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FADevisM_FM.qxp 9/12/08 7:46 PM Page 3

Medical
Notes Clinical Medicine Pocket Guide

Bruce Y. Lee, MD, MBA

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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)
■ ⱖ40 y.o.: Mammogram every year
■ Clinical breast exam: 20-39 y.o. ~q3yr and ⱖ40 y.o. every year
■ Breast self-exam option for ⱖ20 y.o
■ ⬎20% lifetime risk: MRI and mammogram every year
■ 15%-20% lifetime risk: discuss w/physician about MRI
Colon and Rectal CA
■ ⱖ50 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., ⱖ40 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 ⱖ21 y.o., whichever
comes first: Regular Papanicolaou (Pap) test every year or
newer liquid-based Pap test q2yr
■ When ⱖ30 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 øimmunity

BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 2

BASICS

■ ⱖ70 y.o.: If ⱖ3 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: ⱖ35 y.o.:
offer endometrial biopsy every year
Prostate CA (for Men)
■ ⱖ50 y.o.: Offer prostate-specific antigen and digital rectal
examination every year
■ ⱖ45 y.o. high-risk (African-American or strong family history
ⱖ1 first-degree relatives [father, brothers] diagnosis ⬍65 y.o.):
Every year
■ ⱖ40 y.o. higher risk (multiple first-degree relatives): Every
year; if negative consider waiting until ⱖ45 y.o.

Diagnostic and Therapuetic Procedures


Electrocardiogram (ECG)

Rate (Normal: 60–100 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

2
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 3

3
PR Interval (Normal: 0.12–0.20 sec)
■ Short PR (⬍0.12 sec) Could be normal variant or:
■ Wolff-Parkinson-White (WPW): Accessory path RA†RV or
LA†LV so early ventricle activation leads to Δ-wave (initial
slurring of QRS), ⁄QRS duration (usu. ⬎0.10 sec), second-
degree ST-T Δs from altered ventricular activation
■ Lown-Ganong-Levine: AV nodal bypass track into bundle
of His † early ventricle activation w/o Δ-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); øconduc-
tion 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): Rⱕ3 mm in V1–3, normal
variant, LVH, LBBB, LAFB, anterior or anteroseptal MI, COPD
(R/S ratio in V5–6 ⬍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: 0.6–0.10 sec)
■ QRS duration 0.10–0.12 sec: Incomplete RBBB or LBBB
(same as complete RBBB and LBBB except QRS duration),
nonspecific IVCD, LAFB, or LPFB (some)

BASICS
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 fascicu-
lar block criteria; causes: ventricular hypertrophy, MI,
drugs (esp. class IA and IC antiarrhythmics), ⁄K+
■ Ventricle-origin ectopic rhythm (e.g., VT)

QT Interval (Normal: ⬍1⁄2 R-R interval; normal


QT ⬍500 msec)
■ Beginning R wave † end of T wave; varies w/HR
■ Bazett’s formula: QTc = QT/兹RR (normal QTcⱕ440 msec)
■ QTc ⬎0.47 sec (male) and ⬎0.48 sec (female) † long QT syn-
drome (LQTS): (May † torsade de pointes: ventricular tachy-
cardia w/varying QRS morphology): Drugs (e.g.,antiarrhyth-
mics, tricyclics, phenothiazines); abnormal electrolytes (K⫹,
Ca2⫹, Mg2⫹); øthyroid, 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 V1–V3 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

4
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
■ Prinzmetal’s (variant) angina (coronary vasospasm)
■ During exercise testing † ⁄⁄⁄tight coronary artery stenosis
or spasm (transmural ischemia)
■ Acute pericarditis: Concave up ⁄ST (not aVR); no reciprocal
øST (except in aVR); unlike “early repolarization”, usu. T
low amplitude and ⁄HR; may see øPR (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 Δs 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, øK+, 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, V3–6, 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 Page 6

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, øK⫹, Quinidine and
other type 1A antiarrhythmics, CNS dz (long QT), LVH, MVP,
øthyroid
■ Negative or “inverted” U: Ischemic heart dz, MI (in leads
with pathologic Q waves), angina, coronary vasospasm
(Prinzmetal’s 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* T ST
Pre-MI
Hyperacute ⁄Amplitude/width May ⁄
Transmural Injury ⁄⁄⁄
Necrosis ⫹ Terminal inversion Less
Necrosis/Fibrosis ⫹ Inversion
Fibrosis ⫹ Upright

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

■ Conditions resembling MI: WPW pre-excitation (negative


Δ-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 Δs)
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; P’R
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 appear-
ance in II, III, aVF, and usu. discrete ‘P’ in V1; atrial rate = 150-
450/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: ⱖThree 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: ⱖ3 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. nonsus-


tained; 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 ~pre-
vious 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)

8
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 9

9
■ Local anesthesia: infiltrate skin (25-G needle), then Δ 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 per-
pendicular 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 ⱖ12 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 (ørisk 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
■ Δ to formal tracheostomy ⱕ1 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 ø 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)
Pree- Neo- 1-2 4-6 8-12
Age mie nate 6 mo yr yr yr Adult
ET Tube
Diameter (cm) 2.5 3–3.5 3.5–4 4–5 5–5.5 6–7 7.5–8.5
Blade (cm) 0 0–1 1 1–2 2 2–3 4–5
Insert: Lips to
Mid-Trachea
(cm)† 10 11 11–12 12 ⫹ (age/2) ©:~23
ª~21

BASICS
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 12

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 carti-
lage 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
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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 ørisk w/antacids, H2-blockers,
metoclopramide, head-up positioning)
■ Damage to lips, teeth, tongue, airway

Pericardiocentesis

Indications
■ Cardiac tamponade
■ ⁄ pericardial effusion † ø 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
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BASICS

Preparation
■ Continuous ECG monitoring (30° semi-Fowler position pre-
ferred); 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
ⱖ20 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, pneu-
mothorax, 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

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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 30°–45° 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
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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

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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: øBleed 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: øPulmonary 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
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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 fin-
ger breadths inferior to inguinal ligament; with bevel up and
at 45°–60° above skin, insert needle parallel to vessel (steeper
angle †ørisk 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 †ørisk of entering
peritoneum; more medial insertion angle †øchance of enter-
ing femoral artery)
■ IJ: Insert needle at 70° to skin and aim for ipsilateral nipple;
aim lateral; if unsuccessful, withdraw and carefully go

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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 3–4 mm (w/scalpel) through skin and fascia; push
dilator 3–4 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
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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 infiltra-
tion, 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 (16–18-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/1–1.5 mL air); attach pressure monitor and
infusion ports

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21
■ Keep catheter in protective plastic container until zeroing pro-
cedure complete; remove catheter from plastic container and
move tip w/wrist flick † appropriate waveform (monitor screen)
Patient Positioning
■ Subclavian or IJ: Supine and 15° Trendelenburg’s position;
turn pt.’s head away from entry site; place roll under spine
between shoulder blades
■ Femoral: Supine and flat
Technique
■ 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 passage-
way 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 Right Pulmonary Pulmonary


Pressure in mm Hg

atrium ventricle artery capillary


wedge
pressure

BASICS
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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; Δ catheter over wire q3–7d
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 ⫻ ⱖ10 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, car-
diac 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

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■ 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 (18–22-G, 1.5”–2”), over-the-needle catheter (16–20-G
needle) or through-the-needle catheter (14–18-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
y 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
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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/5–10-mL anesthetic
2. Raise skin wheal at rib upper edge in midscapular or poste-
rior axillary line
3. Δ 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 rib’s 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)
■ Δ Sx: e.g., abdominal pain, ⁄SOB
■ Persistent cough

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25
Complications
Pneumothorax, cough, infection, hemothorax, splenic rupture,
abdominal hemorrhage, unilateral pulmonary edema, air
embolism, retained catheter fragment
Light’s 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 Diagnosis Suspected
Amylase Pancreatitis, esophageal rupture
Triglycerides Chylothorax, intrathoracic total
parenteral nutrition
Glucose Rheumatic effusion
Urea or creatinine Urinothorax
Cytology Malignancy

Diagnostic Features of Pleural Fluid


WBC Main
Pleural Fluid Description Count WBC Glucose pH
Parapneumonic Turbid ⁄ PMNs ø ⬎7.3
Empyema Turbid, ⁄ PMNs ø ⬍7.3
purulent
TB Straw color, ⬍10,000 Both ø ⬍7.4
serosanguinous
Malignant Turbid, bloody ⬍10,000 Mono’s ø ⬍7.3
effusion
PE/infarct Straw color, ⁄ Both Serum 7.4
bloody
Collagen vas- Turbid ⁄ø Both
cular disease
RA Green ⁄ø Both øø ⬍7.3
SLE Yellow ⁄ø Both Serum ⬎7.3
Hemothorax Bloody ⁄ø PMNs Serum ⬍7.3

BASICS
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BASICS

Nasogastric and Feeding Tubes


Indications
Nasogastric Tubes
■ Diagnostic gastric lavage: Check for GI bleed
■ Decompress stomach: Ileus, GI obstruction, persistent vomit-
ing, 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 = patient’s ear to umbilicus
■ Premedication: Spray anesthetic † throat back; apply
vasoconstrictor and topical anesthetic † nasal mucosa
■ Liberally apply lubricant along tube/tube tip

*Optional

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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
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BASICS

Complications
■ ⁄⁄⁄ Gagging during placement: spray more topical anesthetic
to back of throat
■ Difficulty passing tube † tube stuck in nose (try other nos-
tril), coils in mouth or esophagus (use ice to chill/stiffen tube)
■ Placement in lung (coughing): Remove immediately
■ Hypovolemia from ⁄⁄⁄ nasogastric tube output: IV fluids
0.5–1 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/30–40 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 †ø 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

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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 (ⱖ20-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 øNa⫹,
hepatorenal syndrome

BASICS
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BASICS

Peritoneal Fluid Assays


Assay Diagnosis Suspected
Amylase Pancreatitic
Triglycerides Chylous
RBC count ⬎50.000/␮L Hemorrhagic ascites (malignancy,
TB, or trauma)
WBC ⬎350/␮L Infection (spontaneous bacterial
peritonitis)
PMNs Bacterial
Mononuclear cells TB or fungal
pH⬍7 Infection

Serum-Ascitic Albumin Gradient (SAAG)


=AlbuminSerum–AlbuminAscites from same day
High (ⱖ1.1 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)
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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
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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
øSensitivity to retroperitoneal injury, ⁄sensitivity to minor intraperi-
toneal injuries, false negative (poor technique or diaphragmatic
injuries), wound infection, false positive (bleeding from incision),
øsensitivity 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):

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■ 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 Foley Coude 3-way


catheter catheter catheter irrigation
catheter
■ Pretest balloon inflation w/saline
■ Skin preparation: Sterile technique; retract foreskin (if pres-
ent) or spread labia (urethral meatus anterior to vagina and
posterior to clitoris); prepare entire penis or periurethral area
(including urethral meatus) w/ⱖ3 povidone-iodine applica-
tions; 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
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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
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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
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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
■ Δ 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 (15°–20°), 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

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37
■ Aspiration of synovial fluid confirms joint space placement
■ If Δ 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 Δ 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 ø pressure to aspirate), cartilage dam-
age (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 Strong negative birefringence, needle-
(gout) shaped, long*
Uricase digestion X-ray diffraction
Ca2⫹ pyrophosphate Weak and birefringence, rhomboid or
dihydrate (CPPD) small rods, pleomorphic*
Pseudogout X-ray diffraction
Ca2⫹ phosphate Not easily visualized*
(hydroxyapatite) Electron microscopy X-ray diffraction
Cholesterol Rhombic or platelike, notched corners,
multicolor, occasionally small, needle-
like*
Chemical determination
Corticosteroids Pleomorphic; variable birefringence*
Postintra-articular steroid Rx
*On polarizing microscope

BASICS
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BASICS

Joint Fluid Characteristics‡


WBC Mucin Δ Glucose*
Dx Appears /mL3 PMNs Clot (mg/dL)
Normal Clear, pale 0–200 ⬍10% Good ~0
yellow
Group I (noninflammatory)
DJD; Clear to 50–4K ⬍30% Good ~0
traumatic slight turbid
arthritis
Group II (noninfectious, mildly inflammatory)
SLE; Clear to 0–9K ⬍20% Good ~0
scleroderma slightly (occasion-
turbid ally fair)
Group III (noninfectious severe inflammatory)
Gout Turbid 100–160K ~70% Poor 10
Pseudogout Turbid 50–75K ~70% Fair/poor ?
RA Turbid 250–80K ~70% Poor 30
Group IV (infectious inflammatory effusions)
Acute Very turbid 150–250K ~90% Poor 90
bacterial
TB TB 2500–100K ~60% Poor 70
*Mean difference between synovial fluid and blood glucose
‡Adapted from Cohen, AS. Cecil’s 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
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■ 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 2–3 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 strepto-
coccus, staphylococcus, or enterics (perianal), or anaerobic
and gram-negatives.
Complications
Abscess actually sebaceous cyst or hematoma, no drainage,
bleeding

BASICS
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H&P

Cranial Nerve Major Functions How to Test


I Olfactory Smell Odor
II Optic Vision Vision chart
III Oculomotor Most eye muscles Follow finger
IV Trochlear Superior oblique Look down at
(eye ø and out) nose
V Trigeminal Face sensation Touch face
Chewing muscles Clench teeth
VI Abducens Lateral rectus Look to side
(eye lateral)
VII Facial Face expressions Smile
Tears/saliva ⁄ø Eyebrows
Taste (anterior 2/3 Sugar or salt
tongue)
VIII Vestibuloco- Hearing Tuning fork
chlear Equillibrium ? Vertigo
(auditory)
IX Glossopharyn- Taste (posterior Gag reflex
geal 1/3 tongue) Swallow
Sense carotid BP Uvula position
X Vagus Larynx/pharynx ? Hoarseness
Parasympathetic Open wide, say
Taste “AH”
XI Spinal Trapezius/ Shoulder
Accessory sternocleidomastoid shrug/raise
Turn head
XII Hypoglossal Move tongue Tongue out

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

Distinguishing
Causes Upper Lower
of Motor Motor Motor Extra-
Defects Neuron Neuron Muscle Cerebellar pyramidal
øStrength ⫹ ⫹ ⫹ ⫺ ⫺
Atrophy ⫺ ⁄⁄⁄ ⁄ ⫺ ⫺
Fasciculations ⫺ ⫹ ⫺ ⫺ ⫺
Babinski’s ⫹ ⫺ ⫺ ⫺ ⫺
⁄Tone ⫹ ⫺ ⫺ ⫺ ⫺
øTone ⫺ ⫹ ⫹/⫺ ⫺ ⫺
Hyperreflexia ⫹ ⫺ ⫺ ⫺ ⫺
Hyporeflexia ⫺ ⫹ ⫹/⫺ ⫺ ⫺
Clasp knife ⫹ ⫺ ⫺ ⫺ ⫺
Ataxia ⫺ ⫺ ⫺ ⫹ ⫺
(continued)

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Distinguishing
Causes Upper Lower
of Motor Motor Motor Extra-
Defects Neuron Neuron Muscle Cerebellar pyramidal
Akinesia ⫺ ⫺ ⫺ ⫺ ⫹/⫺
Chorea or ⫺ ⫺ ⫺ ⫺ ⫹/⫺
athetosis
Intention ⫺ ⫺ ⫺ ⫹/⫺ ⫺
tremor
Resting tremor ⫺ ⫺ ⫺ ⫺ ⫹/⫺

Lower Extremities
Cannot toe walk when ⱖ50% loss S1 † gastrocnemius and anterior
tibialis; cannot heel walk when ⱖ50% 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
■ Milgram’s test: Pt. lies supine and raises legs ~5 cm and
holds for 30 sec † stretches iliopsoas and anterior
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43
abdominal muscles and ⁄ intrathecal pressure; if no leg pain,
no intrathecal pathology

Reflexes
Nerve
Reflex Root Nerve Testing
Jaw Pons Mandibular Tap mandible at down-
branch, ward angle w/mouth
trigeminal slightly open
Biceps C5–6 Musculocu- Tap biceps tendon
taneous w/arm flexed partially
at elbow
Brachiora- C5–6 Radial Strike radius lower end
dialis just above wrist
Normal: Elbow flexion
Triceps C7–8 Radial Tap triceps tendon;
support upper arm; let
forearm hang
Finger C8, T1 Median Either tap palm or hold
pt.’s middle finger
loosely and flick
fingernail down †
normal: finger slightly
extends; abnormal:
Hoffman’s sign (thumb
flexes, adducts)
Upper T7–10 Use blunt object to
abdomen stroke abdomen lightly
in and down
Lower T11–L1
Normal: Umbilicus
abdomen
deviates toward
stimulus
(continued)

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Reflexes
Nerve
Reflex Root Nerve Testing
Patellar L3–4 Femoral Strike patellar tendon
Ankle S1–2 Tibial Tap Achilles tendon
(Achilles) when pt. dorsiflexes
foot at ankle
Normal: Plantar flexion
Cremasteric T12 Genital Stroke inner thigh
reflex branch (gen- Normal: Ipsilateral
itofemoral) scrotal sac move ⁄
Anal wink S2–4 Touch perianal skin
Normal: Anus contracts

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45
Peripheral Nerves

Trigeminal
Anterior cutaneous
nerve neck
C2
Supraclavicular
C3
Axillary C4 C5
Anterior thoracic rami
T2 T1 C6
Lateral thoracic rami T3
Lateral cutaneous T4
nerve arm T5
Median cutaneous T6
nerve arm T7
T8
Lateral cutaneous T9
nerve forearm T10
Iliohypo- T11
Median gastric T12
Ilio-
cutaneous S2 L1
inguinal S3 C8
nerve
forearm C7
Ulnar L2
Radial
Median
Lateral femoral cutaneous
L3
Medial femoral cutaneous
Obturator
Anterior femoral cutaneous

Superficial peroneal
L4 L5
Sural Tibial
Saphenous Saphenous

Medial
Lateral
plantar Sural Deep
plantar
Sole of foot peroneal

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Peripheral Nerves
Great occipital
Lesser occipital C2
Greater auricular
C3
Posterior rami of cervical nerves C4
C5
Supraclavicular
Lateral thoracic rami C6
Posterior thoracic rami C8 C7
Axillary
T10
Posterior cutaneous
nerve forearm
Median cutaneous
nerve arm T12
Lateral cutaneous L1
L2
nerve forearm L3
Median cutaneous L4
S3 S1
nerve forearm S4
S5 S2
Radial L5
Posterior
Median lumbar
Ulnar rami
L2
Posterior sacral rami
Lateral femoral cutaneous
L3
Medial femoral cutaneous
Lateral femoral nerve of calf Obturator
Superficial peroneal
L4 L5
Sural Tibial Sural
Saphenous
Saphenous
Medial
Lateral
plantar
plantar Calcaneal
Sole of foot

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47
Referred Pain

Jaw Left Shoulder


Cardiac Lung
Diaphragm
Right Shoulder (Kehr’s sign)
Liver Pancreas
Gallbladder Cardiac
Diaphragm
Pancreas Arm
Cardiac Cardiac

Periumbilical
Duodenum
Appendix

Epigastric Suprapubic
Duodenum Bladder
Appendix Uterus
Hiatal hernia
Gallbladder
and bile ducts Groin/
Pancreas Inner thigh
Ureters
Kidneys

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Brain Circulation

Anterior
Anterior cerebral artery communicating
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

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Main Artery Region of Brain Sustained
Anterior cerebral Medial frontal and parietal
Anterior corpus callosum
Middle cerebral Lateral frontal, parietal, occipital,
temporal cortex
Lenticulostriate branches †
caudate nucleus, putamen,
upper internal capsule
Posterior cerebral Medial occipital and temporal cortex
Posterior corpus callosum
Upper midbrain
Thalamus
Superior cerebellar Upper cerebellum
Upper pons
Low midbrain
Anterior inferior Upper cerebellum
cerebellar Upper pons
Low midbrain
Posterior inferior Lower cerebellum
cerebellar Medulla
Anterior spinal (ASA) Anterior (ventral) spinal cord

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Parietal lobe
contralateral sensation
Frontal lobe Dominant:
problem solving, reading, writing,
planning, apathy, or math ability
inattention, aphasia, Non-dominant:
contralateral weakness, neglect, difficulty dressing
labile affect,
Broca’s area Occipital lobe
vision problems

Temporal lobe
memory problems,
aggressive sexual behavior
Dominant:
Wernicke’s aphasia
Cerebellum
Midbrain, Pons,
ataxia, dysarthria,
Medulla
dysmetria, intention
CN 3–12
tremor, nystagmus,
scanning speech

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51
Eye Examination
Conjuctiva Zonule
Choroid Anterior
Sclera chamber

Retina
Cornea
Macula

Fovea Vitreous
humor

Pupil
Optic
nerve Iris
Optic Lens
disk

Ciliary body
Left eye Right eye

Optic nerve
Optic chiasm 1
Optic tract 2
3 4
Lateral
geniculate
nucleus
Optic
radiation
5

Left eye Right eye


visual visual
field field
1 Striate cortex

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Optic nerve

Superior
rectus
CN3 Superior
oblique
Inferior CN4
rectus
CN3

Medial
rectus Lateral
CN3 rectus
CN6

Inferior oblique
CN3

Optic
disk
Blood
Optic vessels
cup

Fovea

Optic nerve
(“blind spot”) Macula
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Ear Examination

Tuning Fork Tests

Weber’s test Rinne’s test


Fork at midline forehead Bone conduction: Put fork on
mastoid
Normal: Sound ⫽ both ears Air conduction: Put fork near
ear
Abnormal: Sound lateralizes † Normal: Air conduction
one ear † øipsilateral conductive ⬎ bone
hearing or øcontralateral Abnormal: Bone conduction
sensorineural hearing ⬎ air conduction, which
results in øconductive
hearing

Vertigo
Dix-Hallpike test (Nylen-Barany test): Pt. sits on examination table
and extends legs; turn pt.’s head 30°–45° 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

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Cardiac Manuevers
Mitral
Right- Aortic Regurgi-
Sided Stenosis tation
Mechanism Maneuvers Murmurs (AS) (MR) IHSS*
Preload ⁄ Inspiration, ⁄ ⁄ ø ø
squatting,
raise ⁄legs
Venous ø Expiration, ø ø ø ⁄
return Valsalva’s,
standing,
nitrates,
diuretics
Afterload ⁄ Isometric ⁄ ø
hand grip
ø Valsalva’s, ø ø ø ⁄
vasodila-
tors
*IHSS ⫽ idiopathic hypertrophic subaortic stenosis

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55
Systole Diastole
Comments
Early Mid Late Early Mid Late
Harsh
Heard best @ R base
AS
(radiate R carotid)
Blowing Heard best @ 3rd/4th L ICS
AI (if radiate R sternal border
aortic root dilate, e.g., Marfan)
Low
All MV murmurs heard best@ apex , S1.
Can be confused with Austin Flint
Opening snap
MS (AI: mid-diastolic murmur @ MV
Rumble
when blood enters from aorta &
L atrium simultaneously; No OS)
Opening snap
Radiate L axilla/back;
MI severe MR S3; with isometric
handgrip & stand squat
If LV volume (stand, Valsalva) earlier
clicks, duration, intensity; if LV volume
MVP
(squat, legs, hand grip) delay clicks,
Systolic click duration, intensity
Heard best @ L 2nd ICS (radiate to
PS L neck) + palpable thrill; wide split S2
Blowing
Heard best @ L 2nd/3rd ICS;
PI may during inspiration
Systolic click
Rumble Heard best @ 4th L sternal border;
TS wide split S1; may with inspiration
Opening snap (Carvallo’s sign); TS often occurs with MS

Heard best @ 4th L sternal border; may


TI with inspiration (Carvallo’s sign); 1st degree
rare; usually 2nd degree to pulm HTN
Second degree Heard best @ L base; confused with
PDA Machinery venous hum; if pulmonary HTN,
may disappear systolic murmur,
pulmonic ejection sound

VSD Heard best @ L 3rd/4th ICS and along


sternal border; NI S2

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Inspiration Expiration
Type Causes
S1 S2 S1 S2

Normal or physiologic Intrathoracic


A P AP pressure

Wide, fixed, splitting Atrial septal defect


A P A P
Wide split, varies with Pulmonary stenosis
inspiration A P AP RBBB

Hypertrophic
Paradoxical splitting
PA PA cardiomyopathy

Adapted from University of Washington Advanced Physical Diagnosis


Learning and Teaching at the Bedside, Edition 1.

Heart Sound Causes


S1 Soft: øCardiac output, tachycardia, ⁄⁄⁄MR
Loud: Hyperdynamic (fever, exercise),
mitral stenosis, atrial myxoma
S2 (Aortic) Soft: Calcific AS
Loud: Systemic hypertension (HTN),
dilated aortic root
S2 (Pulmonic) Loud: Pulmonary HTN
S3 (Low frequency, ⁄Atrial pressure † ⁄flow rates (congestive
early diastole) heart failure [CHF] most common, valvular
regurge, left † right shunts)
Normal in age ⬍40 yr
S4 (Low-frequency Stiffened LV (HTN, AS, ischemic or
presystolic portion hypertrophic cardiomyopathy, acute MR
of diastole) from chorda tendinea rupture)

Jugular Venous Pressure (JVP)

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57
a Small and usually
not visible
c
v
R atrial y
contraction
TV opening and
x
atrial emptying
RV contraction Maximal
and TV closure 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

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Sign Causes
Kussmaul’s (during inspiration, Constrictive pericarditis
JVP ⁄distention; øin normal pt.) (negative in cardiac tamponade)
Severe right heart failure
Hepatojugular reflux (push Right ventricular failure if
liver † ⁄venous return to right JVP remains elevated
atrium) (transient only in normal pt.)
Absent A waves Atrial fibrillation
Sinus tachycardia
Dominant A waves Pulmonary HTN
Pulmonary stenosis
Tricuspid stenosis
Right atrial myxoma
Cannon A wave (very large Ventricular tachycardia
A waves) Complete heart block
Paroxysmal nodal tachycardia
Dominant V wave Tricuspid regurgitation
Absent X descent Atrial fibrillation
Exaggerated X descent Cardiac tamponade
Constrictive pericarditis
Large CV waves Tricuspid regurgitation
Constrictive percarditis
Sharp Y descent Constrictive pericarditis
Tricuspid regurgitation
Slow Y descent Right atrial myxoma
Tricuspid stenosis
Absent Y waves Cardiac tamponade

Abdominal Examination

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59
RUQ LUQ
Biliary colic Gastritis
Cholecystitis LLL pneumonia
Duodenal ulcer Pancreatitis
Hepatitis Splenic problems
RLL pneumonia
Periumbilical
Flank Appendicitis
Abdominal aortic Gastroenteritis
aneurysm Mesenteric
Pylelonephritis lymphadenitis
Renal colic Myocardial
ischemia or
McBurney’s point
infarction
RLQ Pancreatitis
Appendicitis
Cecal diverticulitis Back
Ectopic pregnancy Acute pancreatitis
Ovarian cyst Posterior
Ovarian torsion duodenal ulcer
Tubo-ovarian Retrocecal
abscess appendicitis
Ruptured AAA
Suprapubic
LLQ
Ectopic pregnancy
Diverticulitis
Endometriosis
Ectopic pregnancy
Mittelschmerz
Ovarian cyst
PID
Ovarian torsion
Ovarian cyst
Tubo-ovarian
Uterine leiomyoma
abscess
UTI

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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
■ McBurney’s sign: Tenderness right abdomen two-thirds
distance from anterior iliac spine to umbilicus
■ Rovsing’s sign: Palpate LLQ † RLQ pain
Gallbladder Disorders
■ Murphy’s sign: In cholecystitis; pt. breathes out; palpate
below right costal margin at midclavicular line; pt. inspires †
gallbladder moves down, hits your hands; if gallbladder ten-
der then pt. will stop inspiration † ⫹ test; negative in chole-
docholithiasis and ascending cholangitis
■ Charcot’s triad: In cholangitis; RUQ pain, fever, chills,
jaundice
Retroperitoneal Hemorrhage
■ Cullen’s sign: Bluish periumbilical discoloration
■ Grey Turner’s sign: Flank discoloration

Vaginitis
Candida Vulvovaginitis
■ Discharge: Dry cottage cheese–like
■ Symptoms: Vaginal/vulvar pruritus, irritation, burning, sore
■ Examination: Vulva: red, edema, and adherent white clumps
Bacterial Vaginosis
Amsel’s criteria (3 of 4 needed for diagnosis):
■ Discharge: Gray-white, thin, homogenous, adherent
■ Vaginal pH ⬎4.5 (normal pH: 3.8–4.5)
■ 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

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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, øørugae, pH 5–7

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 Prehn’s sign
Spermatic
cord Torsion

Testicular
veins
Varicocele
Testicular Spermatocele
artery
Epididymitis

Vas deferens

Epididymis

Testicle
Hydrocele

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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
I II III IV V
⬍10 y.o. 10–11 y.o. 12–14 y.o. 13–15 y.o. 16⫹ y.o.

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None Small amount; Dark, coarse, Adult quality; Adult (extends
long, downy, starts to curl note distribution to medial
slightly and extend (spare medial thigh)
pigmented laterally thighs)

Pubic Hair
FADavis_Chapter 02.qxd

63
Tanner Stages

Male
9/12/08

(continued)
3:40 PM
Page 63
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I II III IV V
⬍10 y.o. 10–11 y.o. 12–14 y.o. 13–15 y.o. 16⫹ y.o.
No Areola widens; ⁄Elevated, extends ⁄Size, ⁄elevation; Adult; areola
budding budding, small beyond areolar areola ⫹ papilla back to breast
glandular tissue borders; areola form secondary contour;

Breast
surrounds widens mound papilla projects
FADavis_Chapter 02.qxd

64
Female
Testicle 1.6–6 mL; skin 6–12 mL; 12–20 mL, ⬎20 mL,
volume thins, reddens, penis adult
9/12/08

⁄⁄Scrotum
⬍1.5 mL; enlarges; penis: lengthens (and darkens);
penis no change penis: ⁄length,

Testicles
small ⁄circumference
3:40 PM
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65
Stages of Labor

Cervical
Comments Duration Dilation
Contractions ⁄ frequency, Most 0–4 cm
Latent

strength,and regularity; variable


cervical thinning or hours to
1st Stage

effacement days
Most rapid cervical Average 4–10 cm
dilation nulliparous:
Active

5 hr;
multiparous:
2 hr
May blend into active 15 min–3 hr 7–10 cm;
(Deceleration)

phase; more rapid descent; slower


Transition

baby passes lower into pace


pelvis and deeper into
birth canal; when no
anesthesia, often vomiting
and shaking
3rd Stage 2nd Stage

Female actively pushes Nulliparous: Complete


(birth)

out baby 2–3 hr


Nulliparous: ⬎1 cm/hr Multiparous:
Multiparous: ⬎2 cm/hr ⬍1 hr
⬍1–30 min
(placenta
delivery)

Accelerated by
breastfeeding (release
oxytocin) or pitocin

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

Placenta prematurely detaches


Blood (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

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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 Frank breech


Usually normal vaginal delivery position

• Vertical or • Vertical or
longitudinal lie longitudinal lie

• Legs pointed
straight
upward

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

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Front Metopic
Anterior fontanelle
suture
(closes at age 18–24
months, may bulge
Frontal Frontal
with crying or ICP)
bone bone

Coronal
suture Parietal Parietal
bone bone
Sagittal
suture

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

Obstetric Visits and Testing Timeline

68
0 10 20 30 40
Weeks 16 24 28 32 35 37
Every 4 weeks Q 2–4 wks Q 1–2 Q 0.5–1 wk
OB Visits Fetal heart tone Fetal Fundal height
with Doppler General Fetal movement heart & toxemia
tone signs

H&P
Initial Visit Labs
HgB/HCT, blood type, Rh antibody Gonorrhea, chlamydia,
screen, RPR/VDRL, rubella Ab, hep group B strep cx
Bs Ag, UA, urine C&S, Pap (thin
prep), wet prep, PPD, HIV, TSH,
gonorrhea, chlamydia
Sickle cell, Tay-Sachs, cystic fibrosis, VZV, genetic screen, and urine tox screens

Uterus size
Symphysis pubis Midpoint S pubis/umbilicus Umbilicus Size (cm) = Week of gestation
4 regular contractions in 20 minutes or 8 regular contractions in 60 minutes with PROM
FADavis_Chapter 02.qxd

Preterm labor with progressive effacement >80% and cervical dilation >1 cm
69

Biophysical
profile
Non-stress test
RhoGAM If Rh (–)
9/12/08

Pregnancy-
associated Optional
plasma protein
Triple Screen:
␤-HCG, AFP,
estradiol
One-hour If > 140 & 3 hr wnl, then repeat
glucola test @32 wks
3:40 PM

Ultrasound Gestational age Fetal survey prn


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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 (ⱕ5 mm), nodule (⬎5 mm),
pustule (pus-filled)
■ Blister: Fluid-filled vesicle (ⱕ5 mm), bulla (⬎5 mm)

Shoulder Examination

Range of Motion (ROM)


■ Adhesive capsulitis (frozen shoulder): Stiffness, pain, and
ørange 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 0–180°
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

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Impingement (of Rotator Cuff Tendons)


Inflammation (tendonitis, bursitis), bone spurs, or ⁄fluid † squeez-
ing rotator cuff (supraspinatus) tendon against bone (acromion);
tendon may have tiny tears † scar tissue † further damage; night-
time 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; pos-
itive: pain

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

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73
Biceps
Yergason’s 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 insert-
ing 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
Gerber’s 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

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Glenohumeral Joint Instability


“Giving way” feeling or periodic shoulder dislocation; cannot keep
humeral head centered in glenoid socket; shoulder pain in throw-
ing 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 depres-
sion 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
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75
displacement; quantify displacement (mm), and grade end point:
hard (anterior cruciate ligament [ACL] halts forward motion) or
soft (no ACL)

Lachman’s: Anterior drawer variant; flex (15°–20°) 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 sub-
luxes 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

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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
MacMurray’s 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)

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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 hori-
zontal; excessively tight lateral retinaculum † no upward
movement
Soloman’s 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 0°–30°; 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

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Upper and Lower Extremity Muscles

Part Action Muscle Root Nerve


Arm Externally Infraspinatus C5 Suprascapular
rotate
Abduct Supraspinatus
Deltoid C5 Axillary
Elbow Flex Biceps C5–6 Musculocuta-
neous
Brachioradialis Radial
Extend Triceps C8 Radial
Wrist Extend Extensor carpi C6–7 Radial
radialis longus
Extensor carpi C7
ulnaris
Flexor carpi ulnaris C8 Ulnar
Flex Flexor carpi radialis C6–7 Median
Finger Extend Extensor digitorum C7 Radial
5th Abduct 1st dorsal T1 Ulnar
Finger interosseous
Abduct digiti minimi
Thumb Abduct Abductor pollicis T1 Median
brevis
Oppose Opponens pollicis Median
Hip Extend Gluteus maximus L5–S2 Inferior gluteal
Flex Iliopsoas L2,L3 Femoral
Abduct Gluteus medius and L4–S1 Superior
minimus, tensor gluteal
fasciae latae
Thigh Abduct Abductors L2–4 Obturator

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79
Part Action Muscle Root Nerve
Knee Extend Quadriceps femoris L3–4 Femoral
Flex Hamstrings L5–S1 Sciatic
Ankle Dorsi Tibialis anterior L4–5 Peroneal
(flex)
Plantar Gastrocnemius S1–2 Tibial
Soleus
Foot Evert Peronei L5–S1 Peroneal
Invert Tibialis posterior L4 Tibial
Toes Dorsiflex Extensor digitorum L5–S1 Peroneal
longus
Extensor digitorum S1
brevis

H&P
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 80

ALGOR

Algorithms
Hyperprolactinemia (⬍100 ng/mL)
■ Ectopic production
■ Breast stimulation (e.g., breastfeeding)
■ Δ metabolism (liver failure, renal failure)
■ Hypothyroidism
■ Medications (e.g., oral contraceptives, antipsychotics, antide-
pressants, 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)
■ Cushing’s disease
■ Nonclassic congenital adrenal hyperplasia
■ Exogenous androgens
■ Thyroid disease
■ Acromegaly

Uterine Outflow Obstruction


■ Asherman’s syndrome
■ Cervical stenosis

Hypergonadotropic Hypogonadism
(Ovarian Failure)
■ Postmenopausal
■ Premature failure: e.g., autoimmune, chemotherapy,
galactosemia, genetic, 17-hydroxylase deficiency syndrome,
mumps, pelvic radiation
80
Primary Amenorrhea

Pelvic Normal Breast development & Abnormal


ultrasound female Tanner stage
Normal Short
No uterus Height
Uterus <5 >40
ng/mL ng/mL
LH

ALGOR
Hyperandrogenism? Karyotype
Yes <5 >40
ng/mL ng/mL
46XX 46XY FSH
Polycystic ovary
syndrome
Adrenal or Karyotype
FADavis_Chapter 03 .qxd

81

ovarian tumor
No
46XX 46X0

Uterine outflow Mullerian Male Pituitary Turner’s


obstruction? dysgenesis pseudohermaphrodite defect
9/12/08

No Yes

Second-Degree Imperforate GnRH Normal Buccal Abnormal Pure gonadal


Amenorrhea hymen deficiency smear dysgenesis
Transverse
vaginal septum
3:48 PM
Page 81
Secondary Amenorrhea
+ Pregnancy
Pregnancy test

Abnormal
TSH Thyroid
ALGOR

disease

Hyperprolactinemia Prolactin
Normal
Vaginal bleeding
FADavis_Chapter 03 .qxd

82
<7 days Progestin No bleeding
challenge

Normogonadotropic hypogonadism Estrogen/progestogen challenge


Vaginal bleeding No bleeding
9/12/08

<5 ng/mL >40 ng/mL


LH Hypergonadotropic Uterine outflow
Hypogonadotropic hypogonadism
hypogonadism <5 ng/mL >20 ng/mL obstruction?
FSH (ovarian failure)
Vaginal bleeding <7 days
3:48 PM
Page 82
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 83

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

Causes of Renal Azotemia


Cause Findings
Glomerulonephritis UOsm ⬎500, FENa ⬍1
Urine: RBC casts and dysmorphic RBC
Acute tubular necrosis UOsm ⬍350, FENa ⬎1
Urine: Pigmented, granular casts
Ethylene/methylene Metabolic acidosis and ⁄ osmolal
glycol toxicity gap
Tumor lysis syndome ⁄ Uric acid, ⁄ phosphate, and ⁄ K⫹
Multiple myeloma ⁄ Globulins
Interstitial nephritis Urine eosinophilia, skin rash; UOsm
⬍350, FENa ⬎1
Atheroembolism Livedo reticularis and eosinophilia

Nephrotoxic Agents
Mechanism Examples
Tubular toxicity Aminoglycosides, radiocontrast,
amphotericin B, cisplatinum, heavy metals,
cyclosporin
Tubular Acyclovir, sulfonamides, ethylene glycol,
obstruction methotrexate
Interstitial Penicillin, cephalosporin, sulfonamides,
nephritis rifampin, NSAIDs, furosemide, thiazides,
allopurinol
Renal ACE inhibitors, NSAIDs, cyclosporin,
hemodynamics radiocontrast, amphotericin

ALGOR
Workup of Acute Renal Failure

Indications for K+, volume, metabolic acidosis; Yes


Dialysis
urgent dialysis? sx of uremia, pericarditis, encephalopathy
No
ALGOR

■ ⁄⁄⁄ stress or depression

Stop nephrotoxic agents


No
FADavis_Chapter 03 .qxd

84
irradiation, Sheehan’s syndrome)

Transurethral catheterization Obstruction Postrenal Enlarged prostate,


& renal ultrasound azotemia mass, stones
No obstruction

FENa <1, UOsm >500 Yes Prerenal CHF, liver failure,


9/12/08

Hypovolemia? Few hyaline casts, BP azotemia dehydration, volume loss


No
■ Hypothalamic or pituitary destruction (e.g., tumor,

Renal azotemia
3:48 PM
Page 84
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 85

85
Macrocytic Anemia Workup

MCV
Macrocytic >97 fL

Megalocytes

Yes No

Megaloblastic Nonmegaloblastic

B12, folate Abs corr retic


count
Low Normal Low or normal High

Deficiency Drug Liver/ Hemolytic dz


idiopathic thyroid dz Acute blood
loss
Hypersplenism
Schilling Bone No
marrow rx

Aplastic
anemia

ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 86

ALGOR

Microcytic Anemia Workup

MCV
Microcytic <82 fL

Ferritin

Low Normal or high

Fe deficiency Lead

Normal
High

Hgb Lead
electrophoresis toxicity

Thalassemia, other

86
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 87

87
Normocytic Anemia Workup

MCV
Normocytic 82–97 fL

Corrected abs
retic count

Low or normal High

LDH, Suspect
haptoglobin marrow
failure
Normal High Yes No

Blood loss Coombs Bone Anemia of


marrow ex chronic
Positive Negative disease

No
Hemolytic Splenomegaly
anemia Yes

Hypersplenism, drugs, infection, hemoglobinopathy

ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 88

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 C ardiogenic
s hock s hock
Assess volume status
Mild hypotens ion
or normal
Give 0.9% NaCl Corrected serum Na+ Give fluids based
1.0 L/hour until on hemodynamic
correct shock monitoring
or normal
IV: 0.45% NaCl at IV: 0.9% NaCl at
4-14 mL/kg/hour 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
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 89

89
Diabetic Ketoacidosis (continued)
2 Insulin Therapy
<3.3 mEq/L (3.3 mmol/L)
>3.3 mEq/L Check serum K+
(3.3 mmol/L)
Hold insulin
IM/SC insulin
IV insulin
Monitor and give K+

IV regular bolus: 0.15 units/kg IV regular bolus: 0.2 units/kg


+0.2 units/kg IM or SC

0.1 units/kg/hour 0.1 units/kg/hour IV


insulin IM or SC IM or SC
IV

Serum glucose by 50-70 mg/dL/hour


Yes No

Continue above therapy Double insulin OR Hourly IV insulin


infusion hourly bolus of 10 units
Serum glucose
< 250 mg/dL
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 Serum potassium
<3.3 mEq/L 3.3-5.0 mEq/L >5.0 mEq/L

Hold insulin and give Give 20-30 mEq No K+; monitor


40 mEq K+/hour until K+/L of IV fluid every 2 hours
K+ >3.3 mEqL/L until K+ <5.0
mEq/L

(continued )

ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 90

ALGOR

Diabetic Ketoacidosis (continued)


4 No
pH <6.9? 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, Normal
respiration,
or anemia

Consider giving 1/3-1/2 Monitor serum phosphate and


K+ as K+-phosphate consider treatment if level
<1.0 mg/dL (0.30 mmol/L)

Also monitor calcium

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

No
Symptomatic? Monitor magnesium; Monitor as
consider oral needed
Yes magnesium replacement

Magnesium replacement IV if major symptoms


(e.g., life-threatening arrhythmias)

90
GI Bleed
Yes
Airway endangered? Intubate
No

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


Larger bleeds: Central access with PA catheter introducer

ALGOR
CBC, PT/PTT, type and cross
50 mL normal saline
boluses until mean
Low BP of 70
Blood pressure
FADavis_Chapter 03 .qxd

91

Normal or elevated

NG lavage
Negative
Positive for blood
Consider lower
GI source
9/12/08

Emergent Yes
Bright red blood fails to clear after 1 L lavage
endoscopy
Anoscopy,
No
sigmoidoscopy
Peptic ulcer Varices Start empiric H2-blocker
Tagged RBC scan,
H2-blocker Octreotide angiogram, or
3:48 PM

or PPI FFP Consider endoscopy colonoscopy


Page 91
Hematuria Workup
No blood
Drugs, dyes, melanin Urine dipstick
Positive for blood

No RBCs
Myoglobin, Urinalysis
hemoglobin
ALGOR

RBCs
Macroscopic; isomorphic RBCs; Dysmorphic
Pyuria
no proteinuria RBCs/RBC casts

IVP or CT Urine culture Likely glomerular,


FADavis_Chapter 03 .qxd

92
Workup for GN
Consider biopsy
Negative
+ –
9/12/08

UTI Empiric therapy for culture


Mass or negative infection
Cystoscopy
stones Treat Consider interstitial nephritis

Adapted from Li, T. Approach to Hematuria. In: Agha, IA, Green, G, eds.
The Washington Manual: Nephrology Subspecialty Consult. Phialdelphia: Lippincott, 2004,
3:48 PM

and htttp://www.acpmedicine.com/sample/ch10083-f3.htm
Page 92
Hypercalcemia Workup
Yes
IV fluids Correctable by hydration

Normal
Not true hypercalcemia Ionized calcium
Elevated

ALGOR
Stop meds Caused by medications: (e.g.; Excess Familial
Recheck Ca2+ thiazides, lithium, vitamin A or D) Ca2+/ hypocalciuric
in 48-72 hrs vitamin D hypercalcemia
No or
Acute Chronic aluminum
FADavis_Chapter 03 .qxd

93

ATN recovery Renal failure? toxicity


Low
No
PTH-
related High Low
peptide Risk of malignancy
(H & P, CXR, PO4, alk phos) Urinary Ca
High
9/12/08

High Normal High


1°, 3° hyperparathyroidism PTH
Squamous cell Lung carcinoma
(lung, head, & (small, large, adeno, Low
neck), renal cell broncho-alveolar), Granulomas (e.g.;
carcinoma, myeloma, breast, TB, sarcoid, Endocrine (hyperthyroid,
hepatoma, thyroid, prostate histoplasmosis, Addison, acromegaly,
3:48 PM

lymphoma coccidioidomycosis) pheochromocytoma)


Page 93
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 94

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
Hyperkalemia (K+>5.0 meq/L) Management

Lab error, blood draw issues (from vessel with potassium


S purious infusion, fist clenching, tourniquet, traumatic),
Rule out pseudohyperkalemia, hemolysis, leukocytosis,
spurious causes thrombocytosis, genetic syndromes, familial
R eal pseudohyperkalemia, hereditary spherocytosis

S udden rapid ris e or >6.0 meq/L

ALGOR
Serum K+
Emergent Treatment
<6.0 meq/L P eaked or tented T
S T depres s ion
F irs t-degree AV block or los s of P
ECG QR S widening IV calcium gluconate
FADavis_Chapter 03 .qxd

95

B iphas ic wave (s ine wave): QR S & T fus ion


Normal Imminent ventric ular s tands till

Shift K+ intracellular
A bnormal
Renal function
Insulin + glucose +/-
Normal albuterol
9/12/08

P res ent
Metabolic acidosis
A bs ent
Increase K+ excretion R efrac tory
Hemodialysis
Sodium polystyrene sulfate (Kayexelate) & furosemide
3:48 PM

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


Page 95
Hypernatremia (Na+<135 meq/L) Workup

Volume status

Decreased Normal Increased


ALGOR

Urine sodium Urine osmolality Salt excess


Urine osmolality

>700 mOsm/L <700 mOsm/L

Osmotic diuresis Diabetes insipidus


FADavis_Chapter 03 .qxd

96
Response to DDAVP?

UNa <10 mEq/L UNa >10 mEq/L


UOsm >700 mOsm/L UOsm <700 mOsm/L Yes No
9/12/08

Central Nephrogenic
Hypotonic fluid loss, Renal hypotonic diabetes diabetes
Insensible loss, fluid loss, insipidus insipidus
GI loss Diuretics,
Osmotic diuresis
3:48 PM
Page 96
Hypocalcemia Workup
Normal
Low albumin Ionized calcium

ALGOR
Low

Low Appropriately
Hypomagnesemia mg2+ PTH PO4 3 - Hyperphosphatemia
Normal Normal
FADavis_Chapter 03 .qxd

97

Hypoparathyroidism Amylase & lipase Pancreatitis


or renal wasting
Normal

Vitamin D
9/12/08

Drugs (colchicine, phenytoin)


Pseudohypoparathyroidism
3:48 PM
Page 97
Hypokalemia (K+<3.5 meq/L) Workup

Spurious Increased loss Distribution defect


Check urinary spot K+ AML, insulin excess,
alkalosis, hyperglycemia,
>20 mEq/L <10 mEq/L periodic paralysis, B12 therapy
ALGOR

Renal loss Nonrenal loss


Check BP Diarrhea, biliary loss, small
intestinal fistula, laxative abuse
Elevated Normal
FADavis_Chapter 03 .qxd

98
Decreased RTA Type 1
Hyperaldosteronism Plasma HCO3
state RTA Type 2
Increased

>10 Bartter’s, diuretics,


Plasma renin Urinary Cl normotensive
9/12/08

hyperaldosteronism

Increased Decreased Vomiting with


Secondary Primary <10 metabolic alkalosis
hyperaldosteronism hyperaldosteronism
Hyperaldosteronism
3:48 PM

state
Page 98
Hyponatremia (Na+<135 meq/L) Workup

Normal Plasma osmolality High


(280-295 mOs m/kg) (>295 mOs m/kg)
L ow (<280 mOs m/kg)

Pseudohyponatremia Hypotonic hyponatremia Hypertonic


hyponatremia
Hyperproteinemia

ALGOR
Hyperlipidemia Urine osmolality Hyperglycemia
Mannitol therapy
<100 mOs m/kg >100 mOs m/kg

Excess H2O intake Volume status


FADavis_Chapter 03 .qxd

99

Dec reas ed Normal Inc reas ed


<20 meq/L >20 meq/L UOs m>200, <20 meq/L >20 meq/L
Urine sodium UNa>20 Urine sodium
Hypothyroidism
Adrenal
Extrarenal Renal loss insufficiency Renal Edematous states,
loss Diuretics Drugs disease Liver dz,
9/12/08

(GI, skin) (early) SIADH CHF,


Nephrotic
H2O restriction and treat syndrome
underlying disorder;
Isotonic fluid hypertonic saline
replacement for life-threatening Water restriction
3:48 PM

hyponatremia and diuretics


Page 99
Hypoxia Diagnosis

Inc reas ed A-a Gradient (PA-aO2) Dec reas ed


> [A ge (yrs ) + 4] /4 < [A ge (yrs ) + 4] /4

PaCO2
ALGOR

Inc reas ed Type II respiratory failure Respiratory acidosis


Normal or low COPD exacerbation Sleep apnea
Status asthmaticus Sedative overdose
CXR Neuromuscular weakness
Central hypoventilation
FADavis_Chapter 03 .qxd

100
C lear F oc al infiltrates Diffus e infiltrates

Consider PE Pneumonia, atelectasis Hemodynamic


monitoring
9/12/08

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


Wedge pres s ure > 16,
C ardiac index <2.5
ARDS Cardiogenic
pulmonary edema
3:48 PM
Page 100
Hypoxia Management

Pulse oximetry & supplemental O2

ALGOR
>90% <90%
SpO2
FADavis_Chapter 03 .qxd

101

Continue oxygen Mental status


Treat underlying cause Hemodynamic measurements
Close monitoring

⌬MS and/or unstable


Normal and
9/12/08

stable
No improvement
Intubation NIPPP (e.g., BIPAP)
3:48 PM
Page 101
Hypoxia Mechanical Ventilation (Initiation)
PaO2 <55 mm Hg, PaCO2 >50 mm Hg
Indications for intubation: respiratory distress, and pH <7.32
⌬ mental status, respiratory acidosis, Vital capacity <10 mL/kg
refractory hypoxemia, airway protection Negative inspiratory force <25 cm H2O
FEV1 <10 mL/kg
ALGOR

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

Assess clinically and check ABG in 10-15 min


FADavis_Chapter 03 .qxd

102
Respiratory Respiratory Adequate Inadequate
pH and PaCO2 PaCO2 PEEP
alkalosis acidosis
NI/baseline Correct anemia
FiO2 by 10% at a time:
9/12/08

TV No TV follow SpO2, consider Sedate/paralyze


RR ⌬TV/RR** RR early warning
Healthy side dependent
*COPD: Tidal volume = 10 mL/kg;
rate = 10/minute (prevent hyperinflation)
ECMO?
ARDS: Tidal volume = 6-8 mL/kg;
rate = 10-12 /minute (prevent volutrauma)
Consider pressure control ventilation with inverse I:E ratio
3:48 PM

**Sedate/paralyze/control pain
Page 102
Infertility
Male Female
High Low <5 ng/mL >40 ng/mL
Testosterone LH
Normal <5 ng/mL >20 ng/mL
FSH
LH LH LH

ALGOR
Abnormal Normal
High Prolactin
FSH FSH
FSH
Normal Normal
MRI r/o Ovarian
pituitary failure
FADavis_Chapter 03 .qxd

Androgen Testicular
103

adenoma
receptor ultrasound
insensitivity

Hysterosalpingogram
r/o retrograde and laparoscopy
ejaculation,
9/12/08

hypospadia

Low High

Primary MRI r/o


hypogonadism pituitary
3:48 PM

adenoma
Page 103
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 104

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: Miller’s Anesthesia, 6th ed

104
Mechanical Ventilation: While on Ventilator

Acute respiratory distress: tachypnea, hypoxemia, respiratory acidosis

Peak pressure
Increased Decreased

ALGOR
No ⌬

Plateau pressure Pulmonary thromboembolism, Air leak,


extrathoracic process Hyperventilation
(e.g., pain anxiety,
FADavis_Chapter 03 .qxd

No ⌬ agitation)
105

Increased

Decreased Compliance Increased Airway Resistance


Abdominal distention (e.g., gas from positive Acute bronchospasm, aspiration,
pressure ventilation, pneumoperitoneum, endotracheal tube obstruction (e.g., kinking
9/12/08

ascitic fluid, peritoneal dialysis), atelectasis or clenching teeth), obstruction from retained
(e.g., lobar collapse), large pleural effusions, airway secretions (e.g., mucous plugging)
pneumothorax, stiff lung (e.g. acute respiratory
distress syndrome, cardiogenic pulmonary
edema, fluid overload, pneumonia),
hyperinflation (e.g., auto-PEEP in COPD)
3:48 PM
Page 105
Mechanical Ventilation: Modes
Mode Ventilator Breath Initiated
Continuous mandatory ventilation (CMV) At preset intervals, regardless of patient effort
With patient’s respiratory effort; no spontaneous breathing allowed;
Assist-control ventilation mandatory minimum set rate; patient can easily minute ventilation,
but cannot wean rate, on PIP or Vt
ALGOR

Intermittent mandatory ventilation (IMV) At preset interval, spontaneous breathing allowed between breaths
Synchronous intermittent At preset and coordinated with patient’s respiratory effort;
mandatory ventilation (SIMV) spontaneous breathing allowed between breaths
Spontaneously by patient; set level of support pressure (not TV) to assist every
Pressure support spontaneous effort; airway pressure support maintained until patient's
FADavis_Chapter 03 .qxd

inspiratory flow falls below certain cutoff (e.g., 25% of peak flow)

106
No ventilator breath; deliver set pressure to airways maintain lung volume
Continuous positive
and improve oxygenation; FRC and work of breathing (exhale vs. pressure)
airway pressure (CPAP)
may impaired ventilation

No ventilator breath; delivers pressure expiration to keep alveoli open


Positive end expiratory pressure (PEEP)
preserve functional residual capacity (FRC)
9/12/08

Mode Ventilator Breath Terminated


Volume cycled After specified breath volume delivered
Pressure cycled After set pressure attained within ventilator
3:48 PM

Time cycled After set period of time


Page 106
Solitary Thyroid Nodule
Normal or
Radioactive TSH Thyroid
thyroid scan ultrasound

ALGOR
Cold nodule

Hot nodule <1 cm


>1 cm
Cystic Solid
Consider
FADavis_Chapter 03 .qxd

107

radioactive Drainage Fine needle


ablation aspiration

Benign Inconclusive Malignant


9/12/08

Repeat fine needle aspiration in 6 months Normal Frozen Abnormal Surgery


Repeat thyroid ultrasound every 1-2 years section
3:48 PM
Page 107
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 108

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
com- pain to pain to pain to pain
mands
Verbal Oriented Confused Inap- Incom- None
propri- prehen-
ate sible
Eye Sponta- To com- To pain None
opening neous mand
Coma score: ⱖ13 correlates with mild brain injury; 9–12 †
moderate injury; ⱕ8 † severe injury

Tissue Plasminogen Activator


for Acute Stroke Yes No

Evidence of intracranial hemorrhage (e.g., on CT ⫺5 1


scan)?
Suspicion of subarachnoid hemorrhage? ⫺5 1
Recent intracranial surgery, serious head trauma, or ⫺5 1
recent prior stroke?
History of intracranial hemorrhage? ⫺5 1
Uncontrolled hypertension (HTN) at treatment time ⫺5 1
(⬎185 systolic or ⬎110 diastolic)?
Seizure at stroke onset? ⫺5 1
Active internal bleeding? ⫺5 1
Intracranial neoplasm, arteriovenous malformation, ⫺5 1
or aneurysm?
Known bleeding diathesis? ⫺5 1

108
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 109

109
Yes No
Current oral anticoagulant use with PT over 15? ⫺5 1
Use of heparin within last 48 hours and elevated PTT? ⫺5 1
Platelet count ⬎100,000? ⫺5 1
Stroke symptom onset more than 3 hours ago? ⫺5 1
Severe neurologic deficit (e.g., NIHSS ⬍22)? 0 1
Major early infarct signs on CT (⁄⁄edema, mass 0 1
effect, or midline shift)?
Total score: 15 thrombolysis indicated; ⬍13
thrombolysis contraindicated

Migraine Without Aura (Common Migraine)


A. Attacks last 4–72 hr (untreated or unsuccessfully treated)
B. ⱖ2 of following 4 headache characteristics:
1. Unilateral 2. Pulsating 3. Moderate to severe (disturbing or
precluding daily activity) 4. ⁄ by movement
C. ⱖ1 of following 3 associated symptoms:
1. Nausea/vomiting 2. Photophobia 3. Phonophobia

Migraine With Typical Aura (Classic Migraine)


ⱖ1 transient focal neurologic aura symptoms:
1. Visual (99%) 2. Sensory (31%) 3. Aphasic (18%) 4. Motor
(6%); occasional pts. may have atypical aura

ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 110

ALGOR

Gradual development of aura symptoms over ⬎4 min or several


symptoms occurring in succession (usu. alternating body sites in
different attacks)
Aura symptoms ⬎4–60 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 symp-
toms with acute onset that does not spread 3. Aura symptoms
duration ⬍5 min or ⬎60 min 4. Sudden Δ in migraine character-
istics 5. Sudden and substantial ⁄ attack frequency (check for sub-
stance abuse) 6. Onset above age 50 yr 7. Aura without headache
8. Associated with high fever 9. Abnormal neurologic examina-
tion results

Canadian Head CT Rule for Minor


Head Injury
High risk GCS ⬍15 at 3 hr postinjury
Possible open or depressed skull fracture
Any sign of basal skull fracture
ⱖ2 vomiting episodes after injury ⬎65 y.o.
Intermediate risk 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
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 111

111
Cardiovascular

o Left Ventricular Hypertrophy (LVH)

New York Heart Association (NYHA) Functional


Classification for Congestive Heart Failure (CHF)
Class Description
- I No activity limit; no symptoms from ordinary activity
s II Slight, mild activity limit; comfortable with rest or
- mild exertion
- III Marked activity limit; comfortable only at rest
e IV Should be at complete rest, bed/chair confined; any
- phys activity brings discomfort; symptoms at rest

Duke Criteria for Infective Endocarditis (IE)


A. ⫹Blood Culture (BCx) for IE: 1. Two separate BCx † typi-
cal IE organism (S. viridansococci, S. bovis, HACEK* group,
Minor Criteria

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 alter-
nate 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 ⬎38.0°C (100.4°F) C. Vascular
Minor Criteria

phenomena: Major artery emboli, septic pulmonary infarct,


mycotic aneurysm, intracranial hemorrhage conjunctival
hemorrhage, and Janeway’s lesion D. Immunologic phenom-
ena: glomerulonephritis, Osler’s nodes, Roth’s spots, and
rheumatoid factor E. Micro: ⫹BCx but not meet major crite-
rion 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

ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 112

ALGOR

Ear, Nose, and Throat

Diagnosis of Ménière’s Disease


Possible: 1. Episodic Ménière’s-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 ⱖ1 occasion 3. Tinnitus or aural
fullness in treated ear 4. Other causes excluded
Definite: 1. ⱖ2 definitive spontaneous vertigo episodes ⱖ20 min
2. Audiometrically documented hearing loss ⱖ1 occasion
3. Tinnitus or aural fullness in treated ear 4. Other cases
excluded
Certain: Definite Ménière ‘s ⫹ histopathologic confirmation

Gastrointestinal

Child-Pugh Score for Grading Hepatic


Cirrhosis
Parameter 1 2 3
Total bilirubin (mg/dL) ⬍2 2–3 ⬎3
Serum albumin ⬎3.5 2.8–3.5 ⬍2.8
PT (sec prolonged) 1–4 4–6 ⬎6
Hepatic encephalopathy None Grade 1 or 2 Grade 3 or 4
grade
Ascites None Mild Severe/tense
Total score: 5–6 † Grade A † good operative risk; 7–9 † Grade
B † moderate operative risk; 10–15 † Grade C † poor
operative risk

112
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 113

113
Ranson’s Criteria for Pancreatitis
On admission Yes No
Age ⬎55? 1 0
WBC ⬎16K/cubic mm? 1 0
Blood glucose ⬎200 mg%? 1 0
Serum LDH ⬎350 IU/L? 1 0
Serum SGOT ⬎250 SF units? 1 0
Within 48 hr of admission
Hct fall ⬎10%? 1 0
BUN rise ⬎5 mg/dL? 1 0
Serum calcium ⬍8 mg%? 1 0
Arterial pO2 ⬍60 mm Hg? 1 0
Base deficit ⬍4 mEq/L? 1 0
Fluid sequestration ⬎6L? 1 0
Predicted mortality if total score: ⬍3 † 1%; 3–4 † 15%;
5–6 † 40%; ⬎6 † 100%

Liver Disease and AST-to-ALT Ratio


EtOH⬎ 1.5 Intrahepatic cholestasis ⬎1.5
Drug⬎ 2.0 Extrahepatic cholestasis 0.7–0.8
Cirrhosis 1.4–2.0 Acute viral hepatitis ⱕ0.65
Hepatocellular ⬎1.5 Acute MI ⬎3.0
carcinoma

ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 114

ALGOR

Genitourinary

Bishop’s Score for Elective Induction


of Labor
Measure 0 1 2 3
Cervix ⬍1 1–2 3–4 ⬎4
dilated
Cervical ⬎4 cm 2–4 cm 1–2 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 ⱖ5 and rupture of membranes

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115
Ectopic Pregnancy Risk
Questions Yes No
Peritoneal signs or definite cervical motion 2 0
tenderness?
Pain or tenderness, other than midline cramping, 1 0
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 Points


Total
Measure 2 1 0
Heart rate ⬎100 ⬍100 0
Breathing Nl Irregular Absent
Muscle tone/ Active Moderate Limp
movement
Skin color/ Pink Bluish Totally
oxygenation extremities blue
Reflex Crying Whimpering Silence
response to
irritable
stimuli
Total ⱖ7 is normal, and ⬍7 ⫽ distress
Analyte Urine Amniotic Fluid
Bilirubin ⫺ May be present
Creatinine ⁄(ⱖ20) ~Plasma (0.8–4.0)
(mg/dL)
Osmolal 500–800 230–295
(mOsm/kg
H2O)
(continued )

ALGOR
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 116

ALGOR

APGAR Score (Continued )

Analyte Urine Amniotic Fluid


pH Usually Neutral or alkaline
acidic (6.91–7.43)
Protein(mg/dL) ⫺ (1–14) ⫹ (70–840)
Specific gravity 1.005–1.030 1.025
Urea (mg/dL) ⁄(~500–1000) ~Plasma (12.1–41.7)

Biophysical Profile (BPP) Score


Questions Yes No
Heart rate: Normal non-stress test 2 0
Breathing: ⱖ1 breathing episode in 30 min 2 0
Movement: ⱖ2 movements within 30 min 2 0
Muscle tone: ⱖ1 active limb extension and 2 0
flexion episodes (i.e. open/close hand)
Amniotic fluid: ⱖ1 adequate fluid pockets 2 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

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117
Additional criteria: 1. temperature ⬎38.3°C (101°F) 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

Amsel’s 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
Chapter 04 .qxd 9/12/08 3:51 PM Page 118

EQUAT

Cerebral Spinal Fluid (CSF)


Measure Equation
Corrected CSF  CSF proteinin mg/dL  (CSF
protein in traumatic LP RBC/1000)
Corrected CSF WBCs for  CSF WBCs detected  (WBC in
RBCs blood  RBC in CSF/RBC in blood)
CSF IgG Index  [IgG (CSF)/IgG (serum)]/[albumin
(CSF)/albumin (serum)]
Ayala’s quotient  (volume of CSF removed in mL) 
(measures effect of (pressure postremoval of fluid)/
removing CSF on (pressure preremoval of fluid)
pressure) 5.0: ø(subarachnoid block or other
cause of a small CSF reservoir)
5–5.4: borderline ø; 5.5–6.5: Normal;
6.6–7.0: borderline ⁄; 7.0: ⁄
(hydrocephalus, serous meningitis,
or other cause of large CSF
reservoir)

Toxicology Levels
Measure Equation
Half-life (T1/2)  0.693/kelim [0.693  (volume of
distribution)/(clearance)]
kelim  [ln (Cpeak) – ln (Ctrough)]/tinterval
Blood EtOH  (volume ingestedin mL  beverage
concentration “proof”  1.463)/(pt. weightin lb)
Adjusted  phenytoin measured/[(serum
phenytoin albumin  renal function)  0.1] renal
level fx  0.1 if creatinine clear 10 mL/min;
otherwise  0.2
Phenytoin:  (0.55  phenytoin measured/serum
free-drug level albumin)  0.14

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119
Cardiovacular Hemodynamics
Measure Equation/Interpetation
Stroke volume  End diastolic volume  end systolic
(SV) volume Normal: 69–87 mL/beat
SV index (SI)  SV/BSA Normal: 40–50 mL/
contraction/m2
Ejection fraction  (SV  100%)/(end diastolic volume)
(EF) Normal: 55%–78%
Cardiac output (CO)  SV  HR Normal: 3–7 L/min
Blood volume  Plasma volume/(1-Hct) Normal: 2–5.1 L
O2 content in blood  (Hgbin g/dL)  (1.34mL O2/g Hgb) 
(O2 saturationin %)
O2 consumption  BSA * basal O2 consumption  BSA *
125 mL O2/m2
CO (Fick’s method)  (O2 consumption)/{[(O2 content arterial
bloodin vol%)  (O2 content mixed venous
bloodin vol%))  10)]}
CO (indicator-  (60  amount indicator injectedin mg)/
dilution ) [(mean blood concentration
method of indicator)in mg/L)  (time total curve
durationin seconds)]
Cardiac index  SV  HR/BSA Normal:
2.5–4.5 L/min/m2
Heart rate (HR) Normal: 60–100 bpm
Jose and Collison Males:  (0.55  agein years)  118
predicted intrinsic Females:  (0.61  agein years)  119
HR (IHR)
Rate pressure product  (SBPin mm Hg* HRin BPM)/1000
Mean arterial ~ 1/3 * SBP  2/3 * DBP Normal:
pressure (MAP) 70–100 mm Hg
Cardiothoracic ratio  (Transverse diameter of heart on PA
or AP view)/(transverse diameter of
bony thoracic cage) 50% † cardiac
enlargement
(continued )

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Chapter 04 .qxd 9/12/08 3:51 PM Page 120

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Cardiovacular Hemodynamics (Continued )


Measure Equation/Interpetation
QT interval correct  (QT interval)/(Á(RR interval)
(QTc) Normal: 440 msec
RR interval  60/HR
Systemic vascular  (MAP  (mean right atrial pressure))
resistance (SVR)  (80/CO)  (MAP  CVP)  79.92/CO
Normal: 800–1200 dynes/sec/cm5
SVR index (SVRI)  (MAP  CVP)  79.92/CI Normal:
1970–2390
Pulmonary vascular  80  (PA_Pressure  LA Pressure)/
resistance (PVR) pulmonary_flow  80  (mean PA 
mean PCWP)/CO Normal: ~67 / 23
dynes/sec/cm5
PVR index (PVRI)  (Mean PA pressure  PCWP)  80/CI
Normal: 30–240 dyn-s/cm5m2
Shock index  HRin bpm/SBPin mm Hg Persistent ⁄ †
poor prognosis
Normal: 0.5–0.7; 0.9 † admission or
ICU (even with stable VS)
Coronary  DBP  PCWP Normal: 60–80 mm Hg
performance
pressure
Colloid-oncotic  (Globulin  1.4)  (Albumin  5.5)
pressure Normal: 23–29 mm Hg
Pulse pressure  (SBP)  (DBP) Normal: 20–70 mm Hg;
SBP  100–140 mm Hg; DBP 
60–90 mm Hg
Ratio of pulse  (SBP  DBP)/SBP  1  (DBP/SBP)
pressure to Normal: ~0.42; poor prognosis
systolic in CHF: 0.25
pressure
Central venous  (vertical height of jugular venous
pressure (CVP) distention above sternal anglein cm)
in cm H2O  5 cm

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121
CVP in mm Hg  (CVPin cm H2O)/1.36
Mean vascular  DBP  ((SBP  DBP)/3)
pressure
Left cardiac  CI  MAP  0.0144 Normal:
work index 3.4–4.2 kg-m/m2
Left cardiac  CI  MPAP  0.0144 Normal:
work index 540–660 g-m/m2
Left ventricular  SI  MAP  0.0144 Normal:
stroke work 50–62 g-m/m2
index (LVSWI)
RVSWI  SI  MPAP  0.0144 Normal:
7.9–9.7 g-m/m2

Cardiovascular Monitoring
Condition SAP CVP PAP PCWP CO C(a-v)O2 PVR SVR
Hypo- ø ø ø ø ø ⁄ ⁄ ⁄
volemic
Shock Cardio- ø ⁄ ⁄ ⁄ ø ⁄ ⁄ ⁄
genic
Septic ø ø ø ø ⁄ ø ø ø
Cardiac ø ⁄ ⁄ ⁄ ø ⁄ 0 ⁄
tamponade
RV infarct ø ⁄ 0 0 ø ⁄ 0 0⁄
Pulmonary ø ⁄ ⁄ 0⁄ ø ⁄ ⁄ ⁄
embolism
Airway 0⁄ 0⁄ ⁄ 0 0⁄ 0 ⁄ 0
obstruction
Pressure adjusted HR  HR  CVP/MAP

EQUAT
Heart Valves
Valve Gorlin  (CO/(flow_time * HR))/(valve_factor * sqr (valve_gradient))
Chapter 04 .qxd

area Hakki  CO/sqr (ΔP)


Mean Gradient
Problem Comments Stage (mm Hg) Valve Area
EQUAT

Aortic Causes: degenerative, congenital, or Normal 0 3.0–4.0


stenosis rheumatic Mild 25 1.5–2.0

122
9/12/08

(AS) ECG: left atrial enlargement (LAE), Moderate 25–50 1.0–1.5


left bundle branch block, LVH Severe 50 1.0
Critical 8– 0.7
Mitral Causes: rheumatic, valvulitis, congenital, Normal 0 4.0–6.0
stenosis myxoma, thrombus, second-degree to Mild 1–6 1.5–2.0
(MS) severe MAC Moderate 6–12 1.0–1.5
3:51 PM

ECG: LAE (P mitrale), / AFib/RVH Severe 12 1.0


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123
Hematology
Measures Equations
Absolute neutrophil  10  WBCin 1000s  (%PMNs 
count (ANC) %bands)
Neutropenia: 1500 cells/mm3
Transferrin saturation  (Fe/TIBC)  100
(TFS)
Fe replacement Dose  .3  wgt  (100  (Hgb  100)
(parenteral dosing) /age_factor)
for Fe deficiency Adult 15 kg (14.8); child 15 kg

RBC Equations (for other indices see Tab 7)


Index Formula
Estimated Hct  (Hgbin g/dL* 2.8)  0.8  RBC * MCV/10
Hgb at altitude  (6.83 * (e0.000445 * altitude in meters) 
113.3
Hct at altitude  (0.449 * (EXP (0.000859 * (altitudein
meters))))  35.6
Hct-to-Hgb ratio  Hct% as a whole number/Hgbin g/dL
† 3.19: normal; 3.5: hemoconcentration
Absolute reticulocyte  % reticulocytes * (pt.’s Hct/normal Hct)
count
Reticulocyte index  Absolute reticulocyte count/maturation
(2%: adequate factor
response; 2%: Maturation factors: Hct 35%: 1.0; 35% 
øproliferation) Hct 25%: 1.5; 25%  Hct 20%:
2.0; 20%  Hct: 2.5

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Distinguishing Between Fe-Deficiency


and Thalassemia Minor
Formula Equation øøFe Thal. Minor
Mentzer  MCVin femtoliters/ 13 13
RBCs per µL/10^6
England-  ((MCVin femtoliters)  0 (negative)
Fraser ((5 * (HgBin g/dL)) 
(RBC per µL/10^6)  k))
Where k  3.4 if Hct corrected
for plasma trapping (usual)
or 8.4 if not.
M/H ratio M  % microcytes (erythrocyte 0.9 0.9
volume 60 fl)
H  % hypochromic (MCHC
28 g/dL)
RDW &  RDW  HDW 530 530
HDW
product
MCH/RBC  MCH/RBC 4.4 4.4
ratio
RDW/RBC  RDW/RBC 3.3 3.3
ratio
Green and  (MCV2  RDW)/(Hgb 100) 72 72
King

Ventilation Equations
Measures Equations
Minute ventilation  VT  RR
Ventilation index  [RR  (PIP  PEEP)  CO2]/1000
CO2 production  VExp  (FECO2  FICO2) VExp
(VCO2)  expired volume over 1 min.
FECO2 & FICO2  fraction expired
and inspired CO2

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125
Right-to-left  ([pAO2  paO2]  0.003)/
shunt fraction [([pAO2  paO2]  0.003)  5]
(Qs/Qt) 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 capacity  Closing volume  residual volume

Lung Volumes (see lung volume diagram


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

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Chapter 04 .qxd 9/12/08 3:51 PM Page 126

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Lung Volumes (see lung volume diagram


following) (Continued )
Measure Equations
VD/VT  Dead space fraction of TV
Forced VC Volume air expelled forcefully after full breath
(FVC) Normal: 4.0 L
FEV1 Volume air expelled in 1 sec during forced
expiration Normal: 3.0 L FEV1/FVC 60%
FEF25–75  Forced expiratory flow from 25%–75% FVC 
maximum flow when air forcefully expelled
mid-expiration

Predicted Pulmonary Function Tests (PFTs)


for Men
Measure Equation Constant
FEV1  Race  1.08  [(0.043  height) Race:
 (0.029  age)  2.49] Caucasian  1
FVC  Race  1.1  [(0.0576  height) Black  0.87
 (.0269  age)  4.34] Asian  0.93
FEV1/FVC  87.2  (0.18  age)

Predicted PFTs for Women


Measure Equation Constant
FEV1  Race  1.08  [(0.0395  height) Race:
 (.025 * age)  2.6] Caucasian  1
FVC  Race  1.15  [(0.0443  height) Black  0.87
 (.026  age)  2.89] Asian  0.93
FEV1/FVC  89.1(0.19  age)

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127
Predicted PFTs for Children
Measure Males Females
FEV1  e{[(1.2669  (.0174 * Age)]   e{[(1.5016  (.0119 * Age)] 
height)  1.2933 height)  1.5974)
FVC  e{[(1.3731  (.0164 * Age)]   e{[(1.48  (.0127 * Age)] 
height)  1.2782) height)  1.4057)
FEV1/FVC  86.21  88.88

Lung Volumes
Maximum inspiration
Normal resting
inspiration IC IRV
IVC

VT VC

TLC
Normal resting
expiration ERV
FRC

No air in lungs RV Maximum


expiration

VC = Vital capacity VT= Tidal volume


IVC =Inspiratory vital capacity IC = Inspiratory capacity
ERV = Expiratory reserve volume RV = Residual volume
IRV = Inspiratory reserve volume TLC = Total lung capacity
FRC = Functional residual capacity

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Additional Pulmonary Formulae


Measure Equation/Interpretation
A-a gradient  PAO2  PaO2 Normal: 5–25 mm Hg
~age  0.4
Alveolar O2  [(FIO2)  (PB  PH2O)]  (PACO2/R) 
tension [FIO2  (760  47)]  (PACO2/0.8)
(PAO2) Normal: 95–105 mm Hg; respiratory
quotient (R)  0.7–1
Arterial O2 ~100  (0.33  age)
tension Normal: 80–100 mm Hg
(PaO2)
Inspired O2  (FIO2)  (PB  PH2O)
tension Normal: 100–150 mm Hg
(PIO2)
Arterial O2  (Hgb  SaO2  1.36)  (0.003  PaO2)
content Normal: 17–20 mL/dL
(CaO2)
Mixed  ((Hgb  1.36  SvO2)  (0.003  PvO2)
venous O2 Normal: 12–15 mL/dL
content
(CvO2)
A-V O2  CaO2  CvO2
content Normal: 4–5 mL/dL
differential
(Ca-vO2)
Barometric  29.92  (((1)  (6.87535  alt 
pressure 10-6))5.2561)
(PB) Normal: 0–760 mm Hg
Capillary O2  ((Hgb  1.36)  (ScapO2)) 
content (PaO2  0.0031)
(mL/dL) Normal: 21 mL/dL
Oxygenation  FIO2  mean airway pressure/PaO2 0–25:
index (OI) good outcome; 25–40: death chance
40%; 30–1000: 4 hr ⁄risk of worsening/death;
40–1000: consider ECMO

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129
Peak Females:  (((height * 3.72)  2.24) 
expiratory (age * .03)) * 60
flow (PEF) Males:  (((height * 5.48)  1.58) 
prediction (age * .041)) * 60
Peak  100 * (highest_PEF  lowest_PEF)/
expiratory highest_PEF 15 asthma: (20–30: mild
flow persistence; 31–100: moderate to severe
variability persistence
in asthma
Ventilation  (PaCO2)in mm Hg  (RR)  (peak inspiratory
index pressurein cm H2O)/1000 ⁄ † the poorer
the ventilation achieved
Arterial O2 saturation (SaO2)  96%–99%; mixed venous O2
tension (PvO2)  35–45 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)  35–45 mm Hg;
alveolar CO2 tension (PACO2)  35–45 mm Hg; mixed venous CO2
tension (Pv CO2)  40–50 mm Hg; expired CO2 tension (PECO2) 
25–35 mm Hg

Gastrointestinal Equations
Measure Equation
Stool  Stool osmolar  (2  Na  K) 100 †
osmolal osmotic diarrhea, 100 † secretory
gap
Fractional  100  (urine amylase  plasma creatinine)/
excretion of (plasma amylase  urine creatinine) 5%
amylase suggest acute pancreatitis; 1% may
mean macroamylasemia
(continued )

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Gastrointestinal Equations (Continued )


Measure Equation
Serum-to-  Serum albumin in g/dL  ascites albuminin g/dL
ascites 1.1 g/dL portal HTN
albumin
gradient
(SAAG)
Modified  10* (0.957  LN (serum creatinine)) 
model for (0.378  LN (serum bilirubin)) 
end-stage (1.12  LN (INR))  (0.643  cirrhosis cause)
liver disease Cirrhosis cause  0 if cause cholestatic
(MELD) score or EtOH  1 for all others
Pediatric  10 * ((0.480 * in (bilirubin))  (1.857 * in (INR))
end-stage  (0.687 * in (albumin))  infant  growth
liver disease Growth  2/3 for growth failure and 
(PELD) score 0 otherwise; infant  0 for 2 yr  0.436 for
(18 yr) 1 yr or 2 yr and on transplant list prior
to first birthday
Maddrey’s  4.6  (pt.’s PT  control PT)  total bilirubin
discriminant 32 † poor prognosis and may benefit from
function for glucocorticoid treatment
EtOH hepatitis
Hepatitis C  7.81  (3.131  ln (platelet))  (0.781  In
fibrosis (GGT))  (3.467  ln (age))  (.014 
prediction cholesterol) Score  6.91–30: fibrosis more
score likely; -20–4.19: fibrosis less likely
TIPS survival  (0.957  ln (creatinine))  (0.378 
predictor in (bilirubin))  (1.12  ln (INR))  (0.643 
cause) Survival  power (days, EtOH
(risk score  1.127))
Lipase-to-  (Serum lipase/lipase upper limit normal)/
amylase ratio (serum amylase/amylase upper limit
normal) 3 suggests EtOH pancreatitis

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131
Diabetes Formulae
Measurement Equation
Hgb A1C Estimation  (MPG  77.3)/35.6
Mean plasma glucose (MPG)  (35.6 * HbA1C)  77.3

Creatinine Clearance
Normal: Males: 90–130 mL/min; females: 80–125 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  δ  Htcm/PCr δ  0.33 (_birth wt δ infants),
0.45 (term infants 1 yr), 0.55 (males 2–12 yr
& females 13–21 yr), 0.70 (males 13–21 yr)

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Serum Sodium and Water Homeostasis


Total body  0.6  IBW ( 0.85 if female &  0.85 if elderly)
water (TBW) Normal: 18–90 L
Free H2O  TBW  ((serum Na/desired serum Na)  1) 
deficit wtin kg (TBW  0.6 if male & 0.5 if female)
Free H2O  TBW  (1  (serum Na/desired serum Na)) 
excess wtin kg (TBW  0.6 if male & 0.5 if female)
ΔTBW  (Infusate osmolality-urine osmalality)  1
Total body  TBW  Osm Normal: 5000–25000 mOsm
solute
Fluid Intracellular  TBW  (2/3) Normal: 12–60 L
distribution Extracellular  TBW  (1/3) Normal: 3–30 L
Interstitial  TBW  0.222 Normal: 4–20 L
Na  TBW  normal Wtin kg * (pt.’s Na  desired
excess/deficit Na) (TBW  0.6 if male & 0.5 if female)
ΔNa/L  (Infusate Na  serum Na)/(TBW  1)
infusate
Osmolal gap  Measured osmolality  calculated osmolality
Normal: 10 mOsm/kg H2O
Calculated  (2 * Na)  (Glucose/18)  BUN/2.8) 
osmolality (EtOH/4.6). Normal serum osmolality 
285–295 mOsm/kg

Correcting Na+ When


⁄Glucose  Measured Na  0.016*(glucose  100)
(100–440)
⁄Glucose (440)  Measured Na  0.04  (glucose  100)
⁄Protein  Measured Na  (serum _ protein  8) 
0.25
⁄Lipids  Measured Na  plasma _ lipids  0.002

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133
Correcting Ca2+ When
øAlbumin  (Measured Ca2in mg/dL)  (0.8  (4 
albuminin g/dL)) ~(current total serum
Ca2 in mg/dL)  4  (albuminin g/dL)
⁄Globulin  (Measured Ca2in mg/dL)  (0.16  (normal
globulin  globulinin g/dL))
⁄pH  (Measured Ca2in mg/dL)  (0.12  (pH  7.41))

Correcting K+ When
øpH  [(Measured KmEq/L)  [0.6  (7.41  pH)]
⁄Serum Osm  (Measured KmEq/L)  (0.6  (serum
osmolality  290)/10)
⁄Platelets  (Measured KmEq/L)  [0.15  (platelets 
normal platelets)/100  109]

Serum Sodium and Water Homeostasis


Filtration fraction  Glomerular filtration rate/renal plasma
flow Normal: 17%–23%
Osmolar clearance  (urine_osmolality/serum_osmolality) 
(OsmCl) (urine_per_day/24). Normal: 60–180 mL/h
Free H2O  Urine volume/osmolar clearance
clearance Normal: 25–100 mL/h
Urea clearance  (UUN  urine volume)/BUN. Normal:
64–99 mL/min
Transtubular K  ((Urine Kin mEq/L)/(plasma Kin mEq/L))/
gradient ((urine Osmin mOsm/kg H2O)/(plasma
Osmin mOsm/kg H2O))
Very ø: K-sparing diuretics, aldosterone
blockers, H2O diuresis, øK, instrinsic
renal disease, DKA, hyperglycemic
hyperosmolar syndrome
(continued )

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Serum Sodium and Water Homeostasis


(Continued )
Fractional  [(Urine Kin mEq/L)/(plasma Kin mEq/L)]/
excretion of K [(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 Acidosis Alkalosis
Metabolic øPaCO2  1.25  ⁄ PaCO2  0.75 
ΔHCO3 (PaCO2  ΔHCO3
last 2 digits of pH)
Acute ⁄HCO3  0.1  ΔPaCO2 øHCO3 0.2 
ΔPaCO2
Respiratory
Chronic ⁄HCO3  0.4  ΔPaCO2 øHCO3 0.4 
ΔPaCO2

Measure Equation
 (Na)  (Cl  HCO3)
Normal: 8–16 mEq/L
Anion gap (AG)
 (Na  K)  (Cl  HCO3)
Normal: 10–20 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  AG–12
Delta/delta  ΔAG/ΔHCO3 Normal: 1.0–2.0

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135
Acid deficit  Weightin kg  0.5  (measured HCO3 
desired HCO3)
Bicarbonate deficit  0.4  weightin kg  (24  HCO3)
Chloride deficit  0.5  weightin kg  (desired Cl  measured Cl)
Henderson-  6.1  log (HCO3concentration/(0.03 *
Hasselbach (pH) PaCO2))
Winter’s formula (Expected pCO2)  1.5  HCO3  8
for meta-acid / 2
compensation
Urine anion gap  Urine Na  urine K  urine Cl
(UAG) Normal: -10 to 10; extrarenal non-AG
metabolic acidosis: 10 renal non-AG
metabolic acidosis: 10
Acid-base  (24  PaCO2)/HCO3
equation (H)
H/K exchange  K  (0.6  ((pH initial  pH final) 0.1)
index

Measure Prerenal Renal


 
Fractional excretion of Na (FENa ) 1% 1%
 100  (urine Nain mEq/L)/(plasma
Nain mEq/L)/(urine creatininein mg/L)/
(plasma creatininein mg/L)
Renal failure index (RFI)  1% 1%
(urine Nain mEq/L)/(urine creatininein mg/dL)/
(plasma creatininein mg/dL)
BUN/serum creatinine 20 10–15
UUN/BUN ratio 8 3
Urine Osm/plasma Osm 1.3 1.1
Urine creatinine/serum creatinine 40 20
Urine Osm 500 250
Urine specific gravity 1.018 1.012
Urine sediment Hyaline Muddy
casts brown
granular
casts

EQUAT
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EQUAT

Urology Calculations
Measure Equation
Total motile  (Volumein mL)  (sperm density)  (%
functional sperm motile)  (% normal morphology)
Normal: 40,000,000/mL
Testicular volume  0.71  length2in cm2  widthin cm
PSA density  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
øPSA density † benign diagnosis; ⁄ in
PSA density † further investigation
PSA velocity  (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

Pregnancy Calculations
Measure Equation
Nagele’s rule for Estimated day of confinement 
due date (1st day of LMP)  (3 mo)  7 d
Fundal height  Weeks gestation / 2 cm
(MacDonald’s rule) At 20 wk fundal height should 
20 cm / 2 cm; rule holds 20–36
wk; if ø then suggests
oligohydramnios
Menstrual age (weeks)  (Crown  Rump Length)in cm
 6.5

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137
Weight, Energy, and Fluid Calculations
Measurement Equation
Ideal body weight  Sex  sq (height); if male sex,  23;
(IBW) female sex,  21.5
Normal range for body Low normal  20  sq (height)
weight High normal  27  sq (height)
Body mass index (BMI)  Weightin kg/Height in m2
Underweight: 18.5; ideal: 18.5–25;
overweight: 25–30; obese: 30–40;
morbidly obese: 40
Body surface area  0.20247  heightin in.0.725 
(BSA) weightin lb0.425
Basal energy Male: 66.5  (13.75  wtin kg) 
expenditure (5.003  htin cm)  (age  6.775)
(BEE) Female: 655.1  (9.563  wtin kg) 
(1.850  htin cm)  (age  4.676)
Total daily energy Female: [655.1  (9.563  wt)
requirement (1.85  hgt)  (4.676  age)] 
(TDER) 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
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EQUAT

Weight, Energy, and Fluid Calculations


(Continued )
Measurement Equation
Fluid requirements for  TBSA burned (%)  wt (kg)  4 mL
burn victims Give half of total requirements in first
8 hr, then second half over next 16 hr
NPO fluid deficit Required IV fluids  2 mL/kg for each
hour npo
Daily maintenance “4-2-1” rule: for 0–10 kg: 4 mL/kg/hr;
fluid requirements for 10–20 kg:  2 mL/kg/hr; for 20 kg:
 1 mL/kg/hr
Daily maintenance For 0–10 kg  100 mL/kg; for 10–20 kg
fluid requirements  1000 mL  50 mL/kg for each kg
for children 10; for 20 kg  1500 mL 
25 mL/kg for each kg 20

Operating Room Fluid Requirements


Tissue Trauma Examples Fluid Required
Minimal Laparoscopic cholecystectomy, 1–2 mL/kg/hr
eye surgery
Low Ear, nose, throat 3–4 mL/kg/hr
surgery, arthroscopy
Moderate Total joint replacements 5–6 mL/kg/hr
Severe Total hip replacement, 7–8 mL/kg/hr
bowel resection
Emergency Significant trauma 10–15 mL/kg/hr

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139
Fluid Loss (% body weight)
Sign 5% 10% 15%
Mucous membranes Dry Very dry Parched
Sensorium Normal Lethargic Obtunded
Orthostatic Δs in Mild Present Marked
pulse or BP
Urinary flow rate Mild ø ø øøø
Pulse rate Normal/⁄ ⁄ ⁄⁄⁄
Blood pressure Normal Mild ø ø

Injury Fluid Resuscitation


Estimate Formulae
Brooke LR  1.5  wt  % burn/24
Colloid  0.5  wt  % burn/24
D5W  2000/24
Demling’s dextran Dextran 40 in saline  2  wt
FFP  0.5  wt
Run D40 8 hr; titrate additional
LR to maintain UO 30 ML/hr
Evans’ estimate NS  wt  % Burn/24
Colloid  wt  % burn/24
D5W  2000/24
Modified Brooke’s crystalloid LR  2  wt  % burn/24
Parkland’s crystalloid LR  4  wt  % burn/24
Slater’s estimate LR  2000/24
FFP  75  WT/36

EQUAT
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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: 50–600 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 2 /mo 2 /mo 1 /wk Frequent
Exacerbations Brief May 2 /wk Frequent
øphysical
activity
FEV1 or PEF 80% 80% 60%–80% 60%
Short-acting prn prn
bronchodilators
Long-acting  
bronchodilators
Low-dose  
inhaled
steroids
Medium-dose
inhaled steroids
High-dose 
inhaled steroids
Oral steroids
Cromolyn/ 1 or
nedocromil

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141
Leukotriene 2 or 1* or
modifier
Theophylline 3 2*
Omalizumab 1

*Along with low-to-medium dose inhaled steroids

Chronic Obstructive Pulmonary


Disease (COPD)

Additional Rx (e.g., chronic O2)


Recurring Exacerbations
Inhaled Steroids for
Bronchodilators

Rehabilitation
FEV1/ FEV1 (%
COPD Stage FVC Predicted) Symptoms

0 At risk Nl Nl Chronic 
risk factor
exposure
I Mild 70% 80% / prn
IIA 50 /  
80%
Moderate 70%
IIB 30% /   
50%
III Severe 70% 30% Respiratory    
or R heart
failure
(with any
spirometry)

MEDS
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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 55–59 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) ⴙ (macrolide or doxycycline)] or antipneu-
mococcal fluoroquinolone

3. Hospitalized
■ Same as 1.†  mixed infection, viruses, PCP
■ IV azithromycin or [Doxycycline ⫹ ␤-lactam] or IV antipneu-
mococcal fluoroquinolone

*Or other modifying factors


†Including drug-resistant S. pneumoniae

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

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

Congestive Heart Failure (CHF)

Systolic Dysfunction
Receptor Blocker

Additional Later Line Rx:


Spironolactone
or Angiotensin

■ Hydralazine
or Eplerenone
NYHA Class

Implantable
Defibrillator
␤-blocker†

■ Nitrates
Diuretic
Digoxin

■ Dobutamine
Sx ■ Dopamine
■ Revascularization
■ Transplant
I No  
II Yes   

*
IIIa Yes   

*
IIIb Yes     
*
IV Yes    

*If EF ⬍35%
†Avoid in decompensated CHF

MEDS
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MEDS

Diastolic Dysfunction
First-line Mechanism Use Only as Alternative
␤-blocker Maximum diastolic Dihydropyrimidine
filling, øcardiac work CCBs (e.g., amlodipine)
Nondihydropyrimidine
CCBs (avoid in LV
dysfunction)
Angiotensin- ⁄Myocardial relaxation Vasodilators (nitrates,
converting and compliance, hydralazine): øpreload
enzyme øpre- and afterload and angina
inhibitor
or ARB
Diuretics øSx Spironolactone
(? efficacy)

Congestive Heart Failure or Shock


Inotropes
■ Dopamine (2–5 mcg/kg/min): Vasopressor effects ⁄with dose,
⁄AV conduction, arrhythmias, ⁄psychosis, skin necrosis (if
extravasation); (0.5–2.0 mcg/kg/min † renal, cerebral,
mesenteric vasodilation)
■ Epinephrine (shock: 2 mcg/min, then titrate; cardiac arrest:
1 mg IV q3–5 min):  Agonist; bronchodilator ( 2-
agonist); -effects ⁄ with dose, ⁄myocardial O2 consumption;
tachyarrhythmias; splanchnic vasoconstrictor; diabetogenic;
øK
■ Dobutamine (2.5–20 mcg/kg/min):  Agonist peripheral
vasodilator, ⁄ventricular arrhythmias
■ Contraindications: hypertrophic cardiomyopathy
■ Digoxin (125–1000 mcg/day): Toxicity, øK

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145
■ Milrinone (Load: 50 mcg/kg over 10 min; dose: 0.37–75
mcg/kg/min): Vasodilator (systemic, pulmonary, coronary);
øBP, ⁄HR; aggravates atrial, ventricular arrhythmias, headache
■ Amrinone (load: 0.75 mg/kg over 3 min; dose: 5–20 mcg/kg/min
[max 10 mg/kg/d]):  Inotrope and vasodilator for CHF); øøBP,
thrombocytopenia, ⁄AV and ventricular conduction
■ Isoproterenol (initial: 1–4 mcg/min † titrate to HR max:
20 mcg/min):
■ Nonspecific -agonist; øBP; ⁄HR, myocardial infarction (MI)
contraindications: myocardial ischemia, tachycardia, digitalis-
induced bradycardia

Vasopressors
■ Dopamine (6–20 mcg/kg/min): Inotrope at lower doses
■ Norepinephrine (initial: 2 mcg/min; dose: 2–20 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: 0.1–0.5 mcg IV q15min; initial: 100
mcg/min; titrate to 40–200 mcg/min: Postsynaptic -agonist;
reflex bradycardia; coronary, cerebral, and pulmonary
vasoconstriction; ødose if MAO inhibitors
■ Epinephrine (200–600 mcg/kg/min): Typically used only for
inotropic effects
■ Vasopressin (0.04–0.1 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 2–3 (target)

MEDS
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MEDS

Duration of Anticoagulation
Type of DVT At Least
Isolated calf vein ⫹ symptoms 6–12 wk
Low risk (first episode or reversible cause) 3 mo
First episode idiopathic 6 mo
Recurrent 12 mo
Hypercoagulable (may need lifetime) 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 2–3), or IV Heparin
HIGH RISK
■ Major surgery in pt. 60 y.o. with no additional risk factors
or in pt. 40–60 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. 40–60 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
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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 Peak Duration Onset
Humalog 15–30 min 30 min–2.5 hr 3–5 hr
Novolog 10–20 min 1–3 hr 3–5 hr
Regular (R) 30 min–1 hr 2–5 hr 5–8 hr
NPH (N) 1–2 hr 4–12 hr 18–24 hr
Lente (L) 1–21⁄2 hr 3–10 hr 18–24 hr
Ultralente (U) 30 min–3 hr 10–20 hr 20–36 hr
Lantus 1–1.5 hr None (steady level) 20–24 hr
Humulin 70/30 30 min 2–4 hr 14–24 hr
Novolin 70/30 30 min 2–12 hr 24 hr
Novolog 70/30 10–20 min 1–4 hr 24 hr
Humulin 50/50 30 min 2–5 hr 18–24 hr
Humalog 75/25 15 min 30 min–2.5 hr 16–20 hr

MEDS
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MEDS

Oral Diabetes Medications


Second-Generation Sulfonylurea
(ⴙ 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 day’s first meal
Biguanide (⁄insulin sensitivity, øhepatic glucose
production, øglucose GI absorption)*
■ Metformin (Glucophage)
■ Unlike others, does not ⁄weight and may even øweight
■ Side effects: Metallic taste, øserum 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 (ⴙ 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

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149
Endocarditis
Indications for Prophylaxis

Patient Risk
■ High: History of subacute bacterial endocarditis, prosthetic
heart valve, complex congenital heart disease (e.g., transpo-
sition great vessel, tetralogy of Fallot), surgical systemic pul-
monary shunts or conduits
■ Moderate: Most other congenital heart disease, acquired valvu-
lar 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, Kawasaki’s 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
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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 1–2 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 1–2 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 ⴞ 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 ⴞ fluconazole
■ C. burnetii: doxycycline and hydroxychloroquine
■ S. epidermidis: vancomycin, rifampin, and gentamicin

‡complete within 30 min of starting procedure

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

Headaches
Cluster
Strictly unilateral, severe, duration: 15–90 min, associated auto-
nomic 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 min–7 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: 4–72 hr, associ-
ated Sx, females more than males

MEDS
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MEDS

Abortive Treatment
■ Aura or mild-to-moderate early ( 2 hr): First-line analgesics
(ASA ⴙ acetaminophen ⴙ caffeine, ASA ⴙ metoclopramide);
other NSAIDs: anaprox DS, indomethacin, acetaminophen,
COX2 inhibitor, ultram
■ Moderate (⬍4 hr) refractory: Antiemetics (first-line: Reglan,
prochlorperazine; others: Dramamine, Atarax, Phenergan) ⴙ
abortive medications (triptans, indomethacin PR, or
isometheptene)
■ (Severe refractory(2–6 hr): Antiemetics  serotonin agonist
(dihydroergotamine, triptans)
■ Severe refractory(6–72 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

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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
■ øLDL 20%–50%, ⁄HDL 5%–15% øTG 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


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

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Ezetimibe: Cholesterol Absorption Inhibitor


■ øLDL 20%, ⁄HDL 5%
■ Adverse effects: Minimal to date
■ Contraindications: None to date

Fibric Acid Derivative


■ Gemfibrozil, clofibrate, fenofibrate
■ ø⁄ LDL 5%–15%, ⁄HDL 15–30%, øTG 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
■ øLDL: 15%–30%, ⁄HDL 3%–5%, ⁄TG ?%
■ Adverse effects: GI effects (constipation, flatulence, dyspepsia)
■ Contraindications: TG 500 mg/dL

LDL TG HDL First Line Second Line Third Line


High 150 Any Statin Ezetimibe Resin
High 150–400 Any Statin Niacin Ezetimibe
Any 400 Any Fibrates Statin Fish Oil
or niacin
Normal Normal Low None None None

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

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Agents for Specific Conditions

Thiazide Diuretics

Spironolactone
Key:

Central Active
␣-Antagonists
Preferred: Y, 1, 2,

Agonists
␤-Blockers
ACEi/ARB
*, **

Nitrates
Alternative: A

CCB
Caution: ?
Avoid: N

Diabetes 1 N A 2
Renal disease Y Y
Dyslipidemia Y
BPH Y N
COPD/asthma N
Osteoporosis Y
Gout N
Obesity Y
Peptic ulcer N
Edema N
CAD/MI Y Y
Angina Y *
Atrial tachycardia Y **
and fibrillation
Perioperative Y
PVD ? Y
Essential tremor Y
Migraine Y **
Major depression N
Substance abuse † Y Y
Systolic dysfunction Y ? Y
Diastolic dysfunction Y ?
LVH Y Y Y

*Angina, not nifedipine


**Nondihydropyridine CCBs
†Labetalol (combined ␣-␤-blockers)

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Hypertensive Emergencies
■ Quiet room, reduce pain, treat underlying cause
■ Screen target organ damage (e.g., renal, CV, CNS)
■ Rapidly øBP may øperfusion † ischemia and infarction
■ Lower MAP 20%–25% in first hour of treatment; if stable,
lower BP to 160/100–110 in next 2–6 hr
■ IV agents: nitroprusside*, nitroglycerin†, esmolol, labetolol,
hydralazine, phentolamine, fenoldopam, nicardipine‡, enalapril
■ Oral agents: captopril, labetalol, clonidine, hydralazine

Indications to Rapidly øBP

Problem Medications (usually IV)


Eclampsia Hydralazine, labetalol, or Mg2ⴙ
Pheochromocytoma Phentolamine, labetalol
Acute renal failure Fenoldopam, nicardipine,
␤-blockers
Aortic dissection Goal: SBP 100–110 mm Hg:
Labetalol; alternative:
nitroprusside  -blocker (e.g.,
esmolol)
Acute MI Nitroglycerin, ␤-blockers
CHF ⫹ pulmonary edema Nitroglycerin, lasix,
nitroprusside
Hypertensive encephalopathy Nitroprusside, labetalol,
fenoldopam
Monoamine oxidase Phentolamine
(MAO)and tyramine

*Beware cyanide accumulation


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

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CVA: øøøSBP † øcerebral If SBP 220 mm Hg or DBP
perfusion; SBP ⬎185 or DBP 120–140 mm Hg, cautiously ø
⬎110 mm Hg; BP by ~10%–15%: IV
contraindications to tPA use nitroprusside or IV labetalol
Intracranial hemorrhage 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

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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

øComplications in Severe Preeclampsia (at ⱕ34 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 (MV1–12), Metamucil,
thiamine
■ Corticosteroids for refractory hyperemesis

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

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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, isoimmuniza-
tion), 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 øconsciousness; often aura precedes; begin
with motionless stare or activity arrest then † complicated

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motor/sensory actions, automatisms (repeated idiosyncratic


motions)
■ Prophylaxis: carbamazepine, phenytoin, temporal lobe
resection (for failed medical treatment after 1–2 yr)

Generalized (both hemispheres)


■ Absence (petit mal): Often many/day, no aura,
unresponsiveness (blank stare), rhythmic activities (eye
and head movements) autonomic symptoms (incontinence,
øpostural control), postictal clothes picking and lip pursing,
pt. often unaware seizure occurred
■ Typical: 10 sec; nonconvulsive and normal tone
■ Atypical: Longer duration; / ømuscle tone, often
tonic/clonic-like movements
■ Prophylaxis: ethosuximide, valproic acid, clonazepam
■ Tonic-clonic (grand mal): Usually lasts 1 min, associated
with øCO2, ⁄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, øpostural tone, øDTRs, 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”): 1–2 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 5–10 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

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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
e

*Infection in pregnancy

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Herpes Simplex Virus (HSV)


First-Episode Genital HSV
■ Acyclovir: PO  7–10 d or IV  2–7 d or until clinical
improvement † change to PO for 10 d total treatment;
valacyclovir PO  7–10 d or famciclovir PO  7–10 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:  5–10 d)
■ Suppressive: acyclovir, famciclovir, or valacyclovir PO (⁄dose
for HIV)
■ Encephalitis: acyclovir IV  14–21 d
■ Orolabial: acyclovir  7–10 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 ⴛ 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
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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 3–4 mU IV
q4h  10–14 d; alternative: procaine penicillin G 2.4 mU IM
qd  probenecid 500 mg qid  10–14 d; ceftriaxone 2 mg qd
IV/IM  10–14 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. Anti-
nuclear antibody 11. Immunologic disorder (anti-ds-DNA, anti-
Sm, antiphospholipid antibody such as anticardiolipin, VDRL)
■ Salicylates and NSAIDs
■ Hydroxychloroquine: Mild disease  serositis, arthritis  skin
problems

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■ 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

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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
5–10 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 ⫽ 50–100 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

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Subdural Hematoma (SDH)


■ Acceleration/deceleration and rotational forces † tear
bridging veins
■ Crescent-shaped; does not cross dural reflections
■ Density ø with ⁄ subdural age
■ Hyperacute (⬍6 hr): Either hypodense or hyperdense
■ Acute (6 hr–3 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 24–48 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

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167
Neurodegenerative Diseases
■ Parkinson’s disease: Nonspecific atrophy with enlarged
lateral ventricles and widened sulci
■ Huntington’s disease: Caudate atrophy † bilateral øconvexity
of caudate heads or ⁄ relative lateral ventricle volume
■ Pick’s 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

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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, swimmer’s,
oblique, odontoid, and anteroposterior

Normal Study

Measurable Parameters of Normal


Cervical Spines
Parameter Adults Children
Predental space ⱕ3 mm ⱕ4–5 mm
C2–C3 pseudosubluxation ⱕ3 mm ⱕ4–5 mm
Retropharyngeal space ⬍6 mm at C2 1
⁄2–2/3 vertebral
⬍22 mm at C6 body AP distance
Spinal column angulation ⬍11° ⬍11°
at any interspace level
Cord dimension 10–13 mm Adult size ⱖ6 y.o.

From Graber MA, Kathol M. Cervical spine radiographs in the trauma patient.
Am Fam Physician 1999 Jan 15;59(2):331–42

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169
Check A(lignment), B(ones), C(artilage,) D(isk Space), S(oft Tissue)
Cross-table lateral: Must see all 7 vertebral bodies and cervi-
cothoracic 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
■ Hangman’s 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-shoveler’s fracture: Bone avulsion off spinous process;
mechanism: aggressive neck flexion

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■ 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

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171
Trachea

Aortic
arch
Superior Pulmonary
vena cava artery
Left
Right
ventricle
ventricle
Gastric
Diaphragm air bubble

Abnormal Studies

Lung Cancer
■ Adenocarcinoma (most common): Typically peripheral
nodule, can be associated with fibrosis or bullous disease;
can be Pancoast’s, clubbing, hypertrophic pulmonary
osteoarthropathy, Trousseau’s syndrome of hypercoagulability
■ Bronchioloalveolar carcinoma (subset of adenocarcinoma):
Nodule, multiple nodules, alveolar infiltrate; clubbing,
hypertrophic pulmonary osteoarthropathy, Trousseau’s
syndrome
■ Squamous cell carcinoma (strongly associated with tobacco):
Cavitate, most common Pancoast’s (lung apex; superior
pulmonary sulcus † destroy adjacent rib or vertebra,
Horner’s 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

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(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,
Bochdalek’s 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)

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Pleural Effusion: “Blunting” of costophrenic angles
■ Lateral: ⱕ75 mL subpulmonic fluid can be unseen
■ PA: ⱕ175 mL fluid can be unseen
■ Decubitus: ⱖ10 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 12–19 mm Hg:
Pulmonary vessel cephalization
■ 20–25 mm Hg: Interstitial edema, bronchial wall thickening,
interlobular septa fluid (Kerley’s 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 (~T4–T5 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

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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 † ødrainage 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
■ øAfterload 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 † 3–4 mm
beneath epicardial fat stripe; if beyond epicardial fat stripe
may have perforated myocardium; check pacer wire integrity

Pitfalls
■ Relative contraindication: pregnancy

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Chest Computed Tomography
Indications
Evaluate thoracic trauma, pulmonary nodules, aortic dissection/
aneurysm, lung neoplasm and interstitial lung disease, mediasti-
nal and hilar lymphadenopathy vs. vascular strictures, parenchy-
mal 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 con-
ventional 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

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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 ⱖ1–2 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; thick-
walled, air-filled cysts (3 mm – 1 cm)

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■ DDx of multiple cysts: chronic interstitial fibrosis,
Langerhans’ cell histiocytosis, lymphangioleiomyomatosis
Mosaic Attenuation/Perfusion
■ Areas of often patchy øattenuation from regional lung
perfusion differences secondary to airway disease or
pulmonary vascular disease; often pulmonary arteries øin
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

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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 2.5–3.0 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

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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 (Morrison’s 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 (Rigler’s): Air outline both inside and
outside bowel walls
■ Falciform ligament sign: (Supine) outline ligament
■ Football sign: Gas outline peritoneal cavity

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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
(T9–T12), nephrocalcinosis (T12–L2), 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

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Procedure Description
IV contrast: Ionic: ⁄osmolar and Nonionic: øosmolar
■ 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: 5–10 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 54–60 HU, usually 8–10 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

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■ Echinococcal: ⫾Calcified wall, membrane separation,


dependent debris, focal areas ⁄attenuation in cysts
■ Fungal: Multiple, small, hypodense lesions
Cirrhosis
■ Noncontrast: Homogeneous/heterogeneous øattenuation
■ 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 øattenuation
Hemochromatosis
■ Hyperdense liver (⬎75 HU) ~ to Wilson’s 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

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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 12–24 hr
■ Linear hypodensity around pancreatic parenchyma
■ Diffuse, thickened Gerota’s fascia
■ Retropancreatic fluid anterior to splenic vein
■ Delayed formation of pancreatic pseudocyst
Intestines
Acute Appendicitis
■ Dilated appendix ⬎6 mm OR appendicolith
■ Periappendiceal fat stranding

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Crohn’s 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 † 5–10 min. delayed images
■ Pelvic Ca2⫹ (?distinguish vs. phlebolith)

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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

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Patient Preparation
None

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

Normal Study

Confirm Pregnancy
■ Gestational sac ~41⁄2 wk gestation; yolk sac ~5 wk; embryo
~51⁄2 wk
Gestational Age and Fetal Size
■ Crown-rump length (CRL): Measure at 7–13 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
■ 11–14 wk: Evaluate fetal nuchal translucency, nasal bone, and
tricuspid regurgitation (?Down’s syndrome)
■ 18–20 wk: Look for congenital malformations, multiple
pregnancies, placental position
■ ⱖ32 wk: Evaluate fetal size, weight, and fetal growth; verify
placental position
■ Level II (“targeted”) scan: Suspected abnormality

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Abnormal Studies

Vaginal Bleeding in Early Pregnancy


■ Check fetus viability: Visible heartbeat ~6–7 wk
■ Fetal heart rate: At 6 wk ~90–110 bpm; at 9 wk 140–170 bpm;
at 5–8 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 (distri-
bution, deformity); E (erosions, extent); S (soft tissue, swelling)

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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
Charcot’s 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

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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
Reiter’s 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, Paget’s 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

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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, Cushing’s disease,
acromegaly, hypogonadism)
Fractures
■ Simple transverse: Fracture line perpendicular to bone’s 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

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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

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LABS

Toxicology Screen
Amphetamine/ Remains ⫹ 24–48 hr after use
methamphetamine
Barbiturates Remains ⫹ 2–6 wk after use
Benzodiazepines Moderate use: ⫹ for 3–5 d; heavy: ⫹ for
3–6 wk
Carbon monoxide Suggested by ⬎9% carboxyhemoglobin
Cocaine Direct: ⫹5 hr; metabolite
(benzoylecgonine): ⫹ 2–4 d
Heavy use: ⫹ up to 10–22 d
Codeine ⫹1–2 d
⫹3–10 hr, peak blood levels (on empty
stomach: ⬍40–70 min
Ethanol Metabolism rate: (for 70-kg man) 15⫾5
mg/dL/hr
Urine:blood: 1.35:1 (variable);
saliva:blood: 1:20
Heroin ⫹ 1–2 d (detected as morphine)
Hydromorphone ⫹ 1–2 d
Methadone ⫹ 2–3 d
Methaqualone ⫹ 2 wk
Morphine ⫹ 1–2 d
Phencyclidine ⫹ 1–8 d
Propoxyphene Direct: 6 hr; metabolites: 6–48 hr
Tetrahydrocannabinol 2 d/joint; daily use: 3–6 wk; heavy use:
or marijuana 6–11 wk
metabolite

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Other Toxicity Tests
Test ⁄ Cause
Lead (Pb) Children For children with ⁄Pb
(⬍16 y.o.): levels, if screening result is:
⬎10 mcg/dL 10–19 mcg/dL perform
Adults: ⬎20 diagnostic test within 3 mo
mcg/dL 20–44 mcg/dL within 1 mo
45–59 mcg/dL within 48 hr
60–69 mcg/dL within 24 hr
ⱖ70 mcg/dL immediately
Free erythrocyte ⬍35 mcg/dL In adults, lead toxicity or
protoporphyrin chronic exposure
Fe–deficiency (can catch
before manifests in
anemia)
Other anemias: e.g.,
hemolytic anemia, chronic
disease
Acetaminophen Rumack–Matthew
nomogram

LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 194

LABS

Acetaminophen level (µg/mL) 500

200
150 Probable
100 hepatic
toxicity
50
Possible
hepatic
toxicity
10
Hepatic
5 toxicity
unlikely

1
4 8 12 16 20 24
Hours after ingestion

Cerebrospinal Fluid (CSF) Color


Xanthochromia 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
Cloudy or turbid Leukocytes ⬎200 WBC/mm3 or RBCs
⬎400 per mm3
Brown or dark Metastatic melanoma (meningeal
green melanomatosis) or hyperbilirubinemia
Hyperbilirubinemia or purulent

194
Cerebrospinal Fluid (CSF) Findings in
Different Conditions
Hemor- Neo- Neurosy- Guillain–
Test Bacterial Viral Fungal TB rhage plasm philis Barré
Color Cloudy Clear to Clear to Cloudy Xan- Clear to Clear to Clear to
cloudy cloudy thochro- xan- cloudy cloudy
mia thochro-
mia
Opening ⁄ Normal Normal Variable ⁄ ⁄ Normal
pressure or ⁄ or ⁄ or ⁄
WBC ⬎=1000 ⬍100 Variable Variable Normal Normal ⁄ Normal
FADavis_Chapter 07.qxd

per mm3 per mm3 to ⁄ to ⁄ to ⁄


195

Cell PMNs Lympho- Lympho- Early: Lympho- Lympho- Mono- Lympho-


differential cytes cytes PMNs cytes cytes cytes cytes
Late:
Lympho-
cytes
9/12/08

Protein ⁄ Normal ⁄ ⁄ ⁄ Normal ⁄ ⁄


to ⁄ to ⁄

LABS
CSF-to- Normal Normal ø ø ø Normal Normal Normal
serum to ø to ø
glucose
4:00 PM

ratio
Page 195
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LABS

CSF Tests
Test Result Cause
Leukocyte ⁄ ⬎5 WBCs/ Blood (⁄⁄ one WBC for every
mm3 500–1000 RBCs): Subarachnoid
hemorrhage
Predominantly neutrophils
(bacterial meningitis); lymphocytes
(viral meningitis, chronic intracranial
inflammation); eosinophils
(intracranial parasites, aseptic
meningitis, malignancy, VP shunt)
Blood ⫹ Subarachnoid or intracranial
bleeding; traumatic tap
⁄ ⬎80 mg/mL Hyperglycemia
ø ⬍50 mg/mL Hypoglycemia; granulomatous
disease (e.g., TB, sarcoid);
Glucose Newborn: meningitis (e.g., bacterial,
⬍60% Infant: chemical, fungal); subarachnoid
⬍50% serum hemorrhage; neoplasm; certain
glucose CNS viral infections (e.g., HSV,
mumps, lymphocytic
choriomeningitis)

Hormones of the Reproductive System


Follicle–
Stimulating Luteinizing
Hormone (FSH) Hormone LH:FSH
Condition mIU/mL (LH) mIU/mL Ratio
Follicular 2.5–10.2 1.9–12.5
Midcycle 3.4–33.4 8.7–76.3
Luteal 1.5–9.1 0.5–16.9
Pregnant ⬍0.2 0.0–1.5
Postmenopausal 23.0–116.3 15.9–54.0

196
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197
Polycystic ovarian Normal or ⁄ ⬎1.5
syndrome (PCO)
Obesity Can be normal Can be ⁄
or ø
⁄ Thyroid Can be normal Can be ⁄
or ø
Liver disease Can be normal Can be ⁄
or ø
Distinguishing Gonadal Failure
First stage ⁄⁄ ⁄⁄
Second stage Normal or ø Normal or ø
(hypothalamus or
pituitary)

Prolactin (PRL)
⁄ Males and Breast, chest wall, skin, or spinal
nonpregnant cord stimulation: e.g., Manipulation/
females: 20 physical stimulation, surgery, masses,
ng/mL infection
Pregnant: Physiologic: Pregnancy, sleep, exercise,
300 ng/mL eating, stress
Endocrine: e.g., Hypoglycemia,
øthyroid, adrenal adenoma/tumor,
ovarian tumor, PCO
PRL–secreting tumors: e.g., Pituitary
tumors, breast CA, hypernephroma
øPRL inhibiting factor (PIF) synthesis:
Hypothalamic or pineal disorders
øPIF transport: Pituitary stalk
compression (e.g., cerebral aneurysm,
pseudotumor cerebri)
Rheumatism/musculoskeletal: SLE
Various drugs: e.g., Estrogens, TCAs

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Diabetes Insipidus (DI) vs. Syndrome of


Inappropriate Antidiuretic Hormone
Secretion (SIADH)
Test Normal DI SIADH
Serum sodium (meq/L) 135–145 ⬎145 ⬍130
Plasma osmolality (mOsm) 278–298 ⬎295 ⬍275
Urine osmolality (mOsm) 50–1200 ⬍300 ⬎1200
Urine/plasma osmolality ratio 3–4 ⬍1 ⬎4
Urine output (L/d) ~2.5 ⬎2.5 L/d ø
Overnight Water Deprivation Test to Diagnose DI
Procedure Restrict fluid intake for 12–18 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
⁄ Causes of ⁄ ø Causes of ø
Growth ⬎5 ng/ml Pituitary tumor, ⬍1 ng/mL Hypothalamic/
hormone GH resistance, pituitary dam-
(GH) starvation, age, GH gene
drugs mutations
Somat- ⬎463 ng/ ⁄⁄⁄GH: e.g., ⬍123 ng/ øGH, liver
omedin mL Acromegaly mL disease,
C (IGF–I) Normal⁄: nonfunc-
Puberty, tioning
pregnancy, pituitary
obesity tumor,
ønutrition
Normal ø:
First 5–6 years
of life,
advanced age

198
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199
Thyroid Function Tests
Test ⁄ Causes of ⁄ ø Causes of ø
Thyroid– ⬎4.0 mc øThyroid ⬍0.4 mc ⁄Thyroid
stimulating U/mL TSH anti- U/mL Pituitary
hormone bodies disorder Acute
(TSH) Pituitary illness or
resistance malnutrition
Acute Hyponatremia
illness
recovery
Total ⬎11.2 ⁄Thyroid ⬍5.0 øThyroid
thyroxine mcg/dL secretion mcg/dL secretion:
(T4) ⁄Thyroid– øPituitary/
binding øhypothalamus
globulin øTBG: e.g.,
(TBG): e.g., Congenitalø,
Pregnancy chronic
⁄Thyroxine illness
intake
Free ⬎1.9 Same as ⁄T4 ⬍0.7 Same as øT4
thyroxine ng/dL but not ng/dL but not affected
(FT4) affected by by ⁄TBG
TBG
Free ⬎13 Same as ⁄T4 ⬍4.2 Same as ⁄T4
thyroxine but corrects but corrects
index for ⁄TBG for ⁄TBG
Total ⬎200 Same as ⁄T4 ⬍80 Same as
triiodothy- ng/dL ng/dL øT4; when
ronine (T3) T4 normal
or ⁄, ø T4 † T3
conversion : e.g.,
Fasting, surgical
stress
(continued )

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LABS

Thyroid Function Tests


(Continued )
Test ⁄ Causes of ⁄ ø Causes of ø
Thyroglob- ⬎42 Thyroid ⁄ ⬍3 ng/ Tumor
ulin (Tg) ng/mL function, mL mark;
inflammation, postremov-
or cancer (e.g., al/
papillary, ablation
follicular) Surrepti-
tious
thyroxine
use
Congenital
athyreosis
Antithyroglobulin Autoimmune disease (e.g., Hashimoto’s,
Graves’, SLE) and thyroid CA
Thyroperoxidase Autoimmune thyroiditis (used with
(TPO) antithyroglobulin), other autoimmune
disease (e.g., Sjögren’s, SLE, RA, perni-
cious anemia), occasionally other
thyroid disease (e.g., carcinoma)
TSH Receptor Ab Autoimmune thyroid disease: e.g.,
(TRAb) Graves’

Coagulation Studies
Test ⁄ Causes of ⁄ ø Causes of ø
Prothrom- ⬎35 øFactor I, II, V, 25 Vitamin K
bin time sec VII, or X sec Throm-
(PT) øSynthesis: e.g., bophlebitis
Liver disease Drugs: e.g.,
øConsumption: Estrogens,
e.g., DIC griseofulvin
øVitamin K
Drugs: e.g.,
Warfarin

200
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201
Partial ⬎35 øFactor I, II, V, 25 Hypercoagulable
thrombo- sec VIII (hemophilia sec states: DIC
plastin A), IX (hemo-
time philia B),
(PTT) X, XI, or XII
øSynthesis/
⁄consumption/
inhibitors:
e.g., Lupus anti-
coagulant
Drugs: Heparin,
warfarin
Anti- ⬎120 Acute hepatitis/ ⬍80% Hereditary
thrombin % or cholestasis or øAT III
(AT) III ⬎30 Kidney ⬍17 Thrombosis:
mg/ transplant mg/ e.g., DIC
dL øVitamin K dL øSynthesis/
Post–MI ⁄loss
Drugs: Coumadin Drugs: e.g.,
Thrombolytics
Factor ⬎ Inflammation 50% Hemophilia A,
VIII assay 200% (acute phase nor- von Willebrand
nL reactant) mal disease
Pregnancy ⁄Consumption:
(last trimester) DIC
Drugs: OCPs Factor VIII
inhibitor
Fibrinogen ⬎433 Inflammation, 175 øSynthesis: e.g.,
(functional) mg/ infection, mg/ Afibrinogenemia
dL pregnancy, MI dL Consumption:
Drugs: OCPs e.g., DIC
Drugs: e.g.,
Androgens
Bleeding ⬎9 øPlatelet number or function: e.g., Bernard–
time min Soulier syndrome, thrombasthenia, von
Willebrand (some forms)
Vascular wall defects
Drugs: Dextran, indomethacin, salicylates
(continued )

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Coagulation Studies
(Continued )
Test ⁄ Causes of ⁄
Activated ⬎180 øClotting factor (except factors VII and III)
clotting sec Platelet function disorder (but normal in
time pure thrombocytopenia and von
(ACT) Willebrand)
Afibrinogenemia
Circulating anticoagulants
Drugs: Heparin
Fibrin ⬎10 When plasmin dissolves fibrin blood clots †
degrada- mcg FDPs (which inhibit clotting); ⁄⁄⁄ indicates ⁄
tion /mL fibrinolysis or clot breakdown: e.g., DIC,
products primary fibrinolytic disorders, PE
(FDP) Severe liver disease
False-positive: Rheumatoid factor
Thrombin ⬎20 Consumption: e.g., DIC
time sec Hereditary disorders: Hypofibrinogenemia,
dysfibrinogenemia
Drugs: Heparin, fibrinolytic agents (e.g.,
streptokinase, TPA)
D–Dimer ⫹ Venous or arterial thrombosis: e.g., PE/DVT,
MI, recent surgery, infection, sepsis, cancer,
DIC
Drugs: Anticoagulants
Direct Detect RBCs coated with antibodies including, the
Coombs’ following types of hemolysis:
test 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, anti–Kell), other blood group incompatibility
(e.g., RhC, Rhe, RhE, Kid, Duffy, MN, P)
Drug–induced: e.g., Methyldopa, various antibiotics,
L–dopa, quinidine

202
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203
Indirect Detect anti–RBC antibodies in serum (specifically
Coombs’ IgG, but may detect IgM):
test Acquired hemolytic anemia, incompatible blood
transfusion, and anti–Rh antibodies (maternal Rh
sensitization)
Ham Used to diagnose paroxysmal nocturnal
test hemoglobinuria
False-positive: Myeloproliferative disorders,
spherocytosis, transfusion with old RBCs,
hereditary dyserythropoietic anemia type II

Test ø Causes of ø
Vitamin ⬍200 ⁄Requirements (e.g., pregnancy),øintake
B12 pg/mL (e.g., vegan diet)
øIntestinal absorption: Inflammation
(e.g., Crohn’s), disruption (e.g., blind
loop), infection (e.g., D. latum)
øIntrinsic factor: e.g., Pernicious anemia,
⁄metabolism (e.g., ⁄thyroid), gastric CA,
atrophic gastritis, gastrectomy
Note: May be ⁄⁄ in liver or myeloprolifer-
ative disease (e.g., myelocytic leukemia)
B12 In 24 h, øIntrinsic factor
absorption excrete øIleal absorption
(Schilling ⬍8%
test)
Folic acid ⬍2.7 øIntake (e.g., chronic EtOH)/øabsorption
ng/mL (e.g., celiac disease)
øVitamin B12
Various drugs: e.g., Antimalarials,
estrogens, methotrexate

LABS
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LABS

Iron Studies
Test ⁄ Causes of ⁄ ø Causes of ø
Iron (Fe2+) ⬎170 Hemolysis, ⬍60 øIntake/
mcg/dL Non–iron- mcg/dL absorption: e.g.,
deficiency Malnutrition,
anemias celiac disease
and lead Chronic blood
poisoning loss: e.g., GI,
Iron menstrual,
overload: postoperative
e.g., ⁄Iron demand:
Multiple e.g., Pregnancy
blood Drugs: e.g.,
transfusions Allopurinol,
Ineffective cholestyramine,
erythro- colchicine,
poiesis: e.g., methicillin,
Liver disease testosterone
øVitamin B6
or B12
Drugs: e.g.,
Estrogens
Total iron– ⬎450 Fe– ⬍240 Non–iron-
binding mcg/dL deficiency mcg/dL deficiency
capacity anemia anemias
⁄Fe demand: Iron overload:
pregnancy e.g., Hemochro-
(3rd matosis
trimester), øIntake/
infancy øsynthesis/
Poly- ⁄loss protein
cythemia ⁄Thyroid
vera Chronic
Acute liver inflammation:
disease e.g., RA
Drugs: Fluo- Drugs: e.g.,
rides, OCPs Chloramphenicol

204
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205
Ferritin Males: Inflamma- Males: Iron
⬎300 tion (acute ⬍12 deficiency
ng/mL phase ng/mL anemia
Females: reactant): Females:
⬎150 e.g., RA, ⬍12
ng/mL adult Still’s ng/mL
(⬎500)
Iron
overload
Other: Liver
necrosis,
⁄thyroid,
neoplasms
Transferrin ⬎370 Iron ⬍200 øIntake/
mg/dL deficiency mg/dL øsynthesis/
Drugs: Oral ⁄loss protein
contracep- Chronic
tives inflammation
and neoplasms
Hereditaryø:
Atransfer-
rinemia

RBCs
Test ⁄© ⁄ª Causes of ⁄ ø© øª Causes of ø
RBC ⬎6.1 ⬎5.4 ⁄Production: ⬍4.7 ⬍4.2 øProduction:
count ⫻ ⫻ e.g., ⫻ ⫻ e.g., Liver
106/ 106/ Polycythemia 106/ 106/ disease, øFe,
mcL mcL vera, ⁄EPO mcL mcL øbone
production, marrow, renal
Hema- ⬎ ⬎ øblood O2 ⬍ ⬍ failure (øEPO
tocrit 50% 45% 40% 36% production)
Fluid loss †
hemoconcen- Loss:
Hemo- ⬎ ⬎ ⬍ ⬍ Hemorrhage
globin trate: e.g.,
17.4 16.0 13.6 12.0 Destruction
(Hgb) Burns, diuresis
g/dL g/dL g/dL

(continued )

LABS
FADavis_Chapter 07.qxd 9/12/08 4:00 PM Page 206

LABS

RBCs
(Continued)
Test ⁄© ⁄ª Causes of ⁄ ø© øª Causes of ø
Eryth- ⬎19 mIU/ øO2 ⬍0–5 Inflammation/
ropoi- mL (secondary mIU/mL chronic
etin polycythemia)/ disease/renal
(EPO) ⁄O2 demand: disease
e.g., Primary
Pregnancy polycythemia
Anemia (polycythemia
EPO– vera)
producing
masses

RBC Indices
Test ⁄ Causes of ⁄ ø Causes of ø
Mean 95 Abnormal RBC 80 Abnormal Hgb
corpuscular maturation synthesis: e.g.,
volume Spurious causes: øFe, CRF,
(MCV) (fL) Autoagglutination, thalassemia, Pb
⁄WBC poisoning,
chronic disease
Some drugs: e.g.,
Phenytoin
Mean 36 = (HCT/Hct) ⫻ 100 31
corpuscular Spurious causes:
Hgb concen- Lipemia, sample
tration turbidity, hemoly-
(g/dL) sis (in vitro/vivo)
Mean 34 = Hemoglobin/ 26
corpuscular RBC count
hemoglobin See causes of
(pg/cell) ⁄MCV

206
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207
Red cell 14. = (Standard deviation of RBC volume/
distribution 5% MCV) ⫻ 100
width ⁄Variation in RBC size: e.g., øFe, øB12, øfolate,
immune hemolytic anemia, liver disease,
RBC fragmentation

White Blood Cells (WBC)


Total WBC ⁄⬎10 ⫻ I03/µL ø⬍4.5 ⫻ I03/µL
Test ⁄ Causes of ⁄ ø Causes of ø
Absolute  Stress, Inflamma- ⬍1500 øProduction/
neutrophil 7500/ tion, Bacterial /mm3 ømaturation: e.g.,
count mm3 infection øBone marrow,
Myeloprolifera- øB12/folate
tive disorders, ⁄Destruction: e.g.,
Steroids, ⁄Spleen
Splenectomy Margination: e.g.,
Endotoxin,
hemodialysis
Monocyte 8% Viral/parasitic 2% HIV, rheumatoid
infection arthritis, some
Infection cancers
recovery, Colla- Steroids
gen Vascular dis-
ease, Hematologic
malignancies
Basophil ⬎1% Food hypersensi- ⬍0.5 Psychologic/
tivity % physical stress:
Chronic inflam- e.g., Pregnancy,
mation ⁄thyroid
øøThyroid, Some allergic
Radiation, reactions
Splenectomy, Prolonged
Some cancers steroids
(e.g., myeloprolif- Hypersensitivity
erative) reaction
(continued )

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White Blood Cells (WBC)


(Continued)
Total WBC ⁄⬎10 ⫻ I03/µL ø⬍4.5 ⫻ I03/µL
Test ⁄ Causes of ⁄ ø Causes of ø
Lympho- Most viral/some ⬍15% øBone marrow/
cyte bacterial øimmunity
infections, øAdrenocortical/
Some cancers, steroids
Graves’ disease Some cancers,
renal failure, SLE
Eosinophil 4% Allergic reactions, Stress
Parasitic Steroids
infections, Anything †
Chronic skin øWBC production
inflammation,
Myeloprolifera-
tive disorders

Platelets (Plt)
Test ⁄ Causes of ⁄ ø Causes of ø
Plt count 4.5 ⫻ Essential 1.5 øProduction:
105/ (primary) throm- ⫻ 105/ øBone marrow,
3 3
mm bocytosis: Myelo- mm ømegakaryocyte
proliferative (e.g., aplastic
disorders anemia, EtOH,
Reactive radiation), hered-
(secondary) itary (e.g., TAR
thrombocytosis: syndrome,
e.g., Inflamma- Fanconi’s,
tion (e.g., inflam- May–Hegglin)
matory bowel Sequestration:
disease [IBD]), e.g.,
surgery, øspleen Splenomegaly

208
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209
(øbreakdown), ⁄Destruction:
hemorrhage, Immune (e.g.,
malignancy, ITP), mechanical
postinfection (e.g., prosthetic
Drugs: Epineph- valves)
rine, vincristine Various drugs
Mean Plt 11 fL ⁄Platelet 6 fL øProduction
volume turnover: e.g., Myeloprolifera-
ITP tive disorders:
Sudden ø ø gesta- Polycythemia
tional proteinuria rubra vera,
and hypertension essential throm-
Stored EDTA bocythemia,
blood artifact myelofibrosis
Other: Hereditary: Stor-
Bernard–Soulier, age pool disease,
May–Hegglin, Wiskott–Aldrich,
Epstein, Fechtner, TAR syndrome
Sebastian, Alport
øPlatelet Congenital: e.g., Glanzmann’s, Bernard–Soulier, stor-
aggrega- age pool disease, von Willebrand’s
tion Acquired: e.g., Antiplatelet Abs, myeloproliferative
disease, uremia, FDPs, acquired storage pool
disease, medications

Lipids
Test Targets Comments
Total ⬍200 mg/dL
cholesterol
High-density Females: ≥50 mg/dL Highest amount
lipoprotein Males: ⱖ40 mg/dL of protein
(HDL)
(continued)

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LABS

Lipids
(Continued)
Test Targets Comments
⬍2 cardiac risk ⬍160 mg/dL = Total choles-
factors: Medication if: terol – HDL –
⬎190 mg/dL (TG/5)
ⱖ2 cardiac risk ⬍130 mg/dL or
factors: Medication if: = Total choles-
Low-density ⬎160 mg/dL terol – HDL –
Lipoprotein VLDL
CAD or equiva- ⬍100 mg/dL Contains high-
(LDL)
lent (diabetes): Medication if est amount of
⬎130 mg/dL cholesterol
CAD ⫹ multiple ⬍70 mg/dL
uncontrolled Medication if
risks: ⬎100 mg/dL
Very low– ⬍31 mg/dL = (TG/5)
density Contains high-
lipoprotein est amount of
(VLDL) TG
Triglycerides ⬍150 mg/dL
(TG)

Cardiac Markers
Begins to Returns
Test ⁄ Rise Peaks to Normal
Myoglobin ⬎50.0 ng/mL 2 hr 6–8 hr 20–36 hr
Creatine ⬎161 U/L or ⬎4% 3–4 hr 12–24 hr 2d
kinase–MB of total CK
(CK–MB)
Total CK ⬎267 IU/L 4–6 hr 24 hr 3–4 d
Troponin–I ⬎1.0 ng/mL 2–6 hr 12–16 hr 5–10 d
Troponin–T Less specific than I 2–6 hr 12–16 hr 5–14 d

210
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211
Brain (B–Type) Natriuretic Peptide
Level
(pg/mL) Interpretation
Normal ⬍10 Look for other causes of dyspnea
⬍99 Heart failure unlikely
100–300 CHF present Myocardial
stress/injury:
300–600 Mild CHF øexcretion: Renal
Abnormal
600–900 Moderate failure
CHF Primary hyperaldos-
teronism or
900 Severe CHF Cushing’s
⁄Age
Drugs: Cardiac
glycosides, diuretics

Sweat Chloride
⁄ 60 mmol/L Diagnose cystic fibrosis (false-positive:
øAdrenal, øG6PD, glycogen storage disease,
øthyroid, malnutrition, renal failure)
ø Dehydration, heavy perspiration, øaldosterone
Drugs: Corticosteroids

LABS
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LABS

Liver Tests
Test ⁄ Liver Injury Also ⁄ in
Alanine ⬎35 U/L Most specific Heart, pancreas,
aminotrans- for liver injury kidneys, muscle
ferase (ALT) injury
Aspartate ⬎35 U/L øSpecific than Heart, lung, RBCs,
aminotrans- ALT muscle, bone, pan-
ferase (AST) creas, kidney
injury; vitamin A
Gamma(γ) – 51 U/L Biliary tract CHF, SLE (mild ⁄
glutamyl (more respon- from disease and
transpeptidase sive to obstruc- NSAIDs)
tion than AST or
ALT)
Lactic dehy- ⬎333 IU/L Liver isoenzyme LDH–1: Heart mus-
drogenase LDH–5 so LDH5 cle and RBCs
(LDH) LDH4 † liver LDH–2: WBCs
disease LDH–3: Lungs
If LDH1/LDH2: LDH–4: Kidney,
0.85: MI, placenta, pancreas
hemolysis, renal LDH–5: Skeletal
infarct muscle, liver
Alkaline phos- ⬎147 IU/L Liver and bile Kidney, bone, pla-
phatase ducts centa, lung, heart,
stomach, bowel,
benign familial
hyperphos-
phatasemia,
ectopic tumor pro-
duction (e.g.,
hypernephroma)

212
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213
Test ⁄ Causes
Conjug- ⬎0.4 In adults:
ated mg/dL øBilirubin excretion: Liver disease (e.g., EtOH,
bilirubin cancer, primary biliary cirrhosis), cholestasis
(direct) (e.g., drugs, ⁄TPN, pregnancy), biliary tract
obstruction (e.g., cholelithiasis, pancreatic
mass)
In neonates:
Hemolysis: e.g., Hemolytic disease of
newborn
øBilirubin excretion: Liver disease, biliary
obstruction
Pancreatic problems: e.g., Cystic fibrosis,
øøøα–antitrypsin
Intrauterine infections: e.g., Sepsis
Congenital disorders: Dubin–Johnson
syndrome, Rotor’s syndrome, trisomy 18,
galactosemia, tyrosinemia, hereditary
hypermethioninemia
Unconj- ⬎0.7 RBC hemolysis: e.g., Sickle–cell, PNH, G6PD
ugated mg/dL deficiency
bilirubin Liver disease: e.g., Hepatitis, tumor, hepatic
(indirect) congestion from CHF
Biliary tract disease: e.g., Cholangitis, biliary
tract obstruction
Hereditary disorder: Gilbert’s, Crigler–Najjar
Total ⬎8.0 Abnormal protein ⬍6.0 øIntake/
protein g/dL production: e.g., g/dL øabsorption/
Gammopathies øsynthesis
øIntravascular protein: e.g.,
volume: e.g., Malabsorption,
Dehydration liver disease
Drugs: e.g., ⁄Protein loss: e.g.,
Androgens Nephrotic
syndrome, burns,

(continued)

LABS
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LABS

Liver Tests
(Continued )
hemorrhage,
enteropathy,
fistulae
⁄Intravascular
volume: e.g., CHF,
pregnancy
Albumin ⬎5.4 øintravascular ⬍3.4 Causes of øprotein
g/dL volume g/dL above
Drugs: Estrogen
Am- ⁄⬎60 Liver destruction (e.g., cirrhosis), urea cycle
monia mcg/ metabolic defect or urea–splitting UTI: (e.g.,
dL Proteus, Klebsiella), organic acidemias,
hemolysis
ø⬍10 Renal failure and drugs (e.g., lactulose,
mcg/ neomycin)
dL
Antimit- ⫹ Abs vs. liver mitochondria: Primary biliary
ochon- cirrhosis, hepatitis, viral hepatitis, cryptogenic
drial Ab cirrhosis, EBV
Anti- ⫹ ⬎1:80 titer: Autoimmune chronic active
smooth hepatitis
muscle ⬍1:80 titer: Primary biliary cirrhosis, viral
Abs hepatitis, cryptogenic cirrhosis, endometriosis,
Behçet’s, vitiligo, CMV, EBV, HIV

214
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215
Glucose Tests
Test ⁄ Causes of ⁄ ø Causes of ø
Glucose ⬎100 ⁄Glucose ⬍60 ⁄Insulin: e.g.,
mg/dL intake mg/dL Insulinoma
(fast) øInsulin: Postprandial
⬎140 Pancreatic (i.e., glucose
mg/dL disorders, type absorption †
(non- I diabetes ⁄⁄⁄insulin
fast) Insulin resis- surge):
tance: Type II øGastric emp-
diabetes tying (e.g.,
⁄Metabolism: gastrectomy,
e.g., vagotomy)
Pregnancy, øGlucose
⁄thyroid, intake/
⁄adrenal, øproduction:
infection e.g., øAdrenal,
Various drugs: øpituitary,
e.g., TCAs, øglucagon,
corticosteroids liver disease,
øG6PD
Various drugs
Glycosylated ⬎6.5% Chronic hyper- ⬍4.0% ⁄Normal Hgb
hemoglobin glycemia or ⁄Hgb
(HbA1c) øHgb clearance: e.g.,
clearance: e.g., Hemolytic
øSpleen anemias,
False ⁄: e.g., spherocytosis,
Uremia, hemoglo-
⁄triglycerides, binopathies
⁄bilirubin, False ø:
EtOH, salicy- Vitamins C
lates, opiates and E
Fructosamine ⬎223 Measures diabetic control for 2–3 wk vs.
µmol/L HbA1c (4–8 wk); useful where HbA1c may
be inaccurate: e.g., abnormal hemoglobin
(continued)

LABS
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LABS

Glucose Tests
(Continued)
Test ⁄ Causes of ⁄ ø Causes of ø
Insulin ⬎16 yr: Proinsulin ⬎16 yr: ⁄Exogenous
C–peptide ⬎5.0 split † insulin ⬍1.1 insulin: e.g.,
⬍16 yr: and C–peptide; ⬍16 yr: Factitious
⬎3.3 evaluate øglu- ⬍0.4 hypoglycemia
ng/mL cose or resid- ng/mL ⁄⁄⁄EtOH
ual B–cell øøøInsulin
function production:
⁄⁄⁄ Insulin e.g., Type 1
production: diabetes,
e.g., pancreatec-
Insulinomas, tomy
pregnancy
øExcretion:
e.g., CRF
Drugs: Oral
hypoglycemics

Pancreatic Tests
Test Result Causes
Amylase ⁄⬎130 U/L 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
⁄⬍20 U/L Pancreatic destruction: e.g.,
Advanced chronic pancreatitis

216
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217
Lipase ⁄ ⬎160 U/L Injury/inflammation of:
Pancreas
Stomach/intestinal tract, tongue
Various drugs: e.g., Meperidine, mor-
phine, indomethacin
Glucose Screen for gestational diabetes (24 and 28 wk of
tolerance pregnancy)
test Diagnose diabetes when suspected but fasting
blood glucose normal
Fasting: 1 hr: 2 hr:
After
⫹ if ⬎110 drinking ⫹ if ⬎200 ⫹ if ⬎140
mg/dL glucose: mg/dL mg/dL

Tumor Markers
Benign
Tumor Marker ⁄ Cancers Conditions
α–fetoprotein ⬍5.4 ng/mL Primary: Hepa- Cirrhosis, viral
(AFP) (⬎500)* tocellular, non- hepatitis, preg-
seminomatous nancy
germ cell (other:
gastric, biliary,
pancreatic)
CA 19–9 ⬍37 U/mL Primary: Pan- Biliary disease,
(⬎1000)* creas, biliary cirrhosis, pan-
tract (other: creatitis
colon,
esophageal,
hepatic)
CA 27–29 ⬎38 U/mL Primary: Breast Breast, liver,
(⬎100)* (other: colon, kidney disease,
gastric, hepatic, ovarian cysts
lung, ovarian,
pancreatic,
prostate)
(continued)

LABS
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LABS

Tumor Markers
(Continued)
Benign
Tumor Marker ⁄ Cancers Conditions
CA 125 ⬎35 U/mL Primary: Ovar- Cirrhosis, effu-
(⬎200)* ian (other: sion (pleural
breast, endome- and pericardial),
trial, esophagus, endometriosis,
fallopian tube, fibroids, men-
gastric, hepatic, struation, ovar-
lung, pancreas) ian cysts, pelvic
inflammatory
disease (PID),
pregnancy
Calcitonin Males:⬎80 Primary: Thyroid ⁄Gastrin,
Females:⬎ medullary carci- pancreatitis,
70 pg/mL noma (other: thyroiditis, renal
lung, breast, failure,
carcinoids, islet pregnancy,
cell, apudomas) newborns
Carcinoembry- ⬎5 ng/mL Primary: Biliary
onic antigen (⬎10)* Colorectal (other: obstruction,
(CEA) bladder, breast, cirrhosis, IBD,
cervix, gastric, pancreatitis,
hepatic, ENT, peptic ulcer,
lung, lymphoma, tobacco,
medullary thy- øthyroid
roid, melanoma,
pancreas)
Human ⬎5 mIU/mL Primary: øGonads,
chorionic (⬎30)* Nonseminoma- marijuana use
gonadotropin tous germ cell,
gestational tro-
phoblastic dis-
ease (other: GI)
*Level at which cancer likely

218
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219
Prostate Specific Antigen (PSA)
Test ⁄ Causes of ⁄ ø Causes of ø
PSA ⬎10 ng/ 10 ng/mL 0 ng/ Prostate
mL suspicious for mL removal
prostate CA Antiandrogen
Can be ⁄ 4 therapy
ng/mL with
prostate stimu-
lation: e.g.,
Inflammation,
procedures
(e.g., urinary
catheter)
Free PSA ⬎25% Free PSA ⬍11% Prostate
⁄⁄more in BPH CA–associated
PSA is more
protein-bound

Tests to Diagnose Pheochromocytomas


or Other Catecholamine-Secreting
Tumors (e.g., Neuroblastoma)
Medications to stop ASA, clonidine, labetalol, TCAs, lithium,
or avoid prior to other psychoactive medications,
test levodopa/methyldopa, decongestants,
benzodiazepines, muscle relaxants
(mephenesin, methocarbamol),
nitroglycerin, tetracycline, Tylenol
Foods to avoid Avocado, bananas, caffeine, eggplant,
EtOH, pineapples, plums, tobacco, toma-
toes, walnuts, pineapple
(continued)

LABS
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LABS

Tests to Diagnose Pheochromocytomas


or Other Catecholamine-Secreting
Tumors (e.g., Neuroblastoma)
(Continued )
Test ⁄ Comment
Free (unconjugated) ⬎0.50 nmol/L Highest sensitivity
metanephrines
Urine metanephrines ⬎96 mcg/24 hr Highest specificity
Urine vanillylmandelic ⬎7 mg/24 hr Not used as much
acid anymore

⬎100 (max of 400) ⬍20

Leukocyte alkaline Leukemoid reaction CML


phosphatase
Polycythemia vera and myelofi- PNH
brosis with myeloid metaplasia

Electrolytes
Serum Urine
Test ⁄ (Critical⁄) ø (Criticalø) ⁄ ø
Sodium 150 (160) 135 (120) 280 30 meq/d
(Na+) meq/L meq/L meq/d
Potassium 5.0 (6.5) 3.5 (2.5) 80 meq/d 40 meq/d
(K) meq/L meq/L
Chloride 106 (115) 96 (90) 250 110
(Cl–) meq/L meq/L meq/d meq/d
CO2 29 meq/L 20 meq/L

220
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221
Magnesium 3.0 (5.0) 1.8 (1.0) 150 mg/d
(Mg2) mg/dL mg/dL
Phospho- ⬎4.1 ⬍2.4 (1.0) 1.3 g/d 0.9 g/d
rus (HPO4–2, mg/dL mg/dL
–3
PO4 )
Test ⁄ Causes of ⁄ ø Causes of ø
Creatinine ⬎1.4 Renal ⬍0.8 øMuscle mass:
mg/dL insufficiency/fail mg/dL e.g., Muscular
ure: Prerenal dystrophy
(ørenal blood ⁄Cardiac output:
flow), renal e.g., Pregnancy
impairment,
postrenal
obstruction
Muscle break-
down or crea-
tine ingestion
Blood urea ⬎20 Renal ⬍8 øIntake/
nitrogen mg/dL insufficiency/ mg/dL øsynthesis/⁄loss
failure protein
⁄⁄protein ⁄Intravascular
ingestion fluid: e.g.,
GI bleed Pregnancy,
overhydration

LABS
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LABS

Uric Acid
⁄ 750 Seen in gout
mg/24 h ⁄Cell destruction (e.g., hemolysis) or ⁄intake (e.g.,
high–purine diet)
øRenal excretion: e.g., Renal disease, CHF, acidosis,
øthyroid, ⁄parathyroid
Hereditary ⁄production: e.g., Kelley–Seegmiller
syndrome, Lesch–Nyhan
⁄Production and øexcretion: e.g., Alcohol consump-
tion, exercise, glucose-6-phosphate dehydrogenase
deficiency, øfructose–1–phosphate aldolase
ø 250 øøPurine and protein intake
mg/24 h øXanthine oxidase activity: e.g., Hereditary
xanthinuria, liver disease
⁄Renal excretion: e.g., Fanconi’s, intracranial
disease (e.g., SIADH), AIDS

222
Testosterone
⁄ Causes of ⁄ ø Causes of ø
Testosterone Male: Male: testicular Male: Congenital: Primary
⬎1000 tumors ⬍300 (testicular), (e.g.,
Female: Male 10 y.o.: Female:⬍ anorchism), secondary
⬎80 ng/dL precocious puberty 20 ng/dL (pituitary), or tertiary
⁄Adrenals: e.g., (hypothalamus)
Tumors, hyperplasia disruption
Drugs: Acquired (testicular,
Anticonvulsants, pituitary, or hypothal-
biturates, estrogens amic damage):
(through ⁄SHBG) Chemotherapy treat-
FADavis_Chapter 07.qxd

Female: Ovarian ment, x-ray therapy,


223

tumor or PCO trauma, tumor, infec-


tion (e.g., meningitis,
mumps)
Isolated øLH: e.g., Fer-
tile eunuch
9/12/08

Drugs: e.g., acarbose,


digoxin
Free Testosterone free

LABS
testosterone Male:⬎680 index (TFI) = (total Male:⬍100
Female: testosterone/SHBG) Female:
4:00 PM

⬎22 ng/dL ⫻ 100 ⬍3 ng/dL


(continued)
Page 223
Testosterone
(Continued)
Sex hormone Male: ⁄estrogen: e.g., OCPs, Male: ⁄Androgens: e.g.,
binding globulin ⬎1.3 cirrhosis, male ⬍0.4 Hirsutism, virilization,
(SHBG) Female:⬎3. øgonad, pregnancy Female:⬍0. obese post-
5 mcg (6.5–9.7 mcg DHT/ 4 mcg DHT/ menopausal women
DHT/100 mL 100 mL), anorexia, 100 ml Type II diabetes
⁄thyroid øThyroid
Abnormal If Causes
Semen Sperm count: ⬍20 ⫻ 106 Acidic pH: e.g., Seminal vesicle
Analysis Concentration: ⬍10 ⫻ 106/mL dysfunction
FADavis_Chapter 07.qxd

Motile: ⬍35% Obstruction: e.g., Ejaculatory duct


Incomplete ejaculation or spillage

224
Volume: ⬍1.5 mL
Progress.(37°): ⬍2 % Primary/secondary testicular failure
Live: ⬍50% ⁄Semen viscosity/⁄⁄pus (WBCs):
Defects: Head ⬎60%, e.g., Infection
midpiece⬎25%, tail ⬎25% Postvasectomy
9/12/08

Lecithin/Sphingomyelin (L/S)
LABS

⁄ 1.9 Ratio used to determine fetal maturity; measures surfactant production


4:00 PM

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


Page 224
Surfactant production may be ⁄ in: Female fetus, toxemia, HTN, ønutrition,
hemoglobinopathy, intrauterine øgrowth, premature membrane rupture, drug
addiction
False-positive: Contaminate amniotic fluid with blood, meconium, or vaginal
secretions
ø 1.5 Fetal lung immaturity
Surfactant production may be ø in: Toxoplasmosis, renal disease, twins, male
fetus, liver disease, anemia, polyhydramnios, øthyroid, ⁄⁄maternal age, syphilis

Chorionic Gonadotropin b–subunit (b–hCG)


FADavis_Chapter 07.qxd

⁄ 10 mIU/mL Developing placenta: Intrauterine pregnancies and ectopic pregnancies do not
produce hCG at same levels as IUP; identify threatened abortions/miscarriages
225

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
9/12/08

Wk 3 4 5 6 7–8 9–12 13– 17– 25– Non- Post-


After 16 24 40 preg- men-
LMP nant opa-

LABS
usal
mIU/mL 5–50 5–426 18– 1080– 7650– 25,700– 13,300– 4060– 3640– ⬍5.0 ⬍9.5
4:00 PM

7340 56,500 229,000 288,000 254,000 165,400 117,000


Page 225
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LABS

Urine Tests
ⴙ: 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, ønitrate diet
: ⁄Blood glucose, renal causes (e.g., ⁄GFR,
Fanconi’s 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
Myoglobin : Muscle damage (e.g., trauma, hyperthermia,
dermatomyositis, polymyositis)
Hemosiderin : ⁄⁄Intravascular hemolysis † free hemoglobin
† filtered by kidneys
: Dehydration, starvation or øcarbohydrate diets,
DKA, EtOH ketoacidosis, isopropanol toxicity,
pregnancy
Ketones False-positive: ⁄Urine pH (acidic), ⁄urine specific
gravity, phenolphthalein, L–dopa
False-negative: Delayed urine examination
: Hematuria, pyelonephritis, hemolytic anemia
Hemoglobin
False-positive: Urine pus, iodides, bromides

226
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227
Protein : Primary, secondary, and drug-induced
glomerulonephropathy, øtubular 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, Sjögren’s, RA,
polymyositis, scleroderma, Hashimoto’s, juvenile DM,
Addison’s, 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, Sclero- Non- Progressive
mixed derma, specific systemic
con- CREST sclerosis
nective with CREST
tissue
disease,
sclero-
derma,
Sjögren’s

LABS
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LABS

Complement
Test ⁄ Causes of ⁄ ø Causes of ø
Comple- Male: Nonspecific Female:
⁄ Consumption: e.g.,
ment C3 ⬎252 acute phase ⬍88 SLE (especially
mg/dL reactant in mg/dL lupus nephritis),
Female: inflammatory Male: ø complementemic
⬎206 conditions ⬍88 nephritis, subacute
mg/dL mg/dL bacterial
endocarditis, DIC
ø Protein intake/
absorption/
synthesis: e.g.,
Anorexia nervosa,
celiac disease, liver
disease
Comple- Male: Not clinically Female: C4 ø 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), glomeru-
lonephritis,
Henoch–Schönlein
ø Protein intake/
absorption/
synthesis
Total ⬎60 Inflammation ⬍22 ø Catabolism: e.g.,
comple- U/mL Infection U/mL ⴙImmune complex
ment (ølevels may predict
(CH5O) flares, such as
lupus nephritis)
Hereditary
deficiency

228
Hepatitis Tests
Hepatitis A Hepatitis B Hepatitis C
IgM IgM PCR
Anti– anti– Anti– Anti– anti– Anti– or Interpretation
HAV HAV HBsAg HBs HBc HBc HCV RIBA TMA
– – Susceptible to HAV
– Immune to HAV
FADavis_Chapter 07.qxd


229

ⴙ ⴙ Acute HAV
– – – – Susceptible to HBV
– ⴙ ⴙ HBV immunity from vaccine
– ⴙ ⴙ HBV immunity from infection
9/12/08

ⴙ – ⴙ ⴙ Acute HBV
ⴙ – ⴙ – Chronic HBV
(continued)

LABS
4:00 PM
Page 229
Hepatitis Tests
(Continued )
– – ⴙ Recovery from acute HBV OR
Distantly immune,
øanti–HBV OR
False-positive anti–HBc †
HBV-susceptible OR
Chronic with øHBsAg in serum
FADavis_Chapter 07.qxd

– No current infection

230
ⴙ ⁄S/Co Acute, chronic, or past HCV
ⴙ øS/Co Possible HCV infection
ⴙ ⴙ Past or current HCV
ⴙ – False-positive
9/12/08

ⴙ ⴙ Current infection
ⴙ – Past infection or false-positive
anti–HCV
LABS
4:00 PM
Page 230
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231
Hepatitis A Infection
Clinical illness
Viremia

ALT
Total
anti-HAV
Titer

IgM
anti-HAV

Stool HAV

0 1 2 3 4 5 6
Weeks after exposure Adapted from CDC

Acute Hepatitis B Infection With Resolution


ALT

Symptomatic
period Window
period
HBV DNA
Total anti-HBc
HBsAg
Titer

IgM
Anti-HBc Anti-HBs

HBeAg Anti-HBe

0 4 8 12 16 20 24 28 32 36 52 100
Weeks after exposure
Adapted from CDC

LABS
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LABS

Hepatitis C Infection
In acute HCV with resolution:
• Anti-HCV remains
• HCV RNA disappears
• ALT returns to normal
Symptons (20%)

Anti-HCV
ALT in acute
Titer

infection

ALT in chronic infection


HCV RNA in acute infection

0 4 2 3 4 5 6
Months after exposure

May be negative HCV May be negative HCV


RNA window period RNA window period

232
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233
Inflammatory Markers
Test ⁄ Causes
Erythrocyte ⁄ ⴙ: ⁄ inflammation † ⁄ESR; can
sedimentation Male: monitor esponse to therapy; ⁄ in:
rate (ESR) ⬍50 y.o.: Inflammation: e.g., Various
⬎15 mm/hr rheumatolgic disorders, IBD
⬎50 y.o.: Infection: e.g., TB, osteomyelitis,
⬎20 mm/hr endocarditis, PID
Female: Metabolic changes:
⬍50 y.o.: e.g., Pregnancy, thyroid
⬎20 mm/hr diseases
⬎50 y.o.: Renal disease:
⬎30 mm/hr 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., Sphero-
cytosis, polycythemia
Abnormal protein:
e.g., Hypofibrinogenemia,
hypogammaglobulinemia
Drugs: High-dose corticosteroids
C–reactive ⁄ 0.6 Diagnose/monitor: Tissue
protein mg/dL inflammation/injury (e.g.,
(CRP) 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
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LABS

Inflammatory Markers
(Continued)
Test ⁄ Causes
Procalcitonin ⁄ 0.5 Severe infections: e.g., Acute
ng/mL malaria, meningitis, pneumonia,
sepsis (especially children)
Cardiopulmonary bypass

Rheumatologic Antibodies
Anti– CREST syndrome, systemic sclerosis,
centromere scleroderma, Raynaud’s disease
Anti–histone SLE, drug–induced lupus, but nonspecific
(seen in many disorders)
Anti–Jo 1 Polymyositis/dermatomyositis, interstitial
lung disease, Raynaud’s
Anti–Ku SLE, polymyositis/dermatomyositis
Anti–Mi–2 Dermatomyositis/polymyositis
Anti– Highly specific for SLE: Confirm diagnosis
ribosomal P of CNS lupus (psychosis)
Anti– Specific for mixed connective tissue
ribonucleoprotein disease SLE (correlates with SLE activity, if
antiribonucleoprotein is positive without
presence of anti–dsDNA Abs, it means
decreased risk of nephritis), drug–induced
lupus, Sjögren’s, systemic sclerosis, RA
Anti– Highly specific for and suggests poor
topoisomerase I prognosis scleroderma: Associated with renal
(AntiSc1–70) involvement
Anti– Antiphospholipid antibody syndrome:
phospholipid Anticardiolipin and lupus anticoagulant most
commonly measured antiphospholipid
antibodies
Drugs: e.g., Some antibiotics, Ca2ⴙ–channel
blocker

234
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235
SS–A/Ro and Diagnose Sjögren’s syndrome and lupus with
SS–B/La Sjögren’s overlap
SLE: Useful to diagnose ANA-SLE (in ANAⴙ,
ⴙSS–A and ⴙSS–B suggests nephritis)
Antiphospholipid Ab syndrome (ⴙSS–A and
cardiolipin Abs, lupus anticoagulant, and
thromboses), neonatal lupus
Anti–double- Specificity for SLE anti–single-stranded
stranded DNA DNA (anti–single strand seen in healthy
(ds–DNA Ab) patients, SLE pt. relatives, and other
autoimmune disease; not useful for diagnosis):
Diagnose and monitor SLE activity (especially
lupus nephritis)
Other autoimmune disease (usually øtiters):
e.g., RA, Sjögren’s, Graves’, scleroderma,
MCTD, antiphospholipid syndrome,
autoimmune hepatitis
Some infectious diseases: EBV, CMV
Drugs: e.g., Minocycline, etanercept,
infliximab, penicillamine
Rheumatoid Present in normal patients and more common
factor as ⁄ age
⁄ 35 mg/dL RA: ⁄⁄ initial titer † øprognosis, ⁄likelihood of
being positive the longer pt. has disease
Also: Autoimmune disease (e.g., Sjögren’s,
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)
Lupus Common in asymptomatic elderly and
anticoagulant postpartum
Various autoimmune and inflammatory disease:
e.g., SLE, drug–induced lupus, RA, ulcerative
colitis, HIV, hemophilia, multiple myeloma
Drugs: e.g., Procainamide, hydralazine,
dilantin, ACE inhibitors

LABS
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LABS

Anti–Neutrophil Cytoplasmic
Antibodies (ANCA)
Cytoplasmic Strong association: Wegener’s granulomatosis
(C–ANCA) Moderate association: Crescentic
glomerulonephritis
Weak association: Polyarteritis nodosa
Perinuclear Strong association: Crescentic glomerulonephritis
(p–ANCA) Moderate association: Polyarteritis nodosa,
Churg–Strauss vasculitis
Weak association: Wegener’s granulomatosis
Other possible: Henoch–Schönlein purpura,
temporal arteritis
Atypical Primary sclerosing cholangitis, primary biliary
(x–ANCA) cirrhosis, autoimmune hepatitis, SLE, RA

Calcium Studies
Test ⁄ Causes of ⁄ ø Causes of ø
Serum ⬎10.2 ⁄ Vitamin D or ⬍8.5 Vitamin D/Ca2ⴙ
Calcium mg/dL Ca2ⴙ intake mg/dL øintake/
(Ca2ⴙ) ⁄ PTH ø absorption
⁄ Bone ø PTH or
breakdown ⁄ calcitonin
Hereditary Ca2ⴙ sequestra-
disorders: e.g., tion: e.g.,
Familial Saponification
hypocalciuria ø albumin: e.g.,
Metabolic: e.g., Liver disease
⁄⁄ Thyroid, øˆMg2ⴙ or
acromegaly, ⁄ phosphorus
Addison’s (binds Ca2ⴙ)
Drugs: e.g., Osteoblastic
Thiazides, Liⴙ malignancy
Drugs: e.g.,
Aminoglycosides

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237
Test ⁄ Causes of ⁄ ø Causes of ø
Ionized ⬎5.3 Measures ⬍4.4 ø with ⁄ blood
Ca2ⴙ mg/dL physiologically mg/dL pH/⁄ protein/
@ pH active @ pH ⁄ albumin: e.g.,
7.4 nonbound 7.4 Multiple
Ca2ⴙ, ⁄ with myeloma,
ø blood pH or dehydration
ø protein or
ø albumin
Urine ⬎300 ⁄ serum Ca2ⴙ, ⬍100 ø Serum Ca2ⴙ,
Ca2ⴙ mg also specific mg also specific
(UCa) /24hr renal disease: /24hr renal disease
e.g., Idiopathic and drugs (e.g.,
hypercalciuria, thiazides)
RTA
Parathyroid Primary/ ⬍10 ø Parathyroid,
hormone ⬎55 secondary pg/mL ⁄ thyroid,
(PTH) pg/mL ⁄ parathyroid sarcoid, ø Mg,
ø Vitamin D nonparathyroid
⁄ Ca2ⴙ
Vitamin D3: ⬎50 ⬍10 ø Sun
25-hydroxy ng/mL ng/mL exposure
[25(OH)D3] ⁄Ca2ⴙ ø Vitamin D
⁄Vitamin D intake/
intake absorption
1,25-hydroxy ⬎76 ⁄Sunlight ⬍20 Pregnancy
[1,25 pg/mL exposure pg/mL Drugs:
(OH)2D3] phenobarbital,
phenytoin

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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

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239
CDC Recommended Adult
Immunization Schedule
19–49 y.o. 50–64 y.o. ⱖ 65 y.o.
1 dose Td booster q10 yr
Diphtheria, tetanus,
pertussis (Td, DTaP) Substitute 1 dose DTaP for Td
Human papillomavirus 3 doses
(HPV) females
Measles, mumps, 1 or 2 doses 1 dose
rubella (MMR)
Varicella 2 doses (0, 4–8 wk) 2 doses
(0, 4–8 wk)
Inflluenza 1 dose annually 1 dose annually

Pneumococcal 1–2 doses 1 dose

Hepatitis A (HAV) 2 doses (0, 6–12 mo; or 0, 6–18 mo)

Hepatitis B (HBV) 3 doses (0, 1–2, 4–6 mo)

Meningococcal ⱖ1 doses
Disease, Chronic

Disease, Chronic
Diabetes, Heart
Cancer, Cancer

Disease Given
Chronic Liver

Clot Factors
Treatment*

Health-care
Pulmonary
Pregnancy

Asplenia

Workers
ESRD
EtOH

HIV

Td, DTaP 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 )

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CDC Recommended Adult


Immunization Schedule (Continued )

Diabetes, Heart
Cancer, Cancer

Disease Given
Chronic EtOH

Chronic Liver

Clot Factors
Treatment*

Health-care
Pulmonary
Pregnancy

Asplenia

Workers
Disease,

Disease,
Chronic

ESRD
HIV
MMR 1 or 2 doses
Varicella 2 doses (0, 4–8 wk) 2
doses
Flu 1 dose annually 1 1 dose annually
dose
Pneumonia 1–2 1–2 doses 1–2
doses doses
HAV 2 doses 2 2 doses
doses
HBV 3 doses 3 doses
Meningitis 1 dose 1 1 dose
dose
Genital øimmune, 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 Contraindicated

240
Recommended 0–6 Yr
Immunization Schedule
Birth 1 2 4 6 12 15 18 19–23 2–3 4–6
mo mo mo mo mo mo mo mo yrs yrs
HBV HBV HBV HBV HBV series
Rota Rota Rota Rota
DTaP DTaP DTaP DTaP DTaP DTaP
Hfllu Hib Hib Hib Hib Hib
PCV PCV PCV PCV PCV PCV PPV
IPV IPV IPV IPV
FADavis_Chapter 081.qxd

241

Flu Flu (annual)


MMR MMR MMR
Varicella Varicella V
HAV HAV (2 doses) HAV series
9/12/08

MPSV4 MPSV4
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
Range of
Catch-up High-Risk Groups
Recommended Ages
4:35 PM

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CDC Recommended 7–18 Yr


Immunization Schedule
7–10 yr 11–12 yr 13–14 yr 15 yr 16–18 yr
DTaP DTaP DTaP
HPV HPV HPV series
(3 doses)
MCV4
Meningococcal MPSV4 MCV4
MCV4
Pneumococcal PPV
Flu Inflluenza (yearly)
HAV HepA series
HBV HepB series
IPV IPV series
MMR MMR series
Varicella Varicella series
Range of High-Risk
Recommended Ages Catch-Up 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

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243
ECG Interpretation

QRS T R
P P

Q S
P-R interval

Normal Rate 60–100 bpm 0.04 sec


Normal P-R 0.12–0.20 sec 0.20 sec
Normal QRS 0.08–0.12 sec
P wave atrial depolarization; QRS ventricular
depolarization; T wave ventricular repolarization

Microbiology
Normal Flora
Skin
α-Hemolytic streptococci
Coagulase-negative staphylococci
Bacillus species
Respiratory
α-Hemolytic streptococci (not Enterococcus)
Nonhemolytic streptococci
Corynebacteria species
Neisseria species
Coagulase-negative staphylococci*
Haemophilus inflluenzae*
H. parainflluenzae*
(continued )

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Microbiology (Continued )
Moraxella catarrhalis*
N. meningitidis*
Streptococcus pneumoniae*
Genitourinary Tract
α-Hemolytic streptococci (not Enterococcus)
Nonhemolytic streptococci
Coagulase-negative staphylococci*
Corynebacteria species
Lactobacilli
*If not predominant in specimen

Patient List
Name Location Diagnosis/Notes

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245
Test Results
Patient Name:

Test Date/Time Result

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Notes

246
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247
Index

A C
Abdomen, 30, 59–60, 177–185 Calcium correction, 133
Abscess, 37–39, 167, 181 Calcium studies, 236–237
Acetaminophen toxicity, Cancer detection guidelines,
193–194 1–2
Acid/base disorders, 134–135 Cardiac arrhythmias, 2, 7–8
Acute renal failure, 84 Cardiac markers, 210
Amenorrhea, 81–82 Cardiovascular hemodynamics,
Anemia, 85–87, 203–205 119–121
Angina, 5 Catecholamine–secreting
Angioedema, 140 tumors, 219–220
Ankylosing spondylitis, 189 Catheters/catheterization, 15,
Anticoagulants, 145–147 20–22, 32–35, 174
Antidiabetes medications, 148 Central nervous system
Antineutrophil cytoplasmic assessment, 108–110
antibodies, 236 Central venous lines, 17–20, 174
Antinuclear antibody test, 227 Cerebellar disorders, 41–42, 50
APGAR score, 115–116 Cerebral spinal fluid analysis,
Appendicitis, 60, 183 118, 194–196
Arterial line placement, 14–16 Cervical cancer, 1–2
Arthritis, 35–38, 188–189 Cervical spine imaging, 167–170
Arthrocentesis, 35–38 Cervicitis, 162–163
Ascites, 28–30, 179, 185 Charcot’s arthropathy, 188
Asthma, 140–141 Chest imaging, 170–177
Azotemia, 83 Childbirth, 65–67, 158–159
Chorionic gonadotropin, 235
B Chronic obstructive pulmonary
Bile–binding resin, 154 disease, 141
Biophysical profile score, Cirrhosis, 112, 182
116 Coagulation, 200–202
Bone radiography, 187–191 Colitis, 178–179, 184
Brain, 40–41, 48–50 Colon cancer, 1
Brain natriuretic peptide, 211 Complement values and
Breast cancer, 1 disorders, 228
Budd–Chiari syndrome, 183 Cranial nerves, 40–41

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Creatinine clearance, 131 Frequently used number


Cricothyroidotomy, 9–10 template, 238
Crohn’s disease, 184
Cysts, 176–177, 182 G
Gallbladder disease, 60, 183
D Gastrointestinal bleeding, 91
Deep vein thrombosis, 145–147 Gastrointestinal equations,
Diabetes mellitus, 88–90, 131, 129–130
147–148 Genitourinary tract flora,
Diabetes insipidus, 198 243–244
Diagnostic peritoneal lavage, Glasgow Coma Scale, 108
30–32 Glenohumeral joint instability,
Diverticulitis/diverticulosis, 179, 74
184 Glucose tests, 215–216
Gout, 188
E
Ear examination, 53 H
Electrocardiogram, 2–8, 243 Head computed tomography,
Electrolyte values, 220–221 110, 165–167
Endometrial cancer, 2 Headache, 109–110, 151–152
Endotracheal intubation, 11–13, Hearing tests, 53
173 Heart disease, 2–8, 54–56, 111,
Energy calculations, 137 143–145, 149–151, 173
Epididymitis, 61–62 Heart rate values, 2
Epilepsy, 159–161 Heart sounds, 55–56
Extrapyramidal disorders, 41–42 Heart valves, 54–55, 122
Eye examination and anatomy, Helicobacter pylori, 153
51–52 Hemangioma, 182
Hematology values, 123
F Hematuria, 92
Fatty liver, 182 Hemochromatosis, 182
Feeding tube placement, 26–28, Hemophilia, 188
174 Hepatitis, 229–232
Fetal presentations, 67 Herpes simplex, 162
Fibric acid derivatives, 154 Homeostasis, 132–134
Fluid requirement calculations, Hydrocele, 62
138–139 Hypercalcemia, 93
Fontanelle closure, 68 Hyperkalemia, 94–95
Fractures, 165, 169, 190–192 Hyperlipidemia, 153–154
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Hypernatremia, 96 Liver function tests, 212–214
Hyperprolactinemia, 80 Lumbar puncture, 8–9
Hypertension, 154, 156–158, 182 Lung cancer, 171
Hypocalcemia, 97 Lung volumes and values,
Hypogonadism, 80–83 125–129
Hypokalemia, 98
Hyponatremia, 99 M
Hypoprolactinemia, 80 Mechanical ventilation, 102,
Hypoxia, 100–102 104–106
Mediastinal masses, 172
I Ménière’s disease, 112
Immunization schedules, Migraine, 109–110, 151–152
239–242 Muscle/motor disorders, 41–42
Infertility algorithm, 103
Inflammatory markers, 233–235 N
Inotropes, 144–145 Nasogastric tube placement,
Insulin, 147 26–28, 174
Intestinal obstruction or Necrotic bowel, 157
perforation, 157, 178 Nephrotoxic agents, 83
Intra–aortic counterpulsation Neurodegenerative diseases,
devices, 174 167
Intussusception, 179, 184 Niacin, 153
Iron deficiency, 124, 204–205
O
J Obstetrics, 65–67, 69, 114–115,
Joint fluid analysis, 37–38 136, 185–187
Jugular venous pressure Optic nerve, 51–52
measurement, 57–58 Osteonecrosis and
osteoporosis, 189–190
K Ovarian failure, 80
Ketoacidosis, 88–90 Oxygen therapy indications, 142
Kidney stones, 184–185
Knee examination, 74–77 P
Pancreatic tests, 216–217
L Pancreatitis, 113, 183
Labor, 65, 114, 158–159 Paracentesis, 28–30
Lead testing, 193 Patient list template, 244
Lipid values, 209–210 Pelvic inflammatory disease,
Liver disease, 112–113, 181–183 116–117, 157

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Pericardiocentesis, 13–14 Reflex innervation and testing,


Pericarditis, 5 43–44
Peripheral nerve anatomy and Reiter’s syndrome, 189
testing, 43–46 Renal azotemia, 83
Peritoneal fluid assays and Reproductive hormones,
lavage, 30–32 196–197, 223–225
Peritonitis, 157, 185 Respiratory tract flora, 243–244
Pheochromocytoma tests,
219–220 S
Placenta disorders, 66 Sarcoid, 173
Platelet values and disorders, Scabies, 163
208–209 Scrotal disorders, 61–62
Pleural effusion and fluid Seizures, 158–161
assays, 13, 22, 25, 173 Sensory disorders, 41
Pneumonia, 142–143, 173 Serum–ascitic albumin
Pneumoperitoneum, 179–180, gradient, 30
185 Sexually transmitted infections,
Pneumothorax, 172 161–163
Portal venous hypertension, Shock, 144–145
182 Shoulder examination and dis-
Potassium correction, 133 orders, 70–74
Pregnancy, 115, 136, 147, Skin, 70, 243
158–159, 187 Skull fractures, 165
Premature atrial and ventricular Sodium correction, 132
complexes, 7 Soft–tissue calcifications, 190
Prinzmetal’s angina, 5 Spermatocele, 62
Prolactin values, 197 Stroke, 108, 166
Prostate cancer, 2 Subdural hematoma, 166
Prostate–specific antigen, 219 Sweat chloride, 211
Pulmonary tests, volumes, and Syndrome of inappropriate
values, 125–129 antidiuretic hormone, 198
Systemic lupus erythematosus,
R 163–164
Ranson’s pancreatitis criteria,
113 T
Rectal cancer, 1 Tanner development stages,
Red blood cell values and 63–64
disorders, 123, 205–207 Test result template, 245
Referred pain sites, 47 Testicular disorders, 61–62
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251
Testosterone values, 223–225 Urine tests, 226–227
Thalassemia minor, 124 Urology equations, 136
Thoracentesis, 22–25 Uterine disorders, 2, 80
Thoracoscopy tube placement,
174 V
Thyroid function tests, 199–200 Vaginitis/vaginosis, 60–61, 117,
Thyroid nodule, 107 164
Tissue plasminogen activator, Varicocele, 62
108 Vasopressors, 145
Toxic megacolon, 179, 184 Ventilation equations, 124–
Toxicology testing, 118, 192–194 125
Transvenous pacing devices, Vertigo, 53
174 Vestibular disorders, 41
Trauma, 110, 139, 165–166, 183 Vitamin B12 deficiency, 203
Tumors, 167, 171–172, 182, Volvulus, 179
217–218
W
U Weight calculations, 137
Urethritis, 162–163 White blood cell values and
Uric acid values, 222 disorders, 207–208

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