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Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf | |
Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf | |
Lange Instant Access: Hospital Admissions Essential Evidence-Based Orders for Common Clinical Conditions Anil Patel, MD Family Medicine, Class of 2006 University of Pittsburgh Medical Center (UPMC)Pittsburgh, Pennsylvania New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Si... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
Lange Instant Access: Hospital Admissions: Essential Evidence-Based Orders for Common Clinical Conditions Copyright © 2007 by The Mc Graw-Hill Companies, Inc. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
iii Contents Contributing Editors v Preface vii Acknowledgments ix GUIDE TABLES 1 1. CARDIOLOGY 21 2. ENDOCRINOLOGY 69 3. GASTROENTEROLOGY 89 4. HEMATOLOGY/ONCOLOGY 121 5. INFECTIOUS DISEASE 129 6. ELECTROLYTE DISTURBANCE AND NEPHROLOGY 183 7. NEUROLOGY 225 8. PULMONOLOGY 255 9. RHEUMATOLOGY 273 10. TOXICOLOGY 283 11.... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf | |
v Contributing Editors Sheila Alas, MD Chief Resident, Family Medicine UPMC, Pittsburgh, Pennsylvania Robert Barnabei, MD Inpatient Director & Clinical Instructor, Family Medicine UPMC, Pittsburgh, Pennsylvania David Garzarelli, MD Associate Program Director & Clinical Assistant Professor Family Medicine UPMC, Pittsbu... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
vi CONTRIBUTING EDITORS Joseph Secosky, MD Clinical Instructor, Cardiology UPMC, Pittsburgh, Pennsylvania Shripal Shrishrimal, MD Critical Care Fellow UPMC, Pittsburgh, Pennsylvania Phoebe Tobiano, MD Family Medicine, Class of 2006 UPMC, Pittsburgh, Pennsylvania Walton C. Toy, MD Rheumatology Fellow University of Arka... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
vii Preface Writing hospital admissions orders is an important and fundamental responsibility of the hospital-based physician. Surprisingly, there arefew resources available to help interns and residents write the mostfocused and medically necessary admitting orders possible. Lange Instant Access: Hospital Admissions:... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf | |
ix Acknowledgments I would like to dedicate Lange Instant Access: Hospital Admissions to my grandmother who had a lot of influence in my becoming aphysician. I would like to thank all the editors and contributors for their time and hard work devoted to this book. Without their efforts, this manualwould not be possible... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf | |
1 Guide Tables OUTLINE GT-1. Abbreviations 2 GT-2. MIVF 3GT-3. DVT Prophylaxis 4GT-4. GI Stress Ulcer Prophylaxis 6GT-5. Bilevel Positive Airway Pressure (BIPAP) Settings 6GT-6. Initial Ventilator Settings 7GT-7. Antibiotic Spectrum 9Figure GT-1. Dermatomal Map 19Figure GT-2. Vision Testing 20 | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
2 GUIDE TABLES TABLE GT-1: Abbreviations ? Clinical correlation required AAA Abdominal aortic aneurysm ABCs Airway, breathing, circulation ABG Arterial blood gasesac Before meals ACE Angiotensin-converting enzyme ACV Assist-control ventilation ADH Antidiuretic hormone AFB Acid-fast bacilli AIN Acute interstitial nephr... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
GUIDE TABLES 3 CHF Congestive heart failure CI Cardiac index CMP Complete metabolic profile (BMP + LFT)CMV Cytomegalovirus CNS Central nervous system CO Cardiac output COPD Chronic obstructive pulmonary disease CPK Creatine phosphokinase CRP C-reactive protein C&S Culture and sensitivity CT Computed tomography CVA Cer... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
4 GUIDE TABLES FFP Fresh frozen plasma FHx Family history GBM Glomerular basement membrane GC Gonorrhea GERD Gastroesophageal reflux disease GFR Glomerular filtration rate GI Gastrointestinal GU Genitourinary H&H Hemoglobin and hematocrit HIDA Hepatobiliary iminodiacetic acid HIV Human immunodeficiency virus HSV Herpe... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
GUIDE TABLES 5 MAT Multifocal atrial tachycardia MDI Metered-dose inhaler MI Myocardial infarction MIVF Maintenance IV fluid MRI Magnetic resonance imaging NC Nasal cannula NCV Nerve conduction velocity NPO Nothing by mouth NR No response NS Normal saline N/V Nausea/vomiting OOB Out of bedp-ANCA Perinuclear antineutro... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
6 GUIDE TABLES PTT Partial thromboplastin time PUD Pelvic ulcer disease RBC Red blood cellr/o Rule out RUQ Right upper quadrant SBP Systolic blood pressure SCD Sequential compression device SIMV Synchronized intermittent mandatory ventilation SLE Systemic lupus erythematosus SOB Shortness of breath SPEP Serum protein ... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
GUIDE TABLES 7 TVP Transvenous pacing UA Urine analysis UC Ulcerative colitis Unit CCU/ICU/SICU/MICU/neuro-ICUUp ad lib As tolerated Urine R&M Urine random microscopy URI Upper respiratory infection US Ultrasound VDRL Venereal Disease Research Library VMA Vanillylmandelic acid V/Q scan Ventilation-perfusion scan WBC W... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
8 GUIDE TABLES TABLE GT-3: DVT Prophylaxis Mechanical Intermittent pneumatic compression or SCD Graduated elastic anti-embolism stockings Chemical Medical conditions Heparin: 5,000 unit SQ q12h Enoxaparin (Lovenox): 40 mg SQ once daily; if Cr Cl <30 m L/ min 30 mg SQ daily Dalteparin (Fragmin): 2,500 units SQ once dai... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
GUIDE TABLES 9 Enoxaparin: 30 mg SQ q12h starting 12-24 hrs after surgery or 40 mg SQ daily starting 10-12 hrs postsurgery Dalteparin: 5,000 units SQ 8-12 hrs before surgery, then daily starting 12-24 hrs after surgery or 2,500 units SQ 6-8 hrs after surgery, then 5,000 units SQ daily Nadroparin:* 38 units per kg SQ 1... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
10 GUIDE TABLES TABLE GT-4: GI Stress Ulcer Prophylaxis H 2 blockers or PPI for following conditions Mechanical ventilation >48 hrs >30% burn Coagulopathy Head trauma Shock Quadriplegia Severe sepsis Multiple organ failure American College of Gastroenterology guidelines for prevention of NSAID-induced ulcer for high-r... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
11 TABLE GT-6: Initial Ventilator Settings Settings Normal Hypoxic Obstruction condition Restrictive lung condition Fi O 2 21-100% 100% 40-50% 40-50% Tidal volume 5-15 L/kg 6 m L/kg 5-7 m L/kg 5-7 m L/kg RR 12-16 mins 16-24 mins <24 mins 16-24 mins Mode ACV/SIMV ACV/SIMV ACV ACV/SIMVPositive end-expiratory pressure (P... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
12 Note Check CXR after placing patient on ventilator. Check ABG in 30 mins to 1 hr after any change in any parameters. Hypotension treat with IVF Give DVT and GI prophylaxis to all patients on a ventilator. DVT prophylaxis: heparin, 5,000 units SQ bid, or Lovenox, 40 mg SQ daily. GI prophylaxis: pantoprazole (Protoni... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
13 TABLE GT-7: Antibiotic Spectrum Gram-positive Gram-negative Atypical Anaerobe Pseudo-monas Methicillin-resistant Staphylo-coccus aureus (MSSA)Methicillin-susceptible S. aureus (MRSA) First-generation PCN +------Second-generation anti-staphylococcus PCN+-----+ Third-generation amino-PCN+±-±--± Fourth-generation anti... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
14 Third-generation cephalosporin±+-± ±-± Fourth-generation cephalosporin+±-± +-± First-generation quinolones-+-----Second-generation quinolones-+±-±--Third-generation quinolones+++-+-+ Fourth-generation quinolones+++-±-+ Aminoglycoside-±----+ Macrolide + ± + ±--+Tetracycline ± ± + +-± ±Glycopeptide +--±-+ + (continue... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
15 Carbapenems + +-+ ±-+ Ketolide +--±--+Miscellaneous Aztreonam-+--+--Daptomycin +----+ +Linezolid + ± ± ±-+ +Metronidazole---+---Antibiotic classifications PCNs First-generation Second-generation Third-generation Fourth-generation Benzathine PCN Dicloxacillin Amoxicillin Piperacillin PCN G benzathine and PCN G proca... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
16 PCN V Pivampicillin Procaine PCN Cephalosporins First-generation Second-generation Third-generation Fourth-generation Cefadroxil (Duricef) Cefaclor (Ceclor) Cefdinir (Omnicef) Cefepime (Maxipime)Cefazolin (Ancef) Cefotetan Cefditoren Cephalexin (Keflex) Cefoxitin Cefixime (Suprax) Cefprozil Cefoperazone Cefuroxime ... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
17 Quinolones First-generation Second-generation Third-generation Fourth-generation Nalidixic acid (Neg Gram) Ciprofloxacin Levofloxacin (Levaquin) Gemifloxacin Enoxacin Moxifloxacin (Avelox) Lomefloxacin Norfloxacin Ofloxacin Aminoglycosides Macrolides Amikacin Azithromycin (Zithromax) Gentamicin Clarithromycin (Biax... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
18 Meropenem (Merrem) Tetracycline Glycopeptide Ketolide Vancomycin Telithromycin (Ketek) Medication peak and trough levels Medication Peak Trough Amikacin* 20-30 mcg/m L <10 mcg/m LGentamicin (Garamycin) 6-8 mcg/m L <2 mcg/m LStreptomycin 15-40 mcg/m L <5 mcg/m LVancomycin (Vancocin) 20-40 mcg/m L (usually not perform... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
GUIDE TABLES 19 FIGURE GT-1: Dermatomal map. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
20 GUIDE TABLES FIGURE GT-2: Near vision testing. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
21 1 Cardiology* *See Chapter 5 (Table 5-4) for discussion of endocarditis. OUTLINE 1-1. Chest Pain r/o Acute Coronary Syndrome (ACS)/MI 22 1-2. Acute Coronary Syndrome (ACS) 271-3. Acute MI (ST Elevation MI) 301-4. CHF 351-5. Hypertensive Emergency 391-6. Hypotension 441-7. Asystole 461-8. Bradycardia 481-9. Tachyarr... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
22 CARDIOLOGY TABLE 1-1: Diagnosis: Chest Pain r/o Acute Coronary Syndrome (ACS)/MI Disposition Unit/cardiac monitored bed Monitor Vitals Cardiac monitoring Diet NPO if procedure planned same day and after midnight if planned next day, ?1-to 2-g sodium diet Fluid Heplock (flush every shift) O 2 ≥ 2 L O 2 via NC; keep ... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 23 Nursing Call physician if patient reports of chest pain, stool guaiac Avoid Nitroglycerin (NTG) in patient using sildenafil (Viagra) Caffeine-containing products Pregnancy state: avoid ASA and ACERenal insufficiency or pregnancy: avoid spiral CT Management 1. NTG: 0. 4 mg SL × 3 q5min [check BP before gi... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
24 CARDIOLOGY Common etiologies of chest pain Emergent Nonemergent MI GERD PE Esophageal spasm CHF Peptic ulcer disease Aortic aneurysm Hiatal hernia Myocarditis/pericarditis Herpes zoster Tachyarrhythmia Mitral valve prolapse Pneumonia Costochondritis Pneumothorax Mastitis COPD exacerbation Thymoma Asthma exacerbatio... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 25 Thrombolysis in MI (TIMI) score for UA and non-ST-elevation MI and risk of cardiac events Criteria Score Risk of cardiac events in 14 days (TIMI 11B*) Age >65 1 Risk score Death/MI Death, MI, or urgent revascularization More than 3 coronary artery disease (CAD) risk factors (HTN, DM, smoker, ↑ cholestero... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
26 CARDIOLOGY Stress test Exercise stress tests Imaging study dyes 1. Treadmill exercise stress test1. Cardiolite (technetium Tc-99m) 2. Adenosine Imaging should be performed approximately 1 hr after injecting the dye Contraindicated in patient with bronchospasm Long half-life 3. Dobutamine 2. Thallium Useful in patie... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 27 TABLE 1-2: Diagnosis: Acute Coronary Syndrome (ACS) Disposition Unit Monitor Vitals Cardiac monitoring Diet NPO if procedure planned same day and after midnight if planned next day, ?1-to 2-g sodium diet Fluid Heplock (flush every shift) O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% Activity Strict bedr... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
28 CARDIOLOGY Management: ACS (non-ST-elevation MI, unstable angina) 1. NTG, 0. 4 mg SL × 3 q5min (check BP before giving NTG) if pain not responding to NTG and patient is in severe pain consider morphine, 2 mg IV q5min. Note: Hold NTG if SBP <90 or pulse <60 2. Nitropaste, 1 inch q8h, or NTG patch, 0. 2 mg/hr q12h (o... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 29 11. Docusate sodium (Colace): 100 mg PO bid for constipation 12. Dimenhydrinate, 25-50 mg IV over 2-5 mins q4-6h or 50 mg PO q4-5h for nausea, or ondansetron (Zofran), 2-4 mg IV q4h for N/V 13. Consider statin: atorvastatin, 10 mg PO qhs, or simvastatin, 40 mg PO qhs, or pravastatin, 40 mg PO qhs IIb/IIIa... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
30 CARDIOLOGY TABLE 1-3: Diagnosis: Acute MI (ST elevation MI) Disposition Unit Monitor Vitals Cardiac monitoring Diet NPO except medication (if possible cardiac catheterization) Cardiac diet (low sodium and low fat/low cholesterol) Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity S... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 31 FIGURE 1-1: ST elevation MI. TABLE 1-3: Diagnosis: Acute MI (ST elevation MI) (Continued) ECG Leads and Arterial Supply Associations ECG leads Blood vessel Area supplied V1-V4 LAD coronary artery Anterior V5-V6 Left circumflex Lateral I, a VL, V4-V6 Left circumflex Lateral II, III, and a VF RCA Inferior R... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
32 CARDIOLOGY TABLE 1-3: Diagnosis: Acute MI (ST elevation MI) (Continued) Give 15-mcg bolus followed by 6 mcg/min (2 m L/hr) ↑ by 6 mcg/min q5min until patient is chest pain-free, SBP <100 (max: 200 mcg/min) 3. ASA, 325 mg crushed, then 162 mg EC PO daily ± Plavix, 75 mg or 300 mg × 1 dose, then 75 mg PO daily 4. Cons... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 33 TABLE 1-3: Diagnosis: Acute MI (ST elevation MI) (Continued) 13. Colace, 100 mg PO bid for constipation 14. Dimenhydrinate, 25-50 mg IV over 2-5 mins q4-6h or 50 mg PO q4-5h for N/V, or Zofran, 2-4 mg IV q4h for N/V Note If heparin-induced thrombocytopenia present, consider argatroban, 2 mcg/kg/min IV con... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
34 CARDIOLOGY TABLE 1-3: Diagnosis: Acute MI (ST elevation MI) (Continued) Active bleeding or bleeding diathesis (does not include menses) Suspected aortic dissection Significant closed-head or facial trauma within 3 mos Relative contraindications to fibrinolytic therapy History of chronic, severe, poorly controlled HT... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 35 TABLE 1-4: Diagnosis: CHF Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring (mainly K +) Diet Low salt (1-to 2-g) diet, cardiac diet, and fluid restriction 1,200-1,600 m L ?NPO Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Strict bedrest with... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
36 CARDIOLOGY Avoid NSAIDs, pseudoephedrine-containing products (i. e., nasal decongestants) Diastolic dysfunction: avoid vigorous diuresis to maintain CO Aortic stenosis: avoid ACE in severe aortic stenosis; use nitrates with precautions IHSS: avoid vigorous diuresis, digitalis, ACE, and hydralazine Avoid using ACE an... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 37 6. Digoxin: if patient has atrial fibrillation or severe CHF, or EF <30% start at 0. 5-1 mg IV/PO × 1 dose followed by 0. 25 mg IV × 2 doses, then 0. 125-0. 25 mg daily 7. β-Blocker: Hold if ↓ BP or ↓ pulse Most proven is carvedilol, 3. 125 mg PO bid × 2 weeks, then 6. 25 mg PO bid × 2 weeks or Bisoprolol... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
38 CARDIOLOGY TABLE 1-4: Diagnosis: CHF (Continued) Initial dose Max dose Torsemide 10-20 mg daily-bid Titrate to achieve dry weight (up to 200 mg daily) ACE inhibitors Captopril 6. 25 mg tid 50 mg tid Enalapril 2. 5 mg bid 10-20 mg bid Fosinopril 5-10 mg daily 40 mg daily Lisinopril 2. 5-5 mg daily20-40 mg daily Quina... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 39 TABLE 1-5: Diagnosis: Hypertensive Emergency (See BP Classification) Disposition Cardiac-monitored bed/unit Monitor Vitals, BP check q30min, then q2-4h once BP is stable Cardiac monitoring Neuromonitoring Diet ?Clear liquids, ?heart healthy, ?low sodium Fluid Heplock (flush every shift) O 2 ≥2 L O2 via NC;... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
40 CARDIOLOGY Constipation and coughing prophylaxis to prevent intracranial bleeding Consults Cardiology, nephrology Nursing I/O, urine output, daily weights, stool guaiac Avoid ASA, Plavix, caffeine-containing products Management See Management: BP High BP Signs and Symptoms Life-threatening conditions Signs and sympt... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 41 TABLE 1-5: Diagnosis: Hypertensive Emergency (See BP Classification) (Continued) Uncontrolled HTN Urgency Emergency Encephalopathy Pulmonary edema CVACardiac ischemia Management: BP Dosage Onset Duration PO agents Clonidine 0. 1-0. 2 mg initially, then 0. 1 mg q1h up to 0. 830-60 mins6-8 hrs Captopril 12. ... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
42 CARDIOLOGY TABLE 1-5: Diagnosis: Hypertensive Emergency (See BP Classification) (Continued) Dosage Onset Duration Esmolol 5 g in 500 m L D5W, loading dose of 500 mcg/kg over 1 min, then 50-200 mcg/kg/min1-2 mins10-30 mins Trimethaphan 0. 5-5 mg/min (useful in aortic dissection)1-3 mins10 mins Nicardipine 5 mg/hr; ↑ b... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 43 TABLE 1-5: Diagnosis: Hypertensive Emergency (See BP Classification) (Continued) Dosage Onset Duration Caution: ↓ dose if Cr Cl <30, Cr >3, or renal stenosis Maintenance BP management Labetalol, 200-600 mg PO bid (max: 2,400 mg/day) Lopressor, 50-100 mg PO daily Hydralazine, 25-50 mg PO bid-qid Nicardipine... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
44 CARDIOLOGY TABLE 1-6: Diagnosis: Hypotension Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet PRN Fluid Wide open initially (caution in patient with CHF) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC with differential, BMP, calcium, Mg,... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 45 Avoid Antihypertensive medications Management Epinephrine (Levophed): ACLS dosing range of 0. 5-30 mcg/min or mix 4 mg in 500 m L D5W Initially: 4 mcg/min = 30 m L/hr; usual range: 8-12 mcg/min Microgram to m L comparison according to mixture of 4 mg in 500 m L 4 mcg/min = 30 m L/hr6 mcg/min = 45 m L/hr8 ... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
46 CARDIOLOGY TABLE 1-7: Diagnosis: Asystole Disposition ? Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet NPO Fluid Heplock O 2 PRN Activity Bedrest Dx studies Labs CBC, BMP, Mg, PO4, PT/PTT/INR, LFT, ABG, serum toxicology screen, troponin q8h Radiology and cardiac studies CXR (PA and lat... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 47 TABLE 1-7: Diagnosis: Asystole (Continued) Management: Asystole Check for code status before starting CPR Check ABCs Check pulse If no pulse, start CPR Check vitals Consider transcutaneous pacing Epinephrine, 1 mg IV q3-5min Atropine, 1 mg IV q3-5min (max: 0. 04 mg/kg) If asystole persists, consider withh... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
48 CARDIOLOGY TABLE 1-8: Diagnosis: Bradycardia Disposition Unit Monitor Vitals Cardiac monitoring Diet ?NPO Fluid IVF (?wide open-?MIVF) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO4, LFT, TSH, troponin q8h × 3, CPM-MB q6h × 4 Radiology and cardiac studies CXR (... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 49 FIGURE 1-3: Bradycardia. TABLE 1-8: Diagnosis: Bradycardia (Continued) Management: Bradycardia Symptomatic Place patient in Trendelenburg position Atropine: 0. 5-1 mg IV push q3-5min (max: 0. 04 mg/kg) Then consider TCP If NR, dopamine, 5-20 mcg/kg/min If NR, epinephrine, 2-10 mcg/min If NR, isoproterenol... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
50 CARDIOLOGY TACHYARRHYTHMIA TABLE 1-9A: Diagnosis: Atrial Fibrillation/Atrial Flutter Treatment for rate control Diltiazem (Cardizem): 20 mg IV over 2 mins, re-bolus in 15 mins, or Esmolol: 500 mcg/kg IV over 1 min, or Verapamil, 2. 5-5 mg IV initially then 5-10 mg IV, or Lopressor, 50 mg PO If low EF/low BP digoxin,... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 51 FIGURE 1-4: Atrial fibrillation. FIGURE 1-5: Atrial flutter. | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
52 CARDIOLOGY TABLE 1-9B: Diagnosis: Supraventricular Tachycardia (SVT) (Narrow-Complex Tachycardia) Atrial tachycardia Atrial fibrillation/atrial flutter, MAT, sinus/inappropriate tachycardia, sinus nodal reentrant tachycardia, atrial tachycardia AV tachycardia AV nodal reentrant or AV reentrant tachycardia, junctiona... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 53 Avoid Caffeine-containing products Management See Management: SVT (Narrow-Complex Tachycardia) FIGURE 1-6: SVT. Management: SVT (Narrow-Complex Tachycardia) If patient is unstable cardiovert Vagal maneuver/carotid massage NR adenosine, 6 mg NR 12 mg NR 12 mg Cardizem, 15-20 mg (0. 25 mg/ kg) IV over 2 min... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
54 CARDIOLOGY TABLE 1-9B: Diagnosis: Supraventricular Tachycardia (SVT) (Narrow-Complex Tachycardia) (Continued) If PSVT If normal EF β-blocker, calcium channel blocker, digoxin direct current cardioversion Also consider procainamide, amiodarone, or sotalol If EF <40% digoxin NR amiodarone NR diltiazem If unstable card... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 55 TABLE 1-9C: Diagnosis: Ventricular Tachycardia (VT) (Wide-Complex Tachycardia) Disposition Unit Monitor Vitals Cardiac monitoring Diet ?NPO, cardiac diet, low fat, low cholesterol, no caffeine Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
56 CARDIOLOGY FIGURE 1-7: Ventricular tachycardia. TABLE 1-9C: Diagnosis: Ventricular Tachycardia (VT) (Wide-Complex Tachycardia) (Continued) Management: VT (Wide-Complex Tachycardia), Stable Monomorphic may consider synchronized cardioversion If EF <55% amiodarone, 150 mg IV/10 mins, or lidocaine, 0. 5-0. 75 mg/kg, th... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 57 TABLE 1-9D: Diagnosis: Ventricular Fibrillation (V-Fib)/Unstable VT Disposition Unit Monitor Vitals Cardiac monitoring Diet ?NPO, cardiac diet, low fat, low cholesterol, no caffeine Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calc... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
58 CARDIOLOGY FIGURE 1-8: V-fib. TABLE 1-9D: Diagnosis: Ventricular Fibrillation (V-Fib)/Unstable VT (Continued) Management: V-Fib/Unstable VT Start CPR (consider placing patient on ventilator) Precordial thump if no defibrillator immediately available Shock 200 J NR shock 200-300 J and then 360 J If NR epinephrine, 1 ... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 59 TABLE 1-9E: Diagnosis: WPW Syndrome (Short P-R, Narrow-Complex Tachycardia, Delta Wave) Disposition Cardiac-monitored bed/unit Monitor Vitals Cardiac monitoring Diet ?NPO, cardiac diet, low fat, low cholesterol, no caffeine Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activ... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
60 CARDIOLOGY FIGURE 1-9: WPW syndrome. TABLE 1-9E: Diagnosis: WPW Syndrome (Short P-R, Narrow-Complex Tachycardia, Delta Wave) (Continued) Management Delta wave is-VE in V1, V2, and a VR; +VE in I, II, a VL, and a VF; and isoelectric in III Treatment if EF normal Direct current cardioversion or Amiodarone: 150 mg IV o... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 61 TABLE 1-9F: Diagnosis: Torsades de Pointes Disposition Cardiac-monitored bed/unit Monitor Vitals Cardiac monitoring Diet ?NPO, cardiac diet, low fat, low cholesterol, no caffeine Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calcium... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
62 CARDIOLOGY FIGURE 1-10: Torsades de pointes. TABLE 1-9F: Diagnosis: Torsades de Pointes (Continued) Management Polymorphic VT plus QT prolongation Magnesium sulfate: 1-4 g IV bolus over 5-15 mins, or Magnesium sulfate: 2-20 mg/min IV infusion; max: up to 48 hrs until QTc interval <440 msecs Isoproterenol: l2-20 mcg/... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 63 TABLE 1-9G: Diagnosis: Pulseless Electric Activity Disposition Cardiac-monitored bed/unit Monitor Vitals Cardiac monitoring Diet ?NPO, cardiac diet, low fat, low cholesterol, no caffeine Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP,... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
64 CARDIOLOGY Hypo-or hyperkalemia Thrombosis (acute coronary syndrome) Hydrogen ion (acidosis)Trauma Tablets (drugs) Wide QRS: possible massive myocardial injury, hyperkalemia, hypoxia, hypothermia Wide QRS + slow heart: drug overdose (TCA, β-blockers, calcium channel blockers, digoxin) Narrow complex: consider hypovo... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 65 TABLE 1-10: Diagnosis: Aortic Dissection Disposition Unit Monitor Vitals Cardiac monitoring Neuromonitoring Diet NPO Fluid Heplock (flush every shift) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Strict bedrest with bedside commode Dx studies Labs CBC, BMP, PT/PTT/INR, troponin q8h, CPK-MB q6h Rad... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
66 CARDIOLOGY FIGURE 1-11: Aortic dissection. TABLE 1-10: Diagnosis: Aortic Dissection (Continued) Aortic Dissection Classifications De Bakey classification Type I: originates in the ascending aorta, propagates at least to the aortic arch and often beyond it distally Type II: originates in and is confined to the ascendi... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
CARDIOLOGY 67 TABLE 1-10: Diagnosis: Aortic Dissection (Continued) Management: Aortic Dissection Consider surgery if following: Acute dissection of ascending aorta Acute dissection of descending aorta with: Signs of impending rupture (persisting pain, hypotension, left-sided hemothorax) Marfan syndrome Chronic dissecti... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
68 CARDIOLOGY Clonidine, 0. 1-0. 3 mg PO/patch daily, or hydralazine, 10-50 mg PO qid, or Amlodipine, 2. 5-10 mg PO daily, or enalapril, 2. 5-20 mg PO daily Pain management Morphine, 2-5 mg IV q3-4h or Meperidine, 50-100 mg IV/IM q4h PRN (caution in elderly due to risk of delirium) GFR 10-50 m L/min, 75% of normal dose... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
69 2 Endocrinology OUTLINE 2-1. Adrenal Crisis 70 2-2. Diabetic Ketoacidosis (DKA) 732-3. Nonketotic Hyperosmolar Syndrome (NKHS) 772-4. Thyroid Storm (Thyrotoxicosis) 812-5. Myxedema Coma 842-6. Hyperparathyroidism and Severe Hypercalcemia 86 | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
70 ENDOCRINOLOGY TABLE 2-1: Diagnosis: Adrenal Crisis Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Diet Regular Fluid Heplock (flush every shift) O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO 4 , LFT, TSH, T 3 and free T 4 , corti... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 71 Management 1. Hypotension with NS or D 5 NS (2-3 L): 500 m L/hr to wide open 2. Dexamethasone sodium phosphate, 4 mg IV, or hydrocortisone, 100 mg IV q6-8h, for first 24 hrs ( Note: Dexamethasone is preferred because it does not interfere with ACTH stimulation test) or 3. Fludrocortisone: 0. 1-0. 2 mg... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
72 ENDOCRINOLOGY Hypercalcemia Azotemia Eosinophilia ↑ TSH, and ↓ T 3 , T 4 ECG: peaked T waves CT of abdomen: calcification, enlargement, or hemorrhage of adrenal gland CT of head: destruction of pituitary/mass lesion TABLE 2-1: Diagnosis: Adrenal Crisis (Continued) | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 73 TABLE 2-2: Diagnosis: Diabetic Ketoacidosis (DKA) Disposition Unit Monitor Vitals Cardiac monitoring Neuro check Electrolyte monitoring Diet NPO once stable start American Diabetes Association (ADA) diet, complex carbohydrate diet Fluid Caution in patient with CHF NS or 1 / 2 NS first liter should be ... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
74 ENDOCRINOLOGY Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Calculate ∆ / ∆ , Hb A1 C , amylase, lipase, β -HCG, stool guaiac Prophylaxis DVT Consults Endocrinology, diabetic education Nursing Foley catheter, I/O, urine output, stool guaiac, monitor electrolytes Avoid Hypokalemia Management ... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 75 TABLE 2-2: Diagnosis: Diabetic Ketoacidosis (DKA) (Continued) 4. TBW deficit = (35-30. 6) = 4. 4 L 5. X = 75 (m Eq/L)/154 = 0. 496. Replacement volume (L) = 4. 4 L × [1/(1-0. 49)] = 8. 6 L (replace this deficit in 48-72 hrs) Note Correct sodium for hyperglycemia; for each 100 mg/d L ↑ of blood sugar ab... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
76 ENDOCRINOLOGY TABLE 2-2: Diagnosis: Diabetic Ketoacidosis (DKA) (Continued) 5. K+: Potassium depletion should be expected with insulin treatment; if K+ <4 replace with IV boluses add 20-40 m Eq KCl to each liter of IVF change to K+ phosphate to prevent chloride overload (monitor K+ q2h) Vigorously replace K+ Periphe... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 77 TABLE 2-3: Diagnosis: Nonketotic Hyperosmolar Syndrome (NKHS) Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitor Diet NPO once stable start ADA diet Fluid NS, 1-2 L over 1 hr (caution in patient with CHF) NS, 500 m L/hr until fluid deficit is corrected start maintenance 1/2 NS at 15... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
78 ENDOCRINOLOGY Nursing Foley, I/O, urine output hourly (maintain 50 m L/hr) Avoid Hypokalemia Management See Management: Nonketotic Hyperosmolar Syndrome Calculation of Replacement of Total Body Water (TBW) Deficit 1. TBW in hypernatremia = Male: 0. 5 × wt (kg), Female: 0. 4 × wt (kg) 2. Current TBW = TBW × (140/PNa+)... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 79 TABLE 2-3: Diagnosis: Nonketotic Hyperosmolar Syndrome (NKHS) (Continued) N a+ concentration in IV fluids: NS = 154 m Eq/L, 1/2 NS = 75 m Eq/L. Management: Nonketotic Hyperosmolar Syndrome 1. Fluid replacement and electrolyte replacement essential Note: If K+ <3. 3 replace K+ before giving insulin 2. C... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
80 ENDOCRINOLOGY TABLE 2-3: Diagnosis: Nonketotic Hyperosmolar Syndrome (NKHS) (Continued) 9. Mg: Replacement is required only if severe hypomagnesemia or refractory hypokalemia Patients with ventricular arrhythmia treat with magnesium sulfate, 2. 5-5 g IV 10. HCO3: not required unless patient's p H ≤7; treatment: add ... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 81 TABLE 2-4: Diagnosis: Thyroid Storm (Thyrotoxicosis) Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Diet NPO Fluid Heplock (flush every shift) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs Stat total T4 (primary turnaround), BMP, calcium, Mg, PO... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
82 ENDOCRINOLOGY TABLE 2-4: Diagnosis: Thyroid Storm (Thyrotoxicosis) (Continued) Diagnostic Criteria for Thyroid Storm Signs and symptoms Score Signs and symptoms Score Tachycardia CNS 99-109 5 Mild agitation 10110-119 10 Moderate delirium 20120-129 15 Moderate psychosis20 130-139 20 Extreme lethargy 20 >140 25 Severe... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 83 TABLE 2-4: Diagnosis: Thyroid Storm (Thyrotoxicosis) (Continued) Management: Thyroid Storm Adjust dosing of PTU and methimazole in pregnancy ( ↓ dose) PTU: 300-600 mg PO/NG bolus, then 150-300 mg PO/NG q6h (Preferred in elderly, cardiac disease, and pregnant and lactating females) or Methimazole (Tapaz... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
84 ENDOCRINOLOGY TABLE 2-5: Diagnosis: Myxedema Coma Disposition Unit Monitor Vitals (hypothermia) Cardiac monitoring Electrolyte monitoring (hyponatremia, hypoglycemia) Diet High bulk diet (to prevent constipation) Fluid IV hydration essential (caution in patient with CHF) O 2 ≥2 L O2 via NC; keep O2 saturation >92%; ... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 85 Management Prevent heat loss: Cover the patient but avoid external rewarming to prevent vascular collapse Respiratory support Thyroxine: 200-400 mcg IV followed by 50-100 mcg daily Triiodothyronine: 5-20 mcg IV followed by 2. 5-10 mcg IV q8h Hydrocortisone: 100 mg IV q8h; give before thyroid replacemen... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
86 ENDOCRINOLOGY TABLE 2-6: Diagnosis: Hyperparathyroidism and Severe Hypercalcemia Disposition Medical floor/unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Diet Limit calcium to 1,200-1,500 mg/day and vitamin D to 400 IU/day Fluid IVF hydration essential before diuresis O 2 PRN Activity As tolerated Dx ... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
ENDOCRINOLOGY 87 TABLE 2-6: Diagnosis: Hyperparathyroidism and Severe Hypercalcemia (Continued) Hyperparathyroidism Signs and symptoms Hypercalcemia Nephrolithiasis Anemia Bone disease Hypophosphatemia Proximal/distal renal tubular acidosis Hypomagnesemia ↑ Calcitriol production Hyperuricemia Muscle weakness Weakness a... | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
88 ENDOCRINOLOGY TABLE 2-6: Diagnosis: Hyperparathyroidism and Severe Hypercalcemia (Continued) Gallium nitrate: 200 mg IV continuous infusion for 5 days (side effect: nephrotoxicity), not commonly used Dialysis Treat underlying etiology | Lange instant access Patel Anil - Lange instant access_ hospital admissions_ essential evidence-based orders for common clinical conditions-McGraw-Hill Medical Pub. Division 2007.pdf |
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