快速鍵

1. Amiodaron 6 amps + NS 500cc run 34cc/hrs for 6 hours then run 17cc/hr for 18hr

2. Levophed 4amps + D5W 250cc intravenous dripping by pump control, please adjust dose +-1 gett prn to keep SBP > 90 mmhg, max dose 20gett/hr

3. Dopamin run 15 gett/hr by pump control, +- 3gett/hr, to keep SBP >90 mmhg, Max 40 gett/hr, Min 0 gett/hr

4. Midazolam 10A(50mg) + NaCl 40cc[1mg/cc], run 6cc/hr, RANGE 0~10, +/- 2GTT

5. K3PO4 3cc(12meq)+NaCl 100 cc run >6 hr

6. KCl loading: Nacl 250cc +KCL 10meq run > 4 hours

7. Nexium 2A +250 Nacl run 20cc/hr

<ACTH stimulation test>
1. 簽署Cosyntropin(Teracosactide)自費同意書以及病人委託書
    (家屬可以代簽,一份留存病歷,一份傳回至2F門診糖尿病中心)
2. 完成此檢查前,請勿使用steroid (Prednisolone至少停用24小時)
3. NPO since 0:00 on _____(日期) till blood tests done
4. Lying on bed for 30 minutes since 8:30 till the test done
   check ACTH/Cortisol at AM 9:00 on ______(日期)
5. Then Cosyntropin(Teracosactide) 0.25mg/1ml/Amp IV push
6. Check Cortisol after Cosyntropin injection 30mins later
7. Check Cortisol after Cosyntropin injection 60mins later
8. 請確實在該時間點完成抽血

<Adrenal tumor>
@ Urine全部都留24小時：Cr, Na, K, Cortisol, VMA, Cata, 17KS, 17OHC
@ 病人禁用spirolactone, furosemide, B-blocker, ACEI, ARB, steroid, Tricyclic antidepressant, CCB(dihydropyridine類),
Pseudoephedrine(decongestion)
@ 可用 a-Blocker, non-dihydropyridine CCB (Diltiazem, Isoptin), Hydralazine

<<Saline infusion test>>
1. 請病人平躺
2. stat 抽Aldosterone and Renin activity before N/S hydration
3. N/S 2L run 4hr
4. 抽 Aldosterone and renin activity after N/S hydration
5. On EKG monitor, check BP and HR Q15 mins during test
6. If patient complained of SOB, chest discomfort, headache, etc...
    ==> please call Dr to see if the test should be stoped.

<會診單>
Suggestion:
--Control underline disease as your experience
--OAD@@@@@
--Insulin@@@@
--Sliding scale
    Surestep qid with sliding scale
    200~250(1U) 251~300(2U) 301~350(3U) 351-400(4U) 401-450(5U) >451(6U)
    Surestep at 21:00 without sliding scale
--Hypoglycemic education, 如有飢餓, 冒冷汗等低血糖症狀,請立即測量血糖, 再進食. If blood glucose <60 mg/dl:
  1. 50% glucose, 3 vials, Iv stat.
  2. Call resident Dr. stat.
  3. Follow up surestep 15 minutes later.
  4. Hold insulin.
--May check HbA1c, cholesterol, LDL, TG, HDL
--May consult dietitian for diet suggestion if necessary
--If sugar level is still unstable, contact us if need

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IVII

Surestep Q2H
normal saline 100cc + HRI 100u run as:

BS<100  hold 2 hr and follow up eyetone 2 hr later
101-130        0.5cc/hr
131-160          1cc/hr
161-190          2cc/hr
191-220          3cc/hr
221-250          4cc/hr
251-280          5cc/hr
281-310          6cc/hr
311-340          7cc/hr
341-370          8cc/hr
371-400          9cc/hr
401-430         10cc/hr
431-460         11cc/hr
>460  HRI 5u iv  st and run 10 cc/hr

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ABI 適應症

糖尿病病人 >50歲, 一年可做一次篩檢 ;
糖尿病病人< 50歲, 合併一種CAD Risk factor, 一年routin 做一次篩檢
 ( CAD risk factor ; Hypertension or Hyperlipidemia or Smoking or 家族史)

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RAI治療

1 mCi = 1000 uCi

We typically administer 160 uCi/g thyroid tissue [5.9 MBq/g] for Graves' hyperthyroidism and 200 uCi/g [7.4 MBq/g] for toxic adenoma/MNG. A fixed dose of 10 to 15 mCi [370 to 555 MBq] for Graves and 15 to 20 mCi [500 to 740 MBq] for toxic adenoma/MNG is an alternative option.

For patients with significant symptoms of hyperthyroidism and in elderly patients with underlying cardiac disease, we suggest starting a methimazole to achieve euthyroidism prior to radioiodine therapy.

We discontinue methimazole three days prior to radioiodine and restart three days after radioiodine therapy.

For young and middle-aged patients who are less symptomatic, there is no need to pretreat with a thionamide, and radioiodine can be given soon after the diagnosis is made.

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Test for Cushing

## Low dose dexamethasone suppression test:
1. Dexamethasone 0.5mg 1# q6h since 9/11~9/12 (at 8AM, 2PM, 8PM, 2AM), total 2days=8 dose  
2. Collect 24 hours(9/12 08:00 ~ 9/14 08:00) Urine 17-OHC, cortisol x 2 days
3. check serum ACTH, cortisol on 9/13 8AM
異常：urine cortisol > 36mcg/day, serum cortisol > 1.4mcg/dL

## High dose dexamethasone suppression test:
1. Dexamethasone 0.5mg 4# q6h since 9/14~9/15(at 8AM, 2PM, 8PM, 2AM), total 8 dose (16mg)
2. Collect 24 hours(9/16 08:00 ~9/17 08:00) Urine 17-OHC, cortisol x 2 days
3. check serum ACTH, cortisol on 9/16 8AM
如果能夠把baseline的urine cortisol抑制90%以上-->猜cushing disease

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Three comdined pituitary function test

test for growth hormone deficiency
TRH test, LH-RH test, Insulin tolerance test

1. midnight NPO
2. On 20 號 medicut + 3 way, 接N/S(500ml) keep open (勿接IV lock)
3. Bed rest
4. 備血糖機及2amp 50% GW(for hypoglycemia with loss of conscious)
5. 8AM抽血
    ==> GH,  IGF-1,  TSH,  free T4,  LH,  FSH, PRL
           testosterone, E2,  ACTH, Cortisol,  plasma sugar
6. HRI        0.2 u/kg  iv push
    TRH       0.5 mg  iv push  30秒
    LH-RH   100 ug (0.1mg) iv push
7. 8點開始test後，第15' 30' 45' 60' 90' 120'分鐘時
   用血糖機測finger sugar
   同時要抽血測GH,  TSH,  LH,  FSH,  plasma sugar, Cortisol
8. check CBC/DC, Iron, TIBC, Ferritin, PLT, BUN,  Cr,  Na,  K
9. CXR
10. 請家屬幫忙準備含糖食物或飲料(果汁, 豆奶或糖果等)

1. TRH test==>注射TRH30'後，TSH應上升6以上，或大於2倍baseline值
2. LH-RH test==>LH在30' or 60'後上升4~6倍。FSH可能會上升一倍。
3. Insulin tolerance test==>GH在45'~60'後應至少上升7ng/mL(通常都10~20)。Cortisol通常會上升一倍。

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Test for primary aldosteronism

#  hypertension and hypokalemia are controlled
#  avoiding spironolactone and eplerenone

A. Oral sodium loading
<<Oral sodium loading test>>
1. 抽Aldosterone and Renin activity
2. 請病人每天吃鹽6 g，吃兩天
3. 第三天開始留24-hr尿，檢測urine aldosterone, Na/K, Cr.
4. Urine aldosterone excretion >12 to 14 mcg/24 hrs-->確診
5. Urinary excretion of sodium >200 mEq/day-->adequet sample

B. Intravenous sodium loading test (ABAYSALIN)
<<Saline infusion test>>
1. 請病人平躺
2. stat 抽Aldosterone and Renin activity before N/S hydration
3. N/S 2L run 4hr
4. 抽 Aldosterone and renin activity after N/S hydration
5. On EKG monitor, check BP and HR Q15 mins during test
6. If patient complained of SOB, chest discomfort, headache, etc...
    ==> please call Dr to see if the test should be stoped.
7. test 後PAC >10 ng/dL --> 確診，PAC <5 ng/dL --> 排除

C. Captopril challenge test
<<Captopril challenge test>>
1. 請病人至少維持坐立或站立一小時再開始test，直到結束
2. Captopril 25–50 mg PO
3. 服藥後1hr, 2hr各抽一次PRA, Aldosterone, Cortisol
4. Aldosterone >15ng/dl --> 確診

The use of the fludrocortisone suppression test is limited
The captopril suppression test is less standardized alternative if sodium loading is
contraindicated as in heart or renal failure.

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