Kamsi
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A patient comes to the hospital with 1 to 2 hours of crushing substernal chest pain and ST-segment depression in V2-V4. He has a history of peptic ulcer disease and diabetes. He currently has melena. Which of the following will result in the greatest decrease in mortality?
(A) Angioplasty
(B) Metoprolol
(C) Captopril
(D) Nitrates
(E) Emergency bypass
(F) Tirofiban
(G) Heparin
(H) Aspirin
A 56-year-old man presents to your office complaining of fatigue and persistent joint pain for three months. His past medical history is significant for hypercholesterolemia, hypertension, and hepatitis C from injection drug use in the distant past. He has not been treated for hepatitis. He has no drug allergies.
His physical examination is remarkable for a right ventricular heave and a soft holosystolic murmur at the right sternal border. His abdomen is soft, with a liver edge palpable three centimeters below the costal margin and splenomegaly. There are purpuric lesions on his skin. There is no joint deformity or muscle atrophy. Laboratory studies reveal the following:
Hemoglobin 12 g/dL; platelets 410,000/mm3; BUN 47 mg/dL; creatinine 3.2 mg/dL; glucose 130 mg/dL, serum bicarbonate 20 mEq/L; total bilirubin 1.2 mg/dL; AST 88 U/L; ALT 110 U/L.
C3 and C4 levels are low. Rheumatoid factor is positive at a high titer.
Urinalysis -- protein 3+, hemoglobin 1+, with 50 red cells and no white cells or casts.
Immunofluorescence of the renal biopsy shows large glomerular intracapillary deposits, with granular subendothelial deposits outlining the glomerular capillary walls.
What would be the next appropriate step in the management of this patient?
(A) Kidney transplant
(B) Hemodialysis
(C) Prednisone
(D) Interferon and ribavirin
(E) Cyclophosphamide
You are asked to evaluate a 62-year-old man on the orthopedic surgery service for shortness of breath. The patient was initially admitted to the hospital 14 days ago for a right hip fracture and successfully underwent hip replacement surgery 12 days ago. He required treatment for congestive heart failure secondary to excessive postoperative fluid resuscitation. Three days ago, he once again developed shortness of breath and has been progressively worsening without a response to diuretics.
The patient is tachypneic but able to complete sentences. His blood pressure is 137/83 mm Hg, respiratory rate is 26/min, and his heart rate is 108/min. An arterial blood gas on a 50% facemask shows a pH of 7.38, a pCO2 of 30 mm Hg, a pO2 of 72 mm Hg, and a saturation of 90%. The chest x-ray shows mild right basilar atelectasis without signs of congestion. The EKG shows sinus tachycardia with left ventricular hypertrophy, although there is right axis deviation. An echocardiogram estimates the pulmonary artery systolic pressure at 45 mm Hg. The venous duplex reveals bilateral chronic and acute nonocclusive femoral and popliteal thrombi with freely mobile clots. Intravenous heparin is started. What is the most urgent step in the management of this patient?
(A) Spiral CT scan of the chest
(B) V/Q scan
and place the patient on mechanical ventilation
(D) Inferior vena cava filter placement
(E) Initiate coumadin therapy
(F) Embolectomy
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| peraspera
Forum Elite
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1.B
2.C
3.D
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| Kamsi
Forum Guru
Topics: 103
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What do U think about angioplasty or metoprolol in 2nd Q.What's ur diagnosis in 2nd Q
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| salo
Forum Junior
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A
D
F
i think he has cryoglobulinemia secondary to hepC chronic ...not sure abt need for transplant but chronic C infection needs to be treated
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| peraspera
Forum Elite
Topics: 38
Posts: 233
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1.Angioplasty, yes mortality benefit of angiop. is greater, but ONLY 20% of all hospitals in the US can offer emergency angio. If angio. is not available, trombolytics now. he can't have trombolyt. due to melena. Metoprolol will dectease mortality.
2. Patientis present with persistent joint pain, he has hep C cryoglobulinemia + MPGN , I think he needs prednisone- first and then#2 interferonand ribavirin.
Are there explanations of these qs?
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| sukhs
Forum Senior
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B......C.....& E
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| usmle-china
Forum Newbie
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There are good questions.
1. B. Metoprolol
This patient has acute MI or angina. beta-blockers have been shown to improve survival after an acute MI and angina. He also has melena, therefore, Angioplasty is basically contraindicated, because clopidogrel is needed after angioplasty, thus will cause peptic ulcer bleeding.
2. C Prednisone
Patient has hep C cryoglobulinemia + MPGN , Yes, he needs prednisone first and then interferon and ribavirin. If he doesn't have MPGN, then only HPV need to be treated.
3. D Inferior vena cava filter placement
This patient has acute nonocclusive femoral and popliteal thrombi with freely mobile clots, therefore, Inferior vena cava filter placement is needed to prevent more serious PE.
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| SkiKidd
Forum Newbie
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I wanted to say A, C, F. But I can see the argument against Angioplasty b/c of the CI ASA with a current GI bleed. The thing is he is NOT having an MI. ST depression=angina, so technically B Blockers < mortality in MI and in CHF but not in angina, but even still I suppose B is the best answer.
For question 3, you would never waste time with A or B. C is not helpful as he's not having a problem breathing, the problem is perfusing. D is only done for two reasons 1) anticoagulation is contraindicated, or 2) thrombus formation continues while on therapeutic anticoagulation. E would not be emergent enough so F has to be the answer.
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| starcraftbw
Forum Senior
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I'll go with A, C, D
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| Dr.D
Forum Senior
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Kamsi, what are the anwers?
B
C
E
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| aaroho
Forum Junior
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1-B
2-D becoz pt.was not treated for hepatitis c before so immunosuppresive agents like corticosterods,cyclophasphamide may facilitate viral replication.
The optimal approach to Rx is viral suppression with interferon alpha with or without ribavirin.
3-E
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| yasmeen
Forum Guru
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Posts: 936
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angioplasty
ivc filter
prednisolone
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| dr.wad
Forum Senior
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B_
C_ prednisone for membranoproliferative GN secondary to chronic viral infection by HBV.
the biopsy shows type 1 membranoproliferative GN which cause nephrotic syndrome unlike type 2 which cause nephritic syndrome but in type2 the biopsy will show intramembranous and sub epithelial deposits.
N.B causes of GN with low comlement are 1- pos trept GN 2_membranoproliferative GN 3_SLE
3_ D caval filter >>> the emboli are bilateral so embolectomy will be big burden on this patient.
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| dr.wad
Forum Senior
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indeed i need the ans and explanations.....really very nice q.....
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| spmvj
Forum Newbie
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1.B
2.C
3.D
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| anjushree
Forum Guru
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Posts: 386
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A> Angioplasty
D>Interferon And Rivabarin
D>IVC filter
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| anjushree
Forum Guru
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Posts: 386
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Please post answers ---confused in 2nd Q
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| anjushree
Forum Guru
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3+-----means how much in g/24 hr??????? ------protein in urine
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| anjushree
Forum Guru
Topics: 64
Posts: 386
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in pat with MPGN-not receiving t/t for liver ds ,indication for therapy for renal ds---
Poor renal fun
Neprotic syn
new or worsening hypertension
Progressive disease
fibrosis or tubulointerstitial ds in biopsy
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| anjushree
Forum Guru
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ribavarin is relatively contraindicated inrenal ds--as dose related hemolysis occur with renal dysfunction
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| Dr.D
Forum Senior
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Kamsi, Plz post the answers with explantions.
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| yasmeen
Forum Guru
Topics: 67
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i think answer to q2 is hemodialysis coagulopathy is indication of dialysis
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| elitoki
Forum Guru
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Kamsi, plz post the answers. thanks
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