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Medical  Notes Clinical Medicine Pocket Guide

 Bruce Y. Lee,  MD, MBA Purchase additional copies of this book at your health science bookstore or directly from F.A. Davis by shopping online at www.fadavis.com or by calling 800-3233555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book

F.A. DAVIS DAVIS COMPANY COMPANY • Philadelphia

F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2009 by F. A. Davis Company All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Andy McPhee  Developmental Editor: Yvonne Gillam Manager of Art and Design: Carolyn O’Brien Reviewers: Julie Z. Belcher, MD; Anna M. Choo, MD, JD; Carlos Duarte, MD; Brian G. Dwinnell, MD; Adam D. Elkin, MD; Sam Ghaffari, DO; Shilpa Grover, MD; Naghmeh Khodai, MD; Leslie H. Lee, MD; Elizabeth Mack, MD; John Tobias Tobias Musser, Musser, MD; Diane  E. Nuñez, MS, ANP-C; Manali Indravadan Patel, MD, MPH; Mohammad Qasaymeh, MD; Susan D. Wolfsthal, MD; Erica Young, PA; and Kevan M. Zipin, MD 

As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1746/09  $.25.

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1 Diseases and Disorders

American Cancer Society Guidelines: Cancer (CA) Detection Breast CA (Women) ■ 40 y.o.: Mammogram every year ■ Clinical breast exam: 20-39 y.o. ~q3yr and 40 y.o. every year ■ Breast self-exam option for 20 y.o ■ 20% lifetime risk: MRI and mammogram every year ■ 15%-20% lifetime risk: discuss w/physician about MRI Colon and Rectal CA ■ 50 y.o. male or female: Do one of following five: ■ Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year ■ Flexible sigmoidoscopy q5yr ■ Yearly FOBT or FIT and flexible sigmoidoscopy q5yr (preferred) ■ Double-contrast barium enema q5yr ■ Colonoscopy q10yr ■ Start earlier (e.g., 40 y.o.) if: ■ Pt history of colorectal CA, adenomatous polyps, or chronic inflammatory bowel disease ■ Strong family history of colorectal CA or polyps (CA or polyps first-degree relative 60 y.o. or two first-degree relatives any age) ■ Family history of hereditary colorectal CA syndrome Cervical CA (for Women) ■ ~3 yr after begin vaginal intercourse or  21 y.o., whichever comes first: Regular Papanicolaou (Pap) test every year or newer liquid-based Pap test q2yr ■ When 30 y.o.: ■ May continue every year or change to q3yr HPV DNA test and either conventional or liquid-based Pap test ■ If 3 normal Pap tests in a row, may change to q2-3yr ■ If risk factors*: Continue every year *Prenatal DES exposure, HIV, or øimmunity

BASICS

BASICS

■ 70 ■

y.o.: If 3 normal Pap tests in row and no abnormal Pap last 10 years, may stop; if risk factors,* continue every year Total hysterectomy (uterus and cervix): May stop, unless surgery was for cervical CA or pre-CA

Endometrial (Uterine) CA (for Women) ■

High risk for hereditary nonpolyposis colon CA: offer endometrial biopsy every year

35 y.o.:



Prostate CA (for Men) ■ 50 ■

■

y.o.: Offer prostate-specific antigen and digital rectal examination every year  45 y.o. high-risk (African-American or strong family history 1 first-degree relatives [father, brothers] diagnosis 65 y.o.): Every year 40 y.o. higher risk (multiple first-degree relatives): Every year; if negative consider waiting until 45 y.o.

Diagnostic and Therapuetic Procedures Electrocardiogram (ECG) Rate (Normal: 60–100 bpm) ■

Bradycardia:

60 bpm; tachycardia:



100 bpm



P Waves ■ ■ ■

■

■

Normal: P upright (positive), uniform, precedes each ORS None: Rhythm junctional or ventricular Right atrial enlargement (RAE): P 2.5 mm tall in II and/or 1.5 mm in V1; better criteria: (RVH or RV displacement signs) QR, Qr, qR, or qRs in V1 (w/o CAD); QRS in V1  5 mm and ratio V2/V1 voltage  6 Left atrial enlargement (LAE): P duration 0.12 sec in II; notched P in limb leads w/interpeak duration 0.04 sec; terminal P negativity in V1 duration 0.04 sec, depth 1 mm Biatrial enlargement (BAE): RAE and LAE, P in II 2.5 mm tall and 0.12 sec duration; initial and component of P in V1 1.5 mm tall and prominent P-terminal force

2

3 PR Interval (Normal: 0.12–0.20 sec) ■

■

Short PR (0.12 sec) Could be normal variant or: ■ Wolff-Parkinson-White (WPW): Accessory path RA †RV or LA †LV so early ventricle activation leads to Δ-wave (initial slurring of QRS), ⁄QRS duration (usu. 0.10 sec), seconddegree ST-T Δs from altered ventricular activation ■ Lown-Ganong-Levine: AV nodal bypass track into bundle of His  † early ventricle activation w/o Δ-wave ■ AV junctional rhythms w/retrograde atrial activation (inverted P in II, III, aVF) ■ Ectopic atrial rhythms w/origin near AV node Prolonged PR (:0.20 sec): ■ First-degree AV block (PR interval usu. constant); øconduction in atria, AV node, bundle of His, or bundle branch (when contralateral bundle blocked) ■ Second-degree AV block (PR interval normal or ⁄; some P waves do not conduct): Type I (Wenckebach): increasingly ⁄PR until a P not conducted; type II (Mobitz): fixed PR intervals and nonconducted Ps ■ AV dissociation (Ps and QRS dissociated): Incomplete (slow SA node so subsidiary escape pacemaker takes over or subsidiary pacemaker faster than sinus rhythm) or complete (third-degree AV block: atria and ventricles each have separate pacemakers)

QRS Complex ■

■

Poor R wave progression (PRWP): R3 mm in V1–3, normal variant, LVH, LBBB, LAFB, anterior or anteroseptal MI, COPD (R/S ratio in V5–6 1) ), diffuse infiltrative/myopathic processes, WPW pre-excitation, heart rotates clockwise, misplaced leads Prominent anterior forces: R/S ratio 1 in V1 or V2; normal variant, posterior MI, RBBB, WPW pre-excite

QRS Interval (Normal: 0.6–0.10 sec) ■

QRS duration 0.10–0.12 sec: Incomplete RBBB or LBBB (same as complete RBBB and LBBB except QRS duration), nonspecific IVCD, LAFB, or LPFB (some)

BASICS

BASICS

■

QRS duration 0.12 sec: ■ Complete RBBB: RV depolarizes after LV, second half QRS oriented right and anterior  † terminal R’ in V1, terminal R in aVR, and downward ST-T in both V1/aVR; terminal S and upward ST-T in I, aVL, V6 ■ Complete LBBB: LV depolarizes after RV, second half QRS oriented left and posterior  † terminal S and upward ST-T in V1; terminal R and downward ST-T in I, aVL, V6 ■ Nonspecific Intraventricular Conduction Deficit (IVCD): QRS duration 0.10 sec but not bundle branch or fascicular block criteria; causes: ventricular hypertrophy, MI, drugs (esp. class IA and IC antiarrhythmics), ⁄K+ ■ Ventricle-origin ectopic rhythm (e.g., VT)

1 QT Interval (Normal:  ⁄  2 R-R interval; normal QT 500 msec) ■ Beginning R wave  † end of T wave; varies w/HR ■ Bazett’s formula: QTc = QT/ RR (normal QTc440 msec) ■ QTc 0.47 sec (male) and 0.48 sec (female)  † long QT syndrome (LQTS): (May  † torsade de pointes: ventricular tachycardia w/varying QRS morphology): Drugs (e.g.,antiarrhythmics, tricyclics, phenothiazines); abnormal electrolytes (K , Ca2 , Mg 2 ); øthyroid, hypothermia, CNS dz (esp. SAH, CVA, trauma); hereditary LQTS; CAD (post-MI) 





Axis Deviation ■ Left-axis deviation (LAD): ■ LAFB: rS complexes in II, III, aVF; small Qs in I and/or aVL; R-peak time in aVL 0.04 sec, often lurred R downstroke; QRS duration usu. 0.12 sec unless coexisting RBBB, usu. see poor R progression in V1–V3 and deeper S in V5 and V6, may mimic LVH voltage in aVL and mask LVH voltage in V5 and V6 ■ Other causes: LBBB, LVH, inferior MI, ⁄diaphragm ■ Right axis deviation (RAD): ■ LPFB: rS complex in lead I; qR in II, III, aVF, with R in III R in II; QRS duration usu. 0.12 sec unless RBBB ■ Other causes: Cor pulmonale, pulmonary heart disease, pulmonary hypertension

4

5 ST Segment ■

■

ST elevation ■ Normal variant “early repolarization” (usu. concave up, ending w/symmetrical, large, upright T waves) ■ Ischemic heart disease: Acute transmural injury (usu. convex up or straightened); persistent in post-acute MI suggests ventricular aneurysm ■ Prinzmetal’s (variant) angina (coronary vasospasm) ■ During exercise testing  † ⁄⁄⁄tight coronary artery stenosis or spasm (transmural ischemia) ■ Acute pericarditis: Concave up ⁄ST (not aVR); no reciprocal øST (except in aVR); unlike “early repolarization”, usu. T low amplitude and ⁄HR; may see øPR (atrial injury) ■ Other causes: LVH (in right precordial leads w/large S); LBBB; ⁄K+; hypothermia ST Depression ■ Normal variants/artifacts: Pseudo ST depression (poor skin-electrode contact); physiologic J-junctional depression w/sinus tachycardia; hyperventilation ■ Ischemic heart disease: Subendocardial ischemia, non Q-wave MI, reciprocal Δs in acute Q-wave MI (e.g., ST depression in leads I and aVL with acute inferior MI) ■ Nonischemic causes: RVH (right precordial leads) or LVH (left precordial leads, I, aVL), digoxin, øK+, MVP (some), CNS dz, second-degree to IVCD (e.g., WPW, BBB)

T Wave ■ Normal:  T

■

same direction as QRS except in V2; asymmetric w/first half moving more slowly than second half; T always upright in I, II, V3–6, and always inverted in aVR T-wave inversions: Normal variant, myocardial ischemia or infarction or contusion, pericarditis (subacute or old), myocarditis, CNS dz  † ⁄QT (esp. SAH), idiopathic apical hypertrophy, MVP, abnormal electrolytes, O 2, CO2, pH, or temperature, digoxin, post-tachycardia or -pacing, RVH and LVH w/”strain”

BASICS

BASICS

U Waves (Normal: Same Polarity and Usually 1/3 Amplitude of T) ■ Normal:  Asymmetric ■

■

■

w/ascending limb move more rapidly than descending limb (opposite to normal T) Prominent upright U: Sinus bradycardia, øK, Quinidine and other type 1A antiarrhythmics, CNS dz (long QT), LVH, MVP, øthyroid Negative or “inverted” U: Ischemic heart dz, MI (in leads with pathologic Q waves), angina, coronary vasospasm (Prinzmetal’s angina) Nonischemic causes: Some cases of LVH or RVH (usu. in leads with prominent R waves), LQTS

Myocardial Infarction ■ ■ ■

Q-wave MI: Total coronary occlusion Non Q-wave MI: Subtotal occlusion More leads with MI changes (Q waves and ST elevation)  † larger infarct size and worse prognosis

Evolution of Q-Wave MI Q*

T

ST

⁄Amplitude/width

May ⁄

Pre-MI Hyperacute

⁄⁄⁄

Transmural Injury Necrosis



Terminal inversion

Necrosis/Fibrosis



Inversion

Fibrosis



Upright

*Pathologic: duration 0.04 s or ■



Less

25% R-amplitude

Conditions resembling MI: WPW pre-excitation (negative Δ-wave ~ pathologic Qs); IHSS (mimic pathologic Qs); LVH (QS or PRWP in V1-3); RVH (tall R in V1 or V2); LBBB (QS or PRWP in V1-3); pneumothorax (no right precordial R); COPD/cor pulmonale (no R V1-3 and/or inferior Q and RAD); LAFB (Qs anterior chest leads); acute pericarditis (⁄ST); CNS dz (diffuse ST-T wave Δs)

6

7 Atrial Arrythmias ■

■ ■

■

■

■

■

■

Premature atrial complexes: Single or repetitive, unifocal or multifocal, ectopic P (P’) may hide in preceding ST-T; P’R interval nl/ ⁄; P’ may be nonconducted, conducted w/aberration (e.g., wide QRS), or conducted normal Premature junctional complexes: Retrograde P appears before (PR usu. 0.12 sec), during, or after QRS Atrial fibrillation: Poorly defined atrial activity; appearance may ~old saw; ventricular response = irregularly irregular unless AV block Atrial flutter: Regular atrial activity w/”clean” sawtooth appearance in II, III, aVF, and usu. discrete ‘P’ in V1; atrial rate = 150450/min; AV conduction ratio may vary 2:1, 3:1, etc Ectopic atrial tachycardia and rhythm: Ectopic, discrete, unifocal P’ w/atrial rate 250/min (100  † rhythm); ectopic P' waves usu. precede QRS w/P'R interval RP' interval; ventricular response: 1:1 or varying AV block Multifocal atrial tachycardia and rhythm: Three different P morphologies in given lead; rate = 100-250/min ( 100  † rhythm), varying P'R intervals; ventricles: irregularly irregular (i.e., often confused with atrial fibrillation); may be intermittent Paroxysmal supraventricular tachycardia: Different re-entry cicuits; sudden onset and stop; usu. narrow QRS (unless BBB or rate-related aberrant ventricular conduction); types: AV nodal re-entrant tachycardia, AV reciprocating tachycardia, sinoatrial re-entrant tachycardia Junctional rhythms and tachycardias: ■ Junctional escape beats: Origin AV jxn; rate: 40-60 bpm ■ Junctional escape rhythm: 3 Junctional escapes; rate 40-60 bpm; may be AV dissociation or retrograde  † atria ■ Accelerated junctional rhythm: Rate = 60-100 bpm ■ Nonparoxysmal junctional tachycardia: HR 100 bpm

Ventricular Arrythmias ■

Premature ventricular complexes (PVCs): May be unifocal, multifocal, or multiformed; may be isolated single events or couplets, triplets, or salvos (4-6 in row); may occur early in cycle (R-on-T), after T, or late in cycle (fuse w/next QRS = fusion beat)

BASICS

BASICS

■

Ventricular tachycardia (VT): Sustained (30 sec) vs. nonsustained; monomorphic vs. polymorphic vs. torsade-de-pointes (polymorphic associated w/LQTS; phasic variations QRS polarity; rate often 200 bpm; may  † Vfib); AV dissociation vs. retrograde atrial capture; Consider wide complex tachycardia is VT if: AV dissociation, ⁄⁄⁄axis deviation, QRS morphology atypical for BBB, concordance (all precordial leads in same direction), regular rhythm (RR intervals equal, irregularly irregular rhythm suggests atrial fibrillation  aberration or  WPW pre-excitation), QRS morphology ~previous PVCs, very wide QRS complexes ( 0.16 sec), no RS V1-V6, beginning of R to nadir S 0.1 sec in any RS lead

Lumbar Puncture Indications ■

Dx CNS disease, administer CNS treatment or treat hydrocephalus

Contraindications ■

⁄Intracranial pressure (ICP); intracranial mass effect (r/o mass lesion: head CT when signs of ⁄ICP)

■

Bleeding dysfunction Infection near site Elderly: avoid fast and large volume withdrawals.

■ ■

Equipment ■ ■ ■ ■ ■ ■ ■

Skin preparation: sterile sponges, povidone-iodine swabs, and EtOH swabs Mask, sterile field (towels and drapes), and gloves Local anesthetic, usu. lidocaine 1% plain Syringe (3 mL) and needles (22-G  1.5”, 25-G  5/8”) Spinal needles (both 18- and 20-G, 3” length) Three-way stopcock, sterile collection tubes, and manometer Gauze dressings and adhesive bandage

Preparation ■ ■

Sterile technique; skin preparation Find L4-5 space (L4 at iliac crest level)

8

9 ■

Local anesthesia: infiltrate skin (25-G needle), then needle and advance  † infiltrate deeper tissue

Δ

to 22-G

Patient Positioning ■

■

Lateral decubitus: (preferred): Lateral decubitus position at edge of bed, while maximally flexing knees (near chest), hips, and back (opens L3/L4 space) pt. shoulders and hips perpendicular to bed Sitting: (easier for obese or spinal dz/deformity): Pt. sits at bed edge, leans over two pillows, flexes head

Technique ■

■

■ ■

Insert spinal needle into skin and slowly advance (keep perpendicular to skin, hold w/two hands, keep stylet in place); feel “pop”; perforate ligamentum flavum; withdraw stylet, and look for CSF drainage If no CSF and needle advanced 4 cm (in adult), advance 2 mm, remove stylet, and check for CSF drainage; repeat until get CSF or needle advanced 4 cm (then withdraw and redirect needle) Connect three-way stopcock, and attach manometer; measure opening pressure (normal 70-180 mm CSF) Send fluid for studies; remove needle and dress wound; pt. remains supine 12 h (minimize headaches)

Complications Brain herniation (⁄ ICP and mass), infection (meningitis or empyema), subdural hematoma (rapid withdrawal of large volume CSF), bloody tap, spinal epidural hematoma, headache, dry tap  † needle may be too lateral or deep ■ For CSF interpretation see Labs Tab

Cricothyroidotomy Indications ■

Emergent need for airway; airway obstruction above cricoid cartilage level, failed intubation, or laryngeal trauma, mass, or hematoma

BASICS

BASICS

Contraindications ■ ■ ■

Subglottic airway obstruction Intubation possible Uncorrectable coagulopathy

Equipment ■ ■ ■ ■ ■ ■ ■

Suction Local anesthesia (e.g., 1% lidocaine and 1:100,000 epinephrine) Scalpel (ideally, No. 15 blade) Retractors (Army-Navy or large vein refractors) Kelly clamps Suture (2-0 or 3-0 silk, 4-0 vicryl) Cuffed tracheostomy tubes (preferable) or No. 4 or 5 small, flexible endotracheal (ET) tubes.

Preparation ■

Palpate and locate cricothyroid ligament: between cricoid and thyroid cartilages (~1.5 cm inferior to thyroid cartilage); neck strap muscles lateral to ligament

Patient Positioning ■

Neck extended (unless cervical injury)

Technique ■ ■ ■

■

■ ■ ■ ■ ■

Sterilely prepare and drape skin If enough time, infiltrate entry site with lidocaine Scalpel  † 3 cm horizontal (ørisk of thyroid or cricothyroid cartilage damage) or vertical (better in obese when cannot palpate cricothyroid membrane) incision over center of cricothyroid membrane Gently spread subcutaneous tissue w/clamp  † expose cricothyroid membrane; may need retractors to spread neck strap muscles laterally Avoid blood vessels, use scalpel to cut horizontally through membrane; may widen incision with clamp Insert tracheostomy tube or endotracheal tube Inflate tube cuff; suture or tie down tube Ventilate w/Ambu bag Δ to formal tracheostomy 1 week (or risk stenosis)

Complications ■

Bleeding, subglottic/glottic stenosis, chondritis

10

11 Endotracheal Intubation Indications ■ ■

Significant ⁄ CO2 or ø O2 from respiration Protect airway or pulmonary toilet

Contraindications ■ ■

■

Only intubate if necessary Inaccessible/damaged oral cavity/larynx  † nasal intubation (if no coagulopathy, severe intranasal problems, basilar skull fracture, or CSF leak) Cervical spine instability

Equipment ■ ■ ■ ■ ■ ■ ■ ■ ■

Lubricant: Water-soluble 2% lidocaine jelly Tape and skin adhesive O2 and bag-valve-mask ventilation device (Ambu bag) If available: O2 saturation monitor,in-line CO2 monitor Suction apparatus, suction tubing, tips, catheters Laryngoscope w/straight and/or curved blade Endotracheal tubes; syringe (10 mL)  † inflate cuff Flexible metal stylet and Magill forceps Anesthesia

Recommended ET Parameters (for nasal: add 2 cm to each measurement) Age ET Tube Diameter (cm)

Pree- Neomie nate

6 mo

1-2 yr

4-6 yr

8-12 yr

Adult

2.5

3–3.5

3.5–4

4–5

5–5.5

6–7

7.5–8.5

Blade (cm)

0

0–1

1

1–2

2

2–3

4–5

Insert: Lips to Mid-Trachea (cm)†

10

11

11–12

BASICS

12



(age/2)

©:~23 ª~21

BASICS

Preparation

■

■ ■

Rapid-sequence intubation: IV sedative (etomidate)  † sedated, then IV muscle relaxant (succinylcholine); may add sedative (fentanyl or morphine), lidocaine, and/or ⁄⁄-lasting paralytic (vecuronium) Awake intubation: Topical anesthetic, mild sedative and analgesic; stomach should be empty Test laryngoscope; monitor HR, BP, and SaO 2

Patient Positioning ■

Extend head and flex neck; if possible (i.e., no cervical spine problem), place foam material, “doughnut”, or folded towel under occiput

Technique ■ ■ ■ ■

■

Ventilate pt. w/bag-valve-mask; assess airway Remove foreign bodies (e.g., dentures) Assistant: Continuously push back anterolateral cricoid cartilage rim with first and second fingers until tube is placed Open laryngoscope; use dominant hand to open mouth and nondominant hand to insert laryngoscope blade into right (left if left-handed) side of mouth Sweep blade to midline tongue base (sweep tongue to other side); blade tip should be in valleculae (curved blade) or below epiglottis (straight blade)

12

13 ■

■ ■

■ ■ ■ ■

Lift laryngoscope handle straight upward and forward  † expose vocal cord; avoid lips, teeth, and trap tongue; using dominant hand pass lubricated ET tube through right (left if left-handed) corner of mouth and advance tip through vocal cords (while looking) Remove stylet when proximal cuff ends at cord level Advance tube into trachea; inflate cuff (~15 mm Hg); check placement: symmetric chest expansion, breath sounds both lungs (no breath in stomach) Attach in-line CO2 monitor: Check for ⁄O2 saturation and CO2 in exhaled air Secure tube w/tape (upper lip and cheek or neck) Check chest x-ray (tip should be 4 cm above carina) Once tube in place, longer-term sedation (aerosol benzocaine [20%]  † tongue and posterior pharynx, midazolam or thiopental, fentanyl or morphine)

Complications ■ ■ ■

Tube in esophagus or right mainstem bronchus Aspiration (may ørisk w/antacids, H2-blockers, metoclopramide, head-up positioning) Damage to lips, teeth, tongue, airway

Pericardiocentesis Indications ■ ■

Cardiac tamponade ⁄ pericardial effusion  † ø hemodynamics

Contraindications ■ ■

Coagulopathy/bleeding dysfunction Skin infection over needle insertion site

Equipment ■ ■ ■ ■ ■

Skin preparation supplies, sterile gloves, towels/drapes Local anesthetic (1% or 2% lidocaine, 25-G needle, 3-mL syringe) Pulse oximeter, ECG monitoring (V lead) 16- to 18-G spinal needle and No. 11 blade 20-mL syringe and sample tubes

BASICS

BASICS

Preparation ■

■ ■

Continuous ECG monitoring (30° semi-Fowler position preferred); if V lead attached to pericardiocentesis needle  † ⁄ sensitivity; an insulated wire with alligator clips at each end works well Prepare skin; sterile technique; wear sterile gloves, mask, and gown; drape over xiphoid area Local anesthesia (infiltrate skin 1%-2% lidocaine)

Patient Positioning ■

Supine with thorax (i.e., head of bed) elevated 30-45 degrees

Technique ■

■

■ ■ ■

Needle: Insert (2 cm below costal margin to left adjacent to xiphoid with blade) and direct (upward and posterior) at 45-degree angle for 4-5 cm; aim toward right (preferable) or left (⁄risk penetrate RV) scapular tip Advance (aspirate continuously) needle until encounter fluid, check for cardiac pulsations, or ⁄ST on ECG. May feel needle enter cavity Remove blood: (usu. 5-10 mL because most is clotted); if 20 mL, then probably in RV If hemodynamics do not improve, then may need thoracotomy or local pericardial window excision Send fluid for appropriate studies

Complications Myocardial wall injury/penetration, myocardial infarction, pneumothorax, bowel perforation Arterial Line

Indications ■ ■ ■

Hemodynamic monitoring Arterial blood sampling Frequent blood draws

Contraindications ■ ■

Infection or lesion at insertion point Occlusion or thrombosis of artery

14

15 ■ ■

Uncorrectable coagulopathy Systemic infection (use peripheral site)

Equipment ■ ■

■ ■ ■ ■ ■ ■ ■ ■ ■

Peripheral arterial line (with angiocatheter): Angiocatheter (20- or 22-G, 2” length) or arterial line kit, sterile scalpel Femoral arterial line (Seldinger technique): Seldinger kit: needle (16-18 G), 10-mL syringe, guide wire, sterile scalpel, dilator, catheter Skin preparation supplies Local anesthetic (1%-2% lidocaine, 25-G needle, 3-mL syringe) Sterile gloves, towels or drapes, dressing supplies Heparinized saline (pressurized delivery system) Blood gas syringe (for arterial blood sampling) Another 5-mL syringe w/heparinized saline Sutures Arterial pressure monitoring equipment Arm board w/terrycloth roll

Preparation ■

Peripheral (radial): Nondominant hand: perform Allen test (compress radial and ulnar arteries palm blanches; release ulnar artery and check reperfusion of palm; delay 5 sec = abnl choose another site) to confirm collateral circulation Use sterile technique; prepare and drape skin Use lidocaine to infiltrate entry and suture points  †

 †

■ ■

Patient Positioning ■

■

Peripheral:  Usu. radial artery but can do dorsalis pedis; pt. seated and supine; immobilize wrist on arm board w/roll under wrist in slight dorsiflexion Femoral:  Supine

Technique Peripheral Arterial Line (Angiocatheter) ■ ■

Locate pulse w/index finger of nondominant hand; small incision w/scalpel over entry site Insert angiocatheter at 30°–45° to artery bright pulsatile red blood freely catheter; slowly advance catheter until flow stops; withdraw slightly until blood pumps again; advance catheter over needle into vessel  †

 †

BASICS

BASICS

Femoral Arterial Line (Seldinger Technique) ■ ■ ■

Locate pulse and make small incision w/scalpel Connect 10-mL syringe to needle and insert needle at 45° to artery while aspirating on syringe Insert and withdraw (while aspirating) needle until bright red blood pumps into syringe detach syringe and use finger to block off hub of needle Push guidewire through needle (should be no resistance); remove needle over wire Cut incision larger so dilator can enter Use dilator over wire to expand hole, then remove Apply gentle pressure if bleeding Push catheter over wire through hole into artery Remove wire; check for bright red pulsatile blood in catheter hub  †

■ ■ ■ ■ ■ ■

For Peripheral or Femoral Arterial Line ■

■

If no blood, remove catheter and retry insertion; if still no blood, try flushing needle w/heparinized saline; if not successful third time, try another site; cap catheter Suture catheter to skin; draw blood samples prn and attach manometer; sterile dressing

Removal of Arterial Line ■ ■ ■ ■ ■

Wear gloves; remove sutures, then catheter Confirm removed catheter is intact Firm pressure to entry site for 10 min (longer when large lumen or anticoagulation) After bleeding stopped, apply pressure dressing Next day: check blood flow to extremity

Complications ■ ■ ■ ■ ■ ■

Vessel perforation or thrombosis; limb ischemia* Dislodged or loose connections to line Incorrent placement or malfunction of line Air embolus* Infection, suppurative thrombophlebitis, sepsis* Bleeding (apply pressure/additional sutures)

*Remove line immediately

16

17 Central Line Locations ■ ■ ■

Femoral vein: Easy access; far from airways and lungs, but area can be dirty and prevent pt. from walking Internal jugular (IJ) vein: øBleed risk, but poor landmarks and can puncture carotid artery Subclavian vein: Comfortable; clear landmarks; but risk of pneumothorax or bleeding

Indications ■ ■ ■ ■ ■

Hyperalimentation or long-term IV therapy Give medications (e.g., vasoactive/inotropes, phlebitic) Hemodialysis or rapid fluid administration Intracardiac pacing Central venous pressure monitoring

Contraindications ■

■ ■

Subclavian: øPulmonary function (COPD, asthma), high levels of PEEP, coagulopathy, superior vena cava thrombosis, upper thoracic trauma IJ: Tracheostomy, ⁄⁄⁄pulmonary secretions Femoral: Vena caval compromise (clot, extrinsic compression, IVC filter), local infection, cardiac arrest or low flow states, requirements for pt. mobility.

Equipment ■ ■ ■ ■ ■ ■ ■ ■ ■

Central line kits are available Skin preparation supplies (iodine, chlorhexidine, or EtOH) Local anesthetic (1%-2% lidocaine, 25-G needle, 3-mL syringe) Sterile gloves, dressings, towels or drapes Supplies for Seldinger technique (or specific intravascular access kit) Needle (16- to 18-G): For IJ lines, only insert needle 0.5-1.0” (1.5” may  † pneumothorax); 10-mL syringe Guidewire, scalpel, dilator, catheter If the Seldinger technique is not used, a catheter-over-needle system may be used Heparinized saline

BASICS

BASICS

■ ■ ■

Suture Central venous pressure monitoring device May need ultrasound if difficulty inserting

Preparation ■ ■ ■ ■

For both insertion and removal: Use sterile technique; sterile gown, hair cover, face mask/shield Skin preparation; sterile drapes Flush catheter w/saline Liberally infuse area w/local anesthetic

Patient Positioning Supine; stand on side of your dominant hand (right side of pt. if you are right-handed) IJ: Supine; turn pt. head 45° away from insertion side; remove pillow from under pt. head and place pt. in Trendelenburg position Subclavian: Trendelenburg position, remove pillow, towel roll between scapulae

■ Femoral: ■

■

Insertion Points One finger breadth medial to artery and two finger breadths inferior to inguinal ligament; with bevel up and at 45°–60° above skin, insert needle parallel to vessel (steeper angle  †ørisk of entering peritoneum; more medial insertion angle  † less chance of needle entering femoral artery) IJ: Lateral to carotid; Landmark: Apex of triangle (clavicle and two heads of sternocleidomastoid) OR between sternal notch and mastoid process; insert needle at 70° to skin, and aim for ipsilateral nipple Subclavian: 2 cm inferior to junction of lateral third and medial two thirds of clavicle and 2 cm above suprasternal notch; finder needle may be too short to reach vein

■ Femoral vein:

■

■

Needle Approach With bevel up and at 45°-60° above skin, insert needle parallel to vessel (steeper angle  †ørisk of entering peritoneum; more medial insertion angle  †øchance of entering femoral artery) IJ: Insert needle at 70° to skin and aim for ipsilateral nipple; aim lateral; if unsuccessful, withdraw and carefully go

■ Femoral vein:

■

18

19 ■

slightly medial; reassess landmarks; can use long (~3”) angiocatheter instead of regular needle Subclavian: Insert needle bevel up; guide placement w/  nondominant hand: place index finger at sternal notch and thumb at clavicle; keep needle parallel to floor and first aim for clavicle; when hit clavicle, walk needle down (push on needle tip; do not push on syringe) until just below clavicle; then advance needle 4-5 cm; once find vein, rotate needle 90° so that bevel faces caudally; if no blood, withdraw and redirect more cephalad

Technique ■ ■ ■

■ ■ ■ ■ ■ ■ ■

Make sure you continuously aspirate while advancing or withdrawing needle Using appropriate insertion point and approach, locate vein w/finder needle (optional w/femoral vein) Aspirate venous blood w/finder needle, then insert large-bore needle at same site and at same angle; use nondominant hand to grab needle hub and lower needle to parallel vein and aspirate again to reconfirm flow (may use transducer to confirm venous blood); hold needle in place, remove syringe, and thread guidewire into needle; check for ectopy Remove needle over guidewire and continue to hold wire w/gauze; do not let go of guidewire until removed Make incision 3–4 mm (w/scalpel) through skin and fascia; push dilator 3–4 cm over guidewire to expand subcutaneous tissue Thread catheter over guidewire Advance catheter and remove guidewire Aspirate blood and flush each port Suture line in place and consider spacer in small pt STAT chest x-ray to r/o PTX and check line placement

Removing Central Lines ■ ■ ■ ■ ■

If line tunneled/trapped, may have to remove under fluoroscopy Place pt. in Trendelenburg position (reverse Trendenlenburg for femoral lines) and remove any pillows Remove all bandages, gauze, and all suture material Pt. should hum or Valsalva maneuver during line removal Apply sterile dressing (gauze and occlusive dressing)

BASICS

BASICS

Complications Nonplacement/misplacement/nonfunction of line, dislodged line, infection, suppurative thrombophlebitis, catheter-related sepsis, pneumothorax, catheter/guidewire embolism, air embolism, vessel thrombosis, central vein thrombosis, hemorrhage, arrhythmias, myocardial or central vein perforation, pericardial tamponade, infection, hematoma, subcutaneous emphysema or fluid infiltration, arterial puncture/laceration, hemorrhage

Swan-Ganz (SG) Catheters

Indications ■ ■ ■ ■

Acute heart failure or severe hypovolemia Hemodynamic instability Severe pulmonary disease Sample blood and determine cardiac output

Contraindications ■ ■ ■ ■

Infection or lesion at entry point Occlusion or thrombosis of desired vessel Uncorrectable coagulopathy Caution: systemic infection

Equipment ■ ■ ■ ■ ■ ■

Skin preparation (iodine, chlorhexidine, or EtOH) Local anesthetic (1%–2% lidocaine, 25-G needle, 3-mL syringe) Sterile gloves, towels or drapes, dressings Seldinger supplies: Needle (16–18-G), syringe (10 mL), guide wire, scalpel, dilator, catheter Catheter supplies: SG catheter, monitor, protective sheath, syringe (3 mL),heparinized saline Sutures

Preparation ■ ■ ■

Prepare and drape skin; sites: subclavian (preferred), internal jugular (preferred), or femoral veins Local anesthesia: Infiltrate skin entry site SG catheter: Flush each lumen w/heparinized saline; check balloon (inflate w/1–1.5 mL air); attach pressure monitor and infusion ports

20

21 ■

Keep catheter in protective plastic container until zeroing procedure complete; remove catheter from plastic container and move tip w/wrist flick appropriate waveform (monitor screen)  †

Patient Positioning ■

■

Subclavian or IJ: Supine and 15° Trendelenburg’s position; turn pt.’s head away from entry site; place roll under spine between shoulder blades Femoral: Supine and flat

Technique ■ ■

■ ■ ■ ■ ■ ■

Use sterile technique Connect 10-mL syringe to needle; small incision w/scalpel; Seldinger technique: cannulate vessel w/needle, pass wire through needle into vessel (no resistance) and widen passageway w/dilator; thread introducer over wire into incision Remove wire and aspirate blood to confirm placement Flush w/normal saline or heparin solution Tightly cap introducer; suture introducer to skin Insert flushed and zeroed SG catheter; another person needed to inflate/deflate balloon during placement Thread catheter through sheath protector; move protector out of way to end of catheter Watch pressure monitor while advancing catheter; when catheter tip clears introducer, inflate balloon 1-1.5 mL; balloon floats catheter w/blood flow RA and through heart; check for distinctive pressures Further advance catheter “wedge” balloon in PA  †

 †

■

  g    H   m   m   n    i   e   r   u   s   s   e   r    P

 †

Right atrium

BASICS

Right ventricle

Pulmonary artery

Pulmonary capillary wedge pressure

BASICS

■ ■ ■ ■

■

When wedged, deflate balloon and confirm return of pulsatile pulmonary artery pressures Reinflate balloon and reconfirm wedge position Record appropriate pressures Pull protective sheath over catheter and attach to introducer; confirm introducer well sutured and caps tight; chest x-ray to confirm placement Check every day for infection; Δ catheter over wire q3–7d

If Catheter Does Not Place Easily ■

Deflate balloon, then pull catheter back and advance again; flush catheter w/5-10 mL cold saline to stiffen; occasionally, fluoroscopy needed

Removal ■ ■ ■

■ ■

Wear gloves; pt. supine; deflate balloon Slowly remove catheter; may leave introducer for venous access; clean entry site w/sterile soap Remove sutures; remove IV lines from transducer; pt. holds breath while remove introducer; check that entire catheter removed Firm pressure at entry point  10 min; if bleeding stops occlusive dressing  24-48 hrs; culture catheter tip Check site next day for infection or bleeding

 †

Complications See complications for central venous lines; in addition, may cause pulmonary artery perforation, pulmonary infarction, cardiac arrhythmias

Thoracentesis Indications ■ ■

Diagnostic: Most new effusions, unless clear clinical dx with no e/o pleural space infection Therapeutic: Dyspnea from large pleural effusion; also may aid work-up of large effusion

Contraindications ■ ■

No absolute contraindications May need platelets/factor replacement: e.g., platelets 50,000, PT/PTT  2  normal

22

23 ■ ■

Relative contraindication: Cellulitis or herpes zoster at needle puncture site Caution: mechanical or manual ventilation

Equipment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

■ ■ ■

Sterile towel, gauze pads, dressing, drape w/fenestration Basin for preparation solution Syringe(s) (10-20 mL) Needles (22- and 25-G) for infiltration Povidone iodine Local anesthetic (e.g., 1% lidocaine): 10 mL Heparin: 1 mL Atropine: Available at bedside (for vasovagal reaction) Syringe (50- to 60-mL) for aspiration Sterile drainage tubing Three-way stopcock Needle or needle catheter (depends on technique): Hypodermic needle (18–22-G, 1.5”–2”), over-the-needle catheter (16–20-G needle) or through-the-needle catheter (14–18-G needle) Scalpel (needle catheter technique only) Sterile specimen bowl or Vacutainer bottle Analysis containers: Iced blood gas syringe, specimen tubes (red-top and purple-top), sterile transport media for culture or 10-mL sterile container, 5 red-top specimen tubes for cytology or 10- to 50-mL plain bottle

Preparation ■ ■ ■ ■ ■

Start IV; draw serum protein and LDH Pulse-oximetry monitoring; O2 as needed Diagnostic: Premoisten 50– to 60-mL collection syringe with 1 mL heparin (100 U/mL) to prevent clotting Sterile technique, prepare skin with antiseptic; place sterile towels/drape around site Effusion height: Percussion and tactile fremitus

Patient Positioning ■

Upright (preferred): Pt. sits erect on bed edge and extended arms rest on bedside table; large effusion pt. leans forward slightly; insert needle posterior rib at least one interspace below top of effusion; midscapular or posterior axillary line  †

BASICS

BASICS

■ ■

Lateral decubitus: Effusion side down, back at bed edge; insert needle posterior axillary line Supine: Head elevated; insert needle midaxillary; needle should not be lower than 8th intercostal space (ICS)

Technique ■ ■

Needle technique: (Diagnostic  † only small volumes) simple 20- or 22-G needle Needle catheter technique: Insert catheter over or through needle and leave in pleural space

1. Use 25-G needle and syringe w/5–10-mL anesthetic 2. Raise skin wheal at rib upper edge in midscapular or posterior axillary line 3. Δ 25-G  † 3.75-cm 22-G needle (on anesthetic syringe) 4. Insert 22-G needle through wheal and infiltrate subcutaneous tissue, muscle, and rib periosteum 5. Advance needle 1-2 mm  † aspirate subcutaneous tissue/muscle  † infiltrate small amount anesthetic 6. Repeating step 5  † “walk” needle above rib’s superior edge and advance through ICS until  † pleural space 7. Hold needle perpendicular to chest  † avoid trauma to neurovascular bundle of adjacent rib 8. When enter pleural space (may feel “pop”), aspirate fluid to ensure pleural space reached 9. Withdraw needle (grasp with thumb and index finger) 10. No fluid  † “dry tap” (i.e., missed area) 11. Air bubbles  † enter lung parenchyma (too high) 12. Postprocedure chest x-ray

Terminate Procedure When ■ Diagnostic: Removal 50-100 mL fluid ■ Therapeutic: Dyspnea relief or removal 1000 mL fluid ■ May remove larger volumes if monitor pleural pressures q200 mL for second liter and then q100 mL; terminate if pleural pressure  -20 mm Hg ■ Aspirate air  † suggests lung puncture or laceration, unless needle  20-G (making pneumothorax unlikely) ■ Δ Sx: e.g., abdominal pain, ⁄SOB ■ Persistent cough

24

25 Complications Pneumothorax, cough, infection, hemothorax, splenic rupture, abdominal hemorrhage, unilateral pulmonary edema, air embolism, retained catheter fragment

Light’s Criteria (Pleural Fluid = Exudate) 1) Pleural fluid:serum protein ratio 0.5; 2) Pleural fluid LDH 2/3 upper limit of normal serum LDH; 3) Pleural fluid:serum LDH ratio 0.6

Special Pleural Fluid Assays Assay

Diagnosis Suspected

Amylase Triglycerides

Pancreatitis, esophageal rupture Chylothorax, intrathoracic total parenteral nutrition Rheumatic effusion Urinothorax Malignancy

Glucose Urea or creatinine Cytology

Diagnostic Features of Pleural Fluid Pleural Fluid

Description

Parapneumonic Turbid Empyema Turbid, purulent TB Straw color, serosanguinous Malignant Turbid, bloody effusion PE/infarct Straw color, bloody Collagen vasTurbid cular disease RA Green SLE Yellow Hemothorax Bloody

BASICS

WBC Count ⁄ ⁄

Main WBC

PMNs PMNs

Glucose

pH

ø ø



7.3 7.3



10,000 Both

ø



7.4



10,000 Mono’s

ø



7.3

⁄

Both

⁄ø

Both

⁄ø ⁄ø ⁄ø

Both Both PMNs

Serum

7.4

øø Serum Serum



7.3 7.3 7.3

BASICS

Nasogastric and Feeding Tubes Indications Nasogastric Tubes ■ Diagnostic gastric lavage: Check for GI bleed ■ Decompress stomach: Ileus, GI obstruction, persistent vomiting, preabdominal surgery ■ Removal toxins and pill fragments ■ Heating or cooling (temperature abnormalities) ■ Prevent aspiration (e.g., trauma) ■ Deliver medications, feedings, contrast, or charcoal Feeding Tubes ■ Enteral feeding or medication delivery

Contraindications ■ ■ ■

Facial fracture: (Use mouth instead) Possible cervical spine injury (use extreme caution) For feeding tube only: Adynamic ileus, malabsorptive syndromes, intestinal obstruction, gastroenteritis

Equipment ■ ■ ■ ■ ■ ■ ■

16-18 Fr nasogastric tube or feeding tube Lubricant jelly (K-Y or lidocaine) Topical anesthetic (e.g., Hurricane spray)* and nasal vasoconstrictors (e.g., phenylephrine)* Emesis basin; cup of water and straw Catheter tip syringe Suction apparatus Gloves and eye protection, stethoscope, tape, benzoin

Preparation ■ ■ ■

Wear gloves and eyewear when place or remove tube Estimate tube length = patient’s ear to umbilicus Premedication: Spray anesthetic throat back; apply vasoconstrictor and topical anesthetic nasal mucosa Liberally apply lubricant along tube/tube tip  †

 †

■

*Optional

26

27 Patient Positioning ■

Upright or decubitus, neck flexed

Technique ■ ■ ■ ■ ■ ■ ■

■ ■ ■ ■

Turn on suction apparatus (w/tonsil tip attached) Pt. should hold emesis basin and cup of water Insert tube in nostril toward occiput Apply firm, constant pressure to tube while pt. takes small sips of water and swallows Advance until two black lines on tube visible out of nares and nose between second and third black lines Hold tube firmly in place close to nostril Check placement in stomach: Attach catheter tip syringe to tube and inject 30-60 mL air; use stethoscope to hear air “whoosh” over epigastrium; use syringe to aspirate gastric fluid (normal pH 5) Secure tube in two places (nose and second site like forehead or shoulder) w/benzoin and tape Abdominal x-ray to confirm placement (not necessary if suction applied) Mark tube near nose to track proper placement Record suction output volume and character

For Feeding Tube Same procedure as nasogastric tube except: ■ Often need to place tube in duodenum or jejunem so: ■ Advance tube additional 20-40 cm ■ Pt. lays on right side for 8-12 hr ■ Fluid aspirate pH 7 ■ May use metoclopramide or erythromycin to ⁄gastric motility  † enhance tube passage ■ May need fluoroscopy to place ■ Do not use tube (or remove guidewire, if present) until check abdominal plain film for placement Tube Removal ■ Disconnect tube from suction; remove tape ■ Pull steadily to remove tube; discard tube

BASICS

BASICS

Complications ■ ■ ■ ■ ■

■ ■ ■ ■ ■

⁄⁄⁄ Gagging during placement: spray more topical anesthetic

to back of throat Difficulty passing tube  † tube stuck in nose (try other nostril), coils in mouth or esophagus (use ice to chill/stiffen tube) Placement in lung (coughing): Remove immediately Hypovolemia from ⁄⁄⁄ nasogastric tube output: IV fluids 0.5–1 mL LR or NS and 30 mEq KCI/L for every mL of output If tube blockage, try any or all of following: ■ Check tube: Inject air into vent port and listen for hissing (which is normal) ■ Disconnect/reconnect apparatus or reposition tube ■ Irrigate tube w/30–40 mL NS Throat discomfort: Throat lozenges prn Aspiration pneumonia Trauma to nasal mucosa, nares, sinus orifices ( † sinusitis), lung, esophagus, gastric mucosa Tube too low (NGT drains drain bile) Tube too high (⁄aspiration risk) Paracentesis

Indications ■ ■ ■

Therapeutic: Massive ascites  †ø respiration, pain Diagnostic: distinguish transudative vs exudative ascites Dx spontaneous bacterial peritonitis, malignant, chylous

Contraindications ■ ■ ■ ■ ■ ■

Coagulopathy Abdominal adhesions Agitation Significantly distended bowel Pregnancy Infection (e.g., cellulitis at insertion site)

Equipment ■ ■

Paracentesis kits available Skin preparation supplies

28

29 ■ ■ ■ ■ ■ ■

Local anesthetic (1%–2% lidocaine, 25-G needle, 3-mL syringe) Sterile gloves, towels or drapes, and dressing Spinal needle (20-G) Syringe or vacuum bottle Scalpel, #11 blade Butterfly needle (20-G with sterile tubing)

Preparation ■ ■ ■ ■ ■

Decompress bladder (void or urinary catheterization) ID flank region (gas-filled bowel will float to top); avoid previous incisions Prepare skin; sterile technique; prepare and drape skin Local anesthesia: Infiltrate skin entry site, lower fascial levels and peritoneum Ultrasound guidance: If previous abdominal surgery or infection

Patient Positioning ■

Supine or sitting (leaning forward: better w/small amount of fluid); raise bed so pt. is comfortable

Technique ■ ■ ■ ■

■ ■

Sterile technique Insert and advance 20-G spinal needle w/stylet until feel peritoneum “give” Remove stylet; attach syringe and advance needle (5-mm increments) while aspirate until get fluid If remove large volume: Connect tubing btween spinal needle and (butterfly needle) vacuum bottle; placing soft catheter (Seldinger technique) into peritoneal cavity may help Remove needle and sterile dry dressing over site Send fluid for appropriate tests

Complications ■

Perforate organ or blood vesel, bleed/hematoma, persistent site leakage, infection, leaving catheter in abdominal cavity, hypotension, dilutional øNa , hepatorenal syndrome

BASICS

BASICS

Peritoneal Fluid Assays Assay

Diagnosis Suspected

Amylase Triglycerides RBC count 50.000/ L

Pancreatitic Chylous Hemorrhagic ascites (malignancy, TB, or trauma) Infection (spontaneous bacterial peritonitis) Bacterial TB or fungal Infection

WBC 350/ L PMNs Mononuclear cells pH7

Serum-Ascitic Albumin Gradient (SAAG) =AlbuminSerum–AlbuminAscites from same day High (1.1 g/dL)

Portal hypertension (transudative): CHF, cirrhosis, EtOH hepatitis, fulminant hepatic failure, portal-vein thrombosis

Low (1.1 g/dL)

Exudative: Peritoneal carcinomatosis, pancreatic/biliary ascites, peritoneal TB, nephrotic syndrome, serositis, bowel obstruction/infarction

Diagnostic Peritoneal Lavage (DPL) Indications ■ ■

Acute abdominal trauma with coincident major nonabdominal injury (head injury, major fracture) Critically ill pt. in whom an intra-abdominal source of fever or sepsis is suspected

Contraindications ■ ■ ■ ■

Multiple previous abdominal operations Recent abdominal surgery, known abdominal adhesions, or obliteration of abdominal space from infection Pregnancy Caution: Dilated viscera (e.g., bowel loops)

30

31 Equipment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Skin preparation supplies (povidone-iodine solution) Mask, sterile sponges, towels and drapes, gown, gloves Local anesthetic, preferably 1% lidocaine w/1:100,000 epinephrine Syringe (5- or 10-mL) Needles (21-G  1.5” and 25-G  1/8”) Sterile surgical tray, include scalpels (Nos. 11 and 15), scissors, Kelly clamps, pickups, needle holders Sutures (0 silk, 2-0 silk, #1 and 4-0 vicryl, and 4-0 nylon) Peritoneal catheter and connection tubing Normal saline Dressing supplies

Preparation ■ ■ ■ ■ ■

Decompress stomach (nasogastric or orogastric tube) Empty urinary bladder (void or Foley catheter) Prepare and drape skin Entry site: usu. just caudal to umbilicus; if pelvic fracture, supraumbilical If not unconscious/sedated, local anesthesia to skin entry site, lower fascial levels, and peritoneum

Patient Positioning ■

Supine or (if therapeutic) sitting

Technique ■ ■

Use sterile technique Open technique described here. [Alternative: Seldinger abdomen, pass wire over needle, technique (insert needle dilate, and pass catheter through tract)] 5-mm vertical incision (No. 11 blade) down to linea alba fascia; do not enter abdominal cavity Expose linea alba and place stay suture on each side of fascia (0 silk); hemostat “tag” each suture Make 1 cm vertical incision in linea alba; enter peritoneal cavity using blunt dissection; retract abdominal wall w/blunt end of Senn retractor Insert and direct catheter (always keep perpendicular to abdominal wall) right or left iliac region  †

■ ■

 †

■

■

 †

BASICS

BASICS

■ ■ ■ ■ ■ ■

Never force catheter against resistance Gently aspirate fluid into syringe through catheter Attach 1-L sterile saline bag to catheter and empty bag into peritoneal cavity by gravity Drop bag to ground and allow fluid to siphon out Send all fluid to laboratory; remove catheter Suture incision closed (deep fascia: stay sutures of 0 silk; skin: 4-0 vicryl for subcuticular dermal closure and 4-0 nylon for skin closure)

Complications øSensitivity to retroperitoneal injury, ⁄sensitivity to minor intraperi-

toneal injuries, false negative (poor technique or diaphragmatic injuries), wound infection, false positive (bleeding from incision), øsensitivity from prior DPL (introduce gas/fluid into abdomen), bleeding, viscous perforation

Transurethral Catheterization Indications ■ ■ ■ ■

Urinary retention (e.g., neurogenic bladder) Urinary sampling Monitor urinary output Bladder irrigation or tests (e.g., cystogram)

Contraindications ■ ■ ■

Ureteral stricture or disruption Acute urethral or prostatic infection Relative:  Anticoagulated pt. (use ⁄⁄⁄lubricants and nontraumatic technique)

Equipment ■ ■ ■ ■ ■ ■ ■

Skin preparation supplies (povidone-iodine solution) Sterile gloves, gauze, sponges, towels Water-soluble lubricant (may use lidocaine 2% jelly) Syringe (10-mL); sterile water or saline (5 mL) Adhesive tape Urinary drainage system w/tubing and collection bag Urinary catheter (usually 16- or 18-Fr Foley):

32

33 ■

■ ■ ■

urine, smaller balloon Foley: Double-lumen (larger inflation): Usu. used to drain bladder Straight (red Robinson): Straight catheterization Coude: Difficult cases; narrow, curved, firmer tip 3-way irrigation: Retrograde bladder irrigation  †

 †

Preparation

Straight catheter ■ ■

■ ■

Foley catheter

Coude catheter

3-way irrigation catheter

Pretest balloon inflation w/saline Skin preparation: Sterile technique; retract foreskin (if present) or spread labia (urethral meatus anterior to vagina and posterior to clitoris); prepare entire penis or periurethral area (including urethral meatus) w/ 3 povidone-iodine applications; keep one hand sterile while other holds penile shaft Always lubricate catheter tip and shaft May inject lidocaine 2% into urethra preinsertion

Patient Positioning ■

Supine; male: penis straight upward; female: frog-leg position

Technique ■

Always use sterile technique; insert and slowly advance catheter through urethral meatus (male: maintain continuous upward penile traction; retract penis caudally may help pass prostatic urethra)

BASICS

BASICS

■

Urine drains inflate balloon (5 mL of saline); no urine push on bladder; never inflate balloon w/o urinary return ( damaged urethra) Do not attempt multiple passes; if cannot avoid multiple passes, use smaller or Coude catheter placement Gently pull back catheter until mild resistance Tape catheter to thigh w/slight catheter slack Return foreskin to back over penis head  †

 †

 †

■ ■ ■ ■

Complications Difficulty passing catheter (from any lower GU structure/disruption or prostatic enlargement); Traumatic catheterization hematuria, transurethral tear/false passage; infection  †

Suprapubic Catheterization Indications ■ ■ ■

Pelvic trauma causing urethral tear or disruption Need for bladder drainage in the presence of urethral or prostate infection Acute urinary retention when transurethral catheterization not possible

Contraindications ■ ■

Nonpalpable bladder Uncorrectable bleeding diatheses

Equipment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Skin preparation supplies (povidone-iodine solution) Local anesthetic (1% lidocaine  epinephrine; 22-G, 1.5” needle, 10-mL syringe) Razor Sterile gloves, mask, gauze sponges, towels and sheets No. 11 scalpel Syringe (60-mL) Suprapubic catheter (usu. 14-G, 12”); intracatheter needle; needle holder, scissors, and pickups Suture (2-0 silk or nylon) Adhesive tape Urinary drainage system w/bag and tubing Sterile dressings

34

35 Preparation ■ ■ ■ ■ ■ ■ ■

Local anesthetic agent  IV sedation Bladder must be distended and palpable Shave umbilicus to pubis Locate puncture site (midline, 4 cm above pubis) Prepare skin w/alcohol solution Infiltrate skin, subcutaneous, abdominal wall, bladder wall w/local anesthetic Prepare skin w/providone-iodine; sterile towels/drapes

Patient Positioning ■

Supine w/roll under hips

 †

extend abdomen and pelvis

Technique ■ ■ ■ ■ ■

Always use sterile technique Avoid multiple needle passes Catheter-through-needle or sterile Seldinger technique Shallow skin incision (No. 11 blade) While aspirating, advance needle w/syringe through incision (at 60° to abdominal skin) until get urine flow syringe; remove syringe from needle Thread intracath catheter through needle bladder Urine flow in catheter remove needle over catheter Free flow urine through catheter suture catheter in place; attach urine collection device to catheter Sterile dressing  †

■ ■ ■ ■

 †

 †

 †

Complications Difficulty passing the suprapubic catheter, infection, traumatic placement, bowel perforation

Arthrocentesis Indications ■ ■ ■ ■ ■

Dx septic joint or crystal-induced arthritis Traumatic (blood in joint) vs inflammatory effusion Dx intra-articular fracture (blood and fat globules) Sx relief: Pain (hemarthrosis or tense effusion) Give anti-inflammatory or local anesthetic medications

BASICS

BASICS

Contraindications ■ ■ ■ ■

Infection in tissue overlying puncture site Bacteremia Bleeding diatheses Joint prosthesis

Equipment ■ ■ ■ ■ ■

Skin preparation supplies and sterile gloves, drapes, basin, cup, test tubes, gauze, dressings, saline hemostat Local anesthetic Syringes (2, 10, and 20 mL); needles (18, 20, 22, and 25G) Three-way stopcock Green-top tube w/liquid anticoagulant, microscope slides w/coverslips, culture media (for infection)

Preparation ■ ■

Carefully identify landmarks and choose puncture site (avoid nerves, tendons, major vessels) Sterile technique; prepare skin (allow betadine solution to dry btween applications); remove betadine w/EtOH to prevent betadine joint space Δ gloves after skin preparation; apply sterile towels/drape Infiltrate skin w/local anesthetic (22-/25-G needle)  †

■ ■

Patient Positioning ■

■

For knee lateral approach: Supine on examination table, feet at right angle, knee slightly flexed (15°–20°), rolled towel under popliteal space For knee patella tendon approach: Pt. sits upright with foot perpendicular to floor

Technique ■ ■

Attach (18- to 22-G) needle to syringe and insert through skin, subcutaneous tissue, and into joint space Knee lateral approach: Insert needle 1 cm superior/lateral to superior lateral patella; may use hand to grasp and elevate patella slightly; needle under patella at 45° to midjoint area; should be no resistance Other approaches: Enter through patella tendon or medially or laterally directly above joint line  †

■

36

37 ■ ■ ■ ■ ■

Aspiration of synovial fluid confirms joint space placement If Δ syringe: Use hemostat to hold needle hub Aspirate all joint space contents/fluid Remove needle and dress wound; send fluid for tests Larger effusions: Use larger syringe and consider using three-way stopcock (do not have to Δ syringe)

Complications Infection, bleeding, anesthetic hypersensitivity. Fluid stops flowing (joint space drained, needle tip dislodged, or debris/clot obstruct tip), needle dislodged (slightly advance/retract needle, rotate bevel, or use ø pressure to aspirate), cartilage damage (from bouncing needle off bone)

Abscess Incision and Drainage Indications ■

Palpable skin abscess (usu. 5 mm) that does not resolve with conservative measures (warm soaks)

Joint Fluid Crystal Characteristics‡ Crystal

Diagnosis

Monosodium urate (gout)

Strong negative birefringence, needleshaped, long* Uricase digestion X-ray diffraction

Ca2 pyrophosphate dihydrate (CPPD) Pseudogout

Weak and birefringence, rhomboid or small rods, pleomorphic* X-ray diffraction

Ca2 phosphate (hydroxyapatite)

Not easily visualized* Electron microscopy X-ray diffraction

Cholesterol

Rhombic or platelike, notched corners, multicolor, occasionally small, needlelike* Chemical determination

Corticosteroids

Pleomorphic; variable birefringence* Postintra-articular steroid Rx

*On polarizing microscope

BASICS

BASICS

Joint Fluid Characteristics‡ WBC /mL3

Mucin Δ Glucose* PMNs Clot (mg/dL)

0–200



10% Good

~0

Clear to 50–4K slight turbid



30% Good

~0

Dx

Appears

Normal

Clear, pale yellow

Group I (noninflammatory)

DJD; traumatic arthritis

Group II (noninfectious, mildly inflammatory)

SLE; Clear to scleroderma slightly turbid

0–9K



20% Good ~0 (occasionally fair)

Group III (noninfectious severe inflammatory)

Gout Turbid Pseudogout Turbid RA Turbid

100–160K 50–75K 250–80K

~70% Poor ~70% Fair/poor ~70% Poor

10 ? 30

Group IV (infectious inflammatory effusions)

Acute bacterial TB

Very turbid

150–250K

~90% Poor

90

TB

2500–100K ~60% Poor

70

*Mean difference between synovial fluid and blood glucose ‡Adapted from Cohen, AS. Cecil’s Tectbook of Medicine

Contraindications ■ ■ ■

Very large abscesses (may need operating room) Deep abscesses in very sensitive areas (supralevator, ischiorectal, perirectal) Locations: Palmar space, deep plantar spaces, nasolabial folds (may drain to sphenoid sinus)

Equipment ■ ■

Universal precautions materials Local anesthesia: 1% or 2% lidocaine with epinephrine, 10-cc syringe and 25-G needle

38

39 ■ ■ ■ ■ ■ ■

Skin preparation solution and sterile drapes No. 11 scalpel blade with handle Sterile gauze and tape Hemostat, scissors Packing strip (plain or iodoform, 1/2”) Culture swab

Preparation ■ ■

Universal precautions; prepare skin and sterile drapes Infiltrate local anesthetic, allow 2–3 minutes for anesthetic to take effect

Patient Positioning ■

Depends on abscess location

Technique ■ ■ ■ ■ ■ ■

Cut through skin into abscess w/wide incision (No. 11 blade); incision should follow skin fold lines Allow pus to drain; soak up w/gauzes Swab inside abscess cavity (culture swab) Gently explore cavity w/hemostat, break up loculations Pack abscess cavity; dress wound w/gauze and tape May send pus for Gram stain and culture (commonly streptococcus, staphylococcus, or enterics (perianal), or anaerobic and gram-negatives.

Complications Abscess actually sebaceous cyst or hematoma, no drainage, bleeding

BASICS

H&P

Cranial Nerve

Major Functions

How to Test

I

Olfactory

Smell

Odor

II

Optic

Vision

Vision chart

III

Oculomotor

Most eye muscles

Follow finger

IV

Trochlear

Superior oblique (eye ø and out)

Look down at nose

V

Trigeminal

Face sensation Chewing muscles

Touch face Clench teeth

VI

Abducens

Lateral rectus (eye lateral)

Look to side

VII

Facial

Face expressions Tears/saliva Taste (anterior 2/3 tongue)

Smile ⁄ø Eyebrows Sugar or salt

VIII

Vestibulocochlear (auditory)

Hearing Equillibrium

Tuning fork ? Vertigo

IX

Glossopharyngeal

Taste (posterior 1/3 tongue) Sense carotid BP

Gag reflex Swallow Uvula position

X

Vagus

Larynx/pharynx Parasympathetic Taste

? Hoarseness Open wide, say “AH”

XI

Spinal Accessory

Trapezius/ sternocleidomastoid

Shoulder shrug/raise Turn head

XII

Hypoglossal

Move tongue

Tongue out

40

41 Distinguishing Vestibular (peripheral VIII nerve), Cerebellar, and Sensory (afferent pathway: peripheral nerve to thalamus/  parietal lobe) Lesions Finding

Vestibular

Cerebellar

Sensory

Vertigo







Nystagmus



Dysarthria



Limb ataxia



Stand feet together; eyes open







Stand feet together; eyes closed

ø





Vibratory and position sense





ø

Ankle reflexes





ø

Often





Usual

 





Distinguishing Causes Upper Lower of Motor Motor Motor ExtraDefects Neuron Neuron Muscle Cerebellar pyramidal øStrength











Atrophy



⁄⁄⁄

⁄





Fasciculations











Babinski’s











⁄Tone











øTone





 

 / 





Hyperreflexia











Hyporeflexia





 

 / 





Clasp knife











Ataxia











(continued )

H&P

H&P

Distinguishing Causes Upper Lower of Motor Motor Motor ExtraDefects Neuron Neuron Muscle Cerebellar pyramidal

Akinesia









 

 / 

Chorea or athetosis









 

Intention tremor







 

 / 



Resting tremor









 

 / 

 / 

Lower Extremities Cannot toe walk when 50% loss S1 gastrocnemius and anterior tibialis; cannot heel walk when 50% loss L4, L5 tibialis anterior  †

 †

Sciatic Nerve Compression ■

Cross-leg (well leg) straight-raising test: Pt. lies supine and lifts uninvolved  leg up with knee extended; positive:  pain radiates posterior leg foot Straight leg-raising test: Like cross-leg but pt. lifts involved  leg; positive:  pain radiates back below knee; hamstring problem: only posterior thigh pain  †

■

 †

Femoral Nerve Compression ■

Reverse leg-raising test: Pt. lies prone and extends involved leg with knee extended; if pain radiates anterior leg foot, then femoral nerve compression  †

Intrathecal Pathology ■

Milgram’s test: Pt. lies supine and raises legs ~5 cm and holds for 30 sec stretches iliopsoas and anterior  †

42

43 abdominal muscles and ⁄ intrathecal pressure; if no leg pain, no intrathecal pathology

Reflexes

Reflex

Nerve Root

Jaw

Nerve

Testing

Pons

Mandibular branch, trigeminal

Tap mandible at downward angle w/mouth slightly open

Biceps

C5–6

Musculocutaneous

Brachioradialis

C5–6

Radial

Tap biceps tendon w/arm flexed partially at elbow Strike radius lower end just above wrist Normal: Elbow flexion

Triceps

C7–8

Radial

Tap triceps tendon; support upper arm; let forearm hang

Finger

C8, T1

Median

Either tap palm or hold pt.’s middle finger loosely and flick fingernail down  † normal: finger slightly extends; abnormal:  Hoffman’s sign (thumb flexes, adducts)

Upper abdomen

T7–10

Lower abdomen

T11–L1

Use blunt object to stroke abdomen lightly in and down Normal: Umbilicus deviates toward stimulus (continued )

H&P

H&P

Reflexes

Reflex

Nerve Root

Nerve

Testing

Patellar

L3–4

Femoral

Strike patellar tendon

Ankle (Achilles)

S1–2

Tibial

Tap Achilles tendon when pt. dorsiflexes foot at ankle Normal:  Plantar flexion

Cremasteric reflex

T12

Genital branch (genitofemoral)

Stroke inner thigh Normal:  Ipsilateral scrotal sac move ⁄

Anal wink

S2–4

Touch perianal skin Normal:  Anus contracts

44

45

Peripheral Nerves Trigeminal Anterior cutaneous nerve neck

C2

Supraclavicular

C3 C4

Axillary Anterior thoracic rami

T2 T3

Lateral thoracic rami Lateral cutaneous nerve arm Median cutaneous nerve arm Lateral cutaneous nerve forearm Median cutaneous nerve forearm Radial

Ilioinguinal

Iliohypogastric

C5 T1

T4 T5 T6 T7 T8 T9 T10 T11 T12

S2 L1 S3

Ulnar

C8 L2

Median Lateral femoral cutaneous

L3

Medial femoral cutaneous Anterior femoral cutaneous

Obturator

Superficial peroneal L4 L5 Sural

Tibial Saphenous

Medial Lateral plantar plantar Sole of foot

H&P

Sural

C6

Saphenous

Deep peroneal

C7

H&P

Peripheral Nerves Great occipital Lesser occipital

C2

Greater auricular

C3 C4 C5

Posterior rami of cervical nerves Supraclavicular Lateral thoracic rami

C6

Posterior thoracic rami

C8

Axillary

C7

T10

Posterior cutaneous nerve forearm Median cutaneous nerve arm

T12

Lateral cutaneous nerve forearm Median cutaneous nerve forearm Radial Median Ulnar

S3 S1 S4 S5 S2

L1 L2 L3 L4 L5

Posterior lumbar rami L2

Posterior sacral rami Lateral femoral cutaneous

L3

Medial femoral cutaneous

Obturator

Lateral femoral nerve of calf Superficial peroneal

L4 Sural

Tibial

Sural

Saphenous Saphenous Medial Lateral plantar plantar Sole of foot

Calcaneal

46

L5

47 Referred Pain

Jaw Cardiac Right Shoulder Liver Gallbladder Diaphragm Pancreas Cardiac

Left Shoulder Lung Diaphragm (Kehr’s sign) Pancreas Cardiac Arm Cardiac Periumbilical Duodenum Appendix

Epigastric Duodenum Appendix Hiatal hernia Gallbladder and bile ducts Pancreas

H&P

Suprapubic Bladder Uterus

Groin/ Inner thigh Ureters Kidneys

H&P

Brain Circulation

Anterior communicating artery

Anterior cerebral artery Internal carotid

Middle cerebral artery Communicating artery Posterior cerebral artery Superior cerebellar Basilar artery Anterior inferior cerebellar Vertebral artery Anterior spinal Posterior inferior cerebellar

48

49 Main Artery

Region of Brain Sustained

Anterior cerebral

Medial frontal and parietal Anterior corpus callosum

Middle cerebral

Lateral frontal, parietal, occipital, temporal cortex Lenticulostriate branches caudate nucleus, putamen, upper internal capsule  †

Posterior cerebral

Medial occipital and temporal cortex Posterior corpus callosum Upper midbrain Thalamus

Superior cerebellar

Upper cerebellum Upper pons Low midbrain

Anterior inferior cerebellar

Upper cerebellum Upper pons Low midbrain

Posterior inferior cerebellar

Lower cerebellum Medulla

Anterior spinal (ASA)

Anterior (ventral) spinal cord

H&P

H&P

Parietal lobe contralateral sensation Frontal lobe problem solving, planning, apathy, inattention, aphasia, contralateral weakness, labile affect, Broca’s area

Dominant: 

reading, writing, or math ability Non-dominant: 

neglect, difficulty dressing Occipital lobe vision problems

Temporal lobe memory problems, aggressive sexual behavior Dominant: 

Wernicke’s aphasia Midbrain, Pons, Medulla CN 3–12

50

Cerebellum ataxia, dysarthria, dysmetria, intention tremor, nystagmus, scanning speech

51

Eye Examination Conjuctiva Zonule Choroid Sclera

Anterior chamber

Retina Cornea Macula Fovea

Vitreous humor

Pupil

Optic nerve Optic disk

Iris Lens

Ciliary body Left eye

Right eye

Optic nerve 1

Optic chiasm Optic tract Lateral geniculate nucleus

2 4

3

Optic radiation 5 Left eye Right eye visual visual field field 1 2 3 4 5

H&P

Striate cortex

H&P

Optic nerve

Superior rectus CN3

Superior oblique CN4

Inferior rectus CN3 Medial rectus CN3

Lateral rectus CN6

Inferior oblique CN3

Optic disk Blood vessels

Optic cup

Fovea Optic nerve (“blind spot”)

Macula

52

53 Ear Examination Tuning Fork Tests Weber’s test

Rinne’s test

Fork at midline forehead Normal: Sound



both ears

Abnormal: Sound lateralizes  † one ear  † øipsilateral conductive hearing or øcontralateral sensorineural hearing

Bone conduction: Put fork on mastoid Air conduction: Put fork near ear Normal: Air conduction  bone Abnormal: Bone conduction  air conduction, which results in øconductive hearing

Vertigo Dix-Hallpike test (Nylen-Barany test): Pt. sits on examination table and extends legs; turn pt.’s head 30°–45° to one side, and pt. quickly lies back so head hangs over table end; look for nystagmus; repeat whole procedure with head turned in opposite direction Positive:  Nystagmus  † benign paroxysmal positional vertigo

H&P

H&P

Cardiac Manuevers

Mechanism Maneuvers

RightSided Murmurs

Aortic Stenosis (AS)

Mitral Regurgitation (MR) IHSS*

Preload

⁄

Inspiration, squatting, raise ⁄legs

⁄

⁄

ø

ø

Venous return

ø

Expiration, Valsalva’s, standing, nitrates, diuretics

ø

ø

ø

⁄

⁄

ø

ø

⁄

Afterload ⁄

Isometric hand grip

ø

Valsalva’s, vasodilators

*IHSS



ø

ø

idiopathic hypertrophic subaortic stenosis

54

55 Systole

Diastole

Early Mid Late Early Mid Late Harsh

AS Blowing

AI

Comments Heard best @ R base (radiate R carotid) Heard best @ 3rd /4th L ICS (if radiate R sternal border aortic root dilate, e.g., Marfan)

Low

All MV murmurs heard best@ apex , S1. Can be confused with Austin Flint Opening snap (AI: mid-diastolic murmur @ MV Rumble when blood enters from aorta & L atrium simultaneously; No OS)

MS

Opening snap

Radiate L axilla/back; severe MR S3; with isometric handgrip & stand squat If LV volume (stand, Valsalva) earlier clicks, duration, intensity; if LV volume (squat, legs, hand grip) delay clicks, duration, intensity Heard best @ L 2nd ICS (radiate to L neck) + palpable thrill; wide split S2

MI

MVP Systolic click

PS Blowing

PI

Systolic click

Heard best @ L 2nd /3rd ICS; may during inspiration

TS

Heard best @ 4th L sternal border; wide split S1; may with inspiration Opening snap (Carvallo’s sign); TS often occurs with MS

TI

Heard best @ 4th L sternal border; may with inspiration (Carvallo’s sign); 1st degree rare; usually 2nd degree to pulm HTN

Rumble

Second degree

PDA

Machinery

Heard best @ L base; confused with venous hum; if pulmonary HTN, may disappear systolic murmur, pulmonic ejection sound Heard best @ L 3rd /4th ICS and along sternal border; NI S2

VSD

H&P

H&P

Type

Normal or physiologic Wide, fixed, splitting Wide split, varies with inspiration Paradoxical splitting

Inspiration S1

S2

Expiration S1

A P A A

P P

PA

Causes

S2

Intrathoracic pressure

AP A

P

Atrial septal defect

A P

Pulmonary stenosis RBBB

P A

Hypertrophic cardiomyopathy

Adapted from University of Washington Advanced Physical Diagnosis Learning and Teaching at the Bedside, Edition 1.

Heart Sound

Causes Soft: øCardiac output, tachycardia, ⁄⁄⁄MR

S1

Loud: Hyperdynamic (fever, exercise), mitral stenosis, atrial myxoma

S2 (Aortic)

Soft: Calcific AS Loud: Systemic hypertension (HTN), dilated aortic root

S2 (Pulmonic)

Loud: Pulmonary HTN

S3 (Low frequency, early diastole)

⁄Atrial pressure  † ⁄flow rates (congestive heart failure [CHF] most common, valvular regurge, left  † right shunts) Normal in age 40 yr Stiffened LV (HTN, AS, ischemic or hypertrophic cardiomyopathy, acute MR from chorda tendinea rupture)

S4 (Low-frequency presystolic portion of diastole)

Jugular Venous Pressure (JVP) 56

57

a c

Small and usually not visible v

R atrial contraction

y TV opening and atrial emptying

x RV contraction and TV closure

Maximal atrial filling

Sternum 45

°

Right atrium Jugular vein JVP

• Fluid overload • Blockage before heart (SVC obstruction) • CO (e.g., HR, constrictive pericarditis, R heart failure pericardial effusion, TS or TI, cardial tamponade) • Hyperdynamic circulation

H&P

H&P

Sign

Causes

Kussmaul’s (during inspiration, JVP ⁄distention; øin normal pt.)

Constrictive pericarditis (negative in cardiac tamponade) Severe right heart failure

Hepatojugular reflux (push liver  † ⁄venous return to right atrium)

Right ventricular failure if JVP remains elevated (transient only in normal pt.)

Absent A waves

Atrial fibrillation Sinus tachycardia

Dominant A waves

Pulmonary HTN Pulmonary stenosis Tricuspid stenosis Right atrial myxoma

Cannon A wave (very large A waves)

Ventricular tachycardia Complete heart block Paroxysmal nodal tachycardia

Dominant V wave

Tricuspid regurgitation

Absent X descent

Atrial fibrillation

Exaggerated X descent

Cardiac tamponade Constrictive pericarditis

Large CV waves

Tricuspid regurgitation Constrictive percarditis

Sharp Y descent

Constrictive pericarditis Tricuspid regurgitation

Slow Y descent

Right atrial myxoma Tricuspid stenosis

Absent Y waves

Cardiac tamponade

Abdominal Examination

58

59

RUQ Biliary colic Cholecystitis Duodenal ulcer Hepatitis RLL pneumonia Flank Abdominal aortic aneurysm Pylelonephritis Renal colic McBurney’s point RLQ Appendicitis Cecal diverticulitis Ectopic pregnancy Ovarian cyst Ovarian torsion Tubo-ovarian abscess Suprapubic Ectopic pregnancy Endometriosis Mittelschmerz PID Ovarian cyst Uterine leiomyoma UTI

H&P

LUQ Gastritis LLL pneumonia Pancreatitis Splenic problems Periumbilical Appendicitis Gastroenteritis Mesenteric lymphadenitis Myocardial ischemia or infarction Pancreatitis Back Acute pancreatitis Posterior duodenal ulcer Retrocecal appendicitis Ruptured AAA LLQ Diverticulitis Ectopic pregnancy Ovarian cyst Ovarian torsion Tubo-ovarian abscess

H&P

Abdominal Physical Examination Findings Appendicitis ■ ■ ■ ■

Psoas’ sign: Place hand above pt.’s right knee; ask pt. to flex right hip against resistance  † pain Obturator sign: Raise the pt.’s right leg with the knee flexed; rotate leg internally at hip McBurney’s sign: Tenderness right abdomen two-thirds distance from anterior iliac spine to umbilicus Rovsing’s sign: Palpate LLQ  † RLQ pain

Gallbladder Disorders ■

■

Murphy’s sign: In cholecystitis; pt. breathes out; palpate below right costal margin at midclavicular line; pt. inspires  † gallbladder moves down, hits your hands; if gallbladder tender then pt. will stop inspiration  †  test; negative in choledocholithiasis and ascending cholangitis Charcot’s triad: In cholangitis; RUQ pain, fever, chills, jaundice

Retroperitoneal Hemorrhage ■ ■

Cullen’s sign: Bluish periumbilical discoloration Grey Turner’s sign: Flank discoloration

Vaginitis Candida Vulvovaginitis ■ ■ ■

Discharge: Dry cottage cheese–like Symptoms: Vaginal/vulvar pruritus, irritation, burning, sore Examination: Vulva: red, edema, and adherent white clumps

Bacterial Vaginosis Amsel’s criteria (3 of 4 needed for diagnosis): ■ Discharge: Gray-white, thin, homogenous, adherent ■ Vaginal pH 4.5 (normal pH: 3.8–4.5) ■ Clue cells: Bacteria-coated vaginal epithelial cells ■  Whiff (amine) test: KOH  discharge  † fishy odor Trichomonas  Vaginitis ■ ■

Discharge: ⁄⁄⁄, grayish-green, frothy (CO2 bubbles) Symptoms: Vulvar/vaginal pruritus, irritation, edema

60

61 ■

Examination: strawberry cervix (punctate hemorrhage), pH 5.0,  whiff test, wet preparation (vaginal vault, not endocervix): Motile, flagellated trichomonads

Atrophic Vaginitis ■ ■ ■

Discharge: Thin or clear Symptoms: Vaginal irritation Examination: Vagina/vulva: pale, dry, thin, øørugae, pH 5–7

Scrotal Complaints Epididymitis ■ ■

Chlamydia, Gonorrhea, or E. coli 

Insidious onset; dysuria, frequency, urethral discharge; swollen/tender upper posterior testicle Rx: Antibiotics

Torsion ■





Testis Twists on Spermatic Cord Axis

Surgical emergency: Sudden onset; abnormal testis elevation/  axis; “bell clapper” deformity (congenital unanchored swinging testis); absent cremasteric reflex and Prehn’s sign Spermatic cord

Torsion

Testicular veins Testicular artery

Varicocele Spermatocele Epididymitis

Vas deferens Epididymis

Testicle

H&P

Hydrocele

H&P

Appendage Torsion Appendage ■

■

■

■

■



Fluid-Filled Sac Around Testis



Abnormal Tortuous/Dilated Veins

Swelling, dull heaviness, ⁄ with exercise; no scrotal skin change; palpable “bag of worms” Rx: May  † infertility; scrotal support or surgery; ?obstructing mass if sudden onset in older pt.

Spermatocele Accumulation ■ ■

Epididymitis, Hematoma, or

Painless, ⁄size/tenseness from morning waking to later in day; transillumination: translucent fluid Rx: Most resolve spontaneously; surgery if discomfort or tense hydrocele  † testicle atrophy

Varicocele ■



Trauma history, ecchymosis, edema Rx: Surgery if: uncertain diagnosis, ?testicle injury, disruption of tunica albuginea, or no flow Doppler ultrasound

Hydrocele ■

Twists on Testicular

Subacute symptoms, firm tender nodule upper pole epididymis; “blue dot sign” (blue/black spot visible beneath skin on testis/epididymis cranial aspect) Rx: Bedrest and scrotal elevation

Traumatic Injury Rupture ■





Benign Cystic Sperm

Asymptomatic: Painless, freely movable nodule superior to and separate from testis; transilluminates easily Rx: None, unless bothersome

62

63

Tanner Stages    )

  s    d  .   n   e   o    l  .    t   x   a   y   e   i    (   d    V         t   e   )    h    6    l   g    1   u  m    d  o   i    A   t   h    t

      d      e      u      n       i       t      n      o      c

   (

  n   o   ;    i    t   l   a   y   u   i  .    t   o    d    l    b  .    i    i   r   e   y   a   t   s   m    5   u   i    V    )    I    1   q   s    d   e   –    t   r    l    h    3   u  e   a    t    i   g    1    d  o  p   s   h    t    A  n   (  ,

 .   e   l   r   s   o  .   r   u   d   y   a   c   n   e   y   o   t    4   o   t    I    I    l   x   l    I    1   c   s   e   a   –  ,    t    2    k   r   d  r   r   e    1   a   a    t

   t   n  a    D  s   a   l

  ;    t  .   n  ,   y   o  .   u  n    d   y   o   e   w    t   m    1    I   o    I    1   a   y   n    d   l   –    l  ,    t   e    0    l   m    1   a   g   h   g   n   g   m  o   i    l    i    S   l   s   p

 .   o  .   y   e    I    0   n    1   o         N

  r  i  a    H   c  i    b   u    P

H&P

  e  l  a     M

H&P

  s    t    t   s   c   a   e    l   a    j  .   o  e   o   r   e   o  .   r   b  ;   r   r   p   y   a   o    V   a   ;    t   u   l         t   o    l    l    6   u   k   t   i    1    d  c   n  p   a   o  a    A   b  c   p   ;   n   l   a   y   r    l   o    i    i   a  .    t   p   o  .   a   a   d   y   v   p  n   e   o    5    l   c    V    I    1   e       e   –  ,   a   s   d   n    3   e   l    1   z   o  m  u    i   e   r   o    S  r   o  m   a   f   s    d   n  r   a   e   a   l  .    t   l   x   o   o   e  .   e   o   y  ,   e   r   r   a    I    4    d  a   ;    I    I    1   e    d  s   r   s   –    t   a   n   e   n    2   v   o    1   e    d  e   r   d    l   y   o   i   e    E   b   b   w

 ,    L   m    t    0   l   u    2   d        a   ;  ,   e    )   c   s   h    t   n   n  g  e  ,   e   n  r    L   m    k   e   e   f   r    l   u  a   m    t   m    d  :    0   o   s    i   u    2   r   c    d   c   r   –   S  n  n   i   e    2   a   c    1    (   p               ⁄

              ⁄

              ⁄               ⁄

              ⁄

              ⁄

  s   ;    L   n   e   m  s   h    t    2   i   g    1   n  n   –   e   e    6   p   l

              ⁄

  e   ;    l    l   s   a   u   s  .   n   s   o    i  .   e   m    t   y    d   s    i   s   r   d  ,   a    I   w  g   l    I    1   n    1   n   u   a   –    i    d  u    0    l    d  n  o    1   o    d  a   r   e   r   u   l   r   u    A   b  g  s

  :  ,    i   s   s   n    i   n  n    k   e   e   s   d  p  e   ;   ;   g    L   d   s   n   e   r   m ,   e   a   g    h   r    6   s   c   a   –   n   l    i    6  .   n  o    1   h    t   e   n

 .   g   o   n  .    i   y    d    I    0    d    1   o  u    b         N

  ;    L   e   e    l   c   m  m   s   l    l    i    i    5    t   l   u  .   s    1   n  a   e   o   e   m    T  v       p  s

   t     s     a     e    r      B

  l    a       m     eF

64

    s     e   l    c   i   t     s     e

e

65

Stages of Labor

Comments    t   n   e    t   a    L   e   g   a    t    S        t   e      s   v    1    i    t   c    A

   )   n   o   n   i   o    t    i   a    t    i   r   s   e   n   l   a   e   r   c    T  e    D    (   e   g   )   a    t   h    t   r    S   i    d   b    (   n    2   e   a   )   g   t   y   a   n  r    t   e   e   v    S  c   i    l   a    d   l   e   r   p    3   (   d

Duration

Cervical Dilation

Contractions ⁄ frequency, strength,and regularity; cervical thinning or effacement

Most variable hours to days

0–4 cm

Most rapid cervical dilation

Average nulliparous: 5 hr; multiparous: 2 hr

4–10 cm

May blend into active 15 min–3 hr phase; more rapid descent; baby passes lower into pelvis and deeper into birth canal; when no anesthesia, often vomiting and shaking

7–10 cm; slower pace

Female actively pushes out baby

Nulliparous: 2–3 hr

Complete

Nulliparous:

Multiparous:

Multiparous:



1 cm/hr



2 cm/hr

Accelerated by breastfeeding (release oxytocin) or pitocin

H&P



1 hr



1–30 min

H&P

Placenta abruptia More common when mother has high blood pressure or uses cocaine

Blood

Placenta prematurely detaches (incompletely or completely)

Placenta Uterus Cervix Umbilical cord Placenta previa Usually in multiparous women or uterine structural abnormalities (e.g., fibroids)

Placenta implants over or near cervix

66

67

The cephalic or vertex presentation (normal) Usually normal vaginal delivery • Vertical or longitudinal lie Front

Back

• Limbs to chest • Neck flexed

Seated or full breech position Usually normal vaginal delivery

• Vertical or longitudinal lie

Frank breech position

• Vertical or longitudinal lie • Legs pointed straight upward

Front

Back

The transverse position (rare) Usually shoulder first to present; usually cesarean section required

H&P

H&P

Anterior fontanelle (closes at age 18–24 months, may bulge with crying or ICP)

Coronal suture

Front

Metopic suture

Frontal bone

Frontal bone

Parietal bone

Parietal bone

Sagittal suture

Posterior fontanelle (closes at 2 months) Occipital bone Lambdoidal suture

Back

Obstetric Visits and Testing Timeline

68

69    t    k   h   a   g   i   w   i   e  m  s    1   h   n   –   l   e   x    5    i   a  o  g  .    d    0   n   t   s    Q  u   &    F    0    4    t   e    2   l   a  r   –   t   n    1   e  a   e    t    7   Q   F   h  o    3

   5    3   s    k   w    2   4   –    3   2    Q    0    3

   t   n   e   m   e   v   o   m    l   a    t   e    F

   8    2    4    2

   0    2

  s    k    l   e   a   r   e    6   e    1   w   n   e    4    G   y   r   e   v    E

   0    1

  e   n   o  r    t   e    t   r   l   a  p   e  p   o    h   D    l   a   h    t    i   e   t    F  w

   0   s    k   e   e    W

 ,   a    i    d  x   y  c   m  p   a  e    l   r    h   t   c  s  ,   a   B   e  p    h   r   r   u   r   o  o   n  g   o    G

  s    t    i   s    i    V    B    O

  s   n   e   e   r   c   s   x   o    t   e   n    i   r   u    d   n   a  ,   n   e   e   r   c   s   c    i    t   e   n   e   g  ,    V    Z    V  ,   s    i   s   o   r    b    i   y  p    f  ,   e   i    d   h   n   H   c   o  ,   h   S    i    t    t    b   s    i    t   b   (   T   y   n   A  p  ,   i   c   a   a   l   a   V  ,   a    I    d   s   h   l   P   s   y    h    b   R  e  ,   H   a  ,   b   S  ,   m   c   a   a    D    L  e  u    l   r   &    t    P    h    S      i   p  ,   C   c    P   y    L   s    i   t   R  e  ,  ,   y   a   a    T    V   n   p    d    i   e    l    l   o   D  r   e  ,   r   h    l   a    V   u   o    i    l   /  ,   p  r   e    t    i   b   R    t   r   c   o    A  ,   P   e  n   e   n   T    I    U  w  o    l    R  ,  ,   g    k    C  ,   c   g    )    i    H   p    /   n    A    S    B  e   s  e   g  e   r   B  r   p    H  c   s

H&P

  n   o    i    t   a    t   s   e    M   g    f    O   o    R    k    P   e    h    t   e    i   w    W  s   e  m   =    t    )   u  c   n   1   m   i   >   c    (   m  n   o   e    0   i   z    6   t    i   a   n   l    S   i    i   s   d   n   l   a   o   i    i    t   c   s   c   v   r   u   a   r   e   c    t   c    i    l    i   n    d    b   o   c   n   m   r   a   a   %    U   l    0   s   u    8   u   g   e   c   >   r    i    l    i    8   t    b   r   n   m   o  e   u   s   m    /   s    t   e  e    i   c    b   u   f   a   u    i    f   n   p   e    S   m  e   v    t    0   i   n    2  s    i   s   o    i   p   n  e   r    d   g    i   s   n    M   i   r   o  o    t   p   s   c   h    i   a    i    b    t   r   t   u   n  w   p   o   s   c    i   s   r   y   a    h    l   p   u   g   m   e   y   r    S   4    t   r    l   s   o   a    t   e   e    b   z   c  e   s    i   a    i   s    l   s   l    f   s   y   i   s   e   m    h  o   u   r    t   r   r   r   p   e   p   s   e    t    i     o    t   e    U   r    B   n   o    P    N

  n   r   p   y   e   v   r   u   s    l   a    t   e    F

   )   –    (    h    R    f    I

   l   a   n   o    i    t   p    O

   t   a   e   p   e   r   n   e    h    t   s  ,   k    l   n  w   w   r   2    h   3    3   @    &    0    4    1   >    f    I   e   g   a    l   a   n   o    i    t   a    t   s   e    G

  n   :  ,    t   n   P   -   d   i   e   s   r   e    l    t   e  o   e   F  o   u   t    M   y   c   t    i   o  e   r   A    A   n   i   a  r   p   c  ,   d   a    h    G   a   a   c   -   l    S    G   r   n   a   o   o    t   e  o   e   C    h   g    l   s   s   n  c   m   e   u    H   s   p    R   r   a  s    i   -   e    O    l   a   r   g    P    l    T           p

   d   n   u   o   s   a   r    t    l    U

H&P

Skin Examination Lesion Descriptions ■ ■ ■ ■ ■ ■ ■

Macule: Flat; different color; can be seen, not felt Excoriation: Mechanical skin erosion or destruction Lichenification: Chronic irritation  † leathery skin thickening with induration and hyperkeratosis Onycholysis: Nail substance loosening or loss Plaque: Flat, elevated, usu. 5 mm Solid raised, discrete: Papule (5 mm), nodule (5 mm), pustule (pus-filled) Blister: Fluid-filled vesicle (5 mm), bulla (5 mm)

Shoulder Examination Range of Motion (ROM) Adhesive capsulitis (frozen shoulder): Stiffness, pain, and ørange of movement; scar tissue forms post surgery or injury; develops when stop using joint from pain, injury, or chronic health condition (e.g., diabetes or arthritis) ■ Labral tears: Labrum  cartilage disk on glenoid; pain at back or in front on top of shoulder; feels deep inside; palpation does not duplicate pain; pain or “clunking” sound with overhead motion; causes:  fall on outstretched arm, forceful lifting, or repetitive throwing Abduction/external rotation: Pt. places hand behind head and reaches as far down spine as possible; extent of reach should be at least ~C7 level; Forward flexion: Pt. traces out arc while reaching forward (elbow straight); should be able to move hand to a position over head; normal range 0–180° Extension: Ask pt. to reverse direction and trace an arc backward (elbow straight); pt. should be able to position hand behind back Appley scratch test (adduction and internal rotation): Ask pt. to place hand behind back and reach as high up spine as possible; note extent of reach relative to scapula/thoracic spine (should be at least T7); see figure for additional parts of examination ■

70

71

H&P

H&P

Impingement (of Rotator Cuff Tendons) Inflammation (tendonitis, bursitis), bone spurs, or ⁄fluid  † squeezing rotator cuff (supraspinatus) tendon against bone (acromion); tendon may have tiny tears  † scar tissue  † further damage; nighttime shoulder pain Neers’ test: Place your hand on pt. scapula; use other hand to hold pt. forearm; internally rotate pt. arm so that pt. thumb points downward; flex pt. arm forward to position hand over head; pos-  itive:  pain

Hawkin’s (for more subtle impingement): Raise pt. arm to 90° forward flexion; rotate it internally (i.e., thumb pointed down); puts humerus greater tubercle position to further compromise space beneath acromion; positive:  pain

72

73 Biceps Yergason’s test: Flex pt. elbow 90°; pt. resists while externally rotate arm; if pain in biceps tendon positive test biceps tendon injury  †

 †

Rotator Cuff Tear “Rotator cuff” four tendons supraspinatus (most common injured), infraspinatus, subscapularis, teres minor; muscles originate from scapula single tendon unit inserting on humerus greater tuberosity ■ Repetitive overhead work or sports activity (e.g., painting, swimmers) ■ Gradual or acute onset; pain, stiffness; difficulty reaching overhead or behind back; may be snapping sensation Gerber’s liftoff test (check subscapularis function): Pt. places hand behind back, with palm facing out; pt. lifts hand away from back; partial tear will limit movement or cause pain; complete tears prevent movement Drop arm test for supraspinatus tears: Fully abduct pt.’s arm so that hand is over head; have pt. slowly lower arm to side; if suprapinatus torn, at ~90° arm will seem to drop suddenly toward body “Empty can” test for supraspinatus weakness: With elbows extended, thumbs pointing downward, and arms abducted to 90° in forward flexion, pt. attempts to elevate arms against examiner resistance ■





 †

Acromioclavicular Joint Dysfunction Cross-arm test: Pt. raises arm to 90°, then actively abducts, attempting to touch opposite shoulder; pain suggests problem

H&P

H&P

Glenohumeral Joint Instability “Giving way” feeling or periodic shoulder dislocation; cannot keep humeral head centered in glenoid socket; shoulder pain in throwing athletes; anterior glenohumeral joint pain and impingement Sulcus test: With arm extened and at rest at pt.’s side, exert downward traction on humerus, and watch for sulcus or depression lateral/inferior to acromion ■ Apprehension tests: Put humeral head in imminent subluxation or dislocation pt. shows fear ■ Crank (pt. sitting or standing) or fulcrum (pt. supine) test: Place arm in extreme abduction and external rotation, which may cause apprehension ■ Relocation test: Pt. supine. ■ First part (fulcrum test):  Push humeral head forward ■ Second part:  Push humeral head posteriorly prevents anterior subluxation negative apprehension test  †

 †

 †

■

Inferior apprehension test: Hold upper limb in abduction, with pt.’s forearm resting on your shoulder; exert downward pressure over humeral neck; if shoulder unstable, head will be pushed down and groove appears

Knee Examination Anterior Cruciate Ligament (ACL) Anterior drawer: Flex knee ~80°; relax hamstrings; stabilize foot; leg in neutral rotation; pull proximal tibia forward to see anterior

74

75 displacement; quantify displacement (mm), and grade end point: hard (anterior cruciate ligament [ACL] halts forward motion) or soft (no ACL)

Lachman’s: Anterior drawer variant; flex (15°–20°) and externally rotate (relax iliotibial [IT] band) knee; one hand holds inner calf, and other hand holds outer aspect distal thigh; pull tibia anteriorly

Pivot shift: Slight distal traction on leg; apply valgus and internal rotation force to extended knee; (no ACL tibia anteriorly subluxes on distal femur); flex knee 30° (IT band extendor flexor of knee and tibial anterolateral subluxation reduces)  †

 †

 †

Posterior Cruciate Ligament (PCL) Tibial drop back test: Flex knee 80°; compare proximal tibial prominence to femoral condyles; PCL-deficient knee gravity subluxes knee posteriorly; normal knee: tibial plateau located approximately 1 cm anterior to femoral condyles Quadriceps active test: Starting position: flex knee 80°, neutral rotation; apply counterpressure against ankle while pt. fires quadriceps muscle (i.e., tries to straighten leg); quadriceps pulls anteriorly through the tibial tubercle to reduce any posterior  †

H&P

H&P

translation in the knee; if PCL injured, then will see reduction of a posteriorly subluxed tibia with quadriceps contraction

Posterior drawer test: Flex knee 80°, palpate hamstrings to ensure they are relaxed; stabilize foot and keep in neutral rotation; push tibia posteriorly; if PCL-deficient knee Meniscus

MacMurray’s test: Place thumb and finger on joint line; watch face for pain; flex leg, externally rotate foot, abduct and extend leg to test medial meniscal “clicks”; flex leg, internally rotate and adduct for lateral meniscal “clicks”

Squat test: During full squat, check joint line tenderness and rotate each leg internally (test lateral meniscus) and externally (test medial mensiscus)

76

77 Patella

Bulge test: Check for effusion; press down patella  † empty suprapatellar pouch; wipe hand along medial side to displace fluid laterally; compress lateral side, and watch for bulge medially Effusion: tap test: Push sharply on patella; if effusion, patella will bounce off femur Patellar tilt test: With knee flexed 20°, use thumb to flip up lateral edge of patella; normally can tilt patella up above horizontal; excessively tight lateral retinaculum  † no upward movement Soloman’s test: Lift patella away from femur; synovial thickening  † patella hard to grasp Patellar compression test: Attempts to correlate anterior knee pain w/articular degeneration; compress patella down into trochlear groove as pt. flexes and extends knee Lateral patellar apprehension test: Flex knee 45°; keep knee relaxed; use one hand to stabilize leg while using other hand to apply lateral pressure to patella Medial patellar apprehension test: Fully extend knee; apply medial translation force; medial subluxation, which most often occurs in a pt. after a lateral release, occurs in the initial flexion arc of 0°–30°; after this point, the patella reduces into the bony confines of the trochlear groove when the knee is flexed

Patellar displacement (Sage sign): Normally can displace patella medially and laterally 25%–50% of patellar width; ⁄movement  † loose patellar restraints (frequent in adolescent females) Suprapatellar plica snap test: Palpate medial suprapatellar plica midway between medial patellar border and adductor tubercle; roll plica under your fingers while assessing pain/inflammation

H&P

H&P

Upper and Lower Extremity Muscles Part Arm

Action

Externally Infraspinatus rotate Abduct

Elbow

Muscle

Flex

Root

Nerve

C5

Suprascapular

Deltoid

C5

Axillary

Biceps

C5–6

Musculocutaneous

Supraspinatus

Brachioradialis

Radial

Extend

Triceps

C8

Radial

Extend

Extensor carpi radialis longus

C6–7

Radial

Extensor carpi ulnaris

C7

Flexor carpi ulnaris

C8

Ulnar

Flex

Flexor carpi radialis

C6–7

Median

Finger

Extend

Extensor digitorum

C7

Radial

5th Finger

Abduct

1st dorsal interosseous

T1

Ulnar

T1

Median

Wrist

Abduct digiti minimi Thumb Abduct

Hip

Thigh

Abductor pollicis brevis

Oppose

Opponens pollicis

Median

Extend

Gluteus maximus

L5–S2 Inferior gluteal

Flex

Iliopsoas

L2,L3

Abduct

Gluteus medius and minimus, tensor fasciae latae

L4–S1 Superior gluteal

Abduct

Abductors

L2–4

78

Femoral

Obturator

79 Part Knee

Ankle (flex)

Action

Muscle

Root

Nerve

Extend

Quadriceps femoris

L3–4

Flex

Hamstrings

L5–S1 Sciatic

Dorsi

Tibialis anterior

L4–5

Peroneal

Plantar

Gastrocnemius

S1–2

Tibial

Femoral

Soleus Foot

Toes

Evert

Peronei

L5–S1 Peroneal

Invert

Tibialis posterior

L4

Dorsiflex

Extensor digitorum longus

L5–S1 Peroneal

Extensor digitorum brevis

S1

H&P

Tibial

 ALGOR

Algorithms Hyperprolactinemia (100 ng/mL) ■ ■ ■ ■ ■

Ectopic production Breast stimulation (e.g., breastfeeding) Δ metabolism (liver failure, renal failure) Hypothyroidism Medications (e.g., oral contraceptives, antipsychotics, antidepressants, antihypertensives, H2-receptor blockers, opiates)

Hyperprolactinemia (100 ng/mL) ■ ■ ■

Prolactin Empty sella syndrome Pituitary adenoma

Normogonadotropic Hypogonadism (⁄Androgens) ■ ■ ■ ■ ■ ■ ■

Polycystic ovary syndrome Androgen-secreting tumor (ovarian or adrenal) Cushing’s disease Nonclassic congenital adrenal hyperplasia Exogenous androgens Thyroid disease Acromegaly

Uterine Outflow Obstruction ■ ■

Asherman’s syndrome Cervical stenosis

Hypergonadotropic Hypogonadism (Ovarian Failure) ■ ■

Postmenopausal Premature failure: e.g., autoimmune, chemotherapy, galactosemia, genetic, 17-hydroxylase deficiency syndrome, mumps, pelvic radiation

80

81

   L    L    t   r    0   m    0   m   o    4   /    4   /    h   >   g   >   g   n   n    S

   t    h   g    i   e    H

   l   a   m   r   o   n    b    A

  a   e    h   r   r   o   n   e   m    A   y   r   a   m    i   r    P

   H    L

   H    S    F

   0    X    6    4

  e   p   y    t   o   y   r   a    K

   X    X    6    4

   L    L    l   a    5   /   m    5   m   <   g   <   /   m   g   r   n   n   o    N

   &  e    t   g   n  a   e   t   s   m   p  r   o  e    l   n   e  n   v  a   e   T    d  e    t   l   s  a   a  m   e   e   r   f    B

  e   p   y    t   o   y   r   a    K

  s   u   r   e    t   u   o    N

   l   a   m   r   o    N

  s   e    Y

   d   n   c    i   u   v  o    l   e  s   a   r    P    t    l   u   s   u   r   e    t    U

   ?   m   s    i   n   e   g   o   r    d   n   a   r   e   p   y    H

 ALGOR

  s    ’   r   e   n   r   u    T

  y   r   t   a  c    t   e    i   f   u  e    t    i   d    P

  e    t    i    d   o   r    h   p   e  a    l   a  m   r    M  e    h   o    d   u   e   s   p

   Y    X    6    4

   X    X    6    4

  y   r   r   a   r   o   v  e  o   m   o  m    l   u   c  o  a   t    i    t   r   n  n   s   d  e  a   y  n  r   i   c  y   d  r   y  s   A  a    l   v   o   o    P

  o    N

  s    i   n   a  s   e    i   r   n   e    l    l   e   u  g   s    M  y    d

  w    ?   o    l   n    f    t   i   o   u    t   o  c   e  u   r    t   n    i   r   s   e   b    t   o    U

   l   a  s    i    d   a  s   n  e   o  n   g  e   g   e   r   s   y   u    d    P    l   a   m   r   o   n    b    A

   l   r   a  a   c  e   c   u  m    B  s    l   a   m   r   o    N

  y   c    H  n   e    R    i   n   c    i    f    G   e    d

  m   e   u    t   e    t   s   a   p   r   n  r   e   e  e   o   v  s    f   r   m   s   l   e  y  n  a   s   p    h  a   i   n   e   r   m    T  g    Y    I   a   v

  e   e   r   a   e   g    h   e  r   r    D   -   o    d  n   n  e   o    N   o   c  m   e   A    S

 ALGOR

  y   c   n   a   n   g   e   r    P

  a   e    h   r   r   o   n   e   m    A   y   r   a    d   n   o   c   e    S

   d    i   e   s   o   r   a   y  e   s    h    i    T    d

  g   n    i    d   e   e    l    b   o    N

   l   a   m   r   o   n    b    A   +

   t   s   e    t   y   c    H   n   a   –    S    T   n   g   e   r    P

   l   a   m   n   r   o    i    t    N

  c   a    l   o   r    P

  a    i   m   e   n    i    t   c   a    l   o   r   p   r   e   p   y    H

  e   g   n   e    l    l   a    h   c   n   e   g   o    t   s   e   g   o   r   p    /   n   e   g   o   r    t   s    E

  n  e    i    t   g   s  n   e   l   e    l   g   a   o   r   h    P  c

  g   n    i    d   e   s   e   y    l   a    b   d    l   a   7   n   <    i   g   a    V

  m   s    i    d   a   n   o   g   o   p   y    h   c    i   p   o   r    t   o    d   a   n   o   g   o   m   r   o    N

  g   n    i    d   e   e    l    b   o    N

  w    ?   o    l   n    f    t   i   o   u    t   o  c   e  u   r    t   n    i   r   s   e   b    t   o    U

  c    i   p    )   e   m   o   r   s  r   u    t   i    l    i   o    d   a    d  a   f   a  n   n  o  n   a   o  g    i   r   g   r   o   a   e  p   y  v   p   o    (   y   h    H   g   n    i    d   e   e    l    b    l   a   n    i   g   a    V

   L   m    /   g   n    0    4   >

   L   m    /   g   n    0    2   >

   H    H    L    S    F    L    L   m    /   m    /   g   g   n   n    5    5   <   <   s   y   a    d   c    i    7   p  m   <   o   s   g   r   i   n    t    i    d   o    d   e    d  a   e   a  n    l   o    b   n   o  g    l   g  o   a   n    i   o  p   y   g   p   a   y   h    V

   H

82

Hypogonadotropic Hypogonadism ■ ■ ■

⁄⁄⁄ exercise (e.g., marathon running) øøø weight or malnutrition (e.g., anorexia) Chronic illness (e.g., liver, renal, diabetes, inflammatory bowel disease, thyroid)

Causes of Renal Azotemia Cause

Findings

Glomerulonephritis

UOsm 500, FENa 1 Urine: RBC casts and dysmorphic RBC

Acute tubular necrosis

UOsm 350, FENa 1 Urine: Pigmented, granular casts

Ethylene/methylene glycol toxicity

Metabolic acidosis and ⁄ osmolal gap

Tumor lysis syndome

⁄ Uric acid, ⁄ phosphate, and ⁄ K

Multiple myeloma

⁄ Globulins

Interstitial nephritis

Urine eosinophilia, skin rash; UOsm 350, FENa 1

Atheroembolism

Livedo reticularis and eosinophilia

Nephrotoxic Agents Mechanism

Examples

Tubular toxicity

Aminoglycosides, radiocontrast, amphotericin B, cisplatinum, heavy metals, cyclosporin

Tubular obstruction

Acyclovir, sulfonamides, ethylene glycol, methotrexate

Interstitial nephritis

Penicillin, cephalosporin, sulfonamides, rifampin, NSAIDs, furosemide, thiazides, allopurinol

Renal hemodynamics

ACE inhibitors, NSAIDs, cyclosporin, radiocontrast, amphotericin

 ALGOR

 ALGOR ■ ■

⁄⁄⁄ stress or depression Hypothalamic or pituitary destruction (e.g., tumor, irradiation, Sheehan’s syndrome)

  s    i   s   y    l   a    i    D

  e   r   u    l    i   a    F    l   a   n   e    R   e    t   u   c    A    f   o   p   u    k   r   o    W

  s   e    Y

  y    h   ;   t   s  a    i   s  p   o   o   l   a    d    i   h   c  p   a  e   c  c    i    l   n   o  e    b  ,   a   i   s    t   e   t    i    d   m   r   a   c  ,   i   e  r   e   m  p  ,   u  a    l   o   i   v  m   e   r  ,   u   +    f    K  o   x   s   r   ?   s   o   i    f   s   s   l   y   o   n  a    N   o   i    i    t   d   a   t   c  n    i    d  e   n  g   r    I   u

 ,   e    t   a  s    t   s  e   n   o   o   r   t   p  s  ,    d  s   e  s   g   r   a   a  m    l   n    E

  s   s   o  ,   l   e   r   e   u  m    l   u    i   l   a  o    f   r   v  ,   e  n   v    i   o    l   i  ,   t    F  a   r    H    d    C   y    h   e    d

   l   a   a   i   n  m   e   r   t   e    t   s  o   o  z    P  a

   l   i   a  a   n  m   e   e   r   t   e   r   o    P  z   a

  s   e    Y

  n   o    i    t   c   u   r    t   s    b    O

  s    t   n   e   g   a   c    i   x   o    t   o   r    h   p   e   n   p   o    t    S

  o    N

84

  n   o    i    t   a   z   d    i   r   n   e  u    t   e  o   s    h    t   a   r   a   t   c   l    l   u   a   r   l   a    h    t   n   e   e   r   r   u   &   s   n   a   r    T

  n   o    i    t   c   u   r    t   s    b   o   o    N

   0   P    0   B    5  ,   >  s    t   m  s   s  a    O  c    U  e  ,   n   o    l    N    1   i   <  a   y   a   h    N    E  w    F  e    F    ?   a    i   m   e    l   o   v   o   p   y    H

  a    i   m   e    t   o   z   a    l   a   n   e    R

85

Macrocytic Anemia Workup MCV Macrocytic >97 fL

Megalocytes Yes

No

Megaloblastic

Nonmegaloblastic

B12, folate

Abs corr retic count

Low

Normal

Deficiency

Drug idiopathic

Schilling

Bone marrow rx

Low or normal

Liver/ thyroid dz

No

Aplastic anemia

 ALGOR

High

Hemolytic dz Acute blood loss Hypersplenism

 ALGOR

Microcytic Anemia Workup MCV Microcytic <82 fL

Ferritin Low

Normal or high

Fe deficiency

Lead

Normal High

Hgb electrophoresis

Lead toxicity

Thalassemia, other

86

87

Normocytic Anemia Workup MCV Normocytic 82–97 fL

Corrected abs retic count Low or normal

High

LDH, haptoglobin Normal

Blood loss

Suspect marrow failure

High

Yes

Coombs Positive

Hemolytic anemia

Bone marrow ex

Negative

No

No

Anemia of chronic disease

Splenomegaly Yes

Hypersplenism, drugs, infection, hemoglobinopath hemoglobinopathy y

 ALGOR

 ALGOR

Diabetic Ketoacidosis 1

Perform Steps 1, 2, 3, 4, 5, and 6 simultaneously si multaneously.. Fluids (Step 1) should be started as soon as possible. Start IV: 0.9% NaCl at 1.0 L/hour (15-20 mL per kg) After 1 hour Hypovolemic shock 

Give 0.9% NaCl 1.0 L/hour until correct shock

Assess volume status

Corrected

Cardiogenic shock 

Mild hypotension or normal serum Na+ Give

fluids based on hemodynamic monitoring

or normal

IV: 0.45% NaCl at 4-14 mL/kg/hour

IV: 0.9% NaCl at 4-14 mL/kg/hour S erum glucos e <250 <250 mg/dL mg/dL



to 5% dextrose + 0.45% NaCl at 150-250 mL/hour May stop when metabolic control is achieved

88

89

Diabetic Ketoacidosis (continued) Insulin Therapy

2

Check serum K

>3.3 mEq/L (3.3 mmol/L)

<3.3 mEq/L (3.3 mmol/L)

+

Hold insulin IM/SC insulin IV insulin

Monitor and give K+

IV regular bolus: 0.15 units/kg

0.1 units/kg/hour

IV regular bolus: 0.2 units/kg +0.2 units/kg IM or SC 0.1 units/kg/hour IV insulin IM or SC

IV

IM or SC

Serum glucose by 50-70 mg/dL/hour Yes

No

Continue above therapy Serum glucose < 250 mg/dL

Double insulin infusion hourly

OR

Hourly IV insulin bolus of 10 units

Keep serum glucose Continue IV infusion of 0.05-0.10/kg/hour 150-250 mg/dL or give 5-10 units/2hour units/2hours s

May stop when metabolic control is achieved 3 <3.3 mEq/L

Serum potassium 3.3-5.0 mEq/L

Hold insulin and give 40 mEq K+/hour until K+ >3.3 mEqL/L

>5.0 mEq/L

Give 20-30 mEq K+/L of IV fluid

No K+; monitor every 2 hours until K+ <5.0 mEq/L (continued )

 ALGOR

 ALGOR

Diabetic Ketoacidosis (continued) 4

pH <6.9?

No

No bicarbonate

Yes

Give 100 mmol of NaHCO 3 in 400 mg H20 at 200 mg/hour

Check pH after 2 hours & repeat if pH <6.9 5

Serum phosphate

<1.0 mg/dL or cardiac dysfunction, respiration, or anemia

Normal

Consider giving 1/3-1/2 K+ as K+-phosphate

Monitor serum phosphate and consider treatment if level <1.0 mg/dL (0.30 mmol/L)

Also monitor calcium 6

Serum magnesium

<1.8 mg/dL (0.74 mmol/L)

Symptomatic? Yes

No

Monitor magnesium; consider oral magnesium replacement

Normal

Monitor as needed

Magnesium replacement IV if major symptoms (e.g., life-threatening arrhythmias)

90

91

  e    t   a    b   u    t   n    I

  s   e    Y

   d   e   e    l    B    I    G

   ?    d   e   r   e   g   n   o   a    N    d   n   e   y   a   w   r    i    A

  r   e   c   u   s   d   s   e  o   r   c   t   c   i   n   a   r    V   e    I   t    )   e   s   h    t    h    t   a   a  c   c    A   o    i    P   g    h   n    t    i    A   w    G   -   s    6  s    1  e   r   c   o  c   a    8   l    1    (   a   r    t   e   r   n   o  e    C    b   e  :   s   g   r   d   a  e    l   e    l   o    b   w  r    T  e   >  g   r   a    L

 ,   n   r   y   a  r   e   c   y  ,   p   w  e   y  o   s  o  ,   p   c   o   o   p   c    l   r   s    C  m   o   r   u   c  o    B  a  c   r   s   e  o   s   d    i    R  g  o    d    i   s   o  o   o  n    d    i   s   I   o   n    l   g   n    G    A  m   e   g   g  n  o   o    i   a  c    C   s   g   a    T

  e  n   n    i    l   a   a  e   s  m    0    l   l   a   i    t   7    f   n   m   r   u  o   o  s   P   n  e   B    L  s   u    l   m   o    0   b    5   w   o    L

  s   s   o   r   c    d   n   a   e   p   y    t  ,    T    T    P    /    T    P  ,    C    B    C

  e   r   u   s   s   e   r   p    d   o   o    l    B

   d   e    t   a   v   e    l   e   r   o    l   a   m   r   o    N

  e   v    i    t   a   g   e    N

  e   g   a   v   a    l

   G    N

  e   g   a   v   a    l    L    1   r   r   e   e   y    t    k    f   p   c   a   o   o    l   r   c    b   a   s     e   o    2    l   o    d   c    N    H   n   c   o   e    i    t   r   r    i   s    d    l   e   p   o    i    d   o   a    i   m    l    f   s    b   e   n   r    d    t   r   o   o    f   o   a   o    C    t   e    l   v    S    b    i    t    i    d   s   o   e    P   r    t    h   g    i   s   r   e   e   c    B    i    d   r    i    t   a    P    V   o    F   e   r   s    t   F   e   c    Y    O

   t   y   n  p   e  o   c   g   r   s   e  o    d   m    E  n   e

 ALGOR

  r   e   c    l   u   c    i    t   p   e    P

  r   e    k   I   c   P    P   o    l   r    b     o    2    H

 ALGOR

  c   t   s    i    h   s   a   p   r   c   o    C   m   s   B   y   R    /    D  s    C    B    R

  p   u    k   r   o    W   a    i   r   u    t   a   m   e    H

   k   c    i    t   s   p    i    d   e   n    i   r    U

   d   o   o    l    b   o    N

  n    i   n   a    l   e   m  ,   s   e   y    d  ,   s   g   u   r    D

   d   o   o    l    b   r   o    f   e   v    i    t    i   s   o    P

 ,   r   a   N  y    l   s   u   r   G  p   o   e  r   i   o   b    f   m   o  p  r    l   e   g  u   d    i    k   y   r    l   o  s   e   n   o    k    i   W    L    C

  –

  s    i   s   y    l   a   n    i   r    U

  a   s    i    C   r   u    B   y    R    P

  s    C    B    R   o    N

 ,   i   n   n    i   b    b   l   o   o    l   g   g  o   o  m   y  e    M    h

  ;   s    C    B    R   c    i    h   p   r   o   m   o   s    i   a   ;    i   c    i   r   p   u   n   o   i   c   t   e   s   o   o   r   r   c   p   a   o    M  n

  e   r   u    t    l   u   c   e   n    i   r    U

  +

   T    C   r   o    P    V    I

92

  e   v    i    t   a   g   e    N

  s    i   e    t   r    i   r   u    h    t    l   p   u  n  e   c   i   o  n   r   t   l   o  c   a    f   e   i    t    f   y  n   i   p   i   t   s   a   e   r   v  r   e    t   e   i    t   n    h    t   a   i   r   c  g    i   e   e   r   n   d    i   p    i   s   m   n    E   o    C

   I    T    U

   t   a   e   r    T

  y   p   o   c   s   o    t   s   y    C   r   o   s   e   s   n   s   o   a   t    M  s

 ,    4    0    0    2  ,    t    t  .   o   s   c   n    d   i   e   p  ,    i   p    G   L  ,   :    t   m   n   i   a   h   e   h  .   e   p   3   r   l    f      G  e   3  ,    d    l    8    A   a   0    I    i  ,    h   0   a   P   1    h   t  .    h   c   g   l    /   e    A  u    l   :   s   p   n   n    I   o   m  .    C   a   a    /    i   r   t   y   s   u   l   m    t   a   o   a   i   c  .   m  c   e   e   e   p   n   s   i    H   b   c    i   o   u    t    d    h   S  e   c   y   m   a   g   p   o   o   c   r   l   a  .   p   o   r   p   h   w    A  p   w  .   e   w    T   N    /  ,   :    /   :    i   p    L   l   a   t    t    t   m  u   n   h   o   r   a   d    f    d   M  n   a   e   n    t   o   p   t   a   g    d   i   n    A   h   s   a    W   e    h    T

93   a   c   i    i   m    l   r   u    i   a   e    i   c   c   l    l    i   l   a   m  a   c   r   a  c   o    F  p  e   y  p   y    h   h

  a    C   y    H   r    T   a   n      h    P    i     g   r      i    U      H

    w     o      L

     h     g      i      H

  y   s   /   D   m    t   n   u   s  +    i    i   n  c   r   i   e   2    i   c  a  m  o  m   x   x   C   a   o   u   t    i    l    E    t   v   a

  p   u    k   r   o    W   a    i   m   e   c    l   a   c   r   e   p   y    H

  n   o    i    t   a   r    d   y    h   y    b   e    l    b   a    t   c   e   r   r   o    C

    s     e      Y

  s    d    i   u    l    f    V    I

  m   u    i   c    l   a   c    d   e   z    i   n   o    I

   )   ;  .   D   r   g  .   o   e    (   :   A   n   s   i   n  m   o  a    i    t   t   a   i   c  v    i  ,    d  m   e  u    i   m    t   y   h    l    b   i  ,    d  s   e  e   s   d   u   i   a  z   a    i    C    h    t

     d     e      t     a     v     e      l      E

     l     a     m     r     o      N

  a    i   m   e   c    l   a   c   r   e   p   y    h   e   u   r    t    t   o    N

    w     o      L

    c      i     n     o     r      h      C

    o      N

   ?   e   r   u    l    i   a    f    l   a   n   e    R     e      t     u     c      A

    o      N

   )   s   o    h   y  p   c   n   k   a   l   n  a  ,    4   g    i    l   O   a   P   m ,    f   R   o   X    k   C   s  ,    i    P    R    &    H    (      h     g      i      H

  +    2

  s  a  s   r    d   C    h   e    2    k   m   c   7     e   8   p   h   o  c   4    t   n    S  e   i    R

 ALGOR

  y   r   e   v   o   c   e   r    N    T    A

  e   -   d    d   e   i    t    H   a   t   p    T   l   e    P  r   e   p

  m   s    i    d    i   o   r   y    h    t   a   r   a   p   r   e   p   y    h    °    3  ,    °    1

    w     o      L

 ,    d  ,   )    i   y   o   a   r   l   a   y  g  m    h   o   e   t    t   r   m   e  o  y   p  r   c   y  c  o   m    h    (   a  ,   o   r   e  n   h   n  o  c    i   r   i   s   c   d  o   e   o   d   h    d   A  p   n    E

   )   s   ;  .  ,   i   g   s  s  .  ,   i   o   e   s    d    (   i   o  c   y   s  o  m  m   a  c   r   s  o   m  a   l   a   d   s   o    l  ,   p   i   o    i   u   B   o    d   n   T   t    i   s   a    i   r    h  c   c    G   o   c

 ,  ,  ,   o   )    t   t   e   r   n   a   s   a   e    l   a   t   a   m   o   e   o   d   a  e  r   s   n  ,   v   b  o    i   e    l  ,   r   c   a  a  p   r   g   r    ,   a   o   a      l   c    d   m    l   h  o   i     a  ,    l   o   g    l     m    l   c     r   n   e  r   n   a     o   u   o  y  y    h N    L  m   r   m    t    b   s    (    l    l    l    l   &   e  ,   e  ,  ,   a   c  a   c   d   l   a   s  a  a  m  m  m   u  e  n  o  o  o    h   o   h  e   n   t   r    i   a  ,  ,   c   p      h   m   g    )   r   p   a     g   u  n    k  a  e  m      i   y    h    l   c   c   u      H   q    l    (   e    S   n

 ALGOR

Hyperkalemia Management Rule Out Spurious Causes ■ ■ ■ ■ ■ ■ ■ ■ ■

Laboratory error Blood-draw issues (from vessel with potassium infusion, fist clenching, tourniquet, traumatic) Pseudohyperkalemia Hemolysis Leukocytosis Thrombocytosis Genetic syndromes Familial pseudohyperkalemia Hereditary spherocytosis

94

95

   t   n   e   m   e   g   a   n   a    M    )    L    /   q   e   m    0  .    5   >   +    K    (   a    i   m   e    l   a    k   r   e   p   y    H

  m   u    i   s   s   )  ,  ,    i   s   l   s   a    i    t   i   c    i   a  s   o    t   s   o    l    i   t   o   p  a   t   y   y  m   m    h   a  c    t    i   u  c    f   o  ,   o   a   w  r   k  s  r   e    l   t   u  e   h  ,   e   p   e   t   s  e   l   s  ,   m   s  u  s   o   e  q    i   r   y   v   i   s   d  r   a   n   y  n    t    l    i   r   m   o  y   u   s   d   o   r   e   o  m    f   r   c    (   t   e  ,   e   i    t    h  e   h   s  g  ,   n  ,   e   i   n  a   a   u    i   e   i   s   h   g  m   s  c  m  ,    i   n   e  s   e    l   e  a   i   l    l   w   a   c   k  s   a    k   o  r   r   t   r   t   e    d   s   y  e    i   c  p    f    d  ,   p   y   o  y   o  n    h    b   o  o  o    h    l   o    i   d  m    b    d  ,   s   u  o   r   u   r   u   e    f   s   h  e   o    t   s   r   n  p   r   i   p   e    b   a    L

      s      u       o        i       r      u       p        S

  s   e   s    t   u   u  a   o  c   e  s    l   u  u   o    i    R   r   u   p   s

    l    a    e     R

   t   n   e   m    t   a   e   r    T    t   n   e   g   r   e   m    E

    L     /    q    e    m     0  .     6    >    r    o    e    s     i    r     d     i    p    a    r    n    e     d     d    u     S

  +    K   m   u   r   e    S

 ALGOR

  r   a    l   u    l    l   e   c   a   r    t   n    i   +    K    t    f    i    h    S

  e    t   a   n   o   c   u    l   g   m   u    i   c    l   a   c    V    I

   n    o     i    s    u     f     T     P     &     f    o     S    l     i     R    l    t    s     Q    s    s    :     d     )    o     l    e    n    r    v    a    a    t    o    w   s     k    r    c    e    l    a    o    n   u     T     l     i    s    i    c     d     b     (    e    r     V    t    n    e    t    n   o    A   g    n    n   v    e     i    a    e    e    t     i    s    v    n    r    s    e    r    e    w   t    o    e    g    d   c    n    r     i     d   p   e    i    s    e     d    w    e    e      a    n     k    d   t    S    h    i    s    a    p   m    r     R    i    e    T    i    m     P    S    F    Q    B    I

    L     /    q    e    m     0  .     6    <

   G    C    E

    l    a    m    r    o     N

  s    i   s   y    l   a    i    d   o   m   e    H

     /   +   e   s   l   o  o   c  r   u  e    l    t   g   u    b   +    l   n  a    i    l   u   s   n    I

    l    a    m    r    o    n     b     A

  n   o    i    t   c   n   u    f    l   a   n   e    R

   y    r    o    t    c    a    r     f    e     R

   t    n    e    s    e    r     P

    l    a    m    r    o     N

  s    i   s   o    t    d    i    n   c    e    s   a     b   c     A    i    l   o    b   a    t   e    M

  n   o    i    t   e   r   c   x   e

  +

   K   e   s   a   e   r   c   n    I

   l   m    t    h  .    3    8    2    /    5    1    1    0    6    0    0    2    /   p    f   a   e    /    d    i   g   r   m   o  .   e    f   p   s   a   o   r   a  .   u   w    f    &   w   w    )    /    /   e   :    t   p   a    t    l    t   e    h   x   e   m   y   o   r   a    f    K    (    d   e    t   e    t   p   a   a    f    l    d   u    A

  s   e   n   e   r   y    t   s   y    l   o   p   m   u    i    d   o    S

 ALGOR

   d   e   s   a   e   r   c   n    I

  p   u    k   r   o    W    )    L    /   q   e   m    5    3    1   <   +   a    N    (   a    i   m   e   r    t   a   n   r   e   p   y    H

  s   u    t   a    t   s   e   m   u    l   o    V

   l   a   m   r   o    N

   d   e   s   a   e   r   c   e    D

  s   s   e   c   x   e    t    l   a    S

   L    /   m   s    O   m    0    0    7   <

  y    t    i    l   a    l   o   m   s   o   e   n    i   r    U

  y    t    i    l   m   a   u    i   l    d  o   o  m   s  s   e  o   n  e    i   r   i   n    U  r    U

   L    /   m   s    O   m    0    0    7   >

  s   u    d    i   p    i   s   n    i   s   e    t   e    b   a    i    D

  s    i   s   e   r   u    i    d   c    i    t   o   m   s    O

   ?    P    V    A    D    D   o    t   e   s   n   o   p   s   e    R

  o    N

  s   e    Y

   L    /   m   s    L    /    O   q    E  m    0   m    0    0   7    1   <   >   m   a   s    N   O    U   U

   L    /   m   s    L    /    O   q   m    E   0    0   m    0   7    1   >   <   m   a   s    N   O    U   U

96

  c    i   n  s  s   e  e  u   g   t    i   e   d   o   p   r   b   i   a  s    h   i   p   d   i   e   n    N

   l   s  s   e  u   a    t   r    t   e   d    i   n   b   i   p   e   i   a  s    C   n    d   i

  s   c    i    i   n  ,  ,   s   o  s  s  e   r    t   u   c   i   o  s   i   o   t   d   p   l   y   e   c   r   i    h   d    i    t   u    l   u   i   o   a   l    D    f   n   m   e   s    R    O  ,   s   s  ,   o  s    l   s    d   o    i   l   u  e  s    l    f   l   s   o    b    l    i   c    i   s   I   n  n   G   o  e    t   o  s   n   p   I   y    H

97   s    i    t    i    t   a   e   r   c   n   a    P

  a    i   m   e    t   a    h   p   s   o    h   p   r   e   p   y    H      3

   4

   O    P

  p   u    k   r   o    W   a    i   m   e   c    l   a   c   o   p   y    H

  m   u    i   c     w    l     o   a      L   c    d   e   z    i   n   o    I      l     a     m     r     o      N

  n    i   m   u    b    l   a   w   o    L

 ALGOR

     l     a     m     r     o      N

    y      l     e     t     a      i     r     p     o     r     p     p      A

  e   s   a   p    i    l    &   e   s   a    l   y   m    A

     l     a     m     r     o      N

   H    T    P     w     o      L

  +    2

  g   m

  a    i   m   e   s   e   n   g   a   m   o   p   y    H

     l     a     m     r     o      N

  m   s  g    i   n    d    i   i    t   o   r   s   y  a   w    h    t   l   a   r   a   a  n   p  e   o  r   p  r   y  o    H

   )   n  m    i   o   i   s    t   y   d   n   i   e  o   r    h  y    h    D  p  ,   t   a   n  e    i   n  r   a    i   m   c    i   p   a   o    t    i   h   c  p    V    l   y   o   h   c  o    (    d   s  u   g  e   u   s   r   P    D

 ALGOR

  p   u    k   r   o    W    )    L    /   q   e   m    5  .    3   <   +    K    (   a    i   m   e    l   a    k   o   p   y    H

  y  ,   p   a  a    i  ,   r   e    t   s  m    h   c  s  e   t   e  e  c    2    f   y    1   e  c    l    B    d  x  ,   e  g   r   s   n   i   n  e   i   o   p  s    l    i   y    t   u  y   l   u  s   h  a  ,   r    b   n  s    i    i   r  ,   i   a    t   s  p    L   s    i    l   c    i    M  o    D   a   d    A    k   o    l   i   a  r   e   p

  +

    L     /    q     E    m     0     1    <

   K    t   s  o   s  p   o  s    l    d  y   e  r   a   s   i   a  n   r   e   r   u   c   k   n  c    I   e    h     L     /    q    C     E

   m     0     2    >

  s   u   o    i   r   u   p    S

   1   2   e  e   p  p   y  y    T   T    A    A    T   T    R    R

  e   s    l    l   u   a   b   m  a   s  e  ,   v   s  s   i   s  s   t   o  a   o   l   x    l   a    l   y   l   a  r  ,   n   i   a   a   l   e    l   u   r   i   t    b   n  ,   s   o  a   i    f    N  e   l   a    h   r   n   r   i    t   a  s    i   e    D    t   n    i

  s   P   s   B   o    l    l   k   a  c   e   n   h   e    C    R

 ,   s   m   s   c  e   i    i    t   v  n   e   o   r   i   r   s   u  n   t   e    i   e    d   t  ,   o  s   o   s    d    ’    l   r   m   a   r   e   r    t   o    t   r   n  e   a   p   y    B    h

    0     1    >

    d    e    s    a    e    r    c    e     D

   3

    l    a    m    r    o     N

    d    e    t    a    v    e     l     E

   O    C    H   a   m   s   a    l    P

    d    e    s    a    e    r    c    n     I

  m   s    i   n   o   r   e  e    t   s   t   a   o   t    d    l   s   a   r   e   p   y    H

98

   l    C   y   r   a   n    i   r    U

  n    i   n   e   r   a   m   s   a    l    P

  s   m    i   s   s    i    h   o   n    t    i   l   a   o   r   w    k   e  e    l    t   g  a   s   t   n  c   o   t   a    i    i    t    l    i    d    l   s   o   a   m    b   o  a   r    t   e    V   e   p   y   m   H

    0     1    <

  m   s    i   n    d   o   r   e  y   e   s  r   a  a   t   s   e   m  o   r   i   c  r   d    l   e   P   a    D   r   e   p   y    h   m   s    i   n   y    d  r   o   e  a  r   e   s   d   t   a  n  s   e   o   r   o    d   c  c    l   e   n    I   S  a   r   e   p   y    h

99

  p   u    k   r   o    W    )    L    /   q   e   m    5    3    1   <   +   a    N    (   a    i   m   e   r    t   a   n   o   p   y    H

    )    g     k     /    m     h   s    g    O     i     H   m     5     9     2     )    >    g     (     k     /    m    s     O    m     0     8     2   y    <    t    i    l     (   a    w    l    o   o     L

  m   s   o   a   m   s   a    l    P

    )    g     k     /    m     l    s    a    O    m   m    r    o    5     N    9     2       0     8     2     (

    L     /    q    e    m     0     2    >

  a  y   p   a    i    i   c   r   m  a    i   m   e   n  e   e   h   c   r   o   t   y   t    t   r   a    l   l   e  n   g   o    t   p  o   r    i   y  p   e   n   n    H  y   p   y    h    H  a    M

  a    i   m   e   r    t   a   n   o   p   y    h   c    i   n   o    t   o   p   y    H

  y    t    i    l   a    l   o   m   s   o   e   n    i   r    U

  a    i   a   m    i   a   e    i   m   r    t   e  m   a    i   e   n   n    d   e   i   o    t   p   p   o   i   y   r   l   r    h   p   r   o   e  e    d   p  p   y   u   y   H   e    H   s    P

 ALGOR

   g     k     /    m    s     O    m     0     0     1    >

   g     k     /    m    s     O    m     0     0     1    <

  m   u    i    d   o   s   e   n    i   r    U

    d    e    s    a    e    r    c     L    n     /     I    q    e    m     0     2    <

  s   u    t   a    t   s   e   m   u    l   o    V

   l   e   a  s   n  a   e  e   s    i    R    d

  m   y   s   c    i    d   n  s    i   l   a   e   o    i   r   n   c  g    i   y  e   r   f   u   r    h    t   d   f    D   o   A  u   p   s   n   y    i    H

    l  ,    a     0    m    0    r     2    o    >    0     2     N    m    >    s    a     O    N     U    U

    L     /    q    e   e    m    k     0   a    t     d     2   n    e    >    i    s    a    O    2    e    r   m    H    c   u    e    i   s     D    d

  s   e   c   x    E

 ,   s   e    t   a  ,   c  e    t   s  z  ,   i    t   m    d   s  r   F  o   r   o   r   u  e   H    h   o  v   C  p   d    t   n   e   a   i    L    N  y   s   m   e    d    E

  o   s   e   n    i   r    U

    L     /    q    e    m     0     2    <

  n   o  s    i    t   i   c   c    t    i   r   e    t   r   s   i   u   e   r   d   r   d   e  n    t   a  a    W

   t   a  ;   e   r   r    t   e  e  g   n  a   n   i    d   d   r   i   n   i   n  o   l   a   e  m   a   i   s  s   t   e   n   d  c  a   r   e    t    i   o   r    i   n   h  a    t   g   n   n   t   o   t   c   i      i   o   y   r   r   e    l    t   r   e   f   p   s  e  p   i   y    l   e    h   r   d  y  r   o   n   h   f    O    2  u    H

   H    D    A    I    S   s  s   s  c   )   o   i   y    l    t   l    l   e  r   a  r   a   u   (   e   n   i   e   D    R    l    )   a   n   n    i   e    k   r   s   s   s   a   o  ,   r   l   I    t   x    G    E    (

   d    i   t   n   u    l    f   e   c  m   e    i   n  c   a   o   l    t   o  p   s  e   r    I

 ALGOR

  s    i   s   o   n   g   a    i    D   a    i   x   o   p   y    H

    4     /     ]     4     d   +    e    )    s    s    a    r    e    y    r    (    c    e    e     D   g     A     [    <

   )    2    O   a      A    P    (    t   n   e    i    d   a   r    G   a      A

  s    i   s   o    d    i   c   a   y   r   o    t   a   r    i   p   s   e    R

  e   r   u    l    i   a    f   y   r   o    t   a   r    i   p   s   e   r    I    I   e   p   y    T

    4     /     ]     4     d   +    e    )    s    s    a    r    e    y    r    (    c    e    n   g     I     A     [    >

    d    e    s    a    e    r    c    n     I    2

   O    C   a    P

  s   s  n   e  o    i   e  n   s   k   t   a    l   a   o    i   a   d  e   t   e  r   w  n   n  e   e   p  v  r   a  v   a  o   o    l   p   p  e  u   c   v  s  y   e   i   e   t    h    l    l   a  u    S   a    d  m   r    t   e  o    S  r   n   u  e   e   C    N

  n  s   o  u    i   c    t   i   a   t   a    b   r   e  m   c   h   a   t   x  s   e  a    D  s   u    t    P   a    t    O    S    C

   w    o     l    r    o     l    a    m    r    o     N    R

   X    C

100

   s    e    t    a    r    t     l     i     f    n     i    e    s    u     f     f     i     D

   s    e    t    a    r    t     l     i     f    n     i     l    a    c    o     F

   r    a    e     l     C

  c    i   g   m   n   a   i   n  r   o   y   t    i    d   o  n   o   m   e  m    H

  s    i   s   a    t   c   e    l   e    t   a  ,   a    i   n   o   m   u   e   n    P

   E    P   r   e    d    i   s   n   o    C

 ,     6     1    5  .    >    2    <    e    r    x    u   e    s    d    s    n     i    e    r    c    p   a    e    i    g    d    r     d   a    e    C     W

    5  .     2    >    x    e     d    n     i    c    a     i     d    r    a     C  ,     6     1    <    e    r    u    s    s    e    r    p    e    g     d    e     W

  a   m   c   e    i   d   n  e   e   g  y   o  r    i   a    d   r   n   a  o   m    C    l   u   p

   S    D    R    A

101

   t   n   e   m   e   g   a   n   a    M   a    i   x   o   p   y    H

   2

   O    l   a    t   n   e   m   e    l   p   p   u   s    &   y   r    t   e   m    i   x   o   e   s    l   u    P

 ALGOR

   %    0    9   <

  s    t   n   e   m   e   r   s  u   u  s    t   a   a    t   e   s    l   m   c   a   i    t   n  m   e  a    M  n   y    d   o   m   e    H   e    l    b   a    t   s   n   u   r   o    /    d   n   a    S    M

   2

   O   p    S

   %    0    9   >

   d   n   a   e    l    l   a   b   a    t   m   r   s   o    N

  e   s   g   n  u   e  a   n   g  c   i   r   y  g  o    t   x   i   n   o  y   i   n   e   l   r   o   u  e  m   n    d    i    t   n  e   n  u  s   o   o    t   l    C  a   C   e   r    T

       

   )    P    A    P    I    B  ,  .   g  .   e    (    P    P    P    I    N

   t   n   e   m   e   v   o   r   p   m    i   o    N

  n   o    i    t   a    b   u    t   n    I

 ALGOR

   )   n   o    i    t   a    i    t    i   n    I    (

  n   o    i    t   a    l    i    t   n   e    V    l   a   c    i   n   a    h   c   e    M   a    i   x   o   p   y    H

   O   g    2    H    H   m   m   m   g   c    0    k    /    5    5    L   2   <   g   >    2    k    2   m  e    /   c    0    3    O .    1   r    L    7    C   o   a  <   <   f   m   y   y   0    P    t    H    1  ,   p   i   r   o   <   g   c   t    1   a    d   a    H   p   r   n   a   i    V   a   c   p   E   m    F   m    l   s   n   a   i    5    t    i    5    V   e   <   v    i    t    2   a    O   g   a   e    P    N  ,   s   s   e   r  ,   n    t   s    i   s   o    i   s   i    t    d  o  c    d  e   y    t   r   i   c   o  a  o    t   r   a   p   r   y   r   y    i   o   p   t   s  a  a   w   e   r   i   r   r   i   p  a  ,   :   s   e   a   n  r   i   o    i    t   m   a  ,   e    b  s  x   o   u   u    t   t   p   n  a  y    i    t   h   r   s  y   o   l   r    f   a  o    t   s   t   c   n  n   e   o   a   r    i    f    t   m   a         e   c   r    i    d   n    I

   *    O    2    H   m   c    5    P    E    E    P  ,    %    0    0    1    2

   O    i    F  ,   g    k    /    L   m    0    1      8    V    T  ,   n    i   m    /    4    1      2    1   e    t   a   r  ,    l   o   r    t   n   o   c    t   s    i   s   s   a    t   r   a    t   s   :   e    t   a    b   u    t   n    I

   P    E    E    P   e    t   a   u   q   e    d   a   n    I

  a    i   m   e   n   a    t   c   e   r   r   o    C

   2

  n    i   m    5    1      0    1   n    i    G    B    A    k   c   e    h   c    d   n   a   y    l    l   a   c    i   n    i    l   c   s   s   e   s   s    A

   O    C   a    P   e    t   a   u   q   e    d    A

   t   n   e    d   n   e   p   e    d   e    d    i   s   y    h    t    l   a   e    H

  :   r   e  e    d   m    i    i    t   s  g   a  n   n    i    t   o   n   a  c   r  ,   a    2    %    0   O  w    1  p   y    l    S   y   r    b  w  a   e    2   o    l    O    i   l   o    f    F

  y   r   s   o   i    t   s   a   o   r    i    d    i   p   s   c   e   a    R

   R    V    T    R

   2

   O    C   a    P    d   n   e   n   a    i    l    H   e   p   s   a   y   r   s   o   i    t   s   a   o   r   l    i   a   p   k   s   l   e   a    R

102

  e   z   y    l   a   r   a   p    /   e    t   a    d   e    S

   *    *    R   o   R    /    N    V    T        

   b    /    I    N

   R    V    T    R

   ?    O    M    C    E

  o    i    t   a   r    E   :    I   e   s   r   e   v   n    i    h    t    i   w   n   o    i    t   a    l    i    t   n   e   v    l   o   r    t   n   o   c   e   r   u   s   s   e   r   p   r   e    d    i   s   n   o    C

   )   a    )   n   m   o   u    i    t   a   r   a   ;    t    l   ;    f   u   g   l   g   i   n   k    k    /   o    /   r    L   v    i    L   e    t   n   p   m   n   a   m  y   p    h    0   t    8   e    l   v      1   n   o    6   e   r   r    t   =   e   p   =   (   n   e   v   e   e   t   e   o   c   m  r   p   m  u   /   u    (   e    l   u   i   n   z   o   t   e   l   y   o   m   l   v    l   u   v   /   a   r   n   l   a   i    2   a    d    i   m   d   1   a   p    T   /    i   -    /    T    0    0   e   :   1    1   t   :    D    S   a   =   d    P  =   e   D   t   e   e    O   t    S    R    C    *   a   r    A  a   r    *    *

103

   L   m    /   g   n    0    4   >

   L   m    /   g   n    0    2   >

   l   a   m   r   o    N

  y    t    i    l    i    t   r   e    f   n    I

   L   m    /   g   n    5   <

   h   g    i    H

   l   a   m   r   o   n    b    A

  a   y   o   r    /   a  m   r   t    I   i   o   u  n    R   e    t    i   d    M   p  a    h   g    i    H

   H    H    L    S    F

  w   o    L

  e   n   o   r   e   e    l    t   a   s   o    M    t   s   e    T

  m   a   r   y   g  p   o  o   g  c   n  s    i   o   p    l   r   a  a   s  p   a    l   o   r   d   e    t   n   s  a   y    H

  n    i    t   c   a    l   o   r    P

  e    l   a    H    H   m    L    S    F   e    F    L   m    /   g   n    5   <

  n  e   a  r    i   r   l   u   a   i   v  a    f    O

   l   a   m   r   o    N

   H    H    L    S    F

   H    L

   h   g    i    H

 ALGOR

   l   a   m   r   o    N

   l   a   m   r   o    N    H

   S    F

  r   d   a  n    l   u  u   c  o    i    t   s   s  a   r   e   t    l    T  u

  y   n  r   t    i   e  o   v    t   i   g    t    i   p   o   r   e  s    d  c  n   e   n  e   r    A   s   n    i

  e  ,   a    d  n    i   a    d   o   r   i    t   g   a   a  p   o    l   r    t   u  s   o   e   c   r   a  p    j   y   o   e   h    /   r

  a   y   o   r    /   a  m   r   t    I   i   o   u  n    R   e    t    i   d    M   p  a

  m   s   w    i   o   y    d    L   r   a   a  n   m   o    i   r   g    P  o   p   y    h

 ALGOR

Mechanical Ventilation: Extubation Criteria Hemodynamic stability Vital capacity >10 mL/kg Maximum inspiratory pressure <-25 cm H2O Respiratory rate <20 breaths/min Respiratory minute volume (VE) <10-20 L/min + normal PaCO2 Adequate arterial oxygenation (e.g., PaO2/FiO2 ratio >150-200) with FiO2 <40%– 50%, PEEP <5-8 cm H2O Ratio of ventilatory frequency to tidal volume (f/Vt) <100 during 1-2-minute trial of spontaneous ventilation From Miller: Miller’s Anesthesia, 6th ed

104

105

  r   o    t   a    l    i    t   n   e    V   n   o   e    l    i    h    W   :   n   o    i    t   a    l    i    t   n   e    V    l   a   c    i   n   a    h   c   e    M

  s    i   s   o    d    i   c   a   y   r   o    t   a   r    i   p   s   e   r  ,   a    i   m   e   x   o   p   y    h  ,   a   e   n   p   y    h   c   a    t   :   s   s   e   r    t   s    i    d   y   r   o    t   a   r    i   p   s   e   r   e    t   u   c    A

 ,   y   n    t   o   e    i    i    t  ,   a  x   )   n  n    k   l    i   o    t   a   a   i    t   e  n  n    l   a   e   i   t   r   a    i   v    i   r   g    A  e  p  ,   p  .   a   y  g  .    H   e    (

    d    e    s    a    e    r    c    e     D

  e   r   u   s   s   e   r   p    k   a   e    P

       

   o     N

    d    e    s    a    e    r    c    n     I

 ALGOR

 ,   m   s    i    l   s   o    b  s   e   c   m   e  o   o  r    b  p   c    i   m   c   o   r   a   r    h    t   o    h   y   r   t   a  a   r    t   n   o  x   e   m    l   u    P

  e   r   u   s   s   e   r   p   u   a   e    t   a    l    P

       

   o     N

    d    e    s    a    e    r    c    n     I

   d   g  e   )   n   i   n  g    i   n    k   t   a   i   n  ,   g   e   n   i   r    k   g   o  ,   u   e   i  .   m    l   c   t   g   p  .   o   n   a   r   r   s   e   f   a   i   (    t   u   s   p   s  n  n  o    i   o  c   s   a   i   o   i    t  ,   e    t   u   c   c    R   m   u  m   u   r  ,   y   s   r   t  .   a    t   a   s   g   p  s  .   w   s   b   b  e   r    i   o  o  o   (  ,   s    A   h  e   )    d   c    b   h  n   o   e   n  u   t   e   i    t   s   o    t   r   l   t   e  e   a   b   a   r   e   r   e  e  g  c   c   t   h   i   n  e   s   u   n    I   c  c    h   a   r   c  y    A    t   n  a   o  e  w   r    d   l    i   c   n  r   a   e  o  ,   y   r   e   s  s   o  y   v  ,   i   n   t    i   r    )   s    t    i   m  a  o  a    D   r   a   s  u   t   i   i   n  ,    P   o  e  c  s  p  o   )   a   O   u  s    i   e   f   p  n   l   m   e    l   n   C   o  e   f   r    t   e    t   m   u  o  n    i    l   r   a    i   e   o   e   r   e  ,   a   t   p  m   c   f   p   )   r   u   i   c    P   s  u  c   u   n   s  o   i   e   E   n   a   e   a   n   E   s   l    i   e    l   a   m  .   y  p   g  p   P   p   g   u   l  ,    ,  .   i   a  e  g   o   d  .   e   o    i   m  g  n   g   (   e    t   o  .   p   d   r    d   r   a    l   e   o  u   a  g  a   l   a    C   (  ,   a   l   r   n   c  ,   u  ,   e  ,  .    d   n  n  e   )   o   n   e   i    l   e  v  g   o  .   s   t   i    t   t   o  e    f   o   s   e   a   n   l   a   i   p   f    (    d   r   a   i    t   m    i   e   o    i   e   r    t   t   e   l   s  r   u  n   c   i   o  ,    l   s  n  p   l    i    f   e  ,   o  x   d   e  ,   t   v   d  c  a  n   a    D   d   y    l   e   i   r   r   s  a   l    f   a  r   l   u  a  o   m  n   s  e   i   n    f    i   u    b   h    t   s   d  r   o   s   i   c   o  e   e   m  s   t   l   r   e  p   o  e   i  ,    t  .   m   y   s    d  r   c  g   u    i    h  .   e    b  p  s  e    d    A   a   (   n   p

 ALGOR

  s   e    d   o    M   :   n   o    i    t   a    l    i    t   n   e    V    l   a   c    i   n   a    h   c   e    M

   d   e    t   a    i    t    i   n    I    h    t   a   e   r    B   r   o    t   a    l    i    t   n   e    V

  ;  ,    d  n   e   i   o    t   w  a   s   o   l    l    h    l    i    t    t   a   n   a   e   g  e   r   v   n    b    i   e    h   n    t   t   e   a   u    t   n   e   r   e    i   r    t   o   w    f    V    t    f    b  m   e   e   s   r    b   y   o    t   u   l   n   o   i    d    P   s   e   e    I   e    i    t   n  a    P   a   e   n   w   a    t   o   p   n  n  o    l    l    f   o  a  ,   a   o   p  c   e   g    t   n   s   s   t   n   s   o  e   a   r    i   e    i    l   n   t   n    h    t   a    d   a   ;   r    t   p  a   e   e   r   a   r   ;   o  e   w    b   g    f   e    t   t   s   r    f   e   a  ,   r   o   n   u   y   s   o    l   r   t   n   e   a    t   o  s   a   e   v   c   n   a   r   a    t    t   r   e   m    i    t   u   n   u   b   p   n   o    i   s   m   p    t   e    i   s   r   e   n  ,    i    l   s    ’   s   a   e   m   r    t   v   n   r   p   e   y   r   e    t    i    t    t   o    A   a   t   n    i   a   p   d    t   e    h   n    t   s    i   a   e   r    W  m   p    t    A

   )    V    M    C    (   n   o    i    t   a    l    i    t   n   e   v   e   y   r    d    t   o   o   a    M    d   n   a   m   s   u   o   u   n    i    t   n   o    C

  n   o    i    t   a    l    i    t   n   e   v    l   o   r    t   n   o   c      t   s    i   s   s    A

  y   r   e    )   v   e   e   r   s   e   '   m  u    t   t   u  s   s   n   )    l    i   e   w   o  s   s   i    t   o   v   e   s   a   l   r   a   p   f   g  p  .    k   n  s   o   l    i    t   a   u    )   t   e    l   v   n   ;    t    V  u  p    i   e   n   l   r    T    f   a   a   o    t   d  o    t    f    f   e   o   n   h   e   s   n   i    i   n    %   a   x   e    (    h    (   y    5    t   a   r   a   e    2   m  g   r   t   o   n  ,   e    t   r   u   i  .   n    i   a   a   g   s    b  .   s   h   r    i   s   m  e    t   n    (   y   a   n   p  e   e    t   o   r   a   e   i   s   e   p  r   f    t    f   r   e   w   a   r   w    t   o   o   r   b   l   p    t    i   r    i    t    f   s   e   o  p  u   a   o   t    ’    t   b   c   o   n   p  u   e   n   s    t   k   p    i   n   r   v   e    d    i   e   e   o    t   e   u   a   r    d   s   r    t   a   w    f   u   u  w  e   p  o   o  s   r   r   e   s    i    l   s   c   s   a    l    l    h    t    d   e    i   a   e   e   r   r   n   p   w   v   w  g   e   p   l   p  a   m   n    l   y   o    t   C   i    d   i   e    t    b   e   e   h    t    t   e   a   s   R  y   a   a   s   w   s   r   F   a   r   ;   i    l   n  e    l   e   m    i   r    t   a   a   v   ;    d   n   t   ;   f    i    l   n   r   b    i   e   o  s    t   r   w   e   i   o   o  o    d   t   o  u   a   f   ;   a   c   o   p   f   l    f    h   e   e    d  n   y   s   y    t   n   n  a    b   r   a   e   g   o   e   a   t   y   u   t   r   y   o    t   n    l   a   x    b   e   o   s   e   i   r   o   s   p   u  n  p   r   o   a   s    t   e   e    t   r   s   o   e   a   v   n   n   p    l   o    i   n  o    i   r    t    t   a   p   n    A    t   p   n  s   e   i   v   m   o   p   o   d    S    N  n   a

   )    V    M    I    (   n    t   )   o   n   V    i    t   e   M   a    t   I    l    S    i    i    (    t    t   n   m  n   e   r   i   o   v    t   e   t   a   y   n   l   r    i    i   o   s   t    t   n   a   u  e    d   o  v   n   n  y   a   o   r   r   o   m    h   t    t   c   a   n   n   d   e   y   n    t    t    i    S  a   m   m   r   e    t   n    I

   t   r   o   p   p   u   s   e   r   u   s   s   e   r    P

106

   )   e   P   v   A    i    P    t    i    C   s   (   o  e   p  r   s   u   u  s   o  s   r   u  e   p   n    i    t   y   n  a   o  w   r    C   i   a

  n   e   p   o    i    l   o   e   v    l   a   p   )   e   C   e    k   R    F   o   (    t   y    i   n   t   o  c    i    t   a   a   r   p   a    i   c   p   l   x   a   e   u   e   r   d    i   u  s   s   e   r   s   l   e   r   a   p  n   o   s   r   i    t   e   c   v   n    i    l    f   e   u    d  e   ;   v    h    t   r   a   e   s   e   r   e   r    b  p   r   o    t   a    l    i    t   n   e   v   o    N    )    P    E    E    P    (   e   r   u   s   s   e   r   p   y   r   o    t   a   r    i   p   x   e    d   n   e   e   v    i    t    i   s   o    P

  r   o    d    t   a   e    l    i    d   r    t   e   e   n    t   v    i   a    l   e   n   e   v    i    d    i   n   m   e    h   r    i   e   m    t    T   u   w    l    h    t   o    d   a   v   e   e   n   r    h    t    i   a    B   a    t    t   r   e   r   a   o    b    t   a    d   e   r    l    i    t    i   e   u   s   n    f    i   e   c   s    V   e   e   r   p   p    t   s   e   r   s   e    t    f   r   e    A    t    f    A

  e   m    i    t    f   o    d   o    i   r   e   p    t   e   s   r   e    t    f    A

   d    d   e   e    l    l   c   c   y   c   e   y    d   c   e   o   e   r    M   m   u   u   s   s    l   o   e   r    V    P

   d   e    l   c   y   c   e   m    i    T

107

   m    c     1    >

  e    l   u    d   o    N    d    i   o   r   y    h    T   y   r   a    t    i    l   o    S

   d    d    i   n   u   o   r   o   y  s    h  a   r    t    T    l   u

    d     i     l    o     S    m    c     1    <

   r    o     l    a    m    r    o     N

   H    S    T

   c     i    t    s    y     C

   t    n    a    n    g     i     l    a     M

  e  n    l    d   o   e   i    t   e  a   r   n    i   e  p   n  s    i    F  a

  e   g   a   n    i   a   r    D

   e     l    u     d    o    n     d     l    o     C

  e  n   v  a    i    t   c   c  s   a   d    i   o    i   o    d  r   a  y    h    R    t

 ALGOR

   e    v     i    s    u     l    c    n    o    c    n     I

   n    g     i    n    e     B

   e     l    u     d    o    n    t    o     H

  r   e   v  n   e   i    t   o    d    i   c   i    t   s  a  a    l   o   n    i    b   o    d    C  a  a   r

  y   r   e   g   r   u    S     l    a    m    r    o    n     b     A

  n  n   o   e   i   z   t   o   r   c   e    F  s     l    a    m    r    o     N

  s   s   r    h    t   a   n   e   o   y   m   2      1    6   n   y   r    i   e   n   v   o   e    i    t    d   a   r   n    i   p   u   s   o   a   s   a   r   e    l    t    l    d   u   e   e   d   n   i   o   e   r   y   n   h    i    f    t    t    t   a   a   e   e   p   p   e   e    R   R

 ALGOR

Scales Brain and Central Nervous System Glasgow Coma Scale (GCS) Measure

Motor

Verbal

6

5

4

3

2

1

Obeys Localizes Withdraws Flexion Extension None compain to pain to pain to pain mands Oriented Confused

Eye opening

Spontaneous

Inappropriate To command

Incomprehensible To pain

Coma score: 13 correlates with mild brain injury; 9–12 moderate injury; 8 severe injury

None

None

 †

 †

Tissue Plasminogen Activator for Acute Stroke

Yes

No

Evidence of intracranial hemorrhage (e.g., on CT scan)?



5

1

Suspicion of subarachnoid hemorrhage?



5

1

Recent intracranial surgery, serious head trauma, or recent prior stroke?



5

1

History of intracranial hemorrhage?



5

1

Uncontrolled hypertension (HTN) at treatment time (185 systolic or 110 diastolic)?



5

1

Seizure at stroke onset?



5

1

Active internal bleeding?



5

1

Intracranial neoplasm, arteriovenous malformation, or aneurysm?



5

1

Known bleeding diathesis?



5

1

108

109 Yes

Current oral anticoagulant use with PT over 15?



Use of heparin within last 48 hours and elevated PTT?



Platelet count





100,000?

Stroke symptom onset more than 3 hours ago? Severe neurologic deficit (e.g., NIHSS



22)?

Major early infarct signs on CT (⁄⁄edema, mass effect, or midline shift)? Total score: 15 thrombolysis indicated; thrombolysis contraindicated

No

5

1

5

1

5

1

5

1

0

1

0

1



13

Migraine Without Aura (Common Migraine) A. Attacks last 4–72 hr (untreated or unsuccessfully treated) B. 2 of following 4 headache characteristics: 1. Unilateral 2. Pulsating 3. Moderate to severe (disturbing or precluding daily activity) 4. ⁄ by movement C. 1 of following 3 associated symptoms: 1. Nausea/vomiting 2. Photophobia 3. Phonophobia

Migraine With Typical Aura (Classic Migraine) 1 transient focal neurologic aura symptoms: 1. Visual (99%) 2. Sensory (31%) 3. Aphasic (18%) 4. Motor (6%); occasional pts. may have atypical aura 

 ALGOR

 ALGOR

Gradual development of aura symptoms over 4 min or several symptoms occurring in succession (usu. alternating body sites in different attacks) Aura symptoms 4–60 min (motor symptoms may last longer) Headache usually follows or accompanies aura 60 min (up to 42% pts. may have attacks of aura without headache)

“Alarm Symptoms”  † Additional Tests (Including Imaging) 1. Aura symptoms always on same side of body 2. Aura symptoms with acute onset that does not spread 3. Aura symptoms duration 5 min or 60 min 4. Sudden Δ in migraine characteristics 5. Sudden and substantial ⁄ attack frequency (check for substance abuse) 6. Onset above age 50 yr 7. Aura without headache 8. Associated with high fever 9. Abnormal neurologic examination results

Canadian Head CT Rule for Minor Head Injury High risk

GCS 15 at 3 hr postinjury Possible open or depressed skull fracture Any sign of basal skull fracture 2 vomiting episodes after injury 65 y.o.

Intermediate risk

Amnesia  † events 30 min prior to injury Injury mechanism  dangerous activity/event

Consider head computed tomography (CT): 0 high risk, 1 intermediate risk Head CT Indicated : 1 high and 0 intermediate risk

110

111 Cardiovascular Left Ventricular Hypertrophy (LVH)

New York Heart Association (NYHA) Functional Classification for Congestive Heart Failure (CHF) Class

Description

I

No activity limit; no symptoms from ordinary activity

II

Slight, mild activity limit; comfortable with rest or mild exertion

III

Marked activity limit; comfortable only at rest

IV

Should be at complete rest, bed/chair confined; any phys activity brings discomfort; symptoms at rest

Duke Criteria for Infective Endocarditis (IE) A. Blood Culture (BCx) for IE: 1. Two separate BCx typical IE organism (S. viridansococci, S. bovis, HACEK* group, community-acquired S. aureus or enterococci, in absence of  first-degree focus ) or 2. IE organisms from persistent  BCx (2  BCx drawn 12 hr apart or all of 3 or majority of 4  separate BCx with first and last sample drawn 1 hr apart)   †

  a    i   r   e    t    i   r    C   r   o   n B. Evidence of endocardial involvement: 1. Echo for IE    i    M (oscillate intracardiac mass on valve or support structures, in

regurgitant jet path, or  on implanted material without alter-  nate explanation or  abscess  or  new partial dehiscence of  prosthetic valve) or 2. New valve regurgitation A. Predisposing heart condition or intravenous drug user (IVDU) B. Fever: Temperature 38.0°C (100.4°F) C. Vascular   a phenomena: Major artery emboli, septic pulmonary infarct,    i   r   e mycotic aneurysm, intracranial hemorrhage conjunctival    t    i   r hemorrhage, and Janeway’s lesion D. Immunologic phenom   C   r ena: glomerulonephritis, Osler’s nodes, Roth’s spots, and   o   n rheumatoid factor E. Micro: BCx but not meet major crite   i    M rion or no serologic e/o active infection with IE organism F. Echo consistent with IE but not meet major criterion

IE if: 2 major or 1 major

 ALGOR



3 minor or 5 minor

 ALGOR

Ear, Nose, and Throat Diagnosis of Ménière’s Disease Possible: 1. Episodic Ménière’s-type vertigo without documented hearing loss, or sensorineural hearing loss (fluctuate or fixed) with dysequilibrium but without definitive episodes 2. Other causes excluded Probable: 1. One definitive vertigo episode 2. Audiometrically documented hearing loss 1 occasion 3. Tinnitus or aural fullness in treated ear 4. Other causes excluded Definite: 1. 2 definitive spontaneous vertigo episodes 20 min 2. Audiometrically documented hearing loss 1 occasion 3. Tinnitus or aural fullness in treated ear 4. Other cases excluded Certain: Definite Ménière ‘s

histopathologic confirmation



Gastrointestinal Child-Pugh Score for Grading Hepatic Cirrhosis Parameter

1

2

3

Total bilirubin (mg/dL)



2

2–3



3

Serum albumin



3.5

2.8–3.5



2.8

PT (sec prolonged)

1–4

4–6



6

Hepatic encephalopathy grade

None

Grade 1 or 2

Grade 3 or 4

Ascites

None

Mild

Severe/tense

Total score: 5–6 Grade A good operative risk; 7–9 B moderate operative risk; 10–15 Grade C poor operative risk  †

 †

 †

 †

 †

112

 †

Grade

113 Ranson’s Criteria for Pancreatitis

On admission Age



WBC

Yes

No

1

0

1

0

1

0

1

0

1

0

1

0

1

0

8 mg%?

1

0

60 mm Hg?

1

0

4 mEq/L?

1

0

1

0

55?



16K/cubic mm?

Blood glucose Serum LDH



Serum SGOT

200 mg%?



350 IU/L? 

250 SF units?

Within 48 hr of admission Hct fall



BUN rise

10%? 5 mg/dL?



Serum calcium Arterial pO2



Base deficit





Fluid sequestration



6L?

Predicted mortality if total score: 5–6 40%; 6 100%  †

3

 †

1%; 3–4

 †

15%;

 †

Liver Disease and AST-to-ALT Ratio

EtOH

1.5

Intrahepatic cholestasis



Drug

2.0

Extrahepatic cholestasis

0.7–0.8

Cirrhosis

1.4–2.0

Acute viral hepatitis



0.65

Hepatocellular carcinoma



Acute MI



3.0

1.5

 ALGOR

1.5

 ALGOR

Genitourinary Bishop’s Score for Elective Induction of Labor Measure

0

2

3

Cervix dilated



1–2

3–4



Cervical length (effacement)



4 cm (0%)

2–4 cm (0%–50%)

1–2 cm (50%–75%)

1 cm (75%)

Cervical consistency

Firm

Average

Soft

Cervical position

Posterior

Middle or anterior

Zero station notation (presenting part level)

At ischial spines 3 cm

At ischial spines 1 cm

1

1

1

At ischial spines 1 cm

4



At ischial spines 2 cm

point for preeclampsia and each prior vaginal delivery

Subtract 1 point for postdates pregnancy, nulliparity, premature or prolonged rupture of membranes Cervical ripening with prostaglandins if score 5, membranes intact, and no regular contractions; Pitocin labor induction if score 5 and rupture of membranes

114

115 Ectopic Pregnancy Risk Questions

Yes

No

Peritoneal signs or definite cervical motion tenderness?

2

0

Pain or tenderness, other than midline cramping, plus no fetal heart tones and no tissue visible at the cervical os?

1

0

Total score: 1 low risk (1% risk of ectopic pregnancy); 1 intermediate (7%); 1 high (29%)

APGAR Score

Points

Measure

2

Total

1 

0

Nl

Irregular

Absent

Muscle tone/  movement

Active

Moderate

Limp

Skin color/  oxygenation

Pink

Bluish extremities

Totally blue

Reflex response to irritable stimuli

Crying

Whimpering

Silence

Heart rate



Breathing

Total

7

100

0

is normal, and 7

Analyte



100

distress

Urine

Amniotic Fluid

Bilirubin



May be present

Creatinine (mg/dL)

⁄(20)

~Plasma (0.8–4.0)

Osmolal (mOsm/kg H2O)

500–800

230–295

(continued )

 ALGOR

 ALGOR

APGAR Score Analyte

(Continued )

Urine

Amniotic Fluid

pH

Usually acidic

Neutral or alkaline (6.91–7.43)

Protein(mg/dL)



Specific gravity

1.005–1.030

1.025

Urea (mg/dL)

⁄(~500–1000)

~Plasma (12.1–41.7)

(1–14)



(70–840)

Biophysical Profile (BPP) Score Questions

Yes

No

Heart rate: Normal non-stress test

2

0

Breathing: 1 breathing episode in 30 min

2

0

2

0

2

0

2

0

Movement:

2 movements within 30 min



Muscle tone: 1 active limb extension and flexion episodes (i.e. open/close hand) Amniotic fluid:



1 adequate fluid pockets

Abnormal: if total score 8, amniotic fluid  0, or poor nonstress test  † consider delivery or repeat BPP

CDC Diagnostic Criteria for Pelvic Inflammatory Disease (PID) Minimum criteria (empiric treatment in sexually active females at risk for PID if all 3 present): Tenderness: 1. Lower abdominal 2. Uterine/adnexal 3. Cervical motion

116

117 Additional criteria: 1. temperature 38.3°C (101°F) 2. Abnormal cervical or vaginal mucopurulent discharge 3. WBCs on vaginal secretion saline microscopy 4. ⁄ESR 5. ⁄CRP 6. Laboratory evidence of cervical infection with N. gonorrhoeae or C. trachomatis  Definitive criteria: 1. Endometrial biopsy: Histopathologic e/o endometritis 2. Transvaginal U/S or MRI  † thick, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex 3. PID laparoscopic abnormalities

Amsel’s Diagnostic Criteria for Bacterial Vaginosis Homogeneous vaginal discharge (color and amount may vary) 2. Amine (fishy) odor when add KOH to vaginal secretions (“whiff test”) 3. Vaginal pH 4.5 4. clue cells (20%) on microscopy (⁄⁄⁄significant criterion) 1.

 ALGOR

EQUAT

Cerebral Spinal Fluid (CSF) Measure

Equation

Corrected CSF protein in traumatic LP



CSF proteinin mg/dL RBC/1000)

Corrected CSF WBCs for RBCs



CSF IgG Index



Ayala’s quotient (measures effect of removing CSF on pressure)

(volume of CSF removed in mL)  (pressure postremoval of fluid)/  (pressure preremoval of fluid) 5.0: ø(subarachnoid block or other cause of a small CSF reservoir) 5–5.4: borderline ø; 5.5–6.5: Normal; 6.6–7.0: borderline ⁄; 7.0: ⁄ (hydrocephalus, serous meningitis, or other cause of large CSF reservoir)



(CSF

CSF WBCs detected  (WBC in blood  RBC in CSF/RBC in blood)

[IgG (CSF)/IgG (serum)]/[albumin (CSF)/albumin (serum)] 

Toxicology Levels Measure

Equation

Half-life (T1/2)



0.693/kelim [0.693  (volume of distribution)/(clearance)] kelim  [ln (Cpeak) – ln (Ctrough)]/tinterval

Blood EtOH concentration



Adjusted phenytoin level

phenytoin measured/[(serum albumin  renal function)  0.1] renal fx  0.1 if creatinine clear 10 mL/min; otherwise  0.2

Phenytoin: free-drug level

(0.55  phenytoin measured/serum albumin)  0.14

(volume ingestedin mL  beverage “proof”  1.463)/(pt. weightin lb)





118

119 Cardiovacular Hemodynamics Measure

Equation/Interpetation

Stroke volume (SV)

End diastolic volume  end systolic volume Normal:  69–87 mL/beat

SV index (SI)

SV/BSA Normal: 40–50 mL/  contraction/m2

Ejection fraction (EF)



(SV

Cardiac output (CO)



SV

Blood volume



Plasma volume/(1-Hct) Normal: 2–5.1 L

O2 content in blood

(Hgbin g/dL)  (1.34mL O2/g Hgb) (O2 saturationin %)

O2 consumption



CO (Fick’s method)

(O2 consumption)/{[(O 2 content arterial bloodin vol%)  (O2 content mixed venous bloodin vol%))  10)]}

CO (indicatordilution ) method

(60  amount indicator injectedin mg)/  [(mean blood concentration of indicator)in mg/L)  (time total curve durationin seconds)]

Cardiac index



Heart rate (HR)

Normal: 60–100 bpm

Jose and Collison predicted intrinsic HR (IHR)

Males:  (0.55  agein years)  118 Females:  (0.61  agein years)  119

Rate pressure product



Mean arterial pressure (MAP)

~ 1/3 * SBP  2/3 * DBP 70–100 mm Hg

Cardiothoracic ratio







100%)/(end diastolic volume) Normal:  55%–78% 



HR

Normal:  3–7

L/min



BSA * basal O2 consumption 125 mL O2 /m2





BSA *





SV  HR/BSA Normal: 2.5–4.5 L/min/m2

(SBPin mm Hg* HRin BPM)/1000 Normal: 

(Transverse diameter of heart on PA or AP view)/(transverse diameter of bony thoracic cage) 50% cardiac enlargement  †

(continued )

EQUAT

EQUAT

Cardiovacular Hemodynamics (Continued ) Measure

Equation/Interpetation

(QT interval)/(Á (RR interval) Normal:  440 msec

QT interval correct (QTc)



RR interval



Systemic vascular resistance (SVR)



SVR index (SVRI)



Pulmonary vascular resistance (PVR)



PVR index (PVRI)



Shock index



60/HR

(MAP  (mean right atrial pressure))  (80/CO)  (MAP  CVP)  79.92/CO 5 Normal:  800–1200 dynes/sec/cm (MAP  CVP) 1970–2390



79.92/CI Normal:

80  (PA_Pressure  LA Pressure)/  pulmonary_flow  80  (mean PA  mean PCWP)/CO Normal:  ~67  /  23 dynes/sec/cm5 (Mean PA pressure  PCWP) 5 2 Normal:  30–240 dyn-s/cm m



80/CI

HRin bpm /SBPin mm Hg Persistent ⁄ † poor prognosis Normal: 0.5–0.7; 0.9  † admission or ICU (even with stable VS)

Coronary performance pressure



Colloid-oncotic pressure



Pulse pressure



Ratio of pulse pressure to systolic pressure



Central venous pressure (CVP) in cm H2O



DBP



PCWP

Normal:  60–80

(Globulin  1.4)  (Albumin Normal:  23–29 mm Hg

mm Hg



5.5)

(SBP)  (DBP) Normal:  20–70 mm Hg; SBP  100–140 mm Hg; DBP  60–90 mm Hg (SBP  DBP)/SBP  1  (DBP/SBP) Normal:  ~0.42; poor prognosis in CHF: 0.25 (vertical height of jugular venous distention above sternal anglein cm)  5 cm

120

121 CVP in mm Hg



(CVPin cm H2O)/1.36

Mean vascular pressure



DBP

Left cardiac work index



Left cardiac work index



Left ventricular stroke work index (LVSWI)



RVSWI





((SBP  DBP)/3)

CI  MAP  0.0144 3.4–4.2 kg-m/m2

Normal: 

CI  MPAP  0.0144 540–660 g-m/m2 SI  MAP  0.0144 50–62 g-m/m2

Normal: 

Normal: 

SI  MPAP  0.0144 7.9–9.7 g-m/m2

Normal: 

Cardiovascular Monitoring Condition

SAP CVP PAP PCWP CO C(a-v)O2 PVR SVR

Hypovolemic

ø

ø

ø

ø

ø

⁄

⁄

⁄

Cardiogenic

ø

⁄

⁄

⁄

ø

⁄

⁄

⁄

Septic

ø

ø

ø

ø

⁄

ø

ø

ø

Cardiac tamponade

ø

⁄

⁄

⁄

ø

⁄

0

⁄

RV infarct

ø

⁄

0

0

ø

⁄

0

0⁄

Pulmonary embolism

ø

⁄

⁄

0⁄

ø

⁄

⁄

⁄

Airway obstruction

0⁄

0⁄

⁄

0

0⁄

0

⁄

0

Pressure adjusted HR



Shock

HR



CVP/MAP

EQUAT

EQUAT   a   e   r    0  .    0  .    5  .    0   7    0  .    0  .    5  .    A   4   2   1  .  .    6   2   1   0  .   –   –   –   –   –   –    1    0    1   e    0   5   0  .    5  .    0  .       v  .  .  .          0    l    3    1    1    4    1    1   a    V

  s   e   v    l   a    V   t   r   a   e    H

   t    )   n    )   e   )    t    i   n    d  g   e   a    2   2    i    H    5   0    0   –    5    6   r    d    2   –   5   8    0   –   1    1    0   –    G   a    5          1   6      m       r    2   n   g   m   a    ( _   e   e   v    l    M   a   v    (   e    l    l    t   e    l    t   r   e   a   a   e   q   e   a   d  a   a   r   r   e   i    d   r   r   s   c   g   m    l    l   e   m    i   e    i   e    t   a   r   r   v   v    *    d  e   i    d    t   o   M   r   e   o   r   o   S   C    M  o   S    S    N    N   o    t    M    M   c  ,   a    l    f   a _    t   e    i    t   o   v   n   r    l   e   e    H   a   o  ,   g  e   v  ,    )   r    V    (    l   n    /    E   a   g    R    )    /   o    t    )   e    b    i    A   c    i    R   n    L  ,    d    (      H    H   e    t   s   d    F    i    A   g   n   V    t    *    i   n    l   n   e   L  ,      e   u  o   s   o   c    /    k    t   c   m  c   v    l   e       m   n  ,   e    i    )   a   s   o    t  ,   e   e   g   l    )  ,   v _   P   r   v   e  ,   s    l   m   i       Δ   a   b   w   (    t    l   c   u   a    i   o   r   m  a   n   h    t    b   r   c   r    t    fl   o   e   a   q   n    (   m    i    /    /   s    C   e   a   n    l   m  o   m   a   r    O   O   e    i   u  r    P    b   r    C   g    C   (   e   h    (    C    t   e   c   t   e   a   l    h  ,    A   E    i    d   r    t         f   d     :    t     :   a   M   a   n   e     s    l     s   m  e   A    L   u     e   m     e   r     :     s   u    :    b     s   o   n   i   e    i   x    l     u  e     G     u  y   v     G    t   r    k    k     a   h     C   f     a   e     C   e   o   a      C  r     E   l      C  m  s     E    G   H

  e   v   a    l   a   e   r    V   a

  s   m    i   e   c   s    l    i   o   )    b    t   r   n   S   o   e   r   o   t    (    P    A  s   A

122

  s    i    l   s   o   )   a   r   n    t    i   e   S    t    M  s   M    (

123 Hematology Measures

Equations

Absolute neutrophil count (ANC)



10  WBCin 1000s  (%PMNs  %bands) Neutropenia: 1500 cells/mm3

Transferrin saturation (TFS)



Fe replacement (parenteral dosing) for Fe deficiency

Dose  .3  wgt  (100  (Hgb  100) /age_factor) Adult 15 kg (14.8); child 15 kg

(Fe/TIBC)



100

RBC Equations (for other indices see Tab 7) Index

Formula

Estimated Hct



(Hgbin g/dL* 2.8)

Hgb at altitude



Hct at altitude



Hct-to-Hgb ratio

Hct% as a whole number /Hgbin g/dL  † 3.19: normal; 3.5: hemoconcentration

Absolute reticulocyte count



Reticulocyte index (2%: adequate response; 2%: øproliferation)

Absolute reticulocyte count/maturation factor Maturation factors:  Hct  35%: 1.0; 35%  Hct  25%: 1.5; 25%  Hct  20%: 2.0; 20%  Hct: 2.5



0.8



RBC * MCV/10

(6.83 * (e0.000445 * altitude in meters) 113.3



(0.449 * (EXP (0.000859 * (altitude in meters))))  35.6 

% reticulocytes * (pt.’s Hct/normal Hct)



EQUAT

EQUAT

Distinguishing Between Fe-Deficiency and Thalassemia Minor Formula

Equation

Mentzer

MCVin femtoliters /  RBCs per µL/10^6

EnglandFraser

((MCVin femtoliters)  ((5 * (HgBin g/dL))  (RBC per µL/10^6)  k)) Where k  3.4 if Hct corrected for plasma trapping (usual) or 8.4 if not.

M/H ratio

M  % microcytes (erythrocyte volume 60 fl) H  % hypochromic (MCHC 28 g/dL)

RDW & HDW product



RDW

MCH/RBC ratio



RDW/RBC ratio Green and King



øøFe

Thal. Minor

13

13

0



(negative)

0.9

0.9

530

530

MCH/RBC

4.4

4.4



RDW/RBC

3.3

3.3



(MCV2  RDW)/(Hgb 100)

72

72



HDW

Ventilation Equations Measures

Equations

Minute ventilation



VT

Ventilation index



[RR

CO2 production (VCO2)





RR



(PIP  PEEP)



CO2]/1000

VExp  (FECO2  FICO2) VExp  expired volume over 1 min. FECO2 & FICO2  fraction expired and inspired CO2

124

125 Right-to-left shunt fraction (Qs/Qt)



([pAO2 paO2]  0.003)/  [([pAO2 paO2]  0.003)  5] Where: pAO2  FIO2  (pAtm  pH2O)  (paCO2 /R)  [paCO2  FIO2  (1  R)/R] pAtm  760 mm Hg  e(-altitude in meters/7000) pH2O 47 mm Hg  e([Temperature in Celsius-37]/18.4)

Closing capacity







Closing volume



residual volume

Lung Volumes (see lung volume diagram following) Measure

Equations

FRC



ERV  RV  TLC  IC TLC – VC  ERV

IC



TLC



IRV



RV



TV or VT



Physiologic dead space (VD)



VD /VT



IRV  TV RV – FRC





TLC – FRC

VC  RV  IC  FRC RV IRV  FRC  TV

TLC  IRV  TV





VC – ERV

IRV  TV





VC





ERV 

IC – TV  TLC – FRC  TV VC – ERV – TV  RV  VC – FRC  TV FRC – ERV  TLC – VC IRV  TV  FRC  VC



IC



FRC – VC



IC – IRV  TLC – FRC – IRV  VC – ERV  IRV RV  VC – IRV – FRC  alveolar space  dead space Dead space volume/VT  ((PaCO2)  (PCO2 of expiratory gas sample))/(PaCO2) Dead space fraction of TV (continued )

EQUAT

EQUAT

Lung Volumes (see lung volume diagram following) (Continued ) Measure

Equations

VD /VT



Dead space fraction of TV

Forced VC (FVC)

Volume air expelled forcefully after full breath Normal: 4.0 L

FEV1

Volume air expelled in 1 sec during forced expiration Normal: 3.0 L FEV1 /FVC  60%

FEF25–75



Forced expiratory flow from 25%–75% FVC maximum flow when air forcefully expelled mid-expiration



Predicted Pulmonary Function Tests (PFTs) for Men Measure

Equation

FEV1 FVC



FEV1 /FVC



Constant



Race  1.08  [(0.043  (0.029  age)  2.49]



height)

Race  1.1  [(0.0576  (.0269  age)  4.34]



height)

87.2  (0.18



Race: Caucasian  1 Black  0.87 Asian  0.93

age)

Predicted PFTs for Women Measure

Equation

Constant

FEV1



Race  1.08  [(0.0395  (.025 * age)  2.6]



FVC



Race  1.15  [(0.0443  (.026  age)  2.89]



FEV1 /FVC



89.1(0.19



age)

126

height)

Race: Caucasian  1 height) Black  0.87 Asian  0.93

127 Predicted PFTs for Children Measure

Males

Females

FEV1



e{[(1.2669  (.0174 * Age)] height)  1.2933





FVC

e{[(1.3731  (.0164 * Age)] height)  1.2782)





FEV1 /FVC





86.21

e{[(1.5016  (.0119 * Age)] height)  1.5974)

e{[(1.48  (.0127 * Age)] height)  1.4057)







88.88

Lung Volumes Maximum inspiration Normal resting inspiration

IC

IRV IVC

VT

VC TLC

Normal resting expiration

ERV FRC

RV

No air in lungs

VC = Vital capacity IVC =Inspiratory vital capacity ERV = Expiratory reserve volume IRV = Inspiratory reserve volume FRC = Functional residual capacity

EQUAT

Maximum expiration

VT= Tidal volume IC = Inspiratory capacity RV = Residual volume TLC = Total lung capacity

EQUAT

Additional Pulmonary Formulae Measure

Equation/Interpretation

A-a gradient



PAO2  PaO2 ~age  0.4

Normal:  5–25

mm Hg

Alveolar O2 tension (PAO2)

[(FIO2)  (PB  PH2O)]  (PACO2 /R) [FIO2  (760  47)]  (PACO2 /0.8) Normal:  95–105 mm Hg; respiratory quotient (R)  0.7–1

Arterial O2 tension (PaO2)

~100  (0.33  age) Normal:  80–100 mm Hg

Inspired O2 tension (PIO2)



Arterial O2 content (CaO2)



Mixed venous O2 content (CvO2)



A-V O2 content differential (Ca-vO2)



Barometric pressure (PB)

29.92  (((1)  (6.87535 10-6))5.2561) Normal:  0–760 mm Hg

Capillary O2 content (mL/dL)

((Hgb  1.36)  (ScapO2)) (PaO2  0.0031) Normal:  21 mL/dL

Oxygenation index (OI)





(FIO2)



(PB  PH2O) Normal:  100–150 mm Hg (Hgb



SaO2  1.36) Normal:  17–20 mL/dL 

((Hgb

1.36  SvO2) Normal:  12–15 mL/dL 





(0.003



(0.003



PaO2)

PvO2)

CaO2  CvO2 Normal:  4–5 mL/dL







alt





FIO2  mean airway pressure/PaO2 0–25: good outcome; 25–40: death chance 40%; 30–1000: 4 hr ⁄risk of worsening/death; 40–1000: consider ECMO

128

129 Peak expiratory flow (PEF) prediction

Females:  (((height * 3.72)  2.24)  (age * .03)) * 60 Males:  (((height * 5.48)  1.58)  (age * .041)) * 60

Peak expiratory flow variability in asthma

100 * (highest_PEF  lowest_PEF)/  highest_PEF 15 asthma: (20–30: mild persistence; 31–100: moderate to severe persistence

Ventilation index





(PaCO2)in mm Hg  (RR)  (peak inspiratory pressurein cm H2O)/1000 ⁄ † the poorer the ventilation achieved

Arterial O2 saturation (SaO2)  96%–99%; mixed venous O2 tension (PvO2)  35–45 mm Hg; mixed venous O2 saturation (SaO2)  60%–80%; FIO2  0.21 for room air; H2O partial pressure (PH2O)  47 mm Hg; arterial CO2 tension (PaCO2)  35–45 mm Hg; alveolar CO2 tension (PACO2)  35–45 mm Hg; mixed venous CO2 tension (Pv CO2)  40–50 mm Hg; expired CO2 tension (PECO2)  25–35 mm Hg

Gastrointestinal Equations Measure

Equation

Stool osmolar  (2  Na  K) 100  † osmotic diarrhea, 100  † secretory

Stool osmolal gap



Fractional excretion of amylase



100  (urine amylase  plasma creatinine)/  (plasma amylase  urine creatinine) 5% suggest acute pancreatitis; 1% may mean macroamylasemia (continued )

EQUAT

EQUAT

Gastrointestinal Equations (Continued  ) Measure

Equation

Serum-toascites albumin gradient (SAAG)



Serum albumin in g/dL  ascites albuminin g/dL 1.1 g/dL portal HTN

Modified model for end-stage liver disease (MELD) score

10* (0.957  LN (serum creatinine))  (0.378  LN (serum bilirubin))  (1.12  LN (INR))  (0.643  cirrhosis cause) Cirrhosis cause  0 if cause cholestatic or EtOH  1 for all others

Pediatric end-stage liver disease (PELD) score (18 yr)



Maddrey’s discriminant function for EtOH hepatitis

4.6  (pt.’s PT  control PT)  total bilirubin 32 poor prognosis and may benefit from glucocorticoid treatment

Hepatitis C fibrosis prediction score

7.81  (3.131  ln (platelet))  (0.781  In (GGT))  (3.467  ln (age))  (.014  cholesterol) Score  6.91–30: fibrosis more likely; -20–4.19: fibrosis less likely

TIPS survival predictor



Lipase-toamylase ratio

(Serum lipase/lipase upper limit normal)/  (serum amylase/amylase upper limit normal) 3 suggests EtOH pancreatitis



10 * ((0.480 * in (bilirubin))  (1.857 * in (INR))  (0.687 * in (albumin))  infant  growth Growth  2/3 for growth failure and  0 otherwise; infant  0 for 2 yr  0.436 for 1 yr or 2 yr and on transplant list prior to first birthday 

 †



(0.957  ln (creatinine))  (0.378  in (bilirubin))  (1.12  ln (INR))  (0.643 cause) Survival  power (days, EtOH (risk score  1.127)) 

130



131 Diabetes Formulae Measurement

Equation

Hgb A1C Estimation



(MPG

Mean plasma glucose (MPG)



(35.6 * HbA1C)  77.3



77.3)/35.6

Creatinine Clearance Normal: Males: 90–130 mL/min; females: 80–125 mL/min

Calculated



(Urine creatininein mg/dL)  (urine volumein mL)/(creatininein mg/dL * timemin)

Per standard surface area

Calculated creatinine clearance * (1.73/BSAin m2)

Estimated (Cockcroft & Gault)

Males  (140  agein years)  (body weightin kg)/(72  serum creatininein mg/dL) mL/min Females  0.85  (estimated creatinine clearance for males)

Estimated (Mawer)

Males  (LBWin kg  (29.3  (0.203  agein years)))  (1  (0.03  serum creatininein mg/dL))/(14.4  serum creatininein mg/dL) Females  (LBWin kg  (25.3  (0.174  agein yr)  (1 –(0.03  serum creatininein mg/dL))/(14.4  serum creatininein mg/dL)

Pediatric GFR





δ

Htcm /PCr δ  0.33 (_birth wt δ infants), 0.45 (term infants 1 yr), 0.55 (males 2–12 yr & females 13–21 yr), 0.70 (males 13–21 yr) 

EQUAT

EQUAT

Serum Sodium and Water Homeostasis Total body water (TBW)



Free H2O deficit



Free H2O excess



ΔTBW



(Infusate osmolality-urine osmalality)  1

Total body solute



TBW

Fluid distribution

Intracellular  TBW  (2/3) Normal: 12–60 L Extracellular  TBW  (1/3) Normal: 3–30 L Interstitial  TBW  0.222 Normal: 4–20 L

Na excess/deficit





0.6  IBW ( 0.85 if female & Normal: 18–90 L



0.85 if elderly)

TBW  ((serum Na /desired serum Na)  1)  wtin kg (TBW  0.6 if male & 0.5 if female) TBW  (1  (serum Na /desired serum Na))  wtin kg (TBW  0.6 if male & 0.5 if female) 

Osm Normal: 5000–25000 mOsm

TBW  normal Wtin kg * (pt.’s Na  desired Na) (TBW  0.6 if male & 0.5 if female)

ΔNa

 /L infusate



Osmolal gap



Calculated osmolality



(Infusate Na  serum Na)/(TBW



1)

Measured osmolality  calculated osmolality Normal: 10 mOsm/kg H2O (2 * Na)  (Glucose/18)  BUN/2.8)  (EtOH/4.6). Normal serum osmolality  285–295 mOsm/kg

+

Correcting Na When ⁄Glucose (100–440)



Measured Na  0.016*(glucose  100)

⁄Glucose (440)



Measured Na  0.04

⁄Protein



⁄Lipids





(glucose  100)

Measured Na  (serum _ protein  8)  0.25 Measured Na  plasma _ lipids  0.002

132

133 Correcting Ca2+ When (Measured Ca2in mg/dL)  (0.8  (4  albuminin g/dL)) ~(current total serum Ca2 in mg/dL)  4  (albuminin g/dL)

øAlbumin



⁄Globulin



⁄pH



(Measured Ca2in mg/dL)  (0.16 globulin  globulinin g/dL)) (Measured Ca2in mg/dL)



(0.12



(normal



(pH  7.41))



(7.41  pH)]

Correcting K+ When øpH



⁄Serum Osm



⁄Platelets



[(Measured KmEq/L)

(Measured KmEq/L) osmolality  290)/10)

 

[0.6 (0.6

(Measured KmEq/L)  [0.15 normal platelets)/100  109]





(serum (platelets



Serum Sodium and Water Homeostasis Filtration fraction



Glomerular filtration rate/renal plasma flow Normal: 17%–23%

Osmolar clearance (OsmCl)

(urine_osmolality/serum_osmolality)  (urine_per_day/24). Normal: 60–180 mL/h

Free H2O clearance

Urine volume/osmolar clearance Normal: 25–100 mL/h

Urea clearance



Transtubular K gradient

((Urine Kin mEq/L)/(plasma Kin mEq/L))/  ((urine Osmin mOsm/kg H2O)/(plasma Osmin mOsm/kg H2O)) Very ø: K-sparing diuretics, aldosterone blockers, H2O diuresis, øK, instrinsic renal disease, DKA, hyperglycemic hyperosmolar syndrome





(UUN  urine volume)/BUN. Normal: 64–99 mL/min 

(continued )

EQUAT

EQUAT

Serum Sodium and Water Homeostasis (Continued  ) [(Urine Kin mEq/L)/(plasma Kin mEq/L)]/  [(urine creatininein mg/dL)/(plasma creatininein mg/dL)] 10%: renal cause of ⁄K; 10%: extrarenal cause of ⁄K

Fractional excretion of K



Acid/Base Disorder Compensation Type of Disorder

Acidosis øPaCO2  1.25  ΔHCO3 (PaCO2  last 2 digits of pH)

⁄ PaCO2  0.75 ΔHCO3

Acute

⁄HCO3  0.1

 ΔPaCO2

øHCO3 0.2 ΔPaCO2



Chronic

⁄HCO3  0.4

 ΔPaCO2

øHCO3 0.4 ΔPaCO2



Metabolic

Respiratory

Measure

12  †



Equation 

(Na)  (Cl  HCO3) Normal:  8–16 mEq/L



(Na  K)  (Cl  HCO3) Normal:  10–20 mEq/L

Anion gap (AG)

AG

Alkalosis

RTA, diarrhea, CaCl2, other acids

AG 15  † MUDP MUDPALES: ALES: Methanol, Uremia, DKA, Paraldehyde, Alcohol, Lactic Acid, Ethylene glycol, Salicyclates Corrected anion gap



(Observed AG)  (0.25  [(normal serum albumin)in g/L  (observed serum albumin)in g/L)]  (A (AG Gobserved)  (0.25  (4 (44 4 (albuminobserved)]

Delta gap



Delta/delta

 Δ AG/ ΔHCO3

AG  normal AG

134



AG–12

Normal:  1.0–2.0

135 Acid deficit Bicarbonate deficit Chloride deficit HendersonHasselbach (pH) Winter’s formula for meta-acid compensation Urine anion gap (UAG)

Acid-base equation (H) H /K exchange index

Weightin kg  0.5  (measured HCO3  desired HCO3)   0.4  weightin kg  (24  HCO3 )    0.5  weightin kg  (desired Cl  measured Cl )   6.1  log (HCO3 concentration/(0.03 * PaCO2)) (Expected pCO2)  1.5  HCO3  8  /  2 

Urine Na  urine K  urine Cl Normal: -10 to 10; extrarenal non-AG metabolic acidosis: 10 renal non-AG metabolic acidosis: 10  (24  PaCO2)/HCO3 



K  (0.6

Measure



((pH initial  pH final) 0.1)

Prerenal Renal

Fractional excretion of Na (FENa) 1%   100  (urine Na in mEq/L)/(plasma Nain mEq/L)/(urine creatininein mg/L)/  (plasma creatininein mg/L) Renal failure index (RFI)  1% (urine Nain mEq/L)/(urine creatininein mg/dL)/  (plasma creatininein mg/dL) BUN/serum creatinine 20 UUN/BUN ratio 8 Urine Osm/plasma Osm 1.3 Urine creatinine/serum creatinine 40 Urine Osm 500 Urine specific gravity 1.018 Urine sediment Hyaline casts

EQUAT

1%

1%

10–15 3 1.1 20 250 1.012

Muddy brown granular casts

EQUAT

Urology Calculations Measure

Equation

Total motile functional sperm

(Volumein mL)  (sperm density)  (% motile)  (% normal morphology) Normal:  40,000,000/mL

Testicular volume



0.71

PSA density



PSAin ng/mL /prostate volumein cc from

in ng/mL/cc

transrectal ultrasound





length2in cm2  widthin cm

Absolute PSAin ng/mL /weight of prostatectomy specimenin g after removal 

of seminal vesicles

øPSA density  † benign diagnosis; ⁄ in PSA density  † further investigation

PSA velocity

(PSA at time 2 in ng/mL PSA at time 1in ng/mL)/(period between time 1 & time 2)in yr 

0.75

ng/mL/year when 3 tests performed  † further w/u

Pregnancy Calculations Measure

Equation

Nagele’s rule for due date

Estimated day of confinemen confinementt  (1st day of LMP)  (3 mo)  7 d

Fundal height (MacDonald’s rule)



Menstrual age (weeks)



Weeks gestation  /  2 cm At 20 wk fundal height should  20 cm  /  2 cm; rule holds 20–36 wk; if ø then suggests oligohydramnios 

(Crown  Rump Length)in cm 6.5

136

137 Weight, Energy, and Fluid Calculations Measurement

Equation

Ideal body weight (IBW)



Sex  sq (height); if male sex, female sex,  21.5

23;

Normal range for body weight

Low normal  20  sq (height) High normal  27  sq (height)

Body mass index (BMI)



Body surface area (BSA)



Basal energy expenditure (BEE)

Male: 66.5  (13.75  wtin kg)  (5.003  htin cm)  (age  6.775) Female: 655.1  (9.563  wtin kg) (1.850  htin cm)  (age  4.676)

Total daily energy requirement (TDER)

Female: [655.1  (9.563  wt) (1.85  hgt)  (4.676  age)]  activity  injury Male:  (66.5  (13.75  wt)  (5.003  hgt)  (6.775  age))  activity  injury Activity   1.2 confined to bed; 1.3 out of bed; injury  1.05 minor surgery; 1.15 major surgery; 1.1 mild infection; 1.3 moderate infection; 1.6 severe infection; 1.275 skeletal trauma; 1.6 head injury with steroid therapy; 1.25 blunt trauma; 1.25 20% burn; 1.85 20%–40% burn; 1.95 40% burn



Weightin kg / Height Height in m2 Underweight: 18.5; ideal: 18.5–25; overweight: 25–30; obese: 30–40; morbidly obese: 40 0.20247  heightin in.0.725  weightin lb0.425



(continued )

EQUAT

EQUAT

Weight, Energy, and Fluid Calculations (Continued  ) Measurement

Equation

Fluid requirements for burn victims



TBSA burned (%)  wt (kg)  4 mL Give half of total requirements in first 8 hr, then second half over next 16 hr

NPO fluid deficit

Required IV fluids hour npo

Daily maintenance fluid requirements

“4-2-1” rule: for 0–10 kg: 4 mL/kg/hr; for 10–20 kg:  2 mL/kg/hr; for 20 kg:  1 mL/kg/hr

Daily maintenance fluid requirements for children

For 0–10 kg  100 mL/kg; for 10–20 kg  1000 mL  50 mL/kg for each kg 10; for 20 kg  1500 mL  25 mL/kg for each kg 20



2 mL/kg for each

Operating Room Fluid Requirements Tissue Trauma

Examples

Fluid Required

Minimal

Laparoscopic cholecystectomy, eye surgery

1–2 mL/kg/hr

Low

Ear, nose, throat surgery, arthroscopy

3–4 mL/kg/hr

Moderate

Total joint replacements

5–6 mL/kg/hr

Severe

Total hip replacement, bowel resection

7–8 mL/kg/hr

Emergency

Significant trauma

10–15 mL/kg/hr

138

139 Fluid Loss (% body weight) Sign

5%

10%

15%

Mucous membranes

Dry

Very dry

Parched

Normal

Lethargic

Obtunded

Orthostatic Δs in pulse or BP

Mild

Present

Marked

Urinary flow rate

Mild ø

ø

øøø

Normal/⁄  

⁄

⁄⁄⁄

Normal

Mild ø

ø

Sensorium

Pulse rate Blood pressure

Injury Fluid Resuscitation Estimate

Formulae

Brooke

LR  1.5  wt  % burn/24 Colloid  0.5  wt  % burn/24 D5W  2000/24

Demling’s dextran

Dextran 40 in saline  2  wt FFP  0.5  wt Run D40 8 hr; titrate additional LR to maintain UO 30 ML/hr

Evans’ estimate

NS  wt  % Burn/24 Colloid  wt  % burn/24 D5W  2000/24

Modified Brooke’s crystalloid

LR  2



wt



% burn/24

Parkland’s crystalloid

LR  4



wt



% burn/24

Slater’s estimate

LR  2000/24 FFP  75  WT /36

EQUAT

MEDS

Angioedema ■ ■ ■ ■ ■

Epinephrine, diphenhydramine, methylprednisolone Acute/recurrent Rx-resistant:  prednisone Chronic/recurrent: hydroxyzine, cetirizine, fexofenadine, doxepin, desloratadine, loratadine Hereditary angioedema: FFP transfusion, C1 esterase inhibitor Prevention: danazol: 50–600 mg PO qd

Asthma Asthma Severity Mild Mild and Treatment Intermittent Persistent

2  /wk

Symptoms



Night Sx



Exacerbations

FEV1 or PEF Short-acting bronchodilators

2  /mo Brief

80%



prn

2 /wk and 1  /d

Daily





2  /mo



May øphysical activity



80%



1



2



Continua

/wk

Frequent

/wk

Frequent

60%–80%

60%



prn

Long-acting bronchodilators Low-dose inhaled steroids

Moderate Severe Persistent Persistent









Medium-dose inhaled steroids High-dose inhaled steroids



Oral steroids Cromolyn/ nedocromil

1 or

140

141 Leukotriene modifier

2 or

1* or

Theophylline

3

2*

Omalizumab

1

*Along with low-to-medium dose inhaled steroids

Chronic Obstructive Pulmonary Disease (COPD)    )

       2

COPD Stage

FEV1/ FEV1 (% FVC Predicted) Symptoms

  s   r   o    t   a    l    i    d   o    h   c   n   o   r    B

  n   o    i    t   a    t    i    l    i    b   a    h   e    R

  s   n   r   o   o   i    t    f   a   s   b    d    i   r   o  e   r   c   e   a    t   x    S   E    d  g   e   i   n    l   a   r    h  r   n  u   c    I   e    R

0

At risk

Nl

Nl

I

Mild

70%

80%

 / 

prn

50

 / 





 / 













IIA Moderate

70%

IIB III

   O   c    i   n   o   r    h   c  ,  .   g  .   e    (   x    R    l   a   n   o    i    t    i    d    d    A

Chronic  risk factor exposure

80% 30% 50%

Severe

70%

30%

Respiratory or R heart failure (with any spirometry)

MEDS



MEDS

Indications for Chronic O2 Therapy ■ ■ ■

PaO2 55 mm Hg or Sa O2 88% (at rest on room air) if optimal medical regimen 30 d PaO2  55–59 mm Hg or Sa O2 89% (at rest on room air) if cor pulmonale or Hct 55% Consider if PaO2 55 mm Hg or Sa O2 88% during exercise or sleep

Community-Acquired Pneumonia 1. Outpatient: No Cardiopulmonary Disease ■ ■

S. pneumoniae, Mycoplasma, C. pneumoniae, H. influenzae, viruses, Legionella, TB, endemic fungi Advanced generation macrolide (azithromycin or clarithromycin) or doxycycline

2. Outpatient ■ ■



Cardiopulmonary Disease*

Same as 1.†  mixed infection ( atypical), gram-negatives, Moraxella, aspiration (anaerobes) [-lactam (PO/IV)  (macrolide or doxycycline)] or antipneumococcal fluoroquinolone

3. Hospitalized ■ ■

Same as 1.†  mixed infection, viruses, PCP IV azithromycin or [Doxycycline  -lactam] or IV antipneumococcal fluoroquinolone

*Or other modifying factors †Including drug-resistant S. pneumoniae 

142

143 4. Hospitalized (Non-ICU)  Cardiopulmonary Disease* ■ ■

Same as 3.†  enteric gram-negatives, aspiration [IV -lactam  (macrolide or doxycycline)] or IV antipneumococcal fluoroquinolone

5. ICU Admission ■ ■ ■

Same as 4.†  S. aureus  IV -lactam  [IV macrolide or IV fluoroquinolone] Risks for P. aeruginosa:  IV antipseudomonal -lactam  either [IV antipseudomonal fluoroquinolone (ciprofloxacin)] or [IV aminoglycoside  (IV macrolide or fluoroquinolone]

Congestive Heart Failure (CHF) Systolic Dysfunction   s   s   a    l    C    A Sx    H    Y    N

  r   e    k   n  c    i   s   o   n   l   e   B    t   o  r   o    i    t   g  p   n  e    A  c   r   e   o   R

   †   r   e    k   c   o    l    b   -

       

  c   n    i    t    i   x   e   r   o   u    i   g    i    D    D

  e   n  e   o  n    t   c   o   a   n    l   e   o  r   e   n   l   o   p   r    i    E   p  r    S  o

  e   r    l   o    b   t   a   a   l    t    l   n   i   r   a    l    b   p   fi   e   m    I    D

I

No





II

Yes











*

IIIa Yes











*

IIIb Yes













*

IV









Yes

*If EF 35%

†Avoid in decompensated CHF

MEDS

Additional Later Line Rx: ■ Hydralazine ■ Nitrates ■ Dobutamine ■ Dopamine ■ Revascularization ■ Transplant

MEDS

Diastolic Dysfunction First-line

Mechanism

Use Only as Alternative

-blocker

Maximum diastolic filling, øcardiac work

Dihydropyrimidine CCBs (e.g., amlodipine) Nondihydropyrimidine CCBs (avoid in LV dysfunction)

Angiotensinconverting enzyme inhibitor or ARB

⁄Myocardial relaxation and compliance, øpre- and afterload

Vasodilators (nitrates, hydralazine): øpreload and angina

Diuretics

øSx

Spironolactone (? efficacy)

Congestive Heart Failure or Shock Inotropes ■

■

■ ■ ■

Dopamine (2–5 mcg/kg/min):  Vasopressor effects ⁄with dose, ⁄AV conduction, arrhythmias, ⁄psychosis, skin necrosis (if extravasation); (0.5–2.0 mcg/kg/min  † renal, cerebral, mesenteric vasodilation) Epinephrine (shock: 2 mcg/min, then titrate; cardiac arrest:  1 mg IV q3–5 min):   Agonist; bronchodilator (2agonist); -effects ⁄ with dose, ⁄myocardial O2 consumption; tachyarrhythmias; splanchnic vasoconstrictor; diabetogenic; øK Dobutamine (2.5–20 mcg/kg/min):   Agonist peripheral vasodilator, ⁄ventricular arrhythmias Contraindications: hypertrophic cardiomyopathy Digoxin (125–1000 mcg/day):  Toxicity, øK

144

145 ■

■

■ ■

Milrinone (Load: 50 mcg/kg over 10 min; dose: 0.37–75  mcg/kg/min): Vasodilator (systemic, pulmonary, coronary); øBP, ⁄HR; aggravates atrial, ventricular arrhythmias, headache Amrinone (load: 0.75 mg/kg over 3 min; dose: 5–20 mcg/kg/min [max 10 mg/kg/d]):  Inotrope and vasodilator for CHF); øøBP, thrombocytopenia, ⁄AV and ventricular conduction Isoproterenol (initial: 1–4 mcg/min  † titrate to HR max:  20 mcg/min):  Nonspecific -agonist; øBP; ⁄HR, myocardial infarction (MI) contraindications: myocardial ischemia, tachycardia, digitalisinduced bradycardia

Vasopressors ■ ■

■

■ ■

Dopamine (6–20 mcg/kg/min):  Inotrope at lower doses Norepinephrine (initial: 2 mcg/min; dose: 2–20 mg/min;  titrate to response Max: 40 mg/min):  Moderate inotrope; 1 / -agonist (low-dose: ) (high-dose: ); may dampen peripheral A-lines; Rx extravasation with phentolamine Phenylephrine bolus: 0.1–0.5 mcg IV q15min; initial: 100  mcg/min; titrate to 40–200 mcg/min:  Postsynaptic -agonist; reflex bradycardia; coronary, cerebral, and pulmonary vasoconstriction; ødose if MAO inhibitors Epinephrine (200–600 mcg/kg/min):  Typically used only for inotropic effects Vasopressin (0.04–0.1 units/min):  Antidiuretic; procoagulant; coronary vasoconstriction (may need to combine with nitroglycerin); SIADH/H2O intoxication

Deep Vein Thrombosis (DVT) ■

Heparin or low molecular weight heparin and warfarin: Discontinue heparin when INR 2–3 (target)

MEDS

MEDS

Duration of Anticoagulation Type of DVT Isolated calf vein

At Least 

symptoms

6–12 wk

Low risk (first episode or reversible cause)

3 mo

First episode idiopathic

6 mo

Recurrent

12 mo

Hypercoagulable (may need lifetime)

12  mo

DVT Prophylaxis Highest Risk ■ ■

Major surgery in pt. 40 y.o.  prior venous thromboembolism, malignant disease, or hypercoagulable Elective major lower extremity orthopedic surgery, hip fracture, CVA, multiple trauma, or spinal cord injury

LMWH, Warfarin (Target INR 2–3), or IV Heparin HIGH RISK  ■ ■ ■

Major surgery in pt. 60 y.o. with no additional risk factors or in pt. 40–60 y.o.  additional risk factors MI Medical patients with risk factors

LMWH, Unfractionated Heparin 5000 U q8h, or Compression Devices (CDs) MODERATE  ■ ■ ■

Any surgery in pt. 40–60 y.o. and no additional risk factors Major surgery in pt. 40 y.o. with no additional risk factors; general anesthesia 30 min Minor surgery in pt. with risk factors

LMWH, Unfractionated Heparin 5000 U q12h, or CDs LOW RISK  ■

Uncomplicated minor surgery in pt. 40 y.o. with no clinical risk factors; general anesthesia 30 min

146

147 Early Mobilization PREGNANCY  ■

Indications: Mechanical heart valve, rheumatic heart disease, atrial fibrillation, antithrombin III deficiency, antiphospholipid syndrome, prior anticoagulation treatment, factor V Leiden defect, prothrombin G20210A mutation

Unfractionated Heparin or LMWH

Diabetes

Insulin Preparations Onset

Peak

Duration

Onset

Humalog

15–30 min

30 min–2.5 hr

3–5 hr

Novolog

10–20 min

1–3 hr

3–5 hr

30 min–1 hr

2–5 hr

5–8 hr

NPH (N)

1–2 hr

4–12 hr

18–24 hr

Lente (L)

1–21 ⁄ 2 hr

3–10 hr

18–24 hr

30 min–3 hr

10–20 hr

20–36 hr

Lantus

1–1.5 hr

None (steady level)

20–24 hr

Humulin 70/30

30 min

2–4 hr

14–24 hr

Novolin 70/30

30 min

2–12 hr



Novolog 70/30

10–20 min

1–4 hr



Humulin 50/50

30 min

2–5 hr

18–24 hr

Humalog 75/25

15 min

30 min–2.5 hr

16–20 hr

Regular (R)

Ultralente (U)

MEDS

24 hr 24 hr

MEDS

Oral Diabetes Medications Second-Generation Sulfonylurea ( Insulin Secretion) ■ ■

Glipizide (Glucotrol), glyburide (DiaBeta, Micronase, Glynase PresTab), glimepiride (Amaryl) Side effects: Skin rash/pruritus, take 30 min to 1 hr before meals; take glimepiride with day’s first meal

Biguanide (⁄insulin sensitivity, øhepatic glucose production, øglucose GI absorption)* ■ ■ ■

Metformin (Glucophage) Unlike others, does not ⁄weight and may even øweight Side effects: Metallic taste, øserum B12; temporarily stop before hospitalization, surgery, or contrast dye; contraindications: liver and renal disease

Thiazolidinedione (insulin sensitivity)* ■ ■ ■

Rosiglitazone (Avandia), pioglitozone (Actos) Take food, follow liver function tests Side effects: Edema

-Glucosidase

Inhibitor (block starch

digestion)* ■ ■ ■

Acarbose (Precose), miglitol (Glyset) Take with first bite of meal Side effects: GI

Meglitinide ( insulin secretion) ■ ■

Repaglinide (Prandin), nateglinide (Starlix)† Take before meals; do not take if skip meal

Combination Agents ■ ■

Thiazolidinedione and biguanide:  rosiglitazone  metformin (Avandamet) Sulfonylurea and biguanide:  metformin  glyburide (Glucovance);  Glipizide (Metaglip) All may cause GI effects *NO hypoglycemia if only medication †~to meglitinide

148

149 Endocarditis Indications for Prophylaxis Patient Risk ■

■

■

High:  History of subacute bacterial endocarditis, prosthetic heart valve, complex congenital heart disease (e.g., transposition great vessel, tetralogy of Fallot), surgical systemic pulmonary shunts or conduits Moderate:  Most other congenital heart disease, acquired valvular disease, idiopathic hypertrophic subaortic stenosis, mitral valve prolapse (MVP  insufficiency and/or leaflet thickening Low:  Isolated secundum atrial septal defect (ASD), ASD/VSD/PDA 6 mo post-repair if no residual history of coronary artery bypass graft, pacemaker, automatic internal cardiac defibrillator, MVP, Kawasaki’s disease, or rheumatic fever (no valvular dysfunction)

Procedures (Prophylaxis if Moderate or High Risk) ■ ■ ■ ■

Dental:  Bleeding anticipated Respiratory:  Tonsillectomy and adenoidectomy, rigid bronchoscopy, mucosal surgery GU:  Prostate, cystoscopy, urethral dilation GI:  Esophageal varices sclerotherapy/dilation, endoscopic retrograde cholangiopancreatography, mucosal/biliary tract surgery

Endocarditis Prophylaxis Regimens Above Diaphragm ■

Amoxicillin: 2 g PO* or IM/IV†

Penicillin-Allergic ■ ■

Clindamycin: 600 mg PO* Cephalexin or cefadroxil: 2 g PO* Prior to procedure: *1 hr †30 min

MEDS

MEDS

■ ■

Azithromycin or clarithromycin: 500 mg PO* Clindamycin: 600 mg IV† or Cefazolin: 1 g IM/IV†

Below Diaphragm Moderate Risk ■ ■

Amoxicillin: 2 g PO PO* or ampicillin: 2 g IM/IV‡ Penicillin-Allergic: Vancomycin: 1 g IV over 1–2 hr‡

High Risk ■ ■

Ampicillin 2 g IM/ IV IV AND gentamicin 1.5 mg/kg IV (120 mg) ‡ THEN ampicillin 1 g IM/IV or amoxicillin 1 g PO 6 hr later Penicillin-Allergic:  Vancomycin 1 g IV over 1–2 hr AND gentamicin 1.5 mg/kg IV/IM ( 120 mg)‡

Endocarditis Treatment Native Valve ■

■ ■ ■ ■ ■ ■ ■ ■ ■

Presumptive treatment, no history of intravenous drug abuse  (IVDA): penicillin G OR ampicillin and [nafcillin or oxacillin] and gentamicin Presumptive treatment, IVDA:  vancomycin S. viridans or  or bovis: bovis: [penicillin G  gentamicin] OR, ceftriaxone OR [ampicillin and gentamicin] Aminoglycoside resistance:  penicillin G or ampicillin Enterococci, PCN-resistant:  amoxicillin/sulbactam and gentamicin Enterococci  intrinsic penicillin G or ampicillin resistance:  vancomycin and gentamicin S. aureus: [nafcillin or oxacillin] and gentamicin MRSA: Vancomycin Slow-growing gram-negative bacilli:  ceftriaxone Bartonella: gentamicin and doxycycline

Prosthetic Valve ■ ■ ■ ■

Empiric: vancomycin, gentamicin, and rifampin Candida/Aspergillus: amphotericin B  fluconazole C. burnetii: doxycycline and hydroxychloroquine S. epidermidis: vancomycin, rifampin, and gentamicin ‡complete within 30 min of starting procedure

150

151 ■ ■

S. aureus: naf nafcil cillin lin,, rif rifamp ampin in,, and gentamicin MRSA:  vancomycin, rifampin, and gentamicin

Headaches

Cluster Strictly unilateral, severe, duration: 15–90 min, associated autonomic symptoms males more than females Abortive Treatment :  acetaminophen, ■ First-line : 

■

NSAIDs, aspirin Other:  indomethacin, intranasdeal (lidocaine, dihydroergotamine, or capsaicin)

Preventive ■ First-line:  PO ■ ■

corticosteroids, verapamil Others:  Anticonvulsants (valproic acid, topiramate, gabapentin), indomethacin Verapamil, lithium (for chronic cluster)

Tension Bilateral, mild/moderate pressing/tightening, duration: 30 min–7 d, no associated Sx, females more than males Abortive Treatment

sumatriptan,, ■ First-line:  sumatriptan ■

O2 inhalation Other:  Trigger-point injections

Preventive ■

Trichloroacetic acid (TCA) (e.g., amitriptyline), SSRIs

Migraine Unilateral, moderate/severe throbbing, duration: 4–72 hr, associated Sx, females more than males

MEDS

MEDS

Abortive Treatment ■

■

■ ■

Aura or mild-to-moderate early (  2 hr): First-line analgesics (ASA  acetaminophen  caffeine, ASA  metoclopramide); other NSAIDs: anaprox DS, indomethacin, acetaminophen, COX2 inhibitor, ultram Moderate ( 4 hr) refractory: Antiemetics (first-line:  Reglan, prochlorperazine; others: Dramamine, Atarax, Phenergan)  abortive medications  (triptans, indomethacin PR, or isometheptene) (Severe (Seve re refractor refractory(2–6 y(2–6 hr): hr): Antie Antiemetic metics  s   serotonin agonist  (dihydroergotamine, triptans) Severe refractory(6–72 hr)  ■ Antiemetics (IV/IM):  prochlorperazine, metoclopramide, droperidol, diphenhydramine (for dyskinesia) ■ Serotonin agonist:  dihydroergotamine (DHE), triptans ■ Anticonvulsant: valproic acid ■ Antipsychotics with analgesic and antiemetic properties  (IV): chlorpromazine, haloperidol ■ Analgesics/anti-inflamm Analgesics/anti-inflammatories atories (IV/IM): toradol, dexamethasone, hydrocortisone, methylprednisolone

Preventive ■

-blockers: propranolol *†, timolol†, metoprolol

■

Ca 2  channel blockers (?efficacy): verapamil NSAIDs: Aspi Aspirin, rin, nap naproxe roxen n sodium, indometh indomethacin acin Antidepressants: amitriptyline†, doxepin, phenelzine, SSRIs (fluoxetine) Anticonvulsants: valproic acid and derivatives †, topiramate †, phenytoin Serotonin agonist: cyproheptadine , methysergide Vitamin Vit amin supplemen supplementatio tation: n: Petas Petasites ites hybridus  hybridus (butterbur): petadolex, feverfew, vitamin B2, magnesium oxide, coenzyme Q10

■ ■ ■ ■ ■

*First-line unless contraindicated †Preferred agents

152

153 Helicobacter pylori ■ ■ ■

Clarithromycin 500 mg, amoxicillin 1 g, and proton pump inhibitor (PPI) PO bid  7 d (rabeprazole) to 10 d (other PPI) Clarithromycin 500 mg, metronidazole 500 mg, and PPI PO bid  7 d (rabeprazole) to 10 d (other PPIs) Prevpac kit: clarithromycin 500 mg, lansoprazole 30 mg, and amoxicillin 2 capsules 500 mg PO bid  10 d

H. pylori Treatment Failure or Alternative ■ ■

Bismuth subsalicylate 525 mg PO qid, metronidazole 250 mg PO qid, tetracycline 500 mg PO qid, and PPI PO bid  14 d Helidac kit: 1 dose (metronidazole: 1 tab; tetracycline: 1 capsule, and bismuth subsalicylate: 2 tabs) PO qid and PPI or H2-blocker PO bid  14 d

Hyperlipidemia Statin or HMG-CoA Reductase Inhibitor ■ ■ ■

■ ■

Atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin øLDL 20%–50%, ⁄HDL 5%–15% øTG 10%–25% Adverse effects: GI upset, hepatitis, myopathy, myopathy, lupus-like syndrome, rash, peripheral neuropathy, neuropathy, ⁄bleeding risk with Coumadin Contraindications:  Liver disease, myopathy Avoid:  Grapefruit and alcohol

Niacin: Nicotinic Acid ■ ■ ■

øLDL 10%–15%, ⁄HDL 15%–30%, øTG 40% Adverse effects: Flushing, pruritus, GI upset, blurred vision, hepatitis, gout, glucose intolerance, fatigue Contraindications:  Liver disease, diabetes type II, severe gout, hyperuricemia

MEDS

MEDS

Ezetimibe: Cholesterol Absorption Inhibitor ■ ■ ■

øLDL 20%, ⁄HDL 5% Adverse effects: Minimal to date Contraindications:  None to date

Fibric Acid Derivative ■ ■ ■

■

Gemfibrozil, clofibrate, fenofibrate ø⁄ LDL 5%–15%, ⁄HDL 15–30%, øTG 30% Adverse effects: GI disease, cholecystitis, appendicitis, myopathy risk with statin, may ⁄ effects of Coumadin or oral hypoglycemic agents Contraindications:  Hepatic or renal disease, preexisting gallstones

Bile-Binding Resin ■ ■ ■ ■

Cholestyramine, colestipol, colesevelam øLDL: 15%–30%, ⁄HDL 3%–5%, ⁄TG ?% Adverse effects: GI effects (constipation, flatulence, dyspepsia) Contraindications:  TG 500 mg/dL

LDL

TG

HDL

First Line

Second Line

Third Line

High



150

Any

Statin

Ezetimibe

Resin

High

150–400

Any

Statin

Niacin

Ezetimibe

Any



400

Any

Fibrates or niacin

Statin

Fish Oil

Normal

Normal

Low

None

None

None

Hypertension Monotherapy ■

Diuretics (e.g., hydrochlorothiazide), -blocker, ACE inhibitor (ACEi), ARB

154

155 Agents for Specific Conditions Key: Preferred: Y, 1, 2, *, **

Alternative: A Caution: ? 

Avoid: N

Diabetes Renal disease Dyslipidemia BPH COPD/asthma Osteoporosis Gout Obesity Peptic ulcer Edema CAD/MI Angina Atrial tachycardia and fibrillation Perioperative PVD Essential tremor Migraine Major depression Substance abuse Systolic dysfunction Diastolic dysfunction LVH

   B    R    A    /    i    E    C    A

1 Y

  s   r   e    k   c   o    l    B          

N

  s    t   s    i   n   o   g   a    t   n    A   -

   B    C    C

    

A

  s   c    i    t   e   r   u    i    D   e    d    i   z   a    i    h    T

  e   n   o    t   c   a    l   o   n   o   r    i   p    S

  s   e    t   a   r    t    i    N

  e   v    i    t   s   c   t   s    i    A    l   n   a   o   r    t   g   n   A   e    C

2 Y

Y Y

N

N Y N Y N N Y

Y Y Y

* **

Y ? 

Y

Y

Y Y N † ?

** Y Y Y Y

Y

*Angina, not nifedipine **Nondihydropyridine CCBs †Labetalol (combined --blockers)

MEDS

Y ? Y

MEDS

Hypertensive Emergencies ■ ■ ■ ■ ■ ■

Quiet room, reduce pain, treat underlying cause Screen target organ damage (e.g., renal, CV, CNS) Rapidly øBP may øperfusion  † ischemia and infarction Lower MAP 20%–25% in first hour of treatment; if stable, lower BP to 160/100–110 in next 2–6 hr IV agents: nitroprusside*, nitroglycerin†, esmolol, labetolol, hydralazine, phentolamine, fenoldopam, nicardipine‡, enalapril Oral agents: captopril, labetalol, clonidine, hydralazine

Indications to Rapidly øBP Problem Eclampsia

Medications (usually IV) Hydralazine, labetalol, or Mg 2

Pheochromocytoma

Phentolamine, labetalol

Acute renal failure

Fenoldopam, nicardipine, -blockers

Aortic dissection

Goal: SBP 100–110 mm Hg: Labetalol; alternative: nitroprusside  -blocker (e.g., esmolol)

Acute MI

Nitroglycerin, -blockers

CHF

Nitroglycerin, lasix, nitroprusside



pulmonary edema

Hypertensive encephalopathy

Nitroprusside, labetalol, fenoldopam

Monoamine oxidase (MAO)and tyramine

Phentolamine

*Beware cyanide accumulation †Contraindications : ⁄ICP; narrow-angle glaucoma; pericardial tamponade ‡Short half life; øclearance with hepatic or renal insufficiency; may ⁄portal hypertension; may  † reflex tachycardia; alters cyclosporine levels; contraindications:  critical aortic stenosis (AS)

156

157 CVA: øøøSBP  † øcerebral perfusion; SBP 185 or DBP 110 mm Hg; contraindications to tPA use

If SBP 220 mm Hg or DBP 120–140 mm Hg, cautiously ø BP by ~10%–15%: IV nitroprusside or IV labetalol

Intracranial hemorrhage

Careful with IV nitroprusside or labetalol when SBP 200 or DBP 110 mm Hg

Pelvic Inflammatory Disease Parenteral (change to oral 24 hr clinical improvement) ■ ■ ■

[Cefotetan 2 g IV q12hr or cefoxitin 2 g IV q6hr]  doxycycline 100 mg PO/IV q12hr Clindamycin 900 mg IV q8hr  gentamicin load 2 mg/kg IV/IM, then 1.5 mg/kg q8hr Ampicillin/sulbactam 3 g IV q6hr  doxycycline 100 mg PO/IV q12hr

Oral ■

■

[Ceftriaxone 250 mg IM  1 or cefoxitin 2 g IM and probenecid 1 g PO  1 or other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime)]  doxycycline 100 mg PO bid  14 d  metronidazole 500 mg PO bid  14 d Fluoroquinolones (e.g., levofloxacin 500 mg PO qd or ofloxacin 400 mg bid  14 d)  metronidazole 500 mg PO bid  14 d

Peritonitis, Intestinal Perforation, or Necrotic Bowel ■

Ampicillin, gentamicin, and metronidazole

MEDS

MEDS

Pregnancy and Childbirth Problems Mild Chronic Hypertension ■ ■ ■

Mild chronic: methyldopa Moderate gestational:  labetalol Severe acute: labetalol, hydralazine, sodium nitroprusside (beware cyanide accumulation, so limit to few hours), nicardipine

Prevent and Treat Seizures in Preeclampsia or Eclampsia ■

Magnesium sulfate IV

øComplications in Severe Preeclampsia (at ■

34

wk)

Betamethasone IM or dexamethasone

Nausea/Vomiting/Hyperemesis Gravidum ■ ■

■ ■

■ ■

Phosphorated carbohydrates (Emetrol) Antiemetics: metoclopramide (Reglan), not recommended  due to lack of safety data:  ondansetron (Zofran), droperidol (Inapsine) Phenothiazines/antipsychotics: promethazine (Phenergan), prochlorperazine (Compazine), chlorpromazine (Thorazine) Antihistamines: doxylamine succinate (Unisom), doxylamine  pyridoxine (Bendectin), meclizine (Antivert), chlorpheniramine (Chlor-Trimeton), diphenhydramine (Benadryl), trimethobenzamide (Tigan) Others: pyridoxine (B6), multivitamin (MV 1–12), Metamucil, thiamine Corticosteroids for refractory hyperemesis

Premature Labor Tocolytic Agents ■

Magnesium sulfate: Contraindications: myasthenia gravis, ørenal function, recent MI

158

159 ■ ■

■

Terbutaline: Contraindications: antepartum hemorrhage, CV disease, ⁄thyroid, uncontrolled diabetes Ritodrine: Absolute contraindications: uncontrolled DM, maternal cardiac disease, pregnancy-induced HTN, ⁄thyroid, hypovolemia, multiple gestation; relative contraindications:  chronic HTN, DM, migraine, resting tachycardia Nifedipine: PO not effective; contraindications: CHF, AS, concomitant MgSO4 use

Delayed Labor Labor Induction ■

■ ■ ■ ■ ■ ■

Common indications: Pregnancy-induced HTN, premature rupture of membranes, chorioamnionitis, suspected fetal jeopardy (e.g., severe fetal growth restriction, isoimmunization), maternal medical problems (e.g., diabetes mellitus, renal disease), fetal demise, post-term pregnancy Contraindications: Placenta previa or vasa previa, transverse fetal lie, prolapsed umbilical cord, prior classical uterine incision Membrane sweep  Artificial rupture of membranes  Cervically applied prostaglandins: e.g., dinoprostone (Cervidil) or misoprostol IV synthetic oxytocin preparations: e.g., Pitocin Other holistic, CAM, or “natural” methods 

Seizures

Partial (limited on one brain hemisphere) ■

■ ■

Simple: Usually no consciousness change; focal motor, sensory, autonomic, and/or psychology symptoms (may spread) Prophylaxis:  First stage: phenytoin, carbamazepine, valproic  acid adjunctive: phenobarbital, primidone, zonisamide  Complex: Usually øconsciousness; often aura precedes; begin with motionless stare or activity arrest then  † complicated

MEDS

MEDS

■

motor/sensory actions, automatisms (repeated idiosyncratic motions) Prophylaxis:  carbamazepine, phenytoin, temporal lobe  resection (for failed medical treatment after 1–2 yr) 

Generalized (both hemispheres) Absence (petit mal): Often many/day, no aura, unresponsiveness (blank stare), rhythmic activities (eye and head movements) autonomic symptoms (incontinence, øpostural control), postictal clothes picking and lip pursing, pt. often unaware seizure occurred ■ Typical:  10 sec; nonconvulsive and normal tone ■ Atypical: Longer duration;   /  ømuscle tone, often tonic/clonic-like movements ■ Prophylaxis: ethosuximide, valproic acid, clonazepam ■ Tonic-clonic (grand mal): Usually lasts 1 min, associated with øCO2, ⁄blood glucose, ⁄prolactin. 1. Often aura (hours to days pre-attack) 2. Tonic phase: Muscular rigidity, loss of consciousness 3. Clonic phase: Alternating muscular contractions/no movements (muscle atonia) 4. Flaccid coma: loss of consciousness, apnea, øpostural tone, øDTRs, cyanosis 5. Postictal: Confusion, disorientation, weak, headache, muscle pain ■ Prophylaxis:  phenytoin, carbamazepine, phenobarbital, primidone, valproic acid, surgery  ■ Tonic: Tonic phase, no clonic phase ■ Clonic: Just clonic phase, no tonic phase ■ Atonic (“drop attacks”): 1–2 sec; sudden, limp posture  loss of consciousness ■ Myoclonic seizures: No loss of consciousness, rapid muscle contractions  facial and pelvic jerks ■ Status epilepticus: Seizure 30 min; recurring seizures with no consciousness return between seizure events; suspect if seizure lasts 5–10 min Management:  Check ABCs, consider intubation if necessary, administer O 2, telemetry, D 50 W 50 mL IV (adult dosing), thiamine  IV/IM, first: lorazepam IV; then if refractory: fosphenytoin IV  ■

160

161 If persistent at 30 min: Intubate/ventilate, Foley catheter, EEG, follow temperature closely, phenobarbital IV  If persistent at 60 min: pentobarbital IV, midazolam IV, or  propofol IV (titrate per EEG), blood pressure support if necessary 

Sexually Transmitted Infections Chancroid ■ ■

Azithromycin PO or ceftriaxone IM  1 Ciprofloxacin PO  3 d or erythromycin PO



7d

Chlamydia ■ ■ ■ ■

Azithromycin* PO 1 g  1 or doxycycline 100 mg bid Amoxicillin* 500 mg PO tid  10 d Ofloxacin 300 mg PO bid  7 d Erythromycin* 500 mg PO qid  7 d



7d

Gonorrhea (N. gonorrhoeae)  ■ ■ ■ ■ ■ ■ ■

Ceftriaxone: 125 or 250 mg IM  1 (250 if pregnant)  Cefotaxime: 500 mg IM  1 Cefixime: 400 mg PO  1 (and erythromycin base  500 mg PO  qid  7 d, if pregnant)  Ciprofloxacin: 500 mg PO, ofloxacin 400 mg PO, or levofloxacin: 250 mg PO  1 Spectinomycin: 2 g IM  1 Amoxicillin PO 3 g and probenecid 1 g  1 (if pregnant)  Azithromycin: 2 g PO  1 (if pregnant) 

Granuloma Inguinale ■

Tetracycline, doxycycline, sulfamethoxazole, gentamicin, streptomycin, ciprofloxacin, erythromycin  3 wk

*Infection in pregnancy 

MEDS

MEDS

Herpes Simplex Virus (HSV) First-Episode Genital HSV ■

■ ■ ■ ■ ■ ■ ■

Acyclovir: PO  7–10 d or IV  2–7 d or until clinical improvement  † change to PO for 10 d total treatment; valacyclovir PO  7–10 d or famciclovir PO  7–10 d Episodic treatment:  acyclovir: PO  2 d or 5 d; famciclovir: (PO  1 d or 5 d) or valacyclovir: PO  3 d or 5 d (HIV:  5–10 d) Suppressive:  acyclovir, famciclovir, or valacyclovir PO (⁄dose for HIV) Encephalitis:  acyclovir IV  14–21 d Orolabial:  acyclovir  7–10 d or valacyclovir  2 Recurrent orolabial:  penciclovir: topical  4 d Herpetic whitlow:  acyclovir  10 d Keratoconjunctivitis:  trifluridine: eye drops until ulcer epithelialized  †  7 more days

Human Papillomavirus ■

■ ■

Topical treatment:  imiquimod cream, 20% podophyllin

antimitotic solution, 0.5% podofilox solution, 5% 5-fluorouracil cream, trichloroacetic acid (TCA) Procedures: Freezing (cryosurgery), burning (electrocautery), laser treatment Prevention: vaccine (Gardasil): For 9 y.o. and 26 y.o.: IM 3 separate does: second dose 2 mo and third dose 6 mo

Lymphogranuloma Venereum (Rx ■ ■



21 d)

Doxycycline 100 mg PO bid Erythromycin base or sulfisoxazole 500 mg PO qid

Treat Asymptomatic Sexual Contacts ■ ■

Doxycycline 100 mg PO bid Azithromycin 1 g PO  1



7 d or

Nongonococcal Urethritis/Cervicitis ■

First line:  azithromycin 1 g  7 d



1 or doxycycline 100 mg PO bid

162

163 ■

Persistent/recurrent:  PO [metronidazole or tinidazole 2 g

and [erythromycin 500 mg qid



1] 7 d or azithromycin 1 g  1] 

Pediculosis Pubis ■

Permethrin, lindane, pyrethrins with piperonyl butoxide, malathion

Scabies ■

Permethrin: 5% cream, lindane: 1% lotion, crotamiton: 10% cream, ivermectin: PO

Syphilis ■

■ ■

Early (first stage, second stage, early latent): Penicillin G benzathine: 2.4 mU IM  1; alternative: doxycycline: 100 mg PO bid  14 d Late (late latent, third stage): Penicillin G 2.4 mU IM qwk  3 wk or doxycycline: 100 mg PO bid  28 d Neurosyphilis: Aqueous crystalline penicillin G 3–4 mU IV q4h  10–14 d; alternative: procaine penicillin G 2.4 mU IM qd  probenecid 500 mg qid  10–14 d; ceftriaxone 2 mg qd IV/IM  10–14 d

Systemic Lupus Erythematosus Need 4 of 11 Criteria to Diagnose 1. Malar rash 2. Discoid rash 3. Photosensitivity 4. Oral ulcers 5. Arthritis 6. Serositis 7. Renal disorder 8. Neurologic disorder (e.g., seizures, psychosis) 9. Hematologic disorder (hemolytic anemia, leukopenia, lymphopenia, or thrombocytopenia) 10. Antinuclear antibody 11. Immunologic disorder (anti-ds-DNA, antiSm, antiphospholipid antibody such as anticardiolipin, VDRL) ■ Salicylates and NSAIDs ■ Hydroxychloroquine: Mild disease  serositis, arthritis  skin problems

MEDS

MEDS

■ ■ ■ ■ ■ ■

Corticosteroids: Topical, intralesional, systemic Azathioprine: Mild nephritis Methotrexate: Skin and joint disease, serositis Cyclophosphamide: Severe nephritis, vasculitis or CNS disease Cyclosporine: Renal disease Mycophenolate: Renal disease

Vaginal Disorders Atrophic Vaginitis ■

Vaginal creams or tablets: dienestrol, estradiol, conjugated estrogens

Bacterial Vaginosis ■ ■

Metronidazole: 500 mg PO bid or 250 mg PO tid   7 d  or 5 g 0.75% gel intravaginal qd for 5 d Clindamycin: 5 g 2% cream intravaginal qhs  7 d or 300 mg  PO bid   7 d  or 100 mg ovules intravaginally qhs  3 d

Vaginal Trichomoniasis ■ ■

Metronidazole: 2 g PO   1 or 500 mg PO bid Tinidazole: 2 g PO  1



7d

Vulvovaginal Candidiasis Uncomplicated ■ ■

Vaginal applications:  butoconazole, clotrimazole, miconazole, terconazole, tioconazole , nystatin Fluconazole: 150 mg PO  1

164

165 Head Computed Tomography (CT) Indications Craniofacial trauma, acute neurologic dysfunction (72 hr), intracranial masses, sinus disease, temporal bone disease

Patient Preparation Keep pt. hydrated; sedate if agitated; when IV contrast: check serum creatinine and history of allergic reaction

Procedure Description Pt. supine on CT table; slice thickness varies but usually between 5–10 mm; IV contrast not routine, but may be used to evaluate for tumors, cerebral infections, and sometimes cerebrovascular accident

Normal Study Water  0 Hounsfield units (HU); sense bone 1000 HU; blood  50–100 HU



1000 HU; air

Abnormal Studies Skull Fractures ■ ■ ■

Classified: Linear (more common) vs. depressed (inward displacement of fracture fragments) Most clinically significant: Involve paranasal sinus or skull base Distinguish sagittal, coronal, or lambdoidal sutures (undulating, sclerotic margins) and venous channels (sclerotic margins and undulating sides)

Subarachnoid Hemorrhage (SAH) ■ ■ ■

Superficial small arteries/veins injury bleeds into space between pia and arachnoid matter Causes: Trauma, cerebral aneurysm rupture Focal high density in sulci and fissures or linear hyperdensity in cerebral sulci RADIOL

RADIOL

Subdural Hematoma (SDH) ■ ■ ■ ■ ■ ■

■

Acceleration/deceleration and rotational forces  † tear bridging veins Crescent-shaped; does not cross dural reflections Density ø with ⁄ subdural age Hyperacute ( 6 hr):  Either hypodense or hyperdense Acute (6 hr–3 d):  Usually hyperdense (clotted blood) Subacute:  Generally isodense with brain (hemorrhage reabsorbed); suspect if shift of midline structures, but no obvious mass; IV contrast may ⁄ interface between hematoma and adjacent brain; compressed lateral ventricle; effaced sulci; white matter “buckling”; thick cortical “mantle” Chronic: Typically hypodense  septae; rebleeding  † mixed density and fluid levels

Epidural Hematoma ■ ■ ■

Usually associated with skull fracture (esp. calvarium) Hyperdense biconvex mass; usually uniformly high density  hypodense foci (active bleeding) Unlike SDH can cross dural reflections but not cross suture lines (dura tightly adheres to skull)

Diffuse Axonal Injury (“shear injury”) ■ ■ ■ ■

Acceleration/deceleration and rotational forces  † tear axons CT may be normal despite ⁄⁄⁄neurologic deficits Ill-defined high density or hemorrhage areas Locations (from most to least likely): Subcortical white matter, posterior limb internal capsule, corpus callosum, dorsolateral midbrain

Cerebral Contusions ■ ■

From brain impact on osseous ridge or dural fold Ill-defined hypodense area  hemorrhage foci; adjacent SAH common; after 24–48 hr: common changes  † round hematoma

Strokes (Ischemia) ■ ■ ■ ■

Acute ischemia: May be completely normal head CT Gray-white interface loss or blurring (basal ganglia, thalamus or internal capsule) Localized mass effect (from progressing edema): Sulci effacement or asymmetry of lateral ventricles Hyperdense middle cerebral artery from thrombus

166

167 Neurodegenerative Diseases ■ ■ ■

Parkinson’s disease: Nonspecific atrophy with enlarged lateral ventricles and widened sulci Huntington’s disease: Caudate atrophy  † bilateral øconvexity of caudate heads or ⁄ relative lateral ventricle volume Pick’s disease: Atrophy temporal/frontal lobes

Masses ■

■

Tumors: Usually hypodense; poorly defined without IV contrast  calcification, hemorrhage (hyperdense), and edema (hypodense); IV contrast  † contrast-enhancing ring around tumor Abscess: Ill-defined, hypodense without IV contrast; variable edema; often ring-enhanced with IV contrast Pitfalls

■ ■

Metal foreign bodies can cause scatter artifact and obscure small areas of hemorrhage or ischemia Motion  † difficult to visualize acute ischemic changes and isodense structures

Cervical Spine Indications

Neurologic deficits compared with cord lesion, differentiate MS from head injury or intoxication, neck pain/tenderness, or significant distracting injuries; can use 1 of 2 clinical criteria to rule out cervical spine injury (i.e., no cervical spine imaging necessary): 1. Canadian C-Spine Rules  ■ Alert (GCS 15) and not intoxicated ■ No distracting injury (e.g., long bone fracture, large laceration) ■ Not high risk (High risk means age 65 y.o. or dangerous mechanism or paresthesias in extremities)  low risk factor allowing safe ROM assessment (e.g., simple rear

RADIOL

RADIOL

end motor vehicle accident (MVA), seated position in ED, ambulation any time post-trauma, delayed neck pain onset, no midline cervical spine tenderness) ■ Can actively rotate neck 45° left and right 2. National Emergency X-Radiography Utilization Group Criteria:  ■ No posterior midline cervical spine tenderness ■ No evidence of intoxication; no focal neurologic deficit ■ Nl level alertness; no painful distracting injury

Patient Preparation None

Procedure Description Standard five-view trauma series: Cross-table lateral, swimmer’s, oblique, odontoid, and anteroposterior

Normal Study Measurable Parameters of Normal Cervical Spines Parameter

Adults

Children

Predental space



3 mm



C2–C3 pseudosubluxation



3 mm



Retropharyngeal space



Spinal column angulation at any interspace level



Cord dimension

10–13 mm

6 mm at C2 22 mm at C6 11°

4–5 mm 4–5 mm

1

 ⁄ 2–2/3 vertebral body AP distance 11°



Adult size

6 y.o.



From Graber MA, Kathol M. Cervical spine radiographs in the trauma patient. Am Fam Physician 1999 Jan 15;59(2):331–42

168

169 Check A(lignment), B(ones), C(artilage,) D(isk Space), S(oft Tissue) Cross-table lateral: Must see all 7 vertebral bodies and cervicothoracic junction; each of 4 imaginary contour lines must form smooth lordotic curve: 1. anterior vertebral:  vertebral anterior margins; 2. posterior vertebral:  vertebral posterior margins; 3. sinolaminar: sinal canal posterior margin; 4. posterior spinous:  sinous process tips Abnormal Studies Unstable Fractures and Dislocations ■

■

■

■ ■

■

■

Atlanto-occipital dislocation: Junction between atlas and skull; usually anterior dislocation  † prevertebral hematoma  † instant death Facet dislocation: Unilateral with disk widening or subluxation or bilateral; three types (subluxed facets, perched facets, locked facets); extreme flexion Flexion teardrop fracture:  ⁄⁄ Unstable; disrupt all ligaments  intervertebral disk; anteroinferior vertebral body  † posterior displacement into spinal canal; mechanism: severe flexion Jefferson fracture: Atlas fracture at multiple points; axial load (e.g., head-first dive, heavy object fall on top of head) Odontoid fracture: Involve C2;  fractures C1 anterior; pain and inability to move neck; instability sensation (like head wobbling on neck); mechanism: flexion  extension  rotation Hangman’s fracture (traumatic spondylolisthesis of C2):  Bilateral C2 pedicle fracture with anterior displacement C2 on C3; mechanism: neck hyperextension MVA rapid decelerate Cervical burst fracture: Entire vertebral body collapses; fracture fragments  † spinal canal  † neurologic changes; mechanism: axial loading (falling from height)

Stable Fractures and Dislocations ■

Clay-shoveler’s fracture: Bone avulsion off spinous process; mechanism: aggressive neck flexion

RADIOL

RADIOL

■

■

Compression wedge fractures: Anterior vertebral body compression; no posterior ligamentous disruption, so no neurologic injury; mechanism: hyperflexion Extension teardrop fracture: Anterior longitudinal ligament pulls anteroinferior vertebral body corner away from rest of vertebra; commonly at C2; mechanism: forced extension

Pitfalls ■

Relative contraindication: pregnancy

Chest X-Ray Indications Evaluate pulmonary disease, pleural disease, cardiac disease, mediastinal disease, pulmonary edema; initial screen for aortic rupture

Patient Preparation None

Procedure Description Usual (inspiratory PA and lateral); portable (AP); expiratory upright film (suspected pneumothorax); decubitus (free-flowing fluid)

Normal Study

170

171 Trachea Aortic arch Superior vena cava

Pulmonary artery Left ventricle Gastric air bubble

Right ventricle Diaphragm

Abnormal Studies

Lung Cancer ■

■

■

■ ■

Adenocarcinoma (most common): Typically peripheral nodule, can be associated with fibrosis or bullous disease; can be Pancoast’s, clubbing, hypertrophic pulmonary osteoarthropathy, Trousseau’s syndrome of hypercoagulability Bronchioloalveolar carcinoma (subset of adenocarcinoma):  Nodule, multiple nodules, alveolar infiltrate; clubbing, hypertrophic pulmonary osteoarthropathy, Trousseau’s syndrome Squamous cell carcinoma  (strongly associated with tobacco): Cavitate, most common Pancoast’s (lung apex; superior pulmonary sulcus  † destroy adjacent rib or vertebra, Horner’s syndrome, arm pain, hand atrophy), centrally located, endobronchial, atelectasis, postobstruct pneumonia; secrete PTH  † hypercalcemia Large cell carcinoma:  Classically, large ( 3 cm) peripheral mass; gynecomastia/galactorrhea Small cell carcinoma  (strongly associated with tobacco): Usually located centrally, ⁄⁄aggressive, early distant spread

RADIOL

RADIOL

(commonly brain, bones, liver, adrenals, bone marrow), superior vena cava syndrome; paraneoplastic syndromes: e.g., SIADH, ectopic ACTH, Eaton-Lambert, subacute cerebellar degeneration, subacute sensory neuropathy, limbic encephalopathy

Anterior Mediastinal Masses ■ ■ ■

Thoracic inlet: Thyroid masses, lymphoma, cystic hygroma (lymphangioma). Cardiophrenic angle: Prominent pericardial fat, pericardial cysts, foramen of Morgagni hernia Retrosternal space: Lymphoma, thymoma, germ cell tumors, vascular (e.g., ascending aortic aneurysm)

Middle Mediastinal Masses ■ ■ ■ ■

Lymphadenopathy: Malignancy, infection, inflammation Tumors: Trachea, esophagus Vascular (e.g., aneurysms, transection): Aortic arch and great vessels, pulmonary arteries Duplication cysts: Tracheobronchial tree and esophagus

Posterior Mediastinal Masses ■ ■

Neurogenic masses: Nerve root tumors, sympathetic ganglion tumors, paragangliomas Other: Lymphadenopathy, aortic aneurysm, paraspinous abscess, extramedullary hematopoiesis, lateral meningocele, Bochdalek’s hernia

Pneumothorax and Pneumomediastinum ■ ■ ■

Thin white line: Pleural membrane between air in pleural space and air in lung Skin folds: Appear as edge, not line Lung consolidated: Instead of thin line, “edge” between consolidated lung and pleural air

Lobar Atelectasis/Collapse ■ ■

Evidence of volume loss  † shift of trachea/mediastinum/heart to side of collapse and ⁄ipsilateral hemidiaphragm Collapse patterns: Lower lobes (medially and posteriorly); RML (medially against heart PA, RML volume small so maybe no evidence of volume loss); RUL (medially and superiorly); LUL (anteriorly and medially)

172

173 Pleural Effusion: “Blunting” of costophrenic angles ■ ■ ■ ■ ■ ■ ■

Lateral:  75 mL subpulmonic fluid can be unseen PA:  175 mL fluid can be unseen Decubitus:  10 mL can be seen Quantifying:  R-sided difficult because large one can invert diaphragm, L-sided if stomach bubble Loculated:  Can appear mass-like Subpulmonic:  Appearance of ⁄hemidiaphragm “Psuedotumor”:  Collect in major or minor fissures

CHF ■ ■ ■

Left atrial (i.e., mean pulm wedge) pressure 12–19 mm Hg:  Pulmonary vessel cephalization 20–25 mm Hg:  Interstitial edema, bronchial wall thickening, interlobular septa fluid (Kerley’s lines) 25 mm Hg:  Alveolar edema: bilateral symmetric perihilar, coalescent opacities, air bronchograms.

Pneumonia: Infiltrate (= ⁄lung density) ■ ■

Interstitial (frequently viral): Lines (reticular opacities) or nodules Alveolar  (frequently bacterial): Hazy coalescent opacity; obliterate mediastinal/diaphragmatic borders

Sarcoid: Stages:  ■ ■ ■ ■ ■

0:  Normal CXR I: Bilateral hilar, paratracheal and mediastinal lymphadenopathy II: Bilateral hilar/mediastinal adenopathy  interstitial infiltrates III:  Interstitial infiltrates IV:  Fibrosis Line and Tube Placement

Endotracheal Tube ■

■

Ideal position:  5 cm from carina (~T4–T5 interspace) when head neither flexed nor extended; minimal safe distance: 2 cm Dee method to approximate carina position:  Define aortic arch; draw line inferomedially through middle of arch at 45° angle to midline; intersection of midline and diagonal line ~carina position

RADIOL

RADIOL

Thoracostomy Tube ■

■

Placed into pleural space to evacuate air/fluid; in supine pt., air collects anteriorly and fluid collects posteriorly; insert within fissures  † may not function; incorrect placement for empyemas may  † ødrainage and loculation Gap in radiopaque line (last tube fenestration) must be within thoracic cavity; if subcutaneous air, then tube may not be completely inserted

Nasogastric (NGT) and Feeding Tubes ■ ■

Generally chest x-ray not necessary post-NGT placement unless s/p esophagectomy Feeding tubes: Usually placed into proximal small bowel (check abdominal film); for small-bore feeding tube:  rule out placement in lung

Central Venous Pressure Monitors ■

Tip should lie between most proximal venous valves of subclavian or jugular veins and right atrium; placement in heart  † arrhythmias or cardiac perforations

Swan-Ganz Catheters ■

Tip no more distal than proximal interlobar pulmonary arteries (i.e., within mediastinal shadow)

Intra-aortic Counterpulsation Devices ■

■

øAfterload and ⁄cardiac perfusion in cardiogenic shock; synchronized with either aortic pressures or EKG  † diastole: inflate and systole: deflate Catheter should be near aortic isthmus or left main bronchus and above celiac trunk and superior mesenteric artery origins

Transvenous Pacing Devices ■ ■

Frontal view: Pacer tip at apex with no sharp angulations throughout its length Lateral view: Tip embedded in cardiac trabeculae  † 3–4 mm beneath epicardial fat stripe; if beyond epicardial fat stripe may have perforated myocardium; check pacer wire integrity Pitfalls

■

Relative contraindication: pregnancy

174

175 Chest Computed Tomography Indications Evaluate thoracic trauma, pulmonary nodules, aortic dissection/  aneurysm, lung neoplasm and interstitial lung disease, mediastinal and hilar lymphadenopathy vs. vascular strictures, parenchymal vs. pleural processes

Patient Preparation Preferably NPO 2 hr prior; normal hydration; sedate agitated pt.; if IV contrast, check serum creatinine

Procedure Description High resolution chest CT (HRCT): For interstitial lung disease; thinner slices and less tissue scanned but more detail than conventional chest CT

Normal Study ■ ■ ■ ■

■ ■

HRCT “lung windows”: air  black, aerated lung   dark gray, other structures   white Central, branching paired pulmonary arteries  bronchi  connective tissue (bronchovascular bundles) Bronchus: X-section  thin-wall, white circle with central air (black); adjacent artery  solid, white circle Peripherally, arteries and veins: Numerous small “dots” and a few branching lines; arteries branch at acute angles; veins branch at 90° angles Major interlobar fissure pleura  thin, horizontal line traversing lung Normal interstitium invisible on HRCT; interstitial compartments: bronchovascular (surrounds bronchovascular bundle); centrilobular (surrounds distal bronchiolovascular bundle); interlobular septal (often lines perpendicular to pleura); pleural

RADIOL

RADIOL

Abnormal Studies

Air Trapping ■

Abnormal gas retention postexpiration (lung parenchyma remain lucent and normal lung areas  † ⁄attenuation); can appear normal on inspiration, must check on expiration

Bronchiectasis ■

Traction bronchiectasis   bronchial dilation in lung fibrosis or distorted lung architecture  † irregular bronchial dilation; usually segmental and subsegmental bronchi, but may affect small peripheral bronchi or bronchioles; commonly associated with honeycombing

Pulmonary Nodules ■

HCRT can detect nodules 1–2 mm diameter; appearance: well-defined (likely interstitial) vs. ill-defined (likely air space); distribution: perilymphatic, random vs. centrilobular; differential diagnoses (DDx): tumor, granulomas, pneumoconioses, mucous plugs, endobronchial disease, hypersensitivity pneumonia.

Ground Glass Opacity ■

■

Nonspecific term ⁄hazy opacity within lungs not obscuring underlying vessels (if obscure underlying vessels  † consolidation); reflects minimal septal, alveolar interstitium, or alveolar wall thickening or cells or fluid filling alveolar spaces DDx: pulmonary edema; ARDS; pneumonia (viral, mycoplasmal, PCP); hypersensitivity pneumonia; pulmonary hemorrhage; other diffuse interstitial lung disease

Cysts ■ ■ ■

Round, thin walls filled with air (darker than normal aerated lung) Cystic bronchiectasis (multiple dilated bronchi): often clustered together and focal Honeycombing: ⁄⁄lung fibrosis  alveolar destruction; thickwalled, air-filled cysts (3 mm – 1 cm)

176

177 ■

DDx of multiple cysts: chronic interstitial fibrosis, Langerhans’ cell histiocytosis, lymphangioleiomyomatosis

Mosaic Attenuation/Perfusion ■

Areas of often patchy øattenuation from regional lung perfusion differences secondary to airway disease or pulmonary vascular disease; often pulmonary arteries øin size in lucent lung fields

Interlobular Septal Thickening ■

Many clearly visible septal lines (smooth, nodular, or irregular); common with interstitial lung disease

“Tree-in-bud” Appearance ■

Dilated and fluid-filled (i.e., pus, mucus, or inflammatory exudate) centrilobular bronchioles; irregular, no tapering, knobby/bulbous at branch tips

Consolidation ■ ■

Opacity completely obscuring vessels; if bronchi aerated  † branching lucencies (“air-bronchograms”) DDx: Any process filling air spaces with blood, fluid, or inflammatory cells, atelectasis

Pitfalls ■ ■

Requires breath holding Contraindications: See Head Computed Tomography above

Abdominal Plain Film Indications Rule out obstruction or ileus, free air, or calcifications

Patient Preparation None

RADIOL

RADIOL

Procedure Description Usually PA supine, erect (free air), or lateral decubitus (free fluid); show lower anterior ribs

Normal Study ■

Solid organs ■ Liver: RUQ soft-tissue density ■ Spleen: LUQ soft-tissue mass; may not be seen ■ Kidneys: Left higher than right; upper poles tilt medially; should be ~three vertebrae in size ■ Psoas muscle: Line (lumbar spine lesser trochanter) ■ Bladder: If full, pelvic soft-tissue density ■ Uterus: May indent bladder; usually not seen ■ Prostate: Usually only seen if calcified Hollow organs ■ Stomach: Supine; air anterior and fluid posterior ■ Small bowel: Normal 2.5–3.0 cm diameter; valvulae cross entire lumen; often little seen on plain film ■ Colon: Abdominal periphery Normal calcification: Costal cartilage, mesenteric lymph nodes, pelvic vein phleboliths, prostate gland  †

■

 †

■

 †

Abnormal Studies Intestinal Obstruction ■ ■ ■

Dilated loops proximal to obstruction (3 cm small bowel, 6 cm large bowel) Stepladder or hairpin pattern: Air-fluid levels at different heights within same loop “String of pearls”: Small gas bubbles trapped between folds in dilated, fluid-filled loops

Ischemic Colitis ■

Thumbprinting of mucosa, bowel wall thickening

178

179 Volvulus ■

May be normal; ahaustral distention, air-fluid levels, liver/left flank/pelvic overlap

Intussusception ■ ■

Usually in ileocolic region; may be anywhere Soft-tissue mass and small bowel obstruction

Toxic Megacolon ■

Colonic distention with absent haustra; edematous and ulcerated mucosa may  † pseudopolyps

Diverticulosis ■

Gas-filled sacs parallel to colon lumen

Pseudomembranous Colitis ■

Dilated colon, ascites, and nodular thickened haustra

Ascites ■

■

■

Detect 500 mL fluid; accumulate in most dependent areas; supine: hepatorenal recess (Morrison’s pouch); upright: pouch of Douglas Diffusely ⁄density or “ground glass sign” (hazy appearance); indistinct liver, spleen, and psoas muscle margins; colon, liver, and spleen medial displaced away from flank stripe; bulging of flanks “Dog ears”:  Fluid accumulates in peritoneal recesses superolateral to bladder

Free Air (Pneumoperitoneum) ■ ■ ■ ■

Best seen on upright film (below diaphragm domes) Double wall sign (Rigler’s): Air outline both inside and outside bowel walls Falciform ligament sign: (Supine) outline ligament Football sign: Gas outline peritoneal cavity

RADIOL

RADIOL

Pneumoretroperitoneum ■ ■ ■

Air outline right kidney and liver undersurface Unlike pneumoperitoneum, does not move with position change Can extend into mediastinum or neck

Pneumobilia ■ ■

Biliary gas outline bile ducts Pseudopneumobilia:  Normal periductal fat that surrounds and parallels bile duct course

Calcification ■

Appendicoliths, costal cartilages, mesenteric lymph nodes, phleboliths, aging prostate, prostate carcinoma, pancreatitis (T9–T12), nephrocalcinosis (T12–L2), blood vessels, abdominal aortic aneurysm (AAA), uterine fibroids, gallstones, porcelain gallbladder, renal calculi, bladder calculi, bladder tumor, schistosomiasis (Ca2 bladder wall), ovarian teratoma (tooth)

Pitfalls ■ ■ ■

If spine visible, most structures will be visible View overexposed (dark) areas with bright light Artifacts from piercings and metallic objects

Abdominal-Pelvic CT Indications Assess abdominal pathology

Patient Preparation Keep pt. hydrated; sedate agitated pt.; if IV contrast used, check serum creatinine and history of allergic reaction

180

181

Procedure Description IV contrast: Ionic: ⁄osmolar and Nonionic: øosmolar ■ GI contrast media ■ Esophacat (thick barium): Opacify esophagus ■ Gastrograffiin (H2O-soluble): Opacify entire GI tract ■ Readicat (barium): Outpatient examinations opacify all GI tract ■ Outpatient: Readicat first half bottle at qhs before and second half ~ 1 hr before examination; third dose: immediately before scan ■ Urgent: Gastrograffin 3 doses at 1 hr, 30 min, and immediately prior to examination ■ Emergent trauma: First dose in ED and second dose at table ■ Delayed images: 5–10 min post-IV contrast  † visualize urinary system ■ Liver Imaging  ■ Three-phase scan (especially hypervascular lesions such as  hepatoma, metastatic disease, or hemangioma): 1. arterial  (contrast in aorta and main hepatic arteries); 2. portal  venous (contrast  † liver parenchyma and mix with portal blood); 3. equilibrium (contrast in parenchyma  † hepatic veins  † kidneys) ■ First-stage and second-stage liver malignancies usually have hepatic arterial supply (arterial phase) ■ Benign entities and normal liver: Portal venous supply (portal-venous phase)

Normal Study ■

Liver parenchyma: Homogeneous 54–60 HU, usually 8–10 HU  than spleen

Abnormal Studies Liver

Hepatic Abscess ■

Bacterial: Heterogeneous with irregular margin and possible peripheral enhancement, internal septations or papillary projections; may contain gas RADIOL

RADIOL

■ ■

Echinococcal:  Calcified wall, membrane separation, dependent debris, focal areas ⁄attenuation in cysts Fungal:  Multiple, small, hypodense lesions

Cirrhosis ■ ■

Noncontrast:  Homogeneous/heterogeneous øattenuation Contrast:  Fibrosis/regeneration areas may  † isodense to parenchyma; liver surface may be very nodular

Fatty Liver ■ ■

Diffuse:  On noncontrast, hypodense to spleen  † hepatic vasculature more prominent Focal:  Patchy areas øattenuation

Hemochromatosis ■

Hyperdense liver (75 HU) ~ to Wilson’s disease, amiodarone toxicity, and previous Thorotrast exposure

Portal Venous Hypertension ■

Ascites, splenomegaly, or portosystemic varices

Solitary Liver Masses ■ ■

DDx:  Cyst, metastasis, focal nodular hyperplasia, adenoma, hepatoma, focal fatty infiltration, hemangioma Lesions  1 cm  too small to be characterized

Simple Hepatic Cyst ■ ■

Noncontrast:  Density 20 HU, well-defined margins, no perceptible wall Contrast:  No enhancement after contrast

Hemangioma ■ ■ ■

Noncontrast:  Low (dark) attenuation Contrast:  Focal nodular enhancement Delayed:  Centripetal opacification pattern (arterial phase: lesion periphery enhances; equilibrium/early delayed phase: center fills); large hemangioma, central necrotic scar may not enhance

Portal Vein Thrombosis ■

Post-thrombosis, periportal collateral vessels recanalize

182

183 Budd-Chiari Syndrome ■

Hepatosplenomegaly and patchy enhancement; caudate lobe may be enlarged after several weeks; may see collateral circulation

Passive Hepatic Congestion ■

Chronic ⁄hepatic venous pressure  † low attenuation areas

Gallbladder and Biliary System Porcelain Gallbladder ■

Calcification of the gallbladder wall (arrows), often accompanied by stones

Choledocholithiasis ■

May have target and crescent signs

Acute Cholecystitis ■

Cholelithiasis, GB wall thickens, pericholecystic fluid, perforation or hepatic abscess

Pancreas Pancreatitis ■ ■ ■ ■ ■

Enlarged pancreas  infiltration of surrounding fat Peripancreatic fluid collections Pseudocysts: Encapsulated fluid collections Pancreatic necrosis:  No enhancement with IV contrast Pseudoaneurysm: Saccular dilation of artery (most commonly splenic and gastroduodenal)

Pancreatic Injuries ■ ■ ■ ■ ■

May appear normal, especially during first 12 hr; may need to rescan in 12–24 hr Linear hypodensity around pancreatic parenchyma Diffuse, thickened Gerota’s fascia Retropancreatic fluid anterior to splenic vein Delayed formation of pancreatic pseudocyst

Intestines Acute Appendicitis ■ ■

Dilated appendix 6 mm OR appendicolith Periappendiceal fat stranding

RADIOL

RADIOL

Crohn’s Disease ■

See Barium and Gastrograffin Enema above

Ulcerative Colitis ■ ■

See Barium and Gastrograffin Enema above Extraintestinal: Sacroiliitis, cholangitis, and thromboembolic disease

Ischemic Colitis ■

Mucosal “thumbprinting” or thickening of bowel wall

Intussusception ■

Characteristic doughnut/target-shaped intestinal mass

Intestinal Obstruction ■

See Abdominal Plain Film Findings above

Toxic Megacolon ■

Thin bowel wall with irregular nodular configuration

Pseudomembranous Colitis ■ ■

Wall thickening (~15 cm) with target-like appearance, pericolic fat inflammation, ascites “Accordion sign”:  Intraluminal contrast stripes trapped between nodular, hypertrophied wall

Diverticulitis ■

Pericolonic fat inflammation/stranding, pericolonic abscess, focal bowel wall thickening, diverticula near inflammation site

Polyps ■ ■

Benign: Small diameter, stable growth, spherical-shaped, normal mucosa, long stalks, and smooth surface Malignant: Large diameter, sessile, irregular shape, sudden growth, broader base, and puckered mucosa

Kidneys Renal or Ureteral Stones ■ ■ ■

Initial protocol without IV or oral contrast If equivocal: IV contrast 5–10 min. delayed images Pelvic Ca2 (?distinguish vs. phlebolith)  †

184

185 ■

Second-stage signs:  Hydronephrosis, perinephric stranding, and “rim sign”  edematous ureter  soft-tissue rim around pelvic calcification

Peritoneum

Ascites ■ Fluid densities in recesses of peritoneal cavity ■ Serous fluid ~ H2O density; exudative: slightly  H2O dense; acute bleed  most dense ■ Fluid posterior to diaphragm  pleural fluid; Fluid within diaphragm  ascites Free Air (Pneumoperitoneum) ■ Use lung windows to help distinguish vs. bowel gas ■ Falciform ligament and double-wall (see plain film). Peritonitis ■ Ascites  peritoneal and mesenteric thickening ~soft-tissue attenuation; as ages ■ Abscess: Early liquefactive necrosis; mature definable wall and low attenuation center ■ Thicken/obliterate adjacent fat and displacement of adjacent structures ■ ~Hematomas, urinomas, necrotic tumors, pseudocyst  †

 †

 †

Pitfalls ■ ■ ■

Bone artifacts Contraindications: Pregnant, allergy to IV contrast, iodine, shellfish Warnings: Renal insufficiency/failure, metformin

Obstetric Ultrasound

Indications See below

RADIOL

RADIOL

Patient Preparation None

Procedure Description ■ ■

Abdominal and transvaginal scans, Doppler ultrasound 3D and 4D ultrasound

Normal Study Confirm Pregnancy ■

Gestational sac ~41 ⁄ 2 wk gestation; yolk sac ~5 wk; embryo ~51 ⁄ 2 wk

Gestational Age and Fetal Size ■ ■

■

■

Crown-rump length (CRL): Measure at 7–13 wk; estimate gestational age Biparietal diameter: Measure 13 wk; diameter between two sides of head ~2.4 cm at 13 wk to 9.5 cm at term; dating later pregnancy unreliable Femur length: Measure longest bone in body (longitudinal fetal growth) ~1.5 cm at 14 wk to 7.8 cm at term; dating later pregnancy unreliable Abdominal circumference : Important to judge fetal size/weight in late pregnancy; not for dating

Timing of Scans ■

■ ■ ■ ■

Scan at ~7 wk: Confirm pregnancy, exclude ectopic or molar pregnancies, confirm cardiac pulsation and measure CRL for dating 11–14 wk: Evaluate fetal nuchal translucency, nasal bone, and tricuspid regurgitation (?Down’s syndrome) 18–20 wk: Look for congenital malformations, multiple pregnancies, placental position 32 wk: Evaluate fetal size, weight, and fetal growth; verify placental position Level II (“targeted”) scan: Suspected abnormality

186

187 Abnormal Studies Vaginal Bleeding in Early Pregnancy ■ ■

Check fetus viability: Visible heartbeat ~6–7 wk Fetal heart rate: At 6 wk ~90–110 bpm; at 9 wk 140–170 bpm; at 5–8 wk 90 bpm high risk of miscarriage  †

Pitfalls ■

Accuracy highly operator-dependent

Bone Films Indications Suspected fractures, dislocations, joint effusions, arthritis, bone cancer, or bone disease; before and after orthopedic operations

Patient Preparation None

Procedure Description Must see at least two views For long bones, must see joints at both ends

Normal Study Check: A (anatomic appearance, alignment, asymmetry); B (bone density/mineralizations); C (cartilage, contours); D (distribution, deformity); E (erosions, extent); S (soft tissue, swelling)

RADIOL

RADIOL

Abnormal Studies

First-Stage Degenerative Arthritis ■

Joint space narrowing, marginal osteophytes, subchondral sclerosis, subchondral cysts

Calcium Pyrophosphate Deposition Disease ■

Articular cartilage calcification (shoulder, hip, knee, ulna, symphysis), large subchondral cysts, preferentially involve femoropatellar compartment

Charcot’s Arthropathy ■

Fragmentation, osteophytes, soft-tissue swelling, joint destruction, sclerosis

Infectious Arthritis ■

Usually single joint; articular cartilage and cortex destruction

Rheumatoid Arthritis ■ ■

■

Bilateral symmetrical, especially hips and knees Earliest changes: STS, MCP, PIP, ulnar styloid; radiocarpal joint most commonly narrowed; MCP joints of first and second fingers Periarticular demineralization; large joints usually no erosions; marked narrow joint space with intact articular cortex; little or no sclerosis

Gout ■

Juxta-articular erosions; sharply marginated  sclerotic rims; overhanging edges; no joint space narrowing until later; little/no osteoporosis; soft-tissue swelling; tophi not calcified

Hemophilia ■

Epiphyseal overgrowth; resorption of second-degree trabeculae; longitudinal striations; widen knee intercondylar notch; joint effusion; hemosiderin deposit around joint

188

189 Psoriatic Arthritis ■

Involves DIP joints, hands  feet; cup-in-pencil deformity; resorption terminal phalanges; no osteoporosis

Ankylosing Spondylitis ■

Bilateral sacroiliac arthritis; squaring of vertebral bodies; bamboo-spine from continuous syndesmophytes; peripheral large joint erosive arthritis

Reiter’s Syndrome ■ ■

Urethritis, arthritis, conjunctivitis Periostitis at tendinous insertion sites; whiskering; like DISH, ankylosing spondylitis affects feet  hands; also SI joint ~to RA; also, osteoporosis

Lucent Bone Lesions (mnemonic: FOGMACHINES) Fibrous

dysplasia, Osteoblastoma, Giant cell tumor, Metastasis/  Myeloma, Aneurysmal bone cyst, Chondroblastoma/  chondromyxoid fibroma, Hyperparathyroidism (brown tumors)/hemangioma, Infection, Nonossifying fibroma, Eosinophilic granuloma/enchondroma, Solitary bone cyst

Sclerotic Bone Lesions (mnemonic: VINDICATE) ■ Vascular: ■ ■ ■ ■ ■ ■ ■ ■

Hemangiomas, infarct Infection: Chronic osteomyelitis Neoplasm: First stage (osteoma, osteosarcoma), metastatic (prostate, breast) Drugs: Vitamin D, fluoride Inflammatory/Idiopathic Congenital: Bone islands, osteopoikilosis, osteopetrosis, pyknodysostosis Autoimmune Trauma: Fracture (stress) Endocrine/metabolic: ⁄Parathyroid, Paget’s disease

Osteonecrosis ■ ■ ■

Early: Appears normal After weeks to months:  Ill-defined mottling trabecular Late: (Medullary space well away from joint) dense, serpiginous calcification (subchondral bone) microfractures

RADIOL

RADIOL

in dead bone discontinuous subchondral line or “crescent sign” (fracture between subchondral line and adjacent necrotic bone); thick sclerotic zone between living and necrotic bone  †

Soft-Tissue Calcifications ■

■ ■ ■ ■

Dystrophic (amorphous Ca2 may ossification with cortex and medullary space): Vascular (venous insufficiency), infection, (parasitic infestation, cysticercosis, dracunculiasis, Armillifer armillatus), neoplasm (primary bone-forming tumor, osteoma, osteosarcoma, tumor necrosis), drugs (vitamin D), autoimmune (dermatomyositis, scleroderma), trauma (heterotopic ossification, injection granulomas) CPPD chondrocalcinosis; occasionally associated with calcifications in the soft tissues of the spine Metastatic calcification (finely speckled Ca 2) Tumoral calcinosis (large Ca2, usually near joint) First-stage soft-tissue or metastatic osteosarcoma (amorphous, fluffy, confluent Ca2 collection)  †

Osteoporosis ■

Vascular (anemia), drugs (steroids, heparin), dietary deficiency (scurvy, malnutrition, calcium deficiency), idiopathic osteoporosis, congenital (osteogenesis imperfecta), toxic (alcoholism, chronic liver disease), endocrine/metabolic (senile, postmenopausal, pregnancy, diabetes mellitus, hyperparathyroidism, Cushing’s disease, acromegaly, hypogonadism)

Fractures ■

Simple transverse: Fracture line perpendicular to bone’s long axis two fracture fragments Oblique: Fracture line oblique angle to long axis Spiral: Severe oblique fracture, fracture plane rotates along long axis resulting from rotational force Longitudinal: Fracture line nearly parallel to long axis; also known as long oblique fracture Comminuted: Results in two fracture fragments  †

■ ■ ■ ■

190

191 ■

■

Impacted:  End of bone driven into contiguous metaphyseal region without displacement, resulting from axial or compressive force Depressed:  Type of impacted fracture; involves articular surface of bone joint incongruity Avulsion:  Tendon/ligament pulled away from bone, carrying bone fragment with it  †

■

Pitfalls ■

Relative contraindication: pregnancy

RADIOL

LABS

Toxicology Screen Amphetamine/ methamphetamine

Remains



24–48 hr after use

Barbiturates

Remains



2–6 wk after use

Benzodiazepines

Moderate use: 3–6 wk

Carbon monoxide

Suggested by

Cocaine

Direct: 5 hr; metabolite (benzoylecgonine):  2–4 d Heavy use:  up to 10–22 d

Codeine



Ethanol

Metabolism rate: (for 70-kg man) 155 mg/dL/hr Urine:blood: 1.35:1 (variable); saliva:blood: 1:20

Heroin



1–2 d (detected as morphine)

Hydromorphone



1–2 d

Methadone



2–3 d

Methaqualone



2 wk

Morphine



1–2 d

Phencyclidine



1–8 d

Propoxyphene

Direct: 6 hr; metabolites: 6–48 hr

Tetrahydrocannabinol or marijuana metabolite

2 d/joint; daily use: 3–6 wk; heavy use: 6–11 wk





for 3–5 d; heavy:



for

9% carboxyhemoglobin

1–2 d 3–10 hr, peak blood levels (on empty stomach: 40–70 min

192

193 Other Toxicity Tests ⁄

Test

Lead (Pb)

Children (16 y.o.): 10 mcg/dL Adults: 20 mcg/dL

Free erythrocyte protoporphyrin



Acetaminophen

Rumack–Matthew nomogram

35 mcg/dL

Cause

For children with ⁄Pb levels, if screening result is: 10–19 mcg/dL perform diagnostic test within 3 mo 20–44 mcg/dL within 1 mo 45–59 mcg/dL within 48 hr 60–69 mcg/dL within 24 hr 70 mcg/dL immediately In adults, lead toxicity or chronic exposure Fe–deficiency (can catch before manifests in anemia) Other anemias: e.g., hemolytic anemia, chronic disease

LABS

LABS

500    )    L 200   m 150    /   g   µ 100    (    l   e 50   v   e    l   n   e    h   p   o   n 10    i   m   a    t 5   e   c    A

Probable hepatic toxicity Possible hepatic toxicity Hepatic toxicity unlikely

1 4 8 12 16 20 24 Hours after ingestion

Cerebrospinal Fluid (CSF) Color Xanthochromia

Yellow: Blood breakdown products, hyperbilirubinemia, CSF protein 100 mg/dL, RBC 100,000/mm3 Orange: Blood breakdown products, high carotenoid ingestion Pink: Blood breakdown products

Cloudy or turbid

Leukocytes 200 WBC/mm3 or RBCs 3 400 per mm

Brown or dark green

Metastatic melanoma (meningeal melanomatosis) or hyperbilirubinemia Hyperbilirubinemia or purulent

194

195   –   o   n    t    i   y   a   r    d    é    l    l   a   u    i   r   r   e   o   u  a    l    l    G   B   C  c     y   s   s    t   o   y    i   o   r   l    i   r   d   u   h   a   u   e   o   e   p    l    N    C   l   c

     l   o   a    h   p  s   m   r   e   m    t   o   y   y   o    L    N    t   c

   l   a   m   r   o    N

              ⁄

   l   a   m   r   o  r    N  o               ⁄

  -

    o  s   n  e   o   t   y    M  c      l   o   a    h   p  s   m   r   e   m    t   o   y   y   o    L    N    t   c      l   o   a    h   p  s   m   r   e   m    t   o   y   y   o    L    N    t   c

              ⁄

              ⁄

   l   a   m   r   o    N

              ⁄

   l    l   n   o   o    i   a   a   -   m   t   r   s   o  a   r   -   h   m   m   s   e   l   a   n  c   a   r   r   e   o    i   o   o   g    N  p    l   a   h   o   o    C  x   t   m    N    t    N    t   n    i        d   r   o   o  e   r   n   s    i   n   m  g   -   h   a   n  c   a    F   e   o   i   o    H   h   a   h    )   i   r    X    t   m   t    F    i      S    d   e   e   o    l    l    C   y   n   :   s   :    h    b    b    (   o    B   d   y   N  e   p  s   a    i   a    l   u    i   e    T   o   r    t   m   r   r    d    t    C    i    l   a   M  a   y   y   a   a    C    V    P   L   L   c    V    E   t   u    l      F  n    l    l   e   o   o   e    l    t   a   a    h   y    l   r    b   g   r   d   p  s   a   m   a  e    i   a   n   u   r   e    f   r   m    t   e   n   u   o   o   r   a   y   y    l    i   f    F    l    i    C   c    N   o    V    L   c   p    D     s    l    l    l   o   o    l    t   o   m   a   a   a    h   y   a   r    d   r   r    0   m  p  s   m   m   m    i   a   u    b   r    0   e   r   r   r   m    t    V   e    1   o   o  r   o   o   e    l    l   e   y   y   o   r    C  c    N  o        p    L   c    N    t    N   e    l   a    C    l    i    0   m   r   y   a    0   s   e    d    0   m   N    t   u   m    1   r   r   c   o   =  e    M   o   a    l   o    B   C    N    t        p    P               ⁄

              ⁄

              ⁄

              ø

              ⁄

              ⁄

              ⁄

              ø

              ⁄

              ø

              ⁄

              ø

              ⁄

       3

              ⁄

              ⁄

       3

              ø

  r    t    l   s   o   e   o    T    C

              ⁄

              ⁄

   l   a    i    t   g  e   r   n   n  u    i   e   r   n  s    C   s   e    l   e   e    B    l    f   p  r   e   f    i    O  p    W    C   d

  n    i   e    t   o   r    P

  -   e   o   s    t   o  o   -   m   c   i    F   u   r   u   t    S  e   l    C  s   g  a   r

LABS

LABS

CSF Tests Test

Result

Cause

Leukocyte

⁄ 5 WBCs/  mm3

Blood (⁄ one WBC for every 500–1000 RBCs): Subarachnoid hemorrhage Predominantly neutrophils (bacterial meningitis); lymphocytes (viral meningitis, chronic intracranial inflammation); eosinophils (intracranial parasites, aseptic meningitis, malignancy, VP shunt)

Blood



Subarachnoid or intracranial bleeding; traumatic tap Hyperglycemia Hypoglycemia; granulomatous disease (e.g., TB, sarcoid); meningitis (e.g., bacterial, chemical, fungal); subarachnoid hemorrhage; neoplasm; certain CNS viral infections (e.g., HSV, mumps, lymphocytic choriomeningitis)

⁄ ø

Glucose

80 mg/mL 50 mg/mL 

Newborn: 60% Infant: 50% serum glucose

Hormones of the Reproductive System

Condition

Follicle– Stimulating Hormone (FSH) mIU/mL

Luteinizing Hormone LH:FSH (LH) mIU/mL Ratio

Follicular

2.5–10.2

1.9–12.5

Midcycle

3.4–33.4

8.7–76.3

Luteal

1.5–9.1

0.5–16.9

Pregnant



0.2

0.0–1.5

Postmenopausal

23.0–116.3

196

15.9–54.0

197 Normal or ⁄

Polycystic ovarian syndrome (PCO) Obesity

Can be normal or ø

Can be ⁄

⁄ Thyroid

Can be normal or ø

Can be ⁄

Liver disease

Can be normal or ø

Can be ⁄

1.5



Distinguishing Gonadal Failure

First stage

⁄⁄

⁄⁄

Second stage (hypothalamus or pituitary)

Normal or ø

Normal or ø

Prolactin (PRL) ⁄ Males and nonpregnant females: 20 ng/mL Pregnant: 300 ng/mL

Breast, chest wall, skin, or spinal cord stimulation: e.g., Manipulation/  physical stimulation, surgery, masses, infection Physiologic: Pregnancy, sleep, exercise, eating, stress Endocrine: e.g., Hypoglycemia, øthyroid, adrenal adenoma/tumor, ovarian tumor, PCO PRL–secreting tumors: e.g., Pituitary tumors, breast CA, hypernephroma øPRL inhibiting factor (PIF) synthesis: Hypothalamic or pineal disorders øPIF transport: Pituitary stalk compression (e.g., cerebral aneurysm, pseudotumor cerebri) Rheumatism/musculoskeletal: SLE Various drugs: e.g., Estrogens, TCAs

LABS

LABS

Diabetes Insipidus (DI) vs. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) Test

Normal

DI

Serum sodium (meq/L) Plasma osmolality (mOsm) Urine osmolality (mOsm) Urine/plasma osmolality ratio Urine output (L/d)

135–145 278–298 50–1200 3–4 ~2.5

SIADH

145 295 300 1 2.5 L/d 

130 275 1200 4 ø 

Overnight Water Deprivation Test to Diagnose DI

Restrict fluid intake for 12–18 hr Measure urine osmolality/volume, plasma osmolality, and body weight Administer 1 mcg of dDAVP Measure urine osmolality

Procedure

Urine Osmolality

Diagnosis

50% increase after dDAVP 10%–50% increase after dDAVP 10% increase after dDAVP ⁄

Growth hormone (GH)



Somatomedin C (IGF–I)



Neurogenic DI Partial neurogenic DI Nephrogenic DI

Causes of ⁄

5 ng/ml Pituitary tumor, GH resistance, starvation, drugs

463 ng/  ⁄⁄⁄GH: e.g., mL Acromegaly Normal⁄: Puberty, pregnancy, obesity

198

ø

Causes of ø

1 ng/mL Hypothalamic/  pituitary damage, GH gene mutations



123 ng/  øGH, liver mL disease, nonfunctioning pituitary tumor, ønutrition Normal ø: First 5–6 years of life, advanced age



199 Thyroid Function Tests Test Thyroid– stimulating hormone (TSH)

⁄ 4.0 mc U/mL

Total thyroxine (T4)



Free thyroxine (FT4)



Free thyroxine index Total triiodothyronine (T3)



11.2 mcg/dL

1.9 ng/dL

13

200 ng/dL 

ø Causes of ⁄ 0.4 mc øThyroid TSH antiU/mL bodies Pituitary resistance Acute illness recovery 5.0 ⁄Thyroid secretion mcg/dL ⁄Thyroid– binding globulin (TBG): e.g., Pregnancy ⁄Thyroxine intake Same as ⁄T4 0.7 but not ng/dL affected by TBG Same as ⁄T4 4.2 but corrects for ⁄TBG Same as ⁄T4 80 ng/dL

Causes of ø ⁄Thyroid Pituitary disorder Acute illness or malnutrition Hyponatremia

øThyroid secretion: øPituitary/  øhypothalamus øTBG: e.g., Congenitalø, chronic illness

Same as øT4 but not affected by ⁄TBG Same as ⁄T4 but corrects for ⁄TBG Same as øT4; when T4 normal or ⁄, ø T4  † T3 conversion : e.g., Fasting, surgical stress (continued )

LABS

LABS

Thyroid Function Tests (Continued ) ⁄

Test Thyroglobulin (Tg)

Causes of ⁄

42 ng/mL 

Thyroid ⁄ function, inflammation, or cancer (e.g., papillary, follicular)

ø

Causes of ø

3 ng/ mL



Tumor mark; postremoval/   ablation Surreptitious thyroxine use Congenital athyreosis

Antithyroglobulin

Autoimmune disease (e.g., Hashimoto’s, Graves’, SLE) and thyroid CA

Thyroperoxidase (TPO)

Autoimmune thyroiditis (used with antithyroglobulin), other autoimmune disease (e.g., Sjögren’s, SLE, RA, pernicious anemia), occasionally other thyroid disease (e.g., carcinoma)

TSH Receptor Ab (TRAb)

Autoimmune thyroid disease: e.g., Graves’

Coagulation Studies ⁄

Test Prothrombin time (PT)

35 sec 

Causes of ⁄ øFactor I, II, V, VII, or X øSynthesis: e.g., Liver disease øConsumption: e.g., DIC øVitamin K Drugs: e.g., Warfarin

200

ø 25

sec

Causes of ø Vitamin K Thrombophlebitis Drugs: e.g., Estrogens, griseofulvin

201 Partial thromboplastin time (PTT)

35 sec

øFactor I, II, V, VIII (hemophilia A), IX (hemophilia B), X, XI, or XII øSynthesis/ ⁄consumption/ inhibitors: e.g., Lupus anticoagulant Drugs: Heparin, warfarin

25

Antithrombin (AT) III



120 % or 30 mg/  dL

Acute hepatitis/ cholestasis Kidney transplant øVitamin K Post–MI Drugs: Coumadin



80% or 17 mg/ dL

Hereditary øAT III Thrombosis: e.g., DIC øSynthesis/ ⁄loss Drugs: e.g., Thrombolytics

Factor VIII assay



50%

Hemophilia A, von Willebrand disease ⁄Consumption: DIC Factor VIII inhibitor



Inflammation 200% (acute phase nL reactant) Pregnancy (last trimester) Drugs: OCPs

Fibrinogen 433 Inflammation, (functional) mg/  infection, pregnancy, MI dL Drugs: OCPs

Bleeding time

9 min 

sec

normal

175

mg/ dL

Hypercoagulable states: DIC

øSynthesis: e.g., Afibrinogenemia Consumption: e.g., DIC Drugs: e.g., Androgens

øPlatelet number or function: e.g., Bernard– Soulier syndrome, thrombasthenia, von Willebrand (some forms) Vascular wall defects Drugs: Dextran, indomethacin, salicylates (continued )

LABS

LABS

Coagulation Studies (Continued ) Test Activated clotting time (ACT)

Fibrin degradation products (FDP)

⁄

Causes of ⁄

180 sec

øClotting factor (except factors VII and III) Platelet function disorder (but normal in pure thrombocytopenia and von Willebrand) Afibrinogenemia Circulating anticoagulants Drugs: Heparin



10 mcg  /mL

When plasmin dissolves fibrin blood clots  † FDPs (which inhibit clotting); ⁄⁄⁄ indicates ⁄ fibrinolysis or clot breakdown: e.g., DIC, primary fibrinolytic disorders, PE Severe liver disease False-positive: Rheumatoid factor



Thrombin time



20 sec

Consumption: e.g., DIC Hereditary disorders: Hypofibrinogenemia, dysfibrinogenemia Drugs: Heparin, fibrinolytic agents (e.g., streptokinase, TPA)

D–Dimer



Venous or arterial thrombosis: e.g., PE/DVT, MI, recent surgery, infection, sepsis, cancer, DIC Drugs: Anticoagulants

Direct Coombs’ test

Detect RBCs coated with antibodies including, the following types of hemolysis: Autoimmune: Warm autoimmune hemolytic anemia (e.g., idiopathic, SLE, Evans’ syndrome), cold autoimmune hemolytic anemia (e.g., mononucleosis) Alloimmune: Various newborn hemolytic disease (e.g., erythroblastosis fetalis, Rh disease, Rhesus C, ABO, anti–Kell), other blood group incompatibility (e.g., RhC, Rhe, RhE, Kid, Duffy, MN, P) Drug–induced: e.g., Methyldopa, various antibiotics, L–dopa, quinidine

202

203 Indirect Coombs’ test

Detect anti–RBC antibodies in serum (specifically IgG, but may detect IgM): Acquired hemolytic anemia, incompatible blood transfusion, and anti–Rh antibodies (maternal Rh sensitization)

Ham test

Used to diagnose paroxysmal nocturnal hemoglobinuria False-positive: Myeloproliferative disorders, spherocytosis, transfusion with old RBCs, hereditary dyserythropoietic anemia type II ø

Test Vitamin B12

200 pg/mL 

B12 In 24 h, absorption excrete (Schilling 8% test) Folic acid

2.7 ng/mL 

Causes of ø ⁄Requirements (e.g., pregnancy),øintake (e.g., vegan diet) øIntestinal absorption: Inflammation (e.g., Crohn’s), disruption (e.g., blind loop), infection (e.g., D. latum) øIntrinsic factor: e.g., Pernicious anemia, ⁄metabolism (e.g., ⁄thyroid), gastric CA, atrophic gastritis, gastrectomy Note: May be ⁄⁄ in liver or myeloproliferative disease (e.g., myelocytic leukemia) øIntrinsic factor øIleal absorption

øIntake (e.g., chronic EtOH)/ øabsorption (e.g., celiac disease) øVitamin B12 Various drugs: e.g., Antimalarials, estrogens, methotrexate

LABS

LABS

Iron Studies ⁄

Test

Causes of ⁄

ø

Causes of ø

Iron (Fe2+)



170 mcg/dL

Hemolysis, 60 mcg/dL Non–irondeficiency anemias and lead poisoning Iron overload: e.g., Multiple blood transfusions Ineffective erythropoiesis: e.g., Liver disease øVitamin B6 or B12 Drugs: e.g., Estrogens

øIntake/ absorption: e.g., Malnutrition, celiac disease Chronic blood loss: e.g., GI, menstrual, postoperative ⁄Iron demand: e.g., Pregnancy Drugs: e.g., Allopurinol, cholestyramine, colchicine, methicillin, testosterone

Total iron– binding capacity



450 mcg/dL

240 Fe– mcg/dL deficiency anemia ⁄Fe demand: pregnancy (3rd trimester), infancy Polycythemia vera Acute liver disease Drugs: Fluorides, OCPs

Non–irondeficiency anemias Iron overload: e.g., Hemochromatosis øIntake/ øsynthesis/ ⁄loss protein ⁄Thyroid Chronic inflammation: e.g., RA Drugs: e.g., Chloramphenicol

204

205 Ferritin

Males: 300 ng/mL Females: 150 ng/mL

Inflammation (acute phase reactant): e.g., RA, adult Still’s (500) Iron overload Other: Liver necrosis, ⁄thyroid, neoplasms

Males: Iron 12 deficiency ng/mL anemia Females: 12 ng/mL

Transferrin



370 mg/dL

Iron deficiency Drugs: Oral contraceptives



øIntake/ øsynthesis/ ⁄loss protein Chronic inflammation and neoplasms Hereditaryø: Atransferrinemia

200 mg/dL

RBCs Test RBC count

⁄© 

6.1



106 /  mcL

ڻ

5.4 ⁄Production: e.g.,  106 /  Polycythemia mcL vera, ⁄EPO production, øblood O2  45% Fluid loss  † 

Hematocrit



Hemoglobin (Hgb)





17.4 g/dL

16.0 g/dL

50%

Causes of ⁄

ø© 

4.7



106 /  mcL 

40%

hemoconcen trate: e.g., 13.6 Burns, diuresis

øª

Causes of ø

4.2 øProduction: e.g., Liver  106 /  disease, øFe, mcL øbone marrow, renal failure (øEPO  36% production) Loss:  Hemorrhage 12.0 Destruction g/dL 

(continued )

LABS

LABS

RBCs (Continued ) Test Erythropoietin (EPO)

ک

ڻ

19 mIU/  mL 

Causes of ⁄

ø©

øª

øO2 0–5 (secondary mIU/mL polycythemia)/ ⁄O2 demand: e.g., Pregnancy Anemia EPO– producing masses

Causes of ø Inflammation/ chronic disease/renal disease Primary polycythemia (polycythemia vera)

RBC Indices Test Mean corpuscular volume (MCV) (fL)

⁄ 95

Causes of ⁄ Abnormal RBC maturation

ø 80

Spurious causes: Autoagglutination, ⁄WBC Some drugs: e.g., Phenytoin

Mean corpuscular Hgb concentration (g/dL)

36

= (HCT/Hct)  100 Spurious causes: Lipemia, sample turbidity, hemolysis (in vitro/vivo)

31

Mean corpuscular hemoglobin (pg/cell)

34

= Hemoglobin/  RBC count See causes of ⁄MCV

26

206

Causes of ø Abnormal Hgb synthesis: e.g., øFe, CRF, thalassemia, Pb poisoning, chronic disease

207 Red cell distribution width

14.

5%

= (Standard deviation of RBC volume/  MCV)  100 ⁄Variation in RBC size: e.g., øFe, øB12, øfolate, immune hemolytic anemia, liver disease, RBC fragmentation

White Blood Cells (WBC) ⁄10

Total WBC ⁄

Test



I03 /µL

Causes of ⁄

ø4.5 ø



I03/µL

Causes of ø

Absolute  neutrophil 7500/ count mm3

Stress, Inflamma- 1500  /mm3 tion, Bacterial infection Myeloproliferative disorders, Steroids, Splenectomy

øProduction/ ømaturation: e.g., øBone marrow, øB12 /folate ⁄Destruction: e.g., ⁄Spleen Margination: e.g., Endotoxin, hemodialysis

Monocyte

8%

Viral/parasitic infection Infection recovery, Collagen Vascular disease, Hematologic malignancies

2%

HIV, rheumatoid arthritis, some cancers Steroids

Basophil



Food hypersensi- 0.5 tivity % Chronic inflammation øøThyroid, Radiation, Splenectomy, Some cancers (e.g., myeloproliferative)

Psychologic/ physical stress: e.g., Pregnancy, ⁄thyroid Some allergic reactions Prolonged steroids Hypersensitivity reaction

1%

(continued ) LABS

LABS

White Blood Cells (WBC) (Continued ) ⁄10

Total WBC Test

⁄

Lymphocyte

Eosinophil



I03 /µL

Causes of ⁄ Most viral/some bacterial infections, Some cancers, Graves’ disease

4%

ø4.5 ø



I03/µL

Causes of ø

15% øBone marrow/ øimmunity øAdrenocortical/ steroids Some cancers, renal failure, SLE



Allergic reactions, Parasitic infections, Chronic skin inflammation, Myeloproliferative disorders

Stress Steroids Anything  † øWBC production

Platelets (Plt) Test Plt count

⁄ 4.5 

105/ mm3

Causes of ⁄

ø

1.5 Essential (primary) throm-  105/ bocytosis: Myelo- mm3 proliferative disorders Reactive (secondary) thrombocytosis: e.g., Inflammation (e.g., inflammatory bowel disease [IBD]), surgery, øspleen

208

Causes of ø øProduction: øBone marrow, ømegakaryocyte (e.g., aplastic anemia, EtOH, radiation), hereditary (e.g., TAR syndrome, Fanconi’s, May–Hegglin) Sequestration: e.g., Splenomegaly

209 (øbreakdown), hemorrhage, malignancy, postinfection Drugs: Epinephrine, vincristine fL ⁄Platelet turnover: e.g., ITP Sudden ø ø gestational proteinuria and hypertension Stored EDTA blood artifact Other: Bernard–Soulier, May–Hegglin, Epstein, Fechtner, Sebastian, Alport

⁄Destruction: Immune (e.g., ITP), mechanical (e.g., prosthetic valves) Various drugs 6

fL

øProduction Myeloproliferative disorders: Polycythemia rubra vera, essential thrombocythemia, myelofibrosis Hereditary: Storage pool disease, Wiskott–Aldrich, TAR syndrome

Mean Plt volume

11

øPlatelet aggregation

Congenital: e.g., Glanzmann’s, Bernard–Soulier, storage pool disease, von Willebrand’s Acquired: e.g., Antiplatelet Abs, myeloproliferative disease, uremia, FDPs, acquired storage pool disease, medications

Lipids Test

Targets

Total cholesterol



High-density lipoprotein (HDL)

Females: ≥50 mg/dL Males: 40 mg/dL

Comments

200 mg/dL Highest amount of protein (continued )

LABS

LABS

Lipids (Continued ) Test

Targets

Comments

2 cardiac risk 160 mg/dL factors: Medication if: 190 mg/dL 

2 cardiac risk 130 mg/dL factors: Medication if: 160 mg/dL 

Low-density Lipoprotein (LDL)

CAD or equiva- 100 mg/dL lent (diabetes): Medication if 130 mg/dL

= Total cholesterol – HDL – (TG/5) or = Total cholesterol – HDL – VLDL Contains highest amount of cholesterol

CAD  multiple 70 mg/dL uncontrolled Medication if risks: 100 mg/dL Very low– density lipoprotein (VLDL)



31 mg/dL

= (TG/5) Contains highest amount of TG

Triglycerides (TG)



150 mg/dL

Cardiac Markers Begins to Rise

⁄

Test

2 hr

6–8 hr

20–36 hr

3–4 hr

12–24 hr

2d

267 IU/L

4–6 hr

24 hr

3–4 d

1.0 ng/mL

2–6 hr

12–16 hr

5–10 d

Less specific than I 2–6 hr

12–16 hr

5–14 d

Myoglobin



Creatine kinase–MB (CK–MB)



Total CK



Troponin–I



Troponin–T

50.0 ng/mL

Peaks

Returns to Normal

161 U/L or of total CK



4%

210

211 Brain (B–Type) Natriuretic Peptide Level (pg/mL) Normal

Abnormal

Interpretation



10 99

Look for other causes of dyspnea Heart failure unlikely

100–300

CHF present

300–600

Mild CHF

600–900

Moderate CHF

900

Severe CHF

Myocardial stress/injury: øexcretion: Renal failure Primary hyperaldosteronism or Cushing’s ⁄Age Drugs: Cardiac glycosides, diuretics

Sweat Chloride ⁄

60

mmol/L

ø

Diagnose cystic fibrosis (false-positive: øAdrenal, øG6PD, glycogen storage disease, øthyroid, malnutrition, renal failure) Dehydration, heavy perspiration, øaldosterone Drugs: Corticosteroids

LABS

LABS

Liver Tests

⁄

Test

Liver Injury

Also ⁄ in

Alanine aminotransferase (ALT)



35 U/L

Most specific for liver injury

Heart, pancreas, kidneys, muscle injury

Aspartate aminotransferase (AST)



35 U/L

øSpecific than ALT

Heart, lung, RBCs, muscle, bone, pancreas, kidney injury; vitamin A

Gamma(γ ) – glutamyl transpeptidase

51

Lactic dehydrogenase (LDH)



333 IU/L Liver isoenzyme LDH–5 so LDH5 LDH4  † liver disease If LDH1/LDH2: 0.85: MI, hemolysis, renal infarct

LDH–1: Heart muscle and RBCs LDH–2: WBCs LDH–3: Lungs LDH–4: Kidney, placenta, pancreas LDH–5: Skeletal muscle, liver

Alkaline phosphatase



147 IU/L Liver and bile ducts

Kidney, bone, placenta, lung, heart, stomach, bowel, benign familial hyperphosphatasemia, ectopic tumor production (e.g., hypernephroma)

U/L

Biliary tract CHF, SLE (mild ⁄ (more responfrom disease and sive to obstruc- NSAIDs) tion than AST or ALT)

212

213 ⁄

Test

Causes

Conjug- 0.4 mg/dL ated bilirubin (direct)

In adults: øBilirubin excretion: Liver disease (e.g., EtOH, cancer, primary biliary cirrhosis), cholestasis (e.g., drugs, ⁄TPN, pregnancy), biliary tract obstruction (e.g., cholelithiasis, pancreatic mass) In neonates: Hemolysis: e.g., Hemolytic disease of newborn øBilirubin excretion: Liver disease, biliary obstruction Pancreatic problems: e.g., Cystic fibrosis, øøøα–antitrypsin Intrauterine infections: e.g., Sepsis Congenital disorders: Dubin–Johnson syndrome, Rotor’s syndrome, trisomy 18, galactosemia, tyrosinemia, hereditary hypermethioninemia

Unconj- 0.7 mg/dL ugated bilirubin (indirect)

RBC hemolysis: e.g., Sickle–cell, PNH, G6PD deficiency Liver disease: e.g., Hepatitis, tumor, hepatic congestion from CHF Biliary tract disease: e.g., Cholangitis, biliary tract obstruction Hereditary disorder: Gilbert’s, Crigler–Najjar

Total protein

8.0 g/dL 

Abnormal protein production: e.g., Gammopathies øIntravascular volume: e.g., Dehydration Drugs: e.g., Androgens

6.0 g/dL 

øIntake/ øabsorption/ øsynthesis protein: e.g., Malabsorption, liver disease ⁄Protein loss: e.g., Nephrotic syndrome, burns, (continued )

LABS

LABS

Liver Tests (Continued )

hemorrhage, enteropathy, fistulae ⁄Intravascular volume: e.g., CHF, pregnancy 5.4 g/dL

øintravascular volume

3.4 g/dL

Causes of øprotein above Drugs: Estrogen

Albumin



Ammonia

⁄60 Liver destruction (e.g., cirrhosis), urea cycle mcg/  metabolic defect or urea–splitting UTI: (e.g., dL Proteus , Klebsiella ), organic acidemias, hemolysis

Antimitochondrial Ab Antismooth muscle Abs



ø10 Renal failure and drugs (e.g., lactulose, mcg/  neomycin) dL  Abs vs. liver mitochondria: Primary biliary cirrhosis, hepatitis, viral hepatitis, cryptogenic cirrhosis, EBV  1:80 titer: Autoimmune chronic active hepatitis 1:80 titer: Primary biliary cirrhosis, viral hepatitis, cryptogenic cirrhosis, endometriosis, Behçet’s, vitiligo, CMV, EBV, HIV

214

215 Glucose Tests ⁄

Test

100 mg/dL (fast) 140 mg/dL (nonfast)

Glucose



Glycosylated hemoglobin (HbA1c)



Fructosamine



6.5%

223 µmol/L

Causes of ⁄

ø

60 ⁄Glucose intake mg/dL øInsulin: Pancreatic disorders, type I diabetes Insulin resistance: Type II diabetes ⁄Metabolism: e.g., Pregnancy, ⁄thyroid, ⁄adrenal, infection Various drugs: e.g., TCAs, corticosteroids

Chronic hyperglycemia øHgb clearance: e.g., øSpleen False ⁄: e.g., Uremia, ⁄triglycerides, ⁄bilirubin, EtOH, salicylates, opiates



4.0%

Causes of ø ⁄Insulin: e.g., Insulinoma Postprandial (i.e., glucose absorption  † ⁄⁄⁄insulin surge): øGastric emptying (e.g., gastrectomy, vagotomy) øGlucose intake/ øproduction: e.g., øAdrenal, øpituitary, øglucagon, liver disease, øG6PD Various drugs ⁄Normal Hgb or ⁄Hgb clearance: e.g., Hemolytic anemias, spherocytosis, hemoglobinopathies False ø: Vitamins C and E

Measures diabetic control for 2–3 wk vs. HbA Hb A1c (4–8 wk); useful where HbA1c may be inaccurate: e.g., abnormal hemoglobin (continued )

LABS

LABS

Glucose Tests (Continued ) ⁄

Test Insulin C–peptide

Causes of ⁄

16 yr: 5.0 16 yr: 3.3 ng/mL 

ø

16 yr: Proinsulin split  † insulin 1.1 and C–peptide; 16 yr: evaluate øglu- 0.4 cose or resid- ng/mL ual B–cell function ⁄⁄⁄ Insulin production: e.g., Insulinomas, pregnancy øExcretion: e.g., CRF Drugs: Oral hypoglycemics

Causes of ø ⁄Exogenous insulin: e.g., Factitious hypoglycemia ⁄⁄⁄EtOH øøøInsulin production: e.g., Type 1 diabetes, pancreatectomy

Pancreatic Tests Test Amylase

Result ⁄130 U/L

⁄20 U/L

Causes

Injury/inflammation of: Pancreas Salivary gland: e.g., Sialoadenitis Stomach/intestinal Stomach/intes tinal tract, ovaries (e.g., ruptured ectopic pregnancy), skeletal muscle Various drugs: e.g., Bethanechol, cholinergic medications Pancreatic destruction: e.g., Advanced chronic pancreatitis

216

217 Lipase

⁄

Glucose tolerance test

Screen for gestational diabetes (24 and 28 wk of pregnancy) Diagnose diabetes when suspected but fasting blood glucose normal



160 U/ U/L

Injury/inflammation of of: Pancreas Stomach/intestinal Stomach/int estinal tract, tongue Various drugs: e.g., Meperidine, morphine, indomethacin

Fasting:

if 110 mg/dL 

After drinking glucose:

1 h r:

2 h r:

if 200 mg/dL 

if 140 mg/dL 

Tumor Markers

⁄

Tumor Marker

Cancers

Benign Conditions

5.4 ng/mL Primary: HepaCirrhosis, viral (500)* tocellular, nonhepatitis, pregseminomatous nancy germ cell (other: gastric, biliary biliary,, pancreatic)

α

–fetoprotein (AFP)



CA 19–9



37 U/mL (1000)*

Primary: Pancreas, biliary tract (other: colon, esophageal, hepatic)

Biliary disease, cirrhosis, pancreatitis

CA 27–29



38 U/mL (100)*

Primary: Breast (other: colon, gastric, hepatic, lung, ovarian, pancreatic, prostate)

Breast, liver, kidney disease, ovarian cysts

(continued )

LABS

LABS

Tumor Markers (Continued ) Tumor Marker CA 125

Calcitonin

⁄

35 U/mL (200)* 

Males:80 Females: 70 pg/mL

Carcinoembry- 5 ng/mL onic antigen (10)* (CEA)

Human chorionic gonadotropin

Benign Cancers Conditions Cirrhosis, effuPrimary: Ovarian (other: sion (pleural breast, endome- and pericardial), trial, esophagus, endometriosis, fallopian tube, fibroids, mengastric, hepatic, struation, ovarlung, pancreas) ian cysts, pelvic inflammatory disease (PID), pregnancy Primary: Thyroid medullary carcinoma (other: lung, breast, carcinoids, islet cell, apudomas)

⁄Gastrin, pancreatitis, thyroiditis, renal failure, pregnancy, newborns

Primary: Colorectal (other: bladder, breast, cervix, gastric, hepatic, ENT, lung, lymphoma, medullary thyroid, melanoma, pancreas)

Biliary obstruction, cirrhosis, IBD, pancreatitis, peptic ulcer, tobacco, øthyroid

5 mIU/mL Primary: (30)* Nonseminomatous germ cell, gestational trophoblastic disease (other: GI) 

*Level at which cancer likely

218

øGonads, marijuana use

219 Prostate Specific Antigen (PSA) ⁄

Test

Causes of ⁄

ø

10 ng/  10 ng/mL 0 ng/  suspicious for mL mL prostate CA Can be ⁄ 4 ng/mL with prostate stimulation: e.g., Inflammation, procedures (e.g., urinary catheter)

PSA



Free PSA



25%

Free PSA ⁄⁄more in BPH

11%



Causes of ø Prostate removal Antiandrogen therapy

Prostate CA–associated PSA is more protein-bound

Tests to Diagnose Pheochromocytomas or Other Catecholamine-Secreting Tumors (e.g., Neuroblastoma) Medications to stop or avoid prior to test

ASA, clonidine, labetalol, TCAs, lithium, other psychoactive medications, levodopa/methyldopa, decongestants, benzodiazepines, muscle relaxants (mephenesin, methocarbamol), nitroglycerin, tetracycline, Tylenol

Foods to avoid

Avocado, bananas, caffeine, eggplant, EtOH, pineapples, plums, tobacco, tomatoes, walnuts, pineapple (continued )

LABS

LABS

Tests to Diagnose Pheochromocytomas or Other Catecholamine-Secreting Tumors (e.g., Neuroblastoma) (Continued ) ⁄

Test

0.50 nmol/L

Highest sensitivity

96 mcg/24 hr

Highest specificity

7 mg/24 hr

Not used as much anymore

Free (unconjugated) metanephrines



Urine metanephrines



Urine vanillylmandelic acid





Leukocyte alkaline phosphatase

Comment

100 (max of 400)



20

Leukemoid reaction

CML

Polycythemia vera and myelofibrosis with myeloid metaplasia

PNH

Electrolytes Serum Test

⁄ (Critical⁄)

Urine

ø (Criticalø)

⁄

ø

Sodium (Na+)

150

(160) 135 (120) 280 meq/L meq/L meq/d

30

meq/d

Potassium (K)

5.0 (6.5)

3.5 (2.5)

40

meq/d

meq/L

meq/L

Chloride (Cl–)

106 (115)

96

meq/L

(90) meq/L

CO2

29

20

meq/L

meq/L

220

80

meq/d

250

110

meq/d

meq/d

221 Magnesium 3.0 (5.0) 1.8 (1.0) (Mg2) mg/dL mg/dL

150

4.1 Phosphorus (HPO4–2, mg/dL PO4–3)

1.3

⁄

Test

2.4 (1.0) mg/dL 

Causes of ⁄

ø

mg/d g/d

0.9

g/d

Causes of ø

0.8 1.4 øMuscle mass: Renal mg/dL insufficiency/fail mg/dL e.g., Muscular dystrophy ure: Prerenal (ørenal blood ⁄Cardiac output: flow), renal e.g., Pregnancy impairment, postrenal obstruction Muscle breakdown or creatine ingestion

Creatinine



Blood urea nitrogen



20 Renal mg/dL insufficiency/ failure ⁄⁄protein ingestion GI bleed

8 øIntake/ mg/dL øsynthesis/ ⁄loss protein ⁄Intravascular fluid: e.g., Pregnancy, overhydration 

LABS

LABS

Uric Acid

⁄ 750 mg/24 h

Seen in gout ⁄Cell destruction (e.g., hemolysis) or ⁄intake (e.g., high–purine diet) øRenal excretion: e.g., Renal disease, CHF, acidosis, øthyroid, ⁄parathyroid Hereditary ⁄production: e.g., Kelley–Seegmiller syndrome, Lesch–Nyhan ⁄Production and øexcretion: e.g., Alcohol consumption, exercise, glucose-6-phosphate dehydrogenase deficiency, øfructose–1–phosphate aldolase

ø 250 mg/24 h

øøPurine and protein intake øXanthine oxidase activity: e.g., Hereditary xanthinuria, liver disease ⁄Renal excretion: e.g., Fanconi’s, intracranial disease (e.g., SIADH), AIDS

222

223    )

       l  ,   y   r       r  ,  ,   a   s   e   c    t  ,   r   h   a   y   e   i   a   y    t    F   e   y   a   r    i   p   f   g    l    t   r    d   s  ,   e   a  .   n   o   n   r    i   a   a  ,    t   o   u    t   r   i    i   n   g   o  r   )    i   p   c    b  .  .  ,   :   y   e   r   m  g  c   e   s    t   y   )    i   e   r   n   a    t   u   s   h  e   p   h   r  .   e   o  e   :    t   c   e   s   r    P   (   e   a   g   r  ,    H   :  ,    )   o  m    t   r   y   m  m    L   h  a   a    l  ,    (   o  .  ,    l   e   a   u  ,    f   a   )   a   c   r    )   n  ,    t   r  .   m   g    t   m    h   o   i   a   s   y   a   o   d  y    t   -  ,   g   )  .   u  e    l   a    d    i   r    i   s   e   r   x  .   s   n  u   h  a   h    t   i   r   a   d  o  ,   a   e   p  e   n   n   :    i    t   e   e   i   u    t   p    t   c    t   s    (    t   c   o  u  u   i   c   m   m   x   s   g   t   r   i   e   a   g   m   n    i   u   p    l   r   q   t   u   e   e   u  n  u   e   u  o   u   n  s   o   t    i   y   s   g   r   i    h   a   a   o   t   e   n  p   h   i   c   i   m   o   o    l   r    i    i   s    t   t   m    C   C   (   a   (   (   d   A  p  a   C  m    I    t   D   d

      d      e      u      n       i       t      n      o      c

   (

              ø

              ø

   0    0   :    L    1   e   d    /         :    l   a   g   e    l   m  n   a   e   3    M    F     

        :    L

              ø

  e   d    /   :    0   l   a   e   0   g    l   n   a   3   m   e   0    M    F   2      

     e      n   a   s    i   y      o   s   n    t      r   r    l   a  ,   e   )   e  ,   p   s      e    G  n    t   g    b       t    f   r  .   a   :   o   r   a  .   u  g  e   n  r   B   i      s   o    l    O  .   p   a   t   H  r   o   p   u  .   a   s   e      o   s   c   s   e   S  v   C   y   s   :   y    l       t   e    i    P    t   s   h   u  ,    O      s   s   s    0   u   l   v   s   h  :   r  ,   u    1   o   a   e    i      e   a    t   s   e   g  e   o   s   n   t   :   r   c   n          l   r       T    C   :   r   o  e   o  s   o  a   u  a               ⁄

              ⁄

  c   r   o   o   e   o   l   e   c   r   g   i    l    t   u  r   m  m    d  m  u   a   m  a   e    t   n   r    h   r    i   e   u   u    A   u    t   M  p    T   D   A   b   t    (   F   t    M               ⁄

              ⁄

   L    /   :    d   e   g    l   :    0    0   a   n   e    l    0   m    0   a   1   e   8    M    F           

  e   n   o   r   e    t   s   o    t   s   e    T

   )    l    G   a   e   t   B   o   H   e    t   r    f   (   S    /   e   =  e   n   n   )    I   o   r   r   F   o   e   e    t   T    t    (   s   x   s   0   o  e   t   o   0    t   s   d  s   1   e   n  e    T   i    t          0    L    8    d    6   :    /   e   g         :    l   a   n   e    l   m    2   a   e   2    M    F     

  e   n   o   r   e    t   s   o   e   t   e   r   s   e    F   t

LABS

LABS

 ,   n   n   o   e    i    t  ,  .   a   m   z   g   o  s    i  .    l   e    i   e   r   w    t   :    i   e   -   l   s   v   t   a   b   n  ,   s   s   i   e   m  o  u  a    d   g  s   p  a   d    i    I    i   p   o    I    t   r   u  e   o   o    d  s   s   n  e   r   y   e   e   p   h   n   i   r   b   y    A   H  o  m    T   T  .    /    0   T    H         :    D   e    l   :    l   a   g   m   e    4    l  .   m  c   0   a   0   e   m    0    M    F   4   1        ,   e   )   s   n     d    P   y   /  ,    C   c   a   o     e    i   r     u    O   n   T    H  x  ,   e   a  .   e   n   D  e     n   g   l   t     i   r  .   a   s     t   e   g   g  o   e     n   o   m  r   c   n   :   t     o   n  s  ,   p  m  a  ,   s   (      C   e   i  ,    7   )    d   s   d  .    L   i   e   g   o   o  a   9   m  o    T    t   r   h   n  –   r   y   r   o   5   s   i  .    0   r    0   h   e   c   g   6    (   1   t               ⁄

              ⁄

              ø

              ø

              ⁄

 .    L    3   m         :    0   e    0   :    l   g   1   a    /   c   e    l    3    T  .   a   1   m   m   e    H    M    F   5   D      

  n    i    l   u   e   b   n  o   o   l   g   m   r   g   )   o  n   G    h   i    B   x   d   n   H   e   i    S   b   S    (

  e    t   e   r   u  :   c   g   l   u  a   i    )   a   s   e    d   l    l    f    l   c   y   i   r   C    i   a   B   s   r   p   o  s   l   e    t    W   v   a   r   u    (   c    l    l   o   i   s   a   u  n   t   s   c   s    i   n   a   o  e   u    i   e    t   p    t   s   m    j   a   y   u   e    E    l   r   /  ,  .   a    S   y   u   a   t   g   c    C  ,    i  .   a   d  s   y  .   e    j   n   n  m   g  .   :   e   o  o   o   t   o   e   n  n  e   c   c    i   s   e    t    i   :    i   o   t   s   v   c   c   o   i   e   /   e   e    H   t   t   l   c   p  c   p  y   n   f   s   r   u   n   n  a   c   u  r   m  a   e   I    i   v  ,    t    f   t   m    d  .   s   o   i   m  e   g  s    i   s   b   c   y   c   r   S  .   o   n   P    A   d   O   I   e   P               ⁄               ⁄

              ⁄

   L   m    /        6        6    0    0   1    1

   %    5    2

 ,          l    %    %    i    0    0   1   a    6   t    2         L   2              ,        :   m  :    %   :   n    5   )    d    °    t   o   % .    7   a   5    f    i   n    I   u   t   5   1   3   e   2    (    l   o  a   3             .    %   r        :   s    0   H   a   c   t   e   :    5   s   s   c   :   e   e    t   m   n   e   r   m  e   l   e   m  r        c   i   o   r   c   i   p   e   d   u  g  :   e   n   e   n   t    f    l   v   e   i    b   p  o  o  o  o   r   i    A    S   C   M    V   P   L   D  m                0

  s    i   n  s   e   l   y   m  a   e   n    S   A

224

   )    4  .   n   3   o  o    i    t   t   c   u  p    d  u   o   e   r   b   p    t   n   n  a   c   a    t   S   c   /   a   L    f   r   l   u  a   s   m   r    )   s   o   e   r   n    S    (    /   u   s   s    L   e    (   a   e   t   e   m   n    b    i   ;   a    l   y   i    d   e    t    i    l   y   r   u  a    t   r   m   a   n   e    t   o   m   a   g    l   a   m   n    t    i   e   h    t    h    f    i   e   p   n  w    S   n    /    i   o   m    i   r   n    t    i    t   e   c   u    h   e   d   t    i    d  o   c    t   o  r   p   e    d   t    L   e   n   a   s   t   u  c   a    f   o    i    t   r   u   a   S    R               ⁄

   9  .    1

     

              ⁄

225   g    l   s    i   a    l   u   e    l    i  ,   r    i   n   a   h   n   d   g   p   o  ,   m    i   a   e    t  ,   y   s   r   v    i   s   r  ,   u   r    t   t   n  e    i   u  p   o   g  ,   n  u   w    t   a   r   m  ,    l  ,   e   a   u    N  e    i   s   n    T  n   n   a   r   a   e   o   e   t    H  r   s   a  ,    b   c    i   e   a   m    d  m    i    l   m   m  e   a  ,   e   m    d   n  ,   x   e   o    d   e    i   r   o  r   o    t  ,   o    l   u   s   r  ,    t    b    i   y   s   a   s    h   u    h   o   t    t    t   m    i   e   e  ,   m  s    f   w   r   s   e   p    d   o   a   i    l    l    i  ,   a   h   u   p  n    t   o  m   m    fl   x   a   e   w   c   o  r    F   o    i    t    T    d   r   :   :   o   y   n  g    i    i   n    h    i   y   n   e   m    l   n   a   e   i   e   o    b  r    b  p   e  ,   e   y   t    t   y   a   a   u   a   a   i   a   n   m   r    i   m  m    t   e   n   i   y   n   m    t   n   n   a   o   a    i   o    i  ,    t    i   r    t   y  ,    t   e   u   c   h   n   o    t   c   u   t    C   u  s   a   d   a    d  a   :   e   p   o   m  o   s   r   o   e   r    i   v   m  p   d   p   i   n    i    i    t    t   b    i   s   g   t   r   n  o  n  s   n   n  n  e   a   l   o  o  o    t   v   a   i    t   u    i    l    i   p   g   c   o   t   -   t    l   c  ,   c   e   e    l    f   a    i   a   s    f   r   a   s   r   m   u    d   c    t   r   t   u  e   d   l   u   a   e   e   e    S   h  a   F   s    F   S   f

              ø

              ⁄               ⁄

              ø

              ø

              ⁄

              ø

   t   s   e   o  e   s  ,    l   n  g  a   e   a   a    i   s   n   o  r   i    d  r   d   e   r   s   a  ,   c   c   c    l   e   s   i    l    i    i    t   c   i   s   e   g   c   o   n   /   m  a    l    l   a   s   l    b   o   n  n  o   a   t   n   g  o   h   a   o    i   e    )   r   t   p    i    t   r    i   m   p   o   e   s   h    G   c   o   t   r    b   n  ,    l    C    i   a   p   a   a   c   r   i    h    t   o   d  n  s   t  –   c   e   o  a   t   g   o   c   l   n   i   e    b   m    t   a   e   a   o  r   o    (    d   t    t   t   c   a   t   t   n   s   a   e    i   a   e   y   r   e   r   n   e   r   n   s   h   y    t    G   a    t   e   :   n   u    i   e   i   g   s    l   y  ,   r   t    f    b   c   c    i   u  s    i   m    /    t   u   n   a   t   s   s   r   a   s   n  n   a   e   e   e   e    l   r    t  –   g   d    d   b    /   p    i    d  ,    b   e   r   ;   o  y   r   a   g   p   P  e   a   l   n   e   U  n  v   B  n    i    I    l   u   o  ,   n  .    l    i   p   r   s   l  ,   g  ,   e   )  .   e   o    t   e   a   c   s     e   r   u   l   s   r   :    i   n   t   a   e   m   o   r   s   r   r   v   r   o    t   e   m  e   c   e   o   u  c   d    d    I   n   l   g   t   a   :   e   d   t   n  n   a   m  n  n  a   n    t   c   e   a   a   o   o   n  a   r   c   n    i   e   s   y   u   g   t    G   c   t   c   i   s   e   a   a   n   l    l   a   n   a   l   a   c   p  ,    G  n  m    i    b   I    C  g   o   G   n   g   g   h  ,   n   h  e    i   o   r   n  p  e    i   p  e   p   i    t   o   r    l   o  c    d   a   r   r   u  a   u   t   t   o   e   d   s    l    l   n   c    h   v   e   o   n  o  o   r   r   o   i    C    D  p   M    (   N  p

   5  .    1

   L   m    /    U    I   m    0    1

              ø

              ⁄

     

     

  -   -   -   l    t   a   a   s   n   e   s   o   p   o    P  m   u   -   -   t   n  g   n   o  e   r   a    N  p  n

   5  .    9      

   0  .    5      

  –    5   0    2   4

   0   –    0    0   0  ,    4   7    6   1    3   1

  –    7   4    1   2

   0   –    0    0   4  ,    6   5    0   6    4   1

  –    3   6    1   1

  –    0    0   0    0   0  ,    3  ,    4    3   5    1   2

   2    1   –    9

  –    0    0   0    0   0  ,    7  ,    8    5   8    2   2

   8   –    7

   0   –    0    0   0  ,    5   9    6   2    7   2   –    0    0   0    8   5  ,    0   6    1   5

   6

   5

   0   –    4    8   3    1   7

   4

   6    2    4   –    5

   3

   0    5   –    5

  r   P   e    k   t    f   M    W    A   L

LABS

   L   m    /    U    I   m

LABS

Urine Tests

Leukocyte esterase

UTI, vaginal contaminant False-negative: ⁄Urine specific gravity, glucose, ketones, or protein in urine, drugs (gentamicin, Keflex, nitrofurantoin, tetracycline, vitamin C) :

UTI, gross hematuria False-positive: Vaginal contaminant, phenazopyridine, dipstick exposed to air False-negative: ⁄Urine specific gravity, ⁄urobilinogen, bacteria lacking nitrate reductase enzyme, urine pH 6.0, vitamin C supplementation, ønitrate diet :

Nitrite

⁄Blood glucose, renal causes (e.g., ⁄GFR, Fanconi’s syndrome, toxic renal tubular disease, acute glomerulonephritis, nephrosis) False-positive: Ascorbic acid, cephalosporins, ketones, levodopa, probenecid False-negative: ⁄Urine specific gravity, ⁄uric acid, vitamin C supplementation :

Glucose

Myoglobin Hemosiderin

Muscle damage (e.g., trauma, hyperthermia, dermatomyositis, polymyositis) :

⁄⁄Intravascular hemolysis  † free hemoglobin  † filtered by kidneys :

Dehydration, starvation or øcarbohydrate diets, DKA, EtOH ketoacidosis, isopropanol toxicity, pregnancy False-positive: ⁄Urine pH (acidic), ⁄urine specific gravity, phenolphthalein, L–dopa False-negative: Delayed urine examination :

Ketones

Hemoglobin

Hematuria, pyelonephritis, hemolytic anemia False-positive: Urine pus, iodides, bromides :

226

227 Protein

Primary, secondary, and drug-induced glomerulonephropathy, øtubular reabsorption, protein overfllow (e.g., hemoglobinuria, myoglobinuria, multiple myeloma, amyloid) False-positive: Alkaline urine, concentrated urine, contamination by chlorhexidine detergent or body flluids, medications (e.g., penicillin, sulfonamide) :

Antinuclear Antibody (ANA) ⁄ 1:20 Frequency of false-positive ⁄ with age: Common in patients 65 yr Autoimmune disease: e.g., SLE, Sjögren’s, RA, polymyositis, scleroderma, Hashimoto’s, juvenile DM, Addison’s, vitiligo, pernicious anemia, glomerulonephritis, pulmonary fibrosis Chronic infections: e.g., EBV, CMV Neoplasms: e.g., Leukemia

ANA Patterns Rim Homogenous Speckled Nucleolar Diffuse Centromere SLE SLE

SLE, Scleromixed derma, conCREST nective tissue disease, scleroderma, Sjögren’s

NonProgressive specific systemic sclerosis with CREST

LABS

LABS

Complement ⁄

Test

Comple- Male: ment C3 252 mg/dL Female: 206 mg/dL

Causes of ⁄

ø

Nonspecific Female: 88 acute phase reactant in mg/dL inflammatory Male: 88 conditions mg/dL

Causes of ø ⁄Consumption: e.g., SLE (especially lupus nephritis), ø complementemic nephritis, subacute bacterial endocarditis, DIC øProtein intake/ absorption/ synthesis: e.g., Anorexia nervosa, celiac disease, liver disease

Not clinically Comple- Male: ment C4 72 useful mg/dL Female: 75 mg/dL

Total complement (CH5O)

60 U/mL 

Female: 12 mg/dL Male: 13 mg/dL

Inflammation 22 Infection U/mL

228

C4 øonly when classical pathway is activated ⁄Consumption: e.g., SLE, RA, hereditary angioedema (from unopposed lysis of C4), glomerulonephritis, Henoch–Schönlein ø Protein intake/ absorption/ synthesis øCatabolism: e.g., Immune complex (ølevels may predict flares, such as lupus nephritis) Hereditary deficiency

229    )

  n   o    i    t   a    t   e   r   p   r   e    t   n    I

  s   t   s   e    T   s    i   t    i   t   a   p   e    H

      d   n      e   e    i   o      u   n    t      n    i       i       t   c   c   e      n   c    f      o   a   n      c    (   v    i    V   m  m    V   o    A    B   o   r   r    H   V    H   f    f   y    t   y   o    A   o    t    t    t    i    i    H    V   n   n   e   e    l    t   o    V   l   u   u    V   B    b    b    i    i   m  m   B   H    t   e    A    t   c   p   n    H   p   m  m   H   i   e   u   e   e    i    i   e   n    t    t   c   c   s   m  u   s    V   V   u   o   r   c   c    B    B   u   m   u    h    S   I    A   S   H   H   A   C

   R  r   A    C  o   M    P    T    C   s    i    t    i    t   a   p   e    H

   B   s    i    t    i    t   a   p   e    H

   A    B    I    R   –   V    i    t   C   n    A   H   –   c    i    t   B    M   g  n   H    I   a   –   c    i    t   B   n   H    A

  –

         –

  –                         

  –   s    i    t   B   –                –   –   n   H    A   g    A   s   –   –   –                 B    H   –    i    A    M    t   V   –   –          s    I   g  n   A    i    H   a    t    i    t   –   a    i    t   V   p   e   n   A    H    A   H   –             

LABS

LABS

  e    R   m   v   u    i    O    V    t   r    i    C   e   s    V    †   s    H   o    B   c    t   p   n    H     s   n    B    i   o   e   e    i    H   R  g   n   a   s    t    t    l   –    A   o   p   c    V   u  ,    i   a   r   e    C    f   c   e    t   O  s    i    t   n   r    H   a   n   n  e   B   c   o    f   n    l   a  ,   o   o    t   u   e   c    i    H   f    i    b      ø    t   m  m   e   c   n    i    R  e   n    i    V   n    t   h    i   e   o   n   v   v   e   o    i   r    i   r    O   p    t    C   o    i   m    t   r    t    f   i    i   e   i    t    i    f    t   r    H   n   n   u    V   s   s   c   w   y    h   e   c   o    i   c   y   B  o  s   e   e   V   r   l   c    t   r    f    l   c    t   e    H  p  u   i   r  ,    b   r   p   n   n   C   v   n  –   -   s   o      i    H   n    i   u   e   e     e   e    i   a   t    t   –   o   t   s   c    t   s   r    i   s   V  o   r    t   r   c   s   n   l   u   s   s    l    t   s   e   i   a   a   B   h   o   c   o   a   a   u   a   n    R   D      ø   F   H   C   N   A   P    P    F    C   P  a          –

  s   t    )   s   e     d    T    e     u   s     n    i      i   t     t    i   t     n   a    o      C   p    (   e    H

         –

  –

  o   o    C    /    C    /    S     ø    S      ⁄

                                     

      

  –

  –

230

231 Hepatitis A Infection Clinical illness Viremia ALT      r      e       t        i        T

Total anti-HAV

IgM anti-HAV

Stool HAV 0

1

2

3

4

5

6

Weeks after exposure

Adapted from CDC

Acute Hepatitis B Infection With Resolution ALT Symptomatic period Window period HBV DNA

Total anti-HBc

HBsAg

     r      e       t        i        T

IgM Anti-HBc

HBeAg 0

4

8

12

Anti-HBs

Anti-HBe 16 20

24

28 32

36

52

100

Weeks after exposure Adapted from CDC

LABS

LABS

Hepatitis C Infection In acute HCV with resolution: • Anti-HCV remains • HCV RNA disappears • ALT returns to normal

Symptons (20%)

Anti-HCV ALT in acute infection

     r      e       t        i        T

ALT in chronic infection HCV RNA in acute infection

0

4

2

3

4

5

6

Months after exposure May be negative HCV RNA window period

232

May be negative HCV RNA window period

233 Inflammatory Markers Test

⁄

Causes

Erythrocyte sedimentation rate (ESR)

⁄ Male: 50 y.o.: 15 mm/hr 50 y.o.: 20 mm/hr Female: 50 y.o.: 20 mm/hr 50 y.o.: 30 mm/hr

⁄ inflammation  † ⁄ESR; can monitor esponse to therapy; ⁄ in: Inflammation: e.g., Various rheumatolgic disorders, IBD Infection: e.g., TB, osteomyelitis, endocarditis, PID Metabolic changes: e.g., Pregnancy, thyroid diseases Renal disease: e.g., Glomerulonephritis, hemolytic uremic syndrome Heme/oncologic disease: e.g., Malignant neoplasms, ⁄⁄⁄ anemia False-positive: Anything interfering rouleaux formation: Severe leukocytosis ⁄⁄⁄ or abnormal RBCs: e.g., Spherocytosis, polycythemia Abnormal protein: e.g., Hypofibrinogenemia, hypogammaglobulinemia Drugs: High-dose corticosteroids

C–reactive protein (CRP)

⁄ 0.6 mg/dL

Diagnose/monitor: Tissue inflammation/injury (e.g., pancreatitis, IBD, rheumatologic disorders), infections (e.g., bacterial meningitis, sepsis, UTI, PID, TB), malignancy (e.g., lymphoma) If ⁄ 3 d postsurgery, suggests infection ⁄ CAD risk (i.e., coronary artery inflammation)

:

(continued )

LABS

LABS

Inflammatory Markers (Continued ) ⁄

Test

⁄ 0.5 ng/mL

Procalcitonin

Causes Severe infections: e.g., Acute malaria, meningitis, pneumonia, sepsis (especially children) Cardiopulmonary bypass

Rheumatologic Antibodies Anti– centromere

CREST syndrome, systemic sclerosis, scleroderma, Raynaud’s disease

Anti–histone

SLE, drug–induced lupus, but nonspecific (seen in many disorders)

Anti–Jo 1

Polymyositis/dermatomyositis, interstitial lung disease, Raynaud’s

Anti–Ku

SLE, polymyositis/dermatomyositis

Anti–Mi–2

Dermatomyositis/polymyositis

Anti– ribosomal P

Highly specific for SLE: Confirm diagnosis of CNS lupus (psychosis)

Anti– ribonucleoprotein

Specific for mixed connective tissue disease SLE (correlates with SLE activity, if antiribonucleoprotein is positive without presence of anti–dsDNA Abs, it means decreased risk of nephritis), drug–induced lupus, Sjögren’s, systemic sclerosis, RA

Anti– topoisomerase I (AntiSc1–70)

Highly specific for and suggests poor prognosis scleroderma: Associated with renal involvement

Anti– phospholipid

Antiphospholipid antibody syndrome: Anticardiolipin and lupus anticoagulant most commonly measured antiphospholipid antibodies Drugs: e.g., Some antibiotics, Ca2–channel blocker

234

235 SS–A/Ro and SS–B/La

Diagnose Sjögren’s syndrome and lupus with Sjögren’s overlap SLE: Useful to diagnose ANA-SLE (in ANA, SS–A and SS–B suggests nephritis) Antiphospholipid Ab syndrome (SS–A and cardiolipin Abs, lupus anticoagulant, and thromboses), neonatal lupus

Anti–doublestranded DNA (ds–DNA Ab)

Specificity for SLE anti–single-stranded DNA (anti–single strand seen in healthy patients, SLE pt. relatives, and other autoimmune disease; not useful for diagnosis): Diagnose and monitor SLE activity (especially lupus nephritis) Other autoimmune disease (usually øtiters): e.g., RA, Sjögren’s, Graves’, scleroderma, MCTD, antiphospholipid syndrome, autoimmune hepatitis Some infectious diseases: EBV, CMV Drugs: e.g., Minocycline, etanercept, infliximab, penicillamine

Rheumatoid factor ⁄ 35 mg/dL

Present in normal patients and more common as ⁄ age RA: ⁄⁄ initial titer † øprognosis, ⁄likelihood of being positive the longer pt. has disease Also: Autoimmune disease (e.g., Sjögren’s, poly/dermatomyositis, SLE, scleroderma, cryoglobulinemia, MCTD), some infections (e.g., bacterial endocarditis, osteomyelitis, TB, syphilis, hepatitis, EBV) and other disease (e.g., diffuse IPF, cirrhosis, primary biliary cirrhosis, sarcoidosis)

Lupus anticoagulant

Common in asymptomatic elderly and postpartum Various autoimmune and inflammatory disease: e.g., SLE, drug–induced lupus, RA, ulcerative colitis, HIV, hemophilia, multiple myeloma Drugs: e.g., Procainamide, hydralazine, dilantin, ACE inhibitors

LABS

LABS

Anti–Neutrophil Cytoplasmic Antibodies (ANCA) Cytoplasmic (C–ANCA)

Strong association: Wegener’s granulomatosis Moderate association: Crescentic glomerulonephritis Weak association: Polyarteritis nodosa

Perinuclear (p–ANCA)

Strong association: Crescentic glomerulonephritis Moderate association: Polyarteritis nodosa, Churg–Strauss vasculitis Weak association: Wegener’s granulomatosis Other possible: Henoch–Schönlein purpura, temporal arteritis

Atypical (x–ANCA)

Primary sclerosing cholangitis, primary biliary cirrhosis, autoimmune hepatitis, SLE, RA

Calcium Studies ⁄

Test Serum Calcium (Ca2)

10.2 mg/dL 

Causes of ⁄

ø

⁄ Vitamin D or 8.5 Ca2 intake mg/dL ⁄ PTH ⁄ Bone breakdown Hereditary disorders: e.g., Familial hypocalciuria Metabolic: e.g., ⁄⁄Thyroid, acromegaly, Addison’s Drugs: e.g., Thiazides, Li

236

Causes of ø Vitamin D/Ca 2 øintake/ ø absorption ø PTH or ⁄ calcitonin Ca2 sequestration: e.g., Saponification ø albumin: e.g., Liver disease øˆMg2 or ⁄ phosphorus (binds Ca2) Osteoblastic malignancy Drugs: e.g., Aminoglycosides

237 ⁄

Test Ionized Ca2

Causes of ⁄

ø

Causes of ø

4.4 5.3 Measures mg/dL physiologically mg/dL

ø with ⁄ blood pH/⁄ protein/

@ pH 7.4

active nonbound Ca2, ⁄ with ø blood pH or ø protein or ø albumin

⁄ albumin: e.g., Multiple myeloma, dehydration

300 mg /24hr

⁄ serum Ca2, 100 mg also specific renal disease:  /24hr e.g., Idiopathic hypercalciuria, RTA



@ pH 7.4

ø Serum Ca2, also specific renal disease and drugs (e.g., thiazides)

Urine Ca2 (UCa)



Parathyroid hormone (PTH)

Primary/ 55 secondary pg/mL ⁄ parathyroid ø Vitamin D



10 pg/mL

ø Parathyroid, ⁄ thyroid, sarcoid, ø Mg, nonparathyroid ⁄ Ca2

Vitamin D3: 25-hydroxy [25(OH)D3]



50 ng/mL



10 ng/mL

ø Sun exposure ø Vitamin D intake/ absorption Pregnancy Drugs: phenobarbital, phenytoin

1,25-hydroxy 76 [1,25 pg/mL (OH)2D3]

⁄Ca2 ⁄Vitamin D intake ⁄Sunlight exposure

20 pg/mL 

LABS

TOOLS

Frequently Used Numbers

General Laboratory Pharmacy Emergency Room Medicine Neurology Surgery OB/GYN Ophthalmology Dermatology Pediatrics Psychiatry Psychology Radiology Physical Medicine/ Rehabilitation Intensive Care Unit

238

239 CDC Recommended Adult Immunization Schedule 19–49 y.o. Diphtheria, tetanus, pertussis (Td, DTaP)

50–64 y.o.



65 y.o.

1 dose Td booster q10 yr Substitute 1 dose DTaP for Td

Human papillomavirus (HPV)

3 doses females

Measles, mumps, rubella (MMR)

1 or 2 doses

1 dose

Varicella

2 doses (0, 4–8 wk)

2 doses (0, 4–8 wk)

Inflluenza

1 dose annually

1 dose annually

Pneumococcal

1–2 doses

Hepatitis A (HAV)

2 doses (0, 6–12 mo; or 0, 6–18 mo)

Hepatitis B (HBV)

3 doses (0, 1–2, 4–6 mo)

Meningococcal



  y   c   n   a   n   g   e   r    P Td, DTaP

1 dose

1 doses

  r   e   *   c   t   n  n   a   e    C   m  ,    t   r   e   a   c   e   r   n   T   a    C

  c    i   c    t   r   i   n   a   n   y   e   o   r   r   o   r    H   h  a   h  ,   n   C   H   s   C  ,   o  ,    O   e   e   t    t   e   m    l   s   E   e   s   u  a    b  a   e    P   a   s   e    i   s    i    i    D   D    D

  r   n  s   e   e   r   v   i   v   o   a    i    i   n    L   G   t   c   e   c   a    l    i   e   F   p   n  s   s   o  a   t   r   e   l   o    A    h   s    i    C   D   C

  e   r   s   a   r    D    V   c   e      k    R    I    h  r    S    H    t    l   o    E   a   e   W    H

1 dose Td booster q10 yr Substitute 1 dose DTaP for Td

HPV

3 doses for females through 26 y.o. (0, 2, 6 mo) (continued )

TOOLS

TOOLS

CDC Recommended Adult Immunization Schedule (Continued )   y   c   n   a   n   g   e   r    P

   t   r   e   *   r    H   c   t   a   y   e  ,   c   r  ,    O   n  n    H   a    i   e   t   a    i   a   e  ,   e   s   n  n  s   E   n    C   e   s   a   c    l   o  a   o   m  ,    i   e   e   r   e   r   t    t   s   m  s   n   p   e   a   e   i    h   l    i   o   s   c   e   u   D  r    A   r    b   D   C   P   n   T    h   a   a    i    C    C    D

MMR

1 or 2 doses

Varicella

2 doses (0, 4–8 wk) 1 dose annually

Flu

Pneumonia 1–2 doses

1 dose

  r   n  s   e   e   r   e   r   s   v   v    i    i    t   o   a   r    L   G  c    D   c   e   -   k    V   c    R   a    i   e   F    S    I    h   r    t    H   n  s    l   o   a   t    E   a   o   r   e   l   e   W   s   o    h   i    H    C   D   C

2 doses 1 dose annually

1–2 doses

1–2 doses

HAV

2 doses

2 2 doses doses

HBV

3 doses

3 doses

Meningitis 1 dose

1 1 dose dose

Genital øimmune, leukemia, lymphoma, generalized malignancy, CSF leaks, treat with alkylating agents, antimetabolites, x-ray treatment, or ⁄ dose, long-term steroids HAV

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hepatitis A; HBV All patients

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hepatitis B; Flu

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influenza

Risk factor

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240

Contraindicated

241      6    s   –    r      4    y

  s   e    i   r      3    s   e   –    r   s      2    y    V    B      3    H      2   –      9    o      1    m

     8    o      1    m

  e   r   l    Y  u    d    6   e  –   h    0  c    S    d   e  n    d  o   n    i   e  t   a   m   z    i   m   n   o  u   c  m   e    R   m    I

   P   a    T    D

   V    P    P    V    C    P

  s    R   e   e    M   V   i   p   r   y  ,    4   e    t   s    M   s    V   a    l   e   z    V   S   n   s   a    A   P   e   e   u   m    H   M   fl

   b    i    H    )   s    )   e    l   s   a   o   u    d   a   n    l    l   n    (   e    2   a    R   c    (    i    V   r    V    b    M   u    i    C   V   l   a    A    P    H   P    I    F    M   V   H

   P   a    T    D

  n         i   s    R   u    l    i    M    h   M   p   ;   o   a   m  z   e   n   a   e   u    H   fl

  s   p   u   o   r    G    k   s    i    R      h   g    i    H

  n        i

   b    i         H   u   ;    l     o   s    F      5    i   s   ;      1    m   V   s   s   u    B   u   i   r    t   r    H   e   v     o   o   p   p   i      2    l   u  ,        1    m   s   o    h   p   u   c    t   n   d   l   a    P   a   a    t   e   c   a    t   a    b    V    t     o    C   e   a   c   o    T    i    C   o    t   v   c      6    m    R   D   H   P  ,    i    t   a   c   o    i   r   a   g   n   e   n   i    i   n    h    P    t   a   a    V    t    h        e     o    i    C   V   o    T    b   p   V   m    i    P      4    m    R   D   H   P    I    d   P         I        ;    4   e    V    P   i   n   a   c    S    P   a    T   c    P    t   a    b    V   V     o    D   a    M    i   o    T    C   P   ;   v   ;      2    m    R   D   H   P    I   s   s   e    A    V   u   e    t   r   a   s    i   g    B   v   g   i    t    A    H   a   u   i    f    d    t    j    t   a   o   e   o     o   r   n    d   o   p   e   e   c   g   n      1    m         l    h   n   e   a   a        a    t   m   o   c   c    V    R  m    R   o   A      h   o   ;   c    V     t   c    H   o    r    B    B   e      i   ;   s   m    R   a    i      B    H    t   u   l    l    i    t   e   e   a   n   b   p   p   u     a   r   e      l      l      4    h       ,     e      V        V   s   p     c      R      P      i      S    C      V     a     t     a    u     V     V    r      V     P    V   P   m      M    u      B     o     T     l     a      A      fl     C     P     l    B   ;   u      H     R     D     H     P     I      F      M     V     H     M   H   B   m

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CDC Recommended 7–18 Yr Immunization Schedule 7–10 yr

11–12 yr

13–14 yr 15 yr

DTaP

DTaP

HPV

HPV (3 doses)

16–18 yr

DTaP HPV series MCV4

Meningococcal MPSV4

MCV4

MCV4 PPV

Pneumococcal

Inflluenza (yearly)

Flu HAV

HepA series

HBV

HepB series

IPV

IPV series MMR series

MMR

Varicella series

Varicella Range of Recommended Ages

High-Risk Groups

Catch-Up

HBV hepatitis B; DTaP diphtheria, tetanus, pertussis; PPV pneumococcal polysaccharide vaccine; IPV inactivated poliovirus; Flu influenza; MCV4 meningococcal conjugated vaccine; MMR measles, mumps, rubella; HAV hepatitis A; HBV hepatitis B 

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242

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243 ECG Interpretation

P

QRS

T

P

Q

R

S

P-R interval

Normal Rate 60–100 bpm 0.04 sec Normal P-R 0.12–0.20 sec 0.20 sec Normal QRS 0.08–0.12 sec atrial depolarization; QRS ventricular P wave ventricular repolarization depolarization; T wave

Microbiology Normal Flora Skin

-Hemolytic streptococci Coagulase-negative staphylococci Bacillus species α

Respiratory

-Hemolytic streptococci (not Enterococcus ) Nonhemolytic streptococci Corynebacteria species Neisseria  species Coagulase-negative staphylococci* Haemophilus inflluenzae*  H. parainflluenzae*  α

(continued )

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Microbiology

(Continued )

Moraxella catarrhalis*  N. meningitidis*  Streptococcus pneumoniae*  Genitourinary Tract -Hemolytic streptococci (not Enterococcus ) Nonhemolytic streptococci Coagulase-negative staphylococci * Corynebacteria species Lactobacilli α

*If not predominant in specimen

Patient List Name

Location

244

Diagnosis/Notes

245 Test Results Patient Name: Test

Date/Time

Result

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Notes

246

247 Index A

C

Abdomen, 30, 59–60, 177–185 Abscess, 37–39, 167, 181 Acetaminophen toxicity, 193–194 Acid/base disorders, 134–135 Acute renal failure, 84 Amenorrhea, 81–82 Anemia, 85–87, 203–205 Angina, 5 Angioedema, 140 Ankylosing spondylitis, 189 Anticoagulants, 145–147 Antidiabetes medications, 148 Antineutrophil cytoplasmic antibodies, 236 Antinuclear antibody test, 227 APGAR score, 115–116 Appendicitis, 60, 183 Arterial line placement, 14–16 Arthritis, 35–38, 188–189 Arthrocentesis, 35–38 Ascites, 28–30, 179, 185 Asthma, 140–141 Azotemia, 83

Calcium correction, 133 Calcium studies, 236–237 Cancer detection guidelines, 1–2 Cardiac arrhythmias, 2, 7–8 Cardiac markers, 210 Cardiovascular hemodynamics, 119–121 Catecholamine–secreting tumors, 219–220 Catheters/catheterization, 15, 20–22, 32–35, 174 Central nervous system assessment, 108–110 Central venous lines, 17–20, 174 Cerebellar disorders, 41–42, 50 Cerebral spinal fluid analysis, 118, 194–196 Cervical cancer, 1–2 Cervical spine imaging, 167–170 Cervicitis, 162–163 Charcot’s arthropathy, 188 Chest imaging, 170–177 Childbirth, 65–67, 158–159 Chorionic gonadotropin, 235 Chronic obstructive pulmonary disease, 141 Cirrhosis, 112, 182 Coagulation, 200–202 Colitis, 178–179, 184 Colon cancer, 1 Complement values and disorders, 228 Cranial nerves, 40–41

B

Bile–binding resin, 154 Biophysical profile score, 116 Bone radiography, 187–191 Brain, 40–41, 48–50 Brain natriuretic peptide, 211 Breast cancer, 1 Budd–Chiari syndrome, 183

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Creatinine clearance, 131 Cricothyroidotomy, 9–10 Crohn’s disease, 184 Cysts, 176–177, 182

Frequently used number template, 238 G

D

Deep vein thrombosis, 145–147 Diabetes mellitus, 88–90, 131, 147–148 Diabetes insipidus, 198 Diagnostic peritoneal lavage, 30–32 Diverticulitis/diverticulosis, 179, 184

Gallbladder disease, 60, 183 Gastrointestinal bleeding, 91 Gastrointestinal equations, 129–130 Genitourinary tract flora, 243–244 Glasgow Coma Scale, 108 Glenohumeral joint instability, 74 Glucose tests, 215–216 Gout, 188

E

Ear examination, 53 Electrocardiogram, 2–8, 243 Electrolyte values, 220–221 Endometrial cancer, 2 Endotracheal intubation, 11–13, 173 Energy calculations, 137 Epididymitis, 61–62 Epilepsy, 159–161 Extrapyramidal disorders, 41–42 Eye examination and anatomy, 51–52 F

Fatty liver, 182 Feeding tube placement, 26–28, 174 Fetal presentations, 67 Fibric acid derivatives, 154 Fluid requirement calculations, 138–139 Fontanelle closure, 68 Fractures, 165, 169, 190–192

H

Head computed tomography, 110, 165–167 Headache, 109–110, 151–152 Hearing tests, 53 Heart disease, 2–8, 54–56, 111, 143–145, 149–151, 173 Heart rate values, 2 Heart sounds, 55–56 Heart valves, 54–55, 122 Helicobacter pylori, 153 Hemangioma, 182 Hematology values, 123 Hematuria, 92 Hemochromatosis, 182 Hemophilia, 188 Hepatitis, 229–232 Herpes simplex, 162 Homeostasis, 132–134 Hydrocele, 62 Hypercalcemia, 93 Hyperkalemia, 94–95 Hyperlipidemia, 153–154

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249 Hypernatremia, 96 Hyperprolactinemia, 80 Hypertension, 154, 156–158, 182 Hypocalcemia, 97 Hypogonadism, 80–83 Hypokalemia, 98 Hyponatremia, 99 Hypoprolactinemia, 80 Hypoxia, 100–102 I

Immunization schedules, 239–242 Infertility algorithm, 103 Inflammatory markers, 233–235 Inotropes, 144–145 Insulin, 147 Intestinal obstruction or perforation, 157, 178 Intra–aortic counterpulsation devices, 174 Intussusception, 179, 184 Iron deficiency, 124, 204–205

Liver function tests, 212–214 Lumbar puncture, 8–9 Lung cancer, 171 Lung volumes and values, 125–129 M

Mechanical ventilation, 102, 104–106 Mediastinal masses, 172 Ménière’s disease, 112 Migraine, 109–110, 151–152 Muscle/motor disorders, 41–42 N

Nasogastric tube placement, 26–28, 174 Necrotic bowel, 157 Nephrotoxic agents, 83 Neurodegenerative diseases, 167 Niacin, 153 O

J

Joint fluid analysis, 37–38 Jugular venous pressure measurement, 57–58 K

Ketoacidosis, 88–90 Kidney stones, 184–185 Knee examination, 74–77 L

Labor, 65, 114, 158–159 Lead testing, 193 Lipid values, 209–210 Liver disease, 112–113, 181–183

Obstetrics, 65–67, 69, 114–115, 136, 185–187 Optic nerve, 51–52 Osteonecrosis and osteoporosis, 189–190 Ovarian failure, 80 Oxygen therapy indications, 142 P

Pancreatic tests, 216–217 Pancreatitis, 113, 183 Paracentesis, 28–30 Patient list template, 244 Pelvic inflammatory disease, 116–117, 157

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Pericardiocentesis, 13–14 Pericarditis, 5 Peripheral nerve anatomy and testing, 43–46 Peritoneal fluid assays and lavage, 30–32 Peritonitis, 157, 185 Pheochromocytoma tests, 219–220 Placenta disorders, 66 Platelet values and disorders, 208–209 Pleural effusion and fluid assays, 13, 22, 25, 173 Pneumonia, 142–143, 173 Pneumoperitoneum, 179–180, 185 Pneumothorax, 172 Portal venous hypertension, 182 Potassium correction, 133 Pregnancy, 115, 136, 147, 158–159, 187 Premature atrial and ventricular complexes, 7 Prinzmetal’s angina, 5 Prolactin values, 197 Prostate cancer, 2 Prostate–specific antigen, 219 Pulmonary tests, volumes, and values, 125–129 R

Ranson’s pancreatitis criteria, 113 Rectal cancer, 1 Red blood cell values and disorders, 123, 205–207 Referred pain sites, 47

Reflex innervation and testing, 43–44 Reiter’s syndrome, 189 Renal azotemia, 83 Reproductive hormones, 196–197, 223–225 Respiratory tract flora, 243–244 S

Sarcoid, 173 Scabies, 163 Scrotal disorders, 61–62 Seizures, 158–161 Sensory disorders, 41 Serum–ascitic albumin gradient, 30 Sexually transmitted infections, 161–163 Shock, 144–145 Shoulder examination and disorders, 70–74 Skin, 70, 243 Skull fractures, 165 Sodium correction, 132 Soft–tissue calcifications, 190 Spermatocele, 62 Stroke, 108, 166 Subdural hematoma, 166 Sweat chloride, 211 Syndrome of inappropriate antidiuretic hormone, 198 Systemic lupus erythematosus, 163–164 T

Tanner development stages, 63–64 Test result template, 245 Testicular disorders, 61–62

250