Misc #

Allergies #

loratadine ≈ cetirizine < fexofenadine, very roughly
loratadine (Claritin)
- 5mg BID or
- 10mg qday
cetirizine (Zyrtec)
- 5-10mg qday
fexofenadine (Allegra)
- 60mg q12 or
- 180mg qday
fluticasone nasal (Flonase)
- 1-2 sprays qday (110mcg/day)
Naphcon-A/Opcon-A/(Visine-A?) eye drops
- naphozoline (vasoconstrictor) and pheniramine (antihistamine)
- 1-2 drops QID
Max therapy:
- fexofenadine +
- fluticasone +
- Naphcon-A

Semaglutide (Ozempic) (GLP1-RA)
- Ramp up to max tolerated dose
- Roughly 14-18% weight loss at 68 weeks (with diet/exercise)
- Side effects
  - N/V/D → usually get better with time
  - Hypoglycemia (rare without other antihyperglycemics)
Phentermine-topiramate
- ~10% weight loss at 52 weeks
- Side effects
  - Dry mouth
  - Constipation
  - Paresthesias
- Contraindications
  - Pregnancy (topiramate teratogenic)
Oristat
- Inhibits pancreatic lipases → less fat digestion/absorption → poop more fat out
  - Watch fat-soluable vitamins (obvious reasons), Vitamin D most often affected
    - Caution with warfarin as less Vitamin K, so usually need less warfarin dose
- Roughly 4-6% weight loss at 52 weeks

No data on combinations of the above, Semaglutide most effective.

In general, above 9,800ft (3,000m), ascend no more than 1,000 to 2,000ft per day

Diagnosis (2018 Lake Louise Criteria)
- >5 yo
  - HA plus one or more of
    - fatigue/weakness
    - dizziness/lightheadedness
    - GI sx (N/V, anorexia)
- Non-verbal kiddos
  - Fussiness plus one or more of
    - eating disturbance
    - reduced playfulness
    - sleep disturbances (naps or nightime)
- Usually develops 6-12hrs after arrival at altitude
Tx
- Acetazolamide 250mg BID or
- Dexamethasone 4mg q6h
Prevention
- slow ascent
- Acetazolamide 125mg BID, started at least 1 day before ascent
- Dexamethasone 4mg q6-12hrs

Diagnosis
- if sx of AMS
  - Either mental status change or ataxia
- if no sx of AMS
  - Both mental status changes and ataxia
Treatment
- Immediate decent
- Dexamethasone 8mg load, then 4mg q6h
Prevention
- Dexamethasone 4mg q6h

Diagnosis
- Two or more of the following
  - dyspnea at rest
  - cough
  - weakness/decreased exercise capacity
  - chest tightness/congestion
- plus at least two of
  - rales/wheezing on exam
  - tachypnea
  - tachycardia
  - central cyanosis
Treatment
- Immediate decent
- Nifedipine (Procardia) 20mg q8h or 30mg q12hrs
Prevention
- Nifedipine (Procardia) 20mg q8-12hrs

Ambien/Lunesta not approved for long term use. Best for short term help, see below.

Mg glycinate, 400-800mg
- Can use short term or chronically
- Can cause diarrhea
- Use citrate if you need constipation relief
Valarian Root and/or California Poppy
- From Whole Foods/Vitamin Cottage
- Fast acting, doesn’t really require “build up” phase
Yoga
- Nidra style best for sleep
- Good when brain can’t relax

1st tier
- Melatonin 3mg
  - Can be habit forming
  - 10mg melatonin max per day
  - Better results with 3mg per day (??? Paper)
- Benadryl or hydroxazine
  - Non-habit forming
  - OTC
  - Some pts can have paradoxical effect (revved up instead of sedating)
2nd tier
- Trazodone 50-100mg qhs
  - serotonin modulator
  - Must use regularly for best resuilts
- TCAs, amitriptyline 10-75mg
  - Must use regularly, takes a couple weeks to build up to optimal effect
3rd tier
- Seroquel (quetiapine) 25-50mg (<100mg)
  - Anti-psychotic doses in the 100’s of mg
  - Great adjunct for people on SSRIs for anxiety
  - Also great adjunt with pts that have a bend toward paranoia
Misc
- Tomazepam
  - Only benzo approved for sleep
  - Clonazepam/valium (longer acting benzos) could be used too

Great for things like jet-lag for overseas trips, acute external mood things (death of loved one, short term college exam stress)

Ambien 5-10mg for M, 2.5-5mg for F
- 1/2 dose ambien for females (can build up in their bodies)
Lunesta

Deficiency treatment by level

Level (ng/mL)	Treatment	Notes
<12	50k IU qweek, then 800-1000 IU qday	Check Ca and DXA
12-20	800-1000 IU qday	Recheck in 3 months, raise daily dose if not at goal
20-30	600-800 IU qday	Recheck in 3 months, raise daily dose if not at goal

Three finger pulse check
- Fingers together if pt is shorter than doc, apart slightly if taller
- Face pt, R check pts left, L checks pts R
- Feel for quality of pulses
Tongue
- Color
- Scalloping
- Lesions, coatings, etc.

“Euboxia” => treating to make the numbers look good and/or get rid of the nasty little red arrows in the boxes (and not actually fix anything important in the patient)
“Field of Turds” => Having to tip-toe through conversation so as not to step into issues that aren’t related to the current hospital stay/visit
“The less there is to do, the more there is to talk…”

MRI
- Order w/ and w/o if looking for infection/malignancy
- Order w/o for MSK, bone, or MRCP

Iodine => use concentric circles Chlorheidine => just scrub and wipe

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