Internal Medicine 1

ANEMIA

Kinetics of Different Insulin Preparations

Insulin Lispro Regular (R) NPH/lente (N)/(L) Ultralente (U)

Duration Very short Short Intermediate Long

Onset (h) 5-10 min 1/2 - 1 2-4 4-5

Peak ( h) 30-40 min 1-3 6-10 ---

Duration of action (h) 2-3 5-7 14-18 (lente up to 24 hr) 18-28

Differential Diagnosis of Hyperthyroidism Disorder TSH Graves disease Toxic Nodular Goitre Toxic Nodule Thyroiditis Subacute Investigations T4 and T3 Thyroid Antibodies 6 TSI 6 6 6 6 Up to 50% of cases RAIU 6 6 In classical subacute thyroiditis, ESR 6 Other

Approach to Anemia

Lab Values and Treatment of DKA and HONK Diabetic Ketoacidosis (DKA)
Serum 6 BG ( 11-55 mmol/L), Na (correct for 6 BG ) normal or 6 K, HCO3, 6 BUN, 6 Cr, ketonemia (~15 mmol/L), PO4 6 osmolality

Hyperglycemic Hyperosmolar Nonketotic State (HONK) 6 BG (44.4-133.2 mmol/L) in mild dehydration, may have hyponatremia (correct for 6 BG) if dehydration progresses, hypernatremia ketosis usually absent or mild if starvation occurs 6 osmolality metabolic acidosis absent unless underlying precipitant leads to acidosis (e.g. lactic acidosis in MI)

Approach to Microcytic Anemia (MCV < 80)

ABG

metabolic acidosis with 6 AG plus possible 2 respiratory alkalosis if severe vomiting/ dehydration there may be a metabolic alkalosis +ve for glucose and ketones resuscitation monitor degree of ketoacidosis with AG not BG or serum ketone level rehydration: 1L/h NS in first 2 hrs after 1st 2 L, 300-400 ml/h 0.45% NS once BG reaches 13.9 mmol/L then switch to D5W to maintain BG in the range of 13.9 16.6 mmol/L

Urine Treatment

-ve for ketones unless there is starvation ketosis glucosuria

Clinical Features of Liver Disease

Jason Sharpe 2003

Effects of Liver Failure encephalopathy (coma) xanthelasma scleral icterus jaundice fetor hepaticus spider angioma gynecomastia muscle wasting bleeding tendency (bruising) anemia loss of sexual hair ankle edema palmar erythema, Dupuytren's contracture, asterixis

Effects of Portal Hypertension esophageal varices gastric varix --> melena splenomegaly caput medusa ascites testicular atrophy hemorrhoids

Toronto Notes 2006 Editors: Carolyn Shiau and Andrew Toren

Classification of Leukemia

Initial Distribution of IV Fluids (1 Litre)

ECF Solution Intravascular Interstitial NS 333 667 1/2 NS 222 445 1/3 NS 185 370 Ringers 333 667 D5W* 111 222 2/3 1/3 135 271 Colloid 1,000 0 * assuming glucose metabolized ICF 0 333 445 0 667 593 0 2/3 ICF (28L)

TBW (42L) 1/3 ECF (14L)

2/3 1/3 interstitial (9.3 L) intravascular (4.7 L) (Starling's forces maintain balance)

same resuscitatory and emergency measures as DKA rehydration: IV fluids: 1 L/h NS initially evaluate corrected serum Na if serum Na high or normal, switch to 0.45% NS (4-14 ml/kg/h) if serum Na low, maintain NS (4-14 ml/kg/h) when serum BG reaches 13.9 mmol/l switch to D5W insulin therapy: use only regular insulin (R) insulin therapy: initially load 0.15 U/ kg body weight Insulin R bolus use only regular insulin (R) maintenance 0.1 U/kg/h insulin R infusion or IM initially load 0.15 U/ kg body weight insulin R bolus check serum glucose hourly maintenance 0.1 U/kg/h insulin R infusion in general lower insulin requirement compared to DKA check serum glucose hourly K+ replacement: + K replacement less severe K+ depletion compared to DKA as acidosis is corrected, hypokalemia may develop if serum K+ < 3.3 mmol/L, hold insulin and give when K+ 3.5- 5.5 mmol/L add KCL 30-40mEq/L IV fluid 40 mEq K+ HCO3: if K+ is 3.3-5.4, give KCl 20-30 mEq/L IV fluid if pH < 7.0 or if hypotension, arrhythmia, or coma is if serum K+ 5.5 mmol/L, check K+ every 2 h present with a pH of < 7.1 give HCO3 in 0.45% NS search for precipitating event do not give if pH > 7.1 (risk of metabolic alkalosis!) can give in case of life-threatening hyperkalemia mannitol (for cerebral edema)

Total Body Water Division in a 70 kg Adult

Toronto Notes 2006 Editors: Carolyn Shiau and Andrew Toren

Internal Medicine 2
Expected Compensation for Specific Acid-Base Disorders
Disturbance Respiratory Acidosis Acute Chronic Respiratory Alkalosis Acute Chronic Metabolic Acidosis Metabolic Alkalosis PaCO2 (mmHg) 610 610 10 10 1 65-7 HCO3- (mmHg) 61 63 2 5 1 610

An Approach to Acid-Base Disorders

Pulmonary Function Tests (PFTs) Reduced FEV1 < 80% predicted FEV1/FVC > 80% predicted Non Obstructive Defect Lung volumes low, especially FRC, RV FEV1/FVC < 80% predicted Airflow Obstruction Give bronchodilator Lung volumes normal FEV1/FVC normal

Dco decreased

Rise in FEV1 > 12% Dco ASTHMA Normal Low INTERSTITAL LUNG DISEASE

No change in FEV1 Flow volume loop, lung volumes, Dco

ANEMIA, PULMONARY VASCULAR DISEASE

High RV + normal TLC, FRC, and Dco

High FRC, TLC, and RV + low Dco

CHRONIC BRONCHITIS Decreased TLC and FRC + increased RV Decreased TLC and FRC + normal RV

EMPHYSEMA

Nephron Structure and Function

Toronto Notes 2006 Editors: Carolyn Shiau and Andrew Toren Toronto Notes 2006 Editors: Carolyn Shiau and Andrew Toren

NEUROMUSCULAR DISEASE

CHEST WALL DISEASE

Interpreting PFTs

FLOW RATE (L/sec)

LUNG VOLUME (L)

Subcompartments of Lung

Expiratory Flow Volume Curves

Reproduced with permission from S.E. Weinberger, Principles of Pulmonary Medicine, 2nd edition, 1992.

An Approach to Hypernatremia

Internal Medicine 3

FENA EQUATION
FENa+ = Urine [Na+] x Plasma [Cr] / {Plasma [Na+] x Urine [Cr]}

Distinguishing Pre-Renal from Intra-Renal Disease in Acute Renal Failure

Index Urine Osmolality Urine Sodium (mmol/L) < 20 FENa+ Plasma BUN/Cr (SI Units) > 80:1 Pre-Renal > 500 > 40 < 1% < 40:1 > 3% Intra-Renal (e.g. ATN) < 350

INDICATIONS FOR DIALYSIS IN ARF Hyperkalemia (refractory) Acidosis (refractory) Volume overload Elevated BUN (> 35 mM) Pericarditis Encephalopathy Edema (pulmonary) An Approach to Hyponatremia ANION GAP
Anion Gap = Na+ (HCO3+ Cl) osmolar gap = measured osmolality calculated osmolality calculated osmolality = 2 x [Na+] + [urea] + [glucose] (all units are in mmol/L) normal osmolar gap < 10 if gap > 10, consider: ethanol, methanol, ethylene glycol

WATER DEFICIT EQUATION

H2O deficit = TBW x (serum Na+ 140) 140
Toronto Notes 2006 Editors: Carolyn Shiau and Andrew Toren Toronto Notes 2006 Editors: Carolyn Shiau and Andrew Toren

TBW = 0.6 x wt (kg) for men, 0.5 x wt (kg) for women correct H2O deficit with hypotonic IV solution (D5W or 1/2 NS)

Treatment of Hyperkalemia
Medication Dose Onset/Duration 1-5 min/1 hour 10-15 min/1-2h 30 min/2+ h Mechanism Fights membrane effects of K+ Intracellular movement of K+ Intracellular movement of K+ Calcium 10 cc IV may repeat Gluconate 10% (x 2 prn q5-10mins) Sodium Bicarbonate Ventolin/ Albuterol 50 mg IV (may repeat x 1 prn) 10-20 mg (nebulized)

Glucose/insulin 10-20U Insulin R per 100g glucose Kayexalate

30 min/continuous Intracellular movement of K+ Na+/K+ exchange

25g in 25ml 70% sorbitol po Hours q6h +/ 50g in 50ml 70% sorbitol by retention enema Hemodialysis or Peritoneal Dialysis Minutes

Dialysis

Removal of K+ from blood

Classification Schema for Glomerular Diseases