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Differential for new CXR infiltrate in HIV positive patient
PCP, kaposi, lymphoma, CMV, TB, cryptococcosis, hemophilius, cryptococcus, mycoplasma, chlamydia
Well’s criteria
- Signs and symptoms of DVT (3)
- PE is most likely diagnosis or equally likely (3)
- HR> 100 (1.5)
- Immobilization 3 days, or surgery in last 4 wks (1.5)
- Previous hx of PE/DVT (1.5)
- Hemoptysis (1)
- Malignancy (tx 6months) or palliative (1)
Precipitants of DKA
- Recent surgery
- recent trauma
- Pregnancy
- MI
- Infection
- Non-compliance or wrong insulin dose
History for Diabetic Control
Last dose of insulin taken? missed doses? usual sugars?
Symptoms: polyuria, polydipsia
Diet, exercise
Drugs, Alcohol, Smoking
Complications: retinopathy, neuropathy, nephropathy, infections
Investigations in DKA
ABG, lytes, glucose, serum ketones
Lytes to monitor: Na, Ca+2, PO4, K, Cr, Urea
pH, HCO3
Septic work up: CBC, blood cultures, urinalysis, CXR
ECG if K is elevated
Management of DKA
- IV fluids: 1L NS x 2-3 hours until HR and BP normalize
then 500cc/hr x2 hours
then 250 cc/hr x2 hours - Insulin: 10 Units IV push, then 2U/hr drip
- Monitor glucose and lytes Q2H
- When glucose=15, then switch to maintenance fluids , begin diet and regular insulin regimen
Causes of Heart Block
Cardio: inferior MI, coronary spasm, cardiac tumor, congenital
Medications: digitalis overdose, TCA overdose, beta-blockers, calcium channel blockers
Infectious: viral rheumatic fever, lyme disease
Other: sarcoid, amyloid
Lung Nodule History
ID: name, age
Symptoms
-Respiratory symp: cough, sputum, SOB, dyspnea, hemoptysis, wheeze, orthopnea, PND, chest wall pain
-Infectious: history of pneumonia, TB
-Malignant: weight loss, fatigue, night sweats, anorexia, night pain, anorexia
Environment: living conditions, hobbies, pets (cats? birds?), contact with hazardous materials (asbestos)
Habits: smoking, alcohol
Travel
Ddx Lung nodule
- Neoplasm (malignant tends to be >3cm)
- Benign (tends to be <3cm)
- Infectious: TB, histoplasmosis, coccidiomycosis
4 Other: granuloma (from old pneumonia, TB, sarcoid, histoplasmosis), vascular, congenital cyst, round pneumonia, located effusion
Investigations for solitary lung nodule
- CXR: compare to old CXR- look for change, calcifications (associated with benign lesions)
- CT chest, needle guided biopsy
- Sputum for cytology and acid-fast staining
- TB skin test
- Bronchoscopy
- Biopsy or lobectomy
Management Algorithm for Lung Nodule on CXR
- Repeat CXR q3-6 months x2 years
If any changes - CT Chest
- if no dx- consider bronchoscopy or transthoracic needle aspiration
- if no dx- consider biopsy
History for transfusion reaction
- what is the indication for transfusion?
- when did reaction start since starting transfusion?
- how much of blood has been received?
- how was blood checked?
- PMHx, reason for admission, meds, allergies?
Symptoms of transfusion reaction
Resp: respiratory distress, wheezing, tachypnea, chest pain
Anaphylactic: urticaria, rash, resp distress, N/V, diarrhea
Constitutional: chills, fever, feeling of impending doom
MSK: muscle pain, neck pain
Types of transfusion reaction
- Febrile non-hemolytic transfusion reaction
- allergic
- anaphylactic
- acute hemolytic transfusion reaction
- citrate toxicity/hypocalcemia
- hyperkalemia
- circulatory overload
- dilutional coagulopathy
- delayed transfusion reaction
- iron overload- with repeated transfusions over time
- graft vs host disease (4-30 days later), usually in immunocompromised, prevent by using irradiated blood
History for SBO (obstipation, nausea, vomiting, colicky abdo pain)
- appetite, last meal, last bowel movement, passing gas
- PSHx
- PMHx, meds, allergies
History for hip pain and fever
- Trauma?
- Skin lesions?
- arthritis?
- PSHx: previous joint surgery
- Hx of steroid use, corticosteroid joint injection
- Hx of STD
- PMHx, allergies, meds, DM?
- Habits: smoking, alcohol, IV drug use
Diagnosis of septic hip
Joint synovial fluid aspiration Blood culture (positive 50%) CBC, CRP, ESR
History for Dysphagia
- Liquids/solids or both?
History for shortness of breath and hemoptysis
- age
- onset, duration
- previous episode?
- MI symptoms: chest pain, tightness, heaviness, pain in jaw, L arm, palpitations, heaviness/tightness
- Resp: cough, sputum, wheeze, hx of immobilization, leg pain, prev hx of DVT, PE
- GI symptoms: reflux, hx of peptic ulcer, hx of gastritis
Basic info:
- pmhx:
- meds? med compliance?
- allergies:
CXR signs of CHF, pulmonary edema
- enlarged heart
- upper lobe vascular redistribution
- Kerley B lines
- interstitial infiltrates
- pleural effusions
History for microscopic hematuria
Basic info: PMHx, PSHx, meds, allergies, occupation
- hx of trauma
- pain? pain with urination?
- incontinence, frequency, urgency, difficulty voiding
- UTI: fever, nausea, vomiting
- cancer symptoms: weight loss, back pain
Ddx for microscopic hematuria
UTI Nephrolithiasis Hydronephrosis Protatitis Prostate cancer BPH Renal cell carcinoma bladder cancer
Investigations for microscopic hematuria
PSA
U/S renal, bladder, prostate
cystoscopy
IVP
History for patient with inability to urinate and dribbling
- onset of symptoms, previous episodes
- associated urinary symptoms: suprapubic pain, pain on urination, blood in urine, difficulty maintaing stream
- neuro symptoms: constipation, perineal numbness, leg weakness
- cancer symptoms: weight loss, fatigue, night sweats
- new meds?
- ROS
- basic info: PMHx, PSHx, FMHx, ROS hx of cancer BPH
Investigations for urinary hesitancy, dribbling
UA, urine microscopy Urine culture PSA Renal/pelvic ultrasound Cystoscopy
Needle Stick Injury
-history
severity of exposure
- needle gauge
- depth of penetration
- did needle contain blood from a pt
- was blood injected
- is hiv and hepatitis status of pt known?
- is pt high risk pt? (e.g. multiple partners, IV drug user, immigration from endemic area)
- immunization status for hep B
Odds of transmission from needle stick injury for
- HIV
- HepB
- Antigen Hep B
- Antibody Hep C
- HIV: 0.3%
- Hep B: 40%
- Antigen Hep B: 10%
- Antibody Hep C: 5%
Statistics for
- HIV
- Hep B
- Hep C
- HIV: much longer life expectancy due to improved anti-retroviral therapy
- Hep B: 1% will have fulminant hepatic necrosis, which is fatal in 60% of cases. 5% will remain in carrier status with 25-40% of cirrhosis, and 2-5%/year of HCC
- Hep C: >50% of chronic liver disease, same risk of cirrhosis, and HCC as Hep B
Interventions for needle stick injury
- baseline testing: HIV, Hep B, Hep C
- repeat in 6 months
- HIV prophylaxis if pt is high risk
- immunization for HepB
Mammography screening
- yearly mammography after age 50
- starting at age 40 if family history of breast cancer
- starting at 5-10 years before youngest family member’s presentation, if there are 2 first degree relatives with breast cancer (parents, sibs, children)
Breast exam
- inspection: size, symmetry, masses, skin retraction, erythema, dimpling, nipple retraction,ulceration, peau d’orange
- palpation of
- nodes: axillary, infraclavicular, supraclavicular
- breast- light/deep palpation or masses, all 4 quadrants
History for elevated creatinine
- urinary symptoms: suprapubic pain, renal pain, groin pain, pain with urination, blood in urine, frequency, urgency, colour of urine diff initiating or maintaining urinary stream
- neuro symptoms: saddle anesthesia, loss of bowel control
- infectious symptoms: fever, chills, nausea, fatigue
- cancer symptoms: night sweats, weight loss, fatigue
- ROS
- hx of UTI, STD, TB, radiation, hypertension, diabetes, kidney stones
- Basic info: PMHx, PSHx, meds, allergies, smoking, alcohol, drugs, FMHx
Ddx for chronic renal failure
Pre-renal: hypovolemia, poor cardiac output, renal vascular disease, NSAID, liver failure
Renal:
-vascular: malignant hypertensoin, cholesterol emboli, HUS/TTP
-tubulo-interstitial: acute tubular necrosis,
-glomerular- contrast, myoglobinuria, acute glomerulonephritis, DIC, pyelo, myeloma
Post renal obstruction: tumor, stone, BPH, stricture, autonomic dysfunction
Investigations for chronic renal failure
CBC, lytes (PO4, Ca, Mg) urea, creat UA, microscopy, culture INR/PTT, AST, ALT, ALP, GGT, CK, Trops AXR Abdo US Post-void cath
History for 60 yo M, slipped and fell 6 days ago, with hemoptysis
Basic info: PMHx, PSHx, meds, allergies, anticoagulation?
- mobilization since accident?
- shortness of breath? chest pain? pleuritic pain? pain in legs
- neuro symptoms?
Physical exam for PE
Cardio: Heart sounds, murmurs, rate, rhythm, pulses
Resp: trachea midline, air entry, wheezes, crackles, pleuritic pain
MSK: inspect for redness, swelling/size, deformity, palpation for warmth, calf tenderness, Homan’s sign, (pain with dorsiflexion of foot)
Investigations for PE
ABG, D-dimer ECG- S1Q3T3 CXR- hamptons hump, westermark sign, dilatation of proximal PA Doppler ultrasound of legs VQ scan/Spiral CT
Treatment for PE
Anticoagulation
- Heparin (80 U/kg) then infuse at (18U/kg/hr)
- measure PTT Q6H (adjust so that PTT 70-90, about 2.5-3x baseline)
- start coumadin- INR 2-3, continue coumadin for 3 months
