TOP SI 117

Internal Medicine

N. Srikanchanawat
1

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Cardiology
Physical examination of the cardiovascular system
General appearance
- Dyspnea, Tachypnea, Edema, Cyanosis
- Anemia, Edema, Cyanosis, Clubbing of fingers, Anemia, Chest contour
- Clubbing of fingers (Hippocratic nails, , ) clubbing of fingers
DIP & 2 space diamond shape

clubbing of fingers CLUBBING

Cyanotic heart disease (5T: TOF, TGA, Truncus arteriosus, TA, TAPVR)
Lung cancer, Lung abscess
Ulcerative colitis
Bronchiectasis
Benign mesothelioma
Infective endocarditis (IE), Idiopathic, Inherited
Neurogenic tumors
GI disease (Cirrhosis, Regional enteritis), Graves disease
( Graves disease clubbing of fingers Thyroid acropachy)

Examination of veins
- 2 JVP Jugular venous waveform
- JVP (Jugular venous pressure) filling P RA (RAP)
- venous pulse ( JVP) 2 waves/cycle ( A V waves 2 positive
waves) carotid pulse 1 wave
- JVP: 30-45 JVP internal jugular pulse
Sternal angle ( mid-RA)
2 2
- JVP = 3-5 cm, + 5 cm = RAP (RAP = 8-10 cmH2O
> 5 cm Engorged neck vein ( RAP > 10 cmH2O)
- Jugular venous waveform , A V waves (
carotid pulse heart sound)

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- venous pulse 1 cycle 2 positive waves A wave (RA contraction) V wave

(Passive RA filling), 2 descents X descent (RA relaxation) Y descent (RA emptying)
C wave X descent tricuspid valve RA
ventricular systole ( C wave )
waves A-C-X-V-Y

- Prominent A wave RA contraction, PH (), Severe PS, TS, RA

myxoma, Decreased RV compliance
- Prominent V wave RA tricuspid valve ventricular systole,
TR ( V wave severity TR), ASD, TAPVR, PAPVR, Decreased RA
compliance

Examination of arteries
- Pulse: Common carotid, Radial, Brachial, Femoral, Popliteal, Posterior tibial, Dorsalis pedis
- Carotid pulse Carotid bruit (esp. elderly)
Pulse 2 + Radial & Femoral pulse Radiofemoral
delay
- pulse
1. Rate /min; irregular rhythm 1 min
2. Rhythm regular / irregular
3. Amplitude / ( PP & SV)
4. Contour 3 Upstroke, Peak, Downstroke

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5. Equality 2 pulse ( pulse )

e.g. CoA, Takayasus disease, PVD
6. Thrill & Bruit

(Normal arterial pulse)

- Abnormal pulsation
1. Abnormal amplitude
1) Pulsus parvus () PP e.g. Low C.O. (e.g. Shock, AS, MS), Partial arterial
occlusion
2) Pulsus magnus () PP / SV e.g. AR, Anemia, Pregnancy, AV fistula,
Thyrotoxicosis, PDA
3) Pulsus alternans () poor systolic function, HF, Severe myocardial disease
Pulsus alternans (regular rhythm) Bigeminy PVC (pulse irregular rhythm)

(Pulsus alternans)
4) Pulsus paradoxus (, ) preload
e.g. Cardiac tamponade, Constrictive pericarditis, RCM

(Pulsus paradoxus)
2. Abnormal contour
1) Pulsus tardus (upstroke ) Pulsus parvus Pulsus parvus et tardus
Severe AS

(Pulsus parvus et tardus)

2) Pulsus celer (upstroke ) Pulsus magnus Pulsus celer et magnus
(Water-hammer pulse, Collapsing pulse) AR

(Water-hammer pulse)

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3) Pulsus bisferiens (pulse 2 peaks systole) Severe AR, HOCM

(Pulsus bisferiens Severe AR)

(Pulsus bisferiens HOCM)

Examination of precordium
-
1. Inspection () Chest contour (Pectus excavatum, Pectus carinatum), Active precordium
Pectus excavatum CHD chest contour
heart size
2. Palpation ()
1) Apical impulse ( LV) PMI (Point of maximal impulse) ,
5th ICS, Lt. MCL, Lt. lateral decubitus
; Apical impulse
(1) Thrust normal , amplitude & contour
(2) Tap PMI mitral valve ( loud S1),
MS
(3) Slap PMI + , hyperkinetic states e.g. Thyrotoxicosis, Fever,
Anemia, Pregnancy,
(4) Apical heaving PMI PMI
, LVH
- Pressure overload (Concentric hypertrophy) Sustained heaving, PMI shift,
HT, AS, CoA, HCM
- Volume overload (Eccentric hypertrophy) Non-sustained heaving, PMI shift,
Severe AR, Severe MR
LV apical impulse Amplitude
Contour
Thrust

Tap

Slap

Heaving

2) Parasternal heaving ( RV) sternum
RVH
- Pressure overload PH
- Volume overload TR, ASD
3) Thrill murmur (grade 4-6)

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OPSI117

flow Laminar floww murm

mur & thrill, /
/


flow Turbulent flow
f murm
mur = thrill

3.

( thrill
vaalve findinng )
Auscultation (
( ) A-P-T--M ( M-T-PP-A )
- A (Aortic areaa) = RUSB (2ndn ICS)
P (Pulmonic area)
a = LUSB (2nd ICS)
a = LLSB (4th ICS)
T (Tricuspid area)
M (Mitral areaa) = Apex (5th ICS, Lt. MCLL)
- Chest pieece stethoscope 2
1) Bell e.g. DRM ( MS), S3; ( diaphragm
chest wall diaphraggm )
M Ltt. lateral decuubitus Bell
DRM MS
Apexx
2) Diapphragm
e.g. DBM ( AR)
DBM AR
DDiaphragm
LLLSB
- S2 : O-K-T-3

1. Opeening snap
,
early diastoole,
LLSB Apex,

,
MS
2. Periccardial Knockk
3. Tum
mor plop , Attrial myxoma, tumoor

4. S3 , early diasstole, Bell Apex Ltt. lateral decubitus,

C.O. e.g.
e CHF
S3 galloop CHF
Killip class
c 2
S3 > 40 yr.. impaired LV systolic functtion

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Electrocardiography (EKG)
- EKG component
1. Rate
- R-R interval 300-150-100-75-60-50 /min ()
- : HR = 300/ 1,500/
1 = 0.04 sec, 1 = 0.2 sec (5 )
2. Rhythm
- 5
1) Rate < 60/min = Bradycardia, > 100/min = Tachycardia
2) QRS complex 0.1 s (2.5 )
- Narrow QRS origin supraventricular
- Wide QRS ( 3 ) origin ventricle supraventricular with aberrant
conduction or with BBB
3) Regularity
Regular
(1) Precisely regular NSR, SVT, VT
(2) Almost regular Sinus arrhythmia
(3) Irregularly regular
- Premature beat () PAC (Atrial premature beat), PVC
- Escape beat (; sinus arrest sinus exit block) Atrial / Junctional /
Ventricular escape beat
Irregular
(1) Irregularly irregular
- AF, MAT, VF
- AF with show AV conduction ( complete AV block)
(2) Regularly irregular Heart block (SA/AV block)
4) P wave , lead II
- P wave +ve lead II Sinus ( high atrium)
- P wave ve lead II ( Dextrocardia / lead )
- P wave AF, VT, VF, P wave QRS complex
5) P wave & QRS complex ( atrium ventricle
)
- Supraventricular origin
- Ventricular origin, AV dissociation (e.g. 3rd degree AV block)
- Normal sinus rhythm (NSR)
1) Rate: 60-100/min

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2) Rhythm: Regular
3) P wave P sinus
(1) Identical P wave ()
(2) Precede QRS complex ( QRS complex)
(3) (+ve) Lt. lateral & Inferior leads ( +ve lead II)
(-ve) lead aVR
Biphasic lead III, V1 ( biphasic )
4) PR interval: 3-5
5) Narrow QRS complex: 2.5

3. Axis
- R-S lead I aVF plot mean axis -30 +90 normal axis (
0-90 quadrant lead I & aVF +)
- RAD: > +90 (lead I ve, aVF +ve) (esp. elderly, thin), Emphysema, RVH,
Dextrocardia, LPFB
- LAD: < 0 (lead I +ve, aVF ve) (esp. elderly, obese), Diaphragm
(e.g. Pregnancy, Ascites, Carcinomatosis peritonei), LVH, LAFB, HyperK+
- lead I, aVF
I +ve, aVF +ve Normal axis (NAD)
I +ve, aVF ve LAD
I ve, aVF +ve RAD
I ve, aVF -ve Extreme (Supreme) axis deviation (Indeterminated axis)

4. P wave ( Atrial depolarization) sinus lead II, lead aVR

check P wave lead aVR lead ()

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5. PR interval ( SA node AV node) Normal (3-5 ) / Prolonged / Short

6. QRS complex Narrow / Wide (> 3 ); QRS complex:
Q = wave ve; R = wave +ve; S = wave 2 ve; R = wave S
7. ST segment Elevation / Depression, Short / Prolong
ST segment represent action potential Plateau phase: Ca2+ influx, Na+ efflux
Ca2+ ST segment QT interval
- HyperCa2+ Short QT Ca2+ QT
- HypoCa2+ QT prolong Ca2+ QT

(HypoCa2+: QT prolong RR interval PVC T wave Torsades de Pointes)

8. T wave TWI Tall peaked T / Hyperacute T
T wave represent action potential Repolarization: K+ influx
K+ T wave
- HyperK+ Tall peaked T ( > > QRS height) K+
T wave ,
- HypoK+ ( HypoMg2+) Flat T wave, U wave K+
T wave ( ST elevation / depression, TWI ) K+
phase resting membrane potential (RMP) U wave
Rule: Once HypoK+ TWI Ischemia

(HypoK+: Flat T wave & U wave)

(HyperK+: Tall peaked T)
9. QT interval QT prolong ( RR interval)
QT interval 3 QRS complex, ST segment, T wave; QT interval
QT prolong ST segment ( HypoCa2+) & T wave ( HypoK+)
QT

Corrected QT interval (Bazetts formula): QTc RR; QR interval > 0.44 sec = Long QT syndrome
10. U wave prominent clinical (e.g. muscle weakness, polyuria)
HypoK+ ( HypoMg2+)
- Tall peaked T + QT prolong HyperK+ + HypoCa2+ AKI, CKD, Crush
injury, Rhabdomyolysis (K+, PO43- PO43- Ca2+ ),
Pancreatitis (Ca2+ Saponification)

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Enlargement/Hypertrophy
- Atrial enlargement P wave lead II ( + ) & lead V1 ( biphasic RA
component & LA component )
- P wave 2 RA component (depolarize ) & LA component (depolarize )

- Right atrial enlargement (RAE)

Criteria: P wave Amplitude > 2.5 mm Inferior leads (II, III, aVF)

- P wave pattern P RAE P pulmonale Severe lung disease

e.g. Severe COPD resistance lung PH (Pulmonary hypertension) Loud P2

1) RAE RAD
2) RAE duration RA depolarize LA, RA depolarize
LA depolarize
- Left atrial enlargement (LAE)
Criteria:
1. P wave Duration > 3 & LA portion 1
2. P wave LA portion lead V1 drop isoelectric line 1 mm (= amplitude )

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- P wave pattern P LAE P mitrale Mitral valve disease

Mitrale = M-shaped (P )

1) LAE LAD ( normal axis )

2) LAE duration LA portion P wave, LA depolarize
duration P wave
- Right ventricular hypertrophy (RVH)
Criteria:
1. RAD (QRS axis > 100)
2. Tall R (R > S) lead V1, Large S (S > R) lead V6

- DDx Tall R lead V1-V2

1. RVH
2. Cor pulmonale
3. Posterior wall MI
4. RBBB
- RVH Pressure overload Volume overload Volume overload (e.g. ASD, VSD, PDA, TR)
RSR lead V1 ( RBBB)
- RVH enlargement/hypertrophy axis deviation criteria
(RAE, LAE, LVH axis deviation)
- Left ventricular hypertrophy (LVH) (pressure overload)
Criteria:
1. R lead V5 / V6 + S lead V1 / V2 > 35 mm (7 )
(R lead V5 / V6 wall , S lead V1 / V2 wall )
2. R lead aVL > 13 mm

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1. LVH 2 criteria criteria criteria

2. LVH LAD
3. EKG pattern LVH Sense ( 50% LVH), Spec ( EKG
LVH pattern 90% LVH )
- LVH Pressure overload Volume overload
- Pressure overload Strain pattern (Down-sloping ST depression, Asymmetrical TWI)
- Volume overload ST depression, Symmetrical TWI, lead V5-V6 deep Q wave
- Strain pattern (2 Repolarization abnormalities) Pressure overload Severe LVH / RVH

1. Down-sloping ST depression
2. Asymmetrical TWI ( ) Reverse check mark
Asymmetrical TWI Strain pattern Reverse check mark (
9 ) Asymmetrical TWI Digitalis effect Scoop
downward

- HOCM (IHSS) genetic disease; AD; EKG

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1. LVH
2. Strain pattern ( leads tall R wave)
3. Q wave Inferior & Lt. lateral leads ( Significant septal hypertrophy)
HOCM = Hypertrophic obstructive cardiomyopathy; IHSS = Idiopathic hypertrophic subaortic stenosis
disorganized proliferation muscle fibers septum;
sudden death in the young healthy athletes

1) LV outflow obstruction
2) LV impaired diastolic filling ( stiff )
3) Cardiac arrhythmia
Management: Verapamil ( strength ventricular contraction obstruction), -blocker

Basic types of arrhythmia

- Arrhythmia 5 basic types
1. Arrhythmia of sinus origin
1) Sinus tachycardia (HR > 100/min), Sinus bradycardia (HR < 60/min)

2) Sinus arrhythmia NSR irregular vary

HR , HR ; normal phenomenon
3) Sinus arrest, Asystole, Escape beats
- Sinus arrest prolonged Asystole
Pacemaker rescue Escape beats

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Pacemaker SA node (Non-sinus pacemaker)

(1) Atrium: rate 60-75/min
(2) Junctional pacemaker ( AV node): rate 40-60/min
- Junctional escape most common escape sinus arrest
- EKG: P wave, Retrograde P wave ( atrial depolarization
backward)
- rate 40-60/min Junctional rhythm
- rate > 60/min Accelerated junctional rhythm (Junctional tachycardia)
(3) Ventricle: rate 30-40/min
- rate 30-40/min Idioventricular rhythm (IVR)
- rate > 40/min Accelerated IVR

(Accelerate IVR)
2.
3.
4.
5.

Ectopic rhythm e.g. MAT, PAT

Reentrant arrhythmia e.g. PSVT, Atrial flutter, AF
Conduction block e.g. AV block, BBB, Fascicular block (Hemiblock)
Preexcitation syndrome e.g. WPW syndrome, LGL syndrome

Supraventricular arrhythmia
- Supraventricular arrhythmia = Arrhythmia origin Atrium AV node, EKG Narrow QRS
complex
1. Regular rhythm
- P wave e.g. Sinus tachycardia, Atrial tachycardia (PAT), SVT (some types)
- No P wave e.g. SVT, Atrial flutter (P wave saw-toothed)
2. Irregular rhythm
- P wave e.g. MAT, Frequent PAC
- No P wave e.g. AF
- Supraventricular arrhythmia
1. Premature atrial contraction (PAC, Atrial premature beat)
- QRS beat Narrow QRS complex, P wave P
wave sinus
- Relate Sympathetic overtone e.g. 2-agonist, Vasoactive drug, Hyperthyroidism, ,
Hypoxia

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2.

Junctional premature beat QRS beat P wave origin

AV node

3.

Paroxysmal supraventricular tachycardia (PSVT)

- normal heart, reentry loop AV node
- Precipitating cause: Alcohol, Coffee, Excitement
- EKG: regular rhythm, rate150-250/min, No P wave Retrograde P wave Pseudo-R
Pseudo-S , ST depression ( HR Diastolic filling time
Myocardial injury)
- Management: Carotid massage vagal output slow conduction AV node

4.

Atrial flutter
- normal heart underlying heart disease
- reentry loop annulus of tricuspid valve
- EKG: regular rhythm, Saw-toothed appearance (2:1, 3:1, 4:1, etc.), atrial rate 250-350/min
- Carotid massage block
- Management: AHA guideline 2010 (Tachycardia algorithm)

( Carotid massage Atrial flutter 2:1 block 4:1 block)

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5.

HR 150/min DDx 3
1. Sinus tachycardia HR ; HR Max = 220 Age
2. SVT HR ( 80 160)
3. Atrial flutter 2:1 block
Atrial fibrillation (AF)
- Most common cause Long-standing HT
- multiple reentry loops atrium
- pulse Total irregularity, EKG monitoring rate
rate AF 1 min (PR HR HR pulse)
- EKG: irregular rhythm, Fibrillation waves (undulating baseline), atrial rate 350-500/min

6.

Multifocal atrial tachycardia (MAT)

- Sympathetic overtone Severe lung disease Bronchospasm
- random firing ectopic atrial foci
- EKG: irregular rhythm, rate 100-200/min, P wave 3

7.

Paroxysmal atrial tachycardia (PAT)

- Digitalis intoxication ( PAT with AV block)
- ectopic atrial focus reentrant circuit atrium
- EKG: regular rhythm, rate 100-200/min, Warm-up period; PSVT
Carotid massage (response PSVT, response PAT)

Ventricular arrhythmia
- Ventricular arrhythmia = Arrhythmia origin Ventricle
1. Premature ventricular contraction (PVC)
- Sympathetic overtone, Ischemia, Hypo-/HyperK+, HypoMg2+, Drugs
- EKG: Wide bizarre QRS complex, P wave , Compensatory pause

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2.

PVC abnormal repolarization TWI ( ischemia)

Bigeminy = Normal sinus beat PVC 1:1
Trigeminy = Normal sinus beat PVC 2:1

(Bigeminy)
2 PVCs Couple PVC (Pair PVC) prognosis PVC
Rules of malignancy PVC situation trigger VT/VF death
5
1. Frequent PVCs
2. Runs of consecutive PVCs (esp. 3 PVCs = VT)
3. Multiform PVCs
4. R-on-T phenomenon ( PVC T wave initiate VT)
5. PVC in setting of AMI

(Multiform PVCs)
(R-on-T phenomenon)
Ventricular tachycardia (VT)
- EKG: 3 PVCs , P wave (AV dissociation)

PVCs 30 sec Short-run VT, 30 sec Sustained VT

VT pulsatile (amplitude ) = Polymorphic VT (PMVT)
1. Torsades de Pointes Previous QTc prolong, HypoK+, HypoMg2+, Drugs
QT prolong (e.g. Amiodarone, TCA, Thioridazine, Macrolides, Fluoroquinolones),
renal Mg2+ wasting

Management: 50% MgSO4 4 cc (2 g; 0.5 g/cc) + NSS 10 cc IV flush

Amiodarone QT prolong

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Torsades de Pointes Synchronized cardioversion ( QRS amplitude

work) Defib.
2. Non-Torsades de Pointes
EKG VT
1) AF with WPW syndrome

EKG VT Irregular ()
Bundle of Kent rate irregular ( AF) generate QRS
complex Wide QRS complex
2) Sine wave sign HyperK+

EKG VT Rate < 100/min Tall peaked T

VT Tachycardia rate < 100/min VT
Sine wave (HyperK+ repolarization HR )
Management: 10% Calcium gluconate
Ventricular fibrillation (VF)
- VF heart C.O. CPR + Adrenaline
-

3.

(VT VF)

Conduction block
- Conduction block R/O Ischemia, Electrolyte imbalance (esp. HyperK+) ;
1. SA block (Sinus exit block)
2. AV block
1) 1st degree AV block EKG: Prolonged PR interval (> 1 )

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2) 2nd degree AV block 2 types

(1) Mobitz type I (Wenckebach block) EKG: Progressive PR prolongation until Dropped beat
(beat QRS complex P wave) EKG Group beat

(2) Mobitz type II EKG: All-or-none conduction ( Dropped beat Progressive

prolongation of PR interval )

3) 3rd degree AV block (Complete heart block) EKG: AV dissociation (P wave Wide QRS
complex )

3.

1st degree AV block, Mobitz type I Supranodal AV block response

Atropine ( drive AV node)
Mobitz type II, 3rd degree AV block Infranodal AV block response
Atropine ( drive fascicle )
Bundle branch block (BBB)
1) Right bundle branch block (RBBB)
- EKG: Wide QRS complex, RSR (Rabbit ear appearance) in lead V1-V2 with
ST depression & TWI, Slur S in lead V5-V6 (Reciprocal change)
RSR: R wave bundle branch
block bundle branch S wave depolarize

block R Wide QRS complex

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5-10% symptom , Rt. heart

overload e.g. PH, ASD, VSD

(1) Complete RBBB EKG RSR lead V1-V2 Wide QRS complex
(2) Incomplete RBBB EKG RSR lead V1-V2 Narrow QRS complex

2) Left bundle branch block (LBBB)

- EKG: Wide QRS complex, RSR (Broad, Notched R wave) with prolonged upstroke in lead
V5-V6, I, aVL with ST depression & TWI, Reciprocal change in lead V1-V2, LAD
- LBBB Old () New ( ACS); Hx CAD risk factors

RSR lead V1-V2, V5-V6 Non-specific intraventricular conduction delay

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4.

Fascicular block (Hemiblock) Axis deviation wide QRS complex

1) Left anterior fascicular block (LAFB) EKG: LAD -30 +190 ( other cause
LAD), no ST-T change, normal QRS complex

2) Left posterior fascicular block (LPFB) EKG: RAD ( other cause RAD), no ST-T
change, normal QRS complex

- Rules:
1. Wide QRS complex BBB
2. BBB ST depression / TWI lead
3. Heart block R/O HyperK+
HyperK+ Tall peaked T K+ Purkinje fiber K+ SA node
P wave Sinus exit block, AV node AV block Hx CKD
HD Heart block (e.g. Mobitz type I) IVR ( escape) R/O HyperK+

4. AV block R/O Inferior wall MI

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Preexcitation syndrome
- Preexcitation syndrome 2
1. Wolff-Parkinson-White (WPW) syndrome

2.

Bypass pathway = Bundle of Kent ventricle Bundle

of Kent ( Short PR interval Delta wave) Wide QRS complex
premature activation
( BBB Wide QRS complex delayed activation)
- EKG:
1. Short PR interval (< 3 )
2. Delta wave
3. Wide QRS complex
- (e.g. Cholecystectomy EKG ) treat
- WPW syndrome AV node
Bundle of Kent ABCD: Adenosine, Beta-blocker, CCB, Digitalis
Lown-Ganong-Levine (LGL) syndrome

Bypass pathway = James fiber accessory pathway (intranodal) bypass AV nodal delay
ventricle
EKG:
1. Short PR interval (< 3 )
2. No Delta wave
3. Narrow QRS complex
WPW LGL ventricle Short
PR interval Delta wave Wide QRS complex

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Ischemia/Infarction
- Myocardial ischemia/infarction heart 3 zones
1. Zone of ischemia , depolarization , repolarization prolong QT, T change
- Anterior subendocardial & posterior subepicardial ischemia Symmetrical peaked positive T
- Anterior subepicardial & posterior subendocardial ischemia Symmetrical peaked inverted T
2. Zone of injury , depolarization , repolarization ST change
- Subepicardial injury ST elevation ( 1 mm) lead ,
lead ST depression = Reciprocal change
- Subendocardial injury ST depression
3. Zone of infarction necrosis , , EKG 4
1) Hr. 2-3 ( injury, ischemia, necrosis)
- ST elevation (subepicardial injury)
- Giant & peaked T (subendocardial ischemia)
- Q wave ( necrosis )
2) Wk. 2-3 ( injury )
- Q wave
- Biphasic T ( turn TWI)
3) Wk. 3 ( injury LV aneurysm ST elevation )
- necrosis (Q wave) & ischemia (TWI)
4) Long-term ( ischemia > 50% )
- necrosis
- EKG ischemia/infarction lead wall
Lead
Arterial supply
Wall (LV)
I, aVL
Lateral
LCX
II, III, aVF
Inferior
RCA
V1-V4
Anteroseptal
LAD
V5-V6
Anterolateral
LCX
V1-V6
Extensive anterior LAD, LCX
V1-V2 (reciprocal) Posterior
RCA
V1-V2, V3R-V4R RV
RCA
- Acute coronary syndrome (ACS)
1. STE (ST elevate 1 ) plaque rupture clot occlude lumen myocardium
wall = Transmural wall MI Cardiac enzyme
Treatment STE Thrombolytic therapy (TT)

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2. NSTE
1) Unstable angina (UA) plaque rupture clot partial occlude
blood flow , TnT CK-MB
2) Non-Q wave MI (NQwMI) plaque rupture clot occlude lumen
recanalization blood flow myocardium
Cardiac enzyme
Treatment NSTE Anti-coagulant
- ACS EKG 3
1. ST-T change Hyperacute T, ST elevation (STE) / depression; Injury
Hyperacute T Tall peaked T HyperK+ ( Hx: ACS
Hyperacute T) Myocardial injury K+ EKG
Tall peaked T HyperK+
STE J point isoelectric line; J point (Junction point) = QRS
2. TWI ( Symmetrical TWI) Ischemia
TWI Ischemia Symmetrical TWI (mirror image) Asymmetrical
TWI Strain pattern (Reverse check mark), Digitalis effect (Scoop downward), etc.
3. Pathological Q wave (Significant Q wave) = Q wave 1 , 1/4-1/3 Total QRS
complex height; Infarction

(Hyperacute T TWI)

(STE)

(STE with Symmetrical TWI)

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- STE curve ST J point Concave Convex

curve J point STE curve
= Convex, = Concave; STEMI Convex
Concave upward STE
Concave upward STE
1. Generalized Acute pericarditis ( Generalized PR depression )
2. Localized ( wall) ACS
- Persistent STE 2 wk. AMI LV aneurysm remodeling MI
- EKG STE symptoms Early repolarization (J point elevation) common

Early repolarization misnomer term J point elevation

(J point elevation)
- ST depression ACS Horizontal ST depression
( Strain pattern Digitalis effect)

- ST depression Q wave ( STE)

- Rule: ST elevation ST depression ST elevation
ST depression Reciprocal change
- TWI EKG Acute Chronic Hx
Chronic ischemia Symmetrical TWI
- Pathological Q wave ST segment Recent MI ( ST-T change )
Old infarction
STE TT Q wave

(Recent MI)

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- Lateral wall MI (I, aVL), Anterolateral wall MI (V5, V6) LCX occlusion
- Inferior wall MI (II, III, aVF) RCA / PDA occlusion
Rule: Inferior wall MI 2
1. RV infarction run V3R, V4R ( lead V3, V4 represent Rt. heart) STE
1 lead V3R, V4R RV infarction
Inferior wall (LV) & RV RCA
RV infarction BP drop , Cardiogenic shock ; BP drop IV fluid

2. AV block
- Anteroseptal wall MI (V1-V4) LAD occlusion, EKG: Poor R progression in Chest lead
Poor R progression specific Anterior wall MI e.g. RVH, Chronic lung
disease, lead
- Extensive anterior wall MI (V1-V6) LAD & LCX occlusion = Double vessel disease (DVD)
Left main disease
Anteroseptal wall MI, Extensive anterior wall MI Arrhythmia wall
- Posterior wall MI RCA occlusion, EKG: Tall R + ST depression lead V1-V2 (Reciprocal change)
( mirror image Anterior wall MI)
Rule: Tall R lead V1 / V2 Posterior wall MI
RVH RAD, ST segment change; Axis LAD RVH
Posterior wall MI Inferior wall MI RCA
- Limitation EKG Dx MI: LBBB, WPW QRS complex & ST segment
Dx MI EKG
Rule: LBBB WPW syndrome Dx MI EKG
- Generalized low voltage
Limb lead: Amplitude 5 mm
Chest lead: Amplitude 10 mm
DDx:
1. heart skin
1) Morbid obesity
2) Pulmonary emphysema ()
3) Pneumothorax
4) Pleural effusion / Hemothorax
5) Massive pericardial effusion
2. Myocardium generate QRS complex DCM

Miscellaneous EKG changes

- Pulmonary embolism (PE) EKG: S1Q3T3 (SIQIIITIII) sign RV pressure overload, 10%
PE

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S1Q3T3 10% PE pathognomonic sign

EKG common PE Sinus tachycardia
Clinical: , O2 sat. drop CXR PE CXR clear ( clear PE)
Rule: Q lead III aVF Inferior wall MI PE
- Cardiac tamponade EKG: Electrical alternans ( Echo. Swinging heart)

Electrical alternans finding EKG amplitude QRS sign

Cardiac tamponade Pulsus alternans Poor systolic function (EF ) e.g. HF,
Severe myocardial disease
Cardiac tamponade BP drop load IV fluid
Specific treatment: Pericardiocentesis
Becks triad Cardiac tamponade: Hypotension, Engorged neck vein, Distant heart sound
Pulsus paradoxus (SBP 10 mmHg)
- Hypothermia
- EKG change Hypothermia core T 28-32C ( Near drowning, Sepsis, Drugs
, )
- EKG: J-Osborne wave

RSR BBB RSR Rabbit ear () J-Osborne

- Digitalis effect EKG: Asymmetrical TWI Scoop downward ()

Asymmetrical TWI Digitalis effect Scoop downward Strain pattern

Reverse check mark

TOPSI117

- Digitalis intoxication EKG

1. Accelerated junctional rhythm (Junctional tachycardia)
2. PAT with AV block
3. Bidirectional VT

(Junctional tachycardia)

(Atrial tachycardia with 2:1 AV block)

- TCA overdose EKG:
1. Wide QRS complex
2. QT prolong
3. Tall R > 3 mm in aVR

(Bidirectional VT)

Management: 7.5% NaHCO3- 50 cc IV push in 5 min ( Alkalosis

Alkalosis free form TCA )

TOPSI117

Coronary artery disease (CAD)

- Risk factors for CAD 6
1. Age 45 yr. (male), 55 yr. (female) menopause ( surgical menopause )
2. FHx of premature CAD (1st degree relative): Age < 55 yr. (male), < 65 yr. (female)
( Hx CAD ,
, balloon, CABG, Hx SCD)
3. DM
4. HT (BP 140/90 mmHg)
5. HDL < 40 ( on treatment); > 60 risk factor
6. Active smoker; -1 yr. ( study 1 yr. risk
CAD )
- Angina pectoris definition: Chest discomfort cardiac ischemia
- Typical angina characteristic 3
1. Retrosternal chest pain ( referred pain)
2. Precipitated by exertion/emotional stress
3. Relieved by rest/NTG
2 = Atypical angina; 1 = Non-angina ( cardiac)
- chest pain Non-diagnostic chest pain
- Acute myocardial infarction (AMI) Dx criteria ( 2/3 )
1. Angina
2. EKG Myocardial ischemia
3. Cardiac enzyme +ve
( criteria Cardiac enzyme Unstable angina)
- Case heart admit case keep Mg2+ 2, K+ 4, HCO3- 30

Acute Coronary Syndrome (ACS)

Initial management
- MONA
Morphine sulfate 2-4 mg IV add 2-8 mg q 5-15 min
O2 cannula 3 LPM, keep O2 sat. > 90% ( impaired O2 lung HF )
NTG 0.4 mg ( ISDN 5 mg) 1 tab SL q 5 min (Max 3 tab) (C/I: BP drop esp. RV infarct)
ASA gr. V (325) 1 tab stat + Clopidogrel
- MONA 12-lead EKG w/in 10 min 2
1. STE-ACS STEMI
2. NSTE-ACS UA/NSTEMI
- Monitor EKG repeat q 5-10 min, STE New LBBB
AMI

TOPSI117

- STEMI UA/NSTEMI Clopidogrel (Plavix)

1. If plan TT
- Age < 75 yr. loading dose 300 mg (4 tab)
- Age > 75 yr. loading dose 75 mg (1 tab)
2. If plan PPCI loading dose 600 mg (8 tab)
3. If No reperfusion therapy loading dose 300 mg (4 tab)
- 1-blocker C/I cardiogenic shock 3 AME
1. Atenolol 5 mg IV, repeat q 5 min
2. Metoprolol 5 mg IV drip () in 1-2 min, repeat q 5 min (max = 15 mg)
3. Esmolol 50 g/kg (up to 200-300 g/kg ultrashort action -blocker)
- chest pain / CHF / HT NTG IV drip
rate 5-10 g/min add 5-20 g q 5 min SBP 90 mmHg
- plan PPCI GPIIb/IIIa inhibitor (GPI) (Abciximab, Eptifibatide, Tirofiban)
PPCI continue 12 hr. (Abciximab) 24 hr. (Eptifibatide, Tirofiban)

STE-ACS (STEMI)
- Reperfusion therapy w/in 12 hr. (
angina )
1. Thrombolytic therapy (TT)
2. Primary Percutaneous coronary intervention (PPCI)
- .. 3 hr. (Ischemic time < 3 hr.) TT ( C/I): SK 1.5 MU in 5%D/W 100 cc IV drip in 1 hr.
Door-to-needle time ( .. TT) 30 min
- 3 hr. (Ischemic time > 3 hr.) PPCI (CAG + stent/balloon)
Door-to-balloon time ( .. balloon) 90 min
Door to needle/balloon time transfer ..
- Reperfusion therapy STEMI
Transportation time
Duration of onset of symptoms (Ischemic time)
(Incurred time)
< 3 hr.
> 3 hr.
< 30 min
PPCI
PPCI
30-60 min
PPCI or TT + Clopidogrel
PPCI
> 60 min
TT + Clopidogrel
PPCI or TT + Clopidogrel
- Door-to-balloon time 90 min () transfer TT
transfer transfer transfer high risk TIMI risk score for
STEMI
- TIMI risk score for STEMI mortality rate 30 d TT STEMI
High risk transfer PCI (= Facilitated PCI)
- PCI

TOPSI117

1. .. PCI (Door-to-balloon time < 90 min)

2. 3 hr.
3. C/I TT
4. Killip class 3
- Killip class mortality rate STEMI ( Killip class 3 PCI)
Class
Definition
Mortality rate
1 No CHF
6%
2 S3 gallop / Basal lung crepitation
17%
3 Pulmonary edema
30-40%
4 Cardiogenic shock
60-80%
- CABG CAG
1. TVD
2. DVD with Proximal LAD stenosis with LV dysfunction
3. LM disease

NSTE-ACS (UA/NSTEMI)
- Cardiac enzyme Risk stratification ACC/AHA guidelines
Cardiac enzyme
CK-MB: +ve > 3x UNL, MI 6 hr., peak 24 hr., baseline 72 hr.
Troponin (Tn): sense CK-MB, CK-MB, +ve suspected MI
- High risk ( PCI)
1. Recurrent angina ischemia at rest full medication
2. TnT/TnI
3. New ST depression
4. HF / New MR / MR
5. Cardiac stress test High risk
6. Hemodynamic unstable
7. Sustained VT
8. S/P PCI w/in 6 mo. / S/P CABG
10. TIMI risk score/GRACE score High risk
11. LVEF < 40%
- TIMI risk score (TRS) for UA/NSTEMI PCI
Score 0-2 Low risk; Score 3 High risk
History
1. Age 65 yr.
2. Risk factors for CAD 3 ( 6 )
3. Known CAD: stenosis 50%
4. ASA use in past 7d

TOPSI117

Presentation
5. Severe angina 2 episodes in past 24 hr.
6. ST changes 0.5 mm
7. Cardiac enzyme +ve
- High risk Invasive strategy plan PCI
- Low risk Conservative strategy Repeat Troponin
- plan PCI ( high risk)
- 2 Cardiac stress test (Treadmill / Dobutamine stress echo.)
- myocardial ischemia plan PCI
- myocardial ischemia Medication (ASA, Clopidogrel, LMWH
(Enoxaparin), ACEI, -blocker, Statin, Nitrate, Omeprazole, Senokot, Ativan)
- order NSTE-ACS ( 12-lead EKG ST depression)
65 , U/D: HT, DLP
One day
Continue
- ASA gr. V chew stat
- NPO
- Plavix (75) 4 tab stat
- Record V/S, I/O
- On O2 cannula 3 LPM, keep O2 sat. > 90%
- Absolute bed rest
- MO 3 mg + NSS 10 cc IV
Medication
1. ASA gr. V 1x1 pc
- Isordil (5) 1 tab SL prn for chest pain q 5 min
2. Plavix (75) 1x1 pc
(Max 3 tab)
3. Enoxaparin 0.6 cc SC q 12 hr.
- Blood for CK-MB, TnT, BUN/Cr, Electrolytes,
4. Isordil (10) 1x3 pc
FBS, TC, TG, HDL
5. Atenolol (25) 1x1 pc
- CXR
6. Enalapril (5) 1x3 pc
- Repeat EKG, CK-MB, TnT next 6 hr.
7. Simvastatin (20) 1x1 hs
( MONA order
8. Omeprazole (20) 1x2 ac
NTG (1:5) IV drip 5 d/min until chest pain
relieved, if BP < 90/60 mmHg, HR > 110/min,
9. Ativan (0.5) 1x1 hs
flushing or headache, pls. notify)
10. Senokot 2 tab hs ( MOM 30 cc hs)
LMWH (Enoxaparin) NTE-ACS ( low-risk); Dose: 1 mg/kg q 12 hr., 10 mg/0.1 cc
BW 60 kg 0.6 cc SC q 12 hr. 2 d +

Home medication
- ASA 75-162 mg/d
- Clopidogrel (Plavix) (75) 1x1 1 mo.
PCI with drug eluting stent 1 yr.
- 1-blocker (cardioselective) C/I; MI 2 AM
1. Atenolol 50-100 mg/d
! Atenolol GFR < 30 Max dose: 25 mg/d

TOPSI117

Complete heart block

2. Metoprolol 25-50 mg bid (up to 100 mg/d)
ACEI reverse LV remodeling; Captopril short-acting SE (
BP drop ) SE
.. Captopril 6.25 mg ( x2 )
then 12.5 mg in next 2 hr., then 25 mg in next 12 hr., then 50 mg bid
H/M: Captopril (50) 1x2; stable long-acting
ACEI , LVEF , risk factors for CAD , DM
SE ACEI Non-productive cough ( ), Angioedema ( laryngeal
edema) SE ARB Losartan (Cozaar), Valsartan (Diovan)
Spironolactone (Aldactone) 25-50 mg/d LVEF < 40%, HF, DM
Spironolactone Cr 2.5 mg/dl (), 2 mg/dl (), K+ < 5 mmol/L
Atorvastatin (Lipitor) 80 mg/d 2 mo. F/U
Goal: LDL < 100 (must) LDL < 70 (optional; )
Advice Lifestyle modification (, , )
add Fibrate Niacin
Medication aggressive
1. Previous CAD
2. CAD equivalence ( CAD) 3 DM, AAA, PVD

Heart failure (HF)

- HF EF 2
1. Systolic HF: EF < 40-50%
2. Diastolic HF (HF with preserved EF, HFPEF): EF > 40-50%
- HF Dx S&S + CXR Dx HF 3
1. S&S dyspnea, PND, orthopnea, fatigue, abdominal discomfort, ascites, anasarca, engorged neck
vein, gallop, crepitation, pitting edema
2. Investigation
1) CXR cardiomegaly, pulmonary edema, pleural effusion ( ARDS)
2) EKG STEMI, NSTEMI ( cardiac enzyme )
3) Echocardiography EF, chamber size
4) Serum BNP & NT-pro BNP HF NT-pro BNP > 400
(BNP BNP BNP R/O ve +ve
emergency)
3. Therapeutic diagnosis
- NYHA Functional class (FC) (Shortness of breath, SOB) HF & PH
( ACS CCS = Canadian cardiovascular society SOB chest pain)

TOPSI117

FC
Definition
1 Asymptomatic
2 Symptomatic with moderate exertion
3 Symptomatic with minimal exertion
4 Symptomatic at rest
HF Acute & Chronic HF
Acute HF 2
1. Acute cardiogenic pulmonary edema
2. Acute decompensation of chronic HF chronic HF precipitate acute HF
HF S&S = Compensated HF precipitate decompensate Infection,
Na+ intake, , arrhythmia, MI, stress, PE, drug ( Na+), anemia, thyrotoxicosis, IE, RF,
pregnancy
Initial management for Acute HF LMNOP
1. Lasix (Furosemide) 20-80 mg IV ( severity & renal function); urine w/in 15-30 min
double dose
2. MO 3-5 mg IV in 2-3 min; repeat in 3-5 min
Naloxone 2 mg IV; add 2 mg total 10 mg
3. Nitrates NTG 0.6 mg SL q 5-10 min 3-4 NTG Nitroprusside IV
drip
4. O2 cannula 3-5 LPM; O2 sat. O2 mask with bag 8-10 LPM; keep O2 sat. > 90%
5. Position: Fowlers position (+)
Lasix preload & pulmonary congestion
MO & NTG venodilator preload
position Fowlers position V.R. preload
order CHF
One day
Continue
- Lasix 40 mg IV stat
- Regular low salt diet
- On O2 cannula 3 LPM, keep O2 sat. 95%
- Restrict fluid < 1 L/d
- Record V/S q 4 hr., if BP < 90/60 mmHg or
- Record V/S, I/O as ml
> 160/100 mmHg, pls. notify
- Retained Foley catheter
- Record urine output q 4 hr.
- Fowlers position
- Blood for CBC, BUN/Cr, Electrolytes, CK-MB, TnT Medication
1. Furosemide (40) 1x1 pc
- U/A
( )
- CXR
- 12-lead EKG

TOPSI117

Hypertension (HT)
-
1. Essential (1) HT (95%)
2. 2 HT (5%) organic cause
- Cause of 2 HT
1. Renal
1) Parenchyma e.g. DM, PKD, GN
2) Renovascular e.g. Atherosclerosis, FMD, PAN, Scleroderma
2. Endocrine e.g. Hyperaldosteronism, Cushings, Pheochromocytoma, Myxedema, HyperCa2+
3. Other e.g. Medication, OSA, CoA, Polycythema vera
- JNC 7 Classification SBP DBP category
Category
BP
Normal
< 120/80
Pre-HT
120/80
HT stage 1 140/90
HT stage 2 160/100
- severity
1. Mild HT = BP 140/90 (HT stage 1)
2. Moderate HT = BP 160/100 (HT stage 2)
3. Severe HT = BP 180/110
- BP Dx HT
1. BP 5-10 min BP 2 1 min
2. BP 1-2 1 wk. BP Dx HT
- Target organ damage (TOD)
1. LVH Echo. / EKG
2. Microalbuminuria (20-300 mg/d)
3. Extensive atherosclerotic plaque Radiological / U/S
4. HT retinopathy grade 3, 4
- Management
- Mild HT
- TOD, Risk factors for CAD < 3 LSM 1-3 mo.
F/U: BP > 140/90 mmHg Monotherapy (start 1 )
- TOD and/or Risk factors for CAD 3 Monotherapy (start 1 )
e.g. HCTZ (50) x1 pc , Amlodipine (5) x1 ( 1x1) pc , Enalapril (5) 1x1 pc
- Moderate HT
- TOD, Risk factors for CAD < 3 LSM 1 mo.

TOPSI117

F/U: BP > 140/90 mmHg Drug combination (start 2 )

- TOD and/or Risk factors for CAD 3 Drug combination (start 2 )
- Severe HT Drug combination
start Anti-HT (A = ACEI, C = CCB, D = Diuretics)
Step1 ( 1 ) < 55 yr. A, 55 yr. C or D
Step 2 ( 2 ) A+C or A+D
Step 3 ( 3 ) A+C+D
Step 4 (Persistent HT) add : -blocker, -blocker, Spironolactone, Diuretic
, consult HT
Elderly Isolated systolic HT 1st line Anti-HT Diuretics (e.g. HCTZ) electrolyte
condition SE (e.g. HypoNa+, HypoK+) Gout
Goal:
- General: BP 140/90 mmHg
- DM or Renal disease : BP 130/80 mmHg
- DM + Renal disease / Urine protein 1 g/d: BP 125/75 mmHg
- Age 80 yr. ( ISH): BP 150/80 mmHg
ACEI (Enalapril) F/U BUN/Cr
BUN/Cr < 30% continue
BUN/Cr 30-50% dose
BUN/Cr > 50% off
CCB SE: Ankle edema class effect ( CCB ) Ankle edema
ASA (81) 1x1 Framingham risk score 15 (10-year risk 20%)
DM on ASA 50 yr. (male), 60 yr. (female)
GI risk (e.g. Hx ) ASA PPI

Hypertensive crisis
- HT crisis HT emergency & HT urgency
- HT emergency = HT + Acute TOD
Acute TOD HT HT emergency
1. Aorta Acute aortic dissection, Symptomatic aortic aneurysm
2. Heart Acute LV failure, AMI, UA
3. Brain HT encephalopathy, ICH, SAH, Cerebral infarction
4. Kidney Renal insufficiency
5. Placenta ( pregnancy) Severe preeclampsia, Eclampsia
6. Other Accelerated-malignant HT , Severe burn, Severe epistaxis, Surgically related
conditions (Severe HT in patients requiring immediate Sx, Postoperative bleeding from vascular
suture sites, After CABG, After Kidney transplantation), Catecholamine excess state

TOPSI117

PE: Pulse - 2 , BP 2 ( Aortic dissection), Fundoscopy,

CVS, Neuro. TOD
Ix: CBC ( MAHA: Accelerated-malignant HT), U/A, BUN/Cr, Electrolytes, CXR, EKG
Management: Short-acting Anti-HT IV MAP 25% Min-2 hr.
()
1. Sodium nitroprusside (SNP) 0.25-10 g/kg/min
(onset , duration 1-2 min, max dose 10 min)
2. Nitroglycerin (NTG) 5-100 g/kg/min
(onset 2-5 min, duration 5-10 min, CAD)
3. Nicardipine 5-15 mg/hr
(onset 5-10 min, duration 1-4 hr.)
pregnancy (severe preeclampsia / eclampsia) Hydralazine 10-20 mg q 20-30 min
( Hydralazine HT emergency duration , BP )
- order Hypertensive emergency
55 , U/D: DM, HT 10 yr. chest pain, BP 220/110 mmHg, EKG: LVH, TWI at lead aVL,
V1-V6 (HT + Acute TOD: ACS)
One day
Continue
- Admit ICU
- NPO
- ASA gr. V chew stat
- Record V/S, I/O
- Plavix (75) 4 tab stat
- Absolute bed rest
- On O2 cannula 3 LPM
Medication
- MO 3 mg + NSS 10 cc IV
1. ASA gr. V 1x1 pc
- Blood for CK-MB, TnT, BUN/Cr, Electrolytes, FBS, 2. Plavix (75) 1x1 pc
TC, TG, HDL
3. Isordil (10) 1x3 pc
- CXR
4. Atenolol (25) 1x1 pc
- NTG (1:5) IV drip 5 d/min
5. Enalapril (5) 1x3 pc
- Record V/S q 15 min, keep BP < 180/100 mmHg, 6. Simvastatin (20) 1x1 hs
> 90/60 mmHg (Goal: MAP 25% 4-6 hr. ) 7. Omeprazole (20) 1x2 ac
- Record urine output q 4 hr., if < 200 cc/4 hr. pls.
8. Ativan (0.5) 1x1 hs
notify
9. Senokot 2 tab hs ( MOM 30 cc hs)
- Observe neurological sign q 1 hr.
- HT urgency = BP Hx HF, CAD, CVD, Renal disease minimal / no TOD
( BP 180/120 minimal / no TOD)
Management: Oral anti-HT BP in hr.
()
1. Captopril 12.5-50 mg
2. Clonidine load 0.2 mg, then 0.1 mg q 1 hr.

TOPSI117

- Accelerated-malignant HT = BP Retinal exudate/hemorrhage / Papilledema

Retinal exudate/hemorrhage = Accelerated HT
Papilledema = Malignant HT
microvascular organ (e.g. , , , ,
coma, oliguria, renal failure, N/V)
- HT encephalopathy = BP neurological symptoms (e.g. alteration of consciousness,
)

Atrial fibrillation (AF)

- Most common cause Long-standing HT
-
1. Heart
1) Endocardium e.g. MS ( MR, AS, AR MS )
2) Myocardium
(1) Ischemic in origin e.g. IHD
(2) Non-ischemic e.g. Cardiomyopathy, Degenerative process of SA node: Sick sinus
syndrome (SSS, Brady-Tachy syndrome)
3) Pericardium e.g. Pericarditis
2. Heart
1) Aorta e.g. HT
2) Lung disease Hypoxemia, Bronchospasm e.g. COPD
3) Endocrine e.g. Thyrotoxicosis, Pheochromocytoma
4) Drugs e.g. 2-agonist, Vasoactive drug,
- multiple reentry loops atrium
- pulse Total irregularity, EKG monitoring rate
rate AF 1 min (PR HR HR pulse)
- EKG: irregular rhythm, Fibrillation waves (undulating baseline), atrial rate 350-500/min
- CHA2DS2-VASc score ( 2010) risk stroke AF Antiplatelet (ASA)
Oral anticoagulant (OAC, Warfarin) stroke
1. CHF LVEF 35% (+1)
2. HT or on medication (+1)
3. Age 75 (+2)
4. DM (+1)
5. Prior Stroke or TIA or Thromboembolism (+2)
6. Vascular disease (Prior MI / Peripheral artery disease / Aortic plaque) (+1)
7. Age 65-74 (+1)
8. Sex category: Female (+1)

TOPSI117

Score = 0 Low risk No or ASA 75-325 mg OD ( prefer No )

Score = 1 (Stroke rate = 1.3%/yr.) Moderate risk ASA or OAC (Warfarin) ( prefer OAC ;
, counseling + )
Score 2 High risk OAC (Warfarin), keep INR 2-3
(Score = 2: Stroke rate = 2.2%/yr.; Score = 3: Stroke rate = 3.2%/yr.; Score = 4: Stroke rate = 4%/yr.)
Digoxin (Digitalis, Lanoxin) delay AV conduction HR
C/I: 2nd degree AV block, VT, VF, HOCM
Digitalis intoxication arrhythmia Accelerate junctional rhythm, Atrial
tachycardia with AV block, Bidirectional VT
SE: N/V, Xanthopsia, Bradycardia
Digitalis toxicity
1.
2.
3.
4. HypoK+, HyperCa2+ ( HCTZ)
Digitalis toxicity
1. Digoxin
2. HypoK+
3. Digoxin specific sheep Fab fragments

Valvular Heart Disease

- murmur valvular heart disease: MR-Pan, MS-Rumb, AS-Eject, AR-Blow

Mitral regurgitation (MR)

- Cause: Chronic RHD, IE, Trauma
- Symptoms: HF
- Signs:
1. Pansystolic murmur (PSM) at apex, radiate to Lt. axilla
2. Wide splitting S2
3. Prominent V wave
4. PMI shift to the Lt.
5. Lt. atrial thrust, sterna heaving LV ( PH)
- AF ( total irregularity)
- EKG: LAE, LVH, AF
- I/C for Sx:
1. Symptomatic severe MR
2. Asymptomatic EF 55%

Mitral stenosis (MS)

TOPSI117

- Cause: RHD (> 90%), IE, Congenital, SLE, RA, Mucopolysaccharidosis, etc.
- Symptoms: HF, Palpitation ( AF), Stroke (cardioembolism AF)
- Signs:
1. Diastolic rumbling murmur (DRM) at apex, radiate to Lt. axilla or Lt. sternal border
2. Diastolic thrill at apex
3. Presystolic accentuation murmur
4. Palpable P2 & Lt. parasternal heaving ( PH)
MS Apical heaving
5. Loud S1 ( mitral valve calcified ), Loud P2 ( PH)
6. Opening snap ( mitral valve calcified )
7. Prominent A wave ( PH), Prominent V wave ( RV failure TR)
8. Mitral facies, Cachexia, Edema ( Anasarca severe)
- EKG: LAE, AF
- I/C for Sx:
1. Symptomatic severe MS, Mitral valve area 1.5 cm2, FC 3-4, valve PBMV
2. Asymptomatic PH (PASP > 60 mmHg), valve PBMV
(PASP = Pulmonary a. systolic pressure)
- Sx in MS 3
1. Closed mitral commissurotomy (CMC)
2. Open mitral commissurotomy (OMC)
3. Mitral valve replacement (MVR)
- I/C for PBMV: (PBMV = Percutaneous balloon mitral valvotomy)
1. Mitral valve area 1.5 cm2, FC 2-4, valve , clot RA
2. Asymptomatic, Mitral valve area 1.5 cm2, PH (PASP > 50 mmHg > 60 mmHg
), valve
3. Symptomatic severe MS, Mitral valve area 1.5 cm2, FC 3-4 Sx

Aortic stenosis (AS)

- Cause: Congenital, Degenerative, RHD ( AS AR MS MR )
- Symptoms: ASD 5, 3, 2
1. Angina pectoris survival period = 5 yr.
2. Syncope (from hypotension) survival period = 3 yr.
3. Diastolic HF ( concentric LVH) survival period = 2 yr.
- Signs:
1. Systolic ejection murmur (SEM) at RUSB, radiate carotid a., suprasternal notch
severe late-peaking murmur ( peak murmur)

TOPSI117

2.

Pulsus parvus et tardus (carotid pulse , amplitude ; severe AS

HF )
3. Carotid shudder (Carotid thrill) (carotid pulse systole)
4. Gallavardin phenomenon ( murmur apex ; )
5. Apical heaving
6. Prominent A wave ( compliance LV interventricular septum )
7. Bernheim effect ( severe AS interventricular septum RV Rt. sided
HF Lt. sided HF)
- EKG: LVH with strain
- I/C for Sx:
1. Symptomatic severe AS
2. Asymptomatic EF 50%

Aortic regurgitation (AR)

- 2 AR lesion Valve & lesion Aortic root
- Cause:
1. Valve
1) Acute IE, Trauma
2) Chronic RHD, Bicuspid aortic valve, Myxomatous degeneration, Degenerative calcified aortic
valve
2. Aortic root
1) Acute Aortic dissection, Trauma
2) Chronic Marfan syndrome, Annulo-aortic ectasia, HT, Age-related aortic dilatation
- Symptoms:
1. Acute onset: HF with Cardiogenic shock
2. Chronic: HF
- Signs:
1. Diastolic blowing murmur (DBM) at LLSB
2. Austin-Flint murmur (mid-late diastolic rumble) at apex ( severe AR)
3. Apical heaving
4. RV heaving PH (, Rt. sided HF )
5. Peripheral signs chronic AR
1) Water-hammer pulse (Pulsus celer et magnus) ( radial pulse )
2) Corrigans sign ( pulse & suprasternal notch ; visible carotid pulse)
3) Quinckes sign ( dilate & constrict capillary refill
)
4) De Musset sign ( HR; severe AR)

TOPSI117

5)
6)
7)
8)
9)
10)
11)
12)

Mullers sign (uvula HR)

Landolfis sign ( pupil HR; pulsatile pupil)
Pulsus bisferiens (pulse 2 = double systolic impulse carotid a.)
Carotid shudder (Carotid thrill) (carotid pulse systole)
Palmar click (palpable, abrupt flushing systole)
Rosenbachs sign (liver HR)
Gerhardts sign (spleen HR)
Traubes sign (Pistol shot sounds) ( systolic & diastolic murmur pistol shot
Femoral a.)
13) Duroziezs sign ( ---) ( systolic & diastolic bruit chest piece
femoral a. chest piece systolic bruit,
chest piece diastolic bruit; SV systole & reversal flow
diastole )
14) Hills sign ( BP popliteal a. radial a. 20 mmHg; severe AR)
- EKG: LAE, LVH
- I/C for Sx:
1. Symptomatic severe AR
2. Asymptomatic EF 50% ESD > 55 mm EDD > 75 mm
(ESD = End-systolic dimension; EDD = End-diastolic dimension)

Rheumatic fever (RF)

- Rheumatic fever (RF) Mitral valve
- Dx Modified Jones criteria: RF 2 Major 1 Major + 2 Minor
Major criteria (----)
1. Chorea
2. Subcutaneous nodule
3. Carditis (Endo/Myo/Peri)
Endocarditis Murmur
Myocarditis Clinical HF, TnT, CK-MB
Pericarditis Pericardial effusion Pericardial rub, Distant heart sound, Cardiac tamponade
4. Polyarthritis
5. Erythema margitanum
Minor criteria
Clinical
1. Fever
2. Arthralgia
3. Hx of RF / RHD
Laboratory

TOPSI117

1. ESR, CRP (Acute phase reaction)

2. Prolonged PR interval
Ix: CXR, EKG, Echo.
Management: PGS 1.2 MU IM OD for 10 d
Lutembachers syndrome = ASD + Rheumatic MS
I/C for ATB prophylaxis invade mucosa RS/GI/GU tract ( Amoxicillin 2 g adult,
50 mg/kg children)
1. Prosthetic heart valve
2. Previous IE
3. Valvular heart disease
4. CHD

Infective endocarditis (IE)

- Infective endocarditis (IE) endothelial lining heart Vegetation,
Valve (esp. Mitral valve), Endocardium

(Vegetation Mitral valve IE Viridans streptococci)

-
1. heart e.g. CHD (esp. PDA, VSD, HOCM), Valvular heart disease,
Prosthetic heart valve
2. Hx IVDU
3. Nosocomial endocarditis e.g. Intravenous catheter ( CVP), Pacemaker, Double
lumen, Dialysis shunt, etc.
- Valvular heart disease VSD flow endocardium
raw surface thrombosis NBTE (Non-bacterial thrombotic
endocardial lesion) NBTE lesion / skin /
bacteria colonize NBTE lesion IE
- Classification
1. Acute bacterial endocarditis (ABE) progress , wk.,
S. aureus
2. Subacute bacterial endocarditis (SBE) , night sweat, fatigue, weight loss,
Viridans streptococci

TO
OPSI117

3. Prosthetic valvular endocaarditis (PVE)

oral cavitty, flora
skin (esp. IVDU)
-
1. Viridans strepptococci (e.g.. S. mutans, S.
S bovis)
SBE

S
2. HACEK groupp SBE
HACEK grooup Hemophillus aphrophiluus, Actinobaccillus actinomyycetem,
Cardiobacterrium hominis, Eikenella corrrodens, Kinggella kinkae
3. S. aureus ABE
4. Coagulase-neegative staphhylococci (CNS) (e.g. S. eppidermidis, S. lugdunensis)
m-negative rodds e.g. Enterrococcus faeccalis
5. Enteric Gram
- Classsic triad:
1. Fever
2. Heart murmur
3. H/C +ve
- Peripheral manifesstation IE
1. Oslers node painful erythematous nodule / , vascuulitis
immuune complex

2.

3.

Janeway lesion hem

morrhage macule

, ABE
S. aureus, septic embboli

(Janewway lesion
) (Janewway lesion
+ Oslers node )
Splinter hemoorrhage (Subuungual hemorrrhage) capillary
permeability vassculitis microembooli

TO
OPSI117

4.

Roths spot Retinal hemoorrhage

, (wwhite center)

M 1 Major
M + 3 Minoor 5 Minoor
- Dukes criteria Dx IE 2 Major
Majorr criteria
1. Positive H/C
1) Typical microorganism
m
m for IE from H/C
H x II
- Viriddans streptocoocci, Streptoccoccus bovis, HACEK grouup, S. aureus, or
- Com
mmunity-acquired Enterocoocci in the abssence of a primary focus, oor
2) Persistenntly positive H/C,
H defined as
a recovery of a microorgannism consistent with IE from
m:
- H/C drawn > 12 hr.
h apart; or
- All of
o three or a majority
m
of fourr or more sepaarate H/C withh first and lastt drawn at leaast 1 hr.
aparrt
3) Single poositive H/C forr Coxiella burrnetii or phasee I IgG Ab titieer of > 1:800
e
innvolvement
2. Evidence of endocardial
1) Positive echocardiogr
e
ram
- Oscillating intracaardiac mass on
o valve or supporting strucctures or in thhe path of regurgitant
o in implanteed material, in the absence of an alternative anatomicc explanation, or
jets or
- Absccess, or
- Neww partial dehiscence of prossthetic valve, or
2) New valvvular regurgitaation (increase or change in preexisting murmur not ssufficient)
Minorr criteria
1. Predisposition: predisposing heart conddition or IVDUU
2. Fever 38CC
3. Vascular pheenomena: major arterial emboli, septic pulmonary infaarcts, mycotic aneurysm, inntracranial
hemorrhage, conjunctival hemorrhages, Janeway lessions
n
Rothss spots, rheum
matoid factor
4. Immunologic phenomena: GN, Oslers nodes,
s
5. Microbiologicc evidence: poositive H/C buut not meetingg major criterion as noted ppreviously or serologic
evidence of active
a
infection with organissm consistentt with IE
- DDx: SLE, Acute rhheumatic feveer, Atrial myxooma, Collagenn vascular dissease, TTP
- Ix: CBBC, ESR, RF, Echo.
Echo. identiify Vegetationn, Perivalvularr abscess, Chhamber size
Function valve
- Manaagement

TOPSI117

1.
2.

ATB sensitivity, high dose, (

vegetation )
Surgery I/C:
1) Refractory heart failure due to destroy valve
2) Outflow tract obstruction
3) Recurrent major emboli
4) Persistent bacteremia despite optimal ATB 7-10 d
5) Tissue invasion (valve ring, septal abscess)
6) Early prosthetic valve endocarditis (< 2 mo. after valve replacement)

Cardiomyopathy
- Cardiomyopathy () 5
1. Dilated cardiomyopathy (DCM)
2. Hypertrophic cardiomyopathy (HCM)
3. Restrictive cardiomyopathy (RCM)
4. Arrhythmogenic right ventricular cardiomyopathy
5. Unclassified cardiomyopathy

Dilated cardiomyopathy (DCM)

- DCM cardiomyopathy ,
1. Ventricular dilatation (LV LV & RV)
2. Contractility (e.g. LVEF < 40%)
- Cause: e.g. Ischemia, Valvular heart disease (esp. MR & AR chronic
volume overload), Familial, Idiopathic, Infectious myocarditis (viral, bacterial, TB, fungal, rickettsial, HIV),
Toxic, Metabolic, Autoimmune, etc.
50% Idiopathic DCM (IDC) cause W/U
- Treatment: cause () + HF

TOPSI117

Hypertrophic cardiomyopathy (HCM)

- HCM genetic LV (usually 15 mm), AD
point mutation gene encode cardiac sarcomere proteins = Myocardial
disarray + Myocyte (hypertrophy) + Interstitial fibrosis
- Prevalence 1:500, 50% sporadic, 50% familial

Restrictive cardiomyopathy (RCM)

- RCM ventricle (LV / RV / LV+RV) ventricle , compliance
impaired ventricular filling
- Cause: Idiopathic, Eosinophilic endomyocardial disease (Lofflers endomyocarditis), Endomyocardial
fibrosis, Infiltrative cardiomyopathy (e.g. Amyloidosis, Hemochromatosis, Sarcoidosis, GSD, MPS, Fabry
disease), Scleroderma, Carcinoid heart disease, Post-heart transplantation, Post-mediastinal radiation,
Pseudoxanthoma elasticum, Doxorubicin & Anthracycline CMT, etc.
- Symptoms: Rt. HF > Lt. HF ( edema > dyspnea)
- Constrictive pericarditis prognosis
(RCM prognosis ; Constrictive pericarditis Sx )

Pericardial diseases
Acute pericarditis
- Acute pericarditis inflammation pericardium chest pain
- PE: Pericardial friction rub (80%) , LLSB diaphragm ,
( pathognomonic sign)
- Cause
1. Infectious
1) Viral Coxsackie virus A, Coxsackie virus B, Echovirus, Adenovirus, Mumps, HBV, HIV, HSV
Viral Acute pericarditis
2) TB
3) Pyogenic S. pneumoniae, S. aureus, N. menigitidis, N. gonorrhoeae, Legionella spp. etc.
4) Fungal Histoplasmosis, Coccidiodomycosis, Candida, Blastomycosis
5) Other infections Syphilis, Protozoa, Parasite
2. Non-infectious
1) Neoplasm
2) Autoreactive (immune-mediated CVT Sx AMI
(1) Post-pericardiotomy
(2) Post-MI (Dresslers syndrome)
3) Uremia
( uremic toxin Acute pericarditis)

TOPSI117

4) Autoimmune disease RF, SLE, RA, Scleroderma, MCTD, PAN, Wegeners granulomatosis
5) Inflammatory disease Sarcoidosis, Amyloidosis, IBD, Whipples disease, Temporal arteritis
- EKG Acute pericarditis 4 stages

Stage 1 (hours) Generalized concave upward STE + PR depression

lead aVR V1 reciprocal ST depression + PR elevation
Stage 2 (days) STE & PR depression normal, T wave flat
Stage 3 (days-weeks) TWI lead STE
Stage 4 (days-weeks) normal EKG

(12-lead EKG: Stage 1 of Acute pericarditis)

- CXR: Normal; if Cardiomegaly Pericardial effusion > 250 ml
- Management: Viral pericarditis (self-limited) 2-6 wk., NSAIDs
inflammation 1-2 wk.
1. ASA 300-600 mg q 4-6 hr. (2-4 g/d)
(ASA prefer recent MI NSAIDs impair scar formation)
2. Ibuprofen 1,200-1,800 mg/d
3. Indomethacin 75-150 mg/d
( Indomethacin Elderly, CAD Coronary blood flow)
high-dose NSAIDs Omeprazole (20) 1x1 ac
response NSAIDs Colchicine
response NSAIDs & Colchicine Prednisolone 1-1.5 mg/kg 1 mo., then slow tapering
- Complications
1. Recurrent / Chronic pericarditis (20%)
2. Cardiac tamponade (10-15%)

TOPSI117

3.
4.
5.

Constrictive pericarditis (5%)

Effusive-constrictive pericarditis (5%)
Arrhythmia: SVT, PAC

TOPSI117

Chest Medicine
Physical signs in chest disorders
- Finding chest
Conditions
Trachea
Percussion
Midline
Resonance
Normal
Midline
Lobar pneumonia
Dull
Shift (involved)
Atelectasis
Pleural effusion
Shift (opposite)
Hyperresonance
Pneumothorax
Hyperresonance
Emphysema
(diffuse)
Midline
Normal /
Asthma
Hyperresonance

Breath sounds Fremitus

Vesicular
Normal
Bronchial
Increased
Absent
Decreased

Obscure

Decreased

Adventitious sounds
No
Crackles

No

Wheezing

Chest X-ray interpretation

- CXR 5 , , Exposure-Inspiration-Rotation,
Tube & Line
1. film , HN, ,
2. PA AP ( scapula), supine upright
1) PA scapula , , upright ( air stomach ,
spinous process )
2) AP scapula field
3. Exposure-Inspiration-Rotation (symmetry)
1) Exposure T5-8 (mid T spine) Good exposure intervertebral disc
= Underexposure (Underpenetration) infiltration
= Overexposure (Overpenetration)
2) Inspiration Full inspiration Anterior rib 6 Posterior rib 9 ()
3) Rotation (symmetry) spine head of clavicle 2

symmetry clavicle 2

TOPSI117

4.

Tube & Line

1) ETT
- trachea
ETT esophagus bag breath sounds
( CXR confirm ETT) case OR ETT
esophagus bag breath sounds
- ETT = 2/3 trachea ; ETT Difficult intubation

- ETT wall trachea irritate

- Cuff CXR Cuff overinflation tracheal cartilage dilate

P capillary = 25 mmHg cuff P > 25 mmHg capillary tissue
ischemia trachea necrosis

ETT: ETT carina ( neutral /

/ lower border of mandible C spine )
ETT
lower

carina (cm)
border of mandible
Neutral
C5
52
C5
32

C5
72

+ 1 cm
(-
NA
-
trachea , ETT
)
ETT carina ETT upper border of 1st rib (ETT )
2) Tracheostomy tube
- trachea , position
-
- wall

TOPSI117

tracheostomy tube soft tissue tracheostomy tube

tracheostomy tube ETT tracheostomy

3) ICD
- ICD ( pleural effusion )

Side hole inner rib

ICD Rt. ICD Liver & IVC
Lt. ICD Aorta
- Subcutaneous emphysema
4) NG tube anatomy
trachea aspiration
5) Central line CXR 2
(1) Internal jugular venous access
: , ARDS, Pneumothorax
: ,
(2) Subclavian venous access
:
: , coagulopathy bleeding tendency

Line
- Fast catheter SVC, Rt. main bronchus Anterior border of 1st rib, ,
( tear vessel), Arrhythmia (RA), complication
severe Atrial perforation
- Double lumen catheter (DLC) RA , , , dialysis
- Permanent catheter RA , DLC, 2
- Swan-Ganz catheter PA

TOPSI117

complications
1. Ruptured PA ( massive hemoptysis )
2. PA occlusion ( pulmonary infarction: wedge shape tip of
catheter)

5.

6) Pacemaker (RV)
(1) Temporary
(2) Permanent , CXR pace chest wall
: Soft tissue, Bone, Abdomen, Diaphragm, Pleura, Lung parenchyma, Heart,
Mediastinum
1) Soft tissue
(1) Fat
(2) Subcutaneous emphysema muscle
(Pectoralis major m.)
2) Bone Fx : Clavicle, Vertebrae, Humerus, Ribs, Osteoporotic Fx, Metastatic Fx
3) Abdomen
(1) Bowel gas pattern Ileus/SBO/LBO
(2) Calcification anatomical location: GB, Pancreas, Kidney
(3) Free air under dome of diaphragm perforation of hollow viscus organ (e.g. bowel
perforation), signs e.g. Falciform ligament sign, Double bowel wall sign
4) Diaphragm
- Rt. diaphragm Lt. diaphragm ( Rt. liver)
- Silhouette lung (curve diaphragm ) consolidation at RLL / LLL
curve diaphragm
- Deep sulcus sign Pneumothorax
- Flat diagphragm Subpulmonic effusion
- Blunt costophrenic angle Pleural effusion Pleural thickening
5) Pleura
(1) Air: Pneumothorax
- Visceral pleural line DDx Skin fold ( plate X-ray )
Pneumothorax: lung marking pleural line
Skin fold: lung marking pleural line, lung field
(2) Fluid

TOPSI117

: effusion upper lung Apical cap sign

effusion minor fissure 2

infiltration pattern Pleural effusion

6) Lung parenchyma Black or white lesion
- Black lesion
(1) Pneumothorax
(2) Pulmonary embolism (PE) lesion distal PE = Westermark sign
(3) Hyperaerated lung e.g. COPD, AutoPEEP
- White lesion infiltration / mass / effusion
(1) Infiltration
1. Alveolar infiltration
- e.g. Pneumonia, ARDS, Pulmonary edema, Pulmonary hemorrhage, BAC
- Air bronchogram branch
- lesion Silhouette sign ( alveolar
infiltration )
Structure silhoutte
Lung lesion
Rt. diaphragm
RLL
Lt. diaphragm
LLL
Rt. heart border
RML
Lt. heart border
Lingular segment of LUL
- heart liver; heart liver
infiltration heart (Retrocardiac region) = lesion LLL
Hidden area 6 Retrocardiac region, Apex of lung,
Costophrenic area, Hilar area, Subphrenic area, Airway
- Term white lesion
Acinar shadow =
Patchy infiltration =
Consolidation = segment/lobe

TOPSI117

2. Interstitial infiltration
- CNT / lymphatic vv. cell infiltration
- Silhouette sign
- Cause = LIFE: Lymphatic, Idiopathic, Infection, Fibrosis, Edema
- 4 pattern
1) Nodular infiltration miliary TB, pneumoconiosis, CA, infection
2) Reticular infiltration interstitial lung disease, fibrosis, pulmonary
congestion
3) Reticulonodular infiltration PCP, miliary TB, Toxoplasma, CMV
4) Linear infiltration CHF ( cardiomegaly, linear infiltration
peripheral lung = Kerleys B line)
(2) Mass Benign VS Malignant
- Approach to Solitary pulmonary nodule (SPN)
- Nodule = < 3 cm; Mass = > 3 cm
- Intrapulmonary mass irregular border, acute angle
Extrapulmonary mass sharp border, obtuse angle
- mass CXR
(3) Effusion
7) Heart
- AP PA
- CT ratio < 0.5; Portable CXR AP CT ratio cardiomegaly
( > 0.6)
- RAE Thumb sign ( sign )
- LAE Carina angle > 75 Lt. main bronchus
- RVH Apex ( Lateral)
- LVH Straight heart border, Apex
- Globular-shaped heart DDx 3
1. Multi-valvular heart disease
2. Pericardial effusion
3. DCM
- hyperinflation Tubular-shaped heart
8) Mediastinum
- Aorta calcification
Chest pain, BP 2 , CXR Calcified aorta
Aortic dissection
- Median sternotomy wiring open heart Sx ( Heart-lung matchine)
- Mediastinal mass anterior / middle / posterior

TOPSI117

(1) Anterior 3T 1L
- Thyroid Goiter, Neoplasm
- Thymoma
- Teratoma
- Lymphoma
(2) Middle 3A
- Adenopathy Infection, Tumor, Sarcoidosis
- Aneurysm
- Abnormalities of development Bronchogenic cyst, Pericardial cyst, Esophageal
duplication cyst
(3) Posterior
- Neurogenic Neuroblastoma, Ganglioneuroma, Ganglioblastoma
- Nerve root tumor Schwannoma, Malignant Schwannoma, Neurofibroma

Chronic obstructive pulmonary disease (COPD)

- COPD criteria Dx 2
1. Risk factor: smoking > 10 pack-yr air pollution
2. FEV1/FVC < 70% ( Post-bronchodilator)
- chronic productive cough, (),
dyspnea on exertion (DOE)
- PE: expiratory wheezing, increased AP diameter (barrel-shaped chest), decreased breath sounds,
accessory muscle use, hypertrophy of M.Scalene & M.Sternocleidomastoid, pursed lip breathing (
), cyanosis
- Severity 4
Management
Severity
Clinical
FEV1 (Post-bronchodilator)

80%
Mild
SABA
exacerbation

50-80%
SABA + LABA + Theophylline
Moderate
exacerbation

SABA + LABA + Theophylline

30-50%
Severe
ICS ( AE 2 /yr.)
exacerbation
< 30% < 50% SABA + LABA + Theophylline

chronic respiratory failure + ICS + Long-term home O2

Very severe exacerbation
therapy ( respiratory
(PaO2 < 60 mmHg or
+
PaCO2 > 50 mmHg)
failure; O2 2 LPM 15 hr./d)
- Influenza vaccine, Pneumococcal vaccine COPD severity

TOPSI117

- Chest PT (Lung rehab) COPD moderate

- advanced COPD right-sided HF = Cor pulmonale ( chronic PH decompensate)
neck vein engorged, RV heaving, S3, ascites, edema; clubbing CA lung
- COPD 1-antitrypsin deficiency

Acute exacerbation of COPD (AECOPD)

- precipitating cause infection (viral/bacterial), air pollution, 1/3
- AECOPD Anthonisen NR 3
1. DOE
2. sputum
3. sputum pus
severity 3 types
Type 1 (severe) 3
Type 2 (moderate) 2
Type 3 (mild) 1 + 1 : 1) URI 5 , 2) Fever ,
3) Wheezing , 4) , 5) HR 20%
- GOLD (Global initiative for chronic obstructive lung disease): AECOPD = COPD
DOE / cough / sputum variation acute,

- AECOPD severity 4
1. /
2. accessory m. / paradoxical abdominal movement
3. on O2 supplement O2 sat. < 85% Pao2 < 50 mmHg
4. Arterial pH < 7.3
1/4 RCU ventilator (non-invasive )
Ix : CXR, CBC, Sputum G/S, C/S, EKG AECOPD Dx
- AECOPD 4
1. O2 supplement keep O2 sat. 88-92% 3
1) hypoxic drive
2) V/Q mismatch
3) Haldane effect deoxygenated Hb CO2 HbO2
2. Bronchodilator Berodual (Fenoterol/Ipratropium) NB Ventolin (Salbutamol)
NB q 4 hr. with prn for dyspnea
3. Corticosteriod Dexamethasone 5 mg IV q 6 hr.
4. ATB bacterial infection precipitate (/: infected bronchitis)
4 S. pneumonia, H. influenzae, M. catarrhalis, K. pneumoniae

TOPSI117

- D/C 1) bronchodilator q 4 hr., 2) O2 sat. (RA) 90%

24 hr. , 3)
- O2 sat. (RA) < 88% Home O2 therapy
- D/C H/M + Prednisolone (5) 2x3 pc (30-40 mg/d) 7-14 d AE
-
1. Pharmacological
- AE Prednisolone (5) 2x3 pc 7-14 d ( tape off)
- AE 2 /yr. Severe COPD 3
1) Seretide (Salmeterol/Fluticasone) Symbicort (Formoterol/Budesonide) LABA/ICS
1 puff bid
2) Spiriva (Tiotropium) long-acting anticholinergic 1 puff OD
3) Nuelin SR Theodor (Theophylline) 1x2 pc
SR ( NG )
1) 2) control add + add 3)
2. Non-pharmacological
- Influenza vaccine ( ../), Pneumococcal vaccine
- Chest PT

Asthma
- Asthma Dx clinical e.g. , , , ,
, wheezing
- Asthma 3 components
1. Reversible airway obstruction
2. Airway inflammation
3. Bronchial hyperresponsiveness (BHR)
- Asthma: 3R
1. Recurrence
2. Reactivity trigger
3. Responsive bronchodilator
- Severity assessment
Variability of

FEV1, PEF
FEV1, PEF

Mild
Intermittent
Mild
Persistent

1 /wk.

Brief exacerbation
> 1 /wk. < 1 /d

2 /mo.

> 2 /mo.

< 20%
80% of

predicted

20-30%

TOPSI117

Moderate
Persistent
Severe
Persistent

> 1 /wk.

, limit activity

60-80% of
predicted

> 30%

60% of

predicted

- Management (OPD case)

1. New diagnosed asthma: Low dose ICS (< 400 g/d) F/U 3 mo.
- Controlled Low dose ICS OD
- Uncontrolled / Partially controlled Consult specialist
2. Uncontrolled / Partially controlled (): ICS 400-800 g/d add LABA add
Theophylline F/U 3 mo.
- Controlled ICS 50% q 3 mo. Low dose ICS OD, then stop LABA (or other controllers)

Acute asthmatic attack

- Acute asthmatic attack : attack 3 O2, Bronchodilator, Steroid
- order Acute asthmatic attack
One day
Continue
- On O2 cannula 3 LPM, keep O2 sat. > 95%
- NPO
( ETT)
- Record V/S
- NSS 1,000 ml IV drip rate 100 ml/hr
- Ventolin 1 ml + NSS to 3 ml NB stat,
then q 15 min x III, then q 2 hr.
- Berodual 2 ml + NSS to 4 ml NB q 2 hr.
Ventolin
- Dexamethasone 5 mg IV q 6 hr.
- H/M
1. Prednisolone (5) 2x3 pc for 7 d
2. Ventolin MDI 1-2 puff prn for asthmatic attack
3. ATB ( infection)

Pleural diseases
Pleural effusion
- pleural fluid (~ 10 cc, pH 7.6) pathology pleural effusion
- pleural fluid ~ 1,000 cc pleural disease pleural effusion
1,000 cc
- S&S:
1. Asymptomatic effusion , lung function
2. Pleuritic chest pain parietal pleura inflammation

TOPSI117

3. Dry cough
4. Dyspnea
5. PE: Decreased breath sounds, Dullness on percussion
Severity 3
Severity Pleural effusion
CXR finding
Mild
< 300 cc
Blunt costophrenic angle
Moderate
300-800 cc
Fluid curve (Ellis curve)
Severe
> 800 cc
Haziness, Mediastinal shift
I/C for Thoracentesis: pleural effusion ( pleural effusion
CHF volume overload)
Pleural effusion Exudate
1. Infection (Bacteria, TB, Fungus) e.g. Parapneumonic effusion, Empyema
2. Inflammation e.g. CNT disease, Postcardiotomy syndrome, Radiation pneumonitis, Hemothorax,
Pleural infarction ( PE reaction fluid / )
Postcardiotomy syndrome reaction heart pericardium fluid
sac Cardiac tamponade, pericardium chest
Pleural effusion
3. Malignancy e.g. Metastatic CA, Mesothelioma, Lymphoma
4. Pleural infarction ( PE) reaction fluid /
5. GI disease e.g. Pancreatitis, Ruptured esophagus, Hepatic / Subphrenic abscess
Pleural effusion Transudate
1. CHF
( CHF Diuretic Pleural effusion Exudate )
2. Hepatic hydrothorax
3. Hypoalbuminemia e.g. Cirrhosis, Nephrotic syndrome
4. Atelectasis (early)
5. Other e.g. Urinothorax, Peritoneal dialysis, Trapped lung, SVC obstruction
Lights criteria pleural fluid Exudate Transudate
= Exudate
1. Protein: Pleural fluid/Serum > 0.5
2. LDH: Pleural fluid/Serum > 0.6
3. LDH: Pleural fluid > 2/3 UNL of serum LDH (200 IU/L)
pleural fluid
1. Glucose < 60 mg/dl Rheumatoid pleuritis, Empyema, Malignancy, TB, Lupus
pleuritis, Ruptured esophagus
2. pH < 7.3 inflammation, glucose Empyema
pH < 7.2 e.g. ICD, Pleuroscopy

TOPSI117

4.

Amylase Pleural fluid/Serum > 1 Acute pancreatitis, Rupture of pancreatic pseudocyst,

Ruptured esophagus, Malignancy
5. Cholesterol Exudate > 45 mg/dl
6. TG > 110 mg/dl Chylothorax
7. ADA (Adenosine deaminase) pleural fluid Exudative lymphocytic predominate,
ADA > 60 IU/L TB Malignancy
8. G/S, C/S infection
9. Cell count infection
Hemothorax, Pneumothorax Eosinophil pleural fluid
10. Cytology Malignant pleural effusion
- Criteria Pleural effusion Exudate Lights criteria (
serum) Pleural fluid 1. + 2. ( 2 tests) 1. + 2. + 3. ( 3 tests) Exudate
1. Cholesterol > 45 mg/dl
2. LDH > 0.45 UNL of serum LDH
3. Protein > 2.9 g/dl
- Diseases pleural effusion
Diseases
Diagnostic pleural fluid test
Empyema thoracis
Observation (pus, putrid odor), C/S
Malignancy
Cytology
Lupus pleuritis
LE cells, Pleural fluid/Serum ANA > 1.0
TB pleurisy
AFB, C/S
Ruptured esophagus
Salivary amylase, Pleural fluid acidosis (pH ~ 6.0)
Fungal pleurisy
KOH, C/S
Chylothorax
TG > 110 mg/dl, Lipoprotein electrophoresis (Chylomicrons)
Hemothorax
Hct (Pleural fluid/Blood > 0.5)
Urinothorax
Creatinine (Pleural fluid/Serum > 1.0)
Peritoneal dialysis (PD)
Protein < 1 g/dl, Glucose 300-400 mg/dl
Extravascular migration of Observation (milky if lipid are infused),
central venous catheter
Pleural fluid/Serum glucose > 1.0
Rheumatoid pleurisy
Characteristic cytology
- LE cell pleural fluid SLE Lupus pleuritis LE cell
ANA (Ab component nucleus) pleural fluid nucleus neutrophil macrophage
= Hematoxylin body
Hematoxylin body 2
1. Chemotactic factor neutrophil Rosette formation

TOPSI117

2. Phagocytosis neutrophil neutrophil Hematoxylin body

Hematoxylin body neutrophil neutrophil

- Management
1. Treat U/D
2. Therapeutic thoracentesis , dyspnea ,
tap 1-1.5 L Re-expansion pulmonary edema
3. ICD
4. Chemical pleurodesis Recurrent pleural effusion; sclerosing agent (e.g. Talc, Tetracycline,
Doxycycline, Bleomycin) inflammation parietal & visceral pleura fibrosis

5. VATS (Video-assisted thoracoscopy) Complicated pleural effusion

1) Pleurodesis VATS sclerosing agent
2) Pleurectomy parietal pleura ( pleural cavity)
6. Thoracotomy effusion pleural ( ICD drain
)
1) Pleurectomy parietal pleura ( Thoracotomy VATS)
2) Decortication fibrin (thickened pleura) visceral pleura

Empyema thoracis
- Empyema thoracis subset Pleural effusion Exudate
- Pleural fluid: Cell count > 10,000/mm3, pH < 7.2, Glucose < 40 mg/dl, LDH > 1,000 IU/L
- 3 phases
Phase
Wk.
Management
Acute (Exudative)
1 ATB, ICD
= Parapneumonic effusion
Transitional (Fibrinopurulent) 1-2 ATB, ICD, VATS / Thoracotomy for Decortication
()
Chronic (Organizing)
> 2 ATB, ICD, Thoracotomy for Decortication / Empyemectomy
(pleural )
/ Thoracoplasty / Eloesser flap (open drainage)
- S&S: Fever, Tachypnea, Tachycardia, Pleuritic chest pain, Empyema necessitatis (pus chest wall
)

TOPSI117

- Complications: Pulmonary fibrosis, Chest wall contraction, Empyema necessitatis, Bronchopleural fistula
(BPF), Other (e.g. Osteomyelitis, Pericarditis, Mediastinal abscess, Subphrenic abscess, etc.)

Chylothorax
- Chylothorax effusion , TG pleural fluid > 110 mg/dl
- Management:
TPN
Sx chyle leak Thoracic duct

Pneumothorax
- Pneumothorax
1. Spontaneous pneumothorax
1) 1 (PSP) pleural bleb apex lung pathology, (congenital)
young adult (20-30 yr.) bleb (ruptured subpleural bleb),
2) 2 (SSP) U/D lung (e.g. COPD, Asthma, CA, PCP, LCH, LAM) pleural bleb
Hx Smoking
(LCH = Langerhans cell histiocytosis; LAM = Lymphaniololeiomyomatosis)
3) Catamenial Endometriosis visceral pleura / diaphragm
Endometriosis () Pneumothorax,
Management: Hormone therapy (treat as Endometriosis)
4) Neonatal
2. Traumatic pneumothorax (Acquired)
1) Chest injuries trauma
2) Iatrogenic Diagnostic procedure (e.g. Biopsy), Central venous catheter, Ventilator, Post-op.
- S&S: Dyspnea, Pleuritic chest pain, Unequal chest expansion, Hyperresonance on percussion, Decreased
breath sounds
- Trachea shift, Engorged neck vein, C.O., BP Tension pneumothorax
- CXR: Visceral pleural line, No lung marking, ICS , Diaphragm (flattening), Mediastinal shift
( Tension pneumothorax)
parietal visceral pleura 1 cm = 20%, 2 cm = 30%
- Management
1. Needle thoracostomy at 2nd ICS, MCL, rib immediate life-threatening condition
(Tension pneumothorax) ICD
2. ICD at 4th-6th ICS, Anterior-Mid axillary line
3. Chemical pleurodesis recurrence
4. Sx: VATS, Anterior axillary thoracotomy for Excision of subpleural bleb / Mechanical pleural abrasion
/ Pleurectomy / Treat complications

TOPSI117

- Asymptomatic Small pneumothorax < 20% Closed observation: Dyspnea, O2, Repeat
CXR 6 hr., 12 hr., %Pneumothorax
- Pneumothorax ICD
- , Sx
- /,
- off ICD
- Sx
- , Chest PT, suction, scope
- , off ICD
- Sx
ICD: 90% , 10% Sx
- I/C for Sx in Pneumothorax
1. Massive air leakage
2. Persistent air leakage > 3 d healing
3. Recurrence (2nd episode)
Spontaneous pneumothorax 2 = 25%
2 3 > 50%
4. Complications of pneumothorax
5. Previous contralateral pneumothorax recurrence 2
6. Bilateral pneumothorax
7. Large cyst on CXR bleb > 1/3 chest lung dyspnea
8. Occupational I/C in 1st episode recurrence e.g. ,
, ..
- Complications: Hemothorax, Respiratory failure (esp. COPD), Empyema, Tension effect ( Tension
pneumothorax)

Intercostal drainage (ICD)

- ICD I/C:
I/C for ICD insertion
Emergency conditions
1. Pneumothorax
2. Pneumohemothorax
3. Ruptured esophagus

Non-emergency conditions
1. Recurrent pleural effusion
2. Malignant pleural effusion
3. Parapneumonic effusion
4. Chylothorax
5. Pleurodesis
6. Post-op. care
e.g. S/P CABG, Thoracotomy,
Lobectomy

TO
OPSI117

I/C foor ICD removval

1. No
N active air leeak for 24 hr.
2. Fluid
F drainagee < 100 cc/d for
f 2d
3. Non-function
N
tube
- Pneumothorax chest
c tube 20F, 24F
Hemoothorax cheest tube 28F
- 1-Botttle system
P
Pleural
cavity

2 cm
-

Pneumotthorax
: 2 cm, pleural cavityy

trap
( pleural caviity negative
(
n
P
pleuraal cavity
)

- pleural cavity posittive P

move
pleural cavity negaative P

pleural cavvity space

2
1 Brreath sounds
1.
2 (NNon-function tuube) content (e.g. fibbrin) ,
2.

- 2-Botttle system
Pleural cavity
c

2 cm
m
-

Pleural effusion, Hemoothorax

: drain / pleural caviity 1-bottle systeem

pleural cavityy pleural cavityy
reservoir /

reeservoir interfere 2 cm
1-bottle

/ /

Siiphon effect

TOPSI117

- 3-Bottle system
Suction

2 cm

10 cm

: apply Suction 3
(2 2-bottle system)
3-bottle apply suction (
pleural cavity positive P)
- drain ; drain
- Chest tube 2
1. Rubber tube , (Thoracotomy) ICD
2. Silastic tube CXR ( CXR)
- Complications of ICD insertion: Subcutaneous emphysema, Pneumothorax, Hemothorax, Infection,
Empyema, Puncture into organs, Re-expansion pulmonary edema

Acute respiratory distress syndrome (ARDS)

- ARDS ; surfactant ; criteria Dx 4
1. A Acute
2. R Ratio Pao2/Fio2 200
3. D Diffuse alveolar infiltration (Bilateral patchy infiltration)
4. S Swan-Ganz catheter: PCWP < 18 mmHg
( volume status , Cardiogenic pulmonary edema PCWP )
- Pao2:Fio2 ratio 300 = Acute lung injury (ALI)
- TV = 7 cc/kg
Ventilator setting : TV = 8 cc/kg, ALI / ARDS: Low TV = 6 cc/kg ( lung
injury ), RR 20/min, Normal I:E, Therapeutic PEEP (> 5 cmH2O)

TOPSI117

Nephrology
- GFR CrCl Cockcroft-Gault formula
CrCl

BW

Sodium disorders

(x 0.85 if female)

Hyponatremia
- Investigation
1. Urine sp.gr. / Urine osmolarity (Uosm) & ADH effect
2. Urine Na+ (U[Na+]) Na+ & volume status
3. Serum BUN/Cr
- Hyponatremia 3 Hypertonic, Isotonic, Hypotonic
- Hypertonic hyponatremia (Hyper-osmolarity)
1. Glucose (Hyperglycemia) BS 100 mg/dl 100 mg/dl Na+ 1.6 mmol/L
BS

: Corrected Na
Measured Na
1.6
2. Mannitol
3. Maltose
4. Glycine (Hyperglycinemia)
- Isotonic hyponatremia (Iso-osmolarity) = Pseudohyponatremia
1. Lipid (Hyperlipidemia e.g. chylomicron, TG)
2. Protein (Paraproteinemia)
- Hypotonic hyponatremia (Hypo-osmolarity) 2 Uosm
1. Uosm < 100 (Urine sp.gr. )
1) Primary polydipsia (Psychogenic polydipsia)
Management: consult Psychiatrist
2) Beer potomania
3) Correction phase
2. Uosm > 100 (Urine sp.gr. ) Volume status 3
1) Hypovolemia (TBW, TBNa+) signs of volume depletion, 2
(1) Renal loss (U[Na+] > 20) Diuretics, Mineralocorticoid deficiency, Renal salt-wasting
Management: Diuretics, NaCl tab
(2) Extra-renal loss (U[Na+] < 20) Sweating, Diarrhea, Vomiting, 3rd space loss
Management: IV fluid
2) Euvolemia (TBW, TBNa+ ): U[Na+] > 20
(1) SIADH Dx by exclusion ( TFT & Serum morning cortisol normal)
Management: Restrict fluid
(2) Hypothyroidism

TOPSI117

(3) Adrenal insufficiency (Glucocorticoid deficiency)

(4) Stress
(5) Drugs
3) Hypervolemia (TBW, TBNa+) volume ; 2
(1) Renal loss (U[Na+] > 20) AKI, CRF
(2) Extra-renal loss (U[Na+] < 20) Edematous stage: CHF, Cirrhosis, Nephrotic syndrome
- HypoNa+ 12 mmol/L/d (rapid correction of hyponatremia) Central
pontine myelinolysis (CPM, Osmotic demyelination syndrome, ODS) Quadriplegia / Locked-in
syndrome

Potassium disorders
Hyperkalemia
- EKG: (1) Tall peaked T (2) P wave (4) sine (3) Wide QRS
Tall peaked T Flat P wave Wide QRS Sine wave
- Management
1. 10% Calcium gluconate 10 ml IV drip in 10 min (Ca2+ threshold
arrhythmia; esp. EKG change)
2. RI 10 U + 50% glucose 50 ml (RI shift K+ cell; K+ > 6.5)
3. Hemodialysis (HD) I/C

Hypokalemia
- EKG: Flat T wave, U wave
- Vomiting K+
vomiting H+ Metabolic alkalosis filter load HCO3- excrete NaHCO3-
(Na+ HCO3-) Na+ volume contraction Aldosterone (2
hyperaldosteronism) secrete K+ K+
- Management
1. Oral form: Elixir KCl 30 ml q 4 hr. ( dose K+)
2. IV form: KCl add IV
Add K+ 20 mEq IV maintenance; Max () = add 40 mEq
Rate max 60 mEq NSS 1,000 ml; F/U K+ 4 hr. ( F/U )
K+ : KCl 10 mEq in NSS 100 ml
- HypoK+ HypoMg2+
: Mg2+ TAL of Henles loop positive gradient K+
ROMK channel (ROMK = Renal outer medullary K+ channel) Mg2+ ( K+
lumen Mg2+ lumen ) HypoMg2+
Mg2+ K+ lumen ROMK channel loss K+ urine
HypoK+ HypoK+ with HypoMg2+ Mg2+ K+

TOPSI117

Magnesium disorders
Hypomagnesemia
- Management: Mg2+ 3 d F/U Mg2+
1. Oral form: 5% MgCl2 15 ml bid x 3 d
2. IV form: 50% MgSO4 8 ml + NSS 100 ml IV drip in 4 hr.
( D.2-3 8 ml 4 ml; 8-4-4)

Acute kidney injury (AKI)

- Acute kidney injury (AKI) = spectrum renal function w/in 48 hr.; criteria
Dx AKIN (AKI network) ( RIFLE criteria modified)
Stage
Creatinine criteria
Urine output criteria
Cr > 0.3 mg/dl or Urine output < 0.5 cc/kg/hr x 6 hr.
Stage 1
Cr 1.5x
Urine output < 0.5 cc/kg/hr x 12 hr.
Stage 2 Cr 2x
Cr 3x or
Urine output < 0.3 cc/kg/hr x 24 hr.
Stage 3
Cr 4 mg/dl
(oliguria) or Anuria x 12 hr.

1. criteria fluid
2. Creatinine criteria serum Cr 2 48 hr. ( criteria
Dx AKI Cr 2 48 hr. Dx Cr baseline RIFLE
criteria)
3. RRT (Renal replacement therapy) Stage 3
- RIFLE criteria criteria AKI Acute renal failure (ARF); Cr
baseline (RIF severity, LE outcome)
Stage
GFR criteria
Urine output criteria
Urine output < 0.5 cc/kg/hr x 6 hr.
Cr 1.5x or
Risk (Stage 1)
GFR > 25%
Urine output < 0.5 cc/kg/hr x 12 hr.
Cr 2x or
Injury (Stage 2)
GFR > 50%

TOPSI117

Cr 3x or
Urine output < 0.3 cc/kg/hr x 24 hr.
Failure (Stage 3)
Cr 4 mg/dl or (oliguria) or Anuria x 12 hr.
(ARF)
GFR > 75%
Persistent ARF > 4 wk.
Loss
ESRD (CKD stage 5)
ESRD
RIFLE criteria Stage 3 RRT
AKI Asymptomatic ( BUN/Cr ) Symptomatic: S&S 2
1. Volume overload
2. Uremia anorexia, N/V, metallic taste, ,
AKI cause 3
1. Prerenal Volume depletion (e.g. diarrhea), CHF
2. Renal (Intrinsic) ATN, Glomerular disease, Vascular disease, Interstitial disease
3. Postrenal BPH, Gynecologic malignancy, Ureteric stone; Anuria, Urinary
retention, Polyuria Oliguria/Anuria ( intermittent obstruction in urinary tract)
Parameter Prerenal Renal (ATN)
Parameters
Prerenal
Renal
Urine sp. gr.
> 1.020 ~ 1.010
Urine Cr/Plasma Cr
> 40
< 20
Plasma BUN/Plasma Cr
> 20
< 10
+
Urine Na (mEq/L)
< 20
40
N

FENa+ (= N

U
P

100)

Renal failure index (= C

N
U

)
P

<1

>1

<1

>1

Chronic kidney disease (CKD)

- CKD criteria Dx 2 1/2 > 3 mo.
1. GFR < 60 mL/min/1.73m2
2. Evidence of kidney damage Proteinuria, Hematuria, Urine sediment (Cellular cast), Radiologic
(Abnormal kidney on plain KUB / IVP / U/S / MRI), Pathologic
- Lab: CBC NCNC anemia; Elyte K+, PO43-, ( 2 hyperPTH ) Ca2+ ( renal
osteodystrophy vit.D ), acidosis
- DM (diabetic nephropathy) most common, HT (hypertensive nephropathy), Prerenal (HF,
cirrhosis, chronic diarrhea), GN, drug-induced, MM, urinary tract obstruction, PKD, ARF, HIV
- 5 stage GFR
120
1 5 415
90 2 3 30
60

TOPSI117

on Dialysis stage 5
Goal CKD
Stage 1 Dx & Rx U/D, slow progression, CVS risk
Stage 2 Estimate progression
Stage 3 Evaluate & Rx complications
Stage 4 RRT
Stage 5 Dialysis (if uremia)
CKD management
1. Restrict salt (< 2 g/d), protein (0.7-0.8 g/kg/d), K+, Mg2+, PO432. Control BP (goal: 130/80 mmHg) ACEI ( 1st line, add ARB)
3. Control blood sugar (HbA1C < 7)
4. Metabolic:
- Volume overload, Azotemia (BUN/Cr)
- Metabolic acidosis Sodamint (NaHCO3-) if HCO3- < 22
- K+ Kalimate 30 g q 1-2 hr.
- PO43- CaCO3 (625) 1x3-2x3 with meal (max = 8 tab/d)
If [Ca2+][PO43-] > 55 Al(OH)3 short term 1 mo.
5. Anemia (goal: Hb 11-12 g/dl) EPO 80-120 U/kg SC ( wk. 2-3 ), Fe ( I/C),
uremic bleeding DDVAP (Desmopressin) 0.3 g/kg
6. Vitamin D supplement ( stage 3-4)
7. Dialysis (I/C: AEIOU) / Kidney transplantation
CKD
1. Na+ e.g.
2. K+ e.g. ,
3. PO43- e.g. , ,
4.
5. ~ + 500 cc
6. e.g. NSAIDs,
Acute on top CKD = AEIOU + 4Hyper + 1Hypo
Agents Aminoglycoside, Iodine contrast, NSAIDs
ECF deficit (volume depletion), CHF
Infection
Obstructive nephropathy
Uric acid
HyperCa2+, Mg2+, PO43-, HT
HypoK+

TOPSI117

- Life-threatening complication CKD 3 HIV

1. HyperK+
2. Infection (e.g. Pneumonia, UTI, Sepsis)
3. Volume overload ( Pulmonary edema)
- Renal failure = Dr. SOPHA (.)
DM
RPGN
Sarcoidosis, Scleroderma
Obstructive nephropathy
Polycystic kidney disease (PKD)
Hydronephrosis, HIVAN
Amyloidosis

Acute tubular necrosis (ATN)

- ATN 2
1. Ischemic ATN hypovolemia, hypotension, sepsis, shock, prolonged prerenal state, HF, DIC
2. Nephrotoxic ATN Aminoglycosides, Vancomycin, Amphotericin B, Cisplatin, contrast media
- ATN 3 phase
1. Oliguric phase urine output < 400 mL/d; azotemia & uremia
2. Diuretic phase urine output > 500 mL/d; fluid overload, osmotic dieresis ( Na+ & water
retention oliguric phase), tubular cell damage
3. Recovery phase
- tubular function isosmolar urine

Glomerulonephritis (GN)
Rapid progressive glomerulonephritis (RPGN)
- RPGN 3
1. Anti-GBM Ab GBM; Hypersensitivity type 2;
Goodpasture syndrome: involve RS Pulmonary hemorrhage ; Clinical triad:
(1) Proliferative crescentic GN
(2) Pulmonary hemorrhage ( severe)
(3) Anti-GBM +ve (> 90%)
Management: Plasmapheresis + Pulse Methylprednisolone + Cyclophosphamide
2. Immune complex Hypersensitivity type 3; APSGN, IgA nephropathy, SLE
3. Pauci-immune (ANCA associated) (ANCA = Anti-neutrophil cytoplasmic Ab) Hypersensitivity
type 2;
1) Wegener granulomatosis Goodpasture syndrome, involve RS
2) Microscopic polyangiitis inflammation bl. vv.

TOPSI117

3) Churg-Strauss syndrome (CSS) 2 Hx Asthma & CBC

Eosinophil ; Clinical triad:
(1) Asthma
(2) Eosinophilia
(3) Systemic vasculitis involving > 2 extra-pulmonary organs
- RPGN Rifampicin, Penicillamine, Gout (Allopurinol), Nepresol (Hydralazine)
- Pathology: cell Bowmans capsule glomerular injury
Crescent GFR volume overload Lasix (
pathology urine ) & Anti-HT long-acting CCB Amlodipine

TOPSI117

Endocrinology
Diabetes mellitus (DM)
Classification and diagnosis of DM
- DM 4 types
1. Type 1 DM (IDDM) endogenous insulin, , polyuria, polydipsia, unexplained
weight loss, DKA , insulin , HLA association (associate
autoimmune disease )
2. Type 2 DM (NIDDM) insulin resistance, cell dysfunction, gluconeogenesis ,
asymptomatic, micro-/macrovascular complication
3. Other specific types
4. GDM pregnancy 2-4%, 2nd/3rd trimester ( HPL & P
insulin insulin resistance)
- polyuria, polydipsia, unexplained weight loss, fatigue, weakness, blurred vision (water
content lens ), vaginitis, fungal skin infection,
- ADA Diagnostic criteria for DM (ADA = American Diabetes Association)
1. Symptoms of DM + CPG 200 mg/dl
2. FPG 126 mg/dl (x2 symptoms)
3. 2-hr PG in 75 g OGTT 200 mg/dl
( OGTT Dx GDM symptoms high risk FPG )
- FPG < 100 mg/dl, 2-hr PG < 140 mg/dl
- FPG 100 mg/dl < 126 mg/dl Impaired fasting glucose (IFG)
- 2-hr PG 140 mg/dl < 200 mg/dl Impaired glucose tolerance (IGT)
- IFG IGT Dx Prediabetes

Complications of DM
-
1. Acute complication (Hyperglycemic crisis) e.g. DKA, HHS
2. Chronic complication 3
1) Macrovascular e.g. CAD (MI), CVD (Stroke), PVD
2) Microvascular e.g. DN (glomerular capillary), DR (retinal capillary)
3) Diabetic neuropathy Sensory, Motor, Autonomic

Treatments of DM
- FPG < 200 mg/dl HbA1C < 8% Lifestyle modification 1-3 mo.
FPG 200-300 mg/dl Lifestyle modification + 1
FPG 250-350 mg/dl HbA1C > 9% Lifestyle modification + 2
FPG > 300 mg/dl HbA1C > 11% + Lifestyle modification + Insulin

TOPSI117

- 1
1. Metformin (safe ) BMI 23, BP 130/85 mmHg ( on
treatment), TG , HDL
C/I Metformin: Cr > 1.5 (male), > 1.4 (female), GFR < 70 ml/min ( volume overload)
2. SU (e.g. Glibenclamide, Glipizide) BMI < 23, ;
hypoglycemia
- 2nd drug: 1st Metformin SU TZD; 1st SU Metformin TZD
- Dose:
Glibenclamide (5) ac; Max = 4 tab
Glipizide (5) ac; start 1 tab, dose -1 tab/d; Max = 8 tab
Metformin (500) pc; Max = 6 tab
- I/C for Insulin therapy (= C/I )
1. Type 1 DM
2. Hyperglycemic crisis DKA, HHS
3. Pregnancy
4. Surgical condition
5. Severe infection (and other stress)
6. Liver failure, Renal failure
7. Failure/Allergy
Onset
Peak Duration
RI -1 hr. 2-4 hr. 6-10 hr.
NPH 1-2 hr. 4-8 hr. 10-20 hr.

Diabetes care
- Advice Stop smoking, Diet, Exercise, Weight reduction
- Keep:
- BMI < 23 kg/m2 (18.5-22.9)
- BP < 130/80 mmHg; CKD keep BP < 125/75 mmHg
- LDL < 100 mg/dl; CKD/CAD/CVD keep LDL < 70 mg/dl
- TG < 150 mg/dl
- HbA1C < 7%; Complication DM keep HbA1C < 6.5%
- FPG < 130 mg/dl, PP < 140 mg/dl
- Screening 1
1. Renal function BUN/Cr, U/A, MAU
U/A proteinuria
+ve Total protein
ve MAU (Urine microalbumin)

TOPSI117

Total protein
24-hr urine Total protein
Spot urine Dipstick
Spot urine Protein : Cr ratio
Albumin
24-hr urine Albumin
Spot urine Albumin
(Specific dipstick)
Spot urine
Albumin : Cr ratio

2.
3.

Normal
< 300 mg/d
< 30 mg/dl
< 200 mg/g

Overt proteinuria
> 300 mg/d
> 30 mg/dl
> 200 mg/g

Normal
< 30 mg/d

Microalbuminuria
30-300 mg/d

Overt proteinuria
> 300 mg/d

< 3 mg/dl

> 3 mg/dl

NA

< 17 mg/g (male)

17-250 mg/g (male)
> 250 mg/g (male)
< 25 mg/g (female) 25-355 mg/g (female) > 355 mg/g (female)
Eye examination DR q 1 yr.; NPDR q 6 mo.
Microfilament test 10 4 Loss of protective sense ( 4
Loss of protective sense) DM foot

( 10 )
( 4 )
5
1) Wound
2) Callus ( pressure )
3) Monofilament test ( protective sense)
4) Peripheral pulse
5) Infection
- ASA, ACEI, Statins
DM 50 yr. (male), 60 yr. (female) on ASA (81) 1x1 prophylaxis
GI risk (e.g. Hx ) ASA PPI

Hyperglycemic crisis
- DKA (Diabetic ketoacidosis) type 1 DM; criteria Dx
Diabetic
1. Plasma glucose > 250 mg/dl
2. Wide anion gap metabolic acidosis
Ketoacidosis
3. Serum/Urine ketone positive (moderate to large)

TOPSI117

- DKA acute onset, N/V, abdominal distension, abdominal pain, polydipsia, polyuria,
Kussmaul breathing ()
- HHS (Hyperglycemic hyperosmolar state) type 2 DM; criteria Dx
Hyperglycemic
1. Plasma glucose > 600 mg/dl
2. Effective serum osmolarity (2Na+ + Glucose/18) > 320 mOsm/kg Hyperosmolar
( correct Na+ )
3. HCO3- > 15 mmol/L
Nonketotic
4. Serum ketone negative ( mild)
- HHS gradual onset, neuro. (stupor, unconscious, seizure, chorea), CVD
- DKA, HHS 4 volume depletion, drip RI, add K+, pH
1.6)
1. IV fluid ( Corrected Na Measured Na BS
- Low Na+ / BP drop NSS 250-500 cc/hr
- High/Normal Na+ 0.45% NaCl 250-500 cc/hr
2. Insulin drip RI IV IM; BP drop IV ( IV )
- IV route RI 0.1 U/kg stat, then 0.1 U/kg/hr
- IM route RI 10 U IV + 10 U IM stat then 10 U/hr IM
Goal: Plasma glucose 50 mg/dl in 1st hour
Goal 1st hour Double dose RI q 1 hr. Plasma glucose 50-75 mg/dl
3. K+ ( 0.2 3.5-5 3.3-5.2)
- K+ < 3.3 Hold RI, Add K+ 20-30 mEq/hr ( IV fluid) until K+ 3.3 mmol/L,
EKG monitoring
- K+ 3.3-5.2, Normal renal function Add K+ 20-30 mEq in each 1,000 ml of IV fluid,
keep K+ 4-5 mmol/L
- K+ > 5.2 Dont give K+, check K+ q 2 hr.
4. pH ( HCO3-)
- pH < 6.9 7.5% NaHCO3 100 cc, repeat q 2 hr. until pH > 7.0
- pH > 6.9 No NaHCO3
- Plasma glucose 250 mg/dl
1. Change to 5%D/NSS 150-200 cc/hr
( 5%D/NSS 5%D/N/2 NSS 0.45% NaCl)
5%D drip RI ( Hypoglycemia)
2. Switch RI drip to 0.1 U/kg SC ac IV 1-2 hr. SC
off RI drip SC RI off RI drip
insulin Rebound DKA ; keep Plasma glucose 150-200 mg/dl
- order DKA / HHS
BW 60 kg, BS = 660, Na+ = 145, K+ = 4, HCO3- = 16, ABG: pH 6.89, BP 80/50 mmHg
Effective serum osmolarity = 326, Corrected Na+ = 154

TOPSI117

HHS, BP drop
One day
- On O2 cannula 3 LPM
(, GCS < 8 ETT)
- NSS 1,000 cc IV drip in 1 hr. x I,
then NSS 1,000 cc IV drip in 2 hr. x II,
then NSS 1,000 cc IV drip 250 cc/hr
- Add K+ 30 mEq IV fluid
- Blood for CBC, BUN/Cr, Electrolytes, BS, Ketone,
Serum osmolarity ()
- ABG ()
- U/A
- CXR
- DTX q 1 hr.
- Blood for Electrolytes q 6 hr.
- RI 6 U IV stat, then IV drip 6 U/hr
- 7.5% NaHCO3 100 cc + sterile water 200 cc IV
drip in 30-60 min
- ABG at next 2 hr.

Continue
- NPO
- Record V/S, I/O
- Retained Foley catheter
Medication
- Ceftriaxone 2 g IV OD ( infection e.g.
UTI precipitating cause)

Hypoglycemia
- DTX: Plasma glucose < 55 mg/dl (male), < 45 mg/dl (female)
- Whipples triad Dx True hypoglycemia
1. Hypoglycemia
1) Autonomic symptoms (Sympathetic overactivity): (tremor), (palpitation),
(sweating), (hunger), anxiety
2) Neuroglycopenic symptoms: , (alteration of consciousness), ,
, , behavior
2. Plasma glucose < 50 mg/dl (), < 70 mg/dl ( DM)
3. Glucose
- Hypoglycemia 2 types
1. Fasting hypoglycemia
- Drugs: insulin, oral hypoglycemic drugs
- Pituitary insufficiency: GH
- Adrenal insufficiency (Addisons disease): cortisol
- Malignancy
- Islets cell tumor (Insulinoma) look well

TOPSI117

- Non-islets cell tumor (HCC, RCC, retroperitoneal fibrosarcoma, MM, HL) look sick
HL anti-insulin receptor Ab ( receptor ) = Autoimmune hypoglycemia
- Severe critically ill ( sepsis, malaria)
- Liver failure ( glycogenolysis, gluconeogenesis; alcohol )
- Renal failure ()
- Iatrogenic
2. Postprandial hypoglycemia ( hypoglycemia
insulin absorb glucose ) S/P Gastric surgery, Short
bowel syndrome
Severity
1. Mild Autonomic symptoms
2. Moderate Autonomic & Neuroglycopenic symptoms
3. Severe Unconscious
Hypoglycemia conscious
- Conscious (Mild to moderate hypoglycemia) Oral Glucose 15-30 g ( 100 cc
150 cc)
- Conscious (Severe hypoglycemia) IV 50% Glucose 50 cc (push)
DTX 15 min no recovery IV 50% glucose 50 cc DTX
recovery
recovery 10% D/W rate 80 cc/hr DTX q 2-4
hr. 24 hr., keep DTX > 100 mg/dl
Goal: DTX 150-200 mg/dl, clinical stable cause, , , etc.
Hx / ER, DTX Hypoglycemia
Hypoglycemia Vitamin B1 (Thiamine) 100 mg IV ( Vitamin B1
glucose aerobic cellular respiration ) B before G (Vitamin B1 before Glucose)

Thyroid disorders
Thyrotoxicosis
- Thyrotoxicosis = Thyroid hormone
- Hyperthyroidism = Thyrotoxicosis Hyperfunctioning Thyroid gland
- Graves disease = Autoimmune disease Hyperthyroidism TSI
(Thyroid stimulating immunoglobulin) TSH receptor; signs Triad:
1. Exophthalmos eyeball supraorbital margin ( ),
limit EOM
2. Pretibial myxedema
3. Thyroid bruit
- thyroid gland 15-20 g thyroid g (e.g. 3 = 60 g)

TOPSI117

- S&S:
1. Exophthalmos = Lagophthalmos Keratitis
2. Chemosis conjunctiva
3. Lid lag upper lid cornea sclera
4. Lid retraction upper/lower sclera /
5. Onycholysis nail bed ; sign long-standing hyperthyroidism
6. Thyroid acropachy (clubbing of finger)
7. Warm and moist skin
8. Tremor
9. Other: Palpitation, New AF, Weight loss, Systolic HT, PH, Proximal muscle weakness (
Hypokalemic periodic paralysis), , , , Amenorrhea /
Oligomenorrhea, Gynaecomastia / ED
- Specific eye signs Graves disease Graves ophthalmopathy
- Graves disease Methimazole (MMI) Propylthiouracil (PTU) SE 3
SE
PTU
MMI
1. Agranulocytosis
Idiosyncracy
Dose-related
( 30 mg/d )
2. Hepatotoxicity
Hepatitis ( 3 mo.)
Cholestasis
3. ANCA-associated
MMI, acute renal
PTU
vasculitis
dysfunction, arthritis, skin ulcer, rash,
TEN, sinusitis, hemoptysis, ANCA +ve
- PTU ( PTU MMI) 2
1. Pregnancy MMI Scalp defect, Aplasia cutis
2. Thyroid crisis PTU inhibit peripheral conversion T4 T3
- start Antithyroid drug start dose ( DM) Euthyroid

1. MMI (5) 3x2 (30 mg/d)
2. PTU (50) 1x3 2x3 (150-300 mg/d)
- Hyperthyroid ? dose (
goiter ; MMI PTU ) ( 8) Congenital
hypothyroidism ( RDS )
- Antithyroid drug CBC baseline thyrotoxicosis
Transient neutropenia
CBC Agranulocytosis
- F/U CBC, Agranulocytosis

TOPSI117

(PBS PTU Agranulocytosis)

F/U T3 & T4 ( hypothyroid T4 ), 2 mo. euthyroid
F/U euthyroid
MMI 20 mg/d 2x2, MMI 15 mg/d 3x1
F/U hyperthyroidism Body weight ()
18 mo. (1 yr.) TFT T3, T4, TSH relapse
F/U TFT q 2 mo. 6 mo. F/U TFT q 1 yr.
Fail medication dose thyrotoxicosis , dose TFT , major SE
: Agranulocytosis, Hepatitis, TEN I-131 / Sx
I-131 fail medication, heart disease, hypoK+ periodic paralysis, relapse
Pregnancy
1. TBG total T3, T4 N/V, TSH ( low normal )
2. -HCG ( subunit TSH) TSH
pregnancy thyrotoxicosis Graves disease R/O 2
1. Molar pregnancy (Hydatidiform mole) N/V , HT, Ut size > date, U/S: snowstorm, bleeding
; -HCG thyroid gland TSH
2. Hyperemesis gravidarum N/V , U/A ketosis; -HCG thyroid
gland molar pregnancy
GA 20 wk.
Graves disease remission 2nd/3rd trimester (TSH receptor ) treat;
1st trimester treat; symptom -blocker IUGR

Thyroid crisis
- Thyroid crisis (Thyroid storm) Emergency condition, Mortality rate 20-30%, Clinical Dx
- Thyrotoxicosis / / poor compliance
- Precipitating factor Thyroid crisis : GOITER
1. Graves disease
2. Operation (Sx)
3. Infection

TOPSI117

4. Trauma
5. Exogenous thyroid hormone
6. Radioactive iodine
Other: CHF, DKA, Hypoglycemia, Preeclampsia, PE, Stroke, Bowel infarction, Severe
emotional stress, etc.
- Burch and Wartofskys criteria score Dx Thyroid crisis
Score 45: Thyroid crisis
Score 24-44: Impending thyroid crisis
Score < 25: Thyroid crisis
Thermoregulatory dysfunction
Cardiovascular dysfunction
Temperature (F)

Tachycardia

99-99.9
100-100.9
101-101.9

5
10
15

99-109
110-119
120-129

5
10
15

102-102.9

20

130-139

20

103-103.9

25

> 140

25

> 104.0

30

Central nervous system effect

Absent

Congestive heart failure Absent

Mild: pedal edema

Moderate: bibasilar rales

10

Mild: agitation

10

Severe: pulmonary edema

15

Moderate: delirium, psychosis

20

Atrial fibrillation Absent

Present

extreme lethargy
Severe: seizure, coma

Moderate: diarrhea, nausea/vomiting,

10

Precipitant history

30

Gastrointestinal-Hepatic dysfunction
Absent

Negative

Positive

10

10

abdominal pain
Severe: unexplained jaundice

20

- Management
1. Inhibit thyroid hormone synthesis: PTU loading 600-1,000 mg, then 200-250 mg q 4 hr. for 1-2 d
(~ 1,500 mg/d) 600 mg/d
NPO: PTU 400 mg + sterile water 90 cc via rectum q 4-6 hr.
MMI: MMI 20 mg q 4 hr. (120 mg/d); loading dose 60-100 mg

TOPSI117

2.

3.

4.

5.

Thyroid crisis PTU MMI PTU inhibit peripheral conversion

T4 T3
Inhibit thyroid hormone secretion: Lugols solution (8.4 mg/drop) 10 drop q 8 hr.
Lugols solution Inoganic iodide Thyroid hormone , dose
Thyroid hormone Wolff-Chaikoff effect
PTU 1 hr. Lugols solution Lugols solution iodide
Thyroid gland Thyroid hormone
Inhibit peripheral conversion ( Thyroid hormone tissue)
1) Propranolol 20-80 mg q 6 hr. for 1 wk. (); 120 mg q 6 hr.
Asthma CCB
2) Dexamethasone 2 mg q 6 hr. Hydrocortisone 100 mg IV q 8 hr.
Corticosteroid inhibit peripheral conversion relative
adrenal insufficiency
Supportive treatment
1) Paracetamol, Hypothermic blanker,
ASA Thyroid hormone binding site, Thermogenesis
2) IV fluid (Hydration)
3) CHF: LMNOP
4) Other: , Vitamin (esp. Vitamin B)
Treat cause

Subacute thyroiditis
- Thyrotoxicosis hyperthyroidism
- S&S: URI , tenderness thyroid, , refer /
- 3 phases
1. Thyrotoxic phase thyrotoxicosis
2. Hypothyroid phase
3. Recovery phase
- Management: NSAIDs (), -blocker (treat hyperthyroid), Corticosteroid

Hypothyroidism
- Screen TSH; Dx (e.g. full hypothyroid : , ,
) TFT
- 1 hypothyroid T4 TSH ( TSH screen)
: TSH T3, T4 1 hypothyroid 2 (central) hypothyroid
- 1 hypothyroid Eltroxin 50-100 g (tab 50, 100 g)
, heart disease start 100 g OD , F/U 1 mo.
( T1/2 T4 = 5-7 5T1/2 )

TOPSI117

F/U BW ()
, heart disease: start 25 g OD q 1 mo. ( dose
hyperthyroid IHD )
F/U T4 T4 TSH normalize TSH ( 3 mo.)
TSH F/U q 6 mo. life-long!
Eltroxin 1 mo. T4
1. Poor compliance
2. absorption Eltroxin Fe & Ca ( Eltroxin 2 hr.)
3. Dose
Pregnancy: dose Eltroxin thyroid hormone (esp. 1st trimester:
organogenesis) upper limit, dose cretinism ()
pregnancy Fe, Ca advice Eltroxin 2 hr.
Hypothyroid 2 DLP ( DLP hypothyroid , FHx DLP)
Hypothyroid Chol
Alcohol TG
Sex hormone TG & Chol
Hypothyroid HypoNa+ ( hypothyroid TFT Dx)
SIADH Dx R/O Hypothyroid & Adrenal insufficiency
Hypothyroid TRH, Adrenal insufficiency CRH
TRH & CRH ADH HypoNa+ SIADH

Thyroid nodule
- TFT
- TSH screening
- TSH = Hyperthyroid Thyroid scan
- Hot nodule CA , Toxic adenoma cytology treat
hyperthyroid
- Warm / Cold nodule CA Thyroid U/S / FNA / Bx
- TSH FNA ( 4 , negative pressure)
- Positive / Suspicious for malignancy Sx
- Negative for malignancy F/U
- Non-diagnostic ( nodule) U/S-guided FNA Non-diagnostic
risk factors
- High risk (e.g. ) Sx
- Low risk (e.g. ) F/U
- try thyroid nodule Eltroxin 6 mo. response response
F/U, FNA 1-2 ve
Sx

TOPSI117

Thyroid carcinoma
- CA thyroid Hx 3
1. : expose thyroid shield? CA Nasopharynx RT
2. FHx: Medullary thyroid CA ( familial )
3. : , ,
- Risk factors for CA Thyroid
1. Extreme age
2. thyroid ( CA )
3. Thyroid disease
- hormone CA thyrotoxicosis CA
MNG Toxic MNG hormone CA MNG hormone
CA

Calcium disorders
- Serum total Ca2+
1. Free Ca2+ 50%
2. Protein-bound Ca2+ ( albumin) 40-45%,
3. Complexed Ca2+ ( anion e.g. citrate, phosphate, bicarbonate) 10%
- hypo-/hyperCa+ free Ca2+ ( AP
nerve & muscle) free Ca2+ total Ca2+ total Ca2+
correct albumin hypoalbuminemia
- Corrected serum Ca2+ = [(4 - albumin) x 0.8] + Measured serum total Ca2+
albumin 4 g/dl 1 g/dl, total Ca2+ 0.8 mg/dl, correct
( protein-bound Ca2+ ) free Ca2+

Hypercalcemia
- Hypercalcemia = Corrected serum Ca2+ > 10.4 mg/dl
- severity mild, moderate, severe Ca2+ 12 13
(< 12 = mild, 12-13 = moderate, > 13 = severe neurological symptom (alteration of
consciousness, seizure) severe)
- S&S: Polyuria ( nephrogenic DI), Weakness, Fatigue, N/V, Abdominal pain, Constipation, Anorexia,
Weight loss, Alteration of consciousness, Seizure
- hyperCa2+ Stone (esp. opaque stone), Nephrocalcinosis, Calcified basal gg.
- HyperCa2+ EKG: Short QT ( Ca2+ Plateau phase action potential)
- 6 ( 3 > 90%; 1 HyperPTH most common cause
.. Drugs most common cause)
1. Drugs e.g. Ca2++Vit.D, Vit.A overdose (), HCTZ, Li
2. HyperPTH

TOPSI117

1) 1 HyperPTH (parathyroid adenoma (85%), hyperplasia (15%), cancer (< 1%))

2) 3 HyperPTH ( CKD PO43- 2 HyperPTH PO43- parathyroid
hyperplasia parathyroid adenoma)
3. Malignancy = Malignancy-associated hypercalcemia (MAH) 4
1) Humeral-mediated hypercalcemia SCC, CA Breast, Hematologic malignancy PTH-rP
2) Local osteolytic hypercalcemia (LOH) MM, CA Breast cytokine
3) Extrarenal vit.D3 synthesis Lymphoma
4) Ectopic PTH (rare)
4, Familial hypocalciuric hypercalcemia (FHH) (mutation Ca2+ sensor parathyroid gland & kidney
Ca2+ set point)
5. Granulomatous disease (TB, Histoplasma, Sarcoidosis, Wegeners; M granuloma 1-OHase
vit.D )
6. Miscellaneous (toxic goiter, adrenal insufficiency, immobilization, etc.)
- HyperCa2+ PTH PTH HyperPTH
- Management
1. Hydration NSS ( Ca2+, Ca2+ proximal tubule) urine output
3 L/d, ; hydration Lasix
Hydration RLS ( Ca2+ 3 mEq/L) Acetar ( Ca2+ 3 mEq/L)
2. Lasix hydration volume Lasix Ca2+
Lasix loop diuretic Ca2+ loop of Henle
3. Restrict Ca intake Ca2+
4. Pharmacological treatment ( severe hypercalcemia)
1) Bisphosphonate (e.g. Pamidronate) onset 2-4 d, duration 3-4 wk.
C/I: CrCl < 30 ml/min; CrCl (e.g. MM renal failure )
SE :
(1) Drug-induced feve
(2) Myalgia
(3) HypoCa2+
(4) Osteonecrosis of jaw (esp. poor oral hygiene)
(5) FSGS
(6) (e.g. uveitis, scleritis, orbital inflammation)
Fever, Myalgia ( 2 d) ,
2) Calcitonin 4 U/kg IM/IV q 12 hr. onset 2 d Tachyphylaxis;
Severe hyperCa2+ / ( Bisphosphonate + Calcitonin)
3) Steroid Prednisolone 10-40 mg/d Dexamethasone 5 mg IV q 12 hr.; response
HyperCa2+
(1) MM

TOPSI117

(2) Lymphoid malignancy (Lymphoma) Extrarenal vit.D3 synthesis

(3) Granulomatous disease

Hypocalcemia
- Hypocalcemia
1. PO43- Vit.D deficiency ( Renal/Nutritional + Inadequate sunlight exposure)
GI tract disorder, Chronic diarrhea, Malnutrition
2. PO43- Renal failure (PO43- Vit.D Renal osteodystrophy), TLS,
HypoPTH ( post-thyroidectomy), PO43-
HypoCa2+ PO43- Renal failure HypoPTH PTH
PTH Renal failure; PTH HypoPTH
HypoPTH scar ( thyroidectomy) Mg2+
HypoMg2+ 1. Chronic disease 2. Alcohol
3. PO43-
- Renal osteodystrophy ( Renal failure PO43- Vit.D )
1. Osteomalacia Ca2+ & Vit.D mineralization bone
2. Osteitis fibrosa cystica 2 HyperPTH bone resorption (salt & pepper appearance)
- Acute pancreatitis hypoCa2+ ( screen Ca2+ profile Ca2+ poor
prognosis); Acute pancreatitis Ca2+ hyperCa2+
- S&S:
1. Hypocalcemic tenany
2. Unexplained muscle cramp
3. Unexplained seizure ( hypo- & hyper- hypo- )
4. Diarrhea
5. Trousseaus sign
- cuff SBP + 10-20 mmHg 2-3 min Carpopedal spasm = Accoucheurs hand
(adduct thumb, flex MCP, extend IP, flex wrist, flex elbow)
- +ve: response 4 grades
Grade 1
Grade 2
Grade 3 Grade 2 > 1 min
Grade 4 Grade 2 < 1 min
- ve: 5 min response
6. Chvosteks sign facial n. twitch m. hyperexcitability nerves
-
1) Chvostek I facial n. facial n. 2-3 cm
zygomatic arch (/)

TOPSI117

2) Chvostek II facial n. reflex

zygomatic arch
- +ve: response 4 grades
Grade 1 ( 25% esp. )
Grade 2 , Alae nasi
Grade 3 , Alae nasi, M.Orbicularis oculi
Grade 4 facial m.
- ve:
Trousseaus sign, Chvosteks sign +ve: DDx 4
1. HypoCa2+ ()
2. Metabolic alkalosis
3. Hypo-/HyperK+
4. HypoMg2+
HypoCa2+ EKG: QT prolong ( Plateau phase action potential Ca2+ )
Metabolic bone diseases clinical feature 5
1. Fracture
2. Deformity
3. Impaired growth
4. Calcium disorder
5. Bone pain
Metabolic bone diseases 3
1. Rickets ( epiphysis ) Vit.D
2. Osteomalacia ( epiphysis ) Vit.D ( renal failure) mineralization
mineralized matrix
3. Osteoporosis Estrogen ( postmenopause) (bone mass & density
) matrix:mineralized matrix
HypoCa2+ Shock 4
1. Refractory shock shock ATP Ca2+ (cardiac & smooth m. contraction)
2. Rhabdomyolysis PO43- Vit.D Ca2+
3. Massive blood transfusion Citrate anticoagulant citrate
HCO3- citrate citrate Ca2+
4. Plasmapheresis (Plasma exchange) blood component Citrate
anticoagulant

Adrenal insufficiency
Adrenal crisis
-

TOPSI117

1.
2.
3.

Adrenal insufficiency
On steroid e.g. COPD, RA, SLE steroid BP drop
condition Adrenal insufficiency
1) Pituitary/Adrenal gland
2) Bleeding disorder Adrenal hemorrhage
3) Hx Postpartum hemorrhage Sheehans syndrome
4. response NE BP drop IV fluid BP , NE BP = Unexplained
hypotension
- adrenal crisis serum Cortisol ( ACTH) lab push
Hydrocortisone 100 mg IV stat 1 dose lab
- Cortisol level < 20 g/dL adrenal crisis Hydrocortisone 200-300 mg/d
- Cortisol level > 20 g/dL adrenal crisis hydrocortisone W/U cause
- N. meningitidis meningococcemia DIC adrenal hemorrhage
Waterhouse-Friderichsen syndrome (WFS)

TO
OPSI117

Gastroenteroology
Acute diarrhea
- 3 /d (feces > 200 g/d)
- 90% Infecttion (70% virus, 5% bacteria)
A diarrheaa
- ATB Acute
Conditions
ATBB
Mucous bloody diarrhea
Norfloxaccin (400) 1x2 for 3 d
Seveere watery diaarrhea, Stool C/S:
C V. cholerra Tetracycline 2 g/d for 3 d
Stool exam: Trophhozoite of E. histolytica
h
Metronidazole (400) 1x3 for 7 d
Metronidazole (400) 1x3 for 7 d
ATB--associated colitis
c (AAC)
C. difficilee
Vancomyycin 125-500 mg q 6 hr. for 7 d
- AAC on ATB 3 d,
off ATTB 2 mo. ( AAC )
me electrrolytes V/SS urine Ischem
mic ATN
- volum

GI bleeding
- Uppeer & Lower GI tract
Ligament of Treitz (Susspensory
musccle of duodenuum) ligaament DJ juunction
diaphhragm
- S&S:
UGIBB
- Overt
O GIB
1. Hematemeesis
1) Red blood
b
2) Coffeee-ground
2. Blood per rectum
1) Melenna
2) Hemaatochezia (
massive UGIB)
O
GIB FOBT +ve
- Occult
LGIB
- Overt
O GIB Paass blood perr rectum
1. Red bloodd
2. Maroon stoool
3. Melena ( sloww LGIB)
O
GIB FOBT +ve
- Occult
- Sympptoms of bloodd loss: , dyspneaa, angina, synncope, shock

TOPSI117

- GI bleeding ER Resuscitation risk stratification (adapt 3

5 Rockall score) Pre-endoscopy score
Score
1
2
3
Age
80
60-79
Shock
BP drop
Tachycardia (P > 100)
SBP < 100
SBP 100
Comorbidity
HF, IHD,
Renal/Liver failure,
Any major
Disseminated CA
comorbidity
Score 3 High risk NPO, Omeprazole 40 mg IV q 12 hr. ( variceal bleeding
Octreotide 50 g IV, then IV drip 50 g/hr) EGD w/in 24 hr.
Non-variceal bleeding Hx , V/S change drip Controloc
Score 2 Low risk Omeprazole (20) 1x2 ac, Elective EGD w/in 72 hr.
- Variceal bleeding VS Non-variceal bleeding ( clinicial)
Variceal
Non-variceal
Painless
Pain/Painless
Hematemesis (usually)
Hematemesis, Coffee-ground, Melena
Hemodynamic change, Hct < 30%
Vary
Portal HT
No portal HT
- Management of variceal bleeding
1. NPO
2. Octreotide 50 g IV, then IV drip 50 g/hr for 5 d
Somatostatin 250 g IV, then IV drip 250 g/hr
3. Scope EVL / EVS
EVL = Endoscopic variceal band ligation ( rubber band)
EVS = Endoscopic variceal sclerotherapy ( sclerosing agent)
4. Keep Hct 25%, if profound shock: keep Hct 30%
( chronic anemia )
5. ATB: Norfloxacin (400) 1x2 for 7 d prophylaxis bacterial infection, SBP, mortality rate
NPO Ceftriaxone 1 g IV OD
6. Propranolol (non-selective -blocker), keep HR 55-60/min
- Sengstaken-Blakemore (SB) tube ETT ( ETT aspirate )
- Rockall score ( 2 6) Post-endoscopy score 5
Score
0
1
2
3
Age
80
< 60
60-79
Shock
No shock, P < 100, P > 100 (Tachycardia),
BP drop
SBP > 100
SBP > 100
SBP < 100

TOPSI117

Comorbidity

HF, IHD,
Renal/Liver failure,
No major
Any major comorbidity
Disseminated CA
comorbidity
Diagnosis Mallory-Weiss tear, All other diagnoses
Malignancy of
No lesion, No SRH
upper GI tract
Major SRH
Adherent clot, NBBV,
Clean base,
Active bleeding
Dark spot
Rockall score 5-6 High risk NPO, Pantoprazole (Controloc) 80 mg IV stat, then 80 mg + NSS 100
ml IV drip 8 mg/hr. (100 ml/hr.) for 72 hr. Omeprazole 40 mg IV q 12 hr. for 72 hr., then
Omeprazole (20) 1x2 ac for 8 wk.
Rockall score 3-5 Intermediate risk
Rockall score 2 Low risk Omeprazole (20) 1x2 ac, D/C 24 hr.
- Non-variceal bleeding re-bleed 3 d ( PPI 3 d)
Variceal bleeding re-bleed 5 d ( Octreotide 5 d)
- PPI : 4-6 wk. for DU, 8-12 wk. for GU
- Stigmata of recent hemorrhage (SRH) lesion scope 5

1. Clean base Prevalence 49% (), Risk re-bleeding 5%

2. Dark spot / Flat spot Prevalence 23%, Risk re-bleeding 10%
3. Adherent clot Prevalence 13%, Risk re-bleeding 22%
4. Non-bleeding visible vessel (NBBV) Prevalence 8%, Risk re-bleeding 43%
5. Active bleeding Prevalence 7%, Risk re-bleeding 55%
Lesion 3, 4, 5 High risk re-bleeding
- H. pylori +ve NPO 72 hr. H. pylori eradication = Triple therapy for 7-14 d
Triple therapy
1. Omeprazole (20) 1x2 ac
2. Amoxicillin (500) 2x2 or Metronidazole (400) 1x3
3. Clarithromycin (250) 2x2 pc
Triple therapy 3 ( ATB) PPI AOC, MOC,
AOM ( AOC )
Triple therapy PPI 3 mo.

TOPSI117

- Peptic ulcer disease (PUD) complication (e.g. PU perforation) Lifelong PPI (

)
- NSAIDs GI risk, Renal/Liver impairment, CAD; NSAIDs
GI / CV risk risk
GI risk
1. Age > 70 yr.
2. Previous ulcer
3. Previous complicated ulcer ( bleed )
4. Anticoagulant
5. ASA / Multiple NSAIDs
6. NSAIDs high-dose
7. Steroid
0-1 Low risk
2-3 Intermediate risk
> 3 Previous complicated ulcer High risk
CV risk ASA prophylaxis, CAD equivalent Framingham risk score high risk
(10-yr risk 20%)
NSAIDs risk
GI risk
Low
Intermediate
High
NSAIDs + PPI
NSAIDs
COX-2 inhibitor + PPI
Low CV risk
COX-2 inhibitor
High CV risk
NSAIDs + PPI

NSAIDs prefer CV risk Naproxen CV

COX-2 inhibitor CV risk

Gastroesophageal reflex disease (GERD)

- GERD 3
1. Transient LES relaxation (tLESR)
2. Hypotensive LES
3. Anatomic disruption of EG junction (e.g. Hiatal hernia)
- Symptoms:
Typical GERD
1. Heartburn, better in upright position
2. Regurgitation
Atypical GERD
1. Chronic cough
2. Recurrent sore throat
3. Recurrent laryngitis

TOPSI117

4. Dental enamel loss

5. Chest pain
6. Asthma
GERD turn Barretts esophagus (esophageal mucosa intestinal
metaplasia) high risk for AdenoCA
Management
1. Lifestyle modification
1) Elevate head of bed
2) Decrease fat intake
3) Stop smoking
4) Avoid recumbency for 3 hr. postprandially
5) Avoid certain foods Chocolate, Alcohol, Peppermint, Coffee, Onions, Garlic, Fatty food, Tomato
6) Avoid large meals
7) Do not eat before sleeping
8) Avoid medications that can potentiate symptoms CCB, Anticholinergic, Nitrate
9) Chewing gum using
10) Weight loss
2. Medication
1) PPI Omeprazole 20 mg/d (standard dose)
2) H2 blocker Ranitidine 150-300 mg bid
3) Antacid Alum milk
3. Antireflux surgery
4. Endotherapy
PPI Standard dose ( GERD Extra-esophageal manifestation) = dose PPI

1. Omeprazole (Losec, Miracid) 20 mg

2. Pantoprazole (Controloc) 40 mg
3. Esomeprazole (Nexium) 40 mg
4. Rabeprazole (Pariet) 40 mg
5. Lansoprazole (Prevacid) 30 mg
Extra-esophageal manifestation (e.g. , laryngeal asthma) PPI Double dose
standard dose
stable GERD PPI Half dose standard dose
PPI NG feed 2 Esomeprazole (Nexium) & Lansoprazole (Prevacid)
PPI Plavix: Plavix , PPI Pantoprazole (Controloc) 1
metabolize CYP2C19 ( CYP450) drug interaction
PPI Esomeprazole (Nexium) Rabeprazole (Pariet)

TOPSI117

Rabeprazole CYP2C19 metabolize ester form Rabeprazole CYP2C19

- Pregnancy: Omeprazole category C PPI category B PPI PPI
Omeprazole
- I/C for GERD investigation (Upper endoscopy, Ambulatory esophageal pH monitoring)
1. Failure medical treatment
2. Long-term symptoms > 5 yr.
3. Age > 50 yr.
4. Atypical GERD
5. Alarm symptoms Weight loss, Dysphagia, Odynophagia, Nausea, Fever, Hematemesis
6. Cannot R/O other diseases

Liver function test (LFT)

- AST (SGOT) 5-40 U/L, cytoplasm & mitochondria, liver, heart, kidney, RBC;
specific
- ALT (SGPT) 0-40 U/L, cytoplasm liver cell, specific liver
- ALP 40-117 U/L, canalicular membrane liver, bone (esp. bone formation ),
intestine, placenta
- Conditions LFT
1. Viral hepatitis ( Acute hepatocellular damage) ALT AST (AST:ALT 1)
2. Alcoholic liver disease, Cirrhosis AST > ALT 2x
3. Cholestasis ALP > 4x UNML; confirm liver GGT GGT
bone
4. Infiltrative lesion (Tumor, Granuloma) ALP > 4x UNML LFT normal

Cirrhosis
- Signs of Chronic liver disease
1. Parotid gland enlargement
2. Spider nevi ( V-shaped area)
3. Palmar erythema
4. Clubbing of fingers
5. Terrys (white) nail
6. Dupuytren contracture ( alcoholic cirrhosis)
7. Gynaecomastia
8. Testicular atrophy
- Child-Pugh classification prognosis
Score
1
2
2.8-3.5
Albumin
> 3.5
2-3
Bilirubin (TB)
<2

3
< 2.8
>3

TOPSI117

4-6
>6
Easily controlled
Poorly controlled
No
(suppressed with medication)
(refractory)
Grade 1-2
Grade 3-4
Encephalopathy
No
(or suppressed with
(or refractory)
medication)
Albumin 7 (7x4=28, 7x5=35), Bilirubin 2-3, Coagulopathy (PT) bilirubin x2
Prognosis score 7 10
Survival 1-year 2-year
Child A (score 5-6)
100% 85%
Child B (score 7-9)
80%
60%
Child C (score 10-15) 45%
35%
- Management of cirrhosis
1. Symptomatic
2. Treat complication e.g. SBP, HE
3. Liver transplant ( Child B-C)
- cirrhosis diuretics Aldactone (100) 1x1 pc
, ascites add Lasix (40) 1x1 pc
- cirrhosis diarrhea pathogen Vibrio Aeromonas hydrophila
( Aeromonas )
wound infection with septicemia / Vibrio vulnificus
G/S: Gram-negative curved rods ( Vibrio Aeromonas)
Aeromonas Fresh/Waste water Vibrio vulnificus Salt water (Halophilic)
Coagulopathy (PT)
Distended abdomen
(Ascites)

<4

Portal hypertension
- Signs of Portal HT
1. Splenomegaly
2. Abdominal vein dilatation
3. Ascites
- Portal HT Cirrhotic & Non-cirrhotic; Anatomy
1. Pre-hepatic Portal vein thrombosis, Splenic vein thrombosis
2. Intrahepatic
1) Pre-sinusoidal Schistosomiasis, Idiopathic portal HT
2) Sinusoidal Cirrhosis
3) Post-sinusoidal Veno-occlusive disease
3. Post-hepatic Budd-Chiari syndrome
4. Increased flow AV fistula, Splenomegaly

TOPSI117

- Non-cirrhotic portal HT Hx , hormone,

( Hx UVC Portal vein thrombosis )
- Portal vein thrombosis Splenic vein thrombosis 3
1. Cellular component e.g. PV, ET, Hyperleukocytosis ( thrombosis arterial side
venous side)
2. Plasma component APS, Hypergammaglobulinemia, Protein C / Protein S deficiency, AT III deficiency
3. Vessel inflammation (infection / non-infection e.g. vasculitis) injury
inflammation vessel

Ascites
- SAAG 1.1 g/dl (wide SAAG) Portal HT (e.g. Cirrhosis)
- SAAG < 1.1 g/dl, AFTP > 2.5 g/dl Peritoneal disease (e.g. TB peritonitis, Carcinomatosis peritonei)
- Complications of Ascites: CHEST
1. Cellulitis
2. Hepatorenal syndrome (HRS), Umbilical Hernia
3. Effusion (Rt. pleural effusion)
4. Spontaneous bacterial peritonitis (SBP)
5. Tense ascites
- Diuretics Large-volume paracentesis (LVP) = tap > 2 L, 20% Albumin ( 50%
albumin) 10 g 1 L ascitic fluid
e.g. LVP 2 L Albumin 20 g = 20% Albumin 100 ml
LVP Hypotension; LVP HRS
- Albumin 10 g: 20% Albumin 50 ml + Lasix 40-120 mg IV drip in 30 min

Spontaneous bacterial peritonitis (SBP)

-

Ascitic fluid infection 4 types

C/S
Type
PMN (/mm3)
MNB (Monomicrobial non-neutrocytic bacterascites)
< 250
+ve Monomicrobial
SBP (Spontaneous bacterial peritonitis)
+ve Monomicrobial
CNNA (Culture-negative neutrocytic ascites)
-ve
> 250
2 Peritonitis
+ve Polymicrobial
S&S of SBP: Abdominal pain (60%), Fever (50%), Rebound tenderness (10%), HE (10%)
SBP bact. infection urinary/respiratory tract sepsis bacteria
ascitic fluid C/S immune response MNB immune
response SBP bacteria CNNA
MNB SBP CNNA
60% E. coli, Klepsiella, Streptococcus
Management of SBP: Cefotaxime 2 g IV q 12 hr. for 5 d, F/U Ascitic fluid start D.2

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- Risk factors for SBP

1. UGIB
2. Previous SBP
3. AFTP < 1 g/dl
Risk factor 1/3 Prophylaxis: Norfloxacin (400) 1x2 for 7 d
( SBP liver transplant Norfloxacin (400) 1x1
liver transplant)

Hepatitis
Viral hepatitis profile
- Hepatitis A virus (HAV) Acute, viremia ( Ag)
Anti-HAV IgG Anti-HAV IgM
Interpretation

+
+
(
+
) / vaccine
- Hepatitis B (HBV) DNA virus, Acute & Chronic

HBsAg

Anti-HBs

Anti-HBc
IgM
IgG
IgG
IgM

IgG

Interpretation
Acute infection
Chronic infection (carrier)
Past infection
()
vaccine
Window period
Occult infection (virus
Anti-HBs )
Anti-HBs detect

TOPSI117

1. HBsAg & Anti-HBs 2 +ve ( Ag Ab)

2. HBsAg +ve Acute Chronic hepatitis Anti-HBc IgM

3. Anti-HBs +ve Anti-HBc IgG (core Ag; virus vaccine)
vaccine
4. HBsAg Anti-HBs ve Anti-HBc IgM +ve (Window period) IgG +ve (Occult
infection)
HBV infection Vertical transmission () Chronic HBV infection (HBV
carrier) turn Cirrhosis / HCC HBV STD
(immune ) Acute HBV infection jaundice chronic
Management of Chronic HBV infection (HBV carrier)
1. HBeAg +ve Lamivudine 1-2 yr. PEG-IFN 4-6 mo.
2. HBeAg ve HBV DNA > 105 copies/ml Lamivudine > 1-2 yr. PEG-IFN 1 yr.
3. HCC surveillance: U/S + AFP q 6 mo. HBV carrier High risk
1) Age > 40 yr. (male), > 50 yr. (female)
2) Advanced fibrosis / Cirrhosis
3) FHx of HCC
HCC surveillance HBV carrier turn HCC
cirrhosis ( HCV carrier cirrhosis HCC)
Hepatitis C virus (HCV) (> 80%) Chronic; Cirrhosis turn HCC
Anti-HCV IgG
HCV RNA
Interpretation
Acute / Chronic 6 mo. HCV RNA
HCV RNA +ve Chronic
+
+
HCV RNA ve Past infection ( Acute)
Anti-HCV IgG (HCV )
HBV & HCV HIV : HIV 0.3%, HBV 30%, HCV 3-10%
Management of Chronic HCV infection: PEG-IFN weekly + Ribavirin 6-12 mo.
Hepatitis D virus (HDV) HBV ( HBsAg ); viremia (
HAV Ag); Anti-HDV
+ve Acute hepatitis B Co-infection
+ve Chronic hepatitis B Superinfection

Hepatocellular carcinoma (HCC)

- HCC criteria Dx 2 ( cirrhosis ),
1. Radiological criteria 2 imaging techniques +ve (liver mass > 2 cm with arterial hypervascularization)
2. Combined criteria 1 imaging technique +ve + AFP > 200 ng/ml

TOPSI117

- Management of HCC
1. Hepatectomy
2. PEI (Percutaneous ethanol injection) HCC
1) Tumor 3 cm
2) Number 3 sites
3) No ascites / coagulopathy
3. RFA (Radiofrequency ablation) HCC
1) Tumor 6 cm
2) Number 3 sites
3) No ascites / coagulopathy
4. TACE (Transarterial chemoembolization)
5. Liver transplantation

Liver failure
- Definition
1. Acute hepatocellular failure = Hepatocellular jaundice + Coagulopathy
2. Fulminant hepatic failure ( complication Acute hepatocellular failure) = Brain edema + HE
3. Chronic hepatocellular failure = Jaundice + HE + Ascites + Variceal bleeding
- Signs of liver failure
1. Flapping tremor (Asterixis)
2. Fetor hepaticus dimethylsulfide
- F/U LFT Liver failure Liver enzyme ( enzyme
regenerate , confirm coagulogram )

Hepatic encephalopathy (HE)

- HE 4 grade
Grade 1 MS (behavior/mood , sleep disturbance reverse sleep pattern)
Grade 2 Lethargy (drowsy, slurred speech), Confusion, Disorientation
Grade 3 Stupor, Persistent disorientation
Grade 4 Coma; response to pain = 4a, no response = 4b
Grade 3, 4 severe case ET tube ( aspiration)
- Minimal HE (MHE) = HE Grade 0 Subclinical ( detect )
- Precipitating factors of HE: BIG SCALP
Blood transfusion, BUN
Infection
GI bleeding
Sedation BDZ; Flumazenil IV
Constipation Lactulose

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Alkalosis (metabolic)
Low K+, Na+, Glucose (HypoK+, HypoNa+, Hypoglycemia) correct metabolic
Protein intake ( waste product ) restrict protein
- Management of HE
1. Restrict protein 0.5-0.8 g/kg/d 0.25-0.5 g/kg/d q 3-5 d 1-1.5 g/kg/d
2. Lactulose start 30-45 g/d 2-3
Lactulose short-term ATB 1-2 wk. Neomycin 3-6 g/d 2-3d
1-2 g/d Metronidazole 400 mg/d (200 mg bid)
3. Zn 600 mg/d chronic HE
4. Ornithine 9-18 g/d NH3
5. Flumazenil IV BDZ

Hepatorenal syndrome (HRS)

- HRS = Renal failure complication Advanced chronic liver disease ( alcoholic), Liver
failure Portal hypertension pathology (structure, U/A, IVP, renal biopsy)
Liver failure S&S of pre-renal uremia, response IV fluid HRS

- PG (vasodilator) TXA2 (vasoconstrictor) 2 metabolite

Arachidonic acid
- C.O. vasoconstriction bl. vv. GFR
systemic arterial hypotension vasodilator substance muscle, skin, spleen
- HRS 2 types
1. HRS type 1 renal failure (rapidly progressive; < 2 wk.), Cr 2
24 hr. GFR > 50% ( GFR < 20 cc/min)
2. HRS type 2 renal failure
- Management: Albumin IV + Terlipressin (Arterial vasoconstrictor), HD, TIPPS, Liver transplant

Pancreatitis
Acute pancreatitis
- Acute pancreatitis Common cause:
1. Alcohol (40%)
2. Gallstone (40%)
- S&S: Epigastric pain
- Acute pancreatitis case ALT, U/S upper abdomen; Dx Acute pancreatitis
Gallstone
1. ALT > 3x UNL
2. U/S: Gallstone
- Dx Acute pancreatitis 2/3

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1. Abdominal pain Acute pancreatitis

2. Amylase Lipase > 3x UNL
3. Imaging: CT MRI Acute pancreatitis
Acute pancreatitis Gallstone + Cholangitis ERCP w/in 72 hr., then LC prevent
recurrence
Revised Atlanta classification severity Acute pancreatitis
On admission or within 1st 24 hr.
APACHE II score 8
BISAP score 3 (Elevated BUN, Impaired consciousness (GCS < 15), SIRS, Age > 60, Pleural effusion)
Within 1st 48 hr.
Clinical
- Persistent organ failure > 48 hr. (SBP < 90 mmHg or Pao2/Fio2 < 200 or Serum Cr > 2 mg/dl)
- Persistent SIRS > 48 hr.
Ransons score 3
Modified Glasgow score 3
CRP 150 mg/L
ESR 60 mm/hr.
Management
Mild (80%) Supportive
Severe (20%) Enteral feeding, ERCP w/in 72 hr., CT scan with contrast ( wk. )
CT scan with contrast
- Pancreatic necrosis Supportive
- Pancreatic necrosis
- Pancreatic gas Sx
- Pancreatic gas Supportive 5-7 d ATB FNA
FNA:
- Infection Sx
- No infection Supportive
Prognosis: Mild acute pancreatitis 3-5 d, Mortality rate 0-1%
Severe acute pancreatitis Mortality rate 10-30%

Chronic pancreatitis
- Chronic pancreatitis Common cause:
1. Chronic alcoholism (80%)
2. Idiopathic (20%) Early-onset (Age < 35 yr.), Late-onset (Age 35 yr.); genetic,
cystic fibrosis
- S&S: Abdominal pain, Pancreatic enzyme deficiency, DM, Jaundice

TOPSI117

- Ix: U/S, CT, MRCP, ERCP, EUS

- Management
1. Medical treatment
1) Stop alcohol & smoking
2) Analgesic
3) Lipase 90,000 Ph Eur ( 40,000-45,000 Ph
Eur )
4) Antioxidant: Selenium 600 g/d, Vitamin A 9,000 U/d, Vitamin C 500 mg/d, Vitamin E 400 U/d,
Methionine 2 g/d
2. ERCP
3. Sx: Modified Peustow operation ( Pancreatic duct ) Pancreatic head resection (
Pancreatic duct Pancreatic head ) Medical treatment / ERCP

4. Celiac plexus block ( EUS CT-guided posterior Percutaneous approach) Thoracic

splanchnicectomy ~ 2-3 mo.
- Complications of ERCP 4
1. Bleeding
2. Perforation
3. Cholangitis
4. Pancreatitis

Gallstones
- Risk factors of GS = 4F
1. Female
2. Forty
3. Fertile
4. Fat
- Cause: Cholesterol supersaturation, Hypersecretion of mucin & bilirubin, Hypomotility or stasis of GB
- Symptoms: Biliary colic characteristic
1. Severe persistent RUQ / Epigastric pain
2. Duration 1-5 hr.
3. Refer to Rt. scapula
4. After big fatty meal / Night pain
5. Other symptoms e.g. N/V
- Ix: U/S (Sense 95%, Spec 90%), Plain abdomen (+ve opaque stone < 30%)
- Management: Cholecystectomy Open (OC) / Laparoscopic (LC) I/C
I/C for Cholecystectomy

TOPSI117

1.
2.

3.
4.

Symptomatic GS
Asymptomatic GS
1) GS > 2.5-3 cm
2) Premalignant lesion GB polyp > 1 cm, Porcelain GB (Calcified GB)
GB polyp premalignant Porcelain GB
3) Splenectomy in hemolytic anemia (HS, Sickle cell anemia)
4) Bariatric surgery
5) Long-term TPN
Acute cholecystitis ( Complications: Empyema of GB, Emphysematous cholecystitis, GB perforation)

Acute cholecystitis
- Acute cholecystitis
1. Acute calculous cholecystitis (90-95%) relate to GS
2. Acute acalculous cholecystitis (5-10%)
- Pathophysiology: GS Cystic duct obstruction GB distension GB wall inflammation & edema
GB ischemia & necrosis
- Symptoms: RUQ pain Biliary colic Duration ( Biliary colic), N/V, Fever
- Signs:
1. RUQ tenderness with guarding
2. Murphys sign (Inspiratory arrest with deep RUQ palpation)
3. Palpable RUQ mass
- Ix:
1. U/S (Sense 85%, Spec 95%)
1) Thickened GB wall > 4 mm
2) GB distension
3) Posterior acoustic shadow (GS)
4) Pericholecystic fluid
5) Sonographic Murphys sign (Focal tenderness directly over GB)
2. 99Tc-HIDA scan (Sense 95%, Spec 95%)
1) Obstructed cystic duct
2) Non-filling GB ( fill GB)
False negative ( fill GB 30 min) 0.5%, 15-20% fill GB 30-60 min
False positive ( fill GB) fasting TPN, Severe liver disease (uptake
), Cystic duct obstruction chronic inflammation bile flow duodenum
GB

TOPSI117

False positive: Morphine cholescintigraphy Morphine IV

resistance Sphincter of Oddi ( Spec) GB cystic duct
obstruction
- Management
1. ATB: 3rd gen. Cephalosporin / Gentamicin / FQ + Metronidazole (cover Gram negative + Anaerobe)
2. Pain control: Pethidine
NSAIDs
3. Cholecystectomy Open (OC) / Laparoscopic (LC),
1) Immediate cholecystectomy 24-48 hr. GB inflame
, 3-4 d Hx onset 48 hr.
detect onset Interval
cholecystectomy
Early LC (w/in 48 hr.) fail 4%, Delayed LC (> 48 hr.) fail 23%
2) Interval cholecystectomy ATB 6 wk. 2 mo. Sx
Prefer OC > LC , ASA class , , GB wall
unfit for Sx Cholecystostomy (Percutaneous transhepatic cholecystostomy)
drainage ( LA under GA) Off Cholangiography Patent
cystic duct; fail Cholecystostomy Sx
- Complications of Cholecystitis
1. Empyema of GB
2. Emphysematous cholecystitis air GB wall / lumen, Gas-forming Clostridium spp.
3. GB perforation 10% Acute cholecystitis, Fundus
- Management for Complicated cholecystitis
1. Resuscitation
2. Closed monitoring
3. IV ATB
4. Emergency cholecystectomy

Colorectal diseases
Colonic polyposis
- Colonic polyposis polyp
1. Tubular adenoma
- precancerous lesion, turn CA tumor
< 1.5 cm turn CA 2%
> 3.5 cm turn CA 76%
- 2
1) Pedunculated polyp

TOPSI117

2.

3.

2) Sessile polyp CA
Villous adenoma
- precancerous lesion, turn CA (esp. elderly, large tumor)
- mucus , K+ HypoK+ weakness
Familial adenomatous polyposis (FAP, Adenomatous polyposis coli, APC)
- genetic disease, AD, APC gene ( tumor suppressor gene)
chromosome 5q21
- precancerous lesion, polyp , polyp
turn CA
- Dx FAP Sx: LB + Rectum Anal verge +
Ileal-pouch anal anastomosis
- , F/U
- Gardners syndrome = FAP + Extraintestinal manifestations
1) Sebaceous cyst
2) Osteoma (Mandible, Skull, Long bones)
3) Desmoid tumor

Colonic diverticulosis
- Colonic diverticulosis , Sigmoid colon
- Diverticulum pressure lumen , mesenteric site intestinal wall (
blood supply ) weak point
- fiber (esp. fast food) Diverticulosis
- Colonic diverticulosis Colonic diverticulitis
- Colonic diverticulitis > 40 yr.
- S&S: Abdominal pain, Fever, Tenderness Mass, Abscess
Perforation Peritonitis
- Management
1. NPO
2. IV ATB: Gentamicin + Metronidazole
3. Plain film abdomen: perforation ( free air dome of diaphragm)
4. CT
- Sigmoidoscopy BE perforation, 3-6 wk.
- perforation bladder feces urine = Fecaluria
urine = Pneumaturia
- Diverticular hemorrhage Hematochezia, bleed ,
Massive LGIB Sx; Ix: Colonoscopy, Angiography
Most common cause Massive LGIB Diverticular hemorrhage
- Colonic diverticulosis Diverticular hemorrhage > 2 I/C for Sx

TOPSI117

Colorectal cancer (CRC)

- CRC screening average risk: No Hx Adenoma / CRC / IBD, No FHx CRC screen
50 yr.; screen ( )
1. Stool occult blood (FOBT) q 1 yr.
2. Flexible Sigmoidoscopy q 5 yr.
3. Double-contrast barium enema (DCBE) q 5 yr.
4. Colonoscopy q 10 yr.
- Dukes staging of CRC
T1 Invade Submucosa
T2 Invade Muscular layer
T3 Invade Serosa, Perirectal tissue
T4 Invade Adjacent organ
N0 No regional LN metastasis
N1 Metastasis in 1-3 regional LN
N2 Metastasis 4 regional LN
M0 No distant metastasis
M1 Distant metastasis
assess X (e.g. TX, NX, MX)
Stage
TNM
Management
1 100, 200
Early
Sx
2a
300
2b
400
3a 110, 210
Locally
Sx + CMT
advanced 3b 310, 410
3c
T20
TN1
CMT + RT Sx
Metastatic 4
N1 Stage 3 ; M1 Stage 4
- CA Cecum (Rt. side) most common Anemia (PBS: IDA), LBO, Perforation, Bleeding,
bowel habit change feces Cecum liquid
- CA Sigmoid (Lt. side) most common LBO, Bowel habit change, Abnormal defecation,
Constipation, Mucous bloody stool
- CA Transverse colon Rt. side, Anemia
- CA Colon Sigmoid Ix
1. BE Apple-core appearance
2. Sigmoidoscopy + Bx
- CA Colon LN 12 nodes metastasis

TOPSI117

- Early stage (1, 2a) Sx add CMT

1. Age < 40 yr.
2. Pathology Poorly-differentiated
3. Angiolymphatic invasion
- Locally advanced stage (2b, 3) Sx + CMT
- Metastatic stage Liver metastasis Wedge hepatectomy
- CA Rectum S&S: Bowel habit change, Mucous bloody stool, Anorexia, Weight loss, etc.
- CA Rectum PR, BE lesion Sigmoidoscopy
Rectum 15 cm, 3 ( 5 cm)
1. Upper rectum Anal verge 11-15 cm
2. Middle rectum Anal verge 7-11 cm
3. Lower rectum Anal verge 7 cm, PR ()
Anal verge
Clinical: Dentate line
Anatomy: Anorectal junction
- Management: Sx
- Upper rectum AR (Anterior resection)
- Lower rectum APR (Abdomino-perineal resection) Rectum Permanent
colostomy
- Middle rectum AR or APR
- anus LAR (Low anterior
resection, Sphincter sparing operation)
- CA Rectum stage 2 Neoadjuvant chemoradiation Sx

TOPSI117

Infectious Diseases
Acute febrile illness (AFI)
- AFI = T > 38.3C 2 wk.
-
1. Infectious cause: Hx & PE
1) Localized infection w/ specific organ involvement
2) Systemic infection w/o specific organ involvement
2. Non-infectious cause: Drug hypersensitivity, Autoimmune
- DDx AFI systemic infection ( organ-specific symptom)
1. Dengue/Chikungunya infection
2. Rickettsial infection (Scrub/Murine typhus)
3. Leptospirosis
4. Malaria
5. Salmonellosis
6. Other viral infection (Influenza A/B, EBV, JEV)

Dengue infection
- Dengue virus = Stegomyia aegypti (: Aedes aegypti)
- severity 3
1. Undifferentiated fever MP rash
2. Dengue fever (DF) , , Headache, Myalgia, Anorexia, Petechiae, Tourniquet
test +ve ( cuff SBP DBP 5 min, cuff 1 min, +ve
10 /in2)
3. Dengue hemorrhagic fever (DHF) = DF + Plasma leakage (S&S: Hepatomegaly, RUQ tenderness
(), Hemoconcentration, Ascites, Pleural effusion)
- DHF plasma leakage Dengue shock syndrome (DSS) = DHF grade 3, 4
- DF 3 stage
1. Febrile stage 2-7 , ; ORS 5%D/N/2 50%MT (
shock stage plasma leakage ), Paracetamol , N/V
Motilium
Dengue infection Diarrhea
2. Shock stage 1-2 , plasma leakage, ; 5%D/NSS (isotonic), V/S, PP,
capillary refill, Hct bleeding (Hct drop ) Fresh whole blood; shock pulse
, PP fluid
Plasma leakage , Platelet shock,
bleeding , Platelet Thrombocytopenia bleeding
; 24 hr.

TOPSI117

3.

Convalescent stage 2-7 , plasma leak bl.vv., ,

, convalescent rash; IV fluid bl.vv.
pulmonary edema, pleural effusion ascites , observe clinical bleeding platelet

WHO Criteria for DHF (Dengue hemorrhagic fever) 4

1. Fever 2-7 days ( high continuous fever > 38.5C), biphasic
2. Hemorrhagic tendency
1) Tourniquet test +ve
2) Petechiae / Ecchymosis / Purpura
3) Hematemesis / Melena
4) Mucosal bleeding, GIB, Bleeding from injection site, etc.
3. Thrombocytopenia (Platelet < 100,000/mm3)
4. Evidence of plasma leakage
1) Hemoconcentration: Hct 20%
2) Plasma leakage e.g. Pleural effusion, Ascites, Hyponatremia
WHO Criteria for DSS (Dengue shock syndrome) = DHF +
1. Pulse , PP ( 20 mmHg)
2. Hypotension
WHO Grading of DHF
Grade
Description
Symptoms DHF Tourniquet test +ve
1
CBC / Serology DHF bleeding, V/S stable
Bleeding (e.g. Petechiae, Epistaxis, GIB, Melena) V/S stable
2
Impending shock: V/S change Hypotension, PP , Pulse ,
, , , Urine ,
3
Significant bleeding
Profound shock: BP , Massive bleeding
4
DHF grade 1, 2 DF DHF Hemoconcentration (Plasma leakage)
DHF grade 3, 4 = DSS
DHF hemorrhage
DSS Hypovolemic shock bleeding
DSS BP PP (e.g. BP 100/90 mmHg)
Hypovolemic shock BP , PP DSS (e.g. BP 80/50 mmHg)
Paracetamol NSAIDs GIB
menses DHF menses
( Convalescent stage ) = ABCD: Appetite, Bradycardia,
Convalescent rash, Diuresis +

TO
OPSI117

Malaria
- S&S: Spike fever w/
w chill, Headaache, Mild jauundice & anem
mia, Hepatospplenomegaly
( lymphadenoppathy, rash), Hx endem
mic area
- Incubbation period 14 d (Pf), 17 d (Pv)
- Ix:
1. Thick & Thin film, Giemsa stain for malaaria

Pf (Plasm
modium falcipparum) Infeccted RBC , Ring form,
f Double chromatin, Multiple
infection, Marginal form, Maurers dot,
d Crescent--shaped gametocyte

modium vivaxx) Infected RBC

R
, Schuffners dotss,
- Pv (Plasm
2. CBC normaal, thrrombocytopennia
- Compplicated Pf (Severe malariaa) = Cerebral malaria, Markked jaundice, Renal failure,
Pulmoonary edema, CVS collapsse, Hypoglyceemia, Spontanneous bleedinng, Repeated GTC seizure, Acidosis
- Manaagement
1. Uncomplicateed Pf Combined anti-m
malarial (
( 2 )
1) Artesunaate (50) 4x1 foor 3 d ( 6000 mg = 12 taab)
2) Mefloquinne (250) 3 tabb stat, then 2 tab in 6 hr. laater ( 5 taab = 1,250 mgg)
Mefloqquine
(1) 5 tab SE

3 tab
6-24 hr. 2 tab
(2) T = 28 d, Mefloquuine 1 mo.

m

Uncompliccated Pf Artesunaate
2. Complicated Pf (Severe malaria)
a 12 hr., thenn at 24 hr.,
1) Artesunaate 2.4 mg/kg IV stat, then at
then 2.4 mg/kg OD, Total course = 5 d
2) Mefloquine (250) 3 tabb stat, then 2 tab in 6 hr. laater
3. Pv Combbined anti-maalarial
1) Chloroquuine (250) 4-2-2-2( 4 tab stat, 6 hr. 2 tab, 2 tab,,
2 tab;
t 3 = 10 tab)

TOPSI117

2) Primaquine (15) 1x1 for 14 d ( hypnozoite relapsed)

4. Pf+Pv Combined anti-malarial Pf add Primaquine 14 d
Pf: Artesunate (50) 4x1 for 3 d + Mefloquine (250) 3 tab then 2 tab next 6-24 hr.
Pv: Chloroquine (250) 4-2-2-2 + Primaquine (15) 1x1 for 14 d
- order Malaria Complicated Pf (Cerebral malaria) + Pv (BW = 50 kg)
One day
Continue
- Record V/S q 1 hr.
- Regular diet
- Observe neurological sign q 1 hr., if GCS
- Record V/S, I/O as ml
drop > 2, pls. notify
- Retained Foley catheter
- Record urine output q 4 hr.
Medication
1. Primaquine (15) 1x1 for 14 d
- DTX q 6 hr.
2. Artesunate 120 mg IV stat, then at 12 hr., then
- Blood for CBC with PBS, BUN/Cr, Electrolyte,
2+
2+
3at 24 hr., then 120 mg OD (Total 5 d)
Ca , Mg , PO4 , Uric acid, LFT
- U/A
- On O2 cannula 3 LPM, keep O2 sat. 95%
- Dilantin 750 mg (15-20 mg/kg) + NSS 100 cc
IV drip in 20 min
- Mefloquine (250) 3 tab stat, then 2 tab next 6 hr.

Leptospirosis
- 2 serotypes Leptospira interrogans Leptospira biflexa
- S&S: Asymptomatic (Subclinical infection) / Symptomatic
Symptomatic 2 phases
1. Leptospiremic phase D.4-7, Blood & CSF; , ,
(esp. back, calf, neck), N/V, ( vessel vasodilatation), hypotension, stiff neck,
lymphadenopathy, hepatosplenomegaly, rash
2. Immune phase (Leptospiruric phase) Ab, 1 wk., 1-2 d
= Biphasic, , , N/V , meningitis, iridocyclitis, impaired liver & renal
function, phase 4-30 d, blood & CSF 1-2 d
Urine 1-3 wk., severe

Urinary tract infection (UTI)

- SEEK PP: S. saprophyticus (10%), E. coli (80%), Enterobacter, Klepsiella, Proteus,
Pseudomonas

Acute pyelonephritis
- S&S: Triad
1. Fever with chill
2. CVA tenderness

TOPSI117

3. Flank pain
Hx , obstruction, status bed ridden (esp. old CVA), catheter, DM
Ix: CBC, U/A (WBC > 10/HP), MUC
Severity
1. Mild
2. Moderate 1/4
1) High fever
2) Severe flank pain
3) N/V or systemic symptoms
4) WBC > 15,000/mm3
3. Severe Unstable sepsis
Management
- Mild OPD case: Ofloxacin (400) 1x2 Ciprofloxacin (500) 1x2 for 14 d
then F/U D.3 (72 hr.) admit
- Moderate-Severe Admit Ceftriaxone 1 g IV OD for 14 d
(or Ampicillin 1 g IV q 6 hr. + Gentamicin 2 mg/kg IV q 8 hr.)
order
One day
Continue
- Blood for CBC, BUN/Cr, Electrolytes
- Record V/S, I/O q 2 hr.
- U/A, MUC
Medication
- NSS 1,000 ml IV drip rate 80 ml/hr (~ MT) - Ceftriaxone 1 g IV OD
Ceftriaxone D.2 (48 hr.) re-evaluation
- improve switch oral ATB ( OPD case) 14 d
- , WBC , flank pain sense , complication
MUC ( sense ATB), Plain KUB, U/S kidney
Perinephric abscess ( predisposing factor e.g. DM, stone, old CVA status bed ridden)
Percutaneous drainage

Streptococcal infection
- Streptococcus pyogenes (Streptococcus group A, GAS) Erysipelas, Impetigo contagiosa,
Scarlet fever, Toxic shock syndrome (TSS), Necrotizing fasciitis (NF), Rheumatic fever (RF)
- Management of TSS: PGS 6 MU IV q 6 hr. + Clindamycin 900 mg IV q 8 hr.
- Management of RF: PGS 1.2 MU IM OD for 10 d

Staphylococcal infection
-

Management: Cloxacillin 500 mg + NSS 100 cc IV drip in 30 min q 6 hr.

S. aureus joint: dose Cloxacillin 2 g q 6 hr.
S. aureus H/C: dose Cloxacillin 2 g q 4 hr. ( q 6 hr.)

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MRSA ATB: Vancomycin 1 g q 12 hr. ( normal renal function; dose renal

function)

Pneumonia
- adequate sputum: WBC > 25/LF, squamous epithelial cells < 10/LF
- CURB-65 score severity admit
1. Confusion (AMTS 8)
2. Uremia (BUN > 20 mg/dl)
3. RR 30/min
4. BP < 90/60 mmHg (SBP < 90 or DBP 60)
5. Age 65 yr.
Score = 0-1 OPD case
Score = 2 Admit ward (IPD)
Score 3 Admit ICU
- Management
Pathogen / Disease
ATB
S. pneumoniae
Ceftriaxone 2 g IV OD
P. aeruginosa
Ceftazidime 2 g IV q 8 hr + Amikacin 15 MKD IV drip
B. pseudomallei
Ceftazidime 40 mg/kg IV q 8 hr. for 14 d
A. baumannii
Sulperazone (Sulcef) or Ampicillin/Sulbactam (Unasyn)
A. baumannii (MDR) Colistin
CAP (include
Ceftriaxone 2 g IV OD + Azithromycin (250) 2x1 or Clarithromycin (250) 2x2
Atypical pneumonia) ( lobar pneumonia Macrolide)
CAP / HCAP
Levofloxacin (Cravit) (500) 1x1 ( 1x1)
(OPD case)
.. IV form: Levofloxacin 750 mg IV OD
HAP
Tazocin 4.5 g q 6-8 hr. ( CrCl)
Mixed (Aspiration)
Ceftriaxone 2 g IV OD + Clindamycin 600 mg IV q 8 hr.
- CAP ATB 5 d ( IV 48-72 hr. oral ATB 5 d)
- HAP pneumonia admit 72 hr. D/C .. 2 wk.
- K. pneumoniae host DM, Lobar pneumonia
CXR: Lobar consolidation, Bulging of minor fissure ( K. pneumonia)

Pulmonary TB
- Pulmonary TB morning sputum AFB ( 2-3 ); Dx
1. AFB +ve 1
1) CXR TB
2) Sputum C/S TB
2. AFB ve

TOPSI117

1) Clinical + CXR TB
2) Sputum C/S TB
Pleural effusion TB ADA (Adenosine deaminase)
ADA > 60 Very likely TB
ADA 40-60
ADA < 40 Less likely TB
ADA Dx false positive e.g. Parapneumonic
effusion / Empyema ( ADA neutrophil), Hemothorax, AdenoCA, Lymphoma ( ADA
lymphocyte)
Pleural biopsy yield TB pleuritis ( lesion diffuse; malignancy lesion
)
Cytology ve for malignancy repeat Cytology + Pleural biopsy sensitivity
Anti-TB drugs: dose IRZE = 5-10-25-15 MKD; max dose IRZE = 300-600-2,000-1,600
Drugs
Preparation
Dose
Max dose
I (Isoniazid)
Tab 100 mg
300 mg (3 tab)
5 MKD
Tab 300,
10 MKD
BW < 50 kg 450, 600 mg
R (Rifampicin)
450,
600 mg
BW > 50 kg 600 mg
600 mg
Z (Pyrazinamide) Tab 500 mg
2,000 mg (4 tab)
25 MKD
15 MKD
E (Ethambutol)
Tab 400 mg
1,600 mg (4 tab)
( 25 MKD 2 wk. then 15 MKD)
S (Streptomycin)
IV
15 MKD
15 MKD
Tab 200,
concentration-dependent
O (Ofloxacin)
800 mg pc
400 mg
( efficacy )
e.g. 60 kg Anti-TB ( IRZE 300-600-1,500-900 )
Isoniazid (100) 3x1 hs, Rifampicin (600) 1x1 hs, Pyrazinamide (500) 3x1 hs, Ethambutol (400) 2x1 hs
CAT1: 2IRZE / 4IR ( hs)
CAT2: 2IRZES / 1IRZE / 5IRE ( relapsed TB fail sputum 5 +ve,
2 sputum & +ve)
: IRZE ZE (IR ) ZE 3 d/wk., dialysis
dialysis
Pregnancy Liver : 2IRE / 7IR ( Z)
Anti-TB DOTS (Direct observed therapy) supervisor (
, ..)
Anti-TB ARV interact R (Rifampicin) PI ( R CYP450 inducer
PI )

TOPSI117

- SE R secretion ,
( esp. )
- F/U:
1. LFT 2 wk.;
1) Liver enzyme > 3x + Symptoms
2) Liver enzyme > 5x
EOS: E + 2nd line (O + S)
2. Sputum AFB 2 mo., 4 mo.
3. CXR 2 mo., 6 mo.
- anti-TB Anti-TB drug-induced hepatitis (risk: , alcohol, ) ?
1. Admit anti-TB + DM (liver failure hypoglycemia )
F/U Plasma glucose, Electrolytes
2. Hepatitis virus profile (HBsAg, Anti-HCV), supportive & symptomatic Rx for hepatitis, HE
3. admit E 600 mg/d + S 600 mg/d O 400 mg/d
4. admit 2 wk. LFT
5. LFT challenge I 100 200 300 mg/d 1 wk. F/U LFT
6. LFT 2IES / 16IE
- Non-tuberculous mycobacterium (NTM) ATB: EOC
Ethambutol (400) 1x1
Ofloxacin (100) 3x2
Clarithromycin (500) 1x2

Meningitis
- emergency medicine
- S&S: , , , , N/V
-
1. Acute meningitis: < 1 wk., e.g. Virus, Bacteria, Protozoa, Parasite, Systemic infection
2. Subacute meningitis: 1-4 wk., e.g. TB, Parasite, Systemic infection, Syphilis
3. Chronic meningitis: > 4 wk., e.g. TB, Cryptococcus neoformans, Parasite, Syphilis
- CSF profile
Protein
Glucose
Pressure
WBC
Appearance
(9-18 cmH2O) (predominate) (15-40 mg/dl) (50-75 mg/dl)
Organism
PMN
Bacteria

Turbid
TB
(< 45 mg/dl)
(18-30 cmH2O)
Fungus

Lymphocyte
Aseptic
Clear
Normal
Normal
(mostly viral)
- Glucose CSF 2/3

TOPSI117

- Acute bacterial meningitis

- Gram positive e.g. S. pneumoniae, GAS, GBS, S. aureus
- Gram negative e.g. E. coli, K. pneumoniae
common Acute bacterial meningitis (community-acquired) S. pneumoniae
- Viral meningitis UTI symptom Dx; (encephalitis) + vesicles
Herpes Acyclovir 10 mg/kg IV q 8 hr.
- Protozoa meningitis Naegleria fowleri
- Parasitic meningitis 3 Angiostrongylus cantonensis, Gnathostoma spinigerum,
Cysticercosis
- CSF profile Parasitic meningitis A. cantonensis G. spinigerum Eo
Eosinophilic meningitis
- Cysticercosis cyst brain 2 form
1. Parenchymal form Seizure, Focal neurological deficit
2. Subarachnoid form Chronic meningitis
- Systemic infection Meningitis Rickettsial infection (Scrub typhus, Murine typhus),
Leptospirosis
- TB meningitis Subacute Chronic meningitis
Subacute / Chronic meningitis CSF profile low sugar, lymphocytic predominate
treat TB meningitis ( AFB CSF +ve )
- Cryptococcal meningitis meningitis AIDS
Symptoms: , stiff neck ve inflammation
IICP ( inflammation meningitis )
Ix: CSF for India ink, Cryptococcal Ag
- Management of Acute bacterial meningitis: Ceftriaxone 2 g IV q 12 hr. + Dexamethasone 10 mg IV q 6 hr.
ATB Acute bacterial meningitis dose
- treat Acute bacterial meningitis adequate ATB Fungal/TB
meningitis pathogen Parameningeal infection e.g. Subdural empyema, Brain abscess

Nocardiosis
- Nocardia asteroides filamentous Gram positive rod with branching (MAF +ve)
- Nocardiosis OI ( immunocompromised host / on steroid)
- Management
- Sputum MAF +ve: Bactrim 10 MKD ( TMP) IV for 6 mo.
- Brain abscess: Bactrim 15 MKD ( TMP) IV for 12 mo.

Pneumocystis jiroveci pneumonia (PCP)

- Pneumocystis jiroveci (: Pneumocystis carinii) trophozoite pneumocyte type 1
alveoli, tissue invasion

TOPSI117

- PCP OI ( immunocompromised host esp. CD4+ < 200/mm3)

- Clinical Dx
- Ix ( ):
1. Sputum / BAL for GMS stain ( cyst wall)
2. Sputum / BAL for Giemsa stain ( trophozoite)
3. IFA
4. PCR for Pneumocystis
5. Transbroncheal biopsy
- Management: Bactrim SS 4x3 ( DS 2x3) pc for 21 d +
Prednisolone (5) 8x2 ac for 5 d, then 8x1 ac for 5 d, then 4x1 ac for 11 d ( 21 d Bactrim)

Herpes virus infection

- Human herpes virus (HHV)

Herpes simplex
- HSV type 1 (HHV-1) HSV type 2 (HHV-2)
Herpetic gingivostomatitis, Herpes labialis HSV type 1
Herpes genitalis HSV type 2
- lesion group of vesicles ( shallow ulcers)
- Tzanck smear Multinucleated giant cell 60-70%
- Management: Acyclovir 400 mg q 8 hr. for 5 d

Varicella (Chickenpox)
-

VZV (HHV-3),
Incubation period 10-21 d (exposure 2-3 wk. before onset)
1-2 d
highly contagious, Airborne vesicular fluid
varicella admit isolate ( airborne, droplet contact precaution) lesion
crust ~ 6-7 d
expose varicella D.10-21 (= incubation period) exposure
( 1-2 d D.21 )
60% varicella 10 yr.
> 30 yr. (> 98%)
: prodrome , rash e.g. low-grade fever, headache, anorexia,

papulovesicular rash, 4 stage

1. Pruritic, centrifugal, papular
2. Vesicular (vesicle) 1-2 mm = Dewdrops on a rose petal appearance
3. Pustular , = Central umbilication

TOPSI117

4.

Crusting crust 8-12 hr. scar ( 2 bacterial

infection)
2 bacterial infection complication
3-5 d, = Multistage ( papular
crusting),
head face trunk extremities
mucosa palate palate, pharynx, tonsils, conjunctiva, genitalia
&
immunosuppressive varicella , vesicle , bleed vesicle ,
wk. vesicle , scar, wk.2,
complication pneumonia
varicella 1st & 2nd trimester DFIU limb hypoplasia,
scar, eye anomalies, CNS
Acyclovir 10 d severe case immunocompromised host

Herpes zoster (Shingles)

- VZV (HHV-3)
- Management: Acyclovir (800) 1x5 (6, 10, 14, 18, 22 .) for 7 d
- w/in 48 hr. Postherpetic neuralgia ; postherpetic neuralgia
Gabapentin Amytriptyline ( Gabapentin 1 tab tid + Amytriptyline 1 tab hs)
- Zoster headache typical (autonomic) 100% O2

Infectious mononucleosis (IMN, Glandular fever)

- EBV (HHV-4) infection triad
1. Exudative pharyngitis
2. Lymphadenopathy
3. Splenomegaly
- Virus IMN, IMN-like 5 CHETA CMV, HAV, EBV, Toxoplasma, Adenovirus
- Puffy eyelid = Hoaglands sign (bilateral lid swelling)
- CBC: Leukocytosis, Atypical lymphocyte
PBS: Downey cell ( Atypical lymphocyte IMN cytoplasm
RBC, RBC )

- Management: Supportive

TOPSI117

- Steroid IMN I/C

1. Upper airway obstruction (UAO) / Severe tonsillar hypertrophy (prevent UAO)
2. Impending respiratory failure
3. Liver failure
4. Hematologic complication: AIHA, Severe thrombocytopenia
5. Severe malaise and fever
6. Severe CNS / Cardiac diseases

CMV infection
- CMV (HHV-5) CREP: Colitis, Retinitis, Esophagitis, Pneumonia

Fungal infection
- Amphotericin B empirical systemic antifungal ; dose: 0.7 mg/kg
SE: K+-Mg2+---- (HypoK+, HypoMg2+, Azotemia, Fever with chill, Hemolysis)
Order (BW 60 kg): Amphotericin B 45 mg + 5%D/W 500 ml IV drip in 4 hr.
Premedication
1. NSS 500 ml IV drip in 3 hr.
2. CPM 1 amp IV
3. Paracetamol (500) 2 tab
F/U BUN/Cr, Electrolytes, Mg twice a week (., .)
- Conventional Amphotericin B (CAB) severe complication (e.g. HypoK+ cardiac
arrest) I/C Liposomal Amphotericin B (AmBisome) 3-5 mg/kg OD IV drip in
2 hr. (1 vial 50 mg 8,000 )

HIV infection
- Acute retroviral syndrome fever, lymphadenopathy, pharyngitis, MP rash
- Ix HIV : CBC, CD4+, Viral load, ALT, VDRL, CXR
- I/C for start ARV 5
1. AIDS-defining illness
2. Symptomatic patient
1) Oral candidiasis
2) Pruritic papular eruptions (PPE)
3) Chronic fever
4) Chronic diarrhea > 14 d
5) Weight loss > 10% in 3 mo.
6) Herpes zoster > 2 dermatomes
3. Asymptomatic patient with CD4+ < 350/mm3
( CD4+ 350/mm3 start ARV, F/U CD4+ q 6 mo.)
4. Pregnancy ( start ARV CD4+ 350/mm3)

TOPSI117

5. Co-HBV or HCV infection

6. HIVAN (HIV-associated nephropathy)
7. Age > 50 yr. (CD4+ 350-500/mm3) : DM, HT, DLP
ARV 2 NRTI (d4T + 3TC) + 1 NNRTI (NVP)
Start: d4T (30) 1x2 pc, 3TC (150) 1x2 pc, NVP (200) 1x1 pc for 2 wk.
F/U SE 2 wk.:
- Life threatening: Severe rash, TEN, SJS, Severe hepatitis (ALT 5x) Stop ARV
- Mild to moderate: Mild rash, ALT < 5x w/o symptoms Symptomatic & supportive Rx, F/U q 1 wk.
- Improved No SE
- Worsen Stop ARV
- No SE NVP full strength NVP (200) 1x2 pc ( 1x2 pc 3 )
F/U 2 wk., then q 4 wk. x 2, if no SE F/U q 4-6 mo. (F/U 3 : Clinical, CD4+, Viral load)
GPO-vir 2 NRTI + 1 NNRTI; 2
1. S30 d4T (30) + 3TC (150) + NVP (200)
2. Z250 AZT (250) + 3TC (150) + NVP (200)
6 mo. S30, then Z250 long-term SE d4T
SE of d4T: Lipodystrophy, Lactic acidosis,
SE of AZT: Nausea, BM suppression
SE of NVP: Rash, Severe hepatitis SE Efavirenz (EFV) (600) 1x1 hs
EFV pregnancy (esp. 1st trimester) EFV Teratogenic effect
ARV , late hr. 95% virus
(e.g. 1 mo. 60 dose 3 dose)
1x2 12 hr.; 1x1
Prophylaxis for OI
OI
ATB prophylaxis

CD4+
< 200 PCP
Bactrim (SS) 2x1 pc (DS) 1x1 pc
CD4+ > 200
(SS = TMP 80 / SMX 400; DS = TMP 160 / SMX 800) for 3 mo.
< 100 Cryptococcus, Toxoplasma, Fluconazole (200) 2 cap once a week pc
Histoplasma, Penicillium
< 50 MAC, CMV (
CD4+ > 100
Clarithromycin (500) 1x2 pc
for 3 mo.
fundoscope retinitis)
Azithromycin (250) 4x1 once a week pc
CMV IgG +ve / CMV:
Gangciclovir 5 mg/kg IV q 12 hr. for 2-3 wk.
I/C for start ARV in TB patient
CD4+ < 200 Start ARV Anti-TB 2-8 wk.
CD4+ 200-350 Anti-TB 2 mo., then start ARV
CD4+ 350 F/U clinical & CD4 q 6 mo. ( start ARV)

TOPSI117

- F/U: CBC, CD4+, Viral load, FBS, ALT, Lipid profile q 6 mo.
Viral load 2 F/U q 1 yr. ( F/U q 6 mo. )
- DLP on statin F/U AST q 6 mo. Rhabdomyolysis
- Opportunistic protozoa
Protozoa
Management
Intestinal protozoa ( Chronic watery diarrhea)
Cryptosporidium parvum
ARV
Cyclospora cayetanensis, Isospora belli
Bactrim SS (80/400) 2x3 for 14 d
Microsporidia
ARV
Tissue protozoa
ARV + Pyrimethamine 75 mg OD for 3 d,
then 25-50 mg/d for 6 wk. +
Toxoplasma gondii
Sulfadiazine (500) 1x4 for 6 wk. +
Folinic acid 3-10 mg/d
Bactrim SS 4x3 (or DS 2x3) pc for 21 d +
PCP
Prednisolone (5) 8x2 ac for 5 d, then 8x1
ac for 5 d, then 4x1 ac for 11 d

Post-exposure prophylaxis for HIV

- expose blood / secretion HIV infection
1. + 70% alcohol
blood / secretion /mucosa
2. Anti-HIV, HBsAg, Anti-HCV
Anti-HIV, HBsAg, Anti-HBs, Anti-HCV
- ARV Accidental medical injury

Management
Anti-HIV ve No medication ( Hx HIV exposure in 1 mo. IVDU Anti-HIV +ve)
Anti-HIV +ve / secretion
/ bleed , stage AZT + 3TC + Indinavir for 4 wk.
/ bleed , full-borne AIDS AZT + 3TC + Indinavir for 4 wk.
/ bleed , asymptomatic AZT + 3TC for 4 wk.
blood / secretion /
, full-borne AIDS AZT + 3TC + Indinavir for 4 wk.
, full-borne AIDS AZT + 3TC for 4 wk.
, asymptomatic No medication
Intact skin, stage No medication
Dose: AZT (300) 1x2, 3TC (150) 1x2, Indinavir (80) q 8 hr.
- Post-exposure prophylaxis for HBV HBsAg +ve

TOPSI117

- Anti-HBs +ve HBsAg +ve No medication

- Anti-HBs ve HBIG 0.06 cc/kg + HBV 3 doses
HBsAg 24 hr. 24 hr. HBIG

Parasitic infestation
- Antihelminthic drugs
Helminthes
Nematode
Ascaris lumbricoides, Trichuris trichiura,
Enterobius vermicularis, Hookworm
Capillaria philippinensis
Strongyloides stercoralis

Antihelminthic drugs
Albendazole (400) once
Albendazole (400) 1x1 for 10 d
Ivermectin 200 g/kg/d for 2 d
or Albendazole (400) 1x1 for 3 d

Cestode
Taenia solium, Taenia saginata ( Larva) Praziquantel 10 mg/kg once
Cysticercosis ( Egg)
Albendazole (400) 1x2 for 21 d
Fluke
Ophisthorchis viverrini (OV),
Praziquantel 25 MKD tid pc for 1 d
Fasciolopsis buski
Paragonimus westermani
Praziquantel 75 MKD tid pc for 2 d
Fasciola hepatica
Triclabendazole 10 mg/kg once
- Filariasis (Elephantiasis) =
- (3rd stage larva) (e.g. Culex, Aedes, etc.)
lymphatic Microfilaria , around midnight =
Nocturnal subperiodicity, Midnight (Night blood)
Microfilaria Thick blood film
- Nematode 2 species
1. Wuchereria bancrofti

(e.g. , , )
reservoir host
Microfilaria terminal nuclei
Involve Genitalia penis / scrotum / labia

TOPSI117

2. Brugia malayi

(e.g. , , )
Reservoir host (e.g. , , )
Microfilaria Terminal nuclei
, Brugia malayi Terminal nuclei
involve genitalia
Wuchereria , Brugia

- Management
1. DEC 6 MKD for 12 d (W. bancrofti), 6 d (B. malayi) + Albendazole 400 mg/d for 2-3 wk.
DEC = Diethylcarbamazine (Hetrazan)
2. Mass treatment (): DEC 6 mg/kg + Albendazole 400 mg 1 /
3. ()

Fever of unknown origin (FUO)

- FUO criteria Dx 3
1. Fever 38.3C 2 peak
2. 3 wk.
3. W/U .. 1 wk. Dx
- FUO 4
1. Classic FUO infection, CA, autoimmune, drug fever
2. Nosocomial FUO ( ..) sinusitis, C. difficile colitis, PE, post-op., drug fever, septic
thrombophlebitis
3. Neutropenic FUO (ANC < 500 predicted nadir < 500) perianal infection, Aspergillus, Candida
4. HIV-related FUO TB, MAC, CMV, drug fever

TOPSI117

Hematology
- Peripheral blood smear (PBS)
Zone : RBC
Zone : RBC e.g. Polychromasia (Reticulocyte), NRC
- cell PBS
1+ =
2+ = field
3+ = field
- Anemia 1) , 2) , 3)
-
1. Acute (< 2-3 wk.)
1) Bleeding
2) Hemolysis
2. Subacute (2-3 wk. 2-3 mo.) BM disease
1) Aplastic anemia (AA)
2) Anemia of chronic disease (ACD) / Renal disease
3. Chronic (> 2-3 mo.) Nutritional anemia
1) Iron deficiency anemia (IDA)
2) Megaloblastic anemia: B12/Folate deficiency
Chronic intermittent intravascular hemolysis PNH
- Jaundice Hemolysis intravascular extravascular
Intravascular: dark urine ( hemoglobinuria)
e.g. G-6-PD deficiency, PNH, MAHA, Valvular heart diseae (macroangiopathic), DIC, TTP, etc.
Extravascular: hepatosplenomegaly, indirect bilirubin, LDH
e.g. HS, HbH disease, Homozygous HbCS, AIHA

Microcytic anemia
Iron deficiency anemia (IDA)

TO
OPSI117

- IDA
1. Chronic bloodd loss, hemorrrhage, parasite

/ S/P Gaastrectomy
2. Diet (Fe )
p koilonychhia, glossitis, angular stomaatitis
- PE: pale,
- Ix:
1. CBC: MCV
(
pallorr > 1/3 RBCC), no aniso/ppoikilocytosis, Pencil cell (EElongated RBCC)
2. PBS: HCMC (central
Thrombocyytosis (Plt)
Plt acutee phase reacttant IDA
PBS IDA acute blood looss Polychroomasia
Polyychromasia IDA Thalassemiaa SSpherocyte
3. Iron study ( IDDA therapeeutic Dx): Seruum
iron (< 50)), Ferritin, Transferin
T
satturation, TIBC
- Manaagement
1. cause: Dieet, Parasite ( stool occcult blood ) cause
2. FeSO4 (325) 1x3 PO () 6 mo.

SE )
SE: N/V, dysppepsia, consttipation (
- iron supplement: 1-3-7
1 d Clinical
3 d Reticulocyte count
7 d Hb, Hct ( F/U CBC 1 wk.)
( 1 d,, 1 wk., 1 mo.. )

Thalasssemia

(-thalaassemia/HbE disease)
- Extravasccular hemolyssis
- CBC: Anemia, MCVV , RDW
W (RBC distribbution width)
Anisoccytosis
RDW
- PBS: HCMC, Anisoo-/Poikilocytossis
- Hypersplenism = spleen
s
CBC
RBC, WBBC, Platelet spleenectomy

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OPSI117

Thaalassemia splenomegally ( RBC )

hyperrsplenism
- Thalaassemia risk AIHA
- Infecttion specificc Thalasseemia Pythiium insidiosum
m Pyythiosis
lesiion
granulomatous, neccrotizing, supppurative arteritis ( bl. vv.
vascuular insufficienncy, vascular occlusion)
Manaagement: Surggical debridem
ment (Pythium
m funguss ),
Amputation
Pythiuum spp. oomycete ( Kingdom
m Stramenopila, Phylum O
Oomycota)

algae fungus
f
Pseudofunggus ( )
- HbH disease

Hx: 1 wk.
mia, mild spleenomegaly
PE: mild anem
CBC: Hct > 3x
3 Hb 4x Hb (e.g. Hb 7,
7 Hct 30), MCCV (e.g. 60
6 fl)
HbH disease abortion
HbH dissease

HbH disease aboortion

severe
D 4
- Hx 1 wk. DDx
1. G-6-PD deficiency
d
Inntravascular hemolysis
h
2. HS Exttravascular heemolysis
3. HbH diseease Extravaascular hemoolysis
4. Malaria
- Homoozygous HbE (E/E)
-

TOPSI117

- disease
- CBC:
- PBS: Target cell 3+
- Homozygous HbCS disease

disease ( Homozygous HbE disease)

PBS: Basophilic stippling
Basophilic stippling RBC,
RNA ; PBS Basophilic stippling DDx 3
1. Lead poisoning
2. Homozygous HbCS disease
3. Megaloblastic anemia
e.g. Sideroblastic anemia
Management
1. Counseling
2. Folic acid (5) 1x1
Fe
3. Blood transfusion () Fresh whole blood ( RBC )
- Low transfusion , Hb 5-7 g/dl, PRC 10 cc/kg IV drip in 3
hr. + Diuretics
- High transfusion , -thalassemia/HbE severe, Homozygous
-thalassemia Thalassemic facies & Splenomegaly, Hb < 10 g/dl q 2-4
hr., keep Hb > 10 g/dl
High transfusion screen Minor blood group
4. Deferoxamine (Desferal) 40 MKD SC 8-10 hr./d x 5-7 d/wk.;
1. Serum ferritin > 1,000
2. PRC > 20-30 U
5. Splenectomy
- I/C:
1) Age 5 yr.
2) Splenomegaly > 6 cm BLCM + Pressure symptoms
3) Hypersplenism
4) (esp. HbH disease, -thalassemia/HbE )

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OPSI117

Pneumococccal polysacchaaride vaccine (23 serotypess) +

v
4-6 wk.
w
Hib vaccine
Penicillin
P
V 2550 mg 1x2 prophylaxiss
3
Platelet
P
> 800,,000/mm ASA 2-4 mg/kg
m

Splenectoomy PBS: Howell--Jolly body, NRC,

N Giant plaatelet, Cabotss ring
( M spleeen)

Cabots ring remnant

r
mitotic spindlle (microtubuule)

/
8,

M
spleen; Meggaloblastic annemia, Hemolysis
S
PBBS Howeell-Jolly body NRC

Splenectomy
Acccessory spleen

Macrocytic anneemia
- Macroocytic anemiaa (MCV > 100) 5
1. Megaloblasticc anemia B121 /Folate deficciency; MCV > 120 fl
2. Hemolysis/Blood loss MCCV Polychroomasia (Reticuulocyte)
m

MCV
3. MDS defect nuclear maturation

4. Liver diseasee choleesterol metabolism RBBC membranee MCV

5. Hypothyroidissm
O )
- AZZT, Alcohol MCV ( R/O
- MCCV 100-110 fl BM
M disease, Polychromasia bloood loss/ hem
molytic anemia
MCCV > 120 fl Megaaloblastic aneemia

Megaloblastic anemia
a

TOPSI117

1. Vitamin B12 deficiency ()

- (), intrinsic factor stomach (Pernicious anemia), S/P
stomach (Total/partial gastrectomy) ileum 3-5 yr., Diphyllobothrium latum ()
Vitamin B12 Vitamin B12 deficiency

(Diphyllobothrium latum: )
/
- Neurological symptoms e.g. decreased vibratory and proprioceptive sensation,
ataxia, paresthesia, confusion, dementia;
( Folate deficiency neurological symptoms)
- Management: Cobalamin IM 1,000 g/d x 2 wk.
then once a week until Hct normal, then once a month for life
2. Folate deficiency ( 2-3 mo.)
- , folate (pregnancy, hemolytic anemia), alcoholism,
malabsorption, drugs (e.g. TMP, sulfasalazine, pyrimethamine, metrotrexate, OCP, AED)
- Management: Folic acid (5) 1x1 PO pc
Pregnancy ANC Folic acid supplement prophylaxis
PBS:
1. Macroovalocyte
2. Hypersegmented neutrophil ( Megaloblastic anemia, MDS) = neutrophil nucleus 5
lobes 5 6 lobes 1 WBC 100

Myelodysplastic syndrome (MDS)

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OPSI117

- defect nuclear maturration M

MCV
- riskk turn Acute leukemia
- FAB
MDS 5 types
1. Refractory annemia (RA)

2. Refractory annemia with ringged sideroblaast (RARS)
3. Refractory annemia with exccess blast (RAAEB) 2
t
n (RAEB-T)
4. Refractory annemia with exccess blast in transformation
5. Chronic myellomonocytic leeukemia (CMML)
- PBS: Macroovaloccyte, Dysplastic WBC & plaatelet e.g. Bilobe neutrophil

Liver disease
d

- cholesterol metabolism
m
RBC mem
mbrane MCV
M
- PBS: Acanthocyte (Spur cell), Round
R
macroccyte, Target ceell

Hemolytic anemia
G-6-PD deficienncy

XR:

Hx: / Intravasculaar hemolysis

PBSS:
1. Hb leakage cell,
c RBC with Contracted Hb
H
H leak

2. Eccentrocyte cell Hb
Hb

TO
OPSI117

3. Ghost cell
cell Hb leak ceell
4. Polychromasia , compensatioon BM,
hemolysis
c
pallor, hemolysis
5. Spherocyte , central
M
in reduction teest
Ix: Methemoglob
methhylene blue bromocressyl green Heinz boddy
Mannagement
1. Avoid precipiitating factor
2. O2 supplement, bed rest
3. Blood transfuusion

Autoim
mmune heemolytic anemia
a
(AAIHA)

;
1 2 ( SLE, malignancy
m
CLL, lymphooma)
2 types

1. Warm AIHA (IgG;

( Extravasscular hemolyysis; 37C)
; / CLL,
C
lymphoma, autoimmune, drug;
d DAT +vee to IgG
2. Cold AIHA (IggM; Intravasccular hemolysis; < 37C)
Acrocyanoosis (, ,

);

/
infecction (Mycoplaasma, EBV), CCLL, lymphom
ma; DAT
+ve to C3
PE: Anemia, Jaunndice, Splenoomegaly, Acroocyanosis ( cold AIHA)
Ix:
1. CBC
2. PBS: Microsppherocyte, Auttoagglutinatioon (cold > warrm), Polychromasia
AIHA
Ig coat RBC

1) RBCC spleen RBCC

= Microspherocyte
2) RBC
RBC = Autooagglutination
Microspheroccyte AIHA
Spheerocyte AIHA HS
C
test)): +ve
HS (DAAT ve)
3. DAT (Direct Coombs
IAT (Indireect Coombs test) +ve ve

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OPSI117

Serum
S
RBCC Ab
DAT (detect Ab RBC) :
RBC
Cooombs
+ve (Ab RBC Ag
A CCoombs Ab
A Ab
RBC)
IAT (detect free
fr Ab Plaasma) :
Serum Donoor RBC Seerum
free Ab
A Donor RBC incubate T 377C Ab Donorr RBC
Coombs +ve
h titre in coold AIHA
4. Cold agglutinnin: +ve with high
5. ANA (screen autoimmune))
Mannagement
1. cause
2 AIHA
cause
2 AIHHA
CA ( imm
mune 2
2 AIHA
2 ITP ), Hematologgic malignanccy most com
mmon CLLL
2. Prednisolone 1 MKD tape off
b bank AIHA
ve

blood bank most

blood
com
mpatible bloodd drrip
e.g.. PRC 1 U driip in 8 hr.
PRCC room T
4 hr. ( dripp in 4 hr.)
PRC 1 U 2
U drip 4 hr.
h
AIHA plateleet Thrombocytoopenia
2

1. Evans syndrome = AIHA + ITP
2. SLE

Hereditary spheerocytosiss (HS)

AD ( new mutation)
m
membraane protein deefect spherocyte
(HSS mutaation FHx )
Hx: Intermittent jaaundice (
fatigue, stress,
s
pregnaancy, etc.),
1 wk.
Hx Gallstone (w/ or w/o Hx of choolecystectomyy)
CBCC: MCHC (>
( 35)
PBSS: Spherocytees > 50%
PBSS Spheroocytes > 50% RBC
DDx 2
1. HS FHx ( )), OF test
+ve, DAT vve

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OPSI117

2. AIHA
, DAT +vee
A DAT
HS AIHAA AIHA
PBS Polychromasia , Anisocytossis AIHA
Osm
motic fragility (OF) test (Dilutional OF tesst) HS hypotonic saaline = OF test +ve
( thalaassemia )
Mannagement: Foolic acid (5) 1xx1 PO pc

Splenectomy

Microaangiopathic hemolyytic anemia (MAHAA)

- MAHAA blood picture 3 PBS

1. Schistocyte (Fragmented RBC)
R
2. Polychromasia
3. Thrombocytoopenia
P (Preeclam
mpsia, Eclamppsia), Disseminated CA, Proosthetic valve
- DIC, HUS, TTP, TMA, PIH
- DIC (Disseminatedd intravasculaar coagulopathhy) infection, trauuma, shock, m
malignancy, obstetric
o
compplications
- DIC

1. Acute DIC (uncompensateed) Fibrinogen, PT,
aPTT, LDDH, FDP/D-dim
mer
normal
2. Chronic DIC (compensated)

bleeeding throombosis )
( chronnic DIC
- Manaagement of DIC: Treat U/D, FFP / Cryoprecipitate, Platelet
Goal: Fibrinogen > 100 mg/dl
me) Shiga
S toxin S. dysenterriae EHECC, triad
- HUS (Hemolytic urremic syndrom
1. MAHA blood picture
2. Thrombocytoopenia
3. Renal failure
(
thrombocytopenic purpura)) pentad HUS + 2
- TTP (Thrombotic
4. Fever
5. MS

TOPSI117

- TTP defect vWF , vWF Platelet Platelet

vWF Platelet Platelet thrombi vessel (
Kidney Renal failure, Brain MS) Platelet (Thrombocytopenia)
- TTP
- Antiplatelet: Clopidogrel, Ticlopidine
- Antimalarial: Quinine
- CMT: Cyclosporin A (CsA), Gemcitabine, Mitomycin C
- Management of TTP: Plasmapheresis ( vWF Platelet thrombi)

Macroangiopathic hemolytic anemia

- Valvular heart disease, Severe burn, Malignant HT, DIC
- PBS: Schistocyte, Polychromasia
- Management
1. cause (e.g. valvular heart diseae valve replacement)
2. Blood transfusion

Paroxysmal nocturnal hemoglobinuria (PNH)

-

~ 20-30 yr. ( 2 , )
keyword Chronic intermittent intravascular hemolysis
picture IDA Fe loss GI
IDA chronic intravascular hemolysis PNH
mutation gene stem cell ( RBC, WBC, Plt) Pancytopenia
Thrombosis (venous > arterial)
Hepatomegaly Budd-Chiari syndrome ( post-hepatic, non-cirrhotic portal
HT)
Splenomegaly Splenic vein thrombosis
Triad:
1. Hemolytic anemia
2. Pancytopenia
3. Thrombosis
Investigation
1. Ham test (Acid hemolysis test) +ve
2. Flow cytometry: CD55 or CD59 ve
3. CBC: Pancytopenia
4. Urine hemosiderin +ve ( chronic hemosiderin deposit hemosiderinuria)
G-6-PD deficiency acute hemoglobinuria hemosiderinuria
5. abdominal / cerebral v. thrombosis
Management
1. Eculizumab (Anti-C5)

TOPSI117

2.
3.
4.
5.

Fe, Folic acid supplement

Blood transfusion ()
Anticoagulant ( thrombosis )
BM transplantation (Allogenic stem cell transplantation)

Aplastic anemia
-

defect stem cell marrow microenvironment, immune process BM failure

( peripheral pancytopenia & marrow hypoplasia); BM failure hepatosplenomegaly
& , peak 2 : 20-25 yr. & 60 yr.
CBC: Pancytopenia with lymphocyte predominate
PBS Aplastic anemia Polychromasia BM
PBS Polychromasia 2
1. ( compensation BM)
2. PNH
Management
1. Supportive: Blood transfusion, Treatment of infection
2. Specific
1) BM transplantation (Allogenic stem cell transplantation)
2) Immunosuppressive therapy: Anti-thymocyte globulin, Cyclosporine

Bleeding disorders
-

defect 1 2 hemostasis
Clue defect
1 Hemostasis ( Platelet, Vasoconstriction) Petechiae, Mucosal bleeding
2 Hemostasis ( Coagulation factor) Hemarthrosis, Deep hematoma, Delayed bleeding
1 2 hereditary acquired
1 Hemostasis
2 Hemostasis
Hereditary 1. vWD
1. Hemophilia
2. Platelet dysfunction
2. Factor deficiency
Acquired
1. ITP
1. Acquired factor inhibitor
2. DIC
2. Liver disease
3. Hypersplenism
3. Massive blood transfusion (Dilutional coagulopathy)
4. Mechanical platelet obstruction 4. Prolonged ATB ( Vit. K dependent factor)
5. Consumptive coagulopathy
5. Aplastic anemia
Screening test
Disorder
Abnormal screening test
Thrombocytopenia
Platelet count
Platelet dysfunction
Bleeding time

TOPSI117

Hemophilia
aPTT
F7 deficiency
PT
Dysfibrinogenemia
TT
Hypofibrinogenemia aPTT, PT, Fibrinogen
Approach
1. Prolonged aPTT ( normal)
- Bleeding Hemophilia A/B, Severe F11 deficiency, vWD, Acquired F8 inhibitor
- No bleeding F12/HK/PK deficiency, Lupus anticoagulant, Heparin contamination
2. Prolonged PT ( normal)
- Bleeding Severe F7 deficiency
- No bleeding Mild F7 deficiency, Use of oral anticoagulant
3. Prolonged aPTT & PT (platelet normal)
- Bleeding Afibrinogenemia, Severe F2/5/10 deficiency, F5+F8 deficiency, Vit. K deficiency,
Acquire F2/5 inhibitor, Acquire F10 deficiency (amyloidosis)
- No bleeding Hypofibrinogenemia, Mild F2/5/10 deficiency
Spontaneous hemorrhage (petechiae) platelet < 20,000/mm3 ( ITP, DIC, HUS, TTP)
platelet dysfunction ( platelet ) petechiae

Primary immune thrombocytopenia (ITP)

-

Thrombocytopenia approach
1. Exclude Pseudothrombocytopenia
Hx:
- 2-4 wk.
- HIV infection thrombocytopenia disease immune
- Pregnancy
- FHx thrombocytopenia
- Rheumatological condition
- Malignancy thrombocytopenia 1. Invade BM 2. Chronic DIC (
tissue factor platelet consumption )
2. Possible cause W/U cause (, , splenic
sequestration, dilution)
3. cause (teenage female)
- ITP try Prednisolone 1 MKD
- BM study
ITP Isolated thrombocytopenia (Platelet < 100,000/mm3) ; Dx by exclusion ( criteria)
S&S Mucocutaneous bleeding; splenomegaly
DDx: HIV, HCV, Autoimmune (SLE, Graves disease), LPD, Recent vaccination (e.g. MMR), Liver
disease, Drug, Alcohol abuse, TTP, MDS, Leukemia, Inherited thrombocytopenia

TOPSI117

Ix ( exclusion): PBS, DAT ( AIHA), ANA ( SLE), Anti-HIV, Anti-HCV, TFT (

hyperthyroidism), DIC profile ( DIC Coagulogram, D-dimer, Fibrinogen),
LFT ( cirrhosis with hypersplenism), Antiphospholipid Ab ( APS)
30-60 yr.
6 mo. Chronic ITP ( 12 mo.)
treat Platelet < 30,000/mm3, high-risk hemorrhage treat Platelet < 50,000/mm3
Admit Platelet < 10,000/mm3
: Goal: Platelet > 30,000/mm3 ( severe bleeding normal population)
ITP 1st line Anti-D, steroid, IVIg; severity
1. Platelet < 30,000/mm3 with No significant bleeding: OPD case Prednisolone 1 MKD
F/U 2 wk. platelet goal tape off 10 mg/wk
treat 6 wk. ( response 1-3 wk.) steroid resistance hematologist
2. Significant bleeding (e.g. ICH, Intra-abdominal bleeding):
1) Platelet 1 U/10 kg 30,000-60,000/mm3
Platelet 1 U/10 kg raise Hct 6,000-10,000/mm3
Platelet blood bank room T, 5 d ( bacterial contamination )
Platelet group
2) IVIg 1 g/kg x 2d; IVIg emergency Splenectomy
elective splenectomy response steroid steroid-dependent ( dose steroid
platelet ) response high-dose IVIg
Anti-D (Ab Rh Ag) RBC Rh Ag RBC spleen fill spleen
platelet spleen
SE Anti-D Extravascular hemolysis; C/I: Anemia , Rh ve

Hemophilia
- Coagulopathy, prolonged aPTT
- XR (); 80% hemophilia A ( F8), 20% hemophilia B ( F9)
- S&S hemarthrosis (esp. knee jt.), hematoma (intramuscular, retroperitoneal), bruise, mucosal
bleeding (GI (e.g. bleeding per gum), GU), intracranial bleeding
- Severity
Normal factor activity
Clinical
Mild
5-25%
Post-traumatic bleeding
Post-traumatic bleeding,
1-5%
Moderate
Occasional spontaneous bleeding
Severe
< 1%
Spontaneous bleeding from early life
- keep 30-60% 2-3 d
life-threatening (intracranial bleeding) keep 100% 1 wk.
- FFP factor; Cryoprecipitate factor 1, 8, 13, vWF

TOPSI117

hemophilia A cryoprecipitate, hemophilia B FFP

hemophilia FFP
Cryoprecipitate FFP T 0C factor 1, 8, 13, vWF
NSS serum blood group
- F8
- 1 U/kg F8 2%, q 12 hr. ( T1/2)
- FFP 1 cc F8 1 U
- Cryoprecipitate 1 bag (1 U) F8 100 U
- F9
- 1 U/kg F9 1%, q 24 hr. ( T1/2)
- FFP 1 cc F9 1 U
Example:
1. 60 kg hemophilia A intracranial bleeding ?
: 100% F8 50 U/kg = 3,000 U cryoprecipitate 30 bag 12 hr.
15 bag 1 wk. #
2. 60 kg hemophilia () intracranial bleeding ?
: 100% F8 & F9
F9 100% F9 100 U/kg = 6,000 U FFP 6,000 cc
F8 100% F8 50 U/kg = 3,000 U FFP 3,000 cc
FFP 6,000 cc stat 12 hr. 3,000 cc #

Von Willebrand disease (vWD)

- vWD present Bruise, Mucosal bleeding, Hypermenorrhea
- 1 2 hemostatic defect, prolonged aPTT ( F8 deficiency)
- 3 types
1. Type 1 (70-80%): most common, AD; quantitative deficiency
2. Type 2 (15%): AD; qualitative deficiency
3. Type 3 (rare): most severe, AR, vWF < 1% + marked deficiency of F8
Hemarthrosis ( hemophilia)
- vWF ( Cryoprecipitate) F8 Hemophilia A

Hematologic malignancies
Leukemia
-
1. Acute leukemia
1) AML (ANLL) FAB 8 subtypes (M0-M7)
2) ALL FAB 3 subtypes (L1-3)
: 80% AML; : 80% ALL
2. Chronic leukemia CML, CLL

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OPSI117

- FAB classification of AML AML 8 subtypes (M0-M7)

merican-Britishh)
(FAB = French-Am

Namee
Cytogennetics
% (adult)
5%
Minimally differentiaated acute myyeloblastic leuukemia
15%
Acute myeloblastic leukemia, witthout maturation
t(8;21), t(6;9)
25%
Acute myeloblastic leukemia, witth granulocytic maturation
t(15;117)
10%
Acute promyelocytic leukemia (AAPL)
inv(16), ddel(16q)
20%
Acute myelomonoccytic leukemiaa
e
inv(16), t((16;16)
5%
Myeloomonocytic toggether with boone marrow eosinophilia
del(11q), t(9;11),
10%
Acute monoblastic leukemia (M55a)
t(11;119)
Acute monocytic leeukemia (M5b)
M
M6
5%
Acute erythroid leukemia
M
M7
t(1;222)
5%
Acute megakaryocytic leukemia
- APL (M3)
( t(15;17),
APL DIC
leukemia

Promyyelocyte Myeloblast Lymphooid cell Azurophillic granule cyytoplasm,

granule Proomyelocyte Potent tissuee factor (F3)
Tissue factorr
D keep Plattelet leukemia
coagulation cascaade DIC
Subtype
M
M0
M
M1
M
M2
M
M3
M
M4
M44eo
M
M5

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OPSI117

- Granuule cytoplaasm Prom

myelocyte
Auers rod
r
- Hypergranular form
m of APL: Promyelocyte Auers rod (bundles of
Auers rod) Faggot cell

(Faggot cell))
Auers rod
AML ( lymphobblast grannule)
Faggot cell
APL (Hyppergranular foorm)
Manaagement of APPL: ATRA (All-trans retinoicc acid) promyelocytte difffferentiate

maturre cell
M7 (AAcute megakaaryocytic leukkemia) Down synndrome, MF
CMT Leuukemia
blast BM
( CMT
C W
WBC
blast ), CBBC blasst BM blast CMT
blast BM
T-cell ( CD3) lympphoma
ALL B-ceell ( CDD19, 20) proognosis

t(8;14), PBS: Vacuolee WBC

Burkittts cell leukemia (L3)

(Burkkitts cell leukemia)

- CLL
leukemia low-graade malignanccy ( Follicular lymphhoma: ),,

(CLL)

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OPSI117

- Plattelet transfusiion
1. Clinical bleedding ( Plaatelet )
2. Platelet < 10,000/mm3
3. Platelet < 20,000/mm3 +
4. Platelet < 20,000/mm3 + APL
Leukeemia keep Plateleet 10,000/mm3 APL (M3) keeep Platelet 220,000/mm3
DIC
- Flow cytometry ,

histogram

- Stem cell transplannt G-CSFF donor peripheeral blood donor ( steem cell
) transfusioon
BM trransplant

Lymphhoma
- Cervical lymphadeenopathy DDDx
1. URI
2. Bacterial infection of uppeer limb
3. TB lymphadeenopathy (Scrrofula TB cervical lymphaadenopathy)
4. Infectious moononucleosis (IMN)
5. Lymphoma
6. Metastasis ( SCC moouth, pharynxx, larynx, uppeer esophaguss)
C + Hx B symptoms
- Dx Lyymphoma Staaging CT

TOPSI117

- Staging (Ann Arbor system)

Stage 1 1 LN region
Stage 2 2 LN regions diaphragm
Stage 3 2 LN regions diaphragm
Stage 4 organ (e.g. BM, brain, liver)
A B symptoms
B B symptoms
1. Fever (> 38C)
2. Night sweats
3. Significant weight loss (> 10% in 6 mo.)
- LDH ( cell turnover rate) prognosis lymphoma
- CMT: CHOP regimen: Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Oncovin (Viscristine),
Prednisolone x 8 cycles
Echo. (TTE) Doxorubicin (H) SE RCM heart H
COP regimen x 8 cycles

Multiple myeloma (MM)

- MM criteria Dx 3
1. BM Plasmacytosis > 10%
2. M-protein (M = monoclonal) in serum > 3 g/dl
Ix Immunofixation Serum protein electrophoresis (SPEP) urine protein electrophoresis
Bence-Jones protein
3. CRAB: Ca2+, Renal failure, Anemia, Bone lesion (lytic, punched-out)
1. & 3. 2. Non-secretory MM (5%) M-protein

(SPEP in MM)
(SPEP in Non-secretory MM)
- S&S: Bone pain / Pathologic Fx ( osteolytic bone lesion), Hypercalcemia, Anemia/neutropenia/
thrombocytopenia, Recurrent infection, Renal failure
- 2/3 Bence-Jones protein urine (free Ig light chain: or type; type Renal
failure )
- PBS: Anemia, RBC Rouleaux formation, Myelophthisis blood picture (Leukoerythroblastic blood
picture) ( bone marrow plasma cell ), slide ( globulin
), circulating plasma cell

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OPSI117

- Ix Dx MM 3

1. BM Bx Plasmaccytosis > 10%
%
BM Bx / BM
MA flaat bone hemoppoietic cell ; 2
1) PSIS (
)
2) Sternum
( lonng bone & flaat bone hemopoietic
h
cell
c hem
mopoietic cell long
bone calccified flat bone
b hemopoietiic cell BM
M
flat boone )
( Non-secretoryy MM )
2. SPEP M-protein > 3 g/dl
3. Bone survey bone signnificant flaat bone, film skkull punchhed-out lesionn
MM criteriaa ( BM Plasmacytosis < 10% CRAB)
Dx
-
MGUS
M
(Monocclonal gammoopathy of unddetermined siggnificance)

Myeloproliferativve disorder (MPD)

- MPD cell BM prolifferate , old age ( CML middle age ),
Dx R/O ( PV
JAK2 genee mutation), 4
ceell
1. Chronic myelloid leukemia (CML) - WBCC (myeloid series)

Middle age
R Leukemoid reaction
Dx R/O

TO
OPSI117

2.

3.

(Leuukemoid reacction)
Leukemooid reaction WBC
PBS
blast
CML WBC
W

, Basophil
(CBC MPD Basophil
)
1
> 95% Ph : t(9;222) BCR-ABL fusion gene

Polycythemiaa vera (PV) RBC

- > 90% JAK2 genee mutation
R 2 Erythroocytosis JAK2 genee mutation
- Dx R/O
2 Polycyythemia e.gg. plasmaa, EPO
- Dxx MPD WHO
W criteria R/O PV Dx JAKK2 gene mutaation
( > 90%)
Essential throombocythemiaa (ET) Plateelet

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OPSI117

M
te , Prognosis MPD
Megakaryocyt
Dx R/O
R 2 Thrombbocytosis
2 Throm
mbocytosis e.g.
e Acute bloood loss, IDAA, Post-spleneectomy, Infecttion
- 50% JAK2 gene mutation
m
- , 14% < 20
- Criteria foor Dx ET
1. Plateelet 600,0000/mm3 2 mo..
2. evidence IDA ( stainable iron BM
iroon RBBC mass
, normal MCCV)
3. evidence CML ( Ph1)
4. evidence PV (RBC maass )
5. evidence MF ( fibrossis 1/3 biopsy
leukooerythroblastoosis )
6. Exclude Reacctive fibrosis
(normal innflammatory inndex)
ment of ET: Hydroxyurea (HHU)
- Managem
Myelofibrosis (MF) or Agnoogenic myeloid metaplasia (AMM) Fibrous tissue BM
R Reactive fibrosis
f
(BM disturbance)
d
- Dx R/O
- 50% JAK2 gene mutation
m
- PBS: Teaar drop RBC (Dacrocyte), NRC,
N WBC (e.g. Myyelocyte) Myelophthisis
blood piccture (Leukoeerythroblastic blood picturee)

4.

B
JAKK2 mutation Tyrosine kinase (TTK) activity control of prooliferation
- Ph1, BCR-ABL,
& apooptosis; targeted therapy: TK inhibitor
-
Huge splenomegaaly (Massive splenomegaly
s
y; 8 cm BLCCM) DDx
1. MPD: CML, MF
M ( PV & ET huge splenoomegaly)
2. Lymphoma
3. Hairy cell leukemia (HCL)
4. CLL
5. Major thalasssemia
6. Gauchers dissease ( lyysosomal storaage disease)
7. AIHA

TOPSI117

Oncology
Oncologic emergencies
SVC syndrome
- S&S dyspnea, & 2 , headache ( IICP), dysphagia, chest pain, facial plethora
(), vein dilatation neck & chest wall ( collateral circulation)
- Horners syndrome ( CA lung Pancoast tumor)
- malignancy (CXR Lat. view ant. mediastinal mass)
DDX:
1. CA lung small cell lung cancer (SCLC, Oat cell CA)
2. NHL diffuse large B-cell lymphoma (DLBCL)
3. Metastatic CA breast, GI, sarcoma, prostate, melanoma
4. Thymoma > 40
Mediastinal germ cell tumor (Teratoma) AFP, -HCG
Lymphoma, Thymoma
- non-malignancy goiter, aortic aneurysm, thrombosis ( CVP), fibrosis (
inflammation, infection, CMT, RT)
- Ix: ; CA lung
1. CXR (PA upright, Lat.) mediastinal mass, widening of mediastinum, rt. hilar mass
2. LN Bx
- emergency severe symptoms (life-threatening) 3
1. Airway obstruction (stridor) emergency tracheostomy
2. CVS collapse (BP drop)
3. IICP (severe headache, blurred vision, MS, seizure) hyperventilation, 20% mannitol 1 mg/kg
- Management: S&S SVC syndrome CXR (PA upright, Lat.) CT chest
with contrast SVC ( clot SVC); C/I contrast MRI
- identify
- General management head elevation (30-45), bed rest, O2, / IV (),
Diuretic ( hypovolemia
stasis clot SVC syndrome ), Dexamethasone 4 mg q
6 hr. IICP, lymphoma, thymoma
- Severity assessment
- severe symptoms 3 emergency RT
common germ cell tumor AFP, -HCG
+ve Dx non-seminoma germ cell tumor (NSGCT)
- severe symptoms Ix definite Dx
- Specific treatment

TOPSI117

response CMT (e.g. SCLC, lymphoma, germ cell tumor) CMT

response (e.g. NSCLC, metastatic CA) RT control
non-malignancy thrombosis anticoagulant
Balloon venoplasty + SVC stent

Febrile neutropenia (FN)

- Febrile neutropenia criteria DX
1. T 38.3C 1 peak T 38C 1 hr. (2 peaks 1 hr.)
2. ANC < 500 ANC < 1,000 with predicted nadir < 500
- Dx FN Ceftazidime (Fortum) 2 g IV q 8 hr. + Amikacin (Amikin) 15 MKD IV OD
ATB peak 5 d add Amphotericin B 1 MKD IV
- FN BP drop dead > 70%

Tumor lysis syndrome (TLS)

-

TLS Electrolytes PUKCa: PO4, Uric acid, K+; Ca2+

: cell K+, DNA PO4 ( nucleotide), Purine ( uric acid)
cell K+, PO4, Uric acid PO4, Uric acid, K+
PO4 Ca2+ Ca2+
ALL, Burkitt's lymphoma
Burkitts lymphoma q 6 hr. (5 d
CMT) TLS hydration
Management
1. Hydration keep Urine sp.gr. < 1.010
2. Urine alkalinization NaHCO3-, keep urine pH 6.5-7.5
TLS Uric acid toxic tubule ATN (
renal failure CMT , dialysis
AML VS ALL
ALL TLS
AML obstruct bl. vv. Hyperleukocytosis

Hyperleukocytosis
-

Hyperleukocytosis = WBC > 100,000/mm3

AML, ALL, CML
blood viscosity microthrombi bl. vv.
S&S: Dyspnea, Tachypnea, Hypoxia, Respiratory failure, Headache, Alteration of consciousness,
Seizure, IICP, ICH, Oliguria, Renal failure, etc.
Cause of death: ICH, Renal failure
Investigation: CBC ( complication Hct + Leukocrit 30% Platelet <
50,000/mm3), Electrolytes, Uric acid, BUN/Cr, LFT, Coagulogram

TOPSI117

respiratory symptoms ABG

Monitor V/S, I/O, O2 sat., consciousness
Management:
1. Platelet transfusion (keep 20,000/mm3 ALL; 40,000/mm3 AML risk ICH),
Prolonged coagulogram FFP
blood viscosity , keep Hb 10 g/dl + O2
2. CMT
3. Leukapheresis Total exchange transfusion CMT symptoms
Hyperleukocytosis
4. TLS: Hydration, Urine alkalinization, Allopurinol

TOPSI117

Neurology
Stroke
- Definition Stroke (Cerebrovascular disease, CVD) 3
1. Sudden onset of focal/global neurological deficit
2. Lasting more than 24 hr.
3. No apparent cause other than that of vascular origin
- Risk factors
1. Non-modifiable e.g. Age, Sex, Race, FHx
2. Modifiable e.g. HT, AF, DM, DLP, Smoking, Carotid a. stenosis
- Classification
1. Ischemic stroke (85%) TOAST classification 5 subtypes
(TOAST = Trial of ORG 10172 in acute stroke treatment)
1) Large-artery atherosclerosis
(1) Embolic stroke
- Arterial-to-arterial source ICA, Vertebral a., Ascending aorta (esp. TEE
plaque > 0.4 cm)
- Paradoxical Rt.-to-Lt. shunt; clot peripheral v. septal defect (e.g.
PFO, ASD, Pulmonary AVF) brain
(2) Thrombotic (Atherosclerotic) stroke large a. (e.g. ICA; CDUS), mediumsized a. (e.g. MCA)
2) Cardioembolism AF, Vulvular heart disease, Post-MI, Ventricular thrombus, etc.
mural thrombus thromboemboli; High-risk Medium-risk
3) Small-vessel occlusion (Lacunar infarction) relate HT, DM, smoking; Putamen, Basis
pontis, Thalamus, Posterior limb of internal capsule, Caudate nucleus; Perforating br.
occlusion lipohyalinosis / microatheroma; Lacunar syndromes 5
(1) Pure motor stroke () lesion Posterior limb of internal capsule
(2) Pure sensory stroke lesion Thalamus (involve PLV nucleus)
(3) Ataxic hemiparesis ( 2) lesion Posterior limb of internal capsule, Basis
pontis, Corona radiata
(4) Dysarthria-clumsy hand syndrome lesion Basis pontis
(5) Mixed sensorimotor stroke lesion Thalamus & adjacent Posterior limb of internal capsule
4) Stroke of other determined etiology
(1) Hemodynamic CBF Watershed infarction (hypoperfusion distal part of arterial
territories)
(2) Vascular disease Dissection, Moyamoya disease (MMD), Arteritis, Fibromuscular
dysplasia (FMD)
(3) Abnormal coagulation Protein C/Protein S deficiency, Hyperviscosity syndrome, APS

TOPSI117

(4) Cerebral venous sinus thrombosis (CVST) hypercoagulable state;

typical sudden onset of headache
( flow coagulation acute pain)
5) Stroke of undetermined etiology
2. Hemorrhagic stroke (15%)
1) Intracerebral hemorrhage (ICH)
(1) Hypertensive (Spontaneous)
- Basal gg. (esp Putamen) (50%)
- Thalamus (15%)
- Pons (10-15%)
- Cerebellum (10%)
- Lobar (10-20%)
(2) Other causes
- Amyloid angiopathy hemorrhage subcortical white matter
- Anticoagulant / Antithrombotic use
- Brain tumor
- AVM
2) Subarachnoid hemorrhage (SAH)
(1) Aneurysmal Ruptured berry aneurysm ( Circle of Willis)
Anterior circulation: A-Com (30%), P-Com (25%), MCA (20%)
Posterior circulation: BA (10%), VA (5%)
(2) Traumatic brain
(3) AVM SAH
- Management stroke
1. Call acute stroke team, V/S, BLS ( ABC)
2. Exclude stroke mimic 5
1) Hypoglycemia
2) Seizure
3) Hypertensive encephalopathy
4) Complicated migraine
5) Conversion
Ix: BS, BUN/Cr, Electrolytes, CBC, PT, aPTT
3. CT Brain w/o contrast
- Hemorrhagic stroke consult Neurosurgeon
- Ischemic stroke onset 4.5 hr. stroke fast track, rt-PA
4. rt-PA (Alteplase) 0.9 mg/kg (10% in 1 min, 90% in 1 hr.)
Age 18 yr., Onset < 4.5 hr., NIHSS 4, C/I rt-PA

TOPSI117

rt-PA consent form: ICH 7%, Anaphylaxis 0.1%,

30%
ICU, crossmatch FFP 10 cc/kg + notify Neurosurgeon
5. Admit stroke unit
6. ASA 160-300 mg/d w/in 48 hr. onset, 14 d
- AHA guideline 2010 Stroke

TOPSI117

- BP keep Acute stroke

- Ischemic stroke rt-PA keep BP 220/120 mmHg
- Ischemic stroke rt-PA keep BP < 180/105 mmHg
- Hemorrhagic stroke keep normal BP
- rt-PA
1. Antiplatelet, Anticoagulant 24 hr.
2. bleeding rt-PA
3. NG tube, CVP line, A-line 24 hr.
4. Foley catheter & 30 min
- ABCD3-I score ( 2010) risk stroke 48 hr. TIA
1. Age 60 (+1)
2. BP 140/90 mmHg (+1)
3. Clinical features: Speech disturbance (+1) / Unilateral weakness (+2)
4. Duration of symptoms: 10-59 min (+1) / 60 min (+2)
5. DM (+1)
6. Dual TIA (Hx of previous TIA w/in 7 d) (+1)
7. Investigation
- Diffusion-weighted MRI (DWI): Brain ischemia (+1)
- CDUS: Carotid a. stenosis 50% (+1)
Score = 0-3 Low risk (2-day risk = 1%)
Score = 4-5 Moderate risk (2-day risk = 4%)
Score 6 High risk (2-day risk = 8%)
Moderate risk (Score 4) Admit .. 48 hr.
1. Observe stroke rt-TA
2. W/U cause TIA TOAST classification prevention
- neurology Heparin 2
1. Dissection (e.g. Vertebral a. dissection) Heparin clot propagation raw
surface
2. CVST

Stroke syndrome
Brainstem syndromes
- Rule of 4 BS syndromes
Medial BS syndrome lesion 4M
1. Motor nucleus at N.3, 4, 6, 12
2. Motor pathway (Pyramidal tract)
3. MLF
4. Medial lemniscus

TOPSI117

Lateral BS syndrome lesion 4S

1. Spinothalamic tract
2. Spinocerebellar tract
3. Sympathetic pathway
4. Spinal tract of N.5
- Midbrain syndromes
Syndromes
Structures involved
Weber
1. Rootlets of N.3
2. Cerebral
peduncle
Benedikt
1. Rootlets of N.3
(Paramedian basal
2. Red nucleus
infarction)
Claude
(Thalamoperforating)

Parinaud
(Dorsal midbrain)

1. Rootlets of N.3
2. Red nucleus
3. SCP (Brachium
conjunctivum)
Pretectal region

Physical signs
1. Ipsilateral N.3 palsy
2. Contralateral hemiparesis (UMNL) +
Contralateral facial palsy (UMNL)
1. Ipsilateral N.3 palsy
2. Contralateral Holmes tremor
3. () Contralateral hemianesthesia
Benedikt + Contralateral ataxia

Common cause
Occlusion of
Penetrating br. of
PCA
Occlusion of
Paramedian br. of
PCA
Occlusion of
Paramedian br. of
PCA

1.
2.
3.
4.

Pineal gland tumor

Upward gaze palsy

Large pupil, Light-near dissociation
Lid retraction (Collier sign)
Convergence retraction nystagmus
on upward gaze

- Medullary syndromes
Syndromes
Physical signs
Wallenberg
1. Numbness of Ipsilateral face + Contralateral limb
(Lateral medullary)
2. Vertigo
3. Diplopia, Hoarseness, Dysarthria, Dysphagia
4. Ipsilateral Horners syndrome
Medial medullary
1. Contralateral hemiparesis, spare face
2. Contralateral tactile & proprioception
3. Ipsilateral tongue weakness

Common cause
Occlusion of
Vertebral a. (1st)
or PICA (2nd)
Occlusion of
Vertebral a. or
Br. of vertebral a. or
Lower Basilar a.

Bells palsy
-

Bells palsy (Idiopathic facial n. palsy) = Acute onset of unilateral facial palsy (LMNL); , risk
factor, skin lesion HSV, PE neuro. WNL ( N.7)
DDx facial palsy
1. Bells palsy 75%; Dx by exclusion

TOPSI117

2. Ramsay Hunt syndrome

3. Lyme disease
4. Meningitis Fungal
5. TB, virus HIV, Polio
6. Mycoplasma (rare)
7. Brainstem lesion Stroke, Tumor, MS
8. CP angle Schwannoma, Meningioma
9. Systemic disease DM, Sarcoidosis, GBS ( 2 )
10. ENT & other cause Otitis media, Parotid tumor, Temporal bone trauma/tumor, Orofacial
granuloma, Diving (barotrauma, temporal bone pneumocele)
Management: 4-6 wk.
6 d Prednisolone 50 mg/d for 5 d ( 10 mg/d 5 d) nerve edema
weakness paralysis
Ramsay Hunt syndrome = Herpes zoster infection of Geniculate gg.; Bells palsy,
vesicles pharynx, EAM ; involve N.8 SNHL

Seizure
-

1st line GTC Dilantin (Phenytoin)

1st line PS Depakine (Sodium valproate) broad-spectrum AED
Phenytoin GTC
Management
- .. IV Diazepam load Phenytoin continue

- .. Oral Phenytoin load Phenytoin continue

Status epilepticus
-

Status epilepticus = 5 min

2 min 5 min treat status
epilepticus treat neurological outcome (GABA receptor neuron,
resistance GABA receptor)
4
1. Simple partial simple partial seizure (e.g.
conscious )
2. Complex partial complex partial seizure ( conscious)
3. GTC GTC seizure ; treatment aggressive
. neuron exhaust turn coma (/
/ = subtle clonic activity neuron ) 4.
4. Generalized nonconvulsive GTC status epilepticus neuron exhaust

TOPSI117

Management
At 0-5 min: ABC, O2, IV, DTX ( hypoglycemia 50% glucose + B1 100 mg IV)
At 5 min: Valium 10 mg IV bolus ( brain 30 min deposit fat )
repeat Valium 10 mg IV ( SE: Respiratory depression, Hypotension);
At 10 min: Dilantin 20 mg/kg IV drip (Max rate 50 mg/min), drip monitor EKG, BP
SE of Dilantin: BP drop, Arrhythmia
Dilantin , assess
/ heart drip rate < 25 mg/min ( BP drop, Arrhythmia)
Phenytoin solution IV
IV leak skin necrosis = Purple glove syndrome (PGS) = ;
IV site Fosphenytoin () water-soluble ( dose
Phenytoin)

At 30 min: Dilantin 5-10 mg/kg IV drip (Max rate 50 mg/min);

At 40 min: Phenobarbital 20 mg/kg IV drip
Respiratory depression care airway
ETT, assess ; SE BP drop, Arrhythmia Phenytoin

At 1 hr: Phenobarbital 5-10 mg/kg IV drip

= Refractory status epilepticus (mortality on ET tube, refer ICU)
treatment
1. At 5 min: Valium 10 mg add 10 mg
2. At 10 min: Dilantin 20 mg/kg (Max rate 50 mg/min) add 5-10 mg/kg
3. At 40 min: Phenobarbital 20 mg/kg add 5-10 mg/kg

Headache
-

Headache approach 1 2 headache

1. 1 Headache U/D ;
1) Tension-type headache (TTH) most common 1 headache
2) Migraine
3) Cluster headache
2. 2 Headache cause U/D;
1) Systemic disease most common 2 headache
2) Intracranial disease
3) Paracranial disease

- Forehead / Occipital area 1 > 2 headache
- Face 2 > 1 headache

TOPSI117

- Neck 1 = 2 headache
Character headache

Migraine
-

Migraine Hx ( 2 ) , 4-72 hr., ,

aura (), N/V, photophobia, phonophobia, (menstrual migraine)
PE: Complete Neuro. exam + Ophthalmoscope ( fundus R/O 2 cause)
DDx:
1. Migraine
2. Tension-type headache (TTH) 2 /, , ,
aura/ N/V/photophobia /phonophobia
3. Drug-induced migraine

1. , chocolate, caffeine, ,
2. 2
1) Abortive therapy 2 episodes/mo. 30 min
1. NSAIDs Ibuprofen 200-400 mg Naproxen 250-500 mg
2. Cafergot (Ergotamine 1 mg/Caffeine 100 mg) 1 tab
SE: N/V (esp. 1st dose) Plasil (Metoclopramide) 5-10 mg PO/IV
3. Sumatriptan 25-50 mg (repeat in 2 hr.) (max = 200 mg/d)
SE: Chest discomfort; C/I: CAD ( triptans coronary vasoconstriction)
2) Preventive therapy 3 episodes/mo.
(1) Propranolol (40 mg) 1-3 tab bid/tid
(2) Flunarizine (CCB) 5-10 mg OD hs migraine with aura
e.g. Amitriptyline, Sodium valproate, Topiramate

Vertigo
-

Vertigo = hallucination of motion;

TOPSI117

1. Central vertigo
2. Peripheral vertigo
lesion Cerebellum Vertigo () Flocculonodular lobe

Parkinsons disease
-

Parkinsons disease (PD) 4

1. Resting tremor
2. Rigidity
3. Bradykinesia specific PD
4. Postural instability
Rigidity Spasticity
Rigidity =
Spasticity =
Cogwheel rigidity tremor + rigidity; rigidity cogwheel

Myasthenia gravis (MG)

- autoimmune disease Ab nAChR postsynaptic NMJ
- peak 20-30 yr. ( Early-onset), 60-70 yr. ( Late-onset)
- 10% MG Thymoma ; Thymoma Ab Titin & Ab Ryanodine
receptor
- PE:
1. Enhancing ptosis
2. Fatigability of eyelids (upward gaze) 45 sec 1 min ptosis
- Clinical subtypes
1. Early-onset , < 40 yr., AChR Ab +ve, Hyperplasia of thymus gland
2. Late-onset , > 40 yr.
3. Ocular MG mild symptoms, AChR Ab +ve 40-60%, F/U 50-60%
generalized MG, 40% ocular MG
4. Seronegative MG AChR Ab ve Anti-MuSK +ve
- Investigation
1. Tensilon test
2. Neostigmine test 1-2 mg IM, effect w/in 20-40 min; ptosis
Adverse effects: Parasympathetic activation ( Bradycardia ;
test Atropine )
3. AChR Ab generalized MG +ve 85%, ocular MG +ve 50%
4. Electrodiagnostic studies
1) Repetitive nerve stimulation study n. amplitude AP
ACh fatigability of m.

TOPSI117

2) Single fiber EMG generalized MG +ve 95-99%; sense spec

exclude
- Management
1. AChEI Pyridostigmine (Mestinon) 60 mg 1-2 tab tid ( q 4 hr.)
Pyridostigmine ACh weak

2. Immunosuppressive therapy Steroid 0.5-1 mg/kg, Azathioprine

Diseases of peripheral nerve

- 3
1. Mononeuropathy nerve 1
2. Mononeuropathy multiplex nerve
1) Axonal injury
(1) Vasculitis
(2) DM
(3) Sarcoidosis
(4) Leprosy
(5) HIV infection
2) Demyelination/Conduction block
(1) Multifocal acquired demyelinating sensory and motor neuropathy (MADSAM)
(2) Multifocal motor neuropathy (MMN)
(3) Multiple compression neuropathy (Hypothyroid, DM)
(4) Hereditary neuropathy with liability to pressure palsies (HNPP)
3. Polyneuropathy e.g. GBS

Guillain-Barr syndrome (GBS)

-

GBS Ascending paralysis

70-80% URI / GI symptom / Vaccination , ,
/ = Glove-stocking pattern
PE: Symmetrical weakness, Hyporeflexia / Areflexia
Investigation
1. LP: Cyto-albumino dissociation ( cell CSF protein )
2. PNCV (Peripheral n. conduction velocity): Demyelination
Complication : Respiratory failure, Autonomic instability, Pressure sore, Sepsis
Management
1. Supportive
2. IVIG Respiratory failure /
( IVIG refer D.10 Golden period

TOPSI117

Multiple sclerosis and other demyelinating diseases

Multiple sclerosis (MS)
- Multiple sclerosis (MS) demyelinating disease involve CNS BBB
autoAb myelin ( neurodegenerative process) white matter lesion;
lymphocyte ( T & B cell); myelin conduction velocity
-
- 3 Triad: Inflammation, Demyelination, Gliosis
Multiple sclerosis Autopsy MS brain (
scar tissue gliosis)
- N.2, 5, 8 ( myelinated nerve fiber)
- Cord lesion Incomplete cord lesion; recovery
- S&S
1. Visual: Optic neuritis ( Pain on eye movement, Acute visual loss, Central scotoma, Impaired
color vision , RAPD +ve), Dimmed vision,
Double vision
2. Spinal cord: Weakness (UMNL), Painful spasm, Paresthesia, Bladder dysfunction, Constipation,
Sexual dysfunction (Impotence, ED)
3. Brain stem: Internuclear ophthalmoplegia (INO; MLF lesion), Vertigo, Diplopia, Nystagmus,
Dysarthria, Dysphagia, Pseudobalbar palsy
4. Cerebellum: Ataxia, Intention tremor (Dysmetria), Scanning speech
5. Cognitive dysfunction, Depression
6. Other: Neuropathic pain, Myalgia, Fatigue, Heat sensitivity = Uhthoffs phenomenon (
neuro. e.g. T e.g. , ), Exercise intolerance,
Paroxysmal symptoms, Trigeminal neuralgia, Hemifacial spasm, Glossopharyngeal neuralgia, Facial
weakness, Facial myokymia, etc.
- Charcots triad
1. Intention tremor
2. Nystagmus
3. Scanning speech
- Clinical course 4
1. Relapsing/remitting MS (RRMS)
2. Secondary progressive MS (SPMS)
3. Primary progressive MS (PPMS)
4. Progressive/relapsing MS (PRMS)
- Management: IFN-
- MS remyelin perfect myelin
conduction velocity

TOPSI117

Neuromyelitis optica (NMO)

- Neuromyelitis optica (NMO, Devics disease) Optic neuritis + Acute myelitis; neutrophil,
autoAb Aquaporin-4, MRI brain lesion, involve spinal cord 3 levels
- Cord lesion Complete cord lesion; recovery
- Management: Azathioprine (F/U Neutropenia, Hepatitis)

TOPSI117

Rheumatology
Arthritis
- DDx Arthritis
Monoarthritis
1. Septic arthritis (S. aureus, GC)
2. Traumatic arthritis
3. Crystal-induced (Gout, Pseudogout)
4. Rheumatic fever
Acute 5. Hemophilia
6. Reactive arthritis (Reiters syndrome)

Polyarthritis
1. Rheumatic arthritis
2. Viral arthritis
3. GC arthritis
4. Crystal-induced (Gout, Pseudogout)
5. Post-vaccination
6. Connective tissue diseases
(RA, SLE, Scleroderma, Sjgrens syndrome)
7. Serum sickness
8. Reactive arthritis (Reiters syndrome)
1. Connective tissue diseases
(RA, SLE, Scleroderma, Sjgrens syndrome)
2. Crystal-induced (Gout, Pseudogout)
3. OA
4. Seronegative spondyloarthropathy (SpA,
SNSA) (Reactive arthritis (Reiters syndrome),
Psoriatic arthritis, AS, IBD)

1. Crystal-induced (Gout, Pseudogout)

2. TB arthritis
3. OA
Chronic 4. Neuropathic arthropathy (Charcots
joint) DM, syphilis
5. Hemophilia
6. Reactive arthritis (Reiters syndrome)

1. Crystal-induced DDx ( phase) Gout Acute mono.

Pseudogout
2. Reactive arthritis DDx
Acute monoarthritis Septic, Traumatic, Crystal-induced
Acute polyarthritis Rheumatic, Viral, GC
Chronic monoarthritis Crystal-induced, TB, OA
Chronic polyarthritis RA, SLE, SpA
- Joint fluid analysis ( Arthrocentesis)
Non-inflammatory
Inflammatory
Normal
Septic
(e.g. OA)
(e.g. Crystal-induced, RA, SNSA)
Test
Appearance
Clear
Clear, Yellow
Clear to opaque yellow-white
Opaque
WBC (/mm3)
< 200
< 2,000
> 2,000
PMN
50%
75%
< 25%
C/S
-ve
+ve

TOPSI117

Septic arthritis
-

Acute monoarthritis S. aureus (non-GC); Acute polyarthritis N. gonorrhoeae (GC)

Non-GC arthritis: direct inoculation hematogenous ; Hx IVDU, trauma, prosthetic joint
GC arthritis: hematogenous, Hx , peri-menstrual period/pregnancy; Triad:
1. Acute polyarthritis
2. Skin lesion (pustule, vasculitis)
3. Tendon sheath involvement (Tenosynovitis: fusiform swelling)
Ix: Arthrocentesis (cell count, cell diff, G/S, C/S, fresh R/O crystal-induced ), H/C,
Cervical/Urethral swab C/S (in GC)
Management: C/S G/S no bact., Empirical ATB
Non-GC arthritis: Cloxacillin 500 mg IV ( 3-4 min) q 4-6 hr.
Gram ve rods: Ceftriaxone 2 g IV OD Cefotaxime 2 g IV 4-6 hr.
Pseudomonas: Ceftazidime 1-2 g IV q 8 hr. + Gentamicin 3-5 MKD q 8 hr.
Cephalosporin: Ciprofloxacin 400 mg IV q 12 hr. 500-750 mg PO bid
GC arthritis: Ceftriaxone 1g IV OD for 7d
treat Sexual partner : Ciprofloxacin (500) single dose
C/S ATB sense IV 2 wk. switch oral 2-4 wk.
joint fluid drain
source of infection ()
DGI (Disseminated gonococcal infection) Triad:
1. Dermatitis
2. Arthritis
3. Urethritis

Gout
-

Chronic hyperuricemia 10-30 yr. (/: 6.8 mg/dl, postmenopause: 6 mg/dl)

symptom gout stone
Asymptomatic hyperuricemia
Acute hyperuricemia (e.g. TLS) gout uric Urate
nephropathy ARF
Uric ; Hyperuricemia 2
1. Endogenous: > 80% ; 2
1) enzyme (e.g. HGPRT, G-6-PD deficiency), genetic
2) Disease proximal tubule (prototype ADPKD)
** Alcohol 2 & interfere
2. Exogenous: < 20%, e.g. drug, alcohol, protein/purine intake
Gout 3 phases

TOPSI117

1. Acute gouty arthritis (AGA)

- Acute painful monoarthritis
- 30-40 yr., 50-70 yr. (postmenopause)
- 2
1. 1st MTP joint Podagra, , 3-10 d
2. Ankle joint
- X-ray soft tissue swelling
- uric acid normal 1/3 ( stress uric );
subside uric acid baseline
2. Intercritical gout (IC)
3. Chronic tophaceous gout (CTG)
- MSUM joint = Tophi, chalk
- X-ray: Punch-out lesion joint
- exclude infection Arthrocentesis
- Tophi e.g. Finger, Wrist, Knee, Pinna, Achilles tendon, Pressure area
- uric acid Tophi
Tophi Uric acid 10-11 mg/dl
Tophi Uric acid > 11 mg/dl
DDx Pseudogout, Septic arthritis, Traumatic arthritis, Reactive arthritis
Hx 4
1. FHx genetic
2. Skin disease (esp. Psoriasis) cell turnover rate uric
3. Precipitating factors
1) Abrupt change of uric acid (uric)
- Drug e.g. Diuretic, Ethambutol, Pyrazinamide, low-dose ASA, Niacin, Cyclosporine
- Alcohol
- Protein/Purine intake
2) Trauma joint
3) Stress ( strong)
4. Associated diseases 5 : DM, HT, DLP, CAD, obesity (, + stone)
1st Dx Gout BMI, BP, plasma glucose, lipid profile, uric acid, renal function (Cr
dose ), U/A, CBC
Definite Dx: Arthrocentesis MSUM (monosodium urate monohydrate) crystal Needle-shaped,
polarized light Strong birefringence and Negative elongation (
Gout )
Therapeutic Dx: Colchicine 12-24 hr.

TOPSI117

Gout Gouty bursitis CPPD DDx: Gout & CPPD PE Bursitis

Gout
Management: Gout treat 3 Acute arthritis, Hyperuricemia Associated
diseases
1. Acute arthritis treat hyperuricemia abrupt change;
1) Colchicine (0.6) 1x3 (max = 4 tab/d) 24-48 hr.
dose 1x2 1x1
SE: Diarrhea > 3 /d off
2) NSAIDs onset 24-48 hr. ; NSAIDs e.g. Indomethacin (75) 1x1
C/I: Renal/Liver impairment, CAD
NSAIDs albumin albumin NSAIDs free form
2. Hyperuricemia keep uric level 5-6 mg/dl
1) Advice / ( total restrict
endogenous ); Goal: Uric acid 5-6 mg/dl
2) Uric lowering agent attack

1. Start dose ( dose abrupt change attack )

dose check uric level (5-6 mg/dl)
2. Hx Attack 3 episodes/yr. Colchicine (0.6) 1x1 (low dose)
Prevent further attack uric level Tophi Colchicine
3. Uric lowering agent 3-5 yr.
Endogenous ( Alcohol)
I/C Uric lowering agent
1) Attack 3 episodes/yr.
2) Tophi / Punch-out lesion
3) Uric stone ( uricosuric agent)

(1) Allopurinol (tab 100, 300 mg) start (100) 1x1 acute arthritis 1 mo. (
oxypurinol T1/2 ) 2-4 wk. F/U dose (100
200 300; max = 600 mg/d)
I/C 20-30% ( SJS) 6-8 wk.
Hypersensitivity syndrome Allopurinol (mortality rate 50%)
1. Rash ,
2. Liver failure
3. Renal failure
(2) Uricosuric agent < 60 yr. () + (Cr < 3) + ; advice
1.5-2 L/d ;

TOPSI117

1. Benzbromarone 50-100 mg/d

2. Probenecid 0.5-3 g/d ()
3. Sulfinpyrazone 200-800 mg/d
Allopurinol Benzbromarone ( ) treat
gout
3. Associated diseases
Prevention of further attack: Colchicine (0.6) 1x1 (low dose) Uric lowering agent
I/C for Prevention of further attack
1. Attack 3 episodes/yr.
2. Start Uric lowering agent ( attack esp. 1-2 wk.)
Prevent further attack 3 mo. uric level &
attack 6-12 mo. Tophi
F/U: Colchicine (prevent further attack) attack
Allopurinol serum uric acid
AGA gout Poor controlled HT
CTG 2
1. Renal stone
2. Urate nephropathy ( fibrosis interstitium)

Pseudogout (CPPD deposition disease)

-

CPPD = Calcium pyrophosphate dihydrate

AGA Knee joint
Precipitating cause: Sx, trauma, severe illness
Ca2+, PO43- CPPD
Arthrocentesis chalk crystal Rhomboid-shaped, Weakly positive birefringent;
G/S, C/S R/O septic arthritis
X-ray: Chondrocalcinosis articularis
Management: Rest, NSAIDs Colchicine (0.6) 1x3
Gout & Pseudogout ( crystal-induced) / crystal

/ CPPD HyperPTH, Hypothyroid, Gout, OA (previous joint damage),

Neuropathic joint, Wilsons disease, Hemochromatosis, Hemosiderosis, DM, Amyloidosis, Ochronosis
( alkaptonuria), Ca2+, Mg2+, PO43-

Rheumatoid arthritis (RA)

-

RA criteria 7 ( 4/7)
Clinical criteria
1. Morning stiffness 1 hr. for 6 wk.

TOPSI117

2. Arthritis 3 joints for 6 wk.

3. Arthritis of hand joints for 6 wk.
4. Symmetrical arthritis for 6 wk.
5. Rheumatoid nodules ( extensor area; common olecranon)
Laboratory criteria
6. Rheumatoid factor (RF) +ve (RF = IgM IgG = anti-IgG IgM)
7. Radiographic changes (compared with RA)
Ix: ESR, CRP, RF, ANA, X-ray
X-ray
1. Bilateral symmetrical joint space narrowing
2. Subchondral bone destruction
3. Periarticular osteoporosis (Juxtaarticular osteopenia)
4. Soft tissue swelling
5. Deformity (Ulnar deviation, Boutoniere/Swan-neck)
: NSAIDs DMARDs
1. NSAIDs: Naproxen (250) 1x2 Diclofenac (25) 1x3; dose w/in 3 mo.
NSAIDs low-dose Prednisolone 10 mg/d
2. DMARDs (Disease-modifying anti-rheumatic drugs): 3 mo. Dx 3
1) Chloroquine 250 mg/d + Hydroxychloroquine 200 mg bid
2) Metrotrexate 5-7.5 mg/wk ( hepatotoxicity monitor LFT)
3) Sulfasalazine 500-1,000 mg bid/tid

Osteoarthritis (OA)
- OA , 10% 60 OA
- Risk factors: Age 60 yr., Genetic, Abnormal joint structure, Previous joint trauma, Obesity, Repetitive use
- Hx: Morning stiffness 30 min, (/) ,
Morning stiffness = Gelling phenomenon
30 min
- PE: Crepitus on motion, Joint enlargement, Limit ROM
- Common sites
Lower extremities
1. Knee
2. Hip
3. 1st MTP
Upper extremities
1. DIP Heberdens node
2. PIP Bouchards node
3. 1st CMC joint osteophyte Squaring appearance

TOPSI117

Spine
1. C-spine
2. L-S spine
- Ix: X-ray both knees (AP, Lat.)
- Early: Asymmetrical joint space narrowing
- Late:
1. Subchondral bone sclerosis, Subchondral bone cyst ( medial)
2. Marginal osteophyte
3. Vulgus deformity
X-ray hand
- joint lesion DIP, joint OA
- joint lesion PIP, MCP, wrist joint RA
- Management
1. Non-pharmacological: Education, Weight reduction, Quadriceps exercise, Assistive device,
Acupuncture, etc.
2. Pharmacological 2
1) SMOADs (Symptom-modifying OA drugs): Paracetamol, NSAIDs, Tramadol
NSAIDs CV risk, GI risk
CV risk = ASA prophylaxis, CAD equivalent Framingham risk score
high risk (10-yr risk 20%)
GI risk
Low
Intermediate
High
NSAIDs + PPI
NSAIDs
COX-2 inhibitor + PPI
Low CV risk
COX-2 inhibitor
High CV risk
NSAIDs + PPI

NSAIDs prefer CV risk Naproxen CV

COX-2 inhibitor CV risk
NSIADs OA
(1) Celecoxib (Celebrex) (200) 1x1 pc
(2) Naproxen (250) 1x3 pc
(3) Ibuprofen (400) 1x3 pc
2) DMOADs (Disease-modifying OA drugs, Structural-modifying drugs) e.g. Viatril-S
(Glucosamine sulphate) cartilage knee joint ( 1A).
, anti-inflammation ; Dose: 1,500 mg/d 2-3 yr.
3. Surgery Arthroplasty, Osteotomy, Prosthetic joint replacement

Reactive arthritis (Reiters syndrome)

- GI/GU tract infection Chlamydia, Yersinia, Shigella, Salmonella, Campylobacter
- Reiters syndrome Triad:

TOPSI117

1. Reactive arthritis
2. Urethritis (NGU: Non-gonococcal urethritis)
3. Conjunctivitis
- Management: NSAIDs
1. Naproxen (500) 1x3 for 14 d
2. Indomethacin (50) 1x3 for 14 d
- Acute infection ATB

Systemic lupus erythematosus (SLE)

- SLE criteria 11 ( 4/11)
Skin criteria
1. Malar rash butterfly rash, spare nasolabial fold
2. Discoid rash erythematous-raised patches with keratic scaling & follicular plugging
3. Photosensitivity
4. Painless oral ulcers
Systemic criteria
5. Non-erosive arthritis 2 jt. oligoarticular ( 2 jt.), episodic, migratory, symmetrical
6. Serositis: Pleuritis ( pleuritic chest pain, evidence of pleural effusion), Pericarditis ( pericardial
effusion, EKG PR depression, electrical alternans)
7. Renal disorder persistent proteinuria ( 3+ > 0.5 g/d), cellular cast
8. Neurological disorder seizure, psychosis identify cause
Laboratory criteria
9. Hematologic disorder
1) AIHA (DAT +ve)
2) Leukopenia (WBC < 4,000)
3) Lymphopenia (L < 1,500)
4) Thrombocytopenia (Plt < 100,000)
10. ANA +ve
11. Immunologic disorder
1) Anti-dsDNA +ve
2) Anti-Sm +ve
3) Antiphospholipid Ab +ve
(1) Anti-cardiolipin IgG or IgM
(2) Lupus anticoagulant (LA)
(3) False positive serological test for Syphilis > 6 mo. (VDRL +ve; TPHA -ve)
- ANA sense 95% screen false positive elderly, pregnancy, neoplasm, chronic infection,
other autoimmune
- active 2 Complement level & Anti-dsDNA

TOPSI117

- pregnancy Anti-Ro, Anti-La, Antiphospholipid Ab

- SLE
1. Antimalarial drug Hydroxychloroquine Chloroquine
2. NSAIDs arthralgia, myalgia ASA 60-80 MKD Indomethacin 75-150 mg/d
3. Topical steroid skin involvement 0.1% 0.02% TA cream
4. Systemic corticosteroid Prednisolone
- severity
1. Mild: e.g. malar rash, discoid rash, oral ulcer, arthralgia,
myalgia
Management: Antimalarial drug: Hydroxychloroquine 200-400 mg OD Chloroquine 250 mg OD
add Prednisolone 0.5 MKD
2. Moderate: e.g. , , leukocytic vasculitis, bulla, acute cutaneous rash
Management: Antimalarial drug + Prednisolone
add Immunosupressive drug (e.g. Cyclophosphamide, Azathioprine, Metrotrexate)
3. Severe: Major organ involvement
Management: Prednisolone 1-2 MKD + Cyclophosphamide
Pulse therapy
1) Pulse Methylprednisolone 0.5-1 g/d drip IV in 1 hr. for 3-5 d
2) Pulse Cyclophosphamide 1 g/mm2/mo. for 6 mo. ()
- Chloroquine Eye exam SE: Retinopathy
- Prednisolone Stool exam
- Lupus nephritis class 3, 4 high-dose steroid therapy + Cyclophosphamide

Antiphospholipid syndrome (APS)

- APS criteria ( clinical 1 + lab 1 )
Clinical criteria
1. Vascular thrombosis arterial, venous, small vessel
2. Pregnancy morbidity
1) GA < 10 wk. abortion 3 times
2) GA > 10 wk. abortion 1 time
3) GA > 34 wk. premature birth 1 time due to eclampsia
Laboratory criteria (+ve x 2 6 wk.)
1. Anti-cardiolipin IgG or IgM
2. Lupus anticoagulant (LA)
3. Anti-2-glycoprotein I Ab

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Dermatology
Eczema
- 3 Acute, Subacute, Chronic
- Loratadine (10) 1x1 (: , )

Acute eczema
- PE: Vesicle, Serum oozing,
- Management: Wet dressing

Subacute eczema
- PE: Scale, Crust, lichenification
- Management: Topical steroid (0.1% 0.02% TA cream)

Chronic eczema (Lichen simplex chronicus, LSC)

- PE: Lichenification ( + + increased skin marking), Hyperpigmentation, Excoriation ()
- Management: Topical steroid

Dyshidrosis (Pompholyx)
- Dyshidrosis acute eczema , ;
chronic inflammation
term Dyshidrosis sweat gland ; term
Pompholyx ( )
- , 2
- (acute) vesicle 2 bacterial
infection , (subacute)
-
- DDx:
1. Tinea pedis ()
2. Dyshidrosiform pemphigoid ( BP form ; tense bullae BP)
- Management: Topical steroid (Moderate potency), Antihistamine ()
- severe Prednisolone 15-30 mg/d ( 1 wk.)
- vesicle Wet dressing
- 2 bacterial infection ATB: Cloxacillin 1.5-2 g/d 1 wk.

Seborrheic dermatitis
-

Seborrheic dermatitis (Seb derm) Typical distribution: Scalp, , , Nasolabial fold, Retroauricular
(), Groin, Axilla, Interscapular, Sternum, ( sebaceous gland
; T-zone )
Management: Topical steroid (0.1% 0.02% TA cream) apply bid

TOPSI117

Papulosquamous diseases
Psoriasis
-

=
Common site: Scalp, Knee, Elbow, Extensor surface of extremities, Nail
= Auspitzs sign
= Koebners phenomenon (Isomorphic response)
4 types
1. Plaque type (Psoriasis vulgaris) common
2. Guttate type , Streptococcal infection
3. Inverse (Flexural) type , hallmark ;
type response topical steroid
4. Erythrodermic type Exfoliative dermatitis, plaque type
- Nail change Psoriasis 4
1. Pitting nail psoriasis onychomycosis
2. Nail dystrophy
3. Subungual hyperkeratosis
4. Onycholysis

Pityriasis rosea (PR)

- =
- PE: Herald patch (/) with Collarette scale ( Herald patch),
Christmas tree appearance ( line of cleavage)
- Management: Supportive ()

Lichen planus (LP)

- 4P: Purple Polygonal Pruritic Papule; lesion Skin, Mucosa (lace-like at buccal mucosa),
Nail (10-15%); 30-60 yr.
- = Wickhams striae
- 3 types
1. Idiopathic (Classical) LP
2. Drug-induced LP
3. LP associated with other diseases Infection, Chronic GVHD ( LP-like )

Bacterial infection
Erysipelas
- GAS infection Dermis
- lesion ( cellulitis), vesicle bullae

TOPSI117

Erysipeloid
- Erysipelothrix rhusiopathiae
- / (e.g. / )

Fungal infection
-

Candidiasis, , infection keratin (); keratin

2 wk. (14 d) skin 2 wk.
keratin dermis lymphocyte inflammation (
)

Candidiasis
- PE: Discrete erythematous papule, pustule/plaque = Satellite pattern
- Ix: KOH budding yeast with pseudohyphae
- Management: Clotrimazole cream bid for 2 wk.

Dermatophyte infection
- TEM: Trichophyton (skin, nail, hair), Epidermophyton (skin, nail), Microsporum (skin, hair)
- Ix: KOH branching septate hyphae with arthrospore
- Tinea corporis ( ), Tinea cruris ()
- PE: Scaly, pruritic eruption, irregular border with central clearing
- Tinea corporis annular lesion, , active border
- Management: Clotrimazole cream bid for 2 wk. lesion 2 cm
- steroid (e.g. 0.1% TA cream) lesion modified lesion = Tinea
incognito
- / / / response Griseofulvin 500-1,000 mg/day
for 4 wk.
- Tinea capitis ()
-
- PE: Diffuse, erythematous scaly scalp eruption,
- Kerion = Inflammatory tinea capitis ( )
- Ix: Wood lamp
- Management:
1. Griseofulvin 20-25 MKD for 2 mo. (8 wk.)
2. Itraconazole 3-5 MKD (), 200-400 mg/d () for 4-6 wk.
- Onychomycosis (Tinea unguum) ()
- signs : Onycholysis, Subungual hyperkeratosis
- 5 types
1. DLSO (Distal & lateral subungual onychomycosis)
2. SWO (Superficial white onychomycosis)

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3. PSO (Proximal subungual onychomycosis) type I/C Anti-HIV

4. Total dysmorphic onychomycosis Psoriasis
5. Onycholysis
- Ix: ( junction )
KOH KOH KOH keratin (
ideal 30-60 min)
- Management: Itraconazole (Sporal) 200 mg Pulse therapy ( 2x2 1 wk.)
- 3 pulses ( 3 mo.)
- 6 pulses ( 6 mo.)
Itraconazole Fungistatic
Itraconazole CYP450 inhibitor on Statin
Rhabdomyolysis
- Tinea pedis ()
- Interdigital type
- Inflammatory vesicular type DDx Dyshidrosis

Pityriasis versicolor (Tinea versicolor)

- Malassezia furfur ( lipophilic fungi)
- PE: Scaly hypo-/hyperpigmented patch/macule upper back / upper chest / neck ( seborrheic
area)
- lesion 3 , , /
- lesion (fine scale) = Scratch sign
- Ix: KOH Spaghetti and meatballs
- Management:
1. 20% Sodium thiosulfate bid, 15 min , 2 wk.
:
2. 2.5% Selenium sulfide (Selsun) OD, 15 min , 2 wk.
3. Clotrimazole cream bid, 2 wk.
4. Ketoconazole 200 mg/d 1 wk.
5. Ketoconazole shampoo (Nizoral) 2-3 min bid, 2 wk.
Nizoral irritant contact dermatitis
- Advice:

Parasitic infection and Insects

Scabies
- Sarcoptes scabiei var. hominis ()
- severe night itching, , , , genitalia
- PE: Multiple crusted with excoriated papules and burrow

TOPSI117

- Scabietic nodule ( reaction Scabies; nodule )

- immunocompromised host scabies = Norwegian scabies
- Management: 3 , ,
1. :
1) Lindane (0.3% Gamma benzene hexachloride)
( & mucous membrane) 1 (10-12 hr.) , 3 d,
1 wk. ()
SE: Neurotoxic ( < 2 mo. & Pregnancy)
2) 25% Benzyl benzoate 3 d , 1 wk.
3) 6% Sulfur ointment < 2 mo. & Pregnancy
2. :
Treat , < 2 mo., Pregnancy 6% Sulfur ointment
3. : , , (/)

Pediculosis
- Pediculosis capitis () Pediculus humanus capitis ()
- Pediculosis pubis () Phthirus pubis ()
- Management: Lindane (0.3% Gamma benzene hexachloride)
: , 12 hr. , 8-10 d (
)
Treat +

Paederus dermatitis
- Paederus ()
- Management: Topical steroid

Allergy
Fixed drug eruption (FDE)
- NSAIDs, Sulfa, Anticonvulsant localized hypersensitivity
- lesion
; common: Genitalia, Perioral, Periorbital
- Management: , , ( wk.-mo.
)
- lesion Wet dressing + ATB
- lesion Prednisolone 1 mg/kg

Autoimmune vesiculobullous diseases

Pemphigus
- 40-50 yr.

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- AutoAb protein Desmosome Suprabasal separation lesion Flaccid bullae

PMN, Acantholytic cell
Acantholytic cell = keratinocyte intercellular bridging
- mucosal involvement (> 50% present oral ulcer)

Bullous pemphigoid (BP)

- (esp. 80 yr. )
- AutoAb protein Basement membrane Subepidermal separation ( DEJ)
lesion Tense bullae Acantholytic cell, Eosinophil
- mucosal involvement ( 30%)

Leprosy (Hansens disease, HD)

- Leprosy () Mycobacterium leprae, involve skin & peripheral nerve
- droplets , leprosy Genetic susceptibility (esp.
leprosy )
- HIV infection risk leprosy
- M. leprae , incubation period 5-10 yr.
- Criteria Dx Leprosy 4 (Dx 2/3 3 4. )
1. Skin lesion
2. Loss of sensation (Temp )
sensation lesion, sensation Glove-stocking pattern
DM ( attack peripheral n. peripheral neuropathy)
Neuropathic ulcer
3. Nerve
Nerve :
1) : Facial n. Temporal br. & Zygomatic br. ( lagophthalmos exposure
keratitis)
2) : Median n. ( ape hand), Radial n. ( wrist drop), Ulnar n. (
claw hand)
3) : Common peroneal n. ( foot drop), Posterior tibial n. ( claw toe)
4. Slit-skin smear +ve
( blade lesion serum smear AFB)
- Slit-skin smear
1) Globi formation ()
2) Fragmented form ( fragment, )
3) Granular form ()
4) Solid form ()
- PE: pain, T, touch lesion, sensory , autonomic n., motor n., nerve

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test Monofilament 200 g, 2 g, 4 g, 10 g, 300 g /

Skin biopsy DDx
Classification PB & MB ()
1. Paucibacillary (PB) , 2-5 skin lesions, asymmetrical distribution, damage
1 nerve trunk, AFB -ve;
1) I (Indeterminate)
2) T (Tuberculoid)
3) BT- (Borderline tuberculoid PB)
2. Multibacillary (MB) , > 5 skin lesion, more symmetrical distribution, damage
nerve trunks, AFB +ve;
1) BT+ (Borderline tuberculoid MB)
2) BB (Borderline borderline)
3) BL (Borderline lepromatous)
4) LL (Lepromatous)
BT PB MB
BT PB 3
1) Skin lesion < 5 lesions
2)
3) Slit-skin smear ve
(e.g. 5 lesions / 2 / Slit-skin smear +ve) MB
MB lesion (punched-out), pseudopod;
MB ( )
Organ involvements
1. Nerve sensory, motor, autonomic function of peripheral n. (, )
2. Eye visual loss, lagophthalmos, corneal ulceration, acute/chronic iridocyclitis, 2 cataract
3. Testis
Management: Multidrug therapy (MDT), OD 28 d
PB & MB
- (PB) treat 6 mo.
:
D.1 Rifampicin (600) 1 tab + Dapsone (100) 1 tab
D.2-28 Dapsone (100) 1 tab
- (MB) treat 2 yr.
:
D.1 Rifampicin (600) 1 tab + Clofazimine (100) 3 tab
D.2-28 Clofazimine (50) 1 tab + Dapsone (100) 1 tab

TOPSI117

- SE Rifampicin: , N/V, Flu-like symptom, Hepatotoxic, CYP450 inducer ( advice

)
- SE Dapsone: Hemolytic anemia, Dapsone syndrome (drug hypersensitivity: , MP rash, hepatitis,
impaired renal function; 3-4 wk.), Agranulocytosis, Peripheral neuropathy
- SE Clofazimine: ( advice 1-2 yr.),
Dry skin, GI upset ( pigment deposit bowel )
- lab: CBC, LFT, BUN/Cr, G-6-PD ()
G-6-PD deficiency closed F/U; Hct < 30%
Dapsone

Leprosy reaction
- Leprosy reaction () 2 types
1. Type 1 (Reversal reaction, RR) delayed type hypersensitivity (DTH; type 4),
( BT, BB, BL), Hx: , ( severe )
Management: Topical steroid
2. Type 2 (Erythema nodosum leprosum, ENL) immune complex (type 3),
, erythematous dermal to subcutaneous nodule ( EN /
)
Management: Topical steroid + Clofazimine 200-300 mg/d
Type 2 reaction Prednisolone (
off and on , Precipitating factor )
- concept treat Leprosy reaction
1. Anti-inflammatory drug (Topical steroid)
2. Precipitating factor: Infection, Vaccination, Pregnancy
3. Continue MDT
4. Treatment of neuritis, acute iridocyclitis, acute epididymoorchitis
Epididymoorchitis 2nd most common cause infertile Mumps

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Toxicology
Emergency management in toxicology
General management
- ER 4
1. Basic life support (BLS) ABC
1) Airway ETT C/I Succinylcholine
(1) Organophosphate/Carbamate poisoning Succinylcholine
(2) HyperK+
(3) Rhabdomyolysis
2) Breathing metabolic acidosis hyperventilation
3) Circulation
2. Initial evaluation Hx, PE; Toxidrome
e.g. Sympatomimetic: diaphoresis () Anticholinergic: dry skin ()
Sympatolytic: opioid, 2-agonist
Cholinergic: SLUDGE + 3B
Salivation + Small pupil (miosis), Lacrimation, Urination, Diaphoresis + Diarrhea, GI upset, Emesis,
Bradycardia, Bronchorrhea, Bronchospasm
etc. (Sedative, Paracetamol, Alcohol, Amphetamine, Cannabis, Cocaine intoxication/withdrawal)
3. Decontamination
1) Skin /
2) GI 3
(1) Gastric lavage 1 hr. ( stomach)
(2) Single-dose activated charcoal 1 g/kg 1-2 hr.
- activated charcoal 50 g (1 g/kg) in water 500 cc /NG
- corrosive (acid/base), hydrocarbon, Fe, Li, alcohol
C/I Gastric lavage & Single-dose activated charcoal:
1. Unconsciousness/Seizure ( on ET tube) aspiration
2. Corrosive agent / gastric lavage perforation,
single-dose activated charcoal & scope
3. Hydrocarbon aspiration lung
(3) Whole bowel irrigation 2 (, C/I 3 , charcoal),
SR/EC , body packer ()
- PEG in balanced electrolyte /NG rate 2 L/hr (adult), 20-35 cc/kg/hr (child)
anus X-ray (
film )
C/I Whole bowel irrigation:

TOPSI117

4.

1. Unconsciousness/Seizure ( on ET tube) aspiration

2. Gut obstruction Mechanical (SBO, LBO) / Functional (ileus) irrigate
Supportive care

Specific treatment
- 2
1. Enhancement of elimination ; 3
1) Urine alkalinization Salicylate, Phenobarbital ( pKa ,
(Vd < 1 L/kg) & total clearance > 30%); keep urine pH 7.5-8
C/I: Renal failure
2) Multiple-dose activated charcoal AED (Phenytoin, Phenobarbital, Valproate, CBZ), ASA,
Dapsone, Quinidine, Theophylline; feces T1/2
( single-dose decontaminate multiple-dose eliminate)
- activated charcoal 20-30 g (0.5-1 g/kg) q 2-3 hr.
C/I: Gut obstruction
3) Hemodialysis (HD) Li, K+, Alcohol (methanol, ethanol, ethylene
glycol), Salicylate, Phenobarbital, Phenytoin, Valproate, Theophylline
C/I: Hypotension
2. Antidote I/C

Paracetamol toxicity
- Paracetamol absorb GI peak plasma level 45 min, absorb 4 hr.,
oral bioavailability 60-98%
- Paracetamol
- 90-95% conjugate glucuronidation, sulfation urine ()
- 5% urine ()
- < 5% () biotransformation liver CYP2E1, 1A2, 3A4 NAPQI (N-acetyl-pbenzoquinoeimine) centrilobular area , proximal tubule renal failure
- NAPQI glutathione detoxification () toxic
Paracetamol overdose (> 4 g/d) saturate pathway pathway NAPQI
glutathione toxicity
- Toxicity Paracetamol Acute ( 7.5 g 4 hr.) Chronic ( 4 g/d )
hepatitis
- Toxicity Paracetamol clinic 4 phases
Phase 1 (< 1 d) , N/V, liver enz.
Phase 2 (1-3 d) RUQ pain, liver enz.
Phase 3 (3-4 d) peak , pain , liver enz.
Phase 4 (4 d-2 wk.) phase 3 complete (periportal area
regenerate centrilobular area )

TOPSI117

- w/in 1 hr. Gastric lavage

w/in 2 hr. Activated charcoal 1 g/kg via NG
- Paracetamol level Paracetamol 4 hr. ( Paracetamol absorb )
plot Rumack-Matthew nomogram ( 4 hr. plot )

- NAC hepatitis 8 hr. Delayed toxidrome

- NAC
1. precursor glutathione
2. detoxify
3. hepatitis
- NAC 1 tab = 600 mg, 1 amp = 300 mg; Dose:
Oral form: NAC loading 140 mg/kg, then 70 mg/kg q 4 hr. x 17 doses
IV form 3 doses : NAC 150 mg/kg + 5%D/W 200 ml IV drip in 15 min,
then 50 mg/kg + 5%D/W 500 ml IV drip in 4 hr.,
then 100 mg/kg + 5%D/W 1,000 ml IV drip in 16 hr.
- NAC 8 hr. Severe hepatitis 2% (oral form), 0% (IV form)
- order Paracetamol overdose
30 yr., BW 50 kg, Paracetamol 50 90 min PTA, .. 18.30 .
One day
Continue
- Blood for CBC, BUN/Cr, Electrolytes, LFT,
- NPO
Coagulogram
- Record V/S, I/O
- Activated charcoal 50 g (1 g/kg) + water 500 cc
Medication
- Omeprazole 40 mg IV OD ( coagulopathy)
via NG
- Blood for Paracetamol level at 21.00 .
- NAC long (600) loading 12 tab, then 6 tab q 4 hr.
x 17 doses

TOPSI117

( NAC 7.5 g + 5%D/W 200 ml IV drip in 15 min,

then 2.5 g + 5%D/W 500 ml IV drip in 4 hr.,
then 5 g + 5%D/W 1,000 ml IV drip in 16 hr.)
NAC Paracetamol level, Paracetamol level 8 hr.
Paracetamol level plot Rumack-Matthew nomogram 4 hr. ()
- treatment line NAC
- treatment line NAC 3 d F/U LFT Hepatitis
T

8 hr. Paracetamol level Paracetamol level (mg/dl) =

BW
- < 7.5 continue NAC IV 20 hr. F/U LFT 36 hr. (~ 2 d) Hepatitis
- > 7.5 continue NAC IV 3 d F/U LFT Hepatitis
F/U LFT Hepatitis NAC

Gas and toxic inhalation

- Toxic gas 2
1. Asphyxiant
2. Irritant

Asphyxiants
- Asphyxiants O2
1. Simple asphyxiant O2 hypoxia; e.g. CO2, N2, H2,
acetylene (C2H4), butane (gas )
2. Systemic asphyxiant O2 O2 ; e.g. CO, CN, H2S
- CO2
- simple asphyxiant
- dry ice (CO2) / (e.g. ) O2 < 16% ( 21%)
- ; organ O2 heart & brain recent memory
- Management: + O2
- CO
- systemic asphyxiant
- , , (methylene
chloride) metabolite CO
- CO affinity Hb O2 200 CO shift HbO2 dissociation curve to the left
HbCO
CO affinity myoglobin O2 60
- Management: O2
- CO Pigment HbCO Cherry red skin
- CN
- systemic asphyxiant 2

TOPSI117

1. Cyanide salt early onset; e.g. HCN, KCN, ,

2. Cyanogen late onset; e.g. , (methylCN)
CN Fe3+ Cyt. a-a3 mitochondria CN cyt. a-a3 aerobic
metabolism anaerobic lactic acid
CN heart & brain ( aerobic ) Loss of consciousness, metabolic acidosis,
HT, tachycardia bradycardia
CN cyanosis
CN HbO2 ( Arteriolization of
venous blood)
Svo2 90% Lactic acidosis / Wide AG metabolic acidosis suggest
CN poisoning
Management: 100% O2 + Antidote () Sodium nitrite & Sodium thiosulfate
Sodium nitrite MetHb CN Fe3+ sodium thiosulfate CN
Thiocyanate urine

Irritants
- Irritants 2
1. Upper airway irritant (Eyes Vocal cord)
- HCl, SO2, NH3Cl
- (water soluble ) Airway obstruction
2. Lower airway irritant ( Vocal cord Alveoli)
- PH3 (phosgene), NO2
- (water soluble ) Pulmonary edema pneumonitis
asphyxiant & irritant

Air pollution
- Air pollutant 2 particle & gas
- RS & CVS
RS: irritant, CVS: HR & IHD)

Particle
-

Particle (Particulate matter, PM) , mixture ; e.g. , ,

asbestos; inhalable particles
1. Coarse particles (PM-10) (< 10 m)
- ; e.g.
- , ,
2. Fine particles (PM-2.5) (< 2.5 m)
- alveoli ()
- gas (e.g. SO2, NO, VOC) air pollution

TOPSI117

Gas
- Gas (Gaseous pollutant) e.g. SO2, NOx, VOC, CO, O3
- SO2
- upper airway irritant
- . lignite

- SO2 : 2SO2(g) + O2(g) 2SO3(g)

- O3 (Ozone)
- irritant
- NOx + VOC , heat &
UV sunlight O3 ( photo-oxidant product)
- Smog = smoke + fog; component SO2, O3, fine particles (PM-2.5)
- air pollution
1. ,
2. , smog
- High-risk Elderly (), Asthma (), Heart/Lung disease
;

Pesticide toxicity
- Pesticide 4 Insect-, Herb-, Rodent, & Fungicide
- 2 Toxicity & CA

Insecticide
- Insecticide Pesticide ; 3
1. AChEI
- & ; &
- inhalation, oral, skin
- SLUDGE + 3B: Salivation + Small pupil, Lacrimation, Urine incontinence, Diarrhea +
Diaphoresis, GI upset, Emesis, Bradycardia, Bronchorrhea, Bronchospasm
- inhibit AChE > 50% ( delayed manifestation 12 hr.)
- 2
1) Carbamate (reversible) e.g. Carbofuran
- AChE ( min-hr.)
- AChE treat (spontaneous degradation w/in 24-48 hr.)
2) Organophosphate (OP) (irreversible) e.g. Malathion
- AChE ( day-wk.)
- Enzyme aging AChE
- treat stop aging

TOPSI117

- AChE AChE
- Management
1. Supportive: ( secretion ) Suction airway
2. Specific
1) Atropine 2-5 mg IV / IM Atropinization ( secretion )
2) Pralidoxime (2-PAM) 30 mg/kg IV over 20 min, then IV drip 8 mg/kg/hr Antidote,
hydrolyze OP AChE
Atropine muscarinic 2-PAM muscarinic & nicotinic
2. Pyrethrin & Pyrethroid
- Pyrethrin (chrysanthemum)
Pyrethroid stable & toxicity
- : Na+ channel
- Pyrethroid ( ~thrin) 2 type; type 2 cyano group severe
- inhalation, oral ( skin !)
- mammal enz. hydrolyze pyrethroid stable

- : Allergic dermatitis (), AR, Anaphylactoid reaction, Contact dermatitis, Seizure

3. Organochlorine
- DDT ( vector malaria), Endosulfan (, ), Lindane ()
- GABA antagonist Seizure ( Mortality rate )
- food chain ( top food chain)
- fat, liver, brain; CA liver
- antidote; Management seizure

Metal poisoning
Pb (Lead)
- Pb () , , , , , ceramic

- Pb
- Pb Organic lead Skin only!!
Pb inhalation, oral
- Pb absorb 10-15% absorb 50%
- Fe / Ca absorb Pb (> 50%)
- Pb Kidney, Brain, Bone
- Pb bone T1/2 (35 yr.) dynamic equillibrium Pb
Pregnancy, Hyperthyroid bone Pb
- Pb brain, RBC enz. Hb synthesis MCHC anemia
PBS: Basophilic stippling

TOPSI117

- Pb poisoning
1. Acute ;
2. Chronic (common) Multisystemic S&S , ,
, Anemia, HT, Hyperuricemia, Peripheral motor neuropathy (wrist drop, foot drop), Renal tubule
damage
- Lead line gingival-tooth border
-
- threshold Pb ()
1. Nervous system develop ( target)
2. BBB ()
3. Absorb Pb ( 50%)
- Dx Pb poisoning S&S, Anemia Basophilic stippling, blood Pb level ( Pb level bone
)
- Pb 3 yr. (blood Pb) 1 mo. (blood Pb bone)
?
Ans: Protoporphyrin Pb > 3 mo.
RBC 120 d Pb block enz. heme protoporphyrin RBC
RBC protoporphyrin
- Management
1. Avoid exposure ()
2. Chelator: EDTA
3. Ca2+, Fe2+ ( Pb absorb)

As (Arsenic)
- As () Crust () /
- As (w/in 24 hr.) tissue Kidney, Brain, Keratin
(, )
- As poisoning
1. Acute ; Diarrhea ( cholera), Shock, Myocarditis
Management: Chelator: Dimercaprol
2. Subacute / acute; Peripheral neuropathy (),
weakness distal ( GBS)
3. Chronic (: skin & nail changes) , ;
Hyperkeratosis, Hyperpigmentation, Exfoliative dermatitis
Management: Avoid exposure (, chelator)
- As level 3 d ( organic As )

Hg (Mercury)
- Hg () 3 forms

TOPSI117

1.
2.
3.

Elemental (HgO) e.g. HgO thermometer; Inhalation

Salt (HgCl) (inorganic)
Organic (CH3Hg) food chain ( organochlorine) top food chain
chronic toxicity Cerebellar dysfunction (tremor, dysarthria);
Minamata
Hg placenta cerebellar dysfunction
- Management: Symptomatic, Avoid exposure

TOPSI117

Critical Care
Basic life support (BLS)

- BLS (Basic life support) AHA guideline 2010 sequence (Chain of survival)
Early recognition, EMS Early CPR Early defib. ACLS Post-cardiac arrest care
- BLS Chest compression (High-quality CPR) AHA guideline 2010
1. Sequence: C-A-B
2. CPR rate at least 100/min
3. 5 cm (2)
4. Full recoil
5. Interrupt (e.g. check pulse 10 sec, CPR )
6. Airway: Head tilt-Chin lift trauma Jaw thrust
7. Compression-to-ventilation ratio = 30:2
8. Advanced airway chest compression; rate 1 breath/6-8 sec
(8-10 breaths/min), 1 sec/breath; avoid hyperventilation
9. Defibrillator / AED paddle chest compression AED
rhythm shock CPR

TOPSI117

Advanced cardiac life support (ACLS)

Cardiac arrest

- Cardiac arrest AHA guideline 2010

1. Call for help, Activate EMS
2. CPR (30:2), O2, monitor / defibrillator / EKG
3. EKG (confirm 2 leads) Shockable rhythm (VT/VF)
1) VT/VF Defib. 120-200 J (biphasic) CPR 2 min (30:2 x 5 cycles), IV
( Defib. monophasic 360 J)
(1) Check rhythm VT/VF Defib. 120-200 J (biphasic) + Adrenaline 1 mg (
NSS 10-20 cc) q 3-5 min ETT, Capnography

TOPSI117

(2) Check rhythm VT/VF Defib. 120-200 J (biphasic) + Amiodarone 300 mg

(1st dose), 150 mg (2nd dose)
Treat Reversible cause: 5H 5T
Check rhythm EKG VF carotid pulse ( pulse
) EKG VT pulse VT pulse ( Tachycardia
algorithm) Pulseless VT ( Defib. )
2) PEA/Asystole CPR 2 min (30:2 x 5 cycles) + Adrenaline 1 mg q 3-5 min ETT, Capnography;
Check rhythm algorithm
- Reversible cause: 5H 5T
1. Hypovolemia e.g. Blood loss, Volume depletion ( load NSS )
2. Hypoxia e.g. Secretion obstruction, Severe lung parenchymal disease, FB obstruction
3. H+ (Metabolic acidosis) wide / narrow AG
I/C for NaHCO3- (dose: 7.5% NaHCO3- 50 cc IV push in 5 min)
1) Hyperkalemia
2) Previous metabolic acidosis ( HCO3- pH cardiac arrest)
3) TCA overdose
4. Hypo-/Hyperkalemia
Hyperkalemia e.g. AKI oliguria, CKD HD, DIC, G-6-PD deficiency anemia with
intravascular hemolysis, Rhabdomyolysis (e.g. crush injury, infection, drug), K+ supplement
Hyperkalemia treat ( lab )
1) EKG change Stabilize myocardial cell membrane: 10% Ca gluconate 15-30 cc (
10 cc ) 10% CaCl2 5-10 cc IV in 2-5 min
Digitalis intoxication Ca gluconate Digitalis Na+-K+ pump
Na+-K+ pump Hyperkalemia
2) Shift K+ cell
(1) 50% glucose 50 cc + RI 10 U IV in 15 min
(2) 7.5% NaHCO3- 50 cc (1 amp) IV push in 5 min
(3) Ventolin NB 10-20 mg NB in 15 min
3) Promote K+ excretion
(1) Lasix 40-80 mg IV
(2) Kayexelate 15-50 g + Sorbitol PO / Rectal
(3) Hemodialysis
5. Hypothermia e.g. Near drowning, Sepsis, Drugs,
Hypothermia response Defib. ( VF/Pulseless VT)
2
1) Passive rewarming ( Near drowning), , warmer
2) Active rewarming Irrigate NG, Irrigate bladder, Warm IV fluid, Hemofiltration

TOPSI117

6.

Tension pneumothorax Thoracic injury, COPD dyspnea, Barotrauma from

mechanical ventilator, Central line (Internal jugular vein / Subclavian vein),
Thoracentesis
Management: ICD or Needle thoracostomy
7. Tamponade (cardiac) Blunt thoracic injury, Pericardial effusion
Management: Pericardiocentesis ( CPR ROSC) Open cardiac massage ()
8. Toxins e.g. Organophosphate poisoning (Antidote: Atropine), TCA overdose (Antidote:
7.5% NaHCO3-)
9. Thrombosis (pulmonary: PE) Hx DVT, Hypercoagulable state
Management: CPR , poor prognosis
10. Thrombosis (coronary)
Management: PCI ( CPR ROSC)
Fibrinolytics cardiac arrest
( AHA guideline 2005 6H 6T 2010 Hypoglycemia, Multiple trauma 5H 5T)
- ROSC (Return of spontaneous circulation: pulse , BP , PETCO2 40 mmHg, arterial
pressure waveform A-line) Post-cardiac arrest care (keep O2 sat. 94%, Advanced
airway, Capnography waveform, Hyperventilation)

Bradycardia

TOPSI117

- Bradycardia (with pulse) AHA guideline 2010

1. clinical , bradyarrhythmia HR < 50/min
2. Identify & treat cause; Airway, Breathing, O2, Monitor: EKG, BP, O2 sat., IV, 12-lead EKG
3. Persistent bradyarrhythmia 1/5
1) Hypotension
2) Signs of shock
3) Chest pain
4) Alteration of consciousness
5) Heart failure
1/5 = Stable Observe
1/5 = Unstable Atropine 0.6 mg IV bolus ( NSS 10-20 cc) q 3-5 min (Max 3 mg)
( guideline Atropine 0.5 mg Atropine 1 amp = 0.6 mg)
4. Atropine 2nd line therapy 1/3
1) Transcutaneous pacing Fix mode Demand mode; sedate

(1) Diazepam (Valium) 5-10 mg IV

(2) Midazolam (Dormicum) 2-5 mg IV
(3) Fentanyl 25-100 g IV
Demand mode = rate pace
ACLS Fix mode Demand mode artifact transfer
(Fix mode)
1. Output 200 mA, Pacer rate 60/min ( I/C: QTc prolong)
2. Pacer start
3. EKG Spike ( ventricle), EKG Wide QRS complex pace =
Capture (Capture = pace Wide QRS ), axis
Pacing Dual chamber (Atrium + Ventricle) Narrow QRS
4. Output Capture
5. Output 20-25% (); Output > Capture
threshold 10-20% (Capture threshold = Output capture )
2) Dopamine IV drip rate 2-10 g/kg/min ( 1, 2 receptor)
( Dopamine rate > 10 g/kg/min = High dose receptor)
BW

; BW = 60 kg: Dopamine (2:1) IV drip 10 d/min

: d/min
.
3) Adrenaline IV drip rate 2-10 g/min ( receptor receptor)
/

: d/min
.
3 Consult expert, Transvenous pacing
Reversible cause: 5H 5T, IICP ( AHA
guideline 2010) Hypoxia, ACS, HyperK+, Metabolic acidosis

TOPSI117

Tachycardia

- Tachycardia (with pulse) AHA guideline 2010

1. clinical , tachyarrhythmia HR 150/min
2. Identify & treat cause; Airway, Breathing, O2, Monitor: EKG, BP, O2 sat.
3. Persistent tachyarrhythmia 1/5
1) Hypotension
2) Signs of shock
3) Chest pain
4) Alteration of consciousness
5) Heart failure
1/5 = Unstable Synchronized cardioversion (sedate + gel )
- Narrow regular: 50-100 J + Adenosine 6 mg IV push (+ NSS 20 cc flush)
2nd dose: Adenosine 12 mg IV push (+ NSS 20 cc flush)
Adenosine
Adenosine Double syringe technique 3-way, push Adenosine
NSS 20 cc flush Adenosine Endothelium
- Narrow irregular: 120-200 J (biphasic; monophasic 200 J)

TOPSI117

Cardioversion AF New-onset AF ( 48 hr.)

Chronic AF Chronic AF clot heart chamber cardiovert
clot Stroke
- Wide regular: 100 J
- Wide irregular: Defib. 120-200 J ( Synchronized cardioversion)
1/5 = Stable QRS complex
- Narrow QRS complex
1) IV, 12-lead EKG
2) Carotid massage (Vagal maneuver) carotid bruit
: 3
3) Narrow regular ( SVT) Adenosine 6 mg IV push (+ NSS 20 cc flush)
2nd dose: Adenosine 12 mg IV push (+ NSS 20 cc flush)
Synchronized cardioversion 50-100 J ( 50 J )
4) Narrow irregular -blocker CCB (slow rate AF Atrial flutter);

(1) Verapamil 2.5-5 mg IV q 3-5 min (Total max 10 mg)

(2) Diltiazem 5-10 mg IV q 3-5 min (Total max 20 mg)
Narrow regular: 2 AF MAT; MAT lung disease
response Cardioversion
Digoxin guideline 2-3 hr. stable

- Wide QRS complex

1) IV, 12-lead EKG
2) Wide regular, monomorphic Adenosine (terminate SVT with aberrancy /
preexisting BBB)
3) Amiodarone 150 mg (1st dose) over 10 min, repeat VT
Maintenance dose (IV drip): 1 mg/min for 6 hr., then 0.5 mg/min for 18 hr.
(Total max 2,200 mg/d)
1st dose Amiodarone Tachycardia algorithm (150 mg) Cardiac
arrest algorithm (1st dose 300 mg, 2nd dose 150 mg)
DDx in Wide QRS complex tachycardia
1. VT (> 90%)
2. SVT with aberrancy / preexisting BBB
3. WPW syndrome
4. Ventricular paced rhythm
WPW syndrome ABCD: Adenosine, Beta-blocker, CCB,
Digitalis AV node Bundle of Kent

TOPSI117

Shock
Early assessment
- Shock = multisystem end organ hypoperfusion ( hypotension), tissue hypoxia,
lactic acidosis, organ failure
- SBP systolic function, DBP afterload (diastolic function)
- Classification of shock shock 2
1. Hypodynamic (Low C.O.) Vasoconstriction, Afterload (SVR) , C.O. Narrow PP
(< SBP)
1) Hypovolemic shock
2) Cardiogenic shock
3) Obstructive shock Cardiac tamponade, Massive PE, Tension pneumothorax, Severe PHT
2. Hyperdynamic (High C.O., Distributive) Vasodilatation, Afterload (SVR) , C.O. Wide PP
(> SBP)
1) Septic shock
2) Anaphylactic shock
3) Endocrinologic shock Thyroid storm, Adrenal crisis
4) Neurogenic shock
5) Drug & toxin
- MAP = C.O. x SVR MAP = EDV x EF x HR x SVR
C.O. = SV x HR; SV = EDV-ESV; (EDV-ESV)/EDV = EF =
Contractility
factor BP 4 factors
1. Preload (EDV) JVP, CVP, PCWP
1) JVP Cardiogenic & Obstructive; Lung
Cardiogenic shock crepitation; Obstructive shock crepitation
2) JVP Hypovolemic & Hyperdynamic ; afterload (DBP, PP)
2. Afterload (SVR) DBP, PP, Capillary refill
Capillary refill tissue perfusion Hypodynamic shock, afterload
afterload ( Hyperdynamic
afterload capillary refill shock )
3. Contractility (EF) heart sound
1) S1 = contractility ; = contractility
2) S3 S3 gallop = systolic dysfunction = contractility
3) S4 S4 gallop = diastolic dysfunction RCM/HCM LV overload contractility
4. Rhythm (HR) P, EKG; rate BP < 60/min > 150/min
- Hypodynamic shock Goal: SBP 90 mmHg ( shock afterload )

TOPSI117

Hyperdynamic shock Goal: MAP 65 mmHg ( SBP goal SBP > 90 afterload
(DBP) wide PP, MAP 65)
MAP = DBP + PP/3
shock hypo- & hyperdynamic shock 3
1. Septic shock hyperdynamic vascular leakage hypovolemia
hypovolemic shock (hypodynamic) ; mediator
cardiogenic shock (hypodynamic)
2. Hypocalcemia systolic function cardiogenic shock (hypodynamic) Ca2+
vasodilatation ( Ca2+ vasoconstriction) hyperdynamic
shock (); 4 shock Refractory shock,
Rhabdomyolysis, Massive blood transfusion, Plasmapheresis
3. Metabolic acidosis vasodilatation hyperdynamic shock
acidosis cardiogenic shock (hypodynamic)
metabolic acidodsis shock JVP vasopressor
blood loss 10% , pulse , BP drop
blood loss 20% Postural hypotension, BP drop ( adequate tissue perfusion )
blood loss 30% BP drop ( decompensatory shock )
Compensation ( receptor carotid sinus): sympathetic tone tachycardia, vasoconstriction
&
shock fluid 2 ( No. 16, 18)
1. Fluid loading loss e.g. Hypovolemic shock, Septic shock ( underlying
heart disease )
2. Fluid challenge test: NSS 200 cc in 10 min challenge LVEF
/ ( false high CVP RV ), challenge
sign of volume overload e.g. lung crepitation
medicine trauma LRS 2,000 cc in 15 min
trauma heart bleed fluid resuscitation
medicine ER heart septic shock load fluid
load heart failure ( heart fluid
200 cc ) ( LRS NSS
hyperchloremic metabolic acidosis)
Fluid challenge test CVP PCWP fluid
Infusion
CVP (cmH2O) PCWP (mmHg)
Start fluid challenge
200 cc in 10 min
<8
< 10
8-12
10-14
100 cc in 10 min
12
14
50 cc in 10 min
During infusion after
>5
>7
Stop

TOPSI117

10 min

2
2-5
Still > 2

3
3-7
Still > 3

Continue
Wait 10 min
After waiting 10 min
Stop,
Vasoactive drugs
2
3
Repeat
Fluid load Crystalloid; Colloid Crystalloid
Central venous catheter (CVC) ( CVP) 2
1. Percutaneous catheterization Internal jugular vein Subclavian vein
2. Cut down (Venesection) Brachial vein Antecubital vein
I/C for CVC
1. / fluid / (e.g. TPN) IV
2. CVP ( hemodynamic monitoring fluid challenge)
3. Peripheral line
4. RRT (Renal replacement therapy)
5. Pulmonary artery catheter Temporary pacemaker
SVC Brachiocephalic vein (
respiratory fluctuation)
CXR: Sternoclavicular joint Rt. heart border
proximal venous valve CVP
atrium perforation
CVP : Zero point ( AP diameter ), End expiration

on Ventilator (Positive pressure)
: CVP Macrocirculation failure (Shock, BP drop)
Microcirculation failure (Urine , Lactate , Low Scvo2) goal keep CVP
condition

Septic shock
- SIRS (systemic inflammatory response syndrome) criteria ( 2/4 )
1. T > 38C (fever) T < 36C (hypothermia)
2. HR > 90/min
3. RR > 20/min PaCO2 < 32 mmHg
4. WBC > 12,000/mm3 WBC < 4,000/mm3 band form > 10%
- Sepsis = SIRS + H/C x2 +ve
- Severe sepsis = sepsis + organ dysfunction (e.g. oligulia, MS)
- Septic shock = sepsis hypotension adequate fluid resuscitation
- septic shock
1. Macrocirculation myocardial suppression, vasodilatation, vascular leakage

TOPSI117

2. Microcirculation microthrombosis DIC, coagulopathy

2 global tissue hypoxia MODS (multiorgan dysfunction syndrome)
Early goal-directed therapy (EGDT) w/in 6 hr.
1. CVP 10-15 cmH2O; if on ET tube: CVP 15-20 cmH2O
2. MAP 65 mmHg
3. Urine output > 0.5 cc/kg/hr
4. Scvo2 70% microcirculation adequate tissue oxygenation
septic shock 3
1. Hemodynamic support EGDT
2. Source identification ATB surgical drainage ( I/C)
3. Intubation & Mechanical ventilator respiratory failure
ER load NSS Fluid challenge test : NSS 200 cc in 15 min heart
(challenge LVEF)
hemodynamic support 3 part
1. Load NSS 500-1,000 cc in 30 min Goal: JVP 3-5 cm; (JVP + 5 CVP)
goal load ; uncertain invasive monitoring CVP (central line), PCWP
(Swan-Ganz catheter) Goal: CVP > 10-15 cmH2O (8-12 mmHg), PCWP > 15-18 mmHg
2. BP Goal: MAP 65 mmHg
goal
1) Vasopressor: Dopamine 5-20 g/kg/min NE 0.2-2 g/kg/min
Dopamine 5-10 g/min q 5-15 min
Dopamine 5-10 g/kg/min 1 2 receptor
Dopamine > 10 g/kg/min (high dose) receptor
NE 1 receptor
2) goal Hydrocortisone 50 mg IV q 6 hr., tape off off 7 d
3) volume
4) Adrenaline drip titrate dose
Adrenaline receptor
3. Organ perfusion Goal: Urine output > 0.5 cc/kg/hr, Scvo2 70% (esp. dopamine
> 10 g/kg/min NE > 10 g/min)
goal Hct
- Hct < 30% PRC Hct 30% (PRC 1 Hct 3% ongoing blood loss)
- Hct > 30% Dobutamine 5-20 g/kg/min Scvo2 70%
Dobutamine 1 2 receptor

Cardiogenic shock
- AMI LV infarction > 40%
- Cardiogenic shock criteria Dx

TOPSI117

1.

SBP < 90 mmHg for 30 min ( on Vasopressor SBP 90 mmHg)

If HT: MAP 30 mmHg
2. Poor tissue perfusion e.g. , peripheral pulse , Urine output
< 30 cc/hr, Alteration of consciousness
3. Hemodynamic parameter Cardiogenic shock
1) Cardiac index (CI) 2.2 L/min/m2
2) PCWP 15 mmHg
3) PE/CXR: Pulmonary edema
- Management
1. Stabilizing life-threatening hemodynamic condition
2. Early reperfusion therapy
3. Secondary prevention of cardiovascular event
- C.O. check BP
- SBP > 100 mmHg NTG 10-20 g/min IV
- SBP 70-100 mmHg, No signs/symptoms of shock Dobutamine 2-20 g/min IV
- SBP 70-100 mmHg + Signs/symptoms of shock Dopamine 5-15 g/min IV
- SBP < 70 mmHg + Signs/symptoms of shock NE 0.5-30 g/min IV

Mechanical ventilator
- Ventilator ; 2
1. NPPV (non-invasive) e.g. BIPAP, CPAP; RS & GI tract
2. IPPV (invasive) ventilate ETT tracheostomy tube
I/C for ETI
1. Respiratory failure type 1, 2
2. UAO
3. GCS 8 (Prevent aspiration)
4. Pulmonary toilet (e.g. Infected bronchiectasis, Pneumonia secretion )
: Provide oxygenation ( normal PaO2), Provide ventilation ( normal PaCO2), WOB,
Prevent complications (Barotrauma, Hypotension, VAP)
ETT occiput (flex )
No. 7-7.5, 20-22 cm upper incisor
No. 7.5-8, 22-24 cm upper incisor
on ETT off 50% pneumonia
off ETT off 48 hr.
- V/P = compliance (compliance lung pathology; V P )
Limit variable = , Cycle variable =

Modes of ventilator
- 3

TOPSI117

1.

Control mode: CMV (Controlled mandatory ventilation) RR

(unstable: O2 sat. drop, BP drop, cardiac arrhythmia, etc.) 2
1) VCV (VC-CMV, CMV) = Volume control ( CMV mode VCV mode)
- TV TV e.g. Atelectasis, Neuromuscular disease (e.g. MG)
- PIP lung pathology
e.g. 1 TV 500 cc, PIP 20 cmH2O; 2 TV 500 cc, PIP 30 cmH2O
2 ( IP ) = Lung compliance 1
- I time PFR (PIF, peak Inspiratory flow rate)
PFR (flow ) I time ; PFR (flow ) I time
( CMV mode PFR I:E e.g. Raphael, Galileo)
- TV flow (PFR) (Inspiratory valve , expiratory
valve ) = Volume cycling
- order: CMV mode, Triggering, Fio2, TV, PFR ( I:E ), PEEP / no
PEEP, RR
Monitor: round
(1) PIP 35 cmH2O ( IP monitor)
(PIP relate barotrauma most common: Pneumothorax = )
CMV mode PFR PIP
monitor PIP 35 cmH2O ( PCV, PSV mode PIP sustained
monitor PIP 30 cmH2O)
(2) Exhaled TV
( monitor exhaled TV TV cycle bronchospasm
cycle diaphragm
)
CMV mode: guarantee Inhaled TV guarantee Exhaled TV
(3) RR
( 15/min 40/min )
2) PCV (PC-CMV, Pressure A/C) = Pressure control
- IP
(1) P e.g. COPD, Asthma, ARDS P
(2) P e.g. Pneumothorax 1 ( P control P )
- TV lung pathology
e.g. 1 IP 25 cmH2O, Exhaled TV 500 cc; 2 IP 25 cmH2O, Exhaled TV 300 cc
2 TV = Lung compliance 1
- I time I time I:E ratio

TOPSI117

P-ramp (PRT) = Pressure rising time = IP = 0 target IP

, 50 ms; target IP sustain TV
I time I time = Time cycling
( I:E e.g. I:E = 1:2, RR = 20 (3 sec/cycle) I time = 1 sec )
sustain PIP I time alveoli
collapse
- order: PCV mode, Triggering, Fio2, PRT, IP, I time ( I:E), PEEP / no PEEP,
RR
Monitor: round
(1) Exhaled TV ( PCV guarantee inhaled TV guarantee
exhaled TV )
(2) PIP 30 cmH2O ( PIP sustain )
(3) RR
2. Spontaneous mode: PSV (Pressure support ventilation) RR,
( RC esp. Brain stem)
- Wean from ventilator ( T-piece off ETT)
- PS (pressure support) IP PCV mode
P = PS + P (e.g. P 10 cmH2O, PS 10
mmHg 10+10 = 20 cmH2O)
- TV lung pathology
e.g. 1 PS 25 cmH2O, Exhaled TV 500 cc; 2 PS 25 cmH2O, Exhaled TV 300 cc
2 TV = Lung compliance 1
- I time ETS (E-sense) = Expiratory trigger sensitivity = %flow initial peak flow
(100%) flow (e.g. 25%) = Flow cycling
ETS I time , TV ; ETS I time , TV
PSV mode ,
- order: PSV mode, Triggering, Fio2, PRT, PS, ETS, CPAP / no CPAP
(CPAP = continuous positive airway P airway & )
Monitor: round
(1) RR ( )
(2) PIP 30 cmH2O ( PIP sustain )
PIP = PS + CPAP (e.g. PS = 10, CPAP = 5 PIP = 15; PIP
leakage)
(3) Exhaled TV
mode
CMV (VCV) mode: TV PFR ( PIP )
(Volume cycling) cycle RR

TOPSI117

PCV mode: TV IP = P-ramp sustain

PIP I time I:E (Time cycling) cycle RR
PSV mode: trigger TV PS = P-ramp
sustain PS %flow = ETS (Flow cycling) cycle
trigger
Birds ventilator: trigger TV IP I time
PFR (Pressure cycling) cycle controlled E time
order ventilators
CMV (VCV) mode
PCV mode
PSV mode

1. Triggering
1. Triggering
1. Triggering
2. Fio2
2. Fio2
2. Fio2
3. TV
3. P-ramp, IP
3. P-ramp, PS
4. PFR
4. I:E (or I time)
4. ETS
5. PEEP / no PEEP
5. PEEP / no PEEP
5. CPAP / no CPAP
6. RR
6. RR
Monitor
1. RR
1. PIP ( 35 cmH2O) 1. Exhaled TV
2. PIP ( 30 cmH2O) 2. PIP ( 30 cmH2O)
2. Exhaled TV
3. RR
3. Exhaled TV
3. RR
3. Mix control-spontaneous mode: SIMV (Synchronized intermittent mandatory ventilation)
-
1) CNS problem ( ) e.g. Cheyne-Stokes
respiration
2) fail wean PSV mode / T-piece
- Setting 2
1) Setting control mode ( CMV = VC-SIMV PCV = PC-SIMV )
RR (e.g. RR = 12/min TV VC-SIMV IP
PC-SIMV)
2) Setting PSV mode PS
SIMV RR ( control mode) &
PS ( PSV mode) RR (
) PS
TV (spontaneous breathing) PS + lung pathology
- = IMV mode
cycle control mode ( RR)
IMV mode SIMV mode

TOPSI117

(S = synchronized) synchronize

PCV mode & PC-SIMV mode : e.g. RR 12/min

20/min
PCV mode (Pressure A/C) 8 trigger IP
PC-SIMV mode 8 IP PS + lung pathology
- Fio2 PaO2 ; O2 O2 toxicity ( Fio2 0.6
)
- ARDS ventilator CMV mode
1. TV 6 cc/kg 400 cc ( IP)
2. RR 16-20/min ( E time)
3. PFR 40-50 LPM I:E 1:2 E ( PFR)
4. PEEP 4 cmH2O ( alveoli collapsed; need Therapeutic PEEP)
5. Fio2 < 0.6 ( O2 toxicity)

Phases of ventilator
- 6 phases
1. Start of inspiration trigger Inspiratory valve
- Trigger mode = A/C mode
1) C (control = fully control) = Time trigger: RR
2) A (assist = partial control) = Patient trigger: trigger;
( )
(1) Pressure trigger (-2)-(-3) cmH2O (
create P P inspiratory valve )
(2) Flow trigger 2-3 LPM ( pressure trigger; flow
velocity inspiratory valve )
- trigger WOB = Hard to triggering
- trigger
= Auto-triggering (Auto-cycling)
= Auto-PEEP = Dynamic hyperinflation
(DHI) intrathoracic P BP drop & barotrauma
- Neuromuscular disease (e.g. MG, GBS, Neurotoxin) trigger ( )
ventilator flow trigger 1 LPM auto-triggering
Neuromuscular disease weakness
- patient trigger cycle trigger cycle
time trigger
2. Inspiration phase

TOPSI117

1) Fio2 (fractional inspired O2 concentration) keep

optimal O2 sat.
2) TV ( CMV mode) / IP ( PCV mode) / PS ( PSV mode)
3) P-ramp ( PCV, PSV mode)
4) PFR ( CMV mode) / I time I:E ratio ( PCV mode) / ETS ( PSV mode)
- O2 sat. keep
Diseases
Keep O2 sat.
COPD
88%
ARDS
90% (88-92%)
ACS
94%
( AHA guideline 2010)
Post-cardiac arrest
Other conditions (e.g.
Pneumonia, Asthma,
92%
Atelectasis)
- Prevent O2 toxicity
Fio2 = 1 2-3 hr.
Fio2 = 0.8 1-2 d
Fio2 = 0.6 1-2 wk.
Fio2 < 0.6
- O2 toxicity ROP, Irreversible pulmonary fibrosis
- Birds ventilator Fio2 Air-mixed (room air mix 100% O2) mix
Fio2 ( ~ 0.4 0.4)
Fio2 ABG PaO2/Fio2 ratio on air-mixed ,
O2 sat.
- O2 sat. PaO2
O2 sat. (%) PaO2 (mmHg)
95
80
90
60
88
55
75
40
50
27
- Fio2 keep O2 sat. (PaO2/Fio2)1 = (PaO2/Fio2)2 ( shunt
pathology ) O2 sat. PaO2
e.g. ARDS Fio2 = 1 Pao2 = 100 mmHg, keep O2 sat. 90%
PaO2 = 60 mmHg Fio2: (PaO2/Fio2)1 = (PaO2/Fio2)2
100/1 = 60/Fio2 Fio2 0.6
- TV ( CMV mode)
1. Normal lung (post-operative) Normal TV = 8-10 cc/kg

TOPSI117

2. Lung diseases ( Atelectasis) Low TV 6-8 cc/kg

- Obstructive lung diseases Lower airway obstruction e.g. COPD, Asthma;
TV
barotrauma ( Auto-PEEP DHI)
- Restrictive lung diseases e.g. ARDS, Interstitial lung disease, Chest wall disease,
Pulmonary edema, Intra-abdominal HT; low TV
3. Metabolic acidosis ( , I time ), Fever,
Hypercatabolic state, Atelectasis, Neuromuscular disease (e.g. MG, GBS) High TV
10-12 cc/kg
Neuromuscular disease high TV diaphragm move
diaphragm move
TV cc cc/kg
Actual BW ()
IBW (Ideal BW, Predicted BW)
Male: IBW = 0.91(Ht. 152.4) + 50 (Ht. cm)
Female: IBW = 0.91(Ht. 152.4) + 45.5 ( 50 45.5)
IP ( PCV mode) set TV (normal / low / high), monitor PIP 30 cmH2O
PS ( PSV mode) set exhaled TV (normal / low / high), monitor PIP 30
cmH2O (concept IP PCV mode)
P-ramp ( PCV, PSV mode) normal setting: 50-100 ms
- Metabolic acidosis target IP/PS P-ramp
- UAO target IP/PS P-ramp
PFR ( CMV mode) 2 configuration () & value ()
1) Configuration 3 waveform
(1) Square flow I time
(2) Half decelerating flow I time 1/2 initial
(3) Total decelerating flow I time 0
TV Square waveform flow I time
Total decelerating waveform flow I time

- Lower airway obstruction (COPD, Asthma) I time
Square waveform ( Half Total decelerating PFR )
- ARDS PEEP , Atelectasis I time
Total decelerating waveform
2) Value common setting: 40-60 LPM
PFR I time , PFR I time
I time I:E ( PCV mode), ETS ( PSV mode)

TOPSI117

Normal I:E = 1:2-1:3, ETS = 25%

COPD, Asthma E time I:E = 1:3, ETS > 25% ( I time )
Metabolic acidosis I time
( Kussmaul) reverse I:E = 1:1 1:2, ETS < 25% ( I time
), RR ~ 20/min 25/min
- ARDS, CHF with hypoxemia response PEEP I time I:E = 1:2,
ETS < 25%
ARDS, CHF set PEEP PEEP O2 sat.
Prolonged I time
End of inspiration (Cycling from I to E) inspiratory valve , expiratory valve
CMV mode Volume cycling ( TV PFR)
PCV mode Time cycling ( I time)
PSV mode Flow cycling ( %flow ETS)
Birds Pressure cycling ( IP )
Expiration phase elastic recoil
End of expiration PEEP / no PEEP (ZEEP)
(PEEP = positive end expiratory P, ZEEP = zero end expiratory P)
- PEEP
1) Improve hypoxemia ( O2 sat. drop diffuse alveolar infiltration
Fio2 )
(PEEP exudate/transudate alveoli periphery
alveoli air gas PaO2 O2 sat. )
2) PaCO2
3) WOB
4) lung compliance
- Complications of PEEP
1) Barotrauma
(CXR Subcutaneous emphysema: air M. Pectoralis major)
2) Hypotension (Hemodynamic instability)
3) Late phase: hypoxemia / hypercapnia
4) IICP
- Classification of PEEP
1) Physiologic PEEP < 5 cm H2O, Atelectasis ( belief)
2) Therapeutic PEEP Improve hypoxemia Fio2 (
diffuse alveolar infiltration: ALI/ARDS & Pulmonary edema ), WOB
- Absolute C/I of PEEP: Barotrauma (Pneumothorax) PEEP
-

3.

4.
5.

TOPSI117

Relative C/I of PEEP: Unilateral lung disease, Hypotension (Hemodynamic instability), Interstitial
lung disease, IICP
6. How to control RR ( PSV mode)
- Normal RR = 10-15/min ( 16/min)
- COPD, Asthma Low RR
- ARDS, CHF, Severe pneumonia High RR
- RR rate (
) RR RR 5
- Ventilator setting Normal lung
1. Triggering: Pressure trigger / Flow trigger
2. Fio2 0.2-0.4
3. TV 8 cc/kg (8-10 cc/kg)
4. I:E 1:2-1:3
5. PEEP < 5 cmH2O
6. RR 12/min (10-15/min)

Ventilator settings in restrictive lung diseases

- Restrictive lung disease
1. Diffuse
1) Alveolar infiltration volume status
(1) ALI / ARDS
(2) Cardiogenic pulmonary edema ( CHF)
2) Interstitial infiltration Interstitial lung disease
2. Localized
1) Non-unilateral lung lesion, Non-ALI / ARDS / Cardiogenic pulmonary edema Pneumonia,
Atelectasis, Aspiration
2) Unilateral lung lesion Unilateral pneumonia, Unilateral atelectasis, Hemoptysis in unilateral
lung, Pleural lesion
- ventilator Restrictive lung disease
1. Low TV (6 cc/kg)
2. RR (20/min)
3. Normal I:E
MV = TV x RR; Restrictive lung disease Low TV RR MV

- Diffuse alveolar infiltration (ALI / ARDS, Cardiogenic pulmonary edema) Restrictive lung
disease + Fio2 = 1, apply Therapeutic PEEP (> 5 cmH2O), then Fio2 0.6, keep O2 sat. 88-92%
hypoxia IRV / Alveolar recruitment maneuver / Prone position
- Step PEEP 2-3 cmH2O q 5-15 min; step 2

TOPSI117

5 8 10 12 15
5 7 9 11 13 15 ( 2)
Goal: O2 sat.
Monitor: O2 sat., BP, PIP, TV, MV, ABG, CXR
PEEP ? ( 10) PIP mode
ARDS PEEP Cardiogenic pulmonary edema
: ARDS surfactant Cardiogenic pulmonary edema
surfactant fill alveoli ( crepitation alveoli
-)
PEEP ARDS alveoli crepitation
crepitation PEEP ARDS alveoli
( Lasix)
PEEP ARDS BP drop DDx:
1. Pneumothorax (Barotrauma; ) Rx: ICD, off PEEP
PEEP Pneumothorax off PEEP PEEP
lung collapse TV ( PIP)
ARDS COPD Pneumothorax PEEP off PEEP
2. Relative volume depletion Rx: IV fluid ( technique Fluid challenge test), off PEEP
Diffuse interstitial infiltration (Interstitial lung disease) Restrictive lung disease, no PEEP
Therapeutic PEEP interstitial infiltration alveolar infiltration
PEEP alveolar lesion , interstitial lung disease &
1) perfusion interstitial tissue V/Q mismatch
2) barotrauma interstitial lung disease low compliance
Localized lung lesion
1. Pneumonia, Atelectasis, Aspiration ventilator Restrictive lung disease
2. Unilateral lung lesion ventilator Restrictive lung disease + Maneuver (
)
1) Unilateral pneumonia, Unilateral atelectasis Good lung down or Prolonged I time
Good lung down lung lesion lung ventilator
V/Q mismatch
: secretion lung lesion lung
bilateral lung disease
Prolonged I time I time ( CMV mode: PFR; PCV mode: I:E; PSV
mode: ETS) fill lung
alveoli lung = Penduluft effect
2) Hemoptysis in unilateral lung Bad lung down

TOPSI117

Bad lung down lung lesion lung lung

ETT Hemoptysis ETT (

contact silicone clot)
3) Pleural lesion ICD ( I/C)

Ventilator settings in obstructive lung diseases

- Obstructive lung disease e.g. COPD, Asthma
Concept: Low TV (6 cc/kg), RR (10/min), E time (I:E = 1:3) + Physiologic PEEP / no PEEP
( E time COPD, Asthma
E time Auto-PEEP)
- TV & RR MV ( PaCO2) = Permissive hypercapnia: accept if pH > 7.2
ventilator COPD, Asthma normal blood gas

Ventilator settings in metabolic acidosis

- Metabolic acidosis Kussmaul breathing = ventilator
High TV (10-12 cc/kg), RR (20/min 25/min), I time (I:E = 1:2-1:1,
inverse ratio)
- metabolic acidosis respiratory drive =
Patient-ventilator dyssynchrony PSV mode PS TV
- TV RR
- cause metabolic acidosis

Ventilator settings in IICP

- IICP hyperventilation cerebral vasoconstriction metabolic acidosis
High TV (10-12 cc/kg), RR (20/min 25/min), I time (I:E = 1:2, inverse ratio)
- New concept: hyperventilation keep PaCO2 30-35 mmHg prevent hypercapnia

Ventilator settings in neuromuscular diseases

- Neuromuscular disease e.g. GBS, MG, LEMS, Motor neuron disease, Myopathy
High TV metabolic acidosis & IICP RR & I:E normal
High TV (10-12 cc/kg), Normal RR (12/min), Normal I:E (I:E = 1:2-1:3) I time
atelectasis ( atelectasis I time )
Ventilator setting conditions
1. ALI / ARDS, Cardiogenic pulmonary edema
Setting: Low TV, RR , Normal I:E, Therapeutic PEEP
2. Interstitial lung disease, Pneumonia, Atelectasis, Aspiration
Setting: Low TV, RR , Normal I:E, Physiologic PEEP / no PEEP
3. Unilateral pneumonia, Unilateral atelectasis
Setting: Low TV, RR , Normal I:E ( I time Penduluft effect), Good lung down

TO
OPSI117

4. Hem
moptysis in unilateral lung
Setting: Low TV, RR
R , Normaal I:E, Bad lunng down
5. COPPD, Asthma
Setting: Low TV, RR
R , E time , Physioloogic PEEP / noo PEEP; Perm
missive hyperccapnia
6. Metaabolic acidosiis, IICP
Setting: High TV, RR , I timee ( IICCP keep PaaCO2 30-35 mmHg)
m
7. Neuromuscular diseases
N
I:E ( I time
ateelectasis )
Setting: High TV, Normal RR, Normal

condittions conditioon
ccondition
8.
(e.g.. COPD with
w pneumonia with metabbolic acidosis, Kussmaul
breaathing ventilator metabbolic acidosis)

Birds ventilatorr
-

trigger Pressuure trigger

IP ( PCV;; pressure conntrol) TV lungg pathology
me control)
I time PFR ( CMV; volum
IP = Pressure
P
cycling (guaranteee P, V monitoor TV
sppirometer bid;
TV
lung compliance )
PCVV/PSV Birdds PCV/PPSV sustainn PIP I time Birds
PIP

PIP
- Monittor: PIP 35 cmH2O ( PIP )
- RR Controlled
C
E time
t ( RR
control mode
m ventilator )
Coontrolled E tim
me RR ; Controlleed E time RR
- Birds
B ventilatoor

Onn/Off

PFFR

Triggering

IP
Monitor PIP
P
Coontrolled
E time

F 2
Fio

TOPSI117

1)
2)
3)
4)

O2
1/2 (Humidifier system) ( irritate mucosa)

Triggering (Starting effort) pressure triggering (-2)-(-3) cmH2O
Start of inspiration -2 -3
- () Hard to triggering
- Triggering Auto-triggering Auto-PEEP
5) Fio2 (Air-mixed / 100% O2)
Fio2 Air-O2 blender
100% O2 Birds Birds
6) TV IP (PIP 35 cmH2O PIP )
- () IP TV
- IP TV
Exhaled TV (normal / low / high) spirometer
7) RR Controlled E time
- Controlled E time RR
- Controlled E time RR
Controlled E time = off
8) I time PFR
- PFR I time
- PFR I time
9) PEEP valve () expiratory valve; PEEP (
5 cmH2O) PEEP End of expiration; PEEP
= 5 monitor PEEP = 5 ( monitor PEEP valve)
10) PEEP valve TV (e.g. PEEP PIP 15 cmH2O, PEEP =
5 TV PIP 20 cmH2O)
Tips: O2, ,
( Birds )
Birds ventilator: trigger TV IP
I time PFR (Pressure cycling) cycle controlled E time

Birds
1.
2. Manual inspiration bag
Birds

Ventilator alarms
- Alarms ventilator 5 High/Low airway P, Low TV, High/Low RR

TOPSI117

- alarm alarm off alarm

High airway P alarm

High airway pressure alarm

- High airway P alarm alarm PIP 35 cmH2O ( CMV mode, Birds ventilator) 30 cmH2O
( PCV, PSV mode)
- High airway P alarm: alarm off Disconnect bag suction lung 3
: crep., wheeze, decreased breath sounds
1. Disconnect
Disconnect ventilator setting (e.g. PEEP > 10 cmH2O)
2. bag Ambu bag ETT, bag ventilator
e.g. Metabolic acidosis: Kussmaul breathing ( )
COPD: TV , RR , I time , E time
MG: TV , I:E normal, RR normal
bag
1) bag chest move bag Esophageal intubation ETT
2) bag suction
off ETT ( ETT /)
ETT hold mask bag ( ventilate )
3) bag DDx
(1) UAO exclude suction
(2) Refractory bronchospasm wheeze
(3) Bilateral pneumothorax
(4) Severe lung parenchymal disease severe ARDS
4) bag chest move DDx
(1) Pneumothorax (Rt./Lt.) ICD
(2) Atelectasis (Rt./Lt.)
(3) One-lung intubation (Rt./Lt.) ( Rt.) deflate cuff ETT 2-3 cm
lower chest 2
One-lung intubation Pneumothorax Marker ETT Onelung; Pneumothorax
3. Suction ETT
bag , suction ventilator: TV / PFR / IP / PS
4. lung 3
1) Crepitation alveoli; 2 volume status
(1) Volume Cardiogenic pulmonary edema (HF), Volume overload
(2) Volume Pneumonia, Alveolar hemorrhage, Partial atelectasis, ALI / ARDS
progress

TOPSI117

: severe ARDS crepitation alveoli

2) Wheezing / Rhonchi flow lumen flow lumen

( murmur; wheezing Bronchodilator

(1) Flow , Lumen Hyperventilation, Metabolic acidosis

( wheezing, rhonchi)
(2) Flow , Lumen 2 volume status
1. Volume HF, Volume overload
New onset of wheezing R/O Cardiac asthma
Bronchodilator
2. Volume COPD, Asthma, Hyperactive airway, Anaphylaxis
3) Decreased breath sounds

Low airway pressure alarm

- Low airway P alarm 2
1. (Volume leakage) &
1)
(1) ET cuff leakage () (
system )
Rx: Blow cuff
( spring blow cuff leak, blow 2-3 cc;
blow leak ETT )
(2) Dislodgement of ETT ETT ETT & ETT (
ETT vocal cord)
(3) TE fistula
2)
(1) Ventilator circuit leakage , check ventilator circuit
/ ICD
(2) Bronchopleural fistula
2. air hunger, accessory m.; create
negative P positive P P alarm; exhaled
TV ( alarm exhaled TV )
:
1) Metabolic acidosis Kussmaul breathing, shock
2) Hyperventilation CNS lesion / pain / psychogenic
3) Lung pathology

TOPSI117

Rx: TV ( TV CMV mode; IP PCV mode; PS PSV

mode)
flow PCV/PSV mode
sedation muscle relaxant

Low tidal volume alarm

- Low TV alarm High airway P alarm Low
airway P alarm alarm

Low respiratory rate alarm

- Low RR alarm PSV mode; Apnea alarm
( control mode alarm RR ventilator )
- Low RR alarm Apnea alarm PS 5-7 cmH2O
PS TV respiratory alkalosis RC
- PS 5-7 cmH2O Low RR alarm control
mode, setting
-
1. CNS disorder e.g. CNS lesion RC, High-dose sedation
2. PNS disorder e.g. Peripheral nerve, NMJ, Myopathy
3. Others e.g. Anemia, Malnutrition, Electrolyte imbalance, Muscle fatigue

High respiratory rate alarm

- High RR alarm alarm
alarm (High airway P alarm / Low airway P alarm / Low TV alarm) alarm
alarm
1. ventilator: trigger auto-triggering ( )
2.
3.
4. pain, stress, delirium, psychosis

Hypotension
- Hypotension on ventilator Disconnect bag suction lung 3 :
crep., wheeze, decreased breath sounds relate ventilator ,
relate Disconnect BP
- Disconnect hypotension DDx:
1. Tension pneumothorax
2. Other cause of shock
- Disconnect BP DDx:
1. Relative hypovolemia ( PPV Intrathoracic P )
Rx: IV fluid ( optimize preload)

TOPSI117

2. Auto-PEEP ( E time
Intrathoracic P V.R. BP drop)
Rx: E time
- Hypotension on ventilator 3
1. Relative hypovolemia
2. Previous sedation
3. Tension pneumothorax

Hypoxemia
- Hypoxemia on ventilator Disconnect bag suction lung 3 :
crep., wheeze, decreased breath sounds Fio2 O2 sat.
- Fio2 O2 sat. most common: V/Q mismatch
(e.g. HF , volume overload , pneumonia , bronchospasm, etc.)
- Fio2 O2 sat. most common: Intrapulmonary shunt need PEEP > 5 cmH2O
- Hypoxemia on ventilator: Low Fio2, Central / Neuromuscular hypoventilation, V/Q
mismatch, Shunt, Diffusion defect, Low Scvo2

Fight of ventilator
- Fight of ventilator: Respiratory paradox = - e.g.
(Respiratory paradox syndrome fight of ventilator)

- alarm alarm
- hypoxemia / hypercapnia ()
ventilator ventilator
Sedation
Sedation ; 3 (set
sedate cardioversion CPR)
1. Diazepam 5-10 mg IV slowly push
2. Midazolam (Dormicum) 2-5 mg IV slowly push 1-10 mg IV drip
(1. & 2. BDZ , SE: Hypotension)
3. Fentanyl 25-50 g IV 25-100 g/hr IV drip
(3. Opioid )

Arterial blood gas (ABG) interpretation

- Fio2 room air = 0.21
1. O2 cannula 1-5 LPM Fio2 LPM 0.04 ( room air = 0.2)
e.g. O2 cannula 1, 2, 3, 4, 5 LPM Fio2 = 0.24, 0.28, 0.32, 0.36, 0.4
2. O2 mask 6-8 LPM Fio2 0.4, 0.5, 0.6
3. O2 mask with bag 6-10 LPM Fio2

TOPSI117

e.g. O2 mask with bag 6, 7, 8, 9, 10 LPM Fio2 = 0.6, 0.7, 0.8, 0.9, 0.99
Fio2 setting (e.g. OR, recovery room)
med ( MV, flow Fio2 )
- ABG arterial venous 3 components Oxygenation,
Ventilation, Acid-base disorder

Oxygenation
- 3
1. PaO2 room air severity Hypoxemia
PaO2 (mmHg)
Severity of hypoxemia
( room air )
60-80
Mild
40-60
Moderate
< 40
Severe
- PaO2 ( interstitial capillary membrane )
: PaO2 = 100 (Age/4) e.g. 60 PaO2 = 100 15 = 85 mmHg
- metabolism (e.g. CML) PaO2 = 55 mmHg moderate
hypoxemia O2 sat. 99% Pseudohypoxemia
2. A-a gradient (= PAO2 PaO2) room air
- A-a gradient ( interstitial capillary membrane )
: A-a gradient = 2.5 + (Age/4) e.g. 30 A-a gradient = 2.5 + 7.5 = 10
- A-a gradient PAO2 Alveolar gas equation
PAO2 = (Fio2 x 713) (PaCO2/R)
(713 760-47; 47 sea level)
R = Respiratory quotient (RQ); Fio2 < 0.6 R = 0.8; Fio2 0.6 R = 1
PAO2 PaO2 A-a gradient; : 20 mmHg
Wide A-a gradient alveoli / interstitium / vascular
3. PaO2/Fio2 ratio () any level of Fio2; = 500 ( PaO2 100, Fio2 0.2)
- PaO2/Fio2 ratio < 500
- PaO2/Fio2 ratio < 200 alveolar lesion; 3
1) ARDS ( criteria 4 )
2) Cardiogenic pulmonary edema severe HF volume status (PCWP > 18 mmHg)
3) Dead space ventilation (e.g. PE, Lower airway obstruction)
1) & 2) alveolar lesion severe shunt response 100% O2,
PEEP
room air PaO2, A-a gradient ( PaO2/Fio2 ) Fio2
room air PaO2/Fio2
- Hypoxemia A-a gradient, PaO2/Fio2 2

TOPSI117

1.

2.

Normal A-a gradient (Fio2 0.2), Near normal PaO2/Fio2 (Fio2 > 0.2);
1) Decreased Fio2 ( ward smoke inhalation injury)
Rx: Fio2
2) Hypoventilation
(1) Central () e.g. Opioid overdose, Stroke (esp. BS lesion) PaCO2
O2 PaO2
(2) Neuromuscular () e.g. MG, GBS
Rx: MV ( TV, RR)
Wide A-a gradient (Fio2 0.2), Low PaO2/Fio2 (Fio2 > 0.2)
1) V/Q mismatch (most common) , ventilation perfusion ;
response 100% O2
V/Q mismatch 2
(1) ventilation perfusion = Shunt response 100% O2
(2) perfusion ventilation = Dead space (e.g. PE) response 100% O2
treat specific disease
EKG PE (Pulmonary embolism): Sinus tachycardia, S1Q3 pattern
PE BP stable Anticoagulant
PE BP drop Antithrombolytic
2) Shunt ( gas) subset V/Q mismatch ,
response 100% O2;
(1) Intrapulmonary e.g. ARDS, Cardiogenic pulmonary edema; need PEEP
(2) Extrapulmonary e.g. Cyanotic heart disease, Pulmonary AVF; response PEEP (
alveoli)
3) Diffusion defect e.g. Interstitial lung disease
4) Low Mvo2, Scvo2

Ventilation
- PaCO2 ( 35-45 mmHg) Hyper- / Hypoventilation
PaCO2 < 35 mmHg Hyperventilation, Hypocarbia, Hypocapnia
PaCO2 > 45 mmHg Hypoventilation, Hypercarbia, Hypercapnia
- Alveolar ventilation = MV Dead space ventilation = (VT VD) x RR
PaCO

CO
RR VT VD

(PaCO2 4 CO2 production, TV, Dead space volume, RR)

CO2 production & VD
PaCO2 VT & RR = MV (VT x RR) (PaCO2 x MV)1 = (PaCO2 x MV)2
- VD (Dead space volume) PaCO2 Bronchospasm , Auto-PEEP
(e.g. COPD TV , RR Auto-PEEP)

TOPSI117

Acid-base disorder
- pH ( 7.4) PaCO2 ( 40), HCO3- ( 24)
HCO3- venous HCO3- ( HCO3- Electrolytes)
HCO3- ABG HCO3- by calculation HCO3-
- Respiratory acidosis/alkalosis: Predicted HCO3- 2 Predicted pH
Acid
Chronic
4 Base
3 Chronic
5
2

Base
Acute
2
8
Acid
Acute
1
8

PaCO2 HCO3- pH
Acute respiratory acidosis
10 1 0.08
Acute respiratory alkalosis
10 2 0.08
Chronic respiratory acidosis 10 4 0.03
Chronic respiratory alkalosis 10 5 0.02
e.g. PaCO2 = 50 HCO3- = 25 2, pH = 7.32; PaCO2 = 30 HCO3- = 19 2, pH = 7.42
- Acute Chronic Predicted pH pH
Acute Chronic Acute on top Chronic
e.g. Acute exacerbation of COPD: pH 7.22, PaCO2 80, HCO3- 32 Acute on top Chronic
respiratory acidosis
Alcoholic liver disease + SBP + ICH: pH 7.54, PaCO2 12, HCO3- 12 Acute on top Chronic
respiratory alkalosis (Alcoholic liver disease + SBP Chronic respiratory alkalosis
ascites lung volume V/Q mismatch, ICH Cheyne-Stokes respiration
Acute respiratory alkalosis )
- Predicted pH pH / reference /
reference
- respiratory acidosis/alkalosis / 7.40
- metabolic acidosis Predicted pH (7.Predicted PaCO2) metabolic
acidosis reference Predicted pH respiratory acidosis/alkalosis
component acute / chronic / acute on top chronic
( PaCO2 / reference Predicted PaCO2
metabolic acidosis reference )
- Metabolic acidosis: Predicted PaCO2 = (1.5 x HCO3-) + 8 2; Predicted pH = 7.Predicted PaCO2
( Predicted PaCO2 2 Predicted pH; e.g. HCO3- 8 Predicted
PaCO2 = 20 2; Predicted pH = 7.20)

TOPSI117

- Metabolic acidosis AG = Na+-Cl--HCO3- (normal = 12 4)

1. Wide AG (AG > 16) overproduction acid acid , neutralized
HCO3- ; 3
1) Lactic acidosis Type A, B
2) Ketoacidosis DKA, Alcoholic ketoacidosis, Starvation ketoacidosis
3) Non-lactate / Non-ketone 2
(1) Toxico.
- Alcohol Methanol, Ethanol, Ethylene glycol
Methanol fundus Disc hyperemia
Ethylene glycol urine Oxalate crystal
- Non-alcohol Salicylate, Toluene
(2) Non-toxico. Renal failure, Rhabdomyolysis
Wide AG 3 AG/HCO3-
(AG = AG-12; HCO3- = 24-HCO3-)
1) AG/HCO3- = 1 (0.8-1.2) Wide AG (AG HCO3- )
2) AG/HCO3- < 1 (< 0.8) Wide AG + Normal AG (e.g. DKA IV fluid + RI )
AG , acid urine (e.g.
RTA) feces (e.g. diarrhea)
3) AG/HCO3- > 1 (> 1.2) Wide AG + Metabolic alkalosis
HCO3- HCO3- ( Metabolic alkalosis
)
2. Normal AG (AG 16) e.g. Diarrhea (hyperchloremic metabolic acidosis), RTA type 1, 2, 4
- Metabolic alkalosis: Predicted PaCO2 = (0.7 x HCO3-) + 20 2; 2
1. Chloride-responsive (Urine Cl- < 10) Volume depletion (e.g. Vomiting, Long-term diuretic
use); response fluid; volume depletion RAAS aldosterone
( Na+, K+ & H+)
2. Chloride-resistant (Urine Cl- > 10) response fluid;
1) RAAS volume depletion e.g. 1 Hyperaldosteronism,
Renin-producing tumor, Renal a. stenosis, etc. BP
2) RAAS e.g. HCO3- solution, HypoK+, HypoMg2+, Recent diuretic use
BP
- Volume depletion ABG
1. Volume depletion Metabolic alkalosis
Diarrhea Metabolic acidosis (normal AG)
2. Volume depletion poor tissue perfusion Metabolic acidosis (wide AG)
- ABG normal acid-base: pH 7.4, PaCO2 40, HCO3- 24 3
1. Normal

TOPSI117

2. Metabolic acidosis + Metabolic alkalosis (wide AG)

3. Respiratory acidosis + Respiratory alkalosis
condition wide AG 2., RR 30/min
3.(e.g. Acute asthmatic attack PaCO2 hyperventilation
PaCO2 normal ; PaCO2 normal ABG normal acid-base
Respiratory acidosis + Respiratory alkalosis)

Respiratory failure
- Respiratory failure 2 types
1. Hypoxemic (Type 1) PaO2 < 60 mmHg O2 sat < 90%
2. Hypercapnic (Type 2) PaCO2 > 50 mmHg signs of CO2 retention
1) Alteration of consciousness () = CO2 narcosis
( CO2 cerebral vessel dilate IICP)
2)
3) HT ( CO2 vasodilate & heart C.O.)
- O2 sat. drop ETT? Ans: Respiratory failure
Respiratory failure ETT Pneumothorax ( ICD )

Anaphylaxis
- Anaphylaxis criteria Dx 3 ( 1/3 )
1. Acute onset (min-hr.) Skin, Mucosa or both involvement (generalized hives, pruritus & flushing,
swollen lip-tongue-uvula) 1/2
1) Respiratory compromise dyspnea, bronchospasm, stridor, reduced PEF, hypoxemia
2) Hypotension or End-organ dysfunction hypotonia, syncope, incontinence
2. Acute onset (min-hr.) expose Likely allergen 2
1) Skin-mucosa generalized hives, pruritus & flush, swollen lip-tongue-uvula
2) Respiratory compromise
3) Hypotension or End-organ dysfunction
4) Persistent GI symptom crampy abdominal pain, vomiting
3. Acute onset (min-hr.) expose Known allergen + Hypotension (SBP < 90 mmHg or
SBP 30%)
- Pathophysiology: IgE-mediated
( Anaphylactoid = Anaphylaxis immune)
- Common causes: Insect sting, Food, Drug (ATB, NSAIDs)
Other causes ( common): Physical trigger (e.g. Exercise-induced anaphylaxis), Biological fluid (e.g.
Transfusion, Ig)
- Management: Primary survey (ABC), O2, Adrenaline, AH1, AH2, Steroid
- order Anaphylaxis

TOPSI117

One day
- On O2 cannula 3 LPM, keep O2 sat. 95%
- Adrenaline (1:1,000) 0.5 ml IM stat
- Diphenhydramine 50 mg IV stat
- Ranitidine 50 mg IV q 12 hr.
- Methylprednisolone 50 mg IV q 6 hr.
- NSS 1,000 ml IV drip rate 200 ml/hr
- Record V/S q 15 min x IV, q 30 min x II,
then q 1 hr. until stable; keep BP > 90/60 mmHg,
RR < 30/min, P < 120/min

Continue
- NPO
- Observe urticaria
- Retained Foley catheter

TOPSI117

Geriatric Medicine
Geriatric assessment
- 4
1. Physical
- Hx, PE
- Geriatric syndrome 4I: Immobility, Instability, Incontinence, Intellectual impairment
2. Mental
1) Delirium disturbance of consciousness, cognitive function acute onset, fluctuation
(, cause)
2) Dementia memory, higher cortical function 1/4 : aphasia, apraxia, agnosia,
executive function impairment
3) Depression depressed mood + SIG E CAPS: Sleep problem, Interest deficit (anhedonia),
Guilt, Energy deficit (fatigue), Concentration deficit, Appetite disorder, Psychomotor
agitation/retardation, Suicidal ideation
- depressed mood interest deficit SIG E CAPS 5/9
social/occupational dysfunction Major depressive episode (MDE)
- 5/9 Minor depression
- MDE + mania/hypomania Major depressive disorder (MDD)
3. Functional
1) Basic ADL grooming, toileting, bathing, dressing, eating
2) Instrumental ADL house, cook, shop, communication, transport, financial, drug
4. Social
1) Care-giver education, time, attitude, relationship
2) Financial
3) House safety , , , , ,

TOPSI117

Nutrition
- Basal energy expenditure (BEE) (kcal/d)
Male: (10 x BW) + 900
Female: (7 x BW) + 700
- BEE x Stress factor x Activity factor kcal
- Estimate nutrition requirement
CHO: 60% of total calories (< 7 g/kg/d)
Lipid: 1 g/kg/d
Protein: 0.8-1 g/kg/d ( stress: infection, post-op.: 1.2-1.4 g/kg/d; major trauma, sepsis,
pancreatitis: 1.5-2.5 g/kg/d)

Enteral nutrition (EN)

- EN 1st choice C/I
- C/I of EN
1. Mechanical obstruction / Severe hypomotility
2. N/V
3. Severe malabsorption
4. Abdominal pain/diarrhea (postprandial)
5. High-output fistula proximal distal fistula
- EN
1. Short-term (< 6 wk.) NG tube
2. Long-term (> 6 wk.) Gastrostomy, Jejunostomy
- EN 2
1. Blenderized diet (BD) .. ( complete polymeric diet)
2. Commercial formula (Medical food) &
- Commercial formula 2
1. Completeness of diet ()
1) Complete diet
2) Disease-specific diet (Incomplete diet) CHO, lipid, protein -

3) Modular diet (Molecular ingredients) CHO, lipid, protein

2. Molecular size ()
1) Polymeric diet
2) Semi-elemental diet
3) Elemental diet

TOPSI117

- Commercial formula
Complete
Blendera, Ensure, Isocal,
Nutren optimum,
Polymeric
Nutren fiber, Panenteral
Semi-elemental Pregestimil, Nutramigen
Elemental

Disease-specific
Choice DM, Glucerna,
Gen DM, Neomune,
Aminoleban oral, Nepro
-

Peptamen

Modular
Glucose polymer,
Whey protein, Casein,
LCT oils
Disaccharides
Monosaccharides,
Amino acids, MCT oils

Parenteral nutrition (PN)

- inadequate intake (< 50% of daily requirement) for 7 d + EN
- PN 2
1. PPN (Peripheral parenteral nutrition): IV peripheral, 1,000 mOsm (12.5% dextrose)
phlebitis; e.g. Kabiven
2. TPN (Total peripheral nutrition)