npas
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parameter wrote:
what`s the most useful enzyme to diagnose recurrent ischemia ??
Though its not clearly written anywhere I found this line to be explanatory...In view of prolonged elevation of cTn T/I(>1 wk) ,episodes of recurrent ischemia and suspected recurrent MI ,dianosis id made with a serum marker that remains in the blood more briefly,such as CKMB or Myoglobin"
hope this helps Dr Pumpkin and Zainab
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| npas
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answer to ques 93..Indications of early invasive strategy in MI(STEMI)
1.Recurrent ischemia
2.Recurrent MI
3.Cardio shock/hemodynamic instability
4.EF<.4 /CHF/Serious ventricular arrhythmias
5.Routine PCI as a part of invasive strategy after fibrinolysis
SOme of these indications r still out of my clear understanding
Anyways Invasive therapy indication in NSTEMI
1.Recurrence(symptoms at rest/low activity even with treatment,elevated cTn,New ST segment depression,accompanying CHF)
2.EF<.4
3.sustained VA
4.Positive stress test(now why this!!!)
5.decreased BP
6.PCI with in 6 months or previous CABG
good luck
npas
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| npas
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Mazinger I'am listening to all lectures in psych..Gynae lactures r too slow as Dr Pumpkin said.Clearly its upon us to decide which lectures we have to skip..I really like the psych ones.
Dr Pumpkin Gr8 going..just 3 left..good
Zainab..how much paeds left?Don't worry about questions at all..we 3 are any way gonna subscribe for UW..and in that we will cover a lot..
I heard 4 lectures of psych yesterday..will complete it today..
have a gr8 time studying
npas
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| mazinger
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thx for the advice...
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| dr.pumpkin
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hey npas,,
u going at great speed!!! keep it up buddy ...
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| npas
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mazingers question..first one..the 76 yr old
This patient has symptoms very common in the elderly..that is mild form of depression is common,deep tendon reflexes does become slow in elderly which is normal..His BP is ok(is he on a medication!is it CCB)..In these patients we usually do Renal,hepatic,thyroid function test plus serum calcium!!So 2 options strikes to us..but I would go for "E" 'coz differential diagnosis of depression does include "SUBTLE THYROID DYSFUNCTION"..My answer is "e".
npas
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| npas
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Hey friends..As Mazinger correctly said...do make up ur own mind about the answers before analysing my answer.
good luck
npas
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| npas
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Mazingers 2nd q..about the 6 month old boy..
Out of all the causes of acute abdo with mass and blood in stool "Intussusception" seems to be the most possible Dx..and this one is a real emergency..so we would not like to wait for Dx tests..though in the notes its written that Barium enema is both diagnostic and theraupetic I doubt if option D is correct..I would go for "C" since in paedia books its given that hydrostatic reduction/air contrast enema should always be done in the presence of a surgeon in hospital settings..plus barium spillage has high chances of perforation and spillage..
what do u say guys?I'am confused!
npas
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| mazinger
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sorry for the long liners ... I promise I wont do that again...
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| sarika
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hi guys, r these nbme questions?
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| dr.pumpkin
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mazinger`s first ques...
i think i ll go for E..
the guy has been showing depressive symptoms,,with slowing of DTR`S..the weight loss can be attributed to his lack of appetite which may exist wid depressed state...so, i would like to test his thyroid status...
but, weight loss at this age is an alert sign fr malignancy ( but here no other findings are present , so we can safely rule it out in this scenario )..testosterone , s.calcium wuld have been suitable if there was history of prostrate sym ...
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| dr.pumpkin
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2nd question..a 6 month baby colicky pain...
the 6 month old boy had episodes of colicky pain , with passing of currant jelly stool..he is typically releived with passing of the stool ( now the baby is sleeping )...on palpation there is a mass felt in the right lower quadrant. all this makes me think of `ACUTE INTUSSEPTION`..
the next best step would be a barium enema/air enema ( diagnostic and therapeutic ,but safer than barium enema)...
if its same as colon contrast studies,,i ll go for `D`,
if not then i think its `C`, Doing operative intervention..
mazinger,, culd u plzzz help us with this 
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| dr.pumpkin
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3 rd question
a 49 yr old woman with renal failure...
i think its `D`..the patient is showing classic presentation of adult polycystic kidney ds ( long history of flank pain , mass in the flank, hypertention )..pale mucus memb are d/t anemia seconadary to low levels of erythropiotin..
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| mazinger
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agree with all of you from my perspective the answer is e... The physical finding of slow recovery phase of deep tendon reflexes its indicative of hypothiroidism. I wasnt aware that this finding masy be normal in the elderly, but its the only clue pointing to a diagnosis in the vignette. Weight loss is confusing, weight loss in hypothiroidism?? well the elderly are a separate set of the population. The clinical courses of their diseases may differ vastly from regular adults. Depresion in the elderly could give wieght loss and dementia like symptoms..
Regards
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| mazinger
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Agreee with the barium studies this baby has an intussuception, contrast studies are both diagnostic and theurapetic..
For question #3 I am a bit confused, there are things that point to renal cell carcinoma and others that point to APKD.. For renal cell ca unilateral mass, flank pain and hematuria is the classic triad which is only present in 10% of the patients. Its unilateral, and it can give hypertension as well because it can secrete renin. What I am not sure of is that renal cell carcinoma produces renal failure (since its unilateral in nature), which in fact APKD does.. APKD can give hematuria, flank pain, palpable masses, and hypertension, but the hallmark is that it does give renal failure..
So eventhough its an unilateral mass I would go for APKD...
Any comments are welcome
BTW Dear zianab.. Ill be posting new cardio questions tonight...
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| mazinger
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dear zianab I find these questions quite hard.... please have mercy  ....
just kidding.. nice toughy questions, and very board relevant..
BTW are the answers to these questions found on kap notes alone?
hahaha Ill dedicate time to answer these tonight, have to keep up to my reading...
Edited by mazinger on 11/07/06 - 09:12 AM
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| dr.pumpkin
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hi frns...
did abt 70 questions frm Q book today...well i plan to do more tomm...
zianab, i stilll have the last 2 chaps to be done, n i guess i need to revise the newborn , fluids ,electrolyte chap..are you listening to the lectures along wid notes ??
npas, how much of psych have u covered ? frnd , did u revise obs after a read earlier.. i too seem to have forgotten the most of it  ..wat do u say ?will it better revising it before doing UW??
zianab,,will be answering ur questions tomm
gud luck everyone
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| mazinger
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dr.pumpkin wrote:
3 rd question
a 49 yr old woman with renal failure...
i think its `D`..the patient is showing classic presentation of adult polycystic kidney ds ( long history of flank pain , mass in the flank, hypertention )..pale mucus memb are d/t anemia seconadary to low levels of erythropiotin..
I didnt thought of that, cool doctor pumpkin....
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| mazinger
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QS 96: A PATIENT COMES WITH STEMI COMES TO ER,WHAT WILL BE THE STEP WISE MANAGEMENT OF THIS PATIENT?
I dont know the exact steps in the management.. But, I am aware we that is necessary to prioritize some drugs over others since they provide a mortality benefit (between these trombolytics are the most important, but this is obvious so I am not going to discuss them here). The first thing you do after you suspect/diagnose an MI is to give aspirin, to baby aspirins stat, has shown to provide a better outcome. 2 other drugs that have shown better outcomes are beta blockers and ACE inhibitors. The goal of giving betablockers is to get the heart rate between 50 to 60 beats per minute in order to decrease O2 demand (tachycardia and perhaps hypertension are strongly associated to anterior MIs; contrary to inferior wall MIs that are associated to bradycardia and hypotension), you use IV metoprolol for this, beware in hypotension. ACE inhibitors are usually given in the setting of an MI with heart failure, eject fraction <40%, and its also given "prophyllacticly" in ALL anterior MIs even in the absence of heart failure. In the latter setting ACE are only given for 6 weeks if the patients never develope heart failure, in the case the patient does ACE inhibitors should be continued until god knows when (forever). You should avoid ACE Inh in patients with hypotension (sys BP <90), and creatinine levels >2,5, bilateral renal artery stenosis.
I almost forgot, its also ideal to start with the lipid management with statins within 24 hours of the onset of the MI. Patients post MI in the absence of diabetes LDL should be <100 (its really in all patients with CAD or peripheral vascular dzs, or diabetes in tha absence of CAD), in MI patients (CAD) + diabetes LDL levels should be <70. Statins side effects myotoxicity>hepatotoxicity. Niacin, clofibrate (or was it gemfibrozil?  ), cyclosporin increase their myotoxic potential, look for difuse muscular pain, elevation in CK MM, dark urine positive for hemoglobin (urine dipstick positive), but no RBCs are seen under the microscope. Rhabdomyolisis can give high K levels and ATN.
Given this info the treatment should consist of the following
First aspirin and O2
Consider the use of trombolytics.
then pain meds, nitrates, betablockers, ACE, statins.
Sorry I have to go.. Ill be back later..
have fun
Edited by mazinger on 11/09/06 - 05:44 AM
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| npas
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parameter wrote:
QS 94 AND 95 posted by dr pumkin,still needs to be answered!!
Q NO#94 WHAT ARE THE INDICATIONS AND CONTRAINDICATIONS TO DO A THROMBOLYTIC THERAPY ?
Criteria for starting the thrombolytic therapy in STEMI(I'am just considering the cardiology..not about pulmonary emolism like indication):-
*chest pain consistant for angina brought with in 6 hours
*ECG changes____>1mm ST elevation in 2 contiguous limb lead
____>2mm ST 11 11 precordial lead.
*New LBBB
*no contraindications
What r the 'absolute' contraindications...
*Any active internal bleeding/surgery or trauma with in 2 wks
*Head trauma/neoplasm
*Hx of hmg stroke or recent non hmg stroke
*allergy to the thrombolytic considered(esp SK or APSAC)
*BP>200/120
*Pregnancy
*chances of aortic dissection
npas
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| npas
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Hey guys..i think the discussions we r doing is really picking up..I can see we have started being more analytical..gr8
I agree with Dr Pumpkin and mazinger on the PCD answer.
I will give more answers later..its almost 11.30 am ...I have to start my routine study..Zainab and Dr Pumpkin,Good that u r pacing up..I thought I was almost finished with lectures of psych when I saw 3 more in an another dvd..has to finish that..has done 50 questions..will do more today.
Sarika,we r discussing nbme questions too other than Zainabs self made questions.
good luck
npas
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| npas
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mazingers nbme2 answers
c]severe combined immunodeficiency syndrome(note the typical opportunistic infections and lab findings..we can also exclude the other options to reach the answer)
A]Amoxicillin does not alter the course of salmonella enteritidis(only indicated if the infant is <3 months,evidence of severe illness or other accompanying conditions like SLE or cardiac/renal disease)
B] metoprolol(decreases mortality)
GL..npas
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| mazinger
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Totally agree with your 3 answers... way to go npas..
Note that the child has recurrent bacterial infections and low Igs levels (deficient humoral adaptative immunity), and he also has a candida infection with a low lymphocite count (deficient cellular adaptative immunity).
I agree that antibiotics are not given in salmonella infections because they dont alter the course of the dzs...
and for the last one let the mortality benefit guide your answers...
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| mazinger
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QS 97:A PATIENT COMES WITH NSTEMI( NON Q MI) COMES TO ER ,WHAT IS THE STEP WISE MANGENT OF THIS PATIENT?
Dont know  sorry
QS 98:A PATIENT PRESENTS WITH MI IN ER,WHAT IS THE BEST INITIAL DIAGNOSTIC STEP TO DIAGNOSE IT?
Best way to diagnose a MI is EKG then you can support your initial diagnosis with the rising/appearance of enzymes.. Be aware that EKG findings and timing by themselves are sufficient to start trombolytic therapy.
Edited by mazinger on 11/08/06 - 08:14 PM
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| zianab
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cardiology qs
QS 96: A PATIENT COMES WITH STEMI COMES TO ER,WHAT WILL BE THE STEP WISE MANAGEMENT OF THIS PATIENT?
I AGREE WITH MAZINGER'S ANSWER.CARDIAC ANGIOGRAPHY,CARDIAC CATHETERIZATION AND PCI ,CABG HAS TO BE ADDED IN TREATMENT DEPENDING ON PATIENTS NEED.THE REST IS ANSWERED VERY COMPLETELY.
QS 97:A PATIENT COMES WITH NSTEMI( NON Q MI) COMES TO ER ,WHAT IS THE STEP WISE MANGENT OF THIS PATIENT?
GIVE ANTI ISCHEMIC TREATMENT:
TELEMETRY MONITOR,OXYGEN,NITROGLYCERINE,MORPHINE.
BETA BLOCKERS,.ACEI (DEPENDING ON PATIENTS)
ASPIRIN,CLOPIDOGREL IS AN ALTERNATIVE FOR THOSE WITH TRUE ASPIRIN ALLERGY.
HEPARIN, GP II B AND III B INHIBITORS ARE BENEFICIAL FOR HIGH RISK PATIENTS AND THOSE UNDERGOING PERCUTANEOUS INTERVENSION.
STATINS FOR MAINTANCE THERAPY.
VERY IMP POINT: THROMBOLYTICS ARE NEVER USED IN UNSTABLE ANGINA OR NON ST -ELEVATION MI.THIS IS THE MAIN DIFF FROM STEMI.
DECISION CAN BE MADE ON PATIENT'S CONDITION TO GIVE CONSERVATIVE MEDICAL TREATMENT OR EARLY INVASIVE TREATMENT THAT IS CARDIAC CATHETERIZATION
(PCI OR CABG) IS DONE IN HIGH RISK PATIENTS.
qQS 98:A PATIENT PRESENTS WITH MI IN ER,WHAT IS THE BEST INITIAL DIAGNOSTIC STEP TO DIAGNOSE IT?
ans 98:
PATIENT HISTORY,ECG,CARDIAC MARKERS
Q99:WHAT ARE THE NEXT STEPS IN DIAGNOSIS WHICH ARE TAKEN AFTER THE INITIAL STEP?
ANS 99:NON INVASIVE TECHNIQUES CAN BE USED LATER ON TO DETERMINE EXTENT OF DAMAGE
ECHO CAN BE USED
MYOCARDIAL PERFUSION IMAGING ,THALLIUM 201 OR TECHNITIUM ) IS SENSITIVE FOR REGIONS OF DECREASED PERFUSION.CORONOARY ANGIOGRAPHY CAN BE DONE IF NEEDED.
Stress test should never be done in acute MI patient .
DOBUTAMINE STRESS TEST CAN BE DONE IN MI????( I am not sure about it,please let me know?
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