dr.pumpkin
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today`s questions...
ZOLLINGER ELLISON SYNDROME
No#49 What`s the next best step u would do in a patient with intractable ulcer disease ( despite rigorous treatment ) ?
No#50 What`s the gold standard test to diagnose ZE Syndrome ?
No#51 What are the other tests included in the work up ?
No#52 What is the treatment for ZE Syndrome?
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| zianab
Forum Elite
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IN KAPLAN THERE ARE TYPE OF GASTRITIS GIVEN DIFFERENTLY.PLEASE LET ME KNOW WHICH IS CORRECT
GASTRITIS:
QNO 41:WHAT ARE THE 2 TYPES OF GASTRITIS? Q 42 WHAT ARE THE CAUSES OF GASTRITIS?
ANS 41:TWO TYPES
1:EROSIVE GASTRITIS
CAUSED BY:ALCOHOL,NSAIDS,ICU VERY SICK PATEINTS,SEVERE PHYSIOLOGICAL STRESS
2:CHRONIC NON EROSIVE GASTRITIS HAS 2 TYPES:
TYPE A:CHRONIC GASTRITIS WITH AUTOIMMUNE PROCESS.ATROPHIC GASTRITIS,PERNICIOUS ANEMIA,.IT HAS LOW GASTRIC ACID LEVEL AND GASTRIN GREATER THAN 1000PG/ML
TYPE B CHRONIC GASTRITIS:CAUSED BY HELICOBACTER,AND MAIN DIFFERENCE FROM TYPE A IS THAT IT HAS HIGH GASTRIC ACID SECRETION.
DR PUMPKIN YOU HAVE WRITTEN EXCELLENT EXPLANATION FOR GASTRITIS.YOUR ANSWERS WERE VERY COMPLETE AND LOT OF THINGS WERE NOT MENTIONED IN KAPLAN BOOK WHICH YOU TOLD IN YOUR ANSWERS
.keep UP THE GOOD WORK!!!!!!
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| zianab
Forum Elite
Topics: 17
Posts: 282
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THE next qs no was q no 58 ,that is o.k I will correct it.
so here are answers to your qs dr .pumkin ,please do tell me know where I answer wrong or forget to put some important findings.Npas you are missing from the posts????How is it going???Thanks.
No#58 What`s the gold standard test to diagnose ZE Syndrome ?
ans 58:SECRETIN STIMULATION TEST(IN ZE THERE IS PARADOXICAL RISE IN SERUM GASTRIN LEVEL WITH THIS TEST)
No#59 What are the other tests included in the work up ?
ANS 59:ELEVATED GASTRIN LEVEL ,GREATER THAN 200NG/L FASTING
No#60: What`s the next best step u would do in a patient with intractable ulcer disease ( despite rigorous treatment ) ?
ANS 60:SURGERY IS INDICATED WHEN ULCER IS REFRACTORY TO 1 WEEK OF MEDICAL TREATMENT
No#61: What is the treatment for ZE Syndrome?
ANS 61: DISCONTINUE STEROIDS,SMOKING ISCONTINUE NSAIDS,
TRIPLE THERAPY FOR H.PYLORI,H2 BLOCKERS,PPI,IF BLEEDING EDOSCOPY IS DONE AND SUCRALFATE AND MISOPROSTOL USED.
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| dr.pumpkin
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Topics: 4
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hey zianab, npas..
how r u guys doing ? me going slow wid my studies ,, have a few relatives come over to my place fr few days..newys tryin watever i can..completed my cardio wid questions. plan to complete my skipped part..
zianab, gud that u r doing harrison`s reveiw too..it`ll brush up ur medicine  ..
now where has our frnd npas gone ??
npas,,hw r u buddy,,long time no post ?? hope u r doing gud....its been soooo long without u here....hope to see u soon
tk cr all....
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| npas
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MAZINGER..I'AM TRYING THE ANSWERS.
IS IT
B
B
A
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| dr.pumpkin
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guys,,where r mazinger`s questions?
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| npas
Forum Senior
Topics: 8
Posts: 198
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62...Dx OF GASTROPARESIS
GASTRIC EMPTYING STUDIES WITH RADIOISOTOPE LABELLED FOOD
63...Tx is METOCLOPRAMIDE/ ERYTHROMYCIN
<64.. HISTORY OF VAGOTOMY/GASTRIC RESECTION PLUS THE SYMPTOMS OF SWEATING,SHAKING,PALPITATION AND LIGHTHEADEDNESS AFTER A MEAL ITSELF SUGGESTS THE DUMPING SYNDROME.
65..SMALL MULTIPLE MEALS.
66..DIAGNOSIS OF IRRITABLE BOWEL SYNDROME..THIS IS INTERESTING..IF WE R GETTING A QUESTION WITH ALL THE SYMPTOMS OF IBS WE SHOULD FIRST EXCLUDE THE OTHER MORE COMMON THINGS LIKE IBD,LACTOSE INTOLERANCE..etc..but then if all r ruled out and there is pain relief after bowel evacuation,decreased symptoms in the night and alternating constipation and diarrhoea..then the Dx is established.
67..Tx
* HIGH FIBRE DIET
* ANTISPASMODICS
* DIARRHOEA PREDOMINANT___ANTI DIARRHOEAL AGENTS/ALOSETRONE
*CONSTIPATION PREDOM___TEGASOROD
*TCA>/b
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| npas
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Hi friends
there was again a break in the studies..sooo sorry..didn't post for all these days.
Zainab..I'am using UCV,PRE TEST,BLUE PRINT(Q AND A as well as CLINICAL CASES)..I haven't completed any of these though!!!which r ur sources?Ur posting the question is really useful..keep up this good work..
DR PUMPKIN..U r covering paeds fast..gr8 going buddy
So I have started Obstetrics..covered 5 chapters..no questions as for now..will do more paeds questions along with it..
Try answering Mazingers questions..they r good ones..we will also discuss the explanation.
good luck
npas
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| zianab
Forum Elite
Topics: 17
Posts: 282
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CONSTIPATION
Q68:HOW DO YOU DIAGNOSE THAT A PATIENT IS SUFFERING FROM CONSTIPATION?
Q69:HOW DO YOU TREAT IT?
PEPTIC ULCER DISEASE
Q70:WHAT ARE THE CAUSES OF PUD?
Q71:WHICH TYPE OF PU PRESENTS WITH MALIGNANCY?
Q72:HOW DO YOU DIAGNOSE PUD?
Q73:WHAT IS THE TREATMENT OF PUD?
NON ULCER DYSPEPSIA(NUD)
Q74:WHAT ARE THE FINDINGS IN NUD WHEN YOU PERFORM AN EGD AND BARIUM SWALLOW IN NUD PATIENT??
still need to be answered.
I think We will do nbme form 2 with mazinger,I have sent him a message to start posting the qs for form 2 only so that we can asses ourself with atleast with form 1 and form 3.If we do the qs before doing the nbme test online then its no good.I think we should discuss atleast form 2 with mazinger.Lets see when he posts his qs
Edited by zianab on 11/07/06 - 09:19 AM
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| mazinger
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Dear friends sorry but I deleted the questions since I didnt want to spoil anyone's nbmes self assesments... I have received a few pms telling me thats ok, theres people who's willing to discuss nbme, I WILL ONLY POST FORM 2 so you will haver other forms available for your assesment.. I got these from other forum..
regards
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| dr.pumpkin
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Topics: 4
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dear mazinger, r these the answers ? shuld i be giving explanations along with them ??
4. E
17. B
31. C
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| dr.pumpkin
Forum Newbie
Topics: 4
Posts: 168
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CONSTIPATION
No#68 How do you diagnose that a patient is suffering from constipation ?
1. obtain a good HISTORY of : fluid and fiber intake
: any medications ( anticholinergics,ferrous sulfate,calcium channel blockers,diuretics,narcotics ,psychotropics )
:history n symptoms of hypothyroidism, hyperparathyroidsm, Diabetes Mellitus, PARKINSON`S, Prior pelvic surgery, paraplegia, autonomic neuropathy
2.PHYSICAL EXAMINATION : Digital examination to rule out anal stricture,rectocoele,rectal prolapse, eveidence of pelvic floor dysfunction
3LABORATORY IVESTIGATIONS : CBC, SERUM ELECTROLYTES (serum ca), GLUCOSE, TSH ,STOOL TESTING fr occult blood.
4. SIGMOIDOSCOPY/COLONOSCOPY : must in a old patient presenting with recent change in bowel habits, pt wid stool bld +ve
5. ABDOMINAL RADIOGRAPHY WITH MARKERS fr colonic transit time, Defecography.
NO#69 HOW DO YOU TREAT IT ? treat any specific cause ( remove meds causing constipation, trt hypothyroidism,)
1.DIETARY MEASURES : proper fluid and fiber intake
2.STOOL SURFACTANTS : docusate sodium fr softening stools.
3OSMOTIC LAXATIVES milk of magnesia, mg sulfate fr chronic constip. , lactulose, GoLYTELY
4 STIMULANTS :bisacodyl , tegaserod
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| mazinger
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I totally agree with you zianab in the answers... the whole point of posting questions is the we explain a rationale supporting our choices...
BTW Iv been studying for 5 months, I ve been taking it easily.. since Ill be taking step 2 in feb 2nd..
The first question I have my doubts between steroids and epinephrine, it seems like an anaphylactic reaction leading to a shock so I chose epinephrine.
The second question I also go for E, BZDs are mainly used as anticonvulsants and for alcohol detox, lets remember delirium tremens is highly related to seizures and its life threatening so BZDs in general work fine here.. most widely used for this purpose are oxazepam, clorazepate..
The third question I also go for C, why? This patient is not considered in the age group for having a neisseria infx, besides she's taking a thiazide diuretic.. Diuretics such as thiazides and loop diuretics can inhibit the weak acid pump at the proximal tubule decreasing uric acid excretion (probenecid acts at the same spot enhancing uric acid excretion), this is the solely risk factor I find in this patient to relate her to a particular choice...
BTW Dont worry I promise to post only form 2...
What do you think? I am not 100% about the one of the anaph reaction so could anyone please investigate a little further whats the right choice?
Regards
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original mazinger z
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| dr.pumpkin
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PEPTIC ULCER DISEASE
No#70 WHAT ARE THE CAUSES OF PUD ? (includes duodenal and gastric ulcers )
1. Chronic H. Pylori infection
2. NSAIDS induceed ulcers
3.ACID HYPERSECRETORY STATES : ZE Syndrome
4. Stress Induced : burns ,head trauma, prolonged intubation, mechanical ventilation.
No#71 which type is related with malignancy
gastric ulcers.
NO#72 hOW DO YOU DIAGNOSE PUD
Endoscopy wid biopsy ( will help in diagnosing H.pylori indcd ulcers,potentially malignant gasric ulcers)
other tests include : in C/O H.pylori inducd ulcer do urea breath testing , serology
serum gastin levels ( ZE sYNDRME) , CBC ( bleeding ulcers , perforation ) ,
NO#72 HOW DO YOU TREAT PUD
1. h.PYLORI INDUCED : ppi`s with clarithromycin n amoxicillin
2.NSAID induced : Discontinue the agent if poss. give PPI`S , H2 blockers
ANtacids , misoprostol c/b tried also.
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| dr.pumpkin
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Topics: 4
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dear mazinger ,,
u ve given nice explanations fr the questions.....
thnx a lott !! keep posting
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| sheena2005
Forum Elite
Topics: 26
Posts: 257
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Hi zainab.
wow uguys are doing a good job here.thanks for inviting me to join.i will try to add some good pearls to this thread.this Q & A format is really helpful for the revision.
GOOD WORK GUYS!!
GL.
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| zianab
Forum Elite
Topics: 17
Posts: 282
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for us only 4 or 5 imp topics of GI are left.I am going to post everybodys weak point cardiology qs.And the GI topics left ,
I will be posting in between cardiology making sure that we cover everything.We are going to discuss cardiology in detail as it is very imp for exam .Any body new to forum ,we are going topic wise according to kaplan book.
CARDIOLOGY QS:
ISCHEMIC HEART DISEASE:
Q NO 73:WHAT ARE THE MAJOR RISK FACTORS FOR ISCHEMIC HEART DISEASE?
Q74:WHAT ARE THE FACTORS WHICH INCREASE OXYGEN DEMAND?
Q75:WHAT ARE THE FACTORS THAT LOWER OXYGEN CARRYING CAPACITY OF BLOOD?
PRINZMETAL ANGINA:
Q76:WHAT IS THE PATHOGENESIS FOR PRINZMETAL ANGINA?
Q77:HOW DOES THE PATIENT WITH PRINZMETAL ANGINA PRESENT WITH?
Q78:WHAT ARE THE ECG CHANGES IN PATIENT WITH PRINZMETAL ANGINA?
Q79:WHAT IS THE INITIAL DIAGNOSTIC STEP FOR PATIENT WITH PRINZMETAL ANGINA?
Q80:WHAT IS THE TREATMENT FOR PRINZMETAL ANGINA?
Q81:WHAT ARE OTHER CAUSES OF CHEST PAIN?
Q82:IF A PATIENT PRESENTS WITH CHEST PAIN HOW WILL YOU DIFFERENTIATE ANGINA FROM AORTIC DISSECTION?WHAT WILL BE THE FINDINGS IN PATIENT WITH AORTIC DISSECTION?
Q83:IF A PATIENT PRESENTS WITH CHEST PAIN HOW WILL YOU DIFFERNTIATE ANGINA FROM PULMONARY EMBOLISM?WHAT WILL BE THE POSITIVE FINDINGS IN PE PATIENT?
Q84:IF A PATIENT PRESENTS WITH CHEST PAIN HOW WILL YOU DIFFERENTIATE ANGINA FROM PERICARDITIS?WHAT WILL BE THE POSITIVE FINDINGS IN PERICARDITIS PATIENT?
Q85:IF A PATIENT PRESENTS WITH CHEST PAIN HOW WILL YOU DIFFERENTIATE ANGINA FROM MYOCARDITIS ?WHAT WILL BE THE POSITIVE FINDINGS IN MYOCARDITIS?
any body posting plaese answer according to q no and post in bold also please check your books before posting and answer in detail.
thankyou
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| mazinger
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Posts: 918
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ISCHEMIC HEART DZs
Q NO 73:WHAT ARE THE MAJOR RISK FACTORS FOR ISCHEMIC HEART DISEASE?[/b]
First of all High levels LDL cholesterol... more than anything..
Diabetes mellitus
Smoking
High BP
Family history 1st degree relatives with Ischemic heart dzs males <55 females <65 yo
Low HDL <40 if you have HDL >60 you can take a risk factor out of the list..
Q74:WHAT ARE THE FACTORS WHICH INCREASE OXYGEN DEMAND?
Anything that increases the ventricular wall tension (including increased heart workload - increased afterload)
Dilated myocardiopathy
High BP
Aortic Stenosis
Simpathetic stimulation
Q75:WHAT ARE THE FACTORS THAT LOWER OXYGEN CARRYING CAPACITY OF BLOOD?
O2 carrying capacity is mainly determined by the erithrocytes' mass... Anemia
Carbon monoxide intox
Methahemoglobinemia
PRINZMETAL ANGINA:
Q76:WHAT IS THE PATHOGENESIS FOR PRINZMETAL ANGINA?
Also defined as variant angina, it is caused by a coronary vasospasm, its related to vasospasmic phenomena of other vessels, Raynaud, vasospastic headaches..
Q77:HOW DOES THE PATIENT WITH PRINZMETAL ANGINA PRESENT WITH?
Usually is a young, otherwise healthy individual, no CHD risk factors.. Pain occurrs at rest, wakes the patient up during sleep.
Q78:WHAT ARE THE ECG CHANGES IN PATIENT WITH PRINZMETAL ANGINA?
Transient ST segment elevations reflecting transmural ischemia.
NO Q WAVES
NO ENZIMES
Normal coronaries on imaging..
Q79:WHAT IS THE INITIAL DIAGNOSTIC STEP FOR PATIENT WITH PRINZMETAL ANGINA?
Inducing coronary vasospasm by ergot alkaloids.
Q80:WHAT IS THE TREATMENT FOR PRINZMETAL ANGINA?
Ca channel blockers Diltiazem DOC
Nitrates
Beware beta blockers and aspirin are contraindicated..
Beta blockers block B2 receptors could worsen vasospasm.. NSAIDS in general could inhibit prostacyclin pgI2 synthesis (Biologic antagonist of TA2)
Q81:WHAT ARE OTHER CAUSES OF CHEST PAIN?
Pericarditis
Pneumothorax
PEmbolus
Pleuritis -> pneumonia
GERD
Costocondritis
PUD
Q82:IF A PATIENT PRESENTS WITH CHEST PAIN HOW WILL YOU DIFFERENTIATE ANGINA FROM AORTIC DISSECTION?WHAT WILL BE THE FINDINGS IN PATIENT WITH AORTIC DISSECTION?
Description of pain is classic, tearing pain radiating to the back. Could cause sudden occlusion of the vessel such as carotids, coronary or subclavian arteries. Can also cause sudden aortic insufficiency and cardiac tamponade.
Look for marfanoid habitus -> Marfans Sx AD, fibryllin gene defect, hypertension plus cystic medial necrosis. No marfans then think of blunt chest trauma.
1st step if the patient has hypertension perform anti hypertensive measures be4 doing any imaging.
CXR Widening of the mediastinum
Most specific Chest CT with contrast or Transeophageal Eco.
Angina oppresive, crushing pain, ekg findings and description are classic..
Q83:IF A PATIENT PRESENTS WITH CHEST PAIN HOW WILL YOU DIFFERNTIATE ANGINA FROM PULMONARY EMBOLISM?WHAT WILL BE THE POSITIVE FINDINGS IN PE PATIENT?
Sudden onset of SOB - tachypnea and tachycardia, remember pain is not as "sensitive" as these two.. look for risk factors orthopedic surgery of lower extremities, immobilized patients, hypercoagulable states (trombophyllias or neoplasias).
Findings are signs of right ventricular overload, yugular veins are distended, right axis deviation, right parasternal heave, lungs may be clear, loud P component of S2 that increases with inspiration, hypotension, fever, anyways many things.
EKG Sinus tachycardia the most frequent finding.
Deep S1 , Q wave at V3, T wave inversion at V3.
CXR May be normal, hamptoms curve and westermark's sx
ABG Decrease in both pCO2 and pO2.. if there is no decrease in pO2 then its not PE!
V/Q Scan
Pulm Angio Gold standard
Q84:IF A PATIENT PRESENTS WITH CHEST PAIN HOW WILL YOU DIFFERENTIATE ANGINA FROM PERICARDITIS?WHAT WILL BE THE POSITIVE FINDINGS IN PERICARDITIS PATIENT?
2 P's Positional and pleuritic.. Look for a viral infection in the history.
Pericardial friction rub is highly specific and it should be considered as diagnostic.
Q85:IF A PATIENT PRESENTS WITH CHEST PAIN HOW WILL YOU DIFFERENTIATE ANGINA FROM MYOCARDITIS ?WHAT WILL BE THE POSITIVE FINDINGS IN MYOCARDITIS?
Patients with angina the chief complain will be pain and in patients with myocarditis their chief complain is SOB and congestive heart failure. Pain may be present in patients with myocarditis, but its dull and constant and not as severe and episodic as in angina. Myocarditis there could be a mild elevation of enzimes. Diagnosis of myocarditis could be done by echo (dilatation of all chambers, low ejection fraction), and the most specific would be an endomyocardial biopsy which is rarely done.
 
Edited by mazinger on 11/02/06 - 08:17 AM
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original mazinger z
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| npas
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I'am trying to answer Mazingers Qs(the recent ones)
1st one about the 52 year old woman
HER SYMPTOMS(tachycardia,dyspnea,chest pain) PLUS THE HISTORY OF SURGERY AND NO AMBULATION suggests a very likely pulmonary embolism..but the V'/P scan doesnot suggests the same..the question is WHAT DO WE DO IN A LOW PROBABILITY PULMONARY V'/Q SCAN WITH HIGH PRETEST PROBABILITY!!! I THINK WE BETTER CHECK OUT WITH THE GOLD STD TEST AVAILABLE AND THAT IS "PULMONARY ANGIOGRAM"...I think answer is C.
BY THE WAY JUST CHECK OUT THE LATEST IN PE..'COZ I JUST READ ABOUT "COMPRESSION ULTRASONOGRAPHY DONE IN THESE CASES!!DO U GUYS KNOW ABOUT IT..IS IT WHAT WE DO NOW A DAYS INSTEAD OF ANGIOGRAPHY??HELP....
GL
NPAS
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| mazinger
Forum Guru
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I agree with you npas pulmo angio all the way.. excellent rationale..
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original mazinger z
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| mazinger
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Q86 What are the differences bet/ a stable angina and unstable angina? Clnical differences, pathophysiology, prognosis
Q87 What are the differences bet/ an unstable angina and a MI? How can you diferentiate these two in a clinical setting? Treatment
Q88 What are the Diagnostic objectives of performing an exercise treadmill test?
Define a positive test.
In which patients sould you avoid performing this test because they are at increased risk of morbility/mortality during the testing session?
What are the electric disturbances that interfere with the standard EKG reading?
What if a person cannot exercise?
What are the alternatives for these patients?
Q89 After a positive result what is the best next step in the management?
What is the second step in the management?
Q90 What is the standard management for stable angina?
What are the drugs that reduce mortality in these patients?
How do nitrates work?
Q91 what are the indications for the use of clopidogrel?
How does clopidogrel work?
Why does clopidogrel is preferred over ticlopidine?
Q92 How do you diagnose a MI? EKG changes in a time fashion, enzimes, and whats the most useful enzyme for diagnosing recurrent ischemia?
Q93 What are the indications for placing a stent?
What are the indications for going directly into a CABG?
Edited by mazinger on 11/03/06 - 08:06 AM
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original mazinger z
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| npas
Forum Senior
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As far as ur 3rd question about the young woman of 27 is concerned...
SHE HAS A DOCUMENTED HT OF 3rd STAGE IN AN EARLY AGE.Acc TO THE JNC THE INITIAL EVALUATION OF Dx ALSO INVOLVES ECG and LIPID PROFILE..IF ANY OF THESE WERE THERE IN THE OPTION I WOULD HAVE MARKED THAT.
FIRST OPTION DOES NOT YIELD ANY EXTRA INFORMATION.
SINCE THE PHYSICAL EX IS COMPLETELY NORMAL WITH NO HYPERGLYCEMIA OR HYPOKALEMIA I WILL NOT GO FOR URINE CORTISOL.
I WILL GO WITH THE 3rd OPTION OF SERUM ALDO 'COZ IN 15% PATIENTS OF HYPERALDOSTERONISM THERE MAY BE NO HYPOKALEMIA!!
NOW THERE R CERTAIN CONDITIONS IN WHICH WE WILL DO ANGIO OF RENAL VESSELS
1)age <20 or >50
2)HT not treated by 3 or more drugs
3)abdo bruits
4)sudden deterioration with ACE inhibitors
5)pulmonary edema associated with abrupt increase in BP(I still don't understand this point:no
6)any other peripheral vascular/coronary Disease.
SO I THINK THE ANSWER IS "C"
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| mazinger
Forum Guru
Topics: 46
Posts: 918
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I wasnt aware that 15% of patients with Conn's Sx didnt have low K levels.. good to know, I see no hint pointing anywhere, so there's got to be a standard step in the management of handling these patients with isolated hypertension..
Perhaps you are totally right, I DONT KNOW ....
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| npas
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the answer to the 2nd q is "pulmonary embolism"...again I think...but I have considerable confusion myself..
Points to support the Dx
AGE >60 YRS
TYPICAL PRESENTATION..TACHYCARDIA,CHEST DISCOMFORT,DYSPNEA,NECK VEIN DISTENTION,PARASTERNAL HAEVE..Pco2 <35mmHg and Po2<80 ..but THERE R OTHER OPTIONS ALSO WHICH IS HARD TO EXCLUDE..
I'am leaving this for u guys to answer.
I'am complete with my obstetrics reading(except infections and skips here and there)..now lecture for today..What is progress with paeds,Zainab,Dr Pumpkin...?I'am unable to answer all the questions u post,sorry Zainab..its poor time management..what to do!!Will try my best.
good luck
npas
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| npas
Forum Senior
Topics: 8
Posts: 198
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I got the point of hyperaldosteronism from the cmdt..its 5 to 15% only.And then it was given serum aldosterone:renin level is the best Dx in them.But let the others also join the discussion and then we will decide the answer.
npas
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