around the same dose for IV vs Oral
  • 3 strategies for diuretic resistance:
    • 1. Increase frequency of diuretic
      
    • 2. Increase dose of diuretic
      
    • 3. Add thiazide or K sparing diuretics since the tubule will show hypertrophy 
• Thiazide diuretic:
  • Inhibits Na/Cl transporter on luminal DCT cells. This causes an increased gradient for sodium intracellularly, which then allows increased reabsorption of calcium from the lumen and the cell into the interstitial space.
  • Kidney stone treatment:
    • Thiazides increase Calcium reabsorption from the filtrate, thus decreasing calcium in the urine, which will help treat any calcium-containing kidney stones
• Spironolactone, triamterene, and amiloride:
  • Spironolactone, triamterene, and amiloride cause metabolic acidosis with hyperkalemia
• Urine volume proportional to:
  • Urine Volume = serum solutes/urine concentration
• Use Bactrim in a renal failure patient:
  • Bactrim blocks ENac channels and causes Hyperkalemia and acidosis

Vital Symptoms

Hypotensive

• Management:
  • 1. Stop any HTN medications
  • 2. Give a 250-500 mL bolus of LR is patient is acidotic. If it is a renal patient then give 250-500 mL of Normal Saline
  • 3. STAT Hemoglobin/Hematocrit
  • 4. Type and Cross 2 units of blood
  • 5. Give 650mg Tylenol and 25mg benadryl 30 minutes before transfusion
  • 6. Get a CBC in 6 hours

Shock

• Management:
  • 1. Order EKG/CXR/Hemoglobin and Hematocrit
    
  • 2. Give Dopamine pressor starting at 5mcg/kg/min
    
  • 3. Titrate Dopamine until you reach a MAP >60. Maximum dopamine dose is 20mcg/kg/min

SIRS Criteria

• • Body temperature less than 36 C (96.8 F) or greater than 38 C (100.4 F)
  • Pulse greater than 90 beats per minute
  • Tachypnea (high respiratory rate), with greater than 20 breaths per minute; or, an arterial partial pressure of carbon dioxide (PaCO2) less than 4.3 kPa (32 mm Hg)
  • White blood cell count less than 4,000 cells/mm³ (4 x 10⁹ cells/L) or greater than 12,000 cells/mm³ (12 x 10⁹ cells/L); or the presence of greater than 10% immature neutrophils (band forms).

Sepsis

• Def:
  • Sepsis is a Systemic Inflammatory Response System (SIRS) with a documented infection
• Complete w/in 6  and 24 hours of *Sepsis* diagnosis::
  • 6-hour bundle:
    
    • *Blood culture
      
    • *Lactate level
      
    • *Antibiotics
      
    • *CVP = 8-12……………MAP > 65…………….Urine output > 0.5 ml/kg/hr
  • 24-hour bundle:
    
    • *Add steroid to the regiment
      
    • *Maintain blood glucose levels @ 120-150
• Management:
  • Corticosteroids and Septic Shock:
    • *Anti-inflammatory action
      
    • *Magnify vasoconstrictor response by catecholamines
      
    • *IV Hydrocortisone is preferred
      
    • *Steroid therapy should be continued as long as vasopressors are on

Pharmacology

Ibuprofen

• Dosing:
  • 200-400 mg for most uses. Available as a capsule or suspension. Do not exceed 2400 mg if you can avoid it.

Ofirmev

• Dosing:
  • 1g IV q4, Max is 4g/day
    
  • Max one time dose is 1g IV

Pressors

• Goal:
  • MAP > 65
    
  • *Thru Central Line ONLY
• Indications for Pressors:
  • >30 mmHg systolic drop from Baseline…….or…………MAP < 65
• MOA: 
  • Vasoconstricts…….INCREASES HR (a1)
  • Increases Contractility and HR (B1)
  • Vasodilation (B2)
  • Renal vasodilation (dopamine)
• Types:
  • (1) Levophed (norepinephrin)
    • *1st Line
      
    • *Vasoconstricts…..w/ LITTLE Effect on HR, SV, CO
      
    • (a1, B1 agonist)
      
  • (2) Neo (phenylephrine)
    • *a1 agonist……….increases BP…..can decrease BP (reflex bradycardia)
      
    • *OTC decongestant
      
  • (3) Vaso (vasopressin)
    • *0.03 unit/min
      
    • *Smooth mm. agonist
      
  • (4) Epinephrin
    • *0.05-0.15 mcg/kg/min
      
    • *a1, B1, B2 agonist