Moonlighting

Moonlight Medicine

Adrian Paul J Rabe, MD, DPCP

8 Targets of Moonlight Medicine• Infectious Disease• Cardiovascular Medicine• Pulmonary Medicine• Endocrinology• Gastroenterology• Poisons and Snakebites• Pain Medication• Electrolyte Correction

Infectious Disease

Infectious Disease

• URTI• Pneumonia• UTI• Dengue• Typhoid• Leptospirosis

Infectious Disease

URTI

URTI: Presentation

• Symptoms– Cough, colds– 3 to 5 days duration

• Signs– Nasal discharge (clear or yellowish)– Clear breath sounds– No signs of sepsis– Hemodynamically unstable

URTI: Order Sheet

• No labs necessary• Medications– Amoxicillin 500 mg TID or 1 g TID– Clindamycin 300 mg QID for 5 days– Azithromycin 250 mg OD x 5 days or 500

mg OD x 3 days or 1 g OD x 1 dose– Avoid using broad-spectrum antibiotics– Avoid prolonged regimens

• Advice– Increased oral fluid intake (at least

2L/day)

URTI: Watch Out For…

• Persistence– Fever should lyse within 24-48 hours– Post-infectious cough occurs in 40% of patients

• Recurrence– Consider allergic rhinitis – refer to an

allergologist• Seasonal pattern• History of asthma or atopy• Relation to exposure to allergens/certain settings

(bedroom, work)

– If also with weight loss, obstructive ssx, refer to ORL

Infectious Disease

Pneumonia

Pneumonia (CAP): Presentation

• Symptoms– Cough with/without sputum production– Fever– Generalized weakness, anorexia

• Signs– Crackles– Decreased breath sounds• Increased fremiti – consolidation/mass• Decreased fremiti – pleural effusion

–Wheezing

CAP: Order Sheet

• Initial Diagnostics– Chest X-ray– CBC with platelet count

CAP: 2010 GuidelinesDoes the patient have:1.RR ≥ 30/min2.PR ≥ 125/min3.Temp ≥ 400C or ≤ 360C4.SBP < 90 or DBP ≤ 605.Altered mental status, acute6.Suspected aspiration7.Unstable co-morbids8.Chest X-ray: multilobar, pleural effusion, abscess

Low Risk CAP

Moderate Risk vs High

RIsk

No

Yes

Co-morbidities• DM• Active Malignancy• Neurologic disease in

evolution• CHF Class II-IV• Unstable CAD• Renal failure on dialysis• Uncompensated COPD• Decompensated Liver

Disease

CAP: 2010 Guidelines

Does the patient have:1.Severe Sepsis2.Septic Shock3.Need for mechanical Ventilation

Moderate Risk CAP

High Risk CAP

No

Yes

CAP: Antibiotics

• Amoxicillin• Extended macrolides– Azithromycin– Clarithromycin

• B-lactam/B-lactamase inhibitor combination (oral)– Co-amoxyclav– Amoxicillin-sulbactam– Sultamicillin

CAP: Antibiotics

• Oral second generation cephalosporin– Cefaclor– Cefuroxime axetil

• Oral third generation cephalosporin– Cefdinir– Cefixime– Cefpodoxime proxetil

CAP: Antibiotics

• IV non-antipseudomonal B-lactam– Co-amoxyclav– Ampicillin-sulbactam– Cefotiam– Cefoxitin– Cefuroxime– Cefotaxime– Ceftizoxime– Ceftriaxone– Ertapenem

CAP: Antibiotics

• Respiratory fluoroquinolones– Levofloxacin–Moxifloxacin

• Aminoglycosides– Gentamicin– Tobramycin– Netilmicin– Amikacin

CAP: Antibiotics

• IV antipseudomonal B-lactam– Cefoperazone-sulbactam– Piperacillin-tazobactam– Ticarcillin-clavulanic acid– Cefepime– Cefpirome– Imipinem-cilastin–Meropenem

CAP: Low Risk

• Subsequent Diagnostics– Sputum GS/CS optional

• Antibiotics– Previously healthy

• Amoxicillin• Extended macrolides

– Stable co-morbid condition (cover enteric G- bacilli)• B-lactam/B-lactamase inhibitor• 2nd generation oral cephalosporins +/- extended

macrolide• 3rd generation oral cephalosporin +/- extended

macrolide

CAP: Moderate Risk (Admit)

• Subsequent Diagnostics– Blood CS– Sputum GS/CS– Urine antigen for L. pneumophila– Direct fluorescent Ab test for L. pneumophila

• Antibiotics– IV non-antipseudomonal B-lactam +

extended macrolide– IV non-antipseudomonal B-lactam +

respiratory fluoroquinolones

CAP: High Risk (ICU)

• Subsequent Diagnostics– Blood CS– Sputum GS/CS– Urine antigen for L. pneumophila– Direct fluorescent Ab test for L.

pneumophila– ABG

CAP: High Risk (ICU)

• Antibiotics – no risk for Pseudomonas aeruginosa– Same as moderate risk

• Antibiotics – with risk for Pseudomonas aeruginosa– IV antipseudomonal B-lactam + IV

extended macrolide + aminoglycoside– IV antipseudomonal B-lactam + IV

Ciprofloxacin or Levoflocacin (High dose)

CAP: Watch Out For

• Pleural effusion, Lung abscess– Do thoracentesis– Refer to TCVS for CTT if warranted

• Hemodynamic instability/Progressing sepsis– Refer to Pulmo, IDS

• Hospital-acquired pneumonia– Proper precautions in intubated patients

• Exacerbation of co-morbid diseases

CAP: Resolution

• For low-risk– Follow-up after 3 to 5 days

• For moderate-/high-risk– Step down when clinically improving– Some infections (e.g. ESBL organisms) require a

full course via the IV route• Chest X-ray findings– May take up to 6 months to completely resolve

• Vaccination (including those with co-morbids)– Pneumococcal: one time, then q5years– Influenza: annually

Infectious Disease

Urinary Tract Infection

Urinary Tract Infection

• Symptoms of Urethritis– Acute dysuria, hematuria– Frequency– Pyuria– Recent sexual partner change

• Symptoms of Cystitis– Dysuria, Urgency– Suprapubic pain– Hematuria, foul-smelling urine, turbid

urine

UTI: Presentation

• Symptoms of Acute Pyelonephritis– Rapid development– Fever, shaking chills– Nausea, vomiting, abdominal pain– Diarrhea– Diabetes, immunosuppression

• Symptoms of catheter-related UTI–Minimal symptoms– Usually no fever

UTI: Presentation

• Signs of Urethritis– Grossly purulent discharge expressed in

genital tract

• Signs of Cystitis– Suprapubic tenderness– Fever

• Signs of Acute pyelonephritis– Costoverterbal angle tenderness at side of

involved kidney– Fever, signs of sepsis

UTI: Presentation

• Signs of catheter-related UTI– Turbid/foul-smelling urine– Purulent discharge– Suprapubic tenderness

UTI 2004 Guidelines

• Does the patient have complicating risk factors?– Anatomic abnormality– Functional abnormality– Recent UTI or Tract instrumentation (past 2

weeks)– Renal disease/transplant– Antibiotic use (Past 2 weeks)– Immunosuppresion– DM– Catheter, indwelling/intermittent– Hospital-acquired– Symptoms for > 7 days

AFRRAID CH7

UTI 2004 Guidelines

• Uncomplicated Cystitis– Medications (do 7 day regimen in males)

• Cotrimoxazole 800/160 PO BID x 3 days• Ciprofloxacin 250 mg PO BID x 3 days• Ofloxacin 200 mg PO BID x 3 days• Norfloxacin 400 mg PO BID x 3 days• Nitrofurantoin 100 mg QID x 7 days• Cefuroxime 125-250 mg PO BID x 3-7 days

– Increase OFI– No need for U/A or urine cultures except in

males– If unresolved after 7 days, consider as

COMPLICATED

UTI 2004 Guidelines

• Acute Uncomplicated Pyelonephritis– Urinalysis (expect increased WBC;

bacteriuria not the defining parameter; WBC cast is pathognomonic)

– Urine GS/CS– Outpatient treatment: • No signs and symptoms of sepsis• Non-pregnant• Likely to comply with treatment• Follow-up after 3-5 days

UTI 2004 Guidelines

• Acute Uncomplicated Pyelonephritis– Empiric regimen should be started after

culture is taken (Oral)• Ofloxacin 400 mg BID x 14 days• Ciprofloxacin 500 mg BID x 7-10 days• Levofloxacin 250 mg OD x 7-10 days• Cefixime 400 mg OD x 14 days• Cefuroxime 500 mg BID x 14 days• Co-amoxyclav 625 mg TID x 14 days (if GS is

G+)

UTI 2004 Guidelines

• Acute Uncomplicated Pyelonephritis– Empiric regimen should be started after

culture is taken (IV, given until patient is afebrile)• Ceftriaxone 1-2 g IV OD• Ciprofloxacin 200-400 mg IV q12• Levofloxacin 250-500 mg IV OD• Ampicillin-Sulbactam 1.5 g IV q6 (if GS is G+)• Piperacillin-Tazobactam 2.25-4.5 g IV q6-8

– Post-treatment cultures are unnecessary

UTI 2004 Guidelines

• Acute Uncomplicated Pyelonephritis: WOF– Fever after 72 hours of treatment, or

recurrence of symptoms• Imaging studies (KUB-UTZ , KUB-IVP if

Creatinine clearance acceptable)• Repeat urine culture• If without urologic abnormality, treatment

duration is 2 weeks based on culture• If same organism between initial and repeat

culture, treatment duration is 4-6 weeks

UTI 2004 Guidelines

• Asymptomatic bacteriuria– Defined as ≥ 100,000 cfu in 2 consecutive

midstream urine specimens or 1 catheterized specimen

– Should screen for, and treat in• Patients who will undergo GU manipulation or

instrumentation• Post-renal transplant patients up to first 6 months• DM with poor glycemic control, autonomic

neuropathy or azotemia• All pregnant women

– Same antibiotics as acute uncomplicated cystitis

UTI 2004 Guidelines

• Recurrent UTI– More 2x a year, with no urinary tract abnormalities– May give prophylaxis (if symptoms are

unacceptable)• Post-coital (immediately after intercourse)• Daily for 6 to 12 months• Nitrofurantoin 100 mg at bedtime• Cotrimoxazole 200/40 mg at bedtime• Ciprofloxacin 125 mg at bedtime• Norfloxacin 200 mg at bedtime• Cefalexin 125 mg at bedtime

– Same antibiotics as acute uncomplicated cystitis, or may also take 2 double strength Cotrimoxazole single dose as soon as symptoms first appear

UTI 2004 Guidelines

• Complicated UTI– Urine GS/CS– Outpatient• No signs of sepsis• Without marked debilitation• Inability to comply with treatment• Inability to maintain oral hydration/take oral

medications

UTI 2004 Guidelines

• Complicated UTI– Oral• Ciprofloxacin 250 – 500 mg BID x 14 days• Norfloxacin 400 mg BID x 14 days• Ofloxacin 200 mg BID x 14 days• Levofloxacin 250 – 500 mg OD x 10-14 days

UTI 2004 Guidelines

• Complicated UTI– Parenteral• Ampicillin-sulbactam 1.5 – 3 g IV q6• Ceftazidime 1-2 g IV q8• Ceftriaxone 1-2 g IV OD• Imipenem-cilastin 250-500 mg IV q6-8• Piperacillin-Tazobactam 2.25 g IV q6• Ciprofloxacin 200-400 mg IV q12• Ofloxacin 200-400 mg IV q12• Levofloxacin 500 mg IV OD

– At least 7 to 14 days of therapy

UTI 2004 Guidelines

• Complicated UTI– At least 7 to 14 days of therapy– Urine culture should be repeated 1 to 2

weeks after completion of medications• If persistent, refer to urology/nephrology

– If no response, may do• Plain KUB x-ray• KUB-UTZ• Helical CT scan

UTI 2004 Guidelines

• Catheter-associated UTI– If asymptomatic, no need to treat, except

if• With bacterial agents with high-incidence

bacteremia• With neutropenia• Pregnant• Will undergo urologic procedures/post-renal

transplant

– Indwelling catheter should be removed– Long-term indwelling catheters should be

replaced before treatment

UTI 2004 Guidelines

• Candiduria–May treat if• Symptomatic• Critically ill• Neutropenic• Will undergo urologic procedures/post-renal

transplant

– Control diabetes (if present)– Remove catheter, other urinary tract

instruments (if present)

UTI 2004 Guidelines

• Candiduria– Cystitis• Fluconazole 400 mg LD then 200 mg OD x 7-

14 days

– Pyelonephritis• Surgical drainage• Fluconazole 6 mg/kg/day or Amphotericin B IV

0.6 mg/kg/day for 2 to 6 weeks

Infectious Disease

Dengue Fever

Dengue Fever: Presentation

• Symptoms– Fever (Breakbone fever, saddleback fever)– Myalgia, retro-orbital pain (“trangkaso”)– Anorexia, nausea, vomiting– Cutaneous hypersensitivity– Epistaxis, petechiae, bleeding of pre-existing

GI lesions near the time of defervescence– Sudden-onset to acute symptoms

• Signs– Bleeding (petechiae on trunk, spreading face,

extremities)– Fever

Dengue Fever: Order Sheet

• Initial Diagnostics– CBC with PC• Leukopenia• Thrombocytopenia• Hemoconcentration

– Dengue IgM– Crea, Na, K, AST, ALT• Elevated AST more than ALT

Dengue Fever: Order Sheet

• Hydration– Oral fluid intake– Crystalloids: pNSS 1L x 60 or 80

– Colloids (for severe cases) or FFP• Defervescence– Paracetamol– Tepid/Cold sponge bath

• Platelet replacement– 1 unit of platelet concentrate per kg BW– Serial platelet counts (q12 to daily)

Dengue Fever: WOF

• Continued hemorrhage– Aggressive control of fever– Platelet replacement

• Shock– Lasts for only 1-2 days– Intensive care may be necessary

Dengue Fever: Resolution

• 1 week course• Discharge if– Increasing trend of platelet count– No bleeding– No hemodynamic instability

• Advice regarding mosquito control– Ablation of mosquito breeding grounds–Mosquito nets rather than mosquito

repellents

Infectious Disease

Typhoid Fever

Typhoid Fever: Presentation

• Symptoms– Fever in past 1 to 2 weeks– Abdominal pain (not always present)– Headache, chills, cough, myalgia/arthalgia,

diarrhea or constipation

• Signs– Relative bradycardia at the peak of fever– Hepatosplenomegaly, abdominal tenderness– Rose spots: faint, salmon-colored blanching

rash usually located on the trunk

Typhoid Fever: Order Sheet

• Diagnostics– CBC with PC (leukocytosis, sometimes

leukopenia, neutropenia)– Crea, Na, K, AST, ALT (slightly elevated

LFTs)– Blood CS (sensitivity 90% in first week)– Bone marrow CS (even up to 5 days of

theapy)– Duodenal string test/culture– Stool CS (positive in 3rd week if untreated)

• Admit if…– Vomiting, diarrhea, abdominal distension


• Empirical treatment– Ceftriaxone 1-2 g IV OD x 7-14 days– Cefixime 400 mg PO BID x 7-14 days– Azithromycin 1g PO OD x 5 days

• Multidrug resistant– Ciprofloxacin 500 mg PO BID x 5-7 days– Ciprofloxacin 400 mg IV q12 x 5-7 days– Ceftriaxone 2-3 g IV OD x 7-14 days– Azithromycin 1g PO OD x 5 days


• Critically ill (shock, obtundation)– Add Dexamethasone 3 mg IV then 1

mg/kg q6 x 8 doses– Admit to ICU– Refer to IDS– Repeat cultures if none were positive

Typhoid Fever: WOF

• Perforation/Obstruction– Due to invasion of Peyer’s patches– Refer to Surgery

• Continued fever– Lack of susceptibility– Consider another etiology– Refer to an Infectious Disease specialist

Typhoid Fever: Resolution

• Defervescence in 1 week• Return to normal values also in 1

week

Infectious Disease

Leptospirosis

Leptospirosis: Presentation

• Symptoms–Wading in floodwater/exposure to mud– Influenza-like illness: chills, headache, nausea,

vomiting, muscle pain (calves, back or abdomen)– Fever, conjunctival suffusion/hemorrhage– Hemoptysis– Decreased urine output, tea-colored urine– Overt jaundice– Diarrhea– Course progresses within 1 week, rarely 2 weeks

Leptospirosis: Presentation

• Signs– Fever– Conjunctival suffusion– Jaundice and icterus– Calf tenderness– Decreased sensorium

Leptospirosis: Order Sheet

• Initial Diagnostics– Lepto MAT/Dri-Dot– Urine culture (positive at 2nd to 4th week,

and for several months after)– Chest X-ray (check for pulmonary

hemorrhage)– BUN, Crea, Na, K, Cl, alb, Ca, Mg (check for

acute renal failure, electrolyte losses)– Urinalysis (concentrated urine vs renal

failure; picture of UTI may confuse you)– CBC with PC (anemia, leukocytosis)– Stool CS (for patients with diarrhea)


• Mild Leptospirosis– Doxycycline 100 mg PO BID– Ampicillin 500-750 mg PO QID– Amoxicillin 500 mg PO QID

• Moderate/Severe Leptospirosis– Penicillin G 1.5 M u IV QID– Ampicillin 1 g IV QID– Amoxicillin 1 g IV QID– Ceftriaxone 1 g IV OD– Erythromycin 500 mg IV QID


• Hydration– Based on urine output– Replace electrolytes lost

• Transfusion– Based on losses detected by CBC

• Control of hemoptysis– Hydrocortisone 50 mg IV q6– Tranexamic Acid 500 mg TID

Leptospirosis: WOF

• Weil’s syndrome– Heralded by hemoptysis, renal failure,

severe liver dysfunction, or sepsis– Refer to Infectious Disease specialist– Refer to Renal service for early dialysis– Transfer to ICU

Leptospirosis: WOF

• Jarisch-Herxheimer reaction– Occurs in response to antimicrobial therapy,

when massive spirochete kill releases lipoproteins

– Simulates worsening of disease• Fever, chills, myalgias, headache• Tachycardia, tachypnea• Increased WBC, neutrophils• Hypotension

– Supportive therapy– Subsides after 12-24 hours without revision of

meds

Leptospirosis: Resolution

• Jaundice to resolve in 2 to 4 weeks• May discharge if – Creatinine clearance is on upward trend– Urine output at least 0.5 cc/kg/hr– Electrolytes corrected– Platelet/hemoglobin corrected– No ongoing hemoptysis

• Prophylaxis– Doxycycline 200 mg PO once a week if

exposed

Cardiology

Cardiovascular Medicine

• Hypertension• Angina• Myocardial Infarction

Cardiology

Hypertension

Hypertension: Presentation

• Symptoms– Frequently asymptomatic– Aching nape/occipital area– Symptoms of target organ damage

• Signs: Try to detect both cause and effect…– Kidney disease: anemia, oliguria, sallow skin– Cushing’s syndrome: obesity, striae, moon

facies, etc– Hyper/hypothyroidism– Heart failure


• Signs: Taking Blood Pressure– Aneroid instrument vs mercury based

instruments– Seated quietly for 5 minutes (Quiet, private,

with comfortable room temperature)– Bladder cuff is at least half of arm

circumference– Deflation is 2 mmHg/s–Measure both arms, in supine, sitting and

standing positions (detects coarctation, orthostatic changes)

–Measure 1 leg at least once (take ABI)


• Signs– Palpate all possible pulses– Cardiac examination is important– Auscultate carotid and renal bruits

Hypertension: Classification

Classification

Systolic,

mmHg

Diastolic,

mmHg

Normal < 120 And < 80

Prehypertension

120-139

Or 80-89

Stage 1 140-159

Or 90-99

Stage 2 ≥ 160 Or ≥ 100

Hypertension: Order Sheet

• Diagnostics– Urinalysis (renal cause and complication)– BUN, Crea, Na, K, Ca, alb (low K is clue for

aldosteronism and pheochromocytoma)– FBS, Lipid profile (co-morbidities)– CBC (anemia)– ECG (LVH, other abnormalities)


• Lifestyle changes– BMI < 25 kg/m2– Exercise: Near-daily to daily aerobic

activity– Alcohol avoidance/moderation– DASH diet: fruits, vegetables, low fat

dairy, reduced saturated and total fat– Salt-restriction: NaCl < 6 g/d

BEADS


• Medications: Diuretics– Examples• Hydrochlorothiazide 12.5 – 25 mg OD-BID• Furosemide 40-80 mg BID-TID• Spironolactone 25-100 mg OD-BID

– Good for heart failure– Caution in DM, gout, renal failure– K reducer: furosemide, HCTZ– K retainer: spironolactone


• Medications: Beta blockers– Examples

• Atenolol 25-100 mg OD• Metoprolol 25-100 mg OD-BID• Propranolol 40-160 mg BID (not cardioselective)• Carvedilol 12.5-50 mg BID (combined alpha and

beta)

– Good for heart failure, angina, MI, tachycardia

– Caution in 2nd or 3rd degree AV block, asthma/COPD


• Medications: ACE inhibitors– Examples• Captopril 25-200 mg BID-TID• Enalapril 5-20 mg OD• Lisinopril 10-40 mg OD• Ramipril 2.5-20 mg OD-BID

– Good for heart failure, MI, DM– Caution in renal failure, hyperkalemia,

renal artery stenosis, pregnancy–May cause cough, angioedema


• Medications: Angiotensin receptor blockers– Examples• Losartan 25-100 mg OD-BID• Valsartan 80-320 mg OD• Candesartan 2-32 mg OD-BID

– Good for heart failure, MI, DM– Caution in renal failure, hyperkalemia,

renal artery stenosis, pregnancy– Used as second-line to ACE-inhibitors


• Medications: Dihydropyridine CCBs– Examples• Amlodipine 5-10 mg OD• Long-acting Nifedipine 30-60 mg OD

– Good for angina– Caution in heart failure, 2nd or 3rd degree

AV block– Causes peripheral edema


• Medications: Non-Dihydropyridine CCBs– Examples• Long-actingVerapamil 120-360 mg OD-BID• Long-acting Diltiazem 180-420 mg OD

– Good for angina, MI, DM, tachycardia– Caution in heart failure, 2nd or 3rd degree

AV block– Causes peripheral edema


• Medications: Direct Vasodilators– Examples• ISMN 30-60 mg OD• ISDN 5-10 mg BID-TID• Hydralazine 25-100 mg BID-TID

– Nitrates good for angina, MI– Nitrates cause hypotension, headache

(must have at least 8 hours a day drug free), and has reaction with sildenafil

– Hydralazine should not be used in severe coronary artery disease

Hypertension: Follow-up

• BP goal– General: < 140/90– Cardiac risk factors: < 130/80– Albuminuria: < 125/75

• Adjustment– Diuretics: daily to weekly (electrolyte

imbalances)– Beta-blockers: every 2 weeks– ACE-inhibitors and ARBs: every 1 – 2 weeks– CCBs: every 1 – 2 weeks– Vasodilators: Every 1 – 2 weeks

Hypertension: WOF

• Secondary Hypertension– CGN/Nephrotic syndrome/CKD: urinary

findings, edema– Pheochromocytoma: sweating,

palpitations, headache, early target organ damage

– Primary aldosteronism: resistant to medications, low K, weakness

– Connective Tissue Disease: pulse discrepancy, systemic symptoms

– Refer to Renal/Endo/Rheuma

Hypertension: WOF

• Hypertensive Urgency vs Emergency– Both require admission– Emergency: presence of target organ

damage• Reduce blood pressure by 25% over minutes

to 2 hours• Parenteral agents

– Urgency: No target organ damage• Reduce blood pressure over hours• Oral agents

Hypertension: WOF

• Hypertensive Urgency vs Emergency– Nitroprusside: 0.3 ug/kg/min, maximum at 10

ug/kg/min; discontinue if no response after 10 minutes

– Nitroglycerin drip: 5 ug/min, titrate at 5-10 ug/min at 3 to 5 minute intervals• 10 mg/10mL or 50 mg/50 mL, diluted to 10 mg in

100 mL

– Nicardipine drip: 5 mg/h, titrate by 2.5 mg/h at 5-15 minute intervals, maximum at 15 mg/h• 2 mg/2mL or 10 mg/10mL, diluted to 10-20 mg in

100 mL

Cardiology

Angina and the Acute Coronary Syndromes

Angina: Presentation

• Symptoms– Heaviness, pressure, squeezing, localized

retrosternally– Crescendo vs decrescendo– Radiates anywhere between the mandible

and umbilicus– Related to exertion

• Signs– High/low blood pressure, tachy/bradycardia– Heart failure

Angina: Order Sheet

• Complete bed rest• Oxygenation – Target O2 saturation > 90%– Nasal cannula vs face mask vs intubation

• Cardiac monitor• Vital signs• Ask about sildenafil use in past 24

hours– Viagra, cialis, ambigra, adonix, erefil, neo-

up

Angina: Order Sheet

• Give nitrates– Nitroglycerin 0.3-0.6 mg, or via buccal spray– ISDN 5 mg sublingual– 3 doses 5 minutes apart– If persistent, start Nitroglycerin drip

• 10 mg in 100 mL, start at 5 ug, and increased by 5-10 ug/min

• Titrated every 3 to 5 minutes until symptoms are relieved or systolic arterial pressure falls to < 100 mmHg

– Good for pulmonary congestion– Caution in: inferior wall/right-sided infarcts

(hypotension)

Angina: Order Sheet

• Initial Diagnostics– 12-lead ECG (within 10 minutes)– 2D-echocardiogram– Nuclear perfusion scan, cardiac MRI, cardiac

PET– BUN, Crea, Na, K, Ca, alb, Mg, AST– Cardiac enzymes: Trop I/T > CKMB > CKtotal– Urinalysis– Chest X-ray– PT/PTT

UAHR/NSTEMI/STEMI

• Loading Dose– Aspirin 80 mg/tab 4 tabs chewed and

swallowed– Clopidogrel 75 mg/tab 4 tabs chewed and

swallowed–Metoprolol 5 mg IV q5 up to 15 mg (3

doses), then followed in 1-2 hours by 25-50 mg PO q6

–Morphine 2-5 mg IV repeated q5-30 minutes– Captopril 25 mg/tab ½ to 1 tab q8– Heparinization

Angina: STEMI

• Decide whether to do PCI or not– Referral center should be no more than 30 mins

away– Door-to-balloon time should be at most 90 mins– Golden period: not more than 6h, may give 12h

after• Refer to CVS for thrombolysis– Take informed consent– Streptokinase 1.5 M u in pNSS to make 100 cc

to consume over 1 hour– Pre-medication with Diphenhydramine 1 amp IV– Can have hemorrhage, allergic reactions

Angina: STEMI

• Absolute contraindications to thrombolysis– Cerebrovascular hemorrhage at any time– Known structural cerebral vascular lesion (e.g. AVM)– Non-hemorrhagic stroke/event in the past year

• Ischemic stroke within 3 months, except if within 3 hours

– Hypertension (SBP > 180, DBP > 110)– Suspicion of aortic dissection

• Must do Chest/abdominal CT stat if suspected

– Active internal bleeding except menses– Any known malignant neoplasm– Significant closed head/facial trauma in past 3

months

Angina: STEMI

• Admit to ICU/CCU

UAHR/NSTEMI/STEMI

• Loading Dose– Aspirin 80 mg/tab 4 tabs chewed and

swallowed– Clopidogrel 75 mg/tab 4 tabs chewed and

swallowed–Metoprolol 5 mg IV q5 up to 15 mg (3

doses), then followed in 1-2 hours by 25-50 mg PO q6

–Morphine 2-5 mg IV repeated q5-30 minutes– Captopril 25 mg/tab ½ to 1 tab q8– Heparinization

UAHR/NSTEMI/STEMI

• Aspirin and Clopidogrel– Part of antithrombotic therapy–Maintenance • Aspirin 80 mg/tab 1 tab OD (with a meal)• Clopidogrel 75 mg/tab 1 tab OD

–WOF GI bleed, allergy to aspirin

UAHR/NSTEMI/STEMI

• Beta blockers– Part of anti-ischemic therapy–Maintenance • Metoprolol 50 mg BID

– Target: HR 50-60 bpm– Caution in hypotension, asthma, COPD.

Severe pulmonary edema

UAHR/NSTEMI/STEMI

• Calcium channel blockers– Part of anti-ischemic therapy– Used in patients with contraindication to

beta blockers–Maintenance

• Long-actingVerapamil 120-360 mg OD-BID• Long-acting Diltiazem 180-420 mg OD

– Target: HR 50-60 bpm, no chest pain– Avoid rapid-release CCB (e.g. nifedipine)– Caution in pulmonary edema, severe LV

dysfunction, hypotension, bradycardia, heart-block

UAHR/NSTEMI/STEMI

• Morphine– Part of anti-ischemic therapy–Maintenance • None – PRN use only

– Target: no chest pain– Caution in inferior wall/right ventricular

infarction, hypotension, respiratory depression, confusion, obtundation

UAHR/NSTEMI/STEMI

• ACE-inhibitors– Part of long-term cardiac therapy–Maintenance • Captopril 25 mg 1 tab q8• Enalapril 5-20 mg OD

– Gradual increase as patient stabilizes– Good for LV dysfunction, anterior wall MI– Caution in hypotension, renal failure,

hyperkalemia

UAHR/NSTEMI/STEMI

• Statins– Part of long-term cardiac therapy– Plaque stabilization–Maintenance (@HS doses)• Atorvastatin 10 mg, max 80 mg• Rosuvastatin 10 mg, max 40 mg• Simvastatin 20 mg, max 80 mg

– Gradual increase over a period of 2 months– Good for dyslipidemia, MI– Caution in liver disease, rhabdomyolysis

UAHR/NSTEMI/STEMI

• Heparin– Part of anti-thrombotic therapy– Types

• UFH 60 U LD, then 12U/kg/h target PTT 1.5-2.0x normal• Enoxaparin 30 mg IV LD then 1 mg/kg SC q12 (OD if

creatinine clearance < 30 mL/min)• Fondaparinux 2.5 mg SC OD

– If patient is unstable, has poor hemodynamic status, or has risk of bleeding, age > 75 y/o, UFH is preferred

– PTT measurements should be done q6– Duration is 2 to 5 days

UAHR/NSTEMI/STEMI

• Targets– Activity (SUPERVISED)• First 12 hours: Bed rest• 12-24 hours: Dangling legs/sitting in a chair• 2nd-3rd day: Ambulation in room, go to shower• 3rd day and beyond: 185 m (600 feet) at least

3x a day• Sexual activity: 2-4 weeks after event• Work: 1 month after event

UAHR/NSTEMI/STEMI

• Targets– Diet• First 4-12 hours: NPO• If stable: Complex carbohydrates (50-55%),

Fat < 30%, total cholesterol < 200 mg/d, fiber rich

– Bowel care • Stool softeners• Bedside commode rather than bedpan• Laxative

UAHR/NSTEMI/STEMI

• Targets– Sedation• Quiet, reassuring environment• Diazepam 5 mg TID-QID

– Tight glycemic control• Insulin drip preferred in acute setting• Pre-prandial: 90-130 mg/dL (critical care: <

110)• Post-prandial: < 180 mg/dL (critical care: <

180)• Long-term: HbA1c < 7%

UAHR/NSTEMI/STEMI

• Targets– Electrolyte• Mg 1.0 mmol/L• K 4.0-4.5 mmol/L• Ca 2.12-2.52

– Discontinue O2• May discontinue starting 6 hours after

admission, if O2 saturation > 90%

Angina: Watch Out For…

• Arrhythmia – Defibrillate with maximum dose available

up to 3x– Amiodarone 150 mg in 50 to 100 cc pNSS

over 10 minutes, then drip 360 mg in D5W x 6 hours

– Refer to CVS• Mechanical complications–Wall rupture– New-onset mitral regurgitation– Pericarditis– Refer to CVS/TCVS

Angina: Resolution

• Follow-up after 2 weeks – for treadmill exercise test (if appropriate)– Titration of medications– Strengthen previous advice

Chronic Stable Angina

• Symptoms– Same as acute angina– Symptoms > 2 weeks– No worsening, crescendo pattern over

hours/weeks– No increase in frequency

• Signs– Hemodynamically stable– Complete cardiovascular PE should be

done


• Diagnostics– 12-L ECG– Treadmill exercise test– 2D-echo– Crea, Na, K, Mg. Ca, alb– Lipid profile, FBS– Chest X-ray


• Medications– Anti-platelet– Beta blocker– ACE inhibitor– Statin


• Medications– Anti-platelet• Aspirin 80 mg OD• Clopidogrel 75 mg OD if ASA-intolerant

– Beta blocker• Atenolol 25-100 mg OD• Metoprolol 50-100 mg OD-BID• Carvedilol 6.25-50 mg BID


• Medications– ACE inhibitor• Captopril 25-200 mg BID-TID• Enalapril 5-20 mg OD• Lisinopril 10-40 mg OD• Ramipril 2.5-20 mg OD-BID

– Statin• Atorvastatin 10 mg, max 80 mg @HS• Rosuvastatin 10 mg, max 40 mg @HS• Simvastatin 20 mg, max 80 mg @HS


• If with high-risk features, or positive stress test, advice coronary angiography with intervention– Useless to do CA without intervention– PCI vs CABG depends on clinical picture– Refer to CVS in an institution with

PCI/CABG capability

Moonlight Medicine

Adrian Paul J Rabe, MD, DPCP

Pulmonology

Pulmonary Medicine

• Asthma• COPD

Pulmonology

Asthma

Asthma: Presentation

• Symptoms– Trigger

• Allergen• URTI/Pneumonia• Beta blockers. Aspirin• Exercise. Cold air, hyperventilation, laughter• Occupational asthma (Mondays)• Stress

– Dyspnea, shortness of breath, chest tightness• Night exacerbations

– Cough– Younger age group

Asthma: Presentation

• Signs– Tachypnea– Tachycardia, hypertension–Wheezing– Absence of wheezing = severe– Clubbing = uncontrolled

Asthma: Order Sheet

• Diagnostics– ABG (hypercarbia, hypoxemia, alkalosis)– Chest X-ray (rule out infection, other

differentials)– 12-L ECG (rule out cardiac causes of

dyspnea– CBC with PC (infection)

Asthma: Order Sheet

• Oxygenation– O2 support• Intubation if in impending/frank respiratory

failure

• Short acting inhaled beta-agonists– Salbutamol nebulization q5-15–WOF tremors, palpitations

• Inhaled anti-cholinergics– Ipatropium bromide nebulization q5-15–WOF Dry mouth, decreased sputum

production/dry cough

Asthma: Order Sheet

• Glucocorticoids– Hydrocortisone 50 mg IV q6 or 100 mg IV q8– Budesonide nebule q8– WOF Hoarseness, dysphonia, oral

candidiasis, systemic effects• Aminophylline drip– Mix as 1mg/mL– LD 6 mg/kg over 20-30 minutes– Maintenance at 1 mg/kg/hr (use lower dose

in elderly, or in nonsmokers)– Hook to cardiac monitor– WOF flushing, diarrhea, nausea, vomiting,

arrhythmias

Asthma: Order Sheet

• If with status asthmaticus, admit to ICU

• Refer to anesthesia if previous measures don’t work– Propofol, Halothane

• Treat infection–Most common is still viral URTI (supportive

therapy)– See CAP guidelines if with pneumonia

• Check if drug is the trigger

Asthma: Resolution

• Discharge– No wheezing and tolerates room air– No IV glucocorticoids– Infection is treated

Asthma: Resolution

• Discharge Medications– Home medications:– Oral steroid with tapering schedule

• Prednisone at 0.5 -1 mg/kg/d in 2/3-1/3 dosing

– Combination inhaled corticosteroid with long-acting inhaled beta-agonist• Budesonide + Formoterol 160/4.5 or 80/4.5 ug 1-2

puffs BID• Fluticasone + Salmeterol 500/50 or 250/50 or 100/50

1-2 puffs BID• Gargle after use

– Rescue doses of short acting inhaled beta-agonists• Salbutamol neb PRN

Asthma: Outpatient Care

Short Acting Beta agonistMild

intermittentMild

persistentModerate persistent

Severe persistent

Very Severe persistent

ICS low dose

ICS low dose

ICS high dose

ICS high dose

LABA LABA LABA

OCS

≤2/weekSymptoms

Night ≤2/month

3-6/week

3-4/month

Daily

≥5/month

Daily

Frequently

Unremitting

Nightly

Asthma: Outpatient Care

• Smoking cessation• Influenza vaccination annually• Pneumococcal vaccination once

then q5 years

Pulmonology

COPD

COPD: Presentation

• Symptoms– Cough, sputum production, exertional

dyspnea– Smoking– Decreased functional capacity– Chronic symptoms– Older age group

• Signs–Wheezing– Clubbing, cyanosis– Barrel-chest

COPD: Presentation

• Diagnostics– ABG (hypercarbia, hypoxemia)– Chest X-ray (infection, chronic changes –

hyperinflation, fibrosis, cause of COPD)– CBC with PC (infection)– 12-L ECG (consider cardiac etiology)

COPD: Order Sheet

• Oxygenation– O2 support

• Intubation if in impending/frank respiratory failure

• Short acting inhaled beta-agonists AND inhaled anti-cholinergics– Salbutamol nebulization q5-15– Ipatropium bromide nebulization q5-15

• Methylxanthine– Theophylline 10-15 mg/kg in 2 divided

doses– Comes in 100, 200, 300, 400, 450 mg

COPD: Order Sheet

• Glucocorticoids– Hydrocortisone 50 mg IV q6 or 100 mg IV

q8– Budesonide nebule q8– Shift to Prednisolone/Prednisone 30-40 mg

to complete 2 weeks

• Antibiotics– Bronchiectasis with increased sputum

production– 2 weeks of antibiotics directed against

pathogen

COPD: Resolution

• Complete smoking cessation• Pulmonary Rehabilitation (Refer to

Rehab)• Lung volume reduction surgery in

severe emphysema• Oxygen therapy – Resting O2 sat < 88%– O2 sat < 90% if with pulmo HTN, cor pulmonale

• Influenza vaccination annually• Pneumococcal vaccine once then q5

years

COPD: WOF

• Cor Pulmonale– Right heart enlargement on X-ray, ECG– Prominent neck veins and peripheral

edema– Careful diuresis• Furosemide 20-40 mg BID• Spironolactone 25-100 mg OD-BID

Endocrinology

Endocrinology

• Diabetes Mellitus• Thyroid Disease

Endocrinology

Diabetes Mellitus

DM: Presentation

• Symptoms–Weight loss, unexplained– Polyuria, polydipsia– Frothy urine– Decreased vision– Poorly healing wounds, frequent infections– Paresthesias, numbness– Stroke, MI previously– DKA: abdominal pain, nausea, vomiting,

young– HHS: poor appetite, increased sleeping time,

elderly

DM: Presentation

• Signs– Decreased sensation– Non-healing wound– Skin atrophy, Muscle atrophy– Diabetic dermopathy (necrobiosis lipiodica

diabeticorum)– Renal failure– Retinopathy– DKA: ketone breath, normal abdomen,

tachycardic, tachypneic– HHS: obtundation, dehydration

DM Emergency: Order Sheet

• Diagnostics– CBC with PC (infection, anemia)– RBS, BUN, Crea, Na, K, Cl, Ca, alb, Mg, P

(azotemia, low albumin, electrolyte imbalances, anion gap)

– Plasma ketones if available– ABG– Chest X-ray (and X-ray of involved extremity if

with non-healing wound)– Urinalysis with ketones– 12-L ECG– HBA1c (instead of FBS)– CBG


• Computations– Osmolality• 2(Na + K) + BUN + RBS (in mmol/L)• Normal is 276-290 mmol/L

– Anion gap• Na – (Cl + HCO3)• Normal is 10-12 mmol/L

DM Emergency: Order SheetParameters DKA HHS

Blood Chem

Glucose (mg/dL)

250-600 600-1200

Na 125-135 135-145

KNormal to Inc

Normal

Mg Normal Normal

Cl Normal Normal

P Dec Normal

Crea Slight Inc Moderately Inc

Osmolality 300-320 330-380

Ketones ++++ +/-

ABG

HCO3 < 15 mEq/LNormal to slightly dec

pH 6.8-7.3 > 7.3

pCO2 20-30 Normal

Both Anion gap IncNormal to slightly Inc


• ICU admission– If unstable– pH < 7.00– Decreased sensorium

• Refer to Endo

DM Emergency: Order Sheet• Replace fluids– 2-3 L pNSS over first 1-3 hours (10-15 mL/kg/h)– 0.45% NSS at 150-300 mL/h– D5 0.45%NSS at 100-200 mL/h if CBG ≤ 250

mg/dL–WOF congestion, hyperchloremia– HHS: if Na > 150, use 0.45% NSS at the onset

• Insulin– Start only if K > 3.3– 0.1-0.15 u/kg IV bolus– 0.1 u/kg/h IV infusion, target CBG 150-250 mg/dL

• 20 or 100 units regular insulin in pNSS to make 100 cc in soluset dripped via infusion pump (1cc = 1u if 100 u used)


• Assess precipitant– Noncompliance/missed insulin dose– Infection (UTI, pneumonia)–Myocardial infarction– Drugs

• CBG q1-2 hours• Electrolytes and ABG q4 for first

24 hours• NVS, I/O q1


• Correct potassium– K < 5.5: 10 mEq/h– K < 3.5: 40-80 mEq/h

• Correct acidosis only if pH < 7.0 after initial hydration– pH 6.9-7.0: 50 mEqs NaHCO3 + 10 mEqs

KCl in 200 mL sterile water x 1h– pH < 6.9: 100 mEqs NaHCO3 + 20 mEqs

KCl in 400 mL sterile water x 2h– Repeat ABG 2 hours after– Repeat dose q2 hours until pH > 7.0


• Correct magnesium– Target 0.8 to 1 mmol/L– Each gram of Mg will increase Mg by 0.1

mmol/L• 3g MgSO4 in D5W 250 cc x 12h = 0.3

additional Mg


• ICU admission– If unstable– pH < 7.00– Decreased sensorium

• May apply hydration and insulin drip for hyperglycemic states

• Refer to Endo

DM Emergency: Resolution

• Decrease insulin until 0.05-0.1 u/kg/h

• As soon as patient is awake and tolerates feeding, may start patient on diet

• Overlap insulin with subcutaneous insulin– Calculate insulin requirements from

insulin drip used in past 24 hours

DM Inpatient: Insulin Regimens

• NPH Insulin + Regular Insulin– Total Insulin requirement: 0.5-1 u/kg BW • 2/3 pre-breakfast: 2/3 NPH, 1/3 Regular

Insulin• 1/3 pre-supper: ½ NPH, ½ Regular

Insulin– pB = NPH pre-supper– pL = Regular insulin pre-breakfast– pS = NPH pre-breakfast– HS = Regular insulin pre-supper

DM Inpatient: Insulin Regimens

• Glargine Insulin + Lispro Insulin– Total insulin requirement: 0.5-1 u/kg BW• Glargine (Basal) insulin: ½ of total, given at

night• Lispro insulin: other half given in 3 divided

doses, 15 minutes before each meal

– pB = Basal insulin– pL = Lispro insulin pre-breakfast– pS = Lispro insulin pre-lunch– HS = Lispro insulin pre-supper

DM Inpatient: Order Sheet

• Inpatient goals– Pre-prandial 90-130 mg/dL– Post-prandial < 180 mg/dL

• For thin, insulin sensitive patients– Add 1 unit to errant insulin for every 50

mg/dL above target

• For obese, insulin resistant patients– Add 2 units to errant insulin for every 50

mg/dL above target

DM Inpatient: WOF

• Nephropathy– Refer to Renal if with decreasing urine output,

low creatinine clearance, for possible HD

• Ophthalmopathy/Retinopathy– Refer to Ophtha

• Diabetic foot ulcer– Refer to Ortho/TCVS

• Deterioration in sugar control– See previous orders– Refer to Endo

• Acute coronary event

DM Outpatient: Order Sheet

• Diagnostics:– FBS, 2-hour post-prandial glucose– Lipid profile– HBA1c


• Targets– HBA1c < 7%– Pre-prandial glucose (FBS) 90-130 mg/dL– Post-prandial glucose (2h PPBS) < 180 mg/dL– BP < 130/80 (< 125/75 for patients with

renal insufficiency)– Lipid modification (order of decreasing

priority)• LDL < 100 mg/dL• HDL > 40 mg/dL in males, > 50 in females• TG < 150 mg/dL


• Medications: Biguanides– Dose• Metformin 500 mg-1g OD, BID, TID• Adjust every 2-3 weeks

– Goal effect• Reduces HBA1c by 1-2%• Reduces fasting plasma glucose

– Good: weight loss– Caution: Renal insufficiency (Crea > 124

mmol/L), lactic acidosis, GI effects– Hold 24h prior to procedures, while

critically ill


• Medications: Sulfonylureas– Dose

• Glimepiride 1-8 mg OD• Glipizide 2.5-40 mg OD-BID• Take shortly before meals

– Goal effect• Reduces HBA1c by 1-2%• Reduces fasting and post-prandial plasma glucose

– Caution: weight gain, hypoglycemia, renal insufficiency (Crea > 124 mmol/L), liver disease


• Medications: Thiazolidinediones– Dose

• Pioglitazone 15-45 mg OD• Rosiglitazone 1-4 mg OD-BID

– Goal effect• Reduces HBA1c by 0.5-1.5%• Reduces fasting and post-prandial plasma

glucose• Reduces insulin requirements

– Caution: weight gain but redistributes to peripheral areas, hypoglycemia, renal insufficiency (Crea > 124 mmol/L), liver disease, edema, heart failure


• Medications: DPP-IV inhibitors– Dose• Sitagliptin 50-100 mg OD• Vildagliptin 50 mg OD-BID

– Goal effect• Reduces HBA1c by 0.5-1.0%• Reduces insulin requirements

– Good: does not cause weight gain, minimal hypoglycemia

– Caution: Renal insufficiency (use 50 mg OD if Crea > 124 mmol/L), headache, diarrhea, URTI


• Medications: Alpha-glucosidase inhibitors– Dose

• Acarbose 25 mg with evening meal• Maximize to 50 - 100 mg with every meal

– Goal effect• Reduces HBA1c by 0.5-0.8%• Reduces post-prandial plasma glucose

– Good: weight loss– Caution: GI effects (diarrhea, flatulence,

abdominal distention), Renal insufficiency (Crea > 177 mmol/L)


• Medications– If 2 drugs aren’t sufficient, insulin is

recommended– Cost and compliance are of prime

importance


• Diet– Fat 20-35%

• Minimal saturated fat (<7%)• Minimal transfat• Decreased cholesterl (<200 mg/d)• At least 2 servings of fish (Omega-3 fatty acids)

– Carbohydrates 45-65%• Low glycemic index• Sucrose containing food with adjustments in

meds/insulin

– Protein 10-35%– High fiber


• At least 150 minutes/week• Monitor blood sugar before,

during and after exercise– CBG > 250 mg/dL, delay exercise– CBG < 100 mg/dL, eat carbohydrate

before exercise– Pre-exercise insulin modification• Decrease dose• Inject into non-exercising muscle

DM Outpatient: Follow-up

• Home monitoring of glucose• HbA1c q3-6 months• Medical nutrition therapy and

education• Eye examination annually• Foot examination daily by patient,

annually by MD• Screening for albuminuria annually• Lipid profile and Crea annually• BP measurement q4 months

Endocrinology

Thyroid Disease

Thyroid Disease

• Hyperthyroidism• Hypothyroidism

Hyperthyroidism: Presentation

• Symptoms– Hyperactivity, irritability– Heat intolerance, sweating– Palpitations– Weakness, weight loss, diarrhea– Polyuria, oligomenorrhea

• Signs– Tachycardia, sometimes atrial fibrillation– Warm, moist skin– Tremors, muscle weakness– Anterior neck mass

Hyperthyroidism: Order Sheet

• Diagnostics– CBC with PC (infection)– 12-L ECG (atrial fibrillation, tachycardia)– Chest X-ray (rule out infection,

cardiomegaly)– Urinalysis (infection)– Free T4 and TSH (high FT4, low TSH)– Crea, Na, K (low K)– Thyroid UTZ (especially if with nodule/s)


• Burch-Wartofsky scoring– Components• Temperature• CNS• GI• CVS: heart rate• CVS: heart failure• CVS: atrial fibrillation• Precipitant history

– Score • 25-44: impending storm• ≥45: storm


• Therapeutics– Propylthiouracil 600 mg LD then 200-300

mg q6• Orally/NGT• By rectum

– Saturated solution of Potassium Iodide (SSKI) 5 drops q6-8, 1 hour after every PTU dose


• Therapeutics– Propranolol 40-60 mg PO q4• If still no rate control: Verapamil 2.5-5 mg SIVP

q15-30 minutes, maximum of 20 mg• Use digoxin rarely (decreased potency in

hyperthyroidism)

– Glucocorticoids• Dexamethasone 2 mg IV q6• Hydrocortisone 50 mg IV q6

– Treat infection, fever aggressively– Correct electrolytes


• ICU admission– If stable, may admit to Ward

• Refer to Endo

Hyperthyroidism: Resolution

• Discharge– Taper PTU to 200 mg TID– Heart rate controlled with Propranolol BID– Infection/precipitant treated

Hyperthyroidism: Out-patient• Medication adjustment– Preferably Methimazole 30 mg OD– Taper Propranolol until PRN

• Follow-up– 2-4 weeks with repeat FT4 (same laboratory)– Adjust methimazole based on FT4– TSH may be taken eventually to prove

suppression• Dietary avoidance– Seafood– Iodized salt

Hyperthyroidism: Out-patient• 30 to 50% achieve remission on

medical treatment alone– Usually after 12-18 months

• Definitive treatment: once euthyroid– RAI– Surgery– Refer to Endo and GS/ORL

Hyperthyroidism: WOF

• Ophthalmopathy– Steroids• Prednisone 1 mg/kg in 2 divided doses

– Artificial tears– Refer to Ophtha

Hypothyroidism: Presentation

• Symptoms– Weakness– Dry skin, hair loss, impaired healing– Difficulty concentrating– Weight gain, poor appetite– Heart failure

• Signs– Dry coarse skin, cool peripheral extremities– Puffy face, hands and feet; alopecia– Bradycardia– Serous cavity effusions (pericardial, pleural,

peritoneal)– Hyporeflexia

Hypothyroidism: Order Sheet• Diagnostics– Free T4, TSH (low FT4, High TSH)– CBC with PC– 12-L ECG (documentation of heart rate)– Chest X-ray (enlarged heart, pleural

effusion)– Crea, Na, K (hypokalemia)– Thyroid UTZ

Hypothyroidism: Order Sheet• Diagnostics– Free T4, TSH (low FT4, High TSH)– Anti-TPO– CBC with PC– 12-L ECG (documentation of heart rate)– Chest X-ray (enlarged heart, pleural

effusion)– Crea, Na, K (hypokalemia)– Thyroid UTZ

Hypothyroidism: Order Sheet• Therapeutics– Levothyroxine 1.6 ug/kg BW in single dose

before breakfast– If missed dose: may take 2-3 doses of

skipped tablets at once due to long half-life

Hypothyroidism: Follow-up

• Repeat TSH after 2-4 weeks– Use same laboratory– Target lower half of TSH range

Gastroenterology

Gastroenterology

• Peptic Ulcer Disease and GERD• Approach to Jaundice

Gastroenterology

Peptic Ulcer Disease

PUD: Presentation

• Symptoms– PUD: Epigastric pain, usually at night–Metallic/acid taste in the mouth–Melena– NSAID use–Weight loss, early satiety, vomiting

• Signs– Epigastric tenderness– Epigastric mass–Melena on DRE (uncommon)

PUD: Order Sheet

• Diagnostics– CBC with PC– EGD with H. pylori biopsy– Urea breath test– FOBT– Chest X-ray

PUD: Order Sheet

• Therapeutics (Active Bleeding)– PPI drip• Omeprazole 80 mg IV bolus • Omeprazole 80 mg in pNSS to make 100 cc x

10 cc/h (8 mg/h)

– Immediate endoscopy

PUD: Order Sheet

• Therapeutics– Proton pump inhibitors• Omeprazole 20 mg/d• Esomeprazole 20 mg/d• Lansoprazole 30 mg/d• Administer BEFORE a meal• Long-term: pneumonia, osteoporosis

– H2-receptor antagonists• Ranitidine 300 mg @HS• Famotidine 40 mg @HS

PUD: Order Sheet

• Therapeutics– Antacids• Usually for symptom relief• Aluminum hydroxide-Magnesium hydroxide• WOF nephrotoxicity

PUD: Order Sheet

• Therapeutics (H. pylori positive)– OCA/OCM regimen• Omeprazole 20 mg BID• Clarithromycin 250-500 mg BID• Amoxicillin 1g BID or• Metronidazole 500 mg BID

– Refer to GI if no response

PUD: Resolution

• Follow-up after 2-4 weeks– Decision to continue PPI dependent on

symptoms– Gastric ulcers have risk for malignancy

Gastroenterology

GERD

GERD: Presentation

• Symptoms– Burning retrosternal chest pain

worsening/precipitated by recumbency– Regurgitation of sour material into mouth– Cough– Dysphagia

• Signs– Obesity– Usually normal abdominal PE

GERD: Order Sheet

• Diagnostics– EGD– CBC with PC

GERD: Order Sheet

• Therapeutics– Proton-pump inhibitors

• Omeprazole 20 mg/d• Esomeprazole 40 mg/d• Take 30 minutes before breakfast

– Weight reduction– Elevation of head by 4-6 inches during

recumbency– Avoid

• Smoking• Fatty food, large quantities of food/fluid• Alcohol, mint, orange juice• Calcium channel blockers

Gastroenterology

Jaundice: How to work it up

Jaundice: Work-up

• History– Chronicity–Medications– Hospitalizations, blood transfusions– Sexual history– Drug intake

Jaundice: Work-up

• Diagnostics– TB, DB, IB– AST, ALT, Alkaline Phosphatase– PT– Albumin– Hepatitis profile– HBT-UTZ– Coomb’s test

Jaundice: Work-up

Initial Work-up

Isolated elevation of bilirubin

Bilirubin and other tests elevated

Jaundice: Work-upIsolated elevation

of bilirubin

Elevated DB(DB > 15%)

Elevated IB(DB < 15%)

DrugsHemolytic DisordersInherited disorders

Inherited disorders

Indirect Bilirubinemia

• Drugs– History is diagnostic– Rifampicin

• Hemolytic disorders– Precipitated by infection, or other illnesses– Enlarged spleen– Diagnosed by PBS, Coomb’s test– AST, LDH may be elevated

• Inherited Disorders– Criggler-Najjar syndrome, Gilbert’s syndrome– Present in childhood

Direct Bilirubinemia

• Inherited Disorders– Dubin-Johnson syndrome– Rotor syndrome– Present in young to middle-aged

Jaundice: Work-upBilirubin and other

tests elevated

ALT/AST predominant

(Hepatocellular pattern)

Alk Phos predominant(Cholestatic

pattern)

DrugsViral HepatitisAutoimmune

Hepatitis

Ultrasound

Hepatocellular Pattern

• Drugs– Alcohol– Paracetamol ingestion– Other hepatotoxic drugs

• Viral Hepatitis– Detectable by serology

• Autoimmune Hepatitis– ANA positive in some cases

• May do liver biopsy if no diagnosis at this point

Jaundice: Work-up

No Dilated Ducts on Ultrasound

Alk Phos predominant(Cholestatic

pattern)

Dilated Ducts on Ultrasound

Extrahepatic Intrahepatic

Extrahepatic Pattern

• Do CT scan or ERCP to assess cause of obstruction

• Carcinoma– Periampullary CA– Gallbladder CA– Cholangiocarcinoma

• Stone– Filling defect

• Parasitic disease

Intrahepatic Pattern

• Viral Hepatitis• Drugs– Alcoholic Hepatitis– Steroids

• Cholestasis of Pregnancy• TPN• Sepsis• TB• Lymphoma

Poisons

Poisons and Snakebites

• General Principles of Management• Alcohol Toxicity and Withdrawal• Silver Jewelry Cleaner Ingestion• Organophosphate Ingestion• Kerosene Ingestion• Acid and Alkali Ingestion

Poisons

General Principles

General Principles

1. Emergency Stabilization2. Clinical Evaluation3. Elimination of the poison4. Excretion of absorbed substance5. Administration of antidotes6. Supportive Therapy and

Observation7. Disposition

General Principles

1. Emergency Stabilization– Airway– Breathing: Oxygenation and Ventilation– Circulation: Inotropes– Convulsion cessation– Electrolyte/metabolic correction– Coma

General Principles

2. Clinical Evaluation– History: • Time, Mode/Route• Circumstances prior• Pre-existing illnesses or co-morbidities• Home remedies/treatment given

– PE• Complete• Breath odor• Neurologic PE

General Principles

2. Clinical Evaluation– Laboratory Examinations• CBC with PC• Urinalysis• RBS, BUN, Creatinine, Na, K, Ca, alb, Mg• ABG• 12-L ECG• Bilirubins, PT, AST, ALT, Alk Phos• Chest X-ray (best if PA-upright)• Plain abdominal X-ray

General Principles

3. Elimination of the poison– External decontamination

• Discard all clothing• Thorough bathing• Eye irrigation• Protective gear for personnel

– Empty stomach• Induction of emesis (if ingestion occurred within 1

hour)• Gastric Lavage (50-60 mL of tepid sterile water)

– Don’t do in ingestion of caustics, kerosene!– Don’t do if patient is convulsing!

General Principles

3. Elimination of the poison– Limit GI absorption

• Activated charcoal: 50-100 g in 200 mL H2O• Do multiple doses if with enterohepatic recirculation• Contraindicated in caustics• Follow with Na sulfate up to 2 doses, then soap sud

enema for BM

– Demulcent agents• Raw egg albumin: whites of 8-12 eggs

– Cathartics• Na sulfate 15 g in 100 mL H2O• Contraindicated in caustics, easily absorbable

chemicals, ileus, severe fluid and electrolyte imbalances

General Principles

4. Excretion of absorbed substances– Forced diuresis• Mannitol 20% 1 mL/kg within 10 minutes then

2.5-5 mL/kg q6 x 8 doses• Must have good urine output

– Alkalinization (for weak acids)• NaHCO3 1mEq/kg/dose IV targeting urine pH

> 7.5

– Acidification (for weak bases)• Ascorbic Acid 1g IV q6 until urine pH ≤ 5.5

– Dialysis

General Principles

5. Antidotes6. Supportive Therapy– Fluid replacement for losses– Electrolyte correction– Prevention of aspiration, decubitus ulcers– Monitorin VS and I/O

7. Disposition– ER vs Ward vs ICU– Psychiatric evaluation– Social evaluation

Poisons

Alcohol

Alcohol Intoxication

Blood Ethanol (mg/dL)

SymptomsBrain affected

< 50Talkativeness,

euphoriaFrontal Lobe

50-100

Decreased inhibition/increased

confidence, emotional instability, slow

reaction

Parietal Lobe

100-300

Ataxia, slurred speech , diplopia,

decreased attention span

Occipital Lobe

Cerebellum

300-500Visual impairment,

severe ataxia, stuporMidbrain

> 500Respiratory Failure,

comaMedulla

Alcohol IntoxicationCategory Specific % Ethanol

Beer

Lager 2-3%

Pilsen 5-6%

Strong 9-14%

Wine Red/White 7-12%

Fortified Wine Champagne 15-20%

DistillatesWhiskey, rye, rhum, bourbon, gin

40-50%

Local distilledLambanog, tuba

60-80%

Hygiene Products

Perfume/cologne

25-95%

Mouth wash 15-25%


Local Term Volume

Lapad 325 mL

Bilog 325 mL

Kwatro kantos

325 mL

Long neck 750 mL

Beer grande 1000 mL

Beer (regular) 320 mL


• Blood alcohol (mg/dL)–mL ingested x % alcohol x 0.8

6 x kg BW

• Metabolism– Non-alcoholic: 13 to 25 mg/dL per hour– Alcoholic: 30 mg/dL per hour

• Estimated time of recovery– Blood alcohol/metabolic rate


• History– Amount ingested–With what substance

• PE– Evidence of trauma– Level of sensorium

Alcohol Intoxication: Order Sheet

• Labs– Urine ketones– CK MB, MM– Amylase– FOBT


• Therapeutics– NPO– Insert NGT– IVF: D5 0.9 NaCl 1L x 8h

Conscious Unconscious


• Therapeutics– Thiamine 100 mg IM/IV– D50-50 100 mL fast drip IV– Refer to Psych– Evaluate for withdrawal– Observe for 6 hours– Discharge on • Thiamine 50 mg TID OR• Vitamin B complex 1 tab TID• Folic Acid OD, Multivitamins OD

Conscious


• Therapeutics– Thiamine 100 mg IM/IV now then q8– D50-50 100 mL fast drip IV– Refer to Neurology– Observe for return of consciousness

• Fully awake: Observe for 5-7 days, refer to Psychiatry• Partially awake: Work-up for decreased sensorium

(NSS?)• Comatose: Naloxone 2 mg IV q2 minutes for a total

of 10 mg; work-up for decreased sensorium, consider HD

– Same discharge plans

Unconscious

Alcohol Withdrawal: Presentation

• Symptoms/Signs– Autonomic hyperactivity (sweating,

tachycardia)– Increased tremors– Insomnia– Nausea/vomiting– Hallucinations/illusions– Psychomotor agitation/anxiety– Seizures

Alcohol Withdrawal: Order Sheet

• Therapeutics– Diazepam 2.5-5mg q8 x 3 days then taper

for next 2 days before discontinuation– Vitamin B complex TID– Folic Acid OD

Alcohol: Resolution

• Enrol in quitting program• Advice moderation

Poisons

Paracetamol

Paracetamol: Presentation

• Toxic dose if 150-300 mg/kg• Symptoms vary based on time

after exposure– 0-24 hours: asymptomatic, nausea,

vomiting– 24-36 hours: asymptomatic, upper

abdominal pain– 36-72 hours: onset of liver/renal failure– 72-120 hours: jaundice, bleeding,

liver/renal failure

Paracetamol

• History– Time, mode– Intake of other substances/meds– Co-morbidities

• PE– Heart, liver, kidneys– Neurologic examination

Paracetamol: Order Sheet

• Diagnostics– Serum paracetamol– AST, ALT, PT


< 150 mg/k

g

Volume ingested?

N-acetylcysteine

Test dose: 0.1 mL in 0.9 mL NSS IV

Diphenhydramine 1 mg/kg prior to phases

Phase 1: 150 mg/kg in 200 mL D5W x 1h

Phase 2: 50 mg/kg in 500 mL D5W x 4h

Phase 3: 100 mg/kg in 1L D5W x 16h

Observe for 24h

Known Unknown≥

150 mg/k

g

(+) SSx

(-) SSx

Observe for 72h

(+) SSx or AST, ALT or PT abn

(+) SSx or AST, ALT or PT abn


Normalization after 72 hours

Discharge

Paracetamol: WOF

• Acute Renal Failure– IVF hydration– Refer to Renal for possible Dialysis

• Bleeding– Vitamin K 10 mg IV up to q6– Target PT > 60% activity

• Hepatic insufficiency– Vitamin B complex– Vitamin K

• Electrolyte abnormalities– Hypoglycemia, acidosis, hypokalemia,

hypocalcemia

Poisons

Silver Jewelry Cleaner

Silver Jewelry Cleaner

• Active compound is cyanide-derived

• Binds to cytochrome oxidase enzymes, inhibiting cellular respiration

SJC: Order Sheet

• Diagnostics– ABG– Serum cyanide– CBC with PC

• Anticipatory Care– ICU admission– Close monitoring– Treatment for co-ingestants (e.g. alcohol)

SJC: Order Sheet

• Therapeutics– Oxygenation• High flow• Prophylactic intubation esp if with decreased

sensorium

– Na nitrite 300 mg SIVP (over 5 minutes)• Vasodilator, displaces cyanide, producing

methemoglobin• Causes hypotension

– Na thiosulfate 12.5 g (50 mL of a 25% solution) SIVP (over 10 minutes)• Speeds the displacement of cyanide by providing

sulfur for binding

SJC: WOF

• Decreased sensorium– Aspiration precautions– Prophylactic intubation if warranted

• Seizures– Diazepam– Increased oxygen delivery

• Hypoxic encephalopathy– Rapidly reversible if antidote given early– If still not reversed, need prognostication

by Neuro

Poisons

Kerosene

Kerosene

• History– Time– Amount–Mucous membrane irritation– CNS depression, seizures

• PE– Lung findings: crackles, respiratory

distress– Arrhythmia, tachycardia– Sensorial changes

Kerosene: Order Sheet

• Diagnostics– Chest X-ray (6 hours post-ingestion)– ABG

≤ 60 mL ≤ 60 mL + other toxic substance

> 60 mL or unknown

Volume ingested?


≤ 60 mL ≤ 60 mL + other toxic substance

> 60 mL or unknown

Volume ingested?

• Insert NGT• Lavage

with Activated Charcoal

• Insert NGT• Lavage

with water

• Na Sulfate• (BM)• Clean anal

area with petroleum jelly


Observe for 12-24

hours

Observe for 3 days

Sensorial Change

PneumoniaToxic

substances

• Refer to Psych• Discharge

Supportive Care

Kerosene: WOF

• Pneumonia– Penicillin G 200,000 u/kg/d in 6 divided doses– Clindamycin 300 mg PO/IV q6– Metronidazole 500 mg PO/IV q6

• Gastritis– Al-hydoxide-Mg-hydroxide 30 mL q6

• Prolonged PT– Vitamin K 10 mg OD

• Seizures– Diazepam 2.5-5 mg SIVP– Refer to Neuro

Poisons

Acids

Acids

• Causes coagulation necrosis which forms eschars– Damage is self-limiting

• Eventual stenosis of viscus

Acids: Order Sheet

• Diagnostics– Cross-matching– Urine hemoglobin– Chest X-ray upright, plain abdomen– Emergency EGD

Acids: Order Sheet

• Therapeutics– Copious amounts of water to decontaminate

externally– NPO– IVF: D5NSS 1L x 8h–Meperidine 25-50 mg IM– Famotidine 20 mg IV q12– Concentrated acids: Enhance excretion with

Mannitol• Test dose: 1 mL/kg within 10 mins• If with good urine output: 2.5-5.0 mL/kg q6 x 8

doses• Discontinue mannitol if with poor urine output x 2h

Acids: Order Sheet

Grade

Findings

0 Normal

1 Edema, hyperemia of mucosa

2A Friability, blisters, hemorrhages, erosions, whitish membranes, exudates, superficial ulcerations

2B 2A + deep discrete or circumferential ulceration

3A Small scattered areas of multiple ulcerations and areas of necrosis

3B Extensive necrosis

Grade 0-1 Grade 2a/b Grade 3a/b

Endoscopy

Admit to ICUNPOIV hydration,

TPNH2 blockers IVRepeat EGD 24-

48h

Admit to ICUNPOIV

hydration/TPN

H2 blockers IVHydrocortisone

100 mg IV q6 for shock

MeperidineAntibiotics

(anarobes, Gram negatives)

Repeat EGD 24-48h

AdmitObserve for 48

hLiquid diet for

48hH2 blockers

PO/IVDemulcent,

antacids or sucralfate

Psych ReferralDischargeFf-up with

GS/GI

Perforation, Necrosis?

Laparotomy

Yes

No

Acids: WOF

• Acute abdomen– Surgery– Lifelong vitamin B12 if gastrectomy done

• Shock– Fluids, antibiotics as appropriate

• Upper airway obstruction– Tracheostomy– Hydrocortisone 100 mg IV q6

• Upper GI Bleed– Blood transfusion, surgery

Poisons

Alkali

Alkali

• Causes liquefaction necrosis– Damage spreads, and may continue for

days

Alkali: Order Sheet

• Diagnostics– Cross-matching– Urine hemoglobin– Chest X-ray upright, plain abdomen– Emergency EGD

Alkali: Order Sheet

• Therapeutics– Copious amounts of water to

decontaminate externally– NPO– IVF: D5NSS 1L x 8h–Meperidine 25-50 mg IM– Famotidine 20 mg IV q12

Alkali: Order Sheet

Extent Findings

First degree

Superficial mucosal hyperemia, mucosal edema, superficial sloughing

Second degree

Deeper tissue damage, transmucosal (all layers of the esophagus), with exudages, erosions

Third degree

Through the esophagus and into the periesophageal tissues (mediastinum , pleura or peritoneum), deep ulcerations, black coagulum

First degree

Second degree

Third degree

Endoscopy

Admit to ICUNPOIV hydration,

TPNHydrocortisone

100 mg IV q6H2 blockers IVSucralfateRepeat EGD 24-

48h

Admit to ICUNPOIV

hydration/TPN

H2 blockers IVHydrocortisone

100 mg IV q6 for shock

MeperidineAntibiotics

(anarobes, Gram negatives)

Repeat EGD 24-48h

AdmitObserve for 48

hLiquid diet for

48hDemulcent,

antacids

Psych ReferralDischargeFf-up with

GS/GI

Perforation?Laparotomy

Yes

No

Alkali: WOF

• Acute abdomen– Surgery– Lifelong vitamin B12 if gastrectomy done

• Shock– Hypovolemic/Septic: Fluids, antibiotics as

appropriate– Neurogenic: Mepedirine 1 mg/kg/dose IV

• Upper airway obstruction (Glottic edema)– Tracheostomy– Hydrocortisone 100 mg IV q6

• Upper GI Bleed– Blood transfusion, surgery

National Poison Control and Management

Center

(02) 554-8400 loc 2311(02) 524-10780922-896-1541

Pain Pharmacope

ia

Pain Medication

• Most common complaint• Best treatment: address the cause

Pain Pharmacope

ia

NSAIDs

Pain Medication: NSAIDs

• ASA 80-160 mg PO OD• Paracetamol 500-650 mg PO up

to q4• Ibuprofen 400 mg PO up to q4• Naproxen 250-500 mg up to q12• Ketorolac 15-60 mg IM/IV up to q4• Celecoxib 100-200 mg PO up to

q12

Pain Medication: NSAIDs

• Advantages– Deals well with inflammatory pain (muscle

and joint pain, malaise from infection, etc)– Absorbed well from the GI tract

• Disadvantages– GI irritation (except paracetamol)– Peptic ulcer– Nephropathy– Increases blood pressure

• Selectivity for COX-2– Decreases GI symptoms– Increases cardiovascular risk

Pain Pharmacope

ia

Narcotics

Pain Medication: Narcotics

• Morphine 60 mg PO up to q4• Tramadol 50-100 mg PO up to q4

Pain Medication: Narcotics

• Advantages– Broadest efficacy– Very rapid especially if IV

• Disadvantages– Nausea and vomiting– Constipation– Sedation– Respiratory depression

Pain Pharmacope

ia

Anti-depressants

Pain Medication: Anti-depressants

• Duloxetine 30-60 mg/d• Desipramine 50-300 mg/d• Imipramine 75-400 mg/d• Amitriptyline 25-300 mg/d• Doxepin 75-400 mg/d


• Advantages– Very useful for chronic pain• Post-herpetic neuralgia• Diabetic neuropathy• Tension headache• Migraine• Rheumatoid arthritis• Cancer

–More rapid onset of relief


• Disadvantages– Significant number of side effects• Orthostatic hypotension• Heart block/conduction delay• Constipation• Urinary retention

Pain Pharmacope

ia

Anti-convulsants

Pain medication: Anti-convulsants

• Phenytoin 300 mg @ HS• Carbamazepine 200-300 mg up to

q6• Clonazepam 1mg up to q6• Gabapentin 600-1200 mg up to q8• Pregabalin 150-600 mg up to BID

Pain medication: Anti-convulsants

• Advantages– Effective for neuropathic pain (e.g.

trigeminal neuralgia, DM nephropathy)

• Disadvantages– Hepatic toxicity– Dizziness– GI symptoms– Heart conduction disturbances

Electrolytes

Documents

Moonlighting