FADevisM_FM.

qxp

9/12/08

7:46 PM

Contacts Phone/E-Mail
Name
Ph:

e-mail:

Name
Ph:

e-mail:

Name
Ph:

e-mail:

Name
Ph:

e-mail:

Name
Ph:

e-mail:

Name
Ph:

e-mail:

Name
Ph:

e-mail:

Name
Ph:

e-mail:

Name
Ph:

e-mail:

Name
Ph:

e-mail:

Name
Ph:

e-mail:

Name
Ph:

e-mail:

Page 2

FADevisM_FM.qxp

9/12/08

7:46 PM

Page 3

Medical
Notes
Clinical Medicine Pocket Guide

Bruce Y. Lee, MD, MBA

Purchase additional copies of this book at
your health science bookstore or directly
from F.A. Davis by shopping online at
www.fadavis.com or by calling 800-3233555 (US) or 800-665-1148 (CAN)
A Daviss Notes Book

F.A. DAVIS COMPANY Philadelphia

FADevisM_FM.qxp

9/12/08

7:46 PM

Page 4

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright 2009 by F. A. Davis Company
All rights reserved. This product is protected by copyright. No part of it may be
reproduced, stored in a retrieval system, or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher.
Printed in China by Imago
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Acquisitions Editor: Andy McPhee

Developmental Editor: Yvonne Gillam
Manager of Art and Design: Carolyn OBrien
Reviewers: Julie Z. Belcher, MD; Anna M. Choo, MD, JD; Carlos Duarte, MD; Brian G.
Dwinnell, MD; Adam D. Elkin, MD; Sam Ghaffari, DO; Shilpa Grover, MD; Naghmeh
Khodai, MD; Leslie H. Lee, MD; Elizabeth Mack, MD; John Tobias Musser, MD; Diane
E. Nuez, MS, ANP-C; Manali Indravadan Patel, MD, MPH; Mohammad Qasaymeh,
MD; Susan D. Wolfsthal, MD; Erica Young, PA; and Kevan M. Zipin, MD
As new scientific information becomes available through basic and clinical research,
recommended treatments and drug therapies undergo changes. The author(s) and
publisher have done everything possible to make this book accurate, up to date, and
in accord with accepted standards at the time of publication. The author(s), editors,
and publisher are not responsible for errors or omissions or for consequences from
application of the book, and make no warranty, expressed or implied, in regard to
the contents of the book. Any practice described in this book should be applied by
the reader in accordance with professional standards of care used in regard to the
unique circumstances that may apply in each situation. The reader is advised always
to check product information (package inserts) for changes and new information
regarding dose and contraindications before administering any drug. Caution is
especially urged when using new or infrequently ordered drugs.
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered
with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license
by CCC, a separate system of payment has been arranged. The fee code for users of
the Transactional Reporting Service is: 8036-1746/09  $.25.

FADevisM_FM.qxp

9/12/08

7:46 PM

Page 5

Place 2 78  2 78 Sticky Notes here

for a convenient and refillable pad
HIPAA Compliant
OSHA Compliant

Waterproof and Reusable

Wipe-Free Pages
Write directly onto any page of MD Notes
with a ballpoint pen. Wipe old entries off
with an alcohol pad and reuse.

FADevisM_FM.qxp

9/12/08

7:46 PM

Page 6

Look for our other Daviss Notes titles

Coding Notes: Medical Insurance Pocket Guide
ISBN-10: 0-8036-1536-1 / ISBN-13: 978-0-8036-1536-6
Derm Notes: Dermatology Clinical Pocket Guide
ISBN-10: 0-8036-1495-0 / ISBN-13: 978-0-8036-1495-6
ECG Notes: Interpretation and Management Guide
ISBN-10: 0-8036-1347-4 / ISBN-13: 978-0-8036-1347-8
LabNotes: Guide to Lab and Diagnostic Tests
ISBN-10: 0-8036-1265-6 / ISBN-13: 978-0-8036-1265-5
NutriNotes: Nutrition & Diet Therapy Pocket Guide
ISBN-10: 0-8036-1114-5 / ISBN-13: 978-0-8036-1114-6
MA Notes: Medical Assistants Pocket Guide
ISBN-10: 0-8036-1281-8 / ISBN-13: 978-0-8036-1281-5
Neuro Notes: Clinical Pocket Guide
ISBN-10: 0-8036-1747-X / ISBN-13: 978-0-8036-1747-6
Ortho Notes: Clinical Examination Pocket Guide
ISBN-10: 0-8036-1350-4 / ISBN-13: 978-0-8036-1350-8
Providers Coding Notes: Billing & Coding Pocket Guide
ISBN-10: 0-8036-1745-3 / ISBN-13: 978-0-8036-1745-2
PsychNotes: Clinical Pocket Guide
ISBN-10: 0-8036-1286-9 / ISBN-13: 978-0-8036-1286-0
Rehab Notes: Evaluation and Intervention Pocket Guide
ISBN-10: 0-8036-1398-9 /ISBN-13: 978-0-8036-1398-0
Respiratory Notes: Respiratory Therapists Guide
ISBN-10: 0-8036-1467-5 / ISBN-13: 978-0-8036-1467-3
Screening Notes: Rehabilitation Specialists Pocket Guide
ISBN-10: 0-8036-1573-6 /ISBN-13: 978-0-8036-1573-1

For a complete list of Daviss Notes and other titles for health
care providers, visit www.fadavis.com

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 1

1
Diseases and Disorders
American Cancer Society Guidelines:
Cancer (CA) Detection
Breast CA (Women)

40 y.o.: Mammogram every year

Clinical breast exam: 20-39 y.o. ~q3yr and 40 y.o. every year
Breast self-exam option for 20 y.o
20% lifetime risk: MRI and mammogram every year
15%-20% lifetime risk: discuss w/physician about MRI

Colon and Rectal CA

50 y.o. male or female: Do one of following five:
Fecal occult blood test (FOBT) or fecal immunochemical
test (FIT) every year
Flexible sigmoidoscopy q5yr
Yearly FOBT or FIT and flexible sigmoidoscopy q5yr
(preferred)
Double-contrast barium enema q5yr
Colonoscopy q10yr
Start earlier (e.g., 40 y.o.) if:
Pt history of colorectal CA, adenomatous polyps, or
chronic inflammatory bowel disease
Strong family history of colorectal CA or polyps (CA or
polyps first-degree relative 60 y.o. or two first-degree
relatives any age)
Family history of hereditary colorectal CA syndrome

Cervical CA (for Women)

~3 yr after begin vaginal intercourse or 21 y.o., whichever
comes first: Regular Papanicolaou (Pap) test every year or
newer liquid-based Pap test q2yr
When 30 y.o.:
May continue every year or change to q3yr HPV DNA test
and either conventional or liquid-based Pap test
If 3 normal Pap tests in a row, may change to q2-3yr
If risk factors*: Continue every year
*Prenatal DES exposure, HIV, or immunity

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 2

BASICS
70 y.o.: If 3 normal Pap tests in row and no abnormal Pap
last 10 years, may stop; if risk factors,* continue every year
Total hysterectomy (uterus and cervix): May stop, unless
surgery was for cervical CA or pre-CA

Endometrial (Uterine) CA (for Women)

High risk for hereditary nonpolyposis colon CA: 35 y.o.:
offer endometrial biopsy every year

Prostate CA (for Men)

50 y.o.: Offer prostate-specific antigen and digital rectal
examination every year
45 y.o. high-risk (African-American or strong family history
1 first-degree relatives [father, brothers] diagnosis 65 y.o.):
Every year
40 y.o. higher risk (multiple first-degree relatives): Every
year; if negative consider waiting until 45 y.o.

Diagnostic and Therapuetic Procedures

Electrocardiogram (ECG)
Rate (Normal: 60100 bpm)
Bradycardia: 60 bpm; tachycardia: 100 bpm

P Waves
Normal: P upright (positive), uniform, precedes each ORS
None: Rhythm junctional or ventricular
Right atrial enlargement (RAE): P 2.5 mm tall in II and/or
1.5 mm in V1; better criteria: (RVH or RV displacement
signs) QR, Qr, qR, or qRs in V1 (w/o CAD); QRS in V1 5 mm
and ratio V2/V1 voltage 6
Left atrial enlargement (LAE): P duration 0.12 sec in II;
notched P in limb leads w/interpeak duration 0.04 sec;
terminal P negativity in V1 duration 0.04 sec, depth 1 mm
Biatrial enlargement (BAE): RAE and LAE, P in II 2.5 mm
tall and 0.12 sec duration; initial and component of P in V1
1.5 mm tall and prominent P-terminal force

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

3
PR Interval (Normal: 0.120.20 sec)
Short PR (0.12 sec) Could be normal variant or:
Wolff-Parkinson-White (WPW): Accessory path RARV or
LALV so early ventricle activation leads to -wave (initial
slurring of QRS), QRS duration (usu. 0.10 sec), seconddegree ST-T s from altered ventricular activation
Lown-Ganong-Levine: AV nodal bypass track into bundle
of His early ventricle activation w/o -wave
AV junctional rhythms w/retrograde atrial activation
(inverted P in II, III, aVF)
Ectopic atrial rhythms w/origin near AV node
Prolonged PR (:0.20 sec):
First-degree AV block (PR interval usu. constant); conduction in atria, AV node, bundle of His, or bundle branch
(when contralateral bundle blocked)
Second-degree AV block (PR interval normal or ; some P
waves do not conduct): Type I (Wenckebach): increasingly
PR until a P not conducted; type II (Mobitz): fixed PR
intervals and nonconducted Ps
AV dissociation (Ps and QRS dissociated): Incomplete
(slow SA node so subsidiary escape pacemaker takes over
or subsidiary pacemaker faster than sinus rhythm) or
complete (third-degree AV block: atria and ventricles each
have separate pacemakers)

QRS Complex
Poor R wave progression (PRWP): R3 mm in V13, normal
variant, LVH, LBBB, LAFB, anterior or anteroseptal MI, COPD
(R/S ratio in V56 1) ), diffuse infiltrative/myopathic
processes, WPW pre-excitation, heart rotates clockwise,
misplaced leads
Prominent anterior forces: R/S ratio 1 in V1 or V2; normal
variant, posterior MI, RBBB, WPW pre-excite

QRS Interval (Normal: 0.60.10 sec)

QRS duration 0.100.12 sec: Incomplete RBBB or LBBB
(same as complete RBBB and LBBB except QRS duration),
nonspecific IVCD, LAFB, or LPFB (some)

BASICS

Page 3

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 4

BASICS
QRS duration 0.12 sec:
Complete RBBB: RV depolarizes after LV, second half QRS
oriented right and anterior terminal R in V1, terminal R
in aVR, and downward ST-T in both V1/aVR; terminal S and
upward ST-T in I, aVL, V6
Complete LBBB: LV depolarizes after RV, second half QRS
oriented left and posterior terminal S and upward ST-T
in V1; terminal R and downward ST-T in I, aVL, V6
Nonspecific Intraventricular Conduction Deficit (IVCD):
QRS duration 0.10 sec but not bundle branch or fascicular block criteria; causes: ventricular hypertrophy, MI,
drugs (esp. class IA and IC antiarrhythmics), K+
Ventricle-origin ectopic rhythm (e.g., VT)

QT Interval (Normal: 12 R-R interval; normal

QT 500 msec)

Beginning R wave end of T wave; varies w/HR

Bazetts formula: QTc = QT/RR (normal QTc440 msec)
QTc 0.47 sec (male) and 0.48 sec (female) long QT syndrome (LQTS): (May torsade de pointes: ventricular tachycardia w/varying QRS morphology): Drugs (e.g.,antiarrhythmics, tricyclics, phenothiazines); abnormal electrolytes (K,
Ca2, Mg2); thyroid, hypothermia, CNS dz (esp. SAH, CVA,
trauma); hereditary LQTS; CAD (post-MI)

Axis Deviation
Left-axis deviation (LAD):
LAFB: rS complexes in II, III, aVF; small Qs in I and/or aVL;
R-peak time in aVL 0.04 sec, often lurred R downstroke;
QRS duration usu. 0.12 sec unless coexisting RBBB, usu.
see poor R progression in V1V3 and deeper S in V5 and
V6, may mimic LVH voltage in aVL and mask LVH voltage
in V5 and V6
Other causes: LBBB, LVH, inferior MI, diaphragm
Right axis deviation (RAD):
LPFB: rS complex in lead I; qR in II, III, aVF, with R in III R
in II; QRS duration usu. 0.12 sec unless RBBB
Other causes: Cor pulmonale, pulmonary heart disease,
pulmonary hypertension

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 5

5
ST Segment
ST elevation
Normal variant early repolarization (usu. concave up,
ending w/symmetrical, large, upright T waves)
Ischemic heart disease: Acute transmural injury (usu.
convex up or straightened); persistent in post-acute MI
suggests ventricular aneurysm
Prinzmetals (variant) angina (coronary vasospasm)
During exercise testing tight coronary artery stenosis
or spasm (transmural ischemia)
Acute pericarditis: Concave up ST (not aVR); no reciprocal
ST (except in aVR); unlike early repolarization, usu. T
low amplitude and HR; may see PR (atrial injury)
Other causes: LVH (in right precordial leads w/large S);
LBBB; K+; hypothermia
ST Depression
Normal variants/artifacts: Pseudo ST depression (poor
skin-electrode contact); physiologic J-junctional depression
w/sinus tachycardia; hyperventilation
Ischemic heart disease: Subendocardial ischemia, non
Q-wave MI, reciprocal s in acute Q-wave MI (e.g., ST
depression in leads I and aVL with acute inferior MI)
Nonischemic causes: RVH (right precordial leads) or LVH
(left precordial leads, I, aVL), digoxin, K+, MVP (some),
CNS dz, second-degree to IVCD (e.g., WPW, BBB)

T Wave
Normal: T same direction as QRS except in V2; asymmetric
w/first half moving more slowly than second half; T always
upright in I, II, V36, and always inverted in aVR
T-wave inversions: Normal variant, myocardial ischemia or
infarction or contusion, pericarditis (subacute or old),
myocarditis, CNS dz QT (esp. SAH), idiopathic apical
hypertrophy, MVP, abnormal electrolytes, O2, CO2, pH, or
temperature, digoxin, post-tachycardia or -pacing, RVH and
LVH w/strain

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

BASICS
U Waves (Normal: Same Polarity and Usually
1/3 Amplitude of T)

Normal: Asymmetric w/ascending limb move more rapidly

than descending limb (opposite to normal T)
Prominent upright U: Sinus bradycardia, K, Quinidine and
other type 1A antiarrhythmics, CNS dz (long QT), LVH, MVP,
thyroid
Negative or inverted U: Ischemic heart dz, MI (in leads
with pathologic Q waves), angina, coronary vasospasm
(Prinzmetals angina)
Nonischemic causes: Some cases of LVH or RVH (usu. in
leads with prominent R waves), LQTS

Myocardial Infarction
Q-wave MI: Total coronary occlusion
Non Q-wave MI: Subtotal occlusion
More leads with MI changes (Q waves and ST elevation)
larger infarct size and worse prognosis

Evolution of Q-Wave MI
Q*
Pre-MI
Hyperacute
Transmural Injury
Necrosis
Necrosis/Fibrosis
Fibrosis

ST

Amplitude/width

May

Less

Terminal inversion
Inversion
Upright

*Pathologic: duration 0.04 s or 25% R-amplitude

Conditions resembling MI: WPW pre-excitation (negative

-wave ~ pathologic Qs); IHSS (mimic pathologic Qs); LVH
(QS or PRWP in V1-3); RVH (tall R in V1 or V2); LBBB (QS or
PRWP in V1-3); pneumothorax (no right precordial R);
COPD/cor pulmonale (no R V1-3 and/or inferior Q and RAD);
LAFB (Qs anterior chest leads); acute pericarditis (ST); CNS
dz (diffuse ST-T wave s)

Page 6

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 7

7
Atrial Arrythmias
Premature atrial complexes: Single or repetitive, unifocal or
multifocal, ectopic P (P) may hide in preceding ST-T; PR
interval nl/; P may be nonconducted, conducted w/aberration
(e.g., wide QRS), or conducted normal
Premature junctional complexes: Retrograde P appears
before (PR usu. 0.12 sec), during, or after QRS
Atrial fibrillation: Poorly defined atrial activity; appearance
may ~old saw; ventricular response = irregularly irregular
unless AV block
Atrial flutter: Regular atrial activity w/clean sawtooth appearance in II, III, aVF, and usu. discrete P in V1; atrial rate = 150450/min; AV conduction ratio may vary 2:1, 3:1, etc
Ectopic atrial tachycardia and rhythm: Ectopic, discrete,
unifocal P w/atrial rate 250/min (100 rhythm); ectopic
P' waves usu. precede QRS w/P'R interval RP' interval;
ventricular response: 1:1 or varying AV block
Multifocal atrial tachycardia and rhythm: Three different P
morphologies in given lead; rate = 100-250/min (100
rhythm), varying P'R intervals; ventricles: irregularly irregular
(i.e., often confused with atrial fibrillation); may be intermittent
Paroxysmal supraventricular tachycardia: Different re-entry
cicuits; sudden onset and stop; usu. narrow QRS (unless BBB
or rate-related aberrant ventricular conduction); types: AV
nodal re-entrant tachycardia, AV reciprocating tachycardia,
sinoatrial re-entrant tachycardia
Junctional rhythms and tachycardias:
Junctional escape beats: Origin AV jxn; rate: 40-60 bpm
Junctional escape rhythm: 3 Junctional escapes; rate
40-60 bpm; may be AV dissociation or retrograde atria
Accelerated junctional rhythm: Rate = 60-100 bpm
Nonparoxysmal junctional tachycardia: HR 100 bpm

Ventricular Arrythmias
Premature ventricular complexes (PVCs): May be unifocal,
multifocal, or multiformed; may be isolated single events or
couplets, triplets, or salvos (4-6 in row); may occur early in cycle
(R-on-T), after T, or late in cycle (fuse w/next QRS = fusion beat)

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 8

BASICS
Ventricular tachycardia (VT): Sustained (30 sec) vs. nonsustained; monomorphic vs. polymorphic vs. torsade-de-pointes
(polymorphic associated w/LQTS; phasic variations QRS
polarity; rate often 200 bpm; may Vfib); AV dissociation
vs. retrograde atrial capture; Consider wide complex
tachycardia is VT if: AV dissociation, axis deviation, QRS
morphology atypical for BBB, concordance (all precordial
leads in same direction), regular rhythm (RR intervals equal,
irregularly irregular rhythm suggests atrial fibrillation
aberration or WPW pre-excitation), QRS morphology ~previous PVCs, very wide QRS complexes (0.16 sec), no RS
V1-V6, beginning of R to nadir S 0.1 sec in any RS lead

Lumbar Puncture
Indications
Dx CNS disease, administer CNS treatment or treat
hydrocephalus

Contraindications
Intracranial pressure (ICP); intracranial mass effect (r/o mass
lesion: head CT when signs of ICP)
Bleeding dysfunction
Infection near site
Elderly: avoid fast and large volume withdrawals.

Equipment
Skin preparation: sterile sponges, povidone-iodine swabs,
and EtOH swabs
Mask, sterile field (towels and drapes), and gloves
Local anesthetic, usu. lidocaine 1% plain
Syringe (3 mL) and needles (22-G 1.5, 25-G 5/8)
Spinal needles (both 18- and 20-G, 3 length)
Three-way stopcock, sterile collection tubes, and manometer
Gauze dressings and adhesive bandage

Preparation
Sterile technique; skin preparation
Find L4-5 space (L4 at iliac crest level)

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 9

9
Local anesthesia: infiltrate skin (25-G needle), then to 22-G
needle and advance infiltrate deeper tissue

Patient Positioning
Lateral decubitus: (preferred): Lateral decubitus position at
edge of bed, while maximally flexing knees (near chest),
hips, and back (opens L3/L4 space) pt. shoulders and hips
perpendicular to bed
Sitting: (easier for obese or spinal dz/deformity): Pt. sits at
bed edge, leans over two pillows, flexes head

Technique
Insert spinal needle into skin and slowly advance (keep perpendicular to skin, hold w/two hands, keep stylet in place);
feel pop; perforate ligamentum flavum; withdraw stylet,
and look for CSF drainage
If no CSF and needle advanced 4 cm (in adult), advance 2 mm,
remove stylet, and check for CSF drainage; repeat until get CSF
or needle advanced 4 cm (then withdraw and redirect needle)
Connect three-way stopcock, and attach manometer;
measure opening pressure (normal 70-180 mm CSF)
Send fluid for studies; remove needle and dress wound;
pt. remains supine 12 h (minimize headaches)

Complications
Brain herniation ( ICP and mass), infection (meningitis or empyema),
subdural hematoma (rapid withdrawal of large volume CSF), bloody
tap, spinal epidural hematoma, headache, dry tap needle may be
too lateral or deep
For CSF interpretation see Labs Tab

Cricothyroidotomy
Indications
Emergent need for airway; airway obstruction above cricoid
cartilage level, failed intubation, or laryngeal trauma, mass,
or hematoma

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 10

BASICS
Contraindications
Subglottic airway obstruction
Intubation possible
Uncorrectable coagulopathy

Equipment

Suction
Local anesthesia (e.g., 1% lidocaine and 1:100,000 epinephrine)
Scalpel (ideally, No. 15 blade)
Retractors (Army-Navy or large vein refractors)
Kelly clamps
Suture (2-0 or 3-0 silk, 4-0 vicryl)
Cuffed tracheostomy tubes (preferable) or No. 4 or 5 small,
flexible endotracheal (ET) tubes.

Preparation
Palpate and locate cricothyroid ligament: between cricoid
and thyroid cartilages (~1.5 cm inferior to thyroid cartilage);
neck strap muscles lateral to ligament

Patient Positioning
Neck extended (unless cervical injury)

Technique
Sterilely prepare and drape skin
If enough time, infiltrate entry site with lidocaine
Scalpel 3 cm horizontal (risk of thyroid or cricothyroid
cartilage damage) or vertical (better in obese when cannot
palpate cricothyroid membrane) incision over center of
cricothyroid membrane
Gently spread subcutaneous tissue w/clamp expose
cricothyroid membrane; may need retractors to spread neck
strap muscles laterally
Avoid blood vessels, use scalpel to cut horizontally through
membrane; may widen incision with clamp
Insert tracheostomy tube or endotracheal tube
Inflate tube cuff; suture or tie down tube
Ventilate w/Ambu bag
to formal tracheostomy 1 week (or risk stenosis)

Complications
Bleeding, subglottic/glottic stenosis, chondritis

10

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 11

11
Endotracheal Intubation
Indications
Significant CO2 or O2 from respiration
Protect airway or pulmonary toilet

Contraindications
Only intubate if necessary
Inaccessible/damaged oral cavity/larynx nasal intubation
(if no coagulopathy, severe intranasal problems, basilar skull
fracture, or CSF leak)
Cervical spine instability

Equipment

Lubricant: Water-soluble 2% lidocaine jelly

Tape and skin adhesive
O2 and bag-valve-mask ventilation device (Ambu bag)
If available: O2 saturation monitor,in-line CO2 monitor
Suction apparatus, suction tubing, tips, catheters
Laryngoscope w/straight and/or curved blade
Endotracheal tubes; syringe (10 mL) inflate cuff
Flexible metal stylet and Magill forceps
Anesthesia

Recommended ET Parameters (for nasal:

add 2 cm to each measurement)
Age
ET Tube
Diameter (cm)
Blade (cm)
Insert: Lips to
Mid-Trachea
(cm)

BASICS

Pree- Neomie nate

6 mo

1-2
yr

45 55.5
12
2

2.5
0

33.5
01

3.54
1

10

11

1112

4-6
yr

8-12
yr

Adult

67
23

7.58.5
45

12 (age/2)

:~23
~21

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

BASICS
Preparation

Rapid-sequence intubation: IV sedative (etomidate)

sedated, then IV muscle relaxant (succinylcholine); may add
sedative (fentanyl or morphine), lidocaine, and/or -lasting
paralytic (vecuronium)
Awake intubation: Topical anesthetic, mild sedative and
analgesic; stomach should be empty
Test laryngoscope; monitor HR, BP, and SaO2

Patient Positioning
Extend head and flex neck; if possible (i.e., no cervical spine
problem), place foam material, doughnut, or folded towel
under occiput

Technique
Ventilate pt. w/bag-valve-mask; assess airway
Remove foreign bodies (e.g., dentures)
Assistant: Continuously push back anterolateral cricoid cartilage rim with first and second fingers until tube is placed
Open laryngoscope; use dominant hand to open mouth and
nondominant hand to insert laryngoscope blade into right
(left if left-handed) side of mouth
Sweep blade to midline tongue base (sweep tongue to other
side); blade tip should be in valleculae (curved blade) or
below epiglottis (straight blade)

12

Page 12

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 13

13
Lift laryngoscope handle straight upward and forward
expose vocal cord; avoid lips, teeth, and trap tongue; using
dominant hand pass lubricated ET tube through right (left if
left-handed) corner of mouth and advance tip through vocal
cords (while looking)
Remove stylet when proximal cuff ends at cord level
Advance tube into trachea; inflate cuff (~15 mm Hg); check
placement: symmetric chest expansion, breath sounds both
lungs (no breath in stomach)
Attach in-line CO2 monitor: Check for O2 saturation and CO2
in exhaled air
Secure tube w/tape (upper lip and cheek or neck)
Check chest x-ray (tip should be 4 cm above carina)
Once tube in place, longer-term sedation (aerosol benzocaine
[20%] tongue and posterior pharynx, midazolam or
thiopental, fentanyl or morphine)

Complications
Tube in esophagus or right mainstem bronchus
Aspiration (may risk w/antacids, H2-blockers,
metoclopramide, head-up positioning)
Damage to lips, teeth, tongue, airway

Pericardiocentesis
Indications
Cardiac tamponade
pericardial effusion hemodynamics

Contraindications
Coagulopathy/bleeding dysfunction
Skin infection over needle insertion site

Equipment

Skin preparation supplies, sterile gloves, towels/drapes

Local anesthetic (1% or 2% lidocaine, 25-G needle, 3-mL syringe)
Pulse oximeter, ECG monitoring (V lead)
16- to 18-G spinal needle and No. 11 blade
20-mL syringe and sample tubes

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 14

BASICS
Preparation
Continuous ECG monitoring (30 semi-Fowler position preferred); if V lead attached to pericardiocentesis needle
sensitivity; an insulated wire with alligator clips at each end
works well
Prepare skin; sterile technique; wear sterile gloves, mask,
and gown; drape over xiphoid area
Local anesthesia (infiltrate skin 1%-2% lidocaine)

Patient Positioning
Supine with thorax (i.e., head of bed) elevated 30-45 degrees

Technique
Needle: Insert (2 cm below costal margin to left adjacent to
xiphoid with blade) and direct (upward and posterior) at
45-degree angle for 4-5 cm; aim toward right (preferable) or
left (risk penetrate RV) scapular tip
Advance (aspirate continuously) needle until encounter fluid,
check for cardiac pulsations, or ST on ECG. May feel needle
enter cavity
Remove blood: (usu. 5-10 mL because most is clotted); if
20 mL, then probably in RV
If hemodynamics do not improve, then may need
thoracotomy or local pericardial window excision
Send fluid for appropriate studies

Complications
Myocardial wall injury/penetration, myocardial infarction, pneumothorax, bowel perforation

Arterial Line
Indications
Hemodynamic monitoring
Arterial blood sampling
Frequent blood draws

Contraindications
Infection or lesion at insertion point
Occlusion or thrombosis of artery

14

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 15

15
Uncorrectable coagulopathy
Systemic infection (use peripheral site)

Equipment
Peripheral arterial line (with angiocatheter): Angiocatheter
(20- or 22-G, 2 length) or arterial line kit, sterile scalpel
Femoral arterial line (Seldinger technique): Seldinger kit:
needle (16-18 G), 10-mL syringe, guide wire, sterile scalpel,
dilator, catheter
Skin preparation supplies
Local anesthetic (1%-2% lidocaine, 25-G needle, 3-mL syringe)
Sterile gloves, towels or drapes, dressing supplies
Heparinized saline (pressurized delivery system)
Blood gas syringe (for arterial blood sampling)
Another 5-mL syringe w/heparinized saline
Sutures
Arterial pressure monitoring equipment
Arm board w/terrycloth roll

Preparation
Peripheral (radial): Nondominant hand: perform Allen test
(compress radial and ulnar arteries palm blanches; release
ulnar artery and check reperfusion of palm; delay 5 sec =
abnl choose another site) to confirm collateral circulation
Use sterile technique; prepare and drape skin
Use lidocaine to infiltrate entry and suture points

Patient Positioning
Peripheral: Usu. radial artery but can do dorsalis pedis; pt.
seated and supine; immobilize wrist on arm board w/roll
under wrist in slight dorsiflexion
Femoral: Supine

Technique
Peripheral Arterial Line (Angiocatheter)
Locate pulse w/index finger of nondominant hand; small
incision w/scalpel over entry site
Insert angiocatheter at 3045 to artery bright pulsatile
red blood freely catheter; slowly advance catheter until
flow stops; withdraw slightly until blood pumps again;
advance catheter over needle into vessel

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 16

BASICS
Femoral Arterial Line (Seldinger Technique)
Locate pulse and make small incision w/scalpel
Connect 10-mL syringe to needle and insert needle at 45 to
artery while aspirating on syringe
Insert and withdraw (while aspirating) needle until bright red
blood pumps into syringe detach syringe and use finger to
block off hub of needle
Push guidewire through needle (should be no resistance);
remove needle over wire
Cut incision larger so dilator can enter
Use dilator over wire to expand hole, then remove
Apply gentle pressure if bleeding
Push catheter over wire through hole into artery
Remove wire; check for bright red pulsatile blood in catheter
hub

For Peripheral or Femoral Arterial Line

If no blood, remove catheter and retry insertion; if still no
blood, try flushing needle w/heparinized saline; if not
successful third time, try another site; cap catheter
Suture catheter to skin; draw blood samples prn and attach
manometer; sterile dressing

Removal of Arterial Line

Wear gloves; remove sutures, then catheter
Confirm removed catheter is intact
Firm pressure to entry site for 10 min (longer when large
lumen or anticoagulation)
After bleeding stopped, apply pressure dressing
Next day: check blood flow to extremity

Complications

Vessel perforation or thrombosis; limb ischemia*

Dislodged or loose connections to line
Incorrent placement or malfunction of line
Air embolus*
Infection, suppurative thrombophlebitis, sepsis*
Bleeding (apply pressure/additional sutures)

*Remove line immediately

16

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 17

17
Central Line
Locations
Femoral vein: Easy access; far from airways and lungs, but
area can be dirty and prevent pt. from walking
Internal jugular (IJ) vein: Bleed risk, but poor landmarks and
can puncture carotid artery
Subclavian vein: Comfortable; clear landmarks; but risk of
pneumothorax or bleeding

Indications

Hyperalimentation or long-term IV therapy

Give medications (e.g., vasoactive/inotropes, phlebitic)
Hemodialysis or rapid fluid administration
Intracardiac pacing
Central venous pressure monitoring

Contraindications
Subclavian: Pulmonary function (COPD, asthma), high levels
of PEEP, coagulopathy, superior vena cava thrombosis, upper
thoracic trauma
IJ: Tracheostomy, pulmonary secretions
Femoral: Vena caval compromise (clot, extrinsic
compression, IVC filter), local infection, cardiac arrest or low
flow states, requirements for pt. mobility.

Equipment

Central line kits are available

Skin preparation supplies (iodine, chlorhexidine, or EtOH)
Local anesthetic (1%-2% lidocaine, 25-G needle, 3-mL syringe)
Sterile gloves, dressings, towels or drapes
Supplies for Seldinger technique (or specific intravascular
access kit)
Needle (16- to 18-G): For IJ lines, only insert needle 0.5-1.0
(1.5 may pneumothorax); 10-mL syringe
Guidewire, scalpel, dilator, catheter
If the Seldinger technique is not used, a catheter-over-needle
system may be used
Heparinized saline

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 18

BASICS
Suture
Central venous pressure monitoring device
May need ultrasound if difficulty inserting

Preparation
For both insertion and removal: Use sterile technique; sterile
gown, hair cover, face mask/shield
Skin preparation; sterile drapes
Flush catheter w/saline
Liberally infuse area w/local anesthetic

Patient Positioning
Femoral: Supine; stand on side of your dominant hand (right
side of pt. if you are right-handed)
IJ: Supine; turn pt. head 45 away from insertion side;
remove pillow from under pt. head and place pt. in
Trendelenburg position
Subclavian: Trendelenburg position, remove pillow, towel
roll between scapulae

Insertion Points
Femoral vein: One finger breadth medial to artery and two finger breadths inferior to inguinal ligament; with bevel up and
at 4560 above skin, insert needle parallel to vessel (steeper
angle risk of entering peritoneum; more medial insertion
angle less chance of needle entering femoral artery)
IJ: Lateral to carotid; Landmark: Apex of triangle (clavicle and
two heads of sternocleidomastoid) OR between sternal notch
and mastoid process; insert needle at 70 to skin, and aim for
ipsilateral nipple
Subclavian: 2 cm inferior to junction of lateral third and
medial two thirds of clavicle and 2 cm above suprasternal
notch; finder needle may be too short to reach vein

Needle Approach
Femoral vein: With bevel up and at 45-60 above skin, insert
needle parallel to vessel (steeper angle risk of entering
peritoneum; more medial insertion angle chance of entering femoral artery)
IJ: Insert needle at 70 to skin and aim for ipsilateral nipple;
aim lateral; if unsuccessful, withdraw and carefully go

18

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 19

19
slightly medial; reassess landmarks; can use long (~3)
angiocatheter instead of regular needle
Subclavian: Insert needle bevel up; guide placement w/
nondominant hand: place index finger at sternal notch and
thumb at clavicle; keep needle parallel to floor and first aim
for clavicle; when hit clavicle, walk needle down (push on
needle tip; do not push on syringe) until just below clavicle;
then advance needle 4-5 cm; once find vein, rotate needle
90 so that bevel faces caudally; if no blood, withdraw and
redirect more cephalad

Technique
Make sure you continuously aspirate while advancing or
withdrawing needle
Using appropriate insertion point and approach, locate vein
w/finder needle (optional w/femoral vein)
Aspirate venous blood w/finder needle, then insert large-bore
needle at same site and at same angle; use nondominant
hand to grab needle hub and lower needle to parallel vein
and aspirate again to reconfirm flow (may use transducer to
confirm venous blood); hold needle in place, remove syringe,
and thread guidewire into needle; check for ectopy
Remove needle over guidewire and continue to hold wire
w/gauze; do not let go of guidewire until removed
Make incision 34 mm (w/scalpel) through skin and fascia; push
dilator 34 cm over guidewire to expand subcutaneous tissue
Thread catheter over guidewire
Advance catheter and remove guidewire
Aspirate blood and flush each port
Suture line in place and consider spacer in small pt
STAT chest x-ray to r/o PTX and check line placement

Removing Central Lines

If line tunneled/trapped, may have to remove under
fluoroscopy
Place pt. in Trendelenburg position (reverse Trendenlenburg
for femoral lines) and remove any pillows
Remove all bandages, gauze, and all suture material
Pt. should hum or Valsalva maneuver during line removal
Apply sterile dressing (gauze and occlusive dressing)

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 20

BASICS
Complications
Nonplacement/misplacement/nonfunction of line, dislodged line,
infection, suppurative thrombophlebitis, catheter-related sepsis,
pneumothorax, catheter/guidewire embolism, air embolism, vessel
thrombosis, central vein thrombosis, hemorrhage, arrhythmias,
myocardial or central vein perforation, pericardial tamponade,
infection, hematoma, subcutaneous emphysema or fluid infiltration, arterial puncture/laceration, hemorrhage

Swan-Ganz (SG) Catheters

Indications

Acute heart failure or severe hypovolemia

Hemodynamic instability
Severe pulmonary disease
Sample blood and determine cardiac output

Contraindications

Infection or lesion at entry point

Occlusion or thrombosis of desired vessel
Uncorrectable coagulopathy
Caution: systemic infection

Equipment

Skin preparation (iodine, chlorhexidine, or EtOH)

Local anesthetic (1%2% lidocaine, 25-G needle, 3-mL syringe)
Sterile gloves, towels or drapes, dressings
Seldinger supplies: Needle (1618-G), syringe (10 mL), guide
wire, scalpel, dilator, catheter
Catheter supplies: SG catheter, monitor, protective sheath,
syringe (3 mL),heparinized saline
Sutures

Preparation
Prepare and drape skin; sites: subclavian (preferred), internal
jugular (preferred), or femoral veins
Local anesthesia: Infiltrate skin entry site
SG catheter: Flush each lumen w/heparinized saline; check
balloon (inflate w/11.5 mL air); attach pressure monitor and
infusion ports

20

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 21

21
Keep catheter in protective plastic container until zeroing procedure complete; remove catheter from plastic container and
move tip w/wrist flick appropriate waveform (monitor screen)

Patient Positioning
Subclavian or IJ: Supine and 15 Trendelenburgs position;
turn pt.s head away from entry site; place roll under spine
between shoulder blades
Femoral: Supine and flat

Technique

Pressure in mm Hg

Use sterile technique

Connect 10-mL syringe to needle; small incision w/scalpel;
Seldinger technique: cannulate vessel w/needle, pass wire
through needle into vessel (no resistance) and widen passageway w/dilator; thread introducer over wire into incision
Remove wire and aspirate blood to confirm placement
Flush w/normal saline or heparin solution
Tightly cap introducer; suture introducer to skin
Insert flushed and zeroed SG catheter; another person
needed to inflate/deflate balloon during placement
Thread catheter through sheath protector; move protector
out of way to end of catheter
Watch pressure monitor while advancing catheter; when
catheter tip clears introducer, inflate balloon 1-1.5 mL;
balloon floats catheter w/blood flow RA and through
heart; check for distinctive pressures
Further advance catheter wedge balloon in PA
Right
atrium

BASICS

Right
ventricle

Pulmonary
artery

Pulmonary
capillary
wedge
pressure

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 22

BASICS
When wedged, deflate balloon and confirm return of
pulsatile pulmonary artery pressures
Reinflate balloon and reconfirm wedge position
Record appropriate pressures
Pull protective sheath over catheter and attach to introducer;
confirm introducer well sutured and caps tight; chest x-ray to
confirm placement
Check every day for infection; catheter over wire q37d

If Catheter Does Not Place Easily

Deflate balloon, then pull catheter back and advance again;
flush catheter w/5-10 mL cold saline to stiffen; occasionally,
fluoroscopy needed

Removal
Wear gloves; pt. supine; deflate balloon
Slowly remove catheter; may leave introducer for venous
access; clean entry site w/sterile soap
Remove sutures; remove IV lines from transducer; pt. holds
breath while remove introducer; check that entire catheter
removed
Firm pressure at entry point 10 min; if bleeding stops
occlusive dressing 24-48 hrs; culture catheter tip
Check site next day for infection or bleeding

Complications
See complications for central venous lines; in addition, may
cause pulmonary artery perforation, pulmonary infarction, cardiac arrhythmias

Thoracentesis
Indications
Diagnostic: Most new effusions, unless clear clinical dx with
no e/o pleural space infection
Therapeutic: Dyspnea from large pleural effusion; also may
aid work-up of large effusion

Contraindications
No absolute contraindications
May need platelets/factor replacement: e.g., platelets
50,000, PT/PTT 2 normal

22

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 23

23
Relative contraindication: Cellulitis or herpes zoster at needle
puncture site
Caution: mechanical or manual ventilation

Equipment

Sterile towel, gauze pads, dressing, drape w/fenestration

Basin for preparation solution
Syringe(s) (10-20 mL)
Needles (22- and 25-G) for infiltration
Povidone iodine
Local anesthetic (e.g., 1% lidocaine): 10 mL
Heparin: 1 mL
Atropine: Available at bedside (for vasovagal reaction)
Syringe (50- to 60-mL) for aspiration
Sterile drainage tubing
Three-way stopcock
Needle or needle catheter (depends on technique): Hypodermic
needle (1822-G, 1.52), over-the-needle catheter (1620-G
needle) or through-the-needle catheter (1418-G needle)
Scalpel (needle catheter technique only)
Sterile specimen bowl or Vacutainer bottle
Analysis containers: Iced blood gas syringe, specimen tubes
(red-top and purple-top), sterile transport media for culture
or 10-mL sterile container, 5 red-top specimen tubes for
cytology or 10- to 50-mL plain bottle

Preparation
Start IV; draw serum protein and LDH
Pulse-oximetry monitoring; O2 as needed
Diagnostic: Premoisten 50 to 60-mL collection syringe with
1 mL heparin (100 U/mL) to prevent clotting
Sterile technique, prepare skin with antiseptic; place sterile
towels/drape around site
Effusion height: Percussion and tactile fremitus

Patient Positioning
Upright (preferred): Pt. sits erect on bed edge and extended
arms rest on bedside table; large effusion pt. leans
forward slightly; insert needle posterior rib at least one
interspace below top of effusion; midscapular or posterior
axillary line

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 24

BASICS
Lateral decubitus: Effusion side down, back at bed edge;
insert needle posterior axillary line
Supine: Head elevated; insert needle midaxillary; needle
should not be lower than 8th intercostal space (ICS)

Technique
Needle technique: (Diagnostic only small volumes) simple
20- or 22-G needle
Needle catheter technique: Insert catheter over or through
needle and leave in pleural space

1. Use 25-G needle and syringe w/510-mL anesthetic

2. Raise skin wheal at rib upper edge in midscapular or posterior axillary line
3. 25-G 3.75-cm 22-G needle (on anesthetic syringe)
4. Insert 22-G needle through wheal and infiltrate
subcutaneous tissue, muscle, and rib periosteum
5. Advance needle 1-2 mm aspirate subcutaneous
tissue/muscle infiltrate small amount anesthetic
6. Repeating step 5 walk needle above ribs superior
edge and advance through ICS until pleural space
7. Hold needle perpendicular to chest avoid trauma to
neurovascular bundle of adjacent rib
8. When enter pleural space (may feel pop), aspirate fluid to
ensure pleural space reached
9. Withdraw needle (grasp with thumb and index finger)
10. No fluid dry tap (i.e., missed area)
11. Air bubbles enter lung parenchyma (too high)
12. Postprocedure chest x-ray

Terminate Procedure When

Diagnostic: Removal 50-100 mL fluid
Therapeutic: Dyspnea relief or removal 1000 mL fluid
May remove larger volumes if monitor pleural pressures
q200 mL for second liter and then q100 mL; terminate if
pleural pressure -20 mm Hg
Aspirate air suggests lung puncture or laceration, unless
needle 20-G (making pneumothorax unlikely)
Sx: e.g., abdominal pain, SOB
Persistent cough

24

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 25

25
Complications
Pneumothorax, cough, infection, hemothorax, splenic rupture,
abdominal hemorrhage, unilateral pulmonary edema, air
embolism, retained catheter fragment

Lights Criteria (Pleural Fluid = Exudate)

1) Pleural fluid:serum protein ratio 0.5; 2) Pleural fluid LDH
2/3 upper limit of normal serum LDH; 3) Pleural fluid:serum
LDH ratio 0.6

Special Pleural Fluid Assays

Assay
Amylase
Triglycerides
Glucose
Urea or creatinine
Cytology

Diagnosis Suspected
Pancreatitis, esophageal rupture
Chylothorax, intrathoracic total
parenteral nutrition
Rheumatic effusion
Urinothorax
Malignancy

Diagnostic Features of Pleural Fluid

WBC
Main
Pleural Fluid
Description
Count
WBC Glucose
Parapneumonic Turbid

PMNs

Empyema
Turbid,

PMNs

purulent
TB
Straw color,
10,000 Both

serosanguinous
Malignant
Turbid, bloody 10,000 Monos

effusion
PE/infarct
Straw color,

Both
Serum
bloody
Collagen vasTurbid

Both
cular disease

RA
Green

Both
Serum
SLE
Yellow

Both
Hemothorax
Bloody

PMNs Serum

BASICS

pH
7.3
7.3
7.4
7.3
7.4

7.3
7.3
7.3

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 26

BASICS
Nasogastric and Feeding Tubes
Indications
Nasogastric Tubes
Diagnostic gastric lavage: Check for GI bleed
Decompress stomach: Ileus, GI obstruction, persistent vomiting, preabdominal surgery
Removal toxins and pill fragments
Heating or cooling (temperature abnormalities)
Prevent aspiration (e.g., trauma)
Deliver medications, feedings, contrast, or charcoal

Feeding Tubes
Enteral feeding or medication delivery

Contraindications
Facial fracture: (Use mouth instead)
Possible cervical spine injury (use extreme caution)
For feeding tube only: Adynamic ileus, malabsorptive
syndromes, intestinal obstruction, gastroenteritis

Equipment
16-18 Fr nasogastric tube or feeding tube
Lubricant jelly (K-Y or lidocaine)
Topical anesthetic (e.g., Hurricane spray)* and nasal
vasoconstrictors (e.g., phenylephrine)*
Emesis basin; cup of water and straw
Catheter tip syringe
Suction apparatus
Gloves and eye protection, stethoscope, tape, benzoin

Preparation
Wear gloves and eyewear when place or remove tube
Estimate tube length = patients ear to umbilicus
Premedication: Spray anesthetic throat back; apply
vasoconstrictor and topical anesthetic nasal mucosa
Liberally apply lubricant along tube/tube tip
*Optional

26

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 27

27
Patient Positioning
Upright or decubitus, neck flexed

Technique

Turn on suction apparatus (w/tonsil tip attached)

Pt. should hold emesis basin and cup of water
Insert tube in nostril toward occiput
Apply firm, constant pressure to tube while pt. takes small
sips of water and swallows
Advance until two black lines on tube visible out of nares
and nose between second and third black lines
Hold tube firmly in place close to nostril
Check placement in stomach: Attach catheter tip syringe to
tube and inject 30-60 mL air; use stethoscope to hear air
whoosh over epigastrium; use syringe to aspirate gastric
fluid (normal pH 5)
Secure tube in two places (nose and second site like
forehead or shoulder) w/benzoin and tape
Abdominal x-ray to confirm placement (not necessary if
suction applied)
Mark tube near nose to track proper placement
Record suction output volume and character

For Feeding Tube

Same procedure as nasogastric tube except:
Often need to place tube in duodenum or jejunem so:
Advance tube additional 20-40 cm
Pt. lays on right side for 8-12 hr
Fluid aspirate pH 7
May use metoclopramide or erythromycin to gastric
motility enhance tube passage
May need fluoroscopy to place
Do not use tube (or remove guidewire, if present) until check
abdominal plain film for placement

Tube Removal
Disconnect tube from suction; remove tape
Pull steadily to remove tube; discard tube

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 28

BASICS
Complications
Gagging during placement: spray more topical anesthetic
to back of throat
Difficulty passing tube tube stuck in nose (try other nostril), coils in mouth or esophagus (use ice to chill/stiffen tube)
Placement in lung (coughing): Remove immediately
Hypovolemia from nasogastric tube output: IV fluids
0.51 mL LR or NS and 30 mEq KCI/L for every mL of output
If tube blockage, try any or all of following:
Check tube: Inject air into vent port and listen for hissing
(which is normal)
Disconnect/reconnect apparatus or reposition tube
Irrigate tube w/3040 mL NS
Throat discomfort: Throat lozenges prn
Aspiration pneumonia
Trauma to nasal mucosa, nares, sinus orifices ( sinusitis),
lung, esophagus, gastric mucosa
Tube too low (NGT drains drain bile)
Tube too high (aspiration risk)

Paracentesis
Indications
Therapeutic: Massive ascites respiration, pain
Diagnostic: distinguish transudative vs exudative ascites
Dx spontaneous bacterial peritonitis, malignant, chylous

Contraindications

Coagulopathy
Abdominal adhesions
Agitation
Significantly distended bowel
Pregnancy
Infection (e.g., cellulitis at insertion site)

Equipment
Paracentesis kits available
Skin preparation supplies

28

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 29

29
Local anesthetic (1%2% lidocaine, 25-G needle, 3-mL
syringe)
Sterile gloves, towels or drapes, and dressing
Spinal needle (20-G)
Syringe or vacuum bottle
Scalpel, #11 blade
Butterfly needle (20-G with sterile tubing)

Preparation
Decompress bladder (void or urinary catheterization)
ID flank region (gas-filled bowel will float to top); avoid
previous incisions
Prepare skin; sterile technique; prepare and drape skin
Local anesthesia: Infiltrate skin entry site, lower fascial levels
and peritoneum
Ultrasound guidance: If previous abdominal surgery or
infection

Patient Positioning
Supine or sitting (leaning forward: better w/small amount of
fluid); raise bed so pt. is comfortable

Technique
Sterile technique
Insert and advance 20-G spinal needle w/stylet until feel
peritoneum give
Remove stylet; attach syringe and advance needle (5-mm
increments) while aspirate until get fluid
If remove large volume: Connect tubing btween spinal needle
and (butterfly needle) vacuum bottle; placing soft catheter
(Seldinger technique) into peritoneal cavity may help
Remove needle and sterile dry dressing over site
Send fluid for appropriate tests

Complications
Perforate organ or blood vesel, bleed/hematoma,
persistent site leakage, infection, leaving catheter in
abdominal cavity, hypotension, dilutional Na,
hepatorenal syndrome

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 30

BASICS
Peritoneal Fluid Assays
Assay
Amylase
Triglycerides
RBC count 50.000/L
WBC 350/L
PMNs
Mononuclear cells
pH7

Diagnosis Suspected
Pancreatitic
Chylous
Hemorrhagic ascites (malignancy,
TB, or trauma)
Infection (spontaneous bacterial
peritonitis)
Bacterial
TB or fungal
Infection

Serum-Ascitic Albumin Gradient (SAAG)

=AlbuminSerumAlbuminAscites from same day
High (1.1 g/dL)
Portal hypertension (transudative): CHF,
cirrhosis, EtOH hepatitis, fulminant
hepatic failure, portal-vein thrombosis
Low (1.1 g/dL)
Exudative: Peritoneal carcinomatosis,
pancreatic/biliary ascites, peritoneal TB,
nephrotic syndrome, serositis, bowel
obstruction/infarction

Diagnostic Peritoneal Lavage (DPL)

Indications
Acute abdominal trauma with coincident major nonabdominal
injury (head injury, major fracture)
Critically ill pt. in whom an intra-abdominal source of fever
or sepsis is suspected

Contraindications
Multiple previous abdominal operations
Recent abdominal surgery, known abdominal adhesions, or
obliteration of abdominal space from infection
Pregnancy
Caution: Dilated viscera (e.g., bowel loops)

30

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

31
Equipment
Skin preparation supplies (povidone-iodine solution)
Mask, sterile sponges, towels and drapes, gown, gloves
Local anesthetic, preferably 1% lidocaine w/1:100,000
epinephrine
Syringe (5- or 10-mL)
Needles (21-G 1.5 and 25-G 1/8)
Sterile surgical tray, include scalpels (Nos. 11 and 15),
scissors, Kelly clamps, pickups, needle holders
Sutures (0 silk, 2-0 silk, #1 and 4-0 vicryl, and 4-0 nylon)
Peritoneal catheter and connection tubing
Normal saline
Dressing supplies

Preparation

Decompress stomach (nasogastric or orogastric tube)

Empty urinary bladder (void or Foley catheter)
Prepare and drape skin
Entry site: usu. just caudal to umbilicus; if pelvic fracture,
supraumbilical
If not unconscious/sedated, local anesthesia to skin entry
site, lower fascial levels, and peritoneum

Patient Positioning
Supine or (if therapeutic) sitting

Technique
Use sterile technique
Open technique described here. [Alternative: Seldinger
technique (insert needle abdomen, pass wire over needle,
dilate, and pass catheter through tract)]
5-mm vertical incision (No. 11 blade) down to linea alba
fascia; do not enter abdominal cavity
Expose linea alba and place stay suture on each side of
fascia (0 silk); hemostat tag each suture
Make 1 cm vertical incision in linea alba; enter peritoneal
cavity using blunt dissection; retract abdominal wall w/blunt
end of Senn retractor
Insert and direct catheter (always keep perpendicular to
abdominal wall) right or left iliac region

BASICS

Page 31

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 32

BASICS
Never force catheter against resistance
Gently aspirate fluid into syringe through catheter
Attach 1-L sterile saline bag to catheter and empty bag into
peritoneal cavity by gravity
Drop bag to ground and allow fluid to siphon out
Send all fluid to laboratory; remove catheter
Suture incision closed (deep fascia: stay sutures of 0 silk;
skin: 4-0 vicryl for subcuticular dermal closure and 4-0 nylon
for skin closure)

Complications
Sensitivity to retroperitoneal injury, sensitivity to minor intraperitoneal injuries, false negative (poor technique or diaphragmatic
injuries), wound infection, false positive (bleeding from incision),
sensitivity from prior DPL (introduce gas/fluid into abdomen),
bleeding, viscous perforation

Transurethral Catheterization
Indications

Urinary retention (e.g., neurogenic bladder)

Urinary sampling
Monitor urinary output
Bladder irrigation or tests (e.g., cystogram)

Contraindications
Ureteral stricture or disruption
Acute urethral or prostatic infection
Relative: Anticoagulated pt. (use lubricants and
nontraumatic technique)

Equipment

Skin preparation supplies (povidone-iodine solution)

Sterile gloves, gauze, sponges, towels
Water-soluble lubricant (may use lidocaine 2% jelly)
Syringe (10-mL); sterile water or saline (5 mL)
Adhesive tape
Urinary drainage system w/tubing and collection bag
Urinary catheter (usually 16- or 18-Fr Foley):

32

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 33

33

Foley: Double-lumen (larger urine, smaller balloon

inflation): Usu. used to drain bladder
Straight (red Robinson): Straight catheterization
Coude: Difficult cases; narrow, curved, firmer tip
3-way irrigation: Retrograde bladder irrigation

Preparation

Straight
catheter

Foley
catheter

Coude
catheter

3-way
irrigation
catheter

Pretest balloon inflation w/saline

Skin preparation: Sterile technique; retract foreskin (if present) or spread labia (urethral meatus anterior to vagina and
posterior to clitoris); prepare entire penis or periurethral area
(including urethral meatus) w/3 povidone-iodine applications; keep one hand sterile while other holds penile shaft
Always lubricate catheter tip and shaft
May inject lidocaine 2% into urethra preinsertion

Patient Positioning
Supine; male: penis straight upward; female: frog-leg position

Technique
Always use sterile technique; insert and slowly advance
catheter through urethral meatus (male: maintain continuous
upward penile traction; retract penis caudally may help pass
prostatic urethra)

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 34

BASICS
Urine drains inflate balloon (5 mL of saline); no urine
push on bladder; never inflate balloon w/o urinary return
( damaged urethra)
Do not attempt multiple passes; if cannot avoid multiple
passes, use smaller or Coude catheter placement
Gently pull back catheter until mild resistance
Tape catheter to thigh w/slight catheter slack
Return foreskin to back over penis head

Complications
Difficulty passing catheter (from any lower GU structure/disruption
or prostatic enlargement); Traumatic catheterization hematuria,
transurethral tear/false passage; infection

Suprapubic Catheterization
Indications
Pelvic trauma causing urethral tear or disruption
Need for bladder drainage in the presence of urethral or
prostate infection
Acute urinary retention when transurethral catheterization
not possible

Contraindications
Nonpalpable bladder
Uncorrectable bleeding diatheses

Equipment
Skin preparation supplies (povidone-iodine solution)
Local anesthetic (1% lidocaine epinephrine; 22-G, 1.5
needle, 10-mL syringe)
Razor
Sterile gloves, mask, gauze sponges, towels and sheets
No. 11 scalpel
Syringe (60-mL)
Suprapubic catheter (usu. 14-G, 12); intracatheter needle;
needle holder, scissors, and pickups
Suture (2-0 silk or nylon)
Adhesive tape
Urinary drainage system w/bag and tubing
Sterile dressings

34

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 35

35
Preparation
Local anesthetic agent IV sedation
Bladder must be distended and palpable
Shave umbilicus to pubis
Locate puncture site (midline, 4 cm above pubis)
Prepare skin w/alcohol solution
Infiltrate skin, subcutaneous, abdominal wall, bladder wall
w/local anesthetic
Prepare skin w/providone-iodine; sterile towels/drapes

Patient Positioning
Supine w/roll under hips extend abdomen and pelvis

Technique

Always use sterile technique

Avoid multiple needle passes
Catheter-through-needle or sterile Seldinger technique
Shallow skin incision (No. 11 blade)
While aspirating, advance needle w/syringe through incision
(at 60 to abdominal skin) until get urine flow syringe;
remove syringe from needle
Thread intracath catheter through needle bladder
Urine flow in catheter remove needle over catheter
Free flow urine through catheter suture catheter in place;
attach urine collection device to catheter
Sterile dressing

Complications
Difficulty passing the suprapubic catheter, infection, traumatic
placement, bowel perforation

Arthrocentesis
Indications

Dx septic joint or crystal-induced arthritis

Traumatic (blood in joint) vs inflammatory effusion
Dx intra-articular fracture (blood and fat globules)
Sx relief: Pain (hemarthrosis or tense effusion)
Give anti-inflammatory or local anesthetic medications

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 36

BASICS
Contraindications

Infection in tissue overlying puncture site

Bacteremia
Bleeding diatheses
Joint prosthesis

Equipment
Skin preparation supplies and sterile gloves, drapes, basin,
cup, test tubes, gauze, dressings, saline hemostat
Local anesthetic
Syringes (2, 10, and 20 mL); needles (18, 20, 22, and 25G)
Three-way stopcock
Green-top tube w/liquid anticoagulant, microscope slides
w/coverslips, culture media (for infection)

Preparation
Carefully identify landmarks and choose puncture site (avoid
nerves, tendons, major vessels)
Sterile technique; prepare skin (allow betadine solution to
dry btween applications); remove betadine w/EtOH to
prevent betadine joint space
gloves after skin preparation; apply sterile towels/drape
Infiltrate skin w/local anesthetic (22-/25-G needle)

Patient Positioning
For knee lateral approach: Supine on examination table, feet
at right angle, knee slightly flexed (1520), rolled towel
under popliteal space
For knee patella tendon approach: Pt. sits upright with foot
perpendicular to floor

Technique
Attach (18- to 22-G) needle to syringe and insert through
skin, subcutaneous tissue, and into joint space
Knee lateral approach: Insert needle 1 cm superior/lateral to
superior lateral patella; may use hand to grasp and elevate
patella slightly; needle under patella at 45 to midjoint
area; should be no resistance
Other approaches: Enter through patella tendon or medially
or laterally directly above joint line

36

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 37

37

Aspiration of synovial fluid confirms joint space placement

If syringe: Use hemostat to hold needle hub
Aspirate all joint space contents/fluid
Remove needle and dress wound; send fluid for tests
Larger effusions: Use larger syringe and consider using
three-way stopcock (do not have to syringe)

Complications
Infection, bleeding, anesthetic hypersensitivity.
Fluid stops flowing (joint space drained, needle tip dislodged, or
debris/clot obstruct tip), needle dislodged (slightly advance/retract
needle, rotate bevel, or use pressure to aspirate), cartilage damage (from bouncing needle off bone)

Abscess Incision and Drainage

Indications
Palpable skin abscess (usu. 5 mm) that does not resolve
with conservative measures (warm soaks)

Joint Fluid Crystal Characteristics

Crystal

Diagnosis

Monosodium urate
(gout)

Strong negative birefringence, needleshaped, long*

Uricase digestion X-ray diffraction
Weak and birefringence, rhomboid or
small rods, pleomorphic*
X-ray diffraction
Not easily visualized*
Electron microscopy X-ray diffraction
Rhombic or platelike, notched corners,
multicolor, occasionally small, needlelike*
Chemical determination
Pleomorphic; variable birefringence*
Postintra-articular steroid Rx

Ca2 pyrophosphate
dihydrate (CPPD)
Pseudogout
Ca2 phosphate
(hydroxyapatite)
Cholesterol

Corticosteroids
*On polarizing microscope

BASICS

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 38

BASICS
Joint Fluid Characteristics
WBC
Appears
/mL3
PMNs
Clear, pale
0200
10%
yellow
Group I (noninflammatory)
DJD;
Clear to
504K
30%
traumatic
slight turbid
arthritis
Group II (noninfectious, mildly inflammatory)
SLE;
Clear to
09K
20%
scleroderma slightly
turbid
Group III (noninfectious severe inflammatory)
Gout
Turbid
100160K ~70%
Pseudogout Turbid
5075K
~70%
RA
Turbid
25080K
~70%
Group IV (infectious inflammatory effusions)
Acute
Very turbid 150250K ~90%
bacterial
TB
TB
2500100K ~60%

Dx
Normal

Mucin Glucose*
Clot (mg/dL)
Good
~0

Good

~0

Good
~0
(occasionally fair)
Poor
Fair/poor
Poor

10
?
30

Poor

90

Poor

70

*Mean difference between synovial fluid and blood glucose

Adapted from Cohen, AS. Cecils Tectbook of Medicine

Contraindications
Very large abscesses (may need operating room)
Deep abscesses in very sensitive areas (supralevator,
ischiorectal, perirectal)
Locations: Palmar space, deep plantar spaces, nasolabial
folds (may drain to sphenoid sinus)

Equipment
Universal precautions materials
Local anesthesia: 1% or 2% lidocaine with epinephrine, 10-cc
syringe and 25-G needle

38

FADavis_Chapter 01.qxd

9/12/08

3:38 PM

Page 39

39

Skin preparation solution and sterile drapes

No. 11 scalpel blade with handle
Sterile gauze and tape
Hemostat, scissors
Packing strip (plain or iodoform, 1/2)
Culture swab

Preparation
Universal precautions; prepare skin and sterile drapes
Infiltrate local anesthetic, allow 23 minutes for anesthetic to
take effect

Patient Positioning
Depends on abscess location

Technique
Cut through skin into abscess w/wide incision (No. 11 blade);
incision should follow skin fold lines
Allow pus to drain; soak up w/gauzes
Swab inside abscess cavity (culture swab)
Gently explore cavity w/hemostat, break up loculations
Pack abscess cavity; dress wound w/gauze and tape
May send pus for Gram stain and culture (commonly streptococcus, staphylococcus, or enterics (perianal), or anaerobic
and gram-negatives.

Complications
Abscess actually sebaceous cyst or hematoma, no drainage,
bleeding

BASICS

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

H&P

Cranial Nerve
I
Olfactory
II
Optic
III
Oculomotor
IV
Trochlear
V

Trigeminal

VI

Abducens

VII

Facial

VIII

Vestibulocochlear
(auditory)
Glossopharyngeal

IX

Major Functions
Smell
Vision
Most eye muscles
Superior oblique
(eye and out)
Face sensation
Chewing muscles
Lateral rectus
(eye lateral)
Face expressions
Tears/saliva
Taste (anterior 2/3
tongue)
Hearing
Equillibrium

How to Test
Odor
Vision chart
Follow finger
Look down at
nose
Touch face
Clench teeth
Look to side

Gag reflex
Swallow
Uvula position
? Hoarseness
Open wide, say
AH
Shoulder
shrug/raise
Turn head
Tongue out

Vagus

XI

Spinal
Accessory

Taste (posterior
1/3 tongue)
Sense carotid BP
Larynx/pharynx
Parasympathetic
Taste
Trapezius/
sternocleidomastoid

XII

Hypoglossal

Move tongue

40

Smile
Eyebrows
Sugar or salt
Tuning fork
? Vertigo

Page 40

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

41
Distinguishing Vestibular (peripheral VIII
nerve), Cerebellar, and Sensory (afferent
pathway: peripheral nerve to thalamus/
parietal lobe) Lesions
Finding
Vertigo
Nystagmus
Dysarthria
Limb ataxia
Stand feet together;
eyes open
Stand feet together;
eyes closed
Vibratory and position sense
Ankle reflexes

Vestibular

Cerebellar

Often

Usual

Sensory

Distinguishing
Causes
Upper Lower
of Motor
Motor Motor
ExtraDefects
Neuron Neuron Muscle Cerebellar pyramidal
Strength

Atrophy

Fasciculations

Babinskis

Tone

Tone

Hyperreflexia

Hyporeflexia

Clasp knife

Ataxia

(continued)

H&P

Page 41

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 42

H&P

Distinguishing
Causes
Upper Lower
of Motor
Motor Motor
ExtraDefects
Neuron Neuron Muscle Cerebellar pyramidal
Akinesia

/
Chorea or

/
athetosis
Intention

tremor
Resting tremor

Lower Extremities
Cannot toe walk when 50% loss S1 gastrocnemius and anterior
tibialis; cannot heel walk when 50% loss L4, L5 tibialis anterior

Sciatic Nerve Compression

Cross-leg (well leg) straight-raising test: Pt. lies supine and
lifts uninvolved leg up with knee extended; positive: pain
radiates posterior leg foot
Straight leg-raising test: Like cross-leg but pt. lifts involved
leg; positive: pain radiates back below knee; hamstring
problem: only posterior thigh pain

Femoral Nerve Compression

Reverse leg-raising test: Pt. lies prone and extends involved
leg with knee extended; if pain radiates anterior leg foot,
then femoral nerve compression

Intrathecal Pathology
Milgrams test: Pt. lies supine and raises legs ~5 cm and
holds for 30 sec stretches iliopsoas and anterior

42

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

43
abdominal muscles and intrathecal pressure; if no leg pain,
no intrathecal pathology

Reflexes
Reflex

Nerve
Root

Jaw

Pons

Biceps

C56

Brachioradialis

C56

Radial

Triceps

C78

Radial

Tap triceps tendon;

support upper arm; let
forearm hang

Finger

C8, T1

Median

Upper
abdomen

T710

Lower
abdomen

T11L1

Either tap palm or hold

pt.s middle finger
loosely and flick
fingernail down
normal: finger slightly
extends; abnormal:
Hoffmans sign (thumb
flexes, adducts)
Use blunt object to
stroke abdomen lightly
in and down
Normal: Umbilicus
deviates toward
stimulus

Nerve

Testing

Mandibular
branch,
trigeminal
Musculocutaneous

Tap mandible at downward angle w/mouth

slightly open
Tap biceps tendon
w/arm flexed partially
at elbow
Strike radius lower end
just above wrist
Normal: Elbow flexion

(continued)

H&P

Page 43

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

H&P
Reflexes
Nerve
Root
L34

Nerve
Femoral

Testing
Strike patellar tendon

Ankle
(Achilles)

S12

Tibial

Cremasteric
reflex

T12

Genital
branch (genitofemoral)

Tap Achilles tendon

when pt. dorsiflexes
foot at ankle
Normal: Plantar flexion
Stroke inner thigh
Normal: Ipsilateral
scrotal sac move

Anal wink

S24

Reflex
Patellar

Touch perianal skin

Normal: Anus contracts

44

Page 44

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

45
Peripheral Nerves
Trigeminal
Anterior cutaneous
nerve neck
C2
Supraclavicular

C3
C4

Axillary
Anterior thoracic rami
Lateral thoracic rami
Lateral cutaneous
nerve arm
Median cutaneous
nerve arm
Lateral cutaneous
nerve forearm
Median
cutaneous
nerve
forearm
Radial

Iliohypogastric
Ilioinguinal

C5
T2 T1
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12

S2 L1
S3

Ulnar

C8
L2

Median
Lateral femoral cutaneous

L3

Medial femoral cutaneous

Anterior femoral cutaneous

Obturator

Superficial peroneal
L4 L5
Sural

Tibial
Saphenous

Medial
Lateral
plantar
plantar
Sole of foot

H&P

Sural

Saphenous

Deep
peroneal

C6

C7

Page 45

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

H&P

Peripheral Nerves
Great occipital
Lesser occipital

C2

Greater auricular

C3
C4
C5

Posterior rami of cervical nerves

Supraclavicular
Lateral thoracic rami
Posterior thoracic rami

C6
C8

Axillary

C7

T10

Posterior cutaneous
nerve forearm
Median cutaneous
nerve arm

T12

Lateral cutaneous
nerve forearm
Median cutaneous
nerve forearm

S3
S1
S4
S5 S2

Radial
Median
Ulnar

L1
L2
L3
L4
L5

Posterior
lumbar
rami
L2

Posterior sacral rami

Lateral femoral cutaneous
L3

Medial femoral cutaneous

Lateral femoral nerve of calf
Superficial peroneal

Obturator
L4

Sural

Tibial

Sural

Saphenous
Saphenous
Medial
Lateral
plantar
plantar
Sole of foot

Calcaneal

46

L5

Page 46

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

47
Referred Pain
Jaw
Cardiac
Right Shoulder
Liver
Gallbladder
Diaphragm
Pancreas
Cardiac

Left Shoulder
Lung
Diaphragm
(Kehrs sign)
Pancreas
Cardiac
Arm
Cardiac
Periumbilical
Duodenum
Appendix

Epigastric
Duodenum
Appendix
Hiatal hernia
Gallbladder
and bile ducts
Pancreas

H&P

Suprapubic
Bladder
Uterus

Groin/
Inner thigh
Ureters
Kidneys

Page 47

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 48

H&P
Brain Circulation
Anterior
communicating
artery

Anterior cerebral artery

Internal carotid

Middle cerebral artery

Communicating artery
Posterior cerebral
artery
Superior cerebellar
Basilar artery
Anterior inferior
cerebellar
Vertebral artery
Anterior spinal
Posterior inferior cerebellar

48

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

49
Main Artery
Anterior cerebral
Middle cerebral

Posterior cerebral

Superior cerebellar

Anterior inferior
cerebellar
Posterior inferior
cerebellar
Anterior spinal (ASA)

H&P

Region of Brain Sustained

Medial frontal and parietal
Anterior corpus callosum
Lateral frontal, parietal, occipital,
temporal cortex
Lenticulostriate branches
caudate nucleus, putamen,
upper internal capsule
Medial occipital and temporal cortex
Posterior corpus callosum
Upper midbrain
Thalamus
Upper cerebellum
Upper pons
Low midbrain
Upper cerebellum
Upper pons
Low midbrain
Lower cerebellum
Medulla
Anterior (ventral) spinal cord

Page 49

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 50

H&P
Parietal lobe
contralateral sensation
Dominant:
reading, writing,
or math ability
Non-dominant:
neglect, difficulty dressing

Frontal lobe
problem solving,
planning, apathy,
inattention, aphasia,
contralateral weakness,
labile affect,
Brocas area

Occipital lobe
vision problems

Temporal lobe
memory problems,
aggressive sexual behavior
Dominant:
Wernickes aphasia
Midbrain, Pons,
Medulla
CN 312

50

Cerebellum
ataxia, dysarthria,
dysmetria, intention
tremor, nystagmus,
scanning speech

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

51
Eye Examination
Conjuctiva Zonule
Choroid
Sclera

Anterior
chamber

Retina
Cornea
Macula
Fovea

Vitreous
humor

Pupil

Optic
nerve
Optic
disk

Iris
Lens

Ciliary body
Left eye

Right eye

Optic nerve
Optic chiasm
Optic tract
Lateral
geniculate
nucleus

1
2
4

Optic
radiation
5
Left eye Right eye
visual
visual
field
field
1
2
3
4
5

H&P

Striate cortex

Page 51

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

H&P

Optic nerve

Superior
rectus
CN3

Superior
oblique
CN4

Inferior
rectus
CN3
Medial
rectus
CN3

Lateral
rectus
CN6

Inferior oblique
CN3

Optic
disk
Blood
vessels

Optic
cup

Fovea
Optic nerve
(blind spot)

Macula

52

Page 52

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 53

53
Ear Examination
Tuning Fork Tests
Webers test
Fork at midline forehead
Normal: Sound both ears
Abnormal: Sound lateralizes
one ear ipsilateral conductive
hearing or contralateral
sensorineural hearing

Rinnes test
Bone conduction: Put fork on
mastoid
Air conduction: Put fork near
ear
Normal: Air conduction
bone
Abnormal: Bone conduction
air conduction, which
results in conductive
hearing

Vertigo
Dix-Hallpike test (Nylen-Barany test): Pt. sits on examination table
and extends legs; turn pt.s head 3045 to one side, and pt. quickly
lies back so head hangs over table end; look for nystagmus; repeat
whole procedure with head turned in opposite direction
Positive: Nystagmus benign paroxysmal positional vertigo

H&P

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 54

H&P
Cardiac Manuevers

Mechanism Maneuvers
Preload

Venous
return

Afterload

Inspiration,
squatting,
raise legs
Expiration,
Valsalvas,
standing,
nitrates,
diuretics

Mitral
Regurgitation
(MR)
IHSS*

RightSided
Murmurs

Aortic
Stenosis
(AS)

Isometric
hand grip

Valsalvas,

vasodilators
*IHSS idiopathic hypertrophic subaortic stenosis

54

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 55

55
Systole

Diastole

Early Mid Late Early Mid Late

Harsh

AS
Blowing

AI
Low
Opening snap
Rumble

MS

Opening snap

Heard best @ R base

(radiate R carotid)
Heard best @ 3rd/4th L ICS
(if radiate
R sternal
border
aortic root dilate, e.g., Marfan)
All MV murmurs heard best@ apex , S1.
Can be confused with Austin Flint
(AI: mid-diastolic murmur @ MV
when blood enters from aorta &
L atrium simultaneously; No OS)
Radiate L axilla/back;
severe MR S3; with isometric
handgrip & stand squat
If LV volume (stand, Valsalva) earlier
clicks, duration, intensity; if LV volume
(squat, legs, hand grip) delay clicks,
duration, intensity
Heard best @ L 2nd ICS (radiate to
L neck) + palpable thrill; wide split S2

MI

MVP
Systolic click

PS
Blowing

PI

Comments

Systolic click

Heard best @ L 2nd/3rd ICS;

may during inspiration

Heard best @ 4th L sternal border;

wide split S1; may with inspiration
Opening snap (Carvallos sign); TS often occurs with MS
Heard best @ 4th L sternal border; may
with inspiration (Carvallos sign); 1st degree
rare; usually 2nd degree to pulm HTN
Rumble

TS

TI

Second degree

PDA

Machinery

Heard best @ L base; confused with

venous hum; if pulmonary HTN,
may disappear systolic murmur,
pulmonic ejection sound
Heard best @ L 3rd/4th ICS and along
sternal border; NI S2

VSD

H&P

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

H&P

Type

Normal or physiologic
Wide, fixed, splitting
Wide split, varies with
inspiration
Paradoxical splitting

Inspiration
S1

S2

P
P

PA

Causes

S2

S1

A P
A

Expiration

Intrathoracic
pressure

AP
A

Atrial septal defect

AP

Pulmonary stenosis
RBBB

PA

Hypertrophic
cardiomyopathy

Adapted from University of Washington Advanced Physical Diagnosis

Learning and Teaching at the Bedside, Edition 1.

Heart Sound

Causes

S1

S2 (Aortic)

S2 (Pulmonic)
S3 (Low frequency,
early diastole)

S4 (Low-frequency
presystolic portion
of diastole)

Soft: Cardiac output, tachycardia, MR

Loud: Hyperdynamic (fever, exercise),
mitral stenosis, atrial myxoma
Soft: Calcific AS
Loud: Systemic hypertension (HTN),
dilated aortic root
Loud: Pulmonary HTN
Atrial pressure flow rates (congestive
heart failure [CHF] most common, valvular
regurge, left right shunts)
Normal in age 40 yr
Stiffened LV (HTN, AS, ischemic or
hypertrophic cardiomyopathy, acute MR
from chorda tendinea rupture)

Jugular Venous Pressure (JVP)

56

Page 56

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

57
a
c

Small and usually

not visible
v

R atrial
contraction

y
x

RV contraction
and TV closure

TV opening and
atrial emptying
Maximal
atrial filling

Sternum
45
Right atrium
Jugular vein
JVP
Fluid overload
Blockage before heart (SVC obstruction)
CO (e.g., HR, constrictive pericarditis,
R heart failure pericardial effusion, TS or TI,
cardial tamponade)
Hyperdynamic circulation

H&P

Page 57

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

H&P
Sign
Kussmauls (during inspiration,
JVP distention; in normal pt.)
Hepatojugular reflux (push
liver venous return to right
atrium)
Absent A waves
Dominant A waves

Cannon A wave (very large

A waves)
Dominant V wave
Absent X descent
Exaggerated X descent
Large CV waves
Sharp Y descent
Slow Y descent
Absent Y waves

Causes
Constrictive pericarditis
(negative in cardiac tamponade)
Severe right heart failure
Right ventricular failure if
JVP remains elevated
(transient only in normal pt.)
Atrial fibrillation
Sinus tachycardia
Pulmonary HTN
Pulmonary stenosis
Tricuspid stenosis
Right atrial myxoma
Ventricular tachycardia
Complete heart block
Paroxysmal nodal tachycardia
Tricuspid regurgitation
Atrial fibrillation
Cardiac tamponade
Constrictive pericarditis
Tricuspid regurgitation
Constrictive percarditis
Constrictive pericarditis
Tricuspid regurgitation
Right atrial myxoma
Tricuspid stenosis
Cardiac tamponade

Abdominal Examination

58

Page 58

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

59
RUQ
Biliary colic
Cholecystitis
Duodenal ulcer
Hepatitis
RLL pneumonia
Flank
Abdominal aortic
aneurysm
Pylelonephritis
Renal colic
McBurneys point
RLQ
Appendicitis
Cecal diverticulitis
Ectopic pregnancy
Ovarian cyst
Ovarian torsion
Tubo-ovarian
abscess
Suprapubic
Ectopic pregnancy
Endometriosis
Mittelschmerz
PID
Ovarian cyst
Uterine leiomyoma
UTI

H&P

LUQ
Gastritis
LLL pneumonia
Pancreatitis
Splenic problems
Periumbilical
Appendicitis
Gastroenteritis
Mesenteric
lymphadenitis
Myocardial
ischemia or
infarction
Pancreatitis
Back
Acute pancreatitis
Posterior
duodenal ulcer
Retrocecal
appendicitis
Ruptured AAA
LLQ
Diverticulitis
Ectopic pregnancy
Ovarian cyst
Ovarian torsion
Tubo-ovarian
abscess

Page 59

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 60

H&P
Abdominal Physical Examination Findings
Appendicitis
Psoas sign: Place hand above pt.s right knee; ask pt. to flex
right hip against resistance pain
Obturator sign: Raise the pt.s right leg with the knee flexed;
rotate leg internally at hip
McBurneys sign: Tenderness right abdomen two-thirds
distance from anterior iliac spine to umbilicus
Rovsings sign: Palpate LLQ RLQ pain

Gallbladder Disorders
Murphys sign: In cholecystitis; pt. breathes out; palpate
below right costal margin at midclavicular line; pt. inspires
gallbladder moves down, hits your hands; if gallbladder tender then pt. will stop inspiration test; negative in choledocholithiasis and ascending cholangitis
Charcots triad: In cholangitis; RUQ pain, fever, chills,
jaundice

Retroperitoneal Hemorrhage
Cullens sign: Bluish periumbilical discoloration
Grey Turners sign: Flank discoloration

Vaginitis
Candida Vulvovaginitis
Discharge: Dry cottage cheeselike
Symptoms: Vaginal/vulvar pruritus, irritation, burning, sore
Examination: Vulva: red, edema, and adherent white clumps

Bacterial Vaginosis
Amsels criteria (3 of 4 needed for diagnosis):
Discharge: Gray-white, thin, homogenous, adherent
Vaginal pH 4.5 (normal pH: 3.84.5)
Clue cells: Bacteria-coated vaginal epithelial cells
Whiff (amine) test: KOH discharge fishy odor

Trichomonas Vaginitis
Discharge: , grayish-green, frothy (CO2 bubbles)
Symptoms: Vulvar/vaginal pruritus, irritation, edema

60

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 61

61
Examination: strawberry cervix (punctate hemorrhage),
pH 5.0, whiff test, wet preparation (vaginal vault, not
endocervix): Motile, flagellated trichomonads

Atrophic Vaginitis
Discharge: Thin or clear
Symptoms: Vaginal irritation
Examination: Vagina/vulva: pale, dry, thin, rugae, pH 57

Scrotal Complaints
Epididymitis Chlamydia, Gonorrhea, or E. coli
Insidious onset; dysuria, frequency, urethral discharge;
swollen/tender upper posterior testicle
Rx: Antibiotics

Torsion Testis Twists on Spermatic Cord Axis

Surgical emergency: Sudden onset; abnormal testis elevation/

axis; bell clapper deformity (congenital unanchored
swinging testis); absent cremasteric reflex and Prehns sign
Spermatic
cord

Torsion

Testicular
veins
Testicular
artery

Varicocele
Spermatocele
Epididymitis

Vas deferens
Epididymis

Testicle

H&P

Hydrocele

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 62

H&P
Appendage Torsion Twists on Testicular
Appendage
Subacute symptoms, firm tender nodule upper pole
epididymis; blue dot sign (blue/black spot visible beneath
skin on testis/epididymis cranial aspect)
Rx: Bedrest and scrotal elevation

Traumatic Injury Epididymitis, Hematoma, or

Rupture
Trauma history, ecchymosis, edema
Rx: Surgery if: uncertain diagnosis, ?testicle injury, disruption
of tunica albuginea, or no flow Doppler ultrasound

Hydrocele Fluid-Filled Sac Around Testis

Painless, size/tenseness from morning waking to later in

day; transillumination: translucent fluid
Rx: Most resolve spontaneously; surgery if discomfort or
tense hydrocele testicle atrophy

Varicocele Abnormal Tortuous/Dilated Veins

Swelling, dull heaviness, with exercise; no scrotal skin

change; palpable bag of worms
Rx: May infertility; scrotal support or surgery; ?obstructing
mass if sudden onset in older pt.

Spermatocele Benign Cystic Sperm

Accumulation
Asymptomatic: Painless, freely movable nodule superior to
and separate from testis; transilluminates easily
Rx: None, unless bothersome

62

H&P

Pubic Hair

Male

I
10 y.o.
None

II
1011 y.o.
Small amount;
long, downy,
slightly
pigmented

III
1214 y.o.
Dark, coarse,
starts to curl
and extend
laterally

IV
1315 y.o.
Adult quality;
note distribution
(spare medial
thighs)

(continued)

V
16 y.o.
Adult (extends
to medial
thigh)

FADavis_Chapter 02.qxd
9/12/08
3:40 PM

63

Tanner Stages

Page 63

64

Breast

Female

Testicles

Testicle
volume
1.5 mL;
penis
small

I
10 y.o.
No
budding

1.66 mL; skin

thins, reddens,
enlarges; penis:
no change

II
1011 y.o.
Areola widens;
budding, small
glandular tissue
surrounds

612 mL;
penis
lengthens

III
1214 y.o.
Elevated, extends
beyond areolar
borders; areola
widens

1220 mL,
Scrotum
(and darkens);
penis: length,
circumference

IV
1315 y.o.
Size, elevation;
areola papilla
form secondary
mound

20 mL,
adult

V
16 y.o.
Adult; areola
back to breast
contour;
papilla projects

FADavis_Chapter 02.qxd
9/12/08
3:40 PM

H&P

Page 64

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

65

Latent
Active

3rd Stage 2nd Stage

(placenta
(birth)
delivery)

Transition
(Deceleration)

1st Stage

Stages of Labor
Comments
Contractions frequency,
strength,and regularity;
cervical thinning or
effacement
Most rapid cervical
dilation

May blend into active

phase; more rapid descent;
baby passes lower into
pelvis and deeper into
birth canal; when no
anesthesia, often vomiting
and shaking
Female actively pushes
out baby
Nulliparous: 1 cm/hr
Multiparous: 2 cm/hr
Accelerated by
breastfeeding (release
oxytocin) or pitocin

H&P

Duration
Most
variable
hours to
days
Average
nulliparous:
5 hr;
multiparous:
2 hr
15 min3 hr

Nulliparous:
23 hr
Multiparous:
1 hr
130 min

Cervical
Dilation
04 cm

410 cm

710 cm;
slower
pace

Complete

Page 65

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 66

H&P
Placenta abruptia
More common when mother has high
blood pressure or uses cocaine

Blood

Placenta prematurely detaches

(incompletely or completely)

Placenta
Uterus
Cervix
Umbilical
cord
Placenta previa
Usually in multiparous women or
uterine structural abnormalities (e.g., fibroids)

Placenta implants
over or near cervix

66

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

67
The cephalic or vertex
presentation (normal)
Usually normal vaginal delivery
Vertical or longitudinal lie
Front

Back

Limbs to chest
Neck flexed

Seated or full breech position

Usually normal vaginal delivery

Vertical or
longitudinal lie

Frank breech
position

Vertical or
longitudinal lie
Legs pointed
straight
upward

Front

Back

The transverse
position (rare)
Usually shoulder first to
present; usually cesarean
section required

H&P

Page 67

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

H&P

Anterior fontanelle
(closes at age 1824
months, may bulge
with crying or ICP)

Coronal
suture

Front

Metopic
suture

Frontal
bone

Frontal
bone

Parietal
bone

Parietal
bone

Sagittal
suture

Posterior fontanelle
(closes at 2 months)
Occipital bone
Lambdoidal
suture

Back

Obstetric Visits and Testing Timeline

68

Page 68

Fetal heart tone

with Doppler

10

H&P

General

Every 4 weeks

16

20

24

28

Ultrasound

32

Gonorrhea, chlamydia,
group B strep cx

Gestational age

If > 140 & 3 hr wnl, then repeat

@32 wks
Fetal survey prn

If Rh ()

Size (cm) = Week of gestation

Symphysis pubis Midpoint S pubis/umbilicus Umbilicus
4 regular contractions in 20 minutes or 8 regular contractions in 60 minutes with PROM
with progressive effacement >80% and cervical dilation >1 cm

Optional

40
Q 12 Q 0.51 wk
Fetal Fundal height
heart
& toxemia
tone
signs

35 37

Fetal movement

Q 24 wks

30

9/12/08

Triple Screen:
-HCG, AFP,
estradiol
One-hour
glucola test

Pregnancyassociated
plasma protein

RhoGAM

Non-stress test

Biophysical
profile

Preterm labor

Uterus size

Sickle cell, Tay-Sachs, cystic fibrosis, VZV, genetic screen, and urine tox screens

Initial Visit Labs

HgB/HCT, blood type, Rh antibody
screen, RPR/VDRL, rubella Ab, hep
Bs Ag, UA, urine C&S, Pap (thin
prep), wet prep, PPD, HIV, TSH,
gonorrhea, chlamydia

OB Visits

Weeks

FADavis_Chapter 02.qxd
3:40 PM
Page 69

69

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 70

H&P
Skin Examination
Lesion Descriptions
Macule: Flat; different color; can be seen, not felt
Excoriation: Mechanical skin erosion or destruction
Lichenification: Chronic irritation leathery skin thickening
with induration and hyperkeratosis
Onycholysis: Nail substance loosening or loss
Plaque: Flat, elevated, usu. 5 mm
Solid raised, discrete: Papule (5 mm), nodule (5 mm),
pustule (pus-filled)
Blister: Fluid-filled vesicle (5 mm), bulla (5 mm)

Shoulder Examination
Range of Motion (ROM)
Adhesive capsulitis (frozen shoulder): Stiffness, pain, and
range of movement; scar tissue forms post surgery or
injury; develops when stop using joint from pain, injury, or
chronic health condition (e.g., diabetes or arthritis)
Labral tears: Labrum cartilage disk on glenoid; pain at back
or in front on top of shoulder; feels deep inside; palpation
does not duplicate pain; pain or clunking sound with
overhead motion; causes: fall on outstretched arm, forceful
lifting, or repetitive throwing
Abduction/external rotation: Pt. places hand behind head and
reaches as far down spine as possible; extent of reach should be
at least ~C7 level;
Forward flexion: Pt. traces out arc while reaching forward (elbow
straight); should be able to move hand to a position over head;
normal range 0180
Extension: Ask pt. to reverse direction and trace an arc backward
(elbow straight); pt. should be able to position hand behind back
Appley scratch test (adduction and internal rotation): Ask pt. to
place hand behind back and reach as high up spine as possible;
note extent of reach relative to scapula/thoracic spine (should be
at least T7); see figure for additional parts of examination

70

FADavis_Chapter 02.qxd

71

H&P

9/12/08

3:40 PM

Page 71

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 72

H&P
Impingement (of Rotator Cuff Tendons)
Inflammation (tendonitis, bursitis), bone spurs, or fluid squeezing rotator cuff (supraspinatus) tendon against bone (acromion);
tendon may have tiny tears scar tissue further damage; nighttime shoulder pain
Neers test: Place your hand on pt. scapula; use other hand to
hold pt. forearm; internally rotate pt. arm so that pt. thumb points
downward; flex pt. arm forward to position hand over head; positive: pain

Hawkins (for more subtle impingement): Raise pt. arm to 90 forward flexion; rotate it internally (i.e., thumb pointed down); puts
humerus greater tubercle position to further compromise space
beneath acromion; positive: pain

72

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 73

73
Biceps
Yergasons test: Flex pt. elbow 90; pt. resists while externally
rotate arm; if pain in biceps tendon positive test biceps
tendon injury

Rotator Cuff Tear

Rotator cuff four tendons supraspinatus (most
common injured), infraspinatus, subscapularis, teres minor;
muscles originate from scapula single tendon unit inserting on humerus greater tuberosity
Repetitive overhead work or sports activity (e.g., painting,
swimmers)
Gradual or acute onset; pain, stiffness; difficulty reaching
overhead or behind back; may be snapping sensation
Gerbers liftoff test (check subscapularis function): Pt. places
hand behind back, with palm facing out; pt. lifts hand away from
back; partial tear will limit movement or cause pain; complete
tears prevent movement
Drop arm test for supraspinatus tears: Fully abduct pt.s arm so
that hand is over head; have pt. slowly lower arm to side; if
suprapinatus torn, at ~90 arm will seem to drop suddenly toward
body
Empty can test for supraspinatus weakness: With elbows
extended, thumbs pointing downward, and arms abducted to 90
in forward flexion, pt. attempts to elevate arms against examiner
resistance

Acromioclavicular Joint Dysfunction

Cross-arm test: Pt. raises arm to 90, then actively abducts,
attempting to touch opposite shoulder; pain suggests problem

H&P

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 74

H&P
Glenohumeral Joint Instability
Giving way feeling or periodic shoulder dislocation; cannot keep
humeral head centered in glenoid socket; shoulder pain in throwing athletes; anterior glenohumeral joint pain and impingement
Sulcus test: With arm extened and at rest at pt.s side, exert
downward traction on humerus, and watch for sulcus or depression lateral/inferior to acromion
Apprehension tests: Put humeral head in imminent
subluxation or dislocation pt. shows fear
Crank (pt. sitting or standing) or fulcrum (pt. supine) test:
Place arm in extreme abduction and external rotation, which
may cause apprehension
Relocation test: Pt. supine.
First part (fulcrum test): Push humeral head forward
Second part: Push humeral head posteriorly prevents
anterior subluxation negative apprehension test

Inferior apprehension test: Hold upper limb in abduction,

with pt.s forearm resting on your shoulder; exert downward
pressure over humeral neck; if shoulder unstable, head will
be pushed down and groove appears

Knee Examination
Anterior Cruciate Ligament (ACL)
Anterior drawer: Flex knee ~80; relax hamstrings; stabilize foot;
leg in neutral rotation; pull proximal tibia forward to see anterior

74

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 75

75
displacement; quantify displacement (mm), and grade end point:
hard (anterior cruciate ligament [ACL] halts forward motion) or
soft (no ACL)

Lachmans: Anterior drawer variant; flex (1520) and externally

rotate (relax iliotibial [IT] band) knee; one hand holds inner calf,
and other hand holds outer aspect distal thigh; pull tibia anteriorly

Pivot shift: Slight distal traction on leg; apply valgus and internal
rotation force to extended knee; (no ACL tibia anteriorly subluxes on distal femur); flex knee 30 (IT band extendor
flexor of knee and tibial anterolateral subluxation reduces)

Posterior Cruciate Ligament (PCL)

Tibial drop back test: Flex knee 80; compare proximal tibial
prominence to femoral condyles; PCL-deficient knee gravity
subluxes knee posteriorly; normal knee: tibial plateau located
approximately 1 cm anterior to femoral condyles
Quadriceps active test: Starting position: flex knee 80, neutral
rotation; apply counterpressure against ankle while pt. fires
quadriceps muscle (i.e., tries to straighten leg); quadriceps pulls
anteriorly through the tibial tubercle to reduce any posterior

H&P

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 76

H&P
translation in the knee; if PCL injured, then will see reduction of
a posteriorly subluxed tibia with quadriceps contraction

Posterior drawer test: Flex knee 80, palpate hamstrings to ensure

they are relaxed; stabilize foot and keep in neutral rotation; push
tibia posteriorly; if PCL-deficient knee

Meniscus
MacMurrays test: Place thumb and finger on joint line; watch
face for pain; flex leg, externally rotate foot, abduct and extend
leg to test medial meniscal clicks; flex leg, internally rotate and
adduct for lateral meniscal clicks

Squat test: During full squat, check joint line tenderness and
rotate each leg internally (test lateral meniscus) and externally
(test medial mensiscus)

76

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 77

77
Patella
Bulge test: Check for effusion; press down patella empty
suprapatellar pouch; wipe hand along medial side to displace
fluid laterally; compress lateral side, and watch for bulge medially
Effusion: tap test: Push sharply on patella; if effusion, patella will
bounce off femur
Patellar tilt test: With knee flexed 20, use thumb to flip up
lateral edge of patella; normally can tilt patella up above horizontal; excessively tight lateral retinaculum no upward
movement
Solomans test: Lift patella away from femur; synovial thickening
patella hard to grasp
Patellar compression test: Attempts to correlate anterior knee
pain w/articular degeneration; compress patella down into
trochlear groove as pt. flexes and extends knee
Lateral patellar apprehension test: Flex knee 45; keep knee
relaxed; use one hand to stabilize leg while using other hand to
apply lateral pressure to patella
Medial patellar apprehension test: Fully extend knee; apply
medial translation force; medial subluxation, which most often
occurs in a pt. after a lateral release, occurs in the initial flexion
arc of 030; after this point, the patella reduces into the bony
confines of the trochlear groove when the knee is flexed

Patellar displacement (Sage sign): Normally can displace patella

medially and laterally 25%50% of patellar width; movement
loose patellar restraints (frequent in adolescent females)
Suprapatellar plica snap test: Palpate medial suprapatellar plica
midway between medial patellar border and adductor tubercle;
roll plica under your fingers while assessing pain/inflammation

H&P

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

Page 78

H&P
Upper and Lower Extremity Muscles
Part
Arm

Elbow

Action
Muscle
Externally Infraspinatus
rotate
Abduct
Supraspinatus
Deltoid
Flex
Biceps

Wrist

Extend
Extend

Finger
5th
Finger

Flex
Extend
Abduct

Thumb Abduct

Hip

Thigh

Oppose
Extend
Flex
Abduct

Abduct

Brachioradialis
Triceps
Extensor carpi
radialis longus
Extensor carpi
ulnaris
Flexor carpi ulnaris
Flexor carpi radialis
Extensor digitorum
1st dorsal
interosseous
Abduct digiti minimi
Abductor pollicis
brevis
Opponens pollicis
Gluteus maximus
Iliopsoas
Gluteus medius and
minimus, tensor
fasciae latae
Abductors

78

Root
C5

Nerve
Suprascapular

C5
C56

Axillary
Musculocutaneous
Radial
Radial
Radial

C8
C67
C7
C8
C67
C7
T1

Ulnar
Median
Radial
Ulnar

T1

Median

Median
L5S2 Inferior gluteal
L2,L3 Femoral
L4S1 Superior
gluteal
L24

Obturator

FADavis_Chapter 02.qxd

9/12/08

3:40 PM

79
Part
Knee
Ankle
(flex)

Foot
Toes

Action
Extend
Flex
Dorsi

Muscle
Quadriceps femoris
Hamstrings
Tibialis anterior

Root
Nerve
L34 Femoral
L5S1 Sciatic
L45 Peroneal

Plantar

Gastrocnemius
Soleus
Peronei
Tibialis posterior
Extensor digitorum
longus
Extensor digitorum
brevis

S12

Evert
Invert
Dorsiflex

H&P

Tibial

L5S1 Peroneal
L4
Tibial
L5S1 Peroneal
S1

Page 79

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

ALGOR

Algorithms
Hyperprolactinemia (100 ng/mL)

Ectopic production
Breast stimulation (e.g., breastfeeding)
metabolism (liver failure, renal failure)
Hypothyroidism
Medications (e.g., oral contraceptives, antipsychotics, antidepressants, antihypertensives, H2-receptor blockers, opiates)

Hyperprolactinemia (100 ng/mL)

Prolactin
Empty sella syndrome
Pituitary adenoma

Normogonadotropic Hypogonadism (Androgens)

Polycystic ovary syndrome

Androgen-secreting tumor (ovarian or adrenal)
Cushings disease
Nonclassic congenital adrenal hyperplasia
Exogenous androgens
Thyroid disease
Acromegaly

Uterine Outflow Obstruction

Ashermans syndrome
Cervical stenosis

Hypergonadotropic Hypogonadism
(Ovarian Failure)
Postmenopausal
Premature failure: e.g., autoimmune, chemotherapy,
galactosemia, genetic, 17-hydroxylase deficiency syndrome,
mumps, pelvic radiation

80

Page 80

ALGOR

Second-Degree
Amenorrhea

Imperforate
hymen
Transverse
vaginal septum

Yes

Mullerian
dysgenesis

46XX
46XY

GnRH
deficiency

Normal

Buccal Abnormal
smear

Turners

46X0

Karyotype

>40
ng/mL

>40
ng/mL

Short

Pure gonadal
dysgenesis

FSH

LH

Height

Pituitary
defect

46XX

<5
ng/mL

<5
ng/mL

Normal

Abnormal

Male
pseudohermaphrodite

Karyotype

No uterus

Breast development &

female Tanner stage

9/12/08

No

Uterine outflow
obstruction?

No

Yes

Normal

Polycystic ovary
syndrome
Adrenal or
ovarian tumor

Hyperandrogenism?

Uterus

Pelvic
ultrasound

Primary Amenorrhea

FADavis_Chapter 03 .qxd
3:48 PM

81

Page 81

82

Vaginal bleeding <7 days

<5 ng/mL

<5 ng/mL

FSH

LH
>20 ng/mL

>40 ng/mL

No bleeding

Abnormal

Thyroid
disease

Pregnancy

Hypergonadotropic
hypogonadism
(ovarian failure)

Uterine outflow
obstruction?

No bleeding

Estrogen/progestogen challenge

9/12/08

Hypogonadotropic
hypogonadism

Progestin
challenge

Normal

Prolactin

Vaginal bleeding

Normogonadotropic hypogonadism

Vaginal bleeding
<7 days

Hyperprolactinemia

TSH

Pregnancy test

Secondary Amenorrhea

FADavis_Chapter 03 .qxd
3:48 PM

ALGOR

Page 82

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

Hypogonadotropic Hypogonadism
exercise (e.g., marathon running)
weight or malnutrition (e.g., anorexia)
Chronic illness (e.g., liver, renal, diabetes, inflammatory
bowel disease, thyroid)

Causes of Renal Azotemia

Cause
Glomerulonephritis

Findings
UOsm 500, FENa 1
Urine: RBC casts and dysmorphic RBC
UOsm 350, FENa 1
Urine: Pigmented, granular casts
Metabolic acidosis and osmolal
gap
Uric acid, phosphate, and K
Globulins
Urine eosinophilia, skin rash; UOsm
350, FENa 1
Livedo reticularis and eosinophilia

Acute tubular necrosis

Ethylene/methylene
glycol toxicity
Tumor lysis syndome
Multiple myeloma
Interstitial nephritis
Atheroembolism

Nephrotoxic Agents
Mechanism
Tubular toxicity

Tubular
obstruction
Interstitial
nephritis
Renal
hemodynamics

Examples
Aminoglycosides, radiocontrast,
amphotericin B, cisplatinum, heavy metals,
cyclosporin
Acyclovir, sulfonamides, ethylene glycol,
methotrexate
Penicillin, cephalosporin, sulfonamides,
rifampin, NSAIDs, furosemide, thiazides,
allopurinol
ACE inhibitors, NSAIDs, cyclosporin,
radiocontrast, amphotericin

ALGOR

Page 83

84

Hypovolemia?

Renal azotemia

Prerenal
azotemia

Postrenal
azotemia

Enlarged prostate,
mass, stones

Dialysis

CHF, liver failure,

dehydration, volume loss

Yes

9/12/08

No

Yes

Obstruction

FENa <1, UOsm >500

Few hyaline casts, BP

No obstruction

Transurethral catheterization
& renal ultrasound

No

Stop nephrotoxic agents

No

Indications for
K+, volume, metabolic acidosis;
urgent dialysis? sx of uremia, pericarditis, encephalopathy

Workup of Acute Renal Failure

FADavis_Chapter 03 .qxd
3:48 PM

ALGOR

stress or depression
Hypothalamic or pituitary destruction (e.g., tumor,
irradiation, Sheehans syndrome)

Page 84

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

85
Macrocytic Anemia Workup
MCV
Macrocytic >97 fL

Megalocytes
Yes

No

Megaloblastic

Nonmegaloblastic

B12, folate

Abs corr retic

count

Low

Normal

Deficiency

Drug
idiopathic

Schilling

Bone
marrow rx

Low or normal

Liver/
thyroid dz

No

Aplastic
anemia

ALGOR

High

Hemolytic dz
Acute blood
loss
Hypersplenism

Page 85

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

ALGOR
Microcytic Anemia Workup
MCV
Microcytic <82 fL

Ferritin
Low

Normal or high

Fe deficiency

Lead

Normal
High

Hgb
electrophoresis

Lead
toxicity

Thalassemia, other

86

Page 86

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

87
Normocytic Anemia Workup
MCV
Normocytic 8297 fL

Corrected abs
retic count
Low or normal

High

LDH,
haptoglobin
Normal

Blood loss

Suspect
marrow
failure

High

Yes

Coombs
Positive

Hemolytic
anemia

Bone
marrow ex

Negative

No

No

Anemia of
chronic
disease

Splenomegaly
Yes

Hypersplenism, drugs, infection, hemoglobinopathy

ALGOR

Page 87

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

ALGOR
Diabetic Ketoacidosis
1

Perform Steps 1, 2, 3, 4, 5, and 6 simultaneously.

Fluids (Step 1) should be started as soon as possible.
Start IV: 0.9% NaCl at 1.0 L/hour (15-20 mL per kg)
A fter 1 hour
Hypovolemic
s hock

Give 0.9% NaCl

1.0 L/hour until
correct shock

Assess volume status

Corrected

C ardiogenic
s hock

Mild hypotens ion

or normal
serum Na+
Give

fluids based
on hemodynamic
monitoring

or normal

IV: 0.45% NaCl at

4-14 mL/kg/hour

IV: 0.9% NaCl at

4-14 mL/kg/hour
S erum gluc os e <250 mg/dL

to 5% dextrose + 0.45% NaCl at 150-250 mL/hour

May stop when metabolic control is achieved

88

Page 88

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

89
Diabetic Ketoacidosis (continued)
Insulin Therapy

<3.3 mEq/L (3.3 mmol/L)

Check serum K+

>3.3 mEq/L
(3.3 mmol/L)

Hold insulin
IM/SC insulin
IV insulin

Monitor and give K+

IV regular bolus: 0.15 units/kg

0.1 units/kg/hour

IV regular bolus: 0.2 units/kg

+0.2 units/kg IM or SC
0.1 units/kg/hour IV
insulin IM or SC

IV

IM or SC

Serum glucose by 50-70 mg/dL/hour

Yes

No

Continue above therapy

Serum glucose
< 250 mg/dL

Double insulin OR Hourly IV insulin

bolus of 10 units
infusion hourly

Keep serum glucose Continue IV infusion of 0.05-0.10/kg/hour

150-250 mg/dL
or give 5-10 units/2hours

May stop when metabolic control is achieved

3
<3.3 mEq/L

Serum potassium
3.3-5.0 mEq/L

Hold insulin and give

40 mEq K+/hour until
K+ >3.3 mEqL/L

>5.0 mEq/L

Give 20-30 mEq

K+/L of IV fluid

No K+; monitor
every 2 hours
until K+ <5.0
mEq/L
(continued )

ALGOR

Page 89

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

ALGOR
Diabetic Ketoacidosis (continued)
4

pH <6.9?

No

No bicarbonate

Yes

Give 100 mmol of NaHCO3 in 400 mg H20 at 200 mg/hour

Check pH after 2 hours & repeat if pH <6.9

5

Serum phosphate

<1.0 mg/dL or
cardiac dysfunction,
respiration,
or anemia

Normal

Consider giving 1/3-1/2

K+ as K+-phosphate

Monitor serum phosphate and

consider treatment if level
<1.0 mg/dL (0.30 mmol/L)

Also monitor calcium

6

Serum magnesium
<1.8 mg/dL
(0.74 mmol/L)

Symptomatic?
Yes

Normal

No

Monitor magnesium;
consider oral
magnesium replacement

Monitor as
needed

Magnesium replacement IV if major symptoms

(e.g., life-threatening arrhythmias)

90

Page 90

ALGOR

H2-blocker
or PPI

Intubate

Varices

Consider endoscopy

Start empiric H2-blocker

No

Tagged RBC scan,

angiogram, or
colonoscopy

Anoscopy,
sigmoidoscopy

Consider lower
GI source

50 mL normal saline
boluses until mean
BP of 70

Negative

Bright red blood fails to clear after 1 L lavage

Octreotide
FFP

Yes

NG lavage
Positive for blood

Low

Normal or elevated

Blood pressure

CBC, PT/PTT, type and cross

9/12/08

Peptic ulcer

Emergent
endoscopy

Yes

>Two large bore (18 or 16-G Angiocaths) IV access

Larger bleeds: Central access with PA catheter introducer

No

Airway endangered?

GI Bleed

FADavis_Chapter 03 .qxd
3:48 PM

91

Page 91

92

Cystoscopy

Negative

IVP or CT

UTI
Treat

Likely glomerular,
Workup for GN
Consider biopsy

Dysmorphic
RBCs/RBC casts

Empiric therapy for culture

negative infection
Consider interstitial nephritis

Urine culture

Pyuria

RBCs

Urinalysis

Positive for blood

Urine dipstick

9/12/08

Adapted from Li, T. Approach to Hematuria. In: Agha, IA, Green, G, eds.
The Washington Manual: Nephrology Subspecialty Consult. Phialdelphia: Lippincott, 2004,
and htttp://www.acpmedicine.com/sample/ch10083-f3.htm

Mass or
stones

No RBCs

No blood

Macroscopic; isomorphic RBCs;

no proteinuria

Myoglobin,
hemoglobin

Drugs, dyes, melanin

Hematuria Workup

FADavis_Chapter 03 .qxd
3:48 PM

ALGOR

Page 92

ALGOR

Squamous cell
(lung, head, &
neck), renal cell
carcinoma,
hepatoma,
lymphoma

High

PTHrelated
peptide

ATN recovery

Stop meds
Recheck Ca2+
in 48-72 hrs
No

No

Renal failure?

Chronic

Lung carcinoma
(small, large, adeno,
broncho-alveolar),
myeloma, breast,
thyroid, prostate

Low

Excess
Ca2+/
vitamin D
or
aluminum
toxicity

Low

PTH

Endocrine (hyperthyroid,
Addison, acromegaly,
pheochromocytoma)

High

High

Urinary Ca

Low

Familial
hypocalciuric
hypercalcemia

9/12/08

Granulomas (e.g.;
TB, sarcoid,
histoplasmosis,
coccidioidomycosis)

1, 3 hyperparathyroidism

Risk of malignancy
(H & P, CXR, PO4, alk phos)

Acute

Caused by medications: (e.g.;

thiazides, lithium, vitamin A or D)

Elevated

Ionized calcium

Correctable by hydration
Normal

Normal

High

Yes

Not true hypercalcemia

IV fluids

Hypercalcemia Workup

FADavis_Chapter 03 .qxd
3:48 PM

93

Page 93

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

ALGOR

Hyperkalemia Management
Rule Out Spurious Causes
Laboratory error
Blood-draw issues (from vessel with potassium infusion, fist
clenching, tourniquet, traumatic)
Pseudohyperkalemia
Hemolysis
Leukocytosis
Thrombocytosis
Genetic syndromes
Familial pseudohyperkalemia
Hereditary spherocytosis

94

Page 94

ALGOR
R efrac tory

Hemodialysis

Insulin + glucose +/albuterol

Shift K+ intracellular

IV calcium gluconate

Adapted from http://www.aafp.org/afp/20060115/283.html

Sodium polystyrene sulfate (Kayexelate) & furosemide

Increase K+ excretion

P res ent

A bnormal

P eaked or tented T
S T depres s ion
F irs t-degree AV block or los s of P
QR S widening
B iphas ic wave (s ine wave): QR S & T fus ion
Imminent ventric ular s tands till

Emergent Treatment

Lab error, blood draw issues (from vessel with potassium

infusion, fist clenching, tourniquet, traumatic),
pseudohyperkalemia, hemolysis, leukocytosis,
thrombocytosis, genetic syndromes, familial
pseudohyperkalemia, hereditary spherocytosis

9/12/08

A bs ent

Metabolic acidosis

Normal

Renal function

Normal

ECG

S purious

S udden rapid ris e or >6.0 meq/L

<6.0 meq/L

Serum K+

R eal

Rule out
spurious causes

Hyperkalemia (K+>5.0 meq/L) Management

FADavis_Chapter 03 .qxd
3:48 PM
Page 95

95

96
Renal hypotonic
fluid loss,
Diuretics,
Osmotic diuresis

UNa >10 mEq/L

UOsm <700 mOsm/L

Central
diabetes
insipidus

Yes

Nephrogenic
diabetes
insipidus

No

Response to DDAVP?

Diabetes insipidus

<700 mOsm/L

Salt excess

Increased

9/12/08

Hypotonic fluid loss,

Insensible loss,
GI loss

UNa <10 mEq/L

UOsm >700 mOsm/L

Normal

Urine osmolality

Osmotic diuresis

>700 mOsm/L

Decreased

Urine sodium
Urine osmolality

Volume status

Hypernatremia (Na+<135 meq/L) Workup

FADavis_Chapter 03 .qxd
3:48 PM

ALGOR

Page 96

ALGOR

Hypomagnesemia
Normal

mg2+

Normal

Low

PTH

Low

Normal

Amylase & lipase

Normal

PO4 3 -

Pancreatitis

Hyperphosphatemia

Vitamin D
Drugs (colchicine, phenytoin)
Pseudohypoparathyroidism

Appropriately

Ionized calcium

Hypoparathyroidism
or renal wasting

Low albumin

Hypocalcemia Workup

FADavis_Chapter 03 .qxd
9/12/08
3:48 PM

97

Page 97

98
Urinary Cl

Increased

Plasma HCO3

Normal

<10 mEq/L

Distribution defect
AML, insulin excess,
alkalosis, hyperglycemia,
periodic paralysis, B12 therapy

<10

>10

Decreased

Vomiting with
metabolic alkalosis
Hyperaldosteronism
state

Bartters, diuretics,
normotensive
hyperaldosteronism

RTA Type 1
RTA Type 2

Nonrenal loss
Diarrhea, biliary loss, small
intestinal fistula, laxative abuse

Decreased
Primary
hyperaldosteronism

Renal loss
Check BP

>20 mEq/L

Increased loss
Check urinary spot K+

9/12/08

Increased
Secondary
hyperaldosteronism

Plasma renin

Hyperaldosteronism
state

Elevated

Spurious

Hypokalemia (K+<3.5 meq/L) Workup

FADavis_Chapter 03 .qxd
3:48 PM

ALGOR

Page 98

High
(>295 mOs m/kg)

ALGOR

>20 meq/L

SIADH

>20 meq/L

Edematous states,
Liver dz,
CHF,
Nephrotic
syndrome

Water restriction
and diuretics

Renal
disease

Urine sodium

Inc reas ed
<20 meq/L

H2O restriction and treat

underlying disorder;
hypertonic saline
for life-threatening
hyponatremia

Hypothyroidism
Adrenal
insufficiency
Drugs

UOs m>200,
UNa>20

Normal

Volume status

9/12/08

Isotonic fluid
replacement

Renal loss
Diuretics
(early)

Urine sodium

Dec reas ed

Excess H2O intake

Extrarenal
loss
(GI, skin)

<20 meq/L

Hyperglycemia
Mannitol therapy

>100 mOs m/kg

Urine osmolality

Hyperproteinemia
Hyperlipidemia

<100 mOs m/kg

Hypertonic
hyponatremia

Hypotonic hyponatremia

L ow (<280 mOs m/kg)

Plasma osmolality

Pseudohyponatremia

Normal
(280-295 mOs m/kg)

Hyponatremia (Na+<135 meq/L) Workup

FADavis_Chapter 03 .qxd
3:48 PM

99

Page 99

100

Consider PE

C lear

CXR

Wedge pres s ure > 16,

C ardiac index <2.5

Hemodynamic
monitoring

Cardiogenic
pulmonary edema

Wedge pres s ure < 16, C ardiac index >2.5

Pneumonia, atelectasis

Diffus e infiltrates

Sleep apnea
Sedative overdose
Neuromuscular weakness
Central hypoventilation

F oc al infiltrates

Respiratory acidosis

COPD exacerbation
Status asthmaticus

Dec reas ed
< [A ge (yrs ) + 4] /4

Type II respiratory failure

A-a Gradient (PA-aO2)

9/12/08

ARDS

Inc reas ed

Normal or low

PaCO2

Inc reas ed
> [A ge (yrs ) + 4] /4

Hypoxia Diagnosis

FADavis_Chapter 03 .qxd
3:48 PM

ALGOR

Page 100

ALGOR
NIPPP (e.g., BIPAP)

Normal and
stable

Mental status
Hemodynamic measurements

<90%

No improvement

MS and/or unstable

SpO2

9/12/08

Intubation

Continue oxygen
Treat underlying cause
Close monitoring

>90%

Pulse oximetry & supplemental O2

Hypoxia Management

FADavis_Chapter 03 .qxd
3:48 PM

101

Page 101

PaO2 <55 mm Hg, PaCO2 >50 mm Hg

and pH <7.32
Vital capacity <10 mL/kg
Negative inspiratory force <25 cm H2O
FEV1 <10 mL/kg

102

No
TV/RR**

NI/baseline

pH and PaCO2

TV
RR

FiO2 by 10% at a time:

follow SpO2, consider
early warning

Adequate

PEEP

Sedate/paralyze

Correct anemia

Inadequate

ECMO?

Healthy side dependent

PaCO2

Consider pressure control ventilation with inverse I:E ratio

Respiratory
acidosis

9/12/08

*COPD: Tidal volume = 10 mL/kg;

rate = 10/minute (prevent hyperinflation)
ARDS: Tidal volume = 6-8 mL/kg;
rate = 10-12 /minute (prevent volutrauma)
**Sedate/paralyze/control pain

TV
RR

Respiratory
alkalosis

Assess clinically and check ABG in 10-15 min

Intubate: start assist control, rate 12-14/min, TV 8-10 mL/kg, FiO2 100%, PEEP 5 cm H2O*

Indications for intubation: respiratory distress,

mental status,
respiratory acidosis,
refractory hypoxemia, airway protection

Hypoxia Mechanical Ventilation (Initiation)

FADavis_Chapter 03 .qxd
3:48 PM

ALGOR

Page 102

ALGOR

Androgen
receptor
insensitivity

Normal

FSH

High

LH

High

Male

Primary
hypogonadism

MRI r/o
pituitary
adenoma

High

FSH

LH

Low

MRI r/o
pituitary
adenoma

Prolactin

FSH

LH

Female

Ovarian
failure

Normal

>20 ng/mL

>40 ng/mL

Hysterosalpingogram
and laparoscopy

Abnormal

<5 ng/mL

<5 ng/mL

9/12/08

Low

r/o retrograde
ejaculation,
hypospadia

Testicular
ultrasound

Normal

FSH

LH

Normal

Testosterone

Infertility

FADavis_Chapter 03 .qxd
3:48 PM

103

Page 103

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

ALGOR

Mechanical Ventilation: Extubation Criteria

Hemodynamic stability
Vital capacity >10 mL/kg
Maximum inspiratory pressure <-25 cm H2O
Respiratory rate <20 breaths/min
Respiratory minute volume (VE) <10-20 L/min + normal PaCO2
Adequate arterial oxygenation (e.g., PaO2/FiO2 ratio >150-200)
with FiO2 <40%50%, PEEP <5-8 cm H2O
Ratio of ventilatory frequency to tidal volume (f/Vt) <100 during
1-2-minute trial of spontaneous ventilation
From Miller: Millers Anesthesia, 6th ed

104

Page 104

ALGOR

Air leak,
Hyperventilation
(e.g., pain anxiety,
agitation)

Decreased

Increased Airway Resistance

Acute bronchospasm, aspiration,
endotracheal tube obstruction (e.g., kinking
or clenching teeth), obstruction from retained
airway secretions (e.g., mucous plugging)

No

Pulmonary thromboembolism,
extrathoracic process

No

Peak pressure

Decreased Compliance
Abdominal distention (e.g., gas from positive
pressure ventilation, pneumoperitoneum,
ascitic fluid, peritoneal dialysis), atelectasis
(e.g., lobar collapse), large pleural effusions,
pneumothorax, stiff lung (e.g. acute respiratory
distress syndrome, cardiogenic pulmonary
edema, fluid overload, pneumonia),
hyperinflation (e.g., auto-PEEP in COPD)

Increased

Plateau pressure

Increased

Acute respiratory distress: tachypnea, hypoxemia, respiratory acidosis

Mechanical Ventilation: While on Ventilator

FADavis_Chapter 03 .qxd
9/12/08
3:48 PM

105

Page 105

Mode

Ventilator Breath Initiated

106

No ventilator breath; delivers pressure expiration to keep alveoli open

preserve functional residual capacity (FRC)
Ventilator Breath Terminated

Positive end expiratory pressure (PEEP)

After specified breath volume delivered

After set pressure attained within ventilator
After set period of time

Volume cycled

Pressure cycled

Time cycled

Mode

3:48 PM

No ventilator breath; deliver set pressure to airways maintain lung volume

and improve oxygenation; FRC and work of breathing (exhale vs. pressure)
may impaired ventilation

ALGOR

9/12/08

Continuous positive
airway pressure (CPAP)

Pressure support

At preset and coordinated with patients respiratory effort;

spontaneous breathing allowed between breaths
Spontaneously by patient; set level of support pressure (not TV) to assist every
spontaneous effort; airway pressure support maintained until patient's
inspiratory flow falls below certain cutoff (e.g., 25% of peak flow)

At preset interval, spontaneous breathing allowed between breaths

Synchronous intermittent
mandatory ventilation (SIMV)

With patients respiratory effort; no spontaneous breathing allowed;

mandatory minimum set rate; patient can easily minute ventilation,
but cannot wean rate, on PIP or Vt

At preset intervals, regardless of patient effort

Intermittent mandatory ventilation (IMV)

Assist-control ventilation

Continuous mandatory ventilation (CMV)

Mechanical Ventilation: Modes

FADavis_Chapter 03 .qxd
Page 106

ALGOR
Benign

Cold nodule

TSH

Cystic

Drainage

Normal or

Normal

Frozen Abnormal
section

Surgery

Malignant

>1 cm

Fine needle
aspiration

Solid

Inconclusive

<1 cm

Thyroid
ultrasound

9/12/08

Repeat fine needle aspiration in 6 months

Repeat thyroid ultrasound every 1-2 years

Consider
radioactive
ablation

Hot nodule

Radioactive
thyroid scan

Solitary Thyroid Nodule

FADavis_Chapter 03 .qxd
3:48 PM

107

Page 107

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

ALGOR

Scales
Brain and Central Nervous System
Glasgow Coma Scale (GCS)
Measure
6
5
4
3
2
1
Motor
Obeys Localizes Withdraws Flexion Extension None
compain
to pain
to pain to pain
mands
Verbal
Oriented Confused InapIncomNone
propri- prehenate
sible
Eye
SpontaTo com- To pain
None
opening
neous
mand
Coma score: 13 correlates with mild brain injury; 912
moderate injury; 8 severe injury

Tissue Plasminogen Activator

for Acute Stroke
Evidence of intracranial hemorrhage (e.g., on CT
scan)?
Suspicion of subarachnoid hemorrhage?
Recent intracranial surgery, serious head trauma, or
recent prior stroke?
History of intracranial hemorrhage?
Uncontrolled hypertension (HTN) at treatment time
(185 systolic or 110 diastolic)?
Seizure at stroke onset?
Active internal bleeding?
Intracranial neoplasm, arteriovenous malformation,
or aneurysm?
Known bleeding diathesis?

108

Yes

No

5
5

1
1

5
5

1
1

5
5
5

1
1
1

Page 108

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

109
Current oral anticoagulant use with PT over 15?
Use of heparin within last 48 hours and elevated PTT?
Platelet count 100,000?
Stroke symptom onset more than 3 hours ago?
Severe neurologic deficit (e.g., NIHSS 22)?
Major early infarct signs on CT (edema, mass
effect, or midline shift)?
Total score: 15 thrombolysis indicated; 13
thrombolysis contraindicated

Yes

No

5
5
5

1
1
1

0
0

1
1

Migraine Without Aura (Common Migraine)

A. Attacks last 472 hr (untreated or unsuccessfully treated)
B. 2 of following 4 headache characteristics:
1. Unilateral 2. Pulsating 3. Moderate to severe (disturbing or
precluding daily activity) 4. by movement
C. 1 of following 3 associated symptoms:
1. Nausea/vomiting 2. Photophobia 3. Phonophobia

Migraine With Typical Aura (Classic Migraine)

1 transient focal neurologic aura symptoms:
1. Visual (99%) 2. Sensory (31%) 3. Aphasic (18%) 4. Motor
(6%); occasional pts. may have atypical aura

ALGOR

Page 109

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

ALGOR
Gradual development of aura symptoms over 4 min or several
symptoms occurring in succession (usu. alternating body sites in
different attacks)
Aura symptoms 460 min (motor symptoms may last longer)
Headache usually follows or accompanies aura 60 min (up to
42% pts. may have attacks of aura without headache)

Alarm Symptoms Additional Tests

(Including Imaging)
1. Aura symptoms always on same side of body 2. Aura symptoms with acute onset that does not spread 3. Aura symptoms
duration 5 min or 60 min 4. Sudden in migraine characteristics 5. Sudden and substantial attack frequency (check for substance abuse) 6. Onset above age 50 yr 7. Aura without headache
8. Associated with high fever 9. Abnormal neurologic examination results

Canadian Head CT Rule for Minor

Head Injury
High risk

Intermediate risk

GCS 15 at 3 hr postinjury
Possible open or depressed skull fracture
Any sign of basal skull fracture
2 vomiting episodes after injury 65 y.o.
Amnesia events 30 min prior to injury
Injury mechanism dangerous
activity/event

Consider head computed tomography (CT): 0 high risk, 1

intermediate risk
Head CT Indicated : 1 high and 0 intermediate risk

110

Page 110

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

111
Cardiovascular
o

Left Ventricular Hypertrophy (LVH)

New York Heart Association (NYHA) Functional

Classification for Congestive Heart Failure (CHF)
Class
I
II
III
IV

Description
No activity limit; no symptoms from ordinary activity
Slight, mild activity limit; comfortable with rest or
mild exertion
Marked activity limit; comfortable only at rest
Should be at complete rest, bed/chair confined; any
phys activity brings discomfort; symptoms at rest

Minor Criteria

Duke Criteria for Infective Endocarditis (IE)

A. Blood Culture (BCx) for IE: 1. Two separate BCx typical IE organism (S. viridansococci, S. bovis, HACEK* group,
community-acquired S. aureus or enterococci, in absence of
first-degree focus) or 2. IE organisms from persistent BCx
(2 BCx drawn 12 hr apart or all of 3 or majority of 4
separate BCx with first and last sample drawn 1 hr apart)
B. Evidence of endocardial involvement: 1. Echo for IE
(oscillate intracardiac mass on valve or support structures, in
regurgitant jet path, or on implanted material without alternate explanation or abscess or new partial dehiscence of
prosthetic valve) or 2. New valve regurgitation

A. Predisposing heart condition or intravenous drug user

(IVDU) B. Fever: Temperature 38.0C (100.4F) C. Vascular
phenomena: Major artery emboli, septic pulmonary infarct,
mycotic aneurysm, intracranial hemorrhage conjunctival
hemorrhage, and Janeways lesion D. Immunologic phenomena: glomerulonephritis, Oslers nodes, Roths spots, and
rheumatoid factor E. Micro: BCx but not meet major criterion or no serologic e/o active infection with IE organism F.
Echo consistent with IE but not meet major criterion
IE if: 2 major or 1 major 3 minor or 5 minor
Minor Criteria

s
e
-

ALGOR

Page 111

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

ALGOR
Ear, Nose, and Throat
Diagnosis of Mnires Disease
Possible: 1. Episodic Mnires-type vertigo without documented
hearing loss, or sensorineural hearing loss (fluctuate or fixed)
with dysequilibrium but without definitive episodes 2. Other
causes excluded
Probable: 1. One definitive vertigo episode 2. Audiometrically
documented hearing loss 1 occasion 3. Tinnitus or aural
fullness in treated ear 4. Other causes excluded
Definite: 1. 2 definitive spontaneous vertigo episodes 20 min
2. Audiometrically documented hearing loss 1 occasion
3. Tinnitus or aural fullness in treated ear 4. Other cases
excluded
Certain: Definite Mnire s histopathologic confirmation

Gastrointestinal
Child-Pugh Score for Grading Hepatic
Cirrhosis
Parameter
Total bilirubin (mg/dL)
Serum albumin
PT (sec prolonged)
Hepatic encephalopathy
grade
Ascites

1
2
3.5
14
None

2
23
2.83.5
46
Grade 1 or 2

3
3
2.8
6
Grade 3 or 4

None

Mild

Severe/tense

Total score: 56 Grade A good operative risk; 79 Grade

B moderate operative risk; 1015 Grade C poor
operative risk

112

Page 112

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

113
Ransons Criteria for Pancreatitis
On admission
Age 55?
WBC 16K/cubic mm?
Blood glucose 200 mg%?
Serum LDH 350 IU/L?
Serum SGOT 250 SF units?

Yes
1
1
1
1
1

No
0
0
0
0
0

1
1
1
1
1
1

0
0
0
0
0
0

Within 48 hr of admission
Hct fall 10%?
BUN rise 5 mg/dL?
Serum calcium 8 mg%?
Arterial pO2 60 mm Hg?
Base deficit 4 mEq/L?
Fluid sequestration 6L?
Predicted mortality if total score: 3 1%; 34 15%;
56 40%; 6 100%

Liver Disease and AST-to-ALT Ratio

EtOH
Drug
Cirrhosis
Hepatocellular
carcinoma

1.5
2.0
1.42.0
1.5

ALGOR

Intrahepatic cholestasis
Extrahepatic cholestasis
Acute viral hepatitis
Acute MI

1.5
0.70.8
0.65
3.0

Page 113

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

ALGOR

Genitourinary
Bishops Score for Elective Induction
of Labor
Measure

Cervix
1
12
34
4
dilated
Cervical
4 cm
24 cm
12 cm
1 cm
length
(0%)
(0%50%)
(50%75%)
(75%)
(effacement)
Cervical
Firm
Average
Soft
consistency
Cervical
Posterior
Middle or
position
anterior
Zero station
At
At
At
At
notation
ischial
ischial
ischial
ischial
(presenting
spines
spines
spines
spines
part level)
3 cm
1 cm
1 cm
2 cm
1 point for preeclampsia and each prior vaginal delivery
Subtract 1 point for postdates pregnancy, nulliparity, premature
or prolonged rupture of membranes
Cervical ripening with prostaglandins if score 5, membranes
intact, and no regular contractions; Pitocin labor induction if
score 5 and rupture of membranes

114

Page 114

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

115
Ectopic Pregnancy Risk
Questions
Yes
Peritoneal signs or definite cervical motion
2
tenderness?
Pain or tenderness, other than midline cramping,
1
plus no fetal heart tones and no tissue visible at the
cervical os?
Total score: 1 low risk (1% risk of ectopic pregnancy);
1 intermediate (7%); 1 high (29%)

APGAR Score
Measure

Points
2

Heart rate
Breathing
Muscle tone/
movement
Skin color/
oxygenation
Reflex
response to
irritable
stimuli

Total
0

100
Nl
Active

100
Irregular
Moderate

0
Absent
Limp

Pink

Bluish
extremities
Whimpering

Totally
blue
Silence

Crying

No
0

Total 7 is normal, and 7 distress

Analyte
Bilirubin
Creatinine
(mg/dL)
Osmolal
(mOsm/kg
H2O)

Urine

(20)

Amniotic Fluid
May be present
~Plasma (0.84.0)

500800

230295

(continued )

ALGOR

Page 115

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

ALGOR
APGAR Score
Analyte

(Continued )

Urine

pH
Protein(mg/dL)
Specific gravity
Urea (mg/dL)

Usually
acidic
(114)
1.0051.030
(~5001000)

Amniotic Fluid
Neutral or alkaline
(6.917.43)
(70840)
1.025
~Plasma (12.141.7)

Biophysical Profile (BPP) Score

Questions
Heart rate: Normal non-stress test
Breathing: 1 breathing episode in 30 min
Movement: 2 movements within 30 min
Muscle tone: 1 active limb extension and
flexion episodes (i.e. open/close hand)
Amniotic fluid: 1 adequate fluid pockets

Yes
2
2
2
2

No
0
0
0
0

Abnormal: if total score 8, amniotic fluid 0, or poor

nonstress test consider delivery or repeat BPP

CDC Diagnostic Criteria for Pelvic

Inflammatory Disease (PID)
Minimum criteria (empiric treatment in sexually active females
at risk for PID if all 3 present):
Tenderness: 1. Lower abdominal 2. Uterine/adnexal 3. Cervical
motion

116

Page 116

FADavis_Chapter 03 .qxd

9/12/08

3:48 PM

117
Additional criteria: 1. temperature 38.3C (101F) 2. Abnormal
cervical or vaginal mucopurulent discharge 3. WBCs on vaginal
secretion saline microscopy 4. ESR 5. CRP 6. Laboratory
evidence of cervical infection with N. gonorrhoeae or C.
trachomatis
Definitive criteria: 1. Endometrial biopsy: Histopathologic e/o
endometritis 2. Transvaginal U/S or MRI thick,
fluid-filled tubes with or without free pelvic fluid or tubo-ovarian
complex 3. PID laparoscopic abnormalities

Amsels Diagnostic Criteria for Bacterial

Vaginosis
1. Homogeneous vaginal discharge (color and amount may vary)
2. Amine (fishy) odor when add KOH to vaginal secretions
(whiff test) 3. Vaginal pH 4.5 4. clue cells (20%) on
microscopy (significant criterion)

ALGOR

Page 117

Chapter 04 .qxd

9/12/08

3:51 PM

Page 118

EQUAT
Cerebral Spinal Fluid (CSF)
Measure
Corrected CSF
protein in traumatic LP
Corrected CSF WBCs for
RBCs
CSF IgG Index
Ayalas quotient
(measures effect of
removing CSF on
pressure)

Equation
 CSF proteinin mg/dL  (CSF
RBC/1000)
 CSF WBCs detected  (WBC in
blood  RBC in CSF/RBC in blood)
 [IgG (CSF)/IgG (serum)]/[albumin
(CSF)/albumin (serum)]
 (volume of CSF removed in mL) 
(pressure postremoval of fluid)/
(pressure preremoval of fluid)
5.0: (subarachnoid block or other
cause of a small CSF reservoir)
55.4: borderline ; 5.56.5: Normal;
6.67.0: borderline ; 7.0:
(hydrocephalus, serous meningitis,
or other cause of large CSF
reservoir)

Toxicology Levels
Measure
Half-life (T1/2)

Blood EtOH
concentration
Adjusted
phenytoin
level
Phenytoin:
free-drug level

Equation
 0.693/kelim [0.693  (volume of
distribution)/(clearance)]
kelim  [ln (Cpeak) ln (Ctrough)]/tinterval
 (volume ingestedin mL  beverage
proof  1.463)/(pt. weightin lb)
 phenytoin measured/[(serum
albumin  renal function)  0.1] renal
fx  0.1 if creatinine clear 10 mL/min;
otherwise  0.2
 (0.55  phenytoin measured/serum
albumin)  0.14

118

Chapter 04 .qxd

9/12/08

3:51 PM

Page 119

119
Cardiovacular Hemodynamics
Measure
Stroke volume
(SV)
SV index (SI)
Ejection fraction
(EF)
Cardiac output (CO)
Blood volume
O2 content in blood
O2 consumption
CO (Ficks method)

CO (indicatordilution )
method
Cardiac index
Heart rate (HR)
Jose and Collison
predicted intrinsic
HR (IHR)
Rate pressure product
Mean arterial
pressure (MAP)
Cardiothoracic ratio

Equation/Interpetation
 End diastolic volume  end systolic
volume Normal: 6987 mL/beat
 SV/BSA Normal: 4050 mL/
contraction/m2
 (SV  100%)/(end diastolic volume)
Normal: 55%78%
 SV  HR Normal: 37 L/min
 Plasma volume/(1-Hct) Normal: 25.1 L
 (Hgbin g/dL)  (1.34mL O2/g Hgb) 
(O2 saturationin %)
 BSA * basal O2 consumption  BSA *
125 mL O2/m2
 (O2 consumption)/{[(O2 content arterial
bloodin vol%)  (O2 content mixed venous
bloodin vol%))  10)]}
 (60  amount indicator injectedin mg)/
[(mean blood concentration
of indicator)in mg/L)  (time total curve
durationin seconds)]
 SV  HR/BSA Normal:
2.54.5 L/min/m2
Normal: 60100 bpm
Males:  (0.55  agein years)  118
Females:  (0.61  agein years)  119
 (SBPin mm Hg* HRin BPM)/1000
~ 1/3 * SBP  2/3 * DBP Normal:
70100 mm Hg
 (Transverse diameter of heart on PA
or AP view)/(transverse diameter of
bony thoracic cage) 50% cardiac
enlargement
(continued )

EQUAT

Chapter 04 .qxd

9/12/08

3:51 PM

Page 120

EQUAT
Cardiovacular Hemodynamics (Continued )
Measure
QT interval correct
(QTc)
RR interval
Systemic vascular
resistance (SVR)
SVR index (SVRI)
Pulmonary vascular
resistance (PVR)

PVR index (PVRI)

Shock index

Coronary
performance
pressure
Colloid-oncotic
pressure
Pulse pressure

Ratio of pulse
pressure to
systolic
pressure
Central venous
pressure (CVP)
in cm H2O

Equation/Interpetation
 (QT interval)/((RR interval)
Normal: 440 msec
 60/HR
 (MAP  (mean right atrial pressure))
 (80/CO)  (MAP  CVP)  79.92/CO
Normal: 8001200 dynes/sec/cm5
 (MAP  CVP)  79.92/CI Normal:
19702390
 80  (PA_Pressure  LA Pressure)/
pulmonary_flow  80  (mean PA 
mean PCWP)/CO Normal: ~67 / 23
dynes/sec/cm5
 (Mean PA pressure  PCWP)  80/CI
Normal: 30240 dyn-s/cm5m2
 HRin bpm/SBPin mm Hg Persistent
poor prognosis
Normal: 0.50.7; 0.9 admission or
ICU (even with stable VS)
 DBP  PCWP Normal: 6080 mm Hg
 (Globulin  1.4)  (Albumin  5.5)
Normal: 2329 mm Hg
 (SBP)  (DBP) Normal: 2070 mm Hg;
SBP  100140 mm Hg; DBP 
6090 mm Hg
 (SBP  DBP)/SBP  1  (DBP/SBP)
Normal: ~0.42; poor prognosis
in CHF: 0.25
 (vertical height of jugular venous
distention above sternal anglein cm)
 5 cm

120

Chapter 04 .qxd

9/12/08

3:51 PM

Page 121

121
 (CVPin cm H2O)/1.36
 DBP  ((SBP  DBP)/3)

CVP in mm Hg
Mean vascular
pressure
Left cardiac
work index
Left cardiac
work index
Left ventricular
stroke work
index (LVSWI)
RVSWI

 CI  MAP  0.0144 Normal:

3.44.2 kg-m/m2
 CI  MPAP  0.0144 Normal:
540660 g-m/m2
 SI  MAP  0.0144 Normal:
5062 g-m/m2
 SI  MPAP  0.0144 Normal:
7.99.7 g-m/m2

Cardiovascular Monitoring
Condition

Shock

Hypovolemic
Cardiogenic
Septic

SAP CVP PAP PCWP CO C(a-v)O2 PVR SVR

Cardiac

tamponade
RV infarct

0
0
Pulmonary

0
embolism
Airway
0 0

0
obstruction
Pressure adjusted HR  HR  CVP/MAP

EQUAT

Heart Valves

 (CO/(flow_time * HR))/(valve_factor * sqr (valve_gradient))

 CO/sqr (P)
Mean Gradient
Comments
Stage
(mm Hg)
Causes: degenerative, congenital, or
Normal
0
rheumatic
Mild
25
ECG: left atrial enlargement (LAE),
Moderate
2550
left bundle branch block, LVH
Severe
50
Critical
8
Causes: rheumatic, valvulitis, congenital, Normal
0
myxoma, thrombus, second-degree to
Mild
16
severe MAC
Moderate
612
ECG: LAE (P mitrale), / AFib/RVH
Severe
12

Gorlin
Hakki

Valve Area
3.04.0
1.52.0
1.01.5
1.0
0.7
4.06.0
1.52.0
1.01.5
1.0

9/12/08

122

Mitral
stenosis
(MS)

Problem
Aortic
stenosis
(AS)

Valve
area

Chapter 04 .qxd
3:51 PM

EQUAT

Page 122

Chapter 04 .qxd

9/12/08

3:51 PM

Page 123

123
Hematology
Measures
Absolute neutrophil
count (ANC)
Transferrin saturation
(TFS)
Fe replacement
(parenteral dosing)
for Fe deficiency

Equations
 10  WBCin 1000s  (%PMNs 
%bands)
Neutropenia: 1500 cells/mm3
 (Fe/TIBC)  100
Dose  .3  wgt  (100  (Hgb  100)
/age_factor)
Adult 15 kg (14.8); child 15 kg

RBC Equations (for other indices see Tab 7)

Index
Estimated Hct
Hgb at altitude
Hct at altitude
Hct-to-Hgb ratio
Absolute reticulocyte
count
Reticulocyte index
(2%: adequate
response; 2%:
proliferation)

Formula
 (Hgbin g/dL* 2.8)  0.8  RBC * MCV/10
 (6.83 * (e0.000445 * altitude in meters) 
113.3
 (0.449 * (EXP (0.000859 * (altitudein
meters))))  35.6
 Hct% as a whole number/Hgbin g/dL
3.19: normal; 3.5: hemoconcentration
 % reticulocytes * (pt.s Hct/normal Hct)
 Absolute reticulocyte count/maturation
factor
Maturation factors: Hct 35%: 1.0; 35% 
Hct 25%: 1.5; 25%  Hct 20%:
2.0; 20%  Hct: 2.5

EQUAT

Chapter 04 .qxd

9/12/08

3:51 PM

Page 124

EQUAT
Distinguishing Between Fe-Deficiency
and Thalassemia Minor
Formula
Mentzer
EnglandFraser

M/H ratio

Equation
Fe
Thal. Minor
 MCVin femtoliters/
13
13
RBCs per L/10^6
 ((MCVin femtoliters) 
0 (negative)
((5 * (HgBin g/dL)) 
(RBC per L/10^6)  k))
Where k  3.4 if Hct corrected
for plasma trapping (usual)
or 8.4 if not.
M  % microcytes (erythrocyte 0.9
0.9
volume 60 fl)
H  % hypochromic (MCHC
28 g/dL)
 RDW  HDW
530
530

RDW &
HDW
product
MCH/RBC  MCH/RBC
ratio
RDW/RBC  RDW/RBC
ratio
Green and  (MCV2  RDW)/(Hgb 100)
King

4.4

4.4

3.3

3.3

72

72

Ventilation Equations
Measures
Minute ventilation
Ventilation index
CO2 production
(VCO2)

Equations
 VT  RR
 [RR  (PIP  PEEP)  CO2]/1000
 VExp  (FECO2  FICO2) VExp
 expired volume over 1 min.
FECO2 & FICO2  fraction expired
and inspired CO2

124

Chapter 04 .qxd

9/12/08

3:51 PM

Page 125

125
Right-to-left
shunt fraction
(Qs/Qt)

Closing capacity

 ([pAO2  paO2]  0.003)/

[([pAO2  paO2]  0.003)  5]
Where: pAO2  FIO2  (pAtm  pH2O) 
(paCO2/R)  [paCO2  FIO2  (1  R)/R]
pAtm  760 mm Hg 
e(-altitude in meters/7000)
pH2O 47 mm Hg 
e([Temperature in Celsius-37]/18.4)
 Closing volume  residual volume

Lung Volumes (see lung volume diagram

following)
Measure
FRC
IC
TLC
IRV
RV
TV or VT

Physiologic
dead space
(VD)
VD/VT

Equations
 ERV  RV  TLC  IC  TLC  IRV  TV 
TLC VC  ERV
 IRV  TV  TLC FRC  VC ERV  VC 
RV FRC
 VC  RV  IC  FRC  IRV  TV  ERV 
RV IRV  FRC  TV
 IC TV  TLC FRC  TV VC ERV TV 
RV  VC FRC  TV
 FRC ERV  TLC VC  IC  FRC VC 
IRV  TV  FRC  VC
 IC IRV  TLC FRC IRV  VC ERV  IRV
RV  VC IRV FRC  alveolar space  dead
space
 Dead space volume/VT  ((PaCO2)  (PCO2 of
expiratory gas sample))/(PaCO2)
 Dead space fraction of TV
(continued )

EQUAT

Chapter 04 .qxd

9/12/08

3:51 PM

Page 126

EQUAT
Lung Volumes (see lung volume diagram
following) (Continued )
Measure
VD/VT
Forced VC
(FVC)
FEV1
FEF2575

Equations
 Dead space fraction of TV
Volume air expelled forcefully after full breath
Normal: 4.0 L
Volume air expelled in 1 sec during forced
expiration Normal: 3.0 L FEV1/FVC 60%
 Forced expiratory flow from 25%75% FVC 
maximum flow when air forcefully expelled
mid-expiration

Predicted Pulmonary Function Tests (PFTs)

for Men
Measure
FEV1
FVC
FEV1/FVC

Equation
 Race  1.08  [(0.043  height)
 (0.029  age)  2.49]
 Race  1.1  [(0.0576  height)
 (.0269  age)  4.34]
 87.2  (0.18  age)

Constant
Race:
Caucasian  1
Black  0.87
Asian  0.93

Predicted PFTs for Women

Measure
FEV1
FVC
FEV1/FVC

Equation
Constant
 Race  1.08  [(0.0395  height)
Race:
 (.025 * age)  2.6]
Caucasian  1
 Race  1.15  [(0.0443  height) Black  0.87
Asian  0.93
 (.026  age)  2.89]
 89.1(0.19  age)

126

Chapter 04 .qxd

9/12/08

3:51 PM

Page 127

127
Predicted PFTs for Children
Measure
FEV1
FVC
FEV1/FVC

Males
 e{[(1.2669  (.0174 * Age)] 
height)  1.2933
 e{[(1.3731  (.0164 * Age)] 
height)  1.2782)
 86.21

Females
 e{[(1.5016  (.0119 * Age)] 
height)  1.5974)
 e{[(1.48  (.0127 * Age)] 
height)  1.4057)
 88.88

Lung Volumes
Maximum inspiration
Normal resting
inspiration

IC

IRV
IVC

VT

VC
TLC

Normal resting
expiration

ERV
FRC

RV

No air in lungs

VC = Vital capacity
IVC =Inspiratory vital capacity
ERV = Expiratory reserve volume
IRV = Inspiratory reserve volume
FRC = Functional residual capacity

EQUAT

Maximum
expiration

VT= Tidal volume

IC = Inspiratory capacity
RV = Residual volume
TLC = Total lung capacity

Chapter 04 .qxd

9/12/08

3:51 PM

Page 128

EQUAT
Additional Pulmonary Formulae
Measure
A-a gradient
Alveolar O2
tension
(PAO2)
Arterial O2
tension
(PaO2)
Inspired O2
tension
(PIO2)
Arterial O2
content
(CaO2)
Mixed
venous O2
content
(CvO2)
A-V O2
content
differential
(Ca-vO2)
Barometric
pressure
(PB)
Capillary O2
content
(mL/dL)
Oxygenation
index (OI)

Equation/Interpretation
 PAO2  PaO2 Normal: 525 mm Hg
~age  0.4
 [(FIO2)  (PB  PH2O)]  (PACO2/R) 
[FIO2  (760  47)]  (PACO2/0.8)
Normal: 95105 mm Hg; respiratory
quotient (R)  0.71
~100  (0.33  age)
Normal: 80100 mm Hg
 (FIO2)  (PB  PH2O)
Normal: 100150 mm Hg
 (Hgb  SaO2  1.36)  (0.003  PaO2)
Normal: 1720 mL/dL
 ((Hgb  1.36  SvO2)  (0.003  PvO2)
Normal: 1215 mL/dL

 CaO2  CvO2
Normal: 45 mL/dL

 29.92  (((1)  (6.87535  alt 

10-6))5.2561)
Normal: 0760 mm Hg
 ((Hgb  1.36)  (ScapO2)) 
(PaO2  0.0031)
Normal: 21 mL/dL
 FIO2  mean airway pressure/PaO2 025:
good outcome; 2540: death chance
40%; 301000: 4 hr risk of worsening/death;
401000: consider ECMO

128

Chapter 04 .qxd

9/12/08

3:51 PM

Page 129

129
Peak
expiratory
flow (PEF)
prediction
Peak
expiratory
flow
variability
in asthma
Ventilation
index

Females:  (((height * 3.72)  2.24) 

(age * .03)) * 60
Males:  (((height * 5.48)  1.58) 
(age * .041)) * 60
 100 * (highest_PEF  lowest_PEF)/
highest_PEF 15 asthma: (2030: mild
persistence; 31100: moderate to severe
persistence
 (PaCO2)in mm Hg  (RR)  (peak inspiratory
pressurein cm H2O)/1000 the poorer
the ventilation achieved

Arterial O2 saturation (SaO2)  96%99%; mixed venous O2

tension (PvO2)  3545 mm Hg; mixed venous O2 saturation
(SaO2)  60%80%; FIO2  0.21 for room air; H2O partial pressure
(PH2O)  47 mm Hg; arterial CO2 tension (PaCO2)  3545 mm Hg;
alveolar CO2 tension (PACO2)  3545 mm Hg; mixed venous CO2
tension (Pv CO2)  4050 mm Hg; expired CO2 tension (PECO2) 
2535 mm Hg

Gastrointestinal Equations
Measure
Stool
osmolal
gap
Fractional
excretion of
amylase

Equation
 Stool osmolar  (2  Na  K) 100
osmotic diarrhea, 100 secretory
 100  (urine amylase  plasma creatinine)/
(plasma amylase  urine creatinine) 5%
suggest acute pancreatitis; 1% may
mean macroamylasemia
(continued )

EQUAT

Chapter 04 .qxd

9/12/08

3:51 PM

Page 130

EQUAT
Gastrointestinal Equations (Continued )
Measure
Serum-toascites
albumin
gradient
(SAAG)
Modified
model for
end-stage
liver disease
(MELD) score
Pediatric
end-stage
liver disease
(PELD) score
(18 yr)
Maddreys
discriminant
function for
EtOH hepatitis
Hepatitis C
fibrosis
prediction
score
TIPS survival
predictor

Lipase-toamylase ratio

Equation
 Serum albumin in g/dL  ascites albuminin g/dL
1.1 g/dL portal HTN

 10* (0.957  LN (serum creatinine)) 

(0.378  LN (serum bilirubin)) 
(1.12  LN (INR))  (0.643  cirrhosis cause)
Cirrhosis cause  0 if cause cholestatic
or EtOH  1 for all others
 10 * ((0.480 * in (bilirubin))  (1.857 * in (INR))
 (0.687 * in (albumin))  infant  growth
Growth  2/3 for growth failure and 
0 otherwise; infant  0 for 2 yr  0.436 for
1 yr or 2 yr and on transplant list prior
to first birthday
 4.6  (pt.s PT  control PT)  total bilirubin
32 poor prognosis and may benefit from
glucocorticoid treatment
 7.81  (3.131  ln (platelet))  (0.781  In
(GGT))  (3.467  ln (age))  (.014 
cholesterol) Score  6.9130: fibrosis more
likely; -204.19: fibrosis less likely
 (0.957  ln (creatinine))  (0.378 
in (bilirubin))  (1.12  ln (INR))  (0.643 
cause) Survival  power (days, EtOH
(risk score  1.127))
 (Serum lipase/lipase upper limit normal)/
(serum amylase/amylase upper limit
normal) 3 suggests EtOH pancreatitis

130

Chapter 04 .qxd

9/12/08

3:51 PM

Page 131

131
Diabetes Formulae
Measurement
Hgb A1C Estimation
Mean plasma glucose (MPG)

Equation
 (MPG  77.3)/35.6
 (35.6 * HbA1C)  77.3

Creatinine Clearance
Normal: Males: 90130 mL/min; females: 80125 mL/min
Calculated
 (Urine creatininein mg/dL)  (urine
volumein mL)/(creatininein mg/dL * timemin)
Per standard
 Calculated creatinine clearance *
surface area
(1.73/BSAin m2)
Estimated
Males  (140  agein years)  (body
(Cockcroft
weightin kg)/(72  serum creatininein mg/dL)
& Gault)
mL/min
Females  0.85  (estimated creatinine
clearance for males)
Estimated
Males  (LBWin kg  (29.3  (0.203 
(Mawer)
agein years)))  (1  (0.03  serum
creatininein mg/dL))/(14.4  serum
creatininein mg/dL)
Females  (LBWin kg  (25.3  (0.174  agein yr)
 (1 (0.03  serum creatininein mg/dL))/(14.4 
serum creatininein mg/dL)
Pediatric GFR
  Htcm/PCr  0.33 (_birth wt infants),
0.45 (term infants 1 yr), 0.55 (males 212 yr
& females 1321 yr), 0.70 (males 1321 yr)

EQUAT

Chapter 04 .qxd

9/12/08

3:51 PM

Page 132

EQUAT
Serum Sodium and Water Homeostasis
Total body
water (TBW)
Free H2O
deficit
Free H2O
excess
TBW
Total body
solute
Fluid
distribution
Na
excess/deficit
Na/L
infusate
Osmolal gap
Calculated
osmolality

 0.6  IBW ( 0.85 if female &  0.85 if elderly)

Normal: 1890 L
 TBW  ((serum Na/desired serum Na)  1) 
wtin kg (TBW  0.6 if male & 0.5 if female)
 TBW  (1  (serum Na/desired serum Na)) 
wtin kg (TBW  0.6 if male & 0.5 if female)
 (Infusate osmolality-urine osmalality)  1
 TBW  Osm Normal: 500025000 mOsm
Intracellular  TBW  (2/3) Normal: 1260 L
Extracellular  TBW  (1/3) Normal: 330 L
Interstitial  TBW  0.222 Normal: 420 L
 TBW  normal Wtin kg * (pt.s Na  desired
Na) (TBW  0.6 if male & 0.5 if female)
 (Infusate Na  serum Na)/(TBW  1)
 Measured osmolality  calculated osmolality
Normal: 10 mOsm/kg H2O
 (2 * Na)  (Glucose/18)  BUN/2.8) 
(EtOH/4.6). Normal serum osmolality 
285295 mOsm/kg

Correcting Na+ When

Glucose
(100440)
Glucose (440)
Protein
Lipids

 Measured Na  0.016*(glucose  100)

 Measured Na  0.04  (glucose  100)
 Measured Na  (serum _ protein  8) 
0.25
 Measured Na  plasma _ lipids  0.002

132

Chapter 04 .qxd

9/12/08

3:51 PM

Page 133

133
Correcting Ca2+ When
Albumin

Globulin
pH

 (Measured Ca2in mg/dL)  (0.8  (4 

albuminin g/dL)) ~(current total serum
Ca2 in mg/dL)  4  (albuminin g/dL)
 (Measured Ca2in mg/dL)  (0.16  (normal
globulin  globulinin g/dL))
 (Measured Ca2in mg/dL)  (0.12  (pH  7.41))

Correcting K+ When
pH
Serum Osm
Platelets

 [(Measured KmEq/L)  [0.6  (7.41  pH)]

 (Measured KmEq/L)  (0.6  (serum
osmolality  290)/10)
 (Measured KmEq/L)  [0.15  (platelets 
normal platelets)/100  109]

Serum Sodium and Water Homeostasis

Filtration fraction
Osmolar clearance
(OsmCl)
Free H2O
clearance
Urea clearance
Transtubular K
gradient

 Glomerular filtration rate/renal plasma

flow Normal: 17%23%
 (urine_osmolality/serum_osmolality) 
(urine_per_day/24). Normal: 60180 mL/h
 Urine volume/osmolar clearance
Normal: 25100 mL/h
 (UUN  urine volume)/BUN. Normal:
6499 mL/min
 ((Urine Kin mEq/L)/(plasma Kin mEq/L))/
((urine Osmin mOsm/kg H2O)/(plasma
Osmin mOsm/kg H2O))
Very : K-sparing diuretics, aldosterone
blockers, H2O diuresis, K, instrinsic
renal disease, DKA, hyperglycemic
hyperosmolar syndrome
(continued )

EQUAT

Chapter 04 .qxd

9/12/08

3:51 PM

Page 134

EQUAT
Serum Sodium and Water Homeostasis
(Continued )
Fractional
excretion of K

 [(Urine Kin mEq/L)/(plasma Kin mEq/L)]/

[(urine creatininein mg/dL)/(plasma
creatininein mg/dL)] 10%: renal cause of
K; 10%: extrarenal cause of K

Acid/Base Disorder Compensation

Type of Disorder
Metabolic

Acute
Respiratory

Measure

Chronic

Acidosis
Alkalosis
PaCO2  1.25 
PaCO2  0.75 
HCO3 (PaCO2 
HCO3
last 2 digits of pH)
HCO3  0.1  PaCO2 HCO3 0.2 
PaCO2
HCO3  0.4  PaCO2 HCO3 0.4 
PaCO2

Equation

 (Na)  (Cl  HCO3)

Normal: 816 mEq/L
Anion gap (AG)
 (Na  K)  (Cl  HCO3)
Normal: 1020 mEq/L
AG 12 RTA, diarrhea, CaCl2, other acids
AG 15 MUDPALES: Methanol, Uremia, DKA, Paraldehyde,
Alcohol, Lactic Acid, Ethylene glycol, Salicyclates
Corrected anion
 (Observed AG)  (0.25  [(normal
gap
serum albumin)in g/L  (observed serum
albumin)in g/L)]
 (AGobserved)  (0.25  (44 (albuminobserved)]
Delta gap
 AG  normal AG  AG12
Delta/delta
 AG/HCO3
Normal: 1.02.0

134

Chapter 04 .qxd

9/12/08

3:51 PM

Page 135

135
Acid deficit
Bicarbonate deficit
Chloride deficit
HendersonHasselbach (pH)
Winters formula
for meta-acid
compensation
Urine anion gap
(UAG)

Acid-base
equation (H)
H/K exchange
index

 Weightin kg  0.5  (measured HCO3 

desired HCO3)
 0.4  weightin kg  (24  HCO3)
 0.5  weightin kg  (desired Cl  measured Cl)
 6.1  log (HCO3concentration/(0.03 *
PaCO2))
(Expected pCO2)  1.5  HCO3  8
/ 2
 Urine Na  urine K  urine Cl
Normal: -10 to 10; extrarenal non-AG
metabolic acidosis: 10 renal non-AG
metabolic acidosis: 10
 (24  PaCO2)/HCO3
 K  (0.6  ((pH initial  pH final) 0.1)

Measure

Prerenal Renal


Fractional excretion of Na (FENa )

 100  (urine Nain mEq/L)/(plasma
Nain mEq/L)/(urine creatininein mg/L)/
(plasma creatininein mg/L)
Renal failure index (RFI) 
(urine Nain mEq/L)/(urine creatininein mg/dL)/
(plasma creatininein mg/dL)
BUN/serum creatinine
UUN/BUN ratio
Urine Osm/plasma Osm
Urine creatinine/serum creatinine
Urine Osm
Urine specific gravity
Urine sediment

EQUAT

1%

1%

1%

1%

20
8
1.3
40
500
1.018
Hyaline
casts

1015
3
1.1
20
250
1.012
Muddy
brown
granular
casts

Chapter 04 .qxd

9/12/08

3:51 PM

Page 136

EQUAT
Urology Calculations
Measure
Total motile
functional sperm
Testicular volume
PSA density

Equation
 (Volumein mL)  (sperm density)  (%
motile)  (% normal morphology)
Normal: 40,000,000/mL
 0.71  length2in cm2  widthin cm
 PSAin ng/mL/prostate volumein cc from

in ng/mL/cc

transrectal ultrasound

 Absolute PSAin ng/mL/weight of

prostatectomy specimenin g after removal

of seminal vesicles

PSA density benign diagnosis; in

PSA density further investigation
 (PSA at time 2 in ng/mL PSA at time
1in ng/mL)/(period between time 1 &
time 2)in yr
0.75 ng/mL/year when 3 tests
performed further w/u

PSA velocity

Pregnancy Calculations
Measure
Nageles rule for
due date
Fundal height
(MacDonalds rule)

Menstrual age (weeks)

Equation
Estimated day of confinement 
(1st day of LMP)  (3 mo)  7 d
 Weeks gestation / 2 cm
At 20 wk fundal height should 
20 cm / 2 cm; rule holds 2036
wk; if then suggests
oligohydramnios
 (Crown  Rump Length)in cm
 6.5

136

Chapter 04 .qxd

9/12/08

3:51 PM

Page 137

137
Weight, Energy, and Fluid Calculations
Measurement
Ideal body weight
(IBW)
Normal range for body
weight
Body mass index (BMI)

Body surface area

(BSA)
Basal energy
expenditure
(BEE)
Total daily energy
requirement
(TDER)

Equation
 Sex  sq (height); if male sex,  23;
female sex,  21.5
Low normal  20  sq (height)
High normal  27  sq (height)
 Weightin kg/Height in m2
Underweight: 18.5; ideal: 18.525;
overweight: 2530; obese: 3040;
morbidly obese: 40
 0.20247  heightin in.0.725 
weightin lb0.425
Male: 66.5  (13.75  wtin kg) 
(5.003  htin cm)  (age  6.775)
Female: 655.1  (9.563  wtin kg) 
(1.850  htin cm)  (age  4.676)
Female: [655.1  (9.563  wt)
(1.85  hgt)  (4.676  age)] 
activity  injury
Male:  (66.5  (13.75  wt) 
(5.003  hgt)  (6.775  age)) 
activity  injury
Activity  1.2 confined to bed; 1.3 out
of bed; injury  1.05 minor surgery;
1.15 major surgery; 1.1 mild infection;
1.3 moderate infection; 1.6 severe
infection; 1.275 skeletal trauma; 1.6
head injury with steroid therapy;
1.25 blunt trauma; 1.25 20% burn;
1.85 20%40% burn; 1.95 40%
burn
(continued )

EQUAT

Chapter 04 .qxd

9/12/08

3:51 PM

Page 138

EQUAT
Weight, Energy, and Fluid Calculations
(Continued )
Measurement
Fluid requirements for
burn victims
NPO fluid deficit
Daily maintenance
fluid requirements
Daily maintenance
fluid requirements
for children

Equation
 TBSA burned (%)  wt (kg)  4 mL
Give half of total requirements in first
8 hr, then second half over next 16 hr
Required IV fluids  2 mL/kg for each
hour npo
4-2-1 rule: for 010 kg: 4 mL/kg/hr;
for 1020 kg:  2 mL/kg/hr; for 20 kg:
 1 mL/kg/hr
For 010 kg  100 mL/kg; for 1020 kg
 1000 mL  50 mL/kg for each kg
10; for 20 kg  1500 mL 
25 mL/kg for each kg 20

Operating Room Fluid Requirements

Tissue Trauma
Minimal
Low
Moderate
Severe
Emergency

Examples
Laparoscopic cholecystectomy,
eye surgery
Ear, nose, throat
surgery, arthroscopy
Total joint replacements
Total hip replacement,
bowel resection
Significant trauma

138

Fluid Required
12 mL/kg/hr
34 mL/kg/hr
56 mL/kg/hr
78 mL/kg/hr
1015 mL/kg/hr

Chapter 04 .qxd

9/12/08

3:51 PM

Page 139

139
Fluid Loss (% body weight)
Sign
Mucous membranes
Sensorium
Orthostatic s in
pulse or BP
Urinary flow rate
Pulse rate
Blood pressure

5%
Dry
Normal
Mild

10%
Very dry
Lethargic
Present

15%
Parched
Obtunded
Marked

Mild
Normal/
Normal

Mild

Injury Fluid Resuscitation

Estimate
Brooke

Demlings dextran

Evans estimate

Modified Brookes crystalloid

Parklands crystalloid
Slaters estimate

EQUAT

Formulae
LR  1.5  wt  % burn/24
Colloid  0.5  wt  % burn/24
D5W  2000/24
Dextran 40 in saline  2  wt
FFP  0.5  wt
Run D40 8 hr; titrate additional
LR to maintain UO 30 ML/hr
NS  wt  % Burn/24
Colloid  wt  % burn/24
D5W  2000/24
LR  2  wt  % burn/24
LR  4  wt  % burn/24
LR  2000/24
FFP  75  WT/36

FADavis_C05.qxd

9/12/08

3:53 PM

Page 140

MEDS

Angioedema
Epinephrine, diphenhydramine, methylprednisolone
Acute/recurrent Rx-resistant: prednisone
Chronic/recurrent: hydroxyzine, cetirizine, fexofenadine,
doxepin, desloratadine, loratadine
Hereditary angioedema: FFP transfusion, C1 esterase inhibitor
Prevention: danazol: 50600 mg PO qd

Asthma
Asthma Severity
Mild
Mild
Moderate
Severe
and Treatment Intermittent Persistent Persistent Persistent
Symptoms
2 /wk
2 /wk
Daily
Continual
and 1 /d
Night Sx
Exacerbations

FEV1 or PEF
Short-acting
bronchodilators
Long-acting
bronchodilators
Low-dose
inhaled
steroids
Medium-dose
inhaled steroids
High-dose
inhaled steroids
Oral steroids
Cromolyn/
nedocromil

2 /mo
Brief

80%
prn

2 /mo
May
physical
activity
80%
prn

1 /wk
2 /wk

Frequent
Frequent

60%80%

60%




1 or

140

FADavis_C05.qxd

9/12/08

3:53 PM

Page 141

141
Leukotriene
modifier
Theophylline
Omalizumab

2 or

1* or

2*
1

*Along with low-to-medium dose inhaled steroids

At risk

Nl

Nl

Mild

70%

80%
50
80%
30%
50%
30%

IIA
Moderate 70%
IIB
III

Severe

70%

Chronic 
risk factor
exposure
/
/
/
Respiratory
or R heart
failure
(with any
spirometry)

MEDS

Additional Rx (e.g., chronic O2)

Rehabilitation

FEV1/ FEV1 (%
FVC Predicted) Symptoms

Inhaled Steroids for

Recurring Exacerbations

COPD Stage

Bronchodilators

Chronic Obstructive Pulmonary

Disease (COPD)

prn
 


FADavis_C05.qxd

9/12/08

3:53 PM

Page 142

MEDS
Indications for Chronic O2 Therapy
PaO2 55 mm Hg or SaO2 88% (at rest on room air) if
optimal medical regimen 30 d
PaO2 5559 mm Hg or SaO2 89% (at rest on room air) if
cor pulmonale or Hct 55%
Consider if PaO2 55 mm Hg or SaO2 88% during exercise
or sleep

Community-Acquired Pneumonia
1. Outpatient: No Cardiopulmonary Disease
S. pneumoniae, Mycoplasma, C. pneumoniae, H. influenzae,
viruses, Legionella, TB, endemic fungi
Advanced generation macrolide (azithromycin or
clarithromycin) or doxycycline

2. Outpatient Cardiopulmonary Disease*

Same as 1.  mixed infection (
atypical), gram-negatives,
Moraxella, aspiration (anaerobes)
[-lactam (PO/IV) (macrolide or doxycycline)] or antipneumococcal fluoroquinolone

3. Hospitalized
Same as 1.  mixed infection, viruses, PCP
IV azithromycin or [Doxycycline -lactam] or IV antipneumococcal fluoroquinolone

*Or other modifying factors

Including drug-resistant S. pneumoniae

142

FADavis_C05.qxd

9/12/08

3:53 PM

Page 143

143
4. Hospitalized (Non-ICU) Cardiopulmonary
Disease*
Same as 3.  enteric gram-negatives, aspiration
[IV -lactam (macrolide or doxycycline)] or IV antipneumococcal fluoroquinolone

5. ICU Admission
Same as 4. S. aureus
IV -lactam [IV macrolide or IV fluoroquinolone]
Risks for P. aeruginosa: IV antipseudomonal -lactam
either [IV antipseudomonal fluoroquinolone (ciprofloxacin)]
or [IV aminoglycoside (IV macrolide or fluoroquinolone]

Congestive Heart Failure (CHF)













Implantable
Defibrillator






Spironolactone
or Eplerenone

-blocker





Diuretic

No
Yes
Yes
Yes
Yes

Digoxin

I
II
IIIa
IIIb
IV

Sx

or Angiotensin
Receptor Blocker

NYHA Class

Systolic Dysfunction

*If EF 35%

Avoid in decompensated CHF

MEDS

Additional Later Line Rx:

Hydralazine
Nitrates
Dobutamine
Dopamine
Revascularization
Transplant

FADavis_C05.qxd

9/12/08

3:53 PM

Page 144

MEDS
Diastolic Dysfunction
First-line

Mechanism

-blocker

Maximum diastolic
filling, cardiac work

Angiotensinconverting
enzyme
inhibitor
or ARB
Diuretics

Myocardial relaxation
and compliance,
pre- and afterload

Sx

Use Only as Alternative

Dihydropyrimidine
CCBs (e.g., amlodipine)
Nondihydropyrimidine
CCBs (avoid in LV
dysfunction)
Vasodilators (nitrates,
hydralazine): preload
and angina

Spironolactone
(? efficacy)

Congestive Heart Failure or Shock

Inotropes
Dopamine (25 mcg/kg/min): Vasopressor effects with dose,
AV conduction, arrhythmias, psychosis, skin necrosis (if
extravasation); (0.52.0 mcg/kg/min renal, cerebral,
mesenteric vasodilation)
Epinephrine (shock: 2 mcg/min, then titrate; cardiac arrest:
1 mg IV q35 min):  Agonist; bronchodilator (2agonist); -effects with dose, myocardial O2 consumption;
tachyarrhythmias; splanchnic vasoconstrictor; diabetogenic;
K
Dobutamine (2.520 mcg/kg/min):  Agonist peripheral
vasodilator, ventricular arrhythmias
Contraindications: hypertrophic cardiomyopathy
Digoxin (1251000 mcg/day): Toxicity, K

144

FADavis_C05.qxd

9/12/08

3:53 PM

Page 145

145
Milrinone (Load: 50 mcg/kg over 10 min; dose: 0.3775
mcg/kg/min): Vasodilator (systemic, pulmonary, coronary);
BP, HR; aggravates atrial, ventricular arrhythmias, headache
Amrinone (load: 0.75 mg/kg over 3 min; dose: 520 mcg/kg/min
[max 10 mg/kg/d]):  Inotrope and vasodilator for CHF); BP,
thrombocytopenia, AV and ventricular conduction
Isoproterenol (initial: 14 mcg/min titrate to HR max:

20 mcg/min):
Nonspecific -agonist; BP; HR, myocardial infarction (MI)
contraindications: myocardial ischemia, tachycardia, digitalisinduced bradycardia

Vasopressors
Dopamine (620 mcg/kg/min): Inotrope at lower doses
Norepinephrine (initial: 2 mcg/min; dose: 220 mg/min;
titrate to response Max: 40 mg/min): Moderate inotrope;
1/-agonist (low-dose: ) (high-dose: ); may
dampen peripheral A-lines; Rx extravasation with
phentolamine
Phenylephrine bolus: 0.10.5 mcg IV q15min; initial: 100
mcg/min; titrate to 40200 mcg/min: Postsynaptic -agonist;
reflex bradycardia; coronary, cerebral, and pulmonary
vasoconstriction; dose if MAO inhibitors
Epinephrine (200600 mcg/kg/min): Typically used only for
inotropic effects
Vasopressin (0.040.1 units/min): Antidiuretic; procoagulant;
coronary vasoconstriction (may need to combine with
nitroglycerin); SIADH/H2O intoxication

Deep Vein Thrombosis (DVT)

Heparin or low molecular weight heparin and warfarin:
Discontinue heparin when INR 23 (target)

MEDS

FADavis_C05.qxd

9/12/08

3:53 PM

Page 146

MEDS
Duration of Anticoagulation
Type of DVT
Isolated calf vein symptoms
Low risk (first episode or reversible cause)
First episode idiopathic
Recurrent
Hypercoagulable (may need lifetime)

At Least
612 wk
3 mo
6 mo
12 mo
12 mo

DVT Prophylaxis
Highest Risk
Major surgery in pt. 40 y.o.  prior venous
thromboembolism, malignant disease, or hypercoagulable
Elective major lower extremity orthopedic surgery, hip
fracture, CVA, multiple trauma, or spinal cord injury

LMWH, Warfarin (Target INR 23), or IV Heparin

HIGH RISK
Major surgery in pt. 60 y.o. with no additional risk factors
or in pt. 4060 y.o.  additional risk factors
MI
Medical patients with risk factors

LMWH, Unfractionated Heparin 5000 U q8h, or

Compression Devices (CDs)
MODERATE
Any surgery in pt. 4060 y.o. and no additional risk factors
Major surgery in pt. 40 y.o. with no additional risk factors;
general anesthesia 30 min
Minor surgery in pt. with risk factors

LMWH, Unfractionated Heparin 5000 U q12h, or CDs

LOW RISK
Uncomplicated minor surgery in pt. 40 y.o. with no clinical
risk factors; general anesthesia 30 min

146

FADavis_C05.qxd

9/12/08

3:53 PM

Page 147

147
Early Mobilization
PREGNANCY
Indications: Mechanical heart valve, rheumatic heart
disease, atrial fibrillation, antithrombin III deficiency,
antiphospholipid syndrome, prior anticoagulation
treatment, factor V Leiden defect, prothrombin G20210A
mutation

Unfractionated Heparin or LMWH

Diabetes

Insulin Preparations
Onset
Humalog
Novolog
Regular (R)
NPH (N)
Lente (L)
Ultralente (U)
Lantus
Humulin 70/30
Novolin 70/30
Novolog 70/30
Humulin 50/50
Humalog 75/25

Peak
1530 min
1020 min
30 min1 hr
12 hr
1212 hr
30 min3 hr
11.5 hr
30 min
30 min
1020 min
30 min
15 min

Duration
30 min2.5 hr
13 hr
25 hr
412 hr
310 hr
1020 hr
None (steady level)
24 hr
212 hr
14 hr
25 hr
30 min2.5 hr

MEDS

Onset
35 hr
35 hr
58 hr
1824 hr
1824 hr
2036 hr
2024 hr
1424 hr
24 hr
24 hr
1824 hr
1620 hr

FADavis_C05.qxd

9/12/08

3:53 PM

Page 148

MEDS
Oral Diabetes Medications
Second-Generation Sulfonylurea
( Insulin Secretion)
Glipizide (Glucotrol), glyburide (DiaBeta, Micronase, Glynase
PresTab), glimepiride (Amaryl)
Side effects: Skin rash/pruritus, take 30 min to 1 hr before
meals; take glimepiride with days first meal

Biguanide (insulin sensitivity, hepatic glucose

production, glucose GI absorption)*

Metformin (Glucophage)
Unlike others, does not weight and may even weight
Side effects: Metallic taste, serum B12; temporarily stop before
hospitalization, surgery, or contrast dye; contraindications: liver
and renal disease

Thiazolidinedione (insulin sensitivity)*

Rosiglitazone (Avandia), pioglitozone (Actos)
Take
food, follow liver function tests
Side effects: Edema

-Glucosidase Inhibitor (block starch

digestion)*
Acarbose (Precose), miglitol (Glyset)
Take with first bite of meal
Side effects: GI

Meglitinide ( insulin secretion)

Repaglinide (Prandin), nateglinide (Starlix)
Take before meals; do not take if skip meal

Combination Agents
Thiazolidinedione and biguanide: rosiglitazone metformin
(Avandamet)
Sulfonylurea and biguanide: metformin glyburide
(Glucovance); Glipizide (Metaglip)
All may cause GI effects
*NO hypoglycemia if only medication
~to meglitinide

148

FADavis_C05.qxd

9/12/08

3:53 PM

Page 149

149
Endocarditis
Indications for Prophylaxis
Patient Risk
High: History of subacute bacterial endocarditis, prosthetic
heart valve, complex congenital heart disease (e.g., transposition great vessel, tetralogy of Fallot), surgical systemic pulmonary shunts or conduits
Moderate: Most other congenital heart disease, acquired valvular disease, idiopathic hypertrophic subaortic stenosis, mitral
valve prolapse (MVP  insufficiency and/or leaflet thickening
Low: Isolated secundum atrial septal defect (ASD),
ASD/VSD/PDA 6 mo post-repair if no residual history of
coronary artery bypass graft, pacemaker, automatic internal
cardiac defibrillator, MVP, Kawasakis disease, or rheumatic
fever (no valvular dysfunction)

Procedures (Prophylaxis if Moderate or High Risk)

Dental: Bleeding anticipated
Respiratory: Tonsillectomy and adenoidectomy, rigid
bronchoscopy, mucosal surgery
GU: Prostate, cystoscopy, urethral dilation
GI: Esophageal varices sclerotherapy/dilation, endoscopic
retrograde cholangiopancreatography, mucosal/biliary tract
surgery

Endocarditis Prophylaxis Regimens

Above Diaphragm
Amoxicillin: 2 g PO* or IM/IV

Penicillin-Allergic
Clindamycin: 600 mg PO*
Cephalexin or cefadroxil: 2 g PO*
Prior to procedure:
*1 hr
30 min

MEDS

FADavis_C05.qxd

9/12/08

3:53 PM

Page 150

MEDS
Azithromycin or clarithromycin: 500 mg PO*
Clindamycin: 600 mg IV or Cefazolin: 1 g IM/IV

Below Diaphragm
Moderate Risk
Amoxicillin: 2 g PO* or ampicillin: 2 g IM/IV
Penicillin-Allergic: Vancomycin: 1 g IV over 12 hr

High Risk
Ampicillin 2 g IM/IV AND gentamicin 1.5 mg/kg IV (120 mg)
THEN ampicillin 1 g IM/IV or amoxicillin 1 g PO 6 hr later
Penicillin-Allergic: Vancomycin 1 g IV over 12 hr AND
gentamicin 1.5 mg/kg IV/IM (120 mg)

Endocarditis Treatment
Native Valve
Presumptive treatment, no history of intravenous drug abuse
(IVDA): penicillin G OR ampicillin and [nafcillin or oxacillin]
and gentamicin
Presumptive treatment, IVDA: vancomycin
S. viridans or bovis: [penicillin G gentamicin] OR,
ceftriaxone OR [ampicillin and gentamicin]
Aminoglycoside resistance: penicillin G or ampicillin
Enterococci, PCN-resistant: amoxicillin/sulbactam and
gentamicin
Enterococci intrinsic penicillin G or ampicillin resistance:
vancomycin and gentamicin
S. aureus: [nafcillin or oxacillin] and gentamicin
MRSA: Vancomycin
Slow-growing gram-negative bacilli: ceftriaxone
Bartonella: gentamicin and doxycycline

Prosthetic Valve

Empiric: vancomycin, gentamicin, and rifampin

Candida/Aspergillus: amphotericin B fluconazole
C. burnetii: doxycycline and hydroxychloroquine
S. epidermidis: vancomycin, rifampin, and gentamicin
complete within 30 min of starting procedure

150

FADavis_C05.qxd

9/12/08

3:53 PM

Page 151

151
S. aureus: nafcillin, rifampin, and gentamicin
MRSA: vancomycin, rifampin, and gentamicin

Headaches
Cluster
Strictly unilateral, severe, duration: 1590 min, associated autonomic symptoms males more than females

Abortive Treatment
First-line: acetaminophen, NSAIDs, aspirin
Other: indomethacin, intranasdeal (lidocaine,
dihydroergotamine, or capsaicin)

Preventive
First-line: PO corticosteroids, verapamil
Others: Anticonvulsants (valproic acid, topiramate,
gabapentin), indomethacin
Verapamil, lithium (for chronic cluster)

Tension
Bilateral, mild/moderate pressing/tightening, duration: 30 min7 d,
no associated Sx, females more than males

Abortive Treatment
First-line: sumatriptan, O2 inhalation
Other: Trigger-point injections

Preventive
Trichloroacetic acid (TCA) (e.g., amitriptyline), SSRIs

Migraine
Unilateral, moderate/severe throbbing, duration: 472 hr, associated Sx, females more than males

MEDS

FADavis_C05.qxd

9/12/08

3:53 PM

Page 152

MEDS
Abortive Treatment
Aura or mild-to-moderate early ( 2 hr): First-line analgesics
(ASA acetaminophen caffeine, ASA metoclopramide);
other NSAIDs: anaprox DS, indomethacin, acetaminophen,
COX2 inhibitor, ultram
Moderate (4 hr) refractory: Antiemetics (first-line: Reglan,
prochlorperazine; others: Dramamine, Atarax, Phenergan)
abortive medications (triptans, indomethacin PR, or
isometheptene)
(Severe refractory(26 hr): Antiemetics  serotonin agonist
(dihydroergotamine, triptans)
Severe refractory(672 hr)
Antiemetics (IV/IM): prochlorperazine, metoclopramide,
droperidol, diphenhydramine (for dyskinesia)
Serotonin agonist: dihydroergotamine (DHE), triptans
Anticonvulsant: valproic acid

Antipsychotics with analgesic and antiemetic properties

(IV): chlorpromazine, haloperidol
Analgesics/anti-inflammatories (IV/IM): toradol,
dexamethasone, hydrocortisone, methylprednisolone

Preventive
-blockers: propranolol*, timolol, metoprolol
Ca2 channel blockers (?efficacy): verapamil
NSAIDs: Aspirin, naproxen sodium, indomethacin
Antidepressants: amitriptyline, doxepin, phenelzine, SSRIs
(fluoxetine)
Anticonvulsants: valproic acid and derivatives, topiramate,
phenytoin
Serotonin agonist: cyproheptadine, methysergide
Vitamin supplementation: Petasites hybridus (butterbur):
petadolex, feverfew, vitamin B2, magnesium oxide,
coenzyme Q10

*First-line unless contraindicated

Preferred agents

152

FADavis_C05.qxd

9/12/08

3:53 PM

Page 153

153
Helicobacter pylori
Clarithromycin 500 mg, amoxicillin 1 g, and proton pump
inhibitor (PPI) PO bid  7 d (rabeprazole) to 10 d (other PPI)
Clarithromycin 500 mg, metronidazole 500 mg, and PPI PO
bid  7 d (rabeprazole) to 10 d (other PPIs)
Prevpac kit: clarithromycin 500 mg, lansoprazole 30 mg, and
amoxicillin 2 capsules 500 mg PO bid  10 d

H. pylori Treatment Failure or Alternative

Bismuth subsalicylate 525 mg PO qid, metronidazole 250 mg
PO qid, tetracycline 500 mg PO qid, and PPI PO bid  14 d
Helidac kit: 1 dose (metronidazole: 1 tab; tetracycline:
1 capsule, and bismuth subsalicylate: 2 tabs) PO qid and PPI
or H2-blocker PO bid  14 d

Hyperlipidemia
Statin or HMG-CoA Reductase Inhibitor
Atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin
LDL 20%50%, HDL 5%15% TG 10%25%
Adverse effects: GI upset, hepatitis, myopathy, lupus-like
syndrome, rash, peripheral neuropathy, bleeding risk with
Coumadin
Contraindications: Liver disease, myopathy
Avoid: Grapefruit and alcohol

Niacin: Nicotinic Acid

LDL 10%15%, HDL 15%30%, TG 40%
Adverse effects: Flushing, pruritus, GI upset, blurred vision,
hepatitis, gout, glucose intolerance, fatigue
Contraindications: Liver disease, diabetes type II, severe
gout, hyperuricemia

MEDS

FADavis_C05.qxd

9/12/08

3:53 PM

Page 154

MEDS
Ezetimibe: Cholesterol Absorption Inhibitor
LDL 20%, HDL 5%
Adverse effects: Minimal to date
Contraindications: None to date

Fibric Acid Derivative

Gemfibrozil, clofibrate, fenofibrate
LDL 5%15%, HDL 1530%, TG 30%
Adverse effects: GI disease, cholecystitis, appendicitis,
myopathy risk with statin, may effects of Coumadin or oral
hypoglycemic agents
Contraindications: Hepatic or renal disease, preexisting gallstones

Bile-Binding Resin

Cholestyramine, colestipol, colesevelam

LDL: 15%30%, HDL 3%5%, TG ?%
Adverse effects: GI effects (constipation, flatulence, dyspepsia)
Contraindications: TG 500 mg/dL

LDL
High
High
Any

TG
150
150400
400

Normal

Normal

HDL First Line

Any Statin
Any Statin
Any Fibrates
or niacin
Low None

Second Line
Ezetimibe
Niacin
Statin

Third Line
Resin
Ezetimibe
Fish Oil

None

None

Hypertension
Monotherapy
Diuretics (e.g., hydrochlorothiazide), -blocker, ACE inhibitor
(ACEi), ARB

154

FADavis_C05.qxd

9/12/08

3:53 PM

Page 155

155

Osteoporosis
Gout
Obesity
Peptic ulcer
Edema
CAD/MI
Angina
Atrial tachycardia
and fibrillation
Perioperative
PVD
Essential tremor
Migraine
Major depression
Substance abuse
Systolic dysfunction
Diastolic dysfunction
LVH

Central Active
Agonists

Nitrates

Spironolactone

Thiazide Diuretics

1
Y

CCB

-Antagonists

Diabetes
Renal disease
Dyslipidemia
BPH
COPD/asthma

-Blockers

Key:
Preferred: Y, 1, 2,
*, **
Alternative: A
Caution: ?
Avoid: N

ACEi/ARB

Agents for Specific Conditions

2
Y

Y
Y

N
Y
N
Y
N
N
Y

Y
Y
Y

*
**

Y
?
Y
Y
N

Y
**
Y
Y
Y
Y

*Angina, not nifedipine

**Nondihydropyridine CCBs
Labetalol (combined --blockers)

MEDS

Y
?
Y

FADavis_C05.qxd

9/12/08

3:53 PM

Page 156

MEDS

Hypertensive Emergencies

Quiet room, reduce pain, treat underlying cause

Screen target organ damage (e.g., renal, CV, CNS)
Rapidly BP may perfusion ischemia and infarction
Lower MAP 20%25% in first hour of treatment; if stable,
lower BP to 160/100110 in next 26 hr
IV agents: nitroprusside*, nitroglycerin, esmolol, labetolol,
hydralazine, phentolamine, fenoldopam, nicardipine, enalapril
Oral agents: captopril, labetalol, clonidine, hydralazine

Indications to Rapidly BP
Problem
Eclampsia
Pheochromocytoma
Acute renal failure
Aortic dissection

Acute MI
CHF pulmonary edema
Hypertensive encephalopathy
Monoamine oxidase
(MAO)and tyramine

Medications (usually IV)

Hydralazine, labetalol, or Mg2
Phentolamine, labetalol
Fenoldopam, nicardipine,
-blockers
Goal: SBP 100110 mm Hg:
Labetalol; alternative:
nitroprusside  -blocker (e.g.,
esmolol)
Nitroglycerin, -blockers
Nitroglycerin, lasix,
nitroprusside
Nitroprusside, labetalol,
fenoldopam
Phentolamine

*Beware cyanide accumulation

Contraindications: ICP; narrow-angle glaucoma; pericardial tamponade
Short half life; clearance with hepatic or renal insufficiency; may portal
hypertension; may reflex tachycardia; alters cyclosporine levels;
contraindications: critical aortic stenosis (AS)

156

FADavis_C05.qxd

9/12/08

3:53 PM

Page 157

157
CVA: SBP cerebral
perfusion; SBP 185 or DBP
110 mm Hg;
contraindications to tPA use
Intracranial hemorrhage

If SBP 220 mm Hg or DBP

120140 mm Hg, cautiously
BP by ~10%15%: IV
nitroprusside or IV labetalol
Careful with IV nitroprusside or
labetalol when SBP 200 or
DBP 110 mm Hg

Pelvic Inflammatory Disease

Parenteral (change to oral 24 hr clinical
improvement)
[Cefotetan 2 g IV q12hr or cefoxitin 2 g IV q6hr] 
doxycycline 100 mg PO/IV q12hr
Clindamycin 900 mg IV q8hr  gentamicin load 2 mg/kg
IV/IM, then 1.5 mg/kg q8hr
Ampicillin/sulbactam 3 g IV q6hr  doxycycline 100 mg
PO/IV q12hr

Oral
[Ceftriaxone 250 mg IM  1 or cefoxitin 2 g IM and
probenecid 1 g PO  1 or other parenteral third-generation
cephalosporin (e.g., ceftizoxime or cefotaxime)]  doxycycline
100 mg PO bid  14 d
metronidazole 500 mg PO bid  14 d
Fluoroquinolones (e.g., levofloxacin 500 mg PO qd or ofloxacin
400 mg bid  14 d)
metronidazole 500 mg PO bid  14 d

Peritonitis, Intestinal Perforation,

or Necrotic Bowel
Ampicillin, gentamicin, and metronidazole

MEDS

FADavis_C05.qxd

9/12/08

3:53 PM

Page 158

MEDS

Pregnancy and Childbirth Problems

Mild Chronic Hypertension
Mild chronic: methyldopa
Moderate gestational: labetalol
Severe acute: labetalol, hydralazine, sodium nitroprusside
(beware cyanide accumulation, so limit to few hours), nicardipine

Prevent and Treat Seizures in Preeclampsia

or Eclampsia
Magnesium sulfate IV

Complications in Severe Preeclampsia (at 34 wk)

Betamethasone IM or dexamethasone

Nausea/Vomiting/Hyperemesis Gravidum
Phosphorated carbohydrates (Emetrol)
Antiemetics: metoclopramide (Reglan), not recommended
due to lack of safety data: ondansetron (Zofran), droperidol
(Inapsine)
Phenothiazines/antipsychotics: promethazine (Phenergan),
prochlorperazine (Compazine), chlorpromazine (Thorazine)
Antihistamines: doxylamine succinate (Unisom), doxylamine
pyridoxine (Bendectin), meclizine (Antivert),
chlorpheniramine (Chlor-Trimeton), diphenhydramine
(Benadryl), trimethobenzamide (Tigan)
Others: pyridoxine (B6), multivitamin (MV112), Metamucil,
thiamine
Corticosteroids for refractory hyperemesis

Premature Labor
Tocolytic Agents
Magnesium sulfate: Contraindications: myasthenia gravis,
renal function, recent MI

158

FADavis_C05.qxd

9/12/08

3:53 PM

Page 159

159
Terbutaline: Contraindications: antepartum hemorrhage, CV
disease, thyroid, uncontrolled diabetes
Ritodrine: Absolute contraindications: uncontrolled DM,
maternal cardiac disease, pregnancy-induced HTN, thyroid,
hypovolemia, multiple gestation; relative contraindications:
chronic HTN, DM, migraine, resting tachycardia
Nifedipine: PO not effective; contraindications: CHF, AS,
concomitant MgSO4 use

Delayed Labor
Labor Induction
Common indications: Pregnancy-induced HTN, premature
rupture of membranes, chorioamnionitis, suspected fetal
jeopardy (e.g., severe fetal growth restriction, isoimmunization), maternal medical problems (e.g., diabetes mellitus,
renal disease), fetal demise, post-term pregnancy
Contraindications: Placenta previa or vasa previa, transverse
fetal lie, prolapsed umbilical cord, prior classical uterine incision
Membrane sweep
Artificial rupture of membranes
Cervically applied prostaglandins: e.g., dinoprostone
(Cervidil) or misoprostol
IV synthetic oxytocin preparations: e.g., Pitocin
Other holistic, CAM, or natural methods

Seizures
Partial (limited on one brain hemisphere)
Simple: Usually no consciousness change; focal motor,
sensory, autonomic, and/or psychology symptoms (may
spread)
Prophylaxis: First stage: phenytoin, carbamazepine, valproic

acid adjunctive: phenobarbital, primidone, zonisamide

Complex: Usually consciousness; often aura precedes; begin
with motionless stare or activity arrest then complicated

MEDS

FADavis_C05.qxd

9/12/08

3:53 PM

Page 160

MEDS
motor/sensory actions, automatisms (repeated idiosyncratic
motions)
Prophylaxis: carbamazepine, phenytoin, temporal lobe
resection (for failed medical treatment after 12 yr)

Generalized (both hemispheres)

Absence (petit mal): Often many/day, no aura,
unresponsiveness (blank stare), rhythmic activities (eye
and head movements) autonomic symptoms (incontinence,
postural control), postictal clothes picking and lip pursing,
pt. often unaware seizure occurred
Typical: 10 sec; nonconvulsive and normal tone
Atypical: Longer duration; / muscle tone, often
tonic/clonic-like movements
Prophylaxis: ethosuximide, valproic acid, clonazepam
Tonic-clonic (grand mal): Usually lasts 1 min, associated
with CO2, blood glucose, prolactin. 1. Often aura (hours to
days pre-attack) 2. Tonic phase: Muscular rigidity, loss of
consciousness 3. Clonic phase: Alternating muscular
contractions/no movements (muscle atonia) 4. Flaccid coma:
loss of consciousness, apnea, postural tone, DTRs, cyanosis
5. Postictal: Confusion, disorientation, weak, headache,
muscle pain
Prophylaxis: phenytoin, carbamazepine, phenobarbital,

primidone, valproic acid, surgery

Tonic: Tonic phase, no clonic phase
Clonic: Just clonic phase, no tonic phase
Atonic (drop attacks): 12 sec; sudden, limp posture 
loss of consciousness
Myoclonic seizures: No loss of consciousness, rapid muscle
contractions  facial and pelvic jerks
Status epilepticus: Seizure 30 min; recurring seizures with
no consciousness return between seizure events; suspect if
seizure lasts 510 min

Management: Check ABCs, consider intubation if necessary,

administer O2, telemetry, D50W 50 mL IV (adult dosing), thiamine
IV/IM, first: lorazepam IV; then if refractory: fosphenytoin IV

160

FADavis_C05.qxd

9/12/08

3:53 PM

Page 161

161
If persistent at 30 min: Intubate/ventilate, Foley catheter, EEG,
follow temperature closely, phenobarbital IV
If persistent at 60 min: pentobarbital IV, midazolam IV, or
propofol IV (titrate per EEG), blood pressure support if necessary

Sexually Transmitted Infections

Chancroid
Azithromycin PO or ceftriaxone IM  1
Ciprofloxacin PO  3 d or erythromycin PO  7 d

Chlamydia

Azithromycin* PO 1 g  1 or doxycycline 100 mg bid  7 d

Amoxicillin* 500 mg PO tid  10 d
Ofloxacin 300 mg PO bid  7 d
Erythromycin* 500 mg PO qid  7 d

Gonorrhea (N. gonorrhoeae)

Ceftriaxone: 125 or 250 mg IM  1 (250 if pregnant)
Cefotaxime: 500 mg IM  1
Cefixime: 400 mg PO  1 (and erythromycin base 500 mg PO
qid  7 d, if pregnant)
Ciprofloxacin: 500 mg PO, ofloxacin 400 mg PO, or
levofloxacin: 250 mg PO  1
Spectinomycin: 2 g IM  1
Amoxicillin PO 3 g and probenecid 1 g  1 (if pregnant)
Azithromycin: 2 g PO  1 (if pregnant)

Granuloma Inguinale
Tetracycline, doxycycline, sulfamethoxazole, gentamicin,
streptomycin, ciprofloxacin, erythromycin  3 wk

*Infection in pregnancy

MEDS

FADavis_C05.qxd

9/12/08

3:53 PM

Page 162

MEDS
Herpes Simplex Virus (HSV)
First-Episode Genital HSV
Acyclovir: PO  710 d or IV  27 d or until clinical
improvement change to PO for 10 d total treatment;
valacyclovir PO  710 d or famciclovir PO  710 d
Episodic treatment: acyclovir: PO  2 d or 5 d; famciclovir: (PO
 1 d or 5 d) or valacyclovir: PO  3 d or 5 d (HIV:  510 d)
Suppressive: acyclovir, famciclovir, or valacyclovir PO (dose
for HIV)
Encephalitis: acyclovir IV  1421 d
Orolabial: acyclovir  710 d or valacyclovir  2
Recurrent orolabial: penciclovir: topical  4 d
Herpetic whitlow: acyclovir  10 d
Keratoconjunctivitis: trifluridine: eye drops until ulcer
epithelialized  7 more days

Human Papillomavirus
Topical treatment: imiquimod cream, 20% podophyllin
antimitotic solution, 0.5% podofilox solution, 5%
5-fluorouracil cream, trichloroacetic acid (TCA)
Procedures: Freezing (cryosurgery), burning (electrocautery),
laser treatment
Prevention: vaccine (Gardasil): For 9 y.o. and 26 y.o.: IM
3 separate does: second dose 2 mo and third dose 6 mo

Lymphogranuloma Venereum (Rx 21 d)

Doxycycline 100 mg PO bid
Erythromycin base or sulfisoxazole 500 mg PO qid

Treat Asymptomatic Sexual Contacts

Doxycycline 100 mg PO bid  7 d or
Azithromycin 1 g PO  1

Nongonococcal Urethritis/Cervicitis
First line: azithromycin 1 g  1 or doxycycline 100 mg PO bid
7d

162

FADavis_C05.qxd

9/12/08

3:53 PM

Page 163

163
Persistent/recurrent: PO [metronidazole or tinidazole 2 g  1]
and [erythromycin 500 mg qid  7 d or azithromycin 1 g  1]

Pediculosis Pubis
Permethrin, lindane, pyrethrins with piperonyl butoxide,
malathion

Scabies
Permethrin: 5% cream, lindane: 1% lotion, crotamiton: 10%
cream, ivermectin: PO

Syphilis
Early (first stage, second stage, early latent): Penicillin G
benzathine: 2.4 mU IM  1; alternative: doxycycline: 100 mg
PO bid  14 d
Late (late latent, third stage): Penicillin G 2.4 mU IM qwk 
3 wk or doxycycline: 100 mg PO bid  28 d
Neurosyphilis: Aqueous crystalline penicillin G 34 mU IV
q4h  1014 d; alternative: procaine penicillin G 2.4 mU IM
qd  probenecid 500 mg qid  1014 d; ceftriaxone 2 mg qd
IV/IM  1014 d

Systemic Lupus Erythematosus

Need 4 of 11 Criteria to Diagnose
1. Malar rash 2. Discoid rash 3. Photosensitivity 4. Oral ulcers
5. Arthritis 6. Serositis 7. Renal disorder 8. Neurologic disorder
(e.g., seizures, psychosis) 9. Hematologic disorder (hemolytic
anemia, leukopenia, lymphopenia, or thrombocytopenia) 10. Antinuclear antibody 11. Immunologic disorder (anti-ds-DNA, antiSm, antiphospholipid antibody such as anticardiolipin, VDRL)
Salicylates and NSAIDs
Hydroxychloroquine: Mild disease  serositis, arthritis  skin
problems

MEDS

FADavis_C05.qxd

9/12/08

3:53 PM

Page 164

MEDS

Corticosteroids: Topical, intralesional, systemic

Azathioprine: Mild nephritis
Methotrexate: Skin and joint disease, serositis
Cyclophosphamide: Severe nephritis, vasculitis or CNS disease
Cyclosporine: Renal disease
Mycophenolate: Renal disease

Vaginal Disorders
Atrophic Vaginitis
Vaginal creams or tablets: dienestrol, estradiol, conjugated
estrogens

Bacterial Vaginosis
Metronidazole: 500 mg PO bid or 250 mg PO tid  7 d or 5 g
0.75% gel intravaginal qd for 5 d
Clindamycin: 5 g 2% cream intravaginal qhs  7 d or 300 mg
PO bid  7 d or 100 mg ovules intravaginally qhs  3 d

Vaginal Trichomoniasis
Metronidazole: 2 g PO  1 or 500 mg PO bid  7 d
Tinidazole: 2 g PO  1

Vulvovaginal Candidiasis
Uncomplicated
Vaginal applications: butoconazole, clotrimazole,
miconazole, terconazole, tioconazole, nystatin
Fluconazole: 150 mg PO  1

164

Chapter-06.qxd

9/12/08

3:56 PM

Page 165

165
Head Computed Tomography (CT)
Indications
Craniofacial trauma, acute neurologic dysfunction (72 hr),
intracranial masses, sinus disease, temporal bone disease

Patient Preparation
Keep pt. hydrated; sedate if agitated; when IV contrast: check
serum creatinine and history of allergic reaction

Procedure Description
Pt. supine on CT table; slice thickness varies but usually between
510 mm; IV contrast not routine, but may be used to evaluate
for tumors, cerebral infections, and sometimes cerebrovascular
accident

Normal Study
Water 0 Hounsfield units (HU); sense bone 1000 HU; air
1000 HU; blood 50100 HU

Abnormal Studies
Skull Fractures
Classified: Linear (more common) vs. depressed (inward
displacement of fracture fragments)
Most clinically significant: Involve paranasal sinus or skull base
Distinguish sagittal, coronal, or lambdoidal sutures
(undulating, sclerotic margins) and venous channels
(sclerotic margins and undulating sides)

Subarachnoid Hemorrhage (SAH)

Superficial small arteries/veins injury bleeds into space
between pia and arachnoid matter
Causes: Trauma, cerebral aneurysm rupture
Focal high density in sulci and fissures or linear hyperdensity
in cerebral sulci

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 166

RADIOL
Subdural Hematoma (SDH)
Acceleration/deceleration and rotational forces tear
bridging veins
Crescent-shaped; does not cross dural reflections
Density with subdural age
Hyperacute (6 hr): Either hypodense or hyperdense
Acute (6 hr3 d): Usually hyperdense (clotted blood)
Subacute: Generally isodense with brain (hemorrhage
reabsorbed); suspect if shift of midline structures, but no
obvious mass; IV contrast may interface between
hematoma and adjacent brain; compressed lateral ventricle;
effaced sulci; white matter buckling; thick cortical mantle
Chronic: Typically hypodense septae; rebleeding mixed
density and fluid levels

Epidural Hematoma
Usually associated with skull fracture (esp. calvarium)
Hyperdense biconvex mass; usually uniformly high density
hypodense foci (active bleeding)
Unlike SDH can cross dural reflections but not cross suture
lines (dura tightly adheres to skull)

Diffuse Axonal Injury (shear injury)

Acceleration/deceleration and rotational forces tear axons

CT may be normal despite neurologic deficits
Ill-defined high density or hemorrhage areas
Locations (from most to least likely): Subcortical white
matter, posterior limb internal capsule, corpus callosum,
dorsolateral midbrain

Cerebral Contusions
From brain impact on osseous ridge or dural fold
Ill-defined hypodense area hemorrhage foci; adjacent SAH
common; after 2448 hr: common changes round hematoma

Strokes (Ischemia)
Acute ischemia: May be completely normal head CT
Gray-white interface loss or blurring (basal ganglia, thalamus
or internal capsule)
Localized mass effect (from progressing edema): Sulci
effacement or asymmetry of lateral ventricles
Hyperdense middle cerebral artery from thrombus

166

Chapter-06.qxd

9/12/08

3:56 PM

Page 167

167
Neurodegenerative Diseases
Parkinsons disease: Nonspecific atrophy with enlarged
lateral ventricles and widened sulci
Huntingtons disease: Caudate atrophy bilateral convexity
of caudate heads or relative lateral ventricle volume
Picks disease: Atrophy temporal/frontal lobes

Masses
Tumors: Usually hypodense; poorly defined without IV
contrast calcification, hemorrhage (hyperdense), and
edema (hypodense); IV contrast contrast-enhancing ring
around tumor
Abscess: Ill-defined, hypodense without IV contrast; variable
edema; often ring-enhanced with IV contrast

Pitfalls
Metal foreign bodies can cause scatter artifact and obscure
small areas of hemorrhage or ischemia
Motion difficult to visualize acute ischemic changes and
isodense structures

Cervical Spine
Indications
Neurologic deficits compared with cord lesion, differentiate
MS from head injury or intoxication, neck pain/tenderness, or
significant distracting injuries; can use 1 of 2 clinical criteria to
rule out cervical spine injury (i.e., no cervical spine imaging
necessary):
1. Canadian C-Spine Rules
Alert (GCS 15) and not intoxicated
No distracting injury (e.g., long bone fracture, large laceration)
Not high risk (High risk means age 65 y.o. or dangerous
mechanism or paresthesias in extremities) low risk
factor allowing safe ROM assessment (e.g., simple rear

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 168

RADIOL
end motor vehicle accident (MVA), seated position in ED,
ambulation any time post-trauma, delayed neck pain
onset, no midline cervical spine tenderness)
Can actively rotate neck 45 left and right
2. National Emergency X-Radiography Utilization Group Criteria:
No posterior midline cervical spine tenderness
No evidence of intoxication; no focal neurologic deficit
Nl level alertness; no painful distracting injury

Patient Preparation
None

Procedure Description
Standard five-view trauma series: Cross-table lateral, swimmers,
oblique, odontoid, and anteroposterior

Normal Study
Measurable Parameters of Normal
Cervical Spines
Parameter
Predental space
C2C3 pseudosubluxation
Retropharyngeal space
Spinal column angulation
at any interspace level
Cord dimension

Adults
3 mm
3 mm
6 mm at C2
22 mm at C6
11

Children
45 mm
45 mm
1
22/3 vertebral
body AP distance
11

1013 mm

Adult size 6 y.o.

From Graber MA, Kathol M. Cervical spine radiographs in the trauma patient.
Am Fam Physician 1999 Jan 15;59(2):33142

168

Chapter-06.qxd

9/12/08

3:56 PM

Page 169

169
Check A(lignment), B(ones), C(artilage,) D(isk Space), S(oft Tissue)
Cross-table lateral: Must see all 7 vertebral bodies and cervicothoracic junction; each of 4 imaginary contour lines must form
smooth lordotic curve: 1. anterior vertebral: vertebral anterior
margins; 2. posterior vertebral: vertebral posterior margins;
3. sinolaminar: sinal canal posterior margin; 4. posterior spinous:
sinous process tips

Abnormal Studies
Unstable Fractures and Dislocations
Atlanto-occipital dislocation: Junction between atlas and
skull; usually anterior dislocation prevertebral hematoma
instant death
Facet dislocation: Unilateral with disk widening or
subluxation or bilateral; three types (subluxed facets,
perched facets, locked facets); extreme flexion
Flexion teardrop fracture: Unstable; disrupt all ligaments
intervertebral disk; anteroinferior vertebral body
posterior displacement into spinal canal; mechanism:
severe flexion
Jefferson fracture: Atlas fracture at multiple points; axial load
(e.g., head-first dive, heavy object fall on top of head)
Odontoid fracture: Involve C2; fractures C1 anterior; pain
and inability to move neck; instability sensation (like head
wobbling on neck); mechanism: flexion extension
rotation
Hangmans fracture (traumatic spondylolisthesis of C2):
Bilateral C2 pedicle fracture with anterior displacement C2 on
C3; mechanism: neck hyperextension MVA rapid decelerate
Cervical burst fracture: Entire vertebral body collapses;
fracture fragments spinal canal neurologic changes;
mechanism: axial loading (falling from height)

Stable Fractures and Dislocations

Clay-shovelers fracture: Bone avulsion off spinous process;
mechanism: aggressive neck flexion

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 170

RADIOL
Compression wedge fractures: Anterior vertebral body
compression; no posterior ligamentous disruption, so no
neurologic injury; mechanism: hyperflexion
Extension teardrop fracture: Anterior longitudinal ligament
pulls anteroinferior vertebral body corner away from rest of
vertebra; commonly at C2; mechanism: forced extension

Pitfalls
Relative contraindication: pregnancy

Chest X-Ray
Indications
Evaluate pulmonary disease, pleural disease, cardiac disease,
mediastinal disease, pulmonary edema; initial screen for aortic
rupture

Patient Preparation
None

Procedure Description
Usual (inspiratory PA and lateral); portable (AP); expiratory upright
film (suspected pneumothorax); decubitus (free-flowing fluid)

Normal Study

170

Chapter-06.qxd

9/12/08

3:56 PM

Page 171

171
Trachea
Aortic
arch
Pulmonary
artery
Left
ventricle
Gastric
air bubble

Superior
vena cava
Right
ventricle
Diaphragm

Abnormal Studies
Lung Cancer
Adenocarcinoma (most common): Typically peripheral
nodule, can be associated with fibrosis or bullous disease;
can be Pancoasts, clubbing, hypertrophic pulmonary
osteoarthropathy, Trousseaus syndrome of hypercoagulability
Bronchioloalveolar carcinoma (subset of adenocarcinoma):
Nodule, multiple nodules, alveolar infiltrate; clubbing,
hypertrophic pulmonary osteoarthropathy, Trousseaus
syndrome
Squamous cell carcinoma (strongly associated with tobacco):
Cavitate, most common Pancoasts (lung apex; superior
pulmonary sulcus destroy adjacent rib or vertebra,
Horners syndrome, arm pain, hand atrophy), centrally
located, endobronchial, atelectasis, postobstruct pneumonia;
secrete PTH hypercalcemia
Large cell carcinoma: Classically, large (3 cm) peripheral
mass; gynecomastia/galactorrhea
Small cell carcinoma (strongly associated with tobacco):
Usually located centrally, aggressive, early distant spread

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 172

RADIOL
(commonly brain, bones, liver, adrenals, bone marrow),
superior vena cava syndrome; paraneoplastic syndromes:
e.g., SIADH, ectopic ACTH, Eaton-Lambert, subacute
cerebellar degeneration, subacute sensory neuropathy,
limbic encephalopathy

Anterior Mediastinal Masses

Thoracic inlet: Thyroid masses, lymphoma, cystic hygroma
(lymphangioma).
Cardiophrenic angle: Prominent pericardial fat, pericardial
cysts, foramen of Morgagni hernia
Retrosternal space: Lymphoma, thymoma, germ cell tumors,
vascular (e.g., ascending aortic aneurysm)

Middle Mediastinal Masses

Lymphadenopathy: Malignancy, infection, inflammation
Tumors: Trachea, esophagus
Vascular (e.g., aneurysms, transection): Aortic arch and great
vessels, pulmonary arteries
Duplication cysts: Tracheobronchial tree and esophagus

Posterior Mediastinal Masses

Neurogenic masses: Nerve root tumors, sympathetic
ganglion tumors, paragangliomas
Other: Lymphadenopathy, aortic aneurysm, paraspinous
abscess, extramedullary hematopoiesis, lateral meningocele,
Bochdaleks hernia

Pneumothorax and Pneumomediastinum

Thin white line: Pleural membrane between air in pleural
space and air in lung
Skin folds: Appear as edge, not line
Lung consolidated: Instead of thin line, edge between
consolidated lung and pleural air

Lobar Atelectasis/Collapse
Evidence of volume loss shift of trachea/mediastinum/heart
to side of collapse and ipsilateral hemidiaphragm
Collapse patterns: Lower lobes (medially and posteriorly);
RML (medially against heart PA, RML volume small so
maybe no evidence of volume loss); RUL (medially and
superiorly); LUL (anteriorly and medially)

172

Chapter-06.qxd

9/12/08

3:56 PM

Page 173

173
Pleural Effusion: Blunting of costophrenic angles
Lateral: 75 mL subpulmonic fluid can be unseen
PA: 175 mL fluid can be unseen
Decubitus: 10 mL can be seen
Quantifying: R-sided difficult because large one can invert
diaphragm, L-sided if stomach bubble
Loculated: Can appear mass-like
Subpulmonic: Appearance of hemidiaphragm
Psuedotumor: Collect in major or minor fissures

CHF
Left atrial (i.e., mean pulm wedge) pressure 1219 mm Hg:
Pulmonary vessel cephalization
2025 mm Hg: Interstitial edema, bronchial wall thickening,
interlobular septa fluid (Kerleys lines)
25 mm Hg: Alveolar edema: bilateral symmetric perihilar,
coalescent opacities, air bronchograms.

Pneumonia: Infiltrate (= lung density)

Interstitial (frequently viral): Lines (reticular opacities) or nodules

Alveolar (frequently bacterial): Hazy coalescent opacity;
obliterate mediastinal/diaphragmatic borders

Sarcoid: Stages:

0: Normal CXR
I: Bilateral hilar, paratracheal and mediastinal lymphadenopathy
II: Bilateral hilar/mediastinal adenopathy interstitial infiltrates
III: Interstitial infiltrates
IV: Fibrosis

Line and Tube Placement

Endotracheal Tube
Ideal position: 5 cm from carina (~T4T5 interspace) when
head neither flexed nor extended; minimal safe distance:
2 cm
Dee method to approximate carina position: Define aortic
arch; draw line inferomedially through middle of arch at
45 angle to midline; intersection of midline and diagonal
line ~carina position

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 174

RADIOL
Thoracostomy Tube
Placed into pleural space to evacuate air/fluid; in supine pt.,
air collects anteriorly and fluid collects posteriorly; insert
within fissures may not function; incorrect placement for
empyemas may drainage and loculation
Gap in radiopaque line (last tube fenestration) must be
within thoracic cavity; if subcutaneous air, then tube may not
be completely inserted

Nasogastric (NGT) and Feeding Tubes

Generally chest x-ray not necessary post-NGT placement
unless s/p esophagectomy
Feeding tubes: Usually placed into proximal small bowel
(check abdominal film); for small-bore feeding tube: rule out
placement in lung

Central Venous Pressure Monitors

Tip should lie between most proximal venous valves of
subclavian or jugular veins and right atrium; placement in
heart arrhythmias or cardiac perforations

Swan-Ganz Catheters
Tip no more distal than proximal interlobar pulmonary
arteries (i.e., within mediastinal shadow)

Intra-aortic Counterpulsation Devices

Afterload and cardiac perfusion in cardiogenic shock;
synchronized with either aortic pressures or EKG diastole:
inflate and systole: deflate
Catheter should be near aortic isthmus or left main bronchus
and above celiac trunk and superior mesenteric artery origins

Transvenous Pacing Devices

Frontal view: Pacer tip at apex with no sharp angulations
throughout its length
Lateral view: Tip embedded in cardiac trabeculae 34 mm
beneath epicardial fat stripe; if beyond epicardial fat stripe
may have perforated myocardium; check pacer wire integrity

Pitfalls
Relative contraindication: pregnancy

174

Chapter-06.qxd

9/12/08

3:56 PM

Page 175

175
Chest Computed Tomography
Indications
Evaluate thoracic trauma, pulmonary nodules, aortic dissection/
aneurysm, lung neoplasm and interstitial lung disease, mediastinal and hilar lymphadenopathy vs. vascular strictures, parenchymal vs. pleural processes

Patient Preparation
Preferably NPO 2 hr prior; normal hydration; sedate agitated pt.;
if IV contrast, check serum creatinine

Procedure Description
High resolution chest CT (HRCT): For interstitial lung disease;
thinner slices and less tissue scanned but more detail than conventional chest CT

Normal Study
HRCT lung windows: air black, aerated lung dark gray,
other structures white
Central, branching paired pulmonary arteries bronchi
connective tissue (bronchovascular bundles)
Bronchus: X-section thin-wall, white circle with central air
(black); adjacent artery solid, white circle
Peripherally, arteries and veins: Numerous small dots and
a few branching lines; arteries branch at acute angles; veins
branch at 90 angles
Major interlobar fissure pleura thin, horizontal line
traversing lung
Normal interstitium invisible on HRCT; interstitial compartments:
bronchovascular (surrounds bronchovascular bundle);
centrilobular (surrounds distal bronchiolovascular bundle);
interlobular septal (often lines perpendicular to pleura); pleural

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 176

RADIOL
Abnormal Studies
Air Trapping
Abnormal gas retention postexpiration (lung parenchyma
remain lucent and normal lung areas attenuation); can
appear normal on inspiration, must check on expiration

Bronchiectasis
Traction bronchiectasis bronchial dilation in lung fibrosis
or distorted lung architecture irregular bronchial dilation;
usually segmental and subsegmental bronchi, but may affect
small peripheral bronchi or bronchioles; commonly
associated with honeycombing

Pulmonary Nodules
HCRT can detect nodules 12 mm diameter; appearance:
well-defined (likely interstitial) vs. ill-defined (likely air space);
distribution: perilymphatic, random vs. centrilobular;
differential diagnoses (DDx): tumor, granulomas,
pneumoconioses, mucous plugs, endobronchial disease,
hypersensitivity pneumonia.

Ground Glass Opacity

Nonspecific term hazy opacity within lungs not obscuring
underlying vessels (if obscure underlying vessels
consolidation); reflects minimal septal, alveolar interstitium,
or alveolar wall thickening or cells or fluid filling alveolar
spaces
DDx: pulmonary edema; ARDS; pneumonia (viral,
mycoplasmal, PCP); hypersensitivity pneumonia; pulmonary
hemorrhage; other diffuse interstitial lung disease

Cysts
Round, thin walls filled with air (darker than normal aerated
lung)
Cystic bronchiectasis (multiple dilated bronchi): often
clustered together and focal
Honeycombing: lung fibrosis alveolar destruction; thickwalled, air-filled cysts (3 mm 1 cm)

176

Chapter-06.qxd

9/12/08

3:56 PM

Page 177

177
DDx of multiple cysts: chronic interstitial fibrosis,
Langerhans cell histiocytosis, lymphangioleiomyomatosis

Mosaic Attenuation/Perfusion
Areas of often patchy attenuation from regional lung
perfusion differences secondary to airway disease or
pulmonary vascular disease; often pulmonary arteries in
size in lucent lung fields

Interlobular Septal Thickening

Many clearly visible septal lines (smooth, nodular, or
irregular); common with interstitial lung disease

Tree-in-bud Appearance
Dilated and fluid-filled (i.e., pus, mucus, or inflammatory
exudate) centrilobular bronchioles; irregular, no tapering,
knobby/bulbous at branch tips

Consolidation
Opacity completely obscuring vessels; if bronchi aerated
branching lucencies (air-bronchograms)
DDx: Any process filling air spaces with blood, fluid, or
inflammatory cells, atelectasis

Pitfalls
Requires breath holding
Contraindications: See Head Computed Tomography above

Abdominal Plain Film

Indications
Rule out obstruction or ileus, free air, or calcifications

Patient Preparation
None

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 178

RADIOL
Procedure Description
Usually PA supine, erect (free air), or lateral decubitus (free fluid);
show lower anterior ribs

Normal Study
Solid organs
Liver: RUQ soft-tissue density
Spleen: LUQ soft-tissue mass; may not be seen
Kidneys: Left higher than right; upper poles tilt medially;
should be ~three vertebrae in size
Psoas muscle: Line (lumbar spine lesser trochanter)
Bladder: If full, pelvic soft-tissue density
Uterus: May indent bladder; usually not seen
Prostate: Usually only seen if calcified
Hollow organs
Stomach: Supine; air anterior and fluid posterior
Small bowel: Normal 2.53.0 cm diameter; valvulae cross
entire lumen; often little seen on plain film
Colon: Abdominal periphery
Normal calcification: Costal cartilage, mesenteric lymph
nodes, pelvic vein phleboliths, prostate gland

Abnormal Studies
Intestinal Obstruction
Dilated loops proximal to obstruction (3 cm small bowel,
6 cm large bowel)
Stepladder or hairpin pattern: Air-fluid levels at different
heights within same loop
String of pearls: Small gas bubbles trapped between folds
in dilated, fluid-filled loops

Ischemic Colitis
Thumbprinting of mucosa, bowel wall thickening

178

Chapter-06.qxd

9/12/08

3:56 PM

Page 179

179
Volvulus
May be normal; ahaustral distention, air-fluid levels, liver/left
flank/pelvic overlap

Intussusception
Usually in ileocolic region; may be anywhere
Soft-tissue mass and small bowel obstruction

Toxic Megacolon
Colonic distention with absent haustra; edematous and
ulcerated mucosa may pseudopolyps

Diverticulosis
Gas-filled sacs parallel to colon lumen

Pseudomembranous Colitis
Dilated colon, ascites, and nodular thickened haustra

Ascites
Detect 500 mL fluid; accumulate in most dependent areas;
supine: hepatorenal recess (Morrisons pouch); upright:
pouch of Douglas
Diffusely density or ground glass sign (hazy appearance);
indistinct liver, spleen, and psoas muscle margins; colon,
liver, and spleen medial displaced away from flank stripe;
bulging of flanks
Dog ears: Fluid accumulates in peritoneal recesses
superolateral to bladder

Free Air (Pneumoperitoneum)

Best seen on upright film (below diaphragm domes)
Double wall sign (Riglers): Air outline both inside and
outside bowel walls
Falciform ligament sign: (Supine) outline ligament
Football sign: Gas outline peritoneal cavity

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 180

RADIOL
Pneumoretroperitoneum
Air outline right kidney and liver undersurface
Unlike pneumoperitoneum, does not move with position
change
Can extend into mediastinum or neck

Pneumobilia
Biliary gas outline bile ducts
Pseudopneumobilia: Normal periductal fat that surrounds
and parallels bile duct course

Calcification
Appendicoliths, costal cartilages, mesenteric lymph nodes,
phleboliths, aging prostate, prostate carcinoma, pancreatitis
(T9T12), nephrocalcinosis (T12L2), blood vessels,
abdominal aortic aneurysm (AAA), uterine fibroids,
gallstones, porcelain gallbladder, renal calculi, bladder
calculi, bladder tumor, schistosomiasis (Ca2 bladder wall),
ovarian teratoma (tooth)

Pitfalls
If spine visible, most structures will be visible
View overexposed (dark) areas with bright light
Artifacts from piercings and metallic objects

Abdominal-Pelvic CT
Indications
Assess abdominal pathology

Patient Preparation
Keep pt. hydrated; sedate agitated pt.; if IV contrast used, check
serum creatinine and history of allergic reaction

180

Chapter-06.qxd

9/12/08

3:56 PM

Page 181

181
Procedure Description
IV contrast: Ionic: osmolar and Nonionic: osmolar
GI contrast media
Esophacat (thick barium): Opacify esophagus
Gastrograffiin (H2O-soluble): Opacify entire GI tract
Readicat (barium): Outpatient examinations opacify all GI tract
Outpatient: Readicat first half bottle at qhs before and
second half ~ 1 hr before examination; third dose:
immediately before scan
Urgent: Gastrograffin 3 doses at 1 hr, 30 min, and
immediately prior to examination
Emergent trauma: First dose in ED and second dose at table
Delayed images: 510 min post-IV contrast visualize
urinary system
Liver Imaging
Three-phase scan (especially hypervascular lesions such as
hepatoma, metastatic disease, or hemangioma): 1. arterial
(contrast in aorta and main hepatic arteries); 2. portal
venous (contrast liver parenchyma and mix with portal
blood); 3. equilibrium (contrast in parenchyma hepatic
veins kidneys)
First-stage and second-stage liver malignancies usually
have hepatic arterial supply (arterial phase)
Benign entities and normal liver: Portal venous supply
(portal-venous phase)

Normal Study
Liver parenchyma: Homogeneous 5460 HU, usually 810 HU
than spleen

Abnormal Studies
k

Liver
Hepatic Abscess
Bacterial: Heterogeneous with irregular margin and possible
peripheral enhancement, internal septations or papillary
projections; may contain gas

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 182

RADIOL
Echinococcal: Calcified wall, membrane separation,
dependent debris, focal areas attenuation in cysts
Fungal: Multiple, small, hypodense lesions

Cirrhosis
Noncontrast: Homogeneous/heterogeneous attenuation
Contrast: Fibrosis/regeneration areas may isodense to
parenchyma; liver surface may be very nodular

Fatty Liver
Diffuse: On noncontrast, hypodense to spleen hepatic
vasculature more prominent
Focal: Patchy areas attenuation

Hemochromatosis
Hyperdense liver (75 HU) ~ to Wilsons disease,
amiodarone toxicity, and previous Thorotrast exposure

Portal Venous Hypertension

Ascites, splenomegaly, or portosystemic varices

Solitary Liver Masses

DDx: Cyst, metastasis, focal nodular hyperplasia, adenoma,
hepatoma, focal fatty infiltration, hemangioma
Lesions 1 cm too small to be characterized

Simple Hepatic Cyst

Noncontrast: Density 20 HU, well-defined margins, no
perceptible wall
Contrast: No enhancement after contrast

Hemangioma
Noncontrast: Low (dark) attenuation
Contrast: Focal nodular enhancement
Delayed: Centripetal opacification pattern (arterial phase:
lesion periphery enhances; equilibrium/early delayed phase:
center fills); large hemangioma, central necrotic scar may not
enhance

Portal Vein Thrombosis

Post-thrombosis, periportal collateral vessels recanalize

182

Chapter-06.qxd

9/12/08

3:56 PM

Page 183

183
Budd-Chiari Syndrome
Hepatosplenomegaly and patchy enhancement; caudate lobe
may be enlarged after several weeks; may see collateral
circulation

Passive Hepatic Congestion

Chronic hepatic venous pressure low attenuation areas

Gallbladder and Biliary System

Porcelain Gallbladder
Calcification of the gallbladder wall (arrows), often
accompanied by stones

Choledocholithiasis
May have target and crescent signs

Acute Cholecystitis
Cholelithiasis, GB wall thickens, pericholecystic fluid,
perforation or hepatic abscess

Pancreas
Pancreatitis

Enlarged pancreas infiltration of surrounding fat

Peripancreatic fluid collections
Pseudocysts: Encapsulated fluid collections
Pancreatic necrosis: No enhancement with IV contrast
Pseudoaneurysm: Saccular dilation of artery (most
commonly splenic and gastroduodenal)

Pancreatic Injuries
May appear normal, especially during first 12 hr; may need
to rescan in 1224 hr
Linear hypodensity around pancreatic parenchyma
Diffuse, thickened Gerotas fascia
Retropancreatic fluid anterior to splenic vein
Delayed formation of pancreatic pseudocyst

Intestines
Acute Appendicitis
Dilated appendix 6 mm OR appendicolith
Periappendiceal fat stranding

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 184

RADIOL
Crohns Disease
See Barium and Gastrograffin Enema above

Ulcerative Colitis
See Barium and Gastrograffin Enema above
Extraintestinal: Sacroiliitis, cholangitis, and thromboembolic
disease

Ischemic Colitis
Mucosal thumbprinting or thickening of bowel wall

Intussusception
Characteristic doughnut/target-shaped intestinal mass

Intestinal Obstruction
See Abdominal Plain Film Findings above

Toxic Megacolon
Thin bowel wall with irregular nodular configuration

Pseudomembranous Colitis
Wall thickening (~15 cm) with target-like appearance,
pericolic fat inflammation, ascites
Accordion sign: Intraluminal contrast stripes trapped
between nodular, hypertrophied wall

Diverticulitis
Pericolonic fat inflammation/stranding, pericolonic abscess,
focal bowel wall thickening, diverticula near inflammation
site

Polyps
Benign: Small diameter, stable growth, spherical-shaped,
normal mucosa, long stalks, and smooth surface
Malignant: Large diameter, sessile, irregular shape, sudden
growth, broader base, and puckered mucosa

Kidneys
Renal or Ureteral Stones
Initial protocol without IV or oral contrast
If equivocal: IV contrast 510 min. delayed images
Pelvic Ca2 (?distinguish vs. phlebolith)

184

Chapter-06.qxd

9/12/08

3:56 PM

Page 185

185
Second-stage signs: Hydronephrosis, perinephric stranding,
and rim sign edematous ureter soft-tissue rim around
pelvic calcification

Peritoneum
Ascites
Fluid densities in recesses of peritoneal cavity
Serous fluid ~ H2O density; exudative: slightly H2O dense;
acute bleed most dense
Fluid posterior to diaphragm pleural fluid; Fluid within
diaphragm ascites

Free Air (Pneumoperitoneum)

Use lung windows to help distinguish vs. bowel gas
Falciform ligament and double-wall (see plain film).

Peritonitis
Ascites peritoneal and mesenteric thickening
Abscess: Early ~soft-tissue attenuation; as ages
liquefactive necrosis; mature definable wall and low
attenuation center
Thicken/obliterate adjacent fat and displacement of adjacent
structures
~Hematomas, urinomas, necrotic tumors, pseudocyst

Pitfalls
Bone artifacts
Contraindications: Pregnant, allergy to IV contrast, iodine,
shellfish
Warnings: Renal insufficiency/failure, metformin

Obstetric Ultrasound
Indications
See below

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 186

RADIOL
Patient Preparation
None

Procedure Description
Abdominal and transvaginal scans, Doppler ultrasound
3D and 4D ultrasound

Normal Study
Confirm Pregnancy
Gestational sac ~412 wk gestation; yolk sac ~5 wk; embryo
~512 wk

Gestational Age and Fetal Size

Crown-rump length (CRL): Measure at 713 wk; estimate
gestational age
Biparietal diameter: Measure 13 wk; diameter between two
sides of head ~2.4 cm at 13 wk to 9.5 cm at term; dating later
pregnancy unreliable
Femur length: Measure longest bone in body (longitudinal
fetal growth) ~1.5 cm at 14 wk to 7.8 cm at term; dating later
pregnancy unreliable
Abdominal circumference: Important to judge fetal
size/weight in late pregnancy; not for dating

Timing of Scans
Scan at ~7 wk: Confirm pregnancy, exclude ectopic or molar
pregnancies, confirm cardiac pulsation and measure CRL for
dating
1114 wk: Evaluate fetal nuchal translucency, nasal bone, and
tricuspid regurgitation (?Downs syndrome)
1820 wk: Look for congenital malformations, multiple
pregnancies, placental position
32 wk: Evaluate fetal size, weight, and fetal growth; verify
placental position
Level II (targeted) scan: Suspected abnormality

186

Chapter-06.qxd

9/12/08

3:56 PM

Page 187

187
Abnormal Studies
Vaginal Bleeding in Early Pregnancy
Check fetus viability: Visible heartbeat ~67 wk
Fetal heart rate: At 6 wk ~90110 bpm; at 9 wk 140170 bpm;
at 58 wk 90 bpm high risk of miscarriage

Pitfalls
Accuracy highly operator-dependent

Bone Films
Indications
Suspected fractures, dislocations, joint effusions, arthritis, bone
cancer, or bone disease; before and after orthopedic operations

Patient Preparation
None

Procedure Description
Must see at least two views
For long bones, must see joints at both ends

Normal Study
Check: A (anatomic appearance, alignment, asymmetry);
B (bone density/mineralizations); C (cartilage, contours); D (distribution, deformity); E (erosions, extent); S (soft tissue, swelling)

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 188

RADIOL
Abnormal Studies
First-Stage Degenerative Arthritis
Joint space narrowing, marginal osteophytes, subchondral
sclerosis, subchondral cysts

Calcium Pyrophosphate Deposition Disease

Articular cartilage calcification (shoulder, hip, knee, ulna,
symphysis), large subchondral cysts, preferentially involve
femoropatellar compartment

Charcots Arthropathy
Fragmentation, osteophytes, soft-tissue swelling, joint
destruction, sclerosis

Infectious Arthritis
Usually single joint; articular cartilage and cortex destruction

Rheumatoid Arthritis
Bilateral symmetrical, especially hips and knees
Earliest changes: STS, MCP, PIP, ulnar styloid; radiocarpal
joint most commonly narrowed; MCP joints of first and
second fingers
Periarticular demineralization; large joints usually no
erosions; marked narrow joint space with intact articular
cortex; little or no sclerosis

Gout
Juxta-articular erosions; sharply marginated sclerotic
rims; overhanging edges; no joint space narrowing until
later; little/no osteoporosis; soft-tissue swelling; tophi not
calcified

Hemophilia
Epiphyseal overgrowth; resorption of second-degree
trabeculae; longitudinal striations; widen knee intercondylar
notch; joint effusion; hemosiderin deposit around joint

188

Chapter-06.qxd

9/12/08

3:56 PM

Page 189

189
Psoriatic Arthritis
Involves DIP joints, hands feet; cup-in-pencil deformity;
resorption terminal phalanges; no osteoporosis

Ankylosing Spondylitis
Bilateral sacroiliac arthritis; squaring of vertebral bodies;
bamboo-spine from continuous syndesmophytes; peripheral
large joint erosive arthritis

Reiters Syndrome
Urethritis, arthritis, conjunctivitis
Periostitis at tendinous insertion sites; whiskering; like DISH,
ankylosing spondylitis affects feet hands; also SI joint ~to
RA; also, osteoporosis

Lucent Bone Lesions (mnemonic: FOGMACHINES)

Fibrous dysplasia, Osteoblastoma, Giant cell tumor, Metastasis/
Myeloma, Aneurysmal bone cyst, Chondroblastoma/
chondromyxoid fibroma, Hyperparathyroidism (brown
tumors)/hemangioma, Infection, Nonossifying fibroma,
Eosinophilic granuloma/enchondroma, Solitary bone cyst

Sclerotic Bone Lesions (mnemonic: VINDICATE)

Vascular: Hemangiomas, infarct
Infection: Chronic osteomyelitis
Neoplasm: First stage (osteoma, osteosarcoma), metastatic
(prostate, breast)
Drugs: Vitamin D, fluoride
Inflammatory/Idiopathic
Congenital: Bone islands, osteopoikilosis, osteopetrosis,
pyknodysostosis
Autoimmune
Trauma: Fracture (stress)
Endocrine/metabolic: Parathyroid, Pagets disease

Osteonecrosis
Early: Appears normal
After weeks to months: Ill-defined mottling trabecular
Late: (Medullary space well away from joint) dense,
serpiginous calcification (subchondral bone) microfractures

RADIOL

Chapter-06.qxd

9/12/08

3:56 PM

Page 190

RADIOL
in dead bone discontinuous subchondral line or crescent
sign (fracture between subchondral line and adjacent
necrotic bone); thick sclerotic zone between living and
necrotic bone

Soft-Tissue Calcifications
Dystrophic (amorphous Ca2 may ossification with cortex
and medullary space): Vascular (venous insufficiency),
infection, (parasitic infestation, cysticercosis, dracunculiasis,
Armillifer armillatus), neoplasm (primary bone-forming
tumor, osteoma, osteosarcoma, tumor necrosis), drugs
(vitamin D), autoimmune (dermatomyositis, scleroderma),
trauma (heterotopic ossification, injection granulomas)
CPPD chondrocalcinosis; occasionally associated with
calcifications in the soft tissues of the spine
Metastatic calcification (finely speckled Ca2)
Tumoral calcinosis (large Ca2, usually near joint)
First-stage soft-tissue or metastatic osteosarcoma
(amorphous, fluffy, confluent Ca2 collection)

Osteoporosis
Vascular (anemia), drugs (steroids, heparin), dietary
deficiency (scurvy, malnutrition, calcium deficiency),
idiopathic osteoporosis, congenital (osteogenesis
imperfecta), toxic (alcoholism, chronic liver disease),
endocrine/metabolic (senile, postmenopausal, pregnancy,
diabetes mellitus, hyperparathyroidism, Cushings disease,
acromegaly, hypogonadism)

Fractures
Simple transverse: Fracture line perpendicular to bones long
axis two fracture fragments
Oblique: Fracture line oblique angle to long axis
Spiral: Severe oblique fracture, fracture plane rotates along
long axis resulting from rotational force
Longitudinal: Fracture line nearly parallel to long axis; also
known as long oblique fracture
Comminuted: Results in two fracture fragments

190

Chapter-06.qxd

9/12/08

3:56 PM

Page 191

191
Impacted: End of bone driven into contiguous metaphyseal
region without displacement, resulting from axial or
compressive force
Depressed: Type of impacted fracture; involves articular
surface of bone joint incongruity
Avulsion: Tendon/ligament pulled away from bone, carrying
bone fragment with it

Pitfalls
Relative contraindication: pregnancy

RADIOL

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Toxicology Screen
Amphetamine/
methamphetamine
Barbiturates
Benzodiazepines
Carbon monoxide
Cocaine

Codeine

Ethanol

Heroin
Hydromorphone
Methadone
Methaqualone
Morphine
Phencyclidine
Propoxyphene
Tetrahydrocannabinol
or marijuana
metabolite

Remains 2448 hr after use

Remains 26 wk after use
Moderate use: for 35 d; heavy: for
36 wk
Suggested by 9% carboxyhemoglobin
Direct: 5 hr; metabolite
(benzoylecgonine): 24 d
Heavy use: up to 1022 d
12 d
310 hr, peak blood levels (on empty
stomach: 4070 min
Metabolism rate: (for 70-kg man) 155
mg/dL/hr
Urine:blood: 1.35:1 (variable);
saliva:blood: 1:20
12 d (detected as morphine)
12 d
23 d
2 wk
12 d
18 d
Direct: 6 hr; metabolites: 648 hr
2 d/joint; daily use: 36 wk; heavy use:
611 wk

192

Page 192

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

Page 193

193
Other Toxicity Tests
Test
Lead (Pb)

Children
(16 y.o.):
10 mcg/dL
Adults: 20
mcg/dL

Free erythrocyte 35 mcg/dL

protoporphyrin

Acetaminophen

Cause
For children with Pb
levels, if screening result is:
1019 mcg/dL perform
diagnostic test within 3 mo
2044 mcg/dL within 1 mo
4559 mcg/dL within 48 hr
6069 mcg/dL within 24 hr
70 mcg/dL immediately
In adults, lead toxicity or
chronic exposure
Fedeficiency (can catch
before manifests in
anemia)
Other anemias: e.g.,
hemolytic anemia, chronic
disease

RumackMatthew
nomogram

LABS

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS

Acetaminophen level (g/mL)

500
200
150
100

Probable
hepatic
toxicity

50
Possible
hepatic
toxicity
10
5

Hepatic
toxicity
unlikely

1
4 8 12 16 20 24
Hours after ingestion

Cerebrospinal Fluid (CSF) Color

Xanthochromia

Cloudy or turbid
Brown or dark
green

Yellow: Blood breakdown products,

hyperbilirubinemia, CSF protein 100
mg/dL, RBC 100,000/mm3
Orange: Blood breakdown products, high
carotenoid ingestion
Pink: Blood breakdown products
Leukocytes 200 WBC/mm3 or RBCs
400 per mm3
Metastatic melanoma (meningeal
melanomatosis) or hyperbilirubinemia
Hyperbilirubinemia or purulent

194

Page 194

Normal
to

Normal
to
Normal

Lympho- Early:
cytes
PMNs
Late:
Lymphocytes

Normal
to
Lymphocytes

Normal
or

Normal
to
Normal
to

Normal

Normal

Normal
to
Lymphocytes

Neurosy- Guillain
philis Barr
Clear to Clear to
cloudy
cloudy

Normal
to
Lympho- Monocytes
cytes

Hemor- Neorhage
plasm
XanClear to
thochro- xanmia
thochromia

9/12/08

CSF-toserum
glucose
ratio

Protein

Cell
differential

=1000
per mm3
PMNs

Normal Variable
or
Variable Variable

Opening
pressure
WBC

Normal
or
100
per mm3
Lymphocytes

Bacterial
Viral
Fungal
TB
Cloudy
Clear to Clear to Cloudy
cloudy
cloudy

Test
Color

Cerebrospinal Fluid (CSF) Findings in

Different Conditions

FADavis_Chapter 07.qxd
4:00 PM

195

LABS

Page 195

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
CSF Tests
Test
Leukocyte

Result
5 WBCs/
mm3

Blood

80 mg/mL
50 mg/mL

Glucose

Newborn:
60% Infant:
50% serum
glucose

Cause
Blood ( one WBC for every
5001000 RBCs): Subarachnoid
hemorrhage
Predominantly neutrophils
(bacterial meningitis); lymphocytes
(viral meningitis, chronic intracranial
inflammation); eosinophils
(intracranial parasites, aseptic
meningitis, malignancy, VP shunt)
Subarachnoid or intracranial
bleeding; traumatic tap
Hyperglycemia
Hypoglycemia; granulomatous
disease (e.g., TB, sarcoid);
meningitis (e.g., bacterial,
chemical, fungal); subarachnoid
hemorrhage; neoplasm; certain
CNS viral infections (e.g., HSV,
mumps, lymphocytic
choriomeningitis)

Hormones of the Reproductive System

Condition
Follicular
Midcycle
Luteal
Pregnant
Postmenopausal

Follicle
Stimulating
Hormone (FSH)
mIU/mL
2.510.2
3.433.4
1.59.1
0.2
23.0116.3

196

Luteinizing
Hormone
LH:FSH
(LH) mIU/mL Ratio
1.912.5
8.776.3
0.516.9
0.01.5
15.954.0

Page 196

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

197
Polycystic ovarian
syndrome (PCO)
Obesity
Thyroid
Liver disease

Normal or
Can be normal
or
Can be normal
or
Can be normal
or

1.5

Can be
Can be
Can be

Distinguishing Gonadal Failure

First stage
Second stage
(hypothalamus or
pituitary)

Normal or

Normal or

Prolactin (PRL)
Males and
nonpregnant
females: 20
ng/mL
Pregnant:
300 ng/mL

Breast, chest wall, skin, or spinal

cord stimulation: e.g., Manipulation/
physical stimulation, surgery, masses,
infection
Physiologic: Pregnancy, sleep, exercise,
eating, stress
Endocrine: e.g., Hypoglycemia,
thyroid, adrenal adenoma/tumor,
ovarian tumor, PCO
PRLsecreting tumors: e.g., Pituitary
tumors, breast CA, hypernephroma
PRL inhibiting factor (PIF) synthesis:
Hypothalamic or pineal disorders
PIF transport: Pituitary stalk
compression (e.g., cerebral aneurysm,
pseudotumor cerebri)
Rheumatism/musculoskeletal: SLE
Various drugs: e.g., Estrogens, TCAs

LABS

Page 197

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Diabetes Insipidus (DI) vs. Syndrome of
Inappropriate Antidiuretic Hormone
Secretion (SIADH)
Test

Normal

DI

SIADH

Serum sodium (meq/L)

135145
145
130
Plasma osmolality (mOsm)
278298
295
275
Urine osmolality (mOsm)
501200
300
1200
Urine/plasma osmolality ratio 34
1
4
Urine output (L/d)
~2.5
2.5 L/d

Overnight Water Deprivation Test to Diagnose DI

Procedure
Restrict fluid intake for 1218 hr
Measure urine osmolality/volume, plasma
osmolality, and body weight
Administer 1 mcg of dDAVP
Measure urine osmolality
Urine Osmolality
Diagnosis
50% increase after dDAVP
Neurogenic DI
10%50% increase after dDAVP
Partial neurogenic DI
10% increase after dDAVP
Nephrogenic DI

Growth
hormone
(GH)
Somatomedin
C (IGFI)

Causes of

5 ng/ml Pituitary tumor,

GH resistance,
starvation,
drugs
463 ng/ GH: e.g.,
mL
Acromegaly
Normal:
Puberty,
pregnancy,
obesity

198

Causes of

1 ng/mL Hypothalamic/
pituitary damage, GH gene
mutations
123 ng/ GH, liver
mL
disease,
nonfunctioning
pituitary
tumor,
nutrition
Normal :
First 56 years
of life,
advanced age

Page 198

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

Page 199

199
Thyroid Function Tests
Test
Thyroid
stimulating
hormone
(TSH)

Total
thyroxine
(T4)

Free
thyroxine
(FT4)
Free
thyroxine
index
Total
triiodothyronine (T3)

Causes of
4.0 mc Thyroid
U/mL
TSH antibodies
Pituitary
resistance
Acute
illness
recovery
11.2
Thyroid
mcg/dL
secretion
Thyroid
binding
globulin
(TBG): e.g.,
Pregnancy
Thyroxine
intake
1.9
Same as T4
ng/dL
but not
affected by
TBG
13
Same as T4
but corrects
for TBG
200
Same as T4
ng/dL

0.4 mc
U/mL

Causes of
Thyroid
Pituitary
disorder Acute
illness or
malnutrition
Hyponatremia

5.0
mcg/dL

Thyroid
secretion:
Pituitary/
hypothalamus
TBG: e.g.,
Congenital,
chronic
illness

0.7
ng/dL

Same as T4
but not affected
by TBG

4.2

Same as T4
but corrects
for TBG
Same as
T4; when
T4 normal
or , T4 T3
conversion : e.g.,
Fasting, surgical
stress

80
ng/dL

(continued )

LABS

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Thyroid Function Tests
(Continued )
Test
Thyroglobulin (Tg)

42
ng/mL

Antithyroglobulin
Thyroperoxidase
(TPO)

TSH Receptor Ab
(TRAb)

Causes of
Thyroid
function,
inflammation,
or cancer (e.g.,
papillary,
follicular)

3 ng/
mL

Causes of
Tumor
mark;
postremoval/
ablation
Surreptitious
thyroxine
use
Congenital
athyreosis
Autoimmune disease (e.g., Hashimotos,
Graves, SLE) and thyroid CA
Autoimmune thyroiditis (used with
antithyroglobulin), other autoimmune
disease (e.g., Sjgrens, SLE, RA, pernicious anemia), occasionally other
thyroid disease (e.g., carcinoma)
Autoimmune thyroid disease: e.g.,
Graves

Coagulation Studies
Test
Prothrombin time
(PT)

35
sec

Causes of
Factor I, II, V,
VII, or X
Synthesis: e.g.,
Liver disease
Consumption:
e.g., DIC
Vitamin K
Drugs: e.g.,
Warfarin

200

25
sec

Causes of
Vitamin K
Thrombophlebitis
Drugs: e.g.,
Estrogens,
griseofulvin

Page 200

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

Hypercoagulable
states: DIC

Page 201

201
Partial
thromboplastin
time
(PTT)

35
sec

Factor I, II, V,
VIII (hemophilia
A), IX (hemophilia B),
X, XI, or XII
Synthesis/
consumption/
inhibitors:
e.g., Lupus anticoagulant
Drugs: Heparin,
warfarin

25
sec

Antithrombin
(AT) III

120
% or
30
mg/
dL

Acute hepatitis/
cholestasis
Kidney
transplant
Vitamin K
PostMI
Drugs: Coumadin

80%
or
17
mg/
dL

Hereditary
AT III
Thrombosis:
e.g., DIC
Synthesis/
loss
Drugs: e.g.,
Thrombolytics
Factor

Inflammation
50% Hemophilia A,
VIII assay
200% (acute phase
norvon Willebrand
nL
reactant)
mal
disease
Pregnancy
Consumption:
(last trimester)
DIC
Drugs: OCPs
Factor VIII
inhibitor
Fibrinogen 433 Inflammation,
175 Synthesis: e.g.,
(functional) mg/
infection,
mg/
Afibrinogenemia
dL
pregnancy, MI
dL
Consumption:
Drugs: OCPs
e.g., DIC
Drugs: e.g.,
Androgens
Bleeding
9
Platelet number or function: e.g., Bernard
time
min
Soulier syndrome, thrombasthenia, von
Willebrand (some forms)
Vascular wall defects
Drugs: Dextran, indomethacin, salicylates
(continued )

LABS

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Coagulation Studies
(Continued )
Test
Activated
clotting
time
(ACT)

Fibrin
degradation
products
(FDP)
Thrombin
time

DDimer

Direct
Coombs
test

Causes of

180
sec

Clotting factor (except factors VII and III)

Platelet function disorder (but normal in
pure thrombocytopenia and von
Willebrand)
Afibrinogenemia
Circulating anticoagulants
Drugs: Heparin
10
When plasmin dissolves fibrin blood clots
mcg
FDPs (which inhibit clotting); indicates
/mL
fibrinolysis or clot breakdown: e.g., DIC,
primary fibrinolytic disorders, PE
Severe liver disease
False-positive: Rheumatoid factor
20
Consumption: e.g., DIC
sec
Hereditary disorders: Hypofibrinogenemia,
dysfibrinogenemia
Drugs: Heparin, fibrinolytic agents (e.g.,
streptokinase, TPA)

Venous or arterial thrombosis: e.g., PE/DVT,

MI, recent surgery, infection, sepsis, cancer,
DIC
Drugs: Anticoagulants
Detect RBCs coated with antibodies including, the
following types of hemolysis:
Autoimmune: Warm autoimmune hemolytic anemia
(e.g., idiopathic, SLE, Evans syndrome), cold
autoimmune hemolytic anemia (e.g., mononucleosis)
Alloimmune: Various newborn hemolytic disease
(e.g., erythroblastosis fetalis, Rh disease, Rhesus C,
ABO, antiKell), other blood group incompatibility
(e.g., RhC, Rhe, RhE, Kid, Duffy, MN, P)
Druginduced: e.g., Methyldopa, various antibiotics,
Ldopa, quinidine

202

Page 202

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

203
Indirect
Coombs
test

Ham
test

Test

Detect antiRBC antibodies in serum (specifically

IgG, but may detect IgM):
Acquired hemolytic anemia, incompatible blood
transfusion, and antiRh antibodies (maternal Rh
sensitization)
Used to diagnose paroxysmal nocturnal
hemoglobinuria
False-positive: Myeloproliferative disorders,
spherocytosis, transfusion with old RBCs,
hereditary dyserythropoietic anemia type II

Vitamin
B12

200
pg/mL

B12
absorption
(Schilling
test)
Folic acid

In 24 h,
excrete
8%
2.7
ng/mL

Causes of
Requirements (e.g., pregnancy),intake
(e.g., vegan diet)
Intestinal absorption: Inflammation
(e.g., Crohns), disruption (e.g., blind
loop), infection (e.g., D. latum)
Intrinsic factor: e.g., Pernicious anemia,
metabolism (e.g., thyroid), gastric CA,
atrophic gastritis, gastrectomy
Note: May be in liver or myeloproliferative disease (e.g., myelocytic leukemia)
Intrinsic factor
Ileal absorption

Intake (e.g., chronic EtOH)/absorption

(e.g., celiac disease)
Vitamin B12
Various drugs: e.g., Antimalarials,
estrogens, methotrexate

LABS

Page 203

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

Page 204

LABS
Iron Studies
Test

Causes of

Causes of

Iron (Fe2+)

170
mcg/dL

Hemolysis, 60
Nonironmcg/dL
deficiency
anemias
and lead
poisoning
Iron
overload:
e.g.,
Multiple
blood
transfusions
Ineffective
erythropoiesis: e.g.,
Liver disease
Vitamin B6
or B12
Drugs: e.g.,
Estrogens

Intake/
absorption: e.g.,
Malnutrition,
celiac disease
Chronic blood
loss: e.g., GI,
menstrual,
postoperative
Iron demand:
e.g., Pregnancy
Drugs: e.g.,
Allopurinol,
cholestyramine,
colchicine,
methicillin,
testosterone

Total iron
binding
capacity

450
mcg/dL

Fe
240
deficiency
mcg/dL
anemia
Fe demand:
pregnancy
(3rd
trimester),
infancy
Polycythemia
vera
Acute liver
disease
Drugs: Fluorides, OCPs

Nonirondeficiency
anemias
Iron overload:
e.g., Hemochromatosis
Intake/
synthesis/
loss protein
Thyroid
Chronic
inflammation:
e.g., RA
Drugs: e.g.,
Chloramphenicol

204

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

205
Ferritin

Males:
300
ng/mL
Females:
150
ng/mL

Transferrin

370
mg/dL

Inflammation (acute
phase
reactant):
e.g., RA,
adult Stills
(500)
Iron
overload
Other: Liver
necrosis,
thyroid,
neoplasms
Iron
deficiency
Drugs: Oral
contraceptives

Males:
Iron
12
deficiency
ng/mL
anemia
Females:
12
ng/mL

200
mg/dL

Intake/
synthesis/
loss protein
Chronic
inflammation
and neoplasms
Hereditary:
Atransferrinemia

RBCs
Test

Causes of

Causes of

RBC
count

6.1

106/
mcL

5.4

106/
mcL

4.7

106/
mcL

4.2

106/
mcL

Hematocrit

50%

45%

Production:
e.g.,
Polycythemia
vera, EPO
production,
blood O2

36%

Hemoglobin
(Hgb)

17.4
g/dL

16.0
g/dL

40%
Fluid loss
hemoconcen
trate: e.g.,
13.6
Burns, diuresis

Production:
e.g., Liver
disease, Fe,
bone
marrow, renal
failure (EPO
production)
Loss:
Hemorrhage
Destruction

12.0
g/dL

(continued )

LABS

Page 205

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
RBCs
(Continued)
Test
Erythropoietin
(EPO)

19 mIU/
mL

Causes of

O2
05
(secondary
mIU/mL
polycythemia)/
O2 demand:
e.g.,
Pregnancy
Anemia
EPO
producing
masses

Causes of
Inflammation/
chronic
disease/renal
disease
Primary
polycythemia
(polycythemia
vera)

RBC Indices
Test

Causes of

Causes of

Mean
corpuscular
volume
(MCV) (fL)

95 Abnormal RBC

80 Abnormal Hgb
maturation
synthesis: e.g.,
Fe, CRF,
Spurious causes:
thalassemia, Pb
Autoagglutination,
poisoning,
WBC
chronic disease
Some drugs: e.g.,
Phenytoin

Mean
corpuscular
Hgb concentration
(g/dL)

36 = (HCT/Hct) 100

Spurious causes:
Lipemia, sample
turbidity, hemolysis (in vitro/vivo)

31

Mean
corpuscular
hemoglobin
(pg/cell)

34 = Hemoglobin/
RBC count
See causes of
MCV

26

206

Page 206

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

Page 207

207
Red cell
distribution
width

14. = (Standard deviation of RBC volume/

5% MCV) 100
Variation in RBC size: e.g., Fe, B12, folate,
immune hemolytic anemia, liver disease,
RBC fragmentation

White Blood Cells (WBC)

10 I03/L

Total WBC
Test

Causes of

4.5 I03/L

Causes of

Absolute 
neutrophil 7500/
count
mm3

Stress, Inflamma- 1500 Production/

tion, Bacterial
/mm3 maturation: e.g.,
infection
Bone marrow,
MyeloproliferaB12/folate
tive disorders,
Destruction: e.g.,
Steroids,
Spleen
Splenectomy
Margination: e.g.,
Endotoxin,
hemodialysis

Monocyte 8%

Viral/parasitic
2%
infection
Infection
recovery, Collagen Vascular disease, Hematologic
malignancies

HIV, rheumatoid
arthritis, some
cancers
Steroids

1%

Food hypersensi- 0.5

tivity
%
Chronic inflammation
Thyroid,
Radiation,
Splenectomy,
Some cancers
(e.g., myeloproliferative)

Psychologic/
physical stress:
e.g., Pregnancy,
thyroid
Some allergic
reactions
Prolonged
steroids
Hypersensitivity
reaction

Basophil

(continued )

LABS

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
White Blood Cells (WBC)
(Continued)
10 I03/L

Total WBC
Test

4.5 I03/L

Causes of

Lymphocyte

Most viral/some
bacterial
infections,
Some cancers,
Graves disease

Eosinophil 4%

Allergic reactions,
Parasitic
infections,
Chronic skin
inflammation,
Myeloproliferative disorders

Causes of

15% Bone marrow/

immunity
Adrenocortical/
steroids
Some cancers,
renal failure, SLE
Stress
Steroids
Anything
WBC production

Platelets (Plt)
Test
Plt count

Causes of

Causes of

4.5 Essential
1.5
Production:
105/
(primary) throm- 105/ Bone marrow,
3
3
mm
bocytosis: Myelo- mm
megakaryocyte
proliferative
(e.g., aplastic
disorders
anemia, EtOH,
Reactive
radiation), hered(secondary)
itary (e.g., TAR
thrombocytosis:
syndrome,
e.g., InflammaFanconis,
tion (e.g., inflamMayHegglin)
matory bowel
Sequestration:
disease [IBD]),
e.g.,
surgery, spleen
Splenomegaly

208

Page 208

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

Page 209

209
(breakdown),
hemorrhage,
malignancy,
postinfection
Drugs: Epinephrine, vincristine

Destruction:
Immune (e.g.,
ITP), mechanical
(e.g., prosthetic
valves)
Various drugs

Mean Plt
volume

11 fL Platelet
6 fL
turnover: e.g.,
ITP
Sudden gestational proteinuria
and hypertension
Stored EDTA
blood artifact
Other:
BernardSoulier,
MayHegglin,
Epstein, Fechtner,
Sebastian, Alport

Production
Myeloproliferative disorders:
Polycythemia
rubra vera,
essential thrombocythemia,
myelofibrosis
Hereditary: Storage pool disease,
WiskottAldrich,
TAR syndrome

Platelet
aggregation

Congenital: e.g., Glanzmanns, BernardSoulier, storage pool disease, von Willebrands

Acquired: e.g., Antiplatelet Abs, myeloproliferative
disease, uremia, FDPs, acquired storage pool
disease, medications

Lipids
Test

Targets

Total
cholesterol

200 mg/dL

High-density
lipoprotein
(HDL)

Females: 50 mg/dL
Males: 40 mg/dL

Comments

Highest amount
of protein
(continued)

LABS

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Lipids
(Continued)
Test

Targets

Comments

2 cardiac risk 160 mg/dL

factors:
Medication if:
190 mg/dL

Low-density
Lipoprotein
(LDL)

2 cardiac risk 130 mg/dL

factors:
Medication if:
160 mg/dL
CAD or equiva- 100 mg/dL
lent (diabetes): Medication if
130 mg/dL

= Total cholesterol HDL

(TG/5)
or
= Total cholesterol HDL
VLDL
Contains highest amount of
cholesterol

CAD multiple 70 mg/dL

uncontrolled
Medication if
risks:
100 mg/dL
Very low
density
lipoprotein
(VLDL)

31 mg/dL

Triglycerides
(TG)

150 mg/dL

= (TG/5)
Contains highest amount of
TG

Cardiac Markers
Test

Begins to
Rise

Peaks

Returns
to Normal

Myoglobin

50.0 ng/mL

2 hr

68 hr

2036 hr

Creatine
kinaseMB
(CKMB)

161 U/L or 4%
of total CK

34 hr

1224 hr

2d

Total CK

267 IU/L

46 hr

24 hr

34 d

TroponinI

1.0 ng/mL

26 hr

1216 hr

510 d

TroponinT Less specific than I 26 hr

1216 hr

514 d

210

Page 210

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

211
Brain (BType) Natriuretic Peptide
Level
(pg/mL)
Normal

Interpretation

10
99

Look for other causes of dyspnea

Heart failure unlikely

100300

CHF present

300600

Mild CHF

600900

Moderate
CHF

900

Severe CHF

Abnormal

Myocardial
stress/injury:
excretion: Renal
failure
Primary hyperaldosteronism or
Cushings
Age
Drugs: Cardiac
glycosides, diuretics

Sweat Chloride
60 mmol/L

Diagnose cystic fibrosis (false-positive:

Adrenal, G6PD, glycogen storage disease,
thyroid, malnutrition, renal failure)
Dehydration, heavy perspiration, aldosterone
Drugs: Corticosteroids

LABS

Page 211

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Liver Tests
Test

Liver Injury

Also in

Alanine
aminotransferase (ALT)

35 U/L

Most specific
for liver injury

Heart, pancreas,
kidneys, muscle
injury

Aspartate
aminotransferase (AST)

35 U/L

Specific than
ALT

Heart, lung, RBCs,

muscle, bone, pancreas, kidney
injury; vitamin A

Gamma()
51 U/L
glutamyl
transpeptidase

Lactic dehydrogenase
(LDH)

Biliary tract
CHF, SLE (mild
(more responfrom disease and
sive to obstruc- NSAIDs)
tion than AST or
ALT)

333 IU/L Liver isoenzyme

LDH5 so LDH5
LDH4 liver
disease
If LDH1/LDH2:
0.85: MI,
hemolysis, renal
infarct

Alkaline phos- 147 IU/L Liver and bile

phatase
ducts

212

LDH1: Heart muscle and RBCs

LDH2: WBCs
LDH3: Lungs
LDH4: Kidney,
placenta, pancreas
LDH5: Skeletal
muscle, liver
Kidney, bone, placenta, lung, heart,
stomach, bowel,
benign familial
hyperphosphatasemia,
ectopic tumor production (e.g.,
hypernephroma)

Page 212

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

Page 213

213
Test

Causes

Conjug- 0.4
ated
mg/dL
bilirubin
(direct)

In adults:
Bilirubin excretion: Liver disease (e.g., EtOH,
cancer, primary biliary cirrhosis), cholestasis
(e.g., drugs, TPN, pregnancy), biliary tract
obstruction (e.g., cholelithiasis, pancreatic
mass)
In neonates:
Hemolysis: e.g., Hemolytic disease of
newborn
Bilirubin excretion: Liver disease, biliary
obstruction
Pancreatic problems: e.g., Cystic fibrosis,
antitrypsin
Intrauterine infections: e.g., Sepsis
Congenital disorders: DubinJohnson
syndrome, Rotors syndrome, trisomy 18,
galactosemia, tyrosinemia, hereditary
hypermethioninemia

Unconj- 0.7
ugated mg/dL
bilirubin
(indirect)

RBC hemolysis: e.g., Sicklecell, PNH, G6PD

deficiency
Liver disease: e.g., Hepatitis, tumor, hepatic
congestion from CHF
Biliary tract disease: e.g., Cholangitis, biliary
tract obstruction
Hereditary disorder: Gilberts, CriglerNajjar

Total
protein

8.0
g/dL

Abnormal protein
production: e.g.,
Gammopathies
Intravascular
volume: e.g.,
Dehydration
Drugs: e.g.,
Androgens

6.0
g/dL

Intake/
absorption/
synthesis
protein: e.g.,
Malabsorption,
liver disease
Protein loss: e.g.,
Nephrotic
syndrome, burns,
(continued)

LABS

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Liver Tests
(Continued )
hemorrhage,
enteropathy,
fistulae
Intravascular
volume: e.g., CHF,
pregnancy
Albumin 5.4
g/dL
Ammonia

Antimitochondrial Ab
Antismooth
muscle
Abs

intravascular
volume

3.4
g/dL

Causes of protein
above
Drugs: Estrogen

60 Liver destruction (e.g., cirrhosis), urea cycle

mcg/ metabolic defect or ureasplitting UTI: (e.g.,
dL
Proteus, Klebsiella), organic acidemias,
hemolysis
10 Renal failure and drugs (e.g., lactulose,
mcg/ neomycin)
dL

Abs vs. liver mitochondria: Primary biliary

cirrhosis, hepatitis, viral hepatitis, cryptogenic
cirrhosis, EBV

1:80 titer: Autoimmune chronic active

hepatitis
1:80 titer: Primary biliary cirrhosis, viral
hepatitis, cryptogenic cirrhosis, endometriosis,
Behets, vitiligo, CMV, EBV, HIV

214

Page 214

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

Page 215

215
Glucose Tests
Test

Causes of

Causes of

Glucose

100
mg/dL
(fast)
140
mg/dL
(nonfast)

Glucose
60
intake
mg/dL
Insulin:
Pancreatic
disorders, type
I diabetes
Insulin resistance: Type II
diabetes
Metabolism:
e.g.,
Pregnancy,
thyroid,
adrenal,
infection
Various drugs:
e.g., TCAs,
corticosteroids

Insulin: e.g.,
Insulinoma
Postprandial
(i.e., glucose
absorption
insulin
surge):
Gastric emptying (e.g.,
gastrectomy,
vagotomy)
Glucose
intake/
production:
e.g., Adrenal,
pituitary,
glucagon,
liver disease,
G6PD
Various drugs

Glycosylated
hemoglobin
(HbA1c)

6.5%

Chronic hyper- 4.0%

glycemia
Hgb
clearance: e.g.,
Spleen
False : e.g.,
Uremia,
triglycerides,
bilirubin,
EtOH, salicylates, opiates

Normal Hgb
or Hgb
clearance: e.g.,
Hemolytic
anemias,
spherocytosis,
hemoglobinopathies
False :
Vitamins C
and E

Fructosamine 223
mol/L

Measures diabetic control for 23 wk vs.

HbA1c (48 wk); useful where HbA1c may
be inaccurate: e.g., abnormal hemoglobin
(continued)

LABS

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Glucose Tests
(Continued)
Test

Causes of

Causes of

Insulin
Cpeptide

16 yr:
5.0
16 yr:
3.3
ng/mL

Proinsulin
split insulin
and Cpeptide;
evaluate glucose or residual Bcell
function
Insulin
production:
e.g.,
Insulinomas,
pregnancy
Excretion:
e.g., CRF
Drugs: Oral
hypoglycemics

16 yr:
1.1
16 yr:
0.4
ng/mL

Exogenous
insulin: e.g.,
Factitious
hypoglycemia
EtOH
Insulin
production:
e.g., Type 1
diabetes,
pancreatectomy

Test

Result

Pancreatic Tests
Amylase

130 U/L

20 U/L

Causes
Injury/inflammation of:
Pancreas
Salivary gland: e.g., Sialoadenitis
Stomach/intestinal tract, ovaries
(e.g., ruptured ectopic pregnancy),
skeletal muscle
Various drugs: e.g., Bethanechol,
cholinergic medications
Pancreatic destruction: e.g.,
Advanced chronic pancreatitis

216

Page 216

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

217
Lipase

160 U/L

Glucose
tolerance
test

Screen for gestational diabetes (24 and 28 wk of

pregnancy)
Diagnose diabetes when suspected but fasting
blood glucose normal

Injury/inflammation of:
Pancreas
Stomach/intestinal tract, tongue
Various drugs: e.g., Meperidine, morphine, indomethacin

Fasting:
if 110
mg/dL

After
drinking
glucose:

1 hr:

2 hr:

if 200
mg/dL

if 140
mg/dL

Tumor Markers
Tumor Marker

Cancers

Benign
Conditions

fetoprotein
(AFP)

5.4 ng/mL Primary: HepaCirrhosis, viral

(500)*
tocellular, nonhepatitis, pregseminomatous
nancy
germ cell (other:
gastric, biliary,
pancreatic)

CA 199

37 U/mL
(1000)*

Primary: Pancreas, biliary

tract (other:
colon,
esophageal,
hepatic)

Biliary disease,
cirrhosis, pancreatitis

CA 2729

38 U/mL
(100)*

Primary: Breast
(other: colon,
gastric, hepatic,
lung, ovarian,
pancreatic,
prostate)

Breast, liver,
kidney disease,
ovarian cysts

(continued)

LABS

Page 217

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Tumor Markers
(Continued)
Tumor Marker
CA 125

35 U/mL
(200)*

Cancers
Primary: Ovarian (other:
breast, endometrial, esophagus,
fallopian tube,
gastric, hepatic,
lung, pancreas)

Calcitonin

Males:80
Females:
70 pg/mL

Primary: Thyroid
medullary carcinoma (other:
lung, breast,
carcinoids, islet
cell, apudomas)
Primary:
Colorectal (other:
bladder, breast,
cervix, gastric,
hepatic, ENT,
lung, lymphoma,
medullary thyroid, melanoma,
pancreas)

Carcinoembry- 5 ng/mL
onic antigen
(10)*
(CEA)

Human
chorionic
gonadotropin

5 mIU/mL Primary:
(30)*
Nonseminomatous germ cell,
gestational trophoblastic disease (other: GI)

*Level at which cancer likely

218

Benign
Conditions
Cirrhosis, effusion (pleural
and pericardial),
endometriosis,
fibroids, menstruation, ovarian cysts, pelvic
inflammatory
disease (PID),
pregnancy
Gastrin,
pancreatitis,
thyroiditis, renal
failure,
pregnancy,
newborns
Biliary
obstruction,
cirrhosis, IBD,
pancreatitis,
peptic ulcer,
tobacco,
thyroid

Gonads,
marijuana use

Page 218

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

Page 219

219
Prostate Specific Antigen (PSA)
Test

Causes of

PSA

10 ng/
mL

10 ng/mL
0 ng/
suspicious for
mL
prostate CA
Can be 4
ng/mL with
prostate stimulation: e.g.,
Inflammation,
procedures
(e.g., urinary
catheter)

Causes of

Prostate
removal
Antiandrogen
therapy

Free PSA

25%

Free PSA
more in BPH

11%

Prostate
CAassociated
PSA is more
protein-bound

Tests to Diagnose Pheochromocytomas

or Other Catecholamine-Secreting
Tumors (e.g., Neuroblastoma)
Medications to stop
or avoid prior to
test

ASA, clonidine, labetalol, TCAs, lithium,

other psychoactive medications,
levodopa/methyldopa, decongestants,
benzodiazepines, muscle relaxants
(mephenesin, methocarbamol),
nitroglycerin, tetracycline, Tylenol

Foods to avoid

Avocado, bananas, caffeine, eggplant,

EtOH, pineapples, plums, tobacco, tomatoes, walnuts, pineapple
(continued)

LABS

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Tests to Diagnose Pheochromocytomas
or Other Catecholamine-Secreting
Tumors (e.g., Neuroblastoma)
(Continued )
Test

Comment

Free (unconjugated)
metanephrines
Urine metanephrines

0.50 nmol/L

Highest sensitivity

96 mcg/24 hr

Highest specificity

Urine vanillylmandelic
acid

7 mg/24 hr

Not used as much

anymore

Leukocyte alkaline
phosphatase

100 (max of 400)

20

Leukemoid reaction

CML

Polycythemia vera and myelofibrosis with myeloid metaplasia

PNH

Electrolytes
Serum
Test

(Critical)

Urine

(Critical)

Sodium
(Na+)

150 (160) 135 (120) 280

meq/L
meq/L
meq/d

Potassium
(K)

5.0 (6.5) 3.5 (2.5) 80 meq/d 40 meq/d

meq/L
meq/L

Chloride
(Cl)

106 (115) 96 (90)

meq/L
meq/L

CO2

29 meq/L 20 meq/L

220

250
meq/d

30 meq/d

110
meq/d

Page 220

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

221
Magnesium 3.0 (5.0) 1.8 (1.0) 150 mg/d
(Mg2)
mg/dL
mg/dL
Phospho4.1
rus (HPO42, mg/dL
3
PO4 )
Test
Creatinine

Blood urea
nitrogen

2.4 (1.0) 1.3 g/d

mg/dL
Causes of

1.4
Renal
mg/dL insufficiency/fail
ure: Prerenal
(renal blood
flow), renal
impairment,
postrenal
obstruction
Muscle breakdown or creatine ingestion
20
Renal
mg/dL insufficiency/
failure
protein
ingestion
GI bleed

0.9 g/d

Causes of

0.8
Muscle mass:
mg/dL e.g., Muscular
dystrophy
Cardiac output:
e.g., Pregnancy

8
Intake/
mg/dL synthesis/loss
protein
Intravascular
fluid: e.g.,
Pregnancy,
overhydration

LABS

Page 221

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS

Uric Acid
750
mg/24 h

Seen in gout
Cell destruction (e.g., hemolysis) or intake (e.g.,
highpurine diet)
Renal excretion: e.g., Renal disease, CHF, acidosis,
thyroid, parathyroid
Hereditary production: e.g., KelleySeegmiller
syndrome, LeschNyhan
Production and excretion: e.g., Alcohol consumption, exercise, glucose-6-phosphate dehydrogenase
deficiency, fructose1phosphate aldolase

250
mg/24 h

Purine and protein intake

Xanthine oxidase activity: e.g., Hereditary
xanthinuria, liver disease
Renal excretion: e.g., Fanconis, intracranial
disease (e.g., SIADH), AIDS

222

Page 222

Male:680
Female:
22 ng/dL

Testosterone

Testosterone free
index (TFI) = (total
testosterone/SHBG)
100

Causes of
Male: testicular
tumors
Male 10 y.o.:
precocious puberty
Adrenals: e.g.,
Tumors, hyperplasia
Drugs:
Anticonvulsants,
biturates, estrogens
(through SHBG)
Female: Ovarian
tumor or PCO

Male:100
Female:
3 ng/dL

Male:
300
Female:
20 ng/dL

(continued)

Causes of
Congenital: Primary
(testicular), (e.g.,
anorchism), secondary
(pituitary), or tertiary
(hypothalamus)
disruption
Acquired (testicular,
pituitary, or hypothalamic damage):
Chemotherapy treatment, x-ray therapy,
trauma, tumor, infection (e.g., meningitis,
mumps)
Isolated LH: e.g., Fertile eunuch
Drugs: e.g., acarbose,
digoxin

9/12/08

Free
testosterone

Testosterone

Male:
1000
Female:
80 ng/dL

FADavis_Chapter 07.qxd
4:00 PM

LABS

Page 223

223

224

(Continued)
estrogen: e.g., OCPs,
cirrhosis, male
gonad, pregnancy
(6.59.7 mcg DHT/
100 mL), anorexia,
thyroid
Causes

Androgens: e.g.,
Hirsutism, virilization,
obese postmenopausal women
Type II diabetes
Thyroid

Acidic pH: e.g., Seminal vesicle

dysfunction
Obstruction: e.g., Ejaculatory duct
Incomplete ejaculation or spillage
Primary/secondary testicular failure
Semen viscosity/pus (WBCs):
e.g., Infection
Postvasectomy

Male:
0.4
Female:0.
4 mcg DHT/
100 ml

Ratio used to determine fetal maturity; measures surfactant production

Surfactant production with maternal diabetes (normal L/S can be up to 3.4)

Lecithin/Sphingomyelin (L/S)

Sperm count: 20 106

Concentration: 10 106/mL
Motile: 35%
Volume: 1.5 mL
Progress.(37): 2 %
Live: 50%
Defects: Head 60%,
midpiece25%, tail 25%

Abnormal If

Male:
1.3
Female:3.
5 mcg
DHT/100 mL

9/12/08

1.9

Semen
Analysis

Sex hormone
binding globulin
(SHBG)

Testosterone

FADavis_Chapter 07.qxd
4:00 PM

LABS

Page 224

5426

18
7340

1080
56,500

LABS

912

13
16

17
24

25
40

Nonpregnant

5.0
7650
25,700 13,300 4060
3640
229,000 288,000 254,000 165,400 117,000

78

9.5

Postmenopausal

Developing placenta: Intrauterine pregnancies and ectopic pregnancies do not

produce hCG at same levels as IUP; identify threatened abortions/miscarriages
Molar pregnancy and germ-cell neoplasms: Gestational trophoblastic disease
(including malignant tumors), ovary/testicle teratomas
Nontrophoblastic cancers: e.g., Bladder/urinary tract transitional cell, renal,
prostate, GI, neuroendocrine, lung, breast, gynecologic, hematologic

Chorionic Gonadotropin bsubunit (bhCG)

Fetal lung immaturity

Surfactant production may be in: Toxoplasmosis, renal disease, twins, male
fetus, liver disease, anemia, polyhydramnios, thyroid, maternal age, syphilis

9/12/08

mIU/mL 550

Wk
After
LMP

10 mIU/mL

1.5

Surfactant production may be in: Female fetus, toxemia, HTN, nutrition,

hemoglobinopathy, intrauterine growth, premature membrane rupture, drug
addiction
False-positive: Contaminate amniotic fluid with blood, meconium, or vaginal
secretions

FADavis_Chapter 07.qxd
4:00 PM

225

Page 225

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Urine Tests
: UTI, vaginal contaminant
Leukocyte
False-negative: Urine specific gravity, glucose,
esterase
ketones, or protein in urine, drugs (gentamicin,
Keflex, nitrofurantoin, tetracycline, vitamin C)
: UTI, gross hematuria
False-positive: Vaginal contaminant,
phenazopyridine, dipstick exposed to air
Nitrite
False-negative: Urine specific gravity,
urobilinogen, bacteria lacking nitrate reductase
enzyme, urine pH 6.0, vitamin C
supplementation, nitrate diet
: Blood glucose, renal causes (e.g., GFR,
Fanconis syndrome, toxic renal tubular disease,
acute glomerulonephritis, nephrosis)
Glucose
False-positive: Ascorbic acid, cephalosporins,
ketones, levodopa, probenecid
False-negative: Urine specific gravity, uric acid,
vitamin C supplementation
: Muscle damage (e.g., trauma, hyperthermia,
Myoglobin
dermatomyositis, polymyositis)
Hemosiderin : Intravascular hemolysis free hemoglobin
filtered by kidneys
: Dehydration, starvation or carbohydrate diets,
DKA, EtOH ketoacidosis, isopropanol toxicity,
pregnancy
Ketones
False-positive: Urine pH (acidic), urine specific
gravity, phenolphthalein, Ldopa
False-negative: Delayed urine examination
: Hematuria, pyelonephritis, hemolytic anemia
Hemoglobin
False-positive: Urine pus, iodides, bromides

226

Page 226

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

227
Protein

: Primary, secondary, and drug-induced

glomerulonephropathy, tubular reabsorption,
protein overfllow (e.g., hemoglobinuria,
myoglobinuria, multiple myeloma, amyloid)
False-positive: Alkaline urine, concentrated urine,
contamination by chlorhexidine detergent or
body flluids, medications (e.g., penicillin,
sulfonamide)

Antinuclear Antibody (ANA)

 1:20 Frequency of false-positive with age: Common in
patients 65 yr
Autoimmune disease: e.g., SLE, Sjgrens, RA,
polymyositis, scleroderma, Hashimotos, juvenile DM,
Addisons, vitiligo, pernicious anemia, glomerulonephritis,
pulmonary fibrosis
Chronic infections: e.g., EBV, CMV
Neoplasms: e.g., Leukemia
ANA Patterns
Rim Homogenous Speckled Nucleolar Diffuse Centromere
SLE SLE

SLE,
Scleromixed
derma,
conCREST
nective
tissue
disease,
scleroderma,
Sjgrens

NonProgressive
specific systemic
sclerosis
with CREST

LABS

Page 227

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Complement
Test

Comple- Male:
ment C3 252
mg/dL
Female:
206
mg/dL

Causes of
Nonspecific
acute phase
reactant in
inflammatory
conditions

Causes of
Consumption: e.g.,
SLE (especially
lupus nephritis),
complementemic
nephritis, subacute
bacterial
endocarditis, DIC
Protein intake/
absorption/
synthesis: e.g.,
Anorexia nervosa,
celiac disease, liver
disease
Comple- Male:
Not clinically Female: C4 only when
ment C4 72
useful
12
classical pathway
mg/dL
mg/dL
is activated
Female:
Male:
Consumption: e.g.,
75
13
SLE, RA, hereditary
mg/dL
mg/dL
angioedema (from
unopposed lysis of
C4), glomerulonephritis,
HenochSchnlein
Protein intake/
absorption/
synthesis
Total
60
Inflammation 22
Catabolism: e.g.,
comple- U/mL
Infection
U/mL
Immune complex
ment
(levels may predict
(CH5O)
flares, such as
lupus nephritis)
Hereditary
deficiency

228

Female:
88
mg/dL
Male:
88
mg/dL

Page 228

Hepatitis B

Anti
HCV

PCR
or
RIBA TMA

Hepatitis C

Hepatitis Tests

IgM
IgM
Anti anti
Anti Anti anti
HAV HAV HBsAg HBs HBc HBc

Hepatitis A

9/12/08

(continued)

Susceptible to HAV
Immune to HAV
Acute HAV
Susceptible to HBV
HBV immunity from vaccine
HBV immunity from infection
Acute HBV
Chronic HBV

Interpretation

FADavis_Chapter 07.qxd
4:00 PM

229

LABS

Page 229

S/Co
S/Co

(Continued )

Hepatitis Tests
Recovery from acute HBV OR
Distantly immune,
antiHBV OR
False-positive antiHBc
HBV-susceptible OR
Chronic with HBsAg in serum
No current infection
Acute, chronic, or past HCV
Possible HCV infection
Past or current HCV
False-positive
Current infection
Past infection or false-positive
antiHCV

FADavis_Chapter 07.qxd

230

9/12/08
4:00 PM

LABS

Page 230

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

231
Hepatitis A Infection
Clinical illness
Viremia

Titer

ALT

Total
anti-HAV

IgM
anti-HAV

Stool HAV
0

Weeks after exposure

Adapted from CDC

Acute Hepatitis B Infection With Resolution

ALT
Symptomatic
period
Window
period
HBV DNA
Total anti-HBc
Titer

HBsAg

IgM
Anti-HBc

HBeAg
0

12

Anti-HBs

Anti-HBe
16 20

24

28 32

36

52

100

Weeks after exposure

Adapted from CDC

LABS

Page 231

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

Page 232

LABS
Hepatitis C Infection
In acute HCV with resolution:
Anti-HCV remains
HCV RNA disappears
ALT returns to normal

Symptons (20%)

Anti-HCV
Titer

ALT in acute
infection

ALT in chronic infection

HCV RNA in acute infection

Months after exposure

May be negative HCV
RNA window period

232

May be negative HCV

RNA window period

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

Page 233

233
Inflammatory Markers
Test

Erythrocyte

sedimentation Male:
rate (ESR)
50 y.o.:
15 mm/hr
50 y.o.:
20 mm/hr
Female:
50 y.o.:
20 mm/hr
50 y.o.:
30 mm/hr

Creactive
protein
(CRP)

0.6
mg/dL

Causes
: inflammation ESR; can
monitor esponse to therapy; in:
Inflammation: e.g., Various
rheumatolgic disorders, IBD
Infection: e.g., TB, osteomyelitis,
endocarditis, PID
Metabolic changes:
e.g., Pregnancy, thyroid
diseases
Renal disease:
e.g., Glomerulonephritis,
hemolytic uremic syndrome
Heme/oncologic disease: e.g.,
Malignant neoplasms, anemia
False-positive: Anything interfering
rouleaux formation:
Severe leukocytosis
or abnormal RBCs: e.g., Spherocytosis, polycythemia
Abnormal protein:
e.g., Hypofibrinogenemia,
hypogammaglobulinemia
Drugs: High-dose corticosteroids
Diagnose/monitor: Tissue
inflammation/injury (e.g.,
pancreatitis, IBD, rheumatologic
disorders), infections (e.g., bacterial
meningitis, sepsis, UTI, PID, TB),
malignancy (e.g., lymphoma)
If 3 d postsurgery, suggests
infection
CAD risk (i.e., coronary artery
inflammation)
(continued)

LABS

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
Inflammatory Markers
(Continued)
Test
Procalcitonin

0.5
ng/mL

Causes
Severe infections: e.g., Acute
malaria, meningitis, pneumonia,
sepsis (especially children)
Cardiopulmonary bypass

Rheumatologic Antibodies
Anti
centromere
Antihistone
AntiJo 1
AntiKu
AntiMi2
Anti
ribosomal P
Anti
ribonucleoprotein

Anti
topoisomerase I
(AntiSc170)
Anti
phospholipid

CREST syndrome, systemic sclerosis,

scleroderma, Raynauds disease
SLE, druginduced lupus, but nonspecific
(seen in many disorders)
Polymyositis/dermatomyositis, interstitial
lung disease, Raynauds
SLE, polymyositis/dermatomyositis
Dermatomyositis/polymyositis
Highly specific for SLE: Confirm diagnosis
of CNS lupus (psychosis)
Specific for mixed connective tissue
disease SLE (correlates with SLE activity, if
antiribonucleoprotein is positive without
presence of antidsDNA Abs, it means
decreased risk of nephritis), druginduced
lupus, Sjgrens, systemic sclerosis, RA
Highly specific for and suggests poor
prognosis scleroderma: Associated with renal
involvement
Antiphospholipid antibody syndrome:
Anticardiolipin and lupus anticoagulant most
commonly measured antiphospholipid
antibodies
Drugs: e.g., Some antibiotics, Ca2channel
blocker

234

Page 234

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

235
SSA/Ro and
SSB/La

Antidoublestranded DNA
(dsDNA Ab)

Rheumatoid
factor
35 mg/dL

Lupus
anticoagulant

Diagnose Sjgrens syndrome and lupus with

Sjgrens overlap
SLE: Useful to diagnose ANA-SLE (in ANA,
SSA and SSB suggests nephritis)
Antiphospholipid Ab syndrome (SSA and
cardiolipin Abs, lupus anticoagulant, and
thromboses), neonatal lupus
Specificity for SLE antisingle-stranded
DNA (antisingle strand seen in healthy
patients, SLE pt. relatives, and other
autoimmune disease; not useful for diagnosis):
Diagnose and monitor SLE activity (especially
lupus nephritis)
Other autoimmune disease (usually titers):
e.g., RA, Sjgrens, Graves, scleroderma,
MCTD, antiphospholipid syndrome,
autoimmune hepatitis
Some infectious diseases: EBV, CMV
Drugs: e.g., Minocycline, etanercept,
infliximab, penicillamine
Present in normal patients and more common
as age
RA: initial titer prognosis, likelihood of
being positive the longer pt. has disease
Also: Autoimmune disease (e.g., Sjgrens,
poly/dermatomyositis, SLE, scleroderma,
cryoglobulinemia, MCTD), some infections
(e.g., bacterial endocarditis, osteomyelitis, TB,
syphilis, hepatitis, EBV) and other disease
(e.g., diffuse IPF, cirrhosis, primary biliary
cirrhosis, sarcoidosis)
Common in asymptomatic elderly and
postpartum
Various autoimmune and inflammatory disease:
e.g., SLE, druginduced lupus, RA, ulcerative
colitis, HIV, hemophilia, multiple myeloma
Drugs: e.g., Procainamide, hydralazine,
dilantin, ACE inhibitors

LABS

Page 235

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

LABS
AntiNeutrophil Cytoplasmic
Antibodies (ANCA)
Cytoplasmic
(CANCA)

Perinuclear
(pANCA)

Atypical
(xANCA)

Strong association: Wegeners granulomatosis

Moderate association: Crescentic
glomerulonephritis
Weak association: Polyarteritis nodosa
Strong association: Crescentic glomerulonephritis
Moderate association: Polyarteritis nodosa,
ChurgStrauss vasculitis
Weak association: Wegeners granulomatosis
Other possible: HenochSchnlein purpura,
temporal arteritis
Primary sclerosing cholangitis, primary biliary
cirrhosis, autoimmune hepatitis, SLE, RA

Calcium Studies
Test
Serum
Calcium
(Ca2)

Causes of

10.2 Vitamin D or 8.5

mg/dL Ca2 intake
mg/dL
PTH
Bone
breakdown
Hereditary
disorders: e.g.,
Familial
hypocalciuria
Metabolic: e.g.,
Thyroid,
acromegaly,
Addisons
Drugs: e.g.,
Thiazides, Li

236

Causes of
Vitamin D/Ca2
intake/
absorption
PTH or
calcitonin
Ca2 sequestration: e.g.,
Saponification
albumin: e.g.,
Liver disease
Mg2 or
phosphorus
(binds Ca2)
Osteoblastic
malignancy
Drugs: e.g.,
Aminoglycosides

Page 236

FADavis_Chapter 07.qxd

9/12/08

4:00 PM

237
Test
Ionized
Ca2

Urine
Ca2
(UCa)

Parathyroid
hormone
(PTH)

Vitamin D3:
25-hydroxy
[25(OH)D3]

Causes of

5.3
mg/dL
@ pH
7.4

Causes of

Measures
physiologically
active
nonbound
Ca2, with
blood pH or
protein or
albumin
300
serum Ca2,
mg
also specific
/24hr
renal disease:
e.g., Idiopathic
hypercalciuria,
RTA
Primary/
55
secondary
pg/mL parathyroid
Vitamin D

4.4
mg/dL
@ pH
7.4

with blood
pH/ protein/
albumin: e.g.,
Multiple
myeloma,
dehydration

100
mg
/24hr

Serum Ca2,
also specific
renal disease
and drugs (e.g.,
thiazides)

10
pg/mL

50
ng/mL

10
ng/mL

Parathyroid,
thyroid,
sarcoid, Mg,
nonparathyroid
Ca2
Sun
exposure
Vitamin D
intake/
absorption
Pregnancy
Drugs:
phenobarbital,
phenytoin

Ca2
Vitamin D
intake
Sunlight
1,25-hydroxy 76
[1,25
pg/mL exposure
(OH)2D3]

20
pg/mL

LABS

Page 237

FADavis_Chapter 081.qxd

9/12/08

4:35 PM

TOOLS

Frequently Used Numbers

General
Laboratory
Pharmacy
Emergency Room
Medicine
Neurology
Surgery
OB/GYN
Ophthalmology
Dermatology
Pediatrics
Psychiatry
Psychology
Radiology
Physical Medicine/
Rehabilitation
Intensive Care Unit

238

Page 238

FADavis_Chapter 081.qxd

9/12/08

4:35 PM

239
CDC Recommended Adult
Immunization Schedule
5064 y.o. 65 y.o.

1949 y.o.
Diphtheria, tetanus,
pertussis (Td, DTaP)

1 dose Td booster q10 yr

Substitute 1 dose DTaP for Td

1 or 2 doses

Varicella

2 doses (0, 48 wk) 2 doses

(0, 48 wk)

Inflluenza

1 dose annually

Pneumococcal

12 doses

Hepatitis A (HAV)

2 doses (0, 612 mo; or 0, 618 mo)

Hepatitis B (HBV)

3 doses (0, 12, 46 mo)

Meningococcal

1 doses

Td, DTaP

1 dose

1 dose annually

HIV

Health-care
Workers

ESRD

Asplenia

1 dose

Chronic Liver
Disease Given
Clot Factors

Diabetes, Heart
Disease, Chronic
Pulmonary
Disease, Chronic
EtOH

Measles, mumps,
rubella (MMR)

Pregnancy

3 doses
females

Cancer, Cancer
Treatment*

Human papillomavirus
(HPV)

1 dose Td booster q10 yr

Substitute 1 dose DTaP for Td

HPV

3 doses for females through 26 y.o. (0, 2, 6 mo)

(continued )

TOOLS

Page 239

FADavis_Chapter 081.qxd

9/12/08

4:35 PM

TOOLS

MMR

1 or 2 doses

Varicella

2 doses (0, 48 wk)

Flu

1 dose annually

Pneumonia 12
doses
HAV

2 doses

HBV

3 doses

1
dose

HIV

Health-care
Workers

ESRD

Chronic Liver
Disease Given
Clot Factors

Asplenia

Diabetes, Heart
Disease,
Chronic
Pulmonary
Disease,
Chronic EtOH

Pregnancy

Cancer, Cancer
Treatment*

CDC Recommended Adult

Immunization Schedule (Continued )

2
doses
1 dose annually

12 doses

12
doses
2
2 doses
doses
3 doses

Meningitis 1 dose

1
1 dose
dose

Genital immune, leukemia, lymphoma, generalized malignancy, CSF leaks, treat

with alkylating agents, antimetabolites, x-ray treatment, or dose,
long-term steroids
HAV hepatitis A; HBV hepatitis B; Flu influenza
All patients

Risk factor

240

Contraindicated

Page 240

HBV

1
mo

2
mo
HBV
Rota
DTaP
Hib
PCV
IPV
Rota
DTaP
Hib
PCV
IPV

4
mo

12
15
mo mo
HBV

18
mo

Rota
DTaP
DTaP
Hib Hib
PCV PCV
IPV
Flu (annual)
MMR
Varicella
HAV (2 doses)

6
mo

Hib

MMR
V
HAV series
MPSV4

PCV PPV

DTaP

1923 23
46
mo
yrs
yrs
HBV series

Range of
Recommended Ages

Catch-up

High-Risk Groups

9/12/08

HBV hepatitis B; Rota rotavirus; DTaP diphtheria, tetanus, pertussis; Hib Haemophilus influenza type
B; PCV pneumococcal conjugate vaccine; IPV inactivated poliovirus; Flu influenza; MMR measles,
mumps, rubella; HAV hepatitis A; MPSV4 meningococcal

HBV
Rota
DTaP
Hfllu
PCV
IPV
Flu
MMR
Varicella
HAV
MPSV4

Birth

Recommended 06 Yr
Immunization Schedule

FADavis_Chapter 081.qxd
4:35 PM

241

TOOLS

Page 241

FADavis_Chapter 081.qxd

9/12/08

4:35 PM

TOOLS
CDC Recommended 718 Yr
Immunization Schedule
710 yr

1112 yr

1314 yr 15 yr

DTaP

DTaP

HPV

HPV
(3 doses)

Meningococcal MPSV4

MCV4

1618 yr

DTaP
HPV series
MCV4
MCV4

Pneumococcal
Flu

PPV
Inflluenza (yearly)

HAV

HepA series

HBV

HepB series

IPV
MMR
Varicella
Range of
Recommended Ages

IPV series
MMR series
Varicella series
Catch-Up

High-Risk
Groups

HBV hepatitis B; DTaP diphtheria, tetanus, pertussis; PPV pneumococcal

polysaccharide vaccine; IPV inactivated poliovirus; Flu influenza; MCV4
meningococcal conjugated vaccine; MMR measles, mumps, rubella; HAV
hepatitis A; HBV hepatitis B

242

Page 242

FADavis_Chapter 081.qxd

9/12/08

4:35 PM

243
ECG Interpretation

QRS

P-R interval
Normal Rate 60100 bpm
0.04 sec
Normal P-R 0.120.20 sec
0.20 sec
Normal QRS 0.080.12 sec
P wave
atrial depolarization; QRS
ventricular
depolarization; T wave ventricular repolarization

Microbiology
Normal Flora
Skin
-Hemolytic streptococci
Coagulase-negative staphylococci
Bacillus species
Respiratory
-Hemolytic streptococci (not Enterococcus)
Nonhemolytic streptococci
Corynebacteria species
Neisseria species
Coagulase-negative staphylococci*
Haemophilus inflluenzae*
H. parainflluenzae*
(continued )

TOOLS

Page 243

FADavis_Chapter 081.qxd

9/12/08

4:35 PM

TOOLS
Microbiology (Continued )
Moraxella catarrhalis*
N. meningitidis*
Streptococcus pneumoniae*
Genitourinary Tract
-Hemolytic streptococci (not Enterococcus)
Nonhemolytic streptococci
Coagulase-negative staphylococci*
Corynebacteria species
Lactobacilli
*If not predominant in specimen

Patient List
Name

Location

244

Diagnosis/Notes

Page 244

FADavis_Chapter 081.qxd

9/12/08

4:35 PM

245
Test Results
Patient Name:
Test

Date/Time

Result

TOOLS

Page 245

FADavis_Chapter 081.qxd

9/12/08

4:35 PM

TOOLS
Notes

246

Page 246

FADavis_Index .qxd

9/12/08

4:35 PM

Page 247

247
Index
A
Abdomen, 30, 5960, 177185
Abscess, 3739, 167, 181
Acetaminophen toxicity,
193194
Acid/base disorders, 134135
Acute renal failure, 84
Amenorrhea, 8182
Anemia, 8587, 203205
Angina, 5
Angioedema, 140
Ankylosing spondylitis, 189
Anticoagulants, 145147
Antidiabetes medications, 148
Antineutrophil cytoplasmic
antibodies, 236
Antinuclear antibody test, 227
APGAR score, 115116
Appendicitis, 60, 183
Arterial line placement, 1416
Arthritis, 3538, 188189
Arthrocentesis, 3538
Ascites, 2830, 179, 185
Asthma, 140141
Azotemia, 83
B
Bilebinding resin, 154
Biophysical profile score,
116
Bone radiography, 187191
Brain, 4041, 4850
Brain natriuretic peptide, 211
Breast cancer, 1
BuddChiari syndrome, 183

C
Calcium correction, 133
Calcium studies, 236237
Cancer detection guidelines,
12
Cardiac arrhythmias, 2, 78
Cardiac markers, 210
Cardiovascular hemodynamics,
119121
Catecholaminesecreting
tumors, 219220
Catheters/catheterization, 15,
2022, 3235, 174
Central nervous system
assessment, 108110
Central venous lines, 1720, 174
Cerebellar disorders, 4142, 50
Cerebral spinal fluid analysis,
118, 194196
Cervical cancer, 12
Cervical spine imaging, 167170
Cervicitis, 162163
Charcots arthropathy, 188
Chest imaging, 170177
Childbirth, 6567, 158159
Chorionic gonadotropin, 235
Chronic obstructive pulmonary
disease, 141
Cirrhosis, 112, 182
Coagulation, 200202
Colitis, 178179, 184
Colon cancer, 1
Complement values and
disorders, 228
Cranial nerves, 4041

TOOLS

FADavis_Index .qxd

9/12/08

4:35 PM

Page 248

TOOLS
Creatinine clearance, 131
Cricothyroidotomy, 910
Crohns disease, 184
Cysts, 176177, 182

Frequently used number

template, 238

D
Deep vein thrombosis, 145147
Diabetes mellitus, 8890, 131,
147148
Diabetes insipidus, 198
Diagnostic peritoneal lavage,
3032
Diverticulitis/diverticulosis, 179,
184
E
Ear examination, 53
Electrocardiogram, 28, 243
Electrolyte values, 220221
Endometrial cancer, 2
Endotracheal intubation, 1113,
173
Energy calculations, 137
Epididymitis, 6162
Epilepsy, 159161
Extrapyramidal disorders, 4142
Eye examination and anatomy,
5152
F
Fatty liver, 182
Feeding tube placement, 2628,
174
Fetal presentations, 67
Fibric acid derivatives, 154
Fluid requirement calculations,
138139
Fontanelle closure, 68
Fractures, 165, 169, 190192

G
Gallbladder disease, 60, 183
Gastrointestinal bleeding, 91
Gastrointestinal equations,
129130
Genitourinary tract flora,
243244
Glasgow Coma Scale, 108
Glenohumeral joint instability,
74
Glucose tests, 215216
Gout, 188
H
Head computed tomography,
110, 165167
Headache, 109110, 151152
Hearing tests, 53
Heart disease, 28, 5456, 111,
143145, 149151, 173
Heart rate values, 2
Heart sounds, 5556
Heart valves, 5455, 122
Helicobacter pylori, 153
Hemangioma, 182
Hematology values, 123
Hematuria, 92
Hemochromatosis, 182
Hemophilia, 188
Hepatitis, 229232
Herpes simplex, 162
Homeostasis, 132134
Hydrocele, 62
Hypercalcemia, 93
Hyperkalemia, 9495
Hyperlipidemia, 153154

248

FADavis_Index .qxd

9/12/08

4:35 PM

Page 249

249
Hypernatremia, 96
Hyperprolactinemia, 80
Hypertension, 154, 156158, 182
Hypocalcemia, 97
Hypogonadism, 8083
Hypokalemia, 98
Hyponatremia, 99
Hypoprolactinemia, 80
Hypoxia, 100102

I
Immunization schedules,
239242
Infertility algorithm, 103
Inflammatory markers, 233235
Inotropes, 144145
Insulin, 147
Intestinal obstruction or
perforation, 157, 178
Intraaortic counterpulsation
devices, 174
Intussusception, 179, 184
Iron deficiency, 124, 204205
J
Joint fluid analysis, 3738
Jugular venous pressure
measurement, 5758
K
Ketoacidosis, 8890
Kidney stones, 184185
Knee examination, 7477
L
Labor, 65, 114, 158159
Lead testing, 193
Lipid values, 209210
Liver disease, 112113, 181183

Liver function tests, 212214

Lumbar puncture, 89
Lung cancer, 171
Lung volumes and values,
125129

M
Mechanical ventilation, 102,
104106
Mediastinal masses, 172
Mnires disease, 112
Migraine, 109110, 151152
Muscle/motor disorders, 4142
N
Nasogastric tube placement,
2628, 174
Necrotic bowel, 157
Nephrotoxic agents, 83
Neurodegenerative diseases,
167
Niacin, 153
O
Obstetrics, 6567, 69, 114115,
136, 185187
Optic nerve, 5152
Osteonecrosis and
osteoporosis, 189190
Ovarian failure, 80
Oxygen therapy indications, 142
P
Pancreatic tests, 216217
Pancreatitis, 113, 183
Paracentesis, 2830
Patient list template, 244
Pelvic inflammatory disease,
116117, 157

TOOLS

FADavis_Index .qxd

9/12/08

4:35 PM

Page 250

TOOLS
Pericardiocentesis, 1314
Pericarditis, 5
Peripheral nerve anatomy and
testing, 4346
Peritoneal fluid assays and
lavage, 3032
Peritonitis, 157, 185
Pheochromocytoma tests,
219220
Placenta disorders, 66
Platelet values and disorders,
208209
Pleural effusion and fluid
assays, 13, 22, 25, 173
Pneumonia, 142143, 173
Pneumoperitoneum, 179180,
185
Pneumothorax, 172
Portal venous hypertension,
182
Potassium correction, 133
Pregnancy, 115, 136, 147,
158159, 187
Premature atrial and ventricular
complexes, 7
Prinzmetals angina, 5
Prolactin values, 197
Prostate cancer, 2
Prostatespecific antigen, 219
Pulmonary tests, volumes, and
values, 125129

R
Ransons pancreatitis criteria,
113
Rectal cancer, 1
Red blood cell values and
disorders, 123, 205207
Referred pain sites, 47

Reflex innervation and testing,

4344
Reiters syndrome, 189
Renal azotemia, 83
Reproductive hormones,
196197, 223225
Respiratory tract flora, 243244

S
Sarcoid, 173
Scabies, 163
Scrotal disorders, 6162
Seizures, 158161
Sensory disorders, 41
Serumascitic albumin
gradient, 30
Sexually transmitted infections,
161163
Shock, 144145
Shoulder examination and disorders, 7074
Skin, 70, 243
Skull fractures, 165
Sodium correction, 132
Softtissue calcifications, 190
Spermatocele, 62
Stroke, 108, 166
Subdural hematoma, 166
Sweat chloride, 211
Syndrome of inappropriate
antidiuretic hormone, 198
Systemic lupus erythematosus,
163164
T
Tanner development stages,
6364
Test result template, 245
Testicular disorders, 6162

250

FADavis_Index .qxd

9/12/08

4:35 PM

Page 251

251
Testosterone values, 223225
Thalassemia minor, 124
Thoracentesis, 2225
Thoracoscopy tube placement,
174
Thyroid function tests, 199200
Thyroid nodule, 107
Tissue plasminogen activator,
108
Toxic megacolon, 179, 184
Toxicology testing, 118, 192194
Transvenous pacing devices,
174
Trauma, 110, 139, 165166, 183
Tumors, 167, 171172, 182,
217218

U
Urethritis, 162163
Uric acid values, 222

Urine tests, 226227

Urology equations, 136
Uterine disorders, 2, 80

V
Vaginitis/vaginosis, 6061, 117,
164
Varicocele, 62
Vasopressors, 145
Ventilation equations, 124
125
Vertigo, 53
Vestibular disorders, 41
Vitamin B12 deficiency, 203
Volvulus, 179
W
Weight calculations, 137
White blood cell values and
disorders, 207208

TOOLS