Table of Contents
Pneumothorax
Uterine Bleeding
Cardiac Arrest
Retropharyngeal Abscess / Also called hypopharyngeal abscess
xxxx
Diverticulitis
xxxx
Hypoglycemia in pt without DM
www.uptodate.com/contents/hypoglycemia-in-adults-without-diabetes-mellitus-diagnostic-approach
#Orthostatic Hypotension
http://www.uptodate.com/contents/mechanisms-causes-and-evaluation-of-orthostatic-hypotension
Board and Wards:
Pt with a PMH of HTN and Stage IV lung CA with mets to liver, spine, etc has develops severe orthostatic hypotension.
What’s the likely cause?
# Sick Sinus Syndrome (Tachycardia-Bradycardia) s/p pacemaker placement.
Male in early 20s with episodes of tachycardia up to 180s and bradycardia > heart pausing three times in ED, up to 8 seconds, pt LOC > pacemaker. Still having episodes of palpitations and tachycardia.
Plan:
Refer to cardiology
Cardiology to initiate beta blocker.
#Symptomatic bradycardia
Pt observed to c/o of dizziness and lightheadedness when monitor shows bradycardia.
Admit to telemetry
Cardiac monitor
Reviewed 12-lead ECG, CBC, BMP,Coags, CT head, and CXR
Consult cardiology – Cards to see pt in the AM.
Pacemaker placement in the am.
Echocardiogram
HBa1c, FLP, TSH
Antiplatelet tx: cont plavix
Statin: Cont. Pravastatin
Cont pulse ox
consider orthostatic vitals
Bilateral Carotid U/S
Bedside swallow eval before feeding
Cardiac diet
Frequent checks
IVFs
#Bradycardia
-ECG shows 1st degree AV block, bradycardia, possible inferior MI.
-Cardiac enzymes show: Trop I x 2, 0.01 x2.
-Nursing order to ambulate patient and to record HR with exertion; if no elevation suggest cardiology consultation for further evaluation. Patient reports he does not receive routine follow up with cardiology and instead has received care from his Seattle WA PCP.
#Syncopal episode associated with hypotension and bradycardia
-Likely 2/2 to vasovagal from prolonged sex + orthostatic from alkyl nitrites overdose
-Alkyl nitrites are associated with bradycardia
-Pt got 1 L of fluids on the ambulance.
-Pt doing well now, no longer dizzy. Heart rate in the 80s.
-IVFs at 75 ml
#Bradycardia in a pt with a hx of rheumatic fever leaky valve with murmur
-Likely 2/2 to amyl nitrite
-Pulse now in the 80s. Patient asymptomatic.
-Given patient’s history, will get Echocardiogram and serial TnI
-Repeat EKG in the am
-Repeat EKG in the morning and consider cardiology consult in the am if necessary.
#Afib with rvr
Atrial fibrillation with rapid ventricular response.
We will give diltiazem 10 mg IV x 1 and monitor on telemetry. If need be, we will start a low dose of diltiazem drip and titrate as tolerated.
d#2 a/p
diltiazem drip. hr still elevated. blood pressure ok. Lopressor 5mg IV given by RN I was present at the bedside. HR improved. normotensive.
on coumadin. spat it out this morning when more confused. start Rx lovenox.
echocardiogram.
cardiology evaluation.
#DKA
Sample DKA A/P #1
Dx: DKA with dehydration 2/2 URI
Will admit patient to Medical ICU
Will consult Critical Care service
Will start pt on DKA protocol including IV Fluids, Insulin drip, Potassium replacement. Pt doesn’t need bicarb at this point.
Will administer flu shot prior to discharge
2)Dehydration – will start aggressive volume repletion with normal saline.
3)Nausea/vomiting – prn Zofran and Reglan
4)GERD – will continue po PPI
DVT Prophylaxis – ambulation and SCDs
Code Status: Full Code
Sample DKA A/P #2
Diabetic Ketoacidosis
IVFs: NS + KCL 20 mEq / L @ 150 cc / hr
SC insulin sliding scale
Prn Zofran for N/V
High Hgb, Hct, and PLTs likely from dehydration
Will follow leukocytosis
Carb Counting in Diabetes Mellitus
Sample pt #1 Rx:
Lantus 23 units QHS
Carb counting–1 unit of Novolog for every 10grams of carbohydrates,
Sliding scale with 1 unit of Novolog for every 40 points rise in blood sugars after 150.
Sample pt #2 Rx:
Lantus 35 units QHS
Carb counting: Novolog 1 unit for 15g carbs
Sliding Scale: Novolog 1 unit for every 50 over 125 of blood sugars.
#Worsening hypoxemic respiratory distress likely 2/2 to Non-small cell carcinoma of the RUL
CT chest reviewed as above. Total atelectasis of the R.lung, large right pleural effusion due to malignancy, occlusion of Rt mainstem bronchus..
Pt on 4 L NC now. Usually on 2L NC at home as needed.
CT PE protocol ordered to rule out PE given risk factors of VTE in the presence of malignancy.
-Admit to telemetry.
-RT consulted, Duonebs prn, and pulmonary toilette as needed.
-Pending CT PE results-pulmonary medicine consult to assist with bronchial stenting if merited. Mr. Dominguez presently continues to be averse to receiving chemotherapy/radiation therapy.
-Consult Oncology for further recommendations.