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79 Cards in this Set
- Front
- Back
Non-ICU CAP Treatment
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Standard Empiric:
1. Ceftriaxone 1g IVPB STAT then qd 2. Azithromycin 500mg IVPB STAT then qd Alternative Empiric (failed outpatient Rx, suspected resistant orgs, beta-lactam allergy): 1. levofloxacin 750mg qd x 5 days |
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Complicated Female UTI
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1. ampicillin 1-2g IV q6hrs x 7-14d + gentamicin 3-5 mg/kg/day x 7-14d
2. Ceftriaxone 1g IV qd x 7-14d 3. Zosyn 3.375 g IV q6-8hrs x 7-14d |
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Short Acting Insulin
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1. human insulin (novolin/humulin)
2. Aspart (Novolog) 3. Lispro (Humalog) |
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Long-Acting Insulin
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1. NPH
2. Detemir (Levemir) 3. Glargine (Lantus) |
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Sulfonylureas
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1. Glyburide
2. Glipizide 3. Gliclazide 4. Glimepiride |
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Incretin Mimetic (GLP-1 Receptor Agonist)
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Exenatide (Byetta)
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Metformin
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aka Glucophage
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Beta Blockade in CAD
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Titrate to resting HR 55-60 and approximately 75% of the HR that produces angina with exertion
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VTE Prophylaxis
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Standard:
1. Enoxaparin 40mg SC daily BMI > 30 or high VTE risk: 1. Enoxaparin 40mg SC bid GFR < 30 1. Enoxaparin 30mg SC qd *Caution if GFR < 15 |
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Stress Ulcer Prophylaxis
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Mechanical ventilation, home PPI/H2 blocker Rx, coagulopathy + 1 risk factor, or at least 3 risk factors
1. Pantoprazole 40 mg PO/IV qd or 2. Famotidine 20 mg PO/IV bid |
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Stress Ulcer Risk Factors
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1. Sepsis / Shock
2. Hepatic / Renal Failure 3. Significant Trauma 4. Post-OP Transplant 5. High-Dose Steroids 6. Extensive Burns |
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Diets
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1. Regular
2. Carb Controlled 3. Low Fat 4. 2 gram Na 5. Mechanical Soft 6. Clear Liquid |
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Adult Vaccinations
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1. Pneumococcal - age > 65 x 1
2. Influenza (Oct-Feb) - contraindicatd if egg allergy 3. Pertussis |
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Antiemetics
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1. Metoclopramide (Reglan)
2. Prochlorperazine (Compazine) |
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Constipation
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1. Docusate Sodium (100 mg PO bid)
2. Milk of Magnesia (30 ml PO bid PRN) |
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Sleep Hygeine
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1. Go to bed only when tired
2. Bed/bedroom only for sleep/sex 3. Fixed wake-up/bedtimes (regardless of amt of sleep) 4. Avoid naps 5. Get out of bed if unable to sleep w/in 15-20 min 6. No ETOH after 4pm 7. Fixed meal times |
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Hypnotics
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1. Benzos = temazepam (15 mg PO qhs)
2. Nonbenzos = zolpidem, zaleplon, eszopiclone 3. Melatonin receptor agonist (ramelteon) |
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Portosystemic Anastomoses
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1. Left gastric -- > esophageal
2. Paraumbilical -- > superficial / inferior epigastric (caput) 3. Superior rectal -- > middle / inferior rectal (internal hemorrhoids) |
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Diverticulosis
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- painless hematochezia
- 2/2 low fiber diet |
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Diverticulitis
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- fever, leukocytosis, LLQ pain
- BRBPR - colovesicular fistula -- > pneumaturia |
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Aminotransferases
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- ALT > AST in viral hepatitis
- AST > ALT in alcoholic hepatitis - AST elevation in MI |
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Hepatocellular Carcinoma
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- Hep B/C, Wilson's, hemochromatosis, alpha-1 AT, alcoholic cirrhosis
- polycythemia - hypoglycemia - alpha fetoprotein - hematogenous spread |
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Cholelithiasis
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- Female, fat, forty
- Crohn, CF, rapid wt loss - Charcot triad = jaundice, fever, RUQ pain - cholesterol stones = radiolucent - pigment stones = radiopaque |
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PT
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Extrinsic (I, II, V, VII, X)
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PTT
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All factors except VII, XIII (intrinsic)
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Causes of Acute Pancreatitis
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1. Choledocholithiasis (esp < 5mm)
2. ETOH 3. Drugs 4. ERCP 5. Hyperlipidemia (esp TG > 1000) 6. Hypercalcemia 7. Infection 8. Autoimmune 9. CF |
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Acute Pancreatitis Eval
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1. Hydration status (sequestration) - HR, orthostatics, high HCT, BUN)
2. Abd pain radiating to back; guarding, rebound, distention 2. Jaundice 3. Bowel Sounds (Ileus) 4. Flank / umbilical ecchymosis (Grey-Turner / Cullen) 5. CRP indicative of severity |
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Ascending Cholangitis
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- Gallstones + fever, chills, and/or rigors
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Amylase
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- High sens / low spec
- Elevated w/ intestinal ischemia, chronic renal insuff, perforated peptic ulcer, and disorders of salivary glands, fallopian tubes |
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Lipase
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- More sensitive than amylase in acute alcoholic pancreatitis or late presentation (prolonged elevation)
- Elevated in chronic renal insuff, head trauma / intracranial mass, heparin therapy (LPL activation), critical illness |
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Peritoneal Signs
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- Rebound tenderness
- Guarding - Involuntary rigidity |
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Phlegmon
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Walled off inflammatory mass without bacterial infection that may be palpable on physical examination
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Diverticulitis Organisms
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- Bacteroides
- Peptostreptococcus - Clostridium - Fusobacterium - E. coli - Strep |
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Complicated Diverticulitis
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- Abscess or phlegmon
- Fistula - Stricture - Bowel obstruction - Peritonitis |
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Diverticulitis Presentation
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- Fever, leukocytosis, LLQ pain
- Constipation - Perirectal fullness - Trace + guaiac |
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Diverticulitis Mortality
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Stage 1-2: < 5% (abscess)
Stage 3 = 13% (perforated -- > purulent peritonitis) Stage 4 = 43% (free rupture of uninflamed diverticulum) |
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Diverticulitis Diagnosis
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CT (95/100% sens/spec)
- Diverticula - Inflammation of pericolic fat / adjacent tissues - Wall thickness > 4mm - Peridiverticular abscess |
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Outpatient Diverticulitis Treatment
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Outpatient
- Cipro + metronidazole x 7-10d - TMP-SMX + metronidazole - Amoxicillin-clavulanate |
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Inpatient Diverticulitis Treatment
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- Unable to tolerate PO
- Requiring narcotic analgesia - Complicated diverticulitis - Make NPO - NGT if obstruction / ileus - Flagyl + cipro/ceftriaxone |
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Psoas Sign
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Passively extend thigh while lying on side with knees extended
- Appendicitis in retrocecal orientation |
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Depression Screen
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1. Sleep
2. Interest 3. Guilt 4. Energy 5. Concentration 6. Appetite 7. Psychomotor 8. Suicide |
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Causes of Hypernatremia
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Sustained hyperNa only occurs when thirst or access to water is impaired
1. Net Water Loss - Pure water loss (DI, unreplaced insensible losses) - Hypotonic fluid loss (vomiting / diarrhea, NGT, osmotic diuresis, diuretics, burns) 2. Hypertonic Sodium Gain (bicarb, primary hyperaldosteronism, Cushing's, hypertonic feeding preparation) |
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Signs / Symptoms of Hypernatremia (Adults)
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- Elderly often w/ few symptoms until Na > 160
- s/s of dehydration (tachycardia, decr turgor, dry MMs) - Thirst (dissipates as hyperNa progresses) - ALOC (correlates to severity) - Muscle weakness - Convulsions, coma - Orthostasis, tachycardia 2/2 hypovolemia - Brain shrinkage -- > vascular rupture (large acute changes) |
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Hypernatremia Management
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1. Treat Underlying Cause
- Stop GI losses - Control pyrexia - Normalize glucose - d/c diuretics, lactulose, Li - Treat hyperCa, hypoK 2. Correction of HyperNa - Rapid correction (1 mmol/L per hour) if developed over period of hours - Slow correction (0.5 mmol/L per hour) w/ goal decrease in serum Na of 10 mmol/L per day --- > 145 mmol/L - Pure water, D5W, one-quarter normal saline, half normal saline (decr infusion rate req'd for lower tonicity of fluid) 3. Anticonvulsant Rx, airway management if seizures |
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Change in Serum Na
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Effect of 1L infusate on serum Na:
[Infusate Na - Serum Na] / TBW + 1 Effect of 1L infusate containing Na and K: [(Infusate Na + infusate K) - serum Na] / TBW + 1 **divide goal change in Na by calculated change in Na for 1 L solution to obtain total # L solution req'd |
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Infusates
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D5W = 40% ECF distribution
1/4 NS (34 mmol/L), 55% ECF distribution 1/2 NS (77 mmol/L), 73% Ringer's Lactate (130 mmol/L), 97% NS (154 mmol/L), 100% |
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TBW
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TBW = ECF (40%) + ICF (60%)
Nonelderly men = 0.6 x body wt Nonelderly women = 0.5 x body wt Elderly men = 0.5 Elderly women = 0.45 |
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D5W
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ECF distribution = 40%
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Normal Saline
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- 0.9% = 154 mmol/L
- 100% ECF distribution |
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Half Normal Saline
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- 77 mmol/L
- 73% ECF distribution |
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Ringer's Lactate
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- 130 mmol/L Na
- 97% ECF distribution |
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UC CRC Surveillance
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After 8 yrs if pancolitis, 15 yrs for L sided colitis. Repeat q1-2 yrs
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Wells Score for PE
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1. Clinical s/s of DVT (minimum leg swelling + pain with palpation)
2. Alternative dx less likely than PE 3. HR > 100 4. Immobilization or surgery w/in previous 4 wks 5. Previous DVT/PE 6. Hemoptysis 7. Malignancy |
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Iron Deficiency s/s
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- Anemia
- Angular cheilosis - Atrophic glossitis - Pica - Koilonychia - Plummer-Vinson (Fe deficient anemia, esophageal web, atrophic glossitis) |
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Non Gap Acidosis
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1. RTA
2. GI Losses 3. Ureteral fistula 4. Pancreatic fistula 5. Acetazolamide |
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AFFIRM Trial
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Rate control = rhythm control in a-fib
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Goal Hgb in CAD
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> 9-10
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CHADS-2
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CHF, HTN, A, DM, Stroke
0 -- > ASA only 1 -- > ASA / coumadin / dabigatran 2+ -- > warfarin / dabigatran |
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Pulmonary Edema 2/2 CHF
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1. Lasix
2. Morphine (venodilation) 3. Nitrates 4. Oxygen 5. Position / PPV |
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Metformin
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d/c for Cr > 1.5 in men (1.4 in women) -- > risk of lactic acidosis with IV contrast
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SubQ Heparin
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- DVT ppx in renal failure
- tid dosing - Incr risk of HIT |
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Iron Deficiency DDx
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- Chronic bleeding (GI, menstrual)
- Malnutrition - Malabsorption (Celiac, Crohn's, incr gastric pH, subtotal gastrectomy) - Increased demand (pregnancy, EPO) |
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Inpatient DM Management
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- Sliding scale insulin + Lantus
- d/c metformin - serious acute illness predisposes to lactic acidosis - Normal serum Cr at d/c prior to restarting metformin |
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AMS DDx
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- Hypoxia
- Infection / sepsis - Hypercarbia - Brain injury - Drug intoxication / withdrawal - Uremia - Endocrine / metabolic - Acid/base imbalance - DTs - Delirium - Pain, fever - Dementia |
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Warfarin Interactions
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- Broccoli, fresh melon, spinach
- Amiodarone - Antibiotics (esp consider in patients treated for UTI) - NSAIDs |
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IV Nutrition
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D5W = 200 calories per liter
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VBG -- > ABG
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pH increases 0.03 - 0.05
PCO2 decreases 3-5 mmHg |
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Causes of Hypercalcemia
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- CHIMPANZEES
1. Calcium (supplements) 2. Hyperparathyroidism 3. Infection (esp granulomatous - cocci, TB, histo) 4. Mets, Milk of Ca 5. Paget's Disease, TPN 6. Addison's Disease 7. Neoplasm 8. Zollinger-Ellison 9. Endocrine (thyrotoxicosis, pheo) 10. Excess Vit D 11. Sarcoidosis |
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Treatment of Hypercalcemia
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1. NS (4-6 L) to prevent renal failure
2. Bisphophonates 3. Calcitonin (rapid tachyphylaxis) 4. Lasix if volume overloaded 5. Steroids (? utility in malignancy, granulomatous disease, Vit D intoxication) |
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C. Diff Toxin
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- May persist up to 1 yr post-infection
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ESR > 100
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- Paraproteinemia
- Infective endocarditis - Giant cell arteritis - Osteomyelitis - Subacute thyroiditis |
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Hypercalcemic Crisis
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- Ca > 13-15
- Polyuria - Dehydration - Mental status changes |
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Neupogen
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- aka filgrastim
- G-CSF analog - Treatment of neutropenia s/p chemo |
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Tertiary Hyperparathyroidism
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Renal failure -- > wasting -- > parathyroid hyperplasia -- > s/p renal transplant
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Common bone mets
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1. Lung
2. Thyroid 3. Prostate |
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Linezolid
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- G+ including MRSA, VRE
- MAO inhibition |
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Tumor Lysis Syndrome Labs
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1. Uric acid
2. Phos 3. Calcium 4. Creatinine (urate nephropathy) |
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Tumor Lysis Syndrome Treatment
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- Allopurinol
- IVF +/- diuretics - Rasburicase (recombinant urate oxidase) - Alkalinization of urine (bicarb) to increase urate solubility (may cause metabolic alkalosis or CaPO4 precipitation) - Consider HD if uric acid or phos > 10 - HD if uric acid or phos > 10 |
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GI Cocktail
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1. 30cc Maalox
2. 10cc viscous lidocaine |