aaroho
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A 35-year-old healthy white woman presents to your office complaining of three weeks of bleeding gums after she brushes her teeth. She otherwise feels well and has no other complaints. Her dentist says that she has healthy teeth and gums. She has no significant past medical history and does not take any medications. She is a nonsmoker and does not drink alcohol. She is married and has two healthy young children.
Physical examination: blood pressure 132/72 mm Hg; heart rate 60/min; respiratory rate 12/min; temperature 98.5 F
HEENT: good dentition; no gingival hypertrophy or discoloration; no gingival tenderness upon palpation; no oral lesions
Heart: S1, S2, no murmurs
Extremities: no edema
White blood cell count 5,600/mm3; hematocrit 41%; platelets 9,000/mm3
Which of the following is the most specific finding for this patient's condition?
(A) An enlarged spleen
(B) A positive monospot test
(C) A diminished number of megakaryocytes
(D) Antiplatelet antibodies
(E) Hemolysis on peripheral smear
(F) Increased megakaryocytes
A 76-year-old man returns to your clinic for a follow-up appointment after having an echocardiogram and a Holter monitor done. Both test results are normal. The patient has been having sensations of a rapid heartbeat for several years. He describes these episodes as "a strange pounding in my heart" occurring suddenly and ending spontaneously. He has never had syncope, and these episodes are not associated with dyspnea or chest pain.
On physical examination, his pulse is 64/min and regular, and blood pressure is 142/78 mm Hg. The rest of his examination is within normal limits. A repeat EKG shows a normal sinus rhythm, without change from earlier EKGs. An event monitor is put in place. Three months later, you receive a report from the cardiologist that reveals paroxysms of atrial fibrillation with a rapid ventricular response that ends spontaneously.
What is the most appropriate management for this patient's paroxysmal atrial fibrillation at this time?
(A) Begin aspirin 325 mg once a day
(B) Elective cardioversion
(C) Transesophageal echocardiogram
(D) Begin warfarin and adjust the dose based on INR
(E) Send the patient for electrophysiologic testing (EPS)
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| Kamsi
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F Pt has ITP
D
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| dr.wad
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F
D
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| hanialkhadher
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1-D
2-E
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"أقرأ بأسم ربك الذي خلق,خلق الأنسان من علق,أقرأ و ربك الأكرم, الذي علم بالقلم,علم الأنسان ما لم يعلم"
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| dr.wad
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ANTIPLATELET ANTIBODIES ARE PRESENT IN 80% OF CASES AND THEY ARE NOR SPECIFIC.
INCREASED MEGAKARYOCYTES IN BONE MARRW IS DIAGNOSTIC OF ITP IN ABSENCE OF OTHER BLOOD ABNORMALITIES.
HEMOLYSIS OCCURS ONLY IN 10% OF CASES OF ITP ( EVANS SYNDROME ) BUT WITH NEGATIVE COOMBS TEST WHICH DIFFERENTIATE IT FROM AUTIMMUNE HEMOLYTIC ANEMIA.
ENLARGED SPLEEN WITH THROMBOCYTOPENIA SHOULD SUGGEST ANOTHER CAUSE LIKE LEUKEMIA.
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| dr.wad
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FOR THE SECOND Q : AT THIS TIME U HAVE TO PROTECT THE PATIENT FROM THE THROMBOEMBOLISM THAT MAY OCCUR EVEN WHEN HE REGAIN THE SINUS RHYTHM.....THE ATRIUM REGAIN ITS CNTRACTILITY DAYS AFTER THE SINUS RHYTH .
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| peraspera
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F. ITP- increased megakaryicytes
D. due to atriall fibrillation
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| dr in trouble
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ITP---Inc megakaryocytes
D--Warfarin therapy
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| aaroho
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well done guys
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| hanialkhadher
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aaroho wrote:
well done guys
can you post the answers explanations
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"أقرأ بأسم ربك الذي خلق,خلق الأنسان من علق,أقرأ و ربك الأكرم, الذي علم بالقلم,علم الأنسان ما لم يعلم"
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| aaroho
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Explanation:
This is most likely a case of idiopathic thrombocytopenic purpura (ITP). ITP occurs in women three times as frequently as in men and most commonly presents between the ages of 20 to 50. These patients will usually present with signs of superficial bleeding, such as that of the mucosa, epistaxis, skin, gingival, and vagina. In children, ITP is usually precipitated by a viral illness, such as Epstein-Barr virus (EBV), and, therefore, a positive Monospot test can be found.
In adults, there is rarely an association with a specific virus. ITP is an autoimmune disease in which immunoglobulin G (IgG) antibody is produced against glycoprotein IIb/IIIa antigens on the platelet surface. The platelets are not lysed. Instead, macrophages will bring the platelets to the spleen where the destruction will take place. This is why splenectomy is the definitive treatment, even if there is no splenomegaly on examination. Despite the destruction taking place in the spleen, the spleen does not become enlarged.
Bone marrow examination should reveal an increased number of megakaryocytes, with the other cell lines being normal because there is no production problem in ITP. There is no hemolysis in ITP: Hemolysis is found in hemolytic uremic syndrome (HUS), disseminated intravascular coagulation (DIC), and thrombotic thrombocytopenic purpura (TTP), not ITP.
ITP is diagnosed on the basis of a generally healthy person who develops an isolated thrombocytopenia with no identifiable cause, such as marrow infiltration or as a drug effect in a person with a normal-sized spleen. Bone marrow biopsy and an antinuclear antibody test are routinely done. Antiplatelet-antibody testing is not useful to confirm the diagnosis. Although antiplatelet antibodies are often present, their specificity is poor. Many normal subjects harbor antiplatelet antibodies without a low platelet count. You can also have ITP without antiplatelet antibodies present..
(D) Begin warfarin and adjust the dose based on INR
Explanation:
This patient has paroxysmal atrial fibrillation. His risk of embolism is approximately 5% per year without therapy. Warfarin is the appropriate therapy for him. Aspirin is less effective than warfarin but can be given if the patient has contraindications to warfarin. Elective cardioversion is unnecessary because the patient does not have sustained atrial fibrillation. A transesophageal echocardiogram is also not needed because the patient will start warfarin regardless of the findings.. Electrophysiologic testing (EPS) does not need to be performed because the diagnosis of paroxysmal atrial fibrillation is already made and the therapy is anticoagulation on a long-term basis. The INR should be maintained between 2 and 3.
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