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J.A. Katzel, R. Vucescu, R. Garcia

Wards 101
pocket
Clinician’s Survival Guide

SPECIAL VALUE Gam

Now: BL

Op rick 3rd Edition

este
 Digitized by the Internet Archive
in 2023 with funding from
Kahle/Austin Foundation

https://archive.org/details/wards 101 pocketclo000katz

 Fluids, Electrolytes
Cardiology
Endocrinology
Gastroenterology
Geriatrics

pocket
Hematology
HIV
Infectious Diseases
Internal Medicine
Women’s Health
Nephrology
Neurology
Oncology = aS)
~

Pain Management
Pediatrics
Psychiatry
Pulmonary and Critical Care
Rheumatology 18.
Bie
Wards
101
Statistics

Guide
Survival
Clinician's
Appendix 20
Authors: Jed Abraham Katzel, M.D., Rosemary Garcia, M.D., Raluca Vucescu M.D.

Acknowledgements:
James Mazzara, M.D., Andrew Bohmart, M.D., Yolanda Brown, M.D., Abigail Chen, M.D.,
Ruchir Gupta, M.D., Saad Jazrawi, M.D., Linda Kirschenbaum, M.D., Ryan Knueppel, M.D.,
Stephen Kreiger, M.D., Reshma Mahtani, M.D., Jayson Mallie, M.D., Anatasios Manessis, M.D.,
Daniel Nichita, M.D., Salas Sabnis, M.D., Sonali Sethi, M.D., Margaret Smith, M.D.,
Ken Spaeth, M.D., Raghuraman Vidhun, M.D., Elizabeth Ward, M.D., Brian Wong, M.D.,
Fred Y. Wu, M.D., PhD.

Editors: Daniel Nichita, M.D., Rahul Ghugari, M.D.

Production: Alexander Storck
Publisher: Borm Bruckmeier Publishing, LLC, www.media4u.com
© 2012, by Borm Bruckmeier Publishing
1112 Eucalyptus Drive, El Segundo, CA 90245
www.media4u.com
Third Edition

All rights reserved. This publication 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 the prior written
permission of the publisher (Borm Bruckmeier Publishing, LLC, www.media4u.com), except
for brief quotations embodied in critical articles and reviews. For information write
Borm Bruckmeier Publishing, LLC, www.media4u.com.
IMPORTANT NOTICE - PLEASE READ!
This book is based on information from sources believed to be reliable, and every effort has
been made to make the book as complete and accurate as possible and to describe generally
accepted practices based on information available as of the printing date, but its accuracy
and completeness cannot be guaranteed. Despite the best efforts of authors, editors and
publisher, the book may contain errors, and the reader should use the book only as a general
guide and not as the ultimate source of information about the subject matter.
This book is not intended to reprint all of the information available to the author or
publisher on the subject, but rather to simplify, complement and supplement other available
sources. The reader is encouraged to read all available material and to consult the package
insert and other references to learn as much as possible about the subject.
This book is sold without warranties of any kind, expressed or implied, and the publisher and
authors disclaim any liability, loss or damage caused by the content of this book.
IF YOU DO NOT WISH TO BE BOUND BY THE FOREGOING CAUTIONS AND CONDITIONS ,
YOU MAY RETURN THIS BOOK TO THE PUBLISHER FOR A FULL REFUND.
Printed in China through Colorcraft Ltd., Hong Kong
ISBN 978-1-59103-266-3
Preface to the Third Edition

The demands exerted on all levels of medical practitioners from attendings, nurses, fellows,
residents, interns and students continue to increase, while the speed of care delivery and
medical progress reaches new heights. The challenge to provide excellent care is often at
odds with time and cost limitations. This 3rd edition is dedicated to those individuals who
take the extra time to sit at the bedside of their sickest patients and continue to recognize
that they are our-greatest responsibility and also our greatest teachers.

This edition would not be possible without the tremendous work of two chief residents from
Kaiser, Santa Clara - now practicing attendings, Rosemary Garcia and Raluca Vucescu.

Just as with the first two editions, this is not intended to be an all-inclusive text. To the
contrary, our intention is to include the minimum essential information that should be
addressed during rounds. In the past, physicians (like my father) would carry a "little black
book" in their pocket with clinical pearls. Even in this electronic information age, Wards
101 3rd edition is intended to be a modern version of that little black book.

| hope you and your patients benefit from this concise text.

Sincerely,

Jed A. Katzel
Coauthor preface and acknowledgments

Raluca Vucescu, M.D.

Internal Medicine Chief Resident 2010-2011 at Kaiser Santa Clara Hospital
Currently Internal Medicine Physician at Kaiser South San Francisco

As chief residents, the mindset is how can we teach our students and interns the relevant
information in a clear and simple way - and Wards 101 is part of such an endeavor. During
my chief resident year, | was very grateful for the opportunity to co-author the third edition
of Wards 101 and | greatly enjoyed researching the clinical guidelines and literature for the
latest updates.

We hope you will find this pocketbook helpful in every day learning, rounding and patient
care, and as a teaching tool.

Acknowledgements: Jed Katzel, MD, Rosemary Garcia, MD, Fred Y Wu, MD, PhD

Coauthor preface and acknowledgments

Rosemary Garcia, M.D.

Internal Medicine Chief Resident 2010-2011 at Kaiser Santa Clara Hospital
Internal Medicine Physician at Kaiser San Diego

| am very grateful for having had the opportunity to work on researching new Clinical
updates for the third edition of this book. The endeavor to help succinctly organize and
update this information was a great learning experience, and | hope the readers will
continue to benefit from this reference book.

| would like to acknowledge and thank Dr. Jed Katzel who created this book series and
extended the opportunity to co-author this book for this edition. | would also like to thank
Dr. Raluca Vucescu, my Internal Medicine Co-Chief Resident at the time, as we both worked
on suggestions for this edition.
 To Liz, Jim, Marilyn

"Though a little one, the master-word looms large in meaning. It is the open sesame to
every portal, the great equalizer in the world, the true philosopher's stone, which
_transmutes all the base metal of humanity into gold. The stupid man among you it will
make bright, the bright man brilliant, and the brilliant student steady. With the magic word
in your heart all things are possible, and without it all study is vanity and vexation. The
miracles of life are with it; the blind see by touch, the deaf hear with eyes, the dumb speak
with fingers...

. And the master word is Work, a little one, as | have said, but fraught with momentous
sequences if you can but write it on the tablets of your hearts, and bind it upon your
foreheads.” -- William Osler

Additional titles in this series:

Acupuncture pocket
Anatomy pocket
Differential Diagnosis pocket
Drug pocket
Drug pocket plus
Canadian Drug pocket
ECG pocket
ECG Cases pocket
EMS pocket
Homeopathy pocket
Medical Abbreviations pocket
Medical Classifications pocket
Medical Spanish Dictionary pocket
Medical Spanish pocket
Medical Spanish pocket plus
Medical Translator pocket
Normal Values pocket
Nursing Dictionary pocket
Respiratory pocket

Bérm Bruckmeier Publishing LLC on the Internet:

www.media4u.com
6 Ce 1.6.1 Acid-base abnormalities chart 57
5
“Fluids, Electrolytes, Acid- 1.6.2
1.6.3.
Acid-base disorders basics
Primary respiratory acidosis algorithm
58
60
Base 1.6.4 Primary respiratory alkalosis algorithm 61
1.1 General Concepts 29 1.6.5 Metabolic acidosis 62
1.1.1 Body water distribution 29 1.6.6 Renal tubular acidosis 63
1.1.2 Electrolyte distribution and function 29 1.6.7 Metabolic alkalosis 63
1.1.3. Osmolality vs osmolarity 30 1.6.8 Respiratory acidosis
1.2 Electrolyte Repletion 30 (hypoventilation) 64
1.3 Fluid Management Basics 32 1.6.9 Respiratory alkalosis 64
1.3.1 Assessing volume status 32 1.7 5 Board-Style Questions 66
1.3.2 Causes of edema formation 33
EL OLE oS ETE
1.3.3 Three types of volume loss 33
1.3.4 Systemic response to low effective 2 Cardiology
circulating volume 33 2.1 ECG Interpretation 67
1.4 Fluid Replacement 34 2.2 Important Differential Diagnoses 69
1.4.1 Fluid types 34 2.3 Ischemia Localization from ECG
1.4.2 Crystalloid solutions 34 Changes 71
1.4.3 Colloid solutions 35 Angina Classification 72
1.4.4 Distribution of IV fluids in body
Post-Angioplasty Care 72
compartments 35
Murmurs 72
1.4.5 Physiologic effects of various fluids 35
1.4.6 Summary of rules for choosing Valvular Disease 74
replacement fluids 36 Endocarditis 75
1.4.7. Required volume of replacement Duke criteria 75
fluids 36 Risk stratification 75
1.4.8 4-2-1 Rule for maintenance fluids 37 2.8.3 Prophylaxis 76
1.4.9 Fluid replacement in burn patients 37 Rheumatic Heart Disease 77
1.5 Electrolyte Abnormalities 40 2.10 Chest Pain 77
1.5.1 Hypernatremia 40 2.11 Cardiovascular Health 78
1.5.2 Hyponatremia 42 2.11.1 Blood pressure: JNC VII classification
1.5.3. Factors affecting ICF-ECF potassium for adults 78
shifts 44 PRAIA Cardiovascular risk factors 78
1.5.4 Hyperkalemia 44 211-3: HTN target organ damage 79
1.5.5 Hypokalemia 46 2.11.4 Cholesterol classification and
1.5.6 Hypercalcemia 48 guidelines 79
2.11.5 Metabolic syndrome 80
1.5.7 Hypocalcemia 50
2.12 Drugs Affecting Lipoprotein
1.5.8 Hypermagnesemia 52
Metabolism 81
1.5.9 Hypomagnesemia 53
2.13 Hypertensive Emergency 82
1.5.10 Hyperphosphatemia 54
2.13.1 Definitions of terms 82
1.5.11 Hypophosphatemia 56 2.13.2 Possible causes 82
1.6 Acid-Base Disorders 57 2.13.3 Pharmacologic treatment 83
2.14 Atrial Fibrillation (AF) 84 3.3 Diabetes 110
2.14.1 Classification 84 3.3.1 Diagnostic criteria 110
2.14.2 Evaluation and workup 84 3.3.2 Treatment goals 111
2.14.3 Pharmacological management 85 3.3.3. Classification of diabetes mellitus 112
2.14.4 Management of newly discovered AF 86 3.3.4 Insulin pharmacokinetics 113
2.14.5 Pharmacological heart rate control in AF 87 3.3.5 Oral antidiabetic drugs 113
2.14.6 Rate control vs rhythm control inAF 88 3.3.6 Contraindications to metformin use 117
2.14.7 Anticoagulation in nonvalvular AF 89 3.3.7. Metformin toxicity 117
2.14.8 Invasive therapies in AF 89 3.3.8 Treatment oftype 2 diabetes melitus 118
2.15 Heart Failure 90 3.3.9 Treatment of DKA and NKH* 120
2.15.1 NYHA heart failure classification 90 3.4 Adrenal Disorders 121
2.15.2 History and physical examination 91 3.4.1 Adrenal crisis 121
2.15.3 Heart failure workup 92 3.4.2 Adrenal incidentaloma 122
2.15.4 Heart failure treatment 93 3.4.3. Pheochromocytoma 122
2.15.5 Congestive heart failure (CHF) 3.4.4 MEN syndrome 123
overview 93 3.4.5 Systemic steroid equivalency table 123
2.16 Syncope 94 3.5 5 Board-Style Questions 125
21.7 Aortic Aneurysms 95 PE ART, set ers see hed
2.18 Perioperative Cardiovascular
Evaluation 96
4 Gastroenterology
2.18.1 Clinical predictors of increased 4.1 GI Bleeds 126
cardiovascular risk 96 4.1.1 Causes of GI bleeds 126
2.18.2 Assessing functional capacity 97 4.1.2 Steps to diagnosing suspected GI bleeds 127
2.18.3 Risk stratification for noncardiac 4.1.3. Approach to a patient with a Gl bleed 128
procedures 99 4.1.4 Variceal hemorrhage 129
2.18.4 Perioperative cardiac evaluation 4.2 Liver Dysfunction 130
algorithm 100 4.2.1 Approach to abnormal liver function
2.18.5 Exercise testing in patients with CAD 101 tests 130
2.18.6 Evidence-based guidelines for the 4.2.2. Common drug causes of abnormal liver
perioperative testing of surgical patients function tests 130
undergoing non-cardiac procedures 102 4.2.3 Discriminant function - steroid
5 Board-Style Questions 106 administration in alcoholic hepatitis 131
4.2.4 Modified MELD Score 131
4.3 Hepatitis 132
Endocrinology 4.3.1 Viral hepatitis serology 132
< Pituitary Disorders 107 4.3.2 Extrahepatic manifestations of
3.1.1 Ten causes for hyperprolactinemia 107 hepatitis 133
3.1.2 Treatment of prolactinoma 108 4.3.3 Treatment of hepatitis B and C 133
e174 Thyroid Disorders 108 4.4 Jaundice 134
3.2.1 Hyperthyroidism (elevated T3/T4) 109 4.4.1 Differential diagnoses of jaundice 134
3.2.2 Thyroid storm - emergency! 109 4.4.2 Congenital causes of jaundice 136
3.2.3. Hypothyroidism (low T3, 14) 109 4.4.3. Common and commonly confused
3.2.4 Myxedema coma 110 causes of jaundice 137
8
4.5 Ascites 138 6.2 Cytopenias 167
4.5.1 Paracentesis tubes 138 6.3 Cythemia 168
4.5.2 Analysis of ascites fluid 138 6.4 Leukemia 169
4.6 Pancreatitis 139 6.5 Anticoagulation and antithrombosis 171
4.6.1 Prognostic signs in pancreatitis - Ranson’s 6.5.1 Venous thromboembolism prophylaxis 171
criteria 139 6.5.2 Hypercoagulable states 172
4.6.2 Atlanta criteria for severe acute 6.5.3. Managing elevated INR 17Z
pancreatitis 140 6.5.4 Coagulation cascade and
4.6.3. CT scan classification 140 anticoagulants 174
4.6.4 Clinical presentation 141 6.5.5 Platelet activation and antiplatelet
4.6.5 Keys to therapy in pancreatitis 141 agents 175
4.7 Biliary Dysfunction 142 6.6 Heparin-Induced Thrombocytopenia
4.8 Inflammatory Bowel Disease 143 (HIT) 176
4.9 Celiac Disease (Gluten-Sensitive 6.7 Transfusion Basics 177
Enteropathy) 144 6.8 4 Board-Style Questions 179
4.10 Upper GI dysfunction 145
4.10.1 Peptic ulcer disease (PUD) 145
4.10.2 Barrett's esophagus 146 7 HIV
4.11 5 Board-Style Questions 147 7.1 General Information 180
72 HIV Testing (HIV-1) 182
5 Geriatrics 7.3 Initiating Antiretroviral Therapy (ART) in
Treatment-Naive Patients 183
5.1 Dementia in the Elderly 148 7.4 Sites of Action of Anti-Retroviral
5.2 Urinary Incontinence 152 Drugs 184
5.3 Falls in the Elderly 153 7.5 HIV Drugs 184
5.4 Falls - Risk Factors and Prevention 154 7.6 Initial HAART Regimen Approaches* 186
5.5 Insomnia in the Elderly 155 7.7 HAART Drug-Drug Interactions 186
5.6 Visual Impairment 156 7.8 Common CD4 Count-Related
5.7. Auditory Impairment 157 Disease 187
5.8 Pressure Ulcers 158 79 HIV Prophylaxis 187
5.9 5 Board-Style Questions 159 7.10 SOpportunistic Infection Treatments 188
7.11 Virologic Failure 191
6 Hematology 7.12 Diarrhea in AIDS patients 192
7.13 Needle-Stick Post-Exposure
6.1 Anemia 160
Prophylaxis 193
6.1.1 Microcytic anemia 161
7.14 5 Board-Style Questions 194
6.1.2 Thalassemia 162
6.1.3. Other microcytic anemias 164
6.1.4 Megaloblastic anemia - categories 164 8 Infectio
6.1.5 Megaloblastic anemia - causes 165 8.1 Bone 195
6.1.6 Sickle cell anemia 166 8.2 Breast 195
 5
8.3 CNS 196 9.4 Diet and Nutrition Health Effects 232
8.4 Ear 198 9.4.1 Preventive care screening in healthy adults
8.5 Eye 198 (adapted from the U.S. Preventive Services
8.6 Foot 199 Task Force) 232
8.7. Gastrointestinal 200 9.4.2 Dietary recommendations 232
8.8 Genital Tract 203 een Obesity 233
8.9 Heart 206 9.5.1 BMI scale 233
9.5.2 Health risk associated with obesity 234
8.10 Joints 210
9.5.3 Approach to treating obesity 235
8.11 Lung 211 9.5.4 Drug therapy for treating obesity 235
8.12 Pancreas 212 9.6 Osteoporosis 236
8.13 Peritoneum 212 9.6.1 Causes of osteoporosis 236
8.14 Pharynx 212 9.6.2 Secondary causes of osteoporosis 236
8.15 Sinuses 213 9.6.3 Bone density definitions (measured by
8.16 Skin 213 DEXA scan) 237
8.17 Urinary Tract 214 9.6.4 Management of osteoporosis 237
8.18 Special Situations 216 = 4 Board-Style Questions 238
8.19 Sepsis of Unknown Origin 216
8.20 Pneumonia Severity Index - 10 Women's Health and
Risk Stratification 218
Pregnancy
8.21 Surgical Intervention for Infectious
Endocarditis 220 10.1. Pregnancy 239
10.1.1 Pregnancy definitions 239
8.22 Bibliography 221
10.1.2 Obstetric notation 239
8.23 5 Board-Style Questions 222
10.1.3 Gestational milestones 239
Sf rtetoe To haal
10.1.4 Prenatal care 240
Internal Medicine 10.1.5 Gestational diabetes 242
9.1 Preventive Medicine 223 10.1.6 HELLP syndrome criteria 242
9.1.1 US mortality (2009) vs worldwide 10.1.7 Preeclampsia and eclampsia 243
mortality (2004) in all ages 223 10.1.8 Maternal serum markers in fetal
9.1.2 Levels of prevention 223 syndromes 244
9.1.3 Screening tests 224 10.1.9 Drug use in pregnancy 245
9.1.4 Exercise 224 10.2 Algorithms 247
9.1.5 Who needs a stress test before 10.2.1 Abnormal vaginal bleeding 247
beginning an exercise program 225 10.2.2 Vaginal discharge 248
9.2 Adult Vaccinations 226 10.2.3 Breast mass 249
9.2.1 Recommended annual vaccinations
10.2.4 Hirsutism 250
2012 226
9.2.2 Contraindications to vaccines 230
9.2.3. Influenza treatment and prophylaxis 230 11 Nephrology
9.3 Smoking 231
11.1 Acute Renal Failure 252
9.3.1 Smoking cessation recommendations 231 11.1.1 Step 1: Initial tests 253
0 Se
11.1.2 Step 2: Distinguish prerenal, intrinsic,
and postrenal azotemia 253 13 Oncology
11.1.3 Step 3: Identify tubular causes of ARF 254
11.1.4 Step 4: Distinguish the glomerular 13.1 Cancer Screening — 281
diseases 255 ae, ee Rone screening be
F Cast Analysis. 13.1.2 Cervical cancer screening

13.2 Ronal Ulrasound Interpretation 250 a nag 3

11.2 Urinary 256

hla dl ed
Soe BU 13.1.5 Prostate cancer screening 282

retae ds dag 122. Key Oncoogie Definitions 289

tides Hemarutta 258 13.2 ECOG Performance Status Scale 282

ee ee ‘ 13.4 Classifications 284

11.5.3 Clinical evaluation 260 TAP VES wena ay
11.6 Classification of Chronic Renal AeA CATO
reCrAll cancer 78

nde , Aon 13.4.3 Non-small cell lung cancer 289

11.7. Specific Treatments in CRI and 13.4.4 Small cell lung cancer 292
ESRD 262 13.4.5 Ovarian cancer 293
11.8 Six Indications for Acute Dialysis 263 43.6 Cancer of Occult Primary Origin 294
11.9 Renal Tubular Acidosis (RTA) 263) 13.5.1 Workup for cancer of occult primary 295
11.10 Glomerular Arteriole Drug Action 263 43.6 Eight Oncologic Emergencies 296
11.11 Antihypertensive Drug Action Sitesin 13.7 Paraneoplastic Syndromes 297
the Nephron ; 264 13.8 Basic Concepts of Chemotherapy 299
11.12 Three Common Causes of Dilute 13.9 Chemotherapeutic Agents 300
Urine 264 13.9.1 Action of common chemotherapeutic
11.13 5 Board-Style Questions 265 agents 300
13.9.2 Common chemotherapy medications 301
12 Neurology 13.9.3 10 Key chemotherapeutic toxicities
you
should know! 304
12.1. CNS Neuroanatomy 266 13.9.4 Commonly used therapeutic monoclonal
12.2 Four-Minute Neurologic Exam 269 antibodies in oncology 305
12.3 Motor System Evaluation 270 13.9.5 A few common regimens 305
12.4 Mini Mental State Test 271 13.10 Pailiative Care 306
12.5 Glasgow Coma Scale 272 + +°13.11 5 Board-Style Questions 307
12.6 NIH stroke scale (NIHSS) 273) gees : ee oral
West) _Ehiethi Weenie 275 14 Pain Management
12.8 Apnea Testing 276 3 aoe ;
12.9 Cerebrospinal Fluid (CSF) a7 4 Basic Principles of Pain
12.10 Lumbar Puncture 277 ate alc! , hue
{2:11aDerimatomes 278 14.2 Management of Breakthrough Pain 309

12.12 5 Board-Style Questions 260 14.3 Novopiold Analgesics 219

14.4 Opiod Equianalgesic Chart 311
14.5 Converting Doses in Opioid Switches 312
 11
14.6 Fentanyl Transdermal System - 15.15.4 Management of status asthmaticus 335
Duragesic Patch 312 15.16 Pediatric Anemia 336
14.7. Management of Opioid Adverse 15.16.1 Classification of pediatric anemia 336
Effects 313 15.16.2 Common causes of microcytic anemia
14.8 Adjuvant Antidepressants 314 in children 337
15.16.3 Age-specific MCV 337
MESES 15.16.4 Iron deficiency anemia treatment 338
15 Pediatrics 15.17 Growth Charts 339
15.1. Vitals Signs by Age 316 15.17.1 Boys: WHO height- and weight-for-
15.2 Apgar Score 316 age, 0 to 24 Mo 339
15.3 Primitive Reflexes 317 15.17.2 Boys: WHO weight-for-length and
head circ., 0-24 Mo 340
15.4 Recommended 3-Year Well Child
15.17.3Boys: CDC stature- and weight-for-age,
Visit Schedule 317
2-20 Yr 341
15.5 Developmental Milestones 318
15.17.4Boys: CDC BMI-for-age, 2-20 Yr 342
15.6 Tanner Stages of Pubertal Changes 320 15.17.5Girls: WHO height- and weight-for-
15.7. Failure to Thrive - Differential age, 0 to 24 Mo 343
Diagnoses 321 15.17.6Girls: WHO weight-for-length and head
15.8 Recommended Childhood cire., 0-24 Mo 344
Immunization Schedule 2012 322 15.17.7Girls: CDC stature- and weight-for-age,
15.9 Childhood Rash Differentials 323 2-20 Yr 345
15.10 Neonatal Hyperbilirubinemia 324 15.17.8Girls: CDC BMI-for age, 2-20 Yr 346
15.10.1 Hyperbilirubinemia differentials 324
15.10.2Guidelines for phototherapy 324
15.10.3 Bhutani nomogram 325
16 Psychiatry
15.11 Pediatric Neurology 325 16.1 Psychiatric Assessment (Mod. per
15.11.1 Febrile seizures 325 AMODP) 347
15.11.2 Pediatric epilepsy therapy 326 16.2 Affective Symptoms -
15.11.3 Seizure management 326 Differential 349
15.12 Pediatric Infectious Diseases 327 16.3. Mood Disorders 349
15.12.1 Pneumonia 327 16.4 Psychotic Disorders 351
15.12.2 Meningitis 328 16.4.1 Psychotic symptoms 351
15.12.3 Urinary tract infections 329 16.4.2 Psychotic disorders 352
15.12.4 Management of fever of unknown 16.5 Anxiety Disorders 353
origin (FUO) 330 16.6 Somatoform Disorders 356
15.13 Emergency Drugs in Pediatrics 332 16.7 Factitious Disorders 359
15.14 Pediatric Intubation and 16.8 Dissociative Disorders 360
Defibrillation Values 333 16.9 Eating Disorders 361
15.15 Asthma Management 333 16.10 Substance Abuse and Dependence 362
15.15.1 Stepwise approach to managing 16.10.1 Alcohol screening test (CAGE) 362
asthma (patients >5 years) 333 16.10.2 Substance abuse vs. dependence 362
15.15.2 Asthma treatment ladder 334 16.10.3 Drug intoxication and withdrawal 363
15.15.3 Asthma action plan 335
>. (eae
16.11 Personality Disorders 366 17.8.2 Asthma treatment steps 393
16.12 DSM-IV Multiaxial Diagnosis 371 17.8.3. Management of status asthmaticus 394
16.13 Psychotropic Medications 373 17.9 COPD 394
16.13.1 Antipsychotics-typical/econventional 373 17.9.1 Admission criteria for COPD 394
16.13.2 Side effects of typical antipsychotics 373 17.9.2 COPD exacerbation therapy 395
16.13.3 Antipsychotics - atypicals 374 17.9.3 Indications for O therapy 395
16.13.4 Atypical antipsychotic side effects 375 17.10 Pulmonary Embolus (PE) 396
16,13.5 Antidepressants - serotonin-specific 17.10.1 Algorithm for assessing probability of
reuptake inhibitors (SSRIs) 376 PE - 3 steps 396
16.13.6 Tricyclic antidepressants (TCAs) 377 17.10,2Treatment of PE 397
16.13.7 Antidepressants - monoamine oxidase 17.10.3 Heparin dosing 398
inhibitors (MAOIs) (non-selective) 378 17.11 Obstructive Sleep Apnea 398
16,13.8 Antidepressants - heterocyclics 379 17.12 Management of Spontaneous
16.14 Key Points 379 Pneumothorax 399
16.15 5 Board-Style Questions 380 17.13 ARDS 400
17.13.1 Definition 400
17.13.2 Ventilator settings in ARDS 400
17 Pulmonary and Critical 17.14 Critical Care 401
Care 17.14.1 Shock 401
17.1 Physical Exam Findings 382 17.14.2 Swan-Ganz catherization pressures 402
17.2 Chest X-Ray Interpretation 382 17.14.3 Common modes of mechanical
17.3. Exposure-Related Lung Findings 383 ventilation 403
17.4 Key Differentials 383 17.14.4 Sepsis 404
17.14.5 Hypoxia 407
17.5 Management of Hypoxemia 384
17.14.6 Hypercapnia in the ICU 408
17.6 Pleural Effusions 384
17.14.7 Intubation techniques 409
17.6.1 Thoracentesis tubes 384
17.15 5 Board-Style Questions 410
17.6.2 Pleural effusion visual inspection 385
17.6.3 Pleural fluid analysis 385
17.6.4 Specific pleural fluid findings 386 18 Rheumatology
17.7 Spirometry 386
18.1 Approach to Arthralgia 411
17.7.1 Lung volumes and capacities 386
17.7.2. Normal flow volume curve 387 18.2 Approach to Arthralgia in Multiple
17.7.3 Flow volume loop examples 388 Joints 412
17.7.4. Diagnosis on pulmonary function testing 389 18.3 Synovial Fluid Analysis 413
17.7.5 PFT interpretation 389 18.4 Common Crystal Diseases 414
17.7.6 Criteria for staging COPD 390 18.5 Gouty Arthritis Management 414
17.7.7 Criteria for assessing restrictive 18.6 Fibromyalgia 415
disease 390 18.7. Rheumatoid Arthritis 416
17.7.8 Predicted peak flows 390 18.7.1 Classification criteria for RA 416
17.8 Asthma 392 18.7.2 Management of rheumatoid arthritis 417
17.8.1 Stepwise approach to managing 18.8 DMARD (Disease-Modifying
asthma in patients > 5 years 392 Antirheumatic Drugs) 418
 13
18.9 Osteoarthritis 418
18.9.1 Clinical findings in osteoarthritis 418
18.9.2 Management of osteoarthritis 419
18.10 Back Pain 420
18.11 Autoantibodies in Connective Tissue
Diseases 421
18.12 Lupus 421
18.12.1 Management of lupus 422
18.12.2 Agents used in lupus nephrits 423
18.13 Seronegative Spondyloarthropathies 424
18.14 Vasculitis 425
18.15 5 Board-Style Questions 427

19 Statistics
19.1. The 2x2 Bayesian Table 428
19.2 Sensitivity and Specificity 428
19.3 Positive and Negative Predictive
Values 429
19.4 Likelihood Ratios 429
19.5 The Gold Standard 430
19.6 Examples 430
19.6.1 Example 1 430
19.6.2 Example 2 431
19.7. Screening Biases 432
19.7.1 Selection bias 432
19.7.2 Lead time bias 433
19.7.3. Length bias 433
19.7.4 Overdiagnosis 433

20 Appendix
ee
Algorithms
ACLS —- Adult Cardiac Arrest

Start CPR (30:2)

Administer Oxygen
Attach defibrillator/monitor
4
Identify Rhythm and Decide:
eA Shockable? ke
Ventricular Fibrillation Pulseless Electrical Activity
(coarse, fine) (PEA)
Ventricular Tachycardia Asystole
|

Drug Therapy (see Details on following page)

Important considerations:
- Ensure early IV access
- Minimize CPR interruptions
- Consider advanced airway (ET tube or supraglottic airway)
- Treat reversible causes
Adapted from the 2011 AHA/ESC Pocket Guidelines.
 15
ACLS ~ Adult Cardiac Arrest: Doses and Details

* Push hard (2 2 inches [5 cm)) and fast (2 100/min) and allow complete chest recoil
# Minimize interruptions in compressions
© Avoid excessive ventilation
© Rotate compressor every 2 min
© If no advanced airway, 30:2 compression-ventilation ratio
* Quantitative waveform capnography
- If PETCO, <10 mm Hg, attempt to improve CPR quality
© Intra-arterial pressure
~ If relaxation phase (diastolic) pressure <20 mm Hg, attempt to improve CPR quality

© Hypovolemia © Tension pneumothorax

* Hypoxia © Tamponade, cardiac
# Hydrogen ion (acidosis) © Toxins
4Hypoglycemia * Thrombosis, pulmonary
Hypo-/Hyperkalemia * Thrombosis, coronary
* Hypothermia
ES =
i energy for ¢ Biphasic: Manufacturer recommendation (eg, initial dose of
defebrillation 120-200 J); if unknown, use maximum available. Second and
subsequent doses should be equivalent, and higher doses may be
considered
: e Monophasic: 360 J
Drug therapy —-Epinephrine IV/IO dose:
? © 1 mg every 3-5 min.
- Vasopressin IV/IO dose:
* 40 units can replace first or second dose of epinephrine
Amiodarone IV/lO dose:
* First dose: 300 mg bolus
* Second dose: 150 mg
Advanced airway * Endotracheal intubation or supraglottic advanced airway
* Waveform capnography to confirm and monitor ET tube placernent
* 8-10 breaths per minute with continuous chest compressions
Return of * Pulse and blood pressure
* Abrupt sustained increase in PETCO, (typically 240 mm Hg )
* ep * Spontaneous arterial pressure waves with intra-arterial
(ROSC) monitoring

wornETEcom
é

6 2
ACLS - Adult Tachycardia

e Use ABCDE approach

Oxygen (if hypoxemic) and IV access
¢ Cardiac and BP monitoring, oximetry
¢ 12-Lead ECG
e Address identifiable underlying causes

Synchronized cardioversion _
Consider adenosine if ORS is
regular and narrow

¢ Adenosine only if mono-

morphic, regular ORS
¢ Consider antiarrhythmics
¢ Consider cardiology consult
¢ Vegal maneuvers
¢ Adenosine if regular ORS
¢ B-Blocker or CCB
¢ Consider cardiology consult

Adapted from the 2011 AHA/ESC Pocket Guidelines.

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