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レジデントノート

米国にて内科修行中。何ができるか模索している過程を記録していく

Infectious disease (memo from NEJM knowledge plus and MKSAP)

・ABX for extensively drug-resistant pseudomonal infection (resistant to fluoroquinolone, carbapenem, aminoglycoside)

intravenous colistin (polymyxin E)

 

・first recurrance of mild to moderate C.difficile colitis

metronidazole for 14 days

 

・Tx for tuberculous pericarditis

4-drug antituberculous Tx + prednisone

 

・positive result of PPD

> 15mm: normal populatoin,  > 10mm: IV drug abuse, etc,  > 5mm: HIV, etc

 

・flu-like symptoms, pulmonary symptms, pancytopenia, in Ohio

histoplasmosis

 

・GNR bacteremia associated with tunneled central venous catheter 

removal of catheter and 7-14 days of ABX

 

・management of suspected brain abscess (> 2.5cm in imaging study)

CT-guided aspiration

 

・beta-lactam ABX covering MRSA

ceftraroline

 

・Dx of patient with acute symmetric polyarthritis and faint maculopapular rash on chest and extremities associated with recent flu-like symptom

parvovirus B19 (classic slapped cheek appearance usually not occur in adults)

 

・self-limited shigellosis confirmed by microbiologic diagnosis

still require 3 day of ciprofloxacin

 

・fever, chills, asymmetric flaccid paralysis

West Nile virus myeltiis

 

・diarrhea associated with uncooked poultry

campylobacter jejuni 

 

・coinfection with Lyme disease, causing hemolysis 

 Babesia microti

 

・management of mild histoplasmosis

observation without ABX

 

・cough, fever, erythema nodosum in Arizona

coccidiodomycosis

 

・Dx and Tx for broad-based budding yeast from hyperkaratonic skin lesion

blastomycosis /  itraconazole

 

・Tx for clinically stable patient with bacteremic pneumococcal pneumonia susceptible to penicillin 

7 days course of oral amoxicillin

 

・recurrent cystitis treated with trimethoprim-sulfamethoxazole 5 months ago

nitrofurantoin

 

・flu-like symptoms, widened mediastinum in patient exposed to crop dusting

bacillus anthracis

 

・infection after transplantation

CMV infection during middle period (the first few months)

 

・first choice for immunocompromised patients with invasive pulmonary aspergillosis

voriconazole

 

・invasive group A β hemolytic streptococcal (streptococcus pyogenes) infection (necrotizing fasciitis, toxic shock syndrome)

require contact precaution (not only standard precaution)

 

・ABX for cat-scratch fever

azithromycin

 

・choice of statin for HIV patients on ART

no simvastatin 

 

・Tx for syphilis

primary / secondary / early latent: IM benzathin penicillin G x 1

tertiary / late latent: IM benzathin penicillin G x 3 weekly

neurosyphilis: IV aquaous crystalline penicillin G x 10 days

 

・fever, productive cough, gram negative bipolar-staining bacilli, in New mexico

Yersinia pestis (Plague)

 

・Sx of typhoid fever (Salmonella enterica)

constipation followed by diarrhea, salmon-colored rash, relative bradycardia, splenomegaly, hyponatremia

 

・recurrent erysipelas rash and fever

FMF

 

・shaving of hair prior to surgery 

risk factor for surgical site infection (not protective factor)

Neurology (memo from NEJM knowledge plus and MKSAP)

・diagnostic test for patient with 1 week constant headache, worse in the morning, no focal sign, with bilateral papilledema, valsalva maneuver increase pain, using tobacco and oral contraceptive, normal brain MRI without contrast

MR venography for possible dural sinus venous thrombosis

(Dx of pseudotumor cerebri requires exclusion of dural sinus venous thrombosis)

 

・the best physical exam to predict the risk of future falls

pull test

 

・Tx for trigeminal neuralgia

carbamazepine

 

・sign more suggestive of atypical parkinson syndrome than parkinson disease

poor response to high-dose levodopa

 

・admission indication for TIA

ABCD2 score 3 or greater within 72 hours of Sx onset

(> 60 yo: 1, BP > 140/90: 1, hemiparesis: 2, duration > 60 min: 2, DM: 1)

 

・tension-type headache

no proved benefit from muscle relaxant, benzodiazepine, or physical therapy 

 

・cause of decreased position and vibratory sensation, macrocytic anemia

copper deficiency and Vit B12 deficiency

 

・verapamil as migraine prevention

evidence is quite limited (effective for preventing cluster headache)

 

・when DVT prophylaxis should be initiated for patient with acute intracranial hemorrhage resulting in paralysis

by hospital day 4 if stable

 

・the most common neurologic presentation of Wilson disease

parkinsonism

 

・Tx for focal dystonia of neck / spasmodic torticollis

botulinum toxin injection

 

・diabetic amyotrophy

lumbar polyradiculopathy affecting primarily muscles of thigh that classically presents with severe pain at onset followed by weakness and numbness over weeks to months,

occur even in undiagnosed diabetes

 

・Tx for multiple sclerosis-related fatigue

amantadine, modafinil

 

・ring-enhancing brain lesion with central necrosis and hemorrhage

glioblastoma multiforme

 

・confirmatory test for patient with physical exam consistent with brain death

apnea test

 

・management of acute intracranial hemorrhage in patient taking aspirin

benefit of platelet transfusion remains unknown -> not indicated

 

・two neurologic conditions which produce rapid deterioration in cognition and behavior in the absence of trauma, infection, fever, intoxication or other systemic signs

Creutzfeldt Jakob disease and paraneoplastic syndrome

 

・anti-epileptic medication for females actively pursing pregnancy

carbamazepine (lamotorigine, levetiracetam, oxcarbazepine)

 

・preferred anti-epileptic medication for asian patient with HLA-B1502

levetiracetam (others increase the risk of Stevens-Johnson syndrome)

 

・diagnostic test for patient with muscle weakness improving with exercise, orthostatic hypotension

nerve conduciton study for suspected Lambert-Eaton myasthenic syndrome

 

・diagnostic test for postpartum female with recurrent thunderclap headache with normal non-contrast head CT

CT angiography / MR angiography for cerebral vasoconstriction syndrome

 

・Dx of young patient with fever, headache, multifocal signs, lymphocytic pleocytosis in CSF, multifocal areas of demyelination in MRI

acute disseminated encephalomyelitis

 

・dementia, visual hallucination and parkinsonism

dementia with Lewy bodies

 

・dementia, parkinsonism, impairment of vertical eye movement, square wave jerks

progressive supranuclear palsy

 

・Tx for patient with recurrent headache with ipsilateral autonomic feature (tearing, rhinorrhea, ptosis, conjunctival injection)

indomethacin for chronic paroxysmal hemicrania

 

・Capgras syndrome

delusional misidentification syndrome, loss of emotional connnection to meaningful person or place

 

・definition of apraxia

inability to perform previously learned skilled motor tasks despite intact motor and sensory systems

 

・indication of Tx for tic disorder

only when impairing social, academic or occupational function

 

・management of cryptogenic embolic stroke with patent foramen ovale

no intervention (procedure of closure didn't reduce the risk of recurrent stroke)

 

・convulsive seizure, provoked by alcohol intake, worse in the morning

juvenile myoclonic epilepsy

 

・Tx for multiple sclerosis-related spasticity

tizanidine (centrally acting alfa-2 adrenergic agonist), baclofen, cyclobenzaprine

 

・adverse effect of natalizumab for multiple sclerosis

nervous system infection with JC virus resulting in progressive multifocal leukoencephalopathy

 

・management of compulsive behavior in patient with parkinson disease 

reduction of dopaminergic medication

Endocrinology and metabolism (memo from NEJM Knowledge plus and MKSAP)

・Tx for acute episode of diabetic neuropathy

glucose control, low-dose tricycle antidepressant (desipramine), capsaicin cream

 

・mechanism of hypercalcemia due to disseminated tuberculosis

macrophages in tuberculous granuloma activate vitamin D

 

・diagnosis of diabetes by HbA1c

> 6.5% in separate occasion 

 

・outcome of laser photocoagulation for diabetic retionpathy

diminished peripheral and night vision with retention of central vision

 

・evaluation of secondary amenorrhea with normal labs work-up

progesterone challenge test (evaluate whether estrogen is low or normal)

 

・management of bilateral adrenal hyperplasia

conservative management with spironolactone

 

・Tx for myxedema coma

thyroid hormone and stress-dose glucocorticoid until excluding concurrent adrenal insufficiency

 

・maturity-onset diabetes of the young

diagnosed in adolescence, deteriorate slowly, strong family history

 

・monophilament test for diabetic neuropathy

plantar surface of distal hallux and 1st, 3rd, 5th metatarsal head of each foot

 

・Tx of Graves disease ophthalmopathy in the setting of intolerance to anti-thyroid Tx

trial of prednisone, thyroidectomy

 

・indication of parathyroidectomy for primary hyperparathyroidism

symptomatic hypercalcemia (nephrolithiasis, arrhythmia), or regardless of Sx with GFR<60, or T score <-2.5, or fragility fracture, or < 50 yo

 

・gynecomastia in male

imbalance in testosterone-to-estrogen ratio -> check serum levels

 

・euthyroid sick syndrome

TSH no more than 10

 

・hormone deficiency after traumatic brain injury

GH 

 

・Tx for large papirally thryoid cancer (> 4cm)

surgery followed by radioactive iodine therapy 

 

・sudden discontinuation of megestrol for anorexia

cause adrenal insufficiency due to its glucocorticoid activity 

 

・indication of surgery for primary hyperparathyroidism

Ca  > 1mg/dl + upper limit, GFR < 60, osteoporosis, fracture

 

・next management for patient with Sx of thyrotoxicosis, significantly elevated T3, TSH of 1.5

pituitary MRI to evalute TSH-secreting pituitary tumor (TSH usually not detectable in primary thyroid disorder)

 

・next step for patient with persistently elevated ALP (bone isoform), bone scan showing uptake in multiple bones

plain radiograph of bones to diagnose Paget disease (osteitis deformans)

 

・elevated testosterone in female

from ovary or adrenal gland

adrenal gland produce dehydroepiandrosterone sulfate (DHEAS) 

 

・Tx for macroprolactinoma

first line: dopamine agonist

surgery only when failure of medical management or visual deterioration

 

・Somogyi phenomenon

(hypoglycemia during night leads to rebound hyperglycemia in the morning)

this theoretical concept has been disproven as a cause of fasting hyperglycemia

 

・Dawn phenomenon

elevation in glucose during the morning (4AM-8AM) result from physiolosic release of cortisol and GH

 

・adverse effect of chronic opioid use

central hypogonadism -> low libido, erectile dysfunction 

 

・central adrenocorticotropic hormone deficiency during pregnancy

lymphocytic hypophysitis (rare autoimmune disorder)

 

・benign familial hypocalciuric hypercalcemia

high-normal PTH level and family history 

 

・above what of random cortisol level make diagnosis of adrenal insufficiency unlikely in critically ill patients

12

 

・evaluation of male hypogonadism

measure of morning total testosterone level (not free testosterone)

 

・Tx for hirsutism from polycystic ovary syndrome

oral contraceptive which decrease testosterone production by ovary

 

・management of abdominal pain in the setting of DKA (general tenderness, leukocytosis, AMY 1000)

serial abdominal exam

 

・suggestive finding of malignant adrenal incidentaloma

> 4cm,  attenuation > 20

 

・management of amiodarone-induced thyrotoxicosis

prednisone and beta blocker

 

 

鎮静・鎮痛 (ICU)

<鎮痛>

Mild pain (pain score 1-3)

- Fentanyl 25mcg IV q2h prn

- Hydromorphone 0.25mg IV q4h prn

- Morphine 2mg IV q2h prn

- Ketorolac 15mg IV q6h prn

 

Moderate pain (pain score 4-6)

- Fentanyl 50mcg IV q2h prn

- Hydromorphone 0.5mg IV q4h prn

- Morphine 4mg IV q2h prn

- Ketorolac 15mg IV q6h sch 

 

Severe pain (pain score 7-10)

- Fentanyl 75mcg IV q2h prn

- Hydromorphone 1mg IV q4h prn

- Morphine 6mg IV q2h prn

 

[Continuous infusion for analgesia]

Fentanyl 2500mcg/NS 200ml

Start at 25 mcg/hr; titrate by 10 mcg/hr q5 min to PAIN Score 3/10; or to GOAL RASS Score 0 to -1; to a maximum of 200 mcg/hr

(Adjust in opioid tolerant patients. No max when used for comfort measures)

 

Morphine 100mg/NS 90ml

Start at 1 mg/hr; titrate by 1mg/hr q5min to PAIN Score 3/10; or to GOAL RASS Score 0 to -1; to a maximum of 20 mg/hr.

(Adjust in opioid tolerant patients. No max when used for comfort measures)

 

Hydromorphone 50mg/NS 50ml

Start at 0.2 mg/hr; titrate by 0.2 mg/hr q30 min to Pain Score 3/10

or GOAL RASS Score 0 to -1; to a maximum of 2 mg/hr

(No max when used for comfort measures)

 

 

<鎮静>

Propofol 1000mg/100ml

Start at 5 mcg/kg/min; titrate by 5 mcg/kg/min q 10 min

to GOAL RASS Score 0 to -1; to a maximum of 70 mcg/kg/min

 

Dexmedetomidine 200mcg/NS 50ml

Loading dose of 1 mcg/kg over 10 min

THEN Start at 0.2 mcg/kg/hr; titrate by 0.1 mcg/kg/hr q30 min to GOAL RASS Score 0 to -1; to a maximum 1.4 mcg/kg/hr as tolerated.

 

Midazolam 100mg/NS 80ml

Start at 1 mg/hr titrate by 1 mg/hr q5 min to GOAL RASS Score 0 to -1; to a maximum of 10 mg/hr

 

[Neuromuscular blocker]

Cisatracurium 200mg/NS 200ml

Loading dose 0.15 mg/kg = [        ]mg

Start at 3 mcg/kg/min; titrate by 0.5 mcg/kg/min q 20 min

to a maximum of 10 mcg/kg/min to a train of four (TOF) 

of at least 1-2/4 to maintain ventilator synchrony

 

 

<Delirium> 

- Quetiapine 25mg PO q8h sch

- Haloperidol lactate 2mg IV q8h sch

(HOLD if QTC greater than 25% increase from baseline QTC or absolute corrected QT of 0.48)

- Dexmedetomidine iv (the same protocol above)

(dexmedetomidine is the sedation medication of choice in hemodynamically stable patient with significant delirium)

 

(米国一施設基準)

ICU持続静脈注射薬

Amiodarone

[bolus]

amiodarone 150mg in 100ml D5W at 618ml/hr iv x 1

[continuous]

amiodarone/D5W 750mg/500ml

Start at 1 mg/min x 6 hours, then 0.5 mg/min

Maximum rate 1.5 mg/min

 

Diltiazem

diltiazem/NS 100mg/100ml

Loading dose 0.25mg/kg over 2 min

Start at 5 mg/hr

titrate by 5 mg/hr q10 min

Titrate to Goal Ventricular Rate <100

Hold for HR<50 or SBP <90

to a maximum of 15 mg/hr

(Usual range 5 mg/hr to 15 mg/hr)

 

Dobutamine

dobutamine/D5W 250mg/250ml

Start at 2 mcg/kg/min

titrate by 2 mcg/kg/min every 5 min

Titrate to Goal parameter:

to a maximum of 20 mcg/kg/min

(Usual range 1 mcg/kg/min to 20 mcg/kg/min)

 

Dopamine

dopamine/D5W 400mg/250ml

Start at 2 mcg/kg/min

Titrate by 1 mcg/kg/min every 5 min

To a Goal MAP > or = 65 mmHg to a maximum of 25 mcg/kg/min

(Usual range 1 mcg/kg/min to 25 mcg/kg/min)

 

Epinephrine

epinephrine 1mg/NS250ml

Start at 0.01 mcg/kg/min

Titrate by 0.01 mcg/kg/min every 5 min

To a maximum of 1 mcg/kg/min or MAP > 65 mmHg

(Usual range 0.01 mcg/kg/min to 1 mcg/kg/min)

 

Esmolol

esmolol/NS 2500mg/250ml

Start at 50 mcg/kg/min

titrate by 50 mcg/kg/min q5 min

Titrate to Goal to keep HR <100

Hold for HR <50 or SBP <90

to a maximum of 300 mcg/kg/min

(Usual range 50 mcg/kg/min to 300 mcg/kg/min) 

 

Furosemide

furosemide 1000mg/100ml

Start at 5 mg/hr

titrate by 5 mg/hr q60 min

Titrate to Goal Urine Output 0.5 ml/kg/hr

to a maximum of 40 mg/hr

(Usual range 5 mg/hr to 40 mg/hr)

 

Isoproterenol

isoproterenol/D5W 1mg/250ml

Start at 0.01 mcg/kg/min

titrate by 0.01 mcg/kg/min every 5 min

Titrate to Goal parameters:

to a maximum of 0.4 mcg/kg/min

(Usual range 0.01mcg/kg/min to 0.4 mcg/kg/min)

 

Labetalol

labetalol/NS 200mg/200ml

Loading dose 10 mg IV

Start at 2 mg/min

titrate by 1 mg/min every 5 min

Titrate to Goal SBP [      ] mmHg

Hold for HR <50

to a maximum of 8 mg/min

(Usual range 2 mg/min to 8 mg/min)

 

Lidocaine

lidocaine/D5W 2000mg/250ml

Start at 14 mcg/kg/min

titrate by 7 mcg/kg/min

Titrate to eliminate Ventricular Tachycardia

to a maximum of 57 mcg/kg/min

(Usual range 14 mcg/kg/min to 57 mcg/kg/min)

 

Milrinone

milrinone/D5W 20mg/100ml

Loading dose 50 mcg/kg over 10 min

Start at 0.375 mcg/kg/min

titrate by 0.05 mcg/kg/min q30 min

Titrate to Goal parameter:

to a maximum of 0.75 mcg/kg/min

(Usual range 0.375 mcg/kg/min to 0.75 mcg/kg/min)

 

Nicardipine

nicardipine/NS 20mg/200ml

Start at 5 mg/hr

titrate by 2.5 mg/hr every 5 min

Titrate to Goal SBP [      ] mmHg

Hold for HR <50

to a maximum of 15 mg/hr

(Usual range 5 mg/hr to 15 mg/hr)

 

Nitroglycerin

nitroglycerin/D5W 100mg/250ml

Start at 0.1 mcg/kg/min

titrate by 0.2 mcg/kg/min q3 min

Titrate to eliminate chest pain

Maintain SBP > 100 mmHg

to a maximum of 5 mcg/kg/min

(Usual range 0.1 mcg/kg/min to 5 mcg/kg/min)

 

Nitroprusside

nitroprusside/NS 100mg/250ml

Start at 0.5 mcg/kg/min

titrate by 0.5 mcg/kg/min every 2 min

Titrate to Goal SBP [      ] mmHg

to a maximum of 10 mcg/kg/min

(Usual range 0.5mcg/kg/min to 10mcg/kg/min)

 

Norepinephrine

norepinephrine/NS 8mg/250ml

Start at 0.01 mcg/kg/min

Titrate by 0.02 mcg/kg/min every 5 min

To a Goal MAP > or = 65 mmHg to a maximum of 3 mcg/kg/min

(Usual range 0.01 mcg/kg/min to 3 mcg/kg/min)

 

Phenylephrine

phenylephrine/NS 50mg/250ml

Start at 0.3 mcg/kg/min

Titrate by 0.1 mcg/kg/min every 5 min

To a Goal MAP > or = 65 mmHg to a maximum of 10 mcg/kg/min

(Usual range 0.3 mcg/kg/min to 10 mcg/kg/min)

 

Procainamide

procaineamide/NS 1000mg/250ml

Start at 1 mg/min;

titrate by 1mg/min q 20 min

Titrate to Goal parameter:

to a maximum of 6mg/min up to 24 hr

(Usual range 1 mg/min to 6 mg/min)

 

Vasopressin

vasopressin/NS 50units/250ml

Start at 0.01 units/min

Goal MAP > or = 65 mmHg

(Usual range 0.01 units/min to 0.04 units/min)

 

(米国一施設基準) 

疼痛コントロール

This order set is based on the WHO Analgesic Ladder

Directions:

1. Assess pain severity

2. Begin treatment at the appropriate step of the Ladder

3. If starting at Step 2 or 3 ensure the all appropriate medications from Step 1 are administered in addition to the current step

4. Progress through the steps until pain is controlled

 

STEP 1

- Acetaminophen 650mg PO Q4H PRN for mild pain

 

plus celebrex (with higher risk of bleeding)

- Celecoxib 200mg PO Q12H SCH

 

or ketorolac (with lower risk of bleeding)

- Ketorolac 15mg IV Q6H SCH

(maximum dose of 120mg/day for 5 days. avoid in renal dysfunction, GI bleeding, Platelet abnormality, concomitant administration of ACEI, CHF, cirrhosis, asthma)

 

Mild pain (pain score 1-3)

- oxycodone IR 5mg PO Q4H PRN

- oxycodone oral solution (5mg/5ml 5mg) 5mg PO Q4H PRN

 

STEP 2

Moderate pain (pain score 4-6)

(hydromorphone or oxycodone preferred option)

- Hydromorphone 2mg PO Q4H PRN

- Oxycodone IR 10mg PO Q4H PRN

- Oxycodone oral solution (5mg/5ml 5mg) 10mg PO Q4H PRN

- Morphine IR 15mg PO Q4H PRN

 

Unable to take PO

- Hydromorphone 0.5mg IV Q3H PRN

- Morphine 2mg IV Q3H PRN

 

STEP 3

Severe pain (pain score 7-10)

(hydromorphone preferred option) 

- Hydromorphone 4mg PO Q4H PRN

- Morphine 30mg PO Q4H PRN

 

Unable to take PO

- Hydromorphone 0.5mg IV Q2H PRN

- Morphine 4mg IV Q3H PRN

 

(米国一施設基準)

譫妄

検査

- Fingerstick Glucose

- Urine drug screen

- UA + Culture

- CBC/CMP

- Digoxin level PRN

- ABG

- EKG
- Chest portable X-ray

 

コンサルテーション

- psychiatry consult

- speech language consult

 

Medication

All Medications should be used only when non-pharmacologic interventions have failed and caution should be used when dosing these medications in the elderly

 

Caution:

* If QTc>450ms, highly recommend to discuss treatment options with psychiatry prior to ordering any medications below

* Please observe for the following: extrapyramidal symptoms

* If differential diagnosis is alcohol withdrawal or benzodiazepine withdrawal, initiate CIWA protocol

 

For hyperactive delirium with agitation, confusion, restlessness, sleep disturbance x 24 hours 

- Haloperidol 0.5/1mg PO Q2H PRN for hyperactive delirium

(total IV or PO maximum: not to exceed 10mg/24hours)

- Risperidone 0.5mg PO BID PRN for hyperactive delirium

- Quetiapine 12.5mg PO Q6H PRN for hyperactive delirium

 

For hyperactive delirium with combative behavior, spitting, throwing x 24 hours

- Haloperidol 2mg IV Q2H PRN for hyperactive delirium

(total IV or PO maximum: not to exceed 10mg/24hours)

- Risperidone 1mg PO BID PRN for hyperactive delirium

- Quetiapine 25mg PO Q6H PRN for hyperactive delirium

 

 (米国一施設基準)