Acute variceal bleed patient Hospitalised : what complications

1. Infection :
- Most common
- Usually occur as UTI , spontaneous bacterial peritonitis , respiratory infection , aspiration pneumonia or
primary bacteremia.
- PROPHYLAXIS WITH FLOUROQUINOLONES (oflaxacin , cipro , norfloxacin) 7-10 DAYS
2. Encephalopathy
3. Renal failure

Acute variceal bleed pt ,with recently vomit a massive blood next best step ?
>>>>> airway should be maintained first do left decubitas postion or gastric decompression NG tube
if disoriented >>>> intubate first

Pt in ER with variceal bleed having episode of bleed again. What strategy ?

Pt of variceal bleed having episode of bleed again:
- Urgent upper GI endoscopy with either injection sclerotherapy or band ligation is the definite treatment of
choice for pt with active bleeding generally succeful in 80-90%
- All pt with recent variceal bleed are at a high risk of recurrent bleed or early rebleed
- The risk of bleeding is greatest within first 48-72 hours and remain high for the first six weeks
- Important risk factors for rebleed age > 60, severe initial bleed , large varices and presence of renal failure
- In all pt with rebleed within first 48 hours the strategy should be as:
Repeat endoscopy with >>>> if continues to bleed >>>> definite treatment with balloon temponade
Band ligation/ or Portosystemic shunt
- When discharging a pt put on Non Selective B-Blocker (propranol ) reduce portal presuure or hepatic vein pr.

Pt with non specific symptoms like fever and pharyngtiits then afterwards developing neurological symptoms including
confusion , lethargy paralysis and aphasia dysphagia drooling and history of exploring cave
>>>>> RABIES rabies is universally fatal once pt are symptomatic NO EFFECTIVE TREATMENT

Pt had laparoscopic cholecystectomy 10-11 months back then now coming with c/o abd pain RUQ , fever and jaundice
U/S showed bile duct dilation >>> post surgical obstruction complicated by acute cholangitis
Acute cholangitis:
- Triad of charcot Fever, RUQ pain and Jaundice
- History of cholecystectomy particularly laproscopic likely to make post surgical stricture as a cause of
cholangitis
- Post surgical strictures are more common after larparoscopic procedure
- Best diagnostic test is ERCP because if also has therapeutic application
- Management include obtaining blood culture , empiric parenteral antibiotic therapy ( prior to result ) and
emergency ERCP for biliary decompression ( due to high mortality )

pt with suspected clostridium difficli infection : (HI YIELD)

>> Limited endoscopy if unprepared bowel with minimal air inflation is a good diagnostic option in severly ill pt with
suspected Clostridium Difficli associated colitis.
Drugs causing C.difficli : clindamycin , ampicillin , amoxicillin and cephalosporin

Pt of HIV suspected to be infected by Pneumocystis next step ?

>> should be confirmed first with fiberoptic bronchoscopy with Broncheoalveolar Lavage before starting therapy
Pt with severe resp. distress should be admitted to hospital and given IV TMP-SMX , should be converted to oral when
stable
Corticosteroid treatment should be started when A-a > 35 or arterial oxygen tention is 70mm
Pt with pancreatitis due to isotretinoin >>> NPO and Iv fluids are the first line
if NPO/ IV are ineffective >> Dextrose with insulin can be used to reduce the triglyceride levels
(Dextrose containing IV fluids are used because dextrose will cause release of Insulin that will increase metabolism of
triglyceride by stimulating lipoprotein lipase)

Pt veterinary worker / poultry farmer with a triad of meningoencephalitis pneumonia and splenomegaly
>>>> Chlamydia Psittaci pneumonia
Doxycycline 100mg for 21days
HIV pt bited a normal person what infection chances more ?
Eiknella corrodens soft tissue infection :
- Soft tissue or wound infection can occur after a human bite due to exposure to mouth microbes .
- Human bites are more serious than animal bites and can be limb threatening
- Can involve soft tissus , fascia , bone or joints depending upon the extent and the depth of the bite
- Polymicrobial
- Eiknella is a gram ve found in soft tissue infection.
- Rx: Ampicillin- Sulbactem ( coverage for both aerobic and anaerobic bacterias)

Remember Saliva ( human bite ) , Tear and Human Sweat never transmit HIV no need to start prophylaxis.

Very very old man with h/o hypertention and hyper cholesterolemia , CAD comes with co abdominal pain followed by
diarrhea >>>> ACUTE ISCHEMIC COLITIS
ACUTE ISCHEMIC COLITIS :
- The most vulnerable areas are splenic flexure and rectosigmoid junction
- Xray and sigmoidoscopy shows mucosal edema and mucosal ulcerations.

Suspected case of osteomyelitis with bone x ray normal >>>> a three phase technetium bone scan is the diagnostic test of
choice if the plane films were negative ( becomes +ve in 2-3 days )
Although a bone biopsy is the gold standard for diagnosis of osteomyelitis it should be performed when non invasive tests
are ve

Person exposed to rabies now , he was previously exposed and received complete set of vaccine what next step ?
>>>> should receive only active immunization with rabies vaccine

Pt with a h/o peptic ulcer disease comes with c/o sudden pain in the abdomen that is radiating to back abd examination
show severe tenderness and guarding >>>>>> Ulcer perforation.
>>>>>> best test at this time to diagnose >>>> ERECT abdominal radiograph
>> Best management >>> Emergency exploratory laparotomy with surgical repair of perforation

Pt after abdominal surgery coming with complain of nausea vomiting and abdominal distention , on xray multiple air fluid
levels >>>>> Intestinal peforation >>>> most common cause adhesion

OGILVIE syndrome : ( acute colonic pseudoobstruction ) is characterized by the dilation of cecum and right colon in the
absence of mechanical obstruction to the flow of intestinal contents . It tends to involve the right side of the colon and not
the small intestine

Old Pt with AS murmer and painless bleeding >>>> Angiodysplasia

Angiodysplasia: also called Vascular Ectasia:
- Usually unknown include degenerative changes associated with aging and intramuscular hypertrophy that
obstruct submucosal veins
- Associated with Aortic stenosis
Prognosis of pancreatitis : ( Ransons Criteria )
Within first 48 hours :
1. Age > 55
 2. Wbc count > 16000 / cmm
3. LDH >350 iu/l
4. Glucose levels > 200 mg/dl
5. AST > 250 iu/L
After 48 hours :
1. PO2 < 60 mm
2. Calcium < 8 mg/dl
3. BUN increase > 5 mg/dl
4. Hematocrit decrease > 10%
5. Albumin <3.2 mg/dl
6. Estimated fluid deficit >4 L

Heavy drinker with complain od sudden chest pain that is increased on movement accompanied by nausea and vomiting
with high grade fever and dullness on percussion of lower third region and breath sounds are decreased in lower third
region.
>>>> Esophageal perforation followed by medistinus
Esophageal perforation followed by medistinus:
- Chest pain after recurrent episodes of vomiting classic for esophageal rupture ( boerhave syndrome )and may be
complicated by mediastinitis
- Other pain include epigastric and shoulder pain
- Most esophageal tear tend to occur in distal 1/3 and this leads to pleural effusion
- Pleural effusion usually develops six hours after perfotaion
- Urgent management id needed since mediastinits has 40 % mortality rate if not properly diagnosed within 48
hours
- Best test for diagnosis of esophageal perforation is ESOPHAGOGRAM with watersoluble contrast.
- If the test is negative and suspicion is high then barium could be used ( water soluble is preffered to barium
since the later is irritating to mediastinum )

Pt with epistaxis put nasal tampon comes with the complain of high grade fever , vital is destable and a rash resembling
sunburn that involve his palms and soles. >>>> Toxic shock Syndrome
Toxic shock Syndrome:
- Usually caused by S.Aureus exotoxin that act as superantigen
- RX removal of foreign object, supportive therapy extensive fluid replacement (that may reach to 20L a day)
And antibiotic Clindamycin with / without nafcillin ( antibiotic have shown to prevent recurrence )

Remember necrotizing fasciitis first present with intense pain with h/o trauma, some blisters may be noted
Group A streptococci is the causative agent for rapidly spreading cellulitis and necrotizing in most healthy pt
RX is surgicalexploratin and debridement , appropriate IV antibiotics and hemodynamic support should be provided
to all patients with necrotizing fasciitis . Therapy should be delayed to pbtain imaging or laboratory studies .
Clindamycin is the drug of choice for the treatment of NF due to GAS.

Pt with Mallory Weiss Syndrome coming with blood streaks in sputum next step ?/ >>>> Endoscopy for diagnosis and
therapeutic intervention.

Pt after URI comes with co dull back pain , weakness of the lower extremities accompanied by sensory loss and urinary
retention >>>> Transverse Myelitis

Transverse Myelitis:
- Follow URI
- Rapidly progressive weakness of lower ext. accompanied by sensory loss and urinary retention
- Dull back pain may be present
- Neurologic examination shows muscle flaccidity and hyporeflexia but spasticity and hyperreflexia develop
subsequently
 - Other causes must be ruled out especially compressive lesions by obtaining a careful history and performing the
appropriate imaging procedures.

Drugs that can cause pancreatitis : revise chart in the USMLE STEP 2 CK notes
Furosemide and thiazide can cause mild pancreatitis.

Revise Uc and crohns from MTB pg 260

Pt with severe / fulminant ulcerative colitis

>>> next step IV hydration , bowel rest and IV corticosteroids are the mainstay of treatment

Know how to recognize picture of intususseption

Physical findings may include a sausage shaped mass and abdominal distention
Xray show generalized distention of the bowel loop evidence of intestinal obstruction or the crescent sign ( enhanced
density that projects into the air level of the large bowel can be identified in 25 % of the case represent invaginated bowel
loop and is known as cresent sign

African American infant with crying and hand and feet swelling >>>>
Dactilytis ( manifestation of sickle cell )
In older children it may present as these episode occur primarily in joint , back and chest)

Pt on many drugs with sign and symtoms of nausea vomiting and abdominal distention progressivelu getting worse
abdomen sof nontender but bowel sounds are decreased no rebound tenderness and rigidity CBC normal with serum K low
>>>. Acute abdomen syndrome due to hypokalemic paralytic ileus >>> replace IV Potassium

Signs and symptoms of bronchiolitis in infant >>>> RSV bronchiolitis

RSV bronchiolitis
- Clinical presentation include URI in household contacts and th eoccurence in winter january feb and march
- Major cause of brochiolitis and pneumonia in children < 1 year
- Apnoea is an important clue for this
- Tends to be more in infants with preterm and infants with achronic medical condition such as congenital heart
disease chronic lung disease and immune deficiencies.

Pt with a history of foreign sharp object ingestion >>>> urgent endoscopy to remove

Acute electrolyte management : revise MTB

6- month old child with current jelly stool but no pain >>>> Intuseception
>>> Barium contrast enema is both diagnostic and therapeutic effective in 70-90%
COMPLICATION : Perforation of bowel
Risk is in following : 1. Infants < 6 months who have symptoms for least 3 days.
2. Those who appears to have small bowel perforation.
Ultrasound is also an excellent choice as its sensitivity and specificity is near 100% ( If you dont find barium enema then
select ultrasonography ( EXTREMELY HIGH YIELD )
Cat bite if ON HAND is considered HIGH RISK where infection could extend to bones and joints
prophylaxis is recommended the first dose of antibiotics eg ampicillin / sulbactam is usually given parenterally and covers a
broad spectrum of cat mouth flora including pasteurella mutocida .
Subsequently and oral antibiotic ( amoxicillin / clavulanate ) is administered for 3-5 days.

Pt with proximal ureteral obstruction which resulted in hydronephrosis superimposed infection and hemodyanamic
instability >>>> Percutaneous nephrostomy is recommended ( since the condition is fatal)
 General supportive measures and antibiotic therapy should also be given.

Infant with botullinism :

- Constipation is typically the first manifestation of the disease and is followed by lethargy poor suckling and
weak crying .
- Gag reflexes frequently impaired >>> may result in aspiration.

Pt of CF with pneumonia what antibiotic >>>> two anti pseudomonal antibiotic must be used eg (cefipime and amikacin)
In patients with cystic fibrosis , pulmonary exaberation and pneumonia are typically due to pseudomonas or
staphylococcus . Empiric therapy should include two dugs active against Pseudomonas plus vancomycin if there is history
of MRSA
Know anti pseudomonal antibiotics MTB 148

Elderly diabetic with severe pain and presence of granulation tissue on the floor of the external auditory canal at the
osseocartilaginous junction >>>> Malignant otitis externa ( pseudomonas)
>>> IV anti pseudomonal AB should be given initially then converted to oral ( depending on response ) to complete
6-8 weeks of AB therapy

Pt with cirhosis with portal hypertension presents with signs and symptoms of renal failure ( altered mental status , low
urine output , increased creatinine levels )
Hepatorenal syndrome : HRS
- Oliguria + creatintine > 1.5 and decrease sodium excretion
- Ca neb seen in pt with SBP , infection or GI bleed
- The best diagnostic test are determination of urinary sodium levels ( which should be lower than 10 mEq/L) and
urine osmolality ( which should be greater than plasma osmolarity)
Priapism :
- Painful undesired erection that begin as a non ischemic state and progresses to veno-occlusion, acidosis, anoxia
and finally ischemia
- Etiology include thromboembolism ( sickle cell ) neurogenic dysfunction , neoplasm, trauma and medication
- Erection that last longer than 3 hours is considered medical emergency and require urologic consultation
because permanent damage to corpora and impotence can occur.
- When conservative treatment eg ice pakcs and medical treatment ( to decrease arterial flow and increase venous
flow ) is given usually it resolves
- The first line medical treatment is injection of alpha-adrenergic agonist such as phenylephrine or epinephrine
every 5 min until detumuscence is achieved

NOTE Angiographic embolisation is the treatment of choice high flow priapism in pts with arteriocavernous fistula
IV fluids can resolve priapism in pt with sickle cell disease

Pt on many many nsaid and acetaminophen coming with sudden onset of renal colic , urine examination reveals hematuria ,
protein urea and pyuria , Urine culture is sterile , >>> Analgesic Nephropathy >>> DC analgesics

Chlamydia trachomatis is identified on screening in a pregnant women

>>>> Erythromycin should be given to both women and her sexual partner.
Infant should also be treated Erythromycin per orally.
If diagnosed again in pregnancy >>>> Retreat again

Child malnutrished :
Initial treatment of patients with severe malnutrition should address the following issues :
 1. temperature control (warming) ,
2. possible infection ,
3. dehydration and malnutrition (feeding ) .
Dehydration should be treated with Oral rehydration where possible >> NG tube can be used to feed in pt with
impaired consciousness , vomiting and painful ulcers .

Acidosis and alkalosis from MTB

Know the criteria of febrile seizure :

1. age less than 6 years
2. no past history of febrile seizure
3. temperature greater than 38 c
4. no evidence of CNS infection / inflammation
5. no metabolic disturbances
Two types simple and complex:
Simple febrile seizure:
- absence of focal features , < 15 minutes for an isolated event , and for seizures occurring in series a
commulative duration less than 30 mins
- a mild increase in risk for subsequent epilepsy
- But significantly elevated risk for recurrence of febrile seizure
Complex febrile seizure:
- focal features ( postictal paresis) , > 15 minutes for an isolated event , and for seizures occurring in series a
commulative duration greater than 30 mins
- But significantly elevated risk for recurrence of febrile seizure

Child with DM 1 with red hot shiny and swollen lesion in tha back if the neck , very tender slightly elevated and irregular
border >>>>> Cellulitis > the infection is between subcutaneous tissue and fat >>> local anesthesia will not be useful.

Child with hypertrophic pyloric stenosis diagnosed by U/S what next ?? >>> correct electrolyte abnormality before surgery.
Studies have demonstrated an association between the development of infantile hypertrophic pyloric stenosis and the
usage of oral Erythromycin for pertusus
Usage of macrolide in breast feeding women is also linked to development of infantile hypertrophic pyloric stenosis
especially in girls

The common causes of HE include :

- GI bleed
- Hypokalemia
- Hypovolumia
- Hypoxia
- Sedative tranquilizer
- Hypoglycemia
- Metabolic acidosis
- Infection ( SBP )
Antenatal CS therapy has been shown proven to be effective in reducing perinatal morbidity and mortality associated with
preterm labor . INTRAMUSCULAR ROUTE of steroids provides stable and predictable concentration of the drug. The two
commonly employed are betamethasone and dexamethasone

Alcoholic ketoacidosis :
- Characterized by anion gap acidosis , increased osmolal gap , ketonemia or ketonuria and variable blood
glucose levels.
- Impaired insulin secretion along with insulin resistance
- All alcoholics are are considered to be thiamine deficient.
 - Most pt respond to Dextrose Normal Saline ( dextrose lead to increase in insulin secretion lead to metabolism
of ketone bodies to HCO3
Remember blood glucose levels are generally higher in Diabetic ketoacidosis

Know to diagnose all 4 types of PID : know combination of drugs IMP

Enterovirus and arbovirus infection are the most common cause of viral meningitis or encephalitis in the pediatric
population . Most Arbovirus infection are zoonosis ( transmitted through animal vector ): for this reason , these infections
are more common in the rural areas.
Herpes simplex is the most common cause of viral meningitis in the adult population and not in children

Uterine Prolapse :
- Typically seen in multiparous post menopausal woman with history of multiple vaginal deliveries
- The injury to the pelvic ligaments and loss of estrogen weakens the endopelvic fascia
- The uterus and cervix descends down the vaginal canal towards the vaginal orfice ( introitus )
- Pt complain of sensation of pressure or heaviness in the pelvic area which relieved by lying down and
aggrevated by prolong standing or exertion
- Some pt also complain of low back pain dyspareunia or a visible mass at the introitus.
- In chronic cases pt may have bleeding or discharge from ulcerative superficial epithelium.
- All symptomatic pt ( constant sensation of heaviness , pain or bleeding ) should have surgical correction of the
defect in the pelvic support.

Serptonin agonist such as sumatriptan and naratriptan act by blocking 5-HT1 B/D receptor and are currently widely
employed to treat migraine attack.

Intermediate probability V/Q scan >> next step ? >>>> duplex of the lower extremities.
(NOT Pulmonary Angiography because it is invasive)
Warfarin use in pulmonary embolism :
- Occurrence of PE in the setting of reversible risk factors (eg use of OCP immobilization or surgery )
>>> 3-6 months of warfarin therapy
- First episode in the setting of malignancy , anticardiolipin antibodies and antithrombin deficiency
>>>> 12 months of warfarin therapy
- First episode of idiopathic thromboembolism >> 6 month therapy
- Recurrent thromboembolism >>> indefinitely or consider other options too .

Strongest allergen with Asthma >>> House dust mite

Know how to recognize Traumatic lumbar puncture:

Pt with fall >>>> take a deep and detailed history of fall .

Pt with asthma exaberation >>>> what to give immediately b-agonist (not CS because it takes hours to action )

Traumatic lumbar puncture:

- Accidental damage of a blood vessel during a procedure
- RBC count exceeding 6000 /mm may indicate traumatic LP.
- WBC count elvation in traumatic LP is explained by Blood leak if approximately one WBC is present per 750-
1000 rbc
- The protein level is elevated and the glucose level is typically high.

(NOTE : xanthochromia and discoloration of centrifuged CSF due to hemoglobin breakdown are characteristic of
SAH and appear 2-4 hour after rbc enter subarachnoid space )
Drug use suspect >>> Urine immunoassay screens for drug abuse are inexpensive and rapid , they usually provide result
within an hour

Sudden onset severe headache , elevated blood pressure and vomiting >>>> DO CT SCAN first

Opiod withdrawal:
- Criteria for diagnosis of opoid withdrawal are presence of 3 or more
1. GI symptoms such as nausea, vomiting , diorhea and abdominal cramps
2. Myalgia
3. Lacrimation / rhinorhea
4. Piloerection , sweating or papillary dilation
5. Insomnia
6. Autonomic symptoms such as hypertention and tachycardia
Clonidine is a centrally acting antihypertensive medication that is frequently used for treatment of opiod withdrawal
either orally in divided dose or transdermal patch

Pt with history of fall >>>> why fall check drugs antipsychotic , benzodiazepine and antidepressant

Old patient on benzodiaespine admitted on hospital co anxiety restlessness confusion disorientation tremulousness
generalized seizure psychosis elevated heart rate BP and body temperature >>> benzo diazipine withdrawal
Benzodiazipine withdrawal:
- anxiety restlessness confusion disorientation tremulousness generalized seizure psychosis elevated heart rate BP
and body temperature
- advanced withdrawal with abnormal vitals and delirium should be treated rapidly and with sufficient large doses
of withdrawal
- IV lorazepam and Diazepam are used in acute settings.

Alcohol withdrawal : >>>> always always and always thiamine first if wercickes
Wernickes Encephalopathy :
- Characterized by triad of confusion ataxia and nystygmus ( leading to opthalmoplegia )
- Occurs due to thiamine deficiency
- Urgent administration of thiamine either IV or IM
NOTE : thiamine deficiency is common in alcoholics the first step in the treatment of any alcoholic patient is the
administration of thiamine (before glucose ) to prevent the onset or progression of Wernickes Encephalopathy.

Korsakoff psychosis : confabulation is very prominent. It can be prevented by giving thiamine before glucose.

For making diagnosis of schiczophrenia >>>>>>>>>>>> make sure it is 6 months

Psychotic pt good prognostic factors are :
1. Acute onset of symptoms
2. Stable social environment good premorbid functioning
3. No past psychiatric history
4. No family history of psychiatric illness
5. Known precipitating factor of psychosis
6. +ve factors like (hallucination, disorganised thoughts, delusion) do better than ve factors ( blunt effect , loss of
motivation or anhedonia )

Cocaine induced Hypertension / chest pain

Cocaine induced Hypertension / chest pain >>>>> Benzodiazipine should be used as part of the first line therapy.
B-Blockers ( metoprolol ) and Combined alpha and B-Blockers ( labetolol ) should be avoided in the treatment of
cocaine induced MI/Hypertension
Phentolamine is an alpha-adrenergic blocker can be useful

Cocaine induced MI :
- The main factor that lead s to Myocardial ischemia is vasospasm , other mech ( increased oxygen demand also
play a role too
- Vasospasm may lead to coronary artery thrombosis which cannot be reversed by vasodilators agents
- Initial treatment include nitrate ( or calcium chanel blocker ) , aspirin and benzodiazepine.
- If pts does not promptly improve with these drugs
>> immediate Coronary angiography should be done to check for thrombus

REVISE BRAIN LOBES FUCNTION AND ARTERY AND NERVE SUPPLY

REVISE CAUSES OF DEMENTIA FROM NOTES

Thrombolytics should be considered in stroke pt when presents within 3 hours

Hypertension in Stroke :
- Hypertension in acute stroke should not be treated unless it is very severe ( sys > 220 and dias > 120 ) or causes
end organ damage ( pulm edema or angina )
- Most author consider it to be a protective mechanism that intend to preserve perfusion in under perfused areas.
- DONOT DECREASE BP IN ACUTE STROKE

Plasmaphresis or IV immunoglobulin is the mainstay of therapy for pts with severe and progressive Guillaine Barre
Syndrome
Indication for Plasmaphresis :
1. Severe flaccid paralysis
2. Bulbar palsy
3. Progressive respiratory failure
4. Pt on mechanical ventilation
Corticosteroid therapy have no role in the management of pts with GBS.

Remember if scene is given predicting acute PE and low probability V/Q scan is the result
>>> low probability V/Q scan does not rule out PE with clinical high suspicion of PE

Know types of insulin :

Pregnant pt with co headache of sudden onset with hemiparesis and pappiledema

Superior sagital sinus thrombosis :
- Associated with trauma, infection , hyper coagulation , vasculitis , nephritic syndrome , severe dehydration and
pregnancy
- Diagnosis is suggested by history headache and associated condition, physical findings ( hemiparesis,
pappiledema, seizure ) and imaging test.
- MR imaging and MR venography are very useful in establishing the diagnosis.
- Management : typically includes adequate Anticoagulation with Heparin even if an area of hemorrhagic
infarction is demonstrated on CT . Hemorhagic foci that occur in this case are secondary to venous
hypertension.

Septic Pulmonary embolism :

- a well known complication of IV drug abuse
- result from septic thrombophlebitis ( painful subcutaneous mass ) and for tricuspid endocarditis
 - blood culture is usually positive.

Mild fever < 102 F and leukocytosis can occur in PE.

Pt with unilateral headache and horners syndrome ( miosis small pupil , anhidrosis (lack of sweating) , ptosis on the
effected side ) >>> Carotid Dissection
CAROTID DISSECTION :
- can be due to trauma, connective tissue disorder , smoking , neck manipulation , hypertension and three point
restraint seatbelt
- If suspected preferred non invasive imaging is MRA ( magnetic resonance angiography)
- If MRA result unclear and diagnosis still suspected >>> catheter angiography is definite test
- High risk of cerebral infarction.
- Treatment : anticoagulation with platelet agent and / or heparin

Management of Diabetic Ketoacidosis : MISTAKES

- Most pt of DKA are 5-8 litre deficit
- The typically administered initial fluid is normal saline , which is continued until the blood sugar
approaches 250 mg/ dl >>> at this time N/S should be changed to a dextrose containing fluid ( typically
D5%1/2 NS containing 20-40 meq/L pf KCl) which is given at rate of 100-125cc/hour
- Dextrose infusion is very important ito decrease ketone levels .
- At the same time the insulin infusion rate is decreased to 1-2 unitts /hour.
- Starting an insulin infusion will shift the potassium into the cell which could cause dangerous hypokalemia .
Since the total potassium deficit is approximately 300 mEq. The pt should start receiving potassium
supplementation even if potassium is normal.
Another common mistake in the management of DKA is STOPPING IV INSULIN WITHOUT OVERLAPPING
DOSE OF SUBCUTANEOUS INSULIN.
- Generally rapid acting insulin is started when switch from infusion to subcutaneous insulin is made.
- Because S/C insulin takes time to absorb it should be administered 30-60 minutes before insulin is stopped
- Failure can result in RECURENCE OF DK

Complications of MI :
Acute inferior MI with bradycardia and Symptomatic ( RCA supply inferior heart as well as SA node )
>>> give atropine first then fluid management

Sinus bradycardia after an acute inferior wall MI :

- Sinus bradycardia after and acute inferior MI is usually transient and typically resolve in 24 hours
- Pts are usually aymptomatic
- If severe low cardiac output can occur resulting in hypotention and subsequent hemodynamic compromise
- If symptomatic and severe >>> give IV atropine sulphate 0.6-1.0 mg to reverse bradycardia and improve
symptoms

Acute cardiogenic pulmonary edema :

- Intial therapy >>> oxygen , morphine and loop diuretic
- Morphine reduces pt anxiety and decrease work of breathing >>> decrease central sympathetic flowe
>>> arteriolar and venular dilation >>> decrease cardiac pressure
- Loop diuretic decrease pulmonary capp. pressure by removing excess fluid and morphine like action.
Pt with CHF with unknown etiology >>> in a new case of CHF with unknown etiology efforts must be made to rule out
presence of coronary lesion since it is the most common cause of CHF Other important causes are hypertension , valvular
and renovascular disease.
Three important causes of hypoglycemia with an increase plasma insulin insulinoma, exogenous insulin and sulfonylurea
Increased insulin with increased C-Peptide occurs in insulinoma and sulfonylureas >> check for sulfonylurea in his
urine will be useful

Aspirin in higher doses displaces thyroid hormone from THBP , aspirin should therefore should not be used in high dosages
( as an antipyretic ) during thyroid storm because it can worsen the clinical status . other drus that can diplace are lasix
(furosemide) and heparin.

Hypertensive crisis complicated by acute pulmonary edema >>> IV nitroglycerin and IV nitroprusside
All pts with flash pulmonary edema should be evaluated with echocardiography because mitral stenosis and acute
aortic or mitral regurgitation can sometime present with flash pulmonary edema

Pt with bitemporal hemianopsia ,tanned skin , had an intraabdominal sugery many years back for cushings disease
NELSONS Syndrome :
- Pituitary enlargement and hyperpigmentation following bilateral adrenalectomy for cushing disease is termed as
Nelsons syndrome
- Result from loss of feed back by adrenal glucocortisoids following bilateral adrenelectomy >>> increased
ACTH and B-Msh
- Following bilateral adrenelectromy Prophylactic pituitary radiation sometimes prevent nelson syndrome
however this leads to risk for hypopituitarism
- The tumor is aggressive in Nelsons syndrome >. Should be treated with surgery / Radiation.
- Previously bilateral adrenelectomy was preferred procedure for cushings disease but now transsphenoidal
surgery primary pituitary surgery is preferred

Pt with chest pain suggestive of MI are eligible for thrombolytic therapy itf present within 12 hours

Treatment of AF revise

The Diagnosis of ACS acute coronary syndrome is made by the combination of chest pain , EKG abnormalities and
elevation of serum cardiac markers
Know to recognise and treatment of AV BLOCK

Know the blood supply of heart

Narrow and regular QRS complexes tachycardia and absent p waves >>> supra ventricular tachycardia

Short PR interval ( < 0.12) , QRS duration > 0.12 and delta wave >>>. WPW syndrome
It can present as SVT, if verapamil or beta-blocker is given AV nodal conduction is slow and the accessory pathway
conduction will be increase that can lead to VF *( avoid ABCD

PHEOCHROMOCYTOMA PT :
>> measurement of plasma free metanephrine levels or a 24 hour urine collection for measurement of cathcholamines
metanephrine and vanillylmandelic acid levels. Confirmation of biochemical test is required before imaging is
performed ( EXTREMLY HIGH YIELD )
BEFORE SURGERY :Alpha blockade along with liberal salt and water intake is required 10-14 days preoperatively before
surgery to control hypertension and restore intravascular volume .The most common agent used is long acting
noncompetitive alpha blocker phenoxybenzamine 40-80mg daily ( EXTREMLY HIGH YIELD )

Pt of pheochromocytoma during sugery rapidly becomes hypotensive >>>

Even with preoperative alpha blockade some pts have intraoperative complications
Hypotention due to decrease in circulatory catecholamines levels and alpha-blockade thereby leading to a marked decrease
in vascular tone >>> give N/S bolus followed by continuous infusion
( note : Vasopresors (dopamine and dobutamine) are less effective
IV phentoamine is used in acute severe hypertention ( not hypotension during surgery for pheochromocytoma )

Pt with acute MI on multiple medications : which should be continued and which should be stopped.
According to ACC/AHA guidelines Calcium chanel blocker should be stopped,
the only indications are
1. intolerance to b-Blocker ,
2. Post infarction angina refractory to B-Blocker and nitrate and
3. Rapid acting AF with contraindication to B-Blockers

Ischemic chest pain

>>> first oxygen and aspirin 325 mg followed by NO ( avoid in hypotension and recent Sildinalfil use ) , Morphine
and Beta blocker ( presuming no contraindication )

Lidocaine is the drug of choice for pt with TCA induced Ventricular arrhythmia

Pt loss consciousnbess in market otherwise absolutely normal >> Syncope

Syncope : the cause of syncope can be established by careful history taking, simple lab test and EKG
1. careful history taking: preliminary nausea ot lightheadedness (neurocardiogenic) convulsion chest pain dyspnoes ,
palpitation etc.
2. physical examination : may include orthostatic blood changes abnormal cardiac examination response to cardiac
massage, etc.
3. EKG helps to reveal brady or tachyarrhythmia and conduction abnormalities

Becks triad for cardiac temponade is hypotension muffled or distant heart sounds and elevated JVP
>>> cardiac temponade is a surgical emergency and echo should be done urgently , Echo will show diastolic collapse of
both the right atrium and ventricle , however if pt is collapsing one should not wait for echo Rapid pericardiocentesis should
be done.

Acute aortic dissection : is a life threatening condition , All such pt should have emergent surgical intervention.
- The goal of medical therapy is to reduce the shearing stress on the aortic wall and prevent the further
propogation of dissection.
- Give IV B-Blocker the goal should be BP 100-120sys and heart rate less than 60/ min
>>> If still BP is high add nitroprusside ( direct vasodilator )

According to AHA calcium channel blockers can be harmful to patients with acute MI so it should be avoided in acute MI
B-Blockers , Ace inhibitors and statin have significant effect on the secondary prevention of coronary artery disease. And
should be continued indefinitely unless contraindicated

Pt with chronic suppression of hypothamic-pituitary adrenal axis can have hypotension during acute infection. Hypotension
in these patients usually responds to administration of a stress dose of glucocorticoids and hydration
In secondary and tertiary adrenal failure , there are no significant abnormal mineralocorticoid levels.

Sul