moonlighting
TRANSCRIPT
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Moonlight Medicine
Adrian Paul J Rabe, MD, DPCP
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8 Targets of Moonlight Medicine• Infectious Disease• Cardiovascular Medicine• Pulmonary Medicine• Endocrinology• Gastroenterology• Poisons and Snakebites• Pain Medication• Electrolyte Correction
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Infectious Disease
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Infectious Disease
• URTI• Pneumonia• UTI• Dengue• Typhoid• Leptospirosis
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Infectious Disease
URTI
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URTI: Presentation
• Symptoms– Cough, colds– 3 to 5 days duration
• Signs– Nasal discharge (clear or yellowish)– Clear breath sounds– No signs of sepsis– Hemodynamically unstable
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URTI: Order Sheet
• No labs necessary• Medications– Amoxicillin 500 mg TID or 1 g TID– Clindamycin 300 mg QID for 5 days– Azithromycin 250 mg OD x 5 days or 500
mg OD x 3 days or 1 g OD x 1 dose– Avoid using broad-spectrum antibiotics– Avoid prolonged regimens
• Advice– Increased oral fluid intake (at least
2L/day)
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URTI: Watch Out For…
• Persistence– Fever should lyse within 24-48 hours– Post-infectious cough occurs in 40% of patients
• Recurrence– Consider allergic rhinitis – refer to an
allergologist• Seasonal pattern• History of asthma or atopy• Relation to exposure to allergens/certain settings
(bedroom, work)
– If also with weight loss, obstructive ssx, refer to ORL
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Infectious Disease
Pneumonia
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Pneumonia (CAP): Presentation
• Symptoms– Cough with/without sputum production– Fever– Generalized weakness, anorexia
• Signs– Crackles– Decreased breath sounds• Increased fremiti – consolidation/mass• Decreased fremiti – pleural effusion
–Wheezing
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CAP: Order Sheet
• Initial Diagnostics– Chest X-ray– CBC with platelet count
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CAP: 2010 GuidelinesDoes the patient have:1.RR ≥ 30/min2.PR ≥ 125/min3.Temp ≥ 400C or ≤ 360C4.SBP < 90 or DBP ≤ 605.Altered mental status, acute6.Suspected aspiration7.Unstable co-morbids8.Chest X-ray: multilobar, pleural effusion, abscess
Low Risk CAP
Moderate Risk vs High
RIsk
No
Yes
Co-morbidities• DM• Active Malignancy• Neurologic disease in
evolution• CHF Class II-IV• Unstable CAD• Renal failure on dialysis• Uncompensated COPD• Decompensated Liver
Disease
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CAP: 2010 Guidelines
Does the patient have:1.Severe Sepsis2.Septic Shock3.Need for mechanical Ventilation
Moderate Risk CAP
High Risk CAP
No
Yes
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CAP: Antibiotics
• Amoxicillin• Extended macrolides– Azithromycin– Clarithromycin
• B-lactam/B-lactamase inhibitor combination (oral)– Co-amoxyclav– Amoxicillin-sulbactam– Sultamicillin
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CAP: Antibiotics
• Oral second generation cephalosporin– Cefaclor– Cefuroxime axetil
• Oral third generation cephalosporin– Cefdinir– Cefixime– Cefpodoxime proxetil
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CAP: Antibiotics
• IV non-antipseudomonal B-lactam– Co-amoxyclav– Ampicillin-sulbactam– Cefotiam– Cefoxitin– Cefuroxime– Cefotaxime– Ceftizoxime– Ceftriaxone– Ertapenem
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CAP: Antibiotics
• Respiratory fluoroquinolones– Levofloxacin–Moxifloxacin
• Aminoglycosides– Gentamicin– Tobramycin– Netilmicin– Amikacin
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CAP: Antibiotics
• IV antipseudomonal B-lactam– Cefoperazone-sulbactam– Piperacillin-tazobactam– Ticarcillin-clavulanic acid– Cefepime– Cefpirome– Imipinem-cilastin–Meropenem
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CAP: Low Risk
• Subsequent Diagnostics– Sputum GS/CS optional
• Antibiotics– Previously healthy
• Amoxicillin• Extended macrolides
– Stable co-morbid condition (cover enteric G- bacilli)• B-lactam/B-lactamase inhibitor• 2nd generation oral cephalosporins +/- extended
macrolide• 3rd generation oral cephalosporin +/- extended
macrolide
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CAP: Moderate Risk (Admit)
• Subsequent Diagnostics– Blood CS– Sputum GS/CS– Urine antigen for L. pneumophila– Direct fluorescent Ab test for L. pneumophila
• Antibiotics– IV non-antipseudomonal B-lactam +
extended macrolide– IV non-antipseudomonal B-lactam +
respiratory fluoroquinolones
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CAP: High Risk (ICU)
• Subsequent Diagnostics– Blood CS– Sputum GS/CS– Urine antigen for L. pneumophila– Direct fluorescent Ab test for L.
pneumophila– ABG
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CAP: High Risk (ICU)
• Antibiotics – no risk for Pseudomonas aeruginosa– Same as moderate risk
• Antibiotics – with risk for Pseudomonas aeruginosa– IV antipseudomonal B-lactam + IV
extended macrolide + aminoglycoside– IV antipseudomonal B-lactam + IV
Ciprofloxacin or Levoflocacin (High dose)
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CAP: Watch Out For
• Pleural effusion, Lung abscess– Do thoracentesis– Refer to TCVS for CTT if warranted
• Hemodynamic instability/Progressing sepsis– Refer to Pulmo, IDS
• Hospital-acquired pneumonia– Proper precautions in intubated patients
• Exacerbation of co-morbid diseases
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CAP: Resolution
• For low-risk– Follow-up after 3 to 5 days
• For moderate-/high-risk– Step down when clinically improving– Some infections (e.g. ESBL organisms) require a
full course via the IV route• Chest X-ray findings– May take up to 6 months to completely resolve
• Vaccination (including those with co-morbids)– Pneumococcal: one time, then q5years– Influenza: annually
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Infectious Disease
Urinary Tract Infection
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Urinary Tract Infection
• Symptoms of Urethritis– Acute dysuria, hematuria– Frequency– Pyuria– Recent sexual partner change
• Symptoms of Cystitis– Dysuria, Urgency– Suprapubic pain– Hematuria, foul-smelling urine, turbid
urine
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UTI: Presentation
• Symptoms of Acute Pyelonephritis– Rapid development– Fever, shaking chills– Nausea, vomiting, abdominal pain– Diarrhea– Diabetes, immunosuppression
• Symptoms of catheter-related UTI–Minimal symptoms– Usually no fever
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UTI: Presentation
• Signs of Urethritis– Grossly purulent discharge expressed in
genital tract
• Signs of Cystitis– Suprapubic tenderness– Fever
• Signs of Acute pyelonephritis– Costoverterbal angle tenderness at side of
involved kidney– Fever, signs of sepsis
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UTI: Presentation
• Signs of catheter-related UTI– Turbid/foul-smelling urine– Purulent discharge– Suprapubic tenderness
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UTI 2004 Guidelines
• Does the patient have complicating risk factors?– Anatomic abnormality– Functional abnormality– Recent UTI or Tract instrumentation (past 2
weeks)– Renal disease/transplant– Antibiotic use (Past 2 weeks)– Immunosuppresion– DM– Catheter, indwelling/intermittent– Hospital-acquired– Symptoms for > 7 days
AFRRAID CH7
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UTI 2004 Guidelines
• Uncomplicated Cystitis– Medications (do 7 day regimen in males)
• Cotrimoxazole 800/160 PO BID x 3 days• Ciprofloxacin 250 mg PO BID x 3 days• Ofloxacin 200 mg PO BID x 3 days• Norfloxacin 400 mg PO BID x 3 days• Nitrofurantoin 100 mg QID x 7 days• Cefuroxime 125-250 mg PO BID x 3-7 days
– Increase OFI– No need for U/A or urine cultures except in
males– If unresolved after 7 days, consider as
COMPLICATED
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UTI 2004 Guidelines
• Acute Uncomplicated Pyelonephritis– Urinalysis (expect increased WBC;
bacteriuria not the defining parameter; WBC cast is pathognomonic)
– Urine GS/CS– Outpatient treatment: • No signs and symptoms of sepsis• Non-pregnant• Likely to comply with treatment• Follow-up after 3-5 days
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UTI 2004 Guidelines
• Acute Uncomplicated Pyelonephritis– Empiric regimen should be started after
culture is taken (Oral)• Ofloxacin 400 mg BID x 14 days• Ciprofloxacin 500 mg BID x 7-10 days• Levofloxacin 250 mg OD x 7-10 days• Cefixime 400 mg OD x 14 days• Cefuroxime 500 mg BID x 14 days• Co-amoxyclav 625 mg TID x 14 days (if GS is
G+)
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UTI 2004 Guidelines
• Acute Uncomplicated Pyelonephritis– Empiric regimen should be started after
culture is taken (IV, given until patient is afebrile)• Ceftriaxone 1-2 g IV OD• Ciprofloxacin 200-400 mg IV q12• Levofloxacin 250-500 mg IV OD• Ampicillin-Sulbactam 1.5 g IV q6 (if GS is G+)• Piperacillin-Tazobactam 2.25-4.5 g IV q6-8
– Post-treatment cultures are unnecessary
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UTI 2004 Guidelines
• Acute Uncomplicated Pyelonephritis: WOF– Fever after 72 hours of treatment, or
recurrence of symptoms• Imaging studies (KUB-UTZ , KUB-IVP if
Creatinine clearance acceptable)• Repeat urine culture• If without urologic abnormality, treatment
duration is 2 weeks based on culture• If same organism between initial and repeat
culture, treatment duration is 4-6 weeks
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UTI 2004 Guidelines
• Asymptomatic bacteriuria– Defined as ≥ 100,000 cfu in 2 consecutive
midstream urine specimens or 1 catheterized specimen
– Should screen for, and treat in• Patients who will undergo GU manipulation or
instrumentation• Post-renal transplant patients up to first 6 months• DM with poor glycemic control, autonomic
neuropathy or azotemia• All pregnant women
– Same antibiotics as acute uncomplicated cystitis
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UTI 2004 Guidelines
• Recurrent UTI– More 2x a year, with no urinary tract abnormalities– May give prophylaxis (if symptoms are
unacceptable)• Post-coital (immediately after intercourse)• Daily for 6 to 12 months• Nitrofurantoin 100 mg at bedtime• Cotrimoxazole 200/40 mg at bedtime• Ciprofloxacin 125 mg at bedtime• Norfloxacin 200 mg at bedtime• Cefalexin 125 mg at bedtime
– Same antibiotics as acute uncomplicated cystitis, or may also take 2 double strength Cotrimoxazole single dose as soon as symptoms first appear
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UTI 2004 Guidelines
• Complicated UTI– Urine GS/CS– Outpatient• No signs of sepsis• Without marked debilitation• Inability to comply with treatment• Inability to maintain oral hydration/take oral
medications
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UTI 2004 Guidelines
• Complicated UTI– Oral• Ciprofloxacin 250 – 500 mg BID x 14 days• Norfloxacin 400 mg BID x 14 days• Ofloxacin 200 mg BID x 14 days• Levofloxacin 250 – 500 mg OD x 10-14 days
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UTI 2004 Guidelines
• Complicated UTI– Parenteral• Ampicillin-sulbactam 1.5 – 3 g IV q6• Ceftazidime 1-2 g IV q8• Ceftriaxone 1-2 g IV OD• Imipenem-cilastin 250-500 mg IV q6-8• Piperacillin-Tazobactam 2.25 g IV q6• Ciprofloxacin 200-400 mg IV q12• Ofloxacin 200-400 mg IV q12• Levofloxacin 500 mg IV OD
– At least 7 to 14 days of therapy
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UTI 2004 Guidelines
• Complicated UTI– At least 7 to 14 days of therapy– Urine culture should be repeated 1 to 2
weeks after completion of medications• If persistent, refer to urology/nephrology
– If no response, may do• Plain KUB x-ray• KUB-UTZ• Helical CT scan
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UTI 2004 Guidelines
• Catheter-associated UTI– If asymptomatic, no need to treat, except
if• With bacterial agents with high-incidence
bacteremia• With neutropenia• Pregnant• Will undergo urologic procedures/post-renal
transplant
– Indwelling catheter should be removed– Long-term indwelling catheters should be
replaced before treatment
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UTI 2004 Guidelines
• Candiduria–May treat if• Symptomatic• Critically ill• Neutropenic• Will undergo urologic procedures/post-renal
transplant
– Control diabetes (if present)– Remove catheter, other urinary tract
instruments (if present)
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UTI 2004 Guidelines
• Candiduria– Cystitis• Fluconazole 400 mg LD then 200 mg OD x 7-
14 days
– Pyelonephritis• Surgical drainage• Fluconazole 6 mg/kg/day or Amphotericin B IV
0.6 mg/kg/day for 2 to 6 weeks
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Infectious Disease
Dengue Fever
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Dengue Fever: Presentation
• Symptoms– Fever (Breakbone fever, saddleback fever)– Myalgia, retro-orbital pain (“trangkaso”)– Anorexia, nausea, vomiting– Cutaneous hypersensitivity– Epistaxis, petechiae, bleeding of pre-existing
GI lesions near the time of defervescence– Sudden-onset to acute symptoms
• Signs– Bleeding (petechiae on trunk, spreading face,
extremities)– Fever
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Dengue Fever: Order Sheet
• Initial Diagnostics– CBC with PC• Leukopenia• Thrombocytopenia• Hemoconcentration
– Dengue IgM– Crea, Na, K, AST, ALT• Elevated AST more than ALT
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Dengue Fever: Order Sheet
• Hydration– Oral fluid intake– Crystalloids: pNSS 1L x 60 or 80
– Colloids (for severe cases) or FFP• Defervescence– Paracetamol– Tepid/Cold sponge bath
• Platelet replacement– 1 unit of platelet concentrate per kg BW– Serial platelet counts (q12 to daily)
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Dengue Fever: WOF
• Continued hemorrhage– Aggressive control of fever– Platelet replacement
• Shock– Lasts for only 1-2 days– Intensive care may be necessary
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Dengue Fever: Resolution
• 1 week course• Discharge if– Increasing trend of platelet count– No bleeding– No hemodynamic instability
• Advice regarding mosquito control– Ablation of mosquito breeding grounds–Mosquito nets rather than mosquito
repellents
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Infectious Disease
Typhoid Fever
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Typhoid Fever: Presentation
• Symptoms– Fever in past 1 to 2 weeks– Abdominal pain (not always present)– Headache, chills, cough, myalgia/arthalgia,
diarrhea or constipation
• Signs– Relative bradycardia at the peak of fever– Hepatosplenomegaly, abdominal tenderness– Rose spots: faint, salmon-colored blanching
rash usually located on the trunk
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Typhoid Fever: Order Sheet
• Diagnostics– CBC with PC (leukocytosis, sometimes
leukopenia, neutropenia)– Crea, Na, K, AST, ALT (slightly elevated
LFTs)– Blood CS (sensitivity 90% in first week)– Bone marrow CS (even up to 5 days of
theapy)– Duodenal string test/culture– Stool CS (positive in 3rd week if untreated)
• Admit if…– Vomiting, diarrhea, abdominal distension
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Typhoid Fever: Order Sheet
• Empirical treatment– Ceftriaxone 1-2 g IV OD x 7-14 days– Cefixime 400 mg PO BID x 7-14 days– Azithromycin 1g PO OD x 5 days
• Multidrug resistant– Ciprofloxacin 500 mg PO BID x 5-7 days– Ciprofloxacin 400 mg IV q12 x 5-7 days– Ceftriaxone 2-3 g IV OD x 7-14 days– Azithromycin 1g PO OD x 5 days
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Typhoid Fever: Order Sheet
• Critically ill (shock, obtundation)– Add Dexamethasone 3 mg IV then 1
mg/kg q6 x 8 doses– Admit to ICU– Refer to IDS– Repeat cultures if none were positive
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Typhoid Fever: WOF
• Perforation/Obstruction– Due to invasion of Peyer’s patches– Refer to Surgery
• Continued fever– Lack of susceptibility– Consider another etiology– Refer to an Infectious Disease specialist
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Typhoid Fever: Resolution
• Defervescence in 1 week• Return to normal values also in 1
week
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Infectious Disease
Leptospirosis
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Leptospirosis: Presentation
• Symptoms–Wading in floodwater/exposure to mud– Influenza-like illness: chills, headache, nausea,
vomiting, muscle pain (calves, back or abdomen)– Fever, conjunctival suffusion/hemorrhage– Hemoptysis– Decreased urine output, tea-colored urine– Overt jaundice– Diarrhea– Course progresses within 1 week, rarely 2 weeks
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Leptospirosis: Presentation
• Signs– Fever– Conjunctival suffusion– Jaundice and icterus– Calf tenderness– Decreased sensorium
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Leptospirosis: Order Sheet
• Initial Diagnostics– Lepto MAT/Dri-Dot– Urine culture (positive at 2nd to 4th week,
and for several months after)– Chest X-ray (check for pulmonary
hemorrhage)– BUN, Crea, Na, K, Cl, alb, Ca, Mg (check for
acute renal failure, electrolyte losses)– Urinalysis (concentrated urine vs renal
failure; picture of UTI may confuse you)– CBC with PC (anemia, leukocytosis)– Stool CS (for patients with diarrhea)
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Leptospirosis: Order Sheet
• Mild Leptospirosis– Doxycycline 100 mg PO BID– Ampicillin 500-750 mg PO QID– Amoxicillin 500 mg PO QID
• Moderate/Severe Leptospirosis– Penicillin G 1.5 M u IV QID– Ampicillin 1 g IV QID– Amoxicillin 1 g IV QID– Ceftriaxone 1 g IV OD– Erythromycin 500 mg IV QID
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Leptospirosis: Order Sheet
• Hydration– Based on urine output– Replace electrolytes lost
• Transfusion– Based on losses detected by CBC
• Control of hemoptysis– Hydrocortisone 50 mg IV q6– Tranexamic Acid 500 mg TID
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Leptospirosis: WOF
• Weil’s syndrome– Heralded by hemoptysis, renal failure,
severe liver dysfunction, or sepsis– Refer to Infectious Disease specialist– Refer to Renal service for early dialysis– Transfer to ICU
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Leptospirosis: WOF
• Jarisch-Herxheimer reaction– Occurs in response to antimicrobial therapy,
when massive spirochete kill releases lipoproteins
– Simulates worsening of disease• Fever, chills, myalgias, headache• Tachycardia, tachypnea• Increased WBC, neutrophils• Hypotension
– Supportive therapy– Subsides after 12-24 hours without revision of
meds
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Leptospirosis: Resolution
• Jaundice to resolve in 2 to 4 weeks• May discharge if – Creatinine clearance is on upward trend– Urine output at least 0.5 cc/kg/hr– Electrolytes corrected– Platelet/hemoglobin corrected– No ongoing hemoptysis
• Prophylaxis– Doxycycline 200 mg PO once a week if
exposed
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Cardiology
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Cardiovascular Medicine
• Hypertension• Angina• Myocardial Infarction
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Cardiology
Hypertension
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Hypertension: Presentation
• Symptoms– Frequently asymptomatic– Aching nape/occipital area– Symptoms of target organ damage
• Signs: Try to detect both cause and effect…– Kidney disease: anemia, oliguria, sallow skin– Cushing’s syndrome: obesity, striae, moon
facies, etc– Hyper/hypothyroidism– Heart failure
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Hypertension: Presentation
• Signs: Taking Blood Pressure– Aneroid instrument vs mercury based
instruments– Seated quietly for 5 minutes (Quiet, private,
with comfortable room temperature)– Bladder cuff is at least half of arm
circumference– Deflation is 2 mmHg/s–Measure both arms, in supine, sitting and
standing positions (detects coarctation, orthostatic changes)
–Measure 1 leg at least once (take ABI)
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Hypertension: Presentation
• Signs– Palpate all possible pulses– Cardiac examination is important– Auscultate carotid and renal bruits
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Hypertension: Classification
Classification
Systolic,
mmHg
Diastolic,
mmHg
Normal < 120 And < 80
Prehypertension
120-139
Or 80-89
Stage 1 140-159
Or 90-99
Stage 2 ≥ 160 Or ≥ 100
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Hypertension: Order Sheet
• Diagnostics– Urinalysis (renal cause and complication)– BUN, Crea, Na, K, Ca, alb (low K is clue for
aldosteronism and pheochromocytoma)– FBS, Lipid profile (co-morbidities)– CBC (anemia)– ECG (LVH, other abnormalities)
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Hypertension: Order Sheet
• Lifestyle changes– BMI < 25 kg/m2– Exercise: Near-daily to daily aerobic
activity– Alcohol avoidance/moderation– DASH diet: fruits, vegetables, low fat
dairy, reduced saturated and total fat– Salt-restriction: NaCl < 6 g/d
BEADS
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Hypertension: Order Sheet
• Medications: Diuretics– Examples• Hydrochlorothiazide 12.5 – 25 mg OD-BID• Furosemide 40-80 mg BID-TID• Spironolactone 25-100 mg OD-BID
– Good for heart failure– Caution in DM, gout, renal failure– K reducer: furosemide, HCTZ– K retainer: spironolactone
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Hypertension: Order Sheet
• Medications: Beta blockers– Examples
• Atenolol 25-100 mg OD• Metoprolol 25-100 mg OD-BID• Propranolol 40-160 mg BID (not cardioselective)• Carvedilol 12.5-50 mg BID (combined alpha and
beta)
– Good for heart failure, angina, MI, tachycardia
– Caution in 2nd or 3rd degree AV block, asthma/COPD
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Hypertension: Order Sheet
• Medications: ACE inhibitors– Examples• Captopril 25-200 mg BID-TID• Enalapril 5-20 mg OD• Lisinopril 10-40 mg OD• Ramipril 2.5-20 mg OD-BID
– Good for heart failure, MI, DM– Caution in renal failure, hyperkalemia,
renal artery stenosis, pregnancy–May cause cough, angioedema
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Hypertension: Order Sheet
• Medications: Angiotensin receptor blockers– Examples• Losartan 25-100 mg OD-BID• Valsartan 80-320 mg OD• Candesartan 2-32 mg OD-BID
– Good for heart failure, MI, DM– Caution in renal failure, hyperkalemia,
renal artery stenosis, pregnancy– Used as second-line to ACE-inhibitors
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Hypertension: Order Sheet
• Medications: Dihydropyridine CCBs– Examples• Amlodipine 5-10 mg OD• Long-acting Nifedipine 30-60 mg OD
– Good for angina– Caution in heart failure, 2nd or 3rd degree
AV block– Causes peripheral edema
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Hypertension: Order Sheet
• Medications: Non-Dihydropyridine CCBs– Examples• Long-actingVerapamil 120-360 mg OD-BID• Long-acting Diltiazem 180-420 mg OD
– Good for angina, MI, DM, tachycardia– Caution in heart failure, 2nd or 3rd degree
AV block– Causes peripheral edema
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Hypertension: Order Sheet
• Medications: Direct Vasodilators– Examples• ISMN 30-60 mg OD• ISDN 5-10 mg BID-TID• Hydralazine 25-100 mg BID-TID
– Nitrates good for angina, MI– Nitrates cause hypotension, headache
(must have at least 8 hours a day drug free), and has reaction with sildenafil
– Hydralazine should not be used in severe coronary artery disease
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Hypertension: Follow-up
• BP goal– General: < 140/90– Cardiac risk factors: < 130/80– Albuminuria: < 125/75
• Adjustment– Diuretics: daily to weekly (electrolyte
imbalances)– Beta-blockers: every 2 weeks– ACE-inhibitors and ARBs: every 1 – 2 weeks– CCBs: every 1 – 2 weeks– Vasodilators: Every 1 – 2 weeks
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Hypertension: WOF
• Secondary Hypertension– CGN/Nephrotic syndrome/CKD: urinary
findings, edema– Pheochromocytoma: sweating,
palpitations, headache, early target organ damage
– Primary aldosteronism: resistant to medications, low K, weakness
– Connective Tissue Disease: pulse discrepancy, systemic symptoms
– Refer to Renal/Endo/Rheuma
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Hypertension: WOF
• Hypertensive Urgency vs Emergency– Both require admission– Emergency: presence of target organ
damage• Reduce blood pressure by 25% over minutes
to 2 hours• Parenteral agents
– Urgency: No target organ damage• Reduce blood pressure over hours• Oral agents
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Hypertension: WOF
• Hypertensive Urgency vs Emergency– Nitroprusside: 0.3 ug/kg/min, maximum at 10
ug/kg/min; discontinue if no response after 10 minutes
– Nitroglycerin drip: 5 ug/min, titrate at 5-10 ug/min at 3 to 5 minute intervals• 10 mg/10mL or 50 mg/50 mL, diluted to 10 mg in
100 mL
– Nicardipine drip: 5 mg/h, titrate by 2.5 mg/h at 5-15 minute intervals, maximum at 15 mg/h• 2 mg/2mL or 10 mg/10mL, diluted to 10-20 mg in
100 mL
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Cardiology
Angina and the Acute Coronary Syndromes
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Angina: Presentation
• Symptoms– Heaviness, pressure, squeezing, localized
retrosternally– Crescendo vs decrescendo– Radiates anywhere between the mandible
and umbilicus– Related to exertion
• Signs– High/low blood pressure, tachy/bradycardia– Heart failure
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Angina: Order Sheet
• Complete bed rest• Oxygenation – Target O2 saturation > 90%– Nasal cannula vs face mask vs intubation
• Cardiac monitor• Vital signs• Ask about sildenafil use in past 24
hours– Viagra, cialis, ambigra, adonix, erefil, neo-
up
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Angina: Order Sheet
• Give nitrates– Nitroglycerin 0.3-0.6 mg, or via buccal spray– ISDN 5 mg sublingual– 3 doses 5 minutes apart– If persistent, start Nitroglycerin drip
• 10 mg in 100 mL, start at 5 ug, and increased by 5-10 ug/min
• Titrated every 3 to 5 minutes until symptoms are relieved or systolic arterial pressure falls to < 100 mmHg
– Good for pulmonary congestion– Caution in: inferior wall/right-sided infarcts
(hypotension)
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Angina: Order Sheet
• Initial Diagnostics– 12-lead ECG (within 10 minutes)– 2D-echocardiogram– Nuclear perfusion scan, cardiac MRI, cardiac
PET– BUN, Crea, Na, K, Ca, alb, Mg, AST– Cardiac enzymes: Trop I/T > CKMB > CKtotal– Urinalysis– Chest X-ray– PT/PTT
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UAHR/NSTEMI/STEMI
• Loading Dose– Aspirin 80 mg/tab 4 tabs chewed and
swallowed– Clopidogrel 75 mg/tab 4 tabs chewed and
swallowed–Metoprolol 5 mg IV q5 up to 15 mg (3
doses), then followed in 1-2 hours by 25-50 mg PO q6
–Morphine 2-5 mg IV repeated q5-30 minutes– Captopril 25 mg/tab ½ to 1 tab q8– Heparinization
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Angina: STEMI
• Decide whether to do PCI or not– Referral center should be no more than 30 mins
away– Door-to-balloon time should be at most 90 mins– Golden period: not more than 6h, may give 12h
after• Refer to CVS for thrombolysis– Take informed consent– Streptokinase 1.5 M u in pNSS to make 100 cc
to consume over 1 hour– Pre-medication with Diphenhydramine 1 amp IV– Can have hemorrhage, allergic reactions
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Angina: STEMI
• Absolute contraindications to thrombolysis– Cerebrovascular hemorrhage at any time– Known structural cerebral vascular lesion (e.g. AVM)– Non-hemorrhagic stroke/event in the past year
• Ischemic stroke within 3 months, except if within 3 hours
– Hypertension (SBP > 180, DBP > 110)– Suspicion of aortic dissection
• Must do Chest/abdominal CT stat if suspected
– Active internal bleeding except menses– Any known malignant neoplasm– Significant closed head/facial trauma in past 3
months
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Angina: STEMI
• Admit to ICU/CCU
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UAHR/NSTEMI/STEMI
• Loading Dose– Aspirin 80 mg/tab 4 tabs chewed and
swallowed– Clopidogrel 75 mg/tab 4 tabs chewed and
swallowed–Metoprolol 5 mg IV q5 up to 15 mg (3
doses), then followed in 1-2 hours by 25-50 mg PO q6
–Morphine 2-5 mg IV repeated q5-30 minutes– Captopril 25 mg/tab ½ to 1 tab q8– Heparinization
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UAHR/NSTEMI/STEMI
• Aspirin and Clopidogrel– Part of antithrombotic therapy–Maintenance • Aspirin 80 mg/tab 1 tab OD (with a meal)• Clopidogrel 75 mg/tab 1 tab OD
–WOF GI bleed, allergy to aspirin
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UAHR/NSTEMI/STEMI
• Beta blockers– Part of anti-ischemic therapy–Maintenance • Metoprolol 50 mg BID
– Target: HR 50-60 bpm– Caution in hypotension, asthma, COPD.
Severe pulmonary edema
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UAHR/NSTEMI/STEMI
• Calcium channel blockers– Part of anti-ischemic therapy– Used in patients with contraindication to
beta blockers–Maintenance
• Long-actingVerapamil 120-360 mg OD-BID• Long-acting Diltiazem 180-420 mg OD
– Target: HR 50-60 bpm, no chest pain– Avoid rapid-release CCB (e.g. nifedipine)– Caution in pulmonary edema, severe LV
dysfunction, hypotension, bradycardia, heart-block
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UAHR/NSTEMI/STEMI
• Morphine– Part of anti-ischemic therapy–Maintenance • None – PRN use only
– Target: no chest pain– Caution in inferior wall/right ventricular
infarction, hypotension, respiratory depression, confusion, obtundation
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UAHR/NSTEMI/STEMI
• ACE-inhibitors– Part of long-term cardiac therapy–Maintenance • Captopril 25 mg 1 tab q8• Enalapril 5-20 mg OD
– Gradual increase as patient stabilizes– Good for LV dysfunction, anterior wall MI– Caution in hypotension, renal failure,
hyperkalemia
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UAHR/NSTEMI/STEMI
• Statins– Part of long-term cardiac therapy– Plaque stabilization–Maintenance (@HS doses)• Atorvastatin 10 mg, max 80 mg• Rosuvastatin 10 mg, max 40 mg• Simvastatin 20 mg, max 80 mg
– Gradual increase over a period of 2 months– Good for dyslipidemia, MI– Caution in liver disease, rhabdomyolysis
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UAHR/NSTEMI/STEMI
• Heparin– Part of anti-thrombotic therapy– Types
• UFH 60 U LD, then 12U/kg/h target PTT 1.5-2.0x normal• Enoxaparin 30 mg IV LD then 1 mg/kg SC q12 (OD if
creatinine clearance < 30 mL/min)• Fondaparinux 2.5 mg SC OD
– If patient is unstable, has poor hemodynamic status, or has risk of bleeding, age > 75 y/o, UFH is preferred
– PTT measurements should be done q6– Duration is 2 to 5 days
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UAHR/NSTEMI/STEMI
• Targets– Activity (SUPERVISED)• First 12 hours: Bed rest• 12-24 hours: Dangling legs/sitting in a chair• 2nd-3rd day: Ambulation in room, go to shower• 3rd day and beyond: 185 m (600 feet) at least
3x a day• Sexual activity: 2-4 weeks after event• Work: 1 month after event
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UAHR/NSTEMI/STEMI
• Targets– Diet• First 4-12 hours: NPO• If stable: Complex carbohydrates (50-55%),
Fat < 30%, total cholesterol < 200 mg/d, fiber rich
– Bowel care • Stool softeners• Bedside commode rather than bedpan• Laxative
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UAHR/NSTEMI/STEMI
• Targets– Sedation• Quiet, reassuring environment• Diazepam 5 mg TID-QID
– Tight glycemic control• Insulin drip preferred in acute setting• Pre-prandial: 90-130 mg/dL (critical care: <
110)• Post-prandial: < 180 mg/dL (critical care: <
180)• Long-term: HbA1c < 7%
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UAHR/NSTEMI/STEMI
• Targets– Electrolyte• Mg 1.0 mmol/L• K 4.0-4.5 mmol/L• Ca 2.12-2.52
– Discontinue O2• May discontinue starting 6 hours after
admission, if O2 saturation > 90%
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Angina: Watch Out For…
• Arrhythmia – Defibrillate with maximum dose available
up to 3x– Amiodarone 150 mg in 50 to 100 cc pNSS
over 10 minutes, then drip 360 mg in D5W x 6 hours
– Refer to CVS• Mechanical complications–Wall rupture– New-onset mitral regurgitation– Pericarditis– Refer to CVS/TCVS
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Angina: Resolution
• Follow-up after 2 weeks – for treadmill exercise test (if appropriate)– Titration of medications– Strengthen previous advice
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Chronic Stable Angina
• Symptoms– Same as acute angina– Symptoms > 2 weeks– No worsening, crescendo pattern over
hours/weeks– No increase in frequency
• Signs– Hemodynamically stable– Complete cardiovascular PE should be
done
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Chronic Stable Angina
• Diagnostics– 12-L ECG– Treadmill exercise test– 2D-echo– Crea, Na, K, Mg. Ca, alb– Lipid profile, FBS– Chest X-ray
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Chronic Stable Angina
• Medications– Anti-platelet– Beta blocker– ACE inhibitor– Statin
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Chronic Stable Angina
• Medications– Anti-platelet• Aspirin 80 mg OD• Clopidogrel 75 mg OD if ASA-intolerant
– Beta blocker• Atenolol 25-100 mg OD• Metoprolol 50-100 mg OD-BID• Carvedilol 6.25-50 mg BID
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Chronic Stable Angina
• Medications– ACE inhibitor• Captopril 25-200 mg BID-TID• Enalapril 5-20 mg OD• Lisinopril 10-40 mg OD• Ramipril 2.5-20 mg OD-BID
– Statin• Atorvastatin 10 mg, max 80 mg @HS• Rosuvastatin 10 mg, max 40 mg @HS• Simvastatin 20 mg, max 80 mg @HS
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Chronic Stable Angina
• If with high-risk features, or positive stress test, advice coronary angiography with intervention– Useless to do CA without intervention– PCI vs CABG depends on clinical picture– Refer to CVS in an institution with
PCI/CABG capability
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Moonlight Medicine
Adrian Paul J Rabe, MD, DPCP
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Pulmonology
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Pulmonary Medicine
• Asthma• COPD
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Pulmonology
Asthma
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Asthma: Presentation
• Symptoms– Trigger
• Allergen• URTI/Pneumonia• Beta blockers. Aspirin• Exercise. Cold air, hyperventilation, laughter• Occupational asthma (Mondays)• Stress
– Dyspnea, shortness of breath, chest tightness• Night exacerbations
– Cough– Younger age group
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Asthma: Presentation
• Signs– Tachypnea– Tachycardia, hypertension–Wheezing– Absence of wheezing = severe– Clubbing = uncontrolled
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Asthma: Order Sheet
• Diagnostics– ABG (hypercarbia, hypoxemia, alkalosis)– Chest X-ray (rule out infection, other
differentials)– 12-L ECG (rule out cardiac causes of
dyspnea– CBC with PC (infection)
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Asthma: Order Sheet
• Oxygenation– O2 support• Intubation if in impending/frank respiratory
failure
• Short acting inhaled beta-agonists– Salbutamol nebulization q5-15–WOF tremors, palpitations
• Inhaled anti-cholinergics– Ipatropium bromide nebulization q5-15–WOF Dry mouth, decreased sputum
production/dry cough
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Asthma: Order Sheet
• Glucocorticoids– Hydrocortisone 50 mg IV q6 or 100 mg IV q8– Budesonide nebule q8– WOF Hoarseness, dysphonia, oral
candidiasis, systemic effects• Aminophylline drip– Mix as 1mg/mL– LD 6 mg/kg over 20-30 minutes– Maintenance at 1 mg/kg/hr (use lower dose
in elderly, or in nonsmokers)– Hook to cardiac monitor– WOF flushing, diarrhea, nausea, vomiting,
arrhythmias
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Asthma: Order Sheet
• If with status asthmaticus, admit to ICU
• Refer to anesthesia if previous measures don’t work– Propofol, Halothane
• Treat infection–Most common is still viral URTI (supportive
therapy)– See CAP guidelines if with pneumonia
• Check if drug is the trigger
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Asthma: Resolution
• Discharge– No wheezing and tolerates room air– No IV glucocorticoids– Infection is treated
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Asthma: Resolution
• Discharge Medications– Home medications:– Oral steroid with tapering schedule
• Prednisone at 0.5 -1 mg/kg/d in 2/3-1/3 dosing
– Combination inhaled corticosteroid with long-acting inhaled beta-agonist• Budesonide + Formoterol 160/4.5 or 80/4.5 ug 1-2
puffs BID• Fluticasone + Salmeterol 500/50 or 250/50 or 100/50
1-2 puffs BID• Gargle after use
– Rescue doses of short acting inhaled beta-agonists• Salbutamol neb PRN
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Asthma: Outpatient Care
Short Acting Beta agonistMild
intermittentMild
persistentModerate persistent
Severe persistent
Very Severe persistent
ICS low dose
ICS low dose
ICS high dose
ICS high dose
LABA LABA LABA
OCS
≤2/weekSymptoms
Night ≤2/month
3-6/week
3-4/month
Daily
≥5/month
Daily
Frequently
Unremitting
Nightly
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Asthma: Outpatient Care
• Smoking cessation• Influenza vaccination annually• Pneumococcal vaccination once
then q5 years
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Pulmonology
COPD
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COPD: Presentation
• Symptoms– Cough, sputum production, exertional
dyspnea– Smoking– Decreased functional capacity– Chronic symptoms– Older age group
• Signs–Wheezing– Clubbing, cyanosis– Barrel-chest
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COPD: Presentation
• Diagnostics– ABG (hypercarbia, hypoxemia)– Chest X-ray (infection, chronic changes –
hyperinflation, fibrosis, cause of COPD)– CBC with PC (infection)– 12-L ECG (consider cardiac etiology)
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COPD: Order Sheet
• Oxygenation– O2 support
• Intubation if in impending/frank respiratory failure
• Short acting inhaled beta-agonists AND inhaled anti-cholinergics– Salbutamol nebulization q5-15– Ipatropium bromide nebulization q5-15
• Methylxanthine– Theophylline 10-15 mg/kg in 2 divided
doses– Comes in 100, 200, 300, 400, 450 mg
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COPD: Order Sheet
• Glucocorticoids– Hydrocortisone 50 mg IV q6 or 100 mg IV
q8– Budesonide nebule q8– Shift to Prednisolone/Prednisone 30-40 mg
to complete 2 weeks
• Antibiotics– Bronchiectasis with increased sputum
production– 2 weeks of antibiotics directed against
pathogen
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COPD: Resolution
• Complete smoking cessation• Pulmonary Rehabilitation (Refer to
Rehab)• Lung volume reduction surgery in
severe emphysema• Oxygen therapy – Resting O2 sat < 88%– O2 sat < 90% if with pulmo HTN, cor pulmonale
• Influenza vaccination annually• Pneumococcal vaccine once then q5
years
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COPD: WOF
• Cor Pulmonale– Right heart enlargement on X-ray, ECG– Prominent neck veins and peripheral
edema– Careful diuresis• Furosemide 20-40 mg BID• Spironolactone 25-100 mg OD-BID
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Endocrinology
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Endocrinology
• Diabetes Mellitus• Thyroid Disease
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Endocrinology
Diabetes Mellitus
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DM: Presentation
• Symptoms–Weight loss, unexplained– Polyuria, polydipsia– Frothy urine– Decreased vision– Poorly healing wounds, frequent infections– Paresthesias, numbness– Stroke, MI previously– DKA: abdominal pain, nausea, vomiting,
young– HHS: poor appetite, increased sleeping time,
elderly
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DM: Presentation
• Signs– Decreased sensation– Non-healing wound– Skin atrophy, Muscle atrophy– Diabetic dermopathy (necrobiosis lipiodica
diabeticorum)– Renal failure– Retinopathy– DKA: ketone breath, normal abdomen,
tachycardic, tachypneic– HHS: obtundation, dehydration
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DM Emergency: Order Sheet
• Diagnostics– CBC with PC (infection, anemia)– RBS, BUN, Crea, Na, K, Cl, Ca, alb, Mg, P
(azotemia, low albumin, electrolyte imbalances, anion gap)
– Plasma ketones if available– ABG– Chest X-ray (and X-ray of involved extremity if
with non-healing wound)– Urinalysis with ketones– 12-L ECG– HBA1c (instead of FBS)– CBG
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DM Emergency: Order Sheet
• Computations– Osmolality• 2(Na + K) + BUN + RBS (in mmol/L)• Normal is 276-290 mmol/L
– Anion gap• Na – (Cl + HCO3)• Normal is 10-12 mmol/L
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DM Emergency: Order SheetParameters DKA HHS
Blood Chem
Glucose (mg/dL)
250-600 600-1200
Na 125-135 135-145
KNormal to Inc
Normal
Mg Normal Normal
Cl Normal Normal
P Dec Normal
Crea Slight Inc Moderately Inc
Osmolality 300-320 330-380
Ketones ++++ +/-
ABG
HCO3 < 15 mEq/LNormal to slightly dec
pH 6.8-7.3 > 7.3
pCO2 20-30 Normal
Both Anion gap IncNormal to slightly Inc
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DM Emergency: Order Sheet
• ICU admission– If unstable– pH < 7.00– Decreased sensorium
• Refer to Endo
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DM Emergency: Order Sheet• Replace fluids– 2-3 L pNSS over first 1-3 hours (10-15 mL/kg/h)– 0.45% NSS at 150-300 mL/h– D5 0.45%NSS at 100-200 mL/h if CBG ≤ 250
mg/dL–WOF congestion, hyperchloremia– HHS: if Na > 150, use 0.45% NSS at the onset
• Insulin– Start only if K > 3.3– 0.1-0.15 u/kg IV bolus– 0.1 u/kg/h IV infusion, target CBG 150-250 mg/dL
• 20 or 100 units regular insulin in pNSS to make 100 cc in soluset dripped via infusion pump (1cc = 1u if 100 u used)
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DM Emergency: Order Sheet
• Assess precipitant– Noncompliance/missed insulin dose– Infection (UTI, pneumonia)–Myocardial infarction– Drugs
• CBG q1-2 hours• Electrolytes and ABG q4 for first
24 hours• NVS, I/O q1
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DM Emergency: Order Sheet
• Correct potassium– K < 5.5: 10 mEq/h– K < 3.5: 40-80 mEq/h
• Correct acidosis only if pH < 7.0 after initial hydration– pH 6.9-7.0: 50 mEqs NaHCO3 + 10 mEqs
KCl in 200 mL sterile water x 1h– pH < 6.9: 100 mEqs NaHCO3 + 20 mEqs
KCl in 400 mL sterile water x 2h– Repeat ABG 2 hours after– Repeat dose q2 hours until pH > 7.0
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DM Emergency: Order Sheet
• Correct magnesium– Target 0.8 to 1 mmol/L– Each gram of Mg will increase Mg by 0.1
mmol/L• 3g MgSO4 in D5W 250 cc x 12h = 0.3
additional Mg
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DM Emergency: Order Sheet
• ICU admission– If unstable– pH < 7.00– Decreased sensorium
• May apply hydration and insulin drip for hyperglycemic states
• Refer to Endo
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DM Emergency: Resolution
• Decrease insulin until 0.05-0.1 u/kg/h
• As soon as patient is awake and tolerates feeding, may start patient on diet
• Overlap insulin with subcutaneous insulin– Calculate insulin requirements from
insulin drip used in past 24 hours
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DM Inpatient: Insulin Regimens
• NPH Insulin + Regular Insulin– Total Insulin requirement: 0.5-1 u/kg BW • 2/3 pre-breakfast: 2/3 NPH, 1/3 Regular
Insulin• 1/3 pre-supper: ½ NPH, ½ Regular
Insulin– pB = NPH pre-supper– pL = Regular insulin pre-breakfast– pS = NPH pre-breakfast– HS = Regular insulin pre-supper
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DM Inpatient: Insulin Regimens
• Glargine Insulin + Lispro Insulin– Total insulin requirement: 0.5-1 u/kg BW• Glargine (Basal) insulin: ½ of total, given at
night• Lispro insulin: other half given in 3 divided
doses, 15 minutes before each meal
– pB = Basal insulin– pL = Lispro insulin pre-breakfast– pS = Lispro insulin pre-lunch– HS = Lispro insulin pre-supper
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DM Inpatient: Order Sheet
• Inpatient goals– Pre-prandial 90-130 mg/dL– Post-prandial < 180 mg/dL
• For thin, insulin sensitive patients– Add 1 unit to errant insulin for every 50
mg/dL above target
• For obese, insulin resistant patients– Add 2 units to errant insulin for every 50
mg/dL above target
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DM Inpatient: WOF
• Nephropathy– Refer to Renal if with decreasing urine output,
low creatinine clearance, for possible HD
• Ophthalmopathy/Retinopathy– Refer to Ophtha
• Diabetic foot ulcer– Refer to Ortho/TCVS
• Deterioration in sugar control– See previous orders– Refer to Endo
• Acute coronary event
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DM Outpatient: Order Sheet
• Diagnostics:– FBS, 2-hour post-prandial glucose– Lipid profile– HBA1c
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DM Outpatient: Order Sheet
• Targets– HBA1c < 7%– Pre-prandial glucose (FBS) 90-130 mg/dL– Post-prandial glucose (2h PPBS) < 180 mg/dL– BP < 130/80 (< 125/75 for patients with
renal insufficiency)– Lipid modification (order of decreasing
priority)• LDL < 100 mg/dL• HDL > 40 mg/dL in males, > 50 in females• TG < 150 mg/dL
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DM Outpatient: Order Sheet
• Medications: Biguanides– Dose• Metformin 500 mg-1g OD, BID, TID• Adjust every 2-3 weeks
– Goal effect• Reduces HBA1c by 1-2%• Reduces fasting plasma glucose
– Good: weight loss– Caution: Renal insufficiency (Crea > 124
mmol/L), lactic acidosis, GI effects– Hold 24h prior to procedures, while
critically ill
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DM Outpatient: Order Sheet
• Medications: Sulfonylureas– Dose
• Glimepiride 1-8 mg OD• Glipizide 2.5-40 mg OD-BID• Take shortly before meals
– Goal effect• Reduces HBA1c by 1-2%• Reduces fasting and post-prandial plasma glucose
– Caution: weight gain, hypoglycemia, renal insufficiency (Crea > 124 mmol/L), liver disease
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DM Outpatient: Order Sheet
• Medications: Thiazolidinediones– Dose
• Pioglitazone 15-45 mg OD• Rosiglitazone 1-4 mg OD-BID
– Goal effect• Reduces HBA1c by 0.5-1.5%• Reduces fasting and post-prandial plasma
glucose• Reduces insulin requirements
– Caution: weight gain but redistributes to peripheral areas, hypoglycemia, renal insufficiency (Crea > 124 mmol/L), liver disease, edema, heart failure
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DM Outpatient: Order Sheet
• Medications: DPP-IV inhibitors– Dose• Sitagliptin 50-100 mg OD• Vildagliptin 50 mg OD-BID
– Goal effect• Reduces HBA1c by 0.5-1.0%• Reduces insulin requirements
– Good: does not cause weight gain, minimal hypoglycemia
– Caution: Renal insufficiency (use 50 mg OD if Crea > 124 mmol/L), headache, diarrhea, URTI
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DM Outpatient: Order Sheet
• Medications: Alpha-glucosidase inhibitors– Dose
• Acarbose 25 mg with evening meal• Maximize to 50 - 100 mg with every meal
– Goal effect• Reduces HBA1c by 0.5-0.8%• Reduces post-prandial plasma glucose
– Good: weight loss– Caution: GI effects (diarrhea, flatulence,
abdominal distention), Renal insufficiency (Crea > 177 mmol/L)
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DM Outpatient: Order Sheet
• Medications– If 2 drugs aren’t sufficient, insulin is
recommended– Cost and compliance are of prime
importance
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DM Outpatient: Order Sheet
• Diet– Fat 20-35%
• Minimal saturated fat (<7%)• Minimal transfat• Decreased cholesterl (<200 mg/d)• At least 2 servings of fish (Omega-3 fatty acids)
– Carbohydrates 45-65%• Low glycemic index• Sucrose containing food with adjustments in
meds/insulin
– Protein 10-35%– High fiber
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DM Outpatient: Order Sheet
• At least 150 minutes/week• Monitor blood sugar before,
during and after exercise– CBG > 250 mg/dL, delay exercise– CBG < 100 mg/dL, eat carbohydrate
before exercise– Pre-exercise insulin modification• Decrease dose• Inject into non-exercising muscle
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DM Outpatient: Follow-up
• Home monitoring of glucose• HbA1c q3-6 months• Medical nutrition therapy and
education• Eye examination annually• Foot examination daily by patient,
annually by MD• Screening for albuminuria annually• Lipid profile and Crea annually• BP measurement q4 months
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Endocrinology
Thyroid Disease
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Thyroid Disease
• Hyperthyroidism• Hypothyroidism
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Hyperthyroidism: Presentation
• Symptoms– Hyperactivity, irritability– Heat intolerance, sweating– Palpitations– Weakness, weight loss, diarrhea– Polyuria, oligomenorrhea
• Signs– Tachycardia, sometimes atrial fibrillation– Warm, moist skin– Tremors, muscle weakness– Anterior neck mass
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Hyperthyroidism: Order Sheet
• Diagnostics– CBC with PC (infection)– 12-L ECG (atrial fibrillation, tachycardia)– Chest X-ray (rule out infection,
cardiomegaly)– Urinalysis (infection)– Free T4 and TSH (high FT4, low TSH)– Crea, Na, K (low K)– Thyroid UTZ (especially if with nodule/s)
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Hyperthyroidism: Order Sheet
• Burch-Wartofsky scoring– Components• Temperature• CNS• GI• CVS: heart rate• CVS: heart failure• CVS: atrial fibrillation• Precipitant history
– Score • 25-44: impending storm• ≥45: storm
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Hyperthyroidism: Order Sheet
• Therapeutics– Propylthiouracil 600 mg LD then 200-300
mg q6• Orally/NGT• By rectum
– Saturated solution of Potassium Iodide (SSKI) 5 drops q6-8, 1 hour after every PTU dose
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Hyperthyroidism: Order Sheet
• Therapeutics– Propranolol 40-60 mg PO q4• If still no rate control: Verapamil 2.5-5 mg SIVP
q15-30 minutes, maximum of 20 mg• Use digoxin rarely (decreased potency in
hyperthyroidism)
– Glucocorticoids• Dexamethasone 2 mg IV q6• Hydrocortisone 50 mg IV q6
– Treat infection, fever aggressively– Correct electrolytes
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Hyperthyroidism: Order Sheet
• ICU admission– If stable, may admit to Ward
• Refer to Endo
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Hyperthyroidism: Resolution
• Discharge– Taper PTU to 200 mg TID– Heart rate controlled with Propranolol BID– Infection/precipitant treated
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Hyperthyroidism: Out-patient• Medication adjustment– Preferably Methimazole 30 mg OD– Taper Propranolol until PRN
• Follow-up– 2-4 weeks with repeat FT4 (same laboratory)– Adjust methimazole based on FT4– TSH may be taken eventually to prove
suppression• Dietary avoidance– Seafood– Iodized salt
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Hyperthyroidism: Out-patient• 30 to 50% achieve remission on
medical treatment alone– Usually after 12-18 months
• Definitive treatment: once euthyroid– RAI– Surgery– Refer to Endo and GS/ORL
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Hyperthyroidism: WOF
• Ophthalmopathy– Steroids• Prednisone 1 mg/kg in 2 divided doses
– Artificial tears– Refer to Ophtha
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Hypothyroidism: Presentation
• Symptoms– Weakness– Dry skin, hair loss, impaired healing– Difficulty concentrating– Weight gain, poor appetite– Heart failure
• Signs– Dry coarse skin, cool peripheral extremities– Puffy face, hands and feet; alopecia– Bradycardia– Serous cavity effusions (pericardial, pleural,
peritoneal)– Hyporeflexia
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Hypothyroidism: Order Sheet• Diagnostics– Free T4, TSH (low FT4, High TSH)– CBC with PC– 12-L ECG (documentation of heart rate)– Chest X-ray (enlarged heart, pleural
effusion)– Crea, Na, K (hypokalemia)– Thyroid UTZ
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Hypothyroidism: Order Sheet• Diagnostics– Free T4, TSH (low FT4, High TSH)– Anti-TPO– CBC with PC– 12-L ECG (documentation of heart rate)– Chest X-ray (enlarged heart, pleural
effusion)– Crea, Na, K (hypokalemia)– Thyroid UTZ
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Hypothyroidism: Order Sheet• Therapeutics– Levothyroxine 1.6 ug/kg BW in single dose
before breakfast– If missed dose: may take 2-3 doses of
skipped tablets at once due to long half-life
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Hypothyroidism: Follow-up
• Repeat TSH after 2-4 weeks– Use same laboratory– Target lower half of TSH range
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Gastroenterology
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Gastroenterology
• Peptic Ulcer Disease and GERD• Approach to Jaundice
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Gastroenterology
Peptic Ulcer Disease
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PUD: Presentation
• Symptoms– PUD: Epigastric pain, usually at night–Metallic/acid taste in the mouth–Melena– NSAID use–Weight loss, early satiety, vomiting
• Signs– Epigastric tenderness– Epigastric mass–Melena on DRE (uncommon)
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PUD: Order Sheet
• Diagnostics– CBC with PC– EGD with H. pylori biopsy– Urea breath test– FOBT– Chest X-ray
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PUD: Order Sheet
• Therapeutics (Active Bleeding)– PPI drip• Omeprazole 80 mg IV bolus • Omeprazole 80 mg in pNSS to make 100 cc x
10 cc/h (8 mg/h)
– Immediate endoscopy
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PUD: Order Sheet
• Therapeutics– Proton pump inhibitors• Omeprazole 20 mg/d• Esomeprazole 20 mg/d• Lansoprazole 30 mg/d• Administer BEFORE a meal• Long-term: pneumonia, osteoporosis
– H2-receptor antagonists• Ranitidine 300 mg @HS• Famotidine 40 mg @HS
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PUD: Order Sheet
• Therapeutics– Antacids• Usually for symptom relief• Aluminum hydroxide-Magnesium hydroxide• WOF nephrotoxicity
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PUD: Order Sheet
• Therapeutics (H. pylori positive)– OCA/OCM regimen• Omeprazole 20 mg BID• Clarithromycin 250-500 mg BID• Amoxicillin 1g BID or• Metronidazole 500 mg BID
– Refer to GI if no response
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PUD: Resolution
• Follow-up after 2-4 weeks– Decision to continue PPI dependent on
symptoms– Gastric ulcers have risk for malignancy
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Gastroenterology
GERD
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GERD: Presentation
• Symptoms– Burning retrosternal chest pain
worsening/precipitated by recumbency– Regurgitation of sour material into mouth– Cough– Dysphagia
• Signs– Obesity– Usually normal abdominal PE
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GERD: Order Sheet
• Diagnostics– EGD– CBC with PC
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GERD: Order Sheet
• Therapeutics– Proton-pump inhibitors
• Omeprazole 20 mg/d• Esomeprazole 40 mg/d• Take 30 minutes before breakfast
– Weight reduction– Elevation of head by 4-6 inches during
recumbency– Avoid
• Smoking• Fatty food, large quantities of food/fluid• Alcohol, mint, orange juice• Calcium channel blockers
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Gastroenterology
Jaundice: How to work it up
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Jaundice: Work-up
• History– Chronicity–Medications– Hospitalizations, blood transfusions– Sexual history– Drug intake
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Jaundice: Work-up
• Diagnostics– TB, DB, IB– AST, ALT, Alkaline Phosphatase– PT– Albumin– Hepatitis profile– HBT-UTZ– Coomb’s test
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Jaundice: Work-up
Initial Work-up
Isolated elevation of bilirubin
Bilirubin and other tests elevated
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Jaundice: Work-upIsolated elevation
of bilirubin
Elevated DB(DB > 15%)
Elevated IB(DB < 15%)
DrugsHemolytic DisordersInherited disorders
Inherited disorders
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Indirect Bilirubinemia
• Drugs– History is diagnostic– Rifampicin
• Hemolytic disorders– Precipitated by infection, or other illnesses– Enlarged spleen– Diagnosed by PBS, Coomb’s test– AST, LDH may be elevated
• Inherited Disorders– Criggler-Najjar syndrome, Gilbert’s syndrome– Present in childhood
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Direct Bilirubinemia
• Inherited Disorders– Dubin-Johnson syndrome– Rotor syndrome– Present in young to middle-aged
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Jaundice: Work-upBilirubin and other
tests elevated
ALT/AST predominant
(Hepatocellular pattern)
Alk Phos predominant(Cholestatic
pattern)
DrugsViral HepatitisAutoimmune
Hepatitis
Ultrasound
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Hepatocellular Pattern
• Drugs– Alcohol– Paracetamol ingestion– Other hepatotoxic drugs
• Viral Hepatitis– Detectable by serology
• Autoimmune Hepatitis– ANA positive in some cases
• May do liver biopsy if no diagnosis at this point
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Jaundice: Work-up
No Dilated Ducts on Ultrasound
Alk Phos predominant(Cholestatic
pattern)
Dilated Ducts on Ultrasound
Extrahepatic Intrahepatic
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Extrahepatic Pattern
• Do CT scan or ERCP to assess cause of obstruction
• Carcinoma– Periampullary CA– Gallbladder CA– Cholangiocarcinoma
• Stone– Filling defect
• Parasitic disease
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Intrahepatic Pattern
• Viral Hepatitis• Drugs– Alcoholic Hepatitis– Steroids
• Cholestasis of Pregnancy• TPN• Sepsis• TB• Lymphoma
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Poisons
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Poisons and Snakebites
• General Principles of Management• Alcohol Toxicity and Withdrawal• Silver Jewelry Cleaner Ingestion• Organophosphate Ingestion• Kerosene Ingestion• Acid and Alkali Ingestion
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Poisons
General Principles
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General Principles
1. Emergency Stabilization2. Clinical Evaluation3. Elimination of the poison4. Excretion of absorbed substance5. Administration of antidotes6. Supportive Therapy and
Observation7. Disposition
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General Principles
1. Emergency Stabilization– Airway– Breathing: Oxygenation and Ventilation– Circulation: Inotropes– Convulsion cessation– Electrolyte/metabolic correction– Coma
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General Principles
2. Clinical Evaluation– History: • Time, Mode/Route• Circumstances prior• Pre-existing illnesses or co-morbidities• Home remedies/treatment given
– PE• Complete• Breath odor• Neurologic PE
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General Principles
2. Clinical Evaluation– Laboratory Examinations• CBC with PC• Urinalysis• RBS, BUN, Creatinine, Na, K, Ca, alb, Mg• ABG• 12-L ECG• Bilirubins, PT, AST, ALT, Alk Phos• Chest X-ray (best if PA-upright)• Plain abdominal X-ray
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General Principles
3. Elimination of the poison– External decontamination
• Discard all clothing• Thorough bathing• Eye irrigation• Protective gear for personnel
– Empty stomach• Induction of emesis (if ingestion occurred within 1
hour)• Gastric Lavage (50-60 mL of tepid sterile water)
– Don’t do in ingestion of caustics, kerosene!– Don’t do if patient is convulsing!
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General Principles
3. Elimination of the poison– Limit GI absorption
• Activated charcoal: 50-100 g in 200 mL H2O• Do multiple doses if with enterohepatic recirculation• Contraindicated in caustics• Follow with Na sulfate up to 2 doses, then soap sud
enema for BM
– Demulcent agents• Raw egg albumin: whites of 8-12 eggs
– Cathartics• Na sulfate 15 g in 100 mL H2O• Contraindicated in caustics, easily absorbable
chemicals, ileus, severe fluid and electrolyte imbalances
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General Principles
4. Excretion of absorbed substances– Forced diuresis• Mannitol 20% 1 mL/kg within 10 minutes then
2.5-5 mL/kg q6 x 8 doses• Must have good urine output
– Alkalinization (for weak acids)• NaHCO3 1mEq/kg/dose IV targeting urine pH
> 7.5
– Acidification (for weak bases)• Ascorbic Acid 1g IV q6 until urine pH ≤ 5.5
– Dialysis
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General Principles
5. Antidotes6. Supportive Therapy– Fluid replacement for losses– Electrolyte correction– Prevention of aspiration, decubitus ulcers– Monitorin VS and I/O
7. Disposition– ER vs Ward vs ICU– Psychiatric evaluation– Social evaluation
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Poisons
Alcohol
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Alcohol Intoxication
Blood Ethanol (mg/dL)
SymptomsBrain affected
< 50Talkativeness,
euphoriaFrontal Lobe
50-100
Decreased inhibition/increased
confidence, emotional instability, slow
reaction
Parietal Lobe
100-300
Ataxia, slurred speech , diplopia,
decreased attention span
Occipital Lobe
Cerebellum
300-500Visual impairment,
severe ataxia, stuporMidbrain
> 500Respiratory Failure,
comaMedulla
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Alcohol IntoxicationCategory Specific % Ethanol
Beer
Lager 2-3%
Pilsen 5-6%
Strong 9-14%
Wine Red/White 7-12%
Fortified Wine Champagne 15-20%
DistillatesWhiskey, rye, rhum, bourbon, gin
40-50%
Local distilledLambanog, tuba
60-80%
Hygiene Products
Perfume/cologne
25-95%
Mouth wash 15-25%
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Alcohol Intoxication
Local Term Volume
Lapad 325 mL
Bilog 325 mL
Kwatro kantos
325 mL
Long neck 750 mL
Beer grande 1000 mL
Beer (regular) 320 mL
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Alcohol Intoxication
• Blood alcohol (mg/dL)–mL ingested x % alcohol x 0.8
6 x kg BW
• Metabolism– Non-alcoholic: 13 to 25 mg/dL per hour– Alcoholic: 30 mg/dL per hour
• Estimated time of recovery– Blood alcohol/metabolic rate
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Alcohol Intoxication
• History– Amount ingested–With what substance
• PE– Evidence of trauma– Level of sensorium
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Alcohol Intoxication: Order Sheet
• Labs– Urine ketones– CK MB, MM– Amylase– FOBT
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Alcohol Intoxication: Order Sheet
• Therapeutics– NPO– Insert NGT– IVF: D5 0.9 NaCl 1L x 8h
Conscious Unconscious
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Alcohol Intoxication: Order Sheet
• Therapeutics– Thiamine 100 mg IM/IV– D50-50 100 mL fast drip IV– Refer to Psych– Evaluate for withdrawal– Observe for 6 hours– Discharge on • Thiamine 50 mg TID OR• Vitamin B complex 1 tab TID• Folic Acid OD, Multivitamins OD
Conscious
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Alcohol Intoxication: Order Sheet
• Therapeutics– Thiamine 100 mg IM/IV now then q8– D50-50 100 mL fast drip IV– Refer to Neurology– Observe for return of consciousness
• Fully awake: Observe for 5-7 days, refer to Psychiatry• Partially awake: Work-up for decreased sensorium
(NSS?)• Comatose: Naloxone 2 mg IV q2 minutes for a total
of 10 mg; work-up for decreased sensorium, consider HD
– Same discharge plans
Unconscious
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Alcohol Withdrawal: Presentation
• Symptoms/Signs– Autonomic hyperactivity (sweating,
tachycardia)– Increased tremors– Insomnia– Nausea/vomiting– Hallucinations/illusions– Psychomotor agitation/anxiety– Seizures
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Alcohol Withdrawal: Order Sheet
• Therapeutics– Diazepam 2.5-5mg q8 x 3 days then taper
for next 2 days before discontinuation– Vitamin B complex TID– Folic Acid OD
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Alcohol: Resolution
• Enrol in quitting program• Advice moderation
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Poisons
Paracetamol
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Paracetamol: Presentation
• Toxic dose if 150-300 mg/kg• Symptoms vary based on time
after exposure– 0-24 hours: asymptomatic, nausea,
vomiting– 24-36 hours: asymptomatic, upper
abdominal pain– 36-72 hours: onset of liver/renal failure– 72-120 hours: jaundice, bleeding,
liver/renal failure
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Paracetamol
• History– Time, mode– Intake of other substances/meds– Co-morbidities
• PE– Heart, liver, kidneys– Neurologic examination
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Paracetamol: Order Sheet
• Diagnostics– Serum paracetamol– AST, ALT, PT
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Paracetamol: Order Sheet
< 150 mg/k
g
Volume ingested?
N-acetylcysteine
Test dose: 0.1 mL in 0.9 mL NSS IV
Diphenhydramine 1 mg/kg prior to phases
Phase 1: 150 mg/kg in 200 mL D5W x 1h
Phase 2: 50 mg/kg in 500 mL D5W x 4h
Phase 3: 100 mg/kg in 1L D5W x 16h
Observe for 24h
Known Unknown≥
150 mg/k
g
(+) SSx
(-) SSx
Observe for 72h
(+) SSx or AST, ALT or PT abn
(+) SSx or AST, ALT or PT abn
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Paracetamol: Order Sheet
Normalization after 72 hours
Discharge
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Paracetamol: WOF
• Acute Renal Failure– IVF hydration– Refer to Renal for possible Dialysis
• Bleeding– Vitamin K 10 mg IV up to q6– Target PT > 60% activity
• Hepatic insufficiency– Vitamin B complex– Vitamin K
• Electrolyte abnormalities– Hypoglycemia, acidosis, hypokalemia,
hypocalcemia
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Poisons
Silver Jewelry Cleaner
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Silver Jewelry Cleaner
• Active compound is cyanide-derived
• Binds to cytochrome oxidase enzymes, inhibiting cellular respiration
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SJC: Order Sheet
• Diagnostics– ABG– Serum cyanide– CBC with PC
• Anticipatory Care– ICU admission– Close monitoring– Treatment for co-ingestants (e.g. alcohol)
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SJC: Order Sheet
• Therapeutics– Oxygenation• High flow• Prophylactic intubation esp if with decreased
sensorium
– Na nitrite 300 mg SIVP (over 5 minutes)• Vasodilator, displaces cyanide, producing
methemoglobin• Causes hypotension
– Na thiosulfate 12.5 g (50 mL of a 25% solution) SIVP (over 10 minutes)• Speeds the displacement of cyanide by providing
sulfur for binding
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SJC: WOF
• Decreased sensorium– Aspiration precautions– Prophylactic intubation if warranted
• Seizures– Diazepam– Increased oxygen delivery
• Hypoxic encephalopathy– Rapidly reversible if antidote given early– If still not reversed, need prognostication
by Neuro
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Poisons
Kerosene
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Kerosene
• History– Time– Amount–Mucous membrane irritation– CNS depression, seizures
• PE– Lung findings: crackles, respiratory
distress– Arrhythmia, tachycardia– Sensorial changes
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Kerosene: Order Sheet
• Diagnostics– Chest X-ray (6 hours post-ingestion)– ABG
≤ 60 mL ≤ 60 mL + other toxic substance
> 60 mL or unknown
Volume ingested?
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Kerosene: Order Sheet
≤ 60 mL ≤ 60 mL + other toxic substance
> 60 mL or unknown
Volume ingested?
• Insert NGT• Lavage
with Activated Charcoal
• Insert NGT• Lavage
with water
• Na Sulfate• (BM)• Clean anal
area with petroleum jelly
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Kerosene: Order Sheet
Observe for 12-24
hours
Observe for 3 days
Sensorial Change
PneumoniaToxic
substances
• Refer to Psych• Discharge
Supportive Care
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Kerosene: WOF
• Pneumonia– Penicillin G 200,000 u/kg/d in 6 divided doses– Clindamycin 300 mg PO/IV q6– Metronidazole 500 mg PO/IV q6
• Gastritis– Al-hydoxide-Mg-hydroxide 30 mL q6
• Prolonged PT– Vitamin K 10 mg OD
• Seizures– Diazepam 2.5-5 mg SIVP– Refer to Neuro
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Poisons
Acids
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Acids
• Causes coagulation necrosis which forms eschars– Damage is self-limiting
• Eventual stenosis of viscus
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Acids: Order Sheet
• Diagnostics– Cross-matching– Urine hemoglobin– Chest X-ray upright, plain abdomen– Emergency EGD
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Acids: Order Sheet
• Therapeutics– Copious amounts of water to decontaminate
externally– NPO– IVF: D5NSS 1L x 8h–Meperidine 25-50 mg IM– Famotidine 20 mg IV q12– Concentrated acids: Enhance excretion with
Mannitol• Test dose: 1 mL/kg within 10 mins• If with good urine output: 2.5-5.0 mL/kg q6 x 8
doses• Discontinue mannitol if with poor urine output x 2h
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Acids: Order Sheet
Grade
Findings
0 Normal
1 Edema, hyperemia of mucosa
2A Friability, blisters, hemorrhages, erosions, whitish membranes, exudates, superficial ulcerations
2B 2A + deep discrete or circumferential ulceration
3A Small scattered areas of multiple ulcerations and areas of necrosis
3B Extensive necrosis
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Grade 0-1 Grade 2a/b Grade 3a/b
Endoscopy
Admit to ICUNPOIV hydration,
TPNH2 blockers IVRepeat EGD 24-
48h
Admit to ICUNPOIV
hydration/TPN
H2 blockers IVHydrocortisone
100 mg IV q6 for shock
MeperidineAntibiotics
(anarobes, Gram negatives)
Repeat EGD 24-48h
AdmitObserve for 48
hLiquid diet for
48hH2 blockers
PO/IVDemulcent,
antacids or sucralfate
Psych ReferralDischargeFf-up with
GS/GI
Perforation, Necrosis?
Laparotomy
Yes
No
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Acids: WOF
• Acute abdomen– Surgery– Lifelong vitamin B12 if gastrectomy done
• Shock– Fluids, antibiotics as appropriate
• Upper airway obstruction– Tracheostomy– Hydrocortisone 100 mg IV q6
• Upper GI Bleed– Blood transfusion, surgery
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Poisons
Alkali
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Alkali
• Causes liquefaction necrosis– Damage spreads, and may continue for
days
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Alkali: Order Sheet
• Diagnostics– Cross-matching– Urine hemoglobin– Chest X-ray upright, plain abdomen– Emergency EGD
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Alkali: Order Sheet
• Therapeutics– Copious amounts of water to
decontaminate externally– NPO– IVF: D5NSS 1L x 8h–Meperidine 25-50 mg IM– Famotidine 20 mg IV q12
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Alkali: Order Sheet
Extent Findings
First degree
Superficial mucosal hyperemia, mucosal edema, superficial sloughing
Second degree
Deeper tissue damage, transmucosal (all layers of the esophagus), with exudages, erosions
Third degree
Through the esophagus and into the periesophageal tissues (mediastinum , pleura or peritoneum), deep ulcerations, black coagulum
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First degree
Second degree
Third degree
Endoscopy
Admit to ICUNPOIV hydration,
TPNHydrocortisone
100 mg IV q6H2 blockers IVSucralfateRepeat EGD 24-
48h
Admit to ICUNPOIV
hydration/TPN
H2 blockers IVHydrocortisone
100 mg IV q6 for shock
MeperidineAntibiotics
(anarobes, Gram negatives)
Repeat EGD 24-48h
AdmitObserve for 48
hLiquid diet for
48hDemulcent,
antacids
Psych ReferralDischargeFf-up with
GS/GI
Perforation?Laparotomy
Yes
No
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Alkali: WOF
• Acute abdomen– Surgery– Lifelong vitamin B12 if gastrectomy done
• Shock– Hypovolemic/Septic: Fluids, antibiotics as
appropriate– Neurogenic: Mepedirine 1 mg/kg/dose IV
• Upper airway obstruction (Glottic edema)– Tracheostomy– Hydrocortisone 100 mg IV q6
• Upper GI Bleed– Blood transfusion, surgery
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National Poison Control and Management
Center
(02) 554-8400 loc 2311(02) 524-10780922-896-1541
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Pain Pharmacope
ia
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Pain Medication
• Most common complaint• Best treatment: address the cause
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Pain Pharmacope
ia
NSAIDs
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Pain Medication: NSAIDs
• ASA 80-160 mg PO OD• Paracetamol 500-650 mg PO up
to q4• Ibuprofen 400 mg PO up to q4• Naproxen 250-500 mg up to q12• Ketorolac 15-60 mg IM/IV up to q4• Celecoxib 100-200 mg PO up to
q12
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Pain Medication: NSAIDs
• Advantages– Deals well with inflammatory pain (muscle
and joint pain, malaise from infection, etc)– Absorbed well from the GI tract
• Disadvantages– GI irritation (except paracetamol)– Peptic ulcer– Nephropathy– Increases blood pressure
• Selectivity for COX-2– Decreases GI symptoms– Increases cardiovascular risk
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Pain Pharmacope
ia
Narcotics
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Pain Medication: Narcotics
• Morphine 60 mg PO up to q4• Tramadol 50-100 mg PO up to q4
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Pain Medication: Narcotics
• Advantages– Broadest efficacy– Very rapid especially if IV
• Disadvantages– Nausea and vomiting– Constipation– Sedation– Respiratory depression
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Pain Pharmacope
ia
Anti-depressants
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Pain Medication: Anti-depressants
• Duloxetine 30-60 mg/d• Desipramine 50-300 mg/d• Imipramine 75-400 mg/d• Amitriptyline 25-300 mg/d• Doxepin 75-400 mg/d
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Pain Medication: Anti-depressants
• Advantages– Very useful for chronic pain• Post-herpetic neuralgia• Diabetic neuropathy• Tension headache• Migraine• Rheumatoid arthritis• Cancer
–More rapid onset of relief
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Pain Medication: Anti-depressants
• Disadvantages– Significant number of side effects• Orthostatic hypotension• Heart block/conduction delay• Constipation• Urinary retention
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Pain Pharmacope
ia
Anti-convulsants
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Pain medication: Anti-convulsants
• Phenytoin 300 mg @ HS• Carbamazepine 200-300 mg up to
q6• Clonazepam 1mg up to q6• Gabapentin 600-1200 mg up to q8• Pregabalin 150-600 mg up to BID
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Pain medication: Anti-convulsants
• Advantages– Effective for neuropathic pain (e.g.
trigeminal neuralgia, DM nephropathy)
• Disadvantages– Hepatic toxicity– Dizziness– GI symptoms– Heart conduction disturbances
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Electrolytes