FP essentials
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Rhabdomyolysis is the rapid breakdown of skeletal muscle with release of electrolytes, myoglobin, and other proteins into the circulation. The clinical presentation encompasses a spectrum of patients ranging from those with asymptomatic increases in creatine kinase (CK) levels to those with fulminant disease complicated by acute kidney injury (AKI), severe electrolyte abnormalities, compartment syndrome, and disseminated intravascular coagulation. A CK level at least 10 times the upper limit of normal typically is considered diagnostic, as is myoglobinuria. ⋯ Significant electrolyte abnormalities may be present and must be managed to avoid cardiac arrhythmias and arrest. Compartment syndrome can develop as an early or late finding and requires decompressive fasciotomy for definitive management. Intravenous fluids typically are continued until CK levels are lower than 1,000 U/L.
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When patients present with major or life-threatening bleeding due to warfarin use, rapid reversal with coagulation factors and vitamin K often is warranted. Oral vitamin K should be administered if the international normalized ratio is greater than 10 with no evidence of bleeding, but its use is not recommended if international normalized ratios are between 4.5 and 10. The most important factor in the risk of hemorrhage is the intensity of warfarin therapy. ⋯ Use of anticoagulation management services (eg, intervention using automated hospital information system-generated triggers from laboratory and pharmacy data) in the outpatient and inpatient settings can be considered to decrease the risk of complications for patients taking anticoagulants. Services that incorporate clear communication, evidence-based drug management, and patient education are important to ensure safe use of anticoagulants. Management of heparin-induced thrombocytopenia should include heparin discontinuation and initiation of a nonheparin anticoagulant.
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Review Case Reports
Cardiac risk factors: noninvasive testing to detect coronary heart disease.
Patients with acute chest pain should be assessed first for the likelihood of acute coronary syndrome using the Thrombolysis in Myocardial Infarction score or the Agency for Health Care Policy and Research criteria. If assessment indicates high risk, the patient should be admitted to the hospital. Low- and intermediate-risk patients whose chest pain has ceased and who have normal or unchanged electrocardiograms and troponin levels can be monitored for 6 to 8 hours. ⋯ Coronary computed tomographic angiography and magnetic resonance angiography currently are not standard tools for this testing. Testing also is sometimes obtained for asymptomatic outpatients with intermediate risk of coronary heart disease, with the goal of reclassifying them in low- or high-risk categories. Carotid intima-media thickness, ankle-brachial index, coronary artery calcium scores, stress tests, coronary computed tomographic angiography, and magnetic resonance angiography have been suggested for this purpose, but they only result in reclassification of small percentages of patients and are not recommended routinely.
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The diagnosis of irritable bowel syndrome (IBS) should be considered when patients have had abdominal pain/discomfort, bloating, and change in bowel habits for 6 months. Patients may experience variation between periods of constipation and diarrhea. When evaluating patients with IBS, physicians should be alert for red flag symptoms, such as rectal bleeding, anemia, nighttime pain, and weight loss. ⋯ Constipation-dominant IBS can be managed with antispasmodics, lubiprostone, or linaclotide, whereas diarrhea-dominant IBS can be managed with loperamide or alosetron, though the latter drug can cause ischemic colitis. For long-term therapy, tricyclic antidepressants or selective serotonin reuptake inhibitors have good efficacy. Peppermint oil and probiotics also may provide benefit.