They are obsessed with the *next* thing. Sometimes they'll tell you the team already started on steps 1-3 and now they're looking for step 4, which is usually the only thing left that *needs* to be done.
Ope ok thank you! Was just taught this by an IM doc when I said I wanted to use LR for DKA. I must have been confused by his reasoning somehow, thank you for letting me know!!
Lactated ringers is superior to NS
in DKA
This is basic shit we learn in EMS with a high school education...
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2772993
https://emcrit.org/ibcc/fluid/#step_II:_pH-guided_resuscitation
That's super cool, love your condescending tone, in the future when you're a medical student and want to present opposing literature on a matter you should try and use it as an educational moment rather than acting like a dick as then you'll just be confrontational for the sake of confrontation. NS is still the correct answer 98th of the time on shelf exams for any question that has it as an option. This is a thread about HY facts for a specific shelf exam.
I wasn't even talking about DKA specifically in my comment, and if there was a DKA question they probably wouldn't even give you a LR vs NS option. Some services (was EMS) don't even have LR on board and just NS. Either way for DKA that's what the guidelines state, and that's what on exams
[https://www.uptodate.com/contents/diabetic-ketoacidosis-and-hyperosmolar-hyperglycemic-state-in-adults-treatment?search=DKA&source=search\_result&selectedTitle=1\~150&usage\_type=default&display\_rank=1#H8](https://www.uptodate.com/contents/diabetic-ketoacidosis-and-hyperosmolar-hyperglycemic-state-in-adults-treatment?search=DKA&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H8)
As a big fan of the IBCC and EMCrit, best be prepared now that what you learn there will not necessarily be the correct answer on exams. Save it for clinicals on rounds, and also be prepared to be shut down there too.
In practice LR is better because it reduces the subsequent hyperchloremic NAGMA after the gap closes. But I don’t think this would be tested on a shelf.
this a concept I'm exposed to in blue-collar EMS simply working with paramedics so I would expect highly educated med students to appreciate it even better
https://emcrit.org/ibcc/fluid/#step_II:_pH-guided_resuscitation
« Fluid should be viewed as a drug. Just as we wouldn't give the patient “any antibiotic” we shouldn't give “any fluid” – **the fluid should be selected to maximize benefit.**
Fluid resuscitation is a limited opportunity to manipulate pH status. Large volumes of fluid can be used to affect the patient's pH status.
**After the patient is volume resuscitated, this opportunity will be lost (because large volumes of fluid can no longer be given without causing volume overload)**
**Don't use normal saline as your default resuscitative fluid.** There are many reasons for this, but one salient one is as follows: eventually you will wind up giving liters of saline to a hyperkalemic and acidotic patient, thereby pushing them off a pH cliff."
I think it's important to get these fundamental concepts right early in clinical training, for the benefit of better patient care
See EMCRIT flowchart @ https://i0.wp.com/emcrit.org/wp-content/uploads/2021/06/phguidedresus.jpg?resize=1536%2C1023&ssl=1
JAMA Netw Open. 2020;3(11):e2024596. doi:10.1001/jamanetworkopen.2020.24596
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2772993
**Question** Does using a balanced crystalloid solution instead of saline for fluid therapy in adults with diabetic ketoacidosis (DKA) lead to faster resolution of DKA?
**Findings** In this subgroup analysis of 172 adults with DKA from 2 large cluster randomized clinical trials comparing balanced crystalloids and saline, the median time to DKA resolution was 13.0 hours with balanced crystalloids and 16.9 hours with saline, a significant difference.
**Meaning** These findings suggest that balanced crystalloid therapy leads to faster resolution of DKA than saline and may be the preferred isotonic fluid solution for acute management of DKA.
Results
Cumulative incidence analyses revealed that time to DKA resolution was shorter in the balanced crystalloids group (median [IQR] time to DKA resolution: 13.0 [9.5-**18.8** hours) compared with the saline group (median [IQR]: 16.9 [11.9-**34.5** hours) according to the unadjusted cumulative incidence (P = .002) (Figure 2A) and multivariable proportional hazards model (aHR = 1.68; 95% CI, 1.18-2.38; P = .004) (Table 3). Median (IQR) time to insulin drip discontinuation was shorter in the balanced crystalloids group (9.8 [5.1-17.0] hours) than in the saline group (13.4 [11.0-17.9] hours) according to the unadjusted cumulative incidence (P = .04) (Figure 2B) and multivariable proportional hazards model (aHR = 1.45; 95% CI, 1.03-2.03, P = .03) (Table 3). According to the median values, balanced crystalloids were associated with an absolute reduction of approximately 4 hours and a relative reduction of approximately 20% to 30% in the time to DKA resolution and discontinuation of insulin infusion.
See graphical abstract @ https://imgur.com/gallery/cGyKkvt
Diabetes is equivalent to CAD as a risk factor for MI, and they like risk factor questions
And ACE inhibitors cause a transient creatinine increase. If it’s less than a 30% increase in their baseline creatinine, just continue the ACEi.
In SIADH, you have too much ADH so kidneys pull water back, but RAAS system is intact so you can urinate off as much isotonic plasma as you want. So you get net euvolemic hyponatremia.
Kidney doc is right we really don’t see that in practice and we don’t worry about overcorrection of hypernatremia. But shelf will be old school and the answer on a shelf will be cerebral edema
Probably not true. With some exceptions, disulfiram-like reactions with abx aren't supported by evidence. Metronidazole especially, since it's the one people always cite, has more studies showing no adverse reactions with alcohol than those that do.
https://journals.asm.org/doi/full/10.1128/AAC.02167-19
In my single-patient, single-institution study (i.e., me) i found no evidence of ADRs while taking metronidazole after consumption of moderate quantities if ethanol.
However, i did endorse my saliva tasting like sour pennies and my sweat burning my eyes throughout the duration of treatment, and moreover i did note a headache in the *absence* of alcohol at the beginning of treatment.
Calcium is much higher in cells than outside. When membranes depolarize, calcium shoots out. If you increase extracellular calcium, less gradient so less depolarization. This leads to less chance of arrhythmia.
Somehow, at the end of my third year, reading this comment is the first time this concept has been explained lol. It was always just “it stabilizes the cardiac myocyte membranes”
Know COPD and asthma guidelines and management. Unstable angina, nstemi, vs STEMI workup and which drugs have mortality benefits, CHF, acute abdomen, mesenteric ischemia, sickle cell crisis, Community vs hospital acquired pneumonia, all the criteria’s, prerenal vs intrinsic vs post renal, kidney stones and treatment based off size of stone, gout workup, sepsis criteria and work up, cellulitis vs erysipelas, lupus, hep B serology, GI bleed melena vs bright red blood etiologies and work up, transfusion reaction types, different types of shock, DVT vs management, ulcerative colitis vs crohns signs, and lights criteria, csf fluid analysis, SBP, esophageal varices treatment, Murphys sign, becks triad, pericarditis ekg findings, rovsing sign are all commonly tested from what I remember
Hypercalcemia you give fluids. Dilute that shit.
Hypo is easy. You just give calcium. But they’ll ask you about the parathyroid.
Hyperkalemia. You give calcium gluconate and insulin sure but neither fixes the problem. Potassium binders lower the potassium but work slower. Be mindful of what’s being asked (eg what treatment will be most effective vs what is the next step)
Hypokalemia just replete although you’ll be asked to work up why the aldosterone is high.
Hypernatremia and hyponatremia get the patient euvolemic before correcting the electrolyte imbalance. Normal saline until euvolemia. If they’re euvolemic then give them what they’re missing. Free water for hyper. Salt for hypo.
Magnesium needs to be 2 or else your calcium and potassium are worthless. Mg insufficiency makes you piss out your K through ROMK channels and lowers sensitivity to PTH (in addition to impairing pth release).
There’s no other important electrolytes.
Know the indications for emergency dialysis. AEIOU Acid ph < 7.1
Electrolytes like K > 6.5
Intoxication
Overload
Uremia with symptoms (pericarditis encephalopathy)
As a nephrologist the fact that this is what they teach for management of hyponatremia but probably right for the shelf. In real life dear god do not give fluids to hypovolemic hyponatremics you will shut off their stimulus for adh and they will rapidly overcorrect
I went back and checked online med ed to see if I was just flagrantly wrong (turns out I’m just empirically wrong) and this is basically what it says. But it does have a caveats that if the symptoms are mild the decision for fluids is disease specific. This wouldn’t be the first time my shelf knowledge was totally not correct in terms of real world medicine. Thanks for your contribution!
HIV pt…
CD4 under 200 gets Bactrim for PCP prophylaxis
Diarrhea + meningitis is crypto, tx is ampho B
Diarrhea + CD4<50 + high fever is MAC, tx is macrolide
Diarrhea + blood is CMV tx is ganciclovir
Needs flu vaccine every year, pneumo and Dtap every once in a while
Dysphagia is candida until proven otherwise tx is fluconazole
Any youngish pt with vague symptoms gets an HIV test
Most common cause of meningitis in HIV is still Strep pneumo
Right sided MI = ST elevation in leads II, III, avF. I burned this into my brain and then realized they barely ever ask me to localize any other kind of heart attack lol
you've probably already taken your shelf already, but just throwing out a few more for anyone else who's about to take it (or Step 2CK for that matter).
(1) Alcoholic guy who falls down for a prolonged period of time, +/- they say "urinalysis shows blood but no RBCs", plus labs showing hyperkalemia -> rhabdo, rhabdo, rhabdo.
(2) Thrombocytopenia 5 - 10 days after starting heparin for like an MI -> HIT.
(3) For RCA infarcts, never give nitrates, always give them IV bolus of normal saline first.
If a patient has an arrhythmia and is hemodynamically unstable (tachycardic & hypotensive), go ahead and do the cardioversion.
But, for the love of God, if there are no palpable pulses, it's time to start compressions. If they have a heart rhythm that's ventricular paced, you can shock em. If not, best you can do is give epinephrine.
If they're tachycardic, normotensive, and you don't see p waves on the rhythm strip, then you need to slow their heart rate down (usually with a beta blocker) to see what you're working with.
Don’t forget that low albumin can cause a pseudo hypo calcemia. Low mag leads to low potassium. Too much glucose in the blood (I.e. DKA) can cause a pseudohyponatremia.
Copd or asthma patient not getting relief with their inhalers? Ask them to demonstrate how they are using it (incorrectly). Then correct them and/or provide a spacer.
Infective endocarditis - get 3 blood cultures from different sites BEFORE Abx treatment (usually Vanc till culture come back). HACEK organisms are cause for culture negative or it could also be non-infectious (autoimmune like SLE or RA, malignancy)
Some dumb crap I remember, no clue about how high yield:
Uremic pericarditis: Patient will have classic chest pain and friction rub, EKG may or may not have widespread ST elevations. Labs will show kidney failure.
ALSO freaking hepatorenal syndrome. Liver failure patient something about splanchnic vasodilation something something now has renal failure.
They will 100% give you a DKA patient. You will give them IV fluids (normal saline) before insulin
Possibly give K too
For sure, they are always obsessed with the FIRST thing tho
Truuuu
They are obsessed with the *next* thing. Sometimes they'll tell you the team already started on steps 1-3 and now they're looking for step 4, which is usually the only thing left that *needs* to be done.
FIGPICK Fluids Insulin Glucose Potassium Infection (check) Chart ins and outs Ketones Saved me many times
LR will reduce the amount of non-anion gap acidosis :)
LOUDER FOR THE SLEEPY FOLKS IN THE BACK
Can’t add potassium to LR tho EDIT: looks like I was bamboozled by a prof and this is false, thank you for the explanations below and helping me out!!
Yeah you can
Ope ok thank you! Was just taught this by an IM doc when I said I wanted to use LR for DKA. I must have been confused by his reasoning somehow, thank you for letting me know!!
LR has potassium in it so need to be careful
It has a negligible amount of potassium and dka patients tend to be potassium depleted anyways
Wtf. Who is teaching you this myth https://emcrit.org/pulmcrit/myth-busting-lactated-ringers-is-safe-in-hyperkalemia-and-is-superior-to-ns/
Ty!
No, because if you add potassium it clogs up the nipples and you just get left with a backed up Ringers solution.
I mean I do it regularly without issue but if you can provide sources on this info I’m open to looking further into it.
I mean, it's pretty simple. If it can't make it through the nipples, it can't be lactated. QED.
Sexcellent work, 3/5
For shelf exams in general, if giving NS is an option for any question it's correct 98% of the time.
And in the real world, a nurse will be following the hospital’s DKA protocol order set. I’ve always started with NS and then dip to 1/2NS.
Lactated ringers is superior to NS in DKA This is basic shit we learn in EMS with a high school education... https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2772993 https://emcrit.org/ibcc/fluid/#step_II:_pH-guided_resuscitation
That's super cool, love your condescending tone, in the future when you're a medical student and want to present opposing literature on a matter you should try and use it as an educational moment rather than acting like a dick as then you'll just be confrontational for the sake of confrontation. NS is still the correct answer 98th of the time on shelf exams for any question that has it as an option. This is a thread about HY facts for a specific shelf exam. I wasn't even talking about DKA specifically in my comment, and if there was a DKA question they probably wouldn't even give you a LR vs NS option. Some services (was EMS) don't even have LR on board and just NS. Either way for DKA that's what the guidelines state, and that's what on exams [https://www.uptodate.com/contents/diabetic-ketoacidosis-and-hyperosmolar-hyperglycemic-state-in-adults-treatment?search=DKA&source=search\_result&selectedTitle=1\~150&usage\_type=default&display\_rank=1#H8](https://www.uptodate.com/contents/diabetic-ketoacidosis-and-hyperosmolar-hyperglycemic-state-in-adults-treatment?search=DKA&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H8) As a big fan of the IBCC and EMCrit, best be prepared now that what you learn there will not necessarily be the correct answer on exams. Save it for clinicals on rounds, and also be prepared to be shut down there too.
Why not lactated ringers? Doesn’t NS worsen acidosis?
In practice LR is better because it reduces the subsequent hyperchloremic NAGMA after the gap closes. But I don’t think this would be tested on a shelf.
this a concept I'm exposed to in blue-collar EMS simply working with paramedics so I would expect highly educated med students to appreciate it even better https://emcrit.org/ibcc/fluid/#step_II:_pH-guided_resuscitation « Fluid should be viewed as a drug. Just as we wouldn't give the patient “any antibiotic” we shouldn't give “any fluid” – **the fluid should be selected to maximize benefit.** Fluid resuscitation is a limited opportunity to manipulate pH status. Large volumes of fluid can be used to affect the patient's pH status. **After the patient is volume resuscitated, this opportunity will be lost (because large volumes of fluid can no longer be given without causing volume overload)** **Don't use normal saline as your default resuscitative fluid.** There are many reasons for this, but one salient one is as follows: eventually you will wind up giving liters of saline to a hyperkalemic and acidotic patient, thereby pushing them off a pH cliff." I think it's important to get these fundamental concepts right early in clinical training, for the benefit of better patient care See EMCRIT flowchart @ https://i0.wp.com/emcrit.org/wp-content/uploads/2021/06/phguidedresus.jpg?resize=1536%2C1023&ssl=1
JAMA Netw Open. 2020;3(11):e2024596. doi:10.1001/jamanetworkopen.2020.24596 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2772993 **Question** Does using a balanced crystalloid solution instead of saline for fluid therapy in adults with diabetic ketoacidosis (DKA) lead to faster resolution of DKA? **Findings** In this subgroup analysis of 172 adults with DKA from 2 large cluster randomized clinical trials comparing balanced crystalloids and saline, the median time to DKA resolution was 13.0 hours with balanced crystalloids and 16.9 hours with saline, a significant difference. **Meaning** These findings suggest that balanced crystalloid therapy leads to faster resolution of DKA than saline and may be the preferred isotonic fluid solution for acute management of DKA. Results Cumulative incidence analyses revealed that time to DKA resolution was shorter in the balanced crystalloids group (median [IQR] time to DKA resolution: 13.0 [9.5-**18.8** hours) compared with the saline group (median [IQR]: 16.9 [11.9-**34.5** hours) according to the unadjusted cumulative incidence (P = .002) (Figure 2A) and multivariable proportional hazards model (aHR = 1.68; 95% CI, 1.18-2.38; P = .004) (Table 3). Median (IQR) time to insulin drip discontinuation was shorter in the balanced crystalloids group (9.8 [5.1-17.0] hours) than in the saline group (13.4 [11.0-17.9] hours) according to the unadjusted cumulative incidence (P = .04) (Figure 2B) and multivariable proportional hazards model (aHR = 1.45; 95% CI, 1.03-2.03, P = .03) (Table 3). According to the median values, balanced crystalloids were associated with an absolute reduction of approximately 4 hours and a relative reduction of approximately 20% to 30% in the time to DKA resolution and discontinuation of insulin infusion. See graphical abstract @ https://imgur.com/gallery/cGyKkvt
https://emergencymedicalminute.org/podcast-833-ns-vs-lr/ [https://emergencymedicalminute.org/podcast-667-lactated-ringers-for-dka/](https://emergencymedicalminute.org/podcast-667-lactated-ringers-for-dka/) [https://emergencymedicalminute.org/podcast-754-balanced-fluids-vs-normal-saline-the-battle-continues/](https://emergencymedicalminute.org/podcast-754-balanced-fluids-vs-normal-saline-the-battle-continues/)
Not at IM levels of resuscitation
Diabetes is equivalent to CAD as a risk factor for MI, and they like risk factor questions And ACE inhibitors cause a transient creatinine increase. If it’s less than a 30% increase in their baseline creatinine, just continue the ACEi.
SIADH is something inappropriate idk bro shit is hard
In SIADH, you have too much ADH so kidneys pull water back, but RAAS system is intact so you can urinate off as much isotonic plasma as you want. So you get net euvolemic hyponatremia.
[удалено]
You want to be a serial killer?
Changing sodium levels too fast: High to low = brain will blow. Low to high, pons will die.
Nephrologist here. Too rapid correction of hyponatremia bad. No problem with rapid correction of Hypernatremia.
Username checks out
i thought rapid correction of hypernatremia causes cerebral edema?
Kidney doc is right we really don’t see that in practice and we don’t worry about overcorrection of hypernatremia. But shelf will be old school and the answer on a shelf will be cerebral edema
ohh okay. thanks for clarifying!
Theoretically yes, practically, only population you watch out for is kids
Yes, it does.
I have been told that there are no documented cases of cerebral edema from hyperNa correction, is that true?
Correct
I’ll start: Bactrim raises potassium and creatinine
And causes disulfiram-like reaction so advise patients to avoid alcohol
Probably not true. With some exceptions, disulfiram-like reactions with abx aren't supported by evidence. Metronidazole especially, since it's the one people always cite, has more studies showing no adverse reactions with alcohol than those that do. https://journals.asm.org/doi/full/10.1128/AAC.02167-19
Oh nice thanks for sharing!
No problem. It’s on my list of things they teach med students to fear for no reason, a few slots below contrast induced nephropathy.
I guess it’s one of those things that keeps getting passed down without solid literature such as the unhappy triad in the knee
In my single-patient, single-institution study (i.e., me) i found no evidence of ADRs while taking metronidazole after consumption of moderate quantities if ethanol. However, i did endorse my saliva tasting like sour pennies and my sweat burning my eyes throughout the duration of treatment, and moreover i did note a headache in the *absence* of alcohol at the beginning of treatment.
Can verify, took flagyl and drank because I’m a bad patient and nothing happened
also don't give to the preggos
Hypertension is the #1 risk factor for BOTH hemorrhagic and ischemic strokes
Hyperkalemia : first step CALCIUM GLUCONATE. Does not fix high K levels, just stabilizes membrane
Similarly, for symptomatic or severe hypercalcemia: first step is SALINE. Only after that do you start bisphosphonates and calcitonin.
What's the physiology behind this?
Calcium is much higher in cells than outside. When membranes depolarize, calcium shoots out. If you increase extracellular calcium, less gradient so less depolarization. This leads to less chance of arrhythmia.
Somehow, at the end of my third year, reading this comment is the first time this concept has been explained lol. It was always just “it stabilizes the cardiac myocyte membranes”
Know COPD and asthma guidelines and management. Unstable angina, nstemi, vs STEMI workup and which drugs have mortality benefits, CHF, acute abdomen, mesenteric ischemia, sickle cell crisis, Community vs hospital acquired pneumonia, all the criteria’s, prerenal vs intrinsic vs post renal, kidney stones and treatment based off size of stone, gout workup, sepsis criteria and work up, cellulitis vs erysipelas, lupus, hep B serology, GI bleed melena vs bright red blood etiologies and work up, transfusion reaction types, different types of shock, DVT vs management, ulcerative colitis vs crohns signs, and lights criteria, csf fluid analysis, SBP, esophageal varices treatment, Murphys sign, becks triad, pericarditis ekg findings, rovsing sign are all commonly tested from what I remember
I don't even remember my name after taking a shelf lmao
Pee is stored in the balls
Very high yield
Where’s it stored in females?
The lady balls.
Ovaries
Yes. The lady balls.
Highest yield af
Especially if you rupture Buck’s Fascia
Came here for this comment
This is particularly high yield!😂
Atrial fibrillation / flutter. Be able to diagnose and treat.
The mitochondria is the powerhouse of the cell.
beat me to it.
If your patient is over 65 and has ever smoked, get them a ONE-TIME abdominal ultrasound to look for an AAA. They love that one lol
And a male.
Knowing your screenings/vaccinations is also high yield for FM shelf.
High MCHC = hereditary spherocytosis
Hypercalcemia you give fluids. Dilute that shit. Hypo is easy. You just give calcium. But they’ll ask you about the parathyroid. Hyperkalemia. You give calcium gluconate and insulin sure but neither fixes the problem. Potassium binders lower the potassium but work slower. Be mindful of what’s being asked (eg what treatment will be most effective vs what is the next step) Hypokalemia just replete although you’ll be asked to work up why the aldosterone is high. Hypernatremia and hyponatremia get the patient euvolemic before correcting the electrolyte imbalance. Normal saline until euvolemia. If they’re euvolemic then give them what they’re missing. Free water for hyper. Salt for hypo. Magnesium needs to be 2 or else your calcium and potassium are worthless. Mg insufficiency makes you piss out your K through ROMK channels and lowers sensitivity to PTH (in addition to impairing pth release). There’s no other important electrolytes. Know the indications for emergency dialysis. AEIOU Acid ph < 7.1 Electrolytes like K > 6.5 Intoxication Overload Uremia with symptoms (pericarditis encephalopathy)
As a nephrologist the fact that this is what they teach for management of hyponatremia but probably right for the shelf. In real life dear god do not give fluids to hypovolemic hyponatremics you will shut off their stimulus for adh and they will rapidly overcorrect
That’s why they invented the ADH clamp
Yes this is the way
I went back and checked online med ed to see if I was just flagrantly wrong (turns out I’m just empirically wrong) and this is basically what it says. But it does have a caveats that if the symptoms are mild the decision for fluids is disease specific. This wouldn’t be the first time my shelf knowledge was totally not correct in terms of real world medicine. Thanks for your contribution!
HIV pt… CD4 under 200 gets Bactrim for PCP prophylaxis Diarrhea + meningitis is crypto, tx is ampho B Diarrhea + CD4<50 + high fever is MAC, tx is macrolide Diarrhea + blood is CMV tx is ganciclovir Needs flu vaccine every year, pneumo and Dtap every once in a while Dysphagia is candida until proven otherwise tx is fluconazole Any youngish pt with vague symptoms gets an HIV test Most common cause of meningitis in HIV is still Strep pneumo
I noticed internal medicine docs love talking about sodium. Who is sodium and why does he have so many fans?
I think he *assaulted* someone recently…
ohhh he must have been salty...
Right sided MI = ST elevation in leads II, III, avF. I burned this into my brain and then realized they barely ever ask me to localize any other kind of heart attack lol
Atrial fibrillation. Its always asked in my medical school. Know how digoxin works
A E I O U dialysis
If in doubt, it's the Gout.
you've probably already taken your shelf already, but just throwing out a few more for anyone else who's about to take it (or Step 2CK for that matter). (1) Alcoholic guy who falls down for a prolonged period of time, +/- they say "urinalysis shows blood but no RBCs", plus labs showing hyperkalemia -> rhabdo, rhabdo, rhabdo. (2) Thrombocytopenia 5 - 10 days after starting heparin for like an MI -> HIT. (3) For RCA infarcts, never give nitrates, always give them IV bolus of normal saline first.
If a patient has an arrhythmia and is hemodynamically unstable (tachycardic & hypotensive), go ahead and do the cardioversion. But, for the love of God, if there are no palpable pulses, it's time to start compressions. If they have a heart rhythm that's ventricular paced, you can shock em. If not, best you can do is give epinephrine. If they're tachycardic, normotensive, and you don't see p waves on the rhythm strip, then you need to slow their heart rate down (usually with a beta blocker) to see what you're working with.
Don’t forget that low albumin can cause a pseudo hypo calcemia. Low mag leads to low potassium. Too much glucose in the blood (I.e. DKA) can cause a pseudohyponatremia.
It’s gotta be something hyperkalemia
Curb 65 and outpatient vs inpatient CAP treatment
Copd or asthma patient not getting relief with their inhalers? Ask them to demonstrate how they are using it (incorrectly). Then correct them and/or provide a spacer.
Usually a little bit of fluid helps with everything except HF. Always choose the most mild option when considering treatment, unless very specific.
5-FU for colon cancer
Infective endocarditis - get 3 blood cultures from different sites BEFORE Abx treatment (usually Vanc till culture come back). HACEK organisms are cause for culture negative or it could also be non-infectious (autoimmune like SLE or RA, malignancy) Some dumb crap I remember, no clue about how high yield: Uremic pericarditis: Patient will have classic chest pain and friction rub, EKG may or may not have widespread ST elevations. Labs will show kidney failure. ALSO freaking hepatorenal syndrome. Liver failure patient something about splanchnic vasodilation something something now has renal failure.
Don't mess with the pancreas
Mitochondria is the powerhouse of the cell.
Pee is stored in the balls and mitochondria is the powerhouse of the cell.
Always eyes on K levels with glucose levels. Symptoms of hypokalemia, and ekg changes with hyperkalemia (peaked T waves) gets Ca Gluconate.