每日一课

1. 每日一课 12.02-12.20

2. 12.02Emergent management of Appendicitis Signs and symptoms Classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases. Abdominal pain: Most common Nausea: 61-92% Anorexia: 74-78% Vomiting: Nearly follows the onset of pain Diarrhea or constipation Physical examination: Rebound tenderness, pain on percussion, rigidity, and guarding: Most specific finding Rovsing sign Psoas sign Markle sign (pain elicited in a certain area of the abdomen when the standing patient drops from standing on toes to the heels with a jarring landing).

3. 镇肝熄风汤《医学衷中参西录》 组成：怀牛膝30g 代赭石30g 生龙骨20g 生牡蛎20g 生龟板20g 白芍15g 玄参15g 天门冬15g 川楝子6g 生麦芽6g 茵陈6g 甘草3g 主治：糖尿病水不涵木，肝阳上亢证。头目眩晕，目胀耳鸣，或肢体渐觉不利，口角渐形歪斜，舌红苔薄黄，脉长有力 功效：镇肝熄风，滋阴潜阳 趣味记忆：天涯少草龙牡恋，牛鬼折姻缘（天芽芍草龙牡楝，牛龟赭茵玄）

4. 12.03 Emergent management of Appendicitis Workup laboratory tests: CBC:WBC >10,500 cells/µL, Neutrophilia; CRP >1 mg/dL are common Liver and pancreatic function tests Urinalysis (urinary tract conditions) Urinary beta-hCG (early ectopic pregnancy) Imaging study CT scanning with oral contrast medium or rectal Gastrografin enema Ultrasonography MRI: Useful in pregnant patients if graded compression ultrasonography is nondiagnostic

5. 12.04 Emergent management of Appendicitis Treatment General treatmet: NPO, Establish IV access and administer aggressive crystalloid. parenteral analgesic and antiemetic. Appendectomy Antibiotics Broad-spectrum gram-negative and anaerobic coverage is indicated Cefotetan and cefoxitin seem to be the best choices of antibiotics In penicillin-allergic patients, carbapenems are a good option *Antibiotic treatment may be stopped when the patient becomes afebrile and the WBC count normalizes.

6. 旋覆代赭汤《伤寒论》 组成：旋复花15g(包) 人参6g 生姜10g 代赭石30g(先) 甘草6g 半夏15g 大枣10g 功效：降逆化痰，益气和胃 用法：水煎服 主治：糖尿病肾病浊毒犯胃证。恶心呕吐频发，头晕目眩，周身水肿，或小便不利，舌质暗淡，苔白腻，脉沉弦 趣味记忆：旋覆代赭汤，老人下大江（旋覆代赭汤，老人夏大姜） 注意事项：胃热呕吐，阴虚无痰气交阻者不宜

7. 12.05 Acute Upper Gastrointestinal Bleeding Essentials of Diagnosis: • Hematemesis (bright red blood or "coffee grounds"). • Melena in most cases; hematochezia in massive upper gastrointestinal bleeds. • Volume status to determine severity of blood loss; hematocrit is a poor early indicator of blood loss. Hb 10g/L≈400ml • Endoscopy diagnostic and may be therapeutic. Etiology: • Peptic ulcers • Portal hypertension • Vascular anomalies • Gastric neoplasms • Erosive Esophagitis

8. 12.06 Acute Upper Gastrointestinal Bleeding Initial Evaluation Severe: SBP< 100 mmHg Moderate: HR>100 bpm with SBP>100 mmHg Minor: Normal SBP and HR Workup Routine test: CBC Biochemical panel: serum creatinine, liver enzymes. Prothrombin time Blood typing and screening

9. 血府逐瘀汤《医林改错》 组成：桃仁12g 红花10g 当归15g 生地15g 川芎15g 赤芍10g 牛膝10g 橘梗6g 柴胡6g 枳壳10g甘草3g 用法：水煎服 主治：糖尿病兼血瘀证。胸痛、头痛或四肢疼痛日久不愈，或中风偏瘫，眼底出血，苔薄白，舌下络脉显露，脉细涩 趣味记忆：草地芍芎，壳梗当柴，花牛桃 （草地烧穷，壳梗当柴，花牛逃）

10. 12.09 Acute Upper Gastrointestinal Bleeding Treatment General treatment: Nasogastric tube, fluid resuscitation, blood replacement (packed red blood cells, maintain a hematocrit of 25–30%); platelets transfused if platelet count<50,000/mcL. Fresh frozen plasma: coagulopathy and INR > 1.5. One unit for each 5 units of packed red blood cells. Acute Pharmacologic Therapies -Acid inhibitory therapy: Intravenous proton pump inhibitor 80 mg bolus, followed by 8mg/h continuous infusion for 72 hours -Octreotide:100ug bolus, followed by 50–100 ug/h -Three doses of desmopressin (DDAVP), 0.3 ug/kg intravenously, at 12-hour intervals Upper Endoscopy

11. 小蓟饮子《济生方》 组成：生地30g 小蓟15g 滑石15g 通草10g 蒲黄10g 藕节10g 淡竹叶10g 当归6g 山栀子10g 甘草6g 主治：糖尿病伴血淋，尿中带血，小便频数，赤涩热痛，舌红脉数 功效：凉血止血，利水通淋 趣味记忆：六一节牧童当生煮三黄鸡。（六一节木通当生竹山黄蓟）

12. 12.10 Acute Pancreatitis Etiology: Long-standing alcohol consumption Biliary stone disease Endocrine disease Symptoms Abdominal pain: dull, boring, and steady. located in the epigastric region, The pain radiates directly through the abdomen to the back (50%). Nausea, vomiting ,anorexia, diarrhea. Discomfort improves with supine position.

13. 12.11 Acute Pancreatitis-physical • Severe necrotizing pancreatitis: • The Cullen sign • The Grey-Turner sign • Erythematous skin nodules • Polyarthritis Vital sign: Fever (76%) ,tachycardia (65%) , hypotension Digestive system： Abdominal tenderness, muscular guarding (68%), distention (65%) , diminished or absent of bowel sound, Jaundice (28%), hematemesis or melena (5%) Respiratory system： dyspnea (10%), pleural effusion, ARDS, basilar rales in the left lung muscular spasm

14. 真武汤《伤寒论》 组成：茯苓15g 白芍10g 生姜10g 炮附子6g 白术15g 用法：水煎服 主治：糖尿病肾病脾肾阳虚证。小便不利，四肢沉重疼痛，腹痛下利，或肢体浮肿，苔白不渴，脉沉 趣味记忆：珠江少妇灵（术姜芍附苓）

15. 12.12 Acute Pancreatitis-workup laboratory testing -Routine test: Leukocytosis, no hemoconcentration effectively rules out severe disease. -Biochemical panel: ALT >150 U/L suggests gallstone pancreatitis. Electrolytes, renal function, glucose, lipid. -CRP≥ 10 mg/dL strongly indicates severe pancreatitis. -Serum amylase and lipase levels: at least 3 times above the reference range. Other tests -Arterial blood gases -LDH, BUN, bicarbonate levels: admission and at 48 hours Imaging study CT scanning and/or MRI, Abdominal/Endoscopic US, ERCP, Kidneys-ureters-bladder (KUB) radiography.

16. 12.16 Acute Pancreatitis-treatment General treatment: -Gastrointestinal decompression and parenteral nutrition -Aggressive fluid replacement: Most effective within the first 12-24 hours. Initial 500-1000mL/h volume-depleted patient, then 250-300mL/h. adjusting the fluid rate every 1 to 4 hours on the basis of clinical variables. -Antibiotics: <14 days. -Analgesics: meperidine, 100-150mg intramuscularly q3-4h prn. Specific treatment: -Corticosteroids for autoimmune pancreatitis . - Inhibition of pancreatic secretion: PPI, SS, gabexate. -cholecystectomy -Surgery :large areas of the pancreas are necrotic and percutaneous CT-guided aspiration demonstrates infection. Complication therapy: insulin, calcium gluconate , fresh frozen plasma or serum albumin for coagulopathy or hypoalbuminemia. Hypertriglyceridemia: insulin, heparin, or apheresis

17. 理中丸《伤寒论》 组成：人参6g 干姜10g 甘草10g 白术10g 用法：水煎服 主治：糖尿病肾病脾肾阳虚证。自利不渴，呕吐腹痛，不欲饮食，苔白，脉沉 趣味记忆：老人白干温中寒（老人白干）

18. 12.17 Emergent Management of Acute Symptoms of Hypoglycemia Definition < 50 mg/dL (2.8mmol/L) in men < 45 mg/dL (2.5mmol/L)in women < 40 mg/dL (2.2mmol/L) in infants and children Whipple triad is characteristic of hypoglycemia regardless of the cause. History of hypoglycemic symptoms An associated fasting blood glucose of 2.8mmol/L or less immediate recovery upon administration of glucose.

19. 12.18 Emergent Management of Acute Symptoms of Hypoglycemia Determination of hypoglycemia: BG level Determination of Etiology: -malignancy: tumor marker -inappropriate hyperinsulinism: serum insulin level ≥6 uIU/mL and blood glucose values below 40 mg/dL. -insulinomas: C-peptide > 200 pmol/L and proinsulin levels> 5 pmol/L. -MEN 1: Serum calcium, gastrin, or prolactin level for patients with epigastric distress, a history of renal calculi, or menstrual or erectile dysfunction. -Deficiency of insulin contra regulation hormone: thyroid function, cortisol, GH…. Assessment of complication: imaging study, EKG.

20. 葶苈大枣泻肺汤《金匮要略》 组成：葶苈子15g 大枣15g 用法：水煎服 功效：泻肺行水，下气平喘 主治：糖尿病肾病水气凌心证。气喘不能平卧，肢冷，甚或大汗淋漓，心悸怔忡，肢体浮肿，下肢尤甚，舌淡，苔白滑，脉短促或结代 注意事项：泻肺利水峻剂，无胸胁水饮内停者慎用

21. 12.19 Emergent Management of Acute Symptoms of Hypoglycemia General treatment: ABCs, IV access, Oxygen,Monitoring Glucose Supplement: The mainstay of therapy for hypoglycemia is glucose. Other medications may be administered based on the underlying cause or the accompanying symptoms. Mild: 10-20 g of glucose orally; Moderate: 10-20 g of liquid glucose orally; Severe: unconscious and unable to swallow, IV glucose is required. -Wait 15 minutes and recheck -Reading<4mmol/L, or if no physical improvement, repeat. -IV glucose administration as a bolus of 50% 60-100ml or a continuous infusion of 5% or 10% glucose solution need to be maintained . -Once reading >4mmol/L, follow up with a snack to help prevent recurrence.

22. 12.20 Emergent Management of Acute Symptoms of Hypoglycemia Glucose-Elevating Agents Act in the pancreas or the peripheral tissues to increase blood glucose levels. -Glucagon: 1 mg may be useful when intravenous (IV) access is problematic. -Corticosteroids: Prednisolone 0.25-1 mg/kg IV or PO q12h, or dexamethasone 0.5-1 mg/kg IV or PO q24h. Inhibitors of insulin secretion -Octreotide (Sandostatin): A long-acting analog of somatostatin that suppresses insulin secretion for the short-term management of hypoglycemia. It can be given 100-300ug subcutaneously. -Diazoxide: Increases blood glucose by inhibiting pancreatic insulin release and possibly through an extrapancreatic effect. The dose is 3-8mg q8-12h orally.

23. 生脉饮《内外伤辩惑论》 组成：人参10g 麦冬15g 五味子6g 主治：糖尿病肾病气阴两虚证。心悸气短，脉微自汗，口干舌燥，苔薄少津，脉虚数或虚细 功效：益气生津，敛阴止汗 趣味记忆：生脉为人脉（生脉味人麦） 注意事项：无气阴两虚，阳虚汗冷，舌淡胖，脉沉缓不宜

24. 12.23 Emergent Management of Ketoacidosis Essentials of Diagnosis Hyperglycemia > 250 mg/dL(13.9mmol/L). Acidosis with blood pH < 7.3. Serum bicarbonate < 15 mmol/L. Serum positive for ketones.

25. 杞菊地黄丸《麻疹全书》 组成：菊花10g 枸杞10g 熟地15g 山萸肉10g 山药12g 泽泻10g 丹皮10g 茯苓10g 主治：糖尿病眼底病变肝肾阴虚证。腰膝酸软，头晕目眩，两目昏花，视物模糊，或眼睛干涩，迎风流泪等 功效：滋肾养肝明目 记忆：六味地黄+菊花、枸杞 注意事项：忌不易消化食物。 感冒发热病人不宜服用。儿童、孕妇、哺乳期妇女应在医师指导下服用。 对该药品过敏者禁用，过敏体质者慎用

26. 12.24 Emergent Management of Ketoacidosis Fluid therapy : Saline solution 6000-8000ml is infused intravenously in the first 24 hours. 1L of Normal saline over the first hour and 200 to 500mL/hr in subsequent hours until hypotension resolves and adequate circulation is maintained. Small dose of Insulin: 4-6U/hr intravenously. BG reaches 13.9mmol/L, decrease the insulin infusion rate and administer dextrose. Correction of acid-base imbalance: Sodium bicarbonate 80-100ml should be given intravenously if PH<7.1 Correction of electrolytes disturbance: Replace potassium at 10 to 20 mmol/hr (half as potassium chloride and half as potassium phosphate). Monitor serum levels at least every 2 hours initially, and monitor ECG morphology Treatment of infection Other supportive treatment

27. 12.25 Management of DNHS Essentials of Diagnosis Hyperglycemia > 600 mg/dL(33.3mmol/L). Serum osmolality > 320 mosm/kg. No acidosis; blood pH above 7.3. Serum bicarbonate > 15 mmol/L. Normal anion gap (< 14 mmol/L).

28. 补阳还五汤《医林改错》 组成：黄芪60g 当归10g 赤芍10g 地龙6g 川芎10g 红花10g 桃仁10g 主治：糖尿病周围神经病变气虚血瘀证。手足麻木，肢末时痛，少气懒言，舌质淡 紫，苔白，脉沉涩 记忆：补阳当地穷人持红旗（补阳当地芎仁赤红芪） 注意事项： 1）本方证是由于气虚血瘀所致，以正气亏虚为主，原书称为‘因虚致瘀’，故生黄芪用量宜重（可从30~60g开始，效果不显，再逐渐增加），祛瘀药宜轻 2）使用本方，需久服缓治，疗效方显。愈后还应继续服用一段时间，以巩固疗效，防止复发 3）高血压患者可用，但正气未虚者慎用，阴虚阳亢，或阴虚血热，或风，火，痰，湿等余邪未尽者，均忌用

29. 12.26 Management of DNHS • Aggressive volume replacement therapy: normal saline solution 8000-10000ml is infused intravenously in the first 24 hours • Small dose of Insulin should be given: Insulin should be given intravenously by 4-6U/H. • Correction of electrolytes disturbance • Always treat the underlying problem, treat infection if present • Other supportive treatment

30. 12.27 Emergent manage of hypokalemia Causes of hypokalemia -Decreased potassium intake -Potassium shift into the cell  -Renal potassium loss  -Extrarenal potassium loss  Essentials of Diagnosis -Severe hypokalemia may induce dangerous arrhythmias and rhabdomyolysis. -Transtubular potassium concentration gradient (TTKG) can distinguish renal from nonrenal loss of potassium. Hypokalemia with a TTKG > 4 suggests renal potassium loss with increased distal K+ secretion.

31. 四物汤《仙授理伤续断秘方》 组成：当归15g 川芎10g 白芍15g 熟地15g 主治：糖尿病周围神经病变阴虚血瘀证。腿足挛急，酸胀疼痛，肢体麻木或小腿抽搐，夜间尤甚，五心烦热。苔少花剥，脉细涩 功效：补血调血 注意事项：血崩气脱，湿蕴脾胃，非本方所宜 趣味记忆：当地传说（当地川芍）

32. 12.30 Treatment of hypokalemia Potassium replacement therapy was based on the symptoms and the potassium level. Begin therapy after laboratory confirmation of the diagnosis. Oral potassium supplementation is the safest and easiest treatment for mild to moderate deficiency (potassium level of 2.5-3.5 mEq/L) . If the potassium level is less than 2.5 mEq/L, intravenous potassium should be given. Potassium chloride (Klor-Con, K-Dur) Cautions: Total dose of potassium: mild (KCl 8.0g) ,moderate (KCl 24g),severe (KCL 40g), dose<15g KCl/d Concentration<0.3% (40mmol/L) Speed of fluid volume:<20mmol/h (1.5g/h) PS: 10%KCL 30ml= 40 mEq

33. 天王补心丹《摄生秘剖》 组成：人参15g 茯苓15g 玄参15g 丹参15g 橘梗6g 远志10g 当归15g 五味子10g 麦冬15g 天冬15g 柏子仁15g 酸枣仁30g 生地30g 主治：糖尿病心脏自主神经病变心阴亏耗者。心悸，虚烦失眠，神疲健忘，手足心热，口舌生疮，大便干结，舌红少苔，脉细数 功效：滋阴清热，养血安神 注意事项：滋阴药较多，脾胃虚弱，纳食欠佳，大便不实者，不宜长期服用 记忆：补心地归二冬仁，远茯味砂桔三参，阴虚血少生内热，滋阴养血安心神

34. 12.31 Emergent management of hyperkalemia Essentials of Diagnosis Serum potassium level > 5.0 mmol/L Causes: patients taking ACE inhibitors, angiotensin-receptor blockers, potassium-sparing diuretics, or their combination, even with no or only mild kidney dysfunction. ECG: peaked T waves, widened QRS and biphasic QRS–T complexes, or may be normal despite life-threatening hyperkalemia. Measurement of plasma potassium level differentiates potassium leak from blood cells in cases of clotting, leukocytosis, and thrombocytosis from elevated serum potassium. Rule out extracellular potassium shift from the cells in acidosis and assess renal potassium excretion.

35. Thank you！