# 內科值班05
[老胡的投影片](https://drive.google.com/drive/folders/1fQknlwaHUAu8FHacN5_64mroQA-XYm-t)

## Acute kidney injury
Pre/Intrinsic/post-renal AKI; KDIGO stage(RIFLE,AKIN)
Exclude post-renal first! FeNa~ Watch out for AEIOU!
Hx, PE and Labs
U/O? Drugs(NSAID)? Dehydrate? Vitals, mucosa, skin,
bladder; BCS, FeNa, K, ABG, U/A, ±UPCR; Echo: kidney
Management
Emergent HD for AEIOU(or 酸水鉀); Treat sepsis
Foley/PCN for post-renal ; Hydration for pre-renal
Avoid nephron-toxin
Considering → HyperCa(tumor)? MM(A/G, IEP)?
TTP/HUS(blood smear)? RPGN(vasculitis,autoimmune)?

## Metabolic acidosis
PH< 7.36, HCO3< 22; Acidosis→鉀跑到外面; Anion gap!!
Heart dysfunction and SVR↓ if severe.
Hx, PE and Labs
Fever? DM? Drugs(Metformin)? Diarrhea? CKD? BP/RR,
F/S, CBC/BCS, ketone, ABG, AG(Cl), lac, ±Delta/Delta, ±UAG
Management
Find the cause! (AG vs Non-AG)
Survey lactate/ketone/toxin ± OG for AG+ (GOLD MARK)
If lactate acidosis → Treat sepsis/ischemia/DC drugs ± HD
If ketone acidosis → Insulin/water/K
Check UAG/Uph/Uk for RTA if non-AG acidosis

## Hyponatremia
Na↓↑/water↑↑, ADH↑; Hypo/Eu/Hypervolemic
Watch out for seizure/AMS! F/S! 補太快→ODS(CPM)
Hx, PE and Labs
Course-acute? Thiazide? CNS? Lung? HF/Cirrhosis/CKD;
MS,volume; F/S,Uosm,FeNa, ±thyroid/cortisol ±heart echo
Management
Treat accordingly! Hypothyroid, low cortisol→ supply
Dehydration→ Slow rehydration(volume↑, ADH↓)
Volume↑(Dilutional hypoNa): Lasix, ADH anta, 限水
SIADH→限水 ± 3%saline(Avoid 0.9%saline)

## Hypernatremia
Na↑↓/Water↓↓; Na Intake增加 or Water過度流失
Central/nephro DI ; HyperNa降太快 → Brain edema
Hx, PE and Labs
Iatrogenic? Urine amount? Tumor? Li? Vitals, altered MS;
BCS, Na, Sugar, Uosmo/Una/FeNa; ±water-depri +DDAVP
Management
Control non-DI loss(diarrhea, sugar, Lasix, extra-renal)
DDx with Central/Nephro DI; DDAVP test (F/u Uosm)
If central DI → pituitary MRI + Use Nasal spray
If nephro DI → Correct cause/hydrate

## Hyperkalemia
影響心肌細胞膜電位，去活化Na離子通道(QRS↑)
EKG change加鈣! RI+insulin/HCO3/Saline/Lasix/HD
Hx, PE and Labs
CKD? AKI? Urine amount? Drugs? TransCellular shift?
Vitals, HR; ECG,K, ABG, ±CK/LDH, UK/Ucr ; Echo for AKI　
Management
EKG change→CaCl2, RI+ inuslin ± HD
DC drugs causing HyperK (NSAID,MRA,ACEi/ARB,Baktar)
Foley for post-renal AKI
Saline hydration, NaHCO3, ± Lasix ± HD
R/O Rhambdo, tumorlysis, hemolysis, Addison’s

## Hypokalemia
肌肉無力，心肌再極化異常。 K主要在細胞內。
Watch out for K/Mg/Ca, VT/Vf/TdP ; 注意血壓/血鎂
Hx, PE and Labs
GI loss, Drugs(Cisplatin,lasix), Thyroid? Alcoholism? BP?
Vitals, Dehydrate?; BCS, K/Mg/Ca, Cl, ABG, CK, Uk/Cr
Management
Rule out transcellular first! (insulin,thyroid,alkalosis)
Treat K loss/hypoMg; Alkalosis+hypoCl+hypovolemia
If suspect hyperaldo(HTN)→ confirm + MR antagonist
K supplement→ IV 10meq in 500ml, PO 20meq/15ml
rare Acidosis → RTA(type I/II), Fanconi syndrome

## Hypercalcemia
Vitamin D & PTH 調控為主; 腫瘤與PTHrp有關
Cause AMS/constipation/Nephro DI; 腫瘤造成較惡性
Hx, PE and Labs
Cancer? Bone pain? Vit.D?TB?Thiazide? Polyuria/BW loss?
Vitals, MS, Volume, U/O; BCS, Alb/Ca/P, VitD-25,iPTH±rp
Management
Oncologic emergency! Aggressive hydration+ calcitonin
±Bisphosphate/Denosumab, ± Lasix if overload
If hyperparathyroidism, Sesta-MIBI scan ± surgery
R/O MM, TB, sarcoidosis, thyroid, MEN if parathyroid
Steroid if lymphoma

## Tumor lysis syndrome
細胞內釋出: K/P/uric acid/LDH → P↑ Ca↓+ AKI
Watch out for lethal hyperkalemia, urate AKI; Hydrate!
Hx, PE and Labs
ALL/AML/Burkitts/large tumor, hyper-uric? Volume?
Signs of Ca↓; ECG, BCS, K, Ca/P, uric acid, Cr, Uph+cast
Management
Prevention! (hydration+allopurinol+aluminum PO)
Hydration + Kalimate ± Lasix ± HD if hyperK/P+AKI
Rasburicase ± Bicarbonate if hyper-uric
Treat hypoCa only if symptomatic

## Lymphoma
分成Hodgkin/Non-Hodgkin, T/B cell lymphoma, B較多
LN↑+ B symptoms; Watch out for tumorlysis/Infection
Hx, PE and Labs
Lymphadenopathy, fever, night sweats, BW loss; Neck,
axilla,spleen,inguinal; CBC,BCS,K/Ca,LDH,PET/CT+biopsy
Management
Staging, BM biopsy, flowcytometry; Treat accordingly
B cell→ usual R-CHOP; T-cell→ CHOP; Hodgkin→ ABVD
high grade→ ± BMT ; low grade → ± monitor(not treat)
Check HBV/HCV ±HIV: HBV prophylaxis; SVC syndrome?

## Leukemia
ALL/CLL/AML/CML; 不成熟白血球增生 Call VS!
APL(AM3L)→DIC ; Watch out for tumorlysis/Infection
Hx, PE and Labs
Infection? Fatigue? Bleeds? sepsis? Vitals, toxic?, skin;
CBC, smear, DIC, BCS, Ca/P/K, LDH, BM biopsy ±flow
Management
Watch out for infection/DIC/tumorlysis! Call VS!
ALL→GRALL ± Allogenic BMT
AML→I3A7 or Venetoclax+Azacitidine ± Allogenic BMT
APL→ ATRA+ As2O3±chemo ; CML→ Imatinib/Nilotinib
Watch out for leukostasis or retinoid acid syndrome(APL)

## Bone marrow transplant
Autologous→ 用自己的; Allogenic, haplo→用別人的
Neutropenic phase→ INF(viral/fungi/germ); Call VS!
Hx, PE and Labs
Organ function(all could be targeted),signs of infection;
Vitals, from head to toe; CBC, BCS, lact/culture if sepsis
Management
Call VS! Call VS! Call VS!
Septic workup if infection suspected
Broad Abx if sepsis (Tazocin→meropenem→+Azole)
Baktar prophylasix for PJP/Nocardia/Toxo
Engraftment syndrome→ Call VS, + Steroid