dizziness

divided into 3 categories:
1. faintness, 2. vertigo. 3. miscellaneous head sensation

faintness: presyncopal syndromes: blurred vision, feeling of warmth, diaphoresis
vertigo: visual, vestibular, or somatosensory disfunction

diabetes ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS)

                        DKA                       HHS
glucose          250~600                 600~1200
sodium           125~135                 135~145
K                   normal to high          normal
Mg                normal                      normal
Cl                  normal                      normal
P                   decreased                 normal
Cr                 slightly increased       moderate increased
osmolatiry     300~320                  330~380
keto              ++++                       +/-
HCO3           <15                         normal
PH                6.8~7.3                    >7.3

DKA:
symptoms and signs
abdominal pain, shortness of breath, polyuria, thirst, nausea, vomiting
dehydration, hypotension, tachypnea, tachycardia, abdominal tenderness, lethargy

precipitating factors:
infection
infarction
insulin administration inadequate
drug
pregnency

management
1. confirm the diagnosis
2. admission
3. check: electrolyte, acid-base, renal function
4. fluid supplement: 2~3 L N/S for the first 1~3 hr (10~15 mL/kg/hr), than shifted to half saline (150~300
                              mL/hr), half saline and 5% glucose when sugar < 250 (100~200 mL/ hr)
5. Insulin regular: 0.1U/kg IV or 0.3 U/kg IM STAT, than 0.1 U/kg/hr continuous infusion (do not use 
                           insuline if K<3.3)

HHS
prototype: elderly, a several week history of polyuria, decreased oral intake, weight loss, with confusion,
                 lethargy, and coma
precipitating factors: infarction, infection, compromised water intake

management: as DKA








                 

hyponatremia

clinical presentation:
asymptomatic,
general malaise, nausea
lethargy, headache, confusion, seizure, coma

blood osmolality:
hyper- hyperglycemia, mannitol
normal- hyperproteinemia, hyperlipidemia, TURP
hypo-    urine osmolality   <100 mosmo/kg or specific gravity< 1.003  -- primary polydipsia
          
             hypovolemic:
             urine sodium concencration  >20  sodium wasting nephropathy, diuretic use, hypoaldosteronism
             urine sodium concentration  <10 extrarenal loss, remote diuretic use, remote vomiting
             euvolemic:
             SIADH, hypothyroidism, alrenal insufficiency
             hypervolemic:
             CHF, cirrhosis

lab:
urine sodium, potassium, osmolality, plasma osmolality

delta Na=Na inf- Na ser/IBW*0.6 +1

http://www.globalrph.com/saline.htm

4476469

有趣case

2175809
90 y/o female
submandibular pain (4:00), shifted to back and abdomen
arriving ER on 6:30
with mild chest tightness
no dyspnea

syncope

life-threatening conditions
1. cardiac syncope
2. blood loss
3. pulmonary embolism
4. subarachnoid hemorrhage

common
1. vasovagal syncope: most patients have prodromes, including dizziness or lightheadedness, a sense of warmth, pallor, nausea/vomiting, abdominal pain, and diaphoresis
2. orthostatic hypotension
3. medication

rare:
1. neurological syncope: TIA, SAH, complex migraine syndrome
2. psychiatric syncope
3. metabolic: hypoxia, hypoglycemia

associated symptoms:
1. chest pain, palpitation, dyspnea, headache
2. prodromes: sense of warmth, nausea, vomiting, and disphoresis

study:
ECG, Lab, one touch

high risk patients
1. low BP
2. abnormal EKG
3. structural heart disease
4. dyspnea
5. low Hb
6. older age
7. family history of cardiac syncope

acetaminophen intoxication

服藥24小時內, 根據Rumack normogram給予治療
服藥超過24小時, 已具肝功能有無異常給予治療

Stage:
1    hours                  nausea, vomiting
2   24~72 hours      elevated LFTs, RUQ pain
3   3~5 days             jaundice, hepatic failure
4     one week          recovery

N-acetylcysteine
PO: 140 mg/kg, than 70 mg/kg, total 18 dose
IV: 150 mg/kg for 15 min, 50 mg/kg for 4 hours, 100 mg/kg for 14 hours  or
      140 mg/kg for loading, than 70 mg/kg every 4 hour, total 13 dose

如acetaminophen 濃度小於10 mg/L, 且AST為正常, 可不需治療