Master the Wards Notes

CARDIOLOGY

effects Orthostasis

CHEST PAIN  pain changes with body position or breathing?  chest wall tenderness?  pain on exertion? Get an EKG:  compare with an old EKG  ST depression  give LMW heparin  ST elevation  angioplasty or thrombolytics Quality of pain Pleuritic, changes with respiration Pleuritic Pleuritic Radiates to back Tenderness Epigastric pain

Non-Cardiac Chest Pain Features Likely Dx Fever, cough, Pneumonia sputum, dyspnea Sudden onset, Pneumothorax or sharp pain, dyspnea PE Positional, relief Pericarditis with sitting up wide mediastinum Aortic dissection on CXR Tender on palpation Costochondritis Burning quality GERD

Anaphylaxi s PE

Tests X-ray, ABG, oximeter X-ray, ABG, oximeter CT angiogram for PE EKG CT angiogram, MRA, TEE None Improves with antacids

HYPOTENSION  systolic BP ≤ 90 mmHg  treat first, diagnose later! 1. repeat BP manually 2. position patient feet up, head down 3. give fluid bolus 250 - 500 mL normal saline over 15 to 30 minutes Etiology Dehydratio n

Initial clues BUN:creatinine ratio > 15 - 20:1

Sepsis

Fever leukocytosis Rales S3 JVD on exam

MI

Arrhythmia Drug side

Palpitations, syncope β-blocker or Ca++

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Confirm with… Low urine Na+ ˂ 20 mEq/L High urine osmolarity ˃ 500 mOsm/L Blood cultures

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CXR echo high BUN troponin EKG Drugs in history

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channel blocker BP normalizes lying flat Foods, insect bites, drug reaction Sudden dyspnea; recent surgery

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Tilt table test

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History of drug allergies elevated eosinophils CT angiography

How NOT to Kill Your Patient (Contraindications to Therapy) Treatment What to ask about Antiplatelets: ASA, clopidogrel Bleeding Enoxaparin, heparin Bleeding ASA Allergy β-blockers Low BP, severe asthma, COPD Nitrates Low BP Statins Liver dysfunction, myositis ACE inhibitors Hyperkalemia, Hx of cough from ACE-I ARB, spironolactone, eplerenone Hyperkalemia Spironolactone Gynecomastia  heme-postive stool alone is not a contraindication to using ASA, clopidogrel, prasugrel, ticagrelor, or heparin ACUTE CORONARY SYNDROME (ACS)  HISTORY consistent with ischemia is more important than EKG or enzymes  treat for ACS even if the EKG is normal  Troponin & CK-MB do not rise until 3 - 4 hours after the onset of pain  pain is ischemic if it is described as:  dull, squeezing, or pressure  on exertion  substernal  lasts 15 - 30 min/episode  does not change with position, respiration, or on palpation  pain is NOT ischemic if it is described as: o left/right sided o worsen or improves with positon or breathing o sharp, stabbing, or point-like o few seconds in duration o continuous for hour or 1-2 days  

Stress Testing: used when uncertain if patient has an acute ischemic event Angiography  STEMI  ST depression with persistent chest pain despite ASA, clopidogrel, heparin, metoprolol, & nitrates

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ST depression with recurrent chest pain recurrent episodes of ischemic-type chest pain with normal EKG reversible ischemia on stress test

Troponin

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CK-MB

Cardiac Enzymes Rises at 3 – 4 hours Max sensitivity at 12 - 18 hours positive for 1 – 2 weeks

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Rises at 3 – 4 hours Max sensitivity at 12 – 18 hrs positive for 1 – 2 days

Myoglobin

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Rises at 1 – 4 hours

Catheterization

clear history & abnormal EKG need evaluation for angiography

Brain Natriuretic Peptide (BNP)

when etiology of dyspnea unclear

Stress test

when history & EKG are not clear

Echocardiogra m

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Telemetry

continuous EKG monitoring

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looks at wall & valve motion ejection fraction

negative first test excludes nothing  positive test suggests MI  false positive with CHF & renal failure  cannot detect reinfarction from last week  negative first test excludes nothing  positive test suggests MI  best for detecting reinfarction  lacks specificity  negative test at 4 hours excludes MI  positive test is USELESS continued pain with max medical therapy requires angiography  normal BNP excludes CHF  abnormal test is nonspecific  looks for reversible ischemia  catheterize abnormals  normal wall motion excludes MI  high troponin with normal wall motion = false-positive troponin required for ALL ACS patients 

ENDOCRINE

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ICU consult underlying cause of DKA

DIABETES MELLITUS Stress hormones: cortisol, catecholamines (Epi/NE), glucagon, growth hormone  raises glucose & FFA levels IMPORTANT Diagnostic Tests  ICU: labs every 2-4 hr for the first 24 hr  serum HCO3-, anion gap (acidosis elevates K+)  serum HCO3-, glucose, & K+  glucose & K+ levels  ABG or VBG pH in DKA: ABG = VBG  ABG (or VBG)  ICU: treat to resolve acidosis Treatment  1-2L NS/hour for 2-3 hr ICU admission based on acidosis (low serum HCO3- & pH 200 mg/dL “Painless” Thyroiditis Adenoma (TH) abuse Thyroiditi  treatment: diet, exercise, & weight loss s  medications TSH low low low HIGH low  start with metformin 500 mg bid Radioactive HIGH low low high low (renal insufficiency may lead to metabolic or lactic acidosis) I- uptake  can add sulfonylurea, TZDs, or DPP-4 features eye/skin non-tender TENDER involuted,  if 3-4 oral meds not effective HbA1c Common Oral Hypoglycemics Contraindications findings, non-palpable 10/min used to evaluate severity of bleeding if no orthostasis on initial assessment, bleeding is NOT severe (CBC f/u takes 6-12 hr to determine if Hct drop is consistent w/ severe bleeding) for severe bleeding, give: fluids, PLTs, blood, plasma

Esophageal Varices  add Octreotide immediately  banding via endoscopy (alternative is: sclerotherapy)  EKG: assess for MI due to severe anemia & GI bleeding  beta-blockesr (propranolol & nadolol) DO NOT help acute bleeding  know pt’s…CBC, PT/INR, BP, & response to fluids if asked  CBC CANNOT determine severity of bleeding!  Hct only drops 2-3 points with hydration.  Symptomatic anemia requires a transfusion.  symptoms: lightheadedness, dyspnea, fatigue, chest pain Evaluating GI Bleed #1 is to establish SEVERITY! CHECK for ORTHOSTASIS!  WHEN did bleeding start?  STOOL is red or black?  VOMITING bright red or dark “coffee grounds”?  NUMBER of bowel movements or vomiting w/ bloody or black stools?  SYMPTOMS: lightheadedness, SOB, chest pain?  HEART DISEASE Hx?  SCOPE via mouth or rectum previously?  ANTACID use? GASTROENTEROLOGY GI BLEEDING severity is more important than etiology if bleeding is severe…resuscitate with fluids & blood! SBP 1 cm or multiple ulcers  recurrence after H. pylori eradication  distal location near ligament of Treitz  diarrhea (due to acid inactivation of lipase) Diagnostic Tests  serum gastrin (pt must be off PPIs & antacids)  confirm with secretin testing (normal: decrease in gastrin; abnormal: gastrin stays high)  confirm ZES is local & resectable by excluding metastasis via endoscopic U/S & nuclear somatostatin receptor scan Treatment  surgical removal of local disease  lifelong PPIs for metastatic or unresectable disease Diabetic Gastroparesis chronic DM causes nerve damage Presentation  bloating  nausea  constipation  abdominal discomfort Diagnostic Tests nuclear gastric emptying study with barium-soaked bread Treatment  metaclopramide  erythromycin GERD MCC: abnormally relaxed LES; causes 25% of chronic cough ask about…  radiating pain/discomfort?  heartburn? chest pain?  bad taste in mouth? tastes like metal?  sore throat? hoarseness?  night cough? Diagnostic Tests  assess response to Rx with PPIs; 95% resolve within 1 day  specific tests only if symptoms persist  perform EGD or 24-hr pH  surgical resection (Nissen fundoplication) if uncontrolled with PPIs *H. pylori DOES NOT cause GERD

Barrett’s Esophagus

a/w long-standing GERD >5 yrs Dx by EGD (confirm with biopsy) 0.5%/yr develop adenocarcinoma Rx: PPIs & repeat EGD every 2-3 yrs Esophageal Dysplasia from Barrett’s Esophagus  Low-grade dysplasia: PPI & reassess every 6 months  High-grade dysplasia: PPI & endomucosal resection w/ endoscope, OR distal esophagectomy Pancreatitis Presentation  severe epigastric pain & tenderness on palpation!  radiating to the back  nausea & vomiting  Hx of alcohol use  Hx of gallstone disease (increasing due to obesity) Diagnostic Tests  elevated amylase & lipase (lipase is more specific)  Ranson’s Criteria (obsolete): elevated WBC, low Ca++, age >55, high AST & LDH  determines the need for surgical debridement (before CT scans were in use)  CT scan is most sensitive to confirm Dx (but usually unnecessary)  CT & U/S show causes of pancreatitis (stones, obstruction, etc)  used to determine if stone removal is needed  MRCP (magnetic resonance cholangiopancreatography) can diagnostically visualize ductal structures of pancreas & biliary system  ERCP therapeutically removes stones & dilates strictures *MRCP finds the obstruction, ERCP fixes it! Treatment  provide “rest” of the pancreas & IV fluids (150-250 ml/hr)  MCC of death in acute pancreatitis is inadequate fluid replacement

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pancreatic inflammation releases mediators that cause capillary “leaks” NPO analgesics PPIs may help CT with >30% necrosis needs imipenem or meropenem & CT-guided biopsy

infected necrotic pancreatitis (rare) need surgical debridement

Infectious Diarrhea  

SEVERE = volume-depleted & febrile know about….  duration of symptoms  fever?  frequency of bowel movements  lightheadedness?  blood in stool?  others with diarrhea? Diagnostic Tests  blood is only present with invasive pathogens: Campylobacter, Salmonella, Shigella, Yersinia, or Vibrio.  fecal leukocytes (WBCs) = invasive pathogens present  stool culture helps distinguish between pathogens  if blood is NOT visible….  occult blood (guaiac)  fecal leukocytes (methylene blue stain)  culture  ova & parasite exam History Organism AIDS