observership 1

diverticulitis treatment:
IV fluid, invanz(carbapenems) 1g iv qd up to 14 days
Left lower quadrant pain is the most common complaint in Western countries, occurring in 70 percent of patients. Pain is often present for several days prior to admission, which aids in the differentiation of diverticulitis from other causes of acute abdominal symptoms.
The hallmark of diverticular bleeding is painless rectal bleeding, which is usually self-limited.
The diagnosis of acute diverticulitis can often be made on the basis of the history and the physical examination.

• Complicated diverticulitis refers to the presence of a perforation, obstruction, an abscess, or a fistula. Approximately 25 percent of patients diagnosed with diverticulitis for the first time present with complicated diverticulitis. Nearly all of these patients require surgery.
• Uncomplicated diverticulitis, accounting for 75 percent of cases, refers to diverticulitis without the complications noted above. The majority of these patients respond to medical therapy, although up to 30 percent require surgery.

UNCOMPLICATED DIVERTICULITIS — The success rate of conservative treatment, bowel rest and antibiotics, ranges from 70 to 100 percent for patients with acute uncomplicated diverticulitis

Selection for outpatient management — The decision regarding whether to hospitalize a patient with diverticulitis depends upon several factors, including the severity of presentation, the ability to tolerate oral intake, the presence of comorbid diseases, and the available support system. Patients selected for outpatient management should be reliable and understand the indications for seeking immediate medical attention. These include an increase in fever or abdominal pain or the inability to consume adequate fluids. As a general rule, the elderly, immunosuppressed, those with significant comorbidities, and those with high fever or significant leukocytosis should be hospitalized.

antibiotics with activity against gram negative rods and anaerobic

Dietary recommendations — Outpatients should be instructed to consume clear liquids only. Clinical improvement should be evident after two to three days, after which the diet can be advanced slowly. Patients requiring hospitalization can be treated with clear liquids or NPO with intravenous hydration, depending upon the severity of symptoms.

c.difficile infection
risk factor:

1. antibiotics, clindamycin, fluroquinolone, cephalosporin
2. advanced age, hospitalization, severe illness
3. gastric acid suppression (sometimes need to stop using PPI omeprazol)
4. cancer chemo, hemato stem cell transplantation

treatment: metronidazole, vancomycin

pseudomonas

• anti pseudo penicillins(piperacillin, ticarcillin) piperacillin-tazobactam(zosyn): The combination has activity against many Gram-positive and Gram-negative pathogens and anaerobes, including Pseudomonas aeruginosa.
• 3rd cephalosporin, ceftazidime
• 4th cephalo, cefepime
• carbapenem, imipenem, metropenem
• fluoroquinolone(ciproxacin, levoxacin)
• aminoglycosides, gentamicin, tobramycin, amikacin, (always combine w/other antibiotics)

cardiac axis deviation
right axis deviation, I: negative  avF: positive
                             III:positive  avL: negative

• QRS is positive (dominant R wave) in leads III and aVF
• QRS is negative (dominant S wave) in leads I and aVL

left axis deviation

• QRS is positive (dominant R wave) in leads I and aVL
• QRS is negative (dominant S wave) in leads II and aVF

LBBB

• QRS duration of 120 ms
• Dominant S wave in V1
• Broad monophasic R wave in lateral leads (I, aVL, V5-V6)
• Absence of Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in aVL)
• Prolonged R wave peak time > 60ms in left precordial leads (V5-6)

Dominant S wave in V1 with broad, notched (‘M’-shaped) R wave in V6

RBBB

• Broad QRS > 120 ms
• RSR’ pattern in V1-3 (‘M-shaped’ QRS complex)
• Wide, slurred S wave in the lateral leads (I, aVL, V5-6)

Tall R' wave in V1 ("M" pattern) with wide, slurred S wave in V6 ("W" pattern)

syncope
factor V leiden mutation
multiple sclerosis exacerbation
COPD exacerbation advair (fluticasone/salmeterol), duoneb(albuterol/ipratropium)
nursing home acquired pneumonia vancomycin+cefazidime