# 內科值班02

## GI bleeds
Keep vital signs, IC18 x2; UGI?LGI? ; Do Med/GI/Rad/OP
Lethal etiology
EV bleeding, Peptic ulcer, aorto fistula, tumor, ischemia
Hx, PE and Labs
Vital signs; Cirrhosis?NSAID?; Med?,HR(BB?); conjunctiva
CBC+BCS(bili)+PT/aPTT+ABO/Rh ⨯ A級領血(O)
Management
Resuscitate with Crystalloid first! Keep vital signs
If cold sweat/shock→ICU ; correct PLT/PT/aPTT, Reversal
PPI+ Terlipressin if unstable UGI; DDAVP+cryo if uremic
EGD if massive; CTA+embolization LGI ; consult surgeon

## Hypertension
排除中風!有原因? Signs of emergency? + → Treat IV
Lethal etiology
ICH/stroke, HTN emergency, Pheochromocytoma, HELLP
Hx, PE and Labs
Pain?Stress?Med? Signs of TOD,5P for Pheo, focal signs?
NE: EOM, tongue, FNF, pronator ; BCS(organ damage)
Management
Use labetalol or nicardipine if TOD+ ; ↓20% in hours
Pain control and treat stress first!
Use amlodipine if TOD- and no signs of stroke
Doxazosin if Pheo; CT/Neuro if suspected ICH/stroke

## Hypertension
Sugar
AMS→check F/S; Cause?(INF,med); watch out HHS/DKA!
Lethal etiology
Hypoglycemia(mins), HHS/DKA(hours), euglycemic DKA
Hx, PE and Labs
Vital signs, Drugs? F/S! ↑CBC+BCS+blood sugar, AG(+Cl)
HHS/DKA→ Insulin, Iatro, Inf, Infarct, Ischemia, intoxic
Management
D50W 2-3 amp ± D10W 500ml for Hypoglycemia→ F/U
Insulin(Sliding scale)+ cause solving for Hyperglycemia
Check CBC/BCS+osmo+AG+ketone(AC-AC) if Sugar↑+怪
Insulin+IVF+K if DKA/HHS→ F/U Na/K/AG 直到AG正常

## Sugar
- hypoglycemia 或 hyperglycemia都可能讓病人悲劇
- hypoglycemia:最常見，冒冷汗，意識不清 (常見清晨，病人未吃飯時)-> one touch -> D50W 兩隻直接打，一小時後recheck

- hyperglycemia: 通常大於500 insulin打不下來要小心
- 伴隨意識喪失時，要想到HHS, DKA
- 在矯正時，使用insulin pump，同時注意病人Na,K濃度(使用insulin pump需要將病人轉至加護病房)

## Allergy/Angioedema
Maintain CAB, IV/O2/Monitor; Epi 0.5mg IM if unstable
Lethal etiology
Anaphylactic shock, vocal cord edema, bronchospasm
Hx, PE and Labs
Vital signs + SpO2 + Conscious; Drugs?→DC, Food?
No useful tool to determine(tryptase?); Types of allergy
Management
Epinephrine 0.5 mg IM(not IVP) if unstable vitals/CAB
IVF + Epi 6 mcg/kg/hour if persistent shock → ICU
Steroid + anti-histamine(H1+H2); Biphasic reaction
Beta2-agonist INH if bronchospasm, ± Intubation
Allergy
Bone/Joint/Back Pain
在止痛前先弄懂為什麼會痛! 排除致命原因
Lethal etiology
Aortic dissection, AAA, Septic joint, cord compression
Hx, PE and Labs
Trauma?Tumor?Organ? previous pain killer, vital signs,
rash(VZV); ±CBC/DC+BCS, ±plain film, Echo; Cord→ MRI
Management
Watch out for possible lethal cause! Pain score or VAS
Treat with Scanol/NSAID/tramadol/morphine/steroid
講求藥效前先求不傷身體! By oral/clock/ladder
NSAID的禁忌症: CKD,peptic ulcer,CHF,Cirrhosis,Allergy

## Pain
***排除致死原因前勿隨意止痛
- 胸痛：AMI, AA
- AMI:左胸，左肩，左背，有時候左上腹鈍痛，胸悶，像被石頭壓住，冒冷汗
- AA：刺痛，前胸痛後背，如果是血管破裂，疼痛分數可以瞬間從0-10分，會記得疼痛瞬間在做的事情

- 腹痛：AAA, holo organ perforation, ischemic bowel
- red flag: peritoneal sign, 如果有的話，至少KUB看free air，可以考慮切CT

## Nausea & Vomiting
需先排除Acute abdomen/ischemic bowel; IICP? AMI?
Lethal etiology
Acute abdomen, ischemic bowel, IICP,AMI, brain stem
Hx, PE and Labs
Associated s/s; Drugs(chemo)? Focal signs? Abd PE ±NE
Preg? F/S,BCS, KUB±CTA, EKG if old/non-specific, 眼底鏡
Management
Always find the etiology first! ; NGD if obstruct
Primperan(avoid obstruct); novamin; vena if peri-Vertigo
Granisetron; Emend/Olan/steroid/Ativan if Chemo
Monitor F/S and taper DM medication

## Insomnia
先查清楚為什麼會失眠? 一夜失眠不會有事! 呼吸
Lethal etiology
ICH, stroke, hypoxia, CO2 retention ,delirium(+its cause)
Hx, PE and Labs
Associated s/s; Vital signs, orient?, respiratory pattern
±essential NE; CBC/BCS+ABG±brain CT if 怪
Management
不確定安不安全就不要給安眠藥! 病人之前用過?
careful using BZD if delirium(except delirium tremens)
萬用Ativan, may use Zolpidem/Brotizolam/Triazolam
Avoid Vena for insomnia

## Delirium
譫妄死亡率很高! Alcohol? INF? Dementia vs Delirium
Lethal etiology
Delirium tremens; hypoglycemia, ICH, stroke, CO2↑
Serotonin syndrome, Neuroleptic malignant syndrome
Hx, PE and Labs
Alcoholism, progression, Drugs? Infection? Stress?
Vital signs, NE(reflex); F/S, CBC/BCS, ABG, ±CT ±EKG
Management
Treat precipitating factors! Watch out for lethal cause!
Reorientation + Quetiapine(12.5~25mg) ± PRN hadol
Use BZD and avoid beta-blocker if Delirium tremens

## Headache & Dizziness
永遠要考慮腦出血或中風! NE,NE,NE ; 心因性眩暈
Lethal etiology
ICH, Stroke, Head trauma, SAH/IVH; Dizziness → SCD?
Hx, PE and Labs
New onset? Associated s/s, Drugs?; IICP?, NE, ±F/S±BCS
Vertigo→Brain stem?(EOM,FNF±dolleye) ; ±CT ±EKG
Management
Always exclude lethal cause first!
Scanol or NSAID if tension headache or migraine
No effective medication for dizziness; may try Anti-His
Diphenidol if vertigo; may use vena if still vertigo(±MRI)

## Dizziness
- 排除central cause
- 小心focal neurologicala sign或是IICP sign
- NE做完正常就症狀控制

## Input & Output; U/O
學會辨認volume status! Pos: 喘不喘? Neg: 乾不乾?
Lethal etiology
Heart failure, impending shock, AKI+hyperkalemia, Sepsis
Hx, PE and Labs
Drugs? I/O last days; JVD, rales, edema; Echo: IVC+Lung
U/O↓ Echo(bladder+ΔIVC), ±CBC/BCS/HCO3/K/lactate
Management
Echo can help! Bladder, IVC, heart(RV, LVEF), lung B-line
I/O(+): Input↑+喘=Lasix ; Output↓+喘= 先survey ±lasix
I/O(-): Input↓+乾=IVF; Output↑=Med/Ca/DI/DM/postAKI
不確定且病人無症狀且不喘也不乾 → OBS

## Urine output
decreased urine output -> 從post renal cause 開始診斷
-> bladder sono, r/o acute urinary retension -> foley
-> 水太少-> 給水
-> 最後才考慮給利尿劑