Indications for weaning 1. Stable oxygenation (PaO2/FiO2 >200); (PEEP ≤5cm H20) 2. Intact cough and airway reflexes 3. No vasopressor agents being administered FAILURE: 1. RR ≥35 BPM for 5 minutes 2. O2 sat <90% 3. HR >140 BPM; 20% increase/decrease from baseline 4. Systolic BP <90/ >180 mm Hg 5. Increase anxiety diaphoresis SUCCESSFUL 1. Breathing ratio of RR to TV in L <105 Criteria for Admission for CAP 1. RR > 28 BPM 2. BP <90 mm Hg or 30 mm HG below baseline 3. New onset confusion or altered consciousness 4. Hypoxemia: PO2 <60 while breathing Room Air or o2 sat <90% 5. Unstable comorbid condtitons 6. Multilobular 7. Pleural effusion Glascow Coma Scale Eyes 1. No response 2. To pain 3. To command 4. Spontaneously Verbal Response 1. No response 2. Incomprehensible words 3. Inappropriate words 4. Disoriented and converses 5. Oriented Motor Response 1. No response 2. Decerebrate 3. Decorticate 4. Withdraws to pain 5. Localizes pain 6. Obeys to verbal command
KILIPS CLASSIFICATION OF AMI with EXPECTED HOSPITAL MORTALITY RATE Clas Clinical Presentation Expect s ed I No signs of pulmonary or 0-5% venous congestion II Moderate heart failure or 10-20% (+) of bibasal rales, S3 gallop, tachypnea or sings of R heart failure inc. venous and hepatic congestion III Severe heart failure, rales 35-45% >50% of the lung fields or pulmonary edema IV Shock with systolic pressure 85-95% of <90mm Hg and evidence of peripheral vasoconstriction, peripheral cyanosis, mental confusion and oliguria
Leads II, III, AVF I, AVF V1, V2 V3,V4 V5, V6 V1-V3 V3-V6, I, AVL Mirror image of V1 and V2 All V3R, V4R
Corresponding Areas Inferior wall High Lateral Septal Anterior Lateral Anteroseptal Anterolateral Posterior Diffuse/ global RV wall
Pericardial effusion Small: 10mL Moderate: 10-20mL Large: >20mL
Characteris tics Spc gravity PF/S CHON
Transuda te <1.016 <3g or 0.5
Fibrinogen RBC WBC
Negative <10,000 <1,000
Exudativ e >1.016 >3g or >0.5 Positive >10,000 >1,000
S. LDH PF/S LDH pH Glucose
<0.6 <200 IU >7.3 Plasma dec
Amylase Diff CT
>50% lymph
>0.6 >200 IU <7.3
>500 u/mL >50% PMS
AORTIC ANEURYMS De Bakey Type 1 Ascending Aorta and beyond Type 2 Ascending Aorta only Type 3 Aorta distal to the subclavian A.
Type A Type B
I II III IV V VI
Stanford Ascending Descending
MURMUR GRADING So faint Quiet but can be heard by stethoscope Loud Moderately loud with thrill Very loud, audible with stet partly off the chest Very loud, audible with stet removed from the chest
DIAZ STROKE SCALE Character Grade Vomiting 4 Level of consciousness 4 Unarousable 2 Drowsy 0 Awake Fever 3 Respiratory pattern Ataxic/apneustic 3 Hyperventilation 2 Cheynes-strokes 1 Regular/Normal 0 Upper GI bleed 3 Neuro deficit (max at 2 onset) Headache 2 Nuchal rigidity 2 DBP <90 -2 91-99 0 >100 2 SBP
<150 151-169 170-180 181-199 Scoring ≥7 = 90% probable bleed <7 = probable infarct
-2 -1 1 2
Thoracentesis Bottle 1 cell, ct different, total CHON, ldh Bottle 2 AFB, G/S, C/S Bottle 3 cytology and cell block
Indications for Mechanical Ventilation 1. RR >35 BPM 2. Inspiratory force <25 cmH20 3. Vital Capacity < 10-15 cc/kg 4. PaO2 <60 mm Hg with FiO2 >60% 5. PaCO2 >50mm Hg with pH <7.35 6. Absent gag reflex VR Set up TV-500 BUR -16 FiO2 100 PF -50 AC mode
LIGHT’S CRITERIA (exudative if any one of the ff) 1. Pleural CHON/ Serum CHON >0.5 2. Pleural LDH/Serum LDH >0.6 3. Pleural LDH >2/3 upper limit
Motor Neuron Lesions Character UMN LMN Tone Hypertonic Hypotoni clonus c Fasciculati Neg Pos ons Wasting Neg Pos Reflexes Exagerated Neg
Sta ge I
II III
Hepatic encephalopathy Mental Status Asterix ia Euphoria or depression, Either mild confusion, blurred speech, disorientation, asleep Lethargy, moderate Pos confusion Marked confusion, Pos incoherent speech, sleeping, arousable
EEG N
AbN AbN
IV
Coma, initially responsive to noxious stimuli; later unresponsive
Neg
Indications for Thrombolytic Therapy 1. Chest pain consistent with AMI 2. ECG changes a. ST segment elevation >/= 1 mm in atleast 2 contiguous leads b. ST segment elevation >/= 2mm in atleast 2 contiguous chest leads or c. New LBBB 3. Time from chest pain to thrombolytic treatment a. <6h most beneficial b. 6-12h lesser but still important benefits c. 12-24h diminishing benefits but may still be useful in selected patients Absolute Contraindication for Thrombolysis 1. Active internal bleeding (except menses) 2. Recent (within 2 weeks) invasive or surgical procedure 3. Suspected aortic dissection 4. Previous hx of hemorrhagic CVA or SAH 5. Recent head trauma or known intracranial neoplasm 6. Persistent BP >200/120 Relative contraindication for thrombolysis 1. Known bleeding diathesis 2. Prev streptokinase treatment for the past 6-9 months 3. BP >/=180/100 on at least 2 readings 4. Active PUD 5. Hx of thrombotic CVA 6. Prolonged CPR >/= 10m or traumatic CPR 7. Diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic conditions 8. Pregnancy 5 Dressler’s Sign of Post-MI Pericarditis 1. Pericarditis 2. Pneumonitis 3. Pleuritis 4. Pyrexia 5. Pain SEPSIS (>2 or more) Fever >38 or <36 2. Tachypnea >24/min 3. Tachycardia >90/min 1.
AbN
4. 5. 6.
Inc WBC >12, 000 Dec WBC <4,000 CBC >10% Bands
Urine Osmolality Spc Gravity U/P creatinine ratio Urine Na BUN/ Creatinine FE Na (%) Renal failure index Sediment
Causes
Prerena l >500
Renal
>1.018
<1.015
>40
<20
<20 >20
>40 <15
>40 >15
<1 <1
>1 >1
>4
Acellular, transpar ent hyaline cast Hypovole mia; dec CO, inc resistanc e
Muddy brown granular cast
Hyaline casts
GN vasculat is, ATN, nephriti s
Calculi, CA, fibrosis
<350
Post renal <350
Glucose,a mmol/L (mg/dL) Sodium, meq/L Potassium
DKA 13.9–33.3 (250– 600)
HSS 33.3–66.6 (600– 1200)
125–135
135–145
Normal to Inc
Normal
a
Magnesiu m Chloride Phosphate Creatinine Osmolality (mOsm/L) Plasma ketones Sodium bicarb meq/L Arterial pH Arterial Pco2 mm Hg Anion gap [Na-cl + HCO]
Normal
Normal
Normal Slightly inc. 300-320
Normal Normal Moderately inc. 330-380
++++
+/-
<15 meq/L
Normal to slightly dec
6.8-7.3
>7.3
20-30
Normal
Inc
Normal to slightly inc
NYA Classification of CHF Dyspnea occurs with greater than ordinary physical activity (climbs ≥2 flights of stairs with ease II Dyspnea occurs with ordinary physical activity (climbs > 2 flights of stairs but with difficulty) III Dyspnea occurs with less than ordinary physical activity (climbs ≤2 flights of stairs) IV Dyspnea may be present even at rest
Stage
Description
GF R >9 0
Action
I (asym p)
Injury not acute with preserved GFR
II (asym p) III
Mild kidney disease
6089
Moderate
3059
IV (symp ) V (symp )
Severe
1529
Treat complications; ESRD, education Prepare for ESRD treatment
Kidney failure
<1 5
Initiate ESRD treatment
Diagnose and treat progression, comorbid conditions; dec CV risk Estimate rate of progression
I
Therapeutic Classification of CHF A No restrictions B Severe effort restricted C Ordinary effort moderately restricted D Ordinary effort markedly restricted E Confined to bed/chair
Classification of CKD
Neurologic Localizations Cerebell Limb/truncal ataxia um Intent tremors Dysmetria and dysdiadokinesia Brainste Prominent cranial nerve m deficit (CN III-XII) Ipsilateral CN deficits with contralateral limb motor/sensory deficits Ipsilateral CN deficits and cerebellar signs Cerebru Distured higher, intellectual m functions Emotional and behavioral disturbances Speech disturbances and seizure Basal Involuntary movement ganglia Rigidity Bradykinesia Spinal Motor disturbances Cord (UMN/LMN) Sensory disturbances
Peripher al nerves Myoneur al Junction Muscles
Autonomic disturbances Motor disturbances (LMN, distal and symmetrical) Sensory disturbances Autonomic disturbances Fatigability of muscles Proximal weakness of muscles (-) sensory or autonomic disturbances Motor disturbances (proximal and symmetrical) (-) sensory or autonomic disturbances
PDA`
Type I Type II
Type III Type IV
Dopamine Drips 2-5 Vasodilator effect in the µg/kg/min renal vasculature 5-16 Modest increase in µg/kg/min myocardial contractility and rate >15 Vasoconstrictive agent µg/kg/min
Color CHON Pressu re Glucos e Cells
Normal Colorles s 1545mg/dl 30180mm H20 4570mg/d L <6 lymph
CSF Analysis Bac Viral Turbid; Clear Greeni Cloudy sh Inc Mild Inc
TB Xantochromm ic Mild Inc
Inc 200500 Dec
Normal Mild Inc
Normal Mild Inc
Normal
Dec
Inc PMNs 100010000 WBC
Lymph
Lymph AFB stain
COMMON MURMURS Aortic Crescendo-descrendo Stenosis systolic murmur Aortic High pitched blowing Regurgitatio murmur n Mitral Rumbling late diastolic Stenosis murmur following a snap VSD/Mitral Holosystolic blowing Tricuspid murmur Incompeten ce MVP Systolic murmur with
mid systolic click seen in young women Continuous machinery like murmur
Acute Respiratory Failure Hypoxemia (e.g. Pulmonary edema, pneumonia, etc) Hypercarbia (e.g. Pneumothorax, Pleural effusion, Atelectasis) with or with out hypoxemia Post-surgery patients Shock
Approach to patient in COMA 1. Level of Consciousness a. Cortical – Content b. ARAS and Brainstem – Arousal/wakefulne ss c. Medullary – N waking and sleeping 2. Respiratory Pattern a. Chyne stroke – diencephalon, diffuse cervical b. Hyperventilation – brainstem c. Apneustic – PONS d. Ataxic cluster – medulla 3. Pupillary Size and Reaction a. Small reactive – metabolic/ diencephalic b. Midpoint, fixed – Midbrain c. Pinpoint – pons d. Larged fixed – tectal 4. Diencephalic Reflexes – brainstem 5. Motor Responses a. Decerebrate – Brainstem b. Decorticate – above internal capsule
Ca t 1
WHO guidelines for PTB 3 Initial
New smear positive 2 HRZE TB with extensive parenchymal involvement; new case of severe form of extrapulmo TB II Sputum smear 2 positive relapse; txt HRZES failure; txt +1 interruption HRZE III New smear neg PTB; 2 HRZ new less severe form of extrapulmonary TB H-Isoniazid; R-Rifmapicin; ZPyrazinamide; E-ethambutol; SStreptomycin
First line Drugs in TB Dosage Metab
Cont 4HRE
5 HRE
4HRE
Dru g H
Action Cidal; Both
5mg/kg/d ay
Liver
R
Cidal; Both
10-20 mg/kg/da y
Liver
Z
Cidal; intracel l- lular ONLY Static; Both
20-30 mg/kg/da y
Liver
15-20 mg/kg/da y 10-18 mg/kg/da y
Kidne ys
Optic neuritis
Kidne ys
8th nerve palsy
E S
Static; Extrace ll
Cla ss
PTB Classification (ATS) Exposur Infecti CXR e on infiltrates
0 1 2 3 4 5
(-) (+) (+) (+) (+) (+)
(-) (-) (+) (+) (+) (+)
(-) (-) (-) (+) (+) (+)
S.E. Hepatitis; safest in pregnancy Hepatitis; hemolysis; thrombocytopenia Most hepatotoxic
Active Diseas e (-) (-) (-) (+) (-) (+/-)
Anatomic Localizations in Stroke Cerebral Hemisphere, Lateral Aspect (MCA) Hemiparesis Hemisensory deficit Motor aphasia (Broca’s) Central aphasia (Wernicke’s) Unilateral neglect, apraxias Homonnymous hemianopia or quadrantanopia Gaze preference contralateral to the lesion Cerebral Hemispheres, Medial Aspect (ACA) Paralysis of foot and leg with or without paresis of arm Cortical sensory loss over leg Grasp or sucking reflexes Urinary incontinence Gait apraxia Cerebral Hemisphere, Posterior Aspect (PCA) Homonymous hemianopia Cortical blindness Memory deficit Dense sensory loss, spontaneous pain, dysesthesias, choreoathetosis Brainstem, Midbrain (PCA) Third nerve palsy and contralateral hemiplegia Paralysis/paresis of vertical eye movement Convergence nystagmus, disorientation Brainstem, Pontomedullary Junction (Basilar) Facial paralysis Paresis of abduction of eye Paresis of conjugate gaze Hemifacial sensory deficit Horner’s syndrome Diminished pain and thermal sense over half body (with or without face) Ataxia Brainstem, Lateral Medulla (Vertebral A.) Vertigo, nystagmus Horner’s syndrome (miosis, ptosis, dec sweating) Ataxia, falling toward side of the lesion Impaired pain and thermal sense over half body with or without face
Ranson’s Criteria for Acute Pancreatitis At admission or diagnosis Age >55 yo Leukocytosis >16,000 per cubic millimeter Hyperglycemia >11mmol/L (>200 mg/dL) Serum LDH >400 IU/L Serum AST >250 IU/L During initial 48 hours Fall in hematocrit by >10% Fluid deficit >4000mL Hypocalemia <1.9mmol/L (<8.0 mg/dL) Hypoxemia (PO2 <60 mmHg) BUN rise >1.8 mmol/L (>5mg/dL) after IV fluids Hypoalbuminemia <32g/L (<3.2 g/dL) Note: ≥3 factors at the time of admission (1) during initial 48 hours (2) indicates an increased mortality rate. Patients need close monitoring at the ICU
Blood Transfusion Order Transfuse _____ of _______ of patient’s blood type after proper crossmatching Baseline CP status and VS prior to BT Mainline to PNSS at KVO Start initially at 5-10 µgtts/min then increase to 20-25 µgtts after an hour if without BT reaction Monitor VS q15mins for the first 30 minutes while on BT, then q30mins the following minutes Refer for dyspnea, fever, itchiness Thank you
Criteria for Rheumatoid Arthritis (1987 American College of Rheumatology) (Four out of the seven) 1. Morning stiffness – in and around the joints lasting one hour before maximal improvement 2. Arthritis of three or more joint areas – at least 3 joint areas, observed by a physician simultaneously, have soft tissue swelling or joint effusion, not just bony overgrowth 3. Arthritis of hand joints – arthritis of wrist, metocarpophangeal joint, proximal interphangeal joint 4. Symmetric arthritis – simultaneous involvement of the same joint areas on
both sides of the body Rheumatoid nodules – subcutaneous nodules over bony prominences, extensor surfaces or juxtaarticular regions observed by MD 6. Serum rheumatoid factor – demonstration of abnormal amounts of serum rheumatoid by any method for which the result has been positive in less than 5 percent of the normal control subjects 7. Radiographic changes – typical changes of RA on posteroanterior hand and wrist radiographs which must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints Criteria 1-4 must be present for at least 6 weeks Criteria 2-5 must be observed by MD 5.
1982 Criteria for Classification of Systemic Lupus Erythomatosus (SLE) 1. Malar rash – fixed erythema, flat or raised over the malar eminences 2. Discoid rash – erythematous raised patches with adherent keratotic scaling and follicular plugging 3. Serositis – pleuritis or pericarditis documented on ECG, or rub or evidence or pericardial effusion 4. Oral ulcers – oral and nasopharyngeal ulcers 5. Arthritis – nonerosive arthritis involving two or more peripheral joints characterized by
tenderness, swelling or effusion 6. Photosensitivity 7. Hematologic disorder – hematolytic anemia or leukopenia (<4000/uL) or lymphopenia (<1500/uL) or thmbocytopenia (<100,000/uL) 8. Renal disorder – proteinuria > 0.5 gm/day or > than +3, or cellular cast 9. Antinuclear antibody – abnormal titer of ANAs by immunofluorescense or an equivalent assay at any point in time in the absence of drugs 10. Immunologic disorder – Positive LE cell preparation or anti-ds DNA or anti-Sm antibodies 11. Neurologic disorder – seizure without other cause or psychosis without other cause If FOUR of these criteria are present any time during the course of the disease, a diagnosis of SLE is made Some patients present with only one or two criteria but may have SLE Rule out drug induced SLE: hydralazine, INH, procainamide, chlorpromazine and other vasculitides
