• High Sens troponin delta is less than 10-20%, which is less consistent with ACS
• At my institution (Kentucky, USA), call Cardiology for high sensitivity Troponin over 150 or if delta high sensitivity Troponin exceeds 10-20 percent
• Contraindications to nitroglycerin: Sildenafil or other erectile dysfunction med in past 7 days, Bradycardia (HR below 60), Hypotension, R-side or inferior wall MI
• Do not anticoagulate in a Type-2 NSTEMI caused by Hypertensive Urgency, as it increases risk of hemorrhagic stroke
• ASCVD score http://tools.cardiosource.org/ASCVD-Risk-Estimator/
• Low evidence to hold PPI if on Clopidogrel (Maybe worse with Omeprazole, but still no stong indication to hold)

Reference values for liver fibrosis (Friedrich-Rust, 2012)

• F0/F1: For velocities = 1.34 m/s
• F2: For velocities over 1.34 m/s
• F3: For velocities over 1.55 m/s
• F4: For velocities over 1.8 m/s

M. Friedrich-Rust et al. "Performance of Acoustic Radiation Force Impulse imaging for the staging of liver fibrosis: a pooled meta-analysis", Journal of Viral Hepatitis, 2012, 19, e212–e219

Fibrosis Stages

• Stage 2: zone 3 sinusoidal fibrosis plus periportal fibrosis
• Stage 3: bridging fibrosis
• Stage 4: cirrhosis

Formulae and their required lab value inputs

• MELD - Creatinine, INR, Total Bilirubin, Sodium
  References:

  • Ming Jiang, Fei Liu, Wu-Jun Xiong, Lan Zhong, and Xi-Mei Chen, "Comparison of four models for end-stage liver disease in evaluating the prognosis of cirrhosis" World J Gastroenterol. 2008 Nov 14; 14(42): 6546–6550, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2773344/

• Maddrey Discriminant Function - PT, Creatinine, Total Bilirubin
  References:

  • Maddrey WC, Boitnott JK, Bedine MS, Weber FL, Mezey E, White RI, "Corticosteroid therapy of alcoholic hepatitis" Gastroenterology 75 (2): 193–9. PMID 352788

  • Soultati AS, et. al. "Predicting utility of a model for end stage liver disease in alcoholic liver disease" World J Gastroenterol 2006 July 07;12(25):4020-4025

• Child-Pugh - INR, Total Bilirubin, Albumin, Ascites, Encephalopathy
  References:

  • François Durand, Dominique Valla, "Assessment of the prognosis of cirrhosis: Child–Pugh versus MELD", Journal of hepatology April 2005 Volume 42, Issue 1, Supplement, Pages S100–S107

Renal Tubular Acidosis:

• Type I: Distal, Low serum K, High urine pH. Causes: Obstructive uropathy, Sjögren's, Rheumatoid, Lupus, Sickle cell anemia, Hyperthyroid, Hyperparathyroid, Hepatitis, Primary Biliary Cirrhosis, renal medullary cystic disease, chronic UTI
• Type II: Proximal, (usually Fanconi in adults). Low serum K, Glucosuria, Phosphaturia, Proteinuria. Causes: Wilson disease, drugs (Tenofovir, ifosfamide, Acetazolamide), Multiple myeloma
• Type IV: Distal, Low or Normal or High serum K. Causes: Spironolactone or eplerenone, ACE inhibitors or ARBS, Trimethoprim, Pentamidine, NSAIDs, Diabetic nephropathy, HIV/AIDS, Addison's disease, sickle cell disease, urinary tract obstruction, Lupus, Amyloidosis

• Hyperkalemic RTAs include Type 4 (hypoaldosteronism), and voltage-dependent RTA (defects in distal sodium reabsorption)
• HypOkalemic RTAs include Type 1 (Distal - defects in hydrogen ion excretion) and type 2 (Proximal - defects in bicarbonate reabsorption in the proximal tubule)

NYHA Classes

• I - No limitation of physical activity
• II - Slight limitation of physical activity. Comfortable at rest.
• III - Marked limitation of physical activity. Comfortable at rest.
• IV - Unable to carry on any physical activity without discomfort.

ACC Stages

• A - Risk but no symptoms
• B - Structural heart disease (low EF, LVH, dilation), but no symptoms
• C - Symptomatic heart failure
• D - Refractory heart failure requiring Pacemaker, LVAD, transplant

NT-proBNP Cutoffs (from ICON trial)

• 450 - Patients under 50 years old
• 900 - Patients 50-75 years old
• 1800 - Patients over 75 years old

BNP cutoff is 100 (from "Breathing Not Properly" Trial) Indications

• ACEi - Reduced Ejection Fraction
• Spironolactone - NYHA II-IV, CrCl over 30, Cr below 2.5, K below 5
• ARNI (Valsartan/Sacubitril) - NYHS II-IV with reduced ejection fraction
• ICD - No MI within 40 days, NYHA I and LVEF below 30%, NYHA II-IV and LVEF below 35%, LVEF below 40% with nonsustained-VT

Drug Dosing

• 1mg bumetanide is equivalent to 40mg furosemide

Stages

• Stage I (below 160/100)
• Stage II (over 160/100)
• Resistant (on 3 agents including a diuretic)

Daily salt-intake is approximately (23 x 24-hour urine Na in mEq)
If resistant, check Renin/Aldosterone ratio. If over 25 then possible primary hyper-aldo

• Usually give IV Furosemide when urine Osm is over 500
• A loop diuretic will wash out the interstitial gradient and so free water is not reabsorbed even when Aquaporins are open. As a result, a loop diuretic will waste free water (loop diuretic urine is approx 1/2 NS) and so will raise sodium concentration in blood. A Thiazide preserves interstitial gradient so aquaporins reabsorb free water, so Thiazides preserve free water reabsorption and lower sodium concentration.
• If cirrhotic, then just restrict fluids and diuretics - vaptans are contraindicated
• Free water clearance = (1 - (urine Osm / serum Osm)) x DailyUrineVolume
• ElectrolyteFreeWaterClearance = Urine Volume x (1 - ( ( UruneSodium + UrinePotassium ) / SerumSodium ))
  • If FreeWaterClearance over 0 then pt is losing free water and Na will rise
  • If FreeWaterClearance below 0 then pt is retaining free water and Na will drop

DSM 5 Criteria for Dependence (Mild: 2-3, Moderate 4-5, Severe 6 or more)

• Hazardous use
• Social/interpersonal problems related to use
• Neglected major roles to use
• Withdrawal
• Tolerance
• Used larger amounts/longer
• Repeated attempts to quit/control use
• Much time spent using
• Physical/psychological problems related to use
• Activities given up to use
• Craving

Duration of different substances in Urine Drug Screen:

Alcohol	7-12hrs
Amphetamine	2 days
Buprenorphine	4-10 days
Cocaine	2-4 days
Diazepam	30 days
Heroin	1-3 days
Lorazepam	2 days
Opioids	2-4 days
THC (chronic use)	30 or more days

Note, Alprazolam, Fentanyl and synthetics are often not detected in a routine urine tox.

Hemorrhage Class

• Class I - No tachycardia and blood pressure is normal, blood loss less than 750mL or 15% total blood volume
• Class II - Tachycardia (HR over 100) but blood pressure is normal, blood loss 750mL to 1500mL or 15 to 30% total blood volume
• Class III - Tachycardia (HR over 120) and blood pressure is low, and urine output is decreased, blood loss 1500mL to 2000mL or 30% to 40% total blood volume
• Class IV - Tachycardia (HR over 120) and blood pressure is low, and urine output is low, blood loss over 2000mL or over 40% total blood volume

Anemia chronic disease and Iron deficiency anemia both have low serum iron and low Iron saturation. How do we tell them apart?

• Anemia of Chronic Inflammation has Normal/High Ferritin, normal/Low Transferrin
• Iron-Deficiency Anemia has Low Ferritin, High Transferrin

SGLT2 Criteria

• Everyone with DM2 and CKD (KDIGO Rec 4.2.1) regardless of UACR. Must have DM2 and GFR over 30
• Everyone with HFrEF. Empa, Cana, Dapa to reduce CV events, but Empa is only that reduces death
• Everyone with CKD and UACR over 200 ug/mg but NO DM. Only 1 trial with non-diabetic pts, but, EMPA-Kidney is coming
• Not for DM-1, Transplant, Dialysis, PKD, SLE, ANCA, imunosuppressed, past DKA, GFR below 30. May continue SGLT2 if GFR drops below 30 while on SGLT2.

SGLT2 Criteria

• Everyone with DM2 and CKD (KDIGO Rec 4.2.1) regardless of UACR. Must have DM2 and GFR over 30
• Everyone with HFrEF. Empa, Cana, Dapa to reduce CV events, but Empa is only that reduces death
• Everyone with CKD and UACR over 200 ug/mg but NO DM. Only 1 trial with non-diabetic pts, but, EMPA-Kidney is coming
• Not for DM-1, Transplant, Dialysis, PKD, SLE, ANCA, imunosuppressed, past DKA, GFR below 30. May continue SGLT2 if GFR drops below 30 while on SGLT2.

GOLD 2023 Guidelines

GOLD classification systems

• GOLD 1 (mild disease): FEV1 over 80 percent predicted
• GOLD 2 (moderate disease): FEV1 between 50 and 80 percent predicted
• GOLD 3 (severe disease): FEV1 between 30 and 50 percent predicted
• GOLD 4 (very severe disease): FEV1 <30 percent predicted

PFT Results:

• Obstructive Disease ha FEV1/FVC below 70 percent. Air trapping will cause TLC over Upper limit normal.
• Restrictive Disease has FEV1/FVC is normal or high, and TLC below 80 percent predicted

DLCO measures alveolar surface area, and it distinguishes between disease within alveolar tissue and disease outside the lung.

• For Obstructive:
  Asthma - Normal DLCO COPD - Low DLCO
• For Restrictive:
  • Neuromuscular disorder - Normal DLCO
  • Interstitial Lung Disease - Low DLCO

Lung disease with normal DLCO is like a crumpled up paper sac. The surface area is still there, but it cannot expand.

Typical Dialysis Bath

• F-160, Blood Flow Rate 400, Dialysate flow rate 600
• Temp=37 Use lower temps if the patient becomes hypotensive on dialysis or you want to UF a lot. Typical values are 36
• Ca=2.5
• K=3 patient K on BMP was x, and serumK + bathK = 7
• HCO3=30 (patient HCO3 on BMP was x)
• Na=138 (patient Na on BMP was x, target total Na change less than 6mEq)
• Ultrafiltration: x L (patient weight x kg, EDW = x, max 10-13 mL/kg/hr)

PD Hints

• If the patient is on Icodextran at home, then check all sliding scale glucose measurements with a test insensitive to Icodextran, such as serum Glucose, not fingetstick
• If slow draining, add 500 units Heparin to each bag"

• Note that HHS may have small urine and serum ketones, those alone do not define DKA
• DKA should have Glucose over 250, ABG pH below 7.3, serum bicarb below 18, urine and serum ketones and anion gap over 10.
• See http://care.diabetesjournals.org/content/27/suppl_1/s94
• See also http://care.diabetesjournals.org/content/32/7/1335

• HAP, started after the patient had been in a hospital for 48 hours
• HCAP, patient had been hospitalized within 90 days, or lives in a long-term care facility, or has received chemotherapy or IV antibiotics
• VAP - started after the patient had been intubated for 48 hours

AHA/ASA 2013 Guidelines
tPA within 3-4.5 hours of onset unless:

• Age over 80yo
• Oral anticoagulants (regardless of INR), or any dose within the past 2 days
• NIHSS score over 25
• Past history of stroke and diabetes
• Imaging shows infarct covering more than 1/3 of the MCA territory

No keppra ppx unless symptoms of seizure
NIHSS Stroke Scale (https://www.aan.com/Guidelines/Home/GetGuidelineContent/581)

• Level of conciousness: 0 - 3
  • 0 = Alert
  • 1 = Arousable
  • 2 = Repeated stimulation
  • 3 = Motor reflexes only
• Ask month and age: 0 - 2
  • 0 = Both correct
  • 1 = One correct
  • 2 = Neither
• Blink eyes and squeeze hands: 0 - 2
  • 0 = Both correct
  • 1 = One correct
  • 2 = Neither
• Horizontal Extraocular movements: 0 - 2
  • 0 = Normal
  • 1 = Partial gaze palsy
  • 2 = Forced deviation
• Visual Fields: 0 - 3
  • 0 = No visual loss
  • 1 = Partial hemianopia
  • 2 = Complete hemianopia
  • 3 = Blind
• Facial Palsy: 0 - 3
  • 0 = Normal
  • 1 = Minor paralysis (asymmetry on smiling)
  • 2 = Partial paralysis (lower face)
  • 3 = Complete paralysis of one or both sides
• Left arm motor drift: 0 - 4
  • xxx
• Right arm motor drift: 0 - 4
  • xxx
• Left leg motor drift: 0 - 4
  • xxx
• Right leg motor drift: 0 - 4
  • xxx
• Limb ataxia (FNF and Heel/shin) 0 - 2
  • xxx
• Sensation: 0 - 2
  • xxx
• Language/aphasia: 0 - 3
  • xxx
• Dysarthria: 0 - 2
  • xxx
• Inattention: 0 - 2
  • xxx

• Do not anticoagulate in a Type-2 AFib caused by Hypertensive Urgency, as it increases risk of hemorrhagic stroke

HAS-BLED risks

• 0 - 0.9 percent annual risk
• 1 - 3.4 percent annual risk
• 2 - 4.1 percent annual risk
• 3 - 5.8 percent annual risk
• 4 - 8.9 percent annual risk
• 5 or more - 9.1 percent annual risk

CHADSVaSC risks

• 0 - 0.2 percent annual risk
• 1 - 0.6 percent annual risk
• 2 - 2.2 percent annual risk
• 3 - 3.2 percent annual risk
• 4 - 4.8 percent annual risk
• 5 - 7.2 percent annual risk
• 6 - 9.7 percent annual risk
• 7 - 11.2 percent annual risk
• 8 - 10.8 percent annual risk

GINA Guidelines

Exacerbation of Asthma

• Mild (dyspnea with activity)
• Moderate (Dyspnea limits usual activity)
• Severe (Dyspnea at rest, interferes with speaking)

Chronic Asthma:

• Intermittent (Step 1 - Symptoms less than 2 times/week)
  PRN Low Dose Formoterol-ICS
• Mild persistent (Step 2 - Symptoms 2 or more times/week, but not daily)
  PRN Low Dose Formoterol-ICS
• Moderate persistent (Step 3 - symptoms most days, nocturnal awakening due to asthma monthly)
  Daily Low Dose Formoterol-ICS
• Severe persistent (Step 4 - Severely uncontrolled: Daytime asthma symptoms at least twice weekly or Nocturnal awakening due to asthma or Reliever needed for symptoms at least twice weekly or Activity limitation due to asthma)
  Daily Medium-dose Formoterol + ICS

• For CNI-induced diabetes use Metformin (assuming eGFR is ok) and DDP4 blockers like Sitagliptan
• For CNI-induced dyslipidemia use Fluvastatin or Pravastatin. Simvastatin is contraindicated becasue of P450 interactions
• For CNI-induced Hypertension, use CCB or ACE/ARB

USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years

Clinical Frailty Scale
This is a 9-point scale to describe a patients baseline status. It is not a questionnaire, but rather is based on clinical observations.

• Level 1 - Very Fit - daily vigorous activity. This may include patients on chronic BP meds.
• Level 2 - Fit - less frequent or less vigorous activity.
• Level 3 - Managing Well. less frequent or less vigorous activity but some medical symptoms although these do not limit activity.
• Level 4 – Living with Very Mild Frailty. Some symptoms with activity, such as fatigue. Incomplete symptom control. May require help with heavy housework, or difficulty climbing stairs.
• Level 5 – Living with Mild Frailty. Does not attempt heavy housework or climbing stairs
• Level 6 – Living with Moderate Frailty. Dependence for intermediate ADLs, including dependence in bathing.
• Level 7 – Living with Severe Frailty. Dependence in some ADLs.
• Level 8 – Living with Very Severe Frailty. Bed-ridden for periods, such as acute illness.
• Level 9 – Terminally Ill. Independant of activity status

Get a Bone density screening (DEXA) every 2 years if female and between the ages of 65 and 75

Chemotherapy Side Effects: Tenofovir - Monitor for Fanconi (daily K, CO2, Phos, Cr) Cisplatin - Monitor for AKI, Fanconi, RTA-1 (daily K, CO2, Phos, Cr) Surveillance: Monitor for PE or Fanconi

The patient has xxx pulmonary risk factors (COPD, OSA, tobacco)
Elevated risk elective surgery may be reasonable if there is severe but asymptomatic Aortic stenosis (valve area less than 1.0cm**2) or severe mitral stenosis (if cannot balloon commissurotomy) or asymptomatic severe mitral or aortic regurg. 2014 ACC/AHA Pre-op guidelines
If bare-metal stent, may need to postpone elective surgery for 1 month while on Clopidogrel
If drug-eluting-metal stent, may need to postpone elective surgery for 12 months while on Clopidogrel
If balloon angioplasty, may need to postpone elective surgery for 14 days
Smoking cessation 6-8 weeks before elective surgery
If coronary stents, consider continuing Asa and Clopidogrel if BMS or DES placement within 6 weeks of urgent surgery (weigh risks of bleed vs stent thrombosis). Otherwise, try to continue Aspirin alone, and then retsart Clopidogrel soon after surgery
If on Coumadin, hold for surgery and resume with bridge if mechanical mitral valves
Continue statins day of surgery
Continue Pulm-HTN meds day of surgery (PDE inhibitors, endothelin antagonists, prostanoids, ets)

Post-operatively monitor for A-Flutter (peak incidence 1-3 days post-op, with incidence 1 to 30 percent)
If A-Flutter, rate control with betablockers or Calcium channel Blockers (such as Diltiazem, but avoid if reduced EF). Cardioversion is usually not required
If SVT, break with Adenosine and then rate control with beta blockers or Calcium channel Blockers (such as Diltiazem, but avoid if reduced EF or AF)

Pre-operative colonization with Staphylococcus aureus increases SSI risk. Screening and decolonization with intra-nasal mupirocin and pre-operative chlorhexidine bathing remains the most common and effective strategy, especially for orthopedic and cardiovascular surgery. Intra-nasal povidone-iodine immediately before surgery appears effective in preliminary studies, is less expensive, and may be easier to implement in the clinical setting.

• Axis I (clinical syndromes like mood, anxiety, eating disorders): None
• Axis II (personality disorders): None
• Axis IIII (medical conditions): None
• Axis IV (social and environmental problems): None

Titrate Allopurinol for serum urate at below 6 if 1 attack in the past year and CKD-2, or 2 attacks in the past year and CKD-1 (per ACR 2012 Guidelines)

Stage I ulcers, there is a change in the color, consistency, or temperature of the skin, but the skin is intact and the underlying tissues are unaffected Stage II pressure ulcers involve the epidermal layer of skin and may extend into the dermis as well. These usually appear as shallow, open areas or intact serum-filled or serosanguineous blisters Stage III pressure ulcers, such as the one seen in Figure 4, extend into the subcutaneous tissue, and although underlying bone, muscle, and fascia may be visible, the ulcer has no direct involvement of these structures Stage IV pressure ulcers extend into bone or muscle, as is seen in Figure 5

Quarantine

• Symptomatic 20days from positive
• Asymptomatic: 10days from positive

Discharge to Rehab or LTAC:

• Two negative results of COVID-19 PCR, collected 24hrs apart
• Resolution of fever without the use of Acetaminophen
• Improvement in respiratory symptoms

Discharged to home

• If still isolated at hospital, then continue isolation at home
• If not isolated but still has cough or dyspnea, then isolate at home until symptoms clear or 14 days after illness.
• If not isolated in hospital, then no further restrictions on discharge home. CDC Guidelines

• Massive PE. (SBP below 90). Give tPA 150mg IV over 2hrs IF NO contraindications
• Submassive PE - High risk (SBP 90-100, HR over 110, Trop over 100, and RV dysfunction). Start LMWH 1mg/kg subcu Q12h. May give tPA 150mg IV over 2hrs IF NO contraindications.
• Submassive (low risk). Start LMWH 1mg/kg subcu Q12h.

Vaccinations

• Flu annually. If 65yo or older, then prefer quadrivalent formula
• Covid (19yo or older) 2023-24 formula, 1 dose if previously vaccinated with 1 or more doses of older Covid). If immunocompromised and unvaccinated, then do a 3-dose series.
• Zoster - 2 doses if born 1980 or later or Zoster-Recombinant
• HPV 27yo-45yo
• Pneumococcal - 65yo or older
  pneumococcal vaccination at the age of 65 in the absence of underlying medical conditions that increase the risk of pneumococcal infection (Option C). This 64-year-old patient who is a nonsmoker with no significant medical history does not need to receive the vaccine early. Once this patient turns 65 years of age, vaccination with either the 20-valent pneumococcal conjugate vaccine alone or the 15-valent pneumococcal conjugate vaccine followed by the 23-valent pneumococcal polysaccharide vaccine at least 1 year later is indicated.
• Meningococcal
  The quadrivalent meningococcal conjugate vaccine (Option A) is recommended to be given at age 11 to 12 years, with a booster dose at age 16 years. Adults who are at increased risk for meningococcal disease should undergo primary vaccination if they never received age-appropriate vaccination. Increased risk is defined as persistent complement component deficiencies or patients taking eculizumab; functional or anatomic asplenia (including sickle cell disease); HIV infection
• Hep A
• Hep B 2,3,4 doses
• RSV - Over 60yo
• Tdap then Td or Tdap booster every 10 yrs
• MMR 1-2 doses

Screening

• Breast Cancer
  USPSTF B: Mammography every 2 years for women aged 50 to 74
  BRCA. USPSTF B (2013, 2019 draft) recommendation in high risk women (≥ 10% probability of carrying mutation). If family hx or ethnicity/ancestry associated with increased BRCA risk, use a standardized risk assessment tool http://www.breastcancergenescreen.org/
• Colon Cancer
  USPSTF A (2016) Do something to screen for colorectal cancer in adults age 45-75
  USPSTF C: 75-85 y/o
  FOBT, FIT, FIT-DNA, sigmoidoscopy, CT colography, colonoscopy all acceptable
  Favor colonoscopy for higher risk patients: Family history, History of adenoma
• Lung Cancer
  USPSTF B (2013). Annual screening of adults 55-80 years who have a 30 pack-year smoking history and have smoked within the past 15 years

In the AMA guidelines, "The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter". So, if an admission includes high risk procedures that require the internist to monitor for adverse effects, then it has high complexity risk.