1=daily EKG, QUIZ = PRIORITY(like BIBLE reading)
->5
2=QnA during patient care(IMPACT patient care first)
->5
3=text with title(CONTINUE-); just for the purpose of deep learning = recording and listening in
->daily recording at least 5 minutes(summary ===> text book ===> continued)
->LC for 50 minutes with my voice
GMAIL.
(daily = review homework and goal !!! should be done list. = improvement in 2020)
(God, Hanna, Baby, and Family and Me)
HERE= CONTENTS(CHECK AND TO DO LIST)
= OTHERS(in FILE or TEXT itself=recording only/brain recording.)
= WEEKLY CONTENTS should be selected and go deeply
(7days course = Note, Summary, Text and 1st title page) => FILE.
= Others; EKG, Quiz, and other question ( add to FILE)
======================================================================
CC or Ds, : likely vs unlikely (DDx) = What it is. = Upgrade as needed(per consultant).
List:
murmur evaluation(https://depts.washington.edu/physdx/heart/tech4_diastolic.html)
(https://derangedphysiology.com/main/required-reading/cardiology/Chapter%20102/clinical-signs-cardiovascular-disease)
AS
MR
AR
OHT with Sepsis
OHT with PNA
OHT with UTI
OHT with diarrhea
LVAD with fall, SDH
Chest Pain
- stress test prep
x R/O PE
hCMP
dCMP
HOCM - workup. treatment. evaluation.
SOB
Dizziness
Syncope
ICD shock
CP
LVAD
OHT
OHT infection
End stage CMP in HFpEF(how to management)
Pericarditis
Afib
- Drug loading
IM:
v Vancomycin trough
x Hematuria
x Headache
Gastroenteritis or colitis(ix. of abx.? workup)
x Epistaxis
FUO
Hyponatremia
N/V
Seizure
x IC/BPS(Interstitial cystitis/bladder pain syndrome):
Hemoptysis
Tb? evaluation
IDA
Unresponsiveness and intubation or not intubation?
DM management with new meds.
Pancreatitis
Cryptococcus infection(CNS? - Headache)
HypoKalemia, Mg, Ca
HyperKalemia, Mg, Ca
Hypo P
SBO
Drug
Amphetamine intoxication, withdrawal and management
Claustrophobic
Radiology:
CXR
CT
USG- class please(plan it!)
EKG:- class
=====================================================================
Hyponatremia(SIADH vs. Advanced hyponatremia management in cirrhosis, ESRD, CHF, etc. )
Hypokalemia(maximum rate in IV = 20mEq/hr and oral liquid? or sustained release(possible for this but what about liquid?) Some clinicians initiate treatment with 40 mEq given 3 to 4 times per day; may also administer 20 mEq every 2 to 3 hours in conjunction with IV potassium administration with careful monitoring. MAX = PO 40mEq q6hr + IV 20mEq q2hr. (max=20mEq/hr seems like! )
Hypomagnesemia
================================================================
CP:
likely cardiac
- R/O ACS: serial troponin and EKG(q5minutes for active CP)
- Basic labs: CBC, CMP, PT/PTT, Troponin, BNP
- CXR, TTE
less likely ACS:
(DDx. = fatal vs. non fatal; pericarditis/myocarditis, CHF, valvular disease, hCMP, PE, large vessel disease-such as AoD, pulmonary disease, GERD/gastritis, MSK)
- R/O ACS: serial troponin and EKG(q5minutes for active CP)
- Basic labs: CBC, CMP, PT/PTT, Troponin, BNP
- CXR, TTE
VCU heart score
3= discharge
6=CDU
7=Cardiology admission
==================================================================
R/O PE
- Wells Score.
<2 + R/O(if all 8 criteria met)
<2 but cannot R/O then D-dimer or 2-6 => then D-dimer but >6 = CTA or VQ scan directly.
-> D-dimer <500 = r/o
D-dimer = 500 or high = CTA or VQ scan
-> directly CTA or VQ scan for likely (Wells =7)
- Management: stable no => go unstable algorithm(tPA?)
stable => AC contraindicated? yes => Test and IVC
no
- suspicion(low, moderate, high)
low => more than 24 hours = start AC and wait
moderate => more than 4 hours => start and wait
high => just do AC and get workup.
unstable SUSPICION of PE: unstable with/without recurrence on AC,
we suggest more aggressive therapies (ie reperfusion therapies) than anticoagulation including the following:
●Thrombolytic therapy is indicated in most patients, provided there is no contraindication (table 7). Absolute CTX: h/o ICH, known cerebral vascular lesion, malignancy in brain, stroke(ischemic) in 3 months, (3 hours = excluded), suspected Ao. dissection, active bleeding(but mense), head/facial trauma significance in 3 months.
=> NEED whole life h/o brain(bleeding, mass, cancer)
H/O Stroke, Trauma
Concerning Ao. dissection
(3 = absolutely not)
Embolectomy is appropriate for those in whom thrombolysis is either contraindicated or unsuccessful (surgical or catheter-based).
=> VASCULAR SURGEON CAN DO IT?
================================================================
hCMP
dCMP
=======================
Vancomycin trough
Most of them: 15-20(most of them 17!)
Skin/soft tissue or S. viridans: 10-15 (lower goal)
=>
>25 = hold -> decrease it?
>20 = recheck
15-20 = continue
<15 = redosing per guideline and increase(1000 -> 1500? how to do?)
For HD patient,
pre HD level should be in 15-30 => that would make maintenance level in 15-20.
============
Hematuria:
intermittent or continous irrigation !! Ix. of irrigation
Bladder irrigation — Bladder irrigation is reserved for selected patients (eg, postoperative, pharmacologic therapy) or for the management of hematuria. However, if a catheter is not draining properly, it can be irrigated once with sterile saline . If this is not effective, the catheter should be replaced. If there is a suspicion that the latex catheter material contributed to the obstruction, the catheter should be changed to a silicone catheter to reduce future encrustation.
To irrigate the bladder
●Triple-lumen catheters are used for bladder irrigation and are available in larger diameters (20 to 24 F) to aid removal of clot. Irrigation fluid is instilled into the bladder through the irrigation port and drained through the catheter. Intermittent or continuous irrigation can be used depending upon the indication for irrigation.
N/V:
likely 2/2 cardiogenic shock(CHF) and/or ACS related symptom and/or drug induced
and/or gastroenteritis and/or UTI/infection
and/or other food poisoning
- mild to moderate
- vomiting without bloody contents vs. bile contents
- symptomatic control
- avoid precipitating drug (1st of all = always m/cc cause or treatment)
- anti-emetics:
-SE inhibitor(zofran)
-dopaminergic antagonist(haldol, phenergan, compazine)
-BZD(ativan)
- ginger ale
- NPO or clear liquid diet for now
- obtain labs: CBC, CMP, Troponin
- stool workup(if there is any diarrhea)
- UA(if there is any dysuria symptom)
- treat CHF, ACS
=================================================================
Diarrhea:
=================================================================
CP: DDx =
likely ACS(NSTEMI or UA)
-
STEMI
- R/O ACS: serial troponin and EKG
- EKG: STEMI equivalents
-
less likely ACS
-
Prep for stress test: NPO MN, Avoid bb, nitrate(ISMN, ISDN, Nitroglycerin patch) for the 24hours prior to the study unless there is active CP!
=================================================================
Urinary retention:
=================================================================
Hyperkalemia protocol:
=================================================================
Insomnia:
=================================================================
Anxiety:
=================================================================
Uncontrolled DM:
=================================================================
Recurrent hypoglycemia:
=================================================================
LVAD with infection
=================================================================
LVAD with bleeding
LVAD with fall, SDH; likely 2/2 recent fall and/or possible recurrent falls
- no focal neurologic deficit.
- VSS, other physical exam
- on holding bivalirudin(in the setting of bleeding)
- ok to hold it for the next few days.
- discussed with Dr. Cooke
- basic labs: CBC, BMP, PT/PTT
- serial neurologic assessment Q2HR
- f/u CT head wo contrast in the morning
- when it's done, will contact neurosurgery(p9904) to discuss about resuming bivalirudin
(If the size is same, then mostly we would be able to resume bivalirudin per neurosurgery)
- neurosurgery consulted; will f/u rec.
- NPO for now
- PT/OT
- Consult to GI / GU / or Neurosurgery to follow up their rec
=================================================================
LVAD with ADHF
=================================================================
LVAD with low flow alarm
=================================================================
=================================================================
OHT with infection
Cryptococcus Ag in blood
- Repeat cryptococcus Ag(high risk to be involved in CNS), titer >1:500 (high!)
- Fungal culture
- Lumbar puncture to run glc, prt, cell count, and culture/fungal culture/Cryptococcus Ag
- hold SQ or IV HEPARIN 6 hours prior to procedure(cf. Lovenox for 12 hours holding)
=================================================================
OHT with bleeding
=================================================================
Afib(AAD loading)
- failed DCCV -> ablations multiple times
- hold other AAD for the past 2-3 days
- check baseline EKG(QTc<450)
- check BMP(Kidney function, K and Mg)
- GFR >40
- K>4(Mg>2)
- Then start Sotalol loading: 80mg po Q12hr (or Qday)
- can use metoprolol as well(even if they both have b-blockade)
- tolerate and QTc<500 then increase it after 3 days = Sotalol loading 80mg po q12hr ; NOT SUCCESSFUL with QTc<500 then you can increase to 120 or even to 160 after 3 days of loading.
- Tikosyn loading: CrCl and QTc interval (or QT interval if heart rate is <60 beats/minute) must be determined prior to first dose. If QTc >440 msec (>500 msec in patients with ventricular conduction abnormalities), dofetilide is contraindicated. Adjust initial dosage in patients with estimated CrCl <60 mL/minute (see dosage adjustment in renal impairment). Dofetilide may be initiated at lower doses than recommended based on physician discretion; however, if the lower dose is increased, the patient will require rehospitalization for 3 days.
CrCl >60 mL/minute: Initial: No dosage adjustment necessary.
CrCl 40 to 60 mL/minute: Initial: 250 mcg twice daily.
CrCl 20 to 39 mL/minute: Initial: 125 mcg twice daily.
CrCl <20 mL/minute: Use is contraindicated.
=================================================================
OHT with rejection(possible rejection)
=================================================================
OHT/LVAD
- with any concern of infection = really need to do CT scan chest/abd/pelvis.
OHT/LVAD with Abdominal pain
- Should get CT scan: high risk of atypical infection and/or complication such as ischemia/significant infection/gangrene as well.
-
=================================================================
OHT with diarrhea(basic concept!) F/U 6243229 1/10 admission.
- NEED TO DETERMINE infectious? or non-infectious?
- If it's infectious, then how much of workup needed?
- Empirical antibiotics or not?
- general diarrhea without systemic sign of infection or sign of inflammation in Stool workup
: HOLD ANTIBIOTICS.
-------------------------------------[EXAMPLE => KEY POINT = CT / Other evidence of infection!! really important to determine. So it should be done ! ] cf. LVAD = should need more evident sign like normal patient! If so, low threshold to obtain CT scan as well though.
Assessment: _
1. s/p OHT
-+flow cross match
-induction with Simulect
2. diarrhea
3. colitis on CT abd
4. weight loss
5. ecchymosis with fluid collection and communication to pericardium on CT chest
6. RHC with low filling pressure, nl CO
Plan:
1. admit to Tx-MCS
2. repeat CT chest and abdomen
3. pan culture
4. send CMV
5. send stool cultures to include ova and parasites- has well water
6. start Vanc, Flagyl, Cipro (discussed Zosyn but severe Cephalosporin allergy)
7. hydration overnight
8. MMF decreased today from 1500mg BID to 500mg BID- continue reduced dose
9. continue Tac and Pred
10. hold Bactrim, nystatin already held for decreased appetite
11. continue Valcyte
-----------------------------------------
- Low threshold to get CT abd/pelvis
-
+ flank pain and abdominal pain: likely 2/2 irritative symptom from stent related to position change?
unlikely 2/2 Urinary obstruction nor UTI including pyelonephritis, given sterile urinalysis.
- UA, CXR, +- CT abdomen(if it’s tender/severe illness),
- Panculture: Blood Cx., (Urine Cx.) and fungal culture, CMV/EBV IgG/IgM/DNA quantity. + IgG level( for IVIG infusion ! )
* fungitel(pneumonia or bloody stool - any sign of it and then add fungal study! not routinely needed!) l,
legionella urine Ag(mainly pneumonia but other diarrhea possible) .
respiratory/GI direct pathogen test.
- Image workup
- CT abd/pelvis(low threshold to get images)
- IVF bolus(unless overload)
- Start Abx: Vanc and zosyn.(NOT always but mostly). But follow ID recs.
- ID rec.
- Continue anti-rejection medication: MMF 500mg po Q12HR, Prednisone 5mg pOQ day, tacrolimus 6mg po Q12HR.
- OR DECREASE MMF ? (INDICATION? ) OR DECREASE OTHERS in AKI?
=> panculture and treat as severe sepsis(complicated d/t immunosuppressed). But still continue IMMUNOSUPPRESSANT.
# Diarrhea in the setting of OHT with immunosuppressant
- no evident sign of infection/inflammation
- CT showed SBO but no sign of colitis
- likely 2/2 chronic intermittent diarrhea or gastroenteritis and/or related SBO
- infection workup: UA, Stool workup(C. DIFF, Stool WBC/RBC/Culture), EBV/CMV IgG/IgM/PCR, IgG, blood culture, fungal culture
- CT scan with oral contrast done
- No empirical antibiotics for now unless there is any evidence of infection/inflammation from the basic workup
- if there is any evidence of inflammation/infection, then consider further workup as well(direct GI pathogen, fungitell, legionella, etc.)
- Continue Immunosuppressant
- Cyclosporine 75mg po q12hr => 50mg IV infusion for 24 hours
- Azathioprine 100mg po qday => changed to liquid form (no IV available)
- Cyclosporine level
- IVF: NS 100cc/hr for 1 L
Chr. Diarrhea (today = even more → make sure no evident sign of flammation from STOOL, SYSTEMIC) => BUT NO OTHER SIGN OF INFLAMMATION / INFECTION
- Stool workup(C Diff, WBC, RBC, Culture), UA, CT scan
- Blood, Viral workup(CMV, EBV, Viral direct)
- IVIG
- “Reserve urine culture, fungal culture, fungitell, legionella - if everything is negative”.
- “no Abx for now” - without any other sign of infection at all.
They can have URI, Diarrhea, with viral infection however any sign of inflammation/fever/whatever sign of WBC/sign of inflammation anywhere => treat it !!!
PNA = CXR
Abdomen =CT
Stool WBC, UA WBC etc. = then treat it. otherwise wait !!! with other chance !!!
=================================================================
OHT with ADHF
=================================================================
OHT with Afib c RVR
=================================================================
Pericarditis:
=================================================================
Recurrent pericarditis:
================================================================
EP procedure - perioperative antibiotics: ONLY PRIOR TO SURGERY ! (unless dirty, or prolonged.)
Guideline recommendations (off-label): IV: Note:
For most surgical procedures, joint clinical practice guidelines from the American Society of Health-System Pharmacists, Infectious Diseases Society of America, Surgical Infection Society, and Society for Healthcare Epidemiology of America (ASHP/IDSA/SIS/SHEA)
recommend a dose of 2 g within 60 minutes prior to surgical incision (for nonobese patients weighing <120 kg). Only GI susrgery(+ metronidazole)
+-Cefazolin doses may be repeated intraoperatively in 4 hours if procedure is lengthy or if there is excessive blood loss (Bratzler 2013).
For clean and clean-contaminated procedures, continued prophylactic antibiotics beyond surgical incision closure is not recommended, even in the presence of a drain (CDC [Berríos-Torres 2017]).
PREPROCEDURAL ANTIBIOTICS ONCE!! IS GOOD ENOUGH.
Dressler's syndrome:
=================================================================
Dizziness
=================================================================
Syncope
=================================================================
Seizure
=================================================================
IC/BPS(Interstitial cystitis/bladder pain syndrome):
- comorbid with IBS, FMG, Chronic pelvic pain syndrome, etc.(psychologic approach?)
- hx= filling pain with relieved by emptying.
less likely UTI, STI(no risk), structural disease(pelvic mass, vulvovaginitis, cancer),
neurogenic, no h/o radiation, less likely chronic pelvic pain syndrome(chronic prostatitis in
male) = diagnosis of exclusion.
- physical exam: no mass, no pelvic muscle spasm
- bladder scan(to r/o urinary retention)
- labs: UA/microscope
- possible cystscopy/urology consult
- indication of cystoscopy and urology consult
1) hematuria(gross, microscopic = cancer)
2) incontinence
3) retention
- conservative management:
1) anti histamine(hydroxyzine)
2) amitriptyline
3) pentosan(wall buffer)
====================================================================
FUO:(ID note)
=====================================================================
Epistaxis:
likely anterior bleeding
- hemodynamically stable
(acute management = acute therapy/evaluation)
- bend at waist
- blow clot and oxymetazoline spray X2
- pinch alae for 10-15minutes then cotton plug or cold compression as well.
(prohibit causing = uptimate therapy/evaluation)
- hold AC for now
- avoid drying nose/flonase
====================================================================
Gastroenteritis or colitis(ix. of abx.? workup)
Ix. of Anbiotics
1. Sepsis
2. Diverticulisi
3.
----------------------------------
likely posterior bleeding(persistent after packing. more than hours)
- hemodynamically unstable/perfusive bleeding
- CBC, PT/PTT(pt. on AC or LC or others), and Type/Screen
- call ENT
- Foley catheter 30mL -> fill up 10mL and pull and clog it.(As emergent measure)
=====================================================================
Pancreatitis
Pancreatitis with pancreatectomy or transplant?
=============================
SBO:
# Abdominal pain: 2/2 Partial SBO - Passing gas with BS(+), unlikely closed loop obstruction - Improved pain with medical management currently - Will close monitor his condition and would place NTG as needed - Strict NPO - Basic labs: CBC, CMP, PT/PTT, Troponin, Lactate - CT scan with oral contrast - AGS consulted in ED - Serial exam
immediate indication for surgery: regardless partial/full obstruction. full obstruction would have higher chance to proceed to significant complication.
acute abdomen
any sign of ischemia
closed loop obstruction
===================================
Cryptococcus infection(PNA and/or CNS)
1. Disseminated cryptococcal infection with suspected pneumonia and early CNS involvement in an immunocompromised patient status post heart/kidney transplantation in 2018 on chronic immunosuppression; see above for comments -recommend therapeutic lumbar drainage via LPs daily as long as she continues to have headaches and her opening pressure continues to be greater than or equal to 25 cm of CSF; would do this until her pressures are normal on 2 consecutive procedures. If her opening pressure is greater than or equal to 25 cm of CSF would do CSF drainage to reduce pressure by 50% or to a normal pressure of less than or equal to 20 cm of CSF -would continue liposomal amphotericin 350 mg IV daily; would continue to follow closely for renal toxicity. Would ensure adequate hydration-please discuss optimal management with transplant nephrology and pharmacy -would continue flucytosine 2,250 mg p.o. twice daily; will defer dose and dose frequency to pharmacy. Will need to follow closely for bone marrow toxicity. Would measure a flucytosine level after 3 days of therapy; would send this 2 hours after the dose. This peak concentration should be between 30-80 micro g per mL -please obtain a brain MRI when feasible to assess for cryptococcomas; overall these are not deemed likely, however, but if present may affect management -will defer to primary service regarding reduction in immunosuppression
=> ID rec note.
===========================================
EKG
- normal variable in tachycardia
- TWI, ST depression ?
=====================================================
Femoral arterial bleeding (vascular surgeon for deep arterial hemorrhage)
54yo M w/ PMHx of NICM s/p heart tx on 4/26/2019 c/b ECMO due to VT storm and a very complicated post op course with a recent hospitalization for E coli bacteremia and extensive right lower extremity DVT and was discharged on lovenox and antibiotics and now presents with a large spontaneous right thigh hematoma concerning. No evidence of overlying skin threat or compartment syndrome at this time.
- Vasc surgery recommending stat CTA pelvis with RLE for further work up.
- Upload scans from OSH, radiology reads.
- Keep NPO for possible intervention pending CTA results.
- Recommend giving blood products/platelets to reverse AC given increase in thigh hematoma.
- Continue close monitoring of right thigh.
- Vascular surgery will continue to follow. Patient discussed with Fellow Dr. Richard.
==========================================================
HA:
Dangerous sing =
Systemic symptoms, illness, or condition (eg, fever, chills, myalgias, night sweats, weight loss, cancer, infection, giant cell arteritis, pregnancy or postpartum, immunocompromised state, including HIV)
●Neurologic symptoms or abnormal signs (eg, confusion, impaired alertness or consciousness, changes in behavior or personality, papilledema, diplopia, pulsatile tinnitus, focal neurologic symptoms or signs, meningismus, or seizures)
●Onset is sudden (eg, "thunderclap" where pain reaches maximal intensity immediately after onset; or first ever, severe or "worst headache of life")
●Older onset (age ≥50 years)
●Pattern change in previous headache with
•Progression or change in attack frequency, severity, or clinical features, or
•Precipitated by Valsalva maneuver, or with
•Postural aggravation, or with
•Papilledema
TTH(tension type headache) =
Diphenhydramine 25~50mg IV + Chlopromazine2.5~5mg IV(can be additional for breaking pain!)
after fioricet !
For patients with definite or probable TTH of severe intensity who are acutely evaluated and managed in a medical facility, additional treatment options include parenteral chlorpromazine, metoclopramide, the combination of metoclopramide plus diphenhydramine, or intramuscular ketorolac. (See 'Parenteral treatments' above.)
Analgesics can be augmented with a sedating antihistamine, such as promethazine (Phenergan) and diphenhydramine (Benadryl), or an antiemetic, such as metoclopramide (Reglan) and prochlorperazine (Compazine). If this regimen is inadequate, the patient can try acetaminophen or aspirin combined with caffeine and butalbital. This combination is usually quite effective but is also the most frequent cause of chronic daily headache. Before initiating this regimen, patients should be informed of the possibility of chronic daily headache and instructed to limit their use of the combination to twice weekly. The physician should carefully monitor the patient's progress and prescribe only enough medication to support this limited usage.
Diphenhydramine + Acetaminophen + Compazine (antiemetics = =======================
Claustrophobic: PO (0.5 to 2mg)1mg 30-90minutes (stay 12hours?(longer than IV)).
may repeat after 30 mins
IV 1-4mg 5-20minutes (star6-8 hours). may repeat after 5 minutes(50% dose)
Procedural anxiety (premedication) (off-label use):
Oral, Sublingual: 0.5 to 2 mg once 30 to 90 minutes before procedure; if needed due to incomplete response, may repeat the dose (usually at 50% of the initial dose) after 30 to 60 minutes (Chang 2015; Choy 2019; Male 1984; Shih 2019).
IV: 1 to 4 mg or 0.02 to 0.04 mg/kg (maximum single dose: 4 mg) once 5 to 20 minutes before procedure; if needed based on incomplete response and/or duration of procedure, may repeat the dose (usually at 50% of the initial dose) after ≥5 minutes (Choy 2019; manufacturer's labeling). Note: In obese patients, non–weight-based dosing is preferred (Choy 2019)
